IMLE 11/2018

A 34 y.o undergoes a routine checkup, interested in conceiving. She reveals that over the last few months her menstruation shortened from 28 to 20 days. What is the most likely mechanism of this phenomena ?

Decrease in progesterone during the luteal phase.
Decrease in LH prior to ovulation.
Increase in FSH at the beginning of menstrual cycle.
Increase of LH prior to ovulation.

39 y.o single woman with amenorrhea, heat waves, weight gain last year, generally healthy, BMI 34, she has been on oral contraceptive from 20-30 y.o., smoking 20 cig/day since 15 y.o. her FSH levels 40&50 u/L on two separate tests. What is the most likely risk factor?

Over weight
Absence of pregnancies in her past
Prolonged use of oral contraceptives.
Smoking

A 50 years old woman has presented due to worsening of heat waves and disrupted sleep. She has been on fluoxetine over the last two years, to treat heat waves. At 45 yo, she was treated with mastectomy and local radiation due to breast cancer and is now treated with tamoxifen. What is the most appropriate treatment ?

Stop fluoxetine treatment
Increase the dose of fluoxetine
Initiate estrogen treatment
Initiate black cohosh treatment

27 y.o. never pregnant, presents with several years of prolonged lower abdominal pain, especially around menstruation, that has become worst lately. She has been trying unsuccessfully to conceive over the last 2 years. A vaginal bimanual exam reveals granulation of the uterosacral ligament. What most accurate diagnostic test (gold standard in terms of specificity and sensitivity) for her condition?

Contrast abdominal CT
Transvaginal US
Serum CA125 during menstruation
Diagnostic laparoscopic

A 46 yo woman is a candidate for diagnostic laparoscopy due to chronic pelvic pain, dysmenorrhea and dyspareuria. Which most likely anatomic location for typical findings characteristic of the most common diagnosis in this case?

Ovaries
Pouch of douglas
Posterior broad ligament
Uterosacral ligament

56 yo woman presents with vaginal dryness, urinary urgency and incontinence, dyspareuria and increased sensitivity of the breasts. Physical examination is normal except for vaginal atrophy. Which of the patient’s complains have nothing to do with her normal status?

Vaginal dryness
Urinary urgency
Dyspareuria
Sensitivity of the breast

49 y.o. mother of three presents with dysmenorrhea, dyspareuria and chronic pelvic pain which is worst during her period and affects her quality of life. She has undergone laparoscopic resection of endometrotic lesions 10 years ago, and is not interested in conceiving again. Her medical history is positive for hypercoagulability, and pulmonary emboli while using oral contraceptive. What is the most appropriate treatment?

GnRH antagonist
Surgical ablation of the remaining endometriotic lesions
Hysterectomy and oophorectomy
Progesterone treatment

26 yo is treated medically for endometriosis. She complains of gaining weight, acne, changes in her voice, and depression following the beginning of treatment. Which of the following endometriosis treatment causes these adverse effects?

Combined contraceptive
GnRH agonist
Danazole
Progesterone

36 yo woman trying to conceive for 3 months, she has been suffering from endometriosis for the last 10 years, she was diagnosed by a laparoscopic procedure in which 2 cysts – 8 cm diameter were resected and the diagnosis was confirmed histologically. While she was treated with combined oral contraceptive she was asymptomatic, but after the treatment was stopped the pelvic pain is back. Which is the treatment of choice in order to achieve conception in this patient ?

An additional laparoscopic surgery
In vitro fertilization
Treatment with GnRH agonist
Treatment with danazole

A married 30 yo woman with no children is undergoing IVF due to severe sperm disorder. Her history is positive for polycystic ovary disease and 10 follicles of over 14 mm were identified on vaginal US prior to HCG injection. Two days following the injection she presents with abdominal pain, distention and nausea. On exam she is afebrile and hemodynamically stable. Which is most substantial risk factor for her condition?

The woman's age
IVF due to male factor
The number of follicles
Polycystic ovary syndrome

A 30 year old mother of two is treated with IVF for infertility due to a mechanical factor (bilateral salpinx obstruction )which of the following statement is correct regarding the association between fertility treatments and congenital anomalies?

Fertility treatment are not associated with congenital anomalies
There is a 1.8 fold risk of congenital anomalies associated with in vitro fertilization when compared to spontaneous pregnancies
There is a 0,6% increase in the risk of congenital anomalies associated with in vitro fertilization when compared to spontaneous pregnancies
ICSI (intra cytoplasmic sperm infection) minimizes the rate of congenital anomalies with in vitro fertilization

A 39 year old childless woman is treated with in vitro fertilization due to a mechanical infertility after 10 days of ovarian stimulation a vaginal ultrasound demonstrates 3 follicles sized 16,15 and 19mm .Endometrial mucosa is 5mm thick and serum estradiol level is 2200pMol/L (600pg/ml)considering the presented data,which of the following positively predicts treatment success?

The women’s age
Number of follicles
Follicle diameter
Serum estradiol level

A 30 year old woman has a colposcopy due to a finding of high grade squamous intra epithelial lesion (HSIL )on PAP smear ,the colposcopy report stated that the exam was unsatisfactory and the cervical biopsy revealed CIN1 ( cervical intraepithelial neoplasia ). Which of the following is the next therapeutic step?

Radical hysterectomy
Cervical laser ablation
End cervical curettage and conization
Repeat colposcopy in 6 months

A 35 year old woman presents to the emergency room with severe lower abdominal pain with no fever two months prior to her presentation she has gone through endocervical conization due to CIN2 ,her last period was 5 weeks ago ,during her examination she seems in pain and palpitation reveals severe sensitivity and fullness in central and lower abdomen ,laboratory results include a normal leukocyte count ,Hg 11 gr% ,normal urine analysis and a negative pregnancy test, ultrasound shows turbid fluid filling the uterine cavity.
Which of the following is the most likely diagnosis?

Hematometra
Acute cervicitis
Tubo-ovarian abscess
Urinary tract infection

A 41 year old woman was diagnosed with human immunodeficiency virus ( HIV ) a week prior to her presentation in the clinic for a routine checkup. PAP smear 7 months ago was normal . Which of the following tests should be performed at this time?

Colposcopy
Repeat PAP smear
Endocervical curettage( ECC)
Serum human papilloma virus ( HPV ) antibodies

A 39 years old women with polycystic ovary and obesity have received a PAP smear result noting atypical glandular cells. Which of the following is next step in patient workout

Repeat PAP smear in 6 months
Colposcopy, endocervical curettage and endometrial biopsy
Endocervical conization
Endocervical cryo-ablation

A 62 years old women had a endometrial biopsy due to vaginal bleeding. Biopsy result was endometrioid adenocarcinoma FIGO grade 3. What is the most appropriate treatment

Simple hysterectomy, ovaries not included, peritoneal cavity cytology and pelvic lymph node sampling
Radical hysterectomy, peritoneal cytology and pelvic groin lymph node sampling
A simple hysterectomy, including ovaries, peritoneal cavity cytology and pelvic and para aortic lymph node sampling
Radical hysterectomy deferring ovaries from pelvis, peritoneal cavity cytology and omental resection

A 29 years old childless woman with hirsutism had an ultrasound performed due to irregular menstrual period. Ultrasound demonstrate a thickened endometrium and biopsy reveal well differentiated adenocarcinoma grade 1. What is the most appropriate treatment

Repeat ultrasound and biopsy in 6 months
Hysterectomy and salpingo- oophorectomy staging laparotomy followed by radiation treatment
High dose progesterone with follow up by endometrial biopsy
Hysterectomy and salpingo oophorectomy staging laparotomy (omental and lymph node resection) and supplemental chemotherapy

A 70 years old woman had a colporrhaphy due to pelvic organ prolapse 3 days prior to her presentation with left flank pain. Physical examination revealed severe sensitivity upon percussion and ultrasound shows severe hydronephrosis. Which following procedure is most likely to cause injury to ureter

Uterosacral ligament suspension
Sacrospinous ligament fixation
Abdominal sacrocolpopexy
Vaginal mesh colpopexy

An 80 years old widow with a background of heart failure underwent transvaginal hysterectomy and pelvic organ prolapse repair 10 years ago, she now present with prolapse of the vaginal stump. Examination reveals prolapse grade 4 and trial of pessary insertion failed. What is the most appropriate treatment

Abdominal sacrocolpopexy
Laparoscopic sacrocolpopexy
Colpocleisis
Burch colposuspension

In which of the following situations is intraoperative prophylactic antibiotics indicated in addition to preoperative antibiotic treatment?

