45y man no Family hx of colon cancer, no risk factor, came for screening ?
A- start screening at 50y
B- start screening now
Another recall: 45 female no family hx of any cancer and medically free ask for colon cancer screen:
A- no need
B- in age 50
C- do now
Abdulrahman: The answer is to do it at 50 years of age (Dr. J and Dr. Thawaba agrees with this). The new guidelines suggest we start at 45, but I don’t think that the new colonoscopy screening guides are applied in the SMLE. We start at 50 and do colonoscopy every 10 years.
A- start screening at 50y
B- start screening now
Another recall: 45 female no family hx of any cancer and medically free ask for colon cancer screen:
A- no need
B- in age 50
C- do now
Abdulrahman: The answer is to do it at 50 years of age (Dr. J and Dr. Thawaba agrees with this). The new guidelines suggest we start at 45, but I don’t think that the new colonoscopy screening guides are applied in the SMLE. We start at 50 and do colonoscopy every 10 years.
Child came with 10 cm neck swelling that is soft and bogy how you will manage ?
A. surgery
B.sclerotheraby
C.chemotherapy
D.radiation
Another recall: Cyst measures 10× 9 in the side of the neck by FNA clear lymphatic fluid. What is the appropriate management ?
A.Chemotherapy
B.Radiotherapy
C.Sclerotherapy
D. Surgery
Another recall: Child came with 10 cm neck swelling that is soft and bogy how you will manage ?
A- surgery
B- sclerotheraby
C- chemotherapy
D- radiation
Another recall: 2 or 3 yo with swelling behind the ear, and FNA showed was clear lymphatic fluid. What to do:
A- Surgery
B- Sclerotherapy
C- Radiotherapy
D- chemotherapy
Another recall: Rt neck lump 10cm spongy in palpating, fna show lymphatic fluid
A- Surgery
B- Sclerotherapy
C- Chemotherapy
D- Radiotherapy
Another recall: Case of an infant with a lateral neck mass 10*10 cm aspiration revealed a clear lymphatic fluid, what’s the most appropriate ttt?
A- surgical excision
B- Radiotherapy
Abdulrahman: The answer is sclerotherapy. This was also answered by Dr. Thawaba and Dr. J. Sclerotherapy is the first-line treatment for problematic macrocystic hygroma (lymphangioma). Surgical removal of macrocystic LM is indicated if the lesion is symptomatic and sclerotherapy is no longer possible, or resection is possibly curative because the lesion is small and well localized.
A. surgery
B.sclerotheraby
C.chemotherapy
D.radiation
Another recall: Cyst measures 10× 9 in the side of the neck by FNA clear lymphatic fluid. What is the appropriate management ?
A.Chemotherapy
B.Radiotherapy
C.Sclerotherapy
D. Surgery
Another recall: Child came with 10 cm neck swelling that is soft and bogy how you will manage ?
A- surgery
B- sclerotheraby
C- chemotherapy
D- radiation
Another recall: 2 or 3 yo with swelling behind the ear, and FNA showed was clear lymphatic fluid. What to do:
A- Surgery
B- Sclerotherapy
C- Radiotherapy
D- chemotherapy
Another recall: Rt neck lump 10cm spongy in palpating, fna show lymphatic fluid
A- Surgery
B- Sclerotherapy
C- Chemotherapy
D- Radiotherapy
Another recall: Case of an infant with a lateral neck mass 10*10 cm aspiration revealed a clear lymphatic fluid, what’s the most appropriate ttt?
A- surgical excision
B- Radiotherapy
Abdulrahman: The answer is sclerotherapy. This was also answered by Dr. Thawaba and Dr. J. Sclerotherapy is the first-line treatment for problematic macrocystic hygroma (lymphangioma). Surgical removal of macrocystic LM is indicated if the lesion is symptomatic and sclerotherapy is no longer possible, or resection is possibly curative because the lesion is small and well localized.
Pt with a penetrated neck in zone 1 and is bleeding, what is the best management?
A- open and primary repair
B- Endovascular
C- open and ligation
Another recall: Neck penetrating injury on zone 1 with subcutaneous emphysema:
A. Neck exploration
B. CTA
C. Angio embolization
Abdulrahman: The answer is CTA. Here is the approach to neck injuries from Schwartz:
A- open and primary repair
B- Endovascular
C- open and ligation
Another recall: Neck penetrating injury on zone 1 with subcutaneous emphysema:
A. Neck exploration
B. CTA
C. Angio embolization
Abdulrahman: The answer is CTA. Here is the approach to neck injuries from Schwartz:
Trauma patient, with typical signs and symptoms of tension pneumothorax, his GCS is 8, what is your next step in management?
