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OMSB Residency Selection (OMRSE) study materials
OMSB Residency Selection (OMRSE) study resources

OMSB Residency Selection (OMRSE) 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 and an albumin-to-creatinine ratio of 450 mg/g. Which medication class slows progression of his chronic kidney disease and reduces cardiovascular events?

  1. Thiazolidinediones
  2. Alpha-1 blockers
  3. SGLT2 inhibitors Correct answer.
  4. Loop diuretics

Explanation

SGLT2 inhibitors reduce CKD progression and cardiovascular events in patients with diabetic kidney disease, even when glycemic control is already near target. They are recommended in addition to renin-angiotensin blockade when albuminuria persists. Loop diuretics relieve congestion but do not modify disease progression.

Question 2Internal Medicine

A 24-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. TSH is elevated and free T4 is low. Which finding is most consistent with primary hypothyroidism?

  1. Elevated TSH with low free T4 Correct answer.
  2. Low TSH with high free T4
  3. Suppressed TSH with normal free T4
  4. High free T4 with normal TSH

Explanation

Primary hypothyroidism is characterized by failure of the thyroid gland, so pituitary TSH rises in response to low thyroid hormone feedback and free T4 falls. The combination of elevated TSH and low free T4 confirms the diagnosis. A low TSH with high free T4 instead suggests thyrotoxicosis.

Question 3Internal Medicine

A 68-year-old man with atrial fibrillation and a CHA2DS2-VASc score of 4 has a mechanical mitral valve. Which anticoagulation strategy is appropriate?

  1. Dabigatran 150 mg twice daily
  2. Warfarin with target INR 2.5–3.5 Correct answer.
  3. Apixaban 5 mg twice daily
  4. Rivaroxaban 20 mg daily

Explanation

Mechanical heart valves require vitamin K antagonist therapy, as direct oral anticoagulants have been associated with increased thromboembolic and bleeding events in this population. A mechanical mitral valve carries a higher thrombotic risk, so the target INR is 2.5–3.5 rather than 2.0–3.0. DOACs are therefore contraindicated.

Question 4Internal Medicine

A 45-year-old woman has a blood pressure of 152/94 mmHg on two separate visits. She has no other cardiovascular risk factors and normal renal function. Which is the most appropriate initial pharmacologic therapy?

  1. A loop diuretic alone
  2. A beta blocker alone
  3. An alpha-1 blocker alone
  4. A thiazide-type diuretic, ACE inhibitor, ARB, or calcium channel blocker Correct answer.

Explanation

First-line therapy for uncomplicated stage 1 or 2 hypertension includes thiazide-type diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers. Beta blockers, alpha blockers, and loop diuretics are not preferred initial monotherapy unless a specific comorbidity dictates their use. Choice among first-line agents depends on comorbidities and patient characteristics.

Question 5Internal Medicine

A 30-year-old man has a positive tuberculin skin test with 12 mm induration, a normal chest radiograph, and no symptoms. He was recently exposed to a household contact with active pulmonary tuberculosis. What is the most appropriate next step?

  1. Isoniazid plus rifampin for 3 months Correct answer.
  2. Four-drug therapy with isoniazid, rifampin, pyrazinamide, and ethambutol
  3. Chest CT to exclude occult disease
  4. No treatment; repeat testing in one year

Explanation

This patient has latent tuberculosis infection, defined by a positive tuberculin test with no clinical or radiographic evidence of active disease. For recent household exposure, short-course rifamycin-based regimens such as 3 months of isoniazid plus rifampin or 4 months of rifampin are preferred. Active TB treatment is not indicated without evidence of disease.

Question 6Internal Medicine

A 72-year-old woman with a history of heart failure with reduced ejection fraction presents with worsening dyspnea. Which physical examination finding most reliably suggests elevated left ventricular filling pressures?

  1. Elevated jugular venous pressure Correct answer.
  2. Bilateral pedal edema
  3. Hepatomegaly
  4. Systolic murmur at the apex

Explanation

Elevated jugular venous pressure reflects right atrial pressure and is a reliable bedside marker of increased filling pressures, though it can also reflect right-sided disease. In the context of decompensated heart failure, it correlates with elevated left-sided filling pressures. Pedal edema and hepatomegaly are less specific because they occur with venous insufficiency and hepatic disease.

