Saudi Medical Licensing Examination (SMLE) — Questions and Answers

Question 1: A 42-year-old male has his BMI calculated as 32.5 kg/m². How is this classified according to WHO criteria?

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

Correct answer: Obese class I

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

Question 2: 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
Duration of 3 minutes, generalised
Single episode in 24 hours, 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 3: 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?

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

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 4: 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 inhibits CYP2C19, reducing clopidogrel activation (Correct answer)
Omeprazole causes clopidogrel toxicity

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

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

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

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

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

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

Correct answer: Shoulder dystocia

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

Question 8: During laparoscopic cholecystectomy, which structure must be clearly identified in the critical view of safety before clipping?

Portal vein
Cystic duct and cystic artery in Calot's triangle (Correct answer)
Common bile duct
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 9: A patient is prescribed gentamicin for a serious gram-negative infection. Which two adverse effects require monitoring?

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

Correct answer: Nephrotoxicity and ototoxicity

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

Question 10: Which drug is the antidote for opioid overdose?

Flumazenil
Atropine
N-acetylcysteine
Naloxone (Correct answer)

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 11: 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
Prolactinoma (Correct answer)
Sheehan syndrome
Hypothyroidism

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

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

Correct answer: Serotonin syndrome

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

Question 13: In a patient with suspected acute coronary syndrome, which cardiac biomarker is the most sensitive and specific for myocardial injury?

High-sensitivity troponin (Correct answer)
Myoglobin
Creatine kinase-MB (CK-MB)
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 14: Which of the following features distinguishes delirium from dementia?

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

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 15: A patient with gout is prescribed allopurinol. What is its mechanism of action?

Inhibits phosphodiesterase
Blocks urate reabsorption
Increases uric acid excretion
Inhibits xanthine oxidase (Correct answer)

Correct answer: Inhibits xanthine oxidase

Allopurinol is a xanthine oxidase inhibitor that blocks the conversion of hypoxanthine to xanthine and xanthine to uric acid, thereby reducing uric acid production. It should not be started during an acute gout attack as it can worsen the flare.

Question 16: 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 17: 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?

Alzheimer disease (Correct answer)
Delirium
Normal ageing
Vascular dementia

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 18: 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
Haemolytic uraemic syndrome
Nephrotic syndrome (minimal change disease) (Correct answer)
Henoch-Schönlein purpura

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 19: 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
Septic arthritis
Vaso-occlusion leading to bone infarction (Correct answer)
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 20: 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?

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

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

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

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 22: 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?

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

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 23: 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?

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

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 24: 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?

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

Correct answer: Mandatory surgical exploration

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

Question 25: A patient is started on amiodarone for atrial fibrillation. Which organ systems require monitoring due to amiodarone toxicity?

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

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 26: 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
Radical inguinal orchidectomy (Correct answer)
Testicular biopsy
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 27: 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?

Fibroadenoma (Correct answer)
Breast cyst
Breast carcinoma
Phyllodes tumour

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

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

Correct answer: Within 72 hours of delivery

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

Question 29: 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 I gastrectomy
Graham patch (omental patch repair) (Correct answer)
Vagotomy and pyloroplasty
Billroth II gastrectomy

Correct answer: Graham patch (omental patch repair)

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

Question 30: 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?

Tetralogy of Fallot
Atrioventricular septal defect (endocardial cushion defect) (Correct answer)
Ventricular septal defect
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 31: A patient with rheumatoid arthritis on methotrexate develops pancytopenia. What supplement should have been co-prescribed to prevent this complication?

Folic acid (Correct answer)
Vitamin B12
Iron
Calcium

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 32: 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
Administer prothrombin complex concentrate
Hold warfarin and administer oral vitamin K (Correct answer)

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 33: 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?

Legg-Calvé-Perthes disease
Slipped capital femoral epiphysis
Septic arthritis
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 34: 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)
Repeat co-testing in 12 months
No follow-up needed

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 35: 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?

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

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 36: 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?

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

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 37: 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
Ectopic pregnancy
Threatened miscarriage

Correct answer: Complete hydatidiform mole

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

Question 38: Which medication is contraindicated in patients with a history of acute intermittent porphyria?

Aspirin
Metformin
Paracetamol
Barbiturates (Correct answer)

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

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

Correct answer: Stop the transfusion immediately

Fever, rigors, and flank pain during transfusion suggest an acute haemolytic transfusion reaction (ABO incompatibility). The transfusion must be stopped immediately to prevent further haemolysis, DIC, and renal failure.

Question 40: A diabetic patient is found unconscious with profuse sweating, tremor, and a blood glucose of 2.1 mmol/L. What is the immediate treatment?

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

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 41: 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?

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

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

Obsessions (Correct answer)
Compulsions
Overvalued ideas
Delusions

Correct answer: Obsessions

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

Question 43: 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?

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

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

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

Correct answer: Cross-sectional survey

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

Question 45: 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
Primary hyperaldosteronism (Conn syndrome) (Correct answer)
Cushing syndrome

Correct answer: Primary hyperaldosteronism (Conn syndrome)

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

Question 46: A patient develops high-output small bowel fistula postoperatively. What electrolyte abnormality is most likely?

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

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

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

Correct answer: False positive

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

Question 48: 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?

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

Correct answer: Hepatocellular carcinoma

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

Question 49: What is the drug of choice for prevention and treatment of eclamptic seizures?

Magnesium sulphate (Correct answer)
Labetalol
Diazepam
Phenytoin

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 50: 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
Cervical ectropion
Vasa praevia
Placenta praevia (major/complete) (Correct answer)

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

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

Correct answer: Argatroban (direct thrombin inhibitor)

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

Question 52: A pregnant woman requires treatment for a urinary tract infection. Which antibiotic is considered safest in the first trimester?

Ciprofloxacin
Tetracycline
Trimethoprim
Amoxicillin (Correct answer)

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

Sitagliptin
Glipizide
Metformin
Empagliflozin (Correct answer)

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 54: 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?

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

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 55: 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?

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

Correct answer: Croup (laryngotracheobronchitis)

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

Question 56: What is the recommended screening test for gestational diabetes mellitus (GDM) according to SCFHS and Saudi guidelines?

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

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

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

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 58: 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?

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

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 59: 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?

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

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

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

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 61: 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?

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

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 62: 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 63: A neonate born at 32 weeks gestation develops respiratory distress within minutes of birth. Chest X-ray shows ground-glass opacification with air bronchograms. What is the most likely diagnosis?

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

Correct answer: Respiratory distress syndrome (hyaline membrane disease)

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

Question 64: 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?

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

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

Systemic lupus erythematosus
IgA nephropathy
Granulomatosis with polyangiitis
Goodpasture syndrome (Correct answer)

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 66: 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
Pre-eclampsia with severe features (Correct answer)
Gestational hypertension
Eclampsia

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

Naloxone
Flumazenil
Physostigmine
Atropine and pralidoxime (Correct answer)

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 68: 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
Mesenteric ischaemia
Acute intestinal obstruction
Perforated peptic ulcer (Correct answer)

Correct answer: Perforated peptic ulcer

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

Question 69: A primigravida at 37 weeks presents with a frank breech presentation confirmed by ultrasound. She desires vaginal delivery. What is the recommended approach?

Immediate caesarean section
Wait for spontaneous version
Vaginal breech delivery
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 70: A diagnostic test is reported to have a sensitivity of 90%. This means that:

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

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

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

Question 71: A 30-year-old woman undergoes a Pap smear that shows high-grade squamous intraepithelial lesion (HSIL). What is the recommended next step?

Immediate hysterectomy
Repeat Pap smear in 6 months
Colposcopy and biopsy (Correct answer)
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 72: A 35-year-old woman presents with palpitations, weight loss, heat intolerance, and diffuse goitre with a bruit. TSH is suppressed and free T4 is elevated. What is the most likely diagnosis?

Graves disease (Correct answer)
Thyroid carcinoma
Toxic multinodular goitre
Subacute thyroiditis

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 73: 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?

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

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

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

Question 74: 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?

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

Correct answer: Diabetic neuropathic ulcer

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

Question 75: A 55-year-old man with chronic alcoholism is found confused with confabulation, anterograde amnesia, and ataxia. Thiamine was not administered during his recent hospital admission. What is the diagnosis?

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

Correct answer: Korsakoff syndrome

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

Question 76: 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 77: 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?

Acute splenic sequestration crisis (Correct answer)
Haemolytic crisis
Vaso-occlusive crisis
Aplastic 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 78: Which antibiotic class is associated with tendon rupture, particularly the Achilles tendon, especially in elderly patients?

