indications for oxygen home therapy COPD-32
A- 6.3
B- 7.9
C- 7.3
D- 8.3

Better recall: Which of these is an indication for home oxygen therapy in COPD?
A- 1 reading of Po2 <7.8pka
B- 2 readings of Po2 <7.3
C- 1 reading of Po2 <8
D- 2 readings of Po2<6.3

Abdulrahman: The answer is two readings Po2 <7.3. Here are the other indications for long term home oxygen therapy in COPD patient:
1- PaO2 in ABG (out of time of acute attack) less than 55
2- PaO2 55-59 + one of the following: dependent edema (Cor pulmonale), polycythemia (Hct > 56%), pulmonary hypertension, Nocturnal hypoxemia

had prosthetic valve disease since 10 days. Underwent dental procedure and developed infective endocarditis. What's the organism caused infective endocarditis?
A- Staph aureus
B- Staph epidermis
C- Strept viridians

Abdulrahman: The answer is C. Answers vary between references as to what are the organisms that cause infective endocarditis. I’ve decided on what is found Davidson’s and Harrison’s books (approved references by SCFHCS):

Child has inflammation in hemiscrotum upon exploration there was viable testes but inflammation in epididymis and cord and swelling what the dx:
A- epididymitis
B- incarcerated inguinal hernia
C- testicular torsion
D- not remembered

Another recall: unilateral testicular painful swelling since 1 day, on exploration red scrotum viable but cord edematous:
A- Torsion
B- Incarcerated inguinal hernia
C- Testicular appendages torsion
D- epididymitis

Abdulrahman: The answer is epididymoorchitis/epididymitis.
- Epididymitis: Inflamed scrotum and edema
- Appendiceal testis torsion: Vertical testicle and blue dot sign
- Testicular torsion: Horizontal testicle
- Incarcerated inguinal hernia: Inflamed and red inguinal area with a visible mass extending to the scrotum

22 month infant with LEFT inflamed red hemi scrotum, on examination there was red firm irreducible painful scrotal swelling which is extended to to left inguinal region. LEFT testis couldn't be palpated. What is the diagnosis?
A. Torsion appendix testis.
B. testicular torsion
C. epididymo orchitis.
D. incarcerated inguinal hernia

Abdulrahman: The answer is D.

8 years old Female pt brought by her mother to the emergency department with nausea and vomiting after ingestion of 2 packages of paracetamol, each package contains 20 tables, this is happened before 24 hours after fight with her mother. On examination pt looks jaundiced has right hypochondrial tenderness, Bp=90/60mmhg HR=86, no labs provided. What is the stage of paracetamol toxicity?
A-1
B-2
C-3
D-4

Abdulrahman: The answer is B. The patient ingested a toxic amount of paracetamol before 24 hours, has RUQ pain, and early signs of abnormal LFT (jaundiced). Stage 3 will present with much more severe symptoms (encephalopathy, renal failure, acidosis, coagulopathy).

A 2 year old child presented with fever jaundice and a (third thing). Family history: his brother had neonatal jaundice and required multiple blood transfusions. They are from the Mediterranean. temp 38, RBC 4, Hbg 9,) Reticulocyte(3%) Bleeding. Which medication should be avoided in the management?
A- Aspirin
B- amoxicillin
C- ibuprofen
D- acetaminophen

Abdulrahman: The answer is A since the patient most likely has G6PD deficiency (jaundice, family history, and from a Mediterranean region). People always get this question mixed up. Just because the patient is from a Mediterranean area, does not mean he has Mediterranean fever.
- Avoid aspirin in G6PD deficiency.
- Avoid Amoxicillin in familial Mediterranean fever. Macrolides are a better choice if it is in the choices.

Female patient just delivered a baby weighing 3000g. Which of the following is a risk factor for developing postpartum hemorrhage?
A- Fetal Macrosomia
B- Precipitous labour
C- Grand parity

Better recall: 35 y.o , G4p3L2 , medically free, presented in labor which take 16 hrs to deliver a 3 kg baby boy healthy, after delivering the placenta the patient had large amount of bleeding , what could be the cause?
A- grand parity
B- long duration of labor
C- macrosomic baby
D- multiple gestation

Abdulrahman: The answer is long duration of labor. Let’s discuss the choices:
- Grand multiparity: patients who have had ≥5 births (live or stillborn) at ≥20 weeks of gestation.
- Long duration of labor: Prolonged labor requires that, in the face of regular uterine contractions, the cervical dilation is <6 cm for a duration of >20 h in a primipara or >14 h in a multipara. in this case, it is 16 hrs in a multipara women, which is abnormal.
- Marcoscomic baby: 3000 g (which is normal). Macrosomia is >4000-4500g
- Multiple gestation: The patient is delivering one baby only. There is no mentioning of twins.

