Examination and Assessment handbook (1) Flashcards
What is the examination and assessment of the cardiorespiratory
directed at answering?
- What clinical problems does the patient have for which physiotherapy may be helpful?
- Are the any considerations which might influence the choice of treatment?
What comes under subjective history
What the patient tells you
Case notes
patient observation charts
history of presenting condition
past medical and surgical history
social history
drug history
Dyspnoea measures
visual analogue scale
numerical rating scale
modified borg scale
MRC breathlessness scale
What comes under objective assessment
What you see and find for yourself
Observation
cough
breathing pattern assessment
auscultations
Subjective History
A patient with a cardiorespiratory condition may need additional
time to answer questions
Patients with cardiorespiratory problems will have a lots of information in their case notes become familiar with this information before doing the assessment and examination of the patient
Case Notes
DIAGNOSIS:
1.History of Presenting Condition – e.g. From Accident & Emergency or notes
- Past Medical & Surgical History
- Test Results e.g. Full blood count (FBC), arterial blood gases (ABGs), pulmonary function tests (spirometry), sputum culture (MC&S).
4.Imaging e.g. Chest X-ray (CXR), CT Thorax, Thoracic Ultrasound (TUS)
Patient’s Observation Charts
Heart Rate (HR)
Blood Pressure (BP)
Respiratory Rate (RR)
Temperature
History of Presenting Condition
Details of the onset of this episode of illness may be indicated in the case notes.
History of Presenting Condition
What should you do about the problems/symptoms identified by the patient
Make certain of them in person
History of Presenting Condition
Name the symptoms
- Dyspnoea (unpleasant sensation of breathlessness) at rest and/or on exertion.
- Orthopnoea (breathless when lying down flat)
- Cough symptoms – dry/productive/tickly
- Sputum – volume/colour/viscosity - change from usual
• Chest pain – nature (to differentiate cardiac angina pain from MSK thoracic
pain)
• Wheeze or chest tightness
History of Presenting Condition
What should you ascertain for the symptoms
- when it started
- Is it getting better or worse?
- Is it continuous or intermittent?
- What aggravates or eases it?
History of Presenting Condition
How would you get the patient to quantify the problem
- amount and colour of sputum
- numerical rating scale for pain / dyspnoea
- number of stairs patient can climb / how far they can walk without stopping
History of Presenting Condition
For each symptom how does it compare now to normally?
Treatment so far for this episode of illness and its effect, including current medication and any physiotherapy.
Past Medical & Surgical History
What are the Questions you ask?
Original onset or diagnosis of the condition if different to above?
Course of the condition, including any exacerbations, hospital admissions or physiotherapy?
Any other respiratory problems?
Any cardiac problems?
Any other medical illnesses past or present?
Any previous surgery and response to it?
Social History (from patient and/or relative/carer)
Social circumstances living alone?
Type of accommodation? Stairs?
Normal activity levels & usual functional capacity – obtain specific measure of their exercise capacity e.g. how far or long they can walk for, how frequently they exercise.
Smoking History – how long, how many per day, when gave up (if relevant).
Occupation?
Hobbies?
Pets?
Any family history of cardiac or respiratory conditions?
Drug History (from patient or their paper/electronic notes)
Respiratory Medication
- Bronchodilators – inhalers or nebulisers, ask about frequency, dose, relief provided
- Antibiotics – oral, IV or inhaled
- Steroids – long or short-term use, oral or inhaled
• Oxygen – method of delivery, long or short-term use
Analgesia (pain relief)
Non respiratory medication
Dyspnoea Measures
Sensation of breathlessness is subjective, there are measures that quantify an aspect to this sensation.
Similar to pain scales.
Dyspnoea Measures
Visual Analogue Scale
10cm line ask the patient what level they are experiencing
Minimal dysponea🤗I———————————l🤢Maximum
Numerical Rating Scale
Ask patient a number they are feeling breathless out of 10
Modified Borg Dyspnoea Scale
Show patient a scale and get them to point which applies to them
0 Nothing at all
0.5 Very, very slight (just noticeable)
1 Very slight
2 Slight
3 Moderate
4 Somewhat severe
5 Severe
6 More severe
7 Very severe
8 more severe
9 Very, very severe (almost maximal)
10 Maximal
Medical Research Council (MRC) Breathlessness Scale
Grade
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground because of breathlessness, or has
to stop for breath when walking at own pace
4 Stops for breath after walking about 100m or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing or undressing
Objective Assessment
“look, listen and feel” format (observation, auscultation, palpation)
followed by any other special tests required.
