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MMDC Medical Licensing Exam study materials
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MMDC Medical 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 antihyperglycemic agent should be avoided because it requires adequate renal function to prevent lactic acidosis?

  1. Empagliflozin
  2. Metformin Correct answer.
  3. Sitagliptin
  4. Glipizide

Explanation

Metformin is cleared renally and accumulates when eGFR is severely reduced, increasing the risk of lactic acidosis; it is generally contraindicated below an eGFR of about 30. Other agents require dose adjustment or monitoring but are not contraindicated for this specific mechanism.

Question 2Internal Medicine

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

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

Explanation

Tension pneumothorax produces a large air-filled pleural space, giving hyperresonance and absent breath sounds on the affected side. Tracheal deviation, when present, shifts away from the affected side. Dullness with increased fremitus suggests consolidation.

Question 3Internal Medicine

A 24-year-old woman presents with palpitations and heat intolerance. TSH is suppressed and free T4 is elevated. Which antibody is most specific for Graves disease?

  1. Thyroid-stimulating immunoglobulin Correct answer.
  2. Anti-nuclear antibody
  3. Anti-thyroglobulin antibody
  4. Anti-thyroid peroxidase antibody

Explanation

Thyroid-stimulating immunoglobulin binds and activates the TSH receptor, driving the hyperthyroidism of Graves disease and serving as the most specific marker. Anti-TPO and anti-thyroglobulin antibodies occur in Graves disease but also in Hashimoto thyroiditis and other thyroid disorders.

Question 4Internal Medicine

Which electrocardiographic finding is the earliest sign of acute transmural myocardial infarction?

  1. Pathologic Q waves
  2. Hyperacute T waves Correct answer.
  3. T-wave inversion
  4. ST-segment elevation

Explanation

Hyperacute, peaked T waves are the earliest ECG manifestation of acute transmural ischemia, reflecting abrupt loss of the normal repolarization gradient. ST elevation follows, and Q waves and T-wave inversion develop later.

Question 5Internal Medicine

A patient has a serum sodium of 120 mEq/L and is symptomatic with confusion. Which fluid is most appropriate for initial correction of symptomatic hyponatremia?

  1. 0.9% sodium chloride
  2. Lactated Ringer solution
  3. 5% dextrose in water
  4. 3% hypertonic saline Correct answer.

Explanation

Symptomatic severe hyponatremia is treated with hypertonic (3%) saline to raise serum sodium gradually while relieving cerebral edema. Correction should generally not exceed 8 to 10 mEq/L in 24 hours to avoid osmotic demyelination.

Question 6Internal Medicine

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

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

Explanation

Streptococcus pneumoniae remains the most frequently identified cause of community-acquired pneumonia across adult age groups. Atypical organisms and Haemophilus are important but less common overall.

Question 7Internal Medicine

A 45-year-old man has a fasting plasma glucose of 132 mg/dL on two occasions. Which diagnosis is established?

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

Explanation

A fasting plasma glucose of 126 mg/dL or greater on two occasions meets diagnostic criteria for diabetes mellitus. Impaired fasting glucose corresponds to 100 to 125 mg/dL.

Question 8Internal Medicine

Which class of medication is first-line for chronic management of stable angina in a patient without contraindications?

  1. Beta-blockers Correct answer.
  2. Calcium channel blockers of the dihydropyridine type
  3. Long-acting nitrates
  4. Potassium channel openers

Explanation

Beta-blockers reduce myocardial oxygen demand by lowering heart rate and contractility and are first-line antianginal therapy. Dihydropyridine calcium channel blockers and nitrates are useful add-ons or alternatives when beta-blockers are not tolerated.

Question 9Internal Medicine

A 62-year-old woman has a creatinine of 2.4 mg/dL, blood urea nitrogen of 60 mg/dL, and a urine sodium of 8 mEq/L after three days of vomiting. Which category of acute kidney injury is most likely?

  1. Intrinsic renal injury
  2. Prerenal azotemia Correct answer.
  3. Acute interstitial nephritis
  4. Postrenal obstruction

Explanation

Volume depletion from vomiting causes prerenal azotemia, characterized by a BUN-to-creatinine ratio above 20 and low urine sodium reflecting avid sodium reabsorption. Intrinsic and postrenal causes show different urine indices and typically do not improve with volume repletion.

Question 10Internal Medicine

A 30-year-old man has sudden-onset pleuritic chest pain and dyspnea one week after knee surgery. Which test is the most appropriate first step to confirm pulmonary embolism in a hemodynamically stable patient?

  1. Ventilation-perfusion scan
  2. D-dimer assay
  3. Lower extremity venous ultrasound
  4. CT pulmonary angiography Correct answer.

Explanation

In a patient with high pretest probability, CT pulmonary angiography is the preferred confirmatory study because it directly visualizes emboli. D-dimer is most useful to exclude embolism in low-probability patients.

Question 11Internal Medicine

A 55-year-old man with cirrhosis presents with hematemesis. After resuscitation, which medication should be started to reduce the risk of rebleeding from esophageal varices?

  1. Vitamin K
  2. Propranolol
  3. Omeprazole
  4. Octreotide Correct answer.

Explanation

Octreotide, a somatostatin analog, causes splanchnic vasoconstriction and reduces portal pressure during acute variceal hemorrhage. Beta-blockers are used for prophylaxis, not acute control of active bleeding.

Question 12Internal Medicine

A 70-year-old woman has a hemoglobin of 10.5 g/dL, an MCV of 72 fL, and a ferritin of 8 ng/mL. Which finding is most consistent with her diagnosis?

  1. Elevated mean corpuscular hemoglobin
  2. Elevated total iron-binding capacity Correct answer.
  3. Elevated transferrin saturation
  4. Elevated reticulocyte count

Explanation

Iron deficiency anemia produces microcytosis with low ferritin and low transferrin saturation, while total iron-binding capacity rises as the body compensates for low iron stores. The other options are not typical of iron deficiency.

Question 13Internal Medicine

A 28-year-old woman has a blood pressure of 150/95 mmHg, hypokalemia, and a mildly elevated aldosterone with suppressed renin. Which condition is most likely?

  1. Cushing syndrome
  2. Renal artery stenosis
  3. Primary aldosteronism Correct answer.
  4. Pheochromocytoma

Explanation

Hypertension with hypokalemia and an elevated aldosterone-to-renin ratio indicates primary aldosteronism. Renal artery stenosis raises renin, and pheochromocytoma and Cushing syndrome have different biochemical profiles.

Question 14Internal Medicine

Which finding on urinalysis most strongly suggests nephrotic syndrome rather than nephritic syndrome?

  1. Dysmorphic red blood cells
  2. Red blood cell casts
  3. Heavy proteinuria with lipiduria Correct answer.
  4. White blood cell casts

Explanation

Nephrotic syndrome is defined by heavy proteinuria, hypoalbuminemia, edema, and lipiduria with oval fat bodies. Red cell casts and dysmorphic red cells indicate glomerular inflammation typical of nephritic syndrome.

Question 15Internal Medicine

A 65-year-old smoker has a chronic cough and weight loss. Chest radiography shows a peripheral lung mass. Which paraneoplastic syndrome is most associated with squamous cell carcinoma of the lung?

  1. Carcinoid syndrome
  2. SIADH with hyponatremia
  3. Cushing syndrome from ectopic ACTH
  4. Hypercalcemia from parathyroid hormone-related peptide Correct answer.

Explanation

Squamous cell carcinoma commonly secretes parathyroid hormone-related peptide, producing hypercalcemia. SIADH and ectopic ACTH are more typical of small cell carcinoma.

Question 16Internal Medicine

A 40-year-old man has a fasting glucose of 300 mg/dL, pH of 7.15, bicarbonate of 10 mEq/L, and large serum ketones. Which is the most appropriate initial fluid for resuscitation?

  1. 0.45% sodium chloride
  2. 3% hypertonic saline
  3. 0.9% sodium chloride Correct answer.
  4. 5% dextrose in water

Explanation

Diabetic ketoacidosis is managed initially with isotonic saline to restore intravascular volume before insulin and potassium replacement. Hypotonic fluids and dextrose are used later once glucose falls and deficits are partially corrected.

Question 17Internal Medicine

A 50-year-old man has progressive dyspnea and bilateral hilar lymphadenopathy on chest radiography. Biopsy shows noncaseating granulomas. Which finding on physical examination is most consistent with this disease?

  1. Erythema nodosum on the shins Correct answer.
  2. Osler nodes
  3. Janeway lesions
  4. Koilonychia

Explanation

Sarcoidosis causes noncaseating granulomas and bilateral hilar adenopathy and can produce erythema nodosum as a reactive skin finding. The other findings are unrelated to sarcoidosis.

Question 18Internal Medicine

A 33-year-old woman has a blood pressure of 118/76 mmHg, a regular pulse, and a thyroid nodule. TSH is low and free T4 is high. Which finding on radioactive iodine uptake testing most supports a toxic adenoma?

  1. A single area of increased uptake with suppression of the rest of the gland Correct answer.
  2. Multiple areas of increased and decreased uptake
  3. Diffuse homogeneous uptake
  4. Diffusely decreased uptake

Explanation

A toxic adenoma appears as a single hot nodule with suppression of uptake in the surrounding normal thyroid tissue. Diffuse uptake suggests Graves disease, and low uptake suggests thyroiditis.

Question 19Internal Medicine

Which electrocardiographic finding is most consistent with hyperkalemia?

  1. Delta waves
  2. Prolonged QT interval
  3. U waves
  4. Peaked T waves Correct answer.

Explanation

Hyperkalemia produces tall, peaked, narrow-based T waves and can progress to widened QRS complexes and sine-wave patterns. U waves suggest hypokalemia, and delta waves indicate pre-excitation.

Question 20Internal Medicine

A 60-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 3. Which therapy is most appropriate for stroke prevention?

  1. Aspirin alone
  2. No antithrombotic therapy
  3. Oral anticoagulation Correct answer.
  4. Dual antiplatelet therapy

Explanation

A CHA2DS2-VASc score of 2 or higher in men warrants oral anticoagulation to prevent cardioembolic stroke. Antiplatelet monotherapy is inferior to anticoagulation for atrial fibrillation.

Question 21Internal Medicine

A 68-year-old man has a hemoglobin of 9 g/dL, an MCV of 105 fL, and a history of chronic alcohol use. Which laboratory finding would best confirm the suspected vitamin deficiency?

  1. Low reticulocyte count
  2. Elevated methylmalonic acid Correct answer.
  3. Low homocysteine
  4. Elevated ferritin

Explanation

Elevated methylmalonic acid is a sensitive marker of vitamin B12 deficiency and helps distinguish it from folate deficiency, in which methylmalonic acid is normal. Homocysteine is elevated in both deficiencies.

Question 22Internal Medicine

A 22-year-old man has a blood pressure of 160/100 mmHg, episodic headache, palpitations, and diaphoresis. Which test is the most appropriate initial screen for pheochromocytoma?

  1. Aldosterone-to-renin ratio
  2. Plasma free metanephrines Correct answer.
  3. Plasma renin activity
  4. Serum cortisol

Explanation

Plasma free metanephrines are the most sensitive initial biochemical test for pheochromocytoma. The other tests evaluate different causes of secondary hypertension.

Question 23Internal Medicine

A 48-year-old woman has a serum calcium of 11.8 mg/dL, a low phosphate, and an elevated parathyroid hormone level. Which finding is most likely on further evaluation?

  1. Bilateral adrenal hyperplasia
  2. A parathyroid adenoma Correct answer.
  3. Medullary thyroid carcinoma
  4. A pituitary macroadenoma

Explanation

Primary hyperparathyroidism, most often caused by a single parathyroid adenoma, produces hypercalcemia with elevated PTH and low phosphate. The other options relate to different endocrine syndromes.

Question 24Internal Medicine

A 55-year-old man with a history of alcohol use presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be given immediately in addition to thiamine?

  1. Intravenous magnesium
  2. Intravenous glucose Correct answer.
  3. Intramuscular vitamin B12
  4. Oral folate

Explanation

Wernicke encephalopathy requires prompt thiamine, and glucose should be given after or together with thiamine to correct hypoglycemia without precipitating or worsening the deficiency state. Folate, magnesium, and B12 do not treat the acute syndrome.

Question 25Internal Medicine

A 62-year-old man has progressive dyspnea, a history of asbestos exposure, and a pleural mass with pleural thickening. Which finding is most consistent with a malignant mesothelioma?

  1. Elevated chromogranin A
  2. Elevated alpha-fetoprotein
  3. Elevated CA 19-9
  4. Elevated mesothelin Correct answer.

Explanation

Soluble mesothelin-related peptides are elevated in malignant mesothelioma and can support the diagnosis in the appropriate clinical setting. The other markers are associated with different tumors.

Question 26Internal Medicine

A 58-year-old man with a history of myocardial infarction presents with sudden-onset severe tearing chest pain radiating to the back. Blood pressure is 180/100 mmHg in the right arm and 140/90 mmHg in the left arm. Which is the most appropriate initial diagnostic study?

  1. Electrocardiography
  2. Transthoracic echocardiography
  3. Chest radiography
  4. Contrast-enhanced computed tomography of the chest Correct answer.

Explanation

The clinical picture of sudden tearing chest pain with interarm blood pressure difference suggests aortic dissection. Contrast-enhanced CT of the chest is the preferred initial imaging study in stable patients because it rapidly visualizes the aorta and can identify the intimal flap and extent of dissection. It is widely available and highly sensitive and specific.

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 finding is most characteristic of her condition?

  1. Elevated thyroid-stimulating hormone and low free thyroxine Correct answer.
  2. Elevated thyroid-stimulating hormone and elevated free thyroxine
  3. Suppressed thyroid-stimulating hormone and elevated free thyroxine
  4. Suppressed thyroid-stimulating hormone and low free thyroxine

Explanation

The symptoms and signs suggest primary hypothyroidism, most commonly due to Hashimoto thyroiditis. In primary hypothyroidism, the thyroid gland fails to produce adequate thyroxine, leading to elevated TSH due to loss of negative feedback and low free T4. This pattern confirms the diagnosis.

Question 28Internal Medicine

A 68-year-old man with a history of heart failure with reduced ejection fraction (ejection fraction 30%) is admitted with worsening dyspnea and edema. He is currently on furosemide, lisinopril, and carvedilol. Which additional medication has been shown to reduce mortality in this condition?

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

Explanation

Spironolactone, a mineralocorticoid receptor antagonist, has been shown to reduce mortality in patients with heart failure with reduced ejection fraction. It is recommended for patients with NYHA class II-IV symptoms and an ejection fraction ≤35% despite optimal therapy. Close monitoring of potassium and renal function is required.

Question 29Internal Medicine

A 30-year-old woman presents with recurrent episodes of severe abdominal pain, dark urine, and muscle weakness. She reports that her urine turns dark after exposure to sunlight. Which enzyme deficiency is most likely responsible for her symptoms?

  1. Pyruvate kinase
  2. Porphobilinogen deaminase Correct answer.
  3. Glucose-6-phosphate dehydrogenase
  4. Uroporphyrinogen decarboxylase

Explanation

The combination of recurrent abdominal pain, dark urine, and photosensitivity suggests acute intermittent porphyria, which is caused by a deficiency of porphobilinogen deaminase (also called hydroxymethylbilane synthase). This enzyme deficiency leads to accumulation of porphyrin precursors, which can cause neurovisceral symptoms and dark urine. Sunlight exposure can trigger symptoms due to photosensitivity.

Question 30Internal Medicine

A 72-year-old man is brought to the emergency department with sudden onset of right-sided weakness and difficulty speaking. Symptoms began 1 hour ago. Noncontrast head CT shows no hemorrhage. Which is the most appropriate next step in management?

  1. Administer intravenous alteplase Correct answer.
  2. Obtain magnetic resonance imaging of the brain
  3. Perform carotid endarterectomy
  4. Start aspirin

Explanation

The patient presents with acute ischemic stroke within the therapeutic window (within 4.5 hours of symptom onset) and no contraindications. Intravenous alteplase is recommended for eligible patients to improve functional outcomes. Blood pressure must be controlled and bleeding risks assessed before administration.

Question 31Internal Medicine

A 25-year-old man presents with a 2-week history of bloody diarrhea, abdominal cramping, and tenesmus. He has not traveled recently and has no sick contacts. Which finding on colonoscopy is most characteristic of his likely condition?

  1. Pseudomembranes adherent to the mucosa
  2. Skip lesions with deep ulcers
  3. Transmural inflammation with granulomas
  4. Continuous mucosal inflammation from the rectum Correct answer.

Explanation

The presentation is typical of ulcerative colitis, which characteristically involves continuous inflammation of the colonic mucosa starting from the rectum and extending proximally. This pattern helps distinguish it from Crohn disease, which often has skip lesions and transmural inflammation.

Question 32Internal Medicine

A 55-year-old woman with a history of hypertension and diabetes presents with a 2-day history of fever, flank pain, and dysuria. Urinalysis shows pyuria and bacteriuria. She is hemodynamically stable and tolerating oral intake. Which is the most appropriate initial antibiotic regimen?

  1. Oral amoxicillin
  2. Intravenous ceftriaxone
  3. Oral nitrofurantoin
  4. Oral ciprofloxacin Correct answer.

Explanation

The patient has acute pyelonephritis and is stable for outpatient management. Oral ciprofloxacin is a fluoroquinolone with good renal tissue penetration and is recommended as an outpatient regimen for pyelonephritis in areas with low resistance. Nitrofurantoin does not achieve adequate renal tissue levels and should not be used for pyelonephritis.

Question 33Internal Medicine

A 60-year-old man with chronic obstructive pulmonary disease (COPD) presents with worsening dyspnea and increased sputum purulence. He is afebrile with a respiratory rate of 24/min and oxygen saturation of 88% on room air. Chest radiography shows hyperinflation without infiltrates. Which is the most appropriate initial management?

  1. Intravenous diuretics
  2. Noninvasive positive pressure ventilation
  3. Inhaled short-acting beta-agonist and systemic corticosteroids Correct answer.
  4. Oral antibiotics

Explanation

The patient has an acute exacerbation of COPD, characterized by worsening dyspnea and increased sputum. First-line management includes inhaled short-acting bronchodilators and a short course of systemic corticosteroids to reduce inflammation and improve lung function. Antibiotics are indicated when there is increased sputum purulence, but the question asks for initial management; bronchodilators and steroids are the cornerstone.

Question 34Internal Medicine

A 35-year-old man presents with a 3-week history of progressive weakness, numbness, and tingling in his legs that has ascended to his arms. He had a diarrheal illness 2 weeks ago. Physical examination reveals symmetric weakness and areflexia. Which is the most likely diagnosis?

  1. Polio
  2. Myasthenia gravis
  3. Guillain-Barré syndrome Correct answer.
  4. Multiple sclerosis

Explanation

The patient has a classic presentation of Guillain-Barré syndrome (GBS), an acute inflammatory demyelinating polyradiculoneuropathy. It often follows a gastrointestinal infection, such as Campylobacter jejuni, and presents with ascending symmetric weakness and areflexia. The diagnosis is supported by cerebrospinal fluid showing albuminocytologic dissociation and nerve conduction studies.

Question 35Internal Medicine

A 50-year-old woman presents with a 2-month history of progressive dyspnea on exertion, dry cough, and fatigue. She has a history of Raynaud phenomenon and skin thickening on her fingers. Chest examination reveals fine crackles at both bases. High-resolution CT of the chest shows bilateral interstitial fibrosis and honeycombing. Which is the most likely underlying diagnosis?

  1. Systemic lupus erythematosus
  2. Dermatomyositis
  3. Systemic sclerosis Correct answer.
  4. Rheumatoid arthritis

Explanation

The combination of Raynaud phenomenon, skin thickening (sclerodactyly), and interstitial lung disease is characteristic of systemic sclerosis (scleroderma). The interstitial lung disease in systemic sclerosis is typically a nonspecific interstitial pneumonia or usual interstitial pneumonia pattern, leading to fibrosis and honeycombing. This is a common and serious pulmonary complication.

Question 36Internal Medicine

A 65-year-old man with a history of hypertension and diabetes presents with a 1-week history of progressive confusion and lethargy. His medications include hydrochlorothiazide and lisinopril. Laboratory studies show sodium 120 mEq/L, potassium 3.5 mEq/L, and serum osmolality 260 mOsm/kg. Which is the most appropriate initial step in management?

  1. Stop hydrochlorothiazide Correct answer.
  2. Fluid restriction
  3. Start demeclocycline
  4. Administer hypertonic saline

Explanation

The patient has hyponatremia likely due to thiazide diuretic use, a common cause of hypovolemic or euvolemic hyponatremia. The first step is to discontinue the offending agent. If the patient is symptomatic but not seizing, cautious correction with isotonic saline may be considered, but stopping the diuretic is essential.

Question 37Surgery

A 24-year-old man has sudden right testicular pain of 4 hours' duration, a high-riding testis with an absent cremasteric reflex, and no relief with elevation. What is the most appropriate immediate next step in management?

  1. Scrotal ultrasound before any intervention
  2. Urgent scrotal exploration Correct answer.
  3. Trial of antibiotics and analgesia
  4. Elective referral to urology in 1 week

Explanation

Testicular torsion is a surgical emergency in which testicular salvage is time-dependent; detorsion and fixation should occur within roughly 6 hours of symptom onset. When the clinical picture is convincing, imaging must not delay exploration. Doppler ultrasound is useful only when the diagnosis is genuinely uncertain and should not postpone surgery.

Question 38Surgery

Which finding most strongly suggests that a patient's acute abdominal pain requires surgical rather than conservative management?

  1. Pain that migrates to the left lower quadrant over 24 hours
  2. Diffuse cramping pain with hyperactive bowel sounds
  3. Pain relieved by vomiting
  4. Pain that is worse on movement and associated with involuntary guarding Correct answer.

Explanation

Involuntary guarding with movement-related pain reflects parietal peritoneal irritation, a sign of established peritonitis that usually requires operative evaluation. Vomiting that relieves pain and hyperactive bowel sounds suggest a simple obstructive or colicky process that may be managed conservatively at first.

Question 39Surgery

A patient sustains a stab wound to the anterior abdomen with omentum protruding. The patient is hemodynamically stable. How should the eviscerated omentum be managed in the emergency department?

  1. Replace the omentum into the abdomen and observe
  2. Clamp the omentum at its base and refer to outpatient surgery
  3. Apply a dry gauze and discharge with wound care instructions
  4. Cover with a sterile saline-moistened dressing and proceed to laparotomy Correct answer.

Explanation

Evisceration is an indication for laparotomy because it implies violation of the peritoneal cavity. The eviscerated tissue should be kept moist and covered with a sterile dressing while the patient is prepared for the operating room. Attempting to reduce the contents or applying clamps risks contamination and ischemia.

Question 40Surgery

Which is the most common cause of mechanical small bowel obstruction in an adult who has never had abdominal surgery?

  1. Gallstone ileus
  2. Malignancy
  3. Hernia Correct answer.
  4. Adhesions

Explanation

In patients without prior laparotomy, an external hernia is the leading cause of small bowel obstruction and must be sought on examination of the groin. Adhesions predominate overall but are largely confined to patients with previous abdominal operations.

Question 41Surgery

A 55-year-old woman has a 2 cm freely mobile mass in the upper outer quadrant of the breast. Which feature on history most warrants urgent triple assessment?

  1. A fixed, hard mass with skin dimpling Correct answer.
  2. Clear discharge from multiple ducts on squeezing
  3. Cyclical tenderness related to menses
  4. Bilateral diffuse lumpiness

Explanation

A hard, fixed mass with skin tethering suggests malignancy and requires clinical examination, imaging, and tissue sampling. Benign fibrocystic changes typically produce cyclical, bilateral symptoms without fixation or skin changes.

Question 42Surgery

Which is the most appropriate initial fluid resuscitation for an adult with hypovolemic shock from a bleeding duodenal ulcer?

  1. Immediate infusion of 5% dextrose
  2. Hypertonic saline infusion
  3. Oral rehydration with water
  4. Rapid infusion of isotonic crystalloid with blood products as needed Correct answer.

Explanation

Hypovolemic shock is treated with rapid isotonic crystalloid and early blood product transfusion to restore perfusion and oxygen-carrying capacity. Hypertonic saline and dextrose do not restore circulating volume effectively and may worsen hyperglycemia or osmolar shifts.

Question 43Surgery

Which is the most reliable clinical sign of adequate resuscitation after major trauma?

  1. Warm extremities alone
  2. Normalization of blood pressure alone
  3. Urine output of at least 0.5 mL/kg/h with improving mentation Correct answer.
  4. A rise in hematocrit

Explanation

Adequate resuscitation is judged by end-organ perfusion, reflected in urine output, mentation, and capillary refill. Blood pressure can be maintained by vasoconstriction despite ongoing hypoperfusion, and hematocrit falls only slowly with acute hemorrhage.

Question 44Surgery

A patient has a clean laceration of the forearm sustained 10 hours ago. Which factor most increases the risk of wound infection?

  1. Wound length of 3 cm
  2. Presence of devitalized tissue and foreign material Correct answer.
  3. Location on the extensor surface
  4. Suturing within 6 hours of injury

Explanation

Devitalized tissue and foreign material create an environment that supports bacterial proliferation and impair host defenses, markedly raising infection risk. Time to closure, wound length, and location are less influential than the degree of contamination and tissue viability.

Question 45Surgery

A 68-year-old man has painless gross hematuria. Which investigation is essential in the initial evaluation?

  1. Cystoscopy with upper tract imaging Correct answer.
  2. Renal biopsy
  3. Serum prostate-specific antigen only
  4. Urine cytology alone

Explanation

Painless gross hematuria in an older adult requires exclusion of urothelial malignancy with cystoscopy and imaging of the upper urinary tract. Cytology and PSA alone cannot exclude bladder or renal tumors.

Question 46Surgery

A patient develops fever, tachycardia, and a rigid abdomen on the third postoperative day after a laparotomy. What is the most appropriate next step?

  1. Nasogastric decompression alone
  2. Observation with serial examinations
  3. Immediate re-exploration Correct answer.
  4. Oral antibiotics and early discharge

Explanation

Rigid abdomen with fever and tachycardia after laparotomy suggests an acute surgical complication such as anastomotic leak or perforation, which requires urgent re-exploration. Observation or nonoperative measures risk progression to sepsis and death.

Question 47Surgery

Which statement about the management of a patient with a 4 cm abdominal aortic aneurysm is correct?

  1. Regular ultrasound surveillance is appropriate Correct answer.
  2. Surgical repair is indicated at this size
  3. Anticoagulation prevents rupture
  4. Immediate thrombolysis is indicated

Explanation

Elective repair is generally offered for abdominal aortic aneurysms of about 5.5 cm or larger, or when growth is rapid or symptoms develop. Smaller aneurysms are managed with surveillance imaging and risk factor modification.

Question 48Surgery

A 40-year-old man has a 6-hour history of a painful, tender, irreducible groin lump with vomiting. What is the most appropriate management?

  1. Application of a truss
  2. Ultrasound and outpatient follow-up
  3. Urgent surgical exploration Correct answer.
  4. Attempted reduction under sedation and discharge

Explanation

An irreducible, tender hernia with vomiting suggests strangulation or incarceration and requires urgent operative repair. Attempting reduction under sedation risks reducing ischemic bowel into the abdomen and delaying diagnosis.

Question 49Surgery

Which finding on arterial blood gas is most consistent with early septic shock?

  1. Metabolic acidosis with normal anion gap and normal lactate
  2. Metabolic acidosis with a raised lactate Correct answer.
  3. Respiratory alkalosis with normal lactate
  4. Metabolic alkalosis with hypercapnia

Explanation

Septic shock produces lactic acidosis from tissue hypoperfusion and anaerobic metabolism, with a raised anion gap. Early compensation may show respiratory alkalosis, but the lactate elevation is the key surgical concern.

Question 50Surgery

A patient with a suspected perforated peptic ulcer has free air on an erect chest radiograph. Which is the most appropriate initial surgical management?

  1. Conservative management with nasogastric tube and antibiotics
  2. Partial gastrectomy
  3. Laparoscopic omental patch repair Correct answer.
  4. Immediate total gastrectomy

Explanation

A perforated peptic ulcer is typically managed with omental patch repair, peritoneal lavage, and acid suppression, often laparoscopically. Resection is reserved for suspicion of malignancy or other specific indications.