Physiotherapy Management :Cardiorespiratory theme

Mrs Seddon is a 55 year old lady, who was diagnosed with type II diabetes in March of 2011. Her glycaemic control was poor overall, though it had been acceptable when she adhered to a healthy diet. Six months ago she visited the Diabetic Clinic for a routine check-up. Her BP was found to be 160/95, antihypertensive therapy was instituted. Mrs Seddon informed the diabetic specialist nurse that she had been unable to stick to a healthy diet due to the pressures of work. She has never been admitted to hospital before. She is a lifelong smoker, smoking a packet of cigarettes a day since she was 16 years of age. She does not drink. Mrs Seddon is married with two adult children, is 54 (163cm) and weighs 15 stones (95.25kg). Mrs Seddon is an accountant, her workload is particularly stressful, working an average of 60 hours per week. She states that because of her work she is unable to take part in any regular exercise.
For some time she had noticed that if she worked hard during her occasional visits to the gym she would get a tight pain across her chest that sometimes went into her arm and sometimes went up towards her jaw. She had not worried too much about this pain, as it seemed to settle fairly quickly when she rested for a few moments. One morning the pain began when she was sitting at her desk and became more severe than usual. Mrs Seddon described her chest pain as crushing in nature. It was central in her chest but it also radiated down both arms and to her jaw line. Mrs Seddon looked pale and was sweating profusely, though she said she felt cold. Her Secretary was worried enough to call an ambulance.

Paramedics attended and advised Mrs Seddon that she needed to go to hospital and she was taken to the Accident and Emergency department. Following an examination that included electrocardiography (ECG) and some blood tests, Mrs Seddon was diagnosed as having had a myocardial infarction with ST elevation and pathological Q waves and was admitted to the coronary care unit. Percutaneous coronary intervention (PCI) was undertaken as an emergency procedure and stents were applied to the patients left anterior descending (LAD artery). However, post-procedure her left ventricular (LV) function was poor and she continued to experience angina that was resistant to medical therapy. She was referred for coronary artery bypass grafting. Mrs Seddons discharge medications included bisoprolol, atorvastatin, aspirin, clopidogrel, Ramipril and metformin.

Mrs Seddon had a minimally invasive coronary artery bypass graft (MIDCAB) on 28-03-2013 via a left anterior mini-thoracotomy. The left internal mammary artery was used to revascularise.

Questions
1. Explain this ladys clinical features with specific reference to the aetiology and pathophysiology of ischaemic heart disease
2. Formulate a likely post-operative problem list for this lady for the first three days of the post-operative period (the list should include potential/actual problems).
3. For two of the problems:
a) explain why the patient might present with/be at risk of these problems
b) state specific, measurable, appropriate, realistic and timed (SMART) short and long-term goals;
c) justify appropriate management;
d) justify appropriate evaluation methods.
The treatment plan should emphasise the physiotherapy aspects of her care, but refer to the role of other members of the multi-disciplinary team where necessary.

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