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).

A 15 month or 18 month child brought to you, he was last reviewed with the primary care physician and received vaccination when he was 2 months old. Havent received any vaccination after that. He has had multiple times, upper resptract infection. Now he has come with cough fever, runny nose, again Upper respiratory tract infection. Now nbs?
A- Give antibiotics, wait for 10 days and then again start vaccination acording to age.
B- Start vaccination now according to current age.
C- Give the missed vaccination plus start vaccination according to age.

Abdulrahman: The answer is C, unless the signs and symptoms are moderate or severe. Here are the other invalid contraindications to vaccines (يعني تعطيه بالحالات هذه):

Male came to the clinic with right scrotal enlargement and when asked to cough it pulsate and separated from the testis, ask about diagnosis.
A- Varicocele
B- direct inguinal hernia
C- indirect inguinal hernia

Abdulrahman: I will go with indirect inguinal hernia, since it is the one that usually descends into the scrotal sac. Although, you need more info to decide. Here is a way to differentiate each choice:

- Varicocele: They present as a lump, often described as feeling like a “bag of worms” or with a “dragging sensation”, and may disappear while lying flat. It is important to examine the patient lying down, standing up and whilst performing a valsalva maneuver.

- Inguinal hernias (direct and indirect): can pass into the scrotum via the external inguinal ring, entering the inguinal canal initially at the internal ring (indirect hernia) or through Hesslebach’s triangle (direct hernia). Passing into the scrotum they run alongside the spermatic cord. On examination, you cannot “get above” an inguinal hernia within the scrotum (i.e. cannot palpate its superior surface). A cough may exacerbate the swelling and may disappear upon lying flat.

known SCA and received blood transfusions 3 week ago , now he came for hepatitis A vaccine, what to do ?
A- give the vaccine
B- ask him to coma after 3 month
C- come after 6 month
D- come after 9 months

Abdulrahman: The answer is A (Dr. Safdar also agress), since recent blood transfusion is not a reason to delay killed-vaccines like hepatitis A. Here are the actions done in cases of delaying live vaccines:

baby diagnosed with Cystic fibrosis. ..he has + sweat chloride test his brother is normal. to confirm diagnosis of cystic fibrosis....
A- CFTR gen in parent
B- CFTR in sibling
C- Chloride test. .parent
D- Chloride test in sibling

Abdulrahman: The answer is B (also answered by Dr. Safdar). Sweat chloride test is good for screening. The best (confirms the diagnosis) is genetic (CFTR)
If the question was asking about the diagnosis of CF in the sibling, then the answer is chloride test in the sibling.
If the chloride test in sibling was normal AND sibling has no symptoms, then CF is unlikely.
If chloride testing in sibling was normal and sibling has symptoms, then we move the DNA test of sibling (the 2 CF-causing mutation).

AF female 50 on warfarine , palpitation Stable , no medical historywhat's the next ?
A- Stop warfarin
B- Exchange warfarin by ASA
C- Continue on Same medication

Better recall: 55 years old female came to the clinic for regular follow up. 6 months age she was diagnosed with atrial fibrillation. Now she is asymptotic and has no palpitations, her medical history is significant for transit ischemic attack and hypertension. She is on Warfarin, Beta blockers, and statins. What is the most appropriate management for her?
A- Discontinue warfarin
B- Continue warfarin
C- Continue warfarin and start aspirin
D- Discontinue warfarin and start clopidogrel

Abdulrahman: The answer is to continue warfarin, since warfarin is given in cases of atrial fibrillation to prevent emboluses from forming.