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1.A 65-year-old man presents with exertional chest pain relieved by rest. His resting ECG is normal.
What is the most appropriate initial investigation?
A) Coronary angiography
B) Stress ECG
C) Transthoracic echocardiogram
D) Cardiac MRI
E) Serum troponin measurement
2. A 45-year-old woman with a history of rheumatic fever complains of dyspnea on exertion and
palpitations. Cardiac auscultation reveals a loud first heart sound and a distinct opening snap. What
is the most likely diagnosis?
A) Aortic stenosis
B) Mitral stenosis
C) Tricuspid regurgitation
D) Atrial septal defect
E) Pulmonary hypertension
3. A patient with non-valvular atrial fibrillation has a CHA₂ DS₂ -VASc score of 3. Which of the
following is the most appropriate anticoagulation strategy?
A) Aspirin alone
B) Warfarin
C) Clopidogrel
D) Heparin infusion
E) No anticoagulation
4. A 55 - year - old man presents with sudden onset chest pain radiating to his back. His blood
pressure is 190/110 mmHg, and a chest X - ray shows a widened mediastinum. What is the most
likely diagnosis?
A) Pulmonary embolism
B) Acute myocardial infarction
C) Aortic dissection
D) Pericarditis
E) Tension pneumothorax
5. A 60-year-old man with chronic heart failure presents with worsening dyspnea and peripheral
edema. Which medication has been shown to improve long - term survival in heart failure with
reduced ejection fraction?
A) Furosemide
B) Digoxin
C) Carvedilol
D) Amlodipine
E) Diltiazem
6. A 60-year-old smoker presents with cough, hemoptysis, and weight loss. Chest X-ray reveals a
central (hilar) mass. What is the most likely diagnosis?
A) Adenocarcinoma
B) Squamous cell carcinoma
C) Small cell lung cancer
D) Tuberculosis
E) Pneumonia
7. A 25-year-old man experiences episodes of dyspnea and wheezing triggered by cold air exposure.
Spirometry demonstrates an obstructive pattern that reverses with bronchodilators. What is the most
likely diagnosis?
A) Chronic obstructive pulmonary disease (COPD)
B) Asthma
C) Bronchiectasis
D) Sarcoidosis
E) Pulmonary fibrosis
8. A 65-year-old man with known COPD presents with increased shortness of breath. His arterial
blood gas shows a pH of 7.28, PaCO₂ of 55 mmHg, and PaO₂ of 60 mmHg. What is the best
initial treatment?
A) High-flow oxygen therapy
B) Non-invasive ventilation (BiPAP)
C) Intravenous corticosteroids
D) Inhaled short-acting beta-agonists
E) Endotracheal intubation and mechanical ventilation
9. A patient presents with acute pleuritic chest pain and hemoptysis. A CT pulmonary angiogram
confirms a pulmonary embolism. What is the most appropriate initial management?
A) Aspirin
B) Warfarin
C) Intravenous thrombolysis
D) Low molecular weight heparin
E) Placement of an IVC filter
10. A 40- year - old woman presents with a dry cough, bilateral hilar lymphadenopathy on chest
imaging, and tender red nodules on her shins. Which diagnosis is most consistent with these
findings?
A) Tuberculosis
B) Sarcoidosis
C) Lung cancer
D) Interstitial lung disease
E) Bronchiectasis
11. A 30-year-old woman presents with weight loss, palpitations, heat intolerance, and a diffusely
enlarged thyroid gland. Laboratory evaluation reveals a suppressed TSH and elevated free T4. What
is the most likely diagnosis?
A) Graves’ disease
B) Hashimoto’s thyroiditis
C) Thyroid adenoma
D) Subacute thyroiditis
E) Euthyroid sick syndrome
12. A 50-year-old man exhibits central obesity, moon facies, a buffalo hump, and hypertension. His
24-hour urinary free cortisol is elevated. What is the next best test to help confirm the diagnosis of
Cushing syndrome?
A) MRI of the brain
B) Low-dose dexamethasone suppression test
C) Plasma ACTH measurement
D) High-dose dexamethasone suppression test
E) Abdominal CT scan
13. A 60 - year - old man with type 2 diabetes mellitus has persistent proteinuria despite good
glycemic control. Which medication is indicated to slow the progression of diabetic nephropathy?
