Saudi Medical Licensing Examination (SMLE) — Questions and Answers

Question 1: Which medication is contraindicated in patients with a history of acute intermittent porphyria?

Paracetamol
Aspirin
Barbiturates (Correct answer)
Metformin

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 2: 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)
Repeat oxytocin only
Tranexamic acid
Factor VIIa

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 3: A 40-year-old female presents with weight gain, moon face, abdominal striae, and hypertension. Morning cortisol is elevated. What is the next best diagnostic step?

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

Correct answer: Low-dose dexamethasone suppression test

The low-dose dexamethasone suppression test (1 mg overnight or 2-day protocol) is used to confirm the diagnosis of Cushing syndrome before localisation studies. It determines whether cortisol production is autonomous.

Question 4: 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)
Pelvis
Left paracolic gutter
Pericardial space

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 5: 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?

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

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 6: 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?

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

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 7: 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?

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

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

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

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

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

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 10: A patient is started on amiodarone for atrial fibrillation. Which organ systems require monitoring due to amiodarone toxicity?

Kidneys and pancreas
Bone marrow and spleen
Brain and spinal cord
Thyroid, liver, lungs, and eyes (Correct answer)

Correct answer: Thyroid, liver, lungs, and eyes

Amiodarone has a wide toxicity profile requiring monitoring of: thyroid (hypo/hyperthyroidism due to iodine content), liver (hepatotoxicity), lungs (pulmonary fibrosis), eyes (corneal microdeposits, optic neuropathy), and skin (photosensitivity, blue-grey discolouration).

Question 11: 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?

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

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

Open-label trial
Single-blind trial
Double-blind trial (Correct answer)
Triple-blind 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 13: 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?

Perimenopause (Correct answer)
Menopause
Hypothalamic amenorrhoea
Premature ovarian insufficiency

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 14: A child with a febrile seizure is brought to the emergency department. Which of the following features would classify it as a complex febrile seizure?

Duration of 20 minutes, focal onset (Correct answer)
Age 2 years, temperature 39°C
Single episode in 24 hours, generalised
Duration of 3 minutes, generalised

Correct answer: Duration of 20 minutes, focal onset

Complex febrile seizures are characterised by one or more of: duration >15 minutes, focal features, recurrence within 24 hours, or Todd paralysis. A 20-minute seizure with focal onset meets criteria for a complex febrile seizure requiring further investigation.

Question 15: 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?

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

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 16: What is the target HbA1c recommended by Saudi Diabetes Clinical Practice Guidelines for most adult patients with type 2 diabetes?

Less than 8%
Less than 9%
Less than 5.5%
Less than 7% (Correct answer)

Correct answer: Less than 7%

The Saudi Diabetes Clinical Practice Guidelines, aligned with SCFHS standards, recommend an HbA1c target of less than 7% for most non-pregnant adults with type 2 diabetes to reduce microvascular complications.

Question 17: A 5-year-old child presents with periorbital oedema, proteinuria (4+), and hypoalbuminaemia. Serum cholesterol is elevated. What is the most likely diagnosis?

Acute glomerulonephritis
Nephrotic syndrome (minimal change disease) (Correct answer)
Henoch-Schönlein purpura
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 18: 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?

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

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

Total body potassium depletion (Correct answer)
Hypernatraemia
Hypermagnesaemia
Hypercalcaemia

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 20: 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
Continue warfarin at the same dose
Hold warfarin and administer oral vitamin K (Correct answer)
Administer prothrombin complex concentrate

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

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

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 22: 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?

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

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 23: A patient develops QT prolongation on their medication. Which of the following drugs is most likely responsible?

Doxycycline
Cefalexin
Erythromycin (Correct answer)
Amoxicillin

Correct answer: Erythromycin

Erythromycin is well-known to cause QT prolongation by blocking the hERG potassium channel, increasing the risk of torsades de pointes and sudden cardiac death. It should be avoided in patients with pre-existing QT prolongation or those on other QT-prolonging drugs.

