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First-trimester combined screening uses fetal nuchal translucency with maternal serum biochemical markers. It provides risk assessment for common aneuploidies. 21. B. HPV 16 HPV 16 is one of the major high-risk oncogenic HPV types strongly associated with cervical carcinoma. HPV 18 is another important high-risk type. 22. C. Ovarian torsion Acute unilateral pelvic pain with vomiting and reduced ovarian blood flow strongly suggests torsion. It is a gynecologic surgical emergency requiring prompt detorsion. 23. D. Sudden intrauterine fetal death Intrahepatic cholestasis of pregnancy is associated with increased fetal risk, particularly stillbirth. Maternal pruritus with elevated bile acids is characteristic. 24. A. Serum AMH Anti-Müllerian hormone reflects the pool of growing ovarian follicles and is commonly used as an ovarian reserve marker. It is relatively independent of the menstrual cycle. 25. B. Bartholin gland A painless cystic swelling at the posterolateral vaginal introitus is characteristic of a Bartholin cyst. The glands are located near the posterior vaginal vestibule. 26. B. Adenomyosis Adenomyosis typically causes heavy menstrual bleeding and dysmenorrhea with a diffusely enlarged, globular uterus. Unlike fibroids, there is usually no discrete mass. 27. C. Postpartum endometritis Fever, uterine tenderness and foul-smelling lochia after delivery strongly indicate postpartum endometritis. Broad-spectrum IV antibiotics are the standard treatment for significant infection. 28. B. Placenta accreta spectrum Placenta previa with multiple previous cesareans and placental lacunae strongly suggests abnormal placental invasion. Placenta accreta spectrum carries a major risk of severe obstetric hemorrhage. 29. A. Complete hydatidiform mole Excessive β-hCG, uterus larger than dates and a snowstorm ultrasound appearance are classic for complete mole. A complete mole usually lacks an embryo or fetus. 30. B. Sheehan syndrome Postpartum hemorrhage followed by failure to lactate and secondary amenorrhea suggests postpartum pituitary ischemic necrosis. Low gonadotropins and estrogen support hypopituitarism.

ANSWER KEY + EXPLANATIONS 1. B. Cesarean delivery after stabilization Placenta previa causes painless third-trimester bleeding with a soft, non-tender uterus. Complete previa at term requires cesarean delivery; digital vaginal examination is contraindicated. 2. A. Magnesium sulfate followed by delivery Severe preeclampsia with thrombocytopenia, elevated liver enzymes and severe symptoms indicates HELLP/severe disease. At ≥34 weeks, stabilization followed by delivery is definitive; magnesium prevents seizures. 3. C. Methotrexate therapy Stable ectopic pregnancy with an adnexal mass and no major hemoperitoneum can be treated medically. Methotrexate is appropriate when eligibility criteria are fulfilled. 4. D. Occipitotransverse position The sagittal suture lying in the transverse diameter indicates an occipitotransverse position. Persistent transverse arrest may require operative intervention or cesarean delivery depending on circumstances. 5. B. Diagnostic laparoscopy with chromopertubation Laparoscopy with chromopertubation directly assesses tubal patency and pelvic pathology. It can also identify and treat endometriosis or adhesions. 6. A. Cabergoline A small prolactinoma causing hyperprolactinemia is treated first-line with a dopamine agonist. Cabergoline is generally preferred because of its high efficacy and convenient dosing. 7. C. Hysterectomy Symptomatic fibroids with significant anemia in a woman who has completed her family can be definitively treated with hysterectomy. Myomectomy is preferred when future fertility is desired. 8. B. Ceftriaxone plus doxycycline with metronidazole PID requires coverage against gonorrhea, chlamydia and anaerobic organisms. The standard outpatient regimen combines ceftriaxone, doxycycline and metronidazole. 