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Egyptian Board Family Medicine study materials
Egyptian Board Family Medicine study resources

Egyptian Board Family Medicine practice questions

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Question 1Family Medicine Principles and Primary Care Practice

A 28-year-old woman attends the family medicine clinic with 3 days of dysuria and urinary frequency, no fever, no flank pain and no vaginal discharge. She is otherwise healthy and not pregnant. Which is the most appropriate initial management for uncomplicated acute cystitis in primary care?

  1. Immediate referral to urology for cystoscopy before any antibiotic is started
  2. A 3-day course of oral nitrofurantoin with advice on hydration and analgesia Correct answer.
  3. A 7-day course of oral ciprofloxacin as first-line therapy
  4. Awaiting urine culture results before prescribing any antimicrobial

Explanation

Uncomplicated cystitis in a non-pregnant woman is treated empirically with a short course of a first-line agent such as nitrofurantoin, together with symptom relief advice. Culture is reserved for treatment failure, recurrence, pregnancy or atypical features. Fluoroquinolones are reserved because of collateral damage and resistance.

Question 2Family Medicine Principles and Primary Care Practice

In a family medicine practice, which measure best expresses the proportion of patients with hypertension whose blood pressure is controlled according to agreed targets?

  1. The mean waiting time for a routine clinic appointment
  2. The number of antihypertensive prescriptions issued per year
  3. The total number of blood pressure readings taken in the clinic
  4. The percentage of registered hypertensive patients whose latest recorded blood pressure is at target Correct answer.

Explanation

A quality indicator for hypertension care is the proportion of the registered hypertensive population achieving the agreed target blood pressure. This is a clinical outcome measure that reflects both detection and treatment. Prescription counts and activity volumes describe workload rather than control.

Question 3Family Medicine Principles and Primary Care Practice

A 6-month-old infant is brought with a 2-day history of watery diarrhoea and vomiting. He is alert, has moist mucous membranes, drinks eagerly and has normal skin turgor. Which management plan is most appropriate in primary care?

  1. Give oral rehydration solution in small frequent amounts and continue breastfeeding Correct answer.
  2. Prescribe an antidiarrhoeal agent to reduce stool frequency
  3. Withhold all fluids except plain water until diarrhoea settles
  4. Admit for intravenous fluids and nil by mouth for 24 hours

Explanation

A child with some dehydration but who is alert and drinking should receive oral rehydration solution, with continued breastfeeding to maintain nutrition and fluid intake. Antidiarrhoeals are contraindicated in young children. Plain water alone does not replace electrolyte losses.

Question 4Family Medicine Principles and Primary Care Practice

Which statement correctly describes the principle of opportunist screening delivered in general practice?

  1. Screening is offered systematically to eligible patients whenever they attend for any reason Correct answer.
  2. Screening is limited to patients attending for a dedicated screening appointment
  3. Screening is offered only to patients who request it during a consultation
  4. Screening is performed only after a specialist has confirmed the patient is at risk

Explanation

Opportunistic screening means offering a test to eligible patients during any routine contact with the practice, rather than waiting for them to request it. It increases coverage in populations that do not attend dedicated programmes. It remains systematic and based on eligibility criteria.

Question 5Family Medicine Principles and Primary Care Practice

A 45-year-old man with no chronic illness asks about lifestyle advice during a routine visit. Which single recommendation has the strongest evidence for reducing cardiovascular risk in a previously healthy adult?

  1. Drinking two glasses of red wine each evening
  2. Stopping smoking and increasing regular physical activity Correct answer.
  3. Avoiding all dietary fats
  4. Taking a daily multivitamin supplement

Explanation

Smoking cessation and regular physical activity are among the lifestyle measures with the strongest evidence for reducing cardiovascular morbidity and mortality. Multivitamins and alcohol have no such protective role, and fat restriction is not equivalent to a cardioprotective diet.

Question 6Family Medicine Principles and Primary Care Practice

Which of the following best defines the concept of continuity of care in family medicine?

  1. An ongoing therapeutic relationship between a patient and a named clinician over time Correct answer.
  2. Seeing any doctor available at the time of each visit
  3. Transferring all chronic disease care to hospital specialists
  4. Restricting each patient to a single consultation per illness episode

Explanation

Continuity of care refers to the sustained relationship between a patient and a clinician or team across time and episodes of illness. It supports accumulated knowledge of the patient's context and better coordination. It is not the same as seeing whoever is available.