Question 24: What is the recommended screening test for gestational diabetes mellitus (GDM) according to SCFHS and Saudi guidelines?

Random blood glucose at booking
75g OGTT at 24-28 weeks gestation (Correct answer)
Fasting glucose at 12 weeks gestation
HbA1c at 24-28 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 25: 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?

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

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

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

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 27: 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
Infective endocarditis (Correct answer)
Pericarditis
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 28: 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?

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

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 29: A woman at 30 weeks gestation presents with severe pre-eclampsia. Corticosteroids have been administered. Despite antihypertensive therapy, her condition is deteriorating with HELLP syndrome. What is the definitive treatment?

Plasma exchange
Delivery of the fetus and placenta (Correct answer)
Continue expectant management until term
Increase antihypertensive doses

Correct answer: Delivery of the fetus and placenta

The definitive treatment for pre-eclampsia/HELLP syndrome is delivery of the fetus and placenta, as the placenta is the source of the pathology. In severe deteriorating disease, delivery is indicated regardless of gestational age after stabilisation and corticosteroids.

Question 30: 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 31: 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?

Neuroblastoma (Correct answer)
Hepatoblastoma
Wilms tumour
Rhabdomyosarcoma

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 32: 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?

Small cell carcinoma
Squamous cell carcinoma (Correct answer)
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 33: A patient develops methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia. What is the drug of choice?

Amoxicillin-clavulanate
Vancomycin (Correct answer)
Flucloxacillin
Ciprofloxacin

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 34: 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?

Conservative management with analgesia and hydration (Correct answer)
Extracorporeal shock wave lithotripsy
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 35: Which class of drugs is used for the acute management of anaphylaxis?

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

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

Neomycin
Flumazenil
Liver transplantation
Lactulose (Correct answer)

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 37: 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 38: 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?

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

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 39: 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 40: A patient on metformin is scheduled for a CT scan with IV contrast. What precaution should be taken?

Administer metformin with the contrast
Switch to insulin permanently
Hold metformin for 48 hours after the contrast study (Correct answer)
No precaution needed

Correct answer: Hold metformin for 48 hours after the contrast study

Metformin should be held at the time of or before contrast administration and withheld for 48 hours after the procedure. IV contrast can rarely cause contrast-induced nephropathy, and impaired renal function combined with metformin increases the risk of lactic acidosis.

Question 41: 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)
Calcium channel blocker
Amiodarone
Digoxin and diuretics only

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 42: 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)
Medulloblastoma
Craniopharyngioma
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 43: 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?

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

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 44: 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?

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

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 45: What is the mechanism of action of omeprazole?

Irreversible proton pump inhibitor (Correct answer)
Muscarinic receptor antagonist
Prostaglandin analogue
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 46: 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?

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

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 47: Which autoantibody is most specific for systemic lupus erythematosus (SLE)?

Anti-Ro (SSA)
Anti-double-stranded DNA (anti-dsDNA) (Correct answer)
Rheumatoid factor
Anti-nuclear antibody (ANA)

Correct answer: Anti-double-stranded DNA (anti-dsDNA)

While ANA is highly sensitive for SLE, anti-dsDNA antibodies are highly specific and correlate with disease activity, particularly lupus nephritis.

Question 48: 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?

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

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 49: 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
IV fluid resuscitation with normal saline (Correct answer)
IV insulin bolus
Oral rehydration therapy

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

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

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 51: A child presents with a unilateral, painless abdominal mass that does not cross the midline. CT shows an intrarenal mass with areas of haemorrhage and necrosis. What is the most likely diagnosis?

Neuroblastoma
Hepatoblastoma
Renal cell carcinoma
Wilms tumour (nephroblastoma) (Correct answer)

Correct answer: Wilms tumour (nephroblastoma)

Wilms tumour is the most common renal malignancy in children, typically presenting between 3-5 years of age as a painless abdominal mass arising from the kidney. Unlike neuroblastoma, it does not cross the midline and is intrarenal in origin.

