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Unit 4The Upper Quarter and Patients with Dysfunction/Diseases of the Cardiovascular and Pulmonary Systems : 

Unit 4The Upper Quarter and Patients with Dysfunction/Diseases of the Cardiovascular and Pulmonary Systems Lesson 1: Patient Cases: Dysfunction/Disease of the Cardiovascular and Pulmonary Systems Lesson 2: Upper Quarter Screening

Objectives : 

Objectives Following the completion of this unit you will be able to:   Analyze findings from measurement of vital signs, body mass index, and heart and breath sounds. Describe pathological measures of blood pressure, and vital signs with varied condition, impairment and functional activities Understand the use of vital sign measurement and body composition in clinical management and documentation. Describe the elements of an upper quarter screening examination. Analyze the results of the upper quarter screening exam in relation to presentation of red or yellow flags.

Unit Summary : 

Unit Summary In this unit we will review the objectives of measuring vital signs and other pulmonary and cardiac measures. We will discuss normal and abnormal parameters in these regions. Upper quadrant screening including the cervical and thoracic cage will be presented with discussion of patient cases pertinent to these areas.

Assignments & Readings : 

Assignments & Readings Chapters 11 & 12. Boissonnault W. Primary care for the Physical Therapist: Examination and Triage. 2nd Edition Elsevier Inc; 2011. Chapter 11 Systems Review for Cardiovascular and Pulmonary Systems and Vital Signs Chapter 12 Upper Quadrant Screening Examination

Review of Cardiovascular and Pulmonary Systems : 

Review of Cardiovascular and Pulmonary Systems Vital Signs? Why and when should we use them? Baseline measurement of vital signs is needed to determine if abnormal changes occur when the any of the following changes: Exercise Diet Medications Stressful events My guess is that many of your patients have had changes in several of the items listed above during their tenure as a patient. So why isn’t this made routine in our practice?

Patient Case #1 : 

Patient Case #1 Jim is a sixty five year old African American male who presents to your clinic with a diagnosis of Lumbar Spinal Stenosis. His present medical history includes diabetes, hypertension, and hypercholesterolemia. Past medical history includes gout.

Unit 4 : 

Unit 4 Patient Case #1

Patient Demographics : 

Patient Demographics 65 year old African American Retired machinist Referred to PT for a consultation regarding inability to walk long distances and low back pain Diagnosis of lumbar spinal stenosis with moderate central narrowing

Personal Medical History: From the Self-Administered Questionnaire : 

Personal Medical History: From the Self-Administered Questionnaire Illness Hypertension Diabetes Hypercholesterolemia Disc bulge L4-5 Propranolol, acetaminophen (OTC Tylenol), Glucatrol

Follow-up Questions : 

Follow-up Questions What is the first question you would ask the patient regarding the report of hypertension and diabetes?

Answer : 

Answer “Are you being treated for hypertension and diabetes?”

Clinical Decision Making : 

Clinical Decision Making Patient has regular follow ups with primary care physician and is testing blood sugar daily and with A1c testing. Hypertension is a current condition. What follow-up questions would you ask regarding hypertension?

Follow-up Questions: Hypertension : 

Follow-up Questions: Hypertension “Who is treating you?” “What types of treatment are you receiving?” If medications have been prescribed, inquire about any side effects “What symptoms associated with high blood pressure do you experience?” “Do you know what your resting blood pressure and heart rate typically are?” “How long have you had high blood pressure?” “Do you have other heart, vascular, or lung problems?”

Personal Medical History: From the Self-Administered Questionnaire : 

Personal Medical History: From the Self-Administered Questionnaire Prior Physical Therapy Treatment L4-5 disc injury 10 years ago with resolve of symptoms, quit doing exercises after a year Recurrent Gout—every two to three years

Follow-up Questions: : 

Follow-up Questions: What joints or areas of the body (tendons) are affected by the gout? How often does it recur? Did the onset begin with taking propanadol. (Some diuretics used to treat congestive heart failure or hypertension may cause gout because they interfere with the secretion of uric acid from the kidney, thereby causing an elevated level of uric acid.

