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OMSB Family Medicine (OEFM) study materials
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OMSB Family Medicine (OEFM) practice questions

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Question 1Adult Medicine (Internal Medicine in the ambulatory setting)

A 58-year-old woman is newly diagnosed with stage 1 hypertension. She has no diabetes, chronic kidney disease, or albuminuria. Which medication class is recommended as first-line initial therapy?

  1. Thiazide-type diuretic Correct answer.
  2. Alpha-1 blocker
  3. Loop diuretic
  4. Direct renin inhibitor

Explanation

Thiazide-type diuretics, ACE inhibitors, ARBs, and dihydropyridine calcium channel blockers are first-line options for uncomplicated hypertension. Loop diuretics are reserved for volume overload or reduced kidney function, alpha-1 blockers are not first-line, and direct renin inhibitors are not preferred initial therapy.

Question 2Adult Medicine (Internal Medicine in the ambulatory setting)

A 64-year-old man with type 2 diabetes has an estimated glomerular filtration rate of 28 mL/min/1.73 m2. He currently takes metformin 1000 mg twice daily. What is the most appropriate action?

  1. Continue the current metformin dose
  2. Stop metformin and select another agent Correct answer.
  3. Reduce metformin to 500 mg daily
  4. Add basal insulin and continue metformin

Explanation

Metformin should be discontinued when the estimated glomerular filtration rate falls below 30 mL/min/1.73 m2 because of the risk of lactic acidosis. Dose reduction is used for an estimated glomerular filtration rate of 30 to 45 mL/min/1.73 m2, and adding another agent does not remove the contraindication.

Question 3Adult Medicine (Internal Medicine in the ambulatory setting)

A 60-year-old man has no clinical atherosclerotic cardiovascular disease or diabetes. His LDL cholesterol is 170 mg/dL and his 10-year atherosclerotic cardiovascular disease risk is 9%. He has already made lifestyle changes. What is the most appropriate next step?

  1. Repeat lipid panel in 5 years
  2. Ezetimibe monotherapy
  3. High-intensity statin therapy
  4. Moderate-intensity statin therapy Correct answer.

Explanation

A 10-year atherosclerotic cardiovascular disease risk of 9% places this patient in the intermediate-risk category, for which moderate-intensity statin therapy is recommended after lifestyle modification. High-intensity statin therapy is reserved for clinical atherosclerotic cardiovascular disease or a 10-year risk of 20% or greater, while ezetimibe is added when LDL goals are not met.

Question 4Adult Medicine (Internal Medicine in the ambulatory setting)

A 74-year-old woman with nonvalvular atrial fibrillation has hypertension and type 2 diabetes. She has no history of stroke, transient ischemic attack, or bleeding. Her CHA2DS2-VASc score is 4. What is the most appropriate stroke prevention strategy?

  1. No antithrombotic therapy
  2. Aspirin 81 mg daily
  3. DOAC anticoagulation Correct answer.
  4. Clopidogrel 75 mg daily

Explanation

Her CHA2DS2-VASc score is 4 because of age 65 to 74 years, hypertension, diabetes, and female sex, which strongly favors oral anticoagulation. A direct oral anticoagulant is preferred over warfarin in nonvalvular atrial fibrillation because it has comparable efficacy with lower intracranial bleeding risk.

Question 5Adult Medicine (Internal Medicine in the ambulatory setting)

A 68-year-old man with chronic obstructive pulmonary disease has persistent dyspnea and infrequent exacerbations. Spirometry confirms moderate airflow obstruction. What is the most appropriate initial maintenance therapy?

  1. Short-acting beta agonist as needed
  2. Inhaled corticosteroid alone
  3. Long-acting bronchodilator Correct answer.
  4. Oral prednisone daily

Explanation

For chronic obstructive pulmonary disease with persistent dyspnea and infrequent exacerbations, a long-acting bronchodilator, either a long-acting muscarinic antagonist or a long-acting beta agonist, is the recommended initial maintenance therapy. Inhaled corticosteroids are not used as monotherapy, oral corticosteroids are not maintenance therapy, and short-acting agents are for rescue use.

Question 6Adult Medicine (Internal Medicine in the ambulatory setting)

A 30-year-old woman with mild asthma uses a short-acting beta agonist more than twice weekly and wakes at night twice monthly. According to current global asthma guidance, which reliever strategy is preferred for adults?

  1. ICS-formoterol as needed Correct answer.
  2. Ipratropium as needed
  3. Oral montelukast daily
  4. Albuterol alone as needed

Explanation

Current global asthma guidance recommends low-dose inhaled corticosteroid-formoterol as the preferred reliever for adults and adolescents because it reduces severe exacerbations compared with short-acting beta agonist-only treatment. Short-acting beta agonist-only therapy is no longer preferred, and montelukast or ipratropium are not reliever strategies.

Question 7Adult Medicine (Internal Medicine in the ambulatory setting)

A 45-year-old woman has a thyroid-stimulating hormone level of 7.2 mIU/L and a normal free thyroxine level. She has no symptoms, is not pregnant, and thyroid peroxidase antibodies are negative. What is the most appropriate management?

  1. Start levothyroxine 50 mcg daily
  2. Repeat TSH in 6 months Correct answer.
  3. Refer for thyroidectomy
  4. Refer for radioiodine ablation

Explanation

Subclinical hypothyroidism with a thyroid-stimulating hormone level between 4 and 10 mIU/L, no symptoms, and negative thyroid peroxidase antibodies can be monitored with repeat thyroid-stimulating hormone testing in 6 to 12 months. Levothyroxine is indicated for symptoms, pregnancy, a thyroid-stimulating hormone level above 10 mIU/L, or positive thyroid peroxidase antibodies; radioiodine and surgery are not appropriate.

Question 8Adult Medicine (Internal Medicine in the ambulatory setting)

A 70-year-old man with chronic kidney disease stage 3b, estimated glomerular filtration rate 35 mL/min/1.73 m2, presents with an acute gout flare. He has no heart failure. Which anti-inflammatory option is most appropriate?

  1. Indomethacin three times daily
  2. Naproxen twice daily
  3. Low-dose colchicine Correct answer.
  4. High-dose aspirin

Explanation

Nonsteroidal anti-inflammatory drugs such as naproxen and indomethacin should be avoided in chronic kidney disease stage 3b because of nephrotoxicity and hyperkalemia risk. Low-dose colchicine with renal dose adjustment is the preferred listed option, and systemic corticosteroids are another alternative when colchicine is unsuitable.

Question 9Adult Medicine (Internal Medicine in the ambulatory setting)

A 26-year-old nonpregnant woman has dysuria and urinary frequency without fever or flank pain. She has normal kidney function. Local Escherichia coli resistance to trimethoprim-sulfamethoxazole is 25%. Which regimen is preferred for uncomplicated cystitis?

  1. Nitrofurantoin 5 days Correct answer.
  2. Amoxicillin 7 days
  3. Ciprofloxacin 7 days
  4. TMP-SMX 3 days

Explanation

When local Escherichia coli resistance to trimethoprim-sulfamethoxazole exceeds 20%, nitrofurantoin for 5 days is a preferred first-line regimen for uncomplicated cystitis. Fluoroquinolones are reserved because of collateral damage and resistance concerns, and amoxicillin has poor efficacy against Escherichia coli.

Question 10Adult Medicine (Internal Medicine in the ambulatory setting)

A 70-year-old woman has completed 5 years of alendronate therapy for osteoporosis. Her bone mineral density has improved, and she has had no fragility fractures. What is the most appropriate next step?

  1. Start raloxifene daily
  2. Continue another 5 years
  3. Bisphosphonate drug holiday Correct answer.
  4. Switch to teriparatide now

Explanation

After 5 years of oral bisphosphonate therapy, a woman at modest fracture risk can enter a drug holiday with reassessment in 2 to 3 years. Continuing for another 5 years is reserved for patients at high fracture risk, and switching to teriparatide or raloxifene is not routine after stable bone mineral density without new fractures.

Question 11Adult Medicine (Internal Medicine in the ambulatory setting)

A 52-year-old man is newly diagnosed with type 2 diabetes. His glycated hemoglobin is 7.8%, estimated glomerular filtration rate is 88 mL/min/1.73 m2, and he has no atherosclerotic cardiovascular disease, heart failure, or chronic kidney disease. He has started lifestyle counseling. Which medication is the most appropriate initial pharmacologic therapy?

  1. Insulin glargine
  2. Metformin Correct answer.
  3. Empagliflozin
  4. Glipizide

Explanation

Metformin is first-line pharmacotherapy for most adults with type 2 diabetes when lifestyle alone is insufficient, provided renal function is adequate. This patient has no ASCVD, heart failure, or CKD that would prioritize an SGLT2 inhibitor or GLP-1 receptor agonist. His A1c is not markedly elevated and he has no catabolic symptoms, so insulin is not required initially.

Question 12Adult Medicine (Internal Medicine in the ambulatory setting)

A 38-year-old woman has had 8 days of nasal congestion. Her symptoms improved initially, but over the past 24 hours she has developed worsening unilateral facial pain, purulent nasal discharge, and temperature 38.6°C. She has no allergies and is otherwise healthy. Which is the most appropriate management?

