Examination – Evaluation Cycle
Patient: State/Trait
Intervention Examination:
Collect information
Evaluation:
Integrate information
into action
Evaluation is where you answer the question
(s) that is (are) asked of you when your
services are requested –
1. Is there an immediate need for urgent care?
2. Is there a need for medical referral?
3. Can this patient go home yet?
4. Can therapy Intervention help this patient?
(Is there an aspect to the problem that is
reversible? (May have to look at various
interacting levels))
5. What intervention? How long will it take?
How much help? (Will save for specific
interventions)
1. Is there an immediate need for urgent
care?
• An assessment of “stability” – if deemed not
stable – needs urgent care…
2. Is there a need for medical referral?
• Really is still an assessment of “stability” just
on a longer time scale – if deemed stable – but
at risk so needs follow up care…
3. Can this patient go home?
• Again – really a question of stability on
an even longer time scale
• Requires an absolute yes or no
answer, but is only a recommendation,
so justification, pros/cons can be
presented
• Again – a question of “stability” over
longer time frames with appropriate
determination and acceptance of risks
Time scales of stability – feedback loops
Coordinated & Focused
Muscular Activity Work
Bioenergetic Process Environment
O2 Glucose
H2O
Ventilation
CV System Respiration
What information (examination) is
needed, and how to do you evaluate
stability in your patient with pulmonary
disease?
• Urgent care…
• Medical referral….
• Home……
What interventions are warranted from
an evaluation that determines that a
patient is not stable?
• Urgent…
• Medical referral….
• Home…..(see question 4)
4. Can Intervention help this patient?
• Disease – Structures / Functions – Activity –
Participation
• What impairments seem to be causing
reduced activity? How do they interact?
• Are these impairments reversible? Or
irreversible?
Examination – Evaluation Thought
Process
Cardio Pulmonary
Diagnosis
Yes
Is the patient Stable? Examining
Stability
Options for
No Yes
intervention?
Examining
Does the patient have an Endurance
endurance impairment? Impairments
What’s the problem? No Yes
No Disease specific? Yes
Intervention Reversible?
s Interventions
Is Absolute Workload (Function) limitation
associated with Reduced Endurance due to
Disease Specific Impairment?
Yes No
Can response be changed? What is limiting factor?
Reversible vs. Irreversible?
Degree / time frame of
Medically optimized? reversibility?
What does this workload allow?
Specific vs. General training -
•Pacing
Increase maximal workload
•Maximize Efficiency
•Conditioning
•Conditioning
•Biomechanical optimization
Functional Limitations from Endurance
Impairments
• Examples from ICF – limited capacity to complete the
necessary workload for the required time frame when trying
to…
– raise up an object or taking something from one place to another,
such as when lifting a cup or carrying a child from one room to
another.
– move along a surface on foot, step by step, so that one foot is
always on the ground, such as when strolling, sauntering, walking
forwards, backwards, or sideways.
– carry out the coordinated actions and tasks of putting on and
taking off clothes and footwear in sequence and in keeping with
climatic and social conditions, such as by putting on, adjusting and
removing shirts, skirts, blouses, pants, undergarments, saris,
kimono, tights, hats, gloves, coats, shoes, boots, sandals and
slippers.
– wash and dry one's whole body, or body parts, using water and
appropriate cleaning and drying materials or methods, such as
bathing, showering, washing hands and feet, face and hair, and
Endurance Impairments – a multi system, integrated
perspective
• Endurance emerges from multiple integrated systems
providing energy production in a sustainable manner so
that the work (task, functional activity) can be
completed
• Here, sustainable refers to the continuous production
of energy at a sufficient level for work to continue
• This has to do with where the energy for muscular
contraction is coming from:
– Aerobic work = sustainable for hours
– Pure anaerobic work = sustainable for seconds
– Balance of aerobic / anaerobic work = sustainable for up
to 20 minutes, depending on the balance
• At a particular workload – we all have an
endurance impairment – just not resulting from
disease specific reductions in system integration
Particular Impairments
• Electrocardiograph Arrhythmia, Ischemia, Injury, Infarction
• Chest X-Ray Pulmonary Edema Pump Effectiveness & Fluid
Volume
• Arterial Blood Gases Respiration
• Creatinine / BUN Renal Function
• Echocardiograph Pump Effectiveness (LVEF = Systolic) (EDV =
Diastolic)
• BNP Pump Effectiveness
• Heart Sounds Pump Effectiveness
• CK, Troponins Infarction
• CBC Oxygen Carrying Capacity, RBC Production
• Coronary Arteries (Catherization) Myocardial Oxygen Supply (MOS)
• Exercise Test Oxygen Consumption / Energy Production Capacity
• Respiratory Rate / Breathing Mechanics Ventilation
• Lung Sounds Fluid Volume
• JVD / Peripheral Edema Fluid Volume
• HR x SBP = RPP Myocardial Oxygen Demand (MOD)
• For all individual sources of information you need to
consider:
– What impairment (s) is (are) being assessed? What
physiological function is assessed? Are they in isolation or
aggregated with other functions?
– How does this source of information relate to other sources
of information?
– *Why do I need this information?
• Prognosis? Intervention?
– *How often can I update my understanding with
this information?
Information sources
Information Use Dynamicity Considerations
Heart Rate Myocardial oxygen Beat to beat; minute Medication can have a
demand, level of work to minute; activity to powerful impact
activity
Heart rhythm Arrhythmia Moment to moment Pulse vs. ECG
Blood Pressure Effectiveness of pump; Moment to moment Inadequate frequency
vascular resistance
Weight / Edema Fluid retention Day to day
SOB Ventilatory limitation Moment to moment Low specificity
Lung sounds Pump effectiveness Moment to moment Downstream
Oximetry Respiratory limitation Moment to moment Downstream?
Heart sounds Pump effectiveness Moment to moment Difficult to learn
MIP Ventilatory limitation Day to day Barely used
Muscle strength Muscle strength Day to day Primary to endurance
Capability for Work
Skeletal Muscle
Oxygen Consumption
Oxygen Carrying Capacity Respiration
RBC Fluid Volume Ventilation
Pump Effectiveness
Renal Function
Systolic Diastolic
Infarction
Arrhythmia
Injury
=
MOS MOD Ischemia
<
Coronary Arteries
Closer Assessment of Particular Impairments & Interactions
• Coronary Arteries (Angiogram/Catherization) Myocardial Oxygen Supply
(MOS)
• HR x SBP = RPP Myocardial Oxygen Demand (MOD)
Contributing Factors?
= Ischemia?
MOS MOD Injury?
Contributing < Infarct?
Factors?
Coronary Arteries HR x SBP = RPP
Catherization
Contributing Factors?
Coronary Arteries (Catherization)
Closer Assessment of Particular Impairments & Interactions
• Electrocardiograph Arrhythmia, Ischemia, Injury, Infarction
• CK, Troponins Infarction
Pump Effectiveness
Arrhythmia
Infarction Electrocardiography
= •ST Changes
MOS MOD Injury •Blocks
<
Ischemia Biomarkers
•CK; CK-MB
•Troponins
Symptoms
•Chest Pain / Angina
•Anginal Equivalent
Electrocardiograph Ischemia, Injury, Infarction
Electrocardiograph Ischemia
Electrocardiograph Ischemia
Electrocardiograph Injury
Electrocardiograph Injury
Electrocardiograph Infarction
Biomarkers
Enzyme Isoenzyme Normal Onset of Time of Return to
Value Rise Peak Rise Normal
Creatine Kinase 55 - 71 IU 3-6 hours 12-24 hours 24-48 hours
CK-MB 0% - 3% 4-8 hours 18-24 hours 72 hours
Lactate Dehydrogenase 127 IU 12-24 hours 72 hours 5-14 days
LDH – 1 14% - 26% 24-72 hours 3-4 days 10-14 days
Troponin T (cTnT) < .2 mcg/L 2-4 hours 24-36 hours 10-14 days
Troponin I (cTnI) < 3.1 mcg/L 2-4 hours 24-36 hours 10-14 days
Myoglobin 31-80 ng/ml 1-2 hours 6-9 hours 24-36 hours
Source: Data from Christenson RH, Azzazy HME. Biochemical markers of the acute coronary syndromes.
Clinical Chemistry 1998; 44: 1855-1864; Kratz, AK, Leqand – Rowski, KB: Normal reference laboratory
values. New England J of Medicine 1998; 339: 1063-1072.
Closer Assessment of Particular Impairments & Interactions
Echo – Cardiac Output
Pump Effectiveness BNP
Chest XRay
Heart Sounds
Diastolic Blood Pressure Changes
Infarction Systolic
Injury Echo – End Diastolic Volume
Ischemia Echo – Left Ventricular Ejection
Fraction - LVEF
Electrocardiography
•Ectopic beats – PVCs, VTach,
VFib
Arrhythmia
•Pulse Rate
Symptoms
•Palpitations
Echocardiography Report
Diastolic
Systolic
BNP
Hobbs, 2003
Chest X Ray
Classic findings of
congestive heart failure -
note the enlarged heart,
large indistinct hila,
increased prominence of
the pulmonary veins
draining the upper lobes
("reversal of flow"), and
the bilateral alveolar
pulmonary edema.
Heart Sounds
http://www.wilkes.med.ucla.edu/inex.htm
S3: about 140-160 msec after S2, an S3 may be heard if the volume which has
been transferred is abnormally large. It can be thought of as a sound which is
generated when the ventricle is forced to dilate beyond its normal range because
the atrium has overloaded volume. An S3 is usually heard best with the bell of the
stethoscope placed at the apex while the patient is in the left lateral decubitus
position. The presence of an S3 is usually normal in children and young adults,
but pathologic in those over the age of 40.
S4: The late stage of diastole is marked by atrial contraction, or kick, where the
final 20% of the atrial output is delivered to the ventricles. If the ventricle is stiff
and non-compliant, as in ventricular hypertrophy due to long-standing
hypertension, the pressure wave generated as the atria contract produces an S4.
It is heard best with the bell of the stethoscope at the apex.
Electrocardiography
Ectopic beats – PVCs, VTach, VFib
Ectopic Focus Atria Ventricle
1 PAC PVC
-Couplets, Bigeminy,
Trigeminy
Several - Multi focal or
Occasionally Multiform
1 Non Stop Atrial Flutter Ventricular
Tachycardia
Several – Non Atrial Fibrillation Ventricular
Stop Fibrillation
Electrocardiography
Ectopic beats – PVCs, VTach, VFib
Electrocardiography
Ectopic beats – PVCs, VTach, VFib
Electrocardiography
Ectopic beats – PVCs, VTach, VFib
Electrocardiography
Ectopic beats – PVCs, VTach, VFib
Electrocardiography
Ectopic beats – PACs, AFlutter, AFib
Electrocardiography
Ectopic beats – PACs, AFlutter, AFib
Electrocardiography
Ectopic beats – PACs, AFlutter, AFib
Closer Assessment of Particular Impairments & Interactions
Capability for Work
Skeletal Muscle
Oxygen Consumption
Pump Effectiveness
Oxygen Carrying Capacity
Systolic Diastolic
RBC Fluid Volume
Renal Function
Respiration
Infarction
Ventilation
Injury
Arrhythmia
Ischemia
Closer Assessment of Particular Impairments & Interactions
Capability for Work
Skeletal Muscle
Exercise Test
Oxygen
Consumption
CBC
Oxygen Carrying Capacity
Chest XRay
Lung Sounds
RBC Fluid Volume Edema
JVD
Body Weight
Renal Function
Creatinine
BUN
Respiration ABG’s
Ventilation RR, Breathing
Mechanics
CBC / BUN / Creatinine / ABG’s
• CBC – is the patient anemic?
• BUN / Creatinine – are the kidneys
involved?
• ABG’s - is the ventilatory impairment
resulting in respiratory impairment?
Exercise Test
• Stress Test
– Why? What?
• Dobutamine Stress Test
– Why? What?
• Persantine Stress Test
– Why? What?
Examination – Evaluation Thought
Process
CardioPulmonary
Diagnosis
Yes
Is the patient Stable? Examining
Stability
Options for
No Yes
intervention?
Examining
Does the patient have an Endurance
endurance impairment? Impairments
What’s the problem? No Yes
No Disease specific? Yes
Intervention Reversible?
s Interventions
Absolute Workload (Function) Limited
associated with Reduced Endurance due to
Disease Specific Impairment?
Yes No
Can response be changed? What is limiting factor?
Reversible vs. Irreversible?
Degree / time frame of
Medically optimized? reversibility?
What does this workload allow?
Specific vs. General training -
•Pacing
Increase maximal workload
•Maximize Efficiency
•Conditioning
•Conditioning
•Biomechanical optimization
Pulse Response
Pulse with Exercise and Functional Activities
• Rate
– Increase with increased workload
– Steady with steady workload
– Recover with reduced workload
– Rate Pressure Product as indicator of MVO2
• Regularity
– Irregularly Irregular
– Regularly Irregular
Blood Pressure Response
Blood Pressure with Exercise and Functional Activities
What to look for:
• Drop in SBP of ≥ 10 mm Hg – modify or
terminate exercise
• Increase of DBP ≥ 10 mm Hg – modify or
terminate exercise
• Elevation of DBP when should be lower – i.e. if
supine DBP is greater than standing DBP = likely
failing cardiovascular system
Blood Pressure & Pulse During Breathing
• Pulsus Alternans
– Hold breath at midexpiration=pump failure
– SBP ≥ 20 mm Hg variation
• Pulsus Paradoxus
– Dec. pulse strength and SBP (≥ 20 mm Hg) during
inspiration
– Might indicate pump failure – more likely due to
COPD, cardiac tamponade, constrictive pericarditis
• Deep Breathing for 1 minute at ≈ 6 bpm
– Should result in decrease of HR by 15-20 bpm if not –
ANS-Cardiac Dysfunction is possible
Blood Pressure & Pulse in different
positions
Why assess Supine vs. Standing vitals?
1. Status of cardiovascular regulation
– If no inc HR and dec BP = ANS dysfunction
2. Enable perturbation of the system to
determine health of the cardiovascular
system
– Rapid vs. sluggish (≈ 30 seconds for normal)