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PMC Medicine Licensure practice questions

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Question 1Internal Medicine

A 58-year-old man has a fasting plasma glucose of 132 mg/dL on two separate occasions. Which diagnosis is most appropriate?

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

Explanation

A fasting plasma glucose of 126 mg/dL or higher confirmed on a second occasion establishes the diagnosis of diabetes mellitus. Values between 100 and 125 mg/dL define impaired fasting glucose, which is a prediabetic state rather than diabetes.

Question 2Internal Medicine

Which finding on serum testing most strongly suggests iron deficiency anemia rather than anemia of chronic disease?

  1. Elevated ferritin
  2. Normal transferrin saturation
  3. Low serum ferritin Correct answer.
  4. Elevated total iron-binding capacity

Explanation

Ferritin reflects body iron stores and is characteristically low in iron deficiency anemia. In anemia of chronic disease ferritin is typically normal or elevated because it is an acute-phase reactant.

Question 3Internal Medicine

A 70-year-old woman has a blood pressure of 158/92 mmHg averaged over three visits. She has no diabetes or kidney disease. What is the recommended initial pharmacologic therapy?

  1. Loop diuretic alone
  2. Beta blocker alone
  3. Thiazide-type diuretic, ACE inhibitor, ARB, or calcium channel blocker Correct answer.
  4. Alpha blocker alone

Explanation

For uncomplicated hypertension in older adults, first-line agents are thiazide-type diuretics, ACE inhibitors, ARBs, or dihydropyridine calcium channel blockers. Beta blockers and alpha blockers are not preferred initial monotherapy for uncomplicated hypertension.

Question 4Internal Medicine

A patient presents with sudden-onset tearing chest pain radiating to the back. Which imaging study is the most appropriate first-line test when the patient is hemodynamically stable?

  1. Computed tomography angiography Correct answer.
  2. Exercise stress testing
  3. Coronary angiography
  4. Transthoracic echocardiography

Explanation

CT angiography of the aorta is the preferred initial imaging test for suspected acute aortic dissection in a stable patient, with high sensitivity and specificity. Echocardiography is useful in unstable patients or at the bedside but is less definitive for the entire aorta.

Question 5Internal Medicine

Which laboratory pattern is most consistent with primary hypothyroidism?

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

Explanation

Primary hypothyroidism results from thyroid gland failure, so free T4 is low and the pituitary compensates with an elevated TSH. A low TSH with low free T4 instead suggests central (secondary) hypothyroidism.

Question 6Internal Medicine

A 24-year-old woman has a severe throbbing unilateral headache with nausea and photophobia that worsens with activity. What is the most appropriate acute treatment?

  1. Intravenous ceftriaxone
  2. Oral amoxicillin
  3. Oral sumatriptan Correct answer.
  4. Intramuscular haloperidol

Explanation

The presentation is consistent with migraine. Triptans such as sumatriptan are effective acute therapies for moderate to severe migraine attacks. Antibiotics and antipsychotics are not indicated for migraine.

Question 7Internal Medicine

Which finding is most characteristic of nephrotic syndrome?

  1. Hematuria with red cell casts
  2. Hyperkalemia with metabolic acidosis
  3. Massive proteinuria with hypoalbuminemia Correct answer.
  4. Oliguria with elevated creatinine

Explanation

Nephrotic syndrome is defined by heavy proteinuria (typically more than 3.5 g/day) with hypoalbuminemia, edema, and hyperlipidemia. Red cell casts and hematuria are features of nephritic syndrome.

Question 8Internal Medicine

A 65-year-old smoker has chronic productive cough for three months per year for two consecutive years. Which diagnosis best fits?

  1. Pulmonary embolism
  2. Chronic bronchitis Correct answer.
  3. Bronchiectasis
  4. Asthma

Explanation

Chronic bronchitis is defined clinically as a productive cough for at least three months in each of two consecutive years. Smoking is the most common risk factor.

Question 9Internal Medicine

A patient with atrial fibrillation and a CHA2DS2-VASc score of 4 has no bleeding contraindications. What is the most appropriate therapy to reduce stroke risk?

