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Lebanon Medical Colloquium practice questions

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Question 1Internal Medicine

A 58-year-old man with type 2 diabetes has an eGFR of 28 mL/min/1.73 m². Which oral glucose-lowering agent should be stopped because it is contraindicated at this level of kidney function?

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

Explanation

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73 m² because of the risk of lactic acidosis from drug accumulation. Linagliptin, sitagliptin (with dose adjustment) and empagliflozin can still be used at this eGFR, although empagliflozin's glucose-lowering effect is attenuated.

Question 2Internal Medicine

Which finding on the peripheral blood film is most characteristic of iron-deficiency anaemia?

  1. Normocytic cells with rouleaux formation
  2. Microcytic hypochromic red cells Correct answer.
  3. Macrocytic ovalocytes
  4. Schistocytes with thrombocytopenia

Explanation

Iron deficiency limits haemoglobin synthesis, so erythrocytes are produced small (microcytic) and poorly haemoglobinised (hypochromic). Oval macrocytes suggest megaloblastic anaemia, schistocytes suggest microangiopathy, and rouleaux suggest a paraprotein.

Question 3Internal Medicine

A 24-year-old woman has a resting tremor, heat intolerance, weight loss and a smooth diffuse goitre. Which laboratory pattern best fits untreated Graves disease?

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

Explanation

Graves disease is caused by TSH-receptor-stimulating antibodies that drive excess thyroid hormone production. The resulting negative feedback suppresses pituitary TSH while free T4 rises.

Question 4Internal Medicine

Which electrolyte disturbance most typically produces peaked T waves, a widened QRS complex and a sine-wave pattern on the ECG?

  1. Hyperkalaemia Correct answer.
  2. Hypercalcaemia
  3. Hypomagnesaemia
  4. Hypokalaemia

Explanation

Raised extracellular potassium reduces the resting membrane potential gradient and slows conduction, giving tall peaked T waves that progress to QRS widening and eventually a sine-wave morphology. Hypokalaemia instead produces flattened T waves and prominent U waves.

Question 5Internal Medicine

A 68-year-old smoker presents with sudden painless loss of vision in the right eye; fundoscopy shows a pale retina with a cherry-red spot at the macula. What is the most likely diagnosis?

  1. Vitreous haemorrhage
  2. Anterior ischaemic optic neuropathy
  3. Central retinal vein occlusion
  4. Central retinal artery occlusion Correct answer.

Explanation

Acute obstruction of the central retinal artery causes retinal ischaemia and pallor, while the fovea remains red because it is supplied by the choroid, producing the classic cherry-red spot. The visual loss is abrupt and painless.

Question 6Internal Medicine

Which antibody is most specific for systemic lupus erythematosus and is therefore used to support the diagnosis?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for SLE and their titre correlates with disease activity, particularly lupus nephritis. Antinuclear antibody is sensitive but not specific, being positive in many autoimmune and even healthy individuals.

Question 7Internal Medicine

A patient with a history of alcohol excess presents with ataxia, confusion and ophthalmoplegia. Which diagnosis should be considered first?

  1. Multiple sclerosis
  2. Cerebellar haemorrhage
  3. Wernicke encephalopathy Correct answer.
  4. Ischaemic stroke of the posterior circulation

Explanation

The triad of encephalopathy, oculomotor dysfunction and gait ataxia in a thiamine-deficient patient indicates Wernicke encephalopathy, a medical emergency requiring immediate parenteral thiamine. Delay in treatment risks progression to Korsakoff syndrome.

Question 8Internal Medicine

Which of the following is the most common cause of community-acquired pneumonia requiring hospital admission?

  1. Pneumocystis jirovecii
  2. Streptococcus pneumoniae Correct answer.
  3. Legionella pneumophila
  4. Mycoplasma pneumoniae

Explanation

Streptococcus pneumoniae remains the leading bacterial cause of community-acquired pneumonia across all severity levels, including patients requiring admission. It classically produces a lobar consolidation with rusty sputum.

Question 9Internal Medicine

A 45-year-old man has a blood pressure of 168/104 mmHg on three separate visits, with no identifiable secondary cause. What is the most appropriate initial pharmacological therapy?

  1. A loop diuretic as first-line monotherapy
  2. Immediate triple therapy with a beta blocker, alpha blocker and loop diuretic
  3. An alpha blocker as first-line monotherapy
  4. A thiazide-type diuretic, ACE inhibitor, angiotensin receptor blocker or calcium channel blocker Correct answer.

Explanation

For stage 2 hypertension without a secondary cause, guidelines recommend starting one of four major classes: thiazide-type diuretics, ACE inhibitors, angiotensin receptor blockers or calcium channel blockers. Alpha blockers and loop diuretics are not preferred initial agents for uncomplicated hypertension.

Question 10Internal Medicine

A 30-year-old woman has a 3-week history of bloody diarrhoea, urgency and crampy abdominal pain. Which investigation is the most appropriate first step to confirm the diagnosis?

  1. Faecal occult blood testing
  2. Barium enema
  3. Colonoscopy with biopsy Correct answer.
  4. Abdominal ultrasound

Explanation

Suspected inflammatory bowel disease requires colonoscopy with mucosal biopsy to establish the diagnosis, define disease extent and exclude other causes of colitis. Cross-sectional imaging and stool studies support but do not replace endoscopy.

Question 11Internal Medicine

A 72-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. Which anticoagulation strategy is most appropriate?

  1. Aspirin alone indefinitely
  2. No anticoagulation because of bleeding risk
  3. Long-term oral anticoagulation with a direct oral anticoagulant or warfarin Correct answer.
  4. Anticoagulation only during episodes of palpitations

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates sufficient stroke risk to warrant long-term oral anticoagulation. Either a direct oral anticoagulant or a vitamin K antagonist is appropriate, with the choice guided by renal function, valve disease and bleeding risk.

Question 12Internal Medicine

Which pattern of arterial blood gas results is expected in a patient with an acute exacerbation of COPD retaining carbon dioxide?

  1. High pH, raised PaCO2, raised bicarbonate
  2. Low pH, raised PaCO2, raised bicarbonate Correct answer.
  3. High pH, low PaCO2, low bicarbonate
  4. Low pH, low PaCO2, low bicarbonate

Explanation

Acute hypercapnic respiratory failure produces a respiratory acidosis: the PaCO2 rises, pH falls, and bicarbonate increases only modestly as renal compensation takes days to develop. A fully compensated chronic state would show a near-normal pH with a high bicarbonate.

Question 13Internal Medicine

A 26-year-old woman presents with sudden severe headache described as the worst of her life. Which investigation is the most appropriate first test if she is neurologically intact and presents within 6 hours of onset?

  1. MRI of the brain with contrast
  2. Non-contrast CT scan of the head Correct answer.
  3. Carotid Doppler ultrasound
  4. Lumbar puncture immediately

Explanation

A non-contrast CT head performed within 6 hours of a thunderclap headache has very high sensitivity for subarachnoid haemorrhage and is the recommended first investigation. Lumbar puncture is reserved for cases where CT is negative and clinical suspicion persists.

Question 14Internal Medicine

A 55-year-old man with a history of myocardial infarction develops progressive dyspnoea, bibasal crackles and elevated jugular venous pressure. Which medication has the strongest evidence for reducing mortality in heart failure with reduced ejection fraction?

  1. Digoxin
  2. A beta blocker such as bisoprolol Correct answer.
  3. A calcium channel blocker such as amlodipine
  4. A loop diuretic such as furosemide

Explanation

Beta blockers, along with ACE inhibitors or ARBs, mineralocorticoid receptor antagonists and SGLT2 inhibitors, reduce mortality in heart failure with reduced ejection fraction. Diuretics and digoxin relieve symptoms but have not been shown to improve survival.

Question 15Internal Medicine

A 40-year-old woman has polyuria, polydipsia and a serum sodium of 128 mmol/L with low serum osmolality and inappropriately concentrated urine. Which diagnosis is most likely?

  1. Syndrome of inappropriate antidiuretic hormone secretion Correct answer.
  2. Osmotic diuresis from hyperglycaemia
  3. Diabetes insipidus
  4. Primary polydipsia

Explanation

Euvolaemic hyponatraemia with low serum osmolality and urine that is not maximally dilute indicates inappropriate ADH secretion. Causes include small-cell lung cancer, CNS disease and drugs such as SSRIs.

Question 16Internal Medicine

A 60-year-old man has painless jaundice and a palpable non-tender gallbladder, with weight loss over 3 months. Which diagnosis should be suspected?

