RESPIRATORY ASSESSMENT

INTRODUCTION :
Patient was a 54 year old male who had cough and breathing difficulty one month earlier.
SUBJECTIVE EXAMINATION :
Patient was a 54 year old male who was a teacher in school. He was living with his family
and two children. He had diabetes mellitus and undergoing medications for past 6 months.
During his free time he was involved in regular walking and badminton activities. He was
non smoker and non alcoholic person. He had family history of Diabetes mellitus and
hypertension. A month ago he had fever, cough and tightness of chest. After exposed to cool
climate during winter season he had gradual onset of cough with sputum production.
His cough was aggravated when he exposed to allergens or smoke . He had more cough
during early morning times. Along with cough he had breathlessness and nasal congestion.
His dyspnea was moderate(3).
Dyspnea was assessed by Modified Borg Dyspnea Scale. Modified Borg Dyspnea Scale was
adapted from Karla R Kendrick Et al(2000). Sputum was very thick ,sticky and tenacious
(Karen J. Tietze pharma D 2012) with out haemoptysis. He had medications and had relief
from fever and mild relief from cough and chest tightness but his sputum production ,
breathing difficulty and nasal congestion remained same. Because of those reasons he came
to physiotherapy department.
After my initial theory I thought that symptoms could be related to chronic respiratory
infections like chronic obstructive pulmonary disease(COPD) as patient had cough with
productive sputum and breathlessness.
PHYSICAL EXAMINATION :
Patient was alert and ectomorphic.
Vital signs of the patient include :
Temperature : 98 F
Pulse rate : 90 beats per minute
Respiratory rate : 22 breaths per minute.
Blood pressure :125/70.
Inspection and observation :
FACE AND NECK :
Eyes : Eyes looked normal with out dry eye disease (Yung-chieh
Huang Et.al 2018).
Eye lid : Eye lids were normal with out ptosis.
Nose : patient had nasal congestion.
Lips : Lips looked normal with out cyanosis.
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Nasal Flare : he had no nasal flaring.

Thorax :
Patient had no chest wall deformities with Abdomino thoracic breathing pattern.
Extremities :
Both upper limb looked normal with out cyanosis and clubbing and there was no oedema
in both legs.
On palpation :
Position of trachea was assessed by placing right index finger in the sternal notch and
palpated the lateral borders of the trachea which was in normal position. (Suneel Dhand MD)
Tactile vocal fremitus was assessed by palpation of chest wall anteriorly and posteriorly to
detect changes in the intensity of vibrations spoken by patient in constant tone and voice.
His
tactile vocal fremitus was decreased. (Modi P, Tolat S) (2019).
Percussion was assessed anteriorly by placing the middle finger of the left hand in Closed
contact with the chest wall in the intercostal space. A firm sharp tap was then made by the
middle finger of the right hand kept at right angles to middle finger in reclining position.
Patient had increased resonance. (Chest, Heart and Vascular disorders for
physiotherapists by (CASH).
On auscultation :
Breath sounds :
On auscultation patient had wheezes during deep forced expiration. After these findings I felt
patient had bronchiectasis or bronchial Asthma.
PATIENT MANAGEMENT :
DIAGNOSIS, PROGNOSIS AND PLAN :
With subjective examination, physical examination and radiological findings I could say
that
patient was affected by bronchial asthma instead of chronic obstructive pulmonary
disease(COPD) and bronchiectasis as patient had more cough during early morning times
along with breathlessness and wheezes during expiration with out crackles and thick sputum
production with out haemoptysis and had cough due to temperature variations and
aggravated
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by allergens which were key symptoms for bronchial asthma. (Chest, Heart and Vascular
disorders for physiotherapists by CASH). More over patient was non smoker.
According to Rodrigo Athanazio (2012) major risk factors for COPD patients are smoking
for
approximately 90% of the patients and According to Malay Sarkar Et.al (2019) patients with
COPD will have crackles breath sound at the beginning of inspiration along with wheezing.
According to chest, Heart and vascular disorders for physiotherapists by CASH
patients with bronchiectasis will have haemoptysis which is the common feature , copious
purulent sputum and coarse crackles breath sound associated with wheezes. Further more
CT
scan chest showed Bronchial asthma. With these findings I confirmed that patient had
Bronchial Asthma.
The prognosis would be beneficial if the patient followed regular physiotherapy.
TREATMENT PLAN :
The plan that I made was to implement the following goals :
First of all, the short term goal was to reduce dyspnea and to assist in removal of
bronchial secretions.
More over, the long term goal was to improve respiratory muscle power and to achieve
normal activities of daily living.
PHYSIOTHERAPY MANAGEMENT :
Breathing Exercises :
Diaphragmatic breathing (In sitting position with back straight and head, shoulders and arms
in relaxed position place one hand on upper chest and another hand on abdomen, take deep
breath through nose for 2 to 5 seconds and breath out through pursed lips. During inspiration
the hand on abdomen should rise and hand on abdomen should lower during expiration.)
This
exercise was given to improve muscle strength of respiratory muscles mainly diaphragm.
Pursed lip breathing exercises (In sitting position with back straight and head, shoulders and
arms in relaxed position inhale air through nose for 2 to 5 seconds and exhale through lips
tightly pressed. This exercise was given to relieve dyspnea (Nguyen J, Duong H. 2019)
Chest percussion. In side lying position in couch, clapping was performed with slightly
cupped
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hands alternatively to the chest wall with a quick relaxed flexion and extension of wrists. It
was applied over towel. This technique was given to loosen the secretions from the bronchial
walls.
Shaking was given in supine lying by placing both hands anteriorly on chest wall with elbows
slightly bent with body well positioned over the patient. This technique was given to remove
bronchial secretions.
Relaxation positions in sitting and standing were taught to reduce shortness of breath.
Sitting position :
Sit in a chair or in a comfortable position.
Keep feet flat on the floor and lean the chest a little forward.
Rest both elbows on knees
Relax neck and both shoulder region and practice breathing exercises.
Standing position :
Stand with feet and shoulder width apart on sturdy wall.
Lean both hip region on the wall by placing hands on thigh region.
Allow shoulders to relax, lean forward a little and place arms dangle in front.
Practice breathing exercises.
Physiotherapy management of this condition was adapted from chest, Heart and vascular
disorders for physiotherapists by CASH.
Physiotherapy was given for three days in single session per day. Patient had mild
improvement of breathing difficulty and bronchial secretions.
Home Exercises :
Diaphragmatic breathing and pursed lip breathing exercises should be continued for 5 to 10
minutes twice a day.
Patient can follow relaxation positions during breathlessness.
SELF REFLECTION :
Patient should continue breathing exercises regularly to get better improvement as I had
given
therapy for single session in three days . With this case study I had learnt in detail about
physical examination of respiratory patient and it helped me to improve my clinical
reasoning.
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REFERENCES :
Venkatesan prem, Ramesh Chandra Sahoo, Prabha Adhikari (2013) Effect of diaphragmatic
breathing exercise on quality of life in subjects with asthma : A systematic review.
Mike Thomas, Anne Bruton (2014) Breathing exercises for asthma.