Week 6 - study manual

Case study

note: it’s basically 2 different case studies

Anamnesis

Note: this case is divided into 2 courses (A & B)

Impairments

• heart complaint

• chest pain and shortness of breath

• extreme fatigue

Activities -

Partecipation -

Personal factors

• male, 68 yo

• retired at 67 yo, used to be a taxi driver

• he is married

• like gardening

• walks around the block

• 15 years ago - diagnosed with COPD GOLD C (panlobular emphysema → look into this)

• he was not “too fussy“ (undertook things)

Environmental factors

• lives with his wife in Veendam (has a terrace)

COURSE A

• IMPAIRMENTS

• chest pain symptoms

• extreme fatigue

• NON - STEMI with atrial fibrillation

• Infarct affected the heart

• Implantation ICD

• fatigue and constipation → GP referral to hospital

• diagnosis → left and right decompensatio cordis with dilating cardiomyopathy (DCM)

• LVEF was 20%.

• at night ankles become thicker

• he coughs pinkish sputum

  ACTIVITIES

• gardening

  PARTECIPATION

  PERSONAL FACTORS

• fear of straining strong after the surgery

• Hospital gave him diuretics → lost 10kg

• his condition deteriorated in the last 6 months

• he can no longer lie flat

• cannot sleep with a single pillow, he needs more

  ENVIRONAMENTAL FACTORS

Notes

• he was sent to cardiac rehab for 6 weeks x endurance

• Request for help: work in the garden again

COURSE B

Impairments

• Emphysema

• increased pulmonary circulation

• coronary sclerosis

• partial respiratory insufficiency

• moderate dyspnoea

• obstructive, expectoration is still marginal.

• During auscultation, bronchial breath sounds are found mainly in the basal lung areas with fine rhonchi here and there.

• There is also substantial weight loss (BMI 19) and muscle depletion.

• no ischemia

• slow blood pressure

• PVCs (premature ventricular contractions also called ventricular extrasystole)

  

Activities

• needs help with ADLs

• gets into chair 2x day with the help of the nurse

Partecipation -

Personal factors

• PT seems reasonable even after severe exacerbation

• he lies mostly in bed

• it takes a lot of effort to move

medications : cardiotonics, mucolitics, bronchidilatants and analgesics.

Environmental factors

• lies on the bed

• nurses help him

Physiotherapeutic goal (request for help)

PT classes - practice

1) look into terms that are not clear from COURSE A

• non stemi → partial blockage of coronary arteiries ( plaques)

More questions for the anamnesis

• how tired do you get when u walk from a scale of 1 to 10

• describe your routine

• PSC questionnaire

Assessment

1) read chart

2) observation (total, local, functional)

VITALS

3) RR

4) observation respiration pattern

5) saturation

6) auscultation

7) blood pressure

8) heart rate

Specific tests

• Endurance → 6MWT, Bruce test

• 5TSTS, 1 RM (gym) grip strength, TUG

• BORG scale 9extersion) NPRS scale

• MEP test → look this up

• Tampa scale of kinesiophobia

• cardiac anxiety questionnaire (CAQ)

• SQUASH (for ADLs)

• dysponea scale

GOAL: work in the garden again

Treatment

1) endurance: build up of tollerance

• HIIT

• stationary biking

THR:

HIIT + CT = 0.8 (152 - 75) + 75 → 136 BPM (BPM max for PT)

COURSE B

• Note: ischemia not present in course B

Cor pulmonae:

the alveoli in the lungs are diminished due to the emphysema, because of that the perfusion of arteries in the lungs, this increases the presssure and causes coronary sceloris due to plauqe build up. The higher pressures are not tolerated by the right ventricle and it causes the right ventricle to become hyperthrophic overtime.

