Cardio Respiratory Assesment
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This document provides a template for conducting a cardio-respiratory assessment of a patient. It includes sections for collecting information on the patient's chief complaints, medical history, subjective examination involving the history of present illness and associated symptoms, as well as an objective examination involving vital signs, physical inspection, palpation, percussion, and auscultation of the chest, neck, and extremities. The assessment aims to gather comprehensive details on the patient's respiratory and cardiovascular health through a structured interview and physical exam.
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Cardio Respiratory Assesment
- 1. Cardio-Respiratory Assessment for Physiotherapist Rahul A.P Assit Proff: BPT,MPT (CRD&ICU)MIAP LIAHS
- 2. • Name: • Age: • Gender: • Address: • Marital status: • Religion: • Occupation: • Source of referral: • Date of assessment:
- 3. • Chief complaints: Breathlessness Cough with or without expectoration Chest pain Noisy breathing –Wheezing/stridor -Associated complaints Hemoptysis Hoarseness Voice changes Dizziness Fainty /syncope Head ache Ankle swelling Cyanosis
- 4. -Constitutional complaints: Fever Excessive sweating Loss of appetite Nausea Vomiting Weight loss Fatigue Weakness Exercise intolerance Altered sleep
- 5. SUBJECTIVE EXAMINATION • HISTORY OF PRESENT ILLNESS/PRESENT MEDICAL HISTORY Description of symptom Breathlessness • Description of Onset-Date, Time and type(Sudden or Gradual) • Duration-How long, Constant/intermittent
- 6. • Aggravating factors: Position Weather Temperature Anxiety Exercise • Relieving factors: Position Hot Cold Rest
- 7. • Frequency-How often • Course- from onset till time: Better Worse Same • Associated symptoms Sweating Cough Chest discomfort
- 8. • Tick the activities disturbed by breathlessness Climbing stairs -if yes how many steps Walking -if yes how much distance Bathing Toileting Dressing Combing Shopping Grooming Speaking Any other activities
- 9. Cough • Description of Onset -date, time and type(Sudden or Gradual) • Duration- how long, Constant or intermittent • Frequency-how often, Particular day/ particular week/particular season • Aggravating factor Position/weather/temperature/anxiety/exercise/ smoking/particular location • Relieving factor-Position/hot/cold/rest/medications • Course – from onset till time(Better/worse/staying at the same
- 10. • Associated symptoms- Chestpain/wheezing/fever/runnynose/hoarseness/ night sweat/weight loss/headache/dizziness/loss of consciousness • Severity: How bad it is/How it affects activity of daily living • Quantity- how many times does cough comes • Quality- Barking/brassy(harsh & dry)/hoarse/with stridor/wheezy/hacking
- 11. Sputum • Description of onset – date, time and type(Mucoid/ mucopurulent/purulent/blood tinged) • Color-Colorless like egg/white/black/brownish pink/Greenish/red jelly/rusty • Consistency-Thin/thick/viscous/tenacious/frothy • Quantity-Scanty/teaspoon/cup/copious • Time of the day-Morning/evening
- 12. Hemoptysis • Amount : clot/massive • Acute/chronic • Frequency • Associated symptoms Warmth Bubbling sensation With chest pain/dyspnea Without coughing Nausea/vomit/cough
- 13. • History of smoking • History of nose bleed • History of accidents • Exposure to patients with tuberculosis • History of recent surgery • Family history-bleeding disorders • Medications such as aspirin/oral contraceptives
- 14. Chest pain • Origin-location • Onset Date,Time,Type (Sudden/gradual) • Pattern Frequency -How often Duration -How long it lasts Constant or intermittent Course :better/worse/staying the same
- 15. • Aggravating factors Breathing Positions :Lying flat/side lying Movement with arms Rest/exercise Sleeping After eating Stress Anxiety
- 17. • Relieving factors Rest Positions Analgesics Antacids Hot Cold • Severity How it affects ADL VAS scale
- 18. • Associated symptoms Coughing/breathlessness/palpitations/hemoptysis/ vomiting/ leg pain/weakness/muscle fatigue • Time frame-Acute/chronic • Past treatment Past history of pain How it subsided-medicines Past history of heart attack/recent infection History of pulmonary disease/accidents Family history of heart disease
- 19. Past medical history • Surgeries & hospitilisation • Injuries & accidents • Allergies • Medications (Diabetes, Hypertension etc..)
- 20. Personal history • History of smoking Types of tobacco How old when the patient begin smoking How many years the patient smoked How many cigarettes smoked each day Any variation in smoking habits Any attempt to stop smoking Date when the patient last smoked Pack per day
- 21. • History of alcohol intake How old when the patient started alcohol How many years the patient consumed How many pegs each day Any variation in alcoholic habits Any attempt to quit alcohol Date when the patient last taken
- 22. • Family history: • Occupational history: • Environmental history: • Socio-economic history
- 23. Objective assessment • Height: • Weight: • BMI: • Vital signs: Temperature Pulse rate Respiratory rate Blood pressure
- 24. • Pulse Rhythm: regular irregular • Pulse strength 0 -absent 1-Diminished 2- normal 3-increased 4- bounding
- 25. ON OBSERVATION Head Facial expression Eyes-PERRLA Eyes-Sclera clear/muddy,palor,ictrus Eyelid -ptosis Nose –nasal flaring Lips- Cyanosis Lips-Pursed lip breathing
- 26. Neck Position of trachea: midline/right/left Jugular venous pressure: normal/increased/markedly increased Use of accessory muscles and Prominence Tracheal tug
- 27. Thorax COPD Posture: rounded shoulders, protruded neck, kyphosis, outstretched hands Chest wall deformities: Pectus carinatum/Pectus excavatum/ kyphosis/ scoliosis/ kyphoscoliosis Type of breathing: rapid/shallow/deep Effort of breathing: minimal on inhalation and passive on exhalation Pattern of breathing: Thoraco abdominal/abdomino thoracic Abnormal breathing pattern: Apnea/Biot’s//Cheyne- stokes/ Kussmauls/ paradoxical/asthmatic/flail chest Labored Breathing signs:
- 28. • Intercostals indrawing/retractions • Supra clavicular indrawing • Sub costal indrawing • Hoovers sign • Harrisons sulcus Abdomen -abdominal perodox
- 29. Extrimities Upper limb • Clubbing: • Cyanosis: • Nicotine stain: • Capillary filling time: • Tremor Lower limb • oedema
- 30. ON PALPATION • Tracheal position • Subcutaneous emphysema • Tenderness on accessory muscles • Palpation of lymph nodes: axillary /cervical/supraclavicular • Symmetry: symmetrical/asymmetrical Upper zone Middle zone Lower zone
- 31. • Tactile Vocal fremitus Upper zone Middle zone Lower zone • Tactile rhonchial fremitus • Percussion Type of note: resonant/hyper resonant/ stony dullness/woody dullness Level of right border Level of left border Level of heart border Level of diaphragmatic excursion •
- 32. • Pedal oedema Pitting/non pitting Grade Level or extent of oedema • Peripheral skin temperature
- 33. • Auscultation Quantity of breath sound Quality of breath sound Added sound Inspiration : early/mid /late, fine/coarse Expiration : wheeze/rhonchi • Vocal resonance: whispering pectoriloquy,aegophony • Chest expansion Upper zone Middle zone Lower zone
- 34. Thank you…