Patient with 8 hours post-operation, urine output is 50 cc, what to do next?
A- dialysis
B- catheter
C- fluid and electrolytes imbalance
D- follow up

Abdulrahman: The answer is C. This patient could be dehydrated or is having some sort of electrolyte imbalance post-op. I would go with B if the choice was to check the catheter if it was inserted properly to measure the urine, since this could be a mistake that could happen and leads to false results of urine output.

New born just delivered was found microcephaly and hepatosplenomegaly next :
A- Brain radiography
B- Us abdomen
C- Liver function

Abdulrahman: This recall is missing a lot of info to judge. I would go with congenital infection screening. If not there, go for LFTs. This child most likely has a congenital infection (TORCH infections). For example, Congenital CMV infection can be diagnosed by testing a newborn urine, saliva, or blood. We encountered a similar question in our year. Here is the question and the answer:

A teenager presented with chronic cough for the past 7 months. Was diagnosed with cough variant asthma on inhaled fluticasone and albutarol. Cough was disturbing him during sleep and wakes up feeling a dry throat. What will you add to the patient management?
A- Inhaled LABA
B- Nocturnal Antitussive Therapy
C- Adding a Proton Pump Inhibitor
D- Repeat Methacholine Challange Test

Taghreed: Nocturnal asthma symptoms are suggestive of GERD, so the answer is C. If the patient was controlled on medications that he is on, we check first the time of the attacks:
- If on sleep time (while lying down) answer will be adding a Proton Pump Inhibitor (C)
-If attacks not related to lying down answer will be to add an inhaled LABA (A)
- Another thing, if his symptoms are not controlled from the beginning, we have to check for false diagnosis
- Repeating the methacholine challenge test is not correct because if he is symptomatic and responding to dilators, it is the same mechanism when using methacholine

Want to concieve for 3 years, irregular menses, many normal investigations only prolacin level high
A. Ct brain
B. TSH?
C. Mri brain
D. Serum cortisol

Taghreed: we have to exclude primary hypothyroidism as a cause of hyperprolactinemia. This is why we do TSH first. If it is normal, we go for an MRI brain next between these choices.

Another recall: Female with infertility, prolactin high, TSH high, Cause of infertility?
A. hypothyroidism
B. hyperprolactinemia
C. hypopituitarism

Taghreed: The answer in this case is hypothyroidism.

Lactating women present with right breast pain for 6 day on examination, hot tender swelling lateral to the right areola Pt started to take floxacillin Ultrasound showed Cystic lesion, thickened content, What next?
A- Incision and drainage
B- Repeated aspiration
C- Excisional biopsy
D- Reassurance or antibiotic

Another recall: A breastfeeding female patient has a breast lump, mastalgia, and fever. She did imaging and they gave you the differential in the question and said for clinical correlation. Imaging showed cystic lesion with thick fluids within. One of the differentials was breast abscess. What is the management?
A- Aspiration.
B- I&D
C- Antibiotics.

Abdulrahman: This is most likely a case of breast abscess and not mastitis (cystic lesion with thick content). The answer depends on the size. I&D indications in a breast abscess:
5cm or more
Fluctuating
Thinning of the skin
Not responding to abx

Another recall: Lactating mother with a 5 cm breast mass with thinning of the skin and tender?
A. Incision and drainage
B. Conservative with antibiotic

Abdulrahman: The answer here is A. If you want a summary of breast diseases and cancers, I made a summary lecture. Here is a sample:

70 year Old man came complaining that he forgets names of celebrities, names of his friends, and telephone numbers. His wife is worried that he has Alzheimers. A bunch of labs in the q including thyroid were all normal EXCEPT for tender knees reflex!
A. Alzheimers
B. Benign forgetfulness
C. Lew body dementia
D. Hydrocephalus dementia

Another recall: Old man came complaining that (he can’t remember things), he sometimes forgets his friends’ names or celebrities in his community and phone numbers. His wife is worried he has Alzheimer’s. Labs normal. He has tender knees (not something amazing just cause he’s old). No mention how it affects his daily life.
A- Alzheimer’s
B - Benign forgetfulness

Another recall: Old man says he sometimes forgets his friends’ names or celebrities in his community and phone numbers. His wife is worried he has Alzheimer’s. Labs normal. He has tender knees (not something amazing just cause he’s old). No mention how it affects his daily
Life?
A- Alzheimer’s
B- Benign forgetfulness

Abdulrahman: The answer here is benign forgetfulness. The patient has a mild cognitive decline in his memory. It is normal to forget phone numbers and the names of celebrities and friends. Alzheimer’s will be much clearer than this.

Child with absent red reflex
1- mri brain
2- reassurance
3- eye examination under sedation

Another recall: Infant with absent red reflex ( retinoblastoma most likely) What to do ?
A-Immediate referral to ophthalmology
B-Brain MR

Abdulrahman: The answer is to refer the patient to an ophthalmologist. While under the care of ophthalmology, you have to examine the child under sedation for better examination and find the cause for the absent red reflex or leukocoria. This includes:

pt on warfarin with INR 7 without bleeding what to do next;
A. Hold warfarin then reasse after 2 days.
B. Stop warfarine.
C. Give Vit K

Another recall: Patient received 5mg warfarin his inr is 7 , known case of AF ?
A- Reduce to 2.5 mg
B- Same dose
C- Stop warfarin

Abdulrahman: The answer here is to hold warfarin then reasses. It depends on the INR level and if there is bleeding and/or need to undergo an operation or not.
If the patient is going to a procedure:
- Urgent (next 2 days): give Vitamin K
- Emergent: give FFP (ideally with vitamin k). Cryoprecipitate is considered to be a last choice after FFP

Taghreed: Here is a table that will help you from UTD:

Female 45 c/o continues progressive solid liquid dysphagia x 9 ms + vague epigastric pain with eating Laps all normal except hgb slightly low dx
A- Achalsia
B- Esophageal web
C- Squamus c c
D- PUD I think

Taghreed: The answer is C. UTD: Progressive dysphagia, beginning with dysphagia to solids followed by dysphagia to liquids, is usually caused by a peptic stricture or obstructing lesion.
Symptoms of peptic stricture are slowly and gradually progressive, whereas those due to a malignancy progress more rapidly
- Achalasia affects both males and females equally + Progressively worsening dysphagia for solids (91%) and liquids (85%) and regurgitation of bland, undigested food or saliva are the most frequent symptoms in patients with achalasia. Other symptoms include chest pain, heartburn, and difficulty belching.
- Esophageal web is usually intermittent
- Squamous cell cancer of the esophagus or gastric cardia is associated with rapidly progressive dysphagia, initially for solids and later for liquids. In addition, patients may have chest pain, odynophagia, anemia, anorexia, and significant weight loss.

34 year old man presents with slow progressive dysphagia. He has been using H2 blockers for the last year because of retrosternal discomfort. He has not noticed any weight loss. A haemoglobin level was done a month ago which reads 13.3g/dL.
What is the SINGLE most likely diagnosis?
A- Foreign body
B- Plummer-Vinson syndrome
C- Pharyngeal pouch
D- Peptic stricture
E- Esophageal Cancer
Abdulrahman: By exclusion, the answer is most likely D. His hemoglobin is not significantly low. Let’s break the other choices:
- Foreign body: will present with a feeling of a lump, discomfort, sudden choking, retching, or coughing. It might also present with vomiting.
- Plummer-Vinson syndrome: If there is angular stomatitis and IDA.
- Pharyngeal pouch: will present with dysphagia, regurgitation, halitosis (bad breath), chronic cough, hoarseness, pain, and a sense of lump in the throat.
- Esophageal cancer: will present with risk factors, dysphagia, unexplained weight loss , chest pain, pressure, burning sensation, indigestion, coughing, and hoarseness.

Young male patient having only complaint of gross hematuria otherwise normal, on examination normal, on investigation US normal, urine culture normal, now what’s your investigation of choice
A- RENAL BIOPSY
B- URINE ANALYSIS OR renal cytology
C- CYSTOSCOPY
D- RENAL ANGIOGRAPHY

Taghreed: The answer is B. He is young and you need to confirm if it is true hematuria or not.

An old patient presents with painless hematuria, He is medically free and has no other symptoms. Vitally stable. What is the best way to diagnose this condition?
A- Cystoscopy
B- Pelvic US
C- CT abdomen
D- IV pyelogram

Better recall: A 65 year old man presented with frank hematuria. He has no other urinary symptoms. What is the most appropriate next step that will lead to the diagnosis?
A) IVU
B) US abdomen
C) cystoscopy
D) mid stream urine for culture
E) transrectal US

Abdulrahman: The answer is cystoscopy (urinalysis is a better as a first thing to do). The patient is old and has hematuria and no other signs or symptoms (all are red flags for lesions and cancers related to the urogenital tract). In the case of gross hematuria, the genitourinary system is investigated from distal to proximal (i.e. urethrogram, cystogram, etc.)

64 years old women come to clinic complaining of left nipple discharge with bloody stain, otherwise normal, Bilateral mammo was normal, bilateral US shows bilateral duct dilatation with left breast Intraductal papilloma, what is your appropriate management?
A. Close follow up
B. Central duct Excision
C. Imaging guided core biopsy

Another recall: A 35 year old lady presents with a left nipple bloody discharge, by imaging it was suggestive of Intraductal papilloma. What to do next?
A. Central Duct excision
B. Observation
C. Mastectomy
D. image guided biopsy

Abdulrahman: The answer is central duct excision (Dr. Thawaba also agrees), since the diagnosis has already been established and the central duct excision is both therapeutic and diagnostic We do a biopsy first then we decide on the management (e.g., central duct excision).UTD: Patients presenting with pathologic nipple discharge but no palpable mass should first undergo either diagnostic mammography, focused breast ultrasonography, or both, depending on their age and sex . Breast magnetic resonance imaging (MRI) usually follows if mammograms and ultrasound are negative. Suspicious lesions should undergo core needle biopsy with clip placement. Since the diagnosis of intraductal papilloma is confirmed & size is less than 2 cm, we go for vacuum biopsy to remove the whole lesion. If the lesion is > 2 cm in size or if discharge persisted after vacuum, then we do microdochectomy.

32 year old complain of left breast mass with bloody discharge .. on examination the left breast and axilla is normal what will do next
A. Bilateral US
B. FNA
C. Bilat mammography

Abdulrahman: The answer is US. Here the guidelines that are followed in Saudi Arabia as to whether go for mammo or US:
- 40 years of age and above: Mammogram
- Below 40 years of: Ultrasound

50 years old pt with previous ROUX en Y For obesity Developed gall stone with obstructive jaundice Dilated cbd Most appropriat next step :
A- ERCP
B- PTC tube
C- Cholecystectomy
D- Choledochotomy

Abdulrahman: The answer is B (answered also by Dr. Thawaba) The patient had a Roux-n-Y surgery so this changes the anatomy (we can’t do ERCP).