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Personal details.
Name: Mr. M MRN: 22xxx Age: 61 years old Sex: male Race: Indian Job: retired from bank staff Date of admission: 17/6/09 Date of referral: 20/6/09 for pre-op CABG Date of operation: 22/6/09 Date of assessment: 24/6/09 (post-op day 2) Dr diagnosis : Coronary artery disease (CAD) Dr management : post-op CABG (3 graft)
Subjective Assessment
Present history Pt admitted to DSH on 17/6/09 for elective CABG On 22/6/09 pt transferred to CICU for close observation post-op CABG
Pt c/o: Pt complaint of pain at the operation site, back aching, mild dizziness, and sleepy.
Medication
Social history
Pt was a smoker since 40 years ago and take roughly 5 sticks for a day time but has been stopped since 5 month ago Pt lived with his wife accompanied with his children
Investigation
Angiography on 16/6/09 Result:1) Left mainstem 50% stenosis 2) Left anterio descending (LAD) 3) Left circumflex 60% stenosis 4) Right coronary artery (RCA) proximal 60% stenosis, middle 95%stenosis X-ray on 17/6/09 Result: normal (NAD) Echo on 18/6/09 Result: good LV function, EF 70%, chambers size normal and no pericardial effusion
Vital sign
Bp: 102/56 mmhg HR: 92 bpm RR: 23 bpm Temp: 36c Spo2: 100%
ABG on 24/6/09
pH: 741.7 ( 7.35-7.45) PCO2: 35.8 mmol/l (35-45) PO2: 167 mmol/l (95-100) HCO3: 23 mmol/l (22-26) BE: -1 ~ interpretation: metabolic normal
Lab result
Objective assessment
General observation A medium size Indian man was slumped on bed Pt conscious and obey to command Pt look tired and sleepy Pt on nasal prong 3 l/min Pt on IV drip at the left hand Pt CVL on right neck Pt on CBD drainage
Local observation
Pt was covered by gauze at the incision site (chest and left leg) Swelling noted at the operation site of left leg and ankle Pt had right AKA
On palpation
Chest expansion: symmetrical Upper lobe: fair Lateral costal: fair Diaphragm: poor
Chest measurement
Resting 1 2
93
86
Inspiration 1
94.5
87
Expiration 1
94
86.5
3
93
86
2
94
87.5
3
94.5
87
2
93.5
86
3
93
86
Axillary
Xiphoid process 10th rib
93
86.5
87.5
87
87
87
87
Coughing - unproductive cough Sputum -slightly thick and greenish + blood with minimal amount Test result -spirometry: 1000ml (3x) Muscle power - grade 3/5 : able to do by against gravity
Problem listing
Pain at the operation site Back aching Reduce chest expansion and secretion retention Unable to produce an effective cough Muscle weakness at both upper and lower limb
PT Impression
Pain at anterior chest wall area d/t operation wound Back aching d/t prolonged lying and poor blood ciculation Reduce chest expansion d/t poor breathing effort and pain Secretion retention over left and right basal d/t effect of GA and poor breathing pattern
Analysis
Short term goal
Produce effective and productive cough by using pillow to support at operation site at the chest Increase chest expansion Increase muscle strength Improve to normal breathing pattern
Treatment plan
Component of ACBT x2 set DBE 3X Spirometer with coughing 3x Active exercise 3x Sit up at the edge of bed with support - 3x
Home instruction
Keep doing spirometer to increase chest expansion Do the active exercise that has been teach by therapist Support the chest wound with pillow when coughing Elevate the leg same level with heart when sitting or lying Dont lift up the heavy things