IMLE 10/2019

Which of the following is not treatment option for Placenta accreta ?

B-linch
Insertion of ballons
Hysteroctomy
Packed cell
Embolization

What is not a risk factor of intrauterine infection?

Obesity
Eclampsia
Caesarean
Instrumental
Prolonged

A 25-year-old, 1-day post-partum, complains of fever, chills, and lower abdominal pain. On examination her temperature is 39.3 C. Which of the following is the first therapeutic step?

Intravenous vancomycin
Wait for an additional temperature measurement of above 38, in a 2-hour interval
Investigate for source of fever and obtain cultures
Broad spectrum IV antibiotic treatment including 3 antimicrobial agents
Broad spectrum oral antibiotic treatment including 2 antimicrobial agents

A 30-year-old woman, married plus 2 children, presents to the emergency room on the 28 th week of her 3 rd pregnancy with abdominal pain, nausea, and vomiting.
Which of the following supports the diagnosis of acute appendicitis?

MRI demonstrating an elongated structure, at least 5 mm thick, in the right abdomen
Right pelvic tenderness on rectal or vaginal examination
Oral temperature of 39.2 C
Uterine tenderness
A left shift on complete blood count

Which of the following is true regarding hypothyroidism during pregnancy:

Hypothyroidism during pregnancy should be ruled out by repeating TSH testing every 6 weeks
Hashimoto thyroiditis is the most common cause of hypothyroidism during pregnancy✓
Uncontrolled hypothyroidism increases the risk of gestational diabetes
Subclinical hypothyroidism is found in 5% of pregnant women
Screening for hypothyroidism (FT4) should be obtained in all pregnant women

Pre-pregnancy diabetes increases the risk for all the following except:

Tracheoesophageal fistula
Coarctation of the aorta
Renal agenesis
Sacral agenesis
Anencephaly

Which of the following is defined as superimposed preeclampsia?

A 28 years old woman, married plus 1 child, on her 2 nd pregnancy, mild hypertension was noted since her 18 th week of pregnancy. Now on her 28 th week, urine protein is 250 mg over 24 hours.
A 20 y.o woman, 24 week pregnant, presents with feet edema and blood pressure of 145/88, and 140/92 after 30 minutes. this is the first episode in her pregnancy.
A 40 y.o woman, 36 th week pregnancy, presents with severe headaches. Mild hypertension is known since her 32 nd week, and blood pressure at the emergencey room is measured 168/98 and 170/91 an hour apart. Spot urinary protein +2.
A 39 y.o woman, married with 3 children, on her 10 th week of her 4 th pregnancy. Blood pressure at the clinic was 145/88 and 138/98 an hour apart. Urinary spot protein +3.
A 38 y.o woman, married plus 1 child on her 18 th week of her 2 nd pregnancy. Blood pressure at the clinic was 138/100 one week ago, and 24 hour urinary protein 380 mg. blood pressure now 143/82.

Which of the following women has a Bishop score above 7?

Soft, posterior cervix, 2 cm dilated, 50% effaced, head at spina -2
Soft, medial cervix, 3 cm dilated, 70% effaced, head at spina -2
Hard, medial cervix, 2 cm dilated, 80% effaced, head at spina -2
Soft, posterior cervix, 2 cm dilated, 50% effaced, head at spina -1
Hard, posterior cervix, 3 cm dilated, 50% effaced, head at spina -1

Most appropriate magnesium infusion of neuroprotection

long dose 4 gr. During 20-30 min, 1 gr per 1 hour
6 gr over 20-30 min 2gr. Per 12 hour
4 gr over 20-30min 2 gr per 24 hour
6gr over 20-30 min 1 gr per 18 hour
2gr over 20-30min 1 gr /h. over 24hour

All of the following are risk factors for preterm rupture of membranes ( PROM ) except:

Intrauterine infection
Polyhydramnion
Urinary tract infection
Cervical incompetence
Eclampsia

A 23 – year – old primipara woman on her 13th week of pregnancy , presents to the clinic with a temperature of 37 . 5 – 30°C over the last 3 days , malaise , and leg pain. You suspect a primary CMV infection . All of the following are possible complications of primary CMV infection except:

Echogenic bowel
Intra uterine growth restriction
Preterm labor
Brain ventricular dilatation
Oligohydramnion

Which of the following is the meaning of the term Fecundity?

Achievement of a live birth in a cycle of unprotected
Intercourse Mechanical infertility due to cervical stenosis
Achievement of a conception in a cycle of unprotected intercourse
Achievement of a conception in a year of unprotected intercourse

Which of the following has the most significant incluence on a couple’s fertility?

Ethnicity
Geographical location
The man’s age
Line of employment
The woman’s age

True regarding sperm test:

Abnormal sperm test repeat in one week
No need for repeat normal test
Infertility work up should include at least 2 sperm test even if initial test normal incorrect
Annual sperm test

What instructions should be given to a patient referred to a sperm test?

The patient should avoid intercourse for 2 – 5 days , and ejaculate in the laboratory only
The patient should avoid intercourse for 2 – 5 days , and bring the sperm to the laboratory within 1 hour from ejaculation
A sperm test can be performed at any time without any special instructions
The patient should avoid intercourse for 7 days , and bring the sperm to the laboratory within 6 hours from ejaculation
The patient should have normal intercourse with a condom , and bring the sperm in the condom within 1 hour from ejaculation

Cervical Infertility was diagnosed in a couple following diagnostic work up that ruled out other explanations for their infertility Which of the following is the first treatment of cervical infertility?

Antibiotic treatment and intra uterine Insemination
Surgical repair of the cervix by recurrent dilatations
Cervical infertility is self – resolving and does not require treatment
Cervical conization
In vitro fertilization

Which of the following findings on physical examination is the most specific for endometriosis?

Tenderness in the anterior vaginal fornix
Tender nodules in the posterior vaginal fornix , and pain when moving the uterus
A mobile ovarian mass , with a 5 cm diameter
Granulation of the cervical external os
An enlarged and tender uterus

A 26 – year – old woman has been diagnosed with endometriosis and is not interested in conceiving at this point . She has begun danazol treatment . Which of the following describes the mechanism of action of this drug?

Direct anti androgen effect on the endometrial tissue
Direct binding to pituitary estrogen receptors and creating a hypo estrogenic environment
Inhibition of enzymes involved in steroidogenesis , therefore increasing serum estrogen levels
Inhibition of LH and FSH from the hypophysis through a hypothalamic effect

A couple comes for infertility consultation following a year and a half of unsuccessful trials to conceive . The woman is 23 – years – old , was laparoscopically diagnosed as having endometriosis , including endometriomas of 7cm on her right ovary, and 5 cm on the left ovary . In addition , she has a distal Obstruction of the left fallopian tube . The man is 25 – years – old , with severe oligoterato – zoospermia – 3 million sperm cells , with 10k motility , and 1 % normal morphology . Which of the following is true regarding their chances of a successful in – vitro fertilization ?

Endometriosis significantly reduces the rates of conception with in – vitro fertilization, regardless of the male factor
There rates of in – vitro fertilization are mostly influenced by the woman's age and the sperm characteristics , and not by the endometriosis
Endometriosis influences the number of aspirated oocytes , and does not reduce the rate of successful implantation and conception
There is an absolute indication to remove the endometriomas before initiating fertility treatments

Which of the following defines the difference between gamete intra fallopian transfer ( GIFT ) , and zygote intra fallopian transfer ( ZIFT ) ?

In ZIFT , sperm and oocytes are mixed in a catheter and returned to the fallopian tube
In GIFT , oocyte fertilization is performed in vitro
In ZIFT , a fertilized oocyte is returned to the fallopian tube
GIFT requires laparoscopy , while ZIFT may be performed through the cervix without sedation
GIFT is performed when there is a mechanical problem , and ZIFT Is performed when the fallopian tubes are normal

Which of the following regarding the outcome of the use of combined oral contraceptives and systemic and malignant diseases is true?

When used over 3 years , combined oral contraceptives reduce the risk of hepatic carcinoma
Combined oral contraceptives decrease the risk of breast cancer , but increase the risk for benign breast fibrocystic diseases
Combined oral contraceptives reduce the risk of breast and endometrial cancer . This effect begins with the beginning of treatment , and stops when the drug is ceased
Combined oral contraceptives reduce the risk of breast and endometrial cancer within a year of treatment , and the effect continues even after the drug is ceased
Combined oral contraceptives protect bone density deterioration , decrease rheumatoid arthritis progression , and increase the risk of colorectal cancer
A and/or D
B and/or C

A 70 – year – old woman presents with vaginal itching and pain during intercourse. Examination reveals vaginal atrophy, with no unusual discharge. The labia minora are fused in the clitoral area , and a whitish wrinkled surface is found on the perineal skin . Which of the following is the recommended work up and treatment ?

