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Flashcards in Chapter 05 - Recommend Diagnostic Procedures Deck (35)
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1

While reviewing the flow sheet of a patient receiving artificial ventilatory support, you note a progressive rise in heart rate over the last two hours. Which of the following actions would you recommend to help identify the cause of this problem?

  1. measure the patient's inspiratory force
  2. obtain a sputum sample for culture
  3. draw and analyze an arterial blood gas
  4. check the patient's intake and output record

3

Common causes of tachycardia (and other cardiac arrhythmias) in patients with respiratory failure include anxiety, hypoxemia, and hypercapnia. Obtaining an ABG will help confirm or rule out these possibilities.

2

Which of the following tests would you recommend to help assess the effectiveness of steroid treatment for a patient with asthma?

  1. Carbon monoxide diffusing capacity (DLco)
  2. Methacholine challenge test (PC20)
  3. Exhaled nitric oxide test (FeNO)
  4. Treadmill exercise challenge test

3

Analysis of the exhaled fraction of nitric oxide (FeNO) is used in both the diagnosis and management of asthma. In asymptomatic patients on inhaled steroids, low levels indicate effective treatment and good compliance with therapy. High level may indicate inadequate steroid dose, poor treatment compliance, or poor inhaler technique.

3

A 23-year-old firefighter is admitted with suspected smoke inhalation. You place him on a non-rebreathing mask. What is the most appropriate method of monitoring his oxygenation?

  1. arterial blood gas analysis
  2. co-oximetry
  3. pulse oximetry
  4. calculation of P(A-a)O2

2

In the case of smoke inhalation, carbon monoxide (CO) binds to the hemoglobin molecule in place of oxygen. Neither ABGs, standard pulse oximetry nor calculation of the A-a gradient will provide indication of how much oxygen is bound to hemoglobin. Any victim of suspected smoke inhalation must be monitored with CO-oximetry.

4

Which of the following tests would you recommend in order to identify the cause of dyspnea and factors limiting a patient's exercise tolerance?

  1. 6-minute walking distance
  2. overnight oximetry assessment
  3. peak expiratory flow rate
  4. comprehensive exercise test

4

To identify the cause of dyspnea and factors limiting a patient's exercise tolerance, you would need to conduct a comprehensive cardiopulmonary exercise test. The 6-minute walk test only evaluates how well the body as a whole responds to exertion. Its use therefore is limited to determining overall functional capacity or changes in capacity due therapy.

5

A physician asks you to assess a patient's respiratory muscle strength. Which of the following bedside measures would you consider appropriate in order to obtain this data?

  1. Maximum voluntary ventilation: No; Deadspace to tidal volume ratio: Yes; Forced vital capacity: Yes; Maximum inspiratory pressure: Yes
  2. Maximum voluntary ventilation: No; Deadspace to tidal volume ratio: Yes; Forced vital capacity: No; Maximum inspiratory pressure: Yes
  3. Maximum voluntary ventilation: Yes; Deadspace to tidal volume ratio: No; Forced vital capacity: Yes; Maximum inspiratory pressure: No
  4. Maximum voluntary ventilation: Yes; Deadspace to tidal volume ratio: No; Forced vital capacity: Yes; Maximum inspiratory pressure: Yes

4

Bedside measurements used most commonly to assess respiratory muscle function are the maximum inspiratory and expiratory pressures (MIP/NIF and MEP), maximum voluntary ventilation (MVV), and vital capacity (VC).

6

A patient in ICU is receiving a continuous IV drip of an opioid analgesic for sedation and pain relief. Which of the following would you recommend for monitoring this patient?

  1. continuous blood pressure monitoring
  2. intermittent arterial blood gas sampling
  3. pulse oximetry/SPO2 monitoring
  4. real-time waveform capnography

4

Patient receiving large or continuous doses of opioid analgesics must be carefully monitored for respiratory depression/hypoventilation, ideally via a breath-by-breath method like real-time capnography. Impedance-based apnea monitoring would be a satisfactory alternative. Pulse oximetry is notoriously inadequate for detecting hypoventilation (especially in patients receiving supplemental O2 therapy), and intermittent ABG sampling might not reveal severe hypoventilation until it is too late.