Personal Medical History: From the Self-Administered Questionnaire : 

Personal Medical History: From the Self-Administered Questionnaire Medications Propranolol, acetaminophen (OTC Tylenol), Glucatrol

Follow-up Questions: Medications : 

Follow-up Questions: Medications Propranolol “Are you taking this medication for any reason other than high blood pressure?” (may be taking it for angina) “How often do you take the drug?” “How often are you supposed to take the drug?” (propranolol is taken 120-240 mg/day with a maximum dose of 640 mg/day: usual range) “What side effects have you noticed?”

Propranolol : 

Propranolol Trade name: Inderal Slows heart rate and decreases cardiac output; normalizes the excitability of cardiac cell membranes

Propranolol (cont.) : 

Propranolol (cont.) Contraindications Bronchial asthma or bronchospasm, severe COPD Adverse reactions Bradycardia, orthostatic hypotension (if dosage is too high), dizziness, depression, fatigue, and GI disturbances

Follow-up Questions: Medications : 

Follow-up Questions: Medications Acetaminophen (Tylenol) “Why are you taking this medication?” If for BP… “Did your physician tell to take Tylenol for your BP?” “How often do you take the drug?” (daily or times per day) “How much Tylenol do you take each time?” (mg, number of pills per dose, etc.)? “How long have you been taking Tylenol?” (weeks, months, years)

Acetaminophen (Tylenol) : 

Acetaminophen (Tylenol) Contraindications Hypersensitivity to the drug Adverse reactions Rare, but if taken at high doses (>4 g/day) for long-term use, could lead to hepatotoxicity

Personal Medical History: From the Self-Administered Questionnaire : 

Personal Medical History: From the Self-Administered Questionnaire Substance use Smoking: quit 20 years ago Caffeine: three to four cups of coffee per day Alcohol: two drinks per day

Follow-up Questions: Substance Use : 

Follow-up Questions: Substance Use “Do you notice any side effects if you drink more or less than four to five cups of coffee in a day?” “How many days a week do you drink?”

Relevant Medical History : 

Relevant Medical History Hypertension: 20-year history Cigarette smoking: one to two packs per day for 45 years Age: 62 years Skin cancer: melanoma, diagnosed 18 months ago; next physician follow-up in 2 months Acetaminophen (Tylenol): taking for 12 months, approximately 2 g per day

Family Medical History : 

Family Medical History Diabetes Hypertension Heart problems

Follow-up Questions: Family History? : 

Follow-up Questions: Family History? Who in the family? (first-degree relatives) What type of heart problem? Age of diagnosis? Current health status? Priority: initial visit?

Symptom Investigation : 

Symptom Investigation Location 24-hour report Onset Where to start? (body diagram)

Location of Symptoms? : 

Location of Symptoms? Location Descriptor(s) Intensity scale (best/worst) Body diagram Important to note where patient does not have symptoms

24-Hour Report? : 

24-Hour Report? Constant/intermittent Aggravating factors/positions Alleviating factors/positions

History of Symptoms? : 

History of Symptoms? Onset: how? Onset: when? Previous history?

Body Diagram with Symptom Location : 

Body Diagram with Symptom Location 65 year old male

Three Symptomatic Areas: Where to Begin the Interview? : 

Three Symptomatic Areas: Where to Begin the Interview?

Symptom Investigation : 

Symptom Investigation Chief complaint: intermittent central low back pain spreading to both sides of spine and buttock and then down legs rates pain at 7/10 at worst Onset 5 months ago for no apparent reason, just noticed he couldn’t walk in the grocery store without significant discomfort Aggravating factors/positions: walking more than 10 minutes, standing more than 15 minutes Alleviated by sitting or lying on side No significant night pain, sleeping through night

Concerns? Symptom Investigation : 

Concerns? Symptom Investigation Three symptomatic locations: low back, buttocks and legs All pain brought on in a gradually increasing and peripheralizing manner by walking or standing

Review of Systems (ROS) : 

Review of Systems (ROS) What Systems to Screen

Body Diagram with Symptom Location : 

Body Diagram with Symptom Location

ROS: Symptom Location : 

ROS: Symptom Location Cardiac/vascular (throbbing) Gastrointestinal Urogenital General health

