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SMLE practice questions

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Question 1Internal Medicine

A 58-year-old man has a fasting plasma glucose of 7.8 mmol/L on two separate occasions. Which diagnosis is most appropriate?

  1. Diabetes mellitus Correct answer.
  2. Gestational diabetes
  3. Impaired fasting glucose
  4. Normal glucose tolerance

Explanation

A fasting plasma glucose of 7.0 mmol/L or higher confirmed on a second occasion establishes diabetes mellitus. Values between 6.1 and 6.9 mmol/L define impaired fasting glucose.

Question 2Internal Medicine

Which finding on physical examination is most characteristic of mitral stenosis?

  1. A loud opening snap after the second heart sound Correct answer.
  2. A pansystolic murmur at the apex radiating to the axilla
  3. A continuous machinery murmur below the clavicle
  4. A decrescendo diastolic murmur along the left sternal border

Explanation

Mitral stenosis produces a loud first heart sound and an opening snap that follows the second heart sound, along with a mid-diastolic rumble. The other murmurs describe mitral regurgitation, aortic regurgitation, and patent ductus arteriosus respectively.

Question 3Internal Medicine

A 24-year-old woman has fever, a malar rash, and arthralgia. Which autoantibody is most specific for systemic lupus erythematosus?

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

Explanation

Anti-double-stranded DNA is highly specific for systemic lupus erythematosus and correlates with disease activity and nephritis. Antinuclear antibody is sensitive but not specific.

Question 4Internal Medicine

A patient presents with sudden onset of a severe headache described as the worst of life. Which investigation is the most appropriate first step?

  1. Carotid Doppler ultrasound
  2. Non-contrast CT of the head Correct answer.
  3. Lumbar puncture
  4. MRI of the brain

Explanation

Sudden severe headache raises concern for subarachnoid hemorrhage, and non-contrast CT is the first-line test because it rapidly detects acute blood. Lumbar puncture is reserved for cases with a negative CT where clinical suspicion remains.

Question 5Internal Medicine

Which electrolyte abnormality most commonly produces prolonged QT interval and predisposes to torsades de pointes?

  1. Hyperkalemia
  2. Hypomagnesemia Correct answer.
  3. Hypernatremia
  4. Hypocalcemia

Explanation

Hypomagnesemia prolongs the QT interval and predisposes to torsades de pointes, often in combination with hypokalemia. Magnesium is required for proper function of potassium channels.

Question 6Internal Medicine

A 30-year-old man has a blood pressure of 160/100 mmHg with hypokalemia and metabolic alkalosis. Which cause of secondary hypertension is most likely?

  1. Cushing syndrome
  2. Renal artery stenosis
  3. Primary aldosteronism Correct answer.
  4. Pheochromocytoma

Explanation

Hypertension with hypokalemia and metabolic alkalosis is the classic picture of primary aldosteronism, where excess aldosterone causes sodium retention and potassium wasting. The combination of these two laboratory findings points strongly to mineralocorticoid excess.

Question 7Internal Medicine

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

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

Explanation

Streptococcus pneumoniae remains the most frequently identified cause of community-acquired pneumonia in adults. It classically presents with a productive cough and lobar consolidation.

Question 8Internal Medicine

A patient with chronic kidney disease has a hemoglobin of 85 g/L with normal red cell indices. Which mechanism best explains the anemia?

  1. Iron deficiency
  2. Hemolysis
  3. Vitamin B12 deficiency
  4. Reduced erythropoietin production Correct answer.

Explanation

The kidneys produce erythropoietin, and in chronic kidney disease reduced production leads to a normocytic normochromic anemia. Iron and vitamin B12 deficiency would produce microcytic and macrocytic changes respectively.

Question 9Internal Medicine

Which of the following is the most appropriate initial therapy for a patient with an acute exacerbation of asthma and severe respiratory distress?

