D. Preterm labor

State Exam 20.09.2012

Part A

1. 6 years old boy has stool in his underwear daily. He was toilet trained at 2 without difficulty. Over the last 2 years he had developed chronic constipation. The fecal soiling developed over the last 3 months. He is otherwise normal. Examination reveals stool in rectal vault. Initial management should include which of the following?
a. barium enema followed by rectal biopsy
b. time out from school when he has stool in his underwear
c. family consulting
d. clear fecal impaction and short term stool softener use
e. daily enemas for 4 weeks

2. A 2 year old child has multiple episodes of brief shrill cry followed by a prolonged expiration and apnea. He was born after normal pregnancy and delivery. Growth and development are normal. The first episode occurred immediately after the mother refused to give the child some juice; the child became cyanotic, unconscious, and had generalized clonic jerks. A few moments later the child awakened and had no residual effects. Physical examination is normal. Which of the following is most likely diagnosis?
a. Seizure disorder
b. Drug ingestion
c. Hyperactivity with attention deficit
d. Pervasive development disorder
e. Breath-holding spell

3. A 5-month-old child with poor growth presents to the ER with generalized tonic-clonic seizure activity of about 30-minute duration that stops upon the administration of lorazepam. Which of the following information gathered from the mother will be most helpful?
a. The child has had rhinorrhea
b. The child is developmentally normal, as are his siblings
c. The mother has been diluting the infant’s formula to make it last longer
d. number and type of pets
e. The mother is single and unemployed

4. Full term newborn infant is having episodes of cyanosis and apnea which are worse with attempting to feed but seems better with crying. Which of the following is most important next step to quickly establish the diagnosis?
a. Echocardiogram
b. Ventilation perfusion scan
c. Passage of catheter into nose
d. Hemoglobin electrophoresis
e. Bronchoscopic evaluation of palate and larynx

5. 3 month old child is been crying at the same time each day, you suspect colic. What is true about colic?
a. onset at 3 month and peak at 6 months
b. almost all cases are due to lactose intolerance
c. typical at afternoon and evening
d. with any degree of abdominal distension should have CT abdomen

6. 3 year old has persistent rhinorrhea for the last past 6 weeks. Otherwise the patient has been asymptomatic. On physical examination you notice mouth breathing and dark circles under the eyes. In the nose, watery discharge and edematous boggy bluish mucous membrane with no erythema. Most likely diagnosis:
a. chronic bronchitis
b. sinusitis
c. nasal foreign body
d. allergic rhinitis
e. CSF leak

7. 5 year old immunized girl is seen in the emergency department because of fever, sore throat and respiratory distress that has developed in the last 3 hours. She is drooling, holding her neck in a hyperextended position, she has mild stridor but does not have barky cough. The patient most likely to have:
a. viral croup
b. spasmodic cough
c. epiglottitis
d. bacterial tracheitis
e. asthma

8. A 9 mounts boy, previously healthy and normally gaining weight was recently discharge from the hospital. The hospitalization was due to a severe rotavirus diarrhea that requires rehydration. 4 days later the baby still has loss stools. He is now drinking his regular cow's milk formula well. On physical examination he is happy and well hydrated. Repeat rotavirus test is negative. What is the reason for the baby's continued diarrhea?
a. cow milk protein allergy
b. starvation diarrhea
c. secondary lactose intolerance
d. viral gastroenteritis
e. cystic fibrosis

9. a mother brings her 2 year old baby for regular checkup. She is confused about which position to put her baby to sleep. With regard to infant sleeping position, how should you consult the mother?
a. place the baby on the belly
b. place the baby on the side
c. elevate head of the baby's crib
d. elevate the foot of infant crib
e. place on the back

10. The most common neurological sequela associated with bacterial meningitis, and usually presents at the time of initial infection is?
a. mental retardation
b. chronic seizure disorder
c. impaired vision
d. impaired hearing
e. behavioral disturbances

11-THE MOST COMON CAUSE OF VIRAL MENINGOCEPHALITIS IN CHILDREN IS

A-ENTEROVIROS

B-HERPES SIMPLEX VIROS

C-ARBOVIROS

D-MUMPS VIROS

E-RESPIRATORY VIROS

12-A 12 YR OLD BOY PREZENTS WITH A 1 YR HISTORY OF WORENING POLIYURIA AND A 2 TO 3 WEEKS HISTORY OF NAUSEA,FATIGUE AND MALAISE. SERUM CREATENIN IS 4.0 MG.BICARBONAT 15 MG, URINALISIS SHOWS SPECIFIC GRAVITY OF 1.OO4, TRACE LEUKOCYTES, TRACE BLOOD, AND NO PROTEIN, WITH 3-5 WBS PER HIGH POWER FIELED, 3-5 BBC PER HIGH POWER FIELED, AND NO RBC CASTS. WHICH OF THE FOLLOWING IS THE MOST LIKELY DIAGNOSIS:

A-ACUTE POST STREPTOCOCAL NEPHRITIS

B-CHRONIC INTERSTITIAL NEPHRITIS

C-MINIMAL CHANGE NEPHROTIC SYNDROM

D- ACUT INTERSTITIAL NEPHRITIS

E-CHRONIC GLOMERONEPHRITIS

13-TRISOMY 21 IS ASSOCIATED WITH

A-MALROTATION

B-HYPOTONIA

C-CLEFT PALATE

D-RENAL DISEASE

E-PER CAVUS

14-PECAUSE OF SPLENIC DYSFUNCTION AND AN INCREASED RISC OF BACTERIAL INFECTION, CHILDREN WITH SIKLE CELL ANEMIA SHOUD PLACED ON PROPHYLACTIC PENICILIN VK BY 4 WEEKS. AGE CHELDREN WITH SIKLE CELL ANEMIA ARE PARTICULARY SUSCEPTIBLE TO:

A-GRAM NEGATIVE RODS

B-ENCAPSULATED ORGANISMS

C-FUNGAL INFECTION

D-VIRAL INFECTION

E-STAPHLOCOCUS AUREUA

15-YOU HAVE JUST GIVEN A 10 YR OLD AN INJECTION OF POLLEN EXSTRACT AS PRESCRIPED BY HIS ALLERGIST IN HIS CHEST. YOU NOTE THAT HIS FACE IS FLASHED AND HIS VOICE SOUNDS MUFFLED AND STRAINED. WHICH OF THE FOLLOWING IS THE FIRST PRIORITY IN MANAGIG THIS EPISODE OF ANAPHYLAXIS

A-ENDOTRACHEAL INTUBATION

B-INTRAMUSCULAR INJECTION OF DIPHENHYDRAMINE

C-ADMINISTRATION OF INHALED BRONCHODILATOR

D-INTRAMUSCULAR INJECTION OF EPINEPHRINE

E-ADMINISTRATION OF INTRAVINOS CORTICOSTEROIDS

16-A 15 YR OLD GIRL WITH SHORT STATURE, NECK WEBBING AND SEXUAL INFANTILISM IS FOUND TO HAVE COARCATION OF AORTA. A CHROMOSOMAL ANALYSIS IS LIKELY TO DEMONSTRATE WHICH OF THE FOLLOWING

A-MUTATION AT CHROMOSOME 15 Q 21.1

B-TRISOMY 21

C-45 XO KARYOTYPE

D-DEFECT AT CHROMOSOME ANALAYSIS

E-NORMAL CHROMOSOME ANALYSIS

17-A 2 MONTH OLD BOY IS SEEN FOR NONBILOUS VOMITING AFTER HE HAD BEEN BREASTFEEDING WELL UNTIL 2 WEEKS AGO, WHEN VOMITING WORSENED. ON PHYSICAL EX HE HAS JAUDANCE AND GASTRIC PERISTALTIC WAVES ARE SEEN ON THE ABDOMEN. BLOOD TEST REVEAL HYPOKALEMIC, HYPOCHLOREMIC ALKALOSIS. THE MOST LIKLEY DIAGNISIS IS

A-ACUTE HEPATITIS

B-DUODENAL ATRESIA

C-UTI

D-PYLORIC STENOSIS

E-MILK ALLERGY

18-YOU ARE SEEING A 10 YR OLD BOY WITH COMPLAINT OF DOUBLE VISION ESPECIALLY IN THE AFTERNOON. HE TIRES FASTER THAN HIS CLASSMATS IN GYM CLASS DUE TO MUSCLE FATIGUE WITHAWT RESPIRATORY SYMPTOMS. HIS PUPILS AND VISUAL ACUITY ARE NORMAL BUT YOY NOTICE A DISTINCT PTOSIS. THE MOST LIKELY DIG IS

