Gen Med Exam 2 (Allie's Version)

hypertension

persistent elevation of blood pressure

lower

BP tends to be ____ in children until about age 12 when it starts to be similar to adults

increases

prolonged HTN ____ the risk of CVD

- produces a pressure overload on the L ventricle, causing L ventricular hypertrophy

- diastolic dysfunction with impairment of LV relaxation develops early

prevention

____ of HTN

- everyone should know their BP

- frequent monitoring in those with risk factors

- physical activity

treatment; lifestyle

____ of HTN begins with ____ modification

- weight loss

- diet

- reduced Na intake

- PA

- smoking cessation

- alcohol cessation

- stress management

pharmacologic

____ management of HTN

- diuretics

- ACE inhibitors and ARBs

- vasodilators

- Ca2+ channel blockers

- beta blockers

- alpha adrenergic blockers

150; 300

exercise guidelines for HTN

- ACSM encourages ____ to _____ min/week of moderate to vigorous physical activity

- should be individualized to the person!!!

precautions; relative; breath

____ of exercise for pt. with HTN

- medical evaluation/clearance recommended with uncontrolled severe HTN (resting SBP > 180 OR DBP > 110)

- resting SBP > 200 or DBP > 110 is a ____ contradindication to exercise (especially vigorous)

- exercise should be stopped if SBP > 250 or DBP > 115

- avoid ____ hold and valsalva

hypotension

abnormally low blood pressure

orthostatic hypotension

abnormal drop in BP within 3 minutes of standing

- drop in systolic > 20 mmHg or diastolic > 10 mmHg

pooling; decrease; CV

hypotension is caused by ____ of blood in the LEs associated with:

- conditions that ____ vascular volume (dehydration, meds, hemorrhage, burns)

- impaired muscle pump function (bed rest, impaired mobility, SCI

- impaired ____ reflexes (meds, disorders affecting ANS, aging)

non

a fall in BP with an increase in HR indicates a _____ neurogenic cause

- HR is compensating, ANS is intact

neurogenic

a fall in BP with < 10 bpm change in HR indicates a _____ impairment

- baroreflex is not working (HR is not rising appropriately)

dizziness; syncope; blurred

s/s of orthostatic hypotension

- _____, lightheadedness, vertigo

- ____ and presyncope

- weakness, fatigue

- nausea

- ____ vision

- confusion

- falls

BP

diagnosing orthostatic hypotension

- ____ measurements in supine and standing

- tilt table test

cause; medications

treatment of orthostatic hypotension

- alleviate the ____

- conservative measures

- _____

education; slowly; ankle

conservative measures for orthostatic hypotension

- patient ____ : avoid situations that cause excessive vasodilation (alcohol, temp extremes), recommend activity modifications

- elevate HOB, have patient rise _____, wait for BP to stabilize with changes of position

- exercises: ____ pumps, UE/LE ROM, diaphragmatic breathing, crossing legs

- elastic stockings, abdominal binders

- physical fitness

lie; elevate

if there is an excessive drop in BP or the patient is symptomatic you should ____ the patient down, ___ their feet, document and notify the physician if symptoms do not improve

aneurysm

abnormal stretching or dilation of a vessel wall

- diameter 50% greater than normal

- results from vessel wall weakness

Atherosclerosis; marfan's; inflammatory

who is at an increased risk for aneurysms?

- HTN

- _____

- cigarette smoking (5x INCREASED RISK)

- family history

- male

- age

- congenital disorders of CT (_____ disease)

- _____ and infectious diseases

- trauma

location; appearance

aneurysms are named for their _____, size, and _____

asymptomatic

aneurysms are often _____

- people don't know they have one

thrombosis; rupture

aneurysms can lead to ____, dissection (tear), or ____

- MEDICAL EMERGENCY

conservative

a ____ approach is recommended for an aneurysm with physician follow up

- may require surgery, typically when > 5 cm

low; moderate; low; increased

Exercise considerations- ANEURYSM

- little research

- ___ to ____ intensity aerobic activities (may have high and low BP restrictions)

