I85PREP
⌘ K
Palestinian Board Part I study materials
Palestinian Board Part I study resources

Palestinian Board Part I practice questions

One question at a time. Build your Palestinian Board Part I understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Internal Medicine

A 58-year-old man with type 2 diabetes has an eGFR of 28 mL/min/1.73 m² and a urine albumin-to-creatinine ratio of 450 mg/g. Which medication class slows progression of his diabetic kidney disease in addition to glycemic control?

  1. Alpha-glucosidase inhibitors
  2. SGLT2 inhibitors Correct answer.
  3. Thiazolidinediones
  4. Sulfonylureas

Explanation

SGLT2 inhibitors reduce intraglomerular pressure and have proven benefit in slowing eGFR decline and reducing albuminuria in diabetic kidney disease, even at reduced eGFR. Sulfonylureas, thiazolidinediones, and alpha-glucosidase inhibitors lower glucose but lack this renal-protective evidence.

Question 2Internal Medicine

A 45-year-old woman has fatigue, weight gain, cold intolerance, and constipation. TSH is elevated and free T4 is low. Which finding best confirms primary hypothyroidism rather than a central cause?

  1. Elevated TSH with high free T4
  2. Normal TSH with low free T4
  3. Elevated TSH with low free T4 Correct answer.
  4. Low TSH with low free T4

Explanation

Primary hypothyroidism produces an elevated TSH because the pituitary responds to low thyroid hormone with increased secretion. Central hypothyroidism instead shows low or inappropriately normal TSH with low free T4, so the combination of high TSH and low free T4 localizes the defect to the thyroid gland.

Question 3Internal Medicine

A 62-year-old man presents with sudden painless loss of vision in one eye. Fundoscopy shows a pale retina with a cherry-red spot at the macula. Which diagnosis is most likely?

  1. Central retinal vein occlusion
  2. Vitreous hemorrhage
  3. Retinal detachment
  4. Central retinal artery occlusion Correct answer.

Explanation

Central retinal artery occlusion produces sudden painless monocular visual loss with a pale, edematous retina and a cherry-red spot where the choroidal circulation remains visible at the fovea. The other entities cause different fundoscopic patterns and, in retinal detachment, flashing lights or a field defect.

Question 4Internal Medicine

A 70-year-old smoker has chronic cough and progressive dyspnea. Spirometry after bronchodilator shows an FEV1/FVC ratio of 0.55. Which interpretation is correct?

  1. Normal spirometry
  2. Restrictive ventilatory defect
  3. Mixed defect with normal ratio
  4. Obstructive ventilatory defect Correct answer.

Explanation

A post-bronchodilator FEV1/FVC ratio below 0.70 defines persistent airflow obstruction, consistent with COPD in this clinical setting. Restrictive disease preserves or raises the ratio and reduces total lung capacity, while a normal ratio excludes obstruction.

Question 5Internal Medicine

A 55-year-old man has epigastric pain relieved by food and NSAID use. He is positive for H. pylori. Which regimen is appropriate first-line eradication therapy in most settings?

  1. H2 blocker plus antacid alone
  2. Proton pump inhibitor monotherapy
  3. Bismuth subsalicylate alone
  4. Proton pump inhibitor-based triple therapy Correct answer.

Explanation

Standard first-line H. pylori eradication combines a proton pump inhibitor with two antibiotics, typically clarithromycin and amoxicillin or metronidazole, for 14 days. Monotherapy or acid suppression alone does not reliably eradicate the organism and promotes resistance.

Question 6Internal Medicine

A 30-year-old woman has palpitations and heat intolerance. TSH is suppressed and free T4 is elevated. Which finding on examination most supports Graves disease over a toxic nodule?

  1. A firm, fixed thyroid mass
  2. A single palpable thyroid nodule
  3. Tenderness of the thyroid gland
  4. Diffuse symmetric goiter with a bruit Correct answer.