Question 7Internal Medicine

A 19-year-old college student presents with sore throat, fever, and tonsillar exudates. Rapid antigen testing for group A streptococcus is positive. Which antibiotic is the first-line treatment?

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

Explanation

Penicillin or amoxicillin remains first-line for group A streptococcal pharyngitis because resistance has not developed and it effectively prevents acute rheumatic fever. Macrolides are reserved for penicillin allergy. Fluoroquinolones and sulfonamides are not recommended for streptococcal pharyngitis.

Question 8Internal Medicine

A 60-year-old man with chronic obstructive pulmonary disease has a resting oxygen saturation of 88% on room air. Which intervention improves survival in this setting?

  1. Prophylactic antibiotics
  2. Long-term supplemental oxygen Correct answer.
  3. Oral corticosteroids
  4. Inhaled short-acting beta-agonist as needed

Explanation

Long-term oxygen therapy improves survival in patients with COPD and chronic severe hypoxemia, typically defined as PaO2 ≤55 mmHg or oxygen saturation ≤88%. Short-acting bronchodilators and corticosteroids relieve symptoms but do not confer a mortality benefit. Prophylactic antibiotics are not routinely recommended.

Question 9Internal Medicine

A 62-year-old woman presents with a two-day history of severe epigastric pain radiating to the back, nausea, and vomiting. Serum lipase is three times the upper limit of normal. Which is the most common cause of this condition?

  1. Autoimmune pancreatitis
  2. Hypercalcemia
  3. Gallstones Correct answer.
  4. Hypertriglyceridemia

Explanation

Acute pancreatitis is diagnosed by characteristic pain with lipase elevation greater than three times the upper limit of normal. Gallstones and alcohol are the two most common causes worldwide, with gallstones being the leading cause in many populations. Hypertriglyceridemia and hypercalcemia are less common etiologies.

Question 10Internal Medicine

A 55-year-old man with a 40-pack-year smoking history has a 2 cm peripheral lung nodule. Biopsy shows small cell lung cancer limited to one hemithorax. Which treatment is most appropriate for limited-stage small cell lung cancer?

  1. Targeted tyrosine kinase inhibitor
  2. Surgical resection alone
  3. Concurrent chemoradiotherapy Correct answer.
  4. Immune checkpoint inhibitor alone

Explanation

Limited-stage small cell lung cancer is treated with concurrent platinum-based chemotherapy and thoracic radiotherapy, which improves survival compared with sequential therapy. Surgery is rarely appropriate because small cell carcinoma is usually systemic at diagnosis. Targeted agents are not standard for small cell lung cancer.

Question 11Internal Medicine

A 28-year-old woman presents with a malar rash, photosensitivity, and arthralgia. Urinalysis shows proteinuria and red blood cell casts. Which serologic test is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for systemic lupus erythematosus and correlate with disease activity, particularly lupus nephritis. Antinuclear antibody is sensitive but not specific, as it is positive in many autoimmune and non-autoimmune conditions. Rheumatoid factor and antihistone antibodies are associated with other diseases.

Question 12Internal Medicine

A 70-year-old man with type 2 diabetes and a history of myocardial infarction is started on a new medication. Two weeks later he develops confusion, hypotension, and a normal anion gap metabolic acidosis with an elevated lactate. Which medication most likely caused this presentation?

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

Explanation

Metformin can cause lactic acidosis, particularly in patients with renal impairment, heart failure, or other conditions that impair clearance. The presentation of hypotension, confusion, and elevated lactate with a normal anion gap acidosis fits this diagnosis. Other oral agents do not typically cause lactic acidosis.

Question 13Internal Medicine

A 35-year-old man has recurrent calcium oxalate kidney stones. Which dietary recommendation reduces stone recurrence?

  1. Low calcium intake
  2. High fluid intake Correct answer.
  3. High animal protein intake
  4. High sodium intake

Explanation

High fluid intake to achieve urine output of at least 2.5 liters daily reduces supersaturation and stone recurrence. Normal dietary calcium is recommended because restricting calcium increases oxalate absorption and stone risk. High animal protein and high sodium intake both increase calcium excretion and promote stone formation.

Question 14Internal Medicine

A 66-year-old woman with hypertension and diabetes presents with sudden-onset focal neurologic deficit. Noncontrast head CT shows a hyperdense left middle cerebral artery. Which treatment is indicated if she presents within 4.5 hours of symptom onset and has no contraindications?

  1. Observation
  2. Intravenous heparin
  3. Aspirin alone
  4. Intravenous alteplase Correct answer.

Explanation

Intravenous thrombolysis with alteplase or tenecteplase is indicated for acute ischemic stroke within 4.5 hours of symptom onset when there are no contraindications, after excluding hemorrhage on imaging. Heparin is not recommended for acute stroke because of bleeding risk without clear benefit. Aspirin is started after thrombolysis consideration.

Question 15Internal Medicine

A 24-year-old man presents with polyuria, polydipsia, and weight loss. His glucose is 420 mg/dL, arterial pH is 7.12, bicarbonate is 8 mEq/L, and he has large serum ketones. Which is the initial fluid of choice in diabetic ketoacidosis?

  1. 0.45% sodium chloride
  2. 0.9% sodium chloride Correct answer.
  3. Ringer's lactate with potassium
  4. 5% dextrose in water

Explanation

Isotonic 0.9% sodium chloride is the initial fluid for diabetic ketoacidosis to restore intravascular volume and improve tissue perfusion. Dextrose-containing fluids are added later when glucose falls to avoid hypoglycemia. Hypotonic fluids are used only after initial volume resuscitation.

Question 16Internal Medicine

A 50-year-old woman presents with fatigue, pruritus, and jaundice. Laboratory studies show elevated alkaline phosphatase, elevated IgM, and positive antimitochondrial antibodies. Which is the most likely diagnosis?

  1. Primary biliary cholangitis Correct answer.
  2. Cholangiocarcinoma
  3. Autoimmune hepatitis
  4. Primary sclerosing cholangitis

Explanation

Primary biliary cholangitis is an autoimmune cholestatic liver disease characterized by antimitochondrial antibodies, elevated alkaline phosphatase, and elevated IgM, predominantly affecting middle-aged women. Primary sclerosing cholangitis is associated with inflammatory bowel disease and p-ANCA. Autoimmune hepatitis shows elevated transaminases and autoantibodies such as ANA or anti-smooth muscle antibody.

Question 17Internal Medicine

A 40-year-old man with a history of alcohol use disorder presents with confusion, ataxia, and ophthalmoplegia. Which vitamin deficiency is most likely responsible?

  1. Niacin
  2. Folate
  3. Vitamin B12
  4. Thiamine (vitamin B1) Correct answer.

Explanation

Wernicke encephalopathy results from thiamine deficiency and presents with confusion, ataxia, and ophthalmoplegia. It is a medical emergency requiring prompt parenteral thiamine to prevent irreversible Korsakoff syndrome. Vitamin B12 deficiency causes subacute combined degeneration, and niacin deficiency causes pellagra.

Question 18Internal Medicine

A 65-year-old man with a history of chronic kidney disease presents with fatigue and pruritus. Laboratory studies show hemoglobin 8.5 g/dL, ferritin 50 ng/mL, and transferrin saturation 15%. What is the most appropriate next step?

  1. Start oral folic acid
  2. Administer intravenous iron before considering an erythropoiesis-stimulating agent Correct answer.
  3. Transfuse packed red blood cells
  4. Start an erythropoiesis-stimulating agent immediately

Explanation

Anemia of chronic kidney disease with low ferritin and low transferrin saturation indicates iron deficiency, which should be treated with iron before starting an erythropoiesis-stimulating agent. ESA therapy is ineffective and may be harmful in the presence of iron deficiency. Transfusion is reserved for severe symptomatic anemia.

Question 19Internal Medicine

A 60-year-old woman presents with a new painful red eye, decreased vision, and a mid-dilated pupil. Which diagnosis should be suspected?

  1. Anterior uveitis
  2. Conjunctivitis
  3. Acute angle-closure glaucoma Correct answer.
  4. Scleritis

Explanation

Acute angle-closure glaucoma presents with severe eye pain, decreased vision, a mid-dilated pupil, and conjunctival injection. It is an ophthalmologic emergency requiring immediate intraocular pressure reduction. Anterior uveitis causes a constricted pupil and photophobia, and conjunctivitis lacks visual loss.

Question 20Internal Medicine

A 45-year-old man with a history of intravenous drug use presents with fever, a new murmur, and multiple small pulmonary nodules on chest imaging. Blood cultures grow Staphylococcus aureus. Which diagnosis is most likely?