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

Explanation

A CHA2DS2-VASc score of 2 or higher in men indicates sufficient stroke risk to warrant oral anticoagulation. Anticoagulation reduces cardioembolic stroke more effectively than antiplatelet therapy.

Question 10Internal Medicine

Which electrolyte abnormality is most likely in a patient with prolonged vomiting?

  1. Hyperkalemia with metabolic acidosis
  2. Hypokalemia with metabolic alkalosis Correct answer.
  3. Hyperkalemia with metabolic alkalosis
  4. Hypokalemia with metabolic acidosis

Explanation

Vomiting causes loss of gastric acid (hydrogen and chloride), producing a metabolic alkalosis, and renal potassium wasting leads to hypokalemia. The resulting pattern is hypokalemic, hypochloremic metabolic alkalosis.

Question 11Internal Medicine

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

  1. Pseudomonas aeruginosa
  2. Mycoplasma hominis
  3. Streptococcus pneumoniae Correct answer.
  4. Staphylococcus saprophyticus

Explanation

Streptococcus pneumoniae remains the most frequently identified cause of community-acquired pneumonia in adults. Pseudomonas is typically a nosocomial or structurally abnormal lung pathogen.

Question 12Internal Medicine

A 45-year-old man has a serum calcium of 11.8 mg/dL with an inappropriately normal parathyroid hormone level. What is the most likely diagnosis?

  1. Vitamin D deficiency
  2. Primary hyperparathyroidism Correct answer.
  3. Chronic kidney disease
  4. Hypoparathyroidism

Explanation

Hypercalcemia with a nonsuppressed parathyroid hormone level is the hallmark of primary hyperparathyroidism. In hypercalcemia of other causes, PTH should be suppressed.

Question 13Internal Medicine

Which medication is the preferred initial treatment for a patient with newly diagnosed type 2 diabetes and no contraindications?

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

Explanation

Metformin is recommended as first-line pharmacotherapy for type 2 diabetes because of its efficacy, safety profile, low cost, and cardiovascular benefit. Other agents are added or substituted when specific comorbidities or contraindications exist.

Question 14Internal Medicine

A patient with known heart failure with reduced ejection fraction has worsening dyspnea. Which medication class has been shown to reduce mortality in this condition?

  1. Nonsteroidal anti-inflammatory drugs
  2. Beta blockers Correct answer.
  3. Thiazolidinediones
  4. Dihydropyridine calcium channel blockers

Explanation

Beta blockers such as carvedilol, metoprolol succinate, and bisoprolol reduce mortality in heart failure with reduced ejection fraction. Several other drug classes can worsen heart failure and should be avoided.

Question 15Internal Medicine

A 30-year-old presents with fever, polyarthralgia, and a new murmur. Blood cultures grow gram-positive cocci in chains. What is the most likely diagnosis?

  1. Rheumatic fever
  2. Myocarditis
  3. Infective endocarditis Correct answer.
  4. Acute pericarditis

Explanation

Fever, arthralgias, a new murmur, and gram-positive cocci in chains (suggestive of streptococci or enterococci) point to infective endocarditis. Blood cultures plus echocardiography establish the diagnosis.

Question 16Internal Medicine

Which finding on urinalysis is most suggestive of acute interstitial nephritis?

  1. White blood cell casts Correct answer.
  2. Broad waxy casts
  3. Oval fat bodies
  4. Muddy brown casts

Explanation

Acute interstitial nephritis is characterized by sterile pyuria with white blood cell casts and often eosinophiluria. It is commonly drug-induced, such as from proton pump inhibitors or antibiotics.

Question 17Internal Medicine

A 60-year-old with cirrhosis presents with confusion and asterixis. Which precipitant should be evaluated first?

  1. Hyperglycemia
  2. Hyperthyroidism
  3. Hypernatremia
  4. Gastrointestinal bleeding Correct answer.

Explanation

Gastrointestinal bleeding is a common and dangerous precipitant of hepatic encephalopathy because blood protein is metabolized to ammonia. Other precipitants include infection, constipation, and electrolyte disturbance.

