Packrat Test 2 Answers

1) A) Apical and radial pulses at the same time, then finding the difference between the two. The pulse deficit is determined by counting the apical and radial pulses at the same time, then subtracting to find the difference between the two. 2) B) Serum creatinine and potassium levels Native Americans have a much higher rate of kidney disease and renal failure when compared to other races. Native Americans have a 1 in 3 incidence of hypertension. Hypertension is the second leading cause of kidney failure. BUN, creatinine, estimated GFR, and uri- nalysis are performed to assess the function of the kidneys. 3) B) Chronic hypertension The most common cause of LVH is chronic hypertension. 4) A) Premedicate himself 20 minutes prior to starting exercise Exercise-induced asthma is best controlled by using the Proventil inhaler (bronchodilator) approxi- mately 20 minutes prior to exercise, to prevent vasospasm of the bronchioles and shortness of breath with exercise. These bronchodilators usually last approxi- mately 4 hours. They also work quickly to open up the bronchioles if an acute attack/shortness of breath occurs. 5) C) The scotch tape test Enterobiasis infection (pinworms) is caused by small worms that infect the intestines. Symptoms include itching around the anus, which is usually worse at night. The scotch tape test is done by applying the scotch tape on the anal area in the morning; the worms commonly come out at night and will stick to the tape, which is used for diagnosis. 6) C) Moderate persistent asthma Asthma classifications: Intermittent: normal FEV between exacerbations, FEV > 80%; mild persistent, FEV > 80%; moderate persistent, FEV 60–80%; severe persistent, FEV < 60%. 7) D) Psoriasis Auspitz sign is the presence of pinpoint bleeding spots from psoria- sis where the skin is scraped off. 8) C) A long-acting oral theophylline (Theo-Dur) 200 mg every 12 hours Theo- phylline is used to control inflammation of the lungs. Tilade, Intal, and Flovent help to treat inflammation. 9) A) A patch of leukoplakia An early sign of HIV is a hairy patch of leukoplakia on the tongue. 10) B) Mitral stenosis Mitral stenosis is best heard at the fifth ICS to the left of the midclavicular line. It is ausculated as a low-pitched diastolic murmur, grade II/ VI. Aortic regurgitation is a high-pitched diastolic murmur, heard at the second ICS to the right of the sternum. Mitral regurgitation is a pansystolic murmur that radiates to the axilla, loud and high pitched when ausculated. 11) B) Decreased mobility of the tympanic membrane as measured by tympano-gram Fluid behind the ear drum will decrease the mobility of the TM when mea- sured by a tympanogram. When perforation occurs, discharge will flow through the pars tensa portion of the ear drum. 12) C) Status asthmaticus Pulsus paradoxus is most likely to be seen with status asthmaticus. With inspiration, systolic pressure drops due to the increased pres- sure (positive pressure). Some pulmonary risks of having increased pressure include asthma and emphysema. Cardiac causes for pulsus paradoxus include tamponade, pericarditis, and cardiac effusion.

13) B) Increase only the NPH insulin in the morning Increase in the morning NPH is recommended to affect the late afternoon blood sugar readings. Increasing the NPH will lower the afternoon blood sugar readings. NPH is a long-acting insulin, with onset beginning 1–2 hours and peaking in approximately 6–8 hours. Duration of NPH is approximately 18–24 hours. 14) D) Calcium channel blockers Common side effects of calcium channel blockers include headaches, edema of the lower extremities, and heart block or bradycardia. Contraindications for calcium channel blockers include second- or third-degree AV block, bradycardia, and congestive heart failure. 15) D) Penicillin (Pen VK) Pen VK is safe to use for strep throat during pregnancy. Pen VK is a category B medication for pregnancy and lactation. 16) A) Central vision The cones of the eyes are responsible for central vision. 17) A) 3 months The posterior fontanelle normally closes by 3 months of age. The anterior fontanelle closes between 12 and 18 months of age. 18) C) Edema of the ankles and headache Common side effects of calcium channel blockers, such as Procardia, include edema of the ankles, dizziness, headaches, flushing, and weakness. ACE inhibitors tend to have the side effects of angioedema and a dry hacking cough. Diuretics can cause hyperkalemia and hyperuricemia. 19) A) The veins are larger than the arterioles On funduscopic exam of the eye you will see that the veins are larger in size than the arterioles. 20) D) Migraine headaches Contraindications with Betimol (timolol) include heart fail- ure or sinus bradycardia, asthmatic patients, and second- or third-degree AV block. 21) C) It is best heard at the apex at S1 Mitral regurgitation is best heard at the api- cal area; it is a high-pitched, blowing pansystolic murmur. 22) A) Metronidazole (Flagyl) Trichomoniasis symptoms include dysuria, severe vaginal pruritis, and malodorous vaginal discharge. Wet prep will show trichomonads that are pear-shaped and have several flagella (whiplike tails) at one end. CDC recommendation for treatment is metronidazole. 23) D) 12 months The earliest age that MMR is recommended is 12 months. This age is recommended because giving it any earlier may be less effective because the infant still has antibodies from the mother. Antibodies still present from the mother may interfere with the production of the antibodies stimulated by the MMR vaccine. 24) A) Mumps virus Orchitis is caused by the mumps virus. 25) B) Patient is coherent Characteristics of delirium include an acute and dramatic onset of symptoms that is temporary, and usually will worsen in the evening. May last hours to days. Patient is incoherent and disoriented. Usually brought on by fever, shock, drugs, alcohol, or dehydration. 26) D) Bartholin’s gland abscess Bartholin’s glands are located in the base of the labia minora at about the 4 o’clock and 8 o’clock positions. Their function is to provide moisture for the vestibule. They are small (about pea sized) unless they become clogged or infected. If

