School of Health Sciences

CARDIOPULMONARY ASSESSMENT FORM

SUBJECTIVE:

Demographic Data:
Name: S/O,D/O,W/O:
Age: Gender: Male / Female
Residence: Marital status: Married / Single
Primary language: Occupation:
Date of admission: Mode of admission:
Source of history:

Chief Presenting complaint(s):

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HOPC:
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Past medical history:

Medical: _______________________________________________________________________

Surgical: _______________________________________________________________________

Family history:

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Socioeconomic status & social health habits:

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Present & pre-morbid functional status:

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Medications & Treatment history:

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General health status:

Level of awareness: ________________ Body type: _________________

Thyroid: ________________ Lymph nodes: _________________
Smoker / non smoker Packs per day: _________________

Vitals:
Respiratory rate: BP:

Temperature: Oxygen saturation:

Pulse:

SYSTEMIC REVIEW:

Gastrointestinal system:
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Integumentary system:
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Musculoskeletal system:
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Neurological system:
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Urinary system:
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Cardiopulmonary System:

Chest pain: Mild / Moderate / Severe

Resting / Exertional
Dyspnea: Mild / Moderate / Severe
Resting / Exertional
Orthopnea: PND:
Palpitations: Pain/sweats:
Cough: Productive / Non productive
Sputum colour: _________ Amount: ___________
Hemoptysis:
Syncope: Peripheral Edema:
Cyanosis: Clubbing:
Fever: Anemia:
Fatigue: Jaundice:
Nausea: Vomiting:
Hypertension: Hyperlipidemia:
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OBJECTIVE:
Inspection:

i) Shape of chest:
Normal , symmetrical
Barrel shaped Kyphosis
Funnel shaped Lordosis
Pigeon shaped Scoliosis
ii) Symmetry of chest movements: ________________
iii) Breathing pattern:
Abdomino-thoracic
Thoraco-abdominal
Other: __________________
iv) Position of treachea:
Central:
Shifted: Side: R / L
v) Intercoastal spaces:
Normal:
Bulging: side: Side: R / L
Retracted side: Side: R / L
vi) Cutaneous signs:
Janeway lesions
Osler’s nodes
Splinter heamorhage
Other
vii) Extremities:
Warm Cold
Sweaty Dry
Palpation:
Chest wall pain/tenderness:
Tactile fremitus: _______________________
Respiratory excursion:
Anteriorly: Normal / decreased on R/L side
Posteriorly: Normal / decreased on R/L side
Pulses present: Carotid Brachial
Radial Femoral
Popliteal Posterior tibial
Dorsalis pedis
Pulse description: ___________________________________________________________
Apex beat: palpable/non palpable _________________________________________
Percussion:
(Normal: N Dull: D Hyper-resonant: H)

Right Anterior: 2 4 6
Left Anterior: 2 4 6

Right Lateral: 4 6 8
Left Lateral: 4 6 8
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Right Posterior: 2 4 6 8 10
Left Posterior: 2 4 6 8 10
Auscultation:
Breath sounds:
Pattern: __________________
Air entry: __________________
Added sounds:
Crepitations:
Wheeze:
Pleural rub:
Stridor:
Audible in ____________________________________________
Heart sounds: ______________
Murmors: ______________
Adventitious sounds:
Pericardial friction rub
Ejection click
Opening snap

Diagnostic laboratory tests:

Blood cp Yes/no Cardiac enzyme Yes/no
Urine RE Yes/no HCV Yes/no
RFTs Yes/no HIV Yes/no
LFTs Yes/no S.Electrolyte Yes/no
TFTs Yes/no S.calcium Yes/no
BSR Yes/no S. creatinine Yes/no
BFR Yes/no S. Urea Yes/no
ECG Yes/no S. amylase Yes/no
BT.CT Yes/no S.cholestrol Yes/no
Prothrombin time Yes/no

IMAGING:
Chest x ray: AP view/ lateral view / both

Findings: ___________________________________

ECG findings: ___________________________________

Echocardiography: ___________________________________

ETT: ___ ________________________________

ASSESSMENT:
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PHYSICAL THERAPY MANAGEMENT

Short term goals:

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Long term goals:

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Interventions:
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Precautions:
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Home Program:
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Dated:_________________