Examination
You are examining a patient for cardiac rehab with primary complaint of shortness of breath. You are auscultating at the sternal border in the left 2nd intercostal space. Which of the following best describes what you are auscultating?
A. S1 heart sound with closing of the aortic valve
B. S2 heart sound with closing of the aortic valve
C. S1 heart sound with closing of the pulmonary valve
D. S2 heart sound with closing of the pulmonary valve
A. S1 heart sound is heard at the apex of the heart (left 5th intercostal space, mitral valve) rather than the aortic valve
B. S2 heart sound is heard at the right 2nd intercostal space rather than the left
C. S1 is heard at the apex of the heart
D. This is the correct answer. The left 2nd intercostal space is the location of the pulmonary valve and is where S2 is heard best
A 72-year-old male presents to your clinic with primary complaints of shortness of breath and a persistent cough. Upon examination, you find jugular vein distention and abdominal swelling. Which type of heart failure is most likely?
A. Right-sided heart failure
B. Left-sided heart failure
C. Biventricular heart failure
D. Pulmonary embolism
A. Jugular vein distention and abdominal swelling are signs of right-sided heart failure, but cough and SOB indicate the left ventricle has failed as well.
B. Left-sided heart failure presents with lung symptoms such as cough and SOB, but would not present with jugular vein distention and abdominal swelling.
C. This is the correct answer. Biventricular heart failure would present with both left and right-sided heart failure symptoms. Cough and SOB are symptoms of left-sided heart failure whereas jugular vein distention and abdominal swelling are symptoms of right-sided heart failure. Right-sided heart failure also presents with peripheral edema.
D. A pulmonary embolism does present with SOB and cough, but not necessarily jugular vein distention or abdominal swelling. It also would present with chest pain and diaphoresis.
A 65 year old male patient is in the hospital after an MI 2 weeks ago. He is planning to discharge soon to go to cardiac rehab. Which of the following would prevent safe discharge to cardiac rehab at this point?
A. Development of influenza
B. Resting blood pressure of 180/102
C. Compensated heart failure
D. Insulin therapy for diabetes mellitus
A. This is the correct answer. Acute systemic illness or fever is contraindicated with cardiac rehab.
B. Cardiac rehab is contraindicated if resting SBP is >200 or if DBP is >110.
C. Heart failure is a contraindication of cardiac rehab only if uncompensated.
D. Diabetes is a contraindication of cardiac rehab only if uncontrolled. In this case, the patient's diabetes is being controlled with insulin therapy.
A geriatric patient with a history of recent falls is receiving physical therapy for general conditioning. He was recently released from the hospital for pneumonia, and although he was cleared for exercise, he is still having some dyspnea with activity. Based on his presentation, which of the following interventions would be the MOST appropriate to start with in order to improve his cardiovascular fitness?
A. Avoid exercise
B. Focus on light intensity exercise before progressing to moderate intensities
C. Focus on moderate intensity, long duration activities
D. Focus on high intensity interval training
A. The patient was cleared for exercise, and it would be OK to start with light activity to the patient’s tolerance.
B. This is the correct answer. It would be safe to start with gentle activity, but avoid moderate activities until some level of baseline fitness is achieved.
C. This would be appropriate to build towards, but is not likely going to be tolerated early on. The patient should start with light exercise.
D. This patient should avoid HIIT until his fitness is significantly improved and he is no longer having symptoms of pneumonia.
A physical therapist examines the output from a single lead ECG of a patient in an inpatient clinic. The ECG strip is shown. What should the physical therapist determine the heart rate of the patient as?
A. 100 bpm
B. 110 bpm
C. 120 bpm
D. 130 bpm
This is a 6-second strip composed of 13 QRS complexes. Using the 6-second rule, 13 x 10 = 130 bpm, or D
A 45-year-old healthy adult is participating in a treadmill walking test at moderate intensity. Which of the following represents a normal physiologic response in this patient?
