SMLE Internal Medicine 3 — Questions and Answers
Question 1: A 70-year-old male with COPD presents with acute dyspnoea, right-sided pleuritic chest pain, and tachycardia. D-dimer is elevated. What is the next step?
- Start antibiotics for pneumonia
- CT pulmonary angiography (Correct answer)
- Chest X-ray only
- Reassure and discharge
Correct answer: CT pulmonary angiography
With high clinical suspicion for pulmonary embolism (acute dyspnoea, pleuritic pain, tachycardia) and elevated D-dimer, CT pulmonary angiography (CTPA) is the gold standard imaging to confirm or exclude PE.
Question 2: What is the target HbA1c recommended by Saudi Diabetes Clinical Practice Guidelines for most adult patients with type 2 diabetes?
- Less than 5.5%
- Less than 7% (Correct answer)
- Less than 8%
- Less than 9%
Correct answer: Less than 7%
The Saudi Diabetes Clinical Practice Guidelines, aligned with SCFHS standards, recommend an HbA1c target of less than 7% for most non-pregnant adults with type 2 diabetes to reduce microvascular complications.
Question 3: A 35-year-old woman presents with palpitations, weight loss, heat intolerance, and diffuse goitre with a bruit. TSH is suppressed and free T4 is elevated. What is the most likely diagnosis?
- Toxic multinodular goitre
- Graves disease (Correct answer)
- Subacute thyroiditis
- Thyroid carcinoma
Correct answer: Graves disease
Graves disease is the most common cause of hyperthyroidism in young adults, characterised by diffuse goitre with bruit (due to increased vascularity), suppressed TSH, and elevated free T4. It is caused by TSH receptor-stimulating antibodies.
Question 4: A 28-year-old man presents with haemoptysis, haematuria, and bilateral pulmonary infiltrates. Anti-GBM antibodies are positive. What is the diagnosis?
- Granulomatosis with polyangiitis
- Goodpasture syndrome (Correct answer)
- Systemic lupus erythematosus
- IgA nephropathy
Correct answer: Goodpasture syndrome
Goodpasture syndrome (anti-GBM disease) presents with the classic triad of haemoptysis, glomerulonephritis (haematuria), and positive anti-glomerular basement membrane antibodies, affecting both lungs and kidneys.
Question 5: A patient receiving blood transfusion develops fever, rigors, and flank pain 30 minutes into the transfusion. What is the most critical immediate action?
- Slow the transfusion rate
- Administer paracetamol
- Stop the transfusion immediately (Correct answer)
- Give IV hydrocortisone and continue
Correct answer: Stop the transfusion immediately
Fever, rigors, and flank pain during transfusion suggest an acute haemolytic transfusion reaction (ABO incompatibility). The transfusion must be stopped immediately to prevent further haemolysis, DIC, and renal failure.
Question 6: Which of the following conditions is a common cause of secondary hypertension in a young Saudi adult?
- Essential hypertension
- Renal artery stenosis (Correct answer)
- Coarctation of the aorta
- Phaeochromocytoma
Correct answer: Renal artery stenosis
Renal artery stenosis (particularly fibromuscular dysplasia in young patients) is one of the most common causes of secondary hypertension in young adults. It should be suspected when hypertension is resistant to treatment or presents at a young age.
SMLE Internal Medicine 3
A 70-year-old male with COPD presents with acute dyspnoea, right-sided pleuritic chest pain, and tachycardia.
D-dimer is elevated.
What is the next step?