1. A 50-year man referred to the clinic with positive HCV He is asymptomatic with no history of drug use or previous Wood transfusion Physical examination was unremarkable Reviewing of his lab test showed normal LFT with positive ant.-HCV (ELISA). Hepatitis C RNA was negative. US abdomen showed normal liver.
Which of the following is the most appropriate next step in management?

2. what is the meaning of the following liver serology:
Anti-HBc positive
Anti-HBs positive
HBsAg *negative*

3. A 34-year-old man previously healthy brought a laboratory results for hepatitis B virus from test result
• HBsAg Negative
• HBeAg Negative
• Anti-HBc IgG Negative
• Anti-HBsAg Positive
What is the clinical state the laboratory results indicate?

4. Q- Young male c/o fatigue, nausea, vomiting, loss of appetite, jaundice history of eating from outside what is the initial investigation?
Q60-Patient is caucasian and symptoms started when he was introduced to regular food Patient has no history of drug use or alcohol drinking, presented with vomiting, diarrhea and jaundice since 5 days :

5. A 28-year man who was previously healthy, presented to the Emergency Department with 5- days history of right upper quadrant abdominal pain, which was associated with nausea and 2 episodes of vomiting. 2 days later, his family noticed yellowish discolourations of his eyes and skin. No history of alcohol or drug use. On examination, he was jaundiced. Abdominal exam showed tender right upper abdomen
Alkaline phosphatase 109 39-117 IU/L
Alanine aminotransferase 990 5-40 IU/L
Aspartate aminotransferase 789 12-40 IU/L
Which of the following is the most appropriate next step in diagnosis?

6. A 23-year woman was informed that her husband has chronic hepatitis B infection She was worried that he had transmitted the virus to her. She is currently asymptomatic apart from fatigue. What is the first evidence of acute infection in her case?

7. A 40-year-old woman is noticed to be jaundiced
 Result Test
Anti-HBs Negative
Anti-HBc Positive
HBs antigen Positive
IgM anti-HBc Negative
What is the patient’s hepatitis B status?

8. A 30-year- asymptomatic woman to the clinic as pre-employment screening Her examinations are unremarkable. Her laboratory tests revealed, positive HbsAg , anti-HBc(IgG) and anti-HBe but negative anti-HBs and HBeAg
Which of the following statements is the most accurate?

9. A 23-year woman was informed that her husband has chronic hepatitis B infection She was worried that he had transmitted the virus to her. She is currently asymptomatic apart from fatigue. What is the first evidence of acute infection in her case?

10. A 40-year-old woman is noticed to be jaundiced
 Result Test
Anti-HBs Negative
Anti-HBc Positive
HBs antigen Positive
IgM anti-HBc Negative

What is the patient’s hepatitis B status?

11. A 30-year- asymptomatic woman to the clinic as pre-employment screening Her examinations are unremarkable. Her laboratory tests revealed, positive HbsAg , anti-HBc(IgG) and anti-HBe but negative anti-HBs and HBeAg
Which of the following statements is the most accurate?

12. what is- HCV most common genotype in Saudi Arabia ?

13. Q11- Risk of HCV after needle stick injury?
Q11-a drug addict has HCV positive and the physician accidentally got needle stick injury what is the percentage of transmission ?

14. A 43-year-old man with is known to have chronic hepatitis B presents to the clinic for evaluation. He is asymptomatic with normal physical examination (see lab results and report)
Hb 11.9 130-170 g/L (Male) 120-160 g/L (Female)
Platelets count 145 150-400 x 109/L WBC 3.9 4 5-10.5 x 109/L
Direct bilirubin 17 1.5-6.5 pmol/L
Total bilirubin 21 3.5-16.5 pmol/L
Aspartate aminotransferase 89 12-40IU/L
Alanine aminotransferase 61 5-40 IU/L
Alkaline phosphatase 160 39-117 IU/L
US Abdomen: Showed mild coarse liver echotexture. most appropriate treatment option?

