Philippine Heart Center

Comprehensive Cardiac Rehabilitation

Physical Therapy Initial Evaluation
Date of Evaluation: Nov. 17, 2014
S> M.P., a 36 y/o (-)Htn/DM/Asthma, (R)-handed female was referred for PT
eval & Mx 2 to c/o apprehension in doing ADLs, such as walking & climbing
stairs, d/t heart operation. Pt. also c/o constant, localized, sharp, aching pain
on incision site graded 4/10 at rest which immediately aggravates to 8/10
upon movement of B shoulder up to ~90 (as demonstrated by pt.) or upon
exertion (such as in bed mob & transfers), and is gradually relieved by Meds
to 3/10. Pain was described as parang sugat na makirot, hinihila ako
pababa. HPI: 10 years ago, pt. started experiencing easy fatigueability &
palpitations. No consult was done, pt. ignored Sx & cont. c regular ADLs. 4
mos. PTIE (July 2014), pt. was advised to undergo tonsillectomy d/t recurrent
tonsilitis. In that same month, pt. was referred to a cardiologist for clearance
as needed for the operation. Included in the procedures were 2D-Echo &
ECG. Results from these ancillary procedures pointed out presence of an
Atrial Septal Defect: Secundum Type. Upon this discovery, pt.'s cardiologist
advised pt. to undergo surgery to repair the said defect. Due to financial
problems, pt. was not able to immediately undergo surgery. For the next 4
mos. until the surgery, pt. cont. to endure Sx & kept taking frequent bouts of
rest in her ADLs and at work as she was doing before due to her easy
fatigueability. 4 days PTIE, pt. was admitted @ PHC. The next day (3 days
PTIE), pt. underwent Transthoracic (Anterolateral Thoracotomy) ASD closure.
Pt. was under general anesthesia for the whole procedure which lasted for
~1hr. Pt. was asleep for the remainder of the day p the operation and woke
up the next day. Meds for pain, which included Ibuprofen (4oomg bid) &
Paracetamol (500mg qid) were prescribed. Other Meds included Fluimocil
(600mg bid) for phlegm & Lactulose (30cc od) to aid in bowel movement. 2
days p the operation (day of IE), pt. was cleared for PT & was referred for
eval & Mx. PMHx: Unremarkable. Lifestyle: Pt. is a (-) smoker, (-) alcoholic
beverage drinker who works as a teller in a bank for ~8hrs/day. Pt. spends
~6 hrs/day @ work seated. Pt. lives a sedentary lifestyle. No hobbies or
recreational activities were mentioned. Pt. states being busy with work &
taking care of child. Work only requires handling money & conversing with
clients along with occasional movement from one location to another to
transfer files or money. Home situation: Pt. is a single mother who lives in a
2-storey house with child & a maid. Distance from front foor to staircase is
~5m. Staircase consist of 12 steps, and distance from staircase to bedroom
is ~4m. Bathroom is located ~3m from bed room. Kitchen is ~3m away from
staircase. Overhead cabinets are present in pt.'s house. Pt. usually does
household chores such as cleaning, cooking, washing clothes & dishes along
with the helper. Work situation: Pt. takes a jeep ride & a train ride to work
along with an additional ~300m of walking. Pt. states it takes around
~10mins. to cover distance. Distance from main entrance to work area is

~5m, and distance from one room to another in work place is ~2m. Pts
goal: To go back to my premorbid status.