A-PITUITARY TUMOR

B-AMBLYOPIA

C-BOTULISM

D-MYASTHENIA GRAVIS

E-TICK PARALAYSIS

19-A 4 MONTH OLD CHILD WITH VITAMIN D DEFICIENTY RICKETS WOULD BE EXPECTED TO SHOW ALL OF THE FOLLOWING EXCEPT

A-CRANIOTABES

B-BOWLEG

C-ROSARY

D-LOW SERUM PHOSOHATE LEVELS

E-HIGH ALKALINE OHOPHATASE LEVELS

20-WHICH OF THE FOLLOWING CAUSES OF CONGINITAL INFECTION IS ASSOCIATED WITH CATS

A-CYTOMEGALOVIROS

B-RUBELLA

C-TOXOPLASMA GONDO

D-SYPHILIS

E-PARVOVIROS B 19

21. Obese, 9 years old girl, history of persistent headache and blurred vision. Mild vomiting. No fever. In physical examination papilledema. Visual field testing inferior nasal blind spot. MRI normal. LP pressur IS elevats, CSF composition IS normal. Lab. Normal. What IS the most likely diagnosis?

Pseudotumor cerebri

22. 4 day old infant, noted to be sucking on a honey- filled pacifier. You caution the mother against its isr because its contents can cause:

Infantile botulism

23. Infant 8 day old, high TSH and low T4. If this condition IS Left untreated:

Prolonged jaundice

24. Complication of hypernatremic dehydration IS:

Cerebral edema.

25. you are evaluating an Obese, 10 years old boy for diabetes. He has strong Family history of type2 diabetes mellitus. His mother is concern about recent symptoms of polyuria and polydipsia. What of the following is a diagnostic for diabetes mellitus:

a. Non fasting plasma glucose of 210 mg/dl

b. fasting plasma glucose of 110 md/dl

c.2-hour glucose during glucose tolerance test of 165mg/dl

d. acanthosis nigricans on neck

e. symptomes alone are enough to make the diagnosis.

26. Hb 8.5 mcv 110fl, reticulocyt count 0.5. Most likely diagnosis is:

Vitamin B12 deficiency

27. Women O positive give birth at term infant A positive. Ht 55%, bilirubin 12 mg/dl. Wich of the following lab findings ABO hemilytic disease:

A positive coombs test

28. 1 years old, failur to thrive, frequent large voids of diluted urine, excessive thirst and episods of dehydration without vomiting and diarea. Over the years family members reports similar history. The most likely diagnosis is:

Diabete insipidus.

29. 10 years old, Is having "cold" for 14 days, purulent nasal discharge, facial pain. Most likely diagnosis:

Maxillary sinusitis

30. A 6 month infant with large foul smelling stools Is not gaining weight. Cloride 68????

31. A 5 month old child regularily regurgitates large portions of her feeds. PH probe study showed significant periods of low esophageal PH. The child has normal growth and no other significant past medical history. Which is the best management at this point:

a. barium swallow and upper (GL) gastrointestinal series

b. oral reflux medications

c. esophageal manometry

d. close observation only

e. surgical correction

32. a 6 week old is admitted with jaundice, total Bilirubin is 12mg/dl with direct Bilirubin 5mg/dl. What is most likely the disorder?

a. ABO incompability

b. biliary atresia

c. Rh incompability

d. Gilbert disease

e. breast-milk jaundice

33.

34. a 2 year old boy has Teratology of fallot. Today he arrives with acute febrile illness. On examination, he complains of headaches, lethargy, has nystagmus and ataxia. What will be the most appropriate first test to order?

a. Urine drug screen

b. Blood culture

c. lumbar puncture

d. CT of brain

e. echocardiogram

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41- 2 Year old boy is seen because of pallor. His mother sees e drinks 4 glasses of cow's milk a day. A CBS reveals a hemoglobin of 8.2 g/DL an a MCV of 65 fl. Which of the following is compatible with this patients?

a-decreased red blood cell distribuition
B- decreased serum feritin
C- increased reticolocyt count
D- increased serum iron level
E- increased white blood cell count

42- Which of the following reflexes is normally absent in a newborn?

A- STARTLE (moro)

B- hand grasp

c- crossed adductor

D- Asymmetric tonic neck

E- parachute

43- A 2 year old boy is admitted to the hospital with high fever four 6 days, swelling of the ands and feets, scarlentiniform changes of the tongue, generalized reed macular rash, dray sedmentation reet & thrompocytosis. Which of the following is the best initial mangmanet?

