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Arab Board Internal Medicine Clinical Exam study materials
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Arab Board Internal Medicine Clinical Exam practice questions

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Question 1Cardiology

A 58-year-old man with hypertension presents with sudden tearing chest pain radiating to the back. Blood pressure is 190/100 mmHg in the right arm and 150/90 mmHg in the left arm. Which is the most appropriate initial imaging study in a hemodynamically stable patient?

  1. Plain chest radiograph
  2. CT angiography of the aorta Correct answer.
  3. Transthoracic echocardiography
  4. Coronary angiography

Explanation

CT angiography of the aorta is the first-line imaging test for suspected acute aortic dissection in stable patients, with near-unity sensitivity and specificity. It defines the extent, identifies the intimal flap, and guides surgical or endovascular planning.

Question 2Cardiology

Which finding in a patient with suspected infective endocarditis most strongly supports the diagnosis as a minor Duke criterion?

  1. Positive blood cultures for viridans streptococci
  2. Fever above 38.0 degrees Celsius Correct answer.
  3. New mitral regurgitation murmur
  4. Perivalvular abscess on echocardiography

Explanation

Fever is one of the minor modified Duke criteria, along with predisposing heart condition, vascular phenomena, immunologic phenomena, and microbiologic evidence not meeting major criteria. Major criteria include typical organisms in blood cultures and echocardiographic evidence of endocardial involvement.

Question 3Cardiology

A 30-year-old woman has palpitations and a narrow-complex tachycardia at 180 beats per minute that terminates abruptly with intravenous adenosine. Which mechanism best explains the termination?

  1. Direct suppression of atrial ectopic automaticity
  2. Blockade of the sodium current in ventricular myocardium
  3. Vagally mediated reduction in ventricular contractility
  4. Transient AV nodal block interrupting a reentrant circuit that requires the AV node Correct answer.

Explanation

Adenosine produces transient AV nodal conduction block; reentrant supraventricular tachycardias such as AVNRT and AVRT depend on the AV node as part of the circuit, so interrupting conduction terminates them. Its half-life is seconds, making it ideal for diagnosis and acute termination.

Question 4Cardiology

A 72-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. Which anticoagulation strategy is recommended?

  1. Oral anticoagulation with a direct oral anticoagulant or warfarin Correct answer.
  2. Aspirin 81 mg daily alone
  3. Dual antiplatelet therapy with aspirin and clopidogrel
  4. No antithrombotic therapy because of bleeding risk

Explanation

A CHA2DS2-VASc score of 2 or more in men (3 or more in women) is a clear indication for oral anticoagulation to reduce stroke risk. Direct oral anticoagulants are preferred over warfarin in most patients without mechanical valves or moderate-to-severe mitral stenosis.

Question 5Cardiology

Which electrocardiographic finding is most characteristic of acute pericarditis?

  1. Diffuse concave ST-segment elevation with PR-segment depression Correct answer.
  2. Deep Q waves in contiguous leads
  3. Peaked T waves with a shortened QT interval
  4. Reciprocal ST-segment depression in all inferior leads

Explanation

Acute pericarditis typically produces widespread concave ST elevation and PR depression, reflecting diffuse epicardial inflammation. Because the process is not focal, reciprocal changes are limited to aVR and V1 rather than a single coronary territory.

Question 6Cardiology

A 65-year-old woman has exertional dyspnea. Echocardiography shows a mean aortic valve gradient of 48 mmHg, a peak velocity of 4.2 m/s, and an aortic valve area of 0.8 cm2 with normal left ventricular ejection fraction. What is the most appropriate management?

  1. Balloon aortic valvuloplasty as definitive therapy
  2. Aortic valve replacement Correct answer.
  3. Observation with annual echocardiography
  4. Beta-blocker therapy to slow disease progression

Explanation

Severe aortic stenosis is defined by a mean gradient of 40 mmHg or more, peak velocity of 4 m/s or more, or valve area of 1.0 cm2 or less. Symptomatic severe stenosis in a patient with normal ejection fraction warrants aortic valve replacement, which improves survival.

Question 7Cardiology

Which physical examination finding is most specific for cardiac tamponade?

  1. Wide splitting of the second heart sound
  2. Soft first heart sound
  3. Pulsus paradoxus exceeding 10 mmHg Correct answer.
  4. Systolic murmur at the apex

Explanation

Pulsus paradoxus, an inspiratory fall in systolic pressure greater than 10 mmHg, reflects exaggerated ventricular interdependence in tamponade. It is sensitive but also occurs in severe obstructive lung disease, so it must be interpreted with other findings such as elevated jugular venous pressure and tachycardia.

Question 8Cardiology

A 55-year-old man with an anterior ST-elevation myocardial infarction is treated with primary percutaneous coronary intervention. Which medication has been shown to reduce mortality when started early and continued long term?

  1. A dihydropyridine calcium channel blocker
  2. A short-acting nitrate for continuous use
  3. A selective cyclooxygenase-2 inhibitor
  4. An angiotensin-converting enzyme inhibitor Correct answer.

Explanation

Angiotensin-converting enzyme inhibitors reduce mortality and adverse remodeling after myocardial infarction, particularly in anterior infarcts and those with reduced ejection fraction. They should be started early once the patient is hemodynamically stable.

Question 9Cardiology

A 70-year-old woman with heart failure with reduced ejection fraction remains symptomatic despite maximal tolerated doses of an ACE inhibitor and beta-blocker. Her ejection fraction is 30% and she has no significant renal impairment or hyperkalemia. Which addition provides the greatest mortality benefit?

  1. A mineralocorticoid receptor antagonist Correct answer.
  2. A thiazolidinedione
  3. Digoxin
  4. A loop diuretic at higher dose

Explanation

Mineralocorticoid receptor antagonists reduce mortality and hospitalization in patients with heart failure and reduced ejection fraction and are a cornerstone of guideline-directed therapy. They should be added when renal function and potassium permit.

Question 10Cardiology

A 24-year-old athlete collapses during a basketball game and is resuscitated. His father died suddenly at age 35. Electrocardiography shows T-wave inversion in the right precordial leads with a normal QT interval. Which condition is most likely?

  1. Hypertrophic cardiomyopathy
  2. Arrhythmogenic right ventricular cardiomyopathy Correct answer.
  3. Catecholaminergic polymorphic ventricular tachycardia
  4. Long QT syndrome

Explanation

Arrhythmogenic right ventricular cardiomyopathy typically presents with exertional ventricular arrhythmias, right ventricular structural changes, and T-wave inversion in V1 to V3 in the absence of right bundle branch block. It is inherited and associated with sudden cardiac death in young athletes.

Question 11Cardiology

A 68-year-old man presents with syncope. He has a slow, regular pulse of 40 beats per minute. Electrocardiography shows a P wave before each QRS with a constant PR interval of 0.20 seconds and a narrow QRS. Which diagnosis is most likely?

  1. Sinus bradycardia Correct answer.
  2. Third-degree atrioventricular block
  3. Mobitz type I second-degree block
  4. Ventricular escape rhythm

Explanation

A constant PR interval with a 1:1 P-to-QRS relationship and a narrow QRS indicates sinus bradycardia rather than an atrioventricular conduction block. Block would show dropped beats, progressive PR prolongation, or AV dissociation.

Question 12Cardiology

Which echocardiographic finding is the primary diagnostic criterion for heart failure with preserved ejection fraction?

  1. A reduced left ventricular ejection fraction below 40%
  2. Aortic valve area below 1.0 cm2
  3. Severe left ventricular dilatation
  4. Evidence of elevated left ventricular filling pressures with a normal ejection fraction Correct answer.

Explanation

Heart failure with preserved ejection fraction is diagnosed when there are symptoms and signs of heart failure with a normal or near-normal ejection fraction plus objective evidence of elevated filling pressures, such as elevated natriuretic peptides or diastolic dysfunction on echocardiography.

Question 13Cardiology

A 45-year-old man has blood pressure of 168/104 mmHg on three separate visits. He has no symptoms, normal electrolytes, and no evidence of end-organ damage. Which is the most appropriate initial pharmacologic therapy?

  1. Immediate intravenous labetalol infusion
  2. A thiazide-type diuretic, ACE inhibitor, angiotensin receptor blocker, or calcium channel blocker as monotherapy Correct answer.
  3. Observation without treatment for six months
  4. Clonidine started and stopped on alternate days

Explanation

Stage 2 hypertension without end-organ damage is managed with lifestyle measures plus a first-line agent from the thiazide, ACE inhibitor, angiotensin receptor blocker, or calcium channel blocker classes. Combining two agents is often appropriate when blood pressure is 20/10 mmHg or more above target.

Question 14Cardiology

A 60-year-old man with a mechanical mitral valve requires long-term anticoagulation. Which agent is appropriate?

  1. Rivaroxaban
  2. Warfarin with a target INR of 2.5 to 3.5 Correct answer.
  3. Apixaban
  4. Dabigatran

Explanation

Direct oral anticoagulants are contraindicated in patients with mechanical heart valves, where only warfarin has proven efficacy. A mechanical mitral valve requires a higher target INR, generally 2.5 to 3.5, than an aortic valve.

Question 15Cardiology

A 62-year-old man with chronic stable angina develops resting chest pain at 3 a.m. with transient ST-segment elevation that resolves with nitroglycerin. Coronary angiography shows a 50% stenosis of the left anterior descending artery with no thrombus. Which mechanism best explains his presentation?

  1. Microvascular obstruction from embolism
  2. Plaque rupture with thrombosis
  3. Demand ischemia from severe anemia
  4. Coronary vasospasm Correct answer.

Explanation

Transient ST elevation at rest that resolves with nitroglycerin and occurs without a flow-limiting stenosis is characteristic of vasospastic angina. The mechanism is coronary artery smooth muscle hyperreactivity, treated with calcium channel blockers and nitrates.

Question 16Cardiology

Which finding best distinguishes constrictive pericarditis from restrictive cardiomyopathy?

  1. Elevated natriuretic peptide levels
  2. A respirophasic septal bounce with preserved tissue Doppler annular velocities Correct answer.
  3. Reduced left ventricular ejection fraction
  4. Biatrial enlargement

Explanation

Constrictive pericarditis shows exaggerated ventricular interdependence, producing a septal bounce and preserved or increased annular tissue Doppler velocities. Restrictive cardiomyopathy typically shows reduced annular velocities because the myocardium itself is diseased.

Question 17Cardiology

A 35-year-old woman has a blood pressure of 150/95 mmHg, episodic headaches, and palpitations. Plasma metanephrines are markedly elevated. Which is the most appropriate initial imaging study to localize the source?

  1. CT of the abdomen and pelvis Correct answer.
  2. Renal artery duplex ultrasonography
  3. Carotid Doppler ultrasonography
  4. Echocardiography

Explanation

Biochemical evidence of pheochromocytoma should be followed by anatomic imaging of the adrenal glands and abdomen, with CT or MRI being first line. Functional imaging with MIBG or dotatate is used when biochemistry is positive but anatomic imaging is unrevealing.

Question 18Cardiology

Which lipid-lowering strategy is recommended for a patient with established atherosclerotic cardiovascular disease?

  1. High-intensity statin therapy to reduce LDL cholesterol by at least 50% Correct answer.
  2. Bile acid sequestrant monotherapy
  3. Niacin monotherapy
  4. Fibrate monotherapy

Explanation

Patients with clinical atherosclerotic cardiovascular disease benefit from high-intensity statin therapy targeting at least a 50% reduction in LDL cholesterol, with ezetimibe or a PCSK9 inhibitor added if goals are not met. Statins have the strongest evidence for reducing cardiovascular events.