Explanation

Graves disease causes a diffuse, vascular goiter that may have an audible bruit from increased blood flow. A solitary nodule suggests a toxic adenoma, tenderness suggests subacute thyroiditis, and a firm fixed mass raises concern for malignancy.

Question 7Internal Medicine

A 68-year-old woman has sudden severe headache described as the worst of her life. Noncontrast head CT is normal. Which next step is most appropriate?

  1. MRI of the cervical spine
  2. Reassurance and discharge
  3. Lumbar puncture for xanthochromia Correct answer.
  4. Oral triptan therapy

Explanation

A thunderclap headache with a normal noncontrast CT still requires evaluation for subarachnoid hemorrhage, especially if imaging is delayed beyond six hours. Lumbar puncture showing xanthochromia supports the diagnosis when CT is negative.

Question 8Internal Medicine

Which electrolyte disturbance most characteristically produces peaked T waves, widened QRS complexes, and sine-wave patterns on ECG?

  1. Hypokalemia
  2. Hypocalcemia
  3. Hypercalcemia
  4. Hyperkalemia Correct answer.

Explanation

Progressive hyperkalemia causes peaked T waves, PR prolongation, QRS widening, and eventually a sine-wave pattern that precedes cardiac arrest. Hypokalemia flattens T waves with U waves, while calcium abnormalities mainly alter the QT interval.

Question 9Internal Medicine

A 24-year-old man has a positive tuberculin skin test with 12 mm induration, no symptoms, and a normal chest radiograph. He has no prior treatment and no immunocompromise. What does this represent?

  1. Active pulmonary tuberculosis
  2. A false-positive test requiring no action
  3. Latent tuberculosis infection Correct answer.
  4. Nontuberculous mycobacterial disease

Explanation

A positive skin test with no symptoms and a normal chest radiograph indicates latent tuberculosis infection, which warrants treatment to prevent progression to active disease. Active tuberculosis would require compatible symptoms or radiographic findings.

Question 10Internal Medicine

A 60-year-old man with atrial fibrillation has a CHA2DS2-VASc score of 4. He has no contraindication to anticoagulation. Which therapy is recommended for stroke prevention?

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

Explanation

A CHA2DS2-VASc score of 2 or more in men indicates sufficient stroke risk to justify oral anticoagulation, preferably a direct oral anticoagulant or warfarin. Aspirin and dual antiplatelet therapy are inferior to anticoagulation for atrial fibrillation and carry bleeding risk.

Question 11Internal Medicine

A 48-year-old woman has acute severe colicky flank pain radiating to the groin with hematuria. Noncontrast CT shows a 6 mm distal ureteral stone with mild hydronephrosis and no fever. Which initial management is most appropriate?

  1. Analgesia with medical expulsive therapy and observation Correct answer.
  2. Oral potassium citrate for dissolution
  3. Immediate open ureterolithotomy
  4. Percutaneous nephrostomy placement

Explanation

A 6 mm distal ureteral stone without infection or obstruction-related renal failure can be managed with analgesia and observation, often with a medication such as tamsulosin to assist passage. Immediate surgery or nephrostomy is reserved for infection, intractable pain, or high-grade obstruction.

Question 12Internal Medicine

A 35-year-old man has recurrent episodes of severe abdominal pain, hypertension, and tachycardia with hyponatremia. Which test is most appropriate for suspected porphyria?

  1. Serum amylase
  2. Urinary porphobilinogen during an attack Correct answer.
  3. Serum ceruloplasmin
  4. Fecal fat quantification

Explanation

Acute intermittent porphyria is diagnosed by demonstrating elevated urinary porphobilinogen during an acute attack. Serum amylase may be elevated from pancreatitis but is nonspecific, and ceruloplasmin and fecal fat assess unrelated diseases.

Question 13Internal Medicine

A 70-year-old man has resting tremor, bradykinesia, and rigidity. Which medication is most appropriate to initiate for symptomatic control of motor symptoms?