  1. Oral montelukast
  2. Inhaled salmeterol
  3. Nebulized salbutamol with systemic corticosteroids Correct answer.
  4. Prophylactic antibiotics

Explanation

Acute severe asthma is treated with rapidly acting inhaled beta-2 agonists such as nebulized salbutamol plus systemic corticosteroids to reduce airway inflammation. Long-acting agents and leukotriene antagonists are for maintenance, not acute rescue.

Question 10Internal Medicine

A 65-year-old man has progressive dyspnea and bilateral basal crackles. Echocardiography shows an ejection fraction of 30%. Which drug class improves survival in heart failure with reduced ejection fraction?

  1. Calcium channel blockers
  2. Alpha-1 blockers
  3. Thiazolidinediones
  4. Angiotensin-converting enzyme inhibitors Correct answer.

Explanation

ACE inhibitors reduce mortality in heart failure with reduced ejection fraction through afterload reduction and neurohormonal blockade. Several other agents listed can worsen heart failure.

Question 11Internal Medicine

A 45-year-old woman has weight loss, palpitations, and a diffuse goiter with exophthalmos. Which laboratory pattern is expected?

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

Explanation

Graves disease causes primary hyperthyroidism, in which thyroid hormone levels are elevated and TSH is suppressed by negative feedback. Exophthalmos and a diffuse goiter support this diagnosis.

Question 12Internal Medicine

Which finding is most suggestive of nephrotic syndrome?

  1. Proteinuria greater than 3.5 g per day with hypoalbuminemia Correct answer.
  2. Oliguria with a rising creatinine
  3. Hematuria with red cell casts
  4. Sterile pyuria

Explanation

Nephrotic syndrome is defined by heavy proteinuria, hypoalbuminemia, edema, and hyperlipidemia. Red cell casts and hematuria indicate a nephritic picture.

Question 13Internal Medicine

A 70-year-old man has a sudden painless loss of vision in one eye. Fundoscopy shows a pale retina with a cherry-red spot at the macula. What is the most likely diagnosis?

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

Explanation

Central retinal artery occlusion produces sudden painless monocular vision loss with a pale retina and a cherry-red spot at the fovea. The cherry-red spot reflects preserved choroidal perfusion at the macula.

Question 14Internal Medicine

Which of the following best describes the mechanism of action of metformin?

  1. Blocks renal glucose reabsorption
  2. Reduces hepatic gluconeogenesis and improves insulin sensitivity Correct answer.
  3. Inhibits intestinal alpha-glucosidase
  4. Increases insulin secretion from pancreatic beta cells

Explanation

Metformin lowers blood glucose mainly by reducing hepatic gluconeogenesis and enhancing peripheral insulin sensitivity. It does not stimulate insulin release and therefore rarely causes hypoglycemia.

Question 15Internal Medicine

A 28-year-old woman has recurrent episodes of flushing, diarrhea, and wheezing. Which investigation is most appropriate to confirm the suspected diagnosis?

  1. Plasma renin activity
  2. Serum cortisol
  3. Serum calcitonin
  4. 24-hour urinary 5-HIAA Correct answer.

Explanation

Flushing, diarrhea, and bronchospasm suggest carcinoid syndrome, which is confirmed by elevated 24-hour urinary 5-HIAA, a serotonin metabolite. Imaging then localizes the tumor.

Question 16Internal Medicine

A patient with atrial fibrillation has a CHA2DS2-VASc score of 4. What is the most appropriate therapy to reduce stroke risk?

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

Explanation

A CHA2DS2-VASc score of 2 or more in men and 3 or more in women warrants oral anticoagulation. Antiplatelet monotherapy is inferior for stroke prevention in atrial fibrillation.

Question 17Internal Medicine

Which feature distinguishes ulcerative colitis from Crohn disease?

