Internal Medicine

1) A 64 year old male, 3 days after urgent surgery for colon adenocarcinoma,
develops worsening dyspnea and hypoxemia. On examination –room saturation
92%, blood pressure 120/80, pulse 105/min, creatinine 0.9 mg/dl, with no other
abnormal clinical findings. What is the most appropriate next diagnostic step?

A) Abdominal CT
B) Lung CT angiography
C) MRCP
D) Pulmonary function test
E) Cardiac thallium scan

2)A 63 years old male complains of gradual onset of malaise and weight loss on
examination-splenomegaly ,cytogenetic analysis BCR/ABL 1 gene . which of the
following is correct ?
A. Bone marrow fibrosis rules out the diagnosis
B. On CBC -25% of WBC will be blasts
C. Treatment includes tyrosine kinase inhibitor (TKI) imantinib mesylate (Gleevec)
D. Leukopenia is probable finding
E. Allogenic stem cell transplantation (SCT) is contraindicated in this disease

3) 60 years old female is diagnosed with chronic lymphocytic leukemia(CLL) stage 0

she is admitted due to dyspnea . General malaise and dizziness. On examination-mild
splenomegaly without lymphadenopathy with no other abnormal findings labs
hemoglobin 8.0g/ dl reticulocytes 4% ,platelets 250,000, total bilirubin 6mg/dl ,direct
bilirubin 2mg /dl ,lactate dehydrogenase (LDH) 356mg/dl(norm <250). What is the
most likely etiology of the anemia?
A. Hypersplenism
B. Autoimmune hemolytic anemia (AIHA)
C. Thrombotic thrombocytopenic purpura
D. Iron deficiency anemia
E. Immune thrombocytopenic purpura
4) A 31 years old male arrive to ER complaining of fever with pain and erythema of
the eyes. In the past month he complains of painful genital and oral ulcers Knee pain
and Fever. In the past week bilateral eye pain and erythema with photophobia. On
examination fever 38c eye slit lamp bilateral WBC at the anterior chamber. Oral and
genital ulcers , swelling and erythema of knees. With no other abnormal findings .
Which of the following most likely diagnosis?

A- Bechet D.
B- crohn's D
C- Sarcoidosis
D- Systemic lupus erythematosus
E- Systemic herpes simplex infection

5) A 72 year old male status post anterior wall myocardial infraction 10 years ago. He
now complains of increasing dyspnea and is treated with bisoprolol and aspirin on
examination normal vital signs. Rales over the lung bases . echocardiography – left
ventricular ejection fraction (LVEF) 38%. Labs normal CBC , creatinine 0.9mg/dl , urea
35 mg/dl , sodium 136 , potassium 4.5.

Which of the following is the most appropriate treatment ?

A. Implant cardiac re-synchronization treatment (CRT)

B. Add digoxin
C. Automatic implantable cardiac defibrillator (AICD)
D. Add furosemide and ACE inhibitor
E. Add spironolactone

6) A 75 year-old female is admitted to evaluate an episode of syncope during her

morning walk. She has hyperlipidemia and is treated with simvastatin alone. Below is
the ER ECG. What is the most appropriate next step?

 Admit and refer to pacemaker implantation ASAP.

 Refer to 24 hours Holter test.
 Recommend 30-day heart monitoring by implantable monitor.
 Refer to Tilt test.
 Admit for observation alone.
7. A 35 years old female complains of fatigue weight gain despite attempts to avoid
it. Losing hair change of voice and hand tingling . Which of the following can explain
her symptoms ?

A- normal tsh high t4 high t3

B- d high t4 high t3

C-low tsh hight t3 hight t4

D- normal tsh low t3 normal t4

E- high tsh low t3 low t4

8. An 82 years old male with decreased cognitive status , ischemic heart disease ,
diabetes, hypertension . He fell at home and was found after a day laying on the
floor. Labs creatinine 2.5mg/dl (it was 1.3 year ago ) , urea 70mg/dl.

Urinary stick is positive for hemoglobin but sedimentation demonstration only

low amount of RBC.

Which of the following will support the diagnosis ?

A- FeNa 2.5%
B- Dysmorphic RBC on urine sedimentation
C- Numerous urinary granular casts.
D- Elevated serum creatinine phosphokinase
E- Elevated serum lactate dehydrogenase.

9)Which of the following symptoms is suggestive of ischemic heart disease?

A) Lower and middle abdominal pain

B) Epigastric pain that worsens with mild exercise
C) Stabbing pain radiating to the trapezius
D) Dyspnea that improve while climbing steps
E) Upper jaw pain
10) Which of the following is the most early symptoms of patient with pulmonary
hypertension?

A) Cough
B) Exercise dyspnea
C) Syncope
D) Chest pain
E) Peripheral edema

11 )A 21 year old male had fever and throat pain 3 weeks ago. He now complains
of general malaise , headache and weight loss , his blood pressure is high and he
has leg edema . Labs – creatinine 2.4 mg/dl , increased anti- streptolysin O (ASLO)
, low C3 complement level , positive rheumatoid factor (RF) , urinary stick – WBC
++ , protein ++ , RBC ++ , and RBC casts on microscopy.
What is the next step in management?

A) Cyclophosphamide
B) Enalapril
C) Penicillin
D) Dialysis
E) Cyclosporin

12) 48 years female undergoes evaluation for increase dyspnea in the past 3
months , four years ago she was diagnosed with limited cutaneous systemic
sclerosis and Raynaud phenomenon and Gastroesophageal reflux disease , she is

Treated with Nifedipine and Omperazole .

On examination bilateral equal breathing without wheezes or rales

Heart sound : wide split S2 : accentuated P2

Chest x-ray :no abnormal finding , what is the most likely etiology of this
symptoms ?

a)interstitial lung disease

b)myocardial fibrosis

c)pulmonary artery hypertension

d)venous thromboembolic disease

e)sarcoidosis
13) 45 years old healthy male admitted due to distended abdomen in the past
few ,months , on examination :ascites . labs :albumin 3.6 , protein 6.7 , in ascitic fluid
aspiration –albumin 2.0 , protein 2.4 . which likely the most likely etiology ?

a)peritoneal carcnomatosis

b)tuberculosis

c)nephritic syndrome

d)liver cirrhosis

e)constrictive pericarditis

14) a 55 year old male is treated for the past week with ceforal ( cefalexin ) for leg
cellulitis. he now presents with fever and diffuse maculopapular rash. Labs -
creatinine 2.4 mg/dl (baseline is 0.9)and absolute eosinophilia 2000. Urine
sedimentation - white and red blood cells casts. which of the following is the most
appropriate treatment at this time?
a. IV steroids ASAP
b. urgent dialysis
c. cyclophosphomide
d. stop ceforal
e. cyclosporine

15) 34 years old healthy female without medication arrives to the ER complaining of
fever , chills and left flank pain , she also mentions dysuria in the last two days there
is known anatomical variation or recent antibiotic treatment .

Which of the following is the most common pathogen in such cases?

a) citrobacter freundii
b) escherichia coli
c) enterococcus faecium
d) staphylococcus saprophyticus
e) pseudomonas aeruginosa
16 ) 65 years old male has arterial hypertension , stable ischemic heart disease and
controlled diabetes , recently complains of orthostatic hypotension without other
complaints or symptoms , CBC , electrolytes and renal function are all normal .

Which of the following is the most likely etiology ?

a) RAMIPRIL (ACE inhibitor ) -

b) BISOPROLOL ( beta blocker)
c) DOXAZOCIN ( alpha blocker)-
d) EMPAGLIFLOZIN ( sglt2 inhibitor )
e) ASPIRIN

17) A 41 year -old male is evaluated for sudden episodes of increased blood pressure
accompanied by sweating, flushing, headache, and palpations. Each episode lasts for
about half an hour and spontaneously resolves. Which of the following is the most
appropriate next step?

 Urine collection for catecholamines and metanephrines.

 Non- contrast head CT.
 Beta blockers treatment trial.
 Benzodiazepines treatment trial.
 Synacthen ACTH test.

18) A 40 year-old drug abuse male is admitted due to fever of 38.5 Celsius and no
other symptoms. Chest x-ray as part of the evaluation reveals left lower lobe
infiltrate. Echocardiography- large tricuspid valve vegetation. Labs- positive
rheumatoid factor. Blood cultures are pending. Which of the following pathogens is
most likely to grow on blood cultures?

 Enterococcus faecalis.
 Streptococcus gallolyticus.
 Coagulase-negative staphylococci.
 Staphylococcus aureus
 Cardiobacterium hominis.
19) A 45 years old female complains of symmetric wrists and 1-3
metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints pain. In the
past 6 months the pain increased and is accompanied by morning stiffness of over
two hours. She denies any other systemic symptoms. Labs- Increased CRP- with
positive RF and anti-CCP.

Which of the following is the mainstay treatment in the patient?

A. NSAIDs.
B. Glucocorticoids.
C. Methotrexate.
D. Rituximab.
E. Sulfasalazine.

20 )A 28-years old vegan female is evaluated due to increasing fatigue over the past
month. Lab- hemoglobin 5g/dl, hematocrit 25%, MCV 98, Reticulocytes count 25%.

Which of the following is the most likely etiology of her anemia?

A. Vitamin B12 deficiency.

B. Severe iron deficiency.
C. Haemolysis.
D. Lack of erythropoietin production.
E. Bone marrow infiltration.

21)A 58 years old healthy male complains of fever , headache , and general malaise a
week after returning from a business trip to Kenya (Africa ) . on examination at clinic
– fever 39.5, blood pressure 120/70 , pulse 88/min regular , fully alert , with no other
finding . what is the most appropriate next step ?

1- Refer to the ER to test for thick drop and malaria antigen

2- Blood test for venereal disease research laboratory (VDRL)
3- Clinical follow up , most probably a self-limited viral disease
4- Broad spectrum antibiotic treatment and ambulatory clinical follow
up
5- Prophylactic treatment for Neisseria meningitides and referral to
isolated admission
 22) Which of the following is considered an indication for urgent
dialysis ?

1-hypokalemia
2-uremic pericarditis
3-low blood pressure
4-metabolic alkalosis
5-hypernatremia

23) A 67 years old healthy male complains of increasing fatigue and

worsening chronic back pain in the past 3 months . the only
medication he takes for pain is acetaminophen . on examination –
tenderness over the lumbar spine and pitting edema +1 at the legs ,
no other abnormal finding spine x-ray – compression fracture of L1 .
labs – haemoglobin 8g/dl ,wbc 4000, platelets 300000, albumin 2.7
g/dl , total protein 9.2 g/dl , calcium 13.4 mg/dl , creatinine 2.1 mg/dl .
Which of the following test will promote the diagnosis?

1- Bone scan
2- Prostate specific antigen (PSA) levels
3- Serum parathyroid hormone (PTH) level
4- Serum protein electrophoresis and free light chains
5- Echocardiogram

24) A 32 years old man complains of episodic fever, weight loss and night sweats. On
examination- bilateral cervical and axillary lymphadenopathy, up to 2 cm, fixed but
non-tender, chest X-ray- mediastinal lymphadenopathy. What is the most likely
diagnosed?!

