Free SMLE Medicine questions

A 51-year-old woman is admitted with two days of severe headache, now with neck pain, fever and increasing confusion. She is drowsy with neck stiffness and a positive Kernig sign, and there is no rash. Cerebrospinal fluid is turbid with 200 cells/µL that are 90% neutrophils, protein 0.9 g/L, and glucose 1.6 mmol/L against a serum glucose of 6.0 mmol/L. Which of the following is the most likely causative organism?

A 27-year-old woman with asthma has 2 days of worsening wheeze and breathlessness. She is alert, with oxygen saturation 93 percent on 3 L/min by nasal cannula. After 1 hour of continuous nebulised salbutamol and ipratropium, intravenous magnesium, and systemic corticosteroids she remains distressed, and arterial blood gas shows pH 7.28, PCO2 8.8 kPa, and PO2 9.9 kPa. Which of the following is the best next step in management?

A 63-year-old man with type 2 diabetes, hypertension, and stage 4 chronic kidney disease reports 3 months of fatigue. Blood pressure is 132/78 mm Hg with no oedema. Haemoglobin is 9.2 g/dL, MCV 88 fL, eGFR 22 mL/min/1.73 m², ferritin 480 µg/L, and transferrin saturation 32%. Vitamin B12 and folate are normal. Which is the most appropriate next step in management?

A 32-year-old woman has 3 months of low back and alternating buttock pain with morning stiffness lasting about an hour. She denies psoriasis, oral or genital ulcers, eye redness, diarrhoea, urethral discharge, and preceding gastrointestinal or genitourinary infection. Rheumatoid factor and anti-cyclic citrullinated peptide antibodies are negative, serum urate is 260 µmol/L, and pelvic radiography shows bilateral grade 3 sacroiliitis. Which of the following is the most likely diagnosis?

A 25-year-old man attends a pre-employment check-up. He is 192 cm tall with hyperextensible joints. Blood pressure is 148/52 mm Hg with a collapsing radial pulse. Cardiac auscultation reveals a soft, high-pitched, early diastolic decrescendo murmur at the left sternal edge, louder when he sits up, leans forward and holds his breath in full expiration. The apex beat is displaced laterally. Which of the following is the most likely diagnosis?

A 68-year-old man has 6 weeks of progressive abdominal distension and ankle swelling, with no history of liver disease or alcohol use. The jugular venous pressure is elevated, with a third heart sound, bibasilar crackles, shifting dullness, and pitting oedema. Ascitic albumin is 2.0 g/dL with serum albumin 3.6 g/dL, ascitic total protein 3.5 g/dL, and 60 polymorphonuclear cells/mm³. Which is the most likely cause of his ascites?

A 30-year-old previously healthy man has three days of fever, productive cough and pleuritic pain. Temperature is 39.1 °C, respiratory rate 26 breaths/min, blood pressure 118/70 mm Hg, oxygen saturation 91% on room air, and white cell count 18 × 10⁹/L. Chest radiography shows right middle lobe consolidation. He is admitted to a general ward. Which antibiotic regimen is most appropriate?

A 71-year-old woman has 2 days of fever, dysuria, and suprapubic pain, and since this morning has been disoriented with fluctuating attention; last week she was fully alert and independent. Temperature is 38.6 °C. Urinalysis shows nitrites and 60 white cells per high-power field. Leukocytes are 16.5 × 10⁹/L, sodium 132 mmol/L, and corrected calcium 2.06 mmol/L. Which of the following is the most appropriate next step in management?

A 71-year-old man with known chronic obstructive pulmonary disease presents with severe respiratory distress and drowsiness. He responds only to painful stimuli, cannot cooperate with instructions, and his upper airway is full of copious purulent secretions. Respiratory rate is 8 breaths/min and shallow, and oxygen saturation is 74%. Arterial blood gas shows pH 7.18 and PaCO2 10.6 kPa. Which of the following is the best next step in management?