  1. Acute cholecystitis
  2. Choledocholithiasis
  3. Pancreatic head adenocarcinoma Correct answer.
  4. Primary biliary cholangitis

Explanation

Painless obstructive jaundice with a palpable gallbladder (Courvoisier sign) and weight loss suggests malignant obstruction, most often pancreatic head carcinoma. The distended gallbladder indicates gradual obstruction that has not caused the fibrosis seen in chronic stone disease.

Question 17Internal Medicine

A 70-year-old woman has a serum calcium of 2.95 mmol/L, a raised parathyroid hormone level and reduced bone density. Which diagnosis is most likely?

  1. Vitamin D deficiency
  2. Malignancy-associated hypercalcaemia
  3. Secondary hyperparathyroidism from chronic kidney disease
  4. Primary hyperparathyroidism Correct answer.

Explanation

Hypercalcaemia with an inappropriately raised or normal parathyroid hormone level indicates primary hyperparathyroidism, commonly due to a parathyroid adenoma. Malignancy-associated hypercalcaemia typically suppresses PTH.

Question 18Internal Medicine

Which organism is the most frequent cause of infective endocarditis in patients with prosthetic valves within the first year after surgery?

  1. Enterococcus faecalis
  2. Viridans group streptococci
  3. Streptococcus bovis
  4. Coagulase-negative staphylococci Correct answer.

Explanation

Early prosthetic valve endocarditis, occurring within 12 months of surgery, is most often caused by coagulase-negative staphylococci from skin flora acquired perioperatively. Viridans streptococci predominate in native valve disease.

Question 19Internal Medicine

A 32-year-old man has sudden severe pleuritic chest pain and dyspnoea 10 days after knee surgery. His heart rate is 118/min and oxygen saturation is 90% on room air. Which is the most appropriate next step in management?

  1. Start therapeutic anticoagulation while arranging confirmatory imaging Correct answer.
  2. Reassure and discharge with analgesia
  3. Await D-dimer results before any treatment
  4. Start thrombolysis immediately

Explanation

The clinical picture is highly suggestive of pulmonary embolism with haemodynamic stability but hypoxaemia. In a high-probability case, anticoagulation should begin while CT pulmonary angiography is arranged, because waiting for a D-dimer would delay treatment.

Question 20Internal Medicine

A 28-year-old woman with type 1 diabetes presents with vomiting, abdominal pain and deep sighing respiration. Which finding best confirms diabetic ketoacidosis?

  1. Normal pH with glycosuria alone
  2. Respiratory acidosis with a normal anion gap
  3. Metabolic acidosis with raised ketones and a raised anion gap Correct answer.
  4. Metabolic alkalosis with hypokalaemia

Explanation

Diabetic ketoacidosis is defined by a high anion gap metabolic acidosis driven by ketone accumulation, together with hyperglycaemia. Ketones are the key diagnostic marker and should be measured directly rather than relying on urine dipstick alone.

Question 21Internal Medicine

A 65-year-old man has a 3-month history of early satiety, unintentional weight loss and iron-deficiency anaemia. Which investigation is most appropriate to establish a diagnosis?

  1. Upper gastrointestinal endoscopy with biopsy Correct answer.
  2. Abdominal ultrasound
  3. Barium swallow
  4. Serum carcinoembryonic antigen level

Explanation

Dyspepsia with weight loss and iron-deficiency anaemia in an older adult warrants urgent endoscopy to visualise and biopsy a possible gastric or oesophageal malignancy. Imaging and tumour markers are adjuncts, not diagnostic tests.

Question 22Internal Medicine

A patient with known heart failure and reduced ejection fraction develops worsening renal function after starting an ACE inhibitor. Which mechanism best explains this finding?

  1. Immune-complex glomerulonephritis induced by the drug
  2. Direct tubular toxicity of the drug
  3. Reduced angiotensin II-mediated efferent arteriolar constriction lowering glomerular filtration pressure Correct answer.
  4. Increased renin release causing sodium retention

Explanation

Angiotensin II preferentially constricts the efferent arteriole, maintaining intraglomerular pressure when renal perfusion is reduced. ACE inhibition removes this support and can cause a reversible rise in creatinine, especially in patients with renal artery stenosis or volume depletion.

Question 23Internal Medicine

A 50-year-old man presents with fever, a new murmur and splinter haemorrhages. Blood cultures grow Staphylococcus aureus. Which feature would most strongly suggest a need for urgent surgical referral?

  1. A history of treated hypertension
  2. Mild anaemia on full blood count
  3. A single positive blood culture among four sets
  4. A vegetation larger than 10 mm with paravalvular abscess on echocardiography Correct answer.