- ____ resistance if incorporating strengthening (not recommended with cerebral aneurysm)

- restrict exercise training with ____ size of aneurysm

PVD

includes disorders of arterial and venous blood vessels

PAD

arterial occlusive

inflammatory PVD

polyarteritis nodosa

ateritis

kawasaki disease

thromboangiitis

obliterans (buerger's disease)

wegener's granulomatosis

vasomotor PVD

raynaud's

venous PVD

varicose veins

chronic venous insufficiency

VTE

CVI (chronic venous insufficiency)

results from incompetent venous valves, inadequate muscle action, or venous obstruction

- damaged or incompetent valves allow venous blood to pool and flow backward, leading to increased volume and pressure in the vessel (venous HTN)

- veins become enlarged and weak

- Risk factors: age, genetics, obesity, prolonged standing, sedentary lifestyle, smoking, female hormones and pregnancy

varicose; skin; ulcerations

CVI leads to:

- ____ veins

- spider veins

- swelling

- ___ changes (inflammation and fibrosclerotic remodeling)

- hemosiderin staining (rust looking skin)

- chronic leg _____ (80% of all ulcerations)

venous; surgical; prognosis

treatment of CVI

- promote ____ return

- rest and elevation throughout day

- avoid dependent positions

- raise foot of bed 6 in

- compression stockings, pumps

- ROM exercise, progressive ambulation

- wound care prn

- medical and ____ management

- poor ____ for resolution of CVI

true

T/F: you must take caution with compression dressings and elevation with CVI due to common comorbidities of arterial insufficiency, DM, and CHF

arterial

findings with _____ PVD

- aching/cramping that is predictable with activity and elevation

- edema may or may not be present

- reduced muscle mass

- elevation worsens symptoms, dependency improves symptoms

- aching begins at a specific time/distance when walking and goes away with rest, will return with exercise

venous

findings with _____ PVD

- aching, burning, cramping, fatigue while standing, heaviness, night cramping, swelling, throbbing

- edema is worse at the end of day, improves with elevation

- muscle mass is unaffected

- elevation lessens symptoms

- walking lessens symptoms

decreased; cyanotic; cool

more arterial PVD findings

- ____ or absent pulses, bruits may be present

- reduced hair, tight, shiny skin, thick/brittle nails

- ____ or pale skin color, dependent rubor

- ____ skin temp

- ulcers have a pale base, found at high pressure sites such as heel or tip of toes

difficult; hyperpigmented; warm; medial malleolus

more venous PVD findings

- pulses may be _____ to palpate due to edema

- skin: chronic cellulitis, dermatitis, ulceration

- skin color: _____, brown discoloration, often superior to medial malleolus

- skin temp: may be ____ with infection, phlebitis

- ulcers often near _____ and gaiter area of LL, irregular border, often have pink/red base

VTE

Venous thromboembolism, includes DVT and PE.

DVT

typically occurs in LEs or pelvis

- small percentage occurs in UEs

- can progress to pulmonary emboli

pain; dilation

s/s of DVT

- ____ or tenderness in calf

- leg or calf swelling

- ____ of superficial veins

- warmth

- pitting edema

true

T/F: approximately 50% of DVTs are asymptomatic

80%

____ of symptomatic DVTs involve proximal DVT (iliac, femoral, or popliteal)

- usually more severe

- at time of diagnosis > 50% with a proximal DVT already have a PE

causes and risk factors of VTE

- previous venous thrombosis or embolism

- increasing age

- active cancer/cancer treatment

- severe infection

- estrogen containing oral contraceptives

- hormonal replacement therapy

- pregnancy or given birth < 6 weeks

- immobility (bed rest, flight travel, fractures)

- surgery/anesthesia/critical care admission

- central venous catheters

- inherited thrombophilia

- obesity

VTE prevention

education

hydration

activity

mechanical compression

medical management

- goal to decrease hypercoagulability of blood

- low molecular weight heparin

- warfarin

- greenfield filter (catches PE before entering heart)