Review of Systems: General Health : 

Review of Systems: General Health Fatigue: Patient lacks endurance, has elevated blood glucose levels which may lead to a sedentary life style

Review of Systems: CVS, PS : 

Review of Systems: CVS, PS Cardiovascular Negative Pulmonary Negative

Review of Systems: GIS, UGS : 

Review of Systems: GIS, UGS Gastrointestinal Indigestion: follow-up questions Urogenital Negative

Differential Diagnosis : 

Differential Diagnosis Risk Factors AAA Lumbar Stenosis

Physical Examination : 

Physical Examination Systems review: Cardiovascular System and Pulmonary System?

Physical Examination:Alteration of Symptoms : 

Physical Examination:Alteration of Symptoms Pain reproduced in lumbar spine and buttocks with ambulation Discomfort with palpation lateral to L4-5 both sides

Evaluation : 

Evaluation Medical history Symptoms and signs Review of systems and systems review Concerns so far?

AAA: Risk Factors : 

AAA: Risk Factors Males Age: older than 55 years History of HTN, tobacco use TEST: Palpation over Abdomen/Aorta for Pain Provocation and/or Pulsatile Mass: negative

AAA: Clinical Manifestations : 

AAA: Clinical Manifestations Most common: back pain Chronic back pain

AAA: Diagnosis : 

AAA: Diagnosis Physical examination Diagnostic imaging: many found incidentally Ultrasound: 95% to 100% sensitivity and specificity and relatively inexpensive

Vital Signs : 

Vital Signs Resting HR: 90 BPM Resting BP: 130/90 Resting RR: 24 bpm

Lumbar Spinal StenosisNeurogenic v. Vascular Claudication : 

Lumbar Spinal StenosisNeurogenic v. Vascular Claudication Neurogenic Pain occurs after variable distance of walking Pain relieved (slowly) with sitting Pulses present Back pain common Pain is in a dermatomal distribution Sensory loss is in a dermatomal distribution Vascular Pain occurs after a fixed distance of walking Pain relieved (immediately) with rest in standing Pulses diminished or absent Back pain uncommon Pain usually in the muscles exercised Sensory loss in a glove/stocking pattern

Lumbar Spinal Stenosis Diagnosis : 

Lumbar Spinal Stenosis Diagnosis Treadmill Test: Positive MRI: Positive

Findings suggestive of Lumbar Central Stenosis : 

Findings suggestive of Lumbar Central Stenosis Age greater than 50 Leg pain worse when walking, better when sitting + two stage treadmill test Earlier symptom onset on level treadmill Longer recovery time on level treadmill

Treadmill TestChange over time with PT intevention : 

Treadmill TestChange over time with PT intevention

Other intervention : 

Other intervention Intervention plan included exercise program to help control glucose levels, HTN, cholesterol, and lack of endurance. Continue drug therapy to control glucose levels as well as dietary modifications. Short term goals: Lower resting and submaximal HR and BP Increased ambulation time E.g. measures of physiological and functional parameters are closer to or within normal limits

Summary : 

Summary Screen all systems based on review of systems, interview and intake Include physiological parameters in goals and intervention plan Assist in the control of comorbidities through observation of physiological changes from medication, diet, and exercise.

Other Significant Physiological Measures : 

Other Significant Physiological Measures Body Mass Index (BMI) Blood Pressure

Body Mass Index : 

Body Mass Index Gives comparative weight for height information which correlates with body fat

Body Mass Index : 

Body Mass Index How is it measured? What’s the formula? Body weight in kilograms divided by the square of the height in meters. Clinical Guidelines for the Identification, Evaluation and Treatment of Overweight and Obesity in Adults

Should be measured at each initial visit to monitor patients health profile : 

Should be measured at each initial visit to monitor patients health profile Weight (pounds) height (inches)2 Weight (kg) height (m)2 X 704.2

Can we convince our patients of the importance of losing weight? : 

Can we convince our patients of the importance of losing weight? Yes, and here are a few items to support your cause Studies have shown that type 2 diabetes can be prevented by mild changes in diet and physical activity Chobanian et al There is a 5-7% increased risk of heart failure per one unit of BMI over normal

