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Israel Medical Licensing Exam study materials
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Israel Medical Licensing Exam practice questions

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Question 1Internal Medicine

A 68-year-old man with type 2 diabetes and hypertension has an eGFR of 32 mL/min/1.73 m² and a urine albumin-to-creatinine ratio of 450 mg/g. Which medication class slows progression of his chronic kidney disease most reliably?

  1. Angiotensin-converting enzyme inhibitor Correct answer.
  2. Loop diuretic
  3. Alpha-1 adrenergic blocker
  4. Thiazide diuretic

Explanation

Blockade of the renin-angiotensin system with an ACE inhibitor (or ARB) reduces intraglomerular pressure and slows progression of albuminuric diabetic kidney disease, and is indicated when albuminuria exceeds 30 mg/g. Diuretics and alpha-blockers control blood pressure or symptoms but do not confer the same renoprotection. Monitoring of potassium and creatinine after initiation is required.

Question 2Internal Medicine

A 24-year-old woman presents with palpitations and weight loss. TSH is suppressed and free T4 is elevated. Which finding is most characteristic of Graves disease rather than a toxic multinodular goiter?

  1. Diffuse thyroid enlargement with a bruit Correct answer.
  2. Suppressed TSH with normal free T4
  3. Single palpable thyroid nodule
  4. Low uptake on radioactive iodine scan

Explanation

Graves disease is caused by TSH-receptor stimulating antibodies and produces a diffusely enlarged, hypervascular gland, which may generate an audible bruit. Toxic multinodular goiter produces focal nodules with patchy uptake. A low iodine uptake would instead suggest thyroiditis or exogenous hormone use.

Question 3Internal Medicine

A 55-year-old smoker presents with sudden painless loss of vision in one eye described as a curtain descending. Fundoscopy shows a pale retina with a cherry-red spot at the macula. What is the most likely diagnosis?

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

Explanation

Sudden painless monocular visual loss with a pale, opaque retina and a cherry-red spot at the fovea is the classic picture of central retinal artery occlusion, an ocular emergency associated with carotid or cardiac emboli. Retinal vein occlusion produces a blood-and-thunder fundus with hemorrhages. Immediate ophthalmologic referral is warranted.

Question 4Internal Medicine

A 30-year-old man has recurrent episodes of severe abdominal pain, and his urine turns dark on standing. Urine testing is positive for porphobilinogen. Which enzyme deficiency is most likely?

  1. Uroporphyrinogen decarboxylase
  2. Protoporphyrinogen oxidase
  3. Porphobilinogen deaminase Correct answer.
  4. Ferrochelatase

Explanation

Acute intermittent porphyria results from deficiency of porphobilinogen deaminase (hydroxymethylbilane synthase) and presents with neurovisceral attacks and elevated urinary porphobilinogen. Attacks are often precipitated by drugs, fasting or infection. Ferrochelatase and protoporphyrinogen oxidase deficiencies cause erythropoietic protoporphyria with photosensitivity, not acute attacks.

Question 5Internal Medicine

A 72-year-old woman has resting tremor, bradykinesia and rigidity. Which medication is most appropriate to initiate for symptomatic control of her motor symptoms?

  1. Haloperidol
  2. Metoclopramide
  3. Levodopa combined with carbidopa Correct answer.
  4. Valproic acid

Explanation

Levodopa with carbidopa is the most effective symptomatic therapy for Parkinson disease; carbidopa prevents peripheral decarboxylation and reduces nausea. Dopamine-blocking agents such as haloperidol and metoclopramide can worsen parkinsonism. Valproate has no role in motor symptom control.

Question 6Internal Medicine

A 45-year-old man has a blood pressure of 168/104 mmHg on three occasions. He has no symptoms. Which lifestyle measure is most strongly supported to lower blood pressure?

  1. Reducing dietary sodium intake Correct answer.
  2. Increasing caffeine consumption
  3. Starting a high-protein ketogenic diet
  4. Taking a daily multivitamin

Explanation

Sodium restriction consistently lowers blood pressure and is a cornerstone of non-pharmacologic management of hypertension, along with weight loss and exercise. Caffeine can acutely raise blood pressure. Multivitamins and ketogenic diets are not established antihypertensive interventions.

Question 7Internal Medicine

A 60-year-old man with a history of alcohol use presents with confusion, ataxia and ophthalmoplegia. Which diagnosis should be considered first?

  1. Migraine with brainstem aura
  2. Wernicke encephalopathy Correct answer.
  3. Ischemic stroke of the posterior circulation
  4. Multiple sclerosis

Explanation

The triad of encephalopathy, ataxia and oculomotor dysfunction in a patient with alcohol use strongly suggests Wernicke encephalopathy due to thiamine deficiency, and treatment with parenteral thiamine should not be delayed. Posterior circulation stroke can mimic these findings but the classic triad with nutritional risk favors Wernicke. Prompt thiamine prevents progression to Korsakoff syndrome.

Question 8Internal Medicine

A 28-year-old woman has a deep vein thrombosis and reports two prior miscarriages. Which laboratory test is most appropriate to evaluate for an inherited thrombophilia?

  1. Erythrocyte sedimentation rate
  2. D-dimer level
  3. Platelet count
  4. Factor V Leiden mutation analysis Correct answer.

Explanation

Factor V Leiden is the most common inherited thrombophilia and is assessed by genetic testing, particularly in young patients with unprovoked thrombosis or recurrent pregnancy loss. D-dimer supports the diagnosis of acute thrombosis but does not identify a thrombophilia. Platelet count and ESR are nonspecific.

Question 9Internal Medicine

A 66-year-old man with chronic obstructive pulmonary disease has an oxygen saturation of 88% at rest on room air. Which intervention improves survival in this setting?

  1. Long-term oxygen therapy Correct answer.
  2. Inhaled short-acting beta agonist alone
  3. Oral corticosteroids long term
  4. Prophylactic antibiotics continuously

Explanation

Long-term oxygen therapy improves survival in patients with COPD and chronic severe hypoxemia (PaO2 ≤55 mmHg or saturation ≤88%). Bronchodilators relieve symptoms but do not improve mortality. Chronic oral corticosteroids and continuous prophylactic antibiotics are not standard first-line measures and carry significant adverse effects.

Question 10Internal Medicine

A 34-year-old woman has a malar rash, photosensitivity, arthralgia and a positive antinuclear antibody test. Which additional test is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for SLE and correlate with disease activity and lupus nephritis. Rheumatoid factor is nonspecific and seen in many conditions. Anti-histone antibodies are more typical of drug-induced lupus.

Question 11Internal Medicine

A 58-year-old man with hypertension and diabetes presents with sudden onset of tearing chest pain radiating to the back. Blood pressure is 180/100 mmHg in the right arm and 150/90 mmHg in the left arm. Which imaging study is most appropriate for initial evaluation?

  1. Contrast-enhanced computed tomography angiography of the aorta Correct answer.
  2. Abdominal ultrasound
  3. Transthoracic echocardiography
  4. Coronary angiography

Explanation

The presentation suggests acute aortic dissection, and CT angiography of the aorta is the preferred rapid diagnostic modality, showing an intimal flap and false lumen. Interarm blood pressure differential supports the diagnosis. Transthoracic echocardiography may visualize the proximal aorta but is less sensitive for the entire aorta.

Question 12Internal Medicine

A 70-year-old woman on warfarin for atrial fibrillation presents with melena and a hemoglobin of 7.8 g/dL. Her INR is 5.6. Which agent most rapidly reverses the coagulopathy?

  1. Fresh frozen plasma alone
  2. Vitamin K orally alone
  3. Platelet transfusion
  4. Four-factor prothrombin complex concentrate Correct answer.

Explanation

For major bleeding with warfarin and an elevated INR, four-factor prothrombin complex concentrate provides rapid replacement of vitamin K-dependent factors and is preferred over fresh frozen plasma for speed and volume. Intravenous vitamin K should be given concurrently but acts too slowly alone. Platelet transfusion does not correct the coagulopathy.

Question 13Internal Medicine

A 62-year-old man has a serum sodium of 118 mmol/L and is confused but hemodynamically stable. What is the maximum recommended rate of sodium correction in the first 24 hours?

