Case Discussion

Presented to: Subin sir

On 9th March,2014

By : Kumar Vibhanshu

MPT- I year

• Name: Mohammad Sardar

• Age: 64 years

• Sex: Male

• Address: Mominpura, Mysore Road.

• Marital Status: Married

• Religion: Islam

• Occupation: Autodriver

Demographic data:

• Source Of History: Patient & His Wife.

• Date of Admission : 6/03/14, 9:10 p.m.

• Date of Assessment: 9/03/14

Chief complaints:

• Patient complained of fever and chillsfrom last 4 days.

• Patient also complained of cough withsputum. From last 4 days.

• Patient was also feeling difficulty inbreathing from last 20 days.

• Pateint also complained of left lowerlateral side chest tightness.

HISTORY OF PRESENT ILLNESS

Patient was apparently alright 2 weeks back and after which

he developed fever with chills. Patient also had cough with

expectoration and complained of difficulty in breathing

mainly in morning, patient was brought to ESI Rajajinagar

Hospital for treatment on 30/2/2014 from where he reffered

to Udbhav Hospital for the treatment, on that very day.

Patient was in ICU at Udbhav Hospital for 6 days where he

he treated and reffered back to ESI Rajajinagar, for further

treatment on 06/03/14.

Description of symptoms:

Breathlessness

Onset : 12 days back gradual

Setting: gradual increasing initially while walking

Severity: Patient not able to continue his activity. Not even

able to speak.

Frequency: 5-6 times a day

Duration: 15-20 minutes.

Course: worse

Associated symptoms: cough, chest pain.

Aggravating factor: daily activities, walking.

Relieving factor: rest

Nail bed and lips do not turn blue at the episode of

breathlessness

Patient is K/C/O of Tuberculosis

VAS : 6

ATS scale: Grade 3

Type of dyspnea : restrictive dyspnea

Cough

Onset : 2 weeks gradual

Productive

Setting: initially occasionally later during almost all activity

Severity: not affecting daily activities

duration: continuous althrough the day.

Course: worse in morning gets better as day passes by.

Associated symptom: breathlessness and chest pain on left

lower side of lung.

Aggrevating factor: smoking

Relieving factor: rest and medication.

Pattern: Cough first in morning

Sputum:

Mucopurulent

Color : yellow

Consistency: thick

Quantity : ½ cup/day

Time of the day: continuous mainly in morning

Odor: not foul smelling

Hemoptysis: Not present.

Chest pain:

Location: left lower lateral side of the chest.

Onset: sudden

Pattern: intermittent

Provoked symptoms: coughing

VAS: not able to score

Time frame : acute

Fever:

Gradual, intermittent, high grade with chills.

Past medical history: not a known case of DM/HTN. K/C/O

TB and Bronchial Asthma

Past surgical history: not significant

Personal history: smoking bidi everyday since 54yrs

4 packet/day

non alcoholic

has not smoked since 20 days

Social history: total members – 15

earning – 3

socioeconomic status: poor

Family history: no history of TB or any respiratory illness

Occupational history: worked as autodriver for 40 yrs and

continuously exposed to pollution and was regular smoking

at time of driving.

Differential

Diagnosis

Supporting

Features

Unsupporting

Features

Lobar Pneumonia -rigors,pyrexia

-loss of appetite

-cough, non foul

-th. Expansion to

one side

-`chest tightness`

Pleurisy -chest pain

-fever

-cough

-secondary to TB

-Productive cough

Pleural Effusion -breathlessness

-pain

-secondary to TB

-Thorax expansion

-Cyanosis

-Mediastinal shift

-Reduced vocal

fremitus

Lung Abscess -fever

-cough

-dyspnea

-haemoptysis

-halitosis

-foul smelling

sputum

-bad taste in

mouth

OBJECTIVE ASSESSMENT

General appearance: cardio respiratory distress

Awake, alert, attentive

Built: ectomorphic

Vitals:

PR: 72/min volume rhythm normal

RR: 43/min

BP: Not able to monitor

Inspection

Head:

facial expression: showing cardio respiratory distress

Eyes PERRLA : normal

No ptosis, no central cyanosis

No pursed lip breathing

Neck:

Position of trachea: central

Use of accessory muscles: SCM

Trails sign and olivers sign: negative

Thorax:

Posture: kyphotic with rounded shoulder

Symmetrical chest

Apex beat: not visible

Pallor: absent

Clubbing : absent

Cyanosis: absent

edema: absent

No intercostal indrawing

Palpation:

Tracheal position: central

No tenderness over chest or accessory muscles.

Chest symmetry: symmetrical chest movements.

Tactile Vocal Fremitus:

Increased in lower lobe of left lung, upper lobe of left lung and lobes of right lung were less.

Percussion

Dull sounds on lower lobe of left lung, and resonant in other lobes of lung.

Auscultation

• Quantity: normal

• Quality of sound: bronchial sounds on left lung

• Added sound: crackles in lower lobe of left lung

• Measurement of chest expansion:

– Upper Zone : 2.5cm

– Middle Zone: 2.5cm

– Lower Zone : 2 cm

Conclusion: Reduced expansion of the lungs

AP: Transverse diameter: 5:3

Investigation:

Hematology:

HB: 8mg/dl

WBC: 6100/mm3

Sputum: Gram –ve bacteria

Heavy growth of E.coli due to oral fungal

infection.

X-ray

•Trachea centralise

•Cardio thoracic ratio is almost 1:2 which is normal

•Homogenous opacity can be seen in lower lobe of left lung

•Suggestive of left lobar pneumonia

Provisional Diagnosis:

Left lobar Pneumina.

Problem list according to ICF

Primary impairment

• Cough with expectoration.

•Breathlessness affecting daily activities like walking.

•Chest pain on left side of the chest.

Secondary impairment

•Increased work of breathing

•Reduced chest expansion

Activity limitation

Daily activities like walking, dressing, stair climbing

and descending, hygiene maintenance

Participation restriction

Unable to work

Contextual factors

Personal factors

Positive: Cooperative and motivated

Good family support

No significant surgical and family history

Negative: Aged person

Environmental factors

Negative : Hygiene maintenance at home.

Management:

To improve chest expansion.

To increase the ease of brething.

To return to his normal life.

• Positioning:

– Right side lying.

• To improve lung expansion:

– Segmental Breathing exercise

– Incentive spirometry

• Huffing and coughing with splinting

– Self assisted

– Therapist Assisted

Treatment plan:

Positions to relieve breathlessness

• Home advice

– Performing breathing exercise regularly.

– Use of medication regularly.

– Lying on right side.

– Avoid smoking.

Evidence based practice

•Pontifex E,et al. The effect of huffing and directed

coughing on energy expenditure in young symptomatic

patients, Aust j Physiother ; 2002;48(3):209-213

•Feldman J., Traver GA, Taussig LM. Maximal expiratory

flow after postural drainage,europe pubmed central;1979

•Patricia A. Downie. Cash textbook of Chest, heart and

vascular disorders for physiotherapists. 4th edition. Jaypee

Brothers publication

•Robert L. Wilkin, Susan Jones Krider, Richard L.

Sheldon. Clinical assessment in respiratory care.4th edition

•Stuart Porter, Tidy’s Physiotherapy. 14th edition. Elsevier

publication.

THANK YOU