76 YO male patient known to have T2DM on metformin and gliclazide admitted to hospital with sepsis. His RBS readings are between 200-300 mg/dL. Which of the following is the best management for his hyperglycemia during his hospitalization ? A. Start regular insulin sliding scale B. Continue oral hypoglycemic medications C. Start basal-bolus insulin regimen D. Start twice daily insulin regimen
Child with DKA. Labs shows potassium of 2.5. started on ringer lactate and insulin. What complication you should observe? A. Cerebral edema B. Metabolic alkalosis C. Hypoglycemia D. Hypernatremia
An 85-year-old man who has Hashimoto’s thyroiditis was treated with thyroxine. He presents with a hoarse voice for 1 month and 10kg weight loss during the last 4 months, he has unilateral swelling of the thyroid gland. A head and neck surgeon confirmed that he has right recurrent laryngeal nerve palsy. What is the diagnosis? A. Thyroglossal cyst B. Single thyroid nodule C. Medullary thyroid carcinoma ^ D. Anaplastic thyroid carcinoma
A 55-year-old man comes for follow up for HT, he was diagnosed with HT 3 months ago after an episode of transient vision loss in his right eye, he has occasional headaches and fatigue, his current medications include aspirin, lisinopril, and hydrochlorothiazide. His BP is 157/95 and his BMI is 26. Cardiac examination shows a fourth heart sound on auscultation. There are no bruits in the carotids or abdomen, and pulses are 2+ in all extremities. Lab results shows potassium 3.1, creatinine 0.9, plasma renin activity undetectable. Which of the following best explain this patient’s laboratory findings? A. Primary hyperaldosteronism B. Thiazide side effect C. Unilateral renal artery stenosis D. Malignant hypertension
A 35-year-old woman presents to the emergency department in critical condition. She has a dark rash on her legs, and her vital signs are T 35C, HR 110, BP 70/50, and R 22. The patient is admitted to the ICU. Blood cultures are obtained and grow gram-negative diplococci. The patient remains hypotensive. Which of the following is the most likely cause of the patient’s condition? A. Hyponatremia B. Decreased T3 uptake C. Pituitary infarct D. Adrenal artery thrombosis
33 YO male known to have HT on amlodipine, hydrochlorothiazide and perindopril presents with high BP readings at home. He is asymptomatic. His labs are unremarkable except for low potassium. Which of the following is the best next step? A. Urinary catecholamines measurement B. 24-h urinary cortisol measurement C. Measurement of aldosterone-renin ratio D. Renal doppler ultrasound
56 Y.O female presents to the hospital c/o abdominal pain and postural dizziness. She also noticed a scar on the back of her hand that is getting darker. On examination there is hyperpigmentation in the buccal mucosa. Her serum cortisol level is at lower normal limit. What is the best next step to confirm the diagnosis? A. Dexamethasone suppression test B. Urinary catecholamines measurements C. 24-h urinary cortisol measurement ^ D. ACTH stimulation test
8- Patient with symptoms of RA and active arthritis for the first time, what is the most appropriate management? A- Methotrexate B- Methotrexate + Hydroxychloroquine C- Methotrexate + Hydroxychloroquine + Steroid D- Methotrexate + Cyclophosphamide or Sulfasalazine
9- In patient who is known case of RA, which of the following indicates rheumatoid arthritis as a cause of pleural effusions? A- Hemorrhagic B- Transudative C- Glucose 1 mmol/l D- High glucose
Patient with DM and RA, has bone pain and hypercalcemia, high renal function test. What is the most likely diagnosis? A- DM nephropathy B- Amyloidosis C- Membranous glomerulonephritis D- Lupus nephritis
Patient with RA and dyspnea, chest x-ray showed homogenous and well- defined nodule, what is the most likely diagnosis? A- Bronchogenic cancer B- Pulmonary fibrosis C- Caplan syndrome D-TB
RA patient with severe symptoms not responding to methotrexate, hydroxychloroquine, what to add? A- NSAIDs B- Adalimumab C- Cyclophosphamide D- Paracetamol
A lady with manifestations of rheumatoid arthritis that has been progressed, what antibody is needed to confirm diagnosis? A- ANA B- Anti-CCP (Anti-citrullinated protein antibodies) C- Anti-cardiolipin D- Anti RNP
50 years old male comes to his physician complaining of one month history of decreased appetite, nausea, vomiting, epigastric abdominal pain and 6 kg weight loss. Physical exam shows temporal wasting and jaundice. Which of the following is likely to be elevated in this patient? A. Alpha fetoprotein B. Beta human chorionic gonadotropin C. CA 15-3 D. Ca 19-9
23 Y.O. male patient K/C of UC presented with 7-8 bouts of bloody diarrhea per day. Associated with fever and joint pain. O/E patient looks ill and in pain. What is the best next step in management? A. Oral budesonide B. IV methylprednisolone C. Oral 5-ASA D. Azathioprine
45 YO obese female presented to the gastro clinic with history of jaundice and pruritis for 9 months. What is the best next step in evaluation? A. CT liver B. Liver US C. MRCP ^ D. Liver biopsy
30 YO female medically free presented with jaundice for 2 weeks. No flapping tremors or stigmata of chronic liver. AST 1400 ALT 1300 GGT 70 Total bil 60. What is the best next step? A. Discharge with F/U B. Admit and start IV dextrose C. Order PT and INR D. Refer her for liver transplantation
Patient known to have multiple gallstones presents with severe epigastric pain and vomiting. Admitted to the hospital. Labs shows high amylase 250, high WBC and high direct and total bilirubin. What is the most appropriate initial management? A. ERCP B. US C. IVAb D. IV crystalloid infusion
Old man came with jaundice and dark urine. He has palpable gallbladder. Labs shows high direct bilirubin. What is the most likely diagnosis? A. Klatskin tumor B. Perihilar tumor C. CBD stone D. head Pancreatic Cancer
Male patient presents with two days of epigastric abdominal pain and jaundice. Labs shows high lipase and amylase. US abdomen shows multiple gallbladder stones and dilated CBD. Started on IV fluid and antibiotics. What is the best next step? A. Observation B. ERCP C. MRCP D. Cholecystectomy
A 42-year-old female presents with severe pruritus, not relieved by antihistamines, and she frequently awakens at night with severe itching. She has bilateral scleral icterus. Her Hx is remarkable for celiac disease, she adheres to a gluten-free diet, total bilirubin 1.4mg/di, direct bilirubin 0.9mg/dL, ALP is high, AST is high, and ALT is high. What is the most likely diagnosis? A. Primary biliary cirrhosis B. Wilson disease C. Hemochromatosis D. Autoimmune hepatitis
4- A 67-year-old male brought to the ED by his wife saying that he developed weakness and dysarthria after he woke up, she says that he went to sleep having no complaint then woke up 2 hours later with symptoms of weakness and slurred speech, there is no History of stroke, surgery, trauma or hemorrhage, upon examination: power is 2/5 in left side and 5/5 on the right side. CT picture included and shows hypodensity in the right hemisphere. What is the management? A- Aspirin B- Clopidogrel C- Recombinant tissue plasminogen activator D- Heparin
5- Ischemic stroke patient, what is the target for BP control? A- 140/90 B-150/90 C-160/100 D- 240/120 (Should be 220/120)
6-52-year-old woman came to ED due to speech arrest and right arm weakness. The symptoms began suddenly at breakfast but resolved after 30 minutes, the patient has a history of relapsing-remitting multiple sclerosis, three months ago she was hospitalized due to blurry vision in the left eye which was treated with corticosteroids and improved after several weeks, other medical issues include HT and hyperlipidemia, she is currently not taking any disease- modifying therapy for her MS, BP: 170/96 and pulse: 92, BMI is 35 kg, there is a mild afferent pupillary defect in the left eye with diminished visual acuity, which of the following is the next step in treatment of this patient? A- Initiate plasma Heparin B- Initiate Aspirin and Stain therapy C- Initiate disease modifying agent D- Initiate intravenous Heparin infusion
NB: The minimum duration for a relapse has been arbitrarily established at 24 hours, though most are much longer. Clinical symptoms of shorter duration are less likely to represent new lesion formation or extension of previous lesion size. UpTodae
10- Old patient with altered level of consciousness fell from the stairs, was brought to ER, CT brain showed epidural hematoma, what is the most likely affected artery? A- Pontine B- Basilar C- Anterior cerebral artery D- Middle meningeal artery
25-year-old female known case of epilepsy came with generalized tonic- clonic seizure for 35 minutes and started on 20 mg IV lorazepam but did not respond, what are you going to give her next? A- IV Phenytoin B- IV Phenobarbital ^ C- IV Steroid D- IV Fentanyl
Pediatric patient with manifestation of absence seizure, what is the appropriate treatment? A- Ethosuximide B- Na valproate C- Lamotrigine D- Carbamazepine
Patient want to stop smoking, he has HTN and epilepsy, what is the contraindicated drug? A- Bupropion B- Varenicline C- Nicotine patch D- Nicotine gum
Patient with patient confirmed to has meningitis, which antibiotic as a prophylaxis you should give? A- Ciprofloxacin B- Linezolid C- Augmentin D- Cefuroxime ^
Meningitis in child with picture showed petechia, what you should give to his young brother as a prophylaxis? A- Ciprofloxacin B- Rifampin C- Ceftriaxone D- Ampicillin
Patient with meningitis, his sibling is allergic to the primary treatment given for prophylaxis, what to give him as a prophylaxis? A- Erythromycin B- Vancomycin C- Ceftriaxone D- Cefuroxime ^
Tender neck mass after URTI. Labs shows high ESR and hyperthyroidism. What is the best management? A. Steroids B. Methimazole C. NSAID D. Propylthiouracil ^
Pregnant female suffered from gestational diabetes, and she is not controlled on diet. Which drug should be used to control her blood sugar? A. Metformin B. Insulin C. Glyburide D. Liraglutide
Female diagnosed with T2DM, started on diet and exercise. Now her HAlc is 7.2. What is the best next step? A. Start metformin B. Keep her on low cab and fat diet C. Start sulfonylurea D. Start insulin
30 YO female with 12-year history of type 2 diabetes mellitus and has maintained strict glycemic control and all her tests are normal. What is the next step in this patient management for the secondary prevention of diabetic nephropathy? A. Random urine micro-albuminuria level B. Repeat measurement of serum creatinine levels in 6 months C. ACE inhibitor therapy D. Renal biopsy
65 YO male known to have DM and CKD, on metformin 1gm BID and other oral hypoglycemic medication. His CrCI < 25 and HBa1C is 8.5%. What should be the next step? A. Discontinue metformin and start insulin B. Discontinue metformin and start sitagliptin C. Continue metformin and add insulin D. Continue metformin and add liraglutide
60 Y.O. female patient diagnosed with type 2 diabetes. She started metformin 1 gm BID. After 3 months her FBG is normal. RBS is normal. HbA1c is 6.9. which of the following is the best next step? A. Increase metformin dose. B. Add glimepiride. C. No need to change. D. Add DPP-4 inhibitor.
A 29-year-old woman who cannot get pregnant, has been menstruating every other month, and has a milky discharge from the nipples, prolactin level 334, and brain MRI shows pituitary adenoma 0.5cm. Which therapeutic options is most appropriate for this patient? A. No treatment B. Transsphenoidal pituitary surgery C. Trial of a dopamine agonist D. Radiation therapy
24 YO female presented with history of amenorrhea for 3 months. Her prolactin is high. What is the best next step? A. Pelvic U/S B. Random cortisol C. Brain MRI D. Follow up after one month
47 Y.O Female came with fatigue for 2 months associated with weight gain. She also complained of amenorrhea for 6 months and bilateral milky breast discharge. What is the most appropriate next step? A. TSH. B. Serum prolactin ^ C. Mammogram. D. Pituitary MRI.
A 30-year-old woman presents with muscle weakness and weight gain for 3 months. Initially, her face was getting fat, and most recently she has gained additional weight in the truncal region and seems to have difficulty concentrating. BP is high, The PE is notable for a facial plethora, the presence of supraclavicular fat pads, and truncal obesity with prominent purple stria principally in the abdominal region. What is the best next step in management? A. CT of the abdomen B. Plasma ACTH measurement ^ C. MRI brain D. 24-hour urine collection for cortisol
55 Y.O male patient recently diagnosed with DM presented with central weight gain of 12 kg over the last 2 months. Associated with fatigue and weakness. Patient also noticed the development of multiple bruises recently. On examination his BP is 157/94. His labs showed: high free urinary cortisol, high morning 8am cortisol level after administration of 1mg dexamethasone at 11pm, and low ACTH. What is the most appropriate next step in evaluation? A. Late night salivary cortisol B. Brain MRI ^ C. Adrenal CT D. Chest CT
45-year-old woman is investigated for weight gain. She had had been unwell for around four months and described a combination of symptoms including depression, facial male-pattern hair growth and reduced libido. During the work-up she was found to be hypertensive with a blood pressure of 170/100 mmHg. Which one of the following tests is most likely to be diagnostic? A. Renin:aldosterone levels B. High-dose dexamethasone suppression test ^ C. Low-dose dexamethasone suppression test D. 24 hr urinary metanephrines
66 Y.O female known to bronchial asthma on inhaled steroid underwent surgical resection of colorectal cancer. Following the surgery, she was shifted to the ICU due to low BP. Her labs were given: K+: 6 Na: 130 glucose: 55. What is the most likely diagnosis? A. Post-op dehydration. B. Addison crisis. C. SIADH. D. Iatrogenic hypoglycemia
A 60-year-old female presented with hypertension, proximal muscle weakness, weight gain especially in the upper body and purple striae on the lower abdomen. Which of these tests gives a clue about the etiology of the most likely diagnosis? A. High-dose dexamethasone suppression test. etiology B. 24-hour urinary free cortisol. C. Low-dose dexamethasone suppression test. diagnostic D. Midnight salivary cortisol.
10- A female with RA taking Plaquenil (hydroxychloroquine) and she got pregnant, what is your advise regarding her medications? A- Stop medication B- Refer to rheumatology to stop medication C- Switch to steroid D- Continue same medication
Mechanism of action of DMARDs in rheumatological disease? A- Slow the progression B- No effect C- Exacerbate course of disease D- Cure the disease
Patient with RA, on methotrexate, was in remission, her Liver function tests previously was normal but upon this follow up, her LFTS were elevated, next step? A- Start glucocorticoids B- Stop methotrexate C- Investigate for Hepatitis infection D- No relation between methotrexate and LFT
Patient known to have rheumatoid arthritis with rheumatoid nodule and arthritis of the hand joint with morning stiffness, he was treated for pneumonia 2 weeks ago. lab result showed high titer of rheumatoid factor, thrombocytopenia and high WBCs. Bone marrow aspiration showed lymphocytosis, what is the most likely diagnosis? A-SLE B- Felty syndrome ?? (Neutropenia with LGL is more correct!) C- Lymphoma D-TTP
Patient with symmetrical joint pain in PIP and MCP, morning stiffness for more than 30 minutes, what is the best management to give? A- Steroid and methotrexate B- Azithromycin C- Hydroxychloroquine D-NSAIDS
32-year-old female diagnosed with severe RA, rheumatologist decided to start TNF inhibitor as a treatment of choice, which diseases is a high risk this patient to get it as a recurrence? A- Pneumonia B- Tuberculosis C- Septic arthritis D-HIV
35 YO male presented with typical picture of acute appendicitis. He was taken to OR for laparoscopic appendectomy. During OR the appendix appears normal with no inflammation. Both cecum and terminal ileum appears inflamed. What is the best action? A. Right hemicolectomy B. Close without further intervention C. Appendectomy and refer the patient to gastroenterology D. Take biopsy of cecum and terminal ileum
Patient admitted to ICU due to acute pancreatitis and intubated for mechanical ventilation. 3 days later he developed coffee ground emesis. What is the most likely cause? A. H.pylori gastritis B. Dyspepsia C. Stress gastritis D. NSAID induced gastritis
28 YO female presented with jaundice for 2 weeks. Associated with fatigue and arthralgia for 11 months. She is not on any medications and she doesn’t drink alcohol. O/E she has hepatomegaly. Viral hepatitis screening is -ve. AST 920 ALT 890 Alk phos 169 alb 30 Total bilirubin 26. what is the most likely diagnosis? A. Hepatocellular carcinoma B. Primary biliary cirrhosis (alk phos higher than AST and ALT) C. Autoimmune hepatitis (ALT and AST higher than alk phos) D. Acute cholangitis
59 YO male presents with jaundice for two months. On examination he has enlarged liver. CT shows cirrhotic liver with 4X5 hepatic nodule. Which of the following risk factors is strongly associated with this condition? A. Aflatoxin B. Lead toxin C. Wilson disease D. HBV
3- A man complains of weakness in the left half of the body, on clinical examination, there is paralysis of the facial nerve and hemiplegia, the first step in the management? A- Aspirin B- Clopidogrel C- Head CT D- MRI head
7-72-year-old man presented with an episode of right side weakness that lasted 10 minutes and fully resolved, he is clinically stable, he has no other medical illness, on examination:- BP: 110/70, HR: 95, T: 36.6, which of the following is the most appropriate next step in the management? A- Aspirin B- Warfarin with IN target of 3-4 C- Warfarin with IN target of 2-3 D- No additional drug treatment
8- A patient came to ER has weakness and paresthesia in left leg with power of 2/5, other limbs are normal, what is the cause? A- Migraine B- Right MCA infarction ^ C- Right ACA infarction D- Basilar infarction
9- Poorly controlled hypertension came with signs and symptoms of stroke, if you suspect hemorrhage, what would be the most common place? A- Occipital lobe B- Parietal lobe C- Basal ganglia D- Subarachnoid space ^
11-27-year-old healthy male presented with right side weakness, he has significant femur fracture 1 week ago, 2 days ago had pulmonary embolism, brain imaging showed left cerebral infarction. Which of the following is the most likely the cause of his presentation? A- Atrial fibrillation B- Carotid artery stenosis C- Patent foramen ovale D- Hypertrophic cardiomyopathy
A patient has a sudden onset of seizure, he is medically free, has no family history of epilepsy, and no history of recent infection, he has never had any previous episodes of seizures or loss of consciousness, he is not on any medications, electrolytes and other blood tests were all normal, what is the next investigation that should be done for this patient? A- ECG B- EEG ^ C- Brain imaging D- Lumbar puncture
20-year-old female presented to ER with status epilepticus for 5 min, with IV access, what is the first line? A- IV Lorazepam B- Diazepam rectal C- Buccal midazolam D- Oral Midazolam