1

A 28-year-old healthy male is admitted due to two days of burning anterior

chest pain that worsens on breathing and lying down, radiates to the left
trapezius muscle. On examination - pericardial rub.

Which of the following will support the diagnosis?

1
Two mm ST depression on leads V2-6 and on three limbs

2
Pathological Q waves

3
PR depression

4
Sinus bradycardia

1
2

A 65-year-old male with COPD is admitted due to dyspnea and productive

cough. On examination – dyspnea, bilateral wheezes, normal heart sounds,
no murmurs. Chest X-ray is below, hyperinflation.
Labs –
Sodium 140 mEq/L
Potassium 3.5 mEq/L
Chloride 98 mEq/L
Bicarbonate 32 mEq/L
pH 7.32
Pco2 64 mm Hg
Po2 59 mm Hg

Which of the following correctly describes his blood gasses?

1
Metabolic acidosis

2
Respiratory acidosis

3
Metabolic acidosis and respiratory acidosis

4
Respiratory alkalosis

2
3

A 45-year-old male is brought to the ER due to face tingling around the eyes
and spasm of the hands. He underwent total thyroidectomy for papillary
thyroid cancer two days ago. Physical examination is normal. Labs –
Serum calcium level of 6.1 mg/dL
Serum magnesium level of 1.7 mg/dL
Serum phosphorus level of 4.7 mg/dL
Albumin 4 g/L
Kidney function studies are normal

Which of the following is the most appropriate treatment?

1
Calcitriol

2
Calcium

3
Magnesium

4
Recombinant parathyroid hormone

3
4

A 20-year-old male is admitted due to systemic fever with productive cough

and dyspnea. Chest X-ray demonstrates large right lower lobe pneumonia
with pleural effusion. Thoracostomy tube is placed and drains pleural fluid
with pH of 7.10. The patient is treated with IV antibiotics. About 48 hours
afterwards the patient is still with fever and significant effusion is still
present.

Which of the following is the most appropriate treatment?

1
Start anti-tuberculosis treatment

2
Infuse fibrinolytic agent into the drain

3
Inject antibiotics into the drain

Bronchoscopy to evaluate the possibility of atelectasis and identify

4
the causative agent

4
5

A 28-year-old healthy female complains of two weeks of skin hematomas

and nose bleed. She does not take any medications. Physical examination is
normal except for several limb petechiae. Vital signs are normal. Labs –
Hemoglobin- 12.5 g/dL
Leukocyte count- 5700/μL
Platelet count- 10,000lμL
Comprehensive metabolic panel- Normal
The peripheral blood smear shows a paucity of platelets and several large
platelets.

Which of the following is the most likely diagnosis?

1
Henoch-Schonlein purpura

2
Immune thrombocytopenic purpura

3
Thrombotic thrombocytopenic purpura

4
Von Willebrand disease

A 60-year-old male who was a heavy smoker complains of exertional

dyspnea. Spirometry diagnoses chronic obstructive pulmonary disease. No
history of exacerbations.

Which of the following is the most appropriate treatment?

1
Steroid inhalations

2
Oral steroids

3
Long-acting bronchodilators

4
Lung transplant

5
7

A 78-year-old female undergoes evaluations due to osteoporosis with

increased serum protein. She is completely asymptomatic and is taking
calcium, vitamin D, and alendronate.
Labs – Normal CBC, Protein, total- 8.6 g/dL, Albumin- 4.0 g/d, Calcium- 10
mg/dL, Creatinine- 1.2 mg/dL.
Serum protein electrophoresis shows a monoclonal spike. Immunofixation
reveals a serum monoclonal IgG level of 1.5 g/dL; serum IgM and IgA levels
are normal. A radiographic bone survey shows no abnormalities.

Which of the following is the most likely diagnosis?

1
AL amyloidosis

2
Asymptomatic multiple myeloma

3
Monoclonal gammopathy of unknown significance

4
Waldenstrom macroglobulinemia

Which of the following medications is recommended to decrease

cardiovascular risk in patients with type 2 diabetes and reduced L.V ejection
fraction heart failure?

1
Empagliflozin

2
Metformin

3
Linagliptin

4
Glyburide

6
9

A 65-year-old male is evaluated for weight loss and burning epigastric pain
that is aggravated during meals. Gastroscopy demonstrates the finding in
the photo below in proximity to the pylorus.

Which of the following is correct?

1
This is always benign and there is no need for a biopsy

H2 blockers treatment is more effective than PPIs in treating this

2
finding
Common risk factors for this finding are helicobacter pylori and
3
taking NSAIDs
There is no need for repeat gastroscopy in order to confirm the
4
healing of the finding

7
10

Which of the following is correct regarding patients with hemolytic anemia?

1
MCH and MCV levels are usually low

2
Elevated direct bilirubin, normal indirect bilirubin

3
Reticulocyte count is usually high

4
Elevated haptoglobin during intravascular hemolysis

11

A 75-year-old female is evaluated at the ER due to headaches and acute

sight deterioration. On examination – pain of the shoulder muscles. Labs –
increased inflammatory markers. Temporal arteritis is suspected.

Which of the following is the next step in management?

1
Temporal artery biopsy prior to treatment

2
Steroid treatment and temporal artery Doppler ultrasound

3
NSAIDs

4
Infliximab treatment and brain MRI with contrast

8
12

A 52-year-old male with non-ischemic dilated cardiomyopathy and heart

failure is treated with maximal dose of enalapril. NYHA functional
classification II. On examination – regular pulse 70/min, blood pressure
110/72 mmHg, no jugular distention, jugular venous pressure (JVP) 8 cm H20.
He starts treatment with carvedilol 3.125 mg X2/d. One week later the
patient feels well and the dose is increased to 6.25 mg X2/d. A week later he
complains of fatigue, worsening dyspnea, and 3 Kg weight gain. On
examination – pulse 80/min, blood pressure 100/72 mmHg, JVP 12 cm H2O.
Lungs are clear, right upper quadrant tenderness, with positive
hepatojugular reflux, no peripheral edema.

