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Question 1Internal Medicine

A 58-year-old man has fasting plasma glucose of 7.4 mmol/L on two occasions. Which diagnosis is most consistent with these results?

  1. Impaired fasting glucose
  2. Diabetes mellitus Correct answer.
  3. Reactive hypoglycemia
  4. Normal glucose tolerance

Explanation

A fasting plasma glucose of 7.0 mmol/L or higher confirmed on a second occasion establishes the diagnosis of diabetes mellitus. Impaired fasting glucose corresponds to the intermediate range of 5.6–6.9 mmol/L.

Question 2Internal Medicine

Which electrocardiographic finding is the earliest and most reliable sign of acute transmural myocardial infarction?

  1. Prolonged PR interval
  2. Peaked T waves
  3. Pathologic Q waves
  4. ST-segment elevation Correct answer.

Explanation

ST-segment elevation in contiguous leads reflects acute transmural injury and is the defining early ECG sign used to trigger reperfusion. Q waves develop later and indicate established necrosis.

Question 3Internal Medicine

A patient with community-acquired pneumonia has a CURB-65 score of 3. What is the most appropriate disposition?

  1. No treatment needed
  2. Short observation then discharge
  3. Hospital admission, consider intensive care Correct answer.
  4. Outpatient oral antibiotics

Explanation

CURB-65 scores of 2 or more generally warrant hospital admission, and a score of 3 or higher indicates severe disease with consideration of intensive care. Scores of 0–1 are typically managed as outpatients.

Question 4Internal Medicine

Which laboratory pattern is characteristic of iron deficiency anemia?

  1. Normal ferritin with low reticulocyte count
  2. Low ferritin with high total iron-binding capacity Correct answer.
  3. High ferritin with low total iron-binding capacity
  4. High ferritin with normal mean corpuscular volume

Explanation

Iron deficiency produces depleted stores (low ferritin) and a compensatory rise in transferrin, reflected as increased total iron-binding capacity. This distinguishes it from anemia of chronic disease.

Question 5Internal Medicine

A 24-year-old woman reports palpitations and weight loss. TSH is suppressed and free T4 is elevated. Which finding best supports Graves disease over a toxic nodule?

  1. Elevated free T4 alone
  2. Single palpable thyroid nodule
  3. Diffuse goiter with ophthalmopathy Correct answer.
  4. Suppressed TSH alone

Explanation

Diffuse goiter and thyroid eye disease are features of the autoimmune stimulation seen in Graves disease. A solitary nodule suggests a toxic adenoma instead.

Question 6Internal Medicine

Which acid-base disturbance is expected in a patient with prolonged vomiting?

  1. Metabolic alkalosis with high bicarbonate Correct answer.
  2. Metabolic acidosis with low bicarbonate
  3. Respiratory alkalosis with low PaCO2
  4. Respiratory acidosis with high PaCO2

Explanation

Vomiting causes loss of gastric hydrogen and chloride, generating a metabolic alkalosis with elevated bicarbonate. Respiratory compensation raises PaCO2 but the primary disorder is metabolic.

Question 7Internal Medicine

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

  1. Staphylococcus aureus
  2. Mycoplasma pneumoniae
  3. Legionella pneumophila
  4. Streptococcus pneumoniae Correct answer.

Explanation

Streptococcus pneumoniae remains the most frequently identified bacterial pathogen in community-acquired pneumonia. The other organisms cause pneumonia but at lower frequency in typical community settings.

Question 8Internal Medicine

A patient with atrial fibrillation has a CHA2DS2-VASc score of 4. What is the recommended antithrombotic strategy?

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

Explanation

A CHA2DS2-VASc score of 2 or higher in men (3 or higher in women) supports oral anticoagulation to reduce stroke risk. Antiplatelet therapy is inferior to anticoagulation for this indication.

Question 9Internal Medicine

Which renal finding is typical of nephrotic syndrome?

  1. Oliguria with rapid creatinine rise
  2. Hyperkalemia with metabolic acidosis
  3. Red blood cell casts on microscopy
  4. Proteinuria greater than 3.5 g per day Correct answer.

Explanation

Nephrotic syndrome is defined by heavy proteinuria (over 3.5 g/day), hypoalbuminemia, edema, and hyperlipidemia. Red cell casts and rapid renal failure point to nephritic or acute kidney injury patterns.

