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Chronic Obstructive Pulmonary Disease Case Study

Info: 5413 words (22 pages) Nursing Case Study
Published: 12th Feb 2020

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This piece of work will explore the comprehensively physical examination, differential diagnosis and various diagnostic tests to confirm the disease condition that is CHRONIC OBSTRUCTIVE PULMONARY DISEASE. It will then move further to discover the comprehensive treatment plan and present a argument on an excellent method to treat the disease condition on the basis of current evidenced based studies. The actual name of the patient is replaced with another name so as to retain confidentiality (Dimond, 2002).

Mr.X is a 58 year retired office manager came to the emergency ward with his son. He had chief complaints of difficulty in breathing, severe cough, weakness and was feeling discomfort.

Patient general appearance shows that he is weak, sitting in high fowler’s position, respiring through pursed lips. Suggest that this type of breathing is the indication of emphysema. Pursed lip breathing helps in emitting the air which is trapped in the lungs and limits the force for taking breath (Rik Gosselink, 2003).

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History taking and proper investigations are the two main components for confirming the disease condition. Complete history is essential to determine the exact etiology of shortness of breath that includes past history of asthmatic attack, family history of asthma, occupational history, present history of smoking, alcohol intake, medication history, episodes of cough whether it is productive or not, presence of any heart problems (Walsh, 2008).

COPD develops due to the lack of alpha one antitrypsin hereditary factor. Furthermore the occupational hazards along with genetic factor deteriorate the condition. So detail history collection including all the aspects is significant (Yohannes and Hardy, 2003).

History of patient reveals that patient was a chronic smoker from the past 20 years and consume near about twenty cigarettes every day, although patient left smoking 6 months ago his smoking history provides estimation of 20 packs a year. Moreover COPD is more prevalent in patient who consume 20 packs of cigarettes in one year (Georgios et al, 2004). However there are various other diseases that occur due to cigarette smoking such as cancer, heart diseases, pulmonary diseases, influenza, pneumococcal, meningococcal, tuberculosis etc (Arcavi and Benowitz, 2004). Also patient is not able to perform daily activities due to shortness of breath and cough with sputum production. These symptoms are quite common in carcinoma of bronchus, however difficulty in breathing, cough and sputum production are also main clinical symptom of COPD (Pauwels and Rabe, 2004). Moreover, history of the client indicates that plentiful production of sputum for more than three months for two years which shows the presence of chronic bronchitis (GOLD, 2008). Patient is also not able to sleep during night. Awakening during night which occurs by shortness of breath reveal presence of congestive heart failure or asthma (Price, 2010). Complaints of patient we loss of weight, fatigue, chest tightness due to severe episodes of cough, disturbance in sleep. Dietary history shows that patient is non vegetarian, family history does not provide any significant data.

Client having age more than 40 and have sign and symptom such as formation of sputum, difficulty in breathing, history of cigarette smoking and any inhalation of noxious fumes and chances of occurrence of COPD is more at the age above 40 ,therefore patient is believed to have COPD (Vestbo, 2010). Although all the sign and symptom of the client signify that patient is suffering from COPD still functional diagnosis is necessary to confirm the exact diagnosis and proper physical assessment is necessary to confirm the diagnosis (Ferrara, 2011). In high risk cases of COPD proper cardinal sign, body mass index, height and weight of the patient is to be notified as component of assessment (Stockle, 2007). The vital sign of patient are blood pressure:124/76mmHg, height: 174cm, rate of respiration: 20/minute, temperature: 98.2F, Weight: 56kg and body mass index is 19kg/m2.

During inspection it is observed that shape of chest of patient is barrel and patient respire with the help of accessory muscle which indicates presence of emphysema (Smeltzer et al, 2009). This less amount of air in the lungs causes disturbance in breathing pattern (Celli, 2007). This alteration in shape of chest shape occur due to the decrease in flexibility of lungs muscles and therefore extra energy is required for this forceful type of breathing as a result client is not able to eat in adequate manner and loosen the weight (Smeltzer et al, 2009). Percussion indicate presence of tympanic resonance that occur because of less motion of diaphragm and presence of wheezing sounds indicating COPD (Celli, 2007). Auscultation indicate that there is extended forced expiratory pattern due to the decrease in air in the lungs. Congestive heart failure or lung fibrosis is differentiated from COPD on the basis of wheezing sound and presence of ronchi. Club shape finger of patient may indicate the presence of other disease condition such as cancer of lungs, bronchiectasis, and pulmonary fibrosis. The skin mucosa of the client is bluish which signify that less of oxygen in blood (American thoracic society, 2004) .