Explanation

Large vegetations and paravalvular abscess indicate locally destructive infection with high risk of embolisation and valve failure, which are indications for early surgery. Persistent bacteraemia, heart failure and uncontrolled infection are other surgical triggers.

Question 24Internal Medicine

A 34-year-old woman has recurrent venous thromboses and a prolonged activated partial thromboplastin time that does not correct with a 50:50 mix of normal plasma. Which mechanism explains the failure to correct?

  1. Factor VIII deficiency
  2. Platelet function defect
  3. A time-dependent inhibitor such as a lupus anticoagulant Correct answer.
  4. Vitamin K deficiency

Explanation

Failure of the aPTT to correct after mixing with normal plasma indicates an inhibitor rather than a factor deficiency. A lupus anticoagulant is a time- and phospholipid-dependent inhibitor that paradoxically prolongs the aPTT while predisposing to thrombosis.

Question 25Internal Medicine

A 68-year-old man with known cirrhosis presents with haematemesis and hypotension. Which measure most improves survival in acute variceal bleeding?

  1. Oral lactulose alone
  2. Immediate beta blocker therapy
  3. Terlipressin plus prophylactic antibiotics with urgent endoscopic band ligation Correct answer.
  4. Transjugular intrahepatic portosystemic shunt as first-line therapy

Explanation

Combining a vasoactive agent such as terlipressin, prophylactic antibiotics and endoscopic band ligation within 12 hours reduces mortality in acute variceal haemorrhage. TIPS is reserved for refractory bleeding or early rebleeding in selected patients.

Question 26Internal Medicine

A 58-year-old man with type 2 diabetes has an eGFR of 32 mL/min/1.73 m² and an albumin-to-creatinine ratio of 350 mg/g. Which medication class slows progression of his diabetic kidney disease independent of its glucose-lowering effect?

  1. Thiazolidinedione
  2. Sulfonylurea
  3. Alpha-glucosidase inhibitor
  4. Angiotensin receptor blocker Correct answer.

Explanation

Blockade of the renin-angiotensin system with an ACE inhibitor or angiotensin receptor blocker reduces intraglomerular pressure and slows progression of albuminuric diabetic kidney disease beyond what glycaemic control alone achieves. It is the established first-line renoprotective step in patients with hypertension and albuminuria.

Question 27Internal Medicine

A 24-year-old woman has fatigue, weight gain and cold intolerance. Examination shows a diffuse goitre with a smooth, non-tender surface and delayed relaxation of the ankle reflex. Which pattern of thyroid function tests is expected?

  1. High TSH with high free T4
  2. High TSH with low free T4 Correct answer.
  3. Low TSH with high free T4
  4. Low TSH with low free T4

Explanation

Primary hypothyroidism results from failure of the thyroid gland, so free T4 falls and the pituitary drives TSH upward in compensation. The goitre reflects TSH stimulation of an enlarged gland, as seen in Hashimoto thyroiditis.

Question 28Internal Medicine

A 66-year-old man has a resting tremor, cogwheel rigidity and bradykinesia. Which medication is the most effective dopaminergic treatment for the motor symptoms of his Parkinson disease?

  1. Amantadine
  2. Levodopa combined with carbidopa Correct answer.
  3. Trihexyphenidyl
  4. Propranolol

Explanation

Levodopa is the most effective agent for motor symptoms of Parkinson disease because it is the direct precursor of dopamine and crosses the blood-brain barrier. Carbidopa blocks peripheral decarboxylation, increasing delivery to the brain and reducing nausea.

Question 29Internal Medicine

A 47-year-old woman has a 6-month history of episodic epigastric pain that wakes her at night and is relieved by food. Which finding on upper endoscopy most strongly supports a duodenal ulcer?

  1. Diffuse erythema of the gastric antrum
  2. Multiple superficial erosions in the gastric fundus
  3. A clean-based ulcer in the duodenal bulb Correct answer.
  4. A submucosal nodule with central umbilication in the gastric body

Explanation

A discrete ulcer crater in the duodenal bulb is the endoscopic hallmark of peptic ulcer disease, and duodenal ulcers classically cause nocturnal pain relieved by eating. Biopsy or urease testing for Helicobacter pylori should follow.

Question 30Internal Medicine

A 62-year-old man with chronic obstructive pulmonary disease has a resting oxygen saturation of 86% on room air, confirmed on two occasions 3 weeks apart while clinically stable. What is the most appropriate long-term intervention?