Question 7Family Medicine Principles and Primary Care Practice

A 30-year-old woman has a 2-day history of severe unilateral headache with a pulsating quality, nausea and dislike of light. She has had similar episodes before. Which diagnosis is most likely?

  1. Medication-overuse headache
  2. Migraine without aura Correct answer.
  3. Cluster headache
  4. Tension-type headache

Explanation

Recurrent unilateral pulsating headache with nausea and photophobia in a young woman is characteristic of migraine. Tension-type headache is typically bilateral and non-pulsating without prominent nausea. Cluster headache produces short severe attacks with autonomic features around the eye.

Question 8Family Medicine Principles and Primary Care Practice

A 58-year-old woman with type 2 diabetes attends for review. Which parameter should be checked at every routine diabetes review to detect early diabetic kidney disease?

  1. Fasting lipid profile only
  2. Urine albumin-to-creatinine ratio and estimated glomerular filtration rate Correct answer.
  3. Serum calcium and phosphate
  4. Full blood count only

Explanation

Annual assessment of urine albumin-to-creatinine ratio together with estimated glomerular filtration rate detects early diabetic kidney disease. Both markers are needed because albuminuria may precede a fall in filtration rate. Lipids and blood counts are important but do not screen for nephropathy.

Question 9Family Medicine Principles and Primary Care Practice

A 70-year-old man with well-controlled hypertension reports that his blood pressure readings at home are consistently higher than those recorded in the clinic. Which explanation and next step are most appropriate?

  1. This is white-coat effect, so home readings can be ignored
  2. Home devices are unreliable in older adults, so only clinic readings should be used
  3. Home readings may reflect masked hypertension, so ambulatory monitoring and treatment review are warranted Correct answer.
  4. He should stop all antihypertensive medication for two weeks and recheck

Explanation

Higher home than clinic readings suggest masked hypertension, which carries cardiovascular risk and should be confirmed with ambulatory monitoring. Clinic readings alone may underestimate true burden. Abruptly stopping treatment is unsafe.

Question 10Family Medicine Principles and Primary Care Practice

A 24-year-old university student presents with 2 days of sore throat, fever and tonsillar exudate but no cough. A rapid antigen test for group A streptococcus is positive. Which management is most appropriate?

  1. Reassurance and symptomatic treatment only
  2. Oral penicillin for 10 days with analgesia Correct answer.
  3. Immediate tonsillectomy referral
  4. Topical corticosteroid spray alone

Explanation

Confirmed group A streptococcal pharyngitis is treated with a full course of penicillin to shorten illness and prevent complications such as rheumatic fever. Analgesia is added for symptom control. Surgery is reserved for recurrent severe tonsillitis.

Question 11Family Medicine Principles and Primary Care Practice

A 35-year-old woman with no previous illness has a fasting plasma glucose of 6.4 mmol/L on two separate occasions. She is asymptomatic. Which statement is correct?

  1. This is diagnostic of diabetes and drug therapy should be started immediately
  2. This is normal and no action is needed
  3. This requires an oral glucose tolerance test before any lifestyle advice is given
  4. This falls in the impaired fasting glucose range and requires lifestyle intervention with periodic retesting Correct answer.

Explanation

A fasting plasma glucose between 6.1 and 6.9 mmol/L indicates impaired fasting glucose, a prediabetic state managed with lifestyle modification and regular retesting. Diabetes is diagnosed at 7.0 mmol/L or above on two occasions. Lifestyle advice should not be delayed pending further tests.

Question 12Family Medicine Principles and Primary Care Practice

A 62-year-old woman with chronic obstructive pulmonary disease attends for review. Which intervention has the greatest impact on reducing her risk of hospital admission and mortality?

  1. Routine long-term oral corticosteroids
  2. Continuous low-dose antibiotics throughout the year
  3. Annual influenza vaccination and smoking cessation support Correct answer.
  4. Regular chest physiotherapy alone

Explanation

Vaccination and smoking cessation reduce exacerbations, hospital admissions and mortality in COPD and are core components of primary care management. Long-term oral steroids cause harm without proven benefit. Continuous antibiotics are reserved for selected patients with frequent exacerbations.

Question 13Family Medicine Principles and Primary Care Practice

A 3-year-old child is brought with a 2-day history of fever, irritability and pulling at the right ear. Otoscopy shows a bulging, red tympanic membrane. He has no allergies. Which is the most appropriate first-line treatment?

  1. Topical antibiotic ear drops alone
  2. Oral amoxicillin with analgesia Correct answer.
  3. Oral antihistamine and decongestant combination
  4. Observation without analgesia for 72 hours

Explanation

Acute otitis media with a bulging tympanic membrane in a young child warrants oral amoxicillin together with adequate analgesia. Ear drops alone are inadequate for middle-ear infection with an intact drum. Antihistamines and decongestants have no proven benefit.

Question 14Family Medicine Principles and Primary Care Practice

A 50-year-old man with a body mass index of 32 kg/m² and a family history of type 2 diabetes asks how to reduce his risk. Which approach is most strongly supported?

  1. Replacing meals with a very low-calorie diet indefinitely
  2. Taking metformin regardless of glucose values
  3. Starting insulin now to prevent future diabetes
  4. Intensive lifestyle modification targeting 5–10% weight loss and 150 minutes of activity weekly Correct answer.

Explanation

Structured lifestyle programmes achieving modest weight loss and regular physical activity substantially reduce progression to type 2 diabetes in people at high risk. Insulin is not used preventively. Very low-calorie diets are not intended for indefinite use without supervision.

Question 15Family Medicine Principles and Primary Care Practice

A 40-year-old woman presents with a 3-week history of low mood, anhedonia, poor sleep and reduced concentration that is affecting her work. She has no suicidal ideation or psychotic features. Which initial step is most appropriate in primary care?

  1. Structured assessment with supportive counselling and consideration of psychological therapy, with safety-netting Correct answer.
  2. Issuing a long-term sick certificate without further assessment
  3. Immediate referral to psychiatric emergency services
  4. Prescribing an antipsychotic as first-line treatment

Explanation

Moderate depression without risk features is managed in primary care with structured assessment, psychoeducation, psychological therapy and safety-netting, with antidepressants considered according to severity and preference. Emergency referral is reserved for significant risk. Antipsychotics are not first-line for depression.

Question 16Family Medicine Principles and Primary Care Practice

A 65-year-old man with atrial fibrillation has a CHA₂DS₂-VASc score of 3. He has no history of bleeding. What is the most appropriate management regarding stroke prevention?

  1. No anticoagulation because he is over 65
  2. Aspirin alone as adequate prophylaxis
  3. Anticoagulation only if he develops transient ischaemic attack symptoms
  4. Oral anticoagulation with a direct oral anticoagulant or warfarin Correct answer.

Explanation

A CHA₂DS₂-VASc score of 2 or more in a man indicates sufficient stroke risk to recommend oral anticoagulation. Direct oral anticoagulants or warfarin are appropriate; aspirin is not adequate prophylaxis. Anticoagulation should not be deferred until a cerebrovascular event occurs.

Question 17Family Medicine Principles and Primary Care Practice

A 22-year-old woman asks about contraception. She has migraine with aura, is a non-smoker and has no other vascular risk factors. Which contraceptive method is most appropriate?

  1. Combined oral contraceptive pill
  2. Progestogen-only pill or intrauterine device Correct answer.
  3. Combined vaginal ring
  4. Combined contraceptive patch

Explanation

Migraine with aura is a contraindication to combined hormonal contraception because of increased ischaemic stroke risk. Progestogen-only methods and intrauterine devices are suitable alternatives. All combined products, regardless of route, carry the same contraindication.

Question 18Family Medicine Principles and Primary Care Practice

A 55-year-old woman with type 2 diabetes has an HbA1c of 7.2% on metformin monotherapy. She has no hypoglycaemia and no cardiovascular disease. What is the most appropriate next step?

  1. Intensify therapy immediately with basal insulin
  2. Refer for bariatric surgery
  3. Stop metformin and start a sulfonylurea alone
  4. Continue current therapy and reinforce lifestyle measures, reviewing in 3–6 months Correct answer.

Explanation

An HbA1c of 7.2% is close to the usual target of around 7% for most adults, so reinforcing lifestyle measures and reviewing in a few months is appropriate before intensifying therapy. Insulin and surgery are reserved for inadequate control or specific indications.