Biopsy and local treatment with testosterone
Biopsy and clobetasole cream
Surgical excision of the lesion
Biopsy and local alcohol injection
Biopsy and local tacrolimus injection

A 32 – year – old woman presents with vaginal pain. Examination reveals tender, Irregular ulcers in the vagina , and similar ulcers in the oral cavity. Which of the following is the appropriate work up for this patient ?

EBV serology
Ulcer biopsy
Vaginal smear
Examination by an ophthalmologist
Diagnostic therapeutic trial with cyclophosphamide

A 27 – year – old woman presents with severe pain during intercourse , mainly at the beginning of the penetration . Examination with a swab produces pain upon contact with the posterior forchette . Which of the following is the recommended initial treatment ?

Gabapentin 100mg X 3 / d for 3 months
Vestibulectomy
CO2 laser vaporation
Low dose tricyclic antidepressants
Local lignocaine and pelvic floor physiotherapy

A 55 – year – old woman , a generally healthy mother of 3 , has a PAP smear result of high grade squamous intraepithelial lesion ( high grade SIL ) , and referred to a colposcopy. Coniozation biopsy reveals intraepithelial cervical neoplasia, CIN3 , that does not involve the cone margins . Which of the following is the recommended treatment in this patient ?

Radical hysterectomy
Cervical laser ablation
Cryoablation of the lesion with liquid nitrogen
Simple hysterectomy
Repeat colposcopy in 6 months

A-32-year-old woman, who diagnosed with HIV on the previous month, he come in for a gynecological examination. She has a normal PAP smear 2 year ago. Which of the following tests should be performed in her condion?

Endocervical curettage
CT PET
Colposcopy
Serum HPV antibodies
Repeat PAP smear

An overweight single with no children, 31-year-old woman has an endometrial biopsy due to excessive bleeding, biopsy result is atypical endometrial hyperplasia. Which of the following is the recommended treatment for this patient?

Metformin treatment and repeat the biopsy 6 months
Follow up and repeat biopsy after the next menstrution
Hysterectomy and salpingo-oopherectomy
Hysterectomy and endometrial excision
High dose pregesterone and endometrial biopsy follow up

73 year old female, a week after a hysterectomy due to vaginal dome prolapse, complains of gluteal pain that worsens when she shits, which of the following procedures did this woman most probably have ?

Uterosacral ligament suspension
Vaginal mesh colpopexy
Abdominal Sacrocolpopexy
Iliococcygeal vaginal suspension
Sacrospinous ligament fixatioin

Which of the following histological finding is typical for granulose cell tumor?

Back to back endometrial appearance
Endometrial serous papillary epithelium
Transitional epithelium within the tumor
Signet cell epithelium in a normal ovary
Call exner bodies within the tumor

Which of the following findings in tissue from uterine cavity curettage point to partial hydatidiform mole?

Diffuse hydropic changes in the chorionic villi
Maternal RBC's only
Trophoblast diffuse atypia
Triploid karyotype
Negative p57 stain

A 75 – year – old female with atrial fibrillation is treated with coumadin. She is a candidate for lumpectomy and sentinel lymph node biopsy due to right breast malignancy. Which of the following is the recommended preoperative anti-thrombotic therapy ?

Stop coumadin 5 days prior to surgery , cover with clexane (LMWH)
Stop coumadin 5 days prior to surgery , no further treatment needed
Stop coumadin 5 days prior to surgery , cover with aspirin
Stop coumadin 5 days prior to surgery , cover with aspirin

A woman on her 39th week of gestation presents to the emergency room with prolapse of cord. Which of the following statements is most accurate regarding the common situation in which this would occur, and the most appropriate management?

Cord prolapse is more common in term babies, and it requires artificial rupture of membranes and instrumental delivery
Cord prolapse is more common in vertex presentation vs. transverse or footling breech, and it requires an emergency cesarean section
Cord prolapse is more common in term vs. preterm babies, and it requires an emergency cesarean section
Cord prolapse is more common in non vertex presentations, and it requires delivering the baby as soon as possible

A 72 year old male, with ischemic heart disease and a history of anterior wall MI ten years ago, complains of recent worsening dyspnea. He is on metroprolol and aspirin. On examination – heart rate 70/min sinus, blood pressure 140/80, and expiratory rales over the lung bases. Echocardiography –anterior wall akinesia, left ventricular ejection fraction (LVEF) of 38%. What is the most appropriate management at this time?

Add digoxin
There is a clear indication for automatic implantable cardiac defibrillator (AICD) implantation
There is a clear indication for cardiac re-synchronization treatment (CRT) pacemaker implantation
Angiotensin converting enzyme inhibitor (ACEI) and furosemide should be added
Add spironolactone

A 68 year old female with hypertension that is medically treated, diabetes, mitral stenosis due to reheumatic disease, and CVA 3 years ago. She is admitted due to first onset of atrial fibrillation that returned spontaneously to sinus rhythm. Treatment plan includes beta blockers only. On the day before discharge an echocardiography is performed and demonstrates normal cardiac function, moderate left atrium enlargement, and sever mitral stenosis. Which of the following thearpies is recommended in this patient?

Aspirin
Rivaroxaban
Apixaban
Dabigatran
Warfarin

All of the following improve survival with reduced ejection fraction (<35%), except:

Carvedilol
Digoxin
Enalapril
Sacubitril-valsartan (entresto)
Spironolactone

A 56 -year-old female is evaluated at the ER for compressing chest pain and increasing dyspnea that started 3 hours prior to her admission. Past medical history is positive for hypertension treated with ACE inhibitors. On examination – disoriented, temperature 36.6 C°, blood pressure 85/50, heart rate 118/minute, respiratory rate 24/min, room air saturation 90%, Sᴣ gallop on auscultation, inspiratory rales over the lung, limbs feel cold. ECG is below. Chest X-ray – pulmonary edema. She is given aspirin at the ER. Which of the following is the most appropriate management of this patient?

IV metoprolol
Percutaneous Coronary Intervention
Fibrinolytic treatment
Admit to ICU for stabilization

Which of the following is the most correct statement with regards to severe aortic regurgitation?

Coarse systolic murmur over the aorta radiating to the neck
Enhanced s2 over the aorta due to aortic component (A2)
Peripheral pulse is called pulsus parvus et tardus
Wide pulse pressure
ST depression and T wave inversion in leads v1-v2, aVF , and III on ECG are common findings in patients with AR

A 48 year old male with no known heart disease complains of compressing pain at the front chest. On examination- hemodynamically stable, room air saturation is normal, with no other abnormal findings. On ECG –ST segment elevation of 3mm in leads II, III and aVF. He is treated with aspirin, clopidogrel, and heparin. Which of the following is the most appropriate management?

Differential diagnosis includes pulmonary embolism as well
Await troponin levels before decision on primary percutaneous coronary intervention (PCI)
If the patient has known active peptic ulcer disease then fibrinolytic treatment with tissue plasminogen activator (tPA) is the treatment of choice
Primary PCI is the treatment of choice if available at the hospital
Primary PCI is limited to patients who failed therapy with fibrionolytic therapy (tPA)

Acute iv treatment with beta blockers can benefits with st elevation (stemi)which of the following is the most correct statement regarding this treatment ?

Decreas pain and decrease risk of fatal arthymias
Dose not affect infraction size
Decreas the risk of atrial origin fatal arthmyas
Decreas the risk of further blood clots formation in the coranry arteries
Improve the cerebral blood flow

A 20 year old male is diagnosed with meningococcal meningitis, which of the following is correct?

Neisseria meningitidis is the most common etiology of community acquired bacterial meningitis
Meningococcemia may be accompanied by petechial rash
Photophobia is rare sign in bacterial meningitis
Most of the patients with meningococcal do not need adjuvant dexamethasone therapy
Antibiotics treatment is recommended only after bacterial identification and sensitivity analysis
A and/or B
C and/or D

Which of the following is correct regarding c.difficile ?

Stool culture is the best choice for diagnosis
Antibiotic treatment for a pneumonia is a risk factor for the disease
Daptomycin is the treatment of choice
Younger patient are at high risk for disease
Length of treatment is 5 days only

A 20 year old female complains of pain during urination, right flank pain and fever up to 39c. Which of the following is correct?

E.coli is the cause of about 30% of acute uncomplicated UTI
E.coli is the cause of about 30% of acute uncomplicated UTI
In the majority of the cases E.coli is sensitive to common antibiotics treatment and resistance to antibiotics is mostly not a problem in these bacteria
Incidence of UTI is equal among young men and women (ages 18-30)
Beta-lactams antibiotics are the first line treatment for uncomplicated UTI

Which of the following is correct regards to Brucellosis?

