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PGIM MD Medicine practice questions

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Question 1General Internal Medicine

A 24-year-old man presents with sudden-onset severe headache, neck stiffness, and photophobia. Lumbar puncture shows uniformly blood-stained CSF across sequential tubes, and the supernatant is xanthochromic. Which is the most likely diagnosis?

  1. Migraine with aura
  2. Subarachnoid haemorrhage Correct answer.
  3. Tension-type headache
  4. Bacterial meningitis

Explanation

Uniform blood staining that does not clear across sequential collection tubes, together with xanthochromia of the supernatant, indicates true subarachnoid haemorrhage rather than a traumatic tap. Sudden thunderclap headache with meningism in a young adult is the classic presentation.

Question 2General Internal Medicine

Which finding on arterial blood gas in a patient with acute exacerbation of COPD most strongly suggests chronic respiratory acidosis with metabolic compensation?

  1. pH 7.20 with normal bicarbonate and raised PaCO2
  2. pH 7.34 with raised bicarbonate and raised PaCO2 Correct answer.
  3. pH 7.50 with low bicarbonate and low PaCO2
  4. pH 7.44 with normal bicarbonate and normal PaCO2

Explanation

In chronic respiratory acidosis the kidneys retain bicarbonate, so pH is only mildly reduced despite a raised PaCO2. A near-normal or slightly acid pH with elevated bicarbonate and CO2 indicates renal compensation rather than an acute uncompensated state.

Question 3General Internal Medicine

A 58-year-old woman has a fasting plasma glucose of 7.4 mmol/L on two occasions. Which single test is sufficient to confirm a diagnosis of diabetes mellitus in an asymptomatic patient?

  1. Repeat fasting plasma glucose of 7.0 mmol/L or more Correct answer.
  2. Random capillary glucose of 8.0 mmol/L
  3. Urine dipstick positive for glucose
  4. HbA1c of 6.0 percent

Explanation

Diabetes is diagnosed by fasting plasma glucose of 7.0 mmol/L or above, a 2-hour OGTT value of 11.1 mmol/L or above, HbA1c of 6.5 percent or above, or a random glucose of 11.1 mmol/L with symptoms. In an asymptomatic patient a confirmatory repeat abnormal result is required.

Question 4General Internal Medicine

A 70-year-old man with atrial fibrillation has an estimated creatinine clearance of 40 mL/min. Which anticoagulation strategy is most appropriate for stroke prevention?

  1. No anticoagulation
  2. Standard-dose dabigatran
  3. Dose-adjusted apixaban Correct answer.
  4. Aspirin 75 mg daily

Explanation

Apixaban is approved for use in severe renal impairment with dose reduction, making it the preferred direct oral anticoagulant at this creatinine clearance. Dabigatran is largely renally cleared and is contraindicated or requires caution at low clearance.

Question 5General Internal Medicine

A patient with decompensated heart failure has a serum sodium of 128 mmol/L and clinically dry mucous membranes. Which is the most appropriate initial fluid strategy?

  1. Oral water loading
  2. Fluid restriction alone
  3. Intravenous hypertonic saline
  4. Intravenous isotonic saline Correct answer.

Explanation

Hyponatraemia with clinical hypovolaemia indicates a depleted state where restoring circulating volume with isotonic saline is appropriate. Volume repletion suppresses ADH and allows free water clearance, correcting the sodium.

Question 6General Internal Medicine

Which is the most characteristic finding in a patient with primary hyperaldosteronism?

  1. Hypertension with hypokalaemia and suppressed renin Correct answer.
  2. Hypotension with hyperkalaemia and raised renin
  3. Hypertension with hyperkalaemia and raised renin
  4. Normotension with normal potassium and raised renin

Explanation

Autonomous aldosterone secretion causes sodium retention and potassium loss, producing hypertension with hypokalaemia. The excess aldosterone suppresses renin through negative feedback, distinguishing primary from secondary hyperaldosteronism.

Question 7General Internal Medicine

A 30-year-old woman has a butterfly rash, arthralgia, and a positive antinuclear antibody titre. Which additional finding would most strongly support systemic lupus erythematosus?

  1. Rheumatoid factor
  2. Anti-histone antibodies
  3. Anti-mitochondrial antibodies
  4. Anti-double-stranded DNA antibodies Correct answer.