Blood Pressure : 

Blood Pressure When should it be measured? During the review of systems When signs are present What are the signs of hypertension? Click here for the answer What are the signs of hypotension? Click here for the answer During exercise or activity How should blood pressure respond to an increase in activity? Click here for the answer To assist in assessing the urgency of a medical situation

Assessing urgency of a medical situation : 

Assessing urgency of a medical situation Should I call a code, dial 911 or refer for a medical consult? Go on to the next patient case and you can decide

Mrs. Weatherly : 

Mrs. Weatherly Mrs. Weatherly is a 68 year old patient of yours being seen for the diagnosis of Total Knee Replacement at your outpatient private practice. On initial visit her blood pressure was 146/90. She states she and her family Physician have been working on regulating her BP with medication. Today she presents slightly flushed and apparently is not feeling well. You take her BP and it is 180/96. What should you do? A. Call for an ambulance B. Call a family member to take her to the ER C. Suggest she return to her family Physician in a week if BP remains the same D. Contact her family Physician immediately with patient permission Click here for the answer

Mr. Koetter : 

Mr. Koetter Mr. Koetter is a 41 year old male CEO of a wood working factory. You are evaluating him for LBP. BMI is 26.0 kg/m2 Resting BP is 138/88. How would you classify this patient given his age for BMI and BP? a. Normal BMI & Normal BP b. Normal BMI & High Normal BP c. Overweight BMI & High Normal BP d. Overweight BMI & Stage I HTN e. Obesity Class I & Stage I HTN Click anywhere on slide for answer

Mrs. Faske : 

Mrs. Faske Mrs. Faske is a 52 year old female office worker who is being seen for a distal tib/fib fracture that has healed. Part of her program consists of a reconditioning program for return to speed walking. Vitals are being monitored. Initial BP is 140/90. Within 15 minutes of cycling her diastolic BP rises to 100. At 20 minutes in rises to 110. At this point what should you do?

Answer : 

Answer Stop exercise immediately. Monitor vitals over the rest period DBP maximum for a typical patient is 110, it would be much lower for a patient receiving cardiac rehabilitation for example post MI SBP maximum is 250 mm Hg for a typical patient during exercise

Mr. Schmidt : 

Mr. Schmidt Mr. Schmidt is a 68 year old retired vegetable farmer. You are monitoring his vitals while he is exercising aerobically on the treadmill. You note that his resting BP was 130/90 and with 15 minutes of light ambulation his diastolic blood pressure drops to 80. You stop his activity gradually. What is your rationale?

Rationale : 

Rationale Diastolic BP should normally increase with activity. A drop of 10 mm Hg is significant, especially if it should drop with increased metabolic load.

Ankle/Brachial Index : 

Ankle/Brachial Index SBP LE/SBP UE Less than .96 are abnormal Less than .8, predictive value for PVD is 95%. If ABI is greater than 1.1 PVD can be ruled out 99% of the time.

Heart Rate/Pulse : 

Heart Rate/Pulse During activity heart rate should rise in a linear response to an increase in activity An outcome of Aerobic training is the reduction of the resting heart rate. Various types of pulses Normal Regularly irregular Irregularly irregular Gold Standard Test for measurement is the electrocardiogram.

Target Heart Rate : 

Target Heart Rate In healthy individuals 220 - age This should not be used in persons taking Beta blockers and calcium channel blockers.

Ventilatory Rate : 

Ventilatory Rate Normal adult rate is 12 to 20 breaths per minute Ventilatory Response Index (VRI) Rancho Los Amigos Ask patient to inhale normally and then count to 15 out loud over a 7.5 to 8 second period: Level 0: on a single breath Level 1: requires two breaths Level 2: requires three breaths Level 3: requires four breaths Level 4: unable to count Frownfelter, Donna "Dyspnea: Measurement and evaluation". Cardiopulmonary Physical Therapy Journal. FindArticles.com. 10 Jun, 2010. http://findarticles.com/p/articles/mi_qa3953/is_200001/ai_n8886464/

Slide 72: 

