SMLE Internal Medicine 2 — Questions and Answers
Question 1: A 65-year-old diabetic male presents with crushing chest pain radiating to the left arm. ECG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?
- Left anterior descending artery
- Right coronary artery (Correct answer)
- Left circumflex artery
- Left main coronary artery
Correct answer: Right coronary artery
ST elevation in leads II, III, and aVF indicates an inferior STEMI, which is most commonly caused by occlusion of the right coronary artery (RCA), which supplies the inferior wall of the heart in most patients.
Question 2: A patient with liver cirrhosis presents with confusion, asterixis, and elevated serum ammonia. What is the first-line treatment?
- Neomycin
- Lactulose (Correct answer)
- Flumazenil
- Liver transplantation
Correct answer: Lactulose
Lactulose is the first-line treatment for hepatic encephalopathy. It works by acidifying colonic contents, converting ammonia (NH3) to ammonium (NH4+) which cannot be absorbed, and promoting osmotic diarrhoea to eliminate ammonia.
Question 3: Which of the following is the most common cause of community-acquired pneumonia in Saudi Arabia?
- Klebsiella pneumoniae
- Streptococcus pneumoniae (Correct answer)
- Staphylococcus aureus
- Pseudomonas aeruginosa
Correct answer: Streptococcus pneumoniae
Streptococcus pneumoniae remains the most common cause of community-acquired pneumonia worldwide, including Saudi Arabia. Pneumococcal vaccination is part of the Saudi national immunisation programme.
Question 4: A 50-year-old male presents with epigastric pain that improves with eating. Urea breath test is positive. What is the recommended eradication regimen?
- Omeprazole alone for 8 weeks
- Triple therapy: PPI + amoxicillin + clarithromycin for 14 days (Correct answer)
- Bismuth subsalicylate monotherapy
- Sucralfate for 4 weeks
Correct answer: Triple therapy: PPI + amoxicillin + clarithromycin for 14 days
Standard triple therapy consisting of a PPI, amoxicillin, and clarithromycin for 14 days is the recommended first-line H. pylori eradication regimen per current guidelines endorsed by SCFHS.
Question 5: A 40-year-old female presents with weight gain, moon face, abdominal striae, and hypertension. Morning cortisol is elevated. What is the next best diagnostic step?
- Random ACTH level
- Low-dose dexamethasone suppression test (Correct answer)
- MRI of the pituitary
- CT of the adrenal glands
Correct answer: Low-dose dexamethasone suppression test
The low-dose dexamethasone suppression test (1 mg overnight or 2-day protocol) is used to confirm the diagnosis of Cushing syndrome before localisation studies. It determines whether cortisol production is autonomous.
Question 6: A patient with rheumatic heart disease develops new-onset fever, splinter haemorrhages, and a new murmur. Blood cultures grow Streptococcus viridans. What is the diagnosis?
- Rheumatic fever recurrence
- Infective endocarditis (Correct answer)
- Myocarditis
- Pericarditis
Correct answer: Infective endocarditis
The combination of fever, new murmur, splinter haemorrhages, and positive blood cultures with a typical organism (Streptococcus viridans) in a patient with pre-existing valvular disease fulfils Duke criteria for infective endocarditis.
SMLE Internal Medicine 2
A 65-year-old diabetic male presents with crushing chest pain radiating to the left arm.
ECG shows ST elevation in leads II, III, and aVF.
Which coronary artery is most likely occluded?