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity and renal involvement. Their presence in the right clinical context is strongly supportive.

Question 8General Internal Medicine

A patient on treatment for active pulmonary tuberculosis develops painless visual loss and red-green colour confusion. Which drug is the most likely culprit?

  1. Pyrazinamide
  2. Rifampicin
  3. Isoniazid
  4. Ethambutol Correct answer.

Explanation

Ethambutol causes dose-related optic neuritis with reduced visual acuity and impaired colour discrimination. Visual monitoring is advised during therapy, particularly at higher doses or with renal impairment.

Question 9General Internal Medicine

Which electrocardiographic feature is most consistent with hyperkalaemia?

  1. Prominent U waves with flattened T waves
  2. Tall peaked T waves with widened QRS Correct answer.
  3. ST elevation with PR depression
  4. Sawtooth flutter waves

Explanation

Hyperkalaemia initially produces tall peaked T waves and, as severity increases, QRS widening and loss of P waves progressing to a sine wave pattern. These changes reflect impaired myocardial conduction.

Question 10General Internal Medicine

A 65-year-old man has an eGFR of 25 mL/min/1.73m2 and a haemoglobin of 92 g/L with normal iron studies. Which is the most appropriate initial management of his anaemia of chronic kidney disease?

  1. Oral ferrous sulphate alone
  2. No treatment until haemoglobin falls below 70 g/L
  3. Blood transfusion to normalise haemoglobin
  4. Erythropoiesis-stimulating agent Correct answer.

Explanation

Anaemia of chronic kidney disease due to inadequate erythropoietin is treated with an erythropoiesis-stimulating agent once iron stores are adequate and other causes are excluded. The aim is to correct anaemia gradually rather than to normalise haemoglobin.

Question 11General Internal Medicine

A 22-year-old student has a 3-day history of fever, sore throat, and tender cervical lymphadenopathy. Examination shows exudative tonsillitis. Which investigation best confirms the diagnosis of acute Epstein-Barr virus infection?

  1. Blood film for malaria parasites
  2. Throat swab culture
  3. Antistreptolysin O titre
  4. Heterophile antibody test Correct answer.

Explanation

The heterophile antibody test, such as the Monospot, detects antibodies characteristic of acute Epstein-Barr virus infection and is the standard rapid confirmatory test. It is most reliable after the first week of illness.

Question 12General Internal Medicine

A 55-year-old smoker has a persistent cough, weight loss, and a serum calcium of 3.1 mmol/L with a suppressed PTH. Which cause of hypercalcaemia is most likely?

  1. Primary hyperparathyroidism
  2. Humoral hypercalcaemia of malignancy Correct answer.
  3. Sarcoidosis
  4. Vitamin D intoxication

Explanation

Squamous cell lung carcinoma commonly secretes parathyroid hormone-related peptide, causing humoral hypercalcaemia of malignancy with suppressed endogenous PTH. The combination of suppressed PTH and hypercalcaemia in a smoker points to this mechanism.

Question 13General Internal Medicine

A 48-year-old woman presents with tremor, heat intolerance, and weight loss. TSH is suppressed and free T4 is elevated. Which is the most appropriate first-line definitive treatment for Graves disease in a stable patient?

  1. Radioactive iodine ablation
  2. Thionamide antithyroid drug Correct answer.
  3. Levothyroxine
  4. Subtotal thyroidectomy

Explanation

Thionamides such as methimazole or carbimazole are the usual first-line treatment for Graves disease, controlling hyperthyroidism while allowing time for spontaneous remission. Definitive options such as radioiodine or surgery are considered if relapse occurs or drugs are unsuitable.

Question 14General Internal Medicine

A patient with a history of peptic ulcer disease develops sudden severe epigastric pain with board-like rigidity. Which is the most appropriate initial investigation?

  1. Upper gastrointestinal endoscopy
  2. Barium meal
  3. Abdominal ultrasound
  4. Erect chest radiograph Correct answer.

Explanation

An erect chest radiograph can demonstrate free subdiaphragmatic gas indicating a perforated viscus, which is the immediate concern in this presentation. It is rapid and appropriate before further intervention.

Question 15General Internal Medicine

A 62-year-old man with chronic alcohol use has confusion, ataxia, and ophthalmoplegia. Which is the most appropriate immediate treatment?

