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Iraqi Board Family Medicine study materials
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Iraqi Board Family Medicine practice questions

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Question 1Principles of Family Medicine and Primary Care

A 45-year-old man with no symptoms attends a primary care centre for a routine check. Which of the following best describes the core principle of primary care that distinguishes it from specialist hospital care?

  1. It provides episodic care only when the patient requests a specific service
  2. It provides first-contact, continuous and comprehensive care coordinated for the whole person over time Correct answer.
  3. It limits care to a single organ system to maintain clinical depth
  4. It focuses on managing advanced disease requiring specialised technical intervention

Explanation

Primary care is defined by first contact, continuity, comprehensiveness and coordination, delivered to the whole person rather than a single organ system. Specialist care is usually referral-based, episodic and focused on a defined problem. These attributes explain why general practice can manage undifferentiated illness over time.

Question 2Principles of Family Medicine and Primary Care

During a consultation, a patient says he wants antibiotics for a sore throat of two days' duration. Which communication skill is most appropriate for the family physician to use first?

  1. Immediately prescribing a broad-spectrum antibiotic to preserve the doctor-patient relationship
  2. Referring the patient to an ear, nose and throat clinic without further discussion
  3. Exploring the patient's ideas, concerns and expectations before negotiating management Correct answer.
  4. Telling the patient that antibiotics are never useful for sore throat

Explanation

Eliciting the patient's ideas, concerns and expectations is a core consultation skill that allows the physician to understand the agenda behind the request. Negotiation of management then follows from that shared understanding. This approach improves satisfaction and reduces unnecessary prescribing.

Question 3Principles of Family Medicine and Primary Care

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

  1. The uninterrupted availability of a physician at all hours of the day
  2. The transfer of records between hospitals during a single admission
  3. The provision of the same treatment protocol to all patients in a practice
  4. An ongoing therapeutic relationship between a patient and a known physician across episodes of illness Correct answer.

Explanation

Continuity of care refers to the sustained relationship between a patient and a clinician over time, spanning multiple episodes of care and incorporating accumulated knowledge of the patient. It is distinct from mere availability or record transfer. Relational continuity is associated with better preventive care and patient satisfaction.

Question 4Principles of Family Medicine and Primary Care

A 30-year-old woman presents with fatigue. Her family physician suspects iron deficiency anaemia. Which action best reflects the gatekeeping function of primary care?

  1. Advising the patient to attend the emergency department for a blood count
  2. Admitting the patient to hospital for a full workup
  3. Referring directly to a haematologist before any investigations
  4. Investigating the common causes in primary care first and referring only if indicated Correct answer.

Explanation

Gatekeeping means the family physician manages common problems and coordinates access to specialist care, referring when the clinical picture warrants it. Appropriate initial investigation in primary care avoids unnecessary specialist workload and cost. Direct specialist referral or hospital admission for an uncomplicated presentation is not gatekeeping.

Question 5Principles of Family Medicine and Primary Care

Which of the following is the best example of secondary prevention in family practice?

  1. Rehabilitating a patient after a stroke
  2. Providing smoking cessation advice to a healthy teenager
  3. Screening for colorectal cancer in an asymptomatic 55-year-old
  4. Giving aspirin to a patient after a myocardial infarction Correct answer.

Explanation

Secondary prevention aims to detect disease early or prevent its progression in people who already have it; aspirin after myocardial infarction reduces recurrence. Screening asymptomatic people is primary prevention when it aims to detect preclinical disease early, and health advice to a healthy teenager is also primary prevention. Rehabilitation after established stroke is tertiary prevention.

Question 6Principles of Family Medicine and Primary Care

A family physician wants to apply evidence-based medicine to a clinical question. Which is the most appropriate first step?

  1. Searching the internet for any article about the condition
  2. Formulating a focused answerable clinical question from the patient's problem Correct answer.
  3. Applying the most recent guideline without appraisal
  4. Asking a colleague for their personal experience

Explanation

Evidence-based practice begins with converting the clinical uncertainty into a focused, answerable question, often structured by population, intervention, comparison and outcome. This step guides an efficient search and appraisal. Searching without a question or relying on unappraised sources risks irrelevant or biased evidence.

Question 7Principles of Family Medicine and Primary Care

Which of the following best describes the 'patient-centred clinical method' in family medicine?

