Lymph node exam should be performed but unlike

Residency exam – 2016 in lymphomas or other hematologic malignancies,

lymphadenopathy is not usually seen in AML.

King Abdullah University Hospital

1- All can cause lymphadenopathy except:

- AIDS
- sarcoidosis
- *AML
- lymphoma

2- most significant risk factor for AAA: Abdominal aortic aneurysm risk factors include:
Tobacco use-->Smoking is the strongest risk factor.
- age Age--> These aneurysms occur most often in people age 65 and older.
Being male--> Men develop abdominal aortic aneurysms much more often than women do.
- gender Being white.
Family history.
- anti-hypertensive drugs Other aneurysms
- *current smoking

3- all of the following cause hypercalcemia except:

- sarcoidosis Crohn’s disease is a granulomatous disorder that is more commonly
associated with hypocalcemia caused by poor calcium intake and
- *crohn' decreased intestinal calcium absorption related to vitamin D
deficiency as a consequence of malabsorption. A man with Crohn’s
- Hypervitaminosis D disease who presented with hypercalcemia and acute renal failure is
described. Biochemical parameters showed an elevated 1,
- Hyperthyroidism 25-dihydroxyvitamin D level, with a low-normal 25-hydroxyvitamin D
level and decreased parathyroid hormone level

4- All can come with FMF except: The initial attack occurs before the ages of 10 and
Familial Mediterranean fever (FMF) is a disease with 20 years in 65 and 90 percent of cases. In rare
- can cause pleurisy an onset before 20 years of age in 90% of the patients. cases, the initial attack can occur in individuals
However late onset FMF defined as age of onset over older than 50 years of age. In adults, FMF is more
- cause fever in more than 50% of pts 40 years is being recognised more frequently. prevalent in men than in women. It mainly occurs
in families of Mediterranean area
- *first presentation in middle aged adults
- can cause abdominal pain
- inherited condition

Note: Ninety percent of all patients have their first attack before they are 18 years old

5- Young adolescent complaining of painful lump below the knee, with protruding of tibial
tuberosity. the pain occurs during activities :
- Legg-Calv-Perthes disease
- Slipped Capital Femoral Epiphysis
- *Osgood-Schaltter disease
OSGOOD SCHLATTER DISEASE - Common cause of knee pain typically in adolescent male athletes
Etiology: - During early adolescence (13-14 yrs in affected boys and 10-11 yrs in affected girls)periods of rapid growth
quadriceps puts traction apophysis of tibial tubercle where patellar tendon inserts sports like excessive running, jumping,
kneeling traction apophysitis (Osgood Schlatter dis.) worsened by activity and relieved by rest. B/l in 1/4th cases
PE:
- Edema and tenderness over tibial tubercle
- Firm mass can sometimes be felt due to heterotopic bone formation
- Pain reproducible by extending knee against resistance
Radiographic findings: - Non-specific—include anterior soft tissue swelling, lifting of tubercle from shaft, irregularity or
fragmentation of tubercle
Rx:- Activity restriction, stretching exercises and NSAIDS
40% - Descending aorta aneurysm: distal to left subclavian—due to atherosclerosis; risk factor: HTN,
hypercholestrolemia and smoking
- CXR in TAA: widened mediastinal silhoutte, ↑ aortic knob and tracheal deviaton. CXR cannot distinguish
TAA from tortuous aorta—confirm with CT with contrast

ABDOMINAL AORTIC ANEURYSM

- Normal diameter of AA= 1-3 cm AAA=>3cm. unlike thoracic aortic aneurysm, it does not form false
lumen and an intimal flap and is composed of all 3 layers
- Usually found incidentally and needs close follow up because rupture is life-threatening
- Imaging modality of choice: abdominal ultrasound (100% sensitivity and specificity, no need of contrast,
inexpensive), facilitates measurement of aneurysm size and show presence of thrombus
- Screening: men aged 65-75 who have smoked cigarettes have greatest benefit from screening—1 time
abdominal USG in such pts is recommended
- Risk factors for developing AAA: older age (>60 yrs), cig. Smoking, FH of AAA, white race and
atherosclerosis
- The risk of AAA rupture increases in pts with large aneurysm diameter (>/=5.5cm), aortic expansion
rate >0.5cm/6mo and >1cm/year, female gender, current ongoing smoking and HTN (HTN has weak
association with AAA formation and expansion and rupture)
- Rupture of AAA present with: profound hypotension, abdominal or back pain followed by syncope and
examination may show pulsatile mass at or above level of umblicus. AAA can rupture in retroperitoneal
spaceform aortocaval fistulavenous congestion fragile and distended veins in bladder can
rupturegross hematuria
- screening and surgical repair of >/=5.5 cm aneurysm has shown to decrease mortality
- indications for surgical repair or endovascular repair: size >5.5cm, rapid rate of expansion >0.5cm/6mo
and >1cm/year and presence of symtoms (abdominal, back or flank pain; limb ischemia) regardless of
size
- risk of AAA formation and expansion is lower in diabetics than non-diabetics

