case study examples for physiotherapy

AMA 11th Edition Citation Style Guide: Sample Case Study Papers in Physical Therapy

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Marymount Library Physical Therapy Collection Repository

Physical Therapy students can access the Marymount Physical Therapy Collection Repository sample papers.

Below are two Physical Therapy Case report sample papers that exemplify best practices in writing in AMA style:

• Kinesiophobia and Joint Hypermobility Syndrome - Why Fear of Movement Should Matter to Movement Experts
• Patient Function Versus Time as a Driver for Rehab Progression Following Total Shoulder Arthroplasty
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New case studies are released frequently, each challenging a different aspect of clinical reasoning .

Mentor input is added to popular cases around one month later, available to registered members ( click here to join ).

To stay up to date, join us on Facebook and we’ll post new cases and mentor input as they’re released.

Upper arm pain with neurological symptoms

Final year Physio students – get a head start on the job market

Achilles pain case study #2

CPD Case study: worsening proximal calf pain in a 30 year old [10min read]

Case study: Hamstring pain in a Physiotherapist and cyclist [15min read]

CPD Case Study: Heel pain in a teenage footballer [12min read]

How to utilise physiotherapy case studies.

A case study will present an injury or condition along with some context or background information.

As Physiotherapists are well aware, no injury is as simple as the text book presentation and a patient’s situation, background and motivations must be taken into account for successful management of the case.

The world’s best rehab program is worth nothing in the hands of the world’s least motivated patient…

Each of these cases presents a different challenge – it’s not as simple as guessing the correct diagnosis, or going with your standard approach to ankle assessment.

The cases will offer slightly different challenges, from designing a successful management plan without a firm diagnosis, to considering an injury in the context of other physiological factors such as adolescent growth .

Case studies are not the resource to use to memorise different presentations and diagnoses. You could do that by reading any text book – we strongly recommend Brukner & Khan’s Clinical Sports Medicine as a great reference for sports injury info.

Once you’ve absorbed all the injury info and seen a few patients, case studies are the best way to apply that knowledge in different contexts.

Once you’ve gone through and responded to the prompt questions, it doesn’t end there.

You can match your answers against the mentor’s responses and rationale. You could match it against a colleague who has also attempted the case study. Or you could bounce your answers and reasoning off a senior colleague at work.

The goal here is not just getting the right answer – it’s about having the right reasoning behind that answer that is the key building block to a successful career .

Keen to earn a little more or kickstart a mini-business on the side? We’ve got 8 cracking ideas for Physiotherapists to diversify their interests and earn some spare cash in the process (opens in new tab) .

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Case studies in respiratory physiotherapy