Question 10Internal Medicine

A 68-year-old smoker has a hemoglobin of 10.5 g/dL with mean corpuscular volume of 72 fL and low ferritin. What is the most important next step?

  1. Evaluate the gastrointestinal tract for blood loss Correct answer.
  2. Check vitamin B12 level
  3. Start oral iron and reassess in one year
  4. Transfuse packed red cells immediately

Explanation

Iron deficiency anemia in an older adult, especially a smoker, requires evaluation for gastrointestinal blood loss, including malignancy. Iron replacement alone without identifying the source is inadequate.

Question 11Internal Medicine

Which feature best distinguishes an exudative from a transudative pleural effusion?

  1. Unilateral distribution on imaging
  2. Clear straw-colored appearance
  3. Pleural fluid protein to serum ratio above 0.5 Correct answer.
  4. Presence of dyspnea

Explanation

The Light criteria classify an effusion as exudative when the pleural-to-serum protein ratio exceeds 0.5, among other measures. Appearance, laterality, and symptoms do not reliably separate the two types.

Question 12Internal Medicine

Which finding is most characteristic of an upper motor neuron lesion?

  1. Areflexia with flaccid tone
  2. Hyperreflexia with spasticity Correct answer.
  3. Fasciculations and muscle atrophy
  4. Sensory loss confined to a dermatome

Explanation

Upper motor neuron lesions produce increased tone, hyperreflexia, and often an extensor plantar response. Lower motor neuron lesions produce flaccidity, atrophy, and fasciculations.

Question 13Internal Medicine

A patient presents with sudden severe headache described as the worst of life. Which investigation is the most appropriate first step if the CT scan is negative?

  1. Lumbar puncture for xanthochromia Correct answer.
  2. Carotid Doppler ultrasound
  3. Electroencephalography
  4. MRI of the cervical spine

Explanation

A thunderclap headache raises concern for subarachnoid hemorrhage; if CT is negative, lumbar puncture looking for xanthochromia is the next step. Xanthochromia from bilirubin persists for days after the bleed.

Question 14Internal Medicine

Which electrolyte abnormality is most commonly associated with thiazide diuretic use?

  1. Hypercalcemia
  2. Hyponatremia Correct answer.
  3. Metabolic acidosis
  4. Hyperkalemia

Explanation

Thiazides cause sodium and water loss with a tendency toward dilutional hyponatremia, especially in older adults. They also raise calcium and cause hypokalemia rather than hyperkalemia.

Question 15Internal Medicine

A 45-year-old man has a blood pressure of 168/104 mmHg on three separate visits with no identifiable secondary cause. What is the diagnosis?

  1. Hypertensive emergency
  2. Secondary hypertension
  3. Primary hypertension Correct answer.
  4. White coat hypertension

Explanation

Persistently elevated blood pressure without an identifiable cause is primary (essential) hypertension. Hypertensive emergency requires acute target-organ damage, which is absent here.

Question 16Internal Medicine

Which spirometric pattern is expected in chronic obstructive pulmonary disease?

  1. Increased FEV1 with increased FVC
  2. Normal FEV1 with reduced FVC
  3. Reduced FEV1 with reduced FEV1/FVC ratio Correct answer.
  4. Reduced FVC with normal FEV1/FVC ratio

Explanation

COPD produces airflow obstruction, so both FEV1 and the FEV1/FVC ratio fall below the normal threshold. A reduced FVC with preserved ratio suggests restriction instead.

Question 17Internal Medicine

Which vaccine is specifically recommended for adults aged 65 and older to prevent pneumococcal disease?

  1. Human papillomavirus vaccine
  2. Hepatitis A vaccine
  3. Varicella vaccine
  4. Pneumococcal conjugate or polysaccharide vaccine Correct answer.

Explanation

Pneumococcal vaccination with conjugate and/or polysaccharide formulations is recommended for older adults to reduce invasive pneumococcal disease. The other vaccines target unrelated pathogens.

Question 18Internal Medicine

A patient with type 2 diabetes has an eGFR of 35 mL/min/1.73 m2 and albuminuria. Which medication class slows progression of diabetic kidney disease?

  1. Loop diuretics
  2. Thiazolidinediones
  3. Beta blockers
  4. SGLT2 inhibitors Correct answer.

Explanation

SGLT2 inhibitors reduce albuminuria and slow decline in kidney function in diabetic kidney disease, independent of glucose lowering. They are recommended alongside renin-angiotensin blockade.