  1. Intravenous naloxone
  2. Intravenous thiamine Correct answer.
  3. Intravenous glucose alone
  4. Oral folate

Explanation

The triad of confusion, ataxia, and ophthalmoplegia indicates Wernicke encephalopathy, a thiamine deficiency state requiring urgent parenteral thiamine. Thiamine should be given before or with glucose to avoid precipitating or worsening the encephalopathy.

Question 16General Internal Medicine

A 34-year-old woman has recurrent episodes of flushing, diarrhoea, and wheeze. Urinary 5-HIAA is elevated. Which is the most likely diagnosis?

  1. Pheochromocytoma
  2. Medullary thyroid carcinoma
  3. Carcinoid syndrome Correct answer.
  4. VIPoma

Explanation

Carcinoid syndrome results from serotonin-secreting neuroendocrine tumours and presents with flushing, diarrhoea, and bronchospasm. Elevated urinary 5-HIAA, a serotonin metabolite, supports the diagnosis.

Question 17General Internal Medicine

Which finding on liver biochemistry most suggests an obstructive rather than hepatocellular pattern of jaundice?

  1. Markedly raised ALT with modest alkaline phosphatase
  2. Raised alkaline phosphatase with raised bilirubin Correct answer.
  3. Low albumin with prolonged prothrombin time
  4. Raised AST with raised GGT

Explanation

Cholestatic obstruction causes disproportionate elevation of alkaline phosphatase and bilirubin, reflecting bile duct injury and impaired excretion. Hepatocellular injury raises transaminases far more than alkaline phosphatase.

Question 18General Internal Medicine

A patient with acute pancreatitis has a serum calcium of 1.85 mmol/L. Which mechanism best explains this finding?

  1. Saponification of calcium in necrotic fat Correct answer.
  2. Vitamin D deficiency
  3. Hyperparathyroidism
  4. Increased renal calcium excretion

Explanation

In severe pancreatitis, fat necrosis releases fatty acids that bind calcium in a process termed saponification, lowering serum calcium. Hypocalcaemia in this setting is a marker of severe disease.

Question 19General Internal Medicine

A 28-year-old woman has a blood pressure of 168/104 mmHg at 34 weeks gestation with 3+ proteinuria and a platelet count of 90 x 10^9/L. Which is the most appropriate management?

  1. Fluid restriction and diuretics
  2. Expectant management until term
  3. Urgent delivery after stabilisation with antihypertensives and magnesium Correct answer.
  4. Oral labetalol as outpatient

Explanation

Severe pre-eclampsia with thrombocytopenia indicates severe disease, and delivery is the definitive treatment after maternal stabilisation. Magnesium sulphate is given for seizure prophylaxis and antihypertensives control severe hypertension.

Question 20General Internal Medicine

A 45-year-old man has a serum sodium of 118 mmol/L after several days of polydipsia. He is asymptomatic. Which is the most appropriate correction rate?

  1. No more than 8 to 10 mmol/L in 24 hours Correct answer.
  2. Correction by 20 mmol/L in the first 12 hours
  3. Rapid correction to 135 mmol/L within 6 hours
  4. No more than 2 mmol/L in 24 hours

Explanation

Overly rapid correction of chronic hyponatraemia risks osmotic demyelination, so sodium should rise by no more than 8 to 10 mmol/L in 24 hours. Even in asymptomatic patients the correction must be cautious.

Question 21General Internal Medicine

A 60-year-old man has a painful swollen knee. Joint aspiration shows needle-shaped negatively birefringent crystals. Which is the most appropriate treatment for the acute attack in a patient with normal renal function?

  1. Oral colchicine or an NSAID Correct answer.
  2. Allopurinol started at high dose
  3. Probenecid
  4. Intra-articular steroid is contraindicated

Explanation

Acute gout is treated with an NSAID, colchicine, or corticosteroids to control inflammation. Urate-lowering therapy is not started or intensified during an acute attack because shifts in urate can prolong or worsen it.

Question 22General Internal Medicine

Which feature most reliably distinguishes an exudative from a transudative pleural effusion using Light's criteria?

  1. Pleural fluid to serum protein ratio above 0.5 Correct answer.
  2. Pleural fluid glucose above 3 mmol/L
  3. Pleural fluid pH above 7.4
  4. Clear straw-coloured appearance

Explanation

Light's criteria classify an effusion as exudative if the pleural fluid to serum protein ratio exceeds 0.5, the pleural fluid to serum LDH ratio exceeds 0.6, or pleural LDH exceeds two-thirds of the upper limit of normal serum LDH. These ratios reflect increased capillary permeability.

Question 23General Internal Medicine

A 72-year-old man has a haemoglobin of 78 g/L, a mean corpuscular volume of 72 fL, and a ferritin of 12 micrograms/L. Which is the most appropriate next step?

  1. Start oral iron without further investigation
  2. Transfuse two units of packed cells
  3. Check vitamin B12 level
  4. Investigate for gastrointestinal blood loss Correct answer.

Explanation

Iron deficiency anaemia in an older man requires investigation for gastrointestinal blood loss, including possible colorectal malignancy. Iron replacement treats the deficiency but does not address the underlying cause.

Question 24General Internal Medicine

A patient with type 1 diabetes has a blood glucose of 28 mmol/L, arterial pH 7.12, bicarbonate 8 mmol/L, and ketonuria. Which is the most important initial step in management?

  1. Oral rehydration
  2. Subcutaneous long-acting insulin alone
  3. Intravenous fluid resuscitation with isotonic saline Correct answer.
  4. Immediate intravenous bicarbonate

Explanation

Diabetic ketoacidosis is a state of profound volume depletion, so isotonic fluid resuscitation precedes or accompanies insulin therapy. Insulin is then given intravenously with potassium replacement as needed.

Question 25General Internal Medicine

A 40-year-old woman has proximal muscle weakness, a raised creatine kinase, and a heliotrope rash with Gottron papules. Which is the most likely diagnosis?

  1. Dermatomyositis Correct answer.
  2. Polymyositis
  3. Hypothyroidism
  4. Myasthenia gravis

Explanation

Dermatomyositis combines proximal inflammatory myopathy with characteristic skin findings such as a heliotrope rash and Gottron papules. Polymyositis causes muscle weakness without these cutaneous features.

Question 26General Internal Medicine

A 68-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 3 and no contraindication to anticoagulation. Which anticoagulation strategy is most appropriate for long-term stroke prevention?

  1. Start aspirin 75 mg daily indefinitely
  2. Start aspirin plus clopidogrel for 12 months then stop
  3. Start a direct oral anticoagulant such as apixaban at a renally adjusted dose Correct answer.
  4. No antithrombotic therapy is required because the rhythm is rate-controlled

Explanation

A CHA2DS2-VASc score of 2 or more in a man indicates sufficient stroke risk to justify oral anticoagulation, and a direct oral anticoagulant is preferred over warfarin in most non-valvular cases. Antiplatelet monotherapy does not provide adequate stroke prophylaxis in atrial fibrillation. Dual antiplatelet therapy is reserved for specific vascular indications and carries excess bleeding risk without equivalent benefit.

Question 27General Internal Medicine

A 54-year-old woman has a blood pressure of 152/94 mmHg on three separate visits, confirmed with ambulatory monitoring. She has no diabetes, no chronic kidney disease, and no target-organ damage. Which is the most appropriate initial pharmacological therapy?

  1. A thiazide-type diuretic, ACE inhibitor, or dihydropyridine calcium channel blocker as monotherapy Correct answer.
  2. Immediate combination of three agents including a mineralocorticoid antagonist
  3. An alpha blocker as first-line monotherapy
  4. A loop diuretic as first-line monotherapy

Explanation

For uncomplicated stage 1 hypertension, low-dose thiazide-type diuretics, ACE inhibitors, angiotensin receptor blockers, and dihydropyridine calcium channel blockers are all acceptable first-line options. Alpha blockers and loop diuretics are not preferred initial agents for uncomplicated hypertension. Triple therapy is reserved for blood pressure that remains uncontrolled on two agents.

Question 28General Internal Medicine

A 61-year-old man with a 40 pack-year smoking history has progressive exertional breathlessness. Spirometry after bronchodilator shows a post-bronchodilator FEV1/FVC ratio of 0.58. Which diagnosis is most consistent with this finding?

