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Kuwait MOH Doctor Exam practice questions

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Question 1Internal Medicine

A 58-year-old man with type 2 diabetes has an eGFR of 32 mL/min/1.73 m². Which oral glucose-lowering agent should be avoided because of reduced clearance and risk of lactic acidosis?

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

Explanation

Metformin is cleared renally and accumulates when eGFR is below 30 mL/min/1.73 m², which raises the risk of metformin-associated lactic acidosis; guidelines advise stopping it at this level of renal function. The other agents listed do not carry this specific accumulation hazard in the same way.

Question 2Internal Medicine

A 24-year-old woman presents with palpitations and weight loss. TSH is suppressed, free T4 is elevated, and TSH-receptor antibodies are positive. Which finding is most characteristic of Graves disease on examination?

  1. Nodular goitre with tracheal deviation
  2. Single firm thyroid nodule
  3. Tender thyroid with fever
  4. Diffuse non-tender goitre with a bruit Correct answer.

Explanation

Graves disease produces a diffusely enlarged, non-tender goitre with increased vascularity, which may generate an audible bruit over the gland. TSH-receptor antibodies confirm the autoimmune aetiology. A single nodule or tenderness suggests alternative diagnoses.

Question 3Internal Medicine

Which electrocardiographic finding is the earliest sign of acute transmural myocardial infarction?

  1. Pathological Q waves
  2. ST-segment depression
  3. Hyperacute peaked T waves Correct answer.
  4. T-wave inversion

Explanation

Hyperacute, tall peaked T waves are the earliest ECG change in transmural infarction, reflecting acute ischaemia before ST elevation fully develops. Q waves and T-wave inversion occur later in the evolution of the infarct.

Question 4Internal Medicine

A 30-year-old man has a blood pressure of 168/104 mmHg on three separate visits, with no identifiable secondary cause. Which single measurement best confirms sustained hypertension before starting drug therapy?

  1. Resting heart rate
  2. A single office reading
  3. 24-hour ambulatory blood pressure monitoring Correct answer.
  4. Random capillary glucose

Explanation

Ambulatory blood pressure monitoring over 24 hours confirms sustained hypertension and excludes white-coat effect, which is important before committing a young patient to lifelong therapy. Office readings alone can overestimate true blood pressure.

Question 5Internal Medicine

A 45-year-old woman has iron-deficiency anaemia with a haemoglobin of 8.2 g/dL. Which laboratory value is most consistent with this diagnosis?

  1. Normal ferritin with low reticulocyte count
  2. High ferritin with normal transferrin saturation
  3. Low ferritin with high total iron-binding capacity Correct answer.
  4. High ferritin with low total iron-binding capacity

Explanation

Iron deficiency produces low ferritin, reflecting depleted iron stores, with a compensatory rise in total iron-binding capacity and low transferrin saturation. Ferritin is the most specific single indicator of iron stores.

Question 6Internal Medicine

A 62-year-old man with chronic obstructive pulmonary disease has a resting oxygen saturation of 86% on room air. Which intervention improves survival in this setting?

  1. Regular nebulised salbutamol
  2. Long-term domiciliary oxygen therapy Correct answer.
  3. Routine antibiotic prophylaxis
  4. Prophylactic oral corticosteroids

Explanation

Long-term oxygen therapy in patients with chronic hypoxaemia improves survival, and the benefit is greatest when used for at least 15 to 18 hours per day. The indication is based on documented arterial hypoxaemia.

Question 7Internal Medicine

A 28-year-old woman has sudden severe headache reaching maximum intensity within seconds, with neck stiffness. What is the most appropriate next step?

  1. Reassurance and outpatient review
  2. Oral triptan therapy
  3. Urgent non-contrast CT head followed by lumbar puncture if negative Correct answer.
  4. Plain skull radiograph

Explanation

A thunderclap headache raises suspicion of subarachnoid haemorrhage, which requires urgent non-contrast CT; if the CT is negative and suspicion persists, lumbar puncture for xanthochromia is performed. Early diagnosis is critical because of the risk of rebleeding.

Question 8Internal Medicine

Which finding on urinalysis most strongly suggests acute glomerulonephritis rather than a urinary tract infection?

  1. Numerous squamous epithelial cells
  2. Alkaline urine with triple phosphate crystals
  3. Positive nitrite with leucocyte esterase
  4. Red cell casts with dysmorphic red cells Correct answer.

