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Flashcards in Medical Rehab Deck (95):
1

You are asked to consult on a 60-year-old cancer patient with an acute deep vein thrombosis (DVT) in the right upper limb, secondary to a long-standing central venous catheter. What therapy restrictions would you recommend for the patient?

(a) Bed rest for 10-12 days to allow for clot maturation.
(b) No activity restrictions, since upper limb DVTs have a low likelihood of causing a
pulmonary embolus.
(c) Begin resistive exercises 12-24 hours after the patient is therapeutic on an anticoagulant.
(d) Limit therapy to ambulation, balance, and ADL training if anticoagulation is medically
contraindicated

Answer: (d)
Commentary: Because patients with acute upper limb DVT who cannot safely be anticoagulated are at high risk for pulmonary emboli and death, their physical, occupational, or lymphedema therapy should be functional in nature (ie, ambulation, balance, ADL training). Resistive exercises should be deferred until 48 – 72 hours after a patient is therapeutic on an anticoagulant (low molecular weight heparin, unfractionated heparin, or Coumadin). Prolonged bed rest for clot maturation is no longer supported within the medical literature for lower extremity DVTs, since the initial recommendation was based on a single limited study. Although the timing of mobilization following an acute upper limb DVT and institution of therapy has not yet been defined in the literature, bed rest for 10-12 days is overly restrictive. However, placing no activity restrictions on the patient is potentially dangerous, since an immature clot may break off and embolize to the lungs.

Reference: (a) Stubblefield MD and O'Dell MW, editors. Cancer rehabilitation: principles and practice. New York: Demos Medical Publishing; 2009. (b) Stubblefield MD, Pearce CK. Rehabilitation of the cancer patient: identification, evaluation, and rehabilitation of patients with complications of cancer and its treatment from impending fracture to hematologic abnormalities. Paper presented at: American Academy of Physical Medicine and Rehabilitation Annual Assembly; 2011. (c) Kiser TS, Stefans VA. Pulmonary embolism in rehabilitation patientsrelation to time before return to physical therapy after diagnosis of deep vein thrombosis. Arch Phys Med Rehabil 1997;78(9):942-5.

2013

2

A 70-year-old man with COPD presents to your office for follow-up. His forced expiratory
volume in 1 second (FEV1) is 55% of predicted normative values. What would you expect the
patient’s functional limitations to be?

(a) No functional impairment; the patient is able to walk significant distances without
difficulty.
(b) Mild functional impairment; the patient is able to walk significant distances at a slower
speed.
(c) Moderate functional impairment; the patient requires intermittent rest when walking and
climbing stairs.
(d) Severe functional impairment; the patient is only able to ambulate for very short
distances.

Answer: (c)
Commentary: The World Health Organization’s Global Initiative for Chronic Obstructive Lung Disease classifies patients who have an FEV1 between 50%-79% of predicted values as moderately impaired. This equates to the FEV1 dropping between 1-2 liters. Functional impairment develops when the FEV1 falls below 3 liters. Patients with an FEV1 between 30%-49% of predicted values are severely impaired while those with an FEV1 less than 30% are the most impaired.

Reference: (a) Keyser RE, Chan L, Woolstenhulme JG, Kennedy M, Drinkard BE. Pulmonary rehabilitation. In: Braddom RL, editor. Physical medicine and rehabilitation. 4th ed. Philadelphia: Elsevier; 2011 p 744-5. (b) Manasian S. Pulmonary rehabilitation. In: Nesathurai S, Blaustein D, Editors. Essentials of inpatient rehabilitation. Blackwell Science;2001. p 42-43

2013

3

A 28-year-old male firefighter sustained deep dermal burns across his lower face, neck, anterior
chest, and shoulders. To help manage the formation of hypertrophic scars, you recommend

(a) corticosteroid injections directly into localized, early hypertrophic scars.
(b) compression garments to be worn 12 hours a day.
(c) topical silicone to large areas of hypertrophic scar.
(d) ultrasound treatments with passive stretching

Answer: (a)
Commentary: Corticosteroid injections directly into localized, early hypertrophic scars can be
useful, especially in highly cosmetic locations (face or neck) or in scars that are very pruritic.
Compression garments should be worn 23 hours a day until wound erythema begins to abate, usually about 12-18 months after injury. Topical silicone, applied as a sheet, is effective in themanagement of small areas of hypertrophic scar. In a prospective randomized double-blind study,
the effectiveness of ultrasound with passive stretching versus placebo ultrasound with passive stretching showed no difference in joint range of motion or perceived pain between the 2 treatment groups. This finding suggests that, although widely used, ultrasound may not have a beneficial effect on contractures that form secondary to hypertrophic scarring.

2013

4

When is the use of hyperbaric oxygen recommended for the treatment of diabetic foot ulcers?

(a) As first-line treatment
(b) If there are signs of infection
(c) If standard therapy is ineffective
(d) As prophylaxis after wound has healed

Answer: (c)
Commentary: Hyperbaric oxygen therapy is a treatment modality that can be considered for non-infected diabetic foot ulcers that have not responed to other therapies. Systematic review did show improved wound healing at 6 weeks with use of hyperbaric oxygen but no differences were noted at 1 year.

Reference: (a) Miller AO, Henry M. Update on diagnosis and treatment of diabetic foot ulcers

2013

5

A 59-year-old woman with metastatic breast cancer presents with painful swelling of her right
arm over the last year. She underwent a radical mastectomy two years ago followed by radiation
therapy. She describes an aching discomfort along with an ill-defined sensation of numbness and
tingling. Effective decongestive therapy for the treatment of secondary lymphedema requires

(a) long-stretch bandaging of the affected limb.
(b) truncal clearance to facilitate drainage of the affected limb.
(c) intermittent pneumatic compression devices.
(d) low-level laser therapy.

Answer: (b)
Commentary: Truncal clearance is necessary to facilitate lymphatic drainage from affected limbs
by promoting effective pressure gradients, reducing lymphatic network resistance, and
stimulating lymphatic contractility. Short-stretch bandaging is recommended to create large
functional dynamic pressures with low resting pressures helping to prevent circulatory
compromise. Adjuvant intermittent pneumatic compression devices have been found to
significantly reduce limb volume during both Phase 1 and Phase 2 of complete decongestive
therapy. However, the older generation, non-programmable pumps may generate higher pressures
than therapeutically necessary and risk the development of truncal or genital edema, as well as
produce fibrotic cuffs. Low-level laser therapy is still being investigated for the management of
secondary lymphedema, since the wavelength, pulse duration and frequency, dose and dose rate,
duration of treatment, and repetition of treatment must be further defined.

Reference: (a) A randomized, prospective study of a role for adjunctive intermittent pneumatic
compression. Cancer 2002;95(11):2260-7. (b) Mayrovitz HN. The standard of care for
lymphedema: current concepts and physiological considerations. Lymphatic Res Biol
2009;7(2):101-108. (c) Oremus M, Dayes I, Walker K, Raina P. Systematic review: Conservative
treatments for secondary lymphedema. BMC Cancer 2012;12(6):1-15. (d) Szuba A, Achalu R,
Rockson SG. Decongestive lymphatic therapy for patients with breast carcinoma-associated
lymphedema. Cancer 2002;95(11):260-7. http://www.ncbi.nlm.nih.gov/pubmed/12436430. Accessed July 20, 2012.

2013

6

Which clinical tool BEST measures and predicts the safety of ambulation in older adults?

(a) Berg Balance Scale (BBS)
(b) Braden Scale
(c) Timed Up and Go (TUG) test
(d) Katz Index

Answer: (c)
Commentary: The Berg Balance Scale (BBS) is a 56-point scale to evaluate performance during
14 common activities, such as standing, turning and reaching for an object on the floor. It does not rate walking. The Braden Scale is for predicting pressure sore risk, and is used to help determine the risk of skin breakdown or decubitus ulcer. In the Timed Up and Go (TUG) test, a patient is asked to rise from an armchair, walk 3 meters (10 feet), turn around, walk back to the chair, and sit down again (the score is the time in seconds it takes to complete these tasks). This
test has high interrater and content reliability, and predicts whether a patient can safely walk outside alone. The Katz Index is widely used to measure independence in activities of daily living (ADLs), but does not include measures of mobility, such as walking or stair climbing.

7

A 67-year-old man with chronic obstructive lung disease (COPD) is about to start a pulmonary
rehabilitation program. Which option is an appropriate breathing retraining technique for the
patient to learn?

(a) Diaphragmatic breathing
(b) Localized expansion exercises
(c) Rapid, shallow breathing
(d) Head up and bending backward postures


Answer: (b)
Commentary: Breathing retraining techniques for COPD include pursed lips breathing, head
down and bending forward postures, slow deep breathing, and localized expansion exercises (also
known as segmental breathing, wherein the patient is asked to inspire while the clinician applies
pressure to the thoracic cage to resist respiratory excursion in a segment of the lung). These
techniques maintain positive airway pressure during exhalation and help reduce overinflation.
Although diaphragmatic breathing (done by expanding one's belly and thereby allowing the
diaphragm to move down creating more room for the lungs to expand) is widely taught, it has
been shown to increase the work of breathing and dyspnea compared with the natural pattern of
breathing in the patient with COPD.

2012

8

What is the most frequent presenting symptom of brain metastasis?

(a) Focal weakness
(b) Headache
(c) Seizure
(d) Visual disturbance


Answer: (b)
Commentary: Presenting symptoms at the time of diagnosis with brain metastasis, in order of
decreasing frequency, are as follows: (patients can have more than a single symptom): headache,
49%; mental disturbance, 32%; focal weakness, 30 %; gait ataxia, 21 %; seizures, 18%; speech
difficulty, 12%, visual disturbance, 6%; sensory disturbance, 6%; and limb ataxia, 6%.

