Case Study using ICF : Lobectomy

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Original Editor - Sonal Joshi

Top Contributors - Sonal Joshi

Abstract

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

Mr. V is a 45 year old veterinary doctor by profession, who handles cattle & poultry animals. He has H/O of 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

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

History

Mr. V has a history & Chief complaints

• 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 ICD site & Incision site

Investigations

This radiological investigations help us understand the areas of lung involved and is also an outcome measure post physiotherapy treatment.

HRCT (Pre-operative)

• 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)

• Rt. Sided tracheal deviation
• Brochovascular markings significantly reduced in Rt. Upper zone
• Elevated Rt. Hemi diaphragm
• Opacity present at Rt. upper zone

Objective Examination

On Inspection

Mr. V was assessed in sitting position. He was found to have

• Decreased chest expansion Rt. > Lt.
• 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

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

• Dull note present Rt. Upper zone

On Auscultation

• 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

Structural and Functional Impairments

Sr. No.	Structural & Functional Impairement	Clinical Reasoning (due to)	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	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	Seen 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)	Seen 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	On H/O , HRCT & auscultation
8.	Pain at ICD site & incision site	Due to Rt. Lobectomy done two days ago	On 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	seen 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	Seen on inspection
11.	Protracted shoulders	Due to pain at incision & ICD site	seen 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	Tactile vocal resonance
16.	Obesity class I	Due to lifestyle habits & BMI of 32.2Kg/m	On palpation

Activity Limitation

• 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

• 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

Environmental

Sr. No.	Barrier	Facilitator
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

Sr. No.	Barrier	Facilitator
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