  1. Idiopathic pulmonary fibrosis
  2. Chronic obstructive pulmonary disease Correct answer.
  3. Congestive cardiac failure
  4. Asthma with complete reversibility

Explanation

A post-bronchodilator FEV1/FVC ratio below 0.70 confirms persistent airflow obstruction and, in a patient with relevant exposure and symptoms, supports a diagnosis of COPD. Asthma typically shows a greater bronchodilator response and variable obstruction. Restrictive and cardiac causes do not produce an obstructive ratio.

Question 29General Internal Medicine

A 70-year-old woman has a 3-month history of fatigue and is found to have a haemoglobin of 105 g/L with an MCV of 108 fL. Which laboratory test is most appropriate as the initial step to identify the cause of this anaemia?

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

Explanation

A macrocytic anaemia most commonly reflects vitamin B12 or folate deficiency, so measuring both is the logical first step. Ferritin is the key test for microcytic iron deficiency anaemia and is not the primary investigation here. Haemoglobin electrophoresis is used when a haemoglobinopathy is suspected, which typically produces a microcytic or normocytic picture.

Question 30General Internal Medicine

A 46-year-old man is admitted with severe acute pancreatitis. He is resuscitated with crystalloid and given analgesia. Which additional early intervention most improves outcome?

  1. Immediate CT-guided drainage of pancreatic necrosis
  2. Routine nasogastric suction
  3. Adequate intravenous fluid resuscitation with a balanced crystalloid Correct answer.
  4. Prophylactic broad-spectrum antibiotics

Explanation

Early goal-directed fluid resuscitation with balanced crystalloid is the cornerstone of initial management and reduces organ failure and pancreatic necrosis. Prophylactic antibiotics are not recommended in the absence of proven infected necrosis. Drainage is reserved for infected or symptomatic collections, and routine nasogastric suction has no proven benefit.

Question 31General Internal Medicine

A 30-year-old woman has sudden-onset severe headache reaching maximum intensity within seconds, with neck stiffness and photophobia. Which is the most appropriate next investigation?

  1. Carotid Doppler ultrasound
  2. Lumbar puncture without prior imaging
  3. Non-contrast CT head followed by lumbar puncture if CT is negative Correct answer.
  4. MRI of the cervical spine

Explanation

A thunderclap headache raises concern for subarachnoid haemorrhage, for which non-contrast CT is the first-line test, with lumbar puncture for xanthochromia if the CT is negative and clinical suspicion persists. Lumbar puncture without imaging risks herniation if a mass lesion is present. MRI of the spine and carotid Doppler do not evaluate for subarachnoid blood.

Question 32General Internal Medicine

A 58-year-old man with type 2 diabetes has an HbA1c of 8.4% on metformin monotherapy. He has no cardiovascular disease or chronic kidney disease. Which is the most appropriate next step in therapy?

  1. Stop metformin and start insulin
  2. Add a second glucose-lowering agent such as a GLP-1 receptor agonist or SGLT2 inhibitor Correct answer.
  3. Increase the metformin dose beyond the maximum tolerated dose
  4. Add a sulfonylurea as the only option

Explanation

When HbA1c remains above target on metformin monotherapy, adding a second agent from a class with proven benefit is appropriate, and GLP-1 receptor agonists or SGLT2 inhibitors are favoured given their cardiorenal profile. Exceeding the maximum tolerated metformin dose is not useful. Insulin is not required at this stage without marked hyperglycaemia or catabolic features.

Question 33General Internal Medicine

A 64-year-old woman has sudden painless loss of vision in one eye described as a curtain descending over the visual field. She has a history of atrial fibrillation. Which diagnosis should be considered first?

  1. Vitreous haemorrhage
  2. Open-angle glaucoma
  3. Optic neuritis
  4. Central retinal artery occlusion Correct answer.

Explanation

A sudden painless curtain-like visual loss in a patient with atrial fibrillation suggests an embolic central retinal artery occlusion. Glaucoma typically causes painful subacute visual loss with a red eye. Vitreous haemorrhage usually produces floaters and a hazy red reflex, while optic neuritis causes painful visual loss with a relative afferent pupillary defect.

Question 34General Internal Medicine

A 55-year-old man has a serum sodium of 126 mmol/L, a serum osmolality of 268 mOsm/kg, and a urine osmolality of 520 mOsm/kg after several days of reduced oral intake. He is euvolaemic and clinically well. Which is the most appropriate initial management?

