cardio pulmonary assessment

1. CARDIOPULMONARY
ASSESSMENT
1

2. • CONTENTS
Pomr
Measurements
Documentation
Personal details and history
Subjective assessment
Objective assessment
Investigations
Observation
Palpation
Percussion
Auscultation
Prognosis
Treatment
2

3. 3
• POMR- Problem Oriented Medical Records:
Used as the method of recording the
assessment, management and progress of a
patient.
• Divided in five sections
1. Database
2. Problem list
3. Initial plan and goal
4. Progress notes
5. Discharge summary
SOAP: Subjective, objective, analysis, plan

4. Selecting , performing and interpreting
measurements
• Don’t repeat test
• Appropriate to the specific pathology
• Should contribute to course and progression of
Rx
• To be able to replicate for future comparisons
• One should know ‘normal’ to interpret the results
• values depend on age , medicines , fitness levels
4

5. • DOCUMENTATION
• To assist and to maximise compensation for
loss.
• To facilitate efficient care through
communication amongst health care
professionals.
5

6. 6
PERSONAL DETAILS:
Name :
Age :
Gender :
Weight :
Life style :
Occupation :
Residence : emphasis on stairs
Ref. by :
Provisional diagnosis : present diagnosis
Chief complaint :

7. HISTORY: INTERVIEW AND QUESTIONNAIRES
ALLOW sufficient time to express ; without interruption..so
that nothing is missed out
a) H/O presenting condition:
i.e. patient’s current problems,
including relevant information from
medical notes
b) Previous medical history:
i.e. entire list of medical & surgical problems that the
patient has had in past
written in disease specific grouping or chronological
account
7

8. c) Drug history:
List of patient’s current medication ( with dosage)
Drug allergies should also be noted
d) Family history:
List of any major disease suffered by members of
immediate family
e) Social history:
level of support available at home & to gain idea of
patient’s expected contribution to household duties
f) H/O smoking & alcohol use:
no. of pack / yrs may be calculated as relative risk of
COPD. i.e. (average no. of packs/day) (no. of yrs smoked)
8

9. SUBJECTIVE ASSESSMENT:
Based on an interview with patient
Starts with open ended questions: what is the main problem?
what troubles you most?
5 main symptoms of respiratory diseases:
• Breathlessness
• Cough
• Sputum & Hemoptysis
• Wheeze
• Chest pain
9

10. 10

11. For each of these symptoms, ask about :
▪ Duration :
both absolute time since 1st
recognition (months, yrs)
& duration of present symptoms (days, week)
11

12. 12
▪ Severity :
In absolute terms & relative to recent &
distant .past
• Pattern : seasonal or daily variation
• Associated factors : aggravating & relieving

13. DYSPNEA
• A subjective experience of breathing discomfort that
consists of qualitatively distinct sensations that vary
in intensity."
• Other definitions describe it as "difficulty in
breathing", "disordered or inadequate breathing",
"uncomfortable awareness of breathing", and as
the experience of "breathlessness" (which may be
either acute or chronic).
13

14. • O2 delivery from ambient air to the
mitochondria of cell depends on intact
interaction of respiratory , cardiovascular and
muscular systems.
• Same for CO2 elimination.
14

15. CAUSES OF DYSPNEA
1) awareness of normal breathing e.g.anxiety
2) in work of breathing e.g.loss of lung
compliance
3) Abnormality in ventilatory system e.g.
thoracic cage abnormality , obesity..large
pleural effusion , neurological…
15

16. TYPES OF DYSPNEA
1) Acute dyspnea
2) Dyspnea on exertion
3) Dyspnea in cardiac patients
4) Orthopnea
5) Platypnea
6) Trepopnea
7) Functional dyspnea
16

17. 1) ACUTE DYSPNEA
Acute asthma , pulmonary embolism , CHF , upper
airway obstruction , arrhythmias , lt. ventricular
dysfunction..
2) DYSPNEA ON EXERTION
a result of chronic pulmonary disease or CHF,
valvular heart disease.
3) DYSPNEA IN CARDIAC PATIENTS
10
symptom of a decompensating lt. ventricle ; in
cyanotic heart dz. Dyspnea + fatigue because of
low arterial oxyhemoglobin.
17

18. MECHANISM
Lt. ventricle
fails to eject
Normal blood volume
Chronic pulmonary Venous hypertension
Congestion + pulmonary oedema
Stiff or less compliant lungs
+ hypoxic drive WOB
18

19. 4) ORTHOPNEA
• Dyspnea in recumbent position(splanchnic
circulation)
• Pooling of blood in lungs giving rise to
increase in pulmonary capillary pressure and
hence dyspnea.
19

20. 5) Trepopnea
• In one lateral position
• As in unilateral respiratory system pathology
due to V/Q mismatch.
• V > Q in the upper zone , due to pooling of
pulmonary capillary blood to the underneath
side due to gravity.
• Normally , capillaries on the lower side
constrict and that on the upper side
20

21. • open up to shunt blood to the part with
greater ventilation.
• In respiratory disease , this does not happen.
• Hence there is blood circulation in poorly
ventilated alveoli , decreased oxygen
perfusion and thus dyspnea.
21

22. 6) Platypnea
• While assuming sitting from supine
• Causes : hepatopulmonary , pulmonary ,
positional right to left shunt in CV disease,
basilar pulm. Fibrosis.
• Mechanism :redistribution of blood flow to
the lung bases when assuming sitting position
and resultant V/Q mismatch & hypoxemia.
• Does not allow blood to pass in zone 1 &
zone 2 and poorly ventilated alveoli would be
perfused.
22

23. 7) Paroxysmal nocturnal dyspnea
• A sign of CHF
• Causes : cardiac
depression of respiratory centre
during sleep
• Relieved by : elevating trunk without lowering
legs due to pooling of fluid in legs.
23

24. Fluid from extravascular tissues transfers into
the blood stream increase in
intravascular volume of fluid , increases till
compromised left ventricle can no longer
manage it left ventricle pressure
rises when lymphatic drainage from lungs
decrease elevated pulmonary
capillary pressure interstitial edema
dyspnea
24

25. 8) Functional dyspnea
• Dyspnea at rest ; usually in young women.
• Labored breathing
Labored respiration or labored breathing is an
abnormal respiration characterized by evidence of
increased effort to breathe, including the use
of accessory muscles of respiration , stridor ,
grunting, or nasal flaring.
25

26. Visual analog scale
• greatest breathlessness
no breathlessness
26

27. Borg category scale for rating dyspnea
0 Nothing at all
0.5 Very , very slight
1 Very slight
2 Slight
3 Moderate
4 Somewhat severe
5 Severe
6
7 Very severe
8
9 Very , very severe
10 Maximal
27

28. AMERICAN THORACIC SOCIETY DYSPNEA SCALE
Grade Degree
0 None Not troubled with breathlessness except with strenuous
exercise
1 Slight Troubled when hurrying on level / walking up a slight hill
2 Moderate Walks slower than people of same age / has to stop for
breath when walking at own pace on the level
3 Severe Stops after walking 100 yards / after a few minutes
4 Very severe Breathless while dressing undressing
28

29. RATING OF PERCEIVED EXERTION
• 6 No exertion at all
• 7
Extremely light (7.5)
8
• 9 Very light
• 10
• 11 Light
• 12
• 13 Somewhat hard
• 14
• 15 Hard (heavy)
• 16
• 17 Very hard
• 18
• 19 Extremely hard
• 20 Maximal exertion
29

30. Newyork heart association score
(NYHA)
1. Grade I (minimal Dyspnea): Dyspnea on running
or on doing more than ordinary effort .
2. Grade II : on doing ordinary effort .
3. Grade III (considerable Dyspnea) : on doing less
than ordinary effort .
4. Grade IV : Dyspnea at rest.
30

31. • STRIDOR
• during inspiration
• CAUSES
upper airway obstruction
laryngotracheal narrowing due to a tracheostomy
scar,
laryngeal paralysis ,
epiglottitis ,
trauma of intubation , etc.
• STERTOR - rattling noise in throat
- occurs in deep sleep , coma or in dying
patients.
31

32. WHEEZE
• Associated with dyspnea may be due to
pulmonary or cardiac disease. In latter ,its
also k/as cardiac asthma.
• There may be presence of both the above.
• COUGH
• Imp. features are its effectiveness & whether it is
productive or dry
• Severity : range from occasional disturbance to
continual trouble
32

33. • Acute cough : in viral respiratory infection
• Chronic cough : bronchitis , postnasal discharge
syndrome , GE Disorders
• Cough in cardiac conditions : lt. > rt. Heart failure ,
MI
• A loud - barking cough : laryngeal or tracheal dzs
• Recurrent cough after eating : aspiration ,
oesophageal disease.
• Cough at night : asthma , bronchiectasis , heart
failure , oesophageal problems.
• Cough in early morning : bronchitis , postnasal drip
33

34. • Cough +wheeze : COPD , asthma , early lt.
heart failure due to predisposed respiratory
infections
• Cough complications
• Syncope
• Headache
• Back pain
• Muscle tears , inguinal hernias
• Hematomas , urinary incontinence
• Rib fractures, rare vertebral compression #
34

35. • SPUTUM & HEMOPTYSIS:
• Colour, consistency & quantity should be determined
• It clarifies diagnosis & severity of disease
• GRADINGS for sputum by Miller ( 1963 ):
• M1 : mucoid with no suspicion of pus
• M2 : predominantly mucoid, suspicion of pus
• P1 : 1/3 purulent, 2/3 mucoid
• P2 : 2/3 purulent, 1/3 mucoid
• P3 : > 2/3 purulent
35

36. • In clinical practice it is classified as :
• Mucoid
• Mucopurulent
• Purulent
• Estimation of vol. :
• 1 tea spoon
• 1 egg cup
• ½ cup
• 1 cup
36

37. HEMOPTYSIS
• Is coughing up of blood.
• Can be blood streaked to all blood.
• Bleeding site : upper/ lower respiratory tract
• Timing and frequency from history
• Intermittent bouts : bronchiectasis , tuberculosis , fungal
infections , broncholithiasis
• Persistent bld. Streak sputum (daily) : bronchogenic
neoplasm
• Pink frothy sputum : pulmonary edema
• Also in MI , Eisenmenger syn , aortic anneurysm
Bronchus
(high-pressure system)
Pulmonary A. system
(low-pressure system)
Colour : bright red
Amount : large
: Dark or clotted venous blood
: Small
37

38. 38

39. CHEST PAIN
▪ Definitive cause established from diagnostic
medical tests, origin obtained by carefull history
taking
▪ Origin of chest pain : pleurae , chest wall , thoracic
organs
▪ Pleuritic :
▪ from parietal pleura
▪ Sharp stabbing
▪ A/F : inspiration , deep breathing , coughing , laughing
▪ To relieve : pt. applies pressure over the involved site
▪ Referred pain : shoulder , lower thorax , upper abdomen
▪ Accompanying signs : cough , fever , malaise , chills , etc.
39

40. • Cardiac
• Angina
• A discomfort , pressure , squeezing , tight band ,
burning or indigestion..
• Patient localises the pain using whole hand or
closed fist. If localised by a finger-tip – is not angina
• Characteristic buildup of pain due to contraction of
myocardium in inadequate O2 supply.
• Referred superficially..
• Precipited by : exertion , walking uphills , in cold
weather..
40

41. PULMONARY HYPERTENSION
• May mimic angina pectoris
• Found in : VSD , MS , PDA , ASD
• Accompanied by : syncope , raynaud’s phenomenon
• A/F : exertion
• R/F : rest
• Is invariably associated with dyspnea
• Cause : dilation of pulmonary artery or from right
ventricular ischemia
• “Is not relieved by nitrates unlike angina..”
41