Wells Clinical Prediction Rule for DVT

-active CA or w/in last 6 months

-paralysis, paresis or recent immobilization

-bedridden for 3+ days

-surgery requiring anesthesia in last 12 wks

-localized tenderness along deep vein

-entire leg swelling

-calf swelling at least 3 cm larger than asymptomatic leg (10 cm below tib tube)

-pitting edema in symptomatic leg

-superficial veins

-prev DVT

-high prob if 2 or more, unlikely if less than 2

prevent; vein; clot

VTE treatment goals

- _____ PE

- limit extension of thrombus

- limit damage to ____

- prevent another ____

s/s of PE

pleuritic chest pain, diffuse chest discomfort

tachypnea, tachycardia

hemoptysis

anxiety, restlessness, apprehension

dyspnea, persistent cough

sudden death

communicate; risk

mobilization with PE

- ____ with medical team before mobilizing

- need to determine ____ of mortality

- low risk vs high risk dependent on clinical parameters of PE severity, hemodynamic stability, signs of R ventricular dysfunction, and elevated troponins

CV; prevention

exercise safety and ____ prevalence

- increasing prevalence of CV risk factors and disease, particularly among minority groups and children

- shared risk factors exist between CV conditions and many MSK conditions

- APTA advocates for _____, wellness, fitness, health promotion, and management of disease and disability

true

T/F: individuals who do not smoke, maintain a BMI < 30, exercise 3.5 hours/week, and consume ample fruits, vegetables, and whole grains can reduce the risk of chronic illnesses (diabetes, heart attack, stroke, cancer) by an average of 80%

PAVS (Physical Activity Vital Sign)

a quick screening tool to assess PA levels

1. On average how many days per week do you engage in moderate to strenuous exercise? ____ days

2. On average, how many minutes do you engage in exercise at this level? ____ days

Total minutes per week = #1 x #2

Recommended 150 min/week of mod intensity or 75 min/week of vigorous intensity

CVD risk factors

Age, family history, smoking, sedentary, obesity, hypertension, dyslipidemia, prediabetes, stress, diet

emerging CVD risk factors

CRP

- low risk < 1.0 mg/dL

- ave risk 1.0-3.0 mg/dL

- high risk > 3.0 mg/dL

Homocysteine

Kidney disease

Environmental factors, infection, abnormal sleep, etc.

Gender, racial and ethnic disparities

risk assessment and pre-participation screening

can be gathered during subjective questioning or using simple assessment tools

- PAR-Q+ and ePARmedX

- Framingham Risk Score

- ACC/AHA Risk factor profile

- other online resources

screening focuses on: risk factors for disease, s/s of disease, presence of disease

light intensity

- able to talk and/or sing

- RPE <3 or <11 (depending on scale)

- <40% HRR or VO2R

- <64% of maxHR

- <3 METs

moderate intensity

- able to talk but not sing

- RPE 3-4 or 12-13 (depending on scale)

- 40-60% HRR or VO2R

- 64-76% maxHR

- 3-6 METs

vigorous intensity

- difficulty talking

- RPE >5 or >14 (depending on scale)

- > 60% HRR o VO2R

- >76% maxHR

- >6 METs

inpatient; outpatient; maintenance

Cardiac rehab

- phase 1 = ____

- phase 2 = ____

- phase 3 = _____

indications for cardiac rehab

-MI

-stable angina

-CABG

-PTCA or other transcatheter procedure

-stable heart failure, cardiomyopathy

-valve disease/surgery

-heart transplant

-PAD

-at risk for CAD (DM, dyslipidemia, HTN, and obesity)

Phase 1 cardiac rehab

inpatient

goals:

- offset effects of bed rest

- patient monitoring and assessment of hemodynamic responses to allow safe return to activity

- identify impairments that influence prognosis

- prepare patient and support system for home progression

- recommendations for continued cardiac rehab

could be 24 hr stay if PCI, but often < 5 days for uncomplicated MI, CABG

immediate post MI

ECG changes

12-48 hrs post MI

cardiac enzyme changes

3 days to weeks post MI

removal of damaged (necrotic) myofibrils

3 weeks to months post MI

collagen bundle replaces muscle tissue

scar formation

AACVPR

risk stratification that helps to determine prognosis, rate of activity progression, supervision, and monitoring required

CV test and measures

- inspection

- vitals and pulse ox

- circulation

- auscultation

- activity evaluation (aerobic capacity/endurance)

normal

____ CV activity assessment

- gradual increase in HR (10 bpm per MET)

- sinus tachycardia on ECG (no change in chronic arrhythmias

- Gradual increase in SBP (10 mmHg per MET)

- small decrease/no change in DBP

- SpO2 97-100%

- increase in ventilation/hyperpnea

abnormal

____ CV activity assessment

- chronotropic impairment (sinus bradycardia, disproportionate increase, decrease or failure to increase with increasing workload)

- increase in arrhythmia

- ventricular arrhythmias

- ST segment elevation/depression

- chest discomfort/pressure

- SBP > 250, drop > 10 from baseline, or failure to increase with increased workload

- rise or fall of DBP > 10-15 or >115

- desat below 90% with activity

- hyperventilation/dyspnea/wheezing

- angina, SOB, dyspnea, palpitations, dizziness, pallor, fatigue, confusion

RPP

myocardial oxygen consumption is estimated by:

____ = HR x SBP

- aka double product

frequency; intensity

phase 1 ____

2-4x/day, at least 1x/day

____

- RPE < or equal to 13 (fairly light-somewhat hard)

- use of HR not necessarily appropriate, especially if on B-blocker

- monitor hemodynamic and symptomatic responses, ECG findings

duration; type

phase 1 ____

- 10-15 min

- begin with short bouts (3-5 min), use frequent rests (goal 2:1 exercise/rest)

- include warm up and cool down exercises

_____

- functional activities, large muscle group activities

documentation

phase 1 _____

- pt. position, level of assist and time

- type of sitting and/or standing exercises

- time period and distance ambulated, number of stairs

- number and duration of rests

- vital sign response to each activity

- education provided

CR phase 2

outpatient

- class I recommendation (leads to good outcomes)

- involves education, exercise, and behavior change

2

goals of phase ____ CR

- supervision and monitoring of the patient and assisting with implementation of a safe and effective physical activity program

- helping the patient return to vocational and recreational activities

- risk factor reduction

- improve pyschosocial well-being, which influences recovery from heart disease

frequency; intensity

CR phase 2 _____

- at least 3x/week, ideally 5-7x/week

____

- RPE 12-16

- may have exercise test 4-6 wks post hospital discharge

- 40-80% HRR or 75-80% HRmax if test available

- use HR at least 10 bpm below ischemic threshold is (+) exercise test

duration; type

CR phase 2 _____

- 20-60 min

- begin with multiple short intervals (<10 min), gradually increase (+1-2 min/day)

- include 5-10 min warm-up and cool-down (low intensity aerobic activities)

_____

- large-muscle group activities (walking, cycling, functional activity, FUN)

- supplement with increase in daily lifestyle activities (gardening, walk break at work, household work)

exercise testing

useful for diagnosis of CAD, evaluation of symptoms, determining prognosis and severity of disease, evaluation of functional capacity, activity prescription, evaluation of effectiveness of therapy, reassurance and motivation

- many pts. DO NOT have this

without

exercise intensity _____ an exercise test available

- activity should be gradually progressive in logical stepwise fashion of increasing energy costs (METs) with appropriate HR and BP monitoring (initial MET level based on estimate of baseline level of training, likely 2-4 METs)

- titrate based on RPE, s/s, physiologic response

- conservative prescription usually best initially

- FCE (6 min walk)

resistance

patient criteria for _____ training

- min of 5 wks after MI or cardiac surgery including 4 wks of consistent participation in a cardiac rehab program

- min of 3 wks following PTCA including 2 wks of consistent participation in a cardiac rehab program

- no evidence of: symptomatic heart failure, uncontrolled arrhthymias, unstable symptoms, uncontrolled HTN, severe valvular disease

resistance training

_____ _____ guidelines

- elastic bands, free weights, weight machines, body weight

- 2-3x/week, rest day between workouts

- 1 set of 8-10 reps for each major muscle group (30-40% 1-RM for UE, 50-60% 1-RM for LE, RPE 11-14)