2011

9

Which cardiac response is increased as a result of aerobic training?

(a) Oxygen consumption (VO2)
(b) Maximal heart rate
(c) Anginal threshold
(d) Stroke volume at rest


Answer:(d)
Commentary: After an aerobic training program, the anginal threshold is unchanged. Oxygen
consumption (VO2) at rest, and during any given submaximal load remains unchanged, while
VO2 max is increased. The maximal heart rate also does not change, but the heart rate is lower
both at rest and during any submaximal load (bradycardia of training). The stroke volume at rest
is increased, reciprocal to the decrease in heart rate. Although angina threshold is unchanged,
myocardial oxygen demand decreases relative to oxygen consumption, which allows more intense
activity before the ischemic threshold is reached.

2011

10

A 50-year-old man has obstructive sleep apnea (OSA). He is morbidly obese and has a body mass
index (BMI) of 39 kg/m². He is also complaining of chronic low back pain, which he claims
limits his mobility. Which approach would best benefit him?

(a) Prescribe a motorized wheelchair.
(b) Prescribe modafinil (Provigil) for daytime sleepiness.
(c) Schedule opioid analgesics for pain control.
(d) Order surgical referral for a tracheostomy.


Answer: (b)
Commentary: Obstructive sleep apnea (OSA) is characterized by snoring, arousals, and daytime
sleepiness. Most patients with OSA are male, middle-aged, with an average BMI of 32.5 +/-
9.0kg/m2
. Wheelchairs should be used only in cases of compromised mobility and powered
mobility used only when no other options exist. Modafinil can be used as adjunct therapy for
daytime sleepiness. Narcotic analgesics should be prescribed with caution because of depression
of central respiratory drive. Positive airway pressure (PAP) delivered with continuous (CPAP) or
bilevel (BiPAP) pressures can correct upper airway obstruction. If the noninvasive approach is
not effective, tracheostomy may be necessary.

2011

11

A construction company manager is concerned about hiring employees over the age of 40, citing
lower productivity because of lower endurance compared to younger workers. You tell him that the average decline in physical work capacity between the ages of 40 and 60 is

(a) 5% Page 7 of 33
(b) 20%
(c) 35%
(d) 50%


Answer: (b)
Commentary: While variation exists, an average decline of 20% in physical work capacity has
been reported between the ages of 40 and 60 years, due to decreases in aerobic and
musculoskeletal capacity. However, differences in habitual physical activity will influence the
variability seen in individual physical work capacity and its components.

2011

12

Which symptom most frequently impacts quality of life in patients with incurable cancers?

(a) Fatigue
(b) Anorexia
(c) Weakness
(d) Depression

Answer: (a)
Commentary: Cancer patients experience a much broader range of symptoms that impact their quality of life and their ability to address existential issues at the end of life than those listed here. A systematic review of symptom prevalence studies in patients with incurable cancer identified fatigue (74%), pain (71%), lack of energy (69%), weakness (60%) and anorexia (53%) being the most prevalent that impact quality of life. The prevalence of nausea is 40% in the last 6 weeks of life. Fatigue is often the primary condition adversely affecting quality of life.

2011

13

Which statement regarding an independent medical examination (IME) is TRUE?

(a) The traditional physician-patient relationship is not maintained, and confidentiality is not
guaranteed.
(b) The examiner is exempt from potential liability since the purpose of the evaluation is to
assess medical-legal issues, not clinical issues.
(c) Treating providers may conduct an IME as long as records from other providers are also
reviewed.
(d) Because of potential conflicts of interest, only providers no longer in clinical practice
should conduct IMEs.

 


Answer: (a)
Commentary: In the IME context, a traditional physician-patient relationship does not exist, since
the evaluation does not include “intent to treat.” Confidentiality is not guaranteed, since the
examiner is expected to share certain medical information and findings with the referring party. Because a “limited doctor-patient relationship” exists during an IME, the physician is responsible for disclosing in the IME any medical findings that could affect the patient’s health, and he or she is potentially liable for any harm, direct or indirect, that may be sustained by the person examined. Only a provider who is uninvolved with an examinee’s treatment may conduct an
IME, although a treating provider may be an “expert witness.” Legal requirements for qualification as an expert witness vary from state to state. There is no restriction regarding a provider’s clinical status and eligibility to conduct IMEs.

2011

14

A 59-year-old woman with metastatic breast cancer presents with painful swelling of her right arm over the last year. She underwent a radical mastectomy two years ago followed by radiation therapy. She describes an aching discomfort along with an ill-defined sensation of numbness and tingling. Effective decongestive therapy for the treatment of secondary lymphedema requires
(a) long-stretch bandaging of the affected limb.
(b) truncal clearance to facilitate drainage of the affected limb.
(c) intermittent pneumatic compression devices.
(d) low-level laser therapy.

Answer: (b)
Commentary: Truncal clearance is necessary to facilitate lymphatic drainage from affected limbs by promoting effective pressure gradients, reducing lymphatic network resistance, and stimulating lymphatic contractility. Short-stretch bandaging is recommended to create large functional dynamic pressures with low resting pressures helping to prevent circulatory compromise. Adjuvant intermittent pneumatic compression devices have been found to significantly reduce limb volume during both Phase 1 and Phase 2 of complete decongestive therapy. However, the older generation, non-programmable pumps may generate higher pressures than therapeutically necessary and risk the development of truncal or genital edema, as well as produce fibrotic cuffs. Low-level laser therapy is still being investigated for the management of secondary lymphedema, since the wavelength, pulse duration and frequency, dose and dose rate, duration of treatment, and repetition of treatment must be further defined

2013

15

When is the use of hyperbaric oxygen recommended for the treatment of diabetic foot ulcers?
(a) As first-line treatment
(b) If there are signs of infection
(c) If standard therapy is ineffective
(d) As prophylaxis after wound has healed

Answer: (c)
Commentary: Hyperbaric oxygen therapy is a treatment modality that can be considered for non-infected chronic diabetic foot ulcers that have not responded to other therapies. Systematic review did show improved wound healing at 6 weeks with use of hyperbaric oxygen but no differences were noted at 1 year.

2013

16

You see a patient in clinic with what appears to be a non-infected diabetic foot ulcer over the first metatarsal head and order an ankle-brachial index (ABI) study. The patient’s ABI is 1.4. What is your next step in treatment?
(a) Proceed with off loading the ulcer, since blood flow is normal.
(b) Order additional testing, such as an arterial duplex.
(c) Refer for to vascular surgery for urgent revascularization.
(d) Refer for consideration of a transmetatarsal amputation

Answer: (b)
Commentary: Evaluation of vascular status is critical in any patient presenting with diabetic ulcer. The ABI is considered a useful screening tool to look for peripheral arterial disease. Values under 0.91 are considered consistent with peripheral arterial disease. However, calcified vessels can lead to higher values and possibly false negative test results. If ABI is >1.3, this most likely due to calcified, non-compressible vessels; therefore, other means of testing vascular status should be used

2013

17

You are consulted to see a young patient 3 days after the motor vehicle crash in which he
sustained a traumatic brain injury. You note that he is not receiving nutritional support. In starting
nutrition in this patient, which statement concerning enteral compared to parenteral nutrition is
TRUE?

(a) Enteral nutrition has a higher incidence of complications.
(b) Parenteral nutrition is more likely to cause pneumonia.
(c) Enteral access is easier to obtain at a higher cost.
(d) No significant difference exists in measured nutritional parameters

You are consulted to see a young patient 3 days after the motor vehicle crash in which he
sustained a traumatic brain injury. You note that he is not receiving nutritional support. In starting
nutrition in this patient, which statement concerning enteral compared to parenteral nutrition is
TRUE?

(a) Enteral nutrition has a higher incidence of complications.
(b) Parenteral nutrition is more likely to cause pneumonia.
(c) Enteral access is easier to obtain at a higher cost.
(d) No significant difference exists in measured nutritional parameters.
 
Answer: (d)
Commentary: Early feeding of a person who has a traumatic brain injury is associated with fewer
infections and a trend towards better outcomes in terms of survival and disability. Two trials
reported the effect of route of feeding on the incidence of infection of any type, but both trials
showed a trend towards more infection with parenteral nutrition (PN) than with enteral nutrition
(EN). This difference might reflect catheter related infection with PN. In 3 trials reporting the
effect of route of feeding on the occurrence of pneumonia, a trend towards reduced incidence of
pneumonia was found in the PN group.

Although it is easier to provide PN than it is to obtain adequate EN access, EN has a decreased
incidence of complications and lower cost compared to PN, with no significant differences in measured nutritional parameters. Also, providing nutrition to the intestine can stimulate gut
immune function and limit deterioration of the intestinal mucosa characteristic of bacterial
translocation and its potential for contributing to sepsis.

2010

18

Which finding is a functional physiological change seen in the elderly?

(a) Increased drug-binding for highly-protein bound drugs
(b) Doubling of D-dimer levels
(c) Decreased erythrocyte sedimentation rate
(d) Macrocytic anemia

Answer: (b)
Commentary: D-dimer levels are shown to double with aging, especially among African
Americans and functionally impaired individuals. Increased erythrocyte sedimentation rate and
C-reactive protein have also been seen in the elderly. Although anemia occurs with increasing
prevalence with aging, there is convicncing evidence that it is not a normal consequence of aging.
Decreased drug-binding for highly protein-bound drugs in the elderly may lead to higher unbound
or free drug concentrations.


2010

19

When considering risk of cumulative trauma in an older individual, it is important to know the
typical decreases in strength that occur with aging. Between ages 70 and 80 people typically lose
what percentage of their strength?

(a) 5
(b) 15
(c) 30
(d) 50

Answer: (c)
Commentary: Between the ages of 70 and 80 people typically lose 30 percent of their strength.
Muscular weakness occurs after age 30 in association with generalized muscle fiber atrophy,
decreased muscle density and increased intramuscular fat. Between the ages of 50 and 70 people
typically lose 15 percent of their strength.