Penicillins
Cephalosporins
Fluoroquinolones (Correct answer)
Macrolides

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

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

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

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

Correct answer: ACE inhibitors and ARBs

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

Question 81: A term neonate develops jaundice within the first 24 hours of life. The mother is blood group O positive and the baby is blood group A positive. Direct Coombs test is positive. What is the diagnosis?

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

Correct answer: ABO haemolytic disease of the newborn

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

Question 82: What is the most common cause of postpartum haemorrhage?

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

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 83: 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)
Body dysmorphic disorder
Avoidant/restrictive food intake disorder
Bulimia nervosa

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

Single-blind trial
Double-blind trial (Correct answer)
Open-label trial
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 85: Following the epidemiological transition in Saudi Arabia, which of the following is now the leading cause of morbidity and mortality?

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

Correct answer: Cardiovascular diseases

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

Question 86: Which class of medications is first-line for generalised anxiety disorder (GAD)?

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

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

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

Correct answer: Sickle cell disease (HbSS)

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

Question 88: 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 89: 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?

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

Correct answer: Morrison's pouch (hepatorenal recess)

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

Question 90: A health survey measures the proportion of adults in Riyadh who have hypertension on the day of the survey. This measure is best described as:

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

Correct answer: Point prevalence

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

Question 91: Which of the following is the most common site for ectopic pregnancy?

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

Correct answer: Ampulla of the fallopian tube

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

Question 92: 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?

Thyroid scintigraphy
Fine needle aspiration cytology (FNAC) (Correct answer)
Trial of levothyroxine suppression
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 93: 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?

Repeat FNAC in 6 months
Lobectomy or total thyroidectomy (Correct answer)
Radioactive iodine therapy
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 94: A 32-year-old woman has a pervasive pattern of instability in interpersonal relationships, marked impulsivity, recurrent self-harm, chronic feelings of emptiness, and frantic efforts to avoid abandonment. What personality disorder is most likely?

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

Correct answer: Borderline personality disorder

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

Question 95: A 22-year-old woman presents with lower abdominal pain, fever, purulent vaginal discharge, and cervical motion tenderness. What is the most likely diagnosis?

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

Correct answer: Pelvic inflammatory disease (PID)

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

Question 96: 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)
Flail chest
Haemothorax
Tension pneumothorax

Correct answer: Cardiac tamponade

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

Question 97: 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?

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

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

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

Correct answer: 12 months

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

Question 99: 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?

Pericarditis
Infective endocarditis (Correct answer)
Myocarditis
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 100: 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?

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

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

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

Correct answer: Normal fetal well-being

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

Question 102: A trauma patient arrives with paradoxical chest wall movement on the right side. Oxygen saturation is 88% on room air. What is the diagnosis and initial management?

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

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 103: 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?

Turner syndrome
Neural tube defect
Edwards syndrome (trisomy 18)
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 104: A patient undergoes thyroidectomy and develops numbness around the mouth and carpopedal spasm 24 hours postoperatively. What is the most likely cause?

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

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

Coarctation of the aorta
Renal artery stenosis (Correct answer)
Essential hypertension
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 106: 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
Diffuse systemic sclerosis
Systemic lupus erythematosus
Limited cutaneous systemic sclerosis (CREST syndrome) (Correct answer)

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

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

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 108: What is the most common congenital heart defect?

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

Correct answer: Ventricular septal defect

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

Question 109: 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?

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

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

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

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

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

Question 111: What is the recommended initial feeding for a healthy term breastfed newborn according to SCFHS guidelines?

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

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 112: 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)
Glipizide (sulfonylurea)
Insulin glargine

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

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

Correct answer: Both B and C are appropriate

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

Question 114: A 60-year-old male presents with a pulsatile, expansile abdominal mass. CT angiography shows an infrarenal abdominal aortic aneurysm measuring 6.5 cm. What is the recommended management?

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

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 115: 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
Oral antibiotics and sitz baths
Incision and drainage (Correct answer)

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

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

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

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

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 118: A researcher recruits 1,000 disease-free adults and follows them for 10 years to measure who develops type 2 diabetes and why. What study design is being used?

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

Correct answer: Prospective cohort study

A prospective cohort study follows a disease-free group forward in time to measure the incidence of new disease and identify associated risk factors.