Procedure: The patient is asked to breathe normally. Following a normal inhalation, the patient counts aloud to 15 over a 7.5 to 8-second period, taking additional breaths as necessary. A + may be used to indicate a “hurried” count. Level Definition Level 0 Able to count aloud to 15 in 8 seconds without taking a breath. Level 1 Must take 1 breath in 8 seconds in order to complete counting aloud to 15. Level 2 Must take 2 breaths in 8 seconds in order to complete counting aloud to 15. Level 3 Must take 3 breaths in 8 seconds in order to complete counting aloud to 15. Level 4 Must take more than 3 breaths in order to complete counting aloud to 15. From Cardiopulmonary Physical Therapy, 1999, by the Cardiopulmonary Physical//therapy Section of the American Physical Therapy Association. Ventilatory Response Index (VRI)

Pulse Oxygen/Sa02 : 

Pulse Oxygen/Sa02 Shows the saturation of oxygen on hemoglobin in the red blood cells or percentage of oxygen on hemoglobin Normal: 90% to 100% O2 Saturation How is it used in PT?

Mrs. Andres : 

Mrs. Andres Mrs. Andres is a 76 year old female whom you are treating in an acute care facility 3 days status post femur fracture. She has no previous history of lung pathology. You note her Sa02 drops to 88% during transfers. How would you respond to this situation? Stop activity Assess device for accurate assessment, position and retake measurement while patient is not active If accurate, notify nurse/medical personnel in charge

Lung Sounds : 

Lung Sounds A primer on review of auscultation from Loyola University This will take approximately 15 minutes to complete. Please take the time to listen to the case scenarios. http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/pstep29.htm

Lung Sounds and Auscultation : 

Lung Sounds and Auscultation Students from the Royal College of Ireland have submitted an excellent page on auscultation within Physiopedia I would encourage you to take a look. You will be working within this wiki in a future unit. http://www.physio-pedia.com/index.php5?title=Auscultation

Signs of Hypertension : 

Signs of Hypertension Headache usually occipital and present in am Vertigo/dizziness Flushed face Spontaneous nosebleeds Blurred vision Nocturnal urinary frequency Click here to return

Signs of Hypotension : 

Signs of Hypotension Lightheadedness Syncope Nocturnal Urinary Frequency Mental or Visual Blurring Sense of Weakness or Rubbery Legs Click here to return

Normal BP response to activity : 

Normal BP response to activity Systolic BP should rise ~9mm/hg with each metabolic equivalent Diastolic BP should remain the same or decrease Click here to return

Slide 80: 

What should you do? A. Call for an ambulance B. Call a family member to take her to the ER C. Suggest she return to her family Physician in a week if BP remains the same D. Contact her family Physician immediately with patient permission Click here for return

Lesson 2Upper Quarter Screening Examination : 

Lesson 2Upper Quarter Screening Examination Click Here for Audio

Postural Assessment : 

Postural Assessment Click Here for Audio

Gait : 

Gait Observe gait from anterior, posterior and lateral views noting any compensation

Seated Position : 

Seated Position Inspection Vital Signs Click Here for Audio

Head, Face and Neck Inspection : 

Head, Face and Neck Inspection Eyes Mouth Anterior Cervical Area Click Here for Audio

Head Neck and Face Palpation : 

Head Neck and Face Palpation Glands Lymph Nodes Click Here for Audio

Abnormal lumps : 

Abnormal lumps Click Here for Audio

Cr N 1 : 

Cr N 1 Smell The therapist can test smell by using an orange, coffee grounds or vanilla spice. The patients eyes are closed and should be asked to identify the smell.

Cr. N 2 : 

Cr. N 2 Testing of the optic nerve can be quite extensive, including examination of visual acuity, visual fields, color vision and funduscopic evaluation. The majority of this evaluation is well beyond the scope of the physical therapist. However, a simple assessment of the visual fields is brief and often productive for detecting neurological deficits. In testing visual fields, the patient’s visual field will be compared with those of the examiner, through the confrontation tests. The patient sits opposite the therapist and each look into the other’s eyes without looking away during the test. Have the patient focus on the tip of your nose while you focus on the patient’s nose. Move your hand from a lateral position medially while maintaining the position equidistant between yourself and the patient. Have the patient report to you when he sees your hand; compare this to your fields (assuming the examiners field of vision is normal). The optic nerve also carries the afferent limb of the light reflex. Click Here for Audio

