Case Study using ICF : Lobectomy
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)
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[edit | edit source]
|Sr. No.||Structural & Functional Impairement||Clinical Reasoning
|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]
|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]
|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]
- Weir CB, Jan A. BMI classification percentile and cut off points.https://www.ncbi.nlm.nih.gov/books/NBK541070/ (accessed on 04.07.2023)
- 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.