Question 52: 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?

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

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 53: A 65-year-old diabetic male presents with crushing chest pain radiating to the left arm. ECG shows ST elevation in leads II, III, and aVF. Which coronary artery is most likely occluded?

Left anterior descending artery
Right coronary artery (Correct answer)
Left main coronary artery
Left circumflex 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 54: 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?

Insulin glargine
Sulfonylurea monotherapy
GLP-1 receptor agonist
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 55: 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?

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

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 56: 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?

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

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

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

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 58: According to the Saudi National Immunization Program, which two vaccines are administered at birth?

BCG and Hepatitis A
BCG and Hepatitis B (Correct answer)
Rotavirus and BCG
OPV and Hepatitis B

Correct answer: BCG and Hepatitis B

The Saudi immunization schedule administers BCG (to prevent tuberculosis) and Hepatitis B vaccine at birth.

Question 59: A 20-year-old soldier presents after witnessing an explosion with inability to move his legs. Neurological examination and MRI are completely normal. He appears indifferent to his symptoms (la belle indifférence). What is the most likely diagnosis?

Factitious disorder
Somatic symptom disorder
Conversion disorder (functional neurological symptom disorder) (Correct answer)
Malingering

Correct answer: Conversion disorder (functional neurological symptom disorder)

Conversion disorder presents with neurological symptoms (paralysis, blindness, seizures) that are incompatible with recognised neurological disease. It typically follows a stressor, and la belle indifférence (apparent lack of concern) may be present, though it is not diagnostic.

Question 60: 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)
Turner syndrome
Neural tube defect
Down syndrome (trisomy 21) (Correct answer)

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 61: 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?

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

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

Herpes simplex
Behçet disease (Correct answer)
Reactive arthritis
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 63: A 38-year-old man presents with severe headache, visual field defect, and a pituitary mass on MRI. Prolactin level is 250 ng/mL. What is the first-line treatment?

Radiation therapy
Transsphenoidal surgery
Bromocriptine
Cabergoline (Correct answer)

Correct answer: Cabergoline

Dopamine agonists (cabergoline is preferred over bromocriptine) are first-line treatment for prolactinomas regardless of size. Cabergoline effectively reduces prolactin levels and tumour size in most patients.

Question 64: A patient develops high-output small bowel fistula postoperatively. What electrolyte abnormality is most likely?

Respiratory alkalosis
Hypercalcaemia
Metabolic acidosis with dehydration (Correct answer)
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 65: 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?

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

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 66: 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?

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

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 67: 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?

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

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

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

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 69: What is the mechanism of action of SSRIs in treating depression?

Block serotonin reuptake at the presynaptic neuron (Correct answer)
Increase dopamine synthesis
Antagonise serotonin receptors
Block monoamine oxidase enzyme

Correct answer: Block serotonin reuptake at the presynaptic neuron

SSRIs selectively inhibit the serotonin transporter (SERT) at the presynaptic neuron, blocking the reuptake of serotonin from the synaptic cleft. This increases serotonin availability in the synaptic cleft, enhancing serotonergic neurotransmission.

Question 70: A 50-year-old male presents with epigastric pain that improves with eating. Urea breath test is positive. What is the recommended eradication regimen?

Sucralfate for 4 weeks
Bismuth subsalicylate monotherapy
Triple therapy: PPI + amoxicillin + clarithromycin for 14 days (Correct answer)
Omeprazole alone for 8 weeks

Correct answer: Triple therapy: PPI + amoxicillin + clarithromycin for 14 days

Standard triple therapy consisting of a PPI, amoxicillin, and clarithromycin for 14 days is the recommended first-line H. pylori eradication regimen per current guidelines endorsed by SCFHS.

Question 71: 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?

Schizophrenia (Correct answer)
Delusional disorder
Schizoaffective disorder
Brief psychotic 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 72: 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 increases (Correct answer)
PPV becomes equal to sensitivity
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 73: A 22-year-old Saudi male with sickle cell disease presents with severe bilateral hip pain. MRI shows bilateral avascular necrosis of the femoral heads. What is the underlying pathophysiology?