CHAPTER FIVE Case studies in respiratory physiotherapy Lead author Janis Harvey, with contributions from Sarah Ridley, Jo Oag, Elaine Dhouieb, Billie Hurst Case study 1: Respiratory Medicine – Bronchiectasis Out-patient 34 Case study 2: Respiratory Medicine – Lung Cancer Patient 36 Case study 3: Respiratory Medicine – Cystic Fibrosis Patient 38 Case study 4: Respiratory Medicine – COPD Patient 41 Case study 5: Surgical Respiratory – Anterior Resection 43 Case study 6: Surgical Respiratory – Division of Adhesions 44 Case study 7: Surgical Respiratory – Hemicolectomy 46 Case study 8: Surgical Respiratory – Bowel Resection 48 Case study 9: Intensive Care – Patient for Extubation 50 Case study 10: Intensive Care – Surgical Patient 51 Case study 11: Intensive Care – Medical Patient 52 Case study 12: Intensive Care – Patient Mobilisation 54 Case study 13: Cardiothoracic Surgery – Self Ventilating Patient 55 Case study 14: Cardiothoracic Surgery – Intensive Care Patient 57 Case study 15: Paediatric Respiratory Care – Medical Patient 59 Case study 16: Paediatric Respiratory Care – Intensive Care Patient 61 Introduction The area of respiratory physiotherapy reaches a number of patient groups, both in the in-patient and out-patient settings. The case studies that follow are based predominantly in the in-patient environment; however, the components of a respiratory assessment and the subsequent identification of physiotherapy problems and treatment plan could be applied to any patient with respiratory compromise in any clinical setting. Like all other areas of physiotherapy practice, respiratory physiotherapy involves accurate patient assessment in order to identify patient problems. Respiratory assessment should include certain key elements: general observations of the patient; consideration of trends in physiological observations (e.g. HR, BP, oxygen saturations); patient position; auscultation, palpation and, where available, analysis of arterial blood gases and chest X-ray (CXR). Patient problems identified from the assessment generally fall into three main categories: loss of lung volume, secretion retention and increased work of breathing. The extent of any resulting respiratory compromise can vary greatly between patients and may not always be reflected by the ward area in which the patient is being treated. On occasion the most acutely unwell patients are in the general ward areas and not within critical care as expected. A problem-orientated treatment plan may include a combination of a number of interventions such as mobilisation, positioning, breathing techniques (e.g. ACBT, AD), manual techniques (percussion, vibrations), mechanical aids (e.g. IPPB, CPAP) or more invasive measures (e.g. airway suctioning). A respiratory assessment is mainly indicated for patients who have undergone surgery, those with medical respiratory conditions, e.g. exacerbation of COPD, and those requiring critical care. Cardiothoracic surgery and paediatrics are other specialist clinical areas that physiotherapists are involved in providing respiratory care. However, it must be remembered that patients requiring such care may not be in these ward areas exclusively. Physiotherapists working in any clinical area may be required to undertake a respiratory assessment and provide respiratory care. For example, assessment of a stroke patient who has aspirated or an oncology patient who develops respiratory failure following chemotherapy. It is important, therefore, that all physiotherapists are familiar with respiratory assessment and intervention. Another key area of work where physiotherapists are required to undertake respiratory care is in the provision of emergency duty/on-call services. Such services are available to patients who have a condition amenable to physiotherapy, which has either deteriorated or is likely to deteriorate without intervention before daytime service resumes ( Scottish Intercollegiate Guideline Network 2004 ). This can be a very challenging area of work for the physiotherapist on-call, who needs to think clearly while being faced with an acutely unwell patient who is in need of their attention, whatever the time of day. Guidance is available to support the clinician involved in providing such care and to aid ongoing assessment of competence ( Chartered Society of Physiotherapy 2002 ). CASE STUDY 1 Respiratory medicine – bronchiectasis out-patient Subjective assessment PC 35-year-old female Attending routine multidisciplinary bronchiectasis clinic appointment HPC Diagnosed 6/12 ago with bronchiectasis following an in-patient admission with community-acquired pneumonia (CAP) in her right lower lobe. This resulted in the development of bronchiectatic changes. Since diagnosis the patient reports daily production of mucopurulent secretions with excessive coughing and feelings of fatigue PMH CAP Gastric oesophageal reflux SH Married with two children Lifelong non-smoker Full-time employment as drug company representative, involving frequent travel around the United Kingdom Normally leads an active lifestyle with two to three visits a week to the gym, although this has decreased over the past 3/12 DH Omeprazole Consultant handover Patient is currently stable but is concerned about the impact of her cough and increased sputum on everyday life, especially in relation to her work, where she frequently does formal presentations Objective assessment Respiratory Ventilation SV room air SpO 2 99% RR 12 CXR Bronchiectatic changes present in right lower lobe ABG Not appropriate to be taken as stable CVS Temp 37°C HR 70 BP 120/70 CNS Nil of note Renal Nil of note MSK Nil of note Microbiology Staphylococcus aureus in sputum sample 6/12 ago Patient position Sitting in chair Observation Looks well, good colour, breathing pattern normal Patient actively trying to suppress cough and noise of secretions Auscultation Breath sounds throughout both lung fields with mid inspiratory crackles right lower lobe Questions 1. You feel this lady seems a little vague regarding her diagnosis, how will you deal with this issue? 2. Following discussion it is now evident that the patient’s knowledge about her condition is sparse. How will you resolve this issue? 3. What is the range of airway clearance techniques commonly taught to this group of patients? 4. Considering this patient’s condition and lifestyle what would be the advantages and disadvantages to each of the treatments mentioned in the previous question? 5. Your patient seems reluctant to undertake airway clearance management, how will you motivate your patient to undertake regular treatment? 6. What frequency and duration may you suggest to this patient for performing airway clearance techniques? 7. What signs and symptoms would you highlight to your patient to recognize at the start of an exacerbation? 8. Your patient asks what she should do if she has an exacerbation, what advice do you give her? 9. Why would you consider asking this patient if she has any urinary stress incontinence problems? CASE STUDY 2 Respiratory medicine – lung cancer patient Subjective assessment PC 70-year-old male Non-small-cell lung cancer (NSCLC) in the right main bronchus Admitted with an acute deterioration in condition and the family are no longer able to cope with the patient at home HPC Diagnosed 9/12 ago following a 3/12 history of increasing shortness of breath and cough. Two episodes of frank haemoptysis also reported. Following diagnosis, patient was deemed appropriate for a course of chemotherapy, but had limited response to intervention. As an out-patient he had a CT scan, which showed brain and spinal metastases, and he has been suffering uncontrollable pain. As a result he has been bed bound for the past month and has required increasing support from Macmillan oncology nurse specialists PMH Nil of note SH Lives with wife in a bungalow Smokes 40 cpd Retired teacher Close family network Until 2/12 ago independent with walking stick, able to walk to local shops approximately 100 m DH Paracetamol Co-codamol Oramorph Lactulose Build up drinks Handover Patient admitted with a decreased GCS, frail, emaciated Family very concerned, emotional and distressed by patient’s breathing pattern and audible secretions Pain management sub-optimal Objective assessment Respiratory Ventilation SV 4L O 2 via non-venturi system mask, unhumidified SpO 2 95% RR 10–22 CXR No CXR taken on admission Previous CXR (1/12 ago): white out of right lung field, secondary to bronchus obstruction ABG None available CVS Temp 39°C HR 120 BP 105/65 CNS GCS fluctuating between 5 and 8 Renal Catheterised on admission MSK Pain at lower back region in keeping with spinal metastases Microbiology None Patient position Supine Observation Flushed, drowsy, intelligible speech with audible secretions. Agitated at times, with arms flailing and pulling at oxygen mask Normal chest shape with altered breathing pattern illustrated by Cheyne–Stoking Auscultation Breath sounds diminished throughout right lung field with widespread coarse inspiratory/expiratory crackles transmitting throughout left lung field Palpation Decreased chest excursion on right with palpable secretions over trachea and left apex Questions 1. How would you describe Cheyne–Stoking? 