42. PERICARDIAL
• Midline chest pain
• A/F : deep breathing , coughing , swallowing ,
movement , and lying down.
• R/F :sitting up , leaning down , lying on rt. side
• Referred to : left shoulder or scapular region if
central tendon of diaphragm is involved
42

43. • TRACHEITIS:
• Constant burning pain in centre of chest
• Aggravated by breathing
• MUSCULOSKELETAL (CHEST WALL) PAIN:
• Originate from muscles, bones, joints or nerves of
thoracic cage
• Well localised & aggravated by chest , trunk or arm
movements.
• Palpation will reproduce pain
• Can last several weeks..
43

44. • OESOPHAGEAL
• Pattern : radiates through the chest to back.
• Located : substernally and radiates to one or both
arms , it is of squeezing / aching quality thus
confused with cardiac pain.
• A/F :swallowing hot or cold liquids , emotional stress
• R/F : change in position from supine to upright
: antacids , sublingual nitroglycerin
• Causes : oesophageal spasm , oesophageal colic
44

45. • Fatigue and weakness
• due to : depression , anxiety , emotional
stress
: anemia , hypothyroidism , chronic
diseases , CHF
• Pedal edema
• In CHF.. -weight gain , ascites
• Ascites disproportionate to pedal edema – restrictive
cardiomyopathy , constrictive pericarditis
• Pedal edema + dyspnea on exertion - MS , cor
pulmonale
• Hoarseness : URTI , laryngeal dysfunction , CV
conditions
resolves in 1-2 weeks
45

46. • Functional ability
• Inquiry about his ADL
• FIM scale
• QOL
• Imp. to measure the impact of disability on
pt & of response to treatment
• SF – 36 questionnaire
46

47. • OBJECTIVE ASSESSMENT:
• General observation:
• Is pt breathless?
• Is pt comfortable?
• Body built ; BMI
• Is pt on supplemental O2? If so, how much?
• In ICU pt see level of ventilatory support:
• Mode & route of ventilation
• Level of CV support including drugs to control BP
& C.O., pacemakers & other mechanical devices
47

48. • Level of consciousness should also be noted
• It is measured by GCS
• Reduced consciousness – risk of aspiration &
retention of secretions
• See for presence or absence of ryle’s tube, IV line,
CVP line etc
• Signs of respiratory distress: facial grimace, nasal
flaring etc.
• Use of accessory muscles:
48

49. 49

50. INVESTIGATIONS
• Chest X-rays
• PFT
• ABG analysis
• ECG
• Sputum
• CT scan
• Bronchoscopy
50

51. HEMATOLOGY
Hb 12-16 gm %
RBC Count 4.5 – 5.5 /ml/cumm
Platelets 1.5 – 4 lacs / cumm
WBC Count 4000 -10,000 /cumm
Neutrophils 40 -75 %
Lymphocytes 20 -50 %
Eosinophils 1- 5 %
Monocytes 1-3 %
ESR
PCV 38 -44 ml %
MCV 76 -96 fl
MCH 27-32 Pg
MCHC 30-35 gl
BT 1-3 min
CT 3-6 min
51

52. PTT
Blood Group
Rh factor
S.Widal
S.Typhi “O”
S.Typhi “H”
52

53. BIOCHEMISTRY
Bl.urea 10-50 mg/dl
S.Creatinine 0.8-1.4 mg/dl
LFT :SGPT 0-40 U/L
SGOT 0-40 U/L
Alk.PO4 68-200 U/L
Bilirubin
Total 0.0-1.0 mg/dl
Direct 0.0-0.2 mg/dl
Indirect 0.2-0.4 mg/dl
S.Proteins
Total 6.6-8.6 gm/dl
Albumin 3.5-5.5 gm/dl
Globulin 2.5-3.0 gm/dl
A/G Ratio 0.9-2.0
53

54. Lipids : cholesterol 130-220 mg/dl
Triglycerides 30-170 mg/dl
HDL Cholesterol 30-70 mg/dl
VLDL 10-35 mg/dl
LDL 80-200 mg/dl
S.Electrolytes
Na+ 135-155 mmol/L
K+ 3.5-5.5 mmol/L
Cl 98-109 mmol/L
HCO3 22-31 mmol/L
54

55. S.Uric acid M: 3.5-8.5 mg/dl
F : 2.5-6.2 mg/dl
S.Ca 8.4-12.2 mg/dl
S.Po4 2.5-4.5 mg/dl
S.Amylase 0-96 U/L
S.Acetone Upto 5 mg/dl
Cardiac Enzymes
CPK Upto 120 U/L
CPK MB Upto 24 U/L
LDH Upto450 U/L
55

56. FBS Upto 100 mg/dl
PP2BS Upto 150 mg/dl
PG2BS Upto 160 mg/dl
PGBS Upto 150 mg/dl
PGBS Upto 140 mg/dl
RBS Upto 120 mg/dl
R.A Factor
CRP
A.S.O TEST
HbsAg
VDRL
HIV I & II
56

57. Urine Stool
Albumin Occult blood
RBC Pus
Crystals RBC
Cast Ova
Pus Cyst
Others Others
57

58. General observation of skin
▪ Look for presence of pallor or cyanosis
▪ Cyanosis Central
▪ insufficient gas exchange within lungs ; lips
▪ and tongue
▪ Peripheral
▪ -low cardiac output and excessive O2
▪ extraction at the periphery.
▪ -Finger tips , nose , toes , nailbeds
▪ …disappears on warming.
▪ Mixed in acute LVF , MS
58