  1. Community-acquired pneumonia
  2. Infective endocarditis of the aortic valve
  3. Infective endocarditis of the tricuspid valve Correct answer.
  4. Lung cancer

Explanation

Right-sided infective endocarditis, typically involving the tricuspid valve, is common in people who inject drugs and presents with fever, murmur, and septic pulmonary emboli producing pulmonary nodules. Aortic valve involvement more often causes systemic emboli. Pneumonia and lung cancer do not explain the positive blood cultures and murmur.

Question 21Internal Medicine

A 55-year-old woman with a history of hyperparathyroidism presents with fatigue and bone pain. Which laboratory pattern is most consistent with primary hyperparathyroidism?

  1. Low calcium, low phosphate, low PTH
  2. High calcium, low phosphate, high PTH Correct answer.
  3. Low calcium, high phosphate, high PTH
  4. High calcium, high phosphate, low PTH

Explanation

Primary hyperparathyroidism results in inappropriate PTH secretion, causing hypercalcemia and hypophosphatemia due to PTH-mediated bone resorption and renal phosphate wasting. Low calcium with high phosphate and high PTH suggests secondary hyperparathyroidism from kidney disease. Suppressed PTH with hypercalcemia suggests a non-parathyroid cause.

Question 22Internal Medicine

A 30-year-old man presents with a pruritic rash after starting a new medication. He has a fever, eosinophilia, and elevated liver enzymes. Which diagnosis is most likely?

  1. Urticaria
  2. Contact dermatitis
  3. Stevens-Johnson syndrome
  4. DRESS syndrome Correct answer.

Explanation

DRESS syndrome (drug reaction with eosinophilia and systemic symptoms) presents with rash, fever, eosinophilia, and internal organ involvement such as hepatitis, typically 2–8 weeks after starting a medication. Stevens-Johnson syndrome presents with mucosal involvement and skin detachment. Urticaria and contact dermatitis lack systemic features.

Question 23Internal Medicine

A 68-year-old woman with atrial fibrillation and a history of a prior stroke is being evaluated for anticoagulation. Which score is used to estimate stroke risk and guide the decision?

  1. Wells score
  2. CHA2DS2-VASc score Correct answer.
  3. CURB-65 score
  4. HAS-BLED score

Explanation

The CHA2DS2-VASc score estimates stroke risk in nonvalvular atrial fibrillation and guides anticoagulation decisions. HAS-BLED estimates bleeding risk but should not be used alone to withhold anticoagulation. Wells and CURB-65 are used for venous thromboembolism and pneumonia, respectively.

Question 24Internal Medicine

A 22-year-old man presents with sudden severe headache, neck stiffness, and photophobia. CT head is normal, and lumbar puncture shows xanthochromia with elevated red blood cells. Which is the most appropriate next step?

  1. Start oral corticosteroids and discharge
  2. Consult neurosurgery for aneurysm management Correct answer.
  3. Start antibiotics and dexamethasone
  4. Administer intravenous magnesium

Explanation

The presentation is consistent with subarachnoid hemorrhage, confirmed by xanthochromia in the cerebrospinal fluid. Management includes urgent neurosurgical consultation and evaluation for an aneurysm, as well as nimodipine to prevent vasospasm. Antibiotics and dexamethasone treat bacterial meningitis, not subarachnoid hemorrhage.

Question 25Internal Medicine

A 50-year-old man with cirrhosis presents with confusion, asterixis, and elevated ammonia. He has been taking lactulose but continues to have symptoms. Which medication can be added to reduce ammonia production?

  1. Omeprazole
  2. Ciprofloxacin
  3. Metoclopramide
  4. Rifaximin Correct answer.

Explanation

Rifaximin, a nonabsorbable antibiotic, reduces ammonia-producing gut bacteria and is used with lactulose for secondary prophylaxis of hepatic encephalopathy. Ciprofloxacin is systemically absorbed and not recommended for this purpose. Omeprazole and metoclopramide do not reduce ammonia production.

Question 26Internal Medicine

A 58-year-old man is admitted with confusion and a serum sodium of 118 mmol/L that developed over approximately 48 hours. Hypotonic hyponatremia is confirmed, and his confusion is attributed to it. He has no seizures and no focal deficits. Which initial fluid strategy is most appropriate while the underlying cause is investigated?

  1. Administration of intravenous furosemide without fluid replacement
  2. Controlled correction with hypertonic 3% saline under senior supervision, aiming for an initial sodium rise of 4-6 mmol/L over 4 hours with close monitoring Correct answer.
  3. Rapid correction with hypertonic 3% saline to raise sodium by 10 mmol/L within 4 hours
  4. Free water restriction alone with no sodium repletion

Explanation

Confusion attributed to confirmed hypotonic hyponatremia is a moderately severe symptom that can justify urgent controlled hypertonic saline. Under senior supervision, aim for an initial rise of 4-6 mmol/L over four hours, with frequent sodium measurements and reassessment to avoid overcorrection. Isotonic saline can treat hypovolemia, but no hypovolemia is established here.

Question 27Internal Medicine

A 34-year-old woman has a fasting plasma glucose of 132 mg/dL on two occasions and an HbA1c of 6.9%. She is asymptomatic and has a body mass index of 31 kg/m². Which diagnosis is established by these results?

  1. Normal glucose tolerance
  2. Prediabetes requiring no follow-up
  3. Diabetes mellitus Correct answer.
  4. Impaired fasting glucose only

Explanation

Diabetes is diagnosed when fasting plasma glucose is 128 mg/dL or higher on two occasions, or HbA1c is 6.5% or greater. Both of this patient's values meet diagnostic thresholds, so the diagnosis is confirmed without needing an oral glucose tolerance test. Impaired fasting glucose and prediabetes correspond to lower ranges that do not apply here.

Question 28Internal Medicine

A 45-year-old man with no prior cardiac history presents with sudden-onset palpitations and a regular narrow-complex tachycardia at 180 beats per minute. He is hemodynamically stable with a blood pressure of 118/74 mmHg. Which initial intervention is most appropriate?

  1. Oral metoprolol with reassessment in 24 hours
  2. Intravenous amiodarone as first-line therapy
  3. Immediate synchronized cardioversion
  4. Intravenous adenosine followed by a 12-lead ECG during the pause Correct answer.

Explanation

In stable regular narrow-complex tachycardia, adenosine is used diagnostically and therapeutically because it transiently blocks the AV node; a rhythm strip recorded during the pause reveals whether the mechanism is AV nodal reentry, AV reentry, or atrial tachycardia. Synchronized cardioversion is reserved for instability such as hypotension, ischemia, or altered mentation.

Question 29Internal Medicine

A 60-year-old woman with a history of rheumatoid arthritis on long-term prednisone presents with fatigue and dyspnea. Her blood pressure is 88/54 mmHg, sodium is 130 mmol/L, potassium is 5.6 mmol/L, and glucose is 64 mg/dL. Which diagnosis best explains this presentation?

  1. Syndrome of inappropriate antidiuretic hormone secretion
  2. Thyrotoxicosis
  3. Primary hyperaldosteronism
  4. Adrenal crisis from chronic glucocorticoid-induced adrenal suppression Correct answer.

Explanation

Chronic glucocorticoid therapy suppresses the hypothalamic-pituitary-adrenal axis, and abrupt stress or tapering can precipitate adrenal crisis with hypotension, hyponatremia, hyperkalemia, and hypoglycemia. Treatment is immediate parenteral hydrocortisone with isotonic saline and glucose. The combination of hyperkalemia and hypoglycemia points away from SIADH and hyperaldosteronism.

Question 30Internal Medicine

A 52-year-old man is admitted with a large upper gastrointestinal bleed. His hemoglobin is 6.8 g/dL, blood pressure is 92/60 mmHg, and he remains tachycardic after 1 L of crystalloid. Which next step is most appropriate?

  1. Start a nonsteroidal anti-inflammatory drug for pain control
  2. Immediate colonoscopy as the first diagnostic test
  3. Urgent packed red blood cell transfusion while arranging endoscopy Correct answer.
  4. Oral iron therapy and outpatient follow-up

Explanation

Hemodynamically significant upper GI bleeding with a hemoglobin below 7 g/dL requires urgent transfusion and endoscopic evaluation, usually within 24 hours after resuscitation. The restrictive transfusion threshold of about 7 g/dL supports transfusion in this setting. NSAIDs are contraindicated because they worsen mucosal bleeding.

Question 31Internal Medicine

A 68-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4 and a creatinine clearance of 25 mL/min. Which anticoagulation strategy is most appropriate?

