DTR questions I got wrong

Question 1

What are the immediate steps taken to address pheochromocytoma in a patient that presents with hypertensive crisis?

Answer 1

Treat the hypertensive crisis

Treat with phentolamine and phenoxybenzamine

Then you can treat with oral alpha blockers

Once the patient is stable, beta blockers can be considered

Question 2

Peptic ulcer disease is more common in men or women?

Answer 2

Men

Question 3

Duodenal ulcers usually occur in younger or older patients?

Gastric ulcers usually occur in younger or older patients?

Answer 3

Duodenal ulcers usually occur in patients between the ages of 30-55

Gastric ulcers usually occur in patients that are 55-65

Question 4

What does aortic regurgitation sound like?

Answer 4

Diastolic blowing murmur in the second left intercostal space

Question 5

What does a mitral regurgitation sound like

Answer 5

This is an S3 sound heard in the 5th intercostal space, mid clavicular line that can radiate to the neck

Question 6

What does mitral stenosis sound like

Answer 6

Mitral stenosis is a loud S1 murmur, low pitched, apical cresendo rumble that is heard mid-diastole

Question 7

What does aortic stenosis sound like

Answer 7

Systolic, rough, harsh, blowing sound, R sided, 2nd intercostal space, also radiating to the neck

Question 8

What part of the hand rarely is involved in Rheumatoid Arthritis?

Answer 8

The distal interphalangeal joint is rarely involved in RA and more often involved in OA

Metacarpophalangeal joints are more often involved in RA rather than OA

Question 9

Medications recommended for daily consumption for a patient with AIDS to prevent pneumocystis jirovecii

Answer 9

Bactrim (trimethoprim - sulfamethazazole)

Question 10

A patient’s serologies are as follows:
HBsAg, HBeAg, antiBBc and IgM

What is the diagnosis

Answer 10

Acute Hep B

Chronic HBV would be HBsAg, anti-HBc, anti HBe, IgM and IgG

Question 11

What anti-epileptic drug is the long-term drug of choice for treating patients diagnosed with convulsive status epilepticus?

Answer 11

Phenytoin

Question 12

In qualitative research designs, the most important factor to consider when deciding the size of the study sample is:

Answer 12

Data Saturation

The size of a study sample is qualitative research is best determined by data saturation, which occurs when the researcher no longer sees or hears new information in the data he/she is collecting

Question 13

What lab results are indicative of septic shock

Answer 13

Leukocytosis with a shift to the left
Thrombocytopenia
Positive blood cultures
Hypoglycemia
Increased LDH level

Question 14

Symptoms of chronic bronchitis

Answer 14

Increased weight
Shortness of breath
Chronic, productive cough
Can include edema but not always

Question 15

Grade murmurs

Answer 15

1/6 - very faint, barely audible
2/6 - Audible but faint
3/6 - loud and easily heard but no palpable thrill
4/6 - loud and easily heard with a palpable thrill
5/6 - loud and even heard even when the corner of the stethoscope is lifted off the chest

Question 16

What is the hemodynamic profile that reflects obstructive shock?

Cardiac output, Central venous pressure, pulmonary capillary wedge pressure, systemic vascular resistance

Answer 16

CO: Low
CVP: High
PCWP: Low
SRV: High

Normal Ranges:
CO: 4-8L
CVP: 3-8mm Hg
PCWP: 6-12mm Hg
SVR: 800-1200

Question 17

What heart sound coincides with the R wave on an electrocardiogram?

Answer 17

S1

S2 is associated with the closure of aortic and pulmonic valves and is not related to any ECG findings

S3 is associated with left ventricular hypertension, heart failure and pregnancy

S4 is similar to an atrial gallop due to a stiff ventricular wall

Question 18

What is the standard test if pheochromocytoma is suspected

Answer 18

A 24 hour urine test for catecholamines

Question 19

What are common symptoms of pheochromocytoma?