Hysterectomy in a 90 years old woman 90 kg, intraoperative bleeding around 500 ml
Salpingo-oophorectomy in a woman with history of pelvic infection
Cesarean section due to placenta accreta with hemorrhage of 1800 ml
Transvaginal hysterectomy while opening the peritoneum

A 64 years old woman undergoing workup for vaginal bleeding. Ultrasound scan reveals thickened endometrium and solid 6cm in diameter, right ovarian mass. Endometrium biopsy demonstrated complex hyperplasia with atypia, and serum estradiol was high. Hysterectomy with salpingo-oophorectomy was performed. Which of the following is most likely the pathology of the ovarian mass ?

Papillary serous carcinoma
Borderline serous tumor
Transitional epithelium
Granulosa theca cell tumor

24 years old primigravida with vaginal bleeding and hyperemesis on week 7 post menstrual age. Ultrasound reveals a gestational sac with small fetal echo and no pulse, and around it cystic finding with a snow storm appearance. BHCG was 40,000. Curettage was performed . which of the following is the most typical findings in examining the uterine content ?

Absence of fetal blood cells
Negative p-57 stainN
Diffuse types of trophoblast cells
Triploid karyotype 69xxy

26 years old woman with purulent foul smelling vaginal discharge, vaginal itching and burning sensation while urinating, vaginal smear reveals parasites with flagella. Which of the following is the most appropriate treatment ?

Cefazolin 500 mg X 3/d , for 7 days
Single dose of po metronidazole 2g
Single dose of IM penicillin G5000 units
po ciprofloxacin in 500 mg X 2/d , for a week

All of the following vaccines are indicated in pregnancy except?

Pertussis vaccine at 32 weeks gestation
Tetanus vaccine at 10 weeks gestation following exposure
An active varicella vaccine at 13 weeks gestation following exposure
Inactivated polio vaccine (salk) at 28 weeks gestation during a polio epidemic

Which of the following is the most appropriate candidate for trial of labor after cesarean section (TOLAC) given a normal fetal monitor pattern?

History of cesarean section at full dilatation and a 2900 g fetus
History of classic ( longitudinal ) c section
History of cesarean section due to twin pregnancy and induction is now indicated due a macrosomic fetus
History of cesarean section due to non-reassuring fetal monitoring

Which of the following describes the treatment for a pregnant woman with SLE and antiphospholipid syndrome?

Aspirin and coumadin throughout the pregnancy
Plaquenil and clexane starting at 20 weeks PMA
Aspirin and clexane throughout the pregnancy
Aspirin starting at 12 weeks PMA

Which of the following is considered pathology in a woman 1 week postpartum (vs. the end of a normal pregnancy)?

Decrease in total blood volume
Increase in cardiac output
Increase total lung capacity
Increase in platelet adhesion

Which of the following diseases is inherited autosomal dominant fashion?

Achondroplasia
Familial dysanatomia
Cystic fibrosis
Ataxia telangiectasia

Which of the following neonatal complications is typical in pregnancies at unbalanced type 1 diabetic women?

Heart defects
Limb defects
Neonatal hypothyroidism
Neonatal hyperglycemia

A woman in her 38 gestation of gestation with a headache. Blood pressure is 155/115 on two separate measures and urinalysis is positive for protein +3.which of the following is the next step in this patient`s managment ?

Medically stabilize the blood pressure and await spontaneous labor.
Immediate caesarean section
Stabilize blood pressure ,evaluate urine output and coagulation panel and induce labor while administering magnisium sulphate.
Immediate treatment with magnesium,corticosteroids,and nitroprusside while inducing labor

Which of the following statements regarding infections during pregnancy is true?

Para virus B19 may cause severe fetal polycythemia
Varicella virus may cause congenital defects in gastrointestinal tract
Treponema paldidum (syphilis) may cause smaller than normal placenta
Rubella virus may cause blindness and deafness in the neonate

Which of the following defines a normal non stress test ?

Two acceleration of at least 20 beats/min for 10 seconds over 15 minutes
One acceleration of at least 30 beats/min for 30 seconds over 20 minutes
Two acceleration of at least 15 beats for 15 seconds over 20 minutes
One acceleration of at least 10 beats/min for 20 seconds over 15 minutes

A healthy women in her 32 nd week of pregnancy presents to the emergency room with worsening shortness of breath,cough and palpations. Upon arrival her blood pressure is normal, pulse 135 beats/min, temperature 37.1, cbc is normal. Ecg demonstrates sinus tachycardia with significant right axis deviation. Which of the following is most reliable diagnostic test?

D-dimer measurement
Ct angiography
Chest radiograph
Ventilation-perfusion scinigraphy

Which of the following is risk factor for preterm labor?

Maternal age of 30
Regular physical activity during the pregnancy
A history of labor at 34 week gestation
Maternal BMI of 25

A disabled 90 year old female with dementia is referred from nursing home to the hospital due to altered conscious and refusal to eat or drink for past tow days. Her systolic blood pressure 140 and her serum Na level is 163 meq/L which of the following is the most appropriate mean to correct this electrolytes disorder ?

iv 0.9% saline, 2000 ml
iv 0.45% saline , 2000ml
iv 5% dextrose ,2000ml
water via nasogastric tube 2000ml

A 55 year old male has diabetic , end stage renal failure , and treated with permanent hemodialysis , his serum potassium level 6.7 ,ecg shows new AV block with wide complex bradycardia , what is the intial treatment?

Beta agonist inhelation
IV calcium gluconate
IV dextrose and insulin
Order urgent dialysis

A 76 year old male present with abdominal pain , jaundice , and weight loss, he has elevated total bilirubin , elevated direct bilirubin , elevated ALP while ALT and AST are normal , he is admitted due to bilateral DVT , which of the following test most likely confirm the diagnosis ?

Anti HBV igm
CA-125
Anti mitochondrial antobody
CA-19-9

A 32 year old male complains of dysphagia to solid food, weight loss, upper abdominal pain and nausea, all tgese symptoms are worsening in the past month. What is the most appropriate next test?

Gastroscopy
Colonscopy
ERCP
Total body CT

88 years old is admitted due to intermittent chest pain in the last 24 hours, he is unconscious and blood pressure cannot be measured, ecg:
The most appropriate management:

Unsynchronized cardiovention
IV metaprolol 5 mg
Synchronized cardiovention
IV ikacor 5 mg

70 years old male is admitted due to COPD exacerpation, during admition (MAT) is noted, what is the most appropriate management:

Improve breathing and control COPD exacerbation
Beta blockers
Calcium channel blocker
Amiodarone

Xray, 71 years old male with severe heart failure is admitted due to dyspnea and dry cough, what is the correct description:

Bilateral congestion typical of left heart failure
Right pleural effusion typical of right heart failure
Large right consolidation typical of pneumonia
Left hyperinfiltration typical of obstructive disease

The treatment of patient with stable coronary heart disease that not undergo coronary stent placement:

Aspirin alone
Aspirin + clopidogrel
Aspirin + ticagrelor
Aspirin + prasugrel

52 years old acute myocardial infarction 2 years ago treated for systolic heart failure, recently complains breast enlargement and sensitivity, which drugs may cause this phenomenon?

