CV/Pulm Flashcards
A 67-year-old man with chronic obstructive lung disease (COPD) is about to start a pulmonary
rehabilitation program. Which option is an appropriate breathing retraining technique for the
patient to learn?
(a) Diaphragmatic breathing
(b) Localized expansion exercises
(c) Rapid, shallow breathing
(d) Head up and bending backward postures
Answer: (b)
Commentary: Breathing retraining techniques for COPD include pursed lips breathing, head
down and bending forward postures, slow deep breathing, and localized expansion exercises (also
known as segmental breathing, wherein the patient is asked to inspire while the clinician applies
pressure to the thoracic cage to resist respiratory excursion in a segment of the lung). These
techniques maintain positive airway pressure during exhalation and help reduce overinflation.
Although diaphragmatic breathing (done by expanding one’s belly and thereby allowing the
diaphragm to move down creating more room for the lungs to expand) is widely taught, it has
been shown to increase the work of breathing and dyspnea compared with the natural pattern of
breathing in the patient with COPD.
A 48-year-old woman had an acute myocardial infarction (MI) 2 weeks ago. The referring
cardiologist informed you that she had a small MI and an uncomplicated hospital course. In a
situation such as this, which statement is TRUE?
(a) Combined aerobic and resistance training, compared to aerobic training alone, has a
higher risk of adverse outcomes.
(b) Beta blocker agents will attenuate the benefits of exercise training.
(c) A change in left ventricular (LV) dimensions (remodeling) is associated with improving
LV function.
(d) Cardiac rehabilitation will improve both myocardial perfusion and LVelectrophysiologic
parameters.
Answer: (d)
Commentary: After a myocardial infarction (MI), exercise training is initiated within 2-4 weeks.
Combined resistance and aerobic training improves aerobic fitness and muscle strength more than
aerobic training alone, without adverse outcomes. Beta blockers, which are a standard of care to
reduce mortality after an MI, do not attenuate the benefits of exercise training. Following an MI,
a change in left ventricular (LV) dimensions (remodeling) is associated with deteriorating LV
function, ventricular arrhythmias, aneurysm formation, and higher mortality. Cardiac
rehabilitation improves both myocardial perfusion and LV electrophysiologic parameters,
reducing the risk for malignant ventricular arrhythmias and sudden cardiac death after MI.
Which burn patient has the highest risk of developing hypertrophic scars?
(a) Newborn baby
(b) Morbidly obese individual
(c) Heavily pigmented individual
(d) Elderly individual
Answer: (c)
Commentary: A hypertrophic scar is usually defined as a scar that is present at 3 or more
months after the burn injury and is greater than or equal to 2 mm in thickness. Heavily
pigmented patients tend to scar more than persons with less pigment. Little scarring has been
reported in neonates, newborns, elderly and the morbidly obese. Patients with wounds that take
longer than 2-3 weeks to heal, and persons requiring skin grafts, are also considered at risk for
developing hypertrophic scars.
What is the most frequent presenting symptom of brain metastasis?
(a) Focal weakness
(b) Headache
(c) Seizure
(d) Visual disturbance
Answer: (b)
Commentary: Presenting symptoms at the time of diagnosis with brain metastasis, in order of
decreasing frequency, are as follows: (patients can have more than a single symptom): headache,
49%; mental disturbance, 32%; focal weakness, 30 %; gait ataxia, 21 %; seizures, 18%; speech
difficulty, 12%, visual disturbance, 6%; sensory disturbance, 6%; and limb ataxia, 6%.
Which cardiac response is increased as a result of aerobic training?
(a) Oxygen consumption (VO2)
(b) Maximal heart rate
(c) Anginal threshold
(d) Stroke volume at rest
Answer:(d)
Commentary: After an aerobic training program, the anginal threshold is unchanged. Oxygen
consumption (VO2) at rest, and during any given submaximal load remains unchanged, while
VO2 max is increased. The maximal heart rate also does not change, but the heart rate is lower
both at rest and during any submaximal load (bradycardia of training). The stroke volume at rest
is increased, reciprocal to the decrease in heart rate. Although angina threshold is unchanged,
myocardial oxygen demand decreases relative to oxygen consumption, which allows more intense
activity before the ischemic threshold is reached.
- A 50-year-old man has obstructive sleep apnea (OSA). He is morbidly obese and has a body mass
index (BMI) of 39 kg/m². He is also complaining of chronic low back pain, which he claims
limits his mobility. Which approach would best benefit him?
(a) Prescribe a motorized wheelchair.
(b) Prescribe modafinil (Provigil) for daytime sleepiness.
(c) Schedule opioid analgesics for pain control.
(d) Order surgical referral for a tracheostomy.
Answer: (b)
Commentary: Obstructive sleep apnea (OSA) is characterized by snoring, arousals, and daytime
sleepiness. Most patients with OSA are male, middle-aged, with an average BMI of 32.5 +/-
9. 0kg/m2. Wheelchairs should be used only in cases of compromised mobility and powered
mobility used only when no other options exist. Modafinil can be used as adjunct therapy for
daytime sleepiness. Narcotic analgesics should be prescribed with caution because of depression
of central respiratory drive. Positive airway pressure (PAP) delivered with continuous (CPAP) or
bilevel (BiPAP) pressures can correct upper airway obstruction. If the noninvasive approach is
not effective, tracheostomy may be necessary.
- Which symptom most frequently impacts quality of life in patients with incurable cancers?
(a) Fatigue
(b) Anorexia
(c) Weakness
(d) Depression
Answer: (a)
Commentary: Cancer patients experience a much broader range of symptoms that impact their
quality of life and their ability to address existential issues at the end of life than those listed here.
fatigue (74%), pain (71%), lack of energy (69%), weakness (60%) and anorexia (53%) being the
most prevalent that impact quality of life. The prevalence of nausea is 40% in the last 6 weeks of
life. Fatigue is often the primary condition adversely affecting quality of life.
- Which cancer related pathological fractures require surgical management?
(a) Humeral, if life expectancy is less than 3 months
(b) Radial, if pain resolves following radiation
(c) Femoral, if life expectancy is greater than 1 month
(d) Pelvic without acetabular involvement
Answer: (c)
Commentary: The indications for surgery for pathological fractures from cancer are life
expectancy of greater than 1 month with a fracture of a weight-bearing bone, and greater than 3
months for fracture of a non-weight-bearing bone. If pain persists following radiation, fractures
should be managed surgically. Healing rates are low following pathologic fractures, with 1
review of 123 patients reporting a 35% incidence of fracture healing. Fractures of the pelvis are
generally treated conservatively, unless pain persists after radiation or unless they involve the
acetabulum.
