Case scenarios

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Chapter 4 Case scenarios

4.1 Introduction

4.2 Case Scenarios

4.3 Suggested Answers

4.1 Introduction

The following scenarios portray real situations that are not uncommon in clinical practice. Working through them will allow you to pull together the information covered in this book in a problem-solving manner.

For each of the scenarios consider:

• the type of assessment you would undertake (e.g. systems based, functional, social)

• what your assessment aims and priorities would be

• the significance of your assessment findings.

Suggested solutions are provided at the end of this chapter, with explanations to guide your clinical reasoning. These solutions are not all-encompassing, so other ideas may be worth pursuing, e.g. you could discuss your ideas with your supervisor or mentor. You may need to look back at individual assessment tools for further information.

4.2 Case scenarios

Surgical example

You are asked to review James Williams, a 76 year old man, postoperatively on the ward. He had a laparotomy and small bowel resection and returned to the ward 2 hours ago. He is receiving intravenous fluids and is on morphine patient-controlled analgesia (PCA). On your arrival, his respiratory rate is 6 breaths per minute and his Glasgow Coma Scale (GCS) score is 7/15.

• What type of assessment approach is appropriate for this situation?

• Suggest the main aim of your assessment at this stage?

• What assessment tools or other measurements might you need to use/obtain for this patient?

• What are the potential causes of this situation?

• What do you think is the main problem in the above-mentioned scenario?

Medical scenario

John Smith, aged 71, was diagnosed with chronic obstructive pulmonary disease (COPD) 8 years ago following a 10 year history of gradually worsening shortness of breath (SOB) and productive cough in the winter.

Some background information is provided as follows.

• SH:

– Retired policeman
– Married with three children and eight grandchildren
– Lives with wife in three-bedroom house
– Smoker for 40 years × 10 cigarettes per day = 20 pack-years

• DH:

– Seretide accuhaler 500 BD
– Spiriva inhaler 18 μg OD
– Ventolin inhaler PRN
– Simvastatin 4 mg OD

• Medical Research Council (MRC) breathlessness score: 4

• Lung function tests:

– FVC: 3.9 litres (80% predicted)
– FEV1: 1.2 litres (43% predicted)
– FEV1/FVC ratio: 31%

• Hospital admission

– Mr Smith was admitted to hospital via A&E, very anxious, with severe SOB and is currently on a medical ward.
– His SOB had gradually worsened over the past 7 days with cough producing small amounts of thick yellow sputum and increasing wheeze. He is severely limited by breathlessness and at present he is in bed and does not feel able to mobilize.

• Observations and arterial blood gases (ABGs) on admission:

– HR105 b.p.m.
– BP140/90 mmHg
– temperature37.8°C
– SpO289%
– Oxygen2 litres via nasal cannula
– respiratory rate26 breaths per minute
– pH7.36
– PaO27.2 kPa
– PaCO27.5 kPa
– image26.6 mmol l−1
– base excess +3

• Dyspnoea score at rest = 5 on Borg scale

Physiotherapy assessment 1 (acute medical)

You are asked to assess this man shortly after his admission to the respiratory ward:

• What type of assessment approach is appropriate for this situation?

• Suggest the main aims of your assessment at this stage

• What assessment tools are you likely to use now?

Mr Smith is initially given amoxicillin 500 mg, ventolin nebulizers 2.5 mg in 2.5 ml QDS and prednisolone tablets 30 mg and improves quickly.

Two days later he is being considered for discharge home.

Physiotherapy assessment 2 (discharge assessment)

You are asked to re-assess Mr Smith in relation to discharge planning:

• What type of assessment approach is appropriate for this situation?

• What would be the main aim(s) of your assessment at this stage?

• What assessment tools are you likely to use now?

Physiotherapy assessment 3 (acute community)

Mr Smith is now at home shortly after having been discharged as part of the early discharge support service.

He is sleeping downstairs and has home oxygen at 2 l min−1, which he is using intermittently. His SpO2 is 90% on air. He is still very breathless at rest and is expectorating thick yellow sputum.

• What type of assessment approach is appropriate for this situation?

• What would be the main aim of your assessment at this stage?

• What assessment tools are you likely to use now?

Physiotherapy assessment 4 (rehabilitation assessment)

You re-assess Mr Smith 2 weeks later at home during a follow-up visit.

He has recovered from his chest infection and his temperature has now stabilized at 36.8°C. He has stopped using oxygen and his SpO2 on air is 95%. He is no longer SOBAR (short of breath at rest) but he is still unable to walk far in the house without becoming breathless. He wants to know whether he can go back to sleeping upstairs and whether he can get out. He is very anxious concerning the risk of another attack. He wants to keep using the nebulizers and oxygen ‘just in case’.

• What type of assessment approach is appropriate for this situation?

• What would be the main aim of your assessment at this stage?

• What assessment tools are you likely to use now?

Neuromuscular scenario

Jack Jones, aged 59, was admitted this afternoon. Over the past week he has been generally unwell, with a temperature and cough. He was diagnosed with motor neurone disease (MND) 18 months ago. Prior to this, he was very fit and active.

• SH

– He is a former physical education teacher, married with two children. He lives with his wife in a four-bedroom house and has never smoked.

• DH

– Riluzole

• Lung function tests (last performed 2 months ago) (height 185 cm, weight 86 kg and BMI (body mass index) 25.1)

– FEV112.23 litres (60% predicted)
– FVC2.23 litres (52% predicted)
– FEV1/FVC91%

• Observations taken on admission (on air):

– HR85 b.p.m.
– BP120/85 mmHg
– temperature37.5°C
– pH7.414
– Paco27.04 kPa
– Pao29.27 kPa
– image30.8 mmol l−1
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