  1. Presence of granulomas
  2. Transmural inflammation
  3. Continuous mucosal involvement starting in the rectum Correct answer.
  4. Fistula formation

Explanation

Ulcerative colitis involves continuous inflammation of the mucosa beginning in the rectum and extending proximally. Crohn disease is characteristically transmural, segmental, and may spare the rectum.

Question 18Internal Medicine

A patient has a serum sodium of 120 mmol/L with confusion. Which correction rate should be avoided to prevent osmotic demyelination?

  1. Correction of 8 mmol/L in 24 hours
  2. Rapid correction exceeding 10 mmol/L in 24 hours Correct answer.
  3. Correction of 4 mmol/L in 24 hours
  4. Correction of 6 mmol/L in 24 hours

Explanation

Correction of chronic hyponatremia should not exceed 8 to 10 mmol/L in 24 hours because faster correction risks osmotic demyelination syndrome. Slower correction is safe.

Question 19Internal Medicine

A 55-year-old smoker has a chronic cough, weight loss, and a serum calcium of 3.1 mmol/L. Which malignancy is most likely?

  1. Prostate cancer
  2. Multiple myeloma
  3. Squamous cell carcinoma of the lung Correct answer.
  4. Adenocarcinoma of the colon

Explanation

Squamous cell carcinoma of the lung can secrete parathyroid hormone-related peptide, causing hypercalcemia. Smoking and a chronic cough support a primary lung tumor.

Question 20Internal Medicine

Which of the following best explains why a patient with severe liver cirrhosis develops ascites?

  1. Primary hyperaldosteronism
  2. Portal hypertension and reduced plasma oncotic pressure Correct answer.
  3. Increased oncotic pressure from hyperalbuminemia
  4. Excess production of antidiuretic hormone alone

Explanation

Ascites in cirrhosis arises from portal hypertension and hypoalbuminemia, which reduce effective oncotic pressure and promote fluid transudation. Secondary hyperaldosteronism further aggravates sodium and water retention.

Question 21Internal Medicine

A 32-year-old woman has a deep vein thrombosis and a history of recurrent pregnancy loss. Which test is most appropriate to investigate an underlying cause?

  1. Antithrombin III, protein C, and protein S levels Correct answer.
  2. Serum electrophoresis
  3. Antinuclear antibody
  4. Erythrocyte sedimentation rate

Explanation

Recurrent thrombosis and pregnancy loss suggest inherited thrombophilia, so testing antithrombin III, protein C, and protein S is appropriate. Antiphospholipid antibodies should also be checked in this clinical setting.

Question 22Internal Medicine

A patient with chronic obstructive pulmonary disease has a pH of 7.32, PaCO2 of 60 mmHg, and bicarbonate of 30 mmol/L. What does this indicate?

  1. Acute respiratory alkalosis
  2. Acute respiratory acidosis
  3. Chronic respiratory acidosis with metabolic compensation Correct answer.
  4. Compensated metabolic acidosis

Explanation

A raised PaCO2 with a normal-to-raised bicarbonate reflects chronic respiratory acidosis with renal compensation. The pH remains slightly acidemic because compensation is incomplete.

Question 23Internal Medicine

Which of the following is the most appropriate treatment for a patient with an acute attack of gout?

  1. Allopurinol during the acute attack
  2. Low-dose aspirin
  3. Probenecid during the acute attack
  4. Colchicine or a nonsteroidal anti-inflammatory drug Correct answer.

Explanation

Acute gout is treated with anti-inflammatory agents such as colchicine, NSAIDs, or corticosteroids. Urate-lowering therapy is generally not started or adjusted during an acute attack.

Question 24Internal Medicine

A 40-year-old man has a blood pressure of 180/110 mmHg with headache and confusion but no focal neurological deficit. What is the most appropriate initial management?

  1. Gradual reduction of blood pressure over hours with intravenous therapy Correct answer.
  2. Observation without treatment
  3. Rapid reduction of blood pressure to normal within 1 hour
  4. Oral captopril and discharge

Explanation

Hypertensive emergency with end-organ symptoms requires controlled blood pressure reduction over hours, usually with intravenous agents, to avoid ischemic complications from overly rapid lowering.

