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Mongolia Physician Licensing Exam study materials
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Mongolia 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 oral glucose-lowering drug should be stopped because it is contraindicated at this level of kidney function?

  1. Linagliptin
  2. Empagliflozin
  3. Sitagliptin
  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 withheld at this degree of renal impairment and an alternative agent used. The other listed drugs are either dose-adjustable or safe at this eGFR.

Question 2Internal Medicine

Which finding on physical examination most strongly suggests a diagnosis of nephrotic syndrome rather than nephritic syndrome?

  1. Cola-colored urine with hypertension
  2. Flank pain with fever and dysuria
  3. Periorbital edema with frothy urine Correct answer.
  4. Oliguria with red cell casts

Explanation

Nephrotic syndrome is characterized by heavy proteinuria producing frothy urine, hypoalbuminemia, and edema, often periorbital. Red cell casts, cola-colored urine, hypertension, and oliguria are hallmarks of nephritic syndrome with glomerular inflammation. Flank pain with fever points to pyelonephritis.

Question 3Internal Medicine

A 45-year-old woman has fatigue, weight gain, cold intolerance, and a TSH of 18 mIU/L with a low free T4. Which is the most appropriate initial treatment?

  1. Liothyronine monotherapy
  2. Levothyroxine started at a weight-based full replacement dose Correct answer.
  3. Levothyroxine started at a low dose and titrated to TSH
  4. Observation with repeat thyroid function in 6 months

Explanation

For this 45-year-old with no stated cardiovascular disease, a weight-based full replacement dose of levothyroxine is the best listed initial treatment for overt primary hypothyroidism. Follow-up TSH guides dose adjustment. Lower starting doses are generally preferred for older patients or those with cardiovascular disease.

Question 4Internal Medicine

Which electrocardiographic finding is most characteristic of acute pericarditis?

  1. Delta waves with a short PR interval
  2. Diffuse concave ST elevation with PR depression Correct answer.
  3. Reciprocal ST depression in all leads
  4. New left bundle branch block

Explanation

Acute pericarditis typically produces widespread concave ST-segment elevation with PR depression, reflecting diffuse pericardial inflammation. Reciprocal ST depression confined to a coronary territory suggests myocardial infarction instead. Bundle branch block and delta waves indicate conduction or pre-excitation abnormalities.

Question 5Internal Medicine

A 30-year-old presents with sudden-onset pleuritic chest pain and dyspnea after a long flight. Which initial test is most appropriate to confirm pulmonary embolism?

  1. Arterial blood gas analysis
  2. Chest radiograph
  3. CT pulmonary angiography Correct answer.
  4. D-dimer assay

Explanation

CT pulmonary angiography is the imaging standard for confirming pulmonary embolism in a patient with high clinical probability. D-dimer is useful mainly to exclude embolism in low-probability patients, and it lacks specificity. Blood gas and chest radiograph may support the workup but cannot confirm the diagnosis.

Question 6Internal Medicine

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

  1. Streptococcus pneumoniae Correct answer.
  2. Mycoplasma pneumoniae
  3. Pseudomonas aeruginosa
  4. Pneumocystis jirovecii

Explanation

Streptococcus pneumoniae remains the leading cause of community-acquired pneumonia in adults, including those admitted to hospital. Mycoplasma is common in younger outpatients, while Pseudomonas and Pneumocystis typically affect immunocompromised or structurally damaged lungs.

Question 7Internal Medicine

A patient with chronic kidney disease has a potassium of 6.8 mmol/L and peaked T waves on ECG. Which intervention should be given first?

  1. Intravenous calcium gluconate Correct answer.
  2. Oral sodium polystyrene sulfonate
  3. Intravenous furosemide
  4. Subcutaneous insulin alone

Explanation

Intravenous calcium stabilizes the myocardial membrane and is the immediate priority when hyperkalemia produces ECG changes. It does not lower serum potassium but prevents arrhythmia while potassium-lowering measures take effect. Insulin, diuretics, and binders are used afterward to shift or remove potassium.

Question 8Internal Medicine

Which laboratory pattern is typical of iron deficiency anemia?