7

A patient is being considered for participation in a pulmonary rehabilitation program. Which of the following test regimens would you recommend in order to ascertain the patient's cardiopulmonary status?

  1. Cardiopulmonary exercise evaluation: Yes; Pulmonary function testing: Yes; Cardiac (left heart) catheterization: Yes
  2. Cardiopulmonary exercise evaluation: Yes; Pulmonary function testing: Yes; Cardiac (left heart) catheterization: No
  3. Cardiopulmonary exercise evaluation: Yes; Pulmonary function testing: No; Cardiac (left heart) catheterization: Yes
  4. Cardiopulmonary exercise evaluation: No; Pulmonary function testing: Yes; Cardiac (left heart) catheterization: Yes

2

To determine the patient's cardiopulmonary status and exercise capacity, both pulmonary function testing and a cardiopulmonary exercise evaluation should be performed. The pulmonary function testing should include assessment of pulmonary ventilation, lung volume determinations, diffusing capacity (DLco), and pre- and postbronchodilator spirometry.

8

Which of the following spirometry tests would you recommend to evaluate the severity of an obstructive lung disorder?

  1. forced vital capacity
  2. inspiratory capacity
  3. tidal volume
  4. expiratory reserve volume

1

Because obstructive disorders limit airflow, the only measure listed that would help assess the severity of the condition would be the forced vital capacity (including its time components, e.g., FEV1, FEV3). Typically an FEV1/FVC ratio < 70% defines an obstructive ventilatory impairment. With the exception of the RV and TLC (increased in air-trapping) simple lung volumes such as the VT or IC are not useful in assessing the severity of obstructive disorders.

9

You are providing BiPAP with 100% O2 to a 55-year-old female admitted to the ED with signs and symptoms of acute pulmonary edema. Which of the following laboratory tests would you recommend to help the doctor determine whether or not the patient is suffering from congestive heart failure?

  1. total cholesterol
  2. serum electrolytes
  3. B-type natriuretic peptide
  4. blood urea nitrogen

3

B-type natriuretic peptide (BNP) is a cardiac neurohormone secreted by cardiac muscle cells in response to ventricular volume expansion and pressure overload. BNP levels below 100 pg/mL can help rule out the presence of congestive heart failure (CHF), while levels above 500 pg/mL can help confirm this diagnosis. Blood urea nitrogen is a screening test used to assess renal function, total cholesterol is measured to assess risk for heart disease, and by themselves the serum electrolytes will not be diagnostic for CHF.

10

Which of the following tests would you recommend to assess an outpatient's compliance with a smoking cessation program?

  1. exhaled carbon dioxide
  2. forced expiratory volume
  3. exhaled carbon monoxide
  4. diffusing capacity

3

Exhaled carbon monoxide (eCO) measurements provide a quick, easy and noninvasive way for assessing a patient's smoking status. To make the measurement, the patient is instructed to take a deep breath and hold it for 15–20 seconds, after which they exhale into a portable monitor. The monitor samples the end-expired (alveolar) air and measures the eCO level in parts per million (ppm). In general, readings greater than 6 to 10 ppm strongly suggest that the patient has recently smoked.

11

You would recommend repeating tuberculin skin testing on those who previously tested negative if they have:

  1. Potential ongoing exposure to TB: Yes; Received the BCG TB vaccine: No; Close contact with active TB cases: No
  2. Potential ongoing exposure to TB: No; Received the BCG TB vaccine: No; Close contact with active TB cases: Yes
  3. Potential ongoing exposure to TB: Yes; Received the BCG TB vaccine: No; Close contact with active TB cases: Yes
  4. Potential ongoing exposure to TB: Yes; Received the BCG TB vaccine: Yes; Close contact with active TB cases: Yes

3

You would recommend repeating tuberculin skin testing on those who previously tested negative if they either have potential ongoing exposure to TB (such as healthcare workers) or have close contact with active TB cases, such as a family member. Neither initial nor repeat testing of persons who have received the BCG TB vaccine is indicated because these individual always exhibit an immune reaction (false positive).

12

In reviewing a patient's chart you note a history of COPD and a Body Mass Index (BMI) of 15. Which of the following tests would you recommend?

