Case Study using ICF : COPD: Difference between revisions
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== Abstract == | == Abstract == | ||
This article will cover a case study of Mr | This article will cover a case study of Mr S, who has been recently diagnosed with [[COPD (Chronic Obstructive Pulmonary Disease)|COPD]]. He has been recommended physiotherapy for the same. The article follows the journey of the physiotherapist assessing Mr S using [[ICF and Application in Clinical Practice|ICF]] format. | ||
Please note: the below case study is imaginary but inspired | Please note: the below case study is imaginary but inspired by actual COPD patients. Therefore, it may not include all symptoms or signs of the disease condition. Remember that the assessment findings, in reality, will vary slightly from patient to patient, changing the treatment protocol accordingly. | ||
== Client Characteristics == | == Client Characteristics == | ||
A 40-year-old male Mr | A 40-year-old male, Mr S, has had difficulty breathing on stair climbing to his office on 2<sup>nd</sup> floor for almost a year. He complains of persistent cough with expectoration for the last 3-4 years, which increases every 2-3 months & then goes away for some time. 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 two weeks since his discharge has come for [https://www.physio-pedia.com/Pulmonary_Rehabilitation?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal pulmonary rehabilitation] after the recommendation of his pulmonologist. Mr S works as a manager in the marketing department of his company. His job sometimes requires 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 eight years & has quit on regular counselling and treatment for the last two years. He also complains of getting very tired till the end of the day & does not want to go to any social event in the evening with family or friends. Mr. & Mrs S stay on the 4<sup>th</sup> 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. | ||
== [https://www.physio-pedia.com/Respiratory_Assessment?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Examination Findings] == | == [https://www.physio-pedia.com/Respiratory_Assessment?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Examination Findings] == | ||
This consists of Mr | This consists of Mr S's history, investigations and objective examination. | ||
==== History ==== | ==== History ==== | ||
Mr | Mr S has a history of | ||
* Smoking for | * Smoking for eight years, consuming about 1 1/2 packs per day (approx. 30 cigarettes per day). | ||
* Persistent cough with expectoration for 3-4 years(i.e. sign of repeated chest infection). It | * Persistent cough with expectoration for 3-4 years(i.e. sign of repeated chest infection). It typically lasts up to 3-4 months and reduces on over-the-counter symptomatic medication. | ||
* [https://www.physio-pedia.com/Dyspnoea?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Dyspnea] ([https://www.physio-pedia.com/Medical_Research_Council_(MRC)_Dyspnoea_Scale?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal MMRC scale] - Gr.3) | * [https://www.physio-pedia.com/Dyspnoea?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Dyspnea] ([https://www.physio-pedia.com/Medical_Research_Council_(MRC)_Dyspnoea_Scale?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal MMRC scale] - Gr.3) | ||
* Breathlessness & wheezing on moderate exertion (RPE –2 to 4 on Mod. [https://www.physio-pedia.com/Borg_Rating_Of_Perceived_Exertion?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Borg scale]) | * Breathlessness & wheezing on moderate exertion (RPE –2 to 4 on Mod. [https://www.physio-pedia.com/Borg_Rating_Of_Perceived_Exertion?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Borg scale]) | ||
* Fatigue on moderate activity of between 3-5.9 METs | * Fatigue on the moderate activity of between 3-5.9 METs | ||
==== Investigations ==== | ==== Investigations ==== | ||
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* widening of intercoastal spaces | * widening of intercoastal spaces | ||
* flattened diaphragm | * flattened diaphragm | ||
* bullae present in middle & lower zone on the right side | * bullae present in the middle & lower zone on the right side | ||
* increased bronchovascular markings | * increased bronchovascular markings | ||
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===== On Inspection ===== | ===== On Inspection ===== | ||
Mr | Mr S was assessed in standing and sitting positions. He was found to have | ||
* barrel chest appearance of the chest | * barrel chest appearance of the chest | ||
* forward head posture | * forward head posture | ||
* use of accessory muscles (sternocleidomastoid muscle) on minimal exertion | * use of accessory muscles (sternocleidomastoid muscle) on minimal exertion | ||
* breathing pattern is thoraco-abdominal, I:E ratio is 1:1 | * breathing pattern is thoraco-abdominal, I: E ratio is 1:1 | ||
* Height: 170cm | * Height: 170cm | ||
* Weight: 90Kg | * Weight: 90Kg | ||
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===== On Palpation ===== | ===== On Palpation ===== | ||
