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(perifriction rub
    inrercostal
    carditis), associated with each beat of
    (abnormal)
    space, anrerior
    the hearr, sounds like a creak or
    axillary line
    leather being rubbed together.
    Source: Data from LS Bickley. Bate's Guide to Physical Examination and Hisfory
    Taking 17th cd). Philadelphia: Lippincott, 1999.

    24 AClITE CARE HAND nOOK FOR I)I·IYSICAL THERAPISTS
    Pulmonic Area
    Aortic Area
    Figure 1-8. Areas for heart sound auscultation. (Drawn by Barbara Cocanour.
    Ph.D., University of Massac/msetts, Loweff. Departmel1l of Physical Therapy.)
    Figure 1-8. Abnormal sounds should be noted with a description of
    the conditions in which they were heard (e.g., after exercise or during exercise).
    Clinical Tip
    • Always ensure proper function of stethoscope by tapping
    the diaphragm before applying the stethoscope to the patient.
    • Rubbing the stethoscope on extraneous objects can add
    noise and detract from true examination.
    • Auscultation of heart sounds over clothing should be
    avoided, because it muffles the intensity of both normal
    and abnormal sounds.
    • If the patient has an irregular cardiac rhythm, HR
    should be determined through auscultation (apical HR).
    To save time, this can be done during a routine auscultatOry examination with the stethoscope's bell or diaphragm
    in any location.

    CARDIAC SYSTEM
    25
    Diagnostic and Laboratory Measures
    The diagnostic and laboratory measures discussed in this section provide information that is used to determine medical diagnosis, guide interventions, and assist with determining prognosis. The clinical relevance of each test in serving this purpose varies according to the pathology. This section is organized across a spectrum of least invasive to most invasive measures. When appropriate, the test results mOst pertinent to the physical therapist are highlighted. Information
    that bears a direct impact on physical therapy clinical decision making usually includes that which helps the therapist identify indications for intervention, relative or absolute contraindications for intervention, possible complications during activity progression, and indicators of performance.
    Oximetry
    Oximetry (Sa02) is used to indirectly evaluate the oxygenation of a
    patient and can be used to titrate supplemental oxygen. Refer to
    Chapter 2 for a further description of oximetry.
    Electrocardiogram
    ECC provides a graphic analysis of the heart's electrical activity.
    The ECC is commonly used to detect arrhythmias, heart blocks,
    and myocardial perfusion. It can also detect atrial or ventricular
    enlargement. ECC used for continuous monitoring of patients in
    the hospital typically involves a two- or three-lead system. A lead
    represents a particular portion or "view" of the heart. The
    patient'S rhythm is usually displayed in his or her room, in the hall,
    and at the nurses' station. Diagnostic ECC involves a 1 2-lead analysis, the description of which is beyond the scope of this book. For a review of basic ECC rate and rhythm analysis, refer to Table 1-10
    and Figure 1-3.
    Holter Monitoring
    Holter monitoring is 24- or 48-hour ECC analysis. This is performed to detect cardiac arrhythmias and corresponding symptoms during a patient'S daily activity.12 Holter monitoring is different than telemetric monitoring because the ECC signal is
    recorded on a tape, and the subsequent analysis follows from this
    recording.
    Indications for Holter monitoring include the evaluation of syncope, dizziness, shortness of breath with no other obvious cause, pal-

    26 AClffE CARE HANDBOOK FOR PHYSICAL THERAPISTS
    Table 1 -10. Electrocardiograph Interpretation
    Duration
    Wave/Segment
    (sees)
    Amplitude (mm)
    Indicates
    P wave
    <0. 10
    1-3
    Atrial depolarization
    PR interval
    0.12-1).20
    Isoelectric line
    Elapsed time between atrial
    depolarization and ven·
    tricular depolarization
    QRS complex 0.06-1).10 25-30
    Ventricular depolarization
    (maximum)
    and atrial repoiariz3tion
    ST segment
    0.12
    -1/2 co