75-year-old female presented with left abdominal pain, by US there is multiloculates, hard left adrenal mass. CA125 within normal. What's the most appropriate management:
A-Cystectomy.
B-Oophorectomy.
C-Hysterectomy with bilateral oophorectomy.
D-Referer to gynecology oncology centre.

Abdulrahman: I am sure that this is an adnexal mass (not adrenal mass). Her age is definitely worrisome. The patient has O-Rads classification 5 (multilocular cysts with solid components). She should be referred to a gynecologic oncologist to decide what type of surgery to do (oophorectomy or other types of procedures).

Another similar question: Ovarian cyst 6 cm with high ca125 high u/s showed multi Loculated, cystic something . Which of the following is the most appropriate management?
A. cystectomy
B. oopherctomy
C. aspiration
D. observe

Abdulrahman: The answer is B, since the CA125 is high. Between these choices, we have to do an oophorectomy.

Female pt complaining of amenorrhea for 4-months T4 low Prolactin 200 What the dx
A- primary hypothyroidism
B- hyperprolactinemia

Abdulrahman: The question is missing a lot of info and I am sure it will be much more clear in the exam. Judging from the given info, the answer should be a prolactinoma , since it can cause her symptoms of menopause and low t4 (due to secondary hypothyroidsim) and high prolactin (PRL)

- The usual normal range for serum prolactin premenopausal women is up to 30 mcg/L. A serum PRL of >200 micrograms/L is highly suggestive of a PRL-secreting pituitary adenoma (prolactinoma).

-Hypothyroidism predisposes to hyperprolactinemia. However, basal serum prolactin concentrations are normal in most hypothyroid patients,Hypothyroidism and drug-induced hyperprolactinemia (with the exception of risperidone) usually result in mild elevations of prolactin (< 100 ng/mL). Untreated primary hypothyroidism may itself be associated with modest hyperprolactinemia.

24y/o male presented with *diarrhea and fatigue* ader chemotherapy for the treatment of colorectal cancer what electrolytes abnormality would you suspect?
A- hypokalemia
B- hypocalcemia
C- hyponatremia
D- hypomagnesemia

Better recall: pt with colorectal cancer presents with abdominal pain and diarrhea for days now experiencing generalized muscle weakness. ECG shows flattering of T wave. What are possible electrolyte imbalance ?
1/ hypomaganesium
2/ hyponatremia
3/Hypokalemia
4/Hypocalcemia

Abdulrahman: Both hyponatremia and hypokalemia can present with diarrhea. The answer is hypokalemia due to the ECG findings.

- Diarrhea after chemotherapy leads to hypokalemia.
- Hypomagnesemia will be manifested by fatigue and muscle pain.
- Hyponatremia will cause neurological symptoms.

Typical of Osteoarthritis improve on ibuprofen and paracetamol, what’s the next?
A- Do standing x ray
B- MRI

Abdulrahman: The question is short and has to have more info. I will choose A based on the presumption that the patient has not been diagnosed with osteoarthritis yet. Osteoarthritis (OA) is essentially a clinical diagnosis. Radiography may be considered if the diagnosis is unclear or an alternative diagnosis suggested subsequent to initial investigations. Conventional radiographic diagnosis of OA includes narrowing of the joint space, osteophytes, subchondral cysts, and subarticular sclerosis.

child with perforated dum and discharge come out what is the diagnosis
A- acute OM
B- otitis externa
C- Chronic OM

Better recall: Pediatric patient presents with ruptured tympanic membrane confirmed on otoscopy. There is no ear pain but constant purulent discharge in the middle ear. Diagnosis?
A. Acute otitis media
B. Otitis media with effusion
C. Otitis externa

Abdulrahman: The answer is chronic suppurative otitis media based on this given info. UTD: Chronic suppurative otitis media (CSOM), or chronic otomastoiditis, is a perforation of the eardrum with chronic drainage from the middle ear cleft. T It should not be confused with longstanding otitis media with effusion (OME, or "serous" otitis media), or persistent AOM, both of which involve an intact tympanic membrane and no drainage.

As for acute otitis media, occasionally, it requires middle ear effusion (MEE) and acute signs of middle ear inflammation. The tympanic membrane will rupture in the course of AOM. This is usually associated with ear pain and fever of relatively short duration, followed by pain relief associated with the onset of otorrhea. The drainage often has a clear or white appearance. By the time the patient is seen, the perforation may have healed, but the drainage may continue for some time, especially if otitis externa has developed.

A clinical diagnosis of AOM can be made in children with either:-
- Bulging of the tympanic membrane; distinct fullness or bulging of the tympanic membrane is the most specific and reproducible sign of acute inflammation. Pneumatic otoscopy is not necessary in children with bulging of the tympanic membrane.
- Perforation of the tympanic membrane with acute purulent otorrhea if acute otitis externa has been excluded.

Middle aged Females patient has myalgia, joints pain, irritability which are resolved after ingestion of cold milk what's the possible diagnosis
A- 1ry hyperparathyroidism
B- 2ry hyperparathyroidism
C- 3ry hyperparathyroidism
D- Milk alkali syndrome
Abdulrahman: Here is the full question with the answer from Om-Alqura:

Best to prevent asthma exacerbation ?
A- pefr tech
B- spacer device skills
C- change environment

Another recall: Asthmatic child with exacerbation but you should do advice
A. Educate about using if spacer (or inhaler)
B. Educate about using FEV(or omorbidit)
C. Environmental measurement
Another recall: 6 yo child k/c of bronchial asthma He is known player in a school team. Presented with acute exacerbation. Which of the following helps in decreasing recurrence of the exacerbation? (Something like that)
A. Asking how do you use your spacer devices
B. Asking ho to use the spirometry at home ?
C. Environmental measures c.....


