CASE NO 2:
NAME: FehmidaAGE: 42GENDER:Female
MARTIAL STATUS: MarriedOCCUPATION:Housewife
WARD: Medical Ward 2 ADDRESS: Numaish, Karachi
DATE OF ADMISSION: 9.8.2016DATE OF ASSESSMENT: 15.8.2016
DIAGNOSIS: Bronchiectasis with lung abscess
SOCIAL AND MEDICAL OUTLINE:
A 42 years old, married female come to hospital, which has a complete family. She has known
case of Bronchiectasis with lung abscess. She presents with complain of increasing SOB
(Shortness of breath) with fever and productive cough (yellow foul smelling) small in amount
less than one teaspoon for 1 month and admitted in HDU (High Dependency Unit). These
problems are gradual in onset, progressive, exertional, firstly she could walk upto market, now
she develops SOB on rest or even going to washroom.She has problem of SOB (Shortness of
breath) since 1 year back.According to patient’s attendant she was admitted to LNH (Liaquat
National Hosp.)which is 7 months back for complain of SOB where she put on LTOT (Long
Term Oxygen Therapy) for 2 months then left it. Now using O2 at home for 1 month.She also
diagnosed with HTN (Hypertension) since 6 months..
CXR: Large cavity in Rt. lower zone of the lung with consolidation.
CT Scan: CHEST PA: Pulmonary infection most likely Koch’s
H.R.C.T OF THE CHEST: Imaging features are suggestive of interstitial lung disease with
possibility of underlying old granulomatous infection should also be considered
ULTRASOUND: Normal scan of abdomen.
On posture analysis, patient sits upright with relaxation. She also maintain mobility of the
thorax. She is using nebulize for 3-5 min daily.
SUBJECTIVE HISTORY:
PRESENT COMPLAIN:
Patient has complain of increasing SOB (Shortness of breath) with fever and productive cough
(yellow foul smelling) small in amount less than one teaspoon for 1 month.
HISTORY OF PRESENT COMPLAIN:
She presents with complain of increasing SOB (Shortness of breath) with fever and productive
cough (yellow foul smelling) small in amount less than one teaspoon for 1 month. These
problems are gradual in onset, progressive, exertional, firstly she could walk upto market, now
she develops SOB on rest or even going to washroom. She has problem of SOB (Shortness of
breath) since 1 year back. Now using O2 at home for 1 month
PAST MEDICAL HISTORY:
According to patient’s attendant she was admitted to LNH (Liaquat National Hosp.) which is 7
months back i.e Dec 2015 to Jan 2016 for complain of SOB where she put on LTOT (Long Term
Oxygen Therapy) for 2 months then left it. She also diagnosed with HTN (Hypertension) since 6
months..
Patient take tablet Extor 5/80 mg for HTN (Hypertension) since 6 month back.
ADDICTION HISTORY:
No history of addiction.
FAMILY HISTORY:
Not significant.
SURGICAL HISTORY:
No
TRANSFUSION HISTORY:
No.
SOCIOECONOMICAL HISTORY:
Housewife
Co-operative family.
DRUG HISTORY:
Myrin P forte for bronchiectasis
Fortum 1 gm for lung abscess
Deltacortril 5 mg for both bronchiectasis and lung abscess.
Tablet Extor 5/80 mg for HTN (Hypertension) since 6 month back.
INVESTIGATIONS:
CXR: Large cavity in Rt. lower zone of the lung with consolidation.
CT Scan: CHEST PA: Pulmonary infection most likely Koch’s
H.R.C.T OF THE CHEST: Imaging features are suggestive of interstitial lung disease with
possibility of underlying old granulomatous infection should also be considered
ULTRASOUND: Normal scan of abdomen.
BLOOD TEST: Hb is 8.0, ESR is 121, TLC is 9.0 and MCV is 78.
UCE: U is 9, Cr is 0.3, Na+ is 132, Cl- is 90, K is 3.8.
INR: 0.93.
ABG’S: pH – 7.61
pCO2 – 26.5 mm Hg
pO2 – 130 mm Hg
SpO2 – 99.2 %
HCO3 – 29 .9 mEq/L
These are further plans;
SPUTUM CULTURE: Sputum for AFB (Reports were not issued).