2. If a patient is performing a Cheyne–Stoke breathing pattern, what does this indicate? 3. Prior to assessing and treating this patient, what further information do you require? 4. What are the main physiotherapy problems? 5. What are the associated problems for this patient that may affect your physiotherapy intervention? 6. How will you treat the problems that you have highlighted? 7. What outcome measures will you use to evaluate the effectiveness of your intervention? 8. In this scenario, which medical and physiotherapy interventions are inappropriate and why? 9. What do you see as the role of the palliative care team in this scenario? CASE STUDY 3 Respiratory medicine – cystic fibrosis patient Subjective assessment PC 19-year-old female Admitted with acute exacerbation of cystic fibrosis (CF) HPC Diagnosed at birth. Multiple hospital admissions over last 3 years due to exacerbation of CF. On admission patient reporting 1/52 history of increased breathlessness, sputum volume and cough. These symptoms have not responded to a 2/52 course of intravenous antibiotics. In respiratory distress. Dehydrated. Recent weight loss and current BMI 17. Under review for lung transplantation assessment. Patient previously agreed to perform twice daily ACBT in alternate side lying/supine for 20 minutes, but generally non-compliant with suggested airway clearance programme and prescribed medications PMH Asthma Osteoporosis SH Lives at home with parents and sister (non-CF) Unemployed and sedentary lifestyle due to health status DH Ventolin via nebuliser Becotide via inhaler Dnase via nebuliser Colomycin via nebuliser Azithromycin Creon Alendronate Vitamins A, D, E, K Long-term oxygen therapy Handover Patient exhausted and only able to clear small amounts of very thick, purulent bronchial secretions with difficulty. Pyrexial and requiring intravenous fluids. C/O nausea following overnight feed via PEG tube Objective assessment Respiratory Ventilation SV 28% O 2 via venturi system mask SpO 2 85% RR 34 CXR ( Figure 5.1 ) Hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally Intravenous access device in situ Figure 5.1 X-ray for Case Study 3 showing hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally. Intravenous access device in situ . ABG H + 50 nmol/L pCO 2 13 kPa pO 2 7 kPa HCO 3 − 30 mmol/L BE −9.0 CVS Temp 38.5°C HR 129 BP 100/85 CNS Nil of note Renal Nil of note MSK Kyphotic with history of osteoporosis Microbiology Pseudomonas in sputum Patient position Sitting upright in bed holding onto cot sides Observation Pale with signs of central cyanosis. Unable to speak due to SOB and excessive cough. Looks distressed. Breathing pattern shallow, apical with active expiration Auscultation Coarse inspiratory crackles transmitting throughout chest on background of high-pitched expiratory wheeze Palpation Limited chest excursion on inspiration (right = left) Secretions palpable upper, anterior chest wall Questions 1. Considering the above information, list this patient’s physiotherapy problems. 2. What information from the objective assessment led you to this problem list? 3. What does the ABG result tell you? 4. What are the specific signs of hyperinflation on this patient’s X-ray ( Figure 5.1 )? 5. During this admission, how might you initially modify this patient’s normal daily routine of alternate side lying and ACBT for 20 minutes twice a day? 6. Having decided on an acceptable airway clearance technique, what else would you include in your initial treatment plan? 7. Following two physiotherapy sessions with modified ACBT that morning, you feel that the patient is becoming more exhausted and unable to clear her secretions effectively. How might you change your physiotherapy management and with whom would you want to discuss these potential changes? 