Questions

1. A 55-year-old male with chronic liver disease presents with tense ascites. What is the first-line
treatment for this condition?
a. Intravenous albumin
b. Large-volume paracentesis combined with albumin infusion
c. Oral diuretics (spironolactone +/- furosemide)
d. Transjugular intrahepatic portosystemic shunt (TIPS)

2. A 25-year-old male presents with fever, night sweats, weight loss, and cough. Chest X-ray shows
cavitary lesions in the upper lobes. What is the most sensitive diagnostic test for active pulmonary
tuberculosis?
a. Sputum AFB smear microscopy
b. Sputum culture for Mycobacterium tuberculosis
* *

c. GeneXpert MTB/RIF assay

d. Tuberculin skin test
3. A 45-year-old male presents with ascending muscle weakness, areflexia, and autonomic dysfunction.
Nerve conduction studies show demyelination. Which antibody is most commonly associated with the
axonal variant of Guillain-Barré Syndrome (GBS)?
a. Anti-GM1
b. Anti-GQ1b
c. Anti-MAG
d. Anti-GD1b
4. A 60-year-old male complains of excessive daytime sleepiness, snores heavily, and has
witnessed pauses in breathing during sleep. Which diagnostic test is most definitive for confirming
obstructive sleep apnea?
a. Multiple sleep latency test
b. Polysomnography
c. Overnight oximetry
d. Epworth Sleepiness Scale
5. A 70-year-old female with atrial fibrillation, hypertension, and diabetes has a CHA₂DS₂-VASc
score of 4. What is the most appropriate anticoagulation therapy?
a. Warfarin with INR target of 2-3
b. Apixaban
c. Dual antiplatelet therapy (aspirin + clopidogrel)
d. Aspirin monotherapy
6. A 10-year-old boy presents with progressive difficulty in walking and climbing stairs. He has a
waddling gait and uses his hands to push on his thighs to stand up from a sitting position (Gower’s sign).
Which gene mutation is most likely responsible?
a. Dystrophin
b. Myotilin
c. Lamin A/C
d. Caveolin-3
7. A 65-year-old male with a history of ischemic cardiomyopathy presents with sustained
monomorphic ventricular tachycardia (VT) and a blood pressure of 95/60 mmHg. What is the most
appropriate initial management?
a. Amiodarone infusion
b. Synchronized cardioversion
c. Lidocaine bolus
d. Unsynchronized defibrillation
8. A 30-year-old female presents with a tender, enlarged thyroid and systemic symptoms of fever
and malaise. Thyroid function tests show elevated T4 and suppressed TSH. ESR is markedly elevated.
What is the most likely diagnosis?
a. Graves’ disease
b. Subacute thyroiditis (de Quervain thyroiditis)
c. Hashimoto thyroiditis
d. Postpartum thyroiditis
9. A 60-year-old male presents with acute chest pain radiating to his left arm, sweating, and
nausea. ECG shows ST-segment elevation in leads II, III, and aVF. Which artery is most likely occluded?
a. Left anterior descending artery
b. Left circumflex artery
c. Right coronary artery
d. Posterior descending artery
10. A 35-year-old woman presents with ophthalmoplegia, ataxia, and areflexia. CSF analysis shows
albuminocytologic dissociation. Which of the following antibodies is most specific for her condition?
a. Anti-GD1a
b. Anti-GQ1b
c. Anti-GM1
d. Anti-MAG
11. A 70-year-old man presents with a resting tremor, bradykinesia, and rigidity. He is diagnosed
with Parkinson’s disease. Which of the following is the primary pathological hallmark of this condition?
a. Neurofibrillary tangles
b. Lewy bodies
c. Beta-amyloid plaques
d. Gliosis
12. A 35-year-old female with systemic lupus erythematosus presents with nephrotic range
proteinuria and microscopic hematuria. Renal biopsy shows diffuse endocapillary hypercellularity with
subendothelial immune complex deposits. What is the most appropriate treatment?
