Case Study using ICF : Interstitial Lung Disease

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Abstract

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

Please note the below case study is imaginary but inspired from actual ILD 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

A 65-year-old male, Mr. J has complaints of progressive dyspnea with non-productive cough (intermittently) since 3-4 years. He is advised long term oxygen therapy (LTOT) but uses it only SOS. He lives on the first floor with his wife. His building has no lift. His Rate of Perceived Exertion is upto 2 (Modified Borg RPE Scale) on activities of moderate exertion. His HRCT shows ground glass appearance in basal region, along with honeycomb appearance & signet ring sign in middle & lower zones B/L. He recently had an episode of dyspnea for which he required oxygen therapy but no hospital admission was done. On auscultation he presents with inspiratory crepitations, end expiratory crackles with wheezing sometimes & reduced breath sounds in the lower zone B/L. He is easily fatigued on housework (30 on fatigue assessment scale) & is unable to stand for a long time. He used to work in a spice manufacturing unit for 25 years & later was a chef for many years before he retired. He would like to resume cooking again at least at home as he enjoys it.

Examination Findings

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

History

Mr. J has a history of,

• Working in a spice manufacturing unit & as a chef for more than 25 years.
• Smoking for 7 years, with consumption of about 1 pack per day (approx. 20 cigarettes per day)& has quit 4 years ago.
• Non-productive cough since 3-4 years
• Breathlessness on moderate exertion (RPE –2 on Mod. Borg scale)
• Fatigue (Score of 30 on Fatigue Assessment scale)

Investigations

HRCT

This high resolution CT (HRCT) helps us understand the diagnosis of ILD, areas of lung involved and is also an outcome measure post physiotherapy treatment.

• Ground glass appearance in basal region B/L
• Honeycomb appearance & signet ring sign seen in middle & lower zones B/L

Spirometry

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

• FEV1/FVC is increased
• FVC is reduced
• Signs of restrictive pathology

Objective Examination

On Inspection

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

• Rounded shoulders, forward head posture
• Reduced chest movement B/L
• Height: 185cm
• Weight: 78Kg
• BMI: 22.8 Kg/m

On Palpation

Mr. J assessed in standing position had,

• Chest expansion
  • Supramammary-0.5 cm
  • Mammary-0 cm
  • Inframammary -0 cm
• Manual muscle testing
  • B/L lower limb- Gr. 4-
  • Core unable to test as patient getting breathless
  • B/L Upper limb –within normal limit

On Percussion

• Percussion was impaired
• Reduced resonance was found in lower zones B/L

On Auscultation

• Diminished breath sounds B/L lower zone; post >ant
• Inspiratory crepitation in lower & middle zone
• End expiratory crackles with wheezing in Lower zone
• Tactile vocal resonance diminished B/L lower zones

Six Minute Walk Test

In order to improve exercise capacity in Mr. J, 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 is 320 m with 1 stop of 30 sec due to excessive shortness of breath & desaturation below 88 %
• Mr. J also used 1 lit. oxygen via nasal prongs during the 6MWT as per consultation with the pulmonologist
• Ideal for Indian Male: 505.2 m

Summarizing Assessment using ICF

Structural and Functional Impairments

Sr.No.	Structural & Functional Impairement	Clinical Reasoning (due to)	Correlate on Examination
1.	Non productive Cough	Due to chronic airway irritation & fibrosis	From H/O indicating chief complaints & smoking for 7 years
2.	Ground glass appearance	Due to extensive fibrosis & peripheral tissue damage	On HRCT
3.	Signet ring sign	Due to changes of bronchiectasis	On HRCT
4.	Honeycomb appearance	Destruction of alveoli & peripheral airways	On HRCT
5.	Bronchial wall thickening	due to inflammation of airway & presence of irritants	From H/O of smoking & from working in spice factory
6.	Reduced chest expansion	due to lack of proper elastic recoil of lung	On inspection & palpation
7.	Impaired percussion with reduced resonance in lower zones B/L	Extensive tissue damage seen on HRCT	On palpation
8.	Diminished breath sounds with crepitation present with wheezing	Due to bronchiectatic changes with airway inflammation	On auscultation
9.	Tactile vocal resonance reduced	Due to peripheral tissue damage	On auscultation
10.	Shoulder rounded forward neck posture	Due to reduced chest expansion & dyspnea on exertion	On inspection & H/O
11.	RPE –2 on Mod. Borg scale	due to impaired gas exchange causing  chronic desaturation & sec. fatigue	From H/O
12.	Fatigue of 30 on fatigue assessment scale	Due to ventilation-perfusion mismatch leading to chronic desaturation & sec. peripheral muscle weakness	From H/O
13.	Spirometery shows reduced FVC & Increased FEV1/FVC ratio	-Due to secondary fibrosis on chronic respiratory involvement	From Spirometery testing
14.	Six minute walk distance is reduced with a stop required	due to dyspnea on exertion & peripheral muscle weakness secondary to chronic fatigue	From 6MWT
15.	Manual muscle testing shows reduced lower limb strength	Due to impaired gas exchange causing peripheral muscle weakness	On MMT testing

Activity Limitation

• Mr. J has difficulty in performing ADLs such as self-grooming & household chores
• Difficulty in climbing stairs
• Unable to do cooking at home
• Unable to go for walk in area surrounding the house

Participation Restriction

• Mr. J not comfortable using LTOT outside the house in social functions
• He has difficulty to go out independently & meet family or friends

Contextual Factors

Environmental

Sr. No.	Barrier	Facilitator
1.	Lives on 1st floor & has no lift facility	Good family support
2.	Stays with wife, no one younger stays with them (eg. Children)	Has access to physiotherapy home visit due to living in central location

Personal

Sr. No.	Barrier	Facilitator
1.	Has issues about using LTOT	Has quit smoking since four years
2.	Has H/O of smoking for 7 years, thus major risk factor	Motivated to start pulmonary rehabilitation program
3.		Has normal BMI
4.		Has good socioeconomic status, can afford regular PT treatment