UWORLD Flashcards
What is the first step in treating a patient who has hypovolemic hypernatremia?
Restore volume with ISOTONIC fluids (0.9% saline).
What test is needed to diagnose PHEOCHROMOCYTOMA?
Biochemical testing with either 24 hour urine for metanephrines and free catecholamines or plasma free metanephrines to diagnose pheochromocytoma.
What condition presents with difficulty with placental delivery resulting in cord avulsion and necessitates a manual extraction further complicated by placental adherence and severe hemorrhage?
Placenta Accreta – vili attach directly to myometrium instead of decidua.
What shoudl be done for a patient who is exposed to HBV and has a documented response to previous HBV vaccination?
Reassurance
What study involves 2 or more experimental interventions each with 2 or more variables that are studied independently?
Factorial Design
Development of atrioventricular block in a patient with infective endocarditis should raise suspicion for what?
Perivalvular abscess extending into the adjacent cardiac conduction tissues.
What is Metatarsus adductus type I and what is the type of management required?
A congenital foot abnormality characterized by adduction of anterior aspect of the foot with a convex lateral border and concave medial border. Type I overcorrects both passively and actively into abduction. These cases spontaneously correct themselves, no treatment necessary.
What are the symptoms of HOCM and what type of murmur is heard?
Symptoms: Syncope, dyspnea, chest pain.
Murmur: Mid Systolic , Crescendo-Decrescendo along left sternal border w/o carotid radiation.
Most patients with Paget’s disease of the breast have what type of underlying cancer?
Adenocardinoma
What type of reaction is AERD (Aspirin-exacerbated respiratory disease)
Pseudoallergic reaction to NSAIDS.
What is the antiobiotic of choice for prophylaxis and treatment of infections caused by a human bite/dog bite?
Amoxicillin-clavulanate (Augmentin)
Covers gram +/-, and anaerobes.
If a patient is in hypovolemic shock after having a major burn despite adequate initial fluid resuscitation, what do you suspect?
Sepsis due to burn wound infection.
What is the definition of adjustment disorder?
Development of emotional/behavioral symptoms in response to an identifiable stressor within 3 months of onset of the stressor.
What is the treatment for an elderly patient who presents with depressive symptoms as well as memory impairment?
SSRI – pseudodementia/reversible cognitive impairment treatment.
What is multiple system atrophy?
Degenerative disease characterized by:
- Parkinsonism
- Autonomic dysfunction (Postural hypotension, abnormal sweating, disturbance of bowel/bladder control, abnormal salivation/lacrimation, impotence, gastroparesis)
- Widespread neurological signs
Also known as Shy-Dager syndrome.
What is the treatment for Polymyalgia rheumatica?
Low-dose glucocorticoids. (10-20mg daily)
What is the most common cause of Amaurosis fugax?
Retinal emboli from ipsilateral carotid artery.
What kind of rash is seen in secondary syphilis?
Maculopapular rash that typically begins in the trunk and extends to the periphery including the palms and soles.
Often accompanied by generalized lymphadenopathy.
What should be the initial treatment in patient with AFIB and RVR.
Rate control w/ beta blockers or calcium channel blockers.
If hemodynamically unstable, perform immediate synchronized electrical cardioversion.
What is the diagnostic test of choice for Zenker’s diverticulum?
Contrast esophagram, unless the patient has severe trouble swallowing.
When should the oral glucose tolerance test be administered to pregnant patients?
24-28 weeks gestation.
What is a major distinction between glomerular and non glomerular hematuria?
Non glomerular hematuria is not typically accompanied with proteinuria.
A newborn who presents with Jaundice, acholic stools/dark urine, hepatomegaly conjugated hyperbilirubinemia and mild elevation in transaminases should be suspected to have what?
Biliary atresia
Define: a patient’s inability to recall important autobiographical information
Dissociative amnesia - onset typically sudden and preceded by overwhelming/ intolerable events.
What is the most likely cause of acute watery diarrhea with abdominal pain in a patient with extended omeprazole use, hospitalization, comorbid illness?
Clostridium difficile
A patient who presents with 6 months profound fatigue, 4 months fleeting joint pain in knees and elbows, itchy rash on legs 2 months ago. With elevated creatinine, low complement levels, and moderately elevated liver enzymes
Viral hepatitis serology.
A patient who has symptoms of CHF, paroxysmal nocturnal dyspnea, dyspnea on exertion, peripheral edema, hepatomegaly, cardiomegaly, bilateral pleural effusions and a third heart sound who is young and possibly had preceding viral-type symptoms, what is top on differential?
Coxsackie Virus.
What is often the cause of redness and blister development after the start of anticolagulation?
Warfarin-induced skin necrosis.
What is factitious disorder?
Intentional falsification or inducement of symptoms with goal to assume sick role.
What is the immediate treatment for a neonate with bilious emesis?
X-ray to evaluate the need for emergency surgery/ further diagnostic studies. Perform contrast studies in stable patients and determine the level of obstruction.
What is a sustained muscle contraction resulting in twisting, repetitive movements, or abnormal postures called?
Dystonia.
Torticollis = common form of focal dystonia involving sternocleidomastoid muscle.
What type of murmur is typically associated with IV drug abuse?
Tricuspid regurg - holosystolic murmur that gets louder with inspiration.
What are the symptoms of iron poisoning?
Iron poisoning disrupts basic cell processes, abdominal pain, hematemesis, shock, and metabolic acidosis.
Iron pills appear as radiopaque tablets seen in abdominal x-ray.
HIT can predispose patients to what conditions?
- Thrombocytopenia
2. Thrombogenic – arterial and venous clots.
What disease is associated with rapidly progressive dementia, myoclonus and sharp, triphasic synchronous discharges on EEG?
Creutzfeldt-Jakob disease – spongiform encephalopathy cauesd by a prion.
What CURB 65 score warrants hospital admission/ICU stay?
Hospital Admission 2+
ICU: 4+
CURB 65: Confusion, Uremia, Respirations > 30, BP 65
For patients admitted for Community acquired pneumonia, what is preferred treatment for hospitalized patients?
Spectrum fluoroquinolone
or
beta-lactam combined with macrolide.
What disease is characterized by follicular conjunctivitis and pannus (neovascularization) formation in the cornea. Often with concurrent infection in the naspharynx leading to nasal discharge?
Trachoma, caused by Chlamydia trachomatis serotype A-C.
What is the first step in managing a pediatric patient with acquired torticollis?
X-ray to evaluate underlying etiology.
Cervical spine radiographs needed to ensure no cervical spine fracture/dislocation.
Dubin Johnson Syndrome – describe characteristics
Predominately conjugated chronic hyperbilirubinemia, not associated with hemolysis.
Icterus evident, otherwise normal. Patients typically asymptomatic. Illness, pregnancy, OCP use can trigger icterus.
Liver strikingly black.
Conjugated hyperbilirubinemia w/ direct bilirubin fraction >50%, and otherwise normal LFT needs to be present.
What are the most common causes of secondary digital clubbing?
- Lung malignancies
- Cystic fibrosis
- R-L cardiac shunts
* *COPD w/ w/o hypoxemia does not cause digital clubbing.
What disease is often associated with nephrotic syndrome?
Increased risk for accelerated atherosclerosis due to alterations in lipid metabolism of those who have nephrotic syndrome.
Risk for complications such as stroke/MI
What is suspected when a patient has just been discharged from hospital with halluncinations and returns with fever, muscle rigidity, autonomic instability and mental status change? Possibly also elevated creatine kinase, leukocytosis, electrolyte abnromalities?
Neuroleptic Malignant Syndrome
In a patient who has massive hemoptysis, what is the initial procedure of choice after securing airway?
Bronchoscopy to localize the bleeding and possible therapeutic interventions.
What are the characteristics of Adhesive Capsulitis?
- Decreased passive and active range of motion
2. More stiffness than pain.
What is the mechanism of hemophilic arthropathy in those who have hemophilia?
Thought to be cause by iron/hemosiderin deposition leading to synovitis and fibrosis within the joint.
What is the most common predisposing factor for orbital celluitis?
Bacterial sinusitis
What are the typical hallmark ECG presentation of Ventricular aneurysm?
When do Ventricular Aneurysms occur?
- Persistent ST segment elevation after recent MI, deep Q waves in the same leads.
- Typically occur 5 days to 3 months post MI.
Post strep glomerulonephritis is seen how long after a strep throat/skin infection? What are the symptoms?
- 10-20 days after
- Periorbital swelling, hematuria, oliguria, may be hypertensive, urinalysis w/ hematuria w/ RBC casts and proteinuria. Serum C3 complement levels low.
What is the workup for patients w/ suspected secondary Raynaud’s Phenomenon?
- CBC and metabolic panel
- Urinalysis
- ANA and rheumatoid factor
- Erythrocyte sed rate and complement levels.
What is the necessary treatment for HIV patients who have a positive PPD test?
Prophylaxis w/ isoniazid and pyridoxine for 9 months.
What type of conjunctivitis in nenonates presents as copious exudates and eyelid swelling typically 2-5 days age?
Gonococcal conjunctivitis
What is the next step in management of a patient with primary infertility and history of PID?
Hysterosalpingogram.
A new mass on a chest x-ray in patients with hodgkin lymphoma previously treated with chemo and radiation is most likely indicative of what?
A secondary malignancy
What is the greatest risk factor for clear cell adenocarcinoma of the vagina and cervix?
In utero exposure to diethylstilbestrol
What is the next step of management for an immunecompetent individual who is exposed to chicken pox but does not have immunity?