Assessment

VITALS

3) RR

4) observation respiration pattern

5) saturation

6) auscultation

7) blood pressure

8) heart rate

Specific tests

• Endurance → 6MWT, Bruce test

• 5TSTS, 1 RM (gym) grip strength, TUG

• BORG scale 9extersion) NPRS scale

• MEP test → look this up (quello che devi soffiare dentro si chiama cosi)

• Tampa scale of kinesiophobia

• cardiac anxiety questionnaire (CAQ)

• SQUASH (for ADLs)

• dysponea scale

• HADS (hostital anxiety ditress scale)

MB preparations

• watch lecture week 5 → to do lol

PT preparations

1) study task 1

• read KNGF guidelines “cardiac rehab“ (Elco sent the translated part, read that) → TO DO

• ICF core sets (did it, look into week 4)

• look into Hillegass “CHF“ aka congestive heart failure

PT class practice

We talked about how to use spirometry

Instruction:

• Inhale as much as possible

• Exhale as much fast and hard as you can

• Show them where (tube) and how to perform it

• Explain them that they have to put the clip to the nose

• while PT does it, incitate them (Go go go goooo lol)

• Jolanda does it 3 times → learning curve

Protocol: IMT is for PT with reduced inspiratory breathing muscle strength (PI max </= 70 % of what is predicted) or ventilatory limitations in addition to aerobic training

IMT training → inspiratory muscle training

• what to use? It’s like some sort of “whistle object“ and they have to blow into it

• 6 - 12 weeks, IMT: 3 to 4 x week, 2× 15 minutes x day

• IMT: 20 - 40 % of PI - max

Heart failure (CHF)

main function → pump blood

Pump has a “pre - load“ (body → heart ) and an “after - load“ (heart → body)

• The pump can fail, can be pre- load (back ward) or after - load failure (forward)

  Consequences

  • Pre - load → fluid build up (swelling aka edema)

  • after - load → blood not getting to body (fatigue, dysonea)

pre load RA → RV after load → lungs → LA pre-load → LV after- load

Systolic → after load (atrias)

Diastolic → pre- load (hypertrophy of the myocardium, chambers are getting thicker, walls become rigid) (ventricles)

• the problems begin “upstream” and a

• ffect the chain downstream to

  Assignment 1

• a)

  

  Table explained a bit better

  

b)

COPD patients and CHF

COPD leads to progressive damage to the alveoli, reducing gas exchange efficiency (number of alveoli decreases) As a result, oxygenation decreases while carbon dioxide accumulates, causing chronic hypoxia (the blood full of CO2 return to the body) The body compensates by vasoconstricting pulmonary arteries, leading to pulmonary hypertension (pressure increase in the arteries of the lungs) Over time, increased resistance in the lungs forces the right ventricle to work harder, leading to right ventricular hypertrophy. This happens because the right ventricle it’s used to work under low-pressure, but because of the increased pressure in arteries of the lungs, the pressure rises in the right ventricle, it cannot handle it. (right ventricle becomes hyperthrophic) This condition, known as cor pulmonale, eventually leads to heart failure due to reduced cardiac output. Wasserman’s model explains how these progressive inefficiencies in ventilation and circulation lead to metabolic strain, worsening systemic hypoxia and increasing the heart’s workload.

c)

D)

Assigment 2

A)

B) “treatments“

1) PT 2) medicines (GP) 3) surgery

1) PT

• improve angiogenesis → the more blood vessel, the less the resistance.

  By increasing that, we decrease the effort of the heart

  How does it work? heart works bad, the muscle need oxygen anyway, body gets scared cauze it needs air, body produces more blood vessels to get more oxygen in there, body happy, heart happy because the increase of vessels reduces the pressure.

• HOW? HIIT training, resistance training

• lifestyle changes

2) Medicines

• diuretics → gets rid of fluid by making u pee more (for pre-load)

• digitalis purpurea (it’s a flower) → increase contractility of the heart (for after load aka ventricles)

• Dopamine → increase contractility of the heart (for after load aka ventricles)

3) surgery

• transplant (u have to be sick asf)

• syncronizing the beats (left and right side of the heart are fused together to get them to squeeze together) + pace maker to make it work together (just to make sure)

SIDE NOTE: beta blockers (metoprolol) → they help with hypertension, they reduce heart rate (side effect) U DON’T GIVE IT TO PEOPLE WITH HEART FAILURE, only if u want to end their suffering.