2014 - 5th + 7th Flashcards by Fajer e

Patient with recurrent headache that is short and severe 11/10 pain. What is the diagnosis?
A. Cluster headache
B. Migraine with aura
C. Tension headache

A. Cluster headache
Cluster headaches are excruciating attacks of pain in one side of the head Msd headaches by suhail

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A patient diagnosed with non small cell lung cancer was going to do PET/CT for staging. What is considered a positive lymph node?
A. LN that has transverse diameter more than 1 cm on axial view
B. LN that has antero-posterior diameter more than 1 cm on axial view
C. FDG uptake in LN less than uptake in mediastinal pool
D. FDG uptake in LN more than uptake in mediastinal pool

D. FDG uptake in LN more than uptake in mediastinal pool

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A 45-year-old male patient complains of low back pain and morning stiffness. Peripheral joints were not affected. He was later diagnosed with psoriatic arthritis. What is the best treatment option for this patient?
A. Methotrexate
B. Plaquenil
C. TNF inhibitors
D. Azathioprin

C. TNF inhibitors (Note from dr. ashqar: DMARDs, including MTX, are clearly ineffective for treating axial arthropathy and are better reserved for patients with peripheral arthritis. On the other hand, TNF inhibitors improve signs and symptoms of inflammation in both peripheral and axial joints as well as in periarticular tissues such as the entheses)

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What are the antibodies of pernicious anemia?
A. Intrinsic factor
B. Parietal cells
C. Parietal cells and intrinsic factor

C. Parietal cells and intrinsic factor

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64-year-old patient was admitted to the ICU with pneumonia. One day after, the patient deteriorated and went on to develop septic shock. Which of the following is used to monitor the kidneys’ function on a daily basis?
a. Serum creatinine
b. 24-hour urine collection
c. Estimated GFR
d. Inulin clearance

a. Serum creatinine

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A 25-year-old female with a history of chronic SOB and cough. Recently she has been complaining of muscle weakness at the end of the day. Imagining shows a 4x2 cm anterior mediastinal mass. What is the cause of this patient new symptoms?
A. Lung cancer
B. Myasthenia gravis
C. Sarcoidosis

B. Myasthenia gravis
Myasthenia gravis is an autoimmune disorder caused by an Ab-mediated blockade of NMJ transmission resulting in skeletal muscle weakness and rapid muscle fatigue.

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What is the least useful advice for an IBS patient?
A) avoid missing meals
B) restrict coffee or tea to 3 cups a day
C) drink 8-9 cups of water
D) Eat high fiber meals

B) restrict coffee or tea to 3 cups a day

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A young patient with acute pericarditis presenting with muffled heart sound, elevated JVP and hypotension. ECG showed typical diffuse ST elevation. What is the next step in investigation?
a. Echocardiogram
b. CT angiography
c. Holter ECG

a. Echocardiogram

-The diagnosis is Cardiac Tamponade caused by acute pericarditis.
-Muffled heart sound+ Increased JVP+Hypotension->Beck’s Triad
- Echo will show :pericardial effusion ,compression of cardiac chambers (RA and RV) in diastole.

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Typical scenario of Migraine case. Which of the following does NOT prevent future events?
A. Amitryptilline
B. Topiromate
C. Propranolol
D. Sumitriptan

D. Sumitriptan

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A 68 year old woman presenting with GI symptoms. What would make IBS less likely?
a. Patient’s age
b. Urgency
c. Pain with eating

a. Patient’s age

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A patient presented with TIA that resolved. Found to have atrial fibrillation on ECG (was shown in exam). What medication will you give beside propranolol?

Warfarin

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A patient presents with progressive dyspnea and non-productive cough, chest exam reveals bilateral fine crackles. What is the next step to establish the diagnosis?
A. CXR
B. HRCT
C. PFT
D. Bronchoscopy

B. HRCT

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Patient with weakness and tremor, no pretibial myxedema or ophthalmopathy. Elevated T4 and thyroid scan show decreased uptake. What us the diagnosis?
A. Subacute thyroiditis
B. Thyroid adenoma
C. Factitious hyperthyroidism
D. Multinodular goitre

C. Factitious hyperthyroidism

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A 34 year old diabetic on metformin with muscle cramps. He had low k, normal na and low hco3. What is the cause of her hypokalemia?
A. Metformin
B. Lactic acidosis
C. Hyporeninic hypoaldosteronis
D. Osmotic diuresis

D. Osmotic diuresis

Mechanism of osmotic diuresis: substances that are not easily reabsorbed by the renal tubules are retained in the lumen, resulting an increase in osmotic pressure. With the phenomenon of osmosis, wherein water goes through a semipermeable membrane into a solution of high solute concentration, water then goes to the lumen. This leads to a reduction in water reabsorption, thereby resulting in increased urine output. An increase in the filtration of solutes that could not be reabsorbed by the kidneys, such as urea or glucose, can lead to impaired reabsorption of sodium and water cause osmotic diuresis.

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An 80 year old Indian lady migrated recently to Kuwait presented with long history of cough and SOB. She has never smoked in the past. Physical exam showed bilateral diffuse wheezes. CXR showed hyperinflation. PFT showed irreversible obstructive pattern with bronchodilators. What is correct?
A. The patient can’t have COPD since she never smoked
B. We have to do HRCT to diagnose her
C. We should start long acting bronchodilators and assess her need for home oxygen.

C. We should start long acting bronchodilators and assess her need for home oxygen.

Note: HRCT is not used to diagnose COPD. Smoking is a major risk factor for COPD, but alpha antitrypsin deficiency also can cause COPD.

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Which of the following is true regarding multiple sclerosis?
A. Female to male ratio is 3:1
B. It’s associated with high levels of vitamin D
C. It is more common in countries close to the equator
D. There is no difference in prevalence between African Americans and Caucasians

A. Female to male ratio is 3:1

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A middle aged lady is experiencing continued midepigastric pain, nausea, and vomiting for 5 days after being admitted for alcoholic acute pancreatitis. She has had no bowel movements since. On examination, BP was 132/80, HR 101, RR 20. There was no jaundice. She had epigastric tenderness and her abdomen was distended with hypoactive bowel sounds. Labs showed: Normal WBC / HIGH AST & ALT / mildly elevated Total Bilirubin / Amylase 338 / Lipase 988.
A CT was done and showed diffusely edematous pancreas with peripancreatic fluid collections and no necrosis. Which of the following is applicable in management?
A) Enteral feeds by nasojejunal tube
B) IV imipenem
C) Pancreatic debridement
D) Parenteral nutrition

A) Enteral feeds by nasojejunal tube

The management of acute pancreatitis is mainly symptomatic through supplementation; therefore a tube is needed for nutrition. Also in paralytic ileus, enteral nutrition might be productive.

C) Pancreatic debridement -> no necrosis therefore no need for debridement

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What is the most specific test for rheumatoid arthritis?
A. Anti-ccp
B. ESR
C. CRP
D. ANA

A. Anti-ccp

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Indication of biopsy in a 55 yr old patient diagnosed with type 1 diabetes mellitus 4 years ago and had microglobulonemia.
A. Absent retinopathy
B. <5 years nephropathy

B. <5 years nephropathy

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Patient with joint pain and morning stiffness less than 30 minutes. What is the diagnosis?

Osteoarthritis (non-inflammatory pain)

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Five days after starting warfarin for atrial fibrillation, a 60 year-old patient complained of darkly discolored areas of skin in the gluteal region. The reason is for this is:
a. Antithrombin deficiency
b. Protien C deficiency
c. Drug allergy
d. high INR

b. Protien C deficiency

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Headache case with papilledema. What is the red flag in this case?

