a rehabilitation program was devised for the patient, taking into consideration time con straints and resources avail able. He was diligent in exe cuting any ...
a rehabilitation program was devised for the patient, taking into consideration time con straints and resources avail able. He was diligent in exe cuting any exercises asked of him by the physical therapist. Hopefully, this clinical profile will encourage physical thera pists to continue to think crit ically and to carryon the high standard of care that we expect of ourselves on a daily basis.
Turner syndrome (acute brachial neuritis). American I Bone [oint Surg 1996;78:1405-1408.
4. Parsonage M], Turner ]W. Neu ralgic amyotrophy the shoulder girdle syndrome. Lancet June 26, 1948;1:973-978. 5. Ayrnrnd ], Goldner ]L,
Hardaker WT. Neuralgic amy otrophy. Orthop Rev. Dec 1989;18( 12): 12 75-9. 6. Watson C, Schenkman M.
Journal of Accidental Emerg Med. 1997;14:41-43. 2. England ]D. The variations of neuralgic amyotrophy. Muscle and Nerve 1999;22:435-436.
Physical therapy management of serratus anterior muscle paraly sis. Phys Ther. 1995;75:194-202. 7. Reid DC. Sports Injury Assess ment and Rehabilitation. New York: Churchill-Livingstone; 1992. 8. Rockwood CA, Masten FA. The Shoulder, vol 22. Philadelphia: WB Saunders, 1998. 9. Magee KR, Dejong RN. Para lytic brachial neuritis: discussion of clinical features with review of twenty-three cases. JAMA.
3. Misarnore GW Parsonage-
1960;174:1258-1262.
References 1. Darby M], Was AR. Neurologic amyotrophy presenting to an acci dent and emergency department.
10. Meadows]. Orthopedic DIf ferential Diagnosis in Physical Therapy. New York: McGraw Hill; 1999. 11. McConnell ]. j130Approach to the Problem Shoulder-Seminar Manual. Marina Del Rey, Califor nia, 1994. 12. APTA. Guide to Physical Ther apist Practice. November 1998. 13. Kasl Sv. Issues in patient
adherence to health care regimen. I Human Stress. 1975;1(3):5. 14. Payton 00. Psychosocial Aspects of Clinical Practice. New York: Churchill-Livingstone; 1986. 15. Anderson TP. An alternative
frame of reference for rehabilita tion: the helping process versus medical model. Arch Phys Med Rehabil.1975;56:101.
Kimberly Ann Keyser PI; OCS, is a staff physical therapist at Duke University Sports Medicing Center in Durham, NC.
Cardiac Rehabilitation after Acute Myocardial Infarction '/;1/1\,.1
Kinucv L/Picr. 1'T. PhD, and Kim/Jcrl)' K. Clcarv. PT
Acute myocardial infarction is a common diagnosis resulting in hospital admission. In the United States, approximately 1.5 million people experience an acute myocardial infarction each year, and approximately two thirds of them survive. Only 5% of acute myocardial infarctions occur in people younger than 40 years. I Women (41 %) are less likely to be hospitalized for coronary artery disease than men (59 %) because of the cardioprotective effects of estrogen.':' However, coronary artery disease is still the largest killer of women in the United States." Further more, women (42%) are more likely than men (24%) to die within a year of an acute myocardial infarct: Predispos ing risk factors for coronary artery disease and therefore acute myocardial infarction include current cigarette smok ing, hypertension, dyslipi 124
demia, age, gender, diabetes mellitus, family history, and inactivity.' The purpose of this clinical profile is to describe the history and clinical course of a young woman referred for phase I cardiac rehabilitation after acute myocardial infarc tion. Patient History
A 31-year-old woman sought treatment at the emergency room 1 day before this admis sion for severe stuttering chest pain and diaphoresis. At that time she was vaguely diagnosed with gallbladder disease and referred for follow-up as an outpatient with a physician the following week. She returned to the emergency room again the following day, complaining of worsening of her symptoms. A 12-lead electrocardiogram was performed and indicated
Physical1herapv case Reports Volume 3/Number 3
ST segment elevation in the inferior and lateral leads. At that time, a cardiology consult was requested. At the recom mendation of the cardiologist, the patient underwent emer gent diagnostic cardiac catheterization the same day. Coronary angiography showed partial occlusion of the right and left coronary arteries. The patient subsequently underwent percutaneous transluminal coronary angioplasty and stent placement at these sites. Imme diately after sheath removal, the patient's right femoral arte rial puncture site was closed with an extravascular collagen based vascular sealing device. Cardiac rehabilitation was ordered for this patient on the day after her admission to the hospital and emergent cardiac catheterization. The patient's hospital chart contained little
Medication
Dose
Action
Prevacid® (Iansoprazole)
30 mg twice daily
Inhibits gastric acid secretion
Plavix® (c1opidogrel)
75 mg twice daily
Reduces incidence of recurring atherosclerotic events
Enteric coated aspirin
5 9 every day
Produces anticoagulation, analgesia, and antipyresis
Nicotine patch
21 mg every day
Reduces symptoms of nicotine withdrawal
Zyban® (bupropion)
150 mg every day
Reduces symptoms of nicotine withdrawal or depression
Tylenol®(acetaminophen)
1 9 every 6 hrs as needed