  1. 20 to 25 mmol/L
  2. No limit if symptomatic
  3. 8 to 10 mmol/L Correct answer.
  4. 30 to 35 mmol/L

Explanation

Correction of chronic hyponatremia should generally not exceed 8 to 10 mmol/L in 24 hours to avoid osmotic demyelination syndrome. Symptomatic hyponatremia may require hypertonic saline, but the overall rise must still be monitored and limited. Rapid correction risks permanent neurologic injury.

Question 14Internal Medicine

A 26-year-old man has sudden onset of severe headache described as the worst of his life. Non-contrast head CT is normal. What is the next most appropriate step?

  1. Reassurance and discharge
  2. MRI of the cervical spine
  3. Triptan therapy for migraine
  4. Lumbar puncture for xanthochromia Correct answer.

Explanation

A thunderclap headache raises concern for subarachnoid hemorrhage. If non-contrast CT is negative and the presentation is suspicious, lumbar puncture for xanthochromia or CT angiography should follow, as small hemorrhages may not be visible on early CT. Discharge or migraine treatment risks missing a life-threatening cause.

Question 15Internal Medicine

A 48-year-old woman has fatigue, weight gain and cold intolerance. TSH is elevated and free T4 is low. Which finding is most consistent with primary hypothyroidism rather than central hypothyroidism?

  1. Low TSH with low free T4
  2. Elevated TSH with low free T4 Correct answer.
  3. Elevated TSH with elevated free T4
  4. Normal TSH with low free T4

Explanation

Primary hypothyroidism is characterized by an elevated TSH due to loss of negative feedback from thyroid hormones, along with a low free T4. Central hypothyroidism produces low or inappropriately normal TSH with low free T4. Elevated TSH with elevated free T4 would suggest resistance or a TSH-secreting adenoma.

Question 16Internal Medicine

A 64-year-old man has fatigue and a hemoglobin of 9.2 g/dL with an MCV of 108 fL. Which cause is most likely?

  1. Anemia of chronic disease
  2. Thalassemia trait
  3. Iron deficiency
  4. Vitamin B12 deficiency Correct answer.

Explanation

Macrocytic anemia with an elevated MCV points to vitamin B12 or folate deficiency, among other causes. Iron deficiency and thalassemia typically produce microcytic anemia. Anemia of chronic disease is usually normocytic. Vitamin B12 deficiency also warrants evaluation for pernicious anemia and neurologic involvement.

Question 17Internal Medicine

A 56-year-old man with cirrhosis presents with fever, abdominal pain and ascites. Diagnostic paracentesis reveals 700 polymorphonuclear cells per microliter. What is the most appropriate initial treatment?

  1. Therapeutic large-volume paracentesis alone
  2. Intravenous furosemide
  3. Intravenous third-generation cephalosporin Correct answer.
  4. Oral lactulose

Explanation

Spontaneous bacterial peritonitis is diagnosed when the ascitic fluid polymorphonuclear cell count is at least 250/µL, and empiric intravenous third-generation cephalosporin therapy should be started promptly. Lactulose treats hepatic encephalopathy and furosemide treats volume overload, not infection. Paracentesis alone does not treat the infection.

Question 18Internal Medicine

A 22-year-old man has episodes of palpitations with a sudden onset and termination. ECG shows a narrow-complex tachycardia at 180 beats per minute with no visible P waves. He is hemodynamically stable. What is the most appropriate initial management?

  1. Immediate synchronized cardioversion
  2. Intravenous amiodarone bolus
  3. Oral digoxin loading
  4. Vagal maneuvers followed by intravenous adenosine Correct answer.

Explanation

A stable narrow-complex regular tachycardia is most likely atrioventricular nodal reentrant tachycardia, and vagal maneuvers followed by intravenous adenosine are first-line for termination. Synchronized cardioversion is reserved for unstable patients. Amiodarone and digoxin are not first-line for acute termination of SVT.

Question 19Internal Medicine

A 40-year-old woman has episodic headache, palpitations and diaphoresis with markedly elevated blood pressure during attacks. Which test is most appropriate to screen for pheochromocytoma?

