Saudi Medical Licensing Examination (SMLE) — Questions and Answers

Question 1: A premature neonate in the NICU develops feeding intolerance, abdominal distension, bloody stools, and pneumatosis intestinalis on abdominal X-ray. What is the diagnosis?

Intussusception
Meconium plug syndrome
Hirschsprung enterocolitis
Necrotising enterocolitis (Correct answer)

Correct answer: Necrotising enterocolitis

Necrotising enterocolitis (NEC) is the most common GI emergency in premature neonates. Pneumatosis intestinalis (air within the bowel wall) on X-ray is the pathognomonic radiographic finding. Management includes NPO, antibiotics, and surgery if perforation occurs.

Question 2: A diabetic patient is found unconscious with profuse sweating, tremor, and a blood glucose of 2.1 mmol/L. What is the immediate treatment?

Intramuscular glucagon only
Subcutaneous insulin
Oral glucose tablets
IV dextrose 50% bolus (Correct answer)

Correct answer: IV dextrose 50% bolus

In an unconscious patient with severe hypoglycaemia, IV dextrose (50% or 10% depending on access) is the treatment of choice as oral glucose cannot be safely administered. IM glucagon is an alternative if IV access is unavailable.

Question 3: A 42-year-old male has his BMI calculated as 32.5 kg/m². How is this classified according to WHO criteria?

Obese class II
Normal weight
Obese class I (Correct answer)
Overweight

Correct answer: Obese class I

According to WHO classification, a BMI of 30.0–34.9 kg/m² is classified as Obese Class I, associated with increased risk of comorbidities.

Question 4: What is the most common psychiatric comorbidity in patients with substance use disorders?

Bipolar disorder
Depressive disorders (Correct answer)
Personality disorders
Schizophrenia

Correct answer: Depressive disorders

Depressive disorders are the most common psychiatric comorbidity in substance use disorders (dual diagnosis). Depression can be both a risk factor for substance use and a consequence of it. Integrated treatment addressing both conditions simultaneously is recommended.

Question 5: Following the epidemiological transition in Saudi Arabia, which of the following is now the leading cause of morbidity and mortality?

Cardiovascular diseases (Correct answer)
Infectious diseases
Road traffic accidents
Malignancies

Correct answer: Cardiovascular diseases

Saudi Arabia has undergone an epidemiological transition; cardiovascular diseases are now the leading cause of death, driven by high rates of obesity, diabetes, and hypertension.

Question 6: 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?

CT of the adrenal glands
Low-dose dexamethasone suppression test (Correct answer)
MRI of the pituitary
Random ACTH level

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 7: A 45-year-old woman presents with a breast lump. Mammography shows a spiculated mass with architectural distortion. What does this most likely represent?

Fibroadenoma
Breast cyst
Invasive breast carcinoma (Correct answer)
Fat necrosis

Correct answer: Invasive breast carcinoma

A spiculated mass with architectural distortion on mammography is highly suspicious for invasive breast carcinoma (BI-RADS 5). This requires tissue biopsy (core needle biopsy) for histological confirmation before treatment planning.

Question 8: A term neonate develops jaundice within the first 24 hours of life. The mother is blood group O positive and the baby is blood group A positive. Direct Coombs test is positive. What is the diagnosis?

Gilbert syndrome
ABO haemolytic disease of the newborn (Correct answer)
Breast milk jaundice
Physiological jaundice

Correct answer: ABO haemolytic disease of the newborn

Jaundice within the first 24 hours is always pathological. ABO incompatibility (mother O, baby A or B) with a positive direct Coombs test confirms ABO haemolytic disease. Maternal anti-A IgG antibodies cross the placenta and attack fetal red blood cells.

Question 9: A 17-year-old female presents with restricted eating, intense fear of gaining weight, and a BMI of 15 kg/m². She perceives herself as overweight despite being underweight. What is the most likely diagnosis?

Bulimia nervosa
Body dysmorphic disorder
Anorexia nervosa (Correct answer)
Avoidant/restrictive food intake disorder

Correct answer: Anorexia nervosa

Anorexia nervosa is characterised by restriction of energy intake leading to significantly low body weight (BMI <18.5), intense fear of gaining weight, and disturbed body image. A BMI of 15 represents severe anorexia nervosa.

Question 10: A newborn has a heart murmur, a single palmar crease, epicanthal folds, and hypotonia. The karyotype shows trisomy 21. Which cardiac defect is most commonly associated with this condition?

Coarctation of the aorta
Ventricular septal defect
Tetralogy of Fallot
Atrioventricular septal defect (endocardial cushion defect) (Correct answer)

Correct answer: Atrioventricular septal defect (endocardial cushion defect)

Atrioventricular septal defect (AVSD/endocardial cushion defect) is the cardiac anomaly most commonly associated with Down syndrome (trisomy 21). Up to 40-50% of children with Down syndrome have congenital heart disease, with AVSD being the most frequent.

Question 11: A patient on rifampicin for tuberculosis is also taking warfarin. What effect does rifampicin have on warfarin levels?

Decreases warfarin levels (inducer) (Correct answer)
No interaction
Increases warfarin levels (inhibitor)
Unpredictable effect

Correct answer: Decreases warfarin levels (inducer)

Rifampicin is one of the most potent inducers of cytochrome P450 enzymes (especially CYP3A4, CYP2C9). It accelerates warfarin metabolism, significantly decreasing warfarin levels and anticoagulant effect, requiring substantial dose increases and close INR monitoring.

Question 12: A patient develops high-output small bowel fistula postoperatively. What electrolyte abnormality is most likely?

Hypercalcaemia
Metabolic acidosis with dehydration (Correct answer)
Respiratory alkalosis
Hyperkalaemia

Correct answer: Metabolic acidosis with dehydration

High-output small bowel fistulas cause significant losses of sodium, potassium, bicarbonate, and water. This leads to dehydration, metabolic acidosis (from bicarbonate loss), and electrolyte depletion requiring aggressive fluid and electrolyte replacement.

Question 13: A woman presents with a grape-like vesicular mass expelled from the vagina, a markedly elevated beta-hCG level, and a 'snowstorm' appearance on ultrasound. What is the most likely diagnosis?

Complete hydatidiform mole (Correct answer)
Ectopic pregnancy
Missed miscarriage
Threatened miscarriage

Correct answer: Complete hydatidiform mole

A complete hydatidiform mole presents with vaginal bleeding, a uterus larger than dates, markedly elevated beta-hCG, and a classic 'snowstorm' or 'cluster of grapes' appearance on ultrasound. Suction evacuation followed by beta-hCG monitoring is the management.

Question 14: A patient with chronic hepatitis B is started on tenofovir. What is the mechanism of action of this antiviral?

Nucleotide reverse transcriptase inhibitor (Correct answer)
Integrase inhibitor
Capsid assembly inhibitor
Protease inhibitor

Correct answer: Nucleotide reverse transcriptase inhibitor

Tenofovir is a nucleotide analogue reverse transcriptase inhibitor (NtRTI) that incorporates into viral DNA by HBV polymerase/reverse transcriptase, causing chain termination. It has a high barrier to resistance and is first-line for chronic hepatitis B alongside entecavir.

Question 15: What is the Bishop score used for in obstetrics?

Evaluating cervical favourability for induction of labour (Correct answer)
Assessing fetal well-being
Staging of cervical cancer
Determining Apgar score

Correct answer: Evaluating cervical favourability for induction of labour

The Bishop score assesses cervical readiness for induction of labour based on five parameters: cervical dilation, effacement, station, consistency, and position. A score ≥8 indicates a favourable cervix with a high likelihood of successful induction.

Question 16: A 45-year-old woman presents with progressive dyspnoea and a butterfly-shaped infiltrate on chest X-ray. She has a history of mitral stenosis. What is the most likely cause of the radiographic finding?

Pulmonary embolism
Community-acquired pneumonia
Sarcoidosis
Pulmonary oedema (Correct answer)

Correct answer: Pulmonary oedema

A butterfly or bat-wing pattern on chest X-ray is classic for pulmonary oedema. In a patient with mitral stenosis, elevated left atrial pressure leads to pulmonary venous congestion and transudative pulmonary oedema.

Question 17: A 6-month-old infant presents with olive-shaped mass in the right upper quadrant, non-bilious projectile vomiting, and visible peristalsis. What is the most likely diagnosis?

Pyloric stenosis (Correct answer)
Malrotation with volvulus
Intussusception
Duodenal atresia

Correct answer: Pyloric stenosis

Infantile hypertrophic pyloric stenosis classically presents between 2-8 weeks of age (can present later) with non-bilious projectile vomiting, a palpable 'olive-shaped' mass in the right upper quadrant, and visible gastric peristalsis.

Question 18: A 25-year-old man presents with excessive hand washing (>30 times daily) and fear of contamination. He recognises his behaviour is excessive but cannot stop. What type of symptoms are the intrusive thoughts?

Compulsions
Delusions
Obsessions (Correct answer)
Overvalued ideas

Correct answer: Obsessions

Obsessions are recurrent, intrusive, unwanted thoughts, images, or urges that cause marked anxiety (fear of contamination). Compulsions are repetitive behaviours (hand washing) performed to reduce the anxiety caused by obsessions. Insight is preserved in OCD.

Question 19: A 10-year-old child presents with fatigue, bone pain, hepatosplenomegaly, and pancytopenia. Peripheral blood smear shows blast cells with positive PAS staining. What is the most likely diagnosis?

Acute myeloid leukaemia
Chronic myeloid leukaemia
Non-Hodgkin lymphoma
Acute lymphoblastic leukaemia (ALL) (Correct answer)

Correct answer: Acute lymphoblastic leukaemia (ALL)

Acute lymphoblastic leukaemia (ALL) is the most common childhood malignancy. PAS-positive blast cells are characteristic of lymphoblasts. ALL presents with bone marrow failure symptoms (anaemia, bleeding, infection) and organ infiltration (hepatosplenomegaly).

Question 20: A Rh-negative mother delivers a Rh-positive baby. When should anti-D immunoglobulin be administered?

Only if Kleihauer test is positive
Within 7 days of delivery
Within 72 hours of delivery (Correct answer)
Only during the next pregnancy

Correct answer: Within 72 hours of delivery

Anti-D immunoglobulin should be administered within 72 hours of delivery of a Rh-positive baby to a Rh-negative mother to prevent Rh isoimmunisation. A Kleihauer test determines if additional doses are needed for large fetomaternal haemorrhage.

Question 21: A patient on phenytoin is noted to have gingival hyperplasia, hirsutism, and a serum albumin of 25 g/L. How does hypoalbuminaemia affect phenytoin dosing?

Decreased drug efficacy requiring higher doses
Increased free drug levels — may appear therapeutic but cause toxicity (Correct answer)
Increased drug clearance
No effect on dosing

Correct answer: Increased free drug levels — may appear therapeutic but cause toxicity

Phenytoin is >90% protein-bound. In hypoalbuminaemia, more free (unbound) phenytoin is available, increasing pharmacological effect and toxicity risk even when total phenytoin levels appear therapeutic. Adjusted phenytoin levels or free phenytoin levels should be measured.

Question 22: A 40-year-old woman presents with heavy menstrual bleeding, pelvic pressure, and an enlarged, irregular uterus. Ultrasound shows multiple well-circumscribed, hypoechoic masses within the myometrium. What is the most likely diagnosis?

Endometrial polyps
Adenomyosis
Uterine leiomyomas (fibroids) (Correct answer)
Endometrial carcinoma

Correct answer: Uterine leiomyomas (fibroids)

Uterine leiomyomas (fibroids) are the most common benign tumours of the uterus. They present with menorrhagia, pelvic pressure, and an enlarged irregular uterus. Ultrasound shows well-circumscribed, hypoechoic myometrial masses.

Question 23: In the primary survey of a trauma patient (ATLS), what is the correct sequence?

Airway, Circulation, Breathing, Disability, Exposure
Circulation, Airway, Breathing, Disability, Exposure
Airway, Breathing, Circulation, Disability, Exposure (Correct answer)
Breathing, Airway, Circulation, Exposure, Disability

Correct answer: Airway, Breathing, Circulation, Disability, Exposure

The ATLS primary survey follows the ABCDE approach: Airway (with cervical spine protection), Breathing, Circulation (with haemorrhage control), Disability (neurological status), and Exposure (with environmental control). This sequence addresses the most lethal threats first.

Question 24: A 62-year-old male with liver cirrhosis presents with massive haematemesis. Vitals show tachycardia and hypotension. What is the most likely source of bleeding?

Oesophageal varices (Correct answer)
Gastric ulcer
Mallory-Weiss tear
Aorto-enteric fistula

Correct answer: Oesophageal varices

In a patient with liver cirrhosis, massive upper GI bleeding is most commonly from oesophageal varices due to portal hypertension. Variceal bleeding is life-threatening and requires urgent resuscitation and endoscopic intervention.

Question 25: A patient with depression is started on venlafaxine. At low doses it acts primarily on serotonin reuptake. What additional effect does it have at higher doses?

Dopamine reuptake inhibition
MAO inhibition
Noradrenaline reuptake inhibition (Correct answer)
GABA potentiation

Correct answer: Noradrenaline reuptake inhibition

Venlafaxine is a serotonin-noradrenaline reuptake inhibitor (SNRI). At lower doses (75 mg), it primarily inhibits serotonin reuptake. At higher doses (≥150 mg), it additionally inhibits noradrenaline reuptake, providing a dual mechanism that may be more effective for severe depression.