2010

20

A 72-year-old woman is receiving warfarin (Coumadin) for deep venous thrombosis (DVT)
prophylaxis after repair of a hip fracture. She is on several other medications. The medication that
will significantly elevate her international normalized ratio (INR) is

(a) diphenhydramine (Benadryl).
(b) acetaminophen (Tylenol).
(c) carbamazepine (Tegretol).
(d) ranitidine (Zantac).

Answer: (b)

Commentary: Warfarin (Coumadin) is used for anticoagulation in several different disease
conditions while patients are under the care of a physiatrist. One of the drug’s most common
applications is for DVT prophylaxis after repair of a hip fracture. Many medications can alter the
therapeutic efficacy of warfarin. Sulfonamides, acetaminophen, amiodarone, aspirin, and
nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the prothrombin (PT)/INR.
Adrenocorticoids, antacids, antihistamines, carbamazepine, haloperidol, and vitamin C can
decrease the PT/INR.

2010

21

Which physiological change occurs in the cardiovascular system with aging?

(a) Increased resting heart rate
(b) Increased resting cardiac output
(c) Decreased ejection fraction
(d) Decreased orthostatic hypotension

Answer: (c)
Commentary: As a person ages, decreased inotropic responsiveness to adrenergic stimuli leads
to decreased myocardial contractility and, hence, to a decrease in ejection fraction. Resting heart
rate does not change with aging, but maximal heart rate with exercise does decrease
progressively. Cardiac output at rest and with modest exercise is maintained by early
involvement of the Frank-Starling mechanism. There is an increased incidence of orthostatic
hypotension in the elderly due to decreased baroreceptor sensitivity and diminished reflex
tachycardia

2010

22

Upper extremity exercise (eg, crutch walking) leads to a greater increase in heart rate and blood
pressure compared with lower extremity activity (eg, normal walking) due to the

(a) smaller upper extremity muscles, which contract at a higher maximal percentage.
(b) proximity of the upper extremities to the heart and major blood vessels.
(c) upper extremities having to overcome the effect of gravity.
(d) greater range of motion of the upper extremities compared to the lower ones

Answer: (a)
Commentary: Upper extremity work leads to greater increases in heart rate and blood pressure.
When a muscle contracts with a given percentage of its maximum force, its effect on blood
pressure is about the same as during the same percentage of contraction of any other muscle. The
smaller muscles in the upper extremity contract more, and stimulate the cardiovascular system
more relative to the larger lower extremity muscles.

2010

23

You are performing a consultation on a 58-year-old man with a history of diabetes and peripheral
vascular disease who presents with a non-healing foot ulcer. You are concerned that he is at risk
for amputation because his

(a) ankle brachial index (ABI) is 0.8.
(b) ABI is 0.4.
(c) transcutaneous oxygen pressure (TcPO2) is 80mmHg.
(d) TcPO2 is 40mmHg.

Answer: (b)
Commentary: ABI is a noninvasive technique that is used in the assessment of arterial occlusive
disease. The ABI is the ratio between the ankle and the brachial systolic pressure. Normal ABI is
defined as values greater than 0.9. An ABI below 0.4 tends to carry a poor prognosis. TcPO2 is
defined as transcutaneous oxygen, which is in essence a "blood gas" of the skin. Normal TcPO2 is
greater than 50mmHg. Values of more than 40mmHg are associated with healing. Ischemia is
defined as periwound TcPO2

24

Supplemental oxygen therapy in patients with chronic obstructive pulmonary disease (COPD) has
been shown to

(a) improve walking endurance.
(b) increase blood pressures.
(c) maximize work rate.
(d) produce polycythemia.

Answer: (a)
Commentary: Supplemental oxygen therapy is indicated in patients with arterial partial pressure
of oxygen (PO2) continuously less than 55-60mmHg. Home oxygen therapy can decrease
pulmonary hypertension, polycythemia, blood pressure, and pulse. In patients with mild
hypoxemia and exercise desaturation, supplemental oxygen by nasal prongs did not influence
maximum work rate, but did increase mean walking endurance time and exercise tolerance.

2010

25

Which clinical tool BEST measures and predicts the safety of ambulation in older adults?
(a) Berg Balance Scale (BBS)
(b) Braden Scale
(c) Timed Up and Go (TUG) test
(d) Katz Index

Commentary: The Berg Balance Scale (BBS) is a 56-point scale to evaluate performance during
14 common activities, such as standing, turning and reaching for an object on the floor. It does
not rate walking. The Braden Scale is for predicting pressure sore risk, and is used to help
determine the risk of skin breakdown or decubitus ulcer. In the Timed Up and Go (TUG) test, a
patient is asked to rise from an armchair, walk 3 meters (10 feet), turn around, walk back to the
chair, and sit down again (the score is the time in seconds it takes to complete these tasks). This
test has high interrater and content reliability, and predicts whether a patient can safely walk
outside alone. The Katz Index is widely used to measure independence in activities of daily living
(ADLs), but does not include measures of mobility, such as walking or stair climbing.

2012

26

Which barrier is perceived by older individuals to be the LEAST significant obstacle to physical
activity?
(a) Time, money, family commitments
(b) Illness and injury
(c) Fear of injury
(d) Availability of an exercise partner

Answer: (a)
Commentary: Perceived barriers are a powerful negative predictor of physical activity in the
elderly. Although individual variation is the rule, overall obstacles to physical activity tend to
change with age, and seem to increase for many aging individuals. Elderly patients report that
time, money and family commitments are less significant barriers as they age. Availability of an
exercise partner, illness, injury and fear of injury become more prominent concerns as they grow
older.

2012

27

A 67-year-old man with chronic obstructive lung disease (COPD) is about to start a pulmonary
rehabilitation program. Which option is an appropriate breathing retraining technique for the
patient to learn?
(a) Diaphragmatic breathing
(b) Localized expansion exercises
(c) Rapid, shallow breathing
(d) Head up and bending backward postures

Answer: (b)
Commentary: Breathing retraining techniques for COPD include pursed lips breathing, head
down and bending forward postures, slow deep breathing, and localized expansion exercises (also
known as segmental breathing, wherein the patient is asked to inspire while the clinician applies
pressure to the thoracic cage to resist respiratory excursion in a segment of the lung). These
techniques maintain positive airway pressure during exhalation and help reduce overinflation.
Although diaphragmatic breathing (done by expanding one's belly and thereby allowing the
diaphragm to move down creating more room for the lungs to expand) is widely taught, it has
been shown to increase the work of breathing and dyspnea compared with the natural pattern of
breathing in the patient with COPD.

2012

28

Which pulmonary parameter is predictive of mortality in a child with Duchenne muscular
dystrophy?
(a) Maximal expiratory pressure
(b) Peak flow rate
(c) Cough peak flow
(d) Forced vital capacity

Answer:(d)
Commentary: One simple method of assessing the interplay between pump function and load is
the measurement of the forced vital capacity (FVC) and fractional lung volumes. In boys with
Duchenne muscular dystrophy (DMD), the relationship between the absolute value of FVC and
age can be divided into 3 epochs: one of gradual increase coincident with their ambulatory period,
followed by a plateau phase at 10 to 12 years when they become confined to wheelchairs, and
then a gradual but persistent decline thereafter. However, when the FVC is described as a percent
of the predicted value, it is lower than normal and diverges from the normal curve over time. The
decline in FVC to a value of less than 1 liter may also predict mortality in patients who do not
receive assisted ventilation.

2012

29

A 48-year-old woman had an acute myocardial infarction (MI) 2 weeks ago. The referring
cardiologist informed you that she had a small MI and an uncomplicated hospital course. In a
situation such as this, which statement is TRUE?
(a) Combined aerobic and resistance training, compared to aerobic training alone, has a
higher risk of adverse outcomes.
(b) Beta blocker agents will attenuate the benefits of exercise training.
(c) A change in left ventricular (LV) dimensions (remodeling) is associated with improving
LV function.
(d) Cardiac rehabilitation will improve both myocardial perfusion and LVelectrophysiologic
parameters.

Answer: (d)
Commentary: After a myocardial infarction (MI), exercise training is initiated within 2-4 weeks.
Combined resistance and aerobic training improves aerobic fitness and muscle strength more than
aerobic training alone, without adverse outcomes. Beta blockers, which are a standard of care to
reduce mortality after an MI, do not attenuate the benefits of exercise training. Following an MI,
a change in left ventricular (LV) dimensions (remodeling) is associated with deteriorating LV
function, ventricular arrhythmias, aneurysm formation, and higher mortality. Cardiac
rehabilitation improves both myocardial perfusion and LV electrophysiologic parameters,
reducing the risk for malignant ventricular arrhythmias and sudden cardiac death after MI.

2012

30

Which burn patient has the highest risk of developing hypertrophic scars?
(a) Newborn baby
(b) Morbidly obese individual
(c) Heavily pigmented individual
(d) Elderly individual

Answer: (c)
Commentary: A hypertrophic scar is usually defined as a scar that is present at 3 or more
months after the burn injury and is greater than or equal to 2 mm in thickness. Heavily
pigmented patients tend to scar more than persons with less pigment. Little scarring has been
reported in neonates, newborns, elderly and the morbidly obese. Patients with wounds that take
longer than 2-3 weeks to heal, and persons requiring skin grafts, are also considered at risk for
developing hypertrophic scars.

2012

31

Lying quietly is equivalent to how many metabolic equivalents (METs)?

(a) 0.5 to 1.0
(b) 1.5 to 2.5
(c) 3.0 to 3.5
(d) 4.0 to 4.5

Answer: A
Commentary: Lying quietly is 1.0 MET. Climbing stairs is equivalent to 3-4 METs, and heavy
gardening is equivalent to 4-5 METs.

