OSCE practice questions Flashcards
slay the osce exam
Safety Consideration BEFORE exercise for CAD?
Check medication compliance!!
if they dont have nitrate spray, they cannot proceed with exercise: spray every 5 minutes underneath the tongue
ensure to ask: have you had any recent heart palpitations?
Could be indication of more serious conditions (left ventricular dysfunction or myocardial ischemia)
Unstable angina is a contraindication to exercise: onset is unpredictable, can occur at rest, may be a precursor to MI
Uncontrolled HT (>180/110mmHg) - this is an ABSOLUTE CONTRAINDICATION, unstable heart disease, aortic aneurysm, symptomatic hernias, proliferative diabetic retinopathy, retinal laser surgery in last 6 wks, rapidly progressive or terminal illness.
Educate pt’s on angina and its symptoms, their own symptoms, and immediate treatment
Safety Consideration DURING exercise for CAD?
Angina → Potential circumstance of mild chest pain episode → ensure to stop exercise and give him break and recovery; If it goes back down to 0, we can allow him to resume exercise
Hypertensive thresholds
* SBP > 250mmHg or DBP > 115mmHg
* Exaggerated BP response of ≥ 40mmHg SBP to small increase in workload
* Inadequate rise or a drop in blood pressure after commencing exercise, or after increasing intensity – this can indicate severe conditions such as aortic stenosis, left ventricular dysfunction or myocardial ischaemia
Ischaemic/angina/arrhythmic thresholds
* ≥ 1mm ST depression (use RPP at pre-determined IT from CET test - ECG)
* ≥ 2 on the angina scale (moderate)
Use Angina Scale: If pt verbalises 1 on the angina scale, ↓ ex intensity until resolved, stop completely if ≥ 2 & follow administration of nitrates.
Be aware there is silent ischemia, i.e. no angina (pain) – careful monitoring of BP and HR for IT
* Venitrcular arrhythmic threshold (many)
* ≥ 3 on claudication scale (mild)
stop and let pain resolve, then commence next work interval
WARM UP AND COOL DOWN!! (WU/CD)
● prevent sharp increase in workload:
o Change in the arterial haemodynamic resulting in reflex tachycardia (sudden spike in HR)
● Suitable warm up will reduce the incidence of exercise induced myocardial ischaemia or arrythmias
● Ineffective WU/CD may be primary reason for exercise related cardiac problems
VOLUME AND NOT INTENSITY APPEARS TO DRIVE BP AND HR, HIGHER INTENSITIES WITH LOWER REPS APPEAR SAFER…
Aerobic: Initially BP, RPE, angina/claudication scale monitoring every 3-5min then move to every 15-20 min once exercise responses through program are consistent (use HR & BP to calculate RPP and ensure to remain below any predetermined thresholds from CET)
PRT: PRT Monitoring
* Continual monitoring of HR (rest, during and recovery)
* Initially monitor BP and calculate RPP pre and post set
* Monitor RPE within first 1-2 repetitions of a set and initially maintain at 13 ‘somewhat’ hard for first 1-2 weeks and then move to 16 ‘hard’
PRT Post MI with stenting intervention:
* Begin Light-Mod weights 3-5 wks post
PRT Post MI with CABG intervention:
* Very Light weights (20-40% of RM) can begin approx 4 weeks after discharge
* Moderate weights (40-60% of RM) 8 weeks post
* Avoid upper body weights >50%MVC for 8-12 wks to allow sternal healing
PRT Technique
* Rhythmical manner at a slow to moderate controlled speed.