A 35-year-old woman is diagnosed with Graves disease after 5 kg weight loss, palpitations, heat intolerance, and a diffuse goitre with a bruit. Thyroid-stimulating hormone is undetectable, free thyroxine 42 pmol/L, and thyrotropin receptor antibodies strongly positive. She has mild eyelid retraction and proptosis of 20 mm bilaterally without diplopia. She smokes 20 cigarettes daily. Which factor most increases her risk of progressive orbitopathy?

A 58-year-old man with compensated cirrhosis from chronic hepatitis C, cured with direct-acting antivirals two years ago, attends the hepatology clinic. He is asymptomatic, with a firm liver edge, no ascites and no encephalopathy. His Child-Pugh score is A, platelet count 96 x 10⁹/L, albumin 38 g/L, and the international normalised ratio is 1.1. Which of the following is the most appropriate strategy for hepatocellular carcinoma surveillance?

A 47-year-old man has 6 months of fatigue, right upper quadrant discomfort and darkening bronze skin. He also reports reduced libido and aching second and third metacarpophalangeal joints. He drinks no alcohol. Fasting glucose is 9.1 mmol/L, ALT 78 U/L, serum ferritin 1450 µg/L and transferrin saturation 62 percent. His father died of liver cirrhosis. What is the most appropriate confirmatory test?

A 19-year-old competitive footballer attends after his brother died suddenly at 24 and a paternal uncle at 30. He has had 2 episodes of light-headedness and one near-syncope while sprinting. A grade 3 out of 6 systolic murmur at the left lower sternal border becomes louder on standing and during Valsalva, and softer on squatting. There is a fourth heart sound. Which condition should he be screened for?

A 27-year-old man has exertional dyspnea and two episodes of near syncope while playing football. A harsh systolic murmur at the left sternal border increases with Valsalva. Echocardiography shows asymmetric septal hypertrophy of 19 mm, systolic anterior motion of the mitral valve, and a resting left ventricular outflow gradient of 60 mm Hg. What is the most appropriate initial therapy?

A 19-year-old man is newly diagnosed with type 1 diabetes after 4 weeks of polyuria, polydipsia, and 6 kg of weight loss. His mild diabetic ketoacidosis has resolved. He is a university student whose meal times vary from day to day and he plays football three evenings a week. HbA1c is 11.4 % (101 mmol/mol). Which of the following is the most appropriate outpatient insulin regimen?

A 50-year-old man attends for a routine health check. He has no history of cardiovascular disease, diabetes, hypertension or pancreatitis, has never smoked, takes no medication and has no family history of premature coronary disease. His body mass index is 31 kg/m2, waist circumference 106 cm, blood pressure 124/78 mm Hg, and he reports drinking two sugar-sweetened soft drinks daily with minimal physical activity. Fasting lipids show LDL cholesterol 108 mg/dL, HDL cholesterol 38 mg/dL and triglycerides 281 mg/dL. Fasting glucose, TSH, creatinine, urine protein and liver enzymes are all normal, and his estimated 10-year atherosclerotic cardiovascular risk is 4%. Which of the following is the most appropriate next step in management?

A 72-year-old man with chronic obstructive pulmonary disease presents with increasing dyspnoea and purulent sputum. He is drowsy but rousable and follows commands, with no vomiting and an intact cough. Oxygen saturation is 94 percent on 4 L/min. After an hour of nebulised bronchodilators, corticosteroids, and antibiotics, arterial blood gas shows pH 7.26 and PaCO2 72 mm Hg. Which of the following is the most appropriate next step in management?

A 26-year-old man is found unresponsive; his friend reports heroin use. He responds only to painful stimulus with a Glasgow Coma Scale score of 7. Respiratory rate is 6 breaths/min and oxygen saturation is 84% on room air. Pupils are constricted to 1 mm, there are needle marks in the left antecubital fossa, and capillary blood glucose is 6.1 mmol/L. Which of the following is the most appropriate antidote?

A 68-year-old man has an 18-month history of slowing movement and a right-hand tremor that is most obvious at rest and disappears when he reaches for a cup. Examination shows a 4 Hz pill-rolling rest tremor, cogwheel rigidity at the right wrist, decrementing amplitude on repetitive finger tapping, a stooped shuffling gait with reduced right arm swing, and normal ocular movements. Degeneration of which structure explains these findings?

A 63-year-old woman presents with cola-coloured urine and facial puffiness. Two weeks earlier she had a sore throat treated with penicillin V. Blood pressure is 150/94 mm Hg, with periorbital oedema and pitting ankle oedema. Urinalysis shows 3+ blood and 2+ protein with red cell casts. C3 is low and the antistreptolysin O titre is elevated. Which of the following is the most appropriate treatment at this time?

A 66-year-old woman with stage 5 chronic kidney disease not on dialysis, estimated glomerular filtration rate 18 mL/min/1.73 m², develops sudden pleuritic chest pain and breathlessness 5 days after elective total hip replacement. CT pulmonary angiography confirms bilateral segmental pulmonary emboli, and echocardiography shows normal right ventricular size and function with a normal troponin. The surgical wound is dry. What is the most appropriate initial anticoagulation?

A 30-year-old woman with 8 months of rapidly progressive skin thickening, Raynaud phenomenon, and positive anti-RNA polymerase III antibodies has 4 days of severe headache and blurred vision. Blood pressure is 196/114 mm Hg, having been 120/70 mm Hg 2 months ago. Serum creatinine is 238 µmol/L, up from 68 µmol/L, hemoglobin 9.2 g/dL with schistocytes, and platelets 88 × 10⁹/L. What is the most appropriate treatment?

A 57-year-old man with hepatitis C cirrhosis has progressive abdominal distension and ankle swelling. Examination shows spider angiomas, shifting dullness and pitting pedal edema, with no jugular venous distension. The serum-ascites albumin gradient is 16 g/L, ascitic total protein is 14 g/L, the polymorphonuclear count is 90 cells/mm³, cytology is negative and adenosine deaminase is not elevated. What does this ascitic fluid profile most strongly indicate?

A 38-year-old woman with asthma remains symptomatic on a medium-dose budesonide-formoterol inhaler twice daily, with daytime wheeze four days a week, night waking twice weekly, and salbutamol use four times a week. Inhaler technique is correct, adherence is confirmed, she has no rhinosinusitis or reflux, and she does not smoke. Spirometry shows an FEV1 of 68 percent predicted, and blood eosinophils are 0.18 × 10⁹/L. Which addition is most appropriate?

A 61-year-old man with high-grade non-Hodgkin lymphoma and bulky lymphadenopathy was to start chemotherapy the following week. He had poorly controlled type 2 diabetes. He was found collapsed at home and died. Blood on arrival showed potassium 7.4 mmol/L, uric acid 16 mg/dL, phosphate 2.6 mmol/L, corrected calcium 1.7 mmol/L, creatinine 310 µmol/L and lactate dehydrogenase 2100 U/L. Which of the following is the most likely cause of death?

A 29-year-old woman with systemic lupus erythematosus taking mycophenolate mofetil develops a malar rash, temperature 38.1 °C, and painful swelling of both wrists over one week. Blood and urine cultures are negative, creatinine is 68 µmol/L, urinalysis shows no protein or cellular casts, C3 and C4 are mildly reduced, and anti-double-stranded DNA titres are rising. Which is the most appropriate addition to her treatment?

A 47-year-old man with newly diagnosed Burkitt lymphoma developed laboratory tumor lysis syndrome 2 days after his first cycle of chemotherapy and was treated with aggressive intravenous hydration and a single dose of rasburicase. Five days later he is alert, has no cramps, tetany or arrhythmia, and urine output is 1.5 mL/kg per hour. Blood pressure is 124/76 mm Hg and heart rate is 84 beats/min. Laboratory studies now show uric acid 250 µmol/L, creatinine 105 µmol/L, potassium 4.2 mmol/L, phosphate 1.3 mmol/L, corrected calcium 2.30 mmol/L, bicarbonate 24 mmol/L and a falling lactate dehydrogenase. The oncology team is deciding whether the metabolic picture has recovered enough to give the next cycle. Which of the following sets of criteria best indicates readiness to resume chemotherapy?