A- Intubation
B- Needle thoracotomy
Full recall: A 35 year old car driver crashed into a concrete block without a safety belt on. Thirty minutes after and on the way by ambulance to the hospital he begins to become breathless. On administration of 100% oxygen there is not much improvement in this condition. On arrival at the Emergency Department he has lost consciousness (GCS 8) and appears cyanosed with markedly distended jugular veins. Blood pressure 80/40
Heart rate 120 /min
Respiratory rate 34 /min
Temperature 36.6 c
Oxygen saturation 60% on room air
What immediate action should be taken?
A. Intubation and 100% oxygen
B. Rapid infusion of crystalloid
C. Needle decompression
D. IV 0.2 mg adrenaline
Abdulrahman: The answer is intubation and 100% oxygen. This is the full recall. You are not sure if this is a cardiac tamponade or tension pneumothorax. Also, this question is begging you to follow the ATLS protocol. He is unconscious (risk of aspiration and hypoxia), so we have to secure the airway with intubation (ABC). Intubation is Airway and needle decompression is Breathing. If his GCS was normal, I would have gone for needle decompression. Here is an example of how much clearer the questions will be in the exam :D
A- Intubation
B- Needle thoracotomy
Full recall: A 35 year old car driver crashed into a concrete block without a safety belt on. Thirty minutes after and on the way by ambulance to the hospital he begins to become breathless. On administration of 100% oxygen there is not much improvement in this condition. On arrival at the Emergency Department he has lost consciousness (GCS 8) and appears cyanosed with markedly distended jugular veins. Blood pressure 80/40
Heart rate 120 /min
Respiratory rate 34 /min
Temperature 36.6 c
Oxygen saturation 60% on room air
What immediate action should be taken?
A. Intubation and 100% oxygen
B. Rapid infusion of crystalloid
C. Needle decompression
D. IV 0.2 mg adrenaline
Abdulrahman: The answer is intubation and 100% oxygen. This is the full recall. You are not sure if this is a cardiac tamponade or tension pneumothorax. Also, this question is begging you to follow the ATLS protocol. He is unconscious (risk of aspiration and hypoxia), so we have to secure the airway with intubation (ABC). Intubation is Airway and needle decompression is Breathing. If his GCS was normal, I would have gone for needle decompression. Here is an example of how much clearer the questions will be in the exam :D
Pt in ICU received 15 units of blood, now blood coming out from NGT, incision, and cannula site
A- Transfusion reaction
B- Thrombocytopenia
C- Hypocalcemia
D- Von wilbrand
Abdulrahman: This could be a case of dilutional coagulopathy, since he got 15 units of blood. Patients with transfusion reaction will most likely present with bleeding, fever, and signs of shock:
A- Transfusion reaction
B- Thrombocytopenia
C- Hypocalcemia
D- Von wilbrand
Abdulrahman: This could be a case of dilutional coagulopathy, since he got 15 units of blood. Patients with transfusion reaction will most likely present with bleeding, fever, and signs of shock:
65-year-old, heavy smoker is coming for routine checkup. What is the best screening test for him?
A- Osteoporosis
B- Colon cancer
C- AAA
Abdulrahman: Both B and C are correct. I know that this is a textbook presentation of a patient who needs to be screened for AAA. However, I will go with B, because as far as I know, we don't do AAA screening in Saudi Arabia. We only check for AAA in Saudi Arabia if the patient has symptoms (and Dr. J agrees with this). The USPSTF has a Grade B recommendation for screening of AAA in asymptomatic patients. Colon cancer screening is Grade A. This is why I went for colon cancer screening as the best screening test in this case. So, since he chose me between what is best, I will go for colon cancer screening.
A- Osteoporosis
B- Colon cancer
C- AAA
Abdulrahman: Both B and C are correct. I know that this is a textbook presentation of a patient who needs to be screened for AAA. However, I will go with B, because as far as I know, we don't do AAA screening in Saudi Arabia. We only check for AAA in Saudi Arabia if the patient has symptoms (and Dr. J agrees with this). The USPSTF has a Grade B recommendation for screening of AAA in asymptomatic patients. Colon cancer screening is Grade A. This is why I went for colon cancer screening as the best screening test in this case. So, since he chose me between what is best, I will go for colon cancer screening.