* Perform through full joint range of motion
* Avoid holding breath and straining as this may cause excessive rise in BP
* Proper form should be emphasized, lift weight slowly and smoothly, exhale on exertion and inhale during relaxation (2 sec exhale/4 sec inhale)
* Alternate between upper and lower body work to allow for adequate rest between exercises
PRT and PAD
* PRT focus if claudication severe or other limiting factors such as ulcers, painful neuropathy, healing surgical wounds (however avoid leg press) or high falls risk
Previous MI
* ↓ aerobic capacity (50-70%)
* ↓ contractile force of LV → progressive ↓ in EF & SV – manifested as blunted or ↓ SBP response to progressive ex
* May have restricted HR ↑ due to intrinsic disease of SA or AV node
* Anginal symptoms with/without ST segment change, precluding ex to a > level
* Carefully monitor for signs/symptoms of graft occlusion or restenosis (ECG monitoring maybe helpful here)
* Participation in outpatient CR PG should commence ASAP after discharge
* Major consideration is surgical wound discomfort and healing
* Care should be taken with use of weights and upper body activities, the sternum is not fully healed for approx 8-12 weeks
* Teach pt’s about avoiding ADL stress on the healing sternum
* Swimming particularly in public pools should be avoided until wounds are healed to reduce likelihood of infection
* Have pt’s GP check sternum for stability (chest discomfort, clicking) prior to advancing to upper body ex training
Safety Consideration POST exercise for CAD?
Hypertensive Thresholds
● SBP >250mmHg OR DBP > 115 mmHg
● BP has an exaggerated response of ≥ 40 mmHg SBP !!
● No noticeable / Adequate rise or drop in BP pre, during or post exercise
- Could be indication of more serious conditions (left ventricular dysfunction or myocardial ischemia)
Post exercise hypotension
* In most cases this is a beneficial acute effect of exercise, however dependent on medications there could be risk of an exaggerated response
Keep an eye on recovery BP, make sure it returns to resting value or below
* In some instances BP may remain high which could indicate left ventricular dysfunction
In high risk patients watch ST segment returns to pre-exercise levels before turning off monitoring
* ST segment changes is more for CET scenario
* Use HR and SBP to calculate RPP and ensure that returns close to pre-exercise levels
Monitor signs and symptoms
Safety Consideration PRE exercise for PAD?
● Ensure that the client has taken their medication (FIRST THING ALWAYS!)
● Ensure the pt is educated on angina and its symptoms
**o They know to inform you of any symptoms, and they can stop at anytime
● Ask the pt if they’ve experienced any changes in health condition since their last appointment
Hypertensive Thresholds
● SBP >250mmHg OR DBP > 115 mmHg
● BP has an exaggerated response of ≥ 40 mmHg SBP !!
● No noticeable / Adequate rise or drop in BP pre, during or post exercise
- Could be indication of more serious conditions (left ventricular dysfunction or myocardial ischemia)
Safety Consideration POST exercise for PAD?
Hypertensive Thresholds
● SBP >250mmHg OR DBP > 115 mmHg
● BP has an exaggerated response of ≥ 40 mmHg SBP !!
● No noticeable / Adequate rise or drop in BP pre, during or post exercise
- Could be indication of more serious conditions (left ventricular dysfunction or myocardial ischemia)
Post exercise hypotension
* In most cases this is a beneficial acute effect of exercise, however dependent on medications there could be risk of an exaggerated response
Keep an eye on recovery BP, make sure it returns to resting value or below
* In some instances BP may remain high which could indicate left ventricular dysfunction
In high risk patients watch ST segment returns to pre-exercise levels before turning off monitoring
* ST segment changes is more for CET scenario
* Use HR and SBP to calculate RPP and ensure that returns close to pre-exercise levels
Monitor signs and symptoms
Safety Consideration DURING exercise for PAD?
● claudication threshold: ≥ 3 on the claudication scale
U don’t use claudication scale for PRT
Hypertensive Thresholds
● SBP >250mmHg OR DBP > 115 mmHg
● BP has an exaggerated response of ≥ 40 mmHg SBP !!
