Cardio Prep (Review of Systems and Systems Review)

Question 1

Your patient is s/p CABG following Myocardial Infarction. Comorbidities relating atherosclerotic risk factos. Respiratory orders: maintain SpO2 > 94%. You are seeing them in either Acute Care, Inpatient Rehabilitation, or a Skilled Nursing Facility. What questions in the Review of Systems should be Prioritized with this patient?

Answer 1

• Prioritize assessment of signs of ischemia (e.g., “Are you feeling any discomfort, pressure, tightness, or pain in your chest, shoulders, neck, jaw, or arms right now?”). Persistent ischemic symptoms may signal ongoing cardiac strain, such as incomplete resolution of their recent myocardial infarction or graft occlusion after CABG. In this type of patient, ischemic signs could indicate that the heart is unable to meet increased oxygen demands, making mobilization potentially unsafe and necessitating immediate medical evaluation.
• Evaluate dyspnea (e.g., “Do you now feel short of breath, or have you felt shortness of breath while moving around today?”). Use a dyspnea scale. A positive answer here can reveal respiratory or cardiac strain, such as fluid overload, inadequate cardiac output, or pulmonary complications, which are common concerns in a post-CABG patient. Following and MI and surgery, fluid retention can lead to pulmonary congestion or edema, exacerbating shortness of breath. Dyspnea at rest may indicate significant cardiac or pulmonary compromise, necessitating a delay or modification of activity to ensure safety during mobilization.
• Dizziness or lightheadedness (e.g., “Have you felt dizzy or lightheaded, especially when sitting up or moving?”) helps uncover low cardiac output, or potential arrhythmias, and orthostatic hypotension all of which could compromise safety during mobilization. In a post-CABG patient, these symptoms may result from impaired cardiac function, reduced cerebral perfusion due to low cardiac output, or medication effects like beta-blockers or diuretics. They may also signal ischemia or other complications related to the recent myocardial infarction, necessitating gradual transitions, closer monitoring, or further medical evaluation before proceeding.
• Finally, screen for palpitations (e.g., “Have you noticed your heart racing or any unusual heartbeats?”). Palpitations may indicate arrhythmias, such as atrial fibrillation, which are common after CABG due to surgical stress, inflammation, or changes in autonomic regulation. These arrhythmias can reduce cardiac efficiency and increase the risk of hemodynamic instability during exertion. If present, close monitoring or additional consultation is warranted before proceeding with mobilization to ensure patient safety.

Question 2

Your patient is s/p CABG following Myocardial Infarction. Comorbidities relating atherosclerotic risk factos. Respiratory orders: maintain SpO2 > 94%. You are seeing them in either Acute Care, Inpatient Rehabilitation, or a Skilled Nursing Facility. What should be done in the systems review?

(Based on case, details may be added)

Answer 2

• Auscultation is a useful tool to assess lung function in a post-CABG patient. Pay attention to diminished breath sounds, crackles, or wheezing, as these can indicate atelectasis, pulmonary congestion, or restricted lung expansion. For this type of patient, such findings may explain reduced oxygen delivery and dyspnea during activity, which are common contributors to limited mobility. Identifying these issues helps prioritize interventions, such as breathing exercises or adjustments in activity intensity.
• Inspecting for pitting edema offers critical information about fluid management and circulatory function. Press firmly over bony prominences such as the medial malleolus or shin and observe for sustained indentation. Post-CABG patients are at risk of fluid retention due to decreased mobility or heart function, which may lead to peripheral edema. The presence of pitting edema can contribute to reduced functional capacity.
• Evaluating the patient’s cough can provide valuable information about their ability to clear secretions effectively. Ask the patient to demonstrate their cough and observe whether it is strong, productive, or weak. A weak or ineffective cough in this patient population may indicate impaired ventilation, retained secretions, or reduced chest wall mobility, all of which are common after CABG due to pain, fatigue, or pulmonary complications. Identifying a compromised cough can guide interventions like active cycle breathing techniques or other airway clearance strategies to improve respiratory efficiency, reduce activity limitations, and help prevent post operative pulmonary complications.
• Assessing chest wall excursion at the upper, middle, and lower lobes using a tape measure may provide useful data on ventilation ability. This technique helps detect asymmetries or restricted expansion, which are common in post-CABG patients due to the pain and soft tissues changes following surgical trauma. Limited excursion can contribute to impaired oxygenation and exercise tolerance, providing insight into why the patient may experience activity limitations.

Question 3

Your patient is s/p COPD exacerbation due to community acquired pneumonia. Comorbidity of HTN. Respiratory orders: maintain SpO2 > 88%. You are seeing them in either Acute Care, Inpatient Rehabilitation, or a Skilled Nursing Facility. What questions in the Review of Systems should be Prioritized with this patient?

