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Azerbaijan Medical Residents Final Attestation study materials
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Azerbaijan Medical Residents Final Attestation practice questions

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Question 1Internal Medicine (general internal diseases)

A 58-year-old man with chronic obstructive pulmonary disease has a resting arterial blood gas showing pH 7.32, PaCO2 58 mmHg, and bicarbonate 29 mmol/L. Which acid-base disturbance is present?

  1. Mixed respiratory alkalosis
  2. Uncompensated metabolic acidosis
  3. Acute metabolic alkalosis
  4. Compensated respiratory acidosis Correct answer.

Explanation

A raised PaCO2 with acidemia indicates a respiratory acidosis, and the elevated bicarbonate reflects renal retention of base as metabolic compensation. Because the pH is only mildly reduced rather than severely acidic, compensation is partly present.

Question 2Internal Medicine (general internal diseases)

Which finding on physical examination is most characteristic of a large left-sided pleural effusion?

  1. Stony dull percussion note with reduced breath sounds Correct answer.
  2. Hyperresonant percussion note with absent breath sounds
  3. Widespread expiratory wheeze
  4. Fine inspiratory crackles at both bases

Explanation

Fluid in the pleural space dampens sound transmission, producing a stony dull percussion note and diminished breath sounds over the affected area. Vocal resonance is typically reduced as well.

Question 3Internal Medicine (general internal diseases)

A 24-year-old woman reports palpitations and weight loss. Her thyroid function tests show a suppressed TSH with elevated free T4. Which additional finding best supports Graves disease over a toxic nodule?

  1. Diffuse homogeneous goiter with a bruit Correct answer.
  2. Low serum thyroglobulin
  3. A single palpable thyroid nodule
  4. Unilateral exophthalmos only

Explanation

Graves disease is an autoimmune diffuse stimulation of the whole gland, so it typically causes a smooth diffuse goiter and sometimes an audible vascular bruit. A single nodule would instead favor a toxic adenoma.

Question 4Internal Medicine (general internal diseases)

Which electrocardiographic change is the earliest reliable sign of acute transmural myocardial infarction?

  1. Deep symmetrical T-wave inversion
  2. Pathologic Q waves
  3. ST-segment elevation in contiguous leads Correct answer.
  4. Prolonged QT interval

Explanation

ST elevation in leads facing the injured territory reflects acute transmural ischemia and is the finding that should prompt urgent reperfusion. Q waves and T-wave inversion are later or evolving features.

Question 5Internal Medicine (general internal diseases)

A 45-year-old man has a fasting plasma glucose of 7.4 mmol/L on one occasion and no symptoms. What is the most appropriate next step to establish the diagnosis of diabetes mellitus?

  1. Reassure and recheck in five years
  2. Perform an oral glucose tolerance test only if symptomatic
  3. Start insulin therapy immediately
  4. Repeat fasting plasma glucose or measure HbA1c Correct answer.

Explanation

In the absence of classic hyperglycemic symptoms, a single abnormal glucose value is insufficient; the diagnosis requires confirmation by repeating the test or using another validated measure such as HbA1c. Treatment should not begin before confirmation.

Question 6Internal Medicine (general internal diseases)

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

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

Explanation

Streptococcus pneumoniae remains the leading identified cause of community-acquired pneumonia across age groups. It classically produces a lobar consolidation with a rusty sputum.

Question 7Internal Medicine (general internal diseases)

A patient with chronic kidney disease has a hemoglobin of 92 g/L, normal mean corpuscular volume, and low reticulocyte count. Which cause of anemia is most likely?

  1. Hemolytic anemia
  2. Acute blood loss
  3. Iron deficiency
  4. Erythropoietin deficiency Correct answer.

Explanation

The kidneys produce erythropoietin, so advanced chronic kidney disease causes a normocytic normochromic anemia with an inadequate reticulocyte response. Iron studies are usually normal or show functional deficiency.

Question 8Internal Medicine (general internal diseases)

Which physical sign is most specific for ascites on abdominal examination?

  1. Hyperactive bowel sounds
  2. Diffuse abdominal tenderness
  3. Shifting dullness Correct answer.
  4. Visible peristalsis

Explanation

Shifting dullness detects free peritoneal fluid because the dullness moves with gravity when the patient rolls to the side. It is more specific than simple fullness or tenderness.

Question 9Internal Medicine (general internal diseases)

A 30-year-old woman has sudden severe headache, neck stiffness, and photophobia. Which investigation should be performed first if a CT scan is normal?

  1. Electroencephalography
  2. Carotid Doppler ultrasound
  3. Lumbar puncture for cerebrospinal fluid analysis Correct answer.
  4. Serum cortisol measurement

Explanation

The presentation suggests subarachnoid hemorrhage or meningitis, and when cranial imaging is normal a lumbar puncture is needed to examine the cerebrospinal fluid for blood or xanthochromia and for infection.

Question 10Internal Medicine (general internal diseases)

Which laboratory pattern is typical of primary hyperparathyroidism?

  1. Low calcium, high phosphate, high parathyroid hormone
  2. High calcium, low phosphate, high parathyroid hormone Correct answer.
  3. High calcium, high phosphate, low parathyroid hormone
  4. Low calcium, low phosphate, low parathyroid hormone

Explanation

Excess parathyroid hormone mobilizes calcium from bone and increases renal calcium reabsorption while promoting phosphate excretion, so calcium rises and phosphate falls. The hormone level is inappropriately high or normal for the calcium.

Question 11Internal Medicine (general internal diseases)

A 62-year-old smoker has a persistent cough and weight loss. Chest imaging shows a central lung mass, and the serum sodium is 118 mmol/L with concentrated urine. Which mechanism best explains the hyponatremia?

  1. Primary polydipsia
  2. Ectopic antidiuretic hormone secretion Correct answer.
  3. Adrenal insufficiency
  4. Loop diuretic excess

Explanation

Small cell lung cancer commonly secretes antidiuretic hormone ectopically, producing euvolemic hyponatremia with inappropriately concentrated urine. This is the syndrome of inappropriate antidiuresis.

Question 12Internal Medicine (general internal diseases)

Which feature best distinguishes an exacerbation of COPD from acute decompensated heart failure in a patient with both conditions?

  1. Elevated brain natriuretic peptide
  2. Bilateral basal crackles
  3. Purulent sputum with increased dyspnea Correct answer.
  4. Paroxysmal nocturnal dyspnea

Explanation

A change in sputum volume and purulence with worsening breathlessness indicates an infective COPD exacerbation. Heart failure more typically produces crackles, orthopnea, and raised natriuretic peptides.

Question 13Internal Medicine (general internal diseases)

A 35-year-old man has a blood pressure of 168/104 mmHg, hypokalemia, and metabolic alkalosis. Which secondary cause of hypertension should be investigated first?

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

Explanation

Hypertension with spontaneous or diuretic-induced hypokalemia and metabolic alkalosis is the classic presentation of primary aldosteronism. The workup includes the aldosterone-to-renin ratio.

Question 14Internal Medicine (general internal diseases)

Which finding most strongly suggests a diagnosis of infective endocarditis in a patient with a new murmur and fever?

  1. Elevated erythrocyte sedimentation rate
  2. Splinter hemorrhages
  3. Mild leukocytosis
  4. Positive blood cultures drawn from three separate sites Correct answer.

Explanation

Persistent bacteremia documented by multiple blood cultures is a major diagnostic criterion for infective endocarditis. Inflammatory markers and minor skin findings are supportive but nonspecific.

Question 15Internal Medicine (general internal diseases)

A 28-year-old woman has a deep vein thrombosis. Which inherited thrombophilia is most strongly associated with venous thrombosis at a young age?

  1. Glucose-6-phosphate dehydrogenase deficiency
  2. Hereditary spherocytosis
  3. Alpha-1 antitrypsin deficiency
  4. Factor V Leiden mutation Correct answer.

Explanation

Factor V Leiden causes activated protein C resistance and is the most common inherited predisposition to venous thromboembolism. It is particularly relevant in young patients with unprovoked thrombosis.

Question 16Internal Medicine (general internal diseases)

A 70-year-old man has progressive dysphagia for solids and then liquids, with weight loss. Which diagnosis is most likely?

  1. Esophageal carcinoma Correct answer.
  2. Peptic stricture
  3. Gastroesophageal reflux disease
  4. Achalasia

Explanation

Progressive dysphagia that begins with solids and advances to liquids, together with weight loss in an older patient, raises concern for esophageal malignancy. Endoscopy with biopsy is required.