Physical assessment of respiratory system does not provide the relevant and valid information for the detection of disease condition but related co morbid state and differential diagnosis are well judged with the help of thorough examination (Mcivor et al, 2004). However the decrease in flow of air in lungs is not predicted with the help of history collection and general assessment. Therefore pulmonary functional test such as spirometry is useful in diagnosing COPD (Travers et al, 2007). Furthermore for identification and confirmation of the COPD and its progress level can be easily identify with the help of spirometry (Stoloff, 2011). COPD is well detected with the help of satandarized device that is spirometry however this device is inconsistent in clinical area (Gold, 2008). Spirometry reading of patient reveals that FEV1/FVC is 56% , this value is less than 70% and it is categorize as stage two that is moderate. However spirometry is not believed to be valid tool for the evaluation of broad category of airflow obstruction diseases (Borg, 2010, American Thoracic Society, 2004, GOLD, 2008). But provision of bronchodilators are beneficial in diagnosis of asthma and COPD and determine the limit of flow of air that is not reversible fully. Still the exact value of reversibility that helps in judging the patient asthmatic or COPD pdiseases is not known. However differential diagnosis of COPD can be clinically evaluated and also can determine by various non invasive procedures (Vestbo, 2010). Chest radiography is useful technique in excluding various differential diagnosis such as pneumothorax, chronic heart disease, pneumonia (Man et al, 2004).

Therefore, to clear out the differential diagnosis, a proper clinical examination and simple investigations including chest radiography could resolve uncertainty if any (Vestbo, 2010). Radiography of chest mostly exhibit clear interstitial markings in patient with chronic bronchitis however there is no particular outcomes that provide evidence that radiography is beneficial for the diagnosis of COPD or Chronic bronchitis (Kane & Graham, 2004). In the patient, chest radiography reveals that lung field is hyper distensded, diaphragms are flattened and retrosternal space is more which is the sign of emphysema. Moreover determination of various changes in lungs in case of emphysema can be determined with the help of superior type of chest film (Vestbo, 2010). However with the help of chest x ray it is not possible to detect initial stages of COPD (Gold, 2008). Therefore high resolution Computed tomography is used for identifying emphysema in the initial stages. Moreover the lesions in the lungs can be identifying with the help of high resolution computed tomography (HRCT) without any trouble (Gold, 2008).

There are various other diagnostic test which are helpful in COPD confirmation with more accuracy such as arterial blood gas analysis, cardio pulmonary exercise test (GOLD, 2008). The presence of pulmonary emphysema and various other alternative diseases such as asthma and other minor airway diseases can be determined by the value of total lung capacity and diffusing capacity for carbon monoxide(Vandevoorde, 2006) suggest that through examination of blood gas, saturation of oxygen in blood, blood perfusion is determined (Smeltzer et al, 2009). (also supported that arterial blood analysis in moderate and severe cases of COPD should be performed (Vestbo, 2010). However this test is not is not a reliable test to confirm COPD but in high risk cases of emphysema this test is helpful to know hypoxemia (Travers et al, 2010). Value of ABG analysis of patient was PH-7.30, Pao2-84mmHg, Paco2-48mmHg, HCO3-25mg/dl and Sao2 94% Haemoglobin level of patient was 13.4 mg/dl .

Chronic Obstructive Pulmonary Disease is the disease of respiratory system that causes non reversible and progressive decrease in pulmonary function (Higginson, 2010). The air flow is not proper in lungs due to this reduction of lung function. The diseases it includes are bronchitis, asthma and emphysema. It effect more than three million people in England. (Jones, 2001) In the Western World, the main cause of COPD is smoking, smoking is related with over 90% of this disease, however COPD occurs in merely 10% to 20% of chronic chain smokers. (Beyer et al, 2008)Respiratory illness is also occurred by passive smoking. (Higginson, 2010) Genetic factor is also responsible for yhe occurrence of COPD however there is only one genetic factor alpha antitrypsin that involes in causing this disease. The lack of this genetic factor is the single major risk factor for the occurrence of this disease. Though determine in only one percemt cases of COPD. Contact with noxious substances is the most common cause of COPD. (Yohannes and Hardy, 2003) There are various diseases in childhood such as pneumonia and whooping cough prior to the age of 12 year are considered to be the risk factor of bronchiectasis and bronchiolitis. Females are at high risk of COPD than man however argues that there is no difference in occurrence of COPD in male and females (Lindberg, 2006).

