carrothers cp screening lecture 2011 -...

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Cardiopulmonary Screening September 23, 2011

CPTA Annual Conference Long Beach, CA

LeeAnne Carrothers, PT, PhD

Why C-P Screening?

•  CVD responsible for most deaths in the US than any other disease

•  Although patients may come to us with non-CP problems, many have histories of or current CP diagnoses (Freese, Richter and Burlis (2002) ” Self-reported measurement of heart rate and blood pressure in patients by physical therapy clinical instructors.” Physical Therapy: 82(12):1192-200.)

•  Direct Access/Primary Care-You are responsible screening of patients you see off the street

Who should be screened? PT Options

•  Treat •  Refer •  Treat AND Refer

Differential Diagnosis

•  Definitions: – Medical: The determination of which two or

more diseases with similar symptoms is the one from which a patient is suffering based on an analysis of the clinical data.

– Physical Therapy: a label encompassing a cluster of signs and symptoms commonly associated with a disorder or syndrome or category of impairment, functional limitation or disability” (APTA HOD, 1995).

Differential Diagnosis

•  Process: –  Assess patient (exam, interview, systems

review) to determine list of patient findings – Create list of potential causes for a given

symptom/signs –  Perform further tests that enable the clinician to

further delineate the reasons for patient findings. – Once a decision has been reached about the

nature/cause of symptoms, the PT’s responsibility is to take appropriate action within the scope of PT practice, i.e., treat, refer, or treat AND refer.

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When you hear hoofbeats… Review of Systems

•  The primary symptoms of cardiopulmonary diseases include –  Chest pain –  Cough

•  Sputum Production •  Hemoptysis

–  Dyspnea/Orthopnea –  Cyanosis –  Activity Limitations –  Peripheral Edema

Some of these symptoms may be so “routine” the patient doesn’t think to volunteer the symptom – you need to ask about all of them in a systematic manner.

Chest pain

•  Localized chest pain is a common symptom of pleural disorders (presents as pain with max. inspiration), some pneumonias and even fractured ribs from excessive coughing.

•  Asking the patient to localize pain with one or two fingers will guide you to a more careful examination of that area.

Cough

•  A cough is a normal defense mechanism. •  The most common symptom of lung disease is

cough. •  Smoker’s morning cough results from the normal

decrease in coughing during sleep, with buildup of mucus during the night.

•  A cough with expelled sputum or other material is termed “productive”.

•  A non-productive cough can be due to local irritants, viral infections or even psychological.

Sputum Production

•  Sputum production is normal - 75-100 ml is secreted daily by the bronchi.

•  Uninfected sputum is odorless, transparent and whitish gray, resembling mucus

•  Sputum should be described according to color, consistency, quantity, occurrences during the day and the presence of absence of blood.

Hemoptysis

•  Coughing up blood - either clots or blood tinged sputum. •  This usually frightens the patient – so it isn’t a “hidden

symptom”. •  Clots of blood are very serious – indicating malignancies,

pulmonary emboli or cardiac disease. •  Streaks of blood are common in bronchitis, tumors or

pneumonias. •  Blood-tinged (i.e., flecks) sputum is commonly seen in

smokers. •  Ask how much blood – sometimes the patient will even

bring some in to show you!

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Difficulty breathing

•  Dyspnea is the subjective sensation of shortness of breath.

•  Tachypnea is rapid breathing (an objective finding)

•  Orthopnea is difficulty breathing while lying flat

•  Paroxysmal nocturnal dyspnea is the sudden onset of shortness of breath that occurs at night.

Peripheral vs. Central Cyanosis

Which has a worse prognosis???

Peripheral Central

Causes of Chest Pain

•  Cardiac – Ischemic – Stable Angina – Unstable Angina – Printzmetal’s Angina – Coronary Insufficiency/Myocardial

Infarction – Pericarditis

Causes of Chest Pain, cont.