A)H1N1flu
B)HIVinfection
C)Pneumonia
D)EBV/CMVinfection
E)hodgkin'sdisease

25) A 63 years old male with hypertension complains of dyspnea a week after
ablation for atrial fibrillation. On examination- pulse 112/min, blood pressure 88/58,
pulsus paradoxus 16, breaths 18/min, room air saturation 96%, distended jugular
veins, distant heart sounds, normal breathing sounds, ECG: sinus tachycardia. Which
of the following diagnoses is the most likely?
A)cardiactamponade
B)pulmonary vein stenosis
C)pulmonary embolism
D)atrio-esophageal fistula
E)Retroperitoneal bleeding

26) A 60 year old male with morbid obesity and uncontrolled hypertension and
diabetes is brought to the ER due to epigastric pain and significant malaise lasting 30
minutes . on examination - blood pressure 85/40, pulse 50/min regular, bilateral
jugular distention, normal breathing sounds. ECG -ST elevation at leads ||, |||, AVF.
all of the following are acceptable treatment, except ?
a. immediate catheterization and primary PCI
b. heparin
c. aspirin
d. nitrates
e. clopidogrel

27) a 35 year old chronic alcoholic and drug abuse male arrives to the ER
complaining of right upper quadrant abdominal pain and fever of 38c. on
examination significant jaundice, distended abdomen, diffuse tenderness, mild
amount of ascites . Labs - bilirubin 10 mg% (normal <1), pt 20 seconds (normal <13).
discriminating factor 47. what is the recommended treatment?

a. Glucocortecosteroids (prednisone)
b. penecillin
c. furosemide
d. penroxiphylline
e. beta blockers

28) A 29 year old Male undergoes for anemia identified on blood tests. The patient
weakness and tingling of the hands and feet in the past several months. Labs -
positive for tissue transglutaminase (tTG) IgA antibodies .which of the following will
be most diagnostic?

A. brain MRI

B. serum copper and b12 level

C. IV contrast chest CT

D. gastroscopy

E. EMG

29) A 60 year old Male, heavy smoker for decades , describes increasing dyspnea on
exercise over the past several months with frequent episodes of productive cough.
On spirometry- FEV1 35% without improvement following bronchodilators. FVC
60% . Below is the spirometry diagram. Which of the following is the most likely
diagnosis ?

( spirometry )

A. Pulmonary fibrosis

B. Morbid obesity

C. acute asthma

D. pulmonary emphysema

E. Myasthenia gravis

30) Which of the following bacteria is most common in spine osteomyelitis?

A)Staphylococcus aureusa

B) Streptococcus pneumonia

C) Coxiella burnetii

D)Pseudomonas aeruginosa

E) Pertussis

31) 44 year old healthy male is diagnosed with nephrotic syndrome.

Kidney biopsy demonstrates evidence of membranous nephropathy.

He is not taking any Medications . On examinations- no abnormal Finding except

Peripheral 1+ edema.

.LABS - Creatinine 0.8 mg /dl , total cholesterol 310 mg/dl , albumin 3g/dl ,
Antinuclear Antibodies (ANA) negative , Hepatitis B surface Ag and Ab negative,
hepatitis C Ab negative.

24 hours urinary protein 6.5g. Renal ultrasound is normal.

which of the Following will be the most appropriate treatment at this time?

A. ACE inhibitors and statins .

B. Glucoscorticesteroids .
C. Tenofovir .
D. CYCLOSPORINE .
E. E. follow-up alone

32) 52 year old Male Complains of severe left toe pain that started acutely a few
hours prior to his arrival to the ER. Comorbidities - Diabetes , hypertension, chronic
Renal failur with Creatinine about 1.8 mg/dL.

On Examination : Red , swollen, warm , and tender left first metatarsopalageal

joints.

Diagnostic joint Aspiration - 22,000 WBC, Polarized light microscope-Acute gouty

arthritis .

Which of the following is the most appropriate treatment at this time ?

A. Intra articular steroids injection.

B. High-dose ibuprofen twice daily.

C. Allopurinol 100mg once a day .

D. Anakinra .

E. IV cefotaxime.

33) A 50 year old female undergoes gastroscopy due to epigastric pain and diarrhea
multiple Gastric ulcers are seen with no evidence of helicobacter pylori infection she
denies any use of NSAIDs there is no improvement with proton pump inhibitors
which of the following is correct?

A measure fasting serum gastrin levels a week after discontinuing PPI

B - treatment with h2 blockers is more effective than PPI
C - for diagnosis fasting serum gastrin must be 5 times the norm
D - can be associated with lung malignancy 
E - the diagnosis test of choice is PET CT

34)  A 40 year old admitted due to diarrhea for two days he reports 5 watery
diarrhea a day and that a week ago he completed antibiotic treatment for
pneumonia on exam fever 38.1 blood pressure 115/70 pulse 98 /min regular ,soft
abdomen with no peritonitis increased peristalsis lab :WBC 14000 with left shift,
albumin 3,8g/dl ,creatinine, 1,0 mg/dl,normal lactate clostridium difficile toxin is
positive, what is the most appropriate antibiotic treatment?

A - fecal microbiota transplantation 

B - IV vancomycin 
C  - oral vancomycin 
D -IV metronidazole 
E - combined IV metronidazole and vancomycin 

35) 67 years old female With the metastatic breast cancer to the bones in the past
few weeks she is not mobile due to limb pain. She is admitted due to dyspnea and CT
angiography rules out pulmonary embolism. Three days following the CT angio
creatinine is 2mg/dl (normal1,2 mg/dl).which of the following collaborate with the
most likely diagnosis ?

A. Low complement level

B. Numerous dysmorphic red blood cell on urine sedimentation

C. Creatinine level that returns to normal in one week

D. Peripheral blood eosinophilia

E. enlarged kidneys on ultrasound

36) A 60 years old male, complains of chest pain, dizziness, recent three episodes of
syncope, and dyspnea during mild exercise. He also has medically controlled
hypertension and Diabetes. On examination – Blood Pressure 145/82, Pulse 64/min
regular, normal breathing sounds, diminished S2, systolic ejection murmur 3/6 of the
apex radiating to the carotids – echocardiography- severe aortic stenosis .

Which of the following is most appropriate management?

A. Balloon aortic valvuloplasty.

B. Continue current medication.
C. Surgical aortic valve replacement.
D. Transcatheter aortic valve replacement (TAVR).
E. Permanent Pacemaker implantation.

37)A 67 years old male who is smoker, admitted due to right lobar pneumonia with
positive streptococcus pneumonia on blood cultures. He is treated with ceftriaxone
due to bacterial sensitivity. On the fifth day of treatment, his fever is 38.7 C and his
WBC 18,000. Admission and repeat X-ray are given below.

What is best next step in management?

A. Repeat x-ray in 3 days.

B. Change antibiotic treatment to Meropenem.
C. Diagnostic Pleurocentesis.
D. Add Azithromycin to current treatment.
E Continue with the same antibiotic treatment

38) a 61 years old female with hypertension complains of intermittent low grade
fever for 3 weeks with malaise and headaches. She reports unintentional weight loss
of 4 Kg, neck and shoulder pain and rigidity and jaw pain while chewing. Lab –
Normocytic anemia, elevated ESR and alkaline phosphatase.

Which of the following is most appropriate clinical approach?

A. Temporal artery biopsy and treatment with Methotrexate.

B. Treat with Tocilizumab (anti-IL6).
C. Treat with Prednisone and aspirin.
D. CTA of the neck arteries.
E. Liver and bile duct ultrasound.
39) -A 35 year old female is admitted for evaluation of pain and symmetric swelling
of the wrists and 1-3 metacarpophalangeal joints, malar rash, leukopenia, and
anemia. Which of the following will most likely advance the diagnosis?

A) Rheumatoid factor(RF)
B) Double stranded DNA antibodies (dsDNA AB).
C) Anti-neutrophil cytoplasmic antibodies( ANCA)
D) Antiphospholipid antibodies( APLA)
E) Erythropoietin

40) A 52 year old male with liver cirrhosis is diagnosed with spontaneous bacterial
peritonitis. What is the most common pathogen?

A) Staphylococcus Aureus
B) Staphylococcus viridians
C) Pseudomonas aeruginosa
D) Escherichia coli
E)Enterococcus faecalis

41) A 36 years old female with mitral prolapse arrive with a letter from the
dentist requesting advice on how to avoid endocarditis as she is planned for a
root canal treatment. The patient has no allergies and her echocardiography
6 months ago demonstrated thickening of the mitral valve with mild
regurgitation.
What is the most appropriate recommendation?
A) Do not perform dental procedures until echocardiography is repeated.
B) Gentamycin an hour before the procedure.
C) Amoxicillin an hour before the procedure and 8 hours after.
D) Clindamycin for a week before the procedure
E) There is no need for endocarditis prophylaxis in this case.
 42) Which of the following is correct with regards to spirometry results in
patients with advanced pulmonary fibrosis

Residual volume-RV
Total lung capacity-TLC
Forced vital capacity-FVC
Functional residual capacity-FRC
Diffusing capacity for carbon monoxide-DLCO
Forced expiratory volume in second- FEV1.

A) All volumes(RV,FRC,TLC,FVC) will be increased

B) Low airway resistance
C) Significantly decreased DLCO
D) High RV with decrease in all other volumes
E) Normal airway resistance

43) A 70 years old male who is your patient for 10 years for active smoking and
severe COPD. He was lost to follow up for a year because he was overseas. On
examination see finding in photo bellow { clubbing finger} this is a new finding that
was not documented in the medical records of the last visit. No other significant
change which of the following is the most appropriate next step?

A- Follow up in 3 month
B- Chest CT
C- Spirometry
D- Lung scan
E- Echocardiography

44) A 41 year-old female arrives to the ER due to sight loss of the left eye , she
reports pain above the sinuses and rhinorrhea for the past two weeks , she has type
1 diabetes for 20 years and is not well-controlled, on examination – fever 37,2 ,blood
pressure 130 /70,pulse 110/min regular ,left eye proptosis and unresponsive left
pupil , neurological examination – palsy of III ,IV,V,VI cranial nerves .head CT
demonstrates left maxillary sinus mass that protrudes to the left frontal lobe with
surrounding edema . which of the following is the most likely diagnosis

A- anthrax

B-aspergillosis

C-pseudomonas
D- mucormycosis

E- diphtheria

45) A 40 year old healthy female is admitted due to neck pain and rapid heart rate
for the past 3 days . vital signs – fever 38,5c , resting heart rate 120 /min , blood
pressure110/70 labs: low tsh and increase t4 thyriod scan demonstrates diffuse
decreased iodine uptake . what is the most appropriate next step

A-start beta blockers with methimazole or propyltionuracil

B-start NSAIDs

C-start doxycycline

D-refer the patient for thyroidectomy

E-start prednisone 1 mg/h

46) A 60 year old male is brought to the ER due to palpitations and dyspnea . on
examinations respiratory distress, diaphoretic ,diffuse rales over the lungs , normal
rapid heart sounds ,irregular 160 , blood pressure 80/50 .O2 saturations 85 % with
room air ,below is the ECG

What is the most appropriate treatment at this time

A- Decrease head rate with IV-Beta -blockers

b- decrease heart rate with IV non-dihydropyrides calcium blockers

c- immediate electrical cardioversion

d- immediate medical cardioversion with IV amiodarone

e – non- invasive respiratory support with BIPAP and IV furosemide

47) A 30 year old male is admitted due to severe frontal chest pain radiating to the
neck and left shoulder. The pain is exacerbated by deep breath and position change.
On examination  in pain , blood pressure 110/70 , pulse 120/ min , temperature
37.9 , room air saturation 96%, no jugular distention, heart – normal heart sounds
without murmurs, lungs- bilateral breathing sounds without rales or wheezing, labs-
leukocytosis with left shift. ECG is given below.

What is the most appropriate treatment ?

A.Primary percutaneous coronary intervention (PPCI)

B. Echocardiography and initiate with ibuprofen and colchicine
C.Chest X Ray and tube thoracostomy
D.Chest CTA and immediate anticoagulation
E. Chest CTA and immediate fibrinolysis

48) A 63 year old healthy male with no regular medications is diagnosed with acute
bacterial prostatitis. Ciprofloxacin was started, the patient improved, fever resolved,
and he was discharged with 6 weeks of antibiotic treatment. Which of the following
is the most appropriate routine follow-up for ciprofloxacin side effect?

1.serum lipase level

2.serum sodium level

3.stool of clostridium difficile

4.achilles tendon tear

5.blood creatinine level

49) which of following best characterizes Evan's syndrome?