A. Systolic BP decreases, diastolic BP remains stable
B. Systolic BP increases, diastolic BP remains stable
C. Both systolic and diastolic BP increase significantly
D. Diastolic BP increases while systolic BP remains the same
B. This is the correct answer. Systolic BP should increase and diastolic BP should remain relatively stable; might see a slight increase or decrease in diastolic BP
C. Diastolic BP should not increase significantly
D. Diastolic BP can increase slightly, but systolic should always increase with exercise
A 70-year-old female reports unusual fatigue, nausea, and shortness of breath after climbing stairs. She denies chest pain but says she feels “not right.” Her vitals are stable. What is the best next step?
A. Educate the patient on energy conservation
B. Document findings and instruct her to monitor symptoms
C. Suspect possible MI and refer immediately to the emergency department
D. Begin aerobic conditioning to improve fatigue
A. While energy conservation techniques are important for managing fatigue in chronic conditions, this patient’s symptoms are potentially acute and may indicate a life-threatening condition, such as MI
B. Given the patient's symptoms and her age, it's inappropriate to just wait and monitor. MI is a medical emergency, and she needs immediate evaluation
C. This is the correct answer. Fatigue, nausea, and shortness of breath with no chest pain can still be signs of an acute myocardial infarction (MI), especially in older females, who often present atypically. The patient's symptoms are concerning, and even though her vitals are stable, it's critical not to dismiss potential cardiac issues
D. Starting exercise without ruling out a potential MI could be dangerous. The focus needs to be on diagnosing and treating the possible MI first
A patient is receiving cardiac rehab and has a heart rate of 110 during moderate intensity exercise. The patient reports a 16 on the Borg rate of perceived exertion scale. Which class of heart medications is MOST likely present?
A. Beta blockers
B. Angiotensin-converting enzyme (ACE) Inhibitors
C. Calcium channel blockers
D. Angiotensin II receptor blockers
A. This is the correct answer. Beta blockers work on the beta-adrenergic receptors to decrease sympathetic responses to stress, primarily the heart rate. The Borg Scale should represent heart rate divided by 10. Thus there is a disparity in heart rate and exertion, indicating a blunted heart rate.
B. ACE inhibitors block the angiotensin-converting enzyme to prevent vessel constriction during sympathetic responses to stress, primarily blood pressure.
C. Calcium channel blockers work on the heart musculature to decrease the force of contraction, as well as decreasing the vasoconstrictive smooth muscle in the arteries. The primary response is decreased blood pressure.
D. Angiotensin II receptor blockers do not prevent the angiotensin I to angiotensin II conversion; rather, they block the receptors of angiotensin II and have an effect similar to the ACE inhibitors.
You are working with a 70 year old patient who is status post a CABG surgery 5 weeks ago. Which of the following would be the most appropriate intervention?
A. Wall push-ups
B. Squats with a 10 lb dumbbell
C. Supine bench press with a 5 lb bar
D. Walking on the treadmill at 3 mph for 30 minutes
A. Pushing and upper extremity exercise is contraindicated 4-6 weeks after CABG surgery while the sternal incision is healing
B. Lifting is contraindicated 4-6 weeks after CABG surgery
C. Pushing and upper extremity exercise is contraindicated 4-6 weeks after CABG surgery while the sternal incision is healing
D. This is the correct answer. Aerobic exercise is highly recommended after open heart surgery and should be performed for 30-60 minutes
You are working with a patient in the hospital and they are tolerating exercise well without any abnormal symptoms. However, you notice their EKG appears as pictured. What is the diagnosis and what should you do?
A. Atrial flutter, lower exercise intensity and monitor the patient
B. Atrial flutter, stop exercise and allow the patient to rest
C. Atrial fibrillation, lower exercise intensity and monitor the patient
D. Atrial fibrillation, stop exercise and allow the patient to rest
A. The picture shows atrial fibrillation; atrial flutter shows "flutter waves," in which you might see 3-5 P waves; if patient is demonstrating atrial flutter and are asymptomatic, you should decrease exercise intensity and monitor.
B. This is not showing atrial flutter; furthermore, atrial flutter does not indicate stopping exercise if they are asymptomatic, only if they are symptomatic.
C. This is demonstrating atrial fibrillation; however, you should stop exercise altogether rather than lowering intensity; not 911
D. This is the correct answer. Atrial fibrillation is demonstrated by an excessive number of P waves and exercise should be stopped.
You are examining a 64 year old male who has presented to your outpatient clinic with primary complaint of chest pain. While auscultating, you hear a heart sound heard late in diastole. Where is the primary location this heart sound is heard and what is it likely indicative of?
A. Base of the heart, likely indicative of MI
B. Apex of the heart, likely indicative of MI
C. Base of the heart, likely indicative of CHF
D. Apex of the heart, likely indicative of CHF
A. Abnormal heart sounds are heard better at the apex of the heart where the mitral valve is auscultated (left 5th intercostal space, midaxillary).
B. This is the correct answer. Abnormal heart sounds are best heard at the apex of the heart and a heart sound heard late in diastole is S4. In this case, S4 likely indicates MI. S4 can also be indicative of HTN.
C. Abnormal heart sounds are heard at the apex of the heart rather than the base. CHF is more associated with S3 than S4.
D. Abnormal heart sounds are heard at the apex of the heart; however, S4 is more associated with MI or HTN whereas CHF is more associated with an S3 heart sound.
You are treating a patient in the hospital who had a right total hip arthroplasty 2 days ago. You know it is important to keep the patient moving to avoid development of a DVT. Which of the following signs and symptoms would indicate calling the physician about the patient likely having a DVT?
A. Pitting edema of the right leg and right leg 2 cm larger than the left
B. Left leg 4 cm larger than the right and no history of DVT
C. Localized tenderness of the right leg and the right leg 3 cm larger than the left
D. Swollen ankle and recent history of cancer
A. Pitting edema is 1 point on the Well's criteria, but the right leg must be at least 3 cm larger than the left for another point.
B. The right leg rather than the left would likely be swollen in this case, however, one leg 4 cm larger than the other is 1 point. Furthermore, history of DVT is 1 point on the Well's criteria whereas no history of DVT does not increase chance of one currently.
C. This is the correct answer. Localized tenderness and leg swelling of 3 cm or more are 1 point each on Well's criteria. Must score at least 2 points to be considered a likely DVT.
D. Recent history of cancer (6 months or less) is 1 point on Well's criteria; however, swollen ankle is not. It is 1 point only if the entire leg is swollen.
You are treating a patient in an outpatient cardiac rehab. They have made great progress and you feel they may be ready to discharge. Which of the following would MOST indicate that the patient is ready to progress to phase 3 of cardiac rehab?
A. Patient is able to exercise consistently at 5 METs
B. Patient is able to tolerate 20 consecutive minutes of aerobic exercise
C. Patient is able to exercise consistently at 9 METs
D. Patient has weaned from continuous monitoring to spot checks
A. 5 METs is considered necessary for safe resumption of most daily activities, but 9 METs should be considered the exit point for rehab
B. Patients should be able to tolerate 30-60 minutes with 5-10 minutes of warm-up and cool-down
C. This is the correct answer.
D. Patient should be able to self-monitor
You are treating a patient who is 3 days s/p post-transcatheter procedure. You have been working on aerobic conditioning up until now, but you feel your patient is ready for strength training. Which of the following would be a contraindication to resistance exercise training?
A. Patient has uncontrolled dysrhythmias
B. Patient has HTN
C. Patient has DM
D. Patient has moderate tricuspid valve stenosis
A. This is the correct answer. Uncontrolled dysrhythmias are a contraindication to resistance training in cardiac rehab.
B. HTN is only considered a contraindication to resistance training if it is uncontrolled.
C. DM is not a contraindication for resistance training.
D. Valvular disease is only considered a contraindication to resistance training if it is severe.
You are exercising a patient on the treadmill in an outpatient clinic when they begin complaining of SOB. You look at the EKG and notice it appears as pictured. What is the most appropriate course of action?
A. Stop exercise and call 911 immediately
B. Stop exercise and monitor the patient closely
C. Lower the intensity of exercise and monitor closely
D. Continue at same exercise intensity and monitor closely
A is the correct answer. 3 PVCs in a row is considered ventricular tachycardia, which is a medical emergency as it can become ventricular fibrillation.
Which of the following factors would most likely cause an increase in stroke volume?
A. Decreased preload
B. Increased afterload
C. Decreased contractility
D. Increased venous return
A. Increased preload rather than decreased preload increases stroke volume; preload is end-diastolic volume
B. Decreased afterload rather than increased afterload increases stroke volume; afterload is the amount of pressure the ventricle must overcome to pump the blood out, so, it is easier to pump blood with a decreased afterload
C. Increased contractility rather than decreased would increase stroke volume because the heart pumps better with increased contractility
D. This is the correct answer. Increased venous return increases preload, which enhances stroke volume via the Frank-Starling mechanism
You are treating a patient who has been diagnosed with left-sided congestive heart failure. Which of the following would you expect to find in this patient?
A. Decreased cardiac output
B. Increased stroke volume
C. Abnormal S4 heart sound
D. Increased swelling of lower extremities
A. This is the correct answer. CHF causes decreased stroke volume, which decreases cardiac output. CO = HR x SV
B. CHF causes decreased stroke volume rather than increased due to the left ventricle having difficulty pumping blood out
C. CHF is more likely to present with an S3 heart sound than an S4 heart sound
D. Increased swelling of the lower extremities is characteristic of right-sided heart failure rather than left.
You are treating a patient in phase I of cardiac rehab s/p an uncomplicated MI. Which of the following an appropriate target during exercise during their first treatment session?
A. 80% of their HR max
B. Exercise intensity of 6 METs
C. 75% of their HR max
D. Exercise intensity of 5 METs
A. HR max should be kept at 70% or below in the initial phases of cardiac rehab
B. Exercise intensity should be kept at 5 METs or below in the initial phases of cardiac rehab
C. See A
D. This is the correct answer. Exercise intensity should be 5 METs or below
You are exercising a patient who is being treated in cardiac rehab for CHF. You have decided the patient is ready to have their exercises progressed. Which of the following is the MOST likely reason you could progress the patient's exercises?
A. Patient is rating exercise lower on the RPE scale
B. Patient is rating exercise higher on the RPE scale
C. Patient has higher HR than target HR with exercise
D. Patient states they are ready to progress the exercises
A. This is the correct answer. The patient rating the exercise lower on the RPE scale means they are perceiving the exercise as easier.
B. The patient rating the exercise higher on the RPE scale means they are perceiving the exercise as harder than previously.
C. The patient having a lower HR than target would indicate they are ready to progress, not higher HR.
D. No
You are working with a patient in the hospital who was admitted with complaints of dyspnea, weakness, and HTN. The patient is being monitored and, while they are performing bed exercises, you notice the EKG as pictured. What is happening and what is the most appropriate course of action?
A. Second-degree heart block type II, stop exercise and closely monitor
B. Myocardial ischemia, stop exercise and call 911
C. Premature atrial contractions, continue exercising without changing intensity
D. Myocardial infarction, stop exercise and call 911
A. 2nd degree heart block type II would appear as normal until a QRS is suddenly and unpredictably dropped. In this case, however, you would stop exercise and closely monitor.
B. This is the correct answer. Myocardial ischemia presents as ST depression of 2 mm or more, and it is considered a medical emergency.
C. Premature atrial contractions would appear as a P wave very close to the T wave. However, you would continue exercising as normal if this were the case.
D. Myocardial infarction would present as ST elevation of 1 mm or more rather than ST depression. However, this would still be a medical emergency.
A 55-year-old male in phase II cardiac rehab has a resting heart rate of 52 bpm and shows no symptoms during activity. Which of the following best explains how this patient can maintain adequate cardiac output?
A. Decreased end-diastolic volume
B. Increased stroke volume
C. Increased systemic vascular resistance
D. Decreased venous return
A. A decrease in EDV would reduce stroke volume, which would make it harder, not easier, to maintain cardiac output.
B. A low resting HR (like 52 bpm) can be normal in trained individuals. These patients often maintain adequate cardiac output through a larger stroke volume—the heart pumps more blood per beat; CO = HR x SV
C. Increasing systemic vascular resistance makes it harder for the heart to pump blood out (i.e., it increases afterload), which can reduce stroke volume and make it harder to maintain cardiac output
D. Venous return is a key determinant of preload, which directly influences stroke volume via the Frank-Starling mechanism. A decrease in venous return would reduce stroke volume and impair cardiac output
A 45-year-old female with no significant medical history presents with intermittent chest pain that occurs mainly at night and is associated with shortness of breath. The pain lasts for a few minutes and then resolves on its own. Which of the following is most likely triggering her chest pain?
A. Emotional stress
B. Physical exertion
C. Coronary artery spasm
D. Exposure to cold temperatures
A. Emotional stress is more commonly a trigger for stable angina or unstable angina, where the pain is typically related to increased oxygen demand during periods of stress or activity. Prinzmetal's angina, however, is caused by coronary artery spasm and is typically not triggered by emotional stress. It occurs spontaneously, often during rest or at night, when there is no increased physical or emotional stress.
B. Physical exertion is a hallmark trigger for stable angina. However, Prinzmetal's angina is caused by temporary coronary artery spasm, which occurs at rest and is not directly related to exertion or activity. Pain from Prinzmetal's angina often resolves spontaneously after a few minutes, whereas exertion-induced angina pain typically resolves only with rest or medication like nitroglycerin.
C. This is the correct answer. The fact that the angina is occurring at night rather than with exercise and resolves on its own after a few minutes tells you it is Prinzmetal's angina (variant) rather than stable or unstable. In Prinzmetal's angina, the main cause is coronary artery vasospasm.
D. Cold temperatures can indeed cause vasoconstriction and increase the risk of angina. However, Prinzmetal's angina is primarily caused by coronary artery spasm. Presentation of pain occurring mainly at night and lasting for short periods aligns more with coronary artery spasm as the primary trigger, rather than cold-induced vasoconstriction.
You are treating a patient in phase II of their cardiac rehab program. They are currently being treated post-CABG. At what point is it appropriate to begin strength training?
A. 5 weeks
B. 6 weeks
C. 8 weeks
D. 12 weeks
The correct answer is C, 8 weeks. Strength training is initiated after 8 weeks post-CABG to allow the sternal incision to heal. Strength training post-MI should begin at 5 weeks whereas most other cardiac conditions can begin strength training at 3 weeks.
You are treating a patient with peripheral venous disease. You notice moderate edema of the patient's right calf and want to ensure they are wearing their graded compression stocking after your treatment session ends. Which of the following is an appropriate level of compression?
A. 15 mmHg of pressure
B. 20 mmHg of pressure
C. 25 mmHg of pressure
D. 30 mmHg of pressure
D is the correct answer. Graded compression stockings should be at least 30 mmHg of pressure to be sufficient with venous disease.
You are exercising a patient in an outpatient clinic while they are being monitored with a 12-lead EKG. The patient is not demonstrating any abnormal symptoms and seems to be tolerating exercise well. The EKG appears as shown. What is the most appropriate course of action?
A. Continue exercise at current intensity
B. Lower exercise intensity at monitor closely
C. Stop exercise and let the patient rest
D. Call 911 immediately
A. This would be the appropriate course of action for a 1st degree heart block rather than a 2nd degree type II
B. This would be the appropriate course of action for a 2nd degree heart block type I rather than a type II
C. This is the correct answer. This EKG is depicting a 2nd degree heart block type II, which means exercise should be stopped.
D. A 2nd degree heart block type II is not considered an emergency. The only heart block that is is a 3rd degree.