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Kuwait Board Family Medicine study materials
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Kuwait Board Family Medicine practice questions

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Question 1Family Medicine Principles and Patient-Centred Care

A 54-year-old man with type 2 diabetes and hypertension attends his family physician for a routine review. He has no current complaints and his examination is normal. According to the principles of anticipatory care in family medicine, which approach best describes the role of the primary care physician at this visit?

  1. Restrict the consultation to repeat prescribing of his current medication
  2. Refer him to a specialist clinic for every organ system review
  3. Screen for asymptomatic complications and modifiable risk factors relevant to his age and conditions Correct answer.
  4. Defer all preventive assessment until he reports new symptoms

Explanation

Anticipatory care means proactively identifying risks and early disease in patients who feel well, using age-, sex- and condition-specific screening. For a diabetic patient this includes renal, retinal, foot and cardiovascular risk assessment alongside lifestyle counselling. Reactive, symptom-driven or purely administrative consultations miss the preventive purpose of the routine review.

Question 2Family Medicine Principles and Patient-Centred Care

In the patient-centred clinical method, which element most specifically distinguishes the 'integrating' component from simply exploring the patient's ideas, feelings and expectations?

  1. Reaching a shared understanding that connects the patient's agenda with the clinician's agenda Correct answer.
  2. Asking open-ended questions at the start of the interview
  3. Recording the patient's exact words about their illness experience
  4. Summarising the patient's concerns before examining them

Explanation

The patient-centred method moves from exploring the illness experience to finding common ground, and integration refers to linking the patient's agenda with the clinician's perspective and the wider context. Exploration alone (ideas, feelings, expectations) is a separate component. Integration requires a negotiated, shared understanding rather than data gathering or summarising.

Question 3Family Medicine Principles and Patient-Centred Care

A mother brings her 3-year-old child with fever and cough. She is worried about pneumonia and requests an antibiotic. Examination shows a mild viral upper respiratory infection. Which response best exemplifies shared decision-making within family medicine?

  1. Acknowledge her concern, explain the likely viral cause, discuss the expected course and agree on safety-netting and symptom relief Correct answer.
  2. Tell her antibiotics are unnecessary and end the discussion without further explanation
  3. Refer the child to the emergency department to resolve the disagreement
  4. Prescribe an antibiotic to preserve the doctor–patient relationship and reduce her anxiety

Explanation

Shared decision-making combines the clinician's evidence-based view with the patient's (or parent's) values and concerns, producing an agreed plan. Explaining the viral nature, expected course, symptomatic measures and safety-netting respects the mother's worry while avoiding unnecessary antibiotics. Capitulating, dismissing or over-escalating all undermine the partnership.

Question 4Family Medicine Principles and Patient-Centred Care

Which statement best describes the concept of 'continuity of care' as a core value of family medicine?

  1. The transfer of complete records between hospitals at discharge
  2. The uninterrupted availability of the same physician for every emergency presentation
  3. An ongoing therapeutic relationship in which the physician accumulates knowledge of the patient over time Correct answer.
  4. The provision of care by a single nurse for each admission

Explanation

Continuity in family medicine is relational: the accumulated knowledge and trust built through repeated contacts over time. It is not the same as constant availability, nor is it merely informational transfer between institutions. Relational continuity improves communication, adherence and appropriate use of services.

Question 5Family Medicine Principles and Patient-Centred Care

A family physician in a busy clinic wants to improve her care of patients with multimorbidity. Which approach is most consistent with the principles of comprehensive primary care?

  1. Refer every chronic condition to its respective specialty clinic
  2. Manage each chronic disease in a separate dedicated visit
  3. Prioritise the conditions and goals that matter most to the patient, integrating management across problems Correct answer.
  4. Apply the same single-disease guideline to every condition simultaneously

Explanation

Comprehensive care in multimorbidity requires prioritisation negotiated with the patient and integration across conditions, because single-disease guidelines can conflict. Separate disease-focused visits fragment care and increase treatment burden. Referring every condition away abandons the coordinating role of the family physician.

Question 6Family Medicine Principles and Patient-Centred Care

Which of the following best defines the 'denominator' concept that distinguishes family medicine from many hospital specialties?

  1. The physician only sees patients referred with a confirmed diagnosis
  2. The physician serves an undefined population of patients who present with undifferentiated problems Correct answer.
  3. The physician counts only the patients admitted to hospital
  4. The physician restricts practice to a defined age group

Explanation

Family medicine deals with an undifferentiated denominator of people who present with symptoms before diagnosis, rather than a selected referred numerator. This requires tolerance of uncertainty and broad diagnostic reasoning. Confirmed-diagnosis, inpatient-only or age-restricted practice describes narrower specialty settings.