Explanation

Red cell casts and dysmorphic red cells indicate glomerular bleeding, which is the hallmark of glomerulonephritis. Their presence localises the pathology to the glomerulus rather than the lower urinary tract.

Question 9Internal Medicine

A 68-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. Which therapy reduces the risk of cardioembolic stroke?

  1. Oral anticoagulation Correct answer.
  2. Aspirin monotherapy
  3. Clopidogrel monotherapy
  4. No antithrombotic therapy

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates sufficient stroke risk to justify oral anticoagulation, which substantially reduces cardioembolic events. Antiplatelet monotherapy is inferior for stroke prevention in atrial fibrillation.

Question 10Internal Medicine

A 55-year-old woman with rheumatoid arthritis has a haemoglobin of 9.5 g/dL, a normal mean corpuscular volume, low serum iron, low total iron-binding capacity, and a ferritin of 210 µg/L. What is the most likely cause of her anaemia?

  1. Iron-deficiency anaemia
  2. Vitamin B12 deficiency
  3. Thalassaemia trait
  4. Anaemia of chronic disease Correct answer.

Explanation

Chronic inflammation raises ferritin and hepcidin, which lowers serum iron and total iron-binding capacity while ferritin stays normal or high; this pattern defines anaemia of chronic disease. Iron deficiency instead shows low ferritin and raised iron-binding capacity.

Question 11Internal Medicine

A 40-year-old man is admitted with diabetic ketoacidosis. Which initial fluid strategy is most appropriate?

  1. Hypertonic saline
  2. Isotonic saline infusion with potassium replacement as needed Correct answer.
  3. Rapid bolus of 5% dextrose
  4. Fluid restriction until glucose falls

Explanation

DKA causes profound volume depletion, so isotonic crystalloid is given promptly, with potassium replacement guided by serum levels because total body potassium is depleted even when serum values are normal or high. Insulin is started after fluids and potassium are addressed.

Question 12Internal Medicine

A 70-year-old man has progressive dyspnoea, a raised jugular venous pressure, and bilateral basal crackles. Echocardiography shows an ejection fraction of 30%. Which drug class improves survival in this condition?

  1. Mineralocorticoid receptor antagonists Correct answer.
  2. Dihydropyridine calcium channel blockers
  3. Alpha-blockers
  4. Loop diuretics alone

Explanation

In heart failure with reduced ejection fraction, mineralocorticoid receptor antagonists reduce mortality in addition to ACE inhibitors and beta-blockers. Diuretics relieve congestion but have not been shown to improve survival.

Question 13Internal Medicine

A 35-year-old woman presents with fever, a malar rash, arthralgia, and a positive antinuclear antibody test. Which additional finding would most specifically support systemic lupus erythematosus?

  1. Low serum complement C3 only
  2. Anti-double-stranded DNA antibodies Correct answer.
  3. Positive rheumatoid factor
  4. Raised C-reactive protein

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity and renal involvement. Antinuclear antibody is sensitive but not specific, so a more specific marker is needed.

Question 14Internal Medicine

A 50-year-old man has a fasting plasma glucose of 6.7 mmol/L on two occasions. What is the most appropriate interpretation?

  1. Established diabetes mellitus
  2. Impaired fasting glucose, requiring lifestyle intervention and follow-up Correct answer.
  3. Need for immediate insulin therapy
  4. Normal glucose tolerance

Explanation

A fasting plasma glucose between 5.6 and 6.9 mmol/L defines impaired fasting glucose, which signals prediabetes and warrants lifestyle modification with periodic retesting. Diabetes is diagnosed at 7.0 mmol/L or above.

Question 15Internal Medicine

A 60-year-old woman has a serum sodium of 122 mmol/L and appears confused. She has been taking thiazide diuretics. Which finding would suggest SIADH rather than hypovolaemic hyponatraemia?

  1. Hyperkalaemia with metabolic acidosis
  2. Postural hypotension with low urine sodium
  3. Oedema with raised jugular venous pressure
  4. Euvolaemia with inappropriately concentrated urine Correct answer.

Explanation

SIADH causes euvolaemic hyponatraemia with inappropriately concentrated urine and elevated urine sodium, reflecting continued ADH action despite low serum osmolality. Hypovolaemia instead produces postural hypotension with low urine sodium.

Question 16Internal Medicine

A 55-year-old man with cirrhosis presents with haematemesis. After resuscitation, which agent is given to reduce the risk of further variceal bleeding?

