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Albania State Medical Exam (Provimi i Shtetit - Mjekësi) study materials
Albania State Medical Exam (Provimi i Shtetit - Mjekësi) study resources

Albania State Medical Exam (Provimi i Shtetit - Mjekësi) practice questions

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Question 1Internal Medicine

A 58-year-old man with a 20-pack-year smoking history presents with progressive exertional dyspnea and a chronic productive cough. Which spirometric finding is most consistent with a diagnosis of COPD?

  1. Isolated reduction of FVC with preserved FEV1/FVC ratio
  2. Post-bronchodilator FEV1/FVC ratio below 0.70 Correct answer.
  3. Reversible airflow obstruction with a 400 mL improvement in FEV1
  4. Post-bronchodilator FEV1/FVC ratio above 0.80

Explanation

COPD is defined by persistent airflow limitation; a post-bronchodilator FEV1/FVC ratio under 0.70 confirms obstruction. The ratio must be measured after bronchodilator to distinguish fixed from reversible disease.

Question 2Internal Medicine

Which single finding on 12-lead ECG most strongly suggests acute ST-elevation myocardial infarction in a patient with chest pain?

  1. First-degree atrioventricular block
  2. ST elevation in two contiguous leads Correct answer.
  3. Premature ventricular contractions in a bigeminal pattern
  4. Sinus tachycardia at 110 beats per minute

Explanation

STEMI is diagnosed when ST elevation is present in at least two anatomically contiguous leads (or new left bundle branch block with symptoms). Rhythm disturbances alone are non-specific and do not establish infarction.

Question 3Internal Medicine

A 24-year-old woman reports polyuria, polydipsia and weight loss over 6 weeks. Which laboratory test is most appropriate to confirm the diagnosis of new-onset diabetes mellitus?

  1. Urine glucose dipstick positive once
  2. Fasting plasma glucose of 126 mg/dL or higher Correct answer.
  3. Random plasma glucose of 140 mg/dL
  4. Glycated hemoglobin of 5.4 percent

Explanation

Diabetes is diagnosed by fasting plasma glucose of 126 mg/dL or more, a random glucose of 200 mg/dL or more with symptoms, HbA1c of 6.5 percent or more, or a positive oral glucose tolerance test. A single fasting value at the threshold is diagnostic when confirmed.

Question 4Internal Medicine

A 70-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. What is the most appropriate long-term strategy to reduce his risk of cardioembolic stroke?

  1. Aspirin monotherapy
  2. Dual antiplatelet therapy
  3. No antithrombotic therapy
  4. Oral anticoagulation Correct answer.

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates sufficient stroke risk to warrant oral anticoagulation. Antiplatelet agents are inferior to anticoagulation for atrial fibrillation.

Question 5Internal Medicine

Which clinical feature is most characteristic of an acute exacerbation of heart failure with pulmonary congestion?

  1. Unilateral leg swelling
  2. Tracheal deviation toward the affected side
  3. Bibasilar inspiratory crackles Correct answer.
  4. Pleural friction rub

Explanation

Pulmonary venous congestion causes transudation of fluid into alveoli, producing bibasilar crackles and dyspnea. Unilateral leg swelling suggests deep vein thrombosis rather than systemic congestion.

Question 6Internal Medicine

A 45-year-old woman has fatigue, cold intolerance and weight gain. Serum TSH is elevated and free T4 is low. Which is the most likely diagnosis?

  1. Subclinical hyperthyroidism
  2. Thyroid storm
  3. Pituitary adenoma secreting TSH
  4. Primary hypothyroidism Correct answer.

Explanation

A high TSH with a low free T4 confirms primary hypothyroidism, because the pituitary appropriately increases TSH when thyroid hormone is deficient. In central hypothyroidism TSH would be low or inappropriately normal.

Question 7Internal Medicine

Which organism is the most frequent cause of community-acquired pneumonia in adults?

  1. Pneumocystis jirovecii
  2. Legionella pneumophila
  3. Streptococcus pneumoniae Correct answer.
  4. Mycoplasma pneumoniae

Explanation

Streptococcus pneumoniae remains the most commonly identified cause of community-acquired pneumonia across age groups. The other organisms cause atypical or opportunistic disease in narrower populations.

Question 8Internal Medicine

A 30-year-old man has a blood pressure of 158/98 mmHg on three separate visits with no identifiable secondary cause. Which classification is correct?

