I85PREP
⌘ K
Mongolia Feldsher Licensing Exam study materials
Mongolia Feldsher Licensing Exam study resources

Mongolia Feldsher Licensing Exam practice questions

One question at a time. Build your Mongolia Feldsher Licensing Exam understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which electrolyte is primarily responsible for maintaining the resting membrane potential of nerve and muscle cells through the sodium-potassium pump?

  1. Bicarbonate
  2. Chloride
  3. Potassium Correct answer.
  4. Calcium

Explanation

The sodium-potassium ATPase pumps three sodium ions out and two potassium ions in, leaving the cell interior rich in potassium. Because the membrane is most permeable to potassium at rest, potassium efflux largely sets the resting membrane potential near -70 mV.

Question 2Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A feldsher examines a patient with jaundice, right upper quadrant pain, and pale stools. Which laboratory pattern best fits obstructive (cholestatic) jaundice?

  1. Elevated conjugated bilirubin with elevated alkaline phosphatase Correct answer.
  2. Elevated unconjugated bilirubin with low hemoglobin
  3. Elevated unconjugated bilirubin with normal alkaline phosphatase
  4. Low conjugated bilirubin with elevated reticulocyte count

Explanation

In cholestasis, conjugated bilirubin cannot reach the gut and refluxes into blood, so conjugated bilirubin rises and stools become pale. Alkaline phosphatase, a canalicular enzyme, is characteristically elevated because bile flow is obstructed.

Question 3Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which cranial nerve is responsible for the gag reflex afferent limb when the posterior pharynx is stimulated?

  1. Hypoglossal nerve (XII)
  2. Glossopharyngeal nerve (IX) Correct answer.
  3. Optic nerve (II)
  4. Facial nerve (VII)

Explanation

The glossopharyngeal nerve carries general sensation from the posterior third of the tongue and pharynx, forming the afferent limb of the gag reflex. The vagus nerve supplies the efferent motor limb that raises the palate and constricts the pharynx.

Question 4Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient taking warfarin is prescribed a course of rifampicin. What is the most likely consequence for anticoagulation control?

  1. Increased bleeding risk because rifampicin displaces warfarin from albumin
  2. Increased warfarin effect because rifampicin inhibits CYP2C9
  3. No change because the two drugs act on different pathways
  4. Reduced warfarin effect because rifampicin induces hepatic enzymes Correct answer.

Explanation

Rifampicin is a potent inducer of hepatic cytochrome P450 enzymes, including those that metabolize warfarin. Enhanced metabolism lowers warfarin plasma levels and reduces its anticoagulant effect, so INR monitoring and dose adjustment are required.

Question 5Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which type of hypersensitivity reaction underlies anaphylaxis after penicillin administration?

  1. Type IV T-cell-mediated delayed hypersensitivity
  2. Type I IgE-mediated immediate hypersensitivity Correct answer.
  3. Type III immune complex deposition
  4. Type II antibody-mediated cytotoxicity

Explanation

Anaphylaxis is a type I reaction in which allergen cross-links IgE on mast cells, triggering rapid release of histamine and other mediators. This produces bronchospasm, vasodilation, and urticaria within minutes of exposure.

Question 6Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

During normal cardiac cycle, which event produces the first heart sound (S1)?

  1. Rapid ventricular filling
  2. Closure of the aortic and pulmonary valves
  3. Atrial contraction
  4. Closure of the mitral and tricuspid valves Correct answer.

Explanation

S1 is generated by closure of the atrioventricular valves, the mitral and tricuspid, at the onset of ventricular systole. It marks the boundary between diastole and systole and is best heard at the apex.

Question 7Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient presents with polyuria, polydipsia, and hyperglycemia. Which pathophysiological mechanism best explains the polyuria in uncontrolled diabetes mellitus?

