I85PREP
⌘ K
HKMLE Part II study materials
HKMLE Part II study resources

HKMLE Part II practice questions

One question at a time. Build your HKMLE Part II understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 28-year-old man presents with sudden-onset severe headache, neck stiffness and photophobia. His temperature is 38.5°C. Which is the most appropriate immediate next step in management?

  1. CT brain followed by observation for 6 hours
  2. Urgent lumbar puncture before any antibiotics
  3. Intravenous antibiotics and dexamethasone without delay Correct answer.
  4. Oral analgesia and outpatient review in 24 hours

Explanation

In suspected bacterial meningitis, empirical intravenous antibiotics (plus dexamethasone) should be given as soon as possible, ideally within an hour. Lumbar puncture should not delay treatment and is often performed after antibiotics if imaging is needed.

Question 2Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

Which of the following is the most common cause of community-acquired pneumonia in adults in Hong Kong?

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

Explanation

Streptococcus pneumoniae remains the most common bacterial cause of community-acquired pneumonia worldwide, including Hong Kong. Atypical organisms such as Mycoplasma and Legionella are less frequent but important causes.

Question 3Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 55-year-old woman with type 2 diabetes has an eGFR of 28 mL/min/1.73m². Which antihypertensive class provides both blood pressure control and renoprotection in this setting?

  1. Thiazide diuretics
  2. Beta-blockers
  3. Angiotensin-converting enzyme inhibitors Correct answer.
  4. Alpha-blockers

Explanation

ACE inhibitors reduce intraglomerular pressure and slow progression of diabetic nephropathy, and are preferred in patients with proteinuric chronic kidney disease. Renal function and potassium should be monitored after initiation.

Question 4Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A patient presents with a painful, red, swollen joint. Joint aspiration shows needle-shaped, negatively birefringent crystals. What is the diagnosis?

  1. Pseudogout
  2. Septic arthritis
  3. Gout Correct answer.
  4. Rheumatoid arthritis

Explanation

Needle-shaped, negatively birefringent crystals under polarised light are characteristic of monosodium urate crystals, confirming gout. Pseudogout shows rhomboid, positively birefringent calcium pyrophosphate crystals.

Question 5Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

Which of the following is the most appropriate first-line treatment for a patient with newly diagnosed hypertension and no comorbidities?

  1. Calcium channel blocker Correct answer.
  2. Angiotensin receptor blocker
  3. Loop diuretic
  4. Alpha-blocker

Explanation

For most patients with uncomplicated hypertension, a calcium channel blocker, thiazide-type diuretic, or ACE inhibitor/ARB is appropriate first-line. In Hong Kong guidelines, calcium channel blockers are commonly used first-line.

Question 6Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 3-year-old child has a barking cough, inspiratory stridor and hoarse voice. What is the most likely diagnosis?

  1. Epiglottitis
  2. Bronchiolitis
  3. Croup Correct answer.
  4. Foreign body aspiration

Explanation

The combination of barking cough, inspiratory stridor and hoarseness in a young child is classic for croup (laryngotracheobronchitis), usually caused by parainfluenza virus. Treatment includes a single dose of oral dexamethasone.

Question 7Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A patient with atrial fibrillation is being considered for anticoagulation. His CHA2DS2-VASc score is 2. What is the most appropriate management?

  1. Anticoagulation only if symptomatic
  2. Oral anticoagulation Correct answer.
  3. Aspirin alone
  4. No anticoagulation needed

Explanation

A CHA2DS2-VASc score of 2 or more in men (3 or more in women) is an indication for oral anticoagulation to reduce stroke risk. Aspirin is not an adequate substitute for anticoagulation in this context.

Question 8Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

Which vitamin deficiency is most strongly associated with megaloblastic anaemia and neurological symptoms?

  1. Vitamin C
  2. Vitamin D
  3. Vitamin B12 Correct answer.
  4. Vitamin K

Explanation

Vitamin B12 deficiency causes megaloblastic anaemia and can produce neurological symptoms such as peripheral neuropathy and subacute combined degeneration of the spinal cord. Folate deficiency causes megaloblastic anaemia but not the neurological features.

Question 9Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 60-year-old man with chronic obstructive pulmonary disease has an oxygen saturation of 85% on room air. What is the target oxygen saturation range for this patient?

