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.

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

A 40-year-old male, Mr.S, has had difficulty breathing on stair climbing to his office on 2^nd 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 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

It consists of Mr.S's history, investigations and objective examination. This will primarily focus on respiratory assessment along with other systems.

History

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

Chest X-ray

This radiological investigation of the chest helps us understand the areas of lung involved and is also an outcome measure post physiotherapy treatment.

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

Spirometry

Spirometry is the gold standard tool which can be used in the patients for diagnostic, prognostic & treatment montoring.

• FEV1/FVC & FVC are reduced and obstructive abnormality is present  

Objective Examination

On Inspection

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)

On Palpation

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

• Percussion was performed to mark ascend of the 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

In order to improve exercise capacity in Mr.S, we need to assess it using a sub-maximal exercise test such as six minute walk test.

The results after patient assessment were as follows,

• 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 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

• 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

• Mr S has difficulty continuing his marketing job
• He does not feel comfortable going to 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 a building with a lift
3.		Has better access to physiotherapy set-up due to living in an urban city

Personal

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