59. 59

60. SEE FOR …..
• Scars , bruises , trauma , surgical incisions ,
• Ecchymoses –a small haemorrhagic spot larger than
petechia
• Reddened areas ; whether bony landmarks are more
prominent..
• Is skin edematous ?
Grade definitions
Absent Absent / unilateral
Grade + Mild , both feet / ankles
Grade ++ Moderate , both feet +lower
legs , hands or lower arms
Grade +++ Severe generalised bilateral
pitting edema , including both
feet , legs , arms and face. 60

61. Ecchymoses and petechia
61

62. • Peripheral Edema :
• Important sign of cardiac failure
• Also found in : low albumin level
• impaired venous or lymphatic
function
• high dose steroids
62

63. • OBSERVATION OF EYES:
• It should be examined for pallor (anaemia)
• Plethora (increased Hb) or jaundice (yellow colour
due to liver or blood disturbances)
• Drooping of one eyelid with enlargement of that
pupil suggests – Horner’s syndromes (Disturbance in
sympathetic nerve supply to that side of head)
63

64. 64

65. • Observation of hands:
• Fine tremor will be seen with high dose
bronchodilators
• Sweaty hands with irregular flapping tremor – acute
CO2 retention
• Weakness & wasting of small muscles in hand –
early sign of upper lobe tumour involving brachial
plexus (pancoast’s tumour)
• Fingers may show nicotine staining from smoking
65

66. 66

67. NICOTINE STAINING
67

68. CLUBBING OF FINGERS
• Loss of angle between nail bed & nail itself
• Sign of chronic hypoxia
• Vasodilation
• Secretion of growth
factors from lungs
• Overproduction of
prostaglandin E2
68

69. 69

70. SCHAMROTH’S SIGN
70

71. • Grades of clubbing:
• 1 – softening of nail bed
• 2 – obliteration of angle of nail bed
• 3 – overlying skin becomes tense, shiny, wet &
increasing curvature of nail, parrot beak &
drum stick appearance
• 4 – swelling of fingers in all direction asso. with
hypertrophic pul. osteoarthropathy causing
pain & swelling of hand, wrist etc. & X- ray
shows subperiosteal new bone formation
71

72. 72

73. HYPERYTROPHIC PULMONARY
OSTEOARTHROPATHY
• Clubbing of digits
• Periostitis of the long bones , arthritis
• Excessive proliferation of skin & bone at the
distal parts of extremities.
• 10
HPOA : familial cause
• 20 HPOA : Due to an underlying pulmonary ,
cardiac , hepatic or intestinal disease.
73

74. 74

75. JUGULAR VENOUS PULSE AND DISTENSION
• Enters into the superior vena cava and hence
reflects rt. Sided heart function.
• Pulse indicates rt. Atrial pressure.
• Normal JVP corresponds to a vertical height approx
3 to 4 cm above sternal angle.
• Best seen when one lies with the head and neck at
an angle of 45 degrees.
• Note the +nce and –nce of symmetry of JVD
• B/L distension :CHF
• U/L distension : indicates localised problem.
75

76. 76

77. OBSERVATION OF CHEST
• Presence of ICDT :
• Placed between 2 ribs into pleural space to
remove air, fluid or pus
• Used routinely after CT Surgery
• Observation must be made of fluid level within
the tube which should oscillate or swing with
every breath
• If it doesn’t swing – tube is not patent
77

78. • CHEST SHAPE
• It should be symmetrical with the ribs, in adults,
descending at approx 45 degree from spine
• Transverse diameter > AP diameter ( 7 : 5 )
• Thoracic spine should have slight kyphosis
• In infants , trans=AP diameter , round chest.
• With aging , chest turns more round due to
decreased lung compliance , decrease muscle,
Strength skeletal changes in spine.
• Look for +nce of any asymmetry-thoracic pathology.
78

79. COMMON ABNORMALITIES
• Barrel chest : increased AP diameter,
ribs less oblique
prominent sternal angle,
arched sternum
• Seen in kyphosis of aging or hyper-inflation of
pulmonary emphysema
79

80. • Funnel chest (Cobbler’s
chest, Pectus excavatum)
• May be congenital,
following rickets
in childhood or
occupational deformity
in cobblers
• Due to depressed
sternum in lower part,
enlarged cardiac shadow
on chest X-Ray
( Pomfret’s heart )
• Pigeon chest ( Pectus
carinatum, Keeled chest )
• Sternum displaced ant
• Depression on either side
of sternum asso with bead
like enlargement at CC jn
(rickety rosary)
• Transverse groove seen
passing outward from
xiphisternum to midaxillary
line ( Harrison’s sulcus )
80

81. • THORACIC KYPHOSCOLIOSIS :
• Spine is curved & thorax shows corresponding
deformities
• Distortion of underlying lungs – make interpretation
of lung findings very difficult
• BULGING :
• One side may bulge in Pl effusion, pneumothorax,
tumors, aneurysm, empyema, cardiomegaly or
scoliosis
• Localised : Aortic aneurysm, pericardial effusion,
liver abscess, chest wall tumors
81

82. DEPRESSION OR FLATTENING
• Localised : seen in fibrosis, collapse, pleural
adhesions, unilateral muscle wasting due to polio or
congenital absence of pectorals
FLAT CHEST ( PHTHINOID CHEST )
• AP diameter is reduced in chronic nasal obstruction,
b/l TB or childhood rickets
• In advanced TB, scapula is winged & is called alar
chest
82

83. 83

84. normal barrel funnel pectus carinatum
84

85. 85

86. RESPIRATORY RATE
In adults : 12-16 / min
In children : about 40 /min
Rhythm : regular
• I:E = 1:2
• Tachypnea : RR > 20
anxiety , lung diseases metabolic
acidosis.
• Bradypnea: RR < 10
CNS depression by narcotics or trauma
86

87. TYPES OF IRREGULAR RESPIRATORY RHYTHM
1) Rapid shallow breathing ( Tachypnoea )
Causes : Restrictive lung dzs , pleuritic chest
pains , elevated diaphragm
87

