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Cardiopulmonary Final Review
Cardiac Exam
Symptom descriptors – angina, SoB, night dyspnea, orthopnea, link to exertion, palpitation, syncope/dizzy,
sweating
Dyspnea scale – 1+ PT can’t notice, 2+ PT notices, 3+ moderate but pt continues, 4+ pt can’t
continue
Angina scale – 1+ not noticeable, 2+ bothersome, 3+ very uncomfortable, 4+ worst pain ever
Observation
Posture, thoracic deformity, accessory muscles
Affect
Skin color, clubbing, edema, incisions, JVD
RR, breathing pattern, cough
Gait speed, rest requirements
Palpation
Pulses (0 absent, 1+ weak, 2+ norm, 3+ increased, 4+ bounding) & PMI
Skin temp & diaphoresis
Pitting edema grading – 1+ barely, 2+ rebound <15sec, 3+ rebound 15-30sec, 4+ rebound >30sec
Sternal points (sternal, aortic, pulmonic, Rvent, Lvent, epigastric)
Vitals – temp, HR (60-100 norm), RR(~12-16 norm), BP(< 120/80 norm, 140-159/90-99 HTN I), pain
Auscultation
Heart sounds
Aortic – R 2nd space … Pulmonary – L 2nd space
Tricuspid – L 4th space … Mitral – at PMI point
S4 (late diastole, HTN / cardiomyopathy), S1 (lub, AV valve close at start of systole), S2 (dub,
semilunar valve close at end of systole), S3 (early diastole, vent fail / tachy♥, MR)
Adventitious – murmur, click, snap
Differentiate CP and associated symptoms
Cardiac symptoms – Central cyanosis, night dyspnea, palpitation, UE / jaw pain, unusual sweating, syncope
Pulmonary symptoms – Peripheral cyanosis, stridor, wheezing, activity limitation
Worse: deep breath, trunk / pleural stretch
Better: quadruped, lean forward, hold breath
Bi-system symptoms – dyspnea/orthopnea, cough, chest pain,
peripheral edema
Anginas
Chronic, stable – known onset / level of demand … nitroglycerin
Stable – set level of activity … nitroglycerin, rest, no stress
Unstable – at rest or differ from prior onset … nitroglycerin
Prinzmetal – early morning, no exertion link, 2o vasospasm
MI – last 30+min, not relieved by nitroglycerin, sense of doom
GI pain – worse after eating, supine, acid-food
Acute Lecture
Pulmonary artery cathether / Swan Ganz
Internal jugular  subclavian  R atrium
Pulm A pressure, wedge pressure (LVEDvol), LVEDP
** if LVEDP >12 no supine, move & percuss carefully
R heart catheter (Swan Ganz is 1 type)
Continuous venous O2 sat monitor (normal = 60-80%, but arterial normal = 95-98%)
Arterial line
Radial artery or femoral artery
Systemic BP
** DON’T disconnect!!!, no hip √ >60o if femoral, infection, check manually if weird reading
Central venous line
Subclavian vein, internal jugular vein or femoral vein
Cardiopulmonary Final Review
R atrial pressure
** Move carefully
Intravenous line
Superficial vein
Immediate blood input of fluids, electrolytes, medication, nutrition
** Must be changed every 3-4days
Percutaneous intra-cardiac catheter (PICC)
Forearm vein  R atrium
Prevent multi-sticking
** no submersion, watch for bleeds, phlebitis, infection, blocking, clotting, arrhythmia
Intra-aortic balloon pump (IABP)
Femoral artery  descending aorta (just below subclavian)
Inflate / deflate timed to cardiac cycle …  ♥ perfusion
** usually not PT Tx, no hip √, check radial pulses
Extra-corporeal membrane oxygenation (ECMO)
**bleeding, clotting, infection
ABG measures
pO2 (87.5) / pCO2 (40) / HCO3- (24) / pH (7.4) / SaO2 (97)
I & O affecters – fluid retention, oral/IV intake … fluid shift, sweat, wound drain, diarrhea/vomit,
hemorrhage, urine
Pacemakers
Placement coding
1st letter – chamber placed in (O none, A atrium, V ventricle, D dual)
2nd letter – chamber sensed (O none, A atrium, V ventricle, D dual)
3rd letter – pacemaker response to sensed activity (O none, I inhibit, T trigger, D dual)
4th & 5th letters - programmability
Demand pacemaker – kicks in when HR too low … can  HR when SA no can’t (chronotropic incompetence)
Pacemaker precautions
Re-eval every 3-6mo – check function, batter lasts 5-8yr
Avoid full contact sport
Avoid electromagnetic interference – cell phone, MRI, TENS, therapeutic radiation, subway brakes
**Airport – carry ID card…OK to go through security, but don’t stand in scanner long
Pacemaker indications
Usually for brady♥, sinus node dysfunction (sinus arrest, SSS, chronotropic incompetence), ♥ block,
CHF
SSS – sinus brady♥, tachy♥, or alternating
Pacemaker for brady♥, meds/ablation for tachy♥
1st Degree ♥ block – Good Pwave, 1P:1QRS, consistent long PRinterval
2nd Degree ♥ block I –  PRinterval until QRS dropped
2nd Degree ♥ block II – 2+P:1QRS, regular PRinterval when QRS does happen
3rd Degree ♥ block – atrial rate & ventricular rate independent
Linked signs/Sx – syncope, dizzy,  energy, fatigue, exercise intolerance, SoB, palpitation, confusion
Know the medication chart
Exercise Tests and VO2
Ventilation pathologies – COPD, pneumonia, asthma, CF, ARDS, neuromuscular Dz, restrictive Dz
Heart pathologies – CAD, CHF, dysrhythmia, mycarditis, cardiomyopathy
Vascular pathologies – PVD, DVT, DMII
Muscle / endurance pathologies – immobilization, CHF, MD, nutritional Dz, myositis, DMII
VO2 factors – age, gender (♀ 15-30% less), heredity, body composition, endurance training, O2 transport Dz
NO exercise testing
Significant EKG change
Acute PE / infarct
Unstable angina
Acute myocarditis / pericarditis
Cardiopulmonary Final Review
Uncontrolled dysrhythmia
Dissecting aneurysm
Symptomatic severe AS
Systemic infection
Uncontrolled CHF
Careful exercise testing
L main artery disease
Atrioventricular block
Moderate valve stenosis
Ventricular aneurysm
Abnormal electrolytes
Uncontrolled metabolic disease
Severe HTN at rest (>200/110)
Chronic infections
Tachy♥ or brady♥
Mental / physical impairments
Dz exacerbated by exercise
Walking tests
3m or 10m walk test – community ambulation requires 0.5-1.22m/sec
6min (or 12min or 2min) walk test – self-paced…not very great motivationally
10m walk shuttle or 20m run shuttle – externally paced…more motivational
1mi walk test
Step tests – external pacing (metronome)
Stop testing a healthy adult if…
Angina
Failure of normal HR 
 systolic BP by 10+mmHg
Rhythm change
Excessive BP (>250/115)
Complaint of fatigue
SoB, wheezing, cramps, claudication
Equipment failure
Cyanosis