Question 26: A 25-year-old male presents with auditory hallucinations, paranoid delusions, and social withdrawal for 8 months. His speech is disorganised and he has flat affect. What is the most likely diagnosis?

Schizoaffective disorder
Schizophrenia (Correct answer)
Brief psychotic disorder
Delusional disorder

Correct answer: Schizophrenia

Schizophrenia requires ≥6 months of symptoms with at least one month of active-phase symptoms (≥2 of: delusions, hallucinations, disorganised speech, disorganised/catatonic behaviour, negative symptoms). This patient meets criteria with 8 months of symptoms.

Question 27: A 60-year-old male presents with painless obstructive jaundice, weight loss, and a palpable non-tender gallbladder. What is the most likely diagnosis?

Hepatocellular carcinoma
Gallstone in the common bile duct
Pancreatic head carcinoma (Correct answer)
Acute cholangitis

Correct answer: Pancreatic head carcinoma

Courvoisier's law states that painless obstructive jaundice with a palpable gallbladder is unlikely to be due to gallstones. The most likely diagnosis is carcinoma of the head of the pancreas compressing the common bile duct.

Question 28: Which drug is the antidote for opioid overdose?

Flumazenil
Atropine
Naloxone (Correct answer)
N-acetylcysteine

Correct answer: Naloxone

Naloxone is a competitive opioid receptor antagonist used to reverse opioid overdose. It rapidly reverses respiratory depression, sedation, and miosis. Due to its shorter half-life compared to many opioids, repeated doses or an infusion may be needed.

Question 29: A 55-year-old woman presents with a pelvic mass, ascites, and elevated CA-125. CT shows an ovarian mass with peritoneal deposits. What is the most likely diagnosis?

Benign ovarian cyst
Endometriosis
Epithelial ovarian carcinoma (Correct answer)
Ovarian fibroma with Meigs syndrome

Correct answer: Epithelial ovarian carcinoma

Epithelial ovarian carcinoma is the most lethal gynaecological malignancy. It typically presents late with a pelvic mass, ascites, and elevated CA-125. Peritoneal carcinomatosis indicates advanced stage (FIGO III-IV). Surgical debulking and chemotherapy are the mainstay of treatment.

Question 30: A patient with newly diagnosed hypertension has a potassium of 2.8 mmol/L and metabolic alkalosis. The aldosterone-to-renin ratio is elevated. What is the most likely diagnosis?

Renal tubular acidosis
Liddle syndrome
Primary hyperaldosteronism (Conn syndrome) (Correct answer)
Cushing syndrome

Correct answer: Primary hyperaldosteronism (Conn syndrome)

Primary hyperaldosteronism (Conn syndrome) presents with hypertension, hypokalaemia, metabolic alkalosis, and an elevated aldosterone-to-renin ratio. It is the most common cause of secondary hypertension due to adrenal pathology.

Question 31: A 50-year-old female presents with a solitary thyroid nodule. Thyroid function tests are normal. Ultrasound shows microcalcifications and irregular margins. What is the next step?

Immediate thyroidectomy
Trial of levothyroxine suppression
Thyroid scintigraphy
Fine needle aspiration cytology (FNAC) (Correct answer)

Correct answer: Fine needle aspiration cytology (FNAC)

Ultrasound features of microcalcifications and irregular margins are suspicious for thyroid malignancy (TI-RADS 4-5). Fine needle aspiration cytology is the next step to obtain a tissue diagnosis and guide further management.

Question 32: What is the most appropriate contraceptive method for a breastfeeding mother at 6 weeks postpartum?

Combined oral contraceptive pill
Both B and C are appropriate (Correct answer)
Progestogen-only pill
Copper intrauterine device

Correct answer: Both B and C are appropriate

Combined oral contraceptives are contraindicated in breastfeeding women within the first 6 months postpartum as oestrogen can reduce milk production. Both progestogen-only methods and copper IUDs are safe and appropriate for breastfeeding mothers at 6 weeks postpartum.

Question 33: A patient with chronic kidney disease stage 4 has a serum potassium of 6.2 mmol/L and peaked T waves on ECG. What is the most urgent first step?

IV insulin with dextrose
Urgent haemodialysis
IV calcium gluconate (Correct answer)
Oral sodium polystyrene sulfonate

Correct answer: IV calcium gluconate

IV calcium gluconate is the most urgent intervention as it stabilises the cardiac membrane and protects against arrhythmias. It does not lower potassium but buys time for definitive treatment.

Question 34: In a clinical trial, neither the participants nor the investigators know who received the active treatment or the placebo. This study design is called:

Double-blind trial (Correct answer)
Single-blind trial
Triple-blind trial
Open-label trial

Correct answer: Double-blind trial

In a double-blind trial, both participants and investigators are unaware of treatment allocation, reducing performance and detection bias.

Question 35: A patient is scheduled for elective surgery. He is on warfarin for a mechanical heart valve. What is the recommended perioperative anticoagulation strategy?

Stop warfarin 5 days before surgery and bridge with LMWH (Correct answer)
Stop warfarin 1 day before surgery without bridging
Stop warfarin and give aspirin instead
Continue warfarin through surgery

Correct answer: Stop warfarin 5 days before surgery and bridge with LMWH

For high-risk patients on warfarin (mechanical heart valves), the recommended strategy is to stop warfarin 5 days preoperatively, bridge with therapeutic-dose LMWH, hold LMWH 24 hours before surgery, and resume postoperatively when haemostasis is achieved.

Question 36: A 25-year-old male presents to the emergency department with right iliac fossa pain, anorexia, and rebound tenderness. His Alvarado score is 8. What is the most appropriate next step?

Conservative management with antibiotics
Abdominal ultrasound
Immediate appendicectomy (Correct answer)
CT abdomen with contrast

Correct answer: Immediate appendicectomy

An Alvarado score of 7-10 indicates a high probability of acute appendicitis. In a young male with classic presentation and high Alvarado score, immediate appendicectomy (laparoscopic preferred) is the standard of care without need for further imaging.

Question 37: A 5-year-old child presents with painless rectal bleeding. The blood is dark red and mixed with stool. A Meckel scan (technetium-99m pertechnetate) is positive. What is the diagnosis?

Anal fissure
Meckel diverticulum (Correct answer)
Juvenile polyp
Inflammatory bowel disease

Correct answer: Meckel diverticulum

Meckel diverticulum is the most common congenital GI anomaly (rule of 2s: 2% of population, 2 feet from ileocaecal valve, 2 inches long). It contains ectopic gastric mucosa that causes painless bleeding detected by technetium-99m pertechnetate scan.

Question 38: Which antidiabetic medication works by inhibiting sodium-glucose cotransporter 2 (SGLT2) in the proximal tubule?

Glipizide
Metformin
Empagliflozin (Correct answer)
Sitagliptin

Correct answer: Empagliflozin

Empagliflozin (and other gliflozins: dapagliflozin, canagliflozin) inhibits SGLT2 in the proximal renal tubule, reducing glucose reabsorption and causing glycosuria. These drugs also have cardiovascular and renal protective benefits independent of glucose lowering.

Question 39: A 3-year-old child presents with barking cough, inspiratory stridor, and a 'steeple sign' on anteroposterior neck X-ray. What is the most likely diagnosis?

Croup (laryngotracheobronchitis) (Correct answer)
Foreign body aspiration
Bacterial tracheitis
Epiglottitis

Correct answer: Croup (laryngotracheobronchitis)

Croup (acute laryngotracheobronchitis) is characterised by a barking cough, inspiratory stridor, and hoarseness. The 'steeple sign' on AP neck X-ray represents subglottic narrowing, which is the hallmark radiographic finding.

Question 40: Which of the following is the most common site for ectopic pregnancy?

Isthmus of the fallopian tube
Ampulla of the fallopian tube (Correct answer)
Ovary
Cervix

Correct answer: Ampulla of the fallopian tube

The ampulla of the fallopian tube is the most common site for ectopic pregnancy, accounting for approximately 70-80% of all ectopic pregnancies. This is where fertilisation normally occurs and where the embryo may implant abnormally.

Question 41: A 50-year-old man presents with sudden severe abdominal pain. Examination reveals a rigid, board-like abdomen with absent bowel sounds. Erect chest X-ray shows free air under the diaphragm. What is the most likely diagnosis?

Mesenteric ischaemia
Acute pancreatitis
Acute intestinal obstruction
Perforated peptic ulcer (Correct answer)

Correct answer: Perforated peptic ulcer

Free air under the diaphragm (pneumoperitoneum) on erect chest X-ray, combined with a rigid abdomen and peritonitis, is classic for a perforated hollow viscus, most commonly a perforated peptic ulcer.

Question 42: 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 main coronary artery
Left circumflex artery
Right coronary artery (Correct answer)
Left anterior descending 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 43: A newborn presents with bilious vomiting within the first 24 hours of life. An upper GI series shows a 'corkscrew' pattern. What is the most likely diagnosis?

Pyloric stenosis
Hirschsprung disease
Midgut volvulus (Correct answer)
Duodenal atresia

Correct answer: Midgut volvulus

Bilious vomiting in a neonate is a surgical emergency until proven otherwise. A corkscrew or bird's beak pattern on upper GI series is diagnostic of midgut volvulus, which occurs secondary to malrotation and requires emergent Ladd procedure.

Question 44: A pregnant woman at 16 weeks gestation has a quadruple screen showing elevated AFP, low oestradiol, elevated beta-hCG, and elevated inhibin A. What is the most likely associated condition?

Edwards syndrome (trisomy 18)
Down syndrome (trisomy 21) (Correct answer)
Neural tube defect
Turner syndrome

Correct answer: Down syndrome (trisomy 21)

In the quadruple screen for Down syndrome: AFP is low, unconjugated oestriol (uE3) is low, beta-hCG is elevated, and inhibin A is elevated. Note: In neural tube defects, AFP is elevated. The pattern described most closely matches Down syndrome screening with the elevated hCG and inhibin A being key markers.

Question 45: Which of the following conditions is a common cause of secondary hypertension in a young Saudi adult?

Coarctation of the aorta
Phaeochromocytoma
Renal artery stenosis (Correct answer)
Essential hypertension

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.

Question 46: A 60-year-old patient with a history of atrial fibrillation presents with sudden onset right-sided weakness and aphasia. CT brain shows no haemorrhage. What is the most appropriate immediate intervention?

Aspirin 300 mg immediately
Heparin infusion
Observation and repeat CT in 24 hours
IV alteplase within the thrombolytic window (Correct answer)

Correct answer: IV alteplase within the thrombolytic window

In acute ischaemic stroke presenting within the thrombolytic window (4.5 hours) with no contraindications and no haemorrhage on CT, IV alteplase is the standard of care for reperfusion therapy.

Question 47: During laparoscopic cholecystectomy, which structure must be clearly identified in the critical view of safety before clipping?

Common bile duct
Hepatic artery proper
Portal vein
Cystic duct and cystic artery in Calot's triangle (Correct answer)

Correct answer: Cystic duct and cystic artery in Calot's triangle

The critical view of safety requires identification of two structures (cystic duct and cystic artery) entering the gallbladder through Calot's triangle, with the hepatocystic triangle cleared of fat and fibrous tissue. This prevents bile duct injury.

Question 48: A 30-year-old woman undergoes a Pap smear that shows high-grade squamous intraepithelial lesion (HSIL). What is the recommended next step?

Colposcopy and biopsy (Correct answer)
Repeat Pap smear in 6 months
HPV testing alone
Immediate hysterectomy

Correct answer: Colposcopy and biopsy

HSIL on Pap smear requires colposcopy with directed biopsy for histological confirmation. This allows visualisation of the transformation zone, identification of abnormal areas, and tissue sampling to determine the grade of cervical intraepithelial neoplasia (CIN).

Question 49: Which of the following is the MOST important Wilson and Jungner criterion for a disease to be suitable for a screening program?

The disease must be highly infectious
The test must use invasive techniques for high accuracy
The disease must have a high case fatality rate
An effective treatment must be available and early treatment must improve outcomes compared to late treatment (Correct answer)

Correct answer: An effective treatment must be available and early treatment must improve outcomes compared to late treatment

Screening is only justified if early detection leads to better patient outcomes; if treating early confers no advantage over treating at symptom onset, screening provides no benefit.

Question 50: What is the most common congenital heart defect?

Atrial septal defect
Patent ductus arteriosus
Tetralogy of Fallot
Ventricular septal defect (Correct answer)

Correct answer: Ventricular septal defect

Ventricular septal defect (VSD) is the most common congenital heart defect, accounting for approximately 25-30% of all congenital heart disease. Small VSDs often close spontaneously, while large VSDs may cause heart failure and require surgical repair.

Question 51: A 35-year-old woman with a BMI of 40 and PCOS has been trying to conceive for 2 years. She has irregular cycles and anovulation. What is the most appropriate first step?

Weight loss and lifestyle modification (Correct answer)
Clomiphene citrate
Gonadotropin injections
In vitro fertilisation (IVF)

Correct answer: Weight loss and lifestyle modification

In obese women with PCOS and anovulatory infertility, weight loss of even 5-10% of body weight can restore ovulation and improve fertility outcomes. Lifestyle modification is the recommended first step before pharmacological ovulation induction.

Question 52: The attributable risk (risk difference) for lung cancer between smokers and non-smokers is 0.15. What does this number represent?

Smokers are 15 times more likely to develop lung cancer
15 per 100 smokers develop lung cancer attributable to smoking itself (Correct answer)
Non-smokers have a 15% baseline risk of lung cancer
Smoking accounts for 15% of all cancers

Correct answer: 15 per 100 smokers develop lung cancer attributable to smoking itself

Attributable risk of 0.15 means that 15 out of every 100 smokers develop lung cancer as a direct result of smoking, beyond the background rate seen in non-smokers.

Question 53: What is the most appropriate initial fluid resuscitation for a 70 kg adult with a 40% total body surface area (TBSA) burn according to the Parkland formula?

11,200 mL Ringer's lactate in 24 hours (Correct answer)
5,600 mL Ringer's lactate in 24 hours
2,800 mL Ringer's lactate in 24 hours
5,600 mL normal saline in 24 hours

Correct answer: 11,200 mL Ringer's lactate in 24 hours

The Parkland formula: 4 mL × body weight (kg) × %TBSA = 4 × 70 × 40 = 11,200 mL of Ringer's lactate in the first 24 hours, with half given in the first 8 hours and the remainder over the next 16 hours.

Question 54: During a right hemicolectomy, which vessel is ligated at its origin to achieve adequate lymph node clearance for caecal carcinoma?

Ileocolic artery (Correct answer)
Inferior mesenteric artery
Superior mesenteric artery
Middle colic artery

Correct answer: Ileocolic artery

For caecal carcinoma, the ileocolic artery is the primary feeding vessel and is ligated at its origin from the superior mesenteric artery to achieve central lymph node clearance, which is essential for adequate oncological resection.

Question 55: Which of the following medications requires therapeutic drug monitoring due to its narrow therapeutic index in bipolar disorder treatment?

Lithium (Correct answer)
Olanzapine
Lamotrigine
Quetiapine

Correct answer: Lithium

Lithium has a narrow therapeutic index (0.6-1.0 mEq/L for maintenance, 1.0-1.2 for acute mania). Regular monitoring of serum lithium levels, renal function, thyroid function, and calcium is mandatory. Toxicity occurs at levels >1.5 mEq/L and can be life-threatening.

Question 56: Which medication is contraindicated in patients with a history of acute intermittent porphyria?

Barbiturates (Correct answer)
Metformin
Aspirin
Paracetamol

Correct answer: Barbiturates

Barbiturates are strongly contraindicated in acute intermittent porphyria because they induce hepatic cytochrome P450 enzymes, specifically ALA synthase, which increases porphyrin precursor production and can precipitate a life-threatening acute attack.

Question 57: A patient with asthma is prescribed a non-selective beta-blocker for hypertension. What is the expected adverse effect?

Polyuria
Bronchospasm (Correct answer)
Tachycardia
Hyperglycaemia

Correct answer: Bronchospasm

Non-selective beta-blockers (e.g., propranolol) block beta-2 receptors in bronchial smooth muscle, causing bronchoconstriction. This can precipitate severe bronchospasm in asthmatic patients. Cardioselective beta-blockers (beta-1 selective) are safer but should still be used cautiously.

Question 58: 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)
Reassure and discharge
Chest X-ray only

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 59: A 40-year-old male presents with intermittent claudication in the left calf after walking 200 metres. Ankle-brachial index (ABI) is 0.6. What is the initial management?

Immediate surgical bypass
Amputation planning
Endovascular stenting
Smoking cessation, supervised exercise, and antiplatelet therapy (Correct answer)

Correct answer: Smoking cessation, supervised exercise, and antiplatelet therapy

For intermittent claudication (Fontaine stage II), initial management includes risk factor modification (smoking cessation is paramount), supervised exercise programmes, and antiplatelet therapy. Revascularisation is reserved for lifestyle-limiting symptoms despite conservative measures.

Question 60: Which class of medications is first-line for generalised anxiety disorder (GAD)?

Selective serotonin reuptake inhibitors (SSRIs) (Correct answer)
Typical antipsychotics
Benzodiazepines
Mood stabilisers

Correct answer: Selective serotonin reuptake inhibitors (SSRIs)

SSRIs (e.g., escitalopram, sertraline) are first-line pharmacotherapy for generalised anxiety disorder due to their efficacy, safety profile, and low potential for dependence. SNRIs (e.g., venlafaxine) are also first-line alternatives.

Question 61: According to Saudi MOH screening guidelines, at what age should colorectal cancer screening begin in average-risk asymptomatic individuals?

Age 45 years
Age 50 years (Correct answer)
Age 55 years
Age 40 years

Correct answer: Age 50 years

Saudi MOH recommends colorectal cancer screening beginning at age 50 for average-risk individuals, consistent with major international guidelines.

Question 62: 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?

Myocarditis
Pericarditis
Infective endocarditis (Correct answer)
Rheumatic fever recurrence

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.

Question 63: A patient receiving blood transfusion develops fever, rigors, and flank pain 30 minutes into the transfusion. What is the most critical immediate action?

Administer paracetamol
Give IV hydrocortisone and continue
Slow the transfusion rate
Stop the transfusion immediately (Correct answer)

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 64: A 28-year-old woman with a previous caesarean section presents in labour with sudden severe abdominal pain, loss of fetal station, and vaginal bleeding. CTG shows fetal bradycardia. What is the most likely diagnosis?

Placental abruption
Cord prolapse
Placenta praevia
Uterine rupture (Correct answer)

Correct answer: Uterine rupture

Uterine rupture in a patient with a previous caesarean scar presents with sudden severe abdominal pain, cessation of contractions, loss of fetal station (fetus palpable in abdomen), vaginal bleeding, and fetal distress. Emergency laparotomy is required.

Question 65: In Saudi Arabia, according to the Mental Health Act and SCFHS guidelines, involuntary psychiatric admission is permitted under which condition?

When the family requests admission
When there is imminent danger to self or others due to mental illness (Correct answer)
When the patient is homeless
When the patient refuses any medication

Correct answer: When there is imminent danger to self or others due to mental illness

According to Saudi Mental Health Law and SCFHS guidelines, involuntary admission is permitted when a patient with a mental disorder poses an imminent danger to themselves or others, lacks capacity to consent, and requires immediate treatment. Legal safeguards and periodic review are mandatory.

Question 66: A 55-year-old male presents with a change in bowel habit, rectal bleeding, and a palpable mass on digital rectal examination at 6 cm from the anal verge. What is the most likely diagnosis?

Rectal polyp
Haemorrhoids
Rectal carcinoma (Correct answer)
Anal fissure

Correct answer: Rectal carcinoma

A palpable rectal mass with change in bowel habit and rectal bleeding in a patient over 50 is rectal carcinoma until proven otherwise. Digital rectal examination can detect low rectal tumours, and further assessment with rigid sigmoidoscopy and biopsy is essential.

Question 67: A 30-year-old primigravida at 34 weeks gestation presents with severe headache, visual disturbances, and blood pressure of 170/110 mmHg. Urinalysis shows 3+ proteinuria. What is the diagnosis?

Eclampsia
Gestational hypertension
Pre-eclampsia with severe features (Correct answer)
Chronic hypertension

Correct answer: Pre-eclampsia with severe features

Pre-eclampsia with severe features is diagnosed when hypertension (≥160/110 mmHg) occurs after 20 weeks gestation with proteinuria and severe symptoms (headache, visual disturbances, epigastric pain). This requires urgent management including magnesium sulphate and delivery planning.

Question 68: A 40-year-old female presents with a painless, mobile, well-circumscribed 2 cm breast lump. Ultrasound shows a solid, homogeneous mass. What is the most likely diagnosis?

Breast carcinoma
Phyllodes tumour
Breast cyst
Fibroadenoma (Correct answer)

Correct answer: Fibroadenoma

Fibroadenoma is the most common benign breast tumour in women under 40. It presents as a painless, mobile, well-circumscribed mass often described as a 'breast mouse' due to its mobility.

Question 69: Physical inactivity is recognized as a major modifiable risk factor for which of the following groups of conditions?

Hypertension and stroke only
Cardiovascular disease, type 2 diabetes, obesity, and several cancers (Correct answer)
Cardiovascular disease only
Diabetes mellitus only

Correct answer: Cardiovascular disease, type 2 diabetes, obesity, and several cancers

Physical inactivity is a major risk factor for cardiovascular disease, type 2 diabetes, obesity, hypertension, stroke, colon cancer, and breast cancer, among others.

Question 70: A 65-year-old patient with Parkinson disease develops visual hallucinations. Which antipsychotic is safest to use?

Haloperidol
Chlorpromazine
Quetiapine or pimavanserin (Correct answer)
Risperidone

Correct answer: Quetiapine or pimavanserin

Quetiapine (low dose) and pimavanserin (5-HT2A inverse agonist specifically approved for Parkinson disease psychosis) are the safest antipsychotic options as they have the least D2 blocking activity. Typical antipsychotics and most other atypicals can worsen parkinsonian symptoms.

Question 71: A 6-year-old child presents with morning headaches, vomiting, and ataxia. MRI shows a posterior fossa mass. What is the most common posterior fossa tumour in children?

Astrocytoma (pilocytic) (Correct answer)
Craniopharyngioma
Medulloblastoma
Ependymoma

Correct answer: Astrocytoma (pilocytic)

While medulloblastoma is common, pilocytic astrocytoma (cerebellar) is actually the most common posterior fossa tumour in children overall. However, considering all posterior fossa tumours, pilocytic astrocytoma and medulloblastoma are both very common, with pilocytic astrocytoma being the most common benign tumour.

Question 72: A 40-year-old man presents with persistent preoccupation that he has cancer despite multiple normal investigations and reassurance from specialists. The preoccupation has lasted 8 months and causes significant distress. What is the most likely diagnosis?

Conversion disorder
Factitious disorder
Somatic symptom disorder
Illness anxiety disorder (hypochondriasis) (Correct answer)

Correct answer: Illness anxiety disorder (hypochondriasis)

Illness anxiety disorder (formerly hypochondriasis) involves preoccupation with having or acquiring a serious illness with minimal or no somatic symptoms. Despite normal investigations and medical reassurance, the anxiety persists for ≥6 months.

Question 73: A 60-year-old postmenopausal woman presents with vaginal bleeding. Endometrial thickness on ultrasound is 8 mm. What is the most appropriate next step?

Total abdominal hysterectomy
Hormone replacement therapy
Endometrial biopsy (Correct answer)
Reassure and observe

Correct answer: Endometrial biopsy

Postmenopausal bleeding with endometrial thickness >4-5 mm on transvaginal ultrasound requires endometrial biopsy to exclude endometrial carcinoma, which is the most important diagnosis to rule out in this setting.

Question 74: A 12-month-old infant presents with pallor, irritability, and a haemoglobin of 7 g/dL. Peripheral smear shows microcytic hypochromic anaemia with target cells. HPLC shows HbS 80% and HbF 15%. What is the diagnosis?

Beta-thalassaemia major
Sickle cell disease (HbSS) (Correct answer)
Iron deficiency anaemia
Sickle cell trait

Correct answer: Sickle cell disease (HbSS)

HbS of 80% with HbF 15% on HPLC is diagnostic of sickle cell disease (homozygous HbSS). Sickle cell disease is prevalent in Saudi Arabia, particularly in the Eastern Province and southwestern regions. HbF levels above 10% in SCD are common in the Saudi variant.

Question 75: A 70-year-old patient undergoes emergency laparotomy for a perforated duodenal ulcer. Intraoperatively, a large perforation is found. What is the most appropriate surgical procedure?

Graham patch (omental patch repair) (Correct answer)
Billroth I gastrectomy
Vagotomy and pyloroplasty
Billroth II gastrectomy

Correct answer: Graham patch (omental patch repair)

In an emergency setting with a perforated duodenal ulcer, Graham patch (omental patch) repair is the safest and most commonly performed procedure. Definitive ulcer surgery is deferred, and H. pylori eradication and PPI therapy are initiated postoperatively.

Question 76: A 50-year-old woman presents with postmenopausal bleeding. Endometrial biopsy shows complex atypical hyperplasia. What is the recommended management?

Observation and repeat biopsy in 6 months
Endometrial ablation
Progestin therapy alone
Total hysterectomy with bilateral salpingo-oophorectomy (Correct answer)

Correct answer: Total hysterectomy with bilateral salpingo-oophorectomy

Complex atypical hyperplasia has a 25-30% risk of concurrent or progression to endometrial carcinoma. In a postmenopausal woman not desiring fertility, total hysterectomy with bilateral salpingo-oophorectomy is the definitive management.

Question 77: At which temperature range should most vaccines in Saudi Arabia's cold chain be maintained to preserve their potency?

15°C to 25°C
-20°C to -15°C
2°C to 8°C (Correct answer)
0°C to 4°C

Correct answer: 2°C to 8°C

Most vaccines must be stored between 2°C and 8°C (standard refrigerator range); freezing can inactivate many vaccines such as DPT and Hepatitis B.

Question 78: What is the most common cause of iron deficiency anaemia in a premenopausal woman?

Poor dietary intake
Coeliac disease
Colorectal carcinoma
Menorrhagia (Correct answer)

Correct answer: Menorrhagia

Menorrhagia (heavy menstrual bleeding) is the most common cause of iron deficiency anaemia in premenopausal women. A thorough menstrual history should be obtained before pursuing GI investigations.