Female after trauma to anterioc chest clear breath sounds bilaterally with pounding pulse,distended jvp bp110/70 pulse 90 (nearly)
A- Cardiac tamponade
B- Cardiac contusions
C- Tension pneumothorax
D- Pleural effusion
Another recall: A patient with Anterior chest trauma with bruising in the sternum. Patient vitally stable, clear cardiac and respiratory exam, except for pounding pulse. ECG: Arrhythmia X-ray: Sternal Fracture. Echo: Normal What is the diagnosis:
A. Pneumothorax
B. Cardiac contusion
C. Cardiac Tamponade
D. Ventricular rupture
Abdulrahman: The answer is B, since the patient has arrhythmia on the ECG and does not fulfill the criteria for Beck’s triad.
Dayel: Beck’s triad includes:
- The presence of low blood pressure
- Distension of the jugular veins
- Muffled or diminished heart sounds on cardiac auscultation
Although the presence of the complete triad is highly suggestive of cardiac tamponade, only a small number of cases present with all the elements of Beck’s triad at diagnosis.
A- Cardiac tamponade
B- Cardiac contusions
C- Tension pneumothorax
D- Pleural effusion
Another recall: A patient with Anterior chest trauma with bruising in the sternum. Patient vitally stable, clear cardiac and respiratory exam, except for pounding pulse. ECG: Arrhythmia X-ray: Sternal Fracture. Echo: Normal What is the diagnosis:
A. Pneumothorax
B. Cardiac contusion
C. Cardiac Tamponade
D. Ventricular rupture
Abdulrahman: The answer is B, since the patient has arrhythmia on the ECG and does not fulfill the criteria for Beck’s triad.
Dayel: Beck’s triad includes:
- The presence of low blood pressure
- Distension of the jugular veins
- Muffled or diminished heart sounds on cardiac auscultation
Although the presence of the complete triad is highly suggestive of cardiac tamponade, only a small number of cases present with all the elements of Beck’s triad at diagnosis.
Which of the following is the earliest plain radiographic finding of rheumatoid arthritis
A- Juxta-articular osteopenia
B- No abnormality
C- Soft tissue swelling
D- Subchondral erosions
E- Symmetric joint space loss
Abdulrahman: A, B, and C are all early findings. Om-Alqura’s answer is C.
A- Juxta-articular osteopenia
B- No abnormality
C- Soft tissue swelling
D- Subchondral erosions
E- Symmetric joint space loss
Abdulrahman: A, B, and C are all early findings. Om-Alqura’s answer is C.
Adult with Hypertension and Dm has 2 months history of Small perianal painful Swelling Bp: 160 / 100 ?
A-Perianal abscess
B-Preanal fistula
C-Thrombosed pile
Another Recall: 28 years old patient came with severe perianal pain and swelling. On examination, there is 1x1 cm perianal swelling with tenderness. Vitals: normal, no fever. Labs: WBC 8 (normal). Which of the following is the most likely diagnosis ?
A. Anal fistula
B. Anal fissure
C. Perianal abscess
D. Perianal hematoma
Abdulrahman: This is most likely a case of perianal hematoma or a thrombosed pile (external hemorrhoid).
- Anal fistula: pain and discharge and an obvious opening
- Anal hematoma and thrombosed pile: swelling and painful, but vitally stable
- Anal abscess: swelling, painful, high wbc, and the patient will have fever
- Anal fissure: very painfull, and a fissure (crack) will be seen
A-Perianal abscess
B-Preanal fistula
C-Thrombosed pile
Another Recall: 28 years old patient came with severe perianal pain and swelling. On examination, there is 1x1 cm perianal swelling with tenderness. Vitals: normal, no fever. Labs: WBC 8 (normal). Which of the following is the most likely diagnosis ?
A. Anal fistula
B. Anal fissure
C. Perianal abscess
D. Perianal hematoma
Abdulrahman: This is most likely a case of perianal hematoma or a thrombosed pile (external hemorrhoid).
- Anal fistula: pain and discharge and an obvious opening
- Anal hematoma and thrombosed pile: swelling and painful, but vitally stable
- Anal abscess: swelling, painful, high wbc, and the patient will have fever
- Anal fissure: very painfull, and a fissure (crack) will be seen
Pediatric abdominal dissension costpiation PR examination empty rectum while withdrawing the finger gush of stool comes out what is your next action
A-Referral to GS
B-Reassuring
C-Enema
Another recall: 4 y/o boy has chronic constipation despite eating high fiber diet and stool softeners, examination shows empty rectum but after DRI huge gush of stool, management?