The progress of the disease inside body is mostly described by the inflammation that involve central and peripheral airways. By the inhalation of the noxious substances or irritants , inflammation occurs in the central airway. Due to this soreness , there is more secretion of mucus that damage the ciliary clearance. As a result the glands of the mucus turn into large size and therefore more production of mucus take place due to more amount of goblet cells. This increase production of mucus provides an brilliant medium for the growth of microorganism cause the impairment of airway. Repeated infection causes damage to cilliary body and further inflammation. This progression leads to constriction of airway . Following obstruction trapping of air inside lungs occurs that result in hyperinflation, difficulty in breathing and less tolerance to exercise. The chronic obstruction diseases are chronic bronchitis, emphysema (Higginson, 2010).

For the appropriate management of COPD, holistic approach must be taken in account (Paul, 2004). Individually management plan must be made that covers the essential components such as termination of smoking, dietary management and function of lungs should be maintained by medication therapy. Instant treatment in emergency unit is started with the provision of oxygen and sometime bronchodilator may be beneficial to find out reaction to the treatment (Gold, 2008). Moreover administration of oxygen helps in treating hypoxemia and hence improves breathing problem (Downs & Appel, 2007). However excess utilization of oxygen may lead to withholding of carbon dioxide level in lungs. So it should be provided with cautious (Kevin, 2007). Patient was provided with oxygen therapy for short duration, the partial pressure of oxygen of the patient is 74% so there is no requirement of oxgen for long term (Gold, 2008). Drug therapy is beneficial for the treatment of COPD and it is provided according to the seriousness level of disease condition (Incalzi et al, 2006). In mild COPD cases, short acting beta 2 adrenoceptor agonists is advised whereas in moderate and severe cases long acting beta 2 adrenoreceptor agonist are recommended. Moreover anti cholinergic is beneficial and easily bearable in older people. Pharmacotherapy is essential in relieving the various symptoms however there is no medication that reveals long lasting improvement of lung function (Gold, 2004). Suggest that with the combination of different drug therapy can give better result and reduce the harmful effects as compared to large amount of single dosage. The preference of different bronchodilators depends upon, accomplishment of desired reaction and ill effects (Downs & Appel, 2007). Suggest that due to very few harmful effects and less dosage requirement, inhalation route is chosen for treatment (American thoracic society, 2004) . The widely used short acting beta agonist are salbutamol, terbutaline, pirbuterol and salmeterol, formoterol are the long acting beta agonist also methylxanthines such as theophylline , antichollinergic and inhaled corticosteroid are commonly used that are beneficial in reducing m mucus secretion in airway (Nazir and Erbland, 2009).

Pharmacotherapy in the patient was begin with the administration of combined therapy of salbutamol of dose 50µg with ipratropium 20µg. these are the bronchodilators which is provided with the help of inhaled and injection of theophyllin also administered through intra muscular route. There are some other drugs that are beneficial in severe stage such as antioxidants and immunoregulators (Gold, 2008)

Improper nutrition in COPD patient is quite general and it has harmful influence on the pulmonary functioning. So helping the client in maintenance of adequate nutrition level is important and beneficial in improving the respiratory functioning (Shepherd, 2010). Moreover the client whose BMI is less than 21 kg/m2 should be given supplementary diet in order to improve condition of client further (Vermeeren et al, 2001). However age associated alteration in structure, height, muscular changes and if value of BMI is more than also malnutrition cannot be identified (Shepherd, 2010). In patient BMI is in normal category instead patient is advised to take adequate calories, carbhohydrate and proteins in diet. Patient is also advised to avoid caffeine, restrict sodium and taking more milk.

The other preventive measure is vaccination of influenza. It has much influence in prevention of various acute respiratory illnesses along with COPD. This type of vaccination must be advised to each patient suffering from COPD (Wongsurakiat, 2004) .