O>
VS> BP> a = 90/60 mmHg; p = 100/60 mmHg
HR> a = 90 bpm; p=96bpm
RR> a =19 cpm; p=23cpm
O2 Sat: a = 98%; p = 98%
Temp: 36.7C
Findings: VS are stable
Significance: For precautionary measure
OI> Bedfast
> Ectomorph
> Not in apparent pain or respiratory distress
> (+) Gauze on sternal area
> (+) IV line on dorsum of R hand
> (+) Postural deviations (see PA)
> (+) Gait deviation (see GA)
> (-) Excessive sweating
> (-) Central and Peripheral Cyanosis
> (-) Trophic skin changes on (B) UE/LE
Palp> Normothermic (B) UE/LE
> (+) Gr. 2 tenderness on (B) upper back
> (+) Nodules on (B) upper back
> (+) Tightness of (B) upper trapezius
> (+) Non-pitting edema on (R) hand
> (-) Muscle spasm on (B) upper trapezius
> (-) Edema on (L) UE & (B) LE
ROM> All major joints of (B) UE/LE & neck were actively & passively
assessed to be WNL, pain-free, & c (N) end-feels, except for:
AROM
PROM
Normal
Differenc
End-feel
Value
e
(B)
0-90
N/A
0-180
AROM: 90
Empty
Shoulder
PROM: N/A
Flex
(B)
0-90
N/A
0-180
AROM: 90
Empty
Shoulder
PROM: N/A
Abd
(B)
Lat 0-30
0-45
0-45
AROM: 15
Firm

Neck Flex
PROM: 0
Findings: LOM of (B) shoulder flex & abd and (B) lat neck flex AROM
Interpretation: LOM of (B) shoulder d/t pain. PROM of (B) shoulder flex, abd, &
ext not assessed d/t surgical precaution. (B) Neck lat flex LOM d/t tightness
of (B) upper traps. ROM of (R) wrist not assessed d/t presence of IV line.
MMT> All major muscles of (B) UE/LE were grossly graded 5/5, except for:
(B) shoulder flex = 3/5
(B) shoulder abd = 3/5
Remarks: Resistance was not given against flex and abd d/t surgical
precautions.
Cardiopulmonary Assessment>
> Auscultation
> Arrhythmia
> (-) Murmurs
> (-) Crackles on (B) lungs
> (-) Wheezes on (B) lungs
> Dyspnea scale: Grade 1
> Pulse Grade: 2+ (thready)
> Chest expansion measurement
Inhale (inches)
Exhale (inches)
Axilla
25.5
Xiphoid Process 22.5
Subcostal
21.5
Margin

24.5
21
20

Difference
(inches)
1
1.5
1.5

Postural Assessment> All body landmarks viewed from AP & lateral views in
standing, were assessed to be aligned, except for:
Anterior View
Posterior View
Lateral View
(R) shoulder higher (R) shoulder higher (+)
Forward
head
than (L)
than (L)
posture
(+)
Protracted thoracic kyphosis
scapula
Findings: Pt. may be in a protective posture, with increased thoracic kyphosis
and protraction of scapula d/t apprehension from surgical incision
Gait Assessment> Amb s AD c all parameters of gait assessed to be N upon
walking for ~50m on leveled surface. The following gait deviations were
noticed:
(R)

(L)

Stance Phase
Initial Contact
Loading Response
Midstance
Terminal Stance
Pre-swing
Swing Phase
Initial Swing
Mid Swing
Terminal Swing
(B) Step length
(B) Stride length
Cadence
N BOS

DF
N
N
PF
N

DF
N
N
PF
N

N
Hip & Knee Flexion
N

N
Hip & Knee Flexion
N

Functional Assessment> Indep in all aspects of ADLs, except for:

Min diff in self-care, feeding, bed mob, & transfers as manifested by
slowness in doing task due to apprehension
Min diff +1 assist in donning & doffing hospital gown d/t apprehension
from surgical incision
N sitting & standing tolerance
N sitting and standing balance
6-minute walk test: 50m, c SOB RPE: 13
A>
PT Dx> MD Dx of Artial Septal Defect: Secundum Type s/p Transthoracic
(Anterolateral Thoracotomy) ASD closure further defined by min diff in selfcare, feeding, bed mob, & transfers, min diff +1 assist in donning & doffing
hospital gown 2 pain, LOM, & decreased CV endurance.
Prognosis> GOOD
Pt. has a good prognosis since no comorbidities are present that may
further complicate & affect the outcomes of the surgery and the progress
in therapy. The pt. shows active cooperation, participation, & adherence to
PT management and instructions provided. General information showed no
risk factors that may pose as a problem or hindrance. There were no
objective assessments that were out of the normal or that may serve as
further complication for a post-operated patient.
Intervention Scenario>
Primary: RESTORE
o Because we want the pt. to return to her pre-morbid status and
to maintain her strength and ROM as surgical precautions remain