A- cardiac catheterization

B- IVIG & aspirin orally

C- naproxen orally

D- I.V pulse corticosteroids

E- methotrexate orally

44- A 9 month old girl present to the ER with respiratory distress, grunting & cyaiosis. u start O2 by face mask, but the child is still in a significant respiratory distress & become apnoic. The best next step is?

A- start chest compretion

B- performe Heimlich maneuver, maybe the child aspirate something

C- obtain blood gas

D- send the child for RX-chest

E- start bag – valve – mask ventilation with 100/100 o2

45- A 5 year old boy present with a history of grossly blood urine, puffy eyes & headache for 1 day. He has been will with fever & sore throat about 10 days which resolved with out treatment most likely diagnosis?

A- acute cystitis

B- IgA nephropathy

C- acute pyelonefritis

D- postinfaction glomerulonephrtis

E- benign hematuria

46- 10 years old female with fever, pain, swelling in her left elbow for 2 days & right knee for 3 days, today her right knee us OK. The arthritis was preceded by a 3 days history of fever & sore throat 2 weeks ago. Laboratory results reveal un elevated antistreptolwsin. The most likely diagnosis us?

A- S.L.E

B- idiopathic R.A

C- acute rheumatic fever

D- gonococal arthritis

E- psoriatic arthritis

47- Which of the following cancer occurs primarily during childhood?

A- breast cancer

B- renal cell cancer

C- wilms tumor

D- thyroid cancer

E- colon cancer

48- the most important extramedullary site of relapse in childhood acute lymphoblastic leukemia is?

A- Adrenal glands

B- kidney

C- lung

D- heart

49- Very-low-birth –weight (< 1500 g) infant are best describes as?

A- predominantly growth restricted

B- predominantly PREMATURE

C- predominantly postdate

D- the result of maternal illness

E- the result of placental infraction

50- An 18 year old female, u have followed for 6 years, has recently married, she & husband are planning to start a pregnancy.u advise her to start taken folic acid, this is important to prevent?

A- prematurity

B- skull defects

C- chromosomal defects

D- neural tube defects

E- osteopenia

51) A 75 year-old man is complaining that for several months he has been experiencing increasing fatigue. He has a history of hypertension, gastroesophageal reflux disease, and large diaphragmatic hernia. He has not experienced any weight loss or other general symptoms.On physical examination, conjunctival pallor is noted. A fecal occult blood test(FOBT) is positive. Laboratory testing reveals iron deficiency anemia.

Which of the following is most likely cause of this patient’s anemia?

Gastric cancer.

Colorectal cancer.

Angiodysplasia.

Peptic ulcer disease.

Diaphragmatic hernia and esophagitis.

52) A 67 year-old man with a medical history of hypertension presents is complaining of pain of acute onset in his right knee. He was well at the time he went to bed last night. He denies undergoing any trauma. On examination of the right knee: range of motion is limited, surrounding erythema and an effusion are noted. All other joints are normal.

For this patient, which of the following measures can be used to confirm the diagnosis of acute gout?

Serum uric acid measurement.

Arthrocentesis.

Trial of steroid injection for pain relief.

Trial of colchicines for pain relief.

X-ray of the knee.

53) A 36 year-old man who contracted hepatitis B 15 years ago is checked for viral serologies to better understand his hepatitis B status. Test results are negative for hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), and IgM antibody to core protein (IgM anti HBc), but the patient test positive for total anti-HBc.

What is the best explanation for this patient’s serologic profile?

He has acute hepatitis B infection.

He has chronic hepatitis B infection.

He has remote hepatitis B infection.

He has no reliable evidence for ever having been infected with virus hepatitis B.

54) 54) a 43 year old woman was recently diagnosed with diffuse scleroderma. for the past two years she has been experiencing skin thickening with pain and itching. She also reports increasing difficulty with movement of her knees because of thick skin. She denies having any shortness of breath, on examination the patient’s blood pressure is 145/92 mmHg, her pulse is 84 beats/min, and her oxygen saturation is 97%. On room air, the remainder of the physical examination is consistent with her diagnosis of diffuse scleroderma. laboratory data show blood urea nitrogen (BUN) value of 24 mg/dl and a creatinine chemistries urinalysis shows 1+ and 2+ protein. Six months ago, her blood pressure was 125/78 mg/tg and her BUN and creatinine were 12 mg/dl and 0.9 mg/dl, respectively which of the following interventions is most appropriate for this patient of this time?

a. Initiation of angiotensin - converting enzyme (ACE) inhibition.

b.initiation of calcium channel blocker.

c. Initiation of a thiazide diuretic.

d. Renal biopsy.

e. Close monitoring for further elevation of blood pressure.