Question 19Internal Medicine

Which clinical feature most suggests a diagnosis of acute pancreatitis?

  1. Epigastric pain radiating to the back with elevated lipase Correct answer.
  2. Colicky flank pain with hematuria
  3. Right lower quadrant pain with rebound tenderness
  4. Burning retrosternal pain relieved by antacids

Explanation

Acute pancreatitis typically causes severe epigastric pain radiating to the back with lipase elevated more than three times the upper limit of normal. The other patterns localize to different organs.

Question 20Internal Medicine

Which finding is most consistent with a diagnosis of infective endocarditis?

  1. Diffuse abdominal tenderness
  2. Bilateral basilar crackles
  3. Unilateral leg swelling
  4. Splinter hemorrhages and a new murmur Correct answer.

Explanation

Peripheral embolic phenomena such as splinter hemorrhages combined with a new or changing murmur suggest infective endocarditis. Blood cultures and echocardiography confirm the diagnosis.

Question 21Internal Medicine

A patient with known heart failure develops worsening dyspnea, orthopnea, and bilateral crackles. Which therapy is most appropriate for acute decompensation with volume overload?

  1. Beta blocker initiation at high dose
  2. Oral potassium supplement
  3. Intravenous loop diuretic Correct answer.
  4. Intravenous calcium channel blocker

Explanation

Acute decompensated heart failure with congestion is treated with intravenous loop diuretics to achieve decongestion. Beta blockers are initiated cautiously once the patient is stable, not at high dose during decompensation.

Question 22Internal Medicine

Which serologic marker is most specific for systemic lupus erythematosus?

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

Explanation

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

Question 23Internal Medicine

A 30-year-old woman has recurrent episodes of severe abdominal pain, hypertension, and palpitations, with elevated plasma metanephrines. What is the most likely diagnosis?

  1. Primary aldosteronism
  2. Pheochromocytoma Correct answer.
  3. Hyperthyroidism
  4. Cushing syndrome

Explanation

Paroxysmal hypertension with headache, palpitations, and elevated metanephrines is characteristic of pheochromocytoma. Metanephrine measurement is the preferred biochemical screening test.

Question 24Internal Medicine

Which mechanism best explains hypoxemia in a large right-to-left intracardiac shunt?

  1. Reduced inspired oxygen tension
  2. Diffusion limitation across the alveolar membrane
  3. Ventilation-perfusion mismatch with shunt physiology Correct answer.
  4. Alveolar hypoventilation

Explanation

A right-to-left shunt delivers deoxygenated blood into the systemic circulation without contacting ventilated alveoli, producing shunt physiology that is poorly responsive to supplemental oxygen. This is a form of severe ventilation-perfusion mismatch.

Question 25Internal Medicine

A patient with cirrhosis presents with confusion, asterixis, and elevated ammonia. Which precipitant should be sought first?

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

Explanation

Gastrointestinal bleeding is a common precipitant of hepatic encephalopathy because blood protein in the gut increases ammonia production. Identifying and treating the precipitant is essential alongside lactulose.

Question 26Internal Medicine

A 55-year-old man with a history of alcohol use presents with confusion, ataxia, and ophthalmoplegia. Which vitamin deficiency is most likely responsible?

  1. Vitamin C (ascorbic acid)
  2. Vitamin B12 (cobalamin)
  3. Vitamin B1 (thiamine) Correct answer.
  4. Vitamin D (calciferol)

Explanation

Wernicke encephalopathy is caused by thiamine deficiency and classically presents with the triad of confusion, ataxia, and ophthalmoplegia. It is most common in individuals with alcohol use disorder due to poor nutrition and impaired absorption.

Question 27Internal Medicine

A 72-year-old woman is found to have a thyroid-stimulating hormone (TSH) level of 0.1 mIU/L (low) and a free T4 level of 2.5 ng/dL (high). She reports palpitations and weight loss. Which is the most likely diagnosis?

  1. Primary hypothyroidism
  2. Graves' disease Correct answer.
  3. Hashimoto's thyroiditis
  4. Subclinical hypothyroidism

Explanation

A suppressed TSH with elevated free T4 indicates primary hyperthyroidism. Graves' disease is the most common cause of hyperthyroidism in older adults and typically presents with palpitations and weight loss.