Question 7Family Medicine Principles and Patient-Centred Care

A 68-year-old woman with advanced dementia is brought by her daughter. The daughter insists on full resuscitation and intensive treatment for any future illness. The patient, when previously competent, had documented a preference for comfort-focused care. How should the family physician proceed?

  1. Refuse to discuss the matter and refer to the ethics committee immediately
  2. Follow the daughter's request, as family preference overrides the patient's prior wishes
  3. Explore the daughter's concerns and explain the patient's documented wishes, supporting advance care planning consistent with them Correct answer.
  4. Document the daughter's decision as the patient's own preference

Explanation

Previously expressed competent wishes, including advance directives, carry ethical and legal weight and should guide care. The physician's role is to sensitively explore the family's concerns while advocating for the patient's documented preferences. Simply deferring to relatives, avoiding discussion, or misrecording the decision all violate patient autonomy.

Question 8Family Medicine Principles and Patient-Centred Care

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

  1. Measuring HbA1c in a patient with known diabetes
  2. Administering the influenza vaccine to an older adult without current illness Correct answer.
  3. Prescribing antihypertensives to a patient with established hypertension
  4. Arranging rehabilitation after a stroke

Explanation

Primary prevention acts before disease occurs, such as immunisation of a healthy person. Monitoring HbA1c and treating established hypertension are secondary or tertiary activities in people with existing disease. Rehabilitation after stroke is tertiary prevention aimed at limiting disability.

Question 9Family Medicine Principles and Patient-Centred Care

A patient repeatedly presents with vague physical complaints, and the family physician suspects underlying psychological distress. Which principle best guides the physician's approach?

  1. Discharge the patient from the practice for frequent attendance
  2. Order extensive investigations to exclude every possible organic cause
  3. Confront the patient with the suspicion that the symptoms are not real
  4. Explore the meaning and context of the symptoms while maintaining a supportive, non-judgemental relationship Correct answer.

Explanation

Somatisation and medically unexplained symptoms are best managed by exploring meaning and context within a trusting relationship, avoiding confrontation and excessive investigation. Unnecessary testing risks iatrogenic harm, and rejection of the patient is harmful and unethical. A supportive, explanatory approach improves outcomes.

Question 10Family Medicine Principles and Patient-Centred Care

Which of the following best reflects the principle of 'holistic care' in family medicine?

  1. Focusing exclusively on the presenting physical symptom
  2. Considering the patient's physical, psychological, social and cultural context when formulating a management plan Correct answer.
  3. Restricting assessment to the results of laboratory investigations
  4. Treating every patient with the same standard protocol regardless of circumstances

Explanation

Holistic care integrates biological, psychological, social and cultural dimensions of health into assessment and management. It goes beyond the presenting complaint and beyond standardised protocols alone. A purely biomedical or protocol-driven approach omits the patient's context.

Question 11Family Medicine Principles and Patient-Centred Care

A 45-year-old woman attends with fatigue. After history and examination, the physician considers several possible diagnoses. Which cognitive strategy best reduces premature closure in this situation?

  1. Reassuring the patient that fatigue is usually benign without further evaluation
  2. Ordering a broad panel of tests without a clinical hypothesis
  3. Deliberately generating and testing alternative diagnoses before settling on one Correct answer.
  4. Committing to the first plausible diagnosis to save time

Explanation

Premature closure occurs when the clinician accepts a diagnosis too early and stops considering alternatives. Deliberately generating and testing a differential diagnosis counteracts this bias. Anchoring on the first diagnosis, indiscriminate testing without hypotheses, or dismissing symptoms all increase error.

Question 12Family Medicine Principles and Patient-Centred Care

Which of the following statements about the family physician's role as 'gatekeeper' is most accurate?

  1. The gatekeeper is responsible only for emergency referrals
  2. The gatekeeper has no responsibility for the cost of care
  3. The gatekeeper prevents patients from ever seeing a specialist
  4. The gatekeeper coordinates access to specialist and secondary care, balancing patient needs with appropriate resource use Correct answer.

Explanation

The gatekeeping role involves coordinating referrals and access to secondary care, ensuring patients reach appropriate services while using resources responsibly. It is not absolute denial of specialist access, nor does it exclude cost awareness or non-emergency referral. Coordination and advocacy are central.

Question 13Family Medicine Principles and Patient-Centred Care

A 30-year-old man is diagnosed with newly detected hypertension. He is asymptomatic and reluctant to take medication. Which approach best reflects the principle of empowering the patient?

