Pneumonia

General Information
Case no.	15.A Pneumonia
Author(s)	Julie M. Skrzat, PT, DPT, PhD, Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy Aaron S. Frey, DO
Diagnosis	Pneumonia with chronic obstructive pulmonary disease (COPD)
Setting	Emergency department, with transfer to the Intensive Care Unit
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	Explain the pathophysiology of the patient’s diagnosis. Relate the pathophysiology and progression of pathology from chronic cardiovascular or pulmonary disorders to the clinical manifestations and activity/participation limitations seen in physical therapy practice. Select, implement, and interpret physical therapy interventions based on the medical examination findings. Develop an understanding of medical management and how it influences physical therapy plan of care.

Medical
Chief complaint	Shortness of breath (SOB), productive cough
History of present illness	The patient is a 70-year-old man who presented to the emergency department yesterday with reports of a productive cough of thick yellow-greenish sputum and increasing dyspnea × 2 weeks. He denies nausea, vomiting, and diarrhea. He initially presented to the emergency department 1 week ago with similar complaints. He was diagnosed with a COPD exacerbation, prescribed azithromycin, and discharged home. However, after 3 days, his symptoms did not resolve, bringing him back to the emergency department today.
Past medical history	COPD on continuous 2L/min O₂ via nasal cannula at home, hypertension, hypercholesterolemia, atrial fibrillation, smoker × 50 years (1 pack/d)—quit 3 years ago
Past surgical history	Left knee replacement 3 years ago
Allergies	Latex
Medications	Lisinopril, Atorvastatin, Salmeterol, Albuterol inhaler, Warfarin, Metoprolol
Precautions/orders	Activity as tolerated

Social history
Home setup	Resides in a multilevel home with wife. Three steps + one handrail to enter. Half bath on the first floor. Bedroom and bathroom are located on the second floor. Flight of stairs + one handrail to the second floor.
Occupation	Corporate lawyer for 42 years, retired 5 years ago.
Prior level of function	Independent with functional mobility and activities of daily living (ADLs). Modified independent for stairs, but required increased time. (+) driver
Recreational activities	Primarily watching TV and reading. Used to enjoy gardening but now it requires too much energy, leaving him short of breath.

Hospital Day 0: Emergency Department
Vital signs	Presentation	Corrected
Blood pressure (mmHg)	106/68	86/50
Heart rate (beats/min)	Fig. 15.1	98
Respiratory rate (breaths/min)	36	22
Pulse oximetry (SpO₂)	84% 2L/min O₂ via nasal cannula	98% on BiPap
Temperature (°F)	101.2	100.1

Fig. 15.1 The patient’s electrocardiogram upon his arrival to the emergency department.

Imaging/diagnostic test	Hospital day 0: emergency department	Hospital day 1: intensive care unit
Chest X-ray	1. Flattening of diaphragm 2. Alveolar infiltrates in right lower lobe Fig. 15.2	1. Mild to moderate right pneumothorax with persistent right lower lobe infiltrates.
Ultrasound	1. No pericardial effusion	Not reordered
Sputum sample	1. Gram positive for Streptococcus
Blood cultures	1. Negative
Urine analysis	1. Negative

Fig. 15.2 The patient’s chest x-ray upon his arrival to the emergency department. (Adapted from Krukemeyer M, ed. Cardiology, angiology, pulmonology. In: Introductory Guide to Medical Training: From Basic Sciences to Medical Specialties. 1st ed. New York, Thieme; 2015.)

Medical management	Hospital day 0: emergency department	Hospital day 1: intensive care unit
Medications	1. Intravenous (IV) fluids 2. Ceftriaxone IV 3. Methylprednisolone 60 mg IV 4. Duonebs, four times a day 5. Albuterol inhaler, every 2 hours PRN 6. Norepinephrine infusion to maintain mean arterial pressure (MAP) > 65 mmHg. 7. Acetaminophen 1,000 mg	1. Continued per medical plan of care
Respiratory	1. Placed on BiPap 2. Chest physical therapy/airway clearance techniques	1. Continued per medical plan of care
Procedures	1. Arterial line placed 2. Central line placed	1. Chest tube placed Fig. 15.3

Fig. 15.3 An example of a patient’s chest tube.