Answer 19

Chronic severe headache, heart palpitations, diaphoresis, tachycardia, hypertension

These tend to happen over time and are episodic, similar to panic attacks

Question 20

What is the formula to calculate renal creatinine clearance

Answer 20

([140-age in years] x weight in kg) / (72 x serum creatinine) = renal creatinine clearance

Question 21

Creatinine and % of nephron loss in Diminished renal reserve, Renal insufficiency and End stage renal disease

Answer 21

Diminished renal reserve - 50% of nephron loss and double creatinine

Renal insufficiency - 75% of nephron loss and mild azotemia (BUN or creatinine increase)

End stage Renal disease - 90% nephron loss, azotemia and metabolic alterations

Question 22

How do you measure cardiac output?

Answer 22

Heart rate x stroke volume = cardiac output

Question 23

Hemodynamic readings for a patient in septic shock

Cardiac output, pulmonary wedge pressure, systemic vascular resistance

Answer 23

Cardiac output: High
Pulmonary wedge pressure: Low
Systemic Vascular Resistance: Low

Normal Ranges:
CO: 4-8L
CVP: 3-8mm Hg
PCWP: 6-12mm Hg
SVR: 800-1200

Question 24

Treatment of complicated community acquired PNA (diabetes or other comorbidities)

Answer 24

If complicated
Respiratory fluroquinolones (Moxifloxacin or Levofloxacin)

If uncomplicated (no comorbidities)
Macrolides (Azithromycin), Amoxicillin

Question 25

Which type nonexperimental research measures an outcome in groups of individuals who differ by a particular characteristic?

Answer 25

Cohort Cohort research compares particular outcomes in groups of individuals who are alike in many respects but differ according to a particular characteristic

Question 26

According to the latest guidelines, what is the earliest age at which adults should typically receive the herpes zoster vaccine?

Answer 26

50 years old

Question 27

Which type of Medicare reimburses NPs?

Answer 27

Medicare B reimburses NPs at 85% of the Physicians Fee Schedule rate.

Question 28

The elderly should receive pharmacologic treatment for hypertension if their blood pressure meets or exceeds ___

Answer 28

For patients older than 60 years old: 150/90 For patients younger than 60 years old: 140/90

Question 29

What does a chest x-ray normally show for a patient with chronic bronchitis

Answer 29

hyperinflated lungs

Question 30

Given national statistics, what is the most likely age for your patient to die of AIDS complication?

Answer 30

Complications from HIV/AIDS are the #9 leading cause of death for people ages 25-44

Question 31

Persistent vomiting over the course of a week can lead to what blood tests? Acidosis or alkalosis and what metabolic derrangement?

Answer 31

Metabolic alkalosis because of the loss of gastric acid Also look for hypokalemia For diarrhea, likely metabolic acidosis and hyperkalemia

Question 32

What is the course of action most appropriate for management of a suspected kidney stone just above the ureter?

Answer 32

Strain the patient's urine to determine the type of stone so that treatment can be best tailored.

Question 33

What herbal agent is most frequently used to improve symptoms of an enlarged prostate?

Answer 33

St John's wort It is also used to treat depression, anxiety and sleep disorders

Question 34

What is the difference between a complex partial seizure and a simple partial seizure?

Answer 34

A complex partial seizure is characterized by an impaired level of consciousness after a simple partial seizure A simple partial seizure may present with motor findings in a single muscle group that spread to the entire corresponding side of the body, as well as paresthesias and flashing lights.

Question 35

Blunted fever response in elderly patients is caused by

Answer 35

neuro deficit

Question 36

What is the serology testing that would indicate: Active Hep B infection: Chronic Hep B infection Resolved Hep B infection

Answer 36

Active: HBeAg, IgM Chronic: IgM and IgG, anti-HBe Recovered: Anti-HBs (s=stopped)

Question 37

Diverticulitis: Symptoms and physical exam findings

Answer 37

Symptoms: -Mild to moderate aching abd pain in the LLQ -Constipation or loose stools -Nausea and vomiting Physical exam findings: -Low grade fever -LLQ tenderness to palpation