Question 18Internal Medicine

Which antibody is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA antibodies are highly specific for SLE and correlate with disease activity and lupus nephritis. Antinuclear antibody is sensitive but not specific.

Question 19Internal Medicine

A patient with a history of peptic ulcer disease develops sudden severe epigastric pain with board-like abdominal rigidity. What is the most likely diagnosis?

  1. Acute cholecystitis
  2. Perforated peptic ulcer Correct answer.
  3. Acute pancreatitis
  4. Mesenteric ischemia

Explanation

Sudden severe pain with a rigid, board-like abdomen in a patient with ulcer history suggests perforation with peritonitis. Free air on upright imaging supports the diagnosis.

Question 20Internal Medicine

Which of the following is the most appropriate initial step in managing an unresponsive hypoglycemic patient without intravenous access?

  1. Oral glucose gel
  2. Oral metformin
  3. Subcutaneous insulin
  4. Intramuscular glucagon Correct answer.

Explanation

When a hypoglycemic patient cannot take oral glucose and IV access is unavailable, intramuscular or subcutaneous glucagon is the treatment of choice. It mobilizes hepatic glycogen to raise blood glucose.

Question 21Internal Medicine

A 72-year-old man has a serum sodium of 118 mmol/L with confusion. Which correction rate is safest?

  1. Correction no faster than 8-10 mmol/L in 24 hours Correct answer.
  2. No correction at all
  3. Rapid correction by 20 mmol/L in the first hour
  4. Correction to normal within 6 hours

Explanation

Severe hyponatremia should be corrected slowly, generally no more than 8-10 mmol/L in 24 hours, to avoid osmotic demyelination syndrome. Hypertonic saline may be used cautiously for symptomatic cases with close monitoring.

Question 22Internal Medicine

A patient with a mechanical mitral valve requires anticoagulation. Which agent is preferred?

  1. Warfarin Correct answer.
  2. Dabigatran
  3. Rivaroxaban
  4. Apixaban

Explanation

Warfarin remains the anticoagulant of choice for patients with mechanical heart valves. Direct oral anticoagulants are not recommended in this population because of increased thromboembolic and bleeding risk.

Question 23Internal Medicine

A 55-year-old with long-standing type 2 diabetes has a creatinine of 2.6 mg/dL and an estimated GFR of 22 mL/min/1.73 m2. Which medication should be avoided?

  1. Amlodipine
  2. Atorvastatin
  3. Metformin Correct answer.
  4. Insulin

Explanation

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73 m2 because of the risk of lactic acidosis from drug accumulation. Insulin, amlodipine, and atorvastatin can be used with appropriate monitoring.

Question 24Internal Medicine

Which finding best distinguishes an exudative from a transudative pleural effusion?

  1. Pleural fluid glucose above 60 mg/dL
  2. Pleural fluid pH of 7.45
  3. Pleural fluid protein to serum protein ratio above 0.5 Correct answer.
  4. Clear straw-colored appearance

Explanation

Light's criteria classify an effusion as exudative when the pleural fluid to serum protein ratio exceeds 0.5, the pleural to serum LDH ratio exceeds 0.6, or pleural LDH exceeds two-thirds the upper limit of normal serum LDH. Transudates result from pressure imbalances such as heart failure.

Question 25Internal Medicine

A patient develops fever, rash, and eosinophilia two weeks after starting allopurinol. Which diagnosis is most likely?

  1. Serum sickness
  2. Stevens-Johnson syndrome
  3. Anaphylaxis
  4. Drug reaction with eosinophilia and systemic symptoms Correct answer.

Explanation

DRESS syndrome presents with fever, rash, eosinophilia, and multiorgan involvement, typically two to eight weeks after starting a culprit drug such as allopurinol. Withdrawal of the drug and supportive care are essential.

Question 26Internal Medicine

A 68-year-old man with hypertension and type 2 diabetes has an eGFR of 38 mL/min/1.73 m2 and a urine albumin-to-creatinine ratio of 450 mg/g. Blood pressure is 148/88 mmHg. Which medication class slows progression of his kidney disease in addition to lowering blood pressure?