Patient who is moderate or severe deterioration of lung function then pulmonary rehabilitation is beneficial to gain maximum functioning to manage with disease condition. Patients are motivated to do different types of exercise to keep body healty Such as steps up, walking , various arm exercises, self handling of various activites such as taking medication, that helps in keeping the function of different system appropriately. Also exercise for decreasing hyperinflation and manage dyspnoea such as deep breathing and pursed lip is advised to the patient (Barnett, 2008). Moreover advantages of rehabilitation of lung fuction maintain for numerous months even after the end of this program (O` Donell, 2007) .

COPD is the most prevalent problem that effect mostly elderly people. The mai symptom of COPD is shortness of breath, production of cough with sputum. The main cause of occurrence of this disease is cigarette smoking. History taking and physical examination is beneficial in excluding all the differential diagnosis. Through spirometry diagnosis of COPD can be made. Pharmacology is helpful in controlling the further spread of disease but medication does not provide efficient result in long term care.


This case study will throw light on the complete physical examination and diagnostic test and a range of laboratory investigation to confirm the diagnosis. It will then undergo detail treatment plan along with differential diagnosis to explain the appropriate intervention on the basis of present evidence sources. Also it will explore the recent issues regarding care of spinal cord injured patent. The actual name of the patient is changed in the study so that data cannot be recognized (Dimond, 2002).

Mr. Malik Aggarwal is a 21 year old student studying in University of Greenwich doing mastering in marketing. During summer break in France, Malik was struck with an motorbike accident. During accident he fall harshly on the footpath from his bike and was lying towards his abdomen . This accident was witnessed by the policeman and he quickly gave call for first aid management. Ambulance was arrived soon and emergency staff identify the severity of Malik injury, they protect the neck of the victim with the help of strong board and immobilize the part before transferring him to the emergency department of the closest hospital. Patient was awake and also familiarized with current date, day and location. He was also replying in well manner. After reaching hospital, he complained of loss of feeling on his both legs, severe pain in neck, mild pain on his back and all extremities, patient was not able to move his neck and lower extremities properly. The assessment was carried out by the emergency specialist staff, and found that there were contusions and lesions present on his trunk and lower extremities, the restriction of the neck was rapidly maintained by the staff with the help of firm cervical collar. In order to limit further deterioration of condition, patient was supported with cervical traction and head was also supported with motion restricted devices that are helpful in maintaining proper alignment (Grubb, 2006) .

The cardinal signs were checked and indicate that patient has Blood pressure of 100/70, pulse rate: 90/minute, respiration: 20/mt, temperature: 98.4 F and oxygen saturation was 90%.

During history collection main emphasis should be given on complete mechanism that how the injury took place, this data is confirmed from the witness and also who is present at the time of accident to so as to proceed accurately towards confirmation of diagnosis (Schreiber, 2009). Other physical and social factors should be noticed that may interfere with the proper assessment of pain (Cruz-Almeida, 2007). Moreover complete history plays an important role in knowing possible etiology of different symptoms and also helps in excluding differential diagnosis. Proper pharmacological history , family history and dietary history should be taken because it might be beneficial in knowing the disease (Cox, 2008) .

History collection of patient reveals that patient was anxious and had complaint of pain at the site of neck. The constant pain occur due to the contraction of muscles of neck muscls. There were presence of mild lesions on the trunk and extremities. Therefore it might be the case of injury on cervical cord because continual pain is the indication of spinal cord injury (Lee and Ostrander, 2003) . The exact cause of injury is the extreme flexion of head towards the chest that is due to hyperflexion. Moreover if the main reason of spinal cord injury is hyperflexion or hyperextension then it might be the case of spinal cord injury (ElFaramawy, 2009). Client gave appropriate reaction to each question during history taking , this shows that patient has good level of consciousness.

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As patient vital sign indicate that patient has hypotension, low respiratory rate and decrease in temperature. The one reason for the occurrence of hypotension might be the interference of vagal and symphathetic vascular tone (Karlet 2001). The client symptoms of hypotension, bradycardia indicates that it might be due to neurogenic shock (McLeod, 2004).

After the collection of data it is essential to carry out physical assessment by covering all the aspects. Adequate Physical assessment is the basis in determining the injury related to spinal cord (Bono and Lee, 2004). Moreover physical examination especially of neurological system is beneficial in gathering the baseline data. The main section in neurological examination include will be cranial nerves, sensory and motor function and also reflexes (Noah, 2004).

