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:

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.

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.

Skin

Does the skin have a pink, healthy color or a pallor? Is cyanosis present? Cyanosis is a bluish tinge that can be seen centrally or peripherally. Central cyanosis is a result of insufficient gas exchange within the lungs and is not usually seen unless oxygen saturation is less than 80%. A bluish tint may be seen at the mucous membranes (e.g., tongue and lips). Peripheral cyanosis, on the other hand, occurs when oxygen extraction at the periphery is excessive. This type is more closely associated with states of low cardiac output. Areas to observe for peripheral cyanosis include fingertips, toes, nose, and nail beds. A differentiating feature between central and peripheral cyanosis is that peripheral cyanosis normally occurs in the cooler body parts, such as the nail beds, and usually vanishes when the part is warmed. In contrast, central cyanosis does not disappear when the area is warmed.

Are any scars, bruises, or ecchymoses observed? Are there reddened areas suggestive of prolonged pressure? Do the bony landmarks appear more prominent than usual? Are there any signs of trauma to the thorax or any other body parts? Does the skin appear edematous? Does this edema appear to limit joint motion? Are there any surgical incisions, new or old? Do these incisions appear to be healed or seem reddened and swollen? Is there evidence of clubbing of the digits? Digital clubbing can be defined as the loss of angle between the nail bed and the distal interphalangeal joint (Figure 15-3). The cause of clubbing is explained by a variety of theories, including increased perfusion secondary to hypoxemia with arterial desaturation, but this is not an exclusive phenomenon; clubbing has also been observed in nonpulmonary diseases such as hepatic fibrosis and Crohn’s disease.^2–4

Neck

Are the accessory muscles of respiration being recruited for a resting breathing pattern? Do the sternocleidomastoid or trapezius muscles appear prominent? This is an early sign of obstructive lung disease.²

Jugular Venous Distention

The jugular veins empty into the superior vena cava and reflect right-sided heart function. Right atrial pressure (RAP) is evident based on the extent to which the jugular venous pulse (JVP) can be visualized. The more superficial external jugular veins may be seen superior to the clavicles; the internal jugular veins, though larger, lie deep beneath the sternocleidomastoids and are less visible. Jugular venous distention (JVD) can be best seen when the patient lies with the head and neck at an angle of 45 degrees (Figure 15-4). The presence or absence of symmetry of JVD should be noted. The veins are distended bilaterally if there is a cardiac cause such as congestive heart failure (CHF). A unilateral distention is an indication of a localized problem.⁴

Stethoscope

A stethoscope need not be sophisticated to be effective. A physical therapist skilled in auscultation can use any basic stethoscope and be able to identify lung sounds. The stethoscope functions more as a filter to the extraneous noises than as an amplifier. A basic stethoscope consists of earpieces, tubing, and a chest piece. The bell portion of the chest piece assesses low-pitched sounds (i.e., heart sounds). The diaphragm portion discerns high-pitched sounds (Figure 15-6). The tubing should not be so long that sound transmission is dampened. An appropriate length is between 30 cm (12 inches) and 55 cm (21 to 22 inches). The earpieces should fit the physical therapist’s ears comfortably and allow the tuning out of external sounds. Another consideration is to position the earpieces anteriorly, or forward toward the ear canals. Warming the diaphragm before placing it on the patient’s skin is appreciated by the patient.

A study by Gurunga and colleagues evaluated the use of computer lung sound analysis as a diagnostic aid for auscultation. Their conclusion was that the interlistener automated variability was limited by the acuity of the individual listeners and that the use of the automated identification of lungs sounds may improve the overall sensitivity to more accurately pick up wheezes and crackles. The computerized lung sound analysis was 80% more specific and 85% more sensitive to wheezes and crackles. The authors concluded that their data are limited but may prove clinically promising in the future.⁶

Technique

Environment is another element in the correct performance of auscultation. The room or cubicle should be as quiet as possible. Television and radio should be turned off, and any extraneous noises should be minimized or eliminated. This is especially important when auscultation is a new technique for the therapist. Clothing should be removed or draped so that it does not interfere in the assessment of the breath sounds. The patient should be in a sitting position, if possible, for lung sounds. The anterior, lateral, and posterior aspects of the chest should be auscultated both craniocaudally (apices to bases) and side to side (Figure 15-7). The physical therapist places the diaphragm on the patient’s skin so that it lies flat. The patient is instructed to breathe in and out through the mouth. A slightly deeper breath than tidal breathing is suggested. A minimum of one breath per bronchopulmonary segment allows for a comparison of the intensity, pitch, and quality of the breath sounds. Moving the diaphragm from one side to the other side while simultaneously moving it craniocaudally enables the therapist to compare the right side of the chest with the left side of the chest.

Chest Sounds

Chest sounds may be divided into the following categories.

Breath Sounds

The terminology of breath sounds provided in this chapter is a compilation of multiple resources and clinical experience. Recognition of normal breath sounds is the key to the identification of abnormal and adventitious sounds because it offers the listener a point of reference. Normal breath sounds can be broken down into bronchial, bronchovesicular, and vesicular. The American Thoracic Society (ATS) and the American College of Chest Physicians (ACCP) have attempted to provide standardization of the nomenclature and continue to conduct surveys of health care professionals for use of this terminology in clinical practice.

Bronchial sounds can be described as high-pitched and are heard in both the inspiratory and the expiratory phase. A distinguishing feature is the pause that exists between the inspiratory and expiratory phases (Figure 15-8). These sounds are also described as tracheal because their normal location is over the trachea. Bronchovesicular sounds are similar in that they are also high-pitched and have equal inspiratory and expiratory cycles. However, a differentiating feature is the lack of a pause (see Figure 15-8). Bronchovesicular sounds are heard best wherever the bronchi, or central lung tissue, are close to the surface. These areas are supraclavicular and suprascapular (the apices), as well as parasternal and interscapular (the bronchi). The ATS and ACCP, in their 1977 recommendations for pulmonary nomenclature, used the term bronchial to include both bronchial and bronchovesicular sounds. The difference is minor (the pause between the inspiratory and expiratory phases). This recommendation is meant to provide uniformity to lung-sound terminology. Vesicular breath sounds are heard over the remaining peripheral lung fields. These sounds have primarily an inspiratory component, with only the initial one-third of the expiratory phase audible. Their intensity is also softer because of the dampening effect of the spongy lung tissue and the cumulative effect of the air entry from numerous terminal bronchioles. The idea that vesicular sounds reflect air entry in the alveoli has been disproved. Thus, as the therapist auscultates from top to bottom, the breath sounds are quieter at the bases than at the apices. Infants and small children have louder, harsher breath sounds. This is as result of the thinness of the chest wall and the airways’ being closer to the surface.

Abnormal Breath Sounds

Abnormal breath sounds can be described as changes in the sound transmission as a result of an underlying pathologic process. Sound is filtered by the lung tissues because these organs are air-filled; thus sound transmission is dampened over the bases more than over the apices. On the other hand, sound transmission is enhanced when a liquid or solid is the medium. Certain lung pathologies produce abnormal lung sounds. Abnormal sounds can be divided into three types: bronchial, decreased, and absent. Bronchial sounds occur in peripheral lung tissue when it becomes airless—either partially or completely. In a consolidating type of pneumonia, the lung tissue is “airless” because of the complete obstruction of segmental or lobar bronchi by secretions. Sound from the adjacent bronchi is enhanced and becomes higher pitched, and the expiratory component is louder and more pronounced. Compression of lung tissue from an extrapulmonary source also produces bronchial sounds. Examples include compression secondary to increased pleural fluid (pleural effusion) or tumor. Tubular breath sounds is a term used synonymously to mean abnormal bronchial breath sounds.

Decreased or absent breath sounds occur when sound transmission is diminished or abolished. Decreased breath sounds occur when the normal vesicular sounds are further diminished. The term absent sounds means that no sounds are audible. Decreased or absent sounds can be caused by an internal pulmonary pathology or can be secondary to an initially nonpulmonary condition. Hyperinflation caused by emphysema causes decreased sound transmission as a result of the destruction of the acinar units and causes increased air as a result of the loss of normal lung structure. The loss of lung compliance resulting from pulmonary fibrosis also may produce decreased or absent breath sounds. Extrapulmonary causes include tumors, neuromuscular weakness (i.e., muscular dystrophy), and musculoskeletal deformities (i.e., kyphoscoliosis). Pain is a common cause for decreased or absent breath sounds. When the patient attempts to take a deep breath, the volume is limited because of the onset of pain. The causes of the pain can be varied—from incisional (e.g., midsternotomy) to traumatic (e.g., fractured ribs). If no underlying pathologies are present, decreased breath sounds may be a reflection of the depth of respiration or the thickness of the chest wall (e.g., in obesity or with the presence of bandages). The skill of auscultation lies in the differentiation between normal and abnormal breath sounds.