15. A 45-year-healthy man recently diagnosed with hepatitis C virus (HCV) infection and was referred to the clinic for initiation of HCV therapy. HCV RNA viral load quantitation was 2 million lU/ml and a Genotype 4. a Liver ultrasound that was normal with no cirrhosis or focal liver lesions
Test Result Normal Values
RBC 5 4.7-6.1 x 1012/L (Male) 4.2-5.4X 1012/L (Female)
Hb 13 130.170 g/L (Male) 120-160 g/L (Female)
Platelets count 233 150-400 x 109/L WBC 5 4.5-10.5 x 109/L
Alanine aminotransferase 89 5-40 IU/L
Aspartate aminotransferase 56 12-40IU/L
Creabnine 100 44-115 pmol/L
Fibroscan: Showed fibrosis score of F3.
Which of the following Is the recommended treatment?

16. A 62-year patient known case of chronic hepatitis C presented with abdominal pain and swelling Examination showed ascites, abdominal tenderness and peripheral edema Diagnostic ascitic tap done and revealed a neutrophil count of 400/mm (<250 mm) Blood pressure 110/70 mmHg Heart rate 90 /min Temperature 37.6 °C
Which of the following is the appropriate next step in the management?

17. A 60-year-old man presented wrth jaundice for 2 months. Physical examination revealed a nodular enlarged liver (see report).Showed cirrhotic liver with 2 lesions at right lobe measuring 4 x 5 cm. Which of the following risk factors is strongly assoaated with this condition?

18. known case of liver cirrhosis secondary to Hepatitis C has completed treatment. Hepatitis C RNA is negative. How will you follow up this patient?

19. Patient k/c cirrhosis after hepatitis C virus. Now treated and HCV mRNA is negative. on examination unremarkable except for mild angiomata and nevi. what to do?

20. the elevated levels of indirect bilirubin, total bilirubin, AST, ALT, and ALP (alkaline phosphatase) in a 10-year-old child presenting with 2 days of jaundice and fatigue, the most likely diagnosis?

21.  6 YO patient brought by his parents to the hospital because they noticed yellowish discoloration of the sclera. Symptoms started around a week ago. What is the type of hepatitis he has? (No hint at recent travel of needle sticks or eating from contaminated place)

22. acute hepatitis After Restaurant possible cause

23. Q- 6 years old with Jaundice and hepatosplenomegaly what’s is diagnosis ?
Q- child with fever , fatigued, and describes right upper quadrant abdominal pain and nausea. On examination, her skin tone, conjunctivae, and mucous membranes are yellow-tinged diagnosis?

24. A 62-year patient known case of chronic hepatitis C presented with abdominal pain and swelling Examination showed ascites, abdominal tenderness and peripheral edema Diagnostic ascitic tap done and revealed a neutrophil count of 400/mm (<250 mm) Blood pressure 110/70 mmHg Heart rate 90 /min Temperature 37.6 °C
Which of the following is the appropriate next step in the management?

25. A 60-year-o!d man presents with low-grade fever, insomnia and progressive abdominal distention with vague abdominal pain. Physical examination reveals flapping tremor and moderate ascites Ascitic fluid analysis showed high SAAG and neutrophil count of 350 cells/L Which of the following is the most appropriate management?

26. Case of chronic Cirrhosis presented to the ER for decrease level of consciousness for 2 days, PE shows Tense abdomen + lower limb edema, What to do next?

27. Q- Patient did hernia surgery years ago. He has Cirrhosis with progressive ascites. Hernia is present now with cough test. What to do?
Q-another recall : 60y pt with chronic liver disease and ascites came complaining with umbilical hernia. How to treat it?

28. Elderly with signs of heart failure ( lung crpeteaion , lower limb edema , raised jvp ) has a small ventral hernia booked for elective surgery :

29. Women K/C of liver cirrhosis, + ascites, confused. Na level: 126 (normal 135 to 145) Potassium level: within normal range Glucose: 8 (normal 3.9 to 5.5 mmol/L)

30. Q- Cirrhosis patient. Which of the following drugs prevent recurrence of ascites ?
Q- A 48-year-old man with a history of cirrhotic liver disease presents with abdominal distension. Clinical examination reveals tense ascites, which was drained. What is the appropriate type of diuretic to help prevent re accumulation of ascites?

