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Afghanistan Medical Exit Exam study materials
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Afghanistan Medical Exit Exam practice questions

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Question 1Internal Medicine

A 24-year-old man presents with polyuria, polydipsia, and weight loss. His random plasma glucose is 16.8 mmol/L and he has ketones in the urine. Which single measurement most reliably confirms the diagnosis of diabetes mellitus in a symptomatic patient?

  1. Urine glucose dipstick positivity
  2. Random plasma glucose of 11.1 mmol/L or higher Correct answer.
  3. Fasting plasma glucose of 7.2 mmol/L
  4. Glycated hemoglobin of 5.9%

Explanation

In a patient with classic symptoms, a random plasma glucose of 11.1 mmol/L or more establishes the diagnosis without a second test. Fasting glucose requires a value of 7.0 mmol/L or higher, and HbA1c requires 6.5% or higher. Glycosuria alone is nonspecific because it depends on the renal threshold.

Question 2Internal Medicine

A 58-year-old woman with type 2 diabetes has an eGFR of 32 mL/min/1.73 m² and albuminuria. Which antihypertensive class provides the strongest renal protection in this setting?

  1. Angiotensin-converting enzyme inhibitors Correct answer.
  2. Thiazide diuretics
  3. Beta-blockers
  4. Alpha-blockers

Explanation

ACE inhibitors reduce intraglomerular pressure by dilating the efferent arteriole and slow progression of diabetic nephropathy, particularly in patients with albuminuria. They are preferred in diabetic kidney disease unless contraindicated. Other classes lack this specific renoprotective effect.

Question 3Internal Medicine

A 30-year-old woman with type 1 diabetes is found unresponsive. Capillary glucose is 2.1 mmol/L. She has no intravenous access. What is the most appropriate immediate treatment?

  1. Oral glucose gel
  2. Intravenous dextrose
  3. Intramuscular glucagon Correct answer.
  4. Subcutaneous insulin

Explanation

In severe hypoglycemia without intravenous access, intramuscular or subcutaneous glucagon is the treatment of choice because it mobilizes hepatic glucose. Oral glucose is unsafe in an unresponsive patient due to aspiration risk. Intravenous dextrose is preferred only when access is available.

Question 4Internal Medicine

Which finding on physical examination is most characteristic of a patient with a large pericardial effusion?

  1. Systolic ejection murmur
  2. Widened pulse pressure
  3. Bounding peripheral pulses
  4. Pulsus paradoxus Correct answer.

Explanation

A large pericardial effusion raises intrapericardial pressure and impairs right ventricular filling, producing pulsus paradoxus, an exaggerated fall in systolic pressure during inspiration. Bounding pulses and widened pulse pressure suggest a hyperdynamic state such as aortic regurgitation.

Question 5Internal Medicine

A 65-year-old man with chronic obstructive pulmonary disease has a resting oxygen saturation of 86% on room air while stable. What is the most appropriate long-term management?

  1. No supplemental oxygen
  2. Long-term oxygen therapy Correct answer.
  3. Inhaled corticosteroids alone
  4. Oral theophylline

Explanation

Long-term oxygen therapy improves survival in COPD patients with chronic hypoxemia, generally defined as PaO2 of 55 mmHg or less or saturation of 88% or less. A resting saturation of 86% meets this threshold. Other therapies do not correct the hypoxemia.

Question 6Internal Medicine

Which laboratory abnormality is most characteristic of nephrotic syndrome?

  1. Hyperkalemia
  2. Metabolic alkalosis
  3. Hypercalcemia
  4. Hypoalbuminemia Correct answer.

Explanation

Nephrotic syndrome is defined by heavy proteinuria, hypoalbuminemia, edema, and hyperlipidemia. Loss of albumin in urine lowers serum albumin. Electrolyte disturbances such as hyperkalemia are more typical of acute kidney injury or renal tubular acidosis.

Question 7Internal Medicine

A 40-year-old man has a blood pressure of 168/104 mmHg on three separate visits with no identifiable secondary cause. What is the most appropriate initial pharmacologic therapy?

  1. An alpha-blocker
  2. A loop diuretic
  3. A thiazide diuretic Correct answer.
  4. A direct renin inhibitor

Explanation

Thiazide diuretics are recommended as first-line therapy for uncomplicated essential hypertension, along with ACE inhibitors, angiotensin receptor blockers, and calcium channel blockers. Alpha-blockers are not first-line. Loop diuretics are reserved for volume overload or reduced renal function.

Question 8Internal Medicine

Which electrocardiographic finding is most consistent with hyperkalemia?

  1. Prominent U waves
  2. Peaked T waves Correct answer.
  3. Delta waves
  4. Prolonged QT interval

Explanation

Hyperkalemia produces tall, peaked, narrow-based T waves as the earliest electrocardiographic change, followed by PR prolongation and QRS widening. Prominent U waves suggest hypokalemia. A delta wave indicates pre-excitation.

Question 9Internal Medicine

A 55-year-old man with a history of myocardial infarction presents with sudden severe dyspnea. Examination shows a pansystolic murmur at the apex, pulmonary edema, and a new systolic thrill. What is the most likely diagnosis?

  1. Pulmonary embolism
  2. Pericardial tamponade
  3. Aortic dissection
  4. Acute mitral regurgitation from papillary muscle rupture Correct answer.

Explanation

Papillary muscle rupture after myocardial infarction causes acute severe mitral regurgitation with a new pansystolic murmur and rapid pulmonary edema. The sudden presentation and thrill support an acute mechanical complication. Aortic dissection and pulmonary embolism do not produce a new apical pansystolic murmur.

Question 10Internal Medicine

A 28-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. Thyroid-stimulating hormone is elevated and free T4 is low. Which is the most likely cause?

  1. Hashimoto thyroiditis Correct answer.
  2. Graves disease
  3. Subacute thyroiditis
  4. Thyroid hormone resistance

Explanation

Elevated TSH with low free T4 indicates primary hypothyroidism, most commonly caused by Hashimoto thyroiditis in iodine-sufficient areas. Graves disease causes hyperthyroidism. Subacute thyroiditis often follows a viral illness and is usually transient.

Question 11Internal Medicine

A 60-year-old man presents with a 3-week history of progressive dysphagia, initially to solids and now to liquids, with weight loss. What is the most appropriate initial investigation?

  1. Abdominal ultrasound
  2. Esophageal manometry
  3. Upper gastrointestinal endoscopy Correct answer.
  4. Barium swallow

Explanation

Progressive dysphagia with weight loss raises concern for esophageal malignancy, and upper endoscopy allows direct visualization and biopsy. Barium studies may be used if endoscopy is unavailable but do not permit histologic diagnosis. Manometry is reserved for suspected motility disorders.

Question 12Internal Medicine

A 70-year-old woman has a serum creatinine of 220 µmol/L, a urine output of 15 mL/hour, and a fractional excretion of sodium of 1.5%. Which type of acute kidney injury is most likely?

  1. Acute tubular necrosis
  2. Postrenal obstruction
  3. Prerenal azotemia Correct answer.
  4. Acute interstitial nephritis

Explanation

A fractional excretion of sodium below 1% suggests sodium-avid tubules with preserved reabsorptive function, typical of prerenal azotemia. Acute tubular necrosis usually produces a fractional excretion above 2%. Postrenal obstruction and interstitial nephritis have different clinical clues.

Question 13Internal Medicine

A 45-year-old man presents with pleuritic chest pain and a swollen, warm left leg after a long flight. What is the most appropriate initial test to confirm pulmonary embolism?

  1. Transthoracic echocardiography
  2. D-dimer assay
  3. Computed tomography pulmonary angiography Correct answer.
  4. Chest radiograph

Explanation

In a patient with high clinical probability of pulmonary embolism, CT pulmonary angiography is the confirmatory test of choice. D-dimer is useful mainly to exclude embolism in low-probability patients. Chest radiography is often normal and cannot confirm the diagnosis.

Question 14Internal Medicine

A 32-year-old woman with systemic lupus erythematosus presents with proteinuria of 3.5 g/day and active urinary sediment. What is the most appropriate next step?

  1. Renal biopsy Correct answer.
  2. Repeat urinalysis in 6 months
  3. Start high-dose corticosteroids empirically
  4. Reassurance and discharge

Explanation

Lupus nephritis is classified by histologic pattern on renal biopsy, which guides treatment intensity. Biopsy distinguishes proliferative from non-proliferative disease. Empiric steroids without histology may be inappropriate.