  1. polysomnography
  2. exercise stress test
  3. metabolic study
  4. bronchoscopy

3

With a BMI of 15, this patient is severely malnourished. That alone is an indication for measurement of his metabolic parameters (VO2, VCO2, RE, REE) via indirect calorimetry. Add to that COPD—in which the O2 cost of breathing can be very high and excessive carbohydrates can increase ventilatory demand—and the need for a metabolic assessment is apparent. Other clinical situations in which IC studies may be indicated include severe sepsis, multiple trauma, burns, hyper- or hypometabolic states, mechanical ventilation weaning difficulties, and whenever a patient's response to nutritional support is inadequate.

13

A patient has a history of recurrent asthma symptoms that begin early every spring and persist throughout the summer. Which of the following tests would you recommend to help identify the cause of the patient’s symptoms?

  1. pre- and post-bronchodilator spirometry
  2. sputum Gram stain, culture and sensitivity
  3. skin testing to a panel of outdoor allergens
  4. exhaled nitric oxide (NO) analysis

3

Based on the patient history, allergic asthma due to exposure to IgE-mediated environmental allergens is a likely diagnosis. Give that the annual recurrence coincides with pollen seasons (trees pollen early spring, grass pollen May through mid-July, weed pollen late summer) skin testing with a panel of outdoor allergens should be considered. A sputum Gram stain and C&S is used to help diagnose respiratory infections. Neither of the other tests help identify the cause of the patient’s symptoms. Pre/post bronchodilator spirometry only confirms the reversibility of the patient’s obstruction. Exhaled NO analysis is used either to confirm the inflammatory process underlying asthma or monitor to a patient’s response to therapy.

14

A patient with mild chest pain is being rule out for myocardial Infarction or Ischemia;which of the following lab tests would you recommend to help confirm the diagnosis?

  1. alkaline phosphatase
  2. serum troponin
  3. blood urea nitrogen
  4. total cholesterol

2

Cardiac biomarkers or 'enzymes' are used to assess for cardiac muscle damage due to ischemia or infarction. Current cardiac biomarkers include total creatine kinase (CK) and its heart-specific isoenzyme CK-MB, myoglobin, and troponin I. Troponin I is considered the best of these markers. Typically, troponin I serum levels increase soon after an AMI and peak in about 12 hours. Alkaline phosphatase is a liver enzyme used to assess liver function, blood urea nitrogen is a screening test used to assess renal function, and total cholesterol is measured to assess risk for heart disease.

15

CO-oximetry analysis should be performed whenever the following information is needed:

  1. total CO2 content
  2. acid-base status
  3. HCO3 concentration
  4. abnormal Hb levels

4

Unlike the SpO2 and PaO2, CO-oximetry measures the total hemoglobin in a blood sample and fractions of the total (percent saturations) bound to O2 and other chemicals. Measures include total hemoglobin (THb in g/dL), % oxyhemoglobin (HbO2% or SaO2), % carboxyhemoglobin (HbCO%), % methemoglobin (metHb%), and % sulfhemoglobin (SHb%). In addition, total O2 content (CaO2 in mL/dL) of the sample is calculated (total Hb x 1.36 x HbO2%).

16

Which of the following tests would you recommend in order to identify the cause of dyspnea and factors limiting a patient's exercise tolerance?

  1. 6-minute walking distance
  2. overnight oximetry assessment
  3. peak expiratory flow rate
  4. comprehensive exercise test

4

To identify the cause of dyspnea and factors limiting a patient's exercise tolerance, you would need to conduct a comprehensive cardiopulmonary exercise test. The 6-minute walk test only evaluates how well the body as a whole responds to exertion. Its use therefore is limited to determining overall functional capacity or changes in capacity due therapy.

17

A pulmonologist asks you to assess airway responsiveness during a pulmonary function exam. He wants to rule out asthma from chronic bronchitis in a patient complaining of nocturnal wheezing. Which of the following test should you recommend?

  1. bronchoprovocation test
  2. cardiopulmonary stress test
  3. nitrogen washout challenge
  4. thoracic gas volume

1

Tests that are indicated to assess for the presence and the degree of airway responsiveness include bronchoprovocation studies (methacholine or histamine challenge) and expired nitric oxide (FeNO) analysis. They are also indicated to screen individuals who may be at risk from environmental or occupational exposure to allergens.