If patients may be acutely unwell, the more medicalised
A-B-C-D-E assessment is used.
Observation
Body parts
General
Face
Trachea
Thorax
Abdomen
Hands ankle
General observation
Position in the bed
Level of Consciousness (Alert, responsive to Voice, responsive to Pain
or Unresponsive; AVPU)
Attachments/Equipment e.g. drips, drains, oxygen
Signs of pain/anxiety/fatigue
Face observation
Colour e.g. flushed, pale, blue (central cyanosis = severe hypoxia)
Trachea observation
Trachea Centrally positioned or deviated to one side
Thorax observation
Thorax Shape e.g. barrel chest, funnel chest, scoliosis, kyphosis
Surgical Scars – previous thoracic or cardiac surgery
Abdomen observation
Abdomen Distension / obesity
Hands observation
Hands Finger clubbing (nail bed bulging associated with chronic
cardiorespiratory disease)
Tremor or flapping (associated with increased C02)
Nicotine stains
Blue fingers (peripheral cyanosis = inadequate peripheral circulation)
Ankle observation
Ankles Oedema (cardiac failure, immobility, poor venous return)
Cough
Cough is a prominent symptom forpatients with cardiorespiratory disease
Assessment of it can provide important information
The importance of coughing and different types of patients
Most patients will cough readily
some will present with a weak, ineffective or absent cough.
The ability to cough is an essential part of airway defence and should
always be assessed thoroughly
Type of cough and description
Dry :Clear cough sound with no audible respiratory secretions.
NB// Does not necessarily mean there is no sputum
Wet :Audible secretions in the lower respiratory tract
Rattling :Audible secretions in the upper respiratory tract
Productive : Patient is expectorating (spitting out) sputum after coughing
Need to describe the sputum (see below)
Type of sputum
Description
Implication
1)Clear - Saliva-like Not indicative of infection
2)Mucoid - White/milky, opaque Viral infection or non-infective
bronchitis
3) Purulent - Yellow/Green, pus-likeBacterial infection (colour is from dead neutrophils)
4) Frothy -Pink or white froth Pulmonary oedema
5)Frank
haemoptysis- Pure blood Pulmonary haemorrhage, TB, tumour,
cavity, lung infarction, pulmonary embolus.
6)Streaked
haemoptysis- Blood mixed with white/purulent sputum Inflammation of bronchial tree, tumour, cavity
Breathing Pattern Assessment
Observe the patient’s breathing pattern for one minute at rest and consider the following:
See notes
Auscultation
A stethoscope is used to listen to the chest and identify normal and abnormal sounds
Used as an investigation and outcome measure
Auscultation
Preparation
• Eliminate noise: close door, turn off radios/ TV.
• Patient :sitting up in bed or a chair. If possible patient
should not be leaning against anything – they may need help to sit forwards.
- Ask the patient to take their top off (if possible) or ask permission to move the patient’s clothing out of the way - your stethoscope should be touching the patient’s bare skin.
- Always ensure patient comfort. Be considerate and warm the diaphragm of your stethoscope with your hand before auscultation.
Auscultation
Procedure
• posterior chest: ask the patient to keep both arms crossed in front of his/her chest, if possible.
• Ask the patient to breathe deeply through the mouth. Be careful of
hyperventilation. Listen to at least one full inspiration & expiration in each location.
• It is important that you always compare what you hear with the opposite side.
e.g. If you are listening to the left apex, you should follow through by
comparing what you heard with what you hear at the right apex.
• Generally, listen to at least 6 locations on both the anterior and
posterior chest.
• Begin by auscultating the apices of the lungs, moving from side to side and comparing as you approach the bases.
Palpation
Palpation is used as part of the assessment to further investigate the observed and auscultated findings.
An explanation for palpation should be provided and consent obtained from the patient.