A.ITP with spherocytosis

B. ITP with cryoglobunemia

C.ITP with myelodysplastic

D .ITP with hemolytic anemia

E. thrombocytopenia with schistocytosis

50) A 45 year old male is admitted for evaluation of diabetes due to family history of
diabetes and its complications . he denies weight loss, polydipsia, or polyuria, on
examination BMI is 22,normal blood pressure labs, fasting glucose 90mg/dl sugar
level after glucose challenge test 130 ,HbA1c 5.5 %

What is the most likely diagnosis ?

a)impaired fasting glucose

b)impaired glucose tolerance

c)no evidence of diabetes

d)diabetes type 2

e) maturity onset diabetes of the young

51) A 35 year healthy male is brought to the ER with stupor and confusion a day
before his admission he complained of frontal headache and sensitivity to light. on
examination : fever 38.7,nuchal rigidity , spinal tap-100 leucocytes/microliter,mostly
neutrophils,glucose 30mg/dl , protein 90mg/dl .

What is the most appropriate empiric antibiotic treatment?

a)ceftriaxone+vancomycin

b)cefatriaxone+ampicillin

c)ampicillin+vancomycin

d)ceftriaxone+acyclovir

e)cefitraxone+doxycycline

52) which of the following is correct with regards to peptic ulcer disease ?

A) almost ulcers in the duodenum are at the second part of the duodenum
B) malignant ulcer of the duodenum is common
C) Duodenal ulcers are not related to H Pylori
D) One of the most causes of gastrointestinal ulcers is the use of NSAIDs
E) Epigastric pain is characteristic of duodenal ulcer but not gastric ulcer
53) A 27 years old female with mild asthma mostly during season changes .
for past 10 years and is treated with beta agonist ( sulbatamol ) during attacks .
she now reports of severe episode and need for daily inhalations .
WHICH OF THE FOLLOWING is THE MOST APPROPRIATE TREATMENT

1- add oral corticosteroids

2-add PPI

3- add inhaled corticosteroids

4-Add LABA

5- increase salbutamol dose

54) 32 YEARS OLD HEALTHY MALE IS ADMITTED DUE abdominal pain ,diarrhea and
nausea he arrives to the er and HE NOTICED DARK URINe AND DECREASED URINe
OUTPUT, BLOOD PRESSURE 90/60, DRY MUCOSA, LAB TEST:CREATININE 1.8MG/DL
(NORMAL AT BASELINE)

Which of the following is expected on urine test??

A) Osmolality 100milimole/kg, FeNa 0.7%

B) Osmolality 100milimole/kg, FeNa 1.5%
C) Osmolality 200milimole/kg, FeNa 0.7%
D) Osmolality 500milimole/kg, FeNa 2%
E) Osmolality 600milimole/kg, FeNa 0.5%

55 ) a calcium of 12 mg/dl is found on routine blood test of a 33 year old healthy

male he is asymptomatic and feels well , most likely diagnosis ?

1- sarcoidosis

2- lung cancer

3-multiple myeloma

4- multiple endocrine hyperplasia type 1

5-primary hyperparathyroidism
56)A 75 year male with fever and general deterioration eats and drinks very little .
Diagnosed with facial herpes zoster and IV acyclovir is started .On examination –
blood pressure 100/60 mmhg , pulse 100/min regular ,fever 38c without any other
Abnormal findings , which of the following is this patient most likely to develop?
A)acute renal failure
B)congestive heart failure
C)hypothyroidism
D)hypokalemia
E)hypomagnesemia

57) A 25-year-old female is treated with trimethoprim-sulfamethoxazole (Resprim)

due to urinary tract infection. Complains of significant malaise. Labs hemoglobins 8.1
g/dl, WBC 16,000, platelets 58,000. Which of the following is the most likely
diagnosis?

A)Sickle cell anemia

B)Thalassemia

C)Aplastic anemia

D) Anemia of chronic disease

E) Hemolytic anemia

58) A 40-year-old male arrives to the ER with confusion and fever of 38.6"C. On
examination- Hemodynamically and respiratory-stable, no nuchal rigidity. Labs- WBC
6,400, hemoglobin 8.8 g/dl, MCV 90, platelets 60,000, total bilirubin 3.4 mg/dl,
indirect bilirubin 3 mg/dl, creatinine 1.9 mg/dl. Peripheral blood smear image is
given below. Which of the following is the most appropriate treatment?

A)Steroids and IVIG

B)Empiric broad spectrum antibiotics

C)One unit of blood after cross and match

D)Plasma exchange

E)Urgent dialysis

59) A 35-year-old male with Crohn's disease of the terminal ileum and without any
medical treatment complains of unsteady gait and decreased sensation. He also
reports tendency to forget things lately. On examination-unsteady gait, loss of
vibration sensation. Labs-anemia with hemoglobin 8 mg/dl, MCV 120. Previous CBC
was 3 years ago with hemoglobin 14 mg/dl and normal MCV. What is the most likely
diagnosis?

A)Hemolytic anemia

B)Severe iron deficiency

C)Vitamin B12 deficiency

D)Celiac disease

E) Vitamin C deficiency

60) 55-year-old male with severe COPD is treated with bronchodilators. He is

referred to the ER due to complains of dyspnea, yellow sputum producing cough,
fever, and myalgia. On examination - tachypnea 18/min, fever 38.2, room air
saturation 90%, multiple expiratory wheezes over the lungs, no jugular vein
distention. Chest X-ray is without infiltrate or congestion. Which of the following
tests will most likely assist in diagnosis?

A) Arterial blood gasses

B) B-type natriuretic peptide

C)CT Angiography of the pulmonary arteries

D) Echocardiography

E) Troponin
 Pediatrics

1 )A preterm infant born at 29 week of gestation is ventilated since birth due to

respiratory distress syndrome . On 3 rd day of life there is a desaturation to 70% .
There are reduced breathing sound on the right. Chest x-ray is attached(image)

A- Height frequency ventilation

B- Repositioning of the tracheal tube
C- Urgent internal tracheal suction
D- Adding surfactant to ventilated air
E- Inserting a drain into the pleural cavity and continuous suction.

2) A 2 years old is evaluated for speech impairment . His history is positive for
recurred otitis media. Examination is positive for middle ear effusion and cloudy ear
drums. The boy feel well with no restless or fever. Which of the following most
appropriate next step ?

A-prophylactic antibiotics treatment with moxypen(amoxicilin)

B- Intravenous treatment with zinacef ( cefruxime)

C- ear drum puncture and antibiotics treatment according to secretion culture.

D- conductive hearing test

E – ventilation tubes insertion surgery

3) A 7 months old baby presents with 2 days of fever , refuses to eat , and has a
decreased urine output .examination revals decreased consciousness, grey skin ,
decreased capillary fill , temperature 39.8c , pulse 180 bpm , blood pressure 60/40 ,
O2 saturation 95% On room air.

Which of the following is the most appropriate order of actions ?

a. Blood tests , metabolic screening ,lumber puncture , and antibiotic treatment

b. Fluid loading , lumber puncture and head ct .
c. Metabolic screening including lactate and a critical sample and fluid loading .
d. Fundus exam ,fluid loading ,brain imaging antibiotic treatment .
e. Blood test , fluid loading , and antibiotics treatment.
4) A 5 year old boy presents with intermittent periumbilical abdominal pain during
the day , lasting for 30 minutes . physical examination blood count biochemistry and
CRP are all normal .
Which of the following is the recommended approach ?

a- Completing the work up with abdominal CT .

b- Referral to gastroscopy .
c- Observation in the treating clinic.
d- Abdominal x-ray
e- Helicobacter pylori breath test.

5) ( with photo) a bone marrow biopsy of a 2 year old baby with anemia and
hypertension is demonstrated in the photo below. Which combination of signs and
and symptoms may be found in this child ?

a- Right abdominal mass and opsomyoclonus .

b- Right abdominal mass , hematuria and anemia .
c- Weight loss night sweats and hepatosplenomegaly
d- Weight loss and testicular mass .
e- Headaches and morning sickness .

6) 6 years old child with spherocytosis present with 2 days of fever and the findings
presented in the photo

his 10 years old sister had the same symptoms 2 weeks before .

Which of the following complications may appear in this child ?

a) aplastic anemia -
b) hyperbilirubinemia
c) thrombocytosis
d) leukemia
e) lymphoma

7) A 4 year old boy presents with fever up to 39c’ and throat pain for 2 days.
His examination reveals pharyngitis, and the finding in the photo below
 Which of the following is the most common complication of his likely
disease?

A) Toxic shock syndrome

B) Bacterial meningitis
C) Acute encephalitis
D) Para pharyngeal abscess
E) Hemolytic uremic syndrome

8) In which of the following conditions should an 18-months old infant be

referred to developmental evaluation?

A) The infant can’t hop on one foot.

B) The infant can’t copy a circle
C) The infant doesn’t play pretend games
D) The infant can’t say a few words
E) The infant can’t build a 15-cube tower

9) An 8 months old baby, presents with the finding in the attached photo, since birth.
He has been hospitalized 6 times for otitis media and once for pneumonia. He has
had significant hemorrhage following circumcision. Laboratory results are
demonstrated in the table.

Normal value

Hemoglobin gr/dl 12.1 11.5-14

WBC k/mm3 5.5 5-11

PLT (k/mm3) 35 150-500

Mean platelet volume (mpv) f1 5.7 9.4-12.3

IgM Low
IgE High
IgA High
IgG Normal
Which of the following is the best treatment for the baby’s likely disease?

A) Prolonged treatment with oral prednisone (meticorten)

B) Iv Rocephin (ceftriaxone) once weekly
 C) Skin lubrication and topical antibiotics
D) Regular prophylactic treatment with amoxicillin
E) Intravenous immunoglobulins once a month

10)A 2 month -old presents to the emergency room with a generalized seizure. (ECG
is attached). Which of the following blood test would advance the diagnosis?

A. Glucose
B. Sodium
C. TSH
D. Calcium
E. Cortisol

11) 2 month old baby is evaluated for apathy and feeding difficulties , physical
examination reveals tachycardia and a light tremor of the limbs , serum glucose is 35
mg/dl and urine ketones are negative .

Which of the following is the most likely diagnosis ?

a) glycogen storage diseases

b) hyperinsulinemia
c) adrenal insufficiency
d) growth hormone deficiency
e) urea cycle defects

12)A 5 year -old girl is evaluated for inability to walk after 2 days of leg paresthesia.
Examinations reveals gross weakness in both legs and negative deep tendon reflex.
Which of the following will promote the diagnosis?

A. Increasing weakness in the evening

B. 100 mononuclear cells in the CSF
C. Sensory level in neurologic exam
D. Abnormalities in blood pressure and arrhythmias
E. Normal deep tendon reflex in the upper limbs

13) A 2 day old newborn is evaluated for cyanotic events apneas and a high pitched
cry , examination reveals a depressed nose bridge and micropenis laboratory results
are significant for serum glucose of 30 mg /dl and unmeasurable insulin growth
factor 1 which of the following is recommended treatment after initial
stabilization ?
1- oral diazoxide

2- IM glucagon

3- oral mineralocorticoid ( florinef )

4- subcutaneous GH

5- adding cornflower to the feed

14) A 1 day old term newborn has developed hypoxia and shortness of breath ,
pregnancy was significant for polyhydramnios , examination reveals his mouth is full
of large amount of saliva and cow milk based formula he has eaten 30 minutes
earlier . suction has been performed and supplemental oxygen was administrated .
which of the following should be performed immediately ?

1- discontinuing the formula and switching to a non cow milk based formula

2- intubation and mechanical ventilation

3- insertion of a nasogastric tube ,fasting and fluid infusion

4-full sepsis workup and antibiotics treatment

5- echocardiography and chest x-ray

15) Which of the following is true regarding the implication of skin test for cow milk
allergy with significant wheel and flare reaction ?