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

Explanation

Plasma free metanephrines are the most sensitive screening test for pheochromocytoma, and elevations should prompt imaging. Serum cortisol evaluates adrenal cortical function, not the medulla. Renin activity and urine albumin assess other aspects of hypertension and kidney disease.

Question 20Internal Medicine

A 68-year-old man has progressive dyspnea and dry cough. He has never smoked. Chest CT shows bilateral peripheral and lower-lobe predominant reticulation with honeycombing. What is the most likely diagnosis?

  1. Tuberculosis
  2. Pulmonary embolism
  3. Idiopathic pulmonary fibrosis Correct answer.
  4. Chronic obstructive pulmonary disease

Explanation

Idiopathic pulmonary fibrosis presents with progressive dyspnea, dry cough and a usual interstitial pneumonia pattern on CT, characterized by peripheral, lower-lobe predominant reticulation and honeycombing. COPD typically shows hyperinflation and emphysema. Pulmonary embolism and tuberculosis have different radiographic and clinical features.

Question 21Internal Medicine

A 52-year-old man with a history of nephrolithiasis has a serum calcium of 11.2 mg/dL and an inappropriately normal parathyroid hormone level. Which finding best supports primary hyperparathyroidism?

  1. Elevated serum calcium with elevated or inappropriately normal PTH Correct answer.
  2. Low serum calcium with elevated PTH
  3. Elevated serum calcium with suppressed PTH
  4. Normal serum calcium with low PTH

Explanation

Primary hyperparathyroidism is characterized by hypercalcemia with an elevated or inappropriately normal PTH due to autonomous parathyroid secretion. Low calcium with high PTH suggests secondary hyperparathyroidism. Hypercalcemia with suppressed PTH suggests a non-parathyroid cause such as malignancy.

Question 22Internal Medicine

A 74-year-old woman has sudden onset of painless vision loss in the right eye lasting 15 minutes, resolving completely. She has hypertension and atrial fibrillation. What is the most appropriate next step?

  1. Topical antibiotic eye drops
  2. Reassurance without further workup
  3. Urgent evaluation for transient ischemic attack and stroke risk Correct answer.
  4. Elective cataract surgery referral

Explanation

Transient monocular vision loss (amaurosis fugax) is a transient ischemic attack of the retinal circulation and carries a high short-term stroke risk, especially with atrial fibrillation. Urgent evaluation including carotid imaging and cardiac assessment is indicated. Reassurance or eye drops would delay stroke prevention.

Question 23Internal Medicine

A 58-year-old man has acute pancreatitis and develops fever, hypotension and a rising white blood cell count on day 5. Which intervention is most appropriate for suspected infected pancreatic necrosis?

  1. Oral pancreatic enzyme replacement
  2. Immediate open necrosectomy
  3. Intravenous antibiotics with consideration of drainage Correct answer.
  4. Total parenteral nutrition alone

Explanation

Suspected infected pancreatic necrosis is initially managed with intravenous antibiotics and, if necessary, a step-up approach to drainage or minimally invasive debridement. Open necrosectomy is reserved for failure of less invasive measures. Enzyme replacement and parenteral nutrition alone do not treat infection.

Question 24Internal Medicine

A 62-year-old woman with rheumatoid arthritis on long-term prednisone and methotrexate presents with fever, dry cough and hypoxemia. Chest CT shows diffuse ground-glass opacities. Which organism should be specifically considered?

  1. Streptococcus pneumoniae
  2. Mycoplasma pneumoniae
  3. Pneumocystis jirovecii Correct answer.
  4. Influenza virus

Explanation

Immunosuppressed patients on corticosteroids and methotrexate are at risk for Pneumocystis jirovecii pneumonia, which presents with fever, dry cough, hypoxemia and diffuse ground-glass opacities. Streptococcus pneumoniae usually causes lobar consolidation, and Mycoplasma and influenza are less specifically linked to this immunocompromised profile.

Question 25Internal Medicine

A 45-year-old man has recurrent calcium oxalate kidney stones and a history of ileal resection. Which mechanism best explains his stone formation?