Question 25Internal Medicine

Which of the following is the most common cause of acute pancreatitis worldwide?

  1. Gallstones Correct answer.
  2. Hypertriglyceridemia
  3. Infections
  4. Trauma

Explanation

Gallstones and alcohol are the two leading causes of acute pancreatitis worldwide, with gallstones being most common in many populations. Hypertriglyceridemia and trauma are less frequent causes.

Question 26Internal Medicine

A 58-year-old man with a history of myocardial infarction presents with sudden-onset 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 diagnosis is most likely?

  1. Acute myocardial infarction
  2. Acute aortic dissection Correct answer.
  3. Pericarditis
  4. Pulmonary embolism

Explanation

Sudden tearing chest pain radiating to the back with a significant inter-arm blood pressure difference is classic for aortic dissection. The history of hypertension and myocardial infarction are risk factors. Immediate imaging with CT angiography is indicated.

Question 27Internal Medicine

A 45-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. On examination, she has dry skin, bradycardia, and delayed relaxation of deep tendon reflexes. Which laboratory finding is most consistent with her condition?

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

Explanation

Primary hypothyroidism is characterized by an elevated TSH due to loss of negative feedback from thyroid hormones, and a low free T4. The clinical features are typical of hypothyroidism. The other patterns suggest central hypothyroidism or hyperthyroidism.

Question 28Internal Medicine

A 62-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
  2. Niacin (B3)
  3. Thiamine (B1) Correct answer.
  4. Vitamin B12

Explanation

The triad of confusion, ataxia, and ophthalmoplegia is characteristic of Wernicke encephalopathy, caused by thiamine deficiency. It is common in alcoholics due to poor nutrition and impaired absorption. Prompt thiamine replacement is essential to prevent progression to Korsakoff syndrome.

Question 29Internal Medicine

A 70-year-old woman with hypertension and diabetes presents with sudden onset of right-sided weakness and aphasia. Her blood pressure is 180/100 mmHg, and she takes aspirin. Which of the following is the most appropriate initial step in management?

  1. Give intravenous mannitol
  2. Administer intravenous tissue plasminogen activator (tPA)
  3. Start anticoagulation with heparin
  4. Obtain urgent non-contrast CT of the head Correct answer.

Explanation

Before any thrombolytic therapy, a non-contrast CT scan is mandatory to exclude intracranial hemorrhage. The patient's symptoms suggest acute ischemic stroke, but tPA can only be given after hemorrhage is ruled out. Other measures are either contraindicated or not the first step.

Question 30Internal Medicine

A 30-year-old woman presents with recurrent episodes of hypoglycemia, and laboratory tests show a high insulin level and a high C-peptide level during an episode. Which is the most likely cause?

  1. Adrenal insufficiency
  2. Insulinoma Correct answer.
  3. Factitious hypoglycemia due to insulin injection
  4. Severe liver disease

Explanation

Endogenous hyperinsulinism, as in an insulinoma, causes hypoglycemia with elevated insulin and C-peptide. Exogenous insulin administration would suppress C-peptide. Adrenal insufficiency and liver disease cause hypoglycemia with low insulin.

Question 31Internal Medicine

A 55-year-old man with a history of hypertension and smoking presents with sudden severe headache, neck stiffness, and photophobia. A non-contrast CT scan of the head is normal. What is the next most appropriate step?

  1. MRI of the brain
  2. Start antibiotics for bacterial meningitis
  3. Reassure and discharge
  4. Lumbar puncture Correct answer.

Explanation

The presentation is highly suspicious for subarachnoid hemorrhage. A normal CT scan does not rule it out, especially if performed more than 6 hours after symptom onset. Lumbar puncture for xanthochromia is the next step.

Question 32Internal Medicine

A 25-year-old man presents with a 2-week history of fever, night sweats, and a productive cough with blood-streaked sputum. Chest X-ray shows upper lobe cavitation. Which organism is most likely?

  1. Staphylococcus aureus
  2. Klebsiella pneumoniae
  3. Mycobacterium tuberculosis Correct answer.
  4. Streptococcus pneumoniae

Explanation

Upper lobe cavitation with constitutional symptoms and hemoptysis is classic for reactivation tuberculosis. Streptococcus pneumoniae typically causes lobar pneumonia without cavitation. Staphylococcus and Klebsiella can cause cavitation but usually in different clinical settings.

Question 33Internal Medicine

A 68-year-old woman with a history of heart failure and atrial fibrillation presents with worsening dyspnea and edema. She is on furosemide and digoxin. Her digoxin level is 2.8 ng/mL (therapeutic 0.5-2.0). Which electrolyte abnormality predisposes to digoxin toxicity?

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

Explanation

Hypokalemia increases the binding of digoxin to the Na+/K+-ATPase and enhances its toxic effects. Hyperkalemia is more often a consequence of severe digoxin toxicity. Sodium and calcium abnormalities do not directly predispose to digoxin toxicity.

Question 34Internal Medicine

A 50-year-old man with a history of alcohol abuse presents with confusion, jaundice, and asterixis. He has ascites and palmar erythema. Which of the following is the most appropriate initial treatment for his hepatic encephalopathy?

  1. Neomycin
  2. Rifaximin
  3. Lactulose Correct answer.
  4. Metronidazole

Explanation

Lactulose is the first-line treatment for hepatic encephalopathy. It acidifies the colon and traps ammonia. Rifaximin is often added for secondary prophylaxis but is not the initial treatment. Neomycin and metronidazole are alternatives but not first-line.

Question 35Internal Medicine

A 35-year-old woman presents with fatigue, arthralgia, and a malar rash. Laboratory tests show a positive antinuclear antibody (ANA) and anti-double-stranded DNA (anti-dsDNA). Which of the following is the most specific marker for her disease?

  1. Anti-dsDNA
  2. Anti-Smith antibodies Correct answer.
  3. Anti-histone antibodies
  4. Rheumatoid factor

Explanation

Anti-Smith antibodies are highly specific for systemic lupus erythematosus (SLE), though less sensitive than anti-dsDNA. Anti-dsDNA is also specific but anti-Smith is considered more specific. Anti-histone antibodies are associated with drug-induced lupus, and rheumatoid factor is nonspecific.

Question 36Internal Medicine

A 60-year-old man with chronic obstructive pulmonary disease (COPD) has a resting oxygen saturation of 88% on room air. He has a history of cor pulmonale. Which of the following is the most appropriate long-term management?

  1. Oral corticosteroids
  2. Continuous low-flow oxygen therapy Correct answer.
  3. Inhaled beta-2 agonists as needed
  4. Prophylactic antibiotics

Explanation

Long-term oxygen therapy improves survival in COPD patients with chronic hypoxemia (PaO2 ≤55 mmHg or SpO2 ≤88%). It should be used for at least 15 hours per day. The other options are not proven to improve survival in this context.

Question 37Internal Medicine

A 40-year-old woman presents with episodic headaches, palpitations, and sweating. She has a blood pressure of 160/100 mmHg. Which test is most appropriate to confirm the diagnosis?

  1. Serum cortisol
  2. Plasma metanephrines Correct answer.
  3. Plasma renin activity
  4. Urinary 5-HIAA

Explanation

The symptoms suggest pheochromocytoma. Measurement of plasma free metanephrines is the most sensitive test for diagnosis. Serum cortisol is for Cushing's syndrome, plasma renin for renovascular hypertension, and urinary 5-HIAA for carcinoid syndrome.