Palpation trachea
Assess whether the trachea is central or deviated
Palpation thorax
Thorax Palpate upper chest over main bronchi
Palpate lower chest, laterally
Assess for symmetry of movement
Assess for quality of expansion during deep breath
Assess for bronchial fremitus (vibration indicating secretions)
Palpation clvicales
Clavicles Palpate for surgical emphysema (feels like bubble wrap)
Palpation abdomen
Abdomen Assess for distension
Assess for expiratory accessory muscle use
Palpation Hands
Hands Assess for temperature
Assess for swelling
Heart rate
What is the site most commonly palpate the pulse
Wrist
Heart rate procedure
- You will need to be able to see a clock or watch that has a second hand.
- Make sure that the patient is comfortable & as relaxed as possible - one who is distressed may have a faster pulse.
• Place your first and second finger along the artery which can be palpated just medial to the radial styloid process. Apply light pressure until you feel the
pulse.
• Count the pulse for 30 seconds, multiply this measurement by 2 and record the heart rate in beats per minute
Respiratory Rate
If a patient is aware of their respiratory rate being counted
What is an effective way to assess the genuine resting respiratory rate
perform the pulse rate assessment (as above) then:
- Without releasing the patients wrist look for movement of the ribs or abdomen as the patient breathes
- Count the number of breaths the patient takes in 30 seconds
- Multiply this measurement by 2 and record the respiratory rate in breaths per minute
- NB/ in some clinical areas it is necessary to count the respiratory rate for a full minute e.g. post-surgery
Special Tests
The following measures may be used to assess the patient initially and/or to use as ongoing outcome measures to assess the effectiveness of the intervention.
Name the Special Tests
Peak flow
Spirometry
Pulse Oximetry
Exercise Testing
Cardiopulmonary Exercise Testing (CPET)
Incremental shuttle walking test (ISWT)
6 minute walking test (6MWT
Chester step test
Outline what Peak flow is
Used to assess the patient initially and/or to use as ongoing outcome measures to assess the effectiveness of the intervention.
Simple and cheap test that measures maximum expiratory rate (fastest speed patient can breathe out) using a peak flow meter.
In healthy adults normal
PEFR is 400-650L/min which varies according to age, height and sex.
Significant variability in PEFR = PEFR
readings should be viewed with the overall trend.
Describe procedure of peak flow
- Explain to the patient the purpose of PEFR and obtain consent.
- Attach a clean or disposable mouthpiece
- Set the arrow to the zero mark
- Position the patient upright - sitting upright or preferably standing up
• Ask the patient to take a maximal inspiration then to close her or his lips
around the mouthpiece and to exhale as forcibly as possible
• Note the measurement
• Repeat the process a further two times ensuring that the arrow is reset to the
zero mark for each measurement.
• Dispose of the mouthpiece (if appropriate), and ensure that the equipment is
clean
• Make a note of the highest value reached, documenting specific
time/previous medication
• Compare the measurement against a recognised chart of normal values, and
more importantly against the individual’s normal value.
Outline what spirometry is
Spirometry can be used to measure all lung volumes except residual volume and
functional residual capacity.
In the clinical setting a useful measure is that of the
FEV1/FVC ratio as it is a measure of airway limitation.
• FEV1 & FVC are related to height, age and sex of the patient
• SFEV1 – volume of air expelled in the first second of a forced expiration,
starting from full inspiration
• FVC – total volume of air expelled during a forced exhalation
starting from full inspiration
Describe the procedure of spirometry
• Explain to the patient the purpose of spirometry and obtain
consent.
• Attach a clean or disposable mouthpiece to the spirometer & enter the
patient’s age, sex & height into the spirometer when prompted.
• Position the patient upright - sitting upright or preferably standing up
• Ask the patient to take a maximal inspiration then to close her or his lips
around the mouthpiece and to exhale as hard and as fast as possible
- Instruct the patient to keep breathing out until the lungs are ‘empty’.
- Note the measurement
• Some patients may need to practice just emptying their lungs without the
Spirometer before getting them to attempt the test
• Three satisfactory blows should be performed and best values taken for
interpretation.
• Dispose of the mouthpiece, and ensure that the equipment is clean.
