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.

57 yo woman has 3rd-degree hemorrhoids (with NO bleeding). Which of the following is the appropriate management?
A- fiber supplementation
B- rubber band ligation
C- surgical hemorrhoidectomy

Abdulrahman: There are multiple approaches to follow this question. Dr. J: The answer is A. If B and C are together in the choices, they’re both wrong. Colonoscopy is a better choice.
I will explain the approach that I found and helped me in my exam:
- 1st & 2nd degrees: start with conservative. If it fails, go with rubber band ligation.
- 3rd degree: start with conservative. If it fails, go with hemorrhoidectomy. *Exception*: if there’s bleeding go with rubber band ligation.
- 4th degree: hemorrhoidectomy.

Another recall: 48 y/o with grade 3 hemorrhoids at 3 and 11 o’clock What is the best next step?
A-Colonoscopy
B-Hemorrhoidectomy
C-Band ligation
Abdulrahman: The answer here is A, since the patient is above 40

Pt painless defication Blood in th stool. Biles reduced spontanius in 3 areas 3.7....Hb very low
Dx hemmorriid was given which of the following is Definitive management ?
A- conservative manag
B- fiber diet
C- rubbber band ligation
D- hemorroidectomy

Another recall: 24-year-old woman with recurrent on-off PR bleeding after defecation. She has spontaneously reduced hemorrhoids. Hb was low. On examination: 3 hemorrhoids at 2,7,10 O’clock How would u manage?
A - Observation
B - Band ligation
C - Hemorrhoidectomy
D - Conservative

Abdulrahman: The answer is B, because she’s symptomatic. Low Hgb is not from the hemorrhoids, since hemorrhoids do not cause this much bleeding.

Pt came 3 days after roux-Y surgery complaining of fever chills and left shoulder pain. Best diagnostic investigation?
A- Ct with contrast
B- Laparoscopic
C- Endoscopy
D- Exploratory laparotomy

Abdulrahman: This patient most likely has a leak after the surgery. The management depends if the patient is stable or not (you will know in the exam if he is stable or not). The best investigation if stable is CT with contrast. If unstable, exploratory laparotomy.

Pregnant did not feel her fetus movement what is appropriate next step?
A- US
B- CTG

Abdulrahman: This is a very poor recall. We don’t know what gestational age she is at right now or if she has any other complaints.

10 years old boy diagnosed as rheumatic fever for how many years should he receive penicillin
A- 3 years
B- 5 years
C- 10 years
D- 15 years
Abdulrahman: It Depends on the age + the heart condition

Another similar question: A patients with rheumatic carditis without valvular lesion and he is 6 years old How long you will give prophylaxes
A. 5 years
B. 10 years
C. 15 years
D. 20 years
Abdulrahman: C

patient female elderly with symptoms of Orthopnea SOB PND, JVP, Bilateral basal crackles. S3. what is the diagnosis
A- Pulmonary edema
B- MI
C- Mitral regurgitation
D- Right sided heart failure

Abdulrahman: This is a very bad recall and missing important info. Mitral regurgitation can cause pulmonary edema (Left ventricle heart failure + pulmonary edema + S3 gallop). If he asked about the cause of the symptoms, the answer would be A. But if he asked the diagnosis specifically (what originally caused the symptoms and led to the pulmonary edema), then C is most likely. I know I said this a lot, but I am sure it will be much clearer in the exam.

A patient with DVT with ankle-brachial index 0.3 and occlusion size 3 cm. Treatment?
A- Embolectomy
B- Stent
C- tPA

Another recall: Old patient long history of leg claudication *for 2 months* , present with leg pain and ABI <0.3 and , *CTA show artery occlusion more than 3 cm* what to do?
A- amputation
B- thrombolysis
C- embelctomy

Abdulrahman: The answer is amputation (Dr. Abeidi and Dr. J agree with this answer). This is a case of acute limb ischemia on top of chronic limb ischemia. If only acute, give heparin infusion first (faster). I got this question when I got my 100% surgery score. There are two ways to give thrombolysis (catheter directed or systemic). Usually in acute limb ischemia, we give catheter directed thrombolysis. Systemic is given in cases of MI (within the window) or massive PE.

3-month-old baby on check-up presented by his parents to the clinic, he is asymptomatic and the investigations showed: mild microcytic anemia. Which of the following is the most likely diagnosis?
A- Thalassemia.
B- Iron deficiency anemia.
C- Sickle cell disease.
D- Physiological anemia.

Another recall: Asymptomatic baby 4 m come to the clinic by his mother, labs show hemoglobin 9 and low MCH low MCV what is the diagnosis?
A- sickle cell
B- physiological anemia
C- thalassemia trait

Abdulrahman: The answer is thalassemia trait since he’s 3 or 4 months (also answered by Om-Alqura). Let’s discuss the other choices:
- Iron deficiency anemia and physiological anemia: We think about it after 6 months of age. rapid growth and an inadequate intake of dietary iron places children 2 years and under, particularly between 9 and 18 months of age, at the HIGHEST risk of any age group for iron deficiency. It is not the case in our case, since he’s only 3 months old.
- Sickle cell anemia: will have a different presentation and the MCV will be normal (not low)