  1. Making decisions for the patient to ensure adherence
  2. Prioritising the physician's clinical agenda over the patient's concerns
  3. Restricting the consultation to biomedical aspects of the presenting complaint
  4. Exploring both the disease and the illness experience to find common ground with the patient Correct answer.

Explanation

The patient-centred clinical method integrates the biomedical disease perspective with the patient's experience of illness, including feelings, ideas, function and expectations. The goal is to reach common ground on problems and management. This contrasts with a purely physician-led, disease-focused approach.

Question 8Principles of Family Medicine and Primary Care

A 60-year-old diabetic patient attends for review. Which of the following best illustrates the principle of comprehensiveness in family medicine?

  1. Deferring all non-diabetes issues to a future appointment
  2. Focusing only on the HbA1c result during the visit
  3. Addressing glycaemic control, blood pressure, foot care, mood and vaccination status in one review Correct answer.
  4. Referring the patient to five different specialists for each problem

Explanation

Comprehensiveness means the family physician addresses the full range of the patient's health needs, including prevention and psychosocial issues, rather than a single condition. Managing multiple concurrent issues in one review reflects this principle. Fragmenting care across specialists or ignoring non-diabetes issues undermines it.

Question 9Principles of Family Medicine and Primary Care

Which of the following is the most appropriate way for a family physician to manage uncertainty in an undifferentiated presentation?

  1. Ordering every available investigation to exclude all possible diagnoses
  2. Prescribing empirical treatment without follow-up arrangements
  3. Using time as a diagnostic tool with a planned safety-netting review Correct answer.
  4. Referring immediately to a specialist for any uncertain symptom

Explanation

In primary care many presentations are undifferentiated and self-limiting; using time as a diagnostic tool with clear safety-netting advice allows reassessment if symptoms evolve. Blanket investigation or immediate referral for every uncertainty is wasteful and may cause harm. Empirical treatment without follow-up removes the safety net.

Question 10Principles of Family Medicine and Primary Care

Which of the following is the best example of primary prevention delivered in general practice?

  1. Referring a patient with diabetic retinopathy for laser therapy
  2. Administering the childhood measles-mumps-rubella vaccine Correct answer.
  3. Prescribing statins to a patient with established coronary disease
  4. Measuring blood pressure to detect undiagnosed hypertension

Explanation

Primary prevention acts before disease occurs, and immunisation is a classic example. Detecting undiagnosed hypertension is early detection, and statins after established coronary disease aim to prevent recurrence. Laser therapy for existing retinopathy treats established complications.

Question 11Principles of Family Medicine and Primary Care

A family physician is asked to describe the 'biopsychosocial model'. Which statement best captures its use in family practice?

  1. It considers biological, psychological and social factors together when understanding and managing illness Correct answer.
  2. It states that biological factors alone determine the course of disease
  3. It applies only to patients with diagnosed mental illness
  4. It replaces biomedical diagnosis with psychological assessment

Explanation

The biopsychosocial model holds that illness and its management are shaped by interacting biological, psychological and social factors. It complements rather than replaces biomedical assessment. Applying it only to mental illness or ignoring biology misrepresents the model.

Question 12Principles of Family Medicine and Primary Care

Which of the following best describes the role of the family physician as an advocate for the patient?

  1. Prescribing whatever the patient requests regardless of indication
  2. Representing the patient in legal proceedings against the hospital
  3. Deciding on the patient's behalf which treatments are affordable
  4. Helping the patient access needed services and addressing barriers created by the health system Correct answer.

Explanation

Advocacy involves working on behalf of patients to ensure they can access appropriate care and to address system barriers. It does not mean granting every request or taking on legal representation. Advocacy is a recognised professional role of the family physician within the health system.

Question 13Principles of Family Medicine and Primary Care

A 70-year-old with advanced dementia and recurrent aspiration pneumonia is discussed with the family. Which principle best guides the family physician in this discussion?

  1. Continuing all treatments without discussion to avoid conflict
  2. Eliciting the patient's previously expressed wishes and the family's understanding to plan goal-concordant care Correct answer.
  3. Referring the decision entirely to the hospital ethics committee
  4. Deciding unilaterally to withhold all treatment to avoid burden

Explanation

Advance care planning in family practice centres on the patient's values and previously expressed wishes, supported by discussion with the family. The physician facilitates rather than imposes decisions. Avoiding discussion or delegating the whole decision elsewhere fails the patient and family.

