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SLMC ERPM practice questions

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Question 1Medical knowledge and clinical practice (content not enumerated by the source)

A patient with type 1 diabetes develops sweating, tremor, palpitations and confusion. Which single measurement most directly confirms the cause of these symptoms?

  1. Capillary blood glucose Correct answer.
  2. Serum cortisol
  3. Serum potassium
  4. Arterial blood gas

Explanation

The features described are those of hypoglycaemia, which is common in type 1 diabetes treated with insulin. The diagnosis is confirmed by demonstrating a low blood glucose at the time of symptoms, ideally with symptom resolution after correction. Other biochemistry does not address the immediate cause.

Question 2Medical knowledge and clinical practice (content not enumerated by the source)

Which finding on a 12-lead ECG is most characteristic of acute transmural myocardial infarction?

  1. First-degree atrioventricular block
  2. Diffuse PR depression
  3. Sinus tachycardia with normal axis
  4. ST-segment elevation in anatomically contiguous leads Correct answer.

Explanation

Acute transmural ischaemia produces ST-segment elevation in leads facing the infarcted territory, often with reciprocal depression elsewhere. This pattern guides urgent reperfusion decisions. The other listed findings are non-specific or suggest different diagnoses.

Question 3Medical knowledge and clinical practice (content not enumerated by the source)

A 68-year-old presents with sudden-onset right hemiparesis and expressive aphasia that began 90 minutes ago. Non-contrast CT of the head shows no haemorrhage. What is the most appropriate immediate management consideration?

  1. Assess eligibility for intravenous thrombolysis Correct answer.
  2. Give aspirin and discharge home
  3. Arrange elective outpatient MRI
  4. Start therapeutic low-molecular-weight heparin

Explanation

Sudden focal deficits with a clear onset time and no haemorrhage on CT represent acute ischaemic stroke within a potential treatment window. Intravenous thrombolysis should be considered after checking contraindications. Anticoagulation is not an emergency first step and discharge is inappropriate.

Question 4Medical knowledge and clinical practice (content not enumerated by the source)

A child has a barking cough, inspiratory stridor and hoarse voice following a few days of coryza. Which diagnosis is most likely?

  1. Bronchiolitis
  2. Croup (laryngotracheobronchitis) Correct answer.
  3. Epiglottitis
  4. Asthma exacerbation

Explanation

A barking cough with stridor and hoarseness after a viral prodrome is the classic picture of croup, caused by subglottic oedema. Epiglottitis typically causes drooling, high fever and a muffled voice in a toxic child. Bronchiolitis and asthma produce wheeze rather than stridor.

Question 5Medical knowledge and clinical practice (content not enumerated by the source)

Which laboratory pattern is most consistent with iron-deficiency anaemia?

  1. Low vitamin B12 with hypersegmented neutrophils
  2. Low ferritin with microcytic hypochromic red cells Correct answer.
  3. Normal ferritin with target cells and raised HbA2
  4. Raised ferritin with macrocytic red cells

Explanation

Iron deficiency depletes stores, so ferritin falls, and haemoglobin synthesis is impaired, producing microcytic hypochromic red cells. This combination is the standard diagnostic pattern. The other options describe anaemia of chronic disease, thalassaemia trait and megaloblastic anaemia.

Question 6Medical knowledge and clinical practice (content not enumerated by the source)

A patient develops fever, hypotension and widespread erythema with desquamation during the first week after a burn injury. Which complication should be suspected?

  1. Neurogenic shock
  2. Adrenal crisis
  3. Toxic shock syndrome Correct answer.
  4. Hypovolaemic shock from under-resuscitation

Explanation

Fever, hypotension and a diffuse erythematous rash with desquamation in a burn patient suggest a toxin-mediated illness such as toxic shock syndrome, often from colonised wounds. Recognition matters because it requires source control and specific antimicrobial therapy. The other options lack the characteristic rash.

Question 7Medical knowledge and clinical practice (content not enumerated by the source)

Which single intervention most reduces the risk of ventilator-associated pneumonia?

  1. Daily chest physiotherapy
  2. Maintaining the head of the bed elevated at 30 to 45 degrees Correct answer.
  3. Changing the ventilator circuit every 24 hours
  4. Routine prophylactic broad-spectrum antibiotics

Explanation

Semi-recumbent positioning reduces aspiration of oropharyngeal secretions and is a core element of ventilator-associated pneumonia bundles. Prophylactic antibiotics promote resistance, and frequent circuit changes do not reduce infection. Physiotherapy has no established primary preventive role.

Question 8Medical knowledge and clinical practice (content not enumerated by the source)

A pregnant woman at 34 weeks presents with painless bright red vaginal bleeding. Which diagnosis should be considered first?

  1. Placental abruption
  2. Vasa praevia
  3. Placenta praevia Correct answer.
  4. Uterine rupture

Explanation

Painless vaginal bleeding in later pregnancy classically suggests placenta praevia, where the placenta overlies or approaches the cervical os. Digital examination should be avoided until imaging localises the placenta. Abruption usually causes painful bleeding with a tender uterus.

Question 9Medical knowledge and clinical practice (content not enumerated by the source)

Which organism is the most frequent cause of community-acquired pneumonia in adults?

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

Explanation

Streptococcus pneumoniae remains the commonest identified cause of community-acquired pneumonia in adults. Atypical organisms and Legionella are important but less frequent, and Pneumocystis mainly affects immunocompromised hosts. Empiric therapy is therefore designed to cover pneumococcus.

Question 10Medical knowledge and clinical practice (content not enumerated by the source)

A patient on long-term high-dose corticosteroids develops weakness, hyperpigmentation and hypotension. Which test best confirms the underlying endocrine diagnosis?

  1. Serum thyrotropin level
  2. Oral glucose tolerance test
  3. Short synacthen (ACTH stimulation) test Correct answer.
  4. 24-hour urinary metanephrines

Explanation

Suppression of the hypothalamic-pituitary-adrenal axis by exogenous steroids can cause secondary adrenal insufficiency, presenting with weakness and hypotension. The short synacthen test assesses adrenal cortisol reserve and confirms the diagnosis. The other tests assess different endocrine axes.

Question 11Medical knowledge and clinical practice (content not enumerated by the source)

Which feature most strongly suggests a diagnosis of meningitis rather than encephalitis?

  1. Neck stiffness with photophobia and fever Correct answer.
  2. Focal seizures with behavioural change
  3. Asymmetric flaccid weakness
  4. Profound altered consciousness out of proportion to fever

Explanation

Meningeal irritation produces neck stiffness, photophobia and headache with fever, which are typical of meningitis. Encephalitis is characterised more by altered consciousness, seizures and focal deficits reflecting brain parenchymal involvement. The distinction guides lumbar puncture and antiviral decisions.

Question 12Medical knowledge and clinical practice (content not enumerated by the source)

A patient with atrial fibrillation has a CHA2DS2-VASc score of 4. What is the most appropriate management to reduce stroke risk?

  1. Dual antiplatelet therapy
  2. Aspirin monotherapy
  3. Long-term oral anticoagulation Correct answer.
  4. No antithrombotic therapy

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates sufficient stroke risk to warrant oral anticoagulation. Anticoagulation substantially reduces cardioembolic stroke compared with antiplatelet therapy. Aspirin and dual antiplatelet therapy are not equivalent substitutes in this setting.

Question 13Medical knowledge and clinical practice (content not enumerated by the source)

Which clinical sign is most characteristic of a tension pneumothorax?

  1. Tracheal deviation away from the affected side with hypotension Correct answer.
  2. Fine inspiratory crackles at the lung base
  3. Pleural rub with fever
  4. Bilateral pitting peripheral oedema

Explanation

Tension pneumothorax raises intrathoracic pressure, shifting mediastinal structures away from the affected side and impairing venous return, which causes hypotension. It is a clinical diagnosis requiring immediate decompression. Crackles, oedema and rub suggest other conditions.

Question 14Medical knowledge and clinical practice (content not enumerated by the source)

A patient with chronic kidney disease has a potassium of 7.2 mmol/L with peaked T waves on ECG. Which intervention should be given first to protect the myocardium?

  1. Intravenous insulin with glucose
  2. Oral potassium binder
  3. Intravenous calcium gluconate Correct answer.
  4. Oral sodium bicarbonate

Explanation

Hyperkalaemia with ECG changes is a medical emergency, and intravenous calcium stabilises the myocardium immediately without lowering serum potassium. Measures such as insulin with glucose then shift potassium intracellularly. Binders and bicarbonate act too slowly for acute cardiac protection.

Question 15Medical knowledge and clinical practice (content not enumerated by the source)

Which finding is most consistent with nephrotic syndrome?

  1. Sterile pyuria with flank pain
  2. Proteinuria greater than 3.5 g per day with hypoalbuminaemia Correct answer.
  3. Haematuria with red cell casts and hypertension
  4. Hyperkalaemia with metabolic acidosis

Explanation

Nephrotic syndrome is defined by heavy proteinuria, hypoalbuminaemia, oedema and hyperlipidaemia due to glomerular podocyte injury. Red cell casts and hypertension indicate a nephritic picture instead. The other options reflect infection or tubular dysfunction.

Question 16Medical knowledge and clinical practice (content not enumerated by the source)

A patient presents with sudden severe headache described as the worst of life, neck stiffness and photophobia. Which investigation is most appropriate after initial stabilisation?

  1. Immediate lumbar puncture without imaging
  2. Non-contrast CT head followed by lumbar puncture if CT is negative Correct answer.
  3. Electroencephalography
  4. Carotid Doppler ultrasound

Explanation

The presentation suggests subarachnoid haemorrhage. A non-contrast CT is highly sensitive early, and if it is negative, lumbar puncture for xanthochromia is performed to detect bilirubin from lysed red cells. Imaging first avoids the risk of lumbar puncture in raised intracranial pressure.

Question 17Medical knowledge and clinical practice (content not enumerated by the source)

Which mechanism best explains the hypoglycaemic effect of metformin?

  1. Reduction of hepatic gluconeogenesis Correct answer.
  2. Direct stimulation of pancreatic insulin secretion
  3. Blockade of insulin receptors
  4. Inhibition of intestinal glucose absorption only

Explanation

Metformin lowers blood glucose mainly by reducing hepatic gluconeogenesis and improving peripheral insulin sensitivity. It does not stimulate insulin secretion, so it rarely causes hypoglycaemia when used alone. Blocking insulin receptors would worsen diabetes.

Question 18Medical knowledge and clinical practice (content not enumerated by the source)

A patient with sepsis has a lactate of 4 mmol/L and mean arterial pressure of 55 mmHg despite 30 mL/kg of crystalloid. What is the most appropriate next step?

  1. Give a further 60 mL/kg of crystalloid rapidly
  2. Start a vasopressor such as norepinephrine Correct answer.
  3. Administer a diuretic
  4. Transfuse packed red cells to a haemoglobin of 100 g/L

Explanation

Persistent hypotension with raised lactate after adequate fluid resuscitation indicates septic shock requiring vasopressors to restore perfusion pressure. Norepinephrine is first-line. Further large fluid boluses risk overload, and diuretics or transfusion are not indicated here.

Question 19Medical knowledge and clinical practice (content not enumerated by the source)

Which feature most reliably distinguishes an epileptic seizure from a psychogenic non-epileptic attack?

  1. Side-to-side head movements
  2. Closed eyes during the attack
  3. Gradual onset over several minutes
  4. Postictal confusion with a raised prolactin shortly after a generalised event Correct answer.

Explanation

True generalised tonic-clonic seizures are often followed by postictal confusion and a transient rise in prolactin. Features such as closed eyes, side-to-side head movements and gradual onset are more associated with non-epileptic attacks. Definitive diagnosis may require video-EEG.

Question 20Medical knowledge and clinical practice (content not enumerated by the source)

A newborn is noted to have a heart murmur and cyanosis that does not improve with supplemental oxygen. Which congenital lesion is most consistent with this picture?

  1. Transposition of the great arteries Correct answer.
  2. Ventricular septal defect
  3. Atrial septal defect
  4. Patent ductus arteriosus

Explanation

Cyanosis unresponsive to oxygen suggests a right-to-left shunt with mixing of circulations. Transposition of the great arteries produces parallel circulations and severe cyanosis soon after birth. The other lesions typically cause left-to-right shunting and acyanotic presentations.

Question 21Medical knowledge and clinical practice (content not enumerated by the source)

Which statement about the use of opioids for acute pain in palliative care is most accurate?

  1. Opioids should be avoided until pain is severe
  2. Dose should be titrated to effect with monitoring for respiratory depression Correct answer.
  3. Pethidine is preferred for chronic cancer pain
  4. Opioid dose should never be adjusted once started

Explanation

Opioid analgesia for acute cancer pain is titrated to the individual's response, with monitoring for sedation and respiratory depression. Regular reassessment allows dose adjustment. Pethidine is avoided for chronic use because of neurotoxic metabolites.

Question 22Medical knowledge and clinical practice (content not enumerated by the source)

A patient has a fasting glucose of 6.4 mmol/L and a two-hour value of 9.8 mmol/L on an oral glucose tolerance test. What is the correct classification?

  1. Impaired fasting glucose only
  2. Normal glucose tolerance
  3. Impaired glucose tolerance Correct answer.
  4. Type 2 diabetes mellitus

Explanation

A two-hour glucose between 7.8 and 11.0 mmol/L defines impaired glucose tolerance, while fasting values between 6.1 and 6.9 mmol/L indicate impaired fasting glucose. Together these reflect prediabetes. Diabetes requires a two-hour value of 11.1 mmol/L or above.

Question 23Medical knowledge and clinical practice (content not enumerated by the source)

Which infection control measure is most effective for preventing transmission of Clostridioides difficile in hospital?

  1. Alcohol-based hand rub alone
  2. Hand washing with soap and water plus contact precautions Correct answer.
  3. Airborne isolation with negative pressure
  4. Prophylactic oral vancomycin for contacts

Explanation

C. difficile spores are resistant to alcohol, so mechanical hand washing with soap and water is required, alongside contact precautions and environmental cleaning. Alcohol rub alone does not remove spores. Airborne isolation and prophylaxis for contacts are not indicated.

Question 24Medical knowledge and clinical practice (content not enumerated by the source)

A patient with a suspected forearm fracture has severe pain, pallor, paraesthesia and a tense compartment. What is the most appropriate immediate action?

  1. Apply a tight plaster cast for immobilisation
  2. Elevate the limb above the heart and observe
  3. Urgent surgical fasciotomy after removing constricting dressings Correct answer.
  4. Give analgesia and reassess in 24 hours

Explanation

Compartment syndrome is a surgical emergency in which raised tissue pressure compromises perfusion. Constricting dressings should be removed and urgent fasciotomy performed to prevent muscle and nerve necrosis. Delay or immobilisation worsens ischaemia.

Question 25Medical knowledge and clinical practice (content not enumerated by the source)

A woman presents with a painful, red, tender breast and fever during the first weeks of breastfeeding. What is the most appropriate initial management?

  1. Apply ice and observe without treatment
  2. Arrange urgent mastectomy
  3. Continue breastfeeding with appropriate antibiotics Correct answer.
  4. Stop breastfeeding permanently and give no antibiotics

Explanation

Lactational mastitis is usually caused by Staphylococcus aureus and should be treated with antibiotics while continuing milk drainage, which aids resolution. Stopping breastfeeding promotes stasis and abscess formation. Surgery is reserved for abscesses that fail to resolve.

Question 26Medical knowledge and clinical practice (content not enumerated by the source)

A 62-year-old man with type 2 diabetes and an eGFR of 25 mL/min/1.73 m² is admitted with a non-ST-elevation myocardial infarction. Which antiplatelet strategy requires the most careful reconsideration because of his renal function?

  1. Continuing aspirin 75 mg daily indefinitely
  2. Adding a glycoprotein IIb/IIIa inhibitor such as eptifibatide to aspirin and clopidogrel Correct answer.
  3. Using fondaparinux rather than enoxaparin for anticoagulation
  4. Loading with clopidogrel 300 mg before angiography

Explanation

Glycoprotein IIb/IIIa inhibitors are cleared renally and accumulate in chronic kidney disease, markedly increasing bleeding risk; if used at all, dose reduction is required and many clinicians avoid them when eGFR is below 30. Aspirin, a clopidogrel loading dose and fondaparinux (which needs no renal dose adjustment) are all reasonable in this situation. The question tests matching drug elimination to renal function rather than memorising a single contraindication.

Question 27Medical knowledge and clinical practice (content not enumerated by the source)

A 28-year-old woman has a blood pressure of 168/112 mmHg at 37 weeks of gestation, a platelet count of 88 × 10⁹/L, AST of 120 U/L and creatinine of 130 µmol/L. She reports right upper quadrant discomfort. What is the most appropriate immediate management?

  1. High-dose corticosteroids to mature the fetal lungs and delay delivery by two weeks
  2. Delivery after stabilisation with antihypertensives and magnesium sulfate Correct answer.
  3. Oral labetalol alone with reassessment in 48 hours
  4. Expectant management with weekly blood pressure monitoring until 39 weeks

Explanation

This is severe pre-eclampsia with HELLP features (thrombocytopenia, raised transaminases, right upper quadrant pain), and the definitive treatment is delivery once the mother is stabilised. Blood pressure control and magnesium sulfate for seizure prophylaxis precede delivery. Waiting for fetal maturity in this setting risks maternal hepatic, renal and haematological deterioration.

Question 28Medical knowledge and clinical practice (content not enumerated by the source)

A 70-year-old man has a serum sodium of 118 mmol/L after several days of excessive water intake and thiazide use. He is confused but not seizing. Which correction approach is safest?

  1. Give intravenous furosemide without fluid restriction
  2. Restrict fluid alone and recheck in 72 hours
  3. Correct to 135 mmol/L within 12 hours using hypertonic saline
  4. Raise sodium by no more than 8–10 mmol/L in the first 24 hours Correct answer.

Explanation

Overly rapid correction of chronic hyponatraemia can cause osmotic demyelination, so the rise is limited to roughly 8–10 mmol/L per day in patients at risk. Hypertonic saline is reserved for severe symptoms such as seizures, and even then correction is capped. Fluid restriction alone may be too slow when sodium is this low and the patient is symptomatic.

Question 29Medical knowledge and clinical practice (content not enumerated by the source)

A 45-year-old woman has a 3 cm thyroid nodule and a suppressed TSH with a normal free T4. What is the most appropriate next step?

  1. Total thyroidectomy without further testing
  2. Repeat TSH in 12 months
  3. Fine-needle aspiration of the nodule immediately
  4. Thyroid scintigraphy to assess whether the nodule is functioning Correct answer.

Explanation

A suppressed TSH with a nodule suggests a possible autonomous (toxic) nodule, and scintigraphy distinguishes a hot nodule, which is rarely malignant, from a cold one that requires cytology. Fine-needle aspiration is the next step for nodules with normal or elevated TSH or for cold nodules. Surgery is not the initial investigation.

Question 30Medical knowledge and clinical practice (content not enumerated by the source)

A 55-year-old man presents with a painful, swollen left calf after a long-haul flight. Which finding on compression ultrasound would confirm a proximal deep vein thrombosis?

  1. Reduced venous flow augmentation with calf squeeze alone
  2. Increased flow velocity in the superficial femoral artery
  3. Non-compressibility of the common femoral or popliteal vein Correct answer.
  4. A Baker cyst behind the knee

Explanation

The diagnostic criterion for deep vein thrombosis on compression ultrasound is failure of a vein to compress, and proximal thrombus involving the common femoral or popliteal vein is the most clinically important. Reduced augmentation alone is a soft sign and is not diagnostic. Arterial flow and Baker cysts are unrelated findings.

Question 31Medical knowledge and clinical practice (content not enumerated by the source)

A 34-year-old woman has recurrent episodes of palpitations, sweating and headache. During an attack her blood pressure is 210/120 mmHg. Which test is most appropriate to confirm the diagnosis?

  1. Overnight dexamethasone suppression test
  2. Plasma free metanephrines Correct answer.
  3. 24-hour urinary free cortisol
  4. Serum aldosterone-to-renin ratio

Explanation

Paroxysmal hypertension with palpitations, sweating and headache suggests phaeochromocytoma, and plasma free metanephrines are the most sensitive initial biochemical test. Cortisol and aldosterone testing address different endocrine causes of hypertension. The diagnosis should be confirmed biochemically before any imaging.

Question 32Medical knowledge and clinical practice (content not enumerated by the source)

A 78-year-old woman with atrial fibrillation has a fall risk and moderate frailty. Her CHA₂DS₂-VASc score is 3. Which statement about anticoagulation is most accurate?

  1. Aspirin is an equivalent substitute for anticoagulation in frail older adults
  2. Anticoagulation should be delayed until she has had a documented stroke
  3. Anticoagulation should be withheld because any fall risk is an absolute contraindication
  4. Anticoagulation is still recommended because stroke risk outweighs bleeding risk, though the agent and dose should be chosen carefully Correct answer.

Explanation

Fall risk alone is rarely an absolute contraindication; the annual stroke risk at a CHA₂DS₂-VASc of 3 substantially exceeds the risk from falls. The choice of agent and dose should account for renal function, weight and interacting drugs. Aspirin is inferior to anticoagulation for stroke prevention in atrial fibrillation.

Question 33Medical knowledge and clinical practice (content not enumerated by the source)

A 24-year-old man has sudden onset of severe testicular pain on the left, nausea and a high-riding testis. What is the most appropriate immediate action?

  1. Await Doppler ultrasound before any decision
  2. Apply a scrotal support and arrange outpatient review
  3. Urgent surgical exploration Correct answer.
  4. Prescribe antibiotics for epididymitis and review in 24 hours

Explanation

Testicular torsion is a surgical emergency, and the testis can be salvaged only if detorsion occurs within roughly six hours. Ultrasound must not delay exploration when the clinical picture is convincing. Antibiotics and scrotal support are appropriate for epididymitis, which is far less urgent.

Question 34Medical knowledge and clinical practice (content not enumerated by the source)

A 30-year-old woman has a generalised tonic-clonic seizure, and her pregnancy test is positive at about 8 weeks. Which antiepileptic is preferred because of the lowest risk of major congenital malformations?

  1. Valproate
  2. Phenytoin
  3. Topiramate
  4. Levetiracetam Correct answer.

Explanation

Levetiracetam and lamotrigine are the preferred antiepileptics in pregnancy because they carry a lower risk of major congenital malformations than older agents. Valproate in particular is associated with neural tube defects and neurodevelopmental harm and should be avoided where possible. Phenytoin and topiramate carry higher teratogenic risk than levetiracetam.

Question 35Medical knowledge and clinical practice (content not enumerated by the source)

A 68-year-old man has progressive dysphagia, weight loss and iron-deficiency anaemia. Which investigation is the most appropriate next step?

  1. Abdominal ultrasound
  2. Upper gastrointestinal endoscopy with biopsy Correct answer.
  3. Barium swallow
  4. Oesophageal manometry

Explanation

Progressive dysphagia with weight loss and iron deficiency raises concern for oesophageal or gastric malignancy, and endoscopy allows direct visualisation and biopsy in a single procedure. Barium studies and manometry may be used for motility disorders but do not provide tissue diagnosis. Ultrasound does not visualise the oesophageal lumen adequately.

Question 36Medical knowledge and clinical practice (content not enumerated by the source)

A 50-year-old man has a blood pressure of 175/105 mmHg, hypokalaemia and metabolic alkalosis. Which finding would best confirm primary aldosteronism?

  1. Normal aldosterone with normal renin
  2. Elevated aldosterone with elevated renin
  3. Elevated aldosterone with suppressed renin Correct answer.
  4. Low aldosterone with elevated renin

Explanation

Primary aldosteronism is characterised by autonomous aldosterone secretion that suppresses renin, so the ratio of aldosterone to renin is high. Secondary hyperaldosteronism, as in renal artery stenosis, shows both hormones elevated. Low aldosterone with high renin suggests a different cause of salt loss.

Question 37Medical knowledge and clinical practice (content not enumerated by the source)

A 6-year-old child has a barking cough, hoarse voice and inspiratory stridor that began two days after a coryzal illness. He is not drooling and has no trismus. What is the most likely diagnosis?

  1. Viral croup Correct answer.
  2. Bacterial tracheitis
  3. Retropharyngeal abscess
  4. Epiglottitis

Explanation

A barking cough with hoarseness and stridor after a coryzal illness is the classic picture of viral croup (laryngotracheobronchitis). Epiglottitis typically causes drooling, a muffled voice and a toxic appearance, and bacterial tracheitis usually follows a more severe, toxic course. Retropharyngeal abscess causes neck stiffness and dysphagia rather than a barking cough.

Question 38Medical knowledge and clinical practice (content not enumerated by the source)

A 40-year-old woman has a deep partial-thickness burn to 20% of her body surface area. Which fluid resuscitation approach is most appropriate in the first 24 hours?

  1. Rapid boluses of 2 L of crystalloid regardless of weight
  2. Colloid given at twice the calculated crystalloid volume
  3. Fluids withheld until the urine output falls below 0.5 mL/kg/h
  4. Crystalloid calculated by a weight- and burn-surface formula, with the first half given in the first 8 hours from the time of injury Correct answer.

Explanation

Major burns are resuscitated with crystalloid using a formula such as Parkland, with half of the calculated volume given in the first eight hours from the time of injury rather than from presentation. Urine output is then used to titrate the remainder. Colloid is not the routine first-line fluid, and arbitrary large boluses risk fluid overload.

Question 39Medical knowledge and clinical practice (content not enumerated by the source)

A 65-year-old man with known chronic obstructive pulmonary disease has an arterial blood gas showing pH 7.31, PaCO₂ 62 mmHg and bicarbonate 30 mmol/L. How should this be interpreted?

  1. Acute metabolic acidosis
  2. Fully compensated metabolic alkalosis
  3. Acute-on-chronic respiratory acidosis Correct answer.
  4. Normal blood gas for age

Explanation

A raised bicarbonate indicates chronic carbon dioxide retention with renal compensation, while the low pH shows that the rise in PaCO₂ has outstripped compensation, giving an acute-on-chronic picture. A fully compensated respiratory acidosis would have a near-normal pH. Metabolic acidosis would show a low bicarbonate rather than a raised one.

Question 40Medical knowledge and clinical practice (content not enumerated by the source)

A 3-day-old neonate has not passed meconium, feeds poorly and has a distended abdomen. Which diagnosis should be considered first?

  1. Hirschsprung disease Correct answer.
  2. Pyloric stenosis
  3. Duodenal atresia
  4. Gastro-oesophageal reflux

Explanation

Failure to pass meconium within the first 48 hours with abdominal distension suggests Hirschsprung disease, caused by aganglionosis of the distal bowel. Pyloric stenosis presents with projectile non-bilious vomiting at around 3–6 weeks, and duodenal atresia typically produces bilious vomiting soon after birth with a double-bubble sign. Reflux does not cause failure to pass meconium.

Question 41Medical knowledge and clinical practice (content not enumerated by the source)

A 58-year-old woman has a painful red eye with a fixed mid-dilated pupil, blurred vision and a hazy cornea. What is the most appropriate immediate management?

  1. Warm compresses and analgesia
  2. Urgent ophthalmology referral for intraocular pressure-lowering therapy Correct answer.
  3. Topical steroid alone
  4. Topical antibiotic drops and review in 48 hours

Explanation

These features indicate acute angle-closure glaucoma, an ophthalmic emergency in which rising intraocular pressure can cause permanent visual loss within hours. Treatment includes topical and systemic pressure-lowering agents, often with pilocarpine, and definitive laser iridotomy. Antibiotics, steroids alone and warm compresses do not address the closed angle.

Question 42Medical knowledge and clinical practice (content not enumerated by the source)

A 72-year-old man has a hip fracture and is awaiting surgery. Which measure most reduces his risk of venous thromboembolism while he is immobile?

  1. Aspirin 75 mg daily
  2. Compression stockings alone in all patients
  3. Early mobilisation alone without prophylaxis
  4. Pharmacological thromboprophylaxis with a low-molecular-weight heparin, plus mechanical prophylaxis if pharmacological agents are contraindicated Correct answer.

Explanation

Patients with hip fracture are at high risk of venous thromboembolism, and low-molecular-weight heparin started early is the standard pharmacological prophylaxis, with mechanical methods used when bleeding risk precludes anticoagulation. Aspirin is less effective, and mobilisation or stockings alone are insufficient in this high-risk group.

Question 43Medical knowledge and clinical practice (content not enumerated by the source)

A 35-year-old man has sudden hearing loss in the right ear with no preceding infection or trauma. What is the most appropriate initial management?

  1. Urgent referral for high-dose corticosteroids started within days of onset Correct answer.
  2. Reassurance and review in three months
  3. Antibiotics for presumed otitis media
  4. Insertion of a ventilation tube

Explanation

Sudden sensorineural hearing loss is treated as an otological emergency, and early high-dose corticosteroids improve the chance of recovery. Delay beyond a few weeks reduces the likelihood of benefit. Antibiotics and ventilation tubes are appropriate for middle-ear effusion, which is not the diagnosis here.

Question 44Medical knowledge and clinical practice (content not enumerated by the source)

A 60-year-old woman has a fasting glucose of 7.8 mmol/L on two occasions and an HbA1c of 7.2%. She is asymptomatic. What is the correct interpretation?

  1. This meets diagnostic criteria for diabetes mellitus Correct answer.
  2. A repeat test is required before any diagnosis can be made, regardless of symptoms
  3. This is normal for her age
  4. This indicates impaired glucose tolerance only

Explanation

A fasting plasma glucose of 7.0 mmol/L or more, or an HbA1c of 6.5% or more, meets diagnostic criteria for diabetes, and either test alone is sufficient when confirmed. Symptoms are not required for diagnosis. Impaired glucose tolerance is defined by a two-hour oral glucose tolerance test value between 7.8 and 11.0 mmol/L, which is not what is reported here.

Question 45Medical knowledge and clinical practice (content not enumerated by the source)

A 45-year-old man has a blood pressure of 160/95 mmHg and episodes of headache and sweating. He takes no medications. Which secondary cause should be screened for first when there are no other clues?

  1. Renal artery stenosis
  2. Obstructive sleep apnoea Correct answer.
  3. Phaeochromocytoma
  4. Cushing syndrome

Explanation

Obstructive sleep apnoea is the most common secondary cause of hypertension and should be considered in patients with snoring, daytime somnolence or obesity. Phaeochromocytoma is rare and typically presents with paroxysmal symptoms, while Cushing syndrome and renal artery stenosis have additional distinguishing features. Screening for sleep apnoea is therefore the highest-yield first step.

Question 46Medical knowledge and clinical practice (content not enumerated by the source)

A 55-year-old man is admitted with confusion, fever and neck stiffness. A lumbar puncture shows a raised white cell count with a predominance of neutrophils, low glucose and high protein. Which empirical treatment is most appropriate while awaiting culture?

  1. Intravenous ceftriaxone plus vancomycin, with dexamethasone given before or with the first antibiotic dose Correct answer.
  2. Oral amoxicillin alone
  3. Observation without antibiotics until culture results are available
  4. Intravenous aciclovir alone

Explanation

The cerebrospinal fluid profile indicates bacterial meningitis, and empirical therapy should cover the likely organisms, typically a third-generation cephalosporin with vancomycin added where pneumococcal resistance is a concern. Dexamethasone given before or with the first antibiotic dose reduces hearing loss and neurological sequelae in pneumococcal meningitis. Treatment must not wait for culture.

Question 47Medical knowledge and clinical practice (content not enumerated by the source)

A 70-year-old woman has a serum calcium of 3.1 mmol/L and a parathyroid hormone level that is inappropriately normal. Which diagnosis is most likely?

  1. Osteomalacia
  2. Primary hyperparathyroidism Correct answer.
  3. Vitamin D deficiency
  4. Hypoparathyroidism

Explanation

Hypercalcaemia with a parathyroid hormone level that is not suppressed indicates inappropriate parathyroid hormone secretion, most often from a parathyroid adenoma. Hypoparathyroidism and vitamin D deficiency cause low or low-normal calcium, and osteomalacia is associated with low calcium and raised alkaline phosphatase. The combination of high calcium and non-suppressed parathyroid hormone is the key discriminator.

Question 48Medical knowledge and clinical practice (content not enumerated by the source)

A 25-year-old woman has a butterfly rash, arthralgia, oral ulcers and a positive antinuclear antibody with anti-double-stranded DNA. Which organ involvement most strongly predicts long-term mortality and warrants close monitoring?

  1. Lupus nephritis Correct answer.
  2. Alopecia
  3. Cutaneous vasculitis
  4. Sicca symptoms

Explanation

Lupus nephritis is the major determinant of morbidity and mortality in systemic lupus erythematosus and requires regular urinalysis and protein quantification. Skin, hair and sicca features affect quality of life but are not the main drivers of mortality. Early detection of renal involvement allows immunosuppression before irreversible damage occurs.

Question 49Medical knowledge and clinical practice (content not enumerated by the source)

A 62-year-old man has chronic obstructive pulmonary disease with a resting oxygen saturation of 88% on room air when clinically stable. Which intervention improves survival in this situation?

  1. Long-term oxygen therapy for at least 15 hours per day Correct answer.
  2. Routine oral corticosteroids
  3. Continuous antibiotics
  4. Nebulised bronchodilators alone

Explanation

Long-term oxygen therapy improves survival in patients with chronic hypoxaemia, and the benefit depends on using it for at least 15 hours a day. Oral corticosteroids and continuous antibiotics are not indicated for stable disease and carry substantial adverse effects. Bronchodilators relieve symptoms but do not improve survival in this group.

Question 50Medical knowledge and clinical practice (content not enumerated by the source)

A 45-year-old woman has a severe headache, visual disturbance and papilloedema, and imaging shows cerebral venous sinus thrombosis. Which treatment is most appropriate?

  1. Therapeutic anticoagulation with low-molecular-weight heparin, even in the presence of haemorrhagic infarction Correct answer.
  2. Observation with repeat imaging in one week
  3. Aspirin alone
  4. Immediate thrombectomy without anticoagulation

Explanation

Anticoagulation with heparin is the mainstay of treatment for cerebral venous sinus thrombosis, and haemorrhagic infarction is not an absolute contraindication because the underlying process is venous occlusion. Anticoagulation reduces thrombus propagation and improves outcomes. Aspirin and observation are inadequate for an acute thrombosis.