20 Cases note

this note is only a summary for Kaplan USMLE Comprehensive Cases By Dr.Conrad Fischer MD
summarized by Dr Araki USMLE . Sudan
Best way to use this note is to print it and study it along with the Videos , also add your tips
if you dont have 30 hour to watch the Videos , u can read it and google the Media
good luck

01 - Mitral Stenosis
All MS about this case
young female wt Hx of Rheumatic fever
case 1
m c valvular lesion ? (Mitral stenosis)
case 2
m likely risk factor ? ( immigrant)
case 3
what m likely make her seek medical attention ? ( pregnancy ) preg increase plasma volume
case 4
witch murmur ? ( rumbling med diastolic murmur ) plzz try to hear it
case 5
witch will increase the intensity of murmur ? ( leg rising )
increase (squatting / leg rising / expiration)
decrease (standing /valsalva / inspiration )
no effect with hang grip and amylnitrate
case 6
mechanism of hemoptysis ? ( pulmonary HT )
case 7
m likely found on P Ex ? ( dysphagia ) Lt atrium hypertrophy
case 8
what expected to be on Swan Ganz cath ( low : CO . high : Wedge/SVR/PA)
case 9
what auscultatory founding indicate worsening ? ( shortening duration btw the S2 to op snap )
case 10
witch ECG ? ( A fib ) irregular irregular rhythm
case 11
m accurate test ( Cardiac Cath ) initial Echo
case 12
m likely seen on X ray ? ( straining of Lt heart border Lt mean bronchus pushed up )
case 13
best initial Rx ? ( Furosemide )
case 14
same case developed palpitation , best initial Rx ( ECG show A fib ) ? ( Digoxin )
if not there BB or CCB
case 15
pt get worse what Next ? ( Balloon vavuloplasty )

02 - Coagulation Disorders
case 1
young female wt epistaxis ( pic show petechiae on the lower limb )
first test to do ? ( platelet count )
case 2
same pt , only evil on lab was platelet count 17,000 , m likely to be found ? ( Purpura ) on pic
case 3
with drug can induce that ( Amoxicillin)
penicillin / sulfa drug / rifampin / allopurinol / quinidin / lamotrigin
case ( Hemolysis / thrombocytopenia / AIN / SJS / TEN )
case 4
NS in management ? ( Steroid )
case 5
m likely be found ? ( Megakaryocytes ) on pic
case 6
m likely diagnosis ? ( I T P )
case 7
same pt treated and come after 2 month with melena
most effective NS ? ( IV IG ) for the bleeding on GI or Brain
case 8
new case wt epistaxis and petechiae , 2 day after starting a new drug , normal platelet , PTT high
m likely diagnosis ? ( VW D )
case 9
most likely precipitate this ? ( Aspirin )
case 10
best initial test ( Bleeding Time )
case 11
same case BT prolonged , best NS to confirm diagnosis ( factor VIII antigen ) just anther name for VW
case 12
BN Rx ? ( Desmopressin DDAVP )
case 13
new case , 8 y fall and presented after 2 week wt swallowing warm knee (there is a pic)
m likely diagnosis ( Hemophilia A ) more common the H B
case 14
initial test ? ( PTT )
case 15
same pt has prolonged PTT NS ? ( Mixing study )
case 16
m accurate test ? ( factor VIII level)
case17
why the bleeding is delayed ? ( primary plug is with pletelet ) so it go away soon
case 18
NZ Rx ? ( factor VIII ) if mild Desmopressin DDAVP
case 19
new case 48 y female come wt fever , flank pain , hypotesive , tachycardic , +iv heam occult blood ,
Hematuria , prolonged PT/PTT
what expected on lap ? ( low pletelet ) m likely DIC
case 20
m accurate test ? ( D-dimer ) or fibrin split product
case 21

same pt platelet r low , NS ? ( FFP and platelet )

case 22
old man wt Hx of igA nephropathy have rise Cr and oozes Blood on central line , lap normal
m likely diagnoses ? ( Acquired storage pool disorder ) from uremia
case 23
NS Rx ? (Desmopressin DDAVP ) then dialysis
case 24
truck driver presented wt sudden SOB , u start hem on Heparin/Warfarin after 3 day platelet drop
Diagnosis ? ( Heparin induce thrombocytopenia )
case 25
Rx NS ? ( switch to argatroban ) it is direct acting thrombin inhibitor
case 26
m accurate test ? ( platelet factor 4 antibodies )
case 27
9 y boy wt fatigue , diarrhea , Cr 2.8 / BUN 34 ,HTC 29% , platelet low , normal PT/PTT , ( pic show
Jaundice )
m likely diagnosis ? ( HUS )
case 28
m likely etiology ( Shigella ) m c E coli O157,H7 not on the answer
case 29
what the mechanism ? ( decrease ADAMTS 13 )
case 30
m likely to be found ? ( normal PT/PTT )
case 31
Rx NS ? ( FFP Plasma exchange ) if mild no Rx
case 32
what drug can cause this ? ( Clopidogrel ) also Ticlopopidin

03 Sarcoidosis
case 1
African American wt SOB for weeks , misdiagnose with asthma , and she have fatigue , wt loss
m likely diagnosis ? ( Sarcoidosis )
case 2
m likely finding ? ( skin lesion )
bilateral facial palsy only on Lyme and sarcoidosis
case 3
m likely found on this pt ? ( lupus pernio ) on pic , it is mc skin finding do biopsy , Rx steroid
case 4
lung auscultation finding ? ( fine rales/crepitation/crackles ) on media , sign for consolidation
case 5
another media ? (fine rales/crepitation/crackles )
case 6
video show facial palsy ? ( VII CN ) , not like stork , on sarcoidosis both upper and lower half of the face
affected
case 7
if it involve the heart , what u expect to see ? ( 3ed degree heart block ) effect conduction
case 8
many ECG ? ( chose the one show 3ed degree heart block )
case 9
many CXR ? (chose the one show bilateral Hilar adenopathy )
case 10
m likely seen on LAP ? ( high ACE level ) more common than high Ca
case 11
m accurate test ? ( LN biopsy )
case 12
m likely seen on biopsy ? ( non-caseating Granuloma ) with pic
case 13
Rx ? ( steroid )
case 14
drug should be avoided ? ( Interferon ) bcoz it make granuloma
TNF make granuloma and TNF inhibiter open it (bad for TB coz it is infection , but for sarcoidosis not bad )
case 15
pic show reddish brown lesion on legs ? ( erythema nodosum ) use to determine who is getting worse
case 16
m likely prognosis ? ( spontaneous resolution in 80% )
case 17
mechanism of hyperCa ? ( increase Vit D synthesis by macrophages )
case 18
strongest indication of treatment ? ( Uveitis ) , yes it is not the bilateral hilar adenopathy o_O

04 Graves Disease
case 1
young female wt palpitation , sweting , weight loss , anxiety , BP 144/90 , Puls 112
m likely diagnosis ? ( Hyperthyroidism )
case 2
m likely ass wt this finding , pic of Exophthalmoses ? ( Graves D ) mucopolysacharide deposit behind eye
can cause corneal ulcer bcoz it cant closed
case 3
m c finding ? ( pretibial myxedema ) only wt graves D
case 4
new case , he toke the last one and add , pt has thyroid tenderness
what is m likely diagnosis ? ( subacute thyroditis ) dont confuse it wt SILENT thyroiditis ()
case 5
back to graves D ,expected on thyroid profile ? ( TSH low , T4 ^ , RAIU ^ ) if all ^ it is TSH producing
tumor
case 6
ECG ? ( chose the one show Afib ) dont be fowled wt ECG show Multi Focal AT
case 7
first case young female wt palpitation , sweting , weight loss , anxiety , BP 144/90 , Puls 112
m accurate diagnostic test ? ( RAIU )
case 8
best initial therapy ? ( Propylthiouracil PTU ) or methemazol
case 9
m c SE of that drug ? ( neutripenia ) both drug can cause it
case 10
ECG show rapid A fib , Rx ? ( Propranolol )
case 11
new case 1 y wt pic of ( cretinism ) , mother have Hypothyroidism but not adherent to medication
mechanism of feature on this pt ? ( T4 essential for CNS growth )
brain/uterus/gonads , dose not depend on T4 for metabolic rate
case 12
new case , 48 female wt thyroid nodule
NS ? ( TSH / T4 ) if normal Biopsy , if high RAUI
case 13
biopsy show follicular adenoma , NS ? ( Excisional biopsy ) have malignant potential
case 14
new case , old female , 1.5 nodule on the neck , TSH/T4 normal , FNA show medullary Ca
NS ? ( plasma and urine catecholamine ) ass wt MEN so plzz exclude Pheocromocytoma first
if u Operate without that , u may be Kill pt ( hypertensive crisis ) o_O
case 15
new case old female Dx wt Hypothyroidism , she have HT , DM , hyperlipidemea , u start Levothyroxine
m dangerous complication ? ( M I ) suddenly increase metabolic rate

05 - Myasthenia Gravis
case 1
young man , wt double vision get worse through day , cant finish his meals
m likely diagnosis ? (Myasthenia Gravis ) m c affect ocular muscle and masseters muscle ( eating TV )
case 2
m likely found ? ( Ptosis ) on pic
case 3
best initial test ? ( Acetylcholine receptor antibody ) it is not tensilon (edrophonium) test
case 4
m accurate test ? ( Electromyogram )
case 5
best initial therapy ? ( Pyridostigmin ) acetylcholine esterase inhibiter
SE , salivation , lacrimation , Diarrhea
case 6
drug wore the condition ? ( Aminoglycoside / Gentamicin )
case 7
same case worse , unable to walk (Myasthenia crisis )
m likely cause of death ? ( Respiratory failure ) Myasthenia Gravis spare the heart
case 8
best initial Rx ? ( IV IG ) or plasmaphesesis , dont combine them
MG/GB/good paster/TTP : plasmapheresis
case 9
new case young man wt MG manage wt pyridostigmin , maximam doses , he decrease response to
medication
most important imaging study ? ( Chest CT ) if pt under 60 remove thymus
MIBG for occult pheochromocytoma
case 10
CXR ? ( chose the one show ant mediastinal mass )
case 11
same case but he chanre age is 75
what to do ? ( Prednisone )

06 Meningitis
case1
42 y man wt fever , headache , neck stiffness , photophobia
m likely diagnosis ? ( Meningitis )
naeglaria fowelri
case 2
NS ? ( Lumber Puncture ) if there is focal/sever confusion do CT ( any delay to LP give Ax )
case 3
pic of papillodema , what to do next ? ( Cetriaxon/Vancomycin ) there is a delay to LP
case 4
where u but the needle on LP ? ( Subarachnoid space ) under Dura and above Pia
case 5
new case pt has meningitis and focal , u give Ax prior to LP , now gram stain is ve , u suspect bacterial
bcoz there is high neutrophil on LP
witch of the following u can use to detect the etiology ? ( bacterial antigen detection by latex
agglutination )
sensitive like gram stain, but not specific
case 6
new case CSF show 2,700 WBCs , wt 90% neutrophil best Rx ? ( Cetriaxon/Vancomycin/Steroid )
case 7
m accurate test ? ( CSF Culter )
case 8
m likely organism ? ( pneunococcus ) on pic ( G+ve diplococcic )
case 9
what the indication of intrathecal Ax ? ( Ommaya reservoir infection / intraventricular cath )
case 10
m effective thereby for old / alcoholic / COPD / pt on steroid ? ( Add Ampicillin ) for Lsteria
case 11
pt has Gram+ve cocci on cluster ( staph ) m likely to have this bug ? (ventriculoperitoneal shunt /
neurosurgury )
case 12
pt wt meningitis had ventriculoperitoneal shunt 1week ago Rx ? ( Ceftriaxon/Vancomycin )
case 13
pt wt meningitis , HIV and CD 4 45 ? ( Voriconazole ) it is Cryptococcus 1st line Ampho B
Voriconazole . SE : transient ocular problem
case 14
military recruit living in barracks come wt meningitis , Rx ? ( Ceftriaxon/Vancomycin ) N,meningitides
m c risk factor for N,meningitides inf ( Asplenia )
case 15
same pt witch rash u expect ? ( chose the one show petechiae ) on pic
case 16
same case the pt has girl friend she on OCP , what Next ? ( Ciprofloxacin ) Rifambin also but it is relative
contraindication with OCP