Papilledema
MSD Dr Suhail ‘headaches’
Red flags for secondary headaches SNOOP4 Systemic signs and symptoms
Neurological finding in examination Older than 50 y/o
Postural headache
Precipitation of headache with valsava Progression of headache
Presence of papilledema

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A 51-year-old man was admitted to the medical ward after developing an anterior wall myocardial infarction. He was successfully managed with coronary revascularization and stabilized thereafter. Two days later, the patient started to complain of palpitations and dizziness. He became immediately unresponsive with a blood pressure of 92/56. His ECG is shown below. What is the appropriate management of this
patient?
a. DC cardioversion
b. Intravenous amiodarone
c. Intravenous adenosine
d. Atropine

a. DC cardioversion

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A 60-year-old patient with right femur pain. X-ray showed lytic lesion and fracture in the femur. He did fixing surgery for fracture and took biopsy of the lytic area which showed plasma cells. He had normal calcium, RFT, LFT. He had normal peripheral smear and BM biopsy. Serum electrophoresis and immunopheresis showed high IgG, and IgA and normal IgM.
What is the likely diagnosis?
A. Multiple myeloma
B. MGUS
C. Solitary plasmacytoma

C. Solitary plasmacytoma

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A 30 y/o man with progressive breathless for one week. he had headache, fever, wt loss for 2 months. he had central sharp chest pain that was relieved with sitting and leaning forward. O/E raised JVP, bilateral LL edema, BP 90/70, muffled heart sounds, no murmur heard. (CXR of tamponade was provided). Pulse would be? a. pulsus paradoxus b. pulsus alternans c. pulsus bigeminus d. pulsus parvus et tardus

a. pulsus paradoxus The classic quartet of cardiac tamponade: 1) Hypotension 2) Increased JVP 3) Tachycardia 4) Pulsus paradoxus

A patient with SOB and cough did PFT with the following results: FEV1 50% of predicted, FEV1/FVC= 80%, DLCO 50%. What is the diagnosis? A. Bronchial asthma B. Chronic bronchitis C. Interstitial lung disease D. Emphysema

C. Interstitial lung disease Note: FEV1/FVC ratio showed restrictive pattern.

A 50 year old male on glucophage for treatment of DM TYPE 2, he had several occasions of HTN: 150/92, he also complained of nocturea, his urine showed microalbuminurea What’s the next step in his management: A. add ACE inhibitor B. add CCB C. add hydrochlorothiazide

A. add ACE inhibitor

A 60 year old lady complaining of generalized malaise and fatigue, recurrent infections, bleeding gums after brushing teeth, labs showed low hg, low plt, low wbc, bone marrow shows myeloid blast cells with translocation 15:17. What’s the most likely diagnosis? a. CML b. Acute promyelocytic leukemia

b. Acute promyelocytic leukemia

A patient had high MCV, platelet of 40,000 (low) and a blood smear showing macrocytosis. What’s the diagnosis? a. aplastic anemia b. megaloblastic anemia c. hypothyroidism d. chronic liver disease

b. megaloblastic anemia

a 45 yr old female had a seizure, she was previously healthy as described by her friends, today she is confused. CT scan showed hemorrhage involving the right temporal lobe. Her temprature was 38.5. CSF showed 10,000 RBCs, 90 WBCs (90% lymphocytes) and slightly elevated protein. What is the next management? A. start riafmpicin, isonizid, pyrazinamide, ethambutol B. start sulfamethoxazole and trimethoprim C. start IV acyclovir D. defer treatment until MRI rules out a mass lesion

C. start IV acyclovir

Which of the following patients should get the liver transplant? -18 years old with paracetamol overdose - 45 years old with cholangiocarcinoma

18 years old with paracetamol overdose

Patient was started on pheytoin for epilepsy. He then developed a generalized rash with lymphadenopathy and hepatomegaly. Has elevated liver enzymes. Which of the following is a lab finding (repeated)?

Eosinophilia

A patient had the following labs: High serum iron and ferritin, High transferrin saturation, Low TIBC. What is the underlying cause? a. Anemia of chronic disease b. Sideroblastic anemia c. IDA d. Thalassemia major

d. Thalassemia major

A young athletic female who was incidentally discovered to have a murmur with systolic thrill. Her JVP has occasional prominent a waves. This is her chest x-ray. How to manage? a. Device close for patent ductus b. Pulmonary valve valvuloplasty

b. Pulmonary valve valvuloplasty -Many children with pulmonic stenosis remain asymptomatic for years and do not present to a physician until adulthood. Even then many patients remain asymptomatic. When symptoms of pulmonic stenosis develop, they resemble those of aortic stenosis (syncope, angina, dyspnea). -Visible and palpable signs reflect the effects of right ventricular hypertrophy and include prominent jugular venous a wave (due to the forceful atrial contraction against hypertrophied RV), an RV precordial lift or heave, and a left parasternal systolic thrill at the 2nd intercostal space. -Treatment of pulmonic stenosis is ballon valvuloplasty, indicated for symptomatic patients and asymptomatic patients with normal systolic function and a peak gradient >40 to 50 mmHg.

Patient with RA, how will you monitor the activity of his condition? a. Rheumatoid factor b. ESR c. C4 level

ESR (either ESR or CRP)

A patient with unprovoked DVT was put on LMWH and warfarin. When should LMWH be stopped ? a. after 5 days b. after 7 days c. When INR is 2-3 d. 24 hrs after the INR is 2-3 or after 5 days, whichever is longer

d. 24 hrs after the INR is 2-3 or after 5 days, whichever is longer

A 58-year-old woman is a known case of chronic kidney disease on dialysis. Biochemical investigations showed low serum calcium, elevated parathyroid hormone, elevated alkaline phosphatase and elevated phosphate levels. What skeletal abnormality is likely to be found on bone x-ray of this patient? a. Rugger jersey spine b. Dense lesions in the long bones c. Hair-on-end appearance d. Lytic bone lesions

a. Rugger jersey spine

A patient with history of acute rheumatic fever with pansystolic murmur. What to do upon discharge?

Monthly IM long acting penicillin till the age of 40 Duration of secondary prophylaxis for rheumatic fever: 1) Rheumatic fever with carditis and residual heart disease (persistent valvular disease): 10 years or until age 40 (whichever is longer), life time prophylaxis may be needed. 2) Rheumatic fever with carditis but no residual heart disease (no valvular disease): 10 years or until age 21 (whichever is longer) 3) Rheumatic fever without carditis: 5 years or until age 21 (whichever is longer)

-Patient present with hemoptysis, dyspnea, and chest pain. There was an X-ray pic showing mitralization of heart. What is the diagnosis?

Mitral stenosis -Mitralization is a straightening of the left heart border in chest x-ray because of increased prominence of the convexity formed by the main pulmonary artery and its left main branch or the left atrial appendage or both - Hemoptysis is caused by increased pressure causing rupture of pulmonary artery.

Patient diagnosed with rapid progressive glomerulonephritis. Which of the following is a bad prognostic sign? a. Oliguria b. Hematuria c. Proteinuria

a. Oliguria

A 19 year old thin boy (no known medical history, no drug use) with a history of upper respiratory tract infection 2 weeks ago, presented with nausea, vomiting, icterus, fatigue, elevated heart rate. Hemoglobin was 90, platelets and WBCs were normal, AST and ALT and bilirubin were high, alk phos was low. Hepatitis virology and ceruloplasmin and ANA are pending. Till these blood tests come back, what would you like to do to aid in the diagnosis? a. Echocardiography b. Slit lamp c. Liver biopsy d. Urine toxicology

d. Urine toxicology Medications used to treat the URTI may have had some hepatotoxic effect that may have injured the liver, therefore urine toxicology is required.