  1. Warfarin or a renally appropriate direct oral anticoagulant with dose adjustment Correct answer.
  2. Aspirin alone for stroke prevention
  3. Dual antiplatelet therapy
  4. No anticoagulation because of fall risk

Explanation

A CHA2DS2-VASc score of 2 or higher in men warrants oral anticoagulation for stroke prevention in atrial fibrillation. Severe renal impairment requires either warfarin or a direct oral anticoagulant dosed according to renal function, since several agents are contraindicated or need reduction at low clearance. Aspirin and dual antiplatelet therapy are inadequate substitutes.

Question 32Internal Medicine

A 29-year-old woman has a 3-month history of fatigue, heat intolerance, tremor, and weight loss. TSH is suppressed and free T4 is elevated. Which finding on examination is most consistent with this disorder?

  1. Bradycardia with hyporeflexia
  2. Diffuse goiter with a bruit Correct answer.
  3. Painless thyroid nodule with normal uptake elsewhere
  4. Periorbital edema with cold intolerance

Explanation

Graves disease is the most common cause of hyperthyroidism in young women and classically produces a diffuse goiter that may have an audible bruit from increased vascularity. Other findings include lid lag, tremor, and tachycardia. Bradycardia and cold intolerance indicate hypothyroidism instead.

Question 33Internal Medicine

A 47-year-old man presents with acute monoarthritis of the right knee. Joint aspiration shows needle-shaped negatively birefringent crystals. Which treatment is most appropriate for the acute attack?

  1. Probenecid during the acute attack
  2. Intra-articular glucocorticoid or oral colchicine plus later urate-lowering therapy Correct answer.
  3. Long-term antibiotics targeting the joint
  4. Allopurinol started at high dose during the flare

Explanation

Acute gout is treated with anti-inflammatory therapy such as intra-articular glucocorticoid, oral colchicine, or an NSAID, while urate-lowering therapy is started after the flare resolves or with adequate prophylaxis. Allopurinol is not used to abort an acute attack because rapid shifts in urate can prolong or precipitate flares. Antibiotics have no role in crystal arthropathy.

Question 34Internal Medicine

A 64-year-old man with hypertension and hyperlipidemia presents with sudden painless loss of vision in the left eye described as a curtain descending over the visual field. Symptoms lasted 10 minutes and resolved completely. Which mechanism best explains this event?

  1. Vitreous hemorrhage
  2. Optic neuritis
  3. Acute angle-closure glaucoma
  4. Retinal artery embolization from a carotid or cardiac source Correct answer.

Explanation

Transient monocular vision loss described as a curtain over the visual field is amarosis fugax, typically caused by emboli from the ipsilateral carotid artery or heart that transiently occlude the retinal artery. It is a warning sign of stroke and requires urgent evaluation of carotid and cardiac sources. Acute angle-closure glaucoma causes a painful red eye with a fixed mid-dilated pupil.

Question 35Internal Medicine

A 24-year-old woman presents with a 2-week history of fatigue, arthralgias, and a facial rash. Antinuclear antibody is positive at 1:640, and anti-double-stranded DNA is positive. Which additional finding would most strongly support active renal involvement?

  1. Urinary red blood cell casts with proteinuria Correct answer.
  2. Elevated serum complement levels
  3. Elevated erythrocyte sedimentation rate alone
  4. Isolated mild leukopenia

Explanation

Lupus nephritis is suggested by active urinary sediment, including red blood cell casts, along with proteinuria, and is often accompanied by falling complement levels and rising anti-dsDNA titers. Urinalysis is the key screening test because renal involvement can be silent. An isolated elevated sedimentation rate is nonspecific.

Question 36Internal Medicine

A 70-year-old man is admitted with a 3-day history of productive cough, fever, and dyspnea. Chest radiograph shows a right lower lobe infiltrate. Which severity assessment tool is most appropriate to guide the decision about inpatient versus outpatient management?

  1. Child-Pugh score
  2. CURB-65 score Correct answer.
  3. Wells score
  4. Glasgow Coma Scale

Explanation

The CURB-65 score uses confusion, urea, respiratory rate, blood pressure, and age 65 or older to stratify mortality risk in community-acquired pneumonia and to guide site of care. A score of 0 to 1 generally supports outpatient treatment, while higher scores favor admission or intensive care. The Wells score estimates pretest probability of pulmonary embolism, not pneumonia severity.