2009

32

Maximal aerobic power decreases less rapidly in the geriatric athlete compared to the sedentary geriatric person. This difference is because the geriatric athlete has a slower rate of
a maximal heart rate decline.
b. muscle atrophy.
c. cardiac output decline.
d lactate threshold decline.

Option c is correct.

Aerobic power, VO2, is the rate of oxygen consumed during physical activity. Maximal aerobic power, VO2max, decreases less rapidly in physically active geriatric adults in part because they have less rapid decrease in cardiac output. The peak aerobic power required for independent living, which is around 15 ml/(kg∙min), is reached at age 80 to 85 in the sedentary adult and 10 to 20 years later in athletes. The key physiological changes with aging, despite regular physical activity, are a decreased maximal heart rate and a decreased maximal aerobic capacity (VO2max). Exercise does not affect the declining maximal heart rate that occurs with age. Lactate threshold can be maintained in older adults with appropriate regular physical activity, but this is not directly associated with aerobic power. Active and sedentary adults have similar rates of muscular atrophy, or sarcopenia, with age.

2014

33

A 48-year-old man is undergoing rehabilitation after a heart transplant. His resting heart rate is consistently between 90 and 110 beats/minute. What is the most likely explanation for this?

A Prolonged bed rest post-operatively
B Low ejection fraction
C Denervation of the donor heart
D Anemia of chronic disease

Option c is correct.

Cardiac transplantation involves removing the diseased heart and leaving an atrial cuff which results in complete denervation of the donor heart, with loss of both afferent and efferent nerve connections. The donor heart will not respond to vagolytic muscle relaxants, anticholinergics, anticholinesterases, digoxin, nifedipine or nitroprusside. The resting heart rate of a denervated heart varies between 90 and 110 beats/minute due to loss of vagal tone, leading to a small resting stoke volume

2014

34

A patient with cancer receiving which chemotherapeutic agent should be monitored for sensory neuropathy and risk of distal pressure ulcers?

A. Daunorubicin
B Bleomycin
C Vincristine
D 5-fluorouracil

Option c is correct.

Of the chemotherapeutic agents listed, only vincristine can produce neuropathy. Daunorubicin can cause cardiac toxicity and bleomycin can produce pulmonary fibrosis

2014

35

Impairments resulting from chronic disease have become increasingly significant risk factors of disability. Which medical condition has the highest prevalence of activity limitation?

a. Diabetes
b Heart disease
c Mental disorders
d Visual impairments

Option b is correct.

From highest to lowest, the prevalence of activity limitation for the above conditions are heart disease (22.5%), visual impairments (4.4%), mental disorders (3.9%), and diabetes (2.7%). Orthopedic impairments (16%) and arthritis (12.3%) also carry significant risks for the development of activity limitation and disability. Diabetes, mental disorders and visual impairments are less likely to cause activity limitation or disability, when one factors in both the prevalence of the condition and the likelihood that the condition will cause decreased function

2014

36

A 65-year-old man with multiple myeloma (MM) complains of new-onset lower back pain. A skeletal survey performed 6 months earlier showed no evidence of lytic lesions or vertebral body collapse. Further diagnostic work-up should include

a. technetium-99m bone scan.
b. dual-energy x-ray absorptiometry scan.
c. MRI scan of the lumbar spine and pelvis.
d. PET/CT scan.

Option c is correct.

Magnetic resonance imaging can detect diffuse and focal bone marrow lesions in patients with MM without osteopenia or focal osteolytic lesions seen on standard metastatic bone surveys. Conversely, bone surveys can detect lesions not found on MRI of the axial skeleton. A baseline MRI scan of the pelvis and spine may also be useful for risk stratification in patients with smoldering (asymptomatic) MM. Technetium-99m bone scanning (which primarily detects osteoblastic activity) is inferior to conventional roentgenography for the detection of lytic lesions and should not be used. Dual-energy x-ray absorptiometry scanning is not recommended. A PET/CT scan using fluorine-18 (labeled FDG or 18-FDG) appears to correlate with areas of active lytic bone disease but is not recommended for routine use in the management of myeloma patients.

2014

37

A 55-year-old woman with breast cancer consults you regarding the effects of exercise training on cancer-related fatigue. You state that the benefits of exercise on fatigue are greater in patients who

a. have solid tumors, rather than
hematological malignancies.
b. are enrolled in progressive resistance exercise programs, rather than aerobic conditioning programs.
c. are adult survivors of childhood cancers.
d have metastatic disease, rather than primary tumors.

Option a is correct.

A meta-analysis incorporating 1640 patients with cancer-related fatigue found that the benefits of exercise on fatigue were observed for interventions delivered during or postadjuvant cancer therapy. Patients with solid tumors (breast, prostate) benefited more from exercise interventions than did patients with hematological malignancies. Aerobic exercise significantly reduced fatigue but resistance training and alternative forms of exercise failed to reach statistical significance. The data on exercise prescription for adult survivors of childhood cancers is scarce. These patients, in particular, should undergo cardiac screening before engaging in an exercise program because this group has a higher incidence of left ventricular dysfunction. Data are emerging on the potential of exercise intervention in patients with late stage colorectal and lung cancers for improving certain health-related quality-of-life variables, such as mobility, sleep quality and fatigue.

2014

38

Which agent administered before kidney transplantation can increase exercise tolerance?

a. erythropoietin
b. glucocorticoids
c. coenzyme Q10
d vitamin C

Option a is correct.

Studies show that exercise training and treatment with erythropoiesis-stimulating agents such as epoetin (EPO) can increase exercise tolerance in patients pre- and post-renal transplant. Specifically, the findings indicate that exercise training in hemodialysis patients can increase exercise tolerance by 25%. Similar increases are observed after correction of anemia with EPO, although the increase in exercise capacity is small. Over-correction of hemoglobin (Hb) (> 13.0 g/dL) with higher doses of EPO is shown to increase morbidity and mortality. Hemoglobin normalization is not shown to have a beneficial effect on left ventricular mass and volume. Thus, close monitoring of patients with anemia secondary to chronic kidney disease is recommended, especially if they have concomitant cardiac disease. Exercise training helps counteract some of the negative side-effects of antirejection therapy with glucocorticoids including skeletal muscle atrophy, excessive weight gain, and fatigue. Coenzyme Q10 supplementation has been widely used as a complementary therapy to treat aging, stroke, neuromuscular diseases, Parkinson disease, Alzheimer disease, progressive supranuclear palsy, autosomal recessive cerebellar ataxias, amyotrophic lateral sclerosis and Huntington disease, but not decreased exercise tolerance. The role of vitamin C supplementation is currently being studied in the mobilization of iron stores in patients on hemodialysis. It has not been studied with respect to increasing exercise tolerance in this patient population

2014

39

What is the most common primary source of brain metastases?

a. Lung cancer
b. Colorectal cancer
c. Melanoma
d. Genitourinary cancer

Option a is correct.

Lung cancer is the most common primary source of brain metastases, with as many as 64% of patients with stage 4 lung cancer developing brain metastases. Breast cancer is the second most common source (2% to 25% of these patients), followed by melanoma (4% to 20%). Brain metastases from colorectal cancers, genitourinary cancers and sarcomas occur with considerably less frequency (1% of these patients).

2014

40

Palliative care is characterized by

(a) a holistic approach to comprehensive symptom management.
(b) symptom only management in persons with terminal illnesses.
(c) disease modifying therapies.
(d) care provided in the home setting only

Answer: A
Commentary: Palliative care involves a holistic approach to comprehensive symptom
management. This care has a potential role in the management of all disease states that feature an intense and adverse symptom complex. Palliative care typically does not include disease
modifying therapies, although it can be provided in conjunction with these treatments. Palliative
care can be provided in a variety of health care settings and is not limited to persons with terminal
illnesses.


2009

41

Which approach is an initial management strategy for sialorrhea that does not interfere with
swallowing?

(a) Antihistamine medication
(b) Botulinum toxin injection
(c) Irradiation of salivary glands
(d) Salivary duct ligation

Answer: A
Commentary: Antihistamine and anticholinergics have both been used with varying success and
are often first line management options. Botulinum toxin has been used in cases of axillary
hyperhidrosis and case reports identify use in sialorrhea. This approach should be considered
after less invasive measures fail. For very thick secretions, hydration will help make the
discharge thinner and easier to manage. In some cases, irradiation or surgery may be needed to
allow safe swallowing

2009

42

Hydrocolloid dressings facilitate debridement through which mechanism?

(a) Enzymatic
(b) Autolytic
(c) Sharp
(d) Mechanical

Answer: B
Commentary: Hydrocolloid dressings maintain a moist wound environment. Subsequently,
proteases and collagenase digest eschar that is in contact with the wound fluid. This process is
called autolysis. In enzymatic debridement, chemical agents such as papain-urea break down
necrotic tissue. Sharp debridement is performed using an instrument such as a scalpel. An
example of mechanical debridement would be wet-to-dry dressing or whirlpool treatment

2009

43

Which is the most common neuropsychological dysfunction after a liver transplant?

(a) Seizures
(b) Encephalopathy
(c) Stroke
(d) Depression

Answer: B
Commentary: In a study by Ghaus et al, 62% of liver transplant patients developed
encephalopathy. Seizures occurred in 11% and stroke in 9%. In another study by Rothenhausler,
3% of transplant patients had depression.


2009

44

A 37-year-old man presents to your office with a Grade 2 sacral pressure sore which appears
clean, with no necrotic tissue and only a slight amount of serosanguinous drainage. In order to
optimize wound healing, you suggest

(a) allowing a protective eschar to form.
(b) wet to dry gauze dressings.
(c) vacuum-assisted closure.
(d) an occlusive dressing.

