Faculty of Physical Therapy

Physical therapy for internal medicine department

Cardiopulmonary Sheet

Pt name: Eid
………………..…….
mohamed 56
Age: ……………………….…… M
Sex: …………………………
Married
M. status: …………………… No job
Occupation: ………………... Ref. Dept.: ………………
Date: ……………………………..

Chief Complain
Difficulty & shortness of breathing
……………………………………………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………….
Present history
…………………………………….……………………………………………………………………………………………..
Chronic obstructive pulmonary disease (COPD)
……………………………………………………………………………………………………………………………………………….
Bronchial asthma
……………………………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………….
Symptoms:
o Dyspnea: Y/N
o Chest pain: Y/N
VAS: 1 2 3 4 5 6 7 8 9 10
o Cough: Y/N
o sputum: Y/N
o haemptysis: Y/N
o wheezing: Y/N
Past medical history:
Appendectomy
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
Light smoker (3-4 cig/day)
Smoking: ……………………………………………………………………………………………………………………….
Dexamethasone NA-p injection -allear- forbuds
Medication: ……………………………………………………………………………………………………………………………
Vital sign:
Temp.: ……...…….. 120/70
Rt. BP: ………………. Lt. BP: …………………… 96%
SPO2: ……….…..
RR: 23
PR: 81
Pulse Rate Rt Lt
regular weak absent regular weak absent
Carotid
Radial
Dorsalis pedal

Ambulatory status: …………. swelling: ….…. atrophy:…… deformity/symmetry: ………

 Faculty of Physical Therapy
Physical therapy for internal medicine department

Local chest examination:

Inspection:
o Level of consciousness: ………………………………………………………………………………………………………
Conscious
Normal
o Facial expression: …………………………………………………………………………………………………………………
Normal
o Body position: ……………………………………………………………………………………………………………………
o Dyspnae:
Exertional
Type: ………………………………….………….……… 3
Grade: …....…....................................

o Chest pain: No chest pain

Severity: ……………………..………… location: ………………………..……. character: ……………………….
Duration: ………….…………………… radiation: ………………………..……
Exaggerating factors: ………………………………………………………………………………………………………………
Relieving factors: ……………………………………………………………………………………………………………………
O Cough:
Chronic
Type: ………….………………………………………… Productive
character (productive/dry): ………………………………..
Part
Severity (cont. or part.): …………………….... time: ………………………………………………………………….
Supine
Posture: ………………………………………………..
Exaggerating factors: ………………………………………………………………………………………………………………
Relieving factors: ……………………………………………………………………………………………………………………
o Sputum:
Amount: ………………. odor: …………………………. color: Yellowish Supine
…………………. posture: ….……………
Time: …………………………………………………………. consistency: …………………………………………….
Exaggerating factors: ………………………………………………………………………………………………………………
Relieving factors: ……………………………………………………………………………………………………………………
O Hemoptysis: No
Color: …………………………………………………………. consistency: …………………………………………….
o Chest shape:
Barrell chest
Chest wall shape: ………………………………. Normal
chest wall symmetry: …………………………….
Abdemino thoracic
Chest wall movement: ……………………………………………………………………………………………………………
o Breathing pattern: ………………………………………………………………………………………………………………
Tachypnea - abdominothoracic - hyperventilation
Scar: …………………………………… nodule: …………………………………. bruise: ……………………………….
No
surgical incision: ……………………………………………. No
edema: ……………………………………………………
o Clubbing of finger or toes: …………………….
No Grade: ……….…………………………………………..
o Cyanosis:No
Peripheral Central
………………............... …………………………….
…………………………….. ……………………………..

o Accessory neck muscle:

Atrophy: ………………………… spasm: ………………………….. used in breathing: ……………………………….
Jugular venous distension:
……………………………………………………………………………………………………………………………………………….
 Faculty of Physical Therapy
Physical therapy for internal medicine department

……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….

Palpation:
Chest deformity or tenderness: Y/N
Site: ………………………………………........... Degree: …………………………………………………
Neck muscle spasm: Y/N
Site: …………………………………………………
Normal / no tracheal shifting
Tracheal position: …………………………………………………………………………………………………………………..
Chest wall expansion:
Quit breathing Deep breathing
Apical Normal
Upper costal Normal
Middle costal Normal
Lower costal Normal
Post. basal Normal

Tactile vocal fremitus: ……………………………………………………………………………………………………………

Decreased in left lung
Percussion: …………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………….

Diaphragmatic excursion: …………………………………………………………………………………………………..

Auscultation:
Normal breathing sound
normal weak absent
Bronchial
Broncho
vesicular
Vesicular

Adventitious breath sounds

wheeze crackle Plural rub

Problem list:
Dyspnea
1. …………………………………………………………………………………………………………………………………
Cough
2. .…………………………………………………………………………………………………………………………………
 Faculty of Physical Therapy
Physical therapy for internal medicine department

3. Chronic sputum production

…………………………………………………………………………………………………………………………………
4. Difficulty in performing daily activities
…………………………………………………………………………………………………………………………………
5. Shortness of breath
…………………………………………………………………………………………………………………………………
6. Fatigue
…………………………………………………………………………………………………………………………………
7. …………………………………………………………………………………………………………………………………

Long term goal:

Prevent / delay progression of dyspnea
1. .……………………………………………………………………………………………………………………………….
2. Improve endurance & strength of respiratory muscles
…………………………………………………………………………………………………………………………………
3. Postuse correction & positioning
…………………………………………………………………………………………………………………………………
Reduce anxiety , stress & sleep disturb
4. …………………………………………………………………………………………………………………………………
5. ………………………………………………………………………………………………………………………………..
Short term goal:
Airway clearance
1. ………………………………………………………………………………………………………………………………….
Promote Diaphragmatic breathing
2. ………………………………………………………………………………………………………………………………….
Decrease dyspnea
3. …………………………………………………………………………………………………………………………………..
4. …………………………………………………………………………………………………………………………………..
5. ……………………………………………………………………………………………………………………………….....

Precautions:
Avoid any infection or form of breathing
………………………………………………………………………………………………………………………………………………
(Active/passive)
……………………………………………………………………………………………………………………………………………..
PT management: ……………………………………………………………………………………………………………………
1- pulmonary rehabilitation
……………………………………………………………………………………………………………………………………………….
1- Diaphragmatic breathing
………………………………………………………………………………………………………………………………………………
2- pursed lip breathing
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
2- airway clearance techniques
………………………………………………………………………………………………………………………………………………
1- postural drainage
………………………………………………………………………………………………………………………………………………
2- autogenic breathing
……………………………………………………………………………………………………………………………………………
3- cough
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………
Respiratory muscle training : improve strength & endurance of
………………………………………………………………………………………………………………………………………………
diaphragm
………………………………………………………………………………………………………………………………………………
Home/ward instructions: …………………………………………………………………………………..………………….
Aerobic exercise : walking, cycling & swimming
………………………………………………………………………………………………………………………………………………
Education & self - efficiency
………………………………………………………………………………………………………………………………………………
Self- stretching exercises
………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………

PT: …………………………………. Signature: …………………

 Faculty of Physical Therapy
Physical therapy for internal medicine department