07 Atherosclerosis
case 1
52 y old man come wt chest pain off and on fore the past week , wt and wtout exertion , pain is behind
sternum , crushing /squeezing pain , he has HT , DM , hyperlipidemea
m c risk factor ? ( HT ) worst risk factor ( DM )
case 2
witch of the following exclude CAD ? ( chest wall tenderness ) - 95% NPV enough for CK
also change wt positing or breathing
case 3
NS ? ( E C G )
case 4
he show u ECG ? ( Normal )
case 5
back to case , what next ? ( stress test ) Hx of chest pain and ECG normal
case 6
Now if ECG ( show slight t wave and ST depression on V 4/5/6 ) , what Nx ? ( stress echo ) or stress
thallium
u cant read the ECG if there Baseline abnormality
case 7
if stress test show ischemia what next ? ( Aspirin )
case 8
new case , 44 female wt intermitting chest pain for month no risk factor , ECG wt ST elevation . C Enz -ve
what m likely be found on angiogram ? ( abnormality only when give ergonovine ) induce coronary
spasm
menstruating female can't have CAD period , so think prinzmetal angina
case 9
new case CAD pt on sildenafil , HCZ , statin , buproprion , fluoxetin , he should start Aspirine , Nitrate , BB
wetch side effect is expected ? ( Hypotension ) sildenafil + Nitrate = DEATH
case 10
new case wt typical chest pain and ECG show anterior MI ? ( chose ECG shoe ST elevation on V234 )
case 11
initial step in management ? ( Aspirin )
case 12
m likely found on gross pathology autopsy ( chose the pic show white fibrosis btw myocardium of
ventricle )
case 13
new case , old pt has HT , DM , Hyperlipidemea , LDL 60
m likely useful for pt ? ( ACE inhibitor ) bcoz he DM+HT
case 14
68 y pt come to ED wt typical chest pain for an hour , ECG show anterior MI wt ST elevation
m likely to detect in this pt ? ( Myoglobin ) Troponin/CK-MB take 4 - 6 hour
case 15
Aspirin what Nx ? ( Angioplasty ) greatest mortality benefit for ST elevation
case 16
strongest indication of thrombolytic ? ( ST elevation or new Lt BBB within 12 hour )
case 17
same pt , after 5 day return wt chest pain , what Nx ? ( CK-MB ) for reinfarction bcoz it normalized on 2-3

day
Troponin stay high for 2 weeks
case 18
m c cause of erectile dysfunction on postMI pt ? ( Anxiety ) , yes ,far more than BB
case 19
new case 68 pt wt typical chest pain fore 1 hour , aspirin is given and there is an ECG show ST depression
on V345
best next step ? ( Enoxaparin ) , dont panic it is Heparin
case 20
pt is planned to Cath , best next step ? ( Tirofiban ) or abciximab or eptifibatide it is glycoprotein IIb/IIIa
inhipeter
or u can use clopedogril

08 - Multiple Myeloma
case 1
57 old woman wt pain in Rt flank , she feel pop and pain ass wt coughing and roll over her bed , she has Hx
of vertebral compress fracture
m likely diagnosis ? ( M M )
case 2
m likely found on CXR ? ( chose the one show multiple lytic lesion ) don't be fowled by vertebral
compress fracture
case 3
next best diagnostic test ? ( serum protein electrophoresis ) M spik wt IgG (mean one type)
case 4
image of electrophoresis ? ( chose one have tow spik on albumin and on gama range )
spike on first and last (M shape) , Monoclonal spik
WARNING , M spike dose not mean IgM
case 5
m likely be found on preph smear ? ( chose the one show rouleaux formation ) RBCs stuck to each
other
case 6
m accyrate test ? ( BM biopsy ) 30 % plasma cell diagnostic as a single finding
when u combine it wt lytic lesion and monoclonal spik u only need 10 % to diagnose MM
case 7
Technetium bone scan done what u expect ? ( normal ) MM only lytic activity , B scan only detect plastic
activity
case 8
same pt no SOB/confusion/visual disturbance , how u explain absence of hypervescusity ? ( never - IgG is
small )
case 9
best initial Rx ? ( Steroid / Thalidomide )
case 10
her disease controled wt Rx , what next ? ( autologous stem cell trans )
case 11
m c cause of death in MM ? ( infection )

09 Diabetes
case 1
58 y man come for routine exam , he has HT , obese , smoking
appropriate screening test ? ( Diabetes screening )
case 2
appropriate type of screening test ? ( 2 fasting Glucose above 126 ) or (RBG ^200 wt Symptom) or
(OGTT)
case 3
Fasting B G is 180 and 170 , m likely etiology ? ( decrease number of receptor ) = preph insulin resistant
( type 2 )
case 4
best initial Rx ? ( Metformin ) but first trial of life style modification , 25% controled Diet / exercise
Metformin : ( only block gluconeugenisis ) no weight gain , no hypoglycemia
case 5
if despite weight loss and metformin , FBG stay 150 , what adverse effect expected ? ( lactic acidosis )
alpha glucosidase inhibiter ( acrabose / meglitol) : Diarrhea ,flatus
sulphonylureas and natiglenide : hypoglycemia
sulphonylureas : can give SIADH
Glitazones ( rosiglitazone / pioglitazone ) : exacerbation of CHF and fluid overload
case 6
contraindication to metformin ? ( Renal insufficiency ) metformin accumulate
case 7
witch the best drug to control HT in this pt ? ( ACE inh ) protect the Kidney , best for HT/DM
case 8
target BP on Diabetic pt ? ( 130/80 mmHg ) v H/Y
case 9
LDL 134 , what Nx ? (Statin ) lower mortality , treat DM like CAD , so LDL ^100 get Rx
case 10
m c SE of statin ? ( ^transaminase ) ^liver enz , and YES it is NOT myositis
case 11
what u do to monitor compliance ? ( Hg A1C )
case 12
on PE his BP 135/87 mmHg , all LAP is normal , most appropriate action ? ( Microalbumin level )
case 13
on PE his BP 135/87 mmHg , BUN 18 and creatinine 1 despite ACE inh the creatinine 2.2
witch of the following lesion is present ? ( Kimmelstiel Wilson ) it is unique lesion for Diabetic
nephropathy
look to biopsy pic of this
case 14
60 y man with uncontrolled DM for 10 y , he show u many endoscopy pic
witch m likely found ? ( chose the one show extra blood vessels/neuvascularization ) see some pics
plz
case 15
A 25 y G2Pa women in he 2ed trimester present pr prenatal checkup ,
witch test should be done to this pt ? ( Oral GTT )
case 16
he show u a big ulcer in a foot and ask about etiology ? ( Neuropathy )
case 17