ANSWER D

Commentary: An occlusive dressing will help to maintain a moist environment, which is ideal for
wound healing. Allowing eschar to form will inhibit healing. Wet to dry dressing changes are
used only when debridement is required. Vacuum-assisted closure is usually used on grade 3 and grade 4 wounds.

2009

45

A 35-year-old gentleman with a history of Lyme disease that was treated adequately with
antibiotics 1 year ago complains of continued muscle aches, joint pain, fatigue, and difficulty
concentrating. His repeat Lyme serologies have been negative, as have all other laboratory tests.
He has had a full medical work-up from his internist that has been unremarkable. You
recommend

(a) intravenousceftriaxone for 28 days.
(b) sulfasalazine for his muscle and joint pains.
(c) intra-articular cortisone injections for joint pain.
(d) emotional support and symptom management

Answer: D
Commentary: The patient has postLyme disease syndrome, which occurs in a minority of patients
who have had Lyme disease. There is no specific treatment. Physicians should provide support
and management of patient complaints. Antibiotic treatment is contraindicated. Sulfasalazine is
not a treatment for Lyme disease

2009

46

Patients are NOT candidates for bariatric surgery if they are

(a) twice their ideal body weight.
(b) age 50 or younger.
(c) without a psychiatric contraindication.
(d) experiencing skin breakdown.

Answer: D
Commentary: Surgical candidates include persons who are twice their ideal weight, demonstrate
recurrent failure to lose weight through dieting, have no cardiopulmonary or psychiatric
contraindications, and are usually50 years of age or younger in most cases, with minor exceptions. Some patients may ask about this procedure when it is recommended they lose weight in order to mitigate musculoskeletal pain.

2009

47

Two-thirds of infections that occur 1 to 6 months post-transplant are caused by

(a) methicillin-resistant staphylococcus aureus (MRSA).
(b) pneumocystis carinii (PCP).
(c) clostridium difficile (C. diff).
(d) cytomegalovirus (CMV).

Answer: D
Commentary: Transplant patients are at high risk for cytomegalovirus (CMV) infection and frequently receive prophylaxis with acyclovir or ganciclovir

2009

48

Which scale evaluates sensory perception, moisture, activity, mobility, nutrition, and
friction/shear to determine risk of pressure ulcers?

(a) Norton
(b) Barthel
(c) Braden
(d) Beck

Answer: C
Commentary: Both the Braden scale and the Norton scale are used to assess pressure ulcer risk.
The Braden scale consists of 6 factors: sensory perception, moisture, activity, mobility, nutrition,
and friction/shear. The Norton scale assesses 5 factors: physical condition, mental condition,
activity, mobility, and incontinence. The Barthel index measures activities of daily living and
mobility and is not related to assessing pressure ulcer risk. The Beck Depression Inventory and
Beck Anxiety Inventory are not related to pressure ulcers

2009

49

You are consulting on a 28-year-old woman with metastatic cervical cancer. She is married with one young child. At this time, she requires minimum to moderate assistance with her mobility and activities of daily living. The oncology service is debating whether to discharge the patient to home with hospice care or to give her inpatient rehabilitation. You inform them that acute inpatient rehabilitation

(a) improves function and quality of life despite the patient being
at the end of her life.
(b) is too much of a physical demand for her and agree with
hospice care.
(c) takes time away from the patient being with her family, so
hospice is preferable.
(d)
will help the patient to some extent, but not as much as a
patient without cancer.

(a)
When consulted on a patient with cancer, the physiatrist must balance the need to maximize the patient’s independence through rehabilitation with the desire to have the patient return home as soon as possible. Inpatient rehabilitation is useful to improve the patient's quality of life. Functional gains have been demonstrated to be significant and comparable to those gained by patients without cancer. The presence of metastatic disease does not influence functional outcome and should not preclude participation.

2008

50

Cyclobenzaprine is a medication that is used to treat acute musculoskeletal pain. While the exact mechanism of action is unknown, its structure and side effects are similar to what class of drug?

(a)Central alpha2-adrenergic agonist
(b)Tricyclic antidepressant agent
(c)Antihistamine
(d)γ-aminobutyric acid agonist

B

Cyclobenzaprine is structurally similar to tricyclic antidepressants and was first studied as an antidepressant. While its exact mechanism of action is unknown, it is presumed to work at the level of the brainstem or higher with a generalized sedative effect. Tizanidine is a central alpha2-adrenergic agonist. Orphenadrine is an antihistamine. Benzodiazepines, such as diazepam, and baclofen are γ-aminobutyric acid agonists.

2008

51

Individuals with diabetes are at high risk of amputation despite ankle pressures greater than 55 mmHg because
(a) the ankle brachial pressure index must be greater than or equal to 0.3 to prevent limb threatening ischemia.
(b) ankle pressures seldom correlate with severity of symptoms and are unreliable.
(c) calcification of the arterial media results in a spuriously high pressure.
(d) transcutaneous oxygen partial pressures and not ankle pressures correlate with ischemia.

(c)
In patients with diabetes, amputation is a strong possibility, even with ankle pressures higher than 55 mmHg because spuriously high pressures can be present in these patients as a result of calcification of the arterial media. The ankle brachial pressure index (ABPI) is the patient’s brachial pressure compared to the ankle pressure. A resting ABPI greater than 1.0 is considered normal. Patients with intermittent claudication have an ABPI in the range of 0.5 to 0.7, and patients with rest pain or other symptoms of severe ischemia have an ABPI of less than or equal to 0.3. A pressure less than 50 mmHg at the ankle is associated with limb threatening ischemia.

2008

52

Which of the brain tumors listed is a benign tumor?
(a) Medulloblastoma
(b) Astrocytoma
(c) Glioblastoma
(d) Craniopharyngioma

D

The only benign brain tumor listed is craniopharyngioma

2008

53

Lambert-Eaton myasthenic syndrome is most commonly associated with cancer in the
(a) prostate.
(b) breast.
(c) lung.
(d) brain.

(c)
Lambert-Eaton myasthenic syndrome is most commonly associated with small-cell lung cancer, but it may also be seen in kidney and rectal cancer, malignant thymoma, basal cell carcinoma, and leukemia.

2008

54

You have evaluated a 50 year old man for lower extremity muscle pain and discomfort. The pain increases with jogging. You have reviewed his medications, which include simvastatin (Zocor). Baseline laboratory studies were normal 6 months ago. The creatine kinase level is mildly elevated at 185 units/L. The next most appropriate step is to
(a) check thyroid stimulating hormone levels.
(b) order electrodiagnostic study.
(c) switch to a different class of lipid lowering medications.
(d) continue the medication with close monitoring of the creatine kinase levels.

(d)
If a patient on a statin presents with muscle complaints, with or without creatine kinase (CK) elevations, other causes, including strenuous exercise or hypothyroidism, must be considered. If a patient initially has normal or only moderately elevated CK levels, the statin may be continued with close monitoring of symptoms and CK levels; however, if symptoms become intolerable or if the CK level is 10 times the upper limits of normal (ULN) or greater, the statin must be discontinued. If myositis is present or strongly suspected, the statin should be discontinued immediately. Early diagnosis and treatment of symptomatic CK elevations, including cessation of drug therapies potentially related to myopathy, can prevent progression to rhabdomyolysis. Symptoms and CK levels should resolve completely before reinitiating therapy, at a lower dose if possible. Asymptomatic elevation of CK at 10 times the ULN or greater should also prompt discontinuation of the statin. Consideration should also be given to discontinuation of statins before events that may exacerbate muscle injury, such as surgical procedures or extreme physical exertion.Needle electromyography abnormalities are uncommon in statin-induced myopathy. An EMG does not exclude statin-induced myopathy, because it primarily affects type 2 muscle fibers. Electromyography is not routinely performed or recommended unless the clinical presentation does not improve with statin discontinuation or if concern exists about other diagnoses.

2008

55

A patient with a history of cancer treated with chemotherapy complains that her feet feel swollen, cold, and painful. The pain is described as shooting and is rated 10/10. On examination, there is no swelling and no temperature changes, but there is hypesthesia and dysesthesia. Of the following choices, which is the most appropriate pain management for this patient?
(a) MS Contin (extended release morphine sulfate) 15 mg every
12 hours
(b) Prednisone taper starting at 60 mg daily
(c) Neurontin (gabapentin) 300 mg 3 times a day
(d) Naprosyn (naproxen) 500 mg twice daily

(c)
Many chemotherapeutic agents can cause a peripheral neuropathy. Treatment for neuropathic pain includes membrane-stabilizing medications such as Neurontin. Opiates like MS Contin and non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen are not the first line treatment for neuropathic pain. Prednisone is appropriate for complex regional pain syndrome (CRPS), but CRPS is not common in cancer patients after chemotherapy. Further, this patient probably does not have CRPS, considering the absence of swelling, color changes, or temperature changes.

2008

56

A 52-year-old woman with a history of non-alcoholic steatohepatitis underwent a recent liver transplant. Her protein and albumin levels are very low and, on exam, she has anasarca. Your inpatient rehabilitation admission orders should include
(a) referral for paracentesis.
(b) nursing orders to avoid use of an abdominal binder.
(c) high protein diet with high protein oral supplements.
(d) oxandrolone and monitoring of liver enzymes.

(c)
Malnutrition is significant in patients with liver disease. Ascites can promote excessive protein loss. Patients should receive a high protein diet with high protein oral supplements when they are in rehabilitation. Paracentesis would be required only if the patient was having symptoms from the ascites and would probably not be appropriate in the admission orders. Oxandrolone carries a risk of liver damage and therefore should not be prescribed in this patient. Abdominal binders may be used to help with ascites, particularly if the patient has an umbilical hernia from it.