  1. Normal blood pressure
  2. Elevated blood pressure
  3. Stage 1 hypertension Correct answer.
  4. Hypertensive emergency

Explanation

Stage 1 hypertension is defined as systolic 130 to 139 or diastolic 80 to 89 mmHg under the ACC/AHA classification, and values of 158/98 clearly exceed these thresholds. Hypertensive emergency requires acute target-organ damage.

Question 9Internal Medicine

A 62-year-old man with a history of alcohol use presents with hematemesis and melena. He is tachycardic and hypotensive. What is the most appropriate initial step in management?

  1. Immediate oral proton pump inhibitor
  2. Oral iron supplementation
  3. Upper endoscopy before stabilization
  4. Volume resuscitation with intravenous fluids and blood products Correct answer.

Explanation

In acute upper gastrointestinal bleeding, hemodynamic stabilization with intravenous fluids and blood transfusion precedes diagnostic endoscopy. Endoscopy is performed once the patient is resuscitated.

Question 10Internal Medicine

A 55-year-old woman presents with sudden severe headache described as the worst of her life. Non-contrast head CT is normal, but the clinical suspicion for subarachnoid hemorrhage remains high. What is the most appropriate next step?

  1. Lumbar puncture for xanthochromia Correct answer.
  2. Starting antibiotic therapy
  3. Reassurance and discharge
  4. Magnetic resonance imaging of the cervical spine

Explanation

A normal non-contrast CT does not exclude subarachnoid hemorrhage, particularly when performed late after symptom onset. Lumbar puncture showing xanthochromia supports the diagnosis when CT is negative.

Question 11Internal Medicine

A 68-year-old man has a serum creatinine of 2.2 mg/dL and a calculated eGFR of 30 mL/min/1.73 m². Which stage of chronic kidney disease does this represent?

  1. Stage 2
  2. Stage 3b Correct answer.
  3. Stage 5
  4. Stage 1

Explanation

CKD stage 3b corresponds to an eGFR between 30 and 44 mL/min/1.73 m². Stage 1 and 2 require an eGFR of 90 or more and 60 to 89 respectively, and stage 5 requires an eGFR below 15.

Question 12Internal Medicine

A 40-year-old woman presents with fatigue, pallor and a hemoglobin of 8.5 g/dL. Mean corpuscular volume is 72 fL and ferritin is low. What is the most likely cause of her anemia?

  1. Chronic liver disease
  2. Vitamin B12 deficiency
  3. Hemolytic anemia
  4. Iron deficiency Correct answer.

Explanation

Microcytic anemia with low ferritin confirms iron deficiency. Ferritin is the most specific marker of iron stores and falls before other indices become abnormal.

Question 13Internal Medicine

Which finding on urinalysis most strongly suggests nephrotic syndrome?

  1. Heavy proteinuria with hypoalbuminemia and edema Correct answer.
  2. Glycosuria with normal plasma glucose
  3. Microscopic hematuria with red cell casts
  4. Pyuria with positive nitrites

Explanation

Nephrotic syndrome is defined by proteinuria above 3.5 g per day, hypoalbuminemia and edema. Red cell casts indicate a nephritic, inflammatory glomerular process.

Question 14Internal Medicine

A 28-year-old woman with type 1 diabetes presents with nausea, vomiting, abdominal pain and Kussmaul respirations. Blood glucose is 380 mg/dL and arterial pH is 7.15. Which is the most appropriate initial treatment?

  1. Intravenous sodium bicarbonate as the first intervention
  2. Subcutaneous long-acting insulin alone
  3. Intravenous isotonic saline followed by an insulin infusion Correct answer.
  4. Oral metformin

Explanation

Diabetic ketoacidosis is treated with aggressive fluid resuscitation followed by a continuous intravenous insulin infusion once potassium is adequate. Bicarbonate is reserved for severe acidosis and is not first-line.

Question 15Internal Medicine

A 50-year-old man is found to have a blood pressure of 160/100 mmHg with hypokalemia and a metabolic alkalosis. Which secondary cause of hypertension should be considered first?

  1. Cushing syndrome
  2. Renal artery stenosis
  3. Pheochromocytoma
  4. Primary hyperaldosteronism Correct answer.

Explanation

Resistant hypertension with spontaneous or diuretic-induced hypokalemia and metabolic alkalosis suggests primary hyperaldosteronism. The aldosterone excess drives sodium retention and potassium wasting.