Which of the following is the next step in management?

1
Discontinue carvedilol immediately

2
Start furosemide

3
Increase enalapril dose

4
Increase carvedilol dose

9
13

A 54-year-old male with known angina pectoris, CCS function classification II,
is referred to the ER due to increase in angina for the past week. On the day
of admission 30 minutes of pain that did not improve with sublingual
nitroglycerin. On examination - regular pulse 58/min, blood pressure 110/80
mmHg, no other abnormal findings. ECG – ST depression in leads V4-6 that
resolve within a few hours. First troponin is normal and at 6 hours it is 5
times the normal limit.

Which of the following is the most appropriate management?

1
Coronary catheterization

2
Electrocardiographic stress test

3
Coronary arteries CT angiography (CTA)

4
Dipyridamole cardiac scan

10
14

A 38-year-old female is examined at the pulmonary clinic due to prolonged

dry cough. Two months ago, she was diagnosed with parotitis when
complaining of swelling and pain anterior to both ears. Chest X-ray is below.
Bronchoscopy with bronchial lavage is performed and fluid demonstrates
20% lymphocytes, of which 70% are CD4 cells and 14% are CD8.

Which of the following is the most likely diagnosis?

1
Allergic bronchopulmonary aspergillosis

2
Idiopathic pulmonary fibrosis

3
Sarcoidosis

4
Hypersensitivity pneumonitis

11
15

A 71-year-old male is admitted due to clinical and radiological presentation

compatible with community acquired pneumonia. Medical history is positive
for bronchiectasis and severe COPD due to past heavy smoking.

Which of the following should be included in his empiric treatment?

1
Doxycycline to cover atypical causative agents

2
Ceftriaxone to cover klebsiella pneumonia

Vancomycin to cover methicillin resistant staphylococcus aureus

3
(MRSA)

4
Levofloxacin to cover pseudomonas aeruginosa

12
16

A 35-year-old male with a history of asthma is evaluated for acute dysphagia

during a meal. On gastroscopy a mass of meat is evacuated from the mid-
esophagus. After the food removal an esophagoscopy is performed (photo
below) and biopsies are taken form the mid-esophagus.

Which of the following histological findings may assist in diagnosis?

1
Massive type B lymphocyte infiltration

2
Eosinophilic infiltration (≥15 per high power field)

3
Adenocarcinoma cells

4
Presence of helicobacter pylori at the mucosa

13
17

A 43-year-old male, diagnosed with asthma at young age, is treated with low-
dose steroid inhalations and Ventolin. He experiences recurrent asthma
exacerbations that rapidly improve with oral steroids. He now requests
permanent oral steroid treatment to decrease the exacerbations.

Which of the following is recommended?

Due to the rapid improvement with steroids the patient can be

1
started on low dose oral steroids
Do not change current treatment and add oral steroids for
2
exacerbations only

3
Increase steroid inhalations dosage and add long acting beta agonist

4
Start steroid sparing therapy

18

A 69-year-old male has heart failure with decreased left ventricle systolic
function and ejection fraction of 25%, NYHA functional classification III. He is
treated with furosemide, carvedilol, entresto, and spironolactone.

Which of the following is an indication for cardiac resynchronization therapy

(CRTD) implantation?

1
CLBBB on ECG with QRS width greater than 150 msec

2
Disynchronia parameters on echocardiography

3
Well controlled atrial fibrillation with digoxin

4
Signs of anterior wall infarction without relation to QRS width

14
19

A 65-year-old female with diabetes is treated with metformin. Past history of

anaphylaxis to penicillin. Admitted due to nausea, vomiting, and left flank
pain that started 3 days ago. On examination – fever 39.5°C, blood pressure
90/60 mmHg, pulse 120/min, room air saturation 92%, left flank tenderness
on percussion. Labs – WBC 25,000 with left shift. Urine – WBC 250 with
multiple bacteria.

Which of the following is the most appropriate treatment?

1
Gentamycin and ampicillin

2
Ciprofloxacin

3
Trimethoprim sulfamethoxazole

4
Ceftriaxone

20

A 62-year-old male with fever undergoes thoracentesis of pleural effusion. In

fluid - protein 4.1g/dl, LDH 540 units, glucose 40 mg/dl, 2600 WBC/ml with
94% lymphocytes.

Which of the following is the most likely diagnosis?

1
Acute lymphocytic leukemia

2
Amebic abscess

3
Mycoplasma pneumonia

4
Tuberculosis

15
21

A healthy 40-year-old male complains of abdominal and 7 Kg weight loss

over the last 4 months. He does not take any regular medications. On
examination – significant hepato-splenomegaly.
Labs – Leukocyte count- 85,000/μL with 60% polymorphonuclear cells, 15%
bands, 5% metamyelocytes, 3% myelocytes, 1% promyelocytes, 5% basophils,
and 11% lymphocytes
Platelet count- 900,000/μL
Fluorescence in situ hybridization (FISH) assay for (9; 22) translocation is
positive

Which of the following is the most likely diagnosis?

1
Acute myeloid leukemia

2
Chronic myeloid leukemia

3
Myelodysplastic syndrome

4
Leukemoid reaction

22

A healthy 52-year-old male without medications and without surgical history

in the past, is evaluated for an elective orthopedic surgery. Physical
examination is normal.

Which of the following most accurately predicts the risk for bleeding in this
patient?

1
Medical history

2
CBC

3
Platelet function test

Prothrombin time (PT) and activated partial thromboplastin time

4
(aPTT)

16
23

A 34-year-old female is evaluated in the ER due to dyspnea and swelling of

her leg that started this morning. Medical history is positive for 2 early
pregnancy abortions. On examination – swelling of the left calf. Lower limbs
duplex demonstrated thrombosis of the left popliteal vein. Labs – prolonged
PTT.

Which of the following is the most likely diagnosis?

1
Antiphospholipid syndrome

2
Factor V Leiden mutation

3
Homozygous antithrombin deficiency

4
Prothrombin gene mutation (PTc 20 21 0A)

24

An 80-year-old male with paroxysmal atrial fibrillation is treated with

amiodarone for five years.

