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.

36 with le- neck mass, 2x2xm in posterior angle of mandible US: normal thyroid, le- large LN with cysTIc component FNA: all smear shows follicular thyroid
A- Metastatic thyroid cancer
B- Apparent thyroid
C- Ectopic thyroid
D- Thryoglossal cyst

Another recall: 33yo male with painless swelling in the posterior triangle of his neck.
On US thyroid is normal and the swelling has cystic component. FNA shows complete follicular cells. What is the most likely diagnosis?
A. Apparent thyroid
B. Metastatic cancer
C. Ectopic thyroid
D. Thyroglossal cyst

Abdulrahman: Since it is on the posterior triangle of the neck, the answer is a metastatic aberrant thyroid. Aberrant can be meant as metastatic or ectopic normal thyroid. If Papillary cancer is in the choices, go for it. Here is a similar recall or another question from Dr. Thawaba:

Pregnant woman about to deliver, past history significant for Asthma and E.Coli. What to give during delivery?
A- Betamethasone
B- Ampecilline

Abdulrahman: We don’t know at what gestational age she is. It could be this question:

patient with RTA is stable and conscious with a patent airway. His blood pressure is 105/90 mmHg. His GCS score is 15. What is the most appropriate next step?
A. IV Fluid
B. FAST

Abdulrahman: The answer is A (ABC protocol)