2008

57

Vacuum-assisted closure marketed as "Wound VAC" works primarily by
(a) increasing blood flow in the wound and adjacent tissue.
(b) drawing the edges of the wound together.
(c) sealing out potentially harmful bacteria from the wound.
(d) maintaining a moist, anaerobic environment.

(a)
The Wound VAC device increases blood flow to the wound and adjacent tissue, resulting in increased oxygen delivery, increased clearance of bacteria from infected wounds, and wound healing.

2008

58

A 47-year-old man with human immunodeficiency virus (HIV) presents with fever, headache, and memory loss. The most likely diagnosis is
(a) progressive multifocal leukoencephalopathy (PML).
(b) HIV encephalopathy.
(c) cryptococcal meningitis.
(d) central nervous system (CNS) lymphoma.

(c)
The patient most likely has cryptococcal meningitis. Fever would not be present in PML, HIV encephalopathy, or CNS lymphoma. In addition, headache is typically not a feature of PML or HIV encephalopathy.

2008

59

Which statement about primary cerebral lymphoma is TRUE?
(a) It has an increased incidence in patients with (HIV) infection.
(b) It usually presents as a solitary tumor.
(c) It is treated surgically for improved outcome.
(d) It has a median survival of approximately 2 years.

(a)
Primary cerebral lymphoma presents as multiple tumor deposits in the brain and has an increased incidence in patients infected with human immunodeficiency virus (HIV). Surgical removal does not improve outcome.

2008

60

A 50-year-old man complains of malaise, fatigue, and hand arthralgias for the past several months. He was recently diagnosed with diabetes mellitus. On exam, he has mild tenderness to palpation in his bilateral second and third metacarpophalangeal (MCP) joints with erosive lesions on radiographs. He also has a generalized bronzing of his skin. What is the most appropriate initial test to order?
(a) Complete blood count (CBC)
(b) Iron studies
(c) Erythrocyte sedimentation rate (ESR)
(d) Adrenocorticotropic hormone (ACTH) stimulation test

(b)
Hemochromatosis is the diagnosis. It is a commonly inherited, autosomal recessive disorder (5 in 1000 persons) affecting Caucasians of European descent typically in the fourth and fifth decade of life. In hemochromatosis, arthralgias may be the first symptom and are classically in the second and third MCP and proximal interphalangeal (PIP) joints, resembling osteoarthritis (OA) on radiographs. However, OA typically affects the distal interphalangeal joints. The CBC, ESR, and ACTH tests are normal in hemochromatosis.


2008

61

A 56 year old woman with myasthenia gravis is in the intensive care unit with urosepsis. Which antibiotic should be avoided in this patient?
(a) Aztreonam (Azactam)
(b) Gentamicin (Garamycin)
(c) Ceftriaxone (Rocephin)
(d) Ciprofloxacin (Cipro)

(b)
For hospitalized patients, therapy consists of parenteral (or oral once the oral route is available) ceftriaxone, quinolone, gentamicin (plus ampicillin), or aztreonam until defervescence. Then, an oral quinolone, cephalosporin, or trimethoprim-sulfamethoxazole for 14 days may be added to complete treatment. The aminoglycoside class of antibiotics is contraindicated in patients with myasthenia and other neuromuscular junction disorders. Most aminoglycosides exert their effect through reducing the number of acetylcholine quanta released. Use may lead to a myasthenic exacerbation

2008

62

Baclofen is thought to reduce spasticity by
(a) preventing the release of calcium from the sarcoplasmic reticulum.
(b) blocking sodium and potassium channels.
(c) depressing of brainstem neuronal activity.
(d) acting as a gamma-aminobutyric acid agonist.

(d)
Baclofen is an analog of gamma-aminobutyric acid (GABA), a neurotransmitter that exerts inhibitory activity on monosynaptic and polysynaptic reflexes. Dantrolene prevents the release of calcium from the sarcoplasmic reticulum.

2008

63

A 70-year-old man underwent a 2-vessel coronary artery bypass graft and mechanical mitral valve replacement five days ago. You note that he is presently taking Coumadin (warfarin). The primary reason to put this patient on Coumadin after this procedure is to prevent
(a) deep vein thrombosis.
(b) embolic stroke.
(c) coronary artery occlusion.
(d) valvular adhesion.

(b)
Patients are anticoagulated following mechanical valve replacements to prevent thromboembolic strokes. Anticoagulation will also prevent deep vein thromboses, but this is not the primary reason why it is prescribed.

2008

64

What is the measure of the rate of oxygen utilization for the production of energy?

(a) VO2min
(b) Peak VO2
(c) VO2max
(d) VO2

(d) Oxygen uptake (VO2) is the measure used to describe the rate at which oxygen is used in the
production of energy. Maximal oxygen uptake (VO2max) is the maximal rate at which an individual
can use oxygen. Peak VO2 is the measure of oxygen uptake stated when the highest attainable VO2
may not have been reached due to external factors. There is no VO2min measure.


2008

65

4. What adaptations to strength training are seen in elderly persons engaged in a consistent exercise
program?

(a) Hypertrophy of muscle only.
(b) Revascularization of the exercised muscle
(c) Strength gains from Neural and learning factors only
(d) Gains from both neural factors and hypertrophy

(d) Significant evidence exists to show that elderly persons benefit from strength training. In the past it was
believed that adaptations were due to only neural factors. Recent evidence has shown that strength gains
in elderly persons are attributable to both neural factors and muscle hypertrophy.

2008

66

Because urinary tract infections (UTIs) are the most widespread bacterial infection and the most
common source of bacteremia in older adults, treatment for bacteriuria greater than 10,000
CFU/ml in this population is indicated for an older patient with
(a) vaginal atrophy.
(b) a chronic indwelling Foley catheter.
(c) a neurogenic bladder.
(d) increased incontinence.

Answer: (d)
Commentary: Bacteriuria is defined as a quantitative count of 10,000 CFU/ml or more of 1 ormore organisms found in a patient’s urine culture, in the absence of clinical signs or symptoms ofUTI in the host. Vaginal atrophy, neurogenic bladder, and chronic use of urethral or condom
catheters are risk factors for UTIs. However, treatment in the elderly is indicated only if systemicsigns and symptoms -- such as low-grade fever, increased confusion, incontinence, anorexia and
functional decline -- are present.

2011

67

A pharmacologic treatment for orthostatic hypotension that involves fluid retention is
a) fludrocortisone.
b) ephedrine sulfate.
c) midodrine hydrochloride.
d) recombinant human erythropoietin.

Answer: (a)
Commentary: Fludrocortisones (0.05 mg once daily to 0.1 mg twice daily) is a potent
mineralocorticoid with little glucocorticoid activity. It has been used to manage orthostatic hypotension (OH) related to autonomic dysfunction for more than 40 years. The pressor action of fludrocortisones is a result of sodium retention, which occurs over several days. This delayed
action needs to be understood by the clinician as well as the patient to manage expectations and time frame of benefit. Ephedrine (20mg to 30mg up to 4 times daily) acts primarily through the release of stored catecholamines and has additional direct action on adrenoreceptors. It is a
nonselective and mimics epinephrine in its effects. Midodrine (2.5mg to 10mg 2 to 3 times daily) is an alpha 1-adrenorecptor agonist and directly increases blood pressure by arteriolar and venous constriction. Recombinant human erythropoietin has been shown in pilot studies to increase blood pressure by about 10mmHg to 20mmHg in patients with OH. In addition to the increase in red blood cell count and blood viscosity that occurs with epoeitien α, it may have a yet unrecognized
effect on the vasculature.

2011

68

A 36-year-old man has a known history of human immunodeficiency virus (HIV). His family has
observed worsening confusion and memory loss. He later develops progressive paraparesis,
ataxia, posterior column sensory loss, and neurogenic bowel and bladder. The most likely
diagnosis is
(a) viral myelitis.
(b) multiple sclerosis.
Page 25 of 33
(c) cytomegalovirus (CMV) polyradiculopathy.
(d) vacuolar myelopathy.

Answer: (d)
Commentary: Vacuolar myelopathy is the most common cause of spinal cord dysfunction in
human immunodeficiency virus (HIV) patients, being found in 11% to 22% of acquired
immunodeficiency disease (AIDS) cases, and demonstrable in as many as 40% of cases at
autopsy. It is strongly associated with HIV dementia, and shares a virtually identical
histopathology. The other diagnoses are less common, and can be ruled out or in with imaging,
laboratory and electrodiagnostic studies.

2011

69

A 38-year-old woman with cystic fibrosis is scheduled to receive a lung transplant for end-stage
pulmonary disease. She has several questions about her pre- and posttransplant rehabilitation
program. You advise her that
(a) performing upper limb exercises is contraindicated.
(b) interval exercise training is better than continuous training.
(c) she should wait 5 days, postoperatively, before starting any out of bed activity.
(d) stair-climbing activity should not start until 6 weeks after surgery.

Answer: (b)
Commentary: Preoperative rehabilitation for lung transplant patients is essential to physically prepare them for the surgery itself, and to manage their failing strength, decreased thoracic mobility and altered posture. Before surgery, interval exercise training is better than continuous training. Upper limb exercise has been safely used in rehabilitation programs, although it can contribute to dyspnea. Lung transplant patients with end-stage pulmonary disease often do better with interval exercise training than with continuous training because less ventilatory demand is required. Progressive activity should be initiated on the first postoperative day, beginning with range of motion exercises. Before discharge from the hospital, the patient should progress to stairclimbing,
which is the hallmark of recovery.