Which of the following autoimmune diseases is associated with the skin manifestation? A. Crohn’s disease —> erythema nodosum B. Addison’s disease —> hyperpigmentation

B. Addison’s disease —> hyperpigmentation

A young female with abdominal pain and diarrhea. CBC, ESR, CRP, RFT, LFT are done and pending. What another test will you do to differentiate IBS from IBD? a. Fecal occult test b. Fecal calprotectin c. Abdominal ultrasound d. Urea breath test

b. Fecal calprotectin

A type 1 DM patient had hyperglycemia of 26 along with Na= 130. What is the likely cause of the hyponatremia? A. High blood osmolarity B. low aldosterone

A. High blood osmolarity

A patient with hemoptysis and chest x-ray showing bilateral infiltration is suspected to have alveolar hemorrhage. Which of the following supports this diagnosis? A. High DLCO B. Low TLC C. High FRC

A. High DLCO

Patient presenting with cough and green sputum (lung abscess). What is the organism??? (Not sure how the question was written) A. Pseudomona florecensci B. Staph aureus C. Mixed organisms

C. Mixed organisms

A Female had prolonged bleeding after dental extraction, and she needed 2 units of packed RBCs. Her brother died because of prolonged post-operative bleeding and she has relatives who also have prolonged bleeding, both males and females. Her PT was normal, APTT prolonged, and bleeding time normal. What coagulative factor deficiency is likely present? a. Factor VII b. Factor VIII c. Factor XI d. Factor XII

c. Factor XI

A scenario describing stroke presenting after 5 hours from the onset of symptoms, normal CT. How would you treat? A. Aspirin B. Warfarin C. tPA

A. Aspirin Aspirin is given within 24 hrs. tPA(altepase) had to be given within 3-4.5 hrs of onset and only after CT scanning had ruled out hemorrhagic stroke.

-Constrictive pericarditis scenario with typical x-ray. What is the next step in management?

Refer to surgery for pericardiectomy -A Pericardial calcification on chest X-ray -> Constrictive pericarditis. -Causes of constrictive pericarditis: Any cause of acute pericarditis may result in chronic pericarditis > calcified pericardium. Major causes are: idiopathic, post infectious (viral, TB), radiation, post cardiac surgery, uremia, MI, collagen vascular disease. -Difference between constrictive pericarditis vs cardiac tamponade: Treatment: - Medical: diuretics and salt restriction. - Surgical: Pericardiectomy (only if refractory to medical therapy).

Patient with dermatitis herpetiformis. What is the diagnosis? (Something like that) - Celiac disease - Crohn’s disease - Ulcerative colitis

- Celiac disease

Patient with sarcoidosis, on CXR there is only bilateral hilar lymphadenopathy. What stage is his condition? A. Stage 0 B. Stage1 C. Stage2 D. Stage 3 E. Stage 4

B. Stage1

What clinical finding helps to differentiate between diffuse and limited scleroderma? A. Skin thickening of the anterior chest wall B. Nail infarcts C. Dysphagia

A. Skin thickening of the anterior chest wall ( because the limited scleroderma affects the distal extremities)

A 40 year old male developed central chest pain while jogging. He presented to ER within 1 hour. He is conscious and was given sublingual nitrates which relieved his chest pain. His HR is 90 bpm, bp is 150/80 and his JVP is elevated with prominent V wave. His ECG is shown below. What's the next step in the management? a. Admit, cardiac catheterization + coronary angiography + stenting b. Admit, administer aspirin, clopidogrel, BB, LMWH c. Admit, administer aspirin, clopidogrel, LMWH, thrombolytics d. Echocardiogram to conform cardiac temponade and emergency pericardiocentesis

a. Admit, cardiac catheterization + coronary angiography + stenting

A 78-year old female developed a profuse, watery offensive diarrhea after a course of amoxicillin clavulante (augmentin). She was hemodynamically stable, afebrile, and had no abdominal signs. Which of the following the first line therapy for this patient? A. Oral Vancomycin 7 days B. Oral Metronidazole 10-14 days C. Vancomycin and Metronidazole for 10-14 days D. Oral Metronidazole 7 days

B. Oral Metronidazole 10-14 days

A CLL scenario with pallor and high indirect bilirubin and spherocytes, What is the cause?

a. autoimmune hemolytic anemia

A patient presented with complete right ptosis, right pupil not reacting to light, and inability to elevate, depress or adduct the eye. Which nerve is affected? A. Rt CN6 palsy B. Rt CN4 palsy C. Rt CN3 palsy

C. Rt CN3 palsy

A 39 year-old lady with 6 month history of progressive proximal muscle weakness and difficulty swallowing. She Lost 7 kg. Power of 3/5 in upper and lower limbs. CNS examination was normal. What test you will order? A. serum rheumatoid factor B. anti dsDNA C. creatinine phosphokinase D. serum uric acid

C. creatinine phosphokinase Answer: c (polymyositis is a rare disorder affecting the proximal muscles causing symmetrical progressive weakness and wasting it also affect the pharynx and laryngeal muscles causing dysphagia so we check the creatinine kinase levels)

What is the most cost effective modality to diagnose an elderly man with a positive fecal occult blood?

Colonoscopy A positive FOBT is always followed by a flexible sigmoidoscopy (Dr. waleed alazmi 4th year), however the stem is asking for the most COST EFFECTIVE modality. Therefore to ensure cost effectiveness, a positive FOBT is followed by colonoscopy, which is the gold standard.

A 75 year old presented to ER with weakness and SOB. Potassium was 1.6. What is true? A. ECG will most likely show prominent U waves B. We should give calcium gluconate

A. ECG will most likely show prominent U waves

Patient with worsening diabetic nephropathy and the GFR now is 10% of the normal, which of the following will decrease in plasma? a. Creatinine b. Potassium c. Calcium d. Proton

c. Calcium In CKD there will be bone destruction as a result the calcium will be high then as a compensatory mechanism the patient with have hyperparathyroidism which will lower the calcium.

Plasma transfusion is the first line treatment in: a. To reverse vitamin k antagonist (warfarin) in a stable patient with INR of 5 b. Hemophilia A patient before elective surgery c. DIC patient with hypofibrinogenima d. To prevent dilutional coagulopathy in a massively transfused patient after RTA

d. To prevent dilutional coagulopathy in a massively transfused patient after RTA

A 60-year-old female present with tremor, which of the following indicate essential tremor more than Parkinson tremor? A. Worse with alcohol B. Worse when approaching the finger in finger to nose test C. Worse with outstretched hands D. difficulty initiating movement

D. difficulty initiating movement Parkinson Disease the tremor is present at rest and reduces or stops completely when the hand is in motion.

-A 71 year-old has hypertension, asthma, ischemic heart disease. Investigations showed high potassium, what is the appropriate treatment? a. vasodilators b. beta blockers c. thiazide diuretics d. ACE inhibitors

c. thiazide diuretics -One of the side effects of both beta blockers and ACE inhibitors is Hyperkalemia ,and since the patient already has high potassium level, you will not use these drugs -Thiazides leads to hypokalemia ,so it will be helpful in this case to use it to normalize the levels of potassium in this patient.