  1. Normal ferritin with low transferrin saturation
  2. High ferritin with low total iron-binding capacity
  3. High ferritin with normal mean corpuscular volume
  4. Low ferritin with high total iron-binding capacity Correct answer.

Explanation

Iron deficiency produces low serum ferritin and a compensatory rise in total iron-binding capacity, with low transferrin saturation. Ferritin is the most specific single test because it reflects depleted iron stores. High ferritin with low iron-binding capacity instead suggests anemia of chronic disease.

Question 9Internal Medicine

A 62-year-old smoker reports progressive dyspnea and a chronic productive cough. Spirometry shows an FEV1/FVC ratio of 0.60 that does not improve after a bronchodilator. Which diagnosis best fits?

  1. Asthma
  2. Idiopathic pulmonary fibrosis
  3. Chronic obstructive pulmonary disease Correct answer.
  4. Congestive heart failure

Explanation

A post-bronchodilator FEV1/FVC ratio below 0.70 defines persistent airflow obstruction, which in a smoker with chronic productive cough indicates COPD. Asthma usually shows significant reversibility, and fibrotic lung disease causes a restrictive rather than obstructive pattern. Heart failure produces a restrictive pattern with reduced diffusion.

Question 10Internal Medicine

A 24-year-old woman has palpitations and a regular narrow-complex tachycardia at 160 beats/min. Vagal maneuvers fail. Which drug is the preferred next step for acute termination if the rhythm is regular supraventricular tachycardia?

  1. Lidocaine
  2. Adenosine Correct answer.
  3. Digoxin
  4. Amiodarone

Explanation

Adenosine transiently blocks the atrioventricular node and terminates most regular narrow-complex supraventricular tachycardias after vagal maneuvers fail. Its very short half-life makes it safe for repeated bolus dosing. Amiodarone, digoxin, and lidocaine are not first-line for acute termination of this rhythm.

Question 11Internal Medicine

A 70-year-old man has a blood pressure of 168/96 mmHg confirmed on repeated visits despite lifestyle measures. He has no diabetes or kidney disease. Which is the most appropriate initial antihypertensive class?

  1. Alpha-1 blocker
  2. Central alpha-2 agonist
  3. Loop diuretic
  4. Thiazide-type diuretic Correct answer.

Explanation

Thiazide-type diuretics are one of the recommended first-line classes for uncomplicated hypertension, alongside ACE inhibitors, ARBs, and calcium channel blockers. They are effective, inexpensive, and reduce cardiovascular events. Alpha blockers, central agonists, and loop diuretics are generally reserved for specific indications.

Question 12Internal Medicine

A 55-year-old with alcohol-related cirrhosis presents with hematemesis. After resuscitation, which medication should be started before endoscopy?

  1. Oral lactulose
  2. Oral propranolol
  3. Intravenous vitamin K
  4. Intravenous octreotide Correct answer.

Explanation

In suspected variceal bleeding, a vasoactive agent such as octreotide is started as soon as possible, before endoscopy, to reduce portal pressure. Antibiotic prophylaxis and endoscopic band ligation follow. Propranolol is used for prophylaxis of variceal bleeding, not for acute hemorrhage.

Question 13Internal Medicine

Which feature most reliably distinguishes diabetic ketoacidosis from hyperosmolar hyperglycemic state?

  1. Blood glucose above 30 mmol/L
  2. Presence of polyuria
  3. Serum osmolality above 320 mOsm/kg
  4. Significant ketonemia with metabolic acidosis Correct answer.

Explanation

DKA is defined by ketoacidosis with an elevated anion gap, whereas HHS shows marked hyperglycemia and hyperosmolality with minimal ketosis. Both conditions cause polyuria and severe hyperglycemia, so these do not separate them. Osmolality is typically higher in HHS.

Question 14Internal Medicine

A 28-year-old woman has a positive pregnancy test and sudden severe unilateral pelvic pain with vaginal spotting. Which is the most appropriate immediate step?

  1. Start oral methotrexate without imaging
  2. Urgent pelvic ultrasound and quantitative beta-hCG Correct answer.
  3. Elective repeat hCG in one week
  4. Reassurance and outpatient follow-up

Explanation

The presentation suggests ectopic pregnancy, which requires urgent pelvic ultrasound with a quantitative beta-hCG to locate the pregnancy and guide management. Delay risks tubal rupture and hemorrhage. Methotrexate is considered only after diagnosis and assessment of suitability.