Question 37Internal Medicine

A 55-year-old man with a 30-pack-year smoking history has a forced expiratory volume in 1 second to forced vital capacity ratio of 0.62 after bronchodilator, confirming COPD. He has had two exacerbations in the past year and an MRC dyspnea score of 3. Which long-term management is most appropriate?

  1. Prophylactic antibiotics for all patients with COPD
  2. Oral corticosteroids as maintenance therapy
  3. Inhaled short-acting beta-agonist as needed only
  4. Long-acting bronchodilator therapy with assessment for pulmonary rehabilitation Correct answer.

Explanation

Symptomatic COPD with a history of exacerbations warrants maintenance long-acting bronchodilator therapy, and pulmonary rehabilitation improves dyspnea and exercise capacity. Inhaled corticosteroids are added for selected patients with frequent exacerbations or eosinophilic inflammation. Chronic oral corticosteroids and routine prophylactic antibiotics are not recommended for stable disease.

Question 38Internal Medicine

A 40-year-old man is brought in after a witnessed generalized tonic-clonic seizure lasting 3 minutes that has now stopped. He is awake and oriented. Glucose and electrolytes are normal. Which next step is most appropriate?

  1. Discharge without further evaluation
  2. Obtain an EEG and neuroimaging and consider whether antiseizure therapy is indicated Correct answer.
  3. Begin long-term benzodiazepine therapy
  4. Start intravenous phenytoin loading immediately

Explanation

A first unprovoked seizure requires evaluation for reversible causes, EEG to assess epileptiform activity, and brain imaging to exclude structural lesions. Antiseizure medication is generally started when the risk of recurrence is high, such as after a second seizure or abnormal EEG or imaging. Long-term benzodiazepines are not appropriate maintenance therapy.

Question 39Internal Medicine

A 62-year-old man with a history of alcohol use disorder presents with confusion and ataxia. Examination shows ophthalmoplegia and nystagmus. Which treatment should be given immediately?

  1. Intravenous naloxone
  2. Intravenous thiamine before glucose-containing fluids Correct answer.
  3. Intravenous glucose alone
  4. Oral folate supplementation only

Explanation

The triad of confusion, ataxia, and ophthalmoplegia indicates Wernicke encephalopathy from thiamine deficiency. Thiamine must be given before or with glucose-containing fluids, because glucose administration without thiamine can precipitate or worsen the disorder. Untreated Wernicke encephalopathy can progress to irreversible Korsakoff syndrome.

Question 40Internal Medicine

A 58-year-old woman with type 2 diabetes and a creatinine of 2.8 mg/dL is found to have a hemoglobin of 9.2 g/dL with normal mean corpuscular volume, low reticulocyte count, and low serum erythropoietin. Iron studies are normal. Which management is most appropriate?

  1. Erythropoiesis-stimulating agent with target hemoglobin around 10 to 11 g/dL Correct answer.
  2. Immediate blood transfusion to reach a hemoglobin of 14 g/dL
  3. High-dose vitamin B12 injections
  4. Oral iron despite normal iron studies

Explanation

Anemia of chronic kidney disease results from inadequate erythropoietin production and is treated with an erythropoiesis-stimulating agent after iron deficiency is excluded, targeting a hemoglobin of roughly 10 to 11.5 g/dL. Higher targets increase cardiovascular and thrombotic risk without survival benefit. Transfusion is reserved for symptomatic severe anemia.

Question 41Surgery

A 24-year-old man has a 3 cm clean laceration of the forearm with intact distal pulses and sensation. Which is the most appropriate initial management?

  1. Delayed closure after 5 days of antibiotic therapy
  2. Immediate split-thickness skin grafting
  3. Irrigation, debridement of devitalized tissue, and primary closure Correct answer.
  4. Application of a compressive bandage without wound cleaning

Explanation

Most clean traumatic wounds are managed by copious irrigation, removal of devitalized tissue, and primary closure within a few hours of injury. Skin grafting is reserved for substantial tissue loss, and antibiotics do not substitute for mechanical wound preparation.

Question 42Surgery

Which finding most strongly suggests that acute abdominal pain requires urgent operative evaluation?

  1. Board-like abdominal rigidity with absent bowel sounds Correct answer.
  2. Localized tenderness reproduced by abdominal wall contraction
  3. Mild periumbilical discomfort relieved by defecation
  4. Diffuse cramping after a large meal

Explanation

Board-like rigidity with silent abdomen indicates generalized peritonitis, which usually requires urgent surgical exploration. The other patterns describe benign or functional pain that can be evaluated less emergently.

Question 43Surgery

During a laparoscopic cholecystectomy, which structure must be positively identified before clipping the cystic duct and cystic artery?

  1. The falciform ligament
  2. The gastroduodenal artery
  3. The critical view of safety with only two structures entering the gallbladder Correct answer.
  4. The common bile duct crossing the field

Explanation

The critical view of safety requires clearing the hepatocystic triangle so that only the cystic duct and cystic artery are seen entering the gallbladder before any clipping. This prevents misidentification and major bile duct injury.

Question 44Surgery

A patient sustains a stab wound to the anterior chest and becomes hypotensive. Which bedside finding most reliably indicates cardiac tamponade?

  1. Hyperresonance to percussion over the hemithorax
  2. Subcutaneous emphysema at the wound site
  3. Pulsus paradoxus with distended neck veins Correct answer.
  4. Tracheal deviation toward the injured side

Explanation

Tamponade produces elevated venous pressure and impaired diastolic filling, classically with pulsus paradoxus and distended neck veins. Tracheal deviation and hyperresonance instead point to tension pneumothorax.

Question 45Surgery

Which is the most appropriate first step in managing a patient with a tension pneumothorax and hemodynamic instability?

  1. Obtain a chest radiograph before any intervention
  2. Immediate needle decompression followed by tube thoracostomy Correct answer.
  3. Start noninvasive ventilation and observe
  4. Urgent bronchoscopy to localize the air leak

Explanation

Tension pneumothorax is a clinical diagnosis requiring immediate decompression, followed by definitive tube thoracostomy. Imaging and observation delay treatment and risk cardiovascular collapse.

Question 46Surgery

Which parameter is the most sensitive early indicator of inadequate resuscitation in a bleeding trauma patient?

  1. Serum sodium concentration
  2. Platelet count
  3. Base deficit and lactate trend Correct answer.
  4. Body temperature alone

Explanation

Base deficit and lactate reflect the degree of tissue hypoperfusion and respond before conventional vital signs normalize. Sodium, platelets, and temperature are less sensitive markers of resuscitation adequacy.

Question 47Surgery

A patient develops fever, tachycardia, and a firm, tender, erythematous area on the abdominal wall three days after surgery. Which diagnosis should be suspected first?

  1. Surgical site infection with abscess formation Correct answer.
  2. Atelectasis
  3. Urinary tract infection
  4. Superficial thrombophlebitis of the leg

Explanation

Localized wound erythema, induration, and tenderness with fever after surgery point to a surgical site infection, often with an underlying collection. The findings are confined to the wound rather than the chest, urinary tract, or leg.

Question 48Surgery

Which fluid is most appropriate for initial resuscitation of an adult with hypovolemic shock from hemorrhage while blood products are being prepared?

  1. 5% dextrose in water
  2. Free water infusion
  3. Hypertonic saline 3%
  4. Balanced crystalloid in limited volume Correct answer.

Explanation

Balanced isotonic crystalloid in restricted volume is used as a bridge while blood products are prepared, avoiding excessive crystalloid load. Dextrose and free water do not expand the intravascular space effectively and can worsen hyponatremia.

Question 49Surgery

A 55-year-old man has painless jaundice and a palpable gallbladder. Which diagnosis should be considered most strongly?

  1. Viral hepatitis
  2. Choledocholithiasis with colic
  3. Acute cholecystitis
  4. Pancreatic head carcinoma Correct answer.

Explanation

Painless obstructive jaundice with a palpable, distended gallbladder suggests malignant distal bile duct obstruction, classically pancreatic head cancer. Gallstone disease and hepatitis usually produce pain or different clinical patterns.

Question 50Surgery

Which feature best distinguishes an indirect inguinal hernia from a direct inguinal hernia on examination?

  1. Patient age at presentation
  2. Relation of the neck to the inferior epigastric vessels at surgery Correct answer.
  3. Reducibility of the swelling
  4. Presence of pain on coughing

Explanation

The definitive distinction is anatomic: indirect hernias arise lateral to the inferior epigastric vessels, while direct hernias protrude medial to them. Pain, reducibility, and age are supportive but not reliable discriminators.