Clinical Evaluation and Assessment of the Cardiovascular and Pulmonary System

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Chapter 15

Clinical Evaluation and Assessment of the Cardiovascular and Pulmonary System

Donna Frownfelter and Susan M. Butler McNamara

The Guide to Physical Therapist Practice provides a thorough patient management model.¹ It identifies the key components necessary for a thorough examination and evaluation of the patient, tests and measures, identification of impairments, and interventions and outcomes that help the therapist in providing a multisystem examination and evaluation that will lead to appropriate treatment and achievement of optimal function and goals (see Figure 17-2).

This chapter will follow and focus on the flow of the examination, which includes patient and family history, systems review, tests and measures overview, evaluation leading to interventions, and identifying and reaching appropriate outcomes. This flow may continue in a forward, circular manner, or it may go back and forth as a patient’s condition either improves or declines. It is an active process, which may lead to achieving expected outcomes, discharge, or discontinuation of therapy based on many factors. A given patient may have more than one impairment, so all conditions or a multisystem examination should be done to identify all impairments. In addition, prevention and risk factor assessment must be done. For example, if an orthopedic patient is referred for treatment following a total knee replacement (TKR), the therapist may find that he is also prehypertensive with elevated BP and HR, has a family history of heart disease, and is a smoker. Thus, in addition to treating for the primary referral diagnosis of TKR, the therapist may also use the 6A Prevention Pattern to try to decrease the patient’s risk factors for cardiovascular and pulmonary (CVP) disease and to promote wellness.

It is important to remember that although patients may be referred to the physical therapist for a primary cardiovascular and/or pulmonary impairment, they may also have a secondary cardiovascular and/or pulmonary impairment that may or may not have been diagnosed or identified. Another example would be a patient referred to physical therapy after having a cardiovascular accident (CVA). This patient may have right-sided weakness, be slumped to the right side, and have decreasing ventilation on the right lung. Weak pharyngeal muscles may be increasing the patient’s risk for aspiration. In addition, a decreased vital capacity and weakened abdominal muscles may reduce the patient’s ability to keep the airway clear, and poor breath support may make it difficult for the patient to speak clearly, if at all. If the therapist only considers the primary diagnosis of CVA, the potentially life-threatening secondary cardiovascular and pulmonary impairments would be missed, which would limit optimal outcomes.

Screening for risk factors for cardiovascular and pulmonary issues is essential in all patients, including a thorough family history and assessment of other risk factors. A patient may come to the physical therapist after having a “simple” orthopedic procedure such as an ACL repair, but after discussing family history it is discovered that the 30-year-old patient’s father died at age 32 after a massive heart attack. If the therapist checks the patient’s BP on screening, finds that it is 180/100, and discovers that the patient hasn’t been to a doctor in years, the therapist can identify risk factors and help to provide secondary prevention, as well as the primary treatment.

The examination and evaluation provide the therapist with a baseline, against which future visits or sessions will be compared. Depending on the site of practice (e.g., acute care versus long-term care or outpatient, school, or home care), this may occur each time the therapist sees the patient or once a week; regardless, the baseline data are essential as a place to start.

History: Review and Interview

Medical Chart Review

The first component in the examination is obtaining a history. Initially, this can be a review of the medical chart, paying close attention to the notes of the physician, the nurse, and the physician assistant and looking through lab values, tests that were ordered and their results, vital signs, and summary notes. Each practice setting has a variety of available information; as a rule, the more acute the patient’s condition is, the more notes, tests, and results there are to review. It is helpful to learn to screen the chart quickly but also thoroughly in order not to miss information. After the chart review, the therapist should discuss the patient’s case with the nurse, physician, physician’s assistant, and/or other members of the interprofessional team to help develop an understanding of the patient’s condition before beginning the examination.

Patient/Family Interview

If a direct patient interview is possible, asking specific open-ended questions is most valuable. It is optimal to interview the patient directly, and even if the person has some limitations, the initial questions should be directed to the patient. If the patient is very ill or cognitively impaired and unable to provide information, the family and significant others in his or her life may be able to give important information not found directly on the medical chart. It is important for the physical therapist to take the time to listen carefully to what is expressed and relate it to what was found in the chart before performing the examination and evaluation.

In outpatient settings, rehabilitation facilities, or schools, very little information may be available other than a physician’s referral and/or notes. In these cases, the therapist needs to be effective at drawing out important information from the patient during the interview. It is important to be thorough and yet be aware of appropriate time management and efficiency. Interviewing is a skill that improves with practice as the therapist gains more knowledge of diagnoses and patient presentations and becomes better able to obtain information in an organized efficient manner.