Question 15Internal Medicine

A patient with rheumatoid arthritis develops progressive dyspnea and dry cough. Examination reveals bibasilar crackles. Which pulmonary complication is most likely?

  1. Pleural effusion
  2. Interstitial lung disease Correct answer.
  3. Pulmonary embolism
  4. Bronchiectasis

Explanation

Rheumatoid arthritis is associated with interstitial lung disease, typically causing progressive dyspnea, dry cough, and bibasilar crackles on examination. High-resolution CT and pulmonary function testing confirm the diagnosis. Pleural effusion, embolism, and bronchiectasis are less consistent with this insidious presentation.

Question 16Internal Medicine

A 40-year-old man has a fasting glucose of 6.3 mmol/L and an HbA1c of 6.2%. What is the correct interpretation?

  1. Need for immediate insulin
  2. Normal glucose tolerance
  3. Prediabetes Correct answer.
  4. Overt diabetes mellitus

Explanation

A fasting glucose between 5.6 and 6.9 mmol/L and an HbA1c between 5.7% and 6.4% both fall in the prediabetes range. Diabetes requires a fasting glucose of 7.0 mmol/L or higher or an HbA1c of 6.5% or higher. Lifestyle intervention is indicated rather than insulin.

Question 17Internal Medicine

Which finding is most suggestive of bacterial rather than viral meningitis in the cerebrospinal fluid?

  1. Absence of organisms on Gram stain
  2. Neutrophil predominance with low glucose Correct answer.
  3. Normal protein with clear fluid
  4. Lymphocyte predominance with normal glucose

Explanation

Bacterial meningitis typically shows a neutrophilic pleocytosis, low CSF glucose, and elevated protein. Viral meningitis more often produces a lymphocytic pleocytosis with normal glucose. Gram stain may be negative in bacterial disease, so its absence does not exclude it.

Question 18Internal Medicine

A 65-year-old with atrial fibrillation has a CHA2DS2-VASc score of 4. What is the most appropriate management for stroke prevention?

  1. Aspirin monotherapy
  2. Long-term oral anticoagulation Correct answer.
  3. Clopidogrel plus aspirin indefinitely
  4. No antithrombotic therapy

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates sufficient stroke risk to warrant oral anticoagulation. A direct oral anticoagulant or warfarin is appropriate depending on renal function and valve status. Aspirin alone is inferior to anticoagulation for atrial fibrillation.

Question 19Internal Medicine

A 50-year-old presents with acute severe epigastric pain radiating to the back, and serum lipase is three times the upper limit of normal. Which is the most common cause in most populations?

  1. Gallstones Correct answer.
  2. Viral infection
  3. Hypertriglyceridemia
  4. Hypercalcemia

Explanation

Gallstones and alcohol are the two leading causes of acute pancreatitis, with gallstones being most common overall in many populations. Hypertriglyceridemia and hypercalcemia are less frequent causes. Viral infection rarely triggers pancreatitis.

Question 20Internal Medicine

A patient with heart failure and reduced ejection fraction remains symptomatic despite an ACE inhibitor and beta-blocker. Which addition has been shown to reduce mortality?

  1. Digoxin
  2. Amlodipine
  3. Furosemide
  4. Mineralocorticoid receptor antagonist Correct answer.

Explanation

Mineralocorticoid receptor antagonists such as spironolactone reduce mortality in heart failure with reduced ejection fraction when added to standard therapy. Digoxin reduces hospitalizations but not mortality. Furosemide relieves congestion symptomatically, and amlodipine has neutral effects on survival.

Question 21Internal Medicine

A 35-year-old woman has fatigue, arthralgia, a malar rash, and proteinuria. Which serologic test is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity, particularly lupus nephritis. Antinuclear antibody is sensitive but not specific and occurs in many conditions. Rheumatoid factor and anti-CCP point toward rheumatoid arthritis.