Which of the following is correct?

1
TSH monitoring is required

2
Head CT monitoring is required

3
CBC monitoring is required

4
Half-life is about 12 hours

17
25

A 74-year-old nursing home resident female is brought to the ER due to

blurred consciousness for 6 hours. Her daughter reports that she
complained of headaches that started the day before. Medical history is
positive for diabetes, hypertension, and hypothyroidism. On examination –
fever 38.7°C, blood pressure 110/78 mmHg, pulse 102/min, nuchal rigidity.
Head CT is normal. Lumbar puncture – 2000 WBC, 90% neutrophils, protein
150 mg/dl, glucose 40 mg/dl. Gram positive rods on direct smear.

Which of the following is the most appropriate treatment?

1
Acyclovir

2
Ceftriaxone and amphotericin B

3
Ceftriaxone and acyclovir

4
Gentamycin and ampicillin

26

A 70-year-old male who is treated with PPIs is admitted die to abdominal

pain and diarrhea. He was treated with Augmentin for the past week due to
dental infection. On admission - pulse 110/min, blood pressure 120/70
mmHg. Mildly distended abdomen and tender to palpation. Labs – WBC
21,000 with left shift, creatinine 2 (baseline 0.8). Stool culture for C. difficile
toxin is positive.

Which of the following is the most appropriate treatment?

1
Continue Augmentin and add oral metronidazole

2
Discontinue Augmentin and start oral vancomycin

3
Stool implantation ASAP

4
Urgent colectomy

18
27

A 45-year-old male requests an expert opinion and evaluation regarding a

family history of sudden death at young age. He is very concerned and wants
to know if he is at increased risk for sudden death. He is asymptomatic. On
examination - blood pressure 120/80 mmHg, normal heart sounds, S4,
systolic murmur 2/6. Normal lipid panel. His ECG is below.

Which of the following is recommended firstly ?

Without a murmur the patient is at no risk for sudden death and no

1
further evaluation is needed

2
Trans-thoracic echocardiography

3
Electrophysiology test

4
24-hour Holter monitoring

19
28

A 47-year-old male with long standing hepatitis B presents to the ER

complaining of lower limbs edema and abdominal distention. A photo of
abdominal ultrasound is below.

Which of the following is correct regarding the management of this case?

1
No need for ascites aspiration if the patient has no fever

Neutrophil count of over 250 in the ascites fluid is diagnostic of

2
spontaneous bacterial peritonitis
Serum-ascites albumin gradient (SAAG) of 0.9 is indicative of portal
3
hypertension as the ascites etiology
Recommended diuretic protocol is to start with high dose Fusid and
4
add Aldactone if needed

20
29

An 18-year-old female is brought to clinic due to high fever, muscle pain,

anorexia, and throat pain for the past 10 days. She denies sexual activity. On
examination – fever 38.4°C, blood pressure 124/78 mmHg, pulse 90/min,
significant erythema of the tonsils with exudate accompanied by anterior
and posterior cervical lymphadenopathy. Fine maculopapular rash is noted
on the skin. Rapid group A streptococcus antigen is negative.

Which of the following is considered to have the highest sensitivity and

specificity in her diagnosis?

1
Epstein-Barr virus (EBV) capsid antigen (VCA) IgG

2
Cytomegalovirus IgM

3
EBV VCA IgM

4
Rapid plasma reagin (RPR) test

30

A 72-year-old male is admitted due to endocarditis involving the aortic valve.

Which of the following may indicate infectious spread to the tissues

surrounding the valve?

1
Moderate aortic regurgitation on echocardiography

2
25 mm vegetation over the valve on TEE

3
PR segment prolongation to over 240 milliseconds on ECG

4
Weakened S1 on auscultation

21
31

A 20-year-old female with recurrent hypoglycemic episodes is suspected of

self-injecting insulin that belongs to her diabetic sister.

Which of the following tests during hypoglycemia will confirm the diagnosis?

1
HbA1C levels

2
Serum C-peptide levels

3
Serum insulin levels

4
Serum sodium levels

32

A patient is diagnosed with Sjogren’s syndrome.

Which of the following may be an early sign of lymphoma development?

1
Low C4 levels

2
Increased platelet count

3
An anti-SS-A (RO) / anti-SS-B (La) ratio > 2

4
Increased leukocyte count

22
33

An 18-year-old female complains of diarrhea, weight loss, and iron

deficiency anemia.

Which of the following supports the diagnosis of celiac disease?

1
Negative anti-tTG IgA

2
Duodenal biopsy demonstrating rich neutrophilic infiltrate

3
Good clinical response to gluten free diet

4
Duodenal biopsy demonstrating villi elongation

34

A 50-year-old male with long standing alcoholic cirrhosis arrives to the ER

with hematemesis.

Which of the following is the most appropriate immediate treatment?

Insert Sengstaken Blakemore tube to the esophagus to control the

1
bleeding as medications are ineffective in these cases

2
Start IV vasoconstrictors such as octreotide

Varices ligation is the most effective treatment for varices that are
3
continuous from the esophagus to the stomach
There is no role for TIPS in patients with variceal bleeding refractory
4
to medical therapy and ligation

23
35

A 30-year-old healthy male undergoes chest surgery following motor vehicle

accident. Several hours after surgery a white fluid appears in the drain on
the surgery side.

Which of the following will establish the diagnosis of chylothorax?

1
Fluid pH level

2
Fluid cell count

3
Fluid protein level

4
Fluid triglyceride level

36

A 50-year-old male is evaluated for prolonged abdominal pain.

Which of the following adrenal incidentaloma findings is suspicious of

carcinoma?

1
Size greater than 5 cm

2
High fat content

3
Low density (Hounsfield unit (HU) < 10)

4
Homogenous finding

24
37

A 90-year-old male was discharged 5 days ago following a 4-day admission

due to chest pain. He is now readmitted with high fever, cough, and
dyspnea. On examination – fever 38.4°C, 12 breaths/min, blood pressure
120/80 mmHg, pulse 110/min. Labs – WBC 12,000. New right lung infiltrate
on chest X-ray.