A 39-year-old male factory worker suffers from a low voltage-induced electrical injury. The most
serious acute medical complication that can occur is
(a) cardiac arrhythmia.
(b) peripheral neuropathy.
(c) distal extremity amputation.
(d) myelopathy.
Answer: (a)
Commentary: Electrical injuries are usually caused by alternating current of 60Hz. They are
classified as high voltage injuries when the person comes in contact with 1000V or more, or low
voltage when the voltage is below 1000V. A large number of electrical injuries are work related.
Hussman found cardiac arrhythmias to be the most serious medical problem in patients admitted with low voltage injuries (41% of patients). Other complications are soft tissue burns (especially tissues with high water content, such as nerve, muscle and blood vessels), amputations (especially of the fingers and toes), and neurological injuries (to the central or peripheral nervous system).
Peripheral neuropathy is reported in up to 34% of high voltage injuries and a lower incidence is
found in low voltage injuries.
- A 32-year-old maintenance worker with full-thickness burns involving the right hand and forearm is now ready for compressive garments. Which statement regarding his case is correct?
(a) In order to maximize blood flow to grafted sites, compressive garments should not
exceed 15mmHg.
(b) Compressive garments should be worn a maximum of 18 hours a day to avoid graft site
maceration.
(c) In 4 to 6 months full scar maturation will be achieved and compression garments may be
discontinued.
(d) To maintain adequate pressure, compression garments should be replaced every 2 to 3
months.
Answer: (d)
Commentary: Compressive garments should provide capillary level pressures of at least
25mmHg. Wearing time should be increased gradually to 23 hours per day. Most active scarring
occurs between 4 to 6 months after injury, but full scar maturation may take 12 to 18 months. To
maintain adequate pressure, compression garments should be replaced every 2 to 3 months.
A 41- year-old African-American man had an orthotopic heart transplant 2 months ago. He has started outpatient cardiac rehabilitation, 3 times a week. Compared to an age-matched individual with a normal heart, which finding do you expect in this patient when he exercises?
(a) Lower resting heart rate
(b) Higher oxygen consumption
(c) Slower ability to reach maximal heart rate
(d) Higher peak heart rate during maximal exercise
Answer: (c)
Commentary: A transplanted heart is denervated, and has a higher than normal resting heart rate due to loss of vagal tone. It also has lower oxygen consumption during submaximal exercise than that of the normal heart. It achieves a maximal heart rate more slowly than a normal heart, and the peak heart rate achieved during maximal exercise is considerably lower in cardiac recipients than in age-matched controls.
A 38-year-old woman with cystic fibrosis is scheduled to receive a lung transplant for end-stage pulmonary disease. She has several questions about her pre- and posttransplant rehabilitation program. You advise her that
(a) performing upper limb exercises is contraindicated.
(b) interval exercise training is better than continuous training.
(c) she should wait 5 days, postoperatively, before starting any out of bed activity.
(d) stair-climbing activity should not start until 6 weeks after surgery.
Answer: (b)
Commentary: Preoperative rehabilitation for lung transplant patients is essential to physically
prepare them for the surgery itself, and to manage their failing strength, decreased thoracic
mobility and altered posture. Before surgery, interval exercise training is better than continuous
training. Upper limb exercise has been safely used in rehabilitation programs, although it can
contribute to dyspnea. Lung transplant patients with end-stage pulmonary disease often do better with interval exercise training than with continuous training because less ventilatory demand is required. Progressive activity should be initiated on the first postoperative day, beginning with range of motion exercises. Before discharge from the hospital, the patient should progress to stairclimbing, which is the hallmark of recovery.
Which respiratory measure declines when a patient with tetraplegia moves from a supine to seated position?
a) Total lung capacity
b) Functional residual capacity
c) Vital capacity
d) Residual volume
Answer: (c)
Commentary: With the exception of vital capacity (VC), the direction of change in total lung
capacity and functional residual capacity decrease in the supine position and increase in the
seated position, similar to an individual without a spinal cord injury. In contrast, patients with
tetraplegia or high paraplegia have a decrease in the VC in the seated position, which is the result of an increase in the residual volume (RV) caused by the effect of gravity on the abdominal contents, causing the diaphragm to move down into a less efficient position and increasing the RV.
- In a patient with neuromuscular disease, which pulmonary function parameter best represents
abdominal and chest wall strength?
(a) Tidal volume
(b) Maximal inspiratory pressure
(c) Peak cough
(d) Maximal expiratory pressure
Answer: (d)
Commentary: The maximal inspiratory pressure reflects diaphragm strength and ventilatory
ability. Maximum expiratory pressure is indicative of abdominal and chest wall muscle strength
and the ability to cough and clear secretions. The tidal volume represents the normal volume of
air displaced between normal inhalation and exhalation when extra effort is not applied. Peak
cough flow is a measure of the amount of air flow that a patient can generate during a volitional
cough.
- You are performing a consultation on a 58-year-old man with a history of diabetes and peripheral
vascular disease who presents with a non-healing foot ulcer. You are concerned that he is at risk
for amputation because his
(a) ankle brachial index (ABI) is 0.8.
(b) ABI is 0.4.
(c) transcutaneous oxygen pressure (TcPO2) is 80mmHg.
(d) TcPO2 is 40mmHg.
Answer: (b)
Commentary: ABI is a noninvasive technique that is used in the assessment of arterial occlusive
disease. The ABI is the ratio between the ankle and the brachial systolic pressure. Normal ABI is
defined as values greater than 0.9. An ABI below 0.4 tends to carry a poor prognosis. TcPO2 is
defined as transcutaneous oxygen, which is in essence a “blood gas” of the skin. Normal TcPO2 is
greater than 50mmHg. Values of more than 40mmHg are associated with healing. Ischemia is
defined as periwound TcPO2 < 20mmHg.
- Supplemental oxygen therapy in patients with chronic obstructive pulmonary disease (COPD) has
been shown to
(a) improve walking endurance.
(b) increase blood pressures.
(c) maximize work rate.
(d) produce polycythemia.