Varicella Vaccine only.
Individuals who have sickle cell trait and have painless hematuria – what is the pathology?
Renal papillary necrosis
What is the most likely diagnosis when a well-appearing neonate has painless bloody stools?
Milk/soy protein proctocolitis.
What is the rash of eczema herpeticum?
Painful vesicles w/ erythematous base, “punched out” erosions and hemorrhagic crusting.
What is the immediate treatment of choice for patients with symptomatic moderate/severe hypercalcemia?
Intravenous saline hydration
What should be suspected in a male athlete who presents with gynecomastia and increased hematocrit?
Steroid use.
What is the most common cause of gross lower GI bleeding in adults?
Diverticulosis
What is the treatment of choice for cellulitis with systemic signs?
Intravenous nafcillin/cefazolin.
If a patient presents with sx of retroperitoneal hematoma s/p cardiac catherization with sudden onset of hypotension, tachy, flat neck veins and back pain what is the next best step after giving saline bolus?
Non contrast CT of abdomen and pelvis/ abdominal ultrasound to confirm diagnosis.
What is the next step in a patient suspected of having ehrlichiosis?
Doxycycline treatment emperically.
What should be suspected in a patient who has migratory arthritis as well as recent travel to northeastern/upper midwestern US?
Lyme arthritis - lyme disease
What treatment should be given to young patients suspected of having Parkinson’s disease, where tremor is the primary symptom?
Trihexyphenidyl/ anticholinergic medications
What is the treatment for a patient who comes into ED with Acute Decompensated heart failure?
- Supplemental oxygen
- Assisted ventilation as needed
- Agressive IV diuresis
- Vasodilator therapy
What type of bias occurs when patients are lost to follow-up in prospective studies?
Selection bias (attrition bias)
The patient with HTN and undetectable plasma renin activity most likely has what?
Primary hyperaldosteronism.
What is suspected when a patient presents with dyspnea, venous congestion, swelling of the head, neck and arms?
SVC syndrome, most often caused by malignancy. (particularly small cell lung cancer.
What should you think of in an older patient who presents with altered mental status, volume depletion, polyuria?
HHS - hyperosmolar hyperglycemic state
What is a leukemoid reaction and what is typically seen?
Marked increase in leukocytes due to severe infection/ inflammation, Increased leukocyte alkaline phosphatase score is typical for condition.
What is Sialadenosis?
Nontender enlargement of submandibular glands, found in patients with advanced liver disease. Also seen in patients with altered dietary patterns/ malnutrition.
A benign noninflammatory swelling of the salivary glands , associated with abnormal autonomic innervation of the glands.
What is the best immediate treatment for cold extremity/ frost bite?
Rapid re-warming with warm water
What should be suspected in ultrasonogram of abdomen that shows bilateral small kidneys, no evidence of hydronephrosis, kidney biopsy with intimal thickening and luminal narrowing of renal arterioles w/ evidence of sclerosis?
Hypertension
In a patient with non-African descent with suspicion of thalassemia, what is the most appropriate test for initial screening?
CBC, if there is anemia and reduced MCV then further testing required. If CBC is normal, no further testing required.
What is the most appropriate treatment for treating a hypertensive emergency in pregnancy?
- IV hydralazine/ labetalol and oral nifedipine
2. Magenesium sulfate to prevent seizures in pre-eclamptic patients.
When is bilateral gonadectomy recommended in phenotypic female with androgen insensitivity syndrome?
After completion of puberty to decrease risk of gonadal malignancy.
How does Wiskott-Aldrich syndrome cause immune dysfunction?
WAS has a defect in the WAS gene which is found in hematopoietic cells and regulates cytoskeleton changes during cell signalling. Actin cytoskeleton in white blood cells is impaired, results in immune dysfunction.
What is the next best step in treating a patient who presents with sudden onset headache, nausea, eye pain, and non reactive mid-dilated pupil s/p decongestant use?
Opthalmologic consultation, gold standard for diagnosis is gonioscopy, but ocular tonometry measures intraocular pressure and can provide additional information.
Patient is suspected to have acute angle-closure glaucoma.
What is the treatment for symptomatic hepatic encephalopathy/ uremic encephalopathy?
Dialysis
Matching populations in case-control studies is an efficient method to control what?
Confounding.
What is a distinguishing factor between herpangina caused by coxsackie virus vs. herpetic gingivostomatitis?
Herpangina is typically seen in summer/ early fall, with 1 mm gray vesicles on tonsillar pillars, fibrin coated ulcerations.
Posterior oropharyngeal vesicles/ ulcerations
Diagnosis: patient presents with inability to comb hair, fatigue, anxiety, tremor, weight loss, and tachycardia.
Hyperthyroidism
Hyperthyroidism can present with proximal muscle weakness and likely myopathy.
What intervention should be given in a patient who presents with symptoms of ischemic stroke within past 24 hours?
Aspirin
If patient already on aspirin, give aspirin and dipyridamole/clopidogrel.
What is the gold standard for diagnosing malrotation in a neonate?
Upper gastrointestinal contrast study.
Infants who have postprandial regurgitation but are otherwise asymptomatic should be treated how?
Reassurance. Frequent, small-volume feeds, hold infant upright for 20-30 mins after feeds. Place infant prone when awake.
Pt with abdominal pain, microcytic anemia, positive fecal occult blood and hepatomegaly.. most likely diagnosis.
GI malignancy metastatic to the liver.
Idiopathic Intracranial hypertension: After initial evaluation is complete with ocular examination and neurimaging to exclude secondary causes of intracranial hypertension, what should be done next?
Lumbar puncture (LP) to document elevated opening pressure. Papilledema is not a contraindication to LP unless evidence of obstructive/noncommunicating hydrocephalus or a space occupying lesion with/without mass effect or midline shift.
By what mechanism does tamsulosin help with ureteral spasm secondary to stone impaction?
Acts on distal ureter, lowers muscle tone and reduces reflex ureteral spasm.
What alternative therapy is an option for patients who refuse daily injections or have difficulty with dietary restrictions/ frequent INR monitoring?
Rivaroxaban
Cauda equina syndrome is due to a lesion where?
Spinal nerve roots.
Diagnosis/mechanism: Bone and joint pain, skeletal deformities and hearing loss
Paget’s disease – osteoclast hyperfunction
Diagnosis/mechanism: pallor, fatigue, weakness, loss of appetite, easy bruising, petechiae, mucosal hemorrhage, fever. Normocytic/macrocytic anemia, leukopenia, reticulocytopenia, and thrombocytopenia
Acquired aplastic anemia typically from bone marrow injury by radiation, drugs, insecticides, toxins, infections.
Diagnosis: watery diarrhea, tea colored/odorless stool, muscle weakness/cramps, hypo or achlorhydia, facial flushing, lethargy, nausea, vomiting, abdominal pain, weight loss.
VIPoma - rare tumor affecting pancreatic cells that produce VIP.
What is the response stage of psychiatric illness?
When patient demonstrates significant improvement (with/without remission) generally defined as 50% reduction in baseline level of severity.
By what mechanism can intravenous acyclovir cause increase in creatinine?
Acyclovir can cause crystalluria with renal tubular obstruction.
What is the first line treatment for chemotherapy induced nausea?
Serotonin (5HT) receptor antagonists (ondansetron), target 5HT3 receptor.
What are signs that favor lupus as origin of proteinuria vs. preeclampsia in a pregnant patient?
Rapid aggravation of proteinuria, associated clinical signs of active SLE, presence of RBC casts in urinalysis (indicates true nephritis rather than simple protein loss)
Patients who appear to have premature puberty and elevated LH levels should have what?
Brain MRI with contrast to rule out hypothalamic/ pituitary tumors.
What should be given as prophylaxis to individuals who are close contacts of patients infected with bordatella pertussis?
Prophylaxis is recommended for all close contacts despite vaccination status.
Give macrolides. Only azithromycin should be used in those
What type of murmurs warrant further work up and transthoracic Doppler echo in young healthy patients?
Diastolic, continuous murmurs, and loud systolic murmurs.
What are indications to receive prophylactic anti-D immune for an unsensitized Rh-negative pregnant patient?
- 28-32 weeks gestation
- w/in 72 hours of delivery
- ectopic pregnancy
- hydatidiform molar pregnancy
- chorionic villus sampling, amniocentesis
- abdominal trauma
- 2nd and 3rd trimester bleeding
- external cephalic version
Antepartum prophylaxis not needed if father known to be Rh negative.
What should be suspected in a patient with high risk TB who presents with cavitary lesion on CT imaging and likely a fungal ball?
Aspergillus – rapidly growing mold, causes invasive infection primarily in immunocompromised patients.
Meniere’s disease is most likely what type of ear disease?
Inner ear disease.
Diagnosis: young African American woman, painful shins, bilateral hilar adenopathy on x-ray
Sarcoidosis - chronic multisystem disorder due to noncaseating granulomatous inflammation deposited into various organs.
How can you distinguish acidosis due to hypoventilation vs. lactic acidosis?
Lactic acidosis will manifest as metabolic acidosis with decreased HCO3.
What are the gram negative anaerobes that are common constituents of normal human oral flora and can cause infective endocarditis?
HACEK organisms: Haemophilus aphrolphilus Aggregatibacter actinomycetemcomitans Cardiobacterium hominis E corrodens Kingella Kingae
When do alcohol withdrawal seizures typically occur?
12-48 hours after the last drink.
What is the presentation of cyanide toxicity?
