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Egyptian Board Internal Medicine study materials
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Egyptian Board Internal Medicine practice questions

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Question 1Cardiology

A 58-year-old man with a 90-minute history of substernal chest pain has a diagnostic ECG and is diagnosed with ST-elevation myocardial infarction. He presents to a hospital without on-site percutaneous coronary intervention capability, and the transfer time to a PCI centre is estimated at 150 minutes. Which reperfusion strategy is most appropriate?

  1. Transfer for primary PCI without giving any reperfusion therapy
  2. Elective coronary angiography the following morning
  3. Immediate fibrinolysis if there are no contraindications Correct answer.
  4. Observation with serial troponins before deciding on reperfusion

Explanation

When primary PCI cannot be delivered within 120 minutes of first medical contact, immediate fibrinolysis is indicated in STEMI presenting within 12 hours without contraindications, provided it can be given within 30 minutes of diagnosis. A 150-minute predicted transfer clearly exceeds the acceptable PCI delay window.

Question 2Cardiology

A 70-year-old woman with heart failure and reduced ejection fraction has persistent dyspnoea despite maximal tolerated doses of an ACE inhibitor, beta-blocker and mineralocorticoid receptor antagonist. Her eGFR is 55 mL/min/1.73 m² and potassium is 4.6 mmol/L. Which additional agent has the strongest evidence for reducing cardiovascular death and heart failure hospitalisation in this setting?

  1. Ivabradine
  2. Digoxin
  3. Dapagliflozin Correct answer.
  4. Furosemide dose escalation

Explanation

SGLT2 inhibitors such as dapagliflozin reduce cardiovascular death and heart failure hospitalisation in HFrEF when added to standard therapy, and their benefit is independent of diabetes status. They are recommended as part of the four foundational pillars of HFrEF therapy.

Question 3Cardiology

A 24-year-old man collapses during a football match and is resuscitated from ventricular fibrillation. Baseline ECG after resuscitation shows a normal QT interval and no pre-excitation. Echocardiography is structurally normal. Which diagnosis best explains the event?

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

Explanation

CPVT causes adrenergically triggered bidirectional or polymorphic ventricular tachycardia during exertion in a structurally normal heart with a normal resting ECG and QT interval. It typically presents in young people during physical or emotional stress.

Question 4Cardiology

Which ECG finding is the most reliable criterion for left ventricular hypertrophy in a young athletic man?

  1. Cornell voltage criteria with repolarisation changes and left atrial enlargement Correct answer.
  2. Isolated Sokolow-Lyon voltage criteria alone
  3. Sinus bradycardia at rest
  4. Presence of an incomplete right bundle branch block

Explanation

Voltage criteria alone frequently produce false positives in young athletes. Combining voltage with repolarisation abnormalities and left atrial enlargement substantially improves specificity for pathological hypertrophy.

Question 5Cardiology

A 65-year-old man with permanent atrial fibrillation has a CHA2DS2-VASc score of 3. He has no history of bleeding and normal renal function. Which anticoagulation approach is recommended?

  1. Oral anticoagulation with a DOAC or warfarin Correct answer.
  2. Dual antiplatelet therapy
  3. No antithrombotic therapy
  4. Aspirin alone

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates a clear net benefit from oral anticoagulation to prevent stroke. Either a DOAC or a vitamin K antagonist is appropriate, with DOACs generally preferred.

Question 6Cardiology

Which physical examination finding is most characteristic of severe aortic stenosis?

  1. A harsh crescendo-decrescendo systolic murmur at the right upper sternal edge radiating to the carotids Correct answer.
  2. A continuous machinery murmur below the clavicle
  3. An early diastolic murmur at the left sternal edge
  4. A pansystolic murmur at the apex radiating to the axilla

Explanation

Aortic stenosis produces an ejection systolic crescendo-decrescendo murmur loudest at the right second intercostal space, radiating to the carotids, often with a slow-rising low-volume pulse.

Question 7Cardiology

A 30-year-old woman has a blood pressure of 168/104 mmHg and is found to have hypokalaemia and metabolic alkalosis. Which screening test is most appropriate for the suspected cause?

