History of present illness gathered during interview portion of clinical evaluation
Chief complaint
Onset
Symptoms
Exacerbation or relief
Interventions
Current Status
what is the focus of the physical examination
Concentrate on abnormal findings, based on patient complaints or symptoms and info from prior examinations.
Determine whether it is safe to allow exercise in a patient who presents with signs/ symptoms that may or may not be related to a current illness
what is included in the examination of a peripheral artery pulse
dorsi pedal, radial
3 = bounding
2 = normal
1 = reduced/diminished
0 = absent or non-palpable
description of various gait abnormalities
Normal: narrow based, steady
-Antalgic: limping due to pain
-Slow: hemiplegic-weakness
-foot drop
-Shuffling: parkinsons
-Wide base: cerebellar ataxia
-Foot drop or Slapping: sensory ataxia
red flag indicators that warrant a discussion with a physician prior to exercise
-new shortness of breath
-recent syncope
-recent fall
-low leg pain at rest
-severe headache
-pain in bone area
-unexplained tacky/bradycardia
-active wheezing
-SBP: >200 or <86 DBP >110
Know the importance of a thorough history
Determines the diagnosis and often guides subsequent testing and treatment
New York Heart Association functional classifications
Class I: no marked limitations
Class II: slight limitations of PA
Class III: marked limitations of PA (2-5 METS)
Class IV: no PA without discomfort (>2 METS)
relative indications for termination of a GXT
- chest pain
- wheezing
- hypertension
- leg cramps
- fatigue
- arrhythmia
- ST/QRS changes
- SBP decreases>10
Potential EKG conditions during exercise and what they indicate
Left Bundle Branch Block
Right BBB: ST changes in anterior leads
Pre-citation on syndrome
Nonspecific ST-T wave changes with > 1mm depression
Abnormalities due to digoxin therapy or left ventricular hypertrophy
Electronically paced ventricular rhythm
what are the principles of exercise prescription
specificity, progressive overload, reversibility
based on harvard alumni study what is the range of caloric expenditure associated with a decreased risk of morbidity and mortality
Between 500kcal and 3500kcal per week
what is the relationship between pre training peak VO2 and expected range of improvement in untrained individuals
typically untrained individuals can expect a 10-30% improvement in VO2 peak and a work capacity following a 8-12 week period of training
minimal training intensity for exercise in low fit individuals that will elicit fitness benefits
VO2 may be improved at 40% of their max ability
What are the indications for a GXT?
-Evaluate chest pain as a means to assist in the diagnosis of CAD and evaluate other potential or existing cardiac problems.
-Identify a patients future risk or prognosis
what is diabetic ketoacidosis
A type of metabolic acidosis caused by accumulations of ketone bodies in diabetes mellitus.
In patients with poorly controlled diabetes where insulin is very low or absent.
Ketones form because without insulin the body cannot use glucose effectively and h
What is the proper pre-exercise carb supplementation according to blood glucose levels?
If controlled most patients don't need supplementation for exercise less that 60 min.
If blood glucose is less than 100 and exercise will be of low intensity and duration, 5-10g of CHO should be consumed.
If the blood glucose is under 100 and exercise is
Exercise considerations for those with diabetes
Avoid peak insulin action,
Avoid late evening,
Possible avoidance of weight bearing exercise
Why do blood glucose levels rise with exercise?
Poorly controlled patients blood glucose levels are often too low resulting in an increase in counter-regulatory hormones with exercise.
This circumstance causes glucose production by the liver, enhanced free fatty acid release by adipose tissue, and redu
how does diabetes compare to other chronic diseases as far as the level of ongoing daily involvement
Dealing with diabetes requires ongoing special attention.
Exercise should be encouraged based on its benefits, particularly in controlling CVD risk factors.
Exercise training requires additional monitoring to avoid the acute effects of hypoglycemia.
Exerc
Which activities should be avoided in patients with severe diabetic retinopathy?
Valsalva,
Heavy RT,
Vigorous aerobic activity,
Jumping, jarring,
Head-down activities.
Who should be tested for diabetes?
All adults overweight (BMI > 25),
Sedentary adults,
1st degree relative with diabetes,
Previous delivery of large babies,
High risk ethnicities,
Low HDL (< 35),
Triglycerides > 250,
Hypertensive
What is the minimal criteria to qualify a patient for bariatric surgery?
BMI >40 (or >35 with obesity related comorbid conditions)
According to the diabetes prevention program, what is the minimal amount of weight loss that results in a delay in prognosis from pre-diabetes to diabetes?
