Patient History Part 1
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Questions and Answers

What can cause hoarseness in a patient?

  • Aneurysm of the arch of the aorta (correct)
  • Myocardial infarction
  • Congestive heart failure
  • Coronary artery disease

    • Which condition is associated with a dilated pulmonary artery or atrium?

  • Aortic stenosis
  • Angina pectoris
  • Atrial septal defect (correct)
  • Valvular heart disease

    • In the context of patient examination, what does an inappropriate finding suggest?

  • Revise the original hypotheses
  • Assess the effectiveness of medication
  • Refer the patient to another professional (correct)
  • Continue with the current treatment plan

    • When should a physical therapist consider revising a treatment approach?

    <p>When outcome measures indicate no functional progress</p> Signup and view all the answers

    What is an objective of a complete cardiac physical examination?

    <p>Understand the clinical elements involved</p> Signup and view all the answers

    What indicates that a patient is making functional progress towards goals?

    <p>Re-examination shows favorable outcome measures</p> Signup and view all the answers

    What should physical therapists assess before continuing a treatment episode?

    <p>Functional progress towards goals</p> Signup and view all the answers

    What type of diagnostic measures can a physical therapist utilize?

    <p>Physical examination evaluations</p> Signup and view all the answers

    What should be done if a patient's treatment approach shows no improvement?

    <p>Revise the treatment approach or consider referral</p> Signup and view all the answers

    Which aspect of patient history is crucial for understanding their rehabilitation potential?

    <p>The presence of supportive family versus a negative home environment</p> Signup and view all the answers

    What is a primary reason to review a patient’s medical chart?

    <p>To know their primary and secondary diagnoses and the date of their event</p> Signup and view all the answers

    Which of the following is part of the systems review during examination?

    <p>Self-reported symptoms</p> Signup and view all the answers

    Which factor is least likely to impact a patient's rehabilitation goals?

    <p>Favorite sports team</p> Signup and view all the answers

    What is an important contextual factor to consider in patient/client history?

    <p>Social services questions and support</p> Signup and view all the answers

    What information would NOT typically be included in a patient's general health status?

    <p>Patient's hobbies and interests</p> Signup and view all the answers

    Why is it important to collect data on family history during patient evaluation?

    <p>To understand hereditary conditions that may affect prognosis</p> Signup and view all the answers

    Which of the following is NOT a red flag in toddlers and preschoolers related to vital signs?

    <p>Regular appetite</p> Signup and view all the answers

    What should be done if the examination findings do not support the original hypotheses?

    <p>Revisit or revise the hypotheses</p> Signup and view all the answers

    Which part of the stethoscope is essential for auscultation of heart sounds?

    <p>Diaphragm and bell</p> Signup and view all the answers

    What is the interpretation of S1 and S2 heart sounds primarily associated with?

    <p>Valvular closure</p> Signup and view all the answers

    When should a physical therapist consider a referral to another health care provider?

    <p>When the patient shows no functional progress</p> Signup and view all the answers

    What is a symptom that may indicate a cardiac issue in a toddler or preschooler?

    <p>Bounding pulses</p> Signup and view all the answers

    Which aspect of a patient’s care should continue if they are making functional progress?

    <p>The same treatment approach</p> Signup and view all the answers

    Which finding indicates the need for proper auscultation technique during a physical examination of the chest?

    <p>Quality of the stethoscope</p> Signup and view all the answers

    What does S1 represent in heart sounds?

    <p>Closing of the atrioventricular valves</p> Signup and view all the answers

    Which heart sound is considered a normal finding in children and young adults but may be abnormal in older adults?

    <p>S3</p> Signup and view all the answers

    What is the significance of S4 heart sound?

    <p>Heard after atrial contraction</p> Signup and view all the answers

    What constitutes a heart murmur?

    <p>Vibrations from turbulent blood flow</p> Signup and view all the answers

    What is a pericardial friction rub a sign of?

    <p>Pericarditis</p> Signup and view all the answers

    How can auscultation of heart sounds be improved?

    <p>Ensuring a quiet environment</p> Signup and view all the answers

    What does S2 signify in the cardiac cycle?

    <p>Closing of semilunar valves</p> Signup and view all the answers

    What sound is produced during early (diastolic) ventricular filling?

    <p>S3</p> Signup and view all the answers

    What could tachycardia disproportionate to activity indicate?

    <p>Deconditioning</p> Signup and view all the answers

    Which of the following medications is NOT associated with a blunted heart rate response?

    <p>Antibiotics</p> Signup and view all the answers

    What does the S1 heart sound indicate?