  1. Tell him the decision is entirely his with no further input
  2. Provide clear information about risks and options, explore his concerns, and support him in choosing a plan he can commit to Correct answer.
  3. Instruct him to take the medication without discussion
  4. Warn him that he will be responsible if he has a stroke

Explanation

Empowerment involves giving patients the information and support to make informed choices about their health while maintaining a partnership. This includes exploring concerns and agreeing on a feasible plan. Directive instruction, fear-based warnings and complete abdication all undermine the collaborative relationship.

Question 14Family Medicine Principles and Patient-Centred Care

Which of the following best describes the purpose of a 'safety-netting' plan in primary care?

  1. Referring every patient to hospital as a precaution
  2. Documenting that the patient refused all advice
  3. Informing the patient what symptoms to watch for and when to return if the condition does not follow the expected course Correct answer.
  4. Guaranteeing that the diagnosis will not change

Explanation

Safety-netting communicates the expected course of illness, warning signs, and clear instructions on when and how to seek further help. It manages diagnostic uncertainty and supports patient safety. It does not guarantee diagnosis, mandate referral, or merely record refusal.

Question 15Family Medicine Principles and Patient-Centred Care

A family physician notices that many patients in her practice have poorly controlled asthma. Which action best reflects a population-based approach within family practice?

  1. Wait for patients to request asthma reviews
  2. Audit the practice's asthma care, identify gaps, and introduce a systematic review and education programme Correct answer.
  3. Focus only on the patients who attend most frequently
  4. Refer all asthma patients to a respiratory specialist

Explanation

Population-based care uses practice data to identify and address gaps in care for the whole registered population, not just those who present. Audit, recall systems and structured review improve outcomes at scale. Focusing on frequent attenders, mass referral or passive waiting fails to address the population systematically.

Question 16Family Medicine Principles and Patient-Centred Care

In the context of the consultation, which of the following best describes 'agenda setting'?

  1. Negotiating at the start which problems will be addressed in the available time Correct answer.
  2. Writing the physician's list of topics before the patient speaks
  3. Ending the consultation once the first problem is resolved
  4. Allowing the patient to speak uninterrupted for the entire consultation

Explanation

Agenda setting involves eliciting both the patient's and clinician's concerns early and agreeing which will be addressed in the time available. This reduces 'doorknob' presentations and unmet concerns. Unstructured monologue, unilateral lists or premature closure all undermine the process.

Question 17Family Medicine Principles and Patient-Centred Care

A 70-year-old man with heart failure and chronic kidney disease is prescribed multiple medications by several specialists. Which action best reflects the family physician's coordinating role?

  1. Add further medications to address each new symptom
  2. Leave medication reconciliation to the specialists alone
  3. Review the whole medication list for interactions, duplications and appropriateness, and communicate with the specialists Correct answer.
  4. Stop all medications to simplify the regimen

Explanation

The family physician acts as coordinator, performing medication reconciliation across prescribers, identifying interactions and duplication, and liaising with specialists. Adding drugs piecemeal or deferring entirely to specialists fragments care, and stopping everything risks harm. Structured review is the key task.

Question 18Family Medicine Principles and Patient-Centred Care

Which of the following scenarios best illustrates the ethical principle of distributive justice in family practice?

  1. Keeping a patient's diagnosis confidential from unauthorised persons
  2. Allocating limited clinic appointments fairly among patients according to clinical need Correct answer.
  3. Obtaining informed consent before a procedure
  4. Telling the truth about a poor prognosis

Explanation

Distributive justice concerns the fair allocation of scarce resources, such as appointment slots, according to need and equity. Confidentiality, informed consent and truth-telling relate to other principles (autonomy and non-maleficence/beneficence). Recognising which principle applies is essential in ethical reasoning.

Question 19Family Medicine Principles and Patient-Centred Care

A family physician is asked to provide a report for a patient's insurance claim. The patient asks that certain information be omitted. Which response is most appropriate?

  1. Provide the report without informing the patient of its contents
  2. Explain the physician's obligation to provide accurate information and discuss with the patient what is relevant and necessary Correct answer.
  3. Omit the information as requested to preserve trust
  4. Refuse to provide any report at all

Explanation

Physicians must be truthful and accurate in reports while respecting confidentiality and disclosing only relevant information with the patient's knowledge. Discussing content with the patient balances honesty, consent and trust. Falsifying, refusing outright, or acting without the patient's knowledge are all inappropriate.

Question 20Family Medicine Principles and Patient-Centred Care

Which of the following best describes the concept of 'opportunistic screening' in family practice?

  1. Screening only patients admitted to hospital
  2. Screening the entire population by postal invitation only
  3. Offering screening to eligible patients during consultations arranged for other reasons Correct answer.
  4. Screening only patients who request it explicitly

Explanation

Opportunistic screening takes advantage of any consultation to offer evidence-based screening to eligible patients, improving coverage among those who do not attend dedicated programmes. It is distinct from invitation-based population screening and from screening limited to hospitals or self-referral.

Question 21Adult Medicine and Common Chronic Diseases

A 54-year-old Kuwaiti man with a BMI of 33 kg/m² and a fasting plasma glucose of 6.4 mmol/L on two occasions is seen in primary care. Which diagnosis best fits these results?

  1. Impaired glucose tolerance
  2. Type 2 diabetes mellitus
  3. Metabolic syndrome
  4. Impaired fasting glucose (prediabetes) Correct answer.

Explanation

A fasting plasma glucose between 5.6 and 6.9 mmol/L defines impaired fasting glucose, a form of prediabetes. Diabetes requires a fasting value of 7.0 mmol/L or more, or a random value of 11.1 mmol/L or more with symptoms. Impaired glucose tolerance is defined by the 2-hour oral glucose tolerance test value, which is not given here.

Question 22Adult Medicine and Common Chronic Diseases

Which first-line antihypertensive class is preferred in a 60-year-old with stage 2 hypertension and no comorbidity, according to standard adult hypertension guidance?

  1. A centrally acting alpha-2 agonist
  2. An alpha-1 blocker
  3. A thiazide-type diuretic Correct answer.
  4. A loop diuretic

Explanation

Thiazide-type diuretics are one of the recommended first-line options for uncomplicated hypertension in adults, along with ACE inhibitors, ARBs, and calcium channel blockers. Alpha-1 blockers and central alpha-2 agonists are generally reserved as add-on or special-situation agents because of side effects and weaker outcome data. Loop diuretics are used when there is volume overload or reduced kidney function rather than as routine first-line therapy.

Question 23Adult Medicine and Common Chronic Diseases

A 48-year-old woman with type 2 diabetes has an LDL cholesterol of 4.3 mmol/L. She has no clinical atherosclerotic disease. What is the most appropriate lipid target and approach?

  1. Start a moderate-intensity statin with a goal LDL below 2.6 mmol/L Correct answer.
  2. No lipid therapy is needed because she has no cardiovascular disease
  3. Start a statin only if LDL exceeds 5.0 mmol/L
  4. Use fibrate monotherapy with a goal LDL below 3.4 mmol/L

Explanation

Adults with diabetes aged 40–75 are treated with at least moderate-intensity statin therapy, and many guidelines use an LDL goal below 2.6 mmol/L for primary prevention in this group. Fibrates are used mainly for severe hypertriglyceridaemia and are not a substitute for statin therapy here. Diabetes itself is a major cardiovascular risk factor, so the absence of clinical disease does not justify withholding a statin.

Question 24Adult Medicine and Common Chronic Diseases

A 35-year-old man has a blood pressure of 158/98 mmHg on three separate visits. He has no other comorbidity. What is the most appropriate initial drug therapy?

  1. Start a beta blocker as monotherapy
  2. Start an alpha blocker as monotherapy
  3. Start a single first-line agent such as an ACE inhibitor or thiazide Correct answer.
  4. Start combination therapy with two first-line agents

Explanation

For stage 1 hypertension without comorbidity, guidelines generally recommend starting a single first-line agent and reassessing response. Combination therapy is usually reserved for stage 2 hypertension or when the blood pressure is well above target. Beta blockers and alpha blockers are not preferred initial monotherapy for uncomplicated hypertension in this age group.

Question 25Adult Medicine and Common Chronic Diseases

A 62-year-old man with type 2 diabetes and an eGFR of 38 mL/min/1.73 m² has a urinary albumin-to-creatinine ratio of 45 mg/mmol. Which medication best slows progression of his kidney disease?

  1. A long-acting sulfonylurea
  2. A thiazolidinedione
  3. A loop diuretic at the maximum tolerated dose
  4. An ACE inhibitor or ARB at the maximum tolerated dose Correct answer.

Explanation

In diabetic kidney disease with albuminuria, an ACE inhibitor or ARB is the cornerstone of therapy because it reduces intraglomerular pressure and slows progression. Blood pressure and albuminuria should be monitored, and the dose titrated as tolerated. Loop diuretics, thiazolidinediones, and sulfonylureas do not provide this specific renoprotection.

Question 26Adult Medicine and Common Chronic Diseases

A 70-year-old woman with type 2 diabetes on metformin and gliclazide has an HbA1c of 9.1% and a BMI of 24 kg/m². Which addition is most appropriate?