Answer 3

• Inquire about breathing difficulty at rest and whether it worsens with activities such as speaking or mild movements. This can signal the severity of airflow limitation or the presence of hypoxemia. Identifying dyspnea patterns helps determine the patient’s readiness for activity and ensures interventions are tailored to the patient’s current status.
• Similarly, consider assessing for other symptoms of respiratory distress such as chest tightness by asking whether the patient feels any pressure or constriction. Chest tightness may signal increased respiratory workload or exacerbation of airway obstruction. Additionally, explore difficulty sleeping, particularly if they need to sleep propped up or
• Learn about the patient’s cough. Ask about its frequency, whether it is productive, and if there have been any changes in sputum color. Changes in sputum, such as yellow or green discoloration, may indicate an unresolved or worsening infection. A productive cough can also highlight retained secretions, which may be a priority for intervention. experience shortness of breath while lying flat.
• Asking about orthopnea could suggest worsening pulmonary congestion or compromised respiratory mechanics. This symptom may indicate decreased diaphragmatic efficiency when lying down, both of which can exacerbate hypoxemia. Recognizing orthopnea early helps guide positioning strategies and therapeutic interventions to optimize breathing mechanics and maintain adequate oxygenation

Question 4

Your patient is s/p COPD exacerbation due to community acquired pneumonia. Comorbidity of HTN. Respiratory orders: maintain SpO2 > 88%. You are seeing them in either Acute Care, Inpatient Rehabilitation, or a Skilled Nursing Facility.
What should be done in the systems review?

Answer 4

• Start with respiratory assessments, prioritizing auscultation of breath sounds and adventitious sounds such as crackles or wheezing, as these findings can indicate mucus plugging or fluid accumulation. Assessment of transmitted voice sounds can serve as a valuable adjunct, helping to identify areas of consolidation or atelectasis not easily detected by breath sounds alone. This is critical in a post COPD exacerbation patient because retained secretions or excess fluid can significantly impair gas exchange and increase the work of breathing, exacerbating hypoxemia. Identifying these issues early allows for targeted interventions, such as airway clearance techniques or adjustments to oxygen therapy, to optimize ventilation, maintain SpO₂ levels above the prescribed 88%, and prevent further respiratory decline.
• Proceed to cough assessment, evaluating the strength and effectiveness of the patient’s cough. A weak or ineffective cough necessitates airway clearance interventions to prevent further respiratory compromise.
• Consider manual inspection or tape measurements to identify asymmetries or restricted expansion, which may point to localized areas of atelectasis or consolidation. In this case, restricted chest wall movement may signal impaired ventilation in specific lung segments, often due to inflammation, mucus plugging, or post-infectious changes from pneumonia. These findings are particularly relevant because localized hypoventilation can contribute to decreased overall oxygenation, increasing the risk of not maintaining the required SpO₂ threshold of 88%. Early recognition of these impairments can guide targeted interventions, such as segmental breathing exercises or airway clearance techniques, to improve regional lung expansion and overall respiratory function.

Question 5

Your patient is s/p CHF exacerbation secondary to hypertensive heart disease. They are now stable. Respiratory orders: maintain SpO2 > 92%. You are seeing them in either Acute Care, Inpatient Rehabilitation, or a Skilled Nursing Facility. What questions in the Review of Systems should be Prioritized with this patient?

Answer 5

• In this case, verbal inquiries should focus on symptoms that directly impact cardiac and pulmonary function. Dyspnea should be explored in depth by asking if the patient feels short of breath either at rest or with activity. Use a dyspnea scale. This symptom often reflects residual fluid overload, pulmonary congestion, or inadequate cardiac output, all of which are common in the days following a CHF exacerbation. Understanding the severity and triggers of dyspnea is key to determining whether adjustments to the treatment plan are necessary.
• Another priority is assessing for orthopnea or paroxysmal nocturnal dyspnea, which can be evaluated by asking whether the patient needs extra pillows to sleep or experiences episodes of waking up gasping for air. These symptoms suggest ongoing pulmonary congestion or fluid redistribution, which are hallmark features of left-sided heart failure. Their presence may require further fluid management or modifications to physical activity levels.
• Additionally, lightheadedness should be explored, as these symptoms could indicate low cardiac output, arrhythmias, or medication side effects. It is important to investigate whether these symptoms worsen with positional changes, which could reveal orthostatic hypotension.
• Finally, asking about palpitations can help detect poorly controlled atrial fibrillation, a common comorbidity in this patient population, which might necessitate closer monitoring during physical activity

Question 6

Your patient is s/p CHF exacerbation secondary to hypertensive heart disease. They are now stable. Respiratory orders: maintain SpO2 > 92%. You are seeing them in either Acute Care, Inpatient Rehabilitation, or a Skilled Nursing Facility. What should be done in the systems review?