  1. Heparin
  2. Loperamide
  3. Aspirin
  4. Terlipressin Correct answer.

Explanation

Splanchnic vasoconstrictors such as terlipressin reduce portal pressure and are used together with endoscopic therapy in acute variceal haemorrhage. Antibiotic prophylaxis is also given to reduce mortality.

Question 17Internal Medicine

A 65-year-old man has a creatinine of 220 µmol/L and a haemoglobin of 9.8 g/dL. Which finding would most strongly suggest chronic rather than acute kidney injury?

  1. Abundant red cell casts on urinalysis
  2. A potassium of 6.2 mmol/L
  3. Small echogenic kidneys on ultrasound Correct answer.
  4. A serum creatinine that has doubled over 48 hours

Explanation

Small, echogenic kidneys indicate long-standing scarring and support chronic kidney disease. Acute kidney injury typically shows normal or enlarged kidney size.

Question 18Internal Medicine

A 22-year-old man has sudden right-sided pleuritic chest pain and breathlessness. He is tall and thin, and chest examination shows reduced breath sounds on the right. What is the most appropriate immediate investigation?

  1. Spirometry
  2. Sputum culture
  3. D-dimer assay
  4. Chest radiograph Correct answer.

Explanation

The presentation suggests primary spontaneous pneumothorax, and an erect chest radiograph confirms the diagnosis by showing a visible pleural line and reduced lung markings. It also guides the need for drainage.

Question 19Internal Medicine

A 48-year-old woman has proximal muscle weakness, a raised creatine kinase, and a heliotrope rash around the eyes. Which diagnosis is most likely?

  1. Dermatomyositis Correct answer.
  2. Myasthenia gravis
  3. Polymyalgia rheumatica
  4. Hypothyroidism

Explanation

Proximal weakness with raised creatine kinase and characteristic skin changes such as a heliotrope rash indicate dermatomyositis. The condition is associated with underlying malignancy, so age-appropriate screening is recommended.

Question 20Internal Medicine

A 60-year-old man has a blood pressure of 150/92 mmHg, a fasting glucose of 6.9 mmol/L, and a body mass index of 31 kg/m². Which intervention is most appropriate first-line for his blood pressure?

  1. Immediate triple antihypertensive therapy
  2. Lifestyle modification with weight loss and reduced salt intake Correct answer.
  3. Beta-blocker monotherapy
  4. Oral corticosteroid therapy

Explanation

In stage 1 hypertension with low cardiovascular risk, lifestyle measures such as weight loss, salt restriction, and exercise are the appropriate first step, with drug therapy added if targets are not met. Combination therapy is reserved for higher-risk or more severe hypertension.

Question 21Internal Medicine

A 72-year-old man presents with a sudden onset of left-sided weakness and slurred speech. His blood glucose is normal and the onset was 90 minutes ago. What is the most appropriate immediate action?

  1. Immediate lumbar puncture
  2. Aspirin alone with no imaging
  3. Urgent CT head and assessment for thrombolysis Correct answer.
  4. Discharge with outpatient neurology review

Explanation

Acute ischaemic stroke within the thrombolysis window requires urgent CT to exclude haemorrhage before reperfusion therapy is considered. Time is critical because the benefit of thrombolysis declines with delay.

Question 22Internal Medicine

A 55-year-old man has a serum calcium of 3.1 mmol/L with a raised parathyroid hormone level. Which finding is most consistent with primary hyperparathyroidism?

  1. Hypercalcaemia with inappropriately raised PTH and low phosphate Correct answer.
  2. Hypocalcaemia with raised PTH
  3. Hypercalcaemia with raised PTH and raised phosphate
  4. Hypercalcaemia with suppressed PTH

Explanation

In primary hyperparathyroidism, excess PTH raises serum calcium and lowers phosphate through renal phosphate wasting. The key clue is a raised PTH despite hypercalcaemia, which is inappropriate.

Question 23Internal Medicine

A 35-year-old woman has recurrent hypoglycaemia with a blood glucose of 2.2 mmol/L during a fasting test, with inappropriately raised insulin and C-peptide levels. Which diagnosis is most likely?

  1. Factitious hypoglycaemia from exogenous insulin
  2. Chronic liver disease
  3. Insulinoma Correct answer.
  4. Adrenal insufficiency

Explanation

Endogenous hyperinsulinaemia with raised C-peptide during documented hypoglycaemia indicates an insulinoma. Exogenous insulin suppresses C-peptide, which helps to distinguish factitious administration.

Question 24Internal Medicine

A 65-year-old woman with a history of hypertension presents with acute severe chest pain radiating to the back. She has a 4 cm blood pressure difference between arms. What is the most appropriate initial imaging test for suspected aortic dissection?

  1. Chest radiograph
  2. Coronary angiography
  3. CT angiography of the aorta Correct answer.
  4. Transthoracic echocardiography alone

Explanation

CT angiography of the aorta is the first-line investigation for suspected aortic dissection because it rapidly visualises the intimal flap and extent of the dissection. Urgent surgical or medical management depends on the type identified.

Question 25Internal Medicine

A 40-year-old man has recurrent renal stones, a raised serum calcium, and a normal parathyroid hormone level. Which additional finding would most strongly suggest familial hypocalciuric hypercalcaemia?

  1. Suppressed parathyroid hormone with hypercalcaemia
  2. Low urinary calcium excretion with a low calcium-to-creatinine clearance ratio Correct answer.
  3. Metabolic acidosis with hypokalaemia
  4. High urinary calcium excretion

Explanation

Familial hypocalciuric hypercalcaemia results from an inactivating mutation in the calcium-sensing receptor, causing hypercalcaemia with inappropriately low urinary calcium excretion and a low calcium-to-creatinine clearance ratio. This distinguishes it from primary hyperparathyroidism, where urinary calcium is usually high.

Question 26Internal Medicine

A 45-year-old man has a blood pressure of 158/98 mmHg recorded on three separate clinic visits over two months. He takes no medications and has no symptoms. Which diagnosis is most appropriate?

  1. Normal blood pressure
  2. Stage 1 hypertension Correct answer.
  3. White-coat hypertension
  4. Hypertensive emergency

Explanation

Persistent clinic readings of 140/90 mmHg or higher on repeated visits establish a diagnosis of hypertension; values in the 140-159/90-99 range correspond to stage 1 disease. White-coat hypertension requires elevated clinic readings with normal out-of-office readings, which have not been obtained here. Hypertensive emergency requires acute target-organ damage, which is absent.

Question 27Internal Medicine

A 30-year-old woman has a resting heart rate of 118/min, warm peripheries, a fine tremor and a diffuse goitre. Which laboratory pattern best fits untreated Graves disease?

  1. High TSH, high free T4, normal TSH-receptor antibodies
  2. High TSH, low free T4, positive anti-thyroid peroxidase antibodies
  3. Low TSH, high free T4, positive TSH-receptor antibodies Correct answer.
  4. Low TSH, low free T4, low free T3

Explanation

Graves disease is a TSH-receptor antibody-mediated hyperthyroidism, so the pituitary TSH is suppressed while free thyroid hormones are elevated. The stimulating antibodies are detectable in most patients. The clinical picture of tachycardia, tremor and goitre supports this rather than hypothyroidism.

Question 28Internal Medicine

A 58-year-old man has a 4 cm infrarenal abdominal aortic aneurysm found incidentally. He is asymptomatic and the diameter has been stable over 12 months. What is the most appropriate management?

  1. Immediate thrombolysis
  2. Long-term anticoagulation alone
  3. Elective open or endovascular repair now
  4. Ultrasound surveillance with risk-factor control Correct answer.

Explanation

Asymptomatic infrarenal aortic aneurysms below about 5.5 cm in men carry a low rupture risk and are managed with periodic imaging surveillance plus smoking cessation, blood pressure control and statin therapy. Repair is offered when the diameter reaches roughly 5.5 cm, expands rapidly, or symptoms develop.

Question 29Internal Medicine

A 26-year-old man has a 3-day history of bloody diarrhoea, crampy abdominal pain and tenesmus after a course of antibiotics. Which investigation is most likely to establish the diagnosis?

  1. Serum amylase
  2. Stool culture for Salmonella species
  3. Stool testing for Clostridioides difficile toxin or nucleic acid Correct answer.
  4. Upper gastrointestinal endoscopy

Explanation

Antibiotic exposure followed by bloody diarrhoea, cramping and tenesmus suggests pseudomembranous colitis caused by Clostridioides difficile. Testing stool for C. difficile toxin or toxin genes confirms the diagnosis and guides treatment.