A sequencing strategy is helpful in reviewing charts. With experience most therapists develop a specific system that works well for them. Here is just one example of a strategy for reviewing charts:

1. Read the history and the physical and admission medical notes (i.e., the preadmission symptoms, past medical history)—this includes the physician’s notes and the nurse’s notes.

2. Read the most recent medical notes.

3. Scan the remainder of the chart.

4. Read any reports from medical specialists and consultants, such as pulmonologists, neurologists, or oncologists.

5. Review any pertinent lab tests, such as chest radiograph, arterial blood gases (ABGs), complete blood count (CBC), cardiac tests, CAT scans, and MRIs.

6. Review medications—in particular, pulmonary and cardiac drugs.

7. Review any procedures performed (e.g., surgery, intubation, chest tubes, NG tubes).

8. Review the psychosocial information (e.g., family, support systems, education, financial concerns, psychological issues, architectural barriers).

In acute care, discharge planning begins with the first time a therapist sees a patient. Patients are often in the hospital only a brief time, and the physical therapist will be asked to make recommendations for discharge. Any detail of a patient’s background that would affect discharge planning is crucial to know, even on the first day of treatment. Additional information that may be helpful to review (and falls into the category of “as time allows”) includes any documentation recorded by other health professionals, such as nurses, occupational therapists, or speech pathologists. Finally, when the initial chart review is finished, a mental picture of the patient should exist, even before the physical therapist steps into the patient’s hospital room.

Details regarding the patient interview have been covered in Chapter 7. However, there are questions that should be posed to any patient, even if his or her primary condition is not cardiovascular and/or pulmonary. The patient whose primary referring impairment is musculoskeletal or neurological needs to have a screening of the cardiovascular and pulmonary system. The therapist should consider the following questions: What is the patient’s smoking history? Does the patient have a family history of premature coronary artery disease (i.e., a parent or sibling who had a myocardial infarction)? Can the symptoms presented also be signs of a cardiovascular or pulmonary illness? Does the patient have an active or a sedentary lifestyle? What activities precipitate the patient’s symptoms? Do these symptoms include breathlessness? Are there problems with airway clearance, congestion, etc.?

Every patient should be seen as a human being with multiple organ systems. The patient’s problem, whether orthopedic or cardiovascular and pulmonary, should not be viewed in isolation. Another example is the outpatient with a physical therapy diagnosis of low back pain. When questioned about limiting symptoms, the patient might describe cramping leg pain, which is suggestive of peripheral vascular disease (PVD). This should be considered a “red flag” that would lead the therapist to look further into cardiovascular and pulmonary issues or impairments. If this is not taken into consideration and the patient is treated only for low back pain, optimal outcomes and function cannot occur.

System Review and Tests and Measures

Physical Examination of the Chest

After the general physical therapy examination of muscle strength, ROM, activity, and function, the physical examination of the chest comes next. The therapist begins by obtaining vital signs (BP, HR, T, etc.) and then progresses to the examination of the chest wall and auscultation of the heart and lungs. When the information provided by each of these techniques is integrated with the patient’s history, interview, and chart review, the physical therapist can then do the assessment and identify the impairment, prognosis, and appropriate interventions that will lead to optimal outcomes for the patient. It is important to include all of these assessments in an appropriate sequence. For instance, auscultating breath sounds without evaluating the patient’s posture or asymmetry of the chest wall would fail to provide needed clues to the total patient picture and would not facilitate the development of an appropriate plan of care for the patient. All components of the examination must be considered before deciding which interventions should be implemented and which goals and/or outcomes can be developed.

Before we discuss the individual aspects of the chest assessment, a review of the pertinent anatomic landmarks and topographic lines is warranted. Knowledge of the superficial anatomy and its relationship to the underlying heart and lungs aids the therapist in making crucial decisions. The topographical lines allow for more accurate descriptions of the physical findings.

Topographic Anatomic Landmarks

Key anatomic structures include the following:

Sternum

Clavicles

Suprasternal notch

Sternomanubrial angle (angle of Louis for identification of the second rib)

Costal angle

Vertebra prominens

See Box 15-1 and Figure 15-1 for specific definitions and anterior and lateral views of the thorax. Imaginary topographic lines are used to more clearly describe any physical findings (e.g., location of surgical incisions, abnormal breath sounds, etc.; Figure 15-2).

