DTR questions I got wrong Flashcards
What are the immediate steps taken to address pheochromocytoma in a patient that presents with hypertensive crisis?
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
Peptic ulcer disease is more common in men or women?
Men
Duodenal ulcers usually occur in younger or older patients?
Gastric ulcers usually occur in younger or older patients?
Duodenal ulcers usually occur in patients between the ages of 30-55
Gastric ulcers usually occur in patients that are 55-65
What does aortic regurgitation sound like?
Diastolic blowing murmur in the second left intercostal space
What does a mitral regurgitation sound like
This is an S3 sound heard in the 5th intercostal space, mid clavicular line that can radiate to the neck
What does mitral stenosis sound like
Mitral stenosis is a loud S1 murmur, low pitched, apical cresendo rumble that is heard mid-diastole
What does aortic stenosis sound like
Systolic, rough, harsh, blowing sound, R sided, 2nd intercostal space, also radiating to the neck
What part of the hand rarely is involved in Rheumatoid Arthritis?
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
Medications recommended for daily consumption for a patient with AIDS to prevent pneumocystis jirovecii
Bactrim (trimethoprim - sulfamethazazole)
A patient’s serologies are as follows:
HBsAg, HBeAg, antiBBc and IgM
What is the diagnosis
Acute Hep B
Chronic HBV would be HBsAg, anti-HBc, anti HBe, IgM and IgG
What anti-epileptic drug is the long-term drug of choice for treating patients diagnosed with convulsive status epilepticus?
Phenytoin
In qualitative research designs, the most important factor to consider when deciding the size of the study sample is:
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
What lab results are indicative of septic shock
Leukocytosis with a shift to the left
Thrombocytopenia
Positive blood cultures
Hypoglycemia
Increased LDH level
Symptoms of chronic bronchitis
Increased weight
Shortness of breath
Chronic, productive cough
Can include edema but not always
Grade murmurs
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
What is the hemodynamic profile that reflects obstructive shock?
Cardiac output, Central venous pressure, pulmonary capillary wedge pressure, systemic vascular resistance
CO: Low
CVP: High
PCWP: Low
SRV: High
Normal Ranges:
CO: 4-8L
CVP: 3-8mm Hg
PCWP: 6-12mm Hg
SVR: 800-1200
What heart sound coincides with the R wave on an electrocardiogram?
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
What is the standard test if pheochromocytoma is suspected
A 24 hour urine test for catecholamines
What are common symptoms of pheochromocytoma?
Chronic severe headache, heart palpitations, diaphoresis, tachycardia, hypertension
These tend to happen over time and are episodic, similar to panic attacks
What is the formula to calculate renal creatinine clearance
([140-age in years] x weight in kg) / (72 x serum creatinine) = renal creatinine clearance
Creatinine and % of nephron loss in Diminished renal reserve, Renal insufficiency and End stage renal disease
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
How do you measure cardiac output?
Heart rate x stroke volume = cardiac output
Hemodynamic readings for a patient in septic shock
Cardiac output, pulmonary wedge pressure, systemic vascular resistance
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
Treatment of complicated community acquired PNA (diabetes or other comorbidities)
If complicated
Respiratory fluroquinolones (Moxifloxacin or Levofloxacin)
If uncomplicated (no comorbidities)
Macrolides (Azithromycin), Amoxicillin
Which type nonexperimental research measures an outcome in groups of individuals who differ by a particular characteristic?
Cohort
Cohort research compares particular outcomes in groups of individuals who are alike in many respects but differ according to a particular characteristic
According to the latest guidelines, what is the earliest age at which adults should typically receive the herpes zoster vaccine?
50 years old
Which type of Medicare reimburses NPs?
Medicare B reimburses NPs at 85% of the Physicians Fee Schedule rate.
The elderly should receive pharmacologic treatment for hypertension if their blood pressure meets or exceeds ___
For patients older than 60 years old: 150/90
For patients younger than 60 years old: 140/90
What does a chest x-ray normally show for a patient with chronic bronchitis
hyperinflated lungs
Given national statistics, what is the most likely age for your patient to die of AIDS complication?
Complications from HIV/AIDS are the #9 leading cause of death for people ages 25-44
Persistent vomiting over the course of a week can lead to what blood tests?