man had recurrent episodes of arthritis in his big toe, he diagnosed with gout and he is k/c of psoriasis. He is compliant to gout medications but with no improvement and high uric acid level. Now he presented bilateral ankle arthritis, the diagnosis is?
A- Pseudogout arthritis
B- Gout arthritis
C- Psoriasisarthritis ( not sure)

Better recall: patient who had right big toe pain and because of that “written like this” he was diagnosed with gout and treated with allopurinol. He’s a known case of psoriasis. He presented now with right big toe pain, right ankle pain and bilateral knee pain and there was no improvement with allopurinol. Labs shows high uric acid What’s the diagnosis?
A- active pseudo-gout arthritis
B- active gout arthritis
C- psoriasis arthritis
D- Osteoarthritis

Abdulrahman: I think the answer is psoriatic arthritis since he almost fulfills the criteria for psoriatic arthritis (CASPAR) and might be missing more important info in the question. Even though he has been diagnosed with gout, he has not been responding to his medications. He has an established inflammatory articular disease + history of psoriasis (1 point) + dactylitis (1 point). We are missing 1 point to confirm the diagnosis. The symmetrical joint pain (bilateral knee pain) is what is throwing me off also. I hope the full question will be much clearer for you.

Update: Another point of view from an excellent person: Psoriasis is a risk factor for secondary hyperuricemia. The clinical presentation for arthritis involvement goes towards gout + it is a recurrent episode, so it is common to see multiple joints. Based on the recall, the Q mentioned that he took allopurinol during the active episode so I believe this is why he didn’t improve because it doesn’t have an effect unlike NSAID or steroid rapid relief. As you can see in the pic from uptodate I feel the scenario fits it as a recurrent episode for an active gout. Although I don’t agree with bilateral knees. But the ankle involvement is common in recurrent episodes of gout.

Male patient complains of episode of hematemesis. normal past medical history Labs show mild anemia ,All over labs are normal except elevated urea level in blood?
A-Mallory Weiss syndrome
B-erosive gastritis
C-PUD

Better recall: 40 years old adult male medically free presented to ER C/O several episodes of hematemesis for the first time, takes no medication, no family history of similar attacks, normal abdominal examination no guarding no tenderness.
Hgb: 9
Plt: 250
Alk: slightly decrease
All other tests were normal
What is the diagnosis:
A-Erosive gastritis
B-eptic ulcer disease
C-Mallory Weiss syndrome
D-Esophageal varices

Another recall: 30 year old male, presented to ER with several episodes of hematemesis.
No similar previous episodes, not on any medications, no alcohol intake, no smoking, no liver disease/jaundice.
Labs:
Normal ALT
Low ALP
BUN 14 (high)
(Nothing else of significance based on my memory)

Abdulrahman: Even though we have a lot of info in this question, it is still vague. I will go with Erosive gastritis, but you need to check for other clues when you get the full question:

- Varices: No history of liver disease/jaundice (normal labs) or alcohol intake
- Erosive gastritis and PUD: Clinical signs and symptoms may be similar. High urea could be a sign of H-pylori. if the anemia is a B12 anemia, then consider erosive gastritis.
- Mallory-Wiss syndrome: will present with multiple episodes of vomiting then the hematemesis will occur.

39 y / o Patient with symptoms of SLE, arthritis and malar rash, what medication should be started ?
A- Hydroxychloroquine and Mycophenolate mofetil
B- Hydroxychloroquine and Methotrexate and Steroid
C- Hydroxychloroquine
D- Methotrexate

Abdulrahman: The answer is Hydroxychloroquine and steroids. Arthritis in patients with SLE usually responds to NSAIDs or hydroxychloroquine. Patients with arthralgia may benefit from acetaminophen. Glucocorticoids may be added to control arthritis in patients whose symptoms have not resolved while on antimalarials and/or NSAIDs.
- Mild-moderate disease (skin and joints involvement): NSAIDs + HCQ (if failed low dose steroids + MTX)
- Moderate - severe (CNS, cardiac, renal): High dose steroids + cyclosporine

Here is a different but similar question from Umm Al-Qura:

35 years old female known case of SLE came with left and right ankle severe pain a diagnosis of SLE arthritis is made she is already on lupus medications what drug to add ?
A. methotrexate
B. hydroxyurea
C. sulfasalazine
D. prednisolone
Abdulrahman: I will go with D since she has an active disease right now. They did not mention what medications she is taking right now. The patient should be on Methotrexate & Prednisolone. Methotrexate takes time to work. B and C are excluded as they are not used.

