Cardio Week 2

Patient History Part 1

• Accurately gather patient history from patient charts, personal interviews, and observations.
• Allow patients to explain their history at their own pace in their own words.
• Avoid letting personal feelings about the patient's appearance, demeanor, or behavior affect the validity of their chief complaints.

Objective

• Creating an accurate patient history by gathering information from the patient's chart
• Conducting a personal interview with the patient
• Observing the patient.

The Interview

• Building rapport between the patient and therapist
• Permitting the patient to describe their history at their own pace.
• Not allowing personal feelings to unduly question the validity of the chief complaints.
• The evaluator must not allow personal feelings about the patient's appearance, demeanor, or behavior during the interview to affect the validity of the chief complaints.

Examination, History, Systems Review, Plan of Care, Test & Measures, Intervention, Outcomes, Evaluation

• Examination, history, systems review, plan of care, test and measures, intervention, outcomes, evaluation and follow-up
• First determine if the patient is appropriate for PT
• If appropriate, follow proper protocols if further consultation is necessary
• If inappropriate, refer to an appropriate health care provider
• Patient progress should be evaluated against the set goals in care

Examination: History

• Assess social history, activities, participation, & family history
• Evaluate current conditions & patient goals
• Assess symptoms & review of symptoms
• Determine medical/surgical history
• Identify medications & allergies
• Consider other relevant clinical tests including imaging and labs, and review relevant medical records
• Consider contextual factors and social services questions and any self-reported factors

Patient/Client History

• Gather general demographics (age, gender, race/ethnicity, language preferences, education)
• Assess social history (cultural background, family support, social interactions)
• Assess employment (current work, school or personal activities) and living environment (characteristics, support systems)
• Assess general health status (self-report about physical, psychological, and role/social function)
• Collect information about social and health habits (smoking, substance use, physical activity)
• Assess family history of relevant medical conditions
• Obtain medical/surgical history (past and current conditions, treatments)

Relevant Social History, Family History, Occupational History

• Assess past and current self-destructive behaviors (smoking, drug abuse)
• Evaluate family history of relevant medical conditions (diabetes, hypertension, CAD, rheumatic fever)
• Analyze the patient's type of work to better set goals and expectations for treatment and recovery.

Medical Chart Review

• Diagnosis and date of event
• Primary and secondary diagnoses
• Risk factors for heart disease (hypertension, smoking, elevated cholesterol, family history, stress, sedentary lifestyle, older age, obesity, diabetes)
• Surgical procedures and extent
• Hospital course and the physicians’ notes, order sheets and other relevant information.
• Radiological studies (chest x-rays etc), oxygen therapy, clinical laboratory data (Cardiac enzymes etc)
• Electrocardiogram (ECG) and serial monitoring
• Cardiac catheterization, vital signs

Symptoms

• Pain (chest pain, ischemic pain)
• Shortness of breath (dyspnea/dyspnea on exertion)
• Cough
• Palpitations
• Syncope
• Fatigue
• Edema
• Claudication
• Hoarseness

Chest Pain

• Chest pain can be categorized into anginal pain, chest wall pain, pleuritic chest pain, & pericardial pain.
• These types of pain can have similar characteristics that present in different patterns and timeframes.

Anginal Pain

• Characterized by tightness, pressure and shortness of breath, palpitations, indigestion, and burning sensations.
• Patients demonstrate pain using an extended hand or fist on the anterior chest wall.
• It's relieved by nitroglycerin, rest, and occurs at similar heart rate and blood pressure.

Chest Wall Pain

• Result/originates from the parietal pleura or endothoracic fascia
• Not from the visceral pleura, because they have no pain receptors.
• Characteristically experienced by palpation, after activity or during inspiration.

Pleuritic Chest Pain

• Originates from the parietal pleura or endothoracic fascia
• Related to inflammation and chest wall restriction
• Increased pain during breathing related to stretching and irritation of the affected tissues

Pericardial Chest Pain

• Location is often midline. Deep breathing, coughing, swallowing, movement, and lying down may worsen the pain.
• The pain may radiate to the left shoulder or scapular area.
• Each heartbeat can affect the pain, and sitting up or leaning forward, or lying on the right side often relieves the pain.

Dyspnea

• Sensation of difficulty breathing.
• Orthopnea is dyspnea that occurs when a patient is in a lying down position.
• Paroxysmal nocturnal dyspnea(PND) is the transfer of fluid from extravascular spaces to the bloodstream during sleep.

Cough

• CHF, Pulmonary edema
• Thoracic aortic aneurysm
• Compression of trachea or bronchi
• Certain medications (ACE inhibitors)

Palpitation

• Irregular heart beat.
• Benign conditions such as mitral valve prolapse.
• Serious heart conditions like CAD, heart block, or ventricular aneurysm
• Due to PAC, PVC, SVT, A Flutter, or V tach.

Arrhythmia

• Rhythm disturbances causing a rapid, uncoordinated or forceful contraction heart contractions.

Syncope

• Fainting episode.
• Arrhythmias, LV failure, RV outflow obstruction, pulmonary stenosis, pulmonary HTN, orthostatic hypotension, and Valsalva maneuver.

Fatigue

• Caused by minimal or strenuous activity.
• Often accompanies other signs or symptoms during the early stages of diseases including heart conditions.
• Can indicate poor LV function (myocardial infarction, heart failure, hypertension, valvular disease, Cardiomyopathy).

Pedal Edema

• Common cause of bilateral pedal edema = CHF.
• Increased ankle girth, also occurs from ascites.
• Poorly functioning left ventricle, mitral stenosis, or cor pulmonale can cause edema.
• More pronounced during the day but subsides when laying down

Claudication

• Leg pain that occurs with peripheral vascular disease (PVD).
• Can impair physical function and occur simultaneously with heart/lung diseases.
• Symptoms include discoloration or dry, hairless skin.

Hoarseness

• Several cardiovascular conditions can be involved with hoarseness.
• The recurrent laryngeal nerve loops under the arch of the aorta, above the pulmonary artery and returns to the neck.
• An aneurysm in the arch of the aorta, a dilated pulmonary artery, an atrial septal defect, or mitral stenosis can cause hoarseness.

Cardiac Examination

• Assess locations for proper stethoscope placement for auscultation of all heart sounds
• Identify normal S1 and S2 heart sounds.
• Interpret and understand S3 and S4 heart sounds and associated murmurs.
• Different types of breath sounds, extrapulmonary sounds, and voice sounds with the use of appropriate stethoscope technique.
• Establish an appropriate environment during auscultation
• Apply appropriate topographic landmarks
• Assess heart sounds through different areas in a time-dependent manner

Normal Heart Sounds, Valves, & Murmurs

• S1: closing of the atrioventricular valves
• S2: closing of the semilunar valves
• Aortic and pulmonary areas for analysis of heart sounds
• S3 and S4 sounds, and related murmurs.

Heart Sounds, Gallops, & Murmurs

• S1 and S2 are normal heart sounds
• Gallops occur in early diastole (S3) and in pre-systole (S4)
• Murmurs from turbulent blood flow and are identified through valvular heart disease
• Pericardial friction rub is a sign of pericarditis

Stethoscope Technique

• Using stethoscope correctly using appropriate techniques and positioning, ensuring that tubing isn't rubbing against patient's gown or bed rails.
• Avoiding noisy surroundings when listening to breathing.

Exercise Testing:

• Evaluate when exercise testing should be performed, different types and protocols for exercise testing, and termination points for maximal and submaximal testing.
• Calculate target heart rate using age-predictive and Karvonen methods.
• Interpret exercise test reports and formulate exercise prescriptions.
• Understand how exercise tests are used to screen for exercise programs using informal testing.

Exercise Testing Indications

• Evaluate chest pain suggestive of coronary disease
• Determine the severity and prognosis of coronary artery disease
• Evaluation of the effect of medical or surgical treatment
• Evaluate the presence of arrhythmia
• Evaluate hypertension (with activity)
• Assess functional capacity
• Screening for exercise prescriptions
• Provide motivation to modify lifestyle for prevention of coronary artery disease

Maximal versus Submaximal Testing

• Maximal exercise testing is performed prior to hospital discharge. Sometimes this acute testing protocol is no longer part of the standard course of care
• Submaximal exercise testing endpoints frequently occur within 4-6 days of acute MI episodes.

Exercise Testing Considerations

• Recognizing the importance of safety protocols when performing exercise tests.

