Case Study using ICF : COPD

Abstract

This article will include a case study of MrS who has recently been diagnosed with COPD. He has been recommended to do the same with exercise. The story follows the journey of the physiotherapist who evaluated Mr.S using the ICF system.

Please note: the case study below is fictitious but inspired by real COPD patients. Therefore it may not include all signs or symptoms of the disease state. Remember that the test findings in reality will vary slightly from patient to patient with the treatment plan adjusted accordingly.

Client Characteristics

A 40-year-old Mr.S has been finding it almost impossible to breathe on the stairs climbing to his office on the 2nd floor for a year now. He complained of persistent cough of the lungs for the last 3-4 years which increased every 2-3 months & then went away for some time. He had to be admitted to the hospital because of his condition her symptoms & was on medication with oxygen therapy for a week. He was diagnosed with COPD in hospital. Two weeks ago he has been discharged from the hospital for lung rehabilitation after his pulmonologist recommended it. Mr.S works as a manager in sales department of his company. Sometimes his work requires them to sit in meetings for hours together or to drive him around town all day in his two-wheeler. He was a smoker for eight years & has stopped regular counseling and therapy two years ago. He also complained that he gets big tired till the end of the day & doesn’t want to attend any social event with family or friends in the evening. Mr. & Mrs. S live on the 4th floor with lift in the building in a city in urban India. His wife & college-bound son have accompanied him for his first physiotherapy consultation.

Examination Findings

It is Mr.S historical analysis and objective analysis. This will focus primarily on breath testing in conjunction with other systems.

History

Mr.S has a history of

• Smoking for eight years smoking about 1 1/2 packs a day (about 30 cigarettes a day).
• Persistent drooling cough for 3-4 years(i.e. symptoms of repeated chest infections). It usually lasts 3-4 months and reduces over-the-counter indications.
• Dyspnea (MMRC scale – Gr.3)
• Shortness of breath & diarrhea on moderate exertion (RPE –2 to 4 on the Mod. Borg scale) .
• Fatigue at moderate activity between 3-5.9 METs

Investigations

Chest X-ray

This radiation study helps us understand the areas of lung involvement and also serves as a measure of outcome after exercise therapy.

• widening of intercoastal spaces
• flattened diaphragm
• bullae with middle & lower area on right side
• increased bronchovascular markings

Spirometry

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

• FEV1/FVC & FVC are decreased and abnormal obstruction is present [1].

Objective Examination

On Inspection

Mr.S was observed in standing and sitting. They found out he had

• barrel chest appearance of the chest
• forward head posture
• involving muscles (sternocleidomastoid muscle) with minimal effort
• respiratory 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

Mr.S assessed in standing position had,

• Front and rear: the transverse diameter is 1:1
• Chest expansion
  • Supramammary-0.5 cm
  • Mammary-0.5cm
  • Inframammary -0 cm

On percussion

• Perform taps to mark the rise of the diaphragm during exhalation
• Diaphragm deflection reduced to 2 cm

On auscultation

• Decreased bubbly breath sounds in the middle and lower regions of B/L
• Wheeze present B/L on expiration

Six min walk test

In order to improve Mr. S’s exercise capacity, we need to assess it using a submaximal exercise test such as a six-minute walk test.

The results of the patient assessment are as follows

• Distance achieved by Mr S is 280 m
• Ideal for Indian Male: 486.4 m[3]

Summarizing Assessment using ICF

Structural and Functional Impairments[4]

Sr.No. Structural and functional impairment Clinical reasoning (due to) related to examination 1. Cough with sputum due to H/O goblet cell hyperplasia indicating chief complaint and smoking for 8 years 2. Due to central and central airway abnormalities and permanent dilatation lead to overinflation of the lungs H/O in the lower lung area on X-ray indicates emphysema and on palpation 3. Bronchial wall thickening due to airway inflammation and presence of smoking H/O irritants and recurrent chest infections 3. Bronchial wall thickening due to airway wall thickening Bronchial vessel texture increased X-ray4.Reduced Examination and palpation Insufficient lung elastic recoil leading to chest expansion 5. Palpation and X-ray examination revealed chest hyperinflation leading to barrel chest 6. X-ray examination and coughing with H/O7 Extensive damage to lung tissue leading to bullae. Abdominal chest Breathing pattern due to chest hyperinflation seen on exam 8. Dyspnea on exam seen on exam due to use of accessory muscles and increased work of breathing (WOB) shoulders forward and neck forward posture and H/O9.MMRC Gr.3 Lung visible due to airflow restriction and reduced elastic recoil inspection & H/O10. RPE –2 to 4 on Mod. Borg scale due to increased abnormal breathing pattern on WOB and upper chest hyperinflation on H/O11. Moderate activity fatigue between MET 3-5.9 due to increased WOB dyspnea during exercise on H/O12. Reduced six-minute walk distance due to breathlessness Exertion and peripheral muscle weakness secondary to chronic fatigue seen on 6MWT

Activity Limitation

• Mr. S has difficulty riding his two-wheeler due to breathing difficulties
• Frequent coughing and expectoration, unable to sit for a long time in meetings, feeling uncomfortable and easily fatigued
• He is unable to do chores/activities in the evening due to being too tired

Participation Restriction

• Mr. S is having trouble continuing his marketing efforts
• He is reluctant to participate in any social activities with family or friends

Contextual Factors

Environmental

Sr. No.BarrierFacilitator 1. Works well on the second floor with family support 2. Travels on business and works on a two wheeler Lives in a building with an elevator 3. Easier access to physiotherapy facilities due to living in the city

Personal

Sr. No. BarrierFacilitator 1. He is the main earner in the family Quit smoking 2 years ago 2. H/O Smoking for 8 years and thus a major risk factor Motivated to start a pulmonary rehabilitation program 3. He is obese