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Question 1Internal Medicine

A 58-year-old man with a 20-pack-year smoking history presents with progressive dyspnea and a chronic productive cough. Chest examination reveals a barrel-shaped chest and prolonged expiration. Which pulmonary function pattern is most consistent with his likely diagnosis?

  1. Isolated reduction in diffusing capacity with normal spirometry
  2. Reversible airflow obstruction with a 25% improvement in FEV1 after bronchodilator
  3. Obstructive pattern with reduced FEV1/FVC ratio and increased residual volume Correct answer.
  4. Restrictive pattern with reduced FVC and normal FEV1/FVC ratio

Explanation

Chronic obstructive pulmonary disease produces airflow limitation with a reduced FEV1/FVC ratio, air trapping, and increased residual volume. The smoking history, barrel chest, and prolonged expiration all fit an obstructive physiology. Restrictive disease preserves or raises the ratio, and isolated diffusion defects are not the primary spirometric finding.

Question 2Internal Medicine

Which finding on physical examination is most characteristic of a patient with decompensated right-sided heart failure?

  1. Displaced apical impulse with a loud S3
  2. Raised jugular venous pressure with hepatojugular reflux Correct answer.
  3. Pulsus paradoxus
  4. Bilateral basilar crackles

Explanation

Right heart failure raises central venous pressure, producing jugular venous distension and a positive hepatojugular reflux. Peripheral edema and hepatomegaly accompany these findings. Basilar crackles and an S3 reflect left-sided failure, and pulsus paradoxus suggests tamponade or severe obstructive disease.

Question 3Internal Medicine

A 24-year-old woman reports episodic wheezing, chest tightness, and cough that worsen at night and after exercise. Spirometry shows a 15% and 200 mL increase in FEV1 after inhaled salbutamol. What is the most appropriate initial maintenance therapy?

  1. Long-acting beta-agonist monotherapy
  2. Oral theophylline
  3. Oral prednisolone daily
  4. Inhaled low-dose corticosteroid Correct answer.

Explanation

The history and demonstrated bronchodilator reversibility support asthma. Inhaled corticosteroids are the cornerstone of maintenance therapy because they control airway inflammation and reduce exacerbations. Long-acting beta-agonists must not be used as monotherapy in asthma due to safety concerns.

Question 4Internal Medicine

A 45-year-old man has a fasting plasma glucose of 7.8 mmol/L on two occasions. He is asymptomatic. What is the correct diagnosis?

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

Explanation

A fasting plasma glucose of 7.0 mmol/L or higher on two separate occasions establishes the diagnosis of diabetes mellitus, even without symptoms. Impaired fasting glucose corresponds to 5.6 to 6.9 mmol/L. Values below 5.6 mmol/L are normal.

Question 5Internal Medicine

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

  1. T-wave inversion
  2. Pathologic Q waves
  3. ST-segment elevation in contiguous leads Correct answer.
  4. Peaked T waves with a shortened QT interval

Explanation

ST-segment elevation in anatomically contiguous leads reflects acute transmural injury and is the key finding that triggers reperfusion therapy. Pathologic Q waves develop later and indicate established necrosis. T-wave inversion is a nonspecific or later change.

Question 6Internal Medicine

A 30-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. Examination shows dry skin, bradycardia, and delayed relaxation of the deep tendon reflexes. Which laboratory pattern is expected?

  1. Low TSH and low free T4
  2. High TSH and low free T4 Correct answer.
  3. High TSH and high free T4
  4. Low TSH and high free T4

Explanation

The clinical picture is classic for primary hypothyroidism. In primary thyroid failure the gland cannot produce adequate hormone, so free T4 falls and pituitary TSH rises in compensation. The delayed relaxation phase of reflexes is a characteristic sign.

Question 7Internal Medicine

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

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

Explanation

Streptococcus pneumoniae remains the most frequently identified cause of community-acquired pneumonia in adults. It typically presents with abrupt fever, pleuritic chest pain, and lobar consolidation. The other organisms are less common causes.

Question 8Internal Medicine

A 62-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. He has no contraindications to anticoagulation. Which therapy is most appropriate for stroke prevention?