Produces analgesia and antipyresis
vkodarr" (hydrocodone bitartrate)
5 mg every hrs as needed 0.5 mg every 4 hrs as needed BP >90 mmHg
Produces analgesia Stimulates 131-receptors
Inapsine
0.5 ml every 4--6 hrs as needed
Produces sedation
Demerol
25 mg every 4-6 hrs as needed
Produces analgesia and sedation
Xanax® (alprazolam)
Dopamine
information on her medical/surgical history or family history. The only infor mation on the patient's social history that was obtained from the chart was that she was currently unemployed and a smoker. Her current medica tions and laboratory values were as outlined in Tables 1 and 2, respectively. The patient's height was 67" and weight was 226 pounds. Nurs ing notes indicated that she had been very belligerent and distraught during bed rest the previous day after the cardiac catheterization. At one point, the patient refused to maintain the bed rest order and was at great risk for arterial bleeding. Interviewing the patient helped to complete her med ical/surgical, family, and social history profile and provided some preliminary patient sub jective data. On entering the room, the patient's demeanor was cooperative, pleasant, and apologetic. She stated that she was feeling much better than the previous day. She also vol unteered that she was ready to make whatever changes were necessary to improve her health, including immediate
Reduces anxiety
smoking cessation. At this time, the patient did complain of some low back pain from lying in bed the previous day. Initial history-taking revealed
TABLE 2
that she had been amenorrheic for 13 years. She reported attempting one trial of pre marin in the past for 30 days, which did not result in
I
Test
Value
Reference Range
Serum Enzymes
CK CK-MB
1552 147
21-232 fllL
0-5 ng/mL
Troponin I
44.2
0-0.5 ng/mL
AST/SGOT
33
8-28 fllL
Metabolic Panel
Na
K CI Glucose
140 3.7
106 141
136-145 mEq/L
3.5-5.1 mEq/L
100-110 mEq/L
70-110 mg/dL
BUN
6
6-22 mg/dL
Creatinine
0.8
0.6-1.3 mg/dL
Magnesium
1.5
1.6-2.2 mg/dL
Cholesterol Profile
Triglicerides
469
30-200 mg/dL
Cholesterol
269
0-200 mg/dL
30
32-96 mg/dL
HDL LDL
VLDL
*
*Results invalid with triglycerides >400 mg/dL. CK = creatine kinase; CK-MB = creatine kinase-MB; AST = aspartate amino transferase; BUN = blood-urea nitrogen; HDL = high-density lipoprotein; LDL = low-density lipoprotein; VLDL = very-low-density lipoprotein.
Physical Therapy Case Reports Volume .lINumber .l
125
menses. She had not received any hormone replacement therapy since that time. The patient also reported a history of degenerative disc disease over the last 10 years, result ing in pain and weakness in her left lower extremity, con stant bilateral foot pain, and recurrent migraine headaches (approximately 2 to 5 times per year). The patient reported that her father had a history of heart disease, hypertension, and diabetes mellitus but that she did not know the medical history of her mother or mother's family. She stated that she did not know of any family history of stroke or cancer. The patient reported a 32 pack/year history of smok ing but denied any other behavioral health risks. The patient was currently living with her father, stepmother, and husband in a 1-level apartment with 10 steps to enter. She had moved to the area 6 months ago to help care for her father, who had recently undergone coronary artery bypass surgery. She stated that this living situation was quite stressful for her. She was currently unemployed but in the past had assisted her husband with his work, which involved painting, floor instal lation, and other maintenance work. The patient and her husband did not have any health insurance. Before this hospital admission, she did not participate in regular physical activity, did not use any adaptive equipment, and was independent with all activities of daily living and instrumental activities of daily living. Examination
At the time of the initial physi cal therapy examination, the patient was alert and oriented to person, place, time, and situ 126
arion, She was able to respond appropriately to questions 100% of the time and could follow multiple-step directions. She had fairly significant apical alopecia but no cyanosis of the lips or nail beds, nail clubbing, or areas of ecchymosis. A small amount of blood was observed under the dressing at the right groin catheter puncture site, but no redness, swelling, or tenderness was present. Her sit ting and standing posture and chest wall configuration were unremarkable. A peripheral intravenous line was in place in her left forearm. She did not demonstrate pursed lip breath ing, accessory respiratory mus cle activity/adaptive shortening, jugular vein distention, or abnormal breathing pattern. Her abdominal and chest wall movements were equal during inspiration. The patient's cough was effective, nonproductive, and infrequent, and her phona tion was normal.s" With lung auscultation, normal vesicular breath sounds were found over the first to fifth intercostal spaces on the anterior chest wall and second to ninth intercostal spaces on the posterior chest wall bilater ally before and after ambula tion. Normal S1 and S2 heart sounds were clearly audible with auscultation.r" With palpation, the patient's tracheal position was centered. Chest wall motion was normal and symmetric in both the upper and lower chest. Chest pain was absent with palpation and deep breathing. Bilateral dorsal pedal and radial pulses were present and strong. With pal pation, her skin was warm on all extremities and the trunk. Homan's sign was negative (no pain with deep palpation of gastrocnemius muscle belly) for both lower extremities. No peripheral edema was noted.r"