10% weight loss within 4 to 6 months.
Percent weight loss that patients report being disappointing
17%
What is the best predictor of long-term weight loss maintenance according to the National Weight Control Registry?
Combination of diet and exercise therapy:
Regular exercise of 60-90 minutes on most days/week, expending 2500-2800 kcal per week.
What medications are approved by the FDA for long term use for weight loss?
Phentermine
Orlistat
Qsymia
Belvig
What are the factors related to childhood obesity persisting into adulthood?
Severe obesity,
Age of onset,
Childhood BMI, and
Parental obesity
Know the prevalence of overweight and obesity according to the 2008 report from the US Department of Health and Human Services (DHHS)
Males: 73%
Females: 61%
Overall: 67%
Important factors to consider in those with essential hypertension:
Genetics,
Sodium sensitivity,
Inappropriate renin secretion,
Environmental factors (obesity, physical inactivity, and excessive alcohol and salt intake)
What are the steps to properly assess resting BP?
1. Seating for 5 min with feet on floor.
2. No smoking/caffeine for 30 min
3. Appropriate sized cuff
4. Systolic BP (first 2+ Korotkoff sounds)
5. Diastolic BP (disappearance of Korotkoff sounds)
Be familiar with the relationship between blood pressure and diet
Reductions in BP of 5/3.7 mmHG with an improved diet.
Diets target weight reduction.
DASH diet reduces BP by 8-14 mmHg.
Be familiar with drug therapy for for hypertension
-Patients usually need two or more meds:
Diuretics
Beta blockers
Ace inhibitors
Aldosterone antagonists
The relationship between BP response during GXT and risk for developing hypertension
exaggerated/elevated BP response during exercise can be predictor for new onset hypertension
What is the relationship among aerobic exercise training, kidney function, and blood pressure?
Exercise training may decrease BP by improving renal function.
The kidneys plan an important role in BP regulation - exercise training may decrease BP by improving renal function in patients with essential hypertension.
Regular exercise causes favorable c
What are the JNC recomendations for lifestyle modifications?
-weight reduction
-DASH diet
-PA
-moderation of alcohol
recommendation for rechecking BP
-Normal: recheck in 2 yrs
-Pre: recheck in 2 yr
-Stage 1: confirm in 2 months
-Stage 2: within 1 month
what is the relationship between exercise training and total cholesterol and LDL
minimal reductions in total and LDL with exercise training alone
what is the relationship between dyslipidemia and exercise testing
exercise testing should follow protocols used in populations at risk for CAD
What is the NCEP-ATP III dietary recommendation?
dietary fat intake 25-35% of total calories (adopting a Mediterranean diet)
What meds alter lipid concentrations?
Statins
Vibrates
Niacin
Bile acid sequestrants
What is the relationship between body weight, HDL, total cholesterol, triglycerides, and LDL concentrations
All decrease with lowered body weight EXCEPT HDL.
(HDL can increase 4-18%)
What are the target lipid levels in someone without heart disease?
less than 160mg/dl LDL
When does the pathology of atherosclerosis begin?
childhood
Begins with damage to the endothelium - this allows movement of LDL beneath the endothelial layer and thus oxidation occurs.
Be familiar with the relationship between relative risk or coronary heart disease, level of total cholesterol, and age.
CHD reduced 24.5% and 29.5% with every mmol/L decrease in total cholesterol.
Men 65-80 increase risk of CHD by 28% and CVD mortality by 22% for ea 1 mmol/L increase in total cholesterol.
After 80, positive association does not exist. Inverse relationship
What are the EKG changes associated with an acute sub-endocardial MI?
New ST segmentation of T wave changes or new left bundle branch block.
Development of pathological Q-wave
When should one conduct a symptom limited maximal GXT?
generally performed 7+ days post MI
what are the risk factors for coronary artery disease
tobacco use,
dyslipidemia,
hypertension,
sedentary lifestyle,
obesity,
diabetes,
metabolic syndrome,
family history of premature coronary disease,
male,
sleep apnea,
depression/anxiety
What are the reasons for performing a coronary artery bypass surgery (CABS)?
Post-PTCA or stunting with restenosis,
Not a candidate for angioplasty,
Multi vessel disease, or
Difficult vessel lesion
What effects the rate of restenosis after a PTCA?
Diabetes and whether patients are on optimal medical therapy that includes the use of aspirin or Plavix.
Degree of residual stenosis after PTCA.