  1. Oral anticoagulation with warfarin or a direct oral anticoagulant Correct answer.
  2. No antithrombotic therapy
  3. Clopidogrel 75 mg daily
  4. Aspirin 81 mg daily

Explanation

A CHA2DS2-VASc score of 2 or higher in men warrants oral anticoagulation to reduce cardioembolic stroke risk. Antiplatelet therapy is inadequate for atrial fibrillation stroke prophylaxis. Direct oral anticoagulants are preferred over warfarin in most eligible patients.

Question 9Internal Medicine

A 55-year-old man presents with sudden severe epigastric pain radiating to the back, vomiting, and elevated serum lipase three times the upper limit of normal. Which is the most common cause of this condition in developed countries?

  1. Hypertriglyceridemia
  2. Gallstones Correct answer.
  3. Endoscopic retrograde cholangiopancreatography
  4. Alcohol abuse

Explanation

Gallstones and alcohol account for the majority of acute pancreatitis cases, with gallstones being the most common cause in developed countries. The presentation with epigastric pain radiating to the back and markedly elevated lipase is characteristic. Hypertriglyceridemia and post-ERCP injury are less frequent causes.

Question 10Internal Medicine

A 68-year-old woman with type 2 diabetes and hypertension has an eGFR of 32 mL/min/1.73 m² and an albumin-to-creatinine ratio of 450 mg/g. Which medication class slows progression of her chronic kidney disease?

  1. Loop diuretics
  2. Angiotensin-converting enzyme inhibitors Correct answer.
  3. Alpha-1 blockers
  4. Calcium channel blockers

Explanation

Angiotensin-converting enzyme inhibitors reduce intraglomerular pressure and slow progression of diabetic nephropathy with proteinuria. They are indicated in patients with albuminuria and reduced eGFR, with monitoring of potassium and creatinine. Loop diuretics and calcium channel blockers manage volume and pressure but do not specifically slow renal decline.

Question 11Internal Medicine

A 70-year-old man has a hemoglobin of 9.8 g/dL, MCV of 72 fL, and a ferritin of 8 ng/mL. Which finding on history is most likely to explain these results?

  1. Vegetarian diet
  2. Recurrent epistaxis
  3. Colorectal carcinoma Correct answer.
  4. Chronic kidney disease

Explanation

The microcytic anemia with a very low ferritin confirms iron deficiency. In an older man, iron deficiency must be assumed to result from chronic gastrointestinal blood loss until proven otherwise, and colorectal carcinoma is a key concern. Dietary insufficiency rarely causes such profound deficiency in this demographic.

Question 12Internal Medicine

A 35-year-old man presents with a 3-week history of fever, night sweats, weight loss, and a nonproductive cough. Chest radiograph shows right upper lobe infiltrates with hilar adenopathy. He recently emigrated from a high-prevalence region. Which diagnostic test is most appropriate?

  1. Acid-fast bacilli smear and culture of sputum Correct answer.
  2. Serology for Mycoplasma pneumoniae
  3. Sputum Gram stain and culture
  4. Blood cultures for bacteria

Explanation

The subacute course, constitutional symptoms, upper lobe infiltrates, and hilar adenopathy suggest pulmonary tuberculosis. Acid-fast bacilli smear and culture are the appropriate initial microbiological tests, along with nucleic acid amplification testing. Routine bacterial cultures would not detect mycobacteria.

Question 13Internal Medicine

A 60-year-old woman with a history of hypertension presents with sudden-onset severe headache described as the worst of her life. Non-contrast head CT is normal. What is the next most appropriate step?

  1. Reassurance and outpatient follow-up
  2. Start thrombolytic therapy
  3. MRI of the brain without contrast
  4. Lumbar puncture for xanthochromia Correct answer.

Explanation

A thunderclap headache raises concern for subarachnoid hemorrhage, and CT sensitivity declines with time from symptom onset. If CT is negative and suspicion remains high, lumbar puncture looking for xanthochromia is indicated, typically at least 12 hours after onset. Reassurance would risk missing a potentially fatal diagnosis.

Question 14Internal Medicine

Which feature most reliably distinguishes ulcerative colitis from Crohn disease?