Question 79: A 70-year-old male presents with left lower quadrant pain, fever, and leucocytosis. CT shows pericolic fat stranding and a small abscess around the sigmoid colon. What is the initial management?

Emergency sigmoid colectomy
Oral antibiotics and outpatient follow-up
Colonoscopy
IV antibiotics and CT-guided percutaneous drainage (Correct answer)

Correct answer: IV antibiotics and CT-guided percutaneous drainage

Complicated diverticulitis with a small abscess (Hinchey stage I-II) is initially managed with IV antibiotics and CT-guided percutaneous drainage if the abscess is accessible (>3 cm). Surgery is reserved for failed conservative management or complications.

Question 80: A 3-year-old child with sickle cell disease presents with sudden pallor, tachycardia, and a rapidly enlarging spleen. Haemoglobin is 4 g/dL. What is the diagnosis?

Haemolytic crisis
Aplastic crisis
Vaso-occlusive crisis
Acute splenic sequestration crisis (Correct answer)

Correct answer: Acute splenic sequestration crisis

Acute splenic sequestration crisis occurs when sickled red cells pool in the spleen, causing rapid splenic enlargement, severe anaemia, and hypovolaemic shock. It is a life-threatening emergency in young children with SCD requiring urgent transfusion.

Question 81: In a patient with suspected acute coronary syndrome, which cardiac biomarker is the most sensitive and specific for myocardial injury?

Creatine kinase-MB (CK-MB)
High-sensitivity troponin (Correct answer)
Myoglobin
Lactate dehydrogenase (LDH)

Correct answer: High-sensitivity troponin

High-sensitivity troponin (either I or T) is the most sensitive and specific biomarker for myocardial injury and is the preferred test for diagnosing acute myocardial infarction per current guidelines.

Question 82: A 25-year-old male presents with recurrent oral ulcers, genital ulcers, and anterior uveitis. What is the most likely diagnosis?

Reactive arthritis
Behçet disease (Correct answer)
Herpes simplex
Crohn disease

Correct answer: Behçet disease

Behçet disease presents with the classic triad of recurrent oral ulcers, genital ulcers, and uveitis. It is more common in countries along the ancient Silk Road, including Saudi Arabia and the Middle East.

Question 83: A 30-year-old woman presents with episodes of depersonalisation, identity confusion, and amnesia for significant personal events. She has a history of severe childhood abuse. What is the most likely diagnosis?

Schizophrenia
PTSD
Borderline personality disorder
Dissociative identity disorder (Correct answer)

Correct answer: Dissociative identity disorder

Dissociative identity disorder (formerly multiple personality disorder) is characterised by disruption of identity with ≥2 distinct personality states, recurrent gaps in recall, and significant distress. It is strongly associated with severe, repeated childhood trauma.

Question 84: A 40-year-old woman presents with paralysis of the right arm that occurred suddenly after a family argument. She seems unconcerned about the paralysis. Neurological examination reveals inconsistencies — she can unconsciously use the arm in certain postures. Which test finding supports conversion disorder?

Abnormal nerve conduction studies
Elevated CK levels
Positive Hoover sign (Correct answer)
MRI showing a brain lesion

Correct answer: Positive Hoover sign

Hoover sign is positive when there is involuntary hip extension during contralateral hip flexion against resistance, demonstrating that the 'paralysed' leg has preserved motor function. This is a clinical sign of functional (non-organic) weakness and supports conversion disorder.

Question 85: A screening test is positive in a patient who is later confirmed by the gold standard test to NOT have the disease. This result is classified as:

True positive
True negative
False positive (Correct answer)
False negative

Correct answer: False positive

A false positive occurs when the screening test incorrectly identifies disease in a person who does not actually have it, as confirmed by the reference standard.

Question 86: 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?

Graves disease (Correct answer)
Toxic multinodular goitre
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 87: A 25-year-old male sustains a penetrating injury to the neck in Zone II. He is haemodynamically stable with an expanding haematoma. What is the recommended approach?

CT angiography of the neck
Mandatory surgical exploration (Correct answer)
Observation and serial examinations
Endovascular embolisation

Correct answer: Mandatory surgical exploration

Zone II penetrating neck injuries (between the cricoid and angle of mandible) with hard signs (expanding haematoma, active bleeding, airway compromise) require mandatory surgical exploration regardless of imaging. An expanding haematoma is a hard sign indicating vascular injury.

Question 88: A health survey measures the proportion of adults in Riyadh who have hypertension on the day of the survey. This measure is best described as:

Cumulative incidence
Incidence density rate
Period prevalence
Point prevalence (Correct answer)

Correct answer: Point prevalence

Point prevalence measures the proportion of a population affected by a disease at one specific point in time; surveying on a single day yields point prevalence.

Question 89: A newborn presents with ambiguous genitalia, hypotension, hyperkalaemia, and hyponatraemia. 17-hydroxyprogesterone level is markedly elevated. What is the most likely diagnosis?

Turner syndrome
Androgen insensitivity syndrome
5-alpha reductase deficiency
Congenital adrenal hyperplasia (21-hydroxylase deficiency) (Correct answer)

Correct answer: Congenital adrenal hyperplasia (21-hydroxylase deficiency)

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency is the most common cause of ambiguous genitalia with salt-wasting crisis (hyponatraemia, hyperkalaemia). Elevated 17-hydroxyprogesterone is the diagnostic marker. It is more common in consanguineous populations.

Question 90: A trauma patient arrives with paradoxical chest wall movement on the right side. Oxygen saturation is 88% on room air. What is the diagnosis and initial management?

Tension pneumothorax — needle decompression
Rib fracture — analgesia only
Haemothorax — chest tube insertion
Flail chest — intubation and mechanical ventilation if needed (Correct answer)

Correct answer: Flail chest — intubation and mechanical ventilation if needed

Paradoxical chest wall movement indicates flail chest (≥3 consecutive ribs fractured in ≥2 places). Management focuses on adequate analgesia, oxygen supplementation, and mechanical ventilation if respiratory failure develops. The underlying pulmonary contusion often determines the clinical course.

Question 91: A mother brings her 3-year-old child who does not speak, avoids eye contact, engages in repetitive hand flapping, and lines up toys in a specific order. What is the most likely diagnosis?

Autism spectrum disorder (Correct answer)
ADHD
Intellectual disability
Selective mutism

Correct answer: Autism spectrum disorder

Autism spectrum disorder (ASD) is characterised by persistent deficits in social communication and interaction (poor eye contact, lack of speech) and restricted, repetitive patterns of behaviour (hand flapping, lining up objects). Diagnosis is typically made by age 2-3.

Question 92: A 3-year-old child presents with a limp and refusal to bear weight after an upper respiratory infection. Hip X-ray is normal. What is the most likely diagnosis?

Slipped capital femoral epiphysis
Septic arthritis
Transient synovitis (irritable hip) (Correct answer)
Legg-Calvé-Perthes disease

Correct answer: Transient synovitis (irritable hip)

Transient synovitis is the most common cause of atraumatic hip pain in children aged 3-8 years, typically following a viral upper respiratory infection. The child may limp or refuse to bear weight. X-ray is usually normal, and the condition is self-limiting.

Question 93: A patient taking a monoamine oxidase inhibitor (MAOI) eats a meal containing aged cheese and develops a severe hypertensive crisis. What substance in the cheese caused this reaction?

Dopamine
Histamine
Serotonin
Tyramine (Correct answer)

Correct answer: Tyramine

Tyramine is found in aged cheeses, cured meats, and fermented foods. Normally, tyramine is metabolised by MAO in the gut wall and liver. When MAO is inhibited, tyramine is absorbed intact and causes massive noradrenaline release from sympathetic nerve endings, resulting in a hypertensive crisis.

Question 94: A 20-year-old male sustains a fracture of the shaft of the humerus. On examination, there is wrist drop. Which nerve is most likely injured?

Musculocutaneous nerve
Ulnar nerve
Median nerve
Radial nerve (Correct answer)

Correct answer: Radial nerve

The radial nerve runs in the spiral groove of the humerus and is vulnerable to injury in midshaft humeral fractures. Radial nerve injury causes wrist drop (inability to extend the wrist and fingers) and loss of sensation over the anatomical snuffbox.

Question 95: A 30-year-old male from Riyadh presents with fever, dry cough, and bilateral ground-glass opacities. He works at a camel farm. What is the most likely causative organism?

Coxiella burnetii
Mycobacterium tuberculosis
Influenza A H1N1
Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (Correct answer)

Correct answer: Middle East Respiratory Syndrome Coronavirus (MERS-CoV)

MERS-CoV is endemic in Saudi Arabia with dromedary camels serving as the primary zoonotic reservoir. Camel farm workers are at high risk. The presentation with fever, cough, and bilateral ground-glass opacities is characteristic.

Question 96: A 3-year-old child presents with abdominal mass, hypertension, and periorbital ecchymosis (raccoon eyes). Urine catecholamines (VMA and HVA) are elevated. What is the most likely diagnosis?

Wilms tumour
Rhabdomyosarcoma
Hepatoblastoma
Neuroblastoma (Correct answer)

Correct answer: Neuroblastoma

Neuroblastoma arises from neural crest cells (sympathetic nervous system) and is the most common extracranial solid tumour in children. It characteristically produces catecholamines (elevated urinary VMA/HVA), can cross the midline, and causes periorbital metastases (raccoon eyes).

Question 97: A 26-year-old woman presents with cyclical pelvic pain, dysmenorrhoea, dyspareunia, and infertility. Laparoscopy reveals chocolate cysts on the ovaries and powder-burn lesions on the peritoneum. What is the diagnosis?

Dermoid cyst
Ovarian carcinoma
Pelvic inflammatory disease
Endometriosis (Correct answer)

Correct answer: Endometriosis

Endometriosis is characterised by the presence of endometrial tissue outside the uterus. Chocolate cysts (endometriomas) on the ovaries and powder-burn/gunshot lesions on the peritoneum are classic laparoscopic findings. It is a common cause of dysmenorrhoea and infertility.

Question 98: A patient taking clopidogrel is prescribed omeprazole for dyspepsia. What is the clinical significance of this drug interaction?

No clinically significant interaction
Omeprazole inhibits CYP2C19, reducing clopidogrel activation (Correct answer)
Omeprazole causes clopidogrel toxicity
Omeprazole increases clopidogrel's antiplatelet effect

Correct answer: Omeprazole inhibits CYP2C19, reducing clopidogrel activation

Clopidogrel is a prodrug that requires CYP2C19 for activation to its active metabolite. Omeprazole inhibits CYP2C19, potentially reducing clopidogrel's antiplatelet efficacy. Pantoprazole is the preferred PPI in patients on clopidogrel as it has less CYP2C19 inhibition.

Question 99: A 30-year-old male involved in a motor vehicle accident presents with hypotension and a positive FAST examination. Where is the most likely site of fluid accumulation detected by FAST?

Morrison's pouch (hepatorenal recess) (Correct answer)
Left paracolic gutter
Pericardial space
Pelvis

Correct answer: Morrison's pouch (hepatorenal recess)

Morrison's pouch (hepatorenal recess) is the most dependent part of the peritoneal cavity in the supine position and is the most common site where free fluid accumulates in blunt abdominal trauma. It is the most sensitive FAST window.

Question 100: A 40-year-old male presents with epigastric pain radiating to the back, elevated serum lipase (>3× upper limit of normal), and a history of heavy alcohol use. What is the most important initial management?

NPO, IV fluids, and analgesia (Correct answer)
Emergency ERCP
Immediate cholecystectomy
Oral pancreatic enzymes

Correct answer: NPO, IV fluids, and analgesia

Acute pancreatitis management is primarily supportive: nil per os (NPO), aggressive IV fluid resuscitation (preferably Ringer's lactate), and adequate analgesia. ERCP is only indicated if there is evidence of choledocholithiasis with cholangitis.

Question 101: Which of the following is the most common cause of community-acquired pneumonia in Saudi Arabia?

Staphylococcus aureus
Pseudomonas aeruginosa
Klebsiella pneumoniae
Streptococcus pneumoniae (Correct answer)

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 102: A 2-month-old infant presents with conjugated hyperbilirubinaemia, pale stools, and dark urine. Ultrasound shows absent gallbladder. What is the most likely diagnosis and what urgent investigation is needed?

Alagille syndrome — genetic testing
Neonatal hepatitis — liver biopsy
Choledochal cyst — MRCP
Biliary atresia — HIDA scan and intraoperative cholangiogram (Correct answer)

Correct answer: Biliary atresia — HIDA scan and intraoperative cholangiogram

Biliary atresia presents with conjugated hyperbilirubinaemia, pale (acholic) stools, and dark urine. Absent gallbladder on ultrasound supports the diagnosis. HIDA scan shows non-excretion of tracer into the bowel. Kasai portoenterostomy must be performed before 60 days of age for best outcomes.

Question 103: A patient on haloperidol develops high fever (41°C), severe muscle rigidity, autonomic instability, and elevated creatine kinase. What is the diagnosis?

Serotonin syndrome
Acute dystonia
Malignant hyperthermia
Neuroleptic malignant syndrome (NMS) (Correct answer)

Correct answer: Neuroleptic malignant syndrome (NMS)

Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotic medications characterised by the tetrad of fever, rigidity (lead-pipe), autonomic instability, and altered consciousness with elevated CK. Treatment includes stopping the offending agent, dantrolene, and bromocriptine.

