1.
Case Discussion
Presented to: Subin sir
On 9th March,2014
By : Kumar Vibhanshu
MPT- I year

2.
• Name: Mohammad Sardar
• Age: 64 years
• Sex: Male
• Address: Mominpura, Mysore Road.
• Marital Status: Married
• Religion: Islam
• Occupation: Autodriver
Demographic data:

3.
• Source Of History: Patient & His Wife.
• Date of Admission : 6/03/14, 9:10 p.m.
• Date of Assessment: 9/03/14

4.
Chief complaints:
• Patient complained of fever and chills
from last 4 days.
• Patient also complained of cough with
sputum. From last 4 days.
• Patient was also feeling difficulty in
breathing from last 20 days.
• Pateint also complained of left lower
lateral side chest tightness.

5.
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.

6.
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.

7.
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

8.
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.

9.
Aggrevating factor: smoking
Relieving factor: rest and medication.
Pattern: Cough first in morning

10.
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.

11.
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.

12.
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

13.
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.

14.
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
-Cyanosis
-Mediastinal shift
-Reduced vocal

15.
Lung Abscess -fever
-cough
-dyspnea
-haemoptysis
-halitosis
-foul smelling
sputum
-bad taste in
mouth

16.
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

17.
Inspection
Head:
facial expression: showing cardio respiratory distress
Eyes PERRLA : normal
No ptosis, no central cyanosis
No pursed lip breathing

18.
Neck:
Position of trachea: central
Use of accessory muscles: SCM
Trails sign and olivers sign: negative

19.
Thorax:
Posture: kyphotic with rounded shoulder
Symmetrical chest
Apex beat: not visible
Pallor: absent
Clubbing : absent
Cyanosis: absent
edema: absent
No intercostal indrawing

20.
Palpation:
Tracheal position: central
No tenderness over chest or accessory muscles.
Chest symmetry: symmetrical chest movements.

21.
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

22.
• 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

23.
Investigation:
Hematology:
HB: 8mg/dl
WBC: 6100/mm3
Sputum: Gram –ve bacteria
Heavy growth of E.coli due to oral fungal
infection.

24.
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

25.
Provisional Diagnosis:
Left lobar Pneumina.

26.
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

27.
Activity limitation
Daily activities like walking, dressing, stair climbing
and descending, hygiene maintenance
Participation restriction
Unable to work

28.
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.

29.
Management:
To improve chest expansion.
To increase the ease of brething.
To return to his normal life.

30.
• Positioning:
– Right side lying.
• To improve lung expansion:
– Segmental Breathing exercise
– Incentive spirometry
• Huffing and coughing with splinting
– Self assisted
– Therapist Assisted
Treatment plan:

31.
Positions to relieve breathlessness

32.
• Home advice
– Performing breathing exercise regularly.
– Use of medication regularly.
– Lying on right side.
– Avoid smoking.

33.
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

34.
•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.

35.
THANK YOU