  1. A GLP-1 receptor agonist or SGLT2 inhibitor Correct answer.
  2. A thiazolidinedione
  3. A basal insulin
  4. A second sulfonylurea

Explanation

When HbA1c remains well above target despite two oral agents, adding an agent with a different mechanism such as a GLP-1 receptor agonist or SGLT2 inhibitor is appropriate, especially with cardiovascular or renal comorbidity. Basal insulin is also an option but is usually reserved for marked hyperglycaemia or when other agents are unsuitable. Adding a second sulfonylurea or a thiazolidinedione offers little additional benefit and increases side effects.

Question 27Adult Medicine and Common Chronic Diseases

A 66-year-old man with heart failure and reduced ejection fraction has an eGFR of 45 mL/min/1.73 m². Which glucose-lowering class has proven benefit in reducing heart failure hospitalisation?

  1. A DPP-4 inhibitor
  2. A sulfonylurea
  3. An SGLT2 inhibitor Correct answer.
  4. A thiazolidinedione

Explanation

SGLT2 inhibitors reduce heart failure hospitalisation and cardiovascular death in patients with heart failure and reduced ejection fraction, including those with diabetes. Their benefit persists across a range of kidney function, though dose adjustment may be needed at low eGFR. DPP-4 inhibitors, sulfonylureas, and thiazolidinediones do not have this proven heart failure benefit.

Question 28Adult Medicine and Common Chronic Diseases

A 55-year-old woman with type 2 diabetes on metformin has an HbA1c of 8.2%. She has a history of a myocardial infarction. Which add-on agent is most appropriate?

  1. A thiazolidinedione
  2. A sulfonylurea
  3. A DPP-4 inhibitor
  4. A GLP-1 receptor agonist or SGLT2 inhibitor Correct answer.

Explanation

In patients with established atherosclerotic cardiovascular disease, GLP-1 receptor agonists and SGLT2 inhibitors have demonstrated cardiovascular benefit and are preferred add-on agents. DPP-4 inhibitors, thiazolidinediones, and sulfonylureas do not confer this benefit. Metformin is continued unless contraindicated.

Question 29Adult Medicine and Common Chronic Diseases

A 68-year-old man with COPD and type 2 diabetes has been on prednisolone for a flare. Which statement about his diabetes management is most appropriate?

  1. Glucose monitoring can be stopped during steroid therapy
  2. Steroid-induced hyperglycaemia may require temporary insulin or dose adjustment Correct answer.
  3. Oral agents should be doubled regardless of glucose readings
  4. Steroids typically lower blood glucose and require no change

Explanation

Systemic corticosteroids cause insulin resistance and hepatic glucose production, often producing marked hyperglycaemia, especially postprandially. Glucose should be monitored closely, and temporary insulin or adjustment of existing therapy is often needed. Blindly doubling oral agents or stopping monitoring is unsafe.

Question 30Adult Medicine and Common Chronic Diseases

A 42-year-old man has a fasting triglyceride of 6.5 mmol/L and an LDL of 2.1 mmol/L. He drinks alcohol daily. What is the most important initial step?

  1. Reassure him because LDL is normal
  2. Start ezetimibe
  3. Address secondary causes such as alcohol and start a fibrate if needed Correct answer.
  4. Start a high-intensity statin alone

Explanation

Marked hypertriglyceridaemia is often driven by secondary factors such as alcohol, obesity, and uncontrolled diabetes, and addressing these is the first step. A fibrate is the drug of choice when triglycerides remain very high after lifestyle measures because of pancreatitis risk. Statins and ezetimibe primarily target LDL and do not adequately treat severe hypertriglyceridaemia.

Question 31Adult Medicine and Common Chronic Diseases

A 30-year-old woman has a TSH of 8.2 mIU/L and a free T4 within the reference range. She has mild fatigue and no goitre. What is the most appropriate management?

  1. Repeat thyroid function tests in 6–8 weeks before deciding on treatment Correct answer.
  2. Arrange urgent thyroidectomy
  3. Start levothyroxine immediately at a full replacement dose
  4. Start carbimazole

Explanation

Subclinical hypothyroidism with mild symptoms and modest TSH elevation is usually managed by repeating thyroid function tests after several weeks to confirm persistence. Treatment is considered if TSH remains elevated or symptoms progress, starting at a low dose. Carbimazole and thyroidectomy are treatments for hyperthyroidism or structural disease, not hypothyroidism.

Question 32Adult Medicine and Common Chronic Diseases

A 50-year-old woman with treated hypothyroidism on levothyroxine has a TSH of 0.2 mIU/L and palpitations. What is the most appropriate action?