Question 17Internal Medicine (general internal diseases)

Which urinalysis finding best supports a diagnosis of nephritic syndrome?

  1. Sterile pyuria
  2. Broad waxy casts
  3. Red cell casts with dysmorphic red cells Correct answer.
  4. Heavy proteinuria with oval fat bodies

Explanation

Glomerular inflammation allows red cells to enter the tubules, where they form casts; dysmorphic red cells indicate glomerular bleeding. This pattern distinguishes nephritic from nephrotic disease.

Question 18Internal Medicine (general internal diseases)

A patient with atrial fibrillation and a CHA2DS2-VASc score of 4 has no contraindication to anticoagulation. Which treatment is most appropriate for stroke prevention?

  1. No antithrombotic therapy
  2. Dual antiplatelet therapy
  3. Aspirin alone
  4. Oral anticoagulation with a direct oral anticoagulant Correct answer.

Explanation

A high CHA2DS2-VASc score indicates substantial stroke risk, and anticoagulation is recommended. Direct oral anticoagulants are preferred over aspirin or antiplatelets for nonvalvular atrial fibrillation.

Question 19Internal Medicine (general internal diseases)

A 50-year-old man presents with acute severe epigastric pain radiating to the back and a serum lipase three times the upper limit of normal. Which factor is most important in early risk assessment?

  1. Presence of organ failure Correct answer.
  2. History of alcohol use
  3. Serum amylase level
  4. Degree of abdominal tenderness

Explanation

In acute pancreatitis, persistent organ failure defines severe disease and is the strongest determinant of outcome. Amylase levels and tenderness do not correlate reliably with severity.

Question 20Internal Medicine (general internal diseases)

Which finding suggests that a patient with jaundice has obstructive rather than hepatocellular disease?

  1. Low direct bilirubin
  2. Markedly elevated transaminases with normal alkaline phosphatase
  3. Prolonged prothrombin time that corrects with vitamin K
  4. Markedly elevated alkaline phosphatase with modest transaminases Correct answer.

Explanation

Biliary obstruction induces alkaline phosphatase disproportionately, while transaminases rise only modestly. Hepatocellular injury shows the reverse pattern with prominent transaminase elevation.

Question 21Internal Medicine (general internal diseases)

A 60-year-old woman has proximal muscle weakness, a heliotrope rash, and elevated creatine kinase. Which underlying malignancy is most strongly associated with this condition?

  1. Chronic lymphocytic leukemia
  2. Renal cell carcinoma
  3. Ovarian carcinoma Correct answer.
  4. Papillary thyroid carcinoma

Explanation

Dermatomyositis in adults, especially with the classic skin findings, carries a well-recognized association with internal malignancy, and ovarian cancer is among the strongest links in women. Age-appropriate cancer screening is warranted.

Question 22Internal Medicine (general internal diseases)

A 22-year-old man has episodic hypertension, palpitations, diaphoresis, and headache. Which test is the most appropriate initial biochemical screen for pheochromocytoma?

  1. Plasma free metanephrines Correct answer.
  2. Serum cortisol
  3. Urinary albumin-to-creatinine ratio
  4. Plasma renin activity

Explanation

Pheochromocytomas secrete catecholamines that are metabolized to metanephrines, and plasma free metanephrines have high sensitivity for detection. Cortisol and renin assess unrelated endocrine axes.

Question 23Internal Medicine (general internal diseases)

A patient with cirrhosis develops confusion, asterixis, and a raised ammonia level after a gastrointestinal bleed. Which mechanism best explains the encephalopathy?

  1. Bacterial meningitis
  2. Acute cerebral infarction
  3. Hyperglycemic osmotic stress
  4. Increased gut-derived nitrogenous load reaching the brain Correct answer.

Explanation

Blood in the gut is digested into ammonia and other nitrogenous products that the failing liver cannot clear, so they reach the brain and impair neurotransmission. This explains why lactulose and rifaximin reduce the load.

Question 24Internal Medicine (general internal diseases)

A 40-year-old woman has fatigue, arthralgia, a malar rash, and proteinuria. Which serologic test is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA is highly specific for lupus and its titer often tracks disease activity, particularly nephritis. Antinuclear antibody is sensitive but not specific.

Question 25Internal Medicine (general internal diseases)

A 55-year-old man has a serum sodium of 122 mmol/L after several days of excessive water intake. He is asymptomatic and euvolemic. What is the safest initial approach?

  1. Rapid hypertonic saline to raise sodium within hours
  2. Free water intake to dilute the sodium
  3. Fluid restriction with slow correction of sodium Correct answer.
  4. Loop diuretic to excrete water rapidly

Explanation

Asymptomatic chronic hyponatremia should be corrected slowly because rapid rises risk osmotic demyelination. Fluid restriction addresses the dilutional cause, and sodium is allowed to rise gradually.

Question 26Internal Medicine (general internal diseases)

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

  1. ST-segment elevation in the leads facing the infarcted area Correct answer.
  2. Peaked T waves in the precordial leads
  3. Pathological Q waves in the affected leads
  4. T-wave inversion in the affected leads

Explanation

Acute transmural injury produces ST-segment elevation in the leads that face the affected myocardial wall, and this change appears early and guides urgent reperfusion decisions. Peaked T waves may precede it in hyperacute phases but are less reliable, while Q waves and T-wave inversion are later developments.

Question 27Internal Medicine (general internal diseases)

A 45-year-old man has polyuria, polydipsia, and a fasting plasma glucose of 8.4 mmol/L confirmed on a repeat sample. Which diagnosis is established?

  1. Diabetes mellitus Correct answer.
  2. Transient stress hyperglycemia
  3. Impaired fasting glucose
  4. Renal glycosuria

Explanation

A fasting plasma glucose of 7.0 mmol/L or higher on two separate occasions establishes the diagnosis of diabetes mellitus. Confirmation on a repeat sample excludes a single spurious or stress-related value.

Question 28Internal Medicine (general internal diseases)

Which finding on physical examination is most characteristic of a pleural effusion?

  1. Stony dullness to percussion with reduced breath sounds Correct answer.
  2. Widespread expiratory wheeze
  3. Fine inspiratory crackles at the lung bases
  4. Hyperresonance to percussion with reduced breath sounds

Explanation

Fluid in the pleural space dampens sound transmission, producing stony dullness on percussion, decreased tactile vocal fremitus, and reduced breath sounds over the effusion. These signs help distinguish effusion from air or consolidation.

Question 29Internal Medicine (general internal diseases)

A patient with an acute upper gastrointestinal bleed has a pulse of 118/min and a blood pressure of 98/64 mmHg. Which initial step is most appropriate?

  1. Urgent barium swallow study
  2. Discharge with outpatient endoscopy
  3. Immediate oral proton pump inhibitor therapy alone
  4. Rapid intravenous crystalloid resuscitation and cross-matching for blood Correct answer.

Explanation

Hemodynamic instability in acute upper gastrointestinal bleeding requires immediate volume resuscitation with crystalloid and preparation for blood transfusion, followed by urgent endoscopy once stabilized. Airway and circulatory priorities precede diagnostic procedures.

Question 30Internal Medicine (general internal diseases)

A 58-year-old woman has a thyroid-stimulating hormone level below the reference range with an elevated free thyroxine. Which additional finding best supports Graves disease over a toxic nodule?

  1. Elevated serum thyroglobulin
  2. A suppressed thyroid-stimulating hormone level
  3. Diffuse homogeneous uptake on radionuclide scanning Correct answer.
  4. A single palpable nodule in the right lobe

Explanation

Graves disease is an autoimmune process affecting the whole gland, so radionuclide imaging shows diffusely increased homogeneous uptake. A toxic adenoma instead shows a focal area of increased uptake with suppression of the rest of the gland.

Question 31Internal Medicine (general internal diseases)

Which laboratory abnormality is most typical of nephrotic syndrome?

  1. Heavy proteinuria with hypoalbuminemia and hyperlipidemia Correct answer.
  2. Hematuria with red cell casts and hypertension
  3. Metabolic acidosis with a normal anion gap
  4. Sterile pyuria with eosinophiluria

Explanation

Nephrotic syndrome results from increased glomerular permeability to protein, producing proteinuria greater than 3.5 g per day, hypoalbuminemia, edema, and secondary hyperlipidemia. The nephritic pattern instead features hematuria and hypertension.

Question 32Internal Medicine (general internal diseases)

A 35-year-old woman has symmetrical small joint pain, morning stiffness lasting over an hour, and soft tissue swelling of the metacarpophalangeal joints. Which test is most useful to support a diagnosis of rheumatoid arthritis?

