Case Study using ICF : COPD

Original Editor - Sonal Joshi

Top Contributors - Sonal Joshi

This article is currently under construction and may only be partially complete. Please come back soon to see the finished work! (21/11/22)

Abstract

This article will cover a case study of Mr. S who has been recently diagnosed with COPD. He has been recommended physiotherapy for the same. The article follows the journey of the physiotherapist assessing Mr. S using ICF format.

Client Characteristics

A 40-year-old male Mr. S, has difficulty in breathing on stair climbing to his office on 2^nd floor since almost a year. He complains of persistent cough with expectoration from last 3-4 years which increases every 2-3 months & then goes away for some time. Currently, he had to be admitted for exacerbation of his symptoms & was on medication with oxygen therapy for a week. He was diagnosed as suffering from COPD in the hospital. It has been 2 weeks since his discharge has come for pulmonary rehabilitation after recommendation of his pulmonologist. Mr. S works as a manager in marketing department of his company. His job requires sometimes sitting in a meeting for hours together or travelling around the city on his two wheeler for a full day. He was a smoker for 8 years & has quit on regular counselling and treatment since last 2 years. He also complaints of getting very tired till the end of the day & does not want to go for any social event in evening with family or friends. Mr. & Mrs. S stay on the 4^th floor with a lift in the building in an urban city in India. His wife & college going son, have accompanied him for his first physiotherapy consultation.

Examination Findings

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

History

Mr. S has a history of

• Smoking for 8 years, with consumption of about 1 1/2 pack per day (approx. 30 cigarettes per day).
• Persistent cough with expectoration for 3-4 years. It is lasts typically up to 3-4 months and reduces on over the counter symptomatic medication.
• Dyspnea (MMRC scale - Gr.3)
• Breathlessness & wheezing on moderate exertion (RPE –2 to 4 on Mod. Borg scale)
• Fatigue on moderate activity of between 3-5.9 METs

Investigations

Chest X-ray

• widening of intercoastal spaces
• flattened diaphragm
• bullae present in middle & lower zone on the right side
• increased bronchovascular markings

Spirometry

• FEV1/FVC & FVC are reduced
• obstructive abnormality  

Objective Examination

On Inspection

Mr. S was assessed in standing and sitting position. He was found to have

• barrel chest appearance of the chest
• forward head posture
• use of accessory muscles (sternocleidomastoid muscle) on minimal exertion
• breathing pattern is thoraco-abdominal, I:E ratio is 1:1
• Height: 170cm
• Weight: 90Kg
• BMI: 31.1 Kg/m²

On Palpation

Mr. S assessed in standing position had,

• Anterior-Posterior : tranverse diameter is 1:1
• Chest expansion
  • Supramammary-0.5 cm
  • Mammary-0.5cm
  • Inframammary -0 cm

On percussion

• Percussion was performed to mark ascend of diaphragm on exhalation
• Diaphragmatic excursion is reduced to 2 cm

On auscultation

• Diminished vesicular breath sounds B/L middle & lower zone
• Wheeze present B/L on expiration

Six min walk test

• Distance achieved by Mr. S is 280 m
• Ideal for Indian Male: 486.4 m

Summarizing Assessment using ICF

Structural and Functional Impairments

Sr.No.	Structural & Functional Impairement	Clinical Reasoning (due to)	Correlate on Examination
1.	Cough with expectoration	due to hyperactivity of mucus glands	from H/O
2.	Hyperinflation of lungs	due to abnormal & permanent enlargement of airways in middle & lower zone of lung	seen on X-ray,H/O indicating emphysema & palpation
3.	Increased bronchovascular markings	due to thickening of walls of airways	seen on X-ray
4.	Reduced chest expansion	due to lack of proper elastic recoil of lung	seen on inspection & palpation
5.	Barrel shaped chest	due to hyperinflation of chest	seen on inspection, palpation & X-ray
6.	Presence of bullae	due to extensive damage to lung tissue	seen on x-ray & cough with expectoration H/O
7.	Abdominothoracic breathing pattern	due to hyperinflation of chest	seen on inspection
8.	Shoulder protracted with forward neck posture	due to use of accessory muscles & increased work of breathing (WOB)	seen on inspection & H/O
9.	Dyspnea Gr.3 on MMRC	due to airflow limitation & reduced elastic recoil of lungs	seen on inspection & H/O
10.	RPE –2 to 4 on Mod. Borg scale	due to increased WOB, abnormal breathing pattern & hyperinflation of chest	seen on H/O
11.	Fatigue on moderate activity of between METs 3-5.9	due to increased WOB dyspnea on exertion	seen on H/O
12.	Six minute walk distance is reduced	due to dyspnea on exertion & peripheral muscle weakness secondary to chronic fatigue	seen on 6MWT

Activity Limitation

• Mr. S has difficulty in riding on two wheeler due to dyspnea
• He is unable to sit in a meeting for long time due to frequent cough with expectoration about which he is not comfortable & fatigue
• He is not able to do household chores/ activities in evening as he is too tired

Participation Restriction

• Mr. S has difficulty to continue his marketing job
• He is does not feel comfortable going for any social function with family or friends

Contextual Factors

Environmental

Sr. No.	Barrier	Facilitator
1.	Works on 2nd floor	Good family support
2.	Travels to work on a two-wheeler	stays in buiding with a lift
3.		Has better access to physiotherapy set up due to living in urban city

Personal

Sr. No.	Barrier	Facilitator
1.	Main earning member of family	Has quit smoking since two years
2.	Has H/O of smoking for 8 years, thus major risk factor	Motivated to start pulmonary rehabilitation program
3.	Overweight