88. 2) Rapid deep breathing (hyperpnoea,
hyperventilation)
Causes : exs, anxiety, metabolic acidosis in comatose
pts, infarction, hypoxia or hypoglycemia affecting
midbrain or pons.
3)Kussmaul’s respiration(air hunger)
• Rapid and deep breathing
• Seen in diabetic and
starvation ketoacidosis ,
alcoholic and uremia
88

89. • Slow breathing ( bradypnea )
• Secondary to diabetic coma, drug
induced respi depression,
increased ICP
• Cheyne stokes breathing
• Respiration waxes & wanes
cyclically
• Periods of deep breathing
alternate with periods of apnea
• Children and aging people show
this in sleep
• Other causes : heart failure,
uremia, drug induced
respi depression, brain damage
89

90. BIOT’S RESPIRATION
Irregularly irregular respiration
Seen in meningitis , raised ICP..
90

91. • Obstructive breathing
• I:E = 1:3 OR 1:4
• Prolonged expiration due to increased airway
resistance.If RR increases, patient lacks sufficient
time for full expiration and air trapping occurs.
• Types of breathing
• Males : abdominothoracic
Females : thoracoabdominal
Thoracic : diaphragm paralysis, peritonitis,ascites
Abdominal : pleurisy, collapse of lung
91

92. • Chest movement
• Normally both sides move uniformly & there is no
bulging or indrawing
• Accessary muscles not required
• Unilateral diminished movement :
• obstruction of main bronchus
• consolidation
• fibrosis of lung, pleural adhesions
• massive collapse
• hydropneumothorax, pleural effusion
92

93. • Bilateral diminished movements
emphysema
bilateral fibrosis, collapse,
consolidation ,bronchial asthma
hydropneumothorax
• Paradoxical breathing
93

94. • On examination
• Vitals
• Body Temperature :N- 36.5- 37.50
C
• lowest in early morning
• highest in afternoon
• Fever – elevation of body temp. above 37.5 degrees
associated with increased metabolic rate.
• For every 0.6 degree rise in temp. – 10% increase in
O2 consumption & CO2 production
• This places extra demand on CV system –
compensatory rise in HR & RR
94

95. 95

96. • Heart Rate:
• 60-100 beats/min
• Radial pulse is used to count HR
• With the pads of index & middle fingers
compress the radial a. until a maximal pulsation is
detected
• If rhythm – regular, rate – normal, count for 15
sec.
• If rate – unusually fast or slow , count for 60 sec.
96

97. Grades of pulse
• 0 = absent
• 1 = thready , barely palpable
• 2 = weak , difficult to palpate
• 3 = normal
• 4 = aneurysmal / bounding pulse
97

98. Tachycardia Bradycardia
HR >100 beats / min HR <60 beats / min
Seen in : fever , exercises
Anxiety , anemia , hypoxia ,
cardiac diseases ,
bronchodilators and cardiac
drugs.
Normal in atheletes
Some cardiac drugs..e.g. beta
blockers
98

99. • If rhythm – irregular , HR should be counted
by cardiac auscultation ( apex ), as some
beats are not detected peripherally & PR can
be underestimated
• Pulse deficit = HR-PR
• e.g. atrial fibrillation1 ,. Very early diastolic
ventricular ectopic beats
• 3. Some patients with Pacemaker.
99

100. Maximum heart rate : 220 –age
Target heart rate : HRrest + 60-70 % [ MHR - HRrest]
100

101. • Blood Pressure
Measured with sphygmomanometer (mercury)
Tech. of measurement
• Patient should be comfortable, relaxed, arm free of
clothing. Centre inflatable bag over brachial a.
Lower border – 2.5 cm above antecubital crease
• Secure cuff tightly.
Loose cuff – false high readings
• Position of pt’s arm – slightly flexed at elbow
101

102. • Support it yourself or rest it on a pillow or table
(sustained muscle contraction raise diastolic BP
10%).Cuff shd lie at heart level, if diff of 13.6 cm-
error 10mmHg
• Brachial a. below ht level – high BP
above ht level – low BP
NORMAL BLOOD PRESSURE RANGES
Systolic (mmHg) Diastolic (mmHg) Pressure range
130 85 High normal bld.
pressure
120 80 Normal blood pressure
110 75 Low normal bld.
pressure
102

103. • Step 1 - Place the BP cuff on the patient's arm:
Palpate/locate the brachial artery and position the
BP cuff . Wrap the BP cuff snugly around the arm.
• Step 2 - Position the stethoscope: On the same
arm , palpate the arm at the antecubical fossa
(crease of the arm) to locate the strongest pulse
sounds and place the bell of the stethoscope over
the brachial artery at this location.
103

104. • Step 3 - Inflate the BP cuff enough to stop blood
flow ; one should hear no sounds ; i.e 30 to 40
mmHg > normal BP.
• If its unknown, inflate the cuff to 160 - 180
mmHg. (If pulse sounds are heard , inflate to a
higher pressure.)
• Step 4 - Slowly Deflate the cuff: @ 2 - 3 mmHg /
s.
104

105. • Step 5- Listen for the Systolic Reading: The
first occurence of rhythmic sounds heard is
the patient's systolic pressure. This may
resemble a tapping noise at first.
• Step 6 - Continue to listen as the BP cuff
pressure drops and the sounds fade. This will
be the diastolic reading.
105

106. • HYPERTENSION
• On at least 2 consecutive visits 2 or more dia pre
averages >= 90 mm Hg, sys pre > 140 mm Hg .
Its due to change in vascular tone, or aortic valve dzs
• HYPOTENSION : < 90/60 mm Hg, normal finding in
sleep . Daytime hypotension – ht failure, bld loss,
reduced vascular tone.
• Normally from sitting to standing sys pre fall, or
unchanged, dia pre rises
106

107. • Substantial fall in sys pre, >= 20mm Hg, with
symptoms indicate postural hypotension.
Pulsus paradoxus: exaggerated drop, in inspirations
107

