PART A

1
Which of the following side effects is characteristic of anticholinergic drugs
such as biperiden (Dekinet)?

1. Increased drooling
2. Diarrhea
3. Blurred vision
4. Increased sweating
5. Frequent urination

2
A 50-year-old male complains of severe anxiety. All of the following findings
may support the diagnosis of anxiety, except:
1. Palmar hyperhidrosis
2. Tachycardia
3. Tremor
4. Miosis
5. Hyperreflexia

3
A 23-year-old female is taking risperidone 5 mg/d for a long time. She
complains of chest congestion and milky discharge, irregular menses, and
decreased libido. bHCG is negative.
Which of the following tests should be ordered?
1. Amylase
2. Creatinine kinase
3. Renal function tests
4. Prolactin
5. Hemoglobin A1C

4
Which of the following behaviors is characteristic of self-mutilation?
1. Its incidence is the same between the general population and those
with mental illness
2. Mostly there is a wish to die
3. More common in men than women
4. Lasts several years
5. Usually begins in the fifth decade of life
5
A 14-year-old boy skips school very often in the past year. Since childhood, he
sets fires and breaks objects, harasses and beats children in the neighborhood.
Which of the following is most compatible with this disorder?
1. At least two episodes of running away from his parents' house
2. Symptoms must start before the age of 7 years
3. Diagnosis most include animal abuse
4. Symptoms must last for at least 3 months
5. Does not necessitate studies, occupational, or social dysfunction

6
All of the following are correct regarding epidemiology of depression in the
elderly, except:
1. Depression symptoms are present in 15% of the elderly who live in the
community
2. Depression symptoms are present in 15% of the elderly who live in
nursing homes
3. Age itself is a risk factor for depression
4. Widower family status is associated with tendency to depressive
disorder
5. Prolonged physical illness is associated with tendency to depressive
disorder

7
A woman describes an event of near drowning during a family vacation about
six weeks ago. Since the event she has nightmares and intrusive thoughts of
the event, decreased mood, and she is afraid of going into the water.
Which of the following is a typical course of the described disorder?
 1. In most cases symptoms will progress over time
2. In most cases it will resolve spontaneously
3. Improved prognosis if symptoms develop gradually
4. Rate of resolution is 50% within a year
5. Supporting family and friends do not improve prognosis

8
A 60-year-old female has lost 12 kg in the past three months. She awakens
during the night, feels lack of energy, and displays significant sadness and
despair. She cries a lot and lost interest in leisure activities and friends. On
examination she says there is no longer a point to her life. Extensive labs and
imaging studies are all normal.
Which of the following is the recommended treatment?
1. Haloperidol 10mg X1/d
2. Citalopram 20mg X1/d
3. Resprim forte 1 Tab X2/d
4. Biperiden 2mg X1/d
5. Propranolol 10mg X1/d

9
A 35-year-old female with bipolar disorder is brought to the ER and complains
of a rash that started the same day she started a new drug.
Which of the following is the most appropriate clinical approach?
1. The psychiatrist should reassure her and discharge her from the ER
since a rash is not a known side effect of mood stabilizers and
antidepressants
2. Any rash must be taken seriously as carbamazepine and lamotrigine
specifically can cause Steven Johnson syndrome
3. Irrelevant to the cause of the rash, steroids should be added now to the
new drug until the rash resolves
4. She should be admitted to internal medicine because the rash is usually
accompanied by lymphadenopathy
 5. ENT should be consulted as the rash is usually accompanied by
decreased hearing

10
Which of the following situations is correct regarding absolute
contraindication for electroconvulsive treatment (ECT)?
1. A patient with space occupying lesion at the central nervous system
2. Pregnancy
3. Myocardial infarction 1 week ago
4. A patient with increased intracranial pressure
5. None of the mentioned situations is absolute contraindication for ECT

11
Which of the following is not classified under anxiety disorders according to
the DSM-5?
1. Social anxiety disorder
2. Agoraphobia
3. Panic disorder
4. Generalized anxiety disorder
5. Illness anxiety disorder

12
What is the recommended treatment for a patient with long lasting daily
alcohol consumption who presents with confusion and hallucinations three
days after stopping drinking?
1. Support talks and referral to rehabilitation center
2. Antipsychotic medications
3. Cognitive behavioral therapy
4. Benzodiazepines
5. IV ethanol

13
All of the following are characterized by cognitive function impairment,
except:
1. Dysthymic disorder
2. Major depressive disorder
3. Bipolar disorder
4. Schizophrenia
5. Somatic symptom disorder

14
A shy male describes increased sensitivity that does not allow him to develop
intimate relationships. When he tries to talk to other people he feels greatly
insecure. He avoids social activities despite wanting more friends. He avoids
relatioships in fear of denial, humiliation, and criticism.
Which of the following is the most likely diagnosis?
1. Paranoid personality disorder
2. Avoidant personality disorder
3. Schizoid personality disorder
4. Dependent personality disorder
5. Narcissistic personality disorder

15
A 34-year-old schizophrenic female is treated with oral haloperidol 20 mg/d
and no other mediations. She arrives urgently to the ER. On examination -
trembling, diaphoretic, muscle rigidity. Fever is 40.5°C, heart rate 130/min,
blood pressure 195/95. Labs - leukocytosis and elevated CK levels.
Which of the following is the most likely diagnosis?
1. Lithium intoxication
2. Wernicke encephalopathy
3. Serotonin syndrome
4. Neuroleptic malignant syndrome
5. Acute dystonia

16
A 40-year-old female with mood disturbance is treated with sertraline 200 mg
and another drug that she started taking in the last week. She arrives to the ER
in severe restlessness and non-stop diarrhea.
Which of the following drugs is most likely added to her treatment?
1. Lithium
2. Depalept
3. Topiramate
4. Lamictal
5. Carbamazepine

17
A 55-year-old female is afraid of being infected by an infectious disease and
therefore she wears rubber gloves and face mask while at home. She washes
her hands and changes gloves every 30 minutes and cleans the kitchen marble
with special alcoholic detergent three times a day.
On examination, she states that its clear to her that her fear is exaggerated
and irrational and she wants to get rid of it but doesn't know how, and that
every time she tries to resist the urge to wash hands she panics of getting sick
and dying.
Which of the following is the most appropriate treatment?
1. Family group therapy
2. Hypnosis
3. Cognitive behavioral therapy
4. Social skills rehabilitation
5. Dialectical behavior therapy

18
All of the following are advantages of long half-life benzodiazepines, except:
1. Decreased required daily frequency
2. Decreased plasma concentration variability
3. Decreased withdrawal symptoms
4. Decreased sedative effect
5. Better in patients with low compliance to treatment

19
A 40-year-old female reports avoiding touching objects and after touching
something she has to convince herself that she didn't break it. She looks
behind her back many times during the day because she is worri she hadn't
noticed a coin that she dropped or that she stepped on a bug and accidently
killed it. Since childhood she felt disgusted of her father and avoided touching
or hugging him. Her only desire is to clean her house, which she does every
day.
What is the most likely diagnosis?
1. Paranoid personality disorder
2. Hypochondriasis
3. Acute and transient paranoid psychosis
4. Schizophrenia
5. Obsessive compulsive disorder

20
A 34-year-old male who is treated with perphenazine (Perphenan) due to
psychosis develops extrapyrami side effects. All of the following
recommendations are valid, except:
1. Wait and observe
2. Decrease antipsychotic drug dose
3. Change antipsychotic drug to another atypical antipsychotic drug
4. Add antiparkinsonian drug
5. Change to low potency typical antipsychotic drug

21
Which of the following is considered a physiological change during
pregnancy?
1. Increase blood pressure
2. Increased heart rate
3. Increased hemoglobin
4. Increase platelets
5. Increased creatinine
22
A 15-year-old girl reports she had not started menstruation. She reports
breast buds and genital hair, both evident on physical examination. Vaginal
hymen is normal. Ultrasound has not demonstrated a uterus. Which of the
following is the next appropriate test?
1. Karyotype
2. Follow up until the age of 17
3. Hormone profile
4. Brain MRI
5. Progestin challenge test

23
A 70-year-old generally healthy woman presents with symptoms of urinary
urgency, non-stress incontinence, and nocturia (3-4 times a night). Physical
examination demonstrates cystocele grade 2 and uterine prolapse grade 1.
Urinary exam including cultures is normal.
Which of the following is the most appropriate treatment?
1. Antibiotics
2. Anticholinergic treatment
3. A urinary catheter for a few days
4. Tension free vaginal tape (TVT)
5. Transvaginal hysterectomy

24
A 60-year-old woman, in menopause during the last 10 years, presents with
vaginal bleeding. Vaginal ultrasound demonstrates irregular mucosa, 8mm at
the fundus, and 1mm over the rest of the uterus. (demonstrated in the
picture).

Which of the following is the most appropriate recommendation for this

patient?
1. Follow up in 6 months
2. 3-dimensional ultrasound
3. Colposcopy
4. Hysteroscopy
5. Hysterectomy

25
Which of the following is included in the management of premature rupture
of membranes on the 33-week of gestation during the first 48 hours, given
chorioamnionitis was ruled out?
1. Ampicillin + erythromycin + steroids
2. Ampicillin + steroids + tocolytics
3. Ampicillin + steroids + magnesium for fetal neuroprotection
4. Ampicillin + erythromycin + steroids + tocolytics + magnesium for fetal
neuroprotection
5. Ampicillin + steroids + induction of labor

26
A 29-year-old woman has genital Herpes on her 30 week of gestation. Which
of the following is the most appropriate recommendation at this stage?
1. Avoidance of intercourse until a vaginal delivery
 2. Intravenous acyclovir for 10 days
3. Elective cesarean section at 39 weeks of gestation
4. Prophylactic acyclovir from 36 weeks of gestation until delivery
5. Empiric acyclovir treatment of the woman and her partner

27
A 31-year-old woman on the 38th week of her first pregnancy presents to the
local clinic with severe headache. Blood pressure was 140/90 on two separate
measurements.
Which of the following is the next step in managing this case?
1. Routine follow up until 40 weeks of gestation
2. Twice-daily blood pressure measurements until 41 weeks of gestation
3. Initiating treatment with beta blockers
4. 24-hour urine protein collection
5. Referral to the emergency room

28
A 25 weeks pregnant 30-year-old woman has a glucose challenge test (GCT)
result of glucose 203mg/dl. Which of the following is the next step in
managing this patient?
1. Routine follow up
2. Repeat GCT at 28 weeks of gestation
3. Oral glucose tolerance test (OGTT)
4. Initiating treatment for gestational diabetes
5. Initiate treatment with insulin pump

29
Combined oral contraceptives decrease the risk of
1. Thromboembolic events
2. Ovarian cancer
3. Chlamydia lower vaginal tract infections
4. Uterus cervical cancer
5. Gallbladder stones
30
A 32-year-old married woman, with no children, presents with amenorrhea
over the last 18 months. She reports normal sexual development during
puberty, regular menstruation, and no gynecological issues in the past.
Which of the following is the most likely cause of her amenorrhea?
1. Mullerian agenesis
2. Turner syndrome mosaicism
3. Asherman syndrome
4. Eating disorder
5. Diabetes