a. Mycophenolate mofetil and corticosteroids
b. Cyclophosphamide and corticosteroids
c. Hydroxychloroquine
d. Rituximab
13. A patient reports dyspnea on exertion when climbing stairs but remains comfortable at rest.
What is their New York Heart Association (NYHA) functional classification?
a. Class I
b. Class II
c. Class III
d. Class IV
14. A 55-year-old male with fever, cough, and dyspnea has bronchoalveolar lavage (BAL) showing
lymphocytosis >40%. HRCT shows ground-glass opacities. What is the most likely diagnosis?
a. Idiopathic pulmonary fibrosis
b. Hypersensitivity pneumonitis
c. Cryptogenic organizing pneumonia
d. Sarcoidosis
15. A 45-year-old male with a traumatic brain injury has an intracranial pressure (ICP) of 28 mmHg
and mean arterial pressure (MAP) of 80 mmHg. What is the most appropriate intervention to reduce his
ICP?
a. Hypertonic saline infusion
b. Mannitol bolus
c. Ventricular drain placement
d. Hyperventilation

16. A 30-year-old man with early-morning hyperglycemia and a bedtime glucose of 110 mg/dL has a
3 AM glucose reading of 140 mg/dL. What is the most likely cause?
a. Dawn phenomenon
b. Somogyi effect
c. Insulin resistance
d. Delayed gastric emptying
17. A 55-year-old ICU patient with a central venous catheter develops a fever and positive blood
cultures for Staphylococcus aureus. What is the most appropriate next step?
* *

a. Remove the catheter and start vancomycin

b. Replace the catheter and start linezolid
c. Leave the catheter in place and give antibiotics
d. Perform catheter tip culture without removal
18. A 50-year-old male presents with episodic flushing, diarrhea, and wheezing. Diagnosis of a
carcinoid tumor is suspected. Which test is most sensitive?
a. Serum chromogranin A levels
b. Urinary 5-HIAA levels
c. CT abdomen
d. Octreoscan
19. A 40-year-old female presents with palpitations and syncope. ECG shows torsades de pointes.
What is the first-line treatment?
a. Magnesium sulfate IV
b. Amiodarone
c. Defibrillation
d. Lidocaine
20. A 28-year-old patient presents with more than 6 bloody stools daily, fever, and tachycardia. How
is the severity of their ulcerative colitis classified?
a. Mild
b. Moderate
c. Severe
d. Fulminant
21. A 60-year-old male with hematemesis and melena is hypotensive (BP 80/50 mmHg) and
tachycardic (HR 120 bpm). Endoscopy reveals a bleeding duodenal ulcer, but bleeding persists after
intervention. What is the next best step?
a. Repeat endoscopic therapy
b. Surgical intervention
c. Transcatheter arterial embolization
d. High-dose proton pump inhibitor infusion
22. A 70-year-old male presents with progressive fatigue and bone pain. His labs reveal calcium 8.2
mg/dL, phosphate 6.0 mg/dL, PTH 600 pg/mL, and vitamin D 15 ng/mL. What is the best initial step in
management?
a. Administer intravenous calcium gluconate
b. Prescribe phosphate binders and active vitamin D analogs
c. Perform a parathyroidectomy
d. Increase dietary calcium and reduce phosphorus intake
23. A 50-year-old male presents with worsening dyspnea, purulent sputum, and hypoxemia (PaO₂ 50
mmHg on room air) due to a COPD exacerbation. What is the most appropriate next step?
a. Initiate systemic corticosteroids and noninvasive ventilation
b. Administer inhaled salbutamol and oxygen therapy only
c. Prescribe antibiotics and advise pulmonary rehabilitation
d. Proceed with mechanical ventilation immediately
24. A 62-year-old male presents with nephrotic syndrome and restrictive cardiomyopathy. Congo red
staining of a renal biopsy shows apple-green birefringence under polarized light. What is the most
sensitive test to diagnose light-chain amyloidosis?
a. Serum protein electrophoresis (SPEP)
b. Serum free light chain assay
c. Immunohistochemistry for amyloid
d. Bone marrow biopsy
25. A 35-year-old male with pulmonary tuberculosis is not improving after 2 months of first-line
therapy. Sputum microscopy still shows acid-fast bacilli. What is the next step in management?
a. Add a fluoroquinolone to the regimen
b. Perform drug susceptibility testing
c. Switch to second-line therapy empirically
d. Extend the intensive phase of treatment
26. A 40-year-old man with obesity and hypertension is being evaluated for Cushing syndrome. A
low-dose dexamethasone suppression test shows no suppression of cortisol levels. Plasma ACTH levels
are undetectable. What is the most likely next diagnostic step?
a. High-dose dexamethasone suppression test
b. Inferior petrosal sinus sampling
c. CT scan of the adrenal glands
d. MRI of the pituitary
27. A 40-year-old patient with asthma experiences nighttime awakenings 4 times per week and uses
a short-acting β₂-agonist daily. Spirometry shows an FEV₁ of 65% predicted. What is the most appropriate
management step?
a. Step 2: Low-dose ICS
b. Step 3: Low-dose ICS + LABA
c. Step 4: Medium-dose ICS + LABA
d. Step 5: High-dose ICS + LABA + biologics
28. A 78-year-old male presents with syncope. ECG reveals complete heart block with a ventricular
rate of 35 bpm. He is hypotensive with a blood pressure of 80/50 mmHg. What is the most appropriate
immediate intervention?
a. Transcutaneous pacing
b. Atropine 0.5 mg IV
c. Temporary transvenous pacing
d. Dopamine infusion
29. A 50-year-old male with chronic liver disease presents with worsening renal function. His serum
creatinine is 3.0 mg/dL, urine sodium is <10 mEq/L, and there is no proteinuria or hematuria. What is the
best initial management step for Type 1 hepatorenal syndrome?
a. Hemodialysis
b. Large-volume paracentesis
c. Albumin infusion with terlipressin
d. Transjugular intrahepatic portosystemic shunt (TIPS)
30. A 45-year-old man with type 2 diabetes presents with poor glycemic control despite maximal
doses of metformin and glimepiride. His HbA1c is 9.5%. He refuses insulin therapy. Which of the following
is the most appropriate next step in his management?
a. Add a GLP-1 receptor agonist
b. Add a DPP-4 inhibitor
c. Add an SGLT2 inhibitor
d. Switch to insulin therapy

31. A 28-year-old female presents with fatigue, weight loss, and hyperpigmentation of the skin.
Laboratory findings reveal hyponatremia, hyperkalemia, and low serum cortisol. Which test is most
diagnostic for Addison disease?
a. Early-morning serum cortisol
b. Serum ACTH levels
c. ACTH stimulation test
d. Dexamethasone suppression test
32. A 30-year-old male presents with new-onset generalized tonic-clonic seizures. MRI shows
multiple cystic lesions with scolex in the brain. What is the most appropriate treatment?
a. Albendazole and corticosteroids
b. Praziquantel and corticosteroids
c. Combination of albendazole, praziquantel, and corticosteroids
d. Surgical excision of cysts
33. A 40-year-old female presents with chronic abdominal pain relieved by defecation and
associated with changes in stool frequency and consistency. There is no weight loss or blood in stool.
Which finding supports the diagnosis of irritable bowel syndrome (IBS)?
a. Elevated ESR
b. Positive anti-tissue transglutaminase antibodies
c. Normal colonoscopy
d. Positive stool occult blood
34. A 65-year-old male presents with fatigue and splenomegaly. His CBC shows leukocytosis with a
left shift. Bone marrow cytogenetics reveal a t(9;22) translocation. What is the first-line treatment for this
patient?
a. Hydroxyurea
b. Imatinib
c. Dasatinib
d. Allogeneic stem cell transplant
35. A 55-year-old male with multiple myeloma has serum β2-microglobulin of 6.5 mg/L and albumin
of 3.0 g/dL. According to the Revised International Staging System (R-ISS), what is his stage?