30-year-old male presented with 3 wks history of foot drop, tingling in legs, difficulty rising from chair and climbing stairs, dropping objects from hands, O/E normal tone in UL and LL, 4/5 power in upper limbs, 3/5 power in lower limbs, areflexia in LL, with reduced pin prick sensation, history of flu in past 3 months. What test would you do next to diagnose? A. Brain MRI B. Spinal cord MRI C. EMG/NCS

C. EMG/NCS (typical scenario describing Guilian Barre Syndrome)

A patient diagnosed with MALToma. What is the likely cause?

a. H. Pylori

A patient is post op day 7 after CRC surgical removal. He developed widespread purpura on his body. His platelets were 10x10^9. On admission, he was put on LMWH as DVT prophylaxis. What is the most appropriate management? a. Steroids b. IVIg c. Stop LMWH and start warfarin/Fondaparinux

c. Stop LMWH and start warfarin/Fondaparinux

Which of the following doesnt affect GFR? a. Membranoproliferative glomerulopathy b. Minimal change disease c. Membranous glomerulopathy

b. Minimal change disease

44? year-old female with type 1 diabetes on insulin, diagnosed with diabetic nephropathy. Her glucose levels are high and uncontrolled despite taking insulin 3 times daily. Currently, she came for follow up and she has good control of her glucose levels despite taking the same insulin doses. What is the reason behind this? A. Increase in synthesis of insulin by b cells B. Worsening renal function C. Increased glucose in urine D. She was taking steroids

B. Worsening renal function

(30 year old male presented with 3 wks history of foot drop, tingling in legs, difficulty rising from chair and climbing stairs, dropping objects from hands. O/E normal tone in UL and LL, 4/5 power in upper limbs, 3/5 power in lower limbs, areflexia in LL, with reduced pin prick sensation, history of flu in past 3 months.) Regarding the previous question, what is the treatment? A. IV pulse methylprednisolone 1 mg/kg for 5 days B. IVIg dose of 400 mg/kg for 5 days C. pyridostigmine 60 mg every 8 hours D. methylcobalamine for 4 wks

B. IVIg dose of 400 mg/kg for 5 days

A 60 year-old known case of HT, DM, hyperlipidemia, presented with chest pain. While in the hospital he fainted. ECG showed ST elevation V1-V6 and lead 1 and AVL. His BP was 70 so he was given epinephrine, after which his BP was 80. What will you do next? a. Coronary angiography and emergent CABG b. IABP with stenting of the culprit coronary artery

b. IABP with stenting of the culprit coronary artery Patients with clinical and biochemical signs and symptoms of hypoperfusion secondary to cardiac failure or cardiac arrest carry high short term mortality. Various mechanical circulatory devices have been developed to mitigate the adverse outcomes of cardiogenic shock until treating the underlying cause. * Indications of intra aortic ballon pump: 1. Acute congestive heart failure exacerbation with hypotension. 2. As prophylaxis or adjunct treatment in high risk percutaneous coronary intervention. 3. Myocardial infraction with decreased left ventricular function leading to hypotension. 4. Myocardial infraction with mechanical complications causing cardiogenic shock ,e.g.acute mitral regurgitation due to papillary muscle rupture or ventricular septal rupture. 5. Low cardiac output state after coronary artery bypass grafting surgery. 6. As a bridge to definitive treatment in patients with any of the following conditions; intractable angina or myocardial ischemia ,refractory heart failure, or intractable ventricular arrhythmias * Contraindications of intra aortic ballon pump: 1. Uncontrolled spesis 2. Uncontrolled bleeding diathesis. 3. Moderate to severe aortic regurgitation. 4. An aortic aneurysm or aortic dissection. 5. Severe peripheral artery disease unless pretreated with stenting.

A type 1 DM patient had hyperglycemia of 26 along with Na= 130. What is the likely cause of the hyponatremia? A. High blood osmolarity B. low aldosterone

A. High blood osmolarity

A 35 y/o male presented with itchy recurrent patchy round circumcinte plaque with active borders on the groin and trunk. KOH examination of scale in the groin showed branching hyphae. What’s the causative organism? A. Candida Albican B. Dermatophytes C. Malassezia

B. Dermatophytes

A patient with low Hb, low MCV had the following: HbA 91%, HbA2 7%, HbF 1% What is the diagnosis? a. Beta thal major b. Beta thal minor c. HbH disease d. Alpha thal

b. Beta thal minor

A young female is complaining of galactorrhea and amenorrhea, which of the following is correct? A. Primary hypothyroidism has to be ruled out B. Dopamine antagonist can be used for treatment C. It's associated with MEN-2

A. Primary hypothyroidism has to be ruled out Note: primary hypothyroidism can cause hyperprolactinemia and galactorrhea, because increased levels of thyroid-releasing hormone increase secretion of prolactin as well as thyroid-stimulating hormone (TSH).

A 53-year-old male patient, known to be diabetic and hypertensive, presented with dense left sided paralysis of the upper and lower limbs, along with dysarthria. What is the first test you would order? A. MRI B. Angiography C. Lumbar puncture D. CT scan

D. CT scan CT scan is the first test for stroke.

Patient with symptoms of hepatic encephalopathy. What is the treatment?

Lactulose

A case of high mature lymphocytes and positive dual CD5 and CD19 and negative cyclin D1. What is the diagnosis (blood smear below)? a. Hairy cell leukemia b. Chronic lymphocytic leukemia

b. Chronic lymphocytic leukemia

Pregnant woman with sputum and breathlessness. What is causing her breathlesseness?

A. Increased pulmonary capillary pressure Note: In the presence of PH during pregnancy, pulmonary vascular disease prevents the fall in PVR, leading to a further rise in pulmonary arterial pressure (PAP) with increased cardiac output. All these have significant bearing on the overall cardiovascular system during pregnancy.

A 72-year-old patient has history of end-stage kidney disease due to diabetic nephropathy. The patient maintains a good level of activity and easily performs daily tasks while at home. He had diabetic retinopathy that was treated with photocoagulation. He is also known to have ischemic heart disease and had two cardiac stents placed recently. Which of the following is true regarding renal replacement therapy in this patient? a. Peritoneal dialysis is preferred over hemodialysis because it does not require anticoagulation b. Renal transplantation is the preferred option for this patient c. Hemodialysis is the preferred option given his cardiovascular risk

b. Renal transplantation is the preferred option for this patient

A scenario about a patient suspected to have COVID-19. What lab test is specific/characteristic for COVID? A. Low lymphocyte B. Low plt C. Low total WBC D. No specific lab finding for COVID-19

A. Low lymphocyte

A patient presenting with manifestations of acute MI, ECG showed ST elevation in lead V2 to V5. Which artery is most likely involved?

a. Left anterior descending

Patient with prolonged APTT and PT. What is the diagnosis? a.Hemophilia A b.VWF disease

b.VWF disease

Patient with pupura all over her body. Low Hb, platelets, and high LDH. Blood smear showed fragmented RBCs

The question was either what is the diagnosis (TTP) or what is the management (plasma exchange)

-A 45-year-old Indian gentleman is a known case of rheumatic mitral stenosis. He now presents with recent onset of low-grade fever and malaise. On initial assessment, the patient was ill-looking with a pansystolic murmur detected at the apex on chest auscultation. Echocardiography was performed and showed the presence of suspicious lesions on a regurgitant valve. What is the most likely causative organism of this patient's presentation? A. Streptococcus viridans b. Staphylococcus aureus c. Staphylococcus epidermidis d. Streptococcus bovis

A. Streptococcus viridans Healthy valve ->staph.aureus Diseased valve >strep.viridians Prosthetic valve(<60 days of surgery)->staph.epidermidis Prosthetic valve(>60 days of surgery) >streptococcus

Hepatology case with lab values showing gilbert syndrome

A normal appearing 18 year old girl presenting with primary amenorrhea. On examination, the vagina ends blindly and no uterus or ovaries were palpated. Buccal smear revealed chromatin negative nuclei. What is the diagnosis? A. Congenital adrenal hyperplasia B. Turner syndrome C. Androgen insensitivity syndrome D. Prenatal exposure to excess androgen

C. Androgen insensitivity syndrome Note: the absence of sex chromatin in the nucleus of a human somatic cell; this absence identifies the cell as being from a male.

-Patient is oliguric, on US he has bilateral hydronephrosis and he has suprapubic mass. What is the initial management?

Insert foley catheter

60-year-old presented with scrotal edema, ascites, urine routine 4+ protein. Kidney biopsy diffuse thickening of glomerular membrane with subepithelial IgG deposits (there is more to the scenario but it guides toward membranous and its repeated). What is correct? a. cancer should be excluded b. steroid given c. plasma exchange d. Do nothing, it’ll resolve in 2 months

a. cancer should be excluded cancer can cause membranous glomerulonephritis

Hepatology case with lab values showing autoimmune hepatitis

Patient hearing louder in his right ear. Dr did weber test and then rinnes test on left ear which showed air conduction > bone conduction. What is the diagnosis? A. Left sensorineural loss B. Left conductive loss C. Right sensorineural loss D. Right conductive loss

Typical scenario of bacterial meningitis case, what is the management? A. steroids, 3rd generation cephalosporins, vancomycin B. 2nd generation cephalosporins + vancomycin C. 3rd generation cephalosporin + ampicillin D. 3rd generation cephalosporin

A. steroids, 3rd generation cephalosporins, vancomycin

A patient came with shortness of breath and dry cough. HRCT of lung showed bilateral reticulonodular infiltrations with honeycomb appearance. What is the management? A. Corticosteroids B. Oral Pirfenidone

B. Oral Pirfenidone Corticosteroids are used for hypersensitivity pneumonitis. An acute, subacute, or chronic pulmonary disease characterized by an immune-mediated inflammatory response in the alveoli and small airways as a result of exposure to a variety of inhaled antigens. The question did not mention any thing about inhaled antigen. So iPF is more likely than hypersensitivity pneumonitis.

A scenario of hypertrophic obstructive cardiomyopathy. What medication you want to give to relieve his symptoms?

Beta-blocker

Young patient with BMI of 32, and mildly high AST and ALT only. What is the diagnosis?

Fatty liver – associated with a high BMI

A scenario of previously controlled asthma now has exacerbated. Investigations showed high total IgE and eosinophilia. Xray showed bilateral infiltrations. What is correct? A. Inhaled corticosteroids are used for treatment B. Patient has increased risk of developing bronchiectasis C. It can invade the lungs and go to the blood and brain causing meningitis

B. Patient has increased risk of developing bronchiectasis Note: in asthma exacerbation we start iv corticosteroid not inhaled. Bronchiectasis is common among patients with severe uncontrolled asthma and might even make their asthma worse.

A 60 years old diabetic female presented with single painful ulcer on her left shin with necrotic base, blue edges for 6 month with no history of trauma, the ulcer did not improve with antibiotics. She had high leukocytes and ESR. What is the diagnosis? A. Necrobiosis lipoidica diabeticorum (NLD) B. pyoderma gangrenosum C. erythema gangrenosum D. Erythema nodosum

A. Necrobiosis lipoidica diabeticorum (NLD)

A scenario describing a patient with erythema nodosum after few weeks of upper respiratory tract infection. What is the treatment? A. Steroids B. NSAIDS C. Thalidomide

A. Steroids

a 30 years old woman with SLE is planning to get pregnant. Her SLE is controlled on steroids and plaquenil. How would you counsel this patient? A. Continue both drugs B. Stop both drugs C. Stop steroids only D. Stop plaquenil only

A. Continue both drugs (these drugs (the steroid on low dose) are safe to use during pregnancy)

30 years old man was at a party, he was drinking excessive amount of alcohol then became sick and vomited then he vomited again with blood in the vomit. He has no past history of GI bleeding. What is the diagnosis? A. Mallory-Weiss syndrome B. Esophageal varices C. Acute alcoholic gastritis D. Gastric carcinoma

A. Mallory-Weiss syndrome It’s a mucosal tear at (or just below) the gastroesophageal junction as a result of forceful vomiting or retching. It usually occurs after repeated episodes of vomiting. It is most commonly associated with binge drinking in alcoholics.

Barium swallow shown. What is the diagnosis? A. Schatzki ring B. Achalasia

A. Schatzki ring

A smoker on full medical treatment and combined inhalers his tolerance on walking decreased to 30 meters and his FEV1 is 30% of predicted. What is the treatment? A. Pneumonectomy B. Non surgical reduction of lung volume C. Systemic salbutamol D. Pleurodesis

B. Non surgical reduction of lung volume

Patient came from Thailand (something about hepatitis B), he has no prior history of Hepatitis B immunization, which of the following lab findings is correct? A. Anti-HBsAg positive and Anti-HBc IgM positive B. Anti-HBsAg Positive

A. Anti-HBsAg positive and Anti-HBc IgM positive

Patient was started on phenytoin for epilepsy. He then developed a generalized rash with lymphadenopathy and hepatomegaly. Has elevated liver enzymes. Which of the following is a lab finding? A. Eosinophilia B. High ASO titer

A. Eosinophilia

A 38 Year old Lady was recently diagnosed with Hypertension and Diabetes. She had central obesity, abdominal striae, and proximal muscle weakness. Which would more likely to be on her Ecg: A. U wave B. Peaked T wave C. ST elevation D. Delta Wave

A. U wave Note: this scenario describes Cushing syndrome in which there is hypernatremia and hypokalemia. Hypernatremia leads to HTN and hypokalemia manifested as U wave on ECG

Young female with weight loss, palpitations and proptosis. She was started on a medication then developed a fever and sore throat. The family practitioner advised her to stop the medication. Which medication did she take? A. Propanolol B. Carbimazole

B. Carbimazole

Which of the following causes increased DLCO? A. Emphysema B. Polycythemia C. Heart failure

B. Polycythemia

36 year old male presented with fatigue and pallor. Hematocrit 34% reticulocyte index 4. You suspect hemolytic anemia. Which of the following lab abnormalities are NOT associated with hemolytic anemia? a. elevated LDH b. elevated haptoglobin c. elevated indirect bilirubin d. elevated retics

b. elevated haptoglobin

Patient with kussmual breathing, confusion and fever. He had high blood glucose and urine ketones. What is the diagnosis? A. DKA B. Septicemia C. Septicemia with DKA

C. Septicemia with DKA

How to check glucose for the past 3 months?

Glycated hemoglobin

A 21 year-old woman experienced a 3 month history of chronic diarrhea, weight loss, and abdominal pain in the right iliac fossa. She also has aphthous ulcers in her mouth. What is the most common extraintestinal manifestation of Crohn’s disease? a. Episcleritis b. Uveitis c. Arthritis d. Erythema nodosum

c. Arthritis

60 year old male smoker known case of HT, DM, hyperlipidemia presented with dyspnea and 2 syncopal attack. Patient reported history exertional dyspnea after exercise and admission for severe SOB. No history of angina. O/E low carotid pulse and harsh ejection systolic murmur all over pericardium. ECG showed regular sinus rhythm and LBBB. Echo showed severely calcified bicuspid aortic valve with mean arterial pressure 50 mmH, mild aortic regurgitation, Left ventricular hypertrophy with EF 50%. What's true regarding management of this patient? A. surgical consultation for aortic valve replacement B. coronary angiography before surgical replacement C. head Ct before surgical replacement

B. coronary angiography before surgical replacement Exclusion of coronary artery disease by coronary angiography is important in all patients older than 35 years who are being considered for valve surgery. Coronary angiography should also be performed in patients younger than 35 years if they have left ventricular systolic dysfunction, symptoms or signs suggestive of coronary artery disease, or 2 or more risk factors for premature coronary artery disease, excluding gender. Generally the incidence of associated coronary artery disease has been reported to be 50% in patients with aortic stenosis who are older than 50 years. Coronary angiography need not to be performed in young patients with no atherosclerotic risk factors and in circumstances where the risk involved outweighs the benefits.

A 22 year old Kuwaiti woman presented in January 2021 with high fever, myalgia, and headache. Her family members were diagnosed with Covid-19 and one of them admitted to the ICU. She has no past medical history. On examination her temp 38.5, HR 100, and O2 saturation 98% in room air. Her chest xray was normal. What is the best treatment for her at this stage? A. start hydroxychloroquine B. start azithromycin C. regular antipyretics D. remdesivir as a specific antiviral therapy

C. regular antipyretics

A 62 year old patient has hemoptysis, lung infiltrates, and impaired renal function. Urinalysis RBC: 25-20 / HPF, WBC: 3-5/ HPF. C-ANCA +ve. Kidney biopsy showed crescentic glomerulonephritis. What is the most appropriate management? A. Cyclophosphamide B. Broad spectrum antibiotic C. Steroid only D. Steroid, IV cyclophosphamide, plasma exchange

D. Steroid, IV cyclophosphamide, plasma exchange (Wegener treatment)

A 17 years old, known to have sickle cell disease, came to the casuality complaining of fever and knee joint pain. She gave a history of diarrhea 5 days ago. On examination fever=38.9 C and joint was warm tender and swollen. What is the infecting organism? A. Salmonella species B. S.aureus C. Strept. Pyogenes

A. Salmonella species

Patient was asymptomatic and had low platelets and Hb is 13.7 and WBC normal. PT and APTT is normal. What is the cause of her thrombocytopenia?

a. Side effect of new antibiotic

Asymptomatic hyperuricemia in a young man coming for yearly medical check-up. How to manage?

A. Do nothing

A 34 y old woman presented with sharp left sided pain in the jaw worse with washing her face and brushing her teeth, which of the following is the best tx? A. Carbamazepine B. Propranolol C. Presnisolone

A. Carbamazepine

A Scenario of diabetes insipidus and the patient was started on a new anti psych drug. What is the patient taking? A. Lithium B. Carbamazepine C. Fluoxetine

A. Lithium

What is the cause of erosion in RA?

panus formation

A 56-year-old female patient complains of joint pains in both of her hands accompanied by morning stiffness of 15 minutes. On examination, distal and proximal interphalangeal nodes were present along with crepitus. Hypothenar muscle wasting was also noted. The patient was found to have high uric acid level and normal ESR. X-ray of the hands showed joint space narrowing and osteophytes. What is the likely diagnosis in this patient? A. Osteoarthritis B. Chronic tophaceous gout C. Rheumatoid arthritis D. Pseudogout E. Psoriatic arthritis

A. Osteoarthritis

An old man diagnosed in OPD with right middle lobe pneumonia was treated with antibiotics as an outpatient, which of the following is a poor prognostic factor? A. Tachypnea B. Middle lobe pneumonia C. Positive blood culture

A. Tachypnea

Patient found to have pheochromocytoma. What is the most appropriate pre-op management? A. Beta blockade followed by alpha blockade B. Alpha blockade followed by beta blockade

B. Alpha blockade followed by beta blockade

Patient with SLE, how to monitor her condition? A. C3 and C4 B. ESR

A. C3 (for the activity we see the ESR but for monitoring we check the complements)

White nail discoloration and thickening of the nail. Onychomycosis. (I think it’s tinea unguium). What stain is used to confirm? A. Giemsa stain B. PAS stain

B. PAS stain

A patient with renal transplant on heavy immunosuppression, which virus is likely to cause renal impairment? A. Polyoma B. Adenovirus C. Parovirus D. Hepatitis B Virus

A. Polyoma

A patient working on shipyard with interstitial lung disease, what is the cause?

asbestosis

Deficiency in complements will result in severe sepsis due to which organism? A. Herpes simplex B. Herpes zoster C. Aspergillus fumigatus D. Neisseria meningitidis

D. Neisseria meningitidis

64-year-old women presented with weakness for the past 8 months, upper limbs (weakness, fasciculation, areflexia), lower limbs (hypertonia, hyperreflexia, positive planter reflex). Sensory and cerebellar exam normal. What is the diagnosis? A. Progressive muscular atrophy B. ALS C. B12 deficiency D. Syringomyelia

B. ALS ALS give both UMNL & LMNL

A 40-year-old man is rejected from applying to the military. He reports six-month history of central heaviness and dyspnea as well as syncopal attacks in the past month. His past medical history is significant for a heart murmur that was discovered 15 years back. Which of the following is an expected finding during auscultation of the chest? a. Ejection click at the apex b. Wide and fixed splitting of S2 c. Pansystolic murmur at the left sternal border

a. Ejection click at the apex

Patient with hematemesis was controlled and diagnosed with esophageal varices, what should be given to the patient after? (Something like that) A. Omeprazole B. Propranolol C. Somatostatin

B. Propranolol Since the stem mentions that the bleed has been taken care of and is now controlled. Next step should focus on preventing further rebleeds which is done by beta blockers.

A 28 yr old female in her 2nd pregnancy. Worried about her renal function test. What is the most common sensitive test to assess her renal function test? a. Serum uric acid b. Serum creatinine c. 24-hour urine collection to estimate eGFR d. Radionucleotide DMSA

a. Serum uric acid

Patient in ICU with low O2 and low CO2. What is the diagnosis? A. Hyperkalemic respiratory acidosis B. Type 1 respiratory failure C. Type 2 respiratory failure

B. Type 1 respiratory failure

What is the most common cause of COPD in non smokers? a. Second hand smoking b. Indoor exposure to biomass from combustion of wood and fossil fuels

b. Indoor exposure to biomass from combustion of wood and fossil fuels

A 30 year old female with HTN for 2 years. She is on 3 medications to control her HTN, but her BP still averages around 150/95. Her labs: (normal values were included) Na: 145 (H) K: 2.7 (L) HCO3: 31 (H) CT showed left 1.5 adrenal adenoma. Which of the following is most likely to be relevant in this case? A. increased plasma renin B. tumor in zona reticularis C. urine K excretion is low D. urine aldosterone is high

D. urine aldosterone is high HTN refractory to more than 3 medications with hypokalemia is diagnostic for Conn’s syndrome. **Conn’s syndrome** diagnostic criteria is to have plasma aldo : plasma renin ratio more than 30 (high aldo, low renin) and to confirm the diagnosis we do oral sodium loading test. - Procedure: • High-sodium diet (5000 mg) or oral sodium chloride tablets (2 g taken three times daily) for 3 days • Followed by 24-hour urine measurements of aldosterone, sodium (to confirm appropriate sodium loading), and creatinine (to assess adequate urine collection) **Healthy individuals:** RAAS is physiologically suppressed → inhibition of aldosterone secretion **Primary hyperaldosteronism:** failure to suppress aldosterone secretion (high urine aldosterone > 12 mcg/day and urine sodium > 200 mEq)

A patient had alcoholic pancreatitis. His amylase was 5000, PaO2 was 8 (normal 11-13), had abnormal liver enzymes. Which of the following indicates poor prognosis in acute pancreatitis? a. Pancreatic edema on CT b. Amylase >5000 c. Low PaO2

c. Low PaO2 Check Ransons Criteria

35 years old woman with history of SLE, she had 2 abortions. What investigation should be performed? A. Anti-dsDNA antibodies B. ANA C. Antiphospholipid antibodies D. Anti-B2 globulin

Anti-B2 globulin (SLE can predispose to antiphospholipid syndrome the hint in this scenario is repeated miscarriages which characterize this syndrome for that we check Anti-B2 globulin antibodies which is more specific than choosing antiphospholipid antibodies)

How do patients with chronic pancreatitis mostly present? A. Epigastric pain B. Asymptomatic

A. Epigastric pain

Patient with mydriasis and ptosis. What is the diagnosis? A. Horner syndrome B. Posterior communicating artery aneurysm

B. Posterior communicating artery aneurysm

Stroke within window hours, what will you do next? A. Alteplase B. CT C. Aspirin

A. Alteplase Aspirin is given within 24 hrs. tPA (alteplase) had to be given within 3-4.5 hrs of onset and only after CT scanning had ruled out hemorrhagic stroke.

A 14 year old boy is being investigated for iron deficiency anemia. He was discovered to have numerous jejunal polyps. He also has pigmented lesions on his palms and soles. What is the likely cause? a. HNPCC b. FAP c. Peutz Jeghers d. Hereditary hemorrhagic telangiectasia

c. Peutz Jeghers Peutz Jeghers is associated with pigmented lesions on the palms and soles.

Blood smear pic of sickle cells. What is the diagnosis?

Sickle cell anemia

patent had throbbing headache, pain on mastication, blurry vision, and tender temple. ESR is 80. What is the diagnosis?

GCA

A 27 year old female, recently diagnosed with hypothyroidism. She was on levothyroxine for 6 months until she became euthyroid. Now, she present to the clinic with a history of fatigue, dry skin and constipation. TSH was high again. She reported taking a supplement for the last two months with her morning dose of levothyroxine. What supplements is responsible for her current condition? A. Vitamin E B. Vitamin C C. Zinc D. Iron

D. Iron

A patient presents with pneumonia that was complicated by pleural effusion. Thoracocentesis was done and showed: pH of 7.11, LDH of 240, glucose of 4, high neutrophils count (68%), no bacteria on gram stain, and culture is pending. What is an indication for chest tube drainage? A. LDH higher than two-third of the normal limit. B. Low glucose C. pH of 7.11 D. High neutrophils count

A. LDH higher than two-third of the normal limit. Pleural fluid aspiration (thoracocentesis): Diagnostic and therapeutic. Done unless the clinical picture clearly suggests a transudate. Use light’s criteria to know if the plural effusion exudate or transudate. Light's criteria: • Pleural fluid is an exudate if one or more of these criteria are met: 1. Pleural fluid **protein >0.5** serum protein 2. Pleural fluid **LDH >0.6** serum LDH 3. Pleural fluid **LDH >2/3 upper normal serum limit** • More rarely, effusions may consist of: 1. blood (hemothorax) 2. pus (empyema) 3. lymph (chylothorax) from the thoracic duct (trauma or carcinoma)

Patient wound is oozing blood after surgery (i dont remember the exact question)

DIC

A male patient newly presents with cogwheel rigidity, normal eye examination, with clumsiness, gait ataxia and prominent postural hypotension. What is the diagnosis? A. progressive supranuclear palsy B. Parkinson’s disease C. multiple system atrophy

C. multiple system atrophy MSA symptoms include: Autonomic dysfunction (e.g. postural hypotension), Urogenital dysfunction, Parkinsonian features (e.g. cogwheel rigidity), Cerebellar dysfunction (e.g. gait ataxia), Corticospinal tract dysfunction.

A 26-year-old Male patient presents with a swollen, painful ankle. On examination, the ankle joint looks erythematous and tender to touch. He also noted to have a pustular rash on the dorsum of his feet. He reported having a recent Urethral discharge. What is the likely diagnosis in this patient? A. Gonococcal arthritis B. Gout C. Parvo virus infection D. Endocarditis

A. Gonococcal arthritis

A young child was admitted with prominent generalized edema following a viral illness. The patient was found to have heavy proteinuria and was labeled as a case of nephrotic syndrome. Given the patient’s clinical examination and preliminary investigations, the senior physician suggests minimal change disease as the underlying cause. What is expected to be found under light microscopy in this patient? a. No abnormality b. Thickening of the basement membrane c. Crescent formation d. Subepithelial deposits

a. No abnormality

A 63 year old lady with fragility fracture who was later on diagnosed with osteoporosis. She was put on bisphosphonate. What is the mechanism of action of bisphosphonate? A. Increase RANKL B. Decreased osteoclastic activity

B. Decreased osteoclastic activity

A 55-year-old female presented with history of hip, shoulder, and neck pain and stiffness for the past few months. Her laboratory work-up showed Hb = 10 g/dL (low) and ESR = 100 mm/hour (markedly elevated). What is the most likely diagnosis? A. Polymyalgia rheumatica B. Fibromyalgia C. Rheumatoid arthritis D. Lupus arthritis E. Osteoarthritis

A. Polymyalgia rheumatica ( polymyalgia rheumatica causes periarticular pain (shoulders and hips) with morning stiffness more than hour and VERY HIGH ESR)

Asymptomatic old man with splenomegaly high WBC count (high basophils and neutrophils) and high plts. What mutation do you expect to find? a. PMR-RARA b. Translocation 9:22 c. Single code protein mutation (8:21) d. NPMI mutation

b. Translocation 9:22

A middle aged female known case of HCV and cirrhosis presented for investigations. She had high HCV RNA, negative HbsAg, Positive anti-Hbc and anti-HbS. Which of the following is not part of her management? a. Hepatitis B vaccination b. Ultrasound abdomen every 6 months c. Upper endoscope to check for varices d. Anti-viral treatment for Hep. C

Answer: a. Hepatitis B vaccination – due to the negative HbsAg c. Upper endoscope to check for varices – Common complication of cirrhosis

Diabetic patient, they put blood glucose values on breakfast, lunch, dinner, and bedtime. Morning value showed hyperglycemia. What will you do? A. Increase the dose of rapid-acting insulin B. Increase glargine dose at night C. Add intermediate-acting insulin D. No need for dose adjustment

B. Increase glargine dose at night

A 25 year old man presented with multiple times of melena and required frequent admission and blood transfusion, upper endoscopy and colonoscopy were negative and he is asymptotic between the episodes. What’s the dx? a- peptic ulcer disease B- gastric cancer C- microscopic colitis D- Meckel’s diverticulum

D- Meckel’s diverticulum Meckel’s diverticulum is usually clinically silent, hence the asymptomatic periods between the bleeding episodes. Also, a complication of Meckel’s diverticulum is GI bleeding.

A 64 years patient with nephrotic syndrome 2 months. He has congestive heart failure as the echo showed severe diastolic dysfunction. His Create. was 320 (high). Ultrasound showed normal kidney with increased echogenicity, what’s is the most likely underlying finding? a. Positive Congo red stain b. HbA1c of 10 c. Positive hepatitis C

a. Positive Congo red stain In amyloidosis can cause restrictive cardiomyopathy leading to diastolic congestive heart failure.

