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).

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.

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.

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

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).

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.

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

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:

5 y girl presented with pubic hair and smell like adult. What is initial investigation?
A- FSH
B- Testerone
C- 17 hydroxy...
D- Dihroxy…

Abdulrahman: The answer is D. This is most likely a case of premature adrenarche and not precocious puberty, so we will have to do dehydroepiandrosterone sulphate (DHEAS).
Hacker & Moore:

- Precocious puberty: The criteria for diagnosis include development of female secondary sexual characteristics (breast budding, menstruation, and pubic hair) and accelerated growth before age 8 in girls and age 9 in boys. We start the investigations with FSH & LH.
- Incomplete isosexual precocity: is the early appearance of a single secondary sexual characteristic. These conditions include premature thelarche, the isolated appearance of breast development before the age of 4 years (unilateral or bilateral) that resolves spontaneously within months and that is probably secondary to transient estradiol secretion; premature adrenarche, the isolated appearance of axillary hair before the age of 7 years that is the result of premature androgen secretion by the adrenal gland; and premature pubarche, the isolated appearance of pubic hair in girls before the age of 8 years. Premature adrenarche will present with the development of pubic hair, oily skin, oily hair and body odor.

Pregnant pt come with painful breast mass, tinder and redness, asking about diagnosis:
A- mastitis
B- abscess
C- duct Ectasia
D- something

Abdulrahman: This is most likely a case of breast abscess and not mastitis.
- Breast abscess: The diagnosis of should be suspected based on clinical manifestations (localized inflammation of the breast associated with fever and a fluctuant, tender,warm, and palpable mass)
- Mastitis: usually occurs in lactating women and will present with tender, firm, swollen, and diffuse erythematous breast (not mass).

Hydatic cyst question. CT show daughter cysts. What is the definitive management?
A- Surgical deroofing
B- Aspiration
C- Right hepectomy

Another recall: scenario about hydatid cyst 10*13 with daughter cysts, what is the management?
A. Surgical deroofing
B. Percutaneous aspiration
C. Right hepatectomy

Abdulrahman: The best management is surgical deroofing, since this is a WHO stage CE3b. Initially, Albendazole or Mebendazole.