Question 28Internal Medicine

A 60-year-old man with a history of myocardial infarction presents with sudden onset of tearing chest pain radiating to the back. His blood pressure is 180/100 mmHg in the right arm and 140/80 mmHg in the left arm. Which is the most appropriate initial diagnostic study?

  1. Chest radiograph
  2. CT angiography of the aorta Correct answer.
  3. Transthoracic echocardiography
  4. Electrocardiogram

Explanation

The presentation is highly suspicious for aortic dissection, especially with the interarm blood pressure difference. CT angiography of the aorta is the preferred initial imaging study because it rapidly visualizes the entire aorta and can confirm the diagnosis.

Question 29Internal Medicine

A 25-year-old woman presents with fatigue, arthralgias, and a malar rash. Laboratory tests show a positive antinuclear antibody (ANA) and elevated anti-double-stranded DNA (anti-dsDNA) antibodies. Which diagnosis is most likely?

  1. Systemic lupus erythematosus Correct answer.
  2. Sjögren's syndrome
  3. Rheumatoid arthritis
  4. Systemic sclerosis

Explanation

The combination of a malar rash, arthralgias, positive ANA, and elevated anti-dsDNA is highly specific for systemic lupus erythematosus (SLE). Anti-dsDNA antibodies are particularly associated with SLE and can correlate with disease activity.

Question 30Internal Medicine

A 50-year-old man with a history of alcohol use disorder presents with confusion and ataxia. His blood glucose is 45 mg/dL. After intravenous glucose administration, his symptoms improve. Which is the most likely cause of his symptoms?

  1. Hypoglycemia Correct answer.
  2. Wernicke encephalopathy
  3. Alcohol intoxication
  4. Hepatic encephalopathy

Explanation

Hypoglycemia can cause confusion and ataxia, and symptoms resolve rapidly with glucose administration. In patients with alcohol use disorder, hypoglycemia can result from poor oral intake and impaired gluconeogenesis.

Question 31Internal Medicine

A 68-year-old woman with a history of hypertension and diabetes presents with sudden onset of right-sided weakness and aphasia. Her blood pressure is 180/100 mmHg, and her blood glucose is 150 mg/dL. A non-contrast CT scan of the head shows no hemorrhage. Which is the most appropriate next step in management?

  1. Start aspirin and admit for observation
  2. Perform an immediate lumbar puncture
  3. Obtain an MRI of the brain
  4. Administer intravenous tissue plasminogen activator (tPA) Correct answer.

Explanation

The patient has acute ischemic stroke with a last known well time within the thrombolytic window (typically 3-4.5 hours) and no contraindications. Intravenous tPA is indicated to restore perfusion and improve outcomes.

Question 32Internal Medicine

A 30-year-old woman presents with recurrent episodes of severe headache, palpitations, and sweating. She has a blood pressure of 210/120 mmHg during an episode. Laboratory tests show elevated plasma metanephrines. Which is the most likely diagnosis?

  1. Pheochromocytoma Correct answer.
  2. Primary aldosteronism
  3. Cushing's syndrome
  4. Hyperthyroidism

Explanation

The triad of episodic headache, palpitations, and sweating with severe hypertension is classic for pheochromocytoma. Elevated plasma metanephrines are highly sensitive and specific for this tumor.

Question 33Internal Medicine

A 55-year-old man with a history of cirrhosis presents with hematemesis and melena. His blood pressure is 90/60 mmHg and heart rate is 120 bpm. After initial resuscitation, which medication should be started to reduce the risk of rebleeding from esophageal varices?

  1. Propranolol
  2. Vitamin K
  3. Omeprazole
  4. Octreotide Correct answer.

Explanation

Octreotide, a somatostatin analogue, causes splanchnic vasoconstriction and reduces portal pressure, thereby decreasing variceal bleeding. It is recommended in the acute management of variceal hemorrhage.

Question 34Internal Medicine

A 45-year-old woman presents with fatigue, weight gain, and cold intolerance. Her TSH is elevated and free T4 is low. Which is the most appropriate treatment?

  1. Prednisone
  2. Methimazole
  3. Radioactive iodine
  4. Levothyroxine Correct answer.

Explanation

The patient has primary hypothyroidism, indicated by elevated TSH and low free T4. Levothyroxine is the standard replacement therapy and should be initiated to restore euthyroidism.