• Make a note of the highest value reached, documenting specific
time/previous medication.
• Compare the measurement against a recognised chart of normal values – the
spirometer may do this automatically.
Pulse oximetry
Pulse oximetry is a procedure used to measure the oxygen level (or oxygen
saturation) in the blood.
It is considered to be a non-invasive, painless,
general indicator of oxygen delivery to the peripheral tissues.
Pulse oximetry measures the percentage of haemoglobin that is carrying oxygen by
shining an infra-red light into the patient’s finger (or ear lobe).
Oxy-haemoglobin absorbs more infra-red light than deoxy-haemoglobin therefore the oximeter can
detect the proportion of oxy-haemoglobin to deoxy-haemoglobin.
Normal values are 95-98%. Inaccurate readings may be obtained with severe hypotension, low cardiac output, vasoconstriction and hypothermia, all of which reduce the volume of blood to the tissues
Reasons for assessing exercise capacity in patients with respiratory conditions
Exercise testing
Allows the assessor to:
- Determine the level of functional impairment and activity limitation
- Determine factors which may limit exercise capacity
- Provide guidance for exercise prescription
• Identify oxygen desaturation during exercise and aid prescription of
supplemental oxygen
• Evaluate the effectiveness of rehabilitation in altering exercise capacity
A number of methods may be used to assess exercise capacity.
Cardiopulmonary Exercise Testing (CPET)
This is considered the ‘gold standard’ of
exercise testing its a maximal exercise test
and gives detailed information on the
cardiorespiratory system during exercise and indicates the limitations to exercise.
The maximal oxygen uptake (V02max) can be
determined as well as the individual’s anaerobic
threshold.
Limitations CPET
expensive laboratory equipment
specialised staff Physiologists
unsafe for some patients =sub-maximal ‘field tests’ have been developed which show patient’s functional exercise capacity.
Sub maximal tests
Incremental shuttle walking test (ISWT)
6 minute walking test (6MWT
Chester step test
Incremental shuttle walking test (ISWT)
This walking test was designed to simulate a cardiopulmonary exercise test and is a
walking version of the ‘bleep test’.
The patient is required to walk between two
cones in time to a set of auditory beeps played on a CD.
6 minute walking test (6MWT)
The patient walks 30m shuttles for 6 minutes and the distance walked is recorded.
For full instructions follow this link
Chester step test
Patient steps on and off a step of a pre-determined height at a set rate with external audio cues (beats).
After each level is completed, the rate of
stepping increases. It is essentially a step-up version of the bleep test.
The Chester Step Test is typically used to assess patients pre- and post-cardiac
rehabilitation programmes, whereas the walking tests (ISWT & 6MWT) are typically
used to assess patients pre- and post-pulmonary rehabilitation.
Chest X-Ray Interpretation
After clinical examination, the most commonly used special investigation of the
thorax is the chest x-ray.
When viewing a CXR, you should employ a systematic approach
Look at link
Projection
P.A. (postero- anterior) is the usual view in which the subject sits or stands with the anterior surface of the chest against the film and the x-ray tube behind. The patient is asked to take a deep breath in and hold it at which point the x-ray is taken.
A.P. (antero-posterior) is when the film is placed behind the patient and the x-ray tube is in front, that is the beam passes from anterior to posterior. A.P. films are used for ill patients in the I.C.U. and wards.
*Note that if an object is near the film there is little magnification but if the object is further away there is more magnification that is in an A.P. film the heart is magnified.
Lateral view is used to assess distribution and localisation of abnormal shadows seen on P.A or A.P.
Oblique view is used to demonstrate ribs, to assess the heart and aorta and in bronchography.
Decubitus view is taken with the x-ray beam horizontal to the floor and the patient lying on their side in a P.A. position. It is used to show the flow of fluid when an effusion is suspected when there is difficulty interpreting the P.A. film.
CRX Assessment
- Name, date and time.
- Projection: P.A./A.P./lateral etc
- Centering – is the patient rotated? That is are the clavicle ends and spine
symmetrically disposed? - Correct exposure?
Chest x-rays demonstrate:
• Hard tissues
• Soft tissues
• Lung fields and associated structures
Hard tissues clavicle
seen crossing the apices of the lungs
Hard tissues ribs
Ribs - Seen as they curve around the thorax, running parallel.