A-Surgery
B-Increase stool softener dose
C-Refer to oncology
D-Increase high fiber diet
Abdulrahman: This is a case of Hirschsprung’s disease. We start with a barium enema rectally (not orally) to know the extent of the disease. To confirm the diagnosis, we do a rectal air suction biopsy (will show lack of ganglionic cells and/or hypertrophy of cells). Management is through rectal washing and transanal endorectal pull-through.
A-Referral to GS
B-Reassuring
C-Enema
Another recall: 4 y/o boy has chronic constipation despite eating high fiber diet and stool softeners, examination shows empty rectum but after DRI huge gush of stool, management?
A-Surgery
B-Increase stool softener dose
C-Refer to oncology
D-Increase high fiber diet
Abdulrahman: This is a case of Hirschsprung’s disease. We start with a barium enema rectally (not orally) to know the extent of the disease. To confirm the diagnosis, we do a rectal air suction biopsy (will show lack of ganglionic cells and/or hypertrophy of cells). Management is through rectal washing and transanal endorectal pull-through.
Elderly was completely healthy except for elevated BP for the first time
A. Ambulatory BP measurement
B. Start anti HTN
C. Measure the BP two times later on in the clinic
D. Measure BP two time in hom
Abdulrahman: The answer is D (initial). According to the USPSTF and UTD, we start with measuring the BP two times at home, then give the patient an ambulatory BP monitor.
A. Ambulatory BP measurement
B. Start anti HTN
C. Measure the BP two times later on in the clinic
D. Measure BP two time in hom
Abdulrahman: The answer is D (initial). According to the USPSTF and UTD, we start with measuring the BP two times at home, then give the patient an ambulatory BP monitor.
5 y o vomiting and diarrhea for 4 days O/E pt looks dehydrated, hypocative, sunken eyes , doughy skin , dry mecus membranes , cap refill is 4 seconds Bp 90/70 and tachycardic rest of vitals are normal
What is his Na level
A-Low
B-High
C-No corrolation
D-normal
Abdulrahman: It depends if the child has normal diarrhea (hyponatremia) or gastroenteritis (hypernatremia). Since the child has a case of acute diarrhea and vomiting, I will go with B.
What is his Na level
A-Low
B-High
C-No corrolation
D-normal
Abdulrahman: It depends if the child has normal diarrhea (hyponatremia) or gastroenteritis (hypernatremia). Since the child has a case of acute diarrhea and vomiting, I will go with B.
Which part of the urethra is the most vunlerable to injury
A- membranous
B- bulbar
C- prostatic
D- Penile
Abdulrahman: The answer is A. The membranous part of the urethra is the most vulnerable to be injured (our question), but the bulbar is the most commonly injured.
A- membranous
B- bulbar
C- prostatic
D- Penile
Abdulrahman: The answer is A. The membranous part of the urethra is the most vulnerable to be injured (our question), but the bulbar is the most commonly injured.
A child starts to develop an awareness for strangers and separation anxiety. How old is the child in months?
A- 6 months
B- 7 months
C- 12 months
D- 24 months
Better recall: Child started to develop sense of individuality. She recognize strangers and frightens when separated from her parents.
A- 6
B- 7
C- 10
D- 12
Abdulrahman: I’ll go with 10 months, since it’s the closest answer. He’s experiencing stranger anxiety (6 months), sense of individuality (7 months) and separation anxiety (9 months)
A- 6 months
B- 7 months
C- 12 months
D- 24 months
Better recall: Child started to develop sense of individuality. She recognize strangers and frightens when separated from her parents.
A- 6
B- 7
C- 10
D- 12
Abdulrahman: I’ll go with 10 months, since it’s the closest answer. He’s experiencing stranger anxiety (6 months), sense of individuality (7 months) and separation anxiety (9 months)
Pt female 54 case CHF symp controled on acei + furosemide just complianed of intermittent dry cough what to do
A- Stop furosemide
B- Increase furosemide
C- Add beta agonist
D- Do pul function test
Another recall: pt. On furosemide and Acei. Come with non productive cough whats the most appropriate next step ?
A-increase furosemide
B- polmonary function test
C- add inhaler
D- decrease furosemide
Abdulrahman: The choices don’t make any sense. I need a better recall, since I think the question is missing an important choice or info. So we do know that ACE-I causes dry coughing as a side effect. We have to change it to ARBs (if it was one of the choices).