9. C. Digital vaginal examination Digital examination can disrupt a placenta overlying or near the cervical os and cause massive hemorrhage. Ultrasound, including transvaginal ultrasound when appropriately performed, is safe and useful. 10. D. Oxytocin Uterine atony is the most common cause of primary postpartum hemorrhage. Oxytocin is the first-line uterotonic after uterine massage and initial resuscitation. 11. A. HELLP syndrome HELLP stands for hemolysis, elevated liver enzymes and low platelets. It is a severe hypertensive disorder of pregnancy requiring maternal stabilization and delivery. 12. B. Hyperemesis gravidarum Severe persistent vomiting with weight loss, dehydration, ketonuria and electrolyte abnormalities indicates hyperemesis gravidarum. Treatment includes IV fluids, electrolyte correction and antiemetics. 13. C. Endometrial biopsy Postmenopausal bleeding with increased endometrial thickness requires evaluation for endometrial hyperplasia or carcinoma. Endometrial sampling is the key diagnostic investigation. 14. C. Mayer-Rokitansky-Küster-Hauser syndrome MRKH syndrome presents with primary amenorrhea, normal secondary sexual characteristics and absent uterus. The karyotype is typically 46,XX with normal ovarian function. 15. A. Endometriosis Severe dysmenorrhea, deep dyspareunia, infertility and posterior fornix tenderness strongly suggest endometriosis. A fixed retroverted uterus is another classic examination clue. 16. D. Placental abruption Painful vaginal bleeding with a tense, tender uterus and fetal distress is classic for placental abruption. Placenta previa typically causes painless bleeding with a soft uterus. 17. A. Combined oral contraceptive pills For PCOS with menstrual irregularity when pregnancy is not desired, combined OCPs are first-line for cycle control. They also reduce androgen-related symptoms. 18. C. Placenta accreta Failure of placental separation with hemorrhage after cesarean delivery strongly suggests placenta accreta spectrum. Previous cesarean plus placenta previa is a major risk combination. 19. D. Nitrazine test Amniotic fluid is alkaline and turns nitrazine paper blue. Pooling of fluid plus a positive nitrazine test supports rupture of membranes. 20. A. Nuchal translucency with maternal serum markers

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Which is the standard first-trimester combined screening approach? A. Nuchal translucency with maternal serum markers B. Maternal serum AFP alone C. Quadruple test only D. Amniocentesis for every pregnancy 21. A 40-year-old woman presents with postcoital bleeding. On speculum examination, the cervix appears irregular and friable. Pap smear is abnormal and subsequent biopsy shows invasive squamous cell carcinoma. Which HPV type is most strongly associated with cervical cancer? A. HPV 6 B. HPV 16 C. HPV 11 D. HPV 42 22. A 27-year-old woman presents with acute unilateral pelvic pain and vomiting. Pregnancy test is negative and ultrasound shows an enlarged ovary with peripheral follicles. Doppler demonstrates reduced venous and arterial flow. Which is the most likely diagnosis? A. Ruptured ectopic pregnancy B. Pelvic inflammatory disease C. Ovarian torsion D. Endometrial carcinoma 23. A 30-year-old woman at 35 weeks presents with severe itching over the palms and soles. There is no primary skin rash. Laboratory tests show elevated serum bile acids and mild elevation of transaminases. Which fetal complication is particularly associated with this condition? A. Neural tube defect B. Fetal macrosomia C. Congenital cataract D. Sudden intrauterine fetal death 24. A 29-year-old woman presents with inability to conceive for 2 years. She has regular cycles and no symptoms of hyperandrogenism. Semen analysis is normal and ovulation is confirmed. Hysterosalpingography shows bilateral tubal patency. Which investigation is most useful for assessing the ovarian reserve? A. Serum AMH B. Serum hCG C. Serum bilirubin D. Serum cortisol 25. A 26-year-old woman presents with a painless vulvar swelling near the vaginal opening. The swelling is fluctuant and located at the posterolateral aspect of