Posterior parts are seen most clearly, run horizontally or slightly downwards
and the anterior ends curve down and in.
The costal cartilages are invisible except when they become calcified.
The 10th rib should be seen if the x-ray is taken in full inspiration.
Check general shape, density, direction and spacing.
Abnormalities
- Congenital anomaly in number of ribs
- Bifid ribs
- Fractures
- Metastases
Hard tissues sternum
largely hidden by the vertebrae
Hard tissues Thoracic vertebrae
only just visible on a properly exposed P.A. chest film Scoliosis and Kyphosis may be seen.
Hard tissues scapula
medial border and inferior angle should be identified
Soft tissues breasts
Vary in size and shape and can be asymmetrical
Gynomastia may be seen in males
Absence of one or more breasts affects the translucency of the lung bases.
Nipples may cast a shadow.
Soft tissues muscles
The edge of sternocleidomastoid often seen as a vertical line running outwards from the medial end of the clavicle
Pectoralis Major – increased shadowing over the middle and upper parts of the chest.
When absent this can give rise to hypertranslucency
and misleading impression of emphysema.
Lung fields and associated structures
Diaphragm
2 domes, convex upwards.
Laterally the diaphragm meets the chest wall at the acute costo-phrenic angle.
Centrally a tendinous part of the diaphragm is fused to the pericardium and at each side there is a cardiophrenic angle.
The right dome is usually 1 – 3cms higher than the left due to the liver pushing up against it, seen at the 10th rib posteriorly.
Abnormalities
Unilateral elevation of a dome – due to gas distension, inflammatory changes in the lungs and pleura, sub-phrenic abscess, pulmonary
collapse with the diaphragm rising to fill the space left by the diminished lung volume, pulmonary embolus (PE), hepatomegaly, splenomegaly, phrenic palsy
Bilateral elevation – due to pressure from below – obesity, pregnancy, ascites, tumour. In the sub-diaphragmatic area gas may be seen in the
gastric fundus and splenic flexure.
The under surface of the (R) dome
normally inseparable from the liver shadow.
Lung fields and associated structures
Mediastinum
mediastinal shadow due to the heart and great vessels. It should be examined with respect to size, shape and position.
Heart is in the centre of the thorax, outline projection is 1/3rd to (R) and 2/3 to (L).
The normal cardiothoracic ratio is usually 1:2 for a normal adult male.
The translucency of the trachea overlies two cervical and upper 5 thoracic vertebrae. It usually lies centrally or just to the (R) of midline and its walls are parallel to each other.
The bifurcation into the major bronchi can usually just be identified.
The (R) main bronchus enters the lung at the level of T5 and the (L) at T6.
Lung fields and associated structures
Hilar shadows
produced by the main and lobar branches of the pulmonary arteries and veins and hilar lymph glands.
The (L) hilar shadow appears 1-2cms higher than the (R).
Lung fields and associated structures
Lung fields
Radiotranslucency – in normal lungs, the translucency at a given level should be equal on both sides.
Lung fields and associated structures
Pulmonary vascular pattern
constitute the lung markings, almost entirely arterial.
These should be traced from the hilum on each side.
The pattern should be compared on the two sides.
Normally vessels appear larger and more numerous in lower zones (due to erect posture) and increased blood in dependent regions.
Lung fields and associated structures
Fissures
Can only be visualised if they lie tangentially to the path of the x-rays.
In the P.A. film the, horizontal fissure can be seen from the right hilum to the mid-axillary line in the 5th intercostal space in over 75% of cases.
A lateral film is needed to see the oblique fissure.
Lung fields and associated structures
Lung zones
For radiographic examination 3 zones are identified.
Upper zone – portion of lungs lying above the line drawn horizontally at level
of anterior ends of the 2nd rib
Mid zone – between upper zone and above horizontal line drawn at level of
anterior ends of 4th ribs
Lower zone – portion of chest below anterior ends of 4th ribs
Review Areas:
4 areas require particular attention
- Apices
- Hilar regions
- Heart shadow
- Costophrenic angle
Radiographic Appearance of Common Pathologies
Consolidation
Indicates the state of the lung where the alveolar air has been replaced by
- Cellular exudates e.g.pneumonia
- Transudate, e.g. pulmonary oedema
- Blood – trauma, inhalation, infarction
- Neoplastic cells, the alveoli remaining intact
Appearance of airlessness without shrinkage.