  1. Metoclopramide
  2. Levodopa-carbidopa Correct answer.
  3. Propranolol
  4. Haloperidol

Explanation

Levodopa combined with carbidopa is the most effective symptomatic treatment for Parkinson disease motor symptoms. Dopamine-blocking agents such as haloperidol and metoclopramide can worsen parkinsonism, and propranolol is used for essential tremor rather than Parkinson disease.

Question 14Internal Medicine

A 50-year-old woman has symmetric proximal muscle weakness and a heliotrope rash with Gottron papules. Which autoantibody is most specific for her likely diagnosis?

  1. Anti-Scl-70
  2. Anti-histone
  3. Anti-Jo-1 Correct answer.
  4. Anti-double-stranded DNA

Explanation

The combination of proximal weakness and characteristic skin findings indicates dermatomyositis, for which anti-Jo-1 is the most specific antibody and is associated with antisynthetase syndrome and interstitial lung disease. Anti-dsDNA, anti-Scl-70, and anti-histone are associated with lupus, scleroderma, and drug-induced lupus respectively.

Question 15Internal Medicine

A 66-year-old man with cirrhosis presents with confusion, asterixis, and a recent gastrointestinal bleed. Which medication is most appropriate to reduce recurrence of hepatic encephalopathy?

  1. Lactulose Correct answer.
  2. Furosemide
  3. Propranolol
  4. Omeprazole

Explanation

Lactulose is first-line therapy for hepatic encephalopathy because it acidifies the colon and traps ammonia. Furosemide can worsen electrolyte disturbance, omeprazole treats acid-related disease, and propranolol prevents variceal bleeding but does not treat encephalopathy.

Question 16Internal Medicine

A 30-year-old woman has a first episode of acute uncomplicated cystitis with dysuria and frequency. Which treatment is appropriate?

  1. Nitrofurantoin for 5 days Correct answer.
  2. Ciprofloxacin for 14 days
  3. Intravenous vancomycin
  4. No treatment

Explanation

Nitrofurantoin for five days is recommended first-line therapy for acute uncomplicated cystitis in women. Fluoroquinolones are reserved for complicated infection due to collateral damage and resistance, and intravenous vancomycin is excessive for simple cystitis.

Question 17Internal Medicine

A 72-year-old woman has pleuritic chest pain and dyspnea after hip replacement. She is tachycardic and hypoxic, and CT pulmonary angiography shows a saddle embolus. Which initial therapy is most appropriate?

  1. Systemic anticoagulation with heparin Correct answer.
  2. Aspirin monotherapy
  3. Observation with serial D-dimer
  4. Immediate thrombolysis

Explanation

Acute pulmonary embolism without hemodynamic instability is treated with anticoagulation, typically parenteral heparin followed by a direct oral anticoagulant. Thrombolysis is reserved for hemodynamically unstable patients, and aspirin or observation is inadequate.

Question 18Internal Medicine

A 40-year-old man has a blood pressure of 168/104 mmHg on three occasions. He has no diabetes, kidney disease, or heart failure. Which class is appropriate first-line therapy?

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

Explanation

Thiazide-type diuretics, ACE inhibitors, ARBs, and calcium channel blockers are recommended first-line agents for primary hypertension. Alpha blockers, central agonists, and loop diuretics are generally reserved for specific indications or resistant cases.

Question 19Internal Medicine

A 28-year-old woman has fever, polyarthritis, and a malar rash. Urinalysis shows red cell casts and proteinuria. Which finding best supports active lupus nephritis?

  1. Anti-histone antibodies
  2. Rheumatoid factor positivity
  3. Antinuclear antibody positivity alone
  4. Anti-double-stranded DNA antibodies with low complement Correct answer.

Explanation

Anti-dsDNA antibodies and hypocomplementemia correlate with active immune-complex glomerulonephritis in systemic lupus erythematosus. ANA alone is sensitive but not specific, and anti-histone and rheumatoid factor are associated with other conditions.

Question 20Internal Medicine

A 62-year-old man with chronic obstructive pulmonary disease has a resting oxygen saturation of 86% confirmed on two measurements. Which intervention improves survival?