Adventitious Breath Sounds

Adventitious breath sounds are the extraneous noises produced over the bronchopulmonary tree and are an indication of an abnormal process or condition. These sounds may be more easily identifiable than abnormal sounds. Adventitious sounds are classified as crackles (rales), rhonchi, and wheezes. Crackles (rales) are described as discontinuous, low-pitched sounds. They occur predominantly during inspiration. The sound of rubbing hair between the fingers or of Velcro popping simulates crackles. Crackles usually indicate a peripheral airway process. Rhonchi are low-pitched but continuous sounds. These occur in both inspiration and expiration. Snoring is a term used to describe its quality. Rhonchi are attributed to an obstructive process in the larger, more central airways. Wheezes are continuous but high-pitched. A hissing or whistling quality is present. Wheezes that occur predominantly during inspiration are an indication of bronchospasm; wheezes during exhalation are an indication of airway secretions. The airways get larger on inspiration and smaller on exhalation. Consequently, when the patient has bronchospasm, a high-pitched wheeze is heard on inspiration. During exhalation, the airways become more narrow, consequently when air goes past secretions in a narrowed airway, an expiratory wheeze is heard on auscultation. Being able to identify the difference between inspiratory and expiratory wheezing is very important because this will help to determine what treatment is indicated. Inspiratory wheezing indicates that a bronchodilator is needed, whereas expiratory wheezing suggests the need for airway clearance techniques.

Extrapulmonary Sounds

An adventitious sound that is nonpulmonary is the friction rub. It can be described as a rubbing or leathery sound, and it occurs during both inspiration and expiration. The sound is produced when the visceral (inner) pleural lining rubs against the parietal (outer) pleura and is a sign of a primary pleural process, such as inflammation or neoplasm. Pain is usually associated with a friction rub.

Voice Sounds

Voice sounds are vibrations heard through a stethoscope and produced by the speaking voice as it travels down the tracheobronchial tree and through the lung parenchyma. These sounds, over the normal lung, are low-pitched and have a muffled or mumbled quality. The transmission of these vocal vibrations can be increased or decreased in the presence of an underlying pulmonary pathologic process. Bronchophony describes the phenomenon of increased vocal transmission. Words or letters are louder and clearer. It is caused by conditions in which there is increased lung density, as in consolidation due to pneumonia. To assess for bronchophony, the patient is usually asked to repeat “blue moon” or “one, two, three.” Egophony may also be present when there is increased transmission of the vocal vibrations. In this case, the patient is asked to say “eeee.” The underlying process distorts the e sound so that an “aaa” sound is heard over the peripheral area by the examiner. Egophony coexists with bronchophony.

Whispered voice sounds also produce low-pitched vibrations over the chest that are muffled by normal lung parenchyma. In whispered pectoriloquy, these whispered voice sounds become distinct and clear; “one, two, three” or “ninety-nine” are used to evaluate this sound. Whispered pectoriloquy can be present when bronchophony and egophony are absent. This sign is helpful in identifying smaller or patchy areas of lung consolidation.

Voice sounds are a method of confirming abnormal breath sounds. If a patient with significant atelectasis secondary to compression of lung tissue presents with bronchial breath sounds, then egophony and bronchophony are also audible.

Websites are available that allow the beginner in auscultation to hear actual lung sounds. The two websites included in this chapter’s references have links to these auditory sites. Other sites may be found by doing an online search (using Google or another search engine) with key words such as “auscultation of breath sounds.”

Technique

An environment that is as quiet as possible is recommended. Positions used for cardiac auscultation include the following: supine—used for all areas; left lateral decubitus (side-lying)—listening to cardiac apex or mitral area, bell usually used; and sitting—used for all areas. Clinically, there are times when positions may be limited. In those cases, the therapist must listen with the patient in the best position available. However, if possible, the left side-lying position is most valuable because the pathological S₃ and S₄ sounds are heard most clearly. If the patient is in a sitting position, a leaning-forward position may also be used for better auscultation.

