Lactating women present with right breast pain for 6 day . On examination hot tendered swelling lateral to the right areola Pt started to take floxacillin Us /Cystic lesion, thickened content , ddx could be galactocele , abscess , complicated cyst for correlation. What next
A- I&D
B- repeated aspiration
C- Exisional biopsy
D- I forgot could be reassurance or antibiotic

Abdulrahman: This could be a case of breast abscess (mass lateral to the areola, cystic lesion with thickened content, tender, and hot) The choice between aspiration and percutaneous drainage. It also depends on the size.

Indications for percutaneous drainage:
- One abscess (not multiple)
- Small abscess (<5cm)
- The abscess is not drained
- No thinning of the skin (risk of rupture)
- Not necrosed skin

A 60-year-old man is admitted to the Coronary Care Unit with an acute myocardial Infraction. His hemodynamic parameters 2 hours later are: Blood pressure :80/50 mmHg Heart rate 40 /min Oxygen saturation °C 95% on room air Which of the following would be the appropriate management?
A. IV 0.6 mg atropine sulphate
B. Normal saline infusion
C. IV isoproterenol
D. IV dobutamine

Abdulrahman: The answer is A. This patient has bradycardia and hypotension. Om-Alqura also answered this question:

solitary thyroid nodule 4 mm with neck pain ,tsh and t4 normal ,the next step?
A- FNA
B- Flow up with images

Better recall: 24 years old male presented with neck pain for 3 months. Examination and palpation of the neck was normal. TFT was given (all normal). US showed 4x7 mm solid left thyroid nodule. Benign lymph nodes. Most appropriate management?
A- Radioidone scan
B- FNA
C- Follow up imaging
D- Left hemithyroidectomy

Abdulrahman: The answer is follow up with imaging, since the cutoff for FNA is >1cm.

Female small inguinal hernia:
A. Open with mesh
B. Reassuring
C. Small open surgery
D. Laparoscopic

Better recall: Woman in her fifties asymptomatic has a small femoral hernia, what is the best :
management?
A. Conservative
B. Mesh repair
C. Open repair
D. Laparoscopic

Abdulrahman: Since the question asks about the best management, the answer is repair with mesh.

If you have a disease that has high incidence female and equal prevalence in male and female How did that happen
A- Case fatality is high in female
B- Male patient die more from this disease
C- Female carry this disease for longer period
D- Male carry this disease for shorter period

Abdulrahman: The answer is A. High incidence in females + equal prevalence in both genders = More females are dying compared to males.

12 yo girl with weight loss, diarrhea for 10 months? With occasionally bloody diarrhea, periumbilical abd pain after meals asking about dx ?
A- peptic ulcer
B- Crohns

Another recall: 13 years old with 10 month history of periumblical abdominal pain , post prandial pain , vomiting , diarrhea,stool associated with blood sometime , ?
A. Peptic ulcer disease
B. Crohn’s

Abdulrahman: The answer is B, since she doesn’t have risk factors for peptic ulcer and is in the normal age of distribution(onset before 30 years and a second smaller peak at age 60).

82 year old male with very painful micturition what is the most approppriate management
A- Abx for uti
B- Foley catheter
C- Cysoscopy and turp

Abdulrahman: The answer is B. We have to insert a foley’s catheter, since the patient is having symptoms of urinary retention. We can’t give antibiotics straight away without even a urine analysis.

51 Y M with New ascites & Cirrhosis due to nonalcoholic steatohepatitis.DM2, HTN, dyslipidemia. On metformin, lisinopril, and atorvastatin Low-Na diet started Creatinine 1.1, urine protein-crea ratio 16 mg/g. The most appropriate additional treatment is?
A- Discontinue atorvastatin
B- Initiate low-protein diet
C- Discontinue lisinopril
D- Initiate lactulose

Abdulrahman: The answer is C. The same case is written in this website with the answer:

Case of cirrhotic patient with diffuse abdominal pain and fever and
leucocytocis
Ct ascites
Appropriate next step
A- Antibiotics

Abdulrahman: This patient most likely has spontaneous bacterial peritonitis (SBP). If diagnostic paracentesis is in the choices, go for it. If not, go for antibiotics. BMJ: Diagnosis is made, first by eliciting the presence of ascites, then by looking for signs and symptoms consistent with peritoneal irritation, and finally by confirmation with peritoneal fluid testing. Owing to the high prevalence of SBP in hospitalized patients with cirrhosis and ascites, diagnostic paracentesis should be performed on all patients with these two conditions, even in the absence of symptoms suggestive of infection.

p.t after MVA At ER , Vitally stable O/E ( Lift hypochondrium tenderness and ecchymosis) What is the MOST APPROPRIATE TEST:
A- CT
B- FAST
C- DPL
D- Laparotomy

Abdulrahman: Choosing between CT and FAST in trauma cases has always been a controversial topic (especially in the SMLE). I will choose CT scan. If stable, CT. If unstable, laparotomy.

Case of bile duct injury above cystic duct Treatment?

Another recall: Pt had cholecystectomy and cystic duct was injured how would you repair it
A-Hepato jejunostomy
B-Hepato deudeontomy
C-Choldejejuonestomy
D-Cholo deudentomy

Abdulrahman: The most common technique to repair major bile duct injuries is the Roux-en-Y hepaticojejunostomy. Here is the full recall with the answer from Dr. Thawaba:

Patient underwent lap chole for multiple gallstones 7 days ago, presents with vague abdominal pain. On US there is fluid around the gallbladder (something like that) and the CBD is 9 mm. What is the most likely diagnosis or cause?
A - CBD injury
B - Retained stone in CBD
C - Sub-hepatic collection

Abdulrahman: There are different answers to this question between Dr. Thawaba (B) and Dr. J (A). In all honesty, I will go with Dr. J. Here is the explanation:

55 patient came to ER with abdominal distention and vomiting previous history of ventral hernia repair with mesh U/S Target sign and stricture in terminal ileum ?
A- adhesion with mesh
B- late onset chrons
C- mesenteric ischemia

Another recall: 50 or 60 Y/O Pt. Post ventral hernia Surgery with mesh 6 years ago, Pt.
come with abdominal distension. On Radiographic imaging: Cut off sign in the ileum with target sign and soft tissue mass. What is the Diagnosis?
A. Late-onset Crohn’s
B. Adhesions with mesh
C. Small bowel cancer

Abdulrahman: We still couldn’t find an answer to this question (A or B). I will go with since I think the hint is hx ventral hernia Surgery with mesh 6 years ago (most common cause of adhesions).