the vaginal introitus. There is no fever or systemic illness. Which structure is most likely involved? A. Skene gland B. Bartholin gland C. Paraurethral ligament D. Clitoris 26. A 38-year-old woman presents with heavy menstrual bleeding and dysmenorrhea. Ultrasound shows a diffusely enlarged, globular uterus with heterogeneous myometrial echotexture. There is no discrete uterine mass. Which diagnosis is most likely? A. Leiomyoma B. Adenomyosis C. Endometrial polyp D. Ovarian endometrioma 27. A 24-year-old woman develops fever and lower abdominal pain 3 days after an uncomplicated vaginal delivery. The uterus is tender and there is foul-smelling lochia. She has a temperature of 39°C and leukocytosis. Which is the most likely diagnosis? A. Mastitis B. Urinary tract infection C. Postpartum endometritis D. Septic pelvic thrombophlebitis 28. A 32-year-old woman with two previous cesarean deliveries presents at 34 weeks. Ultrasound shows placenta previa with multiple placental lacunae. Color Doppler demonstrates increased vascularity at the uteroplacental interface. Which condition should be strongly suspected? A. Placental abruption B. Placenta accreta spectrum C. Circumvallate placenta D. Placental infarction 29. A 30-year-old woman at 10 weeks presents with vaginal bleeding and excessive nausea. Uterus is larger than expected for gestational age and fetal parts are not palpable. Serum β-hCG is markedly elevated and ultrasound shows a snowstorm appearance. Which is the most likely diagnosis? A. Complete hydatidiform mole B. Partial hydatidiform mole C. Missed abortion D. Ectopic pregnancy 30. A 35-year-old woman presents with secondary amenorrhea following a complicated postpartum hemorrhage. She reports inability to lactate after delivery and persistent fatigue. Serum FSH, LH and estrogen levels are low. MRI shows no pituitary mass. Which diagnosis is most likely? A. PCOS B. Sheehan syndrome C. Premature ovarian insufficiency D. Asherman syndrome

A 27-year-old woman presents with postpartum hemorrhage immediately after vaginal delivery. The uterus is enlarged, soft and poorly contracted. There are no retained placental fragments and no genital tract laceration. Her blood pressure is currently stable. Which is the first-line uterotonic drug? A. Methotrexate B. Magnesium sulfate C. Misoprostol only D. Oxytocin 11. A 34-year-old woman at 37 weeks presents with severe epigastric pain and nausea. Her blood pressure is 160/105 mmHg and she has generalized edema. Laboratory tests show elevated AST/ALT, thrombocytopenia and evidence of hemolysis. Peripheral smear shows fragmented red cells. Which diagnosis best explains this presentation? A. HELLP syndrome B. Acute fatty liver of pregnancy C. Intrahepatic cholestasis of pregnancy D. Gestational thrombocytopenia 12. A 30-year-old woman presents at 10 weeks of pregnancy with persistent vomiting. She is dehydrated and has lost 5 kg from her pre-pregnancy weight. Urinalysis shows ketonuria and serum electrolytes reveal hypokalemia. There is no evidence of gastrointestinal infection. What is the most likely diagnosis? A. Acute appendicitis B. Hyperemesis gravidarum C. Placental abruption D. Molar pregnancy 13. A 42-year-old woman presents with irregular postmenopausal bleeding. She has obesity, hypertension and diabetes mellitus. Transvaginal ultrasound shows an endometrial thickness of 9 mm. What is the next most appropriate investigation? A. CA-125 estimation B. Pap smear alone C. Endometrial biopsy D. Serum progesterone 14. A 25-year-old woman presents with primary amenorrhea. She has normal breast development and scant axillary and pubic hair. Pelvic examination reveals a short blind-ending vagina. Ultrasound shows absence of the uterus and upper vagina. Which diagnosis is most likely? A. Turner syndrome B. Imperforate hymen C. Mayer-Rokitansky-Küster-Hauser syndrome D. Asherman syndrome 15. A 33-year-old woman presents with infertility and severe dysmenorrhea. She reports deep dyspareunia and chronic pelvic pain that worsens during