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Iran Specialty Board - Internal Medicine study materials
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Iran Specialty Board - Internal Medicine practice questions

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Question 1Cardiology

A 58-year-old man with hypertension and no prior cardiac disease presents with sudden tearing chest pain radiating to the back. Blood pressure is 180/100 mmHg in the right arm and 140/80 mmHg in the left arm. Which physical finding most strongly supports the diagnosis of acute aortic dissection?

  1. Bilateral basal crackles on lung auscultation
  2. A new early diastolic murmur at the left sternal border
  3. A pulse deficit between the two radial arteries Correct answer.
  4. A holosystolic murmur at the apex radiating to the axilla

Explanation

Interarm blood pressure difference and pulse deficit reflect differential involvement of the branch vessels by the dissection flap and are classic bedside clues. An early diastolic murmur suggests aortic regurgitation, which can complicate dissection but is neither sensitive nor specific, while crackles indicate heart failure.

Question 2Cardiology

A 70-year-old woman with a history of atrial fibrillation on warfarin presents with sudden painless loss of vision in the left eye. Examination shows a pale retina with a cherry-red spot at the macula. Which mechanism most likely explains this finding?

  1. Embolism to the central retinal artery Correct answer.
  2. Thrombosis of the central retinal vein
  3. Inflammation of the optic nerve head
  4. Vitreous hemorrhage from neovascularization

Explanation

A pale retina with a cherry-red spot at the macula is the hallmark of central retinal artery occlusion, typically caused by an embolus originating from the heart or carotid in patients with atrial fibrillation. Central retinal vein occlusion instead produces a blood-and-thunder fundus with venous engorgement and hemorrhages.

Question 3Cardiology

Which electrocardiographic finding is the earliest and most consistent sign of acute transmural myocardial ischemia in a patient presenting with chest pain?

  1. New left bundle branch block
  2. Peaked T waves with loss of R-wave amplitude
  3. Pathologic Q waves
  4. ST-segment elevation in two contiguous leads Correct answer.

Explanation

ST-segment elevation in anatomically contiguous leads is the defining ECG criterion for acute ST-elevation myocardial infarction and guides immediate reperfusion. Pathologic Q waves indicate established infarction, while peaked T waves and bundle branch block are less specific and may reflect other processes.

Question 4Cardiology

A 65-year-old man with heart failure with reduced ejection fraction (ejection fraction 30%) is being optimized. Which medication has been shown to reduce mortality in this population and should be part of standard therapy?

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

Explanation

Sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, reduces cardiovascular death and heart failure hospitalization compared with enalapril in heart failure with reduced ejection fraction. Amlodipine and diltiazem lack mortality benefit, and diltiazem is contraindicated in reduced ejection fraction due to negative inotropy.

Question 5Cardiology

A 24-year-old man is found to have a blood pressure of 168/104 mmHg on three separate visits with no identifiable secondary cause. Which finding on physical examination is most consistent with long-standing untreated hypertension?

  1. A continuous machinery murmur at the left infraclavicular area
  2. A systolic click followed by a late systolic murmur
  3. An S4 gallop on cardiac auscultation Correct answer.
  4. A widened pulse pressure with a bounding carotid pulse

Explanation

An S4 gallop reflects a stiff, noncompliant left ventricle from chronic pressure overload and is a common finding in long-standing hypertension. A bounding pulse with widened pulse pressure suggests aortic regurgitation, a machinery murmur suggests patent ductus arteriosus, and a click-murmur suggests mitral valve prolapse.

Question 6Cardiology

A 30-year-old woman presents with palpitations and is found to have a narrow-complex tachycardia at 190 beats per minute that terminates abruptly with adenosine. Which mechanism best explains this arrhythmia?

  1. Triggered activity from early afterdepolarizations
  2. Abnormal automaticity of ventricular Purkinje fibers
  3. Enhanced automaticity of the sinus node
  4. Reentry involving the atrioventricular node Correct answer.

Explanation

Paroxysmal supraventricular tachycardia that terminates with adenosine is typically due to reentry involving the atrioventricular node, such as AV nodal reentrant tachycardia or an accessory pathway. Adenosine transiently blocks AV nodal conduction and interrupts the reentrant circuit.

Question 7Cardiology

A 62-year-old man with no prior cardiac history presents with a blood pressure of 210/120 mmHg and evidence of papilledema on fundoscopy. Which term best describes this presentation?

  1. Hypertensive urgency
  2. White-coat hypertension
  3. Accelerated hypertension without target-organ damage
  4. Hypertensive emergency Correct answer.

Explanation

Hypertensive emergency is defined by severe blood pressure elevation accompanied by acute target-organ damage, such as papilledema, encephalopathy, or acute kidney injury. Hypertensive urgency involves severe elevation without acute target-organ damage and does not mandate the same urgent parenteral therapy.

Question 8Cardiology

A 55-year-old man with a history of myocardial infarction develops progressive dyspnea. Echocardiography shows an ejection fraction of 25% with a left ventricular thrombus. Which anticoagulation strategy is most appropriate?

  1. Dual antiplatelet therapy with aspirin and clopidogrel
  2. No anticoagulation, with repeat echocardiography in three months
  3. Warfarin with a target INR of 2.0 to 3.0 Correct answer.
  4. Aspirin 81 mg daily alone

Explanation

Left ventricular thrombus after myocardial infarction carries a high risk of systemic embolization and warrants therapeutic anticoagulation, typically warfarin with a target INR of 2.0 to 3.0 for at least three months. Antiplatelet monotherapy does not provide adequate protection against thrombus embolization.

Question 9Cardiology

A 48-year-old woman presents with pleuritic chest pain and a pericardial friction rub. ECG shows diffuse ST-segment elevation with PR depression. Which finding would most support a diagnosis of acute pericarditis rather than ST-elevation myocardial infarction?

  1. Regional wall motion abnormality on echocardiography
  2. Diffuse concave ST elevation across multiple vascular territories Correct answer.
  3. Reciprocal ST depression in inferior leads
  4. Marked ST elevation confined to leads V1 through V4

Explanation

Acute pericarditis produces diffuse concave ST elevation that does not respect coronary vascular territories, often with PR depression. ST-elevation myocardial infarction produces regional ST elevation with reciprocal depression and corresponding wall motion abnormalities.

Question 10Cardiology

A 72-year-old man with aortic stenosis presents with exertional syncope. Which mechanism most commonly explains syncope in severe aortic stenosis?

  1. Carotid sinus hypersensitivity from baroreceptor stimulation
  2. Vasovagal reflex triggered by ventricular stretch
  3. Reduced left ventricular output during exertion with inadequate cerebral perfusion Correct answer.
  4. Complete heart block from calcific involvement of the conduction system

Explanation

Exertional syncope in aortic stenosis typically results from the fixed obstruction preventing the normal increase in cardiac output during exercise, leading to a fall in cerebral perfusion. Vasovagal and carotid sinus mechanisms are less common, and conduction disease can occur but is not the classic exertional mechanism.

Question 11Cardiology

A 60-year-old woman with a history of rheumatic fever has a loud first heart sound and an opening snap followed by a mid-diastolic rumble at the apex. Which hemodynamic consequence is most expected?

  1. Left ventricular dilatation and eccentric hypertrophy
  2. Aortic root dilatation with aortic regurgitation
  3. Right ventricular volume overload from tricuspid regurgitation
  4. Left atrial enlargement and pulmonary hypertension Correct answer.

Explanation

Mitral stenosis causes obstruction to left atrial emptying, leading to left atrial enlargement and elevated pulmonary pressures with eventual pulmonary hypertension. The left ventricle is typically underfilled and not dilated, unlike in mitral regurgitation or aortic regurgitation.

Question 12Cardiology

A 55-year-old man with dilated cardiomyopathy has an ejection fraction of 30% despite optimal medical therapy and remains symptomatic with NYHA class III symptoms. Which additional therapy has been shown to reduce mortality in this setting?

  1. Digoxin
  2. An implantable cardioverter-defibrillator Correct answer.
  3. Amiodarone
  4. Hydralazine monotherapy

Explanation

An implantable cardioverter-defibrillator reduces mortality in patients with reduced ejection fraction and symptomatic heart failure by preventing sudden cardiac death from ventricular arrhythmias. Digoxin and amiodarone do not reduce mortality, and hydralazine monotherapy lacks the mortality benefit of combination therapy in this population.

Question 13Cardiology

A 34-year-old woman with a mechanical mitral valve is planning pregnancy. Which anticoagulation strategy is most appropriate to reduce both maternal thromboembolic risk and fetal harm?

  1. Switch to a direct oral anticoagulant in the first trimester
  2. Continue warfarin throughout pregnancy
  3. Use low-molecular-weight heparin with close anti-Xa monitoring Correct answer.
  4. Discontinue anticoagulation during the first trimester

Explanation

For mechanical valves, low-molecular-weight heparin with anti-Xa monitoring is often used during pregnancy to avoid warfarin embryopathy while maintaining anticoagulation. Direct oral anticoagulants are contraindicated with mechanical valves, and discontinuing anticoagulation risks valve thrombosis.

Question 14Cardiology

A 68-year-old man with chronic heart failure and an ejection fraction of 35% has a serum potassium of 5.6 mEq/L and a creatinine of 2.4 mg/dL while taking an ACE inhibitor, spironolactone, and a potassium supplement. What is the most appropriate next step?

  1. Add a thiazide diuretic to lower the potassium
  2. Continue all medications and recheck in one month
  3. Increase the spironolactone dose to improve outcomes
  4. Stop the potassium supplement and hold the ACE inhibitor and spironolactone Correct answer.

Explanation

Hyperkalemia above 5.5 mEq/L with renal impairment requires discontinuation of potassium supplements and potassium-retaining drugs, including ACE inhibitors and mineralocorticoid receptor antagonists, until the potassium normalizes. Continuing or increasing these agents risks life-threatening arrhythmia.

Question 15Cardiology

A 40-year-old man with Marfan syndrome is found to have an aortic root diameter of 5.2 cm. Which management is most appropriate?

  1. Beta-blocker therapy with annual echocardiography
  2. Elective aortic root replacement Correct answer.
  3. Losartan therapy alone with no surgical referral
  4. Restriction of strenuous activity only

Explanation

Aortic root diameter of 5.0 cm or greater in Marfan syndrome is generally an indication for elective aortic root replacement to prevent dissection. Beta-blockers and losartan slow progression but do not replace surgery once the threshold is reached.

Question 16Cardiology

A 58-year-old woman presents with palpitations and an irregularly irregular pulse. ECG shows no P waves and an irregular ventricular rate. Which finding on echocardiography is most likely in long-standing atrial fibrillation?

  1. Pericardial effusion
  2. Aortic root dilatation
  3. Left ventricular hypertrophy with a normal left atrium
  4. Left atrial enlargement Correct answer.

Explanation

Long-standing atrial fibrillation causes loss of atrial mechanical contraction and progressive left atrial enlargement, which in turn perpetuates the arrhythmia. Left ventricular hypertrophy, aortic root dilatation, and pericardial effusion are not typical direct consequences of atrial fibrillation.

Question 17Cardiology

A 45-year-old man is referred for evaluation of a systolic murmur. Echocardiography shows asymmetric septal hypertrophy with systolic anterior motion of the mitral leaflet and a dynamic left ventricular outflow gradient. Which intervention is most likely to worsen his obstruction?

  1. Septal myectomy
  2. Beta-blocker therapy
  3. Volume depletion from aggressive diuresis Correct answer.
  4. Disopyramide therapy

Explanation

In hypertrophic obstructive cardiomyopathy, reduced preload from aggressive diuresis worsens the dynamic outflow gradient and can precipitate symptoms. Beta-blockers, disopyramide, and septal myectomy reduce obstruction and symptoms.

Question 18Cardiology

A 67-year-old man with diabetes and peripheral arterial disease presents with resting pain in the left foot and a nonhealing ulcer. Which finding on vascular examination most strongly suggests critical limb ischemia?

  1. A bounding dorsalis pedis pulse
  2. An ankle-brachial index of 0.35 Correct answer.
  3. A warm foot with erythema
  4. A normal triphasic Doppler waveform

Explanation

An ankle-brachial index below 0.4 is consistent with severe peripheral arterial disease and critical limb ischemia in a symptomatic patient. A bounding pulse, warm erythematous foot, or normal triphasic waveform argues against significant arterial insufficiency.

Question 19Cardiology

A 78-year-old woman with severe aortic stenosis and a history of syncope is being evaluated. Which finding on cardiac catheterization is most consistent with severe aortic stenosis?

  1. A mean transvalvular gradient of 12 mmHg with a normal valve area
  2. A peak velocity of 2.0 m/s across the aortic valve
  3. A valve area of 0.8 cm² with a mean gradient of 45 mmHg Correct answer.
  4. A valve area of 2.0 cm² with a mean gradient of 10 mmHg

Explanation

Severe aortic stenosis is defined by a valve area of 1.0 cm² or less, often with a mean gradient of 40 mmHg or more in symptomatic patients. Lower gradients with larger areas indicate mild or moderate disease, and a peak velocity of 2.0 m/s is not severe.

Question 20Cardiology

A 50-year-old man with a history of alcohol use presents with palpitations and an irregularly irregular pulse. ECG shows absent P waves and an irregular ventricular response at 140 beats per minute. He is hemodynamically stable. Which initial management is most appropriate?

  1. Rate control with a beta-blocker or calcium channel blocker Correct answer.
  2. Adenosine administration
  3. Immediate synchronized cardioversion
  4. Atropine administration

Explanation

In hemodynamically stable atrial fibrillation with rapid ventricular response, rate control with a beta-blocker or non-dihydropyridine calcium channel blocker is the initial step. Synchronized cardioversion is reserved for instability, and adenosine and atropine have no role in atrial fibrillation.

Question 21Cardiology

A 62-year-old man with a history of myocardial infarction and an ejection fraction of 30% has an episode of sustained ventricular tachycardia. Which therapy has the strongest evidence for reducing mortality in this setting?

  1. Sotalol alone
  2. Implantable cardioverter-defibrillator placement Correct answer.
  3. Catheter ablation as first-line therapy
  4. Amiodarone alone

Explanation

In patients with reduced ejection fraction and sustained ventricular tachycardia, an implantable cardioverter-defibrillator reduces mortality by terminating lethal ventricular arrhythmias. Antiarrhythmic drugs such as amiodarone and sotalol may suppress arrhythmias but do not improve survival.

Question 22Cardiology

A 35-year-old woman with a mechanical aortic valve is admitted with fever and a new diastolic murmur. Blood cultures grow Staphylococcus aureus. Echocardiography shows a vegetation with a perivalvular abscess. Which management is most appropriate?

  1. Oral antibiotics with outpatient follow-up
  2. Prolonged intravenous antibiotics alone with repeat echocardiography in six weeks
  3. Urgent surgical consultation for valve replacement in addition to antibiotics Correct answer.
  4. Anticoagulation alone with observation

Explanation

Prosthetic valve endocarditis complicated by a perivalvular abscess and a new regurgitant murmur generally requires urgent surgical evaluation for valve replacement alongside intravenous antibiotics. Antibiotics alone are insufficient when there is invasive perivalvular infection and hemodynamic compromise.

Question 23Cardiology

A 58-year-old man with severe heart failure and an ejection fraction of 20% is admitted with worsening dyspnea. He has a history of recurrent ventricular tachycardia and a prior ICD. Which finding on echocardiography most strongly suggests a poor prognosis in this patient?

  1. A normal pulmonary artery systolic pressure
  2. An ejection fraction of 20% with normal right ventricular function
  3. A preserved left atrial size
  4. A restrictive mitral inflow pattern with a short deceleration time Correct answer.

Explanation

A restrictive mitral inflow pattern with a short deceleration time indicates elevated filling pressures and advanced diastolic dysfunction, which is associated with a poor prognosis in heart failure. Preserved atrial size and normal right ventricular function are more favorable findings.

Question 24Cardiology

A 45-year-old man with a history of cocaine use presents with chest pain and ST-segment elevation in the inferior leads. Which mechanism most likely explains his myocardial infarction?

  1. Aortic dissection extending into the right coronary ostium
  2. Coronary vasospasm with thrombosis related to cocaine-induced vasoconstriction Correct answer.
  3. Coronary embolism from atrial fibrillation
  4. Plaque rupture from hyperlipidemia alone

Explanation

Cocaine causes coronary vasoconstriction and increased platelet aggregation, leading to vasospasm and thrombosis even in the absence of significant atherosclerotic plaque. Hyperlipidemic plaque rupture and coronary embolism are possible but less directly linked to the acute cocaine exposure.

Question 25Pulmonology

A 24-year-old man is brought to the emergency department after a bee sting. He is anxious, with stridor, hoarse voice, and urticaria over the chest. Blood pressure is 82/50 mmHg and heart rate 124/min. After intramuscular epinephrine and fluid resuscitation, which airway intervention is most appropriate next?

  1. Awake fiberoptic nasotracheal intubation
  2. Early endotracheal intubation with a smaller tube Correct answer.
  3. Observation with continuous pulse oximetry
  4. Emergent cricothyrotomy

Explanation

Progressive stridor with hoarseness after anaphylaxis indicates laryngeal edema that can rapidly close the upper airway, so the airway must be secured early before edema worsens. Endotracheal intubation with a smaller tube is preferred while landmarks are still visible. Cricothyrotomy is reserved for a failed airway, and observation is unsafe in evolving angioedema.

Question 26Pulmonology

Which finding on arterial blood gas most strongly suggests that hypoxemia in a breathless patient is due to a shunt rather than to hypoventilation?

  1. A normal alveolar-arterial oxygen gradient that corrects with supplemental oxygen
  2. A low arterial partial pressure of oxygen with a respiratory alkalosis
  3. A widened alveolar-arterial oxygen gradient that does not improve with supplemental oxygen Correct answer.
  4. An elevated arterial partial pressure of carbon dioxide with a normal pH

Explanation

Hypoventilation raises carbon dioxide and lowers oxygen but leaves the alveolar-arterial gradient normal and responds well to oxygen. True shunt, as in consolidation or atelectasis, produces a widened A-a gradient with hypoxemia that persists despite high inspired oxygen. This distinguishes shunt physiology from pure hypoventilation.

Question 27Pulmonology

A 58-year-old woman with treated hypertension presents with sudden pleuritic chest pain and dyspnea. She is tachycardic and hypoxemic with a clear chest radiograph. Which test is the most appropriate first-line diagnostic study when she has no hypotension and normal renal function?

  1. Transthoracic echocardiography
  2. D-dimer measurement
  3. Computed tomography pulmonary angiography Correct answer.
  4. Ventilation-perfusion lung scan

Explanation

In a hemodynamically stable patient with a high clinical probability of pulmonary embolism, CT pulmonary angiography is the diagnostic test of choice because it directly visualizes thrombus and offers alternative diagnoses. D-dimer is only useful to exclude embolism in low or intermediate probability patients. Echocardiography is reserved for unstable patients.

Question 28Pulmonology

Which spirometric pattern is characteristic of a large left-sided pleural effusion in an otherwise healthy lung?

  1. Mixed pattern with markedly reduced FEV1/FVC ratio and increased residual volume
  2. Isolated reduction in diffusing capacity with normal volumes
  3. Obstructive pattern with reduced FEV1/FVC ratio and hyperinflation
  4. Restrictive pattern with reduced FVC and preserved or increased FEV1/FVC ratio Correct answer.

Explanation

A large effusion compresses the lung and reduces all lung volumes, producing a restrictive pattern: low FVC with a normal or high FEV1/FVC ratio. Obstructive physiology requires airflow limitation with a reduced ratio. Diffusing capacity is not the primary abnormality in isolated pleural fluid.

Question 29Pulmonology

A 68-year-old man with COPD has a resting PaO2 of 52 mmHg and cor pulmonale on echocardiography. Which intervention has the clearest mortality benefit for him?

  1. Prophylactic azithromycin at low dose indefinitely
  2. Long-term oxygen therapy for at least 15 hours per day Correct answer.
  3. Inhaled short-acting beta-agonist as sole maintenance therapy
  4. Routine oral corticosteroids for six months

Explanation

Long-term oxygen therapy improves survival in COPD patients with severe resting hypoxemia (PaO2 at or below 55 mmHg) or with hypoxemia plus evidence of cor pulmonale or polycythemia. Benefit requires use for at least 15 to 18 hours per day. Bronchodilators relieve symptoms but do not confer this mortality benefit.

Question 30Pulmonology

A 32-year-old woman has episodic wheeze and cough at night. Spirometry is normal when she is asymptomatic. Which test best supports a diagnosis of asthma?

  1. Serum alpha-1 antitrypsin level
  2. Methacholine bronchoprovocation testing Correct answer.
  3. Sputum culture for bacterial pathogens
  4. High-resolution computed tomography of the chest

Explanation

When baseline spirometry is normal but asthma is suspected, demonstrating bronchial hyperresponsiveness with methacholine challenge supports the diagnosis. A negative challenge makes current asthma unlikely. Imaging and alpha-1 antitrypsin testing do not assess variable airflow limitation.

Question 31Pulmonology

Which antibiotic strategy is appropriate for a previously healthy 30-year-old with community-acquired pneumonia treated as an outpatient in a region with low macrolide resistance?

  1. Oral amoxicillin plus high-dose amoxicillin-clavulanate
  2. Oral ciprofloxacin monotherapy
  3. Intravenous vancomycin
  4. Oral azithromycin monotherapy Correct answer.

Explanation

For an otherwise healthy outpatient without comorbidities, a macrolide is recommended when local pneumococcal macrolide resistance is low. It covers atypical organisms as well as susceptible Streptococcus pneumoniae. Routine broad-spectrum or anti-MRSA therapy is not indicated in uncomplicated disease.

Question 32Pulmonology

A 45-year-old man with a body mass index of 38 kg/m2 has daytime sleepiness and witnessed apneas. Which finding on overnight polysomnography defines obstructive sleep apnea?

  1. A sleep efficiency below 85 percent
  2. A periodic limb movement index above 15 per hour
  3. An apnea-hypopnea index of at least 5 per hour with compatible symptoms Correct answer.
  4. A single oxygen desaturation below 90 percent

Explanation

Obstructive sleep apnea is defined by an apnea-hypopnea index of at least 5 events per hour accompanied by symptoms, or by an index of at least 15 even without symptoms. Isolated desaturations or sleep fragmentation do not establish the diagnosis. The apnea-hypopnea index is the central diagnostic metric.

Question 33Pulmonology

A 70-year-old man has a large right-sided pleural effusion. Thoracentesis yields turbid fluid with a pH of 7.05, glucose of 30 mg/dL, and a positive Gram stain. What is the most appropriate immediate management?

  1. Observation with repeat imaging in 48 hours
  2. Tuberculostatic therapy with four drugs
  3. Tube thoracostomy drainage Correct answer.
  4. Video-assisted thoracoscopic decortication immediately

Explanation

Frankly purulent fluid, a pH below 7.20, low glucose, and positive Gram stain indicate complicated parapneumonic effusion or empyema requiring drainage. Prompt tube thoracostomy is the standard next step. Decortication is reserved for failure of drainage or organized empyema.

Question 34Pulmonology

Which mechanism best explains hypoxemia in a patient with severe acute respiratory distress syndrome?

  1. Alveolar hypoventilation from opioid toxicity
  2. Intrapulmonary shunt from alveolar flooding and collapse Correct answer.
  3. Reduced inspired oxygen partial pressure at sea level
  4. Diffusion limitation across a thickened alveolar membrane at rest

Explanation

In ARDS, inflammatory edema floods alveoli and surfactant dysfunction causes collapse, so blood perfuses nonventilated lung units: an intrapulmonary shunt. Shunt causes refractory hypoxemia that responds poorly to supplemental oxygen. Hypoventilation and low inspired oxygen are separate mechanisms.

Question 35Pulmonology

A 55-year-old woman with scleroderma has progressive exertional dyspnea. Which combination of tests is most appropriate to screen for systemic sclerosis-associated interstitial lung disease?

  1. Bronchoalveolar lavage and serum brain natriuretic peptide
  2. Ventilation-perfusion scan and D-dimer
  3. High-resolution computed tomography and pulmonary function tests including diffusing capacity Correct answer.
  4. Chest radiograph and sputum cytology

Explanation

Screening for interstitial lung disease in systemic sclerosis relies on high-resolution CT and pulmonary function testing with diffusing capacity, which together detect early parenchymal disease and physiological decline. Plain radiography is insensitive for early disease. V/Q scanning and D-dimer address thromboembolism, not fibrosis.

Question 36Pulmonology

A 28-year-old woman is intubated for status asthmaticus. Which ventilator strategy is most appropriate?

  1. High respiratory rate with a short expiratory time
  2. Routine high positive end-expiratory pressure above 15 cmH2O
  3. Low tidal volume with a prolonged expiratory time and permissive hypercapnia Correct answer.
  4. High tidal volume to overcome airway resistance

Explanation

In severe asthma, air trapping and dynamic hyperinflation raise the risk of barotrauma and hypotension. A low tidal volume, low rate, and prolonged expiratory time with permissive hypercapnia reduce trapping. High rates or high volumes worsen hyperinflation.

Question 37Pulmonology

A 60-year-old man with alcohol use disorder develops fever, productive cough with foul-smelling sputum, and a cavitary lesion in the superior segment of the right lower lobe. Which organism is most likely?

  1. Streptococcus pneumoniae
  2. Mycoplasma pneumoniae
  3. Anaerobic oral flora Correct answer.
  4. Klebsiella pneumoniae

Explanation

Foul-smelling sputum with a cavitary lesion in a dependent lung segment after aspiration strongly suggests anaerobic infection from oral flora. Anaerobes such as Peptostreptococcus and Fusobacterium are typical. Klebsiella can cause cavitation but classically produces currant-jelly sputum in patients with diabetes.

Question 38Pulmonology

Which statement about the tuberculin skin test is correct?

  1. It converts to positive within 24 hours of infection
  2. It may be falsely negative in miliary tuberculosis or immunosuppression Correct answer.
  3. A positive result proves active pulmonary disease
  4. It is unaffected by prior BCG vaccination

Explanation

The tuberculin skin test measures delayed hypersensitivity and can be falsely negative in disseminated disease, HIV, malnutrition, or other immunosuppression. It cannot distinguish latent from active infection and is influenced by prior BCG vaccination. A positive result indicates infection, not necessarily active disease.

Question 39Pulmonology

A 65-year-old man with a 50 pack-year smoking history has hemoptysis and a 3 cm spiculated mass in the right upper lobe with ipsilateral hilar enlargement. Which diagnosis is most likely?

  1. Small cell lung cancer
  2. Carcinoid tumor
  3. Squamous cell carcinoma Correct answer.
  4. Pulmonary hamartoma

Explanation

A central spiculated mass with hilar adenopathy in a heavy smoker is most consistent with squamous cell carcinoma, which arises centrally and can cause hemoptysis. Small cell carcinoma is also central but usually presents with bulky mediastinal disease and paraneoplastic syndromes. Hamartomas are typically peripheral and benign.

Question 40Pulmonology

A 72-year-old bedridden woman develops dyspnea and hypoxemia after hip surgery. She is hemodynamically stable. Which finding on CT pulmonary angiography confirms acute pulmonary embolism?

  1. Ground-glass opacities in both lower lobes
  2. Pleural effusion with a fluid level
  3. A filling defect within a contrast-opacified pulmonary artery Correct answer.
  4. Calcified hilar lymph nodes

Explanation

The diagnostic finding of acute pulmonary embolism on CT angiography is an intraluminal filling defect in an opacified pulmonary artery. This represents thrombus displacing contrast. Ground-glass opacities and effusions are nonspecific and do not confirm embolism.

Question 41Pulmonology

A 40-year-old man has recurrent hemoptysis, purulent sputum, and clubbing. High-resolution CT shows dilated bronchi with thickened walls in the lower lobes. Which diagnosis is most likely?

  1. Chronic obstructive pulmonary disease
  2. Bronchiectasis Correct answer.
  3. Lymphangioleiomyomatosis
  4. Idiopathic pulmonary fibrosis

Explanation

Chronic productive cough, hemoptysis, and clubbing with CT showing dilated, thick-walled bronchi define bronchiectasis. The condition results from chronic airway infection and inflammation. Idiopathic pulmonary fibrosis produces peripheral reticulation and honeycombing, not dilated airways.

Question 42Pulmonology

A 35-year-old woman has sudden dyspnea after a long flight. She is hypotensive at 80/50 mmHg and tachycardic, with elevated jugular venous pressure and a clear chest. Which management step is most appropriate immediately after starting oxygen and fluids?

  1. Serial D-dimer testing
  2. Oral anticoagulation with warfarin
  3. Systemic thrombolysis Correct answer.
  4. Inferior vena cava filter placement

Explanation

Hypotension with right heart failure after suspected massive pulmonary embolism defines high-risk disease, for which systemic thrombolysis is indicated to restore pulmonary perfusion. Anticoagulation alone is insufficient in shock. IVC filters are reserved for contraindications to anticoagulation or recurrent embolism despite therapy.

Question 43Pulmonology

Which pleural fluid finding is most consistent with an exudate by Light's criteria?

  1. Pleural fluid protein to serum protein ratio of 0.6 with elevated pleural LDH Correct answer.
  2. Pleural fluid protein to serum protein ratio of 0.4
  3. Pleural fluid lactate dehydrogenase below two-thirds the upper limit of normal serum
  4. Serum-pleural fluid albumin gradient greater than 1.2 g/dL

Explanation

Light's criteria classify fluid as exudative when the pleural-to-serum protein ratio exceeds 0.5, the pleural-to-serum LDH ratio exceeds 0.6, or pleural LDH exceeds two-thirds the upper limit of normal serum LDH. A protein ratio of 0.6 therefore indicates exudate. A high serum-pleural albumin gradient suggests transudate.

Question 44Pulmonology

A 50-year-old man with cirrhosis presents with progressive dyspnea and hypoxemia that worsens when he stands and improves when he lies down. What is the most likely mechanism?

  1. Intrapulmonary vascular dilatation with right-to-left shunting Correct answer.
  2. Alveolar hypoventilation from ascites
  3. Pulmonary embolism from a deep vein thrombosis
  4. Airway collapse from reduced lung elastic recoil

Explanation

Platypnea-orthodeoxia in a patient with cirrhosis indicates hepatopulmonary syndrome, in which intrapulmonary vascular dilatations create right-to-left shunting and worsen gas exchange in the upright position. Contrast echocardiography confirms the shunt. This is not caused by hypoventilation or embolism.