31
A 30-year-old woman presents with 3 consecutive early miscarriages. Which of
the following tests is included in the primary work up?
1. Blood pressure Holter
2. Testing for congenital hypercoagulation
3. Karyotyping of both partners
4. Glucose tolerance test
5. Laparoscopic examination of the uterine structure

32
Which of the following is an absolute contraindication for regional anesthesia
for labor?
1. Cesarean section due to prolonged rupture of membranes
2. Back pain
3. Coagulopathy
4. Thrombocytopenia 100,000
5. Hypertension

33
On two semen specimens, taken 6 weeks apart, of a healthy, 30-year-old man,
there were less than 5 million cells per ml.
Which of the following is the diagnostic next step?
 1. Postcoital test
2. Hormone profile (LH, FSH, testosterone)
3. An additional semen exam in 3 months
4. Testing antibodies to sperm
5. Testicular biopsy

34
A healthy, mother of two, 28-year-old woman, had a rich family history of
breast and ovarian cancer, and has been found to be BRCA-1 positive.
Which of the following is the most appropriate recommendation for this
woman?
1. Pelvic MRI twice a year
2. Avoidance of combined oral contraceptives
3. Salpingo-oophorectomy at the age of 35 years
4. Pap smear twice a year
5. Yearly colonoscopy from the age of 40

35
A 38-week pregnant woman has a fetus with a sonographic estimated weight
of 4600 gr. Which of the following factors can provide the best explanation for
this situation?
1. TORCH - congenital infection
2. Gestational age
3. Placental insufficiency
4. Gestational diabetes
5. Smoking

36
Which of the following raises the suspicion of malignancy in an ovarian mass
demonstrated by ultrasound in a 65-year-old woman?
1. Calcifications within an ovarian cyst
 2. A clear cyst with a diameter of 8 cm
3. Sediment in an ovarian cyst
4. Bilateral findings
5. A single thin septum within the cyst

37
A 36-weeks pregnant woman presents with malaise, nausea, repeat vomiting,
headache, and jaundice. Laboratory results are significant for hypoglycemia,
hyperammonemia, and elevated liver enzymes. Which of the following is the
most likely diagnosis?
1. Hemolytic uremic syndrome (HUS)
2. Acute gastroenteritis
3. Viral hepatitis
4. Thrombotic thrombocytopenic purpura (TTP)
5. Acute fatty liver of pregnancy (AFLP)

38
A 22-year-old single woman with no children presents with sudden hirsutism
that started 4 months ago, and discomfort in the lower right abdomen. She
has regular menstruation, and no additional complaints. Her BMI is 21.
Ultrasound demonstrates a 5cm right ovarian mass.
Which of the following is the most likely diagnosis?
1. Polycystic ovary syndrome
2. Sertoli-Leydig tumor
3. Congenital adrenal hyperplasia (CAH)
4. Cushing syndrome
5. Mature cystic teratoma (dermoid)

39
A healthy 30-year-old woman has received the result of atypical squamous
cells of unknown significance (ASC-US) on a routine Pap smear test. She
denies post coital bleeding, and the cervix seems normal on physical
examination
Which of the following is the best recommendation for this woman?
1. Routine follow up
 2. Repeat Pap smear in one year
3. Colposcopy
4. Conization
5. HPV immunization

40
A 27-year-old presents on the 9th week of gestation for her first pregnancy
follow up, after IVF. She has no complaints. Vaginal ultrasound is attached.
Which of the following defines the finding in the picture?

1. Threatened abortion
2. Inevitable abortion
3. Incomplete abortion
4. Missed abortion
5. Anembryonic pregnancy

41
A certain X-linked dominant disease causes a mild disease in females and is
lethal in males. Amale baby is born, with a mild presentation.
Which of the following can be assumed regarding his karyotype?
1. 46XY
2. 47XYY
3. 47XXX
4. 47XXY
5. 47YYY
42
Which of the following could be detected by a bi-manual pelvic examination?
1. A2 cm submucosal myoma
2. The time of ovulation
3. Tenderness on the right adnexa
4. The texture of the salpinges
5. Polycystic ovaries

43
Which of the following requires high-risk pregnancy follow up?
1. A history of unexplained stillbirth
2. The mother is a carrier of fragile-X
3. A history of a child with a congenital heart defect
4. A large for gestational age fetus
5. A history of a cesarean section

44
Which of the following is the most appropriate test to evaluate a suspected
uterine anomaly in a 7-year-old girl?
1. Vaginal ultrasound
2. Diagnostic hysteroscopy
3. Laparoscopy
4. MRI of the abdomen and the pelvis
5. Abdominal X-ray

45
Attached is a uterine X-ray of a 28-year-old woman, performed during
infertility work up.
Which of the following is the most recommended treatment in this case?
1. Salpingectomy and in vitro fertilization
2. Surgical hysteroscopy
3. Ovum donation
4. Ovarian stimulation and intrauterine insemination (COH-IUI)
5. Surrogacy

46
A woman on her 30-week of pregnancy presents with vaginal bleeding and
contractions. Ultrasound demonstrates a pulseless fetus, with biometric
features appropriate for the 28th week of gestation.
Which of the following test results supports a diagnosis of disseminated
intravascular coagulation (DIC)?
1. Low D-Dimer level
2. Low fibrinogen level
3. Short PT/PTT
4. Thrombocytosis
5. Hemoglobin of 13 gr%

47
A 27-year-old single woman with no children, reports lower abdominal pain
during menstruation and intercourse. Her examination is significant for pelvic
tenderness, especially over the sacro-uterine ligaments. Vaginal ultrasound
demonstrates an ovarian cyst with a diameter of 3cm (photo below).

Which of the following describes the first line of treatment in this case?
1. Local vaginal estrogen
2. Local vaginal antibiotics
3. Combined contraceptives
4. Surgical excision of the cyst

48
A woman in the beginning of her pregnancy is interested in genetic testing of
the fetus. Which of the following is true regarding the differences between
chorionic villous sampling (CVS) and amniocentesis?
1. CVS provides a more reliable diagnosis
2. CVS carries a greater risk of a miscarriage
3. CVS allows diagnosis of the mother and the fetus
4. CVS is possible later in the pregnancy
5. CVS is possible only in a vaginal approach

49
Which of the following is a complication of in vitro fertilization?
1. Increased risk of epithelial ovarian cancer
2. Increased risk of endometrial cancer
3. Early menopause
 4. Increased risk of Down syndrome in the fetus
5. Ectopic pregnancy

50
A 29-year-old presents with amenorrhea for 18 months. She describes
menarche at the age of 14, and years of regular menstruation. In addition, the
patient reports excretion of milk from the breasts.
Which of the following details in the patient's history would support the most
likely diagnosis?
1. Hair loss and weight loss
2. New onset of visual disturbance
3. A history of using oral contraceptives
4. A painful rash along a dermatome of the chest
5. Intensive exercise toward triathlon

51
The finding in the picture is revealed during a neonatal examination. The
mother has encountered a febrile illness abroad during the first trimester. The
mother has not received routine immunization and had no prenatal follow up.

Which of the following findings is likely in this newborn, now or further in life?
1. Congenital neural deafness
2. Intracranial calcifications
3. Congenital heart defect- VSD
4. Limb hypoplasia
5. Galactosemia

52
A 4-year-old boy presents with petechia of the trunk and limbs. Examination
does not reveal gingival bleeding, hepatosplenomegaly, or lymphadenopathy.
Complete blood count is normal except for platelets of 25,000/mm3 (normal
values 150-450,000). Peripheral blood smear revealed no blast cells.
Which of the following is the most recommended approach?
1. Intravenous steroids
2. Intravenous immunoglobulins( IVIG)
3. Urgent splenectomy
4. Clinical follow up and avoidance of trauma
5. Rituximab (Mabthera)

53
A 2-year-old boy can run and climb steps, builds a tower of 7 blocks, eats with
a spoon, and can say a 2-3-word sentence.
Which of the following describes this toddler's developmental stage?
1. Normal for his age
2. Delayed gross motor development
3. Delayed fine motor development
4. Significant delay in language development
5. Delay in linguistic and motor development

54
A 3-year-old boy presents with 2 days of fever and a day of left knee pain.
Examination reveals reasonable general condition, a temperature of 39°C. and
the finding in the attached picture. Laboratory results are presented in the
table.
Which of the following is the recommended treatment?
1. IV doxycycline (Doxillin)
2. IV cefazoline (Cefamizin)
3. IV cefotaxime (Claforan)
4. IV clindamycin (Dalacin C)
5. IV vancomycin

55
A 7-year-old boy presents with 2 days of hematuria, several weeks after
having an episode of pharyngitis. His examination is significant for
hypertension. Laboratory results include low serum C3, proteinuria, and
microscopic examination of the urine revealed red blood cell casts.
Which of the following is the most appropriate treatment?
1. Fluid restriction, penicillin, decreasing blood pressure
2. Steroids and anti-hypertension therapy
3. NSAIDs and maintenance fluids
4. Cyclophosphamide (Cytoxan) and steroids
5. Low protein, high calorie diet

56
A 3-year-old boy is undergoing work up due to failure to thrive. History is
positive for several large smelly stools per day, and several episodes of
pneumonia and cough necessitating inhalation therapy. Which of the
following tests will contribute the most to diagnosis?
 1. Complete blood count
2. Stool culture
3. Celiac serology
4. Sweat test
5. Stool calprotectin

57
A 15-vear-old girl complains of nervousness, trouble sleeping, headaches, and
deterioration in her school work. Her examination reveals the findings in the
picture.

Which of the following tests will assist her diagnosis?

1. Serum thyroid stimulating IgG levels
2. Neck ultrasound to characterize the thyroid gland
3. Technetium scan of the thyroid gland
4. Serum anti thyroid peroxidase levels
5. Serum thyroid binding globulin levels

58
A 17-year-old boy is undergoing workup for abdominal pain. Laboratory
results reveal positive, low titer anti-nuclear antibodies (ANA). After a week the
patient is well with no abdominal pain.
Which of the following represents correctly the significance of the blood test
result for this patient?
1. The boy most probably has systemic lupus erythematosus
2. The boy is expected to develop rheumatoid arthritis throughout his life
3. The boy's chances of developing an autoimmune disease are low
 4. The boy should be referred to check additional autoantibodies
5. And abdominal MRI should be performed to rule out inflammatory
bowel disease

59
A 5-year-old boy with autism spectrum disorder (ASD) presents with
restlessness over the last few days, and refusal to walk. History reveals he
doesn't eat much, and his diet is based on schnitzel and water. Examination of
the mouth is shown in the picture. Complete blood count revealed anemia.

Which of the following is the most likely cause of his disease?

1. Hypervitaminosis A
2. Vitamin B deficiency
3. Vitamin C deficiency
4. Hypervitaminosis D
5. Vitamin E deficiency

60
A 3-year-old boy was admitted due to fever and cough over the last 2 days.
Radiological findings are presented in the following X-ray.

Which of the following is the most likely causative agent?

1. Streptococcus pneumonia
2. Chlamydia pneumonia
3. Legionella pneumophilia
4. Mycoplasma pneumonia
5. Klebsiella pneumonia
61
A 16-year-old girl presents with facial swelling and shortness of breath which
appeared the same morning, and had become worse over the last hours. Her
history is positive for a few events of facial swelling that resolved
spontaneously. Examination reveals findings in the attached pictures, heart
rate of 125/min. respiratory rate of 25 breaths/min, blood pressure 110/75,
saturation of 96% in room air, and non-pitting edema of the face, tongue, oral
mucosa, and larynx

.
Which of the following is the most likely finding in her blood work?
1. Anti dsDNA antibodies
2. Decreased C3 levels
3. Decreased albumin levels
4. Increased eosinophil levels
5. Decreased C1 inhibitor levels

62
Complete blood count and blood smear of a 2.5-year-old toddler
demonstrates the findings in the picture and table

Which of the following is the most likely cause of his disease?

 1. Celiac
2. Wilson
3. Thalassemia major
4. Cystic fibrosis
5. Aplastic anemia

63
A 3-year-old boy presents with facial and limb edema. Urinalysis reveals
significant proteinuria and blood work results are presented in the table.

Which of the following is a possible complicate his most likely disease?

1. Intussusception
2. Hemolytic anemia
3. Gastrointestinal bleeding
4. Renal vein thrombosis
5. Mitral valve prolapse

64
A 14-year-old girl presents with 6 weeks of fatigue, weight loss, painless oral
ulcers, and recurrent episodes of high fever. In addition, she reports
intermittent left wrist and right knee pain. Her examination is significant for
the finding in the picture.
Laboratory results are presented in the table.
Which of the following is characteristic of the most likely diagnosis?
1. Positive pathergy test
2. Serum Anti-Smith Ab
3. Elevated serum IgA
4. Elevated serum CPK
5. Blasts in a blood smear

65
A 6-hour-old neonate presents with frothing from the mouth and nose, and
difficulty in breathing during eating. On examination he is generally well, and
cries without respiratory distress.
Which of the following is the next diagnostic test?
1. Insertion of a nasogastric tube
2. Complete blood count and blood gasses
3. Echocardiography
4. ECG
5. Abdominal and chest CT

66
A 10-year-old boy has been clearing his throat and making sniffing voices at
school. His neurological examination is normal.
Which of the following is the boy's most likely diagnosis?
1. Attention deficit disorder
2. Tourette syndrome
3. Vocal tics
4. Chorea minor
5. Anxiety disorder

67
A 36-hour-old newborn girl, delivered at home, is brought to the hospital due
to multiple seizures. Serum glucose is normal, PT, PTT are prolonged, and a CT
scan reveals a focal brain bleed.
Which of the following is the most likely cause of this newborn's bleeding?
1. Maternal thrombocytopenia
 2. Vitamin K deficiency
3. Hemophilia A
4. Congenital CMV infection
5. Traumatic birth

68
A 16-year-old boy with a history of asthma, presents with acute chest pain
after basketball training. Examination reveals a hemodynamically and
respiratory stable teenager, with normal oxygen saturation in room air, and
decreased breath sounds on the right. Chest x-ray is attached.

Which of the following is the most appropriate next step?

1. Insert a right chest drain
2. Admit the boy and supply supplemental oxygen through a face mask
3. Chest CT for evaluation
4. Obtain arterial blood gasses
5. Initiate antibiotic treatment

69
A 16-year-old boy presents with gynecomastia. He is 1.85m tall (>97%) and
his testicles are at a pre-puberty volume.
Which of the following is the most probable diagnosis?
1. Klinefelter syndrome
2. Fragile X syndrome
3. Hypophysial tumor
 4. Breast tumor
5. Adrenal tumor

70
An 8-year-old boy presents to the emergency room with diabetic ketoacidosis
and had been treated accordingly. Two hours later the attached ECG was
performed.

Which of the following is expected in this child's blood work?

1. Hypokalemia
2. Hypernatremia
3. Hypocalcemia
4. Hypermagnesemia
5. Hyperphosphatemia

71
A 15-year-old girl with hypothyroidism and obesity complains of limp and left
hip pain for the past 3 weeks following an injury during sports lesson. The
pain radiates to the knee, occasionally wakens her up from sleep, and
worsened during the past two days to the level that she needs support in
walking. The physical and imaging findings are below. What is the most likely
diagnosis?
1. Legg-Calve-Perthes disease
2. Acute left septic hip
3. Left transient synovitis
4. Slipped capital femoral epiphysis
5. Osteoid osteoma
72
Which of the following describes normal puberty?
1. Breast buds at 9 years of age
2. Increased testicular volume at 8 years of age
3. Genital hair in a 7-year-old girl
4. Axillar hair in a 9-year-old boy
5. Genital hair in a 9-year-old boy

73
A 7-year-old boy presents with a few months of polyuria, polydipsia, failure to
gain weight, headaches, and vomiting. Laboratory results are presented in the
table. After been given vasopressin (ADH) the urinary osmolarity increased
and the blood osmolarity decreased.

Which of the following diseases can explain these findings?

1. Wilms's tumor
2. Hodgkin's lymphoma
3. Rhabdomyosarcoma
4. Langerhans cell histiocytosis
5. Osteosarcoma

74
A 6-month-old infant is referred for work up of constipation and abdominal
distention. The baby passed his first meconium at the age of 3 days, and has
been padding stool every few days after insertion of a rectal thermometer. The
imaging results are attached.
Which of the following test will contribute the most to diagnosis?
1. Colonoscopy
2. Rectal biopsy
3. Abdominal ultrasound
4. Stool calprotectin
5. Sweat test

75
A 9-months-old baby with atopic dermatitis develops the extensive rash
demonstrated in the picture.

Which of the following is the most recommended treatment?

1. Rafapen (penicillin G)
2. Ceforal (cephalexin)
3. Rocephin (ceftriaxone)
4. Moxypen (amoxycillin)
5. Doxillin (doxycycline)

76
A few hours old newborn presents with bilious vomiting. Pregnancy history
includes polyhydramnios. Examination reveals a hypotonic newborn, with a
soft and non-distended abdomen. Imaging is attached.

Which of the following is the most probable diagnosis?

1. Intussusception
2. Duodenal atresia
3. Intestinal malrotation
4. Pyloric stenosis
5. Biliary atresia

77
A 17-year-old boy presents with shortness of breath and nausea starting a few
minutes after being stung by a bee. His examination includes blood pressure
of 65/40, and a heart rate of 140 per minute. He improved after been treated
with an adrenaline injection. He has been stung by bees twice before without
a systemic reaction. His blood work is significant for increased anti bee venom
IgE levels.
1. Which of the following is the best approach?
2. Permanent prophylactic antihistamine treatment
3. Gradual immunization by bee venom
4. Automatic antihistamine injection for self-use
5. Permanent low dose steroids
6. Automatic steroid injection for self-use

78
A 7-year-old boy was brought to the emergency room unconscious after
being in a motor vehicle accident. He wasn't wearing a seat belt. Examination
reveals an occipital hematoma on the head, and a right arm and calf
deformity.
Which of the following is the most appropriate next step?
1. Analgesia with fentanyl
2. Airway evaluation
3. Fixation to a backboard
4. Limb fixation to a splint
5. Evaluation of vital signs

79
A 13-year-old boy presents to the emergency room due to ankle and calf
pain, dizziness and pharyngeal pain, that started 20 minutes before, while
walking in the forest. Examination reveals flushing, blood pressure 70/40,
heart rate of 130/min, respiratory rate of 30/min, saturation 95% in room air,
and the finding in the picture attached.

Which of the following is the mandatory immediate treatment in this case?

1. Oral antihistamine
2. Intravenous steroids
3. Intra muscular epinephrine
4. Intravenous fluid bolus
5. Intravenous antibiotics

80
A 13-year-old girl presents with a few months of intermittent fever, night
sweats, weight loss, and night time itching. Examination is significant for
hepatosplenomegaly and an enlarged right supraclavicular lymph node.
Which of the following is the first next diagnostic test?
1. Abdominal and chest CT
2. AP and lateral chest x-ray
 3. Technetium scan
4. Lymph node biopsy
5. Positron emission tomography (PET) scan

81
A TU-year-old boy is examined in the emergency room due to a short reprile
seizure tollowed by a rew episodes of bloody diarrhea. A week earlier his
brother and sister suffered from diarrhea. Examination reveals a temperature
of 39.50C, poor nutritional condition, and rectal prolapse. Stool smear is
demonstrated in the attached picture. Treatment with intravenous isotonic
solution is initiated.

Which of the following is the recommended treatment at this point?

1. Oral ampicillin (Penibrin)
2. IV trimethoprim/sulfamethoxazole (Resprim)
3. IV cefuroxime (Zinacef)
4. IV ceftriaxone (Rocephine)
5. Oral doxycycline (Doxillin)

82
Blood work was obtained from a generally healthy 6-year-old boy, as per
parental request. Complete blood count was normal, and serum IgA anti TG2
was 100 units (normal value <15 units). The boy does not have abdominal
pain, and passes normal stool once a day. Family history is negative for celiac.
Which of the following describes the recommended approach?
1. Perform abdominal CT
2. Perform serum EMA and genetics for HLA
3. Outpatient follow up of growth curves
4. Endoscopy including small bowel biopsy
5. Gluten free diet and repeat the tests in 6 months
83
Which of the following is the most common serious bacterial infection in
neonates presenting with fever?
1. Bacterial pneumonia
2. Bacterial meningitis
3. Urinary tract infection
4. Primary bacteremia
5. Arthritis/osteomyelitis

84
A 6-year-old girl presents with a week of lower limbs weakness, numbness up
to the navel level, with trouble in urinating and defecating. These complaints
followed a febrile illness. CSF examination revealed a negative gram stain, and
a slightly increased protein level.
Which of the following is the most appropriate treatment?
1. Intravenous steroids
2. Intravenous ceftriaxone
3. Intravenous vancomycin
4. Prophylactic sedation and ventilation
5. Daily physiotherapy and respiratory therapy

85
A 4-year-old boy presents with a week of purulent lesion under his left ear,
which was followed by fever and the finding demonstrated in the attached
picture. Palpation reveals a tender and warm lesion.

Which of the following is the treatment of choice?

1. Amoxycillin (Moxypen)
2. Cephalexin (Ceforal)
3. Penicillin G (Rafapen)
 4. Ciprofloxacin (Ciproxin)
5. Clarithromycin (Klacid)

86
A 3-week-old newborn was admitted due to jaundice. Laboratory results
include total bilirubin of 12 mg/dl, and direct bilirubin 7.5 mg/dl (normal value
<10% of total bilirubin). Which of the following is the most probable
diagnosis?
1. Gilbert disease
2. Crigler Najjar syndrome
3. Biliary atresia
4. Spherocytosis
5. Thalassemia major

87
A 14-year-old girl has lost 10 kg over the last months. Examination reveals a
very thin girl, heart rate of 55/min (normal values 60-80). Laboratory results
include low serum potassium, and elevated liver function tests and cholesterol.
Which of the following is the most likely diagnosis?
1. Ulcerative colitis
2. Crohn's disease
3. Protein losing enteropathy
4. Anorexia nervosa
5. Celiac disease

88
A 2-year-old boy presents with speech difficulties. His history is positive for
multiple ear infections. Examination now reveals bilateral turbid ear drums,
and middle ear effusion. The boy is well, calm, and afebrile.
Which of the following is the most appropriate next step?
1. Prophylactic antimicrobial therapy with Moxypen (amoxycillin)
2. Intravenous cefuroxime (Zinacef)
 3. Middle ear drainage and antibacterial treatment according to discharge
culture
4. Rule out conductive hearing loss
5. Ventilation tube insertion

89
A 16-year-old boy presents with 2 weeks of chest pain, lateral to the lower
sternal border. The pain is worsened by movement and position changing,
and not accompanied by shortness of breath or affected by strain.
Which of the following is a possible treatment for his condition?
1. Naxyn (naproxen)
2. Prednisone (meticorten)
3. Intravenous IgG
4. Acamol (paracetamol)
5. Losec (PPI blocker)

90
A 1-year-old infant is admitted for urinary tract infection and treated
accordingly. She had responded to treatment and improved after 48 hours.
Renal ultrasound is normal.
Which of the following represents the recommended approach?
1. Prophylactic antibiotics and cystography
2. DMSA scan in 6 months
3. Cystography followed by a DMSA scan
4. Follow up by physician
5. Repeat ultrasound in 6 months

91
An 8-year-old girl presents with a 12-day febrile disease, and shortness of
breath over the last day. Examination is significant for inspiratory dyspnea,
92% saturation in room air, mild hepatosplenomegaly, and the finding in the
attached picture. Laboratory findings include leukocytosis with atypical
lymphocytes, a sterile pharyngeal culture, and the findings in the table
attached.
Which of the following treatments may improve the girl's condition now?
1. Left tonsillar drainage
2. Ganciclovir for a month
3. Clindamycin (Dalacin C) for a week
4. A short course of steroids
5. Acyclovir for a week

92
A 4-year-old girl has had 5 episodes of wheezing and shortness of breath over
the last year. She has been treated with bronchodilators and inhaled steroids
as an outpatient. Her recent chest x-ray is normal.
Which of the following predicts continuous symptoms into adulthood?
1. Exposure to cow milk earlier than 1 year of age
2. Being a twin
3. Similar medical history of one of her parents
4. Breast feeding during the first months of life
5. Large for gestational age at birth

93
A 2-year-old boy is brought unconscious to the emergency room after
drowning in a pool. An airway was established and positive pressure
ventilation was given through a bag and mask, with supplemental oxygen.
Examination is significant for a weak and slow pulse, and the cardiac monitor
picture is attached.

Which of the following is the most appropriate next step?

 1. Since it is a sinus rhythm, continue the same treatment
2. Start chest compressions immediately
3. Synchronized cardioversion using 50 joules
4. Intravenous atropine
5. Unsynchronized cardioversion using 50 joules

94
A 2-hour-old newborn is evaluated for central cyanosis. Oxygen saturation in
room air is 60%, heart rate is 160 per minute, breath sounds are good and
equal, and there is no murmur. Hyperoxia test revealed low PaO2. Chest x-ray
is attached.

Which of the following describes the next step in this newborn's care?
1. Urgent cardiac catheterization
2. Mechanical ventilation
3. Immediate treatment Prostaglandin E1
4. Immediate treatment with indomethacin (indon)
5. Raskind balloon atrial septostomy

95
A 3-month-old baby presents with severe restlessness with no additional
symptoms. Examination reveals an afebrile infant, with normal oxygen
saturation in room air, heart rate of 240/min, blood pressure of 80/40. The rest
of the physical examination is normal.
Which of the following will contribute the most to diagnosis?
1. Abdominal x-ray
2. ECG
3. Complete blood count
4. Urinalysis
5. Chest x-ray
96
A 17-year-old girl has been having migraines for the last 2 years, and has been
treated with acamol (acetaminophen). Lately she reports a significant increase
in frequency of the migraines, with no change in their character. Neurological
examination is normal.
Which of the following is the most recommended prophylactic drug at this
point?
1. Naproxen (Naxyn)
2. Anti-epileptics
3. Cannabidiol
4. Sumatriptan (Imitrex)
5. Ibuprofen (Brufen)

97
A 4-month-old baby presents to the emergency room after getting hit by his
2-year-old brother. This is his 3rd time in the emergency room due to falls.
Examination is significant for restlessness, chest tenderness on palpation, he
doesn't move his left leg. Laboratory results including a complete blood count,
biochemistry and inflammatory markers is normal.
X-ray is attached.

Which of the additional findings is likely to be present in this baby?

1. Abdominal mass
2. Increased PTH levels
3. Low calcium levels
4. Increased head circumference
5. Retinal hemorrhages
98
A 4-month-old infant presents with infantile spasm episodes, worsening over
the last 4 weeks. Findings in physical examination are shown in the picture.

Which of the following is the most appropriate first line anti-epileptic drug?
1. Lamotrigine (Lamictal)
2. Carbamazepine (Tegretol)
3. Intra-muscular ACTH
4. Valproic acid (Valporal)
5. Vigabatrin (Sabryl)

99
A 10-day-old newborn presents with significant tremor in 4 limbs. He was
born at 40 weeks of gestation, to a mother with gestational diabetes mellitus.
Examination reveals a generally well, not dysmorphic newborn, with significant
tremor and restlessness. Laboratory results are presented in the table.

Which of the following is the most likely diagnosis?

1. Autoimmune hypothyroidism
2. Transient hypoparathyroidism
3. Turner syndrome
4. Vitamin D deficiency
 5. Congenital hypocalcemia

100
A 2-year-old boy, of Jewish Ashkenazi descent, had developed well until 5
months of age, and then a developmental regression occurs, with an
exaggerated startle reflex. In time deafness and blindness developed, as well
as an inability to speak or walk. Examination reveals marked hypotonia,
macrocephaly, and the retinal finding in the attached picture.

Which of the following is the most likely diagnosis?

1. Tay-Sachs disease
2. Pyruvate carboxylase deficiency
3. Congenital CMV infection
4. Maple syrup urine disease
5. Pyruvate dehydrogenase deficiency

PART B
1
A 55-year-old female is evaluated before gynecological surgery. No past
medical history or any complaint: On examination - blood pressure 120/80
mmHg, pulse 76/min regular, wide and constant S2 split. No other
abnormal findings. Below is her ECG.
 Which of the following is the most likely diagnosis?
1. Mitral stenosis
2. Aortic regurgitation
3. Anteroseptal myocardial infarction
4. Atrial septal defect
5. Bifascicular block (RBBB & left anterior hemiblock)
2
A 20-year old male with Alport syndrome causing terminal renal failure is
admitted to the ER due to chest discomfort and dyspnea over the past
two days. On examination - pericardial friction rub, lungs are clear. Chest
X-ray - cardiomegaly with no infiltrates or edema. He reports starting
hemodialysis a month ago, twice weekly for 3 hours each. Which of the
following is the most appropriate treatment?
1. Treat with colchicine and later increase the dialysis regimen
2. Steroids at 1 mg/kg and later increase the dialysis regimen
3. Urgent dialysis and later increase the dialysis regimen
4. IV high dose diuretics
5. Increase the heparin dose during dialysis

3
A patient with recent diagnosis of chronic renal failure is evaluated by a renal
ultrasound that demonstrates large kidneys. Which of the following diagnoses
can explain this finding?
1. Amyloidosis
2. Familial dyslipidemia
3. Unilateral renal artery occlusion
4. Prolonged use of NSAIDs
5. Chronic nephrolithiasis disease

4
A 65-year-old COPD male smokes 2 packs a day for 30 years. He is admitted
due to disease exacerbation and is known to the team for repeated
admissions, latest one 4 months ago Lately he almost never leaves his house
and is treated with maximum inhalations.
Which of the following is recommended upon discharge?
1. Azithromycin daily
2. Prednisone
3. Theophylline
4. IV Alpa1 antitrypsin
5. Calcium channel blockers

5
A 55-year-old male underwent mechanical prosthetic mitral valve replacement
today. Permanent anticoagulation therapy is considered.
Which of the following is correct?
1. Start heparin and direct oral anticoagulants (DOACs) and after 5
days of combined treatment continue to bitrate DOACs to an INR
1.5-2.0
2. Start direct oral anticoagulants (DOACs) immediately after surgery
3. Start heparin and warfarin and after 5 days of combined treatment
continue to titrate warfarin to an INR 1.5-2.0
4. Start heparin and warfarin and after 5 days of combined treatment
continue to titrate warfarin to an INR 2.5-3.5
5. Permanent subcutaneous heparin alone is the treatment of choice

6
A 70-year-old male is admitted to the ER with fever for a month, lack of
appetite, weight loss, and prolonged cough. X-ray is below. Which of the
following is the most likely diagnosis?

1. Right pneumonia
 2. Right pneumothorax
3. Right lung abscess
4. Right foreign body
5. Right lung space occupying lesion

7
A 60-year-old male is referred due to malaise. His past medical history is
positive for ischemic heart disease and diabetes. On examination - distinct
pale skin and sclera, ulcers at the side of the mouth, and kolonychia. Labs - Hb
6.5. Which of the following is the expected patient's MCV?
1. MCV of 70, findings point out iron deficiency anemia
2. MCV of 85, findings point out anemia secondary to chronic renal
failure
3. MCV of 101, findings point out anemia secondary to alcohol
consumption
4. MCV of 80, findings point out vitamin B12 deficiency anemia
5. MCV of 70, findings point out folic acid deficiency anemia

8
Direct oral anticoagulants (DOACs) are recommended to which of the
following patients?
1. Atrial fibrillation in a patient with creatinine 5.5 and GFR 10
2. Atrial flutter in a patient with mechanical mitral valve
3. Atrial fibrillation in a patient with rheumatic heart disease and
severe mitral stenosis
4. A patient with sinus rhythm and mechanical mitral valve and left
atrial appendage resection
5. Atrial fibrillation in a patient with CHA2DS2 VASc score 3

9
A 24-year-old male undergoes gastroscopy due to abdominal pain and
antrum gastritis is demonstrated with positive helicobacter pylori.
Which of the following is the most appropriate treatment?
1. Amoxicillin with proton pump inhibitor (PPI)
 2. Amoxicillin with tetracycline
3. Levofloxacin
4. Levofloxacin with PPI
5. Levofloxacin, amoxicillin, and PPI

10
A 77-year-old male complains of increasing malaise over the past year. On
examination - splenomegaly. Labs - Hb 7.6 (NL 12-16): WBC 11,000 (NL 4,300-
10,800): PLT 104,000 (NL 150,000-450,000 haptoglobin 201 (NL 50-150).
Coombs test is negative. Peripheral blood smear-teardrop shaped red cells
and nucleated red cells. Bone marrow-dry tap.
Which of the following is the most likely diagnosis?
1. Aplastic anemia
2. Chronic myelocytic leukemia
3. Myelofibrosis
4. Pure red cell aplasia
5. Autoimmune hemolytic. Anemia (AIHA)

11
A 33-year-old male is evaluated at the ER due to headaches and right eye pain
for the past 5 days. He also reports painful ulcer in the scrotum. He denies
fever or joint pain. He also complains of intermittent oral ulcers in the past 5
years. No regular medications On examination - T 36.8°C, pulse 85/min, blood
pressure 130/76 mmHg, five oral mucosal ulcers, no nuchal rigidity, 1 cm ulcer
over his scrotum. Labs-Hb 11.1: WBC 15.600. Normal head CT. lumbar
puncture - 13 leukocytes/UL, 100% lymphocytes, negative Gram stain.Which
of the following is the most likely diagnosis?
1. Syphilis
2. Chancroid
3. Behcet's disease
4. Systemic lupus erythematous
5. Herpes simplex virus infection

12
Patients with atrial fibrillation are at risk for systemic arterial emboli and
stroke. Which of the following patients is considered to have the lowest risk
for embolic CVA?
1. A 45-year-old female with severe mitral stenosis due to rheumatic
heart disease
2. A 64-year-old female with type Il diabetes controlled by
medications
3. A 70-year-old male with hypertension controlled by two
antihypertensive medications
4. A 40-year-old male with controlled heart failure and left ventricle
ejection fraction (LVEF) of 36%
5. A 50-year-old healthy male with documented episodic atrial
fibrillation for the past 6 months

13
A 64-year-old male with diabetes, hypertension, and smoking complains of 6
months of compressing chest pain on moderate exercise, radiating to the left
arm and accompanied by dyspnea. On examination-wide split of S2, a 3/6
holosystolic murmur at the apex, radiating to the axilla
Which of the following is most probable to be found on physical examination?
1. Loud S1
2. Opening snap
3. s3
4. Pulsus parvus et tardus
5. Water hammer pulse

14
An 80-year-old male is admitted to internal medicine department due to new
left pleural effusion. Which of the following is diagnostic of exudative fluid?
1. Fluid to serum protein ratio lower than 0.5
2. Fluid to serum LDH ratio greater than 0.6
3. Fluid LDH lower than half the upper value of serum LDH
4. Albumin difference between the serum and fluid greater than 1.1
 5. Number of white cells in fluid greater than number of white cells in
serum

15
A 45-year-old female is evaluated for abdominal pain and diarrhea. Her
complaints started 3 days ago Initially her stool was soft and later she noticed
fresh blood remains in her stool History taking reveals that 5 days before her
symptoms she attended a picnic and ate a hamburger with potato salad and
mayonnaise. She also reports that two other guests developed diarrhea On
examination-looks well, tachycardic 115/min, hyperperistalsis with diffuse
abdominal tenderness Labs-WBC 17.400, creatinine 1.2 mg/d. positive blood
in stool Which of the following pathogen is the most likely cause of her
symptoms?
1. Bacillus cereus
2. Vibrio cholerae
3. Shiga toxin-producing
4. E.coli Staphylococcus aureus
5. Brucellosis
16
A 50-year-old female with hypothyroidism is treated medically She is admitted
due to fatigue, malaise, and scleral jaundice. On examination-oriented to time
and place, hemodynamically stable, no fever, mild skin and scleral jaundice,
mild right upper quadrant tenderness. No other abnormal findings. Labs-AST
300 (NL 5-40) ALT 370 (NL 14-63) ALP 120(NL 30-115), GGT 55 (NL 5-60),
bilirubin 3 (NL <1) of which 2 is direct History taking-no new medications, viral
evaluation is negative, liver ultrasound in the past was normal without bile
duct dilation, Antinuclear antbodies (ANA) and anti-smooth muscle antibodies
(ASMA) are positive Which of the following is the most likely diagnosis?
1. Primary billary Clinthosis
2. Primary sclerosing cholangitis
3. Autoimmune hepatitis
4. Cirrhosis secondary to HBV infection
5. Acute viral hepatitis

17
Which of the following is not considered a risk factor for developing chronic
obstructive pulmonary disea
 1. Smoking
2. Childhood pneumonia
3. Asthma
4. Adulthood pneumonia
5. Coal mining

18
A 69-year-old male is brought to the ER due to a first episode of compressing
pain at the anterior chest for several hours. On examination no distress, clear
lungs, normal heart sounds without murmurs. Pulse Bimin regular, blood
pressure 120/80 mmHg, room air saturation 97% ECG-normal sinus rhythm,
troponin on admission 564 ng/ml (NL up to 7). Antiplatelet therapy is initiated
with the diagnosis of non-ST elevation myocardial infarction (NSTEMI) Which
of the following is correct with regards to antiplatelet treatment in NSTEMI
patients?
1. Recent papers did not demonstrate an advantage of aspirin and
prasugrel over aspirin and clopidogrel
2. Ticagrelol causes dyspnea shortly after treatment initiation
3. There is no proven advantage of aspirin and clopidogrel over aspirin
alone in patients that were treated conservatively for a year without
catheterization
4. Double antiplatelet therapy is indicated for at least a year, especially
in patients with drug eluting stents, to avoid restenosis
5. It is recommended to stop clopidogrel in patients with NSTEMI that
are treated with beta adrenergic receptor blockers

19
A 19-year-old soldier is referred due to three days of maculopapular rash over
the upper and lower limbs including this pains fover 38°C and headache
severity of 3/10. He reports that the symptoms began several days after
training and sleeping outdoors in the northern part of the country
Examination is normal except for the rash in the photos below Labs-
leukopenia, thrombocytopenia, hyponatremia and mildly elevated liver
function tests Which of the following is the next step in treatment?
 1. High dose aspirin
2. Loratadine
3. Amoxicillin clavulanic acid (Augmentin)
4. Prednisone
5. Doxycycline

20
A 43-year-old male arrives to the ER with high fever, chills, and swelling and
pain of his right leg. He denies chest pain or dyspnea. Past medical history is
positive for type 2 diabetes Past surgical history is positive for right foot
varices ligation On examinant - fever38.7°C, pulse 99/min, blood pressure
138/72 mmHg well defined erythematous warm area at the right leg. Fungi
between the fingers of the feet
Which of the following is the recommended treatment?
1. Low molecular weight heparin
2. Vancomycin
3. Cefazolin
4. Ciprofloxacin
5. Oxacillin
21
A 60-year-old malo is an active smoker. On routine CBC-Hb 19, Hct 55, WBC
8,500, Platelets 300,000, MCV 88. Which of the following is the next step in
evaluation of this patient?
1. Repeat CBC in tube without EDTA
2. Test JAK2 mutation
3. Erythropoietin serum levels
4. Carboxyhemoglobin in arteria blood
5. Lung function test
22
A 67-year-old healthy male, complains of increasing fatigue and back pain in
the past 3 months. The only medication he has been taking is acetaminophen.
On examination-tenderness over the spine and pitting edema at the ankles.
No other abnormal finding: Spine X-ray demonstrates compression fracture of
L1. Labs - Hb 8 g/dL: WBC 4,000; Platelet 300,000: Albumin 2.7 g/dL: Total
Protein 9.2 gl; Calcium 13.4 mg/dl: Creatining 2.1 mg/dl. Which of the
following is correct?
1. Bone scan is essential for diagnosis
2. Prostate specific antigen (PSA) level is essential for diagnosis
3. Serum parathyroid hormone level will be elevated
4. Serum protein electrophoresis & free light chains test should be
performed
5. Echocardiography is essential for diagnosis

23
Which of the following direct oral anticoagulants (DOACs) is a thrombin
inhibitor?
1. Dabigatran
2. Rivaroxaban
3. Apixaban
4. Edoxaban
5. Warfarin

24
A 60-year-old male is brought to the ER due to an episode of palpitations and
dyspnea two hours prior to his arrival. On examination-respiratory distress,
diaphoretic, diffuse rales over the lungs, irregular rapid heart sounds, pulse
160/min, blood pressure 80/50 mmHg, oxygen mask saturation 85%. ECG.
Which of the following is the most appropriate management?
1. Decrease heart rate by IV bata blockers
2. Decrease heart rate by IV non-dihydropyridines calcium channel
blockers
3. Urgent electrical cardioversion
4. Urgent medical cardioversion with IV amiodarone
5. Non-invasive ventilation support with BIPAP and IV diuretics
(furosemide)

25
A 70-year-old male is admitted to the ER following night lower limb bums
from an oven several days ago Pain is severe. Past medical history - diabetes
and hypertension. On examination-pulse regular 100/min, blood pressure
80/50 mmHg, T 39°C, room air saturation 99%. On examination of the foot-
purplo vesicles and severe tenderness Right lower limb CT-soft tissue gas.
Which of the following is correct?
1. Cefazolin (Cefamezin) is the treatment of choice
2. Piperacillin/tazobactam (Tazocin) is the treatment of choice
3. Vancomycin and amikacin are the treatment of choice
4. Debridement of the involved issues without antibiotics is the
treatment of choice
5. Penicillin and clindamycin are the treatment of choice

26
Recently the world is dealing with the corona pandemic that is caused by the
SARS-CoV-2 virus and causes COVID pneumonia and acute respiratory
distress syndrome (ARDS).Which of the following is an ARDS criterion?
 1. PaOy/F10, < 200
2. Right ling infiltrate
3. Pulmonary pressure > 60 mmHg
4. Loft ventricle ejection fraction 35%
5. Decreased right ventricle function

27
A 28-year-old male complains of dyspnoa on moderate and intense exercise.
On examination - blood pressure 130/80 mmHg, pulse regular 84/min, Heart-
sinus, 3/6 holasystolic murmur over the heart base and left sternal border.
ECG-sinus rhythm with left ventricle hypertrophy Echocardiography-
hyperdynamic systolic function with LVEF of 70%, hypertrophy of ventricular
septum, systolic anterior motion (SAM) of the mitral valve, and dynamic
obstruction of the left ventride outlet
Which of the following is a risk factor for sudden death in the patient and
therefore ICD defibrillator implantation should be considered?
1. Documented new onset of atrial fibrillation
2. His father developed ventricular tachycardia on the fourth day
following myocardial infarction
3. A ventricular septum width of 33 mm on echocardiography
4. Increase in blood pressure on stress test
5. Atrial premature beats (APC'S) on ECG

28
A 23-year-old female was diagnosed with ulcerative colitis several months ago
and treated with 5-ASA with no improvement. She is admitted due to severe
colitis exacerbation and is treated with IV steroids with no improvement
Which of the following is the next step in treatment?
1. Azathioprine
2. Methotrexate
3. Natalizumab
4. Usteklunumab
5. Cyclosporine

29
A female, Israeli native, nursing school student, is on clinical rotation and
undergoes a Mantoux test. Result is 10 mm and she is asymptomatic Chest X-
ray is normal.
What is the recommended treatment?
1. Isoniazid for 12 months
2. Rifampin for 4 months
3. Isoniazid + rifampin for 1 month
4. Isoniazid + rifampin for 6 months
5. Rifampin+moxifloxacin for 4 months

30
A 42-year-old healthy male is referred to the ER due to fever of 39.5°C and
malaise COVID 19 swab is negative. On chest X-ray-loft lower lobe infiltrato
consistent with left lobar pneumonia. He was treated accordingly with
levofloxacin with no Improvement after 3 days of treatment.
Which of the following is reasonable?
1. The antibiotic treatment should be changed to cefurocime (Zinacel)
2. Stool cultures should be sent to rule out abdominal infection
3. Immediate chest X-ray should be performed to rule out pleural
effusion as a complication of pneumonia
4. Wait another 72 hours prior to decision on treatment modification
5. The patient has an indication to proceed with partial loft lobectomy

