Internal Medicine Lab

Al-Zaytoonah University Of Jordan
Applied Medical Science Faculty

Physical Therapy Department
Student Name: ___________________
PT for Internal
&
cardiopulmonary
Diseases and their
surgeries lab
(1101335)
Editing By:
Dr. Mostafa Soliman
Lab Supervisor:
PT. Nancy Alryalat
2023-2024
Lab Topics:
Lab 1 Chest surface anatomy
Lab 2 Cardiopulmonary assessment
Lab 3 Localized cardiopulmonary assessment
Lab 4 Examination of the heart
Lab 5 Assessment of vital signs
Lab 6 Pulmonary function test
Lab 7 Physical therapy intervention: breathing exercise
Lab 8 Physical therapy intervention: secretion clearance 1
Lab 9 Physical therapy intervention: secretion clearance 2
Lab 10 Physical therapy in cardiothoracic surgery

Total Marking Criteria:

Reports: Quizzes: Assignment: Mid-term Final Exam:
Exam:
10 10 10 30 40
Reports Marks:
Report #1:
Report #2:
Report #3:
Report #4:
Report #5:
Report #6:
Report #7:
Report #8:
Report #9:
Report #10:
AL-Zaytoonah University of Jordan
Medical Applied Science faculty
Physical therapy department
Chest surface anatomy
lab (1)
Anatomy of the Thorax
Osteology:
• Ribs
• Thoracic vertebrae
• Sternum
Ribs:
• True ribs (vertebrosternal ribs):
1st seven or eight ribs
• False ribs (vertebrochondral
ribs): ribs 8-10
• Floating ribs (free): 11 & 12
• Costosternal joints:
➢ 1st: cartilaginous
➢ 2nd – 7th: synovial
Thoracic vertebrae:
• Body
• Pedicle
• Laminae
• Vertebral foramina
• Transverse process
• Spinous process
• Superior & inferior articular processes
Neurovascular bundles:
Travel in the costal groove of the ribs (i.e., in the
superior portion of the intercostal space) between
the internal and innermost intercostals
• Physicians passing needles into the thorax insert

them just superior to the rib to avoid damaging the
bundle
Sternum:
• Manubrium
• Jugular notch
• Xiphoid process
• Sternal angle or Angle of Louis (at
the junction of the manubrium &
body of sternum): T4-T5 level
Surface landmarks:
• The scapula covers the 2nd to 7th ribs posteriorly (important landmark for defining
lung fields)
• The 2nd rib joins the sternum at the level of the sternal angle (palpable landmark)
Surface anatomy:
• Suprasternal notch
• Clavicle
• Sternal angle
• Xiphoid process
• Sternal attachments for ribs
Articulations:
• Ribs 1, 11, & 12 articulate with
their respective vertebrae
• Ribs 2-10 articulate with their
own vertebra and with the one
above
• Type of joints?
Boundaries of the thoracic inlet:

• The manubrium anteriorly
• 1st ribs and costal cartilage laterally
• 1st thoracic vertebra posteriorly
Pectoral region:
• Pectoralis major:
➢ covers the chest wall
➢ also makes up the anterior wall of the axilla (palpate your anterior axillary
fold and contract your pectoralis major)
➢ clavicular & sterno-costal origins
➢ its tendon inserts into the humerus.
➢ innervated by the medial & lateral pectoral nerves
• Pectoralis minor:
➢ lies beneath the pectoralis major
➢ takes its origin from the 3rd, 4th, & 5th ribs
➢ makes its insertion on the coracoid process of the scapula
➢ innervated by the medial pectoral nerve
-Both the pectoralis minor and major are accessory muscles of respiration
Muscles from abdomen to thorax:

• Rectus abdominus: originating from the
xiphoid process & costal cartilages 5, 6,
&7
• External oblique: attached to the
external surface of the lowest 8 ribs
• Serratus anterior (laterally): inserting
by finger-like processes into ribs 1-8 from
scapula
Intercostals:
1. External intercostal muscle:
➢ its fibers are directed from superior
and lateral to inferior and medial
➢ it loses its fleshy tissue and
becomes a transparent membrane
anteriorly (the external intercostal
membrane)
2. Internal intercostal muscle:

➢ its fibers run perpendicular to those
of the external intercostal muscle
➢ posteriorly on the thoracic wall, it
becomes gradually thins to become
the internal intercostal
membrane from the angle of the
ribs
3. Innermost intercostal muscle: the deepest and thinnest intercostal muscle
All the three intercostal muscles are accessory muscles of respiration
Diaphragm:
• The primary muscle of respiration
• Innervated by the left and right phrenic nerves (C3,
C4, C5)
➢ Patients with damage to the spinal cord above
the level of C3 (e.g., broken neck) require
mechanical respiration.
• Anteriorly: attaches at the level of the xiphoid process
• Posteriorly: curves downward to attach below the 12th
thoracic vertebra
Thorax:
• Pleural cavities:
➢ two; separate
➢ contain few milliliters of fluid allowing the
lungs to move easily inside the thorax
➢ pleural effusion: when the cavity accumulates
fluid in certain diseases
• Pleura:
➢ Visceral & parietal pleura
➢ The cupola (cervical pleura): rises
into the root of the neck where it
can be damaged
Fibrous pericardium = the outermost layer of the sac which contains the heart
• Mediastinum:
• = the mass of tissue / organs separating the pleural cavities
• Extends:
➢ from the thoracic inlet superiorly to the diaphragm inferiorly
➢ from the sternum anteriorly to the bodies of thoracic vertebrae
posteriorly
• Important landmark: the horizontal plane between the sternal angle and
the intervertebral disc of T4 and T5
➢ divides the superior mediastinum from the anterior, middle, and
posterior subdivisions
➢ marks the upper border of the fibrous pericardium
➢ indicates the bifurcation of the trochlea
• Anterior mediastinum:
➢ between the sternum & fibrous pericardium
➢ small
➢ contains the thymus gland (greatly reduced in size in the adult
compared to infants)
• Middle mediastinum:
➢ consists of the pericardium around the heart, its contents and the roots
of the great vessels
• Posterior mediastinum:
➢ the area behind the pericardium and in front of the lower 8 thoracic
vertebrae
Lungs
• Left lung
➢ Upper & lower lobes divided by the oblique fissure
➢ Base of the lung = the lower part of the posterior surface of the lower lobe
➢ Apex
➢ Lingula: part of the upper lobe of the left lung
➢ Cardiac notch
• Right lung
➢ Apex
➢ Base
➢ Horizontal fissure: separates the upper and middle lobes
➢ Oblique fissure: separates the middle and lower lobes
➢ Lower lobe: makes up most of the posterior surface of the lung
➢ Middle lobe: located in the anterior 2/3rds of the lung
➢ Anterior lobe: located in the anterior surface of the lung
➢ Lung disease may affect individual
lobes (at least initially)
Surface landmarks:
• The inferior border of the lung extends to:
➢ 6th rib on the midclavicular line
➢ 8th rib on the midaxillary line
➢ 10th rib on the midscapular line
• The pleura lies two rib levels lower than the inferior
border of the lung:
➢ 8th rib on the midclavicular line
➢ 10th rib on the midaxillary line
➢ 12th rib on the mid-scapular line
Lung structures:
• The lung receive air by the trachea
• The trachea ends in the upper part of the thorax by branching into two main
bronchi
• The right main bronchus branches into 3 labor bronchi (one for each of the 3
lobes)
• The left main bronchus branches into 2 labor bronchi
• The bronchi branch repeatedly within the lungs forming the bronchioles
• The bronchioles end in connection with the alveoli (small, thin-walled air sacs)
• Branching of the labor bronchi is important when it is desired to facilitate
drainage of some particular bronchus by gravity
• Within a lobe, each labor bronchus gives off 2-5 smaller bronchi collectively
known as segmental bronchi (running in different directions within a lobe)
Lung innervation:
• Sympathetic: from the right & left
sympathetic trunks (2-5 thoracic
ganglion)
• Parasympathetic: vagus nerve
Cardiac silhouette:
• Right border: from the 3rd costal cartilage to the 6th costal cartilage (a fingers
breadth from the right margin of the sternum)
• Lower border: across the xiphisternal junction to a point just medial to the mid-
clavicular line in the 5th intercostal space
• Left border: from the apex to the 2nd intercostal space (a finger’s breadth from the
left margin of the sternum)
Heart valves:
• The tricuspid valve: located posterior to the body of sternum at the level of 4th
intercostal space
• The mitral valve: located posterior to the body of sternum at the level of 4th left
costal cartilage
• The aortic valve: located posterior to the left side of sternum at the level of 3rd
intercostal
space
• The pulmonic valve: located at the level of 3rd costal cartilage at the left side of
sternum
Cardiopulmonary assessment
lab (2)
Assessment of cardiopulmonary
SHEET
Examination History
General Local (3P+ F)

Personal
Overview from
head- to toes - Inspection Present
- Palpation Past
- Percussion Family
- Auscultation
1) Inspection:
1- Shape of chest:
The normal shape is elliptical, T:AP=7:5 (T: transverse/ AP: antero-posterior)
Generalized Localized
(Ap=T) will lead to Barrel chest as in COPD bulge Air: pneumothorax
Water: effusions
(AP>T) will lead to Pigeon chest "Pectus carinatum" Solid: tumors

(Prominent srernum with forward protrusion.)
(AP<T) will lead to funnel chest “pectus excavutum” Retraction Lung collapse
Congenital (Inward depression of lower part of
sternum.) May be acquired in shoe makers Fibrosis
2-Chest Expansion: (Symmetrical & Good movement)