Question 119: A patient on metformin is scheduled for a CT scan with IV contrast. What precaution should be taken?

Switch to insulin permanently
Hold metformin for 48 hours after the contrast study (Correct answer)
Administer metformin with the contrast
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 120: 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?

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

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 121: 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?

Necrotising enterocolitis
Imperforate anus
Hirschsprung disease (Correct answer)
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 122: 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?

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

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

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

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

Doxycycline
Cefalexin
Amoxicillin
Erythromycin (Correct answer)

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

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

Correct answer: Age 50 years

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

Question 126: 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?

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

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

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

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 128: 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?

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

Correct answer: Autism spectrum disorder

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

Question 129: Which drug is used as a first-line disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis?

Hydroxychloroquine
Methotrexate (Correct answer)
Prednisolone
Infliximab

Correct answer: Methotrexate

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

Question 130: A 25-year-old male presents with recurrent oral ulcers, genital ulcers, and anterior uveitis. What is the most likely diagnosis?

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

Correct answer: Behçet disease

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

Question 131: 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?

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

Correct answer: IV antibiotics and CT-guided percutaneous drainage

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

Question 132: The attributable risk (risk difference) for lung cancer between smokers and non-smokers is 0.15. What does this number represent?

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

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

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

Question 133: 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
Endometrial polyps
Endometrial carcinoma
Uterine leiomyomas (fibroids) (Correct answer)

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 134: 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?

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

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 135: 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?

Rubella
Kawasaki disease
Scarlet fever (Correct answer)
Measles

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

Hypernatraemia
Hypercalcaemia
Hypermagnesaemia
Total body potassium depletion (Correct answer)

Correct answer: Total body potassium depletion

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

Question 137: 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?

Serotonin
Tyramine (Correct answer)
Dopamine
Histamine

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

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

Correct answer: Randomized controlled trial

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

Question 139: What is the Bishop score used for in obstetrics?

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

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 140: 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)
Start antibiotics for pneumonia
Reassure and discharge
Chest X-ray only

Correct answer: CT pulmonary angiography

With high clinical suspicion for pulmonary embolism (acute dyspnoea, pleuritic pain, tachycardia) and elevated D-dimer, CT pulmonary angiography (CTPA) is the gold standard imaging to confirm or exclude PE.

Question 141: 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?

IgA nephropathy
Post-streptococcal glomerulonephritis (Correct answer)
Minimal change disease
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 142: A premature neonate in the NICU develops feeding intolerance, abdominal distension, bloody stools, and pneumatosis intestinalis on abdominal X-ray. What is the diagnosis?

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

Correct answer: Necrotising enterocolitis

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

Question 143: Which autoantibody is most specific for systemic lupus erythematosus (SLE)?

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

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

Poor dietary intake
Menorrhagia (Correct answer)
Colorectal carcinoma
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 145: Which of the following medications requires therapeutic drug monitoring due to its narrow therapeutic index in bipolar disorder treatment?

Olanzapine
Lamotrigine
Quetiapine
Lithium (Correct answer)

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

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

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

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

Question 147: 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?

Transitional cell carcinoma (urothelial) (Correct answer)
Adenocarcinoma
Squamous cell carcinoma
Small 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 148: 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?

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

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

Vancomycin (Correct answer)
Flucloxacillin
Ciprofloxacin
Amoxicillin-clavulanate

Correct answer: Vancomycin

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

Question 150: A patient attempts suicide by hanging and is found unconscious. After medical stabilisation, what is the most important aspect of the initial psychiatric assessment?

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

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

Phenobarbital IV
Diazepam or lorazepam IV (Correct answer)
Phenytoin IV
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 152: Physical inactivity is recognized as a major modifiable risk factor for which of the following groups of conditions?

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

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

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

Question 153: What is the most appropriate initial fluid resuscitation for a 70 kg adult with a 40% total body surface area (TBSA) burn according to the Parkland formula?

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

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

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

Question 154: A patient with chronic kidney disease stage 4 has a serum potassium of 6.2 mmol/L and peaked T waves on ECG. What is the most urgent first step?

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

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 155: 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?

Premature ovarian insufficiency
Perimenopause (Correct answer)
Hypothalamic amenorrhoea
Menopause

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

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

Correct answer: 2°C to 8°C

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

Question 157: 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?