  1. Long-term continuous oxygen therapy Correct answer.
  2. Inhaled short-acting beta-agonist as needed
  3. Prophylactic antibiotics year-round
  4. Oral corticosteroids for six months

Explanation

Long-term oxygen therapy improves survival in COPD patients with chronic severe hypoxemia documented on two occasions. Bronchodilators relieve symptoms, chronic oral steroids cause harm, and continuous prophylactic antibiotics are not standard for all patients.

Question 21Internal Medicine

A 55-year-old man on warfarin for a mechanical mitral valve has an INR of 7.5 and no bleeding. Which management is most appropriate?

  1. Start aspirin and stop warfarin
  2. Continue the current warfarin dose
  3. Give fresh frozen plasma immediately
  4. Hold warfarin and give vitamin K Correct answer.

Explanation

An INR above 6 with no bleeding warrants withholding warfarin and administering oral vitamin K, with repeat INR monitoring. Continuing the same dose risks bleeding, and plasma is reserved for major bleeding or urgent surgery.

Question 22Internal Medicine

A 68-year-old man has a serum sodium of 118 mmol/L with confusion. He is euvolemic with urine osmolality of 600 mOsm/kg and clinical signs of SIADH. Which correction rate is safest?

  1. Raise sodium by 4 to 6 mmol/L in 24 hours Correct answer.
  2. Give hypertonic saline rapidly regardless of symptoms
  3. Raise sodium by 20 mmol/L in 24 hours
  4. Correct to 140 mmol/L within 6 hours

Explanation

Chronic hyponatremia should be corrected slowly, generally no more than 8 to 10 mmol/L in 24 hours, to avoid osmotic demyelination. Rapid correction, especially to normal within hours, risks severe neurologic injury.

Question 23Internal Medicine

A 45-year-old man has a fasting glucose of 138 mg/dL on two occasions. Which criterion confirms diabetes mellitus?

  1. Random glucose of 140 mg/dL
  2. Fasting plasma glucose of 100 mg/dL or higher
  3. HbA1c of 5.7%
  4. Fasting plasma glucose of 126 mg/dL or higher Correct answer.

Explanation

Diabetes is diagnosed by a fasting plasma glucose of 126 mg/dL or more, a two-hour OGTT value of 200 mg/dL or more, HbA1c of 6.5% or more, or symptomatic random glucose of 200 mg/dL or more. Values below these thresholds indicate prediabetes or normal glucose.

Question 24Internal Medicine

A 58-year-old woman has crushing chest pain with ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

  1. Right coronary artery Correct answer.
  2. Left anterior descending artery
  3. Left circumflex artery
  4. Left main coronary artery

Explanation

ST elevation in the inferior leads II, III, and aVF localizes an inferior myocardial infarction, most often caused by right coronary artery occlusion. The left anterior descending supplies the anterior wall, the circumflex the lateral wall, and the left main a broad territory.

Question 25Internal Medicine

A 34-year-old man has recurrent calcium oxalate kidney stones. Which dietary measure reduces recurrence?

  1. High dietary oxalate intake
  2. Severe dietary calcium restriction
  3. Low fluid intake to reduce urine volume
  4. High fluid intake with normal dietary calcium Correct answer.

Explanation

High fluid intake dilutes urine and reduces stone recurrence, and normal dietary calcium binds intestinal oxalate to limit absorption. Restricting calcium paradoxically increases oxalate absorption and stone risk, and high oxalate intake promotes calcium oxalate stones.

Question 26Internal Medicine

A 64-year-old man is admitted with a 3-day history of vomiting and poor oral intake. Serum sodium is 128 mmol/L. He is clinically euvolemic and has no neurologic symptoms. What is the most appropriate initial step in management?

