Afghanistan Medical Exit Exam (AMC Government Exit Exam — Medicine) Feed

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A 58-year-old male presents to the emergency department with severe, crushing substernal chest pain radiating to the left arm and jaw that started 90 minutes ago. ECG reveals 3 mm ST-segment elevation in leads V1 through V4. His blood pressure is 135/85 mmHg and pulse is 88 bpm. What is the immediate, most appropriate reperfusion strategy?

Internal Medicine

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A 65-year-old female with a history of hypertension and chronic heart failure presents with worsening dyspnea on exertion, orthopnea, and bilateral lower extremity edema. On examination, jugular venous pressure is elevated and bilateral lung basilar crackles are heard. Echocardiography shows a left ventricular ejection fraction (LVEF) of 32%. Which combination of disease-modifying pharmacotherapies has been demonstrated to reduce mortality in heart failure with reduced ejection fraction (HFrEF)?

Internal Medicine

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A 72-year-old male with long-standing poorly controlled hypertension presents with acute onset of severe, tearing interscapular back pain. On physical examination, blood pressure is 185/110 mmHg in the right arm and 140/85 mmHg in the left arm. A grade II/VI early diastolic murmur is heard along the right sternal border. What is the most definitive diagnostic imaging test of choice in a hemodynamically stable patient?

Internal Medicine

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A 62-year-old female presents with palpitations and lightheadedness. An ECG demonstrates irregularly irregular narrow-complex tachycardia with no identifiable P waves and a ventricular rate of 145 bpm. Her blood pressure is 125/80 mmHg. She has a history of type 2 diabetes and hypertension. What is her CHA2DS2-VASc score, and what long-term stroke prevention is indicated?

Internal Medicine

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A 48-year-old male with a history of IV drug use presents with high fever, chills, night sweats, and progressive fatigue for 3 weeks. On physical examination, temperature is 39.1°C, and a new 3/6 holosystolic murmur is heard at the lower left sternal border that increases in intensity with inspiration (Carvallo sign). Transthoracic echocardiography reveals a 12 mm mobile vegetation on the tricuspid valve. What is the most common causative organism?

Internal Medicine

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A 68-year-old male is brought to the clinic with fever, productive cough with rust-colored sputum, and right-sided pleuritic chest pain for 3 days. On physical examination, he is confused (disoriented to time and place), respiratory rate is 32 breaths/min, blood pressure is 88/56 mmHg, pulse is 112 bpm, and blood urea nitrogen is 28 mg/dL (10 mmol/L). Chest X-ray reveals right lower lobe consolidation. Based on the CURB-65 criteria, what is his score and appropriate level of care?

Internal Medicine

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A 34-year-old male from rural Afghanistan presents with a 2-month history of productive cough, hemoptysis, low-grade evening fever, drenching night sweats, and a 7 kg weight loss. A chest radiograph demonstrates bilateral upper lobe cavitary infiltrates. Sputum GeneXpert MTB/RIF confirms Mycobacterium tuberculosis without rifampicin resistance. According to the National Tuberculosis Control Program and WHO guidelines, what is the standard first-line treatment regimen for drug-susceptible pulmonary tuberculosis?

Internal Medicine

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A 60-year-old male with a 40 pack-year smoking history presents with worsening dyspnea and chronic productive cough. Spirometry demonstrates a post-bronchodilator FEV1/FVC ratio of 0.58 and an FEV1 of 45% of predicted value. He experiences frequent exacerbations despite regular use of a short-acting beta-agonist. According to GOLD guidelines, which maintenance inhaler therapy is most appropriate?

Internal Medicine

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A 24-year-old female presents with acute shortness of breath and wheezing. She is using her accessory muscles of respiration, speech is limited to single words, respiratory rate is 36 breaths/min, heart rate is 130 bpm, and oxygen saturation on room air is 89%. Auscultation reveals widespread expiratory wheezing with quiet breath sounds at the bases. What is the immediate first-line emergency management?

Internal Medicine

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A 52-year-old male with chronic hepatitis B cirrhosis presents to the emergency department with hematemesis and melena. On arrival, blood pressure is 85/50 mmHg, pulse is 120 bpm, and he appears pale and confused. In addition to securing the airway and initiating IV crystalloid fluid resuscitation, what is the most appropriate initial pharmacological and procedural management?

Internal Medicine

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A 45-year-old male with decompensated alcoholic cirrhosis presents with worsening abdominal distension, mild abdominal tenderness, low-grade fever (38.2°C), and altered mental status. Diagnostic paracentesis is performed. Analysis of the ascitic fluid reveals an absolute neutrophil count of 420 cells/mm3 (0.42 x 10^9/L). What is the definitive diagnosis and first-line treatment?