- We don’t need to decrease or stop furosemide, since it has nothing to do with his symptoms.
- There are no signs of pulmonary edema, so we don’t have to increase the dose of furosemide.
- Beta blockers can cause tachycardia, which is not preferred in CHF.
- We don’t have to do pulmonary function tests, since there are no indications for it in this case.
A- Stop furosemide
B- Increase furosemide
C- Add beta agonist
D- Do pul function test
Another recall: pt. On furosemide and Acei. Come with non productive cough whats the most appropriate next step ?
A-increase furosemide
B- polmonary function test
C- add inhaler
D- decrease furosemide
Abdulrahman: The choices don’t make any sense. I need a better recall, since I think the question is missing an important choice or info. So we do know that ACE-I causes dry coughing as a side effect. We have to change it to ARBs (if it was one of the choices).
- We don’t need to decrease or stop furosemide, since it has nothing to do with his symptoms.
- There are no signs of pulmonary edema, so we don’t have to increase the dose of furosemide.
- Beta blockers can cause tachycardia, which is not preferred in CHF.
- We don’t have to do pulmonary function tests, since there are no indications for it in this case.
Ped having petechial rash, epistaxis, fever, labs: low hgb, low plt, high wbc how to dx
A- Bone marrow
B- Bleeding profile
C- Blood bulture
D- Electrophoresis
Abdulrahman: This could be a case of acute lymphocytic leukemia (ALL). ALL is the neoplasm of early lymphocytic precursors. ALL is the most common malignancy in children under age 15. Labs will show high WBC and low hgb and platelets. We have to order a blood smear first, but we confirm the diagnosis with a bone marrow biopsy. Histology reveals a predominance of lymphocytes.
Similar question: Child with arthritis , fever, epistaxis, gingival bleeding, results : platelets : is low , Hb is : low , whays the investigation ?
A- Bone marrow aspiration
B- Electrophoresis
C- Anti dsDNA
D- ANA
Abdulrahman: The answer is A (Dr. Safdar also agrees with this). This is most likely a case of aplastic anemia. We have to order a bleeding profile to rule out the other ddx. A bone marrow biopsy is crucial (confirmatory) to determine cellularity or the extent of depletion of the hematopoietic elements. The clinical presentation of aplastic anemia is:
- Anemia (low hgb in our case) due to reduced red cell number
- Infection (fever) due to reduced white cell numbers (especially neutrophils)
- Bruising and bleeding (petechial rash and epistaxis) due to thrombocytopenia.
The answer could also be ANA, since the patient has features of SLE (arthritis, thrombocytopenia, leukopenia, autoimmune hemolytic anemia (low hgb), and fever). Systemic lupus erythematosus can happen in children. In most cases, lupus starts during a child's teenage years (the average age is 12). It is rarely seen in children before the age of 5.
A- Bone marrow
B- Bleeding profile
C- Blood bulture
D- Electrophoresis
Abdulrahman: This could be a case of acute lymphocytic leukemia (ALL). ALL is the neoplasm of early lymphocytic precursors. ALL is the most common malignancy in children under age 15. Labs will show high WBC and low hgb and platelets. We have to order a blood smear first, but we confirm the diagnosis with a bone marrow biopsy. Histology reveals a predominance of lymphocytes.
Similar question: Child with arthritis , fever, epistaxis, gingival bleeding, results : platelets : is low , Hb is : low , whays the investigation ?
A- Bone marrow aspiration
B- Electrophoresis
C- Anti dsDNA
D- ANA
Abdulrahman: The answer is A (Dr. Safdar also agrees with this). This is most likely a case of aplastic anemia. We have to order a bleeding profile to rule out the other ddx. A bone marrow biopsy is crucial (confirmatory) to determine cellularity or the extent of depletion of the hematopoietic elements. The clinical presentation of aplastic anemia is:
- Anemia (low hgb in our case) due to reduced red cell number
- Infection (fever) due to reduced white cell numbers (especially neutrophils)
- Bruising and bleeding (petechial rash and epistaxis) due to thrombocytopenia.
The answer could also be ANA, since the patient has features of SLE (arthritis, thrombocytopenia, leukopenia, autoimmune hemolytic anemia (low hgb), and fever). Systemic lupus erythematosus can happen in children. In most cases, lupus starts during a child's teenage years (the average age is 12). It is rarely seen in children before the age of 5.