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North Macedonia Physician Licensing Exam study materials
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North Macedonia Physician Licensing Exam 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 antihyperglycaemic agent should be stopped because it is contraindicated at this level of renal function?

  1. Insulin glargine
  2. Empagliflozin
  3. Linagliptin
  4. Metformin Correct answer.

Explanation

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73 m² because of the risk of lactic acidosis from accumulation; it should be stopped rather than dose-reduced at this level. The other agents listed can be used with appropriate dose adjustment or monitoring in advanced chronic kidney disease.

Question 2Internal Medicine

Which finding on the resting 12-lead ECG is most characteristic of acute pericarditis?

  1. ST elevation confined to leads V1–V4 with reciprocal depression
  2. Widespread concave ST elevation with PR depression Correct answer.
  3. Sawtooth flutter waves at 300 per minute
  4. Deep Q waves in inferior leads with ST elevation

Explanation

Acute pericarditis classically produces diffuse concave-upward ST elevation in many leads together with PR-segment depression, reflecting inflammation of the pericardium and epicardium. Localised ST elevation with reciprocal changes instead suggests myocardial infarction, and the other options describe different conditions.

Question 3Internal Medicine

A 24-year-old woman has fatigue, weight gain, cold intolerance, and a diffuse goitre. TSH is elevated and free T4 is low. Which antibody is most likely to be positive?

  1. Anti-thyroglobulin antibody
  2. Anti-thyroid peroxidase antibody Correct answer.
  3. TSH-receptor stimulating antibody
  4. Anti-voltage-gated calcium channel antibody

Explanation

The picture is primary hypothyroidism due to Hashimoto thyroiditis, in which anti-thyroid peroxidase antibodies are the most sensitive and characteristic marker. TSH-receptor stimulating antibodies belong to Graves disease, which causes hyperthyroidism.

Question 4Internal Medicine

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

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

Explanation

Acute respiratory acidosis from alveolar hypoventilation raises PaCO2, which lowers pH; bicarbonate rises only slightly and acutely because renal compensation is delayed. A high pH with high bicarbonate would indicate metabolic alkalosis, and low PaCO2 with low pH indicates metabolic acidosis.

Question 5Internal Medicine

A 62-year-old man presents with sudden painless loss of vision in one eye; fundoscopy shows a pale retina with a cherry-red spot at the macula. Which diagnosis is most likely?

  1. Retinal detachment
  2. Central retinal artery occlusion Correct answer.
  3. Vitreous haemorrhage
  4. Central retinal vein occlusion

Explanation

Sudden painless monocular visual loss with a pale, oedematous retina and a cherry-red macula is the classic appearance of central retinal artery occlusion. The cherry-red spot is the normal choroidal colour seen through the thin fovea surrounded by ischaemic retina.

Question 6Internal Medicine

Which clinical feature best distinguishes an epileptic generalised tonic-clonic seizure from a psychogenic non-epileptic attack?

  1. Side-to-side head shaking
  2. Postictal confusion and prolonged drowsiness Correct answer.
  3. Gradual onset with fluctuating course
  4. Closed eyes with resistance to opening

Explanation

Prolonged postictal confusion and drowsiness are characteristic of a true generalised tonic-clonic seizure and are difficult to feign. Side-to-side head shaking, closed eyes resisting opening, and fluctuating gradual onset are features more typical of psychogenic non-epileptic attacks.

Question 7Internal Medicine

A 70-year-old woman has proximal muscle weakness, a raised creatine kinase, and a heliotrope rash with Gottron papules. Which antibody is most specific for the likely diagnosis?

  1. Anti-histidyl-tRNA synthetase (Jo-1) antibody
  2. Anti-Mi-2 antibody Correct answer.
  3. Anti-Scl-70 antibody
  4. Anti-double-stranded DNA antibody

Explanation

The findings describe dermatomyositis, for which anti-Mi-2 antibodies are highly specific and associated with the classic skin manifestations. Anti-Jo-1 defines antisynthetase syndrome with interstitial lung disease, and anti-Scl-70 indicates systemic sclerosis.