  1. Increase the levothyroxine dose
  2. Stop monitoring and continue the same dose
  3. Reduce the levothyroxine dose Correct answer.
  4. Add liothyronine

Explanation

A suppressed TSH with symptoms of thyrotoxicosis indicates over-replacement with levothyroxine. The dose should be reduced and thyroid function rechecked after about 6–8 weeks. Increasing the dose or adding liothyronine would worsen the thyrotoxic state.

Question 33Adult Medicine and Common Chronic Diseases

A 58-year-old man with type 2 diabetes has a blood pressure of 152/94 mmHg. Which antihypertensive class is preferred because of its renoprotective effect?

  1. An ACE inhibitor or ARB Correct answer.
  2. A loop diuretic
  3. An alpha blocker
  4. A beta blocker

Explanation

In patients with diabetes and hypertension, ACE inhibitors or ARBs are preferred first-line agents because they reduce albuminuria and slow progression of nephropathy. Beta blockers, alpha blockers, and loop diuretics do not provide this specific renoprotection. Renal function and potassium should be monitored after initiation.

Question 34Adult Medicine and Common Chronic Diseases

A 45-year-old man has a blood pressure of 178/104 mmHg and a serum potassium of 3.1 mmol/L with no diuretic use. What should be considered in the workup?

  1. Primary hyperaldosteronism Correct answer.
  2. Renal artery stenosis
  3. Cushing syndrome
  4. Pheochromocytoma

Explanation

Hypertension with spontaneous hypokalaemia in a patient not taking diuretics raises suspicion of primary hyperaldosteronism, which is screened with an aldosterone-to-renin ratio. Pheochromocytoma, renal artery stenosis, and Cushing syndrome are other secondary causes but are less specifically associated with unprovoked hypokalaemia. Electrolytes should be checked before screening.

Question 35Adult Medicine and Common Chronic Diseases

A 63-year-old woman with type 2 diabetes has an eGFR of 28 mL/min/1.73 m². Which medication should be reviewed and likely stopped?

  1. Metformin Correct answer.
  2. Atorvastatin
  3. Amlodipine
  4. A proton pump inhibitor

Explanation

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73 m² because of the risk of lactic acidosis. It is also usually reviewed when eGFR falls below 45. Atorvastatin, amlodipine, and proton pump inhibitors do not require routine discontinuation at this eGFR.

Question 36Adult Medicine and Common Chronic Diseases

A 34-year-old woman with type 1 diabetes on a basal-bolus regimen has an HbA1c of 7.0% and no hypoglycaemia. What is the most appropriate statement about her targets?

  1. An HbA1c target of 9% is appropriate for all patients with type 1 diabetes
  2. Only fasting glucose should be monitored in type 1 diabetes
  3. An HbA1c target below 7% is appropriate if achieved without significant hypoglycaemia Correct answer.
  4. HbA1c should not be used to monitor type 1 diabetes

Explanation

For most adults with type 1 diabetes, an HbA1c target below 7% is appropriate when it can be achieved without significant hypoglycaemia. Targets are individualised, and less stringent goals may be used in older patients or those with hypoglycaemia unawareness. HbA1c and glucose monitoring are both used to guide therapy.

Question 37Adult Medicine and Common Chronic Diseases

A 55-year-old man with type 2 diabetes has a fasting glucose of 9.5 mmol/L and an HbA1c of 10.2%. He is symptomatic with polyuria. What is the most appropriate initial therapy?

  1. A DPP-4 inhibitor alone
  2. Lifestyle modification alone
  3. A thiazolidinedione alone
  4. Basal insulin with or without metformin Correct answer.

Explanation

Marked hyperglycaemia with symptoms and HbA1c well above target usually warrants insulin therapy initially to achieve rapid control. Metformin may be continued unless contraindicated. A DPP-4 inhibitor or thiazolidinedione alone would be too slow and insufficient in this setting.

Question 38Adult Medicine and Common Chronic Diseases

A 40-year-old woman has a new diagnosis of hypertension and a history of asthma. Which antihypertensive class should be avoided?

  1. A thiazide diuretic
  2. A calcium channel blocker
  3. An ACE inhibitor
  4. A non-selective beta blocker Correct answer.

Explanation

Non-selective beta blockers can precipitate bronchospasm in patients with asthma and should be avoided. ACE inhibitors, thiazide diuretics, and calcium channel blockers are generally safe in asthma, though ACE inhibitors can cause cough. Beta-1 selective agents may be used cautiously when there is a strong cardiac indication.