Lab		Reference range	Hospital day 0: emergency department	Hospital day 1: intensive care unit
Arterial blood gas	pH	7.35–7.45	7.32	7.37
	PaCO₂	37–43 mmHg	78	49
	PaO₂	80–95 mmHg	76	92
	HCO₃ ^–	20–30 mmol/L	23	25
Complete blood count	white blood cell	5.0–10.0 × 10⁹/L	19.6	15.3
	Hemoglobin	14–17.4 g/dL	10.8	11.1
	Hematocrit	42–52%	36.5	38.2
	Red blood cell	4.1–5.3 million/mm³	3.5	3.7
	Platelet	140,000–400,000/μL	115	240
Electrolytes	Calcium	8.6–10.3 mg/dL	8.9	9.1
	Chloride	98–108 mEq/L	98	100
	Magnesium	1.2–1.9 mEq/L	1.8	1.9
	Phosphate	2.3–4.1 mg/dL	2.9	2.8
	Potassium	3.7–5.1 mEq/L	4.2	4.5
	Sodium	134–142 mEq/L	141	140
Other	Cholesterol	< 200 mg/dL	240	Not reordered
	High-density lipoprotein (HDL)	≥ 35 mg/dL	67
	Low-density lipoprotein (LDL)	65–180 mg/dL	198
	Triglycerides	< 150 mg/dL	210
	Blood urea nitrogen (BUN)	7–20 mg/dL	24
	Creatinine	0.5–1.4 mg/dL	1.6	1.6
	Glucose	60–110 mg/dL	188	176
	brain natriuretic peptide (BNP)	< 100 pg/mL	98	Not reordered
	D-dimer	< 400 ng/mL	58	Not reordered
	International normalized ratio (INR)	0.8–1.2	2.1	2.0
	Lactate	< 2 mmol	3.0	1.2
	Troponin – 1	< 0.03 ng/mL	0.02	Not reordered
	Troponin – 2		0.01
	Troponin – 3		0.02

Pause points
Based on the above information, what are the priorities? Diagnostic tests and measures? Outcome measures? Treatment interventions?

Pause points

Based on the above information, what are the priorities?

Diagnostic tests and measures?
Outcome measures?
Treatment interventions?

Hospital Day 2, Medical Ward: Physical Therapy Examination
Subjective
“It’s so hard to breathe just sitting here, but I don’t want to lose my ability to move.”
Objective
Vital signs	Pre-treatment				Post-treatment
Vital signs	Supine		Sitting	Standing	Sitting
Blood pressure (mmHg)	101/73		100/75	99/74	105/79
Heart rate (beats/min)	117		120	124	125
Respiratory rate (breaths/min)	27		30	32	31
Pulse oximetry on 4 L NC (SpO₂)	89%		90%	84%	91%
Borg scale	5/10 SOB				2/10 SOB, improved with upright posture
Pain	4/10, right flank				5/10, right flank
General	Patient in bed, Fowler’s position, (+) accessory muscle breathing Lines notable for telemetry, NC, central line, arterial line, urinary catheter, chest tube
Cardiovascular and pulmonary	Auscultation: bilateral scattered rhonchi and bronchial breath sounds Electrocardiography: atrial fibrillation with rapid ventricular response Pulses: 2 + bilateral dorsalis pedis and posterior tibialis
Gastrointestinal	Abdomen slightly distended
Genitourinary	(+) urinary catheter
Musculoskeletal	Range of motion	Bilateral upper extremity (BUE): within functional range Bilateral lower extremity (BLE): within functional range
	Strength	B shoulder flexion: 4/5 B elbow flexion: 4/5 B wrist extension: 4/5 B hip flexion: 3 + /5 B knee extension: 4/5 B ankle dorsiflexion: 5/5 Five Times Sit-to-Stand Test: 14.5 seconds
	Aerobic	Unable to perform standardized test at this time.
	Flexibility	Tight pectoralis major and minor, as demonstrated by rounded shoulder posture. Suspect tight hip flexors due to reports of prolonged sitting at home: not tested due to inability to lie flat in side lying or prone.
Neurological	Balance	Static unsupported sitting: minimal assistance Static standing: minimal assistance with rolling walker Dynamic standing: minimal assistance with rolling walker
	Cognition	Alert and oriented × 4
	Coordination	Finger–to–nose: intact BUE
	Cranial nerves	Intact
	Reflexes	Patellar: 2 + bilaterally
	Sensation	Intact to light tough throughout BUE and BLE.
	Tone	Normal throughout BUE and BLE.
	Other	N/A
Functional status
Bed mobility	Supine to sit: moderate assistance with head of bed elevated.
Transfers	Sit to/from stand: minimal assistance with rolling walker.
Ambulation	Ambulated 3 feet from bed to chair with minimal assistance and rolling walker.
Stairs	N/A

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“I want to get back home safely.”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.