● No noticeable / Adequate rise or drop in BP pre, during or post exercise
- Could be indication of more serious conditions (left ventricular dysfunction or myocardial ischemia)
Case Study 1: CAD
Specify the drug class, drug use, mechanism of action and consideration for Ex of: ASPIRIN
- Drug class and type: NSAID ~ Anti-inflammatory drug –> Is also a blood thinner
- mechanism of action: Used to relieve pain and reduce swelling
- consideration for Ex:Makes sure they don’t cut themselves as they will bleed heavily + Blunt trauma → internal bleeding
Case Study 1: CAD
Specify the drug class, drug use, mechanism of action and consideration for Ex of: LIPITOR
- Drug class and type: Statin –> Used to lower LDL
- mechanism of action: Focus on decreasing LDL. Small/negligible effect on HDL (atorvastatin, simvastatin)
NO effect on HR, BP or ECG - consideration for Ex: Can cause muscle pain or cramping of muscles → is a problem when trying to convince someone to exercise (DOMS)
Case Study 1: CAD
Specify the drug class, drug use, mechanism of action and consideration for Ex of: ATENOLOL
- Drug class and type: Beta Blocker –> Antihypertensive for HR
- mechanism of action: decreases HR therefore increase diastolic time and decreases blood pressure
- consideration for Ex: Can cause a plateau in HR around 110 BPM → HR shouldn’t be used as a predictor of intensity
Case Study 1: CAD
Specify the drug class, drug use, mechanism of action and consideration for Ex of: SUB LINGUAL ORAL NITRATE
- Drug class and type: vasodilator –> used to treat angina
- mechanism of action: decreases vascular tone to decrease blood pressire and hence increase myocardial supply
- consideration for Ex: hypotension and tachycardia can occur –> cease exercise and monitor HR and BP
Case Study 2: PAD
Specify the drug class, drug use, mechanism of action and consideration for Ex of: Accupril
- Drug class and type: Ace Inhibitor –> inhibits vasoconstriction
- mechanism of action: Reduces the ACE enzyme activity
(stops Angiotensin 1 conversion to Angiotensin 2)
Allows for Vasodilation of the vessels
Also allows more salt to pass through the kidneys 🡪–> resulting in more water being excreted (Osmosis) - consideration for Ex: Decreases BP, increase HR
Monitor for symptoms of Hypotension
Specify the drug class, drug use, mechanism of action and consideration for Ex of: Crestor
- Drug class and type: Statin –> Lowers LDL
- mechanism of action: Slowing the production of cholesterol in the body to decrease the amount of cholesterol build up in the arteries
- consideration for Ex: Can cause muscle pain or cramping of muscles –> is a problem when trying to convince someone to exercise (DOMS)
Case study 4
What is the hypoglycaemic protocol?
(1)Check BGL – If you cant check treat is as a hypo
If Below 4 mmol/L give 15 grams of fast acting carbs (e.g. 6-7 jelly beans or ½ can of regular soft drink)
(2)Wait 15 minutes, re-check BGL to see if risen above 4 mmol/L
BGL above 4 mmol/L → Go to step 3
Below 4 mmol/L → Repeat Step 1
(3)Eat a snack or meal with long acting carbohydrates
e.g. Slice of bread OR glass of milk OR 1 piece of fruit OR Pasta OR rice
Case study 4
what are the blood glucose thresholds for exericse?
Optimal Range of BGL to commence exercise → 5.5 – 15 mmol/L
Consider having a CHO snack on hand if exercise is vigorous or prolonged duration
4 – 5.4 mmol OR > 15 mmol – Exercise WITH CAUTION if client feeling well
Monitor BGL throughout the session
Below 5 mmol / L – Give CHO snack prior to exercise and wait for BGL to rise
case study 4
safety consideration for pre-exercise for patient with type 2 diabetes?
Check BP and HR
Patient reports poor sensation in feet → Check for ulcers
Can also ask if they are experiencing fever → could be a sign of infection
WEARING ADEQUATE FOOTWEAR!!!!
Head to toe check
– Secondary concerns/complicationsi nvolven early every system
– Common things to look out for
* Neuropathy
* Visionissues/changes/impairment
* CommonCo-morbidities=HTN,CADandPVD.
- You and patients need to be aware of the risks, signs and symptoms of hypoglycaemia before initiating an exercise program
- Pre-exercise blood glucose > 14 mmol/L + blood ketones OR > 16.6 mmol/L +/- ketones blood glucose should be lowered prior to initiating exercise.