Absolute and Relative Contraindications to Exercise Testing

• Recent MI or unstable angina.
• Acute pericarditis or myocarditis.
• Unstable angina.
• Serious ventricular/rapid atrial arrhythmias.
• Untreated second/third-degree heart block.
• Overt congestive heart failure or any acute illness.
• Known left main coronary artery disease
• Severe hypertension.
• Aortic stenosis, idiopathic hypertrophic subaortic stenosis
• Severe ST-segment depression, on the resting electrocardiograph.
• Compensated heart failure

Criteria for Termination of Maximal and Low Level/Submaximal Testing

• Increasing frequency of premature ventricular complexes
• Rapid atrial arrhythmias are significant clinical occurrences that can be indicators of a potential need to stop the test.
• Increased angina, a decrease in systolic blood pressure, or extreme shortness of breath.
• Extreme shortness of breath, dizziness, mental confusion, or lack of coordination
• Severe ST-segment depression.
• Extreme elevation of systolic or diastolic levels of blood pressure.
• On achievement of predicted maximum heart rate
• Patient request to end exercise testing

Testing Protocols

• Common tests include stationary bicycles and treadmills.
• Common exercise protocols include Balke and Bruce.

Modified Bruce Protocol

• Standard protocol, starting with 5 METs
• Increments between stages differ.
• Two 3-minute warm-up stages at 1.7 mph and 0% grade, and 1.7 mph and 5% grade
• Common in older patients or those with limited cardiac capacity.

Interpretation of Results

• Defining the test's outcome, if positive in that the patient developed symptoms of ischemia.
• Identifying any limiting factors and identifying significant ECG changes.
• Understanding findings related to patient symptoms using their heart rate, blood pressure response to activity and heart sounds.
• Determining VO2 max
• Explaining any abnormal findings

Calculation of THR and Karvonen Method

• Determining target heart rate (THR) from maximal or estimated maximal heart rate
• Using the Karvonen method to calculate THR
• Assessing appropriate termination criteria of testing in children and adults.

Pediatric Population/Exercise Testing

• Submaximal treadmill and stair exercise, as well as standardized exercise test protocols for children are different.
• FEV1 < 50% predicted value = monitor SaO2

Prognostic Value of Maximal Exercise Testing

• Screening for coronary disease
• The severity and prognosis assessment when done correctly
• Increased sensitivity/specificity over age 40 for males than females
• Correlation with ischemia and false negatives.

Exercise Testing with Ventilatory Gas Analysis

• Provides information related to O₂, exchange, breathlessness, cardiac performance
• Assess dyspnea, ventilatory reserve, dyspnea index

Pharmacological Testing

• Used when a patient cannot perform upright exercise testing, through adenosine or dipyridamole.
• Inducing physiological stress, with combined low-level treadmill exercise during adenosine infusion.

Patient Evaluation

• Understanding components of cardiac evaluation
• Determine NYHA functional classification and PT practice pattern.

Cardiac Auscultation

• Identifying locations for correct stethoscope placement to assess heart sounds.
• Identifying normal S1 and S2 heart sounds.
• Interpreting S3, S4 heart sounds, and murmurs.
• Understanding different breath sounds, extrapulmonary and voice sounds.

Vital Signs Responses with Activity

• Defining normal and abnormal vital sign ranges.
• Assessing the appropriateness of vital sign changes with activity.
• Measure HR and rhythm (ECG), BP, symptoms, heart/lung sounds. Before and after activity.
• Identify any abnormal responses to activity (rapid increase, decreased rate).

Activity Evaluation

• Determine patient response to different activity levels (supine, sitting, standing, ADLs, ambulation).
• Measure heart rate, rhythm (ECG), BP, symptoms, heart and lung sounds.
• Identify abnormal cardiac responses to activity, which can be indicative of underlying conditions.
• Assess HR and rhythm using an ECG and pulse oximetry.
• Assess heart rhythm, regularity changes, and arrhythmias during testing.

Activity Assessment

• Assessing patient's heart rate and blood pressure under various activity levels (rest, sitting, standing, ADLs, and ambulation)
• Recording activities performed and any adverse symptoms that arise after or during activity (ex: dizziness, chest pain, etc)

Blood Pressure Categories

• Defining normal and abnormal blood pressure ranges using recommended values for systolic and diastolic levels.
• Understanding different hypertension (high blood pressure) categories.
• Identifying criteria for hypertension crisis.