Normal Heart Sounds

The first heart sound (S₁) signifies the closing of the atrioventricular valves. Its duration is 0.10 seconds; it is heard the loudest at the cardiac apex. The two components of S₁ are tricuspid and mitral. Both the diaphragm and the bell of the stethoscope can be used to hear S₁. Its loudness is enhanced by any condition in which the heart is closer to the chest wall (i.e., thin chest wall) or in which there is an increased force to the ventricular contraction (e.g., tachycardia resulting from exercise; Figure 15-9).

The second heart sound (S₂) represents the closing of the semilunar valves and the end of ventricular systole. Its components are aortic and pulmonic. During expiration, these two components are not distinct because the time difference in the closure of the valves is less than 30 milliseconds. However, during inspiration, a splitting of S₂ is audible. This physiologic split results from the increased venous return to the right heart secondary to the decreased intrathoracic pressure that occurs during inspiration. The pulmonic valve closure is delayed as the right ventricular systolic time is lengthened. A split S₂ is heard commonly in children and young adults. The diaphragm of the stethoscope should be used to hear the split. The pulmonic component is the softer sound and is best heard at the LSB, in the second to fourth ICS. The two components may be heard best in the aortic and pulmonic areas, respectively. When the split is heard in both phases of respiration, an underlying cardiac abnormality is suspected. Causes may include right bundle branch block and pulmonary hypertension.2,7

Gallops

The third heart sound (S₃) is a faint, low-frequency sound and reflects the early (diastolic) ventricular filling that occurs after the atrioventricular valves open. S₃ is normal in children and young adults; however, it is usually abnormal in individuals over age 40. An extra effort must be made to auscultate S₃; the bell of the stethoscope should be used. The ideal position to hear S₃ is left side-lying; the bell should be placed over the cardiac apex. Causes of a pathological S₃ may include ventricular failure, tachycardia, or mitral regurgitation. “Ken-TUCK-y” is one sound that has been used to approximate the sound sequencing of S₃ in the cardiac cycle (S₁, S₂, S₃).

The fourth heart sound (S₄) signifies the rapid ventricular filling that occurs after atrial contraction. When present, it is heard before S₁. S₄ may be heard in the “normal” individual with left ventricular hypertrophy. The location of S₄ is similar to that of S₃. Its sound can be described as dull because of the sudden motion of stiff ventricles in response to increased atrial contraction. Pathologies eliciting an S₄ may include systemic hypertension, cardiomyopathies, and coarctation of the aorta. “TENN-es-see” is a sound that approximates the sound sequencing when S₄ is present (S₄, S₁, S₂).

Murmurs

Cardiac murmurs are the vibrations resulting from turbulent blood flow. They may be described based on position in cardiac cycle (systole, diastole), duration, and loudness. Systolic murmurs occur between S₁ and S₂; diastolic murmurs occur between S₂ and S₁. A continuous murmur starts in S₁ and lasts through S₂ for a portion or all of diastole. The loudness of a murmur is a factor of the velocity of blood flow and the turbulence created as it flows through a specific opening such as a valve. Grades I to VI are described in Table 15-1.

Murmurs that are grade III or higher are usually associated with cardiovascular pathology.

Technique

The middle finger of the nondominant hand is placed firmly on the chest wall in an intercostal space and parallel to the ribs. The top of the middle finger of the dominant hand strikes the distal phalanx of the stationary hand with a quick, sharp motion. The impetus of the blow comes from the wrist rather than the elbow and has been likened to that of a paddle ball player (Figure 15-10).² As with auscultation, the therapist must follow the sequence of apices to bases and side to side so that comparisons can be made. This technique is not usually used in infants because percussion is too easily transmitted by a small chest.

Diaphragmatic Excursion

Assessment of diaphragmatic movement can be made with mediate percussion. The patient is asked to breathe deeply and hold that breath. The lowest level of the diaphragm on maximal inspiration coincides with the lowest point where a resonant tone is heard. The patient is then asked to exhale, and mediate percussion is repeated. The lowest area of resonance now moves higher, as the diaphragm ascends with relaxation. The distance between these two points is described as the diaphragmatic excursion; the normal range is 3 to 5 cm (Figure 15-11). Diaphragmatic movement is decreased in patients with COPD.