Which of the following is the most appropriate treatment?

1
Treat the patient as any other patient admitted with pneumonia

2
Add antibiotics coverage of pseudomonas to his antibiotic regimen

The patient can be discharged from the ER with oral Moxypen and
3
community follow-up

4
Admit to ICU due to his age

25
38

A 19-year-old male who plans to donate blood is found to have anemia. He

is completely asymptomatic, usually healthy, and does not take any
medications. Vital signs and physical examination are normal.
Labs –
Hemoglobin- 11.6 gldL
Mean corpuscular volume- 60 fL
Leukocyte count- 5400lμL
Platelet count- 179, 000lμL
Red blood cell distribution width- Normal
Reticulocyte count- 2.3% of erythrocytes
Ferritin- 58 ng/mL
Hemoglobin electrophoresis is normal. The peripheral blood smear shows
target cells.

Which of the following is the most likely diagnosis?

1
Hereditary spherocytosis

2
Iron deficiency

3
Sideroblastic anemia

4
α-thalassemia trait

26
39

An Israeli native is treated with amiodarone due to atrial fibrillation and

develops thyroid dysfunction.

Which of the following is most likely?

1
Autoimmune thyroiditis type 1

2
Autoimmune thyroiditis type 2

3
Hypothyroidism

4
Thyroid carcinoma

27
40

A 70-year-old female is brought to the ER due to nausea, vomiting, and

significant malaise. She was recently diagnosed with depression and
fluoxetine treatment was started. On examination – blurred consciousness,
somnolent, no focal neurological signs. Blood pressure 130/80 mmHg, pulse
70/min. During blood pressure measurement the patient convulses.
Labs –
Serum creatinine- 0.9 mg/dL
Serum sodium- 110 mEq/L
Glucose plasma- 105 mg/dL
Serum osmolality- 245 mOsm/kg H2O
Urine osmolality- 408 mOsm/kg H2O
Urine sodium- 90 mEq/L

Which of the following is the most appropriate treatment?

1
0.9% saline infusion

2
3% saline infusion

3
Furosemide

4
0.45% saline infusion

28
41

A 75-year-old male is admitted due to acute renal failure and bladder outlet
obstruction secondary to BPH. Urinary catheter inserted on admission
drains 800 ml of urine and then 140 ml/h over 24 hours. The patient is
without fever, hemodynamically stable, and without respiratory distress. On
examination – lower limbs edema with no other abnormal findings. Renal
ultrasound – bilateral hydronephrosis. Labs –
Serum creatinine 2.8 mg/dL(was 5.6 on admission)
Serum sodium- 151 mEq/L
Urine osmolality- 326 mOsm/kg H2O (normal, 300-900 mOsm/kg H2O)
Urinalysis- Specific gravity 1.012; pH 5.0; no blood; trace protein; no glucose

Which of the following is the most appropriate treatment?

1
0.45% saline

2
0.9% saline

3
5% dextrose

4
Desmopressin

29
42

A 28-year-old female with ulcerative colitis presents to the ER complaining of

abdominal pain and multiple bloody diarrhea for the past two weeks. On
examination – pulse 110/min, temperature 38.1°C.

Which of the following is correct regarding this patient’s evaluation?

1
Stool calprotectin testing is expected to be normal

CRP is expected to be high even in cases that involve the rectum

2
alone (proctitis)
Stool for cultures, parasites, and clostridium difficile toxin to rule out
3
infectious etiology

4
No role for sigmoidoscopy to evaluate disease severity

43

Which of the following is true regarding treatment with PCSK9 inhibitors?

Proven effective in reducing cardiovascular mortality in patients with

1
coronary disease

2
Mainly increases serum HDL levels

3
Given orally once a month

Patients treated with PCSK9 inhibitors require liver function tests

4
follow-up every three months

30
44

Which of the following is correct regarding anti CCP (Anti cyclic citrullinated
peptide) ?

1
Diagnostic parameter only

2
Correlates with response to anti-TNF therapy

3
Correlates with response to methotrexate therapy

4
Presence predicts more severe disease

45

A 65-year-old female is referred to the ER due to severe malaise, drowsiness,

polyuria, and polydipsia. Medical history is positive for advanced stage
breast cancer with liver metastases. On examination – somnolent,
hemodynamically and respiratory stable, without fever.
Labs –
Blood urea- 40 mg/dL
Calcium- 15.7 mg/dL
Serum creatinine- 1.6 mg/dL
Sodium- 151 mEq/L

Which of the following is the most appropriate treatment?

1
Intravenous bisphosphonate

2
Intravenous furosemide

3
Intravenous glucocorticoids

4
Intravenous 0.9% saline

31
46

A 42-year-old female reports having heart murmur since childhood. On

routine examination – blood pressure 120/75 mmHg, no jugular distention,
heart apex is not deviated, left sternal border (LSB) thrill is present. Heart
sounds are normal, coarse holosystolic 4/6 murmur is maximal at the mid-
left sternal border and radiates to the right chest. No other abnormal
findings on physical examination. Chest X-ray and ECG are normal.

Which of the following is the most likely diagnosis?

1
Mitral regurgitation

2
Aortic stenosis

3
Atrial septal defect

4
Ventricular septal defect

47

A carotid ultrasound of a 60-year-old female following a TIA demonstrates a

thyroid nodule.

Which of the following is correct?

1
If the nodule uptakes radioactive iodine then it is probably benign

2
Most incidental nodules are malignant

3
Thyroid scan is the first step in thyroid nodule evaluation

4
All thyroid nodules should be biopsied by FNA

32
48

A 60-year-old female complains of general malaise and headaches for the

last 3 months. She is usually healthy without regular medications. Physical
examination is normal including vital signs and room air saturation is 98%.
Labs –
Hemoglobin- 16.8 g/dL
Leukocyte count- 15,800/μL with 70 % polymorphonuclear cells, 10% bands,
3% metamyelocytes, 5%basophils, and 12% lymphocytes
Platelet count- 800,000/μL
Analysis for the JAK2 V61 7F mutation is positive

Which of the following is the most appropriate initial treatment?