Question 22Internal Medicine

A 72-year-old with a history of hypertension presents with sudden-onset focal neurologic deficit that resolves within 2 hours, with no infarction on imaging. What is the most appropriate next step?

  1. Discharge without further workup
  2. Begin long-term anticoagulation without further evaluation
  3. Evaluate the carotid arteries and cardiac rhythm for embolic source Correct answer.
  4. Start thrombolysis

Explanation

A transient ischemic attack carries a high short-term stroke risk and requires urgent evaluation for carotid stenosis and atrial fibrillation, the common treatable sources of embolism. Imaging and vascular assessment guide secondary prevention. Discharge without workup, thrombolysis, or empiric anticoagulation is inappropriate.

Question 23Internal Medicine

A 60-year-old with long-standing hypertension develops progressive renal failure, and urinalysis shows mild proteinuria without active sediment. Which is the most likely cause?

  1. Acute interstitial nephritis
  2. Post-streptococcal glomerulonephritis
  3. Hypertensive nephrosclerosis Correct answer.
  4. Renal artery stenosis from fibromuscular dysplasia

Explanation

Chronic hypertension causes nephrosclerosis with gradual loss of kidney function and mild proteinuria, usually without active urinary sediment. Interstitial nephritis typically follows drug exposure with eosinophiluria, and post-streptococcal disease produces an active nephritic sediment. Fibromuscular dysplasia usually affects younger women and presents with difficult hypertension rather than isolated progressive renal failure.

Question 24Internal Medicine

A 45-year-old with type 1 diabetes has a blood glucose of 28 mmol/L, pH 7.15, bicarbonate 10 mmol/L, and positive ketones. After fluids and insulin are started, which electrolyte requires the closest monitoring during treatment?

  1. Phosphate
  2. Calcium
  3. Magnesium
  4. Potassium Correct answer.

Explanation

Insulin drives potassium into cells, and total body potassium is already depleted in DKA, so serum potassium can fall precipitously during treatment. Potassium is checked frequently and replaced when below 5.2 mmol/L with adequate urine output. Calcium, magnesium, and phosphate are less acutely critical in this setting.

Question 25Internal Medicine

A patient with known cirrhosis develops confusion, asterixis, and fever. Which precipitant of hepatic encephalopathy should be sought first?

  1. Excess dietary protein
  2. Infection such as spontaneous bacterial peritonitis Correct answer.
  3. Mild elevation of transaminases
  4. Chronic constipation alone

Explanation

Infection, especially spontaneous bacterial peritonitis, is a common and treatable precipitant of hepatic encephalopathy and should be excluded promptly with diagnostic paracentesis. Other triggers include gastrointestinal bleeding, electrolyte disturbance, and sedatives. Dietary protein restriction and constipation are not the primary precipitants to exclude first.

Question 26Internal Medicine

A 58-year-old man with a 40 pack-year smoking history presents with a 3-week history of a persistent cough and one episode of hemoptysis. Chest radiograph shows a hilar mass. Which diagnostic step is most appropriate next to establish a tissue diagnosis?

  1. Sputum cytology
  2. Bronchoscopy with biopsy Correct answer.
  3. CT-guided percutaneous needle biopsy
  4. Video-assisted thoracoscopic surgery (VATS) biopsy

Explanation

For a central hilar mass, bronchoscopy with biopsy allows direct visualization and tissue sampling of endobronchial lesions, with a high diagnostic yield. Sputum cytology has low sensitivity and is not preferred when a mass is visible. CT-guided biopsy is better for peripheral lesions, and VATS is reserved for cases where less invasive methods fail.

Question 27Internal Medicine

A 45-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. Physical examination reveals dry skin, bradycardia, and delayed relaxation of deep tendon reflexes. Which laboratory test is the most appropriate initial test to confirm the suspected diagnosis?

  1. Serum total T3
  2. Thyroid peroxidase antibodies
  3. Serum free T4
  4. Serum thyroid-stimulating hormone (TSH) Correct answer.

Explanation

Primary hypothyroidism is best screened with serum TSH, which is elevated in primary hypothyroidism due to loss of negative feedback. Free T4 is useful for confirming severity and monitoring but is not the initial screening test. Total T3 and thyroid antibodies are not first-line for diagnosing hypothyroidism.

