Case Study using ICF : Lobectomy

Original Editor - Sonal Joshi

Top Contributors - Sonal Joshi and Kim Jackson

Abstract[edit | edit source]

This article will cover a case study of Mr. V, who has been recently undergone lobectomy secondary to bronchiectasis. He has been recommended physiotherapy in the ICU. The article follows the journey of the physiotherapist assessing Mr. V using ICF format.

Please note the below case study is imaginary but inspired from actual pulmonary surgical patients. Therefore, it may not include all symptoms or signs of the disease condition. Do keep in mind that the patient assessment findings will vary slightly from patient to patient, changing the treatment protocol accordingly.

Client Characteristics[edit | edit source]

Mr. V is a 45 year old veterinary doctor by profession, who handles cattle & poultry animals. He has history of (H/O) repeated chest infection which causes productive cough for the last 5 yr. He recently had such an episode which resulted in him unable to breathe due to severe dyspnea & required hospitalization. He was diagnosed with bronchiectasis and Rt. upper lobe collapse. He was advised & underwent Rt. side upper lobe lobectomy. His current chest X-ray shows Rt. Sided tracheal deviation, volume loss with elevation of diaphragm of Rt. Side. On auscultation he was found to have reduced breath sounds on right upper & middle zone & inspiratory crepitation present Rt. upper & middle zone. His chest expansion is also reduced on the rt. side. The patient is referred for physiotherapy post-operative day-2, can sit up in bed with support and has an intercostal drain on Rt. side. He still has productive sputum but it is painful (On VAS: at rest-2/10, movement- 6/10) for him to cough it out. He is married & has a teenage daughter both who are supportive of his treatment. He wants to start working again as soon as possible after discharge but has been advised a rest of at least 2 weeks. His BMI is 32 & is a non-smoker.

Examination Findings[edit | edit source]

This consists of Mr. V's history, investigations and objective examination.

History[edit | edit source]

Mr. V has a history & Chief complaints of

  • Exposure to poultry & cattle on a regular basis
  • Repeated chest infection in last 5 years
  • Pain On VAS: at rest-2/10, movement- 6/10, at Intercoastal drain (ICD) site & Incision site

Investigations[edit | edit source]

This radiological investigations help us understand the areas of lung involved and is also an outcome measure post physiotherapy treatment.

HRCT (Pre-operative)[edit | edit source]

  • Loss of volume & extensive damage of upper lobe tissue
  • Signet ring sign present in upper & middle zone
  • Dilatation of terminal bronchioles seen in middle zone
  • Presence of bullae in upper & middle lobe

Chest X-ray (Post-operative)[edit | edit source]

  • Rt. Sided tracheal deviation
  • Brochovascular markings significantly reduced in Rt. Upper zone
  • Elevated Rt. Hemi diaphragm
  • Opacity present at Rt. upper zone

Objective Examination[edit | edit source]

On Inspection[edit | edit source]

Mr. V was assessed in sitting position. He was found to have

  • Decreased chest expansion Rt. > Lt. side
  • Trail’s sign present with prominence of sternocleidomastoid on the Rt. side
  • Posture impaired with
    • Rt. Shoulder depressed as compared to Lt.
    • Protracted shoulder
  • Intercostal drain present on Rt. Side laterally
  • Height: 170cm
  • Weight: 93Kg
  • BMI: 32.2 Kg/m(obesity class I)[1]

On Palpation[edit | edit source]

Mr. S assessed in sitting position had,

  • Trail’s sign present with prominence of sternocleidomastoid on the Rt. side
  • Chest expansion
    • Supramammary-0 cm
    • Mammary-0.5 cm
    • Inframamary -0.5 cm

On Percussion[edit | edit source]

  • Dull note present Rt. Upper zone region

On Auscultation[edit | edit source]

  • Diminished vesicular breath sounds B/L upper > middle zone
  • inspiratory crepitation present Rt. middle & lower zone
  • Tactile vocal resonance shows increased resonance Rt. Upper & middle zone

