9/7/11. Why C-P Screening? Who should be screened? Differential Diagnosis. Differential Diagnosis. Definitions:

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1 Why C-P Screening? Cardiopulmonary Screening September 23, 2011 CPTA Annual Conference Long Beach, CA LeeAnne Carrothers, PT, PhD 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): ) 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. 1

2 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 Cough 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. 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 Hemoptysis Sputum production is normal 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. 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! 2

3 Difficulty breathing Peripheral vs. Central Cyanosis 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 Central Which has a worse prognosis??? 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 Causes of Chest Pain, cont. Causes of Chest Pain, cont. GI Hiatal Hernia Reflux Esophagitis Esophageal Spasm Cholecystitis Peptic Ulcer Disease Pancreatitis Psych Anxiety/Panic Attacks 3

4 Causes of Chest Pain, cont. Cardiac Chest Pain Musculoskeletal/Mechanical Cervical Radiculopathy Shoulder disorder/dysfunction Constochondral disorder Xiphodynia 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 HR SBP DBP SBP HR DBP Workload Abnormal Exercise Response--HR Abnormal Exercise Response--SBP Red Flags HR Rise disproportionate to rise in WL Maintenance of HR despite WL Fall in HR despite WL HR Red Flags SBP Rise disproportionate to rise in WL Maintenance of SBP despite WL Fall in SBP despite WL SBP Workload End Point SBP>200mmHg Workload 4

5 Abnormal Exercise Response--DBP Stable angina Red Flags DBP>15 mmhg over resting, regardless of the increase in workload Resting DBP > 95 End Point DBP> 100mmHg Workload DBP 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 Printzmetal s 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. 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 MVO 2 5

6 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 Typical and Atypical Male Irwin and Tecklin, 4 th Ed. 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. 6

7 Typical and Atypical Female Irwin and Tecklin, 4 th 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 Transmural vs. Subendocardial CK (AKA CPK) CK-MB LDH Troponin Myoglobin Pericarditis 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. Signs: Fever Chills Malaise Pericardial Friction Rub 7

8 Pericarditis Symptoms Pulmonary Chest Pain 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 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 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 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 8

9 Pulmonary Embolus Pulmonary Embolus, cont. 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 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 Chest Pain from Psych Causes 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) 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 9

10 Chest Pain from M-S / Mechanical Causes Congestive Heart Failure 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 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 Putting it all together, the sequel. Stable Angina Unstable Angina Printzmetal s Angina MI Location of Pain Behavior of pain Associated Signs Anything above the waist Men: substernal Women: vague GI-like distress Anything above the waist Men: substernal Women: vague GI-like distress Anything above the waist Men: substernal Women: vague GI-like distress Anything above the waist Men: substernal Women: vague GI-like distress Worse with activity Better with rest Relieved by NTG Worse with activity Better with rest Relieved by NTG Increase in frequency/ severity when compared to stable Occurs at rest in early AM Not associated with increase in demand Lasts for > 30 mins Not relieved by NTG worst pain ever ST Depression on 12-lead Arrhythmias Abnormal response to exercise ST Depression on 12-lead Arrhythmias Abnormal response to exercise ST Elevation on 12-lead Enzymes 12 lead ECG Changes Cardiogenic shock CHF Pericarditis Pleural Pain GI Typically substernal May Radiate Over location of inflammation / infection May refer to lower trunk, upper traps Intense stabbing, knifelike Corresponds to dermatomes from which the diseased organ receives its innervation Aggravating: Deep breathing Trunk rotation, side bending Alleviating: All fours Leaning Forward Fever Malaise Pericardial Rub Aggravating: deep breaths Fever Trunk/pleural stretch Pleural Rub Alleviating: Dyspnea Side bending toward involved Dry cough side Small rapid breathing 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) 10

11 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 11