Patients treated w/ nitroprusside who receive prolonged infusions, higher doses, or have underlying renal insufficiency. Patients present with altered mental status, lactic acidosis, seizures, and coma.
In a patient with upper airway cough syndrome, what role does H1 histamine receptor antagonists have if it relieves patient’s symptoms?
Elimination of nasal discharge and cough.
What is the management of a pregnant patient who presents with placenta implanted over internal cervical os?
Undergo cesarean delivery at 36-37 weeks.
This is contraindication to labor and vaginal delivery.
What should be suspected in patients who present with new weight loss, history of IV drug abuse, fatigue, anorexia, mild/borderline impairment?
HIV – patients with HIV are at risk of developing depression and dementia.
If a pregnant patient with severe preeclampsia suddenly presents with dyspnea, hypoxia and crackles, what is the most likely etiology?
Pulmonary edema – due to generalized arterial vasospasm that leads to increased systemic vascular resistance and high cardiac afterload.
Decreased renal function, decreased serum albumin and endothelial damage can also lead to increased capillary permeability.
What is the most common cause of sepsis in patients with sickle cell disease?
Strep pneumoniae – non vaccine serotypes.
Patients should receive prophylactic penicillin until age 5.
What is the pathophys by which constipation can cause cystitis in toddlers?
Constipation = fecal retention –> rectal distension –> compresses bladder and prevents complete voiding. Residual urine potential breeding ground for bacteria and ascend to urethra from perineum.
What is the treatment for a patient with severe PCP with PaO2 35 mmHg on room air?
TMP SMX with corticosteroids
What pregnant patients should be screened for syphillis?
All – at first prenatal visit.
Screen with RPR or VDRL test
What is the cause of low pleural fluid glucose (
Empyema or rheumatic effusion. Glucose concentration in empyema is decreased due to high metabolic activity of leukocytes/bacteria in the fluid.
What is the next best step in a patient who has hypogonadotropic hypogonadism with headaches, low testosterone levels, significant gynecomastia w/w/o galactorrhea and evidence of other pituitary hormonal deficiencies?
Measure prolactin levels.
What should be the first step in managing a patient who presents with progressive ascending paralysis
Meticulous search for a tick.
What kind of lung tumor would cause right arm pain?
Neoplasm in pulmonary apex at thoracic inlet can compress inferior portion of the brachial plexus and cause shoulder pain radiating in ulnar distribution.
What additional metabolic abnormalities can hypothyroidism cause?
Hyperlipidemia, hyponatremia, asymptomatic elevations of creatinine kinase and serum transaminases.
What is the first line treatment for a specific phobia (such as flying on planes)?
Behavioral therapy
What type of psychotherapy focuses on identifying and addressing persistent maladaptive thought patterns in order to change emotions and behaviors?
Cognitive-behavioral therapy.
This therapy is good on its own or in combination with pharmacotherapy.
What changes can occur to patients taking levothyroxine after initiating estrogen therapy and why?
Dose of levothyroxine may need to increase because oral estrogen decreases clearance of thyroxine-binding globulin which leads to elevated TBG levels which bind to the thyroxine.
What organism is most commonly responsible for bacterial rhinosinusitis?
- Strep Pneumo (~30%)
- H. influenzae (~30%)
- Moraxella Catarrhalis (~10%)
What is the pathogenesis of nonalcoholic fatty liver disease?
Associated with insulin resistance.
Most likely diagnosis: low grade fevers, exertional SOB, fintertip pain, urine dark and cloudy, proximal and distal interphalangeal joints swollen
Infective endocarditis
What are the signs and symptoms of Waldenstrom’s Macroglobulinemia?
Rare Chronic plasma cell neoplasm.
- Increased size of spleen, liver and lymph nodes
- tiredness, usually due to anemia
- tendency to bleed and bruise easily
- nightsweats
- headache/dizziness
- various visual problems
- Pain and numbness in the extremities due to a predominantly demyelinating sensorimotor neuropathy.
Why are patients with Graves’ disease the most likely to develop hypothyroidism after treatment with radioactive iodine?
Whole thyroid gland is hyperfunctional in Graves’ disease, radioiodine is taken up by the entire thyroid gland, thereby resulting in complete thyroid ablation.
What aspect of pleural fluid is most helpful in determining the need for chest tube placement in parapneumonic effusion?
pH – if pH is less than 7.2 , probability is very high that fluid needs to be drained. It is almost indicative of an empyema and indicates removal of the fluid by thoracostomy.
Glucose less than 60 mg/dL is also indication for tube thoracostomy.
What is commonly associated with dermatomyositis?
Internal malignancies – ovarian, lung, pancreatic, stomach, colorectal cancers and non-Hodgkin lymphoma.
What test should be administered to an adolescent who has sudden onset psychosis and also presents with arthralgia?
Antinuclear antibodies, to rule out SLE.
What is the most appropriate therapy for a post partyum polymicrobial endometrial infection?
IV clindamycin w/ IV gentamicin (or aminoglycoside)
What vaccines should be given to a patient with splenectomy?
Strep, N. Meningitidis and H. flu should be given at least 14 days before scheduled splenectomy or 14 days after splenectomy.
PCV13 should be given first and PPSV23 at least 8 weeks later.
What is seen on peripheral smear of patients with SCD?
Sickled red cells and Howell-Jolly bodies
What should be suspected in an HIV infected patient with focal neurological signs and multiple non-enhancing lesions with no mass effect on the CT scan?
Progressive multifocal leukoencephalopathy.
What treatment is recommended for a patient who has confirmed PE and decreased GFR
Unfractionated heparin preferred over LMWH, fondaparinux, and rivaroxaban. Reduced renal clearance increases anti-Xa activity levels and bleeding risks.
Most likely diagnosis: Patient presents with vomiting/retching, chest/upper abdominal pain, progression of odynophagia, dyspnea, and septic shock. Fever tachy, tachypnea, cyanosis, subcutaneous emphysema, pneumomediastinum, unilateral pleural effusion with/w/o pneumothorax.
Boerhaave Syndrome
What is the first step necessary in a patient who presents with possible septic arthritis?
Synovial fluid should be obtained urgently for cell count, gram stain and culture.
Diagnosis: pt presents with pain and swelling over inner aspect of eye for 2 days, exam of eye reveals tenderness, edema and redness over medial canthus. Expression of purulent material. visual acuity normal.
Dacryocystitis – infection of the lacrimal sac.
What condition is Intraventricular hemorrhage often seen with?
IVH commonly seen in premature and LBW infants. Patients may present with pallor, cyanosis, hypotension, seizures, focal neurologic signs, bulging/tense fontanel, apnea, and bradycardia. Many cases remain asymptomatic.
When is the meningococcal vaccination booster administered?
At age 16-21 if primary vaccination given before 16th birthday.
What are the immediate steps in treating a >1 month old who is suspected to have bacterial meningitis?
- Obtain Cerebrospinal fluid
- Administer empiric antibioitics.
**reserve head CT for comatose infants, those with focal neurological findings, history of neurosurgical procedure
What is the most likely cause of cerebral palsy?
Prenatal insults to brain development with premature birth before 32 weeks as the greatest risk factor.
What should you expect in a patient with pmh of chronic afib and chf who presents with diarrhea, nausea, and fatigue?
Possible digoxin toxicity.
What are the most common pathologies seen in patients who have analgesic nephropathy?
- Papillary necrosis
- Chronic tubulointerstitial nephritis.
Polyuria and sterile pyuria are early manifestations.
What are the characteristics of alcoholic hallucinosis?
Predominantly auditory hallucinations that occur either during or after a period of heavy alcohol use. Type of withdrawal syndrome that can develop 12-24 hours after the last drink and usually resolves 24-48 hours.
Not DT! sensorium in tact and vital signs are normal.
How does Zollinger Ellison syndrome lead to fat malabsorption?
Excess gastric acid in small intestine causes inactivatino of pancreatic enzymes and injury to mucosal brush border causing diarrhea and steatorrhea.
What is the treatment for patients with primary syphilis?
What about those allergic to original treatment?
- single dose of Intramuscular benzathine penicillin
2. doxycycline for 14 days.
Diagnosis: Cushing’s syndrome that does not response to high dose dexamethasone suppression test?
Ectopic ACTH syndrome.
What is the pathology of a diabetic patient having blurred eyesight status post upper respiratory infection?
Hyperosmolar hyperglycemic state without ketoacidosis, Blurred vision can be caused by the hyperglycemic hyperosmolarity which causes myopic increase in lens thickness.
Etiology of: elderly woman with hyponatremia and poor skin turgor?
Hyponatremia due to Hypovolemia which causes increase in activity of renin-angiotensin-aldosterone and sympathetic nervous systems, stimulates antidiuretic hormone release from pituitary.
What are the typical ABG levels found in a patient who has post op atelectasis?
Hypoxemia
Hypocapnia
Respiratory Alkalosis
What is the most likely cause of anemia in a patient with NSAID and aspirin use?
Iron deficiency anemia.
What is the treatment for a post partum patient with low grade fever and leukocytosis during the first 24 hours?
Reassurance if foul smelling lochia is not noted.
What is the pathophysiological mechanism of isolated systolic hypertension in elderly patients?
Decreased elasticity of the arterial wall.
What is found on renal biopsy in children who have Henoch-Schonlein purpura?
Deposition of IgA in the mesangium.
What is the next appropriate step in a 1 month old who presents with a III/VI harsh holosystolic murmur?
Echocardiography to determine location and size of the defect and to rule out other defects.
Idinavir is a protease inhibitor with what well known side effect?
Crystal induced nephropathy.