Osteomyelitis is more common at the cervical spine than at lumbar spine
Vancomycin is the preferred treatment
About half of the patients have musculoskeletal signs along with fever
More than half the patents develop hepatosplenomegaly
Nervous system involvement is rare

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

Streptococcus pneumonia
S.aureus
Q fever
Pseudomonas
Pertussis

Patient with chronic renal failure stage IV-V also have normocytic normochromic anemia. What is the primary cause for anemia in these patients?

Erythropoitin deficiency
Vitamin B12 or folic acid deficiency
Short half life of RBCs
Iron deficiency due to chronic GI bleeding

A 20 years old HIV patient is found in a confused state with a fever of up to 38.4c . lab-hemoglobin 8.2gr\dl ; platelets 16000\ml ; urea 60mg\dl ; creatinine 2.5mg\dl ; total bilirubin 5.5mg\dl ; direct bilirubin 0.5mg\dl ; indirect bilirubin 5.0mg\dl; LDH 1150 u\I ; Pt 13 sec ; INR 1.08 ; PTT 30 sec ; control PTT 30 sec ; fibrinogen 300mg\dl . schistocytes are seen on peripheral blood smear . Which of the following is the most likely diagnosis ?

Hemolytic- uremic synfrome (HUS)
Von-willebrand disease (VWD)
Immune thrombocytopenic purpura
Disseminated intravascular coagulation
Thrombotic thrombocytopenic purpura

Which of the following is correct wih regards to acute promyelocutic leukemia (ALP)?

Combination of anthracyclin with cyctatarabine is the treatment of choice.
Allogenic hematopoietic stem cell transplant is the treatment of choice.
Cure rates in this leukemia do not exceed 15%.
Retonoic acid-tretinoin (ATRA) is the treatment of choice.
APL patients are prone to systemic thrombotic events due to DIC.

A 62 year old male who is treated with spironolactone and digoxin is admitted with a potassium level of 6.5 , on Ecg spiked – t waves. Which of the following is the most appropriate management?

A calcium gluconate in drip for 20-30 minutes
Dialysis is indicated
Calcium gluconate in push for 2-3 minutes
Immediate kayexalate
Fluid infusion with 0.9% normal saline

Which of the following is the main cause of mortality in patients with chronic kidney disease stage 3-4 ?

Uremia
Cardiovascular disease
Infection
Osteoporotic fractures
Malignancy

In which of the following hemodialysis accesses there is increase rate of infections?

Av fistula
Internal jugular vein
Femoral vein
External jugular vein
Subclavian vein

Urinary tract infection

Renal vein thrombosis
Bilateral renal artery emboli
Niphrolithiasis
Acute renal papillary necrosis

Which of the following is characteristic of IgA neuropathy in adult?

Rapidly deteriorating renal failure
Increased blood pressure
Recurrent episodes of macrohematuria
Nephrotic syndrome
Recurrent urinary tract infection

68 years old female is referred to the ER due to diarrhea and vomiting of 4 days. On admission general deterioration , Blood Pressure 80/40 , heart rate 120/minute, no fever. Labs : creatinine 4mg/dl BUN 90mg/dl . Fluid infusion is started and patient improve as well as blood pressure , on 3rd day of her admission she looks we stable , normal CBC, creatinine 4mg/dl. Which of the following is correct with regards to etiology of her renal damage ?

Interstitial nephritis is the most probable cause of lack improvement in creatinine level
Patient most probably had undiagnosed chronic renal failure
Irreversible damage is most probable one and should prepare for dialysis treatment
Ischemia associated acute kidney injury ( AKI ) is most probably etiology
Kidney biopsy should be performed to diagnose the cause of renal failure

What is the most common cause of chronic renal failure western world?

Glomerular disease
Tubulointerstitial disease
Minimal change disease
Diabetic nephropathy
Nephrolethiasis

66 year old male in brought to ER due to high fever , cough and confusion . In last 3 days the patient complains of abdominal pain and diarrhea for 2 days . On exam fever 39 blood pressure 135/80 heart rate 110/minute breath 22/min . Lung ascultation coarse rales and decrease air sound over the base of the right lung , chest x-ray demonstrate right lower lobe pneumonia . Labs 18.000 WBC with 80% neutrophil . Sputum neutrophils without bacteria , no blood in stool what is the most appropriate treatment ?

Ceftriaxone
Ampicillin
Amoxicillin clavulanic acid
Levofloxacin
Oxacillin

55 year old male diagnosed with COPD and severe obstruction with air trapping according to recent pulmonary function test , he is treated with bronchodilators he is now reffered to ER due to dyspnea , productive cough with yellowish sputum , fever and myalagia . On examination tachypnea 18/min temprature 38.2 room air saturation 90% expiratory wheezing over lung , no jugular vien distention chest x-ray no infiltrate or congestion. Which of the following test will have the most significant contribution to the diagnosis ?

Arterial blood gases
B-type natriunetric peptide
Troponin
Echocardiography
Angio ct of the pulmonary arteries

Which of the following is the most common pathogenesis of lower respiratory tract bacterial infection ?

Aspiration from the oropharynx
Airbrone infection
Hematogenous spread
Gastric content aspiration
Sspread from pleura to the lung tissue

A 60 years old female is admitted with community acquired pneumonia. She undergoes a chest CT that demonstrates large left pleural effusion. Which of the following is the most urgent indication for Thoracostomy tube insertion?

Loculated effusion
Fluid glucose less than 60mg/dl
Fluid pH less than 7.2
Fluid positive for bacteria Gram stain
Presence of pus on diagnostic pleural tap

Which of the following is correct with regards to arterial blood gases during asthma attack?

Oxygen saturation is usually about 90%
Normal paco2 is indicative of severe disease
Increase in paco2 during the beginning of the attack
Blood gases should be obtained during every asthma attack
Pulsus paradoxus resolves during severe attack

A 60-year-old female has acute rheumatoid arthritis. Which of the following is the most expected finding in this patient’s blood tests?

Autoimmune hemolytic anemia
Normochromic normocytic anemia
Leukopenia
Thrombocytopenia
Elevated creatinine levels

A 54 years old female is evaluated for fever malaise decreased appetite headaches and shoulder pain for about 2 months on examination – temprature 38.2 c blood pressure 130/85 heart rate 100/minute tenderness on palpation and decrease pulse at right temporal artery . labs – hemoglobin 10g/dl (normal range 12-16), normal liver function tests and ESR 60mm/h . what is the most likely diagnosis?

Takayasu arteritis
Occiptral neuralgia
Giant cell arteritis
Polymyoalgia rheumatica
Tension headache

A 28 years old female complains of chronic fatigue . high titer of anti dsDNA and antinuclear antibodies are found on blood tests . which of the following will contribute to the diagnosis of systemic lupus erythematosus (SLE) according to the SLICC criteria ?

Butterfly rash of the face and hemolytic anemia
High complement levels and leukopenia
Antiphopholipids antibodies and low complement levels
Anemia(hemoglobin less than 10g/dl)
Uveitis and pericarditis

A 19 years old male is admitted due to blood pressure of 190/120 headaches muscle pain joint pain and abdominal pain . he also has livedo reticularis , left testicle pain and swelling , weight loss of 6kg in the last 6 months . labs – WBCs 15000 , hemglobin 10g/dl ESR 100/h . urinalysis – protein RBCs WBCs all negative . what is the most likely etiology?

Lupus glomerulonephritis
Rheumatoid arthritis
Antiphospholipids syndrome
Polyarthritis nodosa
Sjorgen syndrome

Which of the following most typically characterizes the pain in ankylosing spondylitis?

Usual onset after age 40
Morning stiffness
Noctornal pain
Pain increase with rest
Rapid onset of pain

A 40 years old female is admitted due to scleral jaundice and generalized pruritus. On admission she is hemodynamically stable with no fever. on examination – skin and scleral jaundice , signs of scratching , no other abnormal findings . labs – AST 60 IU/L (normal 30-150) ALT 70 IU/L (normal 14-63) ALP 300 IU/L (30-150) GGT 350 (normal 5-60) bilirubin 5mg/dl (normal up to 1) and direct bilirubin 3.5 . liver ultrasound is normal with no bile duct dilation . antimitochondrial antibodies (AMA) is positive, what is the most likely diagnosis?

Primary biliary cirrhosis
Primary sclerosing cholangitis
Acute alcoholic hepatitis
Cirrhosis secondary to HBV infection
Acute cholangitis

40 year old man with liver cirrhosis secendry to HBV hepatitis is treat with fusid and aldactone du to ascitis, he is brought to ER duto bloody vomiting that started on the morning. On addmission BP 90/50 , tachycardia 120 . No fever, fresh blood is drained by nasogastric tube, after initial treatment with Intravenous fluid and units blood the patient now stable with BP 120/80 and heart rate 80 what next step in managment?