  1. Increased aldosterone secretion causing sodium loss
  2. Osmotic diuresis from glucose exceeding renal reabsorption capacity Correct answer.
  3. Impaired sodium reabsorption in the proximal tubule
  4. Excess ADH secretion causing water retention

Explanation

When blood glucose exceeds the renal threshold, filtered glucose is not fully reabsorbed and remains in the tubular fluid. This osmotic load holds water in the tubule, producing osmotic diuresis with polyuria and subsequent polydipsia.

Question 8Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which vitamin deficiency is most directly associated with megaloblastic anemia and neurological symptoms such as paresthesia and ataxia?

  1. Vitamin C
  2. Vitamin D
  3. Vitamin B12 Correct answer.
  4. Vitamin K

Explanation

Vitamin B12 is required for DNA synthesis and myelin maintenance, so deficiency causes megaloblastic anemia together with subacute combined degeneration of the spinal cord. Neurological signs distinguish it from folate deficiency, which causes anemia without these cord changes.

Question 9Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A feldsher is preparing to give an intramuscular injection. Which muscle is commonly selected in adults because it lies away from major nerves and vessels?

  1. Rectus femoris muscle
  2. Gastrocnemius muscle
  3. Ventrogluteal muscle Correct answer.
  4. Deltoid muscle

Explanation

The ventrogluteal site is preferred for larger intramuscular volumes because it is located away from major nerves and blood vessels. It is identified by placing the palm on the greater trochanter and the index finger on the anterior superior iliac spine.

Question 10Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which class of drug acts by inhibiting the enzyme that converts angiotensin I to angiotensin II?

  1. ACE inhibitors Correct answer.
  2. Calcium channel blockers
  3. Loop diuretics
  4. Beta-blockers

Explanation

ACE inhibitors block angiotensin-converting enzyme, reducing formation of angiotensin II and decreasing aldosterone release. This lowers vasoconstriction and sodium retention, making them useful in hypertension and heart failure.

Question 11Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient has a blood pH of 7.25, low bicarbonate, and low PaCO2. Which acid-base disturbance is present?

  1. Metabolic acidosis with respiratory compensation Correct answer.
  2. Respiratory alkalosis
  3. Metabolic alkalosis
  4. Respiratory acidosis with metabolic compensation

Explanation

A low pH with low bicarbonate indicates a primary metabolic acidosis. The reduced PaCO2 reflects hyperventilation, a respiratory compensation that lowers carbon dioxide and partially corrects the pH.

Question 12Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which structure separates the thoracic cavity from the abdominal cavity?

  1. Pericardium
  2. Diaphragm Correct answer.
  3. Pleura
  4. Linea alba

Explanation

The diaphragm is the dome-shaped musculotendinous partition between the thorax and abdomen. It serves as the principal muscle of inspiration and contains openings for the aorta, esophagus, and inferior vena cava.

Question 13Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient with chronic kidney disease develops fatigue and pallor with low erythropoietin levels. Which mechanism explains the anemia?

  1. Reduced renal erythropoietin production Correct answer.
  2. Increased destruction of red cells by the spleen
  3. Bone marrow infiltration by fibrous tissue
  4. Dietary iron deficiency alone

Explanation

The kidneys produce erythropoietin, which stimulates red cell production in the marrow. In chronic kidney disease, damaged peritubular cells secrete less erythropoietin, leading to normocytic normochromic anemia that improves with erythropoiesis-stimulating agents.

Question 14Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which receptor type is activated by acetylcholine at the neuromuscular junction to trigger muscle contraction?

  1. Beta-adrenergic receptor
  2. Nicotinic acetylcholine receptor Correct answer.
  3. Alpha-adrenergic receptor
  4. Muscarinic M2 receptor

Explanation

Acetylcholine released from the motor neuron binds nicotinic receptors on the motor end plate, opening cation channels and depolarizing the muscle fiber. This depolarization initiates excitation-contraction coupling and muscle shortening.

Question 15Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which antibiotic mechanism is shared by penicillin and cephalosporins?

