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).

Pt right upper quadrant pain amebiasis (dx given) imaging report > right hepatic lobe abcess 10X15 cm poorly defined septations , most appropriate initial tx ?
A. Percutaneous aspiration
B. Metronidazole
C. Rifampin (not sure)
D. Surgical (not sure)
Abdulrahman: The answer here is B, but in this case, it is an amoebic abscess.

Female Pt hematuria and swelling of lower limbs , Hx HTN , Lab low albumin , high creatinine and BUN , UA : 5+ protein , 20 RBCs No Hx URTI , or skin infections or any chronic illnesses or any drugs used . What's Dx ?
A- Acute interstitial nephritis
B- Acute glomerulonephritis
C- Postrenal-obstruction
D- Acute - tubular - necrosis

Abdulrahman: The answer is B. The patient has nephritic syndrome (hematuria, HTN, and some proteinuria).
- He doesn’t have any history of drug abuse (excludes AIN) or any chronic illnesses (excludes AIN and ATN).
- Postrenal obstruction occurs in the case of bladder outlet obstruction due to an enlarged prostate gland or bladder stone. Kidney stones in both ureters (tubes that pass urine from each kidney to the bladder) or in patients with one kidney.

Patient known case of CKD for the past 3 years presented with history of numbness in both hands and in examination sensation was absent below knee level and absent ankle reflex, lab findings suggestive of iron deficiency anemia and high renal function test and mild hyperkalemia, What the next appropriate next step in management?
A- Erythropoietin
B- Vitamin
C- complex
D- Dialysis

Dayel: The Answer is D. This is a case of Urmeic polyneuropathy which is a complication of CKD in this patient.
UpToDate:
- Patients initially present with sensory symptoms involving the distal aspect of the lower extremities. Early sensory symptoms include paresthesias such as tingling or prickling, and, as neuropathy becomes more severe, burning pain develops. Patients with more advanced disease develop motor symptoms including weakness of distal muscles, myoclonus, and even paralysis.
- Symptoms of uremic polyneuropathy are an indication for kidney replacement therapy, including either dialysis or transplantation.

Patient was extubated ader thyroid surgery and immediately developed shortness of breathing and respiratory distress, Examination reveals that both vocal cords are in a semi closed position. How will you secure the airway?
A- Re intubate the patient
B- Tracheostomytube
C- Cricothyroidotory

Dayel: The answer is A. this is a case of bilateral vocal cord paralysis which happened post thyroidectomy.
UTD: Bilateral vocal cord paralysis is usually recognized immediately after surgery when the patient develops dyspnea and stridor upon extubation. Immediate reintubation is usually possible, but a tracheostomy may be required if the patient cannot be orotracheally reintubated (eg, if both vocal cords are adducted).

Abdulrahman: As Dayel said, This is most likely a case of Bilateral vocal cord paralysis. The answer depends if the patient improved after intubation (don’t perform tracheostomy) or not (perform tracheostomy). UTD: Bilateral vocal cord paralysis from injuries to both RLNs is a rare (0.4 percent of cases) but devastating complication of total thyroidectomy. Bilateral vocal cord paralysis is usually recognized immediately after surgery when the patient develops dyspnea & stridor upon extubation.

N&V suprapubic and LT iliac fossa tenderness Preg test & urine dipstick normal , Normal wbc , Initial management?
A- Abd xray
B- Abd CT
C- Diagnostic laparoscopy
D- Analgesia & discharge
Dayel: Missing important information. If there is Ultrasound go for it. Which is the recommended test of suprabuipc region.

Another recall: Female with lower abdominal pain for 6 hours with N/V, on exam there is suprapubic tenderness and left lower Quadrant, pregnancy and Urinalysis are normal:
A. US abdomen
B. Abdominal x ray
C. Laparoscopic exploration
D. Discharge with analgesia

Dayel: The Answer is A

Abdulrahman: As Dayel said, an US would be beneficial as an early investigation. If not there, go for a CT scan. This could be an ovarian torsion.

50 years old male complained of right iliac fossa dull aching pain. Exam showed that he had right iliac fossa mass with positive cough impulse. The examining doctor found a bluish tinge on the mass surface & the percussion tab was positive. The most likely diagnosis is:
A- Right inguinal hernia
B- Right femoral hernia
C- Right vaginal Hydrocele
D- Cyst of morgagni
E- Saphena Varix

Dayel: I don’t know. All of the GS consultants said this is a bad recall. One of them said A is the answer.

Abdulrahman: This is a weird question with 5 choices… I don’t think you will get this question in your exam. I initially thought and believed that it was a saphena varix due to the “bluish tinge”, but the location doesn’t make sense for it to happen there. I agree with Dr.J’s answer (A).

40 years old male presented with shortness of breath for two weeks relieved by rest and worsens with exertion. No Chest Pain and No Palpitations and No Sweating. What is like likely type of chest pain?
Troponin: 0.09 (Normal < 0.04)
A- Typical Anginal Chest Pain
B- Atypical Angina
C- Pulmonary Embolism
D- Myocardial Infraction

Dayel: The answer is B. Atypical Angina may express other signs and symptoms like SOB without chest pain.

Abdulrahman: To add to Dayel, let’s exclude:

Patient with sudden severe epigastric pain for 8h associated with vomiting and nausea, on examination epigastric tenderness,,,labs only given elevated amylase.
What is most helpful to determine the disease severity or something like thing:?
A- Procalcitonin
B- ESR
C- CRP
D- Alt

Abdulrahman: Both A and C are correct. However, I will go with C as it is used as an early indicator of severity and to monitor progression of inflammation. CRP will determine severity during the first 48hrs of symptoms onset. Also, procalcitonin is not used as frequently as CRP. Also, procalcitonin is not used as frequently as CRP.