Assessment and Examination

Question 1

What should we look at in the medical chart review?

Answer 1

Information
Past medical history
Risk factors for cardio and pulm disease
Relevant social history
Occupational history
Home environment assessment

Question 2

What laboratory values should we look at?

Answer 2

Clinical laboratory data
Lab data
Radiological studies
Oxygen therapy
Surgical procedures
ECG and telemetry monitoring
PFT
ABG
Vitals
Hospital course

Question 3

What are examples of “information” we need to look at during chart review?

Answer 3

Diagnosis and date of treatment: primary and secondary diagnosis (fracture hip- pneumonia postop), date (acuteness of situation)
Symptoms: cardiac ischemic symptoms (chest pain, tightness, SOB, palpitations, burning), pulmonary symptoms (SOB, dyspnea on exertion, cough, increased WOB, sputum production), change in symptoms

Question 4

What are characteristics of past medical history?

Answer 4

Orthopedic, neurologic, psychological
Medications
Certain medications may affect patients response to exercise/activity

Question 5

What are risk factors we should look at during chart review?

Answer 5

From history and physical exam: HTN, smoking, family history, older age, obesity, diabetes, sedentary lifestyle, develop realistic goals, identify other rehab team members, decide on precautions to increased activity

Question 6

What are parts of social history, occupational history, and home environment we need to look at during chart review?

Answer 6

Social: smoking, alcohol/drug abuse, friends/family, lifestyle activities, hobbies
Occupation: type of work (allows for realistic goals and developing return to work plan), work hardening program
Home environment: support system (improve ability to respond to disease), if patient requires a lot of care the family’s ability to supply this care and it’s financial resources should be assessed, gather important info about patient’s present compliance, history of medical problems, risk factors, perception and understanding of problem, family situation

Question 7

What lab data should we look at during chart review?

Answer 7

Cardiac enzymes: creatine, LDH
Blood lipids: cholesterol, triglycerides
CBC: Hb, hematocrit, WBC
ABG
Coagulation studies
Electrolyte screening and glucose tolerance test

Question 8

What are we looking for with radiological studies during chart review?

Answer 8

Chest xray: changes in lung space, presence of fluid, heart size, pneumonia serial radiograph to monitor disease progression and effectiveness of treatment
CT
MRI

Question 9

What are indications for oxygen therapy?

Answer 9

Use of supplemental O2 and method of delivery
ABG
Low oxygen but not below 60 mmHg on room air: supplemental O2 with exercise
Resting PO2 less than 60 mmHg or saturation below 90: supplemental O2
Aerosol, inspirometers, bronchodilator treatments; administered before exercise to improve performance

Question 10

Why should we review surgical procedures?

Answer 10

Complications during or following surgery: slower recovery
Greater amount of lung tissue removed: smaller amount of lung is available for O2 and CO2 diffusion so there is greater impairment in performance of activities
Incision
Cardiac

Question 11

What PFT results should we look at during chart review?

Answer 11

PFT via spirometry: static and dynamic
Dynamic values decrease: limitations on exercise as unable to actively move large volumes of air rapidly
Treatment planning: modifications supplemental oxygen (low flung volumes, bronchodilator meds for patients with decrease flow rates or volumes

Question 12

Why should we look at ABG, vitals, and hospital course during chart review?

Answer 12

ABG: serial ABD provides feedback on therapeutic regimen
Vitals: important to review for trends and establishment of baseline
Hospital course: prolonged or complicated hospital course affects activity progression (example- if they are under anesthesia longer they will have a more complicated stay)

Question 13

What are parts of the physical exam?

Answer 13

Inspection, palpation, percussion, auscultation, activity evaluation

Question 14

What are parts of the inspection?

Answer 14

General appearance, facial expression, effort of breathing, breathing through nose/mouth, neck, chest, phonation/cough/sputum production, posture, positioning, extremities

Question 15

What are things we look at with general appearance?

Answer 15

Level of consciousness: if patient can understand the treatment plan (alert, agitate, confused, semi comatose, comatose

Body type: indirect measure of nutrition and indication of level of exercise tolerance (obese has decreased tolerance and increased WOB, cachetic has weakness from wasting muscles, normal)

Body posture: kyphosis, scoliosis

Body position: tripod position indicates increased WOB (COPD- emphysema), view from door (supine, use of pillows, semi fowlers)

Skin tone: cyanotic

Presence of all equipment-monitoring or support: cardiac monitor, pulmonary artery catheter, patient not taking oxygen properly- confused state- cyanotic

Question 16

Upon inspection what should we look at in regards to facial characteristics?