60 y man with uncontrolled DM for 15 y , present with GI disturbance bloating , constipation ,

witch of the following is the best initial management to this pt ? ( Erythromycin ) it is Gastroparesis
also u can use Metachlopramid
case 18
65 yrs man present with weakness , fatigue , confusion . Na 135 mEq/L , K 4.6 mEq/L Cl 100 mEq/L
bicarbonate 12 mEq/L glucose 450 , Which physical finding ? ( Mucormycosis )
case 19
Best initial treatment for pt ? ( Amphotericin )
case 20
Most common adverse effect of treatment ? ( metabolic acidosis )
case 21
Pt placed on Amphotericin B most important next step ? ( surgical debridement )
case 22
48 yrs woman with sever type 2 DM maintained on glargine , aspart present with headache and fever .
glucose 270 mg/dl , bicarbonate 20mE/L . CT of head was done
Most likely diagnosis ? ( malignant otitis media )
case 23
Organism is responsible ? ( pseudomonas )
case 24
Best therapy ? ( Piperacillin / Tazobactam )
case 25
30 yrs woman with type 1 DM . experience lightheadness and headache . her glucose show :
8am 248 , 12noon 150 ,
6pm 120 , 10pm 140 her HbA1c 6.5%
the mechanism ? ( increase epinephrine and glucagon )
case 26
23 yrs history of type 1 DM present with weakness , lightheadness , dyspnea and confusion . PR =125
BP= 92/62 RR=32
Blood glucose = 300
witch Led to this problem ? ( infection )
case 27
Physical examination finding ? ( kussmaul's breathing )
case 28
Lab value indication of severity ? ( serum bicarbonate )
case 29
Best initial therapy ? ( bolus of normal salin )
case 30
Mechanism of hyperkalemia ? ( increase entry of hydrogen ions to the cell )
case 31
Respiratory effect similar to ? ( carbon monoxide )
case 32
Most likely to be found ? ( metabolic acidosis + hyperkalemia )
case 33
Relation among electrolytes ? ( increase glucose , decrease sodium )
case 34
Explain of blood pressure ? ( osmotic dieresis )
case 35
Pt present with DKA glucose = 450 in past half hour the glucose dropped to 100 . she switched to 5%
dextrose in half NS , Adverse effect of therapy ? ( seizures )
case 36
Mechanism of adverse effect ? ( shift of water into cells )

10 Pneumonia
case 1
67 y male with productive couph , fever , he has Hx of COPD , HT , smoking , Puls 105 , BP 105/70 , RR
32
m likely organism , show u pic with G+ve cocci ? ( Strep )
case 2
Next step in management ? ( Pulse Oxemetry ) , NOT CXR (not predict severity), pt may die from
Hypoxia if sever,
then give Abx , then pneumovac and Stop Smoking on discharge
case 3
Next step ? ( IV Ceftriaxon / Azithromycin ) , for out pt Macrolide , Quinolones ( not Cipro )
admission according to severity ( ch pain , SOB , Hypotension , Confusion , Hyponatremia )
case 4
new case , 27 y male , with recurrent episodes of sinus and pulmonary inf witch required hospitalization
He has normal LN and Tonsil , Normal count of B and T cell , normal urine analysis
M likely diagnosis ? ( Common variable immunodeficiency )
case 5
m accurate test ? ( Serum protein electrophoresis SPEP )
case 6
witch best Rx ? ( I V I G )
case 7
pt has recent viral infection , witch organism does predispose to ? ( Staph )
case 8
54y male alcoholic has pneumonia , what m c organism ? ( Strep pneumonia ) o_O , YEP NOT Klepseilla
, it is ass with Alcoholic but not the m c
Hospital accuared/Ventilator (G-ve rode) : E coli , enterobacter , Citrobacter, Morganella , pseudomonas ,
Serratia
Legionella with old / immunodeficint , ass with GI and CNS , S/S
case 9
new case 82 y female , in home lyinf flat secondary to immobility , she has dehydration and alter mantal
status m she developed a new fever and ^^^RR , CXR done
witch m likely location of the pneumonia ? ( Rt upper lobe ) if setting upright , aspiration to Rt lower lobe
case 10
m c organism ? ( Anaerobes )
case 11
67 y male with productive couph , fever , he has Hx of COPD , HT , smoking , Puls 98 , BP 120/80 , RR 14
m likely be found , he play weird sound ? ( Egophony ) try to hear it
case 12
Treatment of choice ? ( Azethromycin )
case 13
24 y female with her husband go to Dominican Republic in honeymoon , 2 day later both developed couph
with CXR show resolving infiltration despite Abx , m likely organism ? ( Strongyloides )
case 14
same case , show pic of Strongyloides , SO plzz see a pic of this organism @
case 15
Rx ? ( Ivermectine )
case 16

32 y women with dry cough , ^LDH , ^direct bilirubin , ^ retic count

he show u otoscopy pic , witch , likely be found ? ( Bullous Myringitis )
case 17
witch CXR will be found ? ( chose the one show bilateral interstitial infiltration )
case 18
m likely diagnosis ? ( Mycoplasma ) pneumonia + cold agglutinin (Hemolysis) + Bullous myringitis
case 19
m accurate test ? ( P C R )
case 20
Rx ? ( Azethromycin )
case 21
new case 48 y Veterinarian , with fever , dray cough , SOB , and CXR show bilateral interstitial infiltrate
m likely organism ? ( Coxiella burnetti ) transmitted exclusively from animal
case 22
Rx ? ( Doxicycline )
case 23
30 y male had allogenic BM transplant secondary to ALL , he developed pneumonia , CXR show bilateral
interstitial infiltrate , m be found , he show u Biopsy pic ? ( chose the one show intranuclear occlusion )
ass with CMV
common google and see it before moving to next case
case 24
67 y female has Stroke she devloped productive cough , fever , he has Hx of DM , HT , Puls 112 , RR 34
m likely diagnosis ? ( Aspiration pneumonia ) Stroke pt loss GAG reflex
case 25
same pt he show u a video of loss gag reflex where is the problem ? ( CN IX and X )
case 26
Rx ? ( Clindamycin )
case 27
1-2 day after started Rx , pt begin to have SOB , RR 40 , increase fever , Po2 on 50% , oxygen 60 mm hg ,
she get intupated , m accurate test to assess the diagnosis ? ( Broncoalveolar lavage )
case 28
Rx ? ( Imipenem + Vancomycin + Levofloxacin )
case 29
same pt Po2 improve sufficiently to extubated , she still febrile , PE show Rt decrease breath sound
witch m likely found CXR ? ( chose the one show Rt Plural effusion )
case 30
same pt , m accurate test ? ( Thoracentesis )
case 31
witch expected in Thoracentesis ? ( PH less than 7.20 + high neutrophil count more than 50.000 )
case 32
Rx ? ( chest tube with drainage )
case 33
witch m likely found on autopsy ? ( chose the one show Empyema )
case 34
pt developed diarrhea after using Abx for while
best initial Rx ? ( oral Mitronidazol )
if get better the reocure , retreat ,,,,, if not improve give Vancomycin
case 35
she is ready to discharge , what recommended ? ( influenza vac and pneumovac )