  1. Plasma aldosterone to renin ratio Correct answer.
  2. 24-hour urinary metanephrines
  3. Renal artery Doppler ultrasound
  4. Overnight dexamethasone suppression test

Explanation

Hypertension with spontaneous or diuretic-induced hypokalaemia and metabolic alkalosis suggests primary aldosteronism. The aldosterone-to-renin ratio is the recommended screening test.

Question 8Cardiology

A patient with acute decompensated heart failure is breathless at rest with bibasal crackles and elevated jugular venous pressure. Which intravenous agent is most appropriate for initial symptom relief?

  1. Intravenous amiodarone
  2. Intravenous verapamil
  3. Intravenous furosemide Correct answer.
  4. Intravenous metoprolol

Explanation

Intravenous loop diuretics are the mainstay for relieving congestion and breathlessness in acute decompensated heart failure with volume overload. They should be given early at an adequate dose.

Question 9Cardiology

A 55-year-old man with a mechanical mitral valve is being counselled on anticoagulation. Which regimen is correct?

  1. Warfarin with a target INR of 2.0 to 3.0
  2. A direct oral anticoagulant at standard dose
  3. Aspirin 100 mg daily
  4. Warfarin with a target INR of 2.5 to 3.5 Correct answer.

Explanation

Mechanical mitral valve prostheses require a higher intensity of anticoagulation than aortic prostheses, with a target INR of 2.5 to 3.5. Direct oral anticoagulants are contraindicated with mechanical valves.

Question 10Cardiology

A 48-year-old man presents with sudden tearing interscapular pain and a blood pressure difference of 30 mmHg between arms. Which imaging test is the investigation of choice for suspected acute aortic dissection in a haemodynamically stable patient?

  1. Transthoracic echocardiography
  2. Contrast-enhanced CT angiography of the aorta Correct answer.
  3. Exercise stress testing
  4. Chest radiograph

Explanation

Contrast-enhanced CT angiography of the entire aorta is the first-line investigation in stable patients with suspected aortic dissection because of its high sensitivity and specificity and its ability to define extent and branch involvement.

Question 11Cardiology

Which finding on ambulatory ECG monitoring best supports a diagnosis of sick sinus syndrome in a patient with recurrent syncope?

  1. A sinus pause of 4 seconds associated with syncope Correct answer.
  2. Frequent premature atrial complexes
  3. Sinus bradycardia at 50 bpm during sleep
  4. Nocturnal heart rate variability

Explanation

Sick sinus syndrome is characterised by symptomatic sinus pauses, sinoatrial exit block or chronotropic incompetence. A pause of 3 seconds or more, particularly when it coincides with symptoms, is diagnostic.

Question 12Cardiology

A 60-year-old woman with hypertension develops acute pulmonary oedema with a blood pressure of 200/110 mmHg. Which initial management is most appropriate?

  1. Rapid intravenous fluid bolus
  2. Sublingual nifedipine
  3. Intravenous nitroglycerin with non-invasive ventilation Correct answer.
  4. Intravenous labetalol bolus followed by oral therapy

Explanation

Hypertensive acute pulmonary oedema is managed with vasodilators such as intravenous nitroglycerin together with non-invasive ventilation and diuretics. Afterload reduction rapidly improves pulmonary congestion.

Question 13Cardiology

Which laboratory finding is most consistent with a diagnosis of cardiac troponin elevation due to acute myocardial infarction rather than chronic myocardial injury?

  1. Persistently elevated troponin over several months
  2. A rise and fall in troponin with at least one value above the 99th percentile and a clinical ischaemic feature Correct answer.
  3. A single mildly elevated high-sensitivity troponin value
  4. Elevated creatine kinase without symptoms

Explanation

Acute myocardial infarction requires evidence of myocardial injury with a dynamic rise and/or fall in troponin plus clinical evidence of ischaemia such as symptoms, ECG changes or imaging. A static elevation indicates chronic injury.

Question 14Cardiology

A 45-year-old man has recurrent palpitations with a regular narrow-complex tachycardia at 180 bpm. Vagal manoeuvres fail. He is haemodynamically stable. Which is the most appropriate next step?