Acidosis or alkalosis and what metabolic derrangement?
Metabolic alkalosis because of the loss of gastric acid
Also look for hypokalemia
For diarrhea, likely metabolic acidosis and hyperkalemia
What is the course of action most appropriate for management of a suspected kidney stone just above the ureter?
Strain the patient’s urine to determine the type of stone so that treatment can be best tailored.
What herbal agent is most frequently used to improve symptoms of an enlarged prostate?
St John’s wort
It is also used to treat depression, anxiety and sleep disorders
What is the difference between a complex partial seizure and a simple partial seizure?
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.
Blunted fever response in elderly patients is caused by
neuro deficit
What is the serology testing that would indicate:
Active Hep B infection:
Chronic Hep B infection
Resolved Hep B infection
Active: HBeAg, IgM
Chronic: IgM and IgG, anti-HBe
Recovered: Anti-HBs (s=stopped)
Diverticulitis: Symptoms and physical exam findings
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
Diverticulitis: Labs, Diagnostics and Treatment
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
Major differences between Osteoarthritis and Rheumatoid Arthritis
Inflammation:
Age:
Joints:
Stiffness/Pain:
Xray findings:
Management:
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
When should a woman first start getting mammograms and how often per US Task Force
First at age 50 and then every 2 years after
Best initial step for treating pheochromocytoma
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
Diagnostic testing for pheochromocytoma
24 hour metanephrine
Assay of urine catecholamines
CT of adrenals is used to confirm and localize the tumor
What is the age that adults should receive the herpes zoster vaccine
Should administered at age 50 in immunocompentent patients although can be administered as early as 19 in immunocompromised patients
What is the standard range for PT and PTT
PT 10-14s
PTT 60-70s
What heart sounds does the R wave on an EKG represent?
S1, S2, S3 or S4?
S1
What are the expected electrolyte abnormalities in Cushing’s Syndrome?
Hyperglycemia
Hypernatremia
Leukocytosis
What type of drugs clear bronchial secretions and could be helpful in asthma that is not responding to short acting beta agonists?
Cholinergic drugs - SAMA - ipratropium bromide
How to calculate creatinine clearance
([140-age in years] x body weight)/72 x serum Cr
What are the lab results seen in SIADH
Hyponatremia
Urine Sodium >20
Serum Osm <280
Urine Osm >100
What labs are consistent with intrarenal failure
Specific Gravity <1.015
Urinary sediment with granular white casts
FENa >3%
Which anti-hypertensives decrease HR?
Beta-blockers
ACE-I decrease BP without changing the HR
What is Cushing’s Triad
Increased systolic blood pressure
Decreased HR
Decreased RR
This happens because of increased ICP
Difference between assist control and SIMV
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
What is the difference between Pressure Support Ventilation and SIMV
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)
Ventilator settings for restrictive lung disease
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
What is the relationship between how much opacification in the lungs on CXR and PEEP
The more opacification in the lungs, the more PEEP needed
What is normal range for PEEP
5-20
DNE 20
Ventilator settings of obstructive lung disease
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
Troubleshooting the vent:
PaO2 is too low
Want to keep the PaO2 75-100
PaO2 is too low: A/C and SIMV: Increase PEEP, increase FiO2
Troubleshooting the vent:
PaCO2 is too high
Want to keep between 35-45
Volume A/C: Increase rate, increase tidal volume
Pressure A/C: Increase rate, increase driving pressure
Troubleshooting the vent:
PaCO2 too low
Want to keep between 35-45
Volume A/C: Decrease rate, lower tidal volume
Pressure A/C: Decrease rate, lower driving pressure
Treatment for high peak airway pressure, low plateau pressure
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
Treatment for high peak airway pressure and high plateau pressure
This means the problem is in the lungs
Mainstem intubation
Atelectasis of a lobe
Pulmonary edema
ARDS - lower tidal volume, increase PEEP
What is Auto PEEP and how do you fix it?
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
Troubleshooting the vent:
Sudden drop in SpO2
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
Troubleshooting the vent:
Fighting the ventilator
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)
Troubleshooting the vent:
Change in the EtCO2
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