  1. 94–98%
  2. 88–92% Correct answer.
  3. 98–100%
  4. 85–90%

Explanation

In patients with COPD who are at risk of hypercapnic respiratory failure, the target saturation is 88–92% to avoid worsening carbon dioxide retention. Oxygen should be titrated using a controlled device such as a Venturi mask.

Question 10Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

Which of the following is a recognised risk factor for the development of hepatocellular carcinoma?

  1. Chronic hepatitis B infection Correct answer.
  2. Asthma
  3. Hypothyroidism
  4. Iron deficiency anaemia

Explanation

Chronic hepatitis B infection is a major risk factor for hepatocellular carcinoma, particularly in endemic areas such as Hong Kong. Cirrhosis from any cause, including hepatitis C and alcohol, also increases risk.

Question 11Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A woman at 34 weeks' gestation presents with painless vaginal bleeding. Which is the most appropriate initial investigation?

  1. Transabdominal ultrasound Correct answer.
  2. Digital vaginal examination
  3. Transvaginal ultrasound
  4. Speculum examination

Explanation

Painless vaginal bleeding in late pregnancy raises suspicion of placenta praevia, and digital or speculum examination is contraindicated until placental position is known. Transabdominal ultrasound is a safe initial step, though transvaginal ultrasound is more accurate when performed by experienced operators.

Question 12Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 70-year-old man has a sudden painless loss of vision in one eye described as a 'curtain coming down'. What is the most likely diagnosis?

  1. Central retinal artery occlusion
  2. Vitreous haemorrhage
  3. Amaurosis fugax Correct answer.
  4. Retinal detachment

Explanation

A transient 'curtain' of visual loss lasting minutes is characteristic of amaurosis fugax, usually due to emboli from the carotid artery. It is a transient ischaemic attack and requires urgent assessment for stroke risk.

Question 13Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

Which of the following is the most appropriate initial management for a patient with an acute asthma attack who has not responded to a beta-2 agonist nebuliser?

  1. Chest physiotherapy
  2. Oral antibiotics
  3. Intravenous magnesium sulfate Correct answer.
  4. Oral theophylline

Explanation

Intravenous magnesium sulfate is recommended for severe asthma not responding to inhaled bronchodilators and systemic corticosteroids. It acts as a smooth muscle relaxant and is usually given as a single infusion.

Question 14Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 45-year-old woman presents with weight loss, palpitations and heat intolerance. TSH is suppressed and free T4 is elevated. What is the most likely diagnosis?

  1. Subclinical hypothyroidism
  2. Diabetes insipidus
  3. Graves' disease Correct answer.
  4. Hypothyroidism

Explanation

Suppressed TSH with elevated free T4 indicates primary hyperthyroidism; Graves' disease is the most common cause in this age group. Clinical features include weight loss, palpitations and heat intolerance.

Question 15Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A patient presents with a deep laceration to the palm that has been bleeding for 15 minutes. What is the first step in management?

  1. Apply direct pressure to the wound Correct answer.
  2. Administer tetanus toxoid
  3. Explore the wound for tendon injury
  4. Irrigate with saline

Explanation

The first priority in managing a bleeding laceration is to control haemorrhage by applying direct pressure. Once bleeding is controlled, the wound can be assessed for neurovascular or tendon injury and cleaned.

Question 16Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

Which of the following is the most common cause of acute pancreatitis in Hong Kong?

  1. Hypertriglyceridaemia
  2. Gallstones Correct answer.
  3. Trauma
  4. Alcohol

Explanation

Gallstones and alcohol are the two most common causes of acute pancreatitis; in Hong Kong, gallstones are the leading cause. Hypertriglyceridaemia and trauma are less common aetiologies.

Question 17Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 65-year-old man has a blood pressure of 180/110 mmHg with no symptoms of end-organ damage. What is the most appropriate management?

  1. Intravenous nitroprusside infusion
  2. No treatment needed
  3. Immediate sublingual nifedipine
  4. Gradual blood pressure reduction with oral agents Correct answer.

Explanation

This represents hypertensive urgency without acute end-organ damage, and blood pressure should be lowered gradually with oral agents over hours to days. Rapid reduction risks cerebral or myocardial ischaemia.