Start B-blocker
Ascite tup
Start refaximin
IV fluid
Gastroscopy and variceall ligation

Which of the following is used as maintenance therapy in inflammatory bowel disease ?

Oral glucocorticoid
Acathioprine
5 Asa (sulfasalazine)
Anti TNF -a (infliximab)
6mercap topurine (6-mp)

What is recommended screening for 35 year old healthy man with brother who was diagnosis with colon cancer at age 50 year?

Colonoscopy at age 40
Colonoscopy now
Colonoscopy at age 50
No need colonoscopy
Colonoscopy at age 60

Which of the following is common eitology of acute pancreatitis ?

Abdomonial trauma
Medication
ERCP
Cholethiasis
Alcohol consumption

27 old woman brought ER with blurred consciousness after sucidal attempted by taking medication that she found at her diabetic grandmother house, capillary glocose check confirm hyperglycemia which of the following test with assist in differentiating between insulin intoxication or sulfanylurea intoxication?

Peripheral blood insulin
C peptide
IGF-I
Cortisol
IGF-11/ IGF-I ration

33 year old healthy man found to have ca 12 ( normal up to 10.5 ), on routine blood test. He feels well and asymptomatic, what is most likely diagnosis?

Sarcoidosis
Lung malignancy
Multiple endocrine neoplasia type 1
Multiple myeloma
Primary hyperparathyroidism

66 year old man bank clerk BMI 31 . Blood test -fasting glocose 138 . LDL 131 , HBA1C 6.7% , triglyceride 210 mg/dl ( normal up to 150) . Fasting glocose was 127 one month ago. What is the most appopriate managment?

New onset diabetes , start therapy with metformin and basal insulin until optimal control HBA1C level low than 5,7%
Borderline require low carbohydrate diet and physical activity regemin no need for medication therapy.
Immediate test for antiglutamic acid decarboxylase (GAD) is needed to distinguish between type 1 and type 2 diabetes
New onset diabetes , start therapy with metformin and instruct patient on healthy life style.
Equivocal diagnosis repeat test in month and decide on therapatic plan.

80 year old man who is clear minded and functional under goes evaluation for depression , past medical history is positive for ischemic heart disease with PTCA and stent insertion to right coronary artery last year. Endocardiography demonstrate moderate decrease in left ventricle function.

Lab : T3 1.1 ( 3,1 – 6,8) T4 0.6 ( 12-22) TSH 54 ( 0.27 – 4.2)
What is the most appopriate managment ?

Low dose T4+ T3 regemin
T3 alone regimen
Low dose T4 regimen at 12,5 – 25
Hight dose T4 regimen at 150-200
Standard dose T4 regimen 75-100

A 5 years old boy present with sleepness rapid appearance of skin lesion seen the attached photography, on examination at the emergency room he was sleep but reacted to a light stimulation , pale,tempreture of 38.5 ,respiratory rate was 40 per min ,blood pressure70/40mmhg,o2 saturation was 95% in room air ,and his heart rate was 70/ min ,treatment with supplemental oxygen was initiated ,a peripheral IV line was inserted and initial lab and blood culture were obtained .which of the following is the most appropriated next step?

Intravenous dopamine dripat at 10mg/min and hydrocortison.
Intravenous dopamine dripat at 10mg/min and hydrocortison.
Repetitive dose of intravenous saline 20ml/kg and systemic antimicrobial treatment
Repetitive dose of intravenous saline 20ml/kg and systemic antimicrobial treatment
20ml/kg intravenous saline and urinary toxic screen.

A 8 year old boy with milk allergy and asthma is examined at the ER due to rhinorrhea, shortness of breath, and itching around the mouth, minutes after eating a cheese containing cake, his examination revealed shortness of breath, cyanosis, prolonged expirium and wheezing over both lungs, the face and pharynx are not swollen, which of the following is the most appropriate immediate treatment?

Corticosteroids
IM Adrenaline
Supplemental oxygen and follow up
Antihistamines
Salbutamol

A 3 month old infant present to the ER with restlessness over the last few day. Examination reveals the conscious and alert ,pale ,normal prefusion ,his pulse is 240/min, blood pressure 80/60 ,normotensive fontanella ,and normal heart rate and lung auscultation ,his ECG is below .which of the following is the most appropriate immediate treatment?

Digoxin(digitalis) loading dose
Rapid Nacl 0.9% infusion
Synchronized cardioversion
Amiodarone loading dose
Vagal maneuver

A 5 year old girl’s examination reveals a 2/6 mid-high sternal border heart murmur, and wide fixed s2 split ,which of the following is the most probable diagnosis?

Atrial septal defect
Aortic stenosis
Ventricular septal defect
Pulmonic stenosis
Tricuspid regurgitation

A 10 years old, generally well boy presents with fever and rhinorrhea for 3 days, on the 4th day shortness of breath and malaise were noticed, examination reveals a sick looking boy, blood pressure of 80/40 mmHg, room air O2 saturation of 96% heart rate of 160/min temprature of 37.1, respiratory rate 30/min, crepitations on both lungs, and an apical 2/6 heart murmur, which of the following is the most appropriate immediate treatment ?

Dopamine
Ceftriaxone (rocephine)
Captopril (capoten)
Oxygen and nebulized beta agonists
IV immunoglobolins

A diagnostic cardiac catherization reveals the following:

Which of the following is the most probable diagnosis?

Patent foramen ovale
Aortic insufficiency
Tetralogy of fallot
Patent ductus arteriosus
Ventrical septal defect

A preterm baby, 30 weeks of gestation was ventilated for 2 days, at 14 days enteral feeding was begun, and at 16 days he developes green colored vomiting, abdominal distention, several events of apnea, hypoglycemia, and metabolic acidosis his abdominal x-ray is attached. which of the following is the most likely diagnosis?

Pyloric stenosis
Intussusception
Duodenal atresia
Biliary atresia
Necrotizing enterocolitis

A neonatal examination revealed the finding shown in the attached picture, what leading mechanism?

Intrauterine infection
Cerebral palsy
Clavicular fracture
Brachial plexus injury
Congenital absence of elbow

Baby was born at home and did not receive standard hospital neonatal care, he was circumscribed on day 8 of life, 1day later he develooed bleeding at the site of circumcision, lab finding showed prolonged pt , possible cause?

Intrauterine infection
Preputitum penis
Neglect performance of circumcision
Congenital disease
Decrease in Vitamin K

Which of the following is the first sign of property in boys?

Testicular growth
Elongation of the penis
High growth spurt
Axillary hair
Hair growth at the penile base

16 y/o boy have severe developmental delay and autisim. Exam reveals his testes large of his age , he has hyperlaxity in his fingers , fascial demorphisim, which of the following is possible diagnosis?

Galactosemia
Klienffilter
Ataxia talangectasia
Fragile x
Prada willi syndrome

4 y/o presents with 2 days history of temperature up to 39, pharyngeal pain, exam reveals strawberry tongue, pallor around mouth, and rash. Tx??

IV vancomycin untill he is better
Trimethoprim _ sulfamethaxole for 1 week
Amoxicillin for 10 days
Doxycycline for 1 week
Pipracillin _ tazobactum for 1 week

3 year old generally healthy boy present to ER with fever and vomiting for a day, his examination is significant for brudzinski and kernings signs ,lab finding revealed turbid c.s.f of gram positive cocci in pairs on gram stain which of the following c.s..f finding are most accurate ?

glucose 50 mg,100 wbc mm, 50% lymphocyte
glucose 200mg, 1500 wbc, 50%lymphocyte
glu 45 mg, 500 wbc,decrease proteins , increase cl-
glu 100mg, 2300 wbc, normal protein and chloride
glucose 2 mg 4500 wbc , protine increase

A 5 year old generally well boy, presents with an infected wound on his right palm. A picture of the finding on examination is attached. Which of the following is the recommended treatment for this patient:

Moxypen(amoxicillin)
Zinnat(cefuroxime)
Respirim(trimethoprim/sulfa)
Ceforal(cephlexin)
Doxilin(doxycycline)

An 8 years old girl is admitted and treated for rheumatic fever, without cardiac involvement. Which of the following will you recommend on discharge?

Immediate diagnosis and treatment of every of streptococcal tonsillitis
Prophylactic treatment with oral penicillin V until the age of 21 years?
Prophylactic treatment with oral penicillin V for the next 5 years
Prophylactic treatment with oral amoxicillin until the age of 40
IM benzanthine penicillin once monthly, until the age of 18?

A 10 years old girl presents with up to 38.3 , cough during the day, headache and purulent nasal discharge over the last 8 days. Examination is significant for tenderness above the maxillary sinuses and post nasal drip . Which of the following is the recommended treatment?