Physical Therapy case Reports Volume 3/Number 3
Active range of motion was normal throughout the trunk and extremities. Sensa tion to light touch was intact in all extremities. Muscle strength was at least fair (3/5) throughout the extremities, but further strength testing with resistance was contraindi cated because of lifting precau tions. During functional activi ties, the patient did not appear to be limited by strength impairments. Sitting and standing bal ance were normal, and gait pattern was unremarkable. She was independent with all func tional mobility tasks including bed mobility (supine to sidely ing, sidelying to short sitting), transfers (from bed, chair, and toilet), and ambulation with out an assistive device. Vital signs recorded before, during, and after exer cise are presented in Table 3. The patient ambulated 880 feet without rest in 7 minutes 30 seconds before requesting to stop because of fatigue. She denied chest pain, shortness of breath, or dizziness during exercise. The patient did not receive supplemental oxygen during ambulation. Normal sinus rhythm was noted on electrocardiogram before, dur ing, and after ambulation, as illustrated in Figures 1, 2, and 3, respectively. Evaluation
At rest, the patient did not show chronic or acute hypoxia (cyanosis, nail clubbing), respi ratory distress (nasal flaring, facial grimacing, pupil dila tion), recruitment of accessory respiratory muscles (activity or hypertrophy of the scalene, sternocleidomastoid, or pec toralis muscles), or abnormal ventilatory pattern (incoordina tion of respiratory muscles, tachypnea, respiratory alter nansl.r" She also did not
Supine
Sitting
Standing
Ambulation
Recovery
Heart rate (bpm)
81
78
84
110
74
Oxygen saturation (%)
96
91
93
>88
98
Blood pressure (mmHg)
92/57
93170
103/65
108161
99/69
appear to have any manifesta tions of heart failure (orthop nea, low blood pressure, dizzi ness/lightheadedness, jugular vein distention, peripheral edema, bilateral lower lobe crackles, S3 or S4 heart soundsj.r" The patient was not at high risk for developing pneumonia or atelectasis because she had normal alveo lar expansion and no retention of secretions (normal chest wall mobility, normal phonation volume, no chest wall pain, effective nonproductive cough, and normal vesicular breath sounds bilateral upper and lower lobesl.:" She had no signs or symptoms of compro mised hemostasis (bleeding, sig nificant ecchymosis, bulge under skin) or infection (red ness, swelling, tenderness) at the catheter puncture site. Her peripheral circulation was nor mal (pulses present and strong, skin warm to touch, no trophic skin changes, no cyanosis), and she did not appear to have a deep vein thrombosis (negative Homan's signs, no unilateral lower extremity peripheral edema) in the involved or unin volved lower extremity.'" She had normal range of motion, strength, sensation, balance,
1_
413
TEL 107
19 SEP 99 11 07
DECREA~E
functional mobility, and gait. Her vital signs at rest were nor mal (heart rate 60 to 100 beats/min; oxygen saturation greater than 90%; blood pres sure less than 90 to 140/60 to 80 mm Hg): During activity, the patient tolerated positional changes and exercise without adverse signs or symptoms. She did not experience orthostasis (drop in blood pressure, dizziness/light headedness ) on assuming upright positions. The patient did not have myocardial ischemia (angina, electrocardio gram changes, elevation in diastolic blood pressure) or exercise-induced heart failure (drop in systolic blood pres sure, dizziness/lightheadedness, pulmonary congestion, short ness of breath) with ambula tion.r" She had slight oxygen desaturation during exercise but was able to maintain oxy gen saturation at greater than 88% breathing room air. Her activity tolerance was fairly limited for a woman her age, most likely because of appre hension about her postcatheter ization and post-myocardial infarction status in addition to a general deconditioned state premorbidly.
ECG SIZE
HR
71
VPB
0
SINUS RHYTHM
25
The physical therapy examination indicated that this patient had integumentary and aerobic capacity/endurance impairments and possibly a gas exchange impairment." In addition to these impairments, she also had multiple coronary artery disease risk factors, including family history, cur rent cigarette smoking, physical inactivity, dyslipidemia, obesity, and stress. The patient's father had known coronary artery disease, which represents a sig nificant family history for coro nary artery disease (myocardial infarction or sudden death before 55 years of age in father or other male first-degree rela tive).' She reported a sedentary lifestyle, especially when unem ployed (sedentary jobs involv ing sitting for a large part of the day and no regular exercise or active recreational pursuits). \ Her high total cholesterol (>200 mg/dL) and low high density lipoprotein cholesterol (