ECG: Reports were not issued.
OTHER BLOOD REPORT: CBC (Reports were not issued).
HbAIC2 (Reports were not issued).
LFTS: Reports were not issued.
URINE D/R: Not accessible
OBJECTIVE EXAMINATION:
OBSERVATION:
POSITION: Patient is in sitting position on bed without ventilator. In hospital patient will use
nebulizedaily for 3-5 min. She looks like moon like face and plethoric.
Patient is oriented, conscious but not obeying our all commands.
CVS (CARDIOVASCULAR SYSTEM) ASSESSMENT:
RESPIRATORY SYSTEM ASSESSMENT:
CHEST SHAPE: Symmetry
BREATHING PATTERN: Shallow breathing.
SPUTUM:Mucopurulent
GCS: 15/15
CHARTS:
VITALS: BP – 110/40 mm Hg
Pulse – 120 beats/min
Temp – A/F
SaO2 – 98% with O2
SUBVITALS: A+,J-,Cl-,Cy-,E-
EQUIPMENT:
Catheterized patient.
PALPATION:
ABDOMEN: Soft, non tender.
PERCUSSION NOTE: Not done.
AUSCULTATION:
BREATH SOUNDS: NVB.
ADDED SOUNDS: Inspiratory crackles (coarse) on right upper chest anteriorly and B/L ½ of
chest posteriorly.
NEUROLOGICAL ASSESSMENT:
Nil
GCS: 15/15
CNS: Intact
MSK ASSESSMENT:
Nil
PRIMARY DIAGNOSIS:
Bronchiectasis with lung abscess.
SECONDARY DIAGNOSIS:
Nil
PROBLEM LIST:
CVS (CARDIOVASCULAR):
RESPIRATORY:
Shortness of breath due to obstruction of airways.
Air entry is reduced bilaterally.
Secretions retention at Rt. upper chest anteriorly and B/L ½ of chest posteriorlydue to
pathological changes.
Breathing pattern is shallow due to incorrect breathing technique.
Reduce mobility (able to walk but reduced than beforebecause patient is hospitalized).
NEUROLOGICAL:
Nil
MSK:
Nil
GOALS:
CVS (CARDIOVASCULAR):
RESPIRATORY:
SHORT TERM GOALS:
Reduce shortness of breath within 2 to 5 days.
Reduce secretion retention within 2 to 5 days (chest clear).
Improve breathing pattern.
Improve symptoms
Reduce complications
Control exacerbations
LONG TERM GOALS:
To regain optimal function capacity.
NEUROLOGICAL:
SHORT TERM GOALS:
Nil
LONG TERM GOALS:
Nil
MSK:
SHORT TERM GOALS:
Nil
LONG TERM GOALS:
Nil
OTHER’S:
SHORT TERM GOALS:
Nil
LONG TERM GOALS:
Nil
TREATMENT:
DAY 1:DATE: 15.8.2016
VITALS:
BP – 100/60 mm Hg
Pulse – 130 beats/min
R/R – 36 /min
Temp – 1000F
SaO2 – 94%
ABG’S:
Not mention in file.
PHYSIOTHERAPY TREATMENT:
CVS (CARDIOVASCULAR):
RESPIRATORY:
Every 2 hours position will change.
ACBT’s which involves;
Breathing control (3-4 times)
Deep breathing exercises or thoracic expansion exercises (1-2 times)
F.E.T (Forced Expiration Technique) or Huffing (3-4 times)
Shaking
Tissue blowing (10 times)
Postural drainage (advice proper positioning of the body to reduce secretion retention)
ADVICE:
ACBT’s which involves;
Breathing control (3-4 times)
Deep breathing exercises or thoracic expansion exercises (1-2 times)
F.E.T (Forced Expiration Technique)or Huffing (3-4 times)
Patient repeat these exercises atleast 3 times once in a day.