Diameter of diseased vessels.
Number of diseased vessels.
Degree of reduction of the stenosis.
What are the adaptations that occur in patients who have had revascularization procedures
Improved cardiac function at rest and during exercise,
Improved exercise capacity,
Greater total work performed,
Improved angina-free exercise tolerance,
Improved neurohormonal tone
What is the association between lifestyle change and different types of procedures or disease states?
-Post-MI patients show greater adoption to lifestyle changes compared to revascularized patients.
-revascularized patients may be less motivated to adhere to lifestyle changes due to the thought they have been cured which has a negative effect on complian
What is the relationship between cardiac rehab and the prevalence and severity of depression?
Depression remains prevalent in patients with coronary heart disease after major cardiac events.
Cardiac rehab does not reduce the prevalence or severity of depression.
what is the primary concern regarding patients post-CABS?
The state of incisional healing and sternal stability,
Hypovolemia, and
Low hemoglobin concentration
What is the benefit of resistance training for patients who have been revascularized?
Improved muscular strength and endurance and possibly attenuating the HR and BP response to any given workload
What are the special considerations when prescribing exercise for revascularized patients?
-incisional discomfort in chest, arm or leg of surgical patient
-may need to restrict upper body movements until soreness subsides
-inital ROM body weight exercises
-resistance bands
-progress to movements that mimic daily movements
-emphasize lower body
What is the best time to evaluate functional capacity in a post CABS patient?
3-4 weeks post surgery the patient should be able to give near maximal physiological effort
Why is aspirin prescribed after stinting?
To prevent blood clots by thinning the blood
Why exercise testing before starting an exercise program in revascularized patients would be warranted?
Exercise is used to evaluate the functional status of the PTCA patient
Why is there exercise intolerance in patients following heart failure?
Manifested by fatigue or shortness of breath on exertion.
Be familiar with exercise capacity in patients with heart failure
Exercise capacity decreases by 30-35% in patients with HFREF or HFPEF compared to normal persons.
Inability to dilate peripheral vasculature sufficiently as a means to increase blood flow to the metabolically active muscles.
Histological and biomechanics
Be familiar with the acceptable exercise intensity in patients with heart failure:
-Aerobic: 60-75% of HRR or RPE: 11-14
-Resistance: 40% of 1RM for upper body and 50% of 1RM for lower body progressing both to 70% 1RM
Be familiar with the relationship between cardiac transplantation and guiding exercise intensity
Roughly the same as patients with heart failure.
what is LVAD
-Left ventricular assistance device
-Can increase cardiac output during exercise and increase flow up to approximately 10 L/min
What is the routine evaluation of patients with heart failure
measured exercise capacity using Bruce or Naughton protocol is recommended
(Prediction equations often over predict functional capacity.)
Appropriate substitutes for walking in patients with PAD and symptoms of intermittent claudication
Arm and leg ergometry, stair stepping, pedal plantar flexion
What are the long term benefits of routine walking in patients with PAD and intermittent claudication
Higher VO2.
Increased walking time,
Enhanced quality of life,
Delayed onset of claudication,
Increased angiogensesis,
Reduced blood viscosity
What are the benefits associated with exercise training in PAD patients with intermittent claudication?
Improvements in walking distance.
(A reduction in adverse cardiovascular event risk)
What determines blood flow to the lower extremities when PAD is present?
Blockage of arteries of the leg by plaque leading to gradual narrowing of the leg arteries causing a lack of blood flow to the muscles of the leg resulting in calf and other leg pain.
What are the best ways to monitor exercise intensity in patients with a fixed rate pacemaker?
Cardiac output and arterial pressure are increased by stroke volume.
Target HR cannot be used.
Use RPE and MET equivalents
What are the indications for pacemaker therapy?
SA node dysfunction (slow HR/Bradycardia)
Conduction block of the AV node
Are external pacemakers still used?
External pacemakers are used as temporary devices that are common in emergency and critical care situations (after open heart surgery) or until permanent device can be implanted.
What is a subarachnoid stroke?
Type of hemorrhagic stroke involving bleeding AROUND the spaces surrounding the brain.
Patients may develop neck stiffness.
(Intracerebral is bleeding INSIDE the brain).
Factors that affect the 6 min walk test in patients who have suffered a stroke.
balance, knee extensor strength, degree of muscle spasticity
Used in the battery of test as a functional outcome of these impairments, but it should not be viewed as a measure of a cardio respiratory fitness test.
