5 y/o boy one testicles undescended. What is the most appropriate management?
A- Orchidectomy
B- Orchidopexy
C- Wait till puberty
Abdulrahman: This is also a controversial topic as to do either orchidectomy or orchidopexy. Some references have the cut-off at 2 years of age due to the high-risk of finding an atrophic testicle and risk of oligospermia, azoospermia, torsion, or even malignancy. Orchidopexy decreases the risk of torsion and blunt trauma to testicle. Based on this, I would go with B, unless the testicle is atrophied. Dr. Thawab also agrees with this answer:
A- Orchidectomy
B- Orchidopexy
C- Wait till puberty
Abdulrahman: This is also a controversial topic as to do either orchidectomy or orchidopexy. Some references have the cut-off at 2 years of age due to the high-risk of finding an atrophic testicle and risk of oligospermia, azoospermia, torsion, or even malignancy. Orchidopexy decreases the risk of torsion and blunt trauma to testicle. Based on this, I would go with B, unless the testicle is atrophied. Dr. Thawab also agrees with this answer:
Case of rheumatoid arthritis compliance on Methotrexate, improved and stable for years without attack, the LFT abnormal, what will you do?
A- Stop MTX
B- Adalimumab
Abdulrahman: The patient is stable for years but is having elevated LFT levels. Methotrexate has been known to cause hepatotoxicity as compared to adalimumab. The answer depends on the LFT levels. According to UTD:
- If the patient is 3-5 or more the upper normal limit, hold MTX and repeat the LFT after 2 weeks. If still high, look for other causes. If the LFTs are decreasing, reduce the dose of MTX.
- If the patient LFT high but 2x or less of the upper normal level, continue the dose and repeat after 2 weeks. if still high, reduce the dose.
A- Stop MTX
B- Adalimumab
Abdulrahman: The patient is stable for years but is having elevated LFT levels. Methotrexate has been known to cause hepatotoxicity as compared to adalimumab. The answer depends on the LFT levels. According to UTD:
- If the patient is 3-5 or more the upper normal limit, hold MTX and repeat the LFT after 2 weeks. If still high, look for other causes. If the LFTs are decreasing, reduce the dose of MTX.
- If the patient LFT high but 2x or less of the upper normal level, continue the dose and repeat after 2 weeks. if still high, reduce the dose.
A 43 year old male while awaiting in the waiting room in clinic felt drowsy and was found hypoglycemic. What would you do in this scenario?
A- Grape Fruit Juice
B- 5% Dextrose Intravenous
C- Normal Saline
D- Intravenous Glucagon
Abdulrahman: The answer is most likely D. Since he is in the hospital, you must give something quickly to replenish his blood sugar level. Grapefruit has a low-glycemic index and may not raise the sugar enough as compared to other types of juices or sugary drinks. 5% dextrose IV is used for maintenance (not to correct the hypoglycemia acutely). Normal saline will not do anything. IM and IV glucagon injection are an emergency choice when patients have passed out or cannot take some form of sugar by mouth.
A- Grape Fruit Juice
B- 5% Dextrose Intravenous
C- Normal Saline
D- Intravenous Glucagon
Abdulrahman: The answer is most likely D. Since he is in the hospital, you must give something quickly to replenish his blood sugar level. Grapefruit has a low-glycemic index and may not raise the sugar enough as compared to other types of juices or sugary drinks. 5% dextrose IV is used for maintenance (not to correct the hypoglycemia acutely). Normal saline will not do anything. IM and IV glucagon injection are an emergency choice when patients have passed out or cannot take some form of sugar by mouth.
A 28 year old primigravidae patient delivered her baby and developed produced bleeding requiring 1L of crystelloid, 4 units of blood transfusion and despite all medical measures patient remained hypotensive and Hb 7.5g/dL and PLT 60. What will you administer in this case?
A- Platelets
B- Cryoprecipitate
Abdulrahman: The answer is B. The patient is bleeding profusely despite the resuscitative measure of giving 1L of crystalloid and 4 units of blood. Platelets will take time to work. Give cryoprecipitate, since it is very fast to fix the profuse bleeding. Cryoprecipitate is obtained from frozen plasma and contains more factor VIII and fibrinogen than FFP.
A- Platelets
B- Cryoprecipitate
Abdulrahman: The answer is B. The patient is bleeding profusely despite the resuscitative measure of giving 1L of crystalloid and 4 units of blood. Platelets will take time to work. Give cryoprecipitate, since it is very fast to fix the profuse bleeding. Cryoprecipitate is obtained from frozen plasma and contains more factor VIII and fibrinogen than FFP.
A 1 year old boy was brought to clinic and Hb was 10.5g/dL and mother started ferrous sulphate drops and after 3 months was assessed and his Hb was 10.3g/dL. The mother decided to continue giving the patient ferrous sulphate drops and despite this measure the hemoglobin level is still low. A CBC was requested and showed Low Hb and Low MCV. What additional tests would you require?