Internal Medicine

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A 28-year-old male healthcare worker presents for evaluation after receiving a 3-dose Hepatitis B vaccination series 6 months ago. His serology results are: HBsAg negative, anti-HBc IgM negative, anti-HBc IgG negative, and anti-HBs positive (titer > 100 mIU/mL). How should these laboratory findings be interpreted?

Internal Medicine

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A 22-year-old female with a 5-year history of type 1 diabetes is brought to the emergency department obtunded. Her breathing is deep and rapid (Kussmaul breathing) with a fruity odor on her breath. Blood glucose is 480 mg/dL, arterial blood gas shows pH 7.15, serum bicarbonate is 8 mEq/L, anion gap is 24 mEq/L, and serum potassium is 5.2 mEq/L. Urine is strongly positive for ketones. What is the fundamental initial sequence of management for Diabetic Ketoacidosis (DKA)?

Internal Medicine

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A 35-year-old female presents with weight loss, heat intolerance, hand tremors, palpitations, and frequent bowel movements. On physical examination, her thyroid gland is diffusely enlarged, non-tender, with a distinct bruit heard over the lobes. She has mild bilateral exophthalmos and lid lag. Serum TSH is < 0.01 mIU/L and free T4 is elevated at 3.8 ng/dL. What is the most likely underlying diagnosis and its characteristic autoantibody?

Internal Medicine

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A 40-year-old female presents with chronic fatigue, anorexia, weight loss, dizziness upon standing, and hyperpigmentation of the buccal mucosa and skin creases. Laboratory tests show: serum sodium 128 mEq/L, serum potassium 5.8 mEq/L, morning serum cortisol 3.1 ug/dL (low), and plasma ACTH 280 pg/mL (markedly elevated). What is the diagnosis and definitive treatment?

Internal Medicine

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A 55-year-old male with long-standing poorly controlled diabetes and hypertension is admitted with generalized edema and fatigue. Blood tests reveal serum creatinine 4.2 mg/dL (baseline 1.1 mg/dL one week ago), blood urea nitrogen 68 mg/dL, and serum potassium 6.8 mEq/L. The ECG shows tall, peaked T waves in precordial leads with PR prolongation. What is the immediate first-line medication to administer to prevent fatal cardiac arrhythmias?

Internal Medicine

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A 28-year-old male presents with dark, tea-colored urine, facial puffiness, and headache 2 weeks after recovering from a severe streptococcal pharyngitis infection. On examination, blood pressure is 160/100 mmHg. Urinalysis shows dysmorphic red blood cells, RBC casts, and 1.5 g/day proteinuria. Serum complement C3 is significantly decreased. What is the most likely renal diagnosis?

Internal Medicine

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A 25-year-old male traveler returning from Nangarhar province presents with sudden onset of shaking chills, followed by high fever (40.0°C) and profuse sweating occurring in regular 48-hour paroxysms. A Giemsa-stained thin blood smear reveals enlarged erythrocytes containing Schuffner dots and amoeboid trophozoites. Blood smear confirms Plasmodium vivax. In addition to blood schizontocidal therapy with chloroquine, what drug must be co-administered to eradicate liver hypnozoites and prevent relapse?

Internal Medicine

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A 19-year-old male college student presents with acute onset of high fever, severe headache, photophobia, nausea, and neck stiffness for 18 hours. Physical examination reveals positive Kernig and Brudzinski signs and a petechial rash on his lower extremities. Lumbar puncture is performed immediately. Which cerebrospinal fluid (CSF) profile is most indicative of acute bacterial meningitis?

Internal Medicine

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A 32-year-old shepherd from central Afghanistan presents with a 4-week history of undulant fever, profuse nocturnal sweating, severe lower back pain, and polyarthralgias. He reports regularly consuming unpasteurized goat milk and raw sheep cheese. On examination, there is localized tenderness over the L4-L5 lumbar vertebrae and mild hepatosplenomegaly. Serum agglutination test (Wright test) is positive with a titer of 1:320. What is the diagnosis and recommended first-line treatment regimen?

Internal Medicine

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A 68-year-old male with a history of hypertension and smoking suddenly develops right-sided hemiparesis and expressive aphasia. Symptoms began exactly 75 minutes ago. On examination, blood pressure is 170/95 mmHg, blood glucose is 130 mg/dL, and non-contrast head CT shows no acute intracranial hemorrhage or territorial infarction. What is the most appropriate next step in management?

Internal Medicine

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A 70-year-old male presents with a resting tremor in his right hand described as 'pill-rolling', which improves with voluntary movement. On physical examination, he demonstrates cogwheel rigidity at the wrists, bradykinesia with masked facies, and a shuffling, festinating gait. What is the fundamental neurochemical deficit in this disease?