  1. Restrict free water intake and reassess sodium in 24 hours Correct answer.
  2. Administer hypertonic 3% saline bolus immediately
  3. Give intravenous furosemide alone to increase water excretion
  4. Rapidly correct sodium by 12 mmol/L in the first 4 hours

Explanation

Mild to moderate euvolemic hyponatremia without severe symptoms is managed conservatively by treating the cause and restricting free water, with slow monitored correction. Hypertonic saline is reserved for severe symptomatic hyponatremia such as seizures or coma. Correction limits exist to avoid osmotic demyelination, so rapid correction is inappropriate here.

Question 27Internal Medicine

A 58-year-old man has a hemoglobin of 9.8 g/dL, a mean corpuscular volume of 72 fL, and a low serum ferritin. Which finding on history is most likely to explain these results?

  1. Chronic heavy alcohol use
  2. Family history of anemia requiring transfusions
  3. Regular use of aspirin or NSAIDs with dark stools Correct answer.
  4. Strict vegan diet for many years

Explanation

Microcytic anemia with low ferritin indicates iron deficiency, and chronic gastrointestinal blood loss from aspirin or NSAIDs is a common cause in older adults. Occult bleeding should prompt evaluation of the gastrointestinal tract. Alcohol use typically causes macrocytosis, and a vegan diet more often causes B12 deficiency with macrocytosis.

Question 28Internal Medicine

A 46-year-old man with no prior cardiac history presents with sudden-onset dyspnea and pleuritic chest pain. He is tachycardic at 118/min, and ECG shows sinus tachycardia with right ventricular strain. Which test is the most appropriate next step to confirm the diagnosis?

  1. CT pulmonary angiography Correct answer.
  2. Transthoracic echocardiography
  3. Coronary angiography
  4. Exercise stress testing

Explanation

The presentation suggests acute pulmonary embolism, and CT pulmonary angiography is the standard confirmatory imaging test in a hemodynamically stable patient. Right ventricular strain on ECG supports the diagnosis. Echocardiography may show right heart strain but does not reliably confirm or exclude pulmonary embolism.

Question 29Internal Medicine

A 52-year-old woman has a blood pressure of 158/96 mmHg on repeated measurements. She has no diabetes, chronic kidney disease, or cardiovascular disease. What is the most appropriate initial pharmacologic therapy?

  1. An alpha blocker as first-line monotherapy
  2. A loop diuretic as first-line monotherapy
  3. Mineralocorticoid receptor antagonist as first-line monotherapy
  4. A thiazide-type diuretic, an ACE inhibitor, or a dihydropyridine calcium channel blocker Correct answer.

Explanation

For uncomplicated hypertension, first-line agents include thiazide-type diuretics, ACE inhibitors or ARBs, and dihydropyridine calcium channel blockers. These classes have outcome data for reducing cardiovascular events. Alpha blockers, loop diuretics, and mineralocorticoid antagonists are not preferred initial monotherapy in uncomplicated hypertension.

Question 30Internal Medicine

A 38-year-old man has a fasting plasma glucose of 132 mg/dL on two separate occasions. Which additional finding would confirm the diagnosis of diabetes mellitus?

  1. Random plasma glucose of 150 mg/dL
  2. Fasting plasma glucose of 118 mg/dL on a third occasion
  3. Two-hour plasma glucose of 220 mg/dL during a 75-g oral glucose tolerance test Correct answer.
  4. Glycated hemoglobin of 5.9%

Explanation

Diabetes is diagnosed when the 2-hour plasma glucose during a 75-g oral glucose tolerance test is 200 mg/dL or higher. A fasting glucose of 126 mg/dL or more, a random glucose of 200 mg/dL or more with symptoms, or an HbA1c of 6.5% or more also confirm the diagnosis. Values below these thresholds indicate prediabetes or normal glucose tolerance.

Question 31Internal Medicine

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

  1. Hyperosmolar hyperglycemic state
  2. Acute pancreatitis
  3. Hepatic encephalopathy
  4. Wernicke encephalopathy Correct answer.

Explanation

Thiamine deficiency causes Wernicke encephalopathy, characterized by confusion, ataxia, and oculomotor dysfunction. Glucose administration without thiamine can precipitate or worsen this condition in at-risk patients. Thiamine should therefore be given before or with glucose in patients with alcohol use disorder.

Question 32Internal Medicine

A 62-year-old man with heart failure and reduced ejection fraction has persistent volume overload despite an ACE inhibitor and beta blocker. Which additional medication improves survival in this condition?

  1. Diltiazem
  2. Amlodipine
  3. Digoxin
  4. A mineralocorticoid receptor antagonist Correct answer.

Explanation

Mineralocorticoid receptor antagonists such as spironolactone improve survival in patients with heart failure and reduced ejection fraction. They are added when symptoms persist despite standard therapy. Digoxin reduces hospitalizations but does not improve survival, and non-dihydropyridine calcium channel blockers are generally avoided in reduced ejection fraction.

Question 33Internal Medicine

A 29-year-old woman has recurrent episodes of severe headache, palpitations, and diaphoresis with markedly elevated blood pressure. Plasma metanephrines are elevated. Which imaging study is most appropriate for localization?

  1. Positron emission tomography of the chest
  2. Magnetic resonance angiography of the brain
  3. Abdominal CT or MRI of the adrenal glands Correct answer.
  4. Renal artery duplex ultrasound

Explanation

Biochemical evidence of pheochromocytoma should be followed by imaging of the adrenal glands, usually CT or MRI. Pheochromocytomas are most often adrenal. Renal artery imaging and brain angiography address different causes of secondary hypertension.

Question 34Internal Medicine

A 70-year-old woman has a serum calcium of 11.2 mg/dL and a serum phosphate of 2.4 mg/dL. Parathyroid hormone is elevated. Which diagnosis is most likely?

  1. Secondary hyperparathyroidism from chronic kidney disease
  2. Hypoparathyroidism
  3. Primary hyperparathyroidism Correct answer.
  4. Malignancy-associated hypercalcemia

Explanation

Primary hyperparathyroidism typically causes hypercalcemia with an inappropriately elevated or high-normal parathyroid hormone and low-normal phosphate. Chronic kidney disease causes secondary hyperparathyroidism with hypocalcemia or low-normal calcium and hyperphosphatemia. Malignancy-associated hypercalcemia usually suppresses parathyroid hormone.

Question 35Internal Medicine

A 48-year-old man presents with fever, productive cough, and a focal infiltrate on chest radiograph. He has no comorbidities and no recent antibiotic use. Which antibiotic is most appropriate for outpatient therapy?

  1. Trimethoprim-sulfamethoxazole alone
  2. Amoxicillin alone Correct answer.
  3. Metronidazole alone
  4. Amoxicillin-clavulanate plus azithromycin

Explanation

High-dose amoxicillin is an appropriate first-line option for uncomplicated community-acquired pneumonia in a patient without comorbidities, because it covers Streptococcus pneumoniae. Combination therapy is reserved for patients with comorbidities or recent antibiotic exposure. Agents without reliable pneumococcal activity are not appropriate monotherapy.

Question 36Internal Medicine

A 34-year-old woman has a deep vein thrombosis of the left leg. She is otherwise healthy, is not pregnant, and has normal renal function. Which anticoagulant is most appropriate for initial and long-term therapy?

  1. Warfarin alone without bridging
  2. Aspirin
  3. A direct oral anticoagulant such as apixaban Correct answer.
  4. Unfractionated heparin infusion

Explanation

Direct oral anticoagulants such as apixaban are recommended for the treatment of acute deep vein thrombosis in patients without contraindications. They offer effective anticoagulation without routine monitoring. Warfarin requires bridging with a parenteral anticoagulant initially, and aspirin is inadequate for treating venous thromboembolism.

Question 37Internal Medicine

A 60-year-old man has a serum creatinine of 2.8 mg/dL and a history of chronic kidney disease. He is given a course of an aminoglycoside. Which monitoring strategy best detects early nephrotoxicity?