1- clinically significant milk allergy

2- the patient has milk specific IgE antibodies

3- the patient has t cells sensitized to cow milk protein

4- the patient has milk specific IgG antibodies

5- the patient has milk specific IgA antibodies

16) A 3. Years old girl is evaluated for a right leg limp for the last seven weeks, with
high fever. Physical examination reveals uveitis and the findings demonstrated in the
photo. The knee was tapped and fluids was drained. Laboratory results are attached.
 Test Result Normal value
Hemoglobin(gr/dl) 12 13-15
WBC (K/mm3) 13000 5-11
PLT (K/mm3) 500 150-500
ESR(mm/hr) 25 10-15
Blood smear No blasts seen
ANA Positive
CRP 2 0-0.05
RF negative
Joint fluid :
WBC (mm3)in joint fluid 2500/mm3
Joint fluid culture Negative

A. Steroids + methotrexate
B. Anti tumor necrosis factor α ( infliximab)
C. Anti CD20 (rituximab)
D. Non- steroidal anti inflammatory agents
E. Pulses of systemic steroids.

17) A 7-year-old girl is evaluated for high fever, malaise, difficulty to raise from a
sitting to a standing position, muscle pain and rash, over the last month. Physical
examination includes a thickening of the skin and rash over the chest, knees, elbows
and arms, as well as the findings in the photo. (2 Pictures: one picture of Gottron
papules and one picture of Heliotrope rash)
Which of the following blood tests will promote the likely diagnosis?
 a)C3 and C4 levels

B) Serum dsDNA levels

C) Serum CPK levels

D) Serum ASLO levels

E) Serum IgE levels

18 )A generally well baby was breast fed until 5 months, and thereafter was fed with
cow milk based formula. the baby does not eat much and at 8 months his growth
percentile fell from 30 to the 3th percentile. which of the following is the common
reason for his condition?

1- psycho-social condition

2-cow milk allergy

3-celiac disease

4-pulmonary disease

5-growth hormone deficiency

19) An 11 months old boy presents with 4 days of high fever, rhinorrhea, and
conjunctivitis. on the 5th day he developed rash seen in the photo below (roseola
infantum). which of the following is the recommended treatment?

1-intravenous immunoglobulins

2- passive immunization for the causative agent

3- prophylactic antibiotic treatment with amoxicillin

4- observation and supportive care

5- vitamin D

20) Which of the following is contraindication for breast feeding?

a)an infant with galactosemia

b)a mother with HIV in the 3rd world

c)a mother who is carrier of hepatitis C

d)a mother receiving treatment for active syphilis

e)a mother with mastitis.

21)A 6 months old infant has infantile spasms. The photo bellow demonstrates the
finding on examination (‫ (صورة رجلين ولد مع بقع بيضاء‬.

Which of the following is a common complication in his most likely disease?

A. Melanoma.
B. Autism.
C. Cerebral Palsy.
D. Schizophrenia.
E. Deafness.

22) A 4 years old presents to the ER with fever, apathy, and recurrent vomiting for a
day. Examination reveals temperature of 40 c, pulse of 50 bpm, BP 150/90 and right
lateral rectus

muscle weakness. Which of the following is the most appropriate next step?

A lumbar puncture and antibiotic treatment according to the results

B - obtaining 2 blood cultures and initiate antibiotics

C - funds exam and if normal perform a lumbar puncture and initiate antibiotics

D - brain CT and if normal perform a lumbar puncture and initiate antibiotics

 E - antibiotics , mannitol , and high frequency ventilation

23) Which of the following is an indication BEHAVIOR for physiotherapy ?

A -10 month old baby that can't sit without support

B- a 2 month old baby that doesn't smile

C- a 3 month old baby that doesn't transfer objects between hands

D- a 11 month old baby that can't walk

E-a 11 month old baby that can't stand

24) 5 year old boy present with 5day's of abdominal pain and bloody diarrhea . over
the last day there has been abrupt development of decreased urinary output , pallor
and malaise , laboratory results and blood smear are attached

Ttest Rresults Nnormal value

Sserum urea 44.0mg/DL 111-38mg/dl
Sserum creatine 11.0 00.2-0.7
Hhemoglbin 66.9gr% 112-13.5gr%
Rreticulocytes% 55% 11-2%
Tthrombocytes 990,000 1510-450,000
Uurinalysis Bblood+++ (--
Picture blood smear

How is the diagnosis most likely disease made ?

A-identifying the causative agent in urine culture

B- identifying E.coli 0157.h7 in the stool

c- renal biopsy

d- clinical symptoms and laboratory results

E- positive coombs test

25) – A 13 years old boy present with a week back pain .

Which of the following warrants immediate work up ?

A-increasing weight percentiles in the last year

B-the back pain improves with rest

c-the back pain wakes him up at night

D-bilateral negative Babinski sign

E-bilateral negative leg lifting test

26)A-3-months-old baby presents to the emergency room with restlessness.

Examination reveals O2"oxygen" saturation of 98% in room air, pulse 230, and 36
breaths per minute, attached are chest x-ray and the ECG.
Which of the following is the most appropriate initial treatment?

A – IV calcium channel blocker.

B – vagal maneuver + IV adenosine if needed.

C – oral or IV systemic steroids.

D – inhalation of Ventolin(salbutamol) + bandicoot(budesonide).

E – IV fusid(furosemide) + PO deralin(propranolol

27) Results of a complete blood count of a 7-week-old baby are demonstrate in the
table below.

Test Result Normal value

Hemogloin 9.3 gr% %gr13.5-12
MCV 90 95-80
RDW %13.7 %16.5-11.5
PLT 280,000 150-450,000
WBC 9000 6000-15,000
Which of the following may be additionally present in this condition?

A – suppression of erythropoietin
B – iron deficiency.

C – hemolytic anemia.

D – transient erythroblastopenia of childhood

E – parvo virus B19 infection.

28) ) A 4 day old newborn with fever has a lumbar puncture , gram strain of CSF
reveals cocci ( photo of small blue dots in a chain like shape with pink agar the cocci
stained blue )which of the following is considered a risk factor for this disea

1)premature rupture of membrane

2) breech delivery

3)vesicular lesions on the cervix during delivery

4)gestational age above 42 weeks and fetal distress during delivery

5)maternal age over 40 year old during the delivery

29) A 15 year old girl presents with loss of 30 kg over the last 6 months and
secondary amenorrhea , the girl is an outstanding student involved in sports and
reports that she is afraid of gaining weight and has no appetite her BMI is less than 3
rd percentile and her pulse is 50 bpm regular , which of the following results is
typical for her condition

1)hypercalcemia

2)hypercholesterolemia

3)hyperkalemia + metabolic acidosis

4)hypomagnesaemia

5) hypoalbuminemia
 30) An 8 months old baby present with fever and drooling and examination reveals
the finding in the (photo) which of the following is recommended treatment ?

A) oral acyclovir (zovirax)

B) oral milrinone

C) topical miconazole (daktarin gel)

d) iv immunoglobulins

E) analgesic agents and a lot of drinking

31) A 3 weeks old baby is evaluated for projectile vomiting after every breastfeeding
over the last couple of days . He is restless, and without fever .
Which of the following is typical on this baby's blood test ?
A- Hyperbilirubinemia with elevated direct bilirubin component
B- Hyperchloremic metabolic acidosis
C- leukocytosis with eosinophilia
D- Hypochloremic metabolic alkalosis
E- leukocytosis with lymphocytosis

32) A 1- year girl presents with 2 days of high fever . A culture from a urine collection
bag grew > 100,000 /ml Gram negative bacteria after 24 hours . The infant still has
fever
.
Which of the following is the recommended approach ?
A- Oral trimethoprime - Sulfamethoxazole (resprime)
B- Admission and intravenous gentamycin
C- Urine serum and if normal repeat urine culture
D-Culture from a urine catheter
F- Repeat urine collection bag culture after cleaning of the perineum

33) A 15 year-old girl evaluated for malaise and fatigue over the last few weeks .
Examination reveals the temperature of 36,6c , blood pressure 80/40 (normal values
100-120//70-80), pulse 112bpm (normal values 60-100) .
Laboratory results are presented in the table , with the findings on the photos
below :
Test Result Normal values
Hemoglobin 12.2 gr% 12-15 gr%
Serum sodium 125 mmol/L 136-145 mmol/L
 Serum potassium 5.9 mmol/L 3.4-4.7 mmol/L
Which of the following is the recommended treatment ?
A- oral- L-thyroxin once daily
B- 2 doses of intravenous iron
C- IV saline-glucose 5% + KCL 4 mq/L
D- IV saline-glucose 5% Hydrocortisone
E- oral prednisone + L-thyrox

34) A 2.5-year-old presents with 3 days of fever and rash, and restlessness over the
last day. Examination reveals fever of 38.1 C, pulse 170 bpm blood pressure 60/30,
O2 saturation 97% in room air. There is a mild skin rash, regular, rapid heart sounds
and 2/6 systolic murmur, chest x ray is normal and the ECG is attached. Which of the
following is the most common cause of this condition?

A- Enterovirus
B- HIV
C- Streptococcus group A
D- Rickettsia
E- Varicella Zoster

35) A 13 year-old girl presents to the emergency room 2 hour after ingesting an
unknown number of acetaminophen pills. Her blood pressure, pulse, and physical
examination are normal. Blood glucose and liver function test are normal, and
acetaminophen levels are 50 mcg/ml. Which of the following represent the most
appropriate approach?

A- Gastric lavage and glucose infusion

B- Recheck acetaminophen levels after 2 hours
C- Intravenous N-acetylcysteine
D- Single dose of activated charcoal and glucose infusion
E- Repeat glucose and liver function test within 2 hours

36) A 7 month old healthy infant present after a self -resolving general seizure lasting
10 minutes . the infant was awake after the episode , his temperature was 40 c and
he had a normal neurological examination . there were no further episodes . which
of the following is true regarding the infant neurologic prognosis ?
a. he has a higher risk of epilepsy than the general population

b. the risk of recurrence is identical to a 2 year old with the same symptom

c. if the episode recurred it will be similar to the current episode

d. his neurologic and cognitive development are expected to be normal for his age

e. the risk of future epilepsy is dependent on the number of recurrences

37) A 6 years old boy present with microscopic hematuria.

2 weeks earlier he had a self resolving throat pain, and cultures were not obtained.
Examination reveals blood pressure 135/90 (normal values 100-120/70-80)
Laboratory results include:

Test                                  Result                     normal

Serum urea                         50                        20-40
Serum creatinine                0.9                      0.4-0.7
Serum antistreptolysin       790 units/L           <300
Which of the following is true regarding diagnosis of this disease?
A- a positive group A streptococcal throat swab is necessary for diagnosis
B- C3 and C4 is expected to be above the normal value 
C- high probability for existence of red blood cells casts in urinalysis 
D- renal biopsy is warranted early in the Course of the disease
E- an Echocardiogram should be performed to evaluate the structure and function of
the valves.

38) A 1-yer-old presents with restlessness, a large vomit, and thereafter intermittent
apathy and restlessness with gradual worsening over the last few hours in the
emergency room. After performing a rectal exam the finding in the photo below is
seen.(Picture of bloody stool in a diaper)
Which of the following is the recommended definitive therapy?

A)Fluid infusion
B)Air enema
C) antibiotic treatment
D)appendectomy
E) Intravenous steroids

39) A 5 year old boy present with a day of groin and right hip pain a week after a viral
upper respiratory disease. Examination reveals a limp and external rotation of the
right hip. Laboratory results include a normal blood count, ESR and CRP. Sonogram
demonstrate an small amount of cleat fluid in the right hip joint. Which if the
following is the recommended treatment?

A.Oral NSAIDs and avoiding strains

B. Drainage of the joint and antibiotics treatment

C..Intraarticular steroids

D.Prednisone( meticorten)

E. Systemic anti- TNF alpha

40) A-6-year boy is evaluated for

developmental delay. His history is
positive for significant hypotony,
feeding difficulties and failure to
thrive during the first month, At 3
 years of age he developed increased appetite and overweight. His physical
examination findings are demonstrated in the photo below. Also he has small
feet and micropenis.

What is this boy’s most likely genetic problem ?