1
Aspirin and phlebotomy

2
Chlorambucil

3
Hydroxyurea

4
Radioisotope phosphorus 32 (32P)

33
49

A 70-year-old male is admitted due to productive cough, dyspnea, and high

fever that started in the past two days. On examination – fever 38.5°C, blood
pressure 110/70 mmHg, pulse 110/min, room air saturation 90%. Right lung
crackles on auscultation. Labs – WBC 18,000 with left shift. Right infiltrate on
chest X-ray.

Which of the following is the most appropriate treatment?

1
Cefazolin

2
Azithromycin and ceftriaxone

3
Piperacillin and tazobactam

4
Vancomycin

50

A 40-year-old healthy male consumes two bottles of beer twice a week. On

routine examination a uric acid level of 7.9 mg/dl is noted (normal up to 6.0).

Which of the following is the most appropriate next step?

1
Allopurinol

2
Colchicine

3
Probenecid

4
Clinical follow-up

34
51

A 32-year-old male complains of lower back pain that appears in the

morning and is alleviated by physical activity. On examination – movement
limitation of the spine and limitation in chest expansion.

Which of the following is the most likely extraarticular manifestations?

1
Malar rash

2
Holosystolic murmur

3
Lymphadenopathy

4
Uveitis

52

A 70-year-old male who is admitted due to unstable angina is planned for

coronary catheterization. Medical history is positive for diabetes,
hypertension, chronic renal failure, and dyslipidemia. He is taking
furosemide, atorvastatin, ramipril, insulin glargine, aspirin, and metoprolol.
On examination – mild edema at the calves, no other abnormal findings.
Hemodynamically and respiratory stable.
Labs –
Serum creatinine- 2.1 mg/dL
Electrolytes- Normal
Estimated glomerular filtration rate 19 mL/min/1.73 m2

Which of the following is the most appropriate treatment to prevent

contrast-induced nephropathy?

1
Hydration with intravenous isotonic saline

2
Hydration with intravenous isotonic saline and furosemide diuresis

3
Oral hydration

4
Prophylactic hemodialysis

35
53

A 32-year-old female complains of hair loss, rash around the nostrils and
face accompanied by photosensitivity and arthralgia for the last 3 months.
History is positive for 3 spontaneous abortions. Labs, including CBC, full
chemistry, and liver enzymes, are all normal. Thyroid function tests and iron
profile are normal. Urinalysis is normal and ANA is negative.

Which of the following is the next step in this patient evaluation?

Due to negative ANA the likelihood of collagen disease including SLE

1
is low and clinical follow-up
is warranted
Repeat ANA testing along with anti-Ro, anti-SM, anti-dsDNA, and
2
complement levels
Refer the patient to a dermatologist to perform capillaroscopy and
3
biopsy of the rash

4
Complete testing for anti-topoisomerase and anti-centromere (ACA)

54

A 24-year-old male is admitted due to fever and chills for the past two days.
Dental treatment 2 weeks prior to his admission. On examination – 38.5°C,
pulse 84/min, blood pressure 140/80 mmHg, no jugular distention. Lungs
clear, heart sounds – diminished S1, physiological S2 split, systolic 3/6
murmur that is maximal at the right second intercostal space and radiates to
the carotids. He is admitted, echocardiogram is ordered and three blood
cultures are taken.

Which of the following is the most appropriate case management?

1
Observation until the above results

2
Start treatment with oral ibuprofen and colchicine

3
Oral cefuroxime twice daily for seven days

4
Empiric antibiotic treatment
36
55

A 20-year-old HIV male who is not treated has CD4 levels of 25. For the past
5 days has low-grade temperature, increasing dyspnea, and productive
cough. On admission – room air saturation 84%, diffuse crepitations over
both lungs. Chest X-ray below. Bronchoscopy with bronchial lavage grow
pneumocystis jirovecii.

Which of the following is the most appropriate treatment?

1
Azithromycin and ceftriaxone

2
Steroids with trimethoprim sulfamethoxazole

3
Steroids with fluconazole

4
Steroids with levofloxacin

37
56

A 20-year-old male with type 1 diabetes arrives to the ER with fever,

abdominal pain, and vomiting. Glucose level is 350 and urinary ketones are
high. Blood gasses – pH 7.16, bicarbonate 16, calculated anion gap 24.

Which of the following is the most appropriate initial treatment?

1
IV insulin at 0.1 units/Kg

2
Hydration with 0.9% normal saline

3
Bicarbonate to correct acidosis

4
SC long-acting insulin

57

Which of the following is correct regarding pulmonary embolism signs on

echocardiography?

Pressure on the right ventricle is a sensitive and specific sign of

1
pulmonary embolism
Most patients with pulmonary embolism will have suspicious findings
2
on echocardiography
In most cases the blood clot in the pulmonary artery can be identified
3
on echocardiography
Decreased right ventricle free wall movement is suspicious of
4
pulmonary embolism

38
58

A 30-year-old male is brought to the ER after his friends found him lying on
the floor at his home. On examination – somnolent, blood pressure 95/60
mmHg, pulse 120/min, normal temperature. No focal neurological signs. ECG
– sinus tachycardia.
Labs –
Serum creatinine- 6.3 mg/dL
Sodium- 151 mEq/L
Potassium- 5.8 mEq/L
Chloride- 121 mEq/L
Bicarbonate- 19 mEq/L
Creatine kinase- 85,000 U/L
Urinalysis: Specific gravity 1.012; 3+ blood; 0-5 erythrocytes; dark granular
casts

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

1
Hemodialysis

2
Intravenous mannitol

3
Rapid infusion of intravenous 0.9% saline

4
Rapid infusion of 5% dextrose in water

39
59

A healthy 27-year-old female is brought to the ER due to dyspnea that

started following an argument with her manager at work. On examination –
dyspnea, 24 breaths/min, hemodynamically stable, no fever.
Labs –
Sodium- 140 mEq/L
Potassium- 3.9 mEq/L
Chloride- 108 mEq/L
Bicarbonate 22 mEq/L
pH- 7.50
pCO2- 28 mm Hg
pO2- 99 mm Hg

Which of the following correctly describes her blood gasses?