glands become clogged or infected, an abscess may form and glands will enlarge and become painful. 27) B) Amenorrhea One common side effect seen in women who have been taking DepoProvera for more than 5 years is amenorrhea. It is a progesterone hormone that causes cessation of periods. 28) D) Stroking the inner thigh of a male client and watching the testicle on the ipsilateral side rise up toward the body The cremasteric reflex test is done by stroking the inner thigh of a male client and watching for the testicle on the ipsi- lateral side to rise up toward the body. 29) C) Serum folate acid and B12 level Serum folate acid and B12 levels would be ordered to evaluate him for folic acid deficiency anemia. Many patients who are deficient in folic acid are also deficient in B12. 30) D) Microaneurysms Microaneurysms are seen with diabetic retinopathy. AV nicking, copper wire arterioles, and flame hemorrhages are seen with uncontrolled hypertension. 31) B) T-score between –1. 0 and –2.5 Osteopenia is defined as a t-score between –1. 0 and – 2.5. Osteoporosis is defined as a t-score of less than –2.5. 32) C. Risk factors for AAA include smoking, hypertension, and periph- eral vascular disease. A bicuspid aortic valve is usually asymptomatic and does not place the patient at risk for aortic aneurysms. 33) B. When an AAA reaches 5.5 cm or greater, surgery usually is indi- cated because the risk of rupture is increased. For asymptomatic aneurysms smaller than 5 cm, the 5-year risk of rupture is less than 1% to 2%, so serial noninvasive monitoring is an alternative strategy. 34) D. The most common cause of a mass lesion of the brain in an HIV patient is toxoplasmosis, which is treated with sulfadiazine with pyrimethamine. 35) B. The serum acetaminophen level of 30 μg/mL, with last ingestion 8 hours previously, is plotted on the nomogram and falls below the “danger zone” of possible hepatic injury. Thus, this patient should be observed. Sometimes, patients will take more than one medica- tion so that serum and/or urine drug testing may be worthwhile. Gastrointestinal activated charcoal, not intravenous charcoal, is used for other ingestions. 36) E. Idiopathic or autoimmune hepatitis is a less-well-understood cause of hepatitis that seems to be caused by autoimmune cell- mediated damage to hepatocytes. A subgroup of these patients includes young women with positive ANAs and hypergammaglob- ulinemia who may have other symptoms and signs of systemic lupus erythematosus. 37) B. Hemochromatosis is a genetic disorder of iron metabolism. Progressive iron overload leads to organ destruction. Diabetes mellitus, cirrhosis of the liver, hypogonadotrophic hypogonadism, arthropa- thy, and cardiomyopathy are among the more common end-stage developments. Skin deposition of iron leads to “bronzing” of the skin, which could be mistaken for a tan. Diagnosis is made early in the course of disease by demonstrating elevated iron stores but can be made through liver biopsy with iron stains. Genetic testing is avail- able. Therapy involves phlebotomy to remove excess iron stores. 38) D. Sclerosing cholangitis is an autoimmune destruction of both the intrahepatic and extrahepatic bile ducts and often is associated with inflammatory bowel disease, most