a. Stage I
b. Stage II
c. Stage III
d. Unable to stage without LDH
36. A 30-year-old patient with ulcerative colitis presents with more than 6 bloody stools per day,
fever, tachycardia, and an ESR of 45 mm/hour. How is the severity of their ulcerative colitis classified?
a. Mild
b. Moderate
c. Severe
d. Fulminant
37. A 40-year-old female with systemic sclerosis presents with progressive dyspnea and restrictive
lung disease on spirometry. HRCT reveals ground-glass opacities and reticulation. Which ILD subtype is
most commonly associated with systemic sclerosis?
a. Idiopathic pulmonary fibrosis (IPF)
b. Nonspecific interstitial pneumonia (NSIP)
c. Desquamative interstitial pneumonia (DIP)
d. Acute interstitial pneumonia (AIP)
38. A 70-year-old male presents with fever, headache, neck stiffness, and altered mental status. CSF
analysis reveals: WBC 1,500/mm³ (90% neutrophils), glucose 30 mg/dL, and protein 120 mg/dL. What is
the most likely organism?
a. Streptococcus pneumoniae
b. Neisseria meningitidis
c. Listeria monocytogenes
d. Haemophilus influenzae
39. A 40-year-old farmer presents with cough, dyspnea, and fever after returning from work. HRCT
shows ground-glass opacities and centrilobular nodules in the upper lobes. Which of the following findings
strongly supports hypersensitivity pneumonitis?
a. Positive serum ANA
b. BAL lymphocytosis >40%
c. Elevated eosinophils in peripheral blood
d. Mosaic attenuation on CT
40. A 25-year-old man reports episodes of sudden muscle weakness triggered by laughter, excessive
daytime sleepiness, and vivid hallucinations upon waking. Which of the following tests confirms the
diagnosis of narcolepsy?
a. Multiple sleep latency test
b. Overnight oximetry
c. Polysomnography
d. Actigraphy
41. A 55-year-old female with sarcoidosis has bilateral hilar lymphadenopathy and diffuse
reticulonodular opacities on chest X-ray. What is the most likely stage of sarcoidosis?
a. Stage 0
b. Stage 1
c. Stage 2
d. Stage 3
42. A 12-year-old boy presents with growth failure and recurrent renal stones. His labs show normal
anion gap metabolic acidosis, hypokalemia, and glycosuria. What is the most likely diagnosis?
a. Renal tubular acidosis type 1
b. Renal tubular acidosis type 2
c. Fanconi syndrome
d. Bartter syndrome
43. A 65-year-old male with a history of smoking presents with worsening dyspnea and productive
cough. His post-bronchodilator FEV₁/FVC is 65%, and FEV₁ is 48% of predicted. According to GOLD
criteria, how is his COPD classified?
a. Mild (GOLD 1)
b. Moderate (GOLD 2)
c. Severe (GOLD 3)
d. Very severe (GOLD 4)
44. A 50-year-old male presents with hematemesis and is stabilized after initial resuscitation.
Endoscopy reveals a Forrest class IIa gastric ulcer. What is the most appropriate next step in
management?
a. Discharge with oral proton pump inhibitors and follow-up
b. Continue IV proton pump inhibitors and monitor for 72 hours
c. Surgical intervention due to high risk of rebleeding
d. Repeat endoscopy after 24 hours
45. A 40-year-old male presents with fatigue, tremors, and behavioral changes. Slit-lamp
examination reveals Kayser-Fleischer rings. Which test is most specific for confirming Wilson disease?
a. Serum ceruloplasmin levels
b. 24-hour urinary copper excretion
c. Liver biopsy with hepatic copper quantification
d. Genetic testing for ATP7B mutation
46. A 45-year-old male presents with fever, headache, and focal neurological deficits. MRI shows a
ring-enhancing lesion in the frontal lobe. What is the most appropriate next step in management?