Question 14Principles of Family Medicine and Primary Care

Which of the following best describes the purpose of a practice audit in primary care?

  1. Punishing clinicians who deviate from guidelines
  2. Comparing current practice against agreed standards to identify and implement improvements Correct answer.
  3. Collecting data for research publications only
  4. Assessing the financial performance of the practice

Explanation

Clinical audit is a quality improvement cycle in which actual practice is measured against explicit standards, and changes are implemented and re-audited. Its purpose is improvement, not sanction or research publication. Financial performance is a separate management activity.

Question 15Principles of Family Medicine and Primary Care

A family physician notices that many patients with asthma in the practice have poor inhaler technique. Which action best reflects a quality improvement approach?

  1. Blaming individual patients for their poor technique
  2. Measuring inhaler technique rates, introducing a structured education intervention and re-measuring Correct answer.
  3. Ignoring the issue because it is not part of the consultation
  4. Referring every asthma patient to a specialist

Explanation

Quality improvement uses a plan-do-study-act cycle: measure the problem, implement a change and re-measure to assess effect. This systematic approach differs from blaming individuals or ignoring the problem. Referring all patients to specialists is neither feasible nor necessary.

Question 16Principles of Family Medicine and Primary Care

Which of the following best describes the concept of 'holistic care' in family medicine?

  1. Considering the patient's physical, psychological, social and spiritual needs in planning care Correct answer.
  2. Using complementary therapies instead of conventional medicine
  3. Providing care only to the patient's immediate family
  4. Treating only the presenting physical complaint

Explanation

Holistic care considers the whole person, including physical, psychological, social and spiritual dimensions, when planning management. It is not a rejection of conventional medicine or a restriction of care to the family unit. It complements the biomedical approach within family practice.

Question 17Internal Medicine in Family Practice

A 52-year-old man with type 2 diabetes has an eGFR of 32 mL/min/1.73 m². Which antihyperglycaemic agent should be avoided in a family practice setting because of reduced renal clearance and risk of lactic acidosis?

  1. Sitagliptin
  2. Empagliflozin
  3. Metformin Correct answer.
  4. Insulin glargine

Explanation

Metformin is cleared renally and accumulates when eGFR falls below about 30 mL/min/1.73 m², increasing the risk of lactic acidosis; most guidance advises stopping it at this level. SGLT2 inhibitors, DPP-4 inhibitors and insulin can all be used with dose adjustment or caution in advanced CKD.

Question 18Internal Medicine in Family Practice

A 28-year-old woman has a 3-day history of dysuria, frequency and suprapubic discomfort, with no fever or flank pain. What is the most appropriate initial management in family practice?

  1. Empirical treatment with oral ciprofloxacin for 7 days
  2. Urine culture and withholding antibiotics until results return
  3. A 3-day course of oral nitrofurantoin with advice on hydration Correct answer.
  4. Immediate referral for intravenous antibiotics

Explanation

Uncomplicated cystitis in a non-pregnant woman is treated empirically with a short course of a first-line agent such as nitrofurantoin. Culture is reserved for complicated, recurrent or treatment-failure cases, and fluoroquinolones are not first-line because of collateral damage and resistance.

Question 19Internal Medicine in Family Practice

Which finding on physical examination most strongly suggests a diagnosis of heart failure with reduced ejection fraction in a patient presenting with breathlessness?

  1. A single early diastolic murmur at the apex
  2. Unilateral leg swelling with calf tenderness
  3. Bilateral basal inspiratory crackles with a raised jugular venous pressure Correct answer.
  4. Inspiratory stridor relieved by sitting forward

Explanation

Raised jugular venous pressure combined with bibasal crackles reflects elevated filling pressures and pulmonary congestion, the classic bedside picture of heart failure. The other findings point to valvular disease, deep vein thrombosis or upper airway obstruction rather than heart failure.

Question 20Internal Medicine in Family Practice

A 34-year-old woman has episodic palpitations, sweating and tremor with documented hypertension. Which initial biochemical test is most appropriate to screen for phaeochromocytoma?

  1. Serum cortisol at midnight
  2. Plasma free metanephrines Correct answer.
  3. Serum thyrotropin
  4. Plasma renin activity

Explanation

Plasma free metanephrines have high sensitivity for phaeochromocytoma and are the preferred initial screening test in a patient with paroxysmal adrenergic symptoms and hypertension. Thyroid function and renin testing address other causes of palpitations or hypertension but not catecholamine excess.