Question 19Cardiology

A 78-year-old woman with a history of syncope has a permanent pacemaker in place. Which finding on the ECG indicates that the pacemaker is capturing the ventricle?

  1. A wide QRS complex immediately following each pacing spike Correct answer.
  2. A pacing spike followed by a P wave only
  3. A pacing spike with no subsequent QRS complex
  4. A narrow QRS complex unrelated to pacing spikes

Explanation

Ventricular capture is confirmed by a wide QRS complex after each pacing spike, because depolarization spreads from the pacing lead through myocardium rather than the conduction system. A spike without a QRS indicates failure to capture.

Question 20Cardiology

A 40-year-old man has a blood pressure of 160/100 mmHg and hypokalemia. He has a high aldosterone concentration with suppressed plasma renin activity. Which is the most appropriate confirmatory test?

  1. Overnight dexamethasone suppression test
  2. Renal artery Doppler ultrasonography
  3. Saline infusion test showing failure to suppress aldosterone Correct answer.
  4. Plasma normetanephrine measurement

Explanation

Primary aldosteronism is confirmed by demonstrating that aldosterone remains elevated despite volume expansion, as with a saline infusion or oral salt loading test. A suppressed renin with elevated aldosterone already suggests the diagnosis, and adrenal imaging then distinguishes adenoma from bilateral hyperplasia.

Question 21Cardiology

Which finding on physical examination is most consistent with severe mitral stenosis?

  1. An opening snap followed by a low-pitched diastolic rumble at the apex Correct answer.
  2. A continuous machinery murmur below the clavicle
  3. A pansystolic murmur radiating to the axilla
  4. A high-pitched early diastolic murmur at the left sternal border

Explanation

Mitral stenosis produces an opening snap and a low-pitched, rumbling mid-diastolic murmur best heard at the apex with the bell in the left lateral decubitus position. The opening snap becomes earlier as the valve becomes more severely stenotic.

Question 22Cardiology

A 50-year-old woman has a pericardial effusion and hypotension. Bedside echocardiography is being performed. Which finding suggests impending tamponade?

  1. Left atrial enlargement
  2. Left ventricular hypertrophy
  3. Aortic valve sclerosis
  4. Right ventricular diastolic collapse Correct answer.

Explanation

Right ventricular diastolic collapse occurs when pericardial pressure exceeds right ventricular filling pressure during early diastole, a sensitive sign of tamponade. Right atrial systolic collapse and inferior vena cava plethora support the diagnosis.

Question 23Cardiology

A 58-year-old man with a prior myocardial infarction is found to have an ejection fraction of 28% after three months of optimal therapy. He is asymptomatic. Which intervention reduces his risk of sudden cardiac death?

  1. Implantation of a cardioverter-defibrillator Correct answer.
  2. Amiodarone started prophylactically
  3. Digoxin started prophylactically
  4. Long-term oral anticoagulation

Explanation

A primary-prevention implantable cardioverter-defibrillator is indicated for patients with ischemic cardiomyopathy and an ejection fraction of 35% or less who remain symptomatic or have not improved after at least three months of optimal medical therapy. It reduces mortality from sudden cardiac death.

Question 24Cardiology

Which mechanism best explains the murmur of hypertrophic obstructive cardiomyopathy?

  1. Left-to-right shunting at the ventricular septum
  2. Regurgitation through a perforated aortic leaflet
  3. Fixed obstruction at the aortic valve level
  4. Dynamic left ventricular outflow tract obstruction exacerbated by reduced preload Correct answer.

Explanation

In hypertrophic obstructive cardiomyopathy, systolic anterior motion of the mitral valve and septal hypertrophy create dynamic outflow obstruction that worsens when preload falls, as with Valsalva or standing. This is why the murmur becomes louder with maneuvers that reduce ventricular volume.

Question 25Pulmonology

A 24-year-old man is brought to the emergency department with sudden-onset pleuritic chest pain and breathlessness. He is tall and thin. Examination shows reduced breath sounds and hyper-resonance over the right hemithorax. Which finding on chest radiography would most strongly support a diagnosis of primary spontaneous pneumothorax?

