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PMC Residency Entrance Exam study materials
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PMC Residency Entrance Exam practice questions

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Question 1Internal Medicine

A 58-year-old man with type 2 diabetes has an eGFR of 32 mL/min/1.73 m². Which oral glucose-lowering agent should be avoided because of reduced efficacy and increased risk of lactic acidosis at this level of kidney function?

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

Explanation

Metformin is cleared renally and accumulates when eGFR falls below about 30 mL/min/1.73 m², raising the risk of lactic acidosis; guidelines advise stopping it at that threshold. Empagliflozin, sitagliptin, and glipizide require dose adjustment but are not contraindicated for this reason.

Question 2Internal Medicine

A 24-year-old woman presents with palpitations and weight loss. TSH is suppressed and free T4 is elevated. Which finding on examination most specifically supports Graves disease over a toxic nodule?

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

Explanation

Graves disease produces a diffusely enlarged gland with increased vascularity, generating a palpable thrill or audible bruit. A solitary nodule suggests toxic adenoma, tenderness suggests subacute thyroiditis, and a fixed hard mass raises concern for malignancy.

Question 3Internal Medicine

Which electrocardiographic finding is most characteristic of hyperkalaemia in a patient with acute kidney injury?

  1. Diffuse ST elevation with PR depression
  2. Sawtooth flutter waves at 300 per minute
  3. Prolonged QT interval with prominent U waves
  4. Tall, peaked T waves with a narrow base Correct answer.

Explanation

Hyperkalaemia classically produces tall, narrow-based peaked T waves, followed by PR prolongation, loss of P waves, and QRS widening as potassium rises further. The other patterns reflect pericarditis, atrial flutter, and hypokalaemia respectively.

Question 4Internal Medicine

A 70-year-old man has a blood pressure of 165/95 mmHg confirmed on three visits and no other cardiovascular risk factors. Which is the most appropriate initial pharmacological class according to standard hypertension guidance?

  1. A loop diuretic such as furosemide
  2. An alpha-blocker such as doxazosin
  3. A centrally acting agent such as clonidine
  4. A thiazide-like diuretic such as indapamide Correct answer.

Explanation

First-line therapy for uncomplicated hypertension in older adults includes thiazide-like diuretics, ACE inhibitors or ARBs, and calcium channel blockers. Alpha-blockers, loop diuretics, and central agents are reserved for specific indications or resistant disease.

Question 5Internal Medicine

A 30-year-old woman has iron deficiency anaemia. Which laboratory pattern is most consistent with this diagnosis?

  1. High ferritin, high serum iron, low total iron-binding capacity
  2. Low ferritin, low serum iron, high total iron-binding capacity Correct answer.
  3. Low ferritin, high serum iron, normal total iron-binding capacity
  4. Normal ferritin, low serum iron, low total iron-binding capacity

Explanation

Iron deficiency lowers iron stores (low ferritin) and serum iron while the liver upregulates transferrin, raising total iron-binding capacity and lowering transferrin saturation. Anaemia of chronic disease shows the opposite pattern, with high ferritin and low binding capacity.

Question 6Internal Medicine

A 45-year-old man has sudden severe epigastric pain radiating to the back with vomiting. Serum lipase is three times the upper limit of normal. Which is the most common cause of this condition in most populations?

  1. Hypercalcaemia
  2. Endoscopic retrograde cholangiopancreatography
  3. Hypertriglyceridaemia
  4. Gallstones Correct answer.

Explanation

Gallstones and alcohol account for the majority of acute pancreatitis cases worldwide, with gallstones the leading cause in most series. Hypertriglyceridaemia, post-ERCP injury, and hypercalcaemia are less frequent causes.

Question 7Internal Medicine

Which organism is the most frequent cause of community-acquired pneumonia requiring hospital admission in adults?

  1. Streptococcus pneumoniae Correct answer.
  2. Mycoplasma pneumoniae
  3. Pneumocystis jirovecii
  4. Legionella pneumophila

Explanation

Streptococcus pneumoniae remains the single most commonly identified pathogen in community-acquired pneumonia across all severity levels. Atypical organisms and Legionella are important but less frequent, and Pneumocystis occurs mainly in immunocompromised hosts.

Question 8Internal Medicine

A patient with decompensated heart failure has a serum sodium of 128 mmol/L and appears euvolaemic on examination. Which additional measurement best distinguishes SIADH from other causes of hyponatraemia?

  1. Serum osmolality above 295 mOsm/kg
  2. Fractional excretion of urea below 10 percent
  3. Random blood glucose above 11 mmol/L
  4. Urine osmolality above 100 mOsm/kg with urine sodium above 30 mmol/L Correct answer.

Explanation

SIADH is a euvolemic, hypotonic hyponatraemia in which ADH excess concentrates the urine above 100 mOsm/kg and urinary sodium is typically above 30 mmol/L on a normal salt intake. Hyperosmolar states and hyperglycaemia cause a different, translocational pattern.

Question 9Internal Medicine

A 62-year-old smoker presents with a 3-week history of cough and haemoptysis. Chest radiograph shows a right hilar mass. Which paraneoplastic syndrome is most strongly associated with small cell lung cancer?

  1. Carcinoid syndrome
  2. Pancoast syndrome
  3. Syndrome of inappropriate antidiuretic hormone secretion Correct answer.
  4. Hypertrophic pulmonary osteoarthropathy

Explanation

Small cell lung cancer is a neuroendocrine tumour that frequently ectopically secretes ADH, producing SIADH and hyponatraemia. Pancoast syndrome and hypertrophic osteoarthropathy occur with other lung cancers, and carcinoid syndrome arises from carcinoid tumours.

Question 10Internal Medicine

A 28-year-old woman has a diastolic decrescendo murmur at the left sternal edge and a bounding pulse. Which haemodynamic lesion best explains these findings?

  1. Mitral stenosis
  2. Aortic regurgitation Correct answer.
  3. Aortic stenosis
  4. Tricuspid regurgitation

Explanation

Aortic regurgitation produces an early diastolic decrescendo murmur along the left sternal edge and a wide pulse pressure with bounding peripheral pulses. Aortic stenosis gives a systolic ejection murmur, mitral stenosis a mid-diastolic rumble, and tricuspid regurgitation a systolic murmur.

Question 11Internal Medicine

A 55-year-old man has a serum creatinine of 180 µmol/L and a urine output of 15 mL/h. His fractional excretion of sodium is 0.4 percent with a urine osmolality of 620 mOsm/kg. Which mechanism best explains his acute kidney injury?

  1. Acute interstitial nephritis
  2. Acute tubular necrosis with impaired reabsorption
  3. Prerenal hypoperfusion with intact tubular reabsorption Correct answer.
  4. Post-renal obstruction

Explanation

A fractional excretion of sodium below 1 percent with concentrated urine indicates avid sodium and water reabsorption by functioning tubules, typical of prerenal hypoperfusion. Acute tubular necrosis impairs reabsorption, raising the fractional excretion above 2 percent.

Question 12Internal Medicine

A 34-year-old woman has a deep vein thrombosis after starting a combined oral contraceptive. Which inherited thrombophilia is most strongly associated with venous thrombosis in this setting?

  1. Dysfibrinogenaemia
  2. Factor V Leiden mutation Correct answer.
  3. Antithrombin deficiency
  4. Protein C deficiency

Explanation

Factor V Leiden is the most common inherited thrombophilia and confers resistance to activated protein C, with a markedly increased risk when combined with oestrogen exposure. The other disorders are rarer and less commonly implicated in this scenario.

Question 13Internal Medicine

A 68-year-old woman with atrial fibrillation is started on apixaban. Which statement best reflects the advantage of a direct oral anticoagulant over warfarin in this setting?

  1. It has fewer food and drug interactions and does not require routine INR monitoring Correct answer.
  2. It is fully reversible with protamine sulphate in an emergency
  3. It is safe in pregnancy and lactation
  4. It has a shorter half-life and therefore requires twice-daily dosing only when renal function is normal

Explanation

Direct oral anticoagulants such as apixaban have predictable pharmacokinetics, fewer dietary and drug interactions than warfarin, and do not need routine INR monitoring. Their reversal agents are specific (andexanet alfa or idarucizumab), and they are contraindicated in pregnancy.