 Peripheral artery aneurysm: popliteal AA-most common followed by femoral AA (located below inguinal
ligament). Compress adjacent structures (nerves and veins) and can cause thrombosis and ischemia.
Frequently associated with AAA

47
Page
  Type I: mild metatarsus adduction characterized by feet that cause over-correction both passively
and actively into abduction spontaneously correct themselves and do not need treatment
 Type II: that correct in to neutral position by passive or active movement Rx: orthotosis or
corrective shoes, and sometimes plaster casts if initial treatment gives no result
 Type III: rigid feet and do not correctRx: managed with serial casts
- Surgical correction may be needed if significant residual metatarsus adductus in 4yo
 Internal tibial torsion is also a physiologic finding in newborns and spontaneous correction occurs in
95% cases

SLIPPED CAPITAL FEMORAL EPIPHYSIS

- Displacement of femoral head on femoral neck due to disruption of proximal femoral growth plate
- Typically in obese children 10-16 yo. The mean age of presentation is 12 years in girls and 13.5 years
in boys. > in adolescent boys than girls.
- Physis (i.e. physical junction between femoral head and neck weakens during early adolescence due to
rapid growth—it is cartilage and not as strong as bone—obesity worsens stress physis fracture and
femoral disc slips
- Additional risk factors: endocrinopathies (eg hypothyroidism, growth hormone def.), renal failure and
radiation history mostly b/l disease at early age
- S/S: insidious onset dull hip pain or referred knee pain and altered gait/limping with no preceding
trauma. Minor trauma can sometimes exacerbate the pain
- High degree of suspicion as knee pain (referred pain) and not hip pain is the common presentation
with this condition
- PE: pt holds affected leg in passive external rotation and loss internal rotation, abduction and flexion as
well as external rotation of thigh when hip is being flexed
- Dx: plain radiograph of hip in AP and frog-leg lateral view posteriorly and inferiorly/medially displaced
femoral head in relation to femoral neck—both hips should be imaged for comparison and contralateral
displacement
- Rx: immediate surgical screw fixation at current degree of displacement to avoid avascular necrosis and
chondrolysis
4
Page
-

LEG CALVE PERTHES DISEASE

- Etiology:
Idiopathic avascular necrosis of femoral head. Can be due to thrombophilia in some patients
Commonly affects boys 4-10 years. Peak incidence is at 5 and 7 years
- S/S:
Mild, chronic hip or knee pain of insidious onset as well as antalgic gait (shorter time weight bearing on
affected side due to pain)
- PE:
As the disease progresses abduction and internal rotation markedly ↓. Proximal thigh atrophy may
also be present
- Dx:
Requires high index of suspicion as initial x-rays may be negative leading to initial diagnosis of transient
synovitis which may occur after viral infection but resolve in 1-4 wks
Persistent symptoms repeat imaging as it can take months for concerning changes to appear on xray

Flattened and fragmented left

femoral head

MRI and bone scans can show subtle femoral head necrosis weeks to
months earlier than x-ray early diagnosis

- Treatment: In general, these patients are managed conservatively

with observation and bracing, the surgery may be indicated in cases
5

where the femoral head is not well contained within the acetabulum.
Pt should refrain from weight-bearing exercises
Page
6- a 70 kg man , with Na 120 >>> calculate deficit Na ??
- 1300
- 560
- *840 ( here the q adopted Na=140 as reference for the calculation not 135)
AVG

Note:
Na Deficit = Sex * Weight * (DesiredNa - SerumNa)
140
Male (0.6), Female (0.5)

7- A child with gastroenteritis, awake and alert, normal vital signs, sunken eyes, depressed
fontanelle, expected percent of dehydration:
- * 5-9%

8- Baby was born with a birth weight of 3 kg, at 1 year of age, he is expected to be:
- * 9 kg triple

9- Baby at 6 months of age, he is expected to have:

-* 44 cm head circumference with closed posterior fontanelle and open anterior fontanelle

10- a patient come to emergency with hypertension, bardycardia , most likely cause:
- * bleeding into cranial cavity

11- 11 yrs old boy complains of chew twitching with drooling and inability to speak which wakes
him from sleep .. which of the following is the best next test:
- * electroencephalogram
- CT scan without contrast
- MRI

12- what's true regarding bladder cancer :

-*Looks like UTI with irritative symptoms and hemtauria
- intravesical chemotherapy is preferred even when the tumor penetrate the muscularis layer
bladder cancer WORK-UP
- partial cystectomy is preferred Initial evaluation of gross hematuria: urinalysis to rule out infection and confirm
microhematuria (>/=3 RBCs/hpf) as red urine can occur in other conditions like
microglobinuria, beet ingestion, rifampin intake
Cystoscopy is recommended for all patients with unexplained gross hematuria or
with microscopic hematuria and other risk factors for bladder cancer
13- most likely of the following that increase the risk of breast cancer:
- *BRCA genes
- biopsy proven LCIS
- age
- family history of breast cancer

14- About ovarian tumors, one is true:

- The risk of ovarian cancer is more with BRCA 1 than BRCA 2
- Epithelial tumors are most likely inherited
Most cases of ovarian cancer are sporadic; in these cases the associated genetic
changes are acquired during a person's lifetime and are present only in certain cells in
the ovary. These changes, which are called somatic mutations, are not inherited

15- Patient with spherocytosis, came to ER with Hb of 5, blood transfusion was ordered. Patient
started to have fever, chills, and headache upon transfusion. The most immediate action to be
done:
- *stop transfusion and give antipyretics
- Recheck the type of donor's and recipient blood for possible mismatch
- give hydrocortisone and continue transfusion

16- All are true except:

- * Bluish discoloration of skin overlying the hernia is mandatory for diagnosis
- Femoral hernia is more like to strangulate
- The pain of the strangulated hernia disappear when it perforates
- a normal hernia can strangulate at any time

17- About hernias, all are true except:

- Indirect inguinal hernias are the most common in females
- Indirect inguinal hernias in infants are due to persistant processus vaginalis
- Direct inguinal hernias are always acquired
- Direct inguinal hernias become more common in the elderly
- * Indirect inguinal hernias are most likely to disappear as the child gets into adulthood

18- About constipation, one is true:

- * A recent change into constipation is more important than chronic constipation
- It's more commonly due to organic causes 95% functional

19- Regarding blood transfusion, one is true:

- Hyperkalemia and metabolic acidosis may occur following blood transfusion
- * Thrombocytopenia is a complication following massive blood transfusion
 BLOOD TRANSUFION REACTIONS

Due to immune complex

deposition—oliguric RF

Plasma free Hb ≥25mg/dl—

repeat type and cross match
show mismatch
Medical emergency
Possibly due to clerical error

IgG antibodies

CXR: B/L interstitial

infiltrates

Blood transfusion
reactions associated with
hypotension
23 Page

- Adverse reaction to blood transfusion occur despite multiple tests and inspections of blood
FEBRILE NON-HEMOLYTIC
- Blood stored leukocytes release cytokines transfused fever, chills and malaise
- Prevention: use leukoreduced blood products
- Treatment: stop transfusion to exclude other serious reactions, administer antipyretics (avoid aspirin in
thrombocytopenic patients) and use leukoreduced blood in future

ACUTE HEMOLYTIC REACTION

- S/S: discomfort at infusion site
- Management: immediate cessation of transfusion while maintaining IV access for fluids (normal saline) and
supportive care

DELAYED HEMOLYTIC REACTION

- Due to anamnestic antibody response to red blood cell antigen to which person was previously sensitized
- Ab’s are undetectable prior to transfusion but reappears rapidly following transfusion
- Low grade hemolysis
- No treatment usually required

ANAPHYLACTIC REACTION
- S/S: hypotension, difficulty breathing LOC, shock and respiratory failure
- Management:
 Stop transfusion immediately
 Give IM epinephrine
 Circulatory and respiratory support with vasopressors and mechanical ventilation
 Histamine blockers and glucocorticoids should also be administered
 Future transfusions: IgA deficient plasma and washed red cell products
24
Page
INDICATIONS FOR SPECIALIZED RBC TREATMENTS

Washed to remove as much

plasma as possible as it
contains proteins including IgA
and can cause allergic reaction

LEUKOREDUCED
- Reduce the no. of transfused leukocytes through filtering, or other methods like saline washing, freezing and
deglycerolizing or buffy coat removal
- It also reduces the risk of HLA alloimmunization and transmission of CMV