Question 38Internal Medicine

A 28-year-old man presents with jaundice, dark urine, and right upper quadrant pain. He recently returned from a trip to Southeast Asia. Laboratory tests show markedly elevated ALT and AST, and IgM anti-HAV is positive. Which of the following is the most appropriate advice regarding his infectivity?

  1. He is not infectious at any time
  2. He is infectious during the prodromal phase and until jaundice resolves Correct answer.
  3. He is infectious for 6 months after recovery
  4. He is infectious only after jaundice appears

Explanation

Hepatitis A is most infectious during the prodromal phase (before jaundice) and remains infectious until jaundice resolves, typically 1-2 weeks after. It does not cause chronic infection. The other options are incorrect regarding the period of infectivity.

Question 39Internal Medicine

A 55-year-old man with type 2 diabetes and a history of myocardial infarction is on metformin and aspirin. His blood pressure is 150/90 mmHg. Which of the following is the most appropriate target blood pressure for this patient?

  1. <150/90 mmHg
  2. <130/80 mmHg Correct answer.
  3. <120/70 mmHg
  4. <140/90 mmHg

Explanation

Current guidelines recommend a target blood pressure of <130/80 mmHg for patients with diabetes and cardiovascular disease to reduce cardiovascular events. The other targets are either too lenient or not supported by evidence.

Question 40Internal Medicine

A 30-year-old woman with a history of recurrent kidney stones has a serum calcium of 2.9 mmol/L (normal 2.1-2.6). Which of the following is the most likely cause?

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

Explanation

Primary hyperparathyroidism is the most common cause of hypercalcemia in outpatients, often leading to recurrent kidney stones. It is characterized by elevated calcium and inappropriately normal or high PTH. The other conditions cause hypocalcemia or are associated with low calcium.

Question 41Surgery

A 24-year-old man sustains a blunt abdominal injury in a road traffic collision. He is haemodynamically stable. Contrast-enhanced CT shows a grade III splenic laceration with no active contrast extravasation. What is the most appropriate initial management?

  1. Non-operative management with observation and serial abdominal examinations Correct answer.
  2. Splenic artery embolisation in all grade III injuries
  3. Immediate exploratory laparotomy and splenectomy
  4. Diagnostic peritoneal lavage to confirm haemoperitoneum

Explanation

Haemodynamically stable patients with blunt splenic injury and no active bleeding on CT are managed non-operatively with observation, bed rest and serial assessment. Embolisation is reserved for specific findings such as active extravasation or pseudoaneurysm. Operative intervention is indicated for haemodynamic instability or peritonitis.

Question 42Surgery

Which finding on history most strongly suggests acute appendicitis rather than mesenteric adenitis in a young adult?

  1. Pain that is worst on the left side and radiates to the back
  2. Generalised colicky abdominal pain relieved by defecation
  3. Pain that migrates from the periumbilical region to the right iliac fossa Correct answer.
  4. A prodrome of watery diarrhoea lasting several days

Explanation

Migration of visceral periumbilical pain to the right iliac fossa as parietal peritoneal irritation develops is the classic pattern of acute appendicitis. Mesenteric adenitis more often produces diffuse or shifting pain, sometimes with a viral prodrome.

Question 43Surgery

A 62-year-old woman has a 3 cm firm, painless breast mass with skin tethering and clinically palpable axillary nodes. Core biopsy confirms invasive ductal carcinoma. Which single factor has the greatest influence on her prognosis?

  1. Presence of skin tethering
  2. Patient age at diagnosis
  3. Tumour grade alone
  4. Axillary lymph node status Correct answer.

Explanation

Axillary lymph node involvement is the single strongest prognostic factor in operable breast cancer, followed by tumour size, grade and receptor status. Skin tethering reflects local invasion but does not carry the same weight as nodal disease.

Question 44Surgery

A 45-year-old man presents with a painful, tender lump in the left groin that appeared while lifting. On examination the swelling is below and lateral to the pubic tubercle and reduces spontaneously when he lies flat. What is the most likely diagnosis?