108. ON PALPATION
• TRACHEAL DEVIATION
• Trachea: Place index finger in medial aspect of
suprasternal notch.
• An equal distance between clavicle & trachea shd
exist bilaterally.If not , indicates mediastinal shift.
• C/L : pneumothorax , pleural effusion
• U/L : collapse , fibrosis , atelectasis
108

109. 109

110. CHEST EXPANSION
• Allows to measure progress or decline in a
patient’s condition.
• U/L restriction : Lobar pneumonia / surgical
incision.
• Symmetrical decrease is seen in COPD.
• DIRECT HAND CONTACT METHOD
• Apical / upper lobe motion.
• Anterolateral / middle lobe / lingula motion
• Lower lobe motion.
• Assess the symmetry and extent of motion.
110

111. • Measurement using tape : at xiphoid ; normal
difference is 3.25 inches.
111

112. • Tenderness:
• Areas of tenderness can be assessed for degree
of discomfort & reproducibility
• Differentiation of chest pain : angina or
mus.sk. Origin
• Subcutaneous emphysema:
• Air in subcutaneous tissues of chest, neck or face
produces crackling in skin on palpation
• It may be due to air leak from a chest tube
112

113. GRADES OF TENDERNESS
0 = no tenderness
1=tenderness to palpation without grimace or
flinch(small sudden movement)
2 = tenderness with grimace/flinch to palpation
3 = tenderness with withdrawal( jump sign)
4 = withdrawal to noxious stimuli ( superficial
palpation , pin-prick or gentle percussion)
113

114. • Tactile Vocal Fremitus :
• Fremitus is palpable vibrations transmitted
through bronchopulmonary system to the chest
wall when patient speaks.
• Ask patient to repeat words ‘99’ or ‘one-two-
three’
• If fremitus is faint ask to speak more loudly
• Palpate & compare symmetrical areas of lungs,
using palmar surface or ulnar surface of hand
114

115. • Identify, describe & localize areas of increased
or decreased fremitus.
• More prominent : in interscapular area than
in lower lung fields.
: on rt side than lt
• Disappears below diaphragm
• Reduced or absent over precordium
• Reduced or absent when voice is soft
115

116. PATHOLOGICAL REDUCED OR ABSENT FREMITUS
• When transmission of vibration from larynx to
surface of chest is impeded
• Causes: obstructed bronchus, COPD,
• Pleural effusion , fibrosis,
• Pneumothorax , infiltrating tumors,
• thick chest wall
• INCREASED in consolidation.
116

117. 117

118. 118

119. ON PERCUSSION
• It sets the chest wall & underlying tissues into
motion, producing audible sounds & palpable
vibrations
• The normal percussion note of the chest is
due to the underlying lung tissue containing
normal amount of air in the lung tissues
• It has distinct clear character with low pitch
119

120. TECHNIQUE
• Hyperextend the middle finger of left hand -
pleximeter finger.
• Press its DIP jt firmly on surface to be percussed.
• Avoid contact by any other part of hand, it would
damp vibrations.
• Position rt forearm quite close to the surface with
hand cocked upward.
• Right middle finger should be partially flexed,
relaxed & poised to strike.
120

121. 121

122. • Strike with a quick , sharp motion.
• Impetus of the blow comes from the wrist.
• Follow from apices to bases and from side -
side.
122

123. • The front of the chest yields a more resonant
note than back because of lesser bulk of
musculature in front than at back
• Impaired note
• When the amount of air in alveoli decreases as in
consolidation, infiltration, fibrosis and collapse of
lung, the lungs fail to vibrate sufficiently to the
percussion stroke
• Loss of resonance resulting in an impaired note
123

124. • Dull note:
• An impaired note of greater degree is a dull
note.
• It is found in consolidation, infiltration,
fibrosis, collapse, pleural thickening
124

125. STONY DULL NOTE:
• A percussion note displaying extreme
dullness is a stony dull note
• Found in PLEURAL EFFUSION because fluid
dampens the vibration of both the chest wall
and underlying lung
• It may also occur in lung fibrosis with pleural
thickening or with solid intrathoracic tumour
125

126. TYMPANY:
• This is drum like resonance which is normally
encountered over stomach, intestines, larynx
and trachea
• When it occurs over chest wall it may be due
to PNEUMOTHORAX, SUPERFICIAL EMPTY
CAVITY, EMPHYSEMA
126

127. SUBTYMPANY
• A hyper resonant note with a boxy quality which
occurs due to relaxed lung just above level of pleural
effusion.
HYPER RESONANCE
• A note in between normal resonance and tympany,
can be elicited over normal lung tissue by keeping
the chest wall in full inspiration during percussion
• E.g. Pneumothorax , emphysema –bullae , large
cavity, congenital lung cyst
127

128. BELL TYMPANY
• This is a high pitched tympanic sound, heard over
the chest in case of massive pneumothorax
• When a silver coin is placed on affected side and
percussed with a second silver coin, the ear or
stethoscope applied over the opposite side of chest
may detect a clear bell like sound.
128

129. KRONIG’S ISTHMUS
• A band of resonance 5-7 cms in width, connecting
lung resonance over the anterior and posterior
aspects of each side of chest. It is bounded medially
by dullness of neck muscles and laterally by dullness
of shoulder muscles
• Abnormalities:-
• -nce on either side pulm. Fibrosis due to TB
• Increased width emphysema
129

130. LIVER DULLNESS & SPAN:
• Normal dullness is in rt. Side,
• 5th space in mid clavicular
• 7th space in mid axillary
• 9th space in scapular line
• Amebic / pyogenic abscess 4th
spa
• Diaphragm paralysis , collapse of LL of lung mid cl
• Emphysema
• Rt.pneumothorax
• Terminal cirrhosis 6th
space mid
• Air in peritoneal cavity clavicular
130