menstruation. Pelvic examination reveals a fixed retroverted uterus with tenderness in the posterior fornix. Which diagnosis is most likely? A. Endometriosis B. Polycystic ovary syndrome C. Cervical polyp D. Functional ovarian cyst 16. A 29-year-old pregnant woman at 36 weeks presents with sudden severe abdominal pain. There is dark vaginal bleeding and the uterus is tense and tender. Fetal heart rate shows persistent bradycardia. Which diagnosis is most likely? A. Placenta previa B. Vasa previa C. Uterine rupture D. Placental abruption 17. A 22-year-old woman presents with oligomenorrhea, acne and increased facial hair. Her BMI is 31 kg/m² and ultrasound shows multiple small peripheral ovarian follicles. Pregnancy test is negative and thyroid function is normal. Which is the most appropriate first-line treatment for menstrual irregularity when pregnancy is not desired? A. Combined oral contraceptive pills B. Immediate ovarian drilling C. Gonadotropin injections D. Bilateral oophorectomy 18. A 37-year-old woman with a previous cesarean delivery presents in labor at 39 weeks. After delivery of the baby, the placenta fails to separate despite controlled cord traction. There is brisk vaginal bleeding and the uterus remains firm. What is the most likely diagnosis? A. Uterine atony B. Uterine inversion C. Placenta accreta D. Cervical tear 19. A 28-year-old woman at 30 weeks presents with watery vaginal discharge. On examination, pooling of clear fluid is seen in the posterior vaginal fornix. The fetal heart rate is normal and there are no contractions. Which test most directly confirms rupture of membranes? A. Serum β-hCG B. Kleihauer-Betke test C. Amniotic fluid bilirubin D. Nitrazine test 20. A 36-year-old woman presents at 11 weeks of pregnancy for routine screening. She has no significant medical history and ultrasound shows a viable singleton pregnancy. She asks about screening for common fetal chromosomal abnormalities.

OBGY MCQs 1. A 26-year-old primigravida at 34 weeks presents with painless bright-red vaginal bleeding. She has no abdominal pain or uterine contractions. The uterus is soft and non-tender, and fetal heart rate is reassuring. Ultrasound shows the placenta completely covering the internal cervical os. What is the most appropriate next step? A. Digital vaginal examination B. Cesarean delivery after stabilization C. Immediate induction with oxytocin D. Amniotomy followed by vaginal delivery 2. A 28-year-old woman at 32 weeks presents with severe headache and visual disturbances. Her blood pressure is 170/110 mmHg on repeated measurements. Urine examination shows 3+ proteinuria and platelet count is 90,000/mm³. She has right upper-quadrant pain and elevated liver enzymes. What is the definitive management? A. Magnesium sulfate followed by delivery B. Continue pregnancy until 37 weeks C. Oral antihypertensive therapy alone D. Betamethasone and outpatient monitoring 3. A 30-year-old woman presents with 7 weeks of amenorrhea and lower abdominal pain. Urine pregnancy test is positive and serum β-hCG is 2500 mIU/mL. Transvaginal ultrasound shows an empty uterine cavity and a left adnexal mass. She is hemodynamically stable with no evidence of significant hemoperitoneum. What is the most appropriate management? A. Immediate laparotomy B. Expectant management in all cases C. Methotrexate therapy D. Dilatation and curettage 4. A 24-year-old primigravida at 39 weeks is in active labor. The fetal head remains high despite adequate uterine contractions. Vaginal examination shows the sagittal suture in the transverse diameter. The fetal heart tracing is currently reassuring. Which fetal malposition is most likely responsible? A. Occipitoanterior position B. Face presentation C. Brow presentation D. Occipitotransverse position 5. A 32-year-old woman presents with infertility for 3 years despite regular unprotected intercourse. Her menstrual cycles are regular and ovulatory. Her husband's semen analysis is normal. Hysterosalpingography demonstrates bilateral tubal block at the ampullary region. Which procedure is most useful for definitive assessment and possible treatment? A. Endometrial biopsy B. Diagnostic laparoscopy with chromopertubation C. Serum prolactin estimation D. Hysteroscopy alone 6. A 29-year-old woman presents with secondary amenorrhea and milky nipple discharge. She is not pregnant and is not taking dopamine-blocking medications. Serum prolactin is markedly elevated on repeated testing. MRI of the pituitary demonstrates a 5-mm pituitary microadenoma. What is the treatment of choice? A. Cabergoline B. Transsphenoidal surgery immediately C. Combined oral contraceptive pills D. Radioiodine therapy 7. A 35-year-old woman presents with heavy menstrual bleeding and pelvic pressure. On examination, the uterus is enlarged and irregular but mobile. Ultrasound shows multiple well-circumscribed hypoechoic masses within the myometrium. Her hemoglobin is 8 g/dL and she has completed her family. Which is the definitive surgical treatment? A. Endometrial ablation B. Myomectomy C. Hysterectomy D. Cervical cerclage 8. A 23-year-old woman presents with acute lower abdominal pain and fever. She has purulent cervical discharge and marked cervical motion tenderness. Pregnancy test is negative and pelvic ultrasound shows no tubo-ovarian abscess. She is diagnosed with pelvic inflammatory disease. Which outpatient antibiotic regimen is most appropriate? A. Acyclovir alone B. Ceftriaxone plus doxycycline with metronidazole C. Fluconazole plus azithromycin D. Penicillin V alone 9. A 31-year-old woman at 28 weeks of pregnancy presents with painless vaginal bleeding. Ultrasound confirms a low-lying placenta without complete previa. There is no active bleeding and the mother is hemodynamically stable. Fetal growth and fetal heart rate are normal. Which investigation should be avoided because of the risk of severe hemorrhage? A. Transabdominal ultrasound B. Transvaginal ultrasound C. Digital vaginal examination D. Fetal growth assessment 10.

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Severe symptomatic hyponatremia with seizures requires urgent cautious correction using 3% hypertonic saline. Correction must be controlled to avoid osmotic demyelination. 22. C. Gilbert syndrome Mild intermittent unconjugated hyperbilirubinemia triggered by fasting or stress with normal liver enzymes is classic for Gilbert syndrome. No specific treatment is required. 23. D. Aggressive IV fluid resuscitation Early aggressive fluid resuscitation is a key component of initial management of acute pancreatitis, especially with hypovolemia. Monitor urine output, hemodynamics and hematocrit closely. 24. A. Dermatomyositis Proximal muscle weakness plus heliotrope rash and Gottron papules strongly indicate dermatomyositis. Markedly elevated CK reflects inflammatory muscle injury. 25. C. Septic pulmonary emboli Right-sided tricuspid endocarditis, especially in IV drug users, commonly produces septic pulmonary emboli. S. aureus is the classic causative organism. 26. A. Increased methylmalonic acid Vitamin B12 deficiency causes macrocytic anemia with neurologic manifestations. Both methylmalonic acid and homocysteine increase, distinguishing it from folate deficiency. 27. D. Pulmonary embolism Recent major orthopedic surgery, sudden dyspnea, hypoxemia and a CT pulmonary arterial filling defect indicate acute PE. Anticoagulation is the standard treatment in hemodynamically stable patients. 28. C. Achalasia cardia Progressive dysphagia to solids and liquids with regurgitation and smooth distal esophageal tapering suggests achalasia. Failure of LES relaxation with absent peristalsis is characteristic. 29. B. Dopamine Parkinson disease results from degeneration of dopaminergic neurons in the substantia nigra pars compacta. Resting tremor, rigidity and bradykinesia are classic manifestations. 30. B. Thyrotoxic periodic paralysis Young Asian men with thyrotoxicosis can develop episodic hypokalemic paralysis, often after carbohydrate-rich meals. The hypokalemia results mainly from intracellular potassium shift.

ANSWER KEY + EXPLANATIONS 1. B. IV fluid bolus Inferior MI with RV infarction causes preload dependence, hypotension and raised JVP. Give IV fluids; nitrates and diuretics can worsen hypotension. 2. A. TSH receptor antibody Graves disease is caused by stimulating TSH receptor antibodies. Diffuse goiter, ophthalmopathy and diffusely increased radioactive iodine uptake support the diagnosis. 3. C. Non-invasive positive-pressure ventilation Acute-on-chronic hypercapnic respiratory failure with respiratory acidosis in COPD is an indication for NIV. It reduces work of breathing and improves alveolar ventilation. 4. D. Lumbar puncture When CT is nondiagnostic but clinical suspicion for subarachnoid hemorrhage remains high, CSF examination is required. Xanthochromia supports the diagnosis. 5. B. IV thiamine The triad of confusion, ophthalmoplegia and ataxia in a malnourished alcoholic indicates Wernicke encephalopathy. Thiamine must be given before glucose to avoid worsening neurologic injury. 6. A. Hashimoto thyroiditis Primary hypothyroidism with a firm diffuse goiter and strongly positive anti-TPO antibodies is typical of Hashimoto thyroiditis. It is the commonest autoimmune cause of hypothyroidism. 7. D. IV alteplase Acute ischemic stroke within the appropriate therapeutic window and without hemorrhage can be treated with IV thrombolysis. Alteplase promotes fibrinolysis and recanalization. 8. B. Phenoxybenzamine Pheochromocytoma requires adequate alpha blockade before surgery. Beta-blockade must never precede alpha blockade because unopposed alpha stimulation can cause severe hypertension. 9. C. Acute mesenteric ischemia Severe abdominal pain out of proportion to examination, especially with atrial fibrillation, strongly suggests embolic mesenteric ischemia. CT angiography is diagnostic and urgent revascularization may be required. 10. D. Emergency ERCP with biliary decompression Ascending cholangitis with shock and biliary obstruction requires urgent source control. ERCP provides rapid biliary drainage after initial resuscitation and antibiotics. 11. A. Primary hyperaldosteronism Hypertension, hypokalemia, metabolic alkalosis, suppressed renin and elevated aldosterone indicate primary hyperaldosteronism. An elevated aldosterone-to-renin ratio is the key screening test. 12. B. IV calcium gluconate In severe hyperkalemia with ECG changes, IV calcium stabilizes the cardiac membrane immediately. It does not lower potassium, so potassium-shifting and removal therapies follow. 13. C. Cryptococcus neoformans Cryptococcal meningitis commonly occurs in advanced HIV infection. Encapsulated budding yeast and positive India ink preparation are classic clues. 14. C. Lactulose Hepatic encephalopathy with asterixis is treated initially with lactulose. It acidifies the colon and converts ammonia to nonabsorbable ammonium, reducing systemic ammonia. 15. B. Heart failure with preserved ejection fraction Preserved EF with impaired relaxation, hypertension and LV hypertrophy indicate HFpEF. Diastolic dysfunction is the central abnormality. 16. D. Streptococcus pneumoniae Lancet-shaped gram-positive diplococci are characteristic of S. pneumoniae. It remains a classic cause of community-acquired lobar pneumonia. 17. A. Post-streptococcal glomerulonephritis Nephritic syndrome appearing 1–3 weeks after streptococcal infection with low C3 is typical of PSGN. RBC casts indicate glomerular inflammation. 18. C. SIADH Small-cell lung carcinoma is strongly associated with ectopic ADH secretion. Hyponatremia, low serum osmolality and inappropriately concentrated urine are characteristic. 19. D. IV hydrocortisone with isotonic saline Adrenal crisis presents with hypotension, hyponatremia, hyperkalemia and low cortisol. Immediate IV hydrocortisone plus aggressive isotonic fluid resuscitation is lifesaving. 20. A. Lipase Lipase is more specific than amylase for acute pancreatitis and remains elevated longer. Gallstones and alcohol are the two major common causes. 21. B. Hypertonic 3% saline