A. Trisomy
B. Expansion of trinucleotides
C. Imprinting impairment
D. Point mutation
E. Multifactorial inheritance

41)A 6-months old baby is evaluated for developmental delay and constipation. Her
examination is significant for hypotony, and the findings in the photo below.

Laboratory results are attached :

Test        Result              Normal values

TSH        1 MIU/L           0.5-4.2 MIU/L

FT4        4 picomol/L      10-20 picimol/L

Which of the following is the most likely diagnosis ? 

1- Primary hypothyroidism.

2- Thyroid dysgenesis

3- Thyroid binding globulin deficiency.

4- Dyshormonogenesis.

5- Pan hypopituitarism

 
42) A 6 hour newborn delivered via CS , is examined due to tachypnea (70 breaths
per minute) O2 saturation is 89% in room air, examination is significant for grunting
intercostal retractions , with normal breath sounds with no wheezing or crackles ,
chest Xray reveals accentuated perihilar marks and fluid in the interlobar fissures .
which of the following is the recommended approach?

A-positive pressure ventilation

B-intrathecal surfactant

C-echocardiography and NSAIDS treatment

D-supplemental oxygen

E-sepsis workup and antibiotics

43) 16 year old girl complains of severe back pain radiating to the right leg over the
last months.examintion (photo)
Which of the following should be next step ?

1)spiral CT

2)symptomatic and treatment and encouraging spots

3) physiotherapy

4)fitting a back -belt

5) spinal MRI

44) A 9 year old boy is evaluated because he cant sit quietly or at dinner,

Teachers report he gets up and walks around in class talks all the time , jumps from
subject to subject , can't wait his turn, and bursts in when others talk/
Which of the following is recommended approach to his condition ?

A-COMBINATION OF BEHAVIORAL AND ANTI DEPRESSIVE

B-COMBINATION OF BEHAVIORAL THERAPY IN THERAPUTIC HORSE BACK RIDING

AND EMOTIONAL THERAPY

C-COMBINATION OF BEHAVIORAL AND PSYCHOTIC THERAPY

D-COMBINATION OF BEHAVIORAL AND STIMULANT THERAPY

E-FOLLOW UP AND OBSERVATION THIS IS NORMAL FOR HIS AGE

45) A 3-year-old boy presents with the findings on the photo below. The rash doesn't
disappear when pressing on it. Complete blood count reveals 18,000 platelets
(normal values 150-450,000) and normal hemoglobin and white blood count. Which
of the following is true regarding his most likely disease?

A)IVIG treatment significantly shortens the disease course

B) The risk of a cerebral hemorrhage is high and therefore treatment with IVIG is
warranted

c) The initial recommended treatment is platelets infusion

D)No evidence that medical treatment prevents severe hemorrhage

E)The definitive treatment in most cases is spleenectomy

46) A 17.5-year-old, generally healthy boy, has +2 urinary protein on several tests.
Examination reveals normal pulse and blood pressure, BMI at 90th percentile, and
normal exam. Complete blood count, renal function, and serum albumin are within
normal limits. Which of the following is the next diagnostic test?
A)Protein/creatinine ratio in first morning urine

B)Renal sonogram

C) Osmolarity of first morning urine

D)Referral to a pediatric nephrologist

E)Serum lipid profile

47) A 16-year-old boy has BMI above the 99th percentile. Laboratory results are
demonstrated below:

Test Result Normal values

HBA1C 6.4% <5.7%
Fasting serum glucose 99 mg / dl <100 mg /dl
serum glucose 2 hours 178 mg / dl <140 mg / dl
after OGTT( Oral Glucose
Tolerance Test)
Which of the following is the most likely diagnosis?

A) Impaired fasting glucose (IFG)

B)Diabetes mellitus type 2

C)Mature onset diabetes of the young (MODY)

D) Impaired glucose tolerance (IGT)

E) Combined IFG+IGT

48) A 2-year-old boy presents with a first episode of the findings in the photo below.
History is positive for recurrent vesicular rash above the lip, the recent one a week
ago. Which of the following is true regarding the likely causative agent and
treatment?

A)Usually the findings in the above photo appear in the first episode of infection
B) The causative agent's RNA is identifiable in pharyngeal secretions during the acute
disease

C)The rash usually appears during a symptomatic infection

D)Prophylactic treatment may be efficient in reducing symptom recurrence

E) Systemic treatment usually shortens the course of the disease

49) An 8-year-old boy, who has fallen off his bicycle complains of intense abdominal
and rib pain. Physical examination in the emergency room reveal full consciousness,
blood pressure of 100/70, pulse 120 bpm, tender abdomen, and the finding in the
attached photo. Isotonic fluid therapy was initiated, at maintenance volume. 30
minutes later blood pressure is 80/50 and the pulse is 160 bpm. Chest x-ray is
normal. Which of the following is the most appropriate next step?

A)Emergent explorative laparotomy

B) High dose dopamine drip

C)Abdomen and pelvic CT

D)Head and neck CT

50)At which of the following ages, does the grasp presented in the photo appear?

3-5 months

6-7 months

8-10 months

14-15 months

16-18 months

Surgery

1)A 38 - year - old healthy female , 24 weeks pregnant , presents with 1.5 cm left
breast mass . On biopsy - invasive breast cancer , ERIPR negative , HER2 Neu
positive . Which of the following is correct in this case ?
 Breast cancer during pregnancy require mastectomy as the
procedure of choice

There is an indication for wide local excision with axillary lymph

node dissection ( ALND ) and one should not perform sentinel
lymph node biopsy

Mastectomy is preferred over breast conserving surgery if the

cancer is high grade or with vascular invasion

In young females the muscle under the tumor needs to be

removed because of the risk for local recurrence

There is no survival benefit for mastectomy over breast conserving

surgery in females at any age

2) what is the reason that sliding hernia repair may be difficult?

1- It includes abdominal organs

2- It reaches the femoral vessels and often adherent to them
3- Part of the wall of hernia sac involves the colonic peritoneum or urinary
bladder
4- There is a tissue gap of the transversalis fascia in the inguinal canal
5- Repair of such hernias must be done laparoscopically and not via open
approach

3) A 37 years old female is interested in bariatic surgery

Which of the following describes current indications for bariatic surgery ?

BMI less than 30

BMI less than 40 without comorbidities

BMI more than 40 or BMI more than 35 with comorbidities

BMI more than 40 with comorbidities

BMI more than 50 with comorbidities

4)A 22 year old male complains of bright red blood per rectum, itching sensation,
and prolapsing tissue during effort to pass bowel movements. The tissue
spontaneously pulls back into the rectum when he stands up.
 What is the most likely diagnosis ?

Hemorroids grade 2

Thrombosed haemorrhoids

Rectal prolapse

Perianal abscess

Chronic rectal fistula

5) which of the following pathogens causes cholangitis mostly?

1)candida albicans

2) strep viridian

3) klebsiella

4) Acinetobacter

5) clostridium difficile

6) A 71 years old healthy male with no prior abdominal surgeries, presents to the ER
with abdominal distention, abdominal pain, vomiting and lack of bowel movements
for 3 days. On examination- soft distended abdomen, diffuse tenderness, without
peritonitis. Abdominal CT demonstrates dilated loops of small bowel until the
terminal ileum. where the around lesions is identified in the bowel lumen .The bowel
distant to the lesion is collapsed, pneumobilia is another finding. What is the most
likely diagnosis?
1) mesenteric event

2) gallstone ileus

3) closed loop obstruction

4) small bowel intussusceptions

5) sigmoid volvulus

7) a 47 years old male presents to the ER with several weeks of upper abdominal
pain and early satiety. No fever or weight loss, epigastric fullness on examination.
Ultrasound and CT scans demonstrate a left liver lobe 7 cm mass with several cysts
inside and peripheral calcification. What is the most likely diagnosis?

1) pyogenic abscess

2) hydatid cyst

3) amebic abscess

4)liver adenoma

5)simple cyst

8) Which of the following most accurately describes Spigelian hernia

Recurrent hernia in previous incision.

Hernia at the posterior aspect of the left diaphragm.

Hernia lateral to the rectus muscle at the arcuate line.

Internal hernia lateral to the duodenum.

Hernia at the obturator foramen.

9 ) A14 year old female is a candidate for resection of fibroadenoma of right breast

Which of the following prophylactic antibiotic regmens is indicated?

A)Augmentin

B) zinnat
C)ceforal

D) no need for prophylactic treatment

E) Dalacin C

10) A 60 year old female is diagnosed with 1,5 cm invasive carcinoma of the right
breast ER-positive, PR- positive, HER2- negative, breast ultrasound demonstrates the
tumor without evidence of axillary metastasis.

What is the recommended procedure?

A-mastectomy and sentinel lymph node biopsy

B- modified radical mastectomy

C-lumpectomy and sentinel lymph node biopsy

D-lumpectomy and axillary lymph node dissection

E-lumpectomy and intra operative radiation

11) A 60 year old male is admitted due to multiple vomiting for a week, plain
abdominal X-ray demonstrates very large stomach and nasogastric tube drains 2000
ml of gastric content without bile.

Which of the following is the most likely to be found on blood tests?

A-hyperkalemia, hypernatremia, metabolic alkalosis

B-hypokalemia, hypochloremia, metabolic alkalosis

C-hyperkalemia, hyperchloremia, metabolic acidosis

D-hypokalemia, hypochloremia, normal acid base balance

E-hypercalcemia, hypernatremia, metabolic acidosis

12) A 30 year-old male is brought to the trauma unit following a severe motor
vehicle accident. He looks scared and complains of pain all over the body. Vital signs
– blood pressure 87/75, pulse 126, 32 breaths/min.

What is this patient’s shock stage?

1- He is not in shock
2- Stage 1
 3- Stage 2
4- Stage 3
5- Stage 4

13) A 50 year old male is brought to the trauma unit following a severe motor vehicle
accident. he looks restless and complains of pain all over the body. vital signs blood
pressure 80/60, pulse 130, 32 breaths/min. all of the following may be the source of
his hemorrhagic shock except ?
a. chest
b. abdomen
c. pelvic fracture
d. long bones fracture
e. wrist fracture

14) A 60 year old female has ischemic heart disease, morbid obesity, hypertension
and diabetes. she is treated with glucomin, long acting insulin, fusid, aspirin and beta
blockers. candidate for major abdominal surgery during the next hours. which of the
following must be continued during the pre-operative period ?
a. glucomin
b. aspirin
c. fusid
d. beta blockers
e. long acting insulin

15) A seventy years old male arrives to the emergency room with acute large bowel
obstruction due to left colon cancer. Vital signs - BP is 85/50 and pulse is 130.

The preferred treatment is:

A. Loop ileostomy.
B. Loop colostomy.
C. Left colectomy.
D. Subtotal colectomy with primary anastomosis.
E. Total abdominal colectomy.

16 )Which of the following is the most significant risk factor for developing delirium?

A. Pain.
B. Fever.
C. Length of surgery.
D. Dementia.
E. Narcotics use.
17) A 42 - year - old female is diagnosed with squamous ulcer of the nipple on
physical examinatio Excisional biopsy is suggested to rule out Paget's disease . What
will be the appropriate treatment if Paget's disease is diagnosed ?

Evaluation of the skull since Paget's disease often involves the skull bones

The involved part of the nipple can be resected without resecting the breast tissue
that is not involved

Axillary evaluation is not indicated in cases of Paget's disease since it is always DCIS
without metastases

Breast imaging is usually negative in Paget's disease and therefore breast conserving
surgery includung nipple resection with ipsilateral axillary evaluation is a valid option

There is no role for radiation therapy in Paget's disease as it was proven to be

ineffective

18) A 30 year old male who is treated for lymphoma, is brought to the trauma unit
following a severe motor vehicle accident. He complains of pain all over the body.
Vital sings- blood pressure 87/75, pulse 126, 32 breaths/ min. Imaging demonstrates
fractures of the pelvis and right femur. All of the following are risk factors for DVT
except.