Assessment take place by mkaintaing proper interpersonal relationship with patient. While doing inspection assess for the mental condition, intellectual and cognitive response of the patient (Crimlisk, & Grande 2004). Assess for the posture of the patient, if posture maintained by patient is decerebrate thenit may indicate trauma in the midbrain. With the help of Glasgow coma scale, level of consciousness should be assessed and also this scale is beneficial in determining the sensory, motor and verbal response. However the response through this scale is not satisfactory in determing the verbal function (Iyer, 2009). Assess for the extremities for spasticity, presence of weakness, flaccidity as these are the significant mark of damage to neurologic system and also assess for the pronator drift which signify hemiparesis (Crimlisk and Grande, 2004).

In the patient, level of consciousness through Glasgow coma is assessed and it is found to be 13 which is normal(Iyer, 2009). Inspection of the patient indicates that there is presence of abrasions on the body and he has difficulty in breathing which is indicated from the use of accessory muscles. This data may be crucial in determine that damage occur in between C3 and C5 vertebrae (Walker, 2009).

Neck and trunk should be properly palpated as it is helpful in determine any kind of defect in the neurological system. Palpation should be done in an appropriate manner starting from the cranium and regularly descending along the vertebral disc. On palpation of patient there is feeling of rigidity of muscles of cervical and tenderness. So there are chances of cervical injury (Noah, 2004). Diagnosis of spinal cord injury is based not just on history collection and examination infact complete neurological examination and radiographic studies are essential for the confirmation of diagnosis (Berney, et al 2011) .

Spinal nerve assessment should be done with the help of hammer that should be strike beneath the knee. Striking causing sending of nerve impulse and thigh muscles contracted due to this flow of nerve impulse. If there is no contraction of muscles then it indicates there is distruption in the pathway and some sensory or motor deficit. In patient there was mild contraction of muscle fibre indicate neurological deficit(Cox, 2008).

After that cranial nerves should be assessed by various method such as recognization of smell, assessment of the vision through snellen chart, assess for speech ,facial expression, assess for optic fundi with the help of opthalmoscope, if there is presence of papilloedema it may be the case of increase intracranial pressure. In patient all the cranial nerves are intact and also no papilloedema is present which exclude the diagnosis of increased intracranial pressure (Cox, 2008) .

Patient motor and sensory function is determined by the American Spinal Injury Association (AISA) impairment scale. In this scale sensory deficit and motor impairment is recognized with the help of broad categorization. In the patient the strength of elbows, wrist was normal, the stretch of the biceps and triceps was also normal. The response of the patient towards light touch and pin prick was normal up to the inguinal area however due to weakness of lower limbs, the response of lower extremities was not adequate indicate sensory deficit due to spinal cord trauma (Dodwell, 2010) .

However the proper alignment of the vertebrae and recognizing of fracture cannot be possible with such scale so for that radiography is essential (Sheerin, 2005). The radiography is beneficial in determine the fracture of thoracic vertebrae, it gives reliable information but it is not useful in case of cervical vertebrae as these vertebrae are to small to be visible appropriately in radiography (Jorge, 2009). Radiography of the patient provide inadequate data as the film was not properly clear.

The deep examination of displacement of bone segments and fractures is possible with the help of computed tomography. The CT scan is beneficial in visualization of the image in different cross section (Jorge, 2009).

It is possible to get exact information regarding injury of bone with the help of CT scan and radiography films however the injury to the soft tissue on the cord, intervertebral disc then these diagnostic test does not provide complete information regarding soft tissues (Sheerin, 2005). The CT scan of patient exhibit that injury take place at the level of C5 spine.

Magnetic Resonance Imaging is helpful in visualization of injury that occurs on soft tissues by providing well clarify image. The further deterioration and injury that occur due to soft tissues is clearly recognized with the help of MRI (Sheerin, 2005). The MRI of patient shows that there is no soft tissue injury.

Functional studies such as positron emission tomography, electromyograms are not of use in case of conscious client. They are only essential in patients who are not cooperative (McDonald and Sadowsky, 2002).

From the above history collection, physical assessment, various diagnostic test it is clear that client has cervical injury at the level of 5 intercostals vertebra.