Most likely diagnosis:
Fever, hypotension, erythema, swelling, pain out of proportion to physical exam findings, air in the deep tissue.
Necrotizing fasciitis.
Most likely diagnosis: spherocytes without central pallor, negative family history, positive Coombs test
AIHA - autoimmune hemolytic anemia
hereditary spherocytosis typically has positive family history and negative coombs test.
Most likely diagnosis: euvolemic hyponatremia, decreased serum osmolarity (
SIADH
What is the measurement in a case-control study that compares exposure of people with the disease to the exposure of people without the disease
Exposure odds ratio
What is the treatment of choice for a patient with malignant necrotizing otitis externa?
Anti-pseudomonal antibiotic – intravenous ciprofloxacin.
In fluoroquinolone resistant P aeruginosa, use penicillins/cephalosporins.
What is the most appropriate therapy for severely deprssed geriatric patients who are not eating, drinking, psychotic and actively suicidal?
Electroconvulsive therapy – good for major depression refractory to antidepressants.
Great when quick response is needed.
Diagnosis: patient falls on outstretched hands, have severe shoulder pain and edema and then positive drop arm test.
Rotator cuff tear.
Supraspinatus is most commonly injured
What is the most appropriate treatment for a patient with left heart failure including SOB, tachypnea, and hypoxemia?
IV diuretics.
What percentage of Hemoglobin S do patients with sickle cell disease have vs sickle cell trait?
SCD: 85-95%
SCT: 35-45%
What is the first line treatment for a patient with OA?
Acetaminophen
Diagnosis: female phenotype, normal ovaries, abnormal vagina, absent uterus precluding menstruation
Mullerian agenesis: failure of mullerian ductal system to differentiate to uterus, cervix, and upper vagina.
What step next: Patient with development dysplasia of the hip concern prior to 6 months, negative orlow and bartoloni
Ultrasound of the hip
post 4-6 months: hip x-ray.
What is the most important next step after diagnosis if Guillain-Barre syndrome is suspected?
Assess patient pulmonary function by serial spirometry.
Most likely cause of fever, chills, hemoglobinuria, flank pain and discomfort at infusion site, and disseminated intravascular coagulation within an hour after transfusion started
Acute hemolytic transfusion reaction due to ABO incompatibility.
What is the first line treatment therapy for patients w/ HTN and renal artery stenosis
ACE or ARBs.
Lupus antiocoagulant does what to PTT?
It is an anti-phospholipid antibody and is pro-thrombotic immunoglobulin that spuriously prolongs partial thromboplastin time in vitro.
What should be thought of when a neonates hypoxia fails to improve with inhaled oxygen?
Congenital heart defect – keep PDA open!
What type of murmur is heard with an aortic dissection?
Diastolic decrescendo murmur.
What is the first step in treating a patient suspected of having acute aortic dissection?
TEE - transesophageal echocardiogram and CT scan of chest with contrast for rapid diagnosis.
Most likely diagnosis: patient with progressive peripheral edema, ascites, elevated JVP, pericardial knock and pericardial calcifications on chest radiograph
Constrictive pericarditis
What cause of restrictive cardiomyopathy can be reversed?
Hemochromatosis.
What is the definition of schizophreniform disorder?
Symptoms must last between 1-6 months.
What is the most likely cause of symmetric fetal growth restriction when mother is asymptomatic?
Early maternal viral infection. Cytomegalovirus typically does not display symptoms for mom.
What is the best next step in treatment of a patient who shows acute rejection of transplant?
IV steroids
What is the first line treatment for adolescents who have acute abnormal uterine bleeding and present with moderate to severe bleeding?
High dose estrogen is first line treatment.
Don’t forget to evaluate for pregnancy and bleeding disorders.
What is seen on neuroimaging of patients with Alzheimer’s dementia?
Atrophy, may be more prominent in the temporal and parietal lobes.
Describe the symptoms of Lateral medullary infarct (Wallenberg syndrome).
- Loss of pain and temperature over ipsilateral face and contralateral body
- ipsilateral bulbar muscle weakness
- vestibulocerebellar impairment
- Horner’s syndrome
What is the cause of renal failure in a patient who has multiple myeloma?
Obstruction of distal and collecting tubules by large laminated casts containing paraproteins (Bence Jones protein) = paraproteinemia
What is the cornerstone of therapy for renal stone disease?
Hydration. Restriction of dietary oxalate is helpful when a patient presents with a history of recurrent calcium stone formation.
What is the next best step in young patients who have symptomatic hypertension with headaches, epistaxis and evidence of left ventricular hypertrophy on ecg?
Evaluate for presence of coarctation of the aorta. Supine bilateral arm and prone right and left leg blood pressures to measure for differential pressures.
What is the primary treatment for prolactinomas?
Dopamine agonists bromocriptine or cabergoline.
What is the best mode of diagnosis for Meckel’s diverticulum?
Technetium-99m pertechnetate scanning
Most likely diagnosis: headache (worse at night), nausea/ vomiting, mental status changes. May also have neurologic symptoms (vision changes, unsteady gait) and seizure. Symptoms can worsen with maneuvers that further increase intracranial pressure.
Intracranial hypertension (ICH)
What is the most common cause of isolated proteinuria in children and what should be done about it?
Transient proteinuria – reevaluate with repeat urine dipstick testing on two separate occasions to rule out persistent proteinuria.
What is the cause of the findings of osteomalacia?
Due to defective mineralization of the organic bone matrix
When should vaccinations for medically stable preterm infants be administered?
Determined by chronologic age not gestational age.
What are the initial screening tests for suspected AI?
simultaneous basal early morning cortisol, ACTH, and cosyntropin test.
Cosyntropin is an ACTH synthetic analogue used primarily for diagnostic purposes. An increase in serum cortisol levels 30-60 mins after administering 250ug cosyntropin virtually rules out primary AI.
What is the drug regimen of choice for immunocompromised patients with suspected bacterial meningitis?
- Vancomycin
- Ampicillin
- Cefepime.
define which bias: investigator’s decision is adversely affected by knowledge of the exposure status
Observer bias.
Most likely cause of patient with hypercalcemia (>13mg/dL) PTH levels suppressed.
Hypercalcemia of malignancy.
What should be done when a child presents with hemarthrosis following minor trauma?
Workup for bleeding disorder – CBC and coagulation studies.
What ear condition is most common in patients with acquired immunodeficiency syndrome?
Serous otitis media – presence of middle ear effusion w/o signs of an active infection. commonly reveals a dull tympanic membrane that is hypomobile on pneumatic otoscopy.
What is a complication of untreated pseudotumor cerebri?
Blindness
What is the most sensitive and rapid test to detect disseminated histplasmosis in immunocompromised patients?
Histoplasma antigen immunoassay of serum/urine.
What is the preferred antifungal treatment for histoplasmosis?
Itraconazole
What is the treatment for kleptomania?
Mainstay treatment is psychotherapy w/ limited evidence of medication.
What nerve is most likely to be damaged after forceful abduction and external rotation at glenohumeral joint?
Axillary nerve/ artery injury due to anterior shoulder dislocation.
What are the recommendations for treatment for a patient who has bipolar disorder and has experienced 2 episodes or more?
Recommend maintenance treatment for many years, if not lifetime.
3+ relapses = lifetime maintenance treatment.
What is the recommended treatment acutely for stroke in a sickle cell patient?
Exchange transfusion recommended – helps decrease the percentage of sickle cells and prevent a second infarct from occurring.
What is the first step in treating a patient with cardiogenic shock due to RVMI?
IV fluid bolus to increase RV preload and maintain cardiac output.
Survivors of sexual assault are at highest risk for what?
PTSD, Depression, suicidality.
What is the most likely cause of marroon colored stools in a patient who has recently had a normal colonoscopy?
Angiodysplasia
In gluconeogenesis, what is alanine converted to?
Pyruvate
What is the intervention for patients who have a duodenal hematoma with epigastric pain and vomiting?
Nasogastric suction and parenteral nutrition.
What is injured in Klumpke palsy and what are the manifestations?
Injury to 8th cervical and 1st thoracic nerves results in hand paralysis and ipsilateral Horner syndrome.
Diagnosis: preoccupation with body dhsape and recurrent eating binges followed by fasting and excessive exercise.
Bulimia nervosa - must occur at least once a week for 3 months for diagnosis.
Diagnosis: patient has repetitive semi-purposeful movements/automatisms with impairment of consciousness.
Focal seizures
Diagnosis: pt s/p prolonged surgery characterized by hypotension, extensive blood loss into tissues and massive blood replacement develops jaundice on post op day 2 with elevated alk phos, ast, alt?
Postoperative cholestasis.
What is the difference between Mobitz type I and Mobitz type II?
Mobitz type I has progressively elongating PR interval leading to non-conducted P wave and “dropped” QRS. Mobitz type II = constant PR and QRS drops suddenly.
Diagnosis: Pt with GERD for 12 years, now difficulty swallowing solids but not liquids. Barium swallow shows area of symmetric circumferential narrowing affecting distal esopagus
Esophageal stricture.
Esophageal adenocardinoma typically appears in patients with GERD > 20 years. Barium swallow generally shows asymmetric narrowing of esophageal lumen.
What is a confounder?
an extraneous factor which has properties linking it with the exposure and outcome of interest
Renal Vein thrombosis is most commonly seen in which nephrotic syndrome?
Membranous glomerulopathy.
How does thyrotoxicosis cause systolic htn?
Caused by hyperdynamic circulation resulting from increased myocardial contractility and heart rate.