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

Explanation

An indirect inguinal hernia passes through the deep ring and lies above and medial to the pubic tubercle, and is the most common groin hernia in younger men. Femoral hernias lie below and lateral to the pubic tubercle.

Question 45Surgery

A 70-year-old man has painless visible haematuria. Which investigation is the most appropriate first-line evaluation to identify a bladder tumour?

  1. Urine cytology alone
  2. Intravenous urography alone
  3. Flexible cystoscopy with upper tract imaging Correct answer.
  4. Renal ultrasound alone

Explanation

Painless visible haematuria in an older adult warrants direct visualisation of the bladder by cystoscopy together with imaging of the upper tracts. Ultrasound and cytology alone cannot exclude urothelial malignancy.

Question 46Surgery

A 30-year-old man is brought in after a stab wound to the left anterior chest. He is hypotensive, with distended neck veins and muffled heart sounds. Which is the most appropriate immediate management?

  1. Emergency thoracotomy or pericardial decompression with fluid resuscitation Correct answer.
  2. CT angiography of the chest before any intervention
  3. Chest drain insertion and observation
  4. Pericardiocentesis followed by discharge if vital signs normalise

Explanation

The triad of hypotension, distended neck veins and muffled heart sounds after penetrating chest trauma indicates cardiac tamponade, usually from a penetrating injury. Prompt surgical decompression and repair are required; pericardiocentesis is only a temporising measure.

Question 47Surgery

A 55-year-old man has a 4 cm abdominal aortic aneurysm. What is the recommended surveillance interval for an asymptomatic aneurysm of this size?

  1. Three-monthly ultrasound surveillance
  2. No further surveillance required
  3. Annual ultrasound surveillance Correct answer.
  4. Immediate surgical repair

Explanation

Asymptomatic abdominal aortic aneurysms between 3 and 4.4 cm are typically monitored with annual ultrasound. More frequent imaging is reserved for larger aneurysms, and repair is considered when the diameter approaches 5.5 cm or the aneurysm becomes symptomatic.

Question 48Surgery

Which clinical feature best distinguishes acute arterial ischaemia from an acute compartment syndrome of the lower limb?

  1. Paraesthesia in the distribution of a single nerve
  2. Absent pulses with pallor and a cold limb Correct answer.
  3. Swelling and tenseness of the affected compartment
  4. Pain out of proportion to findings that worsens with passive stretch

Explanation

Acute arterial occlusion produces the classic features of pulselessness, pallor, coldness and pain, reflecting loss of inflow. Compartment syndrome results from raised tissue pressure with pulses often preserved and pain on passive stretch as the earliest sign.

Question 49Surgery

A 28-year-old woman has a 2 cm thyroid nodule. Fine-needle aspiration cytology is reported as Bethesda category V (suspicious for malignancy). What is the most appropriate next step?

  1. Diagnostic hemithyroidectomy Correct answer.
  2. Observation with annual ultrasound
  3. Repeat fine-needle aspiration in 6 months
  4. Radioiodine ablation

Explanation

Bethesda category V carries a high risk of malignancy and warrants diagnostic surgery, usually a hemithyroidectomy or lobectomy, to obtain histology. Repeat cytology or observation would delay diagnosis of a likely thyroid carcinoma.

Question 50Surgery

A 35-year-old man has a 1 cm pigmented lesion on his back with irregular borders and colour variation. Excisional biopsy confirms a melanoma with a Breslow thickness of 1.2 mm and no ulceration. Which factor most strongly predicts his risk of metastasis?

  1. Presence of itching
  2. Lesion diameter
  3. Family history of melanoma
  4. Breslow thickness Correct answer.

Explanation

Breslow thickness is the strongest predictor of prognosis and metastatic risk in cutaneous melanoma, with ulceration and mitotic rate adding further information. Diameter and symptoms are less powerful predictors.