Question 28Internal Medicine

A 68-year-old man with a history of hypertension and diabetes presents with sudden-onset right-sided weakness and aphasia. Non-contrast CT of the head shows no hemorrhage. He arrives 2 hours after symptom onset. His blood pressure is 185/105 mmHg, and his blood glucose is 7.8 mmol/L. He is not on anticoagulants. Which is the most appropriate immediate management?

  1. Administer aspirin 300 mg rectally
  2. Perform immediate carotid endarterectomy
  3. Start intravenous heparin infusion
  4. Administer intravenous alteplase after lowering blood pressure to <185/110 mmHg Correct answer.

Explanation

Intravenous thrombolysis with alteplase is indicated for acute ischemic stroke within 4.5 hours of symptom onset after excluding hemorrhage. Blood pressure must be reduced to below 185/110 mmHg before administration. Aspirin is given after 24 hours, heparin is not routinely used, and carotid endarterectomy is not an emergency procedure.

Question 29Internal Medicine

A 32-year-old woman presents with a 2-day history of dysuria, frequency, and suprapubic pain. She has no fever or flank pain. Urine dipstick is positive for nitrites and leukocyte esterase. Which is the most appropriate treatment?

  1. Trimethoprim-sulfamethoxazole for 10 days
  2. Nitrofurantoin for 5 days Correct answer.
  3. Ciprofloxacin for 7 days
  4. Amoxicillin for 3 days

Explanation

Acute uncomplicated cystitis in women is typically treated with a short course of antibiotics such as nitrofurantoin for 5 days. Fluoroquinolones are reserved for more complicated infections due to collateral damage and resistance concerns. Amoxicillin has high resistance rates, and a 10-day course of trimethoprim-sulfamethoxazole is longer than necessary for uncomplicated cystitis.

Question 30Internal Medicine

A 55-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. He is given intravenous glucose without thiamine. Which complication is most likely to occur?

  1. Korsakoff syndrome
  2. Hypoglycemic coma
  3. Wernicke encephalopathy Correct answer.
  4. Osmotic demyelination syndrome

Explanation

Administration of glucose without thiamine in a thiamine-deficient patient can precipitate Wernicke encephalopathy, characterized by confusion, ataxia, and ophthalmoplegia. Korsakoff syndrome is a chronic amnestic disorder that may follow, but the acute presentation is Wernicke. Hypoglycemic coma is not caused by glucose administration, and osmotic demyelination is related to rapid correction of hyponatremia.

Question 31Internal Medicine

A 24-year-old man presents with sudden-onset severe headache, neck stiffness, and photophobia. He is alert and oriented. CT of the head is normal. Which is the most appropriate next step in management?

  1. Discharge with analgesic and antiemetic
  2. Start empiric antibiotics and await blood cultures
  3. MRI of the brain
  4. Lumbar puncture for cerebrospinal fluid analysis Correct answer.

Explanation

In a patient with suspected meningitis and a normal CT, lumbar puncture is indicated to obtain cerebrospinal fluid for cell count, glucose, protein, and culture. Empiric antibiotics should be started immediately after blood cultures but before lumbar puncture if lumbar puncture is delayed; however, lumbar puncture is the next diagnostic step. MRI is not routinely needed, and discharge is inappropriate.

Question 32Internal Medicine

A 60-year-old woman with type 2 diabetes and hypertension presents with progressive fatigue, nausea, and pruritus. Laboratory results show hemoglobin 9.8 g/dL, creatinine 3.2 mg/dL, and estimated glomerular filtration rate (eGFR) 18 mL/min/1.73m2. Which is the most likely cause of her anemia?

  1. Erythropoietin deficiency Correct answer.
  2. Anemia of chronic disease
  3. Iron deficiency
  4. Vitamin B12 deficiency

Explanation

Anemia in chronic kidney disease is primarily due to decreased production of erythropoietin by the failing kidneys. Iron deficiency and vitamin B12 deficiency can also cause anemia but are less likely as the primary cause in this context. Anemia of chronic disease is a diagnosis of exclusion and typically occurs with inflammation, not as the direct result of renal failure.