Question 30Internal Medicine

A 64-year-old woman with poorly controlled type 2 diabetes has a serum creatinine of 180 µmol/L and an estimated glomerular filtration rate of 32 mL/min/1.73 m². Which antidiabetic agent requires dose reduction or avoidance because of reduced renal clearance?

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

Explanation

Metformin is cleared renally and accumulates when the eGFR falls, increasing the risk of lactic acidosis; it is generally avoided below an eGFR of 30 and dose-reduced at lower thresholds. Sitagliptin and pioglitazone do not require the same restriction, and insulin can be used with dose adjustment.

Question 31Internal Medicine

A 70-year-old smoker has a chronic productive cough for three months each year for three consecutive years, with no other cause identified. Which diagnosis fits best?

  1. Bronchiectasis
  2. Pulmonary embolism
  3. Chronic bronchitis Correct answer.
  4. Bronchial asthma

Explanation

Chronic bronchitis is defined clinically by a productive cough on most days for at least three months in two consecutive years, after excluding other causes. Smoking is the dominant risk factor. The history given matches this definition precisely.

Question 32Internal Medicine

A 52-year-old man has sudden painless loss of vision in the right eye described as a curtain descending. Fundoscopy is initially normal. Which diagnosis should be considered first?

  1. Amaurosis fugax from a transient ischaemic attack Correct answer.
  2. Acute angle-closure glaucoma
  3. Central retinal artery occlusion
  4. Vitreous haemorrhage

Explanation

A transient curtain-like visual loss lasting minutes and resolving spontaneously is amaurosis fugax, usually due to emboli from the carotid artery or heart. It is a transient ischaemic attack and requires urgent assessment for stroke risk and carotid disease.

Question 33Internal Medicine

A 34-year-old woman has a 2 cm thyroid nodule and a suppressed TSH. Fine-needle aspiration shows follicular cells with abundant colloid and no atypia. Which diagnosis is most likely?

  1. Hashimoto thyroiditis
  2. Toxic adenoma Correct answer.
  3. Papillary carcinoma
  4. Follicular carcinoma

Explanation

A solitary hyperfunctioning nodule with suppressed TSH and benign cytology on aspiration is characteristic of a toxic adenoma, which secretes thyroid hormone autonomously. The suppressed TSH and lack of malignant cytology make this the best choice.

Question 34Internal Medicine

A 60-year-old man with heart failure with reduced ejection fraction has persistent symptoms despite an ACE inhibitor and a beta-blocker. Which additional agent improves survival by blocking aldosterone?

  1. Digoxin
  2. Amlodipine
  3. Furosemide
  4. Spironolactone Correct answer.

Explanation

Mineralocorticoid receptor antagonists such as spironolactone reduce mortality in heart failure with reduced ejection fraction when added to an ACE inhibitor and beta-blocker, provided renal function and potassium are monitored. They act by blocking aldosterone effects.

Question 35Internal Medicine

A 24-year-old man has a 5-day history of fever, sore throat and fatigue, and examination shows tonsillar exudate and tender cervical lymphadenopathy. A heterophile antibody test is negative on day 5. Which test is most useful to confirm the diagnosis?

  1. Epstein-Barr virus viral capsid antigen IgM Correct answer.
  2. Antistreptolysin O titre
  3. Epstein-Barr virus nuclear antigen IgG
  4. Rapid group A streptococcal antigen test

Explanation

Infectious mononucleosis due to Epstein-Barr virus may be heterophile-negative early in the illness, especially in the first week. Viral capsid antigen IgM appears early and confirms acute infection, whereas nuclear antigen IgG indicates past infection.

Question 36Internal Medicine

A 48-year-old man with a 20-pack-year smoking history has a 3 cm spiculated peripheral lung mass with ipsilateral hilar lymphadenopathy but no distant metastases. What is the most appropriate next step?

  1. Simple observation with repeat imaging in one year
  2. Radiotherapy without histological confirmation
  3. Empirical anti-tuberculous therapy
  4. Tissue biopsy with staging of the mediastinum Correct answer.

Explanation

A spiculated mass in a smoker is highly suspicious for lung cancer, and management requires histological confirmation plus staging of the mediastinum and distant sites before treatment planning. Empirical therapy or observation would delay diagnosis.

Question 37Internal Medicine

A 66-year-old man has a 6-month history of early satiety, weight loss and iron-deficiency anaemia. He takes no NSAIDs and has no rectal bleeding. Which investigation is most appropriate?

