SMLE (Saudi Medical Licensing Exam) · Internal Medicine

Clinical Cases

44 practice questions, each with the answer and an explanation.

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Random questions from this topic, one at a time. You see the answer and the explanation straight after each one.

All 44 questions

  1. A 58-year-old smoker has crushing central chest pain for 40 minutes. The ECG shows ST elevation in leads II, III and aVF. Which coronary artery is most likely occluded?
  2. A 65-year-old man with a recent myocardial infarction develops sudden breathlessness and a new loud pansystolic murmur at the apex with pulmonary oedema. What is the most likely cause?
  3. A 70-year-old woman with hypertension reports palpitations. Her pulse is irregularly irregular and the ECG shows no P waves. What is the most appropriate drug to reduce her risk of stroke?
  4. A 45-year-old man has polyuria, polydipsia and a random glucose of 18 mmol/L with ketones in the urine. What is the most appropriate immediate treatment?
  5. A 19-year-old girl with type 1 diabetes has abdominal pain, vomiting and deep sighing breathing. Blood gas shows a low pH and low bicarbonate. What is the diagnosis?
  6. A 55-year-old man with long-standing hypertension has sudden tearing chest pain radiating to the back. His blood pressure differs between the arms. What is the most likely diagnosis?
  7. A 30-year-old woman has fatigue, heat intolerance, weight loss, a diffuse goitre and exophthalmos. Which is the most likely diagnosis?
  8. A 40-year-old woman presents with tiredness, weight gain, cold intolerance and constipation. TSH is high and free T4 is low. What is the best treatment?
  9. A 25-year-old man has recurrent wheeze and cough worse at night and after exercise. Which drug should be used first as a reliever?
  10. A 60-year-old smoker has chronic cough, sputum and breathlessness. Spirometry shows an FEV1/FVC ratio of 0.55 that does not reverse with a bronchodilator. What is the diagnosis?
  11. A 28-year-old woman has a painful swollen left calf after a long flight, and then sudden pleuritic chest pain. What is the best first investigation for pulmonary embolism if the haemodynamics are stab…
  12. A 24-year-old student has fever, headache, neck stiffness and a non-blanching petechial rash. What is the most appropriate immediate management?
  13. A 35-year-old man has fever, night sweats, weight loss and a productive cough for 6 weeks. Chest X-ray shows an upper-lobe cavity. What is the most likely diagnosis?
  14. A 50-year-old man with alcoholic liver disease vomits fresh blood. Examination shows spider naevi and splenomegaly. What is the most likely source of bleeding?
  15. A 32-year-old woman has fatigue, itching and a raised alkaline phosphatase. Anti-mitochondrial antibodies are positive. What is the diagnosis?
  16. A 22-year-old man has bloody diarrhoea, abdominal cramps and weight loss. Colonoscopy shows continuous mucosal inflammation from the rectum. What is the diagnosis?
  17. A 45-year-old man has epigastric pain relieved by eating and a positive urea breath test. What is the treatment?
  18. A 62-year-old man has painless jaundice, weight loss and a palpable non-tender gallbladder. What is the most likely diagnosis?
  19. A 68-year-old woman has a Hb of 8 g/dL, MCV 112 fL and a smooth sore tongue. Which vitamin deficiency is most likely?
  20. A 28-year-old woman has fatigue, a Hb of 9 g/dL, MCV 68 fL and low ferritin. What is the most likely cause?
  21. A 6-year-old boy of Mediterranean descent has mild microcytic anaemia with a normal ferritin and an elevated HbA2. What is the diagnosis?
  22. A 20-year-old man with sickle cell disease has severe bone pain and fever. Which treatment is appropriate for the pain crisis?
  23. A 52-year-old woman has bone pain, anaemia, hypercalcaemia and renal impairment. Serum electrophoresis shows a paraprotein. What is the diagnosis?
  24. A 60-year-old man has night sweats, painless cervical lymph nodes and Reed-Sternberg cells on biopsy. What is the diagnosis?
  25. A 30-year-old woman has a butterfly rash, arthralgia and proteinuria. Which antibody is the most specific for her condition?
  26. A 55-year-old woman has symmetrical morning stiffness of the small joints of the hands lasting over an hour. What is the first-line disease-modifying drug?
  27. A 50-year-old man has a sudden red, hot, swollen first metatarsophalangeal joint. Aspiration shows negatively birefringent needle-shaped crystals. What is the diagnosis?
  28. A 48-year-old woman has a serum creatinine rising over 48 hours after a severe gastroenteritis. Urine sodium is low and urea:creatinine ratio is high. What is the likely cause?
  29. A 35-year-old man has haematuria, hypertension and oedema two weeks after a sore throat. Complement C3 is low. What is the diagnosis?
  30. A 7-year-old child has facial swelling, heavy proteinuria and a normal blood pressure. Which is the most likely diagnosis and treatment?
  31. A diabetic patient has a potassium of 7.1 mmol/L with peaked T waves. What is the first drug to give?
  32. A 65-year-old man has a sodium of 118 mmol/L, low serum osmolality and concentrated urine in the presence of a small cell lung tumour. What is the likely cause?
  33. A 40-year-old woman has episodic headache, sweating and palpitations with a blood pressure of 210/120. Urinary metanephrines are raised. What is the diagnosis?
  34. A 33-year-old man has progressive muscle weakness that is worse at the end of the day and ptosis. Which test is most specific?
  35. A 68-year-old man has a resting tremor, rigidity and bradykinesia. What is the first-line drug?
  36. A 72-year-old woman has sudden weakness of the right arm and face and slurred speech for 1 hour. CT head shows no haemorrhage. What is the treatment within the time window?
  37. A 25-year-old woman has a unilateral throbbing headache with nausea and photophobia that lasts for 12 hours. What is the diagnosis?
  38. A 30-year-old man has a sudden worst-ever headache with neck stiffness. CT head is normal at 12 hours. What is the next investigation?
  39. A 55-year-old man with HIV has a CD4 count of 80 and headache. India ink stain of CSF shows encapsulated yeast. What is the cause?
  40. A 22-year-old student has fever, sore throat, tonsillar exudate and generalised lymphadenopathy. A rash appears after amoxicillin. What is the likely diagnosis?
  41. A traveller returns from a malaria area with fever and rigors. Which is the best initial test?
  42. A 35-year-old woman has dysuria, frequency and a positive nitrite and leucocyte esterase on urinalysis. What is the most likely organism?
  43. A 60-year-old man on warfarin has an INR of 9 with no bleeding. What is the best management?
  44. A 66-year-old man has dyspnoea, ankle oedema and an ejection fraction of 30 percent. Which drug improves survival in heart failure?

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