  1. Inhibition of bacterial protein synthesis at the 30S subunit
  2. Inhibition of bacterial cell wall synthesis Correct answer.
  3. Disruption of the bacterial cell membrane
  4. Inhibition of DNA gyrase

Explanation

Both penicillin and cephalosporins are beta-lactams that bind penicillin-binding proteins and block peptidoglycan cross-linking in the bacterial cell wall. This weakens the wall and leads to bacterial lysis, especially in actively dividing organisms.

Question 16Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient has a lesion of the facial nerve within the facial canal causing ipsilateral facial paralysis with inability to close the eye. Which additional finding is most consistent with this lesion?

  1. Loss of taste over the posterior third of the tongue
  2. Loss of vision in the ipsilateral eye
  3. Deviation of the tongue to the opposite side
  4. Loss of taste over the anterior two-thirds of the tongue Correct answer.

Explanation

The facial nerve carries special sensory fibers from the anterior two-thirds of the tongue through the chorda tympani. A lesion in the facial canal proximal to this branch therefore produces ipsilateral facial weakness together with loss of anterior tongue taste.

Question 17Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which pathophysiological change is characteristic of left ventricular systolic heart failure?

  1. Increased ejection fraction with reduced end-diastolic volume
  2. Primary right ventricular dilation with pulmonary hypertension
  3. Normal ejection fraction with isolated diastolic stiffening
  4. Reduced ejection fraction with increased end-diastolic volume Correct answer.

Explanation

In systolic heart failure, weakened contractility reduces the ejection fraction, and residual blood raises end-diastolic volume and pressure. This leads to pulmonary congestion and compensatory neurohormonal activation.

Question 18Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which hormone is released from the posterior pituitary and increases water reabsorption in the collecting duct?

  1. Thyroid-stimulating hormone
  2. Oxytocin
  3. Antidiuretic hormone Correct answer.
  4. Prolactin

Explanation

Antidiuretic hormone, also called vasopressin, is stored and released by the posterior pituitary. It inserts aquaporin-2 channels in collecting duct cells, increasing water reabsorption and concentrating the urine.

Question 19Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient develops fever, hypotension, and widespread erythema after a wound infection. Which mediator is most responsible for the vasodilation and increased vascular permeability seen in septic shock?

  1. Histamine released from mast cells Correct answer.
  2. Erythropoietin released from the kidneys
  3. Insulin released from pancreatic beta cells
  4. Parathyroid hormone released from the parathyroid glands

Explanation

Histamine released from mast cells and basophils causes vasodilation and increased capillary permeability during inflammatory and septic responses. These changes contribute to the hypotension and tissue edema observed in shock.

Question 20Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which phase of the cardiac action potential in ventricular muscle is primarily caused by calcium influx through L-type channels?

  1. Phase 4 resting potential
  2. Phase 3 repolarization
  3. Phase 2 plateau Correct answer.
  4. Phase 0 depolarization

Explanation

The plateau phase of the ventricular action potential results from a balance between calcium entry through L-type channels and potassium efflux. This prolonged plateau allows calcium-induced calcium release and a sustained contraction.

Question 21Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which type of bone cell is primarily responsible for bone resorption?

  1. Osteoblast
  2. Osteoclast Correct answer.
  3. Osteocyte
  4. Chondrocyte

Explanation

Osteoclasts are multinucleated cells derived from monocyte precursors that resorb bone by secreting acid and proteolytic enzymes. Their activity is stimulated by parathyroid hormone and inhibited by calcitonin.

Question 22Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient with a history of peptic ulcer disease develops sudden severe epigastric pain with board-like abdominal rigidity. Which pathological process is most likely?

  1. Acute pancreatitis
  2. Acute appendicitis
  3. Perforation of a peptic ulcer Correct answer.
  4. Acute cholecystitis

Explanation

Sudden severe epigastric pain with a rigid, board-like abdomen suggests perforation of a peptic ulcer with spillage of gastric contents into the peritoneum. This produces chemical peritonitis and requires urgent surgical evaluation.