- typically can progress 2-5 lbs for UE or 5-10 lbs for LE when 12-15 reps performed comfortably

- emphasize exercise safety

- stop exercises with any concerning s/s

work

assessing a pt's _____ environment

- primary movements (type of contractions) and muscle groups used

- MET demand

- environmental factors (temp stress)

- intermittent heavy work

exercise

____ prescription for return to work

- include both resistance and aerobic training

- include functional exercises (simulate work tasks and muscles used/movement patterns)

- expose them to similar environmental conditions if relevant to work setting

2

phase ____ education

- risk factor reduction (secondary prevention)

- selecting appropriate exercise intensity

- patient self-monitoring during activity

- ability of a patient to recognize adverse symptoms

CR phase 3

maintenance is focus (self monitored home program)

- requires 30-60 min, 3-5x/week, continues indefinitely

- compliance is an issue (20-50% continue exercise after 1 year)

independent

considerations for ____ exercise

- cardiac symptoms are stable

- appropriate responses to exercise (HR, BP, ECG)

- demonstrated knowledge of proper exercise principles and awareness of abnormal s/s

- motivation to continue exercise w/o direct supervision (adherence)

benefits

____ of CR

- risk factor reduction

- improvement in exercise tolerance and symptoms (decreased myocardial O2 demand due to reductions in HR and/or BP at any given submaximal work rate

- increased VO2max and functional capacity

- improved psychosocial well-being and quality of life

- decreased mortality

false (should not start until compensated)

T/F: patients with decompensated (uncontrolled) CHF should begin aerobic exercise training, no matter if CHF is compensated

red

_____ light HF warning signs

- difficulty breathing even at rest

- unrelieved SOB

- wheezing, chest pain, or chest discomfort

- feeling faint

- confusion

- call physician immediately or immediate visit to the ED

yellow

____ light HF warning signs

- weight gain > 3 lbs in 1 day or 5 lbs in 1 week

- increased swelling

- increase cough

- increase in SOB w/ activity

- increase in number of pillows needed

- communicate with physician as the patient may need adjustment in meds

green

_____ light HF warning signs

- no SOB

- no weight gain

- no swelling

- no chest pain

- no decrease in ability to maintain activity level

- proceed with interventions/exercises/activity as planned

heart failure

what condition is the exercise prescription for?

F- 3-5 days/week

I- moderate to high

- 3/10 on dyspnea scale

- also use RPE, many patients on B-blockers

- 50-90% peak VO2 or peak work

- some pts. may benefit from HIIT training

T- progressively increase to 20-60 min/day

T- walking or cycling preferred

tolerate

A person with heart failure can begin resistance training once they can ____ aerobic training

- 3 nonconsecutive days/week

- begin at 40-50% of 1-RM, gradually progress to 60-80%

- 2-3 sets focusing on major muscle groups

- consider NMES

dyspnea

What is often the best monitor of intensity?

NYHA Class 1

Maximum 6.5 METs

- No limitation on PA

- Ordinary PA does not cause undue fatigue, palpitation, or dyspnea

NYHA class 2

maximum 4.5 METs

- slight limitation of PA

- comfortable at rest, but ordinary PA results in fatigue, palpitations, or dyspnea

NYHA class 3

maximum 3.0 METs

- marked limitation of PA

- comfortable at rest, but less than ordinary PA causes fatigue, palpitations, or dyspnea

NYHA class 4

maximum 1.5 METs

- unable to carry out PA without discomfort

- sx. of cardiac insufficiency at rest

- if any PA is undertaken, discomfort is increased

poor; inspiratory

Patients with CHF have ____ ventilatory muscle strength

- Improvements in ventilatory muscle strength and endurance, dyspnea, peak VO2, and 6MWD have been shown after a program involving _____ muscle training

diaphragmatic; decrease

____ breathing and inhibition of excessive accessory muscle use may _____ the work of breathing for a person with HF