Question 16Internal Medicine

A 60-year-old man with known cirrhosis presents with confusion, asterixis and ascites. Which precipitant should be sought first?

  1. Iron overload
  2. Hyperthyroidism
  3. Vitamin D deficiency
  4. Gastrointestinal bleeding Correct answer.

Explanation

Hepatic encephalopathy in cirrhosis is frequently precipitated by gastrointestinal bleeding, which increases the nitrogen load. Other common precipitants include infection, constipation and electrolyte disturbance.

Question 17Internal Medicine

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

  1. Antinuclear antibodies
  2. Anti-double-stranded DNA antibodies Correct answer.
  3. Rheumatoid factor
  4. Anti-CCP antibodies

Explanation

Anti-double-stranded DNA antibodies are highly specific for SLE and correlate with disease activity and lupus nephritis. Antinuclear antibodies are sensitive but not specific.

Question 18Internal Medicine

A 72-year-old woman with osteoporosis and a recent vertebral fracture is being evaluated. Which laboratory value should be checked before starting bisphosphonate therapy?

  1. Serum amylase
  2. Serum calcium and renal function Correct answer.
  3. Serum lipase
  4. Serum creatine kinase

Explanation

Bisphosphonates are contraindicated in hypocalcemia and require adequate renal function. Calcium and creatinine should be measured before treatment initiation.

Question 19Internal Medicine

Which finding on arterial blood gas is most consistent with an acute respiratory acidosis?

  1. Low pH with elevated PaCO2 Correct answer.
  2. Low pH with low PaCO2
  3. High pH with low PaCO2
  4. High pH with elevated PaCO2

Explanation

Acute respiratory acidosis occurs when hypoventilation raises PaCO2, lowering pH. If the process is chronic, renal bicarbonate retention partially corrects the pH toward normal.

Question 20Internal Medicine

A 65-year-old man with a history of smoking presents with a solitary pulmonary nodule measuring 1.5 cm on chest radiography. Which is the most appropriate next step in evaluation?

  1. Contrast-enhanced chest CT Correct answer.
  2. Repeat chest radiography in 2 years
  3. Empiric antibiotic therapy without follow-up
  4. Sputum culture for acid-fast bacilli alone

Explanation

A solitary pulmonary nodule in a high-risk patient requires contrast-enhanced chest CT to characterize size, margins and enhancement. Further management depends on the CT findings and risk of malignancy.

Question 21Internal Medicine

A 45-year-old man presents with acute monoarthritis of the first metatarsophalangeal joint. Joint aspiration shows needle-shaped negatively birefringent crystals. What is the diagnosis?

  1. Septic arthritis
  2. Pseudogout
  3. Gout Correct answer.
  4. Reactive arthritis

Explanation

Negatively birefringent needle-shaped crystals are monosodium urate, diagnostic of gout. Calcium pyrophosphate crystals are rhomboid and positively birefringent.

Question 22Internal Medicine

A 70-year-old woman has a hemoglobin of 9 g/dL, MCV of 105 fL and a normal reticulocyte count. Which is the most likely cause of her anemia?

  1. Acute blood loss
  2. Vitamin B12 deficiency Correct answer.
  3. Iron deficiency
  4. Thalassemia trait

Explanation

Macrocytosis with a low reticulocyte count suggests ineffective erythropoiesis, commonly due to vitamin B12 or folate deficiency. Iron deficiency and thalassemia produce microcytosis, while acute blood loss raises the reticulocyte count.

Question 23Internal Medicine

A 58-year-old man with known heart failure and an ejection fraction of 30 percent is admitted with worsening dyspnea. Which combination of medications has been shown to reduce mortality in heart failure with reduced ejection fraction?

  1. Calcium channel blocker and diuretic alone
  2. Amiodarone and digoxin alone
  3. Angiotensin receptor-neprilysin inhibitor, beta-blocker, mineralocorticoid receptor antagonist and SGLT2 inhibitor Correct answer.
  4. Alpha-blocker and nitrate

Explanation

Guideline-directed medical therapy for HFrEF includes an ARNI or ACE inhibitor, a beta-blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor, all of which reduce mortality. Diuretics relieve congestion but do not improve survival.