Question 21Internal Medicine in Family Practice

A 45-year-old man with a BMI of 33 kg/m² has fasting plasma glucose of 6.8 mmol/L on two occasions. What is the correct diagnostic interpretation?

  1. Gestational diabetes requiring obstetric referral
  2. Impaired fasting glucose, requiring lifestyle intervention and annual retesting Correct answer.
  3. Overt diabetes mellitus requiring immediate insulin
  4. Normal glucose tolerance needing no follow-up

Explanation

Fasting plasma glucose between 6.1 and 6.9 mmol/L defines impaired fasting glucose, a prediabetic state managed with lifestyle change and periodic retesting. Diabetes requires a fasting value of 7.0 mmol/L or more, or other confirmatory criteria.

Question 22Internal Medicine in Family Practice

Which symptom pattern in an elderly patient most suggests a diagnosis of Parkinson disease rather than essential tremor?

  1. Bilateral postural tremor worsened by anxiety
  2. Tremor that disappears during walking
  3. Unilateral resting tremor with rigidity and bradykinesia Correct answer.
  4. Head titubation with a family history of tremor

Explanation

Parkinson disease classically presents with asymmetric resting tremor, cogwheel rigidity and bradykinesia, and the diagnosis requires bradykinesia plus at least one other cardinal feature. Essential tremor is typically bilateral, postural or kinetic, and often familial.

Question 23Internal Medicine in Family Practice

A 24-year-old woman has a 2-week history of low mood, anhedonia and poor sleep after losing her job. She denies suicidal ideation. What is the most appropriate first-line management in family practice?

  1. Reassurance alone with no scheduled review
  2. Immediate referral for electroconvulsive therapy
  3. Structured psychological therapy with active follow-up Correct answer.
  4. Starting a tricyclic antidepressant at a high dose

Explanation

Mild to moderate depression without suicidal ideation is managed first-line with structured psychological therapy such as cognitive behavioural therapy, together with regular monitoring. Electroconvulsive therapy is reserved for severe, treatment-resistant or life-threatening cases.

Question 24Internal Medicine in Family Practice

Which of the following is the most appropriate initial step when a 60-year-old smoker presents with a 6-week history of a non-healing mouth ulcer?

  1. Reassuring the patient that ulcers heal within 3 weeks
  2. Repeating a full blood count in 6 months
  3. Urgent referral for specialist assessment of possible oral malignancy Correct answer.
  4. Prescribing a topical antifungal for 4 weeks

Explanation

An oral ulcer persisting beyond 3 weeks, especially in a smoker, is a red flag for oral squamous cell carcinoma and warrants urgent specialist referral. Antifungal therapy is appropriate only for suspected candidiasis, which does not present as a persistent solitary ulcer in a smoker.

Question 25Internal Medicine in Family Practice

A 66-year-old woman with atrial fibrillation and a CHA₂DS₂-VASc score of 4 has no contraindication to anticoagulation. Which anticoagulant strategy is most appropriate?

  1. No antithrombotic therapy
  2. Aspirin 75 mg daily
  3. Clopidogrel 75 mg daily
  4. A direct oral anticoagulant such as apixaban Correct answer.

Explanation

A CHA₂DS₂-VASc score of 2 or more in women indicates a clear indication for oral anticoagulation, and direct oral anticoagulants are preferred over warfarin in most non-valvular cases. Antiplatelet agents do not provide adequate stroke prevention in atrial fibrillation.

Question 26Internal Medicine in Family Practice

A 40-year-old man has a blood pressure of 158/98 mmHg on three separate visits. He has no diabetes, renal disease or target-organ damage. What is the most appropriate initial pharmacological choice?

  1. An alpha blocker as monotherapy
  2. A loop diuretic as first-line therapy
  3. Immediate combination of three antihypertensives
  4. A thiazide-like diuretic or a calcium channel blocker Correct answer.

Explanation

For stage 1 hypertension without compelling indications, a thiazide-like diuretic, calcium channel blocker or ACE inhibitor/ARB is appropriate first-line therapy. Alpha blockers and loop diuretics are not preferred initial agents for uncomplicated hypertension.