Question 19Family Medicine Principles and Primary Care Practice

A 68-year-old man attends with his daughter, who reports that he has become increasingly forgetful over 18 months and now struggles with managing his finances. Which initial approach is most appropriate?

  1. Reassure the family that memory loss is normal ageing and review in a year
  2. Take a collateral history, perform cognitive testing and arrange investigations to identify reversible causes Correct answer.
  3. Immediately start a cholinesterase inhibitor without assessment
  4. Refer directly to a memory clinic without any initial assessment

Explanation

Progressive cognitive decline affecting function requires structured assessment including collateral history, cognitive testing and investigations for reversible causes before diagnosis or referral. This distinguishes dementia from delirium, depression and metabolic causes. Immediate prescribing without assessment is inappropriate.

Question 20Family Medicine Principles and Primary Care Practice

A 30-year-old man has a 6-week history of low back pain that is worse at night and at rest, with morning stiffness lasting over an hour. He is 30 years old and has no history of trauma. Which feature most strongly suggests an inflammatory cause requiring further investigation?

  1. Pain that improves with rest
  2. Pain that improves with exercise and is associated with prolonged morning stiffness Correct answer.
  3. Pain that began after lifting a heavy object
  4. Pain that radiates below the knee

Explanation

Inflammatory back pain is characterised by improvement with exercise, worsening with rest, prolonged morning stiffness and onset before age 45. These features warrant investigation for spondyloarthritis. Mechanical pain typically worsens with activity and improves with rest.

Question 21Family Medicine Principles and Primary Care Practice

A 4-year-old child with asthma has been using a short-acting beta-agonist more than three times a week and wakes at night with cough twice a week. What is the most appropriate step in primary care?

  1. Add a long-acting beta-agonist alone
  2. Prescribe a course of oral corticosteroids
  3. Start a regular low-dose inhaled corticosteroid with a written action plan and inhaler technique review Correct answer.
  4. Continue the reliever alone and review in 6 months

Explanation

Frequent reliever use and night-time symptoms indicate inadequate control, so regular low-dose inhaled corticosteroid is indicated with an action plan and technique review. Long-acting beta-agonists are not used alone in asthma. Oral steroids are reserved for acute exacerbations.

Question 22Family Medicine Principles and Primary Care Practice

A 52-year-old woman with a 10-year history of type 2 diabetes attends with a painless, non-healing ulcer on the sole of her foot. Which single examination finding most strongly predicts future ulceration and amputation risk?

  1. Slight ankle oedema
  2. Mild dry skin on the dorsum of the foot
  3. Loss of protective sensation on 10 g monofilament testing Correct answer.
  4. A visible superficial fungal infection between the toes

Explanation

Loss of protective sensation, indicating peripheral neuropathy, is a major predictor of foot ulceration and amputation in diabetes. It impairs the patient's ability to detect injury and pressure. Skin dryness, fungal infection and oedema are relevant but less predictive.

Question 23Family Medicine Principles and Primary Care Practice

A 45-year-old woman with treated hypothyroidism on levothyroxine 100 micrograms daily has a persistently raised TSH and normal free T4. She reports good adherence and takes the tablet with breakfast. What is the most appropriate explanation and action?

  1. The dose is too high and should be reduced
  2. She should switch to liothyronine
  3. Absorption may be impaired by food or medication, so advise taking it on an empty stomach and recheck Correct answer.
  4. No action is needed because free T4 is normal

Explanation

A raised TSH with normal free T4 suggests under-replacement, and levothyroxine absorption is reduced by food, calcium and iron. Advising consistent administration on an empty stomach before reassessment is appropriate. Dose reduction would worsen the picture.

Question 24Family Medicine Principles and Primary Care Practice

A 60-year-old man with heart failure and reduced ejection fraction is stable on an ACE inhibitor and beta-blocker. Which additional agent has been shown to reduce mortality and hospitalisation in this setting?

  1. A mineralocorticoid receptor antagonist such as spironolactone Correct answer.
  2. A dihydropyridine calcium channel blocker such as amlodipine
  3. A thiazolidinedione
  4. A non-steroidal anti-inflammatory drug

Explanation

Mineralocorticoid receptor antagonists reduce mortality and heart failure hospitalisation in patients with reduced ejection fraction who remain symptomatic on standard therapy. Dihydropyridine calcium channel blockers, thiazolidinediones and NSAIDs do not confer this benefit and may worsen heart failure.