    <p>Closing of the atrioventricular valves</p> Signup and view all the answers

    What condition may cause a patient to feel lightheaded or dizzy, related to heart rate response?

    <p>Orthostatic hypotension</p> Signup and view all the answers

    In which age group is the S3 heart sound considered abnormal?

    <p>Individuals older than 40 years</p> Signup and view all the answers

    What is a significant concern with an increase in frequency of dysrhythmias?

    <p>Decrease in palpable pulse</p> Signup and view all the answers

    What is the term for an inadequate increase in heart rate during exercise due to poor heart response?

    <p>Chronotropic incompetence</p> Signup and view all the answers

    What is the primary characteristic of a pericardial friction rub?

    <p>A sign of pericarditis</p> Signup and view all the answers

    What should be considered if a patient not on medications exhibits a blunted heart rate response?

    <p>Severe coronary disease</p> Signup and view all the answers

    What does the rate of decline in heart rate following exercise indicate?

    <p>Cardiovascular fitness</p> Signup and view all the answers

    Which heart sound is linked to early diastolic ventricular filling?

    <p>S3</p> Signup and view all the answers

    What type of heart sounds might be detected in normal individuals with left ventricular hypertrophy?

    <p>S4</p> Signup and view all the answers

    What could ineffective heart pumping during tachycardia indicate?

    <p>Heart failure</p> Signup and view all the answers

    Which part of the heart is typically the point of maximal impulse?

    <p>Mitral area</p> Signup and view all the answers

    What do murmurs represent in the context of heart sounds?

    <p>Turbulent blood flow</p> Signup and view all the answers

    Study Notes

    Patient History Part 1

    • An accurate patient history is gathered from the patient's chart, a personal interview, and observation.
    • The patient must be allowed to explain their history in their own words at their own pace.
    • The interviewer should avoid letting personal feelings about the patient's appearance, demeanor, or behavior influence the validity of their chief complaints.

    Objective

    • Complete a thorough patient history by collecting data from patient charts.
    • Conduct a personal interview with the patient.
    • Observe the patient's behavior and demeanor.

    The Interview

    • Establish a positive rapport with the patient.
    • Allow the patient to explain their health history in their own words and at their own pace.
    • Do not let personal feelings about the patient's appearance influence their explanation of their chief complaints.

    Examination, History, Systems Review, Test & Measures, Plan of Care, Diagnosis & Prognosis, Intervention, and Evaluation

    • Examination: Assess the patient's medical history and any clinical tests conducted.
    • History: Obtain a complete medical and social history from the patient and any caregivers.
    • Systems Review: Review the patient's symptoms and relevant bodily systems.
    • Testing & Measures: Evaluate the patient using appropriate tests to gather relevant data.
    • Plan of Care: Develop a plan to address the patient's needs and goals.
    • Diagnosis & Prognosis: Based on the collected data, diagnose and predict the patient's course of treatment.
    • Interventions: Determine and implement appropriate treatments.
    • Evaluation: Regularly assess the patient's progress and adapt the plan of care accordingly.

    Patient/Client History

    • Social History, Activities, & Participation
    • Family History
    • General Demographics
    • General Health Status
    • Growth & Development
    • Living Environment
    • Social Determinants of Health/Habits
    • Social Services Questions
    • Self Report
    • Current Condition(s)/Chief Complaint(s)
    • Mechanisms of injury or disease
    • Onset and pattern of symptoms
    • Patient, family, significant other, and caregiver expectations and goals for the intervention
    • Functional Status and Activity Level
    • Medications
    • Other Clinical Tests
    • Review of available records
    • Review of other clinical findings

    Relevant Social History

    • Self-abusive social habits (excessive drinking, smoking, illicit drug use)
    • Family History (diabetes, hypertension, CAD, rheumatic fever)
    • Occupational History (identifying type of work to set realistic goals)
    • Home environment and family situation (helpful vs. negative environment for rehab success; precautions)

    Medical Chart Review

    • Diagnosis and date of event; knowledge of primary and secondary diagnoses
    • Risk factors for heart disease (HTN, smoking, elevated cholesterol, family history, stress, sedentary lifestyle, older age, obesity, diabetes)
    • Surgical procedures; understanding of specific surgical approaches and procedures
    • Extent of surgery predicts activity performance impairments
    • Hospital course; review physician and caregiver notes, order sheets to reveal pertinent information on clinical course
    • Information regarding clinical status (Cardiac enzymes, blood lipids, CBC count, BUN, creatinine, arterial blood gases, culture and sensitivity, coagulation studies, electrolyte, glucose tolerance)
    • Radiological studies (chest radiographs, CT scan, MRI, scintigraphy)
    • Oxygen therapy and other respiratory treatment (amount, device of O2)
    • Electrocardiogram and serial monitoring
    • Cardiac catheterization data
    • Vital signs recordings