Autoimmune destruction of cartilage
Vaso-occlusion leading to bone infarction (Correct answer)
Septic arthritis
Osteoporosis from chronic anaemia

Correct answer: Vaso-occlusion leading to bone infarction

Sickle cell disease causes vaso-occlusion by sickled red blood cells that obstruct small vessels, leading to ischaemia and infarction of bone tissue. Avascular necrosis of the femoral head is a common complication in Saudi patients with SCD.

Question 74: 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 75: A 28-year-old woman presents with recurrent episodes of binge eating followed by self-induced vomiting. She is of normal weight. Physical examination reveals dental enamel erosion and parotid gland enlargement. What is the diagnosis?

Rumination disorder
Anorexia nervosa, binge-purge type
Binge eating disorder
Bulimia nervosa (Correct answer)

Correct answer: Bulimia nervosa

Bulimia nervosa is characterised by recurrent binge eating followed by compensatory behaviours (purging, laxative use, excessive exercise) at least once a week for 3 months. Unlike anorexia, patients are typically normal weight. Dental erosion and parotid enlargement result from repeated vomiting.

Question 76: A patient on heparin develops heparin-induced thrombocytopenia (HIT) type II. What is the most appropriate alternative anticoagulant?

Aspirin
Argatroban (direct thrombin inhibitor) (Correct answer)
Low molecular weight heparin
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 77: A patient receiving blood transfusion develops fever, rigors, and flank pain 30 minutes into the transfusion. What is the most critical immediate action?

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

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 78: 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?

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

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 79: 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?

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

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

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

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 81: 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?

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

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

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

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 83: Which of the following features distinguishes delirium from dementia?

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

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 84: 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?

Check serum paracetamol level and plot on treatment nomogram (Correct answer)
Administer activated charcoal
Wait for symptoms to develop
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 85: 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?

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

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

Endometrial biopsy (Correct answer)
Hormone replacement therapy
Total abdominal hysterectomy
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 87: 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?

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

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 88: According to WHO growth standards used in Saudi Arabia, a child whose weight-for-height Z-score is below -3 SD is classified as having what degree of malnutrition?

Mild malnutrition
Severe acute malnutrition (Correct answer)
Moderate acute malnutrition
Normal nutritional status

Correct answer: Severe acute malnutrition

According to WHO growth standards adopted by SCFHS, a weight-for-height Z-score below -3 SD indicates severe acute malnutrition (SAM), which requires urgent medical and nutritional intervention including therapeutic feeding and monitoring for complications.

Question 89: 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?

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

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 90: 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?

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

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 91: 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?

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

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

Serotonin syndrome
Malignant hyperthermia
Acute dystonia
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 93: Which of the following conditions is a common cause of secondary hypertension in a young Saudi adult?

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

Correct answer: Renal artery stenosis

Renal artery stenosis (particularly fibromuscular dysplasia in young patients) is one of the most common causes of secondary hypertension in young adults. It should be suspected when hypertension is resistant to treatment or presents at a young age.

Question 94: Which of the following medications requires therapeutic drug monitoring due to its narrow therapeutic index in bipolar disorder treatment?

Quetiapine
Lithium (Correct answer)
Lamotrigine
Olanzapine

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 95: A 30-year-old woman presents with depressed mood, loss of interest, insomnia, poor concentration, feelings of worthlessness, and suicidal ideation for 3 weeks. What is the minimum duration of symptoms required for a diagnosis of major depressive disorder?

1 week
2 weeks (Correct answer)
6 weeks
4 weeks

Correct answer: 2 weeks

According to DSM-5, major depressive disorder requires ≥5 symptoms (including depressed mood or loss of interest) present for at least 2 weeks, causing significant functional impairment. This patient meets the diagnostic criteria.