Answer: (a)
Commentary: Supplemental oxygen therapy is indicated in patients with arterial partial pressure
of oxygen (PO2) continuously less than 55-60mmHg. Home oxygen therapy can decrease
pulmonary hypertension, polycythemia, blood pressure, and pulse. In patients with mild
hypoxemia and exercise desaturation, supplemental oxygen by nasal prongs did not influence
maximum work rate, but did increase mean walking endurance time and exercise tolerance.
- A patient with neuromuscular disease complains of morning headache and excessive daytime
fatigue. What is your initial diagnostic evaluation?
(a) Order chest radiographs.
(b) Order pulmonary function tests.
(c) Monitor end-tidal carbon dioxide levels.
(d) Measure assisted-cough peak flows.
Answer: (c)
Commentary: Patients with neuromuscular disease (NMD) are often sent for pulmonary function
tests designed for patients with lung disease. Patients with NMD often do not have a history of
asthma or cigarette smoking and most of these tests are unnecessary, except for spirometry.
Because underventilation often begins during sleep, spirometry or simple determination of vital
capacity is best done in the supine position. The patient’s carbon dioxide level will provide
insight into hypoventilation and should be monitored, especially when the patient complains of
excess fatigue and headaches.
- Two-thirds of infections that occur 1 to 6 months post-transplant are caused by
(a) methicillin-resistant staphylococcus aureus (MRSA).
(b) pneumocystis carinii (PCP).
(c) clostridium difficile (C. diff).
(d) cytomegalovirus (CMV).
Answer: D
Commentary: Transplant patients are at high risk for cytomegalovirus (CMV) infection and frequently receive prophylaxis with acyclovir or ganciclovir.
- Patients are NOT candidates for bariatric surgery if they are
(a) twice their ideal body weight.
(b) age 50 or younger.
(c) without a psychiatric contraindication.
(d) experiencing skin breakdown.
Answer: D
Commentary: Surgical candidates include persons who are twice their ideal weight, demonstrate recurrent failure to lose weight through dieting, have no cardiopulmonary or psychiatric contraindications, and are usually50 years of age or younger in most cases, with minor exceptions. Some patients may ask about this procedure when it is recommended they lose weight in order to mitigate musculoskeletal pain.
- Which is the most common neuropsychological dysfunction after a liver transplant?
(a) Seizures
(b) Encephalopathy
(c) Stroke
(d) Depression
Answer: B
Commentary: In a study by Ghaus et al, 62% of liver transplant patients developed encephalopathy. Seizures occurred in 11% and stroke in 9%. In another study by Rothenhausler, 3% of transplant patients had depression.
- You are consulting on a 28-year-old woman with metastatic cervical cancer. She is married with one young child. At this time, she requires minimum to moderate assistance with her mobility and activities of daily living. The oncology service is debating whether to discharge the patient to home with hospice care or to give her inpatient rehabilitation. You inform them that acute inpatient rehabilitation
(a) improves function and quality of life despite the patient being
at the end of her life.
(b) is too much of a physical demand for her and agree with hospice care.
(c) takes time away from the patient being with her family, so hospice is preferable.
(d) will help the patient to some extent, but not as much as a patient without cancer.
(a)
When consulted on a patient with cancer, the physiatrist must balance the need to maximize the patient’s independence through rehabilitation with the desire to have the patient return home as soon as possible. Inpatient rehabilitation is useful to improve the patient’s quality of life. Functional gains have been demonstrated to be significant and comparable to those gained by patients without cancer. The presence of metastatic disease does not influence functional outcome and should not preclude participation.
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- A patient with a history of cancer treated with chemotherapy complains that her feet feel swollen, cold, and painful. The pain is described as shooting and is rated 10/10. On examination, there is no swelling and no temperature changes, but there is hypesthesia and dysesthesia. Of the following choices, which is the most appropriate pain management for this patient?
(a) MS Contin (extended release morphine sulfate) 15 mg every 12 hours
(b) Prednisone taper starting at 60 mg daily
(c) Neurontin (gabapentin) 300 mg 3 times a day
(d) Naprosyn (naproxen) 500 mg twice daily
(c) Many chemotherapeutic agents can cause a peripheral neuropathy. Treatment for neuropathic pain includes membrane-stabilizing medications such as Neurontin. Opiates like MS Contin and non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen are not the first line treatment for neuropathic pain. Prednisone is appropriate for complex regional pain syndrome (CRPS), but CRPS is not common in cancer patients after chemotherapy. Further, this patient probably does not have CRPS, considering the absence of swelling, color changes, or temperature changes.
- A 52-year-old woman with a history of non-alcoholic steatohepatitis underwent a recent liver transplant. Her protein and albumin levels are very low and, on exam, she has anasarca. Your inpatient rehabilitation admission orders should include
(a) referral for paracentesis.
(b) nursing orders to avoid use of an abdominal binder.
(c) high protein diet with high protein oral supplements.
(d) oxandrolone and monitoring of liver enzymes.
(c)Malnutrition is significant in patients with liver disease. Ascites can promote excessive protein loss. Patients should receive a high protein diet with high protein oral supplements when they are in rehabilitation. Paracentesis would be required only if the patient was having symptoms from the ascites and would probably not be appropriate in the admission orders. Oxandrolone carries a risk of liver damage and therefore should not be prescribed in this patient. Abdominal binders may be used to help with ascites, particularly if the patient has an umbilical hernia from it.
A 47-year-old man with human immunodeficiency virus (HIV) presents with fever, headache, and memory loss. The most likely diagnosis is
(a) progressive multifocal leukoencephalopathy (PML).
(b) HIV encephalopathy.
(c) cryptococcal meningitis.
(d) central nervous system (CNS) lymphoma.
(c) The patient most likely has cryptococcal meningitis. Fever would not be present in PML, HIV encephalopathy, or CNS lymphoma. In addition, headache is typically not a feature of PML or HIV encephalopathy.
- Which statement about primary cerebral lymphoma is TRUE?
(a) It has an increased incidence in patients with (HIV) infection.
(b) It usually presents as a solitary tumor.
(c) It is treated surgically for improved outcome.
(d) It has a median survival of approximately 2 years.
(a) Primary cerebral lymphoma presents as multiple tumor deposits in the brain and has an increased incidence in patients infected with human immunodeficiency virus (HIV). Surgical removal does not improve outcome.