11 CHF
case 1
68 y female presented to ER with SOB for last few h , when she lies flat SOB increase , she need 3 pillows
to sleep , on PE : RR 28 , Puls 112 , ^JVD , peripheral edema and rales to he apices
m likely diagnosis ? ( Pulmonary edema )
case 2
next best step ? ( Oxygen ) NOT Echo , NOT CXR
case 3
witch expected in this pt , murmurs' ? ( S3 gallop ) listen to that plz
case 4
witch expected CXR in this pt ? ( chose the one show vascular congestion/pulm edema )
case 5
witch make the biggest different in acute management ? ( E C G )
Arrhythmia can change it ( Cardioversion )
case 6
ECG m likely is this pt ? ( chose the one show Atrial flutter ) ass with decompensated CHF
case 7
m likely show on Cath ? ( ^ wedge/Rt A pressure . low COP . ^ SVR )
case 8
best initial Rx ? ( Furosemide ) preload reduction
case 9
mechanism of the benefit of Morphine in pulmonary edema ? ( Dilate pulmonary vein ) I know u thought it
is for pain . but they r not in pain SMARTY
case 10
mechanism of effect of Nitroglycerin ? ( Arterial dilation greater than venous ) bcoz vein r larger than
artery the relative dilation more in veins . So open up venous capacitance vessels will make Blood go
backward from the heart
case 11
witch would Nesiritide be a substitute for? ( Nitrates ) synthetic ANP
case 12
new case 56 y man with Hx of COPD , MI , HT , presents to ER with sever SOB , PE show rales and some
peripheral edema , CXR is unreadable ?
best initial diagnostic test ? ( Brain Natriuretic Peptide BNP )
case 13
pt has ^BNP , what is the most accurate test for Ejection fraction ? ( MUGA ) Nuclear Venticulography
case 14
witch drug lower Mortality ? ( ACE inhibitors )
case 15
64 y woman presents to ED for dyspnea on examination S3 , jugular venous distention edema , orthopnea
are found oxygen , furosemide ,nitrates and morphine are given . still dyspneic BP 114/80
next step ? ( Dobutamine )
case 16
The pt is ready for discharge . placed on enalapril and metoprolol .
which is most likely to decrease his mortality ? ( Spironolactone )
case 17
64 y woman with CHF . she has dilated cardiomyopathy of unclear etiology .her injection fraction has

dropped to less than 15% despite medical therapy her BP remain stable at 115/75 . which medication will
provide with increased mortality benefit ? ( Carvedilol )
case 18
Which is the most common cause of death in these pts ( ventricular tachycardia )
case 19
Person with CHF has persistent S.O.B despite the use of diuretics , digoxin , Spironolactone ,ramipril and
metoprolol ECG show an injection fraction of 16% .
which most likely benefit this pt ? ( biventricular pacemaker )
case 20
Which is the most dangerous cardiac lesion in pregnant woman ? ( Eisenmenger's syndrome )
case 21
48 y male with dyspnea , ranal failure and edema . his ECG shows a speckled septum .
the most likely diagnosis is ? ( amyloid )
case 22
58 y man has a history of CHF secondary to alcoholism progressed to dilated cardiomyopathy with injection
fraction of 22% . what is the only difference in management between this pt and one with CHF secondary to
CAD ( coronary artery bypass graft )
case 23
17 y male with murmur gets worse with the valsalva maneuver and improves with squatting which is
common presentation ? ( S.O.B ) m c in HOCM . it is NOT sudden death
case 24
The location is this patient's murmur best heard ? ( lower left sternal border )
case 25
Which will improve this murmur ? ( Handgrip )
case 26
The pt has two episodes of syncope .
which have the greatest mortality benefit ( Implantable cardioverter defibrillator (AICD) )
case 27
72 y man with PMH of COPD , MI , gout and type II DM present with dry cough . he's on enalapril ,
furosemide , allopurinol and ipratropium . on ECG has injection fraction of 34%
the best next step ? ( switch enalapril to losartan )
case 28
The pt still symptomatic . he has potassium of 6.0 mEq/L the best next step ( Hydralazine & nitrates )
Case 29
His enalapril was changed to Hydralazine and nitrates the hyperkalemia corrects . he developed throbbing
headache . the most likely cause is ( nitrates )

12 - Macrocytic Anemia
case 1
68 y female present with slow fatigue for month , and SOB for last week , Bp 114/70 mmhg , puls 107 ,
there is mild decrease sensation in her LL , on LAP HCR 28% , Hg 9.2 , MCV 118
m likely diagnosis ? ( Vit B12 deficiency )
case 2
witch physical finding most likely be found ? ( Vitiligo ) B 12 DA associated with autoimmune condition like
:
Vitiligo / Addison D / pernicious anemia / Hashimoto thyroiditis
case 3
initial diagnostic test ? ( peripheral blood smear )
case 4
witch m likely found , show u many peripheral smear ? ( chose the one show Hypersegmented
neutrophil )
case 5
confirmatory test ? ( Methylmalonic acid level MMA ) specific for B12 deficiency
case 6
m likely found in LAP (retic,LDH,Bilirubin) ? ( low retic , ^ LDH , ^ Bilirubin )
case 7
what is mechanism of Hyperbilirubinemia ? ( RBCs destruction in BM )
case 8
m likely found , show u many peripheral smear ? NO Hypersegmented neutrophil ( Macro ovalocyte )
case 9
m likely found , show many pic of tong ? ( chose the one show Atrophic glossitis ) smooth tongue
case 10
m likely cause of this pt Disease ? ( Pernicious anemia )
case 11
what u will do to confirm the etiology in this pt ? ( Anti intrinsic factor antibody )
case 12
most serious complication for B12 replacement ? ( Hypkalemia )
case 13
m c neurological abnormality ass with this disease ? ( peripheral neuropathy )