Question 38

Diverticulitis: Labs, Diagnostics and Treatment

Answer 38

Labs and Diagnostics: -Mild-Moderate leukocytosis -Elevated ESR -Stool heme+ -Sigmoidoscopy shows inflamed mucosa -Plain films are obtained on all patients given concern for free air - pneumoperitoneum Treatment: -NPO -IVF -If GIB, treat like PUD -Surgical consultation

Question 39

Major differences between Osteoarthritis and Rheumatoid Arthritis Inflammation: Age: Joints: Stiffness/Pain: Xray findings: Management:

Answer 39

Inflammation: OA - Asymmetrical RA - Symmetrical Age: OA - 53-64 years old RA - 35-50 years old Joints: OA - Weight bearing (knees, hip), fingers, hands, wrists, includes DIPs RA - PIPs, MCPs, wrists (ulnar deviation) Stiffness/Pain: OA - Swelling and edema but no redness or heat, better in the AM, worse as the day progresses, aggravated by activity RA - Swelling and edema with redness and heat, worse in the morning and gets better as the day goes on Xray findings: OA - Narrowing of the joint space, Osteophytes, juxta-articular sclerosis RA - Joint swelling, progressive cortical thinning, joint space narrowing Management: OA - ASA, Acetaminophen, Celebrex RA - Hydroxychloroquine, methorexate, DMARDs

Question 40

When should a woman first start getting mammograms and how often per US Task Force

Answer 40

First at age 50 and then every 2 years after

Question 41

Best initial step for treating pheochromocytoma

Answer 41

Initial treatment: -Phentolamine IV every 5 minutes until controlled, then every 12-24 hours after that -Switch to Phenoxybenzamine PO as soon as possible. Ultimately the most definitive treatment is surgical removal of the tumor

Question 42

Diagnostic testing for pheochromocytoma

Answer 42

24 hour metanephrine Assay of urine catecholamines CT of adrenals is used to confirm and localize the tumor

Question 43

What is the age that adults should receive the herpes zoster vaccine

Answer 43

Should administered at age 50 in immunocompentent patients although can be administered as early as 19 in immunocompromised patients

Question 44

What is the standard range for PT and PTT

Answer 44

PT 10-14s PTT 60-70s

Question 45

What heart sounds does the R wave on an EKG represent? S1, S2, S3 or S4?

Answer 45

S1

Question 46

What are the expected electrolyte abnormalities in Cushing's Syndrome?

Answer 46

Hyperglycemia Hypernatremia Leukocytosis

Question 47

What type of drugs clear bronchial secretions and could be helpful in asthma that is not responding to short acting beta agonists?

Answer 47

Cholinergic drugs - SAMA - ipratropium bromide

Question 48

How to calculate creatinine clearance

Answer 48

([140-age in years] x body weight)/72 x serum Cr

Question 49

What are the lab results seen in SIADH

Answer 49

Hyponatremia Urine Sodium >20 Serum Osm <280 Urine Osm >100

Question 50

What labs are consistent with intrarenal failure

Answer 50

Specific Gravity <1.015 Urinary sediment with granular white casts FENa >3%

Question 51

Which anti-hypertensives decrease HR?

Answer 51

Beta-blockers ACE-I decrease BP without changing the HR

Question 52

What is Cushing's Triad

Answer 52

Increased systolic blood pressure Decreased HR Decreased RR This happens because of increased ICP

Question 53

Difference between assist control and SIMV

Answer 53

Assist Control gives a full breath whenever the patient wants to breath or whenever the machine is set for a rate SIMV will also give a breath but its the amount that the pt can pull. The doc can still choose tidal volume and the pt can initiate the breath on their own

Question 54

What is the difference between Pressure Support Ventilation and SIMV

Answer 54

Pressure support does not have a set rate. It instead boosts the breath that the pt will spontaneously take with a little more pressure. This is good for patients that are not in cardiac arrest or respiratory failure (maybe have AMS)