Mr | Mr S assessed in standing position had, | ||
* Anterior-Posterior : transverse diameter is 1:1 | * Anterior-Posterior: transverse diameter is 1:1 | ||
* Chest expansion | * Chest expansion | ||
** Supramammary-0.5 cm | ** Supramammary-0.5 cm | ||
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===== On percussion ===== | ===== On percussion ===== | ||
* Percussion was performed to mark ascend of diaphragm on exhalation | * Percussion was performed to mark ascend of the diaphragm on exhalation | ||
* Diaphragmatic excursion is reduced to 2 cm | * Diaphragmatic excursion is reduced to 2 cm | ||
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===== [https://www.physio-pedia.com/Six_Minute_Walk_Test_/_6_Minute_Walk_Test?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Six min walk test] ===== | ===== [https://www.physio-pedia.com/Six_Minute_Walk_Test_/_6_Minute_Walk_Test?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal Six min walk test] ===== | ||
* Distance achieved by Mr | * Distance achieved by Mr S is 280 m | ||
* Ideal for Indian Male: 486.4 m<ref>Ramanathan RP, Chandrasekaran B. Reference equations for 6-min walk test in healthy Indian subjects (25-80 years). Lung India: official organ of Indian Chest Society. 2014 Jan;31(1):35.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3960806/</ref> | * Ideal for Indian Male: 486.4 m<ref>Ramanathan RP, Chandrasekaran B. Reference equations for 6-min walk test in healthy Indian subjects (25-80 years). Lung India: official organ of Indian Chest Society. 2014 Jan;31(1):35.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3960806/</ref> | ||
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|- | |- | ||
|11. | |11. | ||
|Fatigue on moderate activity of between METs 3-5.9 | |Fatigue on the moderate activity of between METs 3-5.9 | ||
|due to increased WOB dyspnea on exertion | |due to increased WOB dyspnea on exertion | ||
|seen on H/O | |seen on H/O | ||
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=== Activity Limitation === | === Activity Limitation === | ||
* Mr | * Mr S has difficulty 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 & also fatigue | * He is unable to sit in a meeting for a long time due to frequent cough with expectoration about which he is not comfortable & also fatigue | ||
* He is not able to do household chores/ activities in evening as he is too tired | * He is not able to do household chores/ activities in the evening as he is too tired | ||
=== Participation Restriction === | === Participation Restriction === | ||
* Mr | * Mr S has difficulty continuing his marketing job | ||
* He | * He does not feel comfortable going to any social function with family or friends | ||
=== Contextual Factors === | === Contextual Factors === | ||
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|2. | |2. | ||
|Travels to work on a two-wheeler | |Travels to work on a two-wheeler | ||
|stays in | |stays in a building with a lift | ||
|- | |- | ||
|3. | |3. | ||
| | | | ||
|Has better access to physiotherapy set up due to living in urban city | |Has better access to physiotherapy set-up due to living in an urban city | ||
|} | |} | ||
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|- | |- | ||
|1. | |1. | ||
|He is primary earning member of family | |He is the primary earning member of the family | ||
| | | Quit smoking two years ago | ||
|- | |- | ||
|2. | |2. | ||
|Has H/O of smoking for | |Has H/O of smoking for eight years, thus a major risk factor | ||
|Motivated to start pulmonary rehabilitation program | |Motivated to start a pulmonary rehabilitation program | ||
|- | |- | ||
|3. | |3. |
Revision as of 21:19, 22 November 2022
Original Editor - Sonal Joshi
Top Contributors - Sonal Joshi
Abstract[edit | edit source]
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.
Please note: the below case study is imaginary but inspired by actual COPD patients. Therefore, it may not include all symptoms or signs of the disease condition. Remember that the assessment findings, in reality, will vary slightly from patient to patient, changing the treatment protocol accordingly.
Client Characteristics[edit | edit source]
A 40-year-old male, Mr S, has had difficulty breathing on stair climbing to his office on 2nd floor for almost a year. He complains of persistent cough with expectoration for the last 3-4 years, which increases every 2-3 months & then goes away for some time. 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 two weeks since his discharge has come for pulmonary rehabilitation after the recommendation of his pulmonologist. Mr S works as a manager in the marketing department of his company. His job sometimes requires 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 eight years & has quit on regular counselling and treatment for the last two years. He also complains of getting very tired till the end of the day & does not want to go to any social event in the evening with family or friends. Mr. & Mrs S stay on the 4th 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[edit | edit source]
This consists of Mr S's history, investigations and objective examination.