31
A 35-year-old female with type 1 diabetes diagnosed at the age of 5 years is
controlled and treated with insulin pump. In the last few days - fever, diarrhea,
and vomiting.
On examination - pale, very weak, altered consciousness, blood pressure
90/60 mmHg pulse 110/min regular, room air saturation 99%. Labs - Hb 15;
WBC 20,000; glucose 5500 mg/dl; sodium 130 mEq/L: potassium 5.5 mEq/L:
chloride 100mEq/L, creatinine 1.1 mg/dl; HCO3 12 mEqL: PH 7.12.
Which of the following is part of the initial treatment?
1. Bicarbonate, short acting insulin, IV NaCl 0.45%
2. Bicarbonate, long acting insulin, IV NaCl 0.9%
3. Short acting insulin, IV NaCl 0.9%
4. IV short acting insulin and SC long acting insulin, IV NaCl 0.46%
 5. Short acting insulin, IV NaCl 3%, inhalation salbutamol (Ventolin)

32
A 35-year-old female complains of a year of pruritus and rigidity of the skin
over her fingers that has spread beyond her elbows and involves the chest She
also reports finger cyanosis especially during cold temperatures. Labs -
normocytic normochromic anemia around 10, elevated CRP, creatinine 0.8,
normal urine Anti-Scl-70 (anti topoisomerase 1) positive.
Which of the following extra-cutaneal is expected in this patient?
1. Recurrent aphthae
2. Interstitial lung disease
3. Calcinosis (calcifications)
4. Telangiectasias
5. Hirsutism

33
Which of the following is not a recommended treatment in hepatic
encephalopathy?
1. Rifaximin
2. Lactulose
3. Correct electrolyte abnormalities
4. Corticosteroids
5. Zinc

34
A 60-year-old male with a history of atrial fibrillation is treated with
rivaroxaban (Xarelto) Normal kidney function tests. He is scheduled for a
colonoscopy for polyp removal that was previously demonstrated and not
resected since.
Which of the following is the recommended approach regarding rivaroxaban?
1. Continue treatment without interruption
2. Discontinue treatment 7 days before the procedure
3. Discontinue treatment 5 days before the procedure and confirm
normal INR
 4. Discontinue treatment 2 days before the procedure and no need for
heparin until the procedure
5. Discontinue treatment 3 days before the procedure and start
heparin until the procedure

35
In which of the following the highest residual volume is expected?
1. Pulmonary fibrosis
2. Obesity
3. Asthma
4. Emphysema
5. Pneumonia

36
A patient with routine labs -thyroid stimulating hormone (TSH) 8 mUVL (NL
0.4.4); T3 and T4 normal. Thyr peroxidase (TPO) antibodies are negative. The
patient is asymptomatic with no past medical history. Whici of the following is
the most appropriate approach?
1. Subclinical hypothyroidism, treat with Eltroxin
2. Subclinical hypothyroidism, follow-up only
3. Hypothyroidism, treat with Eltroxin
4. Hypothyroidism, thyroid scan is needed to decide on treatment
5. Results are incorrect, repeat tests

37
Which of the following is correct regarding Q fever?
1. Pneumonia is the most common presentation (about 40% of the
cases)
2. Rickettsia conorii is the causative agent
3. Doxycycline for 2 weeks is the treatment of choice
4. Diagnosis is made by urinary toxin
5. There is chronic phase in this disease

38
Which of the following patients can be diagnosed with acute myeloid
leukemia?
1. A patient with 8% blasts on peripheral blood and t122.9)
translocation
2. A patient with down syndrome and 2% blasts on bone marrow
biopsy
3. A patient with 15% blasts on peripheral blood and inversion of
chromosome 18 -(16) inv
4. A patient with over 50% cells that express BCR-ABL on bone marrow
biopsy
5. A patient diagnosed with essential thrombocytosis that presents
with absolute neutrophilia and PDGFR gene mutation

39
A 45-year-old male is evaluated for frequent urination in the past several
months. He is usually healthy and otherwise asymptomatic and is not on any
current medication. Both his parents had type 2 diabetes. His physical
examination is normal. Labs-fasting glucose 220 mg/dl and HBA1C 8%.
Which of the following is the first line of treatment in this patient?
1. Dipeptidyl peptidase IV inhibitor (Sitagliptin-Januvia)
2. Sodium-glucose cotransporter 2 inhibitor (Empagliflozin-Jardiance)
3. GLP-1 agonist (Liraglutide-Victoza)
4. Biguanide (Metformin)
5. Thiazolidinedione (Rosiglitazone-Avandia)

40
What is the most common cause of death in a 70-year-old male with CKD
stage 4?
1. Cardiovascular disease
2. Pericarditis
3. Metabolic acidosis
4. Recurrent infections
5. Tertiary hyperparathyroidism
41
Which of the following is an indication for urgent dialysis in a patient that has
been unsuccessfully treated conservatively?
1. Hypokalemia
2. Pulmonary edema
3. Low blood pressure
4. Sepsis
5. Hypematremia

42
Which of the following is the most common complication of endoscopic
retrograde cholangiopancreatography (ERCP)?
1. Cholangitis
2. Pancreatitis
3. Perforation
4. Pseudocyst infection
5. Gastritis

43
A 78-year-old male with morbid obesity and uncontrolled hypertension and
diabetes is brought to the ER due to compressing chest pain and significant
malaise that lasted 30 minutes. On admission - blood pressure 80/40 mmHg,
irregular pulse 123/min. Below is his (ECG.)

All of the following are acceptable treatments, except:

 1. Immediate catheterization with primary PCI
2. Heparin
3. Aspirin
4. Nitrates
5. Copidogrel

44
A 21-year-old male is rushed to the ER after being stung by a bee and became
dyspneic. He complains of nausea, abdominal pain and difficulty in breathing.
On examination-respiratory distress, pulse 100/min, erythematous diffuse skin
rash, expiratory wheezes over both lungs
Which of the following is the first step in treatment?
1. IM epinephrine 0.5 mg and repeat injection every 5-20 minutes
2. IM epinephrine 0.5 mg with IV metoprolol 5 mg
3. IM hydrocortisone 150 mg with PO telfast (antihistamine) 180 mg
4. IM hydrocortisone 200 mg and IV metoprolol 5 mg
5. Epinephrine 0.5 mg, hydrocortisone 100 mg, metoprolol 5 mg,
telfast 180 mg

45
A 75-year-old male started treatment with IV acyclovir due to herpes infection
involving the eye and nose. Before treatment the patient had high fever and
barely ate or drank On examination-blood pressure of 100/60 mmHg, pulse
100/min, T 38°C, no other abnormal findings.
Which of the following is this patient most likely to develop?
1. Acute renal failure
2. Heart failure
3. Hypothyroidism
4. Hypokalemia
5. Hypomagnesemia

46
A 30-year-old male is admitted with severe anterior chest pain that radiates to
the neck and left shoulder. The pain is exacerbated by deep breaths and
position changes In examination in pain, blood pressure 110/70 mmHg, pulse
90/min reqular, T 37.9°C room air saturation 96%. No jugular vein distention.
Sinus normal heart sounds without murmurs Lungs-bilateral normal breathing
sounds without ralas or whoezes. Labs-leukocytosis with left shift. (ECG).

Which of the following is the most appropriate treatment?

1. Immediate catheterization with primary percutaneous coronary
intervention
2. Echocardiography and start ibuprofen and colchicine
3. Chest X-ray and tube thoracostomy
4. Chest CTA and immediate anticoagulation therapy
5. Chest CTA and immediate fibrinolytic therapy

47
A 80-year-old male with atrial fibrillation is treated with amiodarone He is
brought to the ER after being found unconscious On admission-pulse 40min
regular blood pressure 130/96, rectal temperature 353°C room air saturation
94%. Stupor, cold and dry skin, delayed reflex relaxation. ECG-sinus
bradycardia.
Which of the following is the most appropriate treatment?
1. IV Levothyroxin 200 mag
2. IV ceftriaxone 2g
3. SC epinephrine 0.5 mg
4. IV naloxone 2mg
5. IV flumazenil 0.1 mg

48
A 20-year-old HIV fomnale patient is admitted due to confusion and favor of
38.4°C Labsb 3.2 gridl, Platelets 16.000, Urea 60 mg/dl, Creatinine 25 mg/dl,
Total Bilirubin 5.5 mg/dl. Direct Bilirubin 0.5 mg/dl, Indirect Bilirubin 5.0 mg/dl,
LDH 1150 UI, PT 13 sec, INR 1.08 PTT 30 sec, Control PTT 30 sec, Fibrinogen
300 mg/dl. Schistocytes (fragmented red cells) are noted on peripheral blood
smear.
Which of the following is the most likely diagnosis?
1. Immune thrombocytopenic purpura (ITP)
2. Thrombotic thrombocytopenic purpura (TTP)
3. Hemolytic-uremic syndrome (HUS)
4. Von Willebrand disease (WWD)
5. Disseminated intravascular coagulation (DIC)

49
A 75-year-old male resides at a nursing home following CVA. His past medical
history includes several myocardial infarctions and systolic heart failure due to
ischemic heart disease and type 2 diabetes He is referred to the ER due to
acute deterioration, fever, chills, and confusion On examination-delirium, fever
38.5°C, saturation 90% with oxygen, systolic blood pressure 80 mmHg pulse
regular 115/min. His limbs are cold, lungs clear, abdomen is soft without
peritonitis, no skin rash no meningeal signs. Chest X-ray is normal. COVID-19
swab negative on PCR Preliminary Gram stain of urine demonstrates Gram
negative bacillus
Which of the following is the first step in management?
1. Norepinephrine
2. IV NaCl 3%
3. IV NaCI 0.9%
4. Extended spectrum Blactamase (ESBL) antibiotic coverage
5. Glucocorticoids

50
A 50-year-old healthy male is admitted due to bloody cough accompanied by
dyspnea for the past two day He also reports bloody urine in the past 24
hours His history is positive for joint pain at the hands and knees with
morning rigidity and no swelling On examination-dyspnea 24 min, blood
pressure 135/80 mm pulse 105 min. T 37 6'C decreased bilateral breathing
sounds with diffuse crackles over the lungs, normal heart sound, soft
abdomen, no organomegaly, elevated purpureal rash over the shins. Labs-
normocytic mild anemia 10, creatinine 2.5 mg dl (normal at baselina) urine
erytrocytes with little protein, urine sediment - dysmorphic red cells and casts
Elevated erythrocyte sedimentation rate 60, positive cytoplasmic
antineutrophilic cytoplasmic antibody (0-ANCA).
Which of the following is the most likely diagnosis?
1. Systemic lupus erythematosus (SLE)
2. Dermatomyositis
3. Granulomatosis with polyangiitis (previous Wegener
granulomatosis)
4. Relapsing polychondritis
5. Cryoglobulinemis vasculitis

51
A 65-year-old male with nephrolithiasis, hypertension, dyslipidemia, renal
failure with creatinine around 2 He is evaluated due to severe foot pain that
started 24 hours prior to Ng admission and increased to the point that he
cannot step on his leg. This is his first episode
On examination the photo below.

Which of the following is the most appropriate treatment?