Answer 16

Facial expression: distress and fatigue- indicate a need for change in treatment
Signs of distress: nasal flaring, sweating, paleness
Effort to breathe- use of face and neck muscles and movement of lips to breathe (pursed lip breathing)

Question 17

What are parts of the neck evaluation (part of inspection)?

Answer 17

Sternocleidomastoid: shortening due to chronic forward bent posture of head and trunk, hypertrophy when used extensively
Jugular vein distention: patient sitting or recumbent in bed head elevated at least 45, if veins distended above level of clavicle, indicates increased volume in the venous system which is an early sign of right sided heart failure

Question 18

What are parts of the chest evaluation during inspection?

Answer 18

Resting chest: symmetry, barrel chest in COPD, asymmetry in scoliosis, thoracic surgery (pain, splinting, or lung or rib loss), congenital defects (funnel or pigeon chest)
Chronic hyperinflation: rib angle increased, intercostal spaces broader anteriorly, diaphragm is stretched flatter and less effective
Musculature: accessory muscle hypertrophy (scalenes, traps, intercostals)
Dynamic chest: breathing patterns
Rate
Inspiratory to expiratory ratio
Symmetry of chest wall motion

Question 19

What are dynamic breathing patterns?

Answer 19

Apnea: periods where breathing is suspended/delayed
Eupnea: normal
Bradypnea: slow breathing
Tachypnea: fast breathing
Hyperapnea: deep active breaths
Prolonged expiration: COPD
Orthopnea: SOB wit sitting, can't be flat
Hyperventilation
Dyspnea: difficulty breathing
Cheyne-stokes: CHF

Question 20

What are parts of phonation, cough, and cough production inspection?

Answer 20

Dyspnea of phonation: speech interrupted for breath
Poor voice control: weak muscles in speaking and breathing
Cough: strength, depth and length of cough; weak muscles= weak cough; bronchospasm= long spasmodic cough; secretions (quantity, color, smell, consistency)

Cough: foul smelling copious purulent sputum is bronchiectasis, blood tinged sputum is sanguineous, frothy sputum is either pulmonary edema or dyspnea (heart failure), productive for more than 3 months for at least 2 years is chronic bronchitis

Question 21

What should we look at when inspecting the extremities?

Answer 21

Digital clubbing: tissue hypoxia
Cyanosis: decreased circulation due to cold, vasospasm, peripheral vascular disease, reduced cardiac output
Calves: blue/purple, peripheral vascular insufficeincy

Question 22

During lung auscultation what would increase/decrease sound transmission mean?

Answer 22

Increased transmission is consolidation

Decreased transmission is air trapping

Question 23

What areas should be auscultated on the heart?

Answer 23

Aortic, pulmonary, tricuspid, mitral, third left ICS (murmurs of aortic and pulmonary areas), S1, S2, abnormal heart sounds

Question 24

What should we palpate during inspection?

Answer 24

Evaluation of muscle activity: palpation of accessory muscles, diaphragm
Chest wall discomfort and pain: musculoskeletal pain from bed rest and inactivity, differentiate musculoskeletal pain from angina pain
Evaluation of circulation: pulses, visual skin inspection

Question 25

What are types of sounds heard when percussing?

Answer 25

Resonance
Dull: liver, other dense tissues
Tympanic/hyperresonant: loud, long hollow, heard over empty stomach and hyper inflated chest

Used to further evaluate any abnormal findings especially changes in lung density

Question 26

What are parts of activity evaluation?

Answer 26

Assessment of patient responses to: rest, sitting, standing, ambulation/activity
Monitor: HR, rhythm, BP, O2 sats

Question 27

What should we look for with HR measurements?

Answer 27

Should increase as work load increases

HR achieved in: health adult, cardiac, pulmonary, kidney, comorbid conditions

Question 28

What are abnormal HR responses?

Answer 28

Rapid rise: severe deconditioning
Decrease in palpated HR: monitored by EKG- indicated an increase in arrhythmias, increase in number of pauses- arrhythmias are increasing
Flat rate of rise: underlying cardiovascular cause

Question 29

What should we look for with HR rhythm?

Answer 29

Should be regular with exercise
If arrhythmia at rest: no change with activity
If change with activity: represent a new finding, benign or life threatening, due to meds, severity of symptoms associated

Question 30

What is evaluation of oxygen saturation?

Answer 30

Pulse oximeter
Normal response: remain in normal range
Patient with chronic pulmonary dysfunction of CHF: desaturate their O2 from hemoglobin with activity
Caution if desaturation less than 90
No exercise if saturation drops to 86 or below