• If the both sides work asynchronous LOCALISED - Unilateral: on the affected
side e.g.: fibrosis, collapse.
• If the both sides work synchronous but the movement is low and slow
GENERALIZED - Bilateral: in bilateral chest disease e.g.: emphysema.
3-Respiration:
- Normally: inspiration is affected by contraction of intercostal muscles &
diaphragm while expiration is a passive process, dependent on elastic recoil of
lungs.
• Rate:
• The normal rate is 12:20 Breath/Min
• more than 20 = Tachypnea
• less than 12= Bradypnea
• Rhythm:
• Inspiration = 1 sec
• Expiration = 2 sec
• Type/ pattern:
• Male = Abdomino-thorax.
• Female = Thoraco-abdomen.
• Accessory muscle
• exaggerated when the diaphragm not working
Litten’s phenomena: Normal bilateral lowering of
lower 6 ribs during deep inspiration due to the movement
of diaphragm or slightly inward motion of the ribs for a
thin person in bright light –
When it happens in one side it called uni-lateral Litten‫ۥ‬s
sign
Causes of uni-lateral Litten‫ۥ‬s sign:
1. Uni-lateral diaphragmatic paralysis
2. Uni-lateral problem in phrenic nerve
3. Fibrosis in uni-lateral lower lobe of a lung
If it happens to an obese person and not in bright light it called HOOVER ‫ۥ‬S sign (COPD
is suspected)
4- Pulsation
5-Chest wall lesion:
1. dilated veins:
➢ cause: SVC obstruction
➢ Dd: visible veins.
2. SC emphysema:
➢ Cause: after tracheostomy, after pneumothorax.
➢ Diagnosis: chest swelling with crackling sensation.
3. scars, ulcers, pigmentation.
4. bony cage:
➢ Sternum: congenital deformity.
➢ Ribs : oblique normally.
➢ More oblique in fibrosis
➢ Horizontal in emphysema.
5. examine breast and axilla
6- position of mediastinum:
A. A- Apex: as CVS
Value of apex in chest cases:
1- shifted:
-pulling of apex: fibrosis & collapse.
-Pushing: pleural effusion, pneumothorax.
-Upward: diaphragmatic paralysis.
2- absent apex: emphysema, left sided Pl. effusion or pneumothorax.
3- in corpulmonale: RVE (shifted out + diffuse)
4- congenital dextrocardia.
B. Trills sign: Tracheal shifting: In thin patients
sternomastoid tendon appears more prominent on side of
tracheal shift due to displacement of trachea behind it.
2) Palpation:
(3T + 2P + chest expansion + any abnormality)
1- Tracheal shifting:
• Normal: midline
• Procedure: from mid-position of the head insert the
index finger between the trachea and the
sternocleidomastoid (right and left), the patient sitting
with semi flexion head
• Abnormal push: to the other side like in case of, Large
pleural effusion, pneumothorax
• Abnormal pull: to the same side like in case of
Collapse of the lung due to central airway obstruction
Local fibrosis
2- Tenderness:
Skin • sutures
Bone • fractures
Muscle • myositis
Pleura • Pleuritis
Lung • abccess
3- TVF (Tactile vocal fremitus):
• It is the palpable vibration initiated at the vocal cords by voice (44or 99)
transmitted through the air and felt on the chest wall.
• The therapist should use only one hand to avoid
distribution of the sounds
• Use his palm or ulnar side of his hand
• The therapist can use his palm or his ulnar side of
his hand
• The patient says 44 (in Arabic) or 99 (in English)
• The sound should be symmetrical any abnormality will make it asymmetrical
• supra-mammary
Anterior • mammary
• intra- mammary
• upper
Lateral • middle
• lower
• supra-scapular
Posterior • intra-scapular the most sensation
• infra-scapular
( 3C )
1- Cavity as in : T.B anything
2- Consalidation which out of
reduces elasticity (3C)
3- Collapse of the lung
with potent broncus
4- Pulsation
5- Palpable sound: wheezing /snore/crepitation
6- Chest expansion: In each position:
• The therapist asks the patient to make expiration
• The therapist takes skin fold
• Then the therapist asks the patient to make a deep inspiration
• Now see the difference between your thumbs before and after inspiration
Lower Posterior basal
at the level of
Apical sternal notch
1:2 cm expansion
at the level of axilla

Upper towards the
sternum
1:2 cm expansion
at the level of
middle nipples
2:3 cm expansion
at the lower costal

toward xiphoid
Lower process with
elevation of the
breast
3:5 cm expansion
Posterior infra-scapular
5:7 cm expansion
at the angle
basal
Localized cardiopulmonary assessment
lab (3)
3) Percussion:
General rules & Basic information
Anterior view Lateral view Posterior view
How to find the sternal angle
How to identify ribs and its inter-costal spaces:

1. To feel the ribs therapist should starts from sternal angle or angle of Louis which
contact with the 2nd rib right and left
2. Below the 2nd rib there is its inter-costal space (2nd inter-costal space)
3. And then below the space there is the 3rd rib and its inter-costal space and so on
Lung is higher than the clavicle with 3:4 cm in length and that part called apex of the
lung End level of the lung is:
 Anterior: at the 6th rib at mid-clavicular line
 Lateral: at the 8th rib at mid-axillary line
 Posterior: at T10: T12 thoracic vertebrae
At left lung: In their half there is a notch called cardiac notch from 4th to 6th rib
At right lung: the lower part of the right lung is covered by upper border of the liver and
above them both the ribs
• end part of the right lung: liver
• end part of the left lung: Heart
There are two types of the sound therapist can hear:
1. Resonant:
When there is air inside.
2. Dullness:
When there is a material with a high density inside (solid)
As the lung is filled with air; so, when the normal sound is resonant while dullness is
abnormal and indicates for a problem and there are some of the problems may be found:
• Secretion
• Fibrosis
• Collapse
• Effusion
• Fluid inside
• Pneumonia
When the therapist makes percussion, he flicks on in the inter-costal space not on the ribs
(as it is a bone, he will hear dullness)
Therapist technique:
1. With the therapist dominant hand he uses his middle finger to flicks
2. The other hand is flat on the area being assessed
3. The therapist flicks on his flat hand on the middle finger in middle phalange with his
middle finger of his dominant
hand
4. He may start with inter-costal
space in one side and then
changed into the opposite inter-
costal space of the other side
5. And may takes a lines and
then shifted to opposite line of (a) Is space by space
the other side and so on (b) Is line by line
If the therapist makes a comparison he compares between: (ant & ant) or (post & post) or
(Lateral & Lateral)
At posterior percussion the patient should make protrusion so the therapist can make
percussion between the vertebrae and the medial border of the scapula (para-vertebral
line)
All percussion should be light percussion as the lung is superficial except two places is
heavy percussion:
• At hepatic area (at 5th intercostal-space) as it covers the lung
• At posterior aspect at back of the lung as it covered by back muscles
There are two places can be dullness and normal:
• At hepatic area at 5th intercostal space at mid-clavicular line
• Bare area of the heart from 4th to 6th ribs at 4th and 5th inter-costal space at para-
sternal line
Resonant may be graded to:
Resonant may be graded to: •is the normal resonance sound of air
•found in all the lungs
Resonant •except hepatic area and bare area of the heart
•more than resonant in intensity

Hyper
•found normally in the apex
resonant •found abnormally in pneumothorax
•is the most powerful resonance (the highest

sound)
Tympany •found normally inTraub’s area
And dullness may be graded to:
Dullness
• is the normal dullness
• found normally in right at hepatic area and left at bare area of the heart
stony dullness
• it is an amplification of dullness
• found in pleural effusion
Special area of the lung:

1. Bare area of the heart
2. Traub’s area
3. Kronig’s isthmus
4. Hepatic area
5. Spleen
1- Bare area of the heart:
1) Location:
• At left lung
• Between 4th and 6th ribs (4th and 5th inter-costal space) between para-sternal and
mid-clavicular line
2) Normal: dullness
3) Abnormal: resonance may be because of: lung enlargement
• Left pneumothorax
• Left emphysema
2- Traub’s area:
1) Location: it has four borders:
• Upper border: from 6th rib mid-clavicular line to 9th rib mid-
axillary line (ab) • Lower border: from 8th rib costochondral
junction (mid-clavicular line) to 11th rib mid-axillary line (dc)
• Right border: from 6th rib mid-clavicular line to 8th rib
costochondral junction (mid-clavicular line) (ad)
• Left border: to 9th rib mid-axillary line to 11th rib mid-
axillary line (bc)
2) Normal: Tympany (as it is filled with gasses)
3) Technique of the percussion:
• Starts from the middle then move up and down and compare (longitudinal)
• Or starts from one side then move to the other (transverse)
4) Abnormal: Dullness and it may be
• Physiological dullness: food that the patient eaten before (so he should be
fastened)
• Pathological: there are four pathology each is related to the border you heard
the sound from:
If the dullness was at If the dullness was at If the dullness was If the dullness was lower
right left upper
Hepatomegaly (Liver Splenomegaly (spleen There is enlargement in There is enlargement in
enlargement) enlargement) lung: pleural effusion GIT like: Tumor/Ascites
Heart: pericardial /Pregnancy
enlargement
3- Kronig’s isthmus (apex of the lung)
1) Location:
• Medial border: from sterno-clavicular joint to spine
C7
• Lateral border: from the junction between med 2/3
and lat 1/3 to spine of the scapula
2) Normal: hyper resonance
3) Abnormal: any apical disease like:
• Apical fibrosis
• Apical tumor (Pancoast tumor)
• Apical TB
boundaries
• Apical effusion
4- Hepatic area
1) Location:
• Right 5th intercostal space at mid-clavicular line
2) Normal: Dullness
3) Abnormal:
• Resonant: Right Pneumothorax/Emphysema
• Dullness at 4th intercostal space: Hepatomegaly/ Right lung
Liver
(fibrosis/ tumors/effusion)
5- Spleen
1) Location: from 9th to 11th ribs at Mid-axillary
line
2) Normal: Dullness
Tidal percussion or diaphragmatic excursion:

1. To see the distance of the diaphragm movement between inspiration and expiration
[(normal 3:5) & (Athlete 5- 7cm)]
2. Percussion is done from sitting position below the inferior angle of the scapula
3. Ask the patient to expire and hold and you percuss till the first point of dullness and
mark it this is first point
4. Then ask the patient to inspire and hold and percuss till the second point of dullness
5. Measure the distance
6. Measure both sides Rt and Lt of diaphragm
Causes of diaphragm descend Causes of diaphragm moving upward