  1. Prophylactic oral corticosteroids
  2. Regular short-acting beta-2 agonist alone
  3. Long-term domiciliary oxygen therapy Correct answer.
  4. Routine nebulised antibiotics

Explanation

Long-term oxygen therapy improves survival in patients with chronic hypoxaemia from COPD when resting arterial oxygen tension is persistently low on stable measurements. It should be prescribed after confirming the degree of hypoxaemia when the patient is clinically stable.

Question 31Internal Medicine

A 35-year-old man has sudden onset of severe left flank pain radiating to the groin, with visible haematuria. Non-contrast CT of the abdomen shows a 6 mm stone at the vesicoureteric junction with mild hydronephrosis. He is afebrile with normal renal function. What is the most appropriate initial management?

  1. Immediate open ureterolithotomy
  2. Long-term indwelling urethral catheterisation
  3. Percutaneous nephrostomy
  4. Analgesia and observation with a trial of spontaneous passage Correct answer.

Explanation

Stones of 6 mm or less at the distal ureter have a reasonable chance of spontaneous passage, and in the absence of fever, obstruction with infection, or renal impairment, analgesia and observation with follow-up are appropriate. Medical expulsive therapy may be added in selected cases.

Question 32Internal Medicine

A 71-year-old woman with hypertension and diabetes has a transient episode of right arm weakness and slurred speech that resolved within 40 minutes. CT of the brain is normal. Which score is used to estimate her early stroke risk after a transient ischaemic attack?

  1. CHA2DS2-VASc score
  2. ABCD2 score Correct answer.
  3. CURB-65 score
  4. Wells score

Explanation

The ABCD2 score combines age, blood pressure, clinical features, symptom duration and diabetes to stratify early stroke risk after a transient ischaemic attack. It helps identify patients who need urgent assessment and secondary prevention.

Question 33Internal Medicine

A 29-year-old woman has a 2-day history of colicky right upper quadrant pain after fatty meals, with fever and a positive Murphy sign. Ultrasound shows gallstones and a thickened gallbladder wall. Which diagnosis is most likely?

  1. Acute cholecystitis Correct answer.
  2. Acute pancreatitis
  3. Renal colic
  4. Acute appendicitis

Explanation

Postprandial right upper quadrant pain with fever, a positive Murphy sign and ultrasound evidence of gallstones with gallbladder wall thickening indicates acute cholecystitis from cystic duct obstruction. Antibiotics and early cholecystectomy are the usual management.

Question 34Internal Medicine

A 68-year-old woman has a haemoglobin of 78 g/L with a mean corpuscular volume of 108 fL. She takes no alcohol and is not pregnant. Which laboratory test best identifies the underlying cause?

  1. Haemoglobin electrophoresis
  2. Serum vitamin B12 and folate levels Correct answer.
  3. Reticulocyte count
  4. Serum ferritin

Explanation

A macrocytic anaemia in a non-drinking, non-pregnant adult most often reflects vitamin B12 or folate deficiency, so measuring both identifies the cause. B12 deficiency also requires assessment for pernicious anaemia and malabsorption.

Question 35Internal Medicine

A 54-year-old man has sudden severe tearing chest pain radiating to the back, with a 25 mmHg difference in systolic pressure between the arms. Which imaging test is the investigation of choice in a haemodynamically stable patient?

  1. Exercise stress testing
  2. Contrast-enhanced CT angiography of the aorta Correct answer.
  3. Plain chest radiograph
  4. Transthoracic echocardiography

Explanation

Interarm blood pressure difference with tearing pain suggests aortic dissection, and contrast-enhanced CT angiography reliably visualises the intimal flap and extent of dissection in a stable patient. It also guides surgical or endovascular planning.

Question 36Internal Medicine

A 44-year-old woman has recurrent episodes of palpitations, sweating and headache with documented blood pressure of 210/120 mmHg during an attack. Which biochemical test is the most appropriate initial screen for phaeochromocytoma?

  1. Serum cortisol after overnight dexamethasone
  2. Plasma renin activity
  3. Serum aldosterone-to-renin ratio
  4. Plasma free metanephrines Correct answer.

Explanation

Paroxysmal hypertension with headache, sweating and palpitations suggests catecholamine excess, and plasma free metanephrines are the most sensitive initial biochemical test for phaeochromocytoma. Measurement should ideally be taken without interfering medications or stress.

Question 37Internal Medicine

A 60-year-old man with a 40 pack-year smoking history has progressive dyspnoea and a dry cough. High-resolution CT shows bilateral peripheral reticulation with honeycombing and traction bronchiectasis, with basal predominance. Which diagnosis is most likely?

  1. Pulmonary tuberculosis
  2. Idiopathic pulmonary fibrosis Correct answer.
  3. Chronic obstructive pulmonary disease
  4. Hypersensitivity pneumonitis

Explanation

Basal-predominant peripheral reticulation with honeycombing and traction bronchiectasis on high-resolution CT is the usual interstitial pneumonia pattern, which in the absence of another cause indicates idiopathic pulmonary fibrosis. Smoking is a recognised risk factor.

Question 38Internal Medicine

A 57-year-old woman with long-standing rheumatoid arthritis has a serum creatinine of 210 µmol/L, active urinary sediment and new hypertension. Which finding on renal biopsy would most strongly suggest a vasculitic glomerulonephritis rather than amyloidosis?

  1. Global glomerulosclerosis with interstitial fibrosis
  2. Diffuse foot process effacement
  3. Amorphous eosinophilic material in the mesangium
  4. Crescents in glomeruli with necrotising lesions Correct answer.

Explanation

Crescent formation with fibrinoid necrosis indicates active vasculitic glomerulonephritis, which can complicate rheumatoid arthritis and requires urgent immunosuppression. Amyloidosis instead shows amorphous Congo red-positive deposits.

Question 39Internal Medicine

A 38-year-old man has jaundice, dark urine and a markedly raised conjugated bilirubin with a normal alkaline phosphatase and no gallstones on ultrasound. Which additional finding would best support Dubin-Johnson syndrome over Gilbert syndrome?

  1. Reduced hepatic glucuronyltransferase activity
  2. Haemolysis on the blood film
  3. A grossly black liver at biopsy with normal hepatic architecture Correct answer.
  4. Isolated unconjugated hyperbilirubinaemia provoked by fasting

Explanation

Dubin-Johnson syndrome is a conjugated hyperbilirubinaemia caused by impaired canalicular excretion, and the liver is characteristically pigmented black by a melanin-like substance with otherwise normal histology. Gilbert syndrome, in contrast, causes unconjugated hyperbilirubinaemia with a structurally normal liver.

Question 40Internal Medicine

A 63-year-old man with decompensated heart failure and an ejection fraction of 25% remains breathless despite optimal diuretic and beta-blocker therapy. Which additional agent improves survival in heart failure with reduced ejection fraction by blocking the mineralocorticoid receptor?

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

Explanation

Mineralocorticoid receptor antagonists such as spironolactone reduce mortality in heart failure with reduced ejection fraction, provided renal function and potassium are monitored. Their benefit is distinct from symptomatic relief with loop diuretics.

Question 41Surgery

A 24-year-old man is brought to the emergency department after a motorcycle crash. He is anxious, with a respiratory rate of 34/min, absent breath sounds over the right hemithorax, hyperresonance to percussion, and distended neck veins. What is the most appropriate immediate step?

  1. Needle decompression of the right pleural cavity Correct answer.
  2. Tube thoracostomy after confirming the diagnosis on CT
  3. Urgent chest radiograph before any intervention
  4. Intravenous fluid bolus and observation

Explanation

The findings describe a tension pneumothorax, which is a clinical diagnosis and a life-threatening emergency. Immediate needle decompression, followed by tube thoracostomy, is required before any imaging. Delay to obtain radiographs or CT can precipitate cardiovascular collapse.

Question 42Surgery

Which finding most reliably distinguishes an indirect inguinal hernia from a direct inguinal hernia on physical examination?

  1. Presence of a cough impulse at the deep ring
  2. Presence of associated hydrocele
  3. Size of the swelling in the standing position
  4. Relationship of the neck of the sac to the inferior epigastric vessels Correct answer.

Explanation

Indirect hernias arise lateral to the inferior epigastric vessels and pass through the deep ring, whereas direct hernias protrude medial to these vessels through Hesselbach's triangle. This anatomic relationship is the definitive discriminator, though it is often confirmed at surgery.

Question 43Surgery

A 58-year-old woman has a 2 cm firm, mobile mass in the upper outer quadrant of the right breast. Core biopsy shows invasive ductal carcinoma. Which single factor is the strongest predictor of long-term outcome?