Answer 6

• For a patient recovering from CHF exacerbation, choosing targeted examinations that address respiratory and circulatory function is the priority. Auscultation of breath sounds is particularly valuable, as it can identify pulmonary congestion, crackles, or diminished breath sounds indicative of fluid overload or atelectasis associated with pleural effusion or pulmonary edema.
• Assessing for pitting edema provides important information about fluid retention and circulatory status. This involves pressing over bony prominences, such as the medial malleolus and tibia, to evaluate the extent and severity of edema. These findings help determine whether interventions to manage fluid overload or improve circulation are necessary.
• Other examination options, such as tape-measured inspection of breathing or manual inspection of breathing symmetry, can provide further data about the patient’s ventilatory function. Measuring chest wall excursion across the upper, middle, and lower thoracic regions offers objective evidence of restricted lung expansion, which is often observed in CHF patients. Manual inspection allows for a tactile evaluation of breathing patterns, identifying any asymmetry or dysfunction that may compromise ventilation

Question 7

Your patient is s/p laparotomy (upper abdominal surgery) complicated by hospital acquired pneumonia (HAP). Respiratory orders: maintain SpO2 > 92%. You are seeing them in either Acute Care, Inpatient Rehabilitation, or a Skilled Nursing Facility. What questions in the Review of Systems should be Prioritized with this patient?

Answer 7

• Dyspnea, or shortness of breath, is a critical symptom to explore. Asking the patient if they feel short of breath at rest or with movement can reveal whether pulmonary complications, such as atelectasis, retained secretions, or lingering effects of pneumonia, are impairing their oxygenation. Use a dyspnea scale. Persistent or worsening dyspnea would suggest the need to adjust therapy intensity or modify the use of supplemental oxygen to maintain safe SpO2 levels above 92%.
• Pain, particularly pain with breathing or coughing, is another essential area of assessment. Post- operative patients frequently experience pain due to the surgical incision, which can limit their ability to take deep breaths or produce an effective cough. Questions such as, “Are you experiencing pain in your chest or abdomen, especially when you breathe deeply or cough?” can uncover barriers to effective ventilation or secretion clearance. Pain that restricts deep breathing may lead to atelectasis, while pain limiting a strong cough can contribute to retained secretions, increasing the risk of complications such as hypoxemia or prolonged recovery. Identifying and addressing pain early is critical to enabling effective participation in therapy.
• Understanding whether the patient has been coughing and whether the cough is productive or dry provides valuable information about their ability to clear secretions. A productive cough may indicate residual infection or mucus in the airways, while a weak or absent cough may suggest reduced chest wall mobility or muscle strength, both of which impair ventilation. Identifying issues with cough effectiveness can guide the choice of airway clearance techniques or breathing exercises.
• Dizziness or lightheadedness, particularly as the patient transitions to upright positions or begins mobilization, should also be assessed. These symptoms may indicate inadequate oxygen delivery, orthostatic hypotension, or fatigue from reduced endurance following surgery and hospitalization. Early identification of these symptoms allows the therapist to implement strategies like paced breathing, gradual transitions, or activity modifications to ensure safe and effective treatment

Question 8

Your patient is s/p laparotomy (upper abdominal surgery) complicated by hospital acquired pneumonia (HAP). Respiratory orders: maintain SpO2 > 92%. You are seeing them in either Acute Care, Inpatient Rehabilitation, or a Skilled Nursing Facility. What should be done in the systems review?

Answer 8

• For a patient recovering from upper abdominal surgery complicated by hospital-acquired pneumonia, the systems review should focus on identifying impairments that directly impact respiratory function and oxygenation. Auscultation of breath and adventitious sounds is a good starting point. This examination allows the therapist to assess for diminished breath sounds, crackles, or wheezing, which may indicate areas of atelectasis, retained secretions, or incomplete resolution of pneumonia.
• To complement the auscultation of breath sounds, transmitted voice sounds should also be assessed. This technique can help confirm findings such as lung consolidation or areas of atelectasis. For example, assessing egophony or bronchophony can reveal increased resonance, which often correlates with consolidated lung regions. Together, these assessments provide a detailed picture of the patient’s pulmonary status and help guide the choice of interventions.
• Manual inspection of breathing symmetry can be another useful assessment. Surgical trauma to the abdomen often disrupts normal diaphragmatic and chest wall movement, leading to asymmetrical or restricted breathing patterns. Observing chest movement in all three lung areas—upper, middle, and lower—provides insight into how effectively the patient is ventilating and whether compensatory strategies, such as accessory muscle use, are being employed. Identifying asymmetries or restricted expansion can guide targeted interventions to optimize ventilation