  1. Furosemide alone without fluid restriction
  2. Fluid restriction and treatment of the underlying cause Correct answer.
  3. Demeclocycline as first-line therapy
  4. Rapid correction with hypertonic 3% saline

Explanation

This picture of concentrated urine with low serum osmolality in a euvolaemic patient is consistent with SIADH, for which fluid restriction and correction of the underlying cause are first-line. Hypertonic saline is reserved for severe symptomatic hyponatraemia or seizures. Demeclocycline is a second-line option for chronic SIADH.

Question 35General Internal Medicine

A 72-year-old woman has fever, productive cough, and right lower zone consolidation on chest radiograph. She has a CURB-65 score of 1. Which is the most appropriate site of care and treatment?

  1. Admission for intravenous antibiotics and intensive care
  2. Admission for observation without antibiotics
  3. Immediate transfer for surgical decortication
  4. Outpatient oral antibiotic therapy with clinical review Correct answer.

Explanation

A CURB-65 score of 0 or 1 identifies low-severity community-acquired pneumonia that can usually be managed as an outpatient with oral antibiotics and appropriate follow-up. Higher scores predict mortality and warrant admission, with intensive care reserved for severe disease. Surgery has no role in uncomplicated pneumonia.

Question 36General Internal Medicine

A 40-year-old man has recurrent calcium oxalate kidney stones. He has normal serum calcium and parathyroid hormone, and no obvious dietary excess. Which additional evaluation is most useful in identifying a treatable cause?

  1. Serum alpha-fetoprotein
  2. 24-hour urine collection for calcium, oxalate, citrate, and uric acid Correct answer.
  3. Serum prostate-specific antigen
  4. Renal artery Doppler

Explanation

A 24-hour urine study identifies hypercalciuria, hyperoxaluria, hypocitraturia, and hyperuricosuria, each of which guides specific dietary or pharmacological therapy. Prostate-specific antigen, renal Doppler, and alpha-fetoprotein are unrelated to stone formation. Targeted metabolic evaluation reduces recurrence.

Question 37General Internal Medicine

A 66-year-old man with known alcoholic cirrhosis presents with haematemesis and melaena. He is haemodynamically stable after initial resuscitation. Which is the most appropriate initial pharmacological therapy?

  1. Immediate beta-blocker initiation at high dose
  2. Vitamin K alone
  3. Oral iron supplementation
  4. A vasoactive agent such as octreotide plus prophylactic antibiotics Correct answer.

Explanation

Acute variceal bleeding is managed with a vasoactive agent such as octreotide or terlipressin together with prophylactic antibiotics, which reduce mortality and rebleeding, followed by endoscopic band ligation. Oral iron and vitamin K do not control active variceal haemorrhage. Non-selective beta-blockers are used for prophylaxis, not acutely at high dose during bleeding.

Question 38General Internal Medicine

A 28-year-old man has a 3-week history of bloody diarrhoea, urgency, and abdominal cramping. Stool cultures are negative. Which finding on colonoscopy most supports ulcerative colitis rather than Crohn disease?

  1. Deep linear ulceration with fistulae
  2. Continuous mucosal inflammation beginning in the rectum Correct answer.
  3. Transmural inflammation with non-caseating granulomas
  4. Skip lesions with intervening normal mucosa

Explanation

Ulcerative colitis characteristically causes continuous mucosal inflammation that begins in the rectum and extends proximally without skip lesions. Crohn disease is characterised by skip lesions, transmural inflammation, granulomas, and fistulae. These distinctions guide prognosis and treatment selection.

Question 39General Internal Medicine

A 35-year-old woman has a 6-month history of fatigue, cold intolerance, weight gain, and constipation. TSH is elevated and free T4 is low, with positive anti-thyroid peroxidase antibodies. Which is the most likely diagnosis?

  1. Hashimoto thyroiditis Correct answer.
  2. Subacute granulomatous thyroiditis
  3. Graves disease
  4. Pituitary adenoma

Explanation

A raised TSH with a low free T4 indicates primary hypothyroidism, and positive anti-thyroid peroxidase antibodies point to Hashimoto thyroiditis as the cause. Graves disease causes hyperthyroidism with a suppressed TSH. Subacute thyroiditis is painful and usually self-limiting, and a pituitary adenoma would produce a low or inappropriately normal TSH.