A) Young age
B) Severe trauma
C) Previous episode of DVT
D) Malignancy
E) Protein C deficiency

19) A 70 year old male is referred for evaluation due to epigastric discomfort, early
satiety, and weight loss over the past several months. Gastric cancer is suspected.
Which of the following is correct?

A) One must perform complete physical examination with special attention to

signs for advanced disease at the umbilicus, above the clavicle, and rectal
examination
B) In all cases of gastric cancer, the treatment is gastrectomy with wide
surgical margins.
C) Gastric cancers are not very aggressive with survival rates more than 5
years in most patients.
D) Gastric cancers respond to chemotherapy only.
 E) Most of gastric tumors are secondary to other malignant primaries.

20) a 30 years old healthy male present to ER with obstructive jaundice , on

admission no apparent distress , but significant skin and scleral icterus , no history
for weight loss , pain or fever . Labs - normal WBC , and CRP , elevated cholestatic
liver enzymes and bilirubin of 5 mostly direct . Abdominal ultrasound demonstrates
cholelithiasis without evidence of cholecystitis or bile duct dilatation . What is the
next step in management ?

A. Cholecystectomy

B. Ursoilt

C. Abdominal CT

D. Percutaneous transhepatic cholangiography (PTU)

E. ERCP

21) which of the following is correct with regards to inguinal hernia development ?

A. There is no association between increase in age and inguinal hernia development .

B. Direct inguinal hernia is most common hernia in women .

C. Inguinal hernia represent 75% of all hernias .

D. Direct inguinal hernia is more common than indirect inguinal hernia .

E. Acute incarceration is the most common presentation of inguinal hernia

22) : A 71 years old healthy male with no prior abdominal surgeries present
to the ER with abdominal distention, abdominal pain, vomiting, and lack of
bowel movement for 3 days. On examination- soft distended abdomen,
diffuse tenderness, without peritonitis. Abdominal CT demonstrates dilated
loops of small bowel until the terminal ileum where a round lesion is
identified in the bowel lumen. The bowel distant to this lesion is collapsed.
Pneumobilia is another finding . What is the most appropriate treatment?
A. MRCP
B. exploration and enterotomy

C. laparoscopic cholecystectomy
 D. laparoscopic cholecystectomy + CBDE.

E. percutaneous drainage of gallbladder

23) A 72 years old male is a. week after fractured hip. He now complains of
abdominal distention and no bowel movement. On examination- distended and
tympanic abdomen, without peritonitis. Abdominal X-ray demonstrates large bowel
dilatation throughout and the cecum diameter is 9.5 cm. No tumor is identified on
gastrografin enema.

What is the next step in management?

A. Total abdominal colectomy

B. Rectosigmoid resection and colostomy
C. Stoma only
D. Colonoscopy and stent insertion
E. IV neostigmine

24) A 58-year-old female complains of abdominal pain , multiple episodes of

diarrhea , repeat episodes of face and neck flushing that resolve spontaneously ,
and repeat asthma attacks . on examination – hepatomegaly and heart murmur .
which of the following blood tests is necessary for diagnosis?

A) Chromogranin A
B) Serotonin ????
C) Neurokinin A
D) Neuropeptide K
E) CEA(carcinoembrionic antigen)

25) a 60 year old male is being evaluated for significant abdominal distension
without tenderness past medical history significant for hypertension that is treated
medically, ischemic heart disease status-post coronary cauterization with stent
insertion and severe heart failure severe peripheral vascular disease status post
multiple surgeries hepatitis b carrier and partially balanced diabetes ultrasound
demonstrates large amount of abdominal free fluid which of the following is the
most likely to explain the abdominal free fluid ?

A) complication of the hypertension medication

B) severe hypoglycemia and failed attempt to treat with combined insulin and
Glucophage
C) severe right heart failure

D) status post multiple attempt to bypass of peripheral arterial obstruction

E) carrier of hepatitis B due to blood transfusion during surgeries

26) A usually healthy 53- year old male that weights 90Kg undergoes uneventful right
colectomy due to cecal tumor . On morning round on Post operative day ! he is stable and
without stress , the abdomen is not distended with appropriate tenderness . Urine output is
normal .
In the assumption that he will not drink during thr day – what is the crystalloid maintenance
that should be given in the next 24 hours ?
A) 80 cc/h
B) 100 cc/h
C) 130 cc/h
D) 145 cc/h
E) 160 cc/h

27) Which of the following is correct regarding primary hyperparathyroidism (PHPTH) and
secondary hyperparathyroidism (SHPTH)?
PHPTH is caused by dysfunction of the gland itself while SHPTH is caused by excessive PTH
secretion caused by hypocalcemia
PHPTH is caused by decreased levels of vitamin D and chronic renal failure while SHPTH is
caused by four gland hyperplasia resulting from hypocalcemia
The treatment is similar in both PHPTH and SHPTH
PHPTH is less common than SHPTH
PHTPH usually involves 2-3 glands while SHPTH involves a single gland

28) What is most likely the diagnosis?

External hemorrhoids
Rectal prolapses
perianal abscess
rectal cancer
giant rectal polyp
29) Which of the following is correct regarding diastasis recti ?
It is a congenital abdominal wall defect that presents following multiple pregnancies or
morbid obesity
The main indication for surgery is to avoid acute organ incarceration or strangulation
It is not defined as a typical hernia as there is no defect in the transversalis fascia
It is an acquired defect and its presence by itself is an indication for surgery
It is typical in multipara women and presents in mid - lower abdomen

30)A 35 year old male present with nausea vomiting and abdominal distension for
the past 12 hours this is his first episode on examination – tender swelling in the
right groin that cannot be reduced he is healthy with no comorbidities what is the
most appropriate next step?

A)urgent surgery

B)IV fluid and observation

C)plain abdominal Xray followed by abdominal CT

D)ultrasound of the groin mass

E)attempt for drainage under local anesthesia

31) which of the following is characteristic of familial adenomatous polyposis

A-hamartomas polyps

B-lipomas

C-desmoid tumors

D-multiple hemangioma of the large bowel

E- intestinal malrotation

32) Which of the following is true regarding thyroid carcinoma?

 A. Usually bad prognosis.
B. Neck radiation during childhood is the most significant risk factor.
C. Cytological diagnosis(FNA) is not sufficient.
D. In most cases the diagnosis is based on thyroid scan.
E. In most cases the tumor is unifocal.

33) a 70 year old male with abdominal pain and distention , gastrografin enema
demonstrate a “ bird peak “ , what is the an acceptable final treatment after treat of
this acute presentation ?

A)Fiber diet

B)Neostigmine

c)SigmoidECTOMY

D) Subtotal colectomy

E)Total colectomy + IPAA

34) In which of the following patient prophylactic treatment for venous

thromboembolism prevention is indicated :-

a. A 20 year old healthy male, umbilical hernia repair candidate

b. A 35 YEAR OLD healthy male ,hemorrhoidectomy candidate
c. A 20 year old female caesarean section candidate
d. A 35 year old male , resection of rectum candidate due to malignancy
e. A 60 year old male , laparoscopic cholecystectomy candidate

35) A 68 - year - old male is admitted due to epigastric pain , weight loss , and
decreased appetite . Comorbidities include controlled hypertension and pre -
diabetes . Abdominal CT is suspicious for a 12 cm exophytic space occupying lesion
( SOL ) at the stomach . biopsy is positive for CD gastrointestinal stromal tumor ( GIST
) with more than 5 mitoses per high power field ( HPF ) . What will the treatment of
this patient include ?

Surgery alone

Chemotherapy alone

Gleevec and surgery

Radiotherapy alone

Surgery and radiotherapy

36) An 82 years – old male with hypertension and mild arthritis is treated with
aspirin and cardiloc , he is independent and aware and is a candidate for right
hemicolectomy and single liver metastasis resection due to carcinoma . all of the
following risk factor predict high surgical mortality in this patient except

A- age above 80

b- hypertension

c-arthritis

d- complex abdominal surgery

e- use of blood thinners

37) 50 years old male alcoholic suggested for urgent surgery due to perforated ulcer
which Of the following is recommended during the pre-operation part ?
A-glipressin
B-avilac
C-Thiamine
D-STEROIDS
E.SANDSTATINE

38) A 68 - year - old male is admitted due to epigastric pain, weight loss, and
decreased appetite. Comorbidities include controlled hypertension and pre -
diabetes. Abdominal CT is suspicious for a space occupying lesion (SOL) at the
stomach. Which of the following is the most diagnostic test?

Complete blood count

Full chemistry, including pancreatic enzymes

Gastroscopy

Colonoscopy

Barium swallow

39)An 80-year-old female with hypertension and diabetes arrives to the ER due to
two days of rectal bleeding On examination-normal blood pressure and respiratory
rate, soft abdomen, cherry red stool on rectal examination Repeat labs-hemoglobin
dropped from 12 to 10 mg/dl. Nasogastric tube-bile content.
She is admitted for colonoscopy and after 24 hours the bleeding stopped.

Which is the most probable etiology for this woman's rectal bleeding?

A. Hemorrhoids

B. AVM

C. Inflammatory bowel disease

D. Colon cancer

E. Diverticulosis

40)A 75 year old male arrives to ER complaining of abdominal pain, swelling and pain
in the right groin, nausea and vomiting. He was diagnosed several years ago with
non-reducible right inguinal hernia post medical history- medically treated
hypertension, ischemic heart disease status post coronary catherization with stents
insertion, congestive heart failure , status post endoscopic aortic aneurism repair,
and partially controlled diabetes. His vital signs- blood pressure 145/95, pulse 92,
temperature 37.8 c’. Labs-glucose 290 mg/dl.

How should this patient be prepared with the diagnosis of incarcerated

inguinal hernia?

A) Hemodynamic and respiratory stabilization, control diabetes, admit for

observation, initial conservative management.
B) Hemodynamic and cardiac stabilization, urgent surgery.
 C) Hemodynamic and respiratory stabilization, control diabetes, plain
abdomen x-ray/ contrast CT- consider surgery if bowel obstruction or
deterioration on sequel imaging is demonstrated.
D) Control diabetes and heart issues, drain abscess and broad spectrum
antibiotics, surgery if no improvement.
E) Urgent surgery without any delay or preoperative preparation.

41) A2 cm sessile polyp is found in the cecum during routine colonoscopy in a 65-
year-old male.The polyp is completely excised and pathology reveals poorly
differentiated adenocarcinoma with submucosal invasion. Chest and abdomen CT-no
distant metastases What is the next step in management?

A. Genetic work-up

B. Formal right hemicolectomy

C. Ceacal resection

D. Repeat colonoscopy in two months

E. Chemotherapy

42) A 35 year old male with Crohn's disease is now on remission without any
treatment. 18 months ago he has been admitted once for disease exacerbation and
was treated with 5 mg prednisone and antibiotics for 1 week. The patient is now a
candidate for finger nail removal under local anesthesia.

What is the recommended treatment to avoid adrenal insufficiency ?

1) ACTH at the acceptable dose for 3 days
2) 50 mg hydrocortisone prior to surgery
3) 100 mg hydrocortisone prior to surgery
4) 150 mg hydrocortisone prior to surgery
5) No need or any special therapy
43) A 48 year old female undergoes abdominal CT following minor trauma , in a
motor vehicle accident in the liver the is an 4 cm incidental finding with peripheral
nodular enhancement , centripteall fill it . CBC , coagulation panel and tumor
markers are all normal WHAT is the next step in treatment: ?

1- percutaneous biopsy

2- resection of the finding

3-follow up

4-radiofrequency ablation

5-colonoscopy to identify the primary tumor

44) 55 years old female is diagnosed with 4 cm breast mass & ipsilateral axillary
suspicious mass. Breast & axillary biopsies are suspicious for triple negative breast
cancer, evaluation for distant metastasis is negative, neo adjuvant chemotherapy is
advised
which of the following is correct with regard to this treatment?

