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cardio-Respiratory asessment for physiotherapist

Research · July 2015

DOI: 10.13140/RG.2.1.2737.0080

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Subin Solomen
Governmental Medical College, Kottayam
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Padmashree Institute of Physiotherapy CARDIO-RESPIRATORY ASSESSMENT

DEMOGRAPHIC DATA

Name:
Age:
Gender:
Address:
Marital status:
Religion:
Occupation:
Source of referral:
Date of assessment:
Source of history:

Chief complaints:

Symptoms Duration

Breathlessness(SOB)
Cough with or without expectoration
Chest pain
Noisy breathing –Wheezing/stridor

Associated symptoms

Hemoptysis
Hoarseness
Voice changes
Dizziness/fainty syncope
Head ache
Altered sensorium
Ankle swelling
Cyanosis

Constitutional symptoms

Fever
Excessive sweating
Loss of appetite
Nausea
Vomiting
Weight loss
Fatigue
Weakness
Exercise intolerance
Altered sleep patern

Prepared by Subin Solomen MPT(M’pal) Cardio-Respiratory Page 1

History of presenting illness:

Description of symptoms:

Breathlessness

Description of onset
o Date
o Time
o Type : sudden/gradual
Seting
o Cause
o Circumstances
o Activities surrounding onset
Severity
o How bad it is
o How it affects activities of daily living
Frequency
o How often
Duration
o How long
o Constant/intermitent
Course
o Beter/worse/same
Associated symptoms
o Sweating
o Cough
o Chest discomfort
Aggravating factors
o Position/weather/temperature/anxiety/exercise
Reliving factors
o Position/hot/cold/rest
During the status of episode
o Can you continue to do what you were doing
o Do you have to sit down or lie down
o Can you continue to speak
Do the atack cause your lips or nail bed to turn blue
 Tick the activities disturbed by breathlessness
o Climbing stairs ( ) if yes how many steps
o Walking ( ) if yes how much distance
o Bathing ( )
o Toileting ( )
o Dressing ( )
o Combing ( )
o Shopping ( )
o Grooming ( )
o Speaking ( )
o Any other activities
Exposure to the patients with tuberculosis
Exposure to asbestos/sand blasting/pigeon feeding
Visual analog scale : _/10
Modified Borg scale:
American thoracic society shortness of breath scale:
MRC Scale :
Types of dyspnea

Diferential diagnosis:

Cough
 o How many?
Quality
o Characteristics
o Barking/brassy(harsh & dry)/hoarse/with stridor/wheezy/hacking
Frequency
o How often?
o Particular day/ particular week/particular season
Duration
o How long it last?
o Constant or intermitent?
Course
o Beter/worse/staying at the same
Associated symptoms
o Chest pain/wheezing/fever/runny nose/hoarseness/night sweat/weight loss/head ache/dizziness/
loss of consciousness

Sputum
 Presence of blood
Other distinguishable material
Diferential diagnosis:
Hemoptysis
Amount : clot/massive
Odor
Color
Appearance
Acute/chronic
Frequency
Streaky/Non streaky/FROTHY BLOOD TINGED
Associated symptoms
o Warmth
o Bubbling sensation
o With chest pain/dyspnea
o WITHOUT COUGHING
o Nausea/vomit/cough
History of smoking
History of nose bleed
History of accidents
Traveled lately?
Exposure to patients with tuberculosis
History of recent surgery
Family history-bleeding disorders
Medications such as aspirin/oral contraceptives

Diferential diagnosis

Chest pain
OPQRSTU FORMAT
Origin
o location
Onset
o Date
o Time
o Type Sudden/gradual
Patern
o Frequency : How often
o Recurrence
o Duration How long it lasts
o Constant or intermitent
o Course :beter/worse/staying the same
Provoked symptoms(aggravating factors)
o Breathing
o Positions :Lying flat/side lying
o Movement with arms
o Rest/exercise
o Sleeping/stress/after eating
o Stress/anxiety
Quality
 o Dull/ aching/pin prickling/throbbing/knife
like/sharp/constricting/sticking/burning/shooting/tearing
Radiating
Referred
Relieving factors
o Rest
o Positions
o Analgesics
o Antacids
o Hot
o cold
Severity
o How it affects ADL
o VAS scale
Associated symptoms
o Coughing/breathlessness/palpitations/hemoptysis/vomiting/ leg pain/weakness/muscle fatigue
Time frame
o Acute/chronic
Past treatment
o Past history of pain
o How it subsided/rest/medicines
o Past history of heart atack/recent infection /history of pulmonary disease/accidents
o Family history of heart disease
What do you think is wrong
o Is this diferent from previous episodes

Diferential diagnosis:

Fever
Description of onset
o Date
o Time
o Type : sudden/gradual
o How did you measure your temperature?
Frequency
o How often
Duration
o How long
o Constant/intermitent
o Did it rise then disappear then reappear
Course
o Beter/worse/same
Associated symptoms
o Chills/head ache/fatigue/cough/diarrhea/pain
o History of sore throat/ear ache/ neck swelling
o Sweating –diaphoresis/night sweats
o Cough
o Chest discomfort
Aggravating factors
o Position/weather/temperature/anxiety/exercise
 Reliving factors
o Position/hot/cold/rest
Past history
o History of recent infections/recent wound
o History of tick/insect/spider bite
o History of exposure to high temperature for prolonged time like playing sports/work
o History of surgery/blood transfusion/
o History of medications
o Thyroid/antidepressants/amphetamines/anticholinergics
Type of fever
o Sustained- continuously elevated for 24 hours
o Remitent- continuously elevated with diurnal variations
o Intermitent- daily elevation with return to normal
o Relapsing- recurring in bouts

Past medical history

o Surgeries & hospitilisation

o Injuries & accidents
o Immunization
o Allergies
o Medications
Past history
SL No Disease

1 Diabetes

2 Hypertension

3 Other

Personal history
History of smoking Yes/no
o Types of tobacco
o How old when the patient begin smoking
o How many years the patient smoked
o How many cigaretes smoked each day
o Any variation in smoking habits
o Any atempt to stop smoking
o Date when the patient last smoked
o Pack year:
History of alcohol intake yes/no
o How old when the patient started alcohol
o How many years the patient consumed
o How many pegs each day
o Any variation in alcoholic habits
o Any atempt to quit alcohol
o Date when the patient last taken
Family history:

Occupational history:

Environmental history:

Diferential diagnosis from history

Sl Condition
No

Objective assessment
Height:

Weight:

BMI:

Clinical presentation:

o General appearance: cardiopulmonary distress/anxiety/pain

o Awake /alert(conscious)/atentive/comprehensive
o Body type:
Ectomorphic/endomorphic/mesomorphic/sthenic/hypersthenic/hyposthenic/asthenias/cachetic/de
b ilitated/failure to thrive
Vital signs:
o Temperature
o Pulse rate
o Respiratory rate
o Blood pressure

Pulse Rhythm:

o regular,
o regularly irregular, bigeminy or trigeminy
o irregularly irregular if yes
check heart rate ,pulse deficit
Pulse Volume:
Absent-0
Diminished -Weak, thready-1+
Normal- 2+
Increased –bounding 3+

Apnea/Eupnea/Bradypnea/Tachypnea/Hypopnea/hyperpnea/sighing/intermitent
IPPA format: inspection, palpation, percussion, auscultation
Inspection & observation
HENT (head, eyes, nose, and throat)
Head

o Facial expression
o Forehead
o Eyes-PERRLA
o Eyes-Sclera clear/muddy,palor,ictrus
o Eyelid -ptosis
o Nose –nasal flaring
o Lips- Cyanosis
o Lips-Pursed lip breathing
Neck
o Position of trachea: midline/right/lef
o Jugular venous pressure: normal/increased/markedly increased
o Use of accessory muscles- SCM/PMi/Tr
o Prominence of accessory muscles
o Trail sign
o Tracheal tug or oliver sign

Thorax

o COPD Posture: rounded shoulders, protruded neck, kyphosis, outstretched hands

o AP:T Ratio: 5:5/5:6/5:7 barrel chest: present/absent
o Chest wall deformities: Pectus carinatum/Pectus excavatum/ kyphosis/ scoliosis/ kyphoscoliosis
o Type of breathing: rapid/shallow/deep
o Efort of breathing: minimal on inhalation and passive on exhalation
o Patern of breathing: Thoraco abdominal/abdomino thoracic
o Abnormal breathing patern: Apnea/Biot’s//Cheyne-stokes/ Kussmauls/ paradoxical/
asthmatic/flail chest
o I:E ratio:
o Labored Breathing signs:
 Intercostals indrawing/retractions
Supra clavicular indrawing
Sub costal indrawing
Hoovers sign
Harrisons sulcus

Abdomen: abdominal paradox

Extremities
Upper limb
o Clubbing: schamroth window test _, grade_ ,clubbing index
o Cyanosis:
o Nicotine stain:
o Capillary filling time:
o Tremor
Lower limb
o oedema
Palpation o Tracheal position
o Subcutaneous emphysema
o Tenderness on accessory muscles
o Palpation of lymph nodes: axillary /cervical/supraclavicular
o Symmetry: symmetrical/asymmetrical
Upper zone
Middle zone
Lower zone
o Tactile Vocal fremitus
Upper zone
Middle zone
Lower zone
o Tactile rhonchial fremitus
o Percussion
Type of note: resonant/hyper resonant/ stony dullness/woody dullness
Level of right border
Level of lef border
Level of heart border
Level of diaphragmatic excursion
o Pedal oedema
Piting/non piting
Grade
Level or extent of oedema
o Peripheral skin temperature

Quantity of breath sound

Auscultation
Quality of breath sound
Added sound
o Inspiration : early/mid /late, fine/coarse
o Expiration : wheeze/rhonchi
Vocal resonance: whispering pectoriloquy,aegophony
Chest expansion
Upper zone
Middle zone
Lower zone

Prepared by Subin Solomen MPT(M’pal) Cardio-Respiratory Page 10

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