8. How might your treatment/management change if your patient was commenced on NIV? 9. Why would it be inappropriate to introduce activity/exercise at this stage? CASE STUDY 4 Respiratory medicine – copd patient Subjective assessment PC 65-year-old male Admitted to respiratory ward with acute exacerbation of COPD HPC Diagnosed 5 years ago with severe emphysema. Recent viral illness that has resulted in a dry cough, wheeze and breathlessness for 1/52. Has been house bound last few days. Normally 1–2 exacerbations per year that are managed by GP. No previous hospital admissions for COPD PMH Hypertension SH Retired engineer. Lives alone in third-floor flat. No lift. Normally manages all ADL independently. Exercise tolerance 50 m on flat – no aid required. Drives a car. No family living locally. No social services required. Smokes 30 cpd DH Salbutamol inhaler Becotide inhaler Atenolol GP letter states that patient has not picked up repeat prescription for inhalers from 1/12 ago Handover Admitted overnight. Patient noted to be drowsy but able to be roused for short periods. When awake, able to talk in short sentences but appears slightly disorientated. Breathing pattern laboured and has a dry, spontaneous cough. Dehydrated but receiving IV fluids Objective assessment Respiratory Ventilation SV 6 L O 2 via a simple face mask SpO 2 97% RR 9 CXR Hyperinflated lung fields with flattened diaphragms Emphysematous bullae upper zones No focal signs of collapse/consolidation ABG H + 58 mmol/L pCO 2 12 kPa pO 2 12 kPa HCO 3 − 30 mmol/L BE +9 CVS Temp 37.5°C HR 115 BP 130/90 CNS Drowsy but able to be roused for short periods Disorientated and confused. Moving all four limbs Renal Nil of note MSK Nil of note Microbiology None available Patient position Slumped lying in bed Observation Obese man with barrel shaped chest and large abdomen. Colour – flushed. Breathing through an open mouth. Predominately a shallow, apical breathing pattern with increased use of accessory muscles. Also demonstrating in-drawing of his lower chest wall on inspiration. Active expiration Auscultation Quiet BS generally with end expiratory polyphonic wheeze throughout Palpation Decreased expansion bi-basally (right = left). No palpable secretions Questions 1. The patient is drowsy with a RR of 9. What may be the contributing factors? 2. What is the difference between fixed and variable oxygen therapy? 3. Which type of oxygen therapy would be more suitable for the patient at this point? 4. What is this patient’s main physiotherapy problem? 5. What led you to this conclusion? 6. What factors may be contributing to this increased WOB? 7. How might your initial treatment plan address this problem of increased WOB? 8. Consider this patient’s CXR report, chest shape and breathing pattern. Would he benefit from lower lateral costal breathing exercises to improve basal chest excursion once he was less drowsy? 9. What goals would you hope to have achieved before this patient was discharged home? CASE STUDY 5 Surgical respiratory – anterior resection Subjective assessment PC 63-year-old male Day 2 post-laparotomy for anterior resection (end to end anastomosis) HPC Emergency admission yesterday with increasing abdominal pain 2/12 altered bowel habit PMH Nil of note- previously fit and well SH Lives with wife, recently retired, independent with ADL, plays golf three times a week, smoker 5 cpd DH Nil of note Handover Acute desaturation this morning. Patient has been coughing – effective and occasionally moist, nil expectorated. Otherwise stable Not been out of bed as yet Objective assessment Respiratory Ventilation SV 4 L O 2 via nasal cannulae SpO 2 90% RR 12 CXR Right basal collapse ABG None available CVS Temp 37.4°C HR 80 BP 130/60 CNS GCS E4 V5 M6 Pain score VAS 2/10 at rest 4/10 on movement/coughing Morphine PCA Renal UO 20–30 mL/hr +1.5 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Talking freely Auscultation Breath sounds throughout, fine end inspiratory crackles right base Palpation Reduced expansion right base, no secretions palpable Questions 1. Is this patient adequately oxygenated? What suggestions might you make? 2. List this patient’s physiotherapy problem(s). 3. What information from the objective assessment led you to this problem list? 4. Why are patients who have undergone surgery/anaesthetic at risk of developing respiratory compromise? 5. What are the treatment options for this patient? 6. What would your initial treatment plan include? 