History[edit | edit source]
Mr S has a history of
- Smoking for eight years, consuming about 1 1/2 packs per day (approx. 30 cigarettes per day).
- Persistent cough with expectoration for 3-4 years(i.e. sign of repeated chest infection). It typically lasts 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 the moderate activity of between 3-5.9 METs
Investigations[edit | edit source]
Chest X-ray[edit | edit source]
- widening of intercoastal spaces
- flattened diaphragm
- bullae present in the middle & lower zone on the right side
- increased bronchovascular markings
Spirometry[edit | edit source]
- FEV1/FVC & FVC are reduced and obstructive abnormality[1]
Objective Examination[edit | edit source]
On Inspection[edit | edit source]
Mr S was assessed in standing and sitting positions. 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 (i.e. Obesity Class I)[2]
On Palpation[edit | edit source]
Mr S assessed in standing position had,
- Anterior-Posterior: transverse diameter is 1:1
- Chest expansion
- Supramammary-0.5 cm
- Mammary-0.5cm
- Inframammary -0 cm
On percussion[edit | edit source]
- Percussion was performed to mark ascend of the diaphragm on exhalation
- Diaphragmatic excursion is reduced to 2 cm
On auscultation[edit | edit source]
- Diminished vesicular breath sounds B/L middle & lower zone
- Wheeze present B/L on expiration
Six min walk test[edit | edit source]
- Distance achieved by Mr S is 280 m
- Ideal for Indian Male: 486.4 m[3]
Summarizing Assessment using ICF[edit | edit source]
Structural and Functional Impairments[4][edit | edit source]
Sr.No. | Structural & Functional Impairement | Clinical Reasoning
(due to) |
Correlate on Examination |
---|---|---|---|
1. | Cough with expectoration | due to hyperplasia of goblet cells | from H/O indicating chief complaints & smoking for 8 years |
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. | Bronchial wall thickening | due to inflammation of airway & presence of irritant | from H/O of smoking & repeated bouts of chest infection |
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 the 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[edit | edit source]
- Mr S has difficulty riding on two wheeler due to dyspnea
- He is unable to sit in a meeting for a long time due to frequent cough with expectoration about which he is not comfortable & also fatigue
- He is not able to do household chores/ activities in the evening as he is too tired
Participation Restriction[edit | edit source]
- Mr S has difficulty continuing his marketing job
- He does not feel comfortable going to any social function with family or friends
Contextual Factors[edit | edit source]
Environmental[edit | edit source]
Sr. No. | Barrier | Facilitator |
---|---|---|
1. | Works on 2nd floor | Good family support |
2. | Travels to work on a two-wheeler | stays in a building with a lift |
3. | Has better access to physiotherapy set-up due to living in an urban city |
Personal[edit | edit source]
Sr. No. | Barrier | Facilitator |
---|---|---|
1. | He is the primary earning member of the family | Quit smoking two years ago |
2. | Has H/O of smoking for eight years, thus a major risk factor | Motivated to start a pulmonary rehabilitation program |
3. | He is obese |
References[edit | edit source]
- ↑ Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, Celli BR, Chen R, Decramer M, Fabbri LM, Frith P. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary. American journal of respiratory and critical care medicine. 2017 Mar 1;195(5):557-82.https://pubmed.ncbi.nlm.nih.gov/28128970/
- ↑ Weir CB, Jan A. BMI classification percentile and cut off points.https://www.ncbi.nlm.nih.gov/books/NBK541070/ (accessed on 22.11.2022)
- ↑ Ramanathan RP, Chandrasekaran B. Reference equations for 6-min walk test in healthy Indian subjects (25-80 years). Lung India: official organ of Indian Chest Society. 2014 Jan;31(1):35.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3960806/
- ↑ Agarwal AK, Raja A, Brown BD. Chronic obstructive pulmonary disease (COPD). StatPearls [Internet]. 2020 Jun 7.https://www.ncbi.nlm.nih.gov/books/NBK559281/(accessed 22.11.2022)