Medulloblastoma
Astrocytoma (pilocytic) (Correct answer)
Ependymoma
Craniopharyngioma

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 158: 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?

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

Correct answer: Combined oral contraceptive pill

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

Question 159: A family physician counsels a healthy 30-year-old patient to begin regular aerobic exercise to reduce his future risk of cardiovascular disease. This is an example of which level of prevention?

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

Correct answer: Primary prevention

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

Question 160: A 6-month-old infant presents with olive-shaped mass in the right upper quadrant, non-bilious projectile vomiting, and visible peristalsis. What is the most likely diagnosis?

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

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 161: 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?

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

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 162: 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)
5-alpha reductase deficiency
Complete androgen insensitivity syndrome (Correct answer)

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 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?

Haemorrhoids
Rectal polyp
Anal fissure
Rectal carcinoma (Correct answer)

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

Hyperkalaemia
Hypernatraemia
Hypercalcaemia
Hypokalaemia (Correct answer)

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 165: 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
Anal fissure
Juvenile polyp
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 166: Which class of drugs is used for the acute management of anaphylaxis?

Corticosteroids
Adrenaline (epinephrine) (Correct answer)
Antihistamines (H1 blockers)
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 167: 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
Direct oral anticoagulant (e.g., rivaroxaban) (Correct answer)
Aspirin 81 mg daily
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 168: A patient with liver cirrhosis presents with confusion, asterixis, and elevated serum ammonia. What is the first-line treatment?

Lactulose (Correct answer)
Liver transplantation
Neomycin
Flumazenil

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 169: 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?

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

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

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

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

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

Correct answer: Henoch-Schönlein purpura (IgA vasculitis)

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

Question 172: 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?

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

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

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

Correct answer: Colonoscopy

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

Question 174: A 35-year-old asymptomatic woman undergoes a Pap smear test for cervical cancer detection. This is an example of which level of prevention?

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

Correct answer: Secondary prevention

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

Question 175: 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 176: 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?

Low-dose dexamethasone suppression test (Correct answer)
MRI of the pituitary
Random ACTH level
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 177: 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
Omeprazole alone for 8 weeks
Bismuth subsalicylate monotherapy
Triple therapy: PPI + amoxicillin + clarithromycin for 14 days (Correct answer)

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

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

Question 179: A 4-month-old infant is found to have developmental hip dysplasia on screening. What is the most appropriate initial treatment?

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

Correct answer: Pavlik harness

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

Question 180: What is the recommended duration of antidepressant treatment after a first episode of major depressive disorder in remission?

6-12 months after remission (Correct answer)
4-6 months after remission
Stop immediately after symptom resolution
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 181: 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 182: 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?

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

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

Correct answer: PPV increases

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

Question 184: A patient with epilepsy on carbamazepine develops Stevens-Johnson syndrome. Which HLA allele is associated with increased risk?

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

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

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

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

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

Correct answer: Immune thrombocytopenic purpura (ITP)

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

Question 187: Which of the following is the MOST important Wilson and Jungner criterion for a disease to be suitable for a screening program?

The test must use invasive techniques for high accuracy
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

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 188: 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?

Choledochal cyst — MRCP
Alagille syndrome — genetic testing
Biliary atresia — HIDA scan and intraoperative cholangiogram (Correct answer)
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 189: Which of the following diseases receives special surveillance attention in Saudi Arabia particularly because of mass gathering events during Hajj?

Typhoid fever
Hepatitis A
Influenza
Meningococcal disease (Correct answer)

Correct answer: Meningococcal disease

Meningococcal disease is a mandatory notifiable condition in Saudi Arabia and requires vaccination for all Hajj pilgrims due to the epidemic risk in mass gatherings.

Question 190: 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?

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

Correct answer: Emergency caesarean section with cord elevation

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

Question 191: 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?

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

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 192: 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?

Cabergoline (Correct answer)
Bromocriptine
Transsphenoidal surgery
Radiation therapy

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

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

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

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

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

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

Correct answer: Panic disorder with agoraphobia

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

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

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

Correct answer: Methylergonovine (Methergine)

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

Question 197: A 10-month-old infant presents with fever, irritability, and a bulging anterior fontanelle. CSF analysis shows elevated WBCs with neutrophil predominance, low glucose, and elevated protein. What is the most likely causative organism?

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

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

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

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

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

Question 199: 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?

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

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

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

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

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

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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