Another similar question: male with RA and the disease was active.. they asked what what would you give him?
A. MTX + prednisolone + hydroxychloroquine
B. MTX + sulfasalazine
all the other options didn’t have prednisolone

Abdulrahman: The answer here is A

Another two similar questions: RA case on Ibuprofen and Methotrexate for 6 months, came with exacerbations. What to add?
A. Adalimumab
B. Azathioprine
C. Cyclophosphamide
D. Hydroxychloroquine

Abdulrahman: A

RA patient with severe symptoms not responding to methotrexate, hydroxychloroquine, what to add?
A. NSAID
B. Adalimumab
C. Sulfasalazine

Abdulrahman: B

Patient P4 came for contraceptive method. Patient had regular cycle but increase in bleeding recently. Hx of CS, and endometritis after the second CS which has been treated. Which of the following is contraindication for IUD?
A. Hx of endometritis
B. Abnormal bleeding
C. Other things not relevant I couldn't remember

Better recall: This patient was using IUD before, but she got pregnant nonetheless. Delivered with C-Section. Then she developed endometritis. Which of the following represent contraindication:
A- previous CS
B- history of Pelvic infection
C- history of contraceptive failure
D- genital bleeding

Abdulrahman: The answer is abnormal bleeding / Genital bleeding. UTD: Here are the absolute, evidence-based contraindications to IUDs:
- Severe distortion of the uterine cavity
- Active pelvic infection (the patient is currently not active)
- Known or suspected pregnancy
- Wilson's disease or copper allergy
- Unexplained abnormal uterine bleeding
= Breast cancer

child presenting with croup and received the usual treatment with no improvement. What is the important investigation to be done?
A- Lateral neck X-ray
B- Chest inspiration and expiration X-ray
C- Visualization by laryngoscopy
D- Chest CT

Abdulrahman: This question is quite difficult and there are a lot of different points of view. I am between A (next step) and C (best test to confirm) since I think that this is bacterial tracheitis (ddx of unresolved croup) and not epiglottitis (no drooling and there was no mentioning of the patient being very sick or history of missing vaccines).

- UTD: Atypical course: Children admitted for croup typically remain in the hospital for <36 hours. The child who does not show improvement as expected (over the course of one to two days) may have an underlying airway abnormality or may be developing a complication of croup. A biphasic illness with poor response to nebulized epinephrine in conjunction with high fever and toxic appearance should prompt consideration of bacterial tracheitis. Bronchoscopic diagnosis: Definitive diagnosis of bacterial tracheitis requires direct visualization of the airway via laryngoscopy and tracheobronchoscopy.

- Nelson: radiographs may be helpful in distinguishing between severe laryngotracheobronchitis and epiglottitis.

To summarize:
- If the patient was treated with only one dose of epinephrine, give another dose (treatment of croup)
- If no improvement after 2 doses and the scenario suggests that the patient is still deteriorating, go for direct visualization by laryngoscope (to diagnose bacterial tracheitis and therefor start antibiotics)
- If the scenario suggest that he was treated as croup, got better, then came back with drooling, go for lateral neck x-ray (to diagnose epiglottis)

A healthy 40 year old man presents for a tuberculosis screen. He is asymptomatic with a normal Chest XR, and his last PPD 5 years ago was negative. Today, his PPD is positive. What is the treatment?
A- Isoniazid for 6 months
B- Isoniazid, Rifampin, Ethambutol and Pyrazinamide
C- Reassurance
D- Rifampicin and isoniazid for 3 months

Another similar question: Nurse during checkup for contract renewal was asymptomatic and normal except PPD of 12mm. What's the management?
A. No need
B. isoniazid 300 mg for 3 months
C. Isoniazid 300 mg for 6 monthes
D. rifampin, isonizid, another drug for 9 months or 6 months

Abdulrahman: The correct answer is isoniazid for 6 months (answered by Umm Al-Qura). Here are 3 ways of managing latent TB:
1. Isoniazid+B6 for 9 months
2. Rifampin for 4 months
3. Isoniazid + Rifampin 3 months

In the first question, Both A and D are correct. I think there was some mistake when writing the recalled choices (mistaken the period or did not write the frequency). If not, I would go for D since INH is not recommended to be given without vitamin B6.