•  Pulmonary/Pleural – Pleurisy

– Pneumothorax

– Pulmonary Embolus


•  GI •  Hiatal Hernia •  Reflux Esophagitis •  Esophageal Spasm •  Cholecystitis •  Peptic Ulcer Disease •  Pancreatitis


•  Psych – Anxiety/Panic Attacks

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• Musculoskeletal/Mechanical – Cervical Radiculopathy – Shoulder disorder/dysfunction – Constochondral disorder – Xiphodynia

Cardiac Chest Pain

•  Ischemic –  Caused by an imbalance of

myocardial supply and demand

•  When demand > supply: –  Abnormal C-V Response to

Exercise* Angina: any pain above the waist that

•  Worsens with activity

•  Lessens with rest •  Is relieved by nitroglycerin

–  Arrhythmia: ischemic myocardium becomes irritable

–  Myocardial Infarction

Anginal Patterns Normal Exercise Response

Workload

HR

SBP

DBP HR

SBP

DBP

Abnormal Exercise Response--HR

Workload

HR Red Flags • HR Rise disproportionate to rise in WL

• Maintenance of HR despite ↑ WL

• Fall in HR despite ↑ WL

Abnormal Exercise Response--SBP

Workload

SBP Red Flags • SBP Rise disproportionate to rise in WL

• Maintenance of SBP despite ↑ WL

• Fall in SBP despite ↑ WL

End Point SBP>200mmHg

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Abnormal Exercise Response--DBP

Workload

DBP

Red Flags • DBP>15 mmHg over resting, regardless of the increase in workload

• Resting DBP > 95

End Point DBP> 100mmHg

Stable angina

•  Has a well-established level of onset

•  Can be reliably predicted with a set level of myocardial demand

•  Can be controlled with a reduction in intensity of activity or by taking NTG

Unstable Angina

•  Definition: Presence of signs/symptoms of inadequate blood supply to the myocardium in the absence of demands that usually provoke this imbalance.

•  Clinical Cues: –  Angina at rest –  Occurrence of the patient’s typical angina at a

significantly lower level of activity than usual. –  Deterioration of a previously stable pattern, i.e., angina

occurring several times a day vs. several times a week. –  Evidence of loss of previously present myocardial

reserve, such as a drop in blood pressure or increase in heart rate with levels of activity previously well tolerated.

Printzmetal’s Angina

•  Angina that is not preceded by an increase in myocardial demand

•  Typically occurs at rest; most often in the early morning Caused by coronary artery spasm (due to presence of risk factors)

•  Treated with drugs to manage vasomotor tone, e.g., calcium antagonists

Myocardial Infarction Mechanisms of Coronary Artery Obstruction

•  Complete obstruction by lesion

•  Obstruction + Thrombus--result is total occlusion

•  Obstruction + Coronary Artery Spasm

•  Near total obstruction + high MVO2

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Complete obstruction by lesion Obstruction + Thrombus

Process

•  Decreased driving pressure beyond lesion –  Ischemia--end result.

•  This triggers a series of events thought to further decrease capacity for CA flow: –  Ischemic myocardium doesn't relax fully, leading to:

•  increased systole, decreased diastole •  decreased LV Compliance •  increased LV end diastolic pressure

•  These cause a further decrease in driving pressure and thus increased ischemia.

Evolution of an MI

•  The process of infarction involves either a single event or a series of events through which the infarction progresses gradually.

•  Changes in the myocardial tissue begin within 15 minutes after the tissue becomes hypoxic.

Diagnosis

•  Symptoms –  Angina: central chest or substernal discomfort.

•  May radiate to arm or jaw •  May wax and wane--not relived by NTG

•  Patients will typically be able to tell the difference between MI pain and angina…frequently accompanied by a sense of foreboding or impending death.

–  Shortness of Breath (SOB) –  Diaphoresis –  Light headedness –  Nausea and vomiting –  Weakness –  Hypotension

•  NOTE: 20-25% OF MI'S ARE SILENT = NO SYMPTOMS.

Typical and Atypical Male Irwin and Tecklin, 4th Ed.

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Typical and Atypical Female Irwin and Tecklin, 4th ed.

Serum Enzymes

•  Based on several assumptions: – elevation of enzymes occurs with cell death

and not just prolonged ischemia. – enzyme rise is not attributable to rise in other

organs

– size of infarct is proportional to amount of rise.

Serum Enzymes

•  CK (AKA CPK) – CK-MB

•  LDH •  Troponin •  Myoglobin

Transmural vs. Subendocardial

Pericarditis

•  Description: Inflammation of the pericardium

•  May develop either as a primary condition or due to a number of other circumstances/conditions

•  Frequently follows MI, CABG Surgery, valve replacement

•  May be acute or chronic –  Chronic form can result in

accumulation of fluid in pericardium that interferes with diastolic filling (cardiac tamponade) or restriction due to formation of fibrinous tissue between visceral and parietal layers.

Pericarditis

•  Signs: –  Fever – Chills – Malaise

–  Pericardial Friction Rub

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Pericarditis Symptoms

•  Substernal pain that may radiate to neck, upper back, upper trapezius, left supraclavicular area or down the left arm to the costal margins –  Aggravated by:

•  Movement associated with deep breathing

•  Trunk rotation, side bending

–  Alleviated by: •  Bending forward •  Kneeling on all fours

Sitting upright •  Breath holding

•  Difficulty swallowing

Pulmonary Chest Pain

•  Pleurisy/Pleuritis –  Description: inflammation of the pleura

caused by infection, injury or tumor

–  Signs: •  Fever, chills •  Pleural Rub •  Tachypnea

–  Symptoms: •  Pain over area of inflammation which: •  Is worse with deep breaths •  Is better with side bending toward affected side •  May refer to lower trunk or upper traps/anterior

shoulder

Pneumothorax

•  Description: free air in the pleural cavity

•  May occur due to pulmonary disease (e.g., ruptured bulla in emphysema), spontaneously, after surgery or trauma.

•  Air enters the pleural cavity and can interfere with ventilation, respiration and cardiac function

Pneumothorax

•  Signs: –  Absent Breath Sounds

– Hyper-resonance to percussion

–  Tracheal/mediastinal shift (away from PTX)

– Rapid, shallow pulse

–  Falling BP

– Dry, hacking, non-productive cough

–  JVD

Pneumothorax

•  Symptoms: –  Pain—typically over the area of air trapping, but

may radiate to ipsilateral shoulder, across the chest, or over the abdomen.

•  Aggravating: –  deep breaths –  pleural stretch

•  Alleviating: –  side bending toward

affected side

–  SOB

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Pulmonary Embolus

•  Description: pulmonary vasculature becomes occluded by a displaced thrombus, an air bubble, a fat globule, clump of bacteria, vegetations from infected heart valves or other particulate matter

•  Most common is due to DVT

Pulmonary Embolus, cont.

•  Three major risk factors: –  Blood stasis, –  endothelial injury, –  hypercoagulable states

•  Other risks: –  > 50 –  Previous history –  Malignant disease –  Inactivity –  Obesity –  Pregnancy –  Clotting abnormality –  OCA use

•  Embolism causes a blockage of blood flow to the lung tissue resulting in pulmonary infarct

Pulmonary Embolus, cont.

•  Signs: Vary greatly, depending on the extent of tissue necrosis – Hemoptysis –  Tachypnea –  Tachycardia –  Fever

•  Symptoms: –  Pleuritic pain – Diffuse chest discomfort –  Apprehension – Cough

Chest pain of GI origin

•  Description – Most pain of GI

origin results from ulceration or infection of the GI mucosa

– Typically has a vague onset

– Unrelated to degree of physical activity

Pain behavior

•  Location: corresponds to dermatomes from which the diseased organ receives its innervation

•  Aggravating: –  Positional, i.e., lying flat –  Food consumption (foods high in acids, fats) –  Palpation over involved organ

•  Alleviating: –  Antacids –  Consumption of food –  Release of gas (burp)

Chest Pain from Psych Causes

•  Description: Chest pain occurs frequently associated with Panic / Anxiety disorders

•  Signs –  Tachycardia –  Dyspnea –  Diaphoresis

•  Symptoms: –  Substernal Chest Pain –  Does not radiate –  Not aggravated by respiratory or M-S Movements –  Associated with hyperventilation and claustrophobia –  Accompanied by subjective sense of impending death

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Chest Pain from M-S / Mechanical Causes

•  Often associated with a history of trauma, injury or overuse

•  Vague Onset •  Pain Behavior

–  Location: •  Most frequently overlies area of injury—may radiate •  Reproducible with palpation

–  Aggravating: •  Movement •  Use of involved structures •  Palpation

–  Alleviating: •  Aspirin/NSAIDs •  Modalities like heat or cold •  Rest

Congestive Heart Failure

•  Definition: physiologic state in which the heart is unable to pump enough blood to meet the metabolic demands of the body at rest or during exercise.

•  Causes: –  Ischemic –  Mechanical e.g., valvular defects –  Arrhythmias –  Renal Insufficiency –  Pericardial Effusion –  Myocarditis/cardiomyopathy –  Pulmonary Embolism

CHF, cont.

Signs and Symptoms

Putting it all together

Location of Pain Behavior of pain Associated Signs

Stable Angina

Anything above the waist

•  Men: substernal •  Women: vague

GI-like distress

•  Worse with activity •  Better with rest •  Relieved by NTG

•  ST Depression on 12-lead •  Arrhythmias •  Abnormal response to

exercise

Unstable Angina



GI-like distress

•  Worse with activity •  Better with rest •  Relieved by NTG •  Increase in frequency/

severity when compared to stable

•  ST Depression on 12-lead •  Arrhythmias •  Abnormal response to

exercise

Printzmetal’s Angina



GI-like distress

•  Occurs at rest in early AM •  Not associated with

increase in demand

•  ST Elevation on 12-lead

MI Anything above the

waist •  Men: substernal •  Women: vague

GI-like distress

•  Lasts for > 30 mins •  Not relieved by NTG •  “worst pain ever”

•  ⊕ Enzymes •  12 lead ECG Changes •  Cardiogenic shock •  CHF

Putting it all together, the sequel.

Pericarditis Typically substernal May Radiate

Aggravating: •  Deep breathing •  Trunk rotation, side bending Alleviating: •  All fours •  Leaning Forward

•  Fever •  Malaise •  Pericardial Rub

Pleural Pain

•  Over location of inflammation / infection

•  May refer to lower trunk, upper traps

•  Intense stabbing, knifelike

Aggravating: •  deep breaths •  Trunk/pleural stretch Alleviating: •  Side bending toward involved

side •  Small rapid breathing

•  Fever •  Pleural Rub •  Dyspnea •  Dry cough

GI •  Corresponds to

dermatomes from which the diseased organ receives its innervation

•  May Radiate •  Aggravating:   Positional, i.e., lying flat   Food consumption   Palpation over involved

organ •  Alleviating:

•  Antacids •  Consumption of food •  Burp

•  Reproducible with palpation over involved organ(s)

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Putting it all together, the end.

M-S (Mechanical)

• May be localized to the area of injury or referred

• Aggravating:  Movement  Palpation • Alleviating:  Splinting/rest  Aspirin/NSAIDs  Modalities

• Signs of injury/ inflammation • History of injury/trauma

Psych • Substernal, accompanied by subjective sense of impending death

• Does Not Radiate • Not aggravated by respiratory or M-S Movements • Associated with hyperventilation and claustrophobia

• Tachycardia • Dyspnea • Diaphoresis

carrothers cp screening lecture 2011 -...

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