Aspirin
Eplerenone
Spironolactone
Hydrochlorothiazide

70 years old male complains abdominal pain, physical examination is normal, labs: (hemoglobin 7.7) (MCH 18) (RDW 24%) (reticulocyte 1.2%) (serum iron 13) (urea 12) what is the next step in evaluation:

Total body ct and oral + iv contrast
Liver and bile duct ultrasound
Colonoscopy
Gastroscopy

61 years old female is admitted due to malaise , (hemoglobin 7.4) ( creatinine 2.2) (LDH 660) (thrombocytopenia 64000), new visual field deficit is demonstrated and temp 38.4 . What is the most important initial study:

Coombs test
Peripheral blood smear
ESR
Blood culture

81 years old male complains lack of apitite and early satiety, physical exam reveals enlarement of spleen, CBC demonstrate 82000, lymphocytes + 120000 thrombocytes, diagnosed with CLL, what stage is the disease:

Very low risk according to rai and binet
Low risk according to rai and binet
Intermediate risk according to rai and binet
Advanced stage, high risk according to rai and binet

21 years old male is admitted for investigation of weight loss and night sweat, enlargement of spleen, cervical + inguinal lymphadenopathy, LABS: mild anemia, normal thrombocytes, hyoerkalemia, elevated uric acid, acute renal failure, what is the most propable disease:

ALL
AML
Lymphoma + tumor lysis syndrome
Severe bacterial sepsis

77 years old female who live at home complains burning sensation, frequency + urgency while urination, urinalysis is negative for nitrates, urine culture is positive with over 100000 colonies of gram positive cocci, what is expected pathogen:

Streptococcus pneumonia
Enterococcus fecalis
Haemophilus influenza
Escherichia coli

A 42 years old female with breast cancer is treated with chemotherapy via port-A-cath central line she admitted with a fever of 40 decrease of systolic Bp to 65 deteriorated consciousness nausea and vomiting which of the following must be included in the initial treatment?

Vancomycin
Ceftriaxone
Levofloxacin
Clindamycin

A 31 years old male born in Ukraine and migrated to israel last year complains of dyspnea weight loss night sweats productive cough in past two months bilateral consolidation are reported on chest x-ray necrotic lymph nodes are identified on CT. What is the next step in evaluation of this paitent ?

Empiric treatment with ceftriaxone
Empiric treatment with levofloxacin
Sputum testing for acid fasting staining (ziehl neelsen)
Rigid bronchoscopy

A 34 years old female is admitted to ER with high fever deteriorated consciousness nausea and vomiting initial physical examination reveals nuchal rigidity a brain CT scan is ordered and will be performed in 10 minutes. What is the next step in management of this paitent?

Blood cultures and delay therapy until CT results
Lumbar puncture , blood cultures and delay therapy until CT results
Blood cultures ,begin empiric antibiotic treatment and continue therapy after CT results
Lumbar puncture ,blood cultures , begin empiric antibiotic treatment and continue therapy after CT results.

A 55 years old male brought unconscious to the ER there is no previous medical history ( ECG attached) what is the diagnosis?

ST elevation MI
Non ST elevation MI
Complete AV block
Pacemaker rhythm

Which of the following causes membranous nephropathy?

Pharyngitis
Psychogenic polydipsia
Alports syndrome
Systematic lupus erythematous

24 old year female is diagnosis with renal failure and hypertension since the age of 20 she had recurrent urinary tract infection during childhood and she has bilateral scarred kidney on ultrasound what is the most likely diagnosis?

Reflux nephropathy
Hypertensive renal disease
Pyelonephritis
Polycystic kidney disease

35 year old Male is referred for evaluation of flank pain and hematuric for the past few months he was recently diagnosed with arterial hypertension suspect lower abdominal masses on physical examination his father and grandfather suffered from kidney problems and the father died of cerebral hemorrhage what is the most likely diagnosis?

Pyelonephritis
Renal stones
Tuberose sclerosis
Polycystic kidney disease

28 year old female presents with facial rash fever limbs edema malaise and renal failure she has lower serum albumin with proteinuria kidney biopsy demonstrates focal glomerulonephritis with sub epithelial and mesangial immune episitis as well as leukocyte infiltration what is the most likely diagnosis?

Lupus nephritis class 3
Lupus nephritis class 2
Lupus nephritis class 1
Membranous glomerlunephritis

Which of the following is caused by genetic mutation of type intravenous collagen in the glomerulas basal membrane?

Berger's syndrome
Liddle's syndrome
Goodpasture syndrome
Alport's syndrome

A 70 year old Male with past history of colon cancer that was treat with surgery and abdominal radiotherapy is admit for evaluation of weight loss fatigue nausea and back pain he has acute renal failure and normocytic anemia ultrasound demonstrates bilateral hydronephritis intravenous fluids do not improve the renal function what is the most likely diagnosis?

Retroperitoneal fibrosis
Aortic aneurysm
Amyloidosis
Renal cell carcinoma

A 55-year-old male is treated with prophylactic aspirin on admission he presents with painless hematuria and no other urinary complaints. He smokes half a pack of cigarettes for 20 years.
Urinalysis shows hematuria. What is the most likely diagnosis?

Kidney stones
Metastatic lung cancer
UTI
Bladder cancer

A 55-year-old male has elevated serum GT (GGT) what is the clinical significance?

GGT is not elevated in obstructive jaundice
GGT is the only marker for liver disease monitoring
GGT is the only test elevated in obstructive jaundice
GGT is elevated in alcohol consumption and fatty liver

A 57-year-old male is evaluated for abdominal pain and diarrhea, he complains of cough, fever and arthritis. Duodenal biopsy show macrophages with periodic acid Schiff staining.
What is the most likely diagnosis?

Chron’s disease
Celiac disease
Whipple disease
Carcinoid syndrome

70 tear old male is admitted to the E.R with abdominal pain and a new atrial fibrillation on the E.C.G. the pain is constant at 10/10, the abdomen is soft with no peritonitis. What is the next step?

CT angiography
Plain abdominal X-ray
Chest X-ray
Serum amylase and lipase

48-year-old female is evaluated for fatigue, arthritis, mood change, new onset of diabetes and enlarged liver. Which of the following supports the diagnosis of hemochromatosis?

CRP
Hemoglobin
Transferrin saturation
Urine and serum copper levels

A 45-year-old male with reflux and abdominal pain, mild epigastric tenderness and no supraclavicular lymphadenopathy. Gastroscopy revels small ulcer, biopsy shows low grade MALToma. What is the recommended treatment at this stage?

Chemotherapy
Partial gastrectomy
Radiotherapy
H. pylori eradication

A 30-year-old male returned from central America yesterday complains of high frequency watery diarrhea with abdominal pain. On physical examination he is slightly pale, mild abdominal tenderness, active peristalsis, no skin rash or lymphadenopathy, no fever blood pressure 100/80 heart rate 100 BPM what is the causing agent?

Enterotoxigenic/ aggressive E. coli
Salmonella
Norovirus
Giardia lamblia

60-year-old female with 2 month of back pain that disturbs her sleep, thirst, constipation, normocytic anemia, thrombocytopenia, leucopenia, acute renal failure and hypercalcemia. What is the most likely diagnosis?

Secondary amyloidosis
Non-Hodgkin lymphoma
Multiple myeloma
B12 deficiency

A 30-year-old male with severe retractable asthma that is treated with multiple cycles of systemic steroids now complains of left thigh and inguinal pain that worsens when he steps. Which test will help confirm the most likely diagnosis?

Auto antibodies
CRP
Left knee X-ray
Left hip joint MRI

A 61-year-old farmer complains of right hip joint pain that worsens in the last year. The pain is worse during work and peaks at the end of the day and during strenuous activity. What is the most likely diagnosis?

Osteoarthritis
Gout
Rheumatoid arthritis
Septic arthritis

Which of the following Antibodies is the most prevalent in patient with lupus?

Anti-SM
Anti double stranded DNA
Rheumatoid factor
Anti-nuclear antibodies

Which of the following is most associated with Raynaud’s phenomenon?

SLE
Polymyositis
Ankylosis spondylitis
Systemic sclerosis

A 71-year-old male is admitted due to right heart failure exacerbation and is treat his persistent hypokalemia. Which of the following blood test may aid in solving this problem?

Serum phosphate level
Serum magnesium level
Serum vitamin K level
Serum vitamin B12

A 51-year-old male is admitted with symptomatic atrial fibrillation. He is started on sotalol. What needs to be followed during his admission?

Renal function
Lung function
QT segment on ECG
Left ventricle ejection fraction (LVEF)

A 47-year-old female with metastatic breast cancer complains of back pain and urinary incontinence on examination symmetric motoric weakness. MRI diagnoses neoplastic spinal cord compression. What is the next step in management?

Radical mastectomy and adjuvant radiation
Radiation therapy within one-week symptoms onset
Immediate therapy with dexamethasone
Urodynamic testing of the pelvic floor for urinary incontinence

A 50-year-old male is diagnosed with small cell lug cancer by chest -abdomen-pelvic CT and a biopsy. What testis essential in the evaluation of the disease?

Brain MRI
Renal ultrasound
Liver and bile ducts ultrasound
EEG

Which of the following treatments has been proved to prolong the life expectancy of patients with chronic obstructive pulmonary disease (COPD)?

Bronchodilator inhalation
Steroid inhalation
Systemic steroids
Oxygen

Which of the fallowing side effects is associated with SGLT2 inhibitors?

Lower respiratory tract infection
Urinary tract infection
Autoimmune diseases
Cardiovascular events

A 76 year-old-female is seropositive for beta 2 glycoprotein, lupus anti-coagulant, anti-cardiolipin. Past history is positive for 3 abortions and lower limb deep vein thrombosis DVT. She now complains of dyspnea and right chest pain.
Which of the following test should be performed?

Lower limbs doppler ultrasound
Serum D-dimer levels
CT-angio of the pulmonary arteries
Heart echo

A 22-year-old-female started taking oral contraceptive 3 months ago. She now has painful lesions on the shins (attached photo). What is the most likely diagnosis?

Discoid lupus
Erythema nodosum
Pyoderma gangrenosum
Pityriasis rosea

Healthy,50 y.o, 1 week with cephalexin for skin infiction diffuse skin praitius alt+ ast x5 what is the diagnosis?

Auto immun hepatitis
HCC
Cholescyctitis
DILT

30 y.o with penicillin for streptococal pharyngitis and dyspnia and mulasia, tachycardia, tachypnia, BP 70/30, treatment?

Stop penicillin and start guinolone
Im epinephrine
Po presone
D loratudine

62 y.o malase and new renal failure , calcium 12.4, normal PTH, what is the diagnosis?

Malignancy associated hypercalcimia
Sarcodiosis
Primary hyperparathyroidsm
Vitamin D intoxicatig

19 y.o diabetes (DM) type 1 nausea , abdominal pain not eating will and stop insulin , biocarbonat 12, what is the diagnosis?

HHS
Diabetic gastroparesis
Acute gastroenteritis
Diabetic keto acidosis

57 y.o female has urosepsis in admissin she develop sever epistaxis and right calf swelling has sever thrombocytopenia , prolong pt,ptt, fragmented cell on blood smear. What is the diagnosis?

Disseminated intravascular coagulation(DIC)
IPT
Autoimmune hemolytic anemia
Aplastic anemia

A patient that underwent Roux-En-Y bypass 6 months ago , now complains of significant malaise , facial flushing , abdominal pain and diarrhea shortly after mostly sweet meals , what is the most likely diagnosis?

Early dumping syndrome
Colon obstruction
Lactic acidosis
Inflammatory bowel disease

An exclusively breast fed 2month old infant is seen in clinic .the mother is a strict vegetarian and does not eat Any animal products. What is the specific dietary vitamin would be given to the mother

Vitamin A
Vitamin B12
Vitamin E
Vitamin K

A 1week old infant presents with fever of 39C and vomiting.On examination he is alert but fussy and cries with palpations of his abdomen .on evaluation urine Analysis shows 50-100 WBC/HPF with positive leukocyte Estrace and nitrites CSF examinations is normal And cultures from Blood,Urine are pending ,Which is the best Empiric Treatment

Ampicilin and gentamicin
Cefriaxone and Ampicillin
Vancomycin and penicillin
Metrionadzole and Azithromycin

An 8 year old child is hospitalized because of paroxysms of severe Colicky Abdominal pain on Exam ,There is Generalized Abdominal Tenderness.An exploratory laparotomy Revelas an edematous Intestine without specific lesions .Postoperatively the Abdominal pain persists and hematuria develops.values of BUN and creatinine are normal.On the next day tender swelling of both Ankles and knead is noted .Which of the following is the most probable diagnosis?

Acute Post streptococcal Glomerulonephritis
Acute lymphoblastic leukemia
Familial Mediterranean Fever
Anphylacted fever

A 4950 male infant is delivered vaginally after a 38 weeks gestation complicates by maternal poorly controlled Type 2 Diabetes.A shoulder dystocia was noted during the delivery.At 4 hours of Age ,The baby’s left Arm is internally Rotated ,And the Forearm is extended and pronated .the baby doesn’t move her left Arm when the examiner assesses the Moro Reflex. Which physical Examination finding is associated with the finding of the Arm?

Absent left thumb
A hyperpigmented patch on the left ches
A 2 -vessel Umbilical Cord
A constricted Left pupil

A 4 year old male presents with 6 days of fever , Erythematous Tongue and lips non Exudative Bulbar Conjunctivitis,Cervical lymphadenopathy,And generalizes Macular Papular Rash .What is the appropriate treatment for this infant ?

Corticosteroid
NSAIDS
IVIG
IV Antibiotics

Male infant born 26week gestation developts tachycardia and abdominal destination prior to passing a blood tinged stool following his first feeding his exam reveals decreased tone and activity tenderness on palpation of the Abdomin,and and paucity of abdominal sounds. His abdomen X-ray shows diffuse pneumatosis intestinal without pneumoperitoneum or portal venous air what the most probable diagnosis?

Respiratory distress syndrome
Intestinal volvulos
Necrotizing enterocolitis
Intussuscueption

Which is the most common complication of child with tetraology of fallot that didn’t undergo acorrectivr surgery?

Brain abscess
Brain hemorrhage
Cerebral thrombosis
Bacterial endocardits

2 years old boy with one month history of slow growing, nontender mass beneath the right mandible the overlyning skin is erythematous and 2 days ago it began to spontaneously produce purulent drainage What is the most probable diagnosis ?

Burkitts lymphoma
Cat scratch disease
Cystic hygroma
Mycobactrial lymphoadenitis

36 week old is born to a mother with gestational diabetes birth weight is 4255g which laboratory result would be expected mostcommonly in this infant?

Hypoglycemia
Hypoglycemia
Hypocalcemia
Hypernatremia

12 years old girl developed jaundice, progressive tremors, emotionl liability and brown discoloration of limbic region of Corina, the girl has abnormality in which metabolic system?

Zinc
Lead
Copper
Iron

6 year old girl came in at end of summer with multiple dark lesions on legs and arms for tue last month, lesion about 1cm in size, dark, nonpalpable, non tender, and not pruritic. She complains of musquito bites over the summer, what is the diagnosis?

Impetigo
Post Inflammatory Hyperpigmentation
HSP
Tinea Corpis

12 year old female seen because of fever, arthritis, oral ulcers, malar rash and photosensitivity, you suspect autoimmune disease, what is the most specific test for this patient?

ANA
Double stranded DNA
Anti- Ro
Anti Histone Ab

Following 2 serious infections with N.meningitides, a diagnosis of terminal complement component dificiency was made. What vaccine is contraindicated in this patient

OPV
BCG
Rotavirus
None of the above

A 5-month-old infant is seen because of attacks of back extension and torticollis that happens a few times every day and last for 2-3 minutes. A Sandifer Syndrome is suspected, What is the reason for this phenomenon?

Hypoxemia attacks
Gastroesophageal reflux
A viral infection
Metabolic encephalopathy

A newborn infant is born with a port-wine nevus which is well demarcated over the distribution of the right trigeminal area of the face. Which is most frequently associated with this condition?

Hemangiomas of the abdominal viscera
Normal mental development
Glaucoma
Microcephaly

A 12-month-old boy is seen because of refusal to walk. He began walking at 10 months of age. He has been doing well until this point. His exam reveals a moderately ill infant with temperature of 39.2 C, an externally rotated left hip with limitation to passive and active motion. What is the causative organism for this illness?

Neisseria Meningitides
Group A streptococcus
Staphylococcus Aureus
Salmonella
All of the answers correct

3-week-old boy presents with a 4-day history of difficulty feeding with evidence of dyspnea and decreased urinary output. He is afebrile and lethargic with skin pallor most notable in the lower extremities. Auscultation of his heart reveals a gallop rhythm and peripheral pulses are absent in the feet. What is the cause of his current symptoms?

Bacterial Sepsis
Cardiogenic shock
Sickle cell disease
Azothermia

A 7-month-old girl has failure to thrive. She passed meconium 24 hours after birth and had one episode of rectal prolapse a month ago. There is no polyuria. She is normotensive on exam. Lab tests reveal a metabolic alkalosis.
Her renal function electrolytes, magnesium and hepatic panel are normal with a decreased serum albumin of 2.8 . What is the most probable diagnosis?

Bartter Syndrome
Cystic fibrosis
Gitelman Syndrome
Renal tubular acidosis

A 17-year-old female presents with a complaint of missed period. Menarche occurred at age 13, and her periods have been regular for last 18 months. She normally bleeds for 4 to 5 days with moderate flow. Her last menses was 2 months ago. After performing a history and physical exam, What would be the next laboratory test in her evaluation?

CBC
Urine β-hCG
Serum quantitative β-hCG
LH level

A patient with hus has the best prognosis when the syndrome is caused by?

Shigella infection
Factor h dificiency
Thrombomoduline deficiency
C3 synthesis mutation

A 10 years old male has cervical lymphodenopathy, eustachian tube blockage, nasal obstruction and epistaxis. A nasopharengeal carcinoma is diagnosed, infection with which organism caused this disease?

Rubella
Varciella
Ebshtain barr virus
Cytomegalo virus

In which immune deficiency disease do patients have a specific difficulty in dealing with an Ebshtain bar virus infection?

X- linked aggamaglobulinemia
X-linked lymphoproliferative syndrome
Ataxia telangioctasia
Chronic granulomatuse disease

A 5 years old boy presents with a number of grand mal seizures and the decision was made to start him on valporic acid treatment . The parents ask which factor may precipitate the appearance of liver necrosis while taking this drug?

Male gender
Age under 2 years
Family history of epilepsy
An allergic reaction to phenobarbitol

A 5- years old girl diagnosed with systemic lupus, is seen because of changes of behaviour and involuntary movements. On exam a milk made grip is noted. This sign represents which clinical problem?

Chorea
Atetosis
Dystonia
Pyramidal sign

12 years old girl is seen because of ptosis and muscle weakness after repetitive use. Mystenia gravis is suspected. Which drug is cotraindicated in this patient?

Penicillin
Propranolol
Succynlcholine
Phenytoin

In which of the following conditions is a tall stature is expected?

Turner syndrome
Klinfeltter syndrome
Celiac disease
Hypothyroidism

During circumcision procedure perform in an infant, a sener hypospadias and bilateral undereducdent tests were found. What should be the next diagnostic step?

Ametabolic screen
Karyotype
Kidney ultrasound
Barium enema

A 6 years old boy is evaluated for headaches. He reports two three episodes over the last 2months that are accompanied by initial onset of blurry vision followed by severe pounding-pain type .what is the cause for the headaches?

Migraine
Posterior fossa tumor
Chronic
Myopia

Which of the following reflexes is normally absent in a new born?

Statle
Plamar grasp
Parachute
Crossed adductor

A 4 years old girl is seen because of hair loss . On exam she has a 5-cm area of alopecia on the scalp over the right ear . Closer examination of the skin of the scalp in this area reveals smooth and shiny skin with no evidence of tiny broken hair or irritation of the underlying scalp.what is the diagnosis in this patient?

Tinea carpitis
Traction alopecia
Trichotilomania
Alopecia areata

A 6 –month-old infant has chronic cough . sweat chloride test show chloride 104 mmol/l (normal is <40) on the right arm and 108 on the left arm with adequete volume of sweat at each site. What is the next appropriate step in evaluating this patient?

Repeat the sweat test for confirmation and refer to a CF center
Refer to a geneticist for futher evaluation
Obtain stool elastase
Complete an endocrine workup for adrenal insuficiency

An 8-year old girl is having episodes where she stops moving and talking, demonstrates a blank facial expression, and rapidly blinks her eyelids. These episodes last about 5-15 seconds, after which she returns completely to her normal behavior, which pattern is expected in an EEG study in this patient?

Hypsarhythmia
Temporal lobe spikes
Generalized 4-5 Hz polyspike and slow wave discharge
Three per second spike and wave

A 6-month-old female infant is seen beacause of cough, shortness of breath, and wheezing. This is the second similar episode in this child . the parents are concerned about the outcomes of the disease in their child . which is a major early childhood risk factor for persistent asthma?

Allergic rhinitis
Parent asthma
Eosinophilia
Allergy to food

A 14-year-old boy with prune belly syndrome is seen because of chronic renal failure for the past 5 years. Which abnormality associated with untreated chronic renal failure is a common finding?

Microcytic anemia
Hyperparathyrodism
Osteosclerosis
Low growth hormone

A 3-year-old boy is evaluated because of few dark red skin lesions that are round and palpable on her thighs and waist. The lesions are slightly hyperkeratotic . biopsy obtained from a lesion reveals an angiokeratoma. The child complains of severe burning pain involving the palms and soles . what is the diagnosis of this patient ?

Gaucher disease
Fabri disease
Krabbe disease
Metachromatic leukodystrophy

It is mandatory to be vaccinated with meningococcal vaccine when traveling to which of the following cities?

Mecca
Johannesburg
Cairo
Moscow

A 12-year-old boy, new emigrant from the USA , is seen with a rash that is diagnosed as erythema migrans. This skin lesion is important in diagnosing an infection with which organism?

Borrelia burgdorferi
Treponema carateum
Mycobacterium lepra
Leptospira icteohemorrhagica

Which site is the most common to be affected with candida infection in 6 months old infant?

Vaginal
Diaper area
Nails
Lower neck

A previously healthy 8 week infant present with a hepoglycemic seizure and blood glucose of 14 mg/dl. on exam she appears helthy well hydrated and the 95% for both weight and length she has been brestfeeding every 3 hours aside from hypoglycemia comprehensive metabolic panel is normal. Her urinalysis showed negative ketones with no reducing substances. What is the most probably diagnosis?

Adrenal insufficiency
Glecogen storage disease
Galactosemia
Congenital hyperinsulinism

10 years 10 years E wing sarcoma presents with fever and neutropenia empiric IV antibiotics are administered an hour later he becomes hypotensive and unresponsive. On exam he has bleeding gums and petechiae. His laboratory results show a low platelet count prolonged PT and PTT his D-dimers are elevated his fibrinogen is decreased and RBC fragments are noted in the blood smear. What is the diagnosis?

Disseminated intravascular coagulopathy (DIC)
Idiopathic thrombocytopenic purpura (ITP)
Hemolytic-uremic syndrome (HUS)
Kassabach-merritt phenomena

A 6 month old male infant has profuse watery diarrhea, his pulse is 200 BPM, he has sunken eyes, capillary refill of 5 seconds, appears grey, and has weak central pulses and absent peripheral pulses. Six trials to get an IV started have been unsuccessful. What is the next step?!

Obtain a saphenous vein cut down
Intubate and administer fluids through nasogastric tube
Place line via an intraosseous needle
Place a subclavian central venous line

10 years old male is making unusual movement in the last 3 month previously healthy with normal development. On examination he grimaces and blinks sporadically .its not associated with pain or irritation .this movement occurs multiple times a day and seems to happen more often when the boy is tired or distressed.what is the diagnosis?

Obsessive-compulsive disorder
Toretto syndrome
Simple motor tics
Normal behavior

8 years old girl with no history present with an acute urticarial rash over the past 3 days . she had viral infection one week age prior to onset of rash. Which of the following is the most appropriate medication for the treatment of acute urticarial rash that lasting more than 3 month

Prednisone
Montelukast
Diphenhydramine
Propranolol

21 years old mother is given birth to a normally apprentice newborn she report that she is taking drugs, the use of which drug by the mother is a contraindication for breastfeed her child?

Codeine
Morphine
Cocaine
Methadone

The active vaccination for varicella is given to all children in Israel .the parent of a 1 years old girl are concerned about the policy and would like to know the fact about administration indication . which of the following patient is allowed to receive this vaccination?

A patient with cellular immunodeficiency
A pregnant women
A patient with humoral immunodeficiency
A patient with leukemia

A 6 month old male is seen because of gross motor delay and cardiomegaly, his parent were married in a consanguineous marriage which syndrome explain this patient condition.

Pompe disease
Tay-sach
Galactosemia
Myotonic muscular dystrophy

5 years old boy ate peanut butter within 5 min he develop shortness of breath, tongue swelling ,generalized urticaria, vomiting ,peanuts IGE is very elevated what should we recommend for the patient management.

Elimination of peanut from diet
Oral antihistamine
Oral steroid at the event of acute allergic reaction
Daily injectable epinepherine

6 years old previously healthy boy present to medical care with fever chills headache, chest radiograph show bilateral extensive interstitial infiltrates. His old sister has a kitten and a parrot, another parrot has died recently from unknown disease. What is the diagnosis of this patient?

Psittacosis
Mycoplasma pneumonia infection
Egionellosis
Influnza virus pnemonia

3 month male seen because of vomit and diarrhea his stool examination reveals a watery stool with no (blood ,white blood cell or lipid drops) reducing substance test positive on stool which diagnosis is consist with this finding

Cow milk protein allergy
Dysentery due to shigella
Intussusception
Lactose intolerance

A 2 years old present with several days of rectal bleeding ,the mother first noticed reddish colored stool 2 days ago and since then changed several diapers with blood. The child is afebrile, alert, playful, and is earing without emesis, he is tachycardic and his abdominal examination is normal. What diagnostic procedure should be ordered at this time?

barium enema
Abdominal ultrasound
Radionuclide scan
Stool culture

A 22-year old woman complains of fear of losing control, palpitations, shortness of breath, and nausea lasting 10 minutes and resolving spontaneously.
An organic workup did not reveal any abnormalities .
Which of the following is the most appropriate treatment:

Aripiprazole
Escitalopram
Haloperidol
Valproic acid

Which of the following is considered a specific phobia?

Technophobia
Pyrophobia
Social phobia
Intimacy phobia

Which of the following is included in the assessment of cognitive function during psychiatric evaluation?

Alterness, memory, and abstract thinking
Abstract thinking, perception disorders, and alterness
Abstract thinking, perception disorders, and alterness
Rate of thought, concentration, and alterness

Which of the following is a negative sign in psychiatry?

Delusion
Unorganized speech
Diminished affect
Hallucinations

A-30-year old man during a psychiatric evaluation describes prescution delusions with no perception disorders. He is restless, his speech is rapid, and when he asked where he lives describes the apartment, the street, and the neighbors, but doesn’t answer the actual question.

Blocking
Neologism
Tangentiality
Circumstantiality
A or/and B
C or/and D

Which of the following symptoms of diagnostic of catatonia?

Catalpsy,mutism, negatism
Narcolepsy,ecopraxia, corproxia
Mannerism, sterotypy panic attack
Stupor, neologism , agitation

Which of the following is not a part of differential diagnosis of schizophrenic like symptoms?

Vitamin B12
Neurosyphilis
Aids
Epilepsy

Which of the following will predict a bipolar disorder in a 30 years old with recurrent episodes of depression

Early onset
Depression without a significant psychomotor delay
Pre partum depretion
A history of good response to ssri

A 25 years old woman describes an almost daily most of the days over the last 3 years she described her concentration diffeclts low self estrogen decrease sleep and appetite she she denies ever experiencing manic symptom which of the following is the most likely diagnosis

Major depression with atypical features
SchiZoid personality disorder
Dysthymia
Cyclothymia

Which of the following is not a symptom of hypomania?

Inflated self esteem
Decreased need for sleep
Distractibility
Slowing of speech rate

Which of the following psychiatric disorder is treated with phototherapy?

Bipolar disorder with psychotic symptoms
Panic disorder with agoraphobia
Depressive disorder with a seasonal component
Obsessive compulsive disorder

A 35 year old man presents to the emergency room with a seizure for the first time in his life , he reveals that he had stopped taking his medication tow days ago after prolonged use.
Which of the following is most probably the medication he has stopped taking?

Risperidone
Clonazepam
Methylphenidate
Fluoxetine

A 40 years old women gave birth of her first baby 2 days ago. The baby is well, for the last week she cries constantly, she denies feeling of guilt sleeping problems and suicidal thoughts, she denies psychiatric disorder in her famly . Which of the following is the most likly diagnosis?

Major depression
Dysthymia
Baby blues
Premenstrual syndrome

An 80 years old man has been brought to the emergency room by his son, who describes an extreme change is his father state over the past 2 months . The father doesn’t speak much , sights , says, repeatedly that he is sick of life and when asked simple question such as what day it is answer with i dont know i dont remember. Which of the following is most likely diagnosis?

Alzheimers dementia
Picks dementia
Pseudo dementia
Eldery schizophrenia

A 42 years old schizophrenic womn on risperidone treatment for 10 years. Is brought to the emergency room by her husband which is worried about irregular movments she has been having lately including sticking out her tongue and making strange noises with her lips.
Which of the following is the most likely diagnosis ?

Akathisia
Parkinsons
Tardive dyskinesia
Dystonia

Which of the following is the most common reason for delirium 3 days after surgery in a 40 year old alcoholic man.

Infection
Pain medication
Post surgery pain
Delirium tremens

Which of the following is not true regarding a child with ADHD.

There is increased risk for ADHD in his siblings.
The child is at decreased risk for behavioral problems compared to the population.
Of all the symptoms hyperactivity is the most common to pass with tim.
There is a good chance he will respond to methylphenidate.

A basically pleasant ; shy. Responsible and hard working man has sustained a head injury in his place of work. Since his injury he has been making sexual comments to his friends loses his concentration easily and is easy to get angry at minimal provocations.
Which part of his brain was most probably injured?

Occipital lobe
Frontal lobe
Temporal lobe
Limbic lobe.

Which of the following is true regarding hoarding disorder by the DSM 5?

Is classified as a separate disorder
Is part of anxiety disorder
Is part of neuro cognitive disorder
Is part of personality disorder

Which of the following is true regarding the suicide risk among psychiatric patients?

Psychiatric patient have a double fold risk for suicide compared to the general population.
There is no established association between psychiatric hospitalization and suicide risk.
A history of psychiatric hospitalization increase the risk for suicide.
The suicide risk during a psychiatric hospitalization is stable.

Which of the following is true regarding the use of atypical (second generation) antipsychotic medications.

There is an FDA warning regarding the risk for metabolic in all of these drugs.
It is a safe treatment for psychosis in adult patients with dementia.
These drugs are more effective in the treatment of negative symptom of schizophrenia as compared to positive symptoms.
Clozapine is the treatment of choice for treatment resistant major depression disorder.

Which of the following is true regarding clozapine treatment?

Dose does not influence the risk for seizures.
A complete blood count should be performed twice a week during the first year of treatment.
Over salivation is a rare adverse effect.
Myocarditis and cardiomyopathy are rare adverse effect.

Which of the following is true regarding lamotrigine?

When a rash appears the dose should be decreased by 50% and patients should be followed.
More effective for manic episodes than for depressive episodes.
There no need for blood level tests to determine the dosing.
Decrease in dose is indicated when used in combination with carbamazepine.
All are correct
All are false

Which of the following i true regarding course of bipolar disorder?

Bipolar disorder most commonly with a manic episodes.
30% of bipolar disorder patient are only manic.
An untreated manic episode will last an average of 13 month.
After approximately 5 episodes the inter episodes gap stabilizes.

A 16 year old giral attends a special needs class at school over the years she is described as a student with difficults especially in concentration an organization socially she is usually very quiet , spends the recess alone and hase no friends when there is a change in rutine such as a cancelled class due to a teachers illness a pop quiz or a field tripe. Her mother says that as an infant she used to bange hear head at the bed bars befor falling a sleep; always played on her own and excited used to jumb up down and wave her hands. Which of the following is the most likly diagnosis?

Paranoid oersonality disorder
Autism spectrum disorder
Childhood schizophrenia
ADHD without hyperactivity

Which of the following drug is most likely tu cause extrapyramidal side effects?

Chlorpromazine
Clozapine
Haloperidol
Ziprasidone

A 23-year-old woman complains of eating binges followed by feeling like she is loosing control. After the binges she goes for long runs and takes laxatives. This happens once a month over the last 6 months. She is 165 cm tall and weigh 70 kg. Which of the following is the most likely diagnosis?

Psychosomatic disorder
Anorexia nervosa
Hypothyrodism
Bulimia nervosa

Which of the following is the treatment for Tourette’s disorder?

Habit reversal
Methylphenidate 10mg/d
Levothyroxine
Inter personal therapy

Which of the following characterizes a child with ADHD according to the Dsm-5?

Hardly speaks during the day
Seems not to be listening when spoken to
Is able to await his turn
Remember his homework and assignments

Which of the following characterizes obession?