7. How would you progress this patient? 8. HDU patients can have many attachments including monitoring (ECG, sats probe), oxygen therapy, catheter and wound drains. What considerations would you have to give before mobilising such a patient? CASE STUDY 6 Surgical respiratory – division of adhesions Subjective assessment PC 74-year-old female Day 3 post-laparotomy and division of adhesions HPC Existing ileostomy – no output for 48 hours, vomiting and no significant fluid intake PMH Small bowel resection and formation of ileostomy 2 years previous for incarcerated hernia COPD Right axillary node clearance Previous pulmonary TB SH Lives alone, housebound, home help three times/day, smokes 10 cpd DH Ventolin inhaler Seretide inhaler Handover Initially in intensive care, intubated and ventilated. Extubated yesterday and transferred to HDU. Stable overnight, difficulty clearing secretions Objective assessment Respiratory Ventilation SV FiO 2 0.28 via face mask cold humidification RR16 SpO 2 89% CXR – taken prior to extubation ( Figure 5.2 ) Scoliosis, rotated, hyperinflated, nil focal Figure 5.2 X-ray for Case Study 6 taken prior to extubation showing the patient has a scolosis with hyperinflated lungs and nil focal in lung fields. ABG H + 36.35 nmol/L pCO 2 5.91 kPa pO 2 7.42 kPa HCO 3 − 28.2 mmol/L BE + 4.7 CVS Temp 36.5°C HR 85 BP 110/50 Noradrenaline 8 mL/hr CNS GCS E4 V5 M6 Pain score VAS 3/10 at rest 8/10 on movement/coughing Morphine PCA Renal UO 50 mL/hr +3.2 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Sitting upright in bed, frail Observation Hyperinflated chest, looks well, chatting freely, dry mouth Auscultation Breath sounds throughout, coarse expiratory crackles throughout Palpation Expansion equal, palpable secretions bilateral upper zones Questions 1. Describe the advantages and disadvantages of patient-controlled analgesia (PCA). 2. Considering this patient’s CXR ( Figure 5.2 ), what additional hardware/monitoring is visible? 3. List this patient’s physiotherapy problem(s). 4. What information from the assessment led you to this problem list? 5. From the assessment information, what suggestions should the physiotherapist make before physiotherapy care commences? 6. What would be your initial treatment plan? 7. Given this patient’s present condition and past history, how might you need to modify the treatments delivered? 8. How would you know if your treatment had been effective (outcome measures)? 9. If the initial treatment plan were to be unsuccessful in clearing secretions, how would you modify your treatment? CASE STUDY 7 Surgical respiratory – hemicolectomy Subjective assessment PC 55-year-old male Day 2 post laparotomy for right hemicolectomy (end to end anastomosis) HPC Elective admission for bowel resection – investigated 6/12 ago due to altered bowel habit and weight loss. Tumour identified and biopsy taken during colonoscopy PMH Nil of note SH Lives alone, independent with ADL, non-smoker DH Nil of note Handover Acute desaturation this morning requiring increased FiO 2 , not been out of bed as yet due to reduced blood pressure, otherwise stable Objective assessment Respiratory Ventilation SV FiO 2 0.6 via face mask cold humidification RR 12 SpO 2 96% CXR Left lower lobe collapse ABG None available CVS Temp 37.4°C HR 80 BP 80/45 CNS GCS E4 V5 M6 Pain score VAS 2/10 at rest 3/10 on movement/coughing Epidural analgesia (Bupivacaine and Morphine mix) Renal UO 30 mL/hr +1.5 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Looks well, talking freely Auscultation Breath sounds throughout, reduced at left base Palpation Reduced expansion left base, no secretions palpable Questions 1. What does the procedure of a right hemicolectomy involve? 2. Why can the presence of an epidural lead to hypotension? 3. List this patient’s physiotherapy problem(s). 4. What information from the objective assessment led you to this problem list? 5. What would be your initial treatment plan? 6. After identifying an appropriate treatment plan, what information/instructions would you handover to the nursing staff caring for the patient? 7. How would you determine if your treatment plan had been effective (outcome measures)? 