  1. Serum uric acid
  2. Antinuclear antibodies
  3. Anti-cyclic citrullinated peptide antibodies Correct answer.
  4. Human leukocyte antigen B27

Explanation

Anti-cyclic citrullinated peptide antibodies are highly specific for rheumatoid arthritis and can appear years before clinical disease. Their presence supports the diagnosis in a patient with a compatible symmetrical small joint pattern.

Question 33Internal Medicine (general internal diseases)

A 68-year-old man has a resting tremor, bradykinesia, rigidity, and a shuffling gait. Which pathophysiological change underlies the condition?

  1. Degeneration of dopaminergic neurons in the substantia nigra Correct answer.
  2. Deposition of amyloid plaques in the cerebral cortex
  3. Loss of motor neurons in the anterior horn
  4. Demyelination of the corticospinal tracts

Explanation

Parkinson disease results from progressive loss of dopaminergic neurons in the substantia nigra pars compacta, reducing striatal dopamine and producing the classic triad of tremor, rigidity, and bradykinesia. Levodopa replacement targets this deficit.

Question 34Internal Medicine (general internal diseases)

A 24-year-old woman has a sudden-onset pleuritic chest pain and dyspnea two weeks after starting a combined oral contraceptive. Which finding is most consistent with a pulmonary embolism?

  1. Hypoxemia with a low probability ventilation-perfusion mismatch pattern on imaging Correct answer.
  2. Elevated D-dimer with a normal chest radiograph and no risk factors
  3. Hypoxemia with hypercapnia and a normal D-dimer
  4. Unilateral leg swelling with a normal D-dimer

Explanation

Pulmonary embolism typically causes hypoxemia, often with a normal chest radiograph, and imaging may show mismatched perfusion defects. The combination of estrogen exposure and pleuritic pain raises clinical probability and warrants further evaluation.

Question 35Internal Medicine (general internal diseases)

A 50-year-old man with a history of alcohol use has confusion, ataxia, and ophthalmoplegia. Which treatment should be given immediately?

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

Explanation

The triad of confusion, ataxia, and ophthalmoplegia suggests Wernicke encephalopathy, a thiamine deficiency state that requires prompt parenteral thiamine. Glucose should be given with thiamine because glucose loading can precipitate or worsen the encephalopathy.

Question 36Internal Medicine (general internal diseases)

Which pattern of arterial blood gases is expected in a patient with an acute exacerbation of asthma?

  1. Metabolic alkalosis with hypoventilation
  2. Respiratory alkalosis with hypoxemia in the early phase Correct answer.
  3. Respiratory acidosis with a normal partial pressure of oxygen
  4. Metabolic acidosis with a high anion gap

Explanation

Acute asthma increases the respiratory rate, lowering the arterial partial pressure of carbon dioxide and producing respiratory alkalosis, while ventilation-perfusion mismatch causes hypoxemia. A normal or rising carbon dioxide level in a severe attack signals impending respiratory failure.

Question 37Internal Medicine (general internal diseases)

A 30-year-old man has a blood pressure of 170/110 mmHg, abdominal bruit, and a creatinine that rose after starting an angiotensin-converting enzyme inhibitor. Which diagnosis should be suspected?

  1. Thyrotoxicosis
  2. Primary aldosteronism
  3. Renal artery stenosis Correct answer.
  4. Pheochromocytoma

Explanation

Renovascular hypertension from renal artery stenosis often presents with resistant hypertension, an abdominal bruit, and a rise in creatinine after angiotensin-converting enzyme inhibition because the stenotic kidney depends on angiotensin II to maintain filtration. Imaging of the renal arteries confirms the diagnosis.

Question 38Internal Medicine (general internal diseases)

A 62-year-old man has a hemoglobin of 78 g/L, a mean corpuscular volume of 108 fL, and a serum vitamin B12 level below normal. Which additional finding is most consistent with B12 deficiency?

  1. Hypersegmented neutrophils on the peripheral blood smear Correct answer.
  2. Target cells and a normal bone marrow
  3. Microcytic red cells with low ferritin
  4. Isolated thrombocytosis with normal red cell indices

Explanation

Vitamin B12 deficiency impairs DNA synthesis and causes megaloblastic anemia with hypersegmented neutrophils and oval macrocytes. Neurological signs such as paresthesias may accompany the hematologic changes.

Question 39Internal Medicine (general internal diseases)

A 55-year-old woman has a serum calcium of 3.1 mmol/L, a normal parathyroid hormone level, and a history of breast cancer. Which mechanism best explains the hypercalcemia?

  1. Parathyroid hormone-related peptide secretion by the tumor Correct answer.
  2. Excessive dietary calcium intake
  3. Vitamin D deficiency
  4. Primary overproduction of parathyroid hormone

Explanation

Humoral hypercalcemia of malignancy is mediated by parathyroid hormone-related peptide, which mimics parathyroid hormone and raises calcium while suppressing the patient's own parathyroid hormone. This pattern is common in solid tumors such as breast and lung carcinoma.

Question 40Internal Medicine (general internal diseases)

A patient with a mechanical mitral valve develops fever and a new regurgitant murmur. Blood cultures grow Staphylococcus aureus. Which finding best supports a diagnosis of infective endocarditis rather than a transient bacteremia?

  1. Vegetation seen on transesophageal echocardiography Correct answer.
  2. A single positive blood culture
  3. A normal white blood cell count
  4. A history of dental cleaning

Explanation

Echocardiographic demonstration of a vegetation on a prosthetic valve, together with persistently positive cultures and a new murmur, fulfills major diagnostic criteria for infective endocarditis. Transesophageal imaging is more sensitive than transthoracic imaging for prosthetic valve involvement.

Question 41Surgery and Surgical Specialties

A 45-year-old man has a 3 cm firm mass in the right lobe of the thyroid and a fine-needle aspiration showing follicular neoplasm. Which operation is the standard initial surgical approach for definitive diagnosis and treatment?

  1. Diagnostic hemithyroidectomy with frozen section or completion thyroidectomy based on histology Correct answer.
  2. Observation with repeat ultrasound in 6 months
  3. Radioactive iodine ablation without surgery
  4. Total thyroidectomy with central neck dissection regardless of histology

Explanation

Follicular neoplasms cannot be classified as benign or malignant by cytology alone because capsular and vascular invasion require histologic assessment. Diagnostic hemithyroidectomy provides the intact specimen needed; if carcinoma is confirmed, completion thyroidectomy is performed. Total thyroidectomy with neck dissection is not justified before malignancy is proven.

Question 42Surgery and Surgical Specialties

Which finding in a patient with acute abdominal pain most strongly suggests perforated peptic ulcer rather than acute pancreatitis?

  1. Hypocalcemia on admission blood tests
  2. Free gas under the diaphragm on an erect chest radiograph Correct answer.
  3. Serum lipase three times the upper limit of normal
  4. Pain radiating to the back with relief on leaning forward

Explanation

Pneumoperitoneum demonstrated by free subdiaphragmatic gas indicates a hollow viscus perforation and is the classic radiologic sign of perforated peptic ulcer. Pancreatitis does not produce free intraperitoneal air, and its hallmark is elevated lipase with epigastric pain radiating to the back.

Question 43Surgery and Surgical Specialties

A 62-year-old woman has a 2.5 cm invasive ductal carcinoma of the left breast, clinically node-negative. Which procedure is the standard approach for axillary staging in this setting?

  1. Supraclavicular lymph node biopsy
  2. Internal mammary chain sampling
  3. Sentinel lymph node biopsy Correct answer.
  4. Routine level III axillary dissection

Explanation

Sentinel lymph node biopsy is the standard for clinically node-negative early breast cancer because it accurately stages the axilla with far less morbidity than full dissection. Axillary lymph node dissection is reserved for clinically positive nodes or a positive sentinel node in selected cases. Level III dissection and internal mammary sampling are not routine staging procedures.

Question 44Surgery and Surgical Specialties

Which parameter is the most reliable early indicator of adequate fluid resuscitation in a young adult with hypovolemic shock from a closed femoral fracture?

  1. Systolic blood pressure alone
  2. Central venous pressure of 15 cm H2O
  3. Hemoglobin concentration measured on admission
  4. Urine output of at least 0.5 mL/kg per hour Correct answer.

Explanation

Urine output reflects renal perfusion and is a sensitive bedside marker of adequate resuscitation, with a target of 0.5 mL/kg per hour in adults. A high central venous pressure does not confirm adequate tissue perfusion and may reflect overfilling or right heart dysfunction. Hemoglobin and blood pressure are unreliable early because of compensatory mechanisms and hemodilution.

Question 45Surgery and Surgical Specialties

A patient develops fever, tachycardia, and a painful erythematous wound with crepitus 4 days after laparotomy. Which organism is most characteristically associated with this presentation?

  1. Clostridium perfringens Correct answer.
  2. Staphylococcus epidermidis
  3. Candida albicans
  4. Escherichia coli

Explanation

Crepitus with rapid systemic toxicity in a surgical wound suggests gas gangrene caused by Clostridium perfringens, an anaerobic spore-forming bacillus. Treatment requires urgent surgical debridement plus high-dose penicillin and supportive care. The other organisms do not typically produce tissue gas and crepitus.

Question 46Surgery and Surgical Specialties

A 30-year-old man has right lower quadrant pain with migration from the umbilicus, fever, and localized peritonitis. Which scoring system is commonly used to stratify the likelihood of acute appendicitis?

  1. Glasgow coma scale
  2. Child-Pugh score
  3. Ranson score
  4. Alvarado score Correct answer.

Explanation

The Alvarado score combines migratory pain, anorexia, nausea, tenderness, rebound tenderness, fever, and leukocytosis to estimate the probability of appendicitis. Child-Pugh assesses hepatic reserve, Ranson predicts pancreatitis severity, and the Glasgow coma scale grades consciousness.

Question 47Surgery and Surgical Specialties

Which feature most reliably distinguishes an indirect inguinal hernia from a direct inguinal hernia on clinical examination?

  1. The hernia emerges through the obturator foramen
  2. The hernia passes through the femoral canal below the inguinal ligament
  3. The defect lies lateral to the inferior epigastric vessels and often enters the scrotum Correct answer.
  4. The defect lies medial to the inferior epigastric vessels

Explanation

Indirect hernias traverse the deep inguinal ring lateral to the inferior epigastric vessels and frequently descend into the scrotum along the spermatic cord. Direct hernias bulge through Hesselbach's triangle medial to those vessels and rarely reach the scrotum. Femoral and obturator hernias follow anatomically distinct routes.

Question 48Surgery and Surgical Specialties

A 70-year-old man has painless gross hematuria and a 2 cm papillary bladder tumor on cystoscopy. Which initial management is most appropriate for a solitary low-grade non-muscle-invasive lesion?

  1. Intravesical BCG without resection
  2. Radical cystectomy
  3. Transurethral resection of the bladder tumor Correct answer.
  4. External beam radiotherapy alone

Explanation

Transurethral resection of the bladder tumor is the diagnostic and therapeutic cornerstone for non-muscle-invasive bladder cancer, establishing grade and stage while removing visible disease. Radical cystectomy is reserved for muscle-invasive or refractory disease. BCG is adjuvant after complete resection, not a substitute for it.

Question 49Surgery and Surgical Specialties

Which finding on contrast-enhanced CT is the most reliable indicator of hemodynamically significant splenic injury requiring intervention in a stable patient?

  1. Active extravasation of contrast material Correct answer.
  2. Small amount of free pelvic fluid
  3. Splenic laceration without perisplenic fluid
  4. Subcapsular hematoma less than 1 cm

Explanation

Active contrast extravasation indicates ongoing arterial bleeding and predicts failure of nonoperative management, often prompting angiography and embolization. Small subcapsular hematomas and minor lacerations usually resolve with observation. Free pelvic fluid alone is nonspecific and may reflect minor hemorrhage.

Question 50Surgery and Surgical Specialties

A 55-year-old woman has a 4 cm pancreatic head mass with painless jaundice and a dilated biliary tree. Which operation offers the best chance of cure if imaging shows no vascular invasion or metastases?

  1. Total pancreatectomy with portal vein resection
  2. Pancreaticoduodenectomy Correct answer.
  3. Palliative biliary stenting alone
  4. Distal pancreatectomy with splenectomy

Explanation

Resectable tumors of the pancreatic head are treated by pancreaticoduodenectomy, which removes the head, duodenum, distal bile duct, and regional nodes. Distal pancreatectomy addresses body and tail lesions, and vascular resection is considered only for borderline-resectable disease. Stenting alone is palliative.