13 Inflammatory Bowl Disease IBD

case 1
24 y female presented with Diarrhea , sometime with Blood , and weight loss , Stool culture , ova and
parasite and C.diff toxin all normal , what is the m likely diagnosis ? ( I B D )
case 2
witch skin lesion m likely present in this pt ? ( Erythema Nodosum ) reddish tender lesion in the ant leg
it indicate the activity of the disease
case 3
witch m likely found in this pt , show u a lot of pic ? ( Pyoderma Gangrenosum )
case 4
he show u endoscopy pic ? ( Uveitis/Iritis )
case 5
m accurate diagnostic test for the ocular finding ? ( Slit Lamp )
case 6
what is the Rx for the ocular finding ? ( Steroid )
case 7
new case 24 y female presented with Diarrhea , sometime with Blood , and weight loss , Stool culture , ova
and parasite and C.diff toxin all normal , now present with Jaundice , dark urine , itching , on PE abdomen
is not tender LAP show AST 12 , ALT 18 and alkaline phosphate 110 , m likely diagnosis ? ( sclerosing
cholangitis )
case 8
what is the worst complication for the sclerosing cholangitis ? ( Cholangiocarcinoma )
case 9
m accurate test sclerosing cholangitis ? ( E R C P ) it NOT biopsy
case 10
most consistent with UC ? ( ANCA +ve and ASCA -ve ) reverse it for CD
case 11
he show u many pic of colonoscopy , witch most likely found ? ( Cobblestoning pattern )
case 12
witch the greatest point of different of UC vs CD ? ( Rectum involvement ) CD spare the Rectum
case 13
initial Rx for maintenance ? ( MESALAMINE )
case 14
pt now present with urinary frequency and burning , she had noticed a foul small to her urine and also a
dark colore witch m likely diagnosis ? ( Rectovesicular fistula )
case 15
witch of the following must be don before start Rx for fistula ? ( P D D )
infeximab open Granulomas and flare TB
if PDD is +ve give INH with infleximab
case 16
disease not controlled with Mesalamin and Budesonide , witch to add ? ( Azathioprine )
case 17
disease not controlled with Mesalamin / Budesonide / 6-Mercaptopurine , pt had persistent disease in
perianal area What to do ? ( Ciprofloxacin / Metronidazol )

14 Systemic Lupus Erythematosus SLE

case 1
26 y female presented with joint pain , pain is bilateral in several joint with swollen , it does not change
through the day , she feel tired and have a skin lesion
m likely diagnosis ? ( S L E )
case 2
best initial test ? ( A N A ) Anti Nuclear Antibody
case 3
m specific test ? ( Anti dsDNA antibody )
Anti Histone antibody is ass with Drug induce Lupus ( spare Brain & Kidney )
case 4
he show u pic of facial rash ? ( Malar Rash )
case 5
he show u pic of palm of the hand with white last 2 finger ? ( Ryanauds phenomenon )
case 6
he show u 5 hand x ray , m likely found in this pt ( normal hand x ray ) SLE it is not deforming to joint
case 7
pt had a CBC , m likely found ? ( Pancytopenia )
case 8
he show u blood smears ? ( chose the one show Spherocytes )
case 9
a mother with SLE gives birth , the baby +ve for anti Ro antibody , he show u ECG ? ( 3ed degree AV
block )
case 10
32 y female G3P0020 , come in her 12th week and concern about spontaneous abortion , she has +ve
VDRL , -ve FTA and elevated aPTT ? ( Antiphospholibid syndrome )
case 11
what expected in this pt ? ( D V T )
case 12
26 y female presented with joint pain , pain is bilateral in several joint with swollen , it does not change
through the day , she feel tired and have a skin lesion , 5 y after diagnosis her complement low , anti ds
DNA ab elevated , and on Urine analysis ( ^proteinuria , ^hematuria , red cell cast )
m accurate diagnostic test ? ( Renal biopsy )
case 13
he show u biopsy pic ? ( Membranous Glomerulonephritis ) ass with SLE
case 14
Rx to this pt nephropathy ? ( Prednison / Mycophenolate )
case 15
pt present afebrile with pleuritic pain and hemoptysis , CBC normal , CXR show bilateral infiltration
m likely diagnosis ? ( Alveolar Hemorrhage )
case 16
witch determine disease activity ? ( decrease complement level )
case 17
he show u pics of fundoscopy ? ( chose the one show central retinal vein occlusion )
case 18
36 y female with SLE presented with speech impairment and right facial dropp for the past 2 h , on PE her

eyes deviate to the left and there is a murmur , LAP show normal complement .
best initial test ? ( Echo ) there is 2 cause for stroke in SLE ( Libman sacks vegetation / Lupus
anticoagulant )
case 19
witch murmur m likely found in this pt ? ( pansystolic ) MR m c valvular lesion ass with Lupus
case 20
5 health care worker with +PDD , and all started on INH , he developed bilateral joint pain in hands and
feet's , rash , with pleuritic pain
why he is the only one get S/S ? ( decrease acetylation rate ) drug induce Lupus
case 21
next step ? ( stop the drug )