Cr. NN 2 & 3 : 

Cr. NN 2 & 3 Pupil reaction Eye movements

Cr. NN 3, 4 & 6Oculomotor Nerve, Trochlear Nerve and Abducens Nerve : 

Cr. NN 3, 4 & 6Oculomotor Nerve, Trochlear Nerve and Abducens Nerve The patient is asked to follow the examiners finger as it is moved to the right, then upward and downward. The patient follows the examiners finger back to the midline where it is moved upward and downward. The examiner then moves his finger to the left, repeating the process. While the patient’s eyes follow the examiner’s finger, the examiner assesses symmetry and range of movement, speed of motion and the presence of any nystagmus. Slight nystagmus at the end range of lateral gaze is normal. (III, IV, VI - Test)     The third cranial nerve can also be tested by the light reflex. Light in one eye will produce pupillary constriction in the same eye (direct response) and pupillary constriction in the opposite eye (consensual response). The third nerve may also be tested by the accommodation reflex.

Cr. N V : 

Cr. N V Cutaneous testing of the face, check ability to clench teeth and open mouth.

Cr. N 7 : 

Cr. N 7 Check symmetry and smoothness of facial expressions. Both eyes should blink with corneal brushing.

Cr. N VIII : 

Cr. N VIII Hearing may be screened grossly be rubbing the fingers together gently next to the patient’s ear and evaluating the intensity and clarity of the sound. Gross tests of balance may be done with the eyes closed. Specific testing of the VIII cranial nerve should be carried out in a specialized laboratory with precise testing equipment.

What is the physiological response being tested by the Rinne test? : 

What is the physiological response being tested by the Rinne test? Click here for answer

Cr. N IX Glossopharyngeal : 

Cr. N IX Glossopharyngeal The glossopharyngeal nerve is best tested by the “gag reflex.” The gag reflex is the reflex contraction in response to a cotton swab tickled at the back of the throat. This reflex is mediated by the glossopharyngeal nerve afferently and the vagus nerve efferently. These findings should be correlated with testing for decreased taste on the posterior one third of the tongue.

Cr. N X Vagus Nerve : 

Cr. N X Vagus Nerve Testing is done by having the patient say “ahh” and observing for elevation of the palatal arch. If one side of the arch is paralyzed it will not be elevated and the median raphe will be pulled toward the opposite side of the lesion.

Cr NN 11 & 12Accessory & Hypoglossal : 

Cr NN 11 & 12Accessory & Hypoglossal Manual muscle testing of the trapezius and to sternocleidomastoid, i.e. shoulder shrugging and cervical rotation, are tested for strength.  Ask the patient to stick their tongue out as far as possible. If the hypoglossal is paralyzed, the tongue will not protrude out straight but rather will deviate to one side. Have the patient try to lick each cheek and assess symmetry and ease of motion. Strength can further be tested by applying pressure to the tongue in different direction with the use of a tongue depressor.

Cr. N 12 : 

Cr. N 12 Hypoglossal Check tongue protrusion for atrophy or deviations Resist tongue by asking the patient to place tongue on the cheek and hold the pressure Click Here for Audio

TMJ : 

TMJ Click Here for Audio

Cervical Spine : 

Cervical Spine AROM/ Passive overpressure

UE Observation : 

UE Observation

UE AROM/ Overpressure : 

UE AROM/ Overpressure

Answer : 

Answer The Rinne test is based on the premise that air conduction lasts longer than bone conduction. Therefore the tuning fork is still vibrating when it is moved to the external auditory meatus and sound waves will stimulate the inner and the patient should hear the sound. Click here to return

References : 

References Boissonnault W. Primary care for the Physical Therapist: Examination and Triage. 2nd Edition Elsevier Inc; 2011 Wiegand, M. Orthopaedic Neurology, Chapter 21 in Orthopaedic Physical Therapy Secrets by Placzek & Boyce. (2001)Hanley & Belfus. Inc. Philadelphia The end of Unit 4

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