a. Empirical broad-spectrum antibiotics
b. Corticosteroids and observation
c. Surgical drainage and culture
d. Antifungal therapy
47. A 70-year-old male with a history of small-cell lung cancer presents with confusion and lethargy.
His labs reveal serum sodium 118 mEq/L, serum osmolality 260 mOsm/kg, and urine osmolality 500
mOsm/kg. What is the first step in management?
a. Restrict fluid intake to 1 L/day
b. Administer hypertonic saline
c. Administer demeclocycline
d. Start vasopressin receptor antagonists
48. A 62-year-old male with restrictive cardiomyopathy is diagnosed with light-chain amyloidosis.
Congo red staining is positive. What test is most sensitive for confirmation?
a. Serum protein electrophoresis (SPEP)
b. Serum free light chain assay
c. Immunohistochemistry for amyloid
d. Bone marrow biopsy
49. A 50-year-old man with episodic flushing, diarrhea, and wheezing is diagnosed with a carcinoid
tumor in the small intestine. Which test is most sensitive for confirmation?
a. Serum chromogranin A levels
b. Urinary 5-HIAA levels
c. CT abdomen
d. Octreoscan
50. A 45-year-old man with poorly controlled diabetes presents with early-morning hyperglycemia.
His bedtime glucose is 110 mg/dL, and his 3 AM glucose reading is 140 mg/dL. What is the most likely
cause?
a. Dawn phenomenon
b. Somogyi effect
c. Insulin resistance
d. Delayed gastric emptying

51. A 25-year-old female presents with petechiae and a platelet count of 20,000/µL. She is
asymptomatic otherwise. What is the first-line treatment for her condition?
a. Corticosteroids
b. Platelet transfusion
c. Rituximab
d. Splenectomy
52. A 35-year-old male with atrial fibrillation presents with palpitations. He has no significant
structural heart disease, and his ECG shows a narrow-complex tachycardia. What is the most appropriate
initial therapy?
a. Beta-blockers
b. Amiodarone
c. Calcium channel blockers
d. Synchronized cardioversion
53. A 28-year-old patient presents with ulcerative colitis confined to the rectum and sigmoid colon.
What is the first-line treatment for mild-to-moderate disease?
a. Oral mesalamine
b. Topical mesalamine (suppository or enema)
c. Azathioprine
d. Infliximab
54. A 78-year-old male presents with syncope. ECG reveals bradyarrhythmia with complete heart
block. He is hypotensive with a blood pressure of 80/50 mmHg. What is the most appropriate immediate
treatment?
a. Transcutaneous pacing
b. Intravenous atropine
c. Dopamine infusion
d. Transvenous pacemaker
55. A 40-year-old male presents with sudden onset dyspnea and pleuritic chest pain. He is
hemodynamically stable. What is the most appropriate initial investigation to confirm pulmonary
embolism?
a. CT pulmonary angiography
b. Ventilation-perfusion (V/Q) scan
c. D-dimer assay
d. Echocardiography
56. A 30-year-old male with severe acute abdominal pain radiating to the back has serum lipase
levels elevated threefold. Which of the following is most indicative of severe acute pancreatitis?
a. Persistent abdominal pain
b. Elevated serum amylase
c. Hematocrit >44% on admission
d. Hypokalemia
57. A 45-year-old male presents with worsening dyspnea and cough. HRCT reveals basal
predominant honeycombing and reticulation with no significant ground-glass opacities. What is the most
likely diagnosis?
a. Nonspecific interstitial pneumonia
b. Idiopathic pulmonary fibrosis (IPF)
c. Acute interstitial pneumonia
d. Cryptogenic organizing pneumonia
58. A 70-year-old female presents with a prolonged QT interval on ECG and polymorphic ventricular
tachycardia (torsades de pointes). What is the first-line treatment?
a. Magnesium sulfate
b. Amiodarone
c. Synchronized cardioversion
d. Lidocaine
59. A 40-year-old male presents with episodic flushing, diarrhea, and wheezing. Octreoscan
identifies a neuroendocrine tumor. Which test confirms the diagnosis?