Question 24Internal Medicine

A 32-year-old woman presents with fever, pleuritic chest pain and a pleural effusion. Pleural fluid analysis shows a pH of 7.10, glucose of 30 mg/dL and a positive Gram stain. What is the most appropriate management?

  1. Diuretics alone
  2. Chest tube drainage with antibiotics Correct answer.
  3. Systemic corticosteroids alone
  4. Observation with repeat thoracentesis in 1 week

Explanation

A parapneumonic effusion with low pH, low glucose and organisms on Gram stain indicates a complicated effusion or empyema requiring drainage plus antibiotics. Delay increases the risk of loculation and sepsis.

Question 25Internal Medicine

A 55-year-old man with long-standing type 2 diabetes has a serum creatinine that has risen from 1.1 to 2.0 mg/dL over 3 months. Urinalysis shows proteinuria but no hematuria. Which diagnosis best fits this picture?

  1. Renal artery thrombosis
  2. Diabetic nephropathy Correct answer.
  3. Post-streptococcal glomerulonephritis
  4. Acute interstitial nephritis

Explanation

Progressive proteinuric renal impairment without hematuria in a patient with long-standing diabetes is typical of diabetic nephropathy. The absence of hematuria and the chronic time course argue against acute glomerulonephritis.

Question 26Internal Medicine

A 68-year-old man with a 40 pack-year smoking history presents with progressive dyspnea on exertion and a chronic cough. Chest examination reveals a barrel-shaped chest and decreased breath sounds bilaterally. Spirometry shows a post-bronchodilator FEV1/FVC ratio of 0.55. Which diagnosis is most likely?

  1. Asthma
  2. Chronic obstructive pulmonary disease Correct answer.
  3. Heart failure
  4. Interstitial lung disease

Explanation

A post-bronchodilator FEV1/FVC ratio below 0.70 confirms persistent airflow obstruction, which in a patient with a significant smoking history and compatible symptoms is diagnostic of COPD. Asthma typically shows reversibility and often a normal ratio, while heart failure and interstitial lung disease produce restrictive or different patterns.

Question 27Internal Medicine

A 24-year-old woman presents with palpitations, heat intolerance, and weight loss. Physical examination reveals a diffusely enlarged, nontender thyroid gland and fine tremor. Laboratory tests show suppressed TSH and elevated free T4. Which is the most appropriate initial diagnostic test to confirm the cause?

  1. Serum thyroid-stimulating immunoglobulin
  2. Radioactive iodine uptake scan Correct answer.
  3. Fine-needle aspiration biopsy
  4. Thyroid ultrasound

Explanation

A radioactive iodine uptake scan helps differentiate among causes of thyrotoxicosis; in Graves' disease, it shows diffusely increased uptake. Thyroid ultrasound and fine-needle aspiration are more useful for structural nodules, and thyroid-stimulating immunoglobulin supports but is not the primary confirmatory test.

Question 28Internal Medicine

A 62-year-old man with type 2 diabetes and hypertension presents with gradually worsening exertional dyspnea and orthopnea. Examination reveals bibasilar crackles, an S3 gallop, and elevated jugular venous pressure. Echocardiography shows an ejection fraction of 30%. Which medication has been shown to reduce mortality in this condition?

  1. Furosemide
  2. Metoprolol succinate Correct answer.
  3. Digoxin
  4. Amlodipine

Explanation

Beta-blockers such as metoprolol succinate, along with ACE inhibitors/ARBs, aldosterone antagonists, and SGLT2 inhibitors, have mortality benefit in heart failure with reduced ejection fraction. Diuretics and digoxin improve symptoms but do not reduce mortality.

Question 29Internal Medicine

A 55-year-old woman presents with a 3-month history of episodic epigastric pain that occurs 2–3 hours after meals and sometimes awakens her at night. She reports no NSAID use. Which is the most likely diagnosis?

  1. Pancreatic cancer
  2. Biliary colic
  3. Peptic ulcer disease Correct answer.
  4. Gastroesophageal reflux disease

Explanation

Epigastric pain that occurs hours after meals and at night is classic for peptic ulcer disease, often due to Helicobacter pylori infection. GERD typically causes heartburn and regurgitation, biliary colic causes right upper quadrant pain after fatty meals, and pancreatic cancer often presents with weight loss and jaundice.

Question 30Internal Medicine

A 70-year-old man with a history of hypertension and smoking presents with sudden onset of severe tearing chest pain radiating to the back. Blood pressure is 180/100 mmHg in the right arm and 150/90 mmHg in the left arm. Which is the most appropriate initial imaging study to confirm the diagnosis?

  1. Coronary angiography
  2. Transthoracic echocardiography
  3. Contrast-enhanced computed tomography of the chest Correct answer.
  4. Chest radiograph

Explanation

Contrast-enhanced CT of the chest is highly sensitive and specific for aortic dissection and is often the first-line imaging in stable patients. Transthoracic echocardiography may miss a dissection limited to the descending aorta, chest radiograph findings are nonspecific, and coronary angiography is not indicated.

Question 31Internal Medicine

A 28-year-old woman presents with fatigue, arthralgias, and a photosensitive rash. Laboratory tests reveal a positive antinuclear antibody test and anti-double-stranded DNA antibodies. Which additional laboratory finding is most specific for systemic lupus erythematosus?

  1. Anti-Smith antibodies Correct answer.
  2. Anti-centromere antibodies
  3. Rheumatoid factor
  4. Anti-histone antibodies

Explanation

Anti-Smith antibodies are highly specific for systemic lupus erythematosus, although less sensitive than anti-dsDNA. Anti-histone antibodies are associated with drug-induced lupus, rheumatoid factor is nonspecific, and anti-centromere antibodies are seen in limited cutaneous systemic sclerosis.

Question 32Internal Medicine

A 50-year-old man with a history of alcohol use presents with confusion, ataxia, and ophthalmoplegia. He is given intravenous glucose without thiamine. Which complication is most likely to occur?

  1. Wernicke encephalopathy Correct answer.
  2. Subdural hematoma
  3. Hypoglycemic coma
  4. Hepatic encephalopathy

Explanation

In patients with alcohol use disorder, glucose administration without thiamine can precipitate or worsen Wernicke encephalopathy, which is characterized by confusion, ataxia, and ophthalmoplegia. Thiamine should always be given before or with glucose in this population.

Question 33Internal Medicine

A 65-year-old woman presents with fatigue and pallor. Laboratory tests show a hemoglobin of 9 g/dL, mean corpuscular volume of 105 fL, and a normal reticulocyte count. Which is the most likely cause?

  1. Iron deficiency anemia
  2. Acute blood loss
  3. Vitamin B12 deficiency Correct answer.
  4. Anemia of chronic disease

Explanation

A macrocytic anemia with a low reticulocyte count suggests a production problem, and vitamin B12 deficiency is a common cause. Iron deficiency and anemia of chronic disease are typically microcytic or normocytic, and acute blood loss would be associated with a high reticulocyte count.

Question 34Internal Medicine

A 58-year-old man with a history of nephrolithiasis presents with sudden onset of severe flank pain radiating to the groin. Urinalysis shows microscopic hematuria. Non-contrast CT of the abdomen and pelvis reveals a 5-mm stone in the distal ureter. Which is the most appropriate initial management?

  1. Percutaneous nephrostomy
  2. Immediate ureteroscopy with stone extraction
  3. Analgesia and observation with hydration Correct answer.
  4. Extracorporeal shock wave lithotripsy

Explanation

Stones smaller than 10 mm, especially those in the distal ureter, often pass spontaneously; initial management includes analgesia, hydration, and observation. Ureteroscopy or lithotripsy is considered if the stone does not pass or if complications arise, and percutaneous nephrostomy is reserved for obstruction with infection.

Question 35Internal Medicine

A 45-year-old man presents with recurrent episodes of severe headache, palpitations, and diaphoresis. During an episode, blood pressure is 210/110 mmHg. Which is the most appropriate initial test to screen for pheochromocytoma?

  1. Plasma renin activity
  2. Abdominal ultrasound
  3. Plasma free metanephrines Correct answer.
  4. Serum cortisol

Explanation

Plasma free metanephrines are the most sensitive screening test for pheochromocytoma. Serum cortisol is used for adrenal cortical disorders, plasma renin activity for renovascular hypertension, and abdominal ultrasound is not a functional screening test.

Question 36Internal Medicine

A 32-year-old man presents with a 2-week history of progressive weakness and areflexia after a diarrheal illness. Cerebrospinal fluid analysis shows albuminocytologic dissociation. Which is the most likely diagnosis?

  1. Multiple sclerosis
  2. Myasthenia gravis
  3. Spinal cord infarction
  4. Guillain-Barré syndrome Correct answer.

Explanation

Guillain-Barré syndrome is an acute inflammatory demyelinating polyneuropathy that often follows a gastrointestinal infection and is characterized by ascending weakness, areflexia, and albuminocytologic dissociation in CSF. Multiple sclerosis typically presents with CNS symptoms, myasthenia gravis with fatigable weakness, and spinal cord infarction with a sensory level.

Question 37Internal Medicine

A 70-year-old man with a history of hypertension and diabetes presents with sudden onset of left-sided weakness and neglect. Non-contrast head CT shows a hyperdense right middle cerebral artery. Which is the most appropriate immediate treatment?

  1. Heparin
  2. Intravenous thrombolysis with alteplase Correct answer.
  3. Aspirin
  4. Surgical decompression

Explanation

The patient has an acute ischemic stroke with a hyperdense MCA sign, indicating a large vessel occlusion. Intravenous thrombolysis with alteplase is indicated within 4.5 hours of symptom onset if there are no contraindications, and mechanical thrombectomy should also be considered. Aspirin is given after thrombolysis, heparin is not routinely used, and decompression is for malignant edema.

Question 38Internal Medicine

A 60-year-old woman with a history of breast cancer presents with confusion, polyuria, and constipation. Laboratory tests show a serum calcium of 13.5 mg/dL and a normal parathyroid hormone level. Which is the most appropriate initial treatment?

  1. Thiazide diuretics
  2. Glucocorticoids
  3. Intravenous fluids with normal saline Correct answer.
  4. Oral calcium supplements

Explanation

The patient has hypercalcemia of malignancy, which is treated initially with aggressive intravenous hydration to restore volume and promote calcium excretion. Oral calcium would worsen hypercalcemia, thiazides reduce calcium excretion, and glucocorticoids are used in specific causes such as lymphoma or granulomatous disease.

Question 39Internal Medicine

A 55-year-old man with a history of alcohol cirrhosis presents with hematemesis and hypotension. After initial resuscitation, which medication should be started to reduce the risk of rebleeding from esophageal varices?

  1. Propranolol
  2. Transfusion of fresh frozen plasma
  3. Vitamin K
  4. Octreotide Correct answer.

Explanation

Octreotide, a somatostatin analogue, reduces splanchnic blood flow and is used acutely to control variceal bleeding. Propranolol is used for prophylaxis, vitamin K and fresh frozen plasma are for coagulopathy, not specifically for variceal bleeding.

Question 40Internal Medicine

A 50-year-old man with a history of alcohol use presents with fever, productive cough, and pleuritic chest pain. Chest radiograph shows a right lower lobe infiltrate with a small pleural effusion. Thoracentesis yields fluid with a pH of 7.10, glucose of 40 mg/dL, and a positive Gram stain. Which is the most appropriate next step?

  1. Chest tube drainage Correct answer.
  2. Repeat thoracentesis in 24 hours
  3. Observation with antibiotics alone
  4. Intrapleural fibrinolytics

Explanation

A pleural fluid pH below 7.20, low glucose, and positive Gram stain indicate a complicated parapneumonic effusion or empyema, which requires chest tube drainage in addition to antibiotics. Observation alone is inadequate, repeat thoracentesis is not sufficient, and fibrinolytics are not first-line.

Question 41Surgery and Surgical Specialties

A 24-year-old man has sudden severe right lower abdominal pain migrating from the umbilicus, with fever and tenderness at McBurney's point. Which finding most supports acute appendicitis over other causes of acute abdomen?

  1. Pain that is relieved by lying still in the fetal position
  2. Absence of any rise in white blood cell count
  3. Rebound tenderness elicited only in the left lower quadrant
  4. Pain that begins periumbilical and then localizes to the right iliac fossa Correct answer.

Explanation

Visceral periumbilical pain followed by somatic localization to the right lower quadrant reflects progression of inflammation to the parietal peritoneum over the appendix. This migratory pattern is the classic clinical hallmark.

Question 42Surgery and Surgical Specialties

Which incision is classically used for open appendectomy and is centered over McBurney's point?

  1. Gridiron (McBurney) incision Correct answer.
  2. Pfannenstiel incision
  3. Midline laparotomy
  4. Kocher subcostal incision

Explanation

The gridiron incision is a muscle-splitting oblique incision centered on McBurney's point and is the classic approach for open appendectomy. It divides the aponeurosis but splits rather than cuts the muscle fibers.

Question 43Surgery and Surgical Specialties

A 55-year-old woman has a painful right groin swelling that appears on standing and disappears when supine. On examination the swelling is lateral to the pubic tubercle. Which diagnosis is most likely?

  1. Psoas abscess
  2. Inguinal hernia Correct answer.
  3. Femoral hernia
  4. Saphenous varix

Explanation

An inguinal hernia lies above and medial to the pubic tubercle, whereas a femoral hernia lies below and lateral to it. The relation to the pubic tubercle is the key surface landmark for distinguishing the two.

Question 44Surgery and Surgical Specialties

Which structure forms the medial boundary of the femoral ring and is at risk of compression in a strangulated femoral hernia?

  1. Inguinal ligament
  2. Pectineal ligament
  3. Femoral vein
  4. Lacunar ligament Correct answer.

Explanation

The femoral ring is bounded medially by the lacunar ligament, which is sharp and unyielding. Its rigidity explains the high risk of strangulation in femoral hernias.

Question 45Surgery and Surgical Specialties

A 62-year-old man has a pulsatile abdominal mass and vague back pain. Which imaging study is the best initial test to confirm an abdominal aortic aneurysm?

  1. Abdominal ultrasound Correct answer.
  2. Upper gastrointestinal endoscopy
  3. Barium enema
  4. Plain abdominal radiograph

Explanation

Abdominal ultrasound is non-invasive, avoids radiation, and reliably measures aortic diameter, making it the preferred initial test for suspected abdominal aortic aneurysm.

Question 46Surgery and Surgical Specialties

A patient with a ruptured abdominal aortic aneurysm is hypotensive. Which principle best guides initial management?

  1. Aggressive crystalloid resuscitation to normal blood pressure before surgery
  2. Permissive hypotension with rapid transfer to the operating room Correct answer.
  3. Immediate CT angiography before any resuscitation
  4. Thrombolysis followed by observation

Explanation

In ruptured abdominal aortic aneurysm, permissive hypotension limits further bleeding and clot disruption until surgical control is achieved. Rapid transfer to the operating room takes priority over normalization of blood pressure.

Question 47Surgery and Surgical Specialties

Which feature most reliably distinguishes a malignant ulcer from a benign gastric ulcer on endoscopy?

  1. Irregular raised everted edges with an undermined base Correct answer.
  2. Smooth, regular margins with a radiating mucosal fold pattern
  3. Presence of a single ulcer in the antrum
  4. Rapid symptomatic response to proton pump inhibitors

Explanation

Malignant gastric ulcers characteristically have irregular, raised, everted margins and a necrotic undermined base. Benign ulcers tend to have smooth, punched-out edges with radiating folds.

Question 48Surgery and Surgical Specialties

A 45-year-old man has epigastric pain, and a chest radiograph shows free air under the diaphragm. Which diagnosis must be excluded first?

  1. Perforated peptic ulcer Correct answer.
  2. Small bowel obstruction
  3. Acute pancreatitis
  4. Acute cholecystitis

Explanation

Pneumoperitoneum on an erect chest radiograph indicates a hollow viscus perforation, most commonly a perforated peptic ulcer. It is a surgical emergency requiring urgent source control.

Question 49Surgery and Surgical Specialties

Which finding on history most strongly suggests acute mesenteric ischemia in an elderly patient with atrial fibrillation?

  1. Painless jaundice with weight loss
  2. Colicky pain relieved by defecation
  3. Pain relieved by antacids
  4. Pain out of proportion to abdominal examination findings Correct answer.

Explanation

Early acute mesenteric ischemia classically produces severe pain with a relatively soft, non-tender abdomen because ischemia begins before transmural infarction and peritonitis develop. Atrial fibrillation is a common source of emboli to the superior mesenteric artery.

Question 50Surgery and Surgical Specialties

A 30-year-old woman has a firm, mobile, well-circumscribed breast mass. Which diagnosis is most likely?

  1. Phyllodes tumor
  2. Fibroadenoma Correct answer.
  3. Mastitis
  4. Invasive ductal carcinoma

Explanation

A firm, smooth, highly mobile mass in a young woman is the classic presentation of a fibroadenoma, a benign fibroepithelial lesion.