Tenderness

Specific superficial or deep landmarks are identified by means of palpation. Determination of gross spinal alignment can be performed by tracing the spinous processes in a cephalocaudal direction. Certain structures can be identified, such as the T4 vertebra or the sternal angle; this augments the physical therapist’s evaluation. Areas of tenderness can be assessed for degree of discomfort and reproducibility. Differentiation of chest wall discomfort of an organic nature, such as in angina, from that of a musculoskeletal condition may be made through palpation. In a patient complaining of chest pain, angina may be ruled out if the physical therapist can reproduce or increase the discomfort by increasing tactile pressure. However, one must also determine that corroborating symptoms (e.g., diaphoresis, tachycardia) are not present. Angina or chest pain secondary to myocardial ischemia usually results from exertion and may be relieved by rest. Crepitus is a crunchy sound often associated with articular structures. However, when bubbles of air occur within subcutaneous tissue, a crackling sensation can be palpated. An air leak from a chest-tube site is one circumstance in which crepitus is palpated over the chest wall. Crepitus can also be secondary to a pleural or friction rub.

Edema

Palpation allows the physical therapist to assess peripheral edema. Dependency of body parts such as lower extremities or sacrum can cause swelling related to cardiac and noncardiac conditions. Assessment of edema is performed by pressing two fingers into the particular areas for 2 to 3 seconds. If an impression is left once the fingers are removed, then pitting or dependent edema is present. The degree of edema is based on the length of time that the indentation lasts. 1+ is the least degree; 4+ is the worst.

Chest Wall Excursion

Evaluation of thoracic expansion allows the therapist to observe a baseline level by which to measure progress or decline in a patient’s condition. Chest wall movement can be restricted unilaterally as a result of lobar pneumonia, scoliosis, muscle weakness, paralysis or a surgical incision. A symmetrical decrease in chest wall motion occurs in the patient with COPD.

The hyperinflation associated with COPD produces an increase in the anteroposterior diameter with a progressive loss of diaphragmatic excursion. Normal chest wall excursion is about 3.25 inches (8.5 cm) in a young adult between 20 and 30 years of age. One method is to use a tape measure at the level of the axilla and xiphoid. In a study of 120 normal subjects, ages ranging from 20 years to 70+ years, Kinney LaPier⁸ performed tape measure readings of subjects in a sitting or standing position at rest and at maximal inspiration (vital capacity) breaths. They found that subjects 20 to 29 years of age had 5.1 ± 6.2 CM excursion. In subjects 70 years and older, the excursion was only 2.5 ± 2.9 cm. The study found a definite decrease in chest wall excursion with age and recommends not utilizing chest wall excursion by tape measure in patients over 65.⁸

The most common method involves direct hand contact. This technique is performed in all planes and from top to bottom. Symmetry and extent of movement are noted. The procedures for this method are found in Table 15-2.

Case Study 15-2

An 8-year-old female admitted to the pediatric inpatient unit presents on chart review (history) with a 4-day history of recurrent fevers, shortness of breath, and lethargy. A chest radiogram shows a right middle lobe infiltrate, based on the following findings:

Anticipated outcomes may include the following.

Treatment interventions may include manual chest percussion, vibration/shaking, postural drainage to right middle lobe area and instruction in huff coughing. Games that may be incorporated to facilitate the huffing and also increase the I : E ratio include blowing bubbles, windmills, kazoos. Handheld airway clearance devices, such as the Flutter, TheraPEP, or Acapella, may also be used.

Case Study 3

A 72-year-old woman presents with symptoms of persistent fevers, left chest wall discomfort, and history of a fall 1 week ago. A CT scan shows a loculated pleural effusion on the left. A left chest tube has been inserted for drainage. The working medical diagnosis is empyema. The patient is a nonsmoker. The following information is learned during the examination component of the patient management model:

Outcomes and treatment interventions must expand beyond the pulmonary diagnosis of empyema because the surgical insertion of a chest tube and the fall itself have impacted the musculoskeletal system as well.

An anticipated outcome would be for the patient to demonstrate no abnormal lung sounds as a result of increased lung volumes. Interventions would include breathing strategies (i.e., left lateral costal and diaphragmatic breathing). Ventilatory strategies could be incorporated into range-of-motion exercises for the shoulder. Incentive spirometry may also facilitate increased lung volumes. Finally, as the patient’s condition becomes less acute, further evaluation may determine whether a balance impairment was the cause of the initial fall.

Table 15-3 presents differentiation of diagnoses by the elements of a chest physical examination.