Internal Medicine

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A 36-year-old female presents with morning stiffness lasting > 1 hour in her hands and wrists for the past 4 months. On examination, there is bilateral, symmetrical swelling and tenderness of the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints, while the distal interphalangeal (DIP) joints are spared. Anti-cyclic citrullinated peptide (anti-CCP) antibodies are strongly positive. What is the first-line disease-modifying antirheumatic drug (DMARD) of choice?

Internal Medicine

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A 28-year-old female presents with a 6-month history of fatigue, intermittent polyarthritis, photosensitive facial skin rash across the cheeks and bridge of the nose sparing the nasolabial folds, and pleuritic chest pain. Urinalysis shows 2+ protein and microscopic hematuria. Antinuclear antibody (ANA) is positive at 1:640 with a homogeneous pattern. Which autoantibody is most specific for Systemic Lupus Erythematosus (SLE) and correlates with active lupus nephritis?

Internal Medicine

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A 52-year-old male with a history of alcohol use disorder presents with sudden onset of excruciating pain and swelling in his left first metatarsophalangeal joint (podagra) that began overnight. On examination, the joint is warm, erythematous, exquisitely tender, and swollen. Arthrocentesis of the joint yields synovial fluid showing needle-shaped crystals with strong negative birefringence under polarized light microscopy. What is the diagnosis?

Internal Medicine

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A 21-year-old male presents with periumbilical abdominal pain that began 14 hours ago and has now localized to the right lower quadrant. He has anorexia, nausea, and low-grade fever (38.0°C). On examination, there is marked tenderness at McBurney point with localized guarding and rebound tenderness. Rovsing sign and Psoas sign are positive. Leukocyte count is 14,800/mm3 with 82% neutrophils. What is the most definitive management?

General Surgery

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A 44-year-old overweight female presents to the emergency department with severe right upper quadrant (RUQ) abdominal pain radiating to the right scapula, accompanied by nausea and vomiting after eating a fatty meal. On examination, temperature is 38.3°C. When the examiner palpates the right subcostal margin during deep inspiration, the patient suddenly arrests inspiration due to sharp pain (positive Murphy sign). Transabdominal ultrasound shows gallstones, gallbladder wall thickening (5 mm), and pericholecystic fluid. What is the diagnosis?

General Surgery

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A 56-year-old male with a history of open appendectomy 10 years ago presents with crampy abdominal pain, obstipation (inability to pass flatus or stool), abdominal distension, and profuse bilious vomiting for 24 hours. On examination, the abdomen is distended with high-pitched, tinkling bowel sounds and diffuse mild tenderness without rebound. An erect abdominal X-ray reveals multiple dilated small bowel loops (> 3 cm) with air-fluid levels in a 'step-ladder' pattern and absence of colonic gas. What is the most common underlying cause?

General Surgery

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A 42-year-old male with a history of chronic alcohol consumption presents with severe, boring epigastric pain radiating directly to his back, accompanied by persistent vomiting. On examination, pulse is 116 bpm and epigastric tenderness is present. Laboratory testing reveals serum amylase of 1,250 U/L and serum lipase of 2,400 U/L (> 3 times the upper limit of normal). What are the two main cornerstones of initial non-surgical management?

General Surgery

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A 50-year-old male with a history of NSAID use presents with sudden onset of severe, generalized abdominal pain that began 2 hours ago. On examination, the patient lies motionless with knees flexed. The abdomen exhibits extreme generalized 'board-like' muscular rigidity and diffuse rebound tenderness. An erect chest X-ray reveals free crescent-shaped gas under the right hemidiaphragm (pneumoperitoneum). What is the immediate treatment of choice?

General Surgery

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A 24-year-old male is brought to the emergency department following a motor vehicle collision. He is in severe respiratory distress, cyanotic, and diaphoretic. Physical examination reveals: blood pressure 75/40 mmHg, pulse 138 bpm, absent breath sounds over the entire right hemithorax, hyperresonance to percussion on the right, and visible tracheal deviation to the left. What is the immediate life-saving intervention?

General Surgery

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A 30-year-old male sustains a stab wound to the left chest. On examination in the trauma bay, he is restless. Blood pressure is 80/50 mmHg, pulse is 125 bpm, jugular veins are distended, and heart sounds are muffled on auscultation. Lung examination reveals bilateral vesicular breath sounds. What is the classic name for this clinical triad, and what is the underlying diagnosis?

General Surgery

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A 70 kg adult male suffers partial-thickness and full-thickness burns over his entire anterior torso (18%) and both entire upper extremities (9% + 9% = 18%), totaling 36