Box 15-1 Anatomic Structures

Suprasternal notch: A depression palpable at the top of the sternum

Sternomanubrial angle: A bony bump where the manubrium meets the body of the sternum; about 5 cm distal to suprasternal notch; also known as the angle of Louis; palpating lateral to this junction, the second ribs are found; they are reference points for identifying intercostal spaces and successive ribs; also, a superficial marking for where the underlying trachea divides into right and left main stem bronchi

Costal angle: The angle formed by the joining of the costal margins with the sternum; normally, no greater than 90 degrees

Vertebra prominens: The spinous process of the seventh cervical vertebra (C7); allows numbering of thoracic vertebra

Fig. 15-1 Anatomy of the chest. A, Topographic landmarks of the chest. B, Bony chest skeleton. *(A from Thompson JM, Wilson SF:* Health assessment for nursing practice, *St Louis, 1996, Mosby. B from Schwartz MH:* Textbook of physical diagnosis: History and examination, *ed 6, St Louis, 2010, Saunders.)*

Fig. 15-2 Anatomic reference lines on the anterior (A), posterior (B), and lateral (C) chest wall. *(Redrawn from Wilkins RL, Stoller JK, Kacmarek RM:* Egan’s fundamentals of respiratory care, *ed 9, St Louis, 2009, Mosby.)*

The anterior view of the thorax has three vertical lines:

Midsternal line (MSL)—a vertical line bisecting the sternum

2 Midclavicular lines (MCLs)—parallel to the MSL, bisecting each clavicle; the borders of the lower lung cross the sixth ribs at the MCLs

Laterally, there are also three vertical lines, originating in their respective axillary folds:

Anterior axillary line (AAL)

Midaxillary line (MAL)

Posterior axillary line (PAL)—like the MCLs, these lines are bilateral

The posterior chest has the following three lines:

Vertebral or midspinal line—runs through the spinous processes of the vertebrae

2 Midscapular lines (MSLs)—parallel to the midspinal line, bisecting the inferior angles of the scapulae

Visual Inspection

Inspection is the foremost element of a systematic review of the chest. The physical therapist should not only observe the features of the patient, but also consider the equipment and any aspect of the patient’s surroundings that would contribute to delineating the true picture of that patient. The therapist should already have a preliminary idea of the patient based on review of the chart and discussion with the physician, nurse, or physician assistant. Interacting with the patient is necessary to determine whether the initial assessment was realistic. Other clinical signs and symptoms the patient exhibits will also be taken into account during the first interaction. Examination and evaluation should continue during any subsequent interventions and patient visits.

General Appearance

The examination should begin as soon as the therapist walks into the patient’s room. Many questions about the appearance of the patient, as well as his or her surroundings, must be considered in order to help determine the patient’s status. The following are some examples of questions typical for the acute care setting:

Does the patient appear comfortable? Is there any facial grimacing? Is the patient awake and alert or somnolent or disoriented? Is there any nasal flaring, wheezing, or pursed-lip breathing? (These are signs of respiratory distress. Nasal flaring can be defined as the outward movement of the nares with inspiration.²) Are the accessory muscles of respiration (i.e., sternocleidomastoid and trapezius) hypertrophied? How is the patient positioned? Is the patient resting comfortably or leaning forward over the bedside table and struggling for breath? What is the patient’s build—stocky, thin, or cachectic? Is the patient’s mobility limited? Can the patient sit unsupported? Should the assessment be performed in stages, allowing the patient to be supine and then to lie on each side? Is there any extra equipment in the patient’s surroundings? Is the patient using supplemental oxygen? Is the oxygen delivered through a nasal cannula or other device? What is the fraction of inspired oxygen (FiO₂)? Are there any monitoring lines, and where are they located? For instance, if an arterial line is present, is it placed in the radial or the femoral artery? Are there electrocardiogram (ECG) leads? Is it a hard line (directly connected to a monitor) or a telemetry line (communicating through radio transmitter)? Are there intravenous (IV) sites? Are they peripheral (antecubital) or central (subclavian or jugular)? Is there a urinary catheter? Are there chest tubes?

These are just a few examples. In other settings, different questions will apply (such as posture and breathing considerations related to functional activities). However, many of these same questions will apply, regardless of the setting. Remember that a visual inspection of general appearance does not apply only to the patient but also to the immediate surroundings, including any equipment or devices that may be attached to the patient. It is extremely important to know what equipment is being used, to understand the purpose of each medical devices, and to be aware of how movement may affect these devices. All tubes and lines attached to the patient must be identified and thought must be given to what may happen to each of these before any physical therapy activity or intervention is performed. In certain cases, a line or tube being dislodged or detached could be a life-threatening occurrence (such as with an arterial line). In other cases, a dislodging or disturbance of lines may only cause inconvenience (such as with an IV) or discomfort (in the case of a urinary catheter). Regardless of the potential consequences, extreme care and planning must precede any movement of or by patients.