Question 15Internal Medicine

A 68-year-old man with atrial fibrillation and a CHA2DS2-VASc score of 4 is being considered for anticoagulation. Which factor most strongly increases his risk of bleeding with warfarin?

  1. A history of falls with head injury Correct answer.
  2. Age of 68 years
  3. Use of a statin
  4. Controlled hypertension

Explanation

A history of falls with head injury markedly increases the risk of intracranial hemorrhage with anticoagulation. Age alone is a modest risk factor, and statin use is not a bleeding risk. Well-controlled hypertension is low risk.

Question 16Internal Medicine

A 50-year-old man presents with a 2-month history of early satiety, bloating, and weight loss. He has a strong family history of gastric cancer. What is the most appropriate diagnostic test?

  1. Serum gastrin level
  2. Hepatobiliary ultrasound
  3. Upper endoscopy with biopsy Correct answer.
  4. Abdominal computed tomography

Explanation

Upper endoscopy with biopsy is the gold standard for diagnosing gastric cancer and allows direct visualization and histologic confirmation. Serum gastrin and imaging are adjuncts but not diagnostic.

Question 17Internal Medicine

A 22-year-old man presents with sudden-onset severe headache described as the worst of his life. What is the most appropriate initial investigation?

  1. Lumbar puncture without imaging
  2. Magnetic resonance imaging of the brain
  3. Electroencephalography
  4. Non-contrast computed tomography of the head Correct answer.

Explanation

Sudden severe headache raises concern for subarachnoid hemorrhage, and non-contrast CT is the initial test of choice because it is rapid and sensitive in the first hours. Lumbar puncture is performed only after imaging to exclude mass effect. MRI is more sensitive later but is not the first-line acute test.

Question 18Internal Medicine

A 60-year-old man with chronic alcohol use presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be given immediately?

  1. Oral folate
  2. Intravenous naloxone
  3. Intravenous glucose alone
  4. Intravenous thiamine Correct answer.

Explanation

The triad of confusion, ataxia, and ophthalmoplegia indicates Wernicke encephalopathy, which is treated urgently with parenteral thiamine. Glucose should not be given before thiamine because it can precipitate or worsen the encephalopathy. Folate and naloxone do not treat this condition.

Question 19Internal Medicine

A 35-year-old woman presents with fatigue, arthralgia, and a malar rash. Which autoantibody is most specific for systemic lupus erythematosus?

  1. Antinuclear antibody
  2. Anti-histone antibody
  3. Rheumatoid factor
  4. Anti-double-stranded DNA Correct answer.

Explanation

Anti-double-stranded DNA is highly specific for systemic lupus erythematosus and correlates with disease activity. Antinuclear antibody is sensitive but not specific. Rheumatoid factor and anti-histone antibodies are associated with other conditions.

Question 20Internal Medicine

A 72-year-old man with chronic kidney disease has a serum potassium of 6.8 mmol/L and peaked T waves. Which intervention should be given first to stabilize the myocardium?

  1. Intravenous insulin with glucose
  2. Oral potassium binder
  3. Intravenous calcium gluconate Correct answer.
  4. Sodium bicarbonate

Explanation

Intravenous calcium stabilizes the myocardial membrane and is the first step in hyperkalemia with electrocardiographic changes. Insulin with glucose and potassium binders shift or remove potassium but do not immediately protect the heart.

Question 21Internal Medicine

A 48-year-old man presents with a 6-month history of progressive exertional dyspnea and orthopnea. Echocardiography shows a left ventricular ejection fraction of 25%. Which medication improves survival in heart failure with reduced ejection fraction?

  1. Dihydropyridine calcium channel blocker
  2. Beta-blocker Correct answer.
  3. Furosemide
  4. Digoxin

Explanation

Beta-blockers are one of the cornerstone therapies that improve survival in heart failure with reduced ejection fraction. Digoxin and loop diuretics improve symptoms but do not improve survival. Dihydropyridine calcium channel blockers may worsen heart failure.

Question 22Internal Medicine

A 62-year-old man with a history of cirrhosis presents with hematemesis. He has a blood pressure of 88/54 mmHg and a hemoglobin of 7.0 g/dL. In addition to fluid resuscitation, which medication should be started before endoscopy?