- A 70-year-old man underwent a 2-vessel coronary artery bypass graft and mechanical mitral valve replacement five days ago. You note that he is presently taking Coumadin (warfarin). The primary reason to put this patient on Coumadin after this procedure is to prevent
(a) deep vein thrombosis.
(b) embolic stroke.
(c) coronary artery occlusion.
(d) valvular adhesion.
(b)Patients are anticoagulated following mechanical valve replacements to prevent thromboembolic strokes. Anticoagulation will also prevent deep vein thromboses, but this is not the primary reason why it is prescribed.
- What is the measure of the rate of oxygen utilization for the production of energy?
(a) V．O2mi
n (b) Peak V．O2
(c) V．2max
O(d) V．O2
(d) Oxygen uptake (VO2) is the measure used to describe the rate at which oxygen is used in the production of energy. Maximal oxygen uptake (VO2max) is the maximal rate at which an individual can use oxygen. Peak VO2 is the measure of oxygen uptake stated when the highest attainable VO2 may not have been reached due to external factors. There is no VO2min measure.
- The most common benign brain tumor in adults is
(a) astrocytoma.
(b) oligoblastoma.
(c) medulloblastoma.
(d) meningioma.
(d) Meningiomas are the most common benign brain tumor, comprising about 15% of all primary brain tumors.
- A 45-year-old woman with advanced acquired immunodeficiency syndrome (AIDS) presents with a gradual onset of forgetfulness and inattention without other focal neurologic deficits. Review of systems is negative for headache and fever. The most likely diagnosis is
(a) toxoplasmosis.
(b) cryptococcal meningitis.
(c) human immunodeficiency virus (HIV) encephalopathy.
(d) central nervous system (CNS) lymphoma.
(c) Also known as AIDS-dementia complex, human immunodeficiency virus (HIV) encephalopathy is usually seen late in the disease course. HIV encephalopathy develops in weeks to months, whereas symptoms of toxoplasmosis and central nervous system (CNS) lymphoma are seen in days to weeks. Fever and headache, along with mental status changes, would be seen in cryptococcal meningitis. Headaches, seizures, and fatigue are commonly seen in toxoplasmosis, along with focal or non-focal neurologic signs. In C
- A 58-year-old man sustained a myocardial infarction 1 week ago. He is undergoing phase 1 of cardiac rehabilitation. His activity level should be limited to how many metabolic equivalents (METs)?
(a) 1
(b) 3
(c) 5
(d) 7
(c) After a myocardial infarction, exercise intensity should start at 2 metabolic equivalents (METs) and gradually progress to a maximum of 5 METs. Patients should await myocardial infarct healing before vigorous exercise greater than 5 METs is performed, usually within 4 to 6 weeks post infarctioin.
- Standing at ease is equivalent to how many metabolic equivalents (METs)?
(a) 1.5 to 2.0
(b) 2.5 to 3.0
(c) 4.0 to 4.5
(d) 5.0 to 5.5
(a) Lying quietly is 1.0 MET. Light housework is 1.2-3.0 METs. Standing at ease is 1.4-2.0 METs. Walking at 3 miles per hour is equivalent to 4.3 METs.
A 67-year-old woman was just admitted to the general rehabilitation unit after a complicated 2-
month course at the acute care hospital. When the physical therapist gets her out of bed on the first
day, what is the most likely finding?
(a) Blood pressure goes from 120/80 to 150/100.
(b) Blood pressure goes from 120/80 to 90/50.
(c) Heart rate goes from 80 to 60.
(d) Heart rate remains at 60.
(b) Orthostatic hypotension is a common cardiovascular complication of immobility. Lying in bed for
a prolonged time causes a central fluid shift that results in an increased intravascular volume. There
is a resultant diuresis and decrease in plasma volume. When a person stands after bed rest, venous
pooling occurs in the lower extremities due to increased venous compliance (orthostatic
intolerance). Person also has blunted cardiac response to rapid changes in posture. With
immobility and deconditioning, the resting heart rate increases, and the heart rate response to
exercise also increases.
- A 36-year-old breast cancer patient presents with myofascial pain involving the upper and middle
trapezius and levator scapulae muscles. She underwent modified radical mastectomy and chest wall
irradiation 1 year ago. The breast has been reconstructed with a rather large implant. You note that
her acromial process on the affected side is depressed and protracted. Lasting relief will most likely
be achieved through a physical therapy program emphasizing
(a) ultrasound followed by shoulder mobilization.
(b) stretching of the pectoralis major and minor muscles.
(c) electrical stimulation of the painful muscles.
(d) isometric resistive exercise of the rhomboid muscles.
b) Muscles within any radiation field are at risk for fibrosis and contracture. The pectoralis major and
minor muscles are commonly shortened following radiation to the chest wall, an integral
component of breast conservation therapy. Radiation-induced shortening of the pectoralis muscles
pulls the scapula into a protracted and depressed position which places tension on the medial and
superior scapular stabilizers. To achieve long-term relief, this patient will require stretching of the
pectoralis muscles
- A 50-year-old man is transferred to your rehabilitation unit after a cardiac transplant. Because of the
transplant, you anticipate that he will have a
(a) lower than normal resting heart rate.
(b) decreased time to achieve maximal heart rate during exercise.
(c) lower than normal peak heart rate achieved during maximal exercise.
(d) lower than normal systolic and diastolic blood pressure.
(c) A transplanted heart is denervated, so it achieves maximal heart rate more slowly because it relies
on circulating catecholamines to achieve a response. The resting heart rate is higher than normal,
most likely because of the loss in vagal input. Peak heart rate achieved during maximal exercise is
considerably lower in transplant patients compare.
- What is the most common primary malignant tumor of the brain in adults?
(a) Medulloblastoma
(b) Meningioma
(c) Glioblastoma multiform
(d) Ependymoblastoma
(c) More than 90% of the primary malignant tumors of the brain in adults are high-grade astrocytomas
and, of these, the most common is glioblastoma multiform. Meningiomas are tumors that occur in
the membranes that cover and protect the brain and spinal cord (the meninges). Meningiomas
usually grow slowly. Medulloblastomas are almost always found in children or young adults.
- What is the primary underlying cause of the restrictive lung disorders that are common in many
neuromuscular disorders?