A 30 yo male with recurrent nose bleeds weight loss cough ENT consultation showed nasal septal perforation + he had pulmonary infiltrates. Dx? A. churg strauss B. wegeners granulomatosis C. polyarteritis nodosa D. microcopic polyangiitis

B. wegeners granulomatosis ( Wegener is characterized by chronic sinusitis, nasal septal perforation(saddle nose) pulmonary infiltration, and glomerulonephritis)

A 69 yr. old male presented to the emergency department with symptoms of right sided weakness, there was no facial weakness, no loss of sensation of the face. Right Upper limb power 5/5 at shoulder, elbow, wrist. Right Lower limb power 3/5 at hip, knee, ankle, also brisk reflexes and extensor plantar response of right lower limb. Which artery is affected? A. right middle cerebral artery B. left middle cerebral artery C. right anterior cerebral artery D. left anterior cerebral artery

D. left anterior cerebral artery

Type I diabetic patient had low K 2.1 (N=3.5-5), glucose 17, high urine ketones, low pH. DKA was diagnosed and 500 ml NS was given. What to do next? A. 0.6 units insulin + 40meq K + 500ml NS B. 6 units insulin + 40meq K + 500ml NS C. Delay insulin infusion + 40meq K + 500ml NS

C. Delay insulin infusion + 40meq K + 500ml NS Note: if K < 4 first replace then give insulin because insulin causes an intracellular shift of K, which cause life-threatening hypokalemia.

A young girl presenting with altered sensorium and fever. She also had thrombocytopenia and abnormal RFT. Peripheral blood smear showed fragmented red cells. Normal APTT, PT, TT. What is the best management? a. Plasma exchange b. IVIG with steroids

a. Plasma exchange

patent had anorexia and nausea. He also had polyuria and thirst as well. His Ca was high, Na and K were normal. He was found to have lung cancer. What is the most likely histopathological type?

Squamous cell carcinoma Note: squamous cell carcinoma has a paraneoplastic syndrome “hyperparathyroidism, high Ca”.

Repeated question scleroderma sign indicating poor prognosis?

Pulmonary hypertension

-Patient with description of complete heart block (HR was 40). Which of the following is true?

Cannon A wave

A female with increased facial hair and oligomenorrhea and menstrual irregularities. What is the diagnosis? A. PCOS B. hirsutism

A. PCOS

A 25 year old female presented with a thyroid nodule. On further history, it was totally asymptomatic with no compressive symptoms. Investigations showed normal TSH. What to do next? A. Thyroid scan B. Thyroid US

B. Thyroid US

Patient suddenly stops then shake, and she dont rememebr what happened, what is the diagnosis? (It was something like this) A. Complex partial seizures B. Other choices where not seizures

A. Complex partial seizures

Description of CML. What is the genetic translocation? A. T(11:14) B. T(9:22) C. T(14:18)

B. T(9:22)

A 20 year old male presented with pancytopenia, he was diagnosed with severe aplastic anemia. What’s the best treatment plan for him? a. Allogenic bone marrow graft b. Cyclosporine alone c. Cyclosporine + ATG d. Cyclosporine + Stanzolol

c. Cyclosporine + ATG

a 67 year old man with gouty arthritis for 4 years. He has a 3-4 attacks per year. He has a history of a surgery for kidney stones. Which medication would you prescribe? A. indomethacin B. colchicine C. prednisolone D. allopurinol

D. allopurinol (in this case its chronic gouty arthritis so the first line is allopurinol all the others are used in acute gout flare)

Pearly lesion on face with palisading dermis. What is the diagnosis? A. Basal cell carcinoma B. Squamous cell carcinoma C. Melanoma

A. Basal cell carcinoma

Sheep farmer presenting with erythema multiforme. What is the diagnosis? A. Cowpox B. Smallpox C. Parapox (Orf) D. Monkeypox

C. Parapox (Orf)

Patient had hypercalcemia, renal impairement, and anemia. What is the diagnosis?

Multiple myeloma

A patient with new onset of deranged liver enzymes: AST, ALT, ALP, high bilirubin. Her liver biopsy was significant for interface hepatitis. What is the best next step in management? a. Ursodeoxycholic acid b. Prednisolone

b. Prednisolone AIH; liver biochemistry shows deranged liver enzymes and pathology shows interface hepatitis. Therefore, stem indicates AIH, which is treated with prednisolone

a case f obstructive sleep apnea. What is the nature of this type of sleep apnea? - Both nasal and respiratory efforts are reduced - Nasal effort is maintained while respiratory effort is reduced - Nasal effort is reduced while respiratory effort is maintained - There is no association between nasal and respiratory effort

- Nasal effort is reduced while respiratory effort is maintained

An elderly patient had dizziness, right sided hearing loss and right sided facial numbness. ENT examination unremarkable. What is the diagnosis? A. Minnere’s disease B. Ramsy hunt syndrome C. Vestibular Schwanoma

C. Vestibular Schwanoma • Minnere’s disease doesn’t explain the facial numbness. • Ramsy hunt is characterized by paralysis of facial nerve w/ rash. • Vestibular shwannoma: ipsilateral facial numbness, hearing loss and imbalance resulting from tumor compressing trigeminal cochlear and vestibular nerves.

Patient with infective endocarditis went to the dentist then he referred him to cardiology. What should be done? A. Nothing B. Give erythromycin C. Give penicillin for 10 years

A. Nothing

A patient known to have alcoholic hepatitis presents with ascites. His serum albumin was 25, ascitic fluid albumin was 6, and PMN count in ascitic fluid was 680/mm^3. What is the diagnosis? a. Acute portal vein thrombosis b. Spontaneous bacterial peritonitis

b. Spontaneous bacterial peritonitis Neutrophil count > 250 cells/mm3 = SBP

Patient with pancytopenia and BM hypocellularity (not sure)

Fanconianemia

A female developed two unprovoked DVTs. She mentioned that multiple family members had similar thrombotic events. Which of the following is the most likely mutation? a. activated protein C resistance (factor V Leiden) b. prothrombin gene mutation c. anti-thrombin III mutation

a. activated protein C resistance (factor V Leiden)

A 35-year-old male presented with single asymptotic clean ulcer on the glans penis for 1 week. He had an unprotected extramarital heterosexual intercourse 2 weeks ago. Upon examination, the ulcer was non tender and indurated. What’s the diagnosis? A. Granuloma inguinale B. Chancroid C. Primary chancre D. Herpes progenitalis

C. Primary chancre

Complete heart block ECG with dizziness but no loss of consciousness. HR was 50, BP was stable. What is the next step?

Implantation of permanent pacemaker

A patient had the following results of ABG: pH of 7.2, Na=140, Cl=105, HCO3=15, K=4, pCO2=25. What is the acid base disorder? a. Primary metabolic acidosis with normal anion gap b. Primary metabolic acidosis with high anion gap c. Primary respiratory acidosis d. Primary respiratory alkalosis

b. Primary metabolic acidosis with high anion gap

A 75 year old male who had an urgent cholecystectomy with post-op bruising, his PT and APTT are elevated but were normal pre-op, fibrinogen level 550 (N:150-450mg/dl), D-dimer was 3.52 (N:0.4-2.5). What’s the management? a. cryoprecipitate b. fresh frozen plasma c. recombinant factor 7 novo seven d. SC vitamin k replacement

b.fresh frozen plasma

Elderly female treated with NSAIDs for chronic back pain for 2 years. She has impaired RFT, anemia, urine dipstick showed trace proteins while 24-hour urine proteins were 1.8. Which of the following will be most likely present? a. Low C3 and C4 b. c-ANCA c. Hypercalcemia

c. Hypercalcemia Elderly with Back pain, anemia and nephrotic syndrome suggest multiple myeloma. So, the patient will have hypercalcemia.

A 28 Year old Lady who is unable to conceive for the past 8 months presented to the clinic. She had amenorrhea for the past 6 months. Physical Examination reveals no abnormalities. LH, FSH, and Estradiol are all low. What could be the reason for this. A. Hypothalamus B. Hypergonadotropic Hypogonadism C. Adrenal

A. Hypothalamus