Question 104: A 5-year-old child presents with periorbital oedema, proteinuria (4+), and hypoalbuminaemia. Serum cholesterol is elevated. What is the most likely diagnosis?

Henoch-Schönlein purpura
Nephrotic syndrome (minimal change disease) (Correct answer)
Acute glomerulonephritis
Haemolytic uraemic syndrome

Correct answer: Nephrotic syndrome (minimal change disease)

Nephrotic syndrome in children is characterised by heavy proteinuria, hypoalbuminaemia, oedema, and hyperlipidaemia. Minimal change disease is the most common cause in children (80%), and it typically responds well to corticosteroid therapy.

Question 105: A 35-year-old male sustains a stab wound to the left chest at the 5th intercostal space, midclavicular line. He has distended neck veins, muffled heart sounds, and hypotension. What is the most likely diagnosis?

Cardiac tamponade (Correct answer)
Haemothorax
Flail chest
Tension pneumothorax

Correct answer: Cardiac tamponade

Beck's triad (distended neck veins, muffled heart sounds, hypotension) is classic for cardiac tamponade. A stab wound at the 5th intercostal space, midclavicular line overlies the heart, making penetrating cardiac injury likely.

Question 106: A patient presents with organophosphate poisoning showing excessive salivation, lacrimation, urination, diarrhoea, and miosis. What is the antidote?

Physostigmine
Atropine and pralidoxime (Correct answer)
Flumazenil
Naloxone

Correct answer: Atropine and pralidoxime

Organophosphate poisoning causes cholinergic crisis by irreversibly inhibiting acetylcholinesterase. Atropine (muscarinic antagonist) treats secretions and bradycardia, while pralidoxime (2-PAM) reactivates acetylcholinesterase if given early (before 'ageing' of the enzyme-inhibitor complex).

Question 107: A 65-year-old male presents with an irreducible, tender inguinal swelling with vomiting and abdominal distension. What is the diagnosis?

Inguinal lymphadenopathy
Strangulated inguinal hernia (Correct answer)
Femoral hernia
Direct inguinal hernia

Correct answer: Strangulated inguinal hernia

An irreducible, tender inguinal hernia with signs of intestinal obstruction (vomiting, distension) indicates strangulation — a surgical emergency requiring urgent exploration to assess bowel viability and perform repair.

Question 108: A child is accidentally given a large dose of iron supplement. What is the specific antidote?

Desferrioxamine (deferoxamine) (Correct answer)
Penicillamine
Dimercaprol (BAL)
EDTA

Correct answer: Desferrioxamine (deferoxamine)

Desferrioxamine (deferoxamine) is the specific chelating agent for iron poisoning. It binds free iron to form ferrioxamine, which is excreted renally (causing vin rosé coloured urine). It is indicated when serum iron exceeds 500 μg/dL or there are systemic symptoms.

Question 109: A 48-year-old woman presents with joint pain, skin tightening of the fingers, Raynaud phenomenon, and dysphagia. Anti-centromere antibodies are positive. What is the most likely diagnosis?

Systemic lupus erythematosus
Diffuse systemic sclerosis
Limited cutaneous systemic sclerosis (CREST syndrome) (Correct answer)
Dermatomyositis

Correct answer: Limited cutaneous systemic sclerosis (CREST syndrome)

Limited cutaneous systemic sclerosis (formerly CREST syndrome) is characterised by Calcinosis, Raynaud phenomenon, Esophageal dysmotility, Sclerodactyly, and Telangiectasia. Anti-centromere antibodies are highly specific for this condition.

Question 110: A 55-year-old male presents with polyuria, polydipsia, and a fasting blood glucose of 9.5 mmol/L on two occasions. What is the most appropriate initial management?

GLP-1 receptor agonist
Insulin glargine
Sulfonylurea monotherapy
Lifestyle modification and metformin (Correct answer)

Correct answer: Lifestyle modification and metformin

According to SCFHS guidelines aligned with international standards, first-line management of newly diagnosed type 2 diabetes includes lifestyle modifications combined with metformin, which improves insulin sensitivity and has cardiovascular benefits.

Question 111: A 15-year-old obese boy presents with a limp and groin pain. X-ray shows posterior displacement of the femoral epiphysis. What is the diagnosis?

Osteomyelitis
Transient synovitis
Slipped capital femoral epiphysis (SCFE) (Correct answer)
Legg-Calvé-Perthes disease

Correct answer: Slipped capital femoral epiphysis (SCFE)

Slipped capital femoral epiphysis (SCFE) typically affects obese adolescents (10-16 years) and presents with hip/groin/knee pain and a limp. X-ray shows posterior and inferior displacement of the femoral epiphysis relative to the neck (Trethowan sign). Urgent surgical pinning is required.

Question 112: A 55-year-old male with a 30-pack-year smoking history presents with painless gross haematuria. Cystoscopy reveals a papillary mass in the bladder. What is the most likely histological type?

Adenocarcinoma
Squamous cell carcinoma
Small cell carcinoma
Transitional cell carcinoma (urothelial) (Correct answer)

Correct answer: Transitional cell carcinoma (urothelial)

Transitional cell carcinoma (urothelial carcinoma) is the most common type of bladder cancer, strongly associated with cigarette smoking. It typically presents as a papillary lesion on cystoscopy.

Question 113: What is the mechanism of action of omeprazole?

Irreversible proton pump inhibitor (Correct answer)
Prostaglandin analogue
Muscarinic receptor antagonist
H2 receptor antagonist

Correct answer: Irreversible proton pump inhibitor

Omeprazole irreversibly inhibits the hydrogen-potassium ATPase (proton pump) on the luminal surface of parietal cells in the stomach. This blocks the final common pathway of acid secretion, providing potent and sustained acid suppression.

Question 114: What is the recommended initial feeding for a healthy term breastfed newborn according to SCFHS guidelines?

Formula supplementation for the first 24 hours
Exclusive breastfeeding initiated within the first hour of life (Correct answer)
Breastfeeding starting at 24 hours of age
Glucose water for the first feed

Correct answer: Exclusive breastfeeding initiated within the first hour of life

SCFHS and WHO guidelines recommend initiation of breastfeeding within the first hour of life (golden hour) with exclusive breastfeeding for the first 6 months. Early skin-to-skin contact and immediate breastfeeding promote bonding and colostrum intake.

Question 115: A 4-year-old child presents with easy bruising, petechiae, and a platelet count of 15,000/μL. WBC and haemoglobin are normal. Peripheral smear shows large platelets. What is the most likely diagnosis?

Aplastic anaemia
Immune thrombocytopenic purpura (ITP) (Correct answer)
Acute lymphoblastic leukaemia
Disseminated intravascular coagulation

Correct answer: Immune thrombocytopenic purpura (ITP)

ITP in children typically presents after a viral infection with isolated thrombocytopenia, petechiae, and bruising. WBC and haemoglobin are normal, and peripheral smear shows large platelets indicating increased platelet destruction with compensatory bone marrow production.

Question 116: A 60-year-old patient with chronic atrial fibrillation and a CHA2DS2-VASc score of 4 is not on anticoagulation. What is the most appropriate anticoagulant?

Clopidogrel and aspirin
Warfarin with INR target 2-3
Direct oral anticoagulant (e.g., rivaroxaban) (Correct answer)
Aspirin 81 mg daily

Correct answer: Direct oral anticoagulant (e.g., rivaroxaban)

Direct oral anticoagulants (DOACs) such as rivaroxaban, apixaban, or dabigatran are now preferred over warfarin for stroke prevention in non-valvular atrial fibrillation due to their predictable pharmacokinetics and lower intracranial bleeding risk.

Question 117: A 45-year-old female presents with a thyroid nodule. Fine needle aspiration cytology (FNAC) shows Bethesda category V (suspicious for malignancy). What is the recommended management?

Observation with serial ultrasound
Radioactive iodine therapy
Repeat FNAC in 6 months
Lobectomy or total thyroidectomy (Correct answer)

Correct answer: Lobectomy or total thyroidectomy

Bethesda category V carries a malignancy risk of 60-75%. Surgery (lobectomy for diagnostic purposes or total thyroidectomy) is recommended. The extent of surgery depends on risk factors, nodule size, and patient preference.

Question 118: A patient develops methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. What is the drug of choice?

Vancomycin (Correct answer)
Ciprofloxacin
Flucloxacillin
Amoxicillin-clavulanate

Correct answer: Vancomycin

Vancomycin is the gold standard treatment for MRSA bacteraemia. It acts by inhibiting cell wall synthesis by binding to D-Ala-D-Ala terminus of peptidoglycan precursors. Trough levels should be monitored (15-20 μg/mL for serious infections). Daptomycin is an alternative.

Question 119: Which class of drugs is used for the acute management of anaphylaxis?

Adrenaline (epinephrine) (Correct answer)
Bronchodilators
Corticosteroids
Antihistamines (H1 blockers)

Correct answer: Adrenaline (epinephrine)

Adrenaline (epinephrine) IM injection (0.5 mg for adults, anterolateral thigh) is the first-line and most critical drug in anaphylaxis management. It acts on alpha-1 (vasoconstriction), beta-1 (chronotropy/inotropy), and beta-2 (bronchodilation) receptors. Delay in administration increases mortality.

Question 120: A 4-month-old infant is found to have developmental hip dysplasia on screening. What is the most appropriate initial treatment?

Open surgical reduction
Closed reduction under general anaesthesia
Spica cast
Pavlik harness (Correct answer)

Correct answer: Pavlik harness

For infants under 6 months with developmental dysplasia of the hip (DDH), the Pavlik harness is the first-line treatment. It maintains the hip in flexion and abduction, promoting concentric reduction and acetabular development. Success rate is approximately 90% when started early.

Question 121: A 2-year-old child presents with recurrent respiratory infections, steatorrhoea, and failure to thrive. A sweat chloride test result is 75 mmol/L. What is the diagnosis?

Cystic fibrosis (Correct answer)
Coeliac disease
Primary ciliary dyskinesia
Immunoglobulin deficiency

Correct answer: Cystic fibrosis

Cystic fibrosis is diagnosed by a sweat chloride concentration ≥60 mmol/L (a result of 75 is diagnostic). The triad of recurrent respiratory infections, malabsorption (steatorrhoea), and failure to thrive is the classic presentation in young children.

Question 122: A pregnant woman at 32 weeks gestation is diagnosed with preterm premature rupture of membranes (PPROM). There are no signs of infection or fetal distress. What is the management?

Induction of labour
Expectant management with antibiotics and corticosteroids (Correct answer)
Immediate delivery by caesarean section
Tocolytics indefinitely

Correct answer: Expectant management with antibiotics and corticosteroids

PPROM at 32 weeks without signs of infection, fetal distress, or placental abruption is managed expectantly. Antibiotics (to prolong latency and reduce infection) and corticosteroids (for fetal lung maturity) are administered while monitoring for complications.

Question 123: A patient undergoes thyroidectomy and develops numbness around the mouth and carpopedal spasm 24 hours postoperatively. What is the most likely cause?

Recurrent laryngeal nerve injury
Wound haematoma
Thyroid storm
Hypocalcaemia from parathyroid damage (Correct answer)

Correct answer: Hypocalcaemia from parathyroid damage

Post-thyroidectomy hypocalcaemia due to inadvertent parathyroid gland damage or devascularisation is a well-known complication. Perioral numbness, Chvostek sign, Trousseau sign, and carpopedal spasm are classic manifestations.

Question 124: A 20-year-old woman presents with hirsutism, acne, oligomenorrhoea, and a BMI of 32. Ultrasound shows polycystic ovaries. What is the first-line management for menstrual irregularity?

Metformin
Combined oral contraceptive pill (Correct answer)
Clomiphene citrate
Spironolactone

Correct answer: Combined oral contraceptive pill

Combined oral contraceptive pills (COCPs) are first-line for managing menstrual irregularity and hyperandrogenism (hirsutism, acne) in PCOS when fertility is not desired. They regulate cycles, reduce androgens, and protect the endometrium from hyperplasia.

Question 125: A 45-year-old man is brought by his family after being found talking to himself, dishevelled, and wandering in the street. He is oriented to person but not to time or place. He has a history of heavy alcohol use and stopped drinking 3 days ago. He has visual hallucinations of insects. What is the most likely diagnosis?

Schizophrenia
Alcoholic hallucinosis
Delirium tremens (Correct answer)
Korsakoff syndrome

Correct answer: Delirium tremens

Delirium tremens is a severe form of alcohol withdrawal occurring 48-96 hours after last drink. It presents with confusion, agitation, visual hallucinations, autonomic hyperactivity (tachycardia, hypertension, fever), and seizures. It has a mortality of 5-15% if untreated.

Question 126: A 55-year-old female presents with a 4 cm mass in the right lobe of the liver. AFP is markedly elevated. She has a history of hepatitis B cirrhosis. What is the most likely diagnosis?

Hepatocellular carcinoma (Correct answer)
Haemangioma
Metastatic colorectal cancer
Focal nodular hyperplasia

Correct answer: Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and frequently develops in the setting of hepatitis B cirrhosis. Markedly elevated AFP (>400 ng/mL) in a cirrhotic patient with a liver mass is highly suggestive of HCC.