What test can be used to confirm the diagnosis of CLL?
Flow cytometry – can prove clonality of the abnormal lymphocytes and generally used to confirm diagnosis.
Most likely diagnosis: unconjugated hyperbilirubinemia, dehydration in first week of life, inadequate stooling.
Breast feeding failure jaundice.
What is the best treatment for breastfeeding failure jaundice in otherwise healthy full-term newborns?
Increase frequency and duration of feeds.
Neonates should breastfeed 8-12 times a day every 2-3 hours for >10-20 minutes per breast.
What is the main mechanism responsible for pain relief in patients with anginal pain treated with nitroglycerin?
Dilation of veins (capacitance vessels) and decrease in ventricular preload.
What is first line pharmacological treatment for generalized social anxiety disorder?
SSRI’s such as paroxetine.
What is the treatment for a laboring patient with placental abruption at term if woman and fetus are stable?
Vaginal delivery
What is the best screening test for a patient who presents with hypertension and hypokalemia?
Early morning plasma aldosterone concentration to plasma renin activity (PRA)
How does immersion in cold water help with paroxysmal supraventricular tachycardia?
It increases vagal tone and decreases conduction through the AV node. This slows heart rate and can break rhythm of PSVT.
What is the USPSTF recommendation for screening mammograms?
every 2 years for women age 50-74. Routine mammography not necessary beyond age 75.
Most likely diagnosis: recurrent abrupt onset of characteristic physical symptoms that resolve within minutes. Symptoms are frequently cardiorespiratory
Panic disorder.
Mechanism by which maternal diabetes leads to polycythemia in newborn.
Maternal diabetes = high insulin in fetus –> fetus in constant anabolism and placenta cannot meet metabolic demands –> fetal hypoxemia –> compensation by increasing hematocrit.
What is the mechanism by which neonates born to women with Graves’ disease develop thyrotoxicosis?
Passage of maternal TSH receptor antibodies across the placenta.
What medications are commonly used in treatment of acute bipolar depression?
Second generation antipsychotics like quetiapine and lurasidone
Anticonvulsants lamotrigine.
Diagnosis in a man who fell on knee and has medial knee pain with focal tenderness?
Pes anserinus pain syndrome (PAPS)
What is the distinction between case control and retrospective cohort studies?
Case control: determine outcome first then look for associated risk factors
Retrospective cohort: ascertain risk factor exposure and determine the outcome.
What patients will show abnormalities in absorption of D-xylose?
Patients with small intestinal mucosal disease.
Patients with malabsorption due to enzyme deficiencies will have normal absorption of D-xylose.
What cancer is the most common source of liver metastatses?
Colorectal cancer.
What is most likely deficient in a 3-4 month patient who presents with hypoglycemia, lactic acidosis, hyperuricemia, and hyperlipidemia? With doll-like face, thin extremities, short stature, protuberant abdomen?
Glucose 6 phosphatase deficiency – Type I glycogen storage disease (Von-Gierke’s disease)
What is the first line pharmacotherapy for monosymptomatic enuresis?
Desmopressin
What is the treatment for patients with prolonged QT intervals?
Beta blockers and pacemakers – avoid electrolyte derangements and medications that block K+ channels.
What test is used to diagnose alpha-1 antitrypsin deficiency?
Serum alpha-1 antitrypsin level.
What is the next step in a patient with expected endometriosis that does not improve with NSAIDS or OCPs?
Laparoscopy with visualization and biopsy of implants is the only way to diagnose endometriosis.
Patients with endometriosis are at increased risk for what?
Infertility due to chronic inflammation and adhesion formation.
What is the most common cause of endocarditis in a patient who has frequent nosocomial UTI?
Enterococci.
Why are aldosterone levels normal in central Adrenal insufficiency?
Aldosterone levels are primarily regulated by renin-angiotensin-aldosterone system.
What is the treatment for patients who have sustained monomorphic ventricular tachycardia?
Hemodynamically unstable/pulseless/severely symptomatic: cardioversion
Stable: amiodarone.
What is the treatment of cat scratch disease in those who are immunocompetent?
5 days of azithromycin.
What condition is characterized by a markedly decreased quantity of bile ducts?
Primary biliary cirrhosis.
Most likely diagnosis: Pt with anterior knee pain, tenderness, erythema, and localized swelling with occupation requiring repetitive kneeling
Prepatellar bursitis due to Staph Aureus
What is the most common cause of B12 deficiency in whites of northern European background?
Pernicious anemia
What is the first line treatment for localized tinea corporis?
topical Clotrimazole/terbinafine
Most likely diagnosis: young african american woman with fatigue, painless oral ulcers, non deforming arthritis, renal abnormalities and cytopenias.
SLE
How long does it take for SSRIs to have beneficial effect noticed?
~4-6 weeks.As long as patient is tolerating medication without significant side effects, continue until this time.
What is hyposthenuria and what population is it often found in?
Impairment of kidney’s ability to concentrate urine. Found in sickle cell patients. Thought to result from red blood cell sickling in vasa rectae of the inner medulla.
What levels of GGT and ferritin would we expected to see in a patient with alcoholic liver disease?
Increased levels of both.
GGT is enzyme present in liver
Ferritin is an acute phase reactant.
What medications are used as prophylaxis to prevent variceal hemorrhage and progression of small varices to large?
Nonselective beta blockers.
What changes should a woman who is planning to get pregnant do to her levothyroxine dose?
Increase levothyroxine as soon as pregnancy is detected.
What is the next best step in treatment of a burn victim who comes in with an indicator of thermal ihalation injury to the upper airway/ smoke inhalation injury to the lungs?
Endotracheal intubation.
Remember in Trauma: ABC
What is the target of CML therapy?
Tyrosine Kinase
What is the change in leukocyte alkaline phosphate activity in CML?
There are low levels – this is how we can differentiate CML from polycythemia vera and other causes of myeloproliferation.
What is the most common side effect of tamoxifen?
Hot flashes
How can you differentiate Measles from Rubella?
Measles tends to be more severe than rubella, high fevers up to 104F, coryza, and malaise. Rash also spreads more gradually and appears darker.
What mechanism does does clopidogrel act by?
P2y12 receptor blocker
Prescribe along with aspirin for dual antiplatelet therapy post MI.
Most likely diagnosis: Fungal infection endemic to central US, mild pulmonary illness, heaped-up skin lesions with a violaceous hue and sharply demarcated border. Wet prep of skin lesions shows yeast.
Blastomycosis
What antibodies are most likely present in Systemic sclerosis?
Antinuclear autoantibodies (ANA)
Anti-topoisomerase-I antibodies.
When is endometrial biopsy warrented for abnormal uterine bleeding? (4)
- Women > 45 and all post menopausal women
2. Women
Patients with RA are at increased risk for what?
- osteopenia
- osteoporosis
- bone fractures.
What is the diagnostic test for a patient who appears to have breath holding spells?
CBC - to evaluate for iron deficiency anemia which could contribute to breath holding spells.
Treatment is supportive and condition usually stops by age 5.
What is the most likely cause of breathing difficulty in a patient who previously presents with difficulty breathing, food intolerances and skin allergies?
Laryngeal edema – due to precipitating event usually accompanied with food allergies and urticaria.
What is the recommendation for women who present at 20 weeks with placenta previa?
Pelvic rest and abstinence from intercourse.
What is a common cause of constrictive pericarditis in developing countries such as Africa/India/China?
Tuberculosis
What antipsychotic can cause hypothermia and by what mechanism?
Fluphenazine – inhibits the body’s shivering mechanism / inhibits autonomic thermoregulation.
What is Albuterol’s role in treating hyperkalemia?
It is a beta-2 agonist that shifts potassium intracellularly.
What is the most common cause of congenital hypothyroidism?
Thyroid dysgenesis.
What is the most common cause of unilateral cervical adenitis in children and what is the treatment?
Staph aureus/ Strep Pyogenes, Treat with incision and drainage and clindamycin.
What is the next step in treating a patient who has elevated serum alk phos indicative of cholestasis?
Evaluate with RUQ ultra sound to assess for intrahepatic/extrahepatic causes of biliary obstruction.
What is the treatment of choice for Dermatitis herpetiformis?
Dapsone
What are the most common underlying causes of cirrhosis in the US?
- Chronic alcohol abuse
2. Viral hepatitis
What is another name for eczema?
Atopic dermatitis
What should you suspect in an HIV patient who presents with cutaneous lesion of large pedunculated exophytic papule with a collarette of scale resembling large pyogenic granuloma or cherry angimoa.
Bacillary angiomatosis due to Bartonella hensalae or Bartonella quintana
What is the most important initial step in the management of HHS? (hyperosmolar hyperglycemic state)?
Fluid replacement with normal saline.
Rheumatoid arthritis predisposes to what disease with kidney involvement?
Amyloidosis – renal involvement is characterized by nephrotic syndrome.
What is the most likely cause of a patient recently in the woods presenting with an erythematous rash w/ occasional vesicles that grow coag negative staph?
Contact dermatitis due to poison sumac, super imposed w/ S. Epidermidis
This is a type IV hypersensitivity reaction.
Hematuria at the end of voiding (terminal hematuria) often suggests what pathology?
Prostatic/bladder cause
What neuroimaging is typically found with schizophrenia?
Enlargement of lateral cerebral ventricles
What is the best therapeutic option for a patient with single brain metastasis from nsclc in surgically accessible location and good performance status?
Surgical resection.
What is next best step in a patient treated with high doses of beta-2 agonists who then presents with tremor, palpitations, muscle weakness, arrhythmias, and headache?