Question 96: A patient on lithium presents with tremor, polyuria, and a serum lithium level of 2.5 mEq/L. What is the immediate management?

Stop lithium, IV fluids, and monitor renal function (Correct answer)
Observation only
Increase lithium dose
Add a thiazide diuretic

Correct answer: Stop lithium, IV fluids, and monitor renal function

Lithium toxicity (levels >1.5 mEq/L) requires immediate cessation of lithium, aggressive IV fluid hydration (normal saline), and monitoring of renal function and electrolytes. Haemodialysis may be needed for severe toxicity (>2.5 mEq/L) or renal impairment.

Question 97: 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?

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

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 98: 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?

Urgent haemodialysis
IV calcium gluconate (Correct answer)
IV insulin with dextrose
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 99: A primigravida at 37 weeks presents with a frank breech presentation confirmed by ultrasound. She desires vaginal delivery. What is the recommended approach?

Vaginal breech delivery
Wait for spontaneous version
Immediate caesarean section
External cephalic version (ECV) attempt (Correct answer)

Correct answer: External cephalic version (ECV) attempt

External cephalic version (ECV) is recommended at 37 weeks for breech presentation in a primigravida with no contraindications. It has a success rate of approximately 50% in nulliparous women and can allow for a subsequent vaginal cephalic delivery.

Question 100: 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?

Annual surveillance with ultrasound
Emergency surgery only if symptomatic
Blood pressure control and observation
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 101: Which of the following is the most common cause of community-acquired pneumonia in Saudi Arabia?

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

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 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?

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

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 103: 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
Aspirin 81 mg daily
Direct oral anticoagulant (e.g., rivaroxaban) (Correct answer)
Warfarin with INR target 2-3

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 104: 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
An effective treatment must be available and early treatment must improve outcomes compared to late treatment (Correct answer)
The disease must have a high case fatality rate
The test must use invasive techniques for high accuracy

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

Benzodiazepines
Typical antipsychotics
Selective serotonin reuptake inhibitors (SSRIs) (Correct answer)
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 106: 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)
Myoglobin
High-sensitivity troponin (Correct answer)
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 107: 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?

Histamine
Dopamine
Tyramine (Correct answer)
Serotonin

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 108: 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?

Anorexia nervosa (Correct answer)
Bulimia nervosa
Body dysmorphic disorder
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 109: 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)
Continue warfarin through surgery
Stop warfarin and give aspirin instead
Stop warfarin 1 day before surgery without bridging

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 110: 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 111: A patient presents with organophosphate poisoning showing excessive salivation, lacrimation, urination, diarrhoea, and miosis. What is the antidote?

Physostigmine
Flumazenil
Atropine and pralidoxime (Correct answer)
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 112: A patient with myasthenia gravis is given an aminoglycoside antibiotic and develops respiratory failure. What is the mechanism of this drug interaction?

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

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 113: 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?

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

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 114: 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?

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

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 115: 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?

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

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 116: 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?

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

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

Calcium
Vitamin B12
Iron
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 118: A 22-year-old university student presents with severe social anxiety, inability to attend classes or speak in groups, and avoidance of social situations for 2 years. CBT has been partially effective. What pharmacotherapy should be added?

SSRI (e.g., sertraline or paroxetine) (Correct answer)
Buspirone
Benzodiazepine long-term
Antipsychotic medication

Correct answer: SSRI (e.g., sertraline or paroxetine)

SSRIs (sertraline and paroxetine have FDA approval for social anxiety disorder) combined with CBT provide the best outcomes for social anxiety disorder. Paroxetine is specifically well-studied for this indication. Long-term benzodiazepine use is avoided due to dependence risk.

Question 119: A patient with asthma is prescribed a non-selective beta-blocker for hypertension. What is the expected adverse effect?

Polyuria
Tachycardia
Hyperglycaemia
Bronchospasm (Correct answer)

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 120: A 35-year-old asymptomatic woman undergoes a Pap smear test for cervical cancer detection. This is an example of which level of prevention?

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

Correct answer: Secondary prevention

Secondary prevention involves early detection of disease in asymptomatic individuals through screening, such as Pap smears for cervical cancer.

Question 121: 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?

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

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 122: 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?

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

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.

Question 123: What is the most common cause of postpartum haemorrhage?

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

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 124: 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?

Hysterectomy
Immediate colposcopy (Correct answer)
No follow-up needed
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 125: A diabetic mother delivers a macrosomic baby. During delivery, the fetal head delivers but the shoulders do not. What is this obstetric emergency called?

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

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

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

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

Quetiapine or pimavanserin (Correct answer)
Chlorpromazine
Risperidone
Haloperidol

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 128: 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?

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

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 129: A 25-year-old woman presents with secondary amenorrhoea, galactorrhoea, and a positive pregnancy test is negative. Prolactin level is markedly elevated. What is the most likely cause?

Polycystic ovary syndrome
Hypothyroidism
Prolactinoma (Correct answer)
Sheehan syndrome

Correct answer: Prolactinoma

A markedly elevated prolactin level with secondary amenorrhoea and galactorrhoea in a non-pregnant woman is most commonly caused by a prolactinoma (pituitary prolactin-secreting adenoma). MRI of the pituitary should be performed to confirm the diagnosis.

Question 130: During a right hemicolectomy, which vessel is ligated at its origin to achieve adequate lymph node clearance for caecal carcinoma?

Ileocolic artery (Correct answer)
Superior mesenteric artery
Inferior 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 131: 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 132: Which antiemetic is the drug of choice for chemotherapy-induced nausea and vomiting?

Metoclopramide
Ondansetron (Correct answer)
Cyclizine
Domperidone

Correct answer: Ondansetron

Ondansetron (a 5-HT3 receptor antagonist) is first-line for chemotherapy-induced nausea and vomiting (CINV). It blocks serotonin receptors in the chemoreceptor trigger zone and vagal afferents. For highly emetogenic chemotherapy, it is combined with dexamethasone and aprepitant (NK1 antagonist).

Question 133: A 28-year-old woman in the third stage of labour has persistent vaginal bleeding despite placental delivery. The uterus is well contracted. What is the most likely cause of the bleeding?

Retained placental fragments
Genital tract trauma (laceration) (Correct answer)
Uterine atony
Coagulopathy

Correct answer: Genital tract trauma (laceration)

When the uterus is well contracted and the placenta has been delivered completely, persistent bleeding is most likely from genital tract trauma (cervical, vaginal, or perineal lacerations). Systematic examination of the birth canal is required.

Question 134: What is the most common type of ovarian cyst in women of reproductive age?

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

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 135: 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?

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

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 136: 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?

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

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 137: 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?

Amputation planning
Endovascular stenting
Immediate surgical bypass
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 138: In Saudi Arabia, according to the Mental Health Act and SCFHS guidelines, involuntary psychiatric admission is permitted under which condition?

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

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 139: Which drug is the antidote for opioid overdose?

Atropine
Naloxone (Correct answer)
N-acetylcysteine
Flumazenil

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 140: 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?

Median nerve
Ulnar nerve
Musculocutaneous 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 141: A patient on rifampicin for tuberculosis is also taking warfarin. What effect does rifampicin have on warfarin levels?

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

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 142: 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 143: A pregnant woman requires treatment for a urinary tract infection. Which antibiotic is considered safest in the first trimester?

Amoxicillin (Correct answer)
Tetracycline
Ciprofloxacin
Trimethoprim

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 144: What is the most common congenital heart defect?

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

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

Diazepam
Labetalol
Phenytoin
Magnesium sulphate (Correct answer)

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 146: 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
Diabetic neuropathic ulcer (Correct answer)
Squamous cell carcinoma
Venous ulcer

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

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

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

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

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 149: 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?

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

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

Inguinal lymphadenopathy
Direct inguinal hernia
Strangulated inguinal hernia (Correct answer)
Femoral 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 151: In the primary survey of a trauma patient (ATLS), what is the correct sequence?

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

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

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

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

CT angiography
Mesenteric angiography
Barium swallow
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 154: 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?

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

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

Hypokalaemia (Correct answer)
Hypercalcaemia
Hypernatraemia
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 156: A 60-year-old male presents with painless obstructive jaundice, weight loss, and a palpable non-tender gallbladder. What is the most likely diagnosis?

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

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 157: 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?

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

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 158: 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)
Tension pneumothorax
Flail chest
Haemothorax

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

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

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 160: A woman in active labour has a cervical dilation of 4 cm that remains unchanged after 4 hours despite adequate contractions. What is this called?

Active phase arrest (Correct answer)
Second stage arrest
Prolonged latent phase
Precipitous labour

Correct answer: Active phase arrest

Active phase arrest is defined as no cervical change for ≥4 hours with adequate contractions (or ≥6 hours with inadequate contractions) in a patient who has entered active labour (≥6 cm historically, though 4 cm was the older threshold).

Question 161: A child is accidentally given a large dose of iron supplement. What is the specific antidote?

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

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

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

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 163: 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?

Anal fissure
Rectal carcinoma (Correct answer)
Haemorrhoids
Rectal polyp

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 164: 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?

Delirium
Alzheimer disease (Correct answer)
Vascular dementia
Normal ageing

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 165: 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
IV immunoglobulin (IVIG) and aspirin (Correct answer)
Oral antibiotics

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

Endometrial ablation
Progestin therapy alone
Observation and repeat biopsy in 6 months
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 167: Which medication used in type 2 diabetes is associated with weight loss and reduced cardiovascular events?

Pioglitazone (thiazolidinedione)
Liraglutide (GLP-1 receptor agonist) (Correct answer)
Insulin glargine
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 168: 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
Transitional cell carcinoma (urothelial) (Correct answer)
Small cell carcinoma
Squamous cell carcinoma

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 169: A 22-year-old male presents with grandiosity, decreased need for sleep (2 hours/night), pressured speech, flight of ideas, and excessive spending for 10 days. He has had previous depressive episodes. What is the most likely diagnosis?

Cyclothymic disorder
Major depressive disorder
Bipolar I disorder, manic episode (Correct answer)
Bipolar II disorder

Correct answer: Bipolar I disorder, manic episode

Bipolar I disorder is diagnosed when a patient has at least one manic episode lasting ≥7 days (or requiring hospitalisation). This patient shows classic manic symptoms (grandiosity, decreased sleep, pressured speech, flight of ideas, excessive spending) lasting 10 days with a history of depression.

Question 170: 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)
Missed miscarriage
Threatened miscarriage
Ectopic pregnancy

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 171: 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?

PTSD
Borderline personality disorder
Schizophrenia
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 172: What is the Bishop score used for in obstetrics?

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

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 173: 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?

Scarlet fever (Correct answer)
Rubella
Measles
Kawasaki disease

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

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

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 175: 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?

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

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 176: A woman presents with a positive pregnancy test, vaginal bleeding, and an adnexal mass. Serum beta-hCG is 2,500 mIU/mL but transvaginal ultrasound shows an empty uterus. What is the most likely diagnosis?

Complete miscarriage
Gestational trophoblastic disease
Threatened miscarriage
Ectopic pregnancy (Correct answer)

Correct answer: Ectopic pregnancy

An empty uterus on transvaginal ultrasound with a beta-hCG above the discriminatory zone (1,500-2,000 mIU/mL) and an adnexal mass is highly suggestive of ectopic pregnancy. This requires urgent management (surgical or medical with methotrexate).

Question 177: 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?

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

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 178: 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
IV alteplase within the thrombolytic window (Correct answer)
Observation and repeat CT in 24 hours
Heparin infusion

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 179: 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?

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

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

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

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 181: 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?

CT pulmonary angiography (Correct answer)
Chest X-ray only
Reassure and discharge
Start antibiotics for pneumonia

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 182: A patient with schizophrenia has been resistant to two adequate trials of different antipsychotics. What is the recommended next pharmacological step?

Start clozapine (Correct answer)
Add a mood stabiliser
Switch to a benzodiazepine
Combine two typical antipsychotics

Correct answer: Start clozapine

Clozapine is the gold standard treatment for treatment-resistant schizophrenia, defined as failure of ≥2 adequate antipsychotic trials. Despite its superior efficacy, it requires regular blood monitoring due to the risk of agranulocytosis.

Question 183: 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?

Subacute thyroiditis
Toxic multinodular goitre
Graves disease (Correct answer)
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 184: 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?

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

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

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

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

Sitagliptin
Empagliflozin (Correct answer)
Glipizide
Metformin

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

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

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 188: 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
Fibroadenoma (Correct answer)
Phyllodes tumour
Breast cyst

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

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

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 190: 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)
In vitro fertilisation (IVF)
Gonadotropin injections
Clomiphene citrate

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 191: 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?

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

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 192: 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?

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

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 193: 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)
IgA nephropathy
Granulomatosis with polyangiitis
Systemic lupus erythematosus

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 194: A 7-year-old child presents 2 weeks after a sore throat with dark-coloured urine, periorbital oedema, and hypertension. Serum complement C3 is low. What is the most likely diagnosis?

Minimal change disease
IgA nephropathy
Post-streptococcal glomerulonephritis (Correct answer)
Membranous nephropathy

Correct answer: Post-streptococcal glomerulonephritis

Post-streptococcal glomerulonephritis typically presents 1-3 weeks after a pharyngeal (or skin) streptococcal infection with nephritic syndrome (haematuria, oedema, hypertension) and low serum C3 complement. ASO titre is usually elevated.

Question 195: A patient attempts suicide by hanging and is found unconscious. After medical stabilisation, what is the most important aspect of the initial psychiatric assessment?

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

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 196: A neonate presents with failure to pass meconium within 48 hours of birth, abdominal distension, and bilious vomiting. Barium enema shows a transition zone in the rectosigmoid. What is the diagnosis?

Imperforate anus
Hirschsprung disease (Correct answer)
Necrotising enterocolitis
Meconium ileus

Correct answer: Hirschsprung disease

Hirschsprung disease (congenital aganglionic megacolon) presents with failure to pass meconium within 48 hours, abdominal distension, and bilious vomiting. Barium enema shows a transition zone between narrow aganglionic distal bowel and dilated proximal bowel.

Question 197: Which of the following statistics is the BEST indicator of the overall quality of healthcare in a country?

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

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 198: A child is brought to the emergency department with burns. The pattern shows clearly demarcated burns on both feet in a stocking distribution with no splash marks. What should be suspected?

Staphylococcal scalded skin syndrome
Accidental scalding
Non-accidental injury (child abuse) (Correct answer)
Epidermolysis bullosa

Correct answer: Non-accidental injury (child abuse)

Symmetrical, sharply demarcated burns in a stocking or glove distribution without splash marks are highly suspicious for immersion burns caused by non-accidental injury. This pattern occurs when a child is held in hot water. Mandatory reporting to child protection services is required.

Question 199: A patient on long-term corticosteroids is to undergo surgery. What perioperative consideration is essential?

No dose adjustment needed
Switch to NSAIDs before surgery
Stress-dose steroids (hydrocortisone) perioperatively (Correct answer)
Abrupt discontinuation of steroids before surgery

Correct answer: Stress-dose steroids (hydrocortisone) perioperatively

Chronic corticosteroid use suppresses the hypothalamic-pituitary-adrenal (HPA) axis. During surgical stress, the adrenal glands cannot mount an appropriate cortisol response, risking adrenal crisis. Stress-dose hydrocortisone (50-100 mg IV) is given perioperatively.

Question 200: In a case-control study investigating the association between a risk factor and a disease, which measure of association is typically calculated?

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

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.

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%

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