  1. Oral bisoprolol
  2. Intravenous adenosine Correct answer.
  3. Intravenous amiodarone infusion
  4. Immediate synchronised DC cardioversion

Explanation

For a stable regular narrow-complex tachycardia after failed vagal manoeuvres, intravenous adenosine is the first-line acute therapy. It terminates most atrioventricular nodal re-entrant and atrioventricular re-entrant tachycardias.

Question 15Cardiology

A 68-year-old man with an inferior STEMI develops bradycardia at 40 bpm with hypotension and no response to atropine. Which intervention is most appropriate?

  1. Intravenous amiodarone
  2. Transcutaneous pacing while arranging transvenous pacing Correct answer.
  3. Isoprenaline infusion as definitive therapy
  4. Immediate implantation of a permanent pacemaker

Explanation

Symptomatic bradycardia unresponsive to atropine in the setting of inferior infarction is managed with transcutaneous pacing as a bridge to transvenous pacing. The conduction disturbance is often transient due to right coronary artery ischaemia.

Question 16Cardiology

Which echocardiographic finding is required to confirm the diagnosis of infective endocarditis in a patient with persistent fever and a prosthetic valve?

  1. Left ventricular hypertrophy
  2. A vegetation or abscess on echocardiography Correct answer.
  3. A pericardial effusion
  4. Diastolic dysfunction

Explanation

A vegetation, abscess, pseudoaneurysm or new valvular dehiscence on echocardiography is a major Duke criterion for infective endocarditis. Transoesophageal echocardiography is preferred in prosthetic valve endocarditis.

Question 17Cardiology

A 72-year-old woman with severe symptomatic aortic stenosis and a logistic EuroSCORE indicating high surgical risk is being considered for intervention. Which factor most strongly favours transcatheter aortic valve implantation over surgical replacement?

  1. Bicuspid aortic valve morphology
  2. Age under 60 years
  3. Severe left ventricular hypertrophy
  4. High surgical risk with suitable transfemoral access Correct answer.

Explanation

TAVI is preferred in patients at high or prohibitive surgical risk with anatomy suitable for the procedure, including adequate transfemoral access. The choice between TAVI and surgery depends largely on surgical risk and anatomical suitability.

Question 18Cardiology

A 35-year-old woman has a blood pressure of 150/95 mmHg and a family history of early-onset hypertension. Which secondary cause should be specifically considered?

  1. Primary aldosteronism
  2. Phaeochromocytoma
  3. Fibromuscular dysplasia of the renal arteries Correct answer.
  4. Cushing syndrome

Explanation

Fibromuscular dysplasia is a non-inflammatory, non-atherosclerotic arteriopathy that predominantly affects young women and causes renovascular hypertension. It should be considered in young women with hypertension, particularly with an abdominal bruit.

Question 19Cardiology

Which class of antiarrhythmic drug is contraindicated in patients with structural heart disease and reduced ejection fraction because of increased mortality?

  1. Amiodarone
  2. Beta-blockers
  3. Class II agents
  4. Class IC agents such as flecainide Correct answer.

Explanation

Class IC agents such as flecainide and propafenone are contraindicated in structural heart disease with reduced ejection fraction because of proarrhythmia and increased mortality, as shown in the CAST trial.

Question 20Cardiology

A 50-year-old man with dilated cardiomyopathy has an ejection fraction of 30% after three months of optimal medical therapy and remains symptomatic with NYHA class II symptoms. Which device is indicated for primary prevention of sudden cardiac death?

  1. Permanent pacemaker
  2. Implantable cardioverter-defibrillator Correct answer.
  3. Cardiac resynchronisation therapy alone
  4. Implantable loop recorder

Explanation

An implantable cardioverter-defibrillator is indicated for primary prevention in patients with symptomatic heart failure and an ejection fraction of 35% or less despite at least three months of optimal medical therapy. Cardiac resynchronisation is added only if there is a broad QRS with left bundle branch block.

Question 21Cardiology

A patient with known hypertrophic cardiomyopathy is being assessed for risk of sudden cardiac death. Which feature is a recognised major risk marker?

  1. A resting heart rate of 60 bpm
  2. A family history of sudden cardiac death in a first-degree relative Correct answer.
  3. A maximum left ventricular wall thickness of 12 mm
  4. Mild mitral regurgitation

Explanation

A family history of sudden cardiac death in a first-degree relative is a major risk marker in hypertrophic cardiomyopathy and contributes to the decision for ICD implantation. Other markers include extreme hypertrophy, unexplained syncope and non-sustained ventricular tachycardia.