Question 127: A 30-year-old male presents with a painless testicular mass. Ultrasound confirms a solid intratesticular lesion. What is the next step?

Trans-scrotal orchidectomy
Testicular biopsy
CT abdomen and pelvis first
Radical inguinal orchidectomy (Correct answer)

Correct answer: Radical inguinal orchidectomy

A solid intratesticular mass in a young male is testicular cancer until proven otherwise. Radical inguinal orchidectomy (not trans-scrotal to avoid scrotal contamination) is both diagnostic and therapeutic. Tumour markers (AFP, beta-hCG, LDH) should be drawn preoperatively.

Question 128: A 60-year-old male presents with a pulsatile, expansile abdominal mass. CT angiography shows an infrarenal abdominal aortic aneurysm measuring 6.5 cm. What is the recommended management?

Blood pressure control and observation
Annual surveillance with ultrasound
Emergency surgery only if symptomatic
Elective surgical repair (open or EVAR) (Correct answer)

Correct answer: Elective surgical repair (open or EVAR)

An abdominal aortic aneurysm ≥5.5 cm carries a significant annual rupture risk and is an indication for elective repair, either open surgical repair or endovascular aneurysm repair (EVAR), depending on anatomy and patient fitness.

Question 129: A woman at 38 weeks gestation presents in labour. On vaginal examination, the umbilical cord is palpated below the presenting part. CTG shows variable decelerations. What is the immediate management?

Emergency caesarean section with cord elevation (Correct answer)
Expectant management
Apply forceps delivery
Augment labour with oxytocin

Correct answer: Emergency caesarean section with cord elevation

Cord prolapse is an obstetric emergency. Immediate management includes elevating the presenting part manually to relieve cord compression, filling the bladder to elevate the fetal head, and emergency caesarean section. The patient should be placed in knee-chest or Trendelenburg position.

Question 130: A patient develops deep vein thrombosis (DVT) on postoperative day 5 after a total hip replacement. According to Virchow's triad, which factor is most directly related to this patient's risk?

Dehydration from fasting
Endothelial injury from surgery
Hypercoagulability from factor V Leiden
Venous stasis from immobilisation (Correct answer)

Correct answer: Venous stasis from immobilisation

While all three components of Virchow's triad (stasis, endothelial injury, hypercoagulability) contribute, venous stasis from postoperative immobilisation is the most significant modifiable risk factor in this setting. Early mobilisation and pharmacological prophylaxis are essential.

Question 131: A patient with type 1 diabetes on insulin develops postprandial hyperglycaemia and fasting hypoglycaemia. The insulin regimen uses NPH and regular insulin. What adjustment is most appropriate?

Discontinue all insulin and start oral agents
Add metformin
Switch to basal-bolus regimen with long-acting and rapid-acting analogues (Correct answer)
Increase NPH dose

Correct answer: Switch to basal-bolus regimen with long-acting and rapid-acting analogues

Switching to a basal-bolus regimen using long-acting insulin (glargine/detemir) and rapid-acting analogues (lispro/aspart) provides more physiological insulin coverage, reducing fasting hypoglycaemia and improving postprandial control.

Question 132: A 25-year-old woman presents with primary amenorrhoea, absent breast development, and a karyotype of 46,XY. Ultrasound shows absent uterus and testes in the inguinal canals. What is the most likely diagnosis?

Turner syndrome
Müllerian agenesis (MRKH syndrome)
Complete androgen insensitivity syndrome (Correct answer)
5-alpha reductase deficiency

Correct answer: Complete androgen insensitivity syndrome

Complete androgen insensitivity syndrome (CAIS) presents in 46,XY individuals as phenotypically female with primary amenorrhoea, absent breast development or breast development without pubic hair, absent uterus, and inguinal/abdominal testes due to complete resistance to androgens.

Question 133: A 55-year-old smoker presents with weight loss, haemoptysis, and a hilar mass on chest X-ray. Serum calcium is elevated. Which lung cancer type is most likely?

Squamous cell carcinoma (Correct answer)
Small cell carcinoma
Large cell carcinoma
Adenocarcinoma

Correct answer: Squamous cell carcinoma

Squamous cell carcinoma of the lung is strongly associated with smoking, central/hilar location, and hypercalcaemia due to PTHrP (parathyroid hormone-related peptide) secretion, a paraneoplastic syndrome.

Question 134: A pregnant woman at 12 weeks gestation undergoes first-trimester screening. Nuchal translucency is 4.5 mm. What is the most appropriate next step?

Chorionic villus sampling (CVS) or cell-free fetal DNA testing (Correct answer)
Reassure and repeat ultrasound in 4 weeks
Amniocentesis at 16 weeks
No further action needed

Correct answer: Chorionic villus sampling (CVS) or cell-free fetal DNA testing

An increased nuchal translucency (≥3.5 mm) is associated with chromosomal abnormalities (particularly trisomy 21), cardiac defects, and other structural anomalies. The next step is either non-invasive prenatal testing (cfDNA) or invasive testing (CVS at this gestation) for definitive diagnosis.

Question 135: What is the drug of choice for prevention and treatment of eclamptic seizures?

Phenytoin
Labetalol
Magnesium sulphate (Correct answer)
Diazepam

Correct answer: Magnesium sulphate

Magnesium sulphate is the gold standard for prevention and treatment of eclamptic seizures, as demonstrated by the Magpie Trial and BEAM Trial. It is superior to diazepam and phenytoin in both preventing recurrent seizures and improving maternal and neonatal outcomes.

Question 136: A 58-year-old patient with long-standing uncontrolled diabetes presents with decreased sensation in a glove-and-stocking distribution. Nerve conduction studies show axonal neuropathy. What type of neuropathy is this?

Autonomic neuropathy
Distal symmetric polyneuropathy (Correct answer)
Cranial neuropathy
Mononeuropathy

Correct answer: Distal symmetric polyneuropathy

Distal symmetric polyneuropathy is the most common form of diabetic neuropathy, presenting with sensory loss in a glove-and-stocking pattern. It is length-dependent, affecting the longest nerves first.

Question 137: A 22-year-old woman presents with lower abdominal pain, fever, purulent vaginal discharge, and cervical motion tenderness. What is the most likely diagnosis?

Endometriosis
Appendicitis
Pelvic inflammatory disease (PID) (Correct answer)
Ovarian torsion

Correct answer: Pelvic inflammatory disease (PID)

The triad of lower abdominal pain, fever, and cervical motion tenderness (chandelier sign) is classic for pelvic inflammatory disease. PID is usually caused by ascending infection from Neisseria gonorrhoeae or Chlamydia trachomatis.

Question 138: A 32-year-old woman has a pervasive pattern of instability in interpersonal relationships, marked impulsivity, recurrent self-harm, chronic feelings of emptiness, and frantic efforts to avoid abandonment. What personality disorder is most likely?

Borderline personality disorder (Correct answer)
Dependent personality disorder
Histrionic personality disorder
Narcissistic personality disorder

Correct answer: Borderline personality disorder

Borderline personality disorder (BPD) is characterised by instability in relationships, self-image, and affects, marked impulsivity, self-harm, chronic emptiness, and desperate avoidance of abandonment. Dialectical behaviour therapy (DBT) is the evidence-based treatment.

Question 139: In a case-control study investigating the association between a risk factor and a disease, which measure of association is typically calculated?

Attributable risk
Relative risk
Odds ratio (Correct answer)
Population attributable risk percent

Correct answer: Odds ratio

Odds ratio is used in case-control studies because incidence data is not directly available; it approximates relative risk when disease prevalence is low.

Question 140: A 35-year-old male presents with a non-healing ulcer on the sole of the foot. He has loss of pain sensation and a warm, well-perfused foot. What is the most likely underlying condition?

Peripheral arterial disease
Venous ulcer
Squamous cell carcinoma
Diabetic neuropathic ulcer (Correct answer)

Correct answer: Diabetic neuropathic ulcer

A non-healing plantar ulcer with loss of pain sensation in a warm, well-perfused foot is characteristic of a neuropathic ulcer, most commonly caused by diabetic peripheral neuropathy. The preserved pulses and warmth distinguish it from arterial ulcers.

Question 141: A patient with a history of peptic ulcer disease presents with massive haematemesis. After initial resuscitation, what is the most appropriate definitive investigation?

Barium swallow
CT angiography
Mesenteric angiography
Upper GI endoscopy (OGD) (Correct answer)

Correct answer: Upper GI endoscopy (OGD)

Upper GI endoscopy (oesophagogastroduodenoscopy) is both diagnostic and therapeutic for upper GI bleeding. It allows identification of the bleeding source and endoscopic haemostasis using clips, thermal coagulation, or injection therapy.

Question 142: What is the first-line medication for obsessive-compulsive disorder (OCD)?

SSRIs at high doses (Correct answer)
Benzodiazepines
Lithium
Typical antipsychotics

Correct answer: SSRIs at high doses

SSRIs at higher doses than used for depression (e.g., fluoxetine 40-80 mg, fluvoxamine 200-300 mg) are first-line pharmacotherapy for OCD. Clomipramine (a tricyclic with strong serotonergic activity) is an alternative. CBT with exposure and response prevention is the first-line psychological treatment.

Question 143: A 55-year-old man with chronic alcoholism is found confused with confabulation, anterograde amnesia, and ataxia. Thiamine was not administered during his recent hospital admission. What is the diagnosis?

Hepatic encephalopathy
Wernicke encephalopathy
Korsakoff syndrome (Correct answer)
Alcohol withdrawal delirium

Correct answer: Korsakoff syndrome

Korsakoff syndrome is characterised by severe anterograde amnesia and confabulation (fabrication of memories to fill gaps) following Wernicke encephalopathy due to thiamine (B1) deficiency. It represents the chronic, irreversible phase of Wernicke-Korsakoff syndrome.

Question 144: Which of the following is the most common electrolyte abnormality in a patient with diabetic ketoacidosis (DKA)?

Hypermagnesaemia
Hypernatraemia
Hypercalcaemia
Total body potassium depletion (Correct answer)

Correct answer: Total body potassium depletion

Despite sometimes presenting with normal or elevated serum potassium (due to transcellular shift from acidosis and insulin deficiency), patients with DKA have significant total body potassium depletion from osmotic diuresis and vomiting.

Question 145: A patient attempts suicide by hanging and is found unconscious. After medical stabilisation, what is the most important aspect of the initial psychiatric assessment?

Obtaining a brain CT scan
Comprehensive suicide risk assessment including intent, plan, and protective factors (Correct answer)
Discharging to outpatient care with follow-up
Prescribing antidepressant medication immediately

Correct answer: Comprehensive suicide risk assessment including intent, plan, and protective factors

After medical stabilisation of a serious suicide attempt, a comprehensive suicide risk assessment is essential. This includes evaluating ongoing suicidal intent, presence of a plan, access to means, psychiatric diagnosis, substance use, social supports, and protective factors to guide the level of care.

Question 146: Which of the following epidemiological study designs provides the HIGHEST level of evidence for evaluating therapeutic interventions?

Randomized controlled trial (Correct answer)
Cross-sectional study
Prospective cohort study
Case-control study

Correct answer: Randomized controlled trial

Randomized controlled trials are the gold standard because randomization controls for both known and unknown confounders, minimizing bias.

Question 147: Which antibiotic class is associated with tendon rupture, particularly the Achilles tendon, especially in elderly patients?

Penicillins
Macrolides
Fluoroquinolones (Correct answer)
Cephalosporins

Correct answer: Fluoroquinolones

Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin) are associated with tendinopathy and tendon rupture, particularly the Achilles tendon. Risk is increased in patients over 60, those on corticosteroids, and organ transplant recipients.

Question 148: A healthcare worker in Saudi Arabia suspects child abuse. According to Saudi child protection law, what is the appropriate action?

Refer to social services only if evidence is clear
Document findings and wait for another episode
Report to the child protection authority (mandatory reporting) (Correct answer)
Discuss with the family first

Correct answer: Report to the child protection authority (mandatory reporting)

Under Saudi child protection law and SCFHS professional standards, healthcare workers are mandated reporters of suspected child abuse. Reporting to the child protection authority is mandatory, regardless of certainty. Failure to report can result in legal consequences.

Question 149: What is the recommended screening test for gestational diabetes mellitus (GDM) according to SCFHS and Saudi guidelines?

Random blood glucose at booking
HbA1c at 24-28 weeks gestation
75g OGTT at 24-28 weeks gestation (Correct answer)
Fasting glucose at 12 weeks gestation

Correct answer: 75g OGTT at 24-28 weeks gestation

The 75g oral glucose tolerance test (OGTT) at 24-28 weeks gestation is the recommended screening test for GDM per Saudi national guidelines, aligned with IADPSG criteria. High-risk women may be screened earlier at the booking visit.

Question 150: A 45-year-old woman presents with irregular heavy periods, hot flushes, and night sweats. FSH is elevated and oestradiol is low. What stage of reproductive life is she in?

Hypothalamic amenorrhoea
Menopause
Premature ovarian insufficiency
Perimenopause (Correct answer)

Correct answer: Perimenopause

Perimenopause (menopausal transition) is characterised by irregular menstrual cycles, vasomotor symptoms (hot flushes, night sweats), and hormonal changes (rising FSH, declining oestradiol). Menopause is diagnosed retrospectively after 12 months of amenorrhoea.

Question 151: A 10-month-old infant presents with fever, irritability, and a bulging anterior fontanelle. CSF analysis shows elevated WBCs with neutrophil predominance, low glucose, and elevated protein. What is the most likely causative organism?

Group B Streptococcus
Haemophilus influenzae type b
Neisseria meningitidis
Streptococcus pneumoniae (Correct answer)

Correct answer: Streptococcus pneumoniae

In infants aged 1-23 months, Streptococcus pneumoniae is the most common cause of bacterial meningitis, followed by Neisseria meningitidis and group B Streptococcus. The Hib vaccine has dramatically reduced H. influenzae meningitis.

Question 152: A patient on warfarin therapy has an INR of 8.5 with no active bleeding. What is the most appropriate management?

Give fresh frozen plasma immediately
Administer prothrombin complex concentrate
Hold warfarin and administer oral vitamin K (Correct answer)
Continue warfarin at the same dose

Correct answer: Hold warfarin and administer oral vitamin K

For supratherapeutic INR (>4.5-10) without active bleeding, the recommendation is to hold warfarin and administer low-dose oral vitamin K (1-2.5 mg). FFP and PCC are reserved for active bleeding or INR >10 with high bleeding risk.

Question 153: A patient being treated with clozapine develops fever, sore throat, and a WBC count of 1,500/μL with an absolute neutrophil count of 400/μL. What is the immediate action?

Discontinue clozapine immediately and isolate the patient (Correct answer)
Add granulocyte colony-stimulating factor and continue clozapine
Reduce the clozapine dose by half
Continue clozapine and add antibiotics

Correct answer: Discontinue clozapine immediately and isolate the patient

Clozapine can cause agranulocytosis (ANC <500/μL), a potentially fatal adverse effect. Clozapine must be immediately discontinued, the patient isolated due to infection risk, blood cultures obtained, and broad-spectrum antibiotics started. G-CSF may be given as adjunct.

Question 154: A family physician counsels a healthy 30-year-old patient to begin regular aerobic exercise to reduce his future risk of cardiovascular disease. This is an example of which level of prevention?

Tertiary prevention
Primordial prevention
Primary prevention (Correct answer)
Secondary prevention

Correct answer: Primary prevention

Primary prevention reduces risk factors in individuals who are currently healthy but at risk; counseling to exercise prevents the development of disease risk factors.

Question 155: A 45-year-old patient presents with progressive exertional dyspnoea, bilateral basal crackles, and an S3 gallop. Echocardiogram shows an ejection fraction of 30%. What is the initial pharmacological management?

ACE inhibitor and beta-blocker (Correct answer)
Digoxin and diuretics only
Calcium channel blocker
Amiodarone

Correct answer: ACE inhibitor and beta-blocker

For heart failure with reduced ejection fraction (HFrEF), first-line pharmacological therapy includes ACE inhibitors (or ARBs) and beta-blockers, which reduce mortality. These should be initiated together with diuretics for symptom relief.

Question 156: What is the most common type of ovarian cyst in women of reproductive age?

Dermoid cyst (mature teratoma)
Functional (follicular) cyst (Correct answer)
Serous cystadenoma
Endometrioma

Correct answer: Functional (follicular) cyst

Functional (follicular) cysts are the most common ovarian cysts in reproductive-age women. They result from failure of a dominant follicle to rupture or regress. Most resolve spontaneously within 2-3 menstrual cycles without intervention.

Question 157: What is the recommended duration of antidepressant treatment after a first episode of major depressive disorder in remission?

6-12 months after remission (Correct answer)
4-6 months after remission
Lifelong treatment
Stop immediately after symptom resolution

Correct answer: 6-12 months after remission

After a first episode of MDD, antidepressant treatment should be continued for 6-12 months after achieving remission (continuation phase) to prevent relapse. The same effective dose should be maintained during this period. Lifelong treatment is considered after 3+ episodes.

Question 158: A patient with heart failure is prescribed digoxin. Which electrolyte abnormality increases the risk of digoxin toxicity?

Hypernatraemia
Hypercalcaemia
Hypokalaemia (Correct answer)
Hyperkalaemia

Correct answer: Hypokalaemia

Hypokalaemia increases the risk of digoxin toxicity because digoxin and potassium compete for binding at the Na+/K+ ATPase pump. Low potassium levels increase digoxin binding, enhancing its toxic effects including cardiac arrhythmias.

Question 159: A patient with rheumatoid arthritis on methotrexate develops pancytopenia. What supplement should have been co-prescribed to prevent this complication?

Iron
Vitamin B12
Calcium
Folic acid (Correct answer)

Correct answer: Folic acid

Folic acid supplementation (5 mg weekly, taken on a different day from methotrexate) reduces the incidence of methotrexate side effects including pancytopenia, stomatitis, and GI upset. Methotrexate inhibits dihydrofolate reductase, causing folate depletion.

Question 160: A 42-year-old woman with a BMI of 38 presents with right upper quadrant pain after a fatty meal, fever, and a positive Murphy sign. What is the most appropriate initial imaging?

Abdominal X-ray
Abdominal ultrasound (Correct answer)
CT abdomen with contrast
MRCP

Correct answer: Abdominal ultrasound

Abdominal ultrasound is the first-line imaging for suspected acute cholecystitis. It can demonstrate gallstones, gallbladder wall thickening, pericholecystic fluid, and a sonographic Murphy sign with high sensitivity and specificity.

Question 161: A diabetic mother delivers a macrosomic baby. During delivery, the fetal head delivers but the shoulders do not. What is this obstetric emergency called?

Breech presentation
Shoulder dystocia (Correct answer)
Brow presentation
Cord prolapse

Correct answer: Shoulder dystocia

Shoulder dystocia occurs when the fetal shoulders become impacted behind the maternal symphysis pubis after delivery of the head. It is more common with fetal macrosomia and maternal diabetes. The McRoberts manoeuvre is the first-line intervention.

Question 162: A patient with liver cirrhosis presents with confusion, asterixis, and elevated serum ammonia. What is the first-line treatment?

Liver transplantation
Lactulose (Correct answer)
Flumazenil
Neomycin

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 163: Which medication used in type 2 diabetes is associated with weight loss and reduced cardiovascular events?

Insulin glargine
Pioglitazone (thiazolidinedione)
Liraglutide (GLP-1 receptor agonist) (Correct answer)
Glipizide (sulfonylurea)

Correct answer: Liraglutide (GLP-1 receptor agonist)

GLP-1 receptor agonists (liraglutide, semaglutide) promote weight loss through central appetite suppression, slow gastric emptying, and improve glycaemic control. The LEADER trial demonstrated cardiovascular mortality benefit with liraglutide in type 2 diabetes patients with CVD.

Question 164: A 28-year-old woman presents with a painful, fluctuant swelling near the anus at the 5 o'clock position. What is the most appropriate management?

Fistulotomy
Oral antibiotics and sitz baths
Incision and drainage (Correct answer)
MRI pelvis

Correct answer: Incision and drainage

A fluctuant, painful perianal swelling is a perianal abscess requiring incision and drainage under local or general anaesthesia. Antibiotics alone are insufficient as the pus needs to be drained. Follow-up is needed to watch for fistula formation.

Question 165: A neonate born at 32 weeks gestation develops respiratory distress within minutes of birth. Chest X-ray shows ground-glass opacification with air bronchograms. What is the most likely diagnosis?

Transient tachypnoea of the newborn
Respiratory distress syndrome (hyaline membrane disease) (Correct answer)
Congenital pneumonia
Meconium aspiration syndrome

Correct answer: Respiratory distress syndrome (hyaline membrane disease)

Respiratory distress syndrome (RDS) occurs in premature infants due to surfactant deficiency. The typical chest X-ray shows bilateral ground-glass opacification with air bronchograms. Treatment includes surfactant replacement and supportive ventilation.

Question 166: A patient presents after ingesting a large number of paracetamol tablets 4 hours ago. He is asymptomatic. What is the most important immediate management step?

Wait for symptoms to develop
Check serum paracetamol level and plot on treatment nomogram (Correct answer)
Administer activated charcoal
Start N-acetylcysteine empirically

Correct answer: Check serum paracetamol level and plot on treatment nomogram

At 4 hours post-ingestion, a serum paracetamol level should be checked and plotted on the Rumack-Matthew nomogram to determine if N-acetylcysteine (NAC) treatment is indicated. Patients may be asymptomatic initially despite potentially hepatotoxic levels.

Question 167: According to the Saudi national immunisation schedule, at what age should the first dose of measles-mumps-rubella (MMR) vaccine be administered?

6 months
9 months
12 months (Correct answer)
18 months

Correct answer: 12 months

Per the Saudi Ministry of Health national immunisation schedule and SCFHS guidelines, the first dose of MMR vaccine is administered at 12 months of age, with a second dose at 18 months.

Question 168: A 30-year-old male presents with colicky loin-to-groin pain and haematuria. Non-contrast CT shows a 4 mm stone in the distal ureter. What is the initial management?

Extracorporeal shock wave lithotripsy
Conservative management with analgesia and hydration (Correct answer)
Percutaneous nephrostomy
Urgent surgical intervention

Correct answer: Conservative management with analgesia and hydration

Ureteric stones less than 5 mm have a high spontaneous passage rate (>90%). Initial management includes adequate analgesia (NSAIDs first-line), hydration, and medical expulsive therapy with an alpha-blocker such as tamsulosin.

Question 169: An infant presents with 'red currant jelly' stools, colicky abdominal pain, and a sausage-shaped mass in the right upper quadrant. What is the initial diagnostic and therapeutic procedure?

Immediate surgery
Abdominal ultrasound only
Air-contrast enema (pneumatic reduction) (Correct answer)
Barium enema

Correct answer: Air-contrast enema (pneumatic reduction)

Intussusception (most commonly ileocolic) is initially managed with air-contrast enema (pneumatic reduction), which is both diagnostic and therapeutic. Ultrasound (showing target/doughnut sign) confirms the diagnosis, and air enema achieves reduction in approximately 80% of cases.

Question 170: A 70-year-old man presents with progressive memory loss, difficulty with familiar tasks, word-finding difficulty, and getting lost in his own neighbourhood over the past year. MMSE score is 18/30. What is the most likely diagnosis?

Vascular dementia
Normal ageing
Alzheimer disease (Correct answer)
Delirium

Correct answer: Alzheimer disease

Alzheimer disease is the most common cause of dementia, characterised by insidious onset and progressive decline in memory (especially short-term), language, visuospatial skills, and executive function. MMSE <24 suggests cognitive impairment.

Question 171: Which drug is the first-line treatment for status epilepticus?

Sodium valproate IV
Phenobarbital IV
Phenytoin IV
Diazepam or lorazepam IV (Correct answer)

Correct answer: Diazepam or lorazepam IV

IV benzodiazepines (lorazepam preferred, diazepam alternative) are first-line for acute status epilepticus. Lorazepam (0.1 mg/kg IV) has a longer duration of action in the CNS than diazepam. If benzodiazepines fail, second-line agents include phenytoin/fosphenytoin, valproate, or levetiracetam.

Question 172: What is the most common cause of postpartum haemorrhage?

Genital tract trauma
Uterine atony (Correct answer)
Retained placenta
Coagulation disorders

Correct answer: Uterine atony

Uterine atony (failure of the uterus to contract adequately after delivery) accounts for approximately 70-80% of all cases of postpartum haemorrhage. Risk factors include overdistended uterus, prolonged labour, grand multiparity, and uterine relaxants.

Question 173: Which study design is MOST appropriate to estimate the prevalence of childhood obesity among school-age children in Saudi Arabia?

Longitudinal cohort study
Case-control study
Randomized controlled trial
Cross-sectional survey (Correct answer)

Correct answer: Cross-sectional survey

A cross-sectional survey measures the proportion of a population with a condition at a single point in time, making it the ideal design for estimating disease prevalence.

Question 174: A child swallows a coin. X-ray shows the coin in the oesophagus at the level of the cricopharyngeus. The child is drooling but not in respiratory distress. What is the management?

Barium swallow
Endoscopic removal within 24 hours (Correct answer)
Heimlich manoeuvre
Observation for 24 hours and repeat X-ray

Correct answer: Endoscopic removal within 24 hours

An oesophageal foreign body with symptoms (drooling indicates inability to handle secretions) requires endoscopic removal within 24 hours to prevent complications such as perforation, mucosal necrosis, or airway compromise.

Question 175: A 32-year-old woman at 28 weeks gestation presents with painless vaginal bleeding. Ultrasound shows the placenta completely covering the internal cervical os. What is the diagnosis?

Cervical ectropion
Placenta praevia (major/complete) (Correct answer)
Vasa praevia
Placental abruption

Correct answer: Placenta praevia (major/complete)

Placenta praevia (major/complete) is diagnosed when the placenta completely covers the internal cervical os. It presents with painless, bright red vaginal bleeding in the third trimester. Digital vaginal examination is contraindicated.

Question 176: Which of the following features distinguishes delirium from dementia?

Fluctuating consciousness with acute onset (Correct answer)
Progressive memory decline over years
Gradual onset and chronic course
Preserved attention and orientation

Correct answer: Fluctuating consciousness with acute onset

Delirium is characterised by acute onset, fluctuating consciousness, impaired attention, and often a identifiable precipitant (infection, medication). Dementia has a gradual onset, progressive course, and preserved consciousness until late stages. Delirium is potentially reversible.

