PHT 218: Fall 2022 Case Study #1

* Final Report *

Chief Complaint
Weakness, difficulty walking
History of Present Illness

This is a 75 y/o female with PMHx HTN, CAD, MI, COPD, DM, admitted on ___ secondary to shortness of breath. She's still an active
smoker and was in her usual state of health until day of admit when she complained of increasing difficulty breathing. In the ED, D-
dimers and troponins were noted to be elevated; CT chest was negative for PE. She was initially admitted to the ICU; cardiology and
pulmonary consults were requested. She was placed on Bipap. Initial impression of COPD exacerbation with flash pulmonary edema
(Systolic/Diastolic CHF) was given. Her LVEF was noted to be at 24%. She had blood transfusion secondary to anemia (Hgb 7.2).
CXR showed infiltrates in the LLL and Levaquin was continued. she underwent cardiac Problem List
cath with PCI with findings including 3V CAD with proximal occlusion of all native Chronic
vessels); DES placed on RCA-SVG. Continued medical management was done and she
Procedure/Surgical History Insertion
stabilized and transferred out of the ICU. PT/OT were started; our service was consulted
of Infusion Device into Superior Vena
to provide recommendations regarding her acute rehab needs. She's admitted to
Cava, Percutaneous Approach Respiratory
undergo acute inpatient rehab.
Ventilation, 2496 Consecutive Hours ,
Review of Systems Assistance with Respiratory Ventilation,
Review of Systems Less than 24 Consecutive Hours,
Constitutional: Negative. Eye: Negative. Continuous Positive Airway Pressure.
Ear/Nose/Mouth/Throat: Negative.
Medications
Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative.
Inpatient
Genitourinary: Negative. Musculoskeletal: Negative. Integumentary:
acetaminophen, 650 mg, 2 TAB, PO,
Negative. Neurologic: Negative. Psychiatric: Negative.
Q4H (Every 4 hours), PRN
Physical Exam aspirin, 81 mg, 1 TAB, PO, Daily
General: Elderly female, obese, pleasant, Awake, No acute distress. On 02 at atorvastatin, 40 mg, 2 TAB, PO, Daily
2L/min docusate, 100 mg, 1 CAP, PO, BID (2
Eye: Pupils are equal, round and reactive to light, Extraocular movements are times a day)
intact. DuoNeb, 3 mL, NEB, Q4HWA (Every 4
HE NT: Normocephalic, Normal hearing. hours while awake)
Neck: Supple, Non-tender, No jugular venous distention. heparin, 5000 Unit, 1 mL, Subcut,
Respiratory: Lungs are clear to auscultation, Breath sounds are equal. Q12Hi (Every 12 hours interval) insulin
Cardiovascular: Normal rate, Regular rhythm. detemir, 10 Unit, 0.1 mL,
Gastrointestinal: Soft, Non-tender, Normal bowel sounds. Subcut, Q24H (Every 24 hours)
Levaquin, 750 mg, 150 mL, IVPB,
Q48H (Every 48 hours)
losartan, 12.5 mg, 0.5 TAB, PO, BID
(2 times a day)
Metoprolol Tartrate, 12.5 mg, 0.5
TAB, PO, BID (2 times a day)
montelukast, 10 mg, 1 TAB, PO, Daily
nicotine 21 mg/24 hr transdermal
film, extended release, 21 mg, 1
Patch, Transdermal, Daily
Plavix, 75 mg, 1 TAB, PO, Daily
potassium chloride, 20 mEq, 1 TAB, PO,
Daily
Saline Flush, 10 mL, IV Push, Daily,
PRN
Saline Flush, 10 mL, IV Push, Q8H
(Every 8 hours)
sertraline, 100 mg, 2 TAB, PO, Daily
 Musculoskeletal: No calf tenderness bilat. BUEs: prox 4+/5; distal 5/5. BLEs: prox 4/5; distal 4+/5.
Integumentary: Intact. ++ scaly, thickened darkened skin on both distal LEs; ++ decreased sensation on both distal LEs.
Neurologic: Alert, Oriented.
Psychiatric: Cooperative, Appropriate mood & affect.
Assessment/ Plan
1. Impaired Mobility, Gait and ADLs secondary to Generalized Debility from complex medical conditions (see below)

− - Patient will undergo an acute in-patient rehabilitation program with multidisciplinary therapies including PT/OT, with daily
physician supervision/Physiatry management, Rehab nursing, Nutrition services and case management.

2. S/P CHF Exacerbation (systolic and diastolic)

− - continue medical management with medications; continue diuretics
− - monitor weights, fluid balance

3. S/p COPD exacerbation

− - continue medical management with meds, inhalers

4. other Cardiovascular: HTN, s/p Cardiac cath, PCI (s/p DES to RCA-SVG), 3V CAD, Cardiomyopathy, recent MI, HLD
-- continue medical management; on metoprolol, ASA, Atorvastatin, Losartan -- continue to monitor BP/HR esp. during therapies

5. other Pulmonary: COPD on Bipap, 02 NC, s/p Respiratory failure, Active smoker, PNA, Lung nodule noted on CXR
-- continue to monitor respiratory status/function, 02 sats during therapies
− - as above; continue medications including inhalers, nebulizers, 02; continue ABx for now.
− - plan for repeat CT chest to follow up lung nodule found on CXR (to be done as OP).

6. Endocrine: DM with peripheral polyneuropathy

-- continue Insulin
-- monitor accuchecks during rehab stay
-- diet management

7. Anemia: s/p Blood transfusion

− - monitor Hgb/Hct levels

8. Mild Dementia
− - stable; continue to monitor while in rehab. SLP if indicated.

9. Bladder and Bowel Functions: start bladder and bowel training programs; bowel meds to prevent constipation.

10. Skin and Wound Care: Rehab nursing to monitor daily; decub. ulcer prevention strategies

11. F/E/N:
− - monitor hydration/fluid status, electrolytes; nutrition consult.
− - will follow up labs.
12. DVT Risk: On Heparin
Symbicort 160 mcg-4.5 mcg/inh, 2
Puff, Inhalation, BID (2 times a day) temazepam, 30 mg, 1 CAP, PO, QHS
(At bedtime)
torsemide, 20 mg, 1 TAB, PO, Daily Home
acetaminophen 325 mg oral tablet, 650 mg, 2 TAB, PO, Q4H (Every 4 hours), PRN
albuterol-ipratropium 2.5 mg-0.5 Lives alone in a 1-level apartment;
mg/3 mL inhalation solution, 3 mL,
NEB, Q4H (Every 4 hours) amLODIPine, 5 mg, PO, Daily aspirin, 325 mg, PO, Daily Previous Level Function: Independent with all
atorvastatin 40 mg oral tablet, 40 mg, activities
1 TAB, PO, Daily
docusate sodium 100 mg oral Current Level of function: grooming: SBA;
capsule, 100 mg, 1 CAP, PO, BID (2 times a day) UE bathing SBA, LE: min A. Sit-stand: SBA,
heparin 5000 units/0.5 mL injectable solution, 5000 Unit, 0.5 mL, Subcut, Q12Hi (Every Gait: min A with RW 100 ft.
12 hours interval) Family History
insulin detemir, 10 Unit, Subcut, Q24H (Every 24 hours) FAMILY HEALTH HISTORY
losartan 25 mg oral tablet, 25 mg, 1
TAB, PO, BID (2 times a day) metFORMIN, 500 mg, PO, Daily Metoprolol Succinate ER 50 Patient Health History
mg oral HEALTH HISTORY
tablet, extended release, 50 mg, 1 COPD Patient
TAB, PO, Daily Diabetes mellitus Patient
montelukast 10 mg oral tablet, 10 mg, 1 TAB, PO, Daily Heart disease Patient
nicotine 14 mg/24 hr transdermal film, extended release, Transdermal, Daily Heart failure Patient
Plavix 75 mg oral tablet, 75 mg, 1 TAB, PO, Daily Poor peripheral circulation Patient
potassium chloride 20 mEq oral tablet, extended release, 20 mEq, 1 Sleep apnea Patient
TAB, PO, BID (2 times a day) Smoker Patient
sertraline 100 mg oral tablet, 100 mg, 1 TAB, PO, Daily
Diagnostic Results
Symbicort 160 mcg-4.5 mcg/inh, 2
Puff, Inhalation, BID (2 times a day) temazepam 30 mg oral capsule, 30
COMPLETED RADIOLOGY IMAGING
mg, 1 CAP, PO, QHS (At bedtime) torsemide 20 mg oral tablet, 20 mg, 1 STUDIES:
TAB, PO, Daily
Vitamin D2, PO, Daily No Imaging Results in the last 36 hours
Allergies penicillin vancomycin
Social History
Social History:

current Impairments/Disabilities requiring 3 hours of daily multidisciplinary therapies (PT/OT): weakness, decreased
activity tolerance/endurance, significant pain levels, poor balance, mild cognitive impairments (memory,
attention/concentration, reasoning, executive functions, etc), motor-sensory deficits, significant limitations
transfer/gait/mobility functions and self-care abilities.

Conditions requiring active medical management! monitoring (medical necessity) include: monitoring of VS, Medication
management, Pain management, Skin and wound care management, Bladder and Bowel Training programs, VTE
Prophylaxis, Monitoring of pulmonary, cardiac, neurologic, renal, hematologic, GI status, Nutritional monitoring and
optimization.

ELOS: 10 days

Goals: Mod I with Gait, Mobility and ADLs Prognosis: Good

Discharge Disposition: Home with Home Health

 CASE STUDY ASSIGNMENT #1 total points: 18/

Review the case study and answer the following questions based on the information.

1. What is the patient’s primary medical diagnosis/es? (2 points)

The primary medical diagnoses are COPD, CHF, and pulmonary edema.

2. What precautions (ex: joint, cardiac, o2 monitoring, sternal, any ordered limitations/restrictions) will need to be
followed during therapy sessions? (2 points)

We can monitor her 02 stats, use the BERG scale of perceived exertion when monitoring her during exercises
because her beta blockers will affect how here BP and HR changes during exercise. This patient is also a DVT
watch because of the Heprin she takes. She has poor balance, so she needs to be treated as a fall risk as well as be
tested to for leg sensation. She has mild dementia so that’s something to consider and watch out for in case she
needs additional cuing.

3. What vitals will need to be monitored? (2 points)

02 saturation levels and levels of exertion.

4. How often should vitals be assessed during a treatment session? (2 points)

Before, during, and after the treatment session.

Review the patient’s inpatient medication list.

5. List each highlighted in- patient medication , indicate what is each highlighted medication is used for, and how
medication may impact therapy session? (5 points)
Acetaminophen- Used to relieve pain such as headcahes, muscle aches, and fevers. This may impact therapy sessions by
casuing nausea and stomach pain.
Aspirin- Used to relieve pain and my impact therapy by causing drowsiness, and an upset stomach.
DuoNeb- Used to treat airway narrowing that may happen with COPD. It is a bronchodilator. It may impact therapy by
causing dizziness, dry mouth and nausea.
Heparin- This is an anticoagulant used to prevent blood clots from forming. It may impact therapy by causing pain in
the stomach and/or in the back.
Levaquin- Used to treat bacterial infections. It may impact therapy by causing vomiting, diarrhea, and headaches.
Losartan-Used to treat high blood pressure. It may impact therapy by causing blurred vision, difficulty breathing,
nausea, and vomiting.
Metoprolol Tartrate- Used to treat high blood pressure aswell as preventing stroke and heart attacks. It may impact
therapy by causing drowsiness, fatigue, and a decrease in heart rate.
 Review the patient’s current level of function and goals.

6.What types of therapeutic interventions would benefit this patient to achieve goals? Provide 1 specific task for each
intervention ( 5 points) 3-5 interventions, ( ex: intervention: LE strengthening: task: supine heel slide with 1# ankle wt,
ex: intervention: gait training: amb with ___AD?______, ___distance?____ x ___how many times during treatment
session ___ )

1. Butterfly Breathing Technique: Seated on bedside, 3 sets x 10 reps. This promotes chest expenditure and
proper breathing

2. Aerobic Conditioning: Portable Hand Bike, seated on bed or chair, 1 set x 10 mins. This will help begin
conditioning her lungs and cardiovascular endurance

3. Active Breathing Cycle: Seated on bed, 2 sets x1 rep. This will help her learn of a good way to clear her
airways of phlegm which promotes better breathing.

4. Pelvic Floor Strengthening: Pelvic tilts laying on bed or mat table, 3 sets x 10 reps with 2 sec holds. This
will help her pelvic strengthen floor muscles which will help with her incontinence and bowel issues.

5. Gait Training: Ambulation with RW, 200ft x 2 reps. This will help train her ambulation techniques to try
and get her back to independent levels of ambulation.