Case study 1

1

• Case study 1
• A patient admitted after experiencing a right
  embolic CVA. She presents with dysphagia and left
  sided hemiparesis. The patient has a temperature
  of 101.6 F, a consolidated left lower lobe on the
  chest x-ray, and a WBC count of 14,000. What
  physical examination procedure will allow you to
  assess the impact of this patients condition on
  respiration?
• SpO2
• Lung Sounds
• PFTs
• Chest Wall Excursion

2

• Case study 1
• A patient admitted after experiencing a right
  embolic CVA. She presents with dysphagia and left
  sided hemiparesis. The patient has a temperature
  of 101.6 F, a consolidated left lower lobe on the
  chest x-ray, and a WBC count of 14,000. What will
  be the goal of the first intervention for
  improving airway clearance?
• Strengthen expiratory muscles
• Improve inspiration
• Improve expiratory flow
• Position for bronchial drainage

3

• Case Study 2
• A patient with severe COPD presents to your
  clinic with dyspnea, a barreled chest, digital
  clubbing, and poor functional capacity. What is
  the first physical examination you will perform?
• Hoovers sign
• Chest wall excursion
• SpO2
• Blood Pressure

4

• Case Study 2
• A patient with severe COPD presents to your
  clinic with dyspnea, a barreled chest, digital
  clubbing, and poor functional capacity. There is
  a positive Hoovers sign, so your next step is
• Teach PLB and test again
• Teach diaphragmatic breathing and test again
• Test MIP and MEP
• Test chest wall excursion

5

• Case Study 3
• A patient with oxygen and steroid dependent COPD
  is experiencing shortness or breath, RR 26, and
  using accessory muscles. The patient is lying in
  bed with HOB 45 degrees and being provided 4L of
  oxygen by nasal cannula. What is the most likely
  reason for this patients symptoms of respiratory
  distress while lying in bed at rest?
• Dynamic hyperinflation
• Poor use of accessory muscles
• Hypoxia
• Anxiety

6

• Case Study 3
• A patient with oxygen and steroid dependent COPD
  is experiencing shortness or breath, RR 26, and
  using accessory muscles. The patient is lying in
  bed with HOB 45 degrees and being provided 4L of
  oxygen by nasal cannula. How would you intervene?
• Move to sitting, forward leaning with UEs
  supported on a bedside table
• Move to supine, UEs over head
• Move to prone, UEs out to side
• Move to standing, forward leaning

7

• Case Study 6
• A patient is admitted to the hospital with a
  medical diagnosis of an acute exacerbation of
  chronic bronchitis. What medical test will best
  indicate to you how severe this condition is now
  compared to baseline?
• PFTs
• ABGs
• Pulsed Oximetry
• Chest X ray

8

• Case Study 6
• A patient is admitted to the hospital with a
  medical diagnosis of an acute exacerbation of
  chronic bronchitis. The first intervention for
  improving the effectiveness of this patients
  cough would be
• Pursed lip breathing
• Huffing
• Expiratory muscle training
• Incentive spirometry

9

• Case Study 7
• A patient with severe COPD, polycythemia and an
  increase in pulmonary artery (PA) pressure has a
  primary complaint of dyspnea at rest with
  occasional productive cough of white secretions.
  The chest x-ray reveals bilateral hyperinflated
  lungs with a flattened diaphragm. To determine
  whether it is safe to proceed your first priority
  should be to
• Test whether SpO2 is less than 90
• Assess social status
• Assess smoking history
• Test whether there is a reversible component to
  the hyperinflation

10

• Case Study 7
• A patient with severe COPD, polycythemia and an
  increase in pulmonary artery (PA) pressure has a
  primary complaint of dyspnea at rest with
  occasional productive cough of white secretions.
  The chest x-ray reveals bilateral hyperinflated
  lungs with a flattened diaphragm. To determine
  the degree to which PT will help this patient
  your first priority should be to
• Test whether SpO2 is less than 90
• Assess social status
• Assess smoking history
• Test whether there is a reversible component to
  the hyperinflation