Question 14Internal Medicine

A 21-year-old student has abrupt-onset fever, severe headache, neck stiffness, and a petechial rash. Which is the most appropriate immediate action?

  1. Administer intravenous ceftriaxone and perform lumbar puncture when safe Correct answer.
  2. Await lumbar puncture results before starting antibiotics
  3. Start acyclovir alone and arrange an outpatient MRI
  4. Give oral amoxicillin and discharge with review in 24 hours

Explanation

Suspected bacterial meningitis with a non-blanching rash is a medical emergency; empirical intravenous antibiotics must be given immediately, with lumbar puncture performed when it is safe and does not delay treatment. Delay in antibiotics worsens outcomes in meningococcal disease.

Question 15Internal Medicine

A 60-year-old man with type 2 diabetes has a serum creatinine of 150 µmol/L and an eGFR of 40 mL/min/1.73 m². Which medication should be reviewed because it may cause hyperkalaemia and worsening renal function when combined with an ACE inhibitor?

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

Explanation

Aldosterone antagonists such as spironolactone raise serum potassium and, when combined with an ACE inhibitor in chronic kidney disease, can precipitate hyperkalaemia and further renal impairment. Calcium channel blockers and statins do not carry this interaction.

Question 16Internal Medicine

A 40-year-old man has recurrent peptic ulcer disease despite eradication therapy. He has fasting gastrin levels markedly elevated and a positive secretin stimulation test. Which is the most likely diagnosis?

  1. Helicobacter pylori reinfection
  2. Coeliac disease
  3. Zollinger-Ellison syndrome Correct answer.
  4. Chronic gastritis related to NSAID use

Explanation

Markedly elevated fasting gastrin with a paradoxical rise after secretin injection is characteristic of a gastrinoma, causing Zollinger-Ellison syndrome. Helicobacter reinfection and NSAID-related gastritis do not raise gastrin to this degree.

Question 17Internal Medicine

Which feature of a headache history most strongly suggests a secondary cause requiring urgent investigation?

  1. New-onset thunderclap headache reaching maximum intensity within one minute Correct answer.
  2. Occurring on waking and improving during the day
  3. Bilateral pressure sensation relieved by rest
  4. Occurring more than 15 days per month for years

Explanation

A thunderclap headache peaking within a minute raises concern for subarachnoid haemorrhage and mandates urgent imaging, often followed by lumbar puncture. The other patterns describe tension-type or chronic headache without red flags.

Question 18Internal Medicine

A 72-year-old man has dysphagia, weight loss, and iron deficiency anaemia. Which investigation is the most appropriate first-line test for suspected oesophageal cancer?

  1. 24-hour pH monitoring
  2. Upper gastrointestinal endoscopy with biopsy Correct answer.
  3. Oesophageal manometry
  4. Barium swallow

Explanation

Endoscopy with biopsy allows direct visualisation, histological confirmation, and staging assessment of suspected oesophageal malignancy. Barium studies, manometry, and pH monitoring assess function or mucosal contour but cannot provide tissue diagnosis.

Question 19Internal Medicine

A 50-year-old woman has a serum calcium of 2.95 mmol/L, low phosphate, and an inappropriately normal parathyroid hormone level. Which is the most likely diagnosis?

  1. Vitamin D intoxication
  2. Primary hyperparathyroidism Correct answer.
  3. Hypoparathyroidism
  4. Malignancy-associated hypercalcaemia

Explanation

Hypercalcaemia with an inappropriately normal or high parathyroid hormone and low phosphate is characteristic of primary hyperparathyroidism. Malignancy suppresses parathyroid hormone, and vitamin D excess raises both calcium and phosphate.

Question 20Internal Medicine

A 25-year-old man has sudden onset of severe testicular pain and a high-riding testis with an absent cremasteric reflex. What is the most appropriate next step?

  1. Immediate surgical exploration Correct answer.
  2. Doppler ultrasound after analgesia
  3. Antibiotics for epididymo-orchitis
  4. Urine culture with outpatient review

Explanation

Testicular torsion is a surgical emergency; when the clinical picture is suggestive, exploration should not be delayed for imaging because prolonged ischaemia leads to loss of the testis. Doppler ultrasound is useful only when torsion is unlikely and should not delay surgery.

Question 21Internal Medicine

A 64-year-old man with cirrhosis presents with confusion and asterixis. He has a serum ammonia of 110 µmol/L and a recent gastrointestinal bleed. Which is the most appropriate initial treatment?

  1. Rifaximin alone
  2. Intravenous flumazenil
  3. Lactulose titrated to two or three soft stools daily Correct answer.
  4. Oral lactulose and protein restriction to 20 g per day

Explanation

Lactulose is first-line for hepatic encephalopathy, acidifying the colon and reducing ammonia absorption, titrated to two or three soft stools daily. Protein restriction is no longer recommended because it worsens catabolism; rifaximin is added for secondary prevention.

Question 22Internal Medicine

A 35-year-old woman has a systolic blood pressure of 210 mmHg with headache and confusion. She is 32 weeks pregnant and urinalysis shows 3+ protein. Which is the most appropriate antihypertensive for acute control?

  1. Oral enalapril
  2. Intravenous labetalol Correct answer.
  3. Oral valsartan
  4. Intravenous furosemide

Explanation

Labetalol is a preferred agent for severe hypertension in pregnancy because it lowers blood pressure safely without fetal toxicity. ACE inhibitors and ARBs are contraindicated in pregnancy because they cause fetal renal failure and oligohydramnios.

Question 23Internal Medicine

A 58-year-old woman has proximal muscle weakness, a heliotrope rash, and Gottron papules. Which underlying malignancy is most strongly associated with this condition?

  1. Ovarian carcinoma Correct answer.
  2. Hepatocellular carcinoma
  3. Renal cell carcinoma
  4. Papillary thyroid carcinoma

Explanation

Dermatomyositis, especially in adults, has a well-recognised association with underlying malignancy, most commonly ovarian, breast, lung, and gastrointestinal cancers. Age-appropriate cancer screening should be pursued at diagnosis.

Question 24Internal Medicine

A 70-year-old man has a haemoglobin of 95 g/L with a mean corpuscular volume of 108 fL. Which combination of tests best distinguishes vitamin B12 deficiency from folate deficiency?

  1. Serum ferritin and transferrin saturation
  2. Serum methylmalonic acid and homocysteine levels Correct answer.
  3. Direct antiglobulin test and lactate dehydrogenase
  4. Reticulocyte count and haptoglobin

Explanation

Both deficiencies raise homocysteine, but only vitamin B12 deficiency raises methylmalonic acid because of impaired methylmalonyl-CoA mutase activity. This distinction guides replacement and avoids masking B12 deficiency with folate alone.

Question 25Internal Medicine

A 45-year-old man with a history of alcohol use presents with fever, epigastric pain, and hypotension. CT shows pancreatic necrosis with gas within the necrotic collection. Which management step is most appropriate?

  1. High-dose corticosteroids
  2. Oral antibiotics with outpatient follow-up
  3. Immediate ERCP with sphincterotomy
  4. Urgent surgical or interventional debridement of infected necrosis Correct answer.

Explanation

Gas within necrotic pancreatic tissue indicates infected necrosis, which carries high mortality and requires urgent source control by surgical or interventional debridement alongside broad-spectrum antibiotics. ERCP, steroids, and outpatient oral therapy are not appropriate for infected necrosis.

Question 26Internal Medicine

A 58-year-old man with a 40-pack-year smoking history presents with a 2-month history of progressive dyspnoea and a chronic productive cough. Chest radiography shows hyperinflation with flattened diaphragms, and spirometry demonstrates a post-bronchodilator FEV1/FVC ratio of 0.55. Which pathophysiological mechanism best explains the development of his airflow limitation?

  1. Irreversible airway obstruction due to airway smooth muscle hypertrophy and mucous gland hyperplasia
  2. Loss of elastic recoil due to alveolar wall destruction and increased lung compliance Correct answer.
  3. Reversible bronchoconstriction mediated by IgE and eosinophilic inflammation
  4. Interstitial fibrosis causing reduced lung volumes and restrictive physiology

Explanation

In chronic obstructive pulmonary disease, the airflow limitation is primarily due to a combination of small airway disease and parenchymal destruction (emphysema). Emphysema leads to loss of elastic recoil, which reduces the driving pressure for expiration and causes dynamic airway collapse. This results in increased lung compliance and hyperinflation, as seen in this patient.

Question 27Internal Medicine

A 42-year-old woman presents with palpitations, heat intolerance, and a 5-kg weight loss over 2 months. On examination, she has a diffuse goitre, lid lag, and a fine tremor. Thyroid function tests show a suppressed TSH and elevated free T4. Which of the following is the most appropriate initial diagnostic test to determine the aetiology of her hyperthyroidism?

  1. Thyroid ultrasound
  2. Radioactive iodine uptake scan Correct answer.
  3. Fine-needle aspiration biopsy of the thyroid
  4. Serum thyroid-stimulating immunoglobulin (TSI) levels

Explanation

The clinical picture is consistent with Graves' disease, but a radioactive iodine uptake scan helps differentiate Graves' disease from other causes of thyrotoxicosis such as toxic multinodular goitre or thyroiditis. Graves' disease typically shows a diffusely increased uptake, whereas thyroiditis shows low uptake. This distinction guides management, as thyroiditis is self-limiting and does not require antithyroid drugs.

Question 28Internal Medicine

A 68-year-old man with a history of hypertension and type 2 diabetes presents with acute onset of severe abdominal pain out of proportion to physical findings. He has atrial fibrillation, and his medications include a beta-blocker and metformin. Laboratory tests show a lactate of 4.5 mmol/L and a white blood cell count of 18,000/µL. Contrast-enhanced CT of the abdomen reveals a thrombus in the superior mesenteric artery. Which of the following is the most appropriate immediate management?

  1. Immediate surgical embolectomy Correct answer.
  2. Intravenous broad-spectrum antibiotics and fluid resuscitation
  3. Systemic anticoagulation with heparin
  4. Endovascular thrombolysis

Explanation

Acute mesenteric ischaemia due to a superior mesenteric artery embolus often requires urgent revascularization to prevent bowel infarction. Surgical embolectomy is the treatment of choice for embolic occlusion, especially when there is evidence of bowel ischaemia (elevated lactate, leukocytosis). Antibiotics and fluids are supportive but do not address the vascular occlusion.

Question 29Internal Medicine

A 55-year-old woman with a history of hypertension and hyperlipidaemia presents with sudden onset of severe tearing chest pain radiating to the back. On examination, she is diaphoretic and has a blood pressure of 180/100 mmHg in the right arm and 150/90 mmHg in the left arm. CT angiography of the chest shows a dissection flap involving the ascending aorta. Which of the following is the most appropriate initial pharmacological therapy?

  1. Intravenous labetalol to reduce heart rate and blood pressure Correct answer.
  2. Sublingual nifedipine for rapid blood pressure reduction
  3. Intravenous furosemide to reduce preload
  4. Intravenous nitroglycerin for blood pressure control

Explanation

For acute aortic dissection involving the ascending aorta (Stanford type A), the immediate goal is to reduce the rate of pressure rise (dP/dt) and shear stress on the aorta. Beta-blockers such as intravenous labetalol are first-line to lower heart rate and blood pressure, followed by additional vasodilators if needed. Nitroglycerin alone may cause reflex tachycardia and increase shear stress.

Question 30Internal Medicine

A 35-year-old man with a known history of intravenous drug use presents with fever, chills, and a new systolic murmur. Blood cultures grow methicillin-sensitive Staphylococcus aureus. Echocardiography reveals a vegetation on the tricuspid valve. He has no history of valvular disease. Which of the following is the most likely predisposing factor for his right-sided endocarditis?

  1. Presence of a central venous catheter
  2. Intravenous drug use Correct answer.
  3. Recent dental procedure
  4. HIV infection

Explanation

Right-sided endocarditis, particularly involving the tricuspid valve, is strongly associated with intravenous drug use. Repeated injection of particulate matter and bacteria leads to endothelial injury and vegetation formation on the right side of the heart. Other predisposing factors include indwelling central lines, but the history of IV drug use is the most direct risk factor in this case.

Question 31Surgery and Allied Surgical Specialties

A 24-year-old man sustains a blunt blow to the left upper quadrant with left shoulder tip pain and rebound tenderness. Which organ injury classically produces referred pain to the left shoulder?

  1. Splenic flexure of colon
  2. Tail of pancreas
  3. Left kidney
  4. Spleen Correct answer.

Explanation

Blood from a ruptured spleen irritates the undersurface of the left hemidiaphragm, which is innervated by the phrenic nerve (C3–C5), producing referred pain to the left shoulder (Kehr sign). This diaphragmatic irritation is the mechanism of the shoulder-tip pain described. The other organs listed do not lie against the diaphragm in a way that produces this classic referral.

Question 32Surgery and Allied Surgical Specialties

A 30-year-old woman has a 2 cm freely mobile, well-defined breast lump. Which single investigation is the definitive diagnostic step for a suspected fibroadenoma?

  1. Fine needle aspiration cytology
  2. Clinical follow-up in 6 months
  3. Core needle biopsy Correct answer.
  4. Mammography alone

Explanation

Core needle biopsy provides histology with tissue architecture, allowing definitive diagnosis of a fibroadenoma and exclusion of phyllodes tumour or carcinoma. Cytology cannot reliably distinguish these entities because architecture is lost. Definitive tissue diagnosis guides whether excision is required.

Question 33Surgery and Allied Surgical Specialties

In the management of a patient with acute appendicitis, which anatomical landmark best guides the position of the appendiceal base during laparoscopic appendicectomy?

  1. The ileocaecal valve
  2. The inferior epigastric vessels
  3. The root of the mesoappendix at the ileum
  4. Convergence of the three taeniae coli on the caecum Correct answer.

Explanation

The three taeniae coli of the caecum converge at the base of the appendix, making them the most reliable intraoperative landmark for locating the appendiceal origin. Following the taeniae along the caecum leads directly to the base. This relationship is constant even when the appendix is retrocaecal or inflamed.

Question 34Surgery and Allied Surgical Specialties

A 45-year-old man presents with a painful, tender swelling in the left groin that enters the deep inguinal ring and passes through the superficial inguinal ring. What is the most likely diagnosis?

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

Explanation

An indirect inguinal hernia enters the deep inguinal ring lateral to the inferior epigastric vessels, traverses the inguinal canal and may emerge through the superficial ring. Deep-ring entry distinguishes it from a direct hernia, which protrudes through the posterior wall of the inguinal canal.

Question 35Surgery and Allied Surgical Specialties

Which of the following is the most appropriate initial fluid resuscitation strategy for an adult with hypovolaemic shock from a bleeding duodenal ulcer?

  1. Oral rehydration with clear fluids
  2. Rapid intravenous crystalloid bolus with cross-matched blood as available Correct answer.
  3. Immediate vasopressor infusion as first-line therapy
  4. Diuretics to maintain urine output

Explanation

The initial priority in haemorrhagic shock is restoring circulating volume with rapid intravenous crystalloid while arranging blood products. Vasopressors are reserved for refractory shock after volume resuscitation. Oral fluids are inadequate in shock.

Question 36Surgery and Allied Surgical Specialties

A patient develops a wound infection 5 days after laparotomy. Which organism is most commonly responsible for surgical site infections following clean-contaminated abdominal surgery?

  1. Clostridium tetani
  2. Mycobacterium tuberculosis
  3. Vibrio cholerae
  4. Staphylococcus aureus Correct answer.

Explanation

Staphylococcus aureus is the most frequent cause of surgical site infection, especially from skin flora. Gram-negative enteric organisms also contribute after clean-contaminated surgery, but S. aureus remains the leading single pathogen. The other organisms listed are not typical causes of postoperative wound infection.

Question 37Surgery and Allied Surgical Specialties

A 60-year-old man has a pulsatile abdominal mass. Which imaging modality is the investigation of choice for elective assessment of an abdominal aortic aneurysm?

  1. Duplex ultrasound of the abdominal aorta Correct answer.
  2. Intravenous urogram
  3. Barium meal
  4. Plain abdominal radiograph

Explanation

Duplex ultrasound is non-invasive, avoids radiation, and accurately measures aortic diameter, making it the preferred initial investigation for elective AAA assessment. CT angiography is used for planning intervention. Plain films and contrast studies do not reliably measure aneurysm size.

Question 38Surgery and Allied Surgical Specialties

Which of the following is the most reliable clinical sign of acute compartment syndrome in a patient with a tibial fracture?

  1. Pallor of the limb
  2. Paralysis of the limb
  3. Pain out of proportion to the injury, worsened by passive stretch Correct answer.
  4. Absent distal pulses

Explanation

Pain out of proportion to the injury and aggravated by passive stretch of the compartment muscles is the earliest and most reliable sign of acute compartment syndrome. Pulselessness, pallor and paralysis are late findings. Early recognition and fasciotomy prevent irreversible muscle necrosis.

Question 39Surgery and Allied Surgical Specialties

A 55-year-old woman has a solitary thyroid nodule. Fine needle aspiration cytology is reported as suspicious for malignancy. What is the most appropriate next step?

  1. Suppressive thyroxine therapy
  2. Diagnostic hemithyroidectomy Correct answer.
  3. Radioiodine ablation
  4. Repeat cytology in 12 months

Explanation

A cytologically suspicious thyroid nodule warrants diagnostic hemithyroidectomy to obtain definitive histology. Indeterminate or suspicious categories carry a significant malignancy risk that surgery resolves. Repeat cytology or medical therapy delays diagnosis.

Question 40Surgery and Allied Surgical Specialties

A 70-year-old man with obstructive jaundice and a pancreatic head mass undergoes a pancreaticoduodenectomy. Which of the following is the most common major complication of this operation?

  1. Portal vein thrombosis
  2. Splenic infarction
  3. Pancreatic fistula Correct answer.
  4. Hepatic encephalopathy

Explanation

Postoperative pancreatic fistula is the most common major complication following pancreaticoduodenectomy, arising from leakage at the pancreaticoenteric anastomosis. It drives much of the associated morbidity and mortality. The other listed complications are uncommon after this procedure.

Question 41Surgery and Allied Surgical Specialties

A 35-year-old man sustains a penetrating stab wound to the right chest. He is haemodynamically stable, and chest radiograph shows a small right haemothorax. Which initial management step is most appropriate?

  1. Discharge with analgesia
  2. Immediate thoracotomy
  3. Pericardiocentesis
  4. Tube thoracostomy and observation Correct answer.

Explanation

A stable patient with a small haemothorax is managed with tube thoracostomy to drain blood and re-expand the lung, followed by observation. Immediate thoracotomy is reserved for massive haemothorax or haemodynamic instability. Pericardiocentesis is for suspected cardiac tamponade.

Question 42Surgery and Allied Surgical Specialties

A 50-year-old woman has a 3 cm renal mass. Which imaging study best characterises renal cell carcinoma and detects venous tumour thrombus?

  1. Plain abdominal radiograph
  2. Barium enema
  3. Retrograde urethrogram
  4. Contrast-enhanced computed tomography of the abdomen Correct answer.

Explanation

Contrast-enhanced CT of the abdomen is the standard investigation for renal cell carcinoma, characterising the mass and detecting extension into the renal vein or inferior vena cava. It also stages local and distant disease. The other studies do not image the kidney adequately.

Question 43Surgery and Allied Surgical Specialties

A 65-year-old man has a biopsy-proven prostate adenocarcinoma with a Gleason score of 8 and a serum PSA of 25 ng/mL. Which of the following best describes the prognostic significance of these findings?

  1. Indolent disease requiring no treatment
  2. High-risk disease with increased likelihood of extracapsular extension Correct answer.
  3. Benign prostatic hyperplasia
  4. Low-risk disease suitable for active surveillance

Explanation

A Gleason score of 8 combined with a PSA of 25 ng/mL places the patient in a high-risk category, with significant risk of extracapsular extension and metastasis. High-risk disease typically warrants multimodal treatment rather than surveillance. Active surveillance is reserved for low-risk disease.

Question 44Surgery and Allied Surgical Specialties

A patient presents with a warm, swollen, tender calf and a Wells score suggesting high probability of deep vein thrombosis. Which investigation is the most appropriate next step?

  1. Magnetic resonance angiography
  2. Contrast venography
  3. Duplex ultrasonography of the leg veins Correct answer.
  4. D-dimer assay

Explanation

When clinical probability of DVT is high, duplex ultrasonography is the appropriate next investigation because it directly visualises thrombus. D-dimer is useful mainly in low-probability cases to exclude DVT. Venography is invasive and reserved for equivocal cases.

Question 45Surgery and Allied Surgical Specialties

A 40-year-old woman has a solitary 4 cm adrenal mass with signs of cortisol excess. Which investigation is most useful in confirming the diagnosis of an adrenocortical adenoma?

  1. Plasma metanephrines
  2. Serum calcitonin
  3. Overnight dexamethasone suppression test Correct answer.
  4. Serum aldosterone concentration

Explanation

Cortisol excess is confirmed biochemically with an overnight dexamethasone suppression test, which fails to suppress cortisol in Cushing syndrome. Imaging then localises the adenoma. Metanephrines screen for phaeochromocytoma, and aldosterone relates to Conn syndrome.

Question 46Surgery and Allied Surgical Specialties

A patient with a 6 cm abdominal aortic aneurysm and a history of smoking presents for elective repair. Which factor most strongly predicts the risk of rupture?

  1. Serum cholesterol level
  2. Family history of hypertension
  3. Body mass index
  4. Aneurysm diameter Correct answer.

Explanation

Aneurysm diameter is the strongest predictor of rupture risk, with risk rising sharply above 5.5 cm. Elective repair is generally recommended at this threshold. Other factors such as smoking and hypertension contribute but are less predictive than size.

Question 47Surgery and Allied Surgical Specialties

A 28-year-old man has a deep partial-thickness burn to 20% of his body surface area. Which fluid regimen is most appropriate in the first 24 hours?

  1. Hypertonic saline at fixed rate
  2. Crystalloid calculated by the Parkland formula Correct answer.
  3. Colloid alone at maintenance rate
  4. Oral fluids only

Explanation

The Parkland formula estimates the first 24-hour crystalloid requirement as 4 mL/kg per percent body surface area burned, with half given in the first 8 hours. This regimen addresses the capillary leak and third-space losses typical of major burns. Colloid and oral fluids alone are inadequate.

Question 48Surgery and Allied Surgical Specialties

A 60-year-old man with a history of alcohol excess presents with severe epigastric pain radiating to the back and elevated serum amylase. Which finding best indicates severe acute pancreatitis?

  1. Mild epigastric tenderness
  2. Serum amylase above twice normal
  3. Normal serum calcium
  4. Organ failure persisting beyond 48 hours Correct answer.

Explanation

Persistent organ failure beyond 48 hours defines severe acute pancreatitis under the revised Atlanta classification. Enzyme elevation alone reflects the presence but not the severity of pancreatitis. Severity is determined by systemic complications and organ dysfunction.

Question 49Surgery and Allied Surgical Specialties

A patient with a suspected small bowel obstruction has a plain abdominal radiograph showing multiple dilated loops with air-fluid levels. Which initial management step is most appropriate?

  1. Discharge with analgesia
  2. Immediate laparotomy regardless of findings
  3. Oral laxatives
  4. Intravenous fluids and nasogastric decompression Correct answer.

Explanation

Initial management of small bowel obstruction involves intravenous fluid resuscitation and nasogastric decompression to relieve distension and vomiting. Surgery is reserved for strangulation, perforation, or failure of conservative management. Laxatives are contraindicated.

Question 50Surgery and Allied Surgical Specialties

A 55-year-old woman has a 2 cm ulcerated lesion on the lower lip. Which histological type is most common for lip carcinoma?

  1. Squamous cell carcinoma Correct answer.
  2. Melanoma
  3. Basal cell carcinoma
  4. Kaposi sarcoma

Explanation

Squamous cell carcinoma is the most common malignancy of the lower lip, related to chronic sun exposure and tobacco use. It often presents as an ulcerated lesion. Basal cell carcinoma is more common on the upper lip and sun-exposed skin elsewhere.