15 RA
case 1
32 y women with pain and stiffness in her joins for the past 7 week , she also c/o fatigue , malaise Wight
loss
m likely diagnosis ? ( R A )
case 2
m likely found on X ray ? ( chose the one show PIP , MCP , wrist involvement ) RA spare DIP
case 3
m reliable way to differentiate RA from Hx ? ( condition improve with use ) AM stiffness less than 1 hour
case 4
witch procedure consider dangerous to this pt ? ( endotracheal intubation )
if cervical spine involved , there is a risk for atlantoaxial subluxation ( C1 - C2 )
case 5
he show u hand pic , witch with RA? ( chose the one show , ulner deviation , swan neck deformity )
case 6
hand X ray in RA pt , ask about it ? ( panuus formation ) take a look in x ray plzz
case 7
new case pt present with rapidly swelling , warm , tender knee and fever , arthrocentesis is done
show u slide , and ask about m likely found in pt ? ( chose the one show staph or strep ) septic artharitis
case 8
Bach to RA case , routine blood test on this pt will show ? typical case for anemia of chronic disease
( normal MCV and platelet low ion TIBC high ferritin )
case 9
m specific test for RA ? ( anti CCP antibodies ) Cyclick Citrulinated Peotide it is sensitive and specific .
case 10
after 12 week on NSAID , wrist splint and phesical therapy , pt still worsen S/S and findind on x ray
what u will do ? ( Methotrexate )
answer DMARDS if fail therapy or abnormal x ray
case 11
he show u many x ray , and ask about one with RA ? ( chose same as case 3 )
case 12
what u should do before give hydrochloroquine ? ( Ophthalmologec exam ) it cause retinal toxicity
case 13
pt on pain , immobility , and deformity progressed despite the use of NSAID , methotrexate , abatacept and
anakinra

what next ? ( Adalimumab ) TNF inhibiter

DO NOT forget to test PDD first , it can reactivate TB

16 - Multiple Sclerosis
case 1
32 y caucasian woman presented with muscular weakness for the last 2 days , she had visual disturbance
twice in the past resolve with Steroid
m likely diagnosis ? ( M S )
case 2
m c presentation of this disease ? ( Visual deficit ) optic neuritis , No cognitive disturbance with MS
case 3
m likely physical finding ? ( Spasticity )
case 4
best initial test ? ( M R I ) NOT LP , LP looking for oligoclonal band in 3% of pt not diagnosed by MRI
case 5
m likely be found , show pic of many MRI ? ( chose the one show multiple white lesion )
case 6
witch of the following m likely found on ocular exam ? ( chose the one show optic nerve pallor ) optic
neuritis
case 7
what the following show , he play a video ? ( internuclear opthalmoplegia ) o_O , goolge it
case 8
what the following show , he play a video ? ( afferent papillary defect )Marcus Gunn pupil , YouTube it

case 9
m accurate diagnostic test ( M R I ) YEP it is best initial and m accurate
case 10
best initial Rx ? ( Steriod )
case 11
witch Rx delay progression ? ( Beta interferon ) only for MS (one disease drug) , alpha interferon for viral
hepatitis
case 12
witch Rx delay progression , no beta interferon in choices ? ( Mitoxantrone )
case 13
witch Rx delay progression , no beta interferon and no Mitixantrone in choices ? ( Natalizumab )
and Glateramer also delay progression in MS
case 14
pt developed progressive multifocal leukoencephalopathy (PML), witch drug to stop ? (Natalizumab )
caused by JC virus , on MRI : multiple white matter lesion with no mass effect no edema no ring enhancing
case 15
mechanism of action for Natalizumab ? ( alpha 4 integrin inhibitor )
case 16
pt has Spasticity , witch drug u use ? ( Baclfen )
case 17
pt has sever fatigue , witch drug to use ? ( Amantadine ) not known how it work
case 18
ethical Q about the right of competent pt to refuse Rx
case 19
pt develops incontinence , bladder palpable to the umbilicus , m likely diagnosis ? ( Atonic bladder )

MS can be ass with atonic bladder or urge incontinence

case 20
how to treat atonic bladder ? ( Bethanechol )
Oxybutynin Tolterodine , for urge incontinence
case 21
MS pt in sever pain not respond to Rx , u decide to give Opiates in high dose that make her sleepy ,
confuse
what should u do ? ( continue the medication and add Pemoline )

17 Acromegaly
case 1
a 44 y man present with daytime somnolence and deep voice , his wife is complaining that he has a new
unpleasant distinct smell , and show u pic of pt face , m likely diagnosis ? ( Acromegaly )
case 2
next best step in management ? ( IGF 1 level ) insulinlike growth factor
case 3
what is the mechanism of daytime somnolence ? ( Sleep Apnea ) coz ^soft tissue of the neck
case 4
he show u many mouth pics , witch m likely ass with this pt ? ( Wide space teeth )
case 5
another many coloscopy pics witch ass with this pt ? ( chose the one show Colonic Polyps )
case 6
pt develop erectile dysfunction , m likely etiology ? ( ^ Prolactin ) GH cosecrision with prolactin
prolactin inhibit GTRH from hypothalamus
case 7
on PE pt has bilateral thenar eminence wasting is noted , etiology ? ( ^ protein synthesis )
case 8
best initial Rx ? ( Surgury ) NOT medication like prolactinoma
case 9
A 16 y old boy present with shor stature , his GH and IGF-1 low ?
whitch should the pt tested for ? ( T4 / TSH ) Thyroxin is necessary for normal release of GH
case 10
A 52 y man present with indistinct abnormal facial features with high GH
m accurate diagnostic test ? ( Glucose suppression test ) normal response is decrease GH
case 11
A 48 y man undergoes transsphenoidal surgery , his BP 150/90 nnHg
witch is the prognosis in term of blood pressure ? ( improvement BP over time )
case 12
a 44 y man present with daytime somnolence and deep voice , his wife is complaining that he has a new
unpleasant distinct smell , he undergoes transsphenoidal surgery
witch of the following complication will occur most Rapidly ? ( Hyper Na ) loss of ADH
NB : m c cause of death is cardiac complication ( DCM / ACS ) from DM & HT