Blood Pressure and PT Considerations

• Identifying systolic and diastolic readings as normal/abnormal.
• Recognize thresholds that necessitate holding of treatment (high systolic or diastolic values).

Pediatric Blood Pressure Reference Chart

• Providing specific blood pressure reference values for patients based on age, from newborns to adolescents.

Heart Rate

• Recognizing normal heart rate range for adults and children (resting)
• Determining appropriate thresholds for holding treatment
• Understanding how HR response varies with age
• Identify tachycardia (Disproportionate to activity)
• Understand how blunt responses to activity can be indicative of underlying conditions (deconditioning, medications, orthostatic hypotension, or other severe cardiac conditions)
• Understand abnormal responses or conditions affecting rhythm (dysrhythmias)

Pediatric Heart Rate Reference Chart

• Providing specific heart rate reference values for patients across different age groups from newborns to adolescents.

Respiratory Rate

• Identifying normal respiratory rates in adults and children (12-20 breaths per minute).
• Recognizing thresholds that necessitate holding treatment when the respiratory rate is abnormal (12 or >30 breaths per minute).

Normal Heart Rate Response to Exercise

• Evaluate heart, vascular and other system responses to different exertion levels, from submaximal to maximal activities.

Abnormal Heart Rate Responses

• Tachycardia disproportionate to activity (deconditioning, medications, orthostatic hypotension, or other severe cardiac conditions).
• Blunted/flat HR response (training effect, medications e.g., beta blockers, antihypertensives or antiarrhythmics, or chronicotropic incompetence).
• Abnormal rhythm response (increase in rate, dysrhythmias).

HR Following Exercise (HR Recovery)

• Determining significant decline in HR following a period of intense exercise.
• Establishing thresholds for failure of sufficient HR decrease (significant risk of mortality or impairment) or related to parasympathetic nervous system dysfunction.

Normal Blood Pressure Response to Exercise

• Recognizing linear/progressive increase in systolic blood pressure (SBP) with increasing exercise workloads.
• Evaluating the modest increase in diastolic blood pressure (DBP) with increasing exercise workloads (in younger patients; a more substantial increase is observed in older patients).
• Identifying and understanding symptoms/conditions resulting in abnormal blood pressure response

Abnormal Blood Pressure Responses

• Recognizing hypertensive response (excessively high SBP increase, elevated DBP or prolonged persistence during activity).
• Identify blunt response, as a possible indication of underlying conditions such as medication or chronotropic incompetence.
• Recognize hypotensive response, as a potential indication of cardiac or cerebrovascular disease or other significant health concerns.
• Recognizing postural hypotension (when there is a significant drop in systolic blood pressure or diastolic blood pressure after standing/sitting from supine position.

Outcome Measures in Cardiac Rehabilitation

• Understand and recognize outcome measures used to evaluate cardiac rehabilitation in a patient's recovery.
• Incorporate the ICF approach in rehabilitation to account for specified goals and ensure appropriate interventions, to improve health status, and plan for the conclusion of care interventions.

Outcome Measures in Acute Care

• Assess self-management of symptoms in patients, as well as aerobic capacity and/or endurance.
• Assess ability to complete self-care/home management tasks, evaluate physiological responses, symptoms related to increased oxygen demands, and level of assistance needed.
• Confirm safety with each given activity

Selection of Measurement Data (Functional Performance)

• Using gold standard (VO₂ max) of functional exercise capacity to measure patient functional performance.
• Identifying other functional performance measures (6MWT, 2MWT, treadmill endurance test, 200-meter walk fast test, other submaximal tests).

Selection of Measurement Data: Health-related quality of life

• Evaluating patient using the Seattle angina questionnaire (impact of chest pain over 4 weeks).
• Identifying and understanding the appropriate target population (individuals with CAD who have experienced chest pain and tightness).
• Evaluate reliability and validity as part of quality-related measurements.
• Employ suggested usage in settings of CAD/MI and actively managing angina/chest symptoms

Selection of Measurement Data: The Minnesota Living with Heart Failure Questionnaire and The Kansas City Cardiomyopathy Questionnaire.

• Understand the use of these questionnaires to assess health-related quality of life.

Physical Activity Readiness Questionnaire-PAR-Q

• Utilizing this questionnaire to properly and safely assess a patient's readiness level for activity levels.
• Identify any limitations or prior conditions that may preclude the patient from starting vigorous activity levels.