Question 27Internal Medicine in Family Practice

A 58-year-old woman with type 2 diabetes has an HbA1c of 8.9% on metformin monotherapy. Which addition offers the greatest cardiovascular benefit in a patient with established atherosclerotic disease?

  1. An SGLT2 inhibitor or GLP-1 receptor agonist with proven cardiovascular benefit Correct answer.
  2. A sulfonylurea
  3. Pioglitazone
  4. A DPP-4 inhibitor

Explanation

In patients with type 2 diabetes and established cardiovascular disease, SGLT2 inhibitors and GLP-1 receptor agonists with proven outcome benefit should be added regardless of HbA1c. Sulfonylureas and DPP-4 inhibitors are glucose-lowering but lack this cardiovascular advantage.

Question 28Internal Medicine in Family Practice

A 30-year-old woman presents with a 3-day history of fever, right-sided pleuritic chest pain and productive cough. Chest examination shows bronchial breathing at the right base. What is the most appropriate next step?

  1. Trial of inhaled bronchodilators alone
  2. Reassurance and symptomatic treatment only
  3. Chest radiograph and initiation of empirical antibiotics for community-acquired pneumonia Correct answer.
  4. Immediate bronchoscopy

Explanation

The combination of fever, pleuritic pain, productive cough and bronchial breathing indicates community-acquired pneumonia, which requires a chest radiograph to confirm and prompt empirical antibiotics. Bronchoscopy is reserved for suspected obstruction or non-resolving disease.

Question 29Internal Medicine in Family Practice

A 48-year-old man has a fasting lipid profile showing LDL cholesterol of 4.9 mmol/L and no other risk factors. What is the most appropriate initial management?

  1. No intervention because he is asymptomatic
  2. Lifestyle modification plus a moderate-intensity statin Correct answer.
  3. Fibrate monotherapy
  4. Niacin therapy

Explanation

An LDL cholesterol above 4.9 mmol/L is a recognised high-risk threshold that warrants statin therapy in addition to lifestyle measures, regardless of calculated risk. Fibrates and niacin are not first-line for isolated LDL elevation.

Question 30Internal Medicine in Family Practice

A 55-year-old woman reports 3 months of fatigue, weight gain and cold intolerance. Which initial test is most appropriate?

  1. Fasting plasma glucose
  2. Serum vitamin B12
  3. Thyroid-stimulating hormone Correct answer.
  4. Serum calcium

Explanation

Symptoms of fatigue, weight gain and cold intolerance suggest hypothyroidism, for which thyroid-stimulating hormone is the most sensitive initial test. Other tests address different causes of fatigue but do not assess thyroid status.

Question 31Internal Medicine in Family Practice

A 62-year-old man with chronic obstructive pulmonary disease has an exacerbation with increased breathlessness and purulent sputum. Which combination is most appropriate for initial management in family practice?

  1. Short-acting bronchodilators plus a course of oral antibiotics and a short course of oral corticosteroids Correct answer.
  2. Long-term oxygen therapy at 4 L/min
  3. Immediate initiation of inhaled corticosteroids alone
  4. Oral antihistamines and a cough suppressant

Explanation

An exacerbation with purulent sputum warrants short-acting bronchodilators, oral antibiotics and a short course of systemic corticosteroids. Long-term oxygen and antihistamines are not appropriate for acute exacerbation management.

Question 32Internal Medicine in Family Practice

A 35-year-old woman has recurrent epigastric pain relieved by food and a positive urea breath test. What is the most appropriate treatment?

  1. Proton pump inhibitor-based triple therapy for Helicobacter pylori eradication Correct answer.
  2. H2 receptor antagonist alone
  3. Long-term proton pump inhibitor alone
  4. Antacid on demand

Explanation

Helicobacter pylori infection with peptic ulcer symptoms should be treated with eradication therapy, typically a proton pump inhibitor plus two antibiotics. Acid suppression alone relieves symptoms but does not eradicate the organism or prevent recurrence.

Question 33Internal Medicine in Family Practice

A 70-year-old man presents with sudden painless loss of vision in one eye lasting 10 minutes, which resolved. What is the most important consideration in family practice?

  1. Transient ischaemic attack requiring urgent assessment for stroke risk Correct answer.
  2. Acute angle-closure glaucoma requiring immediate surgery
  3. Retinal detachment requiring urgent vitrectomy
  4. Migraine with aura requiring analgesia

Explanation

Transient monocular visual loss (amaurosis fugax) is a transient ischaemic attack of the retinal artery and signals high short-term stroke risk, requiring urgent assessment for carotid disease and antithrombotic therapy. The other conditions do not typically present with brief, fully resolving monocular loss.

Question 34Internal Medicine in Family Practice

A 29-year-old woman has a 5-day history of unilateral throbbing headache with photophobia and nausea. What is the most appropriate acute treatment?

  1. Oral antibiotic therapy
  2. A triptan plus an antiemetic Correct answer.
  3. Intravenous fluids alone
  4. A beta blocker for immediate relief

Explanation

Acute migraine is treated with a triptan, often combined with an antiemetic to manage nausea and improve absorption. Beta blockers are used for prophylaxis rather than acute relief, and antibiotics have no role.

Question 35Internal Medicine in Family Practice

A 50-year-old woman with a history of recurrent urinary tract infections presents with fever, rigors and left loin pain. Which feature most strongly suggests pyelonephritis rather than cystitis?

  1. Dysuria
  2. Suprapubic discomfort
  3. Fever with rigors and flank tenderness Correct answer.
  4. Urinary frequency

Explanation

Fever, rigors and flank tenderness indicate upper urinary tract involvement, i.e. pyelonephritis, which requires different management from simple cystitis. Dysuria, frequency and suprapubic pain are lower tract symptoms seen in both conditions.

Question 36Internal Medicine in Family Practice

A 45-year-old man has a 6-month history of heartburn and regurgitation responding to a proton pump inhibitor. Which additional step is most appropriate?

  1. Add a second PPI for lifelong use
  2. Refer for immediate endoscopy in all cases
  3. Review for alarm features and consider step-down therapy after symptom control Correct answer.
  4. Continue high-dose PPI indefinitely without review

Explanation

Uncomplicated gastro-oesophageal reflux disease responding to a PPI is managed by reviewing alarm features and considering step-down or on-demand therapy. Endoscopy is reserved for alarm features, persistent symptoms or age-related risk thresholds.

Question 37Internal Medicine in Family Practice

A 68-year-old man with a history of hypertension presents with sudden-onset severe headache and a blood pressure of 210/120 mmHg. He has no focal neurological deficit. What is the most appropriate immediate action?

  1. Starting an ACE inhibitor and sending him home
  2. Reassurance and outpatient review in 1 week
  3. Rapid reduction of blood pressure to normal within 1 hour in the clinic
  4. Urgent referral for assessment of hypertensive emergency Correct answer.

Explanation

Severe hypertension with acute neurological symptoms suggests a hypertensive emergency and requires urgent hospital assessment with controlled blood pressure reduction. Rapid normalisation in a clinic setting risks cerebral hypoperfusion, and outpatient management is unsafe.

Question 38Internal Medicine in Family Practice

A 32-year-old woman has a 4-week history of symmetrical small-joint pain and morning stiffness lasting 2 hours. What is the most appropriate initial investigation?

  1. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies Correct answer.
  2. Antinuclear antibody alone
  3. Serum uric acid
  4. Erythrocyte sedimentation rate alone

Explanation

Prolonged morning stiffness with symmetrical small-joint involvement suggests rheumatoid arthritis, for which rheumatoid factor and anti-CCP antibodies are the key serological tests. Uric acid addresses gout, and a single inflammatory marker lacks diagnostic specificity.

Question 39Internal Medicine in Family Practice

A 60-year-old woman with type 2 diabetes has an eGFR of 45 mL/min/1.73 m² and albuminuria. Which medication class offers both renal and cardiovascular protection in this setting?

  1. DPP-4 inhibitors
  2. Sulfonylureas
  3. Insulin secretagogues
  4. SGLT2 inhibitors Correct answer.

Explanation

SGLT2 inhibitors slow progression of chronic kidney disease and reduce cardiovascular events in patients with type 2 diabetes and albuminuria, independent of glucose control. Sulfonylureas and DPP-4 inhibitors do not provide this renal protection.

Question 40Internal Medicine in Family Practice

A 40-year-old man has a blood pressure of 160/100 mmHg, hypokalaemia and metabolic alkalosis. Which condition should be considered?

  1. Cushing syndrome
  2. Primary aldosteronism Correct answer.
  3. Renovascular hypertension
  4. Phaeochromocytoma

Explanation

Hypertension with spontaneous hypokalaemia and metabolic alkalosis is a classic presentation of primary aldosteronism, screened with an aldosterone-to-renin ratio. Phaeochromocytoma causes paroxysmal adrenergic symptoms, and renovascular disease does not typically produce hypokalaemia.

Question 41Internal Medicine in Family Practice

A 55-year-old man with a 20-pack-year smoking history presents with haemoptysis and weight loss. What is the most appropriate initial investigation in family practice?

  1. Serum tumour markers alone
  2. Sputum culture only
  3. Urgent chest radiograph and referral for suspected lung cancer Correct answer.
  4. Trial of antibiotics and review in 6 weeks

Explanation

Haemoptysis with weight loss in a smoker is a red flag for lung cancer and requires urgent chest imaging and referral on a suspected cancer pathway. Antibiotic trials and tumour markers do not provide timely diagnosis.

Question 42Internal Medicine in Family Practice

A 68-year-old man with type 2 diabetes and a history of myocardial infarction presents to the family medicine clinic for review. His current medication is metformin 1 g twice daily and his most recent HbA1c is 7.4%. Which additional agent offers the greatest reduction in major adverse cardiovascular events?

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

Explanation

SGLT2 inhibitors such as empagliflozin and GLP-1 receptor agonists with proven cardiovascular outcome benefit are recommended in patients with type 2 diabetes and established atherosclerotic cardiovascular disease, independent of HbA1c. Empagliflozin demonstrated a significant reduction in cardiovascular death in patients with established cardiovascular disease. Sulfonylureas, thiazolidinediones and DPP-4 inhibitors do not carry this proven benefit.

Question 43Internal Medicine in Family Practice

A 72-year-old woman with hypertension and no other comorbidity has a clinic blood pressure of 152/88 mmHg on two occasions. Home readings average 148/86 mmHg. She has no diabetes, chronic kidney disease or albuminuria. According to standard hypertension guidance, what is the most appropriate initial pharmacological therapy?

  1. An ACE inhibitor combined with an angiotensin receptor blocker
  2. A calcium channel blocker or thiazide-like diuretic as first-line Correct answer.
  3. A beta-blocker as monotherapy
  4. A thiazide-like diuretic alone

Explanation

For adults aged 55 years or older of Black African or African-Caribbean family origin, or for older adults generally, a calcium channel blocker or a thiazide-like diuretic is the recommended first-line step. ACE inhibitors or ARBs are first-line for younger patients, particularly those of Black African or African-Caribbean family origin, and for people with diabetes or chronic kidney disease. Combining an ACE inhibitor with an ARB is contraindicated because of hyperkalaemia and acute kidney injury risk.

Question 44Internal Medicine in Family Practice

A 34-year-old woman presents with a 3-day history of dysuria, frequency and suprapubic discomfort. She is afebrile, has no flank pain or vaginal discharge, is not pregnant, and has no known allergies. What is the most appropriate management?

  1. Urine culture and await results before treating
  2. A 3-day course of oral trimethoprim or nitrofurantoin Correct answer.
  3. Immediate referral for intravenous antibiotics
  4. A 7-day course of oral ciprofloxacin

Explanation

Uncomplicated lower urinary tract infection in a non-pregnant woman is managed with a short course of an oral agent such as nitrofurantoin or trimethoprim, guided by local resistance data. Urine culture is not routinely needed for a first uncomplicated episode. Fluoroquinolones are reserved for complicated or upper tract infection because of resistance and adverse effect concerns.

Question 45Internal Medicine in Family Practice

A 58-year-old man with a 30-pack-year smoking history presents with a 6-week history of progressive exertional breathlessness and a chronic productive cough. Spirometry after bronchodilator shows an FEV1/FVC ratio of 0.62 and an FEV1 of 55% predicted. He has had two exacerbations in the past year treated with antibiotics. Which intervention most improves his long-term survival?

  1. Inhaled long-acting beta-2 agonist monotherapy
  2. Regular oral corticosteroids
  3. Prophylactic antibiotics throughout the year
  4. Smoking cessation and long-term domiciliary oxygen if hypoxaemic Correct answer.

Explanation

In COPD, smoking cessation is the single most effective intervention to slow decline in lung function, and long-term oxygen therapy improves survival in patients with chronic hypoxaemia. Inhaled bronchodilators improve symptoms and reduce exacerbations but do not clearly alter mortality. Oral corticosteroids are not used long term because of adverse effects.