  1. Enteric hyperoxaluria from increased intestinal oxalate absorption Correct answer.
  2. Hypercalcemia from primary hyperparathyroidism
  3. Hyperuricosuria from tumor lysis
  4. Reduced urinary citrate due to renal tubular acidosis

Explanation

After ileal resection, unabsorbed fatty acids bind calcium in the gut, leaving free oxalate to be absorbed, producing enteric hyperoxaluria and calcium oxalate stones. Renal tubular acidosis and tumor lysis produce different stone types or mechanisms. Primary hyperparathyroidism causes hypercalciuria but does not explain the post-resection picture.

Question 26Internal Medicine

A 68-year-old man is admitted with community-acquired pneumonia. His CURB-65 score is 2 (confusion and blood urea nitrogen 25 mg/dL). According to standard severity assessment, which setting of care is most appropriate?

  1. Short-stay inpatient ward or observation unit Correct answer.
  2. Discharge home without antibiotics
  3. Direct admission to the intensive care unit for mechanical ventilation
  4. Routine outpatient management with oral antibiotics

Explanation

CURB-65 scores of 2 identify patients at increased 30-day mortality who generally require hospital-level care such as a short-stay ward or observation, with ICU considered when scores reach 4-5 or when there is hemodynamic or respiratory failure. A score of 2 does not mandate ICU admission nor permit routine outpatient therapy.

Question 27Internal Medicine

A 55-year-old woman with type 2 diabetes has an eGFR of 32 mL/min/1.73 m² and an albumin-to-creatinine ratio of 450 mg/g despite maximal ACE inhibitor therapy. Which additional agent has the strongest evidence for slowing progression of diabetic kidney disease in this setting?

  1. Allopurinol
  2. Furosemide
  3. Dapagliflozin Correct answer.
  4. Amlodipine

Explanation

SGLT2 inhibitors such as dapagliflozin reduce progression of albuminuric diabetic kidney disease and are recommended in patients with eGFR above approximately 20-25 mL/min/1.73 m² despite renin-angiotensin blockade. Amlodipine, furosemide and allopurinol do not have this disease-modifying evidence.

Question 28Internal Medicine

A 72-year-old man presents with a 3-week history of fatigue, early satiety and left upper quadrant fullness. Examination reveals splenomegaly. Complete blood count shows hemoglobin 9.0 g/dL, platelets 80,000/µL and leukoerythroblastic smear with teardrop cells. Bone marrow biopsy shows fibrosis. Which diagnosis is most likely?

  1. Primary myelofibrosis Correct answer.
  2. Iron deficiency anemia
  3. Immune thrombocytopenic purpura
  4. Chronic lymphocytic leukemia

Explanation

Massive splenomegaly, teardrop cells, leukoerythroblastic picture and marrow fibrosis in an older adult are classic for primary myelofibrosis. CLL causes lymphocytosis rather than fibrosis, ITP affects platelets alone, and iron deficiency does not produce marrow fibrosis or splenomegaly of this degree.

Question 29Internal Medicine

A 30-year-old woman is diagnosed with Graves disease. She is started on methimazole. Which adverse effect requires immediate discontinuation of the drug and urgent medical evaluation?

  1. Weight gain of 2 kg
  2. Mild pruritic rash
  3. Agranulocytosis with fever and sore throat Correct answer.
  4. Transient mild elevation of liver enzymes

Explanation

Methimazole can cause agranulocytosis, a life-threatening complication presenting with fever and sore throat that mandates immediate drug cessation and urgent evaluation. Mild transaminase elevations and mild rash can often be monitored, and weight gain is expected as thyrotoxicosis resolves.

Question 30Internal Medicine

A 63-year-old man with a history of myocardial infarction presents with 2 hours of substernal chest pressure. ECG shows ST elevation in leads V1-V4. Which coronary artery is most likely occluded?

  1. Right coronary artery
  2. Left anterior descending artery Correct answer.
  3. Left main coronary artery
  4. Left circumflex artery

Explanation

ST elevation in V1-V4 localizes to the anterior wall, supplied by the left anterior descending artery. Right coronary occlusion typically produces inferior changes (II, III, aVF), circumflex occlusion produces lateral changes, and left main occlusion usually causes widespread ST depression with aVR elevation.

Question 31Internal Medicine

A 45-year-old woman presents with episodic severe hypertension, headaches and palpitations. Plasma metanephrines are markedly elevated. She is started on an alpha-blocker. Which additional precaution is essential before surgery?

  1. Starting an ACE inhibitor to prevent postoperative hypertension
  2. Immediate beta-blockade before alpha-blockade to control heart rate
  3. Volume expansion with high salt intake and beta-blockade only after alpha-blockade Correct answer.
  4. Withholding all antihypertensives for 48 hours before surgery

Explanation

In pheochromocytoma, alpha-blockade must precede beta-blockade to avoid unopposed alpha stimulation and hypertensive crisis; patients also require volume expansion because chronic catecholamine excess causes volume contraction. Beta-blockade given first can precipitate severe hypertension.

Question 32Internal Medicine

A 58-year-old man with alcoholic cirrhosis presents with confusion and asterixis. Ammonia is elevated. Which medication is first-line for reducing ammonia production in this setting?

  1. Omeprazole
  2. Rifaximin
  3. Metronidazole
  4. Lactulose Correct answer.

Explanation

Lactulose is first-line therapy for hepatic encephalopathy, acidifying the colon and trapping ammonia while acting as an osmotic laxative. Rifaximin is typically added for secondary prophylaxis after a second episode, and metronidazole and omeprazole are not treatments for encephalopathy.

Question 33Internal Medicine

A 24-year-old man presents with acute monoarthritis of the knee. Joint aspiration shows needle-shaped negatively birefringent crystals. Which finding is most consistent with the diagnosis?

  1. Elevated anti-cyclic citrullinated peptide
  2. Calcium pyrophosphate crystals on microscopy
  3. Positive rheumatoid factor
  4. Hyperuricemia on serum testing Correct answer.

Explanation

Negatively birefringent needle-shaped crystals identify monosodium urate, confirming gout; hyperuricemia supports the diagnosis though serum urate may be normal during an acute attack. Rheumatoid factor and anti-CCP relate to rheumatoid arthritis, and calcium pyrophosphate crystals are rhomboid and positively birefringent.

Question 34Internal Medicine

A 34-year-old woman with no prior medical history presents with 2 weeks of progressive weakness, diplopia and ptosis that worsen through the day. Repetitive nerve stimulation shows a decremental response. Which antibody is most specifically associated with this condition?

  1. Anti-Jo-1 antibody
  2. Anti-double-stranded DNA antibody
  3. Anti-tissue transglutaminase antibody
  4. Anti-acetylcholine receptor antibody Correct answer.

Explanation

Fatigable weakness with ptosis, diplopia and a decremental response to repetitive stimulation indicates myasthenia gravis, in which anti-acetylcholine receptor antibodies are the most specific and common finding. The other antibodies are associated with lupus, antisynthetase syndrome and celiac disease respectively.

Question 35Internal Medicine

A 62-year-old man with chronic kidney disease stage 4 (eGFR 22 mL/min/1.73 m²) develops hyperkalemia with a potassium of 6.8 mmol/L and ECG shows peaked T waves. Which intervention should be given first to stabilize the myocardium?

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

Explanation

Intravenous calcium is the first-line therapy for hyperkalemia with ECG changes because it stabilizes the myocardial membrane within minutes without lowering potassium. Insulin-glucose, binders and furosemide shift or remove potassium but do not immediately protect the heart.

Question 36Internal Medicine

A 58-year-old man is admitted with severe acute pancreatitis. On day 3 he develops fever, tachycardia and a rising white blood cell count. Contrast-enhanced CT shows a fluid collection with gas within it. Which management step is most appropriate?

  1. Observation with repeat imaging in 2 weeks
  2. Immediate total pancreatectomy
  3. Image-guided drainage or surgical debridement of infected necrosis Correct answer.
  4. Initiation of high-dose corticosteroids

Explanation

Gas within a peripancreatic collection after acute pancreatitis indicates infected necrosis, which requires drainage, often image-guided, with surgical debridement if needed. Observation is unsafe with infection, pancreatectomy is not standard, and corticosteroids have no role.

Question 37Internal Medicine

A 70-year-old woman with atrial fibrillation on apixaban presents with a hemoglobin of 6.5 g/dL and melena. Which agent is the specific reversal agent for apixaban in this setting?

  1. Andexanet alfa Correct answer.
  2. Idarucizumab
  3. Vitamin K
  4. Protamine sulfate

Explanation

Andexanet alfa is a specific reversal agent for factor Xa inhibitors such as apixaban and rivaroxaban. Idarucizumab reverses dabigatran, protamine reverses heparin, and vitamin K reverses warfarin.

Question 38Internal Medicine

A 28-year-old man presents with fever, night sweats and a chronic cough. Sputum is positive for acid-fast bacilli. Which finding on chest imaging is most characteristic of reactivation pulmonary tuberculosis?

  1. Diffuse ground-glass opacities
  2. Lower lobe consolidation with air bronchograms
  3. Apical cavitation Correct answer.
  4. Bilateral hilar lymphadenopathy without parenchymal disease

Explanation

Reactivation tuberculosis classically produces upper lobe apical cavitary disease. Bilateral hilar lymphadenopathy without parenchymal disease is more typical of primary tuberculosis, lower lobe consolidation suggests bacterial pneumonia, and diffuse ground-glass opacities suggest viral or interstitial disease.

Question 39Internal Medicine

A 66-year-old man with a history of hypertension presents with sudden onset of severe headache and a third nerve palsy. Non-contrast CT is normal. Which next step is most appropriate to evaluate for subarachnoid hemorrhage?

  1. Immediate MRI of the brain without contrast
  2. Carotid Doppler ultrasound
  3. Lumbar puncture for xanthochromia Correct answer.
  4. Repeat non-contrast CT in 24 hours

Explanation

When subarachnoid hemorrhage is suspected but non-contrast CT is negative, lumbar puncture for xanthochromia is the appropriate next step, ideally after 12 hours from symptom onset. MRI without contrast, delayed repeat CT and carotid Doppler are not first-line for this diagnosis.

Question 40Internal Medicine

A 40-year-old woman with systemic lupus erythematosus presents with new edema, proteinuria of 4 g/day and active urinary sediment. Which finding on renal biopsy would be most consistent with diffuse proliferative lupus nephritis (class IV)?

  1. Global glomerulosclerosis without immune deposits
  2. Isolated mesangial deposits without proliferation
  3. Subendothelial immune complex deposits with endocapillary proliferation Correct answer.
  4. Minimal change disease pattern

Explanation

Class IV lupus nephritis is characterized by subendothelial immune complex deposits and endocapillary proliferation, often with hypocomplementemia and active sediment. Mesangial deposits indicate class II, glomerulosclerosis suggests chronic damage, and minimal change pattern is not a lupus lesion.

Question 41Surgery

A 24-year-old man develops sudden severe right testicular pain with nausea. Doppler ultrasound shows reduced blood flow to the right testis. What is the most appropriate immediate management?

  1. Urgent cystoscopy and urethral dilation
  2. Scrotal elevation and NSAIDs with outpatient review
  3. Surgical exploration with detorsion and fixation Correct answer.
  4. Immediate antibiotic therapy for epididymitis

Explanation

Testicular torsion is a surgical emergency because prolonged ischemia leads to infarction; the window for salvage is roughly six hours. Immediate scrotal exploration allows detorsion, assessment of viability, and bilateral orchidopexy. Doppler findings of decreased flow support but do not delay surgery.

Question 42Surgery

Which finding most strongly suggests that a patient with acute abdominal pain has peritonitis requiring surgical evaluation?

  1. Rebound tenderness with involuntary guarding Correct answer.
  2. Pain relieved by lying prone
  3. Diffuse hyperactive bowel sounds
  4. Bilateral lower quadrant tenderness without rigidity

Explanation

Peritoneal irritation produces involuntary guarding and rebound tenderness, signs that the parietal peritoneum is inflamed and often herald a surgical abdomen. These findings warrant urgent surgical assessment. The other options describe nonspecific or non-peritoneal patterns.

Question 43Surgery

A 45-year-old woman has a 2 cm breast mass. Core biopsy shows invasive ductal carcinoma. Which receptor profile determines eligibility for trastuzumab-based therapy?

  1. Triple-negative status
  2. Progesterone receptor positivity
  3. Estrogen receptor positivity
  4. HER2 overexpression or amplification Correct answer.

Explanation

Trastuzumab is a monoclonal antibody directed against the HER2 receptor, so eligibility requires HER2 overexpression by immunohistochemistry or gene amplification by in situ hybridization. Hormone receptor status guides endocrine therapy, not anti-HER2 agents.

Question 44Surgery

Which patient characteristic most increases the risk of venous thromboembolism after major elective abdominal surgery?

  1. Surgery lasting 45 minutes
  2. Age over 60 years with a history of malignancy Correct answer.
  3. Body mass index of 22
  4. Age under 30 years

Explanation

Advanced age and active malignancy are well-established independent risk factors for postoperative venous thromboembolism and drive the choice of pharmacologic prophylaxis. Young age, normal body mass index, and short operative time are low-risk features.

Question 45Surgery

A 30-year-old man has a small perianal abscess with surrounding cellulitis. What is the definitive treatment?

  1. Oral antibiotics alone
  2. Topical steroid cream
  3. Sitz baths alone
  4. Incision and drainage Correct answer.

Explanation

The definitive treatment of an anorectal abscess is prompt incision and drainage, because antibiotics cannot penetrate the pus-filled cavity adequately. Antibiotics are adjunctive in patients with cellulitis or systemic illness. Delay risks extension and sepsis.

Question 46Surgery

A patient sustains a stab wound to the right upper quadrant and becomes hypotensive. Which finding most strongly indicates the need for immediate operative exploration?

  1. Hemodynamic instability despite fluid resuscitation Correct answer.
  2. Local wound tenderness
  3. Mild leukocytosis
  4. Small pneumoperitoneum on CT

Explanation

Persistent hypotension despite resuscitation after penetrating abdominal trauma indicates ongoing hemorrhage or major organ injury and mandates immediate laparotomy. Tenderness alone or minor CT findings may be managed with observation and serial examination.

Question 47Surgery

Which statement about the surgical management of a 70-year-old patient with symptomatic cholelithiasis is correct?

  1. Observation is preferred because symptoms resolve spontaneously
  2. Laparoscopic cholecystectomy is the preferred elective treatment Correct answer.
  3. Open cholecystectomy is always required after age 65
  4. Endoscopic sphincterotomy alone is curative

Explanation

Laparoscopic cholecystectomy is the standard elective treatment for symptomatic gallstones at any adult age, including older patients, because it prevents recurrent biliary colic and complications. Age alone does not dictate an open approach.

Question 48Surgery

A patient develops a wound infection five days after surgery, with purulent discharge and dehiscence of the fascial layer. What is the priority action?

  1. Return to the operating room for fascial closure Correct answer.
  2. Start corticosteroids to reduce inflammation
  3. Apply topical antibiotics and continue dressing changes
  4. Increase oral analgesia and observe

Explanation

Fascial dehiscence with infection risks evisceration and requires urgent operative exploration and closure. Superficial wound care is inadequate when the fascial layer has failed. Delay risks evisceration and peritonitis.

Question 49Surgery

A 55-year-old man has painless gross hematuria. Which diagnosis must be excluded first?

  1. Benign prostatic hyperplasia
  2. Urothelial carcinoma of the bladder Correct answer.
  3. Acute cystitis
  4. Nephrolithiasis

Explanation

Painless gross hematuria in an older adult is a classic presentation of bladder cancer and mandates cystoscopy and upper tract imaging. Cystitis and stones usually cause pain, and hyperplasia causes obstructive symptoms rather than isolated hematuria.

Question 50Surgery

A patient with a 4 cm abdominal aortic aneurysm is asymptomatic. What is the most appropriate management?

  1. Thrombolytic therapy
  2. Elective surgical repair Correct answer.
  3. Serial ultrasound surveillance with risk factor control
  4. Immediate endovascular repair

Explanation

Aneurysms under 5.5 cm in men carry a low rupture risk, and randomized trials show no survival benefit from early repair; surveillance with blood pressure and smoking control is standard. Repair is reserved for larger or rapidly expanding aneurysms.