Presented By Dr.MD. Monsur Rahman (PT) MPT in Musculoskeletal Disorders MMIPR,Mullana,Ambala,Haryana

1. Case Presentation
Presented
By
MD. MONSUR RAHMAN
MPT in Musculoskeletal DisordersMPT in Musculoskeletal Disorders

2. Name - Mr.S.Ratan
Age - 65
Sex - Male
Occupation - Farmer
Date of admission - 04-10-2017
Date of assessment - 10-10-2017

3. Chief Complaints:
 Difficulty in breathing
 Cough
 fever

4. Past medical history:
 Difficulty in breathing is present since 4 years
and he was using inhaler since the same,
initially the difficulty was on severe exertion
only.
 It became worsen on 02-10-2017, immediately
he got admitted in MM hospital
 During the time of admission patient was
having difficulty in breathing, patient is
conscious ,oriented and obeying commands
on that day he was ventilated in SIMV mode
with the help of ET tube.

5. Cont…
 06-10-2017 he was done tracheostomy and
connected to a ‘T’ piece connector to the
ventilator

6. Present medical status:
 Patient is now(10-10-2017) connected to a ‘T’
piece towards a O2 with 3 liters of O2 on flow
along with atmospheric air.
 On and off nebulization is given in addition to
the chest percussion.

7.  Associated medical problems:
No associated medical problems.
 Socio economic history
patient affordable
 Family history
No relevant family history
 Personnel history:
Chronic smoker since his age 10,
No habit of drinking.

8. On observation
 Body built – mesomorphic
 Shape of the chest
 Barrel shape
 Shoulders forward protruded right 1 inch elevated
than the left.
 Spine – functionally kyphosis present
 spino-scapular distance left 3 inches
right 3 ½ inches
slump posture in high sitting, forward lean posture
while standing.

9. Respiratory movements:
 Respiratory rate - 18 breaths per minute
 Rhythm - wheezing
 Character - abdomino thorasic
 Equality - bilateral diminished
movement
 Accessory muscle usage - found
 Intercostal retraction – ribs found crowded
posteriorly.

10. Mediastinum:
Apex beat not visible
Miscellaneous:
No sign of scars, sinuses, pulsations and no shiny
over lining of the skin.

11. Vitals
 Heart rate 78/ minute
 Respiratory rate 18/ minute
 Blood pressure 120/ 80 mmHg
 Temperature 98° Fahrenheit

12. Palpation:
 Apex beat felt.
 No signs of oedema found.
 No palpable rhonchi, rales found.
 Chest movements found symmetrical.
 Tactile and vocal fremitus not done due to
tracheostomy.
Miscellaneous:
No signs of tenderness and other
vibrations noticed.

13. On examination:
 Percussion:
 anteriorly rt side resonant
lt side resonant
 posteriorly rt side dull
lt side dull
 in axilla rt side dull
lt side dull

14. Auscultation:
 Bilateral air entry clear
 Type vesicular with prolonged expiration.
 Foreign bodies rales, rhonchi or rub not
present
 Vocal resonance abscent (tracheostomy).
 s1 s2 heard normal there is a pause
between s1 and s2.

15. Chest measurement:
 Axillary level - 1 inch
 Nipple level - 2 inches
 xiphisternal level - 3½ inches

16. Range of motion:
 Upper limb
Shoulder flexion 165°, internal rotation 70°
Shoulder abduction 170°, external rotation 100°
Shoulder extension 60°
Elbow flexion 140°, pronation 75°
Elbow extension 0°, supination 80°
Wrist flexion 75°, wrist extension 75°
Ulnar deviation 35°, radial deviation 20°

17.  Lower limb:
Hip flexion 120°,hip extension 20°
Hip abduction 40°, hip adduction 25°
Knee flexion 130°, knee extension 0°
Ankle dorsiflexion 15° , plantarflexion 55°
Inversion 20° , eversion 10°

18. Muscle power
 Shoulder flexors 5
 Shoulder extensors 5
 Shoulder abductors 4+
 Shoulder adductors 5
 Internal rotators 4
 External rotators 4
 Elbow flexors 5
 Elbow extensors 5

19. Cont..
 Wrist flexors 4
 Wrist extensors 4
 Finger grip 4
 Dyspnoea grade 3

20. Investigation
 X ray chest AP supine 04-10-2017

21. X ray chest Sitting AP 09-10-2017

22.  Both the lung fields are hyper inflated.
 lower zones of both the lungs are hazy with
dilated bronchioles.
 Dirty lung appearance due to intestinal
alveolar opacities in lower zones.

23. Echo report:
 Biventricular hypertrophy.
 Cor pulmonale biventricular systolic function.
 Grade 1 left ventricular diastolic dysfunction

24. Arterial blood gas analysis:
07-10-2011
PH 7.43
PCo2 75 mm Hg
PO2 66 mm Hg
HCO3 39.3 mmol/lit

25.  08-10-2011
PCO2 65 mm Hg
PO2 101 mm Hg
HCO3 44.5 mmol/lit
 09-10-2011
PCO2 63 mm Hg
PO2 72 mm Hg
HCO3 44.2 mmol/lit
 10-10-2011
PCO2 69 mm Hg
PO2 86 mm Hg
HCO3 45 mmol/lit

26. Diagnosis:
 COPD

27. Problem list:
 Dyspnoea
 Peripheral muscle weakness
 Functional activities difficult.

28. Medical management:
 Bronchodilators
 Antibiotics
 Candid mouth paint
 Laxatives
 Nutrition measures high protein diet
 Good hydration.

29. Physiotherapy management:
Respiratory system:
 Clearance of airways
 Improve chest expansion
 Improve cough effectiveness
 Improve breathing pattern
Musculoskeletal:
 Improve muscle strength and endurance
Circulatory system:
 Prevent DVT
 Improve and maintain level of functional status
within patient tolerance.

30. Physiotherapy exercises:
 mobilization
Made him to sit in a chair upright
Made him to stand from the chair
Instructed to do active movements for lower
extremities
Asked to do wrist clockwise and anticlockwise
rotation
Every 2 hourly 20 reps 2 sets each.

31.  Body positioning:
The upright position is optimal
A schedule of four point turning(supine, left
sided and right sided is administered.
The head down position is most suitable for him
Over head abduction of arm while performing
breathing exercise.
 Supplemental oxygen:
Low level of O2 deliverd to avoid corbondioxide
narcosis.

32.  Bagging:
Positive pressure is initiated by manually
hyperinflating and helps avoiding of
secretions
 Breathing and coughing maneuvers taught.
 Upper limb strengthening using finger ball
and lower limb endurance are encouraged.