Question 46Internal Medicine in Family Practice

A 26-year-old woman presents with a 2-week history of palpitations, heat intolerance, tremor and 4 kg weight loss despite a good appetite. She has a diffuse goitre and mild bilateral proptosis. TSH is suppressed and free T4 is elevated. She is not pregnant and has no cardiac disease. Which is the most appropriate initial definitive treatment for Graves disease in this patient?

  1. A thiazolidinedione to reduce thyroid hormone synthesis
  2. Radioactive iodine ablation as first-line therapy Correct answer.
  3. A beta-blocker alone as definitive therapy
  4. Total thyroidectomy as first-line therapy

Explanation

In a young, non-pregnant woman with Graves disease without significant ophthalmopathy, radioactive iodine is an accepted first-line definitive treatment alongside antithyroid drugs and surgery. Antithyroid drugs are often used first for a trial of remission, but radioiodine is appropriate definitive therapy when drugs fail or are declined. Beta-blockers control symptoms only and do not treat the underlying hyperthyroidism.

Question 47Pediatrics and Child Health

A 3-year-old child presents with a 2-day history of low-grade fever, runny nose, and a barking cough that worsens at night. He has mild stridor at rest but no drooling and no difficulty swallowing. What is the most appropriate initial management?

  1. Reassurance and saline nasal drops only
  2. Nebulised adrenaline plus a single dose of oral dexamethasone Correct answer.
  3. Oral amoxicillin-clavulanate
  4. Immediate endotracheal intubation

Explanation

This is croup (acute laryngotracheobronchitis), suggested by the barking cough, hoarse voice, and stridor with a viral prodrome. Stridor at rest indicates moderate disease, so a single dose of oral dexamethasone combined with nebulised adrenaline is appropriate for symptomatic relief and reduction of airway oedema. Antibiotics and intubation are reserved for other diagnoses or impending airway failure.

Question 48Pediatrics and Child Health

Which of the following is the most reliable single indicator of adequate hydration in a 6-month-old infant with acute gastroenteritis?

  1. Reduced urine output over 12 hours
  2. Sunken anterior fontanelle
  3. Capillary refill time under 2 seconds Correct answer.
  4. Weight loss of 3% since the last visit

Explanation

Capillary refill time under 2 seconds is a validated sign of adequate peripheral perfusion and is one of the most useful bedside indicators in infants. Sunken fontanelle is subjective and can occur with normal variation, mild weight loss under 5% is not significant, and reduced urine output is helpful but less immediate than perfusion assessment.

Question 49Pediatrics and Child Health

A 4-year-old child with sickle cell disease presents with fever of 39°C, cough, and tachypnoea. Chest radiograph shows a new infiltrate. Which organism is the most important to cover empirically in addition to typical respiratory pathogens?

  1. Staphylococcus aureus
  2. Streptococcus pneumoniae Correct answer.
  3. Chlamydia trachomatis
  4. Mycoplasma pneumoniae

Explanation

Children with sickle cell disease are functionally asplenic and are at high risk of invasive pneumococcal infection, including acute chest syndrome. Streptococcus pneumoniae is the leading bacterial pathogen in this setting, so empirical coverage must include it. Mycoplasma is a consideration in older children but is not the priority, and Staphylococcus aureus and Chlamydia are not the primary concerns.

Question 50Pediatrics and Child Health

A 10-month-old infant is brought with a 3-day history of diarrhoea and vomiting. On examination, he is lethargic, has sunken eyes, and a prolonged capillary refill of 4 seconds. What is the most appropriate first step in management?

  1. Subcutaneous administration of 10 mL/kg of Ringer's lactate
  2. Oral rehydration solution given by nasogastric tube
  3. Rapid intravenous bolus of 20 mL/kg of isotonic saline Correct answer.
  4. Slow intravenous infusion of 5% dextrose at maintenance rate

Explanation

This infant meets criteria for severe dehydration with shock (lethargy, sunken eyes, delayed capillary refill). The priority is rapid intravascular volume expansion with an isotonic crystalloid bolus of 20 mL/kg given intravenously. Oral or nasogastric routes are inadequate in shock, and dextrose-containing maintenance fluids do not correct hypovolaemia.