Question 25Internal Medicine in Family Practice

A 58-year-old man with type 2 diabetes has an eGFR of 32 mL/min/1.73 m². Which antihyperglycaemic agent should be avoided because it requires dose reduction or avoidance at this level of renal function?

  1. Metformin Correct answer.
  2. Linagliptin
  3. Sitagliptin
  4. Empagliflozin

Explanation

Metformin is cleared renally and accumulates when eGFR falls below 45 mL/min/1.73 m², increasing the risk of lactic acidosis; it is generally stopped below 30 and dose-reduced between 30 and 45. Linagliptin is predominantly biliary and needs no adjustment, while empagliflozin and sitagliptin require dose adjustment rather than outright avoidance at this level.

Question 26Internal Medicine in Family Practice

A 45-year-old woman has a blood pressure of 152/96 mmHg on two separate visits. She has no diabetes, no proteinuria and no target-organ damage. According to standard hypertension guidance, what is the most appropriate initial management?

  1. Salt restriction alone with annual review
  2. Lifestyle modification for three months before any drug therapy
  3. Lifestyle modification plus a single antihypertensive agent Correct answer.
  4. Immediate combination therapy with two agents

Explanation

Grade 1 hypertension without target-organ damage or high cardiovascular risk is managed with lifestyle measures plus a single antihypertensive drug, with thiazide-like diuretics, ACE inhibitors, calcium channel blockers or angiotensin receptor blockers being first-line. Waiting three months before drug therapy is reserved for grade 1 hypertension at low risk, and dual therapy is reserved for high-risk or higher-grade patients.

Question 27Internal Medicine in Family Practice

Which finding in a patient with acute community-acquired pneumonia most strongly suggests that outpatient management is unsafe?

  1. Chest pain on deep inspiration
  2. Productive cough with green sputum
  3. Respiratory rate of 32 breaths per minute Correct answer.
  4. Temperature of 38.4 °C

Explanation

A respiratory rate of 30 breaths per minute or more is a CURB-65 criterion and a marker of severity that favours hospital admission. Fever, purulent sputum and pleuritic pain are common in pneumonia but do not by themselves indicate severe disease.

Question 28Internal Medicine in Family Practice

A 30-year-old woman reports 6 months of fatigue, cold intolerance and weight gain. Examination shows a diffuse goitre. Which test is the single most useful first-line investigation?

  1. Thyroid ultrasound
  2. Antithyroid peroxidase antibodies
  3. Serum free T4 and thyroid-stimulating hormone Correct answer.
  4. Serum thyroglobulin

Explanation

Thyroid-stimulating hormone with free T4 establishes the presence and severity of hypothyroidism and is the standard initial test. Antibody testing and imaging are used to determine aetiology only after biochemical confirmation.

Question 29Internal Medicine in Family Practice

A 62-year-old man with atrial fibrillation and a CHA2DS2-VASc score of 1 (hypertension only) asks about stroke prevention. What is the most appropriate recommendation?

  1. No antithrombotic therapy is needed
  2. An oral anticoagulant Correct answer.
  3. Aspirin 325 mg daily
  4. Aspirin 81 mg daily

Explanation

Current guidance favours oral anticoagulation once the CHA2DS2-VASc score is 1 or more in men, because the stroke reduction outweighs bleeding risk. Aspirin has no established net benefit for stroke prevention in atrial fibrillation and is no longer recommended for this purpose.

Question 30Internal Medicine in Family Practice

Which finding most strongly suggests that a patient's iron-deficiency anaemia is caused by chronic blood loss rather than inadequate intake?

  1. Microcytic hypochromic red cells on the film
  2. Low mean corpuscular volume
  3. Serum ferritin of 8 ng/mL Correct answer.
  4. A low transferrin saturation

Explanation

A very low ferritin confirms depleted iron stores, which in an adult man or postmenopausal woman should prompt a search for gastrointestinal blood loss. The other findings are consistent with iron deficiency but do not distinguish its cause.