Question 35Internal Medicine

A 62-year-old man with a history of heart failure with reduced ejection fraction (HFrEF) is admitted with worsening dyspnea and edema. His blood pressure is 110/70 mmHg, and his creatinine is 1.5 mg/dL. Which medication has been shown to reduce mortality in HFrEF?

  1. Sacubitril/valsartan Correct answer.
  2. Furosemide
  3. Digoxin
  4. Amlodipine

Explanation

Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), has been shown to reduce cardiovascular mortality and heart failure hospitalizations in patients with HFrEF compared to enalapril. It is recommended as first-line therapy in appropriate patients.

Question 36Internal Medicine

A 70-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents with increased sputum purulence and dyspnea. He has had two exacerbations in the past year. Which is the most appropriate treatment?

  1. Intravenous diuretics
  2. Inhaled bronchodilators only
  3. Oral theophylline
  4. Antibiotics and systemic corticosteroids Correct answer.

Explanation

Acute exacerbations of COPD with increased sputum purulence are often bacterial and benefit from antibiotics. Systemic corticosteroids shorten recovery time and improve lung function. Inhaled bronchodilators are also used but are not sufficient alone for this presentation.

Question 37Internal Medicine

A 55-year-old woman with a history of hypertension presents with severe headache, blurred vision, and confusion. Her blood pressure is 220/120 mmHg. Fundoscopy reveals papilledema. Which is the most appropriate initial management?

  1. Sublingual nifedipine
  2. Intravenous furosemide
  3. Intravenous labetalol Correct answer.
  4. Oral captopril

Explanation

This is a hypertensive emergency with evidence of end-organ damage (papilledema, confusion). Intravenous labetalol is a preferred agent for controlled blood pressure reduction in hypertensive emergencies, aiming to lower mean arterial pressure by no more than 25% in the first hour.

Question 38Internal Medicine

A 35-year-old woman presents with fever, rash, and hypotension after eating a hamburger at a picnic. She has a diffuse erythematous rash and is diagnosed with toxic shock syndrome. Which organism is most likely responsible?

  1. Staphylococcus aureus Correct answer.
  2. Streptococcus pyogenes
  3. Escherichia coli
  4. Clostridium perfringens

Explanation

Toxic shock syndrome is most commonly caused by Staphylococcus aureus, which produces the toxic shock syndrome toxin-1 (TSST-1). It is associated with the use of superabsorbent tampons and can also occur with skin infections.

Question 39Internal Medicine

A 60-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. He is given intravenous glucose without thiamine. Which complication is most likely to occur?

  1. Hyperkalemia
  2. Hypoglycemic coma
  3. Worsening of Wernicke encephalopathy Correct answer.
  4. Hepatic encephalopathy

Explanation

In patients with alcohol use disorder, glucose administration without thiamine can precipitate or worsen Wernicke encephalopathy because glucose metabolism consumes thiamine. Thiamine should be given before or with glucose.

Question 40Internal Medicine

A 45-year-old woman with a history of recurrent kidney stones is found to have a serum calcium of 11.5 mg/dL and a parathyroid hormone (PTH) level that is inappropriately normal. Which is the most likely diagnosis?

  1. Familial hypocalciuric hypercalcemia
  2. Primary hyperparathyroidism Correct answer.
  3. Tertiary hyperparathyroidism
  4. Secondary hyperparathyroidism

Explanation

Primary hyperparathyroidism is characterized by hypercalcemia with an elevated or inappropriately normal PTH level. It is a common cause of recurrent kidney stones and should be suspected when calcium is high and PTH is not suppressed.

Question 41Surgery

Which finding most strongly suggests that acute abdominal pain is due to peritonitis rather than a nonsurgical cause?

  1. Pain that is poorly localized to the periumbilical region
  2. Pain that is relieved by vomiting
  3. Pain that worsens with movement and is accompanied by guarding Correct answer.
  4. Pain that radiates to the back only after eating

Explanation

Peritoneal irritation produces pain that is accentuated by movement, coughing, or percussion, and is accompanied by involuntary guarding and rebound tenderness. Poorly localized periumbilical pain reflects visceral rather than parietal peritoneal involvement.

Question 42Surgery

A patient has a deep laceration of the palm from a kitchen knife. Which factor is the most important determinant of whether primary wound closure is appropriate?

