Transcript Chest Assessment - NAU jan.ucc.nau.edu web server

Chest Assessment

Read through the chart for
past medical history and
reasons for the present
admission.
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Is the present admission for some
other cause other than
cardiopulmonary or is this a readmission for a long standing
chronic condition ?
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Read the psychosocial history
patient’s age
 marital status
 supportive family (SW’s report)
 will there be at-home care or will
it involve some level of postacute institutional care ?
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Look at the x-ray results :
Diffuse spider webbing ?
 Egg-shell calcifications present ?
 Is the cardiac image obscured ?
 Are there spots on the lungs ?
 Are fractures present ?
 Fluid lines present ?

Left Pneumothorax
CWP - Black Lung
Flail Chest
Cancer - Tumor In Right Lung
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Read the pulmonary function
test results
chronic obstructive lung disease
 restrictive lung disease
 occupational lung disease
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Chronic Obstructive Disease
asthma
 bronchitis
 emphysema
 bronchiectasis
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Restrictive Lung Disease
sarcoidosis
 tuberculosis
 pneumonia
 ARDS
 IRDS
 Valley Fever
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Occupational Lung Disease
psiticosis
 byssinosis - white lung
 CWP - black lung
 silicosis
 asbestosis
 pidgeon breeders disease
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Read the blood gas report
Is the patient acidotic ?
 Is the patient alkalotic ?
 Has the patient metabolically
compensated ?
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Normal Blood Gas Values
pH = 7.35 - 7.45
 PO2 = 80 - 100 mm Hg
 PCO2 = 36 - 44 mm Hg
 HCO3 = 22 - 26 mEq/L
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Read the bacteriology lab report
for any infective organisms
gram positive bacteria
 gram negative bacteria
 yeast infections
 HIV +
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Gram Positive Bacteria :
staphylococcus - osteomyelitis
 streptococcus - septicemia
 clostridium - gangrene
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Gram Negative Bacteria
salmonella - food poisoning
 shigella - dysentery
 klebsiella - pneumonia
 pseudomonas - deep infections
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Hemaglobin & Hematocrit okay ?
Hemaglobin : females - 13-14 g/dl
males - 15 -16 g/dl
 Hematocrit : females - 32 - 42 %
males - 42 - 52 %
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Briefly review the reports by the
various services :
respiratory therapy
 physician’s progress notes
 social worker’s report
 nurses notes
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Patient Evaluation
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Smoking History ?
S.O.B. & when did it start ?
Occupation ? Return to work ?
Is the patient ambulatory ?
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Do they use portable oxygen ?
Are there positions of comfort ?
Talk Test
Physical Exam
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Auscultate the lungs :

adventitious sounds
rales
 rhonchi
 pleural friction rub
 stridor
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Chest measurements - bilateral
excursion - rib flare ? - ant/post
movement of the chest ?
Breathing patterns
See-Saw breathing
 diaphragmatic breathing
 apical breathing
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Double cough ?
Productive cough ?
Quantity of sputum
 Color of sputum
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Vocal fremitus ?
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Patient’s color ?
CO2 narcosis - redness of skin
 hypoxemia - cyanosis - blue cast
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Mediate percussion
Surgical scars ?
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Chest deformations ?
Pectus excavatum
 Pectus carinatum
 cavitations
 barrel chest
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Rate & depth of respiration
Dyspnic ?
 Tachypnic ?
 Nasal flaring ?
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Accessory muscle use ?
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Can the patient perform self-care ?
Can they roll in bed and come to
sitting ?
Can they transfer into a chair ?
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Can they walk in the room or out
into the hall ?
Do they need supplemental
oxygen at rest and during ADL’s
or during exercise ?
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Does the patient have
pitting edema in the lower
extremities ?
1+, 2+, 3+, 4+
 CHF
 renal failure
 metastatic cancer
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Patient Case Study # 1
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82 y/o Caucasian female
Admitted for observation to
EROU (23-hour stay):
falling
 c/o of pain in chest and hip
 PT consult : evaluation for level
of medical care
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Social History
Living alone in a rented apt. at
Meridian Point - minor assisted
living contract
Because of falling hx., Meridian
Point would take her into their
full assisted living units if she
was admitted for 3 days at FMC
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Family lives in Flagstaff, Az.
Family expressing reluctance
about having her move in with
them for companion care
Medical History
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Fractured radius in Jan, 1999
Fractured right femur in August, 1994
Bilateral mastectomy - Cancer - 1980
Pneumonia - 1980, 1990, 1996
Negative for diabetes
Medical Findings
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CT scan of thorax, pelvis WNL
CT scan of brain showed atrophy - WNL
X-Ray of chest showed some diffuse
cloudiness in L > R - no masses
Physical Therapy Exam
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ROM - WNL for all extremities
Strength - 4/5 for age
Gait - 125 ft without LOB w/ FWW
Transfers - SBA ---> min assist
Orientation - 3/3
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Oximetry - SaO2 - 86% on 2
L/min as per nasal cannula
Blood Pressure - 156/88
Heart Rate - 98 bpm
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Breathing - diaphragmatic
Resp. rate - 18/min & shallow
Talk test - normal
No vocal fremitus present
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Fever - 102° F
Subjective Symptoms : “I feel
fine - I want to go home.”
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Auscultation Of Thorax
mild crackles - left lingula, R
middle lobe
 medium crackles - bilateral
anterior, lateral and posterior
basilar BP segments
 all other BP segments clear
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Recommendations ?
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Discharge to home with family
for 24-hour companion care ?
Admission to hospital for 3 days
and then to assisted living at
Meridian Point ?
Back to Meridian Point and
independent apartment living ?
Patient Case Study # 2
 51
year old Native American female
 Admitted to the hospital for :
inebriated pedestrian vs car
 fractured right and left tibia and
fibula in the distal 1/3 of both LE’s
 fractured C3-C4 stable and nondisplaced

multiple abrasions and
lacerations
 closed head injury
 aspiration pneumonia
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Physical Therapy Order :
Mobilize the patient - NWB on
BLE’s
 Functional activities
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 Social
History
Lives with her daughter in Tolani
Lake, Az. She herds cattle on a
small ranch
 Has a significant ETOH hx.
 Has a significant psychiatric hx.
 Has a significant spouse abuse hx.
 Is now divorced
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 Medical
History :
Repeated ETOH detox admissions to
Aspen Hills - ‘92, ‘93, ‘95, ‘98
 Significant for appendicitis in ‘84
 Significant for hypertension
 Significant for COPD (asthma)
 Significant for hyperlipidemia
 Significant for CAD - report of
occasional angina on hard exertion
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Physical Therapy Findings
Full ROM in all uneffected joints
and extremities
 Strength is WNL in BUE’s (5/5)
BLE’s not tested
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Bronchovesicular breath sounds in
the bilateral posterior and lateral
basilar bronchopulmonary
segments of the bilateral lower
lobes
 A Monarch UE GXT was given physical work capacity was Fair
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 BP
at rest = 150/92
 BP at SLGXT = 212/100
 HR at rest = 78 BPM
 HR at SLGXT = 168 BPM
 Max METs obtained = 8.5
 Functional
Mobility
sitting balance = good
 bed mobility = good
 ADL’s = good with self care

Recommendations ?