Amoxicillin- clavulanate ( augmentin)?
Amoxicillin ( mexypen)?
Ciprofloxacin (ciproxin)
Cephalexin (ceforal)
Clindamycin ( dalacinc)
A and/or B
C and/orD

Which of the following is considered normal in the development of a 3 and a half month old infant?

Withdrawal to the word "no"
Transferring an object between hands
Holding an object between a finger and a thumb
Babbling
Smiling in reaction to a voice and seeing a face

A 2 year old rans and climbs stases , builds a tower from 7 blocks, eats from a spoon, and compress a sentence from 2-3 words. Which of the following is true regarding his developmental stage?

Delay in fine motor skills
Delay in language skills
Delay in gross motor skills
Normal for his age
Delay in motor and language skills

Which of the following language skills developmental pattern is normal?

Being able to compose 4 word sentence at 2 years of age
Syllables at 1 year of age, and 2-5 words at 2 years of age
Being able to say 1-2 words at 1 year of age
As long as a child is able to say 30 words at the age of 3 years, language developmental pace is not significant
Being able to say at least 5 separate words at 1 year of age.

1 year old is examined due to the following findings in picture, after having bathed in water that was too hot, according to his mother. Which of the following may be found in a higher incidence in this child?

Cranial fractures
Scapular fractures
Sternal fractures
Jow fractures
Pelvic fractures

A 13 year old boy presents with bloody diarrhea over the last 2 months, intermittent fever, and weight loss. Laboratory is significant for anemia, and elevated inflammatory markers. Intestinal biopsy reveals granulomas in the small bowel wall . Which of the following phenomena is common in the most likely diseases?

Toxic megacolon
Pyoderma gangrenisumc
Oral aphthos
Positive celiac serology
Positive mantuox test

A 1 year old girl was born at 30 week of gestation ,and her NICU stay had surgical excision of the terminal ileum including the cecum and the ascending and transverse colon. She is fed with formula based on cow milk protein, which of the following deficiencies may the girl develop:

Triglycerides
Essential amino acids
phosphor
magnesium
vitamin b 12

a 3 years old boy has been having recurrent events of rectal prolapse since birth, over the last year , since he began attending kindergarten , he had recurrent episodes of shortness of breath, diarrhea and weight loss, attributed to recurrent viral diseases. Which of the following test may aid in diagnosis the cause of the rectal prolapse?

Complete blood count
Stool culture
Alpha antitrypsin level in the stool
Abdominal ultrasound

A 10 years old boy has been experiencing right upper quadrand pain over the last year. Physical examination is significant for jaundice. Laboratory results reveal elevated serum lipase and the attached sonogram. Which of the following is the most likely cause of his disease?

Crohn‘s disease
Peptic ulcer
Autoimmune jaundice
Chronic hemolysis
Cystic fibrosis

A 5 month old infant has been diagnosed as having beta-thalassemia major which of the following is curative treatment for this disease?

Bone marrow transplantion
Iron chelation
Recurrent blood transfusions
Hydroxurea
Splenectomy

A 5yr old boy has recurrent episode of 8-10 grade pain. A blood smear is attached. Which of the following complications are expected in this disease?

Lymphoma
Leaukemia
Pneumococcal infection
Autoimmune disease
Permanent rash

3 years old girl , less active lately ,eating sand , peeling paint off the wall, she has pallor, soft abdomen, non palpable spleen, LABS: HB :7.2. Mcv : 60. RDW:17% RBC:3.2*10/dL Ferritin : 2mg . What is the treatment ?

Vitamin B12
Iron supplement (correct)
Eltroxin
Gluten free diet
Recurrent blood transfusions

10 year old girl present with a slowdown in her growth rate and malaise, laboratory results are attached which of the following will contribute to the confirmation of the common etiology?

Chest and neck MRI looking for a “vanishing gland”
Thyroid sonogram
Technetium scan
Serum antibodies for thyroglobulin and thyroid peroxidase
Serum thyroglubulin

12 year old boy has been diagnosed with type 1 diabetes 9 months ago and has been treated well. Which of the following is true regarding the sport activity of this boy?

Heavy weight gain lifting should be avoided due to a risk of elevated intraocular pressure during valsalva
There is no need to avoid sport, including competitive sports
Sports should be decreased during the first year due to a risk of hypoglycemia
Long run should be avoided due to a risk of arrhythmia
Sport should be avoided during the first year due to tendency of unsatisfactory diabetics control

2 year old has been brought to the ER due to diarrhea and fever over the last day, the parents say he is drinking well. Examination is significant for impaired consciousness, pallor, and malaise. His BP 60/40 and HR 160. Lab results: glucose 40 mg/dl, sodium 125 meq/l, potassium 7meq/l.
Which of the following is the most likely cause?

Obstructive uropathy
Acute adrenal insuficiency
Sulfonyurea ingestion
Water intoxication
Hyponatremic dehydration

A 7 years old boy is hospitalized due to reccurent liver abscess caused by s.aureus. he also has reccurent skin infections with the same causative agent. Which of the following tests will diagnose his mos likely disease?

Killing capacity of natural killer cells
Skin testing of delayed type hypersensitivity?
50% hemolytic complement activity
Neutrophil elastase levels
Neutrophil superoxid (O2) production?
A and/or C
B or/and E

A 17 years old boy has developed urticaria, shortness of breath and impaired consciousness 30 minutes after being stung by a bee. After receiving the standard treatment, the boy had a full recovery. Skin testing was positive for a bee venom. Which of the following is the approach in this case?

Immediate systemic steroid treatment with future bee stings
Immediate anti histamines treatment with future bee stings
Monoonal antibody treatment with future bee stings
Inhaledd beta agonists treatment with future bee stings
Venom immunotherapy for bee venom as soon as possible

A 4-year-old boy has presents with high fever over the last 7 days. His examination is significant for a fine skin rash, right cervical lymphadenitis, non-purulent conjunctivitis, and the finding in the attached photograph.
Which of the following is the recommended treatment?

Intravenous penicillin
Oral steroids
Aspirin + IVIG
Intravenous ceftriaxone
High dose intravenous steroids

A 7 year old boy present with 3 days of abdominal pain, ankle pain, and the rash demostrated in the picture (rash made of dots on buttocks and legs). These lesions are elevated and do not dissapear with pressure, blood count is normal. Whats is the recommended treatment?

IVIG
NSAIDs
oral prednisone
oral ppi
IV hydration and analgesia

A finding in the physical examination of a month and a half old female infant is demonstrated in the attached picture, which of the following is a risk factor for her condition?

Large for gestational age birth weight
Polyhydramnios
Second or third delivery
Delivery…
Southeast asian decent

A 2 years old is examined due to refusal to walk over the last week. When forced to stand up he is restless and prefer to lie down on the side, examination reveals a generally well toddler, which walks with a limp, normal reflexes, and no tenderness over the spine or any other skeletal abnormal finding. Laboratory results include a normal blood count and elevated CRP. Which of the following tests will contribute the most to his diagnosis?

Spinal X-ray
Vertebral biopsy
Hip sonogram
Lumbar puncture
Spinal MRI

A 3 years old girl came home from kindergarten refusing to step on her left leg. Her examination is normal except her inability to bear weight on her left leg. Her x-ray is attached
Which of the following is the most likely the diagnosis?

Ankle sprain
Toddler fracture
Tibial osteomyelitis
Fibular fracture
Ewing sarcoma

Physical examination of the ear of 2 years old child with fever is shown in the attached picture. Which of the following defines this finding?

Otitis with effusion
Otitis with a bulging ear drum
Normal ear drum
Hemotympanum
Cholesteatoma

The attached picture demonstrates findings during routine physical Check-up of a 1 year old infant. Which of the following tests is mandatory in this situation.(picture)

Biopsy from the lesion
Fundoscopy
Fungal culture
Hair fragility testing
Neural conductance testing

An 8 years old boy is examined following a two-minute tonic-clonic generalized seizure from which he was recovered completely. He has normal development and there is no history of head trauma or a family history of convulsive disorder. In examination his temperature is 36.4C blood pressure is 102/65 his pulse is 80 bpm, and he has normal neurologic exam. EEG an MRI are normal. which of the following approaches is recommended?

Valproic acid (Depalept) treatment for 2 years
Carbamazepine (tegratol) treatment for at least one year
Close clinical and developmental follow up
Repeat sleep and awake eeg within a month
Levetiracetam (Keppra) treatment for 6 months

An 8 month old infant has recurrent events of apnea and cyanosis that appear after crying and resolves spontaneously within 30 seconds with full recovery.
Physical neurological and developmental exams are normal. Which of the following is the appropriate approach to this condition?