NEUROLOGICAL:
Nil
MSK:
Nil
OTHER’S:
Nil
DAY 2: DATE: 16.8.2016
VITALS:
BP – 120/90 mm Hg
Pulse – 110 beats/min
R/R – 28 /min
Temp – 98
SaO2 – 96% with off O2
ABG’S:
Not mention in file.
PHYSIOTHERAPY TREATMENT:
CVS (CARDIOVASCULAR):
RESPIRATORY:
Every 2 hours position will change.
ACBT’s which involves;
Breathing control (3-4 times)
Deep breathing exercises or thoracic expansion exercises (1-2 times)
F.E.T (Forced Expiration Technique) or Huffing (3-4 times)
Shaking
Tissue blowing (10 times)
Incentive Spirometry
Postural drainage (advice proper positioning of the body to reduce secretion retention)
ADVICE:
ACBT’s which involves;
Breathing control (3-4 times)
Deep breathing exercises or thoracic expansion exercises (1-2 times)
F.E.T (Forced Expiration Technique)or Huffing (3-4 times)
Incentive Spirometry
Patient repeat these exercises atleast 3 times once in a day.
NEUROLOGICAL:
Nil
MSK:
Nil
OTHER’S:
Nil
DAY 3:DATE: 17.8.2016
VITALS:
BP – 150/90 mm Hg
Pulse – 120 beats/min
R/R – 16 /min
Temp – 1020F
SaO2 – 88% off O2
ABG’S:pH – 7.61
pCO2 – 26.5 mm Hg
pO2 – 130 mm Hg
SpO2 – 99.2 %
HCO3 – 29 .9 mEq/L
PHYSIOTHERAPY TREATMENT:
CVS (CARDIOVASCULAR):
RESPIRATORY:
Every 2 hours position will change.
ACBT’s which involves;
Breathing control (3-4 times)
Deep breathing exercises or thoracic expansion exercises (3-4 times)
F.E.T (Forced Expiration Technique)or Huffing (3-5 times)
Shaking
Tissue blowing (10 times)
Incentive Spirometry
Postural drainage (advice proper positioning of the body to reduce secretion retention)
ADVICE:
ACBT’s which involves;
Breathing control (3-4 times)
Deep breathing exercises or thoracic expansion exercises (1-2 times)
F.E.T (Forced Expiration Technique) or Huffing (3-4 times)
Tissue blowing (10 times)
Incentive Spirometry
Patient repeat these exercises atleast 3 times once in a day.
NEUROLOGICAL:
Nil
MSK:
nil
OTHER’S:
Nil
OUTCOME:
The patient’s family is co-operated but patient is not co-operated throughout the whole treatment
sessions. Sometimes when she follow our commands she feels better but when she is not obeying
our commands she will not feels good. Some problems are solved like SOB is reduce.In hospital
patient will use nebulizer daily for 3-5 min. Patientis in HDU (High Dependency Unit)..Patient’s
main problem is solved i.e: SOB and fever is reduce as compare when she admitted to hospital.
Because of postural drainage she has reduce secretion retention and now her chest is clear than
before. Before the treatment she complains SOB, fever and productive cough and after treatment
her problems are solved not so much but better than before.
After all sessions her SOB is reduce and her chest is also clear because of postural drainage but
in this case patient is LAMA (Leave against medical advice). If patient is stay in hospital we
gain good result.
REFLECTION:
We are satisfied with the given treatment as this treatment is good for the patient. In every
session, patient respond is not normal sometimes she do exercises or sometimes not. We suggest
her incentive spirometryto regain optimal function capacity. In all sessions we do ACBT’S
because it has good result when patient complain SOB or any chest complication. But in this
case we avoid deep inspiration because the increase in negative pressure may move the pus
through healthy lung tissue. In the case of bronchiectasis with lung abscess we always suggest
patient to keep herself incentive spirometry.
In this case we learn that how to manage this patient and how respond these patients before and
after treatment. The treatment which we applied in this patient is good for her but I think if
patient still stay in hospital and continue her treatment she achieves more good health as before.
At start, she presents with SOB, fever and productive cough and after treatment her SOB reduce
and chest is clear as before. In this case we perform ACBT’s, tissue blowing and incentive
spirometryfor bronchiectasis with lung abscess.