A) Metformin
B) Insulin
C) Sodium-glucose cotransporter 2 (SGLT2) inhibitor
D) ACE inhibitor
E) Beta-blocker
14. A patient presents with episodic hypertension, severe headache, palpitations, and diaphoresis.
Laboratory studies reveal elevated plasma metanephrines. What is the most likely diagnosis?
A) Pheochromocytoma
B) Hyperthyroidism
C) Cushing syndrome
D) Primary aldosteronism
E) Renal artery stenosis
15. A 25- year - old woman complains of perioral numbness, muscle cramps, and tingling in her
hands. On examination, a positive Trousseau sign is elicited. Which electrolyte abnormality is most
likely?
A) Hyperkalemia
B) Hypernatremia
C) Hypocalcemia
D) Hypermagnesemia
E) Hyponatremia
16. A 40-year-old man presents with right upper quadrant pain, fever, and jaundice. Laboratory tests
show elevated alkaline phosphatase and bilirubin. Which condition best fits this clinical picture?
A) Hepatitis B
B) Acute cholecystitis
C) Choledocholithiasis without infection
D) Ascending cholangitis
E) Primary biliary cholangitis
17. A 50-year-old man with a long history of alcohol abuse presents with hematemesis and signs of
hypovolemia. What is the most common source of upper gastrointestinal bleeding in this patient?
A) Peptic ulcer disease
B) Esophageal varices
C) Mallory-Weiss tear
D) Gastric cancer
E) Acute gastritis
18. A 35-year-old woman presents with sudden-onset severe epigastric pain radiating to the back,
accompanied by nausea and vomiting. Laboratory tests reveal elevated serum amylase and lipase.
What is the cornerstone of initial management?
A) Immediate endoscopic retrograde cholangiopancreatography (ERCP)
B) Urgent surgical intervention
C) Aggressive intravenous fluid resuscitation with bowel rest
D) High-dose opioid analgesia only
E) Oral feeding with a low-fat diet
19. A 30-year-old woman with chronic diarrhea, weight loss, and iron deficiency anemia undergoes
an upper endoscopy with duodenal biopsy. The biopsy shows villous atrophy. Which serologic test
is most specific for the likely diagnosis?
A) Anti-nuclear antibody (ANA)
B) Anti-endomysial antibody
C) Anti-thyroid peroxidase antibody
D) Anti-tissue transglutaminase (tTG) antibody
E) Anti-smooth muscle antibody
20. A 40-year-old man experiences recurrent episodes of abdominal pain and altered bowel habits.
Extensive investigations, including colonoscopy and imaging, are unremarkable. What is the most
likely diagnosis?
A) Inflammatory bowel disease
B) Irritable bowel syndrome
C) Celiac disease
D) Microscopic colitis
E) Small intestinal bacterial overgrowth
21. A 65-year-old man with a history of hypertension and diabetes is found to have an estimated
glomerular filtration rate (eGFR) of 45 mL/min/1.73 m ² with mild proteinuria. Which class of
medication is indicated to delay progression of chronic kidney disease?
A) Calcium channel blockers
B) Beta-blockers
C) Diuretics
D) ACE inhibitors
E) Direct renin inhibitors
22. A 30-year-old woman presents with periorbital edema, frothy urine, and laboratory findings of
proteinuria exceeding 3.5 g/day, hypoalbuminemia, and hyperlipidemia. What is the clinical
syndrome described?
A) Acute kidney injury
B) Nephrotic syndrome
C) Nephritic syndrome
D) Urinary tract infection
E) Chronic kidney disease
23. A 28-year-old man presents with a history of hematuria since childhood, sensorineural hearing
loss, and a family history of renal disease. Urinalysis shows red blood cell casts. What is the most
likely diagnosis?
A) IgA nephropathy
B) Post-streptococcal glomerulonephritis
C) Alport syndrome
D) Minimal change disease
E) Focal segmental glomerulosclerosis
24. A 70-year-old patient’s ECG reveals peaked T waves. Laboratory evaluation confirms a serum
potassium of 6.5 mEq/L. What is the first step in management to protect the heart?
A) Insulin with dextrose
B) Sodium bicarbonate
C) Nebulized salbutamol
D) Intravenous calcium gluconate
E) Oral kayexalate
25. A 35-year-old man develops dark-colored urine, facial edema, and hypertension one week after
a streptococcal throat infection. Which condition best describes his presentation?
A) Rapidly progressive glomerulonephritis
B) Post-streptococcal glomerulonephritis
C) IgA nephropathy
D) Membranous nephropathy
E) Diabetic nephropathy
26. A 70-year-old woman presents with sudden onset right-sided weakness and aphasia 1 hour ago.
A non-contrast CT scan of the head shows no hemorrhage. What is the most appropriate next step?
A) Immediate carotid endarterectomy
B) Administration of intravenous thrombolysis (tPA)
C) Initiate dual antiplatelet therapy
D) Schedule a magnetic resonance imaging (MRI) study
E) Start intravenous heparin
27. A 65-year-old man exhibits a resting tremor, rigidity, and bradykinesia. Which medication is
considered first-line treatment for his condition?
A) Levodopa-carbidopa
B) Amantadine
C) Selegiline
D) Bromocriptine
E) Anticholinergics
28. A 40-year-old woman experiences fluctuating muscle weakness that worsens with activity and
improves with rest. A positive edrophonium (Tensilon) test is noted. What is the diagnosis?
A) Lambert-Eaton myasthenic syndrome
B) Multiple sclerosis
C) Myasthenia gravis
D) Amyotrophic lateral sclerosis
E) Muscular dystrophy
29. A 55- year - old man develops ascending weakness and areflexia following a gastrointestinal
illness. Cerebrospinal fluid analysis shows elevated protein with a normal cell count. What is the
most likely diagnosis?
A) Multiple sclerosis
B) Guillain–Barré syndrome
C) Poliomyelitis
D) Myelopathy
E) Neuropathy due to vitamin B12 deficiency
30. A 35 - year - old man presents with recurrent episodes of severe, unilateral periorbital pain
accompanied by lacrimation and nasal congestion. These episodes last about 15 minutes. What is
the most likely diagnosis?
A) Migraine headache
B) Tension-type headache
C) Trigeminal neuralgia
D) Cluster headache
E) Sinus headache
31. A 35- year - old man presents with high fever, chills, and cyclic fevers after returning from a
malaria-endemic region. A peripheral blood smear shows ring forms within red blood cells. What
is the diagnosis?
A) Dengue fever
B) Typhoid fever
C) Malaria
D) Babesiosis
E) Leptospirosis
32. A 50-year-old man with a prior history of latent tuberculosis now presents with a chronic cough,
night sweats, and weight loss. What is the standard duration of treatment for active tuberculosis?
A) 4 months
B) 6 months
C) 9 months
D) 12 months
E) 18 months
33. A 40 - year - old man with HIV (CD4 count <50 cells/mm ³ ) presents with dyspnea and a
nonproductive cough. Chest X - ray reveals diffuse interstitial infiltrates. What is the most likely
opportunistic infection?
A) Cytomegalovirus pneumonia
B) Tuberculosis
C) Pneumocystis pneumonia
D) Histoplasmosis
E) Cryptococcal meningitis
34. A 60- year - old patient in septic shock is admitted to the ICU. In addition to broad-spectrum
antibiotics, what is the immediate priority in the management of sepsis?
A) Administration of vasopressors
B) Fluid resuscitation
C) Immediate source control surgery
D) Corticosteroid therapy
E) Mechanical ventilation
35. A 30- year - old woman with a history of intravenous drug use presents with fever and a new
systolic murmur. Which organism is most commonly implicated in infective endocarditis in this
population?
A) Staphylococcus aureus
B) Streptococcus viridans
C) Enterococcus faecalis
D) Pseudomonas aeruginosa
E) HACEK organisms
36. A 40-year-old woman presents with a several-month history of morning stiffness lasting over 1
hour, and symmetrical pain and swelling in her hands. Laboratory studies reveal a positive
rheumatoid factor. What is the most likely diagnosis?
A) Rheumatoid arthritis
B) Osteoarthritis
C) Psoriatic arthritis
D) Systemic lupus erythematosus
E) Reactive arthritis
37. A 25 - year - old woman presents with a malar rash, photosensitivity, arthritis, and fatigue.
Laboratory tests reveal positive anti-double-stranded DNA antibodies. What is the most likely
diagnosis?
A) Rheumatoid arthritis
B) Scleroderma
C) Systemic lupus erythematosus
D) Sjögren’s syndrome
E) Dermatomyositis
38. A 55-year-old man presents with acute onset severe pain in the first metatarsophalangeal joint.
Joint aspiration reveals needle-shaped, negatively birefringent crystals under polarized light. What
is the diagnosis?