Question 31Internal Medicine in Family Practice

A 24-year-old man has an acute asthma exacerbation with a peak expiratory flow of 55% of predicted and no response to two salbutamol nebulisations. Which is the most appropriate next step?

  1. Inhaled corticosteroid dose increase only
  2. Oral prednisolone alone and discharge home
  3. Long-acting beta-agonist inhaler
  4. Ipratropium bromide plus systemic corticosteroid and oxygen Correct answer.

Explanation

Moderate to severe exacerbations are treated with repeated short-acting bronchodilators, ipratropium, systemic corticosteroids and titrated oxygen, with reassessment for admission. Discharge after a poor response is unsafe, and long-acting beta-agonists have no role in acute relief.

Question 32Internal Medicine in Family Practice

Which is the most appropriate first-line treatment for uncomplicated cystitis in a non-pregnant woman with normal renal function?

  1. Amoxicillin for three days
  2. Trimethoprim-sulfamethoxazole for seven days
  3. Nitrofurantoin for five days Correct answer.
  4. Ciprofloxacin for seven days

Explanation

Nitrofurantoin for five days is a recommended first-line option for uncomplicated cystitis because of its efficacy against Escherichia coli and low collateral damage. Fluoroquinolones are reserved for resistant cases, and amoxicillin has poor efficacy because of widespread resistance.

Question 33Internal Medicine in Family Practice

A 70-year-old man on ramipril, furosemide and metformin is admitted with vomiting. His creatinine has risen from 1.0 to 2.1 mg/dL. Which combination best explains a rise in creatinine after vomiting?

  1. Prerenal acute kidney injury from volume depletion Correct answer.
  2. Acute tubular necrosis from metformin
  3. Rhabdomyolysis from furosemide
  4. Acute interstitial nephritis from ramipril

Explanation

Vomiting causes volume depletion, which reduces renal perfusion and produces a prerenal pattern of acute kidney injury with a rising creatinine. Ramipril and furosemide potentiate this by lowering glomerular filtration pressure and further reducing preload.

Question 34Internal Medicine in Family Practice

A 55-year-old man with a 20-pack-year smoking history presents with haemoptysis and a 4 kg weight loss. Chest radiograph shows a right hilar mass. Which investigation provides the most reliable tissue diagnosis?

  1. Bronchoscopy with biopsy Correct answer.
  2. Repeat chest radiograph in six weeks
  3. Serum carcinoembryonic antigen
  4. Sputum cytology

Explanation

Bronchoscopy with biopsy directly samples a central hilar lesion and provides histological confirmation and tumour typing, which determines treatment. Sputum cytology has low sensitivity, and tumour markers do not establish a diagnosis.

Question 35Internal Medicine in Family Practice

A 68-year-old woman with heart failure with reduced ejection fraction (ejection fraction 30%) remains symptomatic despite ramipril and bisoprolol. Which addition has the strongest evidence for reducing mortality?

  1. Amlodipine
  2. Diltiazem
  3. Sacubitril-valsartan Correct answer.
  4. Verapamil

Explanation

Sacubitril-valsartan reduces cardiovascular death and heart failure hospitalisation in reduced ejection fraction and is preferred over an ACE inhibitor in persistently symptomatic patients. Non-dihydropyridine calcium channel blockers are contraindicated because of negative inotropy.

Question 36Internal Medicine in Family Practice

A 35-year-old woman has a 3-month history of fatigue, arthralgia, malar rash and oral ulcers. Which initial serological test best supports a diagnosis of systemic lupus erythematosus?

  1. Anti-cyclic citrullinated peptide
  2. Serum complement C3
  3. Antinuclear antibody Correct answer.
  4. Rheumatoid factor

Explanation

Antinuclear antibody is the most sensitive screening test for systemic lupus erythematosus and a negative result makes the diagnosis very unlikely. Rheumatoid factor and anti-cyclic citrullinated peptide are directed at rheumatoid arthritis, while complement levels reflect disease activity rather than establish the diagnosis.

Question 37Internal Medicine in Family Practice

A 50-year-old man has a fasting plasma glucose of 118 mg/dL and a glycated haemoglobin of 6.0%. He is asymptomatic. What is the correct interpretation?