Video EEG
Electroencephalogram (EEG)
Tilt test to create vagal effect
Clinical follow up and parental reassurance
Electrocardiogram (ECG)

A 3 year old boy that started walking at the age of one year has developed pelvic weakness and lordosis beginning at the age of one and half year and has now severe difficulty in changing from lying down to standing position .A maternal uncle (the mother’s brother ) had this disease and died at young age. Which of the following is expected in this boy blood work?

Significantly increased creatine phosphokinase (CPK)
Metabolic acidosis
Significantly increased ammonia
Significantly increased alpha fetoprotein
Persistent hyperkalemia

A 6 year old boy is examined due to difficulty in concentrating and in school his history including pregnancy, delivery and development is normal, as is his physical and neurological examination.
Which of the following is recommended as first step?

Eye sight examination
EEG
ECG
Thyroid function tests
Computerized attention test

A 1 –day – old baby has prenatal screening significant for bilateral hydronephrosis and oligohydramnios .on examination the baby urinates in a fragmented pattern , urinary stream is low , and there is a palpable mass in his lower abdomen , laboratory results: potassium 6.5, sodium-135 creatinine 1. which of the following is the most likely diagnosis?

Hydro calycosis
Hypospadias
Posterior ureteral value
Vesico- ureteral refllux
Ureteropelvic junction obstruction

A 3-year-old girl diagnosed with weight gain, feet edema. BP – normal. Albumin 1.9 (low), cholesterol 320 mg/dl, renal function – normal, urinay protein-creatinine ratio is above 10. What is most likely diagnosis:

Minimal change disease
Rapidy progressive glomerulonephritis
Membranous nephropathy
Focal segmental glomerulosclerosis
Post infectious

1-year-old child is brought to emergency department due to diarrhea and vomiting over the last 2 days. On examination – impaired consciousness, reaction to pain only, normal turgor, but dry mucosa. Lab results before administration of IV fluids: serum sodium-168. What is most appropriate IV solution:

Albumin 20%
NaCI 0.9%
NaCl 0.33%
NaCl 0.45%

2 months old infant has inspiratory and expiratory stridor for the last week, no fever or any additional complains. On physical examination – 2 hemangiomas 1-2 cm large on lower lip and chin. What is most appropriate treatment:

Propranolol
Prostaglandin E1
Nebulized
Aerosolized
Satulol

5-year-old boy had tonsillectomy and adenoidectomy 3 weeks ago, after surgery vomited few times. Presents with fever, purulent cough, right chest pain, shortness of breath. On examination – seems sick, temp 39, respiratory rate-45 with retractions, reduced breath sounds. Chest x-ray is attached *(opacity on right lobe). What should be performed at this point:

Urgent lung ct
Sputum culture by bronchoalveolar lavage
Direct lung puncture biopsy of the finding
Intravenous treatment with ticarcillin/clavulanute
Intravenous treatment with ticarcillin/clavulanute

A 5-years-old present with stridor, cough and a high fever for a day. Examination reveals a sick boy, with a productive cough and a large amount of purulent sputum. He is not drooling. Which of the following is the most common causative agent of the boy’s condition?

Adenovirus
Parainfluenza virus
Herophilus influenza
Staphylococcus aureus
Moraxella catarrhalis

A 35 – year – old male was treated with a psychiatric drug and developed a life – threatening rash . Which of the following drugs did he most likely receive?

Diazepam
Fluoxetine
Lamotrigine
Clonazepam
Fluvoxamine

A patient has been recently diagnosed with schizoprenia. which of the following predicts bad prognosis?

A limited support system
late onset (older age)
negative symptoms
being single
family history of psychotic disorder

A patient in the psychiatric ward stands for hours in a still, Uncomfortable posture. He is mute, negativism, and smiles to himself without an external stimulus. Which of the following is the best treatment?

Lamotrigine
Electo-compulsive therapy (ECT)
Carbamazepine
Fluvoxamine

A57 years old man in the midst of a divorce crisis report difficulty fallings sleep,feelingangry,depressed&distressed over the last week,he denies feeling despair,gailt,worthlesses or hopeless,he functions partially at work and at home. Whis is the most likely disorder?

Post traumatic stress disorder
Stress disorder
Acute stress disorder
Adaptive disorder
Major depressed

A woman age 60 wishes to discontinue treatment with benzodiazepines . Which of the following drugs carries a higher risk of withdrawl syndrome?

Clonazepam
Zolpidem
Diazepam
Lorazepam

A75-year-old woman was hospitalized in an internal medicine ward due to pneumonia. Three days later she deteriorated, reports nausea, difficulty concentrating, drowsiness and depersonalization. Physical examination reveals tremor and myoclonus. Her son reports that upon admission she had failed to tell the staff she has been taking three tablets of 2mg clonazepam per day for the last year, hence, has not been receiving it for the last 3 days. Which of the following is not a part of benzodiazepine withdrawal syndrome?

Difficulty concentrating
Nausea
Myoclonus
Drowsiness
Depersonalization

A 40 year old homeless woman arrives in an ambulance to the emergency room after she was found without conciousness on the street. Physical examenation reveals an unconscios woman with respiratory depression,narrow pupils, and needle marks on her arms. Which of the following is the best treatment for her current condition?

Fluvoxamine
Diazepam
Naloxone
Carbamezapine
Risperidone

29 years old male was referred after having recurrent plastic surgery, on the same organ which were defined by the doctors as unnecessary. Which organ is the most likely to be the focus of this disorder?

Hips
Arms
Neck
Penis
Eyes

A 32 – year – old schizophrenic female has begun risperidone treatment . Which of the following adverse eflects is typical of risperidone use?

Increased prolactin
Hyperthyroidism
Increased vitamin B12
Increased rate of psoriasis
Weight loss

Which of the following is not included in the advantages of long acting (versus short acting) benzodiazepines?

Plasma levels are more stable
Reducing the frequency of taking the drug during the day
Fewer withdrawal symptoms
A reduced sedative effect

Which of the following is not an indication for topiramate?

Bulimia nervosa
Drug withdrawal
Alcohol withdrawal
Migraine prophylaxis
Seizures

Which of the following is not included in mini mental testing (MMSE), with regards to to cognitive functions?

Short term memory
Orientation
Insight
Long term memory
Naming

A 50 – year – old male is married and father of 2, depressed and is unemployed for 3 months. Which of the following is not a risk factor for complete suicide?

His gender
His age
His employment status
His mental status
His support system

A 23 – year – old female presents with many superficial cuts on her forearms. Which of the following is typical for this behavior?

No intention of dying
Associated with avoidant personality disorder
Incidence is equal across genders
Resolves within a few weeks
Associated with schizoid personality disorder

A 35 – year – old male was treated with perphenazine due to a psychotic state, and developed extrapyramidal adverse effects . Which of the following treatments is not appropriate for this condition?

Watchful waiting
Reduce the dose of the dopamine blocking drug and adding an anticholinergic drug
Reduce the dose of the dopamine blocking drug
Replacing the drug with a dopamine and serotonin blocker
Adding an anticholinergic drug

A 28 – year – old woman was brought to the emergency room after ingesting 90 valium pills. Which of the following is the treatment of choice in this patient?

Flumazenil
Adderall
Modafinil
Nardil
Azenil

In a patient – therapist appointment of a patient with an anxiety disorder, the patient was asked to write a weekly Journal, describing the dates and times in which he had panic attacks , and the thoughts that followed each episode. Which of the following treatment methods is used in this line of interventional treatment ?

Psychodrama
Cognitive behavioral psychotherapy
Dynamic psychanalytic psychotherapy
Hypnosis Movement therapy

A patient confesses to her therapist that she is in love with him . She wishes to cease therapy so they can be a romantic relationship Which of the following describes this episode?

Containing
Therapeutic alliance
Interpretation
Holding
Transference

During a psychiatric evaluation the patient complements the psychiatrist looks, asks her if she is married, and asks her out on a date for that evening. Which of the following describes this behavior?

Impaired social judgment
Impaired reality testing
Impaired orientation to place
Impaired thought process
Impaired time orientation

A 34 – year – old schizophrenic patient begins haloperidol treatment without any other medications . He presents to the emergency room a month later with muscle rigidity, fever of 38 . 9°C , and severe confusion Laboratory examination reveals leukocytosis, elevated liver function test , and elevated creatinine kinase level ( CK ) 786 . Which of the following is the most likely diagnosis?

Hyperprolactinemia
Secondary parkinsonism
Serotonin syndrome
Neuroleptic malignant syndrome
Akathisia

A77 year – old woman has been found wondering around her neighborhood confused and disoriented. During her emergency room examination , she is confused, agitated, and disoriented in time and place . Her husband reports that up until recently she was in good health , except for hypothyroidism treated with eltroxin Over the last few months she has been complaining of dizziness , and 3 weeks ago he found her in the morning laying on the floor beneath the bed , slightly confused and with a sign of blunt trauma on her forehead . He reported that they haven ‘ t thought it important, and therefore did not seek medical attention Which of the following is the most likely diagnosis?