Lung enlargement like: 1. Ascites
1. Emphysema 2. Pregnancy
2. Pneumothorax 3. Paralysis
4. Tumor
4)Auscultation:
At normal stethoscope
• Bell for heart
• Diaphragm for chest
There are many sounds in lung: Normal sounds
Sound Vesicular Bronchial Bronchovesicular Tracheal
Def. It is the sound of the It is harsh hallow In one phase Vesicular It is harsh hallow
whole lung tubular sound at 2nd and the other is tubular sound at
parasternal Bronchial It mid-way suprasternal notch
between them with a pause in-
Inspiration may be between
strong than expiration
Duration • Whole inspiration expiration> inspiration Inspiration = expiration Expiration>
• 1st third of expiration or equal inspiration or equal,
Gap No gabs in-between There is a gab in- No gabs in-between No gabs in-between
between Pause may be heard
Location • Over the whole lung • at 2nd parasternal • Peristernal • at suprasternal notch
• Bottom of lung • (at Manubrium or • 1st and 2nd inter-costal
• Lung periphery beside it ) space
• Inter-scapula
Expiration ❖ Soft ❖ Loud ❖ Medium loud ❖ Very loud
(pitch) ❖ Low pitch ❖ Strong pitch ❖ Medium pitch ❖ High pitch
Shape of
the sound
Surface
anatomy
N.B: Vesicular sound may be harsh in case of children or harsh with long expiration in case of COPD, asthma
May be diminished intensity in late stage of emphysema, obesity, collapse and effusion
Abnormal sounds:
• Bronchial breathing at lung periphery:
➢ Occurs at: pneumonia, TB and lung abscess
• Harsh vesicular (vesicular with prolonged expiration):
➢ it is an abnormal sound of vesicular with normal inspiration and prolonged
expiration
➢ Occurs at: COPD and bronchial asthma
Additional sounds:
Crackles
1. Happens during inspiration
2. Bubbling sound, popping sound and crepitation
3. Crepitation: Secretion of lungs
4. Crackles: Collapse in alveoli
5. Interrupted non-musical sound
Rhonchi
1. Happens during expiration
2. Mild narrowing due to: bronchospasm or secretions
3. Low pitch
4. Continuous musical sound
5. Auscultatory only
Wheezing
1. May considered as an advanced rhonchi
2. Happens during expiration
3. Sever narrowing: obstruction of small airways
4. High pitch
5. Continuous musical sound
6. can be heard auscultatory or without stethoscope
Pleural rub:
1. Happens during inspiration and expiration
2. It occurs due to inflamed pleural surface (pleurisy) rubbing each other during
breathing
3. It is non-musical sound like friction of hair between fingers
4. Best place to heard at mid-axillary and post-axillary line
Examination of the heart
lab (4)
Examination of the heart

1)Percussion: General rules:
• All the heart percussion is resonance except the bare area of the heart is dullness
• The percussion is always heavy percussion except at bare area of the heart it is
light percussion where the heart is superficial
1) Base of the heart:
Normal sound: Resonance
Abnormal sound: Dullness may be as a result of pericardial effusion or mass
tumor...
The base of the heart consists of two areas:
1. Aortic area:
•at 2nd right IC space
•normal sound: resonance
•Abnormal sound: Dullness in the case of: aortic dilation (congestion) or
pericardial effusion or chest cause
2. Pulmonary area:
•at 2nd Left IC space
•normal sound: resonance
•Abnormal sound: Dullness in the case of: pulmonary artery dilation or
hyper-tension or pericardial and pleural effusion
2) Waist of the heart: (the most concave part)
Location: 3rd left IC space from parasternal
line to mid-clavicular line
Normal sound: Resonance
Abnormal sound: Dullness due to:
• Left atrium enlargement
• Pulmonary artery dilatation (congestion)
• Pleural effusion
3) Right border of the heart:
Location: to detect the location of right border
• First determine hepatic dullness (5th IC space at mid-clavicular line)
• Then percuss 2 spaces higher than upper border of
liver to right sternal border. N.B: when the therapist percusses
the right border of the heart he
• it’s at 3rd and 4th right IC space mainly 4th
makes a vertical percussion (like
Normal sound: resonance
the normal percussion except the
Abnormal sound: Dullness due to: middle finger is sided line not
• Right atrial enlargement prone) not with the normal one
• Pericardial effusion
• Other chest causes
4) Bare area of heart:(done by a light percussion)

Location: 4 th,5th,6th left IC spaces from para-sternal line to mid-clavicular
line
Normal sound: dullness
Abnormal sound:
• Resonance due to emphysema, pneumothorax, dextrocardia
• If dullness extent outside mid-clavicular line indicates to: right ventricular
enlargement or pericardial effusion or COPD
5) Lower 1/3 of sternum: (Direct percussion)
Abnormal sound: dullness occurs in RV enlargement
6) Percussion outside apex:
Location of apex: Left 5th IC space mid-clavicular line (percussion done
around it)
Abnormal sound: Dullness due to:
• Pericardial effusion
• Chest wall, pleural or lung disease
2)Auscultation:
There are four heart sounds: Auscultate in the 4 auscultatory areas:
1. Aortic area
2. Pulmonic area
3. Mitral area (Apex of the heart)
4. Tricuspid area (lower third of the sternum)
S1(LUB):
•Normal
•First heart sound
•Marks as the beginning of systole
•Closure of AV valve (mitral and tricuspid valve)
•Loudest at apex or left lower sternal border
•usually single but may be splitted at LLSB (tricuspid area)
•Become louder with tachycardia
•High pitched sound
•Best heard at heart apex with diaphragm
S2 (DUP):
•Normal
•Second heart sound
•Marks as the beginning of diastole
•Closure of semi-lunar valve (Pulmonary P2 and aortic valve A2)
•Loudest at the base of the heart
•High pitched sound
•Best heard at the base with the diaphragm
•Normal (physiological) Splitting of A2 and P2
•A2 comes before P2
•Splitting gets wider with inspiration because of increased venous return and delay of P2
•Splitting narrows in expiration and S2 appears single
•Loud A2- Systemic hypertension
•Loud P2 - Pulmonary hypertension
S3:
•May be normal and may be abnormal
•Heard early in diastole
•Correlates with rapid ventricular filling just after the mitral valve opens
•Low pitched sound
•Better palpated than auscultated
•Heard at the apex with the bell
•S3 is, just after S2 and maybe confused with split S2
•Normal in young healthy (<20y) or athletic ventricles
•S3 (abnormal) usually suggests left heart failure
•Increased volume of blood return to the ventricle can produce S3 (shunts, regurgitant
lesions).
•Better heard in inspiration
•S3 is most often a sign of a flaccid left ventricle
•May be heard in patients with congestive heart failure
S4:
•Always abnormal
•Correlates with atrial contraction
•Low pitched sound better palpated than auscultated
•Heard at the apex with the bell
•Occurs just before S1 and gives the suggestion of split S1
•As left ventricle gets stiff and noncompliant with ageing, the atrial contraction gets more
forceful, hence S4 is common > 60 y
•Hypertension is the commonest cause of S4
•Hypertension induces left ventricle hypertrophy-reduces compliance
•Ischemia-Angina or Myocardial infarction also produces diastolic dysfunction and S4
Murmurs:
Is divided according to the:
1. Time to:
• Systolic.
• Diastolic.
• Continuous.
2. Cause to:
• Regurgitaion or Shunt.
• Ejection or steatosis.
During Systole
❖ AV (mitral & tricuspid) valves closed

❖ Semi-lunar (pulmonary & aortic) valves open
So if there’s a problem during systole it will be due Either:
1. problem in opening:
• Pulmonary valve
• Aortic valve
2. Problem in closer:
• Mitral valve
• tricuspid valve
During diastole
❖ AV (mitral & tricuspid) valves opened

❖ Semi-lunar (pulmonary & aortic) valves closed
So, if there’s a problem during systole it will be due Either:
1. problem in opening:
• Pulmonary valve
• Aortic valve
2. problem in closure:
• Mitral valve
• tricuspid valve
Murmurs are a prolonged sound due to turbulence of flow caused by:
1. stenosis:
• Happens due to a problem in opening:
• In systole: Pulmonary and Aortic valve
• In diastole: Mitral and Tricuspid valve
2. Regurge:
• Happens due to a problem in closure:
• In systole: Mitral and Tricuspid valve
• In diastole: Pulmonary and Aortic valve
Assessment of vital signs
lab (5)
Vital signs
• Vital signs
• Temperature
• Pulse
• Respirations
• Blood pressure
• oxygen saturation
• Taken at each visit and compared to baseline
• Because of the importance of these measurements, they are referred to as Vital
Signs. They are important indicators of the body’s response to physical,
environmental, and psychological stressors.
1.Body Temperature:
• Core temperature – temperature of the body tissues, is controlled by the
hypothalamus (control center in the brain) – maintained within a narrow range.
• Skin temperature rises & falls in response to environmental conditions & depends
on blood flow to skin & amount of heat lost to external environment
• The body’s tissues & cells function best between the range from 36 deg C to 38
deg C
• Temperature is lowest in the morning, highest during the evening.
• Measurements
• Degrees Fahrenheit (°F)
• Degrees Celsius (centigrade; °C)
• Normal adult oral temperature
• 98.6°F
• 37°C
• Temperature Routes:
1. Tympanic 2. Oral 3. Rectal 4. Temporal 5. Axillary
• Normal values of body temperature:
36.5 – 37.5 36 - 37 37 - 38 36.5 – 37.5
• Thermometers – 3 types:
• Glass mercury – mercury expands or contracts in response to heat.
• Electronic – heat sensitive probe, (reads in seconds) there is a probe for

oral/axillary use (red) & a probe for rectal use (blue).
• Infrared Tympanic (Ear) – sensor probe shaped like an otoscope in
external opening of ear canal.
• Fever (pyrexia):
• It is the elevation of the body temperature above 37.5C, and is associated
with an increased metabolic rate oxygen consumption and carbon dioxide
production which cause a compensatory increase in heart rate and
respiratory rate so it is contraindicated to perform exercises in case of
fever.
2. Pulse Rate (Heart Rate):
• Left ventricle contracts causing a wave of blood to surge through arteries – called
a pulse. Felt by palpating artery lightly against underlying bone or muscle.
◼ Carotid, brachial, radial, femoral, popliteal, posterior tibial, dorsalis pedis.
• Assess: rate, rhythm, strength – can assess by using palpation & auscultation.
• Pulse deficit – the difference between the radial pulse and the apical pulse –
indicates a decrease in peripheral perfusion from some heart conditions.
• Procedure for Assessing Pulses:
• Peripheral – place 2nd, 3rd & 4th fingers lightly on skin where an artery passes over
an underlying bone. Do not use your thumb (feel pulsations of your own radial
artery). Count 30 seconds X 2, if irregular – count radial for 1 min. and then
apically for full minute.
• Apical – beat of the heart at it’s apex or PMI (point of maximum impulse) – 5th
intercostal space, midclavicular line, just below lt. nipple – listen for a full minute
“Lub-Dub”
◼ Lub – close of atrioventricular (AV) values – tricuspid & mitral
valves
◼ Dub – close of semilunar valves – aortic & pulmonic valves
• Assess: rate, rhythm, strength & tension:

• Rate – N – 60-100, average 80 bpm
◼ Tachycardia – greater than 100 bpm
◼ Bradycardia – less than 60 bpm
◼ Rhythm – the pattern of the beats (regular or irregular)
• Strength or size – or amplitude, the volume of bld pushed against the wall of an
artery during the ventricular contraction
◼ weak (lacks fullness)
◼ Full, bounding (volume higher than normal)
◼ Absent (cannot be felt or heard)
0----------------- 1+ -----------------2+----------------- 4+
Absent Weak NORMAL Bounding
• Normal Heart Rate: Age Heart Rate (Beats/min)
Infants (1 mo-1 y) 120-160
Toddlers (1-2 y) 90-140
Preschoolers (3-5 y) 80-110
School agers (6-11 y) 75-100
Adolescent (12-15y) 60-90
Adult 60-100
• Radial artery
• Brachial
• Cubital fossa, medial to biceps tendon.
• Carotid
Just lateral to upper border of thyroid cartilage medial to SCM
• Femoral Artery
Below inguinal ligament, midway between ASIS and pubic symphysis.
• Popliteal
• Flex knee before palpating.
• In midline, on popliteal side of lower end of femur (the most difficult to palpate)
• Posterior tibial
• Posterior, inferior to medial malleolus, between flexor digitorum longus and flexor
hallucis longus
• Dorsalis pedis
Lateral to extensor halluces longus, over tarsal bones
Measure HR by stethoscope:
beat of the heart at it’s apex or PMI (point of
maximum impulse) – 5th intercostal space,
midclavicular line, just below lt. nipple – listen
for a full minute “Lub-Dub”
3. Respiratory Rate:
• Assess by observing Rate, Rhythm & Depth
◼ Inspiration – inhalation (breathing in)
◼ Expiration – exhalation (breathing out)
◼ I&E is automatic & controlled by the medulla oblongata
(respiratory center of brain)
◼ Normal breathing is active & passive
◼ Women breathe thoracically, while men & young children breathe
diaphragmatically ***usually
◼ Asses after taking pulse, while still holding hand, so pt is unaware
you are counting respirations
Assessing Respiration:
Rate # of breathing cycles/minute (inhale/exhale-1cycle)

N – 12-20 breaths/min – adult - Eupnea – normal rate & depth breathing
Abnormal increase – Tachypnea
Abnormal decrease – Bradypnea
Absence of breathing – apnea
Depth Amt. of air inhaled/exhaled
normal (deep & even movements of chest)
shallow (rise & fall of chest is minimal)
SOB shortness of breath (shallow & rapid)
Rhythm Regularity of inhalation/exhalation
The normal values of respiratory rate are approximately:

12-20 breaths/min for normal adult.
30-60 breaths/min for normal new born.
25-35 breaths/min for 1 year old.
20-25 breaths/min for preschool child.
4. Arterial Blood pressure (ABP):
Blood pressure is the force that blood exerts against the walls of the blood vessels.
The pressure in the systemic arteries is most commonly measured in the clinical
setting. Blood pressure is stated in millimeters of mercury (mm Hg).
-With every contraction of the heart (systole) the arterial pressure increases, with the
peak called the systolic pressure. pressure drops, with the minimum called the
diastolic pressure.
-Blood pressure is recorded as systolic/diastolic pressure.
-Normal adult blood pressure is between 120/80 +,-20/15 mmHg (i.e.140/95-
100/65).
Classification of Blood Pressure:
Blood Pressure Systolic Diastolic

Category mmHg mmHg
Normal <120 <80
Prehypertension 120–139 80–89
Hypertension
Stage 1 (Mild) 140-159 90-99
Stage 2 160-179 100-109

(Moderate)
Stage 3 (Severe) > 180 > 110
Blood pressure is usually measured by

sphygmomanometer.
Procedure:
1. Wash hands; identify client; explain procedure to client; assist client to a

comfortable position with forearm supported at heart level and palm up.
Rationale: Variations in blood pressure can occur with client
in different positions.
Blood pressure increases when the arm
is below heart level and decreases when above heart level.
(NB: Diastolic blood pressure may increase 10% if arm is unsupported, secondary to
isometric muscle contraction
used to support arm.)
2. Expose the upper arm completely.
3. Wrap deflated cuff around upper arm with center of
bladder over brachial artery.
Lower border of cuff should be about 2 cm above
antecubital space (nearer the antecubital space on an
infant).
Rationale: Placing bladder directly over brachial artery
ensures proper compression of artery during cuff inflation.
Loose or uneven application can result in falsely high
readings.
4.Palpate brachial or radial artery with fingertips.
Close valve on pressure bulb and inflate cuff until pulse disappears.
Inflate cuff 30 mm Hg higher. Slowly release valve and note reading when pulse
reappears.
Rationale: Identify approximate systolic blood pressure reading to prevent
underestimating systolic blood pressure should client have an auscultatory gap.
5. Fully deflate cuff, and wait 1 to 2 minutes.

Rationale: A waiting period prevents falsely high readings by allowing blood
trapped in the vein to be recirculated.
6. Place stethoscope ear piece in ears.
Repalpate the brachial artery and place stethoscope bell or diaphragm over site.
Contraindications to BP:
Do not measure BP
• On arm with lymphedema
• On arm of ipsilateral side of recent
mastectomy
• Over open wound
• Dialysis shunt
5. OXYGEN SATURATION:
- Is a term referring to the concentration of oxygen in the blood.
-It can provide important information about cardiopulmonary dysfunction and is
considered by many to be a fifth vital sign.
-The measurement can be taken by (pulse-oximetry: Is a method used to measure
the concentration of oxygen in the blood, a small device that clips to the body,
typically a finger but may be other areas, using a special light to estimate the
amount of oxygen in the blood).
-Normal values ranges vary between 95% to 99%.
-Mild hypoxemia: Spo2 91% to 94%.
Moderate hypoxemia: Spo2 86% to 90%.
Sever hypoxemia: Spo2 below 85%.
Pulmonary function test
lab (6)
Pulmonary function test

Mechanics of Breathing:
• Inspiration
Active process
• Expiration
Quiet breathing: passive
Can become active
Pulmonary Function Tests Evaluates 1 or more major aspects of the respiratory system
• Lung volumes
• Airway function
• Gas exchange
Indications/purpose:
• Detect disease, It serve as a diagnostic tool investigation
role
• Evaluate severity, extent and monitor the course of disease
• Evaluate treatment
• Measure effects and result of treatment exposures
Pulmonary function tests (PFTs) are a group of tests that measure how well your lungs
works, how well the lungs take in and exhale air, and how efficiently they transfer
oxygen into the blood.
PFT are useful in assessing the functional status of the respiratory system both in
physiological and pathological condition
• It is base on the measurement of volumes of air breathed in and out in normal breathing
and forced breathing
• It is carried out by using a spirometer
Spirometry:
❑ It is an instrument for measuring the air capacity of the lungs
❑ Measurement of the pattern of air movement in and out of the lungs during
controlled ventilatory maneuvers.
❑ Spirometer is used to measure the air flow, ventilatory regulation, ventilatory
mechanics and lung volume during a forced expiratory maneuver from full
inspiration.
❑ PFT used to evaluate physiological aspect of breathing
from respiratory muscle function to the diffusion of
gas at the alveolar wall.
❑ PFT helps physiotherapist to distinguish between
obstructive and restrictive lung problem and to select
appropriate treatment
❑ It also measure the effect of the given treatment.
Lung Factors Affecting Spirometry:

• Mechanical properties
• Resistive elements
1.Mechanical Properties:
• Compliance:
❑ Describes the stiffness of the lungs
❑ Change in volume over the change in pressure
• Elastic recoil:
❑ The tendency of the lung to return to it’s resting state
❑ A lung that is fully stretched has more elastic recoil and thus larger/ maximal
flows of gas
2.Resistive Properties:
Affected by:
Lung volume
❑ Age
❑ Sex
❑ Height
❑ Weight
❑ Race
❑ Disease
Bronchial smooth muscles
Lung volume and capacities:

• Lung volume: are the static volume: of air breathed by an individual, ie volume: of air
present in lung under specific position of the thorax
• 4 lung volumes
• Depends on age, weight, gender and body position
• 2 or more volume: when combined are capacity
There are four lung volumes and four lung capacities.

