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One week ago, a 64-year-old female was admitted to the intensive care unit (ICU) through the hospital Emergency Department in respiratory distress with chief complaints of nonproductive cough and progressively worsening dyspnea on exertion (DOE). Two years ago, she underwent right single lung transplantation due to idiopathic pulmonary fibrosis (IPF). Her postoperative course since transplantation has been complicated by multiple hospitalizations for recurrent respiratory infections and acute graft rejection. For the past month, she has required increased home supplemental oxygen (O2) to 3 L per minute (LPM) via nasal cannula from her typical 2 LPM. Upon ICU admission, her vital signs were: heart rate 90 beats per minute, blood pressure 120/81 mm Hg (mean arterial pressure 94 mm Hg), body temperature 38°C (101°F), oxygen saturation per pulse oximetry (SpO2) 87% at rest on 3 LPM O2 (which dropped to 82% with minimal exertion), and respiration rate 33 breaths per minute with notable distress. Chest radiograph revealed right upper lobe infiltrates; the patient was placed on non-rebreather mask at 10 LPM of O2 and started on broad-spectrum antibiotics. Differential diagnosis upon admission was acute respiratory distress secondary to infection versus acute graft rejection. She has no underlying cardiac disease and her only significant comorbidities are a large hiatal hernia and gastroesophageal reflux disease (GERD) for which she takes omeprazole daily. Other relevant medications include tacrolimus, mycophenolate mofetil, prednisone, and alendronate. Her respiratory status since hospitalization has continued to deteriorate with cultures confirming bronchiolitis obliterans syndrome (BOS). Arterial blood gases show a trend of increasing hypercapnia with worsening hypoxia. The patient has been intubated for the past 2 days and now requires mechanical ventilatory support of pressure control mode, 0.4 fraction of inspired oxygen (FiO2), and positive end-expiratory pressure (PEEP) of 5 cm/H2O. Her critical care team is discussing plans for possible tracheostomy if her status remains unchanged or worsens over the next few days. A physician referral for physical therapy consultation has been made today. The patient lives with her adult daughter.

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Based on the patient's health condition, what do you anticipate will be the contributors to activity limitations?

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What are the physical therapy examination priorities?

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What are the most appropriate physical therapy interventions?

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What precautions should be taken during physical therapy examination and interventions?

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What are possible complications interfering with physical therapy?

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How would this individual's contextual factors influence or change your patient/client management?

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  • BRONCHIOLITIS OBLITERANS SYNDROME: Clinical diagnosis for chronic lung graft rejection
  • ENDOTRACHEAL TUBE: Artificial airway made of plastic tubing orally inserted into a patient's trachea to facilitate maintenance of respiratory activity via a mechanical ventilator
  • IDIOPATHIC PULMONARY FIBROSIS: Progressive, life-threatening lung disease characterized by alveolar scarring, reduced pulmonary compliance, and diminished capacity ...

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