55) A 64 year old man is found to have a markedly elevated absolute lymphocyte count during a preoperativeevaluation for a total knee arthroplast y. He denies experiencing any weight lose, night sweets, or ” lumps and bumps”, which of the following is required to make the diagnosis of CLL in this patient?

a. An ALC (absolute lymphocyte count) greater that 10,000/ml

b. Identification of a monoclonal B cell population with characteristic phenotype by flow cytometny.

c. A bone marrow biopsy with characteristic findings.

d. Thoracic, abdominal, on peripheral lymphadeno pathy.

56) A 71 year-old man with a medical history of CCL presents with new-onset fevers and night sweats, as well as rapidly enlarging nodes in his right axilla. You are concerned about richter transformation.

Which of the following is the best diagnostic intervention of this patient?

Serum flow cytometry.

Fine-needle aspiration of axillary node.

Excisional lymph node biopsy.

Bone marrow biopsy.

57) A 32 year-old man presents with a testicular mass. His examination is unremarkable except for a palpable, firm left testicular mass. The presence of which of the following markers signifies a nonseminimatous testicular cancer?

a. human chorionic gonadotropin(hcG).

b. CA-125.

c. CA 19-9.

d. α-fetoprotein (AFP).

e. carcinoembryonic antigen(CEA).

58) A 38 years old man with a history of testicular cancer presents with fatigue, dyspnea on exertion, and generalized weakness, he underwent chemotherapy 10 years ago. Subsequent serial evaluations have not revealed any remaining testicular cancer. On physical examination, the patient is found to have pale conjunctivae and nail beds, as well as scattered lower-extremity petechiae.

What possible long-term side effects of chemotherapy could be responsible for this patient’s symptoms?

Cardiovascular disease.

Hypercholesterolemia.

Leukemia.

Cerebrovascular disease.

Retroperitoneal fibrosis.

60) A 72 year old woman complains of fatigue, easy bruising, weight loss, and abdominal distention. Her pulse is slightly fast, and she has notable pallor and splenomegaly. Blood counts reveal anemia and thrombocytosis, you are concerned that she may have myelofibro sis, what would you expect to see on this patient's peripheral blood smear if she did have myelofibrosis?

a. Teardrop cells

b. Schistocytes

c. Burr cells

d. A canthocytes

61. A 38 y/o woman with severe asthma is complaining that for the past 2 days she has been experiencing progressive shortness of breathe. On examination, patients respiratory rate is 18 BPM, room air saturation: 86%. She had a few expiratory wheezes with little air movement.
Results of arteriole blood gas: PH;7.2, PaO2; 62 mmHg, PCO2; 63 mmHg.
On the basis of the arterial blood gases measurements which of the following BEST describes this patients condition:
A) Acute hypoxemic respiratory failure
B) Acute hypercarbic respiratory failure
C) Chronic hypercarbic respiratory failure
D)Mixed hypoxemic and hypercarbic respiratory failure

62. A 37 y/o woman is brought for evaluation for altered mental status.
She has no medical problems and only takes OCP.
Her husband reports that the patient has had a fever for 2-3 days.
On examination, patient is febrile (38.9 C), conjunctivae are pale.
She has palpable purpura on her lower extremities.
Lab results: Hb; 6 g/dl, Plt count; 20,000/mm3, creatinine;2.8mg/dl.
Peripheral smear shoes evidence of microangiopathic hemolysis.
which of the following interventions is the MOST appropriate step to take next for this patient?
A) Platelets transfusion t o raise PLT > 50,000/mm3
B) platelets transfusion to raise PLT > 100,000/mm3
C) Initiation of aspirin therapy
D) Plasma exchange for 6 session
E) surgical for splenctomy

63. A 72 y/o woman with COPD and hypertension presents for a follow up visit.
She has recently been admitted for an acute exacerbation of her COPD.
Her most common recent spirometry results shows an FEV1/FVC ratio of 0.48.
Which of the following interventions has been shown to reduce the number of acute COPD exacerbation?
A) Short acting anticholinergic inhalers
B) short acting inhalational Beta-agonists
C) Inhaled corticosteroids
D) Oxygen therapy.