  1. Oral lactulose
  2. Oral propranolol
  3. Intravenous furosemide
  4. Intravenous octreotide Correct answer.

Explanation

Intravenous octreotide reduces splanchnic blood flow and portal pressure and should be started early in suspected variceal bleeding. Propranolol is used for prophylaxis, not acute bleeding. Lactulose treats hepatic encephalopathy, and furosemide would worsen hypovolemia.

Question 23Internal Medicine

A 40-year-old man with a history of recurrent kidney stones has a serum calcium of 2.9 mmol/L and an elevated parathyroid hormone level. Which finding best supports primary hyperparathyroidism?

  1. Low serum phosphate Correct answer.
  2. Low serum chloride
  3. High serum phosphate
  4. Low alkaline phosphatase

Explanation

Parathyroid hormone increases renal phosphate excretion, so primary hyperparathyroidism typically causes hypercalcemia with hypophosphatemia. Hyperphosphatemia suggests secondary hyperparathyroidism from renal failure. Chloride is typically elevated, not low.

Question 24Internal Medicine

A 55-year-old woman with type 2 diabetes and a history of heart failure develops a foot ulcer. Which antihyperglycemic agent is most appropriate given her heart failure?

  1. Pioglitazone
  2. Insulin
  3. Sodium-glucose cotransporter-2 inhibitor Correct answer.
  4. Sulfonylurea

Explanation

SGLT2 inhibitors reduce heart failure hospitalizations and are recommended in patients with heart failure and type 2 diabetes. Pioglitazone causes fluid retention and is contraindicated in heart failure. Sulfonylureas and insulin do not provide this benefit and may cause hypoglycemia.

Question 25Internal Medicine

A 30-year-old man presents with fever, night sweats, weight loss, and a painless cervical lymph node. Biopsy shows Reed-Sternberg cells. What is the most likely diagnosis?

  1. Non-Hodgkin lymphoma
  2. Metastatic carcinoma
  3. Tuberculous lymphadenitis
  4. Hodgkin lymphoma Correct answer.

Explanation

Reed-Sternberg cells are the hallmark of Hodgkin lymphoma, which often presents with painless lymphadenopathy and B symptoms such as fever and night sweats. Non-Hodgkin lymphoma lacks Reed-Sternberg cells. Tuberculosis and carcinoma have different histology.

Question 26Internal Medicine

A 24-year-old woman presents with episodic palpitations, sweating, and tremor relieved by eating. Fasting blood glucose is 2.6 mmol/L with simultaneous elevated insulin and C-peptide. What is the most likely diagnosis?

  1. Factitious hypoglycemia from exogenous insulin
  2. Adrenal insufficiency
  3. Insulinoma Correct answer.
  4. Reactive hypoglycemia after meals

Explanation

Hypoglycemia with inappropriately elevated insulin and C-peptide in the fasting state indicates endogenous hyperinsulinism, most often a pancreatic beta-cell tumor. Exogenous insulin suppresses C-peptide, and adrenal insufficiency produces low cortisol with hypoglycemia but low insulin.

Question 27Internal Medicine

Which finding on physical examination is most characteristic of mitral stenosis?

  1. A decrescendo diastolic murmur at the left sternal border
  2. A pansystolic murmur radiating to the axilla
  3. A midsystolic ejection click and systolic murmur at the apex
  4. A loud opening snap followed by a rumbling diastolic murmur Correct answer.

Explanation

Mitral stenosis produces a loud S1 and an opening snap followed by a low-pitched rumbling mid-diastolic murmur at the apex. The other murmurs describe mitral regurgitation, aortic regurgitation, and mitral valve prolapse respectively.

Question 28Internal Medicine

A 58-year-old man has a fasting plasma glucose of 7.8 mmol/L on two occasions and an HbA1c of 7.2%. He is asymptomatic. What is the most appropriate initial management?

  1. Lifestyle modification with diet and exercise Correct answer.
  2. Starting a sulfonylurea as first-line therapy
  3. No treatment, since he is asymptomatic
  4. Immediate initiation of basal insulin

Explanation

Asymptomatic type 2 diabetes is initially managed with lifestyle modification, adding metformin if targets are not met. Insulin is reserved for severe hyperglycemia or catabolic features, and sulfonylureas are not first-line.