Inadequate reality testing
A bothersome mental image
Repetitive behavior
Does not cause stress

38 years old man has been injured in motor vehicle accident, since then he completely refrains from driving. He has episodes of reliving the accident, and when he is in the area of the accident experiences anxiety, palpitations, and diaphoresis

An undisturbed, dreamless, 8 hours sleep at night
Experiencing the world as a dangerous and scary place
Dramatic and attention drawn behavior
Woman voice cursing at him and blaming him for the accident

50 years old man accuses his wife being unfaithful, he has no proof, he is suspicious and follow her, in examination he reveals that since he was young he found it difficult to trust people and easily offended,tend to interpreting neutral saying as if they were against him.
Which of the following is the most likely the diagnosis?

Avoidant personality disorder
Paranoid personality disorder
Histrionic personality disorder
Dipendent personality disorder

Which of the following caratterizes narchessistic personality disorder?

A chronic feeling of emptiness
Drammatic and theatrical behavior exaggerated demonstration of feeling
Exaggerated occupation with fantasies of success and wealth
Preference for solo activities

Which principal will not be a part psycodynamic psycotherapy treatment?

Encouraging free associations
Having multiple sessions per week
Interpreting dreams
Directing the patient to conduct an anxiety attack diary

For which of the following exposure and response prevention is used?

Obsessive compulsive disorder
Delusional disorder
Schizotypal personality disorder
Dissociative disorder

In which of the following diseases hepatobiliary iminodiacetic acid (HIDA) can be used for diagnosis?

Acute appendicitis
Small bowel perforation
Acute cholecystitis
Thyroid carcinoma

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

Latrogenic injury
Tumor at the vater`s papilla
Coumadin treatment
Penetrating trauma

A 60-year-old male undergoes right hemicolectomy for colon cancer. Pathology reveals invasion to the muscularis layer but not to the peri-colic fat. Seventeen lymph nodes are free of tumor. What is the most acceptable treatment at this time?

Chemotherapy
Completion to subtotal colectomy
Follow-up only
Radiation to the surgical field

A 70-year-old man is admitted to the ER with sever abdominal pain and a fever of 39c. On examination he seems in the pain with diffuse peritonitis, CT demonstrates free abdominal air mild amount of free fluid, and thickening of the sigmoid with fat stranding around it . What is the most appropriate treatment?

Hydration, broad spectrum antibiotics, and close follow-up
Hydration, broad spectrum antibiotics, and urgent colonoscopy
Laparotomy and suturing of the bowel perforation
Laparotomy, resection of the segmoid, and the colostomy

A 68 year-old male is diagnosed with sigmoid volvulus. De-volvulus is performed via sigmoidoscopy and the patient is currently asymptomatic. What is the recommended further treatment?

Follow-up
Elective sigmoidectomy
Emergent sigmoidectomy
Sigmoidopexy to the abdominal wall

A 30-year-old female complains of a mass in the anterior abdominal wall that has increased in size over the past two months and causes discomfort. Abdominal CT demonstrates a homogenous mass that arises from the abdominal wall soft tissue, biopsy demonstrates spindle cells and fibrous strome. Immunohistochemistry staining is positive for b-catenin. What is the recommended treatment?

Chemotherapy
Follow-up
Wide margin excision
Radio frequency ablation (RFA)

A woman undergoes routine mammography with findings compatible with BIRADS5. What is the most appropriate next step?

Follow-up
CT guided biopsy
Stereotactic biopsy
Lumpectomy and sentinel lymph node biopsy

A 60-year-old female undergoes lumpectomy for ductal carcinoma in-situ (DCIS). Pathology reveals that the tumor is invasive ductal carcinoma. What is the most appropriate next step?

Completion to mastectomy
Another surgery for the sentinel lymph node biopsy
Prophylactic contra-lateral mastectomy
Follow-up

For which of the following annual breast MRI follow-up is recommended?

A 65-year-old female with a history of breast cancer
A 35-year-old female following surgery for phyllodes tumor
A man with a history of breast cancer
A 50-year-old female with a history of radiation to the chest due to lymphoma

A 68-year-old female with 3cm invasive breast cancer.
Estrogen receptor (ER) – positive
Progesterone receptor (PR) – positive.
HER2/neu-positive
A biopsy from a suspicious axillary lymph node demonstrates carcinoma. What is the most appropriate treatment?

Lumpectomy and axillary lymph node dissection
Neoadjuvant chemotherapy
Mastectomy and sentinel lymph node biopsy
Lumpectomy and sentinel lymph node biopsy
A or/and B
C or/and D

30 M referred to the ER for severe abdominal pain. Examination pain abdominal peritonitis. Surgery pre pyloric 7mm perforation identified. Preferred surgical procedure?

Heineke mikulicz pyloroplasty
Graham's patch repair
Antrectomy
Pyloric exclusion

58 M appendectomy. During surgery 1.5 cm mass noted appendiceal tip. Pathology- mucinous adenocarcinoma. Appropriate treatment:

Follow-up
Resection of the cecum
Radiation therapy to appendiceal bed
Right hemicolectomy

80 M diagnosed with gastric ulcer that is benign on biopsy. Following therapeutic course for h.pylori and anti acids a repeat gastroscopy is performed and the ulcer is demonstrated again, repeat biopsy is benign as well. What is the most appropriate treatment at this time?

Another therapeutic course for H.pylori and anti acids
Endoscopic resection of the ulcer
Surgical resection of the ulcer
Treatment with sucralfate for 3 moths and repeat gastroscopy

80 M admitted to the ER with abdominal distention and constipation for 4 days. Abdominal CT with rectal examination reveals obstruction sigmoid mass and proximal colon that is vary distended. What is the recommended procedure at this time?

Urgent colonoscopy and biopsy of the mass
Hartmann’s procedure
Sigmoidectomy and anastomosis
Total abdominal colectomy and end ileostomy

69 M complains anal pain during bowel movements and some blood on the toilet paper. A proctologist identifies anal fissure. What is the first line of treatment?

Lateral internal sphincterotomy
NSAIDS
Biofeedback
Topical treatment with nitroglycerin ointment

75 M referred to the ER due to scleral and skin jaundice for the past week. Examination scleral and skin jaundice and looks cachectic. In his right upper quadrant a smooth nontender mass is palpated. Rectal examination- acholic stool. Labs-elevated bilirubin and CA 19-9. What is the common name of the abdominal finding?

Courvoisier sign
Rovsing sing
Virchow node
Murphy sing

What is true with regards of femoral hernia?

The most conmen hernia in female
Cooper’s ligament is the upper border of the hernia
The hernia is medial to the femoral vein
An inguinal hernia is also identified in the majority of the cases

Which of the following is true regarding umbilical hernia in children?

There is high incidence of complications such as incarceration and therefore surgery should be performed as early as possible
Surgery is performed if the hernia does not close until the age of 2 years.
Commonly operated until age of 5 years
It is congenital and common hernia that is most cases will spontaneously close till the age of 2.

Which of the following is true regarding diagnostic laparoscopy for acute abdomen?

The prominent advantage is high diagnostic rate and the ability to treat laparoscopy a number of etiologies that cause acute abdomen
The diagnostic rate is only 50%
It is mostly adventitious in retroperitoneal pathologies
The utility pf diagnostic laparoscopy is decreasing

Which of the following is a clear positive and suspicious finding on diagnostic peritoneal lavage (DPL) for evaluation of acute abdomen?

A-Bilirubin in the lavage fluid
More than 1000 WBCs/ml in the lavage fluid
Creatinine in the lavage fluid
More then 50,000 RBCs/ml in the lavage fluid

Which of the following tests should be preformed in an elderly patient that arrives to the ER with vomiting, acute abdominal pain, fisical findings consist with acute abdomen, and lactic acidosis.