11

• Case study 14
• A 75 year-old male is admitted to the ER with
  acute onset of chest pain and diaphoresis. He was
  diagnosed with a NQMI and admitted to the floor
  in a stable condition on a heparin drip, atenolol
  (a beta blocker), and NTG as needed. The best
  medical test to look for in determining whether
  this patient will have limitations due to left
  ventricular dysfunction is
• Chest x ray
• Exercise stress test
• Dobutamine stress echo
• Angiogram

12

• Case study 14
• A 75 year-old male is admitted to the ER with
  acute onset of chest pain and diaphoresis. He was
  diagnosed with a NQMI and admitted to the floor
  in a stable condition on a heparin drip, atenolol
  (a beta blocker), and NTG as needed. The best PT
  clinical assessment to determine whether
  functional mobility is limited due to left
  ventricular dysfunction is
• Presence of Shortness of breath
• Blood pressure response to activity
• Heart rate response to activity
• Oximetry response to activity

13

• Case Study 15
• A patient admitted with an STEMI s/p CABG 2 2
  days ago medications include atenolol, digoxin,
  captopril and lasix is referred for PT. Blood
  pressure is hypo responsive with ambulation and
  HR becomes bradycardic. After rest the patient
  recovers and stabilizes. For the next walk you
  should examine
• ECG
• SpO2
• Heart sounds
• Lung sounds

14

• Case Study 15
• A patient admitted with an STEMI s/p CABG 2 - 2
  days ago medications include atenolol, digoxin,
  captopril and lasix is referred for PT.
  Recurrent ischemia would best be identified with
• ECG
• SpO2
• Blood pressure
• Heart rate and rhythm

15

• Case Study 15
• A patient admitted with an STEMI s/p CABG 2 - 2
  days ago medications include atenolol, digoxin,
  captopril and lasix is referred for PT. This
  patient should start exercising at
• 65-85 of Max HR
• 50-60 of Max HR
• 16 18 RPE
• 10 12 RPE

16

• You are consulted to treat an 80 year old female
  with past medical history significant for
  coronary artery disease, LVH and diabetes, now
  admitted to your facility with a medical
  diagnosis of worsening left sided heart failure
  and EF of 38. The best indication that this
  patient is in CHF with activity would be
• Shortness of breath
• Poor HR response
• Bilateral Pulmonary crackles
• S4 heart sound

17

• Case Study 17
• A 72 year-old patient has undergone a total knee
  replacement 2 days ago, PMH includes CAD, IDDM,
  and left sided systolic CHF with an EF 35.
  Post operative HcT is 30. The best way to test
  for signs of cardiac limitations associated with
  the low oxygen carrying capacity would be to
  examine ______ during activity.
• SpO2
• Lung sounds
• ECG
• Blood pressure

18

• Case Study 20
• You are consulted to treat an individual with
  dilated cardiomyopathy, LVEF 25 and BNP 900.
  The patient presents with dyspnea and has poor
  exercise tolerance. The best approach to examine
  this patients response to activity
• SpO2
• HR and Rhythm
• Blood Pressure
• ECG

19

• Case Study 20
• You are consulted to treat an individual with
  dilated cardiomyopathy, LVEF 25 and BNP 1000.
  The patient presents with dyspnea at rest and has
  poor exercise tolerance. Since the patient is in
  CHF you can expect
• An S3 heart sound
• Tachycardia
• PVCs
• ST depression

20

• Case Study 23
• During the initial physical therapy evaluation of
  your patient admitted with CHF in the skilled
  nursing facility, you observe the patients
  systolic blood pressure to drop 20 mm Hg below
  resting levels with ambulation of 20 feet in 30
  seconds. If medical management cannot be adjusted
  for this patient, do you anticipate that this
  patient will increase maximal aerobic capacity to
  5 METs?
• Yes
• No