  1. Fistula formation
  2. Skip lesions
  3. Presence of perinuclear antineutrophil cytoplasmic antibodies Correct answer.
  4. Transmural inflammation

Explanation

Ulcerative colitis is associated with perinuclear antineutrophil cytoplasmic antibodies, whereas Crohn disease more often shows anti-Saccharomyces cerevisiae antibodies. Transmural inflammation, skip lesions, and fistulae are features of Crohn disease. Continuous mucosal inflammation confined to the colon characterizes ulcerative colitis.

Question 15Internal Medicine

A 48-year-old man with cirrhosis presents with confusion, asterixis, and a serum ammonia of 120 µmol/L. He has been constipated for five days. Which initial treatment is most appropriate?

  1. Protein restriction to 20 g per day
  2. Lactulose titrated to two to three soft stools daily Correct answer.
  3. Intravenous flumazenil
  4. Oral neomycin as monotherapy

Explanation

Lactulose is first-line therapy for hepatic encephalopathy; it acidifies the colon, traps ammonia, and acts as a laxative to correct constipation. Treatment is titrated to two to three soft stools per day. Routine severe protein restriction is no longer recommended because it worsens malnutrition.

Question 16Internal Medicine

A 65-year-old man has an acute gout flare in the first metatarsophalangeal joint. He has stage 4 chronic kidney disease. Which treatment is most appropriate for the acute attack?

  1. Oral colchicine at reduced dose Correct answer.
  2. Probenecid
  3. High-dose intravenous aspirin
  4. Allopurinol started now at full dose

Explanation

Low-dose colchicine, with dose adjustment for renal impairment, is an appropriate option for acute gout when NSAIDs and steroids are unsuitable. In advanced CKD, colchicine must be used cautiously at reduced doses because it is renally cleared. Allopurinol is not started during an acute flare and probenecid is ineffective in significant renal impairment.

Question 17Internal Medicine

A 72-year-old man with known aortic stenosis presents with exertional syncope and angina. Which finding indicates the highest risk and warrants consideration of valve replacement?

  1. An asymptomatic systolic ejection murmur
  2. Left ventricular ejection fraction of 60%
  3. Aortic valve area of 1.6 cm²
  4. Peak aortic jet velocity of 4.5 m/s Correct answer.

Explanation

Severe aortic stenosis is defined by a peak jet velocity of 4.0 m/s or greater, a mean gradient of 40 mm Hg or more, or a valve area of 1.0 cm² or less. Symptomatic severe stenosis is an indication for aortic valve replacement. A velocity of 4.5 m/s therefore identifies severe disease.

Question 18Internal Medicine

A 28-year-old woman presents with a malar rash, photosensitivity, arthralgia, and oral ulcers. Which autoantibody is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity and lupus nephritis. Antinuclear antibody is sensitive but not specific. Anti-histone antibodies are associated with drug-induced lupus.

Question 19Internal Medicine

A 50-year-old man with alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which treatment should be given immediately in addition to thiamine?

  1. Oral folate
  2. Intramuscular vitamin B12
  3. Intravenous magnesium Correct answer.
  4. Intravenous glucose without thiamine

Explanation

The triad of confusion, ataxia, and ophthalmoplegia indicates Wernicke encephalopathy, treated with intravenous thiamine. Magnesium is an essential cofactor for thiamine-dependent enzymes, and hypomagnesemia is common in alcohol use disorder, so magnesium repletion is given concurrently. Glucose should be given only after or with thiamine to avoid precipitating the syndrome.

Question 20Internal Medicine

A 40-year-old woman presents with polyuria, polydipsia, and a serum sodium of 128 mmol/L. Serum osmolality is low, urine osmolality is high, and urine sodium is 60 mmol/L while she is euvolemic. Which is the most likely diagnosis?

  1. Osmotic diuresis
  2. Diabetes insipidus
  3. Primary polydipsia
  4. Syndrome of inappropriate antidiuretic hormone secretion Correct answer.

Explanation

Euvolemic hyponatremia with low serum osmolality, inappropriately concentrated urine, and high urine sodium characterizes SIADH. The kidneys are reabsorbing water despite hypotonic plasma. Diabetes insipidus and osmotic diuresis produce dilute urine, and primary polydipsia typically yields low urine osmolality.

Question 21Internal Medicine

A 65-year-old man has a 10-year history of Parkinson disease with worsening motor fluctuations and dyskinesias despite optimized levodopa. Which option is most appropriate to add?