Question 22Cardiology

A 40-year-old woman with systemic lupus erythematosus presents with pleuritic chest pain, fever and a pericardial friction rub. Echocardiography shows a small pericardial effusion without tamponade. Which is the most appropriate initial management?

  1. High-dose NSAIDs with colchicine Correct answer.
  2. Intravenous thrombolysis
  3. Emergency pericardiocentesis
  4. Pericardial window surgery

Explanation

Acute pericarditis in connective tissue disease is treated with high-dose NSAIDs plus colchicine as first-line anti-inflammatory therapy. Pericardiocentesis is reserved for tamponade or diagnostic uncertainty.

Question 23Cardiology

Which lipid target is recommended for a patient with established atherosclerotic cardiovascular disease on high-intensity statin therapy?

  1. LDL cholesterol below 3.0 mmol/L
  2. Total cholesterol below 5.0 mmol/L
  3. Triglycerides below 1.7 mmol/L only
  4. LDL cholesterol below 1.4 mmol/L with at least a 50% reduction from baseline Correct answer.

Explanation

Guidelines recommend an LDL cholesterol target of below 1.4 mmol/L (about 55 mg/dL) with at least a 50% reduction from baseline for very high-risk patients with established atherosclerotic cardiovascular disease.

Question 24Cardiology

A 70-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 1 (hypertension only) and a HAS-BLED score of 3. Which is the most appropriate approach to anticoagulation?

  1. Use aspirin plus a proton pump inhibitor
  2. Offer anticoagulation, addressing modifiable bleeding risk factors Correct answer.
  3. Withhold anticoagulation because of the high HAS-BLED score
  4. Start dual antiplatelet therapy

Explanation

A high HAS-BLED score is not a reason to withhold anticoagulation; it should prompt correction of modifiable bleeding risk factors and closer follow-up. A CHA2DS2-VASc score of 1 in men is generally an indication to consider anticoagulation.

Question 25Chest and Respiratory Medicine

A 24-year-old man presents with sudden-onset right-sided pleuritic chest pain and breathlessness. He is tall and thin. Examination shows reduced breath sounds and hyper-resonance over the right hemithorax. Chest radiograph confirms a pneumothorax with visible lung edge but no mediastinal shift. What is the most appropriate initial management?

  1. Chest tube insertion under water seal
  2. Immediate surgical thoracotomy
  3. Observation with supplemental oxygen and reassessment Correct answer.
  4. Needle decompression in the second intercostal space

Explanation

A small primary spontaneous pneumothorax without haemodynamic compromise or mediastinal shift can be managed conservatively with oxygen and observation, since many resolve spontaneously. Needle decompression and chest tube insertion are reserved for tension pneumothorax or symptomatic/large pneumothorax. Thoracotomy is never an emergency initial step.

Question 26Chest and Respiratory Medicine

Which of the following is the most common cause of community-acquired pneumonia requiring hospital admission in adults?

  1. Legionella pneumophila
  2. Streptococcus pneumoniae Correct answer.
  3. Mycoplasma pneumoniae
  4. Chlamydophila psittaci

Explanation

Streptococcus pneumoniae remains the single most frequently identified pathogen in community-acquired pneumonia across all severity levels, including patients requiring admission. Atypical organisms such as Mycoplasma and Legionella are important but less common overall. Psittacosis is rare and linked to bird exposure.

Question 27Chest and Respiratory Medicine

A 55-year-old smoker has a chronic productive cough for three months each year for two consecutive years, with no other cause identified. Spirometry shows an FEV1/FVC ratio of 0.65. Which diagnosis best fits?

  1. Bronchiectasis
  2. Chronic obstructive pulmonary disease Correct answer.
  3. Interstitial lung disease
  4. Asthma

Explanation

Chronic bronchitis is defined clinically by productive cough for at least three months in two consecutive years, and a post-bronchodilator FEV1/FVC below 0.70 confirms persistent airflow obstruction, i.e. COPD. Asthma typically shows reversibility and lacks the chronic productive cough pattern. Bronchiectasis and interstitial disease have different imaging and physiological features.