  1. Normal glucose tolerance
  2. Type 2 diabetes mellitus
  3. Type 1 diabetes mellitus
  4. Prediabetes Correct answer.

Explanation

A fasting glucose between 100 and 125 mg/dL or a glycated haemoglobin between 5.7% and 6.4% defines prediabetes. Diabetes requires a fasting glucose of 126 mg/dL or more, a glycated haemoglobin of 6.5% or more, or a random glucose of 200 mg/dL with symptoms.

Question 38Internal Medicine in Family Practice

A 40-year-old man has a 6-week history of epigastric pain that wakes him at night and is relieved by food. He takes ibuprofen regularly for back pain. What is the most appropriate initial diagnostic step?

  1. Immediate upper gastrointestinal endoscopy
  2. Testing for Helicobacter pylori infection Correct answer.
  3. Serum amylase
  4. Abdominal ultrasound

Explanation

Dyspepsia in a patient under 60 without alarm features is managed by non-invasive testing for Helicobacter pylori and treating if positive. Endoscopy is reserved for alarm features, older age or failure of initial treatment.

Question 39Internal Medicine in Family Practice

A 28-year-old woman has a generalised tonic-clonic seizure. She has had one previous unprovoked seizure 8 months ago. Which statement about starting antiepileptic therapy is most accurate?

  1. Treatment should be deferred until an electroencephalogram is normal
  2. Treatment is never indicated for generalised seizures
  3. Treatment is indicated because two unprovoked seizures define epilepsy Correct answer.
  4. Treatment should be started only after a third unprovoked seizure

Explanation

Two unprovoked seizures more than 24 hours apart establish a diagnosis of epilepsy, and treatment is generally offered after the second seizure because the risk of recurrence is high. An electroencephalogram supports classification but is not a prerequisite for treatment.

Question 40Internal Medicine in Family Practice

A 65-year-old man with chronic obstructive pulmonary disease has an oxygen saturation of 84% on room air during an exacerbation. Which approach to oxygen therapy is safest?

  1. No oxygen unless the patient is confused
  2. Intermittent oxygen only during sleep
  3. Targeted oxygen to keep saturation between 88% and 92% Correct answer.
  4. High-flow oxygen to maintain saturation above 98%

Explanation

In patients with chronic obstructive pulmonary disease at risk of hypercapnia, oxygen should be titrated to a saturation of 88% to 92% to avoid worsening carbon dioxide retention. Uncontrolled high-flow oxygen can precipitate respiratory acidosis.

Question 41Internal Medicine in Family Practice

A 32-year-old woman has a blood pressure of 148/94 mmHg at 20 weeks of gestation with 2+ proteinuria. Which antihypertensive is most appropriate?

  1. Labetalol Correct answer.
  2. Ramipril
  3. Losartan
  4. Spironolactone

Explanation

Labetalol, nifedipine and methyldopa are the preferred antihypertensives in pregnancy. Drugs acting on the renin-angiotensin system are contraindicated because they cause fetal renal failure and oligohydramnios.

Question 42Internal Medicine in Family Practice

A 55-year-old woman with type 2 diabetes has an albumin-to-creatinine ratio of 45 mg/g on two occasions. Which medication slows progression of albuminuria and preserves renal function?

  1. Furosemide
  2. Atenolol
  3. Ramipril Correct answer.
  4. Amlodipine

Explanation

An ACE inhibitor such as ramipril reduces intraglomerular pressure and slows progression of diabetic nephropathy in patients with albuminuria. Calcium channel blockers, beta-blockers and diuretics control blood pressure but lack this specific renoprotective effect.

Question 43Internal Medicine in Family Practice

A 60-year-old man presents with sudden painless loss of vision in the right eye and a cherry-red spot at the macula. What is the most likely diagnosis?

  1. Central retinal artery occlusion Correct answer.
  2. Acute angle-closure glaucoma
  3. Central retinal vein occlusion
  4. Vitreous haemorrhage

Explanation

Sudden painless monocular visual loss with a pale retina and cherry-red spot at the macula is the classic picture of central retinal artery occlusion, an ocular emergency. Central retinal vein occlusion produces a blood-and-thunder fundus with haemorrhages rather than a pale retina.

Question 44Internal Medicine in Family Practice

A 70-year-old woman has a haemoglobin of 9.5 g/dL, an MCV of 105 fL and a normal reticulocyte count. Which cause is most likely?