A lung capacity consists of two or more lung volumes.
• The lung volumes are:
❑ Tidal volume (TV)
❑ Inspiratory reserve volume (IRV)
❑ Expiratory reserve volume (ERV)
❑ Residual volume (RV).
• The four lung capacities are:

❑ Total lung capacity (TLC)
❑ Inspiratory capacity (IC)
❑ Functional residual capacity (FRC)
❑ Vital capacity (VC).
Lung volumes:
Lung capacities:
Physical therapy intervention: breathing exercise
lab (7)
• Chest Physiotherapy:
Is using different modalities with chest diseases to remove excess secretions
(from inside the lungs, by physical means, assist a cough, re-educate breathing
muscles and to try to improve ventilation of the lungs.
• Physical therapy is relevant to the treatment of patients with acute and chronic
lung disease, including obstructive and restrictive pulmonary diseases and also
effective in patients admitted for major surgery and patients with critical illness in
intensive care units
Types of physical therapy intervention:
• Breathing exercises to facilitate ventilation pattern
• Airway clearance techniques (postural draining, percussion, and vibration)
• Facilitating airway clearance technique with effective coughing techniques
• Mobilization, stretching and relaxation Exercises
Breathing exercise
Indication:
1/chronic Reparatory Disease
 obstruction lung disease (COPD, asthma)
 restriction lung disease (lung collapse)
2/ after major abdominal or chest surgery
3/ Respiratory MS weakness
4/post operative complication
5/ Bronchospasm
6/ Orthopedic problems like scoliosis
7/ As stress management and relaxation procedure
Percussion
1/Avoid force expiration-it may increase the turbulence in the air way which leads to
bronchospasm and airway resistance
2/Avoid prolonged expiration-it cause the patient to gasp with the next inspiration and
the breathing pattern become irregular and inefficient
3/Do not allow the patient to use accessory muscles and upper chest (should be quiet)
4/perform deep breathing only for 3-4 times (inspiration and expirations) to avoid
hyperventilation
5/ turning patient head to other side (infection control)

Contraindication:
1. Severe pain and discomfort
2. Patients with reduced conscious level
3. DVT
4. Flail chest
5. Acute TB
6. Acute medical or surgical emergency (fracture, …)
7. Increased ICP (intra cranial pressure)
8. Unstable head or neck injury
9. Active hemorrhage with hemodynamic instability or hemoptysis
10. Anticoagulation
general principle:
1/choose a quit and comfortable place and loosen restricted clothes
2/ teach patient pattern of breathing and aim of breathing
3/ comfortable position sitting or standing or semi fowlers position with

head and trunk elevated approximately: 45° (total support to the head and
trunk and flexing the hip and knees with pillow support) the abdominal
muscle become relaxed
Other positions long setting or high supine position
4/ medically and clinically stable (vital sign)

GOALS OF BREATHING EXERCISE:
• Improve ventilation
• Increase the effectiveness of cough and promote airway clearance
• To prevent post operative pulmonary complications
• To improve the strength endurance coordination of the muscles of ventilation
• Maintain and improve chest and thoracic spine mobility
• Promote relaxation and relive stress
1) inspiratory:
1-Diaphragmatic breathing:
• Diaphragm is the primary muscle for breathing (inspiration) diaphragm
controls breathing at an involuntary level, a patient with primary pulmonary
disease like COPD can be taught breathing control by optimal use of
diaphragm and relaxation of accessory muscles
• Diaphragmatic breathing is a classic techniques that has long been
recommended to patients with COPD. It is a breathing exercise meant to train
your body to breathe from your belly (using your diaphragm) instead of using
your chest muscles to breathe.
• Diaphragmatic breathing ex: are also use to mobilize lung secretion in PD, To
control dyspnea attack and during exertion, Improve ventilation in the bases of
the lungs and loosen secretion
• Mainly focus on diaphragm
• Position sitting or semi sitting
• PT hand rectus abdominal just below ant
costal Margin (Xiphoid process)
• Order takes deep inspiration from your nose,
making u abdominal as a balloon, expired
slowly from your mouth
• Hold or not according aim of exercise (hold
2-3sec)
• Repetition 3-4 time
Fun PT hand:
1/tactical/sensory stimulation of diaphragm and guider
2/ assistance during expiration
3/ resistance during inspiration
➢ The resistance may be manually by hand or by weight or mechanically by elevation of

the foot of the bed
Manually /
• Direction R of diaphragm inward and upward
• Direction R of sternal intercostal ms inward and
downward
Weight/ inspiratory ms training device, weight (1.30- 2.20 kg
or 3-5 Ib) over the epigastric region of his abdomen (Supine)
Mechanical / elevation of the foot end of the bed (use viscera
as a resistance on diaphragm)
Self-monitor:
hand position:
One hand / chest
Other hand/ abdominal and feel of contraction
2- Segmental breathing
Focus on segment of lung, or a section of chest wall that needs increased ventilation or
movement
➢ Apical breathing exercise:
Used: apical pneumothorax e.g. following lobectomy
PT hand below the clavicle using tips of the fingers
Order: take deep breathing from your nose try to move my hand hold
and expired from mouth
Resistances: Hand below clavicle and push downward
❖ Unilateral or bilateral according patient condition

➢ Upper breathing exercise:
PT hand: Under axilla
Order: take deep breathing from your nose try to move my hand
hold and expired from mouth
➢ Right middle lobe or lingula expansion:

PT hand below axilla
Order /take deep breathing from your nose try to move my hand
➢ lower costal expansion:

❖ focused on the lower lateral rib cage and may be done unilaterally or
bilaterally.
• how to identify lower rib?
• Palpation posterior rib and move laterally until reach floating rib
❖ patient stiff lower rib cage (chronic bronchitis, emphysema and asthma,
COPD)
position / sitting or in a hook lying position.
PT hand / lateral aspect of the lower ribs.
➢ BELT EXERCISES TO REINFORCE LATERAL COSTAL BREATHING

Belt width: 30 cm length: 2m
❖ by applying resistance during inspiration tautness the belt when
you take inspiration then expired
❖ by assisting with pressure along the rib cage during expiration
take inspiration then tautness the belt during expiration
advantage disadvantage
1/use with obese patients 1/ tricky, compensatory movement are
2/ use in home program difficult to be noted
3/ give equal pressure all points and takes a 2/ Cannot be used for small and irregular area
large area
➢ Posterior basal expansion

Used in /patients who is in bed in a semi-reclining position for
an extended period of time
Secretion often accumulates over the posterior segments of
lower lobes
Position/ patient sit and lean forward on a pillow, slightly
bending the hips
PT hand/ over the posterior aspect of the lower rib inferior angle of scapula in hand web
space
Order/ take deep inspiration from nose try to move my hand hold expired mouth
3- Glossopharyngeal breathing
❖ Used:
1/ post-polio patients
2/incomplete innervation of diaphragm because of high cervical
cord injury or neuromuscular disorders
3/ patient on mechanical ventilator
❖ Aim: increase lung capacity and cough effectiveness
• Mouth opens oral pharynx filled with air
• Mouth closes air trapped in the oral pharynx
• Mouth remains closed and forces the air back to the open glottis and then into
the lungs
• Glottis closed and air is trapped in the lungs
• Patient take several gulps (6 to 10) of air by closing the mouth the tongue
pushes the air back and trap it in the pharynx the air is then forced to lungs
when the glottis is opened
2) Expiration:
Used/ air trapping (emphysema- COPD)
4-Pursed-lip breathing: used /COPD - asthma
during attack and between attack - relaxation
position: sitting – semi folwer
Order: take normal inspiration from nose count to 2 not deep and expired slowly from O
shape mouth count to 4 (expiration twice inspiration)
❖ shape / backward +vee pressure —> keep open airway
PT hand /abdominal ms (normally not contraction) if the patient contract abdominal this
means the Patient do forced expiration
5/Buteyko breathing:
This therapeutic breathing method uses breath retention exercises to control the speed and
volume of your breath. This helps you to learn to breathe more slowly, calmly, and
effectively and enhance breath control.
Used: asthmatic patient -anxiety – sleep disturbance
• Why asthmatic? Broncho restriction—> narrowing airway —> increase
breathing rate —> rapid shallow breathing and hyperventilation Depend different
level of CO2
• Why is the Control Pause (CP) important?
• The Control Pause test helps to determine breathing volume and tolerance to
carbon dioxide in the blood. Carbon dioxide is required in the blood in order to
release oxygen to muscles and organs. Over-breathing reduces carbon dioxide
levels and therefore decreases oxygenation of the body.
• When CP is low, breathing volume does not match the body’s metabolic
requirements, which results in an increased severity of hyperventilation-related
symptoms. If your Control Pause is less than 20 seconds it is highly likely that
you will regularly experience symptoms such as wheezing, coughing,
breathlessness, fatigue, and sleep-disordered breathing.
• The closer your CP is to 40 seconds, the better the match between breathing
volume and metabolic requirements, and the greater the oxygenation of the body.
Every time your Control Pause increases by five seconds you will experience
significant changes to your health and enjoyment of life
Aim: reduce breathing frequency (rate)/control rate and volume and depth
Preparation
1. Sit on the floor or on a chair.
2. Elongate your spine to maintain an upright posture.
3. Relax your respiration muscles.
4. Breathe normally for a few minutes.
The Control Pause

1. After a relaxed exhale, hold your breath.
2. Use your index finger and thumb to plug your nose.
3. Retain your breath until you feel the urge to breathe, which may include an
involuntary movement of your diaphragm, and then inhale.
4. Breathe normally for at least 10 seconds.
5. Repeat several times.
The Maximum Pause
1. After a relaxed exhale, hold your breath.
2. Use your index finger and thumb to plug your nose.
3. Retain your breath for as long as possible, which is usually twice the length of
time of the Control Pause.
4. Once you’ve reached the point of moderate discomfort, inhale.
5. Breathe normally for at least 10 seconds.
6. Repeat several times.
Check pulse rate (reduce PR- HR -BP)
3) Exercises connected with respiration or exercise to mobilize the chest:

Used/ after operation (cardio thoracic surgery - median sternotomy -
Posterolateral thoracotomy)
➢ median sternotomy position (forward flexion)
to prevent complication of this position —> breathing with posture
correction
order: take deep inspiration from nose while doing this moving trunk
backward (extended trunk or elevated arm upward ) hold and expired
from mouth and return to normal position
➢ Upper limbs and lower limbs:

❖ Abduction, extension with inspiration
❖ Adduction, flexion with expiration
➢ Trunk
❖ Bending forward (flexion) with expiration
❖ Bending backward (extension)with inspiration
❖ Turning trunk with expiration
❖ Lateral flexion with expiration
➢ Thoracic mobilization connected with breathing

❖ Flexion position
❖ Stretch pectorals major
Order /take deep inspiration while that while this clasp your hand
behind the head, move u chest backward then expired and return to
normal position
➢ Shoulder mobilization (flexion) with breathing

Order / take deep inspiration while both arms over head
Then expired while bend forward, arms reach for the floor
✓ Note: do after surgery gradually
➢ Posterolateral thoracotomy
Order / take deep inspiration while correcting trunk then expire
and return to normal position
To increase correction, elevate arm with leaning to opposite side
Physical therapy intervention: secretion clearance 1
lab (8)
postural drainage:
• Postural drainage is a technique used to mobilize large amounts of secretions in

people with respiratory conditions.
• Postural drainage relies on the effects of gravity to drain the secretions (phlegm)
from one or more lung segments into the central airways where it can be
removed via huffing or coughing techniques.
• Determining the drainage position by placing the segmental bronchus in the
most vertical position. In this manner, gravity will have its fullest effect.
• Goals & indications:

• Prevent accumulation of secretions in patients at risk of pulmonary
complications:
• Diseases with increased production or viscosity of mucus
• Prolonged bed rest
• Who has received general anesthesia
• Painful incision causing restricted deep breathing & coughing
• Patients on ventilator, if they are stable enough to tolerate
treatment.
• Removal of secretions which are already accumulated:
• Acute or chronic lung disease as cystic fibrosis
• Generally weak or elderly people
• Patients with artificial airways
• Contraindications:
• Severe hemoptysis
• Hematemesis
• Epistaxis
• Recent neurosurgery
• increased ICP WITH HEAD DOWN (use modified positions)
•Cardiovascular instability (Cardiac arrhythmias, Severe hypertension or

hypotension, Recent MI, Unstable angina)
• Untreated acute conditions as: (Severe pulmonary edema, Congestive heart
failure, Large pleural effusion, Pulmonary embolism, pneumothorax)
• Patient preparation for postural drainage:
Patient
❖ Patient should wear light clothes
❖ Loosen any tight clothes
❖ Explain the treatment to the patient
❖ The therapist should teach the patient how to huff and cuff
❖ Before postural drainage, the client may be given a bronchodilator
medication or nebulization therapy or takes hot drink to loosen secretions
Tools
❖ Tilting table
❖ Pillows
❖ Sputum cup or mug: measurable, transparent and has cover
Time and duration
Time
❖ The best times include early morning (due to night accumulation of
secretions) and early evening (to help the patient to sleep comfortably)
❖ 2 hours after last meal or before meal
❖ If this is done, the most important areas should be treated in the morning.
❖ Postural drainage frequency is scheduled two or three times daily,
depending on the degree of lung congestion
❖ One may treat certain lung areas in the morning and others in the
afternoon rather than doing everything in one treatment.
Duration
❖ Position should be maintained at least 5-10 minutes if tolerated and may
be maintained longer if a large amount of secretions is present or if secretions are
thick.
❖ If several positions are used, it is best to limit the total treatment time to
30-40 minutes as this may become extremely fatiguing to the patient.
Segment detection
❖ Chest x-ray (the most accurate)
❖ Percussion
❖ Auscultation
❖ Patient complain
• Postural drainage positions:

Stopping of the session (2H + 2D + P)

❖ Hemoptysis,
❖ Hemorrhage,
❖ Dizziness,
❖ Dyspnea,
❖ Pale face color
Discontinuing of the session
1. Patient is relatively clear or free for 24-48 hours
2. Relatively clear X- ray
3. Normal or nearly normal breathing sounds (vesicular sound)
4. Patient's ability to deep breathe and cough independently or to position
himself if indicated for home program
Assistive techniques
Percussion: During inspiration and expiration (Cupping)
Vibration: During expiration only (12:20 times) low amplitude with high frequency
Shaking: During expiration only (2:3 times) high amplitude with low frequency
1-Chest percussion
• Chest percussion involves using a cupped hand and alternately clapping both
hands on the person's chest wall. Your hand should not be flat but cupped at
all times as if you were holding liquid in it. Fingers and thumbs adducted.
Cupping the hands provides a cushion of air between the hands provides a
cushion of between the hands and the chest wall to eliminate irritation and
discomfort. while performing percussion, the therapist s shoulder, elbows
and wrists must be loose and flexible, but hands must maintain a cupped
position.
• The percussion technique should be vigorous and rhythmical but should not
involve pain. If there is a pain, your hand is probably not cupped properly
and needs to be softened or adjusted, Mechanical percussion is an alternative
to manual percussion techniques, percussion is done for several minutes or
until the patient needs to alter position to cough
2-Vibration:
• Vibration, is another manual technique, often is used in

combination with percussion to help move secretions to larger
airways. It is applied only during expiratory phase as the patient
is deep breathing. Vibration is applied by placing both hands
directly on the skin and over the chest wall (or one hand on the
top of the other) and gently compressing and rapidly vibrating
the chest wall as the patient breathes out. Pressure is applied in
the same direction as the chest is moving. The vibration is
achieved by the therapist isometrically contracting (tensing) the
muscles of the upper extremities from shoulders to hands.it is
gentle with high frequency
3-Shaking:
• Shaking is a more vigorous form of vibration applied during expiration using an

intermittent bouncing maneuver coupled with wide movements of the therapist s
hands.
Bronchial segment
Right lung Upper lobe

• Apical segment (appears superior, anterior and
posterior)
• Anterior segment (appears anterior)
• Posterior segment (appears posterior)
Middle lobe
• Medial segment (appears anterior)
• Lateral segment (appears anterior)
Lower lobe
• Superior segment (appears posterior)
• Anterior basal (appears anterior)
• Posterior basal (appears posterior)
• Lateral basal (appears posterior)
• Medial basal (appears medial) can’t be seen without surgery {Called
cardiac segment} seen only in right lung
Left lung
Upper lobe
• Anterior segment (appears anterior)
• Posterior apical segment (appears posterior)
• Superior lingula (appears anterior)
• Inferior lingula (appears anterior)
Lower lobe
• Superior segment (appears posterior)

• Anterior basal (appears anterior)
• Posterior basal (appears posterior)
• Lateral basal (appears posterior)
From Anterior:
✓ Upper lobe
✓ Middle
✓ Just a little part from the lower lobe (Anterior basal)
From posterior
✓ Upper lobe except anterior segment
✓ Posterior lobe except Anterior basal
Direction of the segment
‫نظريت البالعت والماسورة الزم البالعة تبقى فوق الماسورة‬

Lung Segment
Elballa3a = Lung segment
Elmasoura= Bronchial segment (Bronchiole)
Lung
Segment
Upper lobe
Segments Direction Position Percussion PIC
Apical Upward Sitting Below clavicle
Ant apical: sitting
+ lean backward
Post apical: sitting
+ lean forward
Anterior Forward Supine Below clavicle just

above the nipple
Posterior Backward Prone + one quarter on Spine of the

+ lateral. opposite side scapula
Posterior Backward Prone +one quarter on Spine of the

apical + opposite side + elevate the scapula
(Left lateral + head 45°

lung) upward
It is the only position that
elevates head in
it
Middle lobe
Lobe Direction Position Percussion PIC
Supine + one
Middle quarter to
Forward + lat. On middle
opposite
(Right lung) + downward side + elevate ribs (Right)
the leg 30°
Supine + one
Forward + quarter on
2 lingula (left On middle ribs
lat. + opposite side
lung) (Left)
downward + elevate the
leg 30°
Lower lobe
Segments Direction Position Percussion PIC
Superior Backward Prone On inferior

angle
Ant basal Forward + Supine + On lower

downward elevate leg ribs
45°
Post basal Backward + Prone + On lower

downward elevate leg ribs
45°
Lateral basal Lateral. + Side lying On outer

opposite + lower ribs
downward
elevate leg
45°
Medial basal Medial. + Side lying On medial

same + border of
(Cardiac segment) downward right
(RT lung) elevate leg scapula
45°
Physical therapy intervention: secretion clearance 2
lab (9)
Teaching the patient an effective cough mechanism:
Definition of cough:
• It is a sudden forced expulsion of air that may be voluntary or

reflexive to eliminate respiratory obstruction and keep lungs
clear
• The cough pump is effective till the 7th generation (there are 23
generation of bronchi) due to the ciliated epithelial cells
present up to terminal bronchioles which raise the secretions
The cough mechanism:
1. Deep inspiration
2. Glottis closes and vocal cords tighten
3. Abdominal muscles contract and the diaphragm elevates,
causing an increase a intrathoracic and intra-abdominal
pressures
4. Glottis opens
5. Explosive expiration of air occurs
Methods for stimulating or facilitating cough:
1. Splinting: when there is incisional pain, by hands or pillows to

restrict the movement of the incision and decreasing the incisional
pain
2. Tracheal trickle: it is indicated in children or unconscious

patients, it used to stimulate reflexive cough, it is a circular
movement with pressure on the trachea at the suprasternal notch
3. Neuromuscular facilitation: by intermittent application of Ice 3-5

seconds: on Para spinal muscles of the thoracic spine which
directly stimulate the afferent nerve it can be for interrupted 30
minutes
4. Suction: endotracheal suctioning may be the only means of

clearing the airways in patients who are unable to cough or huff
voluntarily or after reflex stimulation of the cough mechanism.
Suctioning is indicated in all patients with artificial airways. The
suctioning procedure clears only the trachea and the mainstem
bronchi
5. Humidification: it is mobilization of thick secretions by increase

fluid intake which may be IV
Difference between huff and cough:
• Voluntary or reflexive
• Productive or non- productive
• Doesn’t stimulate huffing
• Deep inspiration with closed glottis
• The increase in the intra-abdominal and intrathoracic pressure is more so causes
forced expiration
Huff
• Voluntary
• Non productive
• Stimulate cough
• More deep than cough
• Deep inspiration with open glottis
• Less pressure and the power of expiration is less
❖ Breathing exercise to remove secretions

The Active Cycle of Breathing Techniques
• Active cycle of breathing technique (ACBT)

combines different breathing techniques that help
clear mucus from the lungs in three phases. The
first phase helps you relax your airways. The
second phase helps you to get air behind mucus and
clears mucus. The third phase helps force the mucus out of
your lungs.
• The technique consists of breathing control, deep breathing and

huffing. These are repeated in a cycle until your chest feels clear.
The patient can carry out ACBT when either sitting or lying
down.
➢ Active breathing exercise used to:
1. Loosen and clear secretions from the lungs. This helps

reduced the risk of chest infections.
2. Improve ventilation in the lungs.
3. Improve the effectiveness of a cough.