  1. Diffuse reticulonodular shadowing
  2. Visible visceral pleural line with absence of lung markings beyond it Correct answer.
  3. Bilateral hilar lymphadenopathy
  4. Air-fluid level within a cavity

Explanation

Primary spontaneous pneumothorax classically occurs in tall thin young men and produces a visible visceral pleural edge with no lung markings peripheral to it. Air-fluid level suggests hydropneumothorax, and the other findings reflect different disease processes.

Question 26Pulmonology

A 68-year-old smoker presents with a 3-week history of cough, haemoptysis and weight loss. Chest radiograph shows a right upper lobe mass with ipsilateral hilar enlargement. Which investigation is most appropriate to obtain a tissue diagnosis and stage the mediastinum in the same procedure?

  1. Sputum cytology
  2. Pulmonary function testing
  3. Bronchoalveolar lavage
  4. Contrast-enhanced CT followed by endobronchial ultrasound-guided transbronchial needle aspiration Correct answer.

Explanation

EBUS-TBNA allows sampling of mediastinal and hilar nodes for both diagnosis and staging in a single minimally invasive procedure. Sputum cytology has low sensitivity, and lavage and lung function do not provide staging.

Question 27Pulmonology

A 30-year-old woman with asthma presents with acute severe exacerbation. She can speak only single words, has a respiratory rate of 34/min and oxygen saturation of 89% on air. Which initial management step is most appropriate?

  1. Immediate non-invasive ventilation
  2. Sedation with morphine
  3. Oral antibiotics and observation
  4. Controlled oxygen to target saturation 94-98% with nebulised salbutamol and ipratropium plus systemic corticosteroids Correct answer.

Explanation

Acute severe asthma is managed with titrated oxygen, repeated bronchodilators, ipratropium and early systemic corticosteroids. Antibiotics are only indicated if bacterial infection is suspected, and sedation is contraindicated.

Question 28Pulmonology

A 62-year-old man with COPD has an exacerbation with increased sputum purulence and volume and increased breathlessness. He is not ventilatory-dependent. Which antibiotic choice is most appropriate for initial empirical therapy in a patient with no recent antibiotic exposure and no risk factors for Pseudomonas?

  1. Amoxicillin-clavulanate or a macrolide Correct answer.
  2. Rifampicin
  3. Vancomycin
  4. Metronidazole

Explanation

In COPD exacerbations with all three cardinal symptoms (increased dyspnoea, sputum volume and purulence), antibiotics are indicated; amoxicillin-clavulanate or a macrolide are appropriate first-line choices. Vancomycin, metronidazole and rifampicin target organisms not typical of community COPD exacerbations.

Question 29Pulmonology

A 55-year-old man has a large right-sided pleural effusion. Pleural fluid analysis shows a protein of 48 g/L (serum 70 g/L), LDH 400 U/L and a pH of 7.10 with glucose 2.0 mmol/L. What is the most likely diagnosis?

  1. Chylothorax
  2. Complicated parapneumonic effusion or empyema requiring drainage Correct answer.
  3. Pulmonary embolism with infarction
  4. Transudative effusion due to heart failure

Explanation

A low pleural fluid pH (<7.20), low glucose and high LDH with exudative protein levels indicate a complicated parapneumonic effusion or empyema, which requires chest tube drainage. Transudates have low protein and LDH, and chylothorax is characterised by high triglycerides.

Question 30Pulmonology

A 45-year-old woman presents with fever, productive cough and right lower zone consolidation. She has a CURB-65 score of 0 and is not hypoxic. What is the most appropriate management setting?

  1. Outpatient management with oral amoxicillin Correct answer.
  2. Admission to intensive care
  3. Inpatient intravenous antibiotics
  4. Immediate thoracotomy

Explanation

A CURB-65 score of 0 with no hypoxia indicates low severity, allowing outpatient oral antibiotic therapy such as amoxicillin. Admission and intensive care are reserved for higher severity scores or hypoxia.

Question 31Pulmonology

A 70-year-old man with a history of tuberculosis treated 20 years ago presents with haemoptysis. Chest CT shows a cavity in the upper lobe with a fungal ball and an air crescent sign. What is the most likely diagnosis?

  1. Invasive pulmonary aspergillosis
  2. Allergic bronchopulmonary aspergillosis
  3. Pneumocystis pneumonia
  4. Aspergilloma Correct answer.

Explanation

An aspergilloma is a fungal ball colonising a pre-existing cavity, often from old tuberculosis, and produces the air crescent sign. Invasive aspergillosis occurs in immunocompromised hosts, and ABPA causes central bronchiectasis with asthma.

Question 32Pulmonology

A 35-year-old man has a history of recurrent sinusitis and bronchiectasis. Semen analysis shows immotile sperm. Chest imaging shows situs inversus. What is the most likely diagnosis?

  1. Common variable immunodeficiency
  2. Cystic fibrosis
  3. Alpha-1 antitrypsin deficiency
  4. Primary ciliary dyskinesia Correct answer.

Explanation

The triad of situs inversus, bronchiectasis and immotile cilia (Kartagener syndrome) is characteristic of primary ciliary dyskinesia. Cystic fibrosis causes bronchiectasis and male infertility but not situs inversus.

Question 33Pulmonology

A 60-year-old woman with no smoking history has a pleural effusion. Thoracocentesis shows a lymphocytic exudate with adenosine deaminase (ADA) of 60 U/L. What is the most likely diagnosis?

  1. Tuberculous pleural effusion Correct answer.
  2. Pneumothorax
  3. Pulmonary embolism
  4. Congestive heart failure

Explanation

A lymphocytic exudate with a high ADA level is highly suggestive of tuberculous pleural effusion. Transudates from heart failure have low ADA, and pneumothorax and pulmonary embolism do not produce this pattern.

Question 34Pulmonology

A 25-year-old man is found to have a small (<2 cm) primary spontaneous pneumothorax with no breathlessness and no underlying lung disease. What is the most appropriate management?

  1. Chest drain insertion
  2. Surgical pleurodesis
  3. Intrapleural fibrinolysis
  4. Observation with reassessment Correct answer.

Explanation

A small primary spontaneous pneumothorax in a stable patient without breathlessness can be managed with observation and reassessment. Chest drainage is reserved for larger or symptomatic cases, and surgery is for recurrence or persistent leak.

Question 35Pulmonology

A 58-year-old man has obstructive sleep apnoea. Which investigation is the gold standard for confirming the diagnosis and assessing severity?

  1. Chest radiograph
  2. Spirometry
  3. Daytime arterial blood gas
  4. Overnight polysomnography Correct answer.

Explanation

Overnight polysomnography measuring apnoea-hypopnoea index is the gold standard for diagnosing and grading obstructive sleep apnoea. Spirometry, blood gas and radiography do not quantify apnoeas.

Question 36Pulmonology

A 40-year-old woman presents with fever, dry cough and dyspnoea. She has a history of bird exposure. Chest CT shows bilateral ground-glass opacities. Which of the following is the most likely diagnosis?

  1. Hypersensitivity pneumonitis Correct answer.
  2. Pneumothorax
  3. Lung adenocarcinoma
  4. Pulmonary tuberculosis

Explanation

Bird exposure with fever, cough and bilateral ground-glass opacities suggests hypersensitivity pneumonitis, an immune-mediated reaction to inhaled antigens. Tuberculosis and malignancy do not typically present with this acute antigen-exposure history.

Question 37Pulmonology

A 65-year-old man with COPD has a resting PaO2 of 52 mmHg on room air and cor pulmonale. Which intervention has been shown to improve survival in this setting?

  1. Regular nebulised salbutamol alone
  2. Prophylactic antibiotics
  3. Oral corticosteroids long term
  4. Long-term oxygen therapy for at least 15 hours per day Correct answer.

Explanation

Long-term oxygen therapy improves survival in COPD patients with severe resting hypoxaemia (PaO2 <55 mmHg) and in those with cor pulmonale. Long-term oral steroids and prophylactic antibiotics are not indicated for this purpose.

Question 38Pulmonology

A 28-year-old woman has recurrent episodes of angio-oedema, urticaria and wheeze after exposure to cats. Which mediator is most central to the immediate hypersensitivity reaction?

  1. Interferon-gamma from T cells
  2. Histamine released from mast cells Correct answer.
  3. Leukotriene B4 from neutrophils
  4. Complement C3a only

Explanation

Immediate type I hypersensitivity is mediated by IgE cross-linking on mast cells, triggering histamine release and the clinical features of allergy. Leukotrienes contribute but are not the primary immediate mediator.

Question 39Pulmonology

A 72-year-old man with a 50 pack-year smoking history has severe emphysema with hyperinflation. Which lung function finding is most characteristic?

  1. Restrictive pattern with reduced total lung capacity
  2. Reduced transfer factor (DLCO) with increased residual volume Correct answer.
  3. Normal DLCO with reduced residual volume
  4. Increased DLCO with reduced total lung capacity

Explanation

Emphysema destroys alveolar-capillary membrane, reducing DLCO, and causes air trapping with increased residual volume and total lung capacity. A restrictive pattern and reduced volumes are seen in interstitial disease.

Question 40Pulmonology

A 50-year-old man presents with sudden severe pleuritic chest pain and hypoxaemia. CT pulmonary angiography shows a saddle embolus. He is haemodynamically stable with no right ventricular dysfunction. What is the most appropriate initial treatment?

  1. Inferior vena cava filter
  2. Observation without anticoagulation
  3. Therapeutic anticoagulation with a direct oral anticoagulant or low-molecular-weight heparin Correct answer.
  4. Systemic thrombolysis

Explanation

Haemodynamically stable pulmonary embolism without right ventricular dysfunction is treated with anticoagulation. Thrombolysis and IVC filters are reserved for massive PE or contraindications to anticoagulation.

Question 41Pulmonology

A 45-year-old woman with systemic sclerosis presents with progressive dyspnoea. High-resolution CT shows ground-glass opacities and honeycombing; pulmonary function tests show a restrictive pattern with reduced DLCO. What is the most likely diagnosis?

  1. Bronchial asthma
  2. Idiopathic pulmonary fibrosis
  3. Interstitial lung disease associated with systemic sclerosis Correct answer.
  4. Pulmonary alveolar proteinosis

Explanation

Systemic sclerosis commonly causes interstitial lung disease, usually nonspecific interstitial pneumonia, with restrictive physiology and reduced DLCO. Idiopathic pulmonary fibrosis occurs without a connective tissue disease, and alveolar proteinosis produces a crazy-paving pattern.

Question 42Pulmonology

A 30-year-old man has a first episode of primary spontaneous pneumothorax. After successful drainage, what is the approximate recurrence rate, and which intervention reduces it?

  1. Recurrence is negligible after drainage
  2. About 30-50% recurrence; smoking cessation reduces recurrence Correct answer.
  3. About 5% recurrence; no intervention needed
  4. About 90% recurrence; antibiotics reduce recurrence

Explanation

Primary spontaneous pneumothorax recurs in roughly 30-50% of patients, and smoking cessation significantly reduces recurrence risk. Antibiotics and drainage alone do not prevent recurrence.

Question 43Pulmonology

A 55-year-old man with chronic obstructive pulmonary disease has a PaCO2 of 60 mmHg and pH of 7.28 during an exacerbation. Which management approach is most appropriate for controlled oxygen therapy?

  1. Target oxygen saturation 88-92% with non-invasive ventilation if acidosis persists Correct answer.
  2. Target oxygen saturation 70-75%
  3. Withhold oxygen entirely
  4. Target oxygen saturation 98-100% with high-flow oxygen

Explanation

In COPD with hypercapnic respiratory acidosis, oxygen should be titrated to 88-92% and non-invasive ventilation used if acidosis persists. High-flow oxygen risks worsening hypercapnia, and withholding oxygen is dangerous.

Question 44Pulmonology

A 60-year-old man with a history of asbestos exposure presents with progressive dyspnoea. Chest radiograph shows bilateral pleural plaques and lower-zone reticular opacities. Which malignancy is most strongly associated with asbestos exposure?

  1. Mesothelioma Correct answer.
  2. Carcinoid tumour
  3. Small cell lung cancer
  4. Pulmonary hamartoma

Explanation

Asbestos exposure is strongly associated with malignant mesothelioma, as well as lung cancer and pleural plaques. Carcinoid tumours and hamartomas are not asbestos-related.

Question 45Gastroenterology and Hepatology

A 45-year-old man has recurrent epigastric pain relieved by meals and a positive urea breath test. What is the most appropriate first-line treatment?

  1. Endoscopic clipping of the gastric mucosa
  2. Helicobacter pylori eradication with triple therapy Correct answer.
  3. Long-term H2 receptor antagonist at bedtime
  4. Proton pump inhibitor alone for 8 weeks

Explanation

Active H. pylori infection with symptoms warrants eradication, typically a proton pump inhibitor plus two antibiotics. Eradication heals ulcers and reduces recurrence. Acid suppression alone does not clear the organism.

Question 46Gastroenterology and Hepatology

Which serum marker is the most sensitive initial test for detecting acute hepatitis B infection?

  1. Hepatitis B surface antigen
  2. IgM antibody to hepatitis B core antigen Correct answer.
  3. IgG antibody to hepatitis B core antigen
  4. Hepatitis B e antigen

Explanation

IgM anti-HBc appears early in acute infection and is the most reliable marker of recent infection, including the window period. HBsAg may clear before antibodies appear.

Question 47Gastroenterology and Hepatology

A 60-year-old woman with cirrhosis presents with hematemesis. After resuscitation, which agent should be started before endoscopy?

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

Explanation

Vasoactive drugs such as octreotide reduce portal pressure and should be started early when variceal bleeding is suspected, before endoscopic therapy. They improve control of bleeding and reduce rebleeding.

Question 48Gastroenterology and Hepatology

Which finding on liver biochemistry most suggests an obstructive rather than hepatocellular pattern of injury?

  1. Marked elevation of alkaline phosphatase with modest ALT rise Correct answer.
  2. ALT greater than 1000 U/L with normal alkaline phosphatase
  3. Isolated hyperbilirubinemia with normal enzymes
  4. Low serum albumin with prolonged prothrombin time

Explanation

A cholestatic or obstructive pattern is characterized by predominant elevation of alkaline phosphatase and gamma-glutamyl transferase relative to aminotransferases. Marked ALT elevation points to hepatocellular injury.

Question 49Gastroenterology and Hepatology

A 30-year-old man has bloody diarrhea with mucus, urgency, and continuous rectal involvement on sigmoidoscopy. Which diagnosis is most likely?

  1. Irritable bowel syndrome
  2. Ischemic colitis
  3. Ulcerative colitis Correct answer.
  4. Crohn disease

Explanation

Continuous mucosal inflammation beginning in the rectum with bloody mucoid diarrhea is characteristic of ulcerative colitis. Crohn disease typically shows skip lesions and rectal sparing.

Question 50Gastroenterology and Hepatology

Which test is the most appropriate initial screen for celiac disease in an adult with chronic diarrhea and iron deficiency?

  1. Hydrogen breath test
  2. Anti-tissue transglutaminase IgA with total IgA level Correct answer.
  3. Fecal calprotectin
  4. Antinuclear antibody

Explanation

IgA anti-tissue transglutaminase is the preferred screening serology, and total IgA must be checked because IgA deficiency causes false-negative results. Duodenal biopsy confirms the diagnosis.