Question 40General Internal Medicine

A 62-year-old man has a 4 cm abdominal aortic aneurysm detected on ultrasound. He is asymptomatic and normotensive. Which is the most appropriate management?

  1. No follow-up required
  2. Immediate endovascular repair
  3. Serial ultrasound surveillance with cardiovascular risk factor modification Correct answer.
  4. Immediate open surgical repair

Explanation

Asymptomatic abdominal aortic aneurysms below 5.5 cm in men are managed with serial ultrasound surveillance, smoking cessation, blood pressure control, and statin therapy, because the rupture risk is low and elective repair carries procedural risk. Repair is offered when the diameter reaches 5.5 cm or expands rapidly. No follow-up would miss progressive enlargement.

Question 41General Internal Medicine

A 24-year-old woman has episodic palpitations, sweating, and headache. She has a blood pressure of 190/110 mmHg during an episode. Which test is most appropriate to confirm the diagnosis?

  1. Serum thyroid-stimulating hormone
  2. Serum cortisol after overnight dexamethasone suppression
  3. Plasma renin and aldosterone ratio
  4. Plasma free metanephrines Correct answer.

Explanation

Episodic headache, sweating, palpitations, and severe hypertension suggest phaeochromocytoma, for which plasma free metanephrines are the most sensitive initial test. The dexamethasone suppression test evaluates Cushing syndrome, and the aldosterone-to-renin ratio evaluates primary aldosteronism, neither of which produces paroxysmal symptoms. TSH testing would assess thyrotoxicosis but not this paroxysmal hypertensive pattern.

Question 42General Internal Medicine

A 48-year-old man has sudden onset of a painful, swollen right calf with warmth and erythema. Doppler ultrasound confirms a proximal deep vein thrombosis. He has normal renal function and no cancer. Which is the most appropriate anticoagulation approach?

  1. Aspirin 300 mg daily
  2. Thrombolysis with alteplase
  3. Compression stockings alone
  4. A direct oral anticoagulant such as apixaban for at least 3 months Correct answer.

Explanation

Provocation-unrelated or unprovoked proximal deep vein thrombosis is treated with anticoagulation for at least 3 months, and direct oral anticoagulants are first-line in patients without contraindications. Aspirin and compression stockings do not treat established thrombosis. Thrombolysis is reserved for limb-threatening or massive pulmonary embolism.

Question 43General Internal Medicine

A 70-year-old man has a 2-week history of progressive ascending symmetrical weakness and areflexia after a diarrhoeal illness. Cerebrospinal fluid shows albuminocytological dissociation. Which is the most likely diagnosis?

  1. Myasthenia gravis
  2. Guillain-Barré syndrome Correct answer.
  3. Polymyositis
  4. Acute ischaemic stroke

Explanation

Ascending symmetrical weakness with areflexia after a preceding infection, together with raised cerebrospinal fluid protein and a normal cell count, is characteristic of Guillain-Barré syndrome. Myasthenia gravis causes fatigable weakness without sensory loss and has a normal cerebrospinal fluid profile. Stroke and polymyositis do not produce this pattern.

Question 44General Internal Medicine

A 44-year-old woman has a serum creatinine of 210 micromol/L, 3+ proteinuria, and microscopic haematuria. Complement C3 and C4 are low. Which diagnosis is most likely?

  1. Minimal change disease
  2. Diabetic nephropathy
  3. Chronic interstitial nephritis
  4. Lupus nephritis Correct answer.

Explanation

Nephritic syndrome with proteinuria, haematuria, and low complement in a young woman strongly suggests lupus nephritis. Minimal change disease causes nephrotic-range proteinuria with a normal complement and no haematuria. Diabetic nephropathy and interstitial nephritis do not typically cause low complement with an active urinary sediment.

Question 45General Internal Medicine

A 65-year-old man with known heart failure with reduced ejection fraction has worsening dyspnoea. He is on furosemide and an ACE inhibitor but no beta-blocker. Which additional agent improves mortality in this setting?

  1. A thiazolidinedione
  2. A non-steroidal anti-inflammatory drug
  3. A beta-blocker such as bisoprolol Correct answer.
  4. A dihydropyridine calcium channel blocker

Explanation

Beta-blockers with proven outcome benefit are a cornerstone of therapy for heart failure with reduced ejection fraction and reduce mortality when added to standard treatment. Dihydropyridine calcium channel blockers, thiazolidinediones, and non-steroidal anti-inflammatory drugs can worsen fluid retention and do not improve survival in heart failure.

Question 46General Internal Medicine

A 52-year-old man has a fasting plasma glucose of 6.4 mmol/L and an HbA1c of 6.1%. He is asymptomatic and has a body mass index of 31 kg/m2. Which is the most appropriate interpretation?

  1. A laboratory error requiring repeat testing without further action
  2. Normal glucose tolerance
  3. Prediabetes, warranting lifestyle intervention and annual monitoring Correct answer.
  4. Overt diabetes requiring immediate insulin

Explanation

A fasting plasma glucose between 5.6 and 6.9 mmol/L and an HbA1c between 5.7% and 6.4% define prediabetes, which warrants intensive lifestyle modification and periodic retesting to prevent progression. Overt diabetes requires a fasting glucose of 7.0 mmol/L or more or an HbA1c of 6.5% or more. The values are not normal and do not indicate laboratory error.

Question 47General Internal Medicine

A 38-year-old woman has a 2-day history of severe unilateral headache with a painful red eye, blurred vision, and a fixed mid-dilated pupil. Which is the most appropriate immediate management?

  1. Topical antibiotic drops
  2. Reassurance and outpatient review in one week
  3. Oral sumatriptan
  4. Urgent ophthalmology referral for intraocular pressure lowering and definitive treatment Correct answer.

Explanation

A painful red eye with a fixed mid-dilated pupil and blurred vision suggests acute angle-closure glaucoma, which is an ophthalmological emergency requiring urgent pressure-lowering therapy and definitive treatment such as laser iridotomy. Sumatriptan treats migraine and would delay sight-saving treatment. Antibiotics and reassurance are inappropriate for this sight-threatening condition.

Question 48General Internal Medicine

A 60-year-old man with a recent myocardial infarction has sudden-onset severe dyspnoea and hypotension. Examination reveals a new harsh pansystolic murmur at the left sternal edge with a thrill and pulmonary oedema. Which is the most likely diagnosis?

  1. Constrictive pericarditis
  2. Mitral valve prolapse
  3. Acute ventricular septal rupture Correct answer.
  4. Aortic stenosis

Explanation

A new harsh pansystolic murmur with a thrill and cardiogenic shock after myocardial infarction suggests ventricular septal rupture, a mechanical complication requiring urgent echocardiography and surgical repair. Aortic stenosis produces an ejection systolic murmur, and mitral valve prolapse is usually chronic and asymptomatic. Constrictive pericarditis causes right heart failure rather than acute shock with a pansystolic murmur.

Question 49General Internal Medicine

A 72-year-old woman has a 3-month history of early satiety, weight loss, and a palpable epigastric mass. Endoscopy shows a large ulcerated gastric lesion, and biopsy confirms adenocarcinoma. Which finding has the greatest influence on determining operability?

  1. Staging with CT of chest, abdomen, and pelvis plus endoscopic ultrasound Correct answer.
  2. Helicobacter pylori stool antigen
  3. Serum gastrin level
  4. Serum carcinoembryonic antigen level

Explanation

Operability in gastric cancer depends on accurate staging for local invasion, nodal involvement, and distant metastases, which is achieved with cross-sectional imaging and endoscopic ultrasound. Tumour markers and H. pylori status do not determine resectability. Serum gastrin is relevant to neuroendocrine tumours rather than gastric adenocarcinoma staging.

Question 50General Internal Medicine

A 50-year-old man has a serum calcium of 3.4 mmol/L, confusion, and a shortened QT interval. He has a history of a parathyroid adenoma. Despite intravenous saline, his calcium remains elevated. Which additional therapy is most appropriate?

  1. Intravenous bisphosphonate such as zoledronic acid Correct answer.
  2. Vitamin D supplementation
  3. Oral calcium carbonate
  4. Thiazide diuretic

Explanation

Severe hypercalcaemia after adequate saline rehydration is treated with an intravenous bisphosphonate, which inhibits osteoclast-mediated bone resorption and lowers calcium over 24 to 48 hours. Oral calcium and vitamin D would worsen the hypercalcaemia. Thiazide diuretics reduce urinary calcium excretion and can exacerbate hypercalcaemia.