1. NSAIDs such as Naproxen
2. Allopurinol
3. Febuxostat
4. Intraarticular steroid injection
5. SC interfukin 1 inhibitor (Anakinra)

52
A 47-year-old female is treated for 1 week with cefalexin (Ceforal) for right leg
cellulitis. She complains of systemic fever and diffuse maculopapular rash.
Labs - creatinine 2.4 mg/dl (baseline 0.9) and BUN 39 mg/dl, absolute
eosinophilia 2100. On urine sediment - red blood cells and white blood cells
casts.
Which of the following is the next step?
1. Urgent hemodialysis
2. Cyclophosphamide
3. IV steroids ASAP
4. Discontinue Ceforal
5. Rituximab

53
Which of the following is the most commonly involved joint in calcium
pyrophosphate dihydrate arthropathy (CPPD arthropathy)?
1. Knee
2. Ankle
3. Shoulder
4. Wrist
5. Elbow

54
A 40-year-old drug abuse male is admitted due to a fever of 38.5'C without
any other symptoms. Chest X-ray demonstrates left lower lobe infiltrate.
Echocardiography - large tricuspid valve vegetation. Labs-positive rheumatoid
factor. Blood cultures are pending.
Which of the following is most probable to grow on blood cultures?
1. Enterococcus faecalis
2. Streptococcus gallolyticus
3. Coagulase-negative staphylococci
4. Staphylococcus aureus
5. Cardiobacterium hominis

55
Which of the following bacteria is most likely to cause infective endocarditis
over normal endotel without structural cardiac defects?
1. Streptococcus viridans
2. Staphylococcus aureus
3. Streptococcus gallolyticus
4. Coagulase negative staphylococcus
5. Haemophilus spp

56
A55-year-old male undergoes abdominal CT due to right lower quadrant pain.
An incidental left adrenal 3 cm mass is demonstrated.
Which of the following is not part of the evaluation?
1. Blood metanephrines
2. 24h urine for free cortisol excretion
3. Midnight salivary or plasma cortisol
4. 24h urine for calcium excretion
5. 1 mg overnight dexamethasone suppression test

57
A 67-year-old male is referred by an occupational physician due to suspected
significant occupational exposure in his past. His chest X-ray demonstrates
"calcified pleural plaques". To which of the following substances was he most
likely exposed?
1. Silica
2. Asbestos
3. Coal miners
4. Beryllium
5. Talc

58
A 48-year-old male is admitted due to increasing abdominal pain and it was
over the past 6 weeks On examination-bilateral axlary lymphadenopathy up to
2 cm and use abdominal tenderness without rebound. Abdominal pelvic CT
scan demonstrated retroperitoneal and mesenteric lymphadenopathy Axillary
lymph node biopsy demonstrates une large B-cell lymphoma PET CT
demonstrates axillary mesenterial and retroperitoneal lymph node
onlargement Bone marrow biopsy is normal
Which of the following is the most appropriate treatment?
1. Combined treatment with rhumab, cyclophosphamide, doxorubicin,
vincristine, and prednisone (R-CHOP)
2. Observation
3. Combined treatment with cyclophosphamide, doxorubicin,
vincristine, prednisone (CHOP). and whole-body radiation
4. Autologous bone marrow transplantation
5. Radiation to involved lymph nodes

59
A healthy 55-year-old male with no medications is admitted to the ER due to
multiple vomiting of stomach content for 3 days. No fever or diamhea, On
examination-dry mucosa, decreased skin turgor, pulse 110/min, blood
pressure 130/85, supine 100/50 standing, Labs - pH 7.45, bicarbonate 32
mEq/dl.
Which of the following is the most expected in this patient?
1. Urine specific gravity < 1.018
2. Urine chloride > 25 mm
3. Urine osmolality < 300 mOsmkg
4. Urine HCO3 < 20 mM
5. Fractional excretion of sodium (FENа) < 1%
60
A 75-year-old female is admitted to fover with anemia, thrombocytopenia,
and acute renal failure The physician on call suspects disseminated
intravascular coagulation (DIC) Which of the following practically rules out
(almost 100%) this possibility?
1. Prolonged PT
2. Normal fibrinogen level
3. Normal levels of fibrin degradation products (FDPs)
4. Platelets count 90.000
5. Presence of schistocytes (fragmented red cell) on peripheral blood
smear
61.Which of the following is the most common incarcerated hernia?
1. Femoral
2. Umbilical
3. Inguinal
4. Incisional
5. Hiatal

62 A 70-year-old male is admitted with fever, chills, right upper quadrant pain,
and scleral jaundice. Abdominal ultrasound - cholelithiasis and bile duct
dilation.
Which of the following is the most recommended next step?
1. Hepatic iminodiacetic acid (HIDA) scan
2. Triphasic abdominal CT
3. Endoscopic retrograde cholangiopancreatography (ERCP)
4. Percutaneous transhepatic cholangiography (PTC)
5. Ultrasound guided gallbladder aspiration for cultures and treat
accordingly

63.Which of the following is considered a negative prognostic factor in thyroid

cancer?
1. Age below 40
2. 3 cm tumor size
3. Tumor without capsular invasion
4. Male gender
5. Well differentiated adenocarcinoma histology

64
Which of the following bariatric procedures is considered restrictive only?
1. Band (LAGB)
2. Biliopancreatic diversion (BPD)
3. Roux-en-Y gastric bypass
4. Duodenal switch (DS)

65
Which of the following patients will require prophylactic treatment for venous
thrombo-embolism?
1. A 35-year-old male, a candidate for proctectomy due to malignancy
2. A 30-year-old healthy male, a candidate for laparoscopic hernia repair
 3. A 35-year-old healthy male, a candidate for hemorrhoidectomy
4. A 30-year-old female, a candidate for planned cesarean section

66
A 57-year-old male, psychiatric patient, is admitted due to abdominal
distention and lack of bowel movements for the past two days. On
examination - blood pressure 130/85, pulse 92/min, T 37.6°C. Abdomen - very
distended, no significant tenderness, empty ampulla on rectal examination.
Abdominal X-ray is given below.

Which of the following is the most appropriate next step?

1. Laxatives and polyethylene glycol

2. Endoscopic decompression
3. Laxatives and enemas
4. Diagnostic laparoscopy
5. Laparotomy with bowel resection
67
A 30-year-old male is operated for right lower abdominal pain and tenderness
and suspected appendicitis. Upon scope insertion the following terminal ileum
finding is demonstrated (photo). The appendix is normal.

Which of the following is suspected?

1. Lymphoma
2. Crohn's disease
3. Perforated adenocarcinoma
4. Typhoid enteritis
5. Diverticulosis
68
A 58-year-old male is a candidate for elective inguinal hernia repair. He is
treated with apixaban (Eliquis) doe to chronic atrial fibrillation.
How long before surgery is this medication should be stopped to avoid
surgical bleeding?
1. 6 hours prior to surgery
2. 12 hours prior to surgery
3. 24 hours prior to surgery
4. 2-3 days prior to surgery
5. 1 week prior to surgery

69
A 30-year-old healthy female is diagnosed with left breast mass. Ultrasound
demonstrates a simple 3 cm cyst. Which of the following is correct?
1. A breast mass larger than 2 cm necessitates surgical removal
2. Cancerous tumors are very common in breast cysts and therefore
surgical removal is warranted
3. Patients with breast cysts are at an increased risk for developing breast
cancer and therefore should be invited for follow-up every 3 months
4. The cyst should be surgically removed with wide margins if cyst
aspiration produces green or yellow fluid
5. No further treatment is warranted if ultrasound demonstrates simple
cyst and aspiration produces straw-colored fluid
70
A 60-year-old male with ischemic heart disease is treated with antiplatelet
therapy due to catheterization last year. He arrives to the ER with malaise, cold
diaphoresis, melena, low blood pressure (100/70), and tachycardia 110/min.
What is the first step in management?
1. ER urgent gastroscopy due to upper gastrointestinal bleeding
2. Rapid fluid resuscitation, blood, and blood products as needed
3. IV antacids and helicobacter pylori eradication with antibiotics
4. Urgent surgery to stop the bleeding - the patient is unstable

71
All of the following are associated with developing incisional hernia, except:
1. Morbid obesity
2. Chronic lung disease
3. Hypertension and renal failure
4. Steroids and chemotherapy
5. Surgical site infection

72
A 65-year-old male is diagnosed with 3 cm breast mass. On biopsy-breast
carcinoma.
Which of the following is correct?
1. Repeat biopsy is recommended due to the rarity of breast cancer in
males
 2. This is most probably lobular breast carcinoma
3. Most male patients report a long course of gynecomastia before the
diagnosis of breast cancer
4. Local and systemic spread will determine the extent of surgery
5. In most cases there is no role for antihormonal therapy since ER/PR
positive tumors are rare in male patients

73
Which of the following is the most common etiology of small bowel
obstruction?
1. Tumors of the small bowel
2. Adhesions following bariatric surgery
3. Intestinal malrotation
4. Incarcerated inguinal hernia
5. Adhesions following abdominal or pelvic surgery

74
A 27-year-old male is brought to the ER following a stab wound to the left
flank below the rib cage. The knife is still stuck to his flank. Initial evaluation -
hypovolemic shock.
Which of the following is the most suitable approach?
1. Retrieve the knife so it will not interfere with the patient's examination
2. Abdominal CT to rule out other injuries
3. Fluid resuscitation, quick survey for bleeding source, initiate blood
products, quick transfer to the operating room
4. Intubation, transfer to ICU until stabilized with fluids and antibiotics,
and then transfer to the operating room
5. High dose dopamine to increase blood pressure

75.
Below are two photos of two patients with dysphagia.
Which of the following is correct?
 1. Patient A has a tumor of the gastroesophageal junction
2. Patient B has mid esophagus diverticulum
3. Patient A has achalasia
4. Patient B has reflux

76
A 58-year-old male is evaluated for mild epigastric pain and discomfort that
started a week ago. He also complains of significant weight loss in the past
several months.
Which of the following is correct regarding suspected gastric tumor?
1. Gastroscopy, lesion biopsies, and endoscopic ultrasound (EUS) should
be performed to determine the type and stage of tumor
2. Gastrectomy with wide margins should be performed regardless of the
tumor location
3. Gastric cancer is usually not aggressive and survival is over 5 years
4. Neoadjuvant chemoradiotherapy followed by surgery can achieve good
results in cases of locally advanced gastric cancer

77
A 25-year-old male is admitted to the ER following a knife stab to the
abdomen. On admission - fully conscious, no distress, hemodynamically
stable. Abdomen - stab wound under the umbilicus approximately 10 cm to
the left of the midline, omentum outside the skin, no peritonitis.
Which of the following is the next step in management?
1. Abdominal CT
2. Exploratory laparotomy
3. Local wound exploration
4. Focused assessment with sonography in trauma (FAST)
5. Diagnostic peritoneal lavage
78
A 45-year-old female is diagnosed with 4.5 cm right breast carcinoma,
HER2NEU (+), ER/PR (-), and axillary lymph node involvement. She undergoes
mastectomy with axillary lymph node dissection, 5 positive lymph nodes.
Which of the following is correct regarding the adjuvant therapy?
1. Despite undergoing mastectomy there is an indication for radiation
therapy
2. Radiation of the surgical field will only decrease local recurrences but
will not affect survival
3. There is no role for radiation therapy if the patient will be treated with
chemotherapy
4. Since the patient has positive lymph nodes then radiation should be
limited to the axilla alone
79
Which of the following is correct regarding cancer in humans?
1. Cancer incidence increases in people over the age of 80 years
2. There is significant phenotype similarity between sporadic and
inherited cancer
3. Approximately 5-10% of breast cancers are inherited and two genes
were identified - BRCA1 and BRCA2
4. Ultraviolet radiation is the only radiation that causes malignant changes
in humans