  1. Intranasal fluticasone alone
  2. Amoxicillin-clavulanate Correct answer.
  3. Oral azithromycin
  4. Observation with intranasal saline irrigation

Explanation

The pattern of initial improvement followed by worsening symptoms is consistent with acute bacterial rhinosinusitis. Amoxicillin-clavulanate is recommended for empiric antibiotic therapy in adults with acute bacterial rhinosinusitis. Saline irrigation or intranasal steroids alone are supportive measures and do not treat bacterial infection.

Question 13Adult Medicine (Internal Medicine in the ambulatory setting)

A 62-year-old man with stage 3 chronic kidney disease (estimated glomerular filtration rate 42 mL/min/1.73 m2) presents with an acutely swollen, painful first metatarsophalangeal joint. Arthrocentesis shows needle-shaped negatively birefringent crystals, and Gram stain and culture are negative. He takes lisinopril and low-dose aspirin. Which is the most appropriate initial treatment for this flare?

  1. Probenecid
  2. Naproxen
  3. High-dose oral colchicine
  4. Intra-articular corticosteroid Correct answer.

Explanation

Intra-articular corticosteroid is effective for acute monoarticular gout and avoids systemic NSAID nephrotoxicity and the need for renal dose adjustment of colchicine. NSAIDs are generally avoided in chronic kidney disease, and high-dose colchicine increases the risk of toxicity in renal impairment. Probenecid is a urate-lowering agent, not a treatment for an acute flare.

Question 14Adult Medicine (Internal Medicine in the ambulatory setting)

A 35-year-old woman reports 2 months of depressed mood, loss of interest, poor sleep, and difficulty concentrating. Her PHQ-9 score is 16, and she denies suicidal ideation. She has no history of mania or psychosis. Which is the most appropriate initial treatment?

  1. Lithium carbonate
  2. Sertraline with CBT Correct answer.
  3. Alprazolam alone
  4. Watchful waiting for 6 weeks

Explanation

A PHQ-9 score of 16 with functional symptoms indicates moderate to severe major depression, for which antidepressant therapy and/or psychotherapy is appropriate. Combined sertraline and cognitive behavioral therapy is an effective initial strategy. Benzodiazepine monotherapy, watchful waiting, and lithium are not appropriate first-line treatments for unipolar depression.

Question 15Adult Medicine (Internal Medicine in the ambulatory setting)

A 48-year-old man has 3 weeks of mechanical low back pain after lifting. He has no leg weakness, bowel or bladder changes, fever, weight loss, or history of cancer. Neurologic examination is normal. Which is the most appropriate next step?

  1. Urgent surgical referral
  2. Plain lumbar radiography
  3. Immediate lumbar MRI
  4. NSAIDs and activity Correct answer.

Explanation

Mechanical low back pain without red flags or neurologic deficits is managed conservatively with NSAIDs and continued activity. Routine imaging within the first 6 weeks is not indicated because it does not improve outcomes and may lead to unnecessary interventions. Urgent surgical referral is reserved for cauda equina syndrome or progressive neurologic deficit.

Question 16Adult Medicine (Internal Medicine in the ambulatory setting)

A 72-year-old woman with heart failure and reduced ejection fraction (35%) is taking lisinopril, carvedilol, and furosemide. Her estimated glomerular filtration rate is 25 mL/min/1.73 m2 and potassium is 5.4 mEq/L. Which additional medication is most appropriate?

  1. Dapagliflozin Correct answer.
  2. Spironolactone
  3. High-dose furosemide
  4. Verapamil

Explanation

SGLT2 inhibitors such as dapagliflozin reduce heart failure hospitalization and cardiovascular death in heart failure with reduced ejection fraction, including in patients with chronic kidney disease. They do not cause hyperkalemia and can be used at an estimated glomerular filtration rate above 20 mL/min/1.73 m2. Spironolactone is contraindicated here because of hyperkalemia.

Question 17Adult Medicine (Internal Medicine in the ambulatory setting)

A 29-year-old woman has 3 episodes per month of unilateral throbbing headache with nausea and photophobia. She has no aura and no cardiovascular disease. Which is the most appropriate acute treatment?

  1. Amitriptyline
  2. Topiramate
  3. Propranolol
  4. Sumatriptan Correct answer.

Explanation

Triptans such as sumatriptan are first-line acute therapy for moderate to severe migraine without cardiovascular contraindications. Propranolol, topiramate, and amitriptyline are preventive medications used when attacks are frequent or disabling, not for immediate abortive treatment.

Question 18Adult Medicine (Internal Medicine in the ambulatory setting)

A 45-year-old man smokes one pack daily and wants to quit. He has no history of depression or seizure. Which medication is most effective as initial monotherapy for smoking cessation?

  1. Bupropion
  2. Clonidine
  3. Nicotine patch
  4. Varenicline Correct answer.

Explanation

Varenicline is a partial nicotinic acetylcholine receptor agonist with superior quit rates compared with nicotine patch or bupropion monotherapy. Bupropion and nicotine replacement are reasonable first-line alternatives, but varenicline is the most effective single agent. Clonidine is a second-line option because of adverse effects.

Question 19Adult Medicine (Internal Medicine in the ambulatory setting)

A 58-year-old man has fatigue. Hemoglobin is 10.2 g/dL, mean corpuscular volume 72 fL, and ferritin 12 ng/mL. He takes no aspirin or NSAIDs and reports no visible bleeding. Which is the most appropriate next step?

  1. Oral iron and repeat in 6 months
  2. H. pylori stool antigen only
  3. Bone marrow biopsy
  4. Colonoscopy and upper endoscopy Correct answer.

Explanation

Iron deficiency anemia in a man older than 50 requires evaluation for gastrointestinal blood loss, even without visible bleeding or symptoms. Colonoscopy and upper endoscopy are recommended to identify a source such as colorectal cancer or peptic ulcer disease. Oral iron alone without source evaluation is inadequate.

Question 20Adult Medicine (Internal Medicine in the ambulatory setting)

A 28-year-old woman who is 8 weeks pregnant has palpitations, heat intolerance, and weight loss. TSH is suppressed, free T4 is elevated, and TSH receptor antibodies are positive. Which is the most appropriate initial treatment?

  1. Propylthiouracil plus propranolol Correct answer.
  2. First-trimester thyroidectomy
  3. Methimazole monotherapy
  4. Radioactive iodine ablation therapy

Explanation

Propylthiouracil is preferred in the first trimester because methimazole is associated with embryopathy. A beta blocker such as propranolol helps control palpitations and tremor. Radioactive iodine is contraindicated in pregnancy, and surgery is generally deferred to the second trimester if needed.

Question 21Child and Adolescent Health (Pediatrics)

A 3-day-old term infant presents with jaundice. Which finding most strongly suggests pathological rather than physiological jaundice?

  1. Mild jaundice limited to the face and sclera
  2. Peak serum bilirubin occurring on day 4 of life
  3. Jaundice within the first 24 hours Correct answer.
  4. Resolution of visible jaundice by day 10 of life

Explanation

Physiological jaundice appears after the first 24 hours, peaks around day 3 to 5 in term infants, and resolves by about 2 weeks. Jaundice visible within 24 hours of birth is always considered pathological and warrants urgent bilirubin measurement and evaluation for hemolysis, sepsis, or congenital infection.

Question 22Child and Adolescent Health (Pediatrics)

Which vaccine is contraindicated in a child with severe combined immunodeficiency (SCID)?

  1. Hepatitis B vaccine
  2. Inactivated poliovirus vaccine
  3. Diphtheria-tetanus-acellular pertussis vaccine
  4. Measles-mumps-rubella vaccine Correct answer.

Explanation

Live attenuated vaccines such as MMR can cause disseminated infection in children with severe combined immunodeficiency and are therefore contraindicated. Inactivated vaccines, including IPV, DTaP, and hepatitis B, do not carry this risk and may be given.

Question 23Child and Adolescent Health (Pediatrics)

A healthy term infant weighs 3.2 kg at birth. By what age would you expect the weight to have approximately doubled?

  1. 5 months Correct answer.
  2. 2 months
  3. 2 weeks
  4. 12 months

Explanation

A healthy term infant typically regains birth weight by 2 weeks and doubles it by about 4 to 5 months. Birth weight is usually tripled by 12 months, so 2 months is too early for doubling.

Question 24Child and Adolescent Health (Pediatrics)

A 2-year-old presents with a first generalized tonic-clonic seizure lasting 3 minutes during a fever of 39°C. He is now alert and has no focal deficits. What is the most appropriate next step?

  1. Start daily phenobarbital to prevent recurrence
  2. Evaluate and treat the source of fever Correct answer.
  3. Perform an immediate lumbar puncture in the emergency department
  4. Reassure the family and discharge without any further assessment

Explanation

This is a simple febrile seizure: generalized, brief, and followed by full recovery without focal signs. Routine lumbar puncture and daily antiseizure prophylaxis are not indicated in a well-appearing vaccinated child; the priority is identifying the fever source and educating caregivers.

Question 25Child and Adolescent Health (Pediatrics)

A 4-year-old with acute otitis media has no penicillin allergy and has not received antibiotics in the past month. What is the first-line antibiotic?

  1. Amoxicillin Correct answer.
  2. Azithromycin
  3. Trimethoprim-sulfamethoxazole
  4. Ciprofloxacin

Explanation

High-dose amoxicillin is first-line for uncomplicated acute otitis media in a child without penicillin allergy because it covers Streptococcus pneumoniae, the most common bacterial pathogen. Alternatives are chosen when there is recent antibiotic exposure, allergy, or treatment failure.

Question 26Child and Adolescent Health (Pediatrics)

A 3-year-old has a barking cough, hoarse voice, and inspiratory stridor that worsened over two days. He is drooling and has a high fever. Which feature most suggests epiglottitis rather than viral croup?

  1. Barking cough
  2. Drooling and high fever Correct answer.
  3. Gradual onset over days
  4. Inspiratory stridor

Explanation

Epiglottitis classically causes acute high fever, drooling, toxic appearance, and a muffled voice, with rapid progression. Viral croup more often produces a barking cough and gradual onset, so drooling with high fever is the most discriminating feature.

Question 27Child and Adolescent Health (Pediatrics)

According to DSM-5 criteria for ADHD, which requirement must be met for diagnosis in a 9-year-old?

  1. Symptoms occur in two or more settings Correct answer.
  2. The child has a full-scale IQ below 70
  3. Symptoms have lasted less than 3 months
  4. Symptoms are present only in the school setting

Explanation

DSM-5 requires several ADHD symptoms before age 12, present in two or more settings, causing impairment, and not better explained by another disorder. Symptoms limited to school or present for only a few months do not meet the criteria.

Question 28Child and Adolescent Health (Pediatrics)

A 15-year-old requests confidential testing for sexually transmitted infection. He is deemed to have capacity and is not at risk of harm. What is the most appropriate response?

  1. Refuse testing until a parent provides consent
  2. Test but inform his parents before results are available
  3. Refer him to adult services without discussion
  4. Provide confidential testing and explain limits of confidentiality Correct answer.

Explanation

Adolescents with capacity can often consent to confidential sexual health testing, and clinicians should explain the limits of confidentiality, such as risk of serious harm or mandatory reporting. Parental consent is not required in this scenario, and disclosure should not occur without the adolescent's agreement.

Question 29Child and Adolescent Health (Pediatrics)

A 4-year-old has fever for 6 days, bilateral conjunctival injection, cracked lips, cervical lymphadenopathy, and a polymorphous rash. Echocardiography shows coronary artery dilation. What is the standard initial treatment?

  1. Intravenous immunoglobulin plus high-dose aspirin Correct answer.
  2. Antibiotics targeting group A streptococcus
  3. Oral corticosteroids alone
  4. Aspirin alone at antiplatelet dose

Explanation

Kawasaki disease is treated with intravenous immunoglobulin 2 g/kg and high-dose aspirin to reduce inflammation and coronary artery complications. Aspirin is later reduced to antiplatelet dosing after defervescence; corticosteroids are not used alone as initial therapy.

Question 30Child and Adolescent Health (Pediatrics)

A 5-day-old presents with poor feeding, tachypnea, and cyanosis. Oxygen saturation is 70% in all limbs and does not improve with supplemental oxygen. Which immediate intervention is most appropriate while awaiting echocardiography?

  1. Start high-flow oxygen and observe
  2. Transfuse packed red blood cells to a hematocrit of 60%
  3. Give intravenous antibiotics for sepsis only
  4. Begin prostaglandin E1 infusion Correct answer.

Explanation

Cyanosis with saturations that do not improve with oxygen in a neonate suggests a duct-dependent congenital heart lesion. Prostaglandin E1 should be started promptly to maintain ductal patency while echocardiography and definitive management are arranged.

Question 31Child and Adolescent Health (Pediatrics)

At what age would a typically developing infant first show a social smile in response to a caregiver's face?

  1. 9 months
  2. 2 weeks
  3. 4 months
  4. 6 weeks Correct answer.

Explanation

A social smile usually appears at 6–8 weeks of age, reflecting early social responsiveness. Smiles before this are often reflexive and not consistently elicited by a face. A 4-month-old may laugh and smile readily, while a 9-month-old may show stranger anxiety.

Question 32Child and Adolescent Health (Pediatrics)

A term newborn is delivered at home, and the parents decline intramuscular vitamin K prophylaxis. Which condition is most likely to occur in the first week without prophylaxis?

  1. Early-onset bacterial sepsis
  2. Vitamin K deficiency bleeding Correct answer.
  3. Transient neonatal hypoglycaemia
  4. Physiological unconjugated jaundice

Explanation

Vitamin K deficiency bleeding can occur in the first week of life in newborns who do not receive vitamin K prophylaxis. Intramuscular vitamin K at birth is recommended for all newborns to prevent this potentially fatal bleeding disorder. Hypoglycaemia, jaundice, and sepsis are unrelated to vitamin K administration.

Question 33Child and Adolescent Health (Pediatrics)

A 2-year-old with acute diarrhoea is alert, has moist mucous membranes, and is drinking normally. What is the most appropriate initial management?

  1. Empirical antibiotics
  2. Immediate intravenous fluid bolus
  3. Oral loperamide
  4. Oral rehydration solution Correct answer.

Explanation

Mild dehydration with normal drinking ability is best treated with oral rehydration solution, which replaces water and electrolytes. Intravenous fluids are reserved for severe dehydration, shock, or inability to drink. Antidiarrhoeals and antibiotics are not routine in uncomplicated acute gastroenteritis.

Question 34Child and Adolescent Health (Pediatrics)

A 7-year-old with asthma uses a short-acting beta-2 agonist two to three times per week and wakes at night twice a month. According to current asthma guidelines, what is the preferred controller therapy?

  1. Long-acting beta-2 agonist alone
  2. Daily oral prednisolone
  3. Montelukast alone
  4. Low-dose inhaled corticosteroid Correct answer.

Explanation

This child has mild persistent asthma with symptoms more than twice a week but not daily. The preferred step 2 controller is a low-dose inhaled corticosteroid, which reduces exacerbations and controls airway inflammation. Long-acting beta-2 agonists are not used as monotherapy in asthma, and oral steroids are for exacerbations.

Question 35Child and Adolescent Health (Pediatrics)

An 11-year-old presents with polyuria, polydipsia, weight loss, and Kussmaul breathing. Capillary glucose is 28 mmol/L and urine ketones are positive. What is the most important initial step in management?

  1. Oral rehydration with glucose
  2. Intravenous isotonic saline Correct answer.
  3. Sodium bicarbonate
  4. Subcutaneous insulin

Explanation

This child has diabetic ketoacidosis, and the initial priority is intravascular volume replacement with isotonic saline. Insulin is started after initial fluid resuscitation, usually as an intravenous infusion, and bicarbonate is avoided unless acidosis is extreme. Oral fluids are unsafe in a child with Kussmaul breathing and possible altered consciousness.

Question 36Child and Adolescent Health (Pediatrics)

A 7-year-old has fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and no cough. A rapid antigen test for group A Streptococcus is positive. What is the treatment of choice?

  1. Ciprofloxacin
  2. Trimethoprim-sulfamethoxazole
  3. Amoxicillin Correct answer.
  4. Azithromycin

Explanation

Penicillin or amoxicillin is first-line therapy for group A streptococcal pharyngitis. Amoxicillin is preferred in children because of palatability and once-daily dosing options. Macrolides are reserved for penicillin allergy, and sulfonamides and fluoroquinolones are not routine first-line agents.

Question 37Child and Adolescent Health (Pediatrics)

A 12-month-old who was exclusively breastfed until 6 months and now eats little solid food is pale. Haemoglobin is 7.5 g/dL with microcytic hypochromic indices. What is the most likely cause?

  1. Thalassaemia trait
  2. Vitamin B12 deficiency
  3. Glucose-6-phosphate dehydrogenase deficiency
  4. Iron deficiency anaemia Correct answer.

Explanation

Iron deficiency is the most common cause of microcytic hypochromic anaemia in infancy, especially with prolonged exclusive breastfeeding and poor iron-rich complementary feeding. Thalassaemia trait also causes microcytosis but is less likely without a family history or ethnic risk. B12 deficiency causes macrocytic anaemia, and G6PD deficiency causes haemolysis.

Question 38Child and Adolescent Health (Pediatrics)

A newborn screening test shows an elevated thyroid-stimulating hormone and a low free thyroxine. What is the most appropriate next step?

  1. Repeat the newborn screen at 2 weeks of age
  2. Start potassium iodide
  3. Levothyroxine after serum confirmation Correct answer.
  4. Observe until 3 months of age

Explanation

An elevated TSH with low free T4 on newborn screening suggests congenital hypothyroidism. Confirmatory serum testing should be done promptly, and levothyroxine should be started without delay to prevent irreversible neurodevelopmental impairment. Iodine is not the treatment, and waiting risks cognitive sequelae.

Question 39Child and Adolescent Health (Pediatrics)

A term newborn is born to a mother with a positive rectovaginal group B Streptococcus culture who received inadequate intrapartum antibiotic prophylaxis. The infant is asymptomatic at 12 hours of age and has no other risk factors. What is the most appropriate management?

  1. Give intramuscular penicillin and discharge at 24 hours
  2. Perform immediate lumbar puncture and start intravenous antibiotics
  3. Discharge home without follow-up
  4. Observe with vital signs for 48 hours Correct answer.

Explanation

For an asymptomatic term infant with maternal GBS colonisation and inadequate prophylaxis but no other risk factors, guidelines recommend observation for 48 hours with monitoring of vital signs and clinical status. A full sepsis evaluation and empiric antibiotics are indicated if the infant becomes symptomatic or has additional risk factors. Prophylactic penicillin is not a treatment for the infant.

Question 40Child and Adolescent Health (Pediatrics)

A 14-year-old presents with 2 months of low mood, loss of interest in activities, insomnia, and declining school performance. He denies suicidal ideation. Which screening tool is most appropriate for depression in this adolescent?

  1. Vanderbilt ADHD rating scale
  2. M-CHAT
  3. PHQ-A Correct answer.
  4. CRAFFT

Explanation

The PHQ-A is a validated adolescent depression screening tool that maps to DSM criteria and is practical in primary care. CRAFFT screens for substance use, the Vanderbilt scale screens for ADHD, and M-CHAT screens for autism in toddlers. A positive screen should prompt a fuller assessment, including suicide risk.

Question 41Women's Health (Obstetrics and Gynecology, including antenatal care)

A 32-year-old woman with no history of abnormal cervical cytology attends for routine cervical cancer screening in a programme that uses cervical cytology alone as the primary test. She has no symptoms and no other risk factors. How often should she be screened?

  1. Every 6 months
  2. Every 10 years
  3. Every 3 years Correct answer.
  4. Only if she develops symptoms

Explanation

When cytology alone is used for average-risk screening, the recommended interval is every 3 years for women aged 21 to 65 years. Programmes using HPV primary testing or cytology-HPV co-testing extend the interval to 5 years. Screening stops after age 65 only when there is an adequate documented record of prior negative results.

Question 42Women's Health (Obstetrics and Gynecology, including antenatal care)

A 28-year-old woman with no personal or family history of neural tube defects is planning her first pregnancy. She takes no regular medication and has a normal body mass index. Which daily folic acid dose should she be advised to start before conception?

  1. 4 mg daily
  2. 40 mg daily
  3. 0.4 mg daily Correct answer.
  4. Folic acid is only needed after a positive pregnancy test

Explanation

Women at average risk of a neural tube defect should take 0.4 mg (400 micrograms) of folic acid daily, starting at least one month before conception and continuing through the first trimester. Higher doses of 4 to 5 mg daily are reserved for women with additional risk such as a previously affected pregnancy, diabetes, obesity or antiepileptic therapy.

Question 43Women's Health (Obstetrics and Gynecology, including antenatal care)

A 26-year-old woman presents with 7 weeks of amenorrhoea, left iliac fossa pain and light vaginal spotting. She has a history of pelvic inflammatory disease. Which diagnosis must be excluded first?

  1. Threatened miscarriage
  2. Physiological vaginal discharge
  3. Ectopic pregnancy Correct answer.
  4. Corpus luteum cyst

Explanation

Any woman of reproductive age with amenorrhoea, abdominal pain and vaginal bleeding must be assumed to have an ectopic pregnancy until excluded, and a history of pelvic inflammatory disease raises that risk further. Rupture causes life-threatening intra-abdominal haemorrhage, so urgent pregnancy testing with transvaginal ultrasound and serial beta-hCG is required.

Question 44Women's Health (Obstetrics and Gynecology, including antenatal care)

A 30-year-old woman at 26 weeks' gestation has a body mass index of 32 kg/m² and no other risk factors. She has not yet been screened for gestational diabetes. Which investigation is most appropriate?

  1. Random capillary glucose at each antenatal visit
  2. 75 g oral glucose tolerance test Correct answer.
  3. Glycated haemoglobin now
  4. Fasting plasma glucose at 28 weeks

Explanation

A 75 g oral glucose tolerance test is the standard diagnostic test for gestational diabetes, offered to all pregnant women not already known to have diabetes, usually at 24 to 28 weeks' gestation. Women with risk factors such as obesity may be tested earlier and retested if the initial result is normal.

Question 45Women's Health (Obstetrics and Gynecology, including antenatal care)

A 34-year-old woman books at 12 weeks' gestation. She has chronic hypertension and a previous pregnancy complicated by preeclampsia at 30 weeks. Which intervention reduces her risk of recurrent preeclampsia?

  1. Prophylactic low molecular weight heparin
  2. Low-dose aspirin started before 16 weeks Correct answer.
  3. Routine calcium supplementation at 2 g daily
  4. Strict bed rest from 20 weeks

Explanation

Low-dose aspirin, usually 75 to 150 mg daily, started before 16 weeks and continued to about 36 weeks, reduces the incidence of preeclampsia in women at high risk, including those with chronic hypertension or a previous preterm preeclampsia. This patient has two major risk factors and clearly qualifies.

Question 46Women's Health (Obstetrics and Gynecology, including antenatal care)

A woman delivers a 4.1 kg infant after a prolonged second stage. Thirty minutes later she has heavy vaginal bleeding. The uterus feels firm and well contracted on abdominal palpation, her blood pressure is 100/60 mmHg and her pulse is 110 beats per minute. Which is the most likely cause of the bleeding?

  1. Coagulopathy
  2. Genital tract laceration Correct answer.
  3. Uterine atony
  4. Uterine inversion

Explanation

A firm, well-contracted uterus makes uterine atony unlikely, so bleeding after a prolonged second stage and delivery of a macrosomic infant points to genital tract trauma. The cervix, vagina and perineum must be carefully inspected under good lighting and any laceration repaired.

Question 47Women's Health (Obstetrics and Gynecology, including antenatal care)

A 24-year-old woman who experiences migraine with aura requests combined oral contraceptive pills. Her blood pressure and body mass index are normal. What is the most appropriate advice?

  1. Combined pills are safe provided her blood pressure is normal
  2. Combined pills are safe if she uses the lowest oestrogen dose
  3. She may use combined pills if she takes them continuously
  4. Use a progestogen-only or non-hormonal method Correct answer.

Explanation

Migraine with aura is an absolute contraindication to combined hormonal contraception because the added oestrogen raises the risk of ischaemic stroke. Progestogen-only methods, the copper intrauterine device and barrier methods are suitable alternatives.

Question 48Women's Health (Obstetrics and Gynecology, including antenatal care)

A 29-year-old woman who is RhD negative and not sensitised delivers a healthy RhD-positive infant at 39 weeks. She received routine antenatal anti-D prophylaxis at 28 weeks. What is the correct advice regarding postnatal anti-D immunoglobulin?

  1. It is required only if the cord blood is direct antiglobulin test positive
  2. It should be given within 72 hours of delivery Correct answer.
  3. It is required only after a caesarean delivery
  4. It is not required because she received antenatal prophylaxis

Explanation

A non-sensitised RhD-negative woman who delivers an RhD-positive baby needs postnatal anti-D immunoglobulin, ideally within 72 hours of delivery, because fetomaternal haemorrhage at birth can immunise her. The antenatal dose given at 28 weeks does not cover this later exposure.

Question 49Women's Health (Obstetrics and Gynecology, including antenatal care)

A 45-year-old nulliparous woman with a body mass index of 36 kg/m² reports 8 months of heavy, irregular menstrual bleeding. Transvaginal ultrasound shows an endometrial thickness of 9 mm with no focal lesion. Which is the most appropriate next step?

  1. Endometrial biopsy Correct answer.
  2. Empirical levonorgestrel intrauterine system without sampling
  3. Reassurance and review in 12 months
  4. Repeat transvaginal ultrasound in 3 months

Explanation

Abnormal uterine bleeding in a woman aged 45 years or older requires endometrial sampling to exclude endometrial hyperplasia or carcinoma, regardless of ultrasound findings. Obesity and nulliparity add further oestrogen-exposure risk. A thin, uniform endometrium does not remove the need for tissue diagnosis in this age group.

Question 50Women's Health (Obstetrics and Gynecology, including antenatal care)

During delivery of a 4.3 kg infant the head delivers, but the anterior shoulder does not and gentle axial traction is unsuccessful. Which manoeuvre should be performed first?

  1. McRoberts' manoeuvre with suprapubic pressure Correct answer.
  2. Fundal pressure to dislodge the shoulder
  3. Symphysiotomy
  4. Delivery of the posterior arm as the first step

Explanation

The first-line manoeuvre for shoulder dystocia is McRoberts' position, hyperflexing the maternal hips, combined with suprapubic pressure; this resolves the majority of cases. More invasive internal manoeuvres are used only if it fails, and the whole sequence should be completed within a few minutes while the neonate is monitored.