• ACBT consists of three main phases:
1. Breathing Control
2. Deep Breathing Exercises or Thoracic Expansion

Exercises
3. Huffing or Forced Expiratory Technique (FET)
1/Breathing control
• For relaxation
• The patient should breathe in through his nose and out through
his mouth with very little effort. Use normal, gentle breathing
with the lower chest while relaxing the upper chest and
shoulders.
• Repeated 3-5 time
2/Thoracic Expansion
• For loosen secretions
• Steps:
1. Try to keep your chest and shoulders relaxed.

2. Put hands in lower costal rib
3. Take a long, slow and deep breath in, through your nose
4. Push u hands upward
5. hold the air in your lungs for 5 sec
6. Breathe out gently and relaxed, Don't force
7. Repeat 3 - 5 times. If the patient feels light-headed then it
is important that they revert back to the breathing control
phase of the cycle
3/Huffing or Forced Expiratory Technique:
✓ Do when a secretion in central airway
➢ For move secretions towards the mouth.
Also called forced expiration technique, huff cough at different,

controlled lengths to move mucus up to the larger airways. This
huffing should be repeated until all mucus has been huffed out of the
lungs.
• Making huff as steaming window or mirror by ask the patient

to put his hand in front of his face.
There are two types of huff:
1. Medium volume huff – this helps to move secretions that are

lower down in your airways. Take a normal sized breath in and
then an active, long breath out until your lungs feel quite
empty. Imagine you are trying to steam up a mirror.
2. High volume huff – this helps move secretions in your upper

airways. Take a deep breath in, open your mouth wide and huff
out quickly.
Followed by cough
Only perform 1-2 huffs together, as repeatedly huffing can make your
chest feel tight.
Note /after forced expiration followed breathing control to prevent

bronchospasm
Repeat the whole cycle for about 10-15 minutes or until your chest
feels clear
Autogenic drainage (AD):
Used different lung volume to remove secretion
Aim: move secretion to upper airway
Stages of the technique:
•Stage 1 (unstick phase) low volume breaths to mobilize secretions

from the peripheral airways designed to "unstick" any secretions (are
in the tidal volume (VT) and expiratory reserve volume (ERV)
range)
•Stage 2 (collect phase) medium (tidal) volume breaths to collect

mucus from the middle airways. These larger breaths are designed to
collect secretion into the larger airways (expand into the inspiratory
reserve volume (IRV).
•Stage 3 (evacuate phase) large volume breaths enabling

expectoration from central airways (approaching the vital capacity
range)
Benefits of AD: Disadvantages of AD

• No equipment is • Patients generally need to
required be over 8 years old
• Patients can • The technique can be
perform their difficult to teach
airway clearance • Patients need the cognitive
independently ability to understand the
• Less effort is be basic physiology behind the
required to technique
expectorate which • To benefit from the
reduces stress on auditory feedback, patients
the pelvic floor need to have a moderate or
large amount of sputum
Steps:
1/ sit in a relaxed seated position with your neck extended slightly.
2/ drink cup of water (hot) or bronco nebulizer to loss secretion
3/ Blow your nose and huff cough to clear your upper airways of
mucus huff and cough before begin technique
Unsticking phase
• Move secretion from peripheral to medial airway
3/ relaxed breathing and expired all air in lung

4/ normal inspiration (small tidal volume) and hold
5/ prolonged expiration (ERV)
Rep 3-5 time
If feel need to cough, suppress cough
collect phase
• Move secretion from medial to proximal
6/ Take in a slightly larger breath, and then exhale, but not as low as in
level one
Listen to crackle (at end phase 1 and beginning phase 2)
If feel need to cough, suppress cough
evacuate phase
take Max deep inspiration and expired rapidly (short time)
Rep 3-5 time
At the end huff and cough This moves the mucus into your mouth.
Then spit it out into a container or tissue.
✓ 3rd phase reverse 1st phase
• each phase should take two to three minutes to complete.

Completing all three phases (one cycle) should take about six
to nine minutes to complete.
• Repeat the cycle until you have cleared your lungs as much as
possible, which should take between 20 and 45 minutes.
Stretching
Stretching is a therapeutic modality designed to elongate
pathologically shortened soft tissue and as a result to increase range of
motion
Types of stretching:
1-Active stretching:
Active stretching involves contraction of the muscle group (agonist)

that is in opposition of the muscles that you are stretching
(antagonist). you are actively moving the target muscle that you want
to stretch.
2-passive stretching:
Passive stretching means that some external force is applied to a joint

to move it without any muscular contraction.
Aims
1. To lengthen shortened soft tissue

2. To enhance joints mobility
3. To breakdown adhesions
4. To improve functional abilities
❖ Accessory muscles (pectoralis major,..)
❖ Pleural stretching position: (phalanx position-Wring

position- Hip flexors stretching position)
Devices for Respiratory muscle training:
Respiratory muscle training devices have been used to increase

strength and endurance of the muscles of either inspiration or
expiration, the patient breathes through a mouthpiece or a face mask
with a resistance applied to either the inspiratory or expiratory limb of
a valve. The valve may be flow resistive or threshold loading.
• Flow resistive device the patient breathes in and out through an

orifice, changing the orifice size leads to changing the
resistance level, the load or the resistance increase by
decreasing the orifice size example
• Threshold loading device: Pressure resistive IMT devices as

(POWER breath plus and Inspiratory muscles training device
(IMT)
Incentive respiratory spirometry
It is a form of ventilator training that concentrate on sustained

maximum inspiration. The patient inhales as deeply as
possible through a small handheld device that provide visual
or auditory feedback about whether a target maximum
inspiration was reached, the purpose of this device is to
increase the volume of inspired air. It is used primary to
prevent alveolar collapse in postoperative patient
Devices for airway clearance
Positive expiratory pressure therapy (PEP) and OPEP devices
The PEP device creates pressure in the lungs and keeps your airways
from closing. The air flowing through the PEP device helps move the
mucus into the larger airway. A Huff Cough will help move the mucus
out of the airways. An oscillating (or vibratory) positive expiratory
pressure (OscPEP) device is a form of PEP that combines high-
frequency air flow oscillations with positive expiratory. The person
blows all the way out many times through a device. Commonly known
by their brand names (Flutter®, Acapella®, AerobikA®, and RC-
Cornet®).
1-Positive expiratory pressure (PEP)

• PEP is also called PEP Therapy, PEP Mask or TheraPEP.
• The PEP device creates pressure in the lungs and keeps your
airways from closing.
• The air flowing through the PEP device helps move
the mucus into the larger airway.
• A Huff Cough will help move the mucus out of the
airways.
• The patient performs a series of 10 to 20 breaths with
the mask or mouthpiece in place.
• The patient then removes the mask or mouthpiece,
and next performs several coughs to raise secretions.
• This sequence of 10 to 20 breaths followed by huff
coughing is repeated 4 to 6 times per PEP therapy
session, each session requires 10 to 20 minutes and
may be performed 1 to 4 times per day as needed.
2-Oscillating PEP:
• An oscillating (or vibratory) positive expiratory pressure

(OscPEP) device is a form of PEP that combines high-
frequency air flow oscillations with positive expiratory. The
person blows all the way out many times through a device.
• Objective: mobilization and evacuation of tracheobronchial

secretion by increasing intrathoracic pressure of distal lungs;
increasing collateral ventilation and training of respiratory
muscles, cough stimulation.
• Mechanism of action: based on physiological effects

of expiration against positive pressure with rapidly
changing/oscillating resistance; it allows to stabilize/open
airways (expansion effect), eliminate air trappings (expansion
effect), dilute and mobilize secretion (thixotropic effect),
stimulate mucociliary clearance (resonant frequency effect
with the ciliary epithelium at a frequency of 12–15 Hz).
• Commonly known by their brand names (Flutter®, Acapella®,

AerobikA®,lung flute, sheaker,quack and RC-Cornet®), give
intrathoracic oscillation
Physical therapy in cardiothoracic surgery
lab (10)
THE ROLE OF PHYSIOTHERAPY IN CARDIAC SURGERY:
Cardiac surgical procedures change respiratory mechanics, defecting in lung

dysfunction.
The physical therapists play an important role in the preparation and rehabilitation of
individuals who are undergoing cardiac surgery, as they have a large quantity of
techniques.
Breathing exercises with and without the use of devices, and respiratory muscle training
in preoperative period of cardiac surgery in reducing postoperative pulmonary
complications.
Pre-operative Physiotherapy
❑ Physiotherapist prior to your surgery and they will provide education on what is
required to facilitate your recovery as smoothly as possible.
❑ Breathing exercises Breathing exercises are very important to prevent chest
complications after surgery such as chest infection or lung collapse.
❑ Practice of deep breathing exercises before the operation, it will be easier to do
these afterwards.
❑ Support coughing After operation it is important to cough to clear any sputum.
The chest wound is supported by holding a pillow or rolled up towel firmly
against the chest and leaning slightly forward
Physiotherapy post Cardiac Surgery:
Exercises after the operation These exercises helps to

remove the secretions produced from the lung lining after a
general anesthetic and which, if left in the lungs, can lead to
pneumonia.
1. Deep Breathing Exercises:
Take 5 deep breaths every hour and then huff and cough to
clear any phlegm from your lungs. Use spirometer and take
5 breaths every hour.
2. Leg exercise:
❖ The following exercises increase the blood circulation and assist in

preventing clots forming in the legs and chest. (Repeat 10 times every
hour).
❖ Ankle Exercises
(i) Move feet up and down at the

ankles. Repeat 10 times every
hour.
(ii) Move feet together in circles.