Question 55

Ventilator settings for restrictive lung disease

Answer 55

Examples of restrictive lung disease: ARDS, aspiration pneumonitis, PNA, pulmonary fibrosis, pulmonary edema The lungs want to collapse Hard to get air in, easy to get air out Want to use assist control using either volume control or pressure control

Question 56

What is the relationship between how much opacification in the lungs on CXR and PEEP

Answer 56

The more opacification in the lungs, the more PEEP needed

Question 57

What is normal range for PEEP

Answer 57

5-20 DNE 20

Question 58

Ventilator settings of obstructive lung disease

Answer 58

Examples of obstructive lung disease COPD, asthma Easy to get air in but hard to get it out Want to use assist/control with volume control Want to make sure that the desired tidal volume is delivered

Question 59

Troubleshooting the vent: PaO2 is too low

Answer 59

Want to keep the PaO2 75-100 PaO2 is too low: A/C and SIMV: Increase PEEP, increase FiO2

Question 60

Troubleshooting the vent: PaCO2 is too high

Answer 60

Want to keep between 35-45 Volume A/C: Increase rate, increase tidal volume Pressure A/C: Increase rate, increase driving pressure

Question 61

Troubleshooting the vent: PaCO2 too low

Answer 61

Want to keep between 35-45 Volume A/C: Decrease rate, lower tidal volume Pressure A/C: Decrease rate, lower driving pressure

Question 62

Treatment for high peak airway pressure, low plateau pressure

Answer 62

This means the problem is high airway resistance Unkink the ET tube Check for mucous plugging Consider bronchospasm - give bronchodilators Too narrow of an ET tube

Question 63

Treatment for high peak airway pressure and high plateau pressure

Answer 63

This means the problem is in the lungs Mainstem intubation Atelectasis of a lobe Pulmonary edema ARDS - lower tidal volume, increase PEEP

Question 64

What is Auto PEEP and how do you fix it?

Answer 64

Dynamic hyper-inflation of the lungs The pressure in the lungs never returns to zero. This is usually due to inadequate time for exhalation On exam, you will see distended neck veins and hear loud wheezing with abd muscle uses on exhalation Treatment: Lower ventilator rate (keep between 10-14) Shorten the inspiratory time to keep I:E 1:3-1:5 Keep the tidal volume between 6-8 Can increase sedation to prevent tachypnea

Question 65

Troubleshooting the vent: Sudden drop in SpO2

Answer 65

First step is to disconnect the pt from the vent and mechanically bag them Make sure the tube is in place by capnography or by color change strip Check breath sounds Obtain ABG Get CXR - look for worsening infiltrates, new PNA, PTX, pulmonary edema Always consider PE If absent breath sounds on one side, pull ET tube back a little bit, may have slid down If in right place, think PE or mucous plugging causing atelectasis Tension PTX should be considered if absent breath sounds and new hypotension

Question 66

Troubleshooting the vent: Fighting the ventilator

Answer 66

Before sedating and paralyzing the patient, make sure you check the following: TSS - Tube, sounds, sats ---Make sure the tube is in the right place ---Make sure the breath sounds are present and equal ---Make sure the patient is not hypoxic Other things to consider: - Auto PEEP - Untreated pain - Make sure the vent is providing adequate rate and vT - Switch to assist control if the pt is getting fatigued - Search for other causes of distress (cardiac ischemia, fever, abd distention, neurologic deterioration)

Question 67

Troubleshooting the vent: Change in the EtCO2

Answer 67

First look at the waveform: -If no waveform: ----ET tube is not in the trachea ---ET tube is completely occluded ---EtCO2 sensor is faulty If there is a waveform, then an ABG should be obtained to determine what the PCO2 is -Rising EtCO2 and PCO2 indicates increase CO2 production or alveolar hyperventilation ---Fever, malignant hyperthermia -Falling EtCO2 with unchanged or rising PCO2 ---Increase in dead space ventilation caused by PE, falling cardiac output or autoPEEP -Falling EtCO2 and falling PCO2 indicates an increase in alveolar ventilation ----Pain, agitation, fever, sepsis