Normal behavior for her age
Huntington' s dementia
Alzheimer' s dementia
Head trauma related dementia
Frontotemporal dementia

A 27 – year – old math teacher male complains of a prolonged depressed mood, for the last 10 years . He reports that life always seemed too hard for him , he has not found pleasure , and mostly felt like a fallure , lacking a direction , passion , or ambition . He felt unattractive and has not sustained a prolonged romantic relationship Lately he has thought of ending his pointless existence , but has not tried to hurt himself because he thought it would hurt his students . Which of the following is the most likely diagnosis?

Borderline personality disorder
Obsessive compulsive disorder
Cyclothymia
Obsessive compulsive personality disorder
Dysthymia

A 55 – year – old generally healthy male , senior engineer in a big software company, with no regular medical treatment , complains of difficulties concentrating , memory loss, and a feeling of slow and non – creative thinking especially in the mornings , over the last few weeks . During his examination he reports significant sadness , difficulty falling asleep, decreased appetite , anhedonia , and thoughts that his life is pointless over the last 2 months . Which of the following is the most likely explanation for his cognitive difficulties?

Pseudodementia
Alzheimer' s dementia
Multiple sclerosis
Vascular dementia
Chronic psychotic disorder

During a psychiatric evaluation of a 35 – year – old male he is asked if he thinks that people are talking about him behind his back In response he answers that the examiner knows the answer to this question as the examiner can anyway read his thoughts. Which is true regarding this evaluation?

Impaired insight
Impaired social judgment
Impaired reality testing
Normal mental status
Impaired orientation

Which of the following is an accepted indication for electroconvulsive therapy (ECT)?

Conversion disorder
Post traumatic disorder
Psychotic depression
Deterioration in attention deficit hyperactive disorder
Anorexia nervosa

A 25 – year – old female who is an English literature student , arrives to the ER after being stopped for driving too fast On examination she reports not sleeping more than 2 hours a night in the past week and that she took a bank loan of 150,000 NIS so she can open her own clothes import business . She is in a very good mood, speaks very fast, laughs a lot , and at times it is hard to follow her thoughts as she rapidly changes subjects. She claims that her thought is fast and strong and that she is more concentrated than she has ever been . She also claims that she has unique abilities to run the business and that she only found out about it this week . Which of the following is the most appropriate treatment?

Fluoxetine
Clarithromycin
Methylphenidate
Amphetamine
Olanzapine

Which of the following is most characteristic of patients with obsessive – compulsive disorder?

Tend to invest time and energy in interpersonal relationships even on account of work and career
Tend to ‘cut the corners’ at work and therefore usually complete assignments on time
Tend to create unstable interpersonal connections and do not maintain stable relationships
Tend to easily distinguish between important and non – important and therefore get rid of invaluable things
Tend to create high self – standards and expectations and tend to criticize themselves

A 32 – year – old male who is a qualified accountant cannot find a job for the past 6 months . He reports that during his studies and Interviews he is nervous , afraid to talk, very nervous in group situations since he is afraid that he will sound nervous and will blush and get confused , and therefore he does not talk . As a result , he does not go out much on new dates and is reluctant to look for a job . Which of the following is the most likely diagnosis?

Panic disorder
General anxiety disorder
Agoraphobia disorder
Social anxiety disorder
Specific phobia

A 26 – year – old frightened female complains of repeat episodes of physical phenomena ” that are accompanied be a strong fear of death during such episode and also fear between the episodes and fear of future episodes . Which of the following is not common in the described diagnosis?

Choking sensation
Dizziness
Nausea
False thoughts
Tremor

A 52 – year – old female who is married with three children is employed as an electrical engineer. She was diagnosed with breast cancer last year and is treated with chemotherapy and radiation . Which of the following is she most likely to develop?

Adjustment disorder
Delirium
Post – traumatic stress disorder
Major depression
Delusional disorder

76 years old male with a past history of prostatectomy, past medical history is positive for hypertension, hyperlipidemia, diabetes mellitus admitted due to abdominal pain and melena. Now after 2 weeks of admission at the surgery department he screams and mumbles in the last 3 nights claiming that demons haunt him and try to kill him. He is in extreme restlessness. During the morning he talks excellent and does not remember what happened at night.
What is the recommended treatment?

Strap to bed during the night
Haloperidol
Paroxetine
Oxazepam
Iloperidone

A 41 years old reports constantly looking over his shoulder since he is concerned that he dropped a coin or accidentally stepped on a bug and killed it. he avoids touching objects, after touching one he needs to convince himself he didn’t break it. Diagnosis?

OCD
Paranoid personality disorder
Hypochondriasis
Acute and transient paranoid psychosis
Schizophrenia

Which of the following best predicts aggression in mentally ill patients?

Previous episodes of aggression
Drug abuse
Exposure to unexpected stress stimuli
The time and course of mental illness
Full compliance with treatment recommendation

A 70 – year – old male is examined at the ER due to groln pain for 6 hours. On examination – a 6 cm tender Inguinal mass . What is the most appropriate next step?

An attempt to reduce the mass
Abdominal CT
Mass aspiration to rule out an abscess
Urgent surgery
Groin ultrasound

An 81 – year – old male is admitted due to multiple vomiting over the last week. What is the most common metabolic abnormality in patients with multiple vomiting due to gastric outlet obstruction?

Hyperkalemia, hyperchloremia , metabolic acidosis
Hyperkalemia , hyperchloremia , metabolic acidosis
Hyponatremia , hypokalemia , metabolic alkalosis
Hyponatremia , hypochloremia , metabolic acidosis
Hypokalemia , hypochloremia , metabolic alkalosis

A 3 – year – old girl is brought to the ER with a mass at the umbilicus that followed an episode of crying and wild behavior . Which of the following is correct regarding umbilical hernia in children?

Very common in children and should resolve until the age of 5 years
Should be operated early due to risk of bowel incarceration
Should be operated after the age of 1 year in order to allow for normal development
Uncommon in children and never resolves spontaneously

A 56 y.o male patient is admitted due to abdominal pain for a month. One of the surgeons suggest to continue the evaluation with diagnostic laparscopy. Which of the following is correct?

This approach is accompanied with many complications
This approach is highly diagnostic
This approach is less common nowdays
4. This approach’s main advantages is to identify retroperitoneal pathology

An elderly patient is brought to the ER with severe abdominal pain and bloody diarrhea for the first time in his life . He also has heart failure . On examination – left upper quadrant tenderness . Labs – lactic acidosis . What is the next step in management?

Abdominal CT
Abdominal ultrasound
Abdominal angiography
Abdominal X – ray supine and upright or left lateral decubitus

50 y.o male, presents to the ER wih acute upper GI hemorrhage. the most common etiology?

Gasto/duadenal ulcer
Mallory weis
Esophageal varices
Gastritis / duadenitis

Which of the following bariatric procedures is considered restrictive only?

LABG
Roux-en y
Duodenal switch
BPD

70 years old male arrives to the ER with fever,chills,RUQ pain,scleral jaundice, abdominal Ultrasaund:bilateral duct dilatation&cholilithiasis what’s the next step?

HIDA scan
Percutaneous cholecystomy
Triphasis abdominal CT
ERCP

A woman age 65 undergoes a virtual colonoscopy that demonstrates cholelithiasis. She denies any other history of abdominal pain or pancreatitis . Does not mention she has reflux associated with certain foods and that responds well to anti/acid medication. Which of the following is the recommended treatment ?

Cholecystectomy
Oral medcation that dissolves the stones
Injection of a substance that dissolves the stone in the gall bladder
Follow up only

During a laparoscopic appendectomy due to a perforated appendicitis a culture is taken from the free fluid in the right lower quadrant. Which of the following bacterias is the most likely to grow?

Group D streptococcus
Streptococcus viridians
Bacteriodes Fragilis
Pseudomona aeuroginosa

Which of the following is the most common etiology for hemobilia?

A tumor at the papilla of vater
Caumadin intake
Iatrogenic injury
Liver penetrating trauma

45 years old pedestrian female involved in motor accident is brought to the ER, on admission blood pressure 130/80, heart rate 100/min on FAST no free abdominal fluid, pelvic x ray- multiple fractures is open book configuration. All of the following will help stable except:

Angioembolization
Pelvic binding with bed sheet
Extraperitoneal packing
Laparotomy

40 y.o. male present to ER with abdomenal stab knife. on admittion fully alert and hemodymamically stable. on examenation 5cm stab wound right and below the umbilicus with protruding omentum outside the skin without perotinitis. most apropiate next step?

Abdomenal CT
Laparotomy
Diagnostic perotineal lavage
FAST
Local wound exploration

Which of the folowing is condidered a negative prognostic factor in patient with thyroid carcinoma?