 Secondary: ADAPT
o Because the pt. needs to modify her activities d/t surgery
precautions.
Problem List>
1. Decreased CV endurance
2. Pain on incision site graded 4/10 at rest, 8/10 upon movement >~90
3. LOM of (B) shoulder flex and abd
4. Min diff in self-care, feeding, bed mob, & transfers
5. Min diff +1 assist in donning & doffing hospital gown
6. Postural deviations
7. Weakness of (B) shoulder flexors and abductors grade 3/5
8. Gait Deviations
LTG>
Rehabilitative> Pt. will be able to walk for ~150m on leveled surface in
6mins c RPE of 11 p 2 wks. of PT sessions.
Preventive> Pt. and caregiver will know and verbalize post-surgery
precautions, preventing the Valsalva maneuver, and will know the
importance of adhering to ward instructions p 1 PT session to prevent
complications and to facilitate recovery.
STG>
1. Pt. will demonstrate CV endurance as manifested by being able to
cover ~100m in the 6-minute walk test c RPE of 13 p 1 week of PT
sessions
2. Pt. will report of pain on incision site from 4/10 1/10 p 1 wk. of PT
sessions to be able to do ADLs c ease
3. Pt. will demonstrate ROM of (B) shoulder flex & abd by 10 within
allowable range p 5 days of PT sessions to be able to do ADLs c less
difficulty
4. Pt. will demonstrate difficulty in self-care, feeding, bed mob, &
transfers from min no diff as manifested by performance time p 1
wk. of PT sessions
5. Pt. will be able to don & doff hospital gown from min +1 completely
independent p 5 days of PT sessions
6. Pt. will demonstrate postural deviations as manifested by thoracic
kyphosis & forward head posture p 5 days of PT sessions to prevent ill
effects of poor posture
7. Pt. will maintain 3/5 strength of (B) shoulder flexors & abductors p 2
wks. of PT sessions to prevent deterioration of condition
8. Pt. will demonstrate proper gait mechanics such as (B) PF, DF, hip &
knee flexion p 1 wk of PT sessions for ease in mobility

P> Pt. will be seen and treated as an in pt. od c the following PT Mx:
1. Cold packs on incision site x 20 min to pain
2. DDBE x 5 reps x 1 set to teach proper breathing technique during
dyspnea
3. Functional training in bed mob and transfers c incorporation of proper
technique using verbal, visual, & tactile cues x 3 reps to facilitate ease
in moving
4. Postural correction in front of mirror using verbal, visual, and tactile
cues to improve posture
a. Chin tucking exercise
b. Scapular retraction as tolerated
5. AROMs of (B) UE towards all motions within allowable range x 10 reps x
2 set to maintain joint integrity
6. PREs of (B) LE towards all motions using 2 lb AW x 10 reps x 2 set to
maintain muscle strength
7. Hallway amb c gait retraining using verbal cues as tolerated to improve
CV endurance and improve gait
Ward instructions:
1. DDBE x 5 reps or as needed to train proper breathing and to address
dyspnea
2. Postural correction as needed using verbal and tactile cues by
caregiver as necessary to help improve posture
3. Coughing c splinting x 3 reps x 2 sets to train coughing
4. AROMs of (B) UE towards all motions within allowable range x 10 reps x
2 set to maintain joint integrity
Pt. Education>
Pt. and caregiver should be knowledgeable of her condition,
precautionary measures that should be observed, and changes that should
be implemented with regard to her lifestyle. Pt. should be compliant with the
ward instructions and should drink her medications prior to the therapy
session. Pt. should practice energy conservation techniques to prevent over
exertion. Pt. should also avoid elevating her arm beyond 90 unless cleared
by her MD. Valsalva maneuver must always be avoided.