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Myanmar MMLE practice questions

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Question 1General Medicine

A patient with type 2 diabetes has an eGFR of 25 mL/min/1.73 m². Which oral glucose-lowering drug should be stopped because it is contraindicated at this level of renal function?

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

Explanation

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73 m² because reduced renal clearance predisposes to lactic acidosis. The other agents listed can be used with dose adjustment or without adjustment at this eGFR.

Question 2General Medicine

Which finding on physical examination is most characteristic of a tension pneumothorax?

  1. Fine inspiratory crackles at the lung bases
  2. Dullness to percussion with increased tactile fremitus
  3. Tracheal deviation toward the affected side
  4. Hyperresonance with absent breath sounds on the affected side Correct answer.

Explanation

Tension pneumothorax produces a hyperresonant hemithorax with absent breath sounds because air accumulates in the pleural space under pressure. Trachea deviates away from the affected side, and dullness with increased fremitus suggests consolidation rather than air.

Question 3General Medicine

A 55-year-old man presents with sudden onset of severe retrosternal chest pain radiating to the back, and a chest radiograph shows a widened mediastinum. Which is the most appropriate immediate step in management?

  1. Arrange an outpatient echocardiogram
  2. Start intravenous thrombolysis
  3. Give sublingual glyceryl trinitrate and discharge
  4. Obtain urgent CT angiography of the aorta and control blood pressure Correct answer.

Explanation

The picture suggests acute aortic dissection, which is confirmed by urgent CT angiography. Blood pressure and heart rate must be controlled promptly with beta-blockade to reduce aortic wall stress before definitive repair.

Question 4General Medicine

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

  1. Klebsiella pneumoniae
  2. Mycoplasma pneumoniae
  3. Streptococcus pneumoniae Correct answer.
  4. Haemophilus influenzae

Explanation

Streptococcus pneumoniae remains the single most frequently isolated pathogen in community-acquired pneumonia across all adult age groups. The other organisms cause CAP less often and are associated with specific risk factors or host states.

Question 5General Medicine

A patient with chronic kidney disease has a serum potassium of 6.8 mmol/L and ECG shows peaked T waves. Which intervention should be given first to stabilise the myocardium?

  1. Intravenous calcium gluconate Correct answer.
  2. Nebulised salbutamol
  3. Oral sodium polystyrene sulfonate
  4. Intravenous insulin with dextrose

Explanation

Intravenous calcium stabilises the cardiac membrane immediately in hyperkalaemia with ECG changes. Insulin-dextrose, salbutamol and potassium binders lower serum potassium but act more slowly.

Question 6General Medicine

Which antibody is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for SLE and correlate with disease activity and lupus nephritis. Antinuclear antibody is sensitive but not specific, being positive in many autoimmune and healthy states.

Question 7General Medicine

A 30-year-old woman has weight loss, palpitations and tremor. TSH is suppressed and free T4 is raised. Which finding would best support Graves disease over a toxic nodule?

  1. Diffuse increased uptake on thyroid scintigraphy Correct answer.
  2. A single hot nodule on thyroid scintigraphy
  3. A multinodular goitre on examination
  4. Low serum thyroglobulin

Explanation

Graves disease shows diffuse increased uptake on scintigraphy due to uniform gland stimulation by TSH-receptor antibodies. A single hot nodule with suppression of the rest of the gland suggests a toxic adenoma.

Question 8General Medicine

Which is the first-line treatment for a patient with newly diagnosed hypertension and no other comorbidities?

  1. An ACE inhibitor
  2. An alpha blocker
  3. A thiazide-like diuretic or calcium channel blocker Correct answer.
  4. A loop diuretic

Explanation

Current guidelines recommend a thiazide-like diuretic or a dihydropyridine calcium channel blocker as initial therapy for uncomplicated hypertension. ACE inhibitors are preferred when there is diabetes or proteinuric renal disease.

Question 9General Medicine

A patient presents with sudden painless loss of vision in one eye described as a curtain falling. Fundoscopy shows a pale retina with a cherry-red spot. What is the diagnosis?

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

Explanation

Central retinal artery occlusion produces sudden painless visual loss with a pale oedematous retina and a cherry-red spot at the macula. It is an ophthalmological emergency associated with embolic cardiovascular disease.

Question 10General Medicine

A 68-year-old man has a haemoglobin of 9.0 g/dL, a mean corpuscular volume of 72 fL and a low serum ferritin. Which is the most important next step?

  1. Transfuse two units of packed red cells
  2. Investigate the gastrointestinal tract for a source of blood loss Correct answer.
  3. Start oral iron and review in three months
  4. Check vitamin B12 level

Explanation

Iron deficiency anaemia in an older man requires investigation for gastrointestinal blood loss, typically with endoscopy, because colorectal cancer must be excluded. Iron replacement alone would treat the deficiency without addressing the cause.

Question 11General Medicine

Which feature best distinguishes an exudative from a transudative pleural effusion?

  1. Pleural fluid glucose above 3 mmol/L
  2. Pleural fluid white cell count below 100 cells/µL
  3. Pleural fluid protein above 30 g/L Correct answer.
  4. Pleural fluid pH above 7.4

Explanation

A pleural fluid protein above 30 g/L (or a fluid-to-serum protein ratio above 0.5) indicates an exudate. Exudates result from increased capillary permeability, whereas transudates arise from altered hydrostatic or oncotic pressures.

Question 12General Medicine

A patient with atrial fibrillation is being considered for anticoagulation. Which score is used to estimate stroke risk?

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

Explanation

The CHA2DS2-VASc score estimates thromboembolic stroke risk in atrial fibrillation and guides the decision to anticoagulate. The HAS-BLED score estimates bleeding risk and is used alongside it.

Question 13General Medicine

A 24-year-old student develops fever, headache, neck stiffness and a non-blanching rash. Which is the most appropriate immediate action?

  1. Give intravenous ceftriaxone without waiting for lumbar puncture Correct answer.
  2. Perform lumbar puncture before any antibiotics
  3. Arrange an outpatient review the next morning
  4. Give oral amoxicillin and discharge

Explanation

Suspected meningococcal septicaemia is a medical emergency, and parenteral antibiotics must be given immediately without waiting for lumbar puncture. Delay in antibiotic administration increases mortality.

Question 14General Medicine

Which of the following is the most common cause of nephrotic syndrome in adults?

  1. Minimal change disease
  2. Membranous nephropathy Correct answer.
  3. Focal segmental glomerulosclerosis
  4. IgA nephropathy

Explanation

Membranous nephropathy is the commonest cause of nephrotic syndrome in white adults, often associated with anti-PLA2R antibodies. Minimal change disease is the leading cause in children.

Question 15General Medicine

A patient with known cirrhosis presents with haematemesis. After resuscitation, which drug should be started to reduce the risk of variceal bleeding?

  1. Intravenous propranolol
  2. Intravenous vitamin K
  3. Intravenous terlipressin Correct answer.
  4. Oral omeprazole

Explanation

Terlipressin is a splanchnic vasoconstrictor used acutely to reduce portal pressure in variceal haemorrhage. Non-selective beta blockers such as propranolol are used for prophylaxis rather than the acute bleed.

Question 16General Medicine

Which electrolyte disturbance is most commonly seen in a patient with prolonged vomiting?

  1. Hypokalaemia with metabolic alkalosis Correct answer.
  2. Hypernatraemia with metabolic acidosis
  3. Hypercalcaemia with metabolic alkalosis
  4. Hyperkalaemia with metabolic acidosis

Explanation

Prolonged vomiting causes loss of hydrogen and chloride ions, producing a hypochloraemic metabolic alkalosis, and renal potassium loss leads to hypokalaemia. This combination is characteristic of persistent vomiting.

Question 17General Medicine

A 45-year-old woman has proximal muscle weakness, a heliotrope rash and Gottron papules. Which investigation is most useful to confirm the diagnosis?

  1. Serum angiotensin-converting enzyme
  2. Rheumatoid factor
  3. Anti-mitochondrial antibody
  4. Serum creatine kinase and electromyography Correct answer.

Explanation

Dermatomyositis is confirmed by elevated muscle enzymes such as creatine kinase together with myopathic electromyography and characteristic skin signs. Anti-mitochondrial antibody is associated with primary biliary cholangitis, not myositis.

Question 18General Medicine

Which is the most appropriate initial management for a patient with an acute attack of gout?

  1. A low-purine diet alone
  2. Non-steroidal anti-inflammatory drugs or colchicine Correct answer.
  3. Probenecid
  4. Allopurinol started at high dose

Explanation

Acute gout is treated with an NSAID, colchicine or corticosteroids to control inflammation. Urate-lowering therapy is not started during the acute attack but may be introduced later with cover.

Question 19General Medicine

A patient has a prolonged prothrombin time with a normal activated partial thromboplastin time. Which condition is most likely?

  1. Heparin therapy
  2. Haemophilia A
  3. Von Willebrand disease
  4. Vitamin K deficiency or warfarin therapy Correct answer.

Explanation

An isolated prolonged prothrombin time reflects deficiency of factor VII or the vitamin K–dependent clotting factors, as seen with warfarin or vitamin K deficiency. Heparin and haemophilia mainly prolong the activated partial thromboplastin time.

Question 20General Medicine

Which of the following is the most common cause of chronic liver disease and cirrhosis in Myanmar and much of Southeast Asia?

  1. Hepatitis B virus infection Correct answer.
  2. Alcohol misuse
  3. Autoimmune hepatitis
  4. Hepatitis A virus infection

Explanation

Chronic hepatitis B infection is a leading cause of cirrhosis and hepatocellular carcinoma across Southeast Asia, including Myanmar. Hepatitis A does not cause chronic liver disease.

Question 21General Medicine

A 70-year-old man has a blood pressure of 170/100 mmHg, confusion, papilloedema and a creatinine rise. What is the most appropriate diagnosis?

  1. Secondary hypertension
  2. White coat hypertension
  3. Hypertensive urgency
  4. Hypertensive emergency Correct answer.

Explanation

Hypertensive emergency is defined by severe blood pressure elevation with acute target-organ damage such as encephalopathy, papilloedema or renal injury. Hypertensive urgency has severe elevation without such damage.

Question 22General Medicine

Which is the most appropriate treatment for a patient with symptomatic bradycardia and haemodynamic compromise unresponsive to atropine?

  1. Intravenous verapamil
  2. Transcutaneous pacing Correct answer.
  3. Intravenous amiodarone
  4. Intravenous adenosine

Explanation

Transcutaneous pacing is indicated for symptomatic bradycardia with haemodynamic compromise when atropine fails. Adenosine, amiodarone and verapamil are used for tachyarrhythmias and would worsen bradycardia.

Question 23General Medicine

Which finding is most consistent with a diagnosis of diabetic ketoacidosis?

  1. pH 7.45 with raised bicarbonate
  2. Blood glucose 4 mmol/L with normal ketones
  3. pH 7.35 with normal anion gap
  4. Blood glucose 30 mmol/L with ketonuria and metabolic acidosis Correct answer.

Explanation

Diabetic ketoacidosis is characterised by hyperglycaemia, ketonaemia and a high-anion-gap metabolic acidosis. A normal or alkaline pH with normal ketones excludes the diagnosis.

Question 24General Medicine

A patient with a history of peptic ulcer disease develops sudden severe epigastric pain with board-like abdominal rigidity and free air under the diaphragm. What is the most likely diagnosis?

  1. Acute cholecystitis
  2. Acute pancreatitis
  3. Perforated peptic ulcer Correct answer.
  4. Small bowel obstruction

Explanation

Sudden severe pain with a rigid abdomen and pneumoperitoneum indicates a perforated peptic ulcer. Free air under the diaphragm is a hallmark of hollow viscus perforation.

Question 25General Medicine

Which feature is most characteristic of Parkinson disease on examination?

  1. Spasticity with hyperreflexia
  2. Chorea with hypotonia
  3. Intention tremor with dysdiadochokinesia
  4. Cogwheel rigidity with a resting tremor Correct answer.

Explanation

Parkinson disease produces the classic triad of bradykinesia, rigidity and resting tremor, often with cogwheel rigidity. Intention tremor and dysdiadochokinesia indicate cerebellar disease.

Question 26General Medicine

A 52-year-old man in Yangon has a fasting plasma glucose of 7.8 mmol/L on two separate occasions and an HbA1c of 7.2%. He is asymptomatic. What is the most appropriate diagnosis?

  1. Impaired glucose tolerance
  2. Normal glucose tolerance
  3. Impaired fasting glucose
  4. Diabetes mellitus Correct answer.

Explanation

A fasting plasma glucose of 7.0 mmol/L or more, or an HbA1c of 6.5% or more, on two occasions establishes diabetes mellitus even without symptoms. Both values here exceed the diagnostic thresholds. Impaired fasting glucose ranges from 6.1 to 6.9 mmol/L and does not apply.

Question 27General Medicine

A 60-year-old man with chronic obstructive pulmonary disease has an arterial blood gas showing pH 7.28, PaCO2 68 mmHg, PaO2 55 mmHg and bicarbonate 30 mmol/L. Which acid-base disturbance is present?

  1. Acute respiratory alkalosis
  2. Metabolic alkalosis
  3. Chronic respiratory acidosis Correct answer.
  4. Metabolic acidosis with respiratory compensation

Explanation

A raised PaCO2 with a low pH indicates respiratory acidosis, and the elevated bicarbonate shows metabolic compensation, which takes days to develop. This pattern therefore reflects chronic rather than acute respiratory acidosis. In acute respiratory acidosis the bicarbonate would be near normal.

Question 28General Medicine

A 35-year-old woman has a 3-month history of fatigue, cold intolerance, weight gain and constipation. Examination shows a diffuse goitre and dry skin. Which investigation is most useful for confirming the diagnosis?

  1. Radioactive iodine uptake scan
  2. Serum thyroglobulin
  3. Serum calcitonin
  4. Serum thyroid-stimulating hormone Correct answer.

Explanation

Primary hypothyroidism is confirmed by a raised thyroid-stimulating hormone with a low free thyroxine. TSH is the most sensitive first-line test because it rises before free T4 falls. The clinical picture here is classic for hypothyroidism.

Question 29General Medicine

A 28-year-old man has a 2-week history of fever, night sweats, weight loss and a non-productive cough. Chest radiograph shows upper-lobe cavitation. Which specimen is most appropriate for confirming pulmonary tuberculosis?

  1. Blood culture
  2. Bronchoalveolar lavage in all patients
  3. Pleural fluid aspiration
  4. Early morning sputum for acid-fast bacilli Correct answer.

Explanation

Sputum smear for acid-fast bacilli and mycobacterial culture is the standard initial investigation for suspected pulmonary tuberculosis. Early morning specimens are preferred because they are most concentrated. Cavitation in the upper lobes is typical of reactivation disease.

Question 30General Medicine

A 65-year-old man has a serum sodium of 122 mmol/L and is drowsy but not fitting. He has been on thiazide diuretics. Which is the most appropriate initial step in management?

  1. Rapid correction with hypertonic saline to a normal sodium within 6 hours
  2. Immediate haemodialysis
  3. Fluid restriction alone without further assessment
  4. Cautious correction with hypertonic saline if symptomatic, aiming for a controlled rise Correct answer.

Explanation

Symptomatic hyponatraemia requires controlled correction, generally with hypertonic saline when severe, but the rate of rise should not exceed about 10 mmol/L in 24 hours. Overly rapid correction risks osmotic demyelination. The underlying cause, here likely thiazide-induced, must also be addressed.

Question 31General Medicine

A 40-year-old woman presents with a sudden severe headache described as the worst of her life, photophobia and neck stiffness. CT brain is normal. Which is the most appropriate next investigation?

  1. MRI of the cervical spine
  2. Lumbar puncture for xanthochromia Correct answer.
  3. Carotid Doppler ultrasound
  4. Electroencephalography

Explanation

A thunderclap headache with a normal CT scan raises concern for subarachnoid haemorrhage, and lumbar puncture looking for xanthochromia is the next step. Xanthochromia may persist for up to two weeks after the bleed. Timing matters, ideally 12 hours or more after onset.

Question 32General Medicine

A 55-year-old man with a 40-pack-year smoking history has progressive dyspnoea and a chronic productive cough. Spirometry shows a post-bronchodilator FEV1/FVC ratio of 0.62. What does this ratio indicate?

  1. Obstructive airway disease Correct answer.
  2. Normal spirometry
  3. Restrictive lung disease
  4. Upper airway obstruction

Explanation

A post-bronchodilator FEV1/FVC ratio below 0.70 defines persistent airflow obstruction and supports a diagnosis of chronic obstructive pulmonary disease. The smoking history and chronic symptoms fit this pattern. Restrictive disease instead shows a reduced FVC with a preserved or raised ratio.

Question 33General Medicine

A 48-year-old woman has fatigue, arthralgia and hyperpigmentation of the skin and gums. Blood pressure is 90/60 mmHg and she reports salt craving. Which investigation is most useful for confirming the diagnosis?

  1. Urinary catecholamines
  2. Serum aldosterone
  3. Serum cortisol with ACTH stimulation test Correct answer.
  4. Plasma renin activity alone

Explanation

Primary adrenal insufficiency is confirmed by a low morning cortisol with a raised ACTH and a blunted response to ACTH stimulation. Hyperpigmentation reflects elevated ACTH and melanocyte-stimulating hormone. Salt craving and hypotension result from aldosterone deficiency.

Question 34General Medicine

A 70-year-old woman has sudden onset of painless loss of vision in the right eye with a cherry-red spot at the macula. Which artery is most likely occluded?

  1. Central retinal artery Correct answer.
  2. Ophthalmic artery
  3. Central retinal vein
  4. Posterior ciliary artery

Explanation

Central retinal artery occlusion produces sudden painless visual loss with a pale retina and a cherry-red spot at the fovea. The fovea retains its red colour because the choroidal circulation supplies it. This is an ophthalmological emergency.

Question 35General Medicine

A 30-year-old man has recurrent episodes of severe abdominal pain, hypertension and palpitations. Plasma metanephrines are markedly elevated. Which is the most appropriate initial imaging investigation to localise the lesion?

  1. Colonoscopy
  2. Barium meal
  3. Abdominal ultrasound alone
  4. Abdominal CT or MRI Correct answer.

Explanation

After biochemical confirmation of phaeochromocytoma, CT or MRI of the abdomen and pelvis is the imaging of choice to localise the adrenal or extra-adrenal tumour. Cross-sectional imaging has high sensitivity for adrenal masses. Ultrasound is less reliable for small lesions.

Question 36General Medicine

A 25-year-old woman has a generalised tonic-clonic seizure. She has no focal neurological deficit and blood glucose, sodium and calcium are normal. Which is the most appropriate initial investigation?

  1. MRI brain with contrast
  2. Lumbar puncture
  3. CT brain Correct answer.
  4. Electroencephalography

Explanation

An urgent CT brain is the first-line investigation for a first seizure to exclude structural causes such as tumour or haemorrhage. It is rapid and widely available. Electroencephalography and MRI follow once acute causes are excluded.

Question 37General Medicine

A 58-year-old man has a creatinine of 300 micromol/L, a potassium of 6.8 mmol/L and ECG changes with a widened QRS complex. Which is the most appropriate immediate treatment?

  1. Oral sodium bicarbonate
  2. Intravenous furosemide alone
  3. Oral potassium binder
  4. Intravenous calcium gluconate Correct answer.

Explanation

Hyperkalaemia with ECG changes is a medical emergency requiring immediate intravenous calcium to stabilise the myocardium. Calcium does not lower the potassium but protects against arrhythmia while other measures shift and remove it. Insulin with glucose and dialysis follow.

Question 38General Medicine

A 32-year-old woman has a history of recurrent oral ulcers, genital ulcers and anterior uveitis. Which finding would best support a diagnosis of Behçet disease?

  1. Raised anti-cyclic citrullinated peptide
  2. Positive rheumatoid factor
  3. Pathergy reaction to skin prick Correct answer.
  4. Positive anti-double-stranded DNA

Explanation

Behçet disease is diagnosed clinically, and a positive pathergy test, an exaggerated skin reaction to a needle prick, supports the diagnosis. Recurrent oral and genital ulceration with uveitis is the classic triad. Serological tests for autoantibodies are typically negative.

Question 39General Medicine

A 66-year-old man has a body mass index of 34 kg/m2, a blood pressure of 150/95 mmHg and a fasting glucose of 6.8 mmol/L. He has a strong family history of type 2 diabetes. Which single measure is most effective for preventing progression to diabetes?

  1. Metformin in all patients regardless of risk
  2. Annual HbA1c testing alone
  3. Intensive lifestyle modification with weight loss Correct answer.
  4. Low-dose aspirin

Explanation

Intensive lifestyle intervention with modest weight loss and increased physical activity is the most effective strategy for preventing progression from impaired glucose tolerance to type 2 diabetes. It outperforms pharmacological approaches in large trials. Metformin is considered in selected high-risk patients but is not the first choice for all.

Question 40General Medicine

A 72-year-old woman has a 6-month history of progressive memory loss and difficulty with daily activities. Which is the most common cause of this presentation?

  1. Vascular dementia
  2. Alzheimer disease Correct answer.
  3. Frontotemporal dementia
  4. Lewy body dementia

Explanation

Alzheimer disease is the most common cause of progressive dementia in older adults, accounting for the majority of cases. It typically presents with insidious memory impairment and gradual functional decline. Other causes are less common and often have distinguishing features.

Question 41Surgery

A 24-year-old man in Yangon has a 6-hour history of colicky periumbilical pain that migrated to the right iliac fossa, with low-grade fever and tenderness at McBurney's point. Which diagnosis is most likely?

  1. Acute cholecystitis
  2. Peptic ulcer perforation
  3. Acute appendicitis Correct answer.
  4. Acute pancreatitis

Explanation

Migratory right lower quadrant pain with localized McBurney point tenderness and low-grade fever is the classic presentation of acute appendicitis. The visceral periumbilical pain comes from the appendix's midgut innervation, then becomes somatic once parietal peritoneum is inflamed. Other listed conditions produce epigastric or right upper quadrant pain instead.

Question 42Surgery

Which clinical feature best distinguishes a simple groin hernia from a strangulated one?

  1. Absence of cough impulse with severe pain and overlying skin changes Correct answer.
  2. A positive transillumination test
  3. A soft non-tender swelling that disappears on lying flat
  4. Presence of a reducible swelling on standing

Explanation

Strangulation implies compromised blood supply, so the hernia becomes irreducible, loses its cough impulse, and the overlying skin becomes erythematous or dusky with severe pain. A reducible swelling suggests an uncomplicated hernia. Transillumination suggests a hydrocele rather than strangulation.

Question 43Surgery

A 45-year-old woman has a 2 cm firm, painless, highly mobile breast lump that feels like a marble. Which diagnosis is most consistent with these findings?

  1. Fibroadenoma Correct answer.
  2. Breast abscess
  3. Inflammatory carcinoma
  4. Paget disease of the nipple

Explanation

A firm, smooth, freely mobile breast lump in a young to middle-aged woman is characteristic of a fibroadenoma, a benign fibroepithelial lesion. Breast abscess would be painful and fluctuant, often with fever. Inflammatory carcinoma causes diffuse induration and skin changes, and Paget disease affects the nipple epidermis.

Question 44Surgery

Which finding on abdominal examination is most suggestive of peritonitis?

  1. Board-like rigidity with rebound tenderness Correct answer.
  2. A palpable pulsatile epigastric mass
  3. A soft abdomen with voluntary guarding only
  4. Hyperactive bowel sounds with colicky pain

Explanation

Peritonitis produces involuntary guarding with board-like rigidity and rebound tenderness as inflamed parietal peritoneum is stretched. Hyperactive bowel sounds suggest obstruction rather than peritonitis, where bowel sounds are typically reduced. A pulsatile epigastric mass raises concern for an aortic aneurysm.

Question 45Surgery

A 30-year-old man sustains a penetrating abdominal wound with a loop of bowel eviscerating through the wound. What is the most appropriate immediate management?

  1. Attempt to reduce the bowel back into the abdomen
  2. Cover the bowel with a sterile saline-soaked dressing and proceed to laparotomy Correct answer.
  3. Irrigate the wound with hydrogen peroxide before transfer
  4. Apply a tight pressure dressing over the eviscerated bowel

Explanation

Eviscerated bowel should be protected with a sterile saline-soaked dressing and kept moist while the patient is resuscitated and taken for laparotomy. Attempted reduction risks introducing contamination and may worsen strangulation. Pressure dressings and caustic solutions damage the exposed bowel.

Question 46Surgery

Which feature of a burn wound is the most reliable indicator for referral to a specialized burn unit?

  1. Superficial partial-thickness burn of 3% on the forearm
  2. A small first-degree burn on the face
  3. Full-thickness burns involving more than 5% of total body surface area Correct answer.
  4. A superficial abrasion over the knee

Explanation

Full-thickness burns exceeding 5% of total body surface area require specialized burn care for excision and grafting. Superficial partial-thickness burns of small size usually heal with dressings. Minor first-degree burns and abrasions do not need burn unit referral.

Question 47Surgery

A patient develops sudden-onset severe epigastric pain radiating to the back with vomiting after a heavy meal and alcohol binge. Serum lipase is markedly elevated. Which diagnosis is most likely?

  1. Acute cholecystitis
  2. Ruptured abdominal aortic aneurysm
  3. Acute pancreatitis Correct answer.
  4. Acute appendicitis

Explanation

Severe epigastric pain radiating to the back after alcohol and a heavy meal, with markedly elevated lipase, strongly suggests acute pancreatitis. Appendicitis causes right lower quadrant pain, while cholecystitis causes right upper quadrant pain. A ruptured aneurysm presents with shock and a pulsatile mass.

Question 48Surgery

Which clinical sign is most characteristic of acute cholecystitis?

  1. Psoas sign
  2. Murphy sign Correct answer.
  3. Cullen sign
  4. Rovsing sign

Explanation

Murphy sign is arrest of inspiration on deep palpation of the right upper quadrant, reflecting an inflamed gallbladder contacting the examiner's hand. Rovsing and psoas signs are associated with appendicitis. Cullen sign refers to periumbilical bruising seen in retroperitoneal hemorrhage or severe pancreatitis.

Question 49Surgery

A 55-year-old man has painless gross hematuria. What is the most appropriate initial investigation to evaluate for a bladder tumor?

  1. Urine cytology alone
  2. Cystoscopy Correct answer.
  3. Renal ultrasound alone
  4. Intravenous urography alone

Explanation

Cystoscopy allows direct visualization and biopsy of bladder lesions and is the gold standard for evaluating painless gross hematuria suspicious for bladder cancer. Urine cytology and imaging are useful adjuncts but cannot exclude a bladder tumor. Ultrasound and urography assess the upper tracts but not the bladder mucosa adequately.

Question 50Surgery

In a patient with acute urinary retention, which is the most appropriate immediate management?

  1. Oral alpha-blocker therapy alone without drainage
  2. Observation with a fluid restriction regimen
  3. Urethral catheterization with controlled decompression Correct answer.
  4. Immediate suprapubic cystostomy without prior catheterization

Explanation

Acute urinary retention is relieved promptly by urethral catheterization, allowing controlled decompression of the bladder. Suprapubic catheterization is reserved for failed urethral catheterization or specific contraindications. Oral medication alone does not relieve acute retention and observation risks bladder injury.