  1. Abdominal ultrasound
  2. Barium enema
  3. Upper gastrointestinal endoscopy Correct answer.
  4. Colonoscopy alone

Explanation

Early satiety, weight loss and iron-deficiency anaemia in an older adult suggest a gastric or oesophageal malignancy, and upper endoscopy with biopsy is the investigation of choice. It allows direct visualisation and tissue sampling.

Question 38Internal Medicine

A 40-year-old woman has a blood pressure of 168/104 mmHg, hypokalaemia of 2.9 mmol/L and metabolic alkalosis. Which screening test is most appropriate?

  1. 24-hour urinary metanephrines
  2. Plasma aldosterone-to-renin ratio Correct answer.
  3. Serum cortisol after overnight dexamethasone
  4. Renal artery Doppler

Explanation

Young hypertension with spontaneous hypokalaemia and metabolic alkalosis suggests primary hyperaldosteronism. The aldosterone-to-renin ratio is the recommended screening test, followed by confirmatory testing if positive.

Question 39Internal Medicine

A 75-year-old woman is admitted with confusion, a urinary tract infection and a serum sodium of 158 mmol/L. She has been unable to drink because of dysphagia. What is the most appropriate initial management?

  1. Intravenous furosemide alone
  2. Free water replacement with careful monitoring of the sodium fall Correct answer.
  3. Rapid correction of sodium with hypertonic saline
  4. Fluid restriction

Explanation

Hypernatraemia in this setting reflects a water deficit from poor intake. Treatment is gradual replacement of free water, orally or intravenously, with frequent sodium monitoring to avoid overly rapid correction and cerebral oedema.

Question 40Internal Medicine

A 32-year-old woman with type 1 diabetes has a blood glucose of 32 mmol/L, pH 7.15, bicarbonate 10 mmol/L and ketonuria. After fluids and insulin are started, which electrolyte change requires the closest monitoring?

  1. Serum potassium falling during treatment Correct answer.
  2. Serum magnesium rising
  3. Serum calcium rising
  4. Serum phosphate rising

Explanation

In diabetic ketoacidosis, total body potassium is depleted even when serum levels appear normal or high, and insulin drives potassium into cells, causing a fall. Potassium must be checked frequently and replaced to prevent arrhythmias.

Question 41Internal Medicine

A 58-year-old man has a pleural effusion. Pleural fluid analysis shows a protein of 12 g/L, an LDH below two-thirds of the serum upper limit and a normal glucose. Which condition is the most likely cause?

  1. Congestive heart failure Correct answer.
  2. Pneumonia with parapneumonic effusion
  3. Pulmonary tuberculosis
  4. Pleural malignancy

Explanation

A low-protein, low-LDH effusion is a transudate, and heart failure is the commonest cause in adults. Exudates, by contrast, have higher protein and LDH and suggest infection, malignancy or tuberculosis.

Question 42Internal Medicine

A 68-year-old man has a 2-week history of a painful blistering rash in a dermatomal band on the left chest. Which treatment started now is most appropriate?

  1. Oral aciclovir for 7 days Correct answer.
  2. Topical corticosteroid alone
  3. Topical permethrin
  4. Oral flucloxacillin

Explanation

Dermatomal pain with grouped vesicles is herpes zoster. Antiviral therapy with aciclovir, valaciclovir or famciclovir reduces duration and complications and should be started as soon as possible, ideally within 72 hours of rash onset.

Question 43Internal Medicine

A 45-year-old man has recurrent epistaxis and examination shows telangiectasia on the lips and tongue. He reports similar lesions in his father. Which complication should be screened for?

  1. Pulmonary arteriovenous malformations Correct answer.
  2. Pulmonary fibrosis
  3. Aortic stenosis
  4. Nephrotic syndrome

Explanation

Hereditary haemorrhagic telangiectasia is an autosomal dominant disorder causing mucocutaneous telangiectasia and visceral arteriovenous malformations. Pulmonary AVMs are common and can cause hypoxaemia, stroke and cerebral abscess, so screening with contrast echocardiography or CT is recommended.

Question 44Internal Medicine

A 50-year-old woman has a 3-month history of fatigue, arthralgia, dry eyes and a persistently raised alkaline phosphatase with a positive antimitochondrial antibody. What is the most likely diagnosis?

  1. Primary sclerosing cholangitis
  2. Autoimmune hepatitis
  3. Haemochromatosis
  4. Primary biliary cholangitis Correct answer.