  1. Prochlorperazine
  2. Metoclopramide
  3. Deep brain stimulation of the subthalamic nucleus Correct answer.
  4. Haloperidol

Explanation

Deep brain stimulation of the subthalamic nucleus or globus pallidus interna is effective for advanced Parkinson disease with motor fluctuations and dyskinesias despite optimized medication. It improves on-time and reduces dyskinesia. Dopamine-blocking antipsychotics and antiemetics can worsen parkinsonism.

Question 22Internal Medicine

A 55-year-old man with no prior cardiac disease has sudden collapse. ECG shows a wide-complex tachycardia at 200 beats per minute with a regular rhythm. He is unresponsive and pulseless. What is the immediate management?

  1. Defibrillation at 200 J
  2. Start chest compressions and follow the cardiac arrest algorithm with defibrillation Correct answer.
  3. Synchronized cardioversion at 100 J
  4. Intravenous adenosine 6 mg

Explanation

A pulseless patient is in cardiac arrest regardless of the underlying rhythm, and management follows the cardiac arrest algorithm with high-quality CPR and defibrillation for shockable rhythms. Synchronized cardioversion requires a pulse and a monitorable QRS. Adenosine is used only in stable narrow-complex tachycardia.

Question 23Internal Medicine

A 30-year-old woman has a platelet count of 25 × 10⁹/L with isolated thrombocytopenia, no schistocytes, and a normal coagulation profile. She has epistaxis and petechiae. Which diagnosis is most likely?

  1. Immune thrombocytopenic purpura Correct answer.
  2. Disseminated intravascular coagulation
  3. Heparin-induced thrombocytopenia
  4. Thrombotic thrombocytopenic purpura

Explanation

Isolated thrombocytopenia with mucocutaneous bleeding and normal coagulation in an otherwise well patient suggests immune thrombocytopenic purpura. DIC and TTP typically show schistocytes and abnormal coagulation or hemolysis. Heparin-induced thrombocytopenia causes thrombosis rather than bleeding.

Question 24Internal Medicine

A 68-year-old man has a 40-pack-year smoking history and a 4 cm peripheral lung mass. Biopsy shows small cell carcinoma. Staging reveals disease confined to one hemithorax with ipsilateral hilar nodes. Which treatment approach is standard?

  1. Observation until symptoms develop
  2. Surgical resection followed by adjuvant chemotherapy
  3. Targeted therapy with a tyrosine kinase inhibitor
  4. Concurrent chemoradiotherapy Correct answer.

Explanation

Limited-stage small cell lung cancer is treated with concurrent chemoradiotherapy, often with prophylactic cranial irradiation, because the disease is highly chemosensitive and radiosensitive but rarely resectable. Surgery is generally not standard for small cell carcinoma. Targeted therapies have no established role in small cell disease.

Question 25Internal Medicine

A 45-year-old woman with a known mechanical mitral valve is 10 weeks pregnant. She requires anticoagulation. Which strategy carries the lowest risk of maternal thromboembolism?

  1. Switch to aspirin
  2. Continue warfarin throughout pregnancy
  3. Switch to low-molecular-weight heparin throughout pregnancy Correct answer.
  4. Stop anticoagulation during pregnancy

Explanation

For mechanical heart valves in pregnancy, low-molecular-weight heparin with careful anti-Xa monitoring avoids warfarin embryopathy while providing effective anticoagulation; warfarin carries teratogenic risk, especially in the first trimester. Aspirin is inadequate for mechanical valve prophylaxis. Discontinuation risks valve thrombosis and stroke.

Question 26Internal Medicine

A 58-year-old man with a 30-pack-year smoking history presents with progressive exertional dyspnea. Physical examination reveals a barrel-shaped chest, hyperresonance to percussion, and diminished breath sounds bilaterally. Spirometry after bronchodilator administration shows an FEV1/FVC ratio of 0.55. Which additional spirometric finding is most consistent with this diagnosis?

  1. A reduced diffusing capacity for carbon monoxide Correct answer.
  2. A normal residual volume with restrictive pattern
  3. An increased FEV1/FVC ratio after bronchodilator administration
  4. A reduced total lung capacity with increased elastic recoil

Explanation

Chronic obstructive pulmonary disease produces airflow obstruction with a post-bronchodilator FEV1/FVC below 0.70, and emphysema causes loss of alveolar-capillary surface area, so the diffusing capacity of the lung for carbon monoxide (DLCO) is characteristically reduced. Hyperinflation raises total lung capacity and residual volume rather than lowering them.

Question 27Internal Medicine

A 24-year-old man is brought to the emergency department after a first generalized tonic-clonic seizure. He has no fever, head trauma, or known epilepsy. Serum sodium, calcium, and glucose are normal. Which diagnostic study is most appropriate as the next step in evaluation?

  1. Noncontrast head CT in the emergency department Correct answer.
  2. Electroencephalography within 24 hours
  3. Lumbar puncture for cerebrospinal fluid analysis
  4. MRI of the brain with and without contrast

Explanation

For a first unprovoked seizure in an adult, emergency neuroimaging with noncontrast head CT is recommended to exclude structural causes such as hemorrhage, mass, or stroke, especially when the patient has not returned to baseline. MRI is more sensitive but is typically arranged electively after the acute phase, and lumbar puncture is reserved for suspected infection.

Question 28Internal Medicine

A 66-year-old woman with a history of hypertension and diabetes presents with sudden painless loss of vision in the right eye that began 2 hours ago. Fundoscopic examination shows a pale, milky retina with a cherry-red spot at the macula. Which underlying condition most strongly predisposes to this presentation?

  1. Vitreous hemorrhage
  2. Retinal vein occlusion
  3. Carotid artery atherosclerosis Correct answer.
  4. Acute angle-closure glaucoma

Explanation

Central retinal artery occlusion produces sudden painless monocular vision loss with a pale retina and cherry-red macula, and it is most often caused by an embolus from ipsilateral carotid atherosclerosis or from the heart. The retina becomes opaque because of ischemia, while the fovea retains its red appearance from the underlying choroidal circulation.

Question 29Internal Medicine

A 34-year-old woman is evaluated for episodic palpitations, diaphoresis, and headache. During a symptomatic episode, plasma metanephrines are markedly elevated. A CT scan shows a 4 cm right adrenal mass. After adequate alpha-adrenergic blockade, which is the definitive treatment for this condition?

  1. Initiation of a beta-blocker alone
  2. Laparoscopic adrenalectomy Correct answer.
  3. Radiofrequency ablation of the mass
  4. Long-term glucocorticoid replacement

Explanation

The presentation is consistent with pheochromocytoma, and surgical resection after adequate preoperative alpha-blockade with a drug such as phenoxybenzamine is the definitive treatment. Beta-blockade may be added only after alpha-blockade to control reflex tachycardia, because unopposed beta-blockade can precipitate a hypertensive crisis.

Question 30Internal Medicine

A 47-year-old man with no known liver disease presents with jaundice and right upper quadrant discomfort. Laboratory studies show a total bilirubin of 6.2 mg/dL with a direct fraction of 5.4 mg/dL, an alkaline phosphatase of 620 U/L, and an alanine aminotransferase of 55 U/L. Ultrasound shows a dilated common bile duct but no gallstones. Which finding would best distinguish a malignant from a benign cause of this cholestatic pattern?

  1. Predominantly indirect hyperbilirubinemia
  2. A normal alkaline phosphatase level
  3. A markedly elevated carbohydrate antigen 19-9 with a pancreatic head mass Correct answer.
  4. Marked elevation of alanine aminotransferase

Explanation

A cholestatic pattern with conjugated hyperbilirubinemia, high alkaline phosphatase, and a dilated duct suggests extrahepatic obstruction. A pancreatic head mass with elevated CA 19-9 points toward malignant obstruction, whereas benign causes such as strictures or stones typically lack a mass lesion.

Question 31Surgery

A 24-year-old man sustains a stab wound to the right anterior chest. He is hypotensive and tachycardic, and the right hemithorax is dull to percussion with absent breath sounds. Which finding most strongly indicates that immediate thoracotomy rather than tube thoracostomy alone is required?

  1. Continued air leak through the chest tube for 12 hours
  2. A small residual pneumothorax on the post-procedure radiograph
  3. Subcutaneous emphysema over the right chest wall
  4. Initial drainage of 1,500 mL of blood from the chest tube Correct answer.

Explanation

Massive hemothorax is defined by initial chest tube output of about 1,500 mL or ongoing loss of roughly 200 mL per hour for two to four hours. Such bleeding usually reflects injury to a systemic artery or major pulmonary vessel and requires operative control. Lesser findings such as a persistent air leak or small residual pneumothorax are managed with continued drainage and observation.

Question 32Surgery

In the initial assessment of a trauma patient, which maneuver is most appropriate for opening the airway while protecting the cervical spine?

  1. Hyperextension of the head with a shoulder roll in place
  2. Neck extension over a rolled towel while applying cricoid pressure
  3. Jaw thrust with manual in-line cervical stabilization Correct answer.
  4. Head-tilt with chin lift and no manual stabilization

Explanation

The jaw thrust performed with manual in-line stabilization displaces the mandible anteriorly without extending the cervical spine, making it the preferred airway maneuver in suspected cervical injury. Head-tilt and chin-lift require neck extension and may aggravate an unstable cervical fracture. Cricoid pressure is used to reduce aspiration risk during intubation and is not an airway-opening maneuver.

Question 33Surgery

A 45-year-old woman has a 2 cm firm mass in the tail of the breast with no skin changes and no palpable axillary nodes. Which feature of the mass most determines the need for tissue diagnosis rather than observation?

  1. Size greater than 1 cm with a solid, irregular border Correct answer.
  2. Presence of cyclical tenderness
  3. Association with the menstrual cycle
  4. Bilateral symmetry of the findings

Explanation

A solid, irregular, dominant mass that persists through the menstrual cycle is suspicious for malignancy and requires imaging plus tissue sampling, usually core needle biopsy. Cyclical tenderness and bilateral symmetry favor benign fibrocystic change. A dominant mass in a woman of this age should not be observed on the basis of size alone.

Question 34Surgery

Which patient characteristic is the strongest predictor of mortality in acute pancreatitis and is used in the bedside assessment of severity?

  1. Mild epigastric tenderness without guarding
  2. Presence of systemic inflammatory response with organ dysfunction Correct answer.
  3. Serum amylase level greater than three times normal
  4. Elevated serum lipase alone

Explanation

Severity in acute pancreatitis is driven by systemic inflammation and organ failure, not by enzyme levels. Persistent organ dysfunction beyond 48 hours defines severe disease and predicts mortality. Amylase and lipase elevations confirm the diagnosis but correlate poorly with prognosis.

Question 35Surgery

A 70-year-old man presents with painless jaundice and a palpable, distended, non-tender gallbladder. What is the most likely diagnosis?

  1. Cholecystitis with a palpable inflammatory mass
  2. Choledocholithiasis with acute cholangitis
  3. Carcinoma of the pancreatic head Correct answer.
  4. Acute hepatitis with hepatic enlargement

Explanation

A palpable, non-tender gallbladder in a jaundiced patient is the Courvoisier sign and suggests malignant obstruction of the distal common bile duct, most often pancreatic head carcinoma. Chronic stone disease usually produces a fibrotic, non-distensible gallbladder. Cholangitis and cholecystitis typically present with pain and fever.

Question 36Surgery

A 60-year-old man has a 3 cm abdominal aortic aneurysm found incidentally. Which factor most strongly influences the decision for elective repair?

  1. Presence of mural thrombus on imaging
  2. Patient's serum creatinine level alone
  3. Maximal transverse diameter and rate of expansion Correct answer.
  4. Degree of atherosclerotic calcification

Explanation

Rupture risk in abdominal aortic aneurysm is driven mainly by maximal diameter and rapid expansion; repair is generally considered at about 5.5 cm in men or with growth over 1 cm per year. Mural thrombus and calcification are common and do not by themselves dictate surgery. Renal function affects operative risk but is not the primary trigger for repair.

Question 37Surgery

A patient develops fever, tachycardia, and abdominal pain on the third postoperative day after colorectal resection. Which complication should be suspected first when the abdomen is distended and bowel sounds are absent?

  1. Atelectasis of the left lower lobe
  2. Deep vein thrombosis of the calf
  3. Superficial wound infection
  4. Anastomotic leak with intra-abdominal sepsis Correct answer.

Explanation

Fever with ileus, distension, and tachycardia after colorectal anastomosis should raise concern for anastomotic leak, which typically appears around days three to seven. Leak causes localized or generalized peritonitis and requires urgent imaging and often reoperation. Atelectasis and wound infection usually produce less systemic derangement and no ileus.

Question 38Surgery

Which finding is most consistent with a diagnosis of acute appendicitis in a young adult?

  1. Periumbilical pain that migrates to the right lower quadrant with localized rebound tenderness Correct answer.
  2. Diffuse cramping pain relieved by defecation
  3. Painless jaundice with dark urine
  4. Right upper quadrant pain radiating to the shoulder

Explanation

Appendicitis classically begins with vague periumbilical pain from visceral afferents and migrates to the right lower quadrant as parietal peritoneum becomes inflamed, producing localized rebound tenderness. Pain relieved by defecation suggests a colonic disorder. Right upper quadrant pain radiating to the shoulder suggests biliary disease.

Question 39Surgery

A 30-year-old man has a reducible inguinal hernia that passes lateral to the inferior epigastric vessels. What is the correct classification?

  1. Indirect inguinal hernia Correct answer.
  2. Femoral hernia
  3. Direct inguinal hernia
  4. Obturator hernia

Explanation

An indirect inguinal hernia traverses the deep inguinal ring lateral to the inferior epigastric vessels and follows the spermatic cord. Direct hernias protrude medial to those vessels through Hesselbach's triangle. Femoral hernias emerge below the inguinal ligament, and obturator hernias pass through the obturator canal.

Question 40Surgery

A 55-year-old woman has a solitary thyroid nodule. Which finding on fine-needle aspiration most strongly indicates the need for thyroidectomy?

  1. Suspicious cytology with nuclear grooves and pseudoinclusions Correct answer.
  2. Colloid-rich benign follicular cells
  3. Cyst fluid with hemosiderin-laden macrophages
  4. Abundant inflammatory cells consistent with Hashimoto thyroiditis

Explanation

Nuclear grooves, pseudoinclusions, and powdery chromatin are cytologic features of papillary thyroid carcinoma, which warrants operative management. Colloid-rich aspirates and cyst fluid with macrophages are typical of benign nodules. Lymphocytic inflammation suggests autoimmune thyroiditis rather than malignancy.

Question 41Surgery

Which mechanism best explains the hypocalcemia that can occur after total thyroidectomy?

  1. Removal or devascularization of the parathyroid glands Correct answer.
  2. Reduced intestinal absorption due to vagal injury
  3. Excessive secretion of calcitonin by residual thyroid tissue
  4. Acute renal failure from anesthetic agents

Explanation

Post-thyroidectomy hypocalcemia results from inadvertent removal or ischemic injury of the parathyroids, which normally maintain calcium homeostasis through parathyroid hormone. Calcitonin lowers calcium but is not secreted in sufficient quantity to cause this pattern. Renal failure and malabsorption are not the operative mechanism.

Question 42Surgery

A 65-year-old man has painless gross hematuria. Which initial evaluation is most appropriate?

  1. Renal ultrasound alone
  2. Cystoscopy with upper urinary tract imaging Correct answer.
  3. Urine cytology alone
  4. Empiric antibiotics and repeat urinalysis in six weeks

Explanation

Painless gross hematuria in an older adult requires evaluation for urothelial malignancy with cystoscopy and imaging of the upper tracts, often CT urography. Urine cytology alone lacks sufficient sensitivity to exclude cancer. Ultrasound alone may miss small urothelial lesions, and empiric treatment delays diagnosis.

Question 43Surgery

A 20-year-old man has sudden severe right testicular pain with nausea and a high-riding testis. What is the most appropriate next step?

  1. Scrotal ultrasound after several hours of observation
  2. Immediate scrotal exploration Correct answer.
  3. Antibiotic therapy for epididymitis
  4. Reassurance and outpatient follow-up

Explanation

Testicular torsion is a surgical emergency, and the testis can be salvaged only if detorsion occurs within a few hours. When the clinical picture is highly suggestive, immediate exploration is preferred over imaging that delays surgery. Antibiotics treat epididymitis, which is not the leading concern here.

Question 44Surgery

Which fluid and electrolyte abnormality is most characteristic of a high-output small bowel fistula?

  1. Metabolic alkalosis with hypokalemia
  2. Hypernatremia with volume overload
  3. Hyperkalemia with metabolic acidosis
  4. Hypovolemia with hyponatremia and hypokalemia Correct answer.

Explanation

Small bowel effluent is rich in sodium, potassium, and bicarbonate, so a high-output fistula causes volume depletion with hyponatremia and hypokalemia. Bicarbonate loss can also produce metabolic acidosis. Hyperkalemia and volume overload are not typical of proximal enteric losses.

Question 45Surgery

A 72-year-old woman has a 6 cm ulcerated, non-healing lesion on the lower lip with palpable submental nodes. What is the most likely diagnosis?

  1. Melanoma
  2. Actinic keratosis
  3. Squamous cell carcinoma Correct answer.
  4. Basal cell carcinoma

Explanation

Squamous cell carcinoma of the lip typically arises on the sun-exposed lower lip as an ulcerated lesion and can metastasize to regional lymph nodes. Basal cell carcinoma rarely metastasizes and more often affects the upper lip or nose. Actinic keratosis is a precursor lesion without nodal spread.

Question 46Surgery

Which finding on abdominal examination most strongly suggests generalized peritonitis requiring urgent laparotomy?

  1. Board-like rigidity with rebound tenderness Correct answer.
  2. A soft abdomen with voluntary guarding only
  3. Hyperactive bowel sounds with cramping
  4. Localized tenderness in the right lower quadrant

Explanation

Board-like rigidity with rebound tenderness indicates generalized parietal peritoneal inflammation, often from a perforated viscus, and mandates urgent surgical evaluation. Hyperactive bowel sounds with cramping suggest obstruction rather than peritonitis. Localized tenderness or voluntary guarding alone is less specific.

Question 47Surgery

A 40-year-old woman has a 4 cm firm, mobile thyroid nodule and no compressive symptoms. Fine-needle aspiration is reported as follicular neoplasm. What is the most appropriate management?

  1. Observation with repeat ultrasound in one year
  2. Suppressive levothyroxine therapy
  3. Diagnostic hemithyroidectomy for histologic assessment Correct answer.
  4. Radioactive iodine ablation

Explanation

Cytology cannot distinguish a benign follicular adenoma from follicular carcinoma because the diagnosis depends on capsular or vascular invasion on histology. Diagnostic hemithyroidectomy provides the surgical specimen needed. Radioactive iodine and suppressive therapy are treatments for established disease, not diagnostic steps.

Question 48Surgery

A patient has a 1.5 cm gallstone in the gallbladder but no symptoms. What is the recommended management?

  1. Elective laparoscopic cholecystectomy
  2. Observation without surgery Correct answer.
  3. Endoscopic retrograde cholangiopancreatography
  4. Ursodeoxycholic acid dissolution therapy

Explanation

Asymptomatic cholelithiasis generally does not require cholecystectomy because most patients never develop complications, and observation avoids operative risk. Cholecystectomy is reserved for symptomatic disease or specific high-risk features. ERCP is therapeutic for duct stones, and dissolution therapy has limited durability.

Question 49Surgery

A 62-year-old man has a 5 cm mass in the cecum with no distant metastases. Which operation is most appropriate?

  1. Segmental sigmoid resection
  2. Right hemicolectomy with regional lymphadenectomy Correct answer.
  3. Total colectomy with ileoanal pouch
  4. Local excision with clear margins only

Explanation

Cecal carcinoma is treated with right hemicolectomy and en bloc regional lymphadenectomy to achieve oncologic clearance and staging. Local excision alone is inadequate because it does not address lymph node spread. Sigmoid resection removes the wrong segment, and total colectomy is excessive for a localized right-sided tumor.

Question 50Surgery

A 35-year-old woman has a 3 cm well-differentiated thyroid papillary carcinoma confined to one lobe with no nodal involvement. Which procedure is most appropriate?

  1. Hemithyroidectomy alone
  2. Simple nodule enucleation
  3. Total thyroidectomy Correct answer.
  4. Radioactive iodine ablation without surgery

Explanation

Total thyroidectomy is standard for papillary thyroid carcinoma because it permits radioiodine ablation, enables thyroglobulin surveillance, and addresses multifocal disease. Hemithyroidectomy alone limits the ability to use radioiodine and monitor recurrence. Enucleation is oncologically inadequate because it leaves residual disease.