A- Serum Iron and Ferritin Level
B- Serum Hb Electrophoresis
C- Bone Marrow Aspiration
D- Serum Folate and Vitamin B12 Level
Abdulrahman: The answer is B (Approved by Om-Alqura) . This is a case of suspicious thalassemia. Let’s break down this question.
- The patient has Low hgb, low mcv (excludes choice D) and has not responded to iron treatment (excludes choice A).
- Bone marrow aspiration is definitely not the next test to do in this case.
A- Serum Iron and Ferritin Level
B- Serum Hb Electrophoresis
C- Bone Marrow Aspiration
D- Serum Folate and Vitamin B12 Level
Abdulrahman: The answer is B (Approved by Om-Alqura) . This is a case of suspicious thalassemia. Let’s break down this question.
- The patient has Low hgb, low mcv (excludes choice D) and has not responded to iron treatment (excludes choice A).
- Bone marrow aspiration is definitely not the next test to do in this case.
56 y/o woman presents to the clinic with a non-healing ulcer over her right lateral malleolus, she is hypertensive but not diabetic. Her pulse examination is normal and her local exam shows dark discoloration of the skin around the ulcer and a viable ulcer bed. Which of the following is the most appropriate next step?
A- CT angio
B- venous duplex US
C- arterial doppler US
D- conventional angio
Abdulrahman: The answer is B. Even though the location suggests that this an arterial ulcer, I think this is a case of venous ulcer because of the dark discoloration around the ulcer and the viable bed. I think this is a bad recall.
A- CT angio
B- venous duplex US
C- arterial doppler US
D- conventional angio
Abdulrahman: The answer is B. Even though the location suggests that this an arterial ulcer, I think this is a case of venous ulcer because of the dark discoloration around the ulcer and the viable bed. I think this is a bad recall.
elderly patient presented with appendicitis managed conservatively and discharged after 7 days. on imaging there is appendiceal mass with no collection. What is the best management?
A- no further intervention
B- open appendectomy after 12 W (colonoscopy is better)
C- lap appendectomy after 12 weeks
Full recall: 58 year old man with appendicitis was treated conservatively with antibiotics. He now presents with an appendiceal mass with no collection l. How will you manage this case ?
A. interval laparoscopic appendectomy after 12 weeks
B. interval open appendectomy after 12 weeks
C. no further intervention
D. Colonoscopy after 6 weeks
Abdulrahman: The answer is colonoscopy after 6 weeks. The patient is elderly and the appendiceal mass could be a metastatic tumor from the colon.
A- no further intervention
B- open appendectomy after 12 W (colonoscopy is better)
C- lap appendectomy after 12 weeks
Full recall: 58 year old man with appendicitis was treated conservatively with antibiotics. He now presents with an appendiceal mass with no collection l. How will you manage this case ?
A. interval laparoscopic appendectomy after 12 weeks
B. interval open appendectomy after 12 weeks
C. no further intervention
D. Colonoscopy after 6 weeks
Abdulrahman: The answer is colonoscopy after 6 weeks. The patient is elderly and the appendiceal mass could be a metastatic tumor from the colon.
A patient with recent rectal surgery comes to you with absent pulses up to the femoral area. How will you manage such a case?
A- enoxaparin
B- heparin
C- warfarin
D- IVC filter
Abdulrahman: This was one of the most controversial questions we’ve encountered in our year, and we still don’t have an answer to it. All the references that we’ve checked and the consultants that we’ve asked have mixed answers between A and D….
A- enoxaparin
B- heparin
C- warfarin
D- IVC filter
Abdulrahman: This was one of the most controversial questions we’ve encountered in our year, and we still don’t have an answer to it. All the references that we’ve checked and the consultants that we’ve asked have mixed answers between A and D….
New mom bring her her (2month) boy to neonatal well-being clinc, mother noticed the baby had inter-meal spitting of milk he is cow milk formula Abdominal examination normal
Growth parmeter normal. Next appropriate mangment:
A- Pyloric ultrasound
B- Reassuring and educate about reflexes
C- Change formula
Abdulrahman: The answer is B. This is a case of Gastroesophageal reflux (GER), it is normal up to 1 year of age. The formula is not an issue in this case. Most infant formula is made with cow's milk that's been altered to resemble breast milk (nutritious and easier to digest)
Growth parmeter normal. Next appropriate mangment:
A- Pyloric ultrasound
B- Reassuring and educate about reflexes
C- Change formula
Abdulrahman: The answer is B. This is a case of Gastroesophageal reflux (GER), it is normal up to 1 year of age. The formula is not an issue in this case. Most infant formula is made with cow's milk that's been altered to resemble breast milk (nutritious and easier to digest)
Pt known to have Hepatitis b and chronic liver disease found to have liver nodule on ultrasound and CT was done Showed 6 cm HCC with high vascularity with normal Portal vein and no invasion! He is well now with controlled ascites with medication. His labs
Albumin: 3.1
Blirubin : very high 40 normal was up to 2
INR:1.5
His ALT and AST were within normal
What is the most appropriate next step in management :
A- surgical resection
B- radiotherapy
C- trascatheter arterial embolization
Abdulrahman: The answer is C. This patient’s Child-pugh is 7 (class B), so he cannot undergo resection, and does not have mets (no need for chemotherapy). This is honestly an advanced question since treatment of HCC is complex and is best managed by a multidisciplinary liver transplant team.
