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.