Question 33Internal Medicine

A 35-year-old woman presents with palpitations, heat intolerance, and weight loss. Physical examination reveals a diffuse goiter, lid lag, and fine tremor. Laboratory tests show suppressed TSH and elevated free T4. Which is the most appropriate initial treatment?

  1. Radioactive iodine therapy
  2. Methimazole Correct answer.
  3. Propylthiouracil
  4. Subtotal thyroidectomy

Explanation

Methimazole is the preferred initial treatment for Graves' disease in non-pregnant patients because it has a better safety profile than propylthiouracil. Radioactive iodine and surgery are definitive options but are not first-line unless there are specific indications. Propylthiouracil is preferred in the first trimester of pregnancy or in thyroid storm.

Question 34Internal Medicine

A 70-year-old man with a history of hypertension and diabetes presents with progressive dyspnea on exertion and orthopnea. Echocardiogram shows an ejection fraction of 30%. He is already on an ACE inhibitor and beta-blocker at target doses. Which additional medication has been shown to reduce mortality in this condition?

  1. Amlodipine
  2. Spironolactone Correct answer.
  3. Furosemide
  4. Digoxin

Explanation

Spironolactone, a mineralocorticoid receptor antagonist, reduces mortality in patients with heart failure with reduced ejection fraction who remain symptomatic despite ACE inhibitor and beta-blocker therapy. Digoxin reduces hospitalizations but not mortality. Furosemide is used for symptom relief but does not improve survival. Amlodipine is not indicated for mortality reduction in heart failure.

Question 35Internal Medicine

A 28-year-old woman presents with recurrent episodes of severe abdominal pain, hypertension, and tachycardia. She reports episodes are triggered by fasting or stress. Urine studies show elevated porphobilinogen. Which enzyme is most likely deficient?

  1. Uroporphyrinogen decarboxylase
  2. Ferrochelatase
  3. Protoporphyrinogen oxidase
  4. Porphobilinogen deaminase Correct answer.

Explanation

Acute intermittent porphyria is caused by deficiency of porphobilinogen deaminase (also known as hydroxymethylbilane synthase) and presents with neurovisceral symptoms. Uroporphyrinogen decarboxylase deficiency causes porphyria cutanea tarda, which presents with skin lesions. Protoporphyrinogen oxidase deficiency causes variegate porphyria, and ferrochelatase deficiency causes erythropoietic protoporphyria.

Question 36Internal Medicine

A 45-year-old man with a history of intravenous drug use presents with fever, chills, and a new heart murmur. Blood cultures grow Staphylococcus aureus. Echocardiogram shows a vegetation on the tricuspid valve. He has no known drug allergies. Which is the most appropriate antibiotic regimen?

  1. Nafcillin plus gentamicin for 2 weeks Correct answer.
  2. Vancomycin for 6 weeks
  3. Ceftriaxone for 4 weeks
  4. Daptomycin for 4 weeks

Explanation

For methicillin-susceptible Staphylococcus aureus (MSSA) right-sided endocarditis, a short course of nafcillin plus gentamicin for 2 weeks is effective in uncomplicated cases. Vancomycin is reserved for MRSA or penicillin allergy. Ceftriaxone is not optimal for staphylococcal endocarditis, and daptomycin is an alternative for resistant cases but not first-line.

Question 37Surgery

A 24-year-old man is brought to the surgical emergency department after a motorcycle crash with severe left upper quadrant pain and hypotension. After resuscitation, which single investigation is most appropriate to confirm free intraperitoneal fluid in this hemodynamically unstable patient?

  1. Diagnostic peritoneal lavage under general anesthesia
  2. Plain abdominal radiograph in the supine position
  3. Focused assessment with sonography for trauma (FAST) Correct answer.
  4. Contrast-enhanced abdominal CT

Explanation

FAST is rapid, non-invasive and can be performed at the bedside in an unstable trauma patient, detecting free intraperitoneal fluid with high specificity. It guides immediate decision-making toward laparotomy without leaving the resuscitation area. CT requires transport and is reserved for stable patients.

Question 38Surgery

Which finding most strongly suggests that a patient with acute abdominal pain has peritonitis requiring urgent surgical assessment?