Question 18Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

Which of the following is the most appropriate treatment for a patient with an uncomplicated urinary tract infection caused by E. coli?

  1. Trimethoprim or nitrofurantoin Correct answer.
  2. Fluconazole
  3. Vancomycin
  4. Metronidazole

Explanation

Uncomplicated urinary tract infections are usually caused by E. coli and respond to oral agents such as trimethoprim or nitrofurantoin. Local resistance patterns should guide the choice.

Question 19Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A newborn is noted to have a bluish discolouration of the lips and tongue that does not improve with oxygen. Which congenital heart defect is most likely?

  1. Patent ductus arteriosus
  2. Atrial septal defect
  3. Ventricular septal defect
  4. Tetralogy of Fallot Correct answer.

Explanation

Cyanosis unresponsive to oxygen suggests a right-to-left shunt, and Tetralogy of Fallot is the most common cyanotic congenital heart defect. It comprises pulmonary stenosis, right ventricular hypertrophy, overriding aorta and ventricular septal defect.

Question 20Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 30-year-old woman presents with fatigue, arthralgia and a malar rash. Which investigation is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity, particularly lupus nephritis. Antinuclear antibody is sensitive but not specific.

Question 21Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A patient with a history of peptic ulcer disease presents with sudden severe abdominal pain and rigidity. What is the most likely diagnosis?

  1. Acute cholecystitis
  2. Acute appendicitis
  3. Perforated peptic ulcer Correct answer.
  4. Renal colic

Explanation

Sudden severe abdominal pain with a rigid, board-like abdomen suggests a perforated peptic ulcer with peritonitis. Erect chest X-ray may show free air under the diaphragm.

Question 22Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

Which of the following is the most appropriate first-line treatment for major depressive disorder in an adult?

  1. Benzodiazepine monotherapy
  2. Selective serotonin reuptake inhibitor Correct answer.
  3. Electroconvulsive therapy
  4. Antipsychotic monotherapy

Explanation

Selective serotonin reuptake inhibitors are first-line pharmacological treatment for moderate to severe depression due to favourable safety and tolerability. Psychotherapy is also an effective first-line option.

Question 23Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 50-year-old man has a serum sodium of 120 mmol/L and is asymptomatic. What is the most appropriate rate of correction?

  1. No more than 8–10 mmol/L in 24 hours Correct answer.
  2. Rapid correction over 2 hours
  3. Immediate hypertonic saline to normalise sodium
  4. Fluid restriction alone regardless of cause

Explanation

Chronic hyponatraemia should be corrected slowly, generally no more than 8–10 mmol/L in 24 hours, to avoid osmotic demyelination syndrome. Acute symptomatic hyponatraemia may require hypertonic saline with careful monitoring.

Question 24Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 2-year-old child presents with fever, sore throat and a strawberry tongue. Examination reveals a sandpaper-like rash. What is the most likely diagnosis?

  1. Measles
  2. Rubella
  3. Kawasaki disease
  4. Scarlet fever Correct answer.

Explanation

Fever, sore throat, strawberry tongue and a sandpaper-like rash are characteristic of scarlet fever, caused by group A streptococcal infection. It is treated with penicillin or amoxicillin.

Question 25Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

Which of the following is a recognised complication of poorly controlled diabetes mellitus?

  1. Myasthenia gravis
  2. Addison's disease
  3. Diabetic retinopathy Correct answer.
  4. Nephrogenic diabetes insipidus

Explanation

Diabetic retinopathy is a microvascular complication of chronic hyperglycaemia and a leading cause of blindness in adults. Regular retinal screening is recommended for all patients with diabetes.

Question 26Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 58-year-old man in Hong Kong presents with a 3-day history of fever, productive cough with rust-coloured sputum and pleuritic chest pain. Chest radiograph shows right lower lobe consolidation. Which organism is the most likely cause?

  1. Klebsiella pneumoniae
  2. Mycoplasma pneumoniae
  3. Mycobacterium tuberculosis
  4. Streptococcus pneumoniae Correct answer.

Explanation

Lobar consolidation with acute fever, pleuritic pain and rust-coloured sputum is the classic presentation of pneumococcal pneumonia, which remains the commonest cause of community-acquired pneumonia. Mycoplasma typically produces a gradual illness with minimal focal signs, Klebsiella is associated with aspiration or alcohol excess and currant-jelly sputum, and tuberculosis is usually more indolent.

Question 27Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 72-year-old woman with hypertension and type 2 diabetes presents with sudden-onset severe headache and vomiting. Her blood pressure is 210/120 mmHg. CT brain shows a hyperdense lesion in the right basal ganglia with surrounding oedema. What is the most likely diagnosis?

  1. Cerebral venous sinus thrombosis
  2. Acute ischaemic stroke
  3. Intracerebral haemorrhage Correct answer.
  4. Aneurysmal subarachnoid haemorrhage

Explanation

A hyperdense collection within the basal ganglia on unenhanced CT, in a patient with marked hypertension, indicates an intracerebral haemorrhage, with hypertensive small-vessel disease being the usual mechanism. Subarachnoid haemorrhage shows blood in the basal cisterns, ischaemic stroke is hypodense, and venous sinus thrombosis has a different distribution and imaging pattern.

Question 28Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 28-year-old primigravida at 10 weeks' gestation presents with a 2-day history of hyperemesis, weight loss and dark urine. Which investigation is most important to perform urgently?

  1. Serum electrolytes and ketones Correct answer.
  2. Oral glucose tolerance test
  3. Serum alpha-fetoprotein
  4. Cervical swab for culture

Explanation

Hyperemesis gravidarum with weight loss and dark urine suggests dehydration and ketosis, so serum electrolytes, urea and ketones are the key urgent investigations to guide fluid and electrolyte replacement. Alpha-fetoprotein screening is performed later in pregnancy, cervical swabs are unrelated, and glucose tolerance testing is not the priority in acute dehydration.

Question 29Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 35-year-old man is brought to the emergency department after a blunt head injury. He is alert and oriented but has clear fluid dripping from his nose. Which finding would best support a diagnosis of cerebrospinal fluid rhinorrhoea?

  1. Blood-stained nasal discharge that clots
  2. Bilateral periorbital bruising
  3. Unilateral pupillary dilatation
  4. Positive glucose on the nasal fluid Correct answer.

Explanation

Cerebrospinal fluid contains glucose, so a positive glucose test on clear nasal fluid after head trauma supports a CSF leak, ideally confirmed with beta-2 transferrin. Blood-stained discharge is nonspecific, periorbital bruising suggests a basal skull fracture but does not confirm a leak, and pupillary dilatation suggests raised intracranial pressure or herniation.

Question 30Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 45-year-old woman has a 4-week history of proximal muscle weakness and difficulty rising from a chair. Creatine kinase is markedly elevated and electromyography shows myopathic changes. Which autoantibody is most specifically associated with dermatomyositis?

  1. Anti-histidyl-tRNA synthetase (Jo-1) Correct answer.
  2. Anti-double-stranded DNA
  3. Anti-nuclear antibody
  4. Anti-mitochondrial antibody

Explanation

Anti-Jo-1 is the commonest myositis-specific antibody and is associated with antisynthetase syndrome, which includes myositis and interstitial lung disease. Anti-dsDNA is associated with systemic lupus erythematosus, anti-nuclear antibody is a nonspecific screening test, and anti-mitochondrial antibody is associated with primary biliary cholangitis.

Question 31Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 66-year-old man with atrial fibrillation on warfarin presents with melaena and a haemoglobin of 7.5 g/dL. His INR is 6.5. Which agent is most appropriate to reverse the coagulopathy urgently?

  1. Prothrombin complex concentrate plus intravenous vitamin K Correct answer.
  2. Platelet transfusion
  3. Fresh frozen plasma alone
  4. Intravenous vitamin K alone

Explanation

Major bleeding with a markedly elevated INR requires rapid reversal, and prothrombin complex concentrate corrects the vitamin K-dependent factors faster than fresh frozen plasma, with intravenous vitamin K given to sustain the correction. Vitamin K alone acts too slowly, fresh frozen plasma alone is slower and volume-heavy, and platelet transfusion does not reverse warfarin.

Question 32Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 4-year-old boy is brought in with a 2-day history of fever, sore throat and a diffuse red rash. Examination shows a fine sandpaper-like rash over the trunk with circumoral pallor and a red tongue with prominent papillae. Which organism is most likely responsible?

  1. Streptococcus pyogenes Correct answer.
  2. Neisseria meningitidis
  3. Epstein-Barr virus
  4. Staphylococcus aureus

Explanation

Scarlet fever is caused by group A beta-haemolytic Streptococcus pyogenes, typically producing fever, sore throat, sandpaper rash, circumoral pallor and a strawberry tongue. Staphylococcus aureus causes toxic shock syndrome with different features, meningococcus causes meningococcal disease, and Epstein-Barr virus causes infectious mononucleosis.

Question 33Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 55-year-old woman is admitted with confusion. Serum sodium is 118 mmol/L and she has generalised seizures. What is the most appropriate initial management?

  1. Slow correction with normal saline
  2. Hypertonic (3%) saline infusion Correct answer.
  3. Oral salt tablets
  4. Fluid restriction alone

Explanation

Severe hyponatraemia with neurological symptoms such as seizures is a medical emergency requiring hypertonic 3% saline to raise the sodium concentration promptly. Fluid restriction, slow correction with normal saline and oral salt are appropriate only for milder or asymptomatic cases, and delaying treatment risks cerebral oedema and death.

Question 34Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 62-year-old man with a 40 pack-year smoking history presents with haemoptysis and weight loss. Chest radiograph shows a right hilar mass. Which paraneoplastic syndrome is most classically associated with small cell lung carcinoma?

  1. Hypoglycaemia
  2. SIADH with hyponatraemia Correct answer.
  3. Carcinoid syndrome
  4. Hypercalcaemia

Explanation

Small cell lung carcinoma is a neuroendocrine tumour that classically secretes antidiuretic hormone, producing syndrome of inappropriate antidiuretic hormone secretion and hyponatraemia. Hypercalcaemia is more typical of squamous cell carcinoma, carcinoid syndrome of carcinoid tumours, and hypoglycaemia of other tumours such as insulinoma.

Question 35Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 30-year-old woman at 36 weeks' gestation presents with a blood pressure of 160/110 mmHg, severe headache and visual disturbance. Urine dipstick shows 3+ protein. Which is the most appropriate initial management?

  1. Immediate caesarean section without stabilisation
  2. Intravenous magnesium sulfate and antihypertensive therapy Correct answer.
  3. Oral labetalol and outpatient review
  4. Fluid restriction and bed rest

Explanation

Severe pre-eclampsia with neurological symptoms requires urgent antihypertensive treatment and magnesium sulfate for seizure prophylaxis, with delivery planned once the mother is stabilised. Outpatient management is unsafe, delivery without stabilisation increases maternal risk, and fluid restriction with bed rest is inadequate for severe disease.

Question 36Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 50-year-old man presents with a painless, gradually enlarging testicular mass. Ultrasound shows a solid intratesticular lesion. Which tumour marker is most useful in the initial assessment of a non-seminomatous germ cell tumour?

  1. Carcinoembryonic antigen
  2. CA 19-9
  3. CA 125
  4. Alpha-fetoprotein Correct answer.

Explanation

Alpha-fetoprotein is elevated in a substantial proportion of non-seminomatous germ cell tumours and, together with beta-hCG and LDH, forms part of the standard tumour marker panel. CA 19-9 is used in pancreatic and biliary disease, carcinoembryonic antigen in colorectal cancer, and CA 125 in ovarian cancer.

Question 37Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 70-year-old woman with a history of hypertension collapses and is found to have a dense left hemiplegia. CT angiography shows occlusion of the right middle cerebral artery. She presents 2 hours after symptom onset and has no contraindications. What is the most appropriate treatment?

  1. Aspirin 300 mg immediately
  2. Intravenous thrombolysis with alteplase Correct answer.
  3. Intravenous heparin
  4. Observation with repeat imaging in 24 hours

Explanation

Acute ischaemic stroke within the thrombolysis window, with a confirmed large vessel occlusion and no contraindications, is treated with intravenous thrombolysis, and thrombectomy should be considered for proximal occlusions. Immediate aspirin is withheld until haemorrhage is excluded and thrombolysis is given, heparin has no role in acute stroke, and observation would miss the treatment window.

Question 38Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 25-year-old man presents with a painless penile ulcer and bilateral inguinal lymphadenopathy. Dark-ground microscopy of the ulcer exudate is positive. What is the most appropriate treatment?

  1. Topical acyclovir
  2. Oral doxycycline
  3. Oral azithromycin
  4. Intramuscular benzathine penicillin Correct answer.

Explanation

The painless ulcer with positive dark-ground microscopy indicates primary syphilis, for which intramuscular benzathine penicillin is the treatment of choice. Azithromycin and doxycycline are alternatives in penicillin allergy but not first-line, and topical acyclovir treats herpes simplex, which causes painful ulcers.

Question 39Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 3-year-old child is brought in with a 1-day history of fever, drooling and difficulty swallowing. He is sitting forward and refuses to lie down. Which is the most appropriate next step?

  1. Reassure and discharge with oral antibiotics
  2. Examine the throat with a tongue depressor
  3. Obtain a lateral neck radiograph before any intervention
  4. Urgent airway assessment and specialist involvement Correct answer.

Explanation

The presentation suggests acute epiglottitis with impending airway obstruction, so the priority is urgent airway assessment with anaesthetic and ENT support. Examining the throat with a tongue depressor can precipitate complete obstruction, discharge is dangerous, and imaging should not delay airway management in an unstable child.

Question 40Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 40-year-old woman presents with episodic palpitations, sweating and headache. Plasma metanephrines are elevated. Which imaging investigation is most appropriate to localise the lesion?

  1. MRI of the brain
  2. Ultrasound of the thyroid
  3. Barium swallow
  4. CT of the abdomen and pelvis Correct answer.

Explanation

Elevated plasma metanephrines indicate phaeochromocytoma, and CT of the abdomen and pelvis is the first-line imaging to localise an adrenal or extra-adrenal tumour. Brain MRI, thyroid ultrasound and barium swallow do not image the adrenal glands or sympathetic chain.

Question 41Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 60-year-old man with cirrhosis presents with haematemesis. He is haemodynamically stable. Which is the most appropriate initial pharmacological therapy?

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

Explanation

Suspected variceal bleeding in cirrhosis is treated with a vasoactive agent such as terlipressin, started before endoscopy, together with prophylactic antibiotics. Propranolol is used for prophylaxis rather than acute bleeding, vitamin K does not control variceal haemorrhage, and lactulose treats hepatic encephalopathy.

Question 42Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 35-year-old woman has a 6-month history of fatigue, cold intolerance and weight gain. TSH is elevated and free T4 is low. Which antibody is most strongly associated with her condition?

  1. Anti-nuclear antibody
  2. TSH receptor antibody
  3. Anti-thyroid peroxidase antibody Correct answer.
  4. Anti-thyroglobulin antibody

Explanation

The picture is primary hypothyroidism, most often due to Hashimoto's thyroiditis, in which anti-thyroid peroxidase antibodies are the most sensitive and characteristic marker. Anti-thyroglobulin antibodies are less sensitive, TSH receptor antibodies cause Graves' disease, and anti-nuclear antibody is nonspecific.

Question 43Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 24-year-old man presents with a 2-week history of fever, night sweats and a non-productive cough. Chest radiograph shows upper lobe infiltrates with cavitation. Which is the most appropriate initial investigation to confirm the diagnosis?

  1. Blood cultures
  2. Sputum smear for acid-fast bacilli Correct answer.
  3. Serum angiotensin-converting enzyme
  4. Sputum cytology

Explanation

The presentation is highly suggestive of pulmonary tuberculosis, and sputum smear for acid-fast bacilli is the key initial test, followed by culture and nucleic acid amplification testing. Blood cultures are used for sepsis, sputum cytology for malignancy, and serum ACE for sarcoidosis.

Question 44Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 45-year-old man is found unresponsive with pinpoint pupils and a respiratory rate of 6 breaths per minute. Which is the most appropriate immediate treatment?

  1. Flumazenil
  2. Naloxone Correct answer.
  3. Atropine
  4. N-acetylcysteine

Explanation

Pinpoint pupils with respiratory depression indicate opioid toxicity, which is reversed with naloxone. Flumazenil reverses benzodiazepines and can precipitate seizures, atropine treats bradycardia and anticholinesterase toxicity, and N-acetylcysteine is the antidote for paracetamol overdose.

Question 45Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 68-year-old woman with a history of hypertension presents with sudden severe abdominal pain radiating to the back. She is hypotensive and has a pulsatile abdominal mass. Which is the most appropriate immediate investigation?

  1. Abdominal ultrasound
  2. Colonoscopy
  3. Urgent CT angiography Correct answer.
  4. Plain abdominal radiograph

Explanation

A pulsatile abdominal mass with hypotension and back pain suggests a ruptured abdominal aortic aneurysm, and urgent CT angiography confirms the diagnosis and informs operative planning in a stable patient. Plain radiography is insensitive, colonoscopy is irrelevant, and ultrasound is useful for screening but less accurate than CT for rupture.

Question 46Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 50-year-old woman with end-stage renal disease on haemodialysis presents with generalised weakness and a peaked T wave on ECG. Serum potassium is 7.2 mmol/L. Which is the most appropriate first treatment?

  1. Oral sodium polystyrene sulfonate
  2. Intravenous calcium gluconate Correct answer.
  3. Urgent haemodialysis
  4. Intravenous insulin with glucose

Explanation

Hyperkalaemia with ECG changes is a cardiac emergency, and intravenous calcium gluconate is given first to stabilise the myocardium. Insulin with glucose, salbutamol and dialysis shift or remove potassium but do not protect the heart immediately, and sodium polystyrene sulfonate acts too slowly.

Question 47Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 30-year-old woman presents with a 2-day history of dysuria and frequency. She is not pregnant and has no allergies. Which is the most appropriate empirical treatment for uncomplicated cystitis?

  1. Nitrofurantoin for 5 days Correct answer.
  2. Ciprofloxacin for 7 days
  3. Metronidazole for 5 days
  4. Intravenous vancomycin

Explanation

Uncomplicated cystitis is usually treated with a short course of nitrofurantoin or trimethoprim, and nitrofurantoin for 5 days is appropriate. Fluoroquinolones are reserved for complicated infection because of resistance and adverse effects, vancomycin treats resistant gram-positive infection, and metronidazole covers anaerobes.

Question 48Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 55-year-old man with type 2 diabetes has an HbA1c of 9.5% despite metformin. He has a body mass index of 32 kg/m² and normal renal function. Which add-on therapy also promotes weight loss?

  1. Semaglutide Correct answer.
  2. Pioglitazone
  3. Glipizide
  4. Insulin glargine

Explanation

Glucagon-like peptide-1 receptor agonists such as semaglutide improve glycaemic control and promote weight loss, which is advantageous in obesity. Sulfonylureas and insulin cause weight gain, and pioglitazone is associated with weight gain and fluid retention.

Question 49Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 70-year-old man with a history of gout presents with a hot, swollen and painful first metatarsophalangeal joint. Joint aspiration shows needle-shaped negatively birefringent crystals. Which is the most appropriate treatment for the acute attack?

  1. Allopurinol at high dose
  2. Colchicine or a non-steroidal anti-inflammatory drug Correct answer.
  3. Probenecid
  4. Febuxostat started immediately

Explanation

Acute gout is treated with colchicine, a non-steroidal anti-inflammatory drug or corticosteroids, and urate-lowering therapy is not started or escalated during an acute attack. Allopurinol, probenecid and febuxostat are urate-lowering agents used for long-term prevention.

Question 50Medical knowledge and clinical practice (unspecified - source does not enumerate domains)

A 28-year-old woman at 30 weeks' gestation presents with a painless episode of vaginal bleeding. She is haemodynamically stable. Which is the most appropriate initial investigation?

  1. Plain pelvic radiograph
  2. Digital vaginal examination
  3. Transvaginal ultrasound Correct answer.
  4. Speculum examination with biopsy

Explanation

Painless bleeding in later pregnancy suggests placenta praevia, and transvaginal ultrasound is safe and accurate for localising the placenta. Digital vaginal examination is avoided because it can provoke catastrophic haemorrhage, biopsy is not indicated, and pelvic radiography has no role.