2011

70

A 41- year-old African-American man had an orthotopic heart transplant 2 months ago. He has
started outpatient cardiac rehabilitation, 3 times a week. Compared to an age-matched individual
with a normal heart, which finding do you expect in this patient when he exercises?
(a) Lower resting heart rate
(b) Higher oxygen consumption
(c) Slower ability to reach maximal heart rate
(d) Higher peak heart rate during maximal exercise

Answer: (c)
Commentary: A transplanted heart is denervated, and has a higher than normal resting heart rate due to loss of vagal tone. It also has lower oxygen consumption during submaximal exercise than
that of the normal heart. It achieves a maximal heart rate more slowly than a normal heart, and the peak heart rate achieved during maximal exercise is considerably lower in cardiac transplant
recipients than in age-matched controls.

2011

71

A 32-year-old maintenance worker with full-thickness burns involving the right hand and forearm
is now ready for compressive garments. Which statement regarding his case is correct?
(a) In order to maximize blood flow to grafted sites, compressive garments should not
exceed 15mmHg.
(b) Compressive garments should be worn a maximum of 18 hours a day to avoid graft site
maceration.
(c) In 4 to 6 months full scar maturation will be achieved and compression garments may be
discontinued.
(d) To maintain adequate pressure, compression garments should be replaced every 2 to 3
months.

Answer: (d)
Commentary: Compressive garments should provide capillary level pressures of at least
25mmHg. Wearing time should be increased gradually to 23 hours per day. Most active scarring
occurs between 4 to 6 months after injury, but full scar maturation may take 12 to 18 months. To
maintain adequate pressure, compression garments should be replaced every 2 to 3 months.

2011

72

A 39-year-old male factory worker suffers from a low voltage-induced electrical injury. The most
serious acute medical complication that can occur is
(a) cardiac arrhythmia.
(b) peripheral neuropathy.
(c) distal extremity amputation.
(d) myelopathy

Answer: (a)
Commentary: Electrical injuries are usually caused by alternating current of 60Hz. They are
classified as high voltage injuries when the person comes in contact with 1000V or more, or low
voltage when the voltage is below 1000V. A large number of electrical injuries are work related.
Hussman found cardiac arrhythmias to be the most serious medical problem in patients admitted
with low voltage injuries (41% of patients). Other complications are soft tissue burns (especially
tissues with high water content, such as nerve, muscle and blood vessels), amputations (especially
of the fingers and toes), and neurological injuries (to the central or peripheral nervous system).
Peripheral neuropathy is reported in up to 34% of high voltage injuries and a lower incidence is
found in low voltage injuries.

2011

73

Osteoblastic lesions are seen in which type of cancer?
(a) Prostate
(b) Lung
(c) Breast
(d) Renal

(a) Bony metastases from prostate cancer usually are blastic, whereas those from breast, lung, and kidney are typically lytic. Knowing whether a metastatic bone lesion is blastic or lytic is important, because lytic lesions have a higher risk of pathologic fracture.

2007

74

Which medication that binds to B-lymphocyte CD20 surface antigens (monoclonal antibody) has recently received a new indication for treatment of rheumatoid arthritis in patients who have failed tumor necrosis factor (TNF) alpha antagonists and who are receiving concomitant methotrexate (Trexall)?
(a) Etanercept (Enbrel)
(b) Abatacept (Orencia)
(c) Anakinra (Kineret)
(d) Rituximab (Rituxan)

(d) Rituximab works by binding to B-lymphocyte CD20 surface antigens (monoclonal antibody) and thereby depleting the B cell population. Its previous indication was for treatment of non-Hodgkin’s lymphoma. Etanercept is a TNF alpha antagonist. Abatacept blocks co-stimulatory molecules and T-cell activation. Anakinra inhibits interleukin-1 type receptors.

2007

75

An 80-year-old man with peripheral neuropathy and multiple medical conditions fell at home and was found several hours later. He was admitted to the hospital for a sacral insufficiency fracture and failure to thrive. During your initial consultation, you notice a skin ulcer in which the entire thickness of the skin is involved without involvement of the underlying fascia. According to the National Pressure Ulcer Advisory Panel, the patient's ulcer is classified as stage
(a) 1
(b) 2
(c) 3
(d) 4

(c) Stage 1: Nonblanchable erythema of intact skin not resolved within 30 minutes; epidermis intact. Stage 2: Partial-thickness skin loss involving the epidermis, possibly into dermis. Stage 3: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage 4: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (eg, tendon or joint capsule).

2007

76

What is the target exercise intensity for optimal aerobic training in a healthy, young individual?
(a) Borg rating of perceived exertion 6.
(b) 70%–80% of maximum heart rate.
(c) Borg rating of perceived exertion 20.
(d) 50%–60% of maximum heart rate.

(b) The target for this individual is 70% to 80% of maximum heart rate. One may use either this value or the Borg scale. The Borg scale ranges from 6 to 20. This person’s goal is Borg 13 (somewhat hard), in the range of 11 to 15 (fairly light to hard).

2007

77

The most common benign brain tumor in adults is
(a) astrocytoma.
(b) oligoblastoma.
(c) medulloblastoma.
(d) meningioma.

(d) Meningiomas are the most common benign brain tumor, comprising about 15% of all primary brain tumors

2007

78

A 45-year-old woman with advanced acquired immunodeficiency syndrome (AIDS) presents with a gradual onset of forgetfulness and inattention without other focal neurologic deficits. Review of systems is negative for headache and fever. The most likely diagnosis is
(a) toxoplasmosis.
(b) cryptococcal meningitis.
(c) human immunodeficiency virus (HIV) encephalopathy.
(d) central nervous system (CNS) lymphoma.

(c) Also known as AIDS-dementia complex, human immunodeficiency virus (HIV) encephalopathy is usually seen late in the disease course. HIV encephalopathy develops in weeks to months, whereas symptoms of toxoplasmosis and central nervous system (CNS) lymphoma are seen in days to weeks. Fever and headache, along with mental status changes, would be seen in cryptococcal meningitis. Headaches, seizures, and fatigue are commonly seen in toxoplasmosis, along with focal or non-focal neurologic signs. In CNS lymphoma, headache, confusion, memory loss, or focal neurologic signs are typically present.

2007

79

A 58-year-old man sustained a myocardial infarction 1 week ago. He is undergoing phase 1 of cardiac rehabilitation. His activity level should be limited to how many metabolic equivalents (METs)?
(a) 1
(b) 3
(c) 5
(d) 7

(c) After a myocardial infarction, exercise intensity should start at 2 metabolic equivalents (METs) and gradually progress to a maximum of 5 METs. Patients should await myocardial infarct healing before vigorous exercise greater than 5 METs is performed, usually within 4 to 6 weeks post infarctioin

2007

80

A 45-year-old woman with fibromyalgia presents to you with complaints of poor sleep. She notes that she has no trouble falling asleep but has a difficult time staying asleep. She has improved her sleep hygiene and eliminated caffeine from her diet. Which medication would you recommend?
(a) Diazepam (Valium)
(b) Eszopiclone (Lunesta)
(c) Chloral hydrate
(d) Fluoxetine (Prozac)

(b) Patients with trouble initiating sleep may require shorter acting medications, while those with fragmented sleep and frequent awakenings may more ideally benefit from medications with an intermediate to long half-life. A third nonbenzodiazepine hypnotic, eszopiclone, is FDA approved for long-term management of insomnia and retains a greater half life (5h–5.8 hours) with evidence of greater sleep maintenance efficacy as compared to the current relatively shorter half-life Z-drugs.

2007

81

Standing at ease is equivalent to how many metabolic equivalents (METs)?
(a) 1.5 to 2.0
(b) 2.5 to 3.0
(c) 4.0 to 4.5
(d) 5.0 to 5.5

(a) Lying quietly is 1.0 MET. Light housework is 1.2-3.0 METs. Standing at ease is 1.4-2.0 METs. Walking at 3 miles per hour is equivalent to 4.3 METs.

2007

82

An unusually high incidence of pressure ulcers is noted on your inpatient rehabilitation unit. As the medical director for the unit, you decide to implement a quality improvement process. The next best step in process would be to
(a) understand the cause of the skin breakdown.
(b) select a strategy to decrease the incidence of pressure ulcers.
(c) organize a team to investigate the problem.
(d) reprimand the nurse manager for the unit.

(c) Various strategies can be used when implementing a quality improvement process. One widely accepted method is FOCUS PDCA. The steps in the process include finding an opportunity, organizing the team, clarifying the current process, understanding the causes of the variation, and selecting a strategy to implement it (FOCUS). Once this has been accomplished, then the strategy involves planning, doing, checking, and acting (PDCA). According to this process, the next best step in the scenario provided would be to organize a team to investigate the problem.

2007

83

Effects of prolonged bed rest include
(a) increased maximum oxygen consumption.
(b) increase of plasma volume.
(c) decreased resting heart rate.
(d) decreased cardiac stroke volume

(d) Prolonged bed rest has detrimental effects, which include an increased resting heart rate, loss of plasma volume, decreased cardiac stroke volume, and decreased maximum oxygen consumption

2007

84

A 67-year-old woman was just admitted to the general rehabilitation unit after a complicated 2-
month course at the acute care hospital. When the physical therapist gets her out of bed on the first
day, what is the most likely finding?
(a) Blood pressure goes from 120/80 to 150/100.
(b) Blood pressure goes from 120/80 to 90/50.
(c) Heart rate goes from 80 to 60.
(d) Heart rate remains at 60.

