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:
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.
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.
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.
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.)
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.
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
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).
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).
30 something year old lady presented 1 week after birth with Bilateral crackles and dyspnea What is the likely cause?
1- MI
2- Pericarditis
3- Peripartum Cardiomyopathy
Abdulrahman: This is most likely a case of peripartum cardiomyopathy. We need more info though.
1- MI
2- Pericarditis
3- Peripartum Cardiomyopathy
Abdulrahman: This is most likely a case of peripartum cardiomyopathy. We need more info though.
Gastric cancer what to do for (T) staging?
Abdulrahman: The answer is endoscopic US (EUS). The T refers to the size and extent of the main tumor. The EUS is done to delineate the depth of the tumor invasion in the gastric wall.
Abdulrahman: The answer is endoscopic US (EUS). The T refers to the size and extent of the main tumor. The EUS is done to delineate the depth of the tumor invasion in the gastric wall.
Another similar question: Pt with oesophageal cancer how to do staging?
A- CT
B- Esophageal US
C- CXR
Abdulrahman: Both CT and Esophageal US are used for staging, however, I will go for Esophageal US.
- CT is used for locating, content, and mets.
- Esophageal US is used for infiltration depth and regional lymph nodes invasion.
To stage an esophageal cancer according to TNM:
- We use CT for N and M
- While T we use endoscopic US
A- CT
B- Esophageal US
C- CXR
Abdulrahman: Both CT and Esophageal US are used for staging, however, I will go for Esophageal US.
- CT is used for locating, content, and mets.
- Esophageal US is used for infiltration depth and regional lymph nodes invasion.
To stage an esophageal cancer according to TNM:
- We use CT for N and M
- While T we use endoscopic US
Patient with stab wound in anterior neck. he is Alert but in labs oxygen sat 82%. What to do NEXT:
A- Oxygen mask
B- Cricothyroidotomy
C- Endotracheal intubation
D- Tracheostomy
Abdulrahman: The answer is C. He has a stab wound in the neck, so the oxygen mask will leak. You can do endotracheal intubation through the neck wound itself. Of course in the full question they will tell you if the patient is in the hospital (endotracheal intubation) or in the scene of the injury or the ambulance (oxygen mask as a temporary measure until intubation is done).
A- Oxygen mask
B- Cricothyroidotomy
C- Endotracheal intubation
D- Tracheostomy
Abdulrahman: The answer is C. He has a stab wound in the neck, so the oxygen mask will leak. You can do endotracheal intubation through the neck wound itself. Of course in the full question they will tell you if the patient is in the hospital (endotracheal intubation) or in the scene of the injury or the ambulance (oxygen mask as a temporary measure until intubation is done).
Pt known case of dm and htn she's on medication metformin bid and her symptoms is controlled her labs are normal except hgb is 8 what to add her?
A- nothing to add
B- give iron
C- Change
Abdulrahman: This question is missing important info (age, other choices, and the labs exactly). Metformin can cause megaloblastic anemia (B12 deficiency), but not to the extent where it causes megaloblastic anemia. We can’t start her on iron without any iron level studies.
A- nothing to add
B- give iron
C- Change
Abdulrahman: This question is missing important info (age, other choices, and the labs exactly). Metformin can cause megaloblastic anemia (B12 deficiency), but not to the extent where it causes megaloblastic anemia. We can’t start her on iron without any iron level studies.
Child with sx of meningitis, on examination he has papilledema, council parents about what complication:
A. Hearing loss
B. Vision loss
C. Septic shock
Abdulrahman: Papilledema carries a high risk of vision loss, while one of the complications of meningitis is hearing loss. Make sure you read the question clearly as to whether he is asking about this patient directly or generally in patients with meningitis. From Om-Alqura:
- Most common complication of meningitis in general —> Hearing loss
- Expected complication of meningitis in case of papilledema is presented —> Vision loss
A. Hearing loss
B. Vision loss
C. Septic shock
Abdulrahman: Papilledema carries a high risk of vision loss, while one of the complications of meningitis is hearing loss. Make sure you read the question clearly as to whether he is asking about this patient directly or generally in patients with meningitis. From Om-Alqura:
- Most common complication of meningitis in general —> Hearing loss
- Expected complication of meningitis in case of papilledema is presented —> Vision loss
RA pt using ansid for joint pain came with unstable state what is intial investigation?
A- Erict X-ray
Better recall: A 53 years old male, known case of RA on NSAIDs. Presented to the ER with severe sudden abdominal pain, nausea and vomiting. On examination there is generalized tenderness and guarding. Which of the following is the investigation of choice?
A- Erect CXR.
B- Supine abdominal X-ray.
C- FAST
D- Colonoscopy.
Abdulrahman: The answer is A, since this patient most likely has a gastric or duodenal perforation (long history of using NSAIDs). We have to do an erect chest x-ray to detect if there is air under the diaphragm, which suggests pneumoperitoneum. Here is an example:
A- Erict X-ray
Better recall: A 53 years old male, known case of RA on NSAIDs. Presented to the ER with severe sudden abdominal pain, nausea and vomiting. On examination there is generalized tenderness and guarding. Which of the following is the investigation of choice?
A- Erect CXR.
B- Supine abdominal X-ray.
C- FAST
D- Colonoscopy.
Abdulrahman: The answer is A, since this patient most likely has a gastric or duodenal perforation (long history of using NSAIDs). We have to do an erect chest x-ray to detect if there is air under the diaphragm, which suggests pneumoperitoneum. Here is an example: