31. A 59-year- man has unsteady gait. On examination, he has decreased proprioception in the lower limbs with positive planter reflexes (positive Babnski) and absent ankle and knee’s reflexes He has anemia Peripheral smear done (see image)
Which of the following is the most likely diagnosis?

32. what is Type of anemia in alcoholism?

33. patient came only with fever and history of Southeast Asia?

34. Patient came only with fever and history of Sub saharan Africa? 

35. A 40-year- man comes to the clinic complaining of fever, He just arrived back from a short trip to a country in Southeast Asia Which of the following is the most likely cause of his Fever’

36. What is the most common disease diagnosed among travelers returning with fever from Southeast Asia?

37. 34-year male presents with chills, fever to 39 °C. Retro-orbital pain, and severe muscle and joint pains

38. Which of the following is the peak biting period for Aedes aegypli mosquito (the primary vector of dengue fever)?

39. Which of the following medications is the most likely that malaria parasites develop resistance to?

40. A 30-year-old man presents to the Emergency Department with history of fever and headache. He recently came from a trip to Sudan, where he stayed there for 10-days. Abdominal examination, palpable spleen 3 cm below costal margin (see lab results).
Temperature 40 ºC
Test Result                                               Normal Values
Hb 9                                                         130-170 g/L (Male) 120-160 g/L (Female)
Platelets count 90                                   150-400 x 109/L
Aspartate aminotransferase 88             12-40 IU/L
Alanine aminotransferase 94                  5-40 IU/L
Which of the following Is the first line treatment option?

41. Which of the following measures is recommended to avoid malaria infection in people traveling to an endemic country?

42. A 27-year-old soldier going to a military mission at the Southern border of Saudi Arabia . His medical history is insignificant apart from a positive history of depression, which is controlled by medication. He came for counselling regarding malaria prevention. Which of the following is the best malaria chemoprophylaxis regimen?

43. A 40-year-old man is planning to travel to Sudan for a short trip Which of the following prophylactic medications is recommended for malaria prevention?

44. A 35-year-old Indian man came to Saudi Arabia for HaJ. He presented with a 4-day history of intermittent fever, shortness of breath, drowsiness, convulsion and confusion. Which of the following is the most probable diagnosis?

45. What is the most common diagnosis for travelers returning with fever from sub-Saharan Africa?

46. A 35-years-old man comes to the clinic complaining of fever He Just come back from a 2-weeks trip to a country in sub-Saharan Africa Which of the following is the most likely cause of his fever?

47. Hodgkin lymphoma case , pt deteriorated Labs ( increase K , phosphate and uric acid , low calcium? What the diagnosis ?

48. 60 years old male with history of Hodgkin lymphoma, taking potassium sparing diuretic for severe hypertension, he is diabetic for 20 years, he had an chemotherapy appointment 1 week before he die
his lab:
Hyperkalemia
High uric acid
High creatinine
What is the cause of his hyperkalemia?

49. A 63-year man has  lymphocytic leukemia started on chemotherapy. His initial lymphocyte count was 73.000. 2 days after chemotherapy, he presents with fatigue and dry mouth which of the following electrolyte abnormality is associated with the above condition?

50. An 18-year- is receiving chemotherapy for acute lymphoblastic leukemia On day 17 of chemotherapy, he has fever. He has no focus of infection (see lab results). Heart rate 110/min Temperalure 38.9 °C
Test Result                                             Normal Values
Platelets count 25                                150-400 x 109/L
WBC 0.6                                                4.5-10.5 x 109/L
Neutrophils 60                                     40-60%
Lymphocytes 20                                   20-40 %
Which of the following is the most appropriate management?

51. A 66-year-old woman presents with lethargy for the past 2 weeks.
Her past medical history includes polymyalgia rheumatic and ischemic heart disease. Clinical examination is unremarkable             Test Result                                                    Normal Value
WBC21                                                         4.5-10.5 x 109/L
Neutrophils 44                                                40-60%
Lymphocytes 60                                             20-40 %
the most likely diagnosis?

52. old patient with Chronic kidney disease present with labs show high WBC and very high lymphocytes with arthritis past medical history includes polymyalgia rheumatic what is diagnosis ?

53. A 4-year-old boy presented to the clinic with history of decreased appetite and activity over the past month. He lost significant weight since his last outpatient visit. Which of the following is the most common cause of cancer ๓ such patient?

54. Which of the following leukemia is the most common in pediatric age group?

55. 60 years old patient after 10 minutes of blood transfusion developed pain in the site of the cannula, difficulty breathing, and is febrile. What is the most likely blood transfusion reaction?

56.  Patient on Total parenteral Nutrition give abnormal value of PT and INR what is the cause ?

57. An elderly man on NSAIDs developed dyspepsia. Endoscopy showed gastritis. Labs showed iron deficiency anemia with Hb= 9. What is the best method of treatment?

58. Child *confused* and fatigued laps microcitic hypochromic anemia with low ferritin , high TIBC, what treatment ?

59. A 9-month infant is suspected to have iron deficiency anemia.
CBC and iron profile ordered pending the results. Which of the following indexes is expected to be high?

60. A 2-year-old girl is seen in the clinic for pallor and Vredness. On examination, she looks healthy with normal vital signs: growth parameter and physical exam apart from conjunctival pallor Blood pressure 90/70 mmHg Heart rate 97 ‘min Respiratory rate 18/min Temperature 36.6 °C Oxygen saturation 95 % (see lab results)
Test Result                                                           Normal Values
RBC 4.5                                                           4.8-7.1 x 1012/L (Newborn) 4.6-48 x 1012A.(ChUd)
Hb 87                                                              165-195 g/L (Newborn) 112-165 (Child»
HCT 0.3                                                          2 0.44-0.64 (Newborn) 0.32-0.42 (Child)
MCH 25                                                           28-33 pg/cell
MCV 74                                                            80-95
Reticulocyte 1.1                                             0.2-1.2%
Platelets count 350                                       150-400 x 109/L
Iron 7                                                               7 2-17.9 pmol/L (Infant) 9-21.5 pmol/L (Child)
Total iron binding capacity 94                      17 9-71.6 pmol/L
Ferritin 12                                                      20-200 pg/L
Which of the following Is the most likely diagnosis?

61. A 2-year- girl brought to Primary Clinic because the mother noticed she is pale. History of drinking 3 pints of cow’s milk daily and is a very picky eater. The mother gave history of similar presentation on 2 of her brother (see lab results).
Test Result                                                  Normal Values
RBC 3                                                           4.8-7.1 x 1012/L (Newborn)
Hb 4                                                             165-195 g/L (Newborn) 112-165 g/L (Child)
MCH 18                                                         28-33 pg/cell
MCV 62                                                         80-95 fl
Reticulocyte 3                                              0.2-1.2%
Platelets count 480                                    150-400 x 109/L
Ferritin 9                                                      20-200 pg/L
Which of the following is the most likely diagnosis?

62. A 59-year woman comes to the clinic with headache dyspnea on exertion and occasional palpitations (see lab results).
Test Result                                           Normal Values
Hb 95                                                    130-170 g/L (Male) 120-160 g4. (Female)
MCV 68                                                  80-95 fl
Platelets count 530                              150-400 x 109/L
Total iron binding capacity 30            11.6-31.3 pmol/L (Male) 9-30.4 pmol/L (Female)
Ferritin 3                                               20-300 pg/L (Male) 20-120 pg/L (Female)
Which of the following is the most likely diagnosis?

63. A 5-year-old child presented with bruising and skin rash that developed over 24 hours. She had had upper respiratory tract infection a week ago. On examination, she appeared well but had purpura skin rash with some bruises on legs No lymphadenopathy or
hepatosplenomegaly (see lab results).
Test Result                      Normal Values
RBC 4.7                           4.8-7.1 x 1012/L (Newborn) 4.64.8×1012/L (Child)
Platelets count 17             150-400 x 10»’L
ESR    3                                 2-10mnVh
Clotting time 5                      5-10 min
Bleeding time 3                   up to 4 min
APTT 35                             30-40 sec
INR 1.1                                0.9-1.2
diagnosis?

64. which of following will curable by splenectomy?

65. Child previous URTI came with petechiae and abrasion Every thing is normal except platelets 15000 ask about Treatment?

66. A 5-year-old boy is brought to your clinic with generalized petechial rash and bruises all over his body. He had an episode of upper respiratory tract infection (URTI) 3 weeks ago. On examination, he is otherwise healthy. His blood tests is only significant for a platelet count of 74,000/mm3• Red blood cells and white cells are within normal range. Which one of the following is the most appropriate management option in this child?

67. 4-year-old boy is brought to the emergency department by his parents wit h bruising and a generalized rash for the past two days. He also had an episode of nose bleed this morning that stopped after 10 minutes of pressure and ice application. He also had a runny nose, mild fever and sneezing 10 days ago that was resolved after one week of conservative management. On examination, There are three bruises over the abdomen, right arm and left buttock as well as generalized non -blanching petechial rash over the trunk
and limbs. A full blood count results:
WBC: 9700 (normal: 4,000-11,000)
RBC: 4.2×10 power 12/L (normal: 3.9-5.6x 10 power 12/L)
Hb: 13.7g/dl (normal : 13-18g/dl ) MCV: 90fl (normal: 76-96fl )
Platelet count: 56×10 power 9/L (normal: 150-400×10 power 9/L)
What is most appropriate next step in management?

68. 7-year-old girl is brought to your practice by her parents, who are extremely concerned about several bruises on the child’s arms, legs and trunk she has developed over the past 2 days. recent medical problem upper respiratory tract infection (URTI) 2 weeks ago with complete resolution. On examination, there are several non-blanching petechial over the trunk and limbs and some bruises. There has been no bleeding event other than bruises and the petechial rash. The rest of the exam is insignificant with no lymphadenopathy or
heptosplenomegaly. A full blood test result :
WBC: 10500 (normal: 4,000-11,000)
RBC: 5×10 (power) 12/L (normal: 3.9-5.6×10(power)12/L)
Hb: 13g/dl (normal . 11.5-16g/dl ) MCV: 85fl (normal: 76-96fl )
Platelet count: 35×10(power)9/L (normal: 150-400×10(power)9/L)
What is next step in management of this child?

69. Two weeks after a viral syndrome, a 2- year-old child develops bruising and generalized petechiae, more prominent over the legs. No heptosplenomegaly or lymph node enlargement is noted. The examination is otherwise unremarkable. Laboratory testing shows the patient to have a normal hemoglobin, hematocrit, and white blood cell (WBC) count and differential. The platelet count is 15,000/μL. Which of the following is the most likely diagnosis?

70. 3-year-old boy is being evaluated in your general practice. A week ago, he was having upper respiratory tract infection. For the past 2 days, he has been having bruises over his trunk and limbs and a petechial rash over his body. This morning he had an episode of nose bleed lasting about 1o minutes. On examination, he looks well and healthy with no distress. He has no fever. There is no splenomegaly or hepatomegaly. He has several non­ blanching petechiae over his trunk and legs and recent bruises on his body. There is no family history of blood disorders. Complete blood count and peripheral blood smear showed thrombocytopenia
with no morphologic platelet abnormalities. Which one of the following is the most likely diagnosis?

71. A 50-year-old man presents with 3-months history of jaundice, arthralgia, Increase in skin pigmentation, and upper abdominal discomfort. He is on oral hypoglycemic medications for recently diagnosed diabetes mellitus. His viral hepatitis screening was negative. Examination revealed a bronze colour skin, enlarged liver with span of 15 cm. no splenomegaly, and testicular atrophy. Cardiac examination revealed a 3rd heart sound (see lab results). Test Result Direct
bilirubin 24 1.5-6.5 pmol/L
Total bilirubin 31 3.5-16.5 pmol/L
Aspartate aminotransferase 79 12-40IU/L
Alanine aminotransferase 112 5-40IUZL
Alkaline phosphatase 109 39-117 IU/L
Ferritin 400 20-300 pg/l (Male) 20-120 pg/L (Female)

Which of the following investigations is the most appropriate next step?

72. A 39-year-old man with asymptomatic hereditary hemochromatosis presentej to the clinic for a check-up (see laD results).
Test Result Normal Values
Alkaline phosphatase 42 39-117 IU/L
Aianlne aminotransferase 20 5-40 IU/L
Aspanate aminotransferase 22 12-40 IU/L
Ferritin 860 20-300 pg/L (Male) 20-120 pg/L (Female)
Which of the following Is the most appropriate management?

73. A case of young male asymptomatic presented abnormal LFT. He is a smoker and drinks alcohol in the weekends . Labs showed high
AST ALT and slightly high iron and TIBC and very high ferritin (450).
What is the cause of his abnormal LFT ?

74. The case about febrile neutropenia and treated with ceftazidime and not improving after 10 days what to add?

75. Q- Patient has leukemia and developed febrile neutropenia what’s the treatment:
Q- Patient was on chemotherapy and after 5 days developed fever with low WBC which of the following is the best initial drug to start the patient on:
Q- Patient with febrile neutropenia, what is the appointment initial antibiotic

76. An 18-year- is receiving chemotherapy for acute lymphoblastic leukemia On day 17 of chemotherapy, he has fever. He has no focus of infection (see lab results). Heart rate 110/min Platelets count 25 150-400 x 109/L WBC 0.6 4.5-10.5 x 109/L Neutrophils 60 40-60%
Lymphocytes 20 20-40 %

77. Patient with Mediterranean fever implied by history of fever and similar occurrence in the family asking about which drug to avoid?

78. A 2-years-old boy presents to the clinic with complain of sudden jaundice, fever for the last 3 days and passage of dark urine. Family history is positive for one brother who has severe neonatal jaundice required exchange transfusion, and they are originated from Mediterranean region (see lab result ).
Blood pressure 110/70 mmHg Heart rate 120 /min
Respiratory rate 22 /min Temperature 38.5 “C
Normal Values
RBC 4 48-7.1 x 1012/L (Newborn) 4 6-48 x 1012/L (Child)
HD 9 165-195 g/L (Newborn)
112-165 gfl. (Child) Reticulocyte 3 0.2-1.2%
Platelets count 300 150-JOO x 109/L
WBC 10 4.5-13.5 x 109/L (2-10 years) 4.5-11.1 X 109/L (11 years-older adult)
Which of the following medications should be avoided in the management?

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

80. 48 years old male patient known with hyperlipidemia with recurrent history of acute pancreatitis presented with vomiting with hemoptysis 1 day ago, all labs are normal, and on examination, the patient had splenomegaly, on radiological examination, there were normal portal veins with enlarged pyloric varicose veins. What is the diagnosis?

81. A 45 year old with history of pancreatitis , then recurrent vomiting, + upper GI bleeding After resuscitation what should be done Splenomegaly, normal portal , thrombo-splenic . He became stable after injection of sclerotherapy , which of the following best way to management ?

82. 52-year-old man comes to the office due to decreased libido and inability to achieve and maintain erections for the past several months. He has also had fatigue, anorexia, and a 5-kg weight loss over the same duration. The patient is married and has one child. He drinks alcohol but does not use tobacco or illicit drugs. Blood pressure is 110/70 mm Hg and pulse is 82/min. Physical examination shows bilateral gynecomastia and firm and small testes.
Laboratory testing shows normal TSH with decreased levels of total triiodothyronine (T3) and thyroxine (T4).

Which of the following is the most likely diagnosis?

83. hepatitis B patient ultrasound showed nodule ,What is the best next step

84. hepatitis B patient ultrasound showed nodule ,What is the best next step

85. A 42-year-old man with hepatitis B cirrhosis evaluated for focal lesion at US abdomen. He is asymptomatic. Currently on diuretics with well-controlled ascites (see lab results and report).
Test Result Normal Values
Hb 110 130-170 gA. (Male) 120-160 g/L (Female)
Platelets count 123 150-400 x 109/L INR 1.5 0.8-1.2 Total bilirubin 16 3.5-16.5 pmol/L
Aspartate aminotransferase 98 12-40IU/L Alanine aminotransferase 65 5-40 IU/L
Alkaline phosphatase 120 39-117 IU/L Albumin 30 34-56 g/L
CT scan of liven Demonstrated a 6 cm lesion with arterial enhancement at RT lobe, portal vein and hepatic veins were patent.
Which of the following is the best treatment option?

86. A 55-year man with chronic hepatitis C present to the clinic for regular follow-up. His examination reveals a palpable right upper quadrant mass. CT scan of his abdomen shows a large 6*6 cm mass in the right lobe of the liver. A mass biopsy confirms the diagnosis hepatocellular carcinoma
What is the most appropriate management steps at this stage?

87. Alcoholic patient with Cirrhosis have multiple hypo-dense lesions in the liver?

88. Which of the following diagnostic tools is the best option for screening for hepatocellular carcinoma in cirrhotic patients?

89.  Patient Complain of cirrhosis after hepatitis C virus. Now treated and hepatitis C virus, mRNA is negative, PE/ unremarkable except for mild angiomata and nevi. To do?

90. A 60-year man presented with 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 associated with this condition?

91. a 47-year-old alcoholic patient with a 6-week history of weight loss, fever, right hypochondrium pain, elevated alpha-fetoprotein, ascites, and a focal liver lesion in a cirrhotic liver, the most likely diagnosis is?
Test Result Nomal Values
Alpha fetoprotein 120 0-40 ng’mL
Abdominal Ultrasound : Showed ascites and focal liver lesion in a cirrhotic liver
Which of the following is the most likely diagnosis?

92. diabetic man rotin follow up asymptomatic HIGH liver ENZYMES , whats the cause :

93. Non-alcoholic hepatostatehorrea ( same mean Non-alcoholic Fatty liver ) what would be your best advice:

94. Elderly with jaundice, RUQ pain (not sure about presentation ) , but investigations shows dilated extra and intra hepatic duct , dx :

95. A 28-year-woman has 2-week history of jaundice and an 11-month history of progressive fatigue and arthralgia. She is not on any regular medication and does not drink alcohol. Her examination reveals hepatosplenomegaly. Viral hepatitis screening tests are negative (see lab results).
Test Result Normal Values
Hb 10 130-170 gA. (Male) 120-160 g/L (Female)
Platelets count 120 150-400 x 109/L WBC 7 4.5-10.5 x 109/L
Total bilirubin 26 3.5-16.5 pmol/L
Aspartate aminotransferase 920 12-40IU/L Alanine aminotransferase 890 5-40 IU/L
Alkaline phosphatase 160 39-117 IU/L Albumin 30 34-56 g/L
Which of the following is the most likely diagnosis?

96. A 36-year-old man presented to the clinic for evaluation of elevated liver enzyme He is asymptomatic with no significant past medical history. He is a smoker and drinks alcohol every weekend. Examination was unremarkable (see lab results and reports).
Total bilirubin 12 3.5-16.5 pmol/L
Aspartate aminotransferase 147 12-40IU/L
Alanine aminotransferase 76 5-40 IU/L
Alkaline phosphatase 119 39-117 IU/L
Albumin 33 34-56 g/L
Iron 3511.7-31.8 pmol/L (Male) 9-30.4 pmol/L (Female)
Total iron binding capacity 34 11.6-31.3 pmol/L (Male) 9-30.4 pmol/L (Female)
Ferritin 423 20-300 pg/L (Male) 20-120 pg’L (Female)
Liver function tests:
Hepatitis screen; Negative HCV, HBsAg was negative with positive HBsAb US Abdomen:
Enlarged liver with no focal lesion.
Which of the following is the most likely cause for his underlying liver disease?

97. A 25-year patient came to the clinic concerned about her sexual relationship after discovering that her husband was diagnosed with hepatitis B and was just started treatment She was tested and all her serology came negative.
What would be the best advice for her sexual relationship with her husband?

98. A 34-year pregnant woman, known case of chronic hepatitis B, comes to the clinic for counselling regarding the risk of hepatitis B transmission to her baby
Test Result Normal Values
Alkaline phosphatase 198 39-117 IU/L
Alanine aminotransferase 120 5-40 IU/L
Aspartate aminotransferase 67 12-40 IU/L
Hepatitis B viral load
1 million copies/ml
Which one of the following the baby should receive to reduce the vertical transmission risk?

99. The patient is known to have hepatitis B. The nurse is known to be vaccinated and a full responder. What will you give the nurse?

100. A 35-year-old nurse is seen in the dime after a recent routine screening for viral hepatitis infection. She was found to have positive antibody to hepatitis C virus (HCV). Her medical history is unremarkable; she has not used drugs or had any history of blood transfusions. She currently feds well and takes no medications. Vital signs and physical examination are normal.
Laboratory studies reveal a positive HCV antibody test but HCV RNA testing is negative
Hb 120 130-170 ga. (Male) 120-160 g/L (Female)
Platelets count 300 150-400 x 109/L WBC 8 4.5-10.5 x 109/L
Aspartate aminotransferase 26 12-40 IU/L Alanine aminotransferase 30 5-40 IU/L
Alkaline phosphatase 80 39-117 IU/L Gamma glutamyl transferase 25 6 to 37 IU/L
Which of the following is the most appropriate action to be done?