131. CARDIAC DULLNESS
• On lt. side , the lung resonance is encroached by an area
of cardiac dullness.
• Normal cardiac dullness is in
• 3rd, 4th lt parasternal line,
• 5th lt mid clavicular line
• Emphysema dullness
• Lt. pneumothorax
• Cardiomegaly
• Heart pushed to lt. side. dullness
131

132. Tidal percussion
• Percussion of upper border of liver dullness on rt.
Side anteriorly on inspiration and expiration serves
to determine the range of lung expansion.
• It is restricted in pulmonary diseases at lung
bases, empyema , subdiaphragmatic abscess ,
hepatic amebiasis.
132

133. TRAUBE’S AREA OR SPACE
• It is bounded :
above by : lung resonance
below by : lt.costal margin
rt. Side by : inferior margin of lt.lobe of liver
lt. side by : anterior border of spleen..
• It is occupied by stomach and hence note is
tympanic due to stomach gas.
• If its dull : pleural effusion on left side.
133

134. SHIFTING DULLNESS
• In case of hydropneumothorax in sitting position,
there is a hyper resonant note above followed by
dullness below
• On changing the posture to supine, this area of
dullness of fluid changed as air and fluid will shift
• This is shifting dullness & signifies presence of
both air and fluid
134

135. PERCUSSION MYOKYMIA
• In a chronically wasted individual as in
pulmonary TB a percussion stroke over the
front of chest close to sternum may cause
transient twitching of muscles which is more
marked on side of pulmonary affection
135

136. DIAPHRAGMATIC EXCURSION
• Diaphragmatic movement can be assessed by
mediate percussion.
• Ask the patient to breathe deeply.
• Hold that breath.
• On percussion the lowest point of resonance
is the lowest level of diaphragm.
• When patient exhales , lowest point of resonance
moves higher , as the diaphragm ascends.
136

137. LIMITATION OF PERCUSSION
• It is not possible to percuss deeper than 5 cm.
hence it is not possible to detect a lung lesion
covered by a layer of air or fluid more than 5 cm
thick
• A lesion less than 2 cms in diameter does not
cause any change in percussion note
• Free fluid less than 200 ml in pleural cavity may
not be detected on percussion
137

138. ON AUSCULTATION
138

139. 139

140. ON AUSCULTATION
• Auscultation is the art of listening to sound produced
by the body
1) breath sounds :- Normal
Abnormal
Adventitious 2)
voice sounds :- Egophony
Bronchophony
Whispered pectoriloquy
3) Extrapulmonary sounds :-
Pleural rub
4) Heart sounds
140

141. NORMAL BREATH SOUNDS
1) Bronchial :
High pitched
Heard in both inspiration and expiration.
Pause in between I & E.
Heard over TRACHEA..
141

142. 2)Bronchovesicular
High pitched
Inspiratory phase = expiratory phase.
No pause in between.
Heard over supraclavicular ,
suprascapular , parasternal ,
interscapular regions….
142

143. 3) Vesicular
Low pitched
I > E ,1/3rd
of it is audible.
Heard in peripheral lung fields..
because of dampening effect of the
spongy lung tissue and the
cummulative effect of air entry from
numerous terminal bronchioles.
apices bases quieter
In children , thin chest wall –airways close to surface
the sounds are louder , harsh and clear..
143

144. ABNORMAL BREATH SOUNDS
• underlying pathology.
• changes
•
• sound transmission
• bronchial
• abnormal sounds decreased
• absent
• Sound is filtered by air-filled lungs ;in liquid / solid
medium , its transmission is enhanced. 144

145. BRONCHIAL
• E.g. consolidating pneumonia
Secretions obstructing
Segmental / lobar bronchi
high pitched , enhance sounds
from adjacent bronchi
louder and more pronounced
expiration
e.g. compression of lung tissue from an
extrapulmonary source-pleural effusion.
145

146. DECREASED OR ABSENT BREATH SOUNDS
• Occurs when sound transmission is diminished or
abolished (vesicular sounds)
• Absent sounds-no sounds are audible.
• Causes :
• 1) Internal pulmonary pathology
• E.g. emphysema destruction of acinar units
increased air =hyperinflation decreased
sound transmission.
• pulmonary fibrosis because of loss of lung
compliance.
146

147. • 2) 20
to initial nonpulmonary pathology
• E.g tumors , neuromuscular weakness ,
musculoskeletal deformities like
kyphoscoliosis . The cause is pain which may
be incisional or traumatic.
• Obesity
147

148. ADVENTITIOUS BREATH SOUNDS
• Are the extraneous noises produced over the
bronchopulmonary tree and indicate an abnormal
condition.
1) Crackles :low pitched sounds
during inspiration
are discontinuous
similar to sound of rubbing hair
between fingers..
indicate a peripheral airway process.
148

149. 2) Rhonchi : low pitched
occur both in inspiration and
expiration
are continuous sounds.
similar to snoring.
due to obstructive process in the
larger , central airways..
149

150. 3) Wheezes : high pitched sounds
during expiration ; may occur in
inspiration due to movement
of air through secretions…
are continuous.
hissing / whistling quality.
an indication of bronchospasm .
150

151. EXTRAPULMONARY SOUNDS
Friction rub is the nonpulmonary adventitious
sound.
Described as a rubbing / leathery sound due to
rubbing of visceral pleural lining against the
parietal pleura ; associated with pain.
Occurs both during inspiration and expiration.
A sign of inflammation or neoplasm.
151

152. VOICE SOUNDS
• Are vibrations produced by the speaking voice
as it travels down the tracheobronchial tree
and through the lung parenchyma.
• Heard through a stethoscope.
• Over the normal lung , these are :
low pitched
muffled / mumbled quality.
152

153. • Their transmission can be increased /
decreased in presence of underlying
pulmonary pathologic process.
• Bronchophony
increased vocal transmission.
words are louder and clearer.
e.g. in increased lung density
as in consolidating pneumonia.
153