  1. ACE inhibitor Correct answer.
  2. Thiazide diuretic
  3. Alpha-1 blocker
  4. Loop diuretic

Explanation

Blockade of the renin-angiotensin system with an ACE inhibitor (or ARB) reduces intraglomerular pressure and slows progression of albuminuric chronic kidney disease. The benefit is greatest in patients with both diabetes and significant proteinuria.

Question 27Internal Medicine

A 58-year-old woman develops sudden-onset palpitations and lightheadedness. ECG shows a narrow-complex tachycardia that is regular at 190 beats/min with no visible P waves. She is hypotensive at 82/50 mmHg and has cool extremities. What is the most appropriate immediate management?

  1. Intravenous amiodarone
  2. Synchronized cardioversion Correct answer.
  3. Oral beta blocker
  4. Vagal maneuvers

Explanation

A regular narrow-complex tachycardia with hemodynamic instability (hypotension, poor perfusion) requires immediate synchronized electrical cardioversion. Pharmacologic or vagal strategies are reserved for stable patients.

Question 28Internal Medicine

A 40-year-old man has recurrent calcium kidney stones. Serum calcium is normal, and he reports several episodes of severe flank pain with no infection. Which dietary measure most reduces recurrence of calcium oxalate stones?

  1. Increasing fluid intake to produce over 2.5 L of urine daily Correct answer.
  2. Supplements of vitamin C at high dose
  3. Restricting dietary calcium to under 400 mg daily
  4. Restricting dietary potassium

Explanation

High fluid intake to achieve urine output above roughly 2.5 L per day is the cornerstone of preventing recurrent calcium stones by reducing urine supersaturation. Dietary calcium restriction is generally discouraged because it can increase oxalate absorption and stone risk.

Question 29Internal Medicine

A 34-year-old woman has fatigue, cold intolerance, and weight gain. Examination shows a diffuse, firm, nontender goiter. TSH is elevated and free T4 is low. Which finding best supports Hashimoto thyroiditis as the cause?

  1. Suppressed TSH with elevated free T4
  2. Positive antithyroid peroxidase antibodies Correct answer.
  3. Elevated thyroid-stimulating immunoglobulin
  4. Low radioactive iodine uptake with a hot nodule

Explanation

Hashimoto thyroiditis is an autoimmune hypothyroidism characterized by antithyroid peroxidase (and antithyroglobulin) antibodies. The combination of primary hypothyroidism with a firm goiter and positive antibodies establishes the diagnosis.

Question 30Internal Medicine

A 62-year-old man is admitted with 3 days of melena. He takes ibuprofen daily. Hemoglobin is 7.2 g/dL, blood pressure 96/60 mmHg, and heart rate 118 beats/min. After two large-bore IV lines are placed and fluid resuscitation is begun, what is the most appropriate next step in management?

  1. Discharge with a proton pump inhibitor
  2. Immediate oral iron therapy
  3. Barium swallow study
  4. Upper endoscopy after initial stabilization Correct answer.

Explanation

In acute upper GI bleeding, the priority is hemodynamic resuscitation followed by urgent endoscopy, which allows identification and endoscopic hemostasis of the bleeding lesion. Endoscopy is performed promptly once the patient is stabilized rather than deferred.

Question 31Surgery and Allied Surgical Specialties

A 24-year-old man has a painful swelling in the scrotum of sudden onset after lifting. Examination shows a high-riding testis with an absent cremasteric reflex and a transverse lie. What is the most appropriate immediate management?

  1. Urgent ultrasound of the scrotum before any intervention
  2. Aspiration of the hydrocele under local anaesthesia
  3. Scrotal exploration with detorsion and bilateral orchidopexy Correct answer.
  4. Antibiotics and analgesia with review in 24 hours

Explanation

Testicular torsion is a clinical diagnosis and a surgical emergency; the testis is salvageable in most cases if detorsion occurs within about six hours. Exploration allows detorsion and fixation of both testes, since the underlying bell-clapper anomaly is usually bilateral. Imaging must not delay surgery when the picture is typical.