Question 45Gastroenterology and Hepatology

A 52-year-old man has recurrent epigastric pain relieved by meals and wakes at night with pain. He takes ibuprofen regularly for knee osteoarthritis. Which single step is most appropriate next in management?

  1. Add a prokinetic agent and reassess in four weeks
  2. Arrange urgent upper endoscopy before any medical therapy
  3. Start a proton pump inhibitor and continue the NSAID unchanged
  4. Stop the NSAID and test for Helicobacter pylori Correct answer.

Explanation

Night pain and meal-relieved dyspepsia suggest peptic ulcer disease, and regular NSAID use is the dominant modifiable risk factor. Guidelines advise stopping the NSAID where possible and testing for H. pylori with a validated test, treating if positive. Endoscopy is reserved for alarm features, older age thresholds, or failure of empirical therapy.

Question 46Gastroenterology and Hepatology

Which serologic pattern is most characteristic of autoimmune hepatitis?

  1. Positive anti-tissue transglutaminase IgA with villous atrophy
  2. Hypergammaglobulinemia with antinuclear and anti-smooth muscle antibodies Correct answer.
  3. Antimitochondrial antibody positivity with elevated alkaline phosphatase
  4. Low ceruloplasmin with Kayser-Fleischer rings

Explanation

Autoimmune hepatitis typically shows markedly raised IgG (hypergammaglobulinemia) together with antinuclear antibodies and anti-smooth muscle antibodies, plus interface hepatitis on biopsy. These serologic markers support the diagnosis in a patient with elevated aminotransferases.

Question 47Gastroenterology and Hepatology

A 45-year-old woman has a 3 cm gallstone and episodic right upper quadrant pain after fatty meals, with normal liver enzymes and no fever. What is the most appropriate management?

  1. Observation with dietary fat restriction alone
  2. Endoscopic retrograde cholangiopancreatography
  3. Elective laparoscopic cholecystectomy Correct answer.
  4. Ursodeoxycholic acid dissolution therapy

Explanation

Symptomatic cholelithiasis with typical biliary colic is best treated by elective laparoscopic cholecystectomy, which prevents recurrence and complications such as cholecystitis or pancreatitis. Dietary measures and observation do not remove the stone burden.

Question 48Gastroenterology and Hepatology

A patient with cirrhosis has ascites. Which regimen is the standard initial diuretic approach?

  1. Intravenous furosemide boluses twice weekly
  2. Furosemide 40 mg daily alone
  3. Hydrochlorothiazide 25 mg daily alone
  4. Spironolactone 100 mg with furosemide 40 mg daily Correct answer.

Explanation

Ascites in cirrhosis is driven by secondary hyperaldosteronism, so spironolactone is the cornerstone, usually combined with furosemide in a 100:40 ratio to maintain potassium balance. This combination gives better natriuresis than either drug alone.

Question 49Gastroenterology and Hepatology

Which finding best indicates spontaneous bacterial peritonitis in a patient with cirrhotic ascites?

  1. Ascitic fluid glucose of 90 mg/dL
  2. Serum-ascites albumin gradient of 1.5 g/dL
  3. Ascitic fluid total protein of 2.5 g/dL
  4. Ascitic fluid polymorphonuclear cell count of 400 per mm3 Correct answer.

Explanation

A polymorphonuclear cell count of 250 per mm3 or more in ascitic fluid defines spontaneous bacterial peritonitis and warrants prompt empiric antibiotics, typically a third-generation cephalosporin. Culture may be negative, so the cell count drives the decision.

Question 50Gastroenterology and Hepatology

A 38-year-old man has chronic hepatitis B with a viral load of 25,000 IU/mL, an ALT twice the upper limit of normal, and a liver biopsy showing bridging fibrosis. Which statement about treatment is correct?

  1. Antiviral therapy is indicated because of active replication with fibrosis Correct answer.
  2. Antiviral therapy is indicated only if the viral load exceeds one million IU/mL
  3. Interferon is contraindicated in all HBeAg-negative patients
  4. Treatment should be deferred until cirrhosis develops on imaging

Explanation

Chronic hepatitis B with active viral replication, elevated ALT, and significant fibrosis meets criteria for antiviral therapy regardless of HBeAg status. Nucleos(t)ide analogues with high genetic barrier such as tenofovir or entecavir are preferred.