Check electrolyte panel – possible potassium decrease.
What should be done in all patients who undergo central venous catheterization?
Chest x-ray to confirm proper placement of the catheter tip and absence of complications before administering drugs/ agents through the catheter.
What lab finding is specific for CNS lymphoma in HIV patients?
Presence of EBV DNA in CSF.
MRI reveals weakly ring-enhancing mass usually solitary and periventricular.
What is the next step in a patient with amenorrhea for >6 months who has a negative pregnancy test and no other symptoms?
Check prolactin, TSH, and FSH levels.
Patients diagnosed with Infectious Mononucleosis are at risk for what?
Autoimmune hemolytic anemia and thrombocytopenia due to cross reactivity of EBV induced antibodies against red blood cells and platelets. These are IgM cold agglutinin antibodies.
What current guidelines are recommended prior to starting lithium therapy?
Obtaining urinalysis, blood urea nitrogen, creatinine, thyroid function tests.
What is the initial workup of an adnexal mass in post menopausal women?
Transvaginal ultrasound
Serum cancer Antigen CA-125 level.
By what mechanism does taking first generation antihistamines cause urinary retention?
First generation H1 have potent anticholinergic effects and may cause urinary retention in men who have underlying BPH.
What is the appropriate treatment for a pt who would like to get pregnant but presents with premature ovarian failure?
In Vitro fertilization
What is the most likely cause of urinary tract infection in patients with alkaline urine (pH >7)?
Proteus mirabilis – secretes urease to alkalinize the urine, leads to formatino of struvite stones.
What is the most likely cause of hypercalcemia in a patient with breast cancer?
production of PTHrP - typically produced locally by tumor metastasis into bone. Not directly by primary tumor.
What is expected to happen to a woman’s creatinine and BUN as pregnancy furthers along?
They are both set to decrease due to the increase in renal plasma flow and GFR.
What is the presentation of caustic poisoning?
No alteration in consciousness.
Presents w/ dysphagia, severe pain, heavy salivation and mouth burns.
What is the most appropriate management of moderate hyperkalemia without significant ECG abnormalities?
Loop Diuretic
What should be suspected in patients who have a combination of hemolytic anemia, cytopenias and hypercoagulable state?
Paroxysmal nocturnal hemoglobinuria.
What is the next step in management when a urethral injury is suspected clinically?
Urethra should be assessed with a retrograde urethrogram prior to insertion of a Foley catheter.
What is the most common primary bone tumor affecting children and young adults?
Osteosarcoma
If a patient presents with galactorrhea and no palpable lump or skin changes, what is next step?
Serum prolactin, TSH , and pregnancy test.
Pituitary imaging in patients with elevated prolactin or suspicious clinical findings.
What are the causes of exudative pleural effusions?
Infection (pneumonia, TB), malignancy, Pulmonary embolism, connective tissue disease and iatrogenic causes.
How is vasovagal syncope diagnosed?
Usually a clinical diagnosis but may be diagnosed using upright tilt table testing.
What is the best initial treatment for patient who is acutely suffering from a migraine headache with nausea and vomiting??
Prochlorperazine or other intravenous antiemetics.
What is the mechanism of cutaneous flushing and pruritis after being given high-dose niacin therapy?
Prostaglandin-induced peripheral vasodilatation.
Can be reduced by low-dose aspirin.
What should be suspected in a 6 month old patient with hepatosplenomegaly, protuberant abdomen, hyporeflexia/areflexia and cherry red macula on opthalmologic exam?
Niemann Pick disease.
What is the first step in addressing a patient who has a new thyroid nodule?
Obtain TSH levels and an ultrasound of the nodule.
Most likely diagnosis: glucocorticoid deficiency, hypogonadism, and hypothyroidism.
Hypopituitarism
Hypopituitarism is not associated with hypoaldosteronism because aldosterone is primarily dependent on the renin-angiotensin system.
What antibiotic should be used in a pregnant woman with asymptomatic bacteriuria?
Amoxicillin, nitrofurantoin and cephalexin are first line antibiotics.
Tetracyclines, fluoroquinolones and TMP-SMX are contraindicated.
What is the earliest renal abnormality present in patients with DM?
Glomerular hyperfiltration.
What treatment should be given to patients with a history of rheumatic fever?
Should receive continuous antibioitic prophylaxis to prevent recurrent group A Streptococcus pharyngitis and limit the progression of rheumatic heart disease.
What can happen to a patient who is on chronic digoxin therapy and then suddenly has amiodarone added to regimen?
Can cause toxicity in a patient and presents with GI symptoms – anorexia, nausea, vomiting, abdominal pain.
What is the first test that should be administered to a patient suspected of having C.diff infection?
C difficile toxin.
What is the underlying cause of Goodpasture’s disease?
Formation of antibodies to the alpha 3 chain of type IV collagen. Expressed strongly in glomerular and alveolar basement membranes.
What type of mutations are most severe?
Nonsense/ frameshift mutations
What is the CSF composition of Guillain Barre?
High protein concentration with normal WBC, RBC and glucose.
What is the basic workup of investigating hypertension? (4)
- Urinalysis
- Chemistry Panel
- Lipid profile
- Baseline ECG.
What is the role of the knee-chest position during a hypercyanotic spell in Tetralogy of Fallot?
Increases systemic vascular resistance, increases pulmonary blood flow and improves symptoms of cyanosis.
How can the diagnosis of laryngomalacia be made in a patient who has chronic “noisy breathing”
Laryngoscopy.
What is the most common cause of abnormal hemostasis in patients with CRF?
Platelet dysfunction – multifactorial reason.
The presence of bilirubin in the urine is indicative of what?
buildup of conjugated bilirubin
What is routine therapy for suppression of PVCs in frequent symptomatic patients?
Beta blockers or CCBs as first line therapy.
Most likely diagnosis: Acute renal failure, fever, rash, recent hx of para-aminobenzoic acid analogue/antibioitic ingestion and WBC on urinalysis
Allergic interstitial nephritis/ acute interstitial nephritis.
Headache, focal neurologic deficit and ring enhancing intracranial lesions on contrast CT in immunocompetent patient w/ adjacent bacterial infection most likely due to what?
Brain abscess due to Viridians streptococci.
MLD: solitary liver mass
Metastatic disease.
MLD: increased dryness in skin that worsens in winter, sometimes referred to as “lizard skin”
Ichthyosis vulgaris.
What is the acid base disturbance most likely in primary adrenal insufficiency.
Normal anion gap and hyperkalemic, hyponatremic metabolic acidosis
What type of research study measures exposure and outcome simultaneously at a particular point of time?
Cross-sectional study.
What medication should be used as initial treatment for bipolar disorder in patients with renal dysfunction?
Valproic Acid – lithium should not be administered.
Normal or increased FEV1/FVC ratio with low VC is seen in what type of lung disease?
Restrictive lung disease.
MLD: fevers, chills, LUQ pain, splenic fluid collection along with left sided pleuritic chest pain
Splenic abscess caused by infective endocarditis.
What is best way to confirm diagnosis of chronic pancreatitis?
CT scan or plain film.
At what CHADSVASC score should patients be given warfarin/target-specific oral anticoagulants?
> /= 2
How do you calculate attributable risk percent? (ARP)?
ARP = (Risk in exposed - risk in unexposed)/ risk in exposed = ( RR - 1)/ RR
Where is the lesion in Broca’s aphasia?
Dominant frontal lobe lesions.
At what Apgar score do neonates not require intervention?
7-9
What is the treatment for patients with WPW who present with AFIB and are stable?
Procainamide if vagal maneuvers and adenosine fail.
What is the first step in treating a patient suspected of having DKA who is stuporous, rapid breathing and hx of weight loss, polydipsia and polyuria?
Fingerstick glucose.
MLD: 34 yo female vague chest discomfort w/ mass see in middle mediastinum on CT scan?
Bronchogenic cyst.
What mitral valve abnormality is seen in hypertrophic cardiomyopathy?
Systolic anterior motion of the mitral valve. An abnormality in the motion of the mitral valve leaflets.
MLD: pt with elevated glucose, htn, weight gain. May also see hypokalemia.
Hypercortisolism (Cushing Syndrome)
MLD: pt w/ telangiectasia, hemoptysis, R-L shunt physiology resulting in finger clubbing and elevated hematocrit.
Hereditary telangiectasia (Osler-Weber-Rendu syndrome)
What is the most common cause of pneumonia in nursing home residents?
Streptococcus pneumoniae.
Vaccination w/ Pneumovax can help prevent this condition.
What is the most likely reason for acute pancreatitis resulting in complicated hypotension?
Intravascular volume loss secondary to local and systemic vascular endothelial injury.
What is the first step in treatment of a hypothermic man who presents with prolonged QT interval at 560msec and bradycardia 31/min?
Active rewarming – typically cardiac issues will reverse after being adequately warmed.
MLD: midline tenderness palpation or percussion of lumbar spine, reflexes normal, babinski’s reflex down going, muscle strength 5/5.
vertebral compression fracture – lumbosacral strain does not result in tenderness to palpation of the spine.
What medication is the most common cause of acquired angioedema?
Ace Inhibitors.
What is the timeframe athletes must abstain from sports after a mono infection?
at least 3 weeks until all symptoms resolve.
Optimization of glycemic control in DM is associated with a reduction in what risk?
Microvascular complications – nephropathy and retinopathy.
What is the most common cause of brain metastasis?
Lung cancer
What is the best next step in treating a patient who presents with suspected infective endocarditis?
Obtain blood cultures from separate venipuncture sites prior to initiating antibiotic therapy.
What is the cause of Membranoproliferative glomeruloneprhitis type 2?
Caused by persistent activation of the alternative complement pathway.
Which antihypertensive medication has the highest reported incidence of peripheral edema within 6 months of therapy?
Calcium channel blockers.
ACE Inhibitors can cause angioedema in appx .1%-.7% of patients.
MLD: pt in labor with previous C-section, w/ sudden intense abdominal pain. Presenting fetal part retracts.
Uterine rupture.
What is Behcet syndrome?
Recurrent painful oral and genital aphthous ulcers, uveitis and erythema nodosum.
What is the test to confirm diagnosis of Aortic dissection?
Transesophageal echocardiogram.
What is the most common extraarticular manifestation of Ankylosing spondylitis?
Anterior uveitis
What two electrolyte abnormalities are often seen in Cushing’s syndrome?
Hypokalemia and hypernatremia – typically due to excessive cortisol binding to aldosterone receptors in the kidney.
Which neoplasm should we be concerned about in a patient who presents with hypercalcemia and a hilar mass?
Squamous cell carcinoma – most probable lung cancer and produces PTHrP.
Define salvage therapy.
Form of treatment for a disease when a standard treatment fails.
What is the pH of transudative pleural effusion?
~7.4-7.55
What should be given to a patient who is suspected of having ethylene glycol poisoning?
Fomepizole or ethanol to inhibit alcohol dehydrogenase.
Sodium bicarb to alleviate acidosis
Hemodialysis in severe cases/ end organ damage.
Patient in labor at 28 weeks with fetus who has bilateral renal agenesis, what is the treatment?
Allow spontaneous vaginal delivery – labor should be allowed to proceed in patients where the fetus has been diagnosed with a severe congenital anomaly incompatible with life.
MLD: 66 yo M w/ 4 week hx increasing backpain and severe constipation, urinating excessively. Medications = acetaminophen and metoprolol.
Multiple Myeloma
What is the most common cause of steatorrhea?
Chronic pancreatitis due to alcohol use.
In what other conditions can pulsus paradoxus be seen besides cardiac tamponade?
Severe asthma/ COPD
What is the treatment for a patient who presents with 2 previous first trimester miscarriages, a positive VDRL, negative FTA-ABS test?
Begin LMWH while waiting for results of Antiphospholipid antibody syndrome, can cause false positive VDRL in women.
MLD: new DM, necrolytic migratory erythema, weight loss, diarrhea, and anemia.
Glucagonoma.
MLD: Patient recent travel to Mexico presents with abdominal pain, nausea, vomiting and diarrhea. Within a few weeks then presents with Myositis, Fever, Eosinophilia, Periorbital edema, Splinter hemorrhages
Trichinellosis
Patients who are victims of smoke inhalation injury should be treated empirically for what?
Cyanide toxicity with hydroxocobalamin or sodium thiosulfate.
What test should be performed on a patient who presents with chronic cough, already on omeprazole and symptoms not improving with antihistamine therapy?
PFTs to test asthma.
What is the likely cause of stroke symptoms in children who have a history of trauma to the soft palate with a foreign body?
Internal carotid artery dissection
What should be on the differential diagnosis of a solitary, painful, lytic long bone lesion with overlying swelling and hypercalcemia in a child?
Langerhans cell histiocytosis and other neoplastic processes.
What is the first step in management of a newborn with respiratory compromise and suspected congenital diaphragmatic hernia?
Endotracheal intubation
Bag and mask ventilation can exacerbate respiratory decline.
What test should be ordered in a patient who is suspected of having SLE?
ANA test – it is the most sensitive for SLE.
If this is positive, confirmatory tests (Anti-dsDNA and anti-Smith) can be performed.
MLD: acute, severely ill patient with abnormal thyroid function tests. Mainly low T3 and total levels.
Euthyroid sick syndrome , “low T3 syndrome”
What is the most appropriate diagnostic test for acute hepatitis B infection?
HBsAg and anti-HBc
What is the most common predisposing factor for acute bacterial sinusitis?
Viral upper respiratory infection.
What is the most common cause of esophagitis in an HIV patient who has severe odynophagia (pain with swallowing) without dysphagia (diffculty swallowing)?
Viral esophagitis.
MLD: 18 yo female recent nasal packing presents with fever, myalgias, marked hypotension and diffuse erythematous macular rash.
Toxic shock syndrome due to Staph Aureus
What are causes of spinal stenosis?
Degenerative arthritis (spondylosis), degenerative disk disease, thickening of the ligamentum flavum.
MLD: post operative patient who suddenly passes out with hypotension and evidence of right heart strain (JVD and RBBB)
Massive Pulmonary Embolism
Molluscum contagiosum being widespread is associated with what?
Impaired cellular immunity – puts pt at risk for more severe widespread disease.
What immunization should be given to a patient who has a clean/minor wound and has received > 3 tetanus toxoid vaccines but has not received a booster in the past 10 years?
Vaccine only, no TIG needed.
TIG only needed in unimmunized/uncertain in severe/dirty wound.
What is the first step in treating a patient who presents with hepatic encephalopathy, hypokalemia and is very aggitated?
Titrate the potassium - Hypokalemia increases renal ammonia production.
MLD: pt presents with headache, bilateral periorbital edema and CN deficits s/p insect bite on cheek.
Cavernous sinus thrombosis.
What is the immediate treatment necessary for a patient who presents with STEMI?
Full dose aspirin and immediate Primary percutaneous coronary intervention within 90 minutes.
Must be within 12 hours of symptom onset.
What should be considered in a patient who presents with elevated liver enzymes, DM, and skin hyperpigmentation?
Hereditary Hemochromatosis.
What is the first priority in a patient who presents with epiglottitis: sudden respiratory distress, dysphagia and drooling and inspiratory stridor?
Secure patient’s airway with endotracheal intubation in the operating room.
Corticosteroids and Nebulized racemic epinephrine can provide relief in a patient with CROUP. this is seen with steeple sign rather than thumprint sign.
What type of thought pattern happens when pt provides unnecessarily detailed answers that deviate from the topic of conversation but remain vaguely related and eventually returns to the original subject?
Circumstantiality.
What is the pathology of anemia of lymphoproliferative disorders?
Due to bone marrow infiltration with cancerous cells.
What is the gold standard for diagnosis of Duchenne muscular dystrophy?
Genetic testing – will show deletion of dystrophin gene on Xp21
MLD: 51 yo man comes in with complaint of several weeks difficulty walking. X ray reveals loss of cartilage, osteophyte development and loose bodies.
Charcot joint - neurogenic arthropathy due to diabetes.
What are the two ways oxygenation can be improved with a patient who is on ventilation?
- Increasing FiO2 (goal is to keep below 40% at all times)
2. Add Positive end-expiratory Pressure - to prevent alveolar collapse
What condition is characterized by precocious puberty, cafe au lait spots and multiple bone defects?
McCune Albright syndrome
This is associated with Cushing’s syndrome and patient can present with moonlike facies.
What is the most likely causative organism of a sudden onset sharply-demarcated, erythematous, edematous, tender skin lesion with raised borders in a febrile patient?
Erysipelas from group A beta hemolytic streptococcus.
What should be suspected in a woman in labor who has painless bleeding and previously had a second trimester ultrasound with placenta previa that resolved by the third trimestor?
Vasa previa
What is the next step in a patient who presents with Trousseau’s syndrome – migratory superficial thrombophlebitis at unusual sites?
A CT of the abdomen to rule out occult visceral malignancy.
MLD: dome-shaped, firm, freely movable cyst or nodule with a small central punctum. Lesion can remain stable or gradually increase in size but usually resolves spontaneously
Epidermal inclusion cyst.
What is the first treatment in a young girl who presents with vaginal foreign body?
Attempt removal with calcium alginate swab or irrigation with warmed fluid.
What diagnostic study is indicated in a patient who presents with oropharyngeal dysphagia (difficulty initiating swallowing)?
Videofluoroscopic modified barium swallow.
What is the most reliable tool for confirming the diagnosis of IUFD?
ultrasonography
B-hCG levels may continue to be elevated due to ongoing placental production of hormone.
What should be done after an episode of IUFD?
Autopsy of fetus and placenta
What is the treatment for uncomplicated acute bacterial rhinosinusitis?
Treat with oral amoxicillin-clavulanic acid.
MLD: 30 yo patient presents with occasional palpitations and decrescendo diastolic murmur best heard at left sternal border while patient is sitting up, leaning forward and holding breath in full expiration?
Aortic Regurgitation due to bicuspid aortic valve.
MLD: young female presents with polyarticular systemic arthritis of acute onset and short duration w/ low grade fever. Resolves in less than two months
Arthritis due to viral infection.
MLD: 34 week gestation woman presents with intense, intolerable generalized pruritis that is significant in palms and soles and worsens at night. Total bile acids are increased. Liver functions may show alk phos elevated, bili elevated, AST/ALT elevated.
Intrahepatic cholestasis of pregnancy – bile formation that develops in 2nd/3rd trimesters. Etiology is unclear.
What is suspected in a chest CT that shows wedge-shaped infarction?
Pulmonary embolism.
What happens to the tactile fremitus on exam of a patient who has a pleural effusion?
Decreased tactile fremitus
What is the next step in treatment of a man who presents with symptoms of Acute bacterial prostatitis?
Midstream urine culture to help direct antibiotic therapy.