Be familiar with the appropriate exercise intensity for a stroke survivor with biomechanical limitations
Aerobic: 40-80% HRR
Resistance: As tolerated, up to 80% of 1RM
ROM: Below the point of discomfort
What is the appropriate exercise intensity for a stroke survivor unable to achieve at least half a mile per hour during walking?
Not all stroke patients can complete a traditional GXT to assess functional capacity.
Alternative: submax testing using lactate, ventilatory threshold, or oxygen pulse.
Ability to achieve a walking speed of >.5 mph for 30 feet indicative that the individu
Which side of the brain is implicated when there are vision problems and awkward/inappropriate behavior?
Right brain damage
(Left brain causes speech and language problems and slow or cautious behavior)
What are the spirometry characteristics expected in a patient suffering from COPD?
reductions in expiratory flow rates including FEV1, the FEV1.
FVC ratio, and the mid-expiratory flow rate.
Loss of tethering or support, diminished elastic recoil.
What are the clinical conditions included in COPD patients?
Chronic Bronchitis,
Emphysema
What are the predicted FEV1 values in patients at various stages of COPD?
-Stage 1: >/= 50% (mild)
-Stage 2: 35-49% (moderate)
-Stage 3: < 35% (severe)
What is the most inappropriate mode of exercise for patients with COPD?
Arm ergometry
Inspiratory muscle training?
What are the adverse physiological effects expected in those with COPD and skeletal muscle dysfunction?
-Reduction on strength
-Reduction in type I fibers and increase in type II
-Hypoxemia/hypercapnia
Primary causes of COPD
Smoking
Decreased aerobic capacity
What is the traditional treatment for COPD
-Smoking cessation
-O2 therapy
-Pharmacological intervention
-Pulmonary rehabilitation
what is the American Thoracic Society Staging system for COPD
-stage 1: >/=50% (mild)
-stage 2: 35-49% (moderate)
-stage 3: < 35% (severe)
Be familiar with the ions conducting depolarization
Sodium and Calcium
Be familiar with the various parts of an EKG
P Wave: Arterial Depolarization
PR Segment: AV Node delay
QRS Complex: Ventricular Depolarization & Re-polarization
ST Segment: Ventricles are contracting & emptying
T Wave: Ventricular Re-polarization
TP Interval: Ventricles relaxing & filling
Know the leads and their locations:
12 Leads:
3 Bipolar: (I = Lateral, II = Inferior, III = Inferior).
3 Unipolar augmented (aVR, aVL = Lateral, aVF = Inferior).
6 precordial (V1-V6); Septal V1&2, Anterior (V3&4,) Lateral (V5&6)
Know what arrhythmia occurs during rapid-firing of multiple atrial automaticity foci
Multi Atrial Tachycardia
Escape rhythm inherent rate ranges
Ventricular: 20-40 bpm
Junctional: 40-60 bpm
Atrial: 60-80 bmp
right axis deviation
0 to (-90) degree
-QRS negative in lead 1
-QRS vector points to patients right side
left axis deviation
90-180 degrees
QRS points upward and to patients left side
Extreme right Axis deviation
(-90) to 180 degrees
What are the EKG characteristics associated with hypertrophy for the RIGHT ATRIA
large P wave with a tall initial component
(diphasic P wave; terminal portion larger)
what are the EKG characteristics associated with hypertrophy for the left atria
large p wave with a wide terminal component
(diphasic P wave; initial portion larger)
what are the EKG characteristics associated with hypertrophy for the right ventricle
R wave greater than S, but progressively gets smaller
what are the EKG characteristics associated with hypertrophy for the left ventricle
inverted T wave that slants downward gradually but up rapidly
(exaggerated QRS amplitude - height and depth).
Know the EKG characteristics of an acute myocardial infarction:
ST segment elevation, about 10 mm or more
What are the EKG characteristics of a significant Q wave
1 mm wide, or 1/3 QRS complex
Indicates previous anterior Myocardial Infarction (necrosis)
Know the affect an infarct has on vectors
Infarcted areas have no vectors
Be familiar with the relationship between the presence of Q waves and infarction location
Negative Q wave in Lead 1 & AVL = Lateral infarction
Negative Q wave in Lead II, II, & AVF = Inferior Infarction
Q Wave in V1-V4 = Anterior infarction
Posterior Infarction is noticed by large R wave & ST depression in V1 & V2
what effect does an infarct have on vectors
cannot detect "toward" vectors, can only detect "away" vectors. negative wave