Abdulrahman: The answer is to ask the child how he is using his spacer device, since it is the most important thing to do first. Some children will put the spacer away from the mouth and breath in, as opposed to securing the mouth on the spacer itself. This is a common mistake in both adults and children.

A 63 years old male, not to have hypertension and is a smoker. Presented with retrosternal chest pain, localized and non radiating.
ECG Showing ST Depression in Lead II, III and aVF.
Blood Pressure: 156/93
Which of the following risk factors is strongly associated with his presentation?
A- Smoking
B- Hypertension
C- Age
D- Male Gender

Another recall that I wrote after my exam: 55 y.o Patient k/c smoker only. Presents with signs and symptoms of MI. ECG shows lead II,III,AVF depression. Hist vitals are:
BP: 150/92
Pulse: 99
Which of the following is the most considerable risk factor for MI in this case?
A. HTN
B. Smoking
C. Age

Abdulrahman: The answer is smoking. The patient isn’t a k/c HTN, his vitals only show hypertension.

Old pt bedridden wz basal ganglia dis, swallow proplem, best to initial feed
A- GASTRSTOMY
B- JUNSTOMY
C- NGT

Another recall: A case of basal ganglia stroke, with difficulty in swallowing and absent gag reflex. History of losing weight. How to provide nutrition?
A. Gastrostomy
B. Jejunostomy
C. NGT

Abdulrahman: The answer is gastrostomy. Dr. Thawaba and Dr. J agree with this answer.

Pregnant at 24 week all is good she’s just complaint of protruding mass from the vagina, diagnosed as posterior vaginal wall Prolapse, what to do ?
A- reassure
B- Emergencydelivery

Another recall: Pregnant with grade 2 posterior vaginal wall prolapse what to do?
A- Wait till she gives birth
B- CS

Abdulrahman: This patient has grade 2 vaginal wall prolapse. The answer is either pelvic floor muscle exercise (good way to start) or pessaries (better).

Hacker and moore: When only a mild degree of pelvic relaxation is present, pelvic floor muscle exercises may improve the tone of the pelvic floor musculature. Pessaries, which provide intravaginal support, may be used to correct prolapse by internally supporting the vagina. They can be considered when the patient is medically unfit or refuses surgery or during pregnancy and the postpartum period. In many patients, pessaries are the treatment of choice.

Scenario of a child abd his brother with Coryza , what’s the causative agent
A- PIV
B- Adenocirus
C- RSV

Abdulrahman: The only info is that he has coryza (runny nose) and his brother has it. I need a better recall. This can help you differentiate between adenovirus and RSV in the exam:

- Adenovirus: are among the most common viruses isolated from young children with febrile respiratory illnesses. The usual duration of illness is five to seven days. Pharyngitis and coryza are common presentations of adenovirus infection. Other symptoms include common cold or flu-like symptoms, fever, acute bronchitis, conjuntivitis, diarrhea, pneumonia, otitis media, pharyngoconjunctival fever, diarrhea, mesenteric adenitis, and hemorrhagic cystitis.

-Respiratory syncytial virus (RSV): Characterized by cough, wheeze, respiratory distress, and hypoxia. RSV can cause severe lower respiratory tract disease, including bronchiolitis, bronchospasm, pneumonia, and acute respiratory failure in children.

Patient 73 kg, pot contaminated abdominal surgery in ICU given 6 L of crystalloids, BP low, HR upper range, normal temp and saturation, urine output 20ml/hr asking what to give now ?
A. Furosemide
B. IVfluids
C. Albumin

Another recall: 78 YO male post-op contaminated abdominal surgery. Admitted to ICU and recieved 6 L of crystalloid IV fluid and 1 PRBC in the last 12 hours. Broad spectrum antibiotics were administered.
Vitals:
BP 70/45
HR: 125
T: 38.6
O2: 93%
Labs:
WBC 8

Most appropriate IV intervention:
A-Albumin
B-2 L crystalloid fluid
C-Norepinephrine
D-Furosemide

Abdulrahman: The answer is norepinephrine, since you want to restore his BP and did not respond to the IV fluids.

Another similar question: Old Patient did urgent abdominal surgery and transferred to ICU, in ICU he was given 7L of Crystalloid and 2PRBC, BP is 90/78 low, urine output 20ml/h, CVP is 40, what to do?
A. Albumin
B. 2 crystalloid
C. Diuretics

Abdulrahman: The CVP changes the whole scenario. He has a high CVP (normal is 8-12) which indicates volume overload, give him diuretics.

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RUQ dull aching pain, fever ,Radiography: will capsulated cyst, next:
A. Metronidazole
B. Surgicaldrainage
C. Percutaneousdrainage
D. Reassuring

Better recall: 36 old male at ER C/O Right abdominal Pain , O/E : fever, anorexia , weight loss , tenderness in RQ and Lower intercostal margines also patient is toxic Temp. 37.9 ( I think but it was elevated ) wbc high, bilirubin high US : cystic lesion without septates CT : homogenous (not sure) and “THICK WALL with Peripheral enhancement - what’s most appropriate Mx :
A- Ceftriaxone
B- Metronidazole
C- Surgical drainage
D- Percutaneous drainage

Abdulrahman: The answer is percutaneous drainage as this is most likely a case of pyogenic abscess (CT findings).