Explanation

Primary biliary cholangitis is an autoimmune cholestatic liver disease of middle-aged women, characterised by antimitochondrial antibodies, a raised alkaline phosphatase and symptoms such as fatigue, pruritus and sicca. It is often associated with other autoimmune conditions.

Question 45Surgery

A 45-year-old man has a 3 cm firm, painless nodule in the right lobe of the thyroid. Fine-needle aspiration shows a follicular neoplasm. Which single investigation best distinguishes a follicular adenoma from a follicular carcinoma?

  1. Repeat fine-needle aspiration after six weeks
  2. Thyroid scintigraphy with technetium-99m
  3. Serum calcitonin measurement
  4. Histological examination for capsular and vascular invasion Correct answer.

Explanation

Follicular adenoma and follicular carcinoma are cytologically identical on fine-needle aspiration; the distinction rests on capsular breach and vascular invasion seen only on the resected specimen. Scintigraphy and repeat cytology cannot separate benign from malignant follicular lesions.

Question 46Surgery

A 28-year-old woman develops fever, tachycardia and a painful, diffusely enlarged thyroid two weeks after an upper respiratory illness. TSH is suppressed and free T4 is raised. What is the most appropriate initial management?

  1. High-dose methimazole with levothyroxine block-replace
  2. Radioiodine ablation
  3. Total thyroidectomy in the acute phase
  4. Supportive treatment with a beta-blocker for symptom control Correct answer.

Explanation

The picture is subacute (de Quervain) thyroiditis, a self-limiting viral inflammatory condition. Symptoms are controlled with NSAIDs and a beta-blocker, and antithyroid drugs are unhelpful because the thyrotoxicosis is due to hormone release rather than synthesis.

Question 47Surgery

During a difficult laparoscopic cholecystectomy, the common bile duct is clipped and divided. Which intraoperative finding most reliably indicates that a major bile duct injury has occurred?

  1. A distended gallbladder with thick walls
  2. Bleeding from the cystic artery
  3. Adhesions between the gallbladder and omentum
  4. Two clips on a single tubular structure with bile leaking from the transected end Correct answer.

Explanation

Division of a clipped tubular structure with bile spillage is the classic sign of a major ductal injury, and the correct response is to convert to open surgery and obtain expert help. Gallbladder wall thickening, arterial bleeding and omental adhesions are common operative findings that do not by themselves imply duct transection.

Question 48Surgery

A 62-year-old man presents with painless obstructive jaundice and a palpable gallbladder. Ultrasound shows dilated intrahepatic ducts with a normal-calibre common bile duct and a distended gallbladder. Which diagnosis does this pattern most suggest?

  1. Primary sclerosing cholangitis
  2. Common bile duct stone
  3. Carcinoma of the head of the pancreas Correct answer.
  4. Acute calculous cholecystitis

Explanation

A palpable, distended gallbladder with jaundice (Courvoisier's law) points to malignant distal obstruction, typically pancreatic head carcinoma, in which the gallbladder dilates because the obstruction is gradual. A common duct stone usually causes pain, and chronic scarring prevents gallbladder distension.

Question 49Surgery

Which feature most strongly predicts a poor prognosis in a patient with resected pancreatic ductal adenocarcinoma?

  1. Positive resection margin with lymph node involvement Correct answer.
  2. A history of type 2 diabetes
  3. Preoperative serum amylase elevation
  4. Tumour located in the body of the pancreas

Explanation

Margin status and nodal involvement are the dominant independent prognostic factors after pancreatectomy and determine the role of adjuvant chemotherapy. Diabetes and tumour site influence presentation but are not the principal survival determinants once resection has been performed.

Question 50Surgery

A 30-year-old man has sudden severe epigastric pain radiating to the back with vomiting. Serum amylase is markedly raised and ultrasound shows gallstones but no duct dilatation. He is haemodynamically stable. What is the most appropriate initial management?

  1. Immediate endoscopic retrograde cholangiopancreatography
  2. Aggressive intravenous fluid resuscitation with analgesia and monitoring Correct answer.
  3. Urgent laparoscopic cholecystectomy within 24 hours
  4. Total parenteral nutrition and prophylactic antibiotics

Explanation

Early management of acute pancreatitis is supportive, with goal-directed intravenous fluids, analgesia and close monitoring. ERCP is reserved for concurrent cholangitis or persistent duct obstruction, and prophylactic antibiotics are not indicated in sterile necrotising pancreatitis.