Question 28Chest and Respiratory Medicine

Which finding on arterial blood gas most strongly suggests a diagnosis of pulmonary embolism in a breathless patient?

  1. Metabolic acidosis with hyperkalaemia
  2. Respiratory acidosis with hypercapnia
  3. Respiratory alkalosis with hypoxaemia Correct answer.
  4. Metabolic alkalosis with hypochloraemia

Explanation

Pulmonary embolism typically causes hyperventilation leading to a fall in PaCO2 and a respiratory alkalosis, often with hypoxaemia. Although none of these findings is specific, the combination of respiratory alkalosis and hypoxaemia raises suspicion. Hypercapnic respiratory acidosis and metabolic disturbances are not characteristic.

Question 29Chest and Respiratory Medicine

A patient with asthma uses a short-acting beta-2 agonist more than three times per week and wakes at night once a week. What is the most appropriate step in management?

  1. Add a low-dose inhaled corticosteroid Correct answer.
  2. Add a long-acting beta-2 agonist alone
  3. Continue as-needed SABA alone
  4. Start oral prednisolone long term

Explanation

Frequent SABA use and nocturnal symptoms indicate inadequately controlled asthma, and inhaled corticosteroids are the cornerstone of controller therapy. Low-dose ICS reduces exacerbations and improves control. Long-acting beta-2 agonists should never be used as monotherapy in asthma because of safety concerns, and long-term oral steroids are inappropriate.

Question 30Chest and Respiratory Medicine

Which is the most appropriate initial investigation for suspected obstructive sleep apnoea?

  1. Overnight polysomnography or home sleep apnoea testing Correct answer.
  2. Bronchoscopy
  3. Awake arterial blood gas
  4. Chest radiograph

Explanation

The diagnosis of obstructive sleep apnoea requires objective measurement of apnoea-hypopnoea events during sleep, obtained by polysomnography or validated home sleep testing. Awake blood gas and imaging do not establish the diagnosis. Bronchoscopy has no role in OSA assessment.

Question 31Chest and Respiratory Medicine

A 68-year-old man with known COPD presents with worsening breathlessness and increased purulent sputum. Arterial blood gas on room air shows pH 7.28, PaCO2 68 mmHg, PaO2 52 mmHg. What is the most appropriate first-line oxygen therapy target?

  1. Controlled oxygen to target SpO2 of 88-92% Correct answer.
  2. Target SpO2 of 99-100%
  3. No oxygen therapy at all
  4. High-flow nasal oxygen at 60 L/min immediately

Explanation

In acute exacerbations of COPD with hypercapnic respiratory acidosis, controlled oxygen therapy targeting SpO2 88-92% is recommended to avoid worsening hypercapnia while correcting hypoxaemia. Overly high oxygen can worsen CO2 retention. High-flow therapy is reserved for selected cases after initial stabilisation.

Question 32Chest and Respiratory Medicine

A 30-year-old woman has recurrent episodes of wheeze and breathlessness triggered by cold air and exercise. Spirometry shows FEV1/FVC 0.72 with a 15% improvement in FEV1 after salbutamol. Which feature best supports asthma over COPD?

  1. Progressive dyspnoea with smoking history of 40 pack-years
  2. Age under 40 at onset with significant bronchodilator reversibility Correct answer.
  3. Hyperinflation on chest radiograph
  4. Chronic productive cough for years

Explanation

Asthma characteristically begins in younger patients and demonstrates significant bronchodilator reversibility, whereas COPD is associated with older age, significant smoking history and progressive fixed airflow obstruction. Chronic productive cough, heavy smoking and hyperinflation favour COPD.

Question 33Chest and Respiratory Medicine

A 45-year-old presents with fever, productive cough and a chest radiograph showing right lower lobe consolidation with air bronchograms. Which feature best distinguishes lobar pneumonia from atelectasis on imaging?

  1. Volume loss of the affected lobe
  2. Presence of a pleural effusion
  3. Shift of the mediastinum toward the opacity
  4. Presence of air bronchograms Correct answer.