1) breast conserving surgery may be achieved with avoidance of

mastectomy
2) sentinel lymph node biopsy is not sufficient and axillary
lymph node dissection is indicated even if there is clinical and
radiological complete response of axilla
3) such treatment increase survival in this patient
4) anti hormonal treatment such tamoxifen has been proved
to be effective in this case
5) surgery without the need for any kind of chemotherapy can
be first line treatment if oncotype diagnosis test will show low
risk of recurrence .

45) A 45-year old female is complaining of dysphagia and a feeling that food does
not pass ,5Kg weight loss. Achalasia is suspected

Which of the following will support the diagnosis?

A. Severe chest pain and a shape of "corkscrew esophagus on barium swallow

B. Food regurgitation, malodor, barium swallow demonstrating diverticulum at the

hypopharynx
C. Burning chest sensation especially during supine position and gastroscopy

demonstrating esophagitis

D. No relaxation of the lower esophageal sphincter (LES) on manometry and

esophageal dilatation without adequate peristalsis

E. Chronic gastric diaphragmatic hernia

46) A 75 year-old female with atrial fibrillation is treated with Coumadin

She in a candidate for lumpectomy and sentinel lymph node biopsy due to breast
cancer

What are the guidelines for anticoagulation therapy prior to surgery

A. Discontinue coumadin for 5 days prior to surgery, no other treatmert needed

B. Discontinue coumadin for 5 days prior to surgery and cover wth ciexane (LMNH)

C. Discontinue coumadin for 5 days prior to surgery and cover with asprn

D. Continue coumadin

E. Switch to aspirin alone a weak before surgery

47) A 42-year-old female with ulcerative colitis is admitted with a fever 39C,
abdomınal pain, tachycardia, elevated WBCs, and bloody stool Xray- distended colon
throughout What is the recommended treatment at this point?

A. Total proctocolectorny with ileal pouch anal anastomosis

B. Total abdominal colectomy with end ileostomy

C. Total proctocolectomy with end ileostomy

D. Total abdominal colectomy with ileorectal anastomosis

E. Loop ileostomy

48) A 60-year-old female undergoes routine mammography that demonstrates one

duster of suspicious calcifications in the right breast DCIS is diagnosed.
When will breast mastectomy be preferred over breast conserving surgery?

A. In cases when suspicious calcifications for malignancy are present in the entire
breast

B. In cases of DCIS mastectomy is preferred over breast conserving surgery

due to the high local recurrence rate

C. Mastectomy is preferred over breast conserving surgery due to increased survival

rates

D. Radiation was not found to be highly effective in DCIS and therefore mastectomy
is prefer

E. In patients younger than the age of 40 years

49) All of the following are true regarding laparoscopic inguinal hernia repair, except.

A. Laparoscopic repair is preferred in patients with bilateral inguinal hernias

B. Laparoscopic repair is recommended for patients with recurrent inguinal hernias

C. General anesthesia is required for laparoscopic repair

D. Laparoscopic repair is especially suitable for physically active patients with small
hernias

E. The anatomic view is identical in both open and laparoscopic inguinal hernia
repairs

50) Which of the following is correct regarding the treatment for gastroesophageal
reflux disease ?

A- A combination of antacid medications and change in life style is sufficient in

most patients
 B- Prolonged PPI is not effective in most patients and anti-reflux surgery is
required
C- - there is no role for antacid medication as reflux is caused by mechanical
dysfunction in the lower esophageal sphincter (LES)
D- Older patients will more commonly develop reflux is caused by mechanical
cancer and therefore there is a need for surgery
E- Surgery for reflux is simple and without complications

Gynecology

1) 25 years old women present to the emergency room with significant abdominal
pain and distention two days post oocyte retrieval .examination reveals a distended
abdomen and moderate pelvic fluid .she has decreased urinary output and mild
dyspnea which of the following is the most likely diagnosis?

A. Ovarian torsion
B. Ovarian bleed following retrieval
C. Ovarian hyperstimulation (OHSS)
D. Pelvic inflammatory disease
E. Ectopic pregnancy
2) A 33 year old primapara ,17 week pregnant ,presents to the emergency room with
abdominal pain ,abdominal sonography results raise a high suspicion of acute
appendicitis .

which of the following next step mangement of this patient ?

A)abdominal pelvic CT ,

B)abdominal and pelvic MRI ,

C) admission for observation ' and surgery if she deteriorates ,

D)admission for intravenous antiobiotic treatment ,

E)surgery as soon as possible

3) A 37-years-old obese woman on the 25 th week of her 6th pregnancy presents to

the emergency room with shortness of breath since the morning. Examination at the
ER reveals a pulse of 128 bpm, 28 breathes per minute, and saturation of 93%,
examination of the limbs was normal. Which of the following tests is the most
sensitive for verifying this patient’s diagnosis?

A. V/Q scan
B. D-dimer
C. Doppler of the lower extremities
D. Spiral CT
E. ECG

4) which of the following describes the karyotype in the picture? Pic : karyotype
image
1) xy, +15, 45

2)XY, +15, 47

3) YY, +t15:2, 46

4)XY, 46

5) XY, +15p, 47

5) A 27 year old single childless healthy woman presents with dysmenorrhea and
dyspareunia. Sonography demonstrate an ovarian turbid cyst , with a diameter of 6
cm. Which of the following treatment is the most appropriate for this patient ?
 A) Two-week treatment with an estrogen agent during the follicular phase
B) Monthly GNRH shots
C) Copper IUD
D) Laparoscopic oophorectomy)
E) Continues combined oral contraceptives

6) A 42 year old woman , married and mother of five , 6 months post a normal
delivery , present to the emergency room with seizure , head CT raises a suspicion of
brain metastases.

Which of the following tests will contribute the most to finding the primary tumor ?

A) Brain MRI
B) Liver and renal function test
C) Beta- HCG
D) Gastroscopy
E) EEG

7) 25 years old woman menstruates once in 90 days ,the bleeding lasts 3-4 days and
is accompanied by pain ,which of the following is the most appropriate way to
describe the condition?

A)hypoamenorrhea

B)metrorrhagia

C)polymenorrhea

D)amenorrhea

e)oligomenorrhea

8) which of the following describes the expected number of chromosomes in a

partial hydatidiform mole?

a)diploid

b)haploid

c)trisomy

d)triploid

e)monosomy
9) You have been called to the maternity ward due to excessive bleeding of a woman
2 hours after twin delivery.

Which of the following is the most common etiology of this condition:

A. Remnant placenta.
B. Vaginal tears.
C. Uterine atony.
D. Coagulopathy.
E. Uterine tear.

10 )A 39 years old woman after IVF treatments presents to the clinic at week
8 of her pregnancy to verify a normal pregnancy. Sonography reveals the
following {image}
 
 
Which of the following can be deduced from the image about the
pregnancy?
 
A.    Chronicity cannot be determined.
B.    Two yolk sac point to a Dichorionic pregnancy.
C.    This is Dichorionic Diamniotic pregnancy. 
D.    Lambda sign points to a monochorionic pregnancy.
E.     Two separate pregnancy sacs point to a dichorionic pregnancy. 

11) A 30-year-old primipara is 40 weeks pregnant with a fetal weight estimation

of 3500 gram she is a fully dilated for 4 hours and the head is positioned at s0. Fetal
monitor is normal. Which of the following is the most appropriate management of
this delivery?

A. Oxytocin administration and revaluation with an hour

B. Vacuum delivery
C. Forceps delivery
D. Caesarean section
E. Intrauterine resuscitation
12) A 60-year-old woman has had amenorrhea for 10 years. She has experienced
vaginal bleeding over the last several months and uterine mucosa biopsy
demonstrated high grade serous papillary carcinoma. Which of the following is true
regarding this condition?

A. The most common histology in uterine cancer

B. In most cases treatment includes surgery and radiation
C. Treatment includes surgery alone with no need for adjuvant radiation or
chemotherapy
D. The prognosis of this tumor is less favourable than endometroid tumors
E. Adjuvant chemotherapy is required for tumors stage 3 and greater only

13) A woman presents with severe right abdominal pain 3 weeks following fetal
implantation . On examination she is hemodynamically stable , with tendreness at
the right lower abdomen and over the right adnexa . Urine beta - HCG is positive .
Sonography reveals 12mm thick uterine mu and a 3 - cm round finding adjacent to
the right ovary , with a fetal pole and pulse . Which of the following is the most
appropriate recommendation for this patient ?

Outpatient follow up of beta levels

Admission for close observation

A single shot of methotrexate

Laparoscopic salpingectomy

Emergent laparotomy

14) which of the following patients best fulfills the criteria for menopause?

A) A 40 years old women with 6 months of amenorrhea

B) A 55 with 2 years of irregular menstruation and heat flashes

C) A 53 years old women with 2 years of amenorrhea

D) A 50 years old women with irregular menstruation and FSH-40 mU/ml

E) A 48 after unilateral oophorectomy

15) A 62 year old woman presents with vulvar itch that bruises her examination
reveals edema and significant erythema with uniting of white plaques biopsy reveals
flattening of the papillae and deep lymphatic infiltration which of the following is the
next step in managing this case ? 

A - PET CTB –
B - vulvectomy 
C - vestibulectomy 
D - topical injection of alcohol 
E - topical steroids ( maximal potency)

16) A 12 year old pre-pubertal healthy girl presents to the emergency room with her
parents with acute left lower abdominal pain, nausea, vomiting. Initial ER evaluation
including vital signs and physical examination is normal, with soft abdomen and no
peritonitis abdominal sonography reveals an enlarged left ovary with poor perfusion.
Which of the following is the most appropriate next step?

A) Abdominal-pelvic CT
B) CBC and CRP
C) Tumor markers
D) Admission for observation and pain management
E) Complete of fast and laparoscopic surgery

17( A 25-year old woman on her 6th pregnancy, the routine fetal weight estimation
at 32 week was below the 3rd percentile.

Which of the following is a possible explanation of this finding?

A) Maternal influenza infection

B) Filamentous insertion of cord
C) Gestational diabetes
D) Posterior placenta
E) Multiparty
18) A15 year old generally healthy and well-developed girl, who hasn't started
menstruating yet , present to the emergency room with her parents due to several
day of lower abdominal pain.

She has been complaining of intermittent abdominal pain for the last year.
Evaluation in the ER reveals hemodynamical stability and a very sensitive lower
abdomen. Abdominal sonography reveals hematocolpus and hematorrhea with
normal appendix.

Which of the following is the best diagnostic test?

A) Physical examination
B) MRI
C) Colposcopy
D) Hysteroscopy
E) Laparoscopy

19) 28 years old woman on her 8 th pregnancy presents with the following routine
lab results ( table ) ( ‫) טבלה‬ 
CMV IgM (+) positive
CMV IgG ( +) positive
CMV avidity low
What is the significance of this results 
A- normal results reflect an old CMV infection , there is no need for further
evaluation. 
B- the test was taken prematurely and needs to be repeated in 1 month 
C- periconceptual CMV infection .
D - re infection with CMV which is NOT associated with fetal complications 
E- new CMV infection , targeted sonographic evaluation is recommended . 

20 )25 years old woman on her 18th week pregnancy present with intolerance to
heat tachycardia , nausea , lab results revealed T4 increase , and low TSH which of
the following is the most common complication of this condition during pregnancy ? 

A-preeclampsia 
B-cardiomyopathy
C-coma
D- IUGR
E-cardiac failure 

21) A 42 year old past C/S woman on her 2nd pregnancy present to the delivery
 room at 39+5 weeks with contractions . sonography reveals frank breech
presentation
and an estimated fetal weight of 3700 gr .
The woman wishes to deliver vaginally .
Which of the following is a contraindication for vaginal delivery in this case ?
A- Estimated fetal weight
B- Frank breech presentation
C- A previous cesarean section
D- Maternal age
E- Gestational age

22) Which of the following is considered a complication of uncontrolled gestational

diabetes mellitus ?
A- Oligohydramnios
B- Intrauterine growth retardation ( IUGR )
C- Neonatal hyperglycemia
D- Neonatal hyperbilirubinemia
F- Fetal brain malformations

23) A 28 year- old is trying to conceive over the last 18 months. She has no past
surgeries, no history of PID. Her partner has 2 children from a previous marriage. Her
menstruation is irregular ( once in 6 months ), and she has acne and hirsutism. Which
of the following is the most appropriate line of treatment?