18

Sputum culture and sensitivity would be indicated in the evaluation of which of the following clinical conditions?

  1. pulmonary edema
  2. bacterial pneumonia
  3. pulmonary embolism
  4. empyema

2

Sputum culture & sensitivity is used to identify microorganisms and their most appropriate drug therapy. Bacterial pneumonia is the obvious infectious process in the choice of answers.

19

Which of the following is the best test for assessing the degree of reversible bronchospasm in an asthmatic patient?

  1. nitrogen washout
  2. spirometry before and after bronchodilation
  3. maximal voluntary ventilation
  4. maximum inspiratory and expiratory force

2

The only test that will give you a picture of how well a bronchodilator treatment works is FVC spirometry before and after bronchodilation. An increase of at least 12-15% in the FEV1 after bronchodilator is used as the threshold to indicate reversibility.

20

Which of the following would provide the best bedside assessment of the need for ventilatory assistance in a patient with myasthenia gravis?

  1. functional residual capacity
  2. vital capacity
  3. closing volume
  4. total lung capacity

2

Myasthenia gravis is a neuromuscular disease that affects muscle strength. Of the tests listed, the vital capacity requires the most muscular effort from the patient and would be the first of the listed tests to decrease in a neuromuscular disorder.

21

In patients with suspected pulmonary thromboembolism whose ordinary X-rays are negative, which of the following procedures can best help establish the diagnosis?

  1. cardiac enzyme determinations
  2. arterial blood gas analysis
  3. cardiovascular stress testing
  4. ventilation/perfusion scans

4

When ordinary X-rays are negative, lung scans are helpful in establishing the diagnosis. A normal perfusion scan generally rules out pulmonary embolism. On the other hand, the demonstration of normal ventilation of an area of lung in the absence of perfusion strongly suggests pulmonary embolism. The gold standard for detecting pulmonary embolism is CT pulmonary angiography (CTPA), which has greater accuracy than ventilation-perfusion scans.

22

A patient admitted to the Emergency Department is suspected of having suffered airway injury due to inhalation of toxic fumes. To determine the location and extent of potential injury you would recommend which of the following procedures?

  1. V/Q scan
  2. chest X-ray
  3. blood gas analysis
  4. bronchoscopy

4

Injury from toxic inhalation or aspiration most immediately affects the airways. In these patients the location and extent of injury is best determined initially using fiberoptic bronchoscopy.

23

You are monitoring a patient with myasthenia gravis and finds that the maximum inspiratory pressure (MIP/NIF) has changed from -35 cm H2O 4 hours ago to -10 cm H2

  1. measuring maximum voluntary ventilation (MVV)
  2. administering oxygen via partial rebreathing mask
  3. administering oxygen via nasal cannula at 5 L/min
  4. obtaining/analysing an arterial blood gas sample

 

4

A rapid decrease in MIP/NIF indicates that the disease has progressed to affect the respiratory muscles. If severe, this can cause hypoventilation and respiratory acidosis. To confirm this, an arterial blood gas should be drawn

24

A patient is admitted with obstructive lung disease. Which of the following would be most helpful in order to distinguish between asthma and emphysema as a diagnosis for this patient?

  1. Arterial blood gas analysis
  2. Maximal voluntary ventilation
  3. Sputum culture and sensitivity testing
  4. Spirometry before and after a bronchodilator

4

Since airway obstruction in asthma is at least partially reversible and that in emphysema is essentially not reversible, FVC spirometry before and after a bronchodilator would be the most helpful way to distinguish between the two. An increase of at least 12-15% in the FEV1 after bronchodilator is used as the threshold to indicate reversibility.

25

A physician requests transcutaneous blood gas monitoring on a premature infant in the NICU. Which of the following conditions would cause you to recommend against using this device to monitor this patient?

  1. hemodynamic instability
  2. congenital heart disease
  3. respiratory distress syndrome
  4. meconium aspiration

1

You should avoid using a transcutaneous monitor on patients with poor skin integrity or those with an adhesive allergy. Since accurate PtcO2 and PtcCO2 values generally require that the patient be hemodynamically stable, you should not use these devices on patients in shock or with poor peripheral circulation. Lengthy set-up and stabilization time (10-20 minutes) also makes the transcutaneous monitor a poor choice for assessing gas exchange in emergency situations.

26

Which of the following is the most effective diagnostic test to quantify the amount of ventilatory impairment in a patient with Guillain-Barre syndrome?

  1. serial end-expired PCO2 measurements
  2. serial P(A-a)O2 measurements
  3. serial vital capacity measurements
  4. serial total lung capacity measurements

3

Guillain-Barré syndrome is an acute inflammatory neuropathy affecting the spinal root and peripheral nerves, causing acute muscle weakness and diminished reflexes. Of the tests listed, only the vital capacity requires muscular effort and is thus the best choice for determining the patient's degree of ventilatory impairment due to muscle weakness. Other bedside measures of muscle strength include the maximum inspiratory and expiratory pressures (MIP/NIF and MEP).

27

A patient in ICU suddenly deteriorates. The attending doctor wants to rule out acute pulmonary embolism as the cause. Which of the following laboratory tests would be most helpful to this end?

  1. d-dimer
  2. PaCO2
  3. hematocrit
  4. troponin I

1

D-dimer is produced by the breakdown of fibrin clots in blood vessels and thus increases in many conditions causing thromboses. However, when the d-dimer level is normal, the presence of both systemic (e.g., DIC) and local thromboses (e.g., pulmonary embolism and DVT) generally can be ruled out. Troponin is a cardiac biomarker used to assess for myocardial infarction, and neither the hematocrit nor the PaCO2 have any diagnostic value in evaluating a patient for the occurrence of pulmonary embolism.

28

You would recommend continuous SpO2 monitoring (versus short-term assessment or spot checks) for which of the following?

  1. child requiring twice daily postural drainage
  2. neonate being screened for congenital heart disease
  3. stable postop adult started on O2 therapy
  4. patient undergoing diagnostic bronchoscopy Correct

4

Whether SpO2 monitoring should be continuous or 'spot checked' only depends on the clinical status of the patient and the monitoring needs of the situation at hand. For example, continuous SpO2 monitoring is usually indicated for all critically ill patients and for detecting desaturation on those undergoing procedures such as bronchoscopy, exercise testing and sleep studies. On the other hand, a spot check usually suffices for evaluating the efficacy of O2 therapy on stable patients. And screening for congenital heart disease via dual oximetry (pre/post-ductal) is a single test that is repeated up to 3 times, but not applied continuously.

29

You would recommend an overnight oximetry evaluation to:

  1. warn against any apparent life-threatening events
  2. screen patients for sleep apnea-hypopnea syndrome
  3. assess for paroxysmal nocturnal dyspnea/CHF
  4. differentiate obstructive from central sleep apnea

2

Overnight oximetry can be used to: (1) help identify patients with sleep apnea-hypopnoea syndrome (SAHS); (2) help assess SAHS patients' response to therapy, such as CPAP; and (3) identify whether serious desaturation occurs in COPD patients during sleep. Because oximetry cannot differentiate obstructive from central sleep apnea, when used to screen for SAHS or assess a patients' response to therapy, it should be combined with measures of airflow and respiratory effort (a Type IV Home Sleep Test). It is also important to remember that oximetry should never be used alone to monitor for life-threatening events like prolonged apnea, since the PCO2 can rise to dangerous levels before a large fall in saturation occurs (especially in patients breathing supplemental O2).

30

A doctor asks your advice on the best way for his home care asthma patient to assess changes in her airway tone over time. You would recommend:

  1. peak expiratory flow rate monitoring
  2. methacholine challenge (provocation) test
  3. carbon monoxide diffusing capacity (DLco)
  4. pre/post bronchodilator spirometry

1

Peak expiratory flow rate monitoring is the primary means by which asthma patients can assess their airway tone over time, as well as changes in tone in response to bronchodilator therapy. Pre/post bronchodilator spirometry is used primarily to determine the effectiveness of bronchodilator therapy or the need for a change in the drug dose or frequency of administration. Methacholine challenge testing is used mainly to assess the severity of airway hyperresponsiveness or evaluate occupational asthma