8. What goals would you hope to have achieved before this patient was discharged home? CASE STUDY 8 Surgical respiratory – bowel resection Subjective assessment PC 80-year-old male Day 3 post-laparotomy for bowel resection HPC Presented to A&E with painful distended abdomen. Bowels not opened for 2/7 previous. Distended loops of bowel and sigmoid volvulus on AXR. Attempted decompression by colonoscopy unsuccessful therefore proceeded to theatre for open procedure PMH Hypertension SH Lives with wife, independently mobile DH Atenolol Handover Patient confused and drowsy since return from theatre. Has a moist, ineffective cough that is not productive Objective assessment Respiratory Ventilation SV 2L O 2 via nasal cannulae RR 17 SpO 2 94% CXR ( Figure 5.3 ) Reduced lung volume bibasally Figure 5.3 X-ray for Case Study 8 showing reduced lung volume bi-basally. ABG H + 49.8 nmol/L pCO 2 4.87 kPa pO 2 10.16 kPa HCO 3 − 18.0 mmol/L BE –8 CVS Temp 37°C HR 100 BP 160/70 CVP +9 CNS GCS E3 V4 M5 Pain score – unable to score reliably Renal UO 35 mL/hr +6 L cumulative fluid balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Drowsy, audible added sounds at mouth Auscultation Breath sounds throughout reduced bibasally, expiratory crackles upper zones Palpation Expansion equally reduced bilaterally, no secretions palpable Questions 1. Explain the patient’s drug history in relation to the past medical history. 2. Why do post-operative patients tend to have a significant positive fluid balance? 3. Why is metabolic acidosis a common finding when analysing the ABG of a post-operative patient? 4. List this patient’s physiotherapy problem(s). 5. What information from the objective assessment led you to this problem list? 6. Systematically analysing this patient’s CXR ( Figure 5.3 ), what signs do you find that would confirm bibasal loss of lung volume? 7. What would be your initial treatment plan? 8. What could be suggested as a management strategy if the patient required regular suctioning and why? CASE STUDY 9 Intensive care – patient for extubation Subjective assessment PC 55-year-old female Day 7 post-laparotomy for subtotoal colectomy and extensive bowel resection, formation of ileostomy HPC Emergency admission from A&E in shock with reduced BP, abdominal pain Unwell for 3–4 days, intermittent diarrhoea and vomiting Theatre findings – patchy infarction of small and large bowel PMH Hypertension SH Lives with son, 10 cpd smoker DH Bisoprolol Handover Stable overnight Possibly for extubation. Just weaned to ASB from SIMV Objective assessment Respiratory Ventilation ASB (PEEP 5 PS 5) ETT size 7.0 FiO 2 0.35 RR 19 Tv 0.46 L SpO 2 97% M1 secretions CXR Nil focal ABG H + 39.7 nmol/L pCO 2 5.06 kPa pO 2 14.15 kPa HCO 3 − 23.1 mmol/L BE –1.5 CVS Temp 38.6°C HR 135 BP 169/88 CVP +11 CNS GCS E3 VT M4 Propofol 10 mL/hr Alfentanil 2 mL/hr Renal UO 50 mL/hr overall +500 mL MSK Nil of note Microbiology Sputum and urine – no growth Patient position Head-up tilt in bed Observation Intubated and ventilated, settled, relaxed breathing pattern Auscultation Breath sounds throughout, no added sounds Palpation Expansion equal, no secretions palpable Questions 1. Define and explain the difference between SIMV and ASB modes of ventilation. 2. What would you look for in a patient assessment that might indicate to you a patient is ready for extubation? 3. The Glasgow Coma Scale (GCS) is used to assess level of consciousness. What are the components of the scoring system? 4. On assessment this patient GCS is E3 VT M5. What is the patient ‘doing’ and what are the implications of this for the patient with regard to readiness to extubate? 5. List this patient’s physiotherapy problem(s). 6. What information from the objective assessment led you to this problem list? 7. What would be your initial treatment plan? 8. How would you assess as to whether the deep breaths the patient was attempting to take were effective? CASE STUDY 10 Intensive care – surgical patient Subjective assessment PC 51-year-old female Day 1 post laparotomy – drainage of pelvic abscess and over sew of serosal tears HPC Admitted previous day with abdominal pain and distension. CT revealed free gas, fluid and faeces in the abdomen and a pelvic collection PMH Ischaemic colitis Hartmans procedure 1 year ago SH Lives with husband Independent with all ADL DH Nil Handover Problems with cuff leak on repositioning. Aiming to place NG tube then reduce sedation Objective assessment Respiratory Ventilation SIMV ETT size 7.0 FiO 2 0.35 PEEP 5 PS 10 Tv 0.419 L RR 14 SpO 2 92% HMEF brown secretions CXR Nil focal ABG H + 52.19 nmol/L pCO 2 4.6 kPa pO 2 10.96 kPa HCO 3 − 16.6 mmol/L BE –9.8 CVS Temp 36.5°C HR 100 BP 140/90 CVP +10 CNS GCS E3 VT M5 Propofol 7 mL/hr Alfentanil 2 mL/hr Renal UO 35 mL/hr +2.5 L cumulative balance MSK Nil of note Microbiology Nil of note Patient position Head-up tilt in bed Observation Intubated, ventilated, settled Auscultation Breath sounds throughout, coarse expiratory crackles right upper/middle zones Palpation Expansion equal, palpable secretions right upper zone Questions 1. Analyse the ABG presented. 