(b) Orthostatic hypotension is a common cardiovascular complication of immobility. Lying in bed for
a prolonged time causes a central fluid shift that results in an increased intravascular volume. There
is a resultant diuresis and decrease in plasma volume. When a person stands after bed rest, venous
pooling occurs in the lower extremities due to increased venous compliance (orthostatic
intolerance). Person also has blunted cardiac response to rapid changes in posture. With
immobility and deconditioning, the resting heart rate increases, and the heart rate response to
exercise also increases

2006

85

The American College of Obstetrics and Gynecologists (ACOG) recommendation regarding exercise
during pregnancy is that
(a) exercise should be 85%–95% of maximum predicted heart rate.
(b) pregnant women may exercise to exhaustion.
(c) exercise should be done 6 days a week for at least 60 minutes daily.
(d) pregnant women should avoid resistive exercises in the supine position

(d) Exercise should be at 60% to 85% of predicted maximum heart rate. Pregnant women should not
exercise to exhaustion. Exercise should be done 3 to 4 days a week for 30 to 45 minutes at a time.
Pregnant women should avoid exercise in the supine position because such a position may decrease
cardiac output, resulting in blood diverting from the splanchnic beds (including the uterus

2006

86

A 50-year-old man is transferred to your rehabilitation unit after a cardiac transplant. Because of the
transplant, you anticipate that he will have a
(a) lower than normal resting heart rate.
(b) decreased time to achieve maximal heart rate during exercise.
(c) lower than normal peak heart rate achieved during maximal exercise.
(d) lower than normal systolic and diastolic blood pressure.

(c) A transplanted heart is denervated, so it achieves maximal heart rate more slowly because it relies
on circulating catecholamines to achieve a response. The resting heart rate is higher than normal,
most likely because of the loss in vagal input. Peak heart rate achieved during maximal exercise is
considerably lower in transplant patients compared with age-matched controls. Systolic and
diastolic blood pressures are higher than normal.

2006

87

A 60-year-old woman with rheumatoid arthritis, hypertension, and hypothyroidism has undergone
bilateral total knee arthroplasty and is currently being admitted to a rehabilitation unit. Which
medication should be discontinued in this postoperative period?
(a) Warfarin (Coumadin)
(b) Etanercept (Enbrel)
(c) Furosemide (Lasix)
(d) Levothyroxine (Synthroid)

(b) Etanercept is typically recommended to be discontinued during the postoperative period in order to
allow adequate tissue healing and prevention of complications. Other immunosuppressive therapies
and disease modifying anti-rheumatic agents should also be discontinued. The remaining
medications do not need to be discontinued in the postoperative period.

2006

88

You are taking care of a 72-year-old man who fell at home and remained on the ground for several
hours. He subsequently developed a sacral pressure ulcer that now has large areas of necrotic tissue
without fluctuance. Which intervention is most appropriate?
(a) Proteolytic enzymes
(b) Triple antibiotic ointment
(c) Incision and drainage
(d) Oral antibiotics

(a) The necrotic tissue in this wound needs debridement. This may be accomplished with surgical
sharp debridement, mechanical nonselective debridement, such as with a wet-to-dry dressing, or
enzymatic debridement with a chemical agent that uses proteolytic enzymes. Topical and oral
antibiotics are not necessary in this patient, as necrotic tissue does not signify an infection. Anincision and drainage would not be appropriate, since no abscess is present

2006

89

You have just performed electrodiagnostic testing on a patient with human immunodeficiency virus
(HIV). He has been complaining of burning in his feet for several months. The study reveals a
symmetric sensory peripheral neuropathy. Which medication is the most likely cause?
(a) Zidovudine (AZT)
(b) Indinavir (Crixivan)
(c) Saquinavir (Fortovase, Invirase)
(d) Didanosine (ddI, Videx

(d) Several of the antiretrovirals, specifically the nucleoside analog reverse transcriptase inhibitors
didanosine (ddI), zalcitabine (ddC, Hivid), stavudine (d4T, Zerit), and lamivudine (3TC, Epivir),can cause a painful neuropathy. The drug AZT is also a reverse transcriptase inhibitor, but
generally does not cause a neuropathy. Instead, it may lead to a myopathy. Saquinavir is a protease
inhibitor that may cause gastrointestinal distress and elevated liver function test results. Indinavir is
another protease inhibitor that may cause hepatotoxicity and nephrolithiasis

2006

90

Which behavior would most likely be a warning sign of substance abuse in a resident colleague?
(a) Deterioration in personal hygiene
(b) Infrequent tardiness to scheduled lectures
(c) Excessive concern regarding patient well-being
(d) Frustration over evening admissions to the rehabilitation unit

(a) Deterioration in personal hygiene is the most likely warning sign of substance abuse in a resident
colleague. Other warning signs of impairment secondary to substance abuse include increased rates
of absenteeism, inability to meet deadlines, loss of concern about patient welfare, and wide
fluctuations in mood and performance.

2006

91

Walking at 3 miles per hour is equivalent to how many metabolic equivalents (METs)?
(a) 1.0 to 1.5
(b) 2.0 to 2.5
(c) 4.0 to 4.5
(d) 5.0 to 5.5

(c) Lying quietly is 1.0 metabolic equivalents (METs). Light housework is 1.2 to 3.0 METs. Standing
at ease is 1.4 to 2.0 METs. Walking at 3 miles per hour is equivalent to 4.3 METs.

2006

92

A 58-year-old African-American man comes into your clinic for an exercise prescription and to
have questions answered. He has hypertension and hyperlipidemia and asks about the difference between land based and aquatic exercises to help with his hyperlipidemia. You advise him that
(a) aquatic therapy has a higher likelihood of on increasing his high-density lipoprotein (HDL)
compared to land based exercises.
(b) aquatic therapy has no added benefit than land based exercises in lowering total cholesterol,
low-density lipoprotein (LDL), or triglycerides.
(c) land based exercises decrease HDL to a greater extent than do aquatic based exercises.
(d) land based exercises lower LDL, total cholesterol, and triglycerides more effectively than
aquatic exercises.

(b) When compared to land based exercises, aquatic exercises have no added benefit in lowering total
cholesterol, low-density lipoprotein or triglycerides. In regards to high-density lipoproteins (HDL),
land based exercises increase HDL to a greater extent than aquatic exercises.

2006

93

One week after mitral valve replacement, which functional activity is safe to prescribe?
a. toilet transfer with a sliding board and pulling on grab bars
b. WC propulsion using bilateral lower limbs
c. bed mobility with trapeze bar
d. ambulation using a pickup walker.

B

Sternal precautions are recommended for the first 6 weeks following sternotomy for heart valve surgery. If a patient performs inappropriate transfer techniques or forceful upper body exercises such as pulling on grab bars, using a trapeze, or pushing down on a pickup walker, sternal dehiscence could result.

94

A 22 year old man with a history of epilepsy and a 30-pack year history of tobacco smoking comes to see you in clinic. He is interested in quitting smoking. Which strategy is the best approach to maximize this patient's success with smoking cessation?

a. Buproprion (Wellbutrin)
b. Varenicline (Chantix) and counseling
c. Transdermal patch for nicotine replacement
d. Transdermal patch with inhaled nicotine replacement

B

Varenicline (Chantix), Buproprion (Wellbutrin), and combination nicotine replacement (patch with inhaler), are all first line treatments to help with smoking cessation. Counseling for smoking cessation is recommended for all interventions to optimize treatment efficacy, so first-line pharmacotherapy plus counseling would optimize the patient's chances of quitting smoking over any pharmacotherapy option alone. Choic A, buproprion (wellbutrin) is not an appropriate choice for this patient, since seizure disorder is a contraindication. Option B is the best choice for this patient because it includes first-line pharmacotherapy that is medically accesptable with this patient's medical history and it includes counseling. Choice (c) is incorrect, since single formulation nicotine replacement (ie, patch alone) has a much lower success rate for maintaining abstinence at 6 months compared with the other interventions. Option d is also a first line pharmacotherapy option for smoking cessation but choice (b) is a better option because it includes counseling.

Because both varenicline (Chantix) and buproprion (Wellbutrin) have an FDA black box warning for neuropsychiatric events, clinical monitoring is indicated for all patients taking those medications. Buproprion an antidepressant, also has an FDA black box warning regarding increased risk of suicidal thinking and behavior in children, adolescents and young adults taking antidepressants. Recent reviews (Cahill, 2014) indicate that the risk of serious adverse events is not increased in any of the smoking cessation treatment options listed here.

Tobacco use is an important modifiable risk factor in many disease processes, including those of cardiovascular disease and stroke. Smoking cessation is important, since smoking has a dose dependent effect: the relative risk of stroke for heavy smokers is twice that of light smokers. Further, the additional health risks from smoking can normalize to baseline for some conditions within 5 years of quitting.

2015

95

A 35-year-old woman comes to your clinic to advance her rehabilitation program. She is planning a treip with a 10-hour airplane ride and asks for your advice about preventing blood clots. Her BMI is 25.2kg/m2 and her only medication is oral birth control pills. What is the best recommendation for her?

a. Sit in an aisle seat and ambulate frequently during the flight.
b. Wear graduated compression stockings that provide 8-10mm Hg of pressure at the ankle.
c. Take a low dose aspirin for 7 days prior to travel through 2 days after travel.
d. Take prophylactic low-molecular weight heparin 1 day prior to travel through 2 days after travel.

A flight of 8 hours or more is considered long-distance travel. As a long-distance traveler using estrogen in her oral birth control pills, she is at increased risk for venous throboembolism (VTE). Recommendations from the american college of chest physicians (Grade 2C evidence) to reduce the risk of VTE in this population include frequent ambulation, calf muscle exercise, sitting in aisle seat if possibleand wearing properly fitted below-knee graduated compression stocking providing 15-30mmHg pressure at the ankles during travel. Other risk factors for VTE during long-distance travel include previous VTE, recent surgery or trauma, active malignancy, pregnancy, advanced age, limited mobility, severe obesity or known thrombophilic disorder. The patient's BMI of 25.2kg/m2 puts her in the overweight category for body mass; extreme obesity is BMI greater than or equal to 40kg/m2. Graduated compression stockings would be an appropriate intervention to recommend, however the pressure gradient should be in the 15-30mmHg category. Aspirin or anticoagulants are specifically not recommended for VTE prophylaxis for long-distance travel.

2015.