Question 39Adult Medicine and Common Chronic Diseases

A 65-year-old man with type 2 diabetes has an ankle-brachial index of 0.7 and claudication. Which medication is most appropriate for secondary prevention?

  1. A fibrate alone
  2. A high-intensity statin with an antiplatelet agent Correct answer.
  3. A thiazolidinedione
  4. A sulfonylurea

Explanation

Peripheral arterial disease is a manifestation of atherosclerosis, and secondary prevention includes a high-intensity statin and an antiplatelet agent such as aspirin. Smoking cessation and blood pressure control are also essential. Fibrates, thiazolidinediones, and sulfonylureas do not provide this cardiovascular protection.

Question 40Adult Medicine and Common Chronic Diseases

A 72-year-old woman with type 2 diabetes on insulin has an HbA1c of 7.8% and had two severe hypoglycaemic episodes. What is the most appropriate adjustment?

  1. Relax the HbA1c target and simplify the insulin regimen Correct answer.
  2. Add a sulfonylurea
  3. Intensify the regimen to reach an HbA1c below 6.5%
  4. Stop all glucose monitoring

Explanation

Older adults with significant hypoglycaemia should have less stringent glycaemic targets, often an HbA1c around 8% or higher, and simplified regimens to reduce hypoglycaemia risk. Intensifying therapy or adding a sulfonylurea would increase the risk of further severe hypoglycaemia. Monitoring should continue.

Question 41Adult Medicine and Common Chronic Diseases

A 45-year-old man has a blood pressure of 145/92 mmHg and a BMI of 31 kg/m². Which lifestyle measure has the greatest effect on lowering blood pressure?

  1. Weight loss and dietary sodium reduction Correct answer.
  2. Reducing physical activity
  3. Increasing caffeine intake
  4. Starting a high-salt diet

Explanation

Weight loss and reduced dietary sodium intake are among the most effective lifestyle measures for lowering blood pressure. The DASH-style diet, physical activity, and moderation of alcohol also contribute. Increasing caffeine or salt intake and reducing activity would raise or fail to lower blood pressure.

Question 42Adult Medicine and Common Chronic Diseases

A 36-year-old woman with type 1 diabetes is planning pregnancy. Which statement about preconception care is most appropriate?

  1. Delay folic acid until the second trimester
  2. Stop insulin during pregnancy
  3. Target an HbA1c below 6.5% before conception and start folic acid Correct answer.
  4. Start an ACE inhibitor for blood pressure control

Explanation

Preconception care in type 1 diabetes includes achieving an HbA1c close to target, ideally below 6.5%, and taking folic acid before conception to reduce neural tube defects. ACE inhibitors are contraindicated in pregnancy and should be stopped. Insulin is continued and adjusted throughout pregnancy.

Question 43Adult Medicine and Common Chronic Diseases

A 60-year-old man with type 2 diabetes has a serum creatinine of 180 µmol/L and an eGFR of 35 mL/min/1.73 m². Which glucose-lowering agent requires dose reduction or avoidance at this eGFR?

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

Explanation

Metformin requires dose reduction when eGFR is between 30 and 45 mL/min/1.73 m² and should be stopped below 30 because of lactic acidosis risk. Sitagliptin requires dose adjustment but is not contraindicated, while insulin and pioglitazone can generally be used with appropriate monitoring. The question asks which agent requires reduction or avoidance, making metformin the best answer.

Question 44Adult Medicine and Common Chronic Diseases

A 52-year-old woman has a TSH of 0.05 mIU/L and a free T4 of 28 pmol/L with palpitations and weight loss. Which finding would most suggest Graves disease rather than a toxic nodule?

  1. A low free T4
  2. A normal thyroid ultrasound
  3. A single palpable nodule on examination
  4. Diffuse goitre with a suppressed TSH and elevated TSH-receptor antibodies Correct answer.

Explanation

Graves disease is characterised by diffuse goitre, suppressed TSH, elevated free T4, and positive TSH-receptor antibodies. A single nodule suggests a toxic adenoma, and a normal ultrasound or low free T4 is not consistent with Graves thyrotoxicosis. Antibody testing and imaging help distinguish the causes.

Question 45Adult Medicine and Common Chronic Diseases

A 58-year-old man with type 2 diabetes has a blood pressure of 148/90 mmHg and an eGFR of 60 mL/min/1.73 m². He is started on an ACE inhibitor. What should be monitored after initiation?

  1. Serum calcium and phosphate
  2. Liver enzymes and bilirubin
  3. White cell count and platelets
  4. Serum creatinine and potassium Correct answer.