80
A 73-year-old male arrives to the ER with vomiting, acute abdominal pain, and
suspected acute abdomen on physical examination. Labs - lactic acidosis.
Which of the following is the next step at the ER?
1. Abdominal CT
2. Supine and upright or left lateral decubitus abdominal
 3. X-ray
4. Abdominal ultrasound
5. Abdominal angiography

81
A 65-year-old female is diagnosed with gastric carcinoma on endoscopy
performed due to weight loss. Heavy smoker. Which of the following findings
on examination will raise the suspicion for metastatic disease?
1. Enlarged supraclavicular node (Virchow node)
2. Enlarged umbilical node (Sister Mary Joseph node)
3. Ovarian mass (Krukenberg tumor)
4. Enlarged liver, jaundice, and ascites
5. All of the above

82
An 80-year-old male has hypertension and diabetes that are medically
controlled. He is a smoker, independent, and active (swims 45 minutes twice a
week). He is a candidate for left inguinal hernia repair.
Which of the following preoperative tests is recommended?
1. Mini-Cog evaluation
2. Echocardiography
3. Carotid arteries Doppler
4. Glucose tolerance test
5. Pulmonary function test

83
Ringer lactate solution contains all of the following, except:
1. Sodium
2. Potassium
3. Calcium
4. Magnesium
5. Chloride
84
A 60-year-old female undergoes routine mammography and biopsy of right
breast suspicious clustered calcifications. DCIS is diagnosed. What is the most
appropriate management?
1. Mastectomy is indicated but immediate reconstruction should be
avoided due to high local recurrence rates in the first few years
2. Mastectomy is preferred over breast conserving surgery in DCIS due to
high local recurrence rates, even if breast conserving surgery can be
technically performed
3. Mastectomy is preferred due to increased long term survival in
comparison to breast conserving surgery
4. Adding Tamoxifen to patients with DCIS decreases local recurrence
rates mainly in young patients
5. There is no indication for adjuvant Tamoxifen treatment in this patient
if she will be treated with breast conserving surgery and radiation

85
A 70-year-old male with no past medical history is evaluated for right inguinal
pain in the past 6 hours. On examination - a tender 6 cm mass.
What is the next step in management?
1. Abdominal CT
2. Mass aspiration
3. Urgent surgery
4. Inguinal ultrasound
5. An attempt to reduce the mass

86
A 50-year-old male with cirrhosis is clear minded, oriented to time and place,
and coherent. He is a candidate to an elective surgery due to colon cancer. On
examination - no ascites. Labs – bilirubin 2.4, albumin 3, PT 18 seconds, INR 2.
Which of the following is recommended?
1. Start diuretics
2. Correct coagulopathy
 3. Start beta blockers, lactulose, and sandostatin
4. Improve serum albumin level
5. Liver biopsy

87
All of the following are consistent with primary hyperparathyroidism, except:
1. A single adenoma will be found in most patients
2. Patients complain of bone pain and frequent urination
3. Fatigue and memory loss are common
4. Increased appetite
5. Decreased concentration and insomnia

88
Which of the following is the most common wound healing inhibitor?
1. Hypocalcemia
2. Infection
3. Vitamin B6 deficiency
4. Aspirin treatment
5. Smoking

89
A 22-year-old male arrives to the ER following a gunshot wound to the pelvis.
He rapidly deteriorates and one of your colleagues is worried that he will
develop the lethal triad of trauma.
1. Which of the following correctly describes this triad?
2. Acidosis, hypothermia, coagulopathy
3. Acidosis, hyperthermia, hyper coagulopathy
4. Alkalosis, hypothermia, coagulopathy
5. Alkalosis, hypothermia, hyper coagulopathy

90
Wound healing has several stages. Which of the following blood cells is the
most dominant in the first two days of wound healing (inflammation phase)?
1. Lymphocytes
 2. Macrophages
3. Fibroblasts
4. Neutrophils
5. Eosinophils

91
Which of the following is the most common location of the base of the
appendix in acute appendicitis?
1. Pelvis (61%)
2. Where the three taeniae coli merge
3. Along the Toldt line
4. Next to the right colic artery that supplies the appendix

92
Which of the following is correct with regards to diagnostic laparoscopy for
suspected acute abdomen?
1. The main advantage is high diagnostic rate (over 80%)
2. It is diagnostic in 50% of the cases
3. The main advantage is diagnosis of retroperitoneal pathologies
4. Its use is decreasing

93
A 60-year-old healthy female with no prior surgeries is admitted to the ER due
to diffuse abdominal pain and vomiting in the past several hours. On
examination - tender, distended abdomen. Abdominal X-ray - air fluid levels
compatible with small bowel obstruction.
Which of the following is the most likely diagnosis?
1. Duodenal ulcer perforation
2. Incarcerated femoral hernia
3. Acute cholecystitis Perforated appendicitis
4. Obstructing left colon cancer

94
A 75-year-old male is referred to the ER due to skin and scleral jaundice for
the past week. On examination - skin and scleral jaundice, cachectic, right
upper quadrant smooth non-tender mass. Rectal examination - acholic stool.
Labs - elevated bilirubin and CA 19-9 levels.
Which of the following is the correct name for this finding?
1. Courvoisier gallbladder
2. Positive Rovsing sign
3. Virchow node
4. Positive Murphy sign

95
Which of the following is the most common etiology for portal vein
pyelophlebitis?
1. Bile duct obstruction by a stone or tumor
2. Diverticulitis, appendicitis
3. Caroli disease
4. Obstruction by ascariasis
5. Previous history of bile duct surgery

96
All of the following fit peptic ulcer disease, except:
1. Pallor
2. Jaundice
3. Multiple vomiting
4. Upper abdominal pain
5. Melena
97
All of the following imaging findings support the diagnosis of gallstone ileus,
except:
1. Calcified mass at the right lower quadrant
2. Air in the bile system
3. Distended loops of small bowel with air-fluid levels
4. Distended gallbladder on US
5. Cholelithiasis on ultrasound

98
A 65-year-old healthy female undergoes routine virtual colonoscopy
(abdominal CT) that demonstrates cholelithiasis and later confirmed by
ultrasound. No past medical history of abdominal pain, jaundice, or
pancreatitis. The patient reports heartburn associated with certain foods that
responds to oral antacids.
Which of the following is recommended?
1. Laparoscopic cholecystectomy
2. Oral medical treatment to dissolve the stones
3. Direct injection of substance to the gallbladder to dissolve the stones
4. Observation only
5. ERCP

99
A 50-year-old female is brought to the ER after being hit by a car as a
pedestrian. On admission - blood pressure 110/70, pulse 110/min, no free
fluid on focused assessment with sonography in trauma (FAST). Pelvic X-ray -
multiple pelvic fractures consistent with open book formation.
All of the following may assist in stabilizing this patient, except:
1. Pelvic sheet wrap
2. Angiography
3. Extraperitoneal packing
4. External pelvic fixation
5. Exploratory laparotomy

100
A 69-year-old healthy male is diagnosed with rectal tumor, 7 cm from the anal
verge. Total body CT and pelvic MRI demonstrate the tumor invading all the
muscle layers (T3) and involved lymph nodes next to it. No distant metastases.
What it the recommended step on his treatment?
1. Abdominoperineal resection
2. Low anterior resection
3. Transanal endoscopic microsurgery
4. Neoadjuvant chemoradiotherapy

101
A 73-year-old male presents with acute lower gastrointestinal bleeding. Which
of the following is the most common etiology?
1. Hemorrhoids
2. Inflammatory bowel disease
3. Arteriovenous malformation (AVM)
4. Neoplasia
5. Diverticulosis

102
An 80-year-old male complains of solid dysphagia, weight loss, and new
hoarseness. He has reflux for many years and is treated with antacids. Upper
GI Tract Barium X-ray- mid esophagus stricture.
Which of the following is the most likely diagnosis?
1. Achalasia
2. Esophageal malignancy
3. Esophageal stricture secondary to reflux
4. Schatzki's ring

103
A 20-year-old male complains of severe anal pain that increase during
defecation as if "knives are cutting him" and accompanied by fresh blood. This
started after an episode of constipation The patient refuses rectal examination
because every contact causes pain and there are no masses outside the anus.
Which of the following is recommended on top of stool softeners and
analgesics?
1. Topical ointment based on calcium channel blockers or nitrates
2. Incision over the hemorrhoid and clot evacuation
3. Surgical resection of internal hemorrhoids
4. Anal dilatation

104
A 49-year-old male with previous abdominal surgeries is admitted to the ER
due to abdominal pain and vomiting. Abdominal X-ray is below.

Which of the following is the most likely diagnosis?

1. Colitis
2. Small bowel obstruction
3. Diverticulitis
4. Large bowel obstruction
5. Bile duct obstruction

105
An 80-year-old male is admitted to the ER due to severe inguinal pain in the
past 2 hours. On examination - a 5 cm rigid, tender, right inguinal mass.
Surgery is decided with the diagnosis of incarcerated inguinal hernia. The
patient is on Plavix due to atrial fibrillation. While waiting for surgery the
patient reports improvement in pain and on repeat examination the mass is
gone.
What is the most recommended approach?
1. Patient can be discharged with planned elective hernia repair
 2. Proceed with the original surgical plan
3. Admit the patient for observation, discharge after 24 hours with follow-
up by his primary physician
4. Admit the patient for observation and operate within the same
admission after Plavix discontinuation
5. Surgery should be avoided and hernia strap is recommended

106
Which of the following is considered a positive prognostic factor on CT in
adrenal incidentaloma?
1. Relatively large amount of lipomatous content
2. Irregular borders
3. High vascularity
4. Slow contrast washout
5. Central necrosis

107
A 53-year-old male is POD1 after cholecystectomy and complains of right
upper quadrant severe pain, fever, chills, and large amount of bile in the drain
that was left at the gallbladder bed. He also complains of fullness and lack of
appetite.
Which of the following is correct?
1. The etiology is bile leak form the cystic duct due to a clip that "fell" off
the cystic duct stump
2. This is a very rare phenomena after surgery for acute cholecystitis and
will self-resolve
3. The treatment should include Antipyretics, and analgesics only
4. ERCP is contraindicated due to his severe condition
5. Blood and urinary cultures should be taken, await results, and start
antibiotics accordingly

108
Which of the following can cause intrinsic cardiogenic shock?
1. Cardiac tamponade
2. Sepsis
 3. Tension pneumothorax
4. Myocardial infarction
5. Head trauma

109
A 55-year-old female is referred for evaluation due to suspected inflammatory
breast carcinoma. Which of the following is likely to be found on examination?
1. Fever above 38°C at diagnosis
2. Retraction of the breast skin with ulceration
3. Thickening of the breast skin will be the only finding on mammography
4. Axillary lymph node involvement is unlikely

110
A 60-year-old male with Crohn's disease is a candidate for Whipple surgery
due to pancreatic tumor. Four months prior to his current admission he was
admitted with Crohn's disease exacerbation and was treated with 40 mg
prednisone per day that was later tapered after his discharge.
Which of the following steroid dose is recommended prior to anesthesia
induction?
1. 300 mg hydrocortisone
2. 200 mg hydrocortisone
3. 100 mg hydrocortisone
4. 50 mg hydrocortisone
5. 500 mg hydrocortisone