Albumin: 3.1
Blirubin : very high 40 normal was up to 2
INR:1.5
His ALT and AST were within normal
What is the most appropriate next step in management :
A- surgical resection
B- radiotherapy
C- trascatheter arterial embolization
Abdulrahman: The answer is C. This patient’s Child-pugh is 7 (class B), so he cannot undergo resection, and does not have mets (no need for chemotherapy). This is honestly an advanced question since treatment of HCC is complex and is best managed by a multidisciplinary liver transplant team.
Scenario chid with bloody diarrhea doctor prescribed ( i remember say consultant) acetaminophen and probiotic Child not improved , now present ill with convulsion and petechic rash on extremities Labrotary ( low HB , low plateat, decrease potassium )
A- heamolytic ureamic syndrome
B- idiopathic thrombothytopenic purpura
C-thrombotic thrombocytopenia purpura
D- not remember
Abdulrahman: The answer is A.
- HUS is more common in children
- Bloody diarrhea is more common with HUS.
- Thrombocytopenia and seizures are present in both TTP and HUS.
Neurological involvement in the acute phase of HUS occurs in 17–52% of children; the most common acute problem is generalised or partial seizure activity in more than half of those with neurological signs.
A- heamolytic ureamic syndrome
B- idiopathic thrombothytopenic purpura
C-thrombotic thrombocytopenia purpura
D- not remember
Abdulrahman: The answer is A.
- HUS is more common in children
- Bloody diarrhea is more common with HUS.
- Thrombocytopenia and seizures are present in both TTP and HUS.
Neurological involvement in the acute phase of HUS occurs in 17–52% of children; the most common acute problem is generalised or partial seizure activity in more than half of those with neurological signs.
Patient with 2x2 peri rectal abscess / collection not sure. She is asymptomatic what is Tx?
A- Conservative
B- I&D
C- Open drainage
Abdulrahman: The answer is B. The primary treatment of anorectal abscess is surgical drainage. Once diagnosed, all perianal and perirectal abscesses should be drained promptly; lack of fluctuance should not be a reason to delay treatment. Any undrained anorectal abscess can continue to expand into adjacent spaces as well as progress to generalized systemic infection.
A- Conservative
B- I&D
C- Open drainage
Abdulrahman: The answer is B. The primary treatment of anorectal abscess is surgical drainage. Once diagnosed, all perianal and perirectal abscesses should be drained promptly; lack of fluctuance should not be a reason to delay treatment. Any undrained anorectal abscess can continue to expand into adjacent spaces as well as progress to generalized systemic infection.
Female patient presented with signs and symptoms of SBO and mass irreducible medial to pupic tubercle. What is your provisional diagnosis?
A-inguinal hernia
B -femoral hernia
C-obturator hernia
D-incisional hernia
Abdulrahman: The answer is A. The location is above and medial to the pubic tubercle. Femoral hernias are inferior to the inguinal ligament, lateral to the pubic tubercle , and medial to the femoral vein.
A-inguinal hernia
B -femoral hernia
C-obturator hernia
D-incisional hernia
Abdulrahman: The answer is A. The location is above and medial to the pubic tubercle. Femoral hernias are inferior to the inguinal ligament, lateral to the pubic tubercle , and medial to the femoral vein.
Scenario about Perforated duodenal ulcer ( not mention diagnose ) and ask about how to manage?
A- Graham ometal patch
Abdulrahman: Answer A is correct. Schwartz: The options for surgical treatment of perforated duodenal ulcer are simple patch closure (graham omental patch), patch closure and HSV, or patch closure and V + D. Simple patch closure, currently the most commonly performed operation for perforated peptic ulcer, should be done in patients with hemodynamic instability and/ or exudative peritonitis signifying a perforation >24 hours old. I don’t think they will make you choose between the types of patches or the addition of HSV and V + D. Here is a table from Schwartz:
A- Graham ometal patch
Abdulrahman: Answer A is correct. Schwartz: The options for surgical treatment of perforated duodenal ulcer are simple patch closure (graham omental patch), patch closure and HSV, or patch closure and V + D. Simple patch closure, currently the most commonly performed operation for perforated peptic ulcer, should be done in patients with hemodynamic instability and/ or exudative peritonitis signifying a perforation >24 hours old. I don’t think they will make you choose between the types of patches or the addition of HSV and V + D. Here is a table from Schwartz:
The dose of insulin & NS to give for patient with dka?
A- 2l normal saline and insulin 0.1unit
Abdulrahman: Answer A is correct. The patient should receive 2 liters of NS with 0.1 units/kg/hr to reach glucose level 150-200. Here is the management of DKA in detail:
A- 2l normal saline and insulin 0.1unit
Abdulrahman: Answer A is correct. The patient should receive 2 liters of NS with 0.1 units/kg/hr to reach glucose level 150-200. Here is the management of DKA in detail: