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MCCQE Part I study materials
MCCQE Part I study resources

MCCQE Part I practice questions

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Question 1Medical Expert (clinical assessment and management)

A 58-year-old man presents with sudden onset of severe tearing chest pain radiating to the back. Blood pressure is 180/100 mmHg in the right arm and 140/90 mmHg in the left arm. Which is the most appropriate initial diagnostic step?

  1. Immediate CT angiography of the aorta Correct answer.
  2. Treadmill exercise stress testing
  3. Transthoracic echocardiography as the sole imaging modality
  4. D-dimer measurement to exclude pulmonary embolism

Explanation

Interarm blood pressure differential with tearing pain suggests acute aortic dissection, for which CT angiography of the aorta is the diagnostic test of choice. Rapid confirmation is essential because management (blood pressure control and surgery for type A) is time-critical.

Question 2Medical Expert (clinical assessment and management)

Which finding on history most strongly suggests a diagnosis of giant cell (temporal) arteritis in an older adult with headache?

  1. Unilateral nasal discharge with facial tenderness
  2. Jaw claudication while chewing Correct answer.
  3. Bilateral throbbing headache worsened by light
  4. Pain reproduced by neck flexion

Explanation

Jaw claudication reflects ischemia of the masseter muscles and is highly specific for giant cell arteritis. It warrants urgent corticosteroid therapy and temporal artery biopsy.

Question 3Medical Expert (clinical assessment and management)

A 24-year-old woman has a blood pressure of 138/86 mmHg at 12 weeks gestation. Which statement best describes the management of this finding?

  1. It warrants immediate renal artery imaging
  2. It meets criteria for chronic hypertension and requires antihypertensive therapy
  3. It indicates preeclampsia and requires immediate delivery
  4. It is normal for pregnancy and requires routine follow-up only Correct answer.

Explanation

Blood pressure below 140/90 mmHg in early pregnancy is within normal limits; hypertension in pregnancy is defined as at least 140/90 mmHg. Gestational hypertension is diagnosed when elevated pressures first appear after 20 weeks.

Question 4Medical Expert (clinical assessment and management)

A 45-year-old woman reports episodic palpitations, sweating, and headache. Which initial biochemical test is most appropriate to screen for pheochromocytoma?

  1. 24-hour urinary cortisol
  2. Plasma free metanephrines Correct answer.
  3. Serum cortisol at midnight
  4. Serum aldosterone-to-renin ratio

Explanation

Plasma free metanephrines (or 24-hour urinary fractionated metanephrines) are the recommended initial screening tests for pheochromocytoma because of their high sensitivity.

Question 5Medical Expert (clinical assessment and management)

A 30-year-old man has a fasting plasma glucose of 6.4 mmol/L on two occasions. What is the most appropriate next step?

  1. Perform a 75-g oral glucose tolerance test or measure HbA1c Correct answer.
  2. Reassure the patient and repeat fasting glucose in 3 years
  3. Start insulin therapy
  4. Diagnose diabetes and start metformin immediately

Explanation

Fasting glucose of 6.1 to 6.9 mmol/L defines impaired fasting glucose (prediabetes). Confirmatory testing with an oral glucose tolerance test or HbA1c clarifies the diagnosis before any pharmacotherapy.

Question 6Medical Expert (clinical assessment and management)

A 72-year-old woman has a hemoglobin of 88 g/L, MCV 72 fL, and ferritin 8 mcg/L. Which is the most appropriate next step in management?

  1. Transfuse packed red cells immediately
  2. Start vitamin B12 replacement
  3. Begin erythropoietin therapy
  4. Start oral ferrous sulfate and investigate the source of blood loss Correct answer.

Explanation

Microcytic anemia with a low ferritin confirms iron deficiency. In an older adult, iron deficiency requires investigation for gastrointestinal blood loss, and oral iron replacement is first-line.

Question 7Medical Expert (clinical assessment and management)

A 68-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 3. Which management is most appropriate?

  1. Start an oral anticoagulant Correct answer.
  2. No antithrombotic therapy is required
  3. Start aspirin monotherapy
  4. Start dual antiplatelet therapy

Explanation

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

Question 8Medical Expert (clinical assessment and management)

A 3-year-old child presents with fever, drooling, and a muffled voice, sitting forward in a tripod position. Which is the most appropriate immediate action?

  1. Obtain a lateral neck radiograph before any intervention
  2. Give oral antibiotics and discharge home
  3. Inspect the throat with a tongue depressor
  4. Prepare for urgent airway assessment in a controlled setting such as the operating room Correct answer.

Explanation

The presentation suggests epiglottitis with impending airway obstruction. The priority is securing the airway in a controlled environment with anesthesia and otolaryngology present.

Question 9Medical Expert (clinical assessment and management)

A 55-year-old woman has a 2-cm solitary thyroid nodule and a normal TSH. Which is the most appropriate next step?

  1. Thyroid ultrasound and, if indicated, fine-needle aspiration Correct answer.
  2. Total thyroidectomy
  3. Observation with repeat TSH in 1 year
  4. Radioactive iodine ablation

Explanation

A euthyroid solitary nodule is evaluated with ultrasound to characterize features and guide fine-needle aspiration based on size and sonographic risk. Surgery or ablation is reserved for confirmed malignancy or compressive symptoms.

Question 10Medical Expert (clinical assessment and management)

Which is the most appropriate first-line pharmacologic therapy for a 40-year-old with newly diagnosed primary hypertension and no comorbidities?

  1. An alpha blocker
  2. A loop diuretic
  3. A direct renin inhibitor
  4. A thiazide-type diuretic, ACE inhibitor, ARB, or calcium channel blocker Correct answer.

Explanation

Guidelines recommend thiazide-type diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers as first-line agents for uncomplicated hypertension. Choice among them depends on comorbidities and patient factors.

Question 11Medical Expert (clinical assessment and management)

A 26-year-old woman has a blood pressure of 150/95 mmHg and new proteinuria at 34 weeks gestation. Which is the most appropriate management?

  1. Admit for monitoring and administer antenatal corticosteroids if delivery is anticipated before 37 weeks Correct answer.
  2. Perform immediate cesarean delivery regardless of maternal and fetal status
  3. Discharge home with weekly blood pressure checks
  4. Start an ACE inhibitor

Explanation

This is preeclampsia with onset at 34 weeks. Management involves close monitoring, blood pressure control, and corticosteroids for fetal lung maturity if early delivery is likely; delivery timing depends on severity and maternal-fetal status.

Question 12Medical Expert (clinical assessment and management)

A 60-year-old man with COPD has an oxygen saturation of 86% on room air. Which is the most appropriate initial oxygen target?

  1. Withhold oxygen unless saturation falls below 80%
  2. Give high-flow oxygen at 15 L/min by non-rebreather mask
  3. Titrate oxygen to a saturation of 88% to 92% Correct answer.
  4. Titrate oxygen to a saturation above 98%

Explanation

In COPD with chronic hypercapnia risk, oxygen is titrated to 88% to 92% to correct hypoxemia while avoiding hyperoxia-related worsening of hypercapnia.

Question 13Medical Expert (clinical assessment and management)

A 70-year-old woman on warfarin for atrial fibrillation has an INR of 8.5 and no bleeding. Which is the most appropriate management?

  1. Give fresh frozen plasma immediately
  2. Give protamine sulfate
  3. Hold warfarin and give oral vitamin K Correct answer.
  4. Continue warfarin at the same dose

Explanation

An INR above 8 without bleeding is managed by withholding warfarin and administering oral vitamin K. Plasma or factor concentrates are reserved for serious bleeding or very high bleeding risk.

Question 14Medical Expert (clinical assessment and management)

A 22-year-old man has sudden onset of right scrotal pain and swelling with a high-riding testis and absent cremasteric reflex. Which is the most appropriate immediate action?

  1. Urgent urologic consultation for surgical exploration Correct answer.
  2. NSAIDs and outpatient follow-up in 48 hours
  3. Antibiotics for epididymitis
  4. Scrotal ultrasound before any consultation

Explanation

Testicular torsion is a surgical emergency; delay risks testicular loss. Doppler ultrasound may be used when readily available and non-diagnostic, but it should not delay surgical exploration.

Question 15Medical Expert (clinical assessment and management)

A 35-year-old woman has a first episode of unprovoked deep vein thrombosis in the left leg. Which is the most appropriate duration of anticoagulation?

  1. At least 3 months, with consideration of extended therapy after risk-benefit discussion Correct answer.
  2. 2 weeks of therapy
  3. Lifelong anticoagulation for all patients
  4. Anticoagulation only until symptoms resolve

Explanation

Provoked or unprovoked VTE is treated for a minimum of 3 months. Extended anticoagulation is individualized based on bleeding risk and recurrence risk.

Question 16Medical Expert (clinical assessment and management)

A 50-year-old man with a BMI of 34 has a fasting glucose of 7.2 mmol/L and an HbA1c of 6.9%. Which is the most appropriate initial pharmacologic therapy?

  1. Metformin with lifestyle modification Correct answer.
  2. A sulfonylurea as first-line
  3. No pharmacotherapy until HbA1c exceeds 9%
  4. Basal insulin

Explanation

Metformin combined with lifestyle intervention is first-line for most patients with newly diagnosed type 2 diabetes. Insulin or other agents are added when there is significant hyperglycemia or symptoms.

Question 17Medical Expert (clinical assessment and management)

A 65-year-old woman presents with fatigue and a hemoglobin of 105 g/L with MCV 108 fL. Which test is most appropriate to determine the cause?

  1. Serum vitamin B12 and folate levels Correct answer.
  2. Hemoglobin electrophoresis
  3. Reticulocyte count only
  4. Serum ferritin

Explanation

Macrocytic anemia prompts evaluation for B12 and folate deficiency, along with review of medications and alcohol use. Ferritin and electrophoresis evaluate different anemia categories.

Question 18Medical Expert (clinical assessment and management)

A 28-year-old woman has a blood pressure of 160/100 mmHg at 30 weeks gestation with a platelet count of 90 x 10^9/L and elevated liver enzymes. Which is the most likely diagnosis?

  1. Chronic hypertension
  2. Gestational hypertension
  3. HELLP syndrome Correct answer.
  4. Acute fatty liver of pregnancy

Explanation

Hemolysis, elevated liver enzymes, and low platelets in a pregnant woman with hypertension define HELLP syndrome, a severe variant of preeclampsia requiring urgent obstetric management.

Question 19Medical Expert (clinical assessment and management)

A 40-year-old man has a blood pressure of 155/100 mmHg and hypokalemia. Which is the most appropriate screening test for primary aldosteronism?

  1. Plasma aldosterone concentration to plasma renin activity ratio Correct answer.
  2. Plasma metanephrines
  3. Serum TSH
  4. 24-hour urinary free cortisol

Explanation

An elevated aldosterone-to-renin ratio is the screening test for primary aldosteronism, which should be suspected in hypertension with spontaneous or diuretic-induced hypokalemia.

Question 20Medical Expert (clinical assessment and management)

A 75-year-old man with known COPD presents with increased sputum purulence and dyspnea. Which is the most appropriate initial management?

  1. Antibiotics alone
  2. Chest tube insertion
  3. Inhaled bronchodilators, systemic corticosteroids, and antibiotics Correct answer.
  4. Intravenous diuretics

Explanation

An acute COPD exacerbation with increased sputum purulence is treated with bronchodilators, a short course of systemic corticosteroids, and antibiotics. Oxygen should be titrated to target saturation.

Question 21Medical Expert (clinical assessment and management)

A 32-year-old woman has a 3-day history of dysuria and frequency without fever or flank pain. Which is the most appropriate management?

  1. Imaging of the urinary tract
  2. Urine culture and await results before treatment
  3. Empiric oral antibiotics for uncomplicated cystitis Correct answer.
  4. Intravenous antibiotics in hospital

Explanation

Uncomplicated cystitis in a nonpregnant woman is treated empirically with oral antibiotics. Culture is reserved for complicated, recurrent, or treatment-failure cases.

Question 22Medical Expert (clinical assessment and management)

A 55-year-old man with cirrhosis presents with hematemesis. After resuscitation, which is the most appropriate initial pharmacologic therapy?

  1. Intravenous vitamin K alone
  2. Intravenous octreotide and prophylactic antibiotics Correct answer.
  3. Oral beta blocker
  4. Oral lactulose

Explanation

Acute variceal hemorrhage is managed with a vasoactive agent such as octreotide and prophylactic antibiotics, followed by endoscopic therapy. Beta blockers are for prophylaxis, not acute bleeding.

Question 23Medical Expert (clinical assessment and management)

A 68-year-old woman has sudden onset of left-sided weakness and a National Institutes of Health Stroke Scale score of 10, with symptom onset 90 minutes ago. CT head shows no hemorrhage. Which is the most appropriate management?

  1. Observation and repeat CT in 24 hours
  2. Intravenous thrombolysis with alteplase or tenecteplase Correct answer.
  3. Immediate anticoagulation with heparin
  4. Aspirin alone

Explanation

Acute ischemic stroke within the thrombolytic window (up to 4.5 hours) without contraindications warrants intravenous thrombolysis. Aspirin is started after thrombolysis or when thrombolysis is contraindicated.

Question 24Medical Expert (clinical assessment and management)

A 45-year-old man with a history of alcohol use presents with confusion, ataxia, and ophthalmoplegia. Which is the most appropriate immediate treatment?

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

Explanation

Wernicke encephalopathy is a medical emergency requiring prompt parenteral thiamine. Thiamine should be given before or alongside glucose to avoid precipitating or worsening the encephalopathy.

Question 25Medical Expert (clinical assessment and management)

A 60-year-old man has a blood pressure of 170/105 mmHg with severe headache, confusion, and papilledema. Which is the most appropriate management?

  1. Oral antihypertensive therapy and discharge
  2. Controlled blood pressure reduction in an intensive care setting Correct answer.
  3. Observation without treatment
  4. Rapid normalization of blood pressure to normal within 1 hour

Explanation

Hypertensive emergency with end-organ dysfunction requires controlled blood pressure reduction in an intensive care setting, generally by about 25% in the first hour. Overly rapid reduction risks ischemia.

Question 26Medical Expert (clinical assessment and management)

A 24-year-old man presents after an ankle inversion injury. The lateral malleolus is tender and he cannot bear weight. Which imaging decision rule best guides whether radiography is needed?

  1. Wells criteria
  2. Alvarado score
  3. Centor criteria
  4. Ottawa ankle rules Correct answer.

Explanation

The Ottawa ankle rules use malleolar and midfoot tenderness plus inability to bear weight to decide when radiography is indicated after ankle injury. They are validated to reduce unnecessary x-rays without missing fractures.

Question 27Medical Expert (clinical assessment and management)

A 30-year-old woman has a 6-month history of episodic palpitations, sweating, and tremor with documented hypertension. Which initial laboratory test is most appropriate to screen for a secondary cause?

  1. Serum cortisol after overnight dexamethasone
  2. Plasma free metanephrines Correct answer.
  3. Serum thyroid-stimulating hormone
  4. Plasma renin-to-aldosterone ratio

Explanation

Episodic palpitations, diaphoresis, and tremor with hypertension suggest pheochromocytoma, for which plasma free metanephrines are the most sensitive screening test. Biochemical confirmation precedes any imaging.

Question 28Medical Expert (clinical assessment and management)

A 70-year-old man has a serum sodium of 122 mmol/L and has had a seizure. He is confused but hemodynamically stable. Which is the most appropriate initial management?

  1. Hypertonic 3% saline infusion Correct answer.
  2. Oral sodium tablets
  3. Isotonic saline at maintenance rate
  4. Fluid restriction alone

Explanation

Severe symptomatic hyponatremia with seizures is a medical emergency requiring hypertonic saline to raise sodium by a few mmol/L rapidly and stop the seizure. Correction must then be slowed to avoid osmotic demyelination.

Question 29Medical Expert (clinical assessment and management)

A 45-year-old woman has a 3-week history of symmetric small-joint pain and morning stiffness lasting 90 minutes. Which finding is most consistent with rheumatoid arthritis rather than osteoarthritis?

  1. Radiographs showing joint space narrowing with osteophytes
  2. Heberden nodes with DIP joint pain
  3. Pain worsened by activity and relieved by rest
  4. Prolonged morning stiffness with MCP joint swelling Correct answer.

Explanation

Rheumatoid arthritis classically causes inflammatory stiffness lasting more than an hour with MCP and PIP swelling. Osteoarthritis causes brief stiffness, DIP involvement, and osteophytes.

Question 30Medical Expert (clinical assessment and management)

A 55-year-old man has a 2-day history of severe periumbilical pain out of proportion to exam findings and a lactate of 4 mmol/L. Which is the most appropriate next step?

  1. Diagnostic laparoscopy
  2. Urgent CT angiography of the abdomen Correct answer.
  3. Barium swallow study
  4. Serial abdominal exams in 24 hours

Explanation

Pain out of proportion to examination with elevated lactate suggests acute mesenteric ischemia, which requires urgent CT angiography to assess the mesenteric vasculature. Delayed diagnosis increases bowel infarction and mortality.

Question 31Medical Expert (clinical assessment and management)

A 28-year-old woman has a 2-day history of unilateral headache with a dilated pupil and ptosis, and the pain is worse in the evening. Which is the most appropriate diagnostic step?

  1. Temporal artery biopsy
  2. Lumbar puncture
  3. MRI of the brain with MR angiography Correct answer.
  4. Serum cortisol measurement

Explanation

A painful Horner syndrome suggests carotid artery dissection, which requires urgent imaging of the head and neck vasculature. MRI with MR angiography assesses for dissection and other causes.

Question 32Medical Expert (clinical assessment and management)

A 62-year-old man reports nocturia, hesitancy, and a weak stream. He has no red flags. Which is the most appropriate initial assessment?

  1. Digital rectal exam and symptom score Correct answer.
  2. Renal ultrasound
  3. Urinary cytology
  4. Urodynamic studies

Explanation

Lower urinary tract symptoms in men are initially assessed with a digital rectal exam, symptom scoring, and urinalysis to evaluate prostate size and exclude other causes. Further testing is guided by findings.

Question 33Medical Expert (clinical assessment and management)

A 35-year-old woman has a 4-month history of fatigue, weight gain, cold intolerance, and constipation. Which is the most appropriate initial test?

  1. Antinuclear antibody
  2. Serum cortisol
  3. Ferritin
  4. Thyroid-stimulating hormone Correct answer.

Explanation

Symptoms of hypothyroidism warrant a thyroid-stimulating hormone level as the most sensitive initial test of thyroid function. Free T4 is added when TSH is abnormal.

Question 34Medical Expert (clinical assessment and management)

A 50-year-old man has sudden onset of severe tearing chest pain radiating to the back. 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 test?

  1. CT angiography of the aorta Correct answer.
  2. Troponin measurement
  3. D-dimer
  4. Chest radiograph

Explanation

Tearing pain with interarm blood pressure difference suggests aortic dissection, and CT angiography is the diagnostic test of choice in a stable patient. Immediate blood pressure control is initiated in parallel.

Question 35Medical Expert (clinical assessment and management)

A 19-year-old woman has a 3-day history of sore throat, fever, and tonsillar exudates with tender anterior cervical nodes. Which is the most appropriate first step in management?

  1. Immediate empiric amoxicillin
  2. Symptomatic care only
  3. Throat culture without antigen testing
  4. Rapid antigen detection test for group A streptococcus Correct answer.

Explanation

Centor criteria support testing for group A streptococcus before antibiotics. Rapid antigen testing allows prompt treatment when positive while avoiding unnecessary antibiotics.