Repeat 10 times every hour.
❖ Quadriceps Exercises: Press

the back of knees against the
bed. heels should lift off the bed
at the same time.
❖ Gluteal Exercises Tighten

your buttocks together, hold
for 5 seconds and relax.
❖ Straight Leg Raising Lift the

leg off the bed, keeping knee
straight.
❑ As well as breathing exercises, physiotherapist need

to start stretching exercises to prevent stiffness.
• These need to be done twice daily and are to

be done slowly.
1. Extension: in Sitting Begin sitting tall, with your

back and neck straight, shoulders back slightly.
Gently take your neck backwards, looking up
towards the ceiling until you feel a mild to moderate
stretch pain-free. Repeat 5 times.
2. Rotation in Sitting: Begin sitting with back and

neck straight and shoulders back slightly. Turn head
looking over one shoulder until you feel a mild to
moderate stretch pain-free. Keep your neck straight
and don't allow your head to poke forwards during
the movement.
3. Rotation in Sitting: Begin sitting tall, with arms

across chest. Keeping legs still, gently rotate to one
side until feel a mild to moderate stretch that is pain
free. Repeat 10 times to each side
4. Side Bend in Sitting: Begin sitting tall, back

straight, hands behind head or neck. Gently bend to
one side, moving elbow towards hip until feel a mild
to moderate stretch pain-free. Make sure you do not
lean forwards. Repeat 5 times on each side
5. Shoulder Extension: Begin standing tall, with neck

and back straight. Gently take arm backwards until
feel a mild to moderate stretch pain free. Repeat 5
times
6. Shoulder Flexion: Begin standing tall with back and

neck straight. Gently raise arm forwards and up until
feel a mild to moderate stretch pain free. Repeat 5
times
❖ Not to do:
❑ DO NOT walk if you feel unwell or if the weather is

inclement.
❑ DO NOT go up hills.
❑ DO NOT push a heavy shopping trolley
Cardiac rehabilitation:
❑ It is defined as, “all measures used to help cardiac patients

return to an active and satisfying life and to prevent re-
occurrence of cardiac events”.
❑ Cardiac Rehabilitation includes exercise, education, and social

and emotional support.
❑ Rehabilitation can be hospital or home based.
BENEFITS OF REHAB PROGRAM:
❑ Offset deleterious psychologic and physiologic effects of bed

rest during hospitalization
❑ Enable patients to return to activities of daily living within the

limits imposed by their disease
❑ Reduces cardiovascular and total mortality
❑ Improves myocardial perfusion
INDICATIONS:
❑ Acute myocardial infarction
❑ Coronary artery bypass
❑ grafting Angioplasty with or without stenting
❑ Valve replacement or repair Heart transplantation
❑ Surgery involving the great vessels Congestive heart failure
❑ Chronic stable angina pectoris
CONTRAINDICATIONS:
❑ Unstable Angina
❑ Uncontrolled Arrhythmias
❑ Resting Systolic Blood Pressure >200 mm hg
❑ Resting Diastolic Blood Pressure >100 mm hg
❑ Recent embolism
❑ Moderate to severe Aortic Stenosis
❑ Acute Systemic illness or fever
❑ Orthopedic problems that would prohibit exercise
❑ Poorly controlled hypertension
❑ Patients unwilling to exercise
Phase 1
Duration: 5 to 7 days.
Components:
❑ Medical evaluation
❑ Reassurance and education
❑ Correction of cardiac misconception
❑ Risk factor assessment
❑ Early individualized Mobilization
❑ Discharge planning
Step 1- PROM, active ankle exercise, self-feeding, orientation to
program
Step 2- same exercise, legs dangling at the side of bed
Step 3- AROM, sitting in chair, bedside commode, more detailed
explanation of the program, light recreation, Assisted ADL, Walking
Step 4- minimal resistance, increase sitting time, patient education,
light activities, independent ADL, walking
Step 5- moderate resistance, unlimited sitting, sitting for meals, seated
ADL, continued patient education
Step 6- increase resistance, walking to bathroom, Stairs, standing

ADL, group meeting
Step 7- increase exercise program, review energy-conservation and
pacing techniques.
Step 8- increase exercise with light weight and increase walking
distance, increase craft activities, discuss home exercise programs
Phase II
Happy to be back HOME……
Is the immediate post-discharge phase.
Duration: 8th day to 6 weeks
Components:
❑ Addresses health education
❑ Exercise
❑ Stress management
Exercise program:
❑ Frequency: 3-5 times/week
❑ Time: 5-30 minutes; interspersed with rest periods and
progress to about 30 minutes
❑ Type: sitting/standing functional activities; ROM exercises;
walking
Phase III
The patient has stabilized and requires ECG monitoring only if signs
and symptoms necessitate.
Duration: 6 weeks to 12 weeks
Goals:
❑ Improve and maintain physical fitness
❑ Provide professional supervision for exercise
❑ Continue with educational and behavioral program
Types of Training
Steady State Training:
❑ Is a sustained activity, where workload and HR are maintained
at a constant sub- maximal intensity.
❑ Jogging, walking, stepping and cycling.
Interval Training:
❑ The exercise is followed by a rest interval.
❑ Is perceived to be less demanding than continuous
❑ High-intensity work can be achieved as there is appropriate

spacing of work- relief intervals.
Circuit Training:
❑ Employs a series of exercise activities.
❑ At the end of the last activity, the individual starts from the
beginning and again moves through the series.
❑ Improves strength and endurance by stressing both the aerobic

and anaerobic systems.
Warm-up period:
❑ To increase in muscle temperature
❑ Increase need for oxygen
❑ Dilation of previously constricted capillaries with increase in

circulation.
❑ Decreases susceptibility of the musculoskeletal system to

injury by increasing flexibility.
Exercise Program:
❑ Frequency: 3-4 times/week
❑ Intensity: 60-70% maximal HR; 40-60% of VO2 max
❑ Time: 20-60 minutes; inclusive of warm up and cool down
❑ Type: aerobic/endurance training
(V̇O2 max (also maximal oxygen consumption, maximal oxygen

uptake or maximal aerobic capacity) is the maximum rate of oxygen
consumption measured during incremental exercise; that is, exercise of
increasing intensity)
Cool-down period:
❑ Prevent pooling of the blood in the extremities by continuing

to use muscles to maintain venous return.
❑ Enhance recovery period with the oxidation of metabolic waste

and replacement of the energy stores
Phase IV
Goals:
❑ Continued improvement and maintenance of fitness.
❑ Unsupervised exercise program
❑ Self-exercise
❑ Long term behavioral modifications
Exercise Program:
❑ Frequency: one session/day; 3-4 days/week Intensity: 60-80%

of VO2; 70-85% of HRR; RPE 12-15
❑ Time: desired 30-60 minutes continuous workout
❑ Type: hill walking, resistance exercise.
(Heart Rate Reserve (HRR) is normally calculated as the difference between

your Maximum Heart Rate (HRmax) and Resting Heart Rate (HRrest).
Exercise intensity can be evaluated by calculating your heart rate as a percentage of
HRR)

Internal Medicine Lab

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Internal Medicine Lab

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Al-Zaytoonah University Of Jordan

Applied Medical Science Faculty

Student Name: ___________________

Lab 1 Chest surface anatomy

Lab 2 Cardiopulmonary assessment

Lab 3 Localized cardiopulmonary assessment

Lab 4 Examination of the heart

Lab 5 Assessment of vital signs

Lab 6 Pulmonary function test

Lab 7 Physical therapy intervention: breathing exercise

Lab 8 Physical therapy intervention: secretion clearance 1

Lab 9 Physical therapy intervention: secretion clearance 2

Lab 10 Physical therapy in cardiothoracic surgery

Total Marking Criteria:

AL-Zaytoonah University of Jordan

Medical Applied Science faculty

Physical therapy department

Chest surface anatomy

Anatomy of the Thorax

• Physicians passing needles into the thorax insert

Boundaries of the thoracic inlet:

Muscles from abdomen to thorax:

2. Internal intercostal muscle:

3. Innermost intercostal muscle: the deepest and thinnest intercostal muscle

All the three intercostal muscles are accessory muscles of respiration

AL-Zaytoonah University of Jordan

Medical Applied Science faculty

Physical therapy department

General Local (3P+ F)

(AP>T) will lead to Pigeon chest "Pectus carinatum" Solid: tumors

2-Chest Expansion: (Symmetrical & Good movement)

Lower Posterior basal

at the level of axilla

at the lower costal

AL-Zaytoonah University of Jordan

Medical Applied Science faculty

Physical therapy department

Localized cardiopulmonary assessment

Anterior view Lateral view Posterior view

How to find the sternal angle

How to identify ribs and its inter-costal spaces:

•more than resonant in intensity

•is the most powerful resonance (the highest

And dullness may be graded to:

Special area of the lung:

Tidal percussion or diaphragmatic excursion:

Causes of diaphragm descend Causes of diaphragm moving upward

AL-Zaytoonah University of Jordan

Medical Applied Science faculty

Physical therapy department

Examination of the heart

Examination of the heart

4) Bare area of heart:(done by a light percussion)

❖ AV (mitral & tricuspid) valves closed

So if there’s a problem during systole it will be due Either:

❖ AV (mitral & tricuspid) valves opened

So, if there’s a problem during systole it will be due Either:

Murmurs are a prolonged sound due to turbulence of flow caused by:

AL-Zaytoonah University of Jordan

Medical Applied Science faculty

Physical therapy department

Assessment of vital signs

36.5 – 37.5 36 - 37 37 - 38 36.5 – 37.5

• Electronic – heat sensitive probe, (reads in seconds) there is a probe for