CALCIUM GLUCONATE INFUSION

- Used to avoid or treat severe hypocalcemia following massive transfusion—specially occurs in pts who have
received equivalent of more than one blood volume of blood transfusion or packed RBCs over 24 hours—
occurs because of presence of citrate which chelates calcium and magnesium in plasma—used as
anticoagulant in whole blood (for transfusions)cause paresthesias

WARMING
- When massive blood transfusion is needed to prevent hypothermia

25
Page
 20- All of the following about uterine prolapse are true, except:
- * Anterior and posterior colporrhaphy are the only effective treatment
- Rings can be used temporarily
- Sacrocolpopexy is a way of management

21- VBAC vs. repeat CS, one is true:

- VBAC has a lower risk of uterine rupture
- * VBAC has a lower risk of blood transfusion (or VBAC needs less blood transfusion)
- VBAC has a lower risk of perinatal morbidity and mortality

22- The strongest layer of the esophagus is:

- Mucosa
- Adventitia
- Muscularis
- * Submucosa

23- A 6-day old baby presented with vomiting and irritability. His serum sodium was 120 and
potassium was 7. What is the most likely cause:
- * CAH
- Hyperaldosteronism
- Pyloric stenosis

24- Infective endocarditis prophylaxis may be recommended in all of the following, except:
- Mitral stenosis
- Aortic stenosis
- * HOCM
- Mitral prolapse without regurgitation
- ASD

25- The most common complication of popliteal artery aneurysm is:

These aneurysms account for up to 70% of all peripheral
- * Thrombosis and embolism leading to limb ischemia arterial aneurysms. The most frequent and severe complication
- Rupture is thromboembolism, with subsequent acute limb ischemia and
major amputation rate of up to 30% in surgical series

26- All are true about mesenteric adenitis, except:

Mesenteric adenitis is a fairly common cause of tummy (abdominal) pain in
- Most likley presents before 18 years of age children aged under 16 years. It is much less common in adults
- May present with shifting abdominal tenderness
-* Definitive diagnosis can only be made at lapratomy (not sure of the answer)
Cross-sectional imaging is routinely applied in the examination of
patients and may help avoid unnecessary surgery in cases of There is no specific test that
mesenteric lymphadenitis. Previously, the diagnosis was most proves a definite diagnosis
frequently made when laparotomy performed to assess presumed of mesenteric adenitis
appendicitis yielded negative findings
a definite diagnosis of mesenteric lymphadenitis was very difficult to make before surgery
CONGENITAL ADRENAL HYPERPLASIA - Depends on the deficiency of enzyme
21-hydroxylase deficiency: - Most commonly due to 21-hydroxylase deficiency—90% cases

- Marked ↑ 17-hydroxyprogesterone is diverted towards adrenal androgen synthesis and leads to

25

hyperandrogenism impair hypothalamic sensitivity to progesterone rapid ↑ GnRH synthesis

↑LH and FSH↑gonadal steroid production (↑17-hydroxyprogesterone, DHEA, testosterone, LH,
Page
 FSH)—ACTH stimulation test exaggerated 17 hydroxyprogesterone response. Cosyntropin stimulation
test is gold standard for partial deficiencies
- ↓ in cortisol↑ACTHadrenal hyperplasia
- ↓ aldosterone salt wasting
- C/F: depend on degree of enzyme deficiency
1. Severe (classic) 21 hydroxylase def—present in infancy with virilization and salt losing crisis
2. Late-onset (non-classic) 21 hydroxylase def (CYP21A2 deficiency)—mild, females present in teens
or twenties with cystic acne non-responsive to meds, irregular menses, and hirsuitism, virilization
not seen; boys present with precocious puberty—hyponatremia variable in both sexes

ADRENOCORTICAL CANCERS:
- Rare, aggressive
- Present in adulthood usually
- Types: androblastoma, arrhenoblastoma, stromal and hilus cell tumor
- C/F: rapidly progressive hirsuitism and sometimes virilization
- Labs: serum DHEA-S (adrenal androgen)—markedly ↑ >700µg/Dl

HYPERALDOSTERONISM

26
Page
 Complications of mesenteric lymphadenitis include the following:
Volume depletion and electrolyte imbalance in patients with severe diarrhea,
nausea, and vomiting.
Abscess formation.
Peritonitis (rare)
- May lead to the formation of abdominal abscesses Sepsis.