1
Mixed anion gap metabolic acidosis and respiratory alkalosis

2
Mixed metabolic alkalosis and respiratory alkalosis

3
Respiratory acidosis

4
Respiratory alkalosis

40
60

A 65-year-old female is evaluated for fatigue and exertion dyspnea for the
past 3 weeks. She underwent gastric bypass surgery 6 months ago with 30
Kg weight loss. On examination - blood pressure 130/80 mmHg, regular
pulse 110/min, no other abnormal findings. Lab – MCV 104 fL, Hb 7.4 g/dl,
vitamin B12 – low normal.

Which of the following tests is recommended for the evaluation of her

anemia?

1
Bone marrow aspiration and biopsy

2
Hemoglobin and electrophoresis

3
Serum homocysteine and methylmalonic acid measurement

4
Serum iron studies

61

Which of the following patients has an indication for bariatric surgery?

1
A 27-year-old male, BMI 26, refuses to try a diet

2
A 35-year-old female, BMI 41, active psychotic disease

An 85-year-old female, BMI 34, uncompensated ischemic heart

3
disease

4
A 56-year-old female, BMI 35, diabetes

41
62

Which of the following is an indication for tracheostomy in a complex patient

at the ICU?

1
Increased ventilation pressures with increased PEEP

2
Hemodynamic instability

3
Prolonged mechanical ventilation

4
Three days after anterior neck surgery

63

A 45-year-old female is six months after kidney transplant and is treated

with cyclosporine A and steroids. She has an incisional hernia at the
transplant site and is referred for surgical hernia repair.

Is she at increased risk for surgical site infection and why?

No, chronic immunosuppression does not increase the risk for

1
surgical site infection
Yes, steroids cause inhibition of collagen production and fibroblast
2
proliferation

3
Yes, due to constant vasoconstriction followed by hypoxia

Yes, due to structural changes in the cell nucleus that decreases DNA
4
production

42
64

An 82-year-old female arrives to the ER complaining of abdominal pain and

vomiting. Medical history is positive for hypertension and chronic renal
failure. No previous surgeries. She had a similar episode in the past where
her hemoglobin was 5.4 and she was diagnosed with duodenitis. She is
taking Nexium once daily. Vital signs on admission – pulse 111/min, blood
pressure 93/46, no fever. On examination – soft abdomen with epigastric
tenderness, no peritonitis, no other abnormalities.

Which of the following blood tests are imperative to decide on further

treatment?

1
CBC only

2
CBC, short chemistry, coagulation panel

3
CBC, short chemistry, liver and pancreas function tests

4
Lactate only

65

A 40-year-old male is treated with prolonged parenteral nutrition due to

malnutrition caused by enteric fistula accompanied by vomiting and
diarrhea. Five days after treatment he develops respiratory failure,
hypotension, and rhabdomyolysis.

Which of the following is the primary etiology?

1
Hypophosphatemia and hypokalemia

2
Hypoglycemia

3
Vitamin B12 deficiency

4
Hypermagnesemia

43
66

Which of the following is the most common etiology for multi-organ failure
fowling abdominal surgery?

1
Bacterial infection

2
Decreased metabolic state

3
Acute pancreatitis

4
Immune compromised disease

67

A 63-year-old male with end stage renal disease is treated with dialysis 3
times a week. He now complains of bone pain and several pathological limb
fractures.

Which of the following is the most common electrolyte abnormality in this

patient?

1
Hypokalemia

2
Hypernatremia

3
Hyperphosphatemia

4
Hypercalcemia

68

Which of the following benign liver lesions may bleed spontaneously?

1
Right lobe 8 cm hemangioma

2
Right lobe 8 cm liver cyst

3
Left lateral segment 5 cm focal lobular hyperplasia (FNH)

4
Caudate lobe 5 cm adenoma
44
69

A 53-year-old female complains of upper abdominal pain that radiates to the

back and is accompanied by nausea and vomiting. Abdominal CT
demonstrates pancreatitis and abdominal US demonstrates cholelithiasis.

Which of the following is a prognostic sign in pancreatitis according to

Ranson’s criteria?

1
Amylase

2
Age

3
Bilirubin

4
Albumin

45
70

A 48-year-old healthy male undergoes right hemicolectomy due to stage 1

cecal carcinoma. After surgery he develops prolonged ileus and has large
amounts of content in the nasogastric tube for 5 days.
On examination – decreased skin turgor, dry mucosa, orthostatic
hypotension.
Labs :
PCO2 50 mmHg
PO2 85 mmHg
HCO3 42 meq/L
Na 132 meq/L
K 3.1 meq/L
Cl 80 meq/L

Which of the following correctly describes his acid-base status?

1
Uncompensated metabolic acidosis

2
Uncompensated respiratory acidosis

3
Respiratory acidosis with metabolic compensation

4
Metabolic alkalosis with respiratory compensation

71

Which of the following bariatric procedures is restrictive only?

1
VBG- vertical bended gastroplasty

2
Laparoscopic adjustable gastric banding

3
Roux-en-Y gastric bypass

4
Biliopancreatic diversion (BPD)

46
72

A 50-year-old female undergoes mammography that demonstrates diffuse

fine calcification at the left breast, BIRADS 4A. Breast ultrasound is normal.
Biopsy – ductal carcinoma in situ (DCIS).

Which of the following is the most appropriate surgery?

1
Left lumpectomy + sentinel lymph node biopsy

2
Left lumpectomy

3
Left mastectomy + sentinel lymph node biopsy

4
Left mastectomy

73

Which of the following is correct regarding Spigelian hernia?

1
Pelvic hernia through the obturator canal

2
Paraduodenal hernia

3
Hernia between the rectus muscle border and the semilunar line

4
Posterior diaphragm left chest hernia

74

All of the following are characteristic of peptic ulcer disease, except:

1
Pallor

2
Jaundice

3
Multiple vomiting

4
Melena

47
75

Which of the following is correct regarding mesh use in inguinal hernia

repair?

1
Increases the risk for surgical site complications

Hernia recurrence is more common with laparoscopic repair in

2
comparison to open repair

3
Requires general anesthesia only

4
Reduces recurrence rates

76

Which of the following is the test of choice for primary diagnosis of H. pylori
infection when there is no need to perform endoscopy?

1
Serum serology

2
Blood culture

3
Urea breath test

4
Urine urea level

77

All of the following are risk factors for incisional ventral hernias, except:

1
Age

2
Emphysema

3
Ascites

4
Jaundice

48
78

Which of the following is correct regarding umbilical hernias?

Umbilical hernia repair is indicated in hernias that do not close by the

1
first year of life

2
Most umbilical hernias in adults are acquired

3
Umbilical hernias are 3 times more common in males than females

4
Umbilical hernia is an indication for surgery

79

A 42-year-old female is admitted due to right lower abdominal pain,

tenderness on palpation, and fever. On diagnostic laparoscopy an inflamed
and thickened Mekel’s diverticulum is identified. The appendix is normal.

Which of the following is the most appropriate next step?

1
Resection of the diverticulum

2
Formal right hemicolectomy

Abort surgery, give antibiotics, and perform Mekel scan (Tc-

3
pertechnetate scintigraphy)

4
Subtotal colectomy

49
80

Which of the following is a risk factor for incisional hernia?

1
Steroid treatment

2
Antihypertensive treatment

3
Rheumatic disease

4
Hepatitis B

81

All of the following are indication for surgery in patients with diverticulitis,
except:

A 40-year-old male after his first admission due to pelvic abscess that
1
was treated with CT guided percutaneous drainage and resolved
A 54-year-old male with recurrent UTIs and suspected colo-vesical
2
fistula
A 69-year-old male with post-diverticulitis stenosis at 40 cm from the
3
anal verge that cannot be passed by a colonoscope
A 70-year-old male following 3 diverticulitis episodes in the last two
4
years that responded to antibiotic treatment only

82

Which of the following is the primary treatment to control variceal bleeding

in patients with Child B cirrhosis?

1
Transjugular intrahepatic portosystemic shunt (TIPS)

2
Endoscopy and varices ligation

3
Surgical spleno-renal shunt

4
Urgent liver transplant

50
83

A 68-year-old male is admitted due to left lower abdominal pain, fever

38.0°C, localized tenderness. Medical history is positive for diverticulosis of
the colon. He is treated with antibiotics and bowel rest and improves. A
photo of his CT on admission is below and the radiologist diagnoses
uncomplicated diverticulitis.

Which of the following is the next step in management?

1
Sigmoidectomy during this current admission

2
Sigmoidectomy in a few months after the inflammation subsides

3
Colonoscopy during this admission

4
Colonoscopy in 4-8 weeks

51
84

A 30-year-old female complains of a right breast mass. On examination – a

firm, smooth, mobile, 2 cm mass at the superior-outer quadrant of the right
breast. No other abnormal findings. Breast ultrasound – hypoechoic mass,
well-defined, slightly lobular, BIRADS 3. Needle biopsy - fibroadenoma.

Which of the following is the most appropriate next step?

1
Observation only

2
Surgery

3
Surgery and radiation therapy

4
Hormonal therapy

85

A 20-year-old male presents with acute appendicitis. Which of the following

is the most common location found on surgery?

1
Retro-cecal

2
Sub-cecal

3
Pelvic

4
Pre-ileal

52
86

Which of the following is the most common liver abscess etiology in the past
20 years?

1
Arterial seeding

Portal seeding (secondary to other intrabdominal inflammatory

2
process)

3
Direct invasion of colonic or duodenal tumors

4
Bile seeding following cholangitis or cholecystitis

87

Which of the following is a risk factor for esophageal cancer?

1
Barrett’s disease

2
Paraoesophageal hernia

3
Drink plenty of coffee

4
Weakening of the upper stomach cardia muscles

53
88

A 76-year-old male is admitted with an obstructing sigmoid colon tumor that

causes perforation and peritonitis. He is referred for urgent surgery.

Which of the following is the most common perforation location?

1
2 cm distal to the tumor

2
2 cm proximal to the tumor

3
Splenic flexure

4
Cecum

89

Which of the following is a fundamental principal in ATLS?

1
Confirmed diagnosis is essential prior to treatment

2
Full history is essential prior to treatment

3
All injuries must be treated

4
Injuries should be treated according to severity

54
90

A 27-year-old male complains of pain and foul-smelling discharge from the

area of the coccyx (photo below).

In which of the following this disease is common?

1
Pregnant females

2
Scandinavians due to cold temperatures and warm clothing

3
People who sit at work for long hours

4
Thin patients with BMI of less than 25

55
91

An 87-year-old male is evaluated for back lipoma. On examination at clinic a

small bulge is noticed at the left inguinal area and is diagnosed as left
indirect inguinal hernia. The patient denies pain, has normal bowel
movements, and eats and drinks regularly.

Which of the following is the most appropriate recommendation for his

hernia?

1
Immediate surgery

2
Surgery in 6 months after staying with abdominal binder

3
Avoid surgery and observation only

4
Follow-up in a month and if there is no pain then refer to surgery

92

A 48-year-old female develops postoperative constipation and took self-

prescribed diarrheic agent containing magnesium. Blood tests reveal high
levels of magnesium.

Which of the following is the earliest sign of hypermagnesemia?

1
Loss of deep tendon reflexes

2
Spastic palsy

3
Frequent cramps

4
Acute decrease in blood pressure

56
93

A 40-year-old female has Crohn’s disease for the past 10 years. She is
admitted to surgery and is a candidate for bowel resection due to her
disease.