2. On handover the presence of a cuff leak has been highlighted. What is the significance of this information? 3. List this patient’s physiotherapy problem(s). 4. What information from the objective assessment led you to this problem list? 5. Positioning is integral to all respiratory physiotherapeutic input. Which position would you choose for this patient and why? 6. What would be your initial treatment plan? 7. If your initial treatment was unsuccessful in clearing the secretions, how might you modify your treatment? 8. What are the potential hazards associated with endotracheal suctioning? CASE STUDY 11 Intensive care – medical patient Subjective assessment PC 72-year-old male Bilateral pneumonia and sepsis, 4 hours post ICU admission HPC Presented to Acute Receiving Unit today. Poor oral intake for 1/52 – dehydrated and weak PMH Mild learning difficulties, irritable bowel syndrome SH Lives with partner, home help twice a week, otherwise independent DH Nil of note Handover Stable since admission; plan to keep sedated for at least 24 hours Objective assessment Respiratory Ventilation Uncut ETT size 8.0 SIMV FiO 2 0.65 PEEP 10 SpO 2 96% RR 25/0 mandatory/spontaneous Tv 0.55 L nil-M1 secretions CXR Collapse consolidation left lower zone, patchy changes right middle zone ABG H + 53.8 nmol/L pCO 2 6.9 kPa pO 2 10.7 kPa HCO 3 − 24 mmol/L BE –1.2 CVS Temp 38°C HR 90 BP 95/55 CVP +12 Noradrenaline 26 mL/hr CNS Pupils 2+ 2+ GCS E2 VT M4 Sedation – Propofol 10 mL/hr, Alfentanil 2 mL/hr Renal UO 30+ mL/hr +1 L balance MSK Nil of note Microbiology No result as yet, commenced on broad-spectrum antibiotics Patient position Head-up tilt in bed Observation Intubated, ventilated, sedated Auscultation Breath sounds throughout, bronchial breathing left lower zone Palpation Reduced expansion left base, no secretions palpable Questions 1. The patient is septic. What information from the objective assessment indicates this? 2. Analyse the ABG presented. 3. Describe bronchial breathing. 4. List this patient’s physiotherapy problems(s). 5. What information from the objective assessment led you to this problem list? 6. What could be your initial treatment plan for each of these problems? 7. Clinically reason through whether MHI would be appropriate for this patient. 8. What would be your short-term goals for this patient? CASE STUDY 12 Intensive care – patient mobilisation Subjective assessment PC 50-year-old male Community-acquired pneumonia Day 41 in ICU HPC Admitted via A&E drowsy, sweaty and ‘unwell’. Quickly deteriorated with respiratory failure, requiring intubation and ventilation Complicated ICU stay with ARDS and two failed extubations PMH Alcohol excess (½ bottle vodka a day) Previous IV drug abuser Previous ICU admission with pneumonia SH Lives alone, first floor flat DH Nil of note Handover Been on CPAP overnight via tracheostomy, now on speaking valve Patient is keen to mobilise Objective assessment Respiratory Ventilation Trache size 8.0 (with inner tube, non-fenestrated) Speaking valve in situ. 2 L O 2 SpO 2 96% RR 20 MP2 secretions on suction CXR No recent ABG H + 39.42 nmol/L pCO 2 5.34 kPa pO 2 11.5 kPa HCO 3 − 24.1 mmol/L BE –0.2 CVS Temp 36.5°C HR 80 BP 140/80 CNS GCS E4 V5 M6 Renal UO 100 mL/hr overall negative balance MSK Nil of note Microbiology MRSA +ve in sputum Patient position High sitting in bed Observation Looks well, strong clear voice Auscultation Breath sounds throughout, no added sounds Palpation Expansion equal, no secretions palpable Questions 1. This patient developed ARDS due to severe pneumonia. What is ARDS? 2. This patient failed two attempts at extubation and so had a tracheostomy inserted to facilitate weaning. What other indications are there for tracheostomy tube insertion?

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