a. Serum chromogranin A levels
b. Urinary 5-HIAA levels
c. CT abdomen
d. Genetic testing for MEN1
60. A 60-year-old male with a STEMI and pulmonary edema presents with cardiogenic shock.
Despite inotropes and diuretics, he remains hypotensive. What is the next step?
a. Initiate intra-aortic balloon pump
b. Administer high-dose dopamine
c. Emergency coronary artery bypass grafting
d. ECMO (extracorporeal membrane oxygenation)
61. A 35-year-old male with persistent fatigue, jaundice, and anemia is found to have a positive
direct Coombs test. What is the most likely diagnosis?
a. Autoimmune hemolytic anemia
b. Microangiopathic hemolytic anemia
c. Paroxysmal nocturnal hemoglobinuria
d. G6PD deficiency
62. A 40-year-old male presents with a harsh, high-pitched, pansystolic murmur at the left lower
sternal border. There are no associated hemodynamic changes. What is the most likely diagnosis?
a. VSD with hemodynamic compromise
b. Maladie de Roger
c. Aortic regurgitation
d. Tricuspid regurgitation
63. A 70-year-old male with atrial fibrillation has a CHA₂DS₂-VASc score of 4. He refuses warfarin
due to dietary restrictions. Which anticoagulant is the best alternative?
a. Aspirin
b. Dabigatran
c. Clopidogrel
d. Dual antiplatelet therapy
64. A 60-year-old male presents with syncope and a narrow-complex regular tachycardia at 160
bpm. What is the most appropriate next step?
a. Adenosine IV
b. Electrical cardioversion
c. Amiodarone infusion
d. Beta-blocker therapy
65. A 25-year-old female presents with a serum sodium of 115 mEq/L and urine osmolality of 500
mOsm/kg. What is the first step in management?
a. Administer hypertonic saline
b. Restrict water intake
c. Start demeclocycline
d. Give vasopressin receptor antagonists
66. A 70-year-old male with systemic sclerosis presents with dyspnea and dry cough. HRCT reveals
ground-glass opacities and traction bronchiectasis. What is the most likely diagnosis?
a. Cryptogenic organizing pneumonia
b. Idiopathic pulmonary fibrosis
c. Nonspecific interstitial pneumonia
d. Acute interstitial pneumonia
67. A 45-year-old man presents with fatigue, high calcium levels, and a low parathyroid hormone
level. What is the most likely cause?
a. Primary hyperparathyroidism
b. Malignancy-associated hypercalcemia
c. Vitamin D toxicity
d. Secondary hyperparathyroidism
68. A 55-year-old male with nephrotic range proteinuria and restrictive cardiomyopathy is suspected
to have light-chain amyloidosis. Which test is most sensitive for confirmation?
a. Serum free light chain assay
b. Bone marrow biopsy
c. Serum protein electrophoresis
d. Immunohistochemistry
69. A 40-year-old patient with acute gout is treated with colchicine. Which of the following is the
most common side effect?
a. Bone marrow suppression
b. Renal impairment
c. Diarrhea
d. Hyperuricemia
70. A 30-year-old female presents with a tender, swollen thyroid. ESR is elevated, and thyroid
function tests reveal transient thyrotoxicosis. What is the most likely diagnosis?
a. Graves’ disease
b. Subacute thyroiditis
c. Hashimoto thyroiditis
d. Postpartum thyroiditis
Answer Key
1. c
2. c
3. a
4. b
5. b
6. a
7. b
8. b
9. c
10. b
11. b
12. b
13. b
14. b
15. c
16. a
17. a
18. b
19. a
20. c
21. c
22. b
23. a
24. b
25. b
26. c
27. c
28. a
29. c
30. a
31. c
32. c
33. c
34. b
35. c
36. c
37. b
38. a
39. b
40. a
41. c
42. b
43. c
44. b
45. c
46. c
47. b
48. b
49. b
50. a
51. a
52. a
53. b
54. a
55. a
56. c
57. b
58. a
59. b
60. a
61. a
62. b
63. b
64. a
65. a
66. c
67. b
68. a
69. c
70. b