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

Explanation

Macrocytosis with an inappropriately low reticulocyte count points to impaired marrow production, most commonly vitamin B12 or folate deficiency. Iron deficiency and thalassaemia cause microcytosis, and acute blood loss raises the reticulocyte count.

Question 45Internal Medicine in Family Practice

A 45-year-old man with alcohol-related cirrhosis has ascites. He is on spironolactone and furosemide. Which finding indicates that the diuretic dose is excessive?

  1. A weight loss of 0.4 kg per day
  2. Serum sodium of 134 mmol/L
  3. Rising creatinine with muscle cramps Correct answer.
  4. Serum potassium of 4.0 mmol/L

Explanation

Worsening renal function with cramps or hypotension suggests over-rapid diuresis and requires dose reduction. The target weight loss is about 0.5 kg daily in patients without peripheral oedema, and mild hyponatraemia is common in cirrhosis.

Question 46Internal Medicine in Family Practice

A 30-year-old man has sudden severe headache, neck stiffness and photophobia. He has a temperature of 38.9 °C and a non-blanching petechial rash. What is the most appropriate immediate action?

  1. Computed tomography of the brain before antibiotics
  2. Oral amoxicillin and outpatient review
  3. Intravenous ceftriaxone without waiting for lumbar puncture Correct answer.
  4. Lumbar puncture before any antibiotics

Explanation

Suspected bacterial meningitis with a non-blanching rash is a medical emergency, and empirical intravenous antibiotics must be given immediately after blood cultures, without waiting for lumbar puncture or imaging. Delay increases mortality.

Question 47Internal Medicine in Family Practice

A 55-year-old man with type 2 diabetes has a glycated haemoglobin of 8.9% despite metformin and lifestyle measures. He has established atherosclerotic cardiovascular disease. Which add-on therapy offers cardiovascular benefit?

  1. Glimepiride
  2. Acarbose
  3. Empagliflozin Correct answer.
  4. Pioglitazone

Explanation

SGLT2 inhibitors such as empagliflozin reduce major adverse cardiovascular events and heart failure hospitalisation in patients with established atherosclerotic disease. Sulfonylureas and acarbose lower glucose without proven cardiovascular benefit.

Question 48Internal Medicine in Family Practice

A 65-year-old woman with a history of hypertension presents with sudden-onset severe epigastric pain radiating to the back and a blood pressure of 180/100 mmHg. Which finding on contrast-enhanced computed tomography most strongly supports aortic dissection?

  1. Peripheral ground-glass opacities
  2. A double-lumen appearance with an intimal flap Correct answer.
  3. A fusiform dilatation of the descending aorta
  4. A calcified aortic valve

Explanation

An intimal flap separating a true and false lumen is the diagnostic hallmark of aortic dissection on contrast-enhanced imaging. Fusiform dilatation suggests aneurysm, while the other findings are unrelated to dissection.

Question 49Internal Medicine in Family Practice

A 40-year-old woman with known mitral stenosis becomes breathless with a heart rate of 140 beats per minute and irregular rhythm. Which drug is most appropriate for rate control in this setting?

  1. Amiodarone
  2. Metoprolol Correct answer.
  3. Digoxin
  4. Adenosine

Explanation

In mitral stenosis, tachycardia shortens diastolic filling time and raises left atrial pressure, so beta-blockers such as metoprolol are preferred for rate control. Adenosine is used for narrow-complex tachycardia in sinus rhythm and is ineffective in atrial fibrillation, while digoxin has a slow onset.

Question 50Internal Medicine in Family Practice

A 62-year-old man with type 2 diabetes and a body mass index of 33 kg/m² attends the family medicine clinic. His blood pressure is 152/94 mmHg on three separate visits, and he is not taking any antihypertensive medication. Which class of agent is the most appropriate initial therapy for this patient?

  1. An angiotensin-converting enzyme inhibitor Correct answer.
  2. A beta blocker
  3. A thiazide-type diuretic
  4. An alpha blocker

Explanation

In a patient with diabetes and hypertension, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker is preferred first-line therapy because it slows progression of diabetic nephropathy and reduces cardiovascular events. Thiazides and calcium channel blockers are acceptable add-on or alternative agents, but the renoprotective benefit makes a renin-angiotensin system blocker the strongest initial choice in this profile.