  1. The patient's occupation
  2. The patient's age
  3. The time elapsed since injury and degree of wound contamination Correct answer.
  4. The length of the laceration in centimeters

Explanation

The decision to close a wound primarily depends mainly on the interval since injury and the degree of bacterial contamination, since these determine the risk of infection after closure. Clean wounds can generally be closed after a longer interval than contaminated or dirty wounds.

Question 43Surgery

Which statement about the initial management of a patient with a suspected tension pneumothorax is correct?

  1. Needle decompression should be performed immediately based on clinical findings Correct answer.
  2. Observation with supplemental oxygen is sufficient if oxygen saturation is above 90%
  3. Chest radiography should be obtained before any decompression
  4. Definitive treatment consists of oral antibiotics and analgesia

Explanation

Tension pneumothorax is a clinical diagnosis and a life-threatening emergency; treatment must not be delayed for imaging. Immediate needle decompression followed by tube thoracostomy is the standard of care.

Question 44Surgery

Which of the following is the most appropriate first step in the local treatment of a superficial partial-thickness burn covering 5% of body surface area?

  1. Application of topical antibiotic ointment under an occlusive plastic wrap
  2. Cool running water irrigation followed by a nonadherent dressing Correct answer.
  3. Application of ice packs directly to the burned skin
  4. Immediate surgical excision and grafting

Explanation

Superficial partial-thickness burns are managed with cooling, gentle cleansing, and a nonadherent dressing that protects the wound while allowing healing. Early grafting is reserved for deeper or larger burns.

Question 45Surgery

Which clinical feature best distinguishes an incarcerated hernia from a strangulated hernia?

  1. A reducible cough impulse
  2. Irreducibility
  3. Presence of systemic signs of ischemia such as severe pain, tenderness, and fever Correct answer.
  4. A soft, nontender swelling

Explanation

Incarceration means the hernia cannot be reduced, whereas strangulation adds compromise of the blood supply with ischemic pain, tenderness, and systemic signs. Strangulation is a surgical emergency requiring urgent exploration.

Question 46Surgery

Which of the following is the most common cause of acute pancreatitis in adults in many populations?

  1. Hyperparathyroidism
  2. Abdominal trauma
  3. Gallstones and alcohol consumption Correct answer.
  4. Viral infection

Explanation

Gallstones and alcohol account for the majority of acute pancreatitis cases in adults. Less common causes include hypertriglyceridemia, medications, hypercalcemia, and trauma.

Question 47Surgery

Which of the following is the most reliable clinical sign of adequate fluid resuscitation in a patient with hypovolemic shock from a gastrointestinal bleed?

  1. Restoration of urine output and improvement in mental status Correct answer.
  2. A decrease in heart rate below 60 beats per minute
  3. Development of peripheral edema
  4. A rise in hemoglobin concentration

Explanation

Adequate resuscitation is judged by clinical endpoints such as urine output, mental status, capillary refill, and hemodynamic stability. Hemoglobin concentration changes lag behind actual blood loss and are unreliable acutely.

Question 48Surgery

A 45-year-old man presents with a firm, painless testicular mass. Which investigation is most appropriate as the initial diagnostic step?

  1. Immediate inguinal orchiectomy without imaging
  2. Scrotal ultrasound Correct answer.
  3. Transscrotal needle biopsy
  4. Serum alpha-fetoprotein and beta-hCG only

Explanation

Scrotal ultrasound reliably distinguishes an intratesticular mass from extratesticular pathology and is the appropriate initial imaging study. Tumor markers support diagnosis and follow-up but do not replace imaging.

Question 49Surgery

A patient develops fever, tachycardia, and abdominal pain 5 days after colorectal surgery. Which complication should be suspected first?

  1. Atelectasis
  2. Deep vein thrombosis
  3. Wound dehiscence
  4. Anastomotic leak Correct answer.

Explanation

An anastomotic leak typically presents around days 3 to 7 after surgery with fever, tachycardia, abdominal pain, and sometimes peritonitis. Prompt evaluation with imaging and possible reoperation is required.

Question 50Surgery

A 60-year-old woman has painless jaundice and a palpable, nontender gallbladder. Which diagnosis should be suspected?

  1. Periampullary malignancy Correct answer.
  2. Acute hepatitis
  3. Acute cholecystitis
  4. Choledocholithiasis with cholangitis

Explanation

Painless jaundice with a palpable, distended gallbladder suggests malignant obstruction of the distal bile duct, such as pancreatic head or periampullary carcinoma. The finding is classically associated with Courvoisier's law.