64. A 52 y/o woman smokes ½ pack of cigarettes per day and drinks 1 bottle of beer a week. She has GERD for which she takes PPI.
Last year her father was diagnosed with esophageal cancer. For this patient which of the following risk factor for esophageal cancer?
A)Tobacco use
B)Alcohol
C) GERD
D) all of the above

65. A 47 y/o woman with SLE is complaining of chest pain, fever and cough of 5 days duration. The results of physical examination are: significant temp. of 38.2C, BP; 95/50 mmHg, HR;114 BPM. Lung examination reveals inspiratory crackles at the bases. CXR shows diffuse infiltrates and a right sided effusion. Patient undergoes thoracosynthesis.
Which of the following thoracosynthesis findings would be consistent with a lupus effusion?
A) excudate
B) transudate

C) very low glucose
D) + gram staining
E) high WBC count

66. A 40 year old women undergo a routine abdominal ultrasound, There is no inflammation but two stones are found in size less then 5 mm she denies any symptoms and she has no past, what is the best next step:
A. Cholecystectomy
B. ERCP
C. Observation
D. PTC
E. MRCP

67. A 18 year old with easy busing, lymphocytes 6000 platelets 200,000 hemoglobin 13 PT 13 PTT 70 which was rechecked 67. What is the most likely diagnosis?
A. Factor 7 deficiency
B. lupus
C. Factor 7 inhibition
D. Glanzmam thrombasthesis

68. A 63 year old man with irregular rhythm who walks 2 mile with no dyspnea was checked in a 12 lead ECG and found to have mobits 2 heart block and LBBB, when Is a pacemaker indicated?
A. In asymptomatic it is not indicated
B. indicated when there is a stable rhythm
C. Indicated only when there is a widen QRS
D. in all AV block it is indicated

69. A 65 year old man with intermittent palpitation for 2 months, the palpitation are unpredicted from several minutes to hours. The paitents history has well controlled hypertension and he denies alcohol use. On ECG there is atrial fibrillation with 94 BPM and left ventricular hypertrophy what is the best next step?
A. Cardiac catherisation
B. Trans esophagus echocardiogram
C. Pulmonary function test
D. CT Angio of chest

70. A 78 year old man with hypertension has shows on ECG atria fibrillation what best describes the use of oral anticoagulant?
A. High risk pt over 75 y are contraindicated
B. low risk for thromboembolic are not indicated
C. The combination of aspirin and Clopidrogrele is equivalent to warfarin in high risk pt
D. Warfarin shown superiority to aspirin in patients over 75 years

71. a 35 years old woman who was diagnosed with atrioventriculare node reentry tachycardia but is not taking medications is admitted to the hospital for a hysterectomy. The night before the surgery she develops tachycardia with heat rate of 114 bpm. Which of the following is the best medication to slow this patient's heart rate and establish sinus rhythm

a. amiodarone

b. procainamide

c. adenosine

d. propafenon

72. a 23 years old man with type I DM presents to routine diabetes management. He had difficulty with adherence and has been managed with twice daily fixed dose insulin. Today his HbA1 is 9%. Which of the following insulin regimens would offer the best glycemic control for this patient

a. long acting insulin injected daily

b. rapid acting insulin injected before meals

c. long acting insulin injected daily and rapid acting insulin before meals

d. continuing current fixed dose insulin mixture injected daily

73. an 82 years old woman with history of breast cancer present to the clinic with complains of headache for the past 2 weeks. She describes daily retro orbital headaches that are worse in the morning. In addition, she notes severe nausea and vomiting. MRI of the brain reveals multiple metastatic lesion. Which of the following is the most appropriate initial management for this patient

a. Biopsy the lesions

b. Surgical resection

c. Dexamethasone

d. Repeat MRI in 6 months

74. a 42 years old man with a medical history significant for lung cancer is brought because of altered mental status. On examination he has orthostatic hypotension and dry mucous membranes. Laboratory evaluation reveals Ca 14.5 mg/dl and creatinine 2 mg/dl. Which of the following is the most appropriate initial management of this patient

a. 0.9% saline bolus

b. Furosemide

c. Pamidronate

d. 0.45% saline bolus

75. a 25 years old man was recently diagnosed with leukemia. Laboratory evaluation reveals pancytopenia, hyperkalemia (K 6.8 Meq/l), uric acid 13 mg/dl, hyperphosphatemia 12 mg/dl and elevated lactate dehyrogenase (LDH). What is the most likely cause of his electrolyte abnormalities