Spinal cord is the basic part of central nervous system. It consists of thirty one segments. However due to the fusion of coccygeal bones there are 30 segments in vertebral column (Sheerin, 2004). Spinal cord has two region that is cervical and lumber and it is consist of grey matter (Sheerin, 2004). Approximation of 500 to 700 people each year suffers from traumatic spinal cord injury in UK. The main aetiology of spinal cord injury is straight mechanical injury and injury develops due to the compression on cord (Pellatt, 2010). This compression develops from traumatic and non traumatic reason (McDonald & Sandusky, 2002). Due to this overstress of cord, intense flexion, extension or rotation develops. If injury develops due to direct force then within little duration discharge of enzymes from cells and vasoactive substance take place. After that neutrophills and macrophages infilterate in that region. The amount of potassium in extracellular fluid boost up and cells become depolarized and result in hypoxic conditions. Where as in case of indirect cause, vascular system compromised causing lack of blood supply in tissues. Which further leads to development of various haemorrhages, due to this haemorrhages the endothelium of blood vessels become disrupted. Further development of aneurysms occurs causing thrombi development in blood vessels. Due to stimulation of vagus nerve, imbalance thermoregulation develops and because of dermal blood vessel dilatation various life threatening sign and symptoms are developed such as neurogenic shock due to vasodilatation (McDonald and Sadowsky, 2002).

There are also development of various syndrome such as anterior cord syndrome which occurs due to the injury to the two third of spinal cord in the anterior side, and next is the posterior cord syndrome that occurs due to the injury to the two third of spinal cord in the posterior side (Bailes et al, 200) .

Central cord syndrome mainly occupies the cervical part of spinal cord. This syndrome usually influence elderly people and develop cervical spondylosis due to hyperextension. This spondylosis and hyperextension injury together put compression on the anterior and posterior side of cord. Due to which ligament turn towards inner side and put force on the anterior horn cells. This will further causes development of oedema (Bailes et al, 200) .

Management of the patient begins from the site of the accident. First priority of the management is the maintenance of the airway, breathing and circulation. Oxygen therapy helps to prevent hypoxic conditions along with that oxygen therapy stop secondary injury that occurs due to the hypoxic conditions. For maintain airway jaw thrust method should be used chin lift method should be avoided as this may deteriorate the neck by extension (Pellatt, 2010). Immediately stabilization of spine must be maintain with the help of stiff cervical colour. The client must be positioned on hard board so as to maintain proper alignment. If there is requirement of intubation then it should be maintained with the help of three people without mobilizing the patient. However immobilization is not as important as the oxygen therapy because death of the patient may take place due to development of encephalopathy in hypoxic condition (Sheerin, 2005).

After the confirmation of diagnosis, drug therapy should be started without any delay. Currently this drug therapy is recognized as basic treatment and helps in limiting secondary damage due to hypoxic condition. Steroid treatment must be started immediately. Methylprednisolone is more preferable. The amount needed for this drug is 30mg/kg in 15minutes, subsequently 5.44mg/kg/hr within 24 hours. Steroid treatment helps in improving neurologic deficit through blood flow toward central nervous system. However this drug is helps in only protection of neurological function and also use of elevated amount this drug result in side effects such as gastric bleeding and infection of wound (Weant, 2008). Further supporting, this drug is usually beneficial within 8 hours of injury. Also in the study organized by the researcher in random controlled trial to see the impact of nimodipine and methylprednisolone on patient with spinal cord injury in acute phase is that both the drugs produce side effects and these drugs are not of much beneficial (Pointillart, 2000).

Also respiratory and cardiovascular function should be adequately maintained in spinal cord injury. Excessive damage if occur by spinal cord injury has remarkable effect on respiratory system. Mostly colloidal solutions maintain pulmonary wedge pressure. (Nockels, 2001) Moreover due to spinal cord injury the tidal volume generated by accessory muscles is not adequate and result in further damage to pulmonary function so there is need of maintainence of respiratory function. Also hypotension may develop in patient as a result of neurogenic shock. Therefore it is essential to check blood pressure and average arterial pressure should be more than 85mmHg. However if blood pressure is too low than it can be managed with the help of vasopressin agent such as dopamine (Sheerin, 2005).

Mr. Malik was provided oxygen about 2 litres/min so as to maintain proper perfusion. Pulse oxymetry was continued and part


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