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




  1. Explain the pathophysiology of the patient’s diagnosis.



  2. 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.



  3. Select, implement, and interpret physical therapy interventions based on the medical examination findings.



  4. 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



No Image Available!




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



No Image Available!




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



No Image Available!




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


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?






























































































































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


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.

Only gold members can continue reading. Log In or Register to continue

Dec 11, 2021 | Posted by in MANUAL THERAPIST | Comments Off on Pneumonia
Premium Wordpress Themes by UFO Themes