Question 36Medical Expert (clinical assessment and management)

A 65-year-old man has a 6-month history of progressive dysphagia to solids and a 7-kg weight loss. Which is the most appropriate initial investigation?

  1. Upper endoscopy Correct answer.
  2. Barium swallow
  3. Trial of a proton pump inhibitor
  4. Esophageal manometry

Explanation

Progressive dysphagia with weight loss raises concern for esophageal malignancy and requires urgent upper endoscopy with biopsy. Endoscopy allows direct visualization and tissue diagnosis.

Question 37Medical Expert (clinical assessment and management)

A 3-year-old child has a barking cough, inspiratory stridor, and a hoarse voice after a coryzal illness. He is not drooling and is comfortable. Which is the most appropriate management?

  1. Antibiotics
  2. Immediate intubation
  3. Epinephrine nebulization
  4. Oral dexamethasone Correct answer.

Explanation

The presentation is consistent with croup, and a single dose of dexamethasone reduces airway edema and symptoms. Nebulized epinephrine is added for moderate to severe distress.

Question 38Medical Expert (clinical assessment and management)

A 58-year-old woman has a hemoglobin of 92 g/L and a mean corpuscular volume of 70 fL. Which finding would most suggest iron deficiency rather than thalassemia trait?

  1. Elevated red cell distribution width Correct answer.
  2. Mildly elevated hemoglobin A2
  3. Target cells on smear
  4. Normal ferritin

Explanation

Iron deficiency produces a heterogeneous microcytosis with elevated red cell distribution width, whereas thalassemia trait typically shows a normal distribution width. Ferritin is the more specific discriminator but is not the option here.

Question 39Medical Expert (clinical assessment and management)

A 72-year-old man has a 2-week history of unilateral throbbing headache, jaw claudication, and scalp tenderness. Which is the most appropriate immediate management?

  1. High-dose corticosteroids Correct answer.
  2. Aspirin
  3. Urgent temporal artery biopsy before treatment
  4. Antibiotics

Explanation

Giant cell arteritis risks irreversible vision loss, so high-dose corticosteroids should begin immediately based on clinical suspicion. Biopsy can follow without delaying treatment.

Question 40Medical Expert (clinical assessment and management)

A 40-year-old man has an acute red, painful eye with photophobia and reduced visual acuity. Slit-lamp exam shows cells in the anterior chamber. Which is the most appropriate management?

  1. Topical antibiotics
  2. Warm compresses
  3. Topical anesthetic drops
  4. Topical corticosteroid drops after ophthalmology referral Correct answer.

Explanation

Anterior uveitis with cells in the anterior chamber requires topical corticosteroids and cycloplegia, typically after urgent ophthalmology assessment. Prompt treatment prevents synechiae and vision loss.

Question 41Medical Expert (clinical assessment and management)

A 68-year-old woman has a 2-day history of a painful vesicular rash in a dermatomal distribution on the chest. Which is the most appropriate treatment?

  1. Oral antibiotic
  2. Topical corticosteroid
  3. Oral acyclovir Correct answer.
  4. Topical antifungal

Explanation

Herpes zoster is treated with antiviral therapy, ideally within 72 hours of rash onset, to reduce duration and complications. Acyclovir or valacyclovir are appropriate.

Question 42Medical Expert (clinical assessment and management)

A 25-year-old woman has a 1-day history of right lower quadrant pain, fever, and anorexia. Which is the most appropriate imaging test for suspected appendicitis?

  1. Barium enema
  2. Ultrasound of the abdomen Correct answer.
  3. Upper GI series
  4. Abdominal radiograph

Explanation

Ultrasound is the preferred initial imaging for suspected appendicitis in young women, avoiding radiation while evaluating the appendix and pelvic organs. CT is used when ultrasound is inconclusive.

Question 43Medical Expert (clinical assessment and management)

A 60-year-old man has a blood pressure of 168/98 mmHg, a potassium of 3.1 mmol/L, and an adrenal incidentaloma. Which is the most appropriate screening test?

  1. Aldosterone-to-renin ratio Correct answer.
  2. Overnight dexamethasone suppression test
  3. Serum cortisol
  4. Plasma metanephrines

Explanation

Hypertension with hypokalemia and an adrenal mass suggests primary aldosteronism, screened with the aldosterone-to-renin ratio. Confirmatory testing follows an elevated ratio.

Question 44Medical Expert (clinical assessment and management)

A 55-year-old woman has a 3-day history of right ear pain, fever, and a bulging, erythematous tympanic membrane. Which is the most appropriate treatment?

  1. Topical corticosteroid drops
  2. Topical antibiotic drops
  3. Oral amoxicillin Correct answer.
  4. Observation only

Explanation

Acute otitis media with a bulging tympanic membrane and systemic symptoms warrants oral antibiotics, with amoxicillin as first-line therapy. Analgesia is also important.

Question 45Medical Expert (clinical assessment and management)

A 45-year-old woman has a 2-day history of unilateral facial weakness that spares the forehead, along with ipsilateral arm weakness. Which is the most appropriate next step?

  1. Urgent CT of the head Correct answer.
  2. Antiviral therapy
  3. Reassurance and outpatient follow-up
  4. Oral corticosteroids

Explanation

Forehead sparing with limb weakness indicates an upper motor neuron lesion such as stroke, requiring urgent neuroimaging. Corticosteroids and antivirals are for Bell palsy, which spares the forehead.

Question 46Medical Expert (clinical assessment and management)

A 30-year-old man has a 2-week history of fevers, night sweats, and a painless testicular mass. Which is the most appropriate initial step?

  1. Antibiotics
  2. Scrotal ultrasound Correct answer.
  3. Serum alpha-fetoprotein and beta-hCG
  4. Testicular biopsy

Explanation

A painless testicular mass raises concern for malignancy and is initially evaluated with scrotal ultrasound. Tumor markers and orchiectomy follow confirmation.

Question 47Medical Expert (clinical assessment and management)

A 62-year-old man has a serum creatinine that rose from 100 to 260 micromol/L over 3 days. He has a history of heart failure and takes furosemide and an ACE inhibitor. Which is the most appropriate initial step?

  1. Urgent dialysis
  2. Hold the ACE inhibitor and assess volume status Correct answer.
  3. High-dose furosemide
  4. Intravenous contrast CT of the kidneys

Explanation

Acute kidney injury in a patient on an ACE inhibitor and diuretic requires assessing volume status and holding nephrotoxic medications. This distinguishes prerenal from intrinsic causes before further testing.

Question 48Medical Expert (clinical assessment and management)

A 35-year-old woman has a 2-day history of a painful, red, swollen leg after a long flight. Which is the most appropriate initial diagnostic test?

  1. D-dimer
  2. CT venography
  3. Contrast venography
  4. Compression ultrasound of the leg Correct answer.

Explanation

Compression ultrasound is the standard initial imaging for suspected deep vein thrombosis. It is noninvasive and highly sensitive for proximal thrombosis.

Question 49Medical Expert (clinical assessment and management)

A 50-year-old man has a 3-month history of early satiety, bloating, and a 5-kg weight loss. He has a family history of gastric cancer. Which is the most appropriate next step?

  1. Upper endoscopy with biopsy Correct answer.
  2. Trial of a proton pump inhibitor
  3. Abdominal ultrasound
  4. Helicobacter pylori stool antigen

Explanation

Dyspepsia with weight loss and a family history of gastric cancer are alarm features requiring urgent upper endoscopy. Endoscopy allows direct visualization and biopsy.

Question 50Medical Expert (clinical assessment and management)

A 24-year-old woman has a 1-week history of palpitations and heat intolerance with a diffusely enlarged, tender thyroid and elevated free T4. Which is the most appropriate initial management?

  1. Beta-blocker for symptom control Correct answer.
  2. Methimazole plus levothyroxine
  3. Radioactive iodine ablation
  4. Subtotal thyroidectomy

Explanation

Beta-blockers control adrenergic symptoms such as palpitations and tremor while the underlying thyrotoxicosis is evaluated. Definitive therapy is chosen after the cause is established.