a. Laboratory error

b. Tumor lysis syndrome

c. Acute renal failure

d. Bone metastases

76. a 75 years old man with lung cancer complains of progressive dyspnea for 2 months. On physical examination he has distended jugular veins, plethoric face and venous collaterals on his chest wall and distant heart sounds. What is the most likely diagnosis

a. Pericardial tamponade

b. Constrictive pericarditis

c. Congestive heart failure

d. Superior vena cava syndrome

77. a 72 years old woman with history of hypertension and tobacco use is complaining about chest pain for the last 2 weeks. She describes the pain as pressure like with radiation to the left arm. It is exacerbated by exertion and relieved by rest. There are no associated symptoms. Her physical examination is unremarkable. ECG shows signs of left ventricular hypertrophy. Laboratory test including cardiac biomarkers are within normal limits. Which of the following is the most likely diagnosis

a. Non STEMI

b. Pericarditis

c. Unstable angina

d. Stable angina

78. a 47 years old woman is evaluated 2 hours after the onset of acute right sided weakness. A noncontrast CT of the head showed no evidence of hemorrhagic event. Her blood pressure at this time is 190/120 mmHg. Which of the following statements concerning blood pressure and the treatment of acute ischemic stroke is the most accurate

a. Elevated blood pressure should be aggressively treated in this setting

b. Cerebral blood flow is independent of intracranial pressure

c. Antihypertension therapy is needed in this patient before giving thrombolytics

d. Hypertension should never be treated in the setting of acute ischemic stroke

79. a 45 years old woman is evaluated for nausea, vomiting and abdominal pain of 3-4 weeks duration. Further history reveals polyuria and muscle weakness although physical examination does not reveal any abnormalities. Her serum Ca level is 13 mg/dl, intact parathyroid hormone is elevated and she is diagnosed with primary hyperparathyroidism. Which of the following is the next step in the management of this patient's hypercalcemia

a. Referral for parathyroidectomy

b. Prescribe hydrochlorothiazide

c. Biophosphonate therapy regardless of her bone mineral density

d. Repeat serum calcium in 3 months

80. a 70 years old man with squamous cell lung cancer is admitted with altered mental status. The patient's wife reports he has become increasingly confused over the last 2 days. Physical examination is significant for heart rate of 115 bpm and dry mucosa membranes. The patient is somnolent and unable to follow commands. Laboratory serum Ca level is 15.1 mg/dl. What is the most appropriate therapy for his hypercalcemia

a. Fluid restriction with loop diuretics

b. Intravenous zoledronic acid

c. Subcutaneous calcitonin

d. Intravascular volume expansion with intravenous normal saline

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90. A 55 hypertension history, 1^st step of manegment:

a.thrombolytic therapy

b.iv morphine

c.pci

d. markers

91.50years old male with inferior mi:

a.lt heart cath’

b. angioplasty

c.surgical repair

d. angioplasty

92. A 65 years old with Diabetes mellitus, hyperlipidemia and tobacco abuse presents with chest pain for the past 3 days. The pain is worse with exertion and was relieved by sublingual nitroglycerin until today when pain persisted. The pain radiates to the jaw and is associated with nausea and diaphoresis. On examination the blood pressure is 90/50, HR 96, on ECG there are ST depression in the inferior leads and the CK-MB and troponin levels are elevated. Which of the following medication should be avoided in thr management of this patient?

a. heparin

b. aspirin

c. nitrates

d.ACE

93. A 40 year old female with a history of coronary artery disease, status post-percutaneous coronary intervention with a drug-eluting stent 1 year ago, presents to the emergency department with fever and right upper quadrant pain for 1 day. An abdominal sonogram reveals gallstones with likely cholecystitis and no biliary ductal dilation. She is admitted for antibiotics and a general surgery consultation, the surgeon is concerned because the patient is on clopidogeral for a drug-eluting stent. If possible, how long should surgery be delayed after stopping the patients clopidogeral:

a. 1 day.

b. 7 days.

c. 1 month.

d. 2 weeks.

94. A 40 y old man with a history of IV drug abuse presents with fever and chills for 1 week. His examination reveals a new holosystolic murmur at the left lower sternal border that increase with inspiration. He is febrile at 38.9C. You plan to admit him for work up and treatment of infective endocarditis. what duration of IV antibiotics is necessary for this patients illness.

a. 4 to 6 weeks. b. 7 to 10 days. c. 3 months. d. 1 year.

95. A 70 year old man with a history of hypertension and diabetes presents to the management of chronic angina for the past year. His chest pain now occurs one or 3 times per month, typically last 5 minutes, and are relieved by rest and sublinguinal nitroglycerin. A recent pharmacologic stress test showed a reversible perfusion defect. What is the most appropriate next step in the management for this patients angina:

a. Add morphine to the patients regimen.

b. Coronary angiography

c. Lifestyle modification including exercise

d. Continue with the current management.

96. A 59 year old female with a history of a heart murmur but no other symptoms or rheumatic fever. The murmur is 2/6 crescendo decrescendo that radiates to the carotid artery. The murmur decreases with valsalva maneuver and on standing, the most likely diagnosis is:

a. aortic stenosis

b- tricuspid regurgitation

c- mitral regurgitation

d- hypertrophy obstructive cardiomyopathy

97. 60 years female ST elevation mi with Left ventricular ejection frcation of 25%, treatment:

a.furasamide

b. coronary bypass

c. icd implant

d. amlodipine

98. 29 old female with cardiac arrest most likely diag:

a. brugada syndrome

b. long QT synd

c.mi

d.stroke

99. A 55 year old male with urosepsis started on IV fluid and pipercillin-tazobactam. His symptoms gradually improved until hospital day-5, when he develops a rash and low grade fever. Lab tests reveal an increased creatinine and a urinalysis with blood cells and eosinophils. What is the most likely diagnosis?

a. prerenal disease

b. Nephrotic syndrome

c. acute tubular necrosis.

d. acute interstitial renal disease

100. A 40 years old woman with history of hypertension & diabetes visit your clinic with the compliant of weight gain. On examination you find – obese femae, moon facies and supraclavic fat pads. You consider cushing syndrome as diagnosis. for this patient, whatis the best diagnostic test for cushing syndrome?

a. high dose dexamethasone suppression test

b. 24-h urine free cortisol

c. random cortisol level

d. plasma adrenocorticotropic hormone level

101- What is the recommendation concerning the administration of MMR vaccine during pregnancy?

a. Contraindicated

b. The same as in non-pregnant woman

c. Only for post exposure

d. Only if there is risk factors

e. Should be administer if there is no………

102- In which gestational age laboratory screening for diabetes should be performed?

a. 10-16week

b. 16-20 week

c. 20-23 week

d. 24-28 week

e. 32-36 week

103- 31 year old woman G2P1 in 40 week gestation has progress in labor from 5 to 6 cm cervical dilation over 2 hours. Which of the following best describe the labor?

a. Prolonged latent phase

b. Accelerate active phase

c. Arrested active phase

d. Protected active phase

e. Normal labor

104- What is the most common complication of Para cervical block?

a. Maternal hypotension

b. CNS toxicity

c. Fetal bradycardia

d. Bleeding

e. arrest of dilation

105- which deleterious effect is associated with oxytocin when given intravenously as a 10 unit bolus?

a. Cardiac arrhythmia

b. Hypotension

c. Neuromuscular block

d. Seizure

e. Uterine relaxation

106- with prima with uneventful cervix and estimated fetal weight of 3800g which is the most apropiate management at 42+0 week gastetion?

a. To re date the pregnancy

b. Cesarean delivery

c. Hospitalization and bed rest

d. Cervical ripening, than labor induction

e. Epidural analgesia prior to induction of labor

107- zygotic division to form dichroniotic diammniotic twins accrue during which of the following time period following fertilization?

a. <72 hours

b. >72 and <120 hours

c. >120 and <240 hours

d. >264 hours

108- ultra sonographic evidence pointing to the diagnosis of monochronionicity in pregnancy with twins include which of the following?

a. T sign

b. Two separated placenta

c. Twin with different gender

d. Dividing membrane of more than 2 mm thick

e. Lambda sign

109- at what time are most non obstetric surgical procedure performed when indicated during pregnancy?

a. 1^st trimester

b. 2^nd trimester

c. 3^rd trimester

d. Post-partum

110- chronically hypertensive woman develop superimposed severe pre eclempsia at 36 week of gestation, all of the following regarding delivery are acceptable except:

a. Magnesium administration

b. Epidural anesthesia

c. Wait for delivery at term

d. Immediate induction of labor

e. Immediate c- section

Part B

1. A pregnant woman with HIV was admitted to hospital which of the following regimen effect pnumoscystisis carnii pneumonia:

A. AMPICILIN

B. ERYTHROMYCIN

C. COTRIMOXAZOLE

D. AZITHRHROMYCIN

E. VANCOMYCIN