EMREE QUESTIONS

Up Till 30/01/2021
 Table of Contents
------- Anesthesia ------ ............................................................................................................ 9
------- Biostatistics & Epidemiology ------ ............................................................................... 10
Types of Studies ........................................................................................................................... 10
Bias ............................................................................................................................................. 12
Statistical Tests ............................................................................................................................ 12
Others ......................................................................................................................................... 13
Epidemiology ............................................................................................................................... 16
Patient Safety .............................................................................................................................. 17
------- Breasts ------ ................................................................................................................ 18
Diagnostic Algorithms .................................................................................................................. 18
Benign Breast Diseases ................................................................................................................. 19
Breast Cancer............................................................................................................................... 20
------- Cardiology ------ .......................................................................................................... 22
Arrhythmias, Arrest, and ECGs ......................................................................................................22
Heart Failure ................................................................................................................................ 27
Coronary Artery Diseases ............................................................................................................. 28
Cardiomyopathies ........................................................................................................................ 32
Valvular Heart Diseases ................................................................................................................ 33
Others ......................................................................................................................................... 34
------- Dermatology & Immunology------ ................................................................................ 38
Dermatitis ...................................................................................................................................38
Psoriasis ......................................................................................................................................38
Acne ............................................................................................................................................ 39
Infections ....................................................................................................................................41
Skin Cancers ................................................................................................................................ 43
Immunology ................................................................................................................................ 44
Others ......................................................................................................................................... 45
------- Diet & Vitamins ------................................................................................................... 50
Diet ............................................................................................................................................. 50
Malnutrition ................................................................................................................................ 50
Vitamins ......................................................................................................................................51
------- Electrolytes ------ ......................................................................................................... 54
Potassium ....................................................................................................................................55
Phosphate ...................................................................................................................................56
Calcium........................................................................................................................................ 57
Acid-Base Balance ........................................................................................................................ 58
Mixed .......................................................................................................................................... 58
------- Endocrinology ------ ..................................................................................................... 59
Pituitary ......................................................................................................................................59
Thyroid ........................................................................................................................................ 60
Parathyroid..................................................................................................................................64
Adrenals ......................................................................................................................................65
Diabetes ......................................................................................................................................66
Others ......................................................................................................................................... 68
------- ENT ------ ..................................................................................................................... 69
Ear............................................................................................................................................... 69
Nose ............................................................................................................................................ 72
Others ......................................................................................................................................... 72
------- Ethics ------ .................................................................................................................. 73
------- Family Medicine ------ .................................................................................................. 75
Well-Being Visits .......................................................................................................................... 75
Prevention & Health-Screening ....................................................................................................76
Others ......................................................................................................................................... 76
------- Forensic Medicine ------ ............................................................................................... 78
Direct Cause of Death ................................................................................................................... 78
Underlying Cause of Death ........................................................................................................... 78
Others ......................................................................................................................................... 79
------- General Surgery ------ .................................................................................................. 80
Post-Operative Care ..................................................................................................................... 80
Appendix .....................................................................................................................................82
Diverticular Diseases .................................................................................................................... 83
Intestinal Obstruction .................................................................................................................. 83
Perforation ..................................................................................................................................84
Burns ........................................................................................................................................... 84
 Infections & Ulcers ....................................................................................................................... 85
Hernias ........................................................................................................................................ 89
Neck Masses ................................................................................................................................ 91
Cysts & Abscesses ........................................................................................................................ 91
Diabetic Foot ............................................................................................................................... 92
Others ......................................................................................................................................... 92
------- Genetics ------ .............................................................................................................. 93
------- Gastroenterology ------ ................................................................................................ 94
Esophagus ...................................................................................................................................94
Stomach ......................................................................................................................................95
Colorectal Diseases ...................................................................................................................... 96
Anal Diseases ............................................................................................................................... 99
Pancreas .................................................................................................................................... 100
Liver .......................................................................................................................................... 101
Gallbladder ................................................................................................................................ 103
Infections .................................................................................................................................. 105
GI Bleeding ................................................................................................................................ 108
Others ....................................................................................................................................... 110
------- Hematology ------ ...................................................................................................... 111
RBCs .......................................................................................................................................... 111
WBCs ......................................................................................................................................... 113
Platelets & Coagulation .............................................................................................................. 113
Oncology ................................................................................................................................... 114
Others ....................................................................................................................................... 115
------- Infectious Diseases ------ ............................................................................................ 116
Microbiology ............................................................................................................................. 116
Antibiotics ................................................................................................................................. 116
Tuberculosis .............................................................................................................................. 117
HIV ............................................................................................................................................ 117
Others ....................................................................................................................................... 117
------- Metabolic Diseases ------ ........................................................................................... 119
Biochemistry.............................................................................................................................. 119
Dyslipidemia .............................................................................................................................. 119
------- Nephrology ------ ....................................................................................................... 121
Nephrotic & Nephritic Syndromes .............................................................................................. 121
Renal Failure.............................................................................................................................. 122
Vascular..................................................................................................................................... 122
Others ....................................................................................................................................... 123
------- Neurology ------ ......................................................................................................... 124
Cerebrovascular ......................................................................................................................... 124
Cranial Nerves ........................................................................................................................... 124
Dementia................................................................................................................................... 126
Neuromuscular .......................................................................................................................... 127
Headaches ................................................................................................................................. 128
Demyelinating Diseases ............................................................................................................. 128
Infections .................................................................................................................................. 129
Tumors ...................................................................................................................................... 130
Movement Disorders ................................................................................................................. 130
Peripheral Neuropathy ............................................................................................................... 132
Others ....................................................................................................................................... 134
------- Obstetrics & Gynecology ------ ................................................................................... 138
Obstetrics .................................................................................................................................. 138
Antenatal .......................................................................................................................................................... 138
Bleeding ............................................................................................................................................................ 142
Hypertension .................................................................................................................................................... 143
Labor ................................................................................................................................................................. 144
CTG.................................................................................................................................................................... 150
Post-Partum ...................................................................................................................................................... 153
Gynecology ................................................................................................................................ 154
Early Pregnancy Problems ................................................................................................................................ 154
Ovarian Diseases............................................................................................................................................... 157
Uterine Diseases ............................................................................................................................................... 159
Cervical Diseases............................................................................................................................................... 160
Vulvovaginal Diseases....................................................................................................................................... 162
Infections .......................................................................................................................................................... 163
Contraception ................................................................................................................................................... 165
Amenorrhea...................................................................................................................................................... 167
Menstrual Cycle & Irregularities ....................................................................................................................... 169
Menopause ....................................................................................................................................................... 170
Infertility ........................................................................................................................................................... 172
Urogynecology .................................................................................................................................................. 173
------- Occupational Medicine ------...................................................................................... 175
Inhalational Injuries ................................................................................................................... 175
 Heavy Metals Poisoning ............................................................................................................. 176
Musculoskeletal Injuries............................................................................................................. 177
Healthcare & Labs ...................................................................................................................... 177
Chemical Factories ..................................................................................................................... 179
General...................................................................................................................................... 179
------- Ophthalmology ------ ................................................................................................. 181
Vascular Diseases....................................................................................................................... 181
Glaucoma .................................................................................................................................. 181
Cataracts ................................................................................................................................... 182
Infections .................................................................................................................................. 182
Others ....................................................................................................................................... 182
------- Orthopedics ------ ...................................................................................................... 186
Hands & Wrists .......................................................................................................................... 186
Forearm..................................................................................................................................... 187
Elbow ........................................................................................................................................ 187
Arm ........................................................................................................................................... 187
Shoulder .................................................................................................................................... 187
Back .......................................................................................................................................... 188
Hip & Femur .............................................................................................................................. 190
Knees ........................................................................................................................................ 191
Legs ........................................................................................................................................... 193
Ankle ......................................................................................................................................... 193
Fractures ................................................................................................................................... 194
Tumors ...................................................................................................................................... 194
Others ....................................................................................................................................... 195
------- Pediatrics ------ .......................................................................................................... 196
Cardiology ................................................................................................................................. 196
Dehydration .............................................................................................................................. 198
Dermatology .............................................................................................................................. 201
Endocrinology ............................................................................................................................ 201
ENT............................................................................................................................................ 202
Gastroenterology ....................................................................................................................... 204
Genetics .................................................................................................................................... 205
 Growth & Development ............................................................................................................. 207
Hematology & Oncology ............................................................................................................ 211
Immunology .............................................................................................................................. 214
Infectious Diseases..................................................................................................................... 215
Metabolic Diseases .................................................................................................................... 219
Musculoskeletal ......................................................................................................................... 220
Neonatology .............................................................................................................................. 222
Nephrology ................................................................................................................................ 227
Neurology .................................................................................................................................. 229
Psychiatry .................................................................................................................................. 231
Pulmonology ............................................................................................................................. 233
Surgery ...................................................................................................................................... 236
Urology...................................................................................................................................... 237
Vaccination ................................................................................................................................ 238
Vasculitis ................................................................................................................................... 239
Well-Being ................................................................................................................................. 240
------- Psychiatry ------ ......................................................................................................... 241
Stages of Change........................................................................................................................ 241
Mood Disorders ......................................................................................................................... 242
Grief & Bereavement ................................................................................................................. 244
Psychotic Disorders .................................................................................................................... 245
Panic & Anxiety Disorders .......................................................................................................... 248
Somatic Disorders ...................................................................................................................... 251
Personality Disorders ................................................................................................................. 253
Sleep Disorders .......................................................................................................................... 254
Dementia & Delirium ................................................................................................................. 254
Eating Disorders ......................................................................................................................... 256
Sexual Disorders ........................................................................................................................ 256
------- Pulmonology ------ ..................................................................................................... 258
Obstructive Lung Diseases .......................................................................................................... 258
Restrictive Lung Diseases ........................................................................................................... 259
Lung Cancer ............................................................................................................................... 259
Pulmonary Embolisms ................................................................................................................ 260
 Infections .................................................................................................................................. 261
Pleural Diseases ......................................................................................................................... 265
Others ....................................................................................................................................... 266
------- Rheumatology ------................................................................................................... 268
Rheumatoid Arthritis ................................................................................................................. 268
Gout .......................................................................................................................................... 268
Systemic Lupus Erythematosus ................................................................................................... 269
Seronegative Arthropathies........................................................................................................ 270
Vasculitis ................................................................................................................................... 271
Others ....................................................................................................................................... 271
------- Toxicology ------......................................................................................................... 273
Ingested Toxins .......................................................................................................................... 273
Injected Toxins........................................................................................................................... 276
------- Trauma ------ ............................................................................................................. 277
General Principles & Resuscitation ............................................................................................. 277
Ocular........................................................................................................................................ 279
Head & Neck .............................................................................................................................. 279
Cardiothoracic ........................................................................................................................... 280
Abdominal ................................................................................................................................. 280
Spinal ........................................................................................................................................ 282
Extremities ................................................................................................................................ 282
Urology...................................................................................................................................... 283
Others ....................................................................................................................................... 283
------- Urology ------ ............................................................................................................. 284
Kidneys...................................................................................................................................... 284
Bladder ...................................................................................................................................... 285
Prostate..................................................................................................................................... 285
Testes ........................................................................................................................................ 286
Infections .................................................................................................................................. 286
------- Vascular ------ ............................................................................................................ 289
Hypertension ............................................................................................................................. 289
9Aorta ....................................................................................................................................... 290
Arterial Diseases ........................................................................................................................ 291
Venous Diseases ........................................................................................................................ 292
AV Fistulas ................................................................................................................................. 293
Others ....................................................................................................................................... 293
 ------- Anesthesia -------
1 A woman developed SOB and chest pain on post-op day 2. On examination, she had
distended JVP and a new murmur. She was diagnosed with tricuspid regurgitation. How
could this have been prevented?
A. Neuraxial anesthesia
B. Anticoagulant HEPARIN
C. Beta blocker
D. Bed rest
Echocardiography
• Findings [21][22][41]

o Dilatation and hypokinesis of the right ventricle (RV)

o Venous reflux with IVC dilation
o Tricuspid regurgitation (tricuspid valve insufficiency)
o ↑ PASP
o Increased right atrial pressure

• Symptomatic nonmassive PE and low-risk submassive PE:

Prescribe anticoagulation for PEif bleeding risk is low.
• High-risk submassive PE: Start anticoagulation for PE and
consider thrombolysis for PE.

2 Which position increases caudal migration of anesthesia?

A. Trendelenburg (head down)
B. Reverse Trendelenburg

3 A patient with flail chest was intubated and sent to the ICU. What is the most accurate
investigation to assess his pulmonary function after intubation?
A. ABG
B. Pulse oximetry
C. Estimated end-tidal CO2
D. Chest x-ray
CO2 detection: gold standard of successful endotracheal intubation [4
 ------- Biostatistics & Epidemiology -------
Types of Studies

1 A study was conducted to measure the prevalence of obesity among teens in Al Ain. They
chose 1,800 students randomly from 8 different schools, and looked at their age, gender,
and family income. They also measured their body weight & height. What type of study is
this?
A. Cohort
B. Case control
C. Cross sectional
D. Experimental
2 A random group of Bedouins were randomly selected to study the effect of sun exposure
on skin diseases. They were given a questionnaire asking about sun exposure, diet, and
skin health. Type of study?
A. Cohort
B. Cross-sectional
C. Prospective
D. Case control
3 A study was done among patients with lung cancer to find out if they had history of
smoking (via a survey). What is the type of study?
A. Case-control
 B. Cross-sectional
C. Cohort
4 A study is comparing the results of a new diet by comparing 2 groups of randomized
people. One group received the new diet whereas the other did not receive anything. What
is the type of the study?
A. Experimental study
B. Cross-sectional study
5 A study was done to compare the risk of developing cancer among 2 groups (100 smokers
vs. 100 non-smokers). They were followed up for 10 years to assess the risk. Type of
study?
A. Cohort
B. Cross-sectional
C. Case-control
D. Randomized control-trial

6 What type of articles has the highest form of evidence?

A. Systemic review
B. Cross section
C. Metanalysis
 Bias

7 A study was conducted to assess how healthy a work environment is. The sample
consisted of immigrants working in construction. What type of bias will the study have?
A. Recall bias
B. Selection bias
Statistical Tests

8 To compare 2 studies done in 1998 & 2003 about delayed melanoma diagnosis, what is
the best method to use?
 A. Chi-square test (looks for association between 2 variables)
B. Independent T-test (determines the difference between 2 unrelated groups)
C. Histogram (graphical display of data using bar charts)
D. Correlation coefficient (measures the strength of the relationship on the same
group)
E. Paired T-test (compares 2 variables on the same subject)
Others
9 A medical university wanted to do a trial comparing new innovation procedures to each
other. After obtaining consent, patients received trials randomly & the outcomes were
outlined. Question??
A. Selection bias & confounding factors are reduced
B. Decrease sample size
1 A study was done in FMHS among European and Asian doctors regarding cardiovascular
0 diseases. European doctors were found to be at higher risk of CVDs than Asian doctors.
What is the next step in this study?
F. Analyze data for confounding variables
G. Start a program for Europeans to  the risk of CVD
1 A study was comparing health burdens of CVA between Yemen and UAE.
1 DALY

DALY = YLL + YLD

1 A study was conducted to assess the correlation between chewing tobacco and the
2 incidence of myocardial infarctions. The odds ratio was found to be 1.14 with a
confidence interval of 0.8-2.3. How do you interpret these results?
 A. Null hypothesis cannot be rectified
B. Chewing tobacco causes MI
C. P-value is required for interpretation
D. T-test is recommended for interpretation
Odds ratio >1 = association (risk likely increased) – risk factor
Odds ratio 1 = no association
Odds ratio < 1 = negative association (risk likely decreased) – protective factor

Since the confidence interval (0.8 – 2.3) includes 1, it means the results are insignificant
and thus the null hypothesis cannot be rejected.
1 Calculate the cumulative risk of a disease. 200 people have the disease. The incidence in
3 the first year was 20 but increased to 90 after 10 years. More details were provided in the
question.
55 %
𝑛𝑜. 𝑜𝑓 𝑛𝑒𝑤 𝑐𝑎𝑠𝑒𝑠( 20 + 90)
𝑥100
𝑡𝑜𝑡𝑎𝑙 𝑛𝑜. 𝑜𝑓 𝑝𝑝𝑙 𝑖𝑛 𝑝𝑜𝑝𝑢𝑙𝑡𝑎𝑡𝑖𝑜𝑛 𝑎𝑡 𝑟𝑖𝑠𝑘 𝑖𝑛 𝑠𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑡𝑖𝑚𝑒 𝑖𝑛𝑡𝑒𝑟𝑣𝑎𝑙(200)
1 Calculate the cumulative incidence.
4

1 There are 39 workers in a company. 13 are working in a grid & are exposed to lead. The
5 other 26 are working in another area & are also exposed to lead. 7/39 were found to have
 blood lead levels. 6 of the 7 are working in the grid area, and 1 is working in the other
area. Calculate the relative risk.
A. 15.3
B. 12
Disease
+ -
Exposure + 6 (A) 7 (B)
 - 1 (C) 25 (D)
Relative risk = probability of disease in exposed / probability of disease in non-exposed
RR = [A / (A+B)] / [C / (C+D)] = [6/13] / [1/26] = 12 (high association; exposure is a risk
factor)
1 Definition of accuracy?
6 The degree of conformity of a measured / calculated quantity to an actual (true) value.
1 What should the p-value be to make sure the results are least likely to be due to chance?
7 A. 0.99
B. 0.95
C. 0.50
D. 0.05
E. 0.01
Although E would be even less likely (depends on the value set by the study)
1 In which domain does the WHO indicator “tobacco in 18+ year-olds” fall?
8 A. Health status
B. Health services
C. Risk factor

1 Something about intercept (what it means for coefficient for pregnant women)?
9 A. Mean value when all x=0 when all variables are 0
B. All the variables were zero – the shortest gestation age is 37.9 weeks
C. Median of gestation period – strong association between 4 parameters – no
interpretation
D. Mean of gestational period
The average length of pregnancy is 37 (37.9) weeks if all variables are 0?
I do not understand the question
2 Intercept?
0 A small table was given providing numbers ranging from -1, 0, +1 for different variables
(level of education, socioeconomic status, relation with gestational age). At the bottom of
the table, they wrote that the intercept = 1.000. R2 was also given.
A. Mean (average)
B. Median (number in the middle)
C. Mode (most repeated number)
D. Intercept at 0 (when you draw x & y on an axis chart)

the intercept (often labeled the constant) is the expected mean value of Y when all X=0.
Start with a regression equation with one predictor, X. If X sometimes equals 0, the
intercept is simply the expected mean value of Y at that value.

2 Calculate sensitivity & specificity.

1
2 Definition of specificity?
2 True negative rate – the proportion of people without the disease who will have a negative
result – how well the test identifies patients who do not have the disease.
Epidemiology
2 What is the most common cause of mortality amongst individuals aged > 40 years in the
3 UAE?
A. Respiratory diseases
B. Cardiovascular diseases
C. Cancer
A. Liver diseases

Indeed, the UAE has one of the highest age-standardised death rates for cardiovascular
disease in the world, that is, 308.9 per 100,000 for males and 203.9 per 100,000 for
females.
2 Al Ain Municipality was astonished by the increasing number of children mortality
4 because of RTAs. What preventive measure can you do?
A. Enforce seat belts
B. Traffic lights
C. Air bags only for licensed cars
D. Install additional humps in the roads
2 Case of a patient with juvenile stomatitis… Which of the following statements is most
5 accurate about screening tests?
A. Screening results should be consistent when the test is done repeatedly
B. Screening tests should be able to find multiple diseases at the same time
C. They should use multiple processes
2 What are the conditions for screening tests?
6 Treatable disease + screening can modify morbidity & mortality
2 Which cancer has the highest mortality rate?
7 A. Ovary
B. Thyroid
C. Pancreas
Lung and bronchus cancer is responsible for the most deaths with 130,180 people expected to die
from this disease. That is nearly three times the 52,580 deaths due to colorectal cancer, which is the
second most common cause of cancer death. Pancreatic cancer is the third deadliest cancer, causing
49,830 deaths.
Patient Safety
• Sentinel Event: an unanticipated event in a healthcare setting resulting in death or serious
physical / psychological injury to a patient(s), not related to the natural course of the
patient’s illness.
• Near Miss Event: any event that could have had adverse consequences but did not and
was not indistinguishable from fully fledged adverse events in all but outcome
• Adverse event: an injury that was caused by medical management (rather than the
underlying disease) and that prolonged the hospitalization, produced a disability at the time
of discharge, or both).

Latent errors (or latent conditions) refer to less apparent failures of organization or
design that contributed to the occurrence of errors or allowed them to cause harm
to patients.

(Faulty ventilator is a latent error. Failure to check its functioning or detect hypoventilation
is an active error. If disconnection of the circuit is identified and corrected before the patient
desaturates, it is a near-miss).

Importance of reporting errors?

------- Breasts -------
Diagnostic Algorithms
1 A 42-year-old woman reports to the surgeon that she is worried about a lump that she
feels the right breast. The surgeon observes a 2 cm by 3 cm mass in the right lower
quadrant of the breast. There are no associated skin changes and the mass has limited
mobility. There is no discharge from the nipple. There is no axillary lymph node
enlargement. Examination of the left breast and axilla was completely normal. A
mammogram report suggests the presence of microcalcifications. Which of the
following is the most appropriate next step in the management of this patient?
A. Observation for one year and repeat the mammography
B. A needle-guided biopsy of the breast
C. Excision biopsy of the breast
D. Partial mastectomy
2 A 54 y/o has a breast mass in her LUQ. It is non-tender & not fixed to the skin.
Mammogram & US showed micro-calcifications & a suspicious mass. How can you
confirm the diagnosis?
A. FNA (tells u if benign or malignant. But mammo shows its malignant)
B. Excision biopsy
C. Incision biopsy
D. Modified mastectomy
I would go with B (excisional biopsy). Best option would be core needle biopsy but it
is not in the options. FNA is the preferred tool for assessing breast tumors with low
probability of malignancy – in this case it says suspicious mass.
3 A 50 y/o female had a breast mammogram that showed microcalcifications suspicious
of cancer. O/E she has no palpable masses. What is your next step?
A. Repeat mammography after 3 months
B. Excisional biopsy
C. Repeat mammography after 12 months
D. Give her tamoxifen for 6 months
4 A woman had BIRAD 3 breast mammogram. What is the next step?
Repeat mammogram in 6 months
Benign Breast Diseases
5 A 26 y/o female is lactating. She developed a painful mass in the right breast that was
warm to touch and fluctuant. She was also febrile. USS showed a 4x4 cm fluid-filled
cyst in the inner aspect of her right breast. What will you do as a first step
management?
A. USS-guided drainage
B. Surgical drainage
C. Analgesia & antibiotics MASTITIS
D. Incision & drainage ABSCESS
Breast abscess = I&D
If the abscess is < 5 cm, needle drainage is possible but I&D is still preferred.
6 A woman presented with fever (39C) & bilateral breast fullness and pain 3 weeks
post-delivery. She has also been feeling unwell and tired most of the time. On
examination, there was no rash or erythema, but her breasts were tender. What is your
diagnosis?
• Breast engorgement >>>>> Breast engorgement
 o Etiology
▪ Primary: initial swelling due to increased milk
production postpartum (during the transition
from colostrum to mature milk)
▪ Secondary: insufficient removal of breast milk (e.g.,
due to infrequent feeds, poor attachment, ineffective
suckling, abrupt cessation of breastfeeding)
o Clinical features: tenderness, firmness, and fullness of
the breast
o Management
▪ Frequent breastfeeding with optimal nursing
techniques
▪ Warm compresses prior to breastfeeding; cold
compresses between feeds
▪ Analgesia
▪ Careful expression of breast milk by hand or with
a breast pump to alleviate pressure.
o Complications: mastitis
A.
• Mastitis >>>> Typically localized, tender, firm,
swollen, erythematous breast (generally unilateral)
• Systemic symptoms (malaise, fever, and chills)
• Pain during breastfeeding [8]
• Reduced milk secretion
• Reactive axillary lymphadenopathy (less common)
B.

• C. Breast abscess (Breast pain, erythema, and edema

• Purulent discharge from the nipple of the affected breast
• Fluctuant mass on palpation
• Possibly overlying skin necrosis
• Fever
• Nausea)

7 A lady developed fever postnatally. O/E her breast was erythematous & tender.
Diagnosis?
Mastitis
8 A breast-feeding lady is complaining of fever & right-sided breast pain that worsens
after feeding her baby. O/E, there is breast tenderness and erythema of the overlying
skin. Next step?
A. Broad-spectrum antibiotics + analgesia & observe
B. Incision & drainage
Mastitis = antibiotics (dicloxacillin / cephalexin) (if MRSA = clindamycin / TMP-
SMX) + analgesia + continue breastfeeding
Breast Cancer
9 What is the most common cancer in women?
A. Breast
B. Cervix
C. Vulva
D. Ovary

Breast cancer was the most common cancer in women worldwide, contributing 25.8% of
the total number of new cases diagnosed in 2020.
10 A 52 y/o female requested an investigation to make sure she does not have breast
cancer. What is the most sensitive & specific investigation?
A. Breast self-examination
B. Physician examination
C. FNA
Most sensitive = MRI with contrast ............. Most specific = biopsy
11 A 55 y/o female came with bloody discharge from the nipple. Most likely diagnosis?
Ductal carcinoma >>>> Invasive ductal carcinoma (IDC)
• Characteristics
o Most common type of invasive breast cancer (∼ 80%) [11]
o Aggressive formation of metastases
A.
B. Duct ectasia green discharge
C. Paget disease
D. Peau d’orange
12 What is the most common location for breast malignancies?
A. Inner upper quadrant
B. Inner lower quadrant
C. Subareolar
D. Outer upper quadrant (b/c most dense)
13 What increases the risk of breast cancer in a woman?
A. History of her great aunt passing away due to breast cancer at the age of 60
B. History of her mother passing away due to breast cancer at the age of 60
C. History of her mother passing away due to breast cancer at the age of 45

Hormonal risk factors

Increased exposure to endogenous estrogen
First viable pregnancy after 35 years of age
Nulliparity and/or absence of breastfeeding [5]
 Early menarche and/or late menopause
Obesity in postmenopausal women (lipocytes convert androstenedione to estrone)

14 What determines the prognosis of breast cancer recurrence?

A. Lymph node involvement
B. Age
Detection of tumor cells in axillary lymph nodes = higher risk of metastatic spread to
other organs + lower survival rates + increased rate of cancer recurrence (4-9 +ve
notes = 70 % risk of recurrence)

• Lymphatic spread: Axillary lymph node status is the one of most important
prognostic factors.

Stage IV
Distant metastases
27% survival
15 A woman suffering from breast cancer with estrogen + receptor was told to take
tamoxifen. What is the mechanism of action of tamoxifen?
A. Blocks estrogen receptor Antiestrogen

• Competitive antagonist on the estrogenreceptors of the breast → ↓ breast cancercell growth

• Agonist on estrogenreceptors in the following tissues:

o Bone tissue→ inhibition of osteoclasts→ ↓ risk of osteoporosisand fractures

o Endometrium→ ↑ proliferation[9]

o Myometrium→ ↑ proliferation

• SE Hot flashes

• ↑ Risk of endometrial cancer [9]

• ↑ Risk of thromboembolic events (e.g., pulmonary embolism, DVT)

• ↑ Risk of uterine sarcoma

B. Modifies the receptor by binding to it and activating it

16 Following a mastectomy, the nurse noticed that the patient has winging of the scapula.
What nerve was injured?
Long thoracic nerve
 ------- Cardiology -------
Arrhythmias, Arrest, and ECGs
1 A patient with chronic atrial fibrillation presented complaining of frequent attacks of
lightheadedness. He took digoxin in the past but has not been on any medications in the
past year. Management?
A. Digitalis preparation
B. Beta blocker
C. Cardioversion

• First-line
o Beta blockers (e.g., metoprolol, atenolol, propranolol)

▪ Preferred when Afib is due to hyperthyroidism and in pregnant patients

▪ Avoid in patients with COPD.

o Nondihydropyridine calcium channel blockers (e.g., diltiazem, verapamil)

▪ Avoid in patients with decompensated heart failure (LV systolic

dysfunction/low ejection fraction).

▪ Can be safely used in heart failure with preserved normal

LV systolic function.

• Second line: digoxin; preferred as first-line therapy in patients with decompensated HFwhen beta
blockers are contraindicated.

• Third line: amiodarone; typically reserved for patients in whom all other options have failed
2 A 30 y/o female patient presented to the clinic with dizziness & headache. ECG shown
below. Best management?

A. Refer to ER
B. Refer for outpatient cardiac clinic
C. Send him back home
Management of acute atrial fibrillation:
§ Unstable = electrical cardioversion
§ Stable =
- > 48 hours = rate control (BB / CCB / digoxin) + CHADS2 to assess for need of
anticoagulants
- < 48 hours = rhythm control (electrical > chemical) + anticoagulation
o No significant heart disease: amiodarone
No significant heart disease: flecainide
3 A 68-year-old patient came complaining of palpitations for 7 days. ECG showed atrial
fibrillation. What is the next appropriate step?
A. Cardioversion (not if he is stable) If tachycardiac then rate control first,
B. Anticoagulation (CHADS-VASC score) then anticoagulated
C. Rate control (if no other comorbidities) – BB + CCB if unstable then cardioversion first
If stable BB + CCB +/- anticoagulation. If unstable cardioversion.
4 A child is unresponsive, hypotensive, and has cold extremities. He had a GCS of 6 or 8
and a pulse of 220 bpm. ECG shows narrow complex ventricular tachycardia. What is
your next step?
A. Synchronized cardioversion
B. Vagal maneuvers
C. Digoxin
Pulse:
§ Sustained: unstable shock then amiodarone; stable amiodarone
§ Unsustained: no risk factors do nothing - risk factor check if inducible sustained then
ICD and amiodarone

Pulseless: shock
5 A patient presented with mild chest pain and palpitations. His HR was 150, and his ECG
showed p-wavs hidden in QRS complexes. Mechanical management failed. What do you
give after cardioversion?

A. Adenosine
B. Amiodarone
C. Adrenaline
If patient is asthmatic verapamil (adenosine causes bronchoconstriction)
Amiodarone is only given if the patient is unstable with significant heart disease

Management of undifferentiated SVT [11][12]

1. Perform vagal maneuvers. [12]

2. Reassess the rhythm.
o Rhythm reverts to normal sinus rhythm: Monitor for recurrence.
o Regular SVT is identified:
▪ No contraindications to adenosine:
Administer adenosine.
▪ Contraindications to adenosine present: Administer
an AV-nodal blocking agent.
o Irregular SVT is identified: See management of stable, irregular
narrow-complex tachycardia.
3. If regular or undifferentiated SVT persists despite adenosine, administer
one of the following:
o A nondihydropyridine calcium channel blocker
▪ Verapamil
▪ Diltiazem
o OR a β-blocker
▪ Metoprolol
▪ Esmolol
4. If regular or undifferentiated SVT persists despite the above measures:
o Start an antiarrhythmic
▪ Amiodarone
▪ Ibutilide
o OR perform synchronized electrical cardioversion.
6 A patient has an ECG showing monomorphic PVCs.

A. Atrial fibrillation
B. Extrasystole (ventricular)
C. AV block
D. Left ventricular hypertrophy

• Treatment is not required in asymptomatic individuals without underlying

structural heartdefects.
• Underlying conditions, e.g., electrolyte imbalances, should be treated.
• Symptomatic patients
o Advise patients to reduce potential triggers like caffeine, alcohol,
stress and smoking.
o Beta blockers or catheter ablation in patients with persistent
symptoms

7 2nd degree heart block (Mobitz I)

Mobitz type I (Wenckebach) [2]
Description
Progressive lengthening of the PR interval until a beat is dropped, which means a
regular atrial impulse does not reach the ventricles (a normal P wave is not followed
by a QRS complex)

8 2nd degree heart block (Mobitz II)

Description
Single or intermittent nonconducted P waves without QRS complexes
The PR interval remains constant.
9 3rd degree heart block

10 A patient with a known history of hypertension for the past 10 years presents with historyof loss of
consciousness. ECG showed left bundle branch block with prolonged PR interval (0.34 seconds). What is
the most likely underlying pathology?
A. Multiple and transient pulmonary embolism (does not present with loss of
consciousness)
B. Orthostatic hypotension (no ECG changes)
C. Complete heart block (Stokes-Adams Syndrome)
D. Paroxysmal hypertensive encephalopathy (acute and have history of high BP)
PR interval is usually increased incomplete heart block. Complete heart block: purkenji
system not working, so ventricles contract on their own + atrium on their own. And if ECG showing LBBB
it means that the left ventricle is contracting after right ventricle. +

• Stokes-Adams attacks [10]

o Sudden losses of consciousness that may occur with brief prodromal symptoms, e.g., dizziness, or

without any warning, usually lasting a few seconds

o Attacks are caused by ventricular asystole, most commonly due to third-degree heart block,

especially idiopathic paroxysmal AV block.

 increased in PR interval shows that the signals are not properly getting to his Purkenji
system so means must be block in system in between.

11 A lady presented with dizziness and headache. ECG provided. Diagnosis?

A. Sinus bradycardia
B. 3rd degree heart block
C. Left bundle branch block
D. Q-wave MI
Management
Asymptomatic or only mildly symptomatic patients typically do not require acute
intervention.
Definitive management depends on the underlying rhythm.
12 Patient was brought in and was
hypotensive and pulseless (no
palpable carotid pulse). ECG
shown. (ventricular tachycardia).
Management?
A. Cardioversion
B. Epinephrine (given after cardioversion
C. Amiodarone
D. Lidocaine
E. Magnesium
• Shockable rhythms
o Epinephrine 1 mg IV/IO
▪ First dose: after second unsuccessful defibrillation attempt
▪ Repeat every 3–5 minutes.
o Amiodarone 300 mg IV/IO (OR lidocaine 1–1.5 mg/kg IV/IO)
▪ First dose: after third unsuccessful defibrillation attempt
▪ An additional dose of 150 mg of amiodarone or 0.5–0.75
mg/kg of lidocaine can be given after 3–5 minutes.
• Nonshockable rhythms: Administer epinephrine 1 mg IV/IO.
o First dose: as soon as possible
o Repeat every 3–5 minutes.

13 A patient was brought to the ER with loss of consciousness. ECG showed ventricular
tachycardia. Management?
A. Cardioversion
B. IV amiodarone (after synchronous cardioversion)
C. IV adenosine
D. Digoxin
14 A patient with history of rheumatic fever now has a grade 2/6 systolic ejection murmur
that increases when he bends forward. What ECG changes do you expect to find
corelating with his current presentation?
A. Diffuse ST elevation (because it increases when leaning forward)
B. ST depressions (aortic stenosis – goes more with ejection systolic murmur)
C. PR interval elongation

Pericarditis friction rub is a scratchy leathery sound heard during both systole & diastole.
It is best heard at the LLSB or apex and increases when the patient is positioned forward.

RF pericarditis diffuse ST elevation

RF aortic stenosis ejection systolic murmur + LV strain leading to ST depressions

Aortic stenosis:
§ LVH = left axis deviation + progressive R-wave elongation
§ LA enlargement = inverted p-waves
15 A hypertensive patient with rheumatic heart disease was found to have a harsh
holosystolic murmur over the LLSB radiating to the axilla. What can you possibly find
on the ECG of this patient?
A. Inverted p-wave in V1
B. Large p-wave amplitude in lead II (due to right atrial enlargement classically
due to pulmonary hypertension from cor pulmonale)
C. Wide QRS
D. Prolonged PR interval (acute mitral regurgitation)

Mitral regurgitation murmur

§ Acute MR due to papillary muscle rupture = ischemia in inferior or posterior leads
§ Chronic MR left LV dilatation & hypertrophy increased QRS voltage + ST-T
wave changes in lateral precordial leads

• Acute MR: Findings are often nonspecific.

o Normal sinus rhythm
o Sinus tachycardia with nonspecific ST and T-
wave abnormalities [6]
o Atrial fibrillation [7]
o Signs of acute ischemia in ischemic MR (see acute coronary
syndrome)
• Chronic MR: ECG changes usually reflect cardiac remodeling.
o Left ventricular hypertrophy (50% of patients) [7]
o P mitrale
o Atrial fibrillation [9]
o Signs of right heart strain with P pulmonale in later stages [7]
 § Chronic MR negative P-wave in V1 and/or wide-notched p-wave in leads II / III /
aVF
§ Late stages: atrial fibrillation
Heart Failure
16 A patient comes with acute heart failure. On examination, there were basal lung crackles
but no lower limb edema. What type of heart failure does he have?
A. Right-sided heart failure
B. Left-sided heart failure
C. Compensated heart failure
D. Combined heart failure

Clinical features of left-sided heart failure

Symptoms of pulmonary congestion
Dyspnea, orthopnea (a sensation of shortness of breath that occurs upon lying down and is
relieved by sitting up)
Pulmonary edema
Paroxysmal nocturnal dyspnea
Nocturnal bouts of coughing and acute shortness of breath
Caused by reabsorption of peripheral edema at night → increased venous return
Cardiac asthma
Increased pressure in the bronchial arteries → airway compression
Physical examination findings [9]
Bilateral basilar rales
Laterally displaced apical heart beat
Coolness and pallor of lower extremities
17 A patient presents with dyspnea on exertion and peripheral edema (symptoms of right-
sided heart failure). What associated finding will be there on examination?
Raised JVP

Clinical features of right-sided heart failure

Symptoms of fluid retention and increased CVP
Peripheral pitting edema: as a result of fluid transudation due to increased venous
pressure
Hepatic venous congestion symptoms
Physical examination findings
Jugular venous distention: visible swelling of the jugular veins due to an increase in
CVP and venous congestion
Kussmaul sign
Hepatosplenomegaly
Hepatojugular reflux: jugular venous congestion induced by exerting manual
pressure over the patient's liver
18 Which of the CXR images shows heart failure?
Signs of HF: pleural effusion / cardiomegaly / Kerley B lines / upper lobe pulmonary
venous congestion

19 A 60 y/o male with history of hypertension & DM was brought to the ER as he had SOB
while going upstairs. He is on aspirin, ACE-inhibitor, sulfonylurea, and beta-blocker. His
pulse, BP, RR, ECG, and cardiac enzymes were normal. What further drug do you want
to add?
A. Digoxin
B. Losartan
C. Morphine
D. Heparin
E. Streptokinase

Digoxin
HFrEF with persistent symptoms despite treatment with appropriate first-line medications.
[1]
NYH Beta blockers / ACE-inhibitors / ARBs loop diuretics ISDN-hydralazine /
A spironolactone / inotropes (digoxin)
If there was an option of furosemide I would go for that.
20 A patient with heart failure &
atherosclerosis is on digoxin. Which
drug increases the risk of digoxin
toxicity?
A. Furosemide (causes hypokalemia)
B. Cholecystramine
C. Losartan
D. ACE inhibitor
E. Statins
Furosemide / thiazides worsen hypokalemia.
Digoxin mainly competes with potassium at its receptors. Less potassium more digoxin,
more potassium less digoxin. ACE inhibitors cause hyperkalemia.

Furosemide and digoxin are often used together but may require more frequent
evaluation of your digoxin, potassium, and magnesium levels. Both lower potassium.
In states of hypokalemia, or low potassium, digoxin toxicity is actually worsened
because digoxin normally binds to the ATPase pump on the same site as potassium.
When potassium levels are low, digoxin can more easily bind to the ATPase pump,
exerting the inhibitory effects.
21 What diuretic shouldn’t be given to a patient with heart failure that is hardly compensated?
A. Mannitol (causes rapid fluid shifts)
B. Thiazide (best option to give b/c loop diuretic)
C. Amiloride it is a diuretic
D. Spironolactone
22 A hypertensive & diabetic patient (with no signs of target organ damage) also has severe
osteoarthritis, presents with shortness of breath. She presented complaining of chest pain.
He started taking his son’s diclofenac 50mg TID for 2 weeks. Now she has increased BP
with pedal edema & crackles over the lungs. Auscultation of the heart reveals S3 heart
sound. Next best step? NSAIDs are contraindicated in HTN Diabetes HF CKD
A. Start fosinopril
B. Stop diclofenac (it causes water retention so switch it to paracetamol)
C. Change labetalol as this is a side effect
D. Change her oral hypoglycemic
23 A patient with history of an MI is on aspirin & lisinopril. He also is diagnosed with knee
arthritis for which he is prescribed naproxen (for 2 weeks). What is the complication of
adding this drug to his medications?
A. Water retention
B. Renal stones
C. Hemorrhagic stroke
Coronary Artery Diseases
- ECG: best initial diagnosis.
- Enzymes: CK-MB + Troponin
o OPD with pain for days/weeks = NO need for cardiac enzymes.
o ED acute chest pain = DO cardiac enzymes.
- Stress testing (exercise tolerance):
o Do it when ECG not diagnostic + uncertain etiology.
o Needs: doctor who can read ECG + patient who can exercise (reach max heart rate).
If you cannot read ECG to detect ischemia ECG (due to baseline abnormality):
1. Nuclear isotope uptake: thallium / sestamibi.
* Normal myocardium = uptake of isotope.
* Infarcted myocardium = decrease uptake of isotope (irreversible).
* Ischemia = return normal uptake with rest (reversible)
2. ECHO detection of wall motion abnormalities.
* Decreased wall motion (dyskinesis, akinesis, hypokinesis).
If patient cannot exercise: Increase myocardium oxygen consumption without exercise.
1. Persantine (Dipyridamole) / adenosine + nuclear isotope.
* Stop caffeine before administering.
* CI: asthma (exacerbate bronchospasm).
2. Dobutamine + Echo:
* CI: ventricular arrhythmias, severe HTN, Beta blocker.

Management: ECG + troponin MONA

• Door to needle (tPA): 60 minutes (ideally within 30
minutes of arrival to hospital;should be within 12 hours
of symptoms)
• Door to balloon (PCI): 90 minutes (you can do it up to 120
minutes)
Dual antiplatelets (aspirin + clopidogrel or ticagrelor) for 6 months (stable angina) or 12
months (ACS) if tolerated with no bleeding, continue – otherwise switch to 1
24 Which of the following is most likely to increase the risk for coronary artery disease?
A. LDL
B. HDL
C. Total cholesterol
25 An old patient had chest symptoms (pain?) for 1 month that has resolved. Troponin is
negative. ECG is given (Q wave in the exam ECG). Diagnosis?

A. STEMI
B. NSTEMI
C. Unstable angina
D. Non-cardiac cause
26 What is the best test for vascular diseases?
A. Echocardiography u will still need to do stress test while seeing the echo
B. ECG
C. Stress test
27 A patient has chest pain on exertion (currently asymptomatic). What would you do?
A. Stress ECG
B. Echocardiography
C. Angiography
TTE is generally not necessary and should not delay reperfusion therapy. However, it may
be a helpful study in patients with atypical symptoms or if the diagnosis is unclear.
28 A man was having chest pain on and off. He denies myocardial infarction symptoms.
What will you do?
A. Troponin test and refer to cardiology according to the result
B. Admit him for further investigations
C. Order an echo after 1 week in the OPD
D. Anticoagulate him
29 A patient presents with chest pain for 16 hours. There is family history of coronary artery
disease. What is the most relevant investigation?
A. Troponin I
B. CRP
C. Echocardiography
D. CBC
30 A man undergoing an endoscopy developed chest pain. ECG shows myocardial
infarction. Next step?
A. Nitrate
B. Coronary angioplasty
C. Beta blockers
 Best step?
A. Nitrates
B. Coronary angioplasty
C. Beta blockers
31 What is the most common complication in the first 24 hours after a myocardial
infarction?
A. Arrhythmia
B. Myocardial rupture
C. Heart failure
D. Pericarditis
E. Dressler syndrome
Post-MI Complications:
a. Electrical = arrhythmias (ventricular)
b. Mechanical = rupture of
a. Papillary muscle MR
b. Wall cardiac tamponade
c. Septal rupture
c. Heart failure
d. Pericarditis:
a. 3-4 days = ischemic pericarditis
b. > 2 weeks = Dressler syndrome
e. LV mural thrombus
Complications based on timeline:
1. 0-24 hours = HF / arrhythmias / cardiogenic shock
2. 1-3 days = pericarditis
3. 3-14 days = wall rupture
4. 2 weeks = Dressler
32 Which will not occur at first in a myocardial infarction?
A. Cardiac hypertrophy
B. Pulmonary congestion
C. Pulmonary edema
D.  systemic vascular resistance
33 How can you prevent coronary vasospasms (atypical vasospastic angina)?
A. Diltiazem (first line is CCB)
B. Propranolol avoid nonselective betablocker in prinzmetal cuz causes vascoconstriction
C. Nitrates (antispasmodics – helpful but not initial treatment) alternative
D. Pharmacotherapy: The goal is to prevent spasms and arrhythmias, and to
improve symptoms during acute attacks. [11][39]
• First-line therapy: calcium channel blockers,
e.g., verapamil, diltiazem, or nifedipine [11]
• Alternatively:
• Long-acting nitrates: e.g., isosorbide dinitrate
• Combination therapy for symptom control: nitrates with up
to two CCBs from different classes [11]

Cardiomyopathies
34 A young male had SOB. CXR was done & showed left ventricular hypertrophy. There is
positive family history of sudden death. Diagnosis?
A. Dilated cardiomyopathy
B. Hypertrophic cardiomyopathy
C. Restricted cardiomyopathy
 Valvular Heart Diseases

35 A patient with a known systolic murmur presents with dyspnea and chest pain. He
recently had an episode of loss of consciousness. Neurological examination was normal.
What is the most likely underlying pathology?
A. Mitral stenosis diastolic
B. Mitral regurgitation
C. Aortic stenosis
D. Aortic regurgitation diastolic
36 A patient came to the ER after a fainting spell. He also has been having mild angina for
the past 2 months. On examination, he had a murmur radiating to the neck. He also came
in with heart failure?? How will you manage him?
A. Admit for further testing
B. Do echocardiogram in the OPD
C. Troponin
D. Troponin and refer to cardiology accordingly
Aortic stenosis: SAD = syncope + angina + dyspnea
If heart failure (acute) admit
37 A man came in after an episode of syncope. He reports that he has been having shortness
of breath for the past 2 days as well as chest pain on and off for the past 2 months. On
examination, you hear a harsh ejection systolic murmur. What is your next step?
E. Troponin test and refer to cardiology according to the result
F. Admit him for further investigations aortic stenosis
G. Order an echo after 1 week in the OPD
H. Anticoagulate him
38 A patient had a pansystolic murmur on examination. Diagnosis?
A. Mitral stenosis (mid-diastolic rumble with opening snap)
B. Aortic stenosis (ejection systolic murmur radiating to the neck)
C. Pulmonary hypertension (due to VSD)
39 A patient undergoes an artificial valve replacement. For how long should he take
warfarin?
A. 6 months
B. 1 year
C. Lifelong
Others
40 Which of the following is NOT a risk factor of heart disease?
A. Systemic hypertension
B. Smoking
C.  uric acid
D.  HDL
41 What is a possible complication of infective endocarditis?
CVA (if left sided thrombus)
Drug user → tricuspid embolus → then it will be PE
42 A patient has radiofemoral delay. Diagnosis?
Coarctation of the aorta

Initial:
§ BP measurement
§ Pulse oximetry (low)
§ Doppler echocardiography - TO CONFIRM
§ X-ray: cardiomegaly / increased pulmonary vascular markings/ figure of 3 sign / rib
notching
§ MRI / CT: complicated cases
§ Genetic testing if suspecting Turner syndrome coarc of aorta and biscupid aorta
Treatment:
§ Initial = PGE1 to keep DA open (indomethacin to close)
§ Surgical / balloon angioplasty
§ Follow up and monitor
43 A patient is complaining of recurrent epistaxis and headache upon exertion. He also has
lower limb weakness after exercise. On examination, he had high BP in both his arms.
Peripheral pulses in his lower limb were weak. What is the next step?
A. Chest CT in complicated cases
B. Check for factor 8 & 9
C. X-ray after echo and doppler
D. Echocardiography (coarctation of the aorta)
E. ECG
44 Why does rib notching occur in coarctation of the aorta?
A. Collateral vessels
B. Left ventricular hypertrophy
C. Aortic regurgitation
D. All of the above
It is the result of obstruction of blood flow at the narrowed aortic segment, in
conjunction with collateral blood flow through the intercostal arteries ..... Rib notching
occurs along the inferior margin of the third to the eighth ribs; it is caused by pulsation of
dilated intercostal arteries
45 What is associated with coarctation of the aorta? Bicuspid aortic valve (60%), VSD,
and/or PDA

A. ASD
B. VSD (or bicuspid aortic valve)
C. PDA
46 What medication causes bradycardia as a side effect?
Beta blocker

• Bradycardia

• Bradyarrhythmia (e.g., AV block)

• Ventricular tachyarrhythmia (torsades de pointes)

• Worsened heart failure (HF)

• Worsened vasospasm due to propranolol use

• Orthostatic hypotension (esp. in elderly patients) [15][16

47 A 50 y/o patient comes with LL edema. He is on lisinopril, amlodipine, and atorvastatin.

Which of the drugs causes LL edema?
A. Lisinopril
B. Amlodipine
C. Atorvastatin

• Effects due to vasodilation

o Peripheral edema (esp. amlodipine)
o Headaches, dizziness
o Facial flushing, feeling of warmth
o Reflex tachycardia: a condition of tachycardia secondary to a
decrease in blood pressure (esp. nifedipine)
▪ Vasodilation lowers the blood pressure, which
stimulates baroreceptors of the sympathetic nervous
system, resulting in reflex tachycardia. [7]
▪ May worsen symptoms of angina
• Gingival hyperplasia
48 A man is complaining of recurrent chest pain that lasts around 10 minutes. He is a known
hypertensive and is suspected to have pulmonary edema. Which drug would you choose
to treat all 3 problems (chest pain, hypertension, pulmonary edema)?
A. Nitrates
B. ACE-inhibitor
C. Nifedipine
D. Furosemide
E. Clopidogrel
Contraindications to the use of any form of nitroglycerin include:
- Hypotension (SBP <90 OR a drop of > 30 mmHg from baseline)
- Bradycardia (<50 bpm)
- Tachycardia
- Right ventricular infarction
- Use of avanfil / sildenafil / vardenafil within 24 hours OR tadalafil within 48
hours (risk of hypotension and/or cardiogenic shock)
Note: Morphine can dilate the venous system and result in a reduction in preload, which
can worsen tachycardia (thereby increasing oxygen demand) and patients with right
sided MIs since they are preload dependent. Giving nitrates to patients who have
recently taken type 5 phosphodiesterase inhibitors (e.g., sildenafil), prevents the
breakdown of cGMP and cause more profound vasodilation.
49 What drug will you avoid in a hypertensive patient who is
also diabetic (uncontrolled) and has gout?
Thiazide
It causes hyperglycemia + hyperuricemia +
hypercalcemia

50 A patient presented complaining of chest pain worsening by lying flat. He had an MI 2

weeks prior. Diagnosis?
A. Myocarditis
B. Pericarditis
C. Myocardial infarction

Postmyocardial infarction syndrome (Dressler syndrome): pericarditis occurring 2–

10 weeks post-MI without an infective cause
Pathophysiology: thought to be due to circulating antibodies against cardiac muscle
cells (autoimmune etiology) → immune complex deposition → inflammation
Clinical features
Signs of acute pericarditis: pleuritic chest pain , dry cough , friction rub
Fever
Laboratory findings: leukocytosis, ↑ serum troponin levels
ECG: diffuse ST elevations
Treatment: NSAIDs (e.g., aspirin), colchicine
Complications (rare): hemopericardium, pericardial tamponade
51 What is true about pericarditis?
1. Pain is relieved by leaning forward
2. ST elevation in leads for a few days
3. Friction rub in systole & diastole
4. Aspirin is the initial treatment
A. 1 + 2 + 3
B. 1 + 2
C. 2 + 3
D. All of the above
Sitting up and leaning forward tends to ease the pain, while lying down and breathing
deep worsens it.
For patients with idiopathic or viral pericarditis, therapy is directed at symptom relief.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy. A full-dose
NSAID should be used (aspirin, 2-4 g/d; ibuprofen 1200-1800 mg/d; indomethacin 75-
150 mg/d); treatment should last at least 7-14 days
52 The ECG findings most commonly seen in myocarditis are diffuse T wave inversions;
saddle-shaped ST-segment elevations may be present (these are also seen in pericarditis).
53 What happens in shock?
Decrease in venous capacity
54 An RTA victim was in the ICU after stabilization. He has a high cardiac index & high
cardiac output but low peripheral resistance. What type of shock?
Spinal (neurogenic)

JVP Variations:
§ Elevated JVP + absent pulsation = SVC obstruction
§ High JVP on inspiration = constrictive pericarditis
§ Absent c wave = constrictive pericarditis
§ Prominent systolic (V) wave = constrictive pericarditis
§ Prominent c wave = tricuspid regurgitation
§ Cannon a wave = CHB / classic AV dissociation / VT / PVCs
§ Prominent a wave = RV hypertrophy / pulmonary stenosis / pulmonary hypertension /
tricuspid stenosis
§ Low / absent a wave = atrial fibrillation / tricuspid regurgitation
55 A patient with history of liver cirrhosis
had GI bleeding due to varices. Which
feature of the JVP waves indicates
pulmonary stenosis (keeping in mind
chronic high right atrial pressure)?
A. Extra-large A wave
B. Large V wave
C. Large A wave (A wave represents the pressure in the right atrium before
contraction – the larger the wave the higher the pressure)
Hepatic vein IVC pressure in IVC
Increased pressure fills right atrium with higher pressure
JVP = representation of right atrial pressure due to backflow of blood
56 A man presents with sudden onset of neurological symptoms involving his toe. On
examination, he has pale cyanotic extremities with livedo reticularis. What is the
diagnosis?
Cholesterol embolism (multiple microthrombi)
• Clinical features
o Severe peripheral, muscular, or visceral embolisms
o Acute renal failure
o Skin involvement (purpura, necroses, livedo reticularis)
o Blue toe syndrome: ischemia due to the occlusion of small digital
vessels (pulses remain palpable because large arteries remain
unaffected)
o Gastrointestinal involvement (e.g., ischemia, pancreatitis)
o CNS symptoms (transient ischemic attack, stroke)
•
o Spindle-shaped vacuoles (“cholesterol clefts”)
• Diagnostics: angiography showing vessel occlusion
• Treatment: angioplasty, endovascular grafting
 ------- Dermatology & Immunology-------
Dermatitis
Contact Dermatitis:
• Delayed type 4 reaction (cell-mediated non-IgE)
• Allergens = chemicals / medicines / bacteria / mold
Atopic Dermatitis:
• Type 1 reaction (IgE mediated)
• Allergens = proteins (food or molds) / medicines (penicillins) / insect bites
• Clinical signs = atopic dermatitis / asthma / food allergy
• Eczema: avoid triggers / emollients / short-term topical steroids
• Contact dermatitis (type IV): avoid triggers / topical steroids
• Urticaria (type I): steroids & antihistamines (+ epinephrine if anaphylaxis)
1 A male patient came complaining of an itchy
skin rash at the area of his belt.

What is the most likely diagnosis?

A. Contact dermatitis
B. Allergic dermatitis
II. How will you manage his condition?
A. Steroids cream
B. Antihistamine
C. Emollient cream

Characteristics of lesions [5]

Intensely pruritic erythematous papules
Vesicles with serous oozing in more severe cases
Distinct borders that correspond to the site and extent of exposure

Distribution
Local (reflects areas and shapes of exposures); examples include:
Rash where jewelry is worn: suggests nickel allergy
Rash on face and eyelids: likely caused by cosmetics
Rash in axillae: likely caused by fragrances or deodorant
Pruritic papulovesicular rash with a linear pattern on extremities: likely caused by urushiol-
producing plants like poison ivy in patients with a history of exposure (urushiol-induced
contact dermatitis)
Ectopic (lesions at a distance from initial exposure): due to inadvertent transfer of allergen
by self or others [6]

Symptomatic therapy
Cool compresses
Calamine lotion, emollients, colloidal oatmeal baths
Wet dressings (e.g., for oozing, crusting lesions)
Corticosteroids
Topical corticosteroids are preferred for localized dermatitis. [6]
Initial treatment: mid-potency topical steroid (e.g., triamcinolone) [5]
No clinical improvement: Escalate to a high-potency topical steroid (e.g., clobetasol). [5]
Consider systemic steroids (e.g., prednisone ) [5]
If > 20% of the body surface area is affected
Or if rapid relief is desired (e.g., involvement of the face and eyelids)
2 Contact dermatitis is which type of hypersensitivity?
A. Type 1
B. Type 2
C. Type 3
D. Type 4
3 A 16-year-old boy had an onset of papules and vesicular eruptions over his face & arms
after taking a walk in the park. He had similar complaints last year when he walked in the
same park. What is the most likely diagnosis?
A. Atopic dermatitis
B. Acute contact dermatitis
4 A male photographer developed white patches on both his forearms. There are more than
8 small patches, and they appear post-working in his dark room at home. His sister has
asthma, and his brother has allergic rhinitis. When he eats shellfish, the rash increases.
Diagnosis?
A. Allergic contact dermatitis
B. Endogenous eczema
C. Scabies
D. Leukoderma
E. Contact dermatitis

Psoriasis
Severity:

§ Mild = < 3% § Moderate = 3 – 10 % § Severe = > 10%

Management:
• Mild = TOPICAL emollients + coal-tar / salicylic acid / calcipotriol / corticosteroids /
calcineurin inhibitor like tacrolimus or pimecrolimus
• Moderate-Severe =
o Topical combination therapy (steroids + calcipotriol)
o SYSTEMIC (methotrexate / ciclosporin / acitretin) as needed
o PHOTOTHERAPY
• Severe / Treatment-resistant =
o Topical + systemic
o Phototherapy
o BIOLOGICS (TNF-alpha inhibitors like infliximab / adalimumab / etanercept)
Systemic corticosteroids are avoided as they are associated with a risk of severe withdrawal
flare.
5 Which dermatological condition does not cause oral ulcers?
A. Lichen planus
B. Psoriatic vulgaris
C. SLE
D. Behcet syndrome
6 Which of the following is used to treat psoriasis?
A. Topical steroid
B. Ketoconazole
C. Cephalexin
D. Aluminum hydroxide
7 A patient has scaly lesions on both her legs and axilla covering around 10% of her body
surface area. Koebner phenomena was seen. How will you treat her?
A. Topical mometasone + oral prednisolone
B. Topical clobetasol + calcipotriol
C. Topical emollients
D. UV
Moderate (since 10%) so topical combination therapy is used.

Cutaneous lesions [2]

• Well-demarcated, erythematous plaques and/or papules with silver-

white scaling
• Typically, a few single lesions initially appear, often becoming confluent. [2]
• Located mainly on the scalp, trunk, elbows, and knees (extensor surfaces), but
any area of the skin may be affected.
• Pruritus in ∼ 80% of cases (typically mild, but may be severe in some cases) [8]
• Characteristic features may be present.
o Auspitz sign [2]
▪ Small pinpoint bleeding when scales are scraped off
▪ Removal of the scales exposes the dermal papillae, which
leads to bleeding.
o Koebner phenomenon: Physical stimuli or skin injury (e.g., trauma,
scratching, irritating clothing) can lead to the appearance of
psoriatic skin lesions on previously unaffected skin(isomorphic
response). [2]

Acne
8 A man is complaining of an itchy rash that developed
suddenly. She denies any history of acne as a teenager. A
picture of the rash was provided (similar to this). What is
the most likely diagnosis?
A. Acne vulgaris
B. Acne fulminans
C. Folliculitis (bacterial / fungal)
D. Bacterial infection

Clinical features
Tender papules and/or pustules, often pruritic
Located at the site of hair follicles
Possible pus drainage from follicular orifices
Potentially multiple lesions
Variable locations (e.g., carbuncles most often develop on the back of the neck)
9 A lady is complaining of an itchy rash on her face. She
denies any history of acne as a teenager. A picture of the
rash was provided (similar to this). What is the most
likely diagnosis?
A. Acne vulgaris
B. Acne fulminans
C. Folliculitis
D. Bacterial infection
1 A man is complaining of an itchy rash that developed
0 suddenly. She denies any history of acne as a teenager. A
picture of the rash was provided (similar to this). What is
the most likely diagnosis?
A. Acne vulgaris
B. Acne fulminans
C. Folliculitis
D. Bacterial infection
Acne fulminans [11]
Definition: a rare, severe form of acne that is characterized by painful ulcerative skin lesions and
systemic inflammatory symptoms
Epidemiology
Rare disease (approx. 200 documented cases)
Age of onset: 13–22 years of age
♂ > ♀ (3:1)
Mainly individuals of northern European descent
Etiology
Adverse effect of isotretinoin (most common)
Idiopathic
Clinical features
Primary lesions
Acute onset
Large, painful nodules, plaques, and ulcers with hemorrhagic crusts
Most commonly located on the trunk
Systemic manifestations
Fever
Myalgia
Weight loss
Arthralgia, arthritis
Rarely hepatosplenomegaly, erythema nodosum, septic osteomyelitis
Diagnostics
↑ CRP, ↑ ESR
Leukocytosis, thrombocytosis, anemia
↑ Liver enzymes
Treatment [12]
Discontinue isotretinoin
Initial monotherapy with systemic corticosteroids
Subsequent combination therapy with oral corticosteroids and isotretinoin
Treatment-resistant cases: cyclosporine, biologics (e.g., anakinra, secukinumab, ustekinumab),
or dapsone
1 A patient has acne all over the face. It is papular & pustular without cysts. He tried OTC
1 remedies recommended by pharmacists with no benefits. Treatment?
A. Benzyl peroxide
B. Oral Isotretinoin
C. Oral Clindamycin

Infections
1 A lady has a skin lesion confined to 1 area on her forearm. She complains that it burns on
2 touching & it radiates to the back. Diagnosis?
A. Herpes zoster
B. Eczema (if no neuralgia + itchy + leathery)
C. Scabies
Main symptoms: dermatomal distribution, typically affecting 1–3 dermatomes on one side
of the body (most commonly affects the cervical, trigeminal, thoracic, and lumbar
dermatomes) [5]
Pain [5]
The most frequent symptom and may precede the rash

Rash onset < 72 hours

Start oral antiviral therapy for herpes zoster in patients with clear indications.
Start IV antiviral therapy for herpes zoster for:
Immunocompromised patients
Disseminated zoster
Neurovascular involvement: e.g., VZV encephalitis, VZV vasculopathy, HZO with retinal
involvement
Antiviral therapy can also be considered in patients without clear indications.
Rash onset ≥ 72 hours
New vesicles continually appearing: same treatment as for rash onset < 72 hours
No new vesicles
Consider supportive care alone for patients with uncomplicated disease.
Consider antiviral therapy for herpes zoster in patients aged ≥ 50 years, with immune
deficiency, or evidence of complications (e.g., disseminated zoster, neurological
involvement).
1 A 62-year-old patient who recently recovered from pneumonia developed a painful rash
3 that extended to the chest but did not cross the midline. There are vesicles on the rash.
Diagnosis?
A. Drug eruption
B. Shingles
1 A 21-year-old university student presented with honey-crusted lesions on his lower lip.
4 Best treatment option?
A. Flucloxacillin (as per plabable)
B. Penicillin + flucloxacillin
C. Augmentin
D. Topical fusidic acid
E. Penicillin only
Augmentin is useful in areas without high rates of resistance.
For limited impetigo: mupirocin topically
For extensive impetigo: cephalexin / dicloxacillin alternatives: erythromycin /
clindamycin / Augmentin
First-line treatment : first generation cephalosporins (e.g., cephalexin) or
dicloxacillin [10]
Alternative: amoxicillin-clavulanate, macrolides [12]
If MRSA infection is confirmed or suspected : clindamycin, trimethoprim-
sulfamethoxazole, doxycycline [10]

1 A woman with recurrent tonsillitis had a history of an ulcer on her leg. She presents with
5 another ulcer that has been there for the past 2 years that has become more painful
recently. She denies hypertension & diabetes. On examination, her leg was tender and
warm. What is true about her condition?
A. Most commonly affects the face
B. Caused by staphylococcus aureus
C. Blood culture will be diagnostic
D. Penicillin is the drug of choice Wrong but best of the wrong, cause A, B, C wronger
Erysipelas lol
§ Streptococcal infection that occurs in adults > kids
§ Lymphatic infection – starts distally then ascends the limb
§ Does not lead to glomerulonephritis / rheumatic fever
§ Treated with amoxicillin
1 A patient presented with a skin rash. On examination, he had small scaly hypopigmented
6 patches on his chest and back. Diagnosis?
 A. Tinea versicolor
B. Tinea corporis
Tinea (Pityriasis) Versicolor:
§ Caused by Malassezia fungus
§ Coppery brown / pale / pink patches (may start as scaly brown resolve and become
white)
§ Wood lamp = yellow-green fluorescence; KOH prep shows spaghetti & meatballs
appearance
§ Managed by topical ketoconazole / selenium sulphate

Tinea Corporis (Ringworm):

§ Caused by dermatophytes
§ Scaly pruritic eruption with sharp regular borders & central clearing
§ KOH shows hyphae + fungal culture
§ Treated with topical / oral clotrimazole
1 A woman has a rash over her arm, trunk, and neck. It is a well-circumscribed annular rash
7 with central clearing and scales on the periphery. The lesions consist of pustules, vesicles,
and plaques. This is the first time she experiences this rash. It is associated with mild
itching. How did she probably get it?
A. Contact with animals (tinea corporis)
B. Contact with chemicals
C. New drug reaction
D. Allergic history
E. Recent history of bacterial infections
Definition: tinea corporis dermatophyte infection affecting a location other than feet, scalp,
nails, and groin; mostly the arms and upper body.
Predisposing factors
Contact with infected individuals or animals
Moist environments (e.g., public swimming pools)
Pathogen: most commonly T. rubrum
Clinical presentation [5]
Initially round, pruritic, erythematous plaque that grows centrifugally
Develops into round, pruritic plaque with central clearing and a scaling, raised border
1 A boy had itchy lesions on his hands (between the webs) and on extensor surfaces, trunk,
8 and neck that worsened at night. His sister had the same complaint. On examination, he
had tracks under his skin. How do you treat them?
A. Tar soap
B. Hydrocortisone lotion
C. Permethrin 1% cream (scabies)
1 What antibiotic is used to treat this condition?
9 A. Clindamycin
B. Levofloxacin
Cat Scratch Disease
- Pathogen: Bartonella henselae (gram -ve aerobic bacillus)
- Mild-moderate: azithromycin (5 days)
- Persistent / disseminated: erythromycin / doxycycline
- CNS involvement / endocarditis: rifampicin + (erythromycin / doxycycline)

Skin Cancers

2 A smoker presents with a painless ulcer on his lower lip. Diagnosis?

0 A. Squamous cell carcinoma
B. Herpes
Appearance
Initial appearance may be plaque-like, nodular, papillomatous, and/or verrucous
All forms eventually ulcerate
Ulcers are typically red with everted edges
The floor of the ulcer resembles granulation tissue and bleeds easily
The skin around the ulcer is inflamed and indurated.
Location
Most commonly on the face and neck
Typical locations include the lower lip, ears, and hands.
2 Which is the in-situ form of squamous cell carcinoma?
1 A. Bowen disease
B. Acanthosis keratosis
Bowen’s disease is a very early form of skin cancer that’s easily treatable. The main sign
is a red, scaly patch on the skin. It affects the squamous cells, which are in the outermost
layer of skin, and is sometimes referred to as squamous cell carcinoma in situ.
Actinic keratosis or solar keratosis is a common skin lesion caused by sun damage that
progresses to squamous cell carcinoma. It has been suggested that actinic keratosis is in
fact SCC in situ.
2 A Caucasian man comes with a “pimple” on his cheek that
2 has been there for a few weeks. It bleeds with shaving.
Most likely diagnosis?
Basal Cell Carcinoma

The picture = Merkel cell carcinoma (most cases

provisionally diagnosed as BCC until biopsy results)

ocalization [6][7]
Typically in areas of skin exposed to sun
Basal cell carcinoma of the face typically occurs
above the line joining the earlobe and the corner of
the mouth
Forehead
Eyelids
Nose and nasolabial fold
Upper lip
The palms, soles of the feet, and mucous
membranes are rarely affected.
Clinical appearance
Pearly nodule with superficial telangiectasia
Nonhealing ulcer with a central depression and
rolled, nontender borders (rodent ulcer)
Scaling plaque (superficial basal cell carcinoma)
Growth
Slow-growing, over months to years
Typically painless
Locally invasive
Very rarely metastasizes
2 A 68-year-old Bedouin man noticed a shiny nasolabial lesion. It went away then came
3 back with a white surface (paler than his skin). He picks on it with a needle; it does not
bleed but has become ulcerated and hasn’t been healing. Diagnosis?
A. Basal cell carcinoma
B. Squamous cell carcinoma
C. Malignant melanoma
2 A farmer presents with a bleeding mole. On inspection, you find a 4 cm macule with an
4 ulcer in the middle. What is the next step?
A. Shave biopsy (used for lesions that are predominantly epidermal w/o extension
into dermis like warts / skin tags / superficial BCC or SCC / seborrheic or actinic
keratoses)
B. Punch biopsy (can be excisional or incisional; used for lesions that are dermal
such as inflammatory or bullous lesions / dysplastic or complex nevi too large for
excision / panniculitis / scalp or hair lesions)
Presentation sounds like BCC which is usually diagnosed with excisional / incisional
biopsy.
Basal cell carcinoma lesions are usually readily identifiable, but the diagnosis should
always be histologically confirmed (via full-thickness biopsy done at the edge of the
lesion).
Dermoscopy: initial clinical evaluation of suspected BCC lesions (dermoscopy cannot
confirm BCC)
Excisional biopsy: (full-thickness biopsy or partial-thickness biopsy) first choice
Most accurate assessment of the histologic subtype of the tumor
Wedge biopsies: used to evaluate large lesions
2 Which of the following indicates a poor prognosis for
5 this skin manifestation? Melanoma???
A. Size > 6 mm
B. Thickness (vertical growth phase)
C. Color variation
D. Irregular border
E. Asymmetry

Negative prognostic factors

Epidemiological features: male sex
Clinical features: type , localization , and presence of ulcerations
Melanoma has a significant risk of metastasis, which is associated with a poorer prognosis.
Tumor thickness, as determined from the Breslow thickness, is the most important
prognostic factor.
Regression
2 A man has a blue-grey flat lesion on his upper back. It has irregular borders and bleeds
6 sometimes. What is the most likely diagnosis?
A. Malignant melanoma
B. Basal cell carcinoma
C. Solar keratosis
D. Benign nevus
Immunology
2 A woman with birds at home has acute symptoms of cough, dyspnea, and fever. These
7 improve when she goes away from home. What is the mechanism of the disease?
A. Degranulation of mast cells
B. Proliferation of Langerhans cells
C. Antigen-antibody complex
D. Infection with mycoplasma kansasii
E. Progressive massive fibrosis
Allergic asthma
IgE-mediated type 1 hypersensitivity to a specific allergen
Characterized by mast cell degranulation and release of histamine after a prior phase of
sensitization
2 A man develops wheezes after eating in a restaurant. On examination, he appears pale.
8 Diagnosis?
A. Anaphylaxis
B. Poison
2 A woman got bitten by an ant on her finger. The finger became swollen and she then
9 developed difficulty in breathing. She had expiratory wheezes but no inspiratory stridor.
How do you manage her?
A. IV epinephrine
B. IV salbutamol
C. IV aminophylline
3 A patient developed an allergic reaction after eating shrimp. What is your management?
0 A. Epinephrine
B. Prednisolone
C. Antihistamine
D. Salbutamol
3 What is the interleukin that increases in parasitic infections?
1 IL-5 (major effect is eosinophil growth)
3 What interleukin works as an anti-viral?
2 IL-6
Others
3 A 48-year-old lady developed a skin lesion on her shin. It began as a nodule/papule then
3 turned into a deep ulcer with necrotic tissue and violaceous borders. What is the
diagnosis?
A. Pyoderma gangrenosum
B. Erythema nodosum
C. Pretibial myxedema
D. Necrobiosis lipoidica diabeticorum

Pyoderma § Rapidly enlarging very painful ulcer

Gangrenosum § Autoinflammatory neutrophilic dermatosis (neutrophil
dysfunction)
§ Full-thickness ulcer with blue undermined borders
§ Pathergy (new lesions appear after local trauma)
§ Associated with IBD / RA / leukemia / monoclonal
gammopathy – usually IgA / chronic active hepatitis /
granulomatosis with polyangiitis
 § Starts suddenly after minor injury pustule / red bump /
blood-blister skin breaks down to an ulcer ulcer deepens
& widens rapidly
§ Several ulcers may develop
§ Treatment:
• Small ulcers = topical steroids / tacrolimus
• Larger / longer duration ulcers = oral prednisone /
ciclosporin / biologics
Erythema Nodosum § Panniculitis (inflammation of subcutaneous fat)
§ Tender red nodules on anterior shin with / without ulceration
resolve alone within 8 weeks through a violaceous brown /
yellow-green bruise-like appearance (erythema contusiformis)
§ Causes:
• Infections (strep throat / viral diseases / pulmonary TB /
chlamydia / fungal or parasitic infections)
• Drugs (sulfonamides / amoxicillin / OCPs / NSAIDs /
salicylates)
• Inflammatory (IBD / sarcoidosis / malignancy /
lymphoma or leukemia)
• Pregnancy
§ Treatment: analgesia (rest / colchicine / NSAIDs /
compression) +/- systemic steroids
Pretibial Myxedema § Diffuse mucinosis (accumulation of excess
glycosaminoglycans in the dermis & subcutaneous tissue)
§ Other names = thyroid dermopathy / infiltrative dermopathy
§ Swelling & lumpiness of LLs
§ Associated with Grave’s disease (pretibial myxedema +
ophthalmopathy + acropachy)
§ Usually asymptomatic but can be itchy / sore
§ Treatment is symptomatic (reduce weight + normalize TFT;
compression stockings; topical steroids)
Necrobiosis Lipodica § Rare granulomatous skin disorder affecting the shins of
Diabeticorum insulin-dependent diabetics
§ Asymptomatic / tender plaques (round / oval / irregular) that
persist for years – the center becomes shiny, pale, thinned, with
prominent blood vessels
§ Minor injury to patches leads to painful / painless ulceration
secondary bacterial infections
§ Treatment if needed: topical / intra-lesional steroids
3 Patient came complaining of a rash. On examination you see hyperpigmentation that turns
4 fluorene coral pink on woods’ lamp. Diagnosis?
 A. Fungal infection
B. Acanthosis nigricans
C. Psoriasis
The more correct answer would be erythrasma. It is a skin condition affecting the skin
folds (axilla / groin / between the toes). Risk factors include warm climate / excessive
sweating / diabetes / obesity / poor hygiene / advanced age / immunocompromised state.
It is caused by Corynebacterium minutissimum (gram +ve non-spore forming aerobic /
facultative bacillus). It may co-exist with fungal infections (tinea / candida) A would
be more correct. It presents with well-defined pink / brown patches with fine scaling &
superficial fissuring; it may be itchy. Diagnosis is done via wood-lamp test that shows a
coral-pink color due to coproporphyrin III release by bacteria. Skin scraping / swab may
also show the bacteria. It is usually self-limiting but topical antiseptics / antibiotics can be
used (fusidic acid / clindamycin / benzoyl peroxide). Extensive infection may need oral
antibiotics (erythromycin / tetracycline).

3 What medication is used to treat genital warts?

5 A. Podophyllotoxin also used to treat molluscum contagiosum
B. 5-fluorouracil
Alternatives = imiquimod / trichloracetic acid

Treatment
Pharmacotherapy: local cytostatic treatment (e.g., 5-FU, trichloroacetic acid, podophyllin,
salicylic acid) or immune response modifiers (e.g., imiquimod, interferon alpha)
Cryotherapy: freezing external warts with CO2, N2O, or N2
In case of numerous warts: curettage, laser surgery, or electrocoagulation
 A systematic review of randomized trials found treatment with topical fluorouracil more
effective than placebo or no treatment for anogenital warts in nonimmunocompromised
adults (relative risk for cure 0.39, 95% CI 0.23-0.67) [60]. However, high-quality,
randomized trials evaluating fluorouracil therapy are lacking, and the use of topical
fluorouracil is limited by potential adverse effects, such as local inflammation, pain,
burning, and ulceration.
3 What is true about lichen planus?
6 A. The disease involves exacerbations with remission periods in between
B. It persists without changing
6 Ps of Lichen Planus = pruritic / polygonal / planar / purple / papules / plaques

Lichen planus may affect the skin, mucosa, scalp, genitalia, and nails, and presents with
varying symptoms depending on the subtype of the disease. The condition is chronic and
usually manifests with several relapses. [8]

First-line therapy
High-potency topical corticosteroids (e.g., betamethasone)
3 A man presents with lesions over the axillary, sacral, and groin areas. He was being
7 treated for tinea for 4 months with no improvement. On examination, you find scaly
lesions with an erythematous base, except over the groin where the lesions were moist.
KOH showed no hyphae. What is the diagnosis?
A. Lichen planus
B. Psoriasis
C. Candidiasis
D. Secondary syphilis (fever + targetoid rash affecting palms & soles)
Well-demarcated, erythematous plaques and/or papules with silver-white scaling
Typically, a few single lesions initially appear, often becoming confluent. [2]
Located mainly on the scalp, trunk, elbows, and knees (extensor surfaces), but any area of
the skin may be affected.
Pruritus in ∼ 80% of cases (typically mild, but may be severe in some cases) [8]
Characteristic features may be present.
Auspitz sign [2]
Small pinpoint bleeding when scales are scraped off
Removal of the scales exposes the dermal papillae, which leads to bleeding.
Koebner phenomenon: Physical stimuli or skin injury (e.g., trauma, scratching, irritating
clothing) can lead to the appearance of psoriatic skin lesions on previously unaffected skin
(isomorphic response). [2]
3 A female had foot cellulitis for which she received IV
8 Augmentin. 3 days after her discharge, she came back
with a rash and complaint of fatigue. What is the
cause?
A. IV antibiotics
B. Lupus nephritis

3 A man had multiple lesions that blanch on pressure. Diagnosis?

9
A. Venous star
B. Spider angioma
Spider angiomata (also referred to as spider telangiectasias) are vascular lesions
 consisting of a central arteriole surrounded by many smaller vessels. They are most
frequently found on the trunk, face, and upper limbs. The body of the lesion (the
central arteriole) can be seen pulsating when compressed with a glass slide. Blood fills
the central arteriole first before traveling to the peripheral tips of each "leg" after
blanching. There are usually multiple radiating legs and surrounding erythema that
may encompass the entire lesion or only its central portion.
4 A patient with type 1 DM and chronic kidney disease is complaining of a dry itchy rash
0 on his legs and back, associated with bipedal edema. On examination, there are scratch
marks. What medication will you use?
A. Gabapentin
B. Oral tacrolimus (immunosuppressant)
C. Topical tacrolimus
D. Topical emollient
Uremic Pruritis
§ Daily bouts of itching that worsen at night & prevent sleep
§ May be generalized localized (back / abdomen / head / arms)
§ Dry skin (xerosis) with scratch marks
§ Treatment:
• Optimize dialysis efficacy
• Non-soap cleansers + emollients to relieve dryness
• Topical capsaicin for localized itch
• IF SEVERE: UVB phototherapy
• Other treatments (usually used if severe): gabapentin / pregabalin
A picture of three lesions was provided (lots of keratosis). What is the diagnosis?
A. Merkel cell carcinoma
B. Seborrheic dermatitis
C. Basal cell carcinoma
D. Squamous cell carcinoma
E. Keratoacanthoma
Keratoacanthoma
Definition: a cutaneous low-grade tumor
More common in middle-aged and elderly individuals [6]
Associated with Muir-Torre syndrome
Characteristic features
Rapid growth (within 2–3 months) in areas of skin exposed to the sun (e.g., the ears)
Lesion: round dome-shaped, erythematous nodule with central crater
Histology: central, hyperkeratotic crater surrounded by squamous epithelium
Treatment: The tumor usually heals without treatment. Nonetheless, surgical removal
is preferred because keratoacanthoma histologically resembles a cSCC, which is
malignant.
A B C D E
 ------- Diet & Vitamins -------
Diet
1 A 30 y/o female came to the physician requesting a good dietary plan. Which component is
accepted in most dietary plan?
A. Decrease complex carbohydrates
B. Decrease protein content
C. Increase fat content
D. Increase simple carbohydrates
E. Increase dietary fibers
2 A 45-year-old man presented for a regular checkup in the clinic. He has hypertension &
dyslipidemia and is afraid of developing a myocardial infarction. What is the best advice to
give him regarding his diet?
A. Decrease salt intake
B. Decrease fat intake
C. Decrease protein intake
Malnutrition
3 A child had edema and pigmentations as well as ulcerations in the cornea. Diagnosis?
A. Kwashiorkor
B. Marasmus
Vitamins
4 A question about a child with edema and other symptoms (incomplete scenario).
A. Wet beriberi
B. Dry beriberi
C. Vitamin A deficiency
5 A 47-year-old man was hospitalized for a cholecystectomy. On post-op day 2, the patient
became ataxic and developed memory problems. On examination, he had diplopia. How
could this have been prevented?
A. Thiamine Wernicke (oculomotor, confusion, ataxia) it is reversible.
Give before glucose !!
B. Vitamin B6
C. Vitamin B12
D. Niacin
6 You are prescribing isoniazid to treat a patient with TB. Which vitamin should you
supplement him with?
Vitamin B6 (pyridoxine)
7 A patient presenting with abdominal pain says she has been taking vitamin D tablets and
exposing herself to the sun excessively. Her labs showed  ionized & total calcium as well
as  PTH. Her vitamin D level was > 400. Normal is 30-100. What is the diagnosis?
A. Hypoparathyroidism
B. Vitamin D toxicity
C. Hypothyroidism
D. Thyroid adenoma
8 A newborn had bleeding from the umbilical stump. What is the most likely cause?
Vitamin K deficiency
9 An old post-menopausal lady did a DEXA scan. The report was provided. Which vitamin
is responsible for this disorder?
Vitamin D

Additional risk factors [8]

Excessive alcohol consumption
Cigarette smoking
Immobilization or inadequate physical activity
Malabsorption (e.g., celiac disease), malnutrition (e.g., diet low in calcium and vitamin
D), anorexia [9]
------- Electrolytes -------
 Potassium
1 A hypertensive patient taking diuretics comes complaining of diarrhea and weakness.
Most likely electrolyte imbalance?
A. Hyponatremia
B. Hypercalcemia
C. Hyperkalemia
D. Hypokalemia probably bc loop or thiazide diuretic
2 A lady pregnant with twins has hyperemesis gravidarum. Which electrolyte abnormality
do you expect to find?
A. Hypokalemia (hypokalemia + hyponatremia + low chloride + metabolic
alkalosis)
B. Hyperkalemia
C. Hyponatremia
D. Hypernatremia
3 What does the ECG show?

Hypokalemia

4 A tourist was lost in the desert and walked a lot. She came to the ER dehydrated. What
does the ECG indicate?

A. Hypokalemia
B. Hyperkalemia (peaked T-waves & flattened p-waves)
C. Hyponatremia
D. Hypernatremia
5 A hypertensive patient has investigation results indicating hyperaldosteronism (hyperNa
and hypoK) (including hypokalemia). What symptom might he have?
Polyurea
Hypokalemia can be precipitated by non–potassium-sparing diuretics or sodium loading.
Symptoms of hypokalemia include the following: Constipation, Polyuria and polydipsia
(because of impaired renal concentrating ability), Weakness, If the serum potassium is
low enough, paralysis and disturbances of cardiac rhythm.
6 What does this ECG show?

Hyperkalemia (peaked T-waves)

7 An ECG is shown with peaked T waves. Which drug should you avoid?

Lisinopril (ACE-inhibitors increase potassium by inhibiting its renal excretion)

8 What type of diuretic will you avoid in patients with hyperkalemia (K level = 5.8)?
A. Spironolactone (potassium-sparing)
B. Furosemide
C. Hydrochlorothiazide
D. Acetazolamide
9 A hypertensive man was on hydrochlorothiazide, but his BP was still high, so the doctor
changed his medicine to furosemide. What electrolyte should you monitor?
A. Potassium
B. Sodium
C. Chloride
D. Calcium
10 What lab value should you monitor in a patient taking ACE-inhibitor?
A. Urea
B. Potassium
C. Creatinine
D. B&C (Potassium and Creatinine)
Side effects of CAPTOPRIL: Cough, Angioedema, Pemphigus vulgaris,
Teratogenicity, hypOtension, high Potassium, Renal failure, Increased creatinine,
Low GFR.
 Phosphate
11 A patient with chronic kidney disease came for routine labs. They showed high phosphate
levels. How will you treat him?
Phosphate binders (ex: calcium acetate)

Treat the underlying cause.

Counsel patients to limit their dietary phosphate intake.
Discontinue medications that may lead to elevated phosphate levels.
Consider pharmacotherapy including phosphate binders (e.g., calcium acetate, aluminum
hydroxide).
Consider indications for renal replacement therapy (RRT), e.g.:
Severely elevated phosphate
Severe AKI or advanced CKD
12 An infant has abnormal digits and fast-growing teeth. Investigations reveal
hypophosphatemia and hypercalcemia. How will you confirm the diagnosis?
A. Urine phosphatamines
B. Elevated PTH (cuz high Ca low P)
C. Increased vitamin D
Hypophosphatasia:
A metabolic bone disease caused by mutation(s) in the ALPL gene on chromosome 1p,
which is responsible for producing alkaline phosphatase (ALP). Deficiency of the bone
isoform of ALP results in accumulation of pyrophosphate, an inhibitor of bone
mineralization. The age of symptom onset and the severity of clinical presentation
varies based on the severity of ALP deficiency.
Diagnosis: low ALP + high PLP (active form of vitamin B6)
 Calcium
13 What is a sign / symptom of hypercalcemia?
A. Constipation
B. Cataracts
C. Trousseau sign
The clinical presentation is variable and ranges from asymptomatic presentation in mild
hypercalcemia to life-threatening clinical features in severe hypercalcemia. See
“Classification of hypercalcemia.”
Nephrolithiasis, nephrocalcinosis (calcium oxalate > calcium phosphate stones)
Bone pain, arthralgias, myalgias, fractures
Constipation
Abdominal pain
Nausea and vomiting
Anorexia
Peptic ulcer disease [10]
 Pancreatitis
Neuropsychiatric symptoms such as anxiety, depression, fatigue, and cognitive dysfunction
Somnolence
Obtundation and coma indicate progression to hypercalcemic crisis
Diminished muscle excitability
Cardiac arrhythmias
Muscle weakness, paresis
Polyuria and dehydration
14 A patient developed facial and arm numbness and twitches after a thyroidectomy. What
investigation would you do?
A. ABG
B. Serum calcium
Neurological manifestations [1][13][14][15]
Tetany: increased neuromuscular excitability (when caused by respiratory alkalosis =
hyperventilation-induced tetany)
Paresthesias: typically tingling or pins-and-needles sensation in extremities and/or in
the perioral area
Spasms (e.g., carpopedal spasm , bronchospasm or laryngospasm ), and cramps
(possible in any muscle)
Stiffness, myalgia
Maneuvers to elicit latent tetany on physical exam
Chvostek sign: short contractions (twitching) of the facial muscles elicited by tapping
the facial nerve below and in front of the ear (∼ 2 cm ventral to the ear lobe) [1]
Trousseau sign: ipsilateral carpopedal spasm occurring several minutes after
inflation of a blood pressure cuff to pressures above the systolic blood pressure [1]
Seizure: may be the initial or only symptom [14]

Cardiovascular manifestations [1][13][14][15]

Congestive heart failure
Hypotension
Cardiac arrhythmias (symptoms may include palpitations, irregular pulse, syncope)
Manifestations of chronic hypocalcemia [1][13][14][15]
Psychiatric manifestations (variable and usually mild; may be reversible), such as
emotional instability, anxiety, depression, confusion/delirium, hallucinosis, or
psychosis
Ophthalmologic manifestations: papilledema (in severe cases), cataracts,
calcifications of the cornea
Neurological manifestations: pseudotumor cerebri, paradoxical CNS calcifications
Dental changes: altered morphology, dental enamel hypoplasia
Growth plate abnormalities and osteomalacia
15 A patient has tingling sensation & muscle twitching post-thyroidectomy. What do you
give him?
A. IV calcium gluconate
B. Vitamin D3
C. Thyroxine
D. Fortified milk

Calcium supplementation [2]

Severe and/or symptomatic hypocalcemia: e.g., tetany, seizures, prolonged QT interval,
serum calcium ≤ 7.5 mg/dL (< 1.9 mmol/L)
IV calcium supplementation: calcium gluconate or calcium chloride
Continuous telemetry [2]
Consider transfer to critical care unit
Mild and/or chronic hypocalcemia: no symptoms or only mild neuromuscular irritability
(e.g., paresthesias), serum calcium 7.6–8.4 mg/dL (1.9–2.12 mmol/L)
Oral calcium supplementation: calcium citrate, calcium carbonate

16 A 36-year-old patient with hypocalcemia was found to have normal PTH levels, normal
vitamin D, and increased creatinine. What is the cause of his hypocalcemia?
A. Pseudohypoparathyroidism
B. Chronic renal disease
C. DiGeorge syndrome
D. Vitamin D deficiency
Acid-Base Balance

17 Interpret ABG values.

Respiratory acidosis & hypoxia
Mixed
18 A patient was diagnosed with ALL and was started on vincristine. He was brought to the
ER as he had a seizure. He was managed with diazepam and is now in the ICU. Urine
osmolality was 900. Blood was sent for urea & electrolytes. What finding do you expect?
A. ↓ Na + ↓ K more solvent less solute
B. ↑ Na + ↓ K
C. ↑ K + ↓ Mg
D. Hypouricemia + ?
E. ↑ K + ?
Vincristine SIADH (hyponatremia + hypouricemia + hypochloremia)
 Hypochloremia hypokalemia

19 Which of the following is the likely result to be found in a baby with pyloric stenosis?
A. Na 122; Cl 83; K 2.2; CO2 x (hypokalemic hypochloremic metabolic alkalosis)
B. Na 135; Cl 108; K 3.8; CO2 x
Heat Stroke Management
- Rapid reduction of the core body temperature to 39 C (immersion in ice water is the most
effective; others are spraying water / fanning / cold IV crystalloids)
- Rehydration
- Electrolyte imbalance management
 ------- Endocrinology -------
Pituitary
1 What is the effect of prolactin on a female after delivery?
A. Inhibit hypothalamus GNRH (True)
B. Increase pituitary gonadotropin (False)
C. Inhibit folliculogenesis (True)
D. Increase luteal phase of menstrual cycle (False) it is
higher in luteal phase to suppress estrogen
Prolactin tends to suppress the secretion of GnRH from the
hypothalamus and in turn decreases the secretion of (FSH)
and (LH) from the anterior pituitary, therefore disrupting the
ovulatorycycle.
PRL has been considered to have an inhibitory effect on
ovarian function through the suppression of centrally derived
gonadotropin secretion.
Infertile women with regular periods but with shortened luteal phases were found to have
higher mean levels of serum prolactin and lower serum progesterone levels in the mid
luteal phase than women with apparently normal ovarian function.
2 A patient is complaining of loss of visions on the sides (bitemporal hemianopia).
Diagnosis?
Pituitary adenoma
3 What visual defect will a man with a pituitary adenoma have?
Bitemporal hemianopia

4 A woman comes in complaining of disturbed vision that is affecting her daily activities.
She is having difficulty driving and has had many close calls because of that. On
examination, she has milky nipple discharge on manipulation of her breasts. Her prolactin
level was 90. What is the first line for managing her hyperprolactinemia?
A. Dopamine antagonist
B. Dopamine agonist (bromocriptine) dopamine inhibits prolactin
C. Surgical resection of the tumor (definitive)
D. Irradiation of the tumor (may be used prior to surgery to shrink tumor)
 Indications
First-line treatment for:
Secretory adenomas (excluding prolactinomas)
Symptomatic nonsecretory adenomas
Pituitary apoplexy with visual symptoms [10]
Second-line treatment if medical management fails in prolactinomas
Procedure: transsphenoidal hypophysectomy [21]
Removal of pituitary tissue; performed under microscopic or endoscopic guidance via the
sphenoidal sinus
May be partial (hemihypophysectomy) or complete (total hypophysectomy)
Follow-up
Monitor for early postoperative complications during hospitalization.
Regular follow-ups are necessary to detect new or recurrent hormone imbalances early

Indications
Prolactinomas: first-line treatment for symptomatic patients and those with macroadenoma
Secretory adenomas: patients who are unsuitable for, or have symptoms refractory to,
surgery
Treatment options
Prolactinomas: Dopamine agonists (cause the adenoma to shrink)
First line: cabergoline
Second line: bromocriptine
ACTH-secreting tumor (see “Cushing disease” for details)
Somatostatin analogs
GH-secreting tumor (see “Acromegaly” for details)
Somatostatin analogs ± cabergoline
TSH-secreting tumor: somatostatin analogs
5 A lady presented with nipple discharge and amenorrhea. Her TSH is 7 and she has low T3
& T4. Prolactin level is 90. What do you do?
A. T3 and T4
B. TSH
C. Imaging of sella turcica
D. Give bromocriptine

MRI sella with IV contrast (gold standard)

Indications
First-line diagnostic modality for suspected secretory or nonsecretory pituitary
adenomas
Postsurgical surveillance after resection of a pituitary mass
Characteristic finding: intrasellar mass
Potential additional findings [7]
Compression of adjacent structures (e.g., impingement on the optic chiasm)
Hemorrhage and necrosis in pituitary apoplexy [10][14]
Cavernous sinus invasion
CT sella with IV contrast
Indications
Second-line diagnostic modality [13]
Supportive findings: similar to MRI
6 A man is complaining of visual disturbances. You notice that he has frontal bossing, a big
mandible, and jaw protrusion. Diagnosis?
Acromegaly

Tumor mass effects

Headache, vision loss (bitemporal hemianopsia), cranial nerve palsies
♀: Oligomenorrhea, secondary amenorrhea, galactorrhea, vaginal atrophy
♂: Erectile dysfunction, decreased libido, ↓ testicular volume
Soft tissue effects
Doughy skin texture, hyperhidrosis [4]
Deepening of the voice, macroglossia with fissures, obstructive sleep apnea
Skeletal effects
Coarsening of facial features slowly progressing with age: enlarged nose, forehead,
and jaw (macrognathia) with diastema
Widened hands, fingers, and feet
Painful arthropathy (ankles, knees, hips, spine)

Transsphenoidal adenomectomy is the method of choice for treating acromegaly. In

patients with inoperable tumors or unsuccessful surgery, medication and
radiotherapy are indicated to reduce tumor size and limit the effects of GH and IGF-
1. [5][6]
Surgery
Transsphenoidal adenomectomy (preferred method)
Surgical debulking (in patients with parasellar disease and inoperable tumors)
Medication
Somatostatin analogs (e.g., octreotide, lanreotide)
Dopamine agonists (e.g., cabergoline): reduce tumor size and GH secretion
GH receptor antagonists (e.g., pegvisomant)
Radiotherapy [7]
Conventional fractionated radiotherapy
Stereotactic radiosurgery (e.g., Gamma Knife, CyberKnife, proton beam)
Assessing IGF-1 and random GH level 12 weeks after the surgery and then annually
Annual hormonal testing for hypopituitarism
Performing MRI at least 12 weeks after the surgery
7 A patient has galactorrhea, amenorrhea, nausea & vomiting, and Parkinson-like
symptoms. These are attributed to a drug that she is taking. What is the mechanism of
action of the drug?
A. Super-sensitivity of dopamine receptors
B. Blocks dopamine receptors

Dopamine receptor antagonists

Gastrointestinal
Diarrhea
Pain
Hyperprolactinema
Neurological
Depression, anxiety
Fatigue
Drowsiness
Restlessness
Lowering of seizure threshold
Overdose leads to reversible extrapyramidal syndrome (e.g., dystonia, parkinsonism,
tardive dyskinesia, and akathisia) and neuroleptic malignant syndrome
Do not combine metoclopramide with antipsychotics because this increases the risk of
dyskinesia!
Antidote: benztropine, biperiden (anticholinergic agents)
Avoid combination with digoxin and antidiabetic drugs.
Contraindicated in patients with suspected small bowel obstruction
8 A diabetic and hypertensive man, on methyldopa and metformin, develops
hyperprolactinemia. Labs also revealed high creatinine. What is the most likely cause?
A. Methyldopa
B. Metformin
C. Dopamine agonist effect
D. CKD
Methyldopa decreases dopamine = increasing prolactin

9 A man was brought in with confusion. Investigations revealed low sodium, and urine
osmolality higher than serum osmolality. Diagnosis?
SIADH (normal volume + hyponatremia)
10 A 17-year-old was complaining of increased thirst and urination. His serum osmolality
was 295. Blood glucose was 98. Water deprivation test was done, and the urine
osmolality did not change. What drug can be used to treat him? Water deprivation →
works (aka ADH increases and osmolality decrease) then its psychogenic. If didn’t
work try giving ADH. If it worked, then dx is central DI (Tx give desmopressin) if still
didn’t work then it is nephrogenic so Tx diuretics.
A. Desmopressin
B. Insulin
Thyroid
11 A lady with a thyroid nodule is asymptomatic. Her TSH level is normal. Imaging shows a
2 cm thyroid nodule with a rim of calcification. What do you do next?
A. FNA
B. Follow up USS after 3 months
C. Partial thyroidectomy
12 A man has a neck mass that moves with swallowing (thyroid nodule) affecting breathing
& swallowing. Next step?
A. FNAC
B. Excisional biopsy
C. Partial thyroidectomy (best management)
A better option would be TSH. And ultrasound
13 A 35 years old woman presents with a swelling in the neck. The swelling has increased in
size gradually over the last two years and the patient feels she has difficulty with
breathing. Examination shows that the mass measures 8cm by 10 cm, soft and not warm
to touch. It moves with deglutition. Which of the following is the most appropriate
management of this mass?
A. Partial thyroidectomy
B. Oral thyroxine
C. Oral propylthiouracil
D. Excision biopsy
E. FNA

Goiter
Best initial step: palpation of thyroid gland (see “Classification of goiter by palpation” below)
Laboratory tests
Initial workup: TSH levels
Possible screen for thyroid antibodies (see thyroid antibodies)
If medullary carcinoma is suspected, check calcitonin levels (see thyroid cancer).
Imaging: determination of goiter size, nodularity, and consistency
Ultrasound
Further evaluation may include: CT, MRI
Interventions
Depend on the suspected pathology
Fine-needle biopsy for cytology

Choice of Surgical Procedure for Thyroid Tumors

14 A 35-year-old patient was diagnosed with papillary thyroid cancer (2x2.5 cm).
Management? Should be total thyroidectomy
A. Lobectomy & isthmectomy
B. Near total thyroidectomy with radioactive iodine (if < 40 y/o)

15 A 26-year-old lady presented with a neck mass. FNA was done and showed follicular
cells. Lobectomy was done and the diagnosis of follicular carcinoma was made. What do
you do next?
A. Thyroidectomy + radioactive iodine
B. Thyroidectomy + external beam radiation
C. Adjuvant chemotherapy
D. Observation
Suspected follicular carcinoma: you do lobectomy if follicular carcinoma do total
thyroidectomy (prognosis of follicular is great with radioactive iodine ablation)

16 A 58 y/o female has a solitary cold nodule in the right side of the neck. FNA showed a
follicular neoplasm. What is the best management?
A. Thyroid lobectomy this is to diagnose if adenoma or carcinoma.
B. Thyroxine
C. Removal of right thyroid lobe with isthmus
D. Radiotherapy

• Well-differentiated thyroid cancer OR medullary cancer: total thyroidectomy +

neck dissection + radioactive iodine ablation + TSH suppression therapy
• Small well-differentiated localized thyroid cancer without nodal / distant metastases:
hemithyroidectomy + TSH suppression therapy
• Anaplastic carcinoma:
o Resectable: total thyroidectomy + radiochemotherapy
o Unresectable / metastatic: palliative
17 A man has thyroid nodules only seen on US (not visible or palpable). FNA showed
Bethesda 3. What do you do now that you know there are atypical cells?
A. Remove the nodule
B. Lobectomy
C. Subtotal thyroidectomy
D. Repeat FNA
Bethesda System
1. Non diagnostic or not satisfactory = repeat FNA with US guidance
2. Benign = clinical follow up
3. Atypia or follicular lesion = Repeat FNA
4. Follicular neoplasm or suspicious follicular neoplasm = thyroid lobectomy
5. Suspicious for malignancy = lobectomy / near total thyroidectomy
6. Malignant = near-total thyroidectomy
18 A 45-year-old lady has an 8mm x 5mm solitary fixed mass. TSH is normal. What is the
best management?
A. FNAC
B. Thyroidectomy
FNAC to determine management.
19 A patient complains of aphonia after thyroid surgery. Which nerve was injured?
Recurrent laryngeal nerve (superior laryngeal nerve is loss of high pitch)
20 What can cause hoarseness of voice after thyroid surgery?
Injury to the recurrent laryngeal nerve
21 What is a poor prognostic factor of medullary cancer? Distant metastasis and older age
Distant metastases is worse than nodal metastases (as in worse).
Mediastinal lymph node metastases (will cause compression)
22 A 52 y/o asymptomatic female has a solid solitary node in the right side of her neck.
What lab result is most likely consistent with this case?
A. Normal TSH
B.  T4
C.  thyroglobulin
D.  antithyroid Ig
E.  T3
23 A patient has symptoms of hyperthyroidism but no thyrotoxicosis on lab investigations.
Radioiodine scan shows diffuse uptake. What is the diagnosis?
A. Subacute thyroiditis
B. Grave’s disease
C. Toxic multinodular goiter
D. Thyroid cancer
§ Subacute = low uptake § Grave’s = diffused / high uptake
§ TMG = patchy uptake § Thyroid cancer = localized uptake
24 What lab values do you expect to find in this patient??
A.  T3  T4  TSH
B.  T3  T4  TSH (hyperthyroidism in
Grave’s)
25 A patient has exophthalmos, fine tremors, anxiety, palpitations, and weight loss. Her
menstrual cycle used to last for 5 days but now only lasts for 1. Diagnosis?
A. Grave’s disease
B. Hashimoto’s disease
C. Hyperthyroidism
D. Thyroid cancer
E. Toxic nodular goiter
26 A 60 y/o female has gradually become isolated. She has no interest in joining family
gatherings. She talks about herself tearfully, and she has gained weight recently. She has
no interest in doing her usual activities. Examination showed an obese woman with
bradycardia and mild crackles in the base of her lungs (pulmonary edema from
hypothyroidism). What is the most likely diagnosis?
A. Hypothyroidism (cuz of the brady)
B. Major depression
27 A female is complaining of dry thinning hair. She has also been gaining weight and
unable to tolerate cold weather. Her menstrual flow has increased. On examination, she
has slow reflexes. Diagnosis?
Hypothyroidism
28 An old woman does not like to interact much with people. She also has constipation,
redness, and weight gain. Diagnosis?
A. Major depressive disorder
B. Hypothyroidism
29 An old lady has decreased bowel movements and relative constipation. She also reports
having hair loss. Her daughter says she hasn’t been as interactive as she was before. What
test do you order?
TSH
30 A 30 y/o pregnant lady, known case of autoimmune thyroiditis on levothyroxine, is
experiencing worsening of her symptoms (cold intolerance & fatigue). TSH is normal and
her T4 is normal on the lower border (0.8). Next step?
A. Reassure her
B. Increase her thyroxine dose
31 What type of tremors occur in hyperthyroidism?
A. Fine tremors
B. Coarse tremors
32 What medication is useful in the treatment of thyrotoxicosis?
Propranolol methimazole (SE agranulocytosis), PTU, carbimazole for definitive Tx
33 What is the effect of propranolol in thyrotoxicosis?
A. Affects heart rate
B. Reverses hyperthyroidism
Parathyroid
1 What causes tertiary hyperparathyroidism?
A. Parathyroid adenoma primary
B. Pituitary gland hyperplasia
C. Chronic renal failure
D. Post-renal transplantation
 Adrenals
1 A patient is complaining of brittle hair, mild hirsutism, striae, and obesity. What is the
most appropriate investigation?
A. ACTH stimulation test
B. Loss of diurnal cortical level
C. Urine free cortisol level
D. ACTH level in blood
First we do 24 hour cortisol urine test
Then we do low dose dexamethasone test
If it did not suppress the cortisol level, then we have cushding syndrome
Then we check the ACTH level
If it low ACTH that means this is adrenal tumor bc adrenal tumor is releasing cortisol and
negative feedback of ACTH
If it high ACTH, then it could be pituitary (cushing disease) or ectopic ACTH
So we do high dose dexamethasone test
If it suppresses the cortisol, this is pituitary
If it does not suppress then this is naughty ectopic tumor
2 A patient has central obesity, hypertension, and abdominal striae. Diagnosis?
Cushing’s syndrome
3 A woman came with worsening fatigue & dizziness.
On examination, she had hyperpigmentation. Her
BP was 80/70 mmHg. Labs showed low Na (124), ↑
K (5.1),normal glucose (72). CBC showed 12%
eosinophil. What will you give her?
A. 1L NS over 1 hour + IV hydrocortisone
(Addison’s disease)
B. 1L NS over 8 hours + IV hydrocortisone
C. 1L NS over 1 hour + oral fluticasone
D. 1L NS over 8 hours + oral fluticasone
Aldosterone increases Na and excretes K
No aldosterone = hyponatremia (hypotension) and hyperkalemia
Hypotension, NV, fatigue, hyperpigmentation = primary failure aka adrenal gland not
producing
Everything except hyperpigmentation = secondary failure aka pituitary
If cortisol is low → u give ACTH
Adrenal gland (1ary insufficiency) there is enough ACTH but the adrenals are not working
so the cortisol will not increase after ACTH administration (cosyncotropin) Tx is
prednisone and fluticasone (cortico and mineralo)
Pituitary (2ndary insufficiency) there is aslan zero ACTH, so when u give ACTH the
cortisol will increase (only give prednisone)
4 A man presented with recurrent headaches. His BP was 180/90 mmHg. Electrolytes
showed Na = 143, K = 2.8, HCO3 = 34, and Cl = 105. Diagnosis?
A. Renal tubular acidosis II
B. Essential hypertension
C. High-salt diet
D. Pheochromocytoma
E. High aldosterone
Hypertension
Sustained systolic blood pressure > 150 mm Hg or diastolic > 100 mm Hg over three
measurements on three different days
Systolic blood pressure > 140 mm Hg or diastolic > 90 mmHg AND resistant to three-
drug therapy with an adrenergic inhibitor, a vasodilator, and a diuretic
See “Secondary hypertension.”
Features of hypokalemia
Fatigue
Muscle weakness, cramping
Headaches
Paresthesia in severe cases due to metabolic alkalosis
Polyuria and polydipsia
Palpitations
Constipation
Absence of significant edema (due to aldosterone escape)
Hypokalemia
5 A patient had an incidental finding of a 4 cm adrenal lipid adenoma. He is asymptomatic.
Management?
Resection
< 4 cm = watch & wait
> 4 cm = resection
Diabetes
6 How do you screen for diabetes?
A. FBS
B. HbA1c
7 A 21-year-old male was diagnosed with DM I. When should you screen for diabetic
retinopathy? Type 1 DM – 5 years after dx
A. After 5 years then annually type 2 DM – now then annually
B. Now then annually
8 A patient with DM I came to the ER with a rigid, tender, and distended abdomen. He also
had vomiting. His BP is low & he is tachycardic. Next step?
A. Resuscitation with IV fluid
B. Insulin & antibiotics
C. X-ray of abdomen
9 A 34-year-old diabetic lady is non-compliant to her medications. She was diagnosed with
pneumonia after which she presented to the ER complaining of abdominal pain &
vomiting, associated with loss of consciousness. Diagnosis?
A. DKA
B. Hyperosmolar coma
C. Hypoglycemia
10 A woman was brought by her boyfriend who was a reliable history giver. He reports that
she has been complaining of lightheadedness and fatigue, but this has never happened to
her before. She had been thinking it was from work stress. What do you do for her?
A. Hydrocortisone + IV hydration
B. Dextrose + IV hydration (hypoglycemia)
C. Toxicology screening
11 A woman came with an infection. ABG revealed a pH of 7.35 and glucose level of 35.
Diagnosis?
Hypoglycemic coma
12 What is the target HbA1c in diabetic patients?
A. < 5
B. < 6
C. < 7
13 What is the mechanism of action of glipizide? sulfonurea
It increases insulin secretion from the pancreas

14 A diabetic patient on insulin comes for follow up. Her morning fasting glucose is 95
mg/dL. Her 2-hours-post-prandial glucose is 180 mg/dL after breakfast and 108 mg/dL
after lunch. What will you do for her? 2 hours post prandial should be <180 for
diabetics
A. Increase morning insulin dose
B. Increase evening insulin dose
C. Decrease morning insulin dose
D. Decrease evening insulin dose
15 A 36 y/o man was diagnosed with diabetes 1 month ago. He was started on 5mg
glyburide that was increased to 15mg. he has been losing weight. Random blood sugar =
221 with high antibodies & no c-peptide. Management? He was misdiagnosed
A.  glyburide dose
B. Add metformin to glyburide
C. Stop glyburide & start insulin
Mechanism of action of sulfonylurea
• Block ATP-sensitive potassium channels of the pancreatic β
cells → depolarization of the cell membrane → calcium influx
→ insulin secretion
16 An old diabetic patient comes complaining of neck pain. He has high creatinine levels.
What analgesic do you give him? Stay away from NSAIDs
A. Celecoxib
B. Diclofenac
C. Ibuprofen
D. Paracetamol
Gastric and duodenal ulcers with the risk of gastrointestinal bleeding and perforation
(inhibition of COX disrupts the production of protective gastric mucosal
prostaglandins)
Risk increases with duration and dose of treatment [2][3]
Prophylaxis:
Administration of proton pump inhibitors (in case long-term intake is needed) [4]
See “Prevention of NSAID-induced GI toxicity” for details.
Increased risk of heart attack and stroke (with the exception of aspirin and
naproxen) [5]
Renal function impairment: Prostaglandins normally maintain renal blood flow by
inducing vasodilation of the afferent arterioles. NSAIDS inhibit prostaglandin
production, which leads to harmful hypoperfusion of the kidneys and reduced GFR.
[6]
Electrolyte and fluid abnormalities (edema, hyperkalemia, hyponatremia)
Worsening of hypertension
In rare cases, acute renal failure
Analgesic nephropathy: prolonged NSAID use results in tubulointerstitial nephritis
and papillary necrosis (↑ crea/BUN ratio, slight ↑ K+) [7]
Aplastic anemia [8]
Pseudoallergic reactions [9]
Urticaria and angioedema
Asthma
Aspirin-exacerbated respiratory disease (AERD)
For side effects of aspirin, see aspirin.
17 90% of glucose absorption occurs at?
A. Proximal tubules
B. Distribution
C. Loop of Henle

Others
18 A man has hypercalcemia, duodenal ulcers, and
hyperparathyroidism. What syndrome does he have?
A. Zollinger Ellison syndrome
B. MEN IIa (also called sipple syndrome)
C. MEN IIb
D. Wermer Syndrome (MEN I)

MEN 1: parathyroid, pancreatic, pituitary

(pancreatic tumors: gastrinoma, insulinoma, VIPoma, gluconoma)
MEN 2: Medullary + pheochromocytoma
2A: hyperparathyroid
2B: multiple neuronomas

19 A 60 y/o female is on Ca, vitamin D, and alendronate. (bisphosphonate) What is her

problem?
A. Osteomalacia
B. Osteoporosis
C. Hypoparathyroidism
20 An osteoporotic patients on medications. Which of the medications can cause jaw
osteonecrosis?
A. Alendronate
B. Raloxifene
 ------- ENT -------
Ear

1 A patient presented with loss of sensation on the left side of his face, associated with a
vesicular eruption on his face & ear. He also had pain in the tympanic membrane and ear
canal. All investigations and imaging studies were normal. What is the diagnosis?
A. Bell’s palsy
B. Acoustic neuroma
C. Herpes zoster oticus (Ramsay-Hunt Syndrome)

Herpes zoster oticus [13]

• Definition:reactivation of VZV in the geniculate ganglion, affecting the

seventh (facial) and eighth (vestibulocochlear) cranial nerves (also known
as Ramsay Hunt syndrome)
• Epidemiology: occurs in 0.3–18% of patients
• Clinical features
o Fever and skin symptoms as in shingles in the auditory canal
and pinna (see “Clinical features” above)
o Vestibulocochlear nerve involvement
→ vertigo and sensorineural hearing loss (SNHL)
oFacial nerve involvement → ipsilateral facial paralysis
• Diagnosis: tone audiometry

2 A patient came complaining of ear discharge. On examination, you find that he has a
ruptured tympanic membrane. Treatment?
A. Topical antibiotics
B. Systemic antibiotics
C. Topical steroids
D. Systemic steroids
For children with AOM and spontaneous tympanic membrane perforation, we suggest oral
rather than topical antibiotic therapy. We prefer amoxicillin or amoxicillin-clavulanate to
other oral agents.
3 A 17-year-old boy had gradual left ear hearing loss. His tympanic
membrane was normal. Audiogram shown. Diagnosis?
A. Otitis media
B. Otosclerosis (carhart notch)
C. Presbycusis
D. Ossicular disruption
4 A patient had painless hearing loss. What important things should be asked in the
history?
Exposure to loud noise
Nose
5 A middle-aged hypertensive man came to the ER with 1 hour of epistaxis. This is the
first man he experiences this. He had a towel soaked with blood and he tells you that he
tried compression & ice but the bleeding did not stop. Rhinoscopy was done but no
source of bleeding or masses were seen. Labs were all normal. What is the cause of his
bleeding?
A. Anterior epistaxis
B. Posterior epistaxis (associated with hypertension + compression does not work)
C. Mass
D. Bleeding disorder (coagulopathy)
6 Most common cause of the common cold?
A. RSV
B. Coxsackie
C. Rhinovirus
7 A female with non-allergic rhinitis presented with cough, runny nose, fever, and
shortness of breath for 5 hours. What will you likely find on examination?
A. Nasal polyp
B. Lymph nodes
8 Non-allergic eosinophilic rhinitis
Eosinophilic nonallergic rhinitis is one of the major forms of nonallergic
rhinitis. It is characterized by the presence of many eosinophils in nasal
secretions, a negative history for allergen exacerbation, and negative skin tests.
Others
9 Nasopharyngeal carcinoma is associated with which organism?
EBV
Nasopharyngeal carcinoma (NPC) is a rare malignancy worldwide, but it is endemic in a
few areas including Southern China, Southeast Asia, North Africa and the Arctic. The
underlying mechanisms behind this remarkable geographic distribution remain unclear.
Although Epstein-Barr virus (EBV) infection has been suggested as a necessary
cause of undifferentiated NPC, EBV itself is not sufficient to cause this malignancy.
Other co-factors, such as environmental risk factors, and/or genetic susceptibility, may
interact with EBV to play a role in the carcinogenesis of NPC. Survival rates differ
significantly between NPC patients in early stages and late stages. Due to the close
associations between EBV infection and NPC risk, EBV-related biomarkers have been
used for early detection and screening for NPC in a few high-incidence areas.
 ------- Ethics -------
1 A 78-year-old patient is diagnosed with metastatic lung cancer; there is no cure for his
condition. His son tells the physician that in the case of a diagnosis of cancer, the
physician must not tell his father. He wishes that his father does not suffer any
psychological distress caused by the knowledge of a terminal diagnosis. Which one of the
following ethical principles supports the son’s request?
A. Patient autonomy
B. Beneficence
C. Justice
D. Non-maleficence
2 A doctor advised the patient to go to a surgeon with more experience although he has
some experience in the procedure. What ethical principle is he applying?
A. Beneficence
B. Non-maleficence
C. Autonomy
D. Justice
3 A female patient with breast cancer was advised to do a biopsy but refused. The doctor
gave her another appointment to revisit this. What ethical principle was followed?
A. Beneficence
B. Non-maleficence
C. Autonomy
D. Justice
4 A woman is advised to undergo a hysterectomy, but she refused. The doctor wants to
contact her family to convince her. What ethical principle is being applied?
A. Beneficence
B. Non-maleficence
C. Autonomy
D. Justice
5 A patient was diagnosed with cancer but did not want anyone to know. The doctor
respected her wishes. What ethical principle was applied?
A. Respecting the patient’s autonomy
B. Non-maleficence
C. Beneficence
D. Justice
6 A patient was diagnosed with hepatitis C. He does not want you to inform his wife as he
fears that she will divorce him, and he believes that he probably has had it for a long time
so she would already be infected. The doctor agreed and did what the patient wanted.
What ethical rule was followed?
E. Respecting the patient’s autonomy
F. Non-maleficence
G. Beneficence
H. Justice
7 A lady had breast cancer but refused biopsy and treatment. The doctor counselled the son
and obtained consent from him. What ethical principle was broken?
Not respecting the patient’s autonomy
8 A patient’s brother is asking for a DNR (do not resuscitate) order for the patient. What do
you do?
Respectfully say no to him and continue to give care
9 A father brought his 2-year-old child with a fractured arm after a fall. The father stated
that the child is aggressive and fussy. What is the best initial step in such a condition?
A. Report the case to child services
B. Establish good rapport with the child and father
C. Explain your role as an advocate to the child
D. Inform the father that you are eligible to report any child abuse
E. Ask the father to step out of the room so that you can interview the child alone
10 An 18 y/o male came for a checkup because he wants to join the police force. His RBS =
11. He asked you not to mention that he is diabetic in the report. What will you do?
A. Take history and discuss his fear & expectation
B. Take history focusing on DM risk factors & do OGTT
C. Refer him to another doctor
 ------- Family Medicine -------
Well-Being Visits
1 A 16-year-old athlete was found to have high BP (140/85 mmHg) on routine checkup.
What will you do?
A. Repeat measurement after 1 week
B. Do echocardiogram
C. Conduct necessary investigations (RFT + U&E)
D. Nothing
2 A 48 y/o man has 1 high BP reading of 144/92 mmHg. He has not visited any doctor for
a long time (no previous reading). What will you do?
A. Assure him that this is normal for his age
B. Repeat measurement after 6 hours
C. Start labetalol
D. Start nifedipine
3 A healthy man came for a routine checkup. His FBS was normal. What advice would
you give him?
Reassure him that it is normal & provide him with tips regarding healthy lifestyle.
4 A post-menopausal lady presents with bilateral knee
pain worried about having weak bones. She gives
history of intermittent inhaled corticosteroid use and
a 20-year-history of smoking. Her last DEXA scan
1 year ago showed a z-score of 2+. What do you
advise to avoid fractures in the future?
A. Alendronate 10 mg (used if dexa < - 2.5 =
osteoporosis)
B. Calcium & vitamin D (b/c she is on inhaled
steroids + menopause)
C. Repeat DEXA scan
D. Weight-bearing exercises
DEXA screening starts at 65 years.

Optimize bone health [8][15]

Optimize calcium and vitamin D
intake.
Treat vitamin D deficiency.
Encourage physical activity,
including strength (resistance) and
balance training.
Avoidance or minimization of the
following:
Tobacco use
Excessive alcohol consumption
Glucocorticoid use

Indications [11]
Treatment: patients who fulfill any
of the diagnostic criteria for
osteoporosis
Prevention: patients with
 osteopenia and an increased
probability of a major osteoporotic
fracture in the next 10 years (as
determined on a clinical risk
assessment tool such as the
FRAX)
Bisphosphonates for osteoporosis
[8][11]
Indications: preferred initial
treatment in all patients

5 A 54 y/o menopausal lady is coming for a routine checkup: no current complaints. No

family history & no history of cancer. BP = 130/70 mmHg. What do you give her?
A. Calcium supplements (600mg)
B. -methyldopa TID
C. Estrogen patch
Same question repeated with history of mother passing away at 53 years due to breast
cancer. *same answer*
6 An 82-year-old male patient was brought to the family medicine clinic after a fall. On
examination, he was walking with wide-based steps, and his upper limbs were abducted
as if he was trying to reach something. When asked to turn around in response to sound,
he turned his whole body around. What is the most likely diagnosis?
A. Parkinson’s disease
B. Visual impairment
7 A 96 y/o lady came to the family physician for a follow up for her hypertension &
osteoarthritis. She is a widow living with her daughter who informs you that her mom is

forgetful & loses her way to the house. She denies syncope, stroke-like symptoms, and
hallucinations. Best diagnostic step?
A. Assess mental status
B. Refer to a neurologist
C. MRI brain
D. Refer to psychiatry
Prevention & Health-Screening
8 A 58 y/o male came to the clinic following trauma to his index finger. You examine the
patient and decide his finger needs suturing. He did not visit the clinic for the past 10
years. No significant PMG. After suturing the wound and tetanus vaccine, what would be
the appropriate screening?
A. ECG
B. Random fasting blood glucose level
C. Measuring BP
D. Chest x-ray
9 A 50 y/o female patient with well-controlled DM II came for her 2-month follow up. She
is exercising 3 days/week & is following dietary advice. She did a pap smear last year.
What is the appropriate screening test to be ordered in this visit?
A. Pap smear
B. Mammogram
C. ECG
D. DEXA scan
The USPSTF recommends that women who are 50 to 74 years old and are at average risk
for breast cancer get a mammogram every two years.
10 What vaccine is a patient with chronic renal failure a candidate for?
A. Hepatitis A
B. Meningitis
C. Pneumococcal
D. Hemophilus influenzae B
11 How can her immunity be achieved?
Vaccination
Others
12 You are a resident in this scenario. You notice that you have encountered 2 cases of
Still’s disease. Although it is a rare disease, you would like to know more about its
prevalence. Who will you approach to get more information?
A. Local pediatrician
B. Family physician
13 A patient with history of IBS & tension headaches came with palpitations & SOB for 8
hours. What is your next step?
A. Assess psychological stress
B. Cardiac / chest exam
C. Troponin I
D. CXR
14 A lady delivered a baby with hearing loss, cataracts, microcephaly, and
hepatosplenomegaly. She is a new immigrant to the UAE from South Africa, and she did
 not take any medications during her pregnancy. How can she avoid this in her future
babies?
A. Rubella vaccination before conception
B. Take folic acid
C. Avoid illicit drugs
D. Genetic testing

Congenital rubella syndrome

Triad of congenital rubella syndrome
Cardiac defect: most common defect (e.g., patent ductus arteriosus, pulmonary artery
stenosis)
Cataracts: Other eye manifestations may also occur later in life, including glaucoma and
salt and pepper retinopathy (abnormal retinal pigmentation)
Cochlear defect: bilateral sensorineural hearing loss

Diagnosis [23]
Newborn and mother
PCR for rubella RNA (throat swab, CSF)
Serology (abnormally high or persistent concentrations of IgM and/or IgG antibodies)
Viral culture (nasopharynx, blood)
Fetus
IgM antibody serology (chorionic villi, amniotic fluid)
PCR for rubella RNA (chorionic villi, amniotic fluid)

Prevention [24]
Immunization of seronegative women before pregnancy
Nationally notifiable condition: Suspected congenital rubella syndrome must be reported
to the local or state health department.
15 A pregnant lady did not visit ANC until 12 weeks of gestation when she was found to
have a  rubella IgG titer. Next step?
A. Rubella IgG IM stat
B. Vaccinate her post-pregnancy
C. Check antibodies at 28 weeks
D. Vaccinate her after weaning
 ------- Forensic Medicine -------
Direct Cause of Death
1 An old man had CHF, pneumonia, and emphysema. He went into cardiopulmonary arrest.
What will you write as the cause of death in his death certificate?
Cardiopulmonary arrest
2 An RTA patient sustained a subdural hemorrhage after a skull fracture as well as
herniation of the brain. Afterwards she went into cardiac arrest. What is the direct cause of
death?
A. Cardiac arrest
B. Herniation
C. Head fracture
D. MVA
3 A patient with a history of heavy smoking & emphysema developed bilateral pneumonia &
died within 2 days. What is the direct cause of death?
A. Pneumonia
B. Cardiac arrest
C. Emphysema
D. Heavy smoker
Underlying Cause of Death
4 An RTA patient sustained a subdural hemorrhage after a skull fracture as well as
herniation of the brain. Afterwards she went into cardiac arrest. What is the underlying
cause of death?
A. Cardiac arrest
B. Herniation
C. Head fracture
D. MVA
5 A patient had a car accident and suffered multiple fractures and cerebral edema followed
by cardiopulmonary arrest. What will you write in the death certificate as underlying cause
of death?
A. Car accident
B. Fractures
C. Cerebral edema
D. Cardiopulmonary arrest
6 A man presents to the ER with emphysema after an RTA. What is the underlying cause of
death?
A. Emphysema
B. Road traffic accident
C. Pulmonary embolism
7 An RTA victim suffered a fracture and developed pulmonary embolism and cardiovascular
collapse after which he died. What is the underlying cause of death?
A. Fracture
B. Pulmonary embolism
C. RTA
8 A patient was in an RTA after which he developed pneumothorax followed by uncal
herniation, then he died. What is the underlying cause of death?
A. RTA
B. Pneumothorax
C. Uncal herniation
Others
9 A lady came in after being raped. She was drunk and had multiple bruises & abrasions.
What will be your initial step?
A. Sexual assault report
B. Check blood alcohol level
C. Take samples / confirm rape
D. Obtain written consent
E. Take forensic evidence
You cannot obtain written consent when she is drunk do that when she sobers up
 ------- General Surgery -------
Post-Operative Care

1 What is the most common surgical complication to occur within 24 hours of surgery?
A. Wound healing problems
B. Myocardial infarction
C. Incisional hernia
D. Hemorrhage
E. Wound infection
2 A patient developed a fever 24 hours after his cholecystectomy, associated with shortness
of breath. On examination, there are crackles in the lung bases. Most likely diagnosis?
A. Basal atelectasis
B. Wound infection
C. UTI
D. DVT
E. Bronchiectasis
F. Bronchial pneumonia
3 A 23 y/o male underwent an appendectomy during which his appendix was found to be
ruptured. 6 days post-op, he developed a fever & chills along with mucus diarrhea. Most
likely diagnosis?
A. Wound abscess
B. Pelvic abscess
C. Lung atelectasis
D. Appendicitis
E. Appendicular abscess
F. Fistula
G. Rupture of appendiceal stump

Appendiceal abscess [19][33][43]

Description: a localized collection of pus and necrotic tissue that forms around an inflamed
appendix, which typically follows an untreated perforated appendix
Clinical features: manifests as a tender mass in the RLQ in an acutely ill patient (i.e., high-
grade fever, possible paralytic ileus, leukocytosis, signs of sepsis)
Treatment
Nonoperative management of acute appendicitis
Abscess < 4 cm: antibiotic therapy alone is usually sufficient.
Abscess > 4 cm: image-guided percutaneous drainage or surgical drainage; send aspirate
for cultures [43][56]
Consider interval appendectomy. [19][33][43
4 A patient presents with fever & diarrhea 10 days post-appendectomy for suppurative
appendicitis. Cause?
A. Pelvic abscess
B. Enterocolitis
C. Ruptured appendiceal stump abscess
D. Enteric fistula
5 A patient underwent a thoracic surgery. Post-op day 10, he had wound discharge & a
hematoma. What is the cause?
A. Infection
B. Surgery
C. Dislodgement of a clot
6 A woman developed SOB following LSCS. What is the source of the thrombosis?
Lower limbs
7 A 70-year-old man was admitted for a surgical procedure. 10-days post-op, when he tried
to mobilize for the first time, he developed sudden unilateral pleuritic chest pain
associated with dyspnea and diaphoresis. It subsided on its own. He was afebrile. What is
the most likely diagnosis?
A. Pulmonary embolism
B. Bronchiectasis
C. Atelectasis
D. Pulmonary infarct
E. ARDS
F. Lobar pneumonia

Common features of PE [5]

Acute onset of symptoms
Dyspnea (> 75% of cases) [5]
Tachycardia and tachypnea (up to 50% of cases) [5]
Sudden pleuritic chest pain (∼ 20% of cases) [5]
Cough and hemoptysis
 Associated features of DVT: e.g., unilaterally painful leg swelling [6]
Less common features of PE [5]
Decreased breath sounds
Dullness to percussion
Split S2
Low-grade fever
Rarely, upper abdominal pain [7][8]
Features of massive PE: (e.g., due to a saddle thrombus)
Presyncope or syncope
Jugular venous distension and Kussmaul sign
Hypotension and obstructive shock
Circulatory collapse
8 A 70-year-old lady underwent hip replacement surgery after fracturing her hip. 7 days
later, she developed symptoms of breathlessness and chest pain when ambulating with her
physiotherapist. What is your initial step in management?
A. USS of lower limbs
B. CT angiogram
C. V/Q scan
D. Chest x-ray?????

The initial evaluation of patients with dyspnea and/or chest pain typically includes
laboratory studies, CXR, and ECG. Findings may suggest but do not confirm PE. [5]
D-dimer [12][21]
Findings
Normal levels: < 500 ng/mL
If ≥ 500 ng/mL: Further testing is required (see below).
Interpretation
High sensitivity and negative predictive value: A negative D-dimer test most likely rules
out PE.
Low specificity
9 A lady received blood and IV fluids to compensate for the blood lost intra-operatively. 6
hours later, she developed shortness of breath, lower limb & sacral edema, and had basal
crackles bilaterally. What is the most likely cause?
A. Pulmonary embolism
B. Fluid overload
C. Atelectasis
Risk factors for fluid overload [9]
Special patient populations: e.g., elderly, pediatric, or pregnant patients
Acute disease: e.g., critical illness, malnourishment, edematous states (e.g.,
decompensated cirrhosis, nephrotic syndrome, CHF)
Chronic disease: e.g., CKD, cardiopulmonary diseases (e.g., cardiomyopathy, COPD)
Iatrogenic: e.g., transfusion of blood products, fluid creep
Findings: clinical signs of hypervolemia (e.g., crackles on pulmonary auscultation)
Management
Reduce infusion rate (de-escalation of treatment) and limit oral fluid intake if
possible.
Respiratory support as needed
Fluid evacuation [3]
10 A patient underwent a cholecystectomy 3 days back for acute cholecystitis. Her liver
enzymes were normal initially, but she developed post-operative painless jaundice. O/E,
there was wound tenderness. No ileus. Likely cause?
A. Ascending cholangitis
B. Acute pancreatitis
C. Clipping of CBD
D. Anesthesia-induced liver injury
Appendix
11 What is the first symptom of acute appendicitis?
A. Generalized abdominal pain
B. Fever
C. Nausea
D. RLQ pain

Migrating abdominal pain: most common and specific symptom

Typically constant and rapidly worsens
Most patients present within 48 hours of symptom onset.
Initial diffuse periumbilical pain: caused by the irritation of the visceral peritoneum (pain
is referred to T8–T10 dermatomes) [6]
Localizes to the RLQ within ∼ 12–24 hours: caused by the irritation of the parietal
peritoneum
12 A boy came complaining of generalized abdominal pain radiating to the right iliac fossa.
On examination, he has rebound tenderness in the right iliac fossa. What is the next step?
A. Take him to surgery
B. Order CBC & urinalysis
C. Order CBC & urinalysis & abdominal US
D. Observation
13 A patient had confirmed acute appendicitis based on clinical examination. Next step?
A. Helical CT with griseofulvin
B. Pelvic US
C. Film images
We need to do imagining before taking to OT (new guidelines)
Best imaging is CT w/o contrast
If not then ABDOMINAL US
Best option from the list above is B lol

Laboratory studies [9][10]

Routine studies
mild leukocytosis with left shift
Tests to evaluate differential diagnoses
β-hCG test; rule out pregnancy (including ectopic pregnancy)
Imaging [9][10][13][19][27]
Options for first-line imaging in nonpregnant adults ; [11][12]
CT abdomen
Ultrasound abdomen
First-line imaging for pregnant adults and children: ultrasound abdomen
Abdominal ultrasound
Supportive findings [10] [30]
Distended appendix (diameter > 6 mm)
Target sign
Acute appendicitisAcute appendicitisAppendicitis with target signAppendicitis with target
sign
CT abdomen with IV contrast
CT abdomen is the most accurate initial imaging modality for appendicitis.
Supportive findings [27]
Distended appendix (diameter > 6 mm)
Edematous appendix with periappendiceal fat stranding
Appendiceal abscessPerforated appendicitis due to fecalith
MRI abdomen and pelvis [14][27][33]
Indications
MRI without IV contrast: pregnant patients
14 A patient came complaining of central abdominal pain that migrated to the right side of
the abdomen. There was pain on digital rectal examination. No rebound tenderness. CBC
showed normal WBCs & neutrophil count. What is the most likely diagnosis?
A. Mesenteric lymphadenitis
B. Pelvic appendicitis (can happen with normal WBCs)
C. Renal colic
D. Diverticulitis
15 A patient presented with abdominal pain that started in the umbilicus and shifted to the
RIF. It was associated with nausea & vomiting. O/E: severe tenderness; no rebound
tenderness. Diagnosis?
A. Appendicitis
B. Lymphatic adenitis
C. Diverticulitis
Supportive care
Bowel rest (NPO)
Intravenous fluids
Empiric antibiotic therapy for acute appendicitis [13][19][36][37]
Indication: all patients with acute appendicitis
Required coverage: against gram-negative and anaerobic organisms
Preoperative antibiotics for uncomplicated appendicitis: Administer one of the following
agents as prophylaxis against surgical site infection (can be discontinued after surgery or
within 24 hours) [14][19][37]
cefazolin; PLUS metronidazole
Operative management
Appendectomy [13][14][19][33][41]
Appendectomy within 24 hours of diagnosis is the current standard of care for acute
uncomplicated appendicitis
Relative contraindications [33][43]
Appendiceal mass
Appendicular abscess
Laparoscopic appendectomy
Interval appendectomy [14][33][45][46][47]
Definition: appendectomy performed 6–8 weeks following the resolution of an acute
episode of appendiceal mass or appendiceal abscess
Indications: currently not routinely recommended ; [14][45]
persistent or recurrent symptoms
Diverticular Diseases
16 A 60-year-old lady with history of constipation had LIF pain and fever that started several
weeks ago. Suddenly, she developed generalized abdominal pain. O/E: abdominal
tenderness, guarding and rigidity with no bowel sounds. Dx?
Perforated Diverticulitis

Low-grade fever
Sigmoid colon most commonly affected → left lower quadrant pain
Possibly tender, palpable mass
Change in bowel habits (constipation in ∼ 50% of cases and diarrhea in 25–35% of
cases)
↑ Urinary urgency and frequency, sterile pyuria
Acute abdomen: indicates possible perforation and peritonitis
Rarely: hematochezia
17 A 52 y/o male presented with heavy PR bleeding. 4 days ago, he had colicky abdominal
pain. His HR is 140 bpm, RR 22 rpm, and his BP is . He was transfused with RBCs.
What is the most likely diagnosis?
A. Colon cancer
B. Rectal cancer
C. Diverticulosis mc cause of lower GI bleeding in adults, asymptomatic
D. Diverticulitis no bleeding, with pain, rarely hematochezia, change in bowel habits
C.
Usually asymptomatic
May manifest with abdominal discomfort or pain, especially if associated with chronic
constipation [6]
Diverticular bleeding [7]

Colonoscopy: diagnostic modality of choice for suspected symptomatic diverticulosis

18 A patient presents with LLQ pain and diarrhea. Diagnosis?

Sigmoid diverticulitis

Approach [8][9][10]
Suspect acute diverticulitis in adult patients presenting with LLQ pain, fever, and
leukocytosis.
The diagnosis is typically confirmed with imaging, preferably CT abdomen with IV
contrast.
Laboratory studies [9][11][12]
leukocytosis
Imaging [9][12][13][14][15][16]
CT abdomen and pelvis with IV contrast [13]
Indications
Preferred initial imaging modality for suspected diverticulitis
Supportive findings
Colonic outpouching
Signs of inflammation
Bowel wall thickening
Screening colonoscopy [9][12][15][18]
Recommended 6–8 weeks after the resolution of the acute episode to assess the extent
of diverticulitis and rule out malignancy
Colonoscopy is contraindicated during an acute episode because of the increased risk
of perforation.
Intestinal Obstruction
19 A woman presents with lower abdominal pain, nausea, and vomiting (small bowel) for 2
days. She hasnot passed any motion for the past 7 days. On examination, she does not
have any abdominal tenderness. Bowel sounds were hyperactive. X-ray shows multiple
air-fluid levels. What is your diagnosis?
A. Volvulus
B. Intussusception
C. Subacute intestinal obstruction
 D. Paralytic ileus

20 A patient was noted to have a volvulus in the sigmoid colon with another small intestinal
volvulus around it. What is this type of volvulus called?
A. Compound
B. Double
C. Knotted
D. Combined
Compound volvulus = ileosigmoid knotting. The long pelvic mesocolon allow the ileum
to twist around the sigmoid colon resulting in gangrene of either or both segments of
bowel. Treated with surgery (decompression, resection, and anastomosis)

21 A patient presents with abdominal pain for the past 12 hours, associated with vomiting &
constipation. He has past history of laparoscopic gastric bypass 18 months ago. AXR
showed multiple air-fluid levels. What could be the cause?
A. Amyand hernia (Amyand hernia is a rare type of inguinal hernia in which the
appendix is contained within the hernia sac)
B. Maydl’s hernia (Maydl's hernia is a rare type of incarcerated hernia popularly
known as a hernia in “W” which describes the orientation of the bowel in the hernia
sac and the vulnerability of the central segment of bowel to undergo intra-
abdominal closed-loop strangulation which may go unnoticed.)
C. Small intestinal adhesions
D. Richter hernia (A Richter hernia occurs when the anti-mesenteric wall of the
intestine protrudes, causing strangulation without obstruction)
E. Petersen hernia (Petersen hernias are internal hernias which occur in the potential
space posterior to a gastrojejunostomy)
22 A patient with history of multiple bowel surgeries presents with symptoms of small bowel
obstruction. What will you do? Stable -> CT. unstable -> Xray
A. Small bowel barium follow-through (Xray) Correctest answer is CT w/
B. USS contrast … if not there then go
C. Barium enema with A
Initial imaging modality: depends on the type of bowel obstruction and hemodynamic
stability of the patient
Acute bowel obstruction [3][14]
Stable patients: CT abdomen and pelvis with IV contrast
Unstable patients: Consider abdominal series x-ray or abdominal ultrasound first, along
with urgent surgical consultation.
Subacute bowel obstruction
Preferred: CT abdomen and pelvis with IV contrast
Alternatives: MRI with and/or without IV contrast, water-soluble contrast challenge, and
specialized dynamic contrast studies
23 A patient presents with constipation. Abdominal x-ray shows air-fluid levels. Diagnosis?
Management?
Small bowel obstruction laparotomy
Perforation
24 A patient with history of peptic ulcer disease presented with acute epigastric abdominal
pain & rigidity. Best imaging?
A. Erect chest x-ray
B. Supine x-ray
C. Abdominal x-ray
D. Gastrograffin with fluoroscopy
25 A 72 y/o lady with osteoporosis of both knees for which she takes NSAID’s. She has a
sudden onset of epigastric pain. O/E, bowel sound were absent & findings suggestive of
peritonitis. Regular HR of 105, BP 135/90, RR 19. Amylase & lipase were normal.
Diagnosis? Random note: Intestinal obs: first there is inc bowel sounds then absent bowel
sounds
A. Perforated empyema of gallbladder
B. Acute pancreatitis
C. Mesenteric venous thrombosis
D. Perforated peptic ulcer
E. Perforated cancer of transverse colon
26 A young lady, known case of PUD treated 2 years ago, presents with abdominal pain for
4 hours. The pain radiates to her right shoulder. She has history of alcohol intake. O/E,
the abdomen does not move with respiration. There is epigastric tenderness with no
rebound tenderness. Bowel sounds are reduced. Diagnosis? PERITONITIS
A. Acute intestinal hemorrhage
B. Small intestinal perforation
C. Intestinal obstruction
Burns
27 A burn patient presents with a suppurative lesion. On examination you notice blue-green
pus with a fruity odor. What is the most likely cause?
A. Pseudomonas
B. Staphylococcus aureus
Pseudomonal cellulitis presents with a dusky red–to–bluish green skin discoloration and
purulent discharge. The typical fruity or mouselike odor has been linked to pseudomonal
infection. Vesicles and pustules may occur as satellite lesions. The eruption may spread to
cover wide areas and cause systemic manifestations.
28 A 30 y/o male sustained 2 burns to his anterior
chest & abdomen. Vitals are normal. His height is
160 cm, weight is 65 kg. After the trauma team
cleared him from fractures and excluding other
burns, how much fluid will you give him in 24
hours?
A. 1.7 L
B. 2.7 L
C. 4.7 L (65 x 18 x 4)
D. 5.7 L

29 A fireman sustained burns to the thorax, neck, and face (around the nose). He was
intubated. While treating the burns, what other problem should you worry about?
A. Inhalational burns
B. Shock (if no mention of burns of face & around the nose)
C. Sepsis
Infections & Ulcers
30 An old bedridden lady has ulcers on her left lateral
malleolus and left lateral greater trochanter. Fat is
seen at the site of the ulcers. What is the type of
ulcer?
A. Decubitus ulcer
B. Venous ulcer
C. Arterial ulcer
D. Neuropathic ulcer

31 A diabetic man had an ulcer on the dorsum of his foot. On examination, it is discharging
serous fluid that has soaked his sock. He also has loss of sensations in the area
surrounding it. Diagnosis?
A. Neurotrophic ulcer
B. Venous ulcer
C. Ischemic ulcer
32 A patient has a decubitus ulcer that is very deep with necrotic borders. Best antibiotic?
A. Ampicillin
B. Erythromycin
C. Cefotaxime
D. Clarithromycin
E. Amoxicillin
Cephalosporins are the strongest.
33 60- year-old male presents with an ulcer over the medial malleolus, varicose veins, and
hyperpigmentation. His left calf muscle was mildly swollen but not tender. Next step?
A. Bed rest
B. Compression bandage
C. Topical antibiotics
D. Heparin
E. 80 mg Enoxaparin
If it was arterial: stent if above the knee; bypass if below the knee

Venous compression therapy

Indications [2][3][20]
Primary treatment modality for:
Most patients with symptomatic mild venous disease or edema
Pregnant patients with any stage of CVD
Adjunct to interventional therapy: patients with skin changes or ulceration
Avoid compression therapy in significant PAD.
Types of compression [2][3]
Graded compression stockings
Elastic or inelastic bandages (e.g., Unna boots)
Adjustable compression garments [3]
Intermittent pneumatic compression device [3][11]
34 A patient has a wound in the back of his thigh with tissue necrosis. How will you manage
him?
A. Clean the necrotic tissue & suture
B. Clean the necrotic tissue & leave it open to be closed later on
C. Suture without removing the necrotic tissue
.
Necrotizing Fasciitis
§ Rapidly progressive infection resulting in extensive necrosis of superficial fascia & overlying
SC fat that can develop into a life-threatening condition within hours
§ Etiology:
- Aerobic + anaerobic; gram +ve + gram -ve
- Polymicrobial (includes E. coli – especially in Fournier gangrene which also includes
Klebsiella and Enterococcus)
- Monomicrobial (most commonly Streptococcus pyogenes / Peptostreptococcus /
Staphylococcus aureus)
§ Clinical features:
- Systemic = fever + chills + altered mental status
- Cutaneous = diffuse erythema + extreme tenderness & pain disproportionate in intensity
& extension in relation to the erythematous area + significant induration of SC tissue +
crepitus (methane & CO2 produced by bacteria) + purple discoloration d/t necrosis or
ecchymosis + bullae + paresthesia
§ Management: imaging & lab studies should not delay surgery immediate surgical &
medical treatment:
- Surgical exploration + debridement send tissue for histopathology
- Blood cultures broad-spectrum antibiotics
- ICU admission
Clostridial Myonecrosis
§ Rapidly spreading necrotizing infection caused by Clostridium perfringens (obligate
anaerobic gram +ve spore-forming) or Clostridium septicum/histolyticum
§ Wounds with compromised blood supply (septic surgical wounds / deep penetrating
wounds ex: knife or gunshots / open fractures) optimum anaerobic environment for
proliferation of C. perfringens necrosis that progresses within 24-36 hours
§ Pathophysiology: secretion of exotoxins (C. perfringens alpha-toxin) degradation of
phospholipids tissue destruction (myonecrosis) + inhibition of leukocyte function + gas
production gas separation into healthy tissue & further colonization and local tissue
destruction edema exacerbation of anaerobic environment
§ Clinical features:
- Incubation period = hours-days (can progress to systemic toxicity within a few hours)
- Local S&S = excruciating muscle pain + massive edema with skin discoloration progressing
from bronze to red-purple to black with overlying bullae + sweet / foul-smelling / non-
odorous discharge + crepitus + spreading infection
- Systemic S&S =
o Early: fever / tachycardia / altered mental status
o Late: shock / multi-organ failure / hemolytic anemia / ARDS / kidney & liver failure
§ Management:
- Immediate surgical exploration debridement (may need to amputate)
- Antibiotics (penicillin + clindamycin or tetracycline --- clindamycin only for penicillin
allergy)
- Tetanus toxoid
- ICU admission
35 A diabetic hypertensive patient came complaining of pain felt all the way from his right
groin to his knee. On examination, his right thigh is swollen, red and warm. There are
crepitations on palpation. Diagnosis?
A. Streptococcal infection
B. Staph. Aureus infection
C. Necrotizing fasciitis (streptococcus pyogenes)
Systemic symptoms: fever, chills, altered mental status
Cutaneous findings
Diffuse erythema (often manifests initially as suspected cellulitis that is not
responding to initial antibiotic therapy)
Extreme tenderness and pain out of proportion to the area of erythema
Significant induration of the subcutaneous tissue
Crepitus: due to the production of methane and CO2 by bacteria
Purple skin discoloration (skin necrosis, ecchymosis)
Bullae
Loss of sensation in the affected area (paresthesias)
Necrotizing fasciitis first spreads along the fascia before spreading to the superficial
cutaneous tissue. Local findings may, therefore, be unremarkable, with patients
experiencing a disproportionate level of pain.

Aerobic and anaerobic, gram-positive and gram-negative bacteria are frequently

isolated.
Both monomicrobial and polymicrobial causes are common. [4][17]
Polymicrobial: wide variety of aerobic and anaerobic pathogens, often of intra-
abdominal or genitourinary origin (E. coli, Bacteroides spp.)
Monomicrobial: commonly group A Streptococcus (S. pyogenes), Peptostreptococcus
spp., S. aureus
Fournier gangrene: usually mixed infection with facultative pathogens (E. coli,
Klebsiella, Enterococcus) and anaerobic bacteria
36 A man developed fever, edema, and crepitus in his leg. Diagnosis?
A. Clostridium perfringens
B. Streptococcus pyogenes
C. Staphylococcus aureus
Gas gangrene (also known as clostridial myonecrosis) is a life-threatening necrotizing soft
tissue infection commonly caused by the rapid proliferation and spread of Clostridium
perfringens from a contaminated wound. The clinical picture includes excruciating muscle
pain, edema with subsequent skin discoloration (red-purple to black) and gas production.
Crepitus, as well as a feathering pattern of gas in soft tissue imaging, are generally present.
Without treatment, gas gangrene is fatal in almost 100% of cases. Surgical debridement in
combination with antibiotic therapy reduces this figure by half.
37 A patient has a warm tender area on the thigh with crepitations. Causative organism?
Clostridium perfringens
38 A male has a venous ulcer over the medial malleolus associated with hyperpigmentation,
visible superficial veins, and mild non-tender calf swelling. He has history of varicose
veins but no history of DVT. Diagnosis?
A. DVT
Could be either … answer bel i7sas
B. Cellulitis
C. Osteomyelitis
D. Neuropathic ulcer
Hernias
39 A 46 years old laborer reports swelling in the right groin. The non-painful swelling is
observable in both the erect and the recumbent positions. Examination reveals a non-
tender irreducible 4 cm mass in the right groin below and on the medial side of the
inguinal ligament. Which of the following is the most likely diagnosis in this patient?
A. Indirect inguinal hernia
B. Femoral hernia Could be either … answer bel i7sas
C. Saphenous vein varicocele (saphena varix)
D. Hydrocele

Non-complicated femoral hernia

A globular, subcutaneous swelling in the groin
Localization: inferior to the inguinal ligament, lateral to the pubic tubercle, and medial to
the femoral vein
Swelling enlarges with coughing (palpable cough impulse) or a Valsalva maneuver
Possibly, non-specific, dragging pain
Complicated femoral hernia: see “Complications” below
• Incarcerated = irreducible hernia where the irreducibility is due to adhesions within the
sac in absence of obstruction or strangulation
• Obstructed = obstruction of the bowel within the hernia manifested by the 4 cardinal
signs (pain + vomiting + distension + constipation)
• Strangulation = occluded blood supply by pressure at the neck of the hernia impairs
viability of the bowel (unless only omentum is strangulated) --- order of occlusion is veins
then arteries producing gangrene
40 An elderly female patient presented with acute abdominal pain & distension. She also has
history of constipation. O/E, there was a tender groin mass and she had increased bowel
sounds. Diagnosis?
A. Incarcerated femoral hernia
B. Psoas abscess
C. Paralytic ileus
41 How do you manage an incarcerated femoral hernia?
Laparotomy
42 Which of the following symptoms indicates an incarcerated / strangulated hernia?
A. Absolute constipation
B. Distension & vomiting
C. Fever
D. Colicky abdominal pain

43 A truck loader came complaining of a mass that appears when he stands & disappears
when supine. On examination there is a non-tender reducible 4cm mass in the right groin
above & medial to the inguinal ligament. Diagnosis?
A. Direct inguinal hernia (from Hasselbach’s triangle medial to the inferior
epigastric artery; most common type in elderly)
B. Indirect inguinal hernia (above & lateral to the inferior epigastric artery)
C. Femoral hernia
D. Saphenous vein varicocele (non-painful, non-reducible, inferomedial)
44 A multiparous woman came with bulging in the abdomen while tensing. No hernia & no
tenderness. Diagnosis?
Recti divarication / diastasis

Definition: a > 2 cm separation of the right and left rectus abdominis muscles
resulting in protrusion of abdominal organs on straining
Risk factors
Conditions that increase intraabdominal pressure (e.g., pregnancy, abdominal
surgery)
Aneurysmal disease
Clinical features
Some patients may be asymptomatic.
Abdominal pain and discomfort
Pelvic instability and lumbar pain
Urinary and/or fecal incontinence
Diagnostics
Physical examination: distortion or extension of the linea alba
Ultrasound: confirms the diagnosis
Treatment
Postpartum exercise: Initiating an exercise program 6–8 weeks postpartum can help
strengthen the abdominal rectus muscles and reduce the abnormal extension of the
linea alba.
Weight loss: may be appropriate in patients who develop diastasis recti due to
obesity.
Surgical repair (e.g., abdominoplasty)
Patients with severe, recurring, and symptomatic diastasis recti
If conservative treatment fails after > 6 months
Complications: pelvic organ prolapse
 Neck Masses
45 A patient has a hard fixed swelling above the angle of the mandible. It does not move on
tongue protrusion. Diagnosis?
A. Parotid mass / enlargement
A. Carotid body tumor ----- Painless, firm, midline neck mass that elevates with
swallowing and tongue protrusion
B. Thyroglossal cyst (moves)
• Ranula cyst (((((Definition: retention cyst arising in the sublingual gland
• Epidemiology: [6]

o ♂≈♀
o Most common between 10–30 years of age
▪ Has been reported in patients aged 3–61 years
o Rare (∼ 3% of salivary cysts)
• Etiology: unclear
• Clinical features
o Translucent blue swelling below the tongue
o Can cause problems swallowing and speaking
• Treatment
o Extirpation of the ranula, including the sublingual gland
o Marsupialization)))))
46 A patient presented with a mass in the midline of the neck. The mass was moving with
tongue protrusion. What is the most likely diagnosis?
A. Thyroglossal cyst
B. Thyroid nodule
C. Bronchial cyst
47 A smoker developed an irregular frontal neck mass that
moves with deglutition. What is the x-ray showing?

A. Widened superior mediastinum (retrosternal

goiter)
B. Mid-mediastinal widening
C. Unfolding of the aorta
D. Metastasis

48 Which of the following is unlikely to present as a lateral superficial neck mass?

A. Cystic hygroma
B. Carotid body tumor
C. TB adenitis
D. Branchial cyst
Definition: a congenital lymphatic cyst (macrocystic lymphangioma) in the posterior
triangle of the neck caused by malformation and obstruction of the fetal lymphatic
system [4]
Epidemiology
∼ 1:6,000 live births [4]
Strongly associated with fetal aneuploidy (e.g., Turner syndrome, trisomy 21) and
congenital malformations (e.g., congenital heart defects)
 Clinical features
Present at birth as a soft, compressible, painless, posterior triangle neck mass
Can cause dysphagia or airway compromise
Positive transillumination test
Diagnostics
Prenatal ultrasound : fluid-filled neck mass with or without septations [5]
Ultrasound to identify mass in infancy
CT or MRI may be used to further assess anatomical structures for surgical planning
Treatment: Small masses may regress spontaneously, but surgical excision is usually
indicated to prevent infection or airway compromise, as well as for cosmesis. [2]
Prognosis: Recurrence is common following surgical excision of extensive hygromas.
49 A 55 y/o man, heavy smoker (40 cigarettes per day for a long time) & alcoholic, is
complaining of a mass on swallowing. O/E he has palpable left jugulogastric node(s).
What cancer does he likely have?
A. Gastric
B. Oropharyngeal
C. Liver
D. Lung

The jugulodigastric lymph nodes, also known as subdigastric lymph nodes, are deep
cervical nodes located below the posterior belly of the digastric muscle and anterior to the
internal jugular vein. They are located in neck node level IIa and receive lymphatic
drainage from the tonsils, pharynx, oral cavity and face.
Cysts & Abscesses
50 Scenario about infected sebaceous cyst. Management?
Complete excision
51 A patient has an abscess in his forearm. Management?
A. I&D with antibiotic
B. Topical antibiotic
C. Systemic antibiotic
52 A patient is complaining of anal pain. On examination you find a cystic mass.
Management?
Incision & drainage
53 A hypertensive patient with many comorbidities presents complaining of abdominal pain
for the past week. On examination, he is febrile with a temperature of 39.8 C & he has
rebound tenderness. Imaging shows a 4-5cm fluid collection in his RLQ. How do you
manage him?
A. Laparotomy & drain the abscess
B. CT-guided drainage (if it fails we go for surgery) cuz more than 4 cm
C. Laparoscopic appendectomy
D. Laparotomy with peritoneal lavage
Diabetic Foot
54 Management of diabetic foot?
Admission & debridement

Treatment
Surgical debridement
Regular wound dressing
Antibiotic therapy if foot ulcers become infected
Interventional or surgical revascularization: in patients with underlying peripheral
artery disease
Amputation if all else fails or severe life-threatening complications arise
Others
55 You have a patient with bilateral enlarged cervical lymph nodes. You are considering
removing the nodes and sending a sample for histopathology and bacterial culture. How
would you fixate the sample?
A. Keep it in the lab till the next day (with nothing)
B. Divide the sample in 2: half in formalin & half in nothing (formalin for
histopathology; nothing for bacterial culture)
C. Divide the sample in 2: half in formalin & half in glyceraldehyde
D. Keep it in formalin
E. Keep it in glyceraldehyde
 ------- Genetics -------
1 A very tall man with lax joints has a genetic disorder. What is the mode of inheritance?
Autosomal dominant

Mutations in genes (e.g., COL5A1, COL3A1) that control the synthesis and processing
of different types of collagen → collagen defects
Autosomal dominant or recessive inheritance with varying patterns of inheritance,
severity, and type of collagen affected

Cardiovascular
aortic dilation, aneurysms, or dissection
Aneurysms/dissections of the iliac, splenic, or renal arteries
Berry aneurysms: rupture leads to subarachnoid hemorrhage
Musculoskeletal
Joint hypermobility
Joint hypermobility
Skin
bruise easily
Skin hyperextensibility
Atrophic scars
Skin hyperextensibility in Ehlers-Danlos syndrome
Other
Organ rupture (e.g., gravid uterus) causing pain and (potentially life-threatening)
internal bleeding, especially seen with vascular EDS
2 A tall lady presented complaining of neurological symptoms (numbness of her hands). She
also has arthralgia & headaches. On examination, her BP is 210 / 160 mmHg. Her heart is
in the 5th intercostal space midclavicular line and you hear S4. Diagnosis?
A. Marfan syndrome
B. Acromegaly

Tumor mass effects

Headache, vision loss (bitemporal hemianopsia)
♀: Oligomenorrhea, secondary amenorrhea, galactorrhea, vaginal atrophy
♂: Erectile dysfunction, decreased libido, ↓ testicular volume
Soft tissue effects
hyperhidrosis
Deepening of the voice, macroglossia with fissures, obstructive sleep apnea
Skeletal effects
Coarsening of facial features slowly progressing with age; enlarged nose, forehead,
and jaw (macrognathia) with diastema
Widened hands, fingers, and feet
3 What is the longest phase in the cell cycle?
Interphase

Interphase is the longest part of the cell cycle. This is when the cell grows and copies its DNA
before moving into mitosis.
 ------- Gastroenterology -------
Esophagus
1 An old man presents with progressive dysphagia (solids liquids) but can still take in
some fluids. He also has hoarseness of his voice. Most likely diagnosis?
Esophageal cancer (SCC)

Early stages [10]

Often asymptomatic
May manifest with swallowing difficulties or retrosternal discomfort
Advanced stages [10]
General signs
Weight loss
Signs of advanced disease
Progressive dysphagia (from solids to liquids) with possible odynophagia
Retrosternal chest or back pain
Cervical adenopathy
Hoarseness and/or persistent cough
Signs of upper gastrointestinal bleeding
Hematemesis
Melena

2 A patient has cancer of the mid 1/3 of the esophagus. He has no history of smoking.
Diagnosis?
A. Adenomatous adenocarcinoma (lower 1/3)
B. Squamous cell carcinoma (upper & middle 1/3)
C. Transitional cell carcinoma
3 A 71-year-old man with a 40-year-history of cigarette smoking is complaining of
progressive dysphagia (solids liquids). He has lost 15 kgs of weight recently Imaging
(upper GI series) showed a distal esophageal stricture. What is the next step?
A. Dilation
B. Esophagoscopy with biopsy
C. Double contrast esophagogram CT
D. Barium radiography (best initial test but not enough)
Esophageal stricture
most common sequela of reflux esophagitis; ingestion of caustic substances
Diagnostics
Barium esophagram (best initial test): narrowing of the esophagus at the gastroesophageal
junction
Endoscopy with biopsies: to rule out malignancy
Treatment
dilation with bougie dilator/balloon dilator
4 A 60 y/o man was diagnosed with cancer in the mid-third of the esophagus. What sign
makes the patient most likely untreatable?
A. Hiccups
B. Hoarseness
C. Regurgitation
D. Weight loss

Advanced stages [10]

General signs
Weight loss
 Dyspepsia
Signs of anemia
Signs of advanced disease
Progressive dysphagia (from solids to liquids) with possible odynophagia
Retrosternal chest or back pain
Cervical adenopathy
Hoarseness and/or persistent cough
Horner syndrome
Signs of upper gastrointestinal bleeding
Hematemesis
Melena
5 A 60-year-old man was diagnosed with cancer of the mid 1/3 of the esophagus. What
makes his esophageal cancer untreatable?
A. Recurrent laryngeal nerve involvement (hoarseness of voice)
B. Involvement of para-cranial lymph nodes
6 A patient has esophageal cancer. What makes the diagnosis of cancer untreatable?
A. Inability to speak full sentences
B. Increased RR (50 rpm)
C. sPO2 < 90 %
D. pCO2 > 45
7 A patient presented with dysphagia. On manometry, you find that he has absent normal
peristalsis and increased lower esophageal sphincter tone. What is your diagnosis?
Achalasia Cardia
Degeneration of inhibitory neurons on myenteric plexus incomplete relaxation of LES
- Best initial test: barium swallow bird beak sign Most accurate test: manometry
- Treatment: myotomy / nitrates / CCBs / botulinum toxin injection

Dysphagia to solids and liquids; can be progressive or paradoxical dysphagia (difficulty

swallowing liquids, while solids are easily swallowed)
Regurgitation
Retrosternal pain and cramps
Weight loss

Esophageal manometry: confirmatory test of choice

Peristalsis is absent or uncoordinated in the lower two-thirds of the esophagus.
Incomplete or absent LES relaxation
High LES resting pressure
No evidence of mechanical obstruction
8 A patient presents with dysphagia, nausea, and vomiting. CXR shows a dilated esophagus
that becomes narrow in the lower 1/3. Bird beak sign What is the diagnosis?
A. Scleroderma
B. GERD
C. Achalasia
D. Diffuse esophageal spasm
Esophageal barium swallow: supportive and/or confirmatory test [8]
Bird-beak sign: dilation of the proximal esophagus with stenosis of the
gastroesophageal junction
Delayed barium emptying or barium retention
 Stomach
9 A young female had a dry cough that increases in the morning. She also complains of
needing to clear her voice regularly, and of voice hoarseness for 6 weeks. She has no
fever. Diagnosis?
A. Allergic rhinitis
B. Hypothyroiditis
C. GERD
D. Viral pharyngitis

Typical symptoms
Retrosternal burning pain (heartburn)
Regurgitation
Dysphagia, odynophagia [13][14]
Water brash: a symptom of excessive salivation triggered by refluxing of stomach
acid
Atypical symptoms
Pressure sensation in the chest/noncardiac chest pain
Belching, bloating
Dyspepsia, epigastric pain
Nausea
Halitosis
Features of GERD complications, e.g., aspiration pneumonia or aspiration
pneumonitis
Extraesophageal symptoms [15]
Chronic nonproductive cough and nighttime cough
Hoarseness
Bronchospasm
Dental erosion
Aggravating factors
Lying down shortly after meals
Certain foods/beverages
Red flags in GERD [15]
Dysphagia, odynophagia [13][14]
Anemia and/or evidence of GI bleeding (e.g., hematemesis, hematochezia)
Unintentional weight loss
Vomiting
Signs of GI bleeding
Presence of > 1 risk factor for Barrett esophagus (see below)

1 A patient with GERD is taking ranitidine. He has a positive urea breath test. What is the
0 long-term management?
Antibiotic (PPI not in the options)
1 A 75 y/o Japanese woman reports repeated episodes of vomiting of undigested food
1 mixed with blood. She has lost 5 kgs in weight over the last one month. Clinical
examination shows a frail woman with mild conjunctival pallor. O/E, you feel a non-
tender slightly mobile mass in the epigastric region. Most likely diagnosis?
A. Colon cancer
B. Gastric cancer
C. Gall bladder cancer
D. Esophageal cancer

Early stages of gastric cancer

 Often asymptomatic
Loss of appetite, nausea
Late stages of gastric cancer
General signs
Weight loss (may be aggravated by reduced calorie intake due to abdominal pain after
meals)
Signs of chronic iron deficiency anemia
Palpable tumor in epigastric region
Signs of gastric outlet obstruction
Dysphagia
Abdominal pain
Early satiety
Vomiting
Signs of upper gastrointestinal bleeding
Hematemesis
Melena
Signs of metastatic disease
Hepatomegaly
Ascites
Left supraclavicular adenopathy (Virchow node)
Palpable umbilical nodule (Sister Mary Joseph node)
Palpable mass on digital rectal examination (Blumer shelf)
Ovarian mass (Krukenberg tumor)
See “Complications” below.
Paraneoplastic syndromes
Leser-Trélat sign
Malignant acanthosis nigricans
1 A patient has an ulcer that causes pain with hunger that improved after eating. He has
2 been gaining weight. Where is the ulcer located?
A. Body of the stomach
B. First half of the duodenum
C. Jejunum
Food aggravates gastric ulcer and relieves pain in duodenal ulcer
1 A patient has persistent GERD symptoms (abdominal pain & dyspepsia worsening at
3 night) despite taking ranitidine 150mg. No weight loss or other red flags. Best next step?
A. Investigate for H. pylori
B. Give triple therapy
C. Double the ranitidine dose
D. Endoscopy

Red flags of dyspepsia present: Consider EGD on a case-by-case basis.

Red flags of dyspepsia absent
Typical dyspepsia: test and treat strategy for H. pylori (noninvasive tests, e.g., urea breath
test)
Positive: H. pylori eradication therapy
Negative: trial of acid suppression with proton pump inhibitors (PPIs)
Typical heartburn : trial of acid suppression with PPIs (empirical therapy) [3][4]

Approach [4]
Although gastritis is diagnosed based on the results of gastric mucosal biopsy, not all
patients require invasive diagnostic testing. For more detailed recommendations, see
“Approach to dyspepsia.”
Initial step: for most patients with upper GI symptoms, follow the test-and-treat strategy
for H. pylori.
 Upper endoscopy and biopsies
Indicated in patients > 60 years old
Consider on a case-by-case basis if red flags for dyspepsia are present , or insufficient or
no response to initial medical management
Additional studies: indicated based on individual evaluation and clinical suspicion
Detecting complications: e.g., ↓ Hb and ↑ BUN/Cr ratio suggest GI bleeding
Evaluating differential diagnoses: e.g., liver chemistries, lipase, amylase to screen for
hepatic or pancreatic disease
Identifying the underlying etiology: e.g., inflammatory markers or antibody testing if there
is suspicion of systemic inflammatory disease or autoimmune disease
1 A patient with GI bleeding was found to have a peptic ulcer on endoscopy. A biopsy was
4 taken. What type of bacteria will you probably find?
A. Gram negative rod
B. Gram positive rod
C. Spiral gram negative H pylori (spirochete)
D. Gram positive cocci
E. Gram negative cocci

A gram-negative, microaerophilic, spiral-shaped bacterium that typically infects the

stomach. A common cause of peptic ulcer disease and chronic gastritis.
1 A patient has benign ulcers on endoscopy. What medication provides the fastest although
5 brief control?
A. Antacid
B. H2 blocker
C. Propantheline
D. Belladonna alkaloids
Fast / short term = antacids Long / lasting effect = H2 blockers
1 What is the mechanism of action of omeprazole?
6 PPI (inhibition of the H+ K+ ATPase system)
1 A man presented with non-bilious vomiting and other GIT symptoms. O/E, there is a
7 succussion splash, but no bowel sounds were present. Diagnosis?
A. Gastric outlet obstruction
B. Small bowel obstruction
C. Colon obstruction
A succussion splash, also known as a gastric splash, is a sloshing sound heard through a
stethoscope during sudden movement of the patient on abdominal auscultation.

Definition: mechanical obstruction of the distal stomach, pyloric channel, or duodenum

Etiology
Malignancy (most common)
Intrinsic lumen reduction: gastric or duodenal cancer
Extrinsic compression: pancreatic or biliary malignancy, lymphoma
Peptic ulcer disease (PUD)
Other: gastric volvulus, strictures , foreign bodies
Clinical features
Postprandial, nonbilious vomiting
Early satiety
Weight loss
Progressive abdominal dilation
Succussion splash: a splashing sound created by the movement of gastric contents
Physiological if present immediately after a meal
Pathological if present after ≥ 3 hours of fasting
Diagnostics
UGI series
CT or MRI abdomen
EGD (confirmatory)
Laboratory studies (supportive): hypokalemic hypochloremic metabolic alkalosis
Saline load test [52]
Definitive treatment
Treat the underlying cause (e.g., H. pylori eradication).
Relieve the obstruction.
Endoscopic stent placement
Surgical options: gastrectomy, gastrojejunostomy
1 A patient presented with dyspepsia. Endoscopy was done and showed multiple fundal
8 gastric polyps with increased chromogranin. What substance will be high in the blood?
A. Histamine
B. Gastrin
C. Somatostatin
D. Cholecystokinin
Gastrinoma (Zollinger-Ellison Syndrome)

Most patients manifest with recurrent, therapy-resistant peptic ulcer disease.

Abdominal pain
Diarrhea and steatorrhea
Dyspeptic symptoms (e.g., heartburn)
Upper gastrointestinal bleeding
Weight loss
Possible symptoms of other endocrine neoplasias (see multiple endocrine neoplasias for
 more information).

Best initial test: esophagogastroduodenoscopy

Important to rule out H. pylori infection and malignant ulcers
Typically reveals multiple ulcers and thick gastric folds
↓ Gastric pH and ↑ basal acid output (> 15 mEq/h) [8]
Confirmatory tests
↑ Serum gastrin (in a fasting serum sample)
A gastrin level > 1000 pg/mL (or 10-fold increase in gastrin levels) is conclusive evidence
of a gastrinoma.
If serum gastrin levels increase (> 100 pg/mL) but are not more than 1000 pg/mL, a
secretin stimulation test should be performed.
Secretin stimulation test (if fasting serum gastrin test is inconclusive)
In healthy individuals, secretin inhibits gastrin secretion.
In patients with gastrinomas, secretin causes a paradoxical and dramatic increase in the
levels of gastrin within a few minutes of administering secretin.
A two-fold increase in gastrin above the basal level is indicative of a gastrinoma.
No increase or only a very slight increase is observed in cases of secondary
hypergastrinemia.
Imaging: only after diagnosis is confirmed to localize the tumor
CT/MRI scan, somatostatin receptor scintigraphy (octreotide scan) and/or endoscopic
ultrasonography
Tumor location [6]
Most gastrinomas are found in an area called the gastrinoma triangle [9]
Duodenum (∼ 70% of cases)
Pancreas (∼ 25% of cases): typically the head
Ectopic locations (5–15% of cases): e.g., liver, peripancreatic lymph nodes, ovaries
Colorectal Diseases
1 What is the first symptom in colon cancer?
A. Weight loss
B. Anal pain
C. Abdominal pain
D. Bleeding (technically change in bowel habits)
Constitutional symptoms [7]
Weight loss
Fever
Night sweats
Fatigue
Abdominal discomfort (symptoms similar to diverticulitis, especially in carcinoma of the
rectosigmoid or descending colon)
Right-sided colon carcinomas [7][8]
Definition: large bowel malignancies arising from the cecum, ascending colon, or
transverse colon
Clinical features
Occult bleeding or melena
Manifestations of iron deficiency anemia (due to chronic bleeding)
Diarrhea
Iron deficiency anemia in men > 50 years of age and postmenopausal women should raise
suspicion for colorectal cancer.
Left-sided colon carcinomas [7][8]
Definition: large bowel malignancies arising from the splenic flexure, descending colon,
sigmoid colon, or the rectosigmoid junction
Clinical features
Changes in bowel habits (size, consistency, frequency)
 Blood-streaked stools
Colicky abdominal pain (due to obstruction)

2 A 67y /o man complains of diarrhea with blood & mucus. Next step of management?
A. Contact the infectious team
B. Do PR examination then prepare for colonoscopy
3 What is the 5-year-survival chance for a patient with colon cancer stage A?
A. > 90 %
B. 70%

Five-year survival rate [2]

Localized disease: 90%
Regional spread: 72%
Distant metastases: 14%
All stages combined: 65%

4 A woman had colonoscopy which

revealed an ascending colon mass.
Biopsy was positive for colorectal
cancer. She has a history of a polyp
adenoma resection a few years ago.
Her 50-year-old father was diagnosed
with colorectal cancer 10 years ago,
and her brother also had a colon
resection for the same reason. What is
she likely to have?
A. Peutz-Jeghers syndrome
B. Hereditary nonpolyposis
colorectal cancer
C. Familial adenomatous polyposis
D. Sporadic colorectal cancer
3-2-1 rule: (3 affected family members, 2 generations, 1 relative under 50 years of age)

Presence of at least three relatives with a Lynch syndrome-associated cancer; all the
following criteria should be present:
One should be a first-degree relative of the other two
At least two consecutive generations affected
At least one relative with a diagnosis before 50 years of age
Exclude cases of familial adenomatous polyposis.
Verify tumors with pathological examination.
5 A 37-year-old patient was found to have multiple colonic
polyps that were removed surgically. His father & brother
have history of colorectal cancer. What should he have
done before?
A. Annual colonoscopy
B. Colectomy at 1 year of age
C. Fecal occult blood & colonoscopy annually
D. Sigmoidoscopy annually

Sigmoidoscopy or colonoscopy every 1 to 2 years starting at age 10 to 12 for people with

FAP. Individuals with AFAP should undergo colonoscopy beginning at age 18 to 20.
Yearly colonoscopy once polyps are found until a colectomy is planned. There are
different types of colon surgery for individuals with FAP and AFAP.
6 A male patient presents with diarrhea. O/E, his abdomen is distended & he has
exaggerated abdominal sounds. PR examination showed an empty rectum. Diagnosis?
A. Diverticulitis
B. Colorectal cancer
7 An old man presents with rectal bleeding & weight loss. O/E there is guarding.
Diagnosis?
Colon cancer
8 A 60 y/o man presents with 2-week history of diarrhea & intermittent abdominal pain.
O/E,his abdomen is distended with hyperactive bowel sounds. There is no tenderness or
guarding. PR examination shows an empty rectum. Abdominal x-ray shows gas in the
small & large intestines (distended bowel loops). What is the most likely cause?
A. Ascending colon cancer
B. Paralytic ileus
C. Descending colon cancer
D. Diverticulitis
E. Bowel obstruction
9 An old man has colon cancer, and his family is asking about the prognosis. What is the
most important factor that determines the prognosis of colorectal cancer?
A. Size of tumor
B. Depth of invasion
C. Histopathology
D. Age
E. Metastasis
F. Location of the tumor
1 A young male presented with abdominal pain, bloating, and watery diarrhea alternating
0 with normal bowel motion. His symptoms are interfering with his work and social life.
Sigmoidoscopy showed normal bowel mucosa. What is the most likely diagnosis?
A. Irritable bowel syndrome
B. Inflammatory bowel disease
IBS is characterized by chronic abdominal pain and changes in bowel habits (see also
“Rome IV criteria for IBS”).
Abdominal pain
Frequency, intensity, and localization generally vary widely from patient to patient
Typically related to defecation
Altered bowel habits: diarrhea and/or constipation
Other gastrointestinal symptoms
Nausea, reflux, early satiety
Passing of mucus, abdominal bloating
 Extraintestinal symptoms
Generalized somatic symptoms (e.g., pain or fatigue, as in fibromyalgia)
Disturbed sexual function
Dysmenorrhea
Increased urinary frequency and urgency
Physical examination: normal
1 A lady has history of abdominal pain relieved by defecation. Endoscopy showed normal
1 mucosa. Diagnosis?
Irritable bowel syndrome
1 Which medication is likely to cause constipation?
2 Ferrous fumarate

Common Adverse Effects

Constipation, diarrhea, dark stools, nausea, epigastric pain. [ref]
1 A 23-year-old male has developed a perianal fistula & a constriction in the ileum. What is
3 the underlying cause?
A. Ulcerative colitis
B. Crohn’s disease
C. Inflammatory bowel disease
1 A patient of Crohn’s disease has multiple fistulas. What is the histopathology of his
4 disease?
A. Non-caseating granulomas
B. Caseating granulomas
C. Crypt abscesses
D. Thinning of the affected wall
E. Inflammation of the mucus membranes
Transmural inflammation: all mucosal layers of the intestinal wall are involved
Noncaseating granulomas
1 What will you monitor Crohn’s patients for on the long term?
5 A. Infection
B. Bone marrow suppression
C. Lupus-like reaction
D. Serum sickness-like reaction
Complications of Crohn’s disease may or may not be related to the inflammation within
the intestine. Intestinal complications of Crohn’s disease include obstruction and
perforation of the small intestine or colon, abscesses (collections of pus), fistulae, and
intestinal bleeding.

Screening for complications and malignancies [6][20]

Intestinal cancer
Chronic inflammation increases the risk of intestinal cancer. [20]
Schedule surveillance colonoscopy with biopsies [11]
After 8 years after CD onset in patients with ≥ 30% colonic involvement.
At diagnosis in patients with primary sclerosing cholangitis
Anemia and malnutrition: e.g., CBC, iron-binding studies, folate, vitamin B12, LDH,
vitamin D, albumin [6]
Osteoporosis: DXA in patients with > 3 months cumulative lifetime exposure to
corticosteroids [20]
1 An 11-year-old girl with IBD has ulcers in her mouth and GI tract. Treatment?
6 A. Methotrexate (immunosuppression)
B. Corticosteroids
C. Azathioprine
D. Infliximab (TNF-alpha blocker)
Management:
Crohns: First line is corticosteroid
Maintenance is biologics like TNF alpha (Infliximab). Then 6MP then 5 ASA
(mesalamine)
Sulfasalazine can also be used to induce remission in mild to moderate crohns
 Ulcerative colitis: first line is mesalamine, then you can maybe
add corticosteroids.
In moderate to severe: TNF alpha and oral steroids
Acute severe: IV steroids
1 Treatment of ulcerative colitis?
7 Sulfasalazine & mesalamine/mesalazine
1 A 75-year-old man presents with fresh rectal bleeding. He also has tenesmus and recently
8 diarrhea. Diagnosis?
A. Diverticular disease constipation
B. Rectal cancer
C. Ulcerative colitis
D. Colon cancer
1 What is the site of
9 lymphatic metastasis in
rectal cancer?
A. Peri-vesicular
B. Inguinal
C. Para-aortic
D. Para-iliac

2 Based on what do you determine the severity of rectal cancer?

0 A. Depth of invasion
B. Site
If no “metastasis” as an option, then “depth of
C. Size of the tumor
D. Metastasis invasion”
Anal Diseases
2 An ulcerative lesion at the anus was biopsied and showed squamous cell carcinoma. What
1 is the site of lymphatic metastasis in anal cancer?
A. Peri-vesicular
B. Inguinal
C. Para-aortic
D. Para-iliac
2 An 18 y/o male has painless PR bleeding for 2 weeks. He notes that he sees fresh blood
2 on tissue papers. No changes in bowel motions. No other symptoms, and he has a normal
diet. He refused PR exam. What is the most likely cause?
A. Hemorrhoids
B. Anal fissure
C. Rectal hematoma
D. Fistula in ano

2 A patient is feeling urinary retention after his open hemorrhoidectomy. What is the cause?
3 Unknown but theory is pain spasm of urinary sphincter / distension of anal canal /
perineum —> dysfunction of trigone / detrusor muscle
 Pancreas
2 A 46-year-old woman presents with sudden episode of abdominal pain which started
4 about 2 hours ago. The pain is located in the epigastrium and radiates to her back. She has
vomited twice since the onset of attack. The pain is made worse by lying flat on her back
and she is more comfortable sitting up and bending forwards. She was informed of the
presence of gallstones in her gall bladder four weeks earlier when she reported pain in the
right hypochondrium. The oral temperature is 39oC, the blood pressure is 120/80 mm Hg
and the radial pulse rate is 118/min. There is no jaundice but there is marked tenderness in
the epigastrium both on deep and superficial palpations. Which of the following is the
most appropriate investigation for the cause of the patient’s pain?
A. Plain abdominal X-ray
B. Serum Amylase
C. Serum bilirubin
D. Barium Swallow
↑ Lipase: ≥ 3× ULN is highly indicative of acute pancreatitis
↑ Amylase: ≥ 3× ULN (less sensitive and specific than lipase)
2 A patient presents with right hypochondrial pain associated with nausea & vomiting. No
5 aggravating / relieving factors / jaundice. Investigation? Should be ultrasound
A. Lipase
B. Bilirubin
C. Uric acid
D. LDH

Ultrasound abdomen [8][24]

Indications: first-line imaging modality for all patients
Supportive findings
Features of acute pancreatitis (visible in 20% of cases) [8]
Enlarged hypoechoic pancreas (pancreatic edema)
CT abdomen and pelvis with IV contrast [6][8][14]
Findings
Features of acute pancreatitis
Enlargement of the pancreatic parenchyma with edema
Indistinct pancreatic margins with surrounding fat stranding
Acute pancreatitisPancreatic necrosis
X-ray chest and abdomen [8][26][27]
Supportive findings
On abdominal x-ray
Sentinel loop sign
Colon cut off sign
Magnetic resonance cholangiopancreatography [4][6][8]
Indications: prior to therapeutic ERCP in suspected biliary pancreatitis
2 A man presents with acute upper abdominal pain. Investigations reveal high triglycerides.
6 Diagnosis?
Pancreatitis
2 A patient is complaining of epigastric pain radiating to the back. He reports consuming
7 large amounts of alcohol 12 hours back. Diagnosis?
Acute Pancreatitis
2 A patient on chronic steroids presented with epigastric pain radiating to the back,
8 associated with nausea. Diagnosis?
Pancreatitis
 Most common causes [1]
Biliary pancreatitis; gallstones
Alcohol-induced
Idiopathic
Other causes [1]
Hypertriglyceridemia-induced pancreatitis: caused by severe hypertriglyceridemia (>
1,000 mg/dL)
Hypercalcemia
Post-ERCP
Drug-induced pancreatitis
Steroids
2 A patient presented with 5 weeks after acute pancreatitis with a 4.5 cm cyst.
9 Diagnosis? First line CT w contrast
Pancreatic pseudocyst
Management?
Observe & follow up (excision if > 5 cm)
3 What predicts a poor prognosis of
0 pancreatitis in thefirst 48 hours?
A. LDH > 600
B.  amylase
C.  triglycerides

3 An alcoholic patient was admitted for 10 days to treat his acute pancreatitis. He came
1 back after discharge complaining of fever & chills. He has a tender epigastrium.
Diagnosis?
A. Pancreatic abscess
B. Duodenal ulcer
Walled-off necrosis
Definition
An encapsulated collection of sterile necrotic material, usually occurring > 4 weeks after
the onset of necrotizing pancreatitis [5]
3 A man presents with painless jaundice for the past 3
2 weeks. On examination, there is asmooth globular
mass in the RUQ that moves with respiration.
Diagnosis?

A. Pseudocyst
B. Cancer of the head of pancreas
C. Empyema of the gallbladder

Tail or body cancer → new onset diabetes (bronze

diabetes)
3 A 60 y/o male patient, chronic alcoholic, is complaining
3 of epigastric pain radiating to the back. It is associated
with clay-colored stools, weight loss, and jaundice. O/E,
he has epigastric tenderness, and an epigastric mass is
felt. Labs showed  hemoglobin and  ALP &
transaminases. USS shown. Diagnosis?
A. Cancer of the head of the pancreas
B. Colon cancer

3 A patient presents with painless progressive jaundice associated with weight loss. On
4 examination, there is a smooth globular epigastric mass. Diagnosis?
Pancreatic adenocarcinoma
3 A scenario of a patient suggestive of pancreatic cancer. What symptom will you expect
5 him to have?
A. Steatorrhea
B. Vomiting
gastrointestinal symptoms
Belt-shaped epigastric pain which may radiate to the back
Nausea
Malabsorption, diarrhea (possibly steatorrhea secondary to exocrine pancreatic
insufficiency)
Jaundice caused by obstruction of extrahepatic bile ducts (especially in tumors of the
pancreatic head)
Courvoisier sign: enlarged, nontender gallbladder and painless jaundice
Pale stools, dark urine, and pruritus
Impaired glucose tolerance (rarely)
Hypercoagulability
Trousseau syndrome: superficial thrombophlebitis (in 10% of cases)
Recurring thrombophlebitis in changing locations (migratory)
Red, tender extremities
Classically associated with pancreatic cancer
Thrombosis (e.g., phlebothrombosis, splenic vein thrombosis)
Liver
3 A 61 y/o with history of liver cirrhosis due to Hep C came to the ER. O/E, his abdomen is
6 distended, and he had ascites (transudate based on investigations). Fluid WBC is 150.
What is the next step of management? (SAAG: Serum albumin – ascitic albumin)

A. Lactulose therapy with protein restriction

B. Peritoneal lavage
C. Start interferon therapy
D. Antibiotics according to the results of fluid culture
spontaneous bacterial peritonitis u give antibiotics and it
is exudate

Interferon therapy would be treatment of underlying cause.

3 A patient with ascites had pleural tapping which showed 350 neutrophils. How will you
7 treat him?
3rd generation cephalosporins
Spontaneous bacterial peritonitis

First-line: 3rd-generation cephalosporin IV, preferably cefotaxime [2][11][24]

Alternative: oral ofloxacin
3 A man came complaining of weight loss for the past 8 months. Liver biopsy showed
8 patchy necrosis, ballooning degeneration, and PMNL infiltrates. What is the most likely
cause?
A. Alcoholic cirrhosis
B. Alcoholic hepatitis
C. Alcoholic siderosis
D. Alcoholic fatty liver
E. Hepatocellular carcinoma
Classical features include inflammation & necrosis. Hepatocytes are classically ballooned
which causes compression of the sinusoids and reversible portal hypertension. The
inflammatory cell infiltrate consists of PNMLs & mononuclear cells.

Alcoholic hepatitis
Macrovesicular steatosis with hydropic swelling and ballooning degeneration of
hepatocytes within the lobules
Damaged hepatocytes typically contain Mallory-Denk bodies (hyaline inclusion
bodies that contain keratin filaments and appear eosinophilic on HE staining).
3 An alcoholic patient passed away due to pneumonia while undergoing treatment. On
9 autopsy, his liver was found to be 2 kg (hepatomegaly as normal liver for his weight
would be 1.8 kg). Liver biopsy revealed cholesterol deposits and necrosis. What is the
underlying cause?
A. Chronic alcoholism
B. Acute hepatitis C
C. Biliary lithiasis
D. Hepatocellular carcinoma

Alcohol-related cirrhosis
Infiltration of lymphocytes
Massive accumulation of fat in hepatocytes
Formation of fibrous septa and regenerative nodules
Perivascular sclerosis of central veins (especially in the early stage)
4 A chronic alcoholic woman came complaining of vomiting of 2-day-duration. She
0 admitted to drinking 2 glasses of beer nightly for the past 20 years. Which of the
following is consistent with her condition?
A. AST > ALT by > 50%
B. Low vitamin K
C. Low y-glutamyl transferase
D. Low ALP
E. Microcytic hypochromic anemia
In non-alcoholic liver disease: ALT > AST
4 An alcoholic patient was advised to quit drinking. He came back 1 week later with a
1 hemoglobin of 10. Reticulocytes were 5%. He also had high cholesterol (300). What is the
diagnosis?
A. Zeive’s syndrome
B. Alcoholic siderosis
C. Budd chiari syndrome
D. Hepatocellular carcinoma

§ Zieve’s Syndrome Triad = jaundice + hemolytic anemia + hyperlipidemia

§ Develops secondary to alcohol-induced liver injury
4 A man died because of pneumonia. Autopsy of the liver showed multiple masses. During
2 his life, he had consistently low hemoglobin. What is the most likely cause of the autopsy
picture?
A. HCC
B. CRC metastasis
C. Hydatid cyst

HCC CRC Mets Hydatid Cyst

4 What infection can cause hepatocellular carcinoma?

3 A. Epstein barre virus
B. Measles
C. Hepatitis B (more common in developing countries)
D. Hepatitis C (more common in developed countries)
4 A scenario about a patient with a liver problem was given. His platelet count was 10,000.
4 What is a contraindication for liver biopsy?
A. Platelet count < 60,000
B. elevated PT & PTT
C. INR > 1.6
D. Hemangioma
Contraindicated in hepatic hemangiomas, as it may cause bleeding
Gallbladder
4 A 54 y/o female is complaining of abdominal pain after eating. The pain is mostly in the
5 RUQ. It is sometimes colicky in nature. She reduced her meals, but the pain was not
relieved. Next step in management?
A. Endoscopy
B. Urea breath test
C. RUQ US
Initial evaluation: laboratory studies and RUQ ultrasound (consider biliary POCUS
if available)
4 A woman has RUQ pain radiating to the back. It worsens on lying down and improves on
6 siting & leaning forward. Murphy’s sign is positive. Diagnosis?
A. Cholecystitis
B. Gallstones
NPO + IV fluids + antipyretics + analgesia surgery within 48-72 hours
Right upper quadrant pain
Typically more severe and prolonged (> 6 hours) than in biliary colic
Postprandial
Radiation to the right scapula (due to referred pain from phrenic nerve irritation)
Positive Murphy sign: sudden pausing during inspiration upon deep palpation of the RUQ
 due to pain
Murphy sign may be falsely negative in patients > 60 years. [4][5]
Guarding
Fever, malaise, anorexia
Nausea and vomiting
4 A lady presented with upper abdominal pain radiating to the back. The pain started after
7 she had lunch and was associated with vomiting. On examination, she has epigastric
tenderness. Ultrasonography showed multiple stones in the CBD and a single stone in the
gallbladder. She was given IV fluids & antibiotics. What is the next step?
A. ERCP (faster & therapeutic – pre-operative ERCP followed by cholecystectomy
with CBD exploration) – only used in cases of obstructive jaundice / cholangitis
B. MRCP (best for diagnosis in case of negative US but high suspicion)
C. CT abdomen
D. Cholecystectomy
4 A patient with sickle cell disease came with acute cholecystitis. US showed 7 stones and
8 an inflamed gallbladder. The CBD was not dilated. Management?
A. Laparoscopic cholecystectomy
B. MRCP
C. ERCP
D. Pericholecystic drain
4 A patient with gallstones had an ultrasound that showed a common bile duct diameter
9 measuring 7mm (borderline normal) – no mention of stones in the CBD. What is the best
next step?
A. ERCP
B. MRCP
If asymptomatic and no stones in the CBD then expectant management.
If symptomatic then elective cholecystectomy.
If there are stones in the CBD, then antibiotics and ERCP if patient is stable, if not then
PTC.
5 An Indian man who has recently come from his home country is complaining of jaundice
0 & pale stools. Labs shown (high total bilirubin + low indirect bilirubin). What is the
cause?
A. Obstructive jaundice (high direct)
B. Prehepatic hemolysis (high indirect)
5 What is Charcot’s triad?
1 A. Fever & rigors + jaundice + palpable gallbladder
B. Fever & rigors + jaundice + RUQ pain
C. Epigastric pain…
5 A patient presents with fever, jaundice, and right hypochondrial pain. Diagnosis?
2 Cholangitis
5 A patient with ulcerative colitis is on medications. She developed jaundice & abnormal
3 LFTs. What is the most likely cause?
A. Primary biliary cirrhosis
B. Primary sclerosing cholangitis
C. Drug induced hepatitis
5 A woman with a history of colectomy presented with itching. Imaging of her biliary tract
4 showed narrowing of intrahepatic bile ducts. Liver biopsy showed periductal onion skin
fibrosis. What is the underlying cause?
A. Primary biliary cirrhosis
B. Ulcerative colitis beaded appearance, intra and extra hepatic. Primary sclerosing
C. Schistosomiasis
Liver biopsy [4]
Not routinely indicated as part of the workup for PSC
Consider in select patients to evaluate for:
Small-duct PSC
Autoimmune hepatitis-PSC overlap syndrome
Finding: concentric periductal onion skin fibrosis (typical but rare)
5 A man noticed slowly developing pruritis & jaundice over the past 2 years. He recently
5 developed abdominal pain. O/E, there is hepatosplenomegaly. He has normal AST/ALT
but  ALP. Diagnosis?
A. Alcoholic liver AST >ALT
B. Primary biliary cirrhosis
C. Liver tumor
Patients are initially often asymptomatic. Signs and symptoms are mainly due to the
resulting cholestasis, liver cirrhosis, and portal hypertension.
Fatigue (usually the first symptom)
Marked generalized pruritus
Hyperpigmentation [6]
Hepatomegaly, dull lower margin, RUQ discomfort
Splenomegaly
Jaundice
Pale stool, dark urine
Maldigestion (may involve manifestations of deficiency of fat-soluble vitamins; e.g.,
osteoporosis) [2]
Xanthomas and xanthelasma [2]

Laboratory tests
↑ Cholestasis parameters (ALP, γ-GT, conjugated bilirubin)
Transaminases (AST/ALT) are within normal limits or slightly elevated
Hypercholesterolemia
↑ Antimitochondrial antibodies (AMA) (> 95%)
↑ ANA (up to 70%)
↑ IgM

5 A woman presented with RUQ pain, pruritus, and jaundice. She also has a skin rash
6 (xanthomas). ANA was negative but AMA was positive. LFTs are deranged and ALP is
high. Management?
AMA primary biliary,
SMA autoimmune hepatitis,
pANCA primary sclerosing
Ursodeoxycholic acid (for PBC) – most unique features of PBC are xanthomas /
xanthelasma + osteoporosis
5 What do you give a patient with primary biliary cirrhosis?
7 USDA (Ursodeoxycholic acid)
5 A 42 y/o lady, P5, presents with severe acute RUQ abdominal pain associated with
8 nausea, vomiting, yellow discoloration of the eyes, and dark urine. Labs show  ALP,
AST, and bilirubin. She is on OCPs. Diagnosis?
A. Biliary colic
B. Drug (OCP) — induced cholestasis
Infections
5 A 25 y/o female patient presented with 3 months history of fever, RIF pain, and weight
9 loss for the past 3 months. O/E, a mass was felt in the RIF. Abdominal x-ray showed
calcification in the RIF. What is the most likely diagnosis?
A. Crohn’s disease
B. Appendicitis
C. Ileocecal TB
D. Right-side diverticulitis
E. Appendicular mass
Intestinal TB can cause calcifications.
6 A couple present to the ER with a pruritic rash, headache, vomiting, and burning
0 sensation in the mouth after eating catfish. Most likely diagnosis?
A. Salmonella
B. Shigella
C. Scombroid toxicity
D. Staph aureus
Histamine fish poisoning
Transmission: Predominantly caused by ingestion of contaminated, inadequately
refrigerated dark-meat fish, e.g. mackerel, bonito, mahi-mahi, and tuna
Mechanism of action: when temperature rises above a certain degree, histidine is
transformed into histamine through histidine decarboxylases produced by bacteria
Clinical features
Scombroid poisoning is often confused with fish allergy
After 5 minutes to 1 hour, symptoms similar to anaphylaxis appear:
Fever
Vomiting, diarrhea
Erythema, flushing, itching, urticaria
Oral burning sensation
Over time, symptoms may aggrevate to:
Respiratory distress due to bronchospasm
Hypotension
Angioedema
Symptoms usually resolve within 48 hours.
Treatment
Antihistamines
Epinephrine and albuterol may be administered in severe cases.

6 A patient with abdominal pain and vomiting develops CNS symptoms and seizures. What
1 is the likely cause? Drooping of the eye and descending paralysis and difficulty
swallowing
Botulism toxin
6 A patient developed diarrhea after receiving amoxicillin. How will you manage him?
2 A. Metronidazole
B. Clindamycin
C. Ciprofloxacin
One of the following:
Metronidazole
Oral vancomycin
Fidaxomicin
6 A patient received multiple antibiotics. He now presents complaining of diarrhea. What is
3 the best diagnostic step?
Clostridium difficile toxin
Pseudomembranous colitis (treated by oral metronidazole
6 What is the treatment of traveler’s diarrhea? Etec (enterotoxigenic E coli) MC cause
4 A. Ciprofloxacin or rifaximin
B. Amoxicillin
Usually, supportive only unless very severe. Aka Treat the dehydration, give bismuth for
mild-moderate cases, and loperimade if using antibiotics.
DON’T GIVE ANTIBIOTICS IF MILD
6 Treatment of salmonella?
5 Common first-line oral antibiotics for susceptible Salmonella infections are
fluoroquinolones (for adults) and azithromycin (for children).
Ceftriaxone is an alternative first-line treatment agent.
6 A medical student did not take precautions in the microbiology lab. He presents with
6 abdominal pain & diarrhea. On examination, he has splenomegaly. What is the causative
organism?
A. Salmonella typhi (typhoid fever = treat with ciprofloxacin)
B. Shigella
C. Entamoeba histolytica
D. Yersinia enterocolitica
E. Clostridium difficile

6 What organism causes food poisoning after eating fried rice?

7 Bacillus cereus
Non-inflammatory (goes away in max 2 days) – supportive treatment only
6 A man had a meal made of meat, potatoes, and green beans. Over the next 3 hours, he had
8 watery diarrhea. He improved with fluids and was able to return to work after 24 hours.
What is the causative organism?
A. Clostridium difficile (post-antibiotics = pseudomembranous colitis bloody
diarrhea)
B. Clostridium perfringens (8 hours after food up to 2 days)
C. Staphylococcus aureus (1-6 hours after food up to 2 days)
D. Yersinia enterocolitica (2 weeks of self-limiting diarrhea)
6 All members of a family present with vomiting. They report that they had meat pie
9 together last night. Best next step?
A. IM ranitidine
B. IV fluids
C. IV ampicillin
D. Oral magnesium hydroxide
7 What is the mechanism of action of cholera toxin?
0 Increases intracellular cAMP (stimulates cAMP)
7 A patient is traveling to an area with endemic entamoeba. What advice do you give him?
1 A. Wash his hands regularly
B. Avoid eating undercooked vegetables
C. Antibiotics
Travelers to endemic areas can reduce the risk of infection by drinking bottled water, not
using ice cubes in drinks, and washing fruits and vegetables with clean water (or by
peeling them yourself).
7 What parasite can infest meat?
2 Hookworm iron deficiency anemia
7
3

What is the interpretation of the following serology results?

HbsAg (-) HbsAb (+) HbcAb (-) Hep C Ab (-)
A. Patient is immunized against hepatitis B
B. Patient has active hepatitis C
C. Patient has chronic hepatitis C
7 A young lady presents with jaundice / cholestasis syndrome. Which lab results indicate
4 acute stage of hepatitis B?
A. HbsAg (+) & HbeAg (+)
B. HbsAg (+) & HbeAb (-)
C. HbsAb (+) & HbcAb (-)
D. HbsAb (+) & HbcAb (+)
7 A homosexual man had hepatitis C 7 years ago and hepatitis A 5 years ago. His partner
5 currently has hepatitis A and has been getting treatment. What advice do you give him?
A. Post-exposure prophylaxis
B. Immunoglobulins
C. Lifestyle modification
D. Check HepA IgM levels
E. Check HepA IgG levels
Hepatitis IgG is protective, so you check to decide whether he needs reassurance or
treatment. IgM would show acute infections.
 GI Bleeding
The Glasgow-Blatchford Bleeding Score (GBS) helps identify which patients with upper GI
bleeding (UGIB) may be safely discharged from the emergency room.

PUD
1. Active bleed OR non-bleeding visible vessels endoscopic therapy IV PPI +
infusion
2. Adherent clot +/- endoscopy IV PPI + Infusion
3. Flat spot / clean base no endoscopy oral PPI

Hematemesis + melena routine blood tests

- Minor observe + elective endoscopy
- Major ABC endoscopy

Acute variceal bleed ABC + terlippressin / somatostatin gastroscopy < 24 huors

- Esophageal variceal band
- Gastric cyanoacrylate injection

Guidelines:
1. No varices = repeat scope by 2-3 years
2. Small varices (no hemorrhaeg) = repeat in 1-2 years
3. Medium / large (no hemorrhage) = BB (propranolol / nadolol)
4. Variceal hemorrhage = vasoactive drug
7 A patient presents with hematemesis. He has BP (70/50 mmHg) and HR. Initial step in
6 his management?
A. Octreotide IV
B. IV fluid (1L)
C. 6 units of blood
D. Omeprazole
E. Upper GI endoscopy.

All patients [9][10][11][12][13][14]

Insert two large-bore peripheral IVs (for possible fluid resuscitation and blood transfusion)
Stable patients
Restrictive transfusion strategy
Unstable patients
ABCDE approach
Consider intubation to protect the airway (e.g., in patients with altered mental state and/or
severe ongoing hematemesis).
Urgent volume resuscitation for hemodynamic instability
IV fluid resuscitation
7 An old man came with fresh bleeding per rectum. On examination, he is tachycardic and
7 hypotensive. Next step?
A. IV fluids
B. Colonoscopy
7 A patient comes with upper GI bleeding. He is managed with fluids and the bleeding
8 stopped. Endoscopy was done and showed a 1 cm ulcer with non-bleeding vessel at the
base of the ulcer. What do you do?
A. Endoscopic clipping of the vessel
B. Angio-embolization of the vessel
C. IV vasopressin
D. H. pylori eradication

Endoscopic hemostasis [10][11][13]

Indications: any high-risk endoscopic findings
Signs of active bleeding
Nonbleeding visible vessel
Adherent clot
Modalities [13]
Injection therapy (e.g., with diluted epinephrine, normal saline)
Cauterization (e.g., heater probes, electrocauterization)
Mechanical therapy (e.g., band ligation, clips)
Polypectomy in the case of bleeding polyp (e.g., in the colon)
7 A patient presented with hematemesis. On examination,
9 he had low BP. USS was provided (showing collapsed
IVC). What is the next best step?
A. Give 1L of fluid
B. Insert a catheter
C. Give blood transfusion
8 A patient presented with melena. Endoscopy revealed an ulcer. Management?
0
A. IV infusion pantoprazole
B. H. pylori eradication
Prior to hemostatic procedures:
Administer pretreatment (e.g., IV PPI) as needed.
Administer anticoagulant reversal if INR > 2.5.
Consider withholding antithrombotic agents.

8 An old man presents with painless rectal bleeding. Colonoscopy revealed

1 multiplediverticula and serpiginous blood vessels in the cecum. What is the best
next step?
A. Dietary modification
B. Angiography to identify the source of bleeding
C. Tagged RBC scan to identify the source of bleeding
D. YAG laser treatment of the lesion
8 A patient came with rectal bleeding & fever. Which investigation will give you a
2 definitive diagnosis?
A. Colonoscopy
B. Fecal occult blood
C. Sigmoidoscopy
Others
8 A patient has a tumor seen on CT. His ALT & AST levels are normal. What is the source
3 of the tumor?
A. Liver
B. Pancreas
C. Epigastrium (all others might affect alt or ast)
D. Biliary duct
8 Which factor do NOT decrease bioavailability? Increase bioavailability
4 A. Protein binding
B. Gastric emptying
C. Hepatic impairment
D. Drug formulation
Factors that affect bioavailability are first pass hepatic metabolism / solubility of a drug /
chemical stability / nature of drug formulation / drug absorption affected by gastric
emptying
8 A patient came after vomiting for 1 hour. His BP was 110/60 mmHg and his pulse was
5 normal. Tongue was dry. Next step?
A. IV fluids
B. IM ranitidine
 ------- Hematology -------
RBCs
1 A 44 y/o lady presented with SOB & dizziness on exertion (walking / climbing upstairs).
No chest pain. She is a known diabetic & hypertensive, compliant to medications. She
weighs 81 kg & her height is 166cm. she eats a balanced diet. No history of coronary
artery disease. No features of hypothyroidism. Auscultation reveals normal heart sounds
& clear lungs with no crackles. What is the most likely cause of dyspnea?
A. Iron deficiency anemia
B. Coronary artery disease
C. Congestive heart failure
D. Hypothyroidism
Signs and symptoms of anemia
Fatigue, lethargy
Pallor (primarily seen in highly vascularized mucosa, e.g., the conjunctiva)
Cardiac: tachycardia, angina, dyspnea on exertion, pedal edema, and cardiomyopathy in
severe cases
Brittle nails, koilonychia (spoon-like nail deformity) , hair loss
Pica, dysphagia
Angular cheilitis: inflammation and fissuring of the corners of the mouth [9]
Atrophic glossitis: erythematous, edematous, painful tongue with loss of tongue papillae
(smooth, bald appearance)
2 A 21-year-old lady presents complaining of SOB and dizziness on exertion / walking /
climbing stairs. She has no chest pain. 3 months ago, she delivered a baby and has been
trying to lose weight since so she has been following a diet of fruits and vegetables. What
is the most likely cause of dyspnea?
Iron deficiency anemia

Decreased iron intake

Chronic undernutrition
Cereal-based diet
Strict vegan diet [1]
3 What values indicate iron deficiency anemia?
A. MCV < 80
B. MCV > 90
C.  TIBC
4 A young female complaining of fatigue has low hemoglobin & low MCV. She has a
normal menstrual cycle and flow. She states that she eats a vegetarian diet. Which lab
value supports iron deficiency anemia?
A.  ferritin
B.  TIBC
High RDW + high transferrin TIBC
5 A 26 y/o woman presented with recent history of fatigue. Her Hb was 8 with
reticulocytosis. Blood smear showed numerous micro-spherocytosis. Haptoglobin was
low. Direct antiglobulin (Coomb’s) test was positive. What is the most likely diagnosis?
A. Hereditary spherocytosis
B. Autoimmune hemolytic anemia Low Haptoglobin High LDH normal MCV =
hemolytic, but spheocytosis hemolytic there will be negative coombs test
C. Thalassemia
6 A woman presented complaining of fatigue.
CBC shows hemoglobin of 8 & platelet count
of 87,000. Blood film shows the following
(bite cells with schistocytes). Diagnosis?
Aortic valve issue
A. Drug-induced hemolytic anemia
B. Microangiopathic hemolytic anemia MAHA coombs negative
C. Spherocytosis
D. Beta thalassemia target cells
background
Etiology [31]
Primary MAHA
Thrombotic thrombocytopenic purpura (TTP)
Hemolytic uremic syndrome (HUS)
Secondary MAHA ; causes include:
Autoimmune disease (e.g., SLE)
HELLP syndrome
Hypertensive emergency
Disseminated intravascular coagulation (DIC)
Drug induced (e.g., quinine, trimethoprim/sulfamethoxazole, cyclosporine)
Pathophysiology
Systemic microthrombi plug small vessels → physical intravascular shearing of RBCs that
pass through the small vessels → intravascular hemolysis, schistocytes, and ↑ free Hb
Characteristically accompanied by thrombocytopenia
Clinical features
Features of anemia (e.g., pallor, fatigue)
Jaundice
Organ dysfunction due to microthrombi formation (e.g., renal dysfunction, altered mental
status)
Petechiae due to thrombocytopenia
Diagnostics in suspected MAHA
Consider MAHA in patients with the following:
CBC showing anemia and thrombocytopenia
Laboratory evidence of hemolysis with a negative DAT
PBS showing abundant schistocytes (typically ≥ 2 per high-power field)
Determine if end-organ damage and/or a secondary cause of MAHA are present.
Management [31][34]
If an evident secondary cause is identified (e.g., HELLP syndrome, hypertensive
emergency, DIC), treat accordingly.
If suspicion for TTP is high:
Refer for urgent plasma exchange.
Consider corticosteroid therapy (e.g., prednisone).
7 A woman presented complaining of fatigue. She is taking methyldopa for essential
hypertension. O/E she has a 3rd degree systolic heart murmur. CBC shows
hemoglobin of8 & platelet count of 87,000. Reticulocytes were also
high. Blood film shows the following (bite cells
withschistocytes). Diagnosis?

A. Drug-induced hemolytic anemia

B. Microangiopathic hemolytic anemia MAHA
coombs negative
C. Spherocytosis
D. Beta thalassemia
Methyldopa causes automimmune hemolytic anemia –
no bite cells or schistocytes
8 An Emirati man received anti-malarial prophylaxis before travelling to India.
Afterwards,he developed weakness and jaundice. What is a possible cause? Quinolone
causes G6PD G6PD Deficiency

Most patients are asymptomatic.

Recurring hemolytic crises may occur, especially following triggers
Arise within 2–3 days after increased oxidative stress [3]
Sudden onset of back or abdominal pain
Jaundice
Dark urine
Transient splenomegaly
Recurrent severe infections causing symptoms of chronic granulomatous disease
9 What is the chance of G6PD in the offspring?
25 % in a family (0.5 (in male) x 0.5 (chance of male)) – 50% in males

Carriers of G6PD deficiency have a 50% chance of passing the altered gene
on to each of their children. Each son of a carrier has a 50% chance of having
G6PD deficiency and each daughter has a 50% chance of being a carrier.
10 A 31-year-old presenting with weakness and fatigue was diagnosed with anemia. He
had
↓ MCV, ↓ TIBC, and ↑ serum iron. Smear showed basophilic stippling and target
[Link] is the most likely diagnosis?
A. Sideroblastic anemia target cells
B. Iron deficiency anemia low MCV high TIBc low iron
C. Thalassemia trait (if iron is normal) low MCV iron normal target cells
Description: anemia caused by defective heme metabolism, which leads to iron
trapping inside the mitochondria [27]
Etiology
Inherited: X-linked sideroblastic anemia due to a δ-ALA-synthase gene defect
Acquired
Vitamin B6 deficiency
Lead poisoning
Alcohol use disorder
Drugs (e.g., chloramphenicol, isoniazid , linezolid)
Copper deficiency
Myelodysplastic syndrome
Malignancy
Diagnostics
CBC: microcytic anemia
Serum iron studies
High ferritin -High iron
High transferrin saturation
Normal/low TIBC
Peripheral blood smear - Basophilic stippling of RBCs
Normocytes/macrocytes (more common in acquired etiologies)
Prussian blue staining of bone marrow: ringed sideroblasts
Treatment
Cessation of the offending agent
Pyridoxine (B6) supplementation (a cofactor for δ-ALA synthase)
11 A 25-year-old patient has anemia. On examination, he has splenomegaly. His labs show
MCV and  iron. Blood film shows basophilic stippling. What is true about this
disease?>>> sideroblastic anemia ???
A. Target cells are seen in the film >>>> seen in thalassemia
B. It is a congenital disease
C. Iron supplements are needed to treat him
D. RDW will be low

WBCs
12 An elderly lady came with weight loss. On examination, she has splenomegaly. She has 
platelets, hemoglobin (9), and ALP. Blood film showed atypical granulocytes at different
stages of maturation. Most likely diagnosis?
A. ALL
B. AML
C. Leukemoid reaction high LAP in leukemoid reaction
D. CML low LAP in CML, Philadelphia chromosomes
CLL has smudge cells

CBC and peripheral blood smear

Leukocytosis with midstage progenitor cells (e.g., myelocytes, metamyelocytes) and
mature cells (e.g., neutrophils)
Thrombocytosis
Basophilia and eosinophilia
Blast cells in peripheral blood can indicate the transition to AP-CML.
Anemia
Further laboratory studies
Leukocyte alkaline phosphatase (LAP): Low LAP is a typical finding and can help
distinguish CML from other types of leukemia and leukemoid reactions [3][4]
Flow cytometry: can be used to assess the type and maturity of leukocytes in order to
detect progression to advanced phases of CML [7][8]
13 A patient has hepatosplenomegaly, night sweats, and weight loss. Labs show anemia &
thrombocytopenia. His blood film showed immature granulocytes in different stages of
maturation. He also has  ALP levels. Diagnosis?
A. CML
B. CLL
C. Leukemoid reaction
D. ALL
14 A 47-year-old has clinical symptoms of CML with CD20+. Bone marrow examination
showed 40% mature lymphocytes. He currently has no active complaint. What is the most
likely complication that he can develop?
A. Disease progression to acute myeloid leukemia
B. Serious infections
 The blast crisis is the terminal stage of CML.
Symptoms resemble those of acute leukemia.
Rapid progression of bone marrow failure → pancytopenia, bone pain
Severe malaise
Subtypes :
Myeloid blast crisis → AML (⅔ of cases)
Lymphoid blast crisis → ALL (⅓ of cases)
15 Which cancer can theoretically be prevented via vaccination?
A. AML
B. CML
16 How can you determine the severity of AML?
A. Immunophenotyping
B. Cytogenic karyotyping
17 A 45-year-old man had a peripheral smear showed the following. Diagnosis?
AML (Auer bodies)

Platelets & Coagulation

18 What is the most common symptom of hemophilia?
A. Hemarthrosis
B. Spontaneous bleed
Spontaneous bleeding or delayed-onset bleeding (joints, muscular and soft tissue, mucosa)
in response to different degrees of trauma
Repeated hemarthrosis (e.g., knee joint) → hemophilic arthropathy (i.e., destruction of
the joint due to repeated hemarthrosis)
Typically develops by early adulthood
Most commonly involves the knees, ankles, and elbows
Recurrent bruising or hematoma formation
Oral mucosa bleeding, epistaxis, excessive bleeding following small procedures (e.g.,
dentist procedures)
Hemophilia C does not typically manifest with spontaneous bleeding, hemarthrosis, or
deep tissue bleeding. [2]
19 A man is complaining of recurrent bleeds from his nose, associated with buccal
telangiectasia. He also reports that he has gum bleeding whenever he has dental
procedures. ESR was high and brain MRI showed a hypodense area. What would be the
next step?
A. Hemicraniectomy
B. IV methylprednisolone
C. Angiogram to check for AVM and which vessel is bleeding
Hereditary hemorrhagic telangiectasia (skin + mucosa + viscera)
HHT: epistaxis + telangectasia + AVM
20 A patient has oozing from the venipuncture site 4-hours after a gastrectomy. She also has
purpuric lesions on her LLs & the dressing over the surgical wound was soaked. Cause?
A.  vitamin K
B. Ineffective electrocautery
C.  platelets
D.  anti-fibrinolytics
21 What does heparin work on?
A. Factor 10
B. Anti-thrombin

Unfractionated heparin (UFH)

Enhances the activity of antithrombin
Oncology
22 A patient with Hodgkin’s lymphoma had cervical lymphadenopathy. What investigation
will you do for staging?
A. US of abdomen & pelvis
B. Biopsy of the liver & spleen
C. CT scan of abdomen & pelvis
23 A patient had anemia of chronic disease. His labs showed high immunoglobulins and
high creatinine. What symptoms do you expect him to have? CRAB –
hypercalcemia, renal abnormalities, anemia, bone pain
A. Bone pain
B. Hepatomegaly
C. Splenomegaly
Multiple myeloma (high immunoglobulins)

Often asymptomatic
Mild fever, night sweats, weakness, and weight loss
Bone pain, especially back pain (most common symptom)
Symptoms of hypercalcemia
Spontaneous fractures
Increased risk of infection
Increased risk of petechial bleeding
Foamy urine (caused by Bence Jones proteins in urine)
24 A patient presented with lower back pain. Investigations showed that she is anemic,  Ca,
 total protein, and  albumin. What is your next step?
A. Treat hypercalcemia
B. Bone marrow biopsy (> 10% plasma cells = MM)
C. MRI of the spine
D. 24 hrs urine collection for Bence protein (they said next so maybe this)

Uptodate says urine first then if positive then biopsy

25 A 72-year-old female came complaining of fatigue. She has
pancytopenia and  BUN & creatinine. ALP & AST are
normal. Blood smear shows tear-drop cells and some
nucleated RBCs. Diagnosis?
A. AML
B. Myelofibrosis
C. CML
D. ALL

26 A 50-year-old man presents with fatigue and early satiety. Blood smear shows tear-drop
cells. Bone marrow smear shows fibrosis with hyper-cellularity. He is JAK 2 positive and
BCR/ABL negative. How will you manage him?
A. Thalidomide (for multiple myeloma)
B. Ruxolitinib (JAK2 inhibitor)
C. Splenic radiation
D. Colchicine
50% of myelofibrosis cases have JAK 2 mutation
Others
27 An elderly hypertensive patient came complaining of blurry vision, headache, and
dizziness. Investigations revealed low platelets and high hemoglobin. Treatment?
A. Steroids
B. Methotrexate
Polycythemia vera treatment: Phlebotomy / Antiplatelet prophylaxis (aspirin) /
Cytoreductive therapy (hydroxyurea / interferon alpha / Ruxolitinib)
AML is a complication of polycythemia vera.
28 A man came complaining with a headache and was found to have high RBCs. What
investigation will you do?
A. Bone marrow
B. Erythropoietin level +peripheral blood smear for JAK 2 kinase then bone marrow
 Suspect polycythemia vera in:
Individuals with elevated hemoglobin and/or hematocrit and normal oxygen
saturation
Patients with features or complications associated with polycythemia vera (e.g.,
hyperviscosity syndrome, splanchnic vein thrombosis)
Rule out other causes of polycythemia.
Order confirmatory laboratory studies for polycythemia vera.
Serum erythropoietin levels (EPO)
Peripheral blood screen for JAK2 mutation [3][12]
Consider bone marrow studies.
Confirm diagnosis based on the diagnostic criteria for polycythemia vera.
29 Blood transfusion reaction
 ------- Infectious Diseases -------
Microbiology
1 A patient presented with pus from a wound that he sustained after cutting himself with a
glass. Wound culture revealed gram +ve catalase +ve pleomorphic organisms arranged in
chains showing white spots & hemolysis on blood agar. What is the causative organism?
A. Actino (Corynebacterium) pyogenes
B. Bacillus cereus
A. Listeria monocytogenes (small kidney-shaped non-motile)

Antibiotics
2 What is the side effect of ceftriaxone
(for a pregnant lady)?
A. Diarrhea
B. Nausea & vomiting when
consumed with alcohol
(disulfiram)
C. Tendon rupture
(fluoroquinolones)
D. Tooth discoloration
(tetracyclines)
E. Ileus
 Tuberculosis
3 A female working as a domestic worker presents with fever and sweating. She reports
having lost 4 kgs of weight. No sore throat. On examination, she has enlarged matted
cervical lymph nodes. Chest is clear. What is the most likely diagnosis?
A. TB lymphadenitis
B. Infectious mononucleosis

A form of extrapulmonary tuberculosis that causes granulomatous inflammation and caseous

necrosis of lymph nodes. Manifests as discrete or matted, nontender lymphadenopathy, with
or without discharging sinus tracts. Most commonly involves the cervical and
supraclavicular lymph node groups
4 A man presents with fever and fatigue for 3 weeks. On examination, he has cervical
lymphadenitis. Histology reveals necrotizing granulomatous inflammation, but AFB
smear is negative. What is true?
A. TB has been excluded
B. TB cannot be excluded until further testing (3 separate samples have to be
negative for AFB to exclude TB)
C. This is a bacterial infection
D. The findings are due to diminished blood supply to the LNs
5 What is the best diagnostic test for TB?
ZN stain of bronchial washings aka AFB (gold standard is culture)

6 An Ethiopian lady working as a housemaid presented with a dry cough. She denies night
sweats or weight loss. CXR was normal but QuantiFERON test was positive. What do
you do? Latent TB
A. Repeat CXR in 3 months
B. Isolate her & contact IDU
C. Repeat QuantiFERON in 3 months
D. Start INH (isoniazid) for 9 months (latent TB)
E. Reassure her
+ve IGRA (QuantiFERON) CXR to exclude active TB INH for 9 months
7 A patient with hepatitis needs TB medications. What combination of medications will you
give him?
A. Isoniazid + pyrazinamide
B. Ethambutol + pyrazinamide
C. Rifampicin + ethambutol
D. Streptomycin + ethambutol
Isoniazid, pyrazinamide, and rifampicin have hepatotoxic potential.
HIV
8 An African man who recently came to Dubai is asking for an HIV test. He is a heavy
smoker, obese, hypertensive on medications, and has family history of hyperlipidemia.
Abdominal aorta could not be auscultated because of his obesity. What tests will you
order for him?
A. ELISA + CXR
B. ELISA + fasting glucose
C. ELISA + abdominal US to screen for AAA
D. Lipid profile + fasting glucose
Others
9 A pregnant lady who has a pet cat enjoys gardening. She came with a neck mass.
Whatinfection is she at a risk of?
Toxoplasmosis

Pathogen: Toxoplasma gondii, an obligate intracellular, single-celled protozoan

Route of transmission
Oral ingestion: The oocysts are excreted in the feces of cats (final host) and are orally
ingested by other mammals such as humans, hoofed animals, and birds (intermediate
hosts). Primary modes of transmission include the following:
Cat feces
Raw or insufficiently cooked meat (most common)
Unpasteurized milk (especially goat milk)
Transplacental transmission: see toxoplasmosis in pregnancy
Via organ transplantation or blood transfusion

Incubation time: 5 days to 3 weeks [3]

Immunocompetent patients
Mainly asymptomatic (∼ 90% of patients)
Symptomatic (< 10% of patients) [6]
Mononucleosis-like symptoms with bilateral cervical adenopathy (but negative
heterophile antibody test) [7]
Rarely: ocular toxoplasmosis
Immunosuppressed patients (e.g., patients with AIDS): primary infection or
reactivation in previously infected individuals [4]
Symptoms of encephalitis in cerebral toxoplasmosis
Visual impairments and pain in ocular toxoplasmosis
10 Which of the following disorders is NOT a notifiable disease to the preventive medicine?
A. Food poisoning
B. Measles
C. Infectious mononucleosis
D. Chickenpox
11 What organism is the most likely to cause infections post-splenectomy?
A. Klebsiella
B. E. coli
C. Strep. Pneumoniae (or Hemophilus influenzae) encapsulated
12 Example of direct transmission?
A. Sexual transmission of chlamydia
B. Hepatitis B infection from needle sharing
C. TB infection through inhalation of air
D. Cholera infection from water
13 Malaria prophylaxis

14 A man is complaining of headache, sweating, and fever. He states that he has been to his
farm recently. Diagnosis? Gram negative coccobacilli brucellosis
A. Brucellosis
B. Neisseria meningitidis
C. Mycoplasma
• Transmission: zoonotic (raw meat / unpasteurized dairy products)
• Risk factors: farmers / veterinarians
• Pathophysiology: non-caseating granulomas
• Clinical features: flu-like / night sweats / fever / painful lymphadenopathy
• Diagnosis: CBC (anemia & neutropenia); LFTs (mild elevation); +ve Rose Bengal
test (serum agglutination) confirm with blood culture
• Treatment: first line (doxycycline + rifampin); second line (doxycycline +
streptomycin)
 ------- Metabolic Diseases -------
Biochemistry
1 Which of these amino acids is in the urea cycle?
A. Leucine
B. Glutamate
C. Proline
D. Ornithine
2 What is the source of GTP energy?
A. Hydrolysis in the nucleus (hydrolyzed by GTPase to GDP in nuclear pores)
B. Hydrolysis in the cytoplasm
Dyslipidemia
3 What drug will not cause dyslipidemia?
A. OCPs
B. Beta blocker
C. ACE inhibitor
D. Thiazide diuretic
ACE inhibitors may decrease triglycerides & increase HDL; captopril may improve
insulin sensitivity

Familial Familial Familial Familial Familial

Hyperchylomi Hypercholest Combine Dysbetalipopr Hypertriglyc
cronemia (I) erolemia d oteinemia (III) eridemia
(IIA) Hyperlipi
demia
(IIB)
Pathoge Deficiency of Defective LDL receptors / Defective ApoE Hepatic
nesis lipoprotein ApoB-100 (AD) (AR) overproductio
lipase / ApoC- n of VLDL
II (AR) (AD)
Lipopro Chylomicron LDL LDL & Remnants of VLDL
tein VLDL VLDL and
Defect chylomicrons
Cholest Normal to mild    Normal to
erol  mild 
 Triglyce  Normal   
rides
4 A 28 y/o man presented with xanthomas all over his hands and body. His father died
at the age of 51 due to a myocardial infarction. Investigations showed an abnormal
lipid profile (LDL = 400; TGs = 200; HDL = 45). His father has CAD. Diagnosis?
A. Familial hypercholesterolemia
B. Familial combined hyperlipidemia
C. Type IV dyslipidemia
 ------- Nephrology -------
Nephrotic & Nephritic Syndromes
1 A patient presented with periorbital & leg edema, proteinuria, and  triglycerides. What
is the diagnosis?
Nephrotic syndrome
2 A boy has bilateral edema with pain on pressure. He has proteinuria but no RBCs in his
urine. Diagnosis?
Nephrotic syndrome
3 A patient was diagnosed with nephrotic syndrome after evaluation for proteinuria. What
is the first line of management of proteinuria in nephrotic syndrome?
ACE-Inhibitor

Antiproteinuric therapy
Indicated in most patients
RAAS inhibitor: ACEI (e.g., ramipril) or ARB (e.g., losartan) are commonly used.
4 A man with proteinuria developed DVT. What is the cause?
 anti-thrombin III
5 A 35-year-old man with a history of rhinitis and hay fever, presents with renal symptoms
(gross hematuria). these symptoms occur every time he gets a URTI. Urinalysis shows
RBC casts. What is the most likely diagnosis?
A. IgA nephropathy
B. Post-streptococcal glomerulonephritis (more common in pediatrics; tea-colored
urine)
C. Thin basement membrane
D. Good pasture syndrome
Recurring episodes of:
Gross or microscopic hematuria
Flank pain
Low-grade fever
And/or nephritic syndrome (including hypertension)
Usually during or immediately following a respiratory or gastrointestinal infection [6]
Can progress to RPGN and/or nephrotic syndrome (< 10% of patients)
Renal Failure
6 A 65-year-old woman with diabetes, hypertension and normal kidney function underwent
a total right hip replacement. She had massive hemorrhage during the operation and was
given 8 units of packed RBC. The blood pressure dropped to 60/40 mm Hg for about two
hours before it was corrected with blood transfusion. Two days after the surgery the
serum creatinine level rose to 4.2 mg/dl (normal <1.5 mg/dl), BUN was 50 mg/dl (normal
10-20 mg/dl) and potassium 5.0 mmol/L (normal 3.5-5.0 mmol/l). There were brown
granular casts in the urine sediment. Which one of the following is the most likely cause
of this complication?
A. Diabetic nephropathy
B. Malignant hypertension
C. Acute tubular necrosis
D. Interstitial nephritis
Diagnostics (see “Diagnostics” below)
Blood findings: azotemia, hyperkalemia, and metabolic acidosis
Urinary findings
↑ Fractional excretion of sodium (FENa)
Myoglobinuria, hemoglobinuria
Urinary sediment
Muddy brown granular casts
Epithelial cell casts
Free renal tubular epithelial cells (due to denudation of the tubular basement membrane)
 Vascular
7 A female patient presents with high BP (200+/100+ mmHg) & has positive fundoscopy
findings (AV nipping). BP was equal in both limbs but she has an abdominal bruit). What
is the most likely cause?
A. Essential hypertension
B. Renal artery stenosis
C. Coarctation of the aorta
D. Abdominal aortic aneurysm
Family history of hypertension is often absent.
Hypertension: severe (i.e., resistant to therapy) and/or early-onset (i.e, hypertension in
individuals < 30 years of age) [3][8]
Abdominal bruit heard over the flank or epigastrium: present during both systole and
diastole [9]
Flash pulmonary edema
Features of atherosclerosis in other parts of the body (e.g., peripheral artery disease,
coronary artery disease, carotid stenosis)
Features of renal insufficiency (e.g., nausea, edema)

8 An old male patient comes with a BP of 200/150 mmHg. On abdominal examination, a

bruit was heard. What is the diagnosis?
A. Renal artery stenosis
B. Aortic aneurysm
Treatment of associated hypertension [8][11][23]
General principles
Multiple agents may be required to achieve blood pressure control.
Regimens including an ACE inhibitor or an ARB are preferable.
Options
ACE inhibitors (e.g., lisinopril )
Angiotensin receptor blockers (e.g., losartan )
Calcium channel blockers (e.g., amlodipine )
Beta blockers (e.g., metoprolol )
 Others
9 A diabetic patient developed acute renal injury after IV contrast for CT scan. HCO 3 was
given to him before he received the contrast. He has good control of his diabetes (HbA1C
is 6.8%) and had a baseline GFR of > 60% 2 months ago. What is a risk factor in his case
for accelerated renal injury?
A. Diabetic nephropathy
B. Baseline GFR
C. Receiving HCO3

10 A 62 y/o man has polycystic kidney disease. On further history taking, he reveals that he
had it since childhood. What is correct about the disease? Autosomal recessive in
childhood, ADPKD adult onset
A. Autosomal recessive (since childhood – appears shortly after birth; rare)
B. X-linked
C. His 36 y/o son has a 90-95% chance of having the disease (ADPKD)
D. Associated with lung cysts
ADPKD is autosomal dominant (appears > 30 years of age) – associated with liver cysts
& Berry aneurysm
11 A patient was found after being lost in the desert for 2 hours. His temperature was 42C
and his creatinine was 3.2 (). What is the cause of his  creatinine?
A. Dehydration
B. Rhabdomyolysis Temperature is 42 that’s why
Classic triad
Myalgia
Generalized weakness
Darkened urine (red to brown)

Blood work [8][10][12]

↑ CPK [10][11]
CMP
↑ BUN, ↑ Creatinine
↑ Potassium, ↑ Phosphate, ↓ Calcium (ionized Ca) [8]
↑ Lactate dehydrogenase
↑ Myoglobin [9][12]
ABG: anion gap metabolic acidosis
 ------- Neurology -------
Cerebrovascular
1 What drug would you recommend for preventing another episode following TIA?
A. Aspirin
B. Clopidogrel
2 A patient presents with upper & lower limb weakness and incoherent speech for 2 hours.
How can you prevent future episodes?
A. Aspirin
B. Clopidogrel
C. Warfarin
Indication: most patients with no contraindications to anticoagulation and/or antiplatelet agents
Choice of agent: based on patient risk, underlying etiology, and existing medications
Single antiplatelet agents (e.g., aspirin, clopidogrel): most common
3 A patient had a TIA that has resolved 6 weeks ago. Upon investigations, you find that hehas
80-90% stenosis of the carotid artery. Management?
A. Carotid endarterectomy if more than >70%
B. Anticoagulants
C. Thrombolysis
Cranial Nerves
I. Olfactory (sensory) anosmia / hyperosmia
II. Optic (sensory) blindness
III. Oculomotor (motor to most eye muscles) ptosis + eye down & out + inability to
move eye up / down / medially + loss of pupillary reflex afferent is optic, efferent is
occulomotor + difficulty accommodating close vision + diplopia
IV. Trochlear (motor to superior oblique) diplopia + eye up & medially + inability to
move eye down & out laterally (indicated by a head tilt) can’t read or go down stairs, palsy will
make it up & out
V. Trigeminal (sensory & motor) paralysis & weakness of target muscles + loss of
sensation in target areas
VI. Abducens (motor to lateral rectus) diplopia + eye medially + inability to move eye
laterally
VII. Facial (sensory & motor)
a. UMNL: affects contralateral lower part of the face
b. LMNL (Bell’s Palsy): affects ipsilateral upper and lower muscles (inability to
close eyelid & loss of corneal reflex)
VIII. Vestibulocochlear (sensory)
a. Vestibular: nystagmus + vertigo
b. Cochlear: unilateral deafness + hearing loss
IX. Glossopharyngeal (sensory & motor) loss of sensation thus no gag reflex + loss of
taste on posterior 1/3 of the tongue (usually associated with CNX damage)
X. Vagus (sensory & motor) deviation of uvula to normal side + vocal cord paralysis
XI. Accessory (motor) paralysis of sternocleidomastoid & trapezius + shoulder drop
XII. Hypoglossal (motor) deviation of tongue to affected side + atrophy of ipsilateral
tongue muscles + speech problems
4 A 45-year-old man presents with a mass on the right side of the face. The mass was first
observed three months ago but has recently become visibly larger. He feels pain over the
mass and is unable to blow a whistle. Clinical examination shows that the mass is likelyto be
the parotid gland. An oral examination shows a foul-smelling discharge from the

duct of the gland and gentle probing shows that it is stenosed at the meatus. Which of the
following features suggests that the mass might be malignant?
A. Presence of pain
B. Recent enlargement
C. Facial nerve palsy
D. Stenosed duct meatus
5 A man presented complaining of facial weakness. He also has a 2-day
history of flu-like symptoms. When asked to smile, the following is
seen (picture). Which nerve is affected?
Right facial nerve Bells palsy, ipsilateral LMNL

6 A patient has a mass on the side of the face. He can’t blow a whistle. Which nerve is
affected?
Facial nerve
7 A man with otitis media had affection of the facial nerve. What do you expect to find?
A. Loss of lacrimation on the affected side
B. Loss of lacrimation on the other side
C. Hyperacusis
D. Inability to frown
8 A patient is complaining of blurred vision when looking to the left side. On lateral gaze,
the right eye moves properly but the left does not, and you notice nystagmus. What nerve
is affected?
A. Left 6th nerve (abducens)
B. Right 6th nerve (abducens)
C. Left 4th nerve (trochlear)
D. 3rd nerve (oculomotor)
Left lateral rectus paralysis

LR6SO4
9 A patient presented with symptoms of trigeminal neuralgia. Treatment?
A. Carbamazepine
B. Indomethacin
 Dementia

10 What is a reversible cause of dementia?

A. Pellagra (reversed with niacin B3 & zinc) Dementia Diarrhea Dermatitis Death
B. Creutzfeldt-Jacob’s disease
C. Multi-infarct dementia
Reversible Causes:
§ B 1 / 3 / 12 deficiency
§ Normal pressure hydrocephalus
§ Neurosyphilis
§ Chronic subdural hematoma
§ Hypothyroidism
§ Medications
§ Severe depression
11 What is the rate limiting enzyme for dopa synthesis?
A. Hydroxylase (tyrosine hydroxylase)
B. Decarboxylase
12 An elderly lady was admitted with myoclonus, weakness, incontinence, speech defect,
confusion, and decreased eating. She has history of valvular disease. Investigations reveal
low albumin. What is the cause of her functional decline?
A. End-stage dementia (corticobasal dementia) – the low albumin is d/t malnutrition
B. End-stage renal disease
C. End-stage liver disease
D. Age-related disability
E. End-stake stroke
13 A 72 y/o patient was brought by his son for evaluation of his dementia. He has decreased
concentration, apathy, and a depressed mood. O/E, the patient was euthymic, had slow
thinking, low verbal fluency, inability to recall recent events & had motor signs. What is
the type of dementia?Lewy body → dementia first + visual then motor. Parkinsons the
parkinsonism first then dementia later
A. Alcohol dementia (no motor signs)
B. Alzheimer dementia (patient does not realize he is forgetting)
C. Huntington dementia (no tremor, way younger)
D. Lewy body dementia (visual hallucinations not a must) cuz motor signs
E. Pseudodementia (know they are forgetting, they come alone to the clinic)

Clinical presentation: The sequence of symptoms is more variable than in most other types
of dementia. [2]
Dementia
Extrapyramidal motor symptoms (parkinsonism), such as:
Bradykinesia
Rigor
Visual hallucinations and paranoid episodes
↑ Sensitivity to neuroleptic medication and metabolic perturbation
Episodic impairment of cognition and/or vigilance
Rapid eye movement sleep behavior disorder (RBD)
Frequent falls
Neuromuscular
14 A lady has progressive proximal weakness throughout the day. Her speech is also
affected. On examination, her sensations are intact. What is the pathophysiology of this
condition? Myasthenia Gravis (cant lift her hand, cant climb her hair) Note: lambert
eaton is presynaptic calcium
NMJ disease (antibodies against post-synaptic Ach receptors)
15 A lady is complaining of inability to comb her hair. She has been feeling pain when
driving and has been having bilateral proximal muscle weakness. Diagnosis?
Myasthenia gravis
16 A patient has ptosis & is unable to move his eyes bilaterally. He is also unable to flex his
neck. What is the cause? Neck muscles are affected
A. Myasthenia gravis
B. Spiral polymyositis
Eye muscle weakness: most common initial symptom
 Triad of:
Ptosis
Diplopia
Blurred vision
Bulbar muscle weakness
Slurred speech
Difficulty chewing and/or swallowing
Proximal limb weakness
Rising from a chair
Climbing stairs
Brushing hair
Deep tendon reflexes are not affected.
Respiratory muscle weakness: causes dyspnea
17 A lady was admitted to the ICU 8 days ago for progressive breathlessness & inability to
raise her hand over her head. What investigation will you do?
A. Edrophonium test
B. 24 hours VMA test
Edrophonium test (Tensilon test)
Used to diagnose MG before AChR antibody test became the common method
Symptoms improve rapidly after administration of a short-acting acetylcholinesterase
inhibitor
High false positive rate
18 A lady complaining of ptosis & diplopia worsening in the evening. What test do you do?
Edrophonium test
19 A lady is complaining of weakness in her jaw and blurred vision (diplopia) that worsen
by the endof the day. What is the best initial test? MG
A. Neck ultrasound
B. Brain MRI
C. Chest CT
D. Echocardiography
E. CSF analysis
§ Myasthenia gravis (look for thymoma) -- ordered after diagnosing the patient with MG

Laboratory studies
AChR antibody test (most specific test)
80–90% of patients with generalized MG have antibodies [4]
100% of patients with thymoma have antibodies [6]
Other associated antibodies: anti-MuSK
Electrodiagnostics
Electromyography (EMG): shows decremental response following repetitive nerve
stimulation
Imaging
Chest CT: every newly diagnosed MG patient to rule out thymoma

§ Best diagnostic test is acetylcholine receptors)

20 A man is complaining of jaw numbness and tingling. He also has been noticing a change
in his voice after talking for a long time over the phone. What investigation should you do
for him? Voice fatigue in myasthenia gravis. Can even affect the bulbar muscles causing
slurred speech
A. Neck ultrasound
B. CT scan
Headaches
21 A 26 y/o male with history of recurrent headaches presented complaining of a severe
headache on the right side of his head. It started as a dull aching pain then became more
severe. It is now throbbing in nature & is associated with vomiting, nausea, and
photophobia. He developed hemiparesis of the left side of his body. What is the most
likely diagnosis?
A. Temporal arteritis
B. Subarachnoid hemorrhage
C. Migraine headache
D. Cluster headache
22 A patient has a history of unilateral pulsating headaches. She likes to be left alone when
she gets them. No symptoms of aura mentioned. What is the most likely cause?
A. Migraine
B. Tension headache
C. Cluster headache
Localization
Typically unilateral, but bilateral headache is possible
Especially frontal, frontotemporal, retro-orbital
Duration: usually 4–24 hours (rarely over 72 hours)
Course: progression of pulsating, throbbing, or pounding pain
Exacerbated by physical activity
Accompanying symptoms: photophobia, phonophobia, and nausea/vomiting
23 A patient is complaining of a band-like headache that improves with paracetamol. He
notes that he works for 12 hours a day. Diagnosis?
A. Tension headache
B. Migraine
C. Cluster headache
24 A female presents complaining of bitemporal headache for the past 2 years. The headache
was controlled for the first year with paracetamol 600mg & ibuprofen 400mg a day. For 1
year, the medications stopped helping and the headache is worsening. No associated
nausea or vomiting, and no red flags. What is the most likely cause?
A. Drug-induced headache
B. Tension headache
C. Migraine without aura
Medication-overuse headache is characterized by an increase in headache frequency
and severity, and increasing refractoriness to abortive and prophylactic pain
medications in patients with a prolonged history of chronic headache and medication
overuse. [6][7][8]
Headache characteristics may differ from the underlying chronic headache and often
include:
Migraine or tension-like quality
Change in type and location of pain during a single episode
 Worse pain in the morning
Associated neck and sinus pain

25 A woman presents with a unilateral band-like headache that occurs for a week to a
month’s time. No aura, photophobia, or other symptoms. Diagnosis?
A. Tension headache
B. Migraine
C. Cluster headache
Demyelinating Diseases
26 A patient presented with ascending weakness with a history of bloody diarrhea 1 week
ago. On examination, patellar and ankle reflexes are absent but plantar reflex was
preserved LP shows 8 lymphocytes & 158 mg proteins. Diagnosis?
Guillain Barre Syndrome
• Campylobacter infection GBS
• CSF high protein & low WBCs = GBS
• Nerve conduction study is helpful.
• Plantar reflex = upper motor = intact
• Treatment: IVIg / plasmapheresis to get rid of IG + supportive (never give steroids)
27 A female patient has history of lower limb weakness that has resolved. Afterwards, she
developed diplopia which resolved after a while. What is your diagnosis? Remitting
relapsing + young female
Multiple sclerosis in acute flare give steroids
Infections
28 An HIV +ve man presented with fever, expressive
aphasia, and altered consciousness. CT image attached
(showing multiple ring enhancing lesions). Diagnosis?

A. Toxoplasmosis
B. Pyogenic abscess
C. Tuberculoma
imaging: CT or MRI with contrast
Multiple ring-enhancing lesions (brain abscesses)
Lesions located predominantly in the basal ganglia and/or the subcortical white matter
29 An old man has CNS symptoms. A picture of a cyst & trophozoite was provided. What is
the cause?

A. Toxoplasmosis
B. Amoebiasis
C. Tinea
D. Hydatid cyst
E. Trypanosomiasis
30 Clinical scenario about TB meningitis (yellow productive cough + nausea & vomiting,
etc.). Which of the following is true?
A. Men are affected more than women
B. No focal lesion
C. Symptoms may resolve without treatment
During adulthood, TB infection rates are consistently higher for men than for women; the
male-to-female ratio is approximately 2:1
31 A patient complains of fever, headache, & neck stiffness. Diagnosis?
Meningitis
32 A patient presented complaining of abdominal pain, headache, and nausea. On
examination, he had palpable purpura. Lumbar puncture showed no organisms. Blood
culture showed kidney-shaped organism. MacConkey was negative.
A. Neisseria gonorrhea
B. Neisseria meningitidis Gram negative coffee bean shape
C. Neisseria lactamica
Diplococcus
Facultative intracellular
Aerobe
Bacterial growth on culture medium is usually challenging
Selective medium: Thayer-Martin agar
Maltose and glucose fermenter

Gram negative, dipolcocci arranged in pairs with aflatten or concave opposing edges
(kidny shape) intracellular inside polymorphoneuclear.
33 An adult has typical signs & symptoms of meningeal irritation suggestive of bacterial
growth. What is the most appropriate treatment?
A. IV ceftriaxone
B. Intrathecal penicillin

Tumors
34 A lady is complaining of morning headache. She had 1 myoclonic seizure but did not
need any respiratory or cardiovascular support. Her husband says that she has been
regurgitating recently & has been vomiting especially in the morning. Most likely
diagnosis?
A. Intracranial tumor
B. Pregnancy
C. GERD
Global
Cushing triad: irregular breathing, widening pulse pressure, and bradycardia
Reduced levels of consciousness
Headache
Vomiting
Papilledema
Psychiatric changes
 In infants: macrocephaly, bulging fontanel, sunset sign
Focal
Diplopia
Cerebral herniation syndrome: see “Subtypes and variants” below.

35 A male patient comes complaining of headache with vision changes for the past 2 weeks.
He also has recurrent episodes of vomiting, and problems with balance. Diagnosis?
Intracranial tumor
36 A patient has abnormal facial sensation (paresthesia), tinnitus, and right-sided ataxia. On
examination, he has loss of corneal reflex.(facial nerve) A tumor in which region can
cause these manifestations?
A. Left cerebellopontine angle
B. Right cerebellopontine angle any tumor in cerebellum causes ataxia on same side
C. Medulla
Etiology: most commonly vestibular schwannomas (acoustic neuroma), although
other cerebellopontine angle tumors may result in the same presentation
Clinical features
Unilateral hearing loss
Tinnitus
Vertigo
Headache
Loss of facial sensation
37 What cancer is most likely to metastasize to the brain? Lung → breast → melanoma
A. Liver
B. Stomach
C.
D. Renal
E. Skin (Lung (16-20) renal (7-10) / skin (7) -- uptodate)
Movement Disorders
38 A lady has a right-sided tremor. She has been moving slower than usual. Diagnosis?
Parkinson’s disease
39 What is true about Parkinson’s disease?
A. Symptom severity is related to the age (worsen with time)
B. M:F ratio is 4:1 / no biochemical test
C. MRI is diagnostic
D. The 3 cardinal signs for diagnosis are bradykinesia + rigidity + fine tremors
(resting pill-rolling tremor; not fine)
Parkinson’s tetrad: resting tremor + rigidity + bradykinesia + postural instability
40 A patient was brought in by his son who noticed that his father had been moving slowly
recently. On inspection, he had an expressionless face. He was not swinging his hands
when walking. The patient was diagnosed with Parkinson’s disease. Which of the
following is not a symptom of Parkinson’s disease?
A. Lead pipe rigidity
B. Festinant gait
C. Fine continuous rapid hand tremors
D. Pill-rolling tremor
41 Which is the most characteristic feature of Parkinson’s?
A. Spasticity
B. Jerky movements
C. Resting tremor that improve with work
42 A man in his 50s is complaining of resting tremors that
were evident during his visit. On examination, the
tremors persisted during activity. Which of the
following is true regarding his condition?
A. Levodopa is the first line treatment (or
carbidopa) – not first line; used for moderate-
severe cases
B. Men & women are equally affected (males >
females)
C. The patient will not be able to voluntarily
control it by movement
D. Alcohol worsens the tremor (no significant
relationship)

43 A patient with parkinsonism is scheduled for brain stimulation therapy. Which part of the
brain is affected in the disease?
A. Substantia nigra compacta
B. Substantia nigra reticularis
C. Caudate nucleus
D. Putamen
44 Parkinson’s is a disease with
multiple etiologies. 10% of cases
are hereditary. What is the protein
gene mutation that can cause
Parkinson’s disease?
A. Tau protein
B. Alpha synuclein
C. LTR4

Tau protein Alzheimer’s

TLR4 (Toll-Like Receptor 4) is a
protein-coding gene; diseases
associated with it = Pertussis &
pyelonephritis
45 A patient has an expressionless face, a shuffling gait, slow movement, and a tremor.
Treatment?
A. Carbidopa
B. Levodopa + carbidopa
46 A 72-year-old patient has a coarse tremor involving his head and body. It does not stop
with action but is relieved by one. What is the cause?
A. Parkinson’s disease
B. Normal for his age
C. Essential tremors
Clinical features
Localization: hands (∼ 90%), head (∼ 30%; "yes-yes” or "no-no” motion), voice (∼
15%)
Mostly bilateral postural tremor with a frequency of 5–10 Hz
Slowly progressive
Worse with sustained voluntary movement , stress or anxiety, fatigue, and caffeine
Improves with alcohol consumption
The essential tremor may be accompanied by an intention tremor and/or a resting
tremor .
Diagnostics: usually a clinical diagnosis of exclusion
Treatment [2]
Drugs of choice: propranolol or primidone
Alternatives (if propranolol and primidone are unresponsive or contraindicated)
Other beta blockers (e.g., atenolol, sotalol)
Other anticonvulsants (e.g., gabapentin, topiramate) including certain
benzodiazepines (e.g., alprazolam, clonazepam)
In drug-resistant cases
Deep brain stimulation (DBS)
Thalamotomy
Peripheral Neuropathy
47 A 50 y/o truck driver, known case of controlled DM for 10 years on Glucophage and
hypertension on labetalol, presents with loss of sensation & motor weakness of the LLs.
He also has jaundice & was scheduled for a cholecystectomy. O/E he also has loss of
sensations in the Uls. What is the cause of the neurological findings?
A. Diabetes
B. Prolonged sitting
C. Obstructive jaundice
D. Labetalol
48 A diabetic patient is complaining of pain in the mid-foot
that worsens on walking. It is associated with numbness.
On examination, there is tenderness over the third web
space that is elicited by palpating other areas as well. He
has history of gastric surgery and forgets to take his
multivitamins. Diagnosis?
A. Diabetic neuropathy
B. Morton’s neuroma
C. Plantar fasciitis
D. Vitamin B12 deficiency
Usually affects your foot between your 3rd and 4th toes. The main symptoms of Morton’s
neuroma include: a shooting, stabbing or burning pain feeling like a small stone is stuck
under your foot Some people may also have tingling or numbness in their foot. The
symptoms may be worse when you move your foot or wear tight or high-heeled shoes. It
often gets worse over time. Feeling crepitus while palpating the 3rd toe (Mulder sign),
commonly seen in runners, Tx is bar padded shoes
49 A diabetic patient has painful neuropathy and deranged renal function. What do you give
him for pain management?
A. Pregabalin affects the kidney function test
B. Tramadol safe in chronic kidney disease
C. Others
Initial therapy
First-line: tricyclic antidepressants (e.g., amitriptyline), SNRIs (e.g., duloxetine), or
gabapentinoids (pregabalin or gabapentin)
Adjuvants: topical analgesics (e.g., lidocaine, capsaicin)
Treatment failure: Consider tramadol. [6]
For further information, see “Pain management.”
50 A lady is complaining of numbness & weakness of her hands for the past 2 months. It was
initially affecting her right hand only but has become bilateral. The numbness is felt over
her thumb, index, and middle fingers, and is exacerbated when driving & during sleep.
What investigation will you do? (carpal tunnel syndrome)
A. Nerve conduction study
B. MRI of cervical spine
C. CT cervical spine
D. Chest x ray
Indications [2][12]
Diagnostic uncertainty or atypical presentation [2]
To rule out alternative diagnoses (e.g., polyneuropathy, radiculopathy)
Presurgical evaluation [12]
Modalities
Nerve conduction studies (confirmatory test): show impaired median nerve conduction
along the carpal tunnel [12]
Prolonged sensory and distal motor latency [14]
May be normal in patients with mild disease
Electromyogram [15]
Usually ordered to rule out alternative diagnoses
May show abnormal spontaneous activity (e.g., fibrillation potentials) or altered action
potential morphology [14]
51 A lady attempted suicide by cutting her wrist. She had
the following deformity afterwards. What other deficit
will you find?
A. Loss of little & ring finger extension at the MCP
joint
B. Loss of sensation over little & ring finger
(ulnar nerve)
C. Loss of flexion & extension of the little and ring
fingers

Median nerve injury cant make a fist ( like the pic but
the little finger and ring finger are fully flexed)

Lesions at the ulnar canal (located in the wrist)

Motor and sensory symptoms (i.e., sensory loss in
the palmar surface of the small finger and medial
aspect of the ring finger) possible

52 A man fell on an outstretched hand and had a fracture for which a cast was placed. After 3
weeks, he developed weakness on dorsiflexion and numbness over the lateral side of his
hand. What is the best next step?
A. Nerve conduction studies
B. Remove cast and do internal fixation
C. X-ray
D. EMG
I would say remove the cast then nerve conduction study.
53 A 70-year-old alcoholic patient is complaining of generalized vague pain. He reports that
he started drinking since the age of 10. His last episode of drinking happened in the past
24 hours. He denies any mood changes or medical illnesses. There were no findings on
examination. What is the cause?
A. Alcoholic dependence
B. Factitious disorder
C. Malingering disorder
D. Pain related to substance abuse
E. Pathological pain (pain related to a medical condition)
F. Pain due to mood disorder
Others
54 Which of the following symptoms indicate a poor
prognosis in a baby with spina bifida?
A.  anal tone
B. Hyperactive bladder
C. Low-set lesion
D. Flaccid paraplegia

The prognosis for individuals with SB depends on the number and severity of
abnormalities. Prognosis is poorest for those with complete paralysis, hydrocephalus,
and other congenital defects.
55 A baby was born with spina bifida. You find out that his mother was taking medications
during her pregnancy. What is the most likely cause?
Valproic acid
56 Which part is responsible for proprioception & awareness of joint position (on a
diagram)?
Dorsal column
57 A 45-year-old patient developed hemiplegia 1 day ago. Power in his lower limbs is 2/5.
He has no reflexes and Babinski is negative. What is the most likely cause?
A. Anterior spinal cord syndrome
B. Spinal cord compression
C. Infection
D. Tumor
E. MND
Acute (within hours)
Back or chest pain [9]
Spinal shock
Bilateral loss of temperature and pain sensation below the level of the lesion due to
damage of the spinothalamic tracts
Lower motor neuron deficits (flaccid paralysis) at the level of and below the lesion
Autonomic dysfunction (bladder, bowel, and sexual dysfunction, orthostatic hypotension)
Absent bulbocavernosus reflex
Late (after days or weeks)
Continued sensory and autonomic dysfunction
Upper motor dysfunction (spastic paraparesis or quadriparesis) below the level of the
lesion due to damage to the corticospinal tracts
Lower motor neuron deficits (flaccid paralysis) at the level of the lesion due to damage to
 the anterior horn
Hyperreflexia

58 Which reflex will be preserved in a brain-dead person?

A. Gag reflex
B. Corneal reflex
C. Pupillary reflex
D. Spinal reflex
59 A patient has weakness in both upper & lower limbs. Sensations are intact. She also has a
speech problem. What is the most likely diagnosis?
A. Cerebral tumor
B. Motor neuron disease (ALS)
C. Anterior column system disease
D. Spinal stenosis
E. Poliomyelitis
General disease characteristics
Both upper motor neuron (UMN) and lower motor neuron (LMN) signs are present (see
Upper motor neuron injury vs. lower motor neuron injury)
Constant disease progression: it usually starts in one arm and/or leg then progresses to the
contralateral side and eventually, after months or years, affects the respiratory system.
Early symptoms
Symptoms are highly variable and potentially non-specific (e.g., subtle vocal changes or
difficulties grasping objects)
Asymmetric limb weakness, often beginning with weakness in the hands and feet
Bulbar symptoms such as dysarthria, dysphagia, and tongue atrophy (20% of cases at
disease onset)
Pseudobulbar palsy with pseudobulbar affect may develop.
Fasciculations, cramps, and muscle stiffness
Weight loss
Split hand sign: a wasting pattern in which the muscles of the thenar eminence atrophy due
to degeneration of the lateral portion of the anterior horn of the spinal cord
Late symptoms
Cognitive impairment (approx. 15% of ALS patients meet the criteria for frontotemporal
dementia)
Autonomic symptoms (e.g., constipation, bladder dysfunction) may develop; the
mechanism of development is unclear. [1]
Life-threatening symptoms
Respiratory failure due to paralysis of respiratory muscles
Dysphagia due to bulbar weakness or pseudobulbar palsy
60 Irritation to the phrenic nerve will lead to shoulder pain. What is the root of the phrenic
nerve?
C3-C5
61 What is seen in a patient with an injury at T10-T11 level?
A. Weakness of ankle reflexes
B. Loss of superficial abdominal reflex (loss of sensation over abdomen)
62 A patient comes with lower back pain. On
examination, knee reflex is absent on the
right and +2 on the left. Also, sensations
are diminished over the medial aspect of
the right legbut are intact over the left leg.
What is the affected nerve root?
A. L2
B. L3
C. L4
D. L5
E. S1

63 Scenario about pudendal nerve block. What is the root of the pudendal
nerve?

A. L2, L3, L4
B. L3, L4, L5
C. S1, S2, S3
D. S2, S3, S4
64 A picture of neurotransmitters was
provided – question asking about pre-
ganglionic Ach receptors.

What is the common feature between

all the neurotransmitters?
A. Atropine is Ach antagonist
B. Neurotransmitters will be
recycled
C. All preganglionic have
nicotinic receptors for
acetylcholine

65 A man has drooping of the right eye. He cannot frown and is not sweating. Which nerve
is involved?
A. Right facial nerve
B. Left facial nerve
C. Right sympathetic chain HORNER SYNDROME
D. Left sympathetic chain
E. Right oculomotor nerve
66 A man had a decreased pupil size with a drooping eyelid, associated with decreased
sweating on the same side of the face. What is the diagnosis?
A. Horner’s syndrome
B. Bell’s palsy
C. Superior vena cava syndrome
D. Lambert Eaton Syndrome
SVC Syndrome:
B. Hemodynamic: edema of upper extremities & face / facial plethora / JVD /
orthostatic hypotension / syncope / renal failure
C. Neck congestion: dyspnea / cough & hoarseness // stridor / dysphagia
D. Neurological symptoms: headache / dizziness / confusion / visual impairment
Lambert Eaton Syndrome:
E. Proximal muscle weakness that improves with repeated muscle stimulation
o Hyporeflexia

Triad of Horner syndrome

Miosis (constriction of the pupil)
Occurs because the sympathetically controlled iris dilator muscle fails to
contract
Leads to anisocoria and a dilation lag on exam
Partial ptosis (drooping of the upper eyelid)
Occurs because the sympathetically controlled superior tarsal muscle fails to
keep the upper eyelid raised
It is milder than ptosis associated with oculomotor nerve or levator palpebrae
muscle lesions.
Anhidrosis (absence of sweating) or reduced sweating on the face and arm,
depending on the location of the lesion
Occurs because the sympathetic innervation of the facial sweat glands is
impaired
Seen in central and preganglionic lesions
Facial flushing due to vasodilatation
(Apparent) enophthalmos
Associated symptoms depending on the etiology:
Atrophy of arm and hand muscles
Pain in the neck or face
67 A patient presented with right-sided facial weakness & inability to express himself. He
also has loss of sensation over the big toe. Choose the possible affected area.

Broca’s area (+ primary motor cortex + primary sensory cortex)

Which of the following CT scan pictures show an intraventricular hemorrhage?
68 A (subdural hematoma) B C (epidural hematoma)

69 What investigation would you do for a lady presenting with abnormal behavior and
weakness?
CT brain

70 A man comes complaining of severe burning orbital pain for the past 10 days. He initially
had double vision and now has a drooping eye lid and is unable to open his eyes. On
examination, you notice mydriasis. His eye is deviated temporally & downwards. Pupils
do not react to light. MRI was done with angiography which were negative. What is the
next step?
A. Steroids
B. Cerebral angiography
C. Edrophonium test
D. EMG
E. Lumbar puncture
Tolosa-Hunt Syndrome steroids are used to reduce swelling

Definition: a syndrome of unknown etiology that is characterized by unilateral periorbital

headache and palsy of one or more oculomotor nerves
Etiology: unknown
Pathophysiology: granulomatous inflammation in the area of the cavernous sinus or the
superior orbital fissure
Clinical features
Severe retro-ocular pain
Eye muscle paresis (ophthalmoplegia)
Treatment: prednisone
71 A patient presented with burning pain in the back & radiating to the left anterior chest.
Diagnosis?
A. Herpetic neuralgia
B. T4 radiculopathy
Main symptoms: dermatomal distribution, typically affecting 1–3 dermatomes on one side
of the body (most commonly affects the cervical, trigeminal, thoracic, and lumbar
dermatomes) ; [5]
Pain [5]
The most frequent symptom and may precede the rash
Usually described as “burning”, “throbbing”, or “stabbing”
Erythematous maculopapular rash that quickly evolves into vesicular lesions [5]
Vesicles are initially clear.
Crusting and involution typically occurs between day 7 and 10
Additional symptoms [5]
Fever, headache, and fatigue
72 A 75 y/o male presented with a rash on his back representing a dermatomal distribution.
What do you do?
A. Give topical antibiotic
B. Give acyclovir (within 72 hours)
C. Blister scraping
D. Refer to a dermatologist
E. Give NSAIDs

Rash onset < 72 hours

Start oral antiviral therapy for herpes zoster in patients with clear indications.
Start IV antiviral therapy for herpes zoster for:
Immunocompromised patients
Disseminated zoster
Neurovascular involvement: e.g., VZV encephalitis, VZV vasculopathy, HZO with retinal
involvement
Antiviral therapy can also be considered in patients without clear indications.

Rash onset ≥ 72 hours

New vesicles continually appearing: same treatment as for rash onset < 72 hours
No new vesicles
Consider supportive care alone for patients with uncomplicated disease.
Consider antiviral therapy for herpes zoster in patients aged ≥ 50 years, with immune
deficiency, or evidence of complications (e.g., disseminated zoster, neurological
involvement).
Supportive care
Provide routine wound care and adequate analgesia for all patients.
Consider adjuvant corticosteroids in select patients.
73 Label the cerebellar vermis + cerebellar tonsil + 4th ventricle + medulla on the diagram.
 ------- Obstetrics & Gynecology -------
Obstetrics
Antenatal
1 What is the EDD of a woman whose LMP was on February 23rd?
A. November 30th
B. November 23rd
C. September 23rd
+ 7 days – 3 months + 1 year
2 A 28 y/o primigravida is at 30 weeks of gestation according to her LMP, but 34 weeks
according to her US scan done at 12 weeks of gestation. In this visit, her fundal height is
consistent with 32 weeks of gestation and so is the US. What is more informative of
accurate gestational age?
A. Fundal height
B. 1st trimester US
C. 2nd trimester US
D. 3rd trimester US
3 At what gestational week will you perform a dating US? 10-14 weeks
Between 11-14 weeks (8-11 weeks is better)

If you're pregnant in England you'll be offered an ultrasound scan at around 10 to 14

weeks of pregnancy. This is called the dating scan. It's used to see how far along in your
pregnancy you are and check your baby's development. The scan may also be part of a
screening test for Down's syndrome.
4 A 25 y/o pregnant woman at 18 weeks of gestation gave a history of still birth at 32
weeks of gestation (unknown cause). What do you have to look for?
A. GDM
B. Pre-eclampsia
C. Antenatal follow up regularly
5 30- year-old female G7P0A6, smokes cigarettes & drinks alcohol, presented to the clinic
because she is worried that her baby has Down Syndrome. US shows nuchal translucency
of 5.2 mm. Triple marker screen showed FP, estradiol, and hCG. Which of the
following will make you proceed to amniocentesis?
A. Alcohol
B. Smoking
C. Nuchal translucency
D. Triple marker screen (results not consistent with a specific disorder)
E. Multiple abortions
F. Mother’s age

Indications for amniocentesis:

- Women > 35 y/o at the time of delivery
- Abnormal nuchal translucency / quad screen / NIPT
- Rh-sensitized pregnancy to obtain fetal blood type or detect fetal hemolysis
- Evaluation of fetal lung maturity (lecithin:sphingomyelin – no longer done)

6 An expecting couple is worried that their child will have Down Syndrome as their relative
had just given birth to a child with Down’s. Best investigation?
Amniocentesis at 15-16 weeks (15-20 weeks)
7 A patient is afraid that her child will have Down Syndrome. What will indicate doing
amniocentesis?
+ve Triple Test (bHCG increased, estriol and AFP decrease)
8 A G3P1+1 L0, presents at 8 weeks of gestation. Her first pregnancy ended in a first-
trimester miscarriage, and her second ended in a stillbirth of a macrosomic baby. What
test will you perform now?
Fasting blood glucose

Diabetic embryopathy
Definition: Anomalies typically develop during the main embryonic period (especially
during blastogenesis) and include neural tube defects, small left colon syndrome,
caudal regression, and renal disorders (e.g., renal agenesis).
Onset: first trimester
Pathophysiology: hyperglycemia → inhibition of myoinositol uptake → abnormalities
in the arachidonic acid-prostaglandin pathway → birth defects and early pregnancy
loss
Cardiovascular defects: congenital heart disease
Transposition of the great vessels
Ventricular septal defect
Truncus arteriosus
Central nervous system defects: neural tube defects
Skeletal defects
Caudal regression syndrome: a congenital condition characterized by the partial or
complete absence of the sacrum and, to a lesser degree, the lower lumbar spine
 Clinical features: based on the spinal lesion the level and disease severity
Lower limb deformities (e.g., inverted champagne bottle appearance due to muscle
wasting) or foot deformities (e.g., club feet)
Mild to severe motor function impairment and paralysis
Anorectal malformations and aplasia or hypoplasia of the sacrum and/or
lumbosacral spine
Bowel and bladder dysfunction (e.g., neurogenic bladder, bladder incontinence)
Flattened buttocks (palpable absent coccyx gives a dimpling appearance to the
buttocks) and shallow gluteal clefts
May occur as part of other caudal syndromes (e.g., VACTERL, OEIS)
Other
Early pregnancy loss
9 G4P3 + A2 woman came to you. Her first pregnancy as terminated at 38 weeks (stillbirth)
with no anomalies. Her second pregnancy terminated at 8 weeks of gestation, and no
cause was found. Her third pregnancy was completed, and she delivered a baby with a
birth weight of 4.5 kg. What is the cause?
A. Increased glucose level
B. Chromosomal anomaly
10 What is the 50g-GTT cut-off value for
diagnosing gestational DM? >7mmol
fasting, >11mmol after 2 hours
A. 7.8 mmol/L
B. 6.6 mmol/L
C. 4.6 mmol/L
D. 8.8 mmol/L
* women with risk factor for GDM, to do 75 g OGTT
as early as possible in first trimester if she can tolerate ,
otherwise between 13-18 weeks, if result is normal then
repeat at 24-28 weeks of pregnancy

11 A pregnant lady with Hashimoto’s thyroiditis is on 0.125 thyroxine. She was stable before
pregnancy but is now having symptoms. Her T4 is normal but her TSH is . Next step?
A. Increase thyroxine dose to 0.175
B. Reassure her that these are symptoms of her pregnancy
C. Take FNA
In primary hypothyroidism, levothyroxine is gradually titrated according to serial TSH
measurements targeting a normal level, for example:
↑ TSH (suggests ↓ T4 activity): typically requires a dose increase
↓ TSH (suggests ↑ T4 activity): typically requires a dose decrease
In secondary hypothyroidism, dosage is titrated according to FT4 levels.
12 What ECG changes are seen in pregnancy?
A. Left atrial hypertrophy
B. Left axis deviation
C. Left strain
D. Left ventricular hypertrophy

ECG changes in normal pregnancy include a reduction in the mean values of PR interval,
sinus tachycardia, left axis deviation, inverted or flattened T waves and a Q wave in lead
DIII. HR, heart rate. Heart rate (HR) increases progressively throughout the pregnancy,
reaching a peak during the third trimester.
13 Which cardiac problem carries the highest mortality risk in pregnancy?
A. Mitral stenosis
B. Coarctation of the aorta
C. Aortic stenosis
§ Others with high risk (up to 50% mortality) are pulmonary hypertension / aortic
diseection / Marfan’s with significant aortic root involvement / myocardial infarction.
§ Moderate risk = moderate-severe MS / severe AS / mechanical heart valves
§ Minimal risk = ASD / VSD / PDA / corrected ToF / tissue valve prosthesis / pulmonary
& tricuspid valve disease / mild MS / arrhythmias
14 A pregnant lady at 8 weeks is complaining of
frequency & urgency. Best treatment?
A. Ampicillin (no longer used a lot
because of high resistance)
B. Penicillin
C. Ciprofloxacin (CI in pregnancy)
D. Gentamicin
E. Nitrofurantoin (used in the 1st & 2nd
trimester – afterwards cephalexin /
amoxicillin are used)
Nitrofurantoin from 0-12-24 weeks

15 A pregnant lady (13 weeks) has asymptomatic bacteriuria. How do you manage her?
A. Take a swab and treat accordingly
Amoxicillin OR nitrofurantoin (3-7 days)
16 A lady at 16-weeks of gestation has E. coli growth on urine culture. What is she at risk
of?
A. Perinatal mortality
B. Acute urinary tract infection
Both possible but higher risk of developing UTI (20-35%)
17 A pregnant lady has an asymptomatic bacteriuria (E. coli growth). What does that
increase the risk of?
A. Preterm labor
B. Perinatal mortality
UTI was not an option.

In pregnant women [58]

Increased risk of preterm labor and birth [59]
Hypertension and preeclampsia
Chorioamnionitis
18 A pregnant lady presents with diarrhea and is diagnosed with giardiasis. How do you
manage her?
A. Observation
B. Paromomycin
First trimester: if mild then just symptomatic; if severe then paromomycin
Second / third trimesters: paromomycin / nitazoxanide / metronidazole
19 Acute tubular necrosis in pregnancy (lady with dehydration)
Although, as previously discussed, ATN can occur in early pregnancy, it can arise in late
pregnancy as well. In the latter instance, ATN most commonly results from
preeclampsia, but it can also be caused by HELLP syndrome or by uterine hemorrhage
with abruptio placentae.
20 A 30-year-old woman, G2P1, at 37 weeks’ gestation mentions that her 3-year-old son has
just developed chickenpox. She is not certain whether she has had the disease herself.
Which one of the following is the next step in management?
A. Administration of varicella-zoster IgIM (Ideally, a VZV serologic test should be
conducted prior to administration of immunoprophylaxis among those women
who report no history of varicella – uptodate)
B. Measurement of varicella IgM level
C. Acyclovir tablets orally
D. Measurement of varicella IgG level IgG shows you if you have antibodies from a
past infection or from a vaccination (as per guidelines)
21 Which drug from the following is not safe in pregnancy?
A. Lithium
B. TCA
22 What is the most important side effect of valproic acid during pregnancy?
Neural tube defects
23 A woman received an injection after the delivery of her baby. What could the problem
be?
Mother is Rh - & child is Rh +

Anti-D immunoglobulin (RhoGAM)

Background
Pathophysiology: See “Rhesus incompatibility” above.
Anti-D prophylaxis protects newborns in subsequent pregnancies.
Only indicated in unsensitized mothers
Indication and implementation
Anti-D prophylaxis should be administered during the 28th week of gestation and within
72 hours following the birth of an Rh-positive baby.
The efficacy of anti-D prophylaxis relies on antibody-mediated immunosuppression.
Further indications in Rh negativity
Following a miscarriage, ectopic pregnancy, or termination of pregnancy
Bleeding during pregnancy
Following invasive procedures (e.g., amniocentesis, chorionic villus sampling)
Dosage
Standard dose: 300 μg (1500 IU) IV/IM
If whole fetal blood is > 30 mL (i.e., fetal RBCs > 15 mL): 300 μg (1500 IU) IM should be
given for every 30 mL of fetal blood volume.
24 A pregnant lady with twin pregnancy at 20 weeks GA presented with abdominal
discomfort. US showed polyhydramnios and a baby larger than the other. In which type
of twin pregnancy does this phenomenon occur?
A. Monochorionic monoamniotic
B. Monochorionic diamniotic
 Twin-to-twin transfusion syndrome [3]
Affects 10–15% of monochorionic twin pregnancies (twins that share the placenta)
Blood is continuously shunted from one twin to the other through vascular anastomoses on
the shared placenta, posing a risk to both fetuses.
Recipient twin
Polycythemia
Hypervolemia
Polyhydramnios in diamniotic pregnancies
Donor twin
Anemia
Growth retardation
Hypovolemia, dehydration (stuck twin or cocooned appearance)
Oligohydramnios in diamniotic pregnancies
Cord entanglement: can occur only in monoamniotic twin pregnancies
Increased risk of neonatal morbidity (growth restrictions, prematurity, cerebral palsy,
congenital abnormalities) and mortality

Identical twins share one placenta. Most commonly, they are in different sacs of fluid,
the amniotic sacs. This type of twin pregnancy is called monochorionic (one placenta)
and diamniotic (two sacs).
25 A pregnant lady comes at 30 weeks GA. O/E the fundal height = 22 weeks. Fetal US
shows a distended bladder with dilated ureters. AFI = 0 oligohydramnios. What is
the cause of the findings?
A. Renal agenesis no distended bladder, lack of urine
B. Posterior urethral valve
C. Spina bifida
D. Gastroschisis

Clinical features [2]

Most common cause of urinary tract obstruction in newborn males
Respiratory distress secondary to pulmonary hypoplasia in cases with severe obstruction
(see “Potter sequence”)
Abdominal distention due to bladder distention
Late manifestations:
Difficulty voiding, poor urinary stream
UTIs → urosepsis
Diurnal enuresis
Failure to thrive
26 Which of the following
conditions is most likely to
reflect a fetal anomaly?
A. Oligohydramnios
B. Polyhydramnios
C. Maternal cholestatic
jaundice
D. Maternal diabetes
mellitus
 Most women with polyhydramnios will not have any significant problems during their
pregnancy and will have a healthy baby. But there is a slightly increased risk of pregnancy
and birth complications, such as: giving birth prematurely (before 37 weeks) your waters
breaking early.

27 A lady smoking 17 cigarettes / day is pregnant. What advice will you give her regarding
the biggest risk on her pregnancy due to smoking?
A. Preeclampsia
B. IUGR
C. Congenital anomalies
D. Oligohydramnios

Maternal causes of iugr

Substance use (e.g., alcohol, cigarettes, cocaine, heroin)
Teratogenic drugs: ACE inhibitors, carbamazepine, phenytoin, warfarin
Systemic diseases resulting in placental insufficiency (see below)
28 A G6P3+A2 lady at 28 weeks of gestation came for a follow up. USS showed that the
baby’s head circumference corresponds with 27 weeks & his body with 24 weeks. AFI =
9. What is the cause of the discrepancy?
A. Wrong date of 1st US (could be if symmetrical)
B. Tracheoesophageal fistula
C. Placental insufficiency (asymmetrical IUGR)

D. Chromosomal defect
E. TORCH
28 What is the fetal lie when the presenting part is smooth & the fetal heart is around the
level of the umbilicus?
A. Breech
B. Cephalic
C. Transverse
D. Other
29 A G6P3+A2 lady at 28 weeks of gestation (LMP) came for a follow up. USS showed that
the baby’s head circumference & body correspond with 24 weeks. The first USS indicates
that she is at 24 weeks. The fetus is viable and moving. AFI = 9. What is the cause of the
discrepancy?
A. Wrong LMP
B. Tracheoesophageal fistula
C. Placental insufficiency
D. Chromosomal defect
E. TORCH
Bleeding
30 A pregnant lady at 30 weeks GA presented with heavy vaginal bleeding & crampy
abdominal pain. She continues to bleed heavily with clots. Next step in management?
A. Fetal US
B. Fetal heart tone
C. Maternal pulse rate & BP
D. Vaginal examination

Initial management of antepartum hemorrhage [1][2][3]

If unstable: ABCDE approach and immediate hemodynamic support, including
emergency blood transfusion
31 A 35 y/o lady G2P1 at 30 weeks of gestation presented with acute abdominal pain in the
lower pelvic & back. She had some vaginal blood spotting. She has a brother with sickle
cell anemia. Diagnosis?
A. Acute sickle crisis
B. Hydronephrosis
C. Placental abruption
Maternal symptoms
Sudden onset of continuous vaginal bleeding (revealed abruptio placentae)
In up to 20% of cases, the hemorrhage is mainly retroplacental and vaginal bleeding
does not occur (concealed abruptio placentae). [4]
Sudden onset of abdominal pain or back pain
Uterine tenderness
Hypertonic contractions (rigid uterus), premature labor
Fetal distress (60% of cases) [4]
Possible diminished or absent fetal movement
Decelerations on fetal heart monitor

32 A 28-year-old lady came with fresh vaginal bleeding for 2 hours at 37 weeks of gestation.
The ultrasound showed a viable pregnancy with an oblique lie. What is the most likely
diagnosis?
A. Placental abruption
B. Placenta previa
 Sudden, painless, bright red vaginal bleeding
Usually occurs during the 3rd trimester (before rupture of the membranes)
Initial bleeding episodes are often self-limited and recur during the onset of labor
Soft, nontender uterus
Usually no fetal distress
33 A G4P3 woman came at 32 weeks of gestation complaining of brownish vaginal
bleeding. She has no abdominal pain. On examination, she was stable and her uterus was
soft & not tender. Fetus was breech. Her cervix was long and closed with no visible
bleeding. USS showed a viable fetus. What is the most likely cause?
A. Excessive show thin effaced cervix
B. Placenta previa
C. Abruptio placenta
34 What is a risk factor of placenta previa?
A. Young age
B. History of placenta previa
Other risk factors:
- Uterine scars (previous surgery / LSCS / fibroid removal / D&C)
- Multiple gestation
- Age 35 or older
35 A lady at 32-weeks of gestation with a marginal placenta presented with bleeding. CTG is
reassuring. What is your next step?
A. Dexamethasone and admit her
B. Dexamethasone and send her home (amboss doesn’t say admit if less than 34..)
C. Antibiotic
D. Induce her
You only send patients with placenta previa home (on their responsibility) if:
- They are asymptomatic
- Live close to the hospital
< 34 weeks' gestation
Single course of antenatal steroids (IM betamethasone or IM dexamethasone) [8][9][10]
Improves neonatal survival, fetal lung maturity, and surfactant production
Indication: 24 0/7 weeks' to 33 6/7 weeks' gestation with a risk of delivery within the next
7 days

> 34 weeks' gestation

Admission for observation and assessment of cervix and fetal wellbeing
Discharge if preterm labor is not confirmed and mother and fetus are well
36 A female at 39 weeks of gestation had passage of mucus & blood clots. She is stable and
her CTG is reactive. Diagnosis?
A. Labor
B. Placental abruption
C. Placenta previa
D. Show
Bloody show: A blood-tinged mucous plug may be discharged when the cervix
shortens and dilates
Hypertension
 Chronic hypertension / Hypertension in pregnancy: antihypertensives
- Pre-eclampsia without severe features: deliver if > 37 weeks; meds if < 37 weeks
- Pre-eclampsia with severe features / eclampsia: magnesium sulfate induce

- If < 36 weeks: give dexamethasone first

Hypertension in Pregnancy
- Antihypertensives in pregnancy: labetalol / methyldopa / nifedipine / hydralazine
- Severe hypertension / eclampsia: magnesium sulfate (monitor reflexes + RR + urine
output) – antidote is magnesium sulfate
37 A pregnant female in the 2nd trimester has a BP 150/90 mmHg. What do you give her to
prevent preeclampsia?
A. Aspirin low-dose aspirin at 12 weeks gestation
B. LMWH
Aspirin for preeclampsia prophylaxis [1][10][18]
Indications [10]
≥ 1 high-risk feature or ≥ 2 moderate-risk factors for preeclampsia.
Regimen
Initiate low-dose aspirin between 12–20 weeks' gestation (optimally before 16 weeks)
38 A G6P5 woman at 32 weeks of gestation presented with a blood pressure of 149/99
mmHg. On examination, there were fundoscopic hypertensive changes (AV nipping &
exudates). She had ++ proteinuria & had  creatinine (1.6).This is a severe feature No
previous records of herBP.
Diagnosis?
A. Chronic hypertension with renal complications
B. Preeclampsia
C. Pregnancy-induced hypertension
D. Gestational hypertension
How will you manage her?
Deliver her I think stabilize
then deliver
Preeclampsia with severe
features [15]
Severe hypertension (systolic
BP ≥ 160 mm Hg or diastolic
BP ≥ 110 mm Hg)
Proteinuria, oliguria
Headache
Visual disturbances (e.g.,
blurred vision, scotoma)
RUQ or epigastric pain
Pulmonary edema
Cerebral symptoms (e.g.,
altered mental status, nausea,
vomiting, hyperreflexia, clonus)
39 A pregnant lady developed gestational hypertension & was managed with labetalol. What
do you tell her after she delivers her baby?
A. Hypertension will resolve after 4-6 weeks postpartum
B. Hypertension will resolve after 12 weeks postpartum (google)
C. She should take labetalol till her next pregnancy
D. She cannot take OCPs till her hypertension resolves
E. She will develop chronic hypertension
Labor
Labor definition: The presence of strong regular painful contractions resulting in progressive
cervical change (3-5 contractions in 10 minutes)
Stages:
• Latent Stage 1: till 4 or 6 cm (< 20 hours in primi; < 14 hours in multi) if it is
prolonged: balloon / amniotomy / misoprostol / oxytocin
• Active Stage 1: till 10 cm (1.2 cm / hour in primi; 1.5 cm hours in multi) if >5 hours
oxytocin if it fails, go for c/s
• Stage 2: full dilation till delivery of the baby (3 hours for primi; 2 hours for multi – add
1 hour if she took an epidural) if prolonged give oxytocin if it fails: c/s if -ve station;
instrumental if +ve station)
• Stage 3: placental delivery (<30 minutes) – signs of placental separation (gush of blood
+ cord lengthening + uterine fundal rebound) --- active management of 3rd stage
(oxytocin 10 units + Brandt-Andrew Maneuver which is controlled cord traction +
uterine massage) check if placenta is complete if incomplete, manual evacuation
if you can’t then ERPOC
Analgesia:
• Paracetamol
• Pethidine IM
• At around 4cm: epidural
• NO (but temporary measure only)
40 When do you say a patient is in labor?
Based on the amount of contractions and dilatation
41 A pregnant lady at 38 weeks GA called her doctor because she had uterine contractions
that started 3 hours ago but have stopped. She had the same contractions yesterday. What
is your diagnosis?
A. False labor
B. True labor
C. Arrest of active labor
D. Prolonged active labor
E. Prolonged latent labor
Braxton Hicks contractions (false labor)
Physiological; begin in the second or third trimester
Irregular, uncoordinated uterine contractions of moderate intensity (helps with fetal
positioning)
Frequency: typically ≤ 2 times/hour
Duration: ≤ 1 minute
Do not increase in frequency, intensity, or duration.
Cervical changes are absent
Typically stop with rest, walking, and/or a change in position.
42 What is a risk factor for preterm labor?
Previous preterm
43 What is cervical cerclage?
It is a gynecological procedure to prevent preterm delivery.
44 A pregnant lady at 30 weeks GA presented with SROM 2 hours ago. Uterine contractions
are present. Cervix was 5cm dilated, and estimated fetal weight is 1.2 kg. What is your
next step in management?
A. Betamethasone
B. Tocolytics
C. C/S
D. Indomethacin
45 A lady at 32-weeks of gestation was admitted because of mild fresh bleeding. Her
placenta is posterior. What do you give her?
Dexamethasone & tocolytics (for maturation of fetal lung)

Indications: recommended for up to 48 hours to facilitate administration of antenatal

corticosteroids in preterm labor and/or transportation to another medical center [13]
≤ 32+0 weeks' gestation
First-line therapy: indomethacin or nifedipine (administered if indomethacin is
contraindicated or its tocolytic effect was insufficient)
Alternative: terbutaline (administered if nifedipine was used as first-line therapy)
> 32+0 and ≤ 34+0 weeks' of gestation
First-line therapy: nifedipine
Alternative: terbutaline
46 A lady with history of chorioamnionitis presented with PPROM at 32 weeks. She is
afebrile & CTG is reassuring. Baby is vertex. What do you do?
A. Dexamethasone & tocolytics (contraindicated because of PPROM)
B. Dexamethasone & antibiotics (ampicillin & gentamicin)
Antibiotics [2]
Indicated only for as prophylaxis against group B streptococcus (GBS) or in preterm
premature rupture of membranes (PPROM) [2]
47 Which drug is not a tocolytic?
A. Nifedipine
B. Indomethacin
C. Oxytocin
D. Terbutaline
48 A 35-year-old G4P3 came at 35 weeks of gestation with ruptured membranes. Her
previous 3 pregnancies were delivered at 37, 38, and 36 weeks respectively. She is a
known case of diabetes. What is a risk factor for her premature rupture of membranes?
A. > 35 years
B. DM
C. Previous history of PROM
D. Multiparity
49 A 28 y/o primigravida at 38 weeks of gestation noticed leakage of fluid 2 hours ago. What
will be your next step of management?
A. Admit her & induce labor immediately
B. Admit her to the labor ward & induce her after 24 hours you wait for natural
induction
C. Admit her to the antenatal ward & wait until 40 weeks of gestation
D. Discharge her home & give her an appointment in the OB clinic after 1wk

Expectant management for up to 12–24 hours is reasonable in otherwise uncomplicated

pregnancies and in the absence of infection
50 What do you do during delivery in case the mother was +ve for chicken pox?
Give immunoglobulins

51 A 24 y/o, G5P4, is in labor. Cervix is dilated to 9cm, and she is well-effaced. She has
been in labor for 8 hours and is now requesting analgesia. What will you do?
A. Pethidine injection IM
B. Epidural analgesia
C. Pudendal block
D. Oxygen & nitric oxide
It is not preferred to give pethidine after 7-8 cm as it crosses the placenta. It has a duration
of action of 2-4 hours so should be ideally given at least 3 hours before birth to prevent
the baby falling asleep.
52 A primigravida is requesting an epidural. What do you give her before it?
A. Antacid delayed gastric emptying in pregnant woman, aspiration pneumonitis is a major
cause of anesthesia related deaths in obstetrics
B. Antibiotics
53 A lady in labor got an epidural (lignocaine) after which she developed hypotension (70/50
mmHg). What will you NOT do?
A. Displace the uterus to the left side
B. IV fluids
C. Trendelenburg position 10 degrees (it helps spread of epidural thus worsens the
hypotension – instead you can put her in reverse trendelenburg)
D. Titrated phenylephrine
54 A woman is in the first stage of labor when you notice the fetal heart rate dropping.
Investigations showed low platelets. What analgesia will you give her?
A. General anesthesia
B. Para-cervical
C. Pudendal block
D. Epidural?????
General anesthesia can be used in place of neuraxial anesthesia if the patient requires C-
section and the platelet count is above 50,000/ul, but below the institutional threshold for
neuraxial anesthesia. However institutional guidelines for epidural or spinal anesthesia often
require a higher value, usually between 70,000-100,000.
55 What pelvic type predisposes to deep transverse arrest?
A. Gynecoid pelvis
B. Android pelvis bc it’s the most common type of pelvis
C. Anthropoid pelvis
n Deep transverse arrest most common type of pelvis found is Android pelvis as it is
the commonest type of abnormal pelvis found
56 A lady in labor had increasing contractions and her cervix dilated from 3 cm to 10 cm.
CTG did not show any accelerations or decelerations and is showing a variability of 10.
What do you do?
A. Encourage the mother to push
B. Give her 10% dextrose saline
C. Give her oxytocin
Normal ctg
Baseline rate: 110–160 bpm
Moderate baseline FHR variability (amplitude 6–25 bpm)
No late or variable decelerations
Early decelerations or accelerations may be present or absent

Acceleration (CTG) [16]

Description: a normal temporal increase in the FHR from the baseline by > 15 bpm for
more than 15 seconds but less than 10 minutes if the gestational age is > 32 weeks, or by >
10 bpm for more than 10 seconds if the gestational age is < 32 weeks
Interpretation
The presence of > 2 accelerations within a span of 20 minutes indicates a reactive fetal
heart rate tracing.
If the acceleration lasts longer than 10 minutes, it should be considered a baseline change
in the fetal heart rate.

Reassuring fetal status

A fetal heart tracing that shows a good beat to beat variability (> 6 bpm), > 2 accelerations
within a 20 minute period, and no evidence of fetal distress (e.g., fetal bradycardia, fetal
 tachycardia, late or variable decelerations, sinusoidal pattern) Indicates fetal well-being.

57 A woman comes in labor. She is fully dilated & fully effaced, and she is having adequate
contractions. Baby is at station +3 and is in occipito-anterior position. CTG shows normal
variability but no accelerations. Management?
A. Encourage the mother to push
B. IV oxytocin
C. C/S
58 A PG lady came with 3hr history of ROM. Her cervix was fully effaced & dilated to 5cm,
station -1, and she had contractions 1 contraction in 3 minutes lasting 45s. After 4 hours,
her cervix was 7cm dilated, the baby was at station 0, and her uterine contractions were
occurring at a rate of 2 in 5 minutes lasting 60s. No molding of fetal head. Diagnosis?
A. Obstructed labor
B. Prolonged first stage of labor
C. Prolonged latent phase of labor
For a PG, the cervix should dilate at a rate of 1 cm / hour so she should have been at 9cm
after 4 hours
first stage starts with uterine contraction
latent: until 4/6 cm
active: ends at 10 cm
59 A woman has been in labor for 8 hours. Her cervix is 10cm, the membrane is ruptured,
and she is having contractions every 10-15 minutes. Next step?
A. IV oxytocin
B. Cervix prostaglandin
C. Cesarean section
D. Follow her regularly

Membrane sweeping (shortens time to onset of labor)

If the cervix is still unfavorable: cervical ripening with prostaglandin E1 or E2 (e.g.,
misoprostol)
Maternal oxytocin infusion
Consider amniotomy (only if the cervix is partially dilated and completely effaced, and the
fetal head is well applied)
Administer under fetal heart rate monitoring.
60 A lady in labor is having uterine contractions every 5-6 min lasting 30s. Cervix = 7cm;
station = +2. Membranes are not ruptured. Next step?
A. Rupture the membranes
B. Give oxytocin
C. C/S
61 A multigravida at 40+2 weeks presents in labor. She is 6cm dilated and 60% effaced.
(some scenario to confuse you about obstructed labor). Next step?
AROM
62 A pregnant lady receiving an oxytocin infusion started having 6 contractions in 10
minutes. What should you do? Should be <5 in 10 minutes
Stop oxytocin infusion
63 How does labor affect the umbilical artery flow & the intervillous spaces?
A. No change in either
B. Both 
C. Umbilical artery flow  but intervillous space 
D. Umbilical artery flow  but intervillous space 
E. Umbilical artery flow: no change, but intervillous space 
64 What maneuver is useful in the 3rd stage of labor?
Brandt Andrews (to determine if the placenta has separated, firm traction is applied to
the umbilical cord with one hand while the other applies suprapubic counterpressure)

65 A primigravida came in labor. She had 1 contraction every 3 minutes lasting 45 seconds
each. Her cervix was 4 cm dilated and the baby was at station -2. After 4 hours, her
contractions had increased to 2 in 5 minutes lasting 45 seconds each. The cervix was 7cm
dilated and the baby was at station -1. There was caput formation & grade 3 molding.
Fetal CTG is reassuring. Urinary catheter could not be inserted. Next appropriate step?
A. IV oxytocin
B. Paravaginal prostaglandin
C. LSCS due to obstructed labor
D. Wait for normal delivery

≥ 6 cm cervical dilation with ruptured membranes and no cervical change after one
of the following:
≥ 4 hours of adequate contractions (≥ 200 Montevideo units)
> 6 hours of inadequate contractions
Usually due to abnormalities of the 3 P's of labor

Breech presentation:

Types:
• Complete: hips & knees flexed
• Incomplete: hips flexed; 1 knee flexed & 1 knee
extended
• Frank: hips felxed but knees extended
• Footling: hips extended
Management:
• Footling / incomplete: elective C/S
• Complete / frank: ECV at 37 weeks if no
contraindications if failure or contraindications
then C/S
66 A woman at 39 weeks of gestation has a complete breech baby. The membrane is intact,
and her cervix is 2 cm (or 4 cm) dilated. CTG is reactive, showing good fetal heartbeat.
The baby weighs 3.8 kg and the placenta is anterior. What will you do?
A. ECV then CS
B. ECV then wait for spontaneous labor
C. Elective C/S
D. Wait for NVD
67 A pregnant lady comes to the ER in labor with her cervix 3 cm dilated. Detailed USS
shows footling presentation. Her cervix is 3cm dilated. Management?
A. Elective C/S
B. ECV & induction
C. ECV & wait for spontaneous labor
Same question with amniotic fluid of 4 (oligo)? Still elective C/S
• Contraindications to ECV:
o Placent previa / significant 3rd trimester bleed
o Ruptured membrane / PROM / preterm
o IUGR
o Placental insufficiency
o Oligohydramnios
o Non-reassuring CTG
o Fetal anomalies
o Severe hypertension
o Previous uterine surgery
o Multiple pregnancies
o Hyperextension of fetal neck
o Any other contraindication to normal delivery
• ECV complications:
o Umbilical cord entanglement
o Placental abruption
o PROM
68 What is a contraindication of ECV?
Oligohydramnios (anterior placenta is not a CI for ECV)
69 What is a contraindication to
induction of labor?
A. Fetal weight 3,800 g
B. Amniotic fluid index 15cm
C. Cervical length 4cm
D. Posterior placenta 1cm away
from the os

70 A pregnant woman comes in labor. Fetal heart rate is decreased. The baby is at station +2
and is in left occipito-transverse position. What instrument do you use?
A. Simpson’s forceps molded,
B. Kielland forceps
C. Vacuum
- Kielland forceps are useful for rotations because of their minimal pelvic curve and
sliding lock. A sliding lock is helpful when there is asynclitism
- Simpson type forceps, which have long tapered blades, tend to be the best fit for a
molded head because of the less concave cephalic curve. Used in OA
- Vacuum extraction is used when a relatively easy extraction is anticipated (eg,
occipito-anterior position with no signs of relative cephalopelvic disproportion).
Wrigley – low and outlet, +2, cesearan
Simpson – traction only, molding, +1
Keilland – traction and rotation
71 What complication is seen more in forceps delivery than vacuum delivery?
A. Facial palsy
B. Intracranial hemorrhage
C. Cephalhematoma
CTG
72 A pregnant lady’s CTG showed the following (late decelerations). What is the most
likely cause?

Uteroplacental insufficiency (placental abruption)

73 A pregnant woman comes in labor. A picture of a CTG is attached – showing
decelerations at the same time of the contractions. What is the cause of this CTG?

A. Abruptio placenta
B. Head compression

74 A primigravida came fully dilated & effaced. The fetus descending well as he moved
from a +1 to a +3 station. CTG attached showing early decelerations). What is the cause?

A. Fully dilated cervix (normal progression of labor)

B. Head deflexion
C. Cord prolapse The attached CTG is variable decel … so Cord prolapse ..
D. Obstructed labor but if the exam showed early decel as described in the stem
… then A and B are both correct … lloll

75 What can cause this CTG?

A. Cord compression
B. Primary CNS dysfunction
Reduced variability can occur due to central nervous system hypoxia/acidosis and resulting
decreased sympathetic and parasympathetic activity, but it can also be due to previous
cerebral injury [23], infection, administration of central nervous system depressants or
parasympathetic blockers

inimal variability
< 6 bpm
Sleeping fetus
Effects of opioids or magnesium
Fetal hypoxia
76 What drug will NOT cause decelerations in the CTG?
A. Diazepam
B. Pethidine
C. Paracetamol
77 Which of these drug does not decrease variability on CTG?
A. Indomethacin
B. Pethidine opioid
C. Magnesium sulfate
D. Diazepam
78 A pregnant lady was 38 weeks of gestation. She was given diazepam 5mg last night and
received indomethacin 37 mg today. CTG afterwards showed FHR of 190 bpm &
reactive. Afterwards, she received IV magnesium sulfate and IM pethidine which further
decreased the FHR to 150 bpm. Which drug does not (or is the least likely) to decrease
the baby’s heart rate?
A. Pethidine
B. Diazepam
C. Magnesium sulfate
D. Indomethacin
79 A woman presents in labor. CTG attached (no accelerations; normal heart rate; no
variability). What will make you think of hypoxia?
A.  acceleration
B. Variability  / 
C. Variable deceleration
D. No acceleration
E. Contractions

minimal variability
< 6 bpm
Sleeping fetus
Effects of opioids or magnesium
Fetal hypoxia

marked variability
> 25 bpm
Fetal hypoxia
Umbilical cord compression
May precede a decrease in variability
80 What is an advantage of a midline episiotomy over mediolateral ones?
A. Less bleeding & easier repair
B. Common practice
C. Gives more room for delivery
D. Lower risk of injury of the anal sphincter
 Post-Partum
81 A 25 y/o female collapsed after delivering a baby. What is your first step in management?
A. Check the records for previous history of drug use
B. IV adrenaline
C. Maintain her airway & breathing
82 A 38 y/o primigravida gave birth to a baby after 12 hours of labor. He weighed 3.8 kg.
She lost 1,800 mL of blood (PPH). No genital lacerations. What is the most likely cause
of her PPH (boggy uterus)?
A. Age > 35 years
B. Baby weight > 3.5 kg
C. Duration of labor (12 hours)
D. Primigravida
E. Prolonged labor (2nd & 3rd stage – excluding 1st)
Risk factors [7] uterine atony
Overdistention of the uterus
Large for gestational age newborn (> 4000 g)
Multiple pregnancies
Polyhydramnios
Exhausted myometrium
Multiparity
Postterm pregnancy
Prolonged delivery
Prolonged oxytocin use
Anatomical abnormalities
Fetal, uterine, abnormal placental implantation
Uterine leiomyomas
Infection: e.g., chorioamnionitis
Other
Medications lowering contractions (e.g., anesthetics, MgSO4)
Preterm delivery
Maternal BMI > 40 kg/m2
84 A woman developed fever and abdominal pain on day 3 post-cesarean section. She also
reports that his lochia has become white. She has history of chlamydia and other
infections. On examination, she has adnexal and parametrial tenderness. She also had
breast tenderness. What is the most likely diagnosis?
A. Tubo-ovarian mass
B. Endometritis
C. Vaginitis
D. Breast abscess

Lower abdominal/pelvic pain

AUB
Fever (if peritonitis or pelvic abscesses develop)
Infertility
Physical examination
Testing for typical pathogens (e.g., chlamydia)
Endometrial biopsy (to evaluate chronic endometritis that is unrelated to pregnancy)

85 A woman post C/S developed postpartum fever associated with white lochia and lower
abdominal tenderness. What medications will you give her?
A. IV clindamycin & gentamycin
B. IV ciprofloxacin
C. Ciprofloxacin and doxycycline
(chronic disease may be treated with doxycycline)

Mild to moderate cases (outpatient treatment) endometritis

One single dose of IM ceftriaxone and oral therapy with doxycycline
Addition of metronidazole should be considered in some cases (e.g., patients who recently
underwent gynecological procedures).
Severe cases (inpatient treatment): clindamycin PLUS gentamicin
86 What causes episiotomy suture breakdown after 5-6 days?
A. Trauma
B. Infection
C. Hematoma
D. Suture allergy
87 A 24 y/o female, now 2 weeks post-partum, feels that her baby is an angel and God is
asking her to kill him. Best method of management?

A. ECT
B. Haloperidol
C. TCA
For post-partum psychosis
Hospitalization is generally indicated, especially if there is a risk of suicide and/or
infanticide. [96]
Pharmacotherapy
Usually antipsychotic medications and/or mood stabilizers (e.g., lithium) [96]
Benzodiazepines may be used for acute symptom management. [96]
ECT may be used in certain cases, e.g.: [96]
Severe symptoms (e.g., catatonia, severe psychotic depression)
Poor response to pharmacotherapy
Patient preference
 Gynecology
Early Pregnancy Problems

1 What is the definition of a miscarriage?

A. Loss of pregnancy within the first 20 weeks
B. Loss of pregnancy < 22 weeks
C. Loss of pregnancy < 24 weeks
D. Loss of pregnancy < 26 weeks
2 A 24-year-old PG presents to A&E with a history of 8-week amenorrhea followed by
heavy vaginal bleeding and severe, crampy abdominal pain. On examination, her heart
 rate is 110/min and blood pressure is 120/80 mm Hg. The uterus is bulky. The cervix is
dilated and there is active bleeding from the cervical os, but no tissue has been expelled.
Which of the following is the most likely diagnosis?
A. Inevitable abortion
B. Threatened Abortion
C. Incomplete abortion
D. Missed Abortion
3 A female presented with vaginal bleeding and crampy abdominal pain. Her LMP was 6
weeks ago. Home pregnancy test was +ve 2 days ago. O/E the uterus size is = 6 weeks
GA. The cervix was closed. Fetal heart was present. What is your diagnosis?
A. Missed abortion
B. Threatened abortion
C. Incomplete abortion
D. Complete abortion
4 A young lady came with 2-hour history of bleeding and lower crampy abdominal pain.
US showed a sac with present fetal heart sounds, and 2cm subchorionic hemorrhage.
Nothing mentioned about the cervical os. Diagnosis?
A. Threatened miscarriage
B. Incomplete miscarriage
C. Complete miscarriage
D. Inevitable miscarriage
5 A female came complaining of amenorrhea
for 5 weeks. It is associated with abdominal
pain which was preceded by vaginal spotting
that stopped. USS shown (small centric
collection + bilateral adnexal mas + closed
cervical os). BhCG was 200. It was repeated
after 24 hours and was 700. How will you
manage her?
A. Methotrexate (if bHCG did not
double in 24 hours = ectopic so may
have been considered)
B. Expectant management (probably a threatened miscarriage – it is likely to be
intrauterine as bHCG doubled so reassurance)
C. Laparotomy / laparoscopy
D. Evacuation
E. Misoprostol
6 A woman presented with abdominal pain and vaginal bleeding. Her B-hCG level was
2,000. Her uterine size was equivalent to the gestational age but there was nothing
inside. What is the most likely diagnosis?
A. Complete abortion
B. Ectopic pregnancy
C. Missed miscarriage
7 A primigravida at 8 weeks of gestation came complaining of massive vaginal bleeding
with lower cramping abdominal pain. Her cervix is open. Next step?
A. Elective D&C
 B. US to see viable fetus
C. Tocolytic agents & wait
D. Discharge & follow up in the clinic
8 A pregnant woman came with an inevitable abortion. Her cervix was 5cm dilated and
she was febrile. CBC revealed leukocytosis. What is the next step?
A. D&C
B. Prostaglandin PV
C. IV oxytocin
D. Hysterectomy
E. Expectant management

Depends mostly on patient preference.

Expectant management (option for women < 14 weeks gestation)
Medical evacuation: combination of mifepristone and misoprostol
Surgical evacuation (D&C): if spontaneous evacuation does not occur after 4 weeks or in
cases of septic abortion or heavy bleeding
9 A patient underwent a therapeutic abortion (?). After a while, abdominal x-ray showed
air under the diaphragm. What is the most likely diagnosis?
A. Uterine perforation D&C
B. Air embolism
C. Communicating pneumothorax
10 A pregnant patient presents with PV bleeding at 8-10 weeks. She is febrile and has an
open cervical os. WBCs were high. What is the least harmful management for an
inevitable / incomplete abortion?
A. Suction evacuation
B. Prostaglandin suppository
C. Oxytocin
D. Hysterectomy
E. Dilatation & curettage
11 A hypertensive lady has history of 2 previous miscarriages. She also has history of LL
DVT. Her mother had Factor V Leiden deficiency, and her aunt had a DVT. What is the
least predisposing factor to recurrent miscarriages (or DVTs)?
A. Hypertension
B. History of DVT
C. History of Factor V Leiden deficiency
D. History of miscarriages
12 A lady at 11 weeks of gestation has history of multiple abortions at 6-8 weeks. What
investigation can help you know the cause of her previous recurrent abortions?
A. Triple test for mongolism
B. Parental chromosomes analysis
C. Anticardiolipin antibody (for antiphospholipid syndrome)
13 A 31-year-old woman, G5P4, who has amenorrhea for 12 weeks and a positive
pregnancy test presents to Emergency with vaginal bleeding. Symphysial-fundal height
measurement corresponds to 22 weeks’ gestation. Ultrasound examination reveals
bilateral cystic masses. No fetal parts are seen during the examination. The cervix is
closed. Diagnosis?
A. Tubal pregnancy
B. Endometriosis
C. Hydatidiform mole
D. Threatened abortion
Complete mole
Vaginal bleeding during the first trimester
Uterus size greater than normal for gestational age
Pelvic pressure or pain
Passage of vesicles that may resemble a bunch of grapes
Endocrine symptoms (due to ↑ β-hCG level)
Preeclampsia (before the 20th week of gestation)
Hyperemesis gravidarum
Ovarian theca lutein cysts: bilateral, large, cystic, adnexal masses that are tender to the
touch
Hyperthyroidism: Very high amounts of hCG may lead to hyperthyroidism because the α-
subunit of hCG structurally resembles TSH. [1][2]

Partial mole
Less severe symptoms than in complete mole
Vaginal bleeding
Pelvic tenderness
14 A pregnant woman has a hCG level of 200,000. USS shows bilateral cystic lesions with
no fetal pole. Diagnosis?

Molar pregnancy
15 A pregnant lady came complaining of lower abdominal pain. BhCG was 100,000 but no
gestational sac nor fetal parts were seen on US. Diagnosis?
Molar pregnancy

Laboratory tests: β-hCG level measurement (initial test of choice) [3]

Markedly elevated (higher than expected for the gestational age)
Higher in complete mole compared to partial mole.
Transvaginal ultrasound
Complete hydatidiform mole
Theca lutein cysts
Echogenic mass interspersed with many hypoechogenic cystic spaces that represent
hydropic villi (referred to as “swiss cheese”, “honeycomb”, “bunch of grapes”, or
“snowstorm”)
No amniotic fluid
No fetal parts
Lack of fetal heart tones
 Partial hydatidiform mole
Fetal parts may be visualized.
Fetal heart tones may be detectable.
Amniotic fluid is present.
Increased placental thickness
16 A woman at 6 weeks of gestation is complaining of PV bleeding & abdominal pain. O/E,
her uterus is the size of 6 weeks & there is bilateral adnexal tenderness. US = no
gestational sac. hCG = 2,000. Diagnosis?
Ectopic pregnancy

Patients usually present with signs and symptoms 4–6 weeks after their last
menstrual period.
Lower abdominal pain and guarding (ectopic pregnancy is often mistaken for
appendicitis due to the similarity of symptoms)
Possibly, vaginal bleeding
Signs of pregnancy
Amenorrhea
Nausea
Breast tenderness
Frequent urination
Tenderness in the area of the ectopic pregnancy
Cervical motion tenderness, closed cervix
Enlarged uterus
Interstitial pregnancies tend to present late, at 7–12 weeks of gestation, because of
myometrial distensibility.
17 A lady with endometriosis had a history of infertility. She came with a BhCG of 2,000
but no gestational sac is seen on USS. She also has bilateral adnexal tenderness. What
most likely cause?
Ectopic pregnancy
§ Endometriosis = tubal disease = higher chances of ectopic
§ Multiple laparoscopic endometriotic treatments = adhesions = higher chance

Serum β-hCG level

Finding: ↑ β-hCG
Additional considerations
Increased β-hCG is verifiable from the eighth day after ovulation.
Serial β-hCG measurements (every 48 hours)
Findings after 48 hours
The expected percentage increase in β-hCG for normal IUPs is determined based on the
initial level. [1][5]
Initial level < 1500 mIU/mL: > 49% expected increase
Initial level 1500–3000 mIU/mL: > 40% expected increase
Initial level > 3000 mIU/mL: > 33% expected increase
Falling β-hCG levels may indicate a failed IUP (e.g., spontaneous abortion) or an ectopic
pregnancy.
An insufficient decline in serial β-hCG measurements following induced abortion should
raise suspicion for ectopic pregnancy
18 A woman with endometriosis came complaining of bleeding for the past 6 hours after 5
weeks of amenorrhea. On examination, the fundal height matched her gestational age.
US shows no gestational sac and bilateral adnexal enlargement. Her B-hCG level is
1,200. What is the most likely diagnosis?
A. Ectopic pregnancy
B. Complete abortion
C. Missed abortion
You should not necessarily see an IUGS at a B-hCG level of 1,200.
19 A lady came with 5 weeks of amenorrhea associated with abdominal pain and vaginal
bleeding. Examination revealed an enlarged uterus. USS showed a bulky uterus with a
centric collection and an adnexal mass. BhCG was 200-300. Diagnosis?
A. Ectopic pregnancy
B. Hydatiform mole
C. Threatened abortion
D. Pregnancy of unknown location
21 How can you confirm an ectopic pregnancy?
A. Lack of intrauterine gestational sac at a B-hCG level of 2,000
B. Gestational sac outside the uterus

Transvaginal ultrasound (TVUS)

Indication: best initial imaging test
Supportive findings
Empty uterine cavity in combination with a thickened endometrial lining
Possible free fluid within the pouch of Douglas
Additional findings in tubal pregnancy
Possible extraovarian adnexal mass
Tubal ring sign (blob sign): an echogenic ring that surrounds an unruptured ectopic
pregnancy
22 A married 25-year-old woman presents with 6-hour history of abdominal pain located in
the left iliac fossa. The pain is persistent, of increasing intensity and not radiating first
experienced while she was lying down. She feels giddy when she tries to stand erect.
The last menstrual period was 6 weeks ago. The radial pulse is 130/min and the BP is
80/40 mm Hg. Pelvic ultrasound examination shows free intra-peritoneal fluid. What is
the most appropriate next step in management?
A. Immediate laparoscopy.
B. Immediate laparotomy.
C. Pregnancy test (urine or serum).
D. Observation for 24 hours in the ICU

Ovarian Diseases
23 What gynecological cancer has the highest mortality?

A. Cervical cancer
B. Ovarian cancer
24 A 12-year-old girl has an 8cm ovarian mass filled with fluid. Diagnosis?
Serous cystadenoma
25 What is the most common ovarian tumor / cancer in girls?
Germ cell tumor
26 A young girl had bilateral ovarian tumors – large in size associated with fluid collection.
They were removed. What is the most likely type of tumor?
A. Germ cell (usually not malignant and asymptomatic except for weight gain)
B. Dermoid (
Most common of all germ cell tumors (90% of all cases)
Most common ovarian tumor in women < 30 years)
C. Luteal
D. Metastatic
E. Stromal
F. Epithelial (cause ascites but in older age)
27 A woman’s pelvic x-ray showed teeth in the ovary. Pregnancy test was positive.
Ovarian teratoma
28 A middle-aged female had ovarian cancer that was removed. Her menarche was at 17
y/o & she has been taking COCPs in between pregnancies (for a total of 5 years). What
increases her chances of getting endometrial cancer?
A. Medroxyprogesterone
B. COCPs
C. Theca cell tumor (unopposed estrogen)
D. Menarche at 17
E. Multiparity

Risk factors for estrogen-dependent tumors

Nulliparity
Early menarche and late menopause
Polycystic ovary syndrome
obesity and diabetes mellitus type 2
Unopposed estrogen replacement therapy
History of breast cancer and tamoxifen treatment
Lynch syndrome
29 A 12-week pregnant lady was found to have a large cyst that was removed
laparoscopically. Histology showed a corpus luteal cyst. What is your next step?
A. Expectant management
B. Parenteral progesterone
C. Oral progesterone
Functional cysts
Watchful waiting with repeat ultrasound
Complications, large cysts, persistent painful cysts: Consider surgery.
30 A 19-year-old presented with vaginal discharge. There was an incidental finding of a 5
cm simple unilocular cyst in her ovary. What is next regarding management?
A. Ask her to wait for 3 months and follow up (for repeat US)
B. Give her OCPs
C. Observation
D. Immediate laparoscopy and evacuation of the cyst
In most patients with functional cysts, watchful waiting is recommended, as cysts often
regress spontaneously.
31 A 15 y/o female has cystic ovaries measuring 7cm & rapidly growing. Next step?
A. Laparotomy
B. Laparoscopy (> 6 cm = surgery; laparoscopy > laparotomy because less
adhesions)
C. Conservative
During surveillance, we proceed with surgery if any of the following occur:

●The mass develops high-risk features of malignancy (or there are new findings
suggestive of metastatic disease).
●The mass is increasing in size or is ≥10 cm.
●Tumor markers become elevated (eg, CA 125 level >35 units/mL in
postmenopausal patients or >200 units/mL in premenopausal patients) or trend
upward.
32 A pregnant female at 16 weeks of gestation presents with mild dragging pain in the left
iliac fossa. O/E there is an adnexal mass. US showed a 10 x 15 cm, multiseptated,
hyperechoic cyst with calcifications in the left ovary (complex cyst). The right ovary is
normal. Management?

A. Laparoscopic / open cystectomy as soon as possible

B. Laparoscopic / open cystectomy at 28 weeks
C. Open cystectomy + C/S at 38 weeks
D. Open/ laparoscopic cystectomy 2-weeks post-partum
Same question repeated but the answer is laparoscopic / open cystectomy immediately
after 1st trimester as A was not an option

The optimal time for semi-elective surgery during pregnancy is after the first
trimester for a number of reasons: (UTD)

●Almost all functional cysts will have resolved by this time.

●Organogenesis is mostly complete, thus minimizing the risk of drug-induced
teratogenesis.
●The hormonal function of the corpus luteum has been replaced by the placenta, so
reduction in progesterone secretion from oophorectomy or cystectomy does not result
in loss of the pregnancy if not replaced.
●Spontaneous pregnancy losses due to intrinsic fetal abnormalities are likely to have
already occurred and will not be erroneously attributed to the surgery.
33 A 44 y/o female G2P2 comes to your clinic. She had her first baby 24 years ago then
used OCPs for 6 weeks after which she had her 2nd baby. She continued OCPs
afterwards. Her mother had history of breast cancer. She is concerned about developing
ovarian cancer. Which of the following increase the risk of getting ovarian cancer?
A. Family history of breast cancer
B. Multiple pregnancies
C. 1st pregnancy at a young age
D. OCPs for > 5 years
An autosomal-dominant inherited gene mutation (BRCA1 or BRCA2) of a tumor
suppressor gene that codes for a DNA repair protein. Associated with an increased risk of
breast cancer (∼ 70%) and ovarian cancer as well as, to a lesser extent, colon, pancreas,
stomach and prostate cancer.
34 A lady underwent bilateral oophorectomy for bilateral
ovarian cancer. Histology showed signet cells. Most
likely cause?
A. Krukenberg tumor metastatic from GI to ovary
B. Hilar cell tumor
C. Endodermal sinus
D. Stromal tumor

Krukenberg tumor: secondary ovarian tumor that most commonly arises from metastatic
spread of gastric carcinoma [51]
Often bilateral
Characteristic mucin-secreting signet ring cells on histology
The exact route of metastatic spread (i.e., lymphatic, hematogenous, or peritoneal) is still
debated.
Uterine Diseases
35 A lady is complaining of irregular heavy bleeding. Management?
OCPs
36 A 31-year-old lady came complaining of dyspareunia. She has 3 kids who were
conceived and delivered normally. She denies any dyspareunia or bleeding???. What is
themost likely diagnosis?
A. Adenomyosis
B. Endometriosis
Approx. one-fourth of affected individuals are asymptomatic. [2]
Chronic pelvic pain that worsens before the onset of menses
Infertility [2]
Dysmenorrhea
Pre- or postmenstrual bleeding
Dyspareunia
37 A lady presents with dysmenorrhea & infertility. Management?
NSAIDs & OCPs (endometriosis)

Asymptomatic endometriosis [7]

Expectant management is sufficient for most patients.
Symptomatic endometriosis
Pharmacological therapy
Mild to moderate pelvic pain without complications
Empiric treatment with NSAIDs and continuous hormonal contraceptives
danazol
Severe symptoms: GnRH agonists (e.g., buserelin, goserelin) and estrogen-progestin
OCPs
Surgical therapy
First-line: laparoscopic excision and ablation of endometrial implants
To treat expanding endometriomas and complications, including:
Infertility
Second-line: open surgery with hysterectomy with or without bilateral salpingo-
oophorectomy
38 A 35 y/o presented with secondary dysmenorrhea. It is not associated with vomiting nor
diarrhea. The pain is localized to the left side. She has tried NSAIDs and OCPs for 6
months. She is also complaining of infertility for 5 years. Management?
A. Diagnostic laparoscopy (endometriosis)
B. Diagnostic laparotomy
39 A lady has an irregular non-tender pelvic mass on examination. What is the best next
step?
Ultrasound
40 A lady presents with heavy vaginal bleeding. USS showed a submucosal fibroid
measuring 4x4 cm. Lab investigations revealed iron deficiency anemia. What is the best
management?
A. Laparoscopic myomectomy
B. Hysteroscopic myomectomy
C. Observation with iron supplement
D. Hysterectomy
E. GnRH agonist

Myomectomy
A uterus-preserving surgical option for the removal of leiomyomas
Indications
Patients with symptomatic leiomyomas who wish to preserve fertility
Approach
Hysteroscopic myomectomy is preferred for submucosal leiomyomas.
Laparoscopic myomectomy may be preferred for subserosal and most intramural
leiomyomas.
Recurrence rate: ∼ 25% within 40 months [4]
Cervical Diseases
41 A lady has 5 kids. Which cancer could she have?
Cervical
42 Which cancer can be caused by a virus?
A. Lung
B. Liver (can be caused by HBV / HCV)
C. Cervix (HPV 16 & 18)
Others:
- Hodgkin’s lymphoma (EBV)
- Kaposi’s sarcoma (HHV-8)
43 A histopathological picture of a cervical lesion was provided. What would you do next
for prevention?
Initiate screening programs
§ Unsatisfactory repeat pap smear after 3 months + treat infection if found
§ ASCU-S HPV:
- Normal = return to normal screening
- Abnormal = colposcopy
§ LSIL / ASC-H / HSIL colposcopy
§ AGC / AIS Adenocarcinoma refer to gynecology oncologist
44 A female with an IUCD is complaining of post-coital bleeding. She was found to have
cervical lesions (circumpolar lesion that does not bleed on touch). Next step?
A. Leave IUCD in place + do high biopsy
B. Leave IUCD in place + take a swab
C. Remove IUCD + do pap smear
D. Remove IUCD + schedule pap smear in 6 weeks
E. Remove IUCD + do punch biopsy
F. Remove IUCD + do colposcopy ??
Cervical biopsy
Description: A cervical biopsy is usually done when abnormalities are found during
a pelvic exam, Pap smear, and/or HPV test. It is often performed as part of a
 colposcopy.

So maybe colposcopy first then biopsy??

45 A 46-year-old woman comes for a routine gynecological visit. On pelvic examination, a

1- cm red, granular lesion is noted on the posterior cervical lip, which is firm and bleeds
on contact. Which one of the following is the next best step for establishing a diagnosis?
A. Cervical cytological smear
B. Punch biopsy
C. Transvaginal ultrasound
D. Colposcopy
46 A 28 y/o newly married female came to the clinic. A pap smear was done, and the results
showed CIN I. After 6 months, another pap smear was done & result showed CN III.
What will be your next step of management?
A. Cone biopsy
B. Colposcopy & biopsy
C. Pap smear after 6 months
D. Repeat pap smear soon

Management
CIN I • 21-24 y/o = repeat cytology at 12 months UNLESS preceded by ASC-H
or higher than colposcopy
• > 24 y/o preceded by ASC-US / LSIL / HPV = only follow up
• > 24 y/o preceded by HSIL = pap smear + HPV test at 12 & 24 months
if abnormal then colposcopy
• > 24 y/o AND HSIL = diagnostic excision procedure
CIN II TREATMENT RECOMMENDED
CIN III • Young & want to bear children = cytology + colposcopy at 6 & 12
months
• Pregnancy: postpone till after delivery unless invasive
Definitive Treatment:
§ Diagnostic + therapeutic = LEEP / LETZ / conization
§ Therapeutic (ablative) = cryotherapy / laser ablation
Follow Up:
§ CIN I / II with margins: pap smear in 12 months and/or HPV
§ CIN II or III w/o margins: pap smear after 6 months + repeat endocervical curettage if
possible
47 A female with low-grade pap smear. Next step?
A. Colposcopy
 B. LEEP
C. Cryotherapy
48 A female with ASCUS repeated the pap smear but it still showed ASCUS. Next step?
A. Colposcopy (check hpv first)
B. Repeat smear
C. Cryotherapy
49 A G3P3 47 y/o patient presented with post-coital bleeding. O/E, she has a fibroid about
the size of 8-10 weeks of gestation. Speculum examination revealed cervical lesions. Pap
smear / colposcopy showed moderate dysplasia & biopsy shows severe dysplasia. What
is the management?
A. Ablation of cervical lesion
B. Hysterectomy
50 A 32 y/o lady has cervical dysplasia. Treatment?
A. Hysterectomy
B. Ablation of the area (depends on the severity of dysplasia)
C. D&C
51 What cervical cancer management method can be used in all stages?
A. Radiotherapy (used in all stages except 1a1)
B. Abdominal hysterectomy
C. Hysterectomy + lymphadenectomy
D. Hysterectomy + chemotherapy
E. Cone biopsy (diagnostic and therapeutic)
Vulvovaginal Diseases
52 A lady had a fluctuant mass at the introitus. Diagnosis?

Bartholin abscess

bartholin gland cyst

Pathophysiology: blockage of the duct by inflammation or trauma → accumulation
of secretions from gland → cyst formation
Clinical features: often asymptomatic but can cause mild dyspareunia
Diagnostics
Pelvic exam: unilateral, palpable mass in the posterior vaginal introitus
Management [1][2]
Conservative approach
Indicated for smaller, asymptomatic cysts ≤ 3 cm
Involves sitz baths to facilitate rupture of the cyst; and/or warm compresses
Surgery
Indicated for larger cysts > 3 cm and/or infected cysts
See “Treatment” of Bartholin gland abscesses below.
53 A lady comes complaining of fever & a vulvar mass. O/E there is a 3x4 cm lesion on the
posterior side of her left labia majora (Bartholin cyst / abscess) that is red & tender. Best
management?
A. Aspiration & drainage
B. I&D with antibiotic coverage
C. Oral antibiotics
D. IV antibiotics
- Cysts = try sitz baths to facilitate rupture / surgery if symptomatic
- Abscess = surgery (marsupialization)
Bartholin gland abscess
Pathophysiology: Bartholin gland or cyst becomes infected
Usually a polymicrobial infection: E. coli ; N. gonorrhoeae
Clinical features
Acute unilateral pain and tender swelling
 Dyspareunia
Pain especially while walking and sitting
Fever
Diagnosis
Pelvic exam: unilateral, tender mass surrounded by edema and erythema in the posterior
vaginal introitus
Treatment: surgery [1][2]
Indicated in all cases of abscess formation and large cysts (> 3 cm)
Involves incision and drainage followed by marsupialization or fistulization with a Word
catheter
Marsupialization: indicated for recurring abscesses
Fistulization with a Word catheter

Infections
54 A female presented with copious, clear, non-odorous vaginal discharge and genitalia
discomfort. She has no pruritis. O/E there are multiple ulcers with vaginal discharge.
What is your diagnosis?
A. Chlamydia
B. Gonorrhea
C. Human papilloma virus
D. Trichomonas vaginalis
E. Herpes simplex
55 A 30-year-old woman, pregnant at 10 weeks of gestation, came for a prenatal checkup.
She had received the varicella vaccine when she was 10 years old. She has been having
recurrent genital herpes with eruptions once a year. On examination, her vagina looks
normal. What do you do?
A. Check her varicella titer
B. Give her Ig
C. Acyclovir
D. Nothing
For all women who present with a genital HSV lesion anytime during pregnancy,
whether with a primary, nonprimary first-episode, or recurrent infection, we
recommend daily suppressive therapy at 36 weeks of gestation until the onset of
labor rather than no therapy (Grade 1A). We use acyclovir 400 mg orally three times
daily; valacyclovir is an alternative (table 2). Suppressive therapy reduces the risk of
clinical recurrence of HSV delivery, and thus the need for cesarean delivery.
However, the clinical impact on neonatal HSV is unknown. (See 'Suppressive
therapy at 36 weeks' above.)
56 A lady came with frothy discharge that has a fishy smell. Wet mount revealed clue cells,
and there was a positive whiff test. pH was 5.4. diagnosis?
Bacterial vaginosis
Bacterial vaginosis: there is an overgrowth of anaerobic organisms, including
Gardnerella vaginalis (small gram-variable cocci), and a decrease in the numbers of
lactobacilli. A ‘clue cell’ is seen. This is an epithelial cell covered with small bacteria so
the edge of the cell is obscured.
57 A 22-year-old primigravida came complaining of white-yellow vaginal discharge with
itching. On examination, she has scratch marks and a fishy odor. How will you treat her?
A. Local antifungal
B. Oral metronidazole
C. Oral ceftriaxone
D. Intramuscular medication
Bacterial vaginosis signs and symptoms may include:
- Thin, gray, white or green vaginal discharge.
- Foul-smelling “fishy” vaginal odor.

- Vaginal itching.
- Burning during urination.
Antibiotics are the mainstay of therapy for bacterial vaginosis. Medications include
metronidazole (Flagyl), clindamycin (Cleocin) oral or vaginal suppositories, and
metronidazole vaginal gel (MetroGel-Vaginal). Metronidazole and clindamycin are the
preferred medications used to treat Gardnerella infections.
58 A woman presented with frothy vaginal discharge associated with itching and burning at
the introitus. On examination, there are hemorrhagic dots on her cervix. Her vaginal pH
was 5.8. What is the most likely cause?
A. Trichomoniasis
B. Candidiasis
59 A woman presents with yellow-green vaginal discharge. She states
that she has 1 sexual partner, but he may not be monogamous.
Histology slides showed the following. How will you manage her?
A. Get her checked for other STDs
B. Treat her & get both of them checked for other STDs
(give both metronidazole to treat trichomoniasis)
60 A woman came complaining of yellow-green frothy discharge. On examination, her
cervix was hyperemic. Hydrogen peroxide was negative. What do you do?
Oral metronidazole for her & her partner
61 A female complains of vaginal itching & whitish frothy discharge. Diagnosis?
Candida
62 A pregnant female has a whitish vaginal discharge. Whiff test is negative. Treatment?
A. Fluconazole
B. Metronidazole
C. Ceftriaxone
63 An asymptomatic pregnant lady had gonorrhea. What do you do?
A. Terminate the pregnancy
B. Take a swab & treat accordingly
C. Treat her with 24 mil penicillin
D. Treat with cefotaxime
The scenario says she had gonorrhea… so should be treated with ceftriaxone (gonorrhea)
+ Azithromycin (azithro for chalmydia)
64 How do you treat PID?
Doxycycline & ciprofloxacin
Alternatively: clindamycin + gentamicin

Outpatient regimen
One single dose of IM ceftriaxone and oral therapy with doxycycline
Signs of vaginitis or recent gynecological instrumentation: Add oral metronidazole.
Contraception
65 A newly married couple is asking for the best method of contraception as they do not
want children for the next 2 years. The wife travels a lot as she is a sales agent so she
does not know when she & her husband will have intercourse, and she notes that she is
quite forgetful. The wife’s father has history of diabetes & her mother had pancreatic
cancer. Her menstrual cycle history is positive for dysmenorrhea. Best option?
A. OCP
B. Diaphragm
C. IUCD
D. Condom
Contraindications of iucd
Uterine abnormalities (i.e. bleeding, malignancy, infection, abnormal anatomy)
Cervical infections
Known or suspected pregnancy
Menorrhagia
Dysmenorrhea
Copper hypersensitivity
In another exam:
A. OCP
B. POP
C. Diaphragm
D. Rhythm
66 A young lady presents to you requesting contraception. She has a 5 cm cyst in one of her
ovaries. It is uniloculated and cystic in appearance. What do you do?
A. Ask her to wait for 3 months and follow up
B. Give her OCPs
C. Give her POPs
D. Immediate laparoscopy and evacuation of the cyst
They will help decrease recurrence so less chance of new cyst – but will not markedly
affect current cyst. You should still do A but since the question is asking about
contraception go for B.
67 A 44-year-old female had an US showing the thickness of her endometrium to be 4mm.
On sampling, the biopsy showed secretory endometrium. What would you give her?
A. COCPs
B. Estrogen only pills
C. Progesterone only pills (cyclic)
68 A 45-year-old lady, known case of uterine myoma, came complaining of vaginal
spotting (intermenstrual bleeding) for 3 months. O/E there is a myoma 8 weeks in size.
Endometrial (pipelle) biopsy showed proliferative endometrium. Next step?
A. Pelvic US
B. Diagnostic hysteroscopy
C. Cyclic hormonal therapy
D. Total hysterectomy
69 A female student is going to get married soon so she started taking OCPs. She
complained of nausea after the first course. What will you do for her?
A. Tell her to continue OCPs & that the nausea will improve gradually
B. Tell her to stop for 2 weeks then resume the same OCP
C. Switch to another OCP with higher estrogen dose
D. Advise her to place an IUCD instead

Nausea is a common side effect of birth control pills, especially in the first few days or
weeks. In most cases, the nausea goes away as the body adjusts (google)
70 Which of the following is true about the side effects of IUDs?
A. Perforation rate is > 1:1,000
B. It stimulates irregular vaginal bleeding (this is also correct..)
Another uncommon complication of IUD placement is uterine perforation, which occurs
in 0.1% of cases. Severe pain or loss of resistance with sounding for IUD insertion are
signs of perforation. If perforation is suspected, the procedure should be stopped and
postponed. The patient’s vital signs should be assessed to identify and signs of
hemorrhage. If any of these signs are evident, the patient should be transported to an
emergency facility rapidly.

Uterine perforation is an uncommon complication of intrauterine device insertion,

with an incidence of one in 1,000 insertions. ??
71 A patient with an IUCD got pregnant. Her LMP was 7 weeks ago. Next step in
management?
A. Reassure the patient & follow up on week 12
B. Remove the IUCD (confirm with US remove IUCD; can be left up to 12
weeks)
C. Tell the patient that the IUCD might cause structural fetal anomaly
D. Serial US
E. Tell her she should abort before 12 weeks GA
72 A patient came wanting contraceptives. She was previously using an IUCD but got
pregnant while having it. She has a history of PID 1-week back which was treated with
antibiotics. What is the contraindication for IUD in this case?
A. History of getting pregnant with IUCD
B. History of PID
C. Previous c-section
Contraindications are severe distortion of uterine cavity / acute pelvic infection / known
or suspected pregnancy / copper allergy or intolerance in case of copper IUD /
undiagnosed uterine bleeding
73 A 22-year-old lady is getting married and wants to start taking “the pill”. She is
clinically free of disease and so is her partner. She mentions that her mother & sister
have history of LL clots. Her maternal grandmother is diabetic and hypertensive, and her
paternal grandmother had pancreatic cancer. What test should you do before you give
her the pill?
A. Bleeding time
B. Factor V Leiden
C. Pap smear
Amenorrhea
74 A 15-year-old girl has amenorrhea. O/E, her breasts are developed, she has pubic &
axillary hair, and she has bilateral inguinal masses. Her external genitalia are normal.
What is your diagnosis?
A. Testicular feminization (complete androgen insensitivity)
B. Bilateral inguinal hernia

C. Turner syndrome

Etiology: X-linked recessive mutation of the gene encoding the androgen receptor (AR
gene)
Karyotype: 46,XY
Pathophysiology: Defects in the androgen receptor result in varying degrees of end organ
insensitivity to androgens.
Clinical features
Complete androgen insensitivity
Female external genitalia and physique
Includes testicular feminization and female breast development
Blind-ended vaginal pouch, uterine and fallopian tube agenesis (due to testicular anti-
Mullerian hormone secretion)
Absent male internal genitalia
Cryptorchid testes: intralabial, inguinal, or abdominal localization of undescended
testicles
Scant or no pubic hair
Primary amenorrhea, infertility
Diagnostics
Before puberty: ↑ testosterone
After puberty: ↑ LH, ↑ estrogen
Genetic testing
 Treatment: depends on receptor status as well as on the phenotype and gender identity
Hormone treatment
Complete androgen insensitivity: estrogen replacement
Partial androgen insensitivity: high-dose androgen therapy in patients with male gender
identity
Gonadectomy: for intraabdominal/intralabial testicles
Typically performed after puberty
Prevents malignant transformation of the abnormally localized gonads
75 A 14-year-old girl is brought by her mom for primary amenorrhea. Her mom had her
menarche at 12 years and is worried because her daughter still did not develop any
breasts or pubertal hair distribution. She reports that the daughter is active at school and
involved in sports. On examination, she is Tanner stage 1. What investigation would you
do?
A. Karyotyping
B. FSH level
C. Bone age test
76 A 16-year-old female presented complaining of amenorrhea. On examination, she has
normal breast development and sparse axillary and pubic hair. Diagnosis?
A. Androgen insensitivity
B. Mullerian agenesis
Refer up^^
77 A 16 y/o girl is brought by her mother as she has not had her period yet. On
examination, she has no breast development & no pubic hair. Her height is 148 cm. USS
shows a small uterus. Lab investigations show  FSH & LH, and  estrogen. Both her
sisters had menarche at the age of 12. Most likely diagnosis?
A. Testicular feminization no uterus
B. Kalman syndrome anosmia
C. CAH ambigious genitalia
D. Gonadal agenesis / dysgenesis Turner syndrome, short, no estrogen cuz no
ovaries (streak ovaries) → feedback to pituitary to inc LH and FSH to increase
estrogen
Classification
Turner syndrome (45,XO)
Pure gonadal dysgenesis (or complete gonadal dysgenesis)
46,XY gonadal dysgenesis (Swyer syndrome)
46,XX gonadal dysgenesis
General clinical features
Delayed puberty
Infertility
Streak gonads
High risk for malignancies (e.g., dysgerminoma, seminoma)
Diagnosis
Clinical presentation
Genetic analysis
Karyotyping
Laboratory findings of hypergonadotropic hypogonadism
Imaging tests (to assess for streak gonads)
 Treatment
Lifelong estrogen and progesterone substitution
Surgical removal of streak gonads

78 A lady presented with amenorrhea but had a negative pregnancy test. She had a 7 cm
adnexal mass. What is the next step? US
79 A 44 y/o is presenting with amenorrhea for 3 months. Her previous cycles were
associated with heavy bleeding. She also gained weight and has hair loss. Next test?
A. hCG rule out pregnancy first then go for TSH
B. TSH
C. FSH & LH
80 A 20-year-old female presented with 10 weeks of amenorrhea. She is trying to lose
weight by doing exercises. She is 163 cm tall & weighs 53 kg. Labs show  FSH,  LH,
 estradiol, normal prolactin & normal TSH. What is the cause of her amenorrhea?
A. Hypothalamic
B. Hypothyroidism
C. PCOS

D. Hyperprolactinemia
Functional hypothalamic amenorrhea: a dysfunction in the pulsatile secretion of GnRH
Etiology
Excessive exercise: e.g., in competitive athletes (also called exercise-induced
amenorrhea)
Reduced calorie intake (e.g., in eating disorders like anorexia nervosa)
Stress
Female athlete triad syndrome: menstrual dysfunction, calorie deficit, and decreased bone
density in athletic female young adults or adolescents
81 A female adult with a BMI of 20 is complaining of amenorrhea. She notes that she has
been isolated for the past while. What is the cause of her amenorrhea?
A. Depression (need more info in question)
B. Eating disorder
82 A 30-year-old lady with secondary amenorrhea for the past 6 months has discontinued
OCPs recently as she wishes to get pregnant. On examination, there was milky discharge
from the nipples. What is the best drug to use?
A. Clomiphene
B. Estrogen
Clomiphene
Blocks hypothalamic estrogen receptors, thereby inhibiting negative feedback and
increasing release of FSH and LH to trigger ovulation
Infertility (for ovulation induction)
Menstrual Cycle & Irregularities
83 How many hours after the LH surge does ovulation occur?
A. 24-36 hours
B. 48 hours
84 In which half of the cycle do PMS symptoms occur?
A. First half
B. Second half
85 A 43-year-old lady came complaining of vaginal spotting for 6 months. Her last
menstrual period was 3 months ago, and she reports that her periods are irregular. She
also suffers from obesity and hirsutism. USS showed thickened endometrium (?).
Diagnosis?
PCOS the endometrium gets thicker and thicker every cycle cuz only estrogen is
available – inc risk of endometrial cancer

Onset of symptoms typically occurs during adolescence.

Menstrual irregularities
Primary or secondary amenorrhea
Oligomenorrhea
Menorrhagia
Infertility or difficulties conceiving
Insulin resistance and associated conditions
Metabolic syndrome (especially obesity)
Skin conditions
Hirsutism
Androgenic alopecia
Acne vulgaris
Oily skin
Acanthosis nigricans
86 A lady with irregular periods (every 55 days) wants to have kids but is unable to
conceive. Her hip circumference is 88cm. her Ferriman Gallway Score is 14. Diagnosis?
A. PCOS
B. Androgen insensitivity
C. Testicular feminization
§ Ferryman Gallway score is used to diagnose hirsutism in females (8 or more). A
total score less than 8 is considered normal, a score of 8 to 15 indicates mild
hirsutism, and a score greater than 15 indicates moderate or severe hirsutism.
A score of 0 indicates absence of terminal hair. in her case it is mild
§ Her hip circumference is normal (97-108 in females) (W:H ratio in females should be
80 or less)
87 What investigations do you order for a woman with symptoms of PCOS (hirsutism &
acne)?
A. Total testosterone + DHEA + 17 hydroxyprogesterone
B. Total testosterone + estradiol + 17 hydroxyprogesterone
C. Free testosterone + DHEA + 17 hydroxyprogesterone
D. Androstenedione + DHEA + 17 hydroxyprogesterone
Confirm hyperandrogenism: Obtain in all women with clinical features of PCOS,
even if features are minimal or unclear. [10]
↑ Testosterone [10]
↑ Androstenedione and ↑ dehydroepiandrosterone sulfate
Free testosterone – We do not suggest the routine measurement of serum free
testosterone
Serum 17-hydroxyprogesterone – We suggest measuring a morning serum 17-
hydroxyprogesterone in the early follicular phase in all women with possible PCOS
to rule out nonclassic congenital adrenal hyperplasia (NCCAH) due to 21-
hydroxylase deficiency.
88 A 13-year-old girl came to the PHC complaining of her irregular period. It has been
irregular since her menarche 6 months ago. She is otherwise healthy, her BMI is normal,
and there are no detectable abdominal masses. What is the most likely diagnosis?
A. Pregnancy
B. Anovulatory cycles – common & normal near menarche and menopause
C. Prolonged luteal phase
D. Endometriosis
E. Polycystic ovarian syndrome
89 A lady has signs & symptoms suggestive of PCOS (hirsutism, clitoral enlargement, etc.).
what investigation is LEAST likely to be helpful?
A. DHEA-serum level
B. Free cortisol level
C. Testosterone levels
D. Dexamethasone suppression test
E. Serum FHS LH:FSH ratio is 2:1 (elevated) in PCOS
90 A 40 y/o female with PCOS has been trying to get pregnant for 5 years. How do you
manage her?
A. Danazol
B. Estrogen
C. NSAID
D. GnRH
For oligo-ovulatory women with PCOS undergoing ovulation induction, we now suggest
letrozole as first-line therapy over clomiphene citrate, regardless of the patient's BMI

Gonadotropin therapy – Another method to induce ovulation is administration of

exogenous gonadotropins [49].
91 A woman complaining of dysmenorrhea and menorrhagia was found to have an enlarged
uterus. What will you give her?
A. Surgical management try pharmacotherapy first
B. Clomiphene
C. Estradiol
D. Leuprorelin aka Leuprolide GnRH agonist prior to surgery to shrink fibroids

92 A young lady, P1, is still complaining of menorrhagia. Medical therapy failed. What is
the next step?
A. High-dose progesterone it prevents the growth of the endometrial lining
B. Hysterectomy
C. Endometrial ablation (infertility)
Menopause
93 A lady developed hot flashes & other menopausal symptoms after bilateral salpingo-
oophorectomy & hysterectomy. What is the cause of her symptoms?
A.  estrogen
B.  progesterone
C.  FSH
94 Treatment of premenopausal women?
Lowest effective systemic estrogen (if she still has her uterus add progestin)
95 A woman has deep dyspareunia and flushing following a total hysterectomy &
bilateralsalpingo-oopherectomy for endometriosis. What do you give her?
A. Estrogen only pills no need for progesterone since no uterus
B. Estrogen & progesterone
C. Depot Provera
96 A 35 y/o lady had a hysterectomy & salpingo-oopherectomy for severe endometriosis.
Currently she is presenting with labile mood & hot flushes (premature menopause).
What will you do?
A. Oral progesterone & estrogen hormonal replacement (no need since no uterus)
B. Oral estrogen replacement (alternatives would be antidepressants / clonidine /
gabapentin)
C. Duphaston
D. Progesterone only
97 A healthy 49-year-old woman, not on any medications, is complaining of hot flashes & a
labile mood that are affecting her life. She had regular cycles that lasted for 23-25 days
previously, but for the past 9 months she has missed 3 cycles. She denies any post-coital
bleeding or stopping. She is asking for medications to help with her symptoms. What
would you give her?
A. SSRI
B. Low-dose combined OCPs
C. Continuous progesterone
D. Cyclic progesterone
98 A healthy old lady has menopausal complaints. She is not obese. No family history of
cancers. Best management option?
A. Combined contraceptives
B. Medroxyprogesterone
C. Tamoxifen
Hormone replacement therapy (HRT) [5]
Indication: short-term treatment of menopausal symptoms
Types
Estrogen therapy: for women who have had a hysterectomy
Estrogen plus progestin therapy: for women with a uterus

Non-hormonal therapy
Non-hormonal therapy is used to treat menopausal vasomotor symptoms in women who
do not want to use hormonal medications or who have contraindications for HRT. [7]
Selective estrogen receptor modulators: tamoxifen, ospemifene , and raloxifene
Paroxetine: for vasomotor symptoms (i.e., hot flashes)
Clonidine and/or gabapentin
99 An office-working lady presents complaining of hot flashes & sleep disturbances. She
has history of breast cancer 2 years ago. Management?
A. HRT (avoided b/c of breast cancer history)
B. Clonidine
C. SSRI
D. Propranolol hydrochloride (causes sleep disturbances)
Clonidine is the non-hormonal drug of choice for menopausal symptoms. It is effective
against tamoxifen-induced hot flashes in post-menopausal women.
10 A post-menopausal lady is complaining of PV bleeding. Her endometrial thickness is
0 2mm. Examination shows vaginal atrophy. Next step?
A. Vaginal estrogen cream
B. Endometrial biopsy
C. USS
It is best to exclude endometrial pathology as well. So we will give vaginal estrogen
cream but still do US.

For atrophic vaginal symptoms: vaginal estrogen creams, rings, or tablets (Estrogen
therapy may reduce the incidence of UTIs and features of overactive bladder.)
10 A 50-year-old female, P8, menopausal for 5 years, came complaining of brownish
1 vaginal discharge not related to intercourse (PMB). Pap smear 3 years ago was normal.
She has history of coronary artery disease and angina. Physical and bimanual
examinations were normal but showed atrophic vagina. US showed endometrial
thickness of 2 mm (or 4 mm). What is the next step in management?
A. Colposcopy
B. Endometrial US
C. Endometrial biopsy
D. Estrogen cream
If endometrial thickness not mentioned go for endometrial US.
If endometrial thickness is > 5mm, go for biopsy.
10 A post-menopausal lady is complaining of dyspareunia. She tried vaginal lubricants and
2 moisturizers but had no response. What do you give her?
Low-dose vaginal estrogen
10 A 40-year-old lady started complaining of dyspareunia after tubectomy. Advice?
3 Use lubricants
10 A 55 y/o lady – menopausal for 5 years — is complaining of bleeding with brownish
4 spotting. Examination shows an easily bruising vagina & cervical stenosis. Her last pap
smear 3 months ago was normal. Next step?
A. Do US scan
B. Vaginal estrogen cream
C. Cyclic progestin
D. Endometrial biopsy

Both USS & endometrial biopsy can be used as an initial step according to uptodate.
10 A post-menopausal lady presents with vaginal bleeding. She is vitally stable and not on
5 any medications. How will you manage her?
USS
Infertility
10 A couple come in for infertility investigations. On history taking, you find out that the
6 husband has recurrent pneumonia, recurrent bronchiectasis, and pancreatic problems. He
is taking pancreatic enzymes, vitamins, and prophylactic antibiotics. What is the best
next investigation?
A. Semen analysis
B. Sweat chloride test
C. Alpha-1-antitrypsin
D. Hysteroscopy

I would go with semen analysis because sweat chloride test will not contribute to the
management of infertility.
10 A married woman is complaining of infertility. She has had 3 abortions managed by
7 D&C after which she hasn’t been able to conceive. Her hormonal profile is normal. Why
can’t she conceive now?
A. Kallman syndrome (condition characterized by delayed or absent puberty and an
impaired sense of smell. This disorder is a form of hypogonadotropic
hypogonadism, which is a condition resulting from a lack of production of
certain hormones that direct sexual development)
B. Asherman’s syndrome
C. Androgen insensitivity
D. Meig’s syndrome
E. Sheehan syndrome
Intrauterine adhesions (Asherman syndrome)
Definition: endometrial adhesions or fibrosis
Etiology
Following uterine dilation or curettage (most common cause)
Postinflammatory (e.g., chlamydia)
Clinical features
Usually asymptomatic
Abnormal uterine bleeding
Secondary amenorrhea
Infertility
Recurrent pregnancy loss
Periodic abdominal pain
Diagnostics [3]
Negative progesterone withdrawal test: No bleeding after progesterone cessation suggests
blockage of the outflow tract.
 Confirmatory test: hysteroscopy to directly visualize adhesions
Hysterosalpingography: honeycomb appearance of the uterus
Treatment
Hysteroscopic resection of the adhesions
Treatment is only indicated if patients are symptomatic.

10 A P1+0 young lady is complaining of infertility. She had 1 previous delivery that was
8 complicated by bleeding and she went into hypovolemic shock. She was also using
cocaine in that pregnancy. She has a low hormone profile. What is the cause of her
infertility?
A. Meig’s syndrome
B. Sheehan syndrome
C. Asherman syndrome
Sheehan syndrome: postpartum necrosis of the pituitary gland. Usually occurs
following postpartum hemorrhage, but can also occur even without clinical evidence
of hemorrhage. [1][2]
During pregnancy, hypertrophy of prolactin-producing regions increases the size of
the pituitary gland, making it very sensitive to ischemia.
Blood loss during delivery/postpartum hemorrhage → hypovolemia → vasospasm of
hypophyseal vessels → ischemia of the pituitary gland → empty sella turcica on
imaging

General symptoms: Intrasellar/parasellar masses (e.g., pituitary macroadenomas,

craniopharyngiomas) can manifest with headache, visual field defects (bitemporal
hemianopsia), and/or diplopia.
Pituitary apoplexy manifests with acute onset of:
Severe headache
Hypopituitarism
Bilateral hemianopia, diplopia (due to damage to CN III)
Sudden hypotension, possibly shock
GH deficiency
During childhood: short stature
Prolactin deficiency
Women: lactation failure following delivery
FSH/LH deficiency
Women: primary amenorrhea (delayed puberty), secondary amenorrhea, irregular
menstrual cycles, infertility
Men: delayed puberty, loss of libido, infertility, testicular atrophy, loss of facial,
axillary and/or pubic hair
TSH deficiency: weight gain, cold intolerance, lethargy, constipation, dry skin (see
“Hypothyroidism”)
ACTH deficiency: weight loss, weakness, hypotension, chronic hyponatremia,
hypoglycemia (see “Adrenal insufficiency”)
Central diabetes insipidus: polyuria, polydipsia
10 A woman with PCOS features (hirsutism, obesity, amenorrhea for 4 months) was
9 worried that she did not get pregnant after 18 months of her marriage. She also recalls
that her last periods were very heavy.
1. What is the initial management?
A. Metformin
B. Clomiphene citrate
C. Exercise & 10% weight loss
2. What is the best management for her?
D. Metformin
E. Clomiphene citrate
F. Exercise & 10% weight loss
Stepwise manner for PCOS:
1. Weight loss (normal BMI)
2. Metformin
3. Clomiphene for 6 cycles (75% ovulation rate)
4. Letrozole aromatase inhibitor
5. FSH / LH injections or LOD
6. IVF (last resort)
11 A lady is complaining of infertility for 2 years, amenorrhea, & a small amount of nipple
0 discharge. She has  TSH levels (7) &  T3 & T4. Prolactin is 90. Next step?
A. Brain CT (sella turcica) scan to look for a tumor
B. Give bromocriptine
C. Serum T3 & T4 (primary hypothyroidism will lead to increase in TSH (normal =
0.4 – 4.0).
Pituitary will increase production of TSH due to hypothyroidism which will lead to
pituitary enlargement which also releases proalcitn. So when the entire pituitary is
enlarged, prolactin production increases but not too much to the level of prolactinoma
(around 20) so if less than 100, think of other causes. If high (200) then think of
prolactinoma.
11 A 27-year-old female underwent radiation therapy for ovarian cancer 2 years ago. As a
1 result, she has vaginal atrophy. She wants to get pregnant and is asking for your advice.
What will you tell her?
A. She can’t conceive
B. High risk of fetal defect
C. Low risk of fetal defect
D. Pregnancy will worsen her condition
Urogynecology
• Stress incontinence:
o On coughing / sneezing / constipation
o Treatment with lifestyle changes Kegel exercise pessaries surgery (TVT
or TOT mesh)
• Urge incontinence:
o Treated with oxybutynin / nerve modulation
• Overflow incontinence:
o Intermittent catheterization / bethanechol / botulinum
11 What drug is used for the management of urge incontinence?
2 Oxybutynin (antispasmodic)
11 A 70-year-old woman is brought by her daughter for dizziness. She is known to have urge
3 incontinence (overactive bladder) managed by oxybutynin. She is also hypothyroid and
taking levothyroxine. She also recently started taking diclofenac. She tells you that she
doesn’t drink enough water because she does not want to go to the toilet [Link]
examination, she was hypotensive. What will you do?
A. Increase levothyroxine dose
B. Stop levothyroxine
C. Increase oxybutynin dose (it would decrease the symptoms she would go to
the toilet less she will drink more water)
D. Stop oxybutynin
E. Change the NSAID to oxycodone
11 An old lady, known case of DM and hypertension, with history of a previous left
4 hemisphere infarction, was admitted to the hospital. During admission, she developed
urinary incontinence. Blood glucose was high. USS showed 60-80 mL residual bladder
volume. What is the cause of her incontinence?
A. Normal pressure hydrocephalus (wet = incontinence; wobbly = ataxia; weird =
cognitive changes)
B. Functional incontinence (incontinence started in the hospital)
C. Overflow incontinence (amboss says atleast 200 ml residual)
D. Diabetic cystopathy
11 A menopausal lady had signs & symptoms of urge incontinence (urgency & frequency).
5 She had no stress incontinence. What is the next step?
A. Treat her conservatively (may be true if it is with oxybutynin)
B. Refer her for pelvic floor exercise
C. Refer her to a urogynecologist
D. Obtain a mid-stream urine sample for culture
You always have to exclude a UTI before managing incontinence.
11 A multiparous lady presents 8 weeks post-delivery with nocturia & incontinence on
6 coughing. She wakes up at night 2 times to micturate. Her symptoms have increased
recently. She has normal urine volume. Diagnosis?
A. Stress incontinence
B. Detrusor hyperactivity
C. Total incontinence (0 control – loses all urine)
11 A 70 y/o multiparous lady came to the clinic.
7 Her cervix is visible at the introitus on stressing
(coughing / straining). She also has visible
cystocele & rectocele. What is the typeof
prolapse?
A. Procidentia
B. Vault prolapse
C. 2nd degree prolapse
D. 3rd degree prolapse
 ------- Occupational Medicine -------
Inhalational Injuries
1 2 workers were brought to the ER after being found in their room unconscious. One of
them was red in color. In their room, an unfinished dinner was found along with a bottle
of beer & open wood store. Most likely diagnosis?
A. Drug abuse
B. Food poisoning
C. CO poisoning
D. Alcohol intoxication
2 A man working in a confined space comes in complaining of headache, dizziness &
weakness. He has low oxygen saturation. What is the likely cause of his symptoms?
A. Carbon monoxide intoxication
B. Paint inhalation
Nonspecific symptoms
Headache
Dizziness
Fatigue
Nausea/vomiting
Neurotoxicity
Altered mental status (e.g., agitation, confusion, somnolence, memory loss)
Seizures
Loss of consciousness/coma
Cardiorespiratory toxicity
Inhalation injury: associated with fire-related exposures
Shock
Other classical signs
Cherry-red skin with bullous skin lesions: after exposure to high levels (rare and usually
seen postmortem)
Fundoscopic findings: bright red retinal vessels, retinal hemorrhages, papilledema
(indicative of cerebral edema)
Symptoms of concurrent cyanide poisoning
Standard pulse oximetry: normal-appearing or ↑ SpO2 (as pulse oximeters cannot
distinguish between COHb and oxyhemoglobin)
3 What gas is produced from cars?
A. CO2
B. CO
4 What is true about carbon monoxide?
A. Binds to hemoglobin
B. It is heavier than air
C. It has an odor
The affinity of hemoglobin for CO is ∼ 240 times stronger than for O2 → formation of
COHb (carboxyhemoglobin)
5 What disease is caused by cotton inhalation?
A. Sarcoidosis
B. Berylliosis form of metal poisoning caused by inhalation of beryllium dusts,
vapors, or its compounds or implantation of the substance in the skin.
C. Histoplasmosis
Byssinosis
6 A carpenter working in a furniture company complains of a runny nose, itching, mild
cough and dizziness at work. He also has cracks on her hands & feet. He feels better when
he goes home & on the weekends. What is the cause?
A. Mercury
B. Organic paint (lead headache + abdominal pain + CNS symptoms)
C. Wood dust inhalation (allergies respiratory & topical symptoms)

Wood dust becomes a potential health problem when wood particles from processes such
as sanding and cutting become airborne. Breathing these particles may cause allergic
respiratory symptoms, mucosal and non-allergic respiratory symptoms, and cancer.
7 A farmer presented with miosis, LOC, convulsions, excessive lacrimation & salivation,
and diarrhea. What is the cause? DUMBELS (Cholinergic) Diarrhea Urination Miosis
Bronchoconstriction Excessive Lacrimation Salivation
A. Organophosphate poisoning (treated with atropine)
B. Head trauma
C. Temporal lobe epilepsy
8 A man working in the petrochemical industry had lab tests showing pancytopenia (Hb
=10 mg/dL; Hct = 20%; Platelets = 20,000; WBCs = 1,500). What is the diagnosis?
A. Benzene toxicity
B. Lead toxicity
C. Mercury poisoning
D. Carbon monoxide poisoning

Benzene is strongly associated with bone marrow toxicity as well as increased risk of
AML.
9 A man presents with SOB after exposure to chlorine while cleaning the swimming pool.
PFT was done and showed restrictive lung disease. He recovered following management.
Advice?
A. Avoid chlorine exposure for 1 week
B. Follow up for repeat PFT after 1 week
C. N95 mask
D. Peak flow meter
10 Multiple workers exposed to the same chemical present with a cough. What is the best
method to reduce exposure?
A. Check if the workplace environment is well-ventilated
B. Make them wear a mask
C. Automated cabinet
11 3 ladies working in the same place are showing symptoms of sinusitis & red eye only
during the weekdays. They are completely fine in the weekend. Best management?
Check the ventilation at the workplace
Heavy Metals Poisoning
12 A man developed weakness in both hands.
You find that it is due to a workplace
toxicityand want to report it to the
ministry of labor. The most likely toxin
is?
A. Mercury
B. Lead
C. Cadmium

Mercury Poisoning
• Hypersensitivity reactions (acute
& chronic)
• Abortions (chronic)
• Renal failure + brain damage (acute & chronic)
• Intestinal ulceration (chronic)
• Sympathomimetic effects (acute & chronic)

13. What is true about lead toxicity?

A. It causes aplastic anemia
B. It affects the non-dominant arm
Lead is mostly retained in the bones & teeth
14 A carpenter (cabinet maker) comes complaining of nausea, dizziness, and headache. He
also notes that he has been having a decline in his memory & concentration. What is the
cause of his symptoms?
Organic paint poisoning (paint poisoning – lead)

Other options???

Lead-based paints were banned for residential use in 1978. Homes built in the U.S. before
1978 are likely to have some lead-based paint. When the paint peels and cracks, it makes
lead paint chips and dust.
Musculoskeletal Injuries
15 A lady working an office-job developed neck pain. It was treated but the pain recurred
when she goes back to work. What will tell her?
A. Adjust the positioning of the computer
B. Use arm & neck splints
C. Neck strengthening exercises
Healthcare & Labs
16 If you were responsible to organize a program to prevent blood-borne disease
transmission among people working in the hospital, what would be the best method to do
so?
A. Hep B Ig to any health worker after needle injury
B. Wear gloves
C. Not recap the syringe after use
17 There was a clostridium difficile outbreak in the hospital. What protective measure can
you take to prevent transmission to other patients?
Use alcohol gel (sanitizer) before contact with patients.
18 How can you ensure the safety of workers working in a lab with volatile chemicals?
A. Use a safe cabinet for keeping & handling the material, and automate the
process
B. Ventilation
C. Limit the time each member spends in the lab
D. Wear protection
19 What safety precautions should be considered in a lab where a scientist is conducting a
research involving toxic fumes?
Ensuring the lab is automated & ventilated
20 How can you prevent infection in the pediatric ward?
Wear gloves
PPE Kit Removal
- Putting on: gown first gloves last
- Removing: gloves first gown last
 Chemical Factories
21 How do you prevent exposure to a highly volatile substance in a chemical factory?
A. Gloves and mask
B. Ventilation
C. Automated cabinet
D. Suction chamber + mask
22 What is the best way to detect the degree of hazards caused by a chemical in a factory?
A. Questionnaire
B. Assess the chemical
C. Check the ventilation
D. Interview the workers
23 In a chemical factory, there is a scientist & a chemist who are handling a dangerous
chemical substance. What can you do to decrease their exposure?
A. Initiate x-ray program yearly
B. Give them gloves and masks
C. Automated cabinets An automated dispensing cabinet is a computerized medicine
cabinet for hospitals and healthcare settings. ADCs allow medications to be stored and
dispensed near the point of care while controlling and tracking drug distribution.
D. Proper handling of the chemical substance
24 A chemist is working in a lab with 3 other workers. They are dealing with chemical
fumes. What should be done to prevent hazardous effects?
A. Ventilated rooms
B. Wear masks and gloves
General
25 Who should you report occupational injuries to?
D. Ministry of labor
E. Ministry of health
F. Authority of health services
26 What is the most common mode of spread of occupational diseases among workers in the
chemical industry?
A. Inhalation
B. Skin
C. Mucus
D. Ingestion
27 What does the Haddon matrix illustrate?
A. Host + agent + environment
B. Time + phase events + injuries
C. Host + vector + agent + environment
Its purpose is to avoid injury / death:
- 1st dimension = host + agent/vector + environment
- 2nd dimension = pre-event + during event + post-event (methods of injury prevention
during each)
28 What is the best way to check the effect of a noise reduction program?
A. Audiometry yearly
B. Check the application of the program
29 What is the definition of safety framework?
The Framework for Safe, Reliable, and Effective Care provides clarity and direction to
health care organizations on the key strategic, clinical, and operational components
involved in achieving safe and reliable operational excellence — a “system of safety,” not
just a collection of stand-alone safety improvement projects.
30 What is the definition of efficiency?
Efficacy: the ability to produce a desired or intended result – in pharmacology it
describes the maximum response that can be achieved with a drug.
 ------- Ophthalmology -------
Vascular Diseases
1 A patient had sudden loss of vision unilaterally that lasted for 1 minute. She described it
as a curtain falling down. Her vision is completely normal now. Diagnosis?
a. Amaurosis fugax (sudden painless loss of vision lasting seconds-minutes
followed by spontaneous recovery – mostly unilateral)
b. Retinal artery embolism (cholesterol embolus / blood thrombus transient
blockage of retinal artery lasting for a few seconds-minutes clot breaks up &
vision is restored)
2 A patient with known history of DM & hypertension presents complaining of painless
transient loss of vision. He describes it as a “curtain falling down” that resolved within 15
minutes. Diagnosis?
A. Amaurosis fugax
B. Retinal artery embolism
C. Retinal detachment
3 A patient, known diabetic and hypertensive for many years, presents complaining of “a
curtain dropping over his eyes”. Diagnosis?
Retinal detachment (amaurosis fugax not an option + no mention if it resolved)
4 A patient, k/c of uncontrolled DM, came
complaining of sudden loss of vision (curtain across
his eyes). He came to the ED (not mentioned
whether it resolved). On fundoscopy,a grey-colored
screen is seen, and part of the retina was raised.
Diagnosis?
A. Retinal detachment
B. Retinal artery occlusion

Prodromal symptoms: result from posterior vitreous detachment

Floaters
Flashes of light (photopsia)
Caused by traction on the retina (e.g., in posterior vitreous detachment via adhesion between the
retina and vitreous body)
Irritation of the retina and perception of optic sensations, such as flashes of light, may occur.
Photopsia is usually absent in the case of exudative retinal detachments.
Localized retinal detachment: scotoma (visual field defect)
Possible curtain or shadow either descending or ascending on the field of vision depending on the
location of detachment
The visual field defects may begin in either the nasal or temporal visual field.
Typically unilateral
Extensive retinal detachment and/or macular involvement
Sudden, painless loss of vision in the affected eye (often described by patients as a curtain
descending over their field of vision)
Relative afferent pupillary defect
References:[1][2][3]
5 A diabetic and hypertensive patient presented with the
complaint of loss of vision for 5 minutes. Picture of the
retina attached. What is the most likely diagnosis?

A. Retinal artery embolism cherry red spot

B. Retinal detachment

Glaucoma
6 A man had sudden pain in the eye associated with abdominal pain and vomiting. On
examination, he had a very red eye and ocular pressure was elevated. Diagnosis?
A. Open-angle glaucoma
B. Acute closed-angle glaucoma
Sudden onset of red painful eye & blurry vision + unwell feeling + nausea & vomiting +
headache + severe ocular pain. Eye appears injected and is tender & hard. Cornea appears
hazy & pupils semi-dilated.
7 An old man comes with open angle glaucoma. Management?
A. - blocker

B. Carbonic anhydrase inhibitor

C. Topical steroid
D. Topical -blocker timolol (B-blocker)
Uworld:
OPEN ANGLE: Timolol + Bimatoprost (topical) (to decrease the volume and pressure
of the aqueous humor) Others → Laser trabeculoplasty and surgical trabeculotomy
CLOSED ANGLE
Timolol, pilocarpine (cholinergic, induces miosis), and then IV acetazolamide
Surgical iridotomy or iridectomy
 Cataracts
8 A patient with a 25-year history of well-controlled diabetes is complaining of decreased
visual acuity in both eyes. He sees rings around light at night. There is no pain. What is
the most likely diagnosis?
A. Closed angle glaucoma
B. Cataract
C. Macular degeneration bilateral loss of central vision, grid test
D. Diabetic retinopathy
Clinical features usually develop gradually (especially in the case of age-related cataracts)
and depend on the localization and cause(s) of lens clouding.
Reduced visual acuity: blurred, clouded, or dim vision, especially at night
Impaired vision: painless, often bilateral
Glare: in daylight, in low sunlight, and from car headlights; associated with halos
around lights
Second sight: a temporary improvement in near vision; especially in patients with nuclear
cataracts
Monocular diplopia: double vision that disappears when the affected eye is covered or shut
Change in color perception
10 A diabetic and hypertensive patient (for many years) presents with difficulty in reading
small prints and halos in his vision (rings around light). Diagnosis?
A. Macular degeneration
B. Cataract
C. Myopia
Infections
11 A patient has a swelling near the lower eyelid medially. The lacrimal gland is inflamed.
Besides referral to ophthalmology, what do you give her? (Dacryoadenitis) Dacryocystitis
A. Oral antibiotic
B. Steroid
C. Anti-inflammatory Warm compress, NSAIDs, then systemic antibodies
Others
12 Which of these fundoscopic changes is seen in hypertension but NOT on fundoscopy of a
patient with diabetic retinopathy?
A. AV nipping
B. Microaneurysms
C. Neovasculature
D. Hemorrhage
Diabetic Retinopathy

Treatment:
§ Mild non-proliferative = anti-VEGF (bevacizumab)
§ Moderate & severe non-proliferative = anti-VEGF + laser
§ Proliferative = anti-VEGF / laser / surgery
13 Which changes are not seen in hypertensive retinopathy? Super sus question
A. Arteriovenous nipping
B. Microaneurysm
C. Exudates
D. Papilledema
Hypertensive Retinopathy
Hypertensive retinopathy
Arteriosclerotic and hypertension-related changes of the retinal vessels
Initial reactive vasoconstriction (vasospasm), followed by sclerosis with breakdown of blood-retinal barrier
and subsequent hemorrhage and exudation
Fundoscopic examination
Cotton wool spots
Retinal hemorrhages (i.e., flame-shaped hemorrhages)
Microaneurysms
Macular star (results from exudation into the macula)
Hard exudates
Arteriovenous nicking: a tapering of a retinal venule at the point where a retinal arteriole crosses the
retinal venule
Elschnig spots: multiple, round, brown-black spots with a bright ring that are scattered throughout the
retina
Marked swelling and prominence of the optic disk with indistinct borders due to papilledema and optic
atrophy (end-stage disease)
The presence of papilledema in a hypertensive patient may indicate a hypertensive crisis and warrants
urgent lowering of blood pressure (
14 A patient with previous history of HIV came to the clinic. Ophthalmoscopic examination
showed cotton wool spots and hemorrhage in the posterior retina. Diagnosis?
A. HIV retinopathy there is cotton wool spots but not hemorrhage
B. Hypertensive retinopathy
15 A patient with TB came complaining of painful eye, red conjunctiva, and photophobia.
Most likely diagnosis?
A. Viral conjunctivitis
B. Bacterial conjunctivitis
C. Uveitis (ocular TB)
D. Glaucoma
16 What is the treatment of uveitis? Cyclopentate = DILATE, topical glucocorticoids
Cyclopentate (muscarinic antagonist = mydriatic)
§ Anterior = steroids / mydriatics / analgesia
§ Intermediate = steroids
§ Posterior = steroids / vitrectomy / cryotherapy / laser photocoagulation
17 A patient with heart failure and DM II was given additional medications (sulphonylurea
& amiodarone). Afterwards, he presented with uniliteral exophthalmos. TFTs were
normal. What is the most likely cause of the exophthalmos? TFTs are normal ???
unilateral ???
A. Amiodarone Causes hyperthyroidism / thyrotoxicosis
B. Ocular trauma
C. Thyrotoxicosis
D. Congestive heart failure
E. Digoxin

18 A patient came with bilateral itchy red eyes. On examination, there were scales on his
upper eyelids. What is the best management? (blepharitis)
A. Topical steroids
B. Wipe with wet warm cottons with baby shampoo
C. Antibiotic drops
Clinical features of blepharitis
Chronic or recurrent red, swollen eyelids and irregular eyelid margins
Crusty, scaly plaques, and/or oily deposits on the eyelid margin and eyelashes
Eye irritation and visual abnormalities

Treatment
Eyelid margin hygiene
Topical antibiotics, in severe disease

Mild to moderate symptoms — For patients with mild to moderate symptoms,

management consists of warm compresses, lid massage, lid washing, and artificial
tears. These patients can generally be managed by the primary care practitioner.

Topical antibiotics — We suggest topical antibiotic therapy for patients who do not
respond to the symptomatic measures described above.
19 An HIV +ve patient has symptoms of raised intracranial pressure. Features are consistent
with TB meningitis based on LP & CSF analysis. What is the most common optic
manifestations associated with his condition?
A. Internuclear ophthalmoplegia
B. Chorioretinitis (if not on TB medications)
C. Optic neuritis (if on TB medications) – most likely answer as the scenario might
have mentioned that he is on ethambutol ethambutol can cause optic neuritis
and color vision disturbances
D. Papilledema (associated with raised ICP)
§ Ocular manifestations of TB in patients include panophthalmitis / endophthalmitis /
posterior uveitis with choroidal tubercles / keratitis / lid mass.
§ Uveitis is the most common TB ocular manifestation.
20 A child was brought by his parents with proptosis, painful eye movements, and a red eye.
They gave history of periorbital abscess which was treated surgically 1 week ago. What
will you give him?
A. IV antibiotics
B. Oral antibiotics
C. Anticoagulants
D. Anticoagulants + antibiotic
E. Surgery
Proptosis + ophthalmoplegia = orbital cellulitis managed by IV antibiotics (cavernous
sinus thrombosis is very rare so I don’t think we need to give anticoagulants)

Features that distinguish cavernous sinus thrombosis from orbital cellulitis include cranial
nerve dysfunction, bilateral eye involvement, and mental status changes. Diagnosis is
based on neuroimaging. MRI is the better study, but CT is also helpful.
Orbital Cellulitis Preseptal Cellulitis
Definition Infection of orbital contents (fat & Infection of eyelid & periorbital soft tissue
extraocular muscles)
Etiology • Most common: Complication of URTI (bacterial rhinosinusitis)
• Acute dacrocystitis
• Ophthalmic surgery
• Infection of teeth / middle ear / face • Local trauma to face / eyelids
• Infected mucocele • Insect / animal bites
• Orbital trauma
Epidemiology Children > adults
Clinical Features • Proptosis + ophthalmoplegia • Ocular pain
• Fever & malaise • Eyelid swelling & erythema
• Reduced vision (diplopia) • Less common: fever & chemosis
• Others (ocular pain / swelling &
erythema / chemosis)
Diagnosis Clinical
Treatment • Empiric IV antibiotics (vancomycin + • Mild non-systemic w/o fever: oral
ceftriaxone / cefotaxime / ampicillin- antibiotics (amoxicillin-clavulunate
sulbactam / pip-tazo / ciprofloxacin / +/- clindamycin / TMP-SMX /
levofloxacin) doxycycline if MRSA suspected) +
• If intracranial extension suspected: f/u
add metronidazole
• Abscess formation: surgical drainage
Complications • Subperiosteal / orbital abscess Very rare
• Blindness (optic nerve involvement)
• Brain abscess
• RARE: cavernous sinus thrombosis /
central retinal artery occlusion
21 What is the diagnosis?

Subconjunctival hemorrhage

Etiology
Transiently increased venous pressure (the most common cause of spontaneous SCH)
due to, e.g., Valsalva maneuver, coughing, vomiting
Traumatic eye injury
Hypertension
Diabetes mellitus
Coagulopathy
Fat embolism (e.g., in the context of long-bone fractures)
Clinical features
Painless red focal lesion visible against the sclera
Signs and symptoms of traumatic eye injury
Changes in visual acuity, photophobia, eye pain, foreign body sensation
Management
Spontaneous SCH: reassurance (usually resolves spontaneously)
Prognosis: good (usually resolves spontaneously within 2–3 weeks)
 ------- Orthopedics -------
Hands & Wrists
1 A young Bangladeshi male is complaining of
pain along the first metacarpal bone. It increases
with ulnar deviation. Diagnosis?
De Quervain Tenosynovitis
2 A lady developed wrist pain 2 months after
delivery. Finkelstein test was positive.
Diagnosis?
A. De Quervain tenosynovitis
B. Carpal tunnel syndrome
C. Acromial bursitis
Pain with or without swelling of the radial
styloid
exacerbated by movement/grasping objects.
Positive Finkelstein test: examiner grasps the
affected thumb and exerts longitudinal
traction across the palm of the hand towards
the ulnar side, which causes pain

3 A man fell off his bicycle and landed on his outstretched

hand. X-ray provided (showing hair-line fracture of the
distal radius). Diagnosis?

A. 1st metacarpal fracture

B. 2nd metacarpal fracture
C. Radial fracture
D. Scaphoid fracture

4 How do you manage a displaced radial fracture?

ORIF

Options include open reduction and internal fixation, fracture fragment excision, and
resection of the radial head with prosthetic replacement.
5 A man cannot extend his wrist following trauma to his hand. Which nerve is injured?
A. Ulnar
B. Radial Wrist drop
C. Brachial plexus
6 A woman working on the computer for a long time is complaining of throbbing pain in
her hand and wrist, associated with loss of sensations over the thumb, index & middle
fingers, and medial aspect of the ring finger. Which nerve is affected? 3 and half
fingers
A. Median nerve (carpal tunnel syndrome)
B. Ulnar nerve
C. Radial nerve
 Forearm
7 A patient had a fracture of the radial bone after sustaining trauma. After reduction, the
limb was cold. What will you do?
a. Splint
b. Open reduction & internal fixation
c. Closed reduction & external fixation
d. Radial artery exploration
Elbow
8 A child fell from a tree and had a fracture of the lateral epicondyle. Management?
A. ORIF
B. Closed reduction
C. Splinting
Conservative (cast immobilization) if non-displaced.
If displaced: ORIF in adults & external fixation in children.

Conservative therapy
Indication: nondisplaced, closed fractures
Procedures
Hanging-arm cast or coaptation splint and sling for approx. one to two weeks with
subsequent follow‑up x‑ray and brace
Early physical therapy to restore function
Surgical treatment
Indication: open fractures, displaced fractures that cannot be reduced, associated injuries
(nerves, blood vessels), floating elbow (simultaneous humerus and forearm fracture),
pseudarthrosis
Procedures
Internal fixation using plates and screws, or intramedullary implants (especially
supracondylar fractures)
External fixation (e.g., open fracture, polytrauma)
Arthroplasty of humeral head or elbow (e.g., in complex fractures), especially in elderly
patients
9 A child has a supracondylar fracture with joint involvement. What will you do?
A. ORIF as per ortho dr
B. Full cast + external reduction
C. External percutaneous pinning
Arm
10 A patient had a fractured humerus with lateral displacement following trauma. How will
you manage him?
A. Splint
B. Open reduction & internal fixation
C. Closed reduction & external fixation
11 What nerve is likely to be injured due to a humeral fracture? Midshaft of humerus
Radial nerve
12 A patient fractured his humerus. He is unable to extend his wrist and fingers, and he has
loss of sensation of the thumb and forefinger on the dorsum of the hand. Which nerve is
affected?
A. Radial nerve (wrist drop)
B. Median nerve
C. Ulnar nerve
13 A patient fell on an outstretched arm. Now, he cannot extend his wrist and has weak
dorsiflexion. He also has sensory loss over the dorsum of the thumb. Which nerve is
affected?
Radial nerve
Shoulder
14 A diabetic patient is complaining of shoulder pain. Most likely diagnosis?
A. Osteoarthritis
B. Capsulitis
C. Frozen shoulder (adhesive capsulitis)

Definition: inflammation and fibrosis of the joint capsule leading to contracture of the
shoulder joint
Epidemiology [2]
♀>♂
Onset > 40 years of age (peak incidence 56 years of age)
Etiology: associated with diabetes mellitus, thyroid disorders (esp. hypothyroidism),
shoulder injuries (e.g., rotator cuff tear, proximal humerus fracture), and
prolonged immobilization
Clinical features
Typically affects the nondominant shoulder
Dull shoulder pain
Stiffness
Severe restriction of both active and passive range of motion of the glenohumeral joint in
all planes, especially:
External rotation
Passive abduction (restricted to < 90°)
Stages [3]
Freezing or painful stage: minimal synovitis with pain, causing a limitation of motion
Frozen or transitional stage: pain decreases, but proliferative synovitis continues (with
axillary adhesions and contraction of the capsule).
Thawing stage: inflammation decreases, movement slowly improves
Prognosis: self-limiting course (improvement typically takes > 1 year)
Complications: atrophy of the deltoid and spinatus muscles
15 A tennis player is complaining of worsening shoulder stiffness. He reports that he hasn’t
been able to raise his arm above his head for the past 3 months. On examination, drop test
and cross-over test were negative. What is the most likely diagnosis?
 A. Rotator cuff tendinitis
B. Rotator cuff tear
C. Adhesive capsulitis
D. Shoulder osteoarthritis
Impingement / Tendinitis:
- Initially: pain with overhead activities & lifting arm to the side
- May be: pain with lowering the shoulder (mild at rest night pain)
- Weakness & loss of motion when raising arm above head
- Stiffness with lifting & movement
Tears:
- Intense pain after a sudden fall / injury
- Weakness of shoulder & arm + snapping sensation with certain movements
- Chronic: gradual worsening of pain / weakness / stiffness
- Pain at night experienced from the start & wakes them up from sleep – day pain is
tolerable
16 What is the best initial management of rotator cuff tendinitis?
A. MRI
B. Opioids to relieve pain
C. Refer to orthopedic surgical treatment
D. Refer him to physical therapy
First step is analgesia for pain (but NSAIDs not opioids) physical therapy

Conservative treatment
Acute
Avoid activities involving overhead movement
Antiinflammatory and analgesic medications (NSAIDs)
Physical therapy: In frozen shoulder, gentle mobilization is followed by progressive
exercises.
Chronic pain may require subacromial glucocorticoid injections.
Surgical treatment
Impingement: arthroscopic decompression, possibly open acromioplasty if evidence of
acromion narrowing is apparent
Rotator cuff tear: arthroscopic or open rotator cuff repair
Removal of calcium deposits with ultrasound-guided needle lavage or extracorporeal
shock wave therapy

UTD >> Once the clinical diagnosis of rotator cuff tendinopathy has been made, physical
therapy is the main treatment.
Back
17 Which of the following is an indication for surgical intervention of disc prolapse?
A. Loss of anal tone
B. Pain radiation to the thigh
C. Loss of sensation over the lateral side of the foot
Spinal cord compression, conus medullaris syndrome, and cauda equina syndrome are
medical emergencies that have the potential to cause permanent neurological damage.
18 A patient sustained trauma to the back after which he had lower limb weakness & low
sphincter tone. Which is the most important complaint?
 sphincter tone

Initiate immediate management of back pain with new neurological symptoms in

patients with back pain and new motor weakness, saddle anesthesia, and/or
bowel/bladder dysfunction.
19 A patient with a spinal injury was able to flex his leg but had loss of sensation over the
lateral side of the left leg. What will indicate a neurology consult?
A. Urinary retention
B. Loss of sensation in the leg
20 A patient with back pain had a +ve straight raise leg test. Which symptoms in a patient
with back pain direct to the need for urgent evaluation?
A. Difficult initiating micturition
B. Loss of ankle reflex
C. Sensory loss at the lateral aspect of the leg

Lumbar stenosis:
• Presents with pseudo claudication (pain in thighs & buttocks when upright or walking
but not when going upstairs)
• Treated by laminectomy

21 A woman is complaining of back pain. MRI showed spinal narrowing throughout many
levels. What is the best initial management? Spinal stenosis
A. Spinal manipulation
B. Physiotherapy
C. NSAIDs
D. Opioid analgesics
E. Decompression
F. Exercise

Conservative management [15][16]

First-line
NSAIDS
Physiotherapy
Second-line: epidural steroid injection
Surgery
Indications [3]
insufficient response to conservative therapy
Surgical options to relieve spinal cord compression [3][18][19]
Laminectomy
22 A patient was diagnosed with disc herniation. Management?
NSAIDs
23 A truck driver is complaining of lower back pain. Examination showed loss of lumbar
flexion. Next step?
A. Spine x-ray ??
B. NSAIDs
C. Bed rest
24 A lady felt back pain after heavy-load lifting. The pain was radiating to her lower limbs.
Anal tone was normal & there were no bladder issues or other red flags. Knee & ankle
reflexes are brisk and symmetrical. Best next step?
A. MRI
B. Back x-ray
C. Gradual return to normal activity
D. Bed rest for 2 days
Red flags = MRI; tenderness = x-ray; no tenderness = NSAIDs and gradual return to work
25 A policeman presented with back pain after lifting a machine from storage. He had no
urinary or nervous issues. Appropriate analgesic was given. What is your next step?
Gradual return to work
26 A policeman is complaining of back pain. He has decreased lordosis. On examination,
there is no tenderness. What is your next step? (mechanical back pain)
A. X-ray
B. MRI
C. Work as tolerated + NSAIDs
27 A 61 y/o female patient is complaining of sudden back pain when lifting her 3-year-old
grandson. She did not have weakness, urinary or stool incontinence. O/E, palpation of the
spinous process of T12 & L1 was painful. What is your next step of management after
giving analgesia?
A. X-ray of thoracic & lumbar spine
B. DEXA scan
C. Advise progressively increasing exercise
D. MRI of thoracic & lumbar spine
X-ray spine
Indications
Routine first-line modality for acute back pain in individuals with no neurological
abnormalities
Suspected vertebral fracture
28 A 61-year-old lady felt sudden pain in her back when lifting her grandson. She has no
weakness and no urinary or stool incontinence. On examination, there was tenderness
over the T12-L1 spinous processes. What is the next step?
A. MRI
B. X-ray
C. DEXA scan
D. Advise increased exercise
29 A 54-year-old truck driver is complaining of lower back pain due to lumbar lordosis for
which he has been taking NSAIDs. He is still complaining of pain. On examination, there

is tenderness over D12 and limited lumbar flexion. He was diagnosed with lordosis. What
is the next step?
A. X-ray
B. Work as tolerated
C. Bed rest
D. Reassure
30 A 21-year-old male came from Cameron to the UAE and passed the medical exam for his
visa. For the past 2 months, he has been having a low-grade fever. He underwent fixation
of his spine for a compression fracture. MRI images provided (before & after procedure).
What is the cause of his fracture?
A. Pott’s disease (mycobacterium bovis)
B. Staphylococcus aureus infection??? if it is osteomyelitis causing the fracture
C. Metastatic bone lesion
He passed his UAE visa exam SO NOT TB.
Staph is the most common cause of spinal infection and does not always present with
high-grade fever.
31 An Indian lady presents with back pain. She also has a fever and a cough. X-ray shows
osteopenia & sclerosis. What is the cause of her back pain?
Pott’s Disease (TB Spondylitis)

Pathophysiology
Hematogenous dissemination of infection to vertebral bodies following primary TB
Infection from vertebral bodies spreads to the intervertebral disk, causing
destruction and collapse of the disk
Common sites of involvement: thoracic and lumbar vertebrae
Clinical features
Constitutional symptoms
Back pain
Spinal tenderness
Kyphosis
Gibbus deformity
Neurological deficit (e.g., paraplegia)
Diagnostics
Imaging: x-ray, CT, or MRI of the spine
Involvement of multiple vertebrae
Osteoporosis of vertebral endplate
Disk space narrowing
Lytic lesions in the anterior vertebral body
Collapse of the vertebral body
Enlarged psoas muscle shadow (psoas abscess)
Spinal cord compression (seen on MRI)
32 An elderly patient with history of prostate cancer is complaining of difficulty walking &
back pain worsening at night. What causes back pain in patients with prostate cancer?
A. Cord compression due to metastasis
B. Decreased calcium
C. Osteoporosis
D. Rapid weight loss
33 A man came to the UAE recently. He comes to
you complaining of low-grade fever and back
pain. He denies any cough but has night sweats.
MRI of the spine showed cord compression in 3
levels which was managed surgically.
What is the cause?
A. Bone metastases
B. TB

Hip & Femur

34 A man developed shortness of breath after a femur operation. Diagnosis?
Fat embolism

Definition: potentially life-threatening condition caused by the entry of fat cells,

usually from bone marrow, into the circulatory system
Etiology
 Traumatic fat embolism (95% of cases)
Most commonly long bone fractures (e.g., femoral fracture)
Orthopedic surgeries
Clinical features
Symptoms develop within 12 hours to 2 weeks of the inciting insult
Hypoxia
Neurological symptoms
Petechial rash
Diagnosis: mainly clinical
anemia, thrombocytopenia

Treatment: supportive care in an intensive care unit

35 A 57 y/o female fell on her right leg after she slipped at home. She does not recall any
pain. She came to the ER where she had a shortened & externally rotated right leg. X-ray
provided showing fracture of neck of femur. Best management option is?
A. Open reduction & internal fixation
B. Bed rest
C. Analgesia
D. Hemiarthroplasty
E. Total hip replacement
Same question repeated with 70 year old lady hemiarthroplasty (less complications
than total hip replacement)

Surgical therapy (usually within 72 hours is indicated for unstable fractures ,

typically adduction fractures, and fragment dislocation
For children and young adults
Attempt preservation of the femoral head
Early open reduction internal fixation (ORIF)(within 6 hours)
For older adults: total hip replacement (THR) or hip hemiarthroplasty (UTD says
theres no difference between both)
36 A patient has a high steppage gate. He has history of a car accident during which he
sustained a cerebellar injury, and fractures of the hip & bilateral femurs. What injury
caused this problem?
A. Common peroneal nerve
B. Tibial nerve
C. Popliteal nerve
D. Cerebellar lesion stroke can cause this gait.
Classically, the gait associated with disturbed proprioception is described as high stepping
and stamping.

Seen in patients with unilateral or bilateral foot drop (i.e., weakness of foot dorsiflexion)
who lift one or both legs when walking, respectively, in order to prevent the foot dragging
on the floor.
Unilateral: peroneal nerve palsy, L5 radiculopathy
Bilateral: amyotrophic lateral sclerosis, peripheral neuropathies (e.g., Charcot-Marie-Tooth
disease, diabetic neuropathy)

Due to its anatomic course, the peroneal nerve is more susceptible to injuries at the level of
the knee; however, issues may arise at the hip involving the sciatic nerve or at the ankle
Knees
37 A camel rider sustained a kick to the lateral side of his right leg just below the knee
caused by the camel stick. The site is slightly bruised and tender to touch. During physical
examination, he is unable to either dorsiflex or evert the foot. There is loss of sensation
over the front and outer half of the leg and dorsum of the foot. If these observations are
the result of damage to a nerve bundle, which of the following is the most likely nerve
affected?
A. Lateral popliteal
B. Peroneal foot drop
C. Tibia
D. Sural
38 A diabetic patient with osteoarthritis developed knee joint pain after trauma. O/E there
was swelling, redness, and tenderness. He was unable to extend his knee. He was febrile
(?). Investigation?
A. Knee x-ray (if not febrile) >>>>> although this should be initial ??
B. Arthrocentesis (if febrile) septic arthritis u go for arthrocentesis
C. Rest & analgesia
39 A patient has swelling and tenderness over the knee and ankle. He has no previous history
of gout but has a positive history in the family. What is the best diagnostic investigation?
A. Serum uric acid level
B. Joint aspiration
40 A diabetic patient has bilateral knee osteoarthritis. He was advised to walk almost daily.
After 1 week, he presented with unilateral effusion & redness of his knee. Vitals were
normal (afebrile). Diagnosis?
A. Hemarthrosis > not logical
B. Gout > no history
C. Osteoarthritis exacerbation > why not??
D. Drug-induced > not logical
E. Septic arthritis only 50% of septic arthritis present with fever >> maybe cuz
diabetic
41 An old patient with osteoarthritis developed severe left knee pain after falling on it. It is
swollen and warm. Diagnosis?
A. Septic arthritis
B. Worsening of osteoarthritis
Acute onset
Classical triad of fever, joint pain, and restricted range of motion
Arthritis
Usually monoarticular
Most commonly affected joints: knees (followed by hip, wrists, shoulders, and ankles)
Joints are swollen, red, warm, and painful.
42 A patient developed septic arthritis. How do you manage him?
A. Send him to the ER
B. Arthrocentesis
Joint drainage
Native joints [9]
Therapeutic arthrocentesis (drained to dryness) is indicated in all patients.
43 What injuries can be diagnosed with Lachman test?anterior drawers test
A. Medial collateral ligament
B. Lateral collateral ligament
C. Anterior cruciate ligament
D. Posterior cruciate ligament

44 Which ligament is the most commonly injured (pointed at with an arrow)?

A. ACL
B. PCL
C. MCL
D. LCL

45 A patient came in following a knee injury. He cannot straighten his knee. He has medial
joint line tenderness with negative drawer tests. Lachman test is negative. What is the
most likely injured structure?
A. Medial meniscus
B. Medial collateral ligament
46 A female athlete is complaining of pain under the patella that started while she was
running and is occurring whenever she squats. All knee examination signs were negative.
What is the most likely diagnosis?
A. Patellofemoral syndrome
B. Meniscal tear
C. ACL rupture
D. MCL rupture
Common in young athletes
Clinical features
Retropatellar or peripatellar pain that worsens with knee flexion during weight-bearing
activity (e.g., ascending and descending stairs, jumping, running) or after periods of
prolonged sitting
Crepitus
Diagnostics
Clinical diagnosis
Treatment
Acute phase
POLICE principle
NSAIDs
Recovery phase
Physical therapy (e.g., quadriceps strengthening)
Switching to low-impact activities
 Legs
47 How do you manage this patient?
External fixation – comminuted long bone fractures aka a
fracture that has been broken in at least 2 places

48 A diabetic patient presented with leg pain. His distal pulses were present, but his right
foot was red, hot and tender. Random blood sugar was normal. X-ray of the leg & thigh
were normal (images provided). What is the best next step?
A. Above knee amputation
B. Below knee amputation
C. Syme’s amputation (if pulseless / gas gangrene)
D. IV antibiotics (pulse is present + x-ray normal)
Ankle
49 An athlete had an ankle injury above the level
of the medial malleolus. He developed lossof
sensation at the sole & loss of flexion of the
toes, as well as loss of inversion. Which nerve
was affected?
A. Posterior tibial nerve
B. Peroneal nerve
C. Medial plantar nerve
D. Lateral plantar nerve
E. Sural nerve

Tibial nerve
A terminal branch of the sciatic nerve
Arises at the apex of the popliteal fossa
Nerve roots: ventral divisions L4–S3
Posterior compartment of the leg
Sural nerve (see below)
Medial calcaneal branch: skin over the heel (not shown in image)
Medial plantar nerve: medial half of the sole (excluding the heel) and the plantar aspect of
medial 3.5 toes
Lateral plantar nerve: lateral half of the sole (excluding the heel) and the plantar aspect of
the lateral 1.5 toes
Tarsal tunnel syndrome
Tibial nerve injury
50 A gardener presented with ankle pain. He has no history of trauma. O/E, the ankle is
swollen, warm, tender, and red. What is the diagnosis?
A. Septic arthritis
B. Pseudogout??
Acute CPP crystal arthritis (pseudogout)
Clinical features
Acute attack of pain and swelling in the affected joint(s)
Monoarthritis (occasionally oligoarthritis)
Most commonly affects the knee and wrist; can also affect other large joints (e.g., hips,
ankles)
Typically self-limited
 Features that differ from acute gout
Longer duration of acute attacks
Possible systemic symptoms [5]
Triggers: can occur spontaneously or be triggered by joint trauma/surgery or acute illness
51 A football player presents with ankle pain & bruising at the joint line. He is able to walkon
it. There is no
tenderness at the tip
of the lateral
malleolus. What is
the first step of
management?
A. X-ray
B. Splint cast
C. Ice, rest,
compression,
elevation

Ottawa ankle rules:

used to indicate
whether x-ray for
ankle and midfoot
injuries is necessary
[9]
X-ray (plain) of the
ankle is indicated
when the patient
experiences pain in
the malleolar region
and has one of the
following features:
Tenderness at the
posterior border or
tip of the lateral
malleolus
Tenderness at the
posterior border or
tip of the medial
malleolus
Inability to bear
weight
 Fractures
Simple (Transverse) Compound (Open) Comminuted Greenstick

52 A patient had a bone cyst with a fracture on top. X-ray

provided. What is the type of fracture?

A. Comminuted
B. Spiral
C. Transverse
D. Greenstick
53 What type of fracture is this?
A. Green stick fracture
B. Comminuted fracture
C. Compound fracture

Tumors
54 What is the most common origin of secondary bone cancer?
A. Skin cancer
B. Lung cancer
C. Bone cancer
Common primary tumors are breast / prostate / lung.
55 An 18-year-old presents with a knee swelling. X-ray was
done and image attached (sunburst appearance &
periosteal reaction). Diagnosis?
Osteosarcoma
56 Which cancer is the least likely to metastasize to bone?
A. Pancreas
B. Thyroid
C. Lung
D. Prostate
Others
57 A man has progressive hearing loss. On further history taking, he tells you that his hat
size has increased. Skull x-ray shows sclerotic lesions with bone thickening. What is the
diagnosis?
A. Paget’s disease
B. Presbycusis (only explains hearing loss)
C. Osteopetrosis (inherited diffuse bone disease; sclerotic appearance on imaging)
Paget’s disease
- Idiopathic disease
- Lytic phase mixed lytic and blastic phase sclerotic phase quiescent stage
- Affects pelvis, skull, vertebral column, and long bones of LLs
- 70-90% asymptomatic
- Symptoms include bone pain / pathological fractures / bony deformities – ex. Saber
shin due to bowing of legs / skull involvement in 40% leading to skull enlargement –
ex: increased hat size / cranial nerve deficit / impaired hearing b/c of ossicle
ankylosis and narrowed internal auditory meatus, headache / cauda equina
syndrome /nerve root compress
- Diagnosis: high ALP / hyperuricemia / urinalysis shows increased markers of
collagen degradation / x-ray shows sclerotic & osteolytic lesions normal Ca
- Management:
o First line = bisphosphonates (induce apoptosis of osteoclasts)
o Second line = calcitonin (if bisphosphonates are poorly tolerated)
o Supportive = vitamin D3 + calcium + NSAIDs
o Surgical therapy indicated in case of bone deformities / biological fractures
58 A patient with 40% kidney function develops osteoarthritis. What analgesic do you
givehim?
A. Paracetamol
B. Ibuprofen
C. Celecoxib
D. Aspirin
 ------- Pediatrics -------
Cardiology
1 A 4-year-old child was referred for a systolic murmur (2/6) heard on the left lower
sternal border. The murmur increases in intensity when lying down. What is the most
likely diagnosis?
A. Atrial septal defect presents in adulthood
B. Innocent murmur
C. Ventricular septal defect
8 S’s of Innocent Murmurs: Soft / Systolic / Short / Sounds S1 & S2 normal /
Symptomless / Special tests like x-ray & ECG normal / Standing or Sitting – varies with
position / Sternal depression
2 A male baby was brought by his mother for a routine checkup. On auscultation of the
chest, you hear a 2/6 holosystolic murmur between the 3rd and 4th parasternal spaces.
What do you tell the mother?
A. Surgery is needed immediately
B. He will have difficulty in breathing during feeding or later on in life
C. Reassure her that this is a normal finding
D. Tell her that this is a positive sign (VSD)
3 A 6-month-old baby has a pansystolic murmur on the LLSB. Cardio exam at 1-month of
age was normal. What is your diagnosis?
A. VSD (harsh holosystolic murmur; louder in small defects)
B. ASD
C. PDA
D. Innocent murmur
4 A 6 y/o healthy child with no active complaints comes for a regular checkup. O/E you
hear a 2/6 pulmonary ejection systolic murmur. CXR shows  pulmonary vasculature,
and echo shows right atrial & ventricular enlargement. Diagnosis?
A. Pulmonary stenosis
B. VSD
C. ASD (ejection systolic murmur)
5 A 4-month-old baby has a pansystolic murmur on the LLSB. Cardio exam at 1-month of
age was normal. What is your diagnosis?
What is the most likely explanation for the appearance of a new murmur?
A. Decrease in pulmonary resistance
B. Ductus arteriosus remains open in the early months
C. It was a big VSD at the start
Medium-large VSDs become symptomatic after high pulmonary vascular resistance
present at birth starts to decrease decreased right ventricular pressure increased
left-to-right shunt right ventricular volume overload & eccentric hypertrophy
excessive pulmonary blood flow pulmonary hypertension decreased CO left
ventricular overload & eccentric hypertrophy.

6 What is seen on the CXR of a child with VSD?

  pulmonary vasculature
Enhanced pulmonary vascular markings + left atrial & ventricular enlargement later
stages = right ventricular and pulmonary artery enlargement
7 What are the components of tetralogy of Fallot?

8 A young girl had a pansystolic murmur & pericardial rub. 2 weeks ago, she had fever &
a sore throat. Findings on investigation?
 ASO
9 A child is brought by his mother with the complaints of arthralgia and subcutaneous
nodules. How will you confirm the diagnosis?
A. ASO titer
B. Culture throat culture
C. ESR diagnoses for the minor criteria
The scenario gave 1 major & minor criteria therefore to DIAGNOSE we need ESR as
the second minor criteria. In order to CONFIRM we can either have high ASO or
culture / +ve rapid streptococcal antigen test.
Any of the following test results can confirm recent GAS infection:
↑ Antistreptolysin O titer (ASO)
↑ Antistreptococcal DNAse B titer (ADB)
Positive throat culture
Positive rapid GAS carbohydrate antigen detection test
10 A little girl has been having joint pain that shifts from one joint to another. She also has
chest pain when lying down. Which of the following will make you consider the
diagnosis of rheumatic fever?
A. Erythema marginatum
B. Erythema infectiosum
C. Fever of 37.5
D. Mitral regurgitation

11 A mother brought in her 10-year-old boy to ask if he is fit to participate in stress contact
activity. She is concerned because his first-degree cousin had sudden death while
running in a marathon at 19 years of age. What should you do?
A. Refer him to a pediatric cardiologist
B. Allow him to participate + request echocardiogram
C. Allow him to participate
D. Do not allow him to participate
Prior to initiating genetic testing in family members, relatives of an affected individual
should be clinically evaluated with history/physical examination, electrocardiography
(ECG), and echocardiography in order to identify clinical evidence of HCM.
12 What is a congenital cardiac inherited gene?
A. P53
B. Brac 1
C. NI
D. NOX2
Dehydration
13 A 9 m/o baby weighing 9kgs is 10% dehydrated. He has low BP and is tachycardic.
What is the deficit requirement?
A. 900 mL
B. 180 mL
C. 90 mL
D. 240 mL
If the question was asking about resuscitation, then it would be B (180 mL) – calculated
as 20 mL/kg.
14 A 9 m/o child is dehydrated. He is 9kg and his dehydration is estimated as 10%. He did
not pass urine for the past 12 hours. How much fluid do you give him?
A. 10 mL/kg NaCl
B. 20 mL/kg NaCl bolus
C. 5% dextrose 30 mL/kg
D. 10% dextrose 20 mL/kg
15 A 10-kg baby is dehydrated with 5% deficit. How much fluid will you give him in 24
hours?
A. 1,000 mL
B. 1,500 mL
C. 2,700 mL

Deficit should be 5 x10 x 10 = 500 ?? if with maintenance then add 100 ml/kg which
is 1000 so 1000 + 500 over 24 h
16 A baby weighing 9kg is dehydrated. How will you calculate how much NS to give him?
10% x body weight in grams
17 An infant is brought in with 2-day history of diarrhea. He is formula-fed by the nanny as
both his parents work. On examination, he is 10% dehydrated and has doughy velvety
skin. He seems lethargic and has a high-pitched cry. Lab values show hypernatremia
(155) & hypokalemia. Diagnosis?
A. Hypernatremic dehydration
B. Juvenile diabetes
C. Juvenile hypoparathyroidism
18 A 4-week-old baby was brought by his mother for dehydration. He had been vomiting
for 3 days. He had a high-pitch cry, and O/E his skin was doughy & velvet-colored.
Serum Na = 155 mmol/L & K = 2.3 mmol/L. What is the cause of his minimal clinical
dehydration?
A. Total body sodium
B. Extracellular fluid accumulation
C. Plasma protein
D. Intracellular potassium
Sodium retains the fluid in the plasma so no apparent volume depletion.
19 A child has hyponatremia and hypokalemia. Treatment?
A. NS
B. ½ NS
C. ¼ NS
20 Child with diarrhea for 48 hrs. No signs of dehydration. Normal vitals. Mx?
A. Reassure and tell mother about red flags of diarrhea
B. Give ORS and reassess after 48 hours
21 A child was brought to the ER with fever, rigors, and diarrhea. In the ER, he becomes
restless and develops a generalized purpuric rash. His BP was 60/40 mmHg. What is
your initial management?
IV fluids (septic shock)
22 A child with 15% dehydration was given IV fluids. Which is the best way to monitor for
good fluid response?
A. Urine output
B. Systolic blood pressure
C. Central venous pressure
D. Heart rate
23 A child is brought by his mother for vomiting due to congenital pyloric stenosis. He is
dehydrated on examination. Which of the following lab values correlate with his case?
A.  Na +  Cl +  K
B.  Na +  Cl +  K
C.  Na +  Cl +  K
D.  Na +  Cl +  K
Hypokalemic hypochloremic metabolic alkalosis
24 A child was admitted with 10% dehydration due to diarrhea and vomiting. He had low
grade fever (38 C) and did not pass urine for 12 hours. What investigation is the most
important to order?
A. CBC & blood culture
B. Stool microscopy & culture
C. Urea & electrolytes
D. Urinalysis
25 A baby was brought for scalding hot water burn extending from the umbilicus to the
groin & both lower limbs. That child was not in distress. What will be affected the most?
A. Sodium (amboss says hyponatremia in acute phase)
B. Urea
C. Water balance
D. Hemoglobin
 Blood gas analysis: monitor for hypoxemia, metabolic, and/or respiratory acidosis
Serum electrolytes: hyperkalemia and hyponatremia occurs in the acute phase
following burns; hypernatremia may occur later. [4]
BUN/creatinine: monitor for acute renal injury
Hemoglobin, hematocrit : monitor for hemolysis
Serum protein and albumin levels

Dermatology
26 A child is brought by his mother for a rash. The nurse sent him back home because it is
contagious. On examination, you notice a pearly rash. Diagnosis?
Molluscum contagiosum

Physical examination: single or multiple lesions in healthy patients; especially

widespread in immunocompromised patients [3]
Nontender, skin-colored, pearly, dome-shaped papules with central umbilication
Predilection sites:
face , trunk , and extremities;
lower abdomen, groin, genitalia, and proximal thighs
Endocrinology
27 A 13-year-old girl was brought for polyuria, polydipsia, and nocturnal enuresis. She has
history of head trauma 1 week ago after falling off her bicycle. Labs show Na = 148,
normal K & Cl, and low urine specific gravity. CT head is normal. Diagnosis?
A. DM
B. Central diabetes insipidus head trauma
C. Nephrogenic diabetes insipidus
D. Psychogenic polydipsia

28 A child was found to have an enlarged thyroid like all the other children living in the
same area. On examination, there is no tenderness. What is the most likely diagnosis?
A. Simple diffuse goiter (endemic iodine deficiency)
B. De Quervain thyroiditis
C. Multi-toxic goiter
D. Grave’s disease
29 A newborn had a big clitoris and fused labia. She has XX chromosomes with uterus and
both ovaries present. Diagnosis?
A. Female pseudo hermo (intersex) congenital adrenal hyperplasia
B. Male pseudo hermo
C. Androgen insensitivity
30 A female child was born with congenital adrenal hyperplasia. She presented with severe
masculinization of the genitalia. What will you tell the mother?
A. Child may be infertile
B. Child may require a clitoroplasty
C. She has an increased risk of ovarian cancer
D. Laparoscopy will be needed to visualize her pelvic organs

31 A child has salt-losing adrenal hyperplasia & ambiguous genitalia. What test is done to
confirm the diagnosis?
A. Testosterone
B. Estrogen
C. 17-hydroxyprogesterone
32 A 6-year-old girl with breast tanner stage 3 has underwent thelarche and pubarche. Her
FSH + LH and estradiol are 60. What is the diagnosis?
A. Hypothalamic
B. Dysplasia
C. McCune Albright Syndrome
D. Constitutional precocious puberty

ENT
33 A 4 y/o child has fever, ear pain, and rhinorrhea. O/E she has cervical lymphadenopathy
& a mobile eardrum. Management? Viral
A. Paracetamol
B. Amoxicillin
C. Decongestant
D. Grommet insertion
E. NSAIDs
 Uncomplicated AOM is self-limiting in most children (∼ 80%). [1][8]
Outpatient observation and surveillance of symptoms for 48–72 hours
Oral analgesia [2]
Acetaminophen
Ibuprofen

34 A 3 y/o female has had 5 attacks of ear pain (in how long?). This time, her temperature
is 39C, and she has bulging & erythema of the eardrum. Next step in management?
A. Refer to an ENT surgeon
B. Assess her hearing
C. Grommet insertion (decreases pain; used for recurrent attacks)
D. Antibiotic
Recurrent otitis media = (> 3 attacks in 6 months) OR (> 4 attacks in 1 year)

Systemic antibiotic therapy in AOM is recommended to relieve symptoms and reduce the
risk of complications in young infants and patients with severe infections. [2]
Topical antibiotics are generally ineffective in treating AOM unless tympanostomy tubes
are present.
Indications
Children [2][8]
Age ≤ 6 months
Age < 2 years with bilateral AOM [1][2][22]
Any age with:
Symptoms that have not improved after 48–72 hours
Severe AOM
Signs of severe systemic illness
Otorrhea not due to otitis externa
Cochlear implants [25]
Adults: Antibiotics (e.g., amoxicillin) are typically given to prevent complications.
35 A child had recurrent otitis media for 2 years. She is irritable and has disturbed sleep.
What advice do you give the mother?
A. Surgical consult
B. Skin biopsy
C. Reassure
36 A child is brought with fever, tonsillar exudates, rash, peri-oral pallor, and cervical
lymphadenopathy. Next step? Scarlet fever? +ve strep throat culture
A. Admit her to start IV benzopenicillin (for non-compliant patients)
B. Echocardiogram
C. Throat culture & wait for the results
D. Throat culture & give methohydroxypenicillin PO (or oral
phenylpenicillamine)
E. IV Ig
Indication: All cases of scarlet fever should be treated with antibiotics, both to
prevent complications and to prevent transmission.
Drug of choice: oral penicillin V
In patients allergic to penicillin: macrolides
In cases of recurrence due to antibiotic resistance: cephalosporins
After 24 hours of antibiotic treatment, the patient is no longer infectious and may
return to daycare or school. [1]
37 A boy presents with symptoms of acute tonsillitis. What antibiotic will you give?
A. Penicillin
B. Amoxicillin
C. Augmentin
D. Fluoroquinolone

38 A young child has recurrent tonsillitis for which he has been treated for in the past 6
months. He also has distorted speech. O/E he has bilateral tonsillar enlargement. What is
the indication for a tonsillectomy in his case?
A. Breathing problem??
B. Recurrent tonsillitis (> 6x per year)
C. Effect on speech
D. Bilateral tonsillar enlargement

39 A 5 y/o boy had URTI symptoms for the past 2 days. He presented with fever,
respiratory distress, and drooling. He can’t lay down & prefers to sit up. He also
developed stridor. Diagnosis?
A. Croup
B. Epiglottitis
Respiratory distress (inspiratory retractions, cyanosis)
Inspiratory stridor
Tripod position: eases respiration as the airway diameter is increased by leaning
 forward and extending the neck in a seated position
Sore throat
Dysphagia and odynophagia
Drooling
Muffled voice (i.e., resembling a “hot-potato” voice) with painful speech
Acute onset of high fever (39–40°C; 102–104°F)
Toxic appearance
Restlessness and/or anxiety
Absence of cough
Tenderness to palpation over larynx/throat [3]
40 A child was brought in with epiglottitis. The doctor wanted to confirm with the
diagnosis with an x-ray. What will you find on x-ray?
Thumb sign epiglottitis
Steeple sign = croup
41 A 5-year-old previously healthy child has a 1-day history of severe pain in the throat,
breathing difficulties and fever. On examination you find an anxious, septic-looking
child with drooling of saliva and stridor. Which one of the following is the most
appropriate initial management?
A. Intubation under general anesthesia
B. Insertion of nasogastric tube
C. Fluid resuscitation and antibiotics IV
D. Anteroposterior & lateral neck x-ray
42 A child was brought in respiratory distress. He was drooling and had audible stridor
(epiglottitis). How will you manage him?
A. Intubation
B. IV ceftriaxone for 7-10 days
C. Rifampicin for close contacts
Endotracheal intubation [4][6][8]
Indications
Respiratory distress
Altered mental status
Inability to swallow
Stridor
Drooling
Voice changes
43 A child was brought in with cough & fever. O/E he had inspiratory stridor. Diagnosis?
Laryngotracheobronchitis (viral croup) Parainfluenza virus
44 A child was brought on for sudden onset of SOB & cough. O/E, he is active but there is
decreased air entry to 1 lung. Diagnosis?
Foreign body aspiration
45 A child had decreased breath sounds over the right infra-scapular region. His
presentation started 2 hours ago.
Foreign body aspiration
46 A mother noticed her baby choking on feeding 2 days after birth. She had
polyhydramnios during her pregnancy. The nurse is unable to pass an NGT till the
stomach. Diagnosis?
A. Tracheoesophageal fistula
B. Choanal atresia
Gastroenterology
47 A 4-week-old baby is brought by his mother due to vomiting after eating. The vomitus is
non-bilious and not associated with diarrhea. He is eager to feed. On abdominal
examination, there is an olive-like mass. Diagnosis?
A. Hypertrophic pyloric stenosis
B. Intussusception
48 A 4-week-old baby has a palpable olive mass on examination. What symptom do you
expect him to have?
Projectile vomiting

Symptoms usually develop between the 2nd and 7th week of age (rarely after the
12th week).
Frequent regurgitation progressing to projectile, nonbilious vomiting immediately
after feeding
An enlarged, thickened, olive-shaped, nontender pylorus (diameter of 1–2 cm)
should be palpable in the epigastrium
A peristaltic wave, moving from left to right, may be evident in the epigastrium
"Hungry vomiter": demands re-feeding after vomiting, demonstrates a strong
rooting and sucking reflex, irritable
If left untreated: dehydration, weight loss, failure to thrive
49 A 9-month-old infant was recently started on solid diet. His mother noticed that he has
been having diarrhea and bloating after ingestion of foods. What is the cause?
Celiac disease (gluten intolerance)

Other options?
50 Clinical scenario of a child with intussusception.
This picture was provided. What is the mechanism
of the condition?
Mesenteric lymph node hyperplasia after
adenovirus infection

§ Causes = polyps / hard stool / lymphoma / viral

origin (ex: post-rota virus peyer patches enlarge risk of intussusception)
§ Best initial test = US
§ Barium enema = diagnostic & therapeutic
51 What test should be done for a patient with multiple sinus infections with history of
appendectomy and small bowel resection? Small bowel obstruction due to CF
A. Alpha-1 antitrypsin
B. Skin sweat test
52 A child has been having diarrhea for 4 days. Now he is passing bloody diarrhea and is
complaining of chills. What is the most likely causative pathogen?
A. Salmonella
B. Verotoxin-releasing E. Coli
It may lead to hemolytic uremic syndrome (hemolytic anemia + renal failure +
thrombocytopenia) in children & TTP in adults.

Toddler or preschooler with history of diarrheal illness

Presents with petechiae, jaundice, and oliguria

A diarrheal illness (usually bloody) for the past 5–10 days precedes the onset
of HUS symptoms in many children. The triad of clinical findings occurring
in HUS consists of:
Thrombocytopenia
Petechiae, purpura
Mucosal bleeding
Prolonged bleeding after minor cuts
Microangiopathic hemolytic anemia
Fatigue, dyspnea, and pallor
Jaundice
Impaired renal function
Hematuria, proteinuria
Oliguria, anuria
53 A 9 m/o female was brought with the complaint of 12 hours of diarrhea. She has no
vomiting nor fever but has 10% dehydration. Most common organism?
A. Rota virus
B. Norwalk virus
C. Shigella high fever
D. E. coli
A major cause of severe diarrhea in infants and children in the US
Leading cause of severe diarrhea among infants and children worldwide, although all age
groups are susceptible to infection.
Most commonly occurs in daycare centers and kindergartens
54 Mariam, a 30-month-old child, was brought by her mother to the clinic because she has a
long history of diarrhea. The mother says that “she never had well-formed stool”. She
passes non-bloody non-foul-smelling diarrhea around 4-6 x a day. Mariam is a delightful
child with normal growth for her age. Diagnosis?
A. Celiac disease
B. Crohn’s disease
C. Disaccharidase deficiency
D. Toddler’s diarrhea
Toddler's diarrhea—also called functional diarrhea, or chronic non-specific diarrhea
of childhood – is a common cause of chronic diarrhea in toddlers (ages 1-3) and pre-
school aged children (ages 3-5). Children with toddler’s diarrhea pass 4 or more
watery / loose stools a day and do not have any other symptoms.
55 A child has abdominal pain & red-jelly stool. On examination, he has a sausage mass in
the abdomen. Diagnosis?
Intussusception
Acute cyclical colicky abdominal pain (sudden screaming or crying spells), often with legs
drawn up, with asymptomatic intervals: Acute attacks occur approx. every 15–30 min.
Vomiting (initially nonbilious)
Abdominal tenderness, palpable sausage-shaped mass in the RUQ , and an “emptiness” or
retraction in the RLQ (Dance sign) during palpation
High-pitched bowel sounds on auscultation
“Currant jelly” stool: Dark red stool (resembling currant jelly) may be noticed in
passed stool or during digital rectal examination (usually a late sign).
Lethargy , pallor, and other symptoms of shock or altered mental status may be present.
56 A child has many polyps in the colon. What is the causative
gene mutation? Familial adenomatous polyposis <<
APC germ line mutation
57 A child had a liver & omental mass. Biopsy & peritoneal fluid analysis revealed high
eosinophils. What is the most likely cause?
A. Helminthic infestation
B. Hepatoblastoma
Genetics
58 Which factor causes the highest increase in risk of having a baby with Down Syndrome?
Maternal age > 40 years
59 What investigation should be done annually
for this child? Guidelines say both cbc and
tft
A. CBC with differentials
B. TFT
C. Lipid profile
D. Echocardiogram
60 A baby has atypical down syndrome features. What is the chromosomal abnormality?
Trisomy 47 XX + 21

Mosaic trisomy 21 (1–2% of cases)

Definition: two cell lines are present, the trisomy 21 cell line and the normal cell line
Pathogenesis
Nondisjunction during mitosis that occurs after fertilization
Depending on the timing of the mitotic error, there is a variable proportion of
trisomic and normal cells.
Phenotypic expression varies according to the ratio of healthy to trisomic cells.
Karyotype: either ♀: 46,XX/47,XX,+21 or ♂: 46,XY/47,XY,+21
Although symptoms may be less severe in mosaic trisomies, the clinical
manifestation generally provides no indication of the underlying genetic mutation
61 A newborn has upward slanting eyes, a flat nasal bridge, and single palmar creases.
What is the chromosomal defect?
A. Trisomy
B. Mosaicism
C. Monosomy
62 A baby has rocker bottom feet with clenched
fists & a small head.

Which syndrome does he have??

A. Trisomy 18 (Edward)
B. Trisomy 13 (Patau)
C. Trisomy 20 (Down)
D. Turner

63 A baby with dysmorphic features presents with tetany (Hypocalcemia). He has

history of multiple previous infections (abdominal / pneumonia / fungal). Echo
findings were [Link] organ is affected?
 A. Thymus
B. Spleen
C. Lymph
Di-George Syndrome (CATCH 22)

CATCH-22 is the acronym for typical features of

DiGeorge syndrome: Cardiac anomalies;
Anomalous face; Thymic aplasia/hypoplasia; Cleft
palate; Hypocalcemia; Chromosome 22.

Diagnosis
Detection of 22q11.2 deletion via fluorescence in
situ hybridization (FISH)
↓ PTH and Ca2+
↓ Absolute T-lymphocyte count
Delayed hypersensitivity skin testing
CXR: absence of thymic shadow
Treatment
Immune deficiency treatment
PCP prophylaxis
Consider bone marrow transplant and/or IVIG
Possible thymus transplantation
64 A 6-year-old boy has a long face & large ears. He has a learning problem as well. What
is the appropriate method of investigation? (fragile X syndrome)
A. FISH
B. Karyotyping
C. Molecular testing
Diagnosis
Molecular genetic detection (PCR, Southern blot)
Echocardiography

Clinical features: The clinical presentation varies depending on the number of

trinucleotide repeats.
50–200 repeats (premutation): ataxia, primary ovarian insufficiency, tremor
> 200 repeats (full mutation):
Intellectual disability of varying severity
Delayed language development
autistic behavior, hyperactivity
Characteristic facial anomalies
Long and narrow face
Prominent forehead and jaw
Large everted ears
Hypermobile joints
In men: postpubertal macroorchidism
Mitral valve prolapse: can lead to mitral regurgitation
Above-average head circumference
Growth & Development
65 A child was brought for a routine checkup. He has delayed speech & walking. What do
you tell his mother about his growth?

A. The doctor’s diagnosis is wrong

B. Growth chart is plotted wrong
C. The child is adjusting well according to
his age
D. Your child has FTT & you have
toinvestigate the cause (same pic
in google under FTT)

Inadequate growth of a child for their

age
Seen in up to 10% of children in the
United States (most < 18 months of
age)
Anthropometric criteria of FTT
Weight-for-age: < 5thpercentile
Length-for-age: < 5thpercentile
Deceleration of weight velocity that
crosses 2 major lines on the growth
chart
66 A child was brought for a routine checkup. He has
delayed speech & walking. What do you tell his
mother about his growth?

A. The doctor’s diagnosis is wrong

B. Growth chart is plotted wrong
C. The child is adjusting well according to his
age
D. Your child has FTT & you have to
investigate the cause
67 A 14-month-old boy was delivered 8-weeks preterm. The mother brought him as she is
concerned that he is not developing like his siblings did. She reports that he only says
“baba” and “mama” and has just started walking unassisted. He is unable to turn pages.
What do you do?
A. Explain to the mother that it is normal for a preterm to be delayed
B. Hearing and visual field testing
C. Reassure the mother that his growth is fine
D. Refer him to psychiatry
E. Evaluate him for autism
68 A 4-year-old child does not talk to others but responds to sound and squeals. He has no
interest in playing with others and prefers to sit alone & play with objects. Diagnosis?
A. ADHD
B. Hearing loss
C. Ankyloglossia (tongue tie)
D. Hypomania

A condition characterized by limited tongue mobility due to an abnormally short

frenulum. Can result in difficult lifting or protruding the tongue. Complications
include difficulty with breastfeeding and speech articulation.
69 A 30-month-old child uses only 2 words, and only his parents are able to understand
them. Next step?
A. Hearing test always rule out hearing loss
B. Language development assessment
C. Intelligence assessment
70 When will a baby start laughing out loud?
A. 2 months
B. 4 months
C. 6 months
D. 9 months
Hematology & Oncology
71 A 6-year-old boy presents with jaundice following treatment with sulphathiazole.
Investigations suggest that the jaundice is due to hemolysis caused by G6DP deficiency.
Which of the followings is true regarding etiology of G6DP deficiency?
A. Inherited as autosomal dominant condition
B. Inherited as sex-linked dominant condition
C. Inherited as sex-linked recessive condition
D. Results from autoantibodies to red cell antigens
X-linked recessive inheritance
72 An anemic child has an MCV of 60 & RDW of 18. Diagnosis?
A. Iron deficiency anemia
B. Thalassemia
73 An 18 m/o baby has microcytic hypochromic RBCs with anisocytosis. Diagnosis?
A. Iron deficiency anemia
B. Hereditary spherocytosis
C. Thalassemia carrier
CBC
↓ Hemoglobin: Anemia is typically defined as a hemoglobin level less than two standard
deviations below the mean (adjusted for age and sex). [1][13]
Women: nonpregnant < 12 g/dL
Men: < 13 g/dL
↓ Hematocrit
Red blood cell indices [12]
Mean corpuscular volume
Typically ↓ (microcytic)
Mean corpuscular hemoglobin
Typically ↓ (hypochromic)
Normal or ↓ reticulocyte count
Red cell distribution width (RDW)
Increases in established IDA
Peripheral blood smear: anisocytosis and hypochromasia (increased zone of central
pallor)

Iron studies
↓ serum ferritin
Further evaluation
↓ Serum iron
↑ Serum transferrin and total iron binding capacity (TIBC)
↓ Transferrin saturation
74 A 15 m/o baby is brought by his mother for SOB & lethargy. O examination, there is no
hepatosplenomegaly. Blood investigations showed reticulocyte count within the normal
range but  hemoglobin,  MCV, and  RDW (20). What is the best test for the most
likely diagnosis?
A. Iron deficiency (check ferritin)
B. Thalassemia trait normal RDW
C. Hemolytic anemia
D. Spherocytosis
75 A child was diagnosed iron deficiency anemia & was prescribed iron supplements 1.5
months ago. His hemoglobin is now normal. What advice do you give him?
A. Stop iron intake and repeat hemoglobin after 2 weeks
B. Continue iron intake for 12 months
C. Continue iron intake till 3 months (google says from 3 to 6)
D. Measure TIBC and base further management on the value
E. Continue iron till MCV is normal
76 A girl has iron deficiency anemia. Which parasite can be the cause?
A. Pinworm
B. Pig tapeworm
C. Hookworm
D. Fish tapeworm
Microcytic anemia (hookworms ingest blood from the intestinal wall)
77 A child was admitted to the hospital with Hb level of 9. He had reduced alpha chains
with excess alpha chains partially removed by chain formation. Diagnosis?
A. Thalassemia minor
B. Thalassemia major
C. Thalassemia intermedia
D. Alpha thalassemia
Alpha-thalassemia intermedia (HbH disease) and alpha-thalassemia major (Bart's
disease): faulty α-globin chain synthesis → ↓ α-chains → impaired pairing of α-
chains with β-chains and γ-chains→ ↑ free β-, γ-chains → ↑ HbH, ↑ Hb-Bart's
78 A 9 y/o Emirati female had a blood test that showed  RBCs, normal reticulocytes / Hb /
WBC / plts. Diagnosis?
A. Beta-thalassemia trait
B. Sickle cell trait
C. Hereditary spherocytosis
D. G6PD deficiency
microcytic hypochromic anemia
Hemolysis evaluation: nonimmune-mediated hemolytic anemia
↓ Haptoglobin, ↑ LDH, ↑ reticulocytes hyperbilirubinemia (indirect)
Peripheral blood smear findings include:
Target cells Teardrop cells Anisopoikilocytosis
79 What is the mode of inheritance of thalassemia?
A. Autosomal dominant
B. Autosomal recessive
C. X-linked recessive
Cause: gene mutations
Beta thalassemia: usually due to point mutations in promoter sequences or splicing
sites
β-globin locus - short arm of chromosome 11
Alpha thalassemia: usually due to deletion of at least one out of the four existing
alleles
The α-globin gene cluster is located on chromosome 16
 Inheritance pattern: autosomal recessive

80 A 4-week-old baby was brought with painful, swollen red hands and feet. He had a high-
pitched cry. On examination, his spleen was 2cm palpable and was tender. What is the
diagnosis? (sickle cell crisis)
A. HbSC disease (trait)
B. HbSS disease (disease)
C. Thalassemia major
D. Thalassemia minor

Sickle cell disease

A group of conditions characterized by mutations in the HbS genotype that result in
phenotypic manifestations similar to sickle cell anemia
Genotypes include HbSS, HbSβ0thal, HbSβ+thal, HbSC, and rarely, HbSD, and HbSE.
Symptoms range from mild to severe
Sickle cell anemia [1]
The most severe clinical presentation of sickle cell disease
Genotypes include homozygous HbSS and compound heterozygous HbSβ0thal (a form of
sickle beta thalassemia).
Sickle cell trait [2]
Refers to the sickle cell carrier genotype (HbAS)
Not considered a form of sickle cell disease
81 A child presented with hand & leg pain. Blood film shown.
Diagnosis?
Sickle cell anemia

Onset
Typically manifests after 3–6 months of age as the production of HbF decreases and HbS levels
increase
Acute manifestations
Vaso-occlusive events
Dactylitis in children < 5 years of age ; [6]
Typically the earliest manifestation of sickle cell disease
Vasoocclusive crises (sickle cell pain crisis) [1][7]
recurrent episodes of severe throbbing or sharp pain
Typically affects the limbs, chest, and back
dactylitis
Acute chest syndrome
Priapism
Stroke
Sickle cell hepatopathy
Organ infarctions (any organ; particularly the spleen)
Avascular necrosis
Infection
Pneumonia
Osteomyelitis; most common cause: Salmonella spp
Sepsis; most common cause: Streptococcus pneumoniae
Acute hemolytic crisis
Splenic sequestration
Aplastic crisis
Chronic manifestations
Cholelithiasis (pigmented stones)
82 A boy had mild hemolytic anemia associated with intermittent jaundice and right upper abdominal pain.
He has other features of sickle cell disease. What supplement should hetake?
A. Folic acid
B. Riboflavin
C. Cobalamin
In the body, folic acid gets converted to folate, which the body uses to make new red blood cells. Since
people with SCD have increased red blood cell production to make up for anemia, they may need more
folate. (google)
83 An 8-year-old has history of fatigue. Her hemoglobin level is 8. What is the most likelyindicator of
hemolysis?
A. Direct Coomb’s test
B. Indirect Coomb’s test
C. G6PD level
D. Haptoglobin level (low)
Also high ldh
84 A young boy has recurrent chest infections. On examination, he is pale & has [Link] likely
diagnosis?
A. Lymphocytic leukemia
B. Mixed immunodeficiency
Recurrent infections (low WBCs) + pallor (low RBCs) + petechiae (low platelets) in ayoung patient =
AML (most common leukemia in young children)
85 A child with leukemia on chemotherapy had very low neutrophils. No fever nor focal signs of infection.
Management?
A. Culture & wait for results
B. Start 3rd generation antibiotics (meropenem for febrile neutropenia)
C. Give immunoglobulin

86 A 12-year-old boy presented with increasing fatiguability associated with weight loss. On examination,
he has enlarged cervical lymph nodes. CXR showed a widened mediastinum. CBC showed a WBC
count of 20, RBC count of 2, and platelet count of20,000. Blood smear showed abnormal blast cells.
What investigation do you need to reach a diagnosis?
A. Bone marrow aspiration
B. Lymph node biopsy (lymphoma)
C. Mediastinal biopsy
D. CT scan

87 On which chromosome is the gene for hemophilia carried?

X chromosome
88 A boy presented with a warm swollen knee. His grandfather had a similar [Link] is the
clotting factor deficient in hemophilia A? 8 then 9 (A then B)
A. Factor VIII
B. Factor X
C. Factor IX hemophilia B
D. Factor II

- Hemophilia A (80%): factor VIII deficiency (x-linked recessive)

- Hemophilia B (20%): factor IX deficiency (x-linked recessive)
- Hemophilia C (very rare): factor XI deficiency (Ashkenazi Jews – autosomal
recessive)
- Von willebrand – Autosomal dominant
89 A 12 y/o female presented with hemarthrosis & bruises on her body. Her grandfather has
hemophilia A. What makes you exclude hemophilia A from the history?
A. Female gender (x-linked so only affecting males)
B. Presence of bruises
C. Grandfather having hemophilia A
90 A little boy is brought by his mother as he has a knee swelling & several bruises on hisleg. he reports
that he has history of a bleeding tendency and that he bled for 2 days after circumcision. His grandfather
had the same problem. Diagnosis?
Hemophilia A
91 A 12-year-old girl had a nosebleed with no trauma. She had the
same symptom some time back. Her 6-year-old brother had
prolonged aftera tooth extraction. You are suspecting an inherited
disorder. What would be the method of inheritance?
A. X-linked
B. Autosomal dominant (von Willebranddisease)
C. Autosomal recessive
The severity of symptoms varies between the different types of vWD. Type 1 and avWD usually manifest
more mildly; type 3 is the most severe form. [2][4]
Often asymptomatic
Symptomatic individuals may develop the following symptoms:
Mucocutaneous bleeding
Ecchymoses, easy bruising
Epistaxis
Bleeding of gingiva and gums
Petechiae
Prolonged bleeding from minor injuries
 Bleeding after surgical procedures or tooth extraction
GI bleeding (can be caused by angiodysplasia)
Menorrhagia (affects up to 92% of women with vWD) [5]
Postpartum hemorrhage
Severe cases: large hematomas, hemarthrosis, life-threatening bleeding (e.g., during childbirth)

Immunology
92 A 6-year-old child was admitted for lethargy. He has had multiple previous hospital admissions for
pneumonia. On examination he was found to have oral thrush. Whichdisease does he most likely
have?
A. X-linked agammaglobulinemia
B. SCIDS
C. DiGeorge Syndrome
Clinical features
Normal at birth
Severe, recurrent infections: bacterial diarrhea, chronic candidiasis (thrush), viral and protozoal infections
Failure to thrive Chronic diarrhea Lymph nodes and tonsils may be absent

Diagnosis
Quantitative PCR: ↓ T-cell receptor excision circles (TRECs); detection of TRECs is used in the newborn
screening for SCID
Flow cytometry: absent T cells CXR: absent thymic shadow Lymph node biopsy: absent germinal centers
Treatment
IV immunoglobulins PCP prophylaxis
Bone marrow transplant or stem cell transplantation - Avoidance of live vaccines
Prognosis: often fatal in the first year of life if left untreated
93 A child was brought by his mother for recurrent infections. His labs show  IgA,  IgM,
 IgG, and absent circulating mature B lymphocytes. He also had absent lymphoidtissue (no lymph
nodes or tonsils). What is your diagnosis?
A. Common Variable Immunodeficiency (CVID)
B. Severe Combined Immunodeficiency (SCID)
C. Bruton’s Agammaglobulinemia
Bruton agammaglobulinemia (X-linked agammaglobulinemia) [3]
Definition: X-linked recessive disease that causes a complete deficiency of mature B lymphocytes
Epidemiology: occurs mainly in boys
Etiology: defect of Bruton tyrosine kinase (BTK) expressed in B cells → complete deficiency of
mature B cells
Clinical features: Symptoms develop between 3 and 6 months of age when maternal IgG levels in
fetal serum start to decrease.
Hypoplasia of lymphoid tissue (e.g., tonsils, lymph nodes)
Recurrent, severe, pyogenic infections (e.g., pneumonia, otitis media), especially with encapsulated
bacteria (S. pneumoniae, N. meningitidis, and H. influenzae)
Hepatitis virus and enterovirus (e.g., Coxsackie virus) infections
Diagnosis
Flow cytometry Absent or low levels of B cells (marked by CD19, CD20, and CD21)
Normal or high T cells Low immunoglobulins of all classes
Absent lymphoid tissue, i.e., no germinal centers and primary follicles
Treatment
IV immunoglobulins Prophylactic antibiotics
94 A child had an eczematous rash and ecchymosis. You suspect child abuse but then find
out that his had similar complaints before he died from fungal meningoencephalitis.
What is the most likely diagnosis?
A. Wiskott-Aldrich Syndrome
B. SCID
C. CVID
WIPE triad: infections + purpura due to low platelets + eczema
Infectious Diseases
95 A child had a VP shunt placed when he was 3 years of age. He presents with a fever.
What is the best way to measure his temperature?
A. Rectal
B. Tympanic
C. Axillary
D. Oral
A rectal temperature is an internal measurement and is slightly higher at 37.6 °C.
A child has rectal temperature of 38C. He is conscious, playful, and generally doing
well. No findings on examination. Next step?
A. Observation
B. Blood culture
C. Antibiotics

96 What is the mode of transmission of measles?

Direct contact (or droplet inhalation)
97 A previously healthy, 10-month-old female child presents to your clinic with a 1-day
history of high fever, runny nose and conjunctivitis. The child looks unwell and is
irritable. Examination of the child's oropharynx shows that it is inflamed and there are
small white spots on the oral mucosa. Which one of the following is the most likely
diagnosis?
E. Kawasaki disease
F. Parvovirus infection
 G. Herpes zoster
H. Measles
Rubella and measles: prodrome fever & rash (face spreads downwards)
- Rubella prodrome: generalized tender lymphadenopathy
- Measles prodrome: cough / coryza / conjunctivitis / Koplik spots
98 A child was brought with the complaint of 2-day history of fever, cough, coryza, non-
purulent conjunctivitis, followed by the development of a pink maculopapular
morbilliform rash (face body). What is your diagnosis?
A. Chickenpox
B. Measles
C. Rubella
D. Kawasaki
99 Scenario of a patient with measles. What will help improve mortality / morbidity?
A. Vitamin A
B. Vitamin C
C. Ribavirin
D. Ig
100 A 9 y/o girl with mumps has ovarian swelling (mumps oophoritis). She presents with
abdominal pain & fever. Management?
A. NSAIDs
B. IV acyclovir
C. IV acyclovir & prednisone
D. IV methylprednisolone
101 A 10 m/o baby was irritable & had a fever that subsided. After 5 days, a maculopapular
rash developed. He had received a vaccine a few days ago. O/E there were no positive
findings. Diagnosis?
A. Roseola infantum first high fever then rash
B. Measles
C. Rubella
D. Erythema infectiosum slapped cheek disease
102 A child got pharyngitis with a maculopapular rash after coming back from a trip. On
examination, he has hepatosplenomegaly. What is the most likely cause?
A. Brucellosis flu-like symptoms, painful lymphadenopathy, UNdulant fever
(Temperature rises gradually and falls (like a wave) over days to weeks.)
B. EBV
C. Lyme disease
Clinical course
Symptoms typically occur in adolescents and young adults and last for 2–4 weeks.
Signs and symptoms
Splenomegaly, fever, fatigue, malaise
Pharyngitis and/or tonsillitis
cervical lymphadenopathy (especially posterior)
hepatomegaly
Maculopapular rash; The rash is caused by the infection itself in about 5% of cases
but is most commonly associated with the administration of aminopenicillin (e.g.,
ampicillin, amoxicillin)
103 A patient presents with cervical lymphadenopathy, fever, maculopapular rash,  WBCs
(18) and atypical lymphocytes on blood smear. His neutrophil count was 52. What
isyour diagnosis?
A. Lymphocytic leukemia
B. Lymphoma
C. Infectious mononucleosis atypical lymphocytes
D. Other infection

(19) Clinical suspicion of IM is confirmed via antibody testing.

(20) Monospot test
(21) Detects heterophile antibodies produced in response to EBV infection using RBCs
from sheep or horses
(22) Patient's serum is mixed with a solution of sheep/horse RBC in vitro
(23) Positive test: cross-reaction between heterophile antibodies and sheep/horse RBCs
→ agglutination
(24) Specificity of ∼ 100%, sensitivity of 85%
(25) Peripheral smear: lymphocytosis with > 10% atypical lymphocytes
104 An 8 y/o boy was brought to you complaining of a sore throat. Examination revealed
fever, lymphadenopathy, hepatosplenomegaly, and erythematous tonsils with
membranous exudates. He also had a faint macular rash. Most appropriate next step in
management?
A. Mono-spot test
B. ASO titer
C. Lymph node biopsy
105 A 6-year-old child has tonsillar exudates, hepatosplenomegaly, generalized
lymphadenopathy, rash, and fever. What will you find in his investigations?
A. Atypical lymphocytes on the peripheral blood film
B. Blast cells in bone marrow aspiration
106 A child has a high fever for 6 days associated with cervical lymphadenopathy,
maculopapular rash, red eyes, and cracked lips. What is your diagnosis?
A. Stills disease
B. SLE
C. Kawasaki
fever for at least 5 days
Specific symptoms include:
Erythema and edema of hands and feet, including the palms and soles (the first
week)
Possible desquamation of fingertips and toes after 2–3 weeks
Polymorphous rash, originating on the trunk
Painless bilateral “injected” conjunctivitis without exudate
Oropharyngeal mucositis
strawberry tongue
Cracked and red lips
Cervical lymphadenopathy (mostly unilateral)
107 A child came complaining of a swollen hot ankle joint, fever, anorexia, and fatigue. He
had the same complaints with a salmon rash 3 months ago; it was diagnosed as 5th
disease and treated. Current diagnosis?
A. Septic arthritis
B. Juvenile rheumatoid arthritis
C. ALL
D. Viral arthritis
Juvenile idiopathic arthritis
(Juvenile rheumatoid arthritis)

Systemic JIA (Still disease)

< 10% of cases
2–4 years [8]
♀=♂
Arthritis involving ≥ 1 joint AND
Intermittent fever that lasts for at least two weeks with fever spikes occurring on at
least 3 consecutive days AND
≥ 1 extra-articular manifestation
Monoarthritis, oligoarthritis, and polyarthritis possible (most commonly affects ≥ 2
joints) [9]
Often involves knees, ankles, and wrists
Transient, migratory, macular, salmon-pink rash
Generalized lymphadenopathy
Splenomegaly and/or hepatomegaly
Serositis (peritonitis, pleuritis, and/or pericarditis)
↑ ESR
↑ Acute phase reactants (e.g., CRP, ferritin)
Anemia, leukocytosis, and thrombocytosis
RF negative
NSAIDs
Poor response to methotrexate and TNF inhibitors (etanercept, adalimumab)
The clinical course is highly variable.
Complete remission occurs in 40–50% of cases.
108 A 6-month-old child has coryza, prolonged cough, and subconjunctival hemorrhage.
Diagnosis?
A. Bronchiolitis
B. Bronchitis
C. Croup
D. Pertussis
Catarrhal stage (1–2 weeks)
upper respiratory infection (mild cough, watery nasal discharge, rarely low-grade
fever)
Paroxysmal stage (2–6 weeks)
Intense paroxysmal coughing (often occurring at night)
Followed by a deep and loud inhalation or high-pitched whooping sound
posttussive vomiting
Infants (< 6 months) may only develop apnea and not the characteristic cough.
Convalescent stage (weeks to months)
Progressive reduction of symptoms
109 A child presented with fever and throat pain. On examination, he was febrile (38.6 C),
and had tender anterior cervical lymph nodes. He had throat exudates. What do you give
him?
Augmentin
Antibiotic used is usually penicillin / amoxicillin. In case of persistent infection or
 recurrence, amoxicillin-clavulanate is used.

110 A child has tonsillitis caused by streptococcus pyogenes. What antibiotic do you use for
treatment?
A. Penicillin
B. Amoxicillin clavulanate
111 A child has perioral pallor, tonsillar exudates, and small red papillae on her tongue.
Diagnosis? Strawberry tongue
Scarlet fever

Exanthem phase
Rash appears 12–48 hours after the onset of fever.
Scarlet‑colored maculopapular exanthem (rash)
Presentation
Fine, erythematous, sandpaper‑like texture
Blanches with pressure
Nonblanching petechiae are often additionally present
Pastia lines
linear, petechial appearance
in the groin, underarm, and elbow creases
Location
Begins on the neck
Tonsillopharyngitis
Pharyngeal erythema, possibly with tonsillar exudates
Strawberry tongue: bright red tongue color with papillary hyperplasia
Typical red, flushed appearance of the cheeks with perioral pallor
112 A child was brought by his mother with 3-day history of poor feeding. He also had a
sore throat. O/E, he was febrile and there was a maculopapular rash with circumoral
pallor. His tongue was coated with red papillae. Management? (scarlet fever)
A. IV antibiotics
B. Oral antibiotics + IV fluids (if he is dehydrated)
C. Oral antibiotics (if he is not dehydrated)
D. IV fluids
E. Oral antibiotics + antiseptic mouthwash

oral penicillin V
Alternative antibiotics
allergic to penicillin: macrolides
After 24 hours of antibiotic treatment, the patient is no longer infectious and may return
to daycare or school.
113 A child was brought by his mother to the ER for fever, rigors, and diarrhea. In the ER,
he becomes restless and develops a generalized purpuric petechial rash. His pulse rate
was 160 bpm, respiratory rate 25-30 rpm, and his BP was 110/60 mmHg. The nurse
gave him oxygen. What is your next step in management?
A. Dopamine
B. IV fluid (if needed according to amboss protocol)
C. Antibiotics (meningococcal picture)
D. 2 units of platelets
You have to start IV antibiotics as early as possible when suspecting meningococcemia
but you always have to resuscitate the patient first.
114 A child fell from a bed (2 feet) 12 hours back. He went to school & came back. Now he
is complaining of fever (40 C), photophobia, and seeing colored lights. He also has
nausea and vomiting. The mother also notes that she left her antidepressant pills in his
room. O/E there is +ve Kernig’s sign.
A. Antidepressant toxicity
B. Meningitis
C. Intracranial bleed
115 A child with a fever and a rash has BP of 110/70 mmHg. What is your next step?
A. IV fluids
B. Antibiotics
IV fluids not needed since he is stable. Management depends on the rest of the scenario.
116 A child was exposed to his grandfather in India who had tuberculosis. He is currently
asymptomatic. Tuberculin skin test was positive. What is the next step?
A. Bronchial / sputum for AFB
B. Gastric aspirate for AFB (in peds)
C. Chest x-ray
+ve PPD but asymptomatic CXR
Metabolic Diseases
117 A child had abnormal ears and forehead associated with hearing impairment. His eyes
are very pale blue in color. What metabolic disease can cause this?
Waardenburg Syndrome
It is a group of genetic conditions that can cause hearing loss and changes in the
pigmentation of hair, skin, and eyes. People with this condition often have very pale
blue eyes or different-colroed eyes (ex: 1 blue & 1 brown eye).
118 A child was brought in by his mother as she noticed decreased cognition. On
examination, he looked well-nourished, but his skin was wrinkled. He had blue eyes and
a musky odor. His abdomen was protruded. What can slow the decrease in cognitive
function?
A. Diet
B. Valproic acid
Increased tyrosine in diet slows progression in phenylketonuria
119 A mother brought her daughter who is on antiepileptics for generalized tonic clonic
seizures as she has started having more frequent attacks. She also has developmental
delay. On examination, she has dysmorphic features, blonde hair and blue eyes, and a
musty odor. Phenylalanine level is normal. There are some EEG changes. How can you
prevent further neurological delay?
A. Diet
B. Valproic acid
Treatment
Low phenylalanine and high tyrosine diet
BH4 deficiency: supplementation of BH4 and possibly levodopa and 5-
hydroxytryptophan
Musculoskeletal
120 A 6-year-old boy has been noticed to have problems with coordinating his voluntary
movements over the last two years. He has a waddling gait and needs to support himself
on his hands when rising from the floor. He has larger calves than other boys, but he
runs more slowly. Which one of the following is the most likely diagnosis?
A. Myotonia
B. Myasthenia gravis
C. Duchenne muscular dystrophy
D. Muscular atrophy
Progressive muscle paresis and atrophy
Starts in the proximal lower limbs (pelvic girdle)
Extends to the upper body and distal limbs as the disease progresses
Weak reflexes
Waddling gait (i.e., Duchenne limp) with bilateral Trendelenburg sign
Gower maneuver
The individual arrives at a standing position by supporting themselves on their thighs and
then using the hands to “walk up” the body until they are upright.
Classic sign of DMD, but also occurs in inflammatory myopathies (e.g., dermatomyositis,
polymyositis) and other muscular dystrophies (e.g., BMD)
Calf pseudohypertrophy (see pathophysiology above)
Scoliosis
Inability to walk by approx. 12 years of age
Cardiac and respiratory muscle involvement
Dilated cardiomyopathy: common cause of death
Cardiac arrhythmias
Respiratory insufficiency
121 A baby has delayed walking and calf-enlargement. His brother died of some muscular
disease. His mother is pregnant with a male fetus. What is the chance that the fetus has
the same disease? X-linked recessive Duchenne
A. 25%
B. 50%
C. 100%
It has the same inheritance patterns as autosomal recessive for human females. The
son of a female carrier has a 50 percent chance of having the trait.
122 An 8 y/o boy complains of pain in his calf muscles. The pain is mostly at night &
sometimes wakes him from sleep. It comes about every other day. Otherwise, he is
healthy & is described as a very active boy. Most likely diagnosis?
A. Rhabdomyolysis
B. Growing pain
C. Osteoid osteoma
123 A child has acute hip pain associated with limping. Most likely cause?
Transient synovitis
124 An obese kid has a painful hip radiating to the knee. On
examination, one leg was shorter than the other (and
externally rotated). X-ray provided.

Diagnosis?
A. Slipped capital femoral epiphysis
B. Transient synovitis
125 A child has a cast placed after a supracondylar fracture. The father notices pallor of the
limb. The limb remained pale after the cast removal. Next step?
A. Fasciotomy
B. Thrombolytic therapy
C. Heparin
D. Brachial artery exploration
126 A child with a tibial fracture required surgery. During the surgery, they found an area of
hyperdensity. A biopsy was taken; it showed monotonous blue cell sheet. What is the
diagnosis?
A. Ewing’s sarcoma
B. Osteosarcoma
C. Chondrosarcoma
D. Rhabdomyosarcoma
Clinical features
localized pain (progressive, worsens at night); tissue mass that is tender to palpation;
erythema
B symptoms
Diagnostics
Conventional X-ray
Lytic bone lesions
Onion skin appearance of the periosteum
Biopsy
Anaplastic small-blue-round-cell malignancy
Tumor cells resemble lymphocytes.
Differential diagnoses include lymphoma and chronic osteomyelitis.
Chromosomal translocation t(11;22); fusion protein EWS-FLI1
Laboratory findings: ↑ ESR, ↑ LDH, leukocytosis
127 A 13-year-old child has right leg pain that worsens at night. X-ray showed Codman’s
triangle. Diagnosis?
Osteosarcoma

Clinical features
pain (progressive, worsens at night and with activity)
tissue mass that is tender to palpation; erythema
Pathologic fractures
Limping, decreased range of motion
Possible B symptoms
Diagnostics [7]
Imaging
Conventional x-ray
Sunburst appearance of lytic bone lesions and/or Codman triangles
Biopsy
Pleomorphic, malignant osteoblasts that produce osteoid
Laboratory
↑ Alkaline phosphatase
↑ LDH
↑ ESR
128 A 9 y/o girl came with pain over the tibia & fever. She & her 2 sisters are anemic &
have a hematological disease. O/E she is febrile and has tenderness over the superior
edge of the tibia. Diagnosis?
A. Septic arthritis
B. Rheumatoid arthritis
C. Osteomyelitis
D. Gout
Acute osteomyelitis and subacute osteomyelitis [5]
Symptoms: pain at the site of infection
Possible localized findings: point tenderness, swelling, redness, warmth
Possible systemic findings: malaise, fever, chills
129 A 10-year-old girl with family history of a blood disorder presents with knee pain. What
is the most likely diagnosis?
A. Osteomyelitis (tibial tenderness + fever)
B. Septic arthritis (knee pain + fever)
C. Hemarthrosis (joint involvement in osteomyelitis is very rare)
130 What lab values do you expect to find in this child?

A.  ALP +  Calcium +  Phosphate

B. N ALP +  Calcium +  Phosphate
C.  ALP +  - N Calcium +  - N Phosphate
D.  ALP +  Calcium +  Phosphate
E. N ALP +  Calcium +  Phosphate
↓ Calcium and ↓ phosphate
↑ Alkaline phosphatase and ↑ PTH in rickets
Neonatology
131 When is a baby considered premature?
A. < 37 weeks
B. < 34 weeks
C. < 28 weeks
132 A macrosomic baby born to a diabetic mother had a glucose level of 2.2 mmol.
Management?
A. Glucose D5%
B. Glucose D10%
C. Tell the mother to wait till blood glucose 
D. Allow the mother to start feeding & check it again
133 A macrosomic baby born to a diabetic mother had a glucose level of 3.2 (or 3.4) mmol.
What do you do?
A. Encourage the mother to breast feed him (2.5 mmol and above)
B. Repeat glucose in 2 hours
C. 5% dextrose
D. 10% dextrose
134 A newborn baby was found to have hyperbilirubinemia, anemia, and hypoproteinemia
(hemolytic anemia in the first 24 hours). He is the 3rd baby to a mother with O – blood
who is also antiglobulin +. She had no antenatal care during this pregnancy. The father’s
blood group is unknown. What is the blood type of the baby?
A. B +
B. A +
C. AB –
D. O +
E. A –
 Problems with the Rh factor occur when the mother's Rh factor is negative and the
baby's is positive. Sometimes, an incompatibility may occur when the mother is blood
type O and the baby is either A or B.
ABO incompatibility can occur only if a woman with type O blood has a baby whose
blood is type A, type B, or type AB. If a baby is type O there won't be a problem with a
negative immune response because type O blood cells don't have immune-response
triggering antigens.

135 A 3-day-old term, breast-fed infant is brought by the mother who reports that the child
has not been active and not feeding well. She also notices jaundice, which was not
present at birth and is increasing. On examination, the temperature is 35.4°C, and the
liver is palpable 2 cm below the costal margin. Which one of the following is the most
likely diagnosis?
A. Rhesus isoimmunization
B. Inadequate breast milk
C. Congenital biliary tract obstruction
D. Sepsis (indirect hyperbilirubinemia; negative Coomb’s)
136 A 6-day-old boy, on breast-feeding, became hypotonic, jaundiced, and is feeding less.
His temperature is 35C, and his HR is 150bpm. What is your next step in management?
A. Septic workup
B. Phototherapy
C. IV fluid + antibiotic
137 A 3-day-old neonate was brought in for jaundice, poor feeding, and lethargy. On
examination, he had hepatomegaly. His temperature was 35.2 C. What is the most
appropriate action?
A. Urine for reducing substances + phototherapy
B. Bilirubin level + phototherapy
C. Conservative measures
D. Septic workup + cover with antibiotics
138 A 4-week-old baby was brought by his mother as she noticed his stools becoming
whitish and his urine becoming dark. He is feeding well. No other symptoms. O/E the
child looks well but has moderate jaundice. The mother shows you greyish stool on
hisdiaper. What is the next step?
A. Abdominal USS
B. CBC
C. Direct & indirect bilirubin
D. Liver function
E. Phototherapy

Physical examination for icterus

Bilirubin tests [7][8]
Transcutaneous bilirubin measurement
Serum bilirubin measurement
Differentiation of direct (conjugated) and indirect (unconjugated) bilirubin
Assessment of degree of jaundice based on nomogram → infants > 95thpercentile must
be evaluated for pathological jaundice (See “Other laboratory tests” below.)
139 A newborn developed jaundice on day 2
with total bilirubin of 260. Direct
bilirubin is . Which of these causes
will you not consider?
A. Breast milk (would be
prolonged)
B. Sepsis (direct would be high)
C. Physiological
140 A 21-day newborn was referred to you from the PHC for evaluation of his increasing
jaundice. He was delivered at term and weighed 2.8 kg. The baby looks healthy and is
breastfeeding well. The mother has no concerns, and her blood type is O+. On
examination, the liver & spleen were not palpable. When you checked the diaper, you
found grayish clay-colored stool. His total serum bilirubin was 360 mmol/L. What is
your next step?
A. Phototherapy
B. Exchange transfusion (he seems well enough so why exchange)
C. Urgent laparotomy
D. Reassurance
E. Abdominal x-ray
F. Liver function test & direct bilirubin (maybe this cuz next step)
141 A term baby had an APGAR score of 1 (1 minute), 5 (5 minutes), and 7 (10 minutes). There
was a true knot in the cord. He developed seizures in the next 24 hours. What willbe your
finding on the head CT of the baby?
A. Periventricular hemorrhage
B. Cerebral atrophy
C. Cerebral infarction
Hypoxic ischemic encephalopathy = cerebral infarction
142 A 4-week-old baby was brought in with vomiting for 2 days and fever of 38.9 C. His BPwas
80/58 mmHg. O/E there was no clear source of infection. Next step?
A. LP + blood culture + urine culture + start IV antibiotics
B. LP + blood culture + urine culture if WBC > 16,000
C. Start him on oral antibiotics
D. Rehydration & observation
143 An infant with mild respiratory distress, received resuscitation after delivery. There is 
breath sounds in the left side of the chest. He was delivered via instrumental delivery
(forceps). Diagnosis?
A. Meconium aspiration
B. Atelectasis
C. Diaphragmatic hernia
D. Pneumothorax
E. Emphysema
144 A baby was delivered using forceps. He had a low APGAR score & was in mild
respiratory distress. Air entry is absent on the left side. Diagnosis?
A. Pneumothorax >> most likely
B. Meconium aspiration >> utd doesn’t say no air entry
C. Congenital emphysema
D. Atelectasis
145 A baby did not cry well on delivery. He was diagnosed with meconium aspiration.
Management?
A. Suction of all meconium & intubation
B. Intubation & positive pressure ventilation
C. Oxygen mask
We concur with the guidelines of the American Heart Association (AHA), the American
Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists
(ACOG), which recommend against routine intrapartum nasopharyngeal suctioning of
newborns with meconium-stained amniotic fluid (MSAF).
146 A baby is in respiratory distress. Management?
Intubate
147 A breech baby had a brachial plexus injury during delivery. The baby now has breathing
problems. Cause?
Diaphragm weakness / paralysis (phrenic nerve injury)
148 A premature infant born at 30 weeks of gestation with SOB
required ventilation at birth. X-ray showed bilateralground
glass appearance. What is the diagnosis?

A. Bronchial pneumonia
B. Lobar pneumonia
C. Hyaline membrane disease aka infant respiratory distress syndrome
D. Meconium aspiration
X-ray chest
Interstitial pulmonary edema with perihilar streaking
Diffuse, fine, reticulogranular (ground-glass) densities with low lung volumes and air
bronchograms
Atelectasis
Blood gas analysis
Hypoxia with respiratory acidosis; may lead to increased lactate levels
Evaluate for partial respiratory failure or global respiratory failure
149 A full-term baby was born at 38 weeks of gestation with a birth weight of 2kg. What is
he at risk of?
A. Hypoglycemia (in diabetic mothers)
B. Hyperlipidemia
C. ARDS (associated with low birth weight)
Smaller gestational age, lower birth weight (LBW), lower serum albumin level, a higher
rate of preterm birth, premature rupture of membranes, antenatal steroid exposure, and
lower Apgar score were associated with an increased development of ARDS by
univariate analysis (P < 0.05).
150 A 2-day-old child has noisy breathing since birth but is feeding well. The mother brings
him in as he has a cold & cough that worsened the noisy breathing. On examination, he
is febrile and has inspiratory stridor. The stridor worsens with supine position.
Diagnosis?
A. Laryngomalacia
B. Bronchopulmonary dysplasia
C. Choanal atresia
Laryngomalacia [24]
Epidemiology
Most common cause of congenital stridor
Symptoms begin within the first 2 months of life and peak at 6–8 months.
Pathophysiology: congenital abnormality of laryngeal cartilage → increased laxity and
collapse of supraglottic structures during inspiration → airway obstruction
Clinical features
Appropriate growth and development
Inspiratory stridor: worsens in supine position, during crying, upper respiratory tract
infections, agitation, and feeding
Reflux may be present.
Severe cases: failure to thrive, sleep-disordered breathing
Diagnosis: Flexible laryngoscopy shows collapse of supraglottic structures during
inspiration and an omega-shaped epiglottis. [25]
Treatment
Reassurance (90% of cases resolve by two years of age)
Supraglottoplasty in severe cases (e.g., severe hypoxemia, apnea, pulmonary
hypertension, failure to thrive)
151 A 4-day-old neonate has abdominal distension and delayed passage of meconium (day
3). He did not pass any stool after the meconium. X-ray shows small and large bowel
loops. Diagnosis?
A. Volvulus
B. Intussusception
C. Hirschsprung’s disease
D. Malrotation
Early presentation
Delayed passage of meconium (> 48 hours)
Distal intestinal obstruction: abdominal distention and bilious vomiting
Digital rectal examination
Tight anal sphincter
Empty rectum
Squirt sign: explosive release of stool and air upon removal of the finger
Palpation of feces via the abdominal wall
Hirschsprung's disease in a 5-day-old male newborn
Late presentation [4]
Chronic constipation with possible inability to pass gas
Failure to thrive/poor feeding

152 What is the treatment of Hirschsprung’s disease?

Segmental colectomy
Surgical correction [6]
Objective: definitive treatment to remove the affected segment of the colon and bring the
normal ganglionic intestinal ends together
Procedures
Total transanal endorectal pull-through: preferred method that can be done in one stage
[6]
Abdominoperineal pull-through (Soave procedure): traditionally performed in two stages:
First stage: diverting colostomy to relieve the dilated bowel .
Second stage
Resection of the aganglionic segment
Anastomoses of the normal ganglionic colon segment to either the distal modified rectum
or normal (unmodified) distal rectum
Preservation of internal anal sphincter function is of the utmost importance.
153 What is the diagnosis?

Duodenal atresia

Clinical features
Intrauterine: polyhydramnios [4]
Postpartum
Vomiting that is typically bilious if the stenosis is distal to the major duodenal
papilla [4]
Atresia or high-grade stenosis: vomiting a few hours after birth [2]
Mild stenosis: vomiting after a few days
Distended upper abdomen and scaphoid lower abdomen [4]
Delayed meconium passage
Diagnostics
Prenatal: ultrasound [5]
Double bubble sign
Air and fluid build up proximal to the obstruction and are separated by the pyloric
sphincter, which resembles two bubbles on imaging, one in the stomach and one in
 the duodenum.
If present, test for associated anomalies (e.g., karyotyping, microarray) [6][7]
Polyhydramnios
Dilation of the stomach and duodenum (proximal to the obstruction) is common.
Postnatal: x-ray of the abdomen [4]
Gasless distal bowel
Double bubble sign

154 A 5-day-old baby was brought by his mother with the complaint of voluminous diarrhea.
He is exclusively breastfed. Urine showed reducing substances and was positive for
glucose. What problem does he have?
A. Congenital lactose intolerance
B. Isomaltase deficiency
C. Glucose-galactose malabsorption
D. Sucrase deficiency
E. Fructose malabsorption
F. Acquired lactase deficiency
Glucose-galactose malabsorption (GGM) is an inherited metabolic disorder. It is caused
by the small intestines not being able to absorb and use glucose and galactose (simple
sugars). Glucose and galactose have very similar chemical structures. The same protein
carries both sugars into the intestines. The intestines absorb the simple sugars which are
used throughout the body. The gene for GGM makes this enzyme work properly. When
this gene is changed (mutated), the enzyme cannot bring the simple sugars into the small
intestines, causing GGM.
155 What increases the risk of neonatal GBS?
A. Maternal GBS
B. ROM for 12 hours
C. Oligohydramnios
156 A newborn’s mother was diagnosed with chickenpox 2 days after delivery. She caught it
from her daughter who was infected from an outbreak at her nursery. What do you give
the newborn?
A. Prophylactic acyclovir
B. Immunoglobulins
C. Vaccination
Administer varicella-zoster immune globulin to infant if maternal infection developed 5
days before or 2 days after delivery
157 A 4-week-old neonate was born with congenital CMV. He has history of seizures and
brain atrophy. Which of the following will you find in the baby?
Hepatosplenomegaly
Blueberry muffin rash, chorioretinitis, sensorineural hearing loss
158 A 3-day-old baby girl was brought by her mother after noticing bloody vaginal
discharge. The baby was born full-term with no complications during the delivery. Next
step in management?
A. Admit her for vaginoscopy
B. CBC & culture
C. Reassure the mother
D. Low vaginal swab
Nephrology
159 A 7 y/o female patient had a UTI 6 weeks ago. The culture showed E. coli & an
antibiotic was given for 1 week. She is well now and is coming for a follow up. What is
the next step in management?
A. US & voiding cystourethrogram
B. Urine dipstick & culture weekly for 6 months
C. Urine culture if symptomatic
D. Continue antibiotic for 1 more week
E. Repeat VCUG every 3 months

For children with a first febrile UTI and without 1) abnormalities on renal
ultrasonography, 2) the combination of temperature ≥39°C (102.2°F) and a pathogen
other than E. coli, 3) poor growth, or 4) hypertension, a strategy of "watchful waiting"
(ie, observation and performance of VCUG with recurrence) seems reasonable

Several observational studies suggest there is little utility in repeating the urine culture
in children with UTI who are treated with an antibiotic to which their uropathogen is
susceptible…. However, urine cultures should be performed after 48 hours of therapy
if the patient fails to respond clinically or if the uropathogen is not susceptible
(intermediate or resistant) to the antibiotic that is being used for treatment.
160 A 6-year-old female has a UTI. Voiding cystourethrogram shows reflux. She was treated
with antibiotics. Now she is well and coming to the clinic for follow up after 4 weeks.
What will you do for her?
A. Follow up VCUG every 3 months for 2 years
B. VCUG when she is symptomatic
C. Continue antibiotics for 6 weeks
D. Renal US & cystography >> this??
E. Do urine dipstick & if positive do urine culture
Antibiotics indicated because of the reflux.
Antibiotic prophylaxis is discontinued when VUR
resolves spontaneously or is surgically corrected,
which is documented by contrast-voiding
cystourethrogram (VCUG), contrast-enhanced
voiding urosonography (ceVUS), or radionuclide
cystogram (RNC).

Imaging
Ultrasound
Indicated in children with febrile UTI and for follow-
ups
Detection of hydronephrosis and dilated ureter
Contrast voiding cystourethrogram (micturating
cystourethrogram)
Indications
Children with ≥ 2 episodes of febrile UTIs or
First febrile UTI in a child and any of the following:
A renal anomaly detected on ultrasound
Fever ≥ 39°C (102.2°F) and a pathogen other than E.
 coli detected in urine culture
Hypertension
Procedure: Contrast is instilled into the bladder
through a urethral catheter; images are obtained via
fluoroscopy while the child is voiding.
Findings: Retrograde reflux of the contrast into the
ureters during micturition is diagnostic of VUR.
Grading: VUR is divided into 5 grades of severity
based on the results of the voiding cystourethrogram.

161 What is the best investigation to determine the probability of hypertension in the future
in a child with a UTI?
A. Renal & bladder US in 1 week
B. Doppler US in 1 month
C. DMSA scan after 6-8 weeks (usually done 4-6 months after a UTI)
D. Voiding MCUG (usually done 2-4 weeks after a UTI – after infection settles)
E. IVP
Indications for DMSA scan:
- Child > 3 y/o with clinical pyelonephritis
- Atypical / recurrent UTI
Tests:
- DMSA = gold-standard for diagnosis of renal parenchymal scarring chronically
(and acutely useful for diagnosis of acute pyelonephritis)
- MCUG = gold-standard for diagnosis of VUR & to evaluate bladder anatomy
and emptying
- USS (KUB) = useful to assess the kidney size and anatomy + bladder thickness +
hydronephrosis / ureteral dilatation

162 A child had a viral infection 1 week ago and is now brought complaining of hematuria.
What investigation will you do?

A. Urinalysis
B. Renal US
C. Biopsy
163 A patient has been complaining of 1-week increase in periorbital edema, facial swelling
& puffiness, and scrotal edema. Best investigation to show the abnormality?
A. Urinalysis (PSGN – RBC casts)
B. Echocardiogram
Initial evaluation [1][4][5]
Urinalysis with microscopy: nephritic sediment
Hematuria with RBC casts
Proteinuria
Pyuria

SO DON’T CHOOSE BIOPSY

indications for renal biopsy — A biopsy is usually performed in patients in whom other
glomerular disorders are being considered because their disease courses deviates from
that of PSGN or they present late without a clear history of prior streptococcal infection.
(See 'Differential diagnosis' above and 'Course and follow-up' above.)
 ●Persistently low C3 levels beyond six weeks are suggestive of a diagnosis of C3
glomerulopathy as C3 levels typically normalize in patients with PSGN by this
timeframe. (See "Membranoproliferative glomerulonephritis: Classification, clinical
features, and diagnosis" and "C3 glomerulopathies: Dense deposit disease and C3
glomerulonephritis".)
●Recurrent episodes of hematuria are suggestive of IgA nephropathy and are rare in
PSGN.
A persistent or progressive increase in serum creatinine is uncharacteristic of PSGN, but
there are occasional patients whose renal function does not fully recover.
164 A 7 y/o boy came with edema in the scrotum, periorbital, and pretibial edema. 2 weeks
ago, he had a sore throat and was treated with amoxicillin. What is the best test to
confirm your diagnosis?
A. High protein in urine
B. High RBC
C. RBC cast PSGN, affecting the glomerulus. Anything affecting
glomerulonephritis causes RBC casts
165 A 15 y/o boy was brought by his mother complaining of periorbital edema that improves
during the day, as well as hematuria. Urinalysis showed red cell casts, and protein ++++.
He also has deranged renal function test & high ASO titer. He has history of URTI 2
weeks ago that was not treated. Diagnosis?
A. IgA nephropathy
B. Post-streptococcal glomerulonephritis
C. Membranous glomerulonephritis
D. Membranous glomerulonephritis
E. Acute renal failure
Approx. 50% of patients remain asymptomatic. Symptoms occur approximately 1–6
weeks following an acute infection.
Nephritic syndrome
Hematuria: tea- or cola-colored urine
Hypertension: can lead to headaches
Edema (prominent facial edema)
Oliguria
Influenza-like symptoms
Flank pain

166 A child with nephrotic syndrome develops renal vein thrombosis. Loss of which protein
can be the cause?
Loss of anti-thrombin 3
167 How do you treat minimal change disease?
Prednisolone
Neurology
168 A preterm baby was born with a birth weight of 1.2 kg & a low APGAR score at birth
developed severe hyperbilirubinemia. What is the most important predictor of cerebral
palsy in this baby?
A. Low APGAR score
B. Low birth weight
C. Hyperbilirubinemia
Idiopathic (most cases)
Risk factors:
Preterm birth and low birth weight (most important risk factors)
TORCH infection
 Perinatal asphyxia
Intracranial hemorrhage
Structural abnormality of the brain
Neonatal seizures
Kernicterus
Postnatal infection (e.g., meningitis, encephalitis)

All types
Patients do not reach certain milestones
Intellectual disability (50%)
Seizure disorder (35%–50%)
Joint contractures
Attention deficit hyperactivity disorder
Spastic type:
↑ Muscle tone in one or more limbs
↑ DTRs
Persistence of primitive reflexes (e.g., positive Babinski sign)
Toe walking or equinus deformity
Muscle weakness and/or atrophy
Scissor gait (as a result of spastic paraplegia of the hip adductors)
Hip dislocation
Scoliosis
Hearing or vision impairment
Non-spastic type:
Abnormal involuntary movements that worsen with stress and disappear with sleep
Chorea
Athetosis
Dystonia
Ataxia
Dysarthria and dysphagia
169 A 4 m/o girl was brought to you. She has a head circumference much larger than
expected. The vessels on her head are distended & she has sunset eyes. Most likely
diagnosis?
A. Macrocephaly
B. Hydrocephalus
C. Meningitis
Features of increased ICP
Headache, nausea, and vomiting
Papilledema
Abnormal gait
Impaired consciousness
Cushing triad
Abducens nerve palsy
Additional features in infants
Macrocephaly: an enlarged head with a circumference greater than the average for age
and sex by two standard deviations
Tense fontanelle
Setting sun sign: persistent downward deviation of the eyes due to increased ICP in
infants and young children
Developmental delays (e.g., psychomotor delays)
Behavioral changes (e.g., irritability)
Other findings
Changes in vital signs resulting from brainstem compression due to herniation
Lower extremity spasticity, hyperreflexia
170 A girl with a large head circumference and sunset eyes was intubated
after birth for 15 minutes. Imaging reveals the following. In which
direction can she not move her eyes?
A. Upwards
B. Downwards
C. Side-to-side
Setting sun sign: persistent downward deviation of the eyes due to increased ICP in
infants and young children
171 MRI of a child with ataxia shows a mass in the vermis (cerebellum). Diagnosis?
A. Medulloblastoma
B. Ependymoma
C. Stroke
Most common cerebellar mass in children.
172 A 5-year-old child had a seizure during which his eyes were deviated to the right. The
seizure lasted for 5 minutes. Afterwards, he was conscious and neurological examination
was normal. He has a history of UTI. What is the most likely diagnosis?
A. Frontoparietal lesion frontal lobe causing the seizure hence the eye deviation
B. Tay Sachs
C. Viral encephalitis
D. Hyper-insulin – hypoglycemia
173 A 10-month-old child had a viral infection during which he had an onset of a febrile
convulsion that lasted for a few minutes (simple convulsion). He had no neurological
deficits. What is the next step in management?
A. Give phenytoin
B. Give barbiturates
C. Do not give antiepileptic medication
D. Carbamazepine
E. Sodium valproate
Febrile seizures primarily occur during the rise in temperature; therefore, prophylactic
measures are often too late because a seizure cannot be anticipated! Long-term
continuous or intermittent prophylaxis with anticonvulsant drugs (e.g., phenobarbital) or
diazepam is not recommended.
174 A mother brings in her child after his teacher noticed that he has episodes of suddenly
gazing during class after which his attention returns to the class. The mother did not
notice anything similar but notes that he sometimes stops for a few seconds in the
middle of talking but then continues what he was saying. Diagnosis?
Absence seizure (petit mal)
175 A child has fever, poor feeding, and seizures for 2 hours. Electrolytes show  Na &
normal K. What is the cause of his seizures?
Low sodium
176 A 10 y/o girl complains of weakness, fatigue, and ptosis in the evening that improve in
the morning. Diagnosis?
Myasthenia Gravis

Clinical course
Symptoms worsen with increased muscle use throughout the day and improve with
rest.
Sometimes associated with exacerbating factors, including:
Medications
Pregnancy
Clinical manifestations [5]
 Eye muscle weakness: most common initial symptom
Triad of:
Ptosis
Diplopia
Blurred vision
Bulbar muscle weakness
Slurred speech
Difficulty chewing and/or swallowing
Proximal limb weakness
Rising from a chair
Climbing stairs
Brushing hair
Deep tendon reflexes are not affected.
Respiratory muscle weakness: causes dyspnea
177 Investigations done for a child revealed that he has peroxidase deficiency (Zellweger
Syndrome). What substance will accumulate in his brain?
A. VLDL
B. Ketones
C. Very long-chain fatty acids
D. Starch
E. Lactate
F. Glucose
178 A child is brought by his mother as he is complaining of
a chronic headache not relieved by medications. Hewas
admitted for investigations including MRI which is
provided.
The next day in the hospital, he was eating breakfast
when he suddenly developed fuzzy tunnel vision. Most
likely diagnosis?
A. Stenosis of the aqueducts
B. Saccular aneurysm rupture
C. Retinal artery obstruction
D. Carotid dissection
MRI showing intraventricular hemorrhage
Aneurysm compresses the ventricles headache
179 A child was brought in following an MVA. In the scene of the accident, he was holdingon
to his mom. When he was brought into the ER, he was crying without any reaction. He
had lacerations on his arms. On examination, he was febrile and had high blood pressure.
His pupils were sluggish to light. After a few minutes, he stopped responding. What is
your diagnosis?
A. Increased ICP
B. Anxiety attack
C. Tumor
180 What is the most common cause of headache in adolescents? Ages 10-19
A. Cushing’s
B. Essential hypertension
C. Renal disease
According to the literature, the secondary headaches due to non-life-threatening
diseases are the most frequent ones in pediatrics. In particular, respiratory tract
infections and minor head trauma represent the majority.???
181 A 3 y/o child has unilateral ptosis. Which nerve is
affected?

A. Oculomotor Levator palpebrae by CN 3

B. Facial unable to close eyes
C. Trigeminal
D. Optic
182 A 3-year-old boy has the following presentation.
Diagnosis?
Bell’s palsy

Additional signs of peripheral facial palsy

Sensory disturbances
Painful sensation around or behind the ear [6]
Impairment of taste in the anterior tongue
Hyperacusis
Dry mouth (as a result of decreased saliva production)
Ocular features
Bell's phenomenon: a physiologic, reflexive movement of the eye (upward and
outward) that occurs when the eyelid is actively closed
Lagophthalmos: The patient cannot fully close the eyes (due to paralysis of the
orbicular oculi muscle). [7]
Decreased lacrimation
Corneal ulceration and keratitis
Ectropion
Facial synkinesis: involuntary movements of the facial muscles (e.g., facial spasms
while closing the eyes)
183 A lady gave birth to a boy with spina bifida. This can be caused by low levels of?
Folic acid
 Psychiatry
184 A child cries when dealing with non-relatives. Diagnosis?
A. Stranger anxiety
B. Phobia
185 A child is missing school because of abdominal pain. The pain usually resolves by the
afternoon, and he is fine on the weekends. She tells you that when at school, she feels
like something terrible will happen. She also has nightmares and asks her mother to
sleep with her. Diagnosis?
A. Separation anxiety
B. Social phobia
C. Hypochondriasis
D. ADHD
186 A 9 y/o girl was brought to the clinic because of abdominal pain that has caused her to
miss a few days of school. She states that she feels like something bad is about to
happen on her way to school. She also has nightmares & asks her mother to sleep next to
her. The mother recalls that the girl had trouble adapting to her previous nursery (unlike
her sister who was fine). Diagnosis?
Agoraphobia – fear of being in inescapable situations (aka standing in a queue)
I think this is separation anxiety

Description: a disorder characterized by excessive fear, anxiety, or avoidance of

separation from major attachment figures
Separation anxiety disorder differs from nonpathological separation anxiety in its
intensity and effect on the social and academic life of the individual.
Separation anxiety is normal in children under a developmental age of 3 years. [30]
Typically develops after a stressful life event, usually involving some form of loss (e.g.,
death of a relative, parental divorce, change of school)
Onset: the condition can occur in, or persist into, adulthood and may have a debilitating
effect on an individual's ability to work or socialize in the absence of attachment figures.
187 A young girl has continuous thoughts of saying curse words. She can’t stop herself from
saying them even though she doesn’t want to. Diagnosis?
A. Obsessions (thoughts) >> I think its this ..
B. Reference
C. Compulsions (actions) >> this should relief the obsession .. in this case it seems
like it doesn’t.. maybe need more info for a proper answer
D. Delusions
Obsessions: distressing thoughts, emotions, and/or sensations that are recurring and
intrusive
Compulsions: repetitive actions to provide relief from anxiety caused by obsessions
(can take up a substantial amount of time)
188 A 3 y/o boy does not talk to others nor plays with them. When you see him in the clinic,
he makes no eye contact, does not answer your questions, and keeps playing with his
wheel. What is your diagnosis?
A. Infantile autism
B. Asperger’s syndrome - high functioning autism
C. Rett’s syndrome – developmental regression in girls, loss of purposeful hand use,
initially normal development. MECP2 gene mutation. Alternating episodes of
hypo and hyperventilation. Rocking back and forth
189 A child does not like to interact with people since birth. He likes to play alone and plays
only with a specific toy. Diagnosis?
Autism
190 A 4-year-old child does not talk to others but responds to sound and squeals. He has no
interest in playing with others and prefers to sit alone & play with objects. Diagnosis?
A. ADHD
B. Autism
Core features
Persistent impairment in communication and social interaction
Restricted, stereotyped patterns of behavior, interests, and activities
Repetitive movements (e.g., stereotyped hand movements)
Additional features
Intellectual impairment
Language impairment
Sensory abnormalities (sensation can be hyporesponsive or enhanced)
Mild ASD
No intellectual impairment
Symptoms may not become fully apparent until school age, when social impairments
and stereotypies begin to exceed limited capabilities.
Affected individuals may develop strategies that mask deficits later in life
191 A 7 y/o girl was talkative at home & playful with her brother. Her mother brings her in
complaining that she is shy & not interactive at school. She only whispers with her
friends via whispering. Diagnosis?
A. Selective mutism
B. Conduct disorder
C. Observation

Fails to speak in specific situations

192 A child has been having motor ticks in his shoulder & neck for the past year, along with
grunting. His teacher complains that he does not pay attention in class. Diagnosis?
A. Tourette syndrome multiple motor tics and >1 vocal tic for >1 year
B. Attention deficit disorder
C. Schizophrenia
D. Conduct disorder
193 A child has multiple motor tics (Tourette syndrome) and corpolalia. What is the best
medical treatment?
A. Carbamazepine
B. Diazepam
C. Haloperidol

Support: counseling and education (for both caregivers and patients)

Behavioral therapy
Indicated for mild, nondisabling symptoms
habit reversal training
Medical therapy [9]
Indicated for severe or refractive cases despite behavioral therapy
Alpha-adrenergic agonists: guanfacine; clonidine
Typical neuroleptic drugs: pimozide, haloperidol, fluphenazine
Atypical neuroleptic drugs: risperidone
tetrabenazine
Pulmonology
194 A 7 y/o boy developed a fever of 37.8C, runny nose, and cough. O/E, the child’s lungs
were hyperinflated & there was reduced air entry in the right lung. What is your next
step of management?
A. Septic workup
B. Chest x-ray
C. Antibiotics and IV fluids
195 A child has intermittent episodes of SOB that go away on their own after a few days.
This has been happening for the past year. One examination, there are rhonchi all
[Link] investigation?
A. Spirometry
B. Peak flow
C. CXR
The two most common lung function tests used to diagnose asthma are spirometry,
exhaled nitric oxide and challenge tests. Spirometry — This is a simple breathing test
that measures how much and how fast you can blow air out of your lungs. It is often
used to determine the amount of airway obstruction you have.
196 A child was brought in for audible wheezing. On examination, there are bilateral high-
pitched wheezes. He is afebrile. Most likely diagnosis?
Bronchial asthma

Asthma can be diagnosed in patients ≥ 5 years of age, based on a combination of: [8]
Demonstration of reversible bronchial obstruction
First-line: PFTs
Second-line (if initial PFTs are inconclusive): bronchial provocation tests
197 A 10 y/o school football player was brought to the ER due to an asthmatic attack. He
was given inhaled salbutamol & ipratropium. He recovered very well. Which treatment
would you add to his usual regimen?
A. Long acting -agonist
B. Fluticasone
C. Sodium cromoglicate
198 An 8-year-old child was brought by his mother with an acute asthma attack. Which if the
following indicate the severity
of his attack?
A. Heart rate > 130 bpm
B. Wheezy chest
C. Diminished air entry
D. Pulsus paradoxus < 10
mmHg

199 What indicates that an asthmatic patient should be admitted?

Inability to complete a sentence

Life-threatening asthma exacerbation (imminent respiratory arrest)

Inability to speak due to dyspnea
Drowsiness, confusion, sweating
Silent chest
Paradoxical breathing
Bradycardia
Altered mental status
PEFR (if performed): < 25% predicted
Signs of type I respiratory failure and/or type 2 respiratory failure
200 A child is brought to you with repeated chest infections caused by pseudomonas and
other bacteria (with strange names). Diagnosis?
A. Cystic fibrosis (pseudomonas is a major cause of lung infections in CF)
B. Primary ciliary dyskinesia
Immotile cilia syndrome (ICS) is an autosomal recessive disease with extensive genetic
heterogeneity characterized by abnormal ciliary motion and impaired mucociliary
clearance. Ultrastructural and functional defects of cilia result in the lack of effective
ciliary motility, causing abnormal mucociliary clearance. This leads to recurrent or
persistent respiratory infections, sinusitis, otitis media, and male infertility. In 50% of
the patients, ICS is associated with situs inversus.

They are both associated with the same mechanism for infection so need more info in
question.. but I suppose CF is more high yield so..
201 A child was brought by his mother as she noticed he had poor
weight gain despite a good appetite. He also had recurrent chest
infections with greenish sputum. CXR was done and showed
ground glass appearance. Best investigation?

Sweat chloride test

202 A girl with cystic fibrosis developed pneumonia. What is the most likely organism?
A. Staphylococcus aureus ??? staph in children, pseudomonas in adults
B. Pseudomonas aeruginosa
C. Hemophilus influenzae
Recurrent or chronic productive cough and pulmonary infections
S. aureus is the most common cause of recurrent pulmonary infection in infancy and
childhood.
P. aeruginosa is the most common cause of recurrent pulmonary infections in
adulthood.
Other commonly involved bacteria
Burkholderia cepacia: can lead to cepacia syndrome, a severe necrotizing
pneumonia
S. pneumoniae
dyspnea
203 A child with cystic fibrosis had staphylococcal pneumonia. He developed sudden
respiratory distress. His trachea was deviated to the right and he had decreased breath
sounds on auscultation over the left chest. There was dullness on percussion. Most
likelydiagnosis?
A. Pleural effusion (would have crackles on auscultation)
B. Pneumothorax
204 A lady pregnant with a girl wants to know the chances of the child having cystic fibrosis
as she has 2 kids with CF already. This means both the parents are carriers
A. 100 %
B. 75 %
C. 50 %
D. 25 % (autosomal recessive)
205 A 6-month-old baby was brought to the PHC with cough and fever. On examination, he
was febrile and there crackles over the chest. Diagnosis?
A. Bronchiolitis
B. Bronchitis
C. Croup
D. Pneumonia LRTI infection, no runny nose no SOB
206 A 2-year-old kid was brought in for a productive cough & fever. Neutrophils were high
and CXR showed infiltrated in 1 lobe (lobar pneumonia). What is the most likely cause?
C. Viral (RSV) nonproductive cough
D. Strep. Pneumoniae
E. Mycoplasma atypical pneumonia
207 A child has shortness of breath and a runny nose. On examination, he had a low-grade
fever and rales were heard over his lungs. Diagnosis?
Bronchiolitis
208 A 14-month-old baby was brought to the PHC with runny nose and shortness of breath.
He was febrile and there were wheezes on auscultation all over both lungs. Diagnosis?
A. Bronchiolitis SOB
B. Asthma
C. Croup
D. Strep. Pneumoniae infection

Initially, URTI symptoms (e.g., copious rhinorrhea, low-grade fever, cough)

Followed by LRTI symptoms [1][4]
Crackles, wheezes; on auscultation
Severe illness: respiratory distress (usually occurs in children < 1 year of age)
Tachypnea or apnea
Prolonged expiration
Nasal flaring
Intercostal retractions
Cyanosis
209 A child was brought by his mother to the ER for a cough. He seemed sick and had a low
BP. He was coughing but not in paroxysms. He also had paradoxical breathing and
supraclavicular recessions. What is the first step of management?
A. IV fluids
B. Oxygen
C. Antibiotics
D. ICU
210 A 7-year-old boy was brought by his mother with a runny nose and wheezing. On
examination, his RR was 45 rpm and he had intercostal recessions. What do you give
him? Note: racemic epinephrine for croup
A. Epinephrine nebulizer
B. Oxygen face mask
C. IV epinephrine
D. Intubation
211 A 12-year-old with moderately severe pneumonia was started on IV antibiotics. CXR
provided (showing pleural effusion). She is vitally unstable and oxygen saturation
was97% on room air.

What is the best next step?

A. Discharge her
B. Admit her in the ICU for observation
C. Surgical consult for chest tube insertion
D. Chest CT
E. Oxygen
Tube thoracostomy
Indications
Pleural effusion in combination with significant cardiac and/or respiratory
decompensation [36]
For recurrent pleural effusion or urgent drainage of infected and/or loculated effusions
[37][38]
Drainage of high-viscosity fluid that is likely to clog [39][40]
Empyema [38][41][42]
Hemothorax
Surgery
212 When will you treat an umbilical hernia in a
6-month-old boy?
A. 4 months
B. 9 months
C. 12 years
3-4 years

213 What is the management of an umbilical hernia in a 6-month-old baby?

A. Wait (no intervention needed at this time)
B. Surgery after 1.5 years
C. Surgery after 3 months
D. Surgery after 12 years
214 A 9 y/o girl presented with fever, and periumbilical pain initially that localized to the
RLQ. She also has nausea but no vomiting. Examination showed tenderness &
reboundtenderness in the RLQ. Diagnosis?
A. Appendicitis
B. Mesenteric adenitis
C. Diverticular disease
Urology
215 A 5 y/o boy was brought by his mother after suddenly developing a fever & right scrotal
swelling 2 hours ago. O/E you find a red right scrotal swelling. Most likely diagnosis?
A. Scrotal abscess
B. Scrotal torsion
C. Torsion of the testicular appendages
D. Hernia

216 A 7 y/o child has pain in the left side of the testis for the past 30 minutes. It had an acute
onset. O/E it is swollen, red, high-riding, and cremasteric reflex is absent. What is
your diagnosis?
A. Testicular torsion
B. Orchitis
C. Cryptorchidism
Abrupt onset of severe testicular pain and/or pain in the lower abdomen
Typically swollen and tender testis and/or lower abdominal tenderness [8]
Nausea and vomiting
Abnormal position of the testis
Scrotal elevation (high-riding testis)
Abnormal transverse position
Possible undescended testes (predisposes to testicular torsion) [9]
Absent cremasteric reflex
Negative Prehn sign
In neonates
Possible absent testis
Firm, painless scrotal mass
Possible acute inflammation: swollen, erythematous (or blue discolored in venous
engorgement), and tender hemiscrotum
217 A 15 y/o boy presented with history of acute scrotal pain for 3 hours. O/E, there is
swelling & erythema of the scrotum. What do you do?
A. Surgical exploration of the scrotum
B. Scrotal ultrasound
C. Broad-spectrum antibiotics
D. Reassure & wait
E. Drainage
 Testicular torsion is a medical emergency and should ideally be treated within 6 hours of
the onset of symptoms for the best chance of testicular salvage. Manual detorsion in the
emergency department may be attempted prior to surgery for immediate pain relief, but
should not delay transferring the patient to the operating room.

218 A 6-year-old boy was brought to the family physician because of enlarged testes. What
is the most likely cause?
A. Testicular cancer
B. Pituitary problem
The most common testicular tumors in prepubescent males are yolk sac tumors and
teratomas (80% of all testicular tumors in young boys).
219 What is the most likely causative organism of UTIs in babies?
A. E. coli
B. Proteus
Congenital Anomalies
o Posterior Urethral Valve:
Leads to post-obstructive uropathy & hydronephrosis
Can be diagnosed prenatally by US (oligohydramnios + hydronephrosis)
Diagnosis post-natal via VCUG
Treated temporarily with catheterization till surgery
o Hypospadias & Epispadias:
Hypospadias (ventral which is bottom of erect penis)
Epispadias (dorsal which is top of erect penis)
NEVER circumcise so you can use the tissue for reconstruction
o Horseshoe kidney:

Vaccination

220 An HbsAg positive mother has a 6-year-old son who is also positive for HbsAg but did
not take any vaccines except for BCG at birth. What vaccines do you give him?
A. DPT, OPV, HBV, MMR, Hib
B. DPT, OPV, MMR, Hib
C. dT, OPV, HBV, MMR, Hib
D. dT, OPV, HBV, MMR Hib is not for children above 5 years
Universal vaccination refers to the administration of HBV vaccine to all infants as a part
of the routine childhood immunization schedule and to all children younger than 11 or
12 years who have not previously received a vaccine. Rapid (0-, 1-, and 2-mo) and
standard (0-, 1- to 2-, 6-mo) schedules have identical efficacy.
 A pregnant lady was found to be HepBsAg +ve. What do you do for the baby?
A. Vaccinate the newborn within 24 hours (+ give him IgG)
B. Start interferon for the mother and give it to the newborn at delivery
C. Vaccinate the newborn after 4 weeks
HepB vaccine is given within 12-24 hours of birth.

221 Which vaccine is contraindicated in a child taking prednisolone?

A. MMR
B. Diphtheria
C. Pertussis
D. Tetanus
Persons receiving large daily doses of corticosteroids (>2 mg/kg per day or >20 mg per day
of prednisone) for 14 days or more should not receive MMR vaccine because it can lead to
complications. Avoid MMR vaccination for at least one month after stopping high dose therapy
222 A 6-month-old baby was brought to your clinic. He was born to an HIV +ve mother.
Which of the following vaccines are contraindicated for him?
A. MMR (although it is a live vaccine, it is not contraindicated if the child is
healthy)
B. Oral polio
C. Pneumococcal vaccine
D. Hemophilus influenzae
E. Diphtheria
IPV is the only recommended vaccine for children with immunodeficiency. We
hypothesized that the live attenuated poliovirus existing in oral polio vaccine (OPV) may
protect uninfected neonates born to HIV-positive mothers through the stimulation of
innate immune system.
223 Which vaccine do you give after a splenectomy?
Strep pneumoniae encapsulated vaccine
Vasculitis
224 A 12 y/o boy presented with abdominal pain, joint
pain,and hematuria. Attached is a picture of a child
with a rash. What is the diagnosis?
Henoch Schoenlein Purpura
IgA vasculitis
GIT: pain & bleeding, Skin:purpura, Joint: arthralgia,
Renal: hematuria
Diagnosis: Clinical,
Biopsy = leukocytoclastic vasculitis
Treatment: steroids for abdominal pain / renal insufficiency
225 A child has the clinical picture of HSP. What is the best next investigation to do for her?
Stool occult blood (or urinalysis) should be IgA antibodies, Cr and BUN, urinalysis –
hematuria, RBC cast, proteinuria
 Well-Being
226 What advice do you give a mother about carrying her newborn?
Carry him with his head inside your elbow and his body resting on your forearm
227 What supplement should be given to a neonate who is exclusively breastfed?
A. Vitamin K
B. Vitamin D
C. Vitamin B12
D. Iron(maybe if preterm)

For the first four months, your breastfed baby needs no additional iron. The iron in their
body at birth was enough for their initial growth

To avoid developing a vitamin D deficiency, the Dietary Guidelines for Americans and
American Academy of Pediatrics recommend breastfed and partially breastfed infants be
supplemented with 400 IU per day of vitamin D beginning in the first few days of life.
228 What sport do you advise an obese child to do?
A. Bicycling
B. Weightlifting
C. Resistance training
D. Yoga
 ------- Psychiatry -------
Stages of Change

1 A chronic smoker developed heart disease and was advised to stop smoking. He had
never thought to quit smoking before and does not want to as he is stressed & busy to
worry about stopping. Which stage of the behavioral cycle is he in?
A. Pre-contemplation
B. Contemplation
C. Action
2 A 45 y/o female has known history of diabetes, hypertension, and bilateral knee
osteoarthritis. She was given paracetamol to control the knee pain and is now able to
tolerate walking. She was convinced about the importance of walking for her health & is
now walking for 30 minutes / day. She came to the clinic after 2 months for follow up.
What stage is she in now?
A. Pre-contemplation
B. Contemplation
C. Action
D. Maintenance
E. Re-evaluation
3 A man decided to stop smoking but found that he is having trouble so he came for help.
pooja what is this behavior? Why not preparation? >> it is
A. Pre-contemplation
B. Contemplation
C. Action
4 A 40-year-old female patient, known diabetic & hypertensive, was started on
medications but her weight did not decrease. For the past 2 months, she has been walking
daily for 30 minutes. Her blood pressure & sugar levels were still not controlled but she
does not wish to add any more medications. What do you think about her daily walking?
A. Pre-contemplation
B. Contemplation
C. Preparation
D. Action
E. Maintenance
 Mood Disorders

5 A 72-year-old man is brought in by his son for

decreased appetite and lack of interest inprevious
activities. He says that his father no longer responds
when his grandchildren greet him, and he is unable to
do basic tasks. His short-term memory is intact, but
they noticed that he calls his grandchild by his son’s
name. The son has recently moved his father to live
closer to him 2 months ago. Diagnosis?
A. Age-related senile dementia
B. Alzheimer’s disease
C. Major depressive disorder
D. Multi-infarct dementia

6 An old man presented with weight loss, labile mood, and poor sleep. He has been having
these symptoms since he moved from his farm because of his family. Most likely
diagnosis?
A. Major depressive disorder
B. Adjustment disorder
7 A 39 y/o female was brought by her husband as he noticed worsening of her symptoms
for the last 2 years. She no longer watches her favorite TV programs as she doesn’t enjoy
them anymore. She withdraws & neglects herself. She says that life is worthless. What
will you give her?
A. Imipramine (TCA for MDD)
B. Haloperidol
C. Clozapine
D. Clonazepam
 First-line antidepressant medications
SSRIs (often trialed first), SNRIs, and the atypical antidepressants bupropion and
mirtazapine
Other antidepressant medications
These medications cause more adverse effects than first-line therapies (e.g., SSRIs).
Options include:
Trazodone: used primarily for insomnia
Tricyclic antidepressants, e.g., amitriptyline, nortriptyline
Monoamine oxidase inhibitors (MAOIs), e.g., phenelzine
8 A male with MDD has cardiac problems (angina). Most appropriate drug to use?
A. Imipramine
B. Fluoxetine
C. Amitriptyline
TCAs are contraindicated in CAD. + can cause cardiac conduction delay and QRS
prolongation
TCAs: Cardiotoxicity due to Na+ channel inhibition in the myocardium: changes in
cardiac conductivity velocity, arrhythmias, prolonged QT interval (predisposes to torsades
de pointes), wide QRS complex

9 A hypertensive and diabetic man presented with symptoms of depression (weight loss
and sleepiness). What is the drug of choice for his treatment?
A. SSRI
B. Mepyramine
10 What is the drug of choice for unipolar depression?
SSRI
11 A 25-year-old female with depression was started on an SSRI. Which of the following is
true?
A. 20% of patients on SSRIs complain of sexual dysfunction
B. Velaxetine (?) is the drug of choice in hypertensive patients – all SSRIs are fine
in hypertension

SSRI Associated with sexual adverse effects

Escitalopram may have fewer general adverse effects than other SSRIs and SNRIs.
12 What is the main side effect of bupropion?
A. Headache
B. Xerostomia
A. Seizure ????????? >> I would go with this cuz its main
B. Arrhythmia
Side effects
Stimulant effect Tachycardia Weight loss
Neuropsychiatric symptoms: insomnia, agitation, headache
Reduction of seizure threshold: Bupropion should be avoided in patients at increased risk
for seizure (e.g., history of epilepsy, anorexia/bulimia, alcohol or benzodiazepine
withdrawal). Does not cause sexual side effects
13 A diabetic hypertensive woman is a known case of depression on amitriptyline 100 mg
OD. She is presenting with severe depression and suicidal ideations and is asking for a
medication refill. She has an appointment with her psychiatrist in 1 week. What is the
best next step?
A. Continue same medication & do direct observation therapy (if you are not a
psychiatrist this is probably more correct) >> question says she has an appt
so maybe this makes more sense?? Idk
B. Double the dose of amitriptyline
C. Reduce amitriptyline and add paroxetine
D. Stop amitriptyline and start paroxetine

Antidepressants may increase risk of suicidal thinking and behavior (suicidality) in

children, adolescents, and young adults (18–24 years of age) with major depressive
disorder and other psychiatric disorders; balance this risk with clinical need.
14 A 29 y/o lady came to the PHC complaining of low mood after her boyfriend left her.
There were scars on both of her wrists. Most appropriate next step?
A. Risk assessment
B. Reassurance
C. Refer her to psychiatry
15 A lady came to the ER after ingesting 30 paracetamol tablets. What puts her at high risk
of suicide?
Previous suicide attempt
16 A lady with known history of MDD has gotten divorced recently. She has a history of
multiple suicide attempts. What puts her at higher risk of attempting suicide again?
Previous suicide attempt
17 A female, KC of MDD (10 years) was brought by the police because she was found
agitated, disinhibited, and talkative. Previous episodes. Dx?
A. MDD
B. Bipolar disease (mania)
C. Schizoaffective disorder
D. Schizophrenia
18 A female was complaining of insomnia, anorexia, lack of interest, and sad mood.
Afterwards she became hyperactive for a period of time during which she was talkative
& only slept for 3-4 hours. Her father had MDD & attempted suicide. Her paternal
grandmother also has history of suicidal attempts. Diagnosis?

A. Bipolar disorder
B. Inherited personality disorder
19 A girl in university has been suffering from depression for the past 6 months. Recently
she developed agitation and irritability. She has become very talkative and hasn’t been
sleeping. Her father & grandfather had similar problems. Diagnosis?
A. Bipolar disorder
B. Paranoid schizophrenia
20 A lady was doing really well in college. When she moved out of town, she developed
depression for 1 month after which she became hyperactive & was doing well. She has a
family history of depression & suicide. Diagnosis?
Bipolar affective disorder
21 A 30-year-old man was brought in by the police. He believes that he has got the ideal and
best solution for environmental pollution and that it will earn him millions of dollars. He
is suspicious that some people want to steal his solution. He talks a lot, displays
hypersexuality, and reports needing less hours of sleep. He has also been spending a lot
of money, and he has history of alcohol abuse. Diagnosis?
A. Mania
B. Alcohol
C. Schizotypal
D. Schizophreniform psychosis
22 A male has 10-day history of talkativeness, grandiose ideas, sexual disinhibition, and
spending a lot of money. Diagnosis?
A. Mania
B. Schizophreniform disorder
C. Schizophrenia
Grief & Bereavement

23 A 54-year-old lady, post-menopause for 4 years, was doing well until her husband died 9
months ago. Afterwards her appetite started decreasing. In addition, she has recently
been diagnosed with myasthenia gravis. What is most likely to increase her suicidal risk?
A. Recent bereavement
B. Menopausal history
C. Myasthenia gravis
24 An old man whose wife died 1 year ago presented with inability to drive due to lack of
concentration. He tearfully mentioned that he has been unable to concentrate at work
since his wife died and has been having memory problems. What is the most likely
diagnosis?
A. Phobic disorder
B. Major depressive disorder
C. Uncomplicated bereavement
D. Somatization disorder

25 A lady presented with nightmares following the death of her husband. She says that she
has been avoiding things that remind her of him, and she is having flashbacks of him.
She has also been contemplating suicide. You notice that she has a grandiose attitude
towards him. What is the most likely diagnosis (duration of symptoms not mentioned)?
A. PTSD
B. Morbid grief (persistent complex bereavement disorder?)
C. Brief grief
D. Adjustment disorder with depressed mood
E. Major depressive disorder
Persistent complex bereavement disorder [5]
Definition: a mental disorder characterized by an unusually prolonged period of grief
and/or mourning (lasting at least 12 months in adults and 6 months in children) resulting
in severe distress and functional impairment.
Overview
Differential diagnosis: PTSD, depressive disorders, and normal grief
Diagnostic criteria
Criterion A: the individual has experienced the death of a close relation or friend
Criterion B
Symptoms related to yearning, longing, and sorrow
Criterion C
Symptoms of reactive distress to the death
Symptoms of social/identity disruption
A desire to die in order to be with the deceased
Feeling that life is meaningless or empty without the deceased, or the belief that one
cannot function without the deceased
Criterion D: clinically significant distress or functional impairment
Criterion E: distress or functional impairment that goes beyond of sociocultural norms
26 A female attempted suicide after her mother’s death. Diagnosis?
A. Post-bereavement
B. Depression
Psychotic Disorders

27 An 18 y/o male presented with the following symptoms for 2 years: neglecting his self-
care, withdrawal, always sitting alone, and decreased school performance. In the clinic,
you notice that he has a flat affect, does not listen to you, and does not make eye contact.
Diagnosis?
A. Schizoid personality disorder > more likely
B. Schizophrenia >> where are the delusions or hallucinations
C. Social phobia
D. Schizotypal personality disorder
E. Psychotic depression
28 A schizophrenic patient on haloperidol started moving a lot (mostly her legs) and has the
feeling of not being able to sit still. What are these symptoms?
A. Tardive dyskinesia
B. Akathisia
C. Bradykinesia
D. Dystonia
29 An 18 y/o male was brought by his father as he has been neglecting himself & isolating
from other people for the past year. Scenario describes other +ve & -ve symptoms.
Diagnosis?
A. Schizoid personality
B. Schizophrenia (if symptoms were there for at least 6 months)
C. Schizotypal personality disorder
30 An 18-year-old male thinks that aliens do not allow him to sleep so that he becomes
angry the next day. He is diagnosed with schizophrenia. Which one of the following
mental elements will be affected most in this patient?
A. Thinking
B. Attention & concentration
C. Mood
31 Which is NOT a side effect of clozapine? SE: Myocarditis, metabolic syndrome/weight
gain, seizure, agranulocytosis
Diarrhea
Side effects are
§ Weight gain
§ Tremors / dizziness / spinning sensation
§ Headache / drowsiness
§ Nausea / constipation
§ Dry mouth / increased salivation
§ Blurred vision
§ Fast heart rate
§ Increased sweating
32 A psychiatric patient believes that parts of her intestines are absent. What kind of
delusions is she having?
A. Nihilistic
B. Persecutory
the delusion of nonexistence: a fixed belief that the mind, body, or the world at large—or
parts thereof—no longer exists
33 You were called to the ER to see a 50 y/o female with history of depression. She says
that she has an empty belly & chest, and that she does not have a jaw, so she won’t eat.
Which delusion does she have?
A. Nihilistic
B. Perception
C. Paranoid
34 A school student is complaining of sudden episodes of falling that occur during
classwhenever he laughs or gets
excited. He says that he can hear
and understand what is
happening during the attacks. His
friends report no seizure-like
activity. He has no confusion or
drowsiness following the attacks.
What is the diagnosis?
A. Cataplexy
B. Organic cataplexy
C. Hypersomnia
D. Catatonia
E. Epilepsy
35 Depersonalization is a clinical feature of which of the following?
A. Bulimia nervosa
B. Narcissistic personality disorder
C. Temporal lobe epilepsy > google
D. Body dysmorphic disorder
36 A 2-week-old neonate was brought by his mother complaining that he is evil and won’t
live for long. Diagnosis? Yeeees
A. Postpartum psychosis
B. Neurosis
37 A woman came in saying that she hears sounds of people who aren’t there as they talk
about hurting her. She also has been having a recurrent dream where she sees a man
standing above a child watching him sleep. She denies any knowledge of the child nor
the man. Her past medical history is evident for multiple unexplained injuries in
childhood. The next day, she comes back to you shouting and acting as if she has never
seen you before. What is the most likely diagnosis?
A. Therapist plan dissociative personality
B. Severe child abuse
C. Schizophrenia
D. Drug abuse
E. Genetics
Dissociative Personality
Associated with:
• History of physical / sexual abuse and/or neglect in childhood
• MDD / PTSD / borderline personality disorder / somatic symptom disorder
Diagnostic criteria:
Alternation of at least 2 separate personality states that cause identity disruption and
dominate at different times. Involves:
• Depersonalization & derealization
• Frequent gaps in recall of normal daily events / personal information that are
significantly different from ordinary forgetfulness
Treatment: psychotherapy
38 A lady was found roaming around 50 km away from her house. She did not remember
anything about her identity. You find out that her husband and child recently died in a car
accident. What do you do for her?
A. Take her home to bring back the memories
B. Psychotherapy
C. Prescribe fluoxetine
D. Prescribe amitriptyline
Panic & Anxiety Disorders
39 A 23-years-old single male was brought to ER exhausted and frightened. His father tells
you that his son, who was previously healthy, had, for no apparent reason, a sudden
attack of fear, dizziness, sweating, palpitations and the feeling that his heart is going to
stop beating. The symptoms started to decrease gradually after about 10 minutes.
Diagnosis?
A. Panic attack
B. Delirious state
C. Alcohol withdrawal phenomena
D. Social phobia
40 What drug is used to rapidly reverse a panic attack?
A. SSRI
B. Benzodiazepine (alprazolam)
 C. Bupropion
41 A 19 y/o female, previously healthy, experienced sweating, palpitations, tremors, and
fear that she will die. Diagnosis?
A. Agoraphobia
B. Panic disorder
C. Delirium tremens
D. Alcohol withdrawal
42 A 13 y/o girl came to the ER with palpitation & sweating. She feels that she is going to
die from a heart attack. She had 2 previous episodes. Diagnosis?
A. Myocardial infarction
B. Arrhythmia
C. Panic disorder
STUDENTS FEAR the 3Cs:” Sweating, Trembling, Unsteadiness (dizziness),
Derealization, Elevated heart rate (palpitations), Nausea, Tingling, and Shortness of
breath; FEAR of dying or going crazy; Chest pain, Choking, and Chills.
43 A young female develops episodes of muscle weakness,
light headedness, and perioral tingling. She is worried
about having similar episodes. Cause?
Hyperventilation (panic attack?)

A girl came in hyperventilating after failing her math

exam. Diagnosis?
A. Hyperventilation syndrome
B. Munchausen syndrome

Definition: a condition characterized by an increase in minute ventilation that exceeds

metabolic demands without a clear organic precipitant
Etiology: frequently associated with panic disorder and anxiety disorder
Pathophysiology: hyperventilation → hypocarbia → respiratory alkalosis [22]
Clinical features [23]
Cardinal feature: transient hyperventilation
Additional symptoms include:
Dizziness, lightheadedness
Chest pain, palpitations
Paresthesias (typically in extremities and/or the perioral area)
Carpopedal spasm
Anxiety, sense of impending doom
Diagnosis [23][24]
Hyperventilation syndrome is a diagnosis of exclusion.
44 A mother is severely anxious about her son’s school performance. The child is healthy &
has no psychological problem. What disorder does the mother have?
Generalized anxiety disorder >> need more info in question for this diagnosis
45 A 45 y/o female with backpain & headache for 1-year experienced  worries. She is
always worried that her kids will die in a car accident. Her worries have increased for the
past 6 months. Most likely diagnosis?
A. Generalized anxiety disorder
B. Phobia
C. Obsessive compulsive disorder
D. Panic disorder
E. Bipolar disorder
46 A lady presented with chest pain and shortness of breath. These had a sudden onset and
were not related to effort. She has had 4 previous similar episodes, 1 occurred when
shopping in the mall and the other 3 happened when she was in bed about to go to sleep.
Diagnosis?
A. ACS
B. Anxiety (panic attack)
47 What drugs will you use to treat patients with anxiety?
SSRIs / benzodiazepine
- Psychosocial (CBT & look into causes or triggers of anxiety)
- Pharmacotherapy:
o 1st line: SSRIs (fluoxetine / escitalopram)
o 2nd line: SNRIs (venlafaxine / duloxetine)
o Adjuvant therapy:
1st: atypical antipsychotics / antihistamines
2nd: mood stabilizers
Buspiron
If they have mood disturbances --> start with antipsychotics
48 A 21 y/o university student has poor performance in his presentations. He gets
palpitations, sweating, and tachypnea whenever he stands to present in front of his
students. He is thinking of quitting university. Most likely diagnosis?
A. Social phobia
B. Agoraphobia
C. Specific phobia
D. Non-specific anxiety
E. Hypochondriasis
49 A man got a new job as a representative but is anxious to present seminars. He has
managed to avoid 3 seminars so far and is thinking of quitting his job. Diagnosis?
A. Simple anxiety
B. Social phobia
C. Agoraphobia
D. Panic disorder
Social anxiety disorder (SAD): fear/anxiety out of proportion to a social situation where
one may be scrutinized by others (e.g., meeting new people at a party, eating in public)
Performance-only SAD: symptoms of fear/anxiety restricted only to public speaking or
performing in front of crowds
Paruresis (shy bladder syndrome): fear/anxiety associated with urinating when other
people are present, e.g., in public restrooms
Clinical features
palpitations, sweating
Anticipatory anxiety
fear of embarrassment
Avoidance of the aforementioned triggers
50 A patient has anxiety when presenting in front of his colleagues. Treatment?
Beta blockers
51 A 33-year-old man is very scared of travelling abroad which has led to him refusing any
business task that mandates him travelling around. What is the most likely diagnosis?
A. Social phobia
B. Panic disorder
C. Schizophrenia
D. Agoraphobia
Agoraphobia is a fear of being in situations where escape might be difficult or
that help wouldn't be available if things go wrong.
52 A girl with anxiety and social phobia got a job as a receptionist in a hotel. She is afraid
that she will lose her job.
1. What is the first line of management for her condition?
A. Supportive psychotherapy
B. Dialectic behavioral therapy
C. Deep breathing
D. Bupropion
E. Paroxetine (SSRIs first line)
2. What is the most proven therapy?
A. Supportive psychotherapy (in the form of CBT)
B. Dialectic behavioral therapy (this is also a form of CBT)???
C. Deep breathing
D. Bupropion
E. Paroxetine

Patient preference for psychotherapy — For patients with either SAD or SAD,
performance-only who prefer psychotherapy rather than medication, we suggest first-
line treatment with either individual or group CBT customized for SAD rather than
other psychotherapies.
53 A 26-year-old man gets anxious in crowds and when presenting in front of colleagues.
He has an interview soon and is seeking your help. What is the best medication for his
condition?
A. Beta blockers
B. MAO inhibitors
54 A woman was raped 3 years ago. She comes to you complaining of impulses to cut her
wrists, anxiety, nightmares and flashbacks of the incident. What is your diagnosis?
PTSD (symptoms > 1 month)
55 A man has recurring flashbacks after witnessing a car accident 2 months ago. He has
been scared to travel in a car since then. Diagnosis?
PTSD
56 What medication can be used for PTSD?
SSRI or venlafaxine
57 A patient is complaining that he always has to count things and can’t stop this. What is
this?
A. Obsessions
B. Compulsions
C. Hallucination
Obsessions are involuntary thoughts, images, or impulses that occur over and over again
in your mind. Compulsions are behaviors or rituals that you feel driven to act out again
and again. Usually, compulsions are performed in an attempt to make obsessions go
away.
58 What is the mechanism of action of the drugs used to treat OCD?
Increase serotonin availability (SSRI)
inhibition of serotonin reuptake in synaptic cleft → ↑ serotonin levels
Somatic Disorders
59 A lady has had alternating diarrhea & constipation as well as chest pain at rest for 6 days.
She presented to the clinic complaining of dysuria. The symptoms were associated with
stress as her husband has lost his job. Which symptom was not associated with anxiety?
A. Diarrhea
B. Constipation
C. Dysuria
D. Chest pain
60 A young male is worried that he has AIDS even though he has done all investigations
and was assured that he doesn’t have any illness. Diagnosis?
A. Hypochondriasis now it is called Illness anxiety disorder
B. Somatization
C. Conversion disorder
D. Dissociative disease
61 A young woman came to you because she believes that she has breast cancer despite
reassurance by multiple radiologists that her exams were normal. Her mother died of
breast cancer. What is your diagnosis?
Hypochondriasis
62 A young patient in his 20s is worried about having HIV. He did several blood tests & you
reassured him that he is negative but he still worries of having HIV. Diagnosis?
Hypochondriasis

63 What will help you diagnose a factitious fever?

A. Pulse rate
B. Urinalysis
C. Blood culture
Factitious fever and self-induced infection are other challenging causes of fever. In
factitious fever, high temperatures do not associate tachycardia or skin warmth. Self-
induced infection occurs generally by self-injection of body fluids, pyretic substances or
other contaminated materials. Self-inoculation of various substances including materials
contaminated with feces, pure microbiological cultures, coliform bacilli and foreign
proteins has been reported. Patients have serial episodes of unexplained polymicrobial
bacteremia, or recurrent soft-tissue infections. The underlying disorder for factitious
fever may be the Munchausen syndrome and the Munchausen syndrome by proxy.
64 A young lady had an argument with her parents after she rejected a marriage proposal.
Suddenly afterwards, she went blank and could not move her limbs. What is the
diagnosis?
A. Schizophrenia
B. Conversion disorder

Conversion disorder is also known as functional neurological symptom disorder.

Patients present with neurological symptoms that cannot be fully explained by a
neurological condition.
Patients may be calm and unconcerned when describing their symptoms (sometimes
referred to as “la belle indifférence”).
65 A lady is unable to talk & can only express herself by writing. This problem started after
she lost her job. Diagnosis?
A. Hysterical aphonia (type of conversion disorder)
B. MDD
C. Adjustment disorder
D. Stress disorder
66 A girl became silent (talkless) after breaking up with her boyfriend. She has been writing
everything in notes and claims that she has always been a shy girl. What personality
disorder does she have?
A. Dependent personality disorder
B. Narcissistic personality disorder
C. Acute stress disorder
D. Hysterical aphonia
67 A man has strong beliefs that he suffers from cancer despite reassurance by multiple
doctors that all examinations & investigations were normal. Despite spending lots of
money on expensive tests, he still thinks he has cancer and that the doctors are hiding it
from him. What disorder does he have?
A. Somatic disorder
B. Illness anxiety disorder
 Personality Disorders

68 A lady presented to the ER to suture her wrist following self-injury. She has done this
multiple times before as she has chronic feelings of emptiness and mood instability. She
also has unstable relationships and impulsive behaviors. On examination, she has
multiple lacerations on her wrists. Diagnosis?
A. Borderline PD
B. Histrionic PD
C. Narcissistic PD
D. Avoidant PD
E. Antisocial PD
69 A patient came complaining of difficulty in coping after his girlfriend broke up with him.
He is upset because he doesn’t even know why she left him. On further questioning, he
says that she told him that she is tired of making decisions for him. He tells you that she
used to decide where they would go, what they would eat, what house they would buy.
He tells you that he needs to have a new girlfriend as soon as possible. What disorder
does he have?
A. Dependent personality disorder
B. Narcissistic disorder
C. Acute stress disorder
70 A male has no friends, social anxiety, and magical thinking. He has eccentric behavior.
What is your diagnosis?
A. Schizotypal personality disorder (magical thinking, no hallucinations)
B. Schizoid personality (lack of social interest, don’t like to make friends, like to be
alone)
C. Schizophrenia (hallucinations)
71 A 22-year-old male was brought by the police for bizarre behavior. He says he can
communicate with aliens living in space. In addition, he was wearing an odd outfit. He
denies any form of hallucinations. Which personality disorder does he have?
A. Paranoid
B. Schizotypal
C. Schizoid
D. Histrionic
72 A 20 y/o male came was brought by his mother. She notes that he is shy & isolated. He is
not social & his main hobby is collecting stamps. Diagnosis?
A. Psychopathic
B. Schizotypal
C. Anxiety
Schizoid would be more correct
Sleep Disorders
73 A case scenario was given about a man with hypersomnolence since he was a teenager.
He sleeps for 6-7 hours a night but still feels very sleepy in the morning. Which
statement is true about his illness? (idiopathic hypersomnia – relieved by amphetamines)
A. Men are affected more than women
B. Adults & children have the same symptoms
C. Symptoms can be relieved by antidepressants
Epidemiology
Prevalence: ∼ 15% of population in the US [24]
Sex: ♂ = ♀
Age of onset: 15–25 years of age
74 A young obese guy feels tired even after long hours of sleep. Diagnosis?
Obstructive sleep apnea
75 What is true about narcolepsy?
A. Symptoms are the same in males & females
B. Symptoms are the same in adults & children
C. It is similar to insomnia
D. Antidepressants are used for treatment
Prevalence: 25–50:100,000 [1]
Incidence: ∼ 0.8:100,000 individuals per year
Sex: ♂ = ♀
Bimodal distribution
First peak at 15 years
Another smaller peak around age 35
Dementia & Delirium
76 You were asked to evaluate a 63 y/o female patient is in a nursing home. You heard her
screaming from outside asking to take her out of this prison. She was confused and
refuses to take her medication. She asked to be alone. Diagnosis?
A. Delirium
B. Major depression
C. Brain injury
acute (hours to days) alteration in the level of awareness and attention
Other features may include:
Disorganized thinking
 Illusions
Hallucinations (mostly visual)
Cognitive deficits (e.g., memory)
Reversal of the sleep-wake cycle
Emotional lability
Agitation, combativeness
The severity of symptoms fluctuates throughout the day and worsens in the evening
(termed sundowning).
Symptoms are reversible
77 An old male in nursery care is brought to the ER because he was found in the morning to
be disoriented, confused, and was refusing to take his medications. He has no fever.
What is the cause of his problem?
A. Acute infection
B. Occult malignancy
C. Alzheimer dementia
78 An elderly patient has been in a nursing home for the past 8 years because of multi-
infarct dementia. He was doing well but today he wasn’t able to recognize his caretaker
and he refused to take his regular medication. What is the most likely underlying
pathology?
A. Acute urinary tract infection

B. Major depressive disorder

C. Social isolation
79 What is the main distinguishable feature between schizophrenia & delirium?
A. Hallucinations
B. Delusions
C. Loss of consciousness
80 An old man who lives alone comes to you complaining of forgetfulness for the past 3
months. He states that he has been unable to find his car in parking lots. His son also tells
you that he has been calling his grandchildren with his sons’ names. He is able to drive
and maintain his personal hygiene. What is the most likely diagnosis?
A. Schizophrenia
B. Dementia
C. Depression
81 An old man was brought by his son for occasional short-term memory loss, depression
and irritability. He has been forgetting things like where he parked his car. The son also
reports that his father had 1 episode of thinking that his neighbors are poisoning him.
Diagnosis?
A. Dementia
B. Schizophrenia
C. Personality disorder
82 A 70-year-old man came complaining of weight loss. His BMI was 18 kg/m2. Blood
tests and other investigations were normal. Upper & lower endoscopy was done and was
also normal. You instruct the patient to return after 4 weeks with a diary documenting his
intake. He comes back after 4 weeks having lost more weight and unable to produce the
diary. What is your next step?
A. Repeat CBC
B. Repeat endoscopy
C. Repeat CXR
D. Repeat echocardiography
E. Cognition evaluation
F. Repeat colonoscopy
83 A 70 y/o man was brought to the clinic by his son due to memory loss. He had 1 episode
of losing his way home after prayer. The son also noticed that his father was calling him
by his grandson’s name. He mentions that his father is happy and doing well. Diagnosis?
A. Alzheimer’s disease
B. Age-related (senile) dementia >> question seems like its this cuz not severe
C. Major depressive disorder
84 Which of the following is used for non-pharmacological treatment of dementia?
A. Exercise
B. Leisure time including mental activities
C. Adding new ways of doing daily activities
D. All of the above
85 A 95-year-old widowed lady, living with her daughter, comes to the clinic. Her daughter
notes that she has been very forgetful and no longer knows her way around the house. No
weakness / syncope / stroke-like symptoms / hallucinations. What is the next step in
management?

A. Refer to psychiatry
B. Start Aricept (donepezil) – depends on what clinic she attended
C. Start memantine. Start with rivastigmine/donepezil/galantamine for mild AD. Then
for mod/severe Memantine + Donepezil
D. Refer to care worker
Eating Disorders
86 A girl was brought by her mother for weight loss. On examination, she has a lot of
lanugo hair. Diagnosis?
Anorexia nervosa
87 Bulimia nervosa
Sexual Disorders
88 A male who was happy for being successful in his job wanted to celebrate with his wife,
but she was busy with her friends’ parties & shopping. He came to see you. Even though
he was angry from his wife, he looked calm. Which phase of his sexual life is affected?
A. Desire
B. Excitation
C. Plateau
D. Orgasm
E. Resolution
89 A man has erectile dysfunction but reports having good morning erections. Who do you
refer him to?
A. Neurology
B. Psychiatry
C. Cardiology
90 Which drugs will you avoid in a patient with erectile dysfunction?
A. Amitriptyline
B. Fluoxetine
C. A & B
81 A 10-year-old boy was brought by his mother as she noticed that he likes to dress up like
girls. He also keeps telling her that he does not want his male genitalia. What is the
diagnosis?
A. Gender dysphoria
B. Oppositional defiant disorder
 - The person feels trapped in the body of the wrong sex. They assume the identity of
the desired sex, but the goal is not sexual.
- Management:
o Exclude organic causes & schizophrenia (delusions)
o Psychosocial (psychotherapy)
o Biological: surgical management
82 A recently married lady came complaining of unsatisfactory intercourse & dyspareunia
since her marriage. PV exam was done easily but her thighs were in a contracted state
afterwards (vaginismus). Management?
A. Out-patient psychotherapy
B. Instruments for daily vaginal dilation
C. Local estrogen cream
D. Perineorrhaphy

Pelvic floor physical therapy: considered best initial treatment option ; consists of a
combination of modalities, such as patient education, internal manual techniques,
dilatation exercises, local tissue desensitization, and home exercises (e.g., Kegel
exercises).
Psychotherapy
Anxiolytic drugs: in conjunction with other therapeutic modalities
Local botox injections for refractory cases
 ------- Pulmonology -------
Obstructive Lung Diseases
1 A young footballer presented with episodes of SOB, cough, and lightheadedness. He
reports that these episodes occur solely during exercise. His ECG was normal. What is the
next investigation that should be done? Exercise induced asthma
A. CXR
B. PFT
C. Echo
2 What is the most significant indicator of a life-threatening asthmatic attack?
A. FEV of 50%
B. RR of 24 rpm
C. HR of 104 bpm
D. Prolonged wheeze
E. Pulse oximetry < 90%

Life-threatening asthma exacerbation (imminent respiratory arrest)

Inability to speak due to dyspnea
Drowsiness, confusion, sweating
Silent chest
Paradoxical breathing
Bradycardia
Altered mental status
PEFR (if performed): < 25% predicted
Signs of type I respiratory failure and/or type 2 respiratory failure
3 A woman 8-weeks post-partum was recently diagnosed with asthma. She was on Beta
agonists and steroids, but her symptoms were not controlled, and she has had multiple
hospital admissions. She presents complaining of 12 hours of wheezing. On examination,
there is a loud S1 as well as inspiratory wheezes more than expiratory ones. She is using
accessory muscles and her sPO2 is 73%. She has peripheral edema. Apart from admission,
what will you do?
A. ABG
B. IV ketamine
C. Mechanical intubation (hypoxia = status asthmaticus)
D. Anticoagulation
E. Check potassium level
4 An asthmatic patient presented with SOB & wheezing. He was managed in the ER with
salbutamol after which he developed severe SOB,  JVP & deviated trachea. Best
management?
A. Salbutamol
B. Needle insertion (tension pneumothorax)
5 An asthmatic patient on inhaled corticosteroids is complaining that his symptoms have
become more often (daily). He wakes up many times with a cough. Best medication to
add?
A. Salbutamol (reliever) saba comes before laba stepwise
B. Salmeterol (controller) LABA
C. Budesonide
6 A guy with history of asthma presents with respiratory symptoms induced by exercise &
cold air. He uses salbutamol inhaler as needed. In the ER, inhaled albuterol is given and
his FEV1/FVC improved. What management do you advise?
A. Inhaled corticosteroids + SABA as needed
B. Oral prednisolone
C. Ipratropium
D. LABA
7 A patient came to the ER with an asthmatic attack. She had RR (~30), O2 saturation
(92%), and peak flow < 45% of predicted. He was managed with O2 & ABA. What drug
to add next?
A. Oral prednisolone
B. Inhaled fluticasone
C. Ipratropium bromide 500 g inhaled nebulizer

Administer initial medical therapy according to severity (see relevant sections below for
details).
Severe asthma exacerbation: Supplemental O2 + SABA + SAMA + oral/IV
corticosteroids; consider IV magnesium
Moderate asthma exacerbation: Supplemental O2 + SABA; consider oral corticosteroids
Mild asthma exacerbation: SABA; consider oral corticosteroids
8 Which medication used for asthma can cause tremors?
A. Albuterol (salbutamol) (beta agonist activates receptors on skeletal muscles)
B. Ipratropium bromide
C. Budesonide
D. Montelukast
9 Why don’t we use theophylline for asthma?
Narrow therapeutic margin
Nausea/vomiting, stomach/abdominal pain, headache, trouble sleeping, diarrhea, irritability,
restlessness, nervousness, shaking, or increased urination may occur.
10 What is the most common symptom of emphysema?
Cough

Presenting findings [2]

Chronic cough with expectoration
Dyspnea and tachypnea
Initial stages: only on exertion
Advanced stages: continuously
Pursed lip breathing
This style of breathing increases airway pressure and prevents bronchial collapse
during the last phase of expiration.
More commonly seen in patients with emphysema
Prolonged expiratory phase, end-expiratory wheezing, crackles, muffled breath
sounds, and/or coarse rhonchi on auscultation
Cyanosis due to hypoxemia
11 A male with history of smoking presents with progressive cough and dyspnea. He also
has cardiomegaly on previous CXR. FEV1 / FVC was < 70%. What is the most likely
diagnosis?
A. Emphysema
B. COPD (cor pulmonale) Right sided heart failure
C. Heart failure
Key finding: FEV1/FVC < 70% after bronchodilator inhalation
Typical supportive findings
↓ FEV1
Normal or ↓ FVC
In the presence of significant emphysema and small airway abnormalities:
 ↑ TLC (total lung capacity), FRC (functional residual capacity), RV (residual
volume)
↓ DLCO

12 Management of Chronic obstructive pulmonary disorder

SABA LAMA LABA ICS PDE4-I Steroids
Restrictive Lung Diseases
13 A female with rheumatoid arthritis – on methotrexate and ibuprofen – developed
worsening dyspnea. Her FEV1/FVC ratio was 45%. What is your diagnosis?
A. Lung cancer
B. Pulmonary fibrosis
C. Methotrexate pneumonitis
D. Caplan syndrome (rheumatoid pneumoconiosis)

PFTs in patients with methotrexate pneumonitis typically reveal a restrictive pattern

with a decrease in the diffusing capacity for carbon monoxide (DLCO), hypoxemia,
and an increased alveolar-arterial (A-a) gradient
14 An Afro-American complaining of dyspnea was found to have bilateral interstitial
nodules on CXR. Renal biopsy showed crescentic glomerulonephritis. What is the most
likely pulmonary biopsy finding?
Non-caseating granuloma (sarcoidosis

Features of sarcoidosis are GRUELING: Granulomas, aRthritis, Uveitis, Erythema

nodosum, Lymphadenopathy, Interstitial fibrosis, Negative TB test, and
Gammaglobulinemia.

Chest x-ray
Preferred initial test
Sarcoidosis is often an incidental finding detected on chest x-ray
Findings: bilateral hilar lymphadenopathy with or without reticular opacities

Biopsy: the gold standard for diagnosis

Histological findings
Noncaseating granulomas with giant cells
Asteroid bodies
Schaumann bodies
15 A lady has a lung problem. She has normal FEV1: FVC ratio but low FVC & low TLC.
CXR showed honeycomb appearance. What is the most likely diagnosis?
A. COPD
B. Interstitial fibrosis
Typical pattern findings
Honeycombing: multiple cystic lesions within the lung parenchyma due to fibrosis
Irregular thickening of intralobular septa
ground glass opacity
Traction bronchiectasis (irreversible dilatation of the bronchi and bronchioles due to
fibrosis)
 Pulmonary function tests (PFTs)
Restrictive lung disease pattern
↓ Total lung capacity and ↓ vital capacity
Normal or ↓ FEV1
↓ FVC
Normal or ↑ FEV1:FVC ratio
Decreased diffusing capacity for CO (DLCO): highly sensitive parameter
Lung Cancer
16 A 58-year-old recently retired man presents with shortness of breath. He has been
smoking 20 cigarettes / day since he was 20 years old and has been working in building
construction sites. He also gave history of working in an insulation piping company. On
examination, he had lower limb edema. CXR was done and showed left lateral calcified
pleural plaques (thickened lung wall) and basal fibrosis. What is the most likely
diagnosis?
A. Asbestosis (mesothelioma – cancer of the pleura) Occupation
B. Silicosis
17 What lung cancer causes pleural thickening and weight loss?
A. Mesothelioma
B. Adenocarcinoma
C. Small cell carcinoma
D. Large cell carcinoma
18 A patient has been cancer-free for 8 years, but he was recently found to have a metastatic
pulmonary nodule. What is the 5-year-percentage of him being cancer free??
A. 25%
B. 50%
The 2-year and 5-year overall survival rates of single lung metastatic nodule were 62%
and 50%, respectively. The 2-year and 5-year overall survival rate of initial multiple lung
metastatic nodules were 45% and 5%
19 A patient being treated for oat-cell carcinoma (SSC) came with
weight loss due to loss of appetite because of the chemotherapy,
associated with nausea and vomiting. What do you give him?
A. Prochlorperazine
B. Amitriptyline
C. Megesterol acetate (synthetic progesterone used for
treatment of breast & endometrial cancer + increases
appetite & promotes weight gain) – cancer &
chemotherapy cause vomiting; this will improve the
appetite
Small cell lung cancer is also known as “oat-cell” cancer because the cells look like oats
under the microscope. It often starts in the bronchi, then quickly grows and spread to
other parts of the body, including the lymph nodes.
 20 A 50-year-old man presented with cough and hemoptysis. He tells you that he has been a
smoker since he was 15 years old. CXR showed a right upper lobe opacity, and
percutaneous aspiration revealed evidence of squamous cell carcinoma. What would be
the best treatment?
A. High-level radiotherapy
B. Palliative radiotherapy
C. Chemotherapy
D. Surgical intervention

Preferred: surgical resection with or without chemotherapy [35][55][56]

Nonsurgical candidates (e.g., those with inoperable disease or significant
comorbidities): radiotherapy, e.g., stereotactic radiotherapy [35]
Pulmonary Embolisms
21 A lady developed SOB 5 days after a C/S. What is the source of the PE?
A. LL DVT
B. Pelvic thrombophlebitis
22 A woman came to you with sudden onset of chest pain and hemoptysis. This was
preceded by 2 days of lower limb swelling and pain. She is known to be hypertensive and
diabetic (on glyburide). She is also taking OCPs. The patient tells you that she had just
come from the USA after a 16-hour flight. She was there for her mother’s funeral as she
passed away from complications of breast cancer. What is the most likely cause of her
symptoms?
Long flight
23 A pregnant woman presented with sudden onset of pleuritic chest pain. It was not preceded
by any event as she was lying down for hours before it occurred, but states thatshe has had
leg swelling for the past day. What is the diagnosis?
A. Pulmonary edema
B. Pulmonary infarction
C. Pulmonary embolism
D. Bronchiectasis
24 A 48 y/o man presents to the hospital with SOB & right-sided chest pain. His vitals were
normal except for his  HR. CXR was normal. PO2 = 60 & pCO2 = 35; pH = 7.44. After giving
him an O2 mask, his pO2 = 85. What is your next step in management?
A. CT angiogram PE
B. Lung function test
C. Doppler US
Hemodynamically stable patients (e.g., systolic BP > 90 mm Hg): Assess PTP of PE.
Low PTP of PE
PERC > 0: Obtain D-dimer
Intermediate PTP of PE: Obtain D-dimer.
Elevated D-dimer: Obtain confirmatory imaging.
Normal D-dimer: No further testing for PE is required; consider alternative diagnoses.
High PTP of PE: Obtain confirmatory imaging.
Management of pulmonary embolism
25 What is the characteristic ECG finding in pulmonary embolism?
S1Q3T3
 Infections
26 An Indian patient presented with a cough, weight loss, and night sweats. CXR showed
lower zone infiltration. How will you confirm the diagnosis?
A. PPD
B. Ziehl-Neelsen stain of bronchial washing
27 A 25 y/o Indian male, working as a hospital porter, presented with weight loss, night
sweats, and blood-stained sputum. Diagnosis?
Pulmonary TB
28 A patient with HIV came presenting with SOB and high fever. His CXR showed bilateral
interstitial infiltration. What is the most appropriate antibiotic?
A. Ciprofloxacin
B. Trimethoprim
C. 4 drugs for TB
D. 2 drugs for TB
Pneumonia in HIV +ve patient = Pneumocystis jiroveci

X-ray chest
Findings
Diffuse, bilateral, symmetrical, interstitial infiltrates extending from the perihilar region
(butterfly pattern)
May be normal in the early stages of PCP
CT chest without contrast (HRCT may increase diagnostic accuracy)
Indicated if PCP is still suspected in a patient with a normal chest x-ray
Findings
Ground-glass attenuation: symmetrical, diffuse, interstitial infiltrates
Pneumatoceles

Antibiotic therapy
High-dose TMP/SMX
29 A patient had a productive cough (yellow sputum) that has become blood tinged. He alsohas
been having fever for the past 3 weeks and has lost 2 kgs of weight. What is the mostlikely
diagnosis?
A. TB
B. Malignancy
30 A patient was diagnosed with PCP. What should you check for?
HIV status
31 An old patient presented with
community acquired pneumonia and
was started on levofloxacin and has
been improving. What type of bacteria
does levofloxacin workagainst?
A. Gram positive + gram negative
B. Gram positive + gram
negative + atypical
C. Gram negative + atypical

32 A 55-year-old man came to the clinic with community acquired pneumonia. Sputum
culture revealed streptococcus pneumoniae. Which antibiotic will you give him?
A. Amoxicillin (also used for children with otitis media)
B. Cefuroxime
C. Augmentin
D. Azithromycin
For CAP:
- Amoxicillin + macrolide (azithromycin / clarithromycin)
- Penicillin allergy → 3rd generation cephalosporin + macrolide
Monotherapy with one of the following:
Amoxicillin
Doxycycline
A macrolide (only in areas with a pneumococcal macrolide resistance < 25%)
Azithromycin
Clarithromycin
33 A man presenting with a cough had a CXR done that showed bilateral opacities. Best
treatment?
A. Vancomycin
B. Azithromycin
Ceftriaxone + azithromycin OR
Moxifloxacin

34 An elderly man had community acquired

pneumonia. Culture revealed streptococcus and he
was started on antibiotics after which he improved.
4 days later, he came back complaining of fever
and cough. CXR was done (showed cavitation).
What is the causative organism?
A. Legionella
B. Chlamydia
C. Pseudomonas (air-fluid level = abscess;
common in ICP & HAP)
D. Staph. Aureus (pneumatocele may be
present) MC coinfection

35 What will you find on auscultation of the chest of a patient

with this x-ray?
Right middle lobe crepitations

36 Diagnosis?
Lower lobe pneumonia

37 A patient presents with fever & cough. CXR shown.

Diagnosis?

A. Middle lobe pneumonia

B. Atelectasis
38 What does the CXR show?
Right lobe consolidation

39 A 68-year-old patient has pneumonia. What

are the indications for admission?
Age
CURB-65

40 A construction worker presented with night sweats and weight loss associated with a
cough. Most likely diagnosis?
A. TB
B. Lung cancer
41 A man developed a lung nodule after his kidney transplant. Sputum culture showed a
fungus. Petri dish showed aspergillus fumigatus. What is the
best treatment?
A. Voriconazole IV
B. Caspofungin use as a alternative combo
C. Linezolid
ICP aspergillus fumigatus invasive lung nodule
42 A patient developed pneumonia post-cardiac transplant. Culture showed normal flora. He
took antibiotics for 4 months but did not improve. What is the most likely cause?
A. Aspergillus (found in air & URT pathogenic in ICP; culture will show normal
flora & antibiotics won’t work)
B. Mycoplasma
C. Nocardia brasiliensis
D. Cytomegalovirus
E. Mycobacterium avium
 Pleural Diseases
43 Chylous material was aspirated from a pleural effusion. What is the most likely cause?
A. TB
B. Lymphoma
C. Trauma
D. CHF
Causes of chylous pleural effusion:
§ Trauma
§ Malignancy (lymphoma / bronchogenic carcinoma)
§ Congenital lymphatic anomalies
44 A man presents with 6-week-history of cough & shortness of breath after which he
developed pleural effusion & tracheal shift. What is the cause of the effusion?
A. Acute infection
B. Malignancy
C. Autoimmune
45 A smoker presents with weight loss, cough, and bloody sputum. O/E, his trachea is
deviated to the left side. There are crackles & decreased air entry on the right side. What
is the likely cause of the pleural effusion?
Lung malignancy
46 A man comes in following asbestos exposure. Trachea is deviated to the right & his left
chest is dull to percussion. There is decreased breath sounds on the left side. Diagnosis?
A. Pleural effusion
B. Pneumonia
C. Collapse goes to same side
D. Bronchiectasis
47 A patient with heart failure presented with pleural effusion. What will you find on
examination?
A. Stony dullness
B. Decreased air entry
Inspection and palpation
Asymmetric expansion
Reduced tactile fremitus
Auscultation
Faint or absent breath sounds
Pleural friction rub
Percussion: dullness over the area of effusion
48 A CXR was showing a pleural effusion and a table was attached showing the serum and
pleural fluid protein & LDH. What is your next step?
The case was transudative. Generally you treat the underlying cause UNLESS large
effusion leading to compressive symptoms then chest tube.

Indications of pleurodesis:
- Pneumothorax: recurrent / secondary
- Pleural effusion: rapidly reaccumulating malignant effusion
Indications of therapeutic thoracentesis:
- Large effusion with dyspnea and/or cardiac decompensation
- Complicated parapneumonic effusions

Others
49 A patient presented with basal inspiratory rubs. Diagnosis?
Rib fracture (pleural friction rub)

Viral infections
Most common cause

Pleurisy (pleuritis) : inflammation of the pleura tissues around lungs.

Viral infections
Bacterial infections
Serositis : Inflammation of the linings of lungs, heart, and abdominal organs.
Autoimmune conditions like rheumatoid arthritis, inflammatory bowel disease, and
juvenile idiopathic arthritis can lead to serositis. Kidney failure, infections, and AIDS are
among other potential causes.
Pleural Effusion
Chest injuries: Broken ribs, Car collisions, assaults, and sports injuries are among
potential causes of chest injuries.
50 An old farmer presents with history of cough and weight loss. On examination, you notice
clubbing. CXR shows multiple small plaques in the upper lobes. Diagnosis?
A. Bronchogenic cancer
B. External allergic alveolitis (long-term oxygen decrease clubbing)
Acute (commencing 4–8 hours after exposure) [2]
Flu-like symptoms: fever, chills, malaise, cough, headache
Dyspnea without wheezing
Chest tightness [4]
Diffuse fine crackles upon auscultation
Symptoms subside after 12 hours to several days (in the absence of additional exposure)
Subacute (weeks to months after continuous exposure)
Insidious onset of fatigue
Possible progression to persistent productive cough and dyspnea
 May begin noticing weight loss
Chronic (months after continuous exposure)
Insidious onset of fatigue, productive cough, progressive dyspnea, cyanosis
Bilateral rales
Weight loss

Inhalation of organic particles (< 5 microns), primarily through occupational exposure

(notifiable occupational disease) [1]
Farmers are frequently affected
51 A man had sudden onset of chest pain while exercising. What is the most likely
diagnosis?
Spontaneous pneumothorax
52 Calculation of alveolar-arterial gradient.
30 (PAO2 – PaO2) alveolar – artery
PAO2 = PiO2 – (PaCO2 / 0.8) – PaO2 = 150 – (PaCO2 / 0.8)
Example:
PaO2 = 150
PCO2 = 48
PO2 = 60
150 – (48/0.8) – 60 = 30
(normal for a healthy non-smoker young-adult is 5-10 mmHg)
53 A patient presented with sudden onset of shortness of
breath. USS of the lung shown (showing multiple - > 3 –
vertical B lines). What is the possible cause?
A. Pulmonary edema (sandy beach appearance)
B. Pneumothorax (barcode)
C. Pneumonia

54 You have a patient with recurrent chest infections that you investigated for immune
deficiency, but all results were normal. You are suspecting ciliary dyskinesia syndrome so
you took a sample from the airways to investigate for ciliary problems. How will you
fixate the cilia till you can examine the slides in the histopathology lab?
A. Spray alcohol
B. Spray water
C. Spray formalin
D. Spray glyceraldehyde
E. Do nothing
couldn’t find a definitive answer
55 A young footballer presents with episodes of SOB and cough. CXR shows heart
enlargement and increased vascular markings.
Pulmonary hypertension
 ------- Rheumatology -------
Rheumatoid Arthritis
1 A patient with rheumatoid arthritis is taking methotrexate. What advice do you give her to
prevent contractures after inflammation?
A. Exercise
B. Cold compression
C. Rest
Stretching. Acutely, inflamed joints should be rested to prevent exacerbation of
symptoms. For non-inflamed joints, active or active-assisted stretching of all major joints
is essential to prevent contracture formation and maintain the current range of motion to
perform most activities of daily living.
2 A lady complains of joint pain & morning stiffness in the proximal interphalangeal joints.
The stiffness improves as the day goes by. Investigations show elevated ESR. Diagnosis?
A. Osteoarthritis
B. Rheumatoid arthritis
3 A lady has joint pain in the PIPs that is worse in the morning & gets better during the day.
Diagnosis? Management?
NSAIDs (rheumatoid arthritis)
RA doesn’t affect DIP

Initiate acute antiinflammatory treatment with glucocorticoids and NSAIDs for disease
flares.
Long-term treatment
Initiate treatment with conventional DMARD monotherapy.
Consider short-term concomitant antiinflammatory treatment.
Initiate nonpharmacological management.
Consider surgical treatment in specific cases (e.g., patients with severe joint deformities).
Gout

- Acute: colchicine / NSAIDs / steroids

- Chronic: if < 2 attacks / year: allopurinol
4 A patient came to the ER with joint pain. The ER doctors aspirated the synovial fluid
from the affected joint & sent it to the lab, but he forgot to write from which joint the
sample was obtained. The analysis of the fluid showed -ve birefringent needle-shaped
crystals. Which joint was aspirated?
A. 1st metatarsal joint
B. Knee

5 A man came with a typical presentation of gout. He reports that exercise worsens the
pain. What is typical for this disease (gout)?
A. Women are affected more men
B. Associated with polyarthritis
C. It affects small joints
D. The condition gets worse with exercise
Peripheral small joints in the lower extremities are especially affected.
6 A diabetic patient with stage 3
CKD presents with acute pain in
the 1st metatarsophalangeal joint.
On examination, the joint is red &
swollen, and he is unable tofully
flex the big toe. An acute attack of
gout. What is the best treatment
option for his acute attack?
A. Allopurinol (not started
during acute flares as it
may worsen the symptoms)
B. Colchicine (not contraindicated but dose adjustment and close monitoring is
important – signs of toxicity are leukopenia / elevation of AST / neuropathy)
C. NSAIDs (diclofenac sodium) (nephrotoxic)
D. Steroids (may be the best option)
E. Indomethacin (nephrotoxic)
7 A patient on aspirin develops gout. Which gout medication will interact with aspirin?
A. Allopurinol (higher risk of ulcers)
B. Colchicine
8 A 56-year-old hypertensive patient on diuretics was diagnosed with gout. What drug do
you give instead of what he is taking?
A. Losartan good for gout
B. Atenolol
C. Amlodipine good for gout
D. Thiazides bad for gout
Google says either losartan or amlodipine
Systemic Lupus Erythematosus
 9 Picture of butterfly rash. Patient has symptoms of malar rash &
photosensitivity. Diagnosis? She also has joint pains and
decreased night vision. What is your most likely diagnosis?
A. Rheumatoid arthritis
B. SLE
C. Vitamin A deficiency
10 A 28 y/o lady comes to the ER complaining of bruises & gingival bleeding. She reports
history of fatigue & malaise. Over the past 2 weeks, she has had arthralgia of her hands &
feet, pleuritic chest pain, and abdominal pain. She had red scar patches over her forehead.
Auscultation of her heart reveals a friction rub. Diagnosis?
A. Rheumatoid arthritis
B. SLE
C. Scleroderma
11 A man is complaining of bilateral leg pain preventing him from going up stairs. He is
ANA +ve and has anti-sm antibodies. What is the most likely diagnosis?
SLE
12 How do you confirm the diagnosis of SLE?
D. ANA
E. Rheumatoid factor

Other options??
13 A pregnant lady with SLE gave birth. Her child was bradycardic. Which auto-antibody is
associated with high risk of heart block in the fetus?
A. Anti-Ro (neonates) SSA >> amboss
B. Anti-Jo (polymyositis)
C. ANA (sensitive for SLE)
D. Anti-double stranded DNA (specific to SLE)
E. Anti-histone (drug-induced SLE)
14 A middle-aged African woman with history of joint pain was brought to the ER by her
family for new onset of neuropsychiatric symptoms (sudden disturbed behavior). She reports
that she recently took aspirin for a headache she had 1 week ago. She has a familyhistory of
schizophrenia (brother). On examination, she has a macular rash on her cheeks and nose.
Investigations showed that she is ANA +ve. What is the cause of her manifestations?
A. Aspirin
B. Thrombosis
C. Cerebral vasculitis
D. Malignancy
E. Infection

Seronegative Arthropathies
Ankylosing Spondylitis
• Sacroiletis (morning stiffness > 1 hours; low back pain decreases with use)
• X-ray shows bamboo sign (lateral lumbar)
• Treatment: NSAIDs +/- local steroids TNF-alpha inhibitor
15 A 22 y/o patient presents with conjunctivitis. On further questioning, he reported chronic
back pain for 2 years. The pain worsens in the morning. No history of urine changes, pain
with walking, or food poisoning. Diagnosis?
A. Ankylosing spondylitis
B. Rheumatoid arthritis
C. Reiter’s disease
16 A patient is complaining of knee pain. On examination, his knee was tender and warm,
and his eyes were red. Diagnosis?
A. Reactive arthritis
B. Viral arthritis
A. C. Septic arthritis

Reiter syndrome: Can’t see, can’t pee, can’t climb a tree (uveitis + arthritis + urethritis)
Classic triad of reactive arthritis (seen in approximately one-third of affected individuals):
“can't see (conjunctivitis), can't pee (urethritis), can't climb a tree (arthritis)”.
 Vasculitis
17 A man has chronic sinusitis, high creatinine, and +++ blood on urine dipstick. Diagnosis?
A. Wegener granulomatosis
B. Churg Strauss
C. Mixed cryoglobulinemia
D. Hemolytic uremic syndrome
Granulomatosis with polyangiitis (GPA, previously known as Wegener granulomatosis)

ENT involvement: often the first clinical manifestation

Chronic rhinitis/sinusitis: nasopharyngeal ulcerations → nasal septum perforation →
saddle nose deformity
Chronic otitis and/or mastoiditis
Lower respiratory tract: potentially life-threatening
Treatment-resistant, pneumonia-like symptoms with cough, dyspnea, hemoptysis
Renal involvement: potentially life-threatening
Pauci-immune glomerulonephritis (Pauci‑immune indicates that there is little evidence of
immune complex/antibody deposits.) → rapidly progressive (crescentic)
glomerulonephritis (RPGN) with possible pulmonary-renal syndrome
Typically causes hematuria and red cell casts
18 What are the microscopical findings of ANCA +ve Wegner’s?
Polyangitis granuloma (granulomatosis with polyangiitis)

Laboratory analysis
Blood
PR3-ANCA/c-ANCA (anti-proteinase 3)
Urine
microscopic hematuria
dysmorphic RBC and RBC casts → nephritic sediment
Imaging: chest x-ray/CT show multiple bilateral cavitating nodular lesions
Pathology
Typically shows classic triad of:
Necrotic, partially granulomatous vasculitis of small and medium-sized vessels
Necrotizing granulomas; mainly in lung and upper airways
Necrotizing glomerulonephritis
19 A man with renal & respiratory symptoms underwent renal biopsy that showed linear IgG
deposits. He was ANCA +ve. Diagnosis?
A. Goodpastures syndrome (no upper respiratory symptoms)
B. Granulomatosis with polyangiitis
ANCA +ve = Wegener / good pasture
- Kidney + lungs = good pasture (anti-GBM)
- Kidney + lungs + sinuses = Wegener
Linear deposition of immunoglobulin G (IgG) along GBM is the hallmark of anti-GBM
glomerulonephritis, and is occasionally accompanied by deposition along tubular basement
membrane (TBM).
20 A patient complaining of cough and shortness of breath had  urea & creatinine levels
and was ANCA +ve. Renal biopsy showed focal necrotizing vasculitis. CXR showed
bilateral interstitial nodules. What is another symptom that he could he have?
A. Hemoptysis (goodpasture syndrome)
B. Angina
C. Hemothorax
D. Hemorrhagic pericarditis
21 A man has progressively worsening kidney function. Biopsy showed IgG linear deposits
in the glomerular basement membrane.
Goodpasture syndrome
22 What are the classical features of temporal arteritis?
Common signs and symptoms of GCA reflect the involvement of the temporal artery and
other medium-sized arteries of the head and the neck and include visual disturbances,
headache, jaw claudication, neck pain, and scalp tenderness. Constitutional
manifestations, such as fatigue, malaise, and fever, may also be present.
50% GCA have polymyalgia rheumatica, >40 y.o. giant cell means giant year old
Takayaso pulseless disease (decreased radial and brachial), <40 y.o
Others
23 A young male, smoker, is complaining of pain just left to the sternum. He exercises
3x/week with his friends. He is under a lot of stress recently because of his studies. He is
able to maintain weightlifting but reports that the pain increases with deep breathing and
pulling / pushing against the wall with his arms. O/E, lungs are normal. Diagnosis?
E. Costochondritis
F. T3-T5 prolapse
G. Esophageal spasm
Clinical features
Sharp, well-localized pain that is reproducible on palpation of costal cartilage
History of recent exercise/exertion/chest wall trauma
Diagnostics
Clinical diagnosis [51]
CXR: normal
Treatment
Pain management
Acetaminophen
NSAIDs (e.g., naproxen, ibuprofen)
Supportive care
Physical therapy (i.e., stretching exercises)
Reduction of activities that provoke symptoms
Cough suppressants
Heat or ice packs
24 A female has symmetrical upper and lower limb muscle pain & weakness. Her proximal
muscles are affected more than the distal. Investigations show that she is anti-Jo1
positive. Diagnosis?
Polymyositis

Limb weakness
pelvic and shoulder girdle muscles, leading to difficulties combing hair, standing up
from a sitting position, and climbing stairs
myalgia
In inclusion body myositis, the weakness may be:
Asymmetrical
Additionally affecting distal muscle groups
 Axial muscle weakness
dysphagia

25 A woman presented complaining of dysphagia and thickening of the skin. What antibody
will you find on serology?
A. Scl 70 (= topoisomerase scleroderma)
B. Anti-double strand DNA
CREST:
Calcinosis
Raynaud phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia

SSc-specific autoantibodies
Anticentromere antibodies: associated with limited SSc
Anti-Scl-70 (anti-topoisomerase I antibody): associated with severe and rapidly
progressive diffuse SSc, limited SSc
Anti-RNA polymerase III: associated with diffuse SSc
26 A patient presented with a purpuric rash. He has no previous history of URTI or
abdominal pain. On examination, he has palpable purpura. Investigations revealed low
complement (C3 & C4). He is hepatitis C positive. Hepatitis B is negative. What is the
most likely diagnosis?
A. IgA nephropathy
B. Membranous nephropathy
C. Membranoproliferative glomerulonephritis
D. Mixed cryoglobulinemia associated with hepC and low compliments
Type II and III cryoglobulinemia (i.e., mixed cryoglobulinemia): 90% of cases
Viral infection: most common etiology (HCV infection in 70–90% of cases)

The triad of arthralgia, palpable purpura, and fatigue is seen in ∼ 80% of patients
with cryoglobulinemic vasculitis.
27 Which organism inhibits neuraminidase leading to hemolytic syndrome? ETEC
hemorrhagic and enterotoxic
A. Staphylococcus aureus
B. Streptococcus pneumoniae
C. Escherichia coli
 ------- Toxicology -------

Ingested Toxins
1 A patient presented with generalized body pain, restlessness, excessive lacrimation, and
sneezing. He admits to using drugs but does not tell you the kind. What drug do you
suspect he is taking?
A. TCA
B. Lithium
C. Opioids
D. Cannabis
E. Alcohol
F. Benzodiazepines
2 A 30 y/o was brought to the ER after he was found unconscious on the side of the [Link]
had pin-point pupils. What is the most appropriate drug to administer?
A. Diazepam
B. Haloperidol
C. Naloxone

3 A 30 y/o businessman underwent an inguinal hernia repair. The next day, he was confused
and developed a tremor, headache, nausea, palpitations, and anxiety. Most likelydiagnosis?
A. Cannabis intoxication
B. Alcohol withdrawal
C. Anesthesia

4 A 45 y/o businessman was admitted to surgical

ward for left inguinal hernia. He has no
chronic disease. The next morning, he became
 restless, sweaty & tremulous. Thesurgery
was postponed, RBS was normal.
Diagnosis?
A. Agitated depression
B. Alcohol withdrawal symptoms
C. Cannabis intoxication
D. Hospital phobia
5 What sign would be present in a patient coming with alcohol withdrawal?
A. Apathy
B. Tachycardia
C. Hypersomnia
D. Insomnia
6 Which symptom is expected in delirium tremens?
A. Vivid visual hallucinations
B. Disinhibited behavior
C. Rigidity
7 What sign is predictive of alcohol toxicity?
Tachycardia

Alcohol withdrawal delirium (delirium tremens) [2][3]

Definition: persistent alteration of consciousness and sympathetic hyperactivity due to alcohol
withdrawal
Onset: usually 72–96 hours after cessation of or reduction in alcohol consumption
Clinical features
Symptoms of altered mental status
Impaired consciousness
Visual and tactile hallucinations (usually small moving objects, e.g., mice, crawling insects)
Worsening symptoms of autonomic instability
Tachycardia
Hypertension
Anxiety
Nausea
Worsening symptoms of neurological impairment
Psychomotor agitation (e.g., fidgeting, restlessness, tearfulness)
Alcohol withdrawal seizures can occur during this phase.
Insomnia
Rest and intention tremor
Duration: usually 2–3 days; may be lethal
8 A male was brought to the ER with restlessness, tremors, etc. (alcohol withdrawalsymptoms).
Treatment?
A. Chlordiazepoxide it is a benzodiazepine, which is first line for alcohol withdrawal
B. Chlorpromazine
C. Olanzapine
Management of alcohol withdrawal = chlordiazepoxide + thiamine + folic acid +
multivitamins

First-line: benzodiazepines
Shorter or intermediate-acting (e.g., oxazepam, lorazepam): Consider in patients
with a slow metabolism (e.g., the elderly, those with liver failure).
Longer acting (e.g., chlordiazepoxide, diazepam): preferred in all other patients
9 A patient with known history of alcohol intake developed delirium tremens. Which of the
following will help decrease his symptoms?
A. Corticosteroids
B. Thiamine
C. Cobalamin
Thiamine supplementation
Patients with Wernicke encephalopathy: therapeutic-dose thiamine
All other patients: prophylactic-dose thiamine
1 A lady is being treated with haloperidol. She was brought by her husband to the ER as she
0 developed a fever. On examination, she was tachycardic, hypertensive, and had a
temperature of 40 degrees. What is the most likely diagnosis?
A. Overdose
B. Allergic reaction
C. Neuroleptic malignant syndrome

Rx
Discontinuation of the antipsychotic drug
Pharmacotherapy
Dantrolene
Alternatives: bromocriptine, apomorphine, or amantadine
Benzodiazepines

1 A child is brought in after he ingested some tablets. Gastric lavage is being considered.
1 Which of the following is a contraindication to gastric lavage?
A. Aspirin
B. Caustic soda aka sodium hydroxide, it will cause re-exposure to the corrosive
agent
C. Diazepam
1 A baby was found with many medicine bottles including digoxin, PPI, and 2 others. The
2 mother found half chewed tablets in his mouth. She brought him in within 30 minutes. He
was drowsy. Management?
A. Gastric lavage & charcoal
B. Induce emesis
C. Review the bottles of the medication > this first
1 A patient came complaining of bloody diarrhea and dizziness after an iron overdose.
3 Management?
A. IV deferoxamine
B. Hemodialysis
1 A lady with epilepsy & psychiatric illness developed a seizure & coarse tremor followed
4 by confusion and a coma. She has no fever. What is the most likely cause?
A. Carbamazepine toxicity
B. TCA toxicity
C. Lithium toxicity
D. Neuroleptic malignant syndrome

Clinical features
Gastrointestinal
Nausea, vomiting, and diarrhea
Neuromuscular
Altered mental status, confusion
Somnolence
Delirium, encephalopathy
Coarse tremors, seizures
Ataxia, slurred speech
Hyperreflexia
Acute renal failure
1 A 40-year-old lady was brought by her family as she was agitated and anxious. Her
5 family say that she is depressed as she has recently gotten divorced and quit her job. On
examination, you notice that she is diaphoretic, and her pupils are 7mm. what is the
cause?
A. Opioid toxicity miosis resp cns depression
B. Sympathomimetic drug toxicity
C. Cholinergic toxicity miosis and sweating
D. Anticholinergic toxicity dry and mydriasis
1 An 18-year-old boy came back home after spending a night at his friend’s house. His
6 mother noticed that he was anxious, restless, sweating, and had increased lacrimation. She
brought him to the ER where he was complaining of fatigue and a headache. No appetite
changes. He was mildly hypertensive, and his pupils were dilated. His speech was intact,
and he denied taking any drugs. What drug did he take?
A. Alcohol (withdrawal)
B. Glue inhalation
C. Amphetamine longer lasting effect
D. Cocaine both meth and cocaine have mydriasis
E. Opioids
1 A 30-year-old male presented with flu-like symptoms, rhinorrhea, irritability, and
7 sweating. These symptoms are most likely due to withdrawal of which drug?
A. Amphetamine
B. Cocaine (crash, hypersomnolence, angina, suicidality, nightmares, increased
appetite)
C. Heroin (increased secretions, goosebumps)
D. Cannabis

caused by sudden cessation or reduction of opioid intake after prolonged chronic use
CNS arousal and sympathetic hyperactivity
Tachycardia, hypertension
Anxiety, insomnia, irritability, agitation
Mydriasis, yawning, lacrimation
Hyperreflexia, muscle cramps
Flu-like symptoms
Rhinorrhea, diaphoresis, piloerection, ; chills
Myalgia, arthralgia
Gastrointestinal symptoms
Nausea, vomiting, diarrhea
Abdominal pain
Injected Toxins
1 What is the most likely cause of death (long term) in a patient with history of heroin
8 intake?
A. Cerebellar atrophy
B. Pontine hemorrhage
C. Peripheral neuropathy
D. Septicemia
Most common cause of death in heroin intake is respiratory depression. Cuz Overdose
 ------- Trauma -------
General Principles & Resuscitation
1 A patient was found to the ER following trauma to her chest, abdomen, and pelvis. On
examination, there are decreased breath sounds with dullness on percussion over the left
lung. How do you manage her?
Chest tube insertion

Clinical features
Dyspnea and diminished/absent breath sounds
Decreased tactile fremitus, dullness on percussion
Chest pain
Flat neck veins, hemorrhagic shock and respiratory distress in severe hemorrhage
Chest wall deformity
Paradoxical chest wall movement
Crepitus on palpation

Treatment
Chest tube insertion into the 5th intercostal space at the midaxillary line
Thoracotomy indicated if
Chest tube output > 1500 mL immediately after placement or 200 mL/hour for 2–4
hours [5]
Multiple transfusions required
2 A patient was involved in an RTA which caused multiple fractures, trauma to the
abdomen, epidural hematoma, and pneumothorax. What will you treat first?
Pneumothorax

P-THORAX: Pleuritic pain, Tracheal deviation, Hyperresonance, Onset sudden,

Reduced breath sounds (and dyspnea), Absent fremitus, X-ray show collapse.

Unstable (high risk) [6][7][8]

Suspected tension pneumothorax
Emergency needle thoracostomy, followed immediately by chest tube placement
Emergency chest tube placement
Stable (low risk): Primary spontaneous pneumothorax [6][8]
Apex-to-cupola distance < 3 cm
Usually resolves spontaneously
3 A pregnant lady was brought to the ER after an RTA. She had a pneumothorax, so needle
decompression was done. Her oxygen saturation was normal. Abdominal examination
revealed no tenderness & positive bowel sounds. What is the next step in management?
A. FAST scan
B. Head CT
C. Chest x-ray
D. Chest tube
4 A patient was brought to the emergency following an RTA. His GCS was 8. On
examination, he was cyanosed. He had unilateral reduced air entry on the left side (lower
lobe) with hyperresonance on percussion. X-ray attached (showing flail chest?). What is
your next step?
A. Admission to ICU
B. Tube insertion intubation? Chest tube?
C. Oxygen man6i8yyan u will give oxygen and chest tube at the same time
Intubation & control ventilation surgical chest tube
More options needed
5 A patient was brought in following RTA. His GCS is 8. He has a flail chest with  air
entry to the left side. His pupils are fixed & dilated. He also has some fractures. Next
step?
A. Intubation
B. Chest tube
C. Mannitol
D. Surgical correction of fracture
E. Laparotomy
6 An RTA victim was brought in with flail chest. He was intubated and his saturation
improved. He had equal air entry. He also had a unilateral fixed pupil. He was
hypotensive and was given fluids after which his blood pressure mildly improved. He
hadabdominal distension, which was dull to percussion, as well as a tibial fracture. What
is the next step in management?
A. Laparotomy
B. Limb splinting
C. Mannitol infusion
D. Chest tube insertion
7 A patient was brought in after a motorcycle accident. He had a flail chest and a fractured
femur. He was intubated & put on respiratory support. He has  BP and is tachycardic.
His spO2 is normal. His left pupil is fixed & dilated. His abdomen is distended & dull on
percussion. Next best step?
A. IV mannitol
B. Chest tube insertion
C. Laparotomy
D. Splinting of femur fracture
8 A patient was brought in after an MVA. He had a distended abdomen. What is your nextstep
after he is intubated and stabilized? Should be CT first cuz he is stable. If unstable then
laparotomy
A. Diagnostic laparoscopy / laparotomy
B. MRI
9 A 29 y/o lady was involved in an RTA. She
didn’t open her eyes to painful stimuli. She
extends her limbs to painful stimuli & was
saying inappropriate words. GCS?
A. 7
B. 6 (E1 V3 M2)
C. 5
D. 4

10 A polytrauma patient was brought to you unconscious. He had flail chest & multiple other
injuries. Which of the following is an indication for intubation? <8 intubate
A. GCS < 6
B. Sternal fracture
C. Diaphragmatic rupture
11 An RTA patient sustained severe brain injury. What is the best thing do in order to
achieve the best outcome?
A. Maintain airway
B. Monitor BP
Abcde
12 A trauma patient has low BP. First step?
A. Cross match & transfuse blood
B. IV mannitol
C. IV fluids
13 An RTA patient weighing 80 kg had low BP and was resuscitated with IV fluids. What isthe
best way to know if the resuscitation was successful?
A. HR < 100 bpm
B. SBP > 90 mmHg
C. Urine output 40 mL/hour
D. Central venous pressure > 2
14 An RTA patient was brought into the ER. He was given 500 mL of fluid in the
ambulance. What bedside intervention shouldn’t you do?
A. Epinephrine (reduces tissue perfusion)
B. Oxygen
C. IV fluid infusion
D. Aspirin
I would go with D as it may increase the risk of intracranial bleeding. yes
 Ocular
15 A man was punched in the eye. What is your diagnosis
based on the image?
Hyphema

Blood in the anterior chamber refer to

ophthalmology for management:
§ Shield + bedrest for 5 days + sleep with head upright
§ If persists / re-bleeds = surgical drainage
Head & Neck
§ Epidural = biconvex § Subdural = lenticular (crescent)
§ Intra-arachnoid = within brain parenchyma § Intra-ventricular = within ventricles
16 Choose the CT scan showing an epidural hematoma.

17 A girl was hit on her head and developed a subdural hematoma. Which of the following CT
images is correct?
18 A lady is complaining of a headache & morning vomiting. Her history was
insignificantapart from a time 4 months ago when she got hit on her head while playing
ice hockey. Diagnosis?
A. Subdural hematoma (chronic) >> amboss doesn’t say vomiting in clinical features
B. Brain tumor >> most likely
C. Meningitis
19 A patient hit his head on the steering wheel due to an MVA. He has CSF rhinorrhea and
raccoon eyes. Diagnosis? + battle sign (postauricular bleed)
A. Basal skull fracture
B. Temporal skull fracture
C. Subarachnoid hemorrhage
Cardiothoracic
20 When inserting a central venous catheter, a patient developed hypotension, tachycardia,
and distended neck veins. What is the most probable diagnosis?
A. Tension pneumothorax
B. Hemothorax
C. Subclavian artery injury
D. Pulmonary air embolism
Iatrogenic pneumothorax: mechanical ventilation with high PEEP (barotrauma),
thoracocentesis, central venous catheter placement, bronchoscopy, lung biopsy
21 Where do you insert the needle in thoracentesis? No definitive answer
A. 8th rib
B. 6th rib
4th – 6th rib
Thoracentesis is typically performed between
6th and 8th ribs along the midclavicular line → 7th intercostal
8th and 10th ribs along the midaxillary line → 9th intercostal
10th and 12th ribs along the paravertebral line → 10th intercostal
22 A patient was brought to the ER following an RTA. On examination, he was hypotensive
and had muffled heart sounds and distended JVP. Chest was clear on examination.
Diagnosis? Becks triad
A. Pneumothorax
B. Cardiac tamponade pericardiocentesis
C. Hemothorax
Abdominal
23 A patient developed pain at the tip of his shoulder after an accident. He was found to have
a splenic rupture. What is this sign called?
A. Kehr’s sign
B. Cullen’s sign
C. Brudzinski’s sign
D. Grey Turner sign
24 How do you manage a stable patient with splenic tear?
Conservative + ICU monitoring

If low-grade injury in hemodynamically stable patients

Conservative management (e.g. hospital observation with frequent ultrasound
examination)
Angiographic embolization of the injured blood vessel is becoming more widely-used in
stable patients
 If high-grade splenic injuries and/or hemodynamically unstable patients
Laparotomy
If only peripheral rupture: trial of splenic salvage – suturing, coagulation, or ligation of the
injured blood vessel
Alternative: partial splenic resection
If hilar rupture: splenectomy
If necessary, reimplantation of splenic tissue
Alternative: consider angiographic embolization if patients are stable
25 A man was brought to the emergency after an RTA. He had severe hypotension (80/50
mmHg) and was given IV fluids. Afterwards his BP increased to 90/70 mmHg and his
pulse decreased to 125 bpm. Liver US attached. What is your next step?
A. Diagnostic peritoneal lavage
B. CT scan of the abdomen (if laceration is not severe + stable hemodynamically)
C. Urgent laparotomy (if severe laceration) or unstable
D. Send to ICU for observation
E. Blood transfusion n the ICU

The cut off is 90/60 so idk what to consider here

26 CT abdomen with a hematoma near the liver. Diagnosis?

Hepatic contusion
27 A patient was involved in an RTA and was brought in stage 3 hypovolemic shock. Which
organ would you embolize?
Spleen
28 What imaging modality is most useful for detecting a ruptured spleen?
A. X-ray
B. US
C. CT scan
D. MRI

In hemodynamically stable patients (or in unstable patients in which temporary

stabilization with IV fluid resuscitation is successful)
Method of choice: abdominal CT scan (with contrast)
29 A female involved in an RTA (while wearing a seatbelt) is complaining of diffuse
abdominal pain. Bowel sounds are absent. X-ray shows fluid in the peritoneal cavity.
Which organ is most likely injured?
A. Liver
B. Spleen
C. Kidney
D. Bowel
If restrained = bowel injury
If unrestrained = liver / spleen laceration
30 A female had a seatbelt sign post-RTA. She is complaining of abdominal pain. O/E: no
bowel sounds. CT abdomen is normal. What organ is affected? Duodenal hematoma and
pancreatic contusion normal CT until a few days later
A. Liver
B. Intestine
C. Spleen
31 A patient with penetrating abdominal trauma needs treatment for bacteroides fragilis but
you do not have metronidazole. What drug can be used instead?
A. Clindamycin
B. Tineam (Imipenem / cilastatin)
AMBOSS
Metronidazole
OR clindamycin
OR extended-spectrum penicillin with penicillinase inhibitor
32 A man fell on a rod and puncture his gluteal area. He comes complaining of abdominal
pain. On examination, there is a puncture wound 2 cm away from the anal verge. He is
vitally stable. Lateral decubitus abdominal x-ray shows free gas in the abdomen. What is
your next step?
A. Gastrographin enema
B. Urgent laparotomy
C. CT scan >> why not?
D. Colonoscopy

Spinal
33 An RTA victim with a GCS of 3 but stable (???) was
brought to the ER. His CT scan showed anterior
displacement of all cervical spines (CT provided). Next
step?
A. MRI
B. Neurological examination (he is comatose so you
can’t examine)
§ CT scan if not severe: continue MRI to see extent of
spinal cord damage
§ You can give steroids to prevent the spinal cord from
swelling and thus prevent further damage to nerves from inflammation.
Extremities
34 A male is brought to the ER after being rescued from an MVA. On examination, he had
severe deformity of his right thigh and he was experiencing excruciating pain. What is
your next step?
A. IV morphine
B. Oral ketorolac
C. Observation

Acute pain management

General approach: lowest effective dose should be prescribed/administered for the shortest
duration possible
Common uses
Acute severe pain (e.g., ureteric colic, fractures)
Emergency pain management and sedation (e.g., acute coronary syndrome, pulmonary
edema) [10]
Analgosedation during surgery
35 An RTA victim complained of left leg burning pain that he rated as 10/10, occurring at
rest. The skin over his left leg was wood-like (paresthesia). What analgesic do you give
him?
A. Oral NSAID
B. PCA morphine
C. IV morphine
D. Oral paracetamol
E. Topical NSAID
36 A man was hit by a car. He was brought to the ER with calf swelling and was
complaining of ankle pain with loss of sensation. What sign on examination would
indicate compartment syndrome?
A. Pain out of proportion on examination
B. Compartment pressure of 5 mmHg
C. Groin lymphedema
The normal pressure within a compartment is less than 10 mmHg.
If the intra-compartmental pressure reaches 30 mmHg or greater, acute compartment
syndrome is present.

symptoms of ACS typically progress rapidly

Early features
Pain out of proportion to the extent of apparent injury
Worsens with passive stretching or extension of muscles
Extreme tenderness to touch
Soft tissue swelling
Tight, wood-like muscles
Later features
Neurologic deficits
Paresthesia (e.g., pins and needles sensation)
Muscle weakness or paralysis
Impaired perfusion
Cold extremity with pallor
Absent or weak distal pulses
37 A patient had severe pain & numbness of his left leg after an RTA. On examination,
dorsalis pedis pulse is absent. Management?
Fasciotomy

Indications: strongly suspected or confirmed acute compartment syndrome

Techniques
Fasciotomy: incision(s) in the skin and fascia to relieve compartment pressure and
restore perfusion
Escharotomy: incision of circumferential compressing burn eschar
Fibulectomy: removal of the fibula to decompress all four compartments of the leg
Urology
38 A young male involved in an RTA came with no urine
output. On examination, there was blood at the urethral
meatus, and the urinary bladder was enlarged (palpable) &
tender. Retrograde urethrogram was done (shown).
What is the diagnosis?
A. Membranous urethral injury
B. Sacral fracture
C. Rupture of the bladder
What is the next step in management?
A. Urethral catheterization
B. Suprapubic catheterization
C. IV fluid
D. Cystoscopic catheterization

Almost exclusively seen in men

Anterior urethral injuries
Direct trauma to the perineum (direct blow, straddle injury): bulbous urethra is most
 commonly injured, leading to scrotal hematoma
In conjunction with penile fracture
Iatrogenic
Posterior urethral injuries: significant pelvic fracture due to trauma (e.g., a vehicle
collision): bulbomembranous junction is commonly injured

39 A polytrauma patient has blood at the urethral meatus and suprapubic tenderness. What is
the next step?
Ascending urethrogram

Retrograde urethrogram: to rule out suspected urethral injury

First diagnostic step (before catheterization) in a patient with suspected urethral
injury
Others
40 A patient was brought to the ER after a car accident. He had a closed tibial fracture. His
BP was 80/55 mmHg and he was tachycardic. Most likely cause of  BP?
A. Tibial fracture
B. Pelvic injury
C. Abdominal injury
D. Septic shock
 ------- Urology -------
Kidneys
1 A patient presents with RLQ pain radiating to his groin. Urinalysis showed RBCs and
crystals. What is the diagnosis?
Nephrolithiasis
2 A patient presented with renal stone. Urine analysis showed low citrate levels. How do
you treat him? Uric acid stone
A. Increase hydration
B. Allopurinol
C. Potassium citrate
D. Penicillamine
E. Hydrochlorothiazide
3 A patient with nephrolithiasis passed a 5x5 mm stone and brought it to you. Urine
analysis showed RBCs but no WBCs. Next step?
A. Serum calcium
B. PTH
C. 24-hour urine analysis
D. Chemical analysis of the stone
4 A patient has hematuria & right flank pain radiating to the testis. His CT scan showed a
staghorn stone 3x4 cm. What is the treatment?
A. Extracorporeal shockwave
B. Percutaneous lithotripsy
C. Pyelonephrotomy
5 A patient has a kidney stone measuring 5mm. Treatment?
A. Shock wave
B. Nephrectomy
C. Transcutaneous nephrostomy
D. Conservative management
Conservative up to 5 mm.
5 – 7 mm = medical (MET)

First-line: tamsulosin
(alpha blocker)
Relieves ureter muscle
spasms
Promotes the passage of
ureteral stones ≤ 10 mm
Reduces the need for
analgesics
Bladder
6 A 62-year-old male presents with gross hematuria. Cystoscopy was done and showed a
papillary growth that was removed and sent for pathology (showed transitional cell
carcinoma that does not invade the muscularis mucosa). What is the next step of
management?
A. Radical cystectomy
B. Partial cystectomy
C. Intravesical BCG vaccine
D. Systemic chemotherapy
E. Radiotherapy

Nonmuscle invasive
First line: transurethral resection of bladder tumor (TURBT)
Additional treatments include:
Intravesical adjuvant chemotherapy (e.g., mitomycin C or epirubicin) [39]
Immunotherapy with intravesical bacillus Calmette-Guérin (BCG)

Nonmetastatic muscle invasive

First-line treatment
Neoadjuvant chemotherapy (cisplatin-based combination regimens)
AND radical cystectomy with bilateral pelvic lymph node dissection and urinary diversion
Prostate
7 A 60 y/o male complains of nocturia. He also has urine dribbling during the day with
weakening of the urine stream. He has a history of UTI a few months ago. PR
examination revealed a smoothly enlarged prostate gland. Most likely diagnosis?
A. Benign prostatic hypertrophy
B. Prostate cancer
C. UTI
D. Bladder cancer
8 An old man presented with dribbling. He has no dysuria, hematuria, or bacteriuria. Most
likely diagnosis?
A. Benign prostatic hyperplasia
B. Prostate cancer
 Irritative symptoms (storage LUTS; LUTS associated with OAB) [8]
Urinary frequency
Urinary urgency and urge incontinence
Nocturia
Occasionally dysuria
Obstructive symptoms (voiding LUTS; LUTS associated with BOO) [8]
Hesitancy
Straining to urinate
Poor and/or intermittent stream (not continuous)
Prolonged terminal dribbling
Sensation of incomplete voiding
Additional symptoms: gross hematuria
Digital rectal examination (DRE) findings: symmetrically enlarged, smooth (no nodules),
firm, nontender prostate with rubbery or elastic texture
9 What is the gold-standard treatment for benign prostatic hyperplasia?
A. Transurethral resection of the prostate (TURP)
B. Open surgery
C. Transurethral ablation

TURP is the gold standard therapy for BPH

Indications [21]
Insufficient improvement with pharmacological therapy
BPH that is causing complications (see “Complications of BPH”)
1 An old man presents with chronic constant back pain associated with urgency and urge
0 incontinence. He has history of hemorrhoids that were treated. All labs were normal apart
from PSA which was elevated. Rheumatoid factor was negative. What is the most likely
cause of the back pain?
A. Prostate cancer metastasis
B. Degenerative arthritis

Symptoms
Typically asymptomatic
Patients may present with features of complicated lower urinary tract symptoms (LUTS),
including: [5]
Urinary retention
Hematuria
Advanced prostate cancer can manifest with:
Constitutional symptoms
Features of metastatic disease; examples include:
Bone pain (due to bone metastasis, especially in the lumbosacral spine)
Lymphedema (caused by obstructing metastases in the lymph nodes)

Features suggestive of prostate cancer include:

Localized indurated nodules on an otherwise smooth surface
Prostatomegaly, lobar asymmetry, obliteration of the sulcus
Hard nontender nodules
1 An old man with back pain has difficulty of passing urine. Straight leg raise test was
1 negative, but he had tenderness over L5. His PSA was high. What is the most likely cause
of his back pain?
A. Bone metastasis (prostate cancer)
B. Pyelonephritis
1 A 68-year-old man came complaining of dribbling and other urinary symptoms. On DRE,
2 he had a moderately enlarged firm prostate. PSA was 7.8 initially and 7.9 after 4
weeks. What is the next step?
A. Alpha-blocker & follow up PSA > I would say this
B. 5-alpha-reductase & follow up PSA
C. TURP
D. Transrectal biopsy with antibiotic coverage
E. Transurethral biopsy with antibiotic coverage

1 A 59-year-old male presented to the family physician with mild urinary obstruction
3 symptoms. Physical examination showed enlarged non-tender prostate without
irregularity. PSA was 8.9 and after a few weeks it was 8.8. Next step in management?
A. Start on -blocker & follow PSA
B. Start on 5--reductase (finasteride) & follow PSA
C. Trans-rectal biopsy with antibiotics coverage
D. Trans-urethral biopsy with antibiotics coverage
E. Trans-urethral prostate resection
Testes
14 A 22 y/o had right-sided testicular pain & swelling. Next step?
A. Urgent surgical management
B. Observation
15 A male came with severe unilateral testicular pain. Diagnosis?
Testicular torsion
16 How do you manage testicular torsion?
Emergency surgery (surgical exploration)
Infections
1 You are suspecting cystitis in a patient with UTI symptoms. How will you confirm it?
7 A. Ultrasound
B. Urinalysis

Urinalysis
Indications: best initial test
Specimen collection method
1 A newly married woman is complaining of recurrent cystitis. Urine culture is negative.
8 What advice do you give her?
A. Voiding after intercourse
B. Douching after intercourse
C. Use a condom
D. Take trimethoprim after intercourse (amboss says daily antibiotic)

Behavioral modifications [60]

Increased fluid intake
Timely bladder voiding
Postcoital voiding
Adequate genital hygiene
Clean intermittent catheterization
 Indicated for individuals with neurogenic bladder
Reduces incidence of catheter-associated UTIs

Antibiotic prophylaxis [10]

Indication: may be considered in all women with recurrent uncomplicated UTIs
Continuous prophylaxis
Typically taken for 3–12 months with periodic reassessment
Regimens
Trimethoprim (TMP) daily
TMP/SMX daily
Cephalexin daily
Nitrofurantoin daily
Fosfomycin every 10 days
Intermittent or postcoital prophylaxis
Recommended for women who have recurrent UTIs associated with sexual activity
Substances
TMP/SMX
Cephalexin
Nitrofurantoin
1 Treatment of simple UTI in a woman awaiting culture?
9 A. Nitrofurantoin for 4 days
B. TMP-SMX for 7 days
C. Amoxicillin
D. Ciprofloxacin

Empiric antibiotic treatment of uncomplicated lower UTIs

First-line treatment
Nitrofurantoin for 5 days
Trimethoprim/sulfamethoxazole (TMP/SMX) for 3 days
Fosfomycin (single dose)
Second-line treatment: beta-lactam antibiotics for 5–7 days
Aminopenicillins plus beta-lactamase inhibitors, e.g., amoxicillin/clavulanic acid
Oral cephalosporins, e.g., cefpodoxime, cefdinir, or cefaclor
Alternatives: Consider fluoroquinolones, e.g., ciprofloxacin for 3 days for patients with
previous infections with bacteria resistant to other drug classes.

Options for the initial empiric treatment of complicated lower UTIs include:
Fluoroquinolones PO or IV: e.g., ciprofloxacin or levofloxacin
Beta lactams
Second-generation or third-generation cephalosporins: e.g., ceftriaxone
Extended-spectrum penicillins: e.g., ampicillin/sulbactam
2 A patient had symptoms of cystitis. What is the treatment?
0 A. Co-trimoxazole (TMP-SMX) for 3 days
B. Nitrofurantoin for 3 days
C. Ciprofloxacin for 7 days
2 A lady presenting with dysuria, frequency, and urgency was diagnosed with a UTI. What
1 is the best treatment as outpatient care?
A. Amoxicillin for 14 days
B. Trimethoprim-sulfamethoxazole for 10 days (10 days is a lot, amboss says 3)
C. Augmentin for 10 days
D. Erythromycin for 14 days
2 A patient had symptoms of pyelonephritis. What is the treatment?
2 A. Co-trimoxazole for 14 days
B. Nitrofurantoin for 14 days
C. Ciprofloxacin for 14 days (if complicated, if not complicated 5 to 7 days)
2 A woman with a UTI was treated with antibiotics. She came back 1 week later because
3 her symptoms did not subside. What is your next step?
A. Urine culture (and antibiotics according to culture)
B. Renal ultrasound
C. Admit for IV antibiotics
D. VCUG
If recurrent ultrasound (but this time the first episode did not resolve so the empiric
antibiotics may have not covered the causative organism)
2 A patient presented with genital ulcers that he noticed while urinating. He has multiple
4 sexual partners but practices safe sex. On examination, you notice 2 rows of flat filiform
papules that are light in color. What will you do? (HPV)
A. Reassure
B. Cautery & education about STDs
C. Antibiotics & education about STDs
D. Follow for malignant potential
2 A man had multiple ulcers in the genital region associated with a
5 rash on the palms & soles. What is the causative organism?
Treponema Pallidum (syphilis)
Types:
• Primary syphilis:
o Painless genital ulcer (it becomes painful if it becomes
secondarily infected with bacteria) chancres heal spontaneously
o Painless adenopathy
• Secondary syphilis:
o Rash (palms & soles) + alopecia areata + mucus patches + condyloma lata
• Tertiary syphilis:
o Neurosyphilis
o Aortitis (aortic regurgitation, aortic aneurysm)
o Gummas (skin and bone lesions)
Diagnosis:
- VDRL or RPR - FTA for neurosyphilis
Treatment: penicillin
2 A male has purulent urethral discharge. His culture is positive for Neisseria gonorrhea. He
6 was treated with antibiotics but is still complaining of clear discharge. Urinalysis shows
WBCs but no bacterium. Gram stain showed multiple neutrophils but no organism. What
is the cause?
A. Resistant gonorrhea
B. Chlamydia by NAAT
 ------- Vascular -------
Hypertension
1 What regulates blood pressure?
A. Arterioles
B. Heart
C. Veins
2 A young patient with hypertensive was found to have “string of beads” appearance of her
renal arteries. Diagnosis? Polyarteritis nodosa also
A. Atherosclerosis
B. Fibrodysplasia
C. Fibromuscular dysplasia
Long-standing involvement of renal arteries hypertension

Imaging
Imaging modalities
Best initial tests for renal FMD: duplex ultrasonography and/or CT angiography (see
“Diagnostics” in renal artery stenosis)
Best initial tests for cerebrovascular FMD: CT angiography
Gold standard: digital subtraction angiography (DSA)
Finding
Common finding: “string of beads” sign
Less commonly: a single, circumferential/tubular stenotic lesion
Laboratory tests: serum creatinine
3 A patient who is a known hypertensive &
diabetic for 2 years came with a BP of 200/160
mmHg. Fundoscopy showed some retinal
changes (AV nipping and papilledema).
Diagnosis?
A. Chronic hypertension
B. Malignant hypertension
4 What antihypertensive drug causes angioneurotic edema?
A. ACE-inhibitor
B. CCB

5 A 55 y/o hypertensive male patient has a BP of 145/95 mmHg. What is the best drug for
his management?
A. Beta blocker
B. ACE-inhibitor
C. Nifedipine (CCB)
6 A hypertensive patient on beta-blockers has uncontrolled BP. What medication will you
add for him?
A. Nifedipine
B. Diuretics
C. Nitroglycerin
7 What is the mechanism of action of labetalol?
Selective for post-synaptic  adrenergic & non-selective for  adrenergic receptors
8 A hypertensive and diabetic patient, taking beta-blockers, has been having knee pain for
which he was given NSAIDs. Since then, his blood pressure has not been maintained in
the normal range. What should you do?
Stop NSAIDs & start paracetamol
NSAIDS make htn worse according to amboss
Aorta
9 When do you screen for abdominal aortic aneurysm?
Abdominal USS done once for those aged 65-75 y/o with history of smoking.
10 A patient with hypertension came with a pulsating abdominal mass. He is on lisinopril.
Examination showed high SBP of 160. US showed infrarenal aortic aneurysm 4.5 cm in
size with a mural clot. Next step?
A. Surgery (if > 5 cm)
B. Anticoagulant (no as clot can rupture)
C. Increase dose of lisinopril (we need to control his BP – alternative is to add
CCB)
D. Stent
E. Follow up (perfect answer is follow up + increase dose or add another
hypertensive)
 Elective repair
Fusiform aneurysm with maximum diameter ≥ 5.5 cm and low or acceptable
surgical risk
Small fusiform aneurysm expanding ≥ 1 cm per year
Saccular aneurysm [1]
Aneurysm with maximum diameter 5.0–5.4 cm in women
Small aneurysm (4.0–5.4 cm) in patients requiring chemotherapy,
radiotherapy, solid organ transplantation: individual approach

11 An old hypertensive and diabetic lady had been complaining of epigastric pain for the
past 2 months, not relieved by ranitidine. She presents now complaining of acute
epigastric pain radiating to the back for the past 2 hours. Her BP was 150/95 mmHg, HR
115 bpm, and RR 19 rpm. Diagnosis?
A. Aortic dissection
B. Myocardial infarction
C. Perforated peptic ulcer
D. Prinzmetal angina

Sudden and severe tearing/ripping pain

Location
Anterior chest (ascending) or back (descending)
Interscapular or retrosternal pain
Neck and jaw
Abdomen or periumbilical, colicky pain
Character: migrates as the dissected wall propagates caudally
Hypertension or hypotension
Asymmetrical blood pressure and pulse readings between limbs
Wide pulse pressure [6]
Syncope, diaphoresis, confusion, or agitation

12 A hypertensive patient (not on any medications) has a pulsatile abdominal swelling.

Diagnosis?
Abdominal aortic aneurysm
13 What is the most common presentation of abdominal aortic aneurysm?
A. Pulsating abdominal mass
B. Intermittent claudication
C. GI bleeding
D. Lower back pain

Lower back pain

Pulsatile abdominal mass at or above the level of the umbilicus
Bruit on auscultation
Peripheral thrombosis and distal atheroembolic phenomena (e.g., blue toe syndrome
and livedo reticularis)
Decreased ankle brachial index
14 A 22-year-old patient is suspected to have coronary arch disease??????. What
is the bestdiagnostic step?
A. CT angiography (for coronary arteries)
B. MRA
C. Echo (for aortic arch)
 Arterial Diseases

15 A middle-aged man is complaining of calf pain when

walking that goes away with rest (intermittent
claudication). O/E, capillary refill is decreased & dorsalis
pedis is palpable but weak.
What is the investigation done?
A. Arteriography
B. Venography

Imaging [7][18][19]
Angiography: preferred modality for assessment for revascularization
Modalities [18]
First-line: MR angiography (MRA) without and with IV contrast
Contraindications for MRI (e.g., prior stent placement): CT angiography with IV contrast
(CTA)
Digital subtraction angiography: considered the gold standard for PAD; uncommonly used
[19]
Findings: demonstration of site(s) and extent of arterial occlusion or stenosis and collateral
blood flow
Duplex ultrasound [19]
Indications [18]
Patients with contraindications for angiography (e.g., contrast allergy)
Findings: Elevated peak systolic velocity (PSV) and PSV ratio suggest PAD.

What is shown in the image (not this one)?

A. Arteriovenous anastomosis in the left leg
B. Obstruction in the left leg
C. Arteriovenous anastomosis of the right leg
D. Right side vascular obstruction
16 A diabetic patient presents with severe constant abdominal pain. PMH significant
foratrial fibrillation. His abdomen is distended but not tender. Diagnosis?
A. Mesenteric artery occlusion
B. Acute pancreatitis
C. Sigmoid volvulus
Venous Diseases
17 A patient had an ulcer over his foot associated with skin hyperpigmentation. Diagnosis?
Varicose veins

Generalized or localized pain, lower extremity discomfort/cramping, and limb swelling

Worse while standing, relieved by walking and raising of legs
Pruritus, tingling, and numbness
Edema (may be unilateral) that starts in the ankle
Telangiectasias
Yellow-brown or red-brown skin pigmentation of the medial ankle; later of the foot and possibly lower
leg
RBC breakdown leads to hemosiderin release → accumulation in the dermis → skin pigmentation
May lead to stasis dermatitis; a scaly, pruritic rash
varicose veins
Lipodermatosclerosis: Localized chronic inflammation and fibrosis of skin and subcutaneous tissues of
lower leg [7]
Painful, indurated, and hardened skin
Atrophie blanche: white, coin- to palm-sized atrophic plaques
18 A young lady, known case of hypertension, presents with a swollen tender leg. She uses
COCPs. Her aunt has protein C deficiency & her mother has a history of DVT. Which of
the following is unlikely to cause her presentation?
A. Aunt’s history of protein C deficiency
B. Mother’s history of DVT
C. Hypertension
D. Use of COCPs
19 What causes the highest risk for DVT?
A. Knee surgery
B. DVT in pregnancy
Obesity, inactivity after operation, elevated preoperative hematocrit and postoperative
FBG, long operative duration, and bilateral knee arthroplasty were risk factors for DVT in
patients aged over 70 years.
20 A lady came to the ER with swollen leg (DVT?). She is a known diabetic and
hypertensive. She takes glyburide and tranexamic acid for DUB. Her BP was 160/100
mmHg. What is likely to be linked with her current condition?
A. Uncontrolled hypertension
B. Prolonged use of tranexamic acid
C. Glyburide
Antifibrinolytics: group of drugs that impair fibrinolysis, typically by interfering
with plasmin formation
Tranexamic acid
Aminocaproic acid
21 A female has several risk factors for developing DVT. What (from the history) is the least
likely reason for her to develop DVT?
NSAIDs
22 A woman came with swelling and pain of her right leg. She reports having travelledrecently
to receive surgical management for her cancer. On examination, her calf is swollen, red, and
tender. How do you treat her?
Anticoagulation

Initial parenteral anticoagulation (for the first 5–10 days)

Low molecular weight heparin (LMWH)
Long-term anticoagulation (for 3–6 months)
Direct oral anticoagulants (DOACs): first-line therapy in nonpregnant patients (preferred
over VKAs)
23 A man presented with a painful leg. The pain was extending from the medial malleolus to the
lower end of the knee in a cord-like distribution. On examination, his leg was red and warm. There
was no calf muscle tenderness. Most likely diagnosis?
A. Deep venous thrombosis
B. Superficial venous thrombosis
C. Popliteal artery occlusion
24 USS of the chest of a hypotensive patient was provided
(showing dilated IVC). What is the cause of the hypotension?
Pseudohypotension

AV Fistulas
25 An old man on dialysis underwent angioplasty for an AV graft that was unsuccessful due to
thrombosis (and thrombectomy failed). Another graft is currently being prepared. How could you
have prevented its failure?
A. Monitor flow thrill by physical examination
B. Streptokinase
C. Aspirin
D. Use another way for dialysis
E. Catheter

Among hemodialysis patients at high risk for AV graft failure who are also at low risk for
bleeding, we suggest dipyridamole plus aspirin
Others
26 What suture will you use for vascular ligation?
A. Silk
B. Nylon
C. Polypropylene > google
D. Catgut

For larger arteries, some surgeons still recommend monofilament nonabsorbable suture material,
such as polypropylene.