Radiographic appearance the same whatever the cause and often whatever the stage of consolidation.
Consolidation may be:
Complete - All air in affected area has been replaced.
Degree of radiopacity depends on the thickness of consolidation in the line of the x-ray beam.
Homogenous shadowing, loss of vascular markings.
Although alveoli contain fluid bronchi will probably still contain air which contrasts with shadow = air bronchogram
Incomplete - Only some of the alveoli are affected and there is only a slight increase in the overall radiopacity – may show as fine mottling or as a faint ground glass shadowing.
Consolidation may also be lobar, sub-lobar, segmental or sub-segmental.
Radiographic Appearance of Common Pathologies
Atelectasis/collapse
Appearance of airlessness with shrinkage
> ATELECTASIS
absorption collapse as a sequel to bronchial obstruction, due to;
Extrinsic pressure - tumour, glandular mass, aneurysm
Intrinsic disease – bronchial Ca, granulation tissue, exudates
Viscid sputum – asthma
Inhaled material – foreign body, blood
Smaller area of lung affected than with collapse.
> COLLAPSE:
compression collapse, usually lobar or segmental caused by:
- Large pleural effusion
- Tumour
- Tension pneumothorax
- Ascites, hepatomegaly, splenomegaly all cause local collapse
> Appearance the same whatever the cause and is modified by several factors:
- Degree of shrinkage
- ? accompanying consolidation
- State of pleura
- Pre-existing condition of lung
Full collapsed lung: the hemithorax of the affected side will be radio opaque.
Partial collapsed lung: (lobe, segment, sub-segmental) and
there is no accompanying consolidation, there will be no increase in radiopacity.
Only evidence will be a shift in normal landmarks – position of fissures, vascular pattern, hilar shadow
Radiographic Appearance of Common Pathologies
Pulmonary oedema
Accumulation of excessive fluid in the interstitial spaces of the lung with subsequent movement of fluid into the alveolar spaces. Due to imbalance between rate of production and removal.
Many causes – some examples • Heart failure • Fluid overload – excess i.v. fluid, renal failure • Cerebral disease – CVA, trauma • Liver disease
Radiographic Appearance of Common Pathologies
Pneumothorax
Air within the pleural cavity.
- Spontaneous – commonly caused by rupture of emphysematous subpleural bleb
- External entry of air, for example due to a penetrating wound
• From the mediastinum, for example due to a ruptured trachea,bronchus,
oesophagus. Pneumo-mediastinum may result from violent coughing Large pneumothorax may cause mediastinal shift to the normal side, the
displacement increasing on expiration.
A small pneumothorax is best demonstrated on P.A. radiograph exposed on expiration (usually performed routinely on a patient with a suspected
pneumothorax.
Radiographic Appearance of Common Pathologies
Emphysema
Reduction in size and number of vascular markings, best seen in middle and outer thirds of the lungs. Air trapping shows an increase in the volume of lung – ‘over inflation’ and flattening of the contours of the diaphragm.
Heart shadow often long and narrow and the cardiothoracic ratio at 1:3 or 1:4. Lung fields usually appear more translucent.
Radiographic Appearance of Common Pathologies
Bullae
These are thin walled spherical or oval translucencies which vary in diameter from a few mm to several cms. Often seen at the periphery of the lung at the base or apex.
Their walls are smooth and regular. They are often difficult to differentiate from a pneumothorax.
Radiographic Appearance of Common Pathologies
Chronic bronchitis
Often no specific radiological signs, but the x-ray should be examined to assess degree of emphysema, determine whether cardiovascular changes or cor pulmonale are developing and to determine the presence of other disease, for example, TB.
There may be:
- Small ill-defined opacities seen anywhere in the lungs which may indicate small areas of consolidation or scarring from previous inflammation
- Linear shadows – may represent old fibrotic changes
- Altered vascular pattern
Radiographic Appearance of Common Pathologies
Chronic asthma
Only one third of chronic asthma patients exhibit radiographic abnormalities.
There may be:
- Airways obstruction may lead to over inflation of lungs, lowering of the domes of the diaphragm
- Transient areas of consolidation
- Alteration in vascular markings.
Other Thoracic Imaging
Thoracic Ultrasound (TUS)
Uses ultrasound waves to produce an image of the thoracic structures. Can differentiate between consolidation and effusion and can also assess diaphragm function.
It is portable and does not expose the patient to radiation therefore is a
useful alternative to CT imaging. Some specialised physiotherapists are additionally trained to carry out TUS.
Other Thoracic Imaging
Blood tests
Physiotherapist working with both in-patients and out-patients with cardiorespiratory problems will have access to a variety of blood test results.
The most relevant to physiotherapists are usually the arterial blood gas (ABG) and the full blood count (FBC)
Other Thoracic Imaging
Arterial blood gas
Blood gas analysis gives a reading of the partial pressures exerted by oxygen and carbon dioxide dissolved in the plasma of arterial blood. It also measures the pH and the level of bicarbonate in the blood.
The base excess (BE) is a calculated figure (i.e. not directly measured) which provides an estimate of the surplus amount of alkali
within the blood.
Normal ABG values
Normal values for ABGs:
- pH 7.35-7.45
- PaCO2 4.7-6.0
- PaO2 10.7-13.3
- HCO3- 22-26
- BE -2 to +2
Other Thoracic Imaging
Full blood count
This will provide information about the number and type of cells found within the blood. Raised white cell count (WCC) may indicate infection, reduced haemoglobin (Hb) may indicate blood loss and low platelets may indicate an increased likelihood
of bleeding.
Normal FBC values
Normal Values:
Haemoglobin (Hb) Males 130–180 g/ L
Females 115–165 g/ L
White cell count (WCC)
Total 3.6–11.0 × 109/ L
Neutrophils 1.8–7.5 × 109/ L
Lymphocytes 1.0–4.0 × 109/ L
Monocytes 0.2–0.8 × 109/ L
Eosinophils 0.1–0.4 × 109/ L
Basophils 0.02–0.10 × 109/ L
Platelets 140–400 × 109/ L
State what the ABCDE stands for
A = Airway
Note type of airway – ETT (artificial airway from mouth to trachea),
tracheostomy, patient’s own
B = Breathing
Note method of ventilation – self, ventilator, mode, fraction of inspired
oxygen (Fi02), ventilator settings
Respiratory observations - RR, ABGs, Sa02
Look, listen and feel (observation, auscultation, palpation) assessment of
respiratory function
CXR, CT scan
C = Circulation
Cardiovascular system observations - HR, BP, ECG trace, note any inotropes.
D = Disability
Sedation level, alertness (AVPU), note any sedatives, recent paralysing agents
Muscle power, functional ability, PROM
E = Exposure
Note all attachments and awareness of purpose/importance
Observe limb oedema, temperature, skin colour e.g. Mottled
Wounds, incisions, injuries (trauma patient).
Other Thoracic Imaging
Computed Tomography (CT)
The patient lies on a table then, using an x-ray tube and detectors, a computer reconstructs signals received from the detectors. The images acquired are transverse (axial) cross-sections of the patient.
To orientate the patient, it is convention to view all CT images as if it from the patient’s feet.
It can be used to localise tumours and assist with the diagnosis of bronchial, alveolar and interstitial lung diseases. It is a costly procedure and exposes the patient to a dose of radiation, however it is the gold standard for lung imaging
What is A-B-C-D-E Assessment
This type of assessment is used when assessing an acutely unwell patient. It is a standardised assessment used by all medical professionals in emergency situations.
You may be required to assess routine patients in this format in acute care settings such as intensive care or high dependency.
Radiographic Appearance of Common Pathologies
Pleura effusion
Fluid within the pleural cavity.
Homogenous shadow devoid of pulmonary markings. Pleural fluid occupies space in the thorax at the expense of underlying lung which retracts towards the hilum –appearance depends on the elasticity of the lung.
Presence or absence of pleural adhesions may cause loculations of fluid.