commonly ulcerative colitis. Patients present with jaundice or symptoms of biliary obstruction; cholangiography reveals the characteristic beading of the bile ducts. 39) C. Primary biliary cirrhosis is thought to be an autoimmune disease leading to destruction of small- to medium-size bile ducts. Most patients are women between the ages of 35 and 60 years, who usually present with symptoms of pruritus and fatigue. An alkaline phos- phatase level elevated two to five times above the baseline in an oth- erwise asymptomatic patient should raise suspicion for the disease. No specific therapy is available. 40) A. Wilson disease is an inherited disorder of copper metabolism. The inability to excrete excess copper leads to deposition of the mineral in the liver, brain, and other organs. Patients can present with ful- minant hepatitis, acute nonfulminant hepatitis, or cirrhosis, or with bizarre behavioral changes as a result of neurologic damage. Kayser- Fleischer rings develop when copper is released from the liver and deposits in Descemet membrane of the cornea. 41) The correct answer is B, phlebotomy. PV is a disorder that causes overproduction of RBC’s. 42) The correct answer is D, Selenium sulfide. Pityriasis versicolor is caused by a yeast. 43) The correct answer is E, Rubeola. The symptoms are pathognomonic for Rubeola (Measles). 44) The correct answer is C. All others are seen in conductive hearing loss. 45) The correct answer is E. Right ventricular enlargement occurs because of an increase in pulmonary pressure. The RVH causes right axis deviation. 46) The correct answer is B, Atenolol. Beta blockers can mask signs of hypoglycemia (eg. Tachycardia) and should be used sparingly. 47) The correct answer is A. Mitral valve murmurs are best heard on left side at the apical impulse. 48) The correct answer is D. Bullous myringitis is the complication associated with Mycoplasma. 49) The correct answer is B. The symptoms must be present for a designated period of time. 50) The correct answer is C. The results of therapy is most accurately seen on spirometry. 51) The correct answer is B, Adenosine. It is first line in the treatment of paroxysmal supraventricular tachycardia. 52) The correct answer is D. You want to start warfarin, but cover with heparin until therapeutic levels of warfarin are reached. 53) The correct answer is A. The patients bradycardia is severe, probably a result of an inferior MI. Atropine is the agent of choice in this situation. Mobitz I heart block has a good prognosis (vs complete heart block), so transvenous pacing is not required. 54) The correct answer is A. Fistulas are common with Crohns disease because of its transmural nature, but are uncommon with ulcerative colitis. 55) The correct answer is B. Renal ultrasound is the next appropriate step to assess for hydronephrosis and to evaluate for bilateral ureteral obstructions, which are common sites of metastases of cervical cancer. Her physical examination and urine studies (showing a FE >

1%) are inconsistent with hypovolemia, so intravenous infusion is unlikely to improve her renal function. Use of loop diuretics may increase her urine output somewhat but does not help to diagnose the cause of her renal failure or to improve her outcome. Further imaging may be necessary after the ultrasound, but use of intravenous contrast at this point may actually worsen her renal failure. 56) C. This individual is suffering from heat exhaustion, which can lead to rhabdomyolysis and release of myoglobin. Myoglobinuria leads to a reddish appearance and positive urine dipstick reaction for blood, but microscopic analysis of the urine likely will demonstrate no red cells. 57) C. The antistreptolysin-O titers typically are elevated and serum complement levels are decreased in poststreptococcal GN. 58) D. Goodpasture (antiglomerular basement membrane) disease typically affects young males, who present with hemoptysis and hematuria. Antibody against type IV collagen, expressed in the pulmonary alveolar and glomerular basement membrane, leads to the pulmonary and renal manifestations. Hypertension typically is absent. After the initial clinical signs, renal insufficiency usually progresses rapidly. Anti-GBM antibodies almost always are present; the gold standard for diagnosis is renal biopsy. 59) The correct answer is B. The patients country of origin, the chronic and slowly progressive nature of the pain in association with the fever, and night sweats are highly suggestive of TB osteomyelitis of the spine or Potts disease. Bacterial osteomyelitis presents more acutely, often with high, spiking fevers. Metastatic breast cancer and MM are extremely rare in this age group. 60) The correct answer is C. Listeria monocytogenes is a gram-positive rod that causes appx 10% of all cases of meningitis. It is more common in the elderly and in patients with impaired cell-mediated immunity. It is also more common in neonates. It is NOT sensitive to cephalosporins, and specific therapy with ampicillin must be given.