Abdominal angio-ct
Diagnostic peritonial lavage
Abdominal ultrasound
Abdominal angiography

Which of the following is true regarding acute upper gastrointestinal bleeding

It only includes bleeding that are proximal to vaters ampulla
It only includes bleeding that are from the stomach or duodenum
It is the most common etiology of significant bleeding from th GI tract
Mostly arises from esophageal varices

which of the followimg bariatric procedures is considered as restrictive only

Laparoscopic adjustable gastric banding LAGB
Biliopancreatic diversion BPD
Roux-en-y gastric bypass
duodenal swich DS

All of the following are considered an advantage of sleeve gastrectomy over Roux-en-y gastric bypass EXCEPT

Decrease in incidence of internal hernia episodes
Dumping syndrome
Malabsorbtion
Decrease in incidence of leak

Whick of the following is correct regarding Barret’s esophagus

It is not related related to GERD
It involves metaplasia
It involves dysplasia
An anti reflux procedure solves the problem

70 years old male is admitted to the ER dou to fever, chills right upper quadrant pain and scleral jaundice , abdominal ultrasound demonstrates cholelithiasis with bile duct dilation which of the following tests is included in this patient

Hepatic iminodiacetic acid scan ( HIDA)
Abdominal ct
ERCP
Percutaneos transhepatic choloangiography (PTC)

60 y old healthy female undergoes virtual colonoscopy (abdominal ct ) gallstones are suspected and later confirmed by abdominal US there is no history of pancreatitis or jaundice but the patient does describe reflux that is dependent on food types and responds well to anticid tablets with of the following is recommended treatment:

Laparoscopic cholecystectomy
Oral medication that can dissolve the stone
Injection of dissolving substance directly into the gallbladder
Follow-up

55-year-old male arrives to the ER directly from the airport describing abdominal pain in the past 4 days, associated with vomiting during his trip to Africa. The pain was diffused and after several hours it localized to the lower abdomen he was treated there with IV fluid and analgesics with temporary improvement he now complains of RLQ pain and fever with decreased appetite and no vomiting. On examination he has RLQ tenderness and guarding. With of the following will be included in this patient management ?

Abdominal CT to confirm the diagnosis of peri appendicular abscess followed by laparoscopic appendectomy
Abdominal CT to confirm the diagnosis of peri appendicular abscess and laparoscopic drainage if it cannot be drained percutaneously
Abdominal CT to confirm the diagnosis of peri appendicular abscess followed by antibiotic treatment
Followed by drainage and antibiotics scheduled laparoscopic interval appendectomy 6 weeks after discharge with no further evaluation

During laparoscopy for perforated appendicitis a culture is taken from the abdominal fluid with of the following bacteria is the most likely to grow:

Escherichia coli
Streptococcos viridans
Group d streptococci
Pseudomonas aeruginosa

A polyp is resected from the cecum in colonscopy and pathology revels carcinoma in situ or intramucosal carcinoma. With of the following layers cannot be involved by the cell in order to establish the diagnosis?

Muscolaris propria
Submucosa
Muscolaris mucosai
Neck of the polyp
A or/and C
B or/and D

A 20 year old male with known familial adenomatous polyposis in his family undergoes colonoscopy that demonstrates thousands of polyps throughout the colon,enterscopy until the fourth part of the duodenum is negative and neck ultrasound rules out thyroid disease .what is the next step in the management of this patient?

Repeat colonscopy in a year
Total procto colectomy with ileal pouch anal anastomosis(IPAA)
Subtotal colectomy and permanent ileostomy
Cystoscopy to rule out urine bladder transitional cell carcinoma (TCC)

A 50 year old male complians of melena and fatigue .in the ER he is hemodynamcly stable with fresh blood in his nasogastric tube.gastroscopy demonstrates a malfunction with an exposed blood vessel that bled in the submucosa in the lesser curvature about 6 cm from the gastro esophagyeal junction. What is the most likely diagnosis?

Dieulafoy's lesion
Stomach adenocarcinoma
Antral ulcer
Duodenal ulcer

A previously healthy 70 year old male is admitted to the ER due to bloody bowel movements. he never had a colonoscopy performed and he does not take any medications. his abdomen is soft without tenderness .there is bile in the nasogastric tube and fresh blood on rectal examination .which of the following is the most commmon etiology of this bleeding?

Colon ischemia
Diverticulosis
Colon adenocarcinoma
Inflammatory bowel disease

What does damage control mean when treating trauma patient?

Stop bleeding and infectious in an unstable a trauma patient
Focus on anatomical reconstruction of injuries in a stable trauma patient
Packing only in an unstable trauma patient
Focus on anatomical reconstruction of injuries in a stable and unstable trauma.

A 61 year old male is admitted to the ER due to abdominal pain .his abdomen is distended tympnaic on percusion ,without perotenitis ,he is hemodynamcly stable with no fever and mild leukocytosis. An abdominal x-Ray is performed (below). What is the most probable diagnosis?

Sigmoid volvulus
Pseudo obstruction
Obstructing rectal tumour with incomeptent ileocecal valve
Gastric dilation

A 40 year old female is fiagnosed with a 1.2 cm isoechoic, regular border, nodule of the left thyroid lobe. TSH<0.005(nl 0.5-4.5) what is the most appropriate next step in her evaluation?

Repeat neck untrasound in 3 months
Ultrasound guided nodule biopsy
Iodine scan
Serum calcitonin

A 40 year old male undergoes FNA of a 2 cm thyroid nodule. In which of the following repeat FNA is recommended ?

Bethesda I-non diagnostic
Bethesda IV -follicular neoplasm
Bethesda V- suspicious for malignancy
Bethesda VI- malignant

A 50 year old male is diagnosed with primary hyperaldostronism. A CT scan demonstrated a 1 cm right adrenal nodule and a 1.5 cm left adrenal nodule. Which of the following is next step in this patient’s evaluation?

MIBG scan
Sesta -MIBI scan
Adrenal vein sampling
Adrenal ultrasound

For which of the following tumours is barrett’s esophagitis a risk factor?

Squamous cell carcinoma
Adenocarcinoma
Leomyosarcoma
Gastrointestinal stromal tumor (GIST)

Which of the following test is diagnostic for gastroesophageal reflux?

Endoscopy
Manometry
PH mentoring
esophagography

A 60 years old, female is admitted for evaluation of gastric cancer, on gynecological examination and rectal examination an extensive fullness is palpated in the pelvis and is suspicious for tumor spread what is the name of the pathology?

Blummer’s shelf
Kurken bergs tumor
Sister Mary joseph metastatic node
Virchow’s metastatic nodes
A or/and B
C or/and D

33 years female is admitted with acute cholecystitis what is the preferred timing of cholecystectomy in this patient?

Six week since the onset of cholecystitis
Three month since symptoms onset
Within a week of symptoms onset
Wait for at least a week and no longer than six weeks

All of the following are a part of Reynold’s pentad in cholangitis except?

Jaundice
Low blood pressure
paO2<60 mmhg
Right upper quadrant pain

What is the most common etiology of chronic pancreatitis?

Hyperparathyroidism
Medications
Trauma
Alcohol

17 years old male was stabbed by knife above the umbilicus. On examination he is hemodynamically stable abdominal ct iv contrasts does not demonstrating free air or fluid, the patient is admitted for observation, 6 hours later the patient develops diffuse abdominal tenderness. What is the most appropriate treatment at this point?

Abdominal ct with oral contrast
Board spectrum antibiotics and clinical follow up
Urgent gastroscopy
Explorative laparotomy

45 year old female, no previous submission or surgeries, came with right upper quadrant pain that started at evening, accompanied with nausea, no vomiting or fever, which of the following signs approve the dx:

Rovsing sign
Murphy sign
McBurney sign
Obturator sign

Healthy 45 years old male came to the ER with epigastric pain, the patient reported severe pain started at 10 am, at physical ex: HR 110, BP 90/60, T 38.5. significant epigastric with guarding rebound.
Labs:18000 wbc, 18% stab HB 14 chest exray is below. Wwhat should be the next step in treating the patient:

Abdominal ct
Urgent surgery
Urgent gastroscopy
Gastrografin study

45 years old male is admitted to the ER with RLQ pain and 38 temperature, on examination RLQ peritonitis was confirmed with abdominal ct and appendectomy was performed. 0.6 cm carcinoid tumor at the tip of the pancreas was detected, no lymphatic invasion, and the dissection resulted in free(clear) margins.

Follow-up
Repeat test and abdominal ct
Right hemicolectomy
Perform FDG scan

55 years old female with primary hyperparathyroidism. .Which of the following is an indication for surgery:

Ca 11 +N8.6-10.5
Recent nephrolithiasis
Osteopenia with bone density at forearm 1.8
Familial hypercalcemia

Which of the following confirms the diagnosis of hirsshpring disease:

Barium enema
Rectal manometry
Rectal biopsy
Abdominal ct

IMLE 11/2018

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