- Can be associated with cervical lymphadenopathy

27- A child's length reaches 1 meter at:

- * 4 years double length

28- All of the following are risk factors for endometrial hyperplasia except:
- * Intermittent COCP use
- DM
- Obesity

29- One of the following vaccines is given by 2 routes in the Jordanian National Program:
- * Polio opv ipv

30- One of the following is not caused by an enterovirus:

- * Herpetic whitlow Herpetic whitlow is caused by a virus called "herpes simplex".
- Hand-foot-mouth disease
- Aseptic meningitis
- Herpangina
- Poliomyelitis

31- One of the following is most prognostic factor of the function in post trauma patient:
-the overall Glasgow coma scale
- low verbal response
-low motor response
-low eye response

32- 16 years old obese female .. With history of morning headache .. examination was normal
except for bilateral papilledema .. MRI was normal ... what's the next step :
_*LP with manometry PYQS

- CT scan without contrast

- EGG

33- All of the following are found in acute inflammatory demyelinating encephalomyelitis
except:
 The CSF may be normal in ADEM or reveal a lymphocytic pleocytosis

- * sensory level
- Normal CSF studies
- Fever and encephalopathy
- Loss of vision The arms can be involved if the
demyelinating lesion affects the cervical
- Cerebellar ataxia cord. Respiratory failure may appear with
high cervical lesions that extend into the
brainstem. Aphasia, movement disorders,
Aphasia, movement disorders, and sensory deficits are unusual
and sensory deficits are unusual.
34- All are true about b-lactam antiobiotic except:
- * no need for dose adjustment in renal impairmanet patients
- they inhibit bacterial cell wall synthesis
- they are bactericidal
(acute interstitial allergic nephritis). ... Side effect of
- Penicillin can cause allergic interstitial nephritis certain antibiotics such as penicillin, ampicillin,
methicillin, and sulfonamide medicines

35- True about IUGR babies except:

- * all IUGR babies must be delivered by CS
- Usually associated with oligohydramnios
- Pre-eclampsia is a known potential cause
severe
Presence of symptoms - Persistent headache or other
cerebral or visual disturbances - Persistent epigastric pain
36- One is true in Pre-eclampsia: systolic >160 Diastolic BP ≥ 110 mmHg Proteinuria of 2+ or more by urine
dipstick or a total protein level of ≥2 gm/liter in a 24-hour urine sampling
- severe PET is when BP 140/90 Abnormal lab findings Obvious fetal growth restriction Neurological effects: •
Scotomata, hyperreflexia • Eclamptic convulsions
- * uric acid level is expected to be elevated
- hematocrit is expected to be low increased pcv

Tricuspid atresia requires

emergency intervention.
37- One of the following requires a patent foramen ovale for survival: Initially ... addition, if there
- Tetrology of Fallot is no ASD or patent
foramen ovale (PFO), an
- * Tricuspid atresia emergent balloon atrial
septostomy is performed to
- Truncus arteriosus ensure survival.

38- All of the following are features of PCO, except:

- Acanthosis nigricans
- * Low risk of miscarriage
- High LH:FSH
- Low level of sex hormone binding globulin (SHBG)

39- About precocious puberty, one is true:

- It is defined as the development of secondary sexual characteristics at the age of 8
- It is more common in males
- * No management is needed in the constitutional type

- Occurs in Turner syndrome
Girls who have Turner syndrome don't have typical ovarian
development. Because the ovaries are responsible for making
the hormones that control breast growth and menstruation, most
girls with TS will not go through all of the changes associated
with puberty unless they get treatment for the condition.

40- The most common benign liver tumor is:

- * Hemangioma
- Hepatic adenoma
- Focal nodular hyperplasia

41- Which of the following is the most likely indicator of acute liver failure:
PT is the most useful indicator of synthetic function.
- * PT PT is a better predictor of poor outcome than liver function tests, and is used in standard criteria for determining the need
- Bilirubin for liver transplant. The following two prognostic factors (see the link below) have been shown to confer a > 90%
mortality in acute liver failure secondary to paracetamol overdose: • H+ > 50 nmol/l (pH < 7.3) • Creatinine > 300 µmol/l
- Albumin with PT > 100 secs and grade 3 or 4 encephalopathy.