(a) Recurrent pneumonia
(b) Prolonged wheelchair use
(c) Respiratory muscle weakness
(d) Intrinsic lung damage
(c) Respiratory impairment in neuromuscular disease is due to weakness of the diaphragm, chest, and
abdominal musculature. The other listed factors have not been shown to play a significant role
- The surgical transplant service requests physical therapy recommendations for a patient beginning
to reject a single lung transplant. In addition to pursed lip and diaphragmatic breathing,
recommendations should include
(a) a focus on passive stretching and isometrics.
(b) telemetry monitoring while out of bed.
(c) an aerobic exercise program.
(d) minimizing of supplemental oxygen.
(c) During rejection, lung transplant patients should perform basic breathing exercises. They can
continue to perform aerobic exercise as tolerated with oxygen supplementation.
- Which structure is NOT part of the pain pathway for rapid transmission of immediate pain?
(a) Rexus lamina 2,3
(b) Lissauer’s tract
(c) C fibers
(d) Periaqueductal gray matter
(c) C fibers are unmyelinated fibers that modulate slow pain (“second pain”) rather than acute pain.
“First pain” is mediated by A-delta nociceptors and is brief and localized.
- A pulmonary rehabilitation patient has a temperature of 101.5° and is breathing at a rate of 10
breaths per minute. In order to optimize his percent hemoglobin saturation at a given O2 partial
pressure, it would be best to
(a) administer an antipyretic and encourage him to breathe more rapidly.
(b) not treat his fever, but encourage him to breathe more rapidly.
(c) administer an antipyretic and encourage him to maintain his current respiratory rate.
(d) not treat his fever and encourage him to maintain his current respiratory rate.
(a) A number of different factors have the capacity to shift the hemoglobin-oxygen dissociation curve.
Acidosis, elevated temperature, and increased PCO2 all cause the curve to shift to the right. Thus,
controlling this patients fever and encouraging him to expire more rapidly thereby reducing PCO2
and acidosis and would increase the degree of hemoglobin saturation at a given O2 partial pressure.
- A 75-year-old patient with metastatic breast cancer, hypertension, and diabetes is admitted to the
hospital for radiation of a pathological femoral fracture. Her severe osseous pain was controlled
during the initial 72 hours of admission with intravenous morphine, 5 mg/hour. Eager to facilitate
discharge, a well-meaning house officer converts her to oral sustained-release morphine sulfate,
120 mg tid. Twenty-four hours after receiving the first dose of oral morphine, the patient becomes
increasingly confused and somnolent. The most likely explanation for this change in mental status
is
(a) the dose of oral morphine is excessive (not an accurate IV to PO conversion).
(b) radiation-induced hypersomnolence.
(c) accumulation of morphine metabolites.
(d) hypercalcemia.
(c) Morphine sulfate is glucoronidated in the liver to produce two metabolites; morphine-6-glucoronide
and morphine-3-glucoronide. Both of these compounds are renally excreted and can accumulate in
elderly patients with compromised renal function. Morphine-6-glucoronide is a m-receptor agonist
and is believed to contribute to morphine-induced analgesia. Morphine-3-glucoronide has been
implicated in the undesirable neuropsychological side effects of morphine therapy and does not
provide significant analgesia. Due to first-pass effect, the serum concentration of morphine
metabolites is much higher when morphine is administered orally
- A thrombocytopenic cancer patient has severe pain related to osseous metastases. Recognizing
that pain from osteolytic metastases is prostaglandin mediated, you choose to initiate therapy with
(a) Naproxen (Naprosyn, Aleve).
(b) Celecoxib (Celebrex).
(c) Valproic acid (Depakote).
(d) Acetaminophen (Tylenol).
(b) Nonsteroidal anti-inflammatory drugs reversibly inhibit cyclooxygenase, the enzyme responsible
for the conversion of arachadonic acid to prostaglandins. Given the importance of prostaglandins in
mediating metastatic bone pain, use of an NSAID represents appropriate first-line therapy for this
patient. For thrombocytopenic patients, use of a cyclooxygenase-2 specific inhibitor such as
celecoxib or refocoxib will place the patient at a much lower risk of hemorrhage.
- In conducting an exercise tolerance test on a patient with a history of exertional angina, a fall in
systolic blood pressure at Bruce Protocol Stage II should trigger
(a) stabilization at the current exercise level.
(b) an increase in exercise intensity.
(c) discontinuation of the test.
(d) a reduction in exercise intensity.
(c) If systolic blood pressure fails to rise during exercise testing with increasing workload, ischemia
should be suspected. A fall in systolic blood pressure may reflect significant ischemia and is an
indication for aborting the exercise tolerance test.
- A leukemic patient undergoing allogeniec bone marrow transplant has recovered from a painful
varicella zoster outbreak. He continues to complain of dysesthetic pain in the affected dermatome.
Hoping to reduce to patient’s risk of developing chronic post-herpetic neuralgia, you initiate
therapy with
(a) oxycodone (Roxicodone).
(b) ibuprofen (Motrin).
(c) carbamazepine (Tegretol).
(d) amitriptyline (Elavil).
(d) Of the medications listed, only amitriptyline has been demonstrated to reduce the incidence and
severity of post-herpetic neuralgia. While carbamazepine has well demonstrated analgesic effects,
it would be a poor choice in a bone marrow transplant patient given the risk of aggravating
leukopenia. Similarly, the anti-platelet effects of ibuprofen are undesirable in this clinical context.
While opioids have been shown to be effective in controlling neuropathic pain, adjuvant analgesics
generally remain first-line therapy. Opioids have not been shown to influence the incidence of
post-herpetic neuralgia.
- At the time of seroconversion, an HIV-infected patient treated prophylactically with azathioprine
(AZT) for 4 months develops rapidly progressive weakness of all extremities over several days
with sensory sparing. Distal and proximal weakness are comparable. The most likely cause of
weakness is
(a) Chronic demyelinating polyneuropathy.
(b) Acute demyelinating polyneuropathy.
(c) HIV myopathy.
(d) AZT myopathy.
(b) AIDP generally develops over days in HIV patients early in the course of disease. Often AIDP
presents at the time of seroconversion. While CIDP may also develop early in the disease course, it
usually develops gradually, over weeks. Myopathy does not occur at a particular stage in the
disease. Similar to most myopathic processes, HIV myopathy affects proximal muscles to a greater
extent. AZT myopathy presents after 9 or more months of drug use.
- When referring to the neurological manifestations of HIV, time locking describes
(a) the simultaneous occurrence of central and peripheral nervous systems processes.
(b) the occurrence of multiple pathological processes within one part of the neuraxis.
(c) the tendency for particular neurological processes to occur during certain disease stages.
(d) the capacity of a neurological or medical process to exacerbate a subclinical neurological
process.
(c) Time locking refers to the predictability with which certain neurological manifestations of HIV
develop during particular disease stages. For example, AIDS dementia complex is a late
complication of AIDS which generally occurs when the CD4 count falls below 250/ml. O’Dell MW, Dillon ME. Rehabilitation management in persons with AIDS and HIV infection.
- A patient with stable angina develops chest pain and EKG changes during stage V of the Bruce
protocol. You inform him that his risk of suffering a myocardial infarction during moderate
exertion is
(a) none.
(b) low.
(c) moderate.
(d) high.
(b) Patients who are able to complete Stage IV of the Bruce protocol without anginal symptoms have a
low risk of myocardial infarction. Glassman SJ, Rashbaum IG, Walker WC. Candiopulmonary rehabilitation and cancer rehabilitation. 1.
- A patient presents with Stage I upper extremity lymphedema related to primary breast cancer
therapy. She is interested in pharmaceutical and dietary treatment options. Which of the
following would be appropriate in the management of this patient?
(a) Reduced protein consumption
(b) Treatment with a diuretic
(c) Reduced salt consumption
(d) Treatment with a benzopyrone.
(c) Moderation in salt consumption will avoid increased intravascular volume and capillary
ultrafiltration thereby reducing the likelihood of lymphedema progession. Diuretics should not be
used in the management of uncomplicated lymphedema. Reduced protein consumption will
potentially lead to hypoalbuminemia and reduced colloid osmotic pressure of the plasma. This will
increase ultrafiltration, worsening lymphedema. Benzopyrone therapy has not been shown to
benefit lymphedema related to breast cancer, and is associated with hepatotoxicity
- Delerium commonly complicates the rehabilitation of patients with advanced cancer. The most
common cause of delerium in this patient population is
(a) organ failure.
(b) drugs.
(c) hypoxia.
(d) brain lesions.
(b) In a series of 140 cancer patients with delerium, 59% were found to have some degree of
phyarmacological contribution. Organ failure, fluid/electrolyte imbalance, and infection were also
important contributing factors. Posner JB. Neurologic complications of cancer
- Which statement is TRUE regarding central nervous system (CNS) tumors?
(a) Meningiomas are the most common form of primary tumor
(b) Metastatic disease makes up approximately 50% of CNS tumors
(c) Glioblastoma multiforme has a median survival rate of 5 years
(d) Brain tumor treatment side effects do not affect outcome
(b) Meningiomas are the second most common form of primary tumors. Gliomas are the most
common. Glioblastoma multiforme has a median survival rate of less than 1 year. Treatment side
effects do affect outcome. Fifty percent of CNS tumors are metastatic.
- Which of the listed vaccinations should be given as part of appropriate medical management for
patients participating in a comprehensive pulmonary rehabilitation program?
(a) Legionella and mycoplasma avium intracellulare
(b) Influenza and mycoplasma avium intracellulare
(c) Pneumococcus and legionella
(d) Influenza and pneumococcus
(d) Medical management including appropriate use of inhalers, early antibiotic therapy for respiratory
infections, pneumococcal vaccine, and annual influenza vaccine.
- During aerobic exercise, patients with cystic fibrosis should
(a) avoid use of supplemental oxygen.
(b) receive balanced fluid supplementation.
(c) receive hypotonic fluid supplementation.
(d) utilize supplementation oxygen for oxygen saturation <94%.
(b) Patients with cystic fibrosis are at risk for excessive sodium and chloride loss during exercise.
They should therefore receive balanced fluid supplementation. Oxygen is indicated if patients’
oxygen saturation drops below 88%.
- A head and neck cancer patient completed external beam radiation therapy 1 week ago. You inform
the patient that prevention of cervical soft tissue contractures requires daily cervical range-of-motion
exercises for at least
(a) 1 month.
(b) 6 months.
(c) 1 year.
(d) 5 years.
(d) The late effects of external beam radiation therapy can continue for at least 5 years. Fibrosis of
fascia, skin, and muscles following radiation therapy is mediated by radiation-induced
microvascular injury. Daily cervical range-of -motion exercises should be performed for at least 5
years after completion of treatment to insure that progressive fibrosis does not occur.
- A patient with squamous cell carcinoma of the larynx elected to undergo organ preservation therapy
with intensive external beam radiation therapy to the anterior neck. He now presents with painless
bilateral lower extremity weakness. Which initial diagnostic test is most likely to be abnormal?
(a) Magnetic resonance imaging of the brain
(b) Nerve conduction studies of the lower extremities
(c) Thyroid stimulating hormone level test
(d) Computed tomography scan of the abdomen
(c) Patients who receive external beam radiation therapy to the anterior neck are at risk for developing
hypothyroidism. If their thyroid function tests are not monitored, they may initially present with
signs and symptoms of hypothyroidism. Myopathy is a common presenting complaint. This patient
is also at risk for radiation induced cervical myelopathy. However, since radiation
hypofractionation techniques have become the standard of care, the incidence of this dreaded
complication has significantly diminished.
- A patient with far advanced prostate cancer metastatic to liver and bone achieves pain control
through the use of a subcutaneous hydromorphone infusion. The therapy is complicated by
significant sedation. You therefore initiate therapy with
(a) Clonidine (Catapres).
(b) Pemoline (Cylert).
(c) Methylphenidate (Ritalin).
(d) Naloxone (Narcan).
(c) Opioid-based pharmacotherapy is the current standard of care for severe cancer-related pain. Side
effect management is an integral dimension of competent pain management. Opioid-induced
sedation can be managed through the use of psychostimulants such as methylphenidate (Ritalin).
Epidural and intrathecal drug delivery can also be used to minimize neuropsychological toxicity.
Pemoline (Cylert), a psychostimulant, is not widely used because of concern over hepatotoxocity,
particularly in patients with liver metastases.
- A young breast cancer survivor expresses concern over her risk of developing lymphedema. You
explain that an increased incidence of lymphedema is associated with
(a) hypertension.
(b) diabetes mellitus.
(c) osteoarthritis.
(d) obesity
(d) Obesity and weight gain has consistently been shown to increase breast cancer survivors’ risk of
developing lymphedema.