Explanation

Air bronchograms occur when alveoli are filled with exudate while bronchi remain air-filled, which is characteristic of consolidation such as pneumonia. Atelectasis typically shows volume loss with mediastinal shift toward the affected side and crowded vessels, and air bronchograms are less prominent.

Question 34Chest and Respiratory Medicine

A patient with a large pleural effusion has a diagnostic thoracentesis. Which finding most strongly indicates an exudate by Light's criteria?

  1. Pleural fluid LDH below two-thirds of the upper normal serum limit
  2. Pleural fluid protein/serum protein ratio of 0.6 Correct answer.
  3. Pleural fluid pH of 7.45
  4. Pleural fluid glucose of 90 mg/dL

Explanation

Light's criteria classify an effusion as exudative if the pleural protein/serum protein ratio exceeds 0.5, the pleural/serum LDH ratio exceeds 0.6, or pleural LDH exceeds two-thirds of the upper normal serum limit. A protein ratio of 0.6 satisfies the protein criterion. Normal glucose, low LDH and alkaline pH do not indicate exudate.

Question 35Chest and Respiratory Medicine

A 60-year-old man with a history of unprovoked deep vein thrombosis presents with pleuritic chest pain. CT pulmonary angiography confirms bilateral pulmonary emboli. He is haemodynamically stable. What is the most appropriate initial anticoagulant strategy?

  1. Aspirin 300 mg daily
  2. Prophylactic-dose low-molecular-weight heparin
  3. Systemic thrombolysis
  4. Therapeutic low-molecular-weight heparin or a direct oral anticoagulant Correct answer.

Explanation

For haemodynamically stable pulmonary embolism, therapeutic anticoagulation with low-molecular-weight heparin or a direct oral anticoagulant is standard. Prophylactic dosing is inadequate, aspirin is not an anticoagulant, and thrombolysis is reserved for haemodynamic instability or massive PE.

Question 36Chest and Respiratory Medicine

A 70-year-old man has a 3 cm peripheral lung nodule with no mediastinal lymphadenopathy on CT and no distant metastases. Which investigation is most appropriate to obtain a tissue diagnosis?

  1. CT-guided percutaneous transthoracic biopsy Correct answer.
  2. Sputum cytology alone
  3. Open thoracotomy as first step
  4. Bronchoscopy with endobronchial biopsy

Explanation

For a peripheral lung lesion without endobronchial involvement, CT-guided percutaneous biopsy offers the highest diagnostic yield with acceptable safety. Sputum cytology has low sensitivity, bronchoscopy is better for central lesions, and thoracotomy is not a first-line diagnostic procedure.

Question 37Chest and Respiratory Medicine

A 35-year-old woman has episodic angioedema, flushing and wheeze after eating shellfish. Serum tryptase is elevated during an attack. Which mediator is primarily responsible for her symptoms?

  1. Leukotriene B4 from neutrophils
  2. Prostaglandin I2 from endothelium
  3. Histamine released from mast cells Correct answer.
  4. Bradykinin from the kallikrein system

Explanation

IgE-mediated anaphylaxis triggers mast cell degranulation with histamine release, producing angioedema, flushing, bronchospasm and hypotension. Bradykinin-mediated angioedema occurs in hereditary angioedema and ACE inhibitor reactions, not shellfish allergy.

Question 38Chest and Respiratory Medicine

Which of the following best indicates that a patient with COPD has chronic type 2 respiratory failure?

  1. PaO2 < 60 mmHg with PaCO2 > 50 mmHg on room air when stable Correct answer.
  2. PaO2 90 mmHg with PaCO2 35 mmHg
  3. PaO2 55 mmHg with PaCO2 30 mmHg
  4. SpO2 95% with pH 7.30

Explanation

Chronic type 2 respiratory failure is defined by persistent hypoxaemia (PaO2 below 60 mmHg) together with hypercapnia (PaCO2 above 50 mmHg) measured when the patient is clinically stable. Normal or low CO2 indicates type 1 failure or normal gas exchange.

Question 39Chest and Respiratory Medicine

A 28-year-old man has a 2-week history of fever, night sweats, weight loss and a productive cough. Sputum is positive for acid-fast bacilli. Which public health measure is most important for his close household contacts?

  1. Isolation of contacts for six weeks
  2. Immediate BCG vaccination of all contacts
  3. Routine chest radiograph only after symptoms develop
  4. Screening and, where indicated, chemoprophylaxis Correct answer.

Explanation

Contact tracing with screening for active and latent tuberculosis is the key public health intervention for household contacts of a smear-positive case, with chemoprophylaxis for those with latent infection. BCG does not replace screening, and asymptomatic contacts still require evaluation.

Question 40Chest and Respiratory Medicine

A 62-year-old with known COPD has an acute exacerbation. Which intervention has been shown to reduce mortality in patients with acute hypercapnic respiratory failure?

  1. Non-invasive ventilation Correct answer.
  2. Prophylactic antibiotics in all cases
  3. Nebulised saline
  4. Chest physiotherapy

Explanation

Non-invasive ventilation reduces intubation rates and mortality in acute hypercapnic respiratory failure from COPD exacerbation when used alongside standard medical therapy. Nebulised saline and routine physiotherapy lack mortality benefit, and antibiotics are given when bacterial infection is suspected rather than prophylactically in all cases.

Question 41Chest and Respiratory Medicine

A 50-year-old woman with scleroderma presents with progressive exertional dyspnoea. Examination shows fine bibasal crackles and clubbing. High-resolution CT shows peripheral reticulation and honeycombing. Which physiological pattern is expected on pulmonary function testing?

  1. Normal spirometry with isolated reduced diffusion capacity
  2. Restrictive pattern with reduced diffusion capacity Correct answer.
  3. Obstructive pattern with bronchodilator reversibility
  4. Obstructive pattern with increased residual volume

Explanation

Scleroderma-associated interstitial lung disease produces a restrictive ventilatory defect with reduced total lung capacity and impaired gas transfer. Honeycombing and reticulation on CT correspond to fibrosis, which reduces lung volumes and diffusion capacity. Obstructive patterns are not characteristic.

Question 42Chest and Respiratory Medicine

A 40-year-old man develops sudden severe breathlessness and pleuritic pain after a long-haul flight. He is tachycardic and hypotensive. Bedside echocardiography shows right ventricular dilatation. What is the most appropriate immediate management?

  1. Systemic thrombolysis Correct answer.
  2. Observation with serial troponin
  3. Oral anticoagulation with warfarin
  4. Prophylactic low-molecular-weight heparin

Explanation

This presentation indicates high-risk (massive) pulmonary embolism with haemodynamic instability and right ventricular strain, for which systemic thrombolysis is indicated to restore pulmonary perfusion. Oral anticoagulation and prophylactic heparin act too slowly and are inadequate in shock. Observation is dangerous in unstable PE.

Question 43Chest and Respiratory Medicine

A 58-year-old smoker has a Pancoast tumour of the right lung apex. Which clinical feature is most characteristic?

  1. Superior vena cava obstruction with facial swelling
  2. Bilateral hilar lymphadenopathy
  3. Paraneoplastic hypercalcaemia
  4. Horner syndrome with ipsilateral shoulder pain Correct answer.

Explanation

Pancoast tumours invade the apical chest wall and lower brachial plexus, causing shoulder and arm pain, and may involve the sympathetic chain producing ipsilateral Horner syndrome (ptosis, miosis, anhidrosis). Bilateral hilar adenopathy, SVC obstruction and hypercalcaemia are not specific to apical tumours.

Question 44Chest and Respiratory Medicine

A 72-year-old with COPD and a history of recurrent exacerbations is being assessed for long-term oxygen therapy. Which criterion supports its prescription?

  1. SpO2 of 92% during an acute exacerbation
  2. Nocturnal cough with normal daytime gases
  3. PaO2 of 70 mmHg with normal CO2
  4. PaO2 persistently ≤ 55 mmHg on room air when stable Correct answer.

Explanation

Long-term oxygen therapy improves survival in patients with chronic severe hypoxaemia, generally defined as a stable room-air PaO2 of 55 mmHg or less, or 56-59 mmHg with evidence of cor pulmonale or polycythaemia. Measurements during an acute exacerbation are unreliable and must be repeated when stable.

Question 45Gastroenterology and Hepatology

A 52-year-old Egyptian man presents with recurrent epigastric pain relieved by meals and occasionally waking him at night. He has been using NSAIDs for chronic knee pain. Which single finding on upper endoscopy would most strongly support a duodenal ulcer over functional dyspepsia?