Well differentiated carcinoma in histology
size 1.5 cm
male gender
age below 40

Which of the following is typical in primary hyperparathyroidism?

Oliguria
Kidney stones
Diarrhea
Increased appetite

Which of the following is the most common etiology of primary hyperaldosteronism?

Bilateral adrenal hyperplasia
Aldosterone producing adenoma
Famillal hyperaldosteronism
Aldosterone producing adenocarcinoma

Which of the following CT findings is a positive prognostic factor for adrenal incidentaloma?

ill – defined margins
High vascularity
Slow contrast washout
High lipid content

A 45 – year – old healthy female is at the ER due to right upper quadrant pain that started the night before . Pain was accompanied by some nausea but no vomiting or fever. The ER doctor reports that Murphy sign was positive . What is the most likely diagnosis?

Acute appendicitis
Cholecystitis
Diverticulitis
Pancreatitis

Which of the following increases the risk for postoperative surgical site infection?

BMI 22
Hypothermia
Increased oxygen delivery
Septal scrub the night before surgery

A 33 – year – old male arrives at the ER with abdominal pain. On abdominal CT a retroperitoneal mass suspicious of sarcoma is identified Sarcoma may arise from all of the following cell, except:

Epithelial cells
Muscle cells
Lipid cells
Bone cells

A 32 – year – old male is evaluated for an abdominal mass . On biopsy – desmoid tumor. Which of the following has a high incidence of desmoid tumor?

Familial adenomatous polyposis
Ehlers – Danlos syndrome
Neurofibromatosis
Crohn’s disease
Zollinger – Ellison syndrome

When is the correct timing of preoperative prophylactic antibiotic treatment?

When is the correct timing of preoperative prophylactic antibiotic treatment ?
The evening before surgery
3 hours before surgery
Within an hour before surgery

Which of the following metabolic changes are common after gastrectomy?

Low albumin
Elevated triglycerides
Hyperglycemia
Vitamin B12 deficiency anemia

Childhood radiation exposure is the most important risk for which of the following?

Medullary thyroid carcinoma
Thyroid lymphoma
Follicular thyroid carcinoma
Papillary thyroid carcinoma

Which of the following is a risk factor for wound dehiscence?

Prolonged steroid use
Use of metal skin staples
Use of synthetic sutures
Use of prophylactic antibiotics

Which of the following correctly characterizes an amebic abscess in comparison to pyogenic (bacterial) abscess?

Amebic abscess is usually without jaundice while jaundice is common in pyogenic abscess
Amebic abscess is usually at age over so while pyogenic abscess is mostly between ages 20 to 40
Amebic abscess is usually presents with several lesions while pyogenic abscess is mostly solitary
Amebic abscess is more common in diabetic patients while pyogenic abscess is less common in diabetic patients

Which of the following delays wound healing?

Infection
Hypocalcemia
Vitamin B6 deficiency
Aspirin

What is the most common etiology of small bowel obstruction in industrialized countries?

Small bowl tumors
Incarcerated inguinal hernia
Post open surgery adhesions
Intestinal malrotation

A 71 – year – old female is at the ER due to epigastric pain. After a history and physical examination – what blood tests would you ask for?

Lactate only
CBC , short chemistry , liver and pancreatic function tests
CBC and short chemistry
CBC only

A 28 – year – old male is at the ER due to upper abdominal pain without signs of peritonitis . Which of the following imaging studies would you ask for?

No signs of peritonitis , no need for imaging studies at this time , observation only
Plain abdominal X – ray
Abdominal CT
Abdominal ultrasound
A and/or D
B and/or C

A 24 – year – old male is at the ER due to bloody vomiting . On gastroscopy – duodenal ulcer . Which of the following is the most common cause of duodenal ulcer?

NSAIDS
Smoking
Alcohol
Helicobacter pylori

A patient undergoes colonoscopy with an incomplete resection of a polyp. Which of the following pathology results will be an indication for oncological surgical resection ?

Intra – mucosal carcinoma
Hamartoma
Hyperplastic polyp
Tubulo – villous adenoma with high – grade dysplasia

A 60 yo female undergoes routine mammography that demonstrates cultures of suspicious calcification in three different areas of her right breast. Biopsy from two of those areas, 5cm apart diagnosed Ductal carcinoma in situ (DCIS). What is the most appropriate management?

Mastectomy with or without immediate breast reconstruction.
Mastectomy with or without immediate breast reconstruction, but also wide axillary lymph node dissection.
Neoajuvant therapy with antihormonal medication.
Breast conserving surgery with excision of one of the calcification groups diagnosed with DCIS.

A 73 yo male is brought to the ER due to acute lower GI bleeding. Which of the following is the most common etiology?

Hemorrhoids
inflammatory bowel disease
Diverticulosis
Arteriovenous malformation (AVM)
Neoplasia

A 20 – year – old male complains of one week of severe anal pain that increases substantially during defecation as cutting knives sensation with fresh blood . It all started following constipation . The patient refuses rectal examination due to pain with every touch but no mass is seen outside the anus . What is the recommended treatment on top stool softeners and analgesics ?

Calcium channel blockers ointment
Incision over the hemorrhoid and blood clot removal
Surgical excision of the internal hemorrhoids
Anal dilatation
Laxatives and polyethylene glycol solution

A 57 – year – old psychiatric patient is admitted due to abdominal distention and lack of bowel movements. On examination – blood pressure 130/85 , heart rate 92/minute, temperature 37.6°C. The abdomen is very distended , without significant tenderness. Ampule is empty on rectal examination. Abdominal X – ray is below. What is the most appropriate next step ?

Diagnostic laparoscopy
Laxatives and enemas
Laparotomy with involved bowel resection
Endoscopic decompression
Laxatives and polyethylene glycol solution

A 50 – year – old male , status post kidney transplant . At some point following the transplantation a rejection occurred . Which of the following rejections may completely resolve with appropriate treatment?

Acute rejection
Chronic rejection
Hyper acute rejection
B lymphocytes rejection

A 76 – year – old male who is usually healthy without medications , can climb two floors with no difficulty . He is a candidate for elective right inguinal hernia repair. Which cardiac evaluation is required prior to surgery ?

Echocardiography
ECG
Stress test
Holter

A 35 – year – old male with Crohn ‘ s disease is currently on remission and without any treatment . During the Last year he was treated with 5 mg prednisone and antibiotics for one week due to an episode of exacerbation . He is now a candidate for finger nail removal under local anesthesia . Which of the following is recommended to avoid adrenal insufficiency?

No need for any treatment prior to surgery
50 mg hydrocortisone prior to surgery
100 mg hydrocortisone prior to surgery
150 mg hydrocortisone prior to surgery

A 65 – year – old female is admitted due to fever, chills, and jaundice. Ultrasound demonstrates cholelithiasis with bile duct dilatation . Which of the following is the most probable bacteria that led to these symptoms?

Staphylococcus aureus
Streptococcus pyogenes
E . Coli
Bacteroides

In whom of the following . venous thromboembolism prophylactic therapy is indicated?

A 20 – year – old male , usually healthy , candidate for umbilical hernia repair
A 35 – year – old male , usually healthy , candidate for hemorrhoidectomy
A 35 – year – old male , candidate for rectal Surgery due to malignancy
A 30 – year – old female , candidate for planned caesarean section

A cirthotic patient is referred to an inguinal hernia repair. Which scoring system is used to assess the risk and mortality?

Glasgow score system
Child – Pugh score
APACHE score
Ranson ' s criteria score

Staging of hemorrhagic shock is according to the percent blood loss. What is the percent blood loss in stage 3?

5 – 15%
35 – 50%
30 – 40%
20 – 30%
45 – 60%

A 30 – year – old male is brought to the trauma unit due to chest trauma . Blood pressure is low and heart rate of 122 / minute Chest X – ray – wide mediastinum. What is the most likely diagnosis ?

Cardiac tamponade
Tension pneumothorax
Sepsis
Head trauma

A 22 – year – old male is brought to the trauma unit following a gun – shot wound to the pelvis . He rapidly deteriorates and one of your colleagues is concerned that the patient may suffer from the lethal triad . What is the lethal triad?

Acidosis , hyperthermia , coagulopathy
Acidosis , hypothermia , coagulopathy
Alkalosis , hypothermia , coagulopathy
Alkalosis , hyperthermia , coagulopathy

Which of the following is not included in Ringer Lactate solution?

Calcium
Sodium
Magnesium
Potassium

A mother of a 16 – year – old male with hand injury is interested about wound healing and is told that wound healing has several stages . Which of the following blood cells is the most dominant during the first two days of the inflammation phase?

Fibroblasts
Neutrophils
Macrophages
Lymphocytes

IMLE 10/2019

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