154. • Egophony
• Here also there is increased transmission
• When patient says “eeee” , underlying process
distorts e and thus “aaa” is heard over the
peripheral area.
• It coexists with bronchophony.
• Whispered pectoriloquy
• Whispered voice sounds become clear and distinct.
“One-two-three” and “ ninety-nine ” are used for
evaluation…
• Are method of identifying abnormal breath sounds.
154

155. APEX BEAT
• Palpated in the precordium left 5th
intercostal space, at the point of intersection
with the left midclavicular line.
• In children = in the fourth rib interspace
medial to the nipple.
• The apex beat may also be found at
abnormal locations; in many cases
of dextrocardia, the apex beat may be felt on
the right side.
155

156. Significance of apex beat
• Lateral and/or inferior displacement indicates
cardiomegaly
• The apex beat may also be displaced by other
conditions:
• Pleural or pulmonary diseases
• Deformities of the chest wall or the thoracic vertebra
• Apex beat may not be palpable, either due to a
thick chest wall, or conditions where the stroke
volume is reduced; such as during ventricular
tachycardia or shock.
156

157. • A forceful impulse = hypertension
• An uncoordinated (dyskinetic) apex beat
involving a larger area than normal =
ventricular dysfunction e.g. aneurysm
following myocardial infarction
157

158. HEART SOUNDS
• S1 SOUND
due to : closing of atrioventricular valves
duration : 0.10 sec
heard at : cardiac apex – loudest
2 components : tricuspid -4th
-5th
ICS , LSB
mitral -5th
ICS , MCL
LOUDNESS INCREASES WITH TACHYCARDIA.
158

159. • S2 SOUND
due to : closure of semilunar valves.
two components :
1) aortic in 2nd
ICS , rt. Sternal border
2) pulmonic in 2nd
ICS , at lt. sternal border.
• Splitting of S2 is audible only during
inspiration . Normal in children and young
adults.
• If heard throughout respiration ; there’s a
cardiac pathology .e.gRBB block , pulmonary
hypertension.
159

160. What do you think the heart
sounds are due to ???
160

161. • Opening of valves is a slowly developing
process, so no production of noise…
• Closure of valves is a sudden process, leads to
vibration of surrounding fluid which causes
noise…………
• Textbook of physiology-A.K.JAIN
161

162. GALLOPS S3 , S4
• S3 -faint , low frequency
sound
• reflects the early
ventricular filling;
• after atrioventricular
valves open.
• abnormal over age of
40
• Position : left side-lying
• At : cardiac apex by
bell.(S1,S2,S3)
• ventricular failure,
tachycardia , MR
• S4 -rapid ventricular filling
After atrial contraction.
• Heard before S1
• Location same as s3
• S4 , S1 , S2
Tenn –es-see
e.g. systemic hypertension ,
cardiomyopathies ,
coarctation of aorta
162

163. MURMURS
• Are the vibrations resulting from turbulent
blood flow.
• Described based on whether occurs during
systole , diastole , its duration and loudness.
• Systolic murmurs occur in between S1 and S2.
• Diastolic murmurs occur between S2 and S1 .
163

164. Grades of murmurs……
I. : Faint --- requires concentrated effort to hear.
II. : Faint ---audible immediately.
III. : Louder than 2. --- intermediate intensity.
IV. : loud --- intermediate intensity ; associated with
palpable vibration (thrill).
V. : very loud --- thrill present.
VI. :audible without stethoscope..
• Murmurs with grades 3. and higher suggest
cardiovascular pathology.
164

165. WHEN DOES THE HEART GET ITS
BLOOD SUPPLY ?????
165

166. • During diastole,the arteries which had
undergone squeezing , again become patent…
hence allows blood to flow through aortic
pressure into the coronary
arteries…………supplies blood to heart…
166

167. EXERCISE TOLERANCE TEST
• 6 min walk test
• 12 min walk test
• Shuttle walk test
167

168. Six minute walk test
1) For INDIAN children aged 7-12 years
mean distance : 609 +/-166 meters
Boys :670.74 +/- 86.21 meters
Girls :548.93 +/- 44.78 meters
PMID : 22016153
YEAR : 2012
168

169. 2) For INDIAN adults aged 40-60 years
Mean distance came to : 536.1 +/- 46.9 m
PMID : 23575339
YEAR : 2013
3) Done on 444 individuals from 7 countries
Mean +/- SD = 571 +/- 90 m
Males walk 30 m more than females.
PMID : 20525717 ; PULMONARY DEPT. ; SPAIN
169

170. 12 MIN WALKING DISTANCE(MILES)
13-19 20-29 30-39 40-49 50-59 60+
MALES > 1 .87 > 1.77 > 1.7 > 1.66 > 1.59 > 1.56
FEMALES > 1.52 > 1.46 > 1.4 > 1.35 > 1.31 > 1.19
170

171. SHUTTLE WALK TEST
• It’s a standardised field walking test provoking a
symptom-limited maximal performance.
• METHOD :
• 1)Patient walks up and down a 10 m course.
• 2)Speed of walking is dictated by computer-
generated audio signal played on a tape-recorder.
• 3) Walk at a steady pace and turn around on hearing
signal…
171

172. 172

173. • 4)Increment in speed at every 1 min..
• 5)no verbal encouragement..only ask to
increase speed at each min.
• 6)test ends if : a)patient is too breathless to
maintain particular speed.
• b) patient is > 0.5 m from the
cone when the beep sounds.
• c) 85 % of predicted maximum
HR is obtained. [210- (0.65*age)]
173

174. PLAN OF TREATMENT:
• Short term
• Long term
174

175. PROGRESS NOTES:
175

176. DISCHARGE SUMMARY:
• Treatment
• Outcome
• Home programmes
176

177. • REFERENCES
• Cardiovascular and pulmonary physical
therapy-4th
edition(donna)
• P J mehta
• Cash
• Textbook of physiology – A.K.JAIN
177

178. • t
178