Explanation

ACE inhibitors can cause a rise in serum creatinine and hyperkalaemia, so renal function and potassium should be checked after starting and after dose changes. A small creatinine rise is acceptable, but a large rise or hyperkalaemia requires dose adjustment or stopping the drug. Calcium, white cell count, and liver enzymes are not the primary monitoring parameters for ACE inhibitors.

Question 46Adult Medicine and Common Chronic Diseases

A 58-year-old man with type 2 diabetes has an LDL cholesterol of 3.4 mmol/L. He has no history of cardiovascular disease and is not taking a statin. According to standard lipid-lowering guidance for adults with diabetes, what is the most appropriate initial lipid-lowering strategy?

  1. Start ezetimibe monotherapy and recheck lipids in 3 months
  2. Recommend dietary change alone and recheck lipids in 12 months
  3. Start a moderate-intensity statin and aim for at least a 30% LDL reduction Correct answer.
  4. Start a high-intensity statin and aim for an LDL below 1.4 mmol/L

Explanation

Adults with diabetes aged 40 or older are treated as having elevated cardiovascular risk and should generally receive a moderate-intensity statin, with a target of at least 30% LDL reduction. High-intensity treatment with very low LDL targets is reserved for those with established atherosclerotic disease or additional major risk factors. Lifestyle advice alone is insufficient for a patient with diabetes at this risk level.

Question 47Adult Medicine and Common Chronic Diseases

A 47-year-old woman with type 2 diabetes on metformin has a fasting glucose of 8.0 mmol/L and an HbA1c of 7.6%. She has no symptoms and no significant hypoglycaemia risk. What is the most appropriate HbA1c target for her?

  1. Below 9.0%
  2. Below 6.0%
  3. Below 7.0% Correct answer.
  4. Below 8.5%

Explanation

For most non-pregnant adults with diabetes who are not at high risk of hypoglycaemia, an HbA1c target of below 7.0% is recommended to reduce microvascular complications. Tighter targets such as below 6.0% are generally reserved for patients who can achieve them safely without hypoglycaemia. Relaxed targets such as 8.5% or 9.0% are reserved for frail, elderly, or hypoglycaemia-prone patients.

Question 48Adult Medicine and Common Chronic Diseases

A 64-year-old man with type 2 diabetes attends for review. His eGFR is 52 mL/min/1.73 m² and his urine albumin-to-creatinine ratio is 45 mg/mmol on two separate samples. Which medication should be added to reduce the risk of progressive kidney disease?

  1. A sodium-glucose cotransporter-2 inhibitor Correct answer.
  2. A thiazolidinedione
  3. A sulfonylurea
  4. A dipeptidyl peptidase-4 inhibitor

Explanation

In patients with type 2 diabetes and albuminuria, SGLT2 inhibitors slow the progression of chronic kidney disease and reduce cardiovascular events, independent of glucose lowering. They are recommended in addition to a renin-angiotensin system blocker when albuminuria is present. DPP-4 inhibitors, sulfonylureas, and thiazolidinediones do not have this kidney-protective effect.

Question 49Adult Medicine and Common Chronic Diseases

A 55-year-old man is admitted with a three-day history of productive cough, fever, and pleuritic chest pain. Chest examination shows bronchial breathing and crackles at the right base. Which finding best supports a diagnosis of community-acquired pneumonia over acute bronchitis?

  1. Focal crackles and bronchial breathing on auscultation Correct answer.
  2. A history of cigarette smoking
  3. Purulent sputum production
  4. A raised white cell count

Explanation

Community-acquired pneumonia involves alveolar consolidation, producing focal signs such as bronchial breathing, crackles, and dullness to percussion. Acute bronchitis is a mucosal infection without consolidation, so focal auscultatory findings are typically absent. A raised white cell count, purulent sputum, and smoking history occur in both conditions and do not distinguish them.

Question 50Adult Medicine and Common Chronic Diseases

A 70-year-old man with heart failure and reduced ejection fraction is reviewed. He is already on an ACE inhibitor and a beta-blocker but remains symptomatic, with a blood pressure of 118/72 mmHg and a normal serum potassium and renal function. Which additional medication improves survival in this setting?

  1. A calcium channel blocker
  2. Digoxin
  3. A loop diuretic
  4. A mineralocorticoid receptor antagonist Correct answer.

Explanation

Mineralocorticoid receptor antagonists such as spironolactone or eplerenone reduce mortality and hospitalisation in patients with heart failure and reduced ejection fraction who remain symptomatic despite ACE inhibitor and beta-blocker therapy. Loop diuretics relieve congestion but do not improve survival. Digoxin reduces hospitalisation but not mortality, and calcium channel blockers are not indicated for systolic heart failure.