Question 177: Which class of antihypertensive drugs is teratogenic and absolutely contraindicated in pregnancy?

Methyldopa
Calcium channel blockers
Labetalol
ACE inhibitors and ARBs (Correct answer)

Correct answer: ACE inhibitors and ARBs

ACE inhibitors and ARBs are teratogenic, particularly in the second and third trimesters, causing renal agenesis, oligohydramnios, pulmonary hypoplasia, and fetal death. They are absolutely contraindicated throughout pregnancy. Methyldopa and labetalol are safe alternatives.

Question 178: A 2-year-old child presents with high fever for 5 days, bilateral non-exudative conjunctivitis, strawberry tongue, cervical lymphadenopathy, and a polymorphous rash. What is the most important treatment to prevent complications?

Corticosteroids alone
Antipyretics and observation
Oral antibiotics
IV immunoglobulin (IVIG) and aspirin (Correct answer)

Correct answer: IV immunoglobulin (IVIG) and aspirin

Kawasaki disease requires treatment with IV immunoglobulin (2 g/kg single infusion) and high-dose aspirin to reduce the risk of coronary artery aneurysms. Treatment should be initiated within 10 days of fever onset for maximum benefit.

Question 179: A 6-year-old child presents with polydipsia, polyuria, weight loss, and a blood glucose of 22 mmol/L. Blood pH is 7.15 and ketones are strongly positive. What is the immediate priority in management?

Subcutaneous insulin injection
Oral rehydration therapy
IV insulin bolus
IV fluid resuscitation with normal saline (Correct answer)

Correct answer: IV fluid resuscitation with normal saline

In paediatric diabetic ketoacidosis, the immediate priority is IV fluid resuscitation with 0.9% normal saline to correct dehydration and restore circulation. IV insulin infusion (NOT bolus) is started after the first hour of fluid resuscitation to avoid cerebral oedema.

Question 180: A woman undergoes cervical screening. HPV testing is positive for high-risk HPV types 16 and 18, but cytology is normal. What is the recommended follow-up?

No follow-up needed
Hysterectomy
Immediate colposcopy (Correct answer)
Repeat co-testing in 12 months

Correct answer: Immediate colposcopy

HPV 16 and 18 are the highest-risk types for cervical cancer. Even with normal cytology, guidelines recommend direct referral to colposcopy for HPV 16/18 positive results due to their high oncogenic potential.

Question 181: A pregnant woman requires treatment for a urinary tract infection. Which antibiotic is considered safest in the first trimester?

Ciprofloxacin
Amoxicillin (Correct answer)
Trimethoprim
Tetracycline

Correct answer: Amoxicillin

Amoxicillin (category B) is one of the safest antibiotics during pregnancy, including the first trimester. Fluoroquinolones are contraindicated (cartilage damage), tetracyclines (teeth discolouration, bone effects), and trimethoprim is avoided in the first trimester (folate antagonist, neural tube defect risk).

Question 182: A 10-year-old boy has difficulty sustaining attention, is easily distracted, fidgets constantly, talks excessively, and has difficulty waiting his turn. Symptoms have been present since age 5 and affect school and home. What is the most likely diagnosis?

Conduct disorder
Attention deficit hyperactivity disorder (ADHD), combined type (Correct answer)
Autism spectrum disorder
Oppositional defiant disorder

Correct answer: Attention deficit hyperactivity disorder (ADHD), combined type

ADHD combined type is diagnosed when criteria for both inattention and hyperactivity-impulsivity are met for ≥6 months, with onset before age 12, and symptoms present in ≥2 settings (school and home). This child meets all criteria.

Question 183: Which drug is used as a first-line disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis?

Methotrexate (Correct answer)
Hydroxychloroquine
Prednisolone
Infliximab

Correct answer: Methotrexate

Methotrexate is the anchor DMARD and first-line treatment for rheumatoid arthritis. It works by inhibiting dihydrofolate reductase and has immunomodulatory effects. It is given weekly (not daily) with folic acid supplementation. Monitoring includes FBC, LFTs, and renal function.

Question 184: A 35-year-old woman experiences recurrent, unexpected panic attacks with palpitations, shortness of breath, chest pain, and fear of dying. She now avoids crowded places. What is the most accurate diagnosis?

Generalised anxiety disorder
Specific phobia
Social anxiety disorder
Panic disorder with agoraphobia (Correct answer)

Correct answer: Panic disorder with agoraphobia

Panic disorder is characterised by recurrent unexpected panic attacks with persistent concern about future attacks. When the patient develops avoidance of situations where escape might be difficult (crowded places), agoraphobia is diagnosed as a comorbid condition.

Question 185: A woman at 41 weeks gestation presents for routine assessment. Non-stress test shows a reactive pattern. What does this indicate?

Need for contraction stress test
Fetal compromise requiring immediate delivery
Fetal anaemia
Normal fetal well-being (Correct answer)

Correct answer: Normal fetal well-being

A reactive non-stress test (NST) shows ≥2 accelerations of ≥15 bpm above baseline lasting ≥15 seconds within a 20-minute period, indicating normal fetal autonomic function and well-being. This is reassuring.

Question 186: A diagnostic test is reported to have a sensitivity of 90%. This means that:

90% of healthy individuals will test negative
90% of individuals with the disease will test positive (Correct answer)
90% of people with a positive result truly have the disease
10% of healthy individuals will test positive

Correct answer: 90% of individuals with the disease will test positive

Sensitivity (true positive rate) is the proportion of truly diseased individuals correctly identified by the test; 90% sensitivity means 90% of sick people test positive.

Question 187: A breastfed infant develops prolonged jaundice beyond 14 days of life. The infant is well, gaining weight, and passing normal stools. Total bilirubin is 200 μmol/L (unconjugated). What is the most likely cause?

G6PD deficiency
Hypothyroidism
Biliary atresia
Breast milk jaundice (Correct answer)

Correct answer: Breast milk jaundice

Breast milk jaundice is a common cause of prolonged unconjugated hyperbilirubinaemia in well, thriving breastfed infants. It is benign and self-limiting, typically resolving by 12 weeks. Importantly, conjugated hyperbilirubinaemia must be excluded to rule out biliary atresia.

Question 188: A patient with epilepsy on carbamazepine develops Stevens-Johnson syndrome. Which HLA allele is associated with increased risk?

HLA-B*15:02 (Correct answer)
HLA-B*57:01
HLA-B*58:01
HLA-DQ2

Correct answer: HLA-B*15:02

HLA-B*15:02 is strongly associated with carbamazepine-induced Stevens-Johnson syndrome and toxic epidermal necrolysis, particularly in Southeast Asian populations. SCFHS guidelines recommend HLA testing before starting carbamazepine in at-risk populations.

Question 189: A patient on isoniazid for tuberculosis develops peripheral neuropathy. Which vitamin deficiency is responsible and what supplement prevents this?

Vitamin C (ascorbic acid)
Vitamin B6 (pyridoxine) (Correct answer)
Vitamin B12 (cyanocobalamin)
Vitamin B1 (thiamine)

Correct answer: Vitamin B6 (pyridoxine)

Isoniazid inhibits pyridoxal phosphokinase and competes with pyridoxal phosphate (active form of vitamin B6), leading to pyridoxine deficiency. This manifests as peripheral neuropathy. Prophylactic pyridoxine (10-25 mg/day) prevents this complication.

Question 190: A 28-year-old man presents with haemoptysis, haematuria, and bilateral pulmonary infiltrates. Anti-GBM antibodies are positive. What is the diagnosis?

Goodpasture syndrome (Correct answer)
Granulomatosis with polyangiitis
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 191: A 7-year-old child presents with a sore throat, fever, and a fine sandpaper-like rash that spares the face. There is circumoral pallor and a strawberry tongue. What is the diagnosis?

Kawasaki disease
Measles
Scarlet fever (Correct answer)
Rubella

Correct answer: Scarlet fever

Scarlet fever is caused by group A beta-haemolytic Streptococcus (GAS) producing erythrogenic toxin. The sandpaper rash, circumoral pallor, and strawberry tongue are classic features. Treatment with penicillin prevents rheumatic fever.

Question 192: A patient on heparin develops heparin-induced thrombocytopenia (HIT) type II. What is the most appropriate alternative anticoagulant?

Argatroban (direct thrombin inhibitor) (Correct answer)
Low molecular weight heparin
Aspirin
Warfarin immediately

Correct answer: Argatroban (direct thrombin inhibitor)

In HIT type II, all heparins (including LMWH due to cross-reactivity) must be stopped. A non-heparin anticoagulant such as argatroban (direct thrombin inhibitor) or fondaparinux should be initiated. Warfarin alone is contraindicated acutely as it can cause skin necrosis.

Question 193: Which of the following is the recommended screening test for colorectal cancer in an average-risk 50-year-old Saudi patient?

Barium enema
Carcinoembryonic antigen (CEA) level
Colonoscopy (Correct answer)
CT colonography

Correct answer: Colonoscopy

Colonoscopy is the gold standard screening test for colorectal cancer, recommended starting at age 50 in average-risk individuals per Saudi Cancer Society and SCFHS guidelines. It allows both detection and removal of precancerous polyps.

Question 194: A patient is prescribed gentamicin for a serious gram-negative infection. Which two adverse effects require monitoring?

Nephrotoxicity and ototoxicity (Correct answer)
Hepatotoxicity and cardiotoxicity
Pulmonary toxicity and dermatotoxicity
Neurotoxicity and haematotoxicity

Correct answer: Nephrotoxicity and ototoxicity

Aminoglycosides (gentamicin, tobramycin, amikacin) require monitoring for nephrotoxicity (elevated creatinine, reduced GFR) and ototoxicity (vestibular and cochlear damage causing dizziness and hearing loss). Trough and/or peak levels guide dosing to minimise toxicity.

Question 195: A screening test has a sensitivity of 85% and specificity of 90%. If the prevalence of the disease increases in the tested population, what happens to the positive predictive value (PPV)?

PPV remains unchanged
PPV becomes equal to sensitivity
PPV increases (Correct answer)
PPV decreases

Correct answer: PPV increases

As disease prevalence increases, the proportion of true positives among all positive tests rises, so PPV increases accordingly.

Question 196: A 35-year-old multiparous woman has an atonic uterus after delivery with estimated blood loss of 1,500 mL. Uterine massage and oxytocin have been administered. What is the next pharmacological step?

Methylergonovine (Methergine) (Correct answer)
Tranexamic acid
Factor VIIa
Repeat oxytocin only

Correct answer: Methylergonovine (Methergine)

After initial oxytocin and uterine massage fail to control postpartum haemorrhage from uterine atony, second-line uterotonics include methylergonovine (ergometrine), carboprost (15-methyl PGF2α), and misoprostol. Methylergonovine is contraindicated in hypertension.

Question 197: A patient with myasthenia gravis is given an aminoglycoside antibiotic and develops respiratory failure. What is the mechanism of this drug interaction?

Aminoglycosides block neuromuscular junction transmission (Correct answer)
Aminoglycosides cause direct muscle toxicity
Aminoglycosides increase acetylcholine release
Aminoglycosides deplete cholinesterase

Correct answer: Aminoglycosides block neuromuscular junction transmission

Aminoglycosides have neuromuscular blocking properties — they inhibit presynaptic acetylcholine release and block postsynaptic receptors. In myasthenia gravis patients (who already have reduced acetylcholine receptors due to autoantibodies), this can precipitate a myasthenic crisis with respiratory failure.

Question 198: Which of the following statistics is the BEST indicator of the overall quality of healthcare in a country?

Infant mortality rate (Correct answer)
Crude death rate
Total fertility rate
Crude birth rate

Correct answer: Infant mortality rate

Infant mortality rate is the most sensitive indicator of healthcare quality as it reflects nutrition, sanitation, maternal care, and the overall effectiveness of the health system.

Question 199: A patient on an SSRI starts taking tramadol and develops agitation, myoclonus, hyperreflexia, diaphoresis, and diarrhoea. What is the most likely diagnosis?

Anticholinergic toxicity
Neuroleptic malignant syndrome
Malignant hyperthermia
Serotonin syndrome (Correct answer)

Correct answer: Serotonin syndrome

Serotonin syndrome results from excessive serotonergic activity, often from combining serotonergic drugs (SSRI + tramadol). The triad includes altered mental status, autonomic instability, and neuromuscular hyperactivity (myoclonus, hyperreflexia). Treatment involves stopping offending agents and cyproheptadine.

Question 200: A 4-year-old child presents with a purpuric rash on the buttocks and lower extremities, abdominal pain, and joint swelling. Urinalysis shows haematuria and proteinuria. What is the most likely diagnosis?

Kawasaki disease
Meningococcaemia
Henoch-Schönlein purpura (IgA vasculitis) (Correct answer)
Idiopathic thrombocytopenic purpura

Correct answer: Henoch-Schönlein purpura (IgA vasculitis)

Henoch-Schönlein purpura (IgA vasculitis) is characterised by palpable purpura (typically on buttocks and lower limbs), arthralgia, abdominal pain, and renal involvement (haematuria/proteinuria). Platelet count is normal, distinguishing it from ITP.

Saudi Medical Licensing Examination (SMLE)

The SMLE is administered by the Saudi Commission for Health Specialties (SCFHS) and assesses medical graduates' readiness for supervised clinical practice in Saudi Arabia.

200

Questions

270 min

Time Limit

50%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds