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Russia Primary Medical Accreditation - General Medicine study materials
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Russia Primary Medical Accreditation - General Medicine practice questions

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Question 1Internal Medicine / Therapeutics (general adult care)

A 58-year-old man has a fasting plasma glucose of 7.4 mmol/L on two separate occasions. Which diagnosis is most appropriate?

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

Explanation

A fasting plasma glucose of 7.0 mmol/L or higher confirmed on two occasions establishes diabetes mellitus. Impaired fasting glucose corresponds to values between 6.1 and 6.9 mmol/L.

Question 2Internal Medicine / Therapeutics (general adult care)

Which finding on physical examination is most characteristic of left-sided heart failure?

  1. Hepatomegaly with ascites
  2. Raised jugular venous pressure
  3. Bilateral basal inspiratory crackles Correct answer.
  4. Pitting ankle oedema

Explanation

Left-sided heart failure causes pulmonary congestion, producing basal inspiratory crackles. Jugular venous distension, hepatomegaly and peripheral oedema reflect right-sided congestion.

Question 3Internal Medicine / Therapeutics (general adult care)

A patient with an acute exacerbation of asthma is treated with inhaled salbutamol. Which mechanism produces bronchodilation?

  1. Leukotriene receptor antagonism
  2. Beta-2 adrenergic receptor stimulation Correct answer.
  3. Muscarinic receptor blockade
  4. Mast cell stabilisation

Explanation

Salbutamol is a short-acting beta-2 agonist that relaxes bronchial smooth muscle. Muscarinic blockade (ipratropium) and leukotriene antagonism act through different pathways.

Question 4Internal Medicine / Therapeutics (general adult care)

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

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

Explanation

Streptococcus pneumoniae remains the most frequently identified pathogen in community-acquired pneumonia. Atypical organisms and Gram-negative bacilli are less common overall.

Question 5Internal Medicine / Therapeutics (general adult care)

A 45-year-old woman has a blood pressure of 158/98 mmHg on three separate visits. What is the correct diagnostic classification?

  1. Grade 1 hypertension Correct answer.
  2. High-normal blood pressure
  3. Grade 3 hypertension
  4. Grade 2 hypertension

Explanation

Grade 1 hypertension corresponds to systolic 140–159 mmHg or diastolic 90–99 mmHg. Values of 160–179/100–109 define grade 2, and 180/110 or higher defines grade 3.

Question 6Internal Medicine / Therapeutics (general adult care)

Which laboratory finding is typical of iron-deficiency anaemia?

  1. High serum ferritin
  2. Raised mean corpuscular volume
  3. Increased reticulocyte count
  4. Low serum ferritin Correct answer.

Explanation

Iron deficiency depletes body iron stores, so serum ferritin falls and is the most specific single test. The anaemia is microcytic and hypochromic with a low reticulocyte count.

Question 7Internal Medicine / Therapeutics (general adult care)

A patient presents with sudden-onset severe epigastric pain radiating to the back, and serum lipase is three times the upper limit of normal. Which diagnosis is most likely?

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

Explanation

Sudden severe epigastric pain radiating to the back with lipase elevated more than three times the upper limit is diagnostic of acute pancreatitis. Biliary colic and perforation produce different patterns.

Question 8Internal Medicine / Therapeutics (general adult care)

Which electrocardiographic finding is characteristic of acute ST-elevation myocardial infarction?

  1. ST-segment elevation in contiguous leads Correct answer.
  2. Sawtooth flutter waves
  3. Delta wave with short PR interval
  4. Diffuse ST depression with PR elevation

Explanation

Acute transmural ischaemia produces ST elevation in leads facing the infarct territory. Reciprocal depression may appear in opposite leads but is not the defining feature.

Question 9Internal Medicine / Therapeutics (general adult care)

A 30-year-old woman has fatigue, weight gain, cold intolerance and a raised TSH with low free T4. Which is the most likely diagnosis?

  1. Secondary hypothyroidism
  2. Nephrotic syndrome
  3. Subclinical hyperthyroidism
  4. Primary hypothyroidism Correct answer.

Explanation

A high TSH with low free T4 indicates failure of the thyroid gland itself, i.e. primary hypothyroidism. Secondary hypothyroidism would show low or inappropriately normal TSH.

Question 10Internal Medicine / Therapeutics (general adult care)

Which spirometry pattern is expected in a patient with chronic obstructive pulmonary disease?

  1. Increased FEV1/FVC ratio with normal FEV1
  2. Normal FEV1/FVC ratio with reduced FVC
  3. Reduced FEV1/FVC ratio with reduced FEV1 Correct answer.
  4. Normal FEV1/FVC ratio with reduced diffusion capacity alone

Explanation

COPD causes airflow obstruction, giving a post-bronchodilator FEV1/FVC below 0.70 with reduced FEV1. Restrictive disease preserves or raises the ratio.

Question 11Internal Medicine / Therapeutics (general adult care)

A patient with atrial fibrillation has a CHA2DS2-VASc score of 3. What is the recommended antithrombotic strategy?

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

Explanation

A CHA2DS2-VASc score of 2 or more in men (or 3 or more in women) warrants oral anticoagulation to prevent stroke. Antiplatelet monotherapy is inferior for stroke prevention in AF.

Question 12Internal Medicine / Therapeutics (general adult care)

Which finding best distinguishes exudative from transudative pleural effusion using Light's criteria?

  1. Pleural fluid glucose above 3 mmol/L
  2. Pleural fluid pH above 7.4
  3. Pleural fluid protein/serum protein ratio above 0.5 Correct answer.
  4. Pleural fluid lactate dehydrogenase below 100 U/L

Explanation

Light's criteria classify an effusion as exudative if the pleural protein/serum ratio exceeds 0.5, pleural LDH/serum LDH exceeds 0.6, or pleural LDH exceeds two-thirds the upper normal serum limit.

Question 13Internal Medicine / Therapeutics (general adult care)

A 60-year-old man with type 2 diabetes has an eGFR of 35 mL/min/1.73 m². Which oral glucose-lowering drug should be avoided because of reduced clearance?

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

Explanation

Metformin is contraindicated when eGFR falls below 30 mL/min/1.73 m² and should be reviewed at lower thresholds because of lactic acidosis risk. Linagliptin requires no dose adjustment and SGLT2 inhibitors may be used with caution.

Question 14Internal Medicine / Therapeutics (general adult care)

Which feature most strongly suggests a diagnosis of infective endocarditis in a patient with fever and a new murmur?

  1. Positive blood cultures for typical organisms Correct answer.
  2. Elevated C-reactive protein
  3. Splenomegaly on examination
  4. Recent dental procedure

Explanation

Persistent bacteraemia with typical organisms is a major Duke criterion for infective endocarditis. Inflammatory markers and historical features are supportive but not diagnostic.

Question 15Internal Medicine / Therapeutics (general adult care)

A patient with acute gouty arthritis has normal renal function and no peptic ulcer history. Which treatment is appropriate for the acute attack?

  1. Low-dose aspirin
  2. High-dose naproxen Correct answer.
  3. Allopurinol at high dose
  4. Probenecid

Explanation

Non-steroidal anti-inflammatory drugs such as naproxen are first-line for acute gout when renal function is preserved and there is no GI contraindication. Urate-lowering drugs are not started during an acute attack without cover.

Question 16Internal Medicine / Therapeutics (general adult care)

Which electrolyte disturbance is most commonly associated with prolonged vomiting?

  1. Respiratory alkalosis with hyperkalaemia
  2. Hyperchloraemic metabolic acidosis with hyperkalaemia
  3. High anion gap metabolic acidosis
  4. Hypochloraemic metabolic alkalosis with hypokalaemia Correct answer.

Explanation

Vomiting loses gastric hydrochloric acid and potassium, producing a hypochloraemic metabolic alkalosis with hypokalaemia. Renal compensation increases bicarbonate reabsorption and further wastes potassium.

Question 17Internal Medicine / Therapeutics (general adult care)

A patient with decompensated cirrhosis and ascites is treated with spironolactone. Which adverse effect requires monitoring?

  1. Hyperkalaemia Correct answer.
  2. Hypokalaemia
  3. Hypernatraemia
  4. Metabolic alkalosis

Explanation

Spironolactone is a potassium-sparing aldosterone antagonist, so hyperkalaemia is the key risk, especially with renal impairment or ACE inhibitor use. Loop diuretics cause the opposite effect.

Question 18Internal Medicine / Therapeutics (general adult care)

Which clinical feature is most typical of an acute exacerbation of chronic bronchitis caused by a bacterial infection?

  1. Haemoptysis with weight loss
  2. Diffuse urticarial rash
  3. Increased sputum purulence Correct answer.
  4. Sudden pleuritic chest pain

Explanation

Increased sputum purulence, together with increased volume and dyspnoea, suggests bacterial exacerbation of chronic bronchitis. Pleuritic pain suggests pneumonia or pulmonary embolism.

Question 19Internal Medicine / Therapeutics (general adult care)

A patient with a suspected peptic ulcer has a negative rapid urease test but clinical features suggesting Helicobacter pylori infection. What is the most appropriate next step?

  1. Repeat endoscopy within 24 hours
  2. Check serum amylase
  3. Perform a urea breath test or stool antigen test Correct answer.
  4. Start empirical eradication therapy immediately

Explanation

When the rapid urease test is negative but suspicion remains, a urea breath test or stool antigen test confirms active infection. Serology cannot distinguish past from current infection.

Question 20Internal Medicine / Therapeutics (general adult care)

A 70-year-old man on warfarin has an INR of 8.5 without bleeding. What is the most appropriate management?

  1. Give intravenous heparin
  2. Withhold warfarin and give oral vitamin K Correct answer.
  3. Give fresh frozen plasma immediately
  4. Continue warfarin at the same dose

Explanation

An INR above 8.0 without bleeding is managed by withholding warfarin and giving low-dose oral vitamin K. Fresh frozen plasma is reserved for major bleeding or before urgent surgery.

Question 21Internal Medicine / Therapeutics (general adult care)

Which is the most common cause of nephrotic syndrome in adults?

  1. IgA nephropathy
  2. Membranous nephropathy Correct answer.
  3. Acute post-streptococcal glomerulonephritis
  4. Minimal change disease

Explanation

Membranous nephropathy is the commonest cause of nephrotic syndrome in white adults, whereas minimal change disease predominates in children. IgA nephropathy and post-streptococcal disease are nephritic.

Question 22Internal Medicine / Therapeutics (general adult care)

A patient with type 1 diabetes develops sweating, tremor and confusion with a capillary glucose of 2.8 mmol/L. After oral glucose the patient remains drowsy and cannot swallow safely. What is the next step?

  1. Give another oral glucose drink
  2. Start an insulin infusion
  3. Give intravenous glucose or intramuscular glucagon Correct answer.
  4. Give intravenous bicarbonate

Explanation

Severe hypoglycaemia with impaired consciousness requires parenteral therapy, either intravenous glucose or intramuscular glucagon. Oral glucose is unsafe when swallowing is impaired.

Question 23Internal Medicine / Therapeutics (general adult care)

A patient with severe hyponatraemia (serum sodium 112 mmol/L) has confusion and a seizure. What is the correct initial approach?

  1. Rapid correction with 0.9% saline over one hour
  2. Fluid restriction alone
  3. Hypertonic 3% saline with careful monitoring of sodium rise Correct answer.
  4. Oral salt tablets

Explanation

Severe symptomatic hyponatraemia with seizures requires hypertonic saline with close monitoring to raise sodium by a controlled amount. Rapid correction risks osmotic demyelination.

Question 24Internal Medicine / Therapeutics (general adult care)

A patient with suspected pulmonary embolism has a low pretest probability and a D-dimer of 300 ng/mL (normal <500). What is the appropriate next step?

  1. Start therapeutic anticoagulation
  2. Proceed to CT pulmonary angiography
  3. Perform a ventilation-perfusion scan
  4. Pulmonary embolism is excluded; no further imaging Correct answer.

Explanation

In a patient with low pretest probability and a negative D-dimer, pulmonary embolism is effectively excluded and imaging or anticoagulation is unnecessary. A high-sensitivity D-dimer has strong negative predictive value.

Question 25Internal Medicine / Therapeutics (general adult care)

A patient with rheumatoid arthritis on methotrexate develops fever, cough and bilateral infiltrates. Which adverse effect of methotrexate should be considered?

  1. Pulmonary alveolar proteinosis
  2. Drug-induced pneumonitis Correct answer.
  3. Pulmonary embolism
  4. Tuberculous reactivation

Explanation

Methotrexate can cause hypersensitivity pneumonitis presenting with fever, cough and bilateral infiltrates. It is a diagnosis of exclusion but should prompt withdrawal of the drug.

Question 26Internal Medicine / Therapeutics (general adult care)

A 55-year-old man with a 40 pack-year smoking history presents with a chronic cough and weight loss. Chest X-ray shows a right hilar mass. Which paraneoplastic syndrome is most commonly associated with small cell lung cancer?

  1. Cushing syndrome
  2. Carcinoid syndrome
  3. Hypercalcaemia
  4. Syndrome of inappropriate antidiuretic hormone secretion Correct answer.

Explanation

Small cell lung cancer is a neuroendocrine tumour that frequently ectopically secretes antidiuretic hormone, causing SIADH and hyponatraemia. Hypercalcaemia is more typical of squamous cell carcinoma, and ectopic ACTH causing Cushing syndrome is less common.

Question 27Internal Medicine / Therapeutics (general adult care)

A 45-year-old woman presents with a 3-month history of fatigue, weight loss, and hyperpigmentation of the skin and buccal mucosa. Blood tests show hyponatraemia and hyperkalaemia. Which test is most appropriate to confirm the diagnosis?

  1. Overnight dexamethasone suppression test
  2. Adrenocorticotropic hormone (ACTH) stimulation test Correct answer.
  3. Serum cortisol at 8 am
  4. Plasma renin activity

Explanation

Primary adrenal insufficiency (Addison's disease) is suggested by hyperpigmentation, hyponatraemia, and hyperkalaemia. The ACTH stimulation test is the gold standard for confirming adrenal insufficiency, showing a subnormal cortisol response to synthetic ACTH.

Question 28Internal Medicine / Therapeutics (general adult care)

A 60-year-old man with hypertension and diabetes presents with sudden onset of severe tearing chest pain radiating to the back. Blood pressure is 180/100 mmHg in the right arm and 140/80 mmHg in the left arm. Which is the most appropriate initial imaging study?

  1. Electrocardiogram
  2. Chest X-ray
  3. Transthoracic echocardiography
  4. Contrast-enhanced computed tomography of the aorta Correct answer.

Explanation

The clinical picture suggests aortic dissection. Contrast-enhanced CT of the aorta is the preferred initial imaging test in stable patients because it rapidly visualises the entire aorta and can confirm the diagnosis.

Question 29Internal Medicine / Therapeutics (general adult care)

A 70-year-old woman with a history of hypertension and diabetes presents with sudden onset of right-sided weakness and aphasia. Non-contrast CT of the head shows no haemorrhage. She is within 3 hours of symptom onset. Which is the most appropriate immediate treatment?

  1. Intra-arterial thrombectomy
  2. Intravenous heparin
  3. Aspirin 300 mg orally
  4. Intravenous alteplase Correct answer.

Explanation

Intravenous thrombolysis with alteplase is indicated for acute ischaemic stroke within 4.5 hours of onset after excluding haemorrhage. Aspirin is given after 24 hours, and thrombectomy is reserved for large vessel occlusion.

Question 30Internal Medicine / Therapeutics (general adult care)

A 25-year-old man presents with sudden onset of severe headache, neck stiffness, and fever. Lumbar puncture shows turbid cerebrospinal fluid with a neutrophil predominance, low glucose, and high protein. Which organism is the most likely cause?

  1. Streptococcus pneumoniae Correct answer.
  2. Neisseria meningitidis
  3. Herpes simplex virus
  4. Listeria monocytogenes

Explanation

Bacterial meningitis in adults is most commonly caused by Streptococcus pneumoniae. The CSF findings of neutrophilic pleocytosis, low glucose, and high protein are typical of bacterial meningitis.

Question 31Internal Medicine / Therapeutics (general adult care)

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

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

Explanation

Primary biliary cholangitis is characterised by fatigue, pruritus, jaundice, elevated alkaline phosphatase, and antimitochondrial antibodies. It predominantly affects middle-aged women.

Question 32Internal Medicine / Therapeutics (general adult care)

A 65-year-old man with chronic obstructive pulmonary disease presents with worsening dyspnoea and purulent sputum. He is alert and not in respiratory distress. Arterial blood gas shows pH 7.32, PaCO2 60 mmHg, and PaO2 55 mmHg. Which is the most appropriate initial oxygen therapy?

  1. No oxygen therapy unless PaO2 falls below 40 mmHg
  2. High-flow oxygen to maintain SpO2 at 100%
  3. Non-invasive ventilation immediately
  4. Controlled oxygen therapy to target SpO2 88–92% Correct answer.

Explanation

In COPD patients with chronic hypercapnia, controlled oxygen therapy targeting SpO2 88–92% is recommended to avoid worsening hypercapnia and acidosis. High-flow oxygen can suppress respiratory drive and exacerbate CO2 retention.

Question 33Internal Medicine / Therapeutics (general adult care)

A 30-year-old woman presents with palpitations, heat intolerance, and weight loss. She has a diffuse goitre and bilateral exophthalmos. Which antibody is most specific for this condition?

  1. Anti-thyroglobulin antibodies
  2. Anti-thyroid peroxidase (anti-TPO) antibodies
  3. Thyroid-stimulating immunoglobulin (TSI) Correct answer.
  4. Anti-microsomal antibodies

Explanation

The clinical picture is consistent with Graves' disease. Thyroid-stimulating immunoglobulin (TSI) is the most specific antibody for Graves' disease, as it stimulates the TSH receptor.

Question 34Internal Medicine / Therapeutics (general adult care)

A 55-year-old man with a history of alcohol abuse presents with confusion, ataxia, and ophthalmoplegia. Which vitamin deficiency is most likely responsible?

  1. Vitamin C (ascorbic acid)
  2. Vitamin B1 (thiamine) Correct answer.
  3. Vitamin D (calciferol)
  4. Vitamin B12 (cobalamin)

Explanation

The triad of confusion, ataxia, and ophthalmoplegia is characteristic of Wernicke's encephalopathy, caused by thiamine (vitamin B1) deficiency, commonly seen in alcohol abuse.

Question 35Internal Medicine / Therapeutics (general adult care)

A 40-year-old woman presents with recurrent episodes of severe abdominal pain, hypertension, and palpitations. During an attack, her blood pressure is 200/110 mmHg and heart rate is 120 bpm. Which is the most appropriate initial test to confirm the diagnosis?

  1. Plasma renin activity
  2. Serum cortisol
  3. Urinary 5-hydroxyindoleacetic acid (5-HIAA)
  4. Plasma free metanephrines Correct answer.

Explanation

The episodic symptoms suggest pheochromocytoma. Plasma free metanephrines are the most sensitive initial test for pheochromocytoma.

Question 36Internal Medicine / Therapeutics (general adult care)

A 65-year-old man with a history of hypertension and diabetes presents with acute onset of severe abdominal pain out of proportion to physical findings. He has atrial fibrillation. Which diagnosis should be suspected?

  1. Acute cholecystitis
  2. Acute mesenteric ischaemia Correct answer.
  3. Acute pancreatitis
  4. Perforated peptic ulcer

Explanation

Severe abdominal pain out of proportion to examination findings in a patient with atrial fibrillation suggests acute mesenteric ischaemia due to an embolus to the superior mesenteric artery.

Question 37Internal Medicine / Therapeutics (general adult care)

A 70-year-old woman with osteoporosis has been on alendronate for 5 years. She now presents with a low-trauma subtrochanteric femoral fracture. Which is the most likely cause?

  1. Hyperparathyroidism
  2. Paget's disease of bone
  3. Long-term bisphosphonate therapy Correct answer.
  4. Vitamin D deficiency

Explanation

Long-term bisphosphonate use is associated with atypical femoral fractures, typically subtrochanteric or diaphyseal, often preceded by prodromal thigh pain.

Question 38Internal Medicine / Therapeutics (general adult care)

A 50-year-old man presents with haemoptysis, haematuria, and renal impairment. He has a history of chronic sinusitis. Chest X-ray shows nodular opacities. Which is the most likely diagnosis?

  1. Polyarteritis nodosa
  2. Granulomatosis with polyangiitis Correct answer.
  3. Systemic lupus erythematosus
  4. Goodpasture syndrome

Explanation

Granulomatosis with polyangiitis (Wegener's) typically presents with upper respiratory tract involvement (sinusitis), lung nodules, and glomerulonephritis. Haemoptysis and haematuria reflect pulmonary and renal involvement.

Question 39Internal Medicine / Therapeutics (general adult care)

A 60-year-old man with type 2 diabetes and a history of myocardial infarction is on metformin. His HbA1c is 8.5%. Which additional medication has been shown to reduce cardiovascular mortality in this population?

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

Explanation

Empagliflozin, an SGLT2 inhibitor, has been shown to reduce cardiovascular mortality in patients with type 2 diabetes and established cardiovascular disease.

Question 40Internal Medicine / Therapeutics (general adult care)

A 25-year-old man presents with sudden onset of severe testicular pain. On examination, the testis is high-riding and the cremasteric reflex is absent. Which is the most appropriate immediate management?

  1. Antibiotics for epididymitis
  2. Urgent surgical exploration Correct answer.
  3. Analgesia and observation
  4. Scrotal ultrasound

Explanation

Testicular torsion is a surgical emergency. The diagnosis is clinical, and immediate surgical exploration is required to salvage the testis; imaging should not delay surgery.

Question 41Cardiology

A 58-year-old man has blood pressure 165/102 mmHg on three separate office visits over two months. He has no diabetes, no target-organ damage, and no other cardiovascular risk factors. According to current hypertension staging, how is his condition classified?

  1. Grade 2 hypertension Correct answer.
  2. Grade 1 hypertension
  3. Grade 3 hypertension
  4. High-normal blood pressure

Explanation

Grade 2 hypertension corresponds to systolic 160–179 mmHg or diastolic 100–109 mmHg. A reading of 165/102 mmHg falls in this band on repeated measurements, so the diagnosis is grade 2.

Question 42Cardiology

Which ECG finding is the earliest and most characteristic sign of acute transmural myocardial infarction?

  1. ST-segment elevation in leads facing the infarct Correct answer.
  2. Peaked T waves in the affected leads
  3. Deep Q waves in the affected leads
  4. New left bundle branch block

Explanation

Acute transmural injury produces ST-segment elevation in the leads overlying the infarcted territory, which is the defining early sign. Q waves and T-wave inversion evolve later as necrosis and ischemia progress.

Question 43Cardiology

A patient with chronic heart failure has dyspnea at rest and is comfortable only in bed. Which NYHA functional class does this represent?

  1. Class II
  2. Class III
  3. Class IV Correct answer.
  4. Class I

Explanation

NYHA class IV is defined by symptoms at rest or with minimal exertion, with the patient unable to carry out any activity without discomfort. Dyspnea at rest therefore places the patient in class IV.

Question 44Cardiology

Which murmur is most characteristic of mitral stenosis?

  1. A diastolic rumble at the apex with an opening snap Correct answer.
  2. A crescendo-decrescendo systolic murmur at the right upper sternal border
  3. A holosystolic murmur at the apex radiating to the axilla
  4. An early diastolic decrescendo murmur at the left sternal border

Explanation

Mitral stenosis produces a low-pitched mid-diastolic rumble heard best at the apex, often preceded by an opening snap. The murmur reflects turbulent flow across the narrowed valve during diastole.

Question 45Cardiology

Which medication is the first-line antiplatelet agent for long-term secondary prevention after myocardial infarction?

  1. Heparin
  2. Acetylsalicylic acid Correct answer.
  3. Warfarin
  4. Dipyridamole

Explanation

Acetylsalicylic acid irreversibly inhibits platelet cyclooxygenase and is the standard long-term antiplatelet for secondary prevention after myocardial infarction. It is continued indefinitely unless contraindicated.

Question 46Cardiology

A 30-year-old man has a blood pressure of 190/110 mmHg with headache and blurred vision but no chest pain or focal neurologic deficit. Which diagnosis best fits?

  1. Secondary hypertension
  2. Hypertensive emergency
  3. Hypertensive urgency Correct answer.
  4. White-coat hypertension

Explanation

Severe hypertension with symptoms but without acute target-organ damage is classified as hypertensive urgency. Hypertensive emergency requires evidence of acute organ injury such as encephalopathy, pulmonary edema, or renal failure.

Question 47Cardiology

Which finding on echocardiography is the primary criterion for diagnosing heart failure with reduced ejection fraction?

  1. Preserved mitral annular velocity
  2. Left ventricular ejection fraction of 50% or more
  3. Normal left ventricular wall thickness
  4. Left ventricular ejection fraction of 40% or less Correct answer.

Explanation

Heart failure with reduced ejection fraction is defined by a left ventricular ejection fraction of 40% or less together with symptoms and signs of heart failure. Values of 41–49% define the mildly reduced category.

Question 48Cardiology

A 64-year-old woman with atrial fibrillation has a CHA2DS2-VASc score of 3. What is the appropriate antithrombotic strategy?

  1. Oral anticoagulation Correct answer.
  2. Acetylsalicylic acid alone
  3. Dual antiplatelet therapy
  4. No antithrombotic therapy

Explanation

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

Question 49Cardiology

Which ECG feature distinguishes atrial flutter from atrial fibrillation?

  1. Irregularly irregular ventricular rhythm
  2. Narrow QRS complexes
  3. Regular sawtooth flutter waves at about 300 per minute Correct answer.
  4. Absence of discernible P waves

Explanation

Atrial flutter is characterized by organized sawtooth flutter waves, typically at an atrial rate near 300 per minute, often with regular conduction such as 2:1. Atrial fibrillation shows disorganized fibrillatory activity without discrete flutter waves.

Question 50Cardiology

A 70-year-old man has exertional syncope, a crescendo-decrescendo systolic murmur at the right upper sternal border radiating to the carotids, and a diminished second heart sound. What is the most likely diagnosis?

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

Explanation

The triad of exertional syncope, an ejection systolic murmur radiating to the carotids, and a soft second heart sound points to aortic stenosis. Fixed outflow obstruction limits the ability to increase cardiac output during exertion.