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She has no signs of hypovolemia or edema. What is the appropriate immediate treatment for severe symptomatic hyponatremia? A. Oral salt tablets only B. Hypertonic 3% saline C. Dextrose 5% infusion D. Normal saline at maintenance rate 22. A 34-year-old man presents with recurrent episodes of jaundice. Episodes occur after fasting or strenuous exercise and resolve spontaneously. Total bilirubin is mildly elevated with predominantly unconjugated hyperbilirubinemia. Liver enzymes and hemoglobin are normal. What is the most likely diagnosis? A. Dubin-Johnson syndrome B. Crigler-Najjar syndrome C. Gilbert syndrome D. Hemolytic anemia 23. A 58-year-old man with chronic alcohol use presents with severe epigastric pain and vomiting. He is tachycardic, hypotensive and has abdominal distension. Laboratory tests show elevated lipase and rising hematocrit. There is no evidence of cardiac or renal failure. What is the most important initial management principle? A. Immediate laparotomy B. Prophylactic antibiotics in all cases C. High-dose steroids D. Aggressive IV fluid resuscitation 24. A 38-year-old woman presents with proximal muscle weakness and difficulty climbing stairs. She has a heliotrope rash and violaceous papules over the knuckles. Creatine kinase is markedly elevated. Electromyography shows a myopathic pattern. Which diagnosis is most likely? A. Dermatomyositis B. Myasthenia gravis C. Guillain-Barré syndrome D. Polymyalgia rheumatica 25. A 55-year-old man presents with fever, weight loss and a new cardiac murmur. He has a history of intravenous drug use. Blood cultures repeatedly grow Staphylococcus aureus. Echocardiography shows a vegetation on the tricuspid valve. Which complication is particularly associated with this condition? A. Splenic infarction only B. Rheumatic mitral stenosis C. Septic pulmonary emboli D. Aortic dissection 26. A 44-year-old woman presents with fatigue, pallor and numbness in both feet. She has a smooth beefy tongue and impaired vibration sensation. CBC shows macrocytosis and hypersegmented neutrophils. Serum vitamin B12 is low. Which additional finding is most likely? A. Increased methylmalonic acid B. Decreased homocysteine C. Increased serum ferritin only D. Microcytosis 27. A 63-year-old man develops sudden severe dyspnea and pleuritic chest pain. He underwent hip replacement 10 days ago. He is tachycardic and hypoxemic, and ECG shows sinus tachycardia. CT pulmonary angiography demonstrates a large pulmonary arterial filling defect. What is the most likely diagnosis? A. Acute pericarditis B. Tension pneumothorax C. Acute myocardial infarction D. Pulmonary embolism 28. A 52-year-old man presents with progressive difficulty swallowing solids followed by liquids. He has regurgitation of undigested food and nocturnal cough. Barium swallow shows smooth tapering at the gastroesophageal junction. Upper endoscopy excludes a mechanical obstruction. What is the most likely diagnosis? A. Esophageal carcinoma B. Diffuse esophageal spasm C. Achalasia cardia D. Peptic stricture 29. A 68-year-old man presents with tremor, bradykinesia and rigidity. His tremor is prominent at rest and decreases during voluntary movement. He has a shuffling gait and reduced arm swing. There is no history of drug-induced parkinsonism. Which neurotransmitter deficiency is central to this disorder? A. Acetylcholine B. Dopamine C. GABA D. Serotonin 30. A 47-year-old woman presents with recurrent episodes of muscle weakness. Episodes occur after carbohydrate-rich meals and last several hours. Serum potassium during an attack is 2.5 mEq/L. Thyroid function tests show suppressed TSH with elevated free T4. Which diagnosis best explains the presentation? A. Addisonian crisis B. Thyrotoxic periodic paralysis C. Myasthenic crisis D. Familial hyperkalemic periodic paralysis