18 Hypertension
case 1
48 yrs man found to have BP 145/95 mmhg
Best next step ? ( repeat blood pressure in 1-2 weeks )
case 2
Pt has repeated episodes of HTN first therapy ( life style modification )
case 3
LDL is measured 175 mg/dl best next step ? ( Atorvastatin )
case 4
Pt had BP 145/95 mmhg two weeks ago , 152/95 mmhg last week and 148/90 mmhg now .
most effective management ? ( weight loss )
case 5
after correct Rx , BP remains elevated 150/94 mmhg best next step ( hydrochlorothiazide )
case 6
Common adverse effect is ( hypercalcaemia )
case 7
Pt on hydrochlorothiazide BP 144/96 mmhg after several months
best next step ? ( Acebutolol )
case 8
52 yrs man has history of benign prostate hypertrophy , BP 144/90mmhg
initial therapy ? ( Doxazosin )
case 9
Most common adverse effect ? ( orthostatic hypotension )
case 10
65 yrs woman with history of osteoporosis on examination BP 150/90 mmhg .
best initial therapy ? ( hydrochlorothiazide )
case 11
54 yrs woman with history of calcium oxalate kidney stones BP 150/90 mmhg .
best initial therapy ? ( hydrochlorothiazide )
case 12
Pt has history of CHF , DM , HTN and migraine headache controlled by metoprolol , enalapril , metformin ,
hydrochlorothiazide and spironolactone . he present with acute pain in right big toe NSAIDs and colchicines
are started .best next step ? ( stop hydrochlorothiazide )
case 13
58 yrs women with history of HTN for 15 yrs . partially adherent to hydrochlorothiazide and metoprolol . BP
ranged 130-150/90-100 mmgh , Expected eye examination ? ( hypertensive retinopathy ) plz check
some pics
case 14
Auscultation ( S4 gallop )
case 15
Urine analysis ? ( protenuria )
case 16
EKG ? ( concentric left ventricular hypertrophy )
case 17
Forgetness CT scan shows ? ( multi-infarct dementia )
case 18

52 yrs man present to ED with headache blurry vision , S.O.B and palpation. BP 220/140 mmgh
Next step ? ( IV labetolol )
case 19
Which drug has greatest risk of depression ? ( reserpine )

19 - Infectious Endocarditis
case 1
48 man come to ER with Fever , murmur for the last 3 week on exam he show u a pic ( IV drug mark on
hand )
m likely diagnosis ? ( Infective endocarditis )
case 2
best initial test ? ( Blood Culture ) have 95% sens , o_O , yes it is not Echo
case 3
m likely found in this pt , he show u pic of fundoscopy ? ( chose the one show Roth spot )
case 4
he show u pic of finger with red line on the nail , what is it ? ( splinter hemorrhage )
case 5
again some leg pic ? ( chose the one show jeneway lesion )
eruthema nodusum wt : sarcoidosis/syphlis/preg/strep inf
case 6
another pic of eyes ? ( chose the one show subconjectiva peticheia )
case 7
witch murmur m likely found ? ( Mitral regurg ) on media
case 8
witch murmure will increase with respiration ( Tricusped regurg ) all Rt heart murmure
it us mc Valve affected on IV drug abuser
case 9
bet area to hear M regurg murmure ? ( Apex )
case 10
CXR with multiple round region on the Rt side ( multiple little abscess ) from septic emboli , witch V lesion
m likely found ? ( T regurg )
case 11
Blood culture pending , next step ? ( start antibiotic )
case 12
best empiric therapy ? ( Vancomycin / Gentamicin )
case 13
after start Abx , he developed redness and flushing at the neck line , next step ? ( decrease the rate of
infusion ) Red man syndrome ass with rapid infusion of first does Vanco
case 14
m likely be found on LAP ? ( low complement level )
case 15
68 y old female present have fever and murmur , culture grow strep bovis
next step ? ( Colonoscopy ) s.bovis asso with colon CA
# rifampin is added for pt with prosthetic valve for good penetration
case 16
stat Q ask about sensitivity ? ( it is easy one )
case 17
another stat Q about PPV ? ( also easy one )
case 18
54 y male has progressive aortic stenosis , he went valve replacement 2 week ago , he now present with

fever 102 F , blood culture grow staph aureus , he is on Vanco and Genta
next step ? ( Transesophageal echo TEE ) with prothsetic valve do NOT go with TTE

case 19
TEE is don he has freely mobile vegetation , blood culture grow sensitive staph aureus
he is on Vanco and Genta , what next ? ( change Vanco to Nafcillin ) it is Sensitive
case 20
35 y homless , alcoholic in Seattle present to ED with fever and murmure , blood culture is nivetive , Echo
show vegetation , he is diagnosed with PCR
what is the m likely organism ? ( Bartonella ) when u see alcoholic + homeless + culture negative
case 21
pt has Hx of AS and about to going for colonoscopy
witch of the following indicated ? ( no prophylaxis required ) Non for GI procedure
case 22
pt with AR going to have prostate biopsy
witch of the following indicated ? ( no prophylaxis needed ) also NON for GU procedure
case 23
pt had prosthetic valve going for dental fillings
witch of the following indicated ? ( no prophylaxis needed ) dental filling dose not cause significant
bleeding
case 24
pt with unrepared cyanotic heart disease going for tonsillectomy
witch of the following indicated ? ( oral Amoxicillin before )

20 Hemochromatosis
case 1
50 y man wt fatigue , joint pain , skin darkening , erectile dysfunction
m likely diagnosis ? ( Hemochromatosis )
case 2
site of the defect ? ( Duodenum ) over absorption of iron in Duodenum ()
another cause is chronic blood transfusion , but less common
case 3
mood of inheritance ? (auto recessive ) 25 % - can skip generation in male and female
case 4
u tap the joint and show u pic , wich present ? ( +ve birefringent / rhomboid shape crystal )
Ca pyrophosphate ( psudogout )
case 5
most likely be found ? ( D M ) bronze diabetes , iron build up on pancreas
case 6
test most likely to show abnormality ? ( Echocardiogram ) restrictive cardiomypathy
case 7
m c cause of death ? ( Cirrhosis ) it is not HEART FAILURE
also hemochromatosis m c cause of Hepatoma
case 8

hear sound , witch associated with hemochromatosis ? ( chose S4 ) I know it hard , just practice it
case 9
witch u will use on liver biopsy ? ( Prussian blue )

case 10
bet initial test ? ( iron study ) ^iron low TIBC
case 11
m accurate diagnostic test ? ( HFE gen and MRI ) dont panic . there is no liver biopsy
that test may replace liver biopsy soon
case 12
what will be found on cardiac cath ? ( decrease COP increase PCWP )
case 13
m likely found on iron study ? ( ^ iron - ^ ferritin low TIBC ) exactly the opposite of ID anemia
case 14
witch organism this pt at risk of ? ( Vibrio vulnificus ) also Yersinea and Legonela
case 15
mechanism of erectile dysfunction ? ( iron deposit on pituitary ) cause low LH/FSH
case 16
treatment of choice ? ( phlebotomy )

I hope it help u
GOOD LUCK
Dr . Araki . Sudan