Question 8Internal Medicine

A 45-year-old man with alcohol-related cirrhosis has ascites. After a large-volume paracentesis, which intravenous fluid is recommended to prevent post-paracentesis circulatory dysfunction?

  1. Ringer's lactate
  2. Fresh frozen plasma
  3. Human albumin Correct answer.
  4. 0.9% sodium chloride

Explanation

Albumin is the recommended colloid after large-volume paracentesis because it reduces the risk of post-paracentesis circulatory dysfunction and its complications. Crystalloids and fresh frozen plasma do not adequately maintain oncotic pressure in this setting.

Question 9Internal Medicine

A 30-year-old woman has a blood pressure of 168/104 mmHg, hypokalaemia, and metabolic alkalosis. Which screening test is most appropriate for the suspected cause?

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

Explanation

Hypertension with unprovoked hypokalaemia and metabolic alkalosis suggests primary hyperaldosteronism, for which the plasma aldosterone-to-renin ratio is the initial screening test. Metanephrines screen for phaeochromocytoma, which does not typically cause hypokalaemia.

Question 10Internal Medicine

A 68-year-old man has iron-deficiency anaemia and a positive faecal immunochemical test. Which is the most appropriate next investigation?

  1. Abdominal ultrasound
  2. Oral iron therapy and reassessment in 6 months
  3. Repeat faecal immunochemical test in 12 months
  4. Colonoscopy Correct answer.

Explanation

Iron-deficiency anaemia in an older man with a positive faecal immunochemical test requires direct evaluation of the lower gastrointestinal tract for colorectal cancer, and colonoscopy is the investigation of choice. It allows both diagnosis and biopsy of any lesion.

Question 11Internal Medicine

A 55-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 3. Which anticoagulation strategy is recommended?

  1. Aspirin alone
  2. Long-term oral anticoagulation with a direct oral anticoagulant Correct answer.
  3. No antithrombotic therapy
  4. Dual antiplatelet therapy

Explanation

A CHA2DS2-VASc score of 2 or more in men carries a clear indication for oral anticoagulation, and a direct oral anticoagulant is preferred over aspirin or dual antiplatelet therapy. Antiplatelet agents provide inadequate stroke prevention in atrial fibrillation.

Question 12Internal Medicine

Which finding is most consistent with nephrotic-range proteinuria?

  1. Urinary protein excretion greater than 3.5 g per 24 hours with hypoalbuminaemia Correct answer.
  2. Urinary protein excretion of 300 mg per 24 hours
  3. Sterile pyuria with white cell casts
  4. Haematuria with red cell casts and normal albumin

Explanation

Nephrotic syndrome is defined by proteinuria above 3.5 g per 24 hours together with hypoalbuminaemia and oedema. Red cell casts indicate a nephritic picture, and 300 mg per day is within the normal to mildly elevated range.

Question 13Internal Medicine

A 40-year-old woman has recurrent epistaxis and mucocutaneous telangiectasia. Her father had similar problems. Which diagnosis is most likely?

  1. Von Willebrand disease
  2. Haemophilia A
  3. Immune thrombocytopenia
  4. Hereditary haemorrhagic telangiectasia Correct answer.

Explanation

Recurrent epistaxis with mucocutaneous telangiectasia and a family history in an autosomal dominant pattern is characteristic of hereditary haemorrhagic telangiectasia. Von Willebrand disease causes mucosal bleeding but not telangiectasia, and haemophilia A is X-linked with joint bleeding.

Question 14Internal Medicine

A 60-year-old man has a serum calcium of 3.1 mmol/L with a raised parathyroid hormone. Which imaging or localisation step is appropriate before parathyroidectomy?

  1. Abdominal CT
  2. Whole-body PET-CT as first-line
  3. Bone scan
  4. Parathyroid ultrasound followed by sestamibi scanning if needed Correct answer.

Explanation

In primary hyperparathyroidism, non-invasive localisation with neck ultrasound and, if necessary, sestamibi scintigraphy guides minimally invasive parathyroidectomy. These modalities are preferred over extensive or unrelated imaging.

Question 15Internal Medicine

Which feature most strongly suggests a diagnosis of infective endocarditis rather than a non-infective cause of fever in a patient with a prosthetic valve?

  1. Persistent bacteraemia with the same organism on repeated cultures Correct answer.
  2. Raised inflammatory markers alone
  3. A single positive blood culture for a skin commensal
  4. Eosinophilia

Explanation

Persistent bacteraemia with an identical organism on repeated cultures is a major microbiological criterion for infective endocarditis. A single culture of a skin commensal is often contamination, and inflammatory markers are non-specific.

Question 16Internal Medicine

A 72-year-old woman has a low-trauma wrist fracture. Which investigation should be performed to assess for osteoporosis and guide treatment?

  1. Dual-energy X-ray absorptiometry of the hip and spine Correct answer.
  2. Plain radiograph of the lumbar spine
  3. Serum alkaline phosphatase alone
  4. Serum calcium alone

Explanation

A fragility fracture in an older adult warrants bone mineral density measurement by dual-energy X-ray absorptiometry to confirm osteoporosis and guide pharmacological therapy. Plain radiographs and isolated biochemistry do not measure bone density.

Question 17Internal Medicine

A 35-year-old man has bloody diarrhoea and abdominal pain; colonoscopy shows continuous inflammation from the rectum. Which finding supports ulcerative colitis rather than Crohn disease?

  1. Granulomas on biopsy
  2. Continuous mucosal inflammation confined to the colon Correct answer.
  3. Perianal fistulae
  4. Transmural inflammation with skip lesions

Explanation

Ulcerative colitis characteristically causes continuous, superficial inflammation beginning in the rectum and confined to the colon. Transmural skip lesions, granulomas, and perianal fistulae favour Crohn disease.

Question 18Internal Medicine

A 50-year-old man has sudden severe tearing chest pain radiating to the back. Which initial imaging study is most appropriate in a haemodynamically stable patient?

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

Explanation

In a stable patient with suspected acute aortic dissection, contrast-enhanced CT angiography of the aorta is the preferred initial study because it rapidly confirms the diagnosis and defines the extent of the dissection. Echocardiography and plain radiography are less definitive.

Question 19Internal Medicine

A 28-year-old woman has a first episode of severe acute pancreatitis. Which aetiology should be excluded first in the absence of gallstones or alcohol use?

  1. Pancreatic cancer
  2. Hypertriglyceridaemia Correct answer.
  3. Hypercalcaemia
  4. Coeliac disease

Explanation

After gallstones and alcohol, hypertriglyceridaemia is the most common cause of acute pancreatitis and should be checked early because it alters management. Hypercalcaemia is a recognised but less frequent cause, and pancreatic cancer rarely presents as acute pancreatitis in this age group.

Question 20Internal Medicine

A 65-year-old man with chronic obstructive pulmonary disease has a resting oxygen saturation of 88% and a pO2 of 52 mmHg on room air. Which intervention improves survival in this situation?

  1. Oral corticosteroids indefinitely
  2. Antibiotic prophylaxis with azithromycin
  3. Regular nebulised salbutamol alone
  4. Long-term oxygen therapy for at least 16 hours daily Correct answer.

Explanation

Long-term oxygen therapy for at least 16 hours per day improves survival in chronic obstructive pulmonary disease with severe resting hypoxaemia. The other options do not have this mortality benefit in stable disease.

Question 21Internal Medicine

A 30-year-old woman has sudden severe headache described as the worst of her life. Which investigation is the most appropriate initial test if she is stable and has no focal deficit?

  1. Non-contrast CT head within 6 hours of onset Correct answer.
  2. MRI of the cervical spine
  3. Electroencephalography
  4. Lumbar puncture as the first test

Explanation

A non-contrast CT head performed within 6 hours of a sudden severe headache is highly sensitive for subarachnoid haemorrhage and is the first-line test. Lumbar puncture is reserved for cases with a negative CT and ongoing suspicion.

Question 22Internal Medicine

A 45-year-old man has bipolar disorder and has been taking lithium for years. He now presents with coarse tremor, ataxia, and confusion, and a lithium level of 2.8 mmol/L. Which is the most appropriate immediate management?

  1. Give intravenous calcium gluconate
  2. Stop lithium and arrange haemodialysis for severe toxicity Correct answer.
  3. Start a thiazide diuretic
  4. Continue lithium and reduce the dose

Explanation

A lithium level of 2.8 mmol/L with neurological toxicity is severe and requires stopping the drug and arranging haemodialysis, which effectively removes lithium. Continued dosing or diuretics would worsen the toxicity.

Question 23Internal Medicine

A 58-year-old woman with type 2 diabetes develops a painless ulcer on the plantar surface of the foot. Which finding on examination most strongly predicts impaired healing?

  1. Bounding dorsalis pedis pulses
  2. Absent vibration sensation with a monofilament deficit Correct answer.
  3. Warm dry skin
  4. Bilateral pitting oedema

Explanation

Loss of protective sensation on monofilament testing indicates peripheral neuropathy, which impairs recognition of injury and strongly predicts poor ulcer healing. Warm skin, bounding pulses, and oedema are not the features that most strongly predict impaired healing.

Question 24Internal Medicine

A 68-year-old man has a serum sodium of 118 mmol/L after several days of vomiting and poor intake. He is confused but not seizing. Which correction strategy is safest?

  1. Fluid restriction alone
  2. Rapid correction with 5% dextrose
  3. Slow correction with hypertonic saline only if severe symptoms, aiming for a rise of no more than 8–10 mmol/L in 24 hours Correct answer.
  4. Rapid correction with normal saline to normalise sodium within 6 hours

Explanation

Symptomatic severe hyponatraemia requires careful correction, generally with hypertonic saline only when there are severe neurological symptoms, and the rise should be limited to about 8–10 mmol/L in 24 hours to avoid osmotic demyelination. Rapid normalisation risks serious neurological injury.

Question 25Internal Medicine

A 60-year-old woman with rheumatoid arthritis has been on methotrexate for years. She develops fever, breathlessness, and diffuse pulmonary infiltrates. Which diagnosis should be considered?

  1. Rheumatoid nodule
  2. Pulmonary embolism
  3. Methotrexate-induced pneumonitis Correct answer.
  4. Pleural effusion from heart failure

Explanation

Methotrexate can cause a hypersensitivity pneumonitis presenting with fever, breathlessness, and diffuse infiltrates, and the drug should be stopped while other causes are excluded. Rheumatoid nodules and heart failure do not typically produce this acute febrile presentation.

Question 26Internal Medicine

A 62-year-old man has a fasting plasma glucose of 7.4 mmol/L on two separate occasions. He is asymptomatic. Which finding confirms a diagnosis of diabetes mellitus according to standard diagnostic criteria?

  1. A random plasma glucose of 11.1 mmol/L or higher with classic osmotic symptoms Correct answer.
  2. A glycated haemoglobin of 5.9% on a single measurement
  3. A 2-hour plasma glucose of 7.0 mmol/L during an oral glucose tolerance test
  4. A fasting plasma glucose of 6.1 mmol/L on a third occasion

Explanation

Diabetes is confirmed by a fasting glucose of 7.0 mmol/L or above, a 2-hour OGTT value of 11.1 mmol/L or above, HbA1c of 6.5% or above, or a random glucose of 11.1 mmol/L or above accompanied by classic symptoms. In an asymptomatic patient, a single abnormal value should be repeated to confirm the diagnosis.

Question 27Internal Medicine

A 34-year-old woman has a resting heart rate of 118/min, weight loss, heat intolerance, and a diffuse goitre with a smooth texture. Which laboratory finding is most consistent with Graves disease rather than a toxic multinodular goitre?

  1. Suppressed TSH with a low thyroid uptake of radioiodine
  2. Suppressed TSH with a diffusely increased thyroid uptake of radioiodine Correct answer.
  3. Elevated TSH with a diffuse goitre
  4. Suppressed TSH with a focal hot nodule on scintigraphy

Explanation

Graves disease is caused by TSH-receptor-stimulating antibodies that drive diffuse, uniform overproduction of thyroid hormone, so radioiodine uptake is diffusely increased. A toxic multinodular goitre typically shows patchy or focal uptake, and thyroiditis shows low uptake.

Question 28Internal Medicine

A 24-year-old man has an acute asthma attack with a peak expiratory flow of 45% of predicted, a heart rate of 118/min, and difficulty completing sentences. Which initial treatment is most appropriate?

  1. Oral antibiotics alone with observation
  2. Long-acting beta-2 agonist alone
  3. Intravenous beta-blockers and a sedative
  4. Repeated inhaled short-acting beta-2 agonist plus systemic corticosteroids and oxygen Correct answer.

Explanation

An acute severe asthma attack is managed with repeated doses of a short-acting inhaled beta-2 agonist, early systemic corticosteroids, and titrated oxygen to maintain saturation. This combination addresses bronchospasm and the underlying airway inflammation.

Question 29Internal Medicine

A 70-year-old man has a blood pressure of 158/94 mmHg on three clinic visits and an average home reading of 150/92 mmHg. He has no diabetes or kidney disease. Which management step is most appropriate first?

  1. Start lifestyle modification and a single antihypertensive drug Correct answer.
  2. Withhold treatment until the blood pressure exceeds 180/110 mmHg
  3. Admit for intravenous antihypertensive therapy
  4. Start three antihypertensive drugs simultaneously

Explanation

Confirmed stage 1 hypertension in an older adult without high-risk comorbidity is treated with lifestyle measures plus a single first-line agent, then reassessed. Intravenous therapy and multi-drug starting regimens are reserved for hypertensive emergencies or specific high-risk situations.

Question 30Internal Medicine

A 58-year-old man with type 2 diabetes and an eGFR of 32 mL/min/1.73 m2 has a potassium of 5.9 mmol/L and a bicarbonate of 19 mmol/L. He takes an ACE inhibitor and a potassium-sparing diuretic. Which action is most appropriate?

  1. Continue both drugs and repeat the electrolytes in one month
  2. Add a thiazide diuretic to lower the potassium
  3. Increase the ACE inhibitor dose to protect the kidneys
  4. Stop the potassium-sparing diuretic and ACE inhibitor, and treat the hyperkalaemia Correct answer.

Explanation

Hyperkalaemia with metabolic acidosis in advanced chronic kidney disease is commonly worsened by drugs that reduce renal potassium excretion, such as ACE inhibitors and potassium-sparing diuretics. These agents should be withheld, the potassium actively treated, and safer alternatives considered.

Question 31Internal Medicine

A 66-year-old man has progressive exertional dyspnoea and bilateral basal fine crackles. Chest imaging shows lower-zone reticular opacities, and pulmonary function tests show a reduced FVC with a normal or raised FEV1/FVC ratio. Which pattern does this most suggest?

  1. Isolated small-airway obstruction
  2. Obstructive lung disease
  3. Restrictive lung disease Correct answer.
  4. Normal lung function

Explanation

A reduced FVC with a preserved or increased FEV1/FVC ratio indicates a restrictive ventilatory defect, consistent with interstitial lung disease. Obstructive disease instead lowers the FEV1/FVC ratio.

Question 32Internal Medicine

A 48-year-old woman has fatigue, arthralgia, and a raised alkaline phosphatase with a positive antimitochondrial antibody. Which condition is most likely?

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

Explanation

A cholestatic enzyme pattern with antimitochondrial antibodies in a middle-aged woman is characteristic of primary biliary cholangitis. Primary sclerosing cholangitis is associated with inflammatory bowel disease and typical biliary strictures, while autoimmune hepatitis raises transaminases.

Question 33Internal Medicine

A 72-year-old man with atrial fibrillation is admitted with a 24-hour history of melaena and a haemoglobin of 78 g/L. He is haemodynamically stable. Which step is most appropriate before resuming anticoagulation?

  1. Resuscitate, investigate and treat the bleeding source, then reassess the balance of stroke and bleeding risk Correct answer.
  2. Start aspirin instead of anticoagulation
  3. Restart the anticoagulant immediately at the previous dose
  4. Permanently discontinue anticoagulation without reassessment

Explanation

In anticoagulant-associated gastrointestinal bleeding, the priority is haemodynamic resuscitation, identifying and treating the bleeding lesion, and then weighing stroke risk against rebleeding risk. Anticoagulation is usually resumed once haemostasis is secure because stroke risk persists.

Question 34Internal Medicine

A 29-year-old woman has a 3-week history of polyuria, polydipsia, and weight loss. Capillary glucose is 22 mmol/L and she has ketonuria but no vomiting. Which initial management is most appropriate?

  1. Intravenous fluids, intravenous insulin infusion, and potassium replacement with monitoring Correct answer.
  2. Oral metformin and dietary advice
  3. Intravenous glucose with no insulin
  4. Subcutaneous long-acting insulin alone and outpatient review

Explanation

New-onset diabetes with ketosis indicates diabetic ketoacidosis, which is treated with isotonic fluid resuscitation, a fixed-rate intravenous insulin infusion, and careful potassium replacement. Insulin shifts potassium intracellularly, so potassium must be checked and replaced.

Question 35Internal Medicine

A 55-year-old woman has sudden severe colicky right flank pain radiating to the groin with visible haematuria. She is afebrile with normal renal function. Which initial investigation is most appropriate?

  1. Serum amylase
  2. Non-contrast computed tomography of the abdomen and pelvis Correct answer.
  3. Intravenous pyelography
  4. Diagnostic laparoscopy

Explanation

Non-contrast CT of the abdomen and pelvis is the investigation of choice for suspected renal colic because it identifies stones, their size and location, and alternative diagnoses. Ultrasound is preferred in pregnancy or when radiation must be avoided.

Question 36Internal Medicine

A 63-year-old man has chronic heart failure with reduced ejection fraction, an ejection fraction of 30%, and persistent symptoms despite an ACE inhibitor and beta-blocker. Which additional drug class improves survival in this setting?

  1. Calcium channel blocker
  2. Mineralocorticoid receptor antagonist Correct answer.
  3. Digoxin
  4. Loop diuretic

Explanation

Mineralocorticoid receptor antagonists reduce mortality in chronic heart failure with reduced ejection fraction when added to an ACE inhibitor and beta-blocker. Loop diuretics relieve congestion but do not improve survival, and digoxin reduces hospitalisation without a mortality benefit.

Question 37Internal Medicine

A 40-year-old man has sudden severe pleuritic chest pain and breathlessness after a long-haul flight. He is tachycardic and hypoxic. Which finding on a computed tomography pulmonary angiogram would confirm pulmonary embolism?

  1. Atelectasis in the lung bases
  2. Bilateral pleural effusions
  3. An intraluminal filling defect within a pulmonary artery Correct answer.
  4. Cardiomegaly

Explanation

CT pulmonary angiography confirms pulmonary embolism by demonstrating an intraluminal filling defect in a pulmonary artery. Pleural effusions, cardiomegaly, and atelectasis are non-specific and can occur in many conditions.

Question 38Internal Medicine

A 31-year-old woman has recurrent painful oral ulcers, genital ulcers, and anterior uveitis. A pathergy test is positive. Which diagnosis is most likely?

  1. Systemic lupus erythematosus
  2. Granulomatosis with polyangiitis
  3. Reactive arthritis
  4. Behçet disease Correct answer.

Explanation

Recurrent oral and genital ulceration with uveitis and a positive pathergy reaction is characteristic of Behçet disease, a systemic vasculitis. Lupus and reactive arthritis can cause oral ulcers but do not typically produce the full triad with pathergy.

Question 39Internal Medicine

A 67-year-old woman has a 2-month history of early satiety, unintentional weight loss, and a palpable epigastric mass. Which investigation is most appropriate to establish the diagnosis?

  1. Upper gastrointestinal endoscopy with biopsy Correct answer.
  2. Abdominal ultrasound
  3. Barium follow-through
  4. Serum carcinoembryonic antigen

Explanation

Dyspepsia with weight loss and a palpable mass raises concern for gastric malignancy, and endoscopy with biopsy provides direct visualisation and histological confirmation. Imaging and tumour markers support staging but do not establish the diagnosis.

Question 40Internal Medicine

A 52-year-old man has sudden onset of a severe occipital headache, neck stiffness, and photophobia. A non-contrast CT scan of the head is normal. Which next step is most appropriate?

  1. Lumbar puncture for xanthochromia after at least 12 hours from symptom onset Correct answer.
  2. Empirical antibiotics without further investigation
  3. Immediate discharge with analgesia
  4. Magnetic resonance imaging of the cervical spine

Explanation

A normal CT within hours of a suspected subarachnoid haemorrhage does not exclude the diagnosis, so lumbar puncture for xanthochromia is performed, ideally at least 12 hours after onset when bilirubin has formed. A positive result prompts vascular imaging.

Question 41Surgery

A 24-year-old man is brought to the emergency department after a stab wound to the left anterior chest. He is anxious, with blood pressure 85/50 mmHg, distended neck veins, and absent breath sounds over the left hemithorax with hyperresonance on percussion. Which is the most appropriate immediate intervention?

  1. Urgent chest tube insertion after confirming the diagnosis on chest radiograph
  2. Immediate needle decompression of the left pleural space Correct answer.
  3. Emergent thoracotomy in the operating room
  4. Pericardiocentesis in the subxiphoid approach

Explanation

The clinical picture of hypotension, distended neck veins, absent breath sounds, and hyperresonance indicates tension pneumothorax, a clinical diagnosis that must be treated before imaging. Immediate needle decompression relieves the obstructive shock and is followed by tube thoracostomy. Waiting for a radiograph or attempting pericardial drainage delays treatment of a rapidly fatal condition.

Question 42Surgery

Which finding on physical examination is most characteristic of acute appendicitis when the appendix lies in a retrocecal position?

  1. Pain elicited on passive extension of the right hip Correct answer.
  2. Pain in the right lower quadrant during rectal examination
  3. Rebound tenderness at McBurney point
  4. Cutaneous hyperesthesia over the right iliac fossa

Explanation

A retrocecal appendix may lie close to the psoas muscle, so irritation can produce pain on passive extension of the right hip, known as a positive psoas sign. Internal rotation of the flexed hip instead tests the obturator sign. The other listed findings do not specifically indicate a retrocecal position.

Question 43Surgery

A 58-year-old woman has a 2 cm ulcerated lesion on the lower lip with a firm, mobile submental lymph node. Biopsy confirms squamous cell carcinoma. Which factor most strongly predicts regional nodal metastasis in lip carcinoma?

  1. Absence of ulceration
  2. Location on the lower lip rather than the upper lip
  3. Tumor thickness greater than 4 mm Correct answer.
  4. Female sex

Explanation

For cutaneous and lip squamous cell carcinoma, tumor thickness and depth of invasion are among the strongest predictors of nodal metastasis and guide the decision for elective neck dissection. Lower lip location is actually more common but not protective against spread, and ulceration indicates more advanced local disease rather than being protective.

Question 44Surgery

Which parameter is the most reliable early indicator of adequate resuscitation in a patient with hemorrhagic shock from a pelvic fracture?

  1. Systolic blood pressure alone
  2. Serum lactate clearance Correct answer.
  3. Urine output over the first hour
  4. Hemoglobin concentration

Explanation

Lactate reflects the global oxygen debt of shock, and its clearance over time tracks the adequacy of resuscitation better than single static values. Hemoglobin can remain normal early in acute hemorrhage, and blood pressure is maintained by compensation until decompensation occurs. Urine output is useful but is influenced by diuretics and renal injury.

Question 45Surgery

A 45-year-old man presents with painless jaundice and a palpable, distended, non-tender gallbladder. Which diagnosis does this combination most strongly suggest?

  1. Sclerosing cholangitis
  2. Choledocholithiasis with cholangitis
  3. Acute calculous cholecystitis
  4. Pancreatic head carcinoma Correct answer.

Explanation

A palpable, non-tender distended gallbladder accompanying painless obstructive jaundice constitutes Courvoisier law and raises strong suspicion of malignant obstruction, typically pancreatic head or periampullary carcinoma. In calculous disease the gallbladder is usually fibrotic and non-distensible, and cholangitis presents with pain and fever.

Question 46Surgery

During laparoscopic cholecystectomy, the critical view of safety requires which of the following before the cystic duct and artery are clipped?

  1. Routine intraoperative cholangiography in every patient
  2. Complete mobilization of the gallbladder from the liver bed
  3. Clearance of fat and fibrous tissue from the hepatocystic triangle with only two structures entering the gallbladder Correct answer.
  4. Division of the cystic duct before dissection of the triangle of Calot

Explanation

The critical view of safety is achieved when the hepatocystic triangle is cleared of fat and fibrous tissue and only two structures are seen entering the gallbladder, with the lower third of the gallbladder separated from the cystic plate. This exposure prevents misidentification of the common bile duct. Cholangiography is an adjunct and is not mandatory for the view.

Question 47Surgery

A 30-year-old man has a penetrating wound to zone II of the anterior neck with expanding hematoma and airway compromise. Which management step is indicated?

  1. Emergent operative exploration of the neck Correct answer.
  2. Barium swallow study before any intervention
  3. Selective observation with serial CT angiography
  4. Compression dressing and transfer for outpatient follow-up

Explanation

Hard signs of vascular or aerodigestive injury in neck zone II, such as an expanding hematoma, airway compromise, or active bleeding, mandate immediate operative exploration. Observation and imaging are reserved for stable patients without hard signs. Contrast studies are inappropriate when the airway is threatened.

Question 48Surgery

Which is the most common cause of small bowel obstruction in a patient who has never undergone abdominal surgery?

  1. Malignant tumor of the small bowel Correct answer.
  2. Hernia
  3. Gallstone ileus
  4. Crohn disease stricture

Explanation

In a virgin abdomen, small bowel obstruction is most often caused by malignancy, whereas adhesions dominate in patients with prior surgery. Hernias are a frequent cause overall but usually occur in patients with a history of prior operations or identifiable groin defects. Gallstone ileus and Crohn strictures are less common causes.

Question 49Surgery

A 62-year-old woman has a 1.5 cm papillary thyroid carcinoma confined to the thyroid without lymph node involvement. Which factor most influences the extent of thyroidectomy?

  1. Presence of extrathyroidal extension Correct answer.
  2. Family history of type 2 diabetes
  3. Serum thyroglobulin level before surgery
  4. Patient preference for a smaller scar

Explanation

Extrathyroidal extension, tumor size, nodal status, and contralateral disease determine whether lobectomy or total thyroidectomy is appropriate. A 1.5 cm intrathyroidal tumor may be managed with lobectomy, but extrathyroidal extension shifts the decision toward total thyroidectomy and possible radioiodine therapy. Preoperative thyroglobulin is not used to stage disease.

Question 50Surgery

Which is the most appropriate initial management of a hemodynamically stable patient with a grade III splenic laceration and no active contrast extravasation on CT?

  1. Diagnostic peritoneal lavage followed by laparotomy
  2. Nonoperative management with monitoring in a facility capable of immediate surgery Correct answer.
  3. Immediate splenectomy
  4. Splenic artery embolization in all cases

Explanation

Hemodynamically stable patients with splenic injury and no active bleeding can be managed nonoperatively with close observation, serial examinations, and access to immediate operative care. Splenectomy is reserved for hemodynamic instability or failure of nonoperative management. Routine embolization is not required without active extravasation or a pseudoaneurysm.