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.

شرح بسيط لكيف تحلّون أسئلة الMost appropriate في أي قسم بالإختبار:

Infertile women for three years came to clinic with her husband, she wants to conceive but she couldn’t, semen analysis is normal, induction of ovulation by clomiphene citrate was done, (i think every thing else is normal regarding labs) what to do next:
A-IVF
B-IUI
C-laparoscopy
D-induction again(with another drug not clomiphene)

Abdulrahman: I will most likely go with B, since she most likely has a cervical problem and not a hormonal problem (her menstruation is fine). We have to do a tubal patency test beforehand to decide. Here are the reasons for management from UTD:
- Another hormone (aromatase inhibitors?): Anovulatory WHO 2 patients who have a poor outcome with clomiphene (no ovulation or thin endometrium) may have a better response with aromatase inhibitors. WHO 2 patients are women may secrete normal amounts of gonadotropins and estrogens. However, FSH secretion during the follicular phase of the cycle is subnormal.
- Laparoscopic ovarian drilling by diathermy or laser is a surgical treatment to induce ovulation in anovulatory PCOS patients.
- Intrauterine insemination (IUI): cervical factors infertility are best treated by IUI to bypass cervical factors (eg, scanty or abnormal mucus that might impair fertility).
- In vitro fertilization (IVF): is the next option for patients with cervical factor infertility who fail to conceive with IUI.


Similar question: Female coming to the fertility clinic to conceive ovulation is normal and did semen analysis for the husband and it’s normal , what the is most appropriate?
A. Tubal patency test
B. The other three are hormones

Abdulrahman: The answer is A. UTD: Assessment of fallopian tube patency: perform HSG as the first-line test for evaluation of tubal patency because of its therapeutic, as well as diagnostic, benefits. If HSG is not available, non or minimally invasive alternatives to HSG for investigation of tubal subfertility include chlamydia antibody testing and/or hysterosalpingo-contrast sonography (HyCoSy).

43 year old man has Hypertension, ACEI is initiated and his Creatinine rises from 1.2 to 1.5, his potassium is increasing, next best step?
A- Add thiazide diuretic
B- Continue same regimen
C- Switch to amlodipine
D- Add beta blocker

Dayel: I Would go with B. Rise of K and Cr levels are expected in any pt taking ACE-I, we don't stop until Cr raises 30% or serum K above 5.6mmol/L. Pubmed: ACE inhibitor therapy should not be discontinued unless serum creatinine level rise above 30% over baseline during the first 2 months after initiation of therapy or hyperkalemia (serum potassium level >or=5.6 mmol/L)

Abdulrahman: Agree with Dayel if the BP is controlled. If it is not controlled, we should add a thiazide. If the potassium is more than 5.5, add amlodipine.

A patient with a history of radiofrequency ablation is at risk for hypothyroidism. He comes for a checkup and his labs show a TSH of 5 (Normal is 0.5 - 5.0). What will you do to establish a diagnosis?
A- Repeat TSH in 4 weeks
B- Measure T4 levels
C- Thyroid scan
D- Thyroid US

Abdulrahman: The answer is A. We don’t do any tests right now since he doesn’t have abnormal results and we don’t suspect a pituitary disease.

Here is a better recall for the second question.