  1. Diffuse gastric mucosal atrophy
  2. A clean-based ulcer crater in the duodenal bulb Correct answer.
  3. Erythematous antral mucosa with no break
  4. A sliding hiatal hernia

Explanation

A discrete mucosal break with depth (an ulcer crater) in the duodenal bulb is the endoscopic hallmark of peptic ulcer disease and distinguishes it from functional dyspepsia, where endoscopy is normal or shows only non-specific erythema. Nocturnal pain and NSAID use further support ulcer disease.

Question 46Gastroenterology and Hepatology

A 34-year-old woman is diagnosed with Helicobacter pylori infection and has no prior antibiotic exposure or allergy. According to current guideline-based first-line eradication, which regimen is most appropriate in a region of low clarithromycin resistance?

  1. Bismuth quadruple therapy for 14 days as the only acceptable option
  2. PPI alone for 8 weeks
  3. Amoxicillin monotherapy for 10 days
  4. Standard triple therapy (PPI plus clarithromycin and amoxicillin) for 14 days Correct answer.

Explanation

In areas of low clarithromycin resistance, standard triple therapy with a proton pump inhibitor plus clarithromycin and amoxicillin for 14 days remains an accepted first-line regimen. Duration of 14 days improves eradication rates over 7–10 days.

Question 47Gastroenterology and Hepatology

A 45-year-old man with chronic hepatitis C genotype 4 has compensated liver disease and no prior treatment. Which pretreatment assessment is most important before starting direct-acting antiviral therapy?

  1. Measurement of serum ceruloplasmin
  2. Serum alpha-fetoprotein every 3 months
  3. Assessment of renal function and screening for hepatitis B coinfection Correct answer.
  4. Liver biopsy to stage fibrosis in all patients

Explanation

Before direct-acting antivirals, baseline renal function guides choice of regimen (some agents are renally cleared), and hepatitis B screening is essential because HBV reactivation can occur during or after DAA therapy. Non-invasive fibrosis assessment is preferred over routine biopsy.

Question 48Gastroenterology and Hepatology

A 60-year-old woman with cirrhosis presents with tense ascites. Diagnostic paracentesis shows a polymorphonuclear cell count of 480 cells/mm³. What is the most appropriate immediate management?

  1. Oral lactulose titrated to two soft stools daily
  2. Intravenous ceftriaxone plus intravenous albumin Correct answer.
  3. Fluid restriction to 1 L per day
  4. Observation and repeat paracentesis in 48 hours

Explanation

A polymorphonuclear count of 250 cells/mm³ or more in ascitic fluid defines spontaneous bacterial peritonitis, which requires prompt intravenous third-generation cephalosporin therapy. Adding intravenous albumin reduces the risk of hepatorenal syndrome and mortality.

Question 49Gastroenterology and Hepatology

Which laboratory pattern is most typical of acute hepatitis B infection in the window period, when HBsAg has become undetectable but anti-HBs has not yet appeared?

  1. IgG anti-HBc positive with HBsAg positive
  2. Anti-HBs positive with HBsAg positive
  3. IgM anti-HBc positive with HBsAg negative Correct answer.
  4. HBeAg positive with total anti-HBc negative

Explanation

During the window period, HBsAg clears before anti-HBs becomes detectable, and IgM antibody to hepatitis B core antigen is the sole serological marker of recent infection. Detection of IgM anti-HBc therefore confirms acute HBV.

Question 50Gastroenterology and Hepatology

A 70-year-old man reports new iron-deficiency anemia and a change in bowel habit. Colonoscopy reveals a mass in the right colon. Which feature most strongly favors a right-sided over a left-sided colorectal carcinoma?

  1. Tenesmus and frequent small stools
  2. Early overt rectal bleeding
  3. Iron-deficiency anemia with a palpable mass Correct answer.
  4. Progressive obstruction with narrow stools

Explanation

Right-sided colon cancers tend to grow into the capacious cecum and ascending colon, presenting insidiously with iron-deficiency anemia and a palpable mass rather than obstruction. Left-sided tumors more often cause obstructive symptoms and visible bleeding.