- IF client feels well and adequately hydrated and ketones are not present, postponing exercise is not compulsory based solely on hyperglycemia.
- Ketones are seldom elevated in T2D
make sure they have water bottle on hand because of poly urea that leads to poly dypsia; make sure they are hydrated
Case study 4
safety consideration during exercise for patient with T2D
Monitor for signs of Hypertension
SBP >250mmHg OR DBP > 115 mmHg
BP has an exaggerated response of ≥ 40 mmHg SBP !!
Monitor for signs of Hypotension
Inadequate rise (or drop) of BP after commencing exercise OR increase in workload
if BGLs are below target , o5.5, exercise with caution
with BGLs are increase and above pre exercise levels, exerfcise with caution
if glucose levels are below 4.0, not safe to continue exercie –> commence hypoglycaemia protocol
Check BP and HR
Gradually Decrease intensity of exercise at the end of the session to decrease the Venus pooling in the periphery
Sudden stop in exercise can cause syncope
Avoid Valsalva for Resistance Training
safety considerations post exercise for patient with T2D
Monitor for signs of Hypotension
Exercise is a vasodilator and thus can cause excessive BP lowering in combination with medication
Monitor for signs of Hypoglycemia
Exercise increases insulin sensitivity on the cells (via GLUT 4 translocation) → can lead to hypoglycemia
CHEck BP and HR
any case study//adverse event
Your patient when exercising starts getting pale, reports feeling light headed and sweats. What do you do?
determine if its a hypoglycaemic event or hypotensive event
Check BP, HR and BGLs
address low BP first before attending to BGLs; assume its CVD event always regardless of condition →hypotension means brain may be starved of oxygen
Hypotensive event management: lay down, elevate feet
if low BGLs proceed with hypoglycaemic protocol
(1)Check BGL – If you cant check treat is as a hypo
If Below 4 mmol/L give 15 grams of fast acting carbs (e.g. 6-7 jelly beans or ½ can of regular soft drink)
(2)Wait 15 minutes, re-check BGL to see if risen above 4 mmol/L
BGL above 4 mmol/L → Go to step 3
Below 4 mmol/L → Repeat Step 1
(3)Eat a snack or meal with long acting carbohydrates
e.g. Slice of bread OR glass of milk OR 1 piece of fruit OR Pasta OR rice
adverse event
What do you do if your patient expereinces angina?
- give nitrate spray -1 spray evry 5 mins under tongue –> if more than 3 applications needed, call ambulance
How do you calculate Rate Pressure Product?
RPP = HR x SBP
What do you say at the end of the OSCE after you have dealt with the adverse event?
Make sure you say you will DOCUMENT EVERYTHING THAT HAPPENED!!
Tim said in the lecture lots of people forget this lol
Specify the drug class, drug use, mechanism of action and consideration for Ex of: Ventolin
- Drug class and type: bronchodilator
- mechanism of action:
ETO: making breathing easier
Action: relaxing muscles in the lungs
- consideration for Ex: Might risk hyperventilation, palpitations
Specify the drug class, drug use, mechanism of action and consideration for Ex of: Metformin
- Drug class and type: Biguanide
- mechanism of action:
ETO: decrease BGL
Action: reduce hepatic (liver) glucose output and improve glucose uptake into the muscle and fat cells - consideration for Ex:Minimal risk of hypoglycaemia but should be monitored
Specify the drug class, drug use, mechanism of action and consideration for Ex of: Atacand Plus
- Drug class and type: 1)Angiotensin 2 receptor blocker
AND
2)Diuretic - mechanism of action:
ETO: increase urination (water pill) and lower blood pressure
Action: By reducing the amount of fluid in your body, there’s less pressure on your blood vessels, which also lowers your blood pressure. By blocking hormone angiotensin II (cause blood vessel constriction), Atacand Plus relaxes your blood vessels, allowing blood to flow more easily and reducing blood pressure.
It can also be used to treat heart failure as it decreases the Afterload of the heart (as a result of lowered blood pressure) and thus puts less strain on the heart muscle during a contraction
- consideration for Ex:Can result in post exercise hypotension → monitor!