- Ammonia

42- One of the follow is wrong:

- PT monitors the extrinsic pathway
- PTT monitors the intrinsic pathway
- Prolongation of both PT and PTT means a defect in the common pathway
- * Patients with a normal platelet count would have a normal bleeding time

43- The most common indication for intubation in trauma is:

- Inhalational injury
-* Altered level of consciousness Schwartz

- Facial injury
- Hematoma in the cervical region

44- In the primary survey for a traumatized patient, it is important to ask him or his family about
all of the following, except:
- Last meal
- Current medications
- * Any abnormal movements while transferring the patient from the trauma scene
- Past diseases
- Allergies

45- One of the following is wrong about the uses of carcinoembryonic antigen:
-* for diagnosis
- for prognosis
- for follow up the treatment
- to know the severity of the disease

46- The most appropriate immediate management for a patient with anaphylactic shock is:
- * IM epinephrine
- H1 blocker
- H2 blocker
- Glucagon

47- About rheumatoid arthritis, one is wrong:

- * Asymmetric involvement of the joints

48- A 23-year-old female presented with a breast mass in the upper outer quadrant. She has no
past medical history. What is the most appropriate imaging modality:
- * Ultrasound
- Mammogram

49- Which of the following is wrong about nephrogenic diabetes insipidus :

- can occur in sickle cell child
- can be caused by hypercalcemia
- can be treated by thiazide
- x-linked
- * vasopressin levels normal or low

50- All of the following about solitary pulmonary nodule are true, except:
- Must be less than 3 cm
- Must be surrounded by aerated lung field
- Can't be multiple
- * Can be associated with atelectasis and lymphadenopathy
- Can be of any shape or border

51- The most appropriate test to start with in evaluating a thyroid nodule is:
- * Radioisotope scan
- FNA Fine needle aspiration biopsy (FNAB) is the most important step in the workup of the thyroid nodule

- CT
- MRI

52- The most characteristic ECG finding in AV canal ..:

- * AV block The most characteristic feature of AVSD on the ECG is superior orientation of the
frontal QRS loop. The p wave axis may also be superior in associated left atrial
- ventricular ectopics isomerism. First degree heart block is present in the majority and prolongation of
- atrial ectopics the QRS complex in over half of patients with AVSD.

- supra ventricular tachycardia

53- A 4-year-old child presented with left earache. Temperatue was 38.3 rectally. On otoscope, a
dull tympanic membrane was seen with absent light reflex. One of the following is true:
- * Streptococcus pneumonia is the most common cause
- Antihistamines are used in treatment
- This condition is not common in this age
- Tubes are usually needed for treatment
- The treatment of choice is giving one dose of ceftriaxone IM

55- One of the following is a mismatch:

- HSV 2: genital ulcers Redness or itching of the vagina are not common symptoms of bacterial
vaginosis unless the woman has a co-infection of BV and yeast. Some
- HPV 6: genital warts women with bacterial vaginosis have no symptoms at all, and the
- Trichomonas: sexually transmitted vaginitis is only discovered during a routine gynecologic exam.062018/11/

-* Bacterial vaginosis: very itchy

56- All of the following can be associated with steotorrhea, except:

- * Lactose intolerance
- Celiac disease
- Pancreatic insufficiency

57- All of the following side effects of oxytocin except

- * hypernatremia
- hyperbilirubinemia
- increased risk of rupture
Oxytocin is produced in the hypothalamus and is secreted into the bloodstream by the posterior pituitary gland

58- One of the following about IUCD is wrong:

- * The risk of infection after inserting an IUCD is 20%
- If pregnancy occurs on top of an IUCD, the IUCD should be removed
- Screening for STDs is recommended prior to insertion
- If PID develops, the IUCD should be removed

59- One of the following about contraception is wrong:

- Copper IUD may be used up to 10 years
- Hormonal IUD may be used up to 5 years
-* Implanon should be inserted every 3 weeks
- depo-provera is given every 3 months

60- Chronic atrial fibrillation can lead to all of the following except:
-* Pulmonary embolism
- Stroke
- Acute limb ischemia
- Mesenteric ischemia

61- All of the following are possible causes of metabolic alkalosis, except:
- * Hyperkalemia
- Vomiting
- Loop diuretics

62- Doppler ultrasound may be useful in all of the following, except:

- * Measurement of abdominal circumference
- Measurement of amniotic fluid pockets
- Detection of congenital heart defects
- Detection of the middle cerebral artery
- Detection of renal agenesis

63- One of the following is true regarding ureteric obstruction:

- * Mainly due to stones
- Usually associated with infection proximal to the obstruction
- it will increase urea and creatinine

64- All of the following about urge incontinence are true, except:
- Anticholinergics are an effective treatment
- *Colposuspension is a successful method for treatment