Question 29Internal Medicine

A 66-year-old woman with hypertension and atrial fibrillation is found to have a serum sodium of 128 mmol/L. She is euvolemic and has a urine osmolality of 520 mOsm/kg with a urine sodium of 60 mmol/L. What is the most likely cause?

  1. Diuretic-induced hyponatremia
  2. Syndrome of inappropriate antidiuretic hormone secretion Correct answer.
  3. Hyperglycemic hyponatremia
  4. Primary polydipsia

Explanation

Euvolemic hyponatremia with concentrated urine and high urine sodium in the absence of diuretics or hyperglycemia suggests SIADH. Diuretics cause hypovolemia, primary polydipsia gives dilute urine, and hyperglycemia raises measured osmolality.

Question 30Internal Medicine

A 44-year-old man presents with a 3-day history of fever, productive cough, and pleuritic chest pain. Chest examination reveals dullness to percussion and bronchial breath sounds over the right lower zone. What is the most appropriate initial diagnostic step?

  1. CT pulmonary angiography
  2. Chest radiograph Correct answer.
  3. Bronchoscopy
  4. Sputum acid-fast bacilli smear

Explanation

The presentation suggests community-acquired pneumonia, and a chest radiograph is the standard initial imaging to confirm consolidation and assess extent. CT angiography is for suspected pulmonary embolism, and bronchoscopy is not first-line.

Question 31Internal Medicine

A 52-year-old woman with rheumatoid arthritis on long-term prednisolone presents with fatigue, weight gain, and a round face. Which test is most useful to confirm iatrogenic Cushing syndrome?

  1. Serum cortisol measured at random
  2. Overnight 1 mg dexamethasone suppression test Correct answer.
  3. Serum thyroid-stimulating hormone
  4. Anti-cyclic citrullinated peptide antibody

Explanation

The overnight dexamethasone suppression test screens for cortisol excess; failure to suppress confirms hypercortisolism. Random cortisol is unhelpful because of diurnal variation, and the other tests assess thyroid disease and rheumatoid arthritis.

Question 32Internal Medicine

A 35-year-old man presents with a 2-week history of bloody diarrhea, tenesmus, and crampy abdominal pain. Colonoscopy shows continuous inflammation starting at the rectum. Which feature most favors ulcerative colitis over Crohn disease?

  1. Skip lesions with normal intervening mucosa
  2. Granulomas on mucosal biopsy
  3. Transmural inflammation with fistula formation
  4. Continuous mucosal inflammation beginning in the rectum Correct answer.

Explanation

Ulcerative colitis characteristically affects the rectum and extends proximally in a continuous fashion. Skip lesions, transmural disease with fistulae, and granulomas are features of Crohn disease.

Question 33Internal Medicine

A 70-year-old man with chronic obstructive pulmonary disease has an arterial blood gas showing pH 7.28, PaCO2 62 mmHg, and bicarbonate 28 mmol/L. What is the acid-base disturbance?

  1. Acute respiratory acidosis Correct answer.
  2. Metabolic alkalosis
  3. Chronic respiratory alkalosis
  4. Metabolic acidosis with respiratory compensation

Explanation

A low pH with elevated PaCO2 indicates respiratory acidosis. The bicarbonate of 28 mmol/L reflects only limited renal compensation, consistent with acute rather than chronic respiratory acidosis.

Question 34Internal Medicine

A 29-year-old woman presents with a 3-week history of palpitations, heat intolerance, and weight loss. Examination shows a diffuse goiter and fine tremor. Which laboratory finding is most consistent with Graves disease?

  1. Elevated TSH with low free T4
  2. Elevated TSH with elevated free T4
  3. Suppressed TSH with elevated free T4 and positive TSH-receptor antibodies Correct answer.
  4. Suppressed TSH with low free T4

Explanation

Graves disease is a TSH-receptor antibody-mediated hyperthyroidism producing a suppressed TSH and elevated free T4. Elevated TSH with high free T4 suggests a TSH-secreting adenoma, and the low-T4 patterns indicate hypothyroidism.

Question 35Internal Medicine

A 62-year-old man with a 40 pack-year smoking history presents with progressive dyspnea and a 5 kg weight loss. Chest radiograph shows a right hilar mass with ipsilateral mediastinal widening. Which paraneoplastic syndrome is most associated with this tumor type?

  1. Hypercalcemia from parathyroid hormone-related peptide Correct answer.
  2. Hypoglycemia from insulin-like growth factor 2
  3. Syndrome of inappropriate antidiuretic hormone secretion
  4. Carcinoid syndrome

Explanation

Squamous cell carcinoma of the lung, typically central and smoking-related, is associated with hypercalcemia mediated by parathyroid hormone-related peptide. SIADH is more typical of small cell carcinoma, and carcinoid syndrome arises from carcinoid tumors.

Question 36Internal Medicine

A 47-year-old woman presents with a 4-month history of symmetrical small-joint pain and morning stiffness lasting more than an hour. Examination shows swelling of the metacarpophalangeal and proximal interphalangeal joints. Which antibody is most specific for this condition?

  1. Anti-histone antibody
  2. Antinuclear antibody
  3. Anti-cyclic citrullinated peptide antibody Correct answer.
  4. Rheumatoid factor

Explanation

Anti-CCP antibody is highly specific for rheumatoid arthritis, whereas rheumatoid factor is sensitive but less specific. Antinuclear antibody is a screening test for lupus, and anti-histone antibodies are associated with drug-induced lupus.

Question 37Internal Medicine

A 58-year-old man with a history of alcohol use presents with confusion and ataxia. He has ascites, spider angiomas, and asterixis. Which precipitant of hepatic encephalopathy should be identified and corrected first?

  1. Gastrointestinal bleeding Correct answer.
  2. Hypernatremia
  3. Metabolic alkalosis
  4. Hyperthyroidism

Explanation

Gastrointestinal bleeding is a common and life-threatening precipitant of hepatic encephalopathy because the blood provides a large protein load that is converted to ammonia. Hypernatremia, hyperthyroidism, and metabolic alkalosis are not typical precipitants.

Question 38Internal Medicine

A 68-year-old woman presents with acute severe left-sided pleuritic chest pain and dyspnea 10 days after hip replacement surgery. Her heart rate is 112/min and oxygen saturation is 89% on room air. Which test is most appropriate to confirm the diagnosis?

  1. Troponin measurement
  2. D-dimer assay
  3. CT pulmonary angiography Correct answer.
  4. Chest radiograph

Explanation

The presentation suggests pulmonary embolism with a high pretest probability, so CT pulmonary angiography is the confirmatory test. D-dimer is useful mainly to exclude embolism in low-probability patients, and chest radiograph and troponin do not confirm embolism.

Question 39Internal Medicine

A 33-year-old man presents with recurrent episodes of severe abdominal pain, hypertension, and palpitations. During an attack his blood pressure is 190/110 mmHg and he is diaphoretic. Which test is most appropriate for diagnosis?

  1. Plasma renin activity
  2. 24-hour urinary fractionated metanephrines Correct answer.
  3. Serum aldosterone-to-renin ratio
  4. Serum cortisol after overnight dexamethasone

Explanation

Episodic headache, sweating, tachycardia, and severe hypertension suggest pheochromocytoma, diagnosed by elevated fractionated metanephrines in plasma or 24-hour urine. Cortisol testing assesses Cushing syndrome, and renin and aldosterone testing assess primary aldosteronism.

Question 40Internal Medicine

A 74-year-old man is admitted with a 2-day history of fever, cough, and confusion. He has a history of stroke with residual dysphagia. Which factor most increases his risk of aspiration pneumonia?

  1. Impaired swallowing reflex from prior stroke Correct answer.
  2. Recent use of a beta-blocker
  3. History of hypertension
  4. Mild renal impairment

Explanation

Dysphagia with an impaired swallowing reflex allows oropharyngeal contents to enter the lower airway, the key mechanism of aspiration pneumonia. The other factors do not directly predispose to aspiration.

Question 41Surgery

A patient has a 3 cm laceration over the forearm that is clean, linear, and 4 hours old. Which is the most appropriate management?

  1. Delayed primary closure after 5 days
  2. Primary closure after irrigation and debridement Correct answer.
  3. Skin grafting
  4. Healing by secondary intention

Explanation

Clean, well-vascularized wounds seen within about 6 to 8 hours can be closed primarily after thorough irrigation and removal of devitalized tissue. The low bacterial load and good tissue viability favor uncomplicated primary repair.

Question 42Surgery

Which clinical feature most reliably distinguishes a simple abscess from cellulitis alone?

  1. Lymphangitic streaking
  2. Low-grade fever
  3. A fluctuant, localized collection Correct answer.
  4. Erythema extending beyond the margin

Explanation

A true abscess contains a localized pocket of pus that feels fluctuant on palpation and requires drainage. Cellulitis is a spreading infection of the dermis without a discrete collection.

Question 43Surgery

A young man develops sudden severe testicular pain with a high-riding testis and absent cremasteric reflex. What is the most urgent step?

  1. Scrotal ultrasound before any intervention
  2. Immediate surgical exploration Correct answer.
  3. Urine culture and observation
  4. Antibiotic therapy for epididymitis

Explanation

Testicular torsion is a surgical emergency and the testis can be salvaged only if detorsion occurs promptly, ideally within 6 hours. When the clinical picture is convincing, exploration should not be delayed for imaging.

Question 44Surgery

Which finding on abdominal examination is most suggestive of peritonitis?

  1. Involuntary rigidity with rebound tenderness Correct answer.
  2. Localized tenderness without guarding
  3. Voluntary guarding that resolves with reassurance
  4. Hyperactive bowel sounds

Explanation

Involuntary rigidity and rebound tenderness reflect parietal peritoneal irritation and are the classic signs of peritonitis. Voluntary guarding is under patient control and can be relaxed.

Question 45Surgery

A patient with a stab wound to the right lower chest has stable vital signs, and a chest radiograph shows a small pneumothorax without hemothorax. What is the most appropriate initial management?

  1. Tube thoracostomy and observation Correct answer.
  2. Discharge with analgesia
  3. Exploratory laparotomy
  4. Immediate thoracotomy

Explanation

A small, simple pneumothorax without hemodynamic compromise is managed with tube thoracostomy drainage and monitoring. Thoracotomy is reserved for massive hemorrhage or persistent air leak.

Question 46Surgery

Which is the most common cause of small bowel obstruction in an adult who has had previous abdominal surgery?

  1. Gallstone ileus
  2. Hernia without prior surgery
  3. Adhesions Correct answer.
  4. Malignancy

Explanation

Postoperative adhesions are the leading cause of small bowel obstruction in adults with prior abdominal operations. Hernias are the leading cause in patients without surgical history.

Question 47Surgery

A patient has a firm, painless testicular mass. Which tumor marker is most characteristically elevated in a pure seminoma?

  1. Alpha-fetoprotein
  2. Beta-human chorionic gonadotropin Correct answer.
  3. CA 19-9
  4. Carcinoembryonic antigen

Explanation

Pure seminomas may raise beta-hCG in a minority of cases, but alpha-fetoprotein is never elevated in pure seminoma. Elevation of AFP indicates a nonseminomatous component.

Question 48Surgery

Which factor most increases the risk of wound dehiscence after laparotomy?

  1. Early ambulation
  2. Use of absorbable skin sutures
  3. Poor nutritional status Correct answer.
  4. Short operative time

Explanation

Malnutrition impairs collagen synthesis and wound healing, weakening fascial repair. Other major risks include infection, increased abdominal pressure, and poor surgical technique.

Question 49Surgery

A patient with a large burn has decreased urine output and tachycardia despite fluid resuscitation. Which formula is commonly used to guide initial fluid requirements in the first 24 hours?

  1. Glasgow coma scale
  2. Parkland formula Correct answer.
  3. Ranson criteria
  4. Rule of nines

Explanation

The Parkland formula estimates 24-hour crystalloid needs as 4 mL/kg per percent total body surface area burned, with half given in the first 8 hours. The rule of nines estimates burn area, not fluid volume.

Question 50Surgery

A patient presents with painless jaundice, a palpable gallbladder, and weight loss. Which diagnosis is most likely?

  1. Acute pancreatitis
  2. Periampullary malignancy Correct answer.
  3. Acute cholecystitis
  4. Choledocholithiasis

Explanation

Painless jaundice with a palpable, distended gallbladder suggests malignant obstruction of the distal bile duct, as described by Courvoisier's law. Gallstones typically produce painful jaundice and a contracted gallbladder.