37 ys male typical case of pnonia Cxr showed rt lower lobe consBlidaBon + moderate effusion
A- Azithro + ciftrix
B- Sam meds + serial ct
C- Same + thoracocentesis
D- Same + something else

Abdulrahman: The answer is ampicillin + gentamicin + thoracocentesis. Here is a summary of pleural effusion from Om-Alqura:

65 years man presents to your clinic and looks weak , dehydrated, pale , thin and emacitaed. he complains of anal itching , discomfort from the pas few months. On examination, you find an anal mass that is 2 cm away from the anal verge , cauliflower like and friable. What is your most likely diagnosis?
A- Anal Cancer
B- Rectal Cancer .
C- condyloma accuminatae
D….

Abdulrahman: The answer is Anal carcinoma. The location of a rectal cancer is identified by its distance from the anal verge rather than the dentate line. Low (distal) rectal cancers are located 4 to 8 cm from the anal verge, middle rectal cancers 8 to 12 cm, and upper (proximal) rectal cancers 12 to 15 cm. The anal canal is 0 to 4 cm from the anal verge. This question was also answered by Dr. Thawaba in last year’s quiz that he made:

A 46 years old asymptomatic man. His mother recently died of metastatic colon cancer. She was diagnosed with colon Cancer 5 years ago at age 69 years. Which of the following is the most appropriate colorectal cancer screening strategy for this patient?
A- Colonoscopy every 5 years
B- Colonoscopy every 10 years
C- CT Colonography every 10 years
D- Fecal immunochemical testing every 5 years

Abdulrahman: I will go with a colonoscopy every 10 years, since he has a family member that was diagnosed with cancer after the age of 60. In that case, we can start screening early, but the screening interval is the same. In Schwartz’s and UTD, it says to do it every 5 year, but as far as what I’ve found, it did not specify regarding screening if the family member is above 60 years of age or below.

A 72 year old man presented with an episode of right sided weakness that lasted 10 minutes and fully resolved and he is clinically stable, he has no other medical illness. On examination: BP 110/70, HR 95, T 36.6 Which of the following is the most appropriate next step in the management?
A. Aspirin.
B. Warfarin, INR 3-4
C. Warfarin, INR 2-3
D. No additional drug treatment

Abdulrahman: The answer here is aspirin, since he had a transient ischemic attack (high risk of developing a subsequent stroke).
Here is another similar question, but the patient has Afib:

RUQ pain, for 12 hours, no fever, no jaundice. U.S findings “ non thickened G.B wall with multiple gall stones, CBD is obsecured “, what’s your diagnosis:
A- Acute Pancreatitis
B- Obstructive jaundice
C- Acute Cholecystitis
D- Ascending cholangitis

Another recall: A female patient presents with right upper quadrant pain for 12 hours. She is afebrile and not jaundiced. An ultrasound reveals a non-thickened gallbladder wall with multiple stones. The CBD is obscured. What is the most likely diagnosis?
A- Acute Pancreatitis
B- Obstructive jaundice
C- Acute Cholecystitis
D- Ascending Cholangitis

Abdulrahman: Both are very poor recalls. It’s not B or D, since the patient is not jaundiced and there is some inflammation that is obscuring the CBD. It could be a case of acute pancreatitis or suspected cholecystitis since there are no signs of imaging for inflammation.

Summary of chest cavity emergencies

Pt who’s kno. Case of CHF present with af , what medication you will give to control the rate :
A- digoxin
B- adenosine
C- amlodipine

Another recall: Patient known case congestive heart failure with atrial fibrillation. Which of the following could be given for rate control:
A. Digoxin
B. Lidocaine
C. Adenosine
D. Verapamil

Abdulrahman: The answer is digoxin, since we want to control the rate (not rhythm). Beta blockers would be a better choice. Calcium channel blockers (e.g., verapamil and diltiazem) are used as a second line after BB, but you avoid using them in patients with decompensated heart failure (LV systolic dysfunction/low ejection fraction).

Old (mostly 50) female NO PAST SURGICAL NOR MEDICAL hx and she presented with complaints of urine incontinence with coughing and sneezing (obvious for stress incontinence) most appropriate management?
A. Pelvic floor exercise
B. Urethral sling
C. Colporrhaphy
D. Burch procedure

Abdulrahman: The answer is A, since it is the first line management in such cases (strengthening the pelvic floor muscle).

Elderly pt fell down on his leg 2 weeks ago from that time he was bed ridden presented with shortness of breath and dyspnea and found to have high renal profile Which of the following if found in the urine indicates that he is suffering from cholesterol embolism?
A- granural cast
B- hyaline cast
C- esinophiluria
D- RBS cast

Another recall:Patient with acute kidney injury, how to know if the cause is cholesterol emboli? options include
A- red cell cast
B- epithelial cast
C- Hyaline cast
D- Eosinophiluria

Abdulrahman: Both C and D are correct. I would go with eosinophiluria, since approximately, 20–70% of patients with cholesterol crystal embolism (CCE) have eosinophilia/uria.

Diabetic patient with pseudo hyper epithelializing in situ, what you should do?
A- Amputate toe
B- Ulcer Debridement
C- Follow up
D- Repeat biopsy

Another recall: Diabetic pt had ulcer in big toe after biopsy show hyperepitheliomatous hyperplasia:
A- surgical deperment

Another recall: Diabetes with ulcer in big toe of foot for 5 y came for follow up ex there is white discoloration and biopsy show hyperepithelialization next step?
A- Surgical depridment.
B- big toe Amputation
C- observation

Abdulrahman: The answer is to repeat the biopsy. We found this question from a book:

Case about 6 months old , only on breastfeeding till last 2 weeks his mother started introducing fruits purée and fruit juices to him , he became lethargic , vomiting , ....,.., on examination there was Splenohepatomegaly !! Asking about the Dx ?

Another recall: 6 m boy presented with abnormal movement and yellowish discoloration for 1 week .
He is exclusively breast feeding 2 week ago his mother started to interduce fruit and fruit juice, since that , pt started vomiting, irritable, On examination:
Hepatospleenomegaly
Distended abdomin
Generalised jaundice
Urine: positive reducing substances( normal is negative)
Dx?
A. Tyrosinemia
B. galactosemia
C. Alpha 1 anti trypsin def
D. conginital fructose intolerance

Abdulrahman: The answer is Congenital fructose intolerance (also answered by Dr. Safdar)

Infant Has Cataract jaundice he has brother who has same presentation don’t recall the rest but it was Galactosemia presentation ,Urine / +ve for urine-reducing substances test (normal negative “written like this “) How to confirm Dx?
A. HIDA SCAN
B. Urine-reducing substances test
C. Coom test
D. Alpha anti
E. Alpha antitrypsin test

Another recall: 3 day old baby girl with seizures, bilateral cataract, jaundice Positive urine reducing substances What’s the best diagnostic tool?
A. Hida scan
B. Coombs test
C. Urine reducing substances
D. Alpha 1 anti trypsin

Another recall: Urine / +VE for Urine-reducing substances test (normal negative “written like this “) Which of the following has the HIGHEST DIAGNOSTIC VALUE
A. HIDA SCAN
B. urine-reducing substances test
C. Coombs test
D. alpha antitrypsin test

Abdulrahman: The answer is urine-reducing substances, as this is most likely a case of galactosemia. UTD: galactose-1-phosphate uridyl transferase (GALT) activity in red blood cells (RBCs) is the gold standard for diagnosis.