Patient assessment, before anyone exercises

A 72-year-old female with heart failure reports weakness and palpitations. Based on her medications, which laboratory value is critical to assess before exercise testing?

1. Serum Potassium
   A loop diuretic wastes potassium, and weakness with palpitations suggests hypokalemia, which raises arrhythmia risk during exercise.
2. Thyroid Hormone
   Thyroid disease can cause palpitations, but nothing on this list makes it the critical check before testing.
3. Lipid Profile
   Cholesterol values guide long-term therapy and have no bearing on whether testing is safe today.
4. Serum Albumin
   Albumin reflects nutrition and liver status and does not explain weakness and palpitations on a loop diuretic.
5. Coagulation INR
   INR matters for warfarin; aspirin does not call for INR monitoring, and the symptoms point to an electrolyte problem.

A patient provides the following current medication list: Which effect on the heart rate response to exercise should be anticipated?

1. Reduced or blunted peak heart rate
   Diltiazem is a non-dihydropyridine calcium channel blocker that slows the sinus and AV nodes, so the heart rate response is blunted.
2. No significant effect on heart rate
   That would be true of lisinopril and metformin, but not of diltiazem.
3. Rapid onset of atrial fibrillation
   Diltiazem is used to control atrial fibrillation; it does not provoke it.
4. Increased incidence of tachycardia
   Reflex tachycardia belongs to dihydropyridines such as nifedipine; diltiazem slows the heart.
5. Exaggerated chronotropic response
   This list contains a drug that lowers heart rate, so the response is expected to be smaller, not larger.

A patient scheduled for a symptom-limited exercise test arrives reporting generalized body aches, severe fatigue, and a fever of 101°F (38.3°C) that began yesterday. What is the correct clinical action?

1. Give antipyretics and test
   Lowering the temperature hides the fever but not the infection, and the CEP does not give medications without an order.
2. Limit intensity to 5 METs
   An arbitrary MET cap does not remove the risk of exercising during a systemic infection.
3. Proceed wearing a face mask
   A mask limits spread to others but does nothing for the patient's own risk.
4. Postpone the exercise test
   An acute febrile illness with body aches is a contraindication to symptom-limited testing; the test is rescheduled after recovery.
5. Perform a submaximal test
   The contraindication applies to exercise during acute infection, so a lighter test is still deferred.

A 58-year-old female completes the Duke Activity Status Index (DASI) as part of her pre-exercise assessment, resulting in a score of 38.2. Based on the standard regression equation, what is her estimated functional capacity?

1. 16.4 mL·kg⁻¹·min⁻¹
   This is 0.43 × 38.2 without adding the 9.6 intercept.
2. 10.9 mL·kg⁻¹·min⁻¹
   This value does not come from either term of the DASI equation; the result should exceed 9.6 for any positive score.
3. 38.2 mL·kg⁻¹·min⁻¹
   This repeats the raw index score; the DASI score is not itself a VO2 value.
4. 47.8 mL·kg⁻¹·min⁻¹
   This adds 9.6 to the raw score and skips the 0.43 multiplier.
5. 26.0 mL·kg⁻¹·min⁻¹
   The DASI equation is VO2 = 0.43 × score + 9.6, so 0.43 × 38.2 + 9.6 ≈ 26.0 mL·kg⁻¹·min⁻¹ (about 7.4 METs).

A patient with chronic heart failure provides the symptom log below during a pre-exercise check-in. Based on these findings, what is the most likely clinical status?

1. Acute heart failure decompensation
   A 6-lb gain over 5 days with new edema and then orthopnea is fluid retention, the classic picture of worsening heart failure.
2. Expected post-exercise fatigue
   Fatigue does not add pounds of weight or make a patient need extra pillows to breathe.
3. Medication-induced hypotension
   Low blood pressure would cause dizziness, not steady weight gain, edema and orthopnea.
4. Stable chronic heart failure status
   Stable status would mean steady weight and no new symptoms; this log shows the opposite.
5. Normal daily fluid fluctuation
   Day-to-day changes are small; a steady climb of several pounds with symptoms is not normal variation.

A patient with type 1 diabetes presents for a scheduled session with the point-of-care values shown below. What is the appropriate course of action?

1. Begin at 40% intensity
   Lowering intensity is acceptable when ketones are absent; with moderate ketones exercise is not done at all.
2. Postpone session and refer
   Glucose above 250 mg/dL with moderate ketones means insulin deficiency; exercise can push it toward ketoacidosis, so the session is held and the care team informed.
3. Perform resistance training
   Any exercise is advised against with moderate or large ketones, not just aerobic work.
4. Hydrate and re-test later
   Fluids alone do not clear ketones; this patient needs insulin management, not another attempt at the session.
5. Administer insulin bolus
   Dosing insulin is outside the CEP's role and needs the prescriber's direction.

A 68-year-old male presents for a maximal exercise test. His pre-exercise assessment reveals the clinical status shown below. How is this finding classified regarding exercise testing?

1. Absolute contraindication to testing
   Without symptoms or acute organ damage, severe resting hypertension falls on the relative list, not the absolute one.
2. Indication for immediate stress testing
   Very high resting pressure is a reason for caution and control first, not urgency to test.
3. Relative contraindication to testing
   Resting systolic pressure above 200 or diastolic above 110 mmHg is listed as a relative contraindication; testing is held unless a physician judges the benefit to outweigh the risk.
4. Normal finding for age group
   210/115 mmHg is severe hypertension at any age.
5. Insufficient data to classify risk
   The resting pressure alone is enough to classify this finding.

A patient reports occasional dizziness upon standing. The clinical exercise physiologist assesses positional vital signs. Based on the data below, which condition is indicated?

1. Autonomic dysreflexia
   Dysreflexia is a hypertensive surge in spinal cord injury, the opposite of a pressure drop on standing.
2. Postural tachycardia syndrome
   POTS needs a rise of 30 bpm or more without a pressure drop; here the rise is 22 bpm and pressure falls.
3. Orthostatic hypotension
   Systolic falls 26 mmHg and diastolic 16 mmHg within 3 minutes of standing, past the 20/10 mmHg criteria.
4. Chronotropic incompetence
   This term describes a weak heart rate rise during exercise; here heart rate climbs appropriately.
5. Normal hemodynamic response
   A small dip that recovers is normal; a sustained drop beyond 20/10 mmHg is not.

A 60-year-old male arrives for testing. His resting blood pressure is significantly elevated, and he reports new symptoms. Based on the assessment below, how should this patient be triaged?

1. Acute autonomic stress
   Anxiety can raise pressure somewhat, but it does not explain 210/132 mmHg with visual disturbance.
2. Isolated systolic hypertension
   Isolated systolic hypertension has a normal diastolic value; here diastolic is 132 mmHg.
3. White coat hypertension
   White coat readings are elevated in the clinic without symptoms of organ injury.
4. Hypertensive emergency
   Pressure above 180/120 mmHg with new headache and blurred vision suggests target-organ involvement, which makes it an emergency.
5. Hypertensive urgency
   Urgency is severe elevation without signs of organ damage; the visual and neurological symptoms move it beyond that.

A 58-year-old female on canagliflozin reports nausea and fatigue before exercise, despite a glucose of 138 mg/dL. What is the priority action?

1. Proceed with low-intensity cycling
   Normal glucose does not exclude ketoacidosis on this drug class, so starting exercise first is unsafe.
2. Administer rapid-acting carbohydrates
   Glucose of 138 mg/dL is not low, so carbohydrate does not address the problem.
3. Encourage hydration and begin session
   Fluids are reasonable, but beginning exercise before ruling out ketoacidosis skips the key check.
4. Monitor glucose every 15 minutes
   Glucose is the wrong marker here; it can stay near normal while ketones rise.
5. Test for serum or urine ketones
   SGLT2 inhibitors such as canagliflozin can cause ketoacidosis with near-normal glucose, so nausea and fatigue call for a ketone check.

A clinical exercise physiologist reviews the morning schedule of a patient with Type 1 diabetes who utilizes rapid-acting insulin. Based on the timing below, the patient is at highest risk for which acute event during the 09:00 session?

1. Insulin resistance spike
   Exercise increases insulin sensitivity, adding to the glucose-lowering effect.
2. Acute hypoglycemia
   Lispro peaks about 1–2 hours after injection, so a 09:00 session at 75% HRR lands on peak insulin action after a small breakfast.
3. Hyperglycemic ketosis
   Ketosis follows too little insulin; this patient has just injected a rapid-acting dose.
4. Post-exercise hypotension
   A pressure drop can follow exercise, but the schedule points to an insulin-glucose mismatch.
5. Exercise-induced hyperglycemia
   Glucose rises with brief, very intense efforts or insulin deficiency, not with moderate exercise at peak insulin.

A patient taking atorvastatin reports bilateral thigh soreness that has persisted for several days without recent heavy activity. What is the most appropriate action?

1. Encourage hydration for delayed onset soreness
   DOMS follows unaccustomed exercise; this patient had no recent heavy activity.
2. Refer for possible statin-related myalgia
   Unexplained, symmetric thigh pain in a statin user fits statin-associated muscle symptoms, which the prescriber needs to evaluate.
3. Design a program to flush lactic acid buildup
   Lactate clears within an hour after exercise and does not cause days of soreness.
4. Advise the patient to stretch more frequently
   Stretching does not address a possible drug side effect, and it delays the right referral.
5. Apply ice to the affected quadriceps muscles
   Ice treats a local strain; this pain is bilateral and unrelated to activity.

Which laboratory value is MOST critical to review before exercise testing in a patient with diabetes?

1. Total cholesterol
   Cholesterol guides long-term risk, not whether today's test is safe.
2. Blood glucose level
   A pre-test glucose reading shows whether the patient is low or too high to exercise safely that day.
3. Vitamin D level
   Vitamin D status does not affect same-day exercise safety.
4. White blood cell count
   A white cell count is not a routine pre-test check in diabetes.

A 50-year-old male with controlled hypertension presents with a resting BP of 158/96 mm Hg. He mentions taking an over-the-counter medication for a head cold this morning. Which agent is the most likely cause?

1. Guaifenesin extract
   Guaifenesin thins mucus and has no vasoconstrictor effect.
2. Dextromethorphan HBr
   This cough suppressant acts centrally and does not raise blood pressure at usual doses.
3. Pseudoephedrine HCl
   Pseudoephedrine is a sympathomimetic decongestant that can raise blood pressure and heart rate.
4. Chlorpheniramine maleate
   This antihistamine causes drowsiness and dry mouth, not a meaningful pressure increase.
5. Acetaminophen PM
   Acetaminophen with a sedating antihistamine is not a typical cause of a pressure rise.

Which intake finding places a patient entering outpatient cardiac rehabilitation in the high-risk category for exercise participation?

1. Uncomplicated stent placement
   An uncomplicated revascularization is a low-risk feature.
2. Functional capacity of 8 METs
   A capacity of 7 METs or more is a low-risk finding.
3. Normal exercise blood pressure
   A normal hemodynamic response with exercise lowers the risk category.
4. Resting ejection fraction of 35%
   An ejection fraction below 40% is one of the criteria for the highest-risk group, which calls for the closest ECG and clinical supervision.
5. Resting ejection fraction of 55%
   An ejection fraction of 50% or more is a low-risk feature, not a high-risk one.