  1. Diffuse cramping pain relieved by vomiting
  2. Localized tenderness reproduced by straight-leg raising
  3. Hyperactive bowel sounds with intermittent colic
  4. Rebound tenderness with involuntary guarding on palpation Correct answer.

Explanation

Rebound tenderness and involuntary guarding are classic signs of parietal peritoneal inflammation and indicate a surgical abdomen. They signal that the inflammatory process has spread to involve the parietal peritoneum. Colic and vomiting point more toward luminal obstruction without peritonitis.

Question 39Surgery

A 45-year-old woman has right upper quadrant pain, fever and jaundice. Ultrasound shows gallstones and a dilated common bile duct. What is the most appropriate initial management of suspected acute cholangitis?

  1. Percutaneous cholecystostomy without biliary decompression
  2. Intravenous fluids and antibiotics with urgent biliary drainage by ERCP Correct answer.
  3. Emergency laparoscopic cholecystectomy within 6 hours
  4. Oral ursodeoxycholic acid and outpatient review in 6 weeks

Explanation

Acute cholangitis is a biliary sepsis requiring resuscitation, broad-spectrum antibiotics and urgent decompression of the obstructed biliary tree, usually by ERCP. Cholecystectomy alone does not relieve the ductal obstruction and is generally deferred until the sepsis is controlled.

Question 40Surgery

A 30-year-old man has a stab wound to the anterior abdominal wall with omentum protruding through the wound. He is hemodynamically stable. What is the most appropriate next step?

  1. Application of a sterile dressing and discharge with oral antibiotics
  2. Urgent CT scan of the abdomen before any wound care
  3. Operative wound exploration under local anesthesia and discharge if fascia is intact Correct answer.
  4. Immediate exploratory laparotomy

Explanation

Omental evisceration indicates a fascial defect and a high likelihood of intra-abdominal injury, so formal wound exploration is required. In a stable patient, local exploration can determine whether the peritoneum is breached and guide the need for laparotomy or laparoscopy. Simple dressing and discharge is unsafe.

Question 41Surgery

A 38-year-old woman has a 6 mm common bile duct stone with mild cholangitis. After successful ERCP clearance, what is the recommended definitive treatment?

  1. Repeat ERCP in 3 months
  2. Laparoscopic cholecystectomy during the same admission Correct answer.
  3. Percutaneous transhepatic cholangiography
  4. Long-term low-fat diet and observation

Explanation

After endoscopic clearance of a common bile duct stone, the gallbladder remains a source of further stones and recurrent pancreatitis or cholangitis. Laparoscopic cholecystectomy during the same admission is the standard definitive treatment for a fit patient. Observation leaves the patient at high risk of recurrence.

Question 42Surgery

Which patient with acute appendicitis is most appropriately managed with intravenous antibiotics alone rather than appendectomy?

  1. A 60-year-old with a perforated appendix and generalized peritonitis
  2. A 28-year-old with an appendiceal mass and no peritonitis who improves on antibiotics Correct answer.
  3. A 10-year-old with a high fever and rigid abdomen
  4. A 25-year-old with a 12-hour history and localized right lower quadrant peritonitis

Explanation

An appendiceal mass without generalized peritonitis that responds to antibiotics may be managed conservatively with interval appendectomy considered later. Perforation with generalized peritonitis and rigid abdomen require urgent source control. Antibiotics alone are not appropriate when there is diffuse peritonitis.

Question 43Surgery

A 70-year-old man has a painful, tender right groin swelling that appeared 4 hours ago after lifting. It is irreducible and he is vomiting. What is the most important initial step?

  1. Ultrasound of the groin before any intervention
  2. Application of a truss and analgesia
  3. Urgent manual reduction under sedation and analgesia, with surgery if unsuccessful Correct answer.
  4. Elective hernia repair in 2 weeks

Explanation

An irreducible painful groin hernia with vomiting suggests strangulation or obstruction and requires urgent reduction or operative repair. Manual reduction under sedation and analgesia is attempted first in the absence of peritonitis, followed by surgery if it fails. Delay risks bowel ischemia.

Question 44Surgery

A 55-year-old woman has a hard, painless breast lump with skin dimpling. Which investigation provides the definitive diagnosis?

  1. Breast ultrasound alone
  2. Mammography alone
  3. Core needle biopsy with histology Correct answer.
  4. Fine needle aspiration cytology alone

Explanation

Core needle biopsy provides histology, allows grading and receptor status assessment, and is the definitive diagnostic test for a suspected breast carcinoma. Imaging supports the diagnosis but cannot confirm it. Cytology may be inconclusive for invasive disease.

Question 45Surgery

A 62-year-old man has painless gross hematuria. Which diagnosis must be excluded first?

  1. Acute bacterial prostatitis
  2. Urethral stricture
  3. Renal cell carcinoma of the kidney
  4. Urothelial carcinoma of the bladder Correct answer.

Explanation

Painless gross hematuria in an older adult is a classic presentation of bladder cancer until proven otherwise, and cystoscopy is required. Prostatitis and stricture usually cause pain or obstructive symptoms. Renal cancer can cause hematuria but is less commonly painless gross hematuria as the sole sign.

Question 46Surgery

A 22-year-old man has sudden severe right testicular pain with nausea and a high-riding testis. What is the most appropriate immediate action?

  1. Urgent surgical exploration for testicular torsion Correct answer.
  2. Antibiotics for epididymo-orchitis and review in 24 hours
  3. Scrotal support and NSAIDs with outpatient follow-up
  4. Scrotal ultrasound before any intervention

Explanation

Sudden severe testicular pain with a high-riding testis suggests testicular torsion, which is a surgical emergency requiring immediate exploration and detorsion. Ultrasound must not delay surgery when the clinical picture is typical. Delay risks testicular loss.

Question 47Surgery

Which finding is most characteristic of acute arterial occlusion of the lower limb?

  1. Chronic ulceration at the medial malleolus
  2. Gradual onset of claudication relieved by rest
  3. Pallor, pulselessness, pain and paresthesia of sudden onset Correct answer.
  4. Warm, swollen leg with pitting edema

Explanation

Acute arterial occlusion presents with the classic features of pain, pallor, pulselessness, paresthesia and paralysis of sudden onset. Gradual claudication and chronic ulcers suggest chronic arterial or venous disease. A warm swollen leg suggests deep vein thrombosis.

Question 48Surgery

A 68-year-old man has a 6 cm abdominal aortic aneurysm. He is asymptomatic. What is the most appropriate management?

  1. Immediate emergency surgery
  2. Elective open or endovascular repair Correct answer.
  3. Strict blood pressure control alone
  4. Serial ultrasound every 12 months

Explanation

Abdominal aortic aneurysms of 5.5 cm or more in men carry a high rupture risk and should be considered for elective repair, usually endovascular when anatomically suitable. Surveillance is appropriate for smaller aneurysms. Emergency surgery is reserved for rupture or symptomatic aneurysms.

Question 49Surgery

A patient develops fever, tachycardia and a painful, erythematous surgical wound with purulent discharge on the third postoperative day. What is the most appropriate initial management?

  1. Start oral antibiotics and observe for 48 hours
  2. Reassure and apply a compressive dressing
  3. Open the wound and drain the pus, then start antibiotics Correct answer.
  4. Immediate reoperation with wide excision of the wound

Explanation

A postoperative wound abscess requires prompt opening and drainage of the collection; antibiotics alone cannot penetrate an undrained abscess. Antibiotics are used as an adjunct, especially with cellulitis or systemic sepsis. Reassurance or compression will allow the infection to progress.

Question 50Surgery

A 40-year-old man has a deep laceration over the volar aspect of the wrist with inability to flex the index finger at the distal interphalangeal joint. What is the most appropriate management?

  1. Skin closure alone with splinting
  2. Surgical exploration and repair of the flexor tendon Correct answer.
  3. Physiotherapy starting immediately without exploration
  4. Application of a compression bandage and early mobilization

Explanation

Loss of distal interphalangeal flexion after a volar wrist laceration suggests flexor tendon injury, which requires surgical exploration and repair. Skin closure alone would allow tendon retraction and permanent loss of function. Early mobilization without repair is inappropriate.