Which of the following is the most reliable test to evaluate her nutritional
status?

1
Calcitonin level

2
Pre-albumin level

3
Glutamine level

4
TSH level

94

Which of the following is the test of choice to diagnose postoperative

pulmonary emboli?

1
Chest angiography CT

2
Serum D-dimer levels

3
Physical examination of the calves

4
Upright chest X-ray

57
95

A 35-year-old male arrives to the ER and is diagnosed with esophageal

perforation. On admission – pulse 102, blood pressure 76/34. Left pleural
effusion on chest X-ray.

Which of the following is the most significant risk factor in this patient?

1
Age

2
Heart rate

3
Blood pressure

4
Chest X-ray finding

96

Which of the following is the most appropriate treatment for inflammatory

breast cancer?

1
Neoadjuvant chemotherapy, mastectomy, radiation therapy

2
Mastectomy, adjuvant chemotherapy, radiation therapy

3
Neoadjuvant chemotherapy, mastectomy, follow-up

4
Mastectomy, radiation therapy

58
97

A 45-year-old male, who underwent cardiac catheterization two months ago,

is treated with Aspirin and Plavix. He arrives to the ER with hematemesis
that started several hours ago. On examination – pale, pulse 110, blood
pressure 100/70.

Which of the following are the immediate steps and at what order?

Initial hemodynamic status assessment, fluids and blood

1
resuscitation, history and physical examination, nasogastric tube
insertion
Rule out acute cardiac event, platelets infusion, urgent gastroscopy
2
at the ER
Initial hemodynamic status assessment, urinary catheter,
3
angiography to locate and treat the bleeding
Locate the bleeding by performing urgent gastroscopy and
4
colonoscopy at the ER

98

Which of the following is correct regarding the gastric cells and their
function?

1
Gastrin is secreted by the G cells located at the antrum

2
Somatostatin is secreted by the D cells located at the fundus

3
Mucus is secreted by the parietal cells located mostly at the antrum

4
Ghrelin is secreted by cells located at the antrum

59
99

A 50-year-old female complains of tingling around her mouth and

paresthesia at the finger tips following parathyroidectomy.

Which of the following is the most common etiology?

1
Decrease in serum calcium levels

2
Decrease in serum PTH levels

3
Decrease in serum vitamin D levels

4
Decrease in serum TSH levels

100

Which of the following is an indicator for shock in trauma patients?

1
Patient is alert to time and place

2
Pulse 98/min

3
Breaths 17/min

4
Urine output 10 ml in two hours

60
101

A 61-year-old male develops post-ERCP necrotizing pancreatitis and is on

ventilation and nutritional support.

Which of the following is the best and most appropriate feeding method?

1
Parenteral (IV) nutrition via central line

2
Enteral feeding via nasojejunal tube

3
Elemental oral feeding

4
Enteral feeding via nasogastric tube

102

Which of the following is the most common metabolic abnormality following

partial gastrectomy?

1
Hypochromic anemia

2
Megaloblastic anemia

3
Lipid absorption disorder

4
Osteoporosis and osteomalacia

61
103

A 52-year-old female arrives to the ER complaining of abdominal pain and

vomiting. Medical history is positive for hypertension and chronic renal
failure. She had a similar episode in the past where her hemoglobin was 5.4
and she was diagnosed with duodenitis. She is taking Nexium once daily.
Vital signs on admission – pulse 121/min, blood pressure 83/46, no fever. On
examination - peritonitis with diffuse tenderness.

Which of the following is the first diagnostic imaging?

1
Upright chest X-ray with diaphragms

2
Kidney and abdominal ultrasound

3
Abdominal-pelvic CT

4
Abdominal-back MRI

104

Which of the following is included in the lethal triad during shock?

1
Hyperthermia

2
Metabolic alkalosis

3
Coagulopathy

4
Pulmonary edema

62
105

A 75-year-old female is admitted for left colectomy due to a 3 cm tumor.

Which of the following is the recommended preparation regimen on the day

before surgery?

Mechanical bowel preparation with diarrheic agents combined with

1
IV antibiotics
Mechanical bowel preparation with diarrheic agents combined with
2
oral antibiotics

3
Combined oral and IV antibiotics

Mechanical bowel preparation with diarrheic agents combined with

4
enemas

106

A 35-year-old male is evaluated for prolonged abdominal pain. Evaluation

includes multiple duodenal ulcers on gastroscopy, serum gastrin levels of
1500 pg/ml, and a small tumor at the first part of the duodenum on CT.

Which of the following is the most likely diagnosis?

1
Insulinoma

2
Zollinger-Ellison syndrome

3
Carcinoid syndrome

4
VIPoma

63
107

A 45-year-old female complains of dysphagia and a feeling that the “food is

stuck”, weight loss of 10 Kg.

Which of the following will support the diagnosis of achalasia?

Severe chest pain and esophageal spasm with corkscrew esophagus

1
on barium swallow
Food regurgitation, foul odor, upper esophagus diverticulum on
2
barium swallow
Burning sensation at the chest, especially in supine position,
3
esophagitis on gastroscopy
Lack of lower esophageal sphincter (LES) relaxation on manometry,
4
esophageal dilation, no effective peristaltic waves

108

Which of the following is correct regarding breast cancer in men?

1
Constitutes only 25% of all breast cancer cases

Only a small percent of the cases is estrogen and progesterone

2
receptor positive

3
The prognosis per stage is the same between males and females

4
It is not common practice to perform sentinel node biopsy in males

64
109

An asymptomatic young female has sodium levels of 125 mg/dl following

routine cholecystectomy.

Which of the following is the treatment of choice?

1
Hypertonic sodium solution

2
Normal saline

3
Sodium chloride tablets

4
Free water restriction

110

A 51-year-old male with liver cirrhosis and hepatocellular carcinoma (HCC) is

a candidate for surgery.

Which of the following may assist to predict his surgical risk?

1
Doppler US

2
Alpha-fetoprotein levels

3
Child-Pugh classification

4
Liver enzymes

65