Question 23Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which mechanism explains why aminoglycosides are effective against aerobic bacteria but not against strict anaerobes?

  1. They bind only to fungal ribosomes
  2. They are destroyed by gastric acid before absorption
  3. Their uptake into bacteria requires an oxygen-dependent energy process Correct answer.
  4. They are inactivated by bacterial capsules in anaerobic species

Explanation

Aminoglycoside entry into bacteria depends on an oxygen-dependent active transport across the cell membrane. Strict anaerobes lack this respiratory transport, so the drug cannot reach its ribosomal target and is ineffective against them.

Question 24Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

Which vessel carries deoxygenated blood from the right ventricle to the lungs?

  1. Aorta
  2. Pulmonary artery Correct answer.
  3. Superior vena cava
  4. Pulmonary vein

Explanation

The pulmonary artery arises from the right ventricle and carries deoxygenated blood to the lungs for gas exchange. It is the exception to the rule that arteries carry oxygenated blood.

Question 25Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient with a history of rheumatic fever now has a mid-diastolic murmur at the apex. Which valvular lesion is most likely?

  1. Mitral regurgitation
  2. Mitral stenosis Correct answer.
  3. Aortic stenosis
  4. Tricuspid regurgitation

Explanation

Rheumatic heart disease commonly causes mitral stenosis through leaflet thickening and commissural fusion. The resulting narrowed orifice produces a mid-diastolic murmur at the apex, often with an opening snap.

Question 26Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A feldsher administers a vaccine into the deltoid region of an adult. Which nerve is most at risk of injury if the injection is placed too low and too posterior on the arm?

  1. Axillary nerve Correct answer.
  2. Radial nerve
  3. Median nerve
  4. Ulnar nerve

Explanation

The axillary nerve and posterior circumflex humeral artery wind around the surgical neck of the humerus, close to the lower deltoid injection zone. Injections placed too low and posteriorly can therefore injure the axillary nerve, producing deltoid weakness and sensory loss over the lateral shoulder. Correct landmarking at the mid-deltoid avoids this risk.

Question 27Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient taking a high dose of a loop diuretic such as furosemide develops muscle weakness, cardiac arrhythmia, and flattened T waves with U waves on ECG. Which electrolyte disturbance best explains these findings?

  1. Hyponatremia
  2. Hypercalcemia
  3. Hypokalemia Correct answer.
  4. Hyperkalemia

Explanation

Loop diuretics block sodium reabsorption in the thick ascending limb, reducing the lumen-positive potential that drives potassium reabsorption and increasing distal potassium loss. The resulting hypokalemia causes muscle weakness and characteristic ECG changes including flattened T waves and prominent U waves. Hyperkalemia instead produces tall peaked T waves.

Question 28Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A 58-year-old man has crushing retrosternal chest pain and ST-segment elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

  1. Left circumflex artery
  2. Left anterior descending artery
  3. Left main coronary artery
  4. Right coronary artery Correct answer.

Explanation

Leads II, III, and aVF are inferior leads, so ST elevation there localizes an inferior myocardial infarction. The right coronary artery supplies the inferior wall in most people, making its occlusion the most likely cause. Left anterior descending occlusion typically produces anterior changes in V1–V4.

Question 29Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient with a deep vein thrombosis of the femoral vein suddenly develops pleuritic chest pain, dyspnea, and hemoptysis. Which pathophysiological sequence best explains this presentation?

  1. Thrombus embolizes through the venous system to lodge in a pulmonary artery branch Correct answer.
  2. Thrombus crosses a patent foramen ovale and lodges in a cerebral artery
  3. Thrombus forms in situ within the pulmonary arterial tree due to local endothelial injury
  4. Thrombus propagates into the inferior vena cava and obstructs hepatic venous return

Explanation

Deep vein thrombi can detach and travel with venous blood through the right heart into the pulmonary circulation, where they lodge and obstruct pulmonary artery branches. This pulmonary embolism causes sudden dyspnea, pleuritic pain, and sometimes hemoptysis from pulmonary infarction. The embolus originates in the leg veins rather than forming in the lungs.

Question 30Basic and Clinical Sciences Foundation (anatomy, physiology, pathology, pharmacology)

A patient is given a competitive antagonist at the acetylcholine receptor of the neuromuscular junction. Which change in the dose-response curve for acetylcholine is expected?

  1. An unchanged curve with a prolonged duration of acetylcholine action
  2. A parallel shift to the right with unchanged maximal response Correct answer.
  3. A reduced maximal response with unchanged half-maximal concentration
  4. A parallel shift to the left with increased potency

Explanation

A competitive antagonist binds reversibly at the same receptor site as the agonist, so higher agonist concentrations can overcome the blockade. This shifts the dose-response curve to the right in parallel while the maximal achievable response stays the same. Noncompetitive antagonism instead lowers the maximal response.

Question 31Internal Medicine and Adult Primary Care

A 58-year-old man in Ulaanbaatar presents with sudden-onset crushing retrosternal chest pain radiating to the left arm, sweating, and nausea that began 40 minutes ago. ECG shows ST elevation of 2 mm in leads V2–V4. Which is the most appropriate immediate management step in a feldsher-staffed setting?

  1. Give intramuscular diclofenac for pain and arrange an outpatient cardiology visit next week
  2. Give oral amoxicillin and observe for 6 hours before deciding on transfer
  3. Activate emergency transfer for reperfusion and give aspirin 300 mg chewed plus sublingual nitroglycerin if blood pressure allows Correct answer.
  4. Order a treadmill exercise stress test to confirm the diagnosis before any treatment

Explanation

ST-elevation myocardial infarction is a time-critical emergency; the priority is immediate analgesia, antiplatelet therapy with chewed aspirin, and rapid transfer to a facility capable of reperfusion. Nitroglycerin relieves ischemia but must be avoided in hypotension or suspected right ventricular infarction. Nothing should delay reperfusion for further outpatient testing.

Question 32Internal Medicine and Adult Primary Care

Which single measurement is the diagnostic threshold for hypertension when confirmed on repeated office visits in an adult?

  1. Systolic ≥120 mmHg or diastolic ≥70 mmHg
  2. Systolic ≥130 mmHg or diastolic ≥60 mmHg
  3. Systolic ≥140 mmHg or diastolic ≥90 mmHg Correct answer.
  4. Systolic ≥160 mmHg or diastolic ≥100 mmHg

Explanation

The conventional office threshold for diagnosing hypertension in adults is a sustained systolic pressure of at least 140 mmHg or diastolic pressure of at least 90 mmHg. Values in the 120–139/80–89 range are termed elevated or pre-hypertensive and warrant lifestyle advice and monitoring. Confirmation usually requires repeated readings on separate occasions.

Question 33Internal Medicine and Adult Primary Care

A 24-year-old student has polyuria, polydipsia, weight loss, and a random capillary glucose of 16 mmol/L with ketones in the urine. Which diagnosis best fits?

  1. Type 2 diabetes mellitus with hyperosmolar state
  2. Diabetes insipidus
  3. Renal glycosuria
  4. New-onset type 1 diabetes mellitus with ketosis Correct answer.

Explanation

Young age, rapid weight loss, marked hyperglycemia, and urinary ketones point to absolute insulin deficiency typical of type 1 diabetes. Ketosis signals impending ketoacidosis and requires urgent insulin and fluid therapy. Hyperosmolar state usually occurs in older type 2 patients with extreme glucose and minimal ketones.

Question 34Internal Medicine and Adult Primary Care

A 70-year-old with known COPD presents with increased sputum purulence, increased breathlessness, and increased sputum volume. Which is the most appropriate initial antibiotic choice for a feldsher in primary care?

  1. Amoxicillin or another first-line agent such as doxycycline, together with inhaled bronchodilators Correct answer.
  2. No antibiotic, since antibiotics are never indicated in COPD
  3. Oral vancomycin
  4. Intravenous ceftriaxone for all exacerbations regardless of severity

Explanation

An exacerbation with all three cardinal symptoms (increased dyspnea, sputum volume, and sputum purulence) justifies antibiotic therapy, usually with amoxicillin, doxycycline, or a macrolide, alongside bronchodilators and corticosteroids. Antibiotic choice should reflect local resistance patterns. Reserve broad-spectrum intravenous agents for severe cases requiring hospital care.

Question 35Internal Medicine and Adult Primary Care

Which finding on physical examination is most characteristic of community-acquired pneumonia?

  1. A friction rub heard only in systole at the apex
  2. Focal crackles and dullness to percussion over one lung zone with fever Correct answer.
  3. Hyperresonance and diminished breath sounds over both bases
  4. Bilateral wheezing that clears completely with a bronchodilator

Explanation

Consolidation from pneumonia produces focal crackles, bronchial breath sounds, and dullness to percussion, usually with fever and productive cough. Wheeze that resolves with bronchodilators suggests asthma, and hyperresonance suggests hyperinflation or pneumothorax. A systolic apical rub is not a pulmonary sign.

Question 36Internal Medicine and Adult Primary Care

A 45-year-old woman has epigastric burning pain relieved by food and worsened at night, with a positive test for Helicobacter pylori. Which regimen is appropriate?

  1. Proton pump inhibitor alone for 4 weeks
  2. Proton pump inhibitor plus two antibiotics such as amoxicillin and clarithromycin for 10–14 days Correct answer.
  3. Antacid on demand only
  4. Long-term oral corticosteroid

Explanation

Eradication of H. pylori requires combination therapy, typically a proton pump inhibitor with two antibiotics for 10–14 days. Successful eradication reduces ulcer recurrence and complications. Acid suppression alone relieves symptoms but does not eliminate the organism.

Question 37Internal Medicine and Adult Primary Care

Which clinical feature most strongly suggests an acute ischemic stroke rather than hypoglycemia in a patient with sudden hemiparesis?

  1. Bilateral sweating with tremor and confusion
  2. Improvement of symptoms after oral glucose
  3. Capillary glucose of 4.5 mmol/L with focal unilateral weakness and dysarthria Correct answer.
  4. Blood pressure of 100/60 mmHg with generalized weakness

Explanation

Hypoglycemia can mimic stroke, so glucose must be measured immediately; a normal glucose with focal unilateral deficits favors stroke. The key is that hypoglycemia is a reversible mimic and must be excluded before attributing deficits to cerebral ischemia. Time of onset also determines thrombolysis eligibility.

Question 38Internal Medicine and Adult Primary Care

Which is the recommended first-line drug for uncomplicated essential hypertension in most adults, especially those over 55 or of African descent?

  1. A thiazide-type diuretic or a calcium channel blocker Correct answer.
  2. A loop diuretic
  3. A direct renin inhibitor
  4. An alpha blocker

Explanation

Guidelines recommend a thiazide-type diuretic or a dihydropyridine calcium channel blocker as initial therapy for older adults and people of African ancestry, in whom ACE inhibitors are less effective as monotherapy. Beta blockers and ACE inhibitors remain appropriate for younger patients or specific comorbidities. Loop diuretics are reserved for volume overload or renal impairment.

Question 39Internal Medicine and Adult Primary Care

A 62-year-old man with type 2 diabetes has an eGFR of 35 mL/min/1.73 m² and persistent albuminuria. Which medication class slows progression of diabetic kidney disease?

  1. Metformin at full dose
  2. Aminoglycoside antibiotics
  3. ACE inhibitor or angiotensin receptor blocker Correct answer.
  4. High-dose loop diuretic as monotherapy

Explanation

Blockade of the renin-angiotensin system with an ACE inhibitor or ARB reduces intraglomerular pressure and slows progression of albuminuric diabetic nephropathy. Renal function and potassium must be monitored after initiation. Metformin requires dose reduction or discontinuation at this eGFR.

Question 40Internal Medicine and Adult Primary Care

A 30-year-old woman presents with fever, dysuria, and flank pain with costovertebral angle tenderness. Which management approach is most appropriate?

  1. A single dose of topical antiseptic
  2. Only an antispasmodic for pain
  3. Urine culture and a systemic antibiotic such as ciprofloxacin, with hospital referral if vomiting or sepsis occurs Correct answer.
  4. Observation without antibiotics

Explanation

Flank pain and fever indicate pyelonephritis, which requires systemic antibiotics guided by urine culture. Oral fluoroquinolones are commonly used for outpatient therapy, but vomiting, sepsis, or pregnancy warrants hospital admission for intravenous treatment. Simple cystitis without systemic features can be treated with shorter courses.

Question 41Internal Medicine and Adult Primary Care

A 68-year-old woman with atrial fibrillation has a CHA2DS2-VASc score of 4. What is the appropriate antithrombotic strategy?

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

Explanation

A score of 2 or more in women (or 1 in men) indicates high stroke risk and warrants oral anticoagulation. Direct oral anticoagulants are preferred in most nonvalvular cases because of a better safety profile, with warfarin used for mechanical valves or severe mitral stenosis. Aspirin is inferior for stroke prevention in atrial fibrillation.

Question 42Internal Medicine and Adult Primary Care

A 55-year-old man with a 30-pack-year smoking history has chronic productive cough for 3 months each year for 3 consecutive years. Spirometry shows a post-bronchodilator FEV1/FVC ratio of 0.65. What is the diagnosis?

  1. Interstitial pulmonary fibrosis
  2. Bronchiectasis
  3. Chronic obstructive pulmonary disease Correct answer.
  4. Asthma

Explanation

A post-bronchodilator FEV1/FVC below 0.70 confirms persistent airflow obstruction, and the combination of chronic productive cough and heavy smoking fits COPD. Asthma typically shows variable, reversible obstruction and atopy. Bronchiectasis and fibrosis have different imaging and clinical features.

Question 43Internal Medicine and Adult Primary Care

A 40-year-old man has a fasting glucose of 6.8 mmol/L on two occasions. What is the correct interpretation?

  1. Overt diabetes requiring immediate insulin
  2. Normal glucose tolerance
  3. Impaired fasting glucose (prediabetes) requiring lifestyle intervention and periodic retesting Correct answer.
  4. A laboratory error that should be ignored

Explanation

Fasting glucose between 6.1 and 6.9 mmol/L defines impaired fasting glucose, a prediabetic state. Management centers on weight loss, diet, and exercise, with annual retesting. Diabetes is diagnosed at fasting glucose of 7.0 mmol/L or higher, or with other confirmatory tests.

Question 44Internal Medicine and Adult Primary Care

A 72-year-old man with heart failure and reduced ejection fraction has worsening dyspnea and bilateral basal crackles. Which combination improves mortality in heart failure with reduced ejection fraction?

  1. Digoxin alone
  2. A thiazolidinedione
  3. ACE inhibitor or ARB with a beta blocker and a mineralocorticoid receptor antagonist Correct answer.
  4. A calcium channel blocker such as verapamil

Explanation

Mortality benefit in heart failure with reduced ejection fraction comes from neurohormonal blockade: an ACE inhibitor or ARB, a beta blocker, and a mineralocorticoid receptor antagonist, often with an SGLT2 inhibitor. Digoxin reduces hospitalizations but not mortality. Non-dihydropyridine calcium channel blockers and thiazolidinediones can worsen heart failure.

Question 45Internal Medicine and Adult Primary Care

A 28-year-old woman has recurrent episodes of palpitations, heat intolerance, weight loss, and tremor, with a diffuse goiter and suppressed TSH. Which is the most appropriate initial treatment for symptom control?

  1. Subtotal thyroidectomy before any drug therapy
  2. Levothyroxine
  3. Radioactive iodine as first-line in all patients
  4. A beta blocker such as propranolol plus an antithyroid drug Correct answer.

Explanation

Hyperthyroidism is controlled symptomatically with beta blockers while thionamides such as methimazole or propylthiouracil reduce hormone synthesis. Radioactive iodine and surgery are definitive options after control and evaluation. Levothyroxine would worsen thyrotoxicosis.

Question 46Internal Medicine and Adult Primary Care

Which statement about the transmission of tuberculosis is correct for a feldsher advising a household contact?

  1. It is inherited genetically from parents
  2. It is transmitted by mosquito bites
  3. It spreads mainly by sharing food and utensils
  4. It spreads through airborne droplet nuclei from a person with pulmonary disease, so ventilation and masking reduce transmission Correct answer.

Explanation

Pulmonary tuberculosis spreads through airborne droplet nuclei, particularly in crowded, poorly ventilated settings. Contact tracing, ventilation, and respiratory protection reduce transmission. It is neither foodborne, vector-borne, nor inherited.

Question 47Internal Medicine and Adult Primary Care

A 50-year-old man presents with sudden severe epigastric pain radiating to the back, vomiting, and elevated serum lipase. Which initial measure is most important?

  1. Immediate oral feeding to stimulate recovery
  2. Aggressive intravenous fluid resuscitation with analgesia and nil-by-mouth status Correct answer.
  3. High-dose oral antibiotics
  4. Routine urgent laparotomy

Explanation

Acute pancreatitis is managed with early aggressive fluid resuscitation, analgesia, antiemetics, and temporary fasting, with enteral feeding resumed as tolerated. Antibiotics are not routine without infected necrosis. Surgery is reserved for complications such as infected necrosis or biliary obstruction.

Question 48Internal Medicine and Adult Primary Care

A 65-year-old with type 2 diabetes on metformin and glibenclamide presents with sweating, tremor, and confusion. Capillary glucose is 2.6 mmol/L. What is the immediate management?

  1. Give more glibenclamide
  2. Give intravenous insulin
  3. Give a beta blocker to control tremor
  4. Give oral glucose if conscious and able to swallow, then recheck glucose and adjust therapy Correct answer.

Explanation

Symptomatic hypoglycemia in a conscious patient is treated with fast-acting oral carbohydrate, followed by glucose recheck and adjustment of the sulfonylurea dose. Intravenous dextrose is used if the patient cannot swallow or is unconscious. Sulfonylurea-induced hypoglycemia may recur and requires observation.

Question 49Internal Medicine and Adult Primary Care

A 35-year-old man has an acute gout attack with a hot, swollen first metatarsophalangeal joint. Which treatment is appropriate for the acute episode?

  1. An NSAID such as indomethacin, or colchicine if NSAIDs are contraindicated Correct answer.
  2. Aminoglycoside antibiotics
  3. Allopurinol started alone at high dose during the attack
  4. A thiazide diuretic

Explanation

Acute gout is treated with an NSAID, colchicine, or corticosteroids to control inflammation. Urate-lowering therapy such as allopurinol is not started during an acute flare without cover because rapid shifts can prolong the attack. Thiazides raise urate and are avoided.

Question 50Internal Medicine and Adult Primary Care

A 78-year-old woman is found to have a hemoglobin of 95 g/L with a mean corpuscular volume of 72 fL. Which is the most likely cause?

  1. Iron deficiency anemia Correct answer.
  2. Folate deficiency
  3. Acute blood loss with normal iron stores
  4. Vitamin B12 deficiency

Explanation

A microcytic anemia with low MCV most commonly reflects iron deficiency, especially in older adults where gastrointestinal blood loss must be investigated. B12 and folate deficiency produce macrocytosis. Acute blood loss initially shows normal MCV until iron stores are depleted.