- After cardiac rehabilitation, patients with coronary artery disease remain asymptomatic at exertional
levels that previously provoked angina. This change occurs primarily because of increased
(a) coronary collateralization and neoangiogenesis.
(b) serum hemoglobin concentrations.
(c) myocardial mitochondrial enzyme concentrations.
(d) oxidative enzyme concentrations in skeletal muscle.
(d) Peripheral training effects are largely responsible for the enhanced functional status of patients who
undergo cardiac rehabilitation. Increased oxygen extraction and a wider arteriovenous oxygen
difference have been described. Improved utilization of oxygen by active muscles, because of an
increase in oxidative enzymes, is an important factor.
- For optimal sensitivity, cardiac stress testing conducted 4 to 8 weeks following myocardial infarction
must proceed to what percentage of a patient’s age-adjusted maximal heart rate?
(a) 60%
(b) 75%
(c) 85%
(d) 90%
(c) For both functional and diagnostic testing, patients must proceed to 85% of their age-adjusted
maximal heart rate. Otherwise half of the abnormalities will be missed. Patients on beta blockers
should be tested to a work load that would incur oxygen consumption of 80% of maximal oxygen
consuption (V02.max).
- In a patient being evaluated for pulmonary rehabilitation, which sign suggests restrictive lung
disease?
(a) Plentiful sputum production
(b) Pursed lip breathing
(c) Paradoxical breathing
(d) Hyperresonant lung sounds
(c) Patients with restrictive lung disease, contingent on the underlying etiology, will rely on purely
diaphragmatic or paradoxical breathing. Sputum production, auxillary muscle use, and
hyperresonant lung sounds are characteristic of patients with predominant oxygenation impairment.
Pursed lip breathing is used to prevent end expiratory airway collapse.
- A patient with Kugelberg-Welander disease is hospitalized with acute respiratory failure. Work-up
reveals the patient to have peak cough flows less than 270L/min. After successfully weaning the
patient from ventilatory support, in order to minimize future episodes of acute respiratory failure,
you instruct the patient in
(a) manually assisted cough.
(b) air shifting.
(c) pursed lip breathing.
(d) inspiratory resistive loading.
(a) During otherwise benign upper respiratory tract infections, patients with predominantly ventilatory
impairment generally develop acute respiratory failure due to ineffective coughing. When peak
cough flows are less than 300L/min patients should be taught maximal insufflation techniques.
- A 45-year-old breast cancer patient complains of diminished exertional tolerance. She completed
adjuvant chemotherapy 1 year ago. Chest x-ray reveals evidence of congestive heart failure. Which
agents could have caused this patient’s symptoms?
(a) Cyclophosphamide (Cytoxan) and methotrexate (Rheumatrix)
(b) Docetaxel (Taxotere) and bleomycin (Blenoxane)
(c) Cisplatinum (Platinal AQ) and 5-fluorouracil (5-FU)
(d) Doxorubicin (Adriamycin) and herceptin (Trastuzumab)
(d) Doxorubicin (Adriamycin) and herceptin (Trastizumab) are increasingly common antineoplastics
used in primary breast cancer treatment. Both are associated with cardiac toxicity. Patients who
receive either agent have a multigated angiogram (MUGA) scan prior to the initiation of
chemotherapy to establish baseline cardiac function. Signs or symptoms suggestive of cardiac
failure indicate the need for a repeat MUGA scan and referral to a cardiologist.
- A 65-year-old brain tumor patient receiving inpatient rehabilitation develops nausea, fever, and
headache several hours after radiation therapy. You prescribe
(a) ceftriaxone.
(b) dexamethasone.
(c) nimodipine.
(d) sumatriptan.
(b) Radiation reactions may occur at any time during or after radiation therapy. Acute reactions that
occur within hours after the first dose are caused by edema, and manifested by headache, nausea,
vomiting, somnolence and fever. Worsening neurological symptoms may occur with dose fractions
greater than 2 Gray. Symptoms are preventable through use of corticosteroids, eg, dexamethasone 2
mg daily or twice daily.
- Workers who participate in a cardiovascular training program have been found to
(a) communicate with their supervisors better.
(b) be more efficient.
(c) have better job performance evaluations.
(d) report fewer sick days.
(d) Workers who participated in a cardiovascular training program were compared to a control group.
Those in the training program reported 51% fewer sick days than controls despite no change in their
maximum oxygen consumption (VO2max).
- You are conducting an exercise tolerance test on a patient 2 months after successful heart transplant.
Relative to a patient with similar clinical characteristics following coronary artery bypass grafting,
you would rely more heavily on monitoring which parameter?
(a) Heart rate
(b) Perception of pain
(c) Intracardiac pressure via Swan Ganz
(d) Electrocardiogram changes
(d) The transplanted heart is denervated and therefore cardiac ischemia does not cause pain. Because
vagal tone is lost, the resting heart rate following transplant is close to 100 beats per minute.
Exercise induced increase in heart rate is blunted and peak heart rates are generally 20% to 25%
lower than age-matched controls. Swan Ganz monitoring is not required. Braddom RL, editor. Physical medicine and rehabilitation.
- In reviewing the pulmonary function tests of a patient with Duchenne muscular dystrophy before
prescribing an exercise program, relative to a healthy normal person, you would expect the patient to
have
(a) increased tidal volume and increased functional residual capacity.
(b) decreased tidal volume and decreased functional residual capacity.
(c) increased tidal volume and unchanged vital capacity.
(d) unchanged tidal volume and decreased vital capacity.
(b) Duchenne muscular dystrophy, like all myopathies, causes a restrictive pattern of respiratory
compromise. Therefore, functional residual capacity, tidal volume, residual capacity, and vital
capacity are all reduced relative to age-matched normals.
- A patient with advanced chronic obstructive pulmonary disease (COPD), coronary artery disease,
and copious airway secretions has begun a pulmonary rehabilitation program. The program
involves progressive aerobic conditioning on a treadmill. In order to enhance the efficacy of the
program, you recommend all the following EXCEPT
(a) nutritional counseling and increased carbohydrate intake.
(b) application of positive airway pressure breathing.
(c) low flow supplemental intranasal oxygen.
(d) inspiratory resistive loading.
(a) Optimizing the nutritional status of patients undergoing pulmonary rehabilitation is critical for
treatment success. However, inappropriately increasing carbohydrate consumption can aggravate
hypercapnia. DeLisa JA, Gans BM, editors.