Summarizing Assessment using ICF[edit | edit source]

Structural and Functional Impairments[2][edit | edit source]

Sr. No. Structural & Functional Impairement Clinical Reasoning

(due to)

Correlate on Examination
1. Break in the continuity of skin at Rt. Post lateral aspect of chest wall Due to the operative procedure of Rt. Upper lobe removal From post-operative notes & inspection
2. Collapse of Rt. Upper lobe Due to secondary bronchiectasis causing extensive tissue damage, Reduced bronchovascular markings, air entry, Trail’s sign present on Rt. side From HRCT, X-ray, palpation & auscultation
3. Rt. Sided tracheal deviation Due to collapse of Rt. Upper lobe & Trail’s sign present on Rt. side On X-ray & palpation
4. Elevation of Rt. diaphragm Due to volume loss of Rt. Upper lobe On X-ray
5. Dilatation of bronchioles & airway in Rt. Upper & middle lobe due to chronic inflammation of airway as a result of repeated chest infections & presence of irritant (poultry & cattle exposure) On HRCT
6. Presence of bullae in Rt. Upper & middle lobe due to extensive damage to lung tissue seen on HRCT & cough with expectoration H/O
7. Productive cough for the last 5 years Daily exposure to irritant causing repeated infections leading to sec. bronchial dilatation, impaired mucociliary clearance  system & hyper secretion of goblet cells From H/O , HRCT & auscultation
8. Pain at ICD site & incision site Due to Rt. Lobectomy done two days ago From post-operative notes & chief complaints
9. Reduced chest expansion of Rt. side due to lack of proper elastic recoil of lung as a result of Rt. Upper lobe removal & post-operative pain On inspection & palpation
10. Postural deviation with Rt. Shoulder depressed as compared to Lt. Due to loss of lung volume on Rt. Side & pain due to ICD On inspection
11. Protracted shoulders Due to pain at incision & ICD site On inspection
12. Reduced breath sounds on Rt. side Due to loss of lung volume On auscultation
13. Inspiratory crepitation present in Rt. side Due to accumulation of secretions and reduced chest expansion On auscultation
14. Dull note present in Rt. Upper zone Due to Rt. Upper lobe surgical removal On percussion
15. Increased resonance in Rt. Upper & middle zone Due to Bronchiectasis & Rt. Upper lobe collapse On Tactile vocal resonance
16. Obesity class I Due to lifestyle habits & BMI of 32.2Kg/m On H/O, Inspection, palpation

Activity Limitation[edit | edit source]

  • Mr. V has difficulty to sit up in bed without support.
  • He has difficulty in doing self-grooming activities.
  • Has difficulty in eating independently due to pain.
  • He has difficulty in talking for a lot time due to pain.
  • He is unable to walk

Participation Restriction[edit | edit source]

  • Mr. V is unable to resume his job as a veterinarian
  • He is currently unable to resume his social life due to hospital admission

Contextual Factors[edit | edit source]

Environmental[edit | edit source]

Sr. No. Barrier Facilitator
1. Works with poultry & cattle which caused his disease progression Good family support
2. Does not have access to physiotherapy set up due to living in rural area for his work

Personal[edit | edit source]

Sr. No. Barrier Facilitator
1. Sole earning member of family Motivated to start pulmonary rehabilitation program post discharge
2. Wants to resume job too early, which may cause post op. complications He is non-smoker
3. Obesity class I

References[edit | edit source]

  1. Weir CB, Jan A. BMI classification percentile and cut off points. (accessed on 04.07.2023)
  2. Schiavon M, Comacchio GM, Mammana M, Faccioli E, Stocca F, Gregori D, Lorenzoni G, Zuin A, Nicotra S, Pasello G, Calabrese F. Lobectomy with artery reconstruction and pneumonectomy for non-small cell lung cancer: a propensity score weighting study. The Annals of Thoracic Surgery. 2021 Dec 1;112(6):1805-13.