  1. Patient age at diagnosis
  2. Tumor grade alone
  3. Presence of microcalcifications
  4. Axillary lymph node status Correct answer.

Explanation

Axillary nodal involvement remains the most powerful prognostic factor in breast cancer and guides adjuvant therapy decisions. Tumor grade, receptor status, and size add information but do not supersede nodal status.

Question 44Surgery

A 45-year-old man presents with severe epigastric pain radiating to the back, and CT shows necrosis of more than 30% of the pancreas with a fluid collection. Which complication should be most closely monitored in the first two weeks?

  1. Portal vein thrombosis
  2. Infected pancreatic necrosis Correct answer.
  3. Splenic artery aneurysm rupture
  4. Colonic fistula

Explanation

Infected pancreatic necrosis is the leading cause of late mortality in severe acute pancreatitis and typically develops after the first week. Surveillance with clinical signs, inflammatory markers, and imaging guides the need for intervention.

Question 45Surgery

Which statement about the blood supply of the stomach is correct?

  1. The short gastric arteries arise from the left gastric artery
  2. The right gastric artery is a branch of the proper hepatic artery Correct answer.
  3. The left gastroepiploic artery arises from the gastroduodenal artery
  4. The right gastroepiploic artery arises from the splenic artery

Explanation

The right gastric artery usually arises from the proper hepatic artery and runs along the lesser curvature. The short gastric and left gastroepiploic arteries arise from the splenic artery, while the right gastroepiploic artery comes from the gastroduodenal artery.

Question 46Surgery

A 70-year-old man has painless gross hematuria. Cystoscopy shows a 3 cm papillary tumor of the bladder wall, and biopsy shows a high-grade urothelial carcinoma invading the lamina propria. What is the correct T stage?

  1. T1 Correct answer.
  2. Tis
  3. Ta
  4. T2

Explanation

T1 denotes invasion of the subepithelial connective tissue (lamina propria) without muscularis propria involvement. Ta is noninvasive papillary disease and T2 requires invasion of the detrusor muscle.

Question 47Surgery

A 30-year-old man sustains a stab wound to the left chest and arrives with a systolic blood pressure of 70 mmHg and distended neck veins. Chest tube drainage is 1,600 mL immediately. What is the most appropriate next step?

  1. Insertion of a second chest tube
  2. Urgent operative thoracotomy Correct answer.
  3. Pericardiocentesis
  4. Continued observation with repeat chest radiograph

Explanation

Massive hemothorax with hemodynamic instability and initial drainage exceeding 1,500 mL is an indication for urgent thoracotomy. Pericardiocentesis addresses tamponade rather than pleural hemorrhage. Continued observation in an unstable patient is unsafe.

Question 48Surgery

Which clinical feature best supports a diagnosis of acute appendicitis over mesenteric lymphadenitis in a 12-year-old child?

  1. Pain migrating from the periumbilical region to the right lower quadrant Correct answer.
  2. Temperature of 38 degrees Celsius
  3. Diffuse abdominal tenderness
  4. History of recent upper respiratory infection

Explanation

Migration of pain to the right lower quadrant reflects progression of inflammation to the parietal peritoneum over the appendix. Mesenteric lymphadenitis more often produces diffuse or right-sided tenderness without classic migration.

Question 49Surgery

A 62-year-old woman has a 5 cm abdominal aortic aneurysm. Which threshold generally indicates elective repair in an asymptomatic patient?

  1. Presence of mild claudication
  2. Diameter of 5.5 cm or rapid growth Correct answer.
  3. Presence of mural thrombus
  4. Diameter of 4.0 cm

Explanation

Elective repair is generally recommended when the aneurysm reaches 5.5 cm in men, or grows rapidly, because rupture risk rises steeply above this size. Smaller asymptomatic aneurysms are managed with surveillance.

Question 50Surgery

A patient develops fever, tachycardia, and a painful, erythematous wound with crepitus 48 hours after surgery. What is the most important initial management step?

  1. Topical antibiotic ointment and outpatient follow-up
  2. Observation for 24 hours
  3. Urgent surgical debridement and broad-spectrum antibiotics Correct answer.
  4. Oral antibiotics alone

Explanation

Crepitus and rapid systemic toxicity suggest necrotizing soft tissue infection, a surgical emergency. Prompt radical debridement combined with intravenous broad-spectrum antibiotics is essential; antibiotics alone are insufficient.