MLD: Pt w/ episodic pounding sensation, chronic diarrhea, weight loss, valvular heart disease w/ tricuspid regurgitation.
Carcinoid syndrome.
How do the RDW and RBC count differ in IDA vs. Thalassmeia?
IDA: RDW is increased, RBC is decreased.
Thalassemia: both are normal.
MLD: thrombocytopenia, hemolytic anemia, renal failure and signs of AMS. What is next best step for diagnosis confirmation?
TTP - obtain blood smear.
How does ABG differ in COPD vs. CHF?
ABG in COPD will show respiratory acidosis and hypoxia.
What is the next step when a child presents with fingerstick blood specimen with elevated lead level?
Venous blood level of lead must be drawn to confirm abnormal values.
What is the main risk factor associated with AAA expansion and rupture?
Current Cigarette smoking
What is the diagnosis and where is the infarction of a patient who presents with bulbar dysfunction, contralateral facial weakness and contralateral limb weakness?
Dysarthria-clumsy hand syndrome due to basis pontine infarction.
What is the most effective treatment for the pain due to Uremic pericarditis?
Dialysis.
What occurs to calcium in the setting of respiratory alkalosis.
More calcium will bind to Albumin due to the open binding spots after hydrogen ions unbind from albumin due to the respiratory alkalosis.
Patients with a single episode of major depression and respond to acute treatment of SSRI should continue antidepressant treatment for how long?
4-9 months – continuation phase of treatment. Dose should be maintaned at the level that achieved remission and not reduced.
What is the most sensitive lab value for orthostatic hypotension?
BUN/ Serum creatinine ratio. Increases with increasing severity of hypovolemia.
Second to weight loss, what lifestyle modification will have the greatest effect on treating hypertension?
DASH diet – high in fruit and vegetables and low in saturated fat and total fat.
What is the most likely toxicity in using hydroxychloroquine for SLE?
Retinal toxicity.
MLD: elderly female 65 yo, presents with extreme fatigue and no other symptoms. Lymphadenopathy and splenomegaly are seen and dramatic lymphocytosis with predominance of mature lymphocytes seen.
Chronic lymphocytic leukemia.
What is recommended in a patient who presents with acute pulmonary edema w/ decompensated congestive heart failure or bradycardia in the setting of MI?
Diuretics – beta blockers should be avoided in patients with decompensated congestive heart failure or bradycardia.
What is the initial management of comedonal (noninflammatory) acne without a significant inflammatory component?
Topical retinoids with added organic acid preparations if intial therapy fails.
MLD: 54 yo male SOB, dullness to percussion over the right lower lobe, breath sounds are louder especially during expiration over right lung base compared to left lung base. Heart exam normal, no murmur, moderate peripheral edema.
Consolidation of the lung.
What are the four contraindications to administering the rotavirus vaccine?
- Anaphylaxis to vaccine ingredients
- History of intussusception
- History of uncorrected congenital malformation of GI tract
- SCID.
What is the pathophysiology of hypothyroidism stimulating galactorrhea?
Hypothyroidism leads to increased TRH which stimulates prolactin production.
Which is more associated with osteoporosis: excess alcohol use, vegetarian diet?
Excess alcohol use – alcohol consuption causes a dose-dependent increase in the risk of osteoporotic fractures.
MLD: HCV patient presents with palpable purpura, proteinuria and hematuria
Mixed cryoglobulinemia.
What is the initial management of a patient who presents within 4 hours of acetaminophen toxic ingestion?
Gastric Decontamination with activated charcoal and obtain acetaminophen levels.
What finding is seen in sickle cell patients who are suffering from aplastic crisis?
Low or absent reticulocytes (
What is the strongest predictor of stent thrombosis after intracoronary stent implantation?
Premature discontinuation of antiplatelet therapy.
What is the pathophysiology of hereditary angioedema?
Deficiency or dysfunction in C1 inhibitor, results in elevated levels of edema producing factors, C2b and bradykinin
What are leiomyomata uteri?
Uterine fibroids
Where is the primary hormonal source for an obese child that displays with premature adrenarche (pubic hair, axillary hair, acne, and body odor)?
Adrenal glands.
What is the effect of Acetaminophen and NSAIDS on the metabolism of warfarin.
Potentiates the effect of warfarin by decreasing metabolism due to inhibition of CYP450 enzymes in liver.
How many signs and symptoms do patients need to diagnosed with Kawasaki disease.
4 of the 5: Conjunctivitis, oral mucosal changes, rash, extremity changes, cervical lymphadenopathy.
How do you calculate the risk of obtaining a disease?
Divide number of exposed diseased patients/ total number of exposed people.
What is the appropriate next step in management of a patient who presents with multiple painful subcutaneous nodules on anterior surface of lower legs and high susceptibility to sarcoidosis?
Chest x-ray.
How does thyroid axis change during pregnancy? (Total T4, Free T4, TSH)?
Increased T4/T3 concentrations
Slight increase in T4 (due to increase in thyroxine binding globulin)
Decreased TSH levels.
What first step should be done in a patient who presents with swollen painful calf that has likely probability of having DVT?
Compression US.
What is the cause of a varicocele?
Tortuous dilation of the pampiniform plexus of veins.
What is the underlying cause of Fanconi Anemia?
Chromosomal breaks
What are the next steps following a normal contraction stress test?
Antepartum fetal testing may be repeated 1 week later.
How is urinary retention due to epidural anesthesia treated?
Short term indwelling catherization
What is the most common malignancy diagnosed in patients exposed to asbestos?
Bronchogenic carcinoma
What is recommended for all patients who have probable benign prostatic hyperplasia based on history and rectal examination?
Urinalysis
What is the arrhythmia most specific for digitalis toxicity?
Atrial tachycardia with AV block
What electrolyte abnormality can be caused by TMP-SMX and by what mechanism?
Hyperkalemia – blockate of epithelial sodium channel in the collecting tubule.
Intention tremor is associated with what type of brain dysfunction?
Cerebellar dysfunction
What are the symptoms of ischemic hepatopathy?
Rapid/massive increase in the transaminases with modest accompanying elevations in total bilirubin and alk phos.
What is the pathophys of patients with Crohn disease being predsposed to nephrolithiasis?
Predisposed to hyperoxaluria due to fat malabsorption. Calcium is preferentially bound by fat and leaves oxalate unbound and free to be absorbed into the blood stream.
What is the defense mechanism that involves transforming unacceptable feelings and impulses into their extreme opposites?
Reaction formation
What should be suspected in a person of Northern European ancestry who presents with hemolytic anemia, jaundice and splenomegaly?
Hereditary Spherocytosis
What should be done in patients who present with isolated thrombocytopenia?
Test for HEP C/ HIV, as thrombocytopenia may be the initial presentation of HIV infection.
What anti malarial should be prescribed to people traveling to Sub Saharan Africa, Amazon basin, Southern and Southeast Asia?
Mefloquine, atovaquone-proguanil and doxy are recommended due to chloroquine resistant plasmodium falciparum
What type of heart sound is heard with acute aortic dissection?
Early decrescendo diastolic murmur heard best along the left sternal border at the third and fourth intercostal space with the patient sitting up, leaning forward and holding breath after full expiration.
Patients with classic cesarean delivery or extensive myomectomy require what upon arrival to hospital?
Urgent laparotomy follwoed by hysterotomy for delivery or uterine repair.
If a patient does not have congestive heart failure, what is the best way to evaluate pleural effusion?
Evaluate with thoracentesis.
Common in travelers in tropical regions, characterized by pruritic, elevated, serpiginous lesions of skin. Infection acquired through contact with sand.
Cutaneous larva migrans.
What is an important cause of hypocalcemia in alcoholics?
Hypomagnesemia.
What is the definition of malignant hypertension?
Presence of severe hypertension (>180/120 mmHg) associated with retinal hemorrhages, exudates, and/or papilledema.
What is a common complication associated with Bronchiectasis?
Hemoptysis
What is the pathophysiology of osteomalacia?
Defective mineralization of the organic bone matrix.
What is the gold standard for evaluating the cervix for possible cervical incompetence?
Transvaginal ultrasound.
What is the diagnosis and treatment of a young man who presents with nongonococcal urethritis, asymmetric oligoarthritis and conjunctivitis, mouth ulcers, enthesitis and low back pain?
Reactive arthritis , treatment is NSAIDS.
What is the most likely cause of death of an infant with meningococcemia who presents with sudden vasomotor collapse and skin rash?
Adrenal hemorrhage – Waterhouse Friderichsen syndrome.
The pronator drift is sensitive and specific for what condition?
Upper motor neuron disease.
What is the treatment of a stye/hordeolum?
Treated with warm compresses, Incision and drainage is performed if resolution does not begin in the next 48 hours.
What results in fever, eye pain and inflammation and preauricular lymphadenopathy, followed by the development of painful corneal opacities. Highly contagious and often occurs in outbreaks?
Epidemic keratoconjunctivitis
MLD: post op patient presents with “salmon colored” peritoneal fluid soaking dressing.
Wound dehiscence
What is the most likely muscle damaged in a patient who has undergone an endoscopic thoracic sympathectomy for hyperhidrosis and presents with partial ptosis?
Superior tarsal muscle
Levator palpebrae results in full ptosis
What is a hallmark finding in Toxic shock syndrome?
Desquamation of the palms.
What is the appropriate immediate treatment for a patient who presents with acute angle closure if an ophtamologist is not available?
Provide eye dropsand systemic medications to lower intraocular pressure.
Timolol maleate, apraclonidine and pilocarpine drops can be administered about a minute apart.
