Cardio Week 2

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Questions and Answers

What is a primary objective during a patient interview?

To control the pace of the patient's explanation

To evaluate the therapist's experience

To establish a rapport with the patient (correct)

To focus primarily on the patient's grooming habits

What should therapists avoid during patient interviews?

Letting personal feelings about the patient influence the interview (correct)

Conducting the interview at the patient’s comfortable pace

Gathering data from the patient's chart

Allowing patients to explain their history in their own words

Which of the following reflects a necessary step in the evaluation process?

Making assumptions before patient interviews

Taking notes only on the patient's appearance

Revising hypotheses based on examination findings (correct)

Avoiding the use of outcome measures

When is it appropriate to refer a patient to another professional?

When the examination is deemed inappropriate for PT Signup and view all the answers

What indicates progress during the intervention phase?

Functional progress towards goals following re-examination Signup and view all the answers

What is the primary cause of increased contractility?

Low cardiac output Signup and view all the answers

What heart sound is indicative of heart failure?

Gallop Signup and view all the answers

How does the heart rate typically respond during incremental exercise?

It increases in a linear manner with each MET Signup and view all the answers

What happens to the LV filling time as exercise intensity increases?

It is impaired Signup and view all the answers

Which heart sound is typically heard best at the apex of the heart?

Lub Signup and view all the answers

What can contribute to a decrease in stroke volume during exercise?

Impaired LV filling time Signup and view all the answers

Which type of stethoscope component is used to hear the 'Dup' heart sound?

Diaphragm Signup and view all the answers

What best describes the sound frequency of a 'Gallop' heart sound?

Low and hard to hear Signup and view all the answers

What does anaerobic metabolism indicate during maximal exercise?

The onset of exhaustion Signup and view all the answers

What is meant by critical heart rate in the context of exercise?

It varies based on an individual's conditioning level Signup and view all the answers

Which condition can induce exercise-related changes in heart sounds?

Normal in athletes Signup and view all the answers

In what phase of the cardiac cycle does the 'Lub' sound occur?

Beginning of systole Signup and view all the answers

What characterizes the normal heart rate response in a sedentary individual compared to a trained individual during exercise?

Trained individuals have a more gradual increase in heart rate Signup and view all the answers

Where is the 'Dup' heart sound best heard?

2nd intercostal space Signup and view all the answers

What is likely to happen when the body's demand for oxygen exceeds the available supply during exercise?

Anaerobic metabolism begins to dominate Signup and view all the answers

What can higher than normal frequencies of heart sounds indicate?

High ventricular pressure Signup and view all the answers

What normal heart sound corresponds to the closing of the atrioventricular valves?

S1 Signup and view all the answers

Which heart sound is considered a key sign in heart failure and occurs after S2?

S3 Signup and view all the answers

In which demographic is the presence of S3 generally considered abnormal?

Individuals over 40 years Signup and view all the answers

What is the phenomenon associated with S4 heart sounds?

Rapid ventricular filling after atrial contraction Signup and view all the answers

What kind of heart sound would you expect to hear in a normal individual with left ventricular hypertrophy?

S4 Signup and view all the answers

What condition does a pericardial friction rub typically indicate?

Pericarditis Signup and view all the answers

Which type of heart murmur is associated with turbulent blood flow?

Valvular murmur Signup and view all the answers

Where is the point of maximal impulse located in a normal heart?

Mitral area Signup and view all the answers

What is the primary objective of exercise testing?

To determine when exercise testing is performed Signup and view all the answers

Which method is NOT a part of calculating target heart rate range?

Lipid profile assessment Signup and view all the answers

What does Systolic pressure doing during the exercise testing described?

Increases while diastolic pressure remains the same Signup and view all the answers

What should a physical therapist do if the examination findings do not support their original hypotheses?

Revise the treatment approach or refer to another provider Signup and view all the answers

Which of the following is a key component of evaluating patient progress during care?

Re-examining outcome measures Signup and view all the answers

Which of these tests should an entry-level physical therapist be able to perform?

Submaximal tests such as 6MWT Signup and view all the answers

What does 'termination points of maximal and submaximal testing' refer to?

Indicators for stopping an exercise test Signup and view all the answers

What is the possible action if a patient is not making functional progress toward their goals?

Consider revising treatment or referring to another provider Signup and view all the answers

What is the primary purpose of submaximal exercise testing?

To estimate VO2max. Signup and view all the answers

Which of the following is NOT a mode of submaximal testing?

Swimming pools Signup and view all the answers

How should the mode of submaximal testing be selected?

According to the fitness program for the patient. Signup and view all the answers

Given her health background, what risk category does the 48-year-old female fall into?

Moderate risk Signup and view all the answers

What is required before the 48-year-old female starts a vigorous exercise program?

A medical exam and a supervising physician. Signup and view all the answers

What is the significance of having a physician available during maximum exercise for this patient?

To monitor potential medical emergencies. Signup and view all the answers

Which factor does NOT affect the choice of exercise testing mode for a patient?

Patient’s age and weight. Signup and view all the answers

What should the HDL cholesterol level be for optimal cardiovascular health?

Above 60 mg/dL Signup and view all the answers

Study Notes

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)

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).

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.

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Description

Test your knowledge on key concepts related to cardiovascular assessment and evaluation in physical therapy. This quiz covers essential topics including patient interviewing techniques, heart sounds, contractility, and the physiological responses to exercise. Prepare to enhance your understanding of cardiovascular health management.