Question 32Surgery and Allied Surgical Specialties

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

  1. A swelling that descends into the scrotum
  2. A cough impulse present on standing
  3. An impulse felt lateral to the inferior epigastric vessels Correct answer.
  4. A reducible swelling above the inguinal ligament

Explanation

Indirect hernias pass lateral to the inferior epigastric vessels through the deep ring, while direct hernias bulge medial to them through Hesselbach's triangle. Scrotal descent and reducibility do not reliably separate the two. The distinction is confirmed at surgery by the relation of the sac to the inferior epigastric vessels.

Question 33Surgery and Allied Surgical Specialties

A 62-year-old woman has a 3 cm ulcerated, painless mass at the lower anal canal extending to the anal margin. Biopsy shows squamous cell carcinoma. Which management is most appropriate for the primary tumour?

  1. Chemoradiotherapy with mitomycin and fluorouracil Correct answer.
  2. Wide local excision alone
  3. Topical imiquimod
  4. Abdominoperineal excision of the rectum

Explanation

Anal squamous cell carcinoma is primarily treated with combined chemoradiotherapy, which preserves the sphincter and achieves good local control. Surgery is reserved for salvage of residual or recurrent disease. Abdominoperineal resection is not first-line for a chemoradiosensitive tumour.

Question 34Surgery and Allied Surgical Specialties

A 45-year-old man presents with severe epigastric pain radiating to the back, vomiting, and a serum lipase three times the upper limit of normal. Which single initial step most improves outcome?

  1. Urgent endoscopic retrograde cholangiopancreatography
  2. Early aggressive intravenous fluid resuscitation Correct answer.
  3. Prophylactic broad-spectrum antibiotics
  4. Immediate CT of the abdomen with contrast

Explanation

Early goal-directed intravenous fluid resuscitation is the cornerstone of initial management of acute pancreatitis and reduces pancreatic necrosis and organ failure. CT is not needed to make the diagnosis and is most useful after 72 hours if complications are suspected. Antibiotics are not given prophylactically, and ERCP is reserved for concurrent cholangitis or persistent biliary obstruction.

Question 35Surgery and Allied Surgical Specialties

Which is the most common cause of acute mechanical small bowel obstruction in an adult who has had no previous abdominal surgery?

  1. Incarcerated hernia Correct answer.
  2. Gallstone ileus
  3. Malignancy
  4. Adhesions

Explanation

In patients without prior laparotomy, an incarcerated or strangulated hernia is the leading cause of small bowel obstruction. Adhesions dominate only in patients with previous abdominal surgery. Malignancy and gallstone ileus are less common causes.

Question 36Surgery and Allied Surgical Specialties

A 30-year-old woman has a 2 cm freely mobile, smooth breast lump. Ultrasound shows a well-defined hypoechoic mass, and core biopsy confirms a fibroadenoma. She is asymptomatic. What is the most appropriate management?

  1. Tamoxifen for five years
  2. Mastectomy with sentinel node biopsy
  3. Reassurance and observation with review Correct answer.
  4. Wide local excision with radiotherapy

Explanation

A biopsy-proven fibroadenoma that is small, well-defined, and asymptomatic can be safely observed; many regress over time. Excision is reserved for large, growing, or symptomatic lesions or diagnostic uncertainty. Malignant management is inappropriate for a benign lesion.

Question 37Surgery and Allied Surgical Specialties

A 58-year-old man has painless gross haematuria. Which investigation is the most appropriate initial assessment of the upper urinary tract?

  1. Intravenous urography
  2. Renal artery Doppler
  3. CT urography Correct answer.
  4. Retrograde urethrogram

Explanation

CT urography is the imaging test of choice for painless haematuria because it detects urothelial tumours, stones, and renal masses with high sensitivity. It is combined with cystoscopy to complete the evaluation. Intravenous urography has largely been superseded.

Question 38Surgery and Allied Surgical Specialties

A 70-year-old man has a hard, nodular prostate with a PSA of 18 ng/mL. Biopsy shows adenocarcinoma, Gleason score 4+3=7. Which factor in this presentation most strongly predicts a poor prognosis?

  1. Patient age at diagnosis
  2. Nodular consistency on examination
  3. Gleason grade pattern 4 component Correct answer.
  4. Serum PSA level

Explanation

The Gleason grade, particularly the presence and proportion of pattern 4 or 5, is one of the strongest predictors of prostate cancer behaviour. Higher grade correlates with extracapsular extension, metastasis, and cancer-specific mortality. PSA and clinical stage contribute but are less powerful than grade.

Question 39Surgery and Allied Surgical Specialties

A 35-year-old man has a 4 mm radiopaque stone in the distal ureter with mild hydronephrosis, no fever, and controlled pain. What is the most appropriate initial management?

  1. Immediate open ureterolithotomy
  2. Ureteroscopy with laser lithotripsy
  3. Observation with analgesia and hydration Correct answer.
  4. Percutaneous nephrostomy

Explanation

Small distal ureteric stones under 5-6 mm have a high chance of spontaneous passage, so observation with analgesia and hydration is appropriate if there is no obstruction with infection. Intervention is indicated for failure to pass, uncontrolled pain, or sepsis.

Question 40Surgery and Allied Surgical Specialties

A 6-year-old boy has a painless, smooth scrotal swelling that transilluminates and does not reduce. What is the most likely diagnosis?

  1. Varicocele
  2. Testicular tumour
  3. Indirect inguinal hernia
  4. Hydrocele Correct answer.

Explanation

A hydrocele is a fluid collection in the tunica vaginalis that transilluminates brightly and does not reduce. It is common in children and often resolves spontaneously. Hernias contain bowel and do not transilluminate, while varicoceles feel like a bag of worms and tumours are solid.

Question 41Surgery and Allied Surgical Specialties

A 55-year-old woman has a 1.5 cm papillary thyroid carcinoma confined to one lobe with no lymph node involvement. What is the most appropriate surgical management?

  1. Observation with annual ultrasound
  2. Hemithyroidectomy alone Correct answer.
  3. Total thyroidectomy with central neck dissection
  4. Radioactive iodine ablation without surgery

Explanation

For a small, low-risk, unifocal papillary carcinoma confined to one lobe, hemithyroidectomy (lobectomy) is adequate and avoids the risks of bilateral surgery. Total thyroidectomy with neck dissection is reserved for larger, bilateral, or node-positive disease. Radioactive iodine follows total thyroidectomy in selected high-risk cases.

Question 42Surgery and Allied Surgical Specialties

A 28-year-old woman has a 2 cm thyroid nodule and a fine-needle aspirate reported as Bethesda category III (atypical cells of undetermined significance). What is the most appropriate next step?

  1. Suppressive levothyroxine
  2. Immediate total thyroidectomy
  3. Radioactive iodine therapy
  4. Repeat fine-needle aspiration or molecular testing Correct answer.

Explanation

Bethesda III aspirates carry an indeterminate risk of malignancy, so repeat aspiration or molecular testing is used to refine the diagnosis before committing to surgery. Diagnostic lobectomy is also acceptable. Immediate total thyroidectomy or radioiodine would overtreat a lesion that is often benign.

Question 43Surgery and Allied Surgical Specialties

A 48-year-old man has a 2 cm distal rectal adenocarcinoma. Endoscopic ultrasound shows invasion into the muscularis propria with no involved nodes. Which operation is most appropriate?

  1. Anterior resection Correct answer.
  2. Local transanal excision
  3. Hartmann's procedure
  4. Abdominoperineal resection

Explanation

A tumour of the mid to upper rectum with T2 stage and no nodal disease is treated by anterior resection with total mesorectal excision. Local excision is inadequate for T2 lesions because of the risk of involved lymph nodes. Abdominoperineal resection is reserved for very low tumours involving the sphincter.

Question 44Surgery and Allied Surgical Specialties

Which of the following is the most reliable early clinical sign of hypovolaemic shock in a trauma patient?

  1. Narrowed pulse pressure Correct answer.
  2. Bradycardia
  3. Hypertension
  4. Widened pulse pressure

Explanation

Early compensated shock produces tachycardia and peripheral vasoconstriction, which narrows the pulse pressure before systolic pressure falls. Bradycardia and hypotension are late or atypical findings. A widened pulse pressure suggests a hyperdynamic state rather than hypovolaemia.

Question 45Surgery and Allied Surgical Specialties

A 22-year-old man has a stab wound to the left fifth intercostal space with hypotension and distended neck veins. Which is the most appropriate immediate action?

  1. Pericardiocentesis
  2. Needle decompression of the left chest
  3. Emergency thoracotomy Correct answer.
  4. Chest drain insertion

Explanation

Penetrating chest trauma with hypotension and raised venous pressure suggests cardiac tamponade, which in a trauma setting requires immediate surgical decompression via thoracotomy or sternotomy. Pericardiocentesis is at best a temporising measure and may be unreliable. Chest decompression treats tension pneumothorax, which would not cause distended neck veins in the same way.

Question 46Surgery and Allied Surgical Specialties

A 40-year-old man has an acute abdomen with free gas under the diaphragm on erect chest radiograph. Which is the most common cause of perforation in this age group?

  1. Perforated appendicitis
  2. Perforated peptic ulcer Correct answer.
  3. Perforated diverticulitis
  4. Perforated oesophageal cancer

Explanation

Perforated peptic ulcer is the leading cause of free intraperitoneal gas in a young to middle-aged adult. Perforated diverticulitis and appendicitis usually produce localised signs and are less common causes of massive pneumoperitoneum. Malignant perforation is rare.

Question 47Surgery and Allied Surgical Specialties

A 65-year-old woman has right upper quadrant pain, fever, and jaundice (Charcot's triad). Ultrasound shows a dilated common bile duct with stones. What is the most appropriate definitive management after initial resuscitation and antibiotics?

  1. Endoscopic retrograde cholangiopancreatography with stone extraction Correct answer.
  2. Cholecystectomy alone
  3. Observation with a repeat ultrasound in one week
  4. Percutaneous transhepatic cholangiography

Explanation

Charcot's triad indicates ascending cholangitis with biliary obstruction, and urgent biliary drainage by ERCP with stone extraction is the definitive early step. Antibiotics and resuscitation are given concurrently. Cholecystectomy addresses the gallbladder but does not relieve the obstructed duct in the acute setting.

Question 48Surgery and Allied Surgical Specialties

A 3-day-old boy born at term has bilious vomiting and a scaphoid abdomen. Abdominal radiograph shows a double bubble with no distal gas. What is the most likely diagnosis?

  1. Pyloric stenosis
  2. Hirschsprung disease
  3. Malrotation with volvulus
  4. Duodenal atresia Correct answer.

Explanation

A double bubble with no distal gas in a neonate with bilious vomiting is classic for duodenal atresia. Bilious vomiting in a neonate is a surgical emergency until malrotation with volvulus is excluded. Pyloric stenosis presents later with non-bilious vomiting.

Question 49Surgery and Allied Surgical Specialties

A 2-year-old child has a painful, red, swollen scrotum with fever and dysuria. Ultrasound shows increased blood flow to the testis. What is the most appropriate management?

  1. Intravenous antibiotics Correct answer.
  2. Observation without treatment
  3. Radiotherapy
  4. Scrotal exploration

Explanation

Epididymitis in a child presents with fever, dysuria, and increased testicular blood flow on Doppler, and is treated with antibiotics. If torsion cannot be excluded, exploration is performed. Radiotherapy has no role in infection.

Question 50Surgery and Allied Surgical Specialties

A 50-year-old woman has a 4 cm unilocular ovarian cyst with a normal CA-125 and no solid components or ascites. What is the most appropriate management?

  1. Observation with repeat ultrasound Correct answer.
  2. Chemotherapy
  3. Bilateral salpingo-oophorectomy
  4. Immediate laparotomy and staging

Explanation

A unilocular cyst without solid components, septation, or ascites in a premenopausal woman with a normal CA-125 is usually benign and can be observed with follow-up imaging. Surgery is reserved for persistent, enlarging, or complex cysts. Staging and chemotherapy are for suspected malignancy.