- Regarding exercise in severe heart failure, which of the following is true?
(a) Strengthening should be done isometrically.
(b) Exercise heart rate should be at 80%-90% of estimated maximum heart rate.
(c) Rapid hemodynamic changes may occur during warm-water aquatic therapy.
(d) Telemetry is never necessary.
(c) One limitation to the use of aquatic therapy in severe heart failure is its potential to produce rapid
hemodynamic changes. Isometric strengthening can result in increased afterload, with the
possibility of deleterious effects on ventricular function. In severe heart failure, it is generally
recommended that the exercise heart rate be kept at least 10 beats per minute below the
arrhythmia/severe dyspnea level. Telemetry is recommended in this population (at least at the
initiation of their exercise program), as they are usually at the highest level of risk stratification.
- The most common symptom associated with cancer and its treatment is
(a) pain.
(b) weakness.
(c) anorexia.
(d) fatigue.
(d) Fatigue is the most common complaint of cancer patients, affecting up to 78% of patients, with
70% noting that fatigue affected their daily routine. Portenoy RK, Miaskowski C. Assessment and management of cancer-related fatigue
- Which of the following conditions is least likely to exacerbate preexistent lymphedema?
(a) Scuba diving in cold water
(b) Airplane travel
(c) Phlebotomy
(d) Sun exposure
(a) Conditions associated with decreased atmospheric pressure will cause lymphedema to progress.
Activities or situations that lead to increased blood flow in the affected extremity (eg, burns, heat,
physical exertion, trauma) exacerbate lymphedema. Atmospheric pressure increases during scuba
diving, therefore, it has the capacity to ameliorate lymphedema.
- A patient with metastatic lung cancer presents to the emergency department with new-onset back
pain and lower extremity weakness suspected to be due to spinal metastases. Initial management
should include
(a) observation for 24 hours and careful reexamination for progressive neurologic deficits.
(b) emergent irradiation prior to imaging.
(c) empiric administration of high-dose dexamethasone in the absence of contraindications.
(d) alteration of the patient’s chemotherapy regimen
(c) A randomized controlled trial of high-dose steroids (96mg dexamethasone) versus placebo
concluded that steroid-treated patients with spinal cord compression from malignant epidural
disease were more likely to retain or regain ambulation. Surgery and radiation may be indicated,
contingent on tumor location and type and on prior radiation history. Dexamethasone should be
administered to patients before imaging in order to alleviate pain and to optimize neurologic
recovery. (a) Posner JB. Neurologic complications of cancer.
- A 45-year-old colon cancer patient presents with new urinary incontinence and dull pain radiating
into the right buttock. Physical examination fails to reveal evidence of lower extremity motor or
sensory deficits. Of the following, the MOST appropriate next step in the patient’s evaluation
would include
(a) pelvic computed tomography with contrast.
(b) lower extremity electromyogram.
(c) positron-emission tomography scan.
(d) urodynamics studies.
(a) The sacral plexus is usually involved by tumor from the colon, prostate, bladder, or uterus.
Presenting symptoms usually begin as a dull, aching, midline pain, which may radiate into the
buttocks. The pain may be associated with numbness in the perianal region. Numbness and
aresthesias may extend to involve the buttock and posterior aspect of the thigh. Bowel and bladder
function are often compromised. Computed tomography and magnetic resonance imaging scans of
the pelvis are excellent tools for detecting presacral masses and sacral destruction.
- Patients with head and neck malignancies who are receiving radiation therapy should be instructed
that cervical range-of-motion activities should be
(a) initiated only when radiation sessions have been completed.
(b) performed throughout the course of radiation therapy to prevent contracture.
(c) limited to movement planes contralateral to the involved side.
(d) initiated no sooner than 1 month after radiation therapy.
(b) Radiation therapy causes rapid and potentially irreversible fibrosis of muscle and other soft tissue
structures. In order to mitigate the inevitable fibrosis that attends high-dose external-beam radiation
therapy delivered to patients with head and neck cancer, cervical range-of-motion exercises should
begin at the outset of radiation and be continued through the entire course.
- In general, the risk of fracture is lower for blastic metastases than for lytic metastases. Which one
of the following tumors tends to form blastic metastases?
(a) Lung
(b) Multiple myeloma
(c) Prostate
(d) Renal cell
(c) In general, lytic lesions are considered more prone to fracture, although blastic lesions are not
immune to fracture. Lytic lesions typically occur with primary or metastatic lesions of the
following malignancies: breast, lung, kidney, thyroid, gastrointestinal tumors, neuroblastoma,
lymphoma, and melanoma. Prostate cancer tends to form blastic metastases.
- The most common neurologic disturbance associated with cranial irradiation is
(a) short-term memory deficit.
(b) anomia.
(c) bradykinesia.
(d) high-frequency hearing loss.
(a) Cranial irradiation typically has more side effects in children than in adults. Common side effects
include short-term memory loss, fatigue, and occasional gait apraxia.
rehabilitation: the complete approach. Malden (MA): Blackwell Science; 2000. p 1701.
134. Foot ulcers in patients with diabetes
(a) are frequently associated with plantar foot callus.
(b) commonly occur even with clinically asymptomatic neuropathy.
(c) are most frequently located over the malleolus.
(d) are more common when subtalar hypermobility exists.
(a) Neuropathic ulcers typically occur in patients with impaired or absent sensation due to peripheral
neuropathy. Plantar callus formation is indicative of excessive pressure and is a common site of
ulcer formation. Ulcers most commonly occur under the metatarsal heads and toes and along the
lateral borders of the forefoot. Rigidity of the subtalar and ankle joints adversely alters plantar
pressures and increases the risk of ulceration. Changes in joint motion are the result of increased
glycosylation of collagen and associated thickening and cross linking of collagen bundles seen in
diabetes
- Noninvasive nocturnal assisted ventilation in patients with neuromuscular disease has been
associated with
(a) increased polycythemia.
(b) accelerated pulmonary hypertension.
(c) decreased daytime PaCO2.
(d) increased daytime fatigue.
(c) Assisted ventilation should be considered in pulmonary involvement from neuromuscular disease.
Alternative measures such as low-flow oxygen may exacerbate hypercapnia. Gay PC, Edmonds LC. Severe hypercapnia after low-flow oxygen therapy in patients with neuromuscular
disease and diaphragmatic dysfunction