A 50-year-old woman presents with recurrent episodes of proximal muscle weakness. She has hypertension and occasional muscle cramps. Serum potassium is 2.4 mEq/L and bicarbonate is elevated. Plasma renin is suppressed and aldosterone is markedly elevated. What is the most likely diagnosis? A. Primary hyperaldosteronism B. Addison disease C. SIADH D. Renal tubular acidosis 12. A 67-year-old man with chronic kidney disease presents with weakness and palpitations. ECG shows tall peaked T waves and widening of the QRS complex. Serum potassium is 7.2 mEq/L. There are no clinical features suggesting hypocalcemia. Which treatment should be given first to stabilize the myocardium? A. IV insulin with glucose B. IV calcium gluconate C. Oral sodium polystyrene sulfonate D. Nebulized salbutamol 13. A 30-year-old woman presents with fever, neck stiffness and altered sensorium. CSF shows high opening pressure, lymphocytic predominance and low glucose. India ink preparation demonstrates encapsulated budding yeast. She is HIV-positive with a very low CD4 count. Which organism is responsible? A. Candida albicans B. Aspergillus fumigatus C. Cryptococcus neoformans D. Toxoplasma gondii 14. A 48-year-old man with cirrhosis presents with confusion and altered behavior. He has asterixis and no focal neurological deficits. Serum ammonia is elevated and there is no evidence of intracranial bleeding. Which treatment is most appropriate for the acute episode? A. Mannitol B. Levodopa C. Lactulose D. Phenytoin 15. A 56-year-old woman presents with progressive exertional dyspnea and fatigue. Echocardiography shows preserved ejection fraction with impaired ventricular relaxation. She has long-standing hypertension and left ventricular hypertrophy. There is no significant valvular disease. Which type of heart failure is most likely? A. High-output heart failure B. Heart failure with preserved ejection fraction C. Right-sided failure due to pulmonary embolism D. Heart failure with reduced ejection fraction 16. A 40-year-old man presents with fever, productive cough and pleuritic chest pain. Chest X-ray shows right lower-lobe consolidation with air bronchograms. Sputum Gram stain demonstrates lancet-shaped gram-positive diplococci. Which organism is the most likely cause? A. Klebsiella pneumoniae B. Staphylococcus aureus C. Mycoplasma pneumoniae D. Streptococcus pneumoniae 17. A 19-year-old man develops cola-colored urine and periorbital puffiness. He had an episode of sore throat approximately 2 weeks earlier. Urinalysis shows RBC casts and significant hematuria. Serum C3 is reduced. Which diagnosis best explains these findings? A. Post-streptococcal glomerulonephritis B. IgA nephropathy C. Minimal-change disease D. Membranous nephropathy 18. A 62-year-old smoker presents with chronic cough and weight loss. Chest imaging shows a central hilar mass. Serum sodium is 118 mEq/L with low serum osmolality and inappropriately concentrated urine. There is no edema or significant renal disease. Which paraneoplastic syndrome is most likely? A. Hypercalcemia due to PTHrP B. Polycythemia C. SIADH D. Cushing syndrome 19. A 28-year-old woman presents with fatigue, dizziness and hyperpigmentation. She has recurrent vomiting, abdominal pain and postural hypotension. Serum sodium is low and potassium is elevated. Morning cortisol is low with markedly elevated ACTH. Which treatment is required for acute adrenal crisis? A. Methimazole B. Desmopressin C. Furosemide D. IV hydrocortisone with isotonic saline 20. A 46-year-old man presents with severe epigastric pain radiating to the back. He has repeated vomiting and a history of gallstones. Serum lipase is more than three times the upper limit of normal. Ultrasound shows gallstones without evidence of common bile duct obstruction. Which enzyme is more specific for acute pancreatitis? A. Lipase B. Amylase C. Alkaline phosphatase D. AST 21. A 72-year-old woman develops confusion and a generalized seizure. She is taking a thiazide diuretic for hypertension. Serum sodium is 112 mEq/L with low serum osmolality.