  1. Weekly serum creatinine only
  2. Routine renal ultrasound
  3. Serial serum potassium levels only
  4. Daily serum creatinine and urine output monitoring Correct answer.

Explanation

Aminoglycosides can cause acute kidney injury, and early detection relies on monitoring serum creatinine and urine output. Daily monitoring allows timely discontinuation or dose adjustment. Potassium alone is insufficient, and renal ultrasound does not detect drug-induced tubular injury.

Question 38Internal Medicine

A 45-year-old man has a 6-month history of fatigue, weight loss, and night sweats. Examination reveals cervical lymphadenopathy. Which finding on biopsy would best confirm a diagnosis of Hodgkin lymphoma?

  1. Monoclonal B-cell proliferation
  2. Reed-Sternberg cells Correct answer.
  3. Auer rods
  4. Noncaseating granulomas

Explanation

Hodgkin lymphoma is characterized by Reed-Sternberg cells on biopsy. Monoclonal B-cell proliferation suggests non-Hodgkin lymphoma, and Auer rods are seen in acute myeloid leukemia. Noncaseating granulomas suggest sarcoidosis.

Question 39Internal Medicine

A 66-year-old woman with type 2 diabetes has an eGFR of 28 mL/min/1.73 m2 and an albumin-to-creatinine ratio of 400 mg/g. Which medication most slows progression of her kidney disease?

  1. A loop diuretic
  2. An ACE inhibitor or ARB Correct answer.
  3. A thiazide diuretic
  4. A beta blocker

Explanation

ACE inhibitors or ARBs reduce albuminuria and slow progression of diabetic kidney disease, particularly in patients with albuminuria. They are recommended even in advanced chronic kidney disease with monitoring of creatinine and potassium. Diuretics and beta blockers treat comorbid conditions but do not specifically slow kidney disease progression.

Question 40Internal Medicine

A 72-year-old man with atrial fibrillation falls frequently and has a history of intracranial hemorrhage. He has a CHA2DS2-VASc score of 5. Which consideration most influences the decision about anticoagulation?

  1. His CHA2DS2-VASc score alone
  2. Bleeding risk from his fall history and prior intracranial hemorrhage Correct answer.
  3. His blood pressure control
  4. His age alone

Explanation

In atrial fibrillation, the decision to anticoagulate balances stroke risk against bleeding risk. A history of intracranial hemorrhage and frequent falls substantially increase bleeding risk and require careful individualized assessment. Age and the CHA2DS2-VASc score alone do not capture this bleeding risk.

Question 41General Surgery

A 24-year-old man presents with a 6-hour history of periumbilical pain that migrated to the right lower quadrant, associated with anorexia and low-grade fever. On examination there is tenderness at McBurney's point with guarding. Which is the most appropriate next step in management?

  1. Colonoscopy to exclude a caecal tumour
  2. Observation with serial abdominal examinations for 24 hours
  3. Discharge with oral antibiotics and outpatient review in 48 hours
  4. Urgent appendectomy after appropriate resuscitation Correct answer.

Explanation

The clinical picture is classic for acute appendicitis, and the standard of care is appendectomy after brief resuscitation with intravenous fluids and antibiotics. Delay increases the risk of perforation and peritonitis. Cross-sectional imaging may be used when the diagnosis is equivocal, but it should not delay surgery in clear-cut cases.

Question 42General Surgery

Which structure is most commonly the first to become obstructed in a strangulated indirect inguinal hernia?

  1. The femoral vein at the inguinal ligament
  2. The bowel at the internal ring Correct answer.
  3. The omentum at the external ring
  4. The testis within the scrotum

Explanation

An indirect inguinal hernia passes through the deep (internal) ring, which is the narrowest point of the sac and the site where bowel most often becomes constricted. Strangulation typically occurs at this neck. The external ring is wider and less commonly the point of obstruction.

Question 43General Surgery

A 45-year-old woman has a 2 cm firm, mobile, non-tender breast mass. Which investigation provides the highest diagnostic accuracy for a solid breast lesion?

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

Explanation

Core needle biopsy yields histological architecture and allows grading and receptor testing, giving high diagnostic accuracy for solid breast masses. Cytology cannot distinguish invasive from in situ disease. Imaging alone is insufficient to confirm malignancy.

Question 44General Surgery

Which finding is most characteristic of acute cholecystitis on abdominal ultrasound?

  1. Multiple small cysts throughout the liver
  2. Dilated common bile duct with a visible stone
  3. A hyperechoic pancreas with peripancreatic fluid
  4. Thickened gallbladder wall with a sonographic Murphy's sign Correct answer.

Explanation

Acute cholecystitis typically shows gallbladder wall thickening, pericholecystic fluid, and a sonographic Murphy's sign. A dilated duct with a stone suggests choledocholithiasis rather than cholecystitis. The other options describe unrelated hepatic or pancreatic pathology.

Question 45General Surgery

A 60-year-old man presents with painless obstructive jaundice and a palpable, non-tender gallbladder. What is the most likely diagnosis?

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

Explanation

Painless obstructive jaundice with a palpable, distended gallbladder (Courvoisier's law) suggests a malignant obstruction, most commonly pancreatic head carcinoma. Gallstone obstruction usually produces a scarred, non-distensible gallbladder. Cholangitis and hepatitis present with pain or systemic features.

Question 46General Surgery

What is the most common cause of acute pancreatitis worldwide?

  1. Gallstones and alcohol Correct answer.
  2. Viral infection
  3. Hypertriglyceridaemia
  4. Abdominal trauma

Explanation

Gallstones and alcohol account for the majority of acute pancreatitis cases in most populations. Hypertriglyceridaemia and trauma are less common causes. Viral infection is a rare aetiology.

Question 47General Surgery

A patient has a deep partial-thickness burn involving 20% of total body surface area. Which is the most appropriate initial fluid resuscitation formula?

  1. 5% dextrose at maintenance rate
  2. Parkland formula using lactated Ringer's solution Correct answer.
  3. Hypertonic saline at a fixed rate
  4. Colloid infusion alone

Explanation

The Parkland formula (4 mL/kg/%TBSA of lactated Ringer's over 24 hours, half in the first 8 hours) is the standard initial resuscitation for major burns. Dextrose and colloid-only regimens are inappropriate for acute burn shock. Hypertonic saline is not first-line.

Question 48General Surgery

Which is the most reliable clinical sign of adequate resuscitation in a patient with hypovolaemic shock?

  1. A respiratory rate below 20 per minute
  2. A rising haematocrit
  3. Warm extremities with a normal blood pressure
  4. Urine output of at least 0.5 mL/kg/hour Correct answer.

Explanation

Urine output is a sensitive marker of renal perfusion and therefore of adequate resuscitation, with a target of 0.5 mL/kg/hour in adults. Blood pressure can remain normal until significant volume loss has occurred. A rising haematocrit may reflect haemoconcentration rather than adequate resuscitation.

Question 49General Surgery

A 30-year-old man has a penetrating abdominal stab wound with evisceration of omentum. What is the most appropriate management?

  1. Urgent laparotomy Correct answer.
  2. CT scan followed by observation
  3. Wound closure with outpatient follow-up
  4. Local wound exploration and discharge

Explanation

Evisceration after penetrating abdominal trauma is an indication for urgent laparotomy because of the high likelihood of intra-abdominal injury. Local exploration or observation is inappropriate when bowel or omentum is exteriorised. Delay increases the risk of peritonitis and sepsis.

Question 50General Surgery

Which is the most common cause of small bowel obstruction in an adult who has not had previous abdominal surgery?

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

Explanation

In patients without prior surgery, malignancy is a common cause of small bowel obstruction, whereas adhesions dominate in those with previous laparotomy. Gallstone ileus and intussusception are less common. Identifying the likely cause guides the choice of imaging and operative planning.