A-clomiphene citrate shots for 2 weeks .

B- Gonadotropins for hormonal stimulation.

C- insemination during a natural cycle.

D- IVF without ICSI.

e-one tablet of letrozole for 5 days.

24)A-32 year old normally developed woman present for routine checkup she
describes amenorrhea for the last 18 months she has never been pregnant had regular
menstruation and no gynecological issues in past , which most plausible explanation for
her amenorrhea ?

A)mullarian
B)turner
C)asherman

D)eating disorder
E)diabetes

25) 50 years old women present with postcoital bleeding . PAP-HGSIL colposcopy
was performed and acetic acid dye revealed area of acetowhite epithelial and
punctuation . positive schiller test and normal histology on cervical biopsy . Which is
the most appropriate step in imaging this patient ?

A- Routine follow up
B- HPV typing
C- Repeat PAP in 3-6 months
D- Diagnostic conization
E- Total hysterectomy

26) 39 year old female , 38 week pregnant and had 3 pregnancies present with
general malaise BP in ER 170/100 on 3 tests , urine protein +3 , treatment for
hypertension started , what is the next step :

Decrease blood pressure and follow up at 40 weeks

Completing 24 h urine test for protein

Admission to intensive care unit for blood pressure management

IV magnesium and delivery

Emergent c section

27) A routine pelvic ultrasound of a healthy and an asymptomatic 45 year old woman
demonstrated the ed ovarian finding showed in the attached image , CA-125 was
normal.

Which of the following is the most appropriate recommendation for this woman ?

a) Repeat physical examination and sonogram in 3 months

b) Total body PET-CT
c) Percutaneous aspiration of the fluid for cytology
d) Laparoscopic excision
e) Hysterectomy and salpingo-oophorectomy
 28) 65 Years old women has had laparoscopy for oophorectomy , admitted due
to complex cyst

Final pathology reveal SEROUS PAPILLARY CARCINOMA

what is the next step in management :

1- follow up in 3 month

2-PET –CT

3- COMBINED CHEMOTHERAPY

4- AVASTIN

5- STAGING SURGERY

29) elevated Alpha feta protein (AFP) levels were found in the second trimester
screening. Which of the following test should be offered to affirm or rule out neural
tube defects?

A. targeted sonography
B. Chorionic villous sampling
C. Amniocentesis
D. Non invasive prenatal testing NIPT
E. Fetal brain MRI

30) A 42 year old generally healthy woman turns for consultation regarding birth
control . she smoke 10 cigarettes per day.

A-there is no need to birth control at her age.

B-combined oral contraceptive

.
C-vaginal ring.
 D-periodic abstinecs.

E- leonvgestrel releasing intrauterine device.

Psychiatrics

1) a 46 year old male is admitted to the orthopedic department , 3 days after

suregery he develops restlessnes and looks scared even without external stimuli . he
is positive for alcohol abuse for many years .
Which of the following is the most appropiate treatment ?

a-lorazepam

b-haloperidol

c-zopiclone

d- trazodone

e-paroxetine

2) A 65-year-old male arrives to the ER complaining of abdominal pain and severe

constipation for a week, on examination – distended abdomen and mild tenderness.
Which of the following medication is the most likely the cause of these symptoms?

a-clozapine

b- risperidone

c- paliperidone

d- diazepam

e- brotizolam

3) A 25 year old male arrives to the ER with fever of 41.6, restlessness ,muscle
rigidity and mutism. Labs – leukocytosis and elevated CPK . he reports that a week
ago he started treatment with long acting injection due to his first psychotic
episode. All of the following are appropriate treatment for this condition except ?

a- propranolol

b- dantrolene
c- levodopa

d- lorazepam

e-amantadine

4) A 20 year old female is admitted for evaluation following suicide attempt by

swallowing 20 pills because of break up from her male partner on examination cut
scars on her arms she reports cutting her self to feel pain that will mask her
loneliness feeling . she has anger outbursts bulimic eating episodes , frequent mood
changes and uncontrollable impulsive behavior , which of is the most appropriate
treatment ?

a- dialectic behavior therapy

b- hypnosis therapy

c social skills rehabilitation

d- biofeedback

e-family group therapy

5) An 84 - year - old healthy male with no previous mental illness is brought to the ER
by his family's request . According to them in the past month " he is deteriorating ,
looks sad , does not take interest in anything including his grandchildren that he
loves , decreased function , and barely keeps his hygiene " . On examination - time ,
place , and identity oriented , answers laconically and to the point , looks sad , and
states that he is a burden on his family and that he is tired of living . All of the
following are expected findings , except :

Depressive affect that does not respond to external stimuli

Confabulations and catastrophic reactions

Despair , guilt , and lack of self esteem

Multiple answers of " I don't know "

Feeling without purpose , and suicide thoughts

6) A 19 year old female is treated in the past two weeks with venlafaxine and lithium
due to depression she is brought to the ER by her parents and admitted due to fever,
tremor, constant diarrhea and extreme restlessness. On examination – rigidity,
hyperactive reflexes and myoclonic jerks.

Which of the following is the most likely explanation to her symptoms?

1. Akathisia
2. Catatonia
3. Serotonin syndrome
4. Dystonia
5. Neuroleptic malignant syndrome

7) during a psychiatric evaluation of a 55 year old femle shi is asked for her adress. In
response she jumps on the chair ,takes off her pants ,and sings the national anthem .

Which of the following is correct regarding her disorders ?

1conscious impairment

2)thought process impairment

3)impaired social judments

4)impaired insight

5)impaired readlity testing

8) A 27 year old male teacher complains of “constantly depressed mood

forever”.he says that life is duty that is hard to hold on to. He complains of
nervousness and lack of satisfaction in everything he does. many times , he
thinks he is a failure and is feeling guilty for not achieving more at work and
at his studies. because of this feeling he minimizes his social activities and
almost never enjoys anything.
He does not seem to find passion in anything including his relationship
What is the most likely diagnosis .
a) bipolar disease, manic type
b)Dysthymia
c)schizophreniform disorder
d)paraphilic disorder
e)major depressive disorder with psychotic features

9) A-40-year-old male's evaluation reveals a prolonged pattern of suspiciousness,

inability to trust people, great envy to his wife, and constant suspicion that she is
unfaithful without any prove. A week ago, when repairing his car, he blamed the
business owner of cheating him and charging more money than needed. Similar
argument occurred with the air conditioning technician and his land lord. He writes
numerous complaint letters to the city mayor. What is the most likely diagnosis?
A – schizoid personality disorder.

B – histrionic personality disorder.

C – dependent personality disorder.

D – paranoid personality disorder

E – schizotypal personality disorder.

10) A-45-year-old male complain of stress, discomfort feeling, and tension that
increase when he leaves his house, on buses, in the mall, and on flights, because of
this he stopped flying overseas and in the past year he goes to the mall only
accompanied by another person, usually his wife. What is the most likely diagnosis?

A – obsessive compulsive disorder.

B – agoraphobia disorder

C – general anxiety disorder.

D – social anxiety disorder.

E – specific phobia

11) all the following are vulnerability factors for post traumatic stress disorder
except

1) multiple recent stresses episodes

2) recent alcohol use

3) borderline personality disorder

4) vulnerability to develop a psychiatric disorder

5) male gender

12) Which of the following symptoms is most characteristic of functional

neurological symptoms disorder (conversion disorder)

1)severe anxiety and psychomotor restlessness

2)symptoms that imitate neurological disease due to psychological conflicts and

mental stressors
3)anxiety following loss of organ function

4)malingering for secondary gain

5)memory loss without any organic finding

13) A 38-old male married with two children, work for the past 15 years as an
engineer and is described as a caring and devoted family man. Since young age he
reports washing his hand hundreds of time a day and also describes several cleaning
and tidiness rituals that take up to two hours of his time each day. Since his twins
were born he describes repeating compulsive thoughts that scare him very much
that he might hurts his kids with a knife. He is reported to take care of his kids well
but refuses to enter the kitchen because of the knives and is scared to be left with
kids alone. He seeks psychiatric help due to his condition. What is the most
appropriate medical treatment?

A- Phenelzine
B- Risperidone
C- Diazepam
D- Perphenazine
E- Fluvoxamine

14) during psychiatric evaluation a schizophrenic patient reports of a suicide attempt

he planned to jump off a bridge but eventually retreated . the psychiatrist respond
you are telling me something very significant and dangerous . I am very happy you
retreated . what stopped you from jumping ? the patient replies with an inadequate
smile " there was a small fence" what is the represented psychiatric status ?

A. concrete thinking

b. false thoughts
c. associative loosening

d. logic disorder

e. perception disorder

15) The consulting psychiatrist called to the department of surgery to evaluate a

patient who threatens to commit suicide. On examination the patient reports being
married with two children, started drinking alcohol 10 years ago and was never
under psychiatric treatment. He reports feeling weak with sever pain.
Which of the following is correct with regards to the suicide evaluation of this
patient?
A- physically weak patients do not usually act on their threat to suicide 
B- the risk of suicide is higher in married men compared to singles
C- very low suicide risk since the patient was never under psychiatric treat
D- alcohol addiction increases suicide risk
F-severe pain decreases suicide risk

16) Which of the following is correct regarding the prognosis of patients that were
diagnosed with their first brief psychotic disorder ?
        1- About 70% will develop schizophrenia in the future.

        2- About 50% will develop major psychiatric disorders in the future.

        3- 60-70% will develop obsessive compulsive disorder in the future.

        4- About 80% will develop bipolar disease in the future.

        5- About 95% will develop major psychiatric.

17) A 13-year-old boy is brought for psychiatry evaluation. He has known

diagnosis of mental and development retardation. On examination - low stature,
elongated head and ears, articular laxity, and enlarged testicles. Which of the
following is the most likely psychiatric disorder? 
       1- Autism spectrum disorder.

       2- Schizophrenia.

       3- Eating disorder.

       4- Bipolar disorder.
       5- Hoarding disorder.

18) A 25 - year - old male is admitted to the psychiatric department and is treated
with perphenazine ( Perphenan ) at a dose of 16 mg twice daily for a week without
any other treatment . He complains of restlessness , inability to sit at one place , and
unpleasant sensation of the muscles that make him constantly move . What is the
most appropriate initial treatment ?

Add biperiden ( Dekinet )

Add propranolol ( Deralin )

Stop perphenazine ( Perphenan )

Add clonazepam ( Clonex )

Add vitamin E

19) A 48 year old male with no psychiatric back ground, married with 3 children , is
brought to ER following a suicide attempt with swelling pills immediately after the
attempt he called for an ambulance and asked to be brought to the ER since he was
afraid that something could happen to him. He tells the ER psychiatrist that he
decided to take pills after he found out he was going to get fired from work and now
he regrets his suicide attempt and aggress to continue psychiatric follow up and
treatment, he and his family request to discharge home saying "don’t worry we are a
supportive family and we will observe him and take care of everything.

What is the most appropriate approach and why ?

A-ADMIT,BY LAW EVERY PERSON WITH SUICIDE ATTEMPTE NEED TO BE ADMITTED

B-CAN BE DISCHARGED HE IS AT LOW RISK BECAUSE HE IS ADULT

C-CAN BE DISCHARGED LOW RISK FOR ANOTHER SUICIDE ATTEMPTE SOON AFTER
HIS PREVIOUS ONE

D-CAN BE DISCHARGED HE HAS GOOD HOME SUPPORT SYSTEM

E-CAN BE DISCHARGED THE SUICIDE WAS IMPULSIVE

20) All of the following are specifiers for major depression except :

A-hoarding characteristics

B-psychotic characteristics

C-catatonic characteristics

D-beginning of symptoms following delivery

E-seasonal pattern symptoms