A) Pseudogout
B) Gout
C) Septic arthritis
D) Rheumatoid arthritis
E) Osteoarthritis
39. A 70- year - old woman presents with a new onset temporal headache, jaw claudication, and
visual disturbances. What is the most appropriate immediate management?
A) High-dose corticosteroids
B) Nonsteroidal anti-inflammatory drugs (NSAIDs)
C) Methotrexate
D) Aspirin
E) Referral for temporal artery biopsy only
40. A 60 - year - old man presents with joint pain and stiffness that worsens with activity and
improves with rest. Radiographs of the knees show joint space narrowing with osteophyte
formation. What is the most likely diagnosis?
A) Rheumatoid arthritis
B) Osteoarthritis
C) Gout
D) Psoriatic arthritis
E) Septic arthritis
41. A 35 - year - old woman presents with fatigue and pallor. Laboratory evaluation shows low
hemoglobin, a low mean corpuscular volume (MCV), and decreased serum ferritin levels. What is
the most likely diagnosis?
A) Iron deficiency anemia
B) Anemia of chronic disease
C) Thalassemia minor
D) Vitamin B12 deficiency
E) Hemolytic anemia
42. A 55-year-old man presents with numbness, ataxia, and a smooth, red tongue. Laboratory tests
reveal macrocytic anemia and low vitamin B12 levels. Which condition is the most common cause
of his vitamin B12 deficiency?
A) Dietary deficiency
B) Malabsorption due to Crohn’s disease
C) Gastrectomy history
D) Pernicious anemia
E) Pancreatic insufficiency
43. A 60-year-old man complains of headache, blurred vision, and pruritus following a hot shower.
Laboratory studies show an elevated hematocrit and a positive JAK2 mutation. What is the most
likely diagnosis?
A) Essential thrombocythemia
B) Polycythemia vera
C) Myelofibrosis
D) Chronic myeloid leukemia
E) Iron deficiency
44. A 65-year-old man presents with bone pain, recurrent infections, and anemia. Serum protein
electrophoresis reveals a monoclonal (M) spike. What is the most likely diagnosis?
A) Non-Hodgkin lymphoma
B) Chronic lymphocytic leukemia
C) Multiple myeloma
D) Acute lymphoblastic leukemia
E) Waldenström macroglobulinemia
45. A 70 - year - old woman on long-term warfarin therapy presents with an elevated INR and
bleeding from a minor cut. To rapidly reverse the effects of warfarin, which of the following should
be administered?
A) Fresh frozen plasma
B) Prothrombin complex concentrate
C) Intravenous vitamin K
D) Subcutaneous heparin
E) Platelet transfusion
46. A 50-year-old woman presents with confusion, seizures, and lethargy. Laboratory studies reveal
a serum sodium of 120 mEq/L. Which of the following is the most common cause of her
hyponatremia?
A) Diuretic use
B) Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
C) Hypovolemia from gastrointestinal loss
D) Adrenal insufficiency
E) Heart failure
47. A 60-year-old man with hyperkalemia has an ECG that shows peaked T waves. Which agent is
used to stabilize the cardiac membranes immediately?
A) Insulin with dextrose
B) Sodium bicarbonate
C) Calcium gluconate
D) Nebulized beta-agonist
E) Oral kayexalate
48. A 65-year-old woman admitted for elective surgery is started on prophylactic anticoagulation to
prevent deep venous thrombosis. Which medication is most commonly used for DVT prophylaxis
in the hospital setting?
A) Warfarin
B) Unfractionated heparin
C) Low molecular weight heparin
D) Direct oral anticoagulant (DOAC)
E) Aspirin
49. A 45-year-old man who smokes expresses a desire to quit. Which of the following is considered
first-line pharmacotherapy for smoking cessation?
A) Nicotine replacement therapy
B) Varenicline
C) Bupropion
D) Clonidine
E) Cytisine
50. A 40- year - old woman with known primary adrenal insufficiency presents to the emergency
department with hypotension, abdominal pain, and vomiting. Laboratory studies reveal
hyponatremia and hyperkalemia. What is the most appropriate initial treatment for an acute adrenal
crisis?
A) Oral hydrocortisone
B) Intravenous hydrocortisone and aggressive fluid resuscitation
C) High-dose fludrocortisone
D) Insulin with dextrose
E) Immediate adrenalectomy