31. Patient known to have liver cirrhosis due to hepatitis C infection presents with ascites which did not respond to repeated paracentesis. Which of the following is the appropriate management?

32. woman with hepatomegaly underwent upper abdomen MRI and found to have a 3cm lesion In the liver that shows peripheral beaded enhancement in the early phase with progressive central filling in the delayed phase.
Which of the following is the most likely diagnosis?

33. Patient with hepatic benign tumor diagnosis is hemangioma (mentioned), decided to be managed conservatively, but we should advise the Patient to ?

34. Smoker and obese patient, at imagining there is 4×4 cm hepatic hemangioma. What is the most important thing to advise the pt ?

35. an 18 -month-old- child presents to the emergency center having had a brief, generalizing tonic-clonic seizure. he is now postictal and has a temperature of 40 c (104 f) during the lumber puncture (which ultimately proves to be normal), he has a large, watery stool that has both blood and mucus in it. which of the following is the most likely diagnosis in this patient?  

36. Pediatric patient with shigella toxin positive

37. female presented with back pain and fever, she was given NSAIDs and advised for bed rest at home, then presented with inability to move lower limbs, O/E tenderness on the midback. Spinal MRI: Diffuse discitis on T6, What is the most appropriate next step?

38. 10 month old child with 3 days fever, vomiting, corpus watery diarrhea, on exam lethargic, cold and pale, tachycardia and mild tachypnea, which of the following will diagnose the case?

39. patient is receiving clindamycin and ceftazidime as treatment for endometritis after a cesarean section. the patient subsequently develops diarrhea, and stool testing reveals the presence of bacterial enterotoxin. What is the most appropriate course of action?

40. A 34-year-old man, a known case of ulcerative colitis on azathioprine 100mg/day with tapering doses of steroids, presented to the clinic with 6-7 episodes of bloody diarrhea, lower abdominal pain, and low-grade fever. On abdominal examination, there was mild tenderness in the left lower abdomen. Stool culture was negative, but the stool test for Clostridium difficile toxins was positive (see lab results).
Blood pressure: 110/70 mmHg
Heart rate: 100/min Temperature: 38.4 °C
Oxygen saturation: 95%
Test Results (Normal Values):
• RBC: 5 (4.7-6.1 x 10^12/L for males, 4.2-5.4 x 10^12/L for females)
• Hb: 11 (130-170 g/L for males, 120-160 g/L for females)
• Platelets count: 456 (150-400 x 10^9/L)
• WBC: 16 (4.5-10.5 x 10^9/L)
• ESR: 67 (2-10 mm/h for males, 3-15 mm/h for females)
• Albumin: 29 (34-56 g/L)
Which of the following is the most appropriate treatment?

41. 53-year-old woman with a known history of diabetes recently returned from Egypt. She presented to the Emergency Department with a 3-day history of progressive redness and pain on her right shin. She has a positive history of allergy to penicillin. On examination, her right leg had a red lesion, which was tender but without an ulcer. She was started on oral antibiotics. The next day, she complained of abdominal pain, watery diarrhea, and fever (temperature 37.8°C). What is the most likely diagnosis?

42. old man came complain of tender abdominal bloody stool and history of take amoxicillin from 3 wks for UTI sigmoidoscopy inflamed mucosa with plaque like lesions?

43. What is electrolytes testing present with Osmotic gap of stool vibrio cholera ?

44. 16YO with camping presents after 7 days of Flatulence and greasy foul-smelling diarrhea, when asked about his camping
activities, he reports that his friend collected water from a stream but did not boil or chemically treat the water before they drank it, reports nausea, weight loss and abdominal cramps followed by sudden diarrhea, what is the most appropriate treatment?

45. Q -An 8 year old girl with persistent and continuous diarrhea, she drinks 3 [pints of goat milk per day and is a fussy eater. Which of the following conditions explain her presentation? Labs: Hb Low, MCV High and MCHC High
Q- Child with a long history of watery diarrhea ( foul-smelling stool) abdominal bloating and pain, what’s the Diagnosis ?

46. 17y man complains of intense left flank pain that radiates to the groin, stone passage, which he has experienced so many times since
childhood, his uncle had the same problem, urinalysis shows hexagonal crystals, the urinary cyanide nitroprusside test is positive, cause of this condition?

47. signs of infection diagnosed as deep aspergillosis, What is the treatment?

48. A 62-year-old woman comes to the emergency department due to 3 days of fever, chest pain, shortness of breath, and cough. The cough has been occasionally productive of small amounts of bright red blood. The patient was diagnosed with giant cell arteritis a month ago after developing new headaches, jaw claudication, and transient vision loss. She was started on high-dose prednisone, which has since been tapered to 40 mg daily. She also has a history of hypertension, which is well controlled with amlodipine. The patient has a 30-pack-year smoking history. Temperature is 38.4 (101.1 F), blood pressure is 120/72 mm Hg, pulse is 94/min, and respirations are 18/min; oxygen saturation is 93% on room air. Physical examination shows a frail woman in mild distress with moist mucous membranes and no lymphadenopathy. Lung auscultation reveals occasional crackles in the left lung. Leukocyte count is 7,400/mm3 with 15% neutrophils, hemoglobin is 13.2 g/dL, and creatinine is 0.8 mg/dL. CT scan of the lungs reveals a 1-cm cavitation and multiple nodules surrounded by ground-glass infiltrates. The patient is admitted to the hospital and started on empiric broad-spectrum antibiotics.
Further laboratory results are as follows:
Serum and urine Histoplasma antigen negative Serum and urine Blastomyces antigen negative Serum galactomannan positive. Blood cultures no growth to date Sputum cultures mixed bacterial flora
What is the most likely diagnosis in this patient?

49. child with pica, hepatosplenomegally and failure to thrive. Coming from a low socioeconomic economic status family. HGB low Lead – 2 high PT normal PTT normal INR normal Iron normal What’s the most appropriate treatment?

50. PT complaining of dizziness after waking up, hot warm and flushes Watery diarrhea , itching On examination Abdomen examination normal Respiratory exam reveal wheezing Cardiac exam (murmur maybe) I’m not sure but there is finding What you will order ?

51. Long case with Kayser–Fleischer ring and low Ceruloplasmin how to treat?

52. girl has been brought to the Gastroenterology Clinic by her parents due to the observation of fine hand tremors. Further examination revealed jaundice and a palpable spleen. The following are her lab results:
• Copper: 0.8 (Normal Values: 1.72-3.54 mmol/L for males, 1.72-3.76 mmol/L for females)
• Direct bilirubin: 22.32 (Normal Values: 1.5-6.5 pmol/L)
• Total bilirubin: 38.2 (Normal Values: 3.5-16.5 pmol/L)
• Aspartate aminotransferase: 243 (Normal Values: 12-40 IU/L)
• Alanine aminotransferase: 165 (Normal Values: 5-40 IU/L)
• Albumin: 23 (Normal Values: 34-56 g/L)
• Total Proteins: 46 (Normal Values: 60-84 g/L)
• Serum ceruloplasmin: Low
• 24 hours urine copper: High
Given this clinical and laboratory profile, what is the most appropriate treatment option?

53. Question of a coworker how got exposed and spilled on himself radioactive fluid what he should do next ?

54. A 56-year-old woman was exposed to chemical burns to her trunk. on arrival to the Emergency Department, she was conscious and alert. Examination showed 5 cm x 11 cm wound at her back with burned clothes and powder of chemicals on her clothes and skin
Which of the following is most appropriate next step after removing her clothes?

55. Burn patient, resuscitation done, which of the following reflect a good resuscitation has been achieved?

56. 25% Total body surface area(TBSA) burn case what would be present ?

57. Female patient had massive burn 40% she is intubated with 100% o2 How to determine her outcome by ?

58. burn patient and resuscitation done, which of the following reflect a good resuscitation has been achieved?

59. 70 kg with 2nd degree burn, head and right arm . How would you resuscitate?

60. An 18-year man involved in bum accident, he has 2nd degree bum to his both lower limbs Weight 70 kg , Using Parkland formula, which of the following is most appropriate fluid resusatation?

61. Pt with stroke, confirmed by imaging haemorrhage asking Most definitive treatment of haemorrhage stroke?

62. Patient presented with left side hemiparesis , absent gag reflex and fecal incontinence of tarry stool diagnosed as stroke what is the best next step :

63. A 31-year-old man was involved in road traffic accident; examination revealed he is fully oriented GCS15/15 before reaching the hospital paramedic reported interval unresponsiveness. The patient suddenly lost consciousness and dilatation of left pupil was noted (see report). X-ray of the skull: Left temporal fracture. Which is the following most likely diagnosis?

64. A 70-year-old man complains of a sudden severe headache while Bending down to pick up his keys this morning He describes it as the worst headache he has ever had; he says it was like being hit on the back of the neck Which of the following is the most likely diagnosis

65. A 69-year-old man presents to the clinic with increasing fatigue, drowsiness, and difficulty to arouse. He recently went on vacation two weeks ago and experienced multiple falls during this time. He denies any head injury.
Neurological examination shows no focal or lateralizing findings, and head and scalp examinations are negative for tenderness or deformity. Plain X-ray of the skull is normal. Here are the relevant lab results:
• RBC: 5.1 x 10^12/L (Male), 4.2-5.4 x 10^12/L (Female)
• Hb: 132 g/L (Male), 120-160 g/L (Female)
• HCT: 0.40 (Male), 0.37-0.48 (Female)
• MCH: 30 pg/cell (Normal Range: 28-33 pg/cell)
• MCHC: 322 g/L Normal Range: 320-360 g/L)
• MCV: 88 fl (Normal Range: 80-95 fl)
• Reticulocyte: 0.9% (Normal Range: 0.2-1.2%)
• Platelet count: 200 x 10^9/L. (Normal Range: 150-400 x 10^9/L)
• WBC: 5.5 x 10^9/L (Normal Range: 4.5-10.5 x 10^9/L)
• Neutrophils: 50% (Normal Range: 40-60%)
• Eosinophils: 2% (Normal Range: 1-4%)
• Basophils: 0.8%
• Lymphocytes: 32%
• Monocytes: 4.1%
• Calcium: 2.3 mmol/L
• Ionized calcium: 1.2 mmol/L
• Magnesium: 0.8 mmol/L
• Thyroid-Stimulating Hormone: 4.4 pU/mL
• Thyroxine (T4 free serum): 12 pmol/L
• Sodium: 136 mmol/L
• Potassium: 4.2 mmol/L
Based on this information, which of the following is the most likely diagnosis?

66. Elderly pt after fall down had altered level of consciousness, Ct brain shows extradural hematoma..
which artery injured?

67. A 73-year-old diabetic man presents with right-sided weakness.
The weakness is equal in the right face, arm and leg. Sensation, speech and comprehension are intact. Which of the following arteries is affected?

68. Elderly man brought by his wife to the ER with a change in personality.
He is medically free. Left leg power is 2/5 with loss of sensation in the same leg. All other limbs are normal. Where is the lesion?

69. 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 lapse in 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?

70. Case of stroke came in 4 hours what is the most important next step ?

71. 52s woman comes to the 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 w/ corticosteroids and improvement after several weeks. The patient’s other medical issues include HTN and hyperlipidemia. She is currently not taking any disease-modifying therapy for her MS. BP is 170/96 and pulse is 92. BMI is 35kg there is a mild afferent pupillary defect in the left eye w/ diminished visual acuity, which of the following is the next step in treatment of this patient?

72. 55 Years old male DM type 2 Complain of left arms weakness for 5 hour then improved before 2 days , Now on examination everything normal no carotid beruit except new cardiac murmur noticed on auscultation What is the initial investigation ?

73. Female patient came with history of sudden loss of vision in the left eye that resolved spontaneously after 60 minutes What is the most likely diagnosis?

74. 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?

75. An 18-year boy known to have epilepsy since childhood is brought to the Emergency Department after having repeated tonic-donic seizures at home. He is compliant with his medication, which is sodium valproate. In the Emergency Department, he is unconscious and continuously convulsing, After oxygenation and securing which of the following intravenous drugs should be administered?

76. A 9-month-old Infant presents to Emergency Room with active generalized tonic-clonic seizure for 5 minutes ago. He has flu-like illness today and the review of system was unremarkable. The child was connected to cardiopulmonary monitor and intravenous access immediately attained. Blood pressure 80/50 mmHg Heart rate 132/min Respiratory rate 31 /min Temperature 39.6 “COxygen saturation 95 % which of the following Is the most appropriate next step In management?

77. 5 month old infant. mother brought him to clinic because he stopped smiling and low activity. While examining the patient, he suddenly started to flex his arms and legs with back arching and jerkiness. What is the possible finding on ECG?

78. 4 months on breastfeeding, This is her first baby came with 2 days history of lethargy constipation, fever, response weak when light directed to his eyes , long scenario cause ?

79. 17- days old baby brought to the hospital because of reluctant to feed and seizure since last night. On exam the baby weight is 3Kg, inactive, has generalized increased tone. CSF: clear, Glucose 3 mmol (normal 2.8-5), protein 0.22 (normal 0.22-0.33), cells 10 (normal up to 10). Which of the following is the most likely diagnosis?

80. A 15 months old child is brought to the emergency department after having a generalized tonic-clonic seizure that lasted approximately 5 minutes. The parents say that the child had been previously well but developed cough and rhinorrhea earlier that day with a temperature of 39.2 C. Which of the following is the most appropriate management?

81. A 5-year-old boy is brought to the Emergency Department after episode of convulsion that involved all limbs 1 hour ago. It continued for 3 minutes and associated with drooling and loss of consciousness. He had runny nose, mild cough and fever for last 3 days. On physical examination, he was fully active with mild congested throat. Blood pressure 120/80 mmlg Heart rate 98 /min Respiratory rate 22 /min Temperature 37.9°C Which of the following is the most appropriate treatment?

82. child starting brief seizure (less than 30 seconds) , EEG (generalized 3-Hz spike-and-wave activity.) what is Treatment?

83. A 6 years old was brought by his parents with history of sudden abrupt loss of environmental awareness with lip smacking followed by sudden return to normal baseline. Brain Imaging= Normal, EEG= 3-Hz spikes Which of the following is the most appropriate diagnosis?

84. 7 yeas came with history of focal seizures in upper limps that lasts 7 minutes. He is aware to surroundings Seizer happened in the morning Cause

85. years old girl HER mother noted 8 abnormal movements in form of tonic colonic some time associated with mouth deviation and last few seconds and resolve with out intervention and in the morning she noticed the same movements when the patient comb her hair and resolve, systemic review and .examination unremarkable EEG-show Focal sharp spick in the cenrto-temporal area What is the DX?

86. Female pt complaining of amenorrhea for 4-months T4 low Prolactin 200 What the diagnosis

87. Female came with white breast discharge and high prolactin, what radiology you will do?

88. A 40-year woman was incidentally detecied to have a 13-mm pituitary macro-adenoma on a CT of the head arranged to evaluate cause for her recurrent headaches. Apart from the headaches that she had suffered for the last 8 months, she had no history ol any significant medical illness and was not on any regular medications. Her general physical and systemic examination was unremarkable. Which of the following is the most appropriate next step in her management’’

89.  -patient complain of Erection, Thyroid hormone normal

90. Married 3 years ago with irregular menses and milk expressed manually .. next step:

91. Q-Patient with history of thyroid nodules also she have milky discharge from the breast and amenorrhea since 6 m lap result show that TSH high T4 high Prolactin level 6000 very high , What is the most appropriate management?
Q-Patient was present with hyperthyroidism symptoms (Weight loss, ect) and there were small Goiter in the neck, she missed her period lately, and develop milky discharge from nipples. What will you do ?

92. Y.O female diagnosed with hyperprolactinemia for one year on cabergoline. Which of the following is an indication for brain MRI in this patient?

93. patient came with low libido and low activity BMI 40 ,refer to endocrinologist FSH LH TSH T3 low ,MRI brain show 2.5 cm pituitary adenoma what’s most likely dx?