    Symptoms

    • Pain: chest pain, ischemic pain
    • Dyspnea/Dyspnea on exertion
    • Cough
    • Palpitations
    • Syncope
    • Fatigue
    • Edema
    • Claudication
    • Hoarseness

    Chest Pain

    • Pain
    • Anginal pain
    • Chest wall pain
    • Pleuritic chest pain
    • Pericardial pain

    Anginal Pain

    • Classic cardiac-chest pain, tightness, pressure, shortness of breath, palpitations, indigestion, burning
    • Characteristically demonstrated by patients using their entire hand or closed fist against the anterior chest wall.
    • Relieved by nitroglycerin (30 sec to 1 min); comes on at the same heart rate and blood pressure and is relieved by rest.
    • Associated with feelings of doom, cold sweats, shortness of breath, often seen with ST-segment depression

    Chest Wall Pain

    • Evoked by palpation or deep breaths
    • Does not occur during but rather after exertion.
    • Worsen with inspiration.
    • Associated with trunk motions

    Pleuritic Chest Pain

    • Originates from the parietal pleura or endothoracic fascia
    • Parietal pleura and endothoracic fascia have pain receptors
    • Visceral pleura do not

    Pericardial Chest Pain

    • Midline, deep breathing, coughing, swallowing, movement, and lying down may make it worse
    • If the central tendon of the diaphragm is involved, may be referred to the left shoulder or scapular area.
    • Each heartbeat may affect the pain; sitting up and leaning forward or lying on the right side often relieves the pain.

    Dyspnea

    • Defined as the sensation of difficulty in breathing
    • Orthopnea: Dyspnea that occurs when the patient is in the recumbent position
    • Need for multiple pillows under their head
    • Paroxysmal Nocturnal Dyspnea (PND): Transfer of fluid from extravascular tissues into the bloodstream during sleep.
    • Strong predictive value as a sign of CHF

    Angina and Dyspnea Scales

    • 5-grade angina scale (0-4): Measures severity of angina pain.
    • 5-grade dyspnea scale (0-4): Measures severity of dyspnea.
    • 10-grade angina scale (0-10): Measures severity of angina pain on a scale
    • Symptoms include pain, discomfort in chest, neck, jaw, arms, shortness of breath, dizziness, syncope, orthopnea, paroxysmal nocturnal dyspnea, ankle edema, palpitations, tachycardia, intermittent claudication, known heart murmur, unusual fatigue or shortness of breath with usual activities

    Cough

    • CHF due to pulmonary edema
    • Thoracic aortic aneurysm, dry and non-productive, due to compression of the trachea or bronchi
    • Certain medications (ACE inhibitors)

    Palpitation

    • Presence of an irregular heartbeat
    • Caused by benign conditions (e.g., mitral valve prolapse) or serious conditions (e.g., CAD, heart block, ventricular aneurysm)
    • Can be due to PAC, PVC, SVT, A flutter, A fib, or V tach

    Cardiac Syncope

    • Arrhythmias
    • LV failure or outflow obstruction (e.g., aortic stenosis)
    • RV outflow obstruction or failure (e.g., pulmonary stenosis, pulmonary hypertension)
    • Orthostatic hypotension
    • Valsalva maneuver

    Fatigue

    • Induced by minimal activity or exertion
    • Often accompanied by other associated signs, but in the early stages of disease fatigue may be the only symptom.
    • Poor LV functions (CAD, CHF, HTN, Valvular Cardiomyopathy, myocarditis)
    • In CHF, is probably related to cardiac output insufficient to perfuse the entire body adequately including the skeletal muscles.

    Pedal Edema

    • CHF is a common cause of bilateral pedal edema.
    • Patients may complain only of increased abdominal girth, which results from ascites.
    • If a poorly functioning left ventricle, cor pulmonale or mitral stenosis is the cause; it usually follows dyspnea on exertion.
    • Patients with CHF and altered renal function commonly report edema of the ankles and lower legs while upright during the day but decrease during the night.

    Claudication

    • Leg pain associated with Peripheral Vascular Disease (PVD)
    • Often occurs simultaneously with heart disease.
    • Can be functionally disabling.
    • Signs, including skin discoloration, hairless skin, or can occur without physical findings.
    • Core temperature and peripheral pulses need to be assessed.

    Hoarseness

    • Several cardiovascular conditions can cause hoarseness due to the left recurrent laryngeal nerve looping under the arch of the aorta and above the pulmonary artery as it returns to the neck.
    • An aneurysm of the arch of the aorta, a dilated pulmonary artery or atrium resulting from an atrial septal defect, or mitral stenosis can cause hoarseness.

    Cardiac Examination

    • Assess all elements of a complete cardiac physical examination except conducting a 12-lead ECG.
    • Identify locations for stethoscope placement for auscultation of heart sounds.
    • Identify normal S1 and S2 heart sounds.
    • Interpret findings related to S3 and S4 heart sounds and murmurs

    Physical Examination of the Chest: Auscultation

    • Skill depends on
      • Use of a functional stethoscope (diaphragm and bell)
      • Proper technique
      • Knowledge of different categories of chest sounds
      • Breath sounds, extrapulmonary sounds, voice sounds, and heart sounds
    • Topographic landmarks should be assessed to aid in auscultation of heart sounds and murmurs.
    • Proper positioning and quiet environments for accurate auscultation.
    • Selective listening to the sounds of a cardiac cycle for each of the five topographic areas.

    Heart Sounds

    • Normal Heart Sounds : S1 (closing of atrioventricular valves), S2 (closing of semilunar valves).
    • Gallops (S3: early diastolic ventricular filling, S4: rapid ventricular filling after atrial contraction)
    • Murmurs (vibrations from turbulent blood flow, Valvular Heart Disease, systolic versus diastolic)
    • Pericardial Friction Rub (sign of pericarditis)
    • Specific locations for auscultation of heart sounds (Aortic, Pulmonary, Tricuspid, and Mitral areas).

    Vitals with Activity

    • Define normal and abnormal vital sign ranges.
    • Assess appropriateness of changes in vitals with activity.
    • Measures should include EKG, BP, and rhythm (heart and lung sounds) before and after activity.
      • Assess resting heart rate before and after activity, resting BP before and after activity, as well as response of symptoms.

    Activity Assessment

    • Activity evaluation table (Rest/supine, Sit, Stand, ADL activity, Ambulation) showing necessary vitals at each activity

    Blood Pressure Categories

    • Normal: <120 systolic, <80 diastolic
    • Elevated: 120-129 systolic, <80 diastolic
    • High Blood Pressure (Hypertension) Stage 1: 130-139 systolic, 80-89 diastolic
    • High Blood Pressure (Hypertension) Stage 2: 140 or higher systolic, 90 or higher diastolic
    • Hypertensive Crisis: >180 systolic or >120 diastolic (consult your doctor immediately)

    Blood Pressure and PT Considerations

    • Systolic BP < 120 mm Hg, Diastolic BP ≤ 80 mm Hg is normal.
    • Systolic BP ≥ 200 mm Hg and/or Diastolic BP ≥ 100 mm Hg warrants holding treatment of a patient

    Pediatric Blood Pressure Reference Chart

    • Blood pressure values vary based on the patient's age

    Heart Rate

    • Normal heart rate: 60 to 100 beats per minute
    • The patient's heart rate should be assessed before and after activity

    Pediatric Heart Rate Reference Chart

    • Heart rate values vary based on the patient's age
    • A higher heart rate (tachycardia) may be disproportionate to the activity.

    Respiratory Rate

    • Normal respiratory rate: 12-20 breaths per minute

    Pediatric Respiratory Rate Reference Chart

    • Respiratory rate values vary based on the patient's age

    Normal Heart Rate Response

    • Linear increase in heart rate with increased workload, and rhythm remains regular.
    • Maximal exertion level involves a less linear increase in heart rate and oxygen increase.
    • Isometric/static exercise involves less pronounced heart rate increase.
    • The normal heart rate response to incremental exercise involves an increase in heart rate with progressive workloads

    Abnormal Heart Rate Responses

    • Tachycardia (disproportionate to activity) – Usually indicative of deconditioning
    • Blunted Heart Rate Response – Training effect, medications, or chronotropic incompetence
    • Abnormal Rhythm – Increase in frequency of dysrhythmias; Dysrhythmias can result in decrease in pulse.
    • Heart rate recovery following exercise – A failure to decrease at least 12 beats within the first minute, or 22 beats by the end of the second minute.
    • This could be associated with increased mortality risk

    Abnormal Blood Pressure Responses

    • Hypertensive – SBP excessively increases (>10 mmHg per MET increase), DBP increases (> 10 mmHg above resting); Post-exercise DBP remains elevated during recovery, or SBP fails to level out.
    • Blunted or Flat response – Medications (antihypertensives or beta-blockers), poor LV function, cannot increase CO

    Hypotensive Response

    • SBP falls during exercise (>10-20 mmhg);
    • Seen in elderly patients, diabetes mellitus, autonomic dysfunction, recent bed rest, recent surgery, or on antihypertensive medication.
    • Symptoms to observe: Palor, Diaphoresis, Lightheadedness

    Summary of Abnormal Responses to Activity

    • Specific physiological variables (HR, rhythm, systolic and diastolic BP, SpO2.) and responses to endurance activity.

    Assessing Postural Hypotension

    • A drop exceeding 20 mm Hg systolic and 10 mm Hg diastolic, accompanied by a 10-20% increase in heart rate.

    Exercise Testing

    • Understanding different types of exercise testing and protocols
    • Knowing the termination points for maximal and submaximal exercise testing
    • Calculating an individual's THR (Target Heart Rate) using age-specific or Karvonen methods
    • Interpreting the results of an exercise test
    • Formulate an exercise prescription using the results of the test(s)
      • When performing exercise testing, proper knowledge of contraindications is key.
    • Safe testing depends on understanding when a test needs to be terminated.

    Entry-Level Physical Therapist Skills

    • Interpret treadmill stress test results.
    • Perform submaximal tests (6MWT, shuttle test).
    • Interpret the results of exercise tests.

    Review: Submaximal Exercise Testing

    • Primary Purpose: Estimate VO2 max or determine functional response to exercise
    • Testing Protocols: Commonly use stationary bicycles or treadmills with established protocols.

    Exercise Testing Recommendations

    • Individuals with no known CV or metabolic/renal disease, and no suggestive symptoms need no medical clearance for moderate intensity exercise, but should be evaluated for vigorous activity.
    • Individuals with known CV/renal/metabolic disease and no symptoms may continue at moderate intensity but should have medical clearance before progressing to vigorous.
    • Those with known CV/renal metabolic disease or symptoms should be evaluated medically prior to any exercise.

    Calculation of THR

    • Formulas for calculating PMHR, predicted maximal heart rate, (Range) method for THR (Target Heart Rate) using age-specific or Karvonen methods, (and Karvonen method adjustments for submaximal testing)

    Pediatric Population

    • Submaximal treadmill and stair exercise protocols for individuals less than 3 years.
    • Standardized exercise test protocols for those older than 6 years and motor skills must be considered.
    • If FEV1 is <50% of predicted, monitor SaO2.

    Prognostic Value of Maximal Exercise Testing

    • Useful for non-invasive screening method.
    • Demonstrates greater sensitivity/specificity in men over 40.
    • Can have high false-negative results in women.
    • Ischemia can be correlated to more severe disease during early stages.

    Exercise Testing in Acute Care

    • Additional testing with ventilatory gas analysis (O2 exchange, breathlessness, cardiorespiratory performance, exercise limitation).
    • Additional non-invasive cardiac imaging immediately post-exercise to assess myocardial O2 supply and demand relationship.

    Pharmacological Stress Testing

    • Used when upright exercise isn't possible.
    • Agents (adenosine or dipyridamole) are injected to induce physiological stress.
    • It can involve a combined low-level treadmill exercise during adenosine infusion

    Patient Evaluation

    • Understand the elements of a cardiac evaluation
    • Determine NYHA functional classification
    • Develop a PT practice pattern

    Outcome Measures

    • Understand the importance of outcome measures in cardiac rehabilitation (CR).
    • Provide commonly used outcome measures in CR.
    • Develop clinical reasoning for selecting appropriate outcome measures in CR.

    Importance of measuring outcomes

    • Ensuring quality of care.
    • Documentation must include records of expected and observed outcomes.

    Functional Performance

    • Use gold standard (VO2 max) for measuring functional exercise capacity. Other measures include (self-paced walk test, 2MWT, 3MWT, 6MWT, 12MWT, modified walk test)
    • Treadmill endurance test, 200-meter walk fast test are also useful.
    • 400 meters or less on the walk test may suggest a higher mortality risk for the patient.
    • Seattle Angina Questionnaire, Minnesota Living with Heart Failure Questionnaire , Kansas City Cardiomyopathy Questionnaire.

    Other functional performance measures

    • Timed Up and Go (TUG): Assessment of risk of falls (predictor and outcome measure)

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    Cardiopulmonary Week 2 PDF

    Description

    This quiz focuses on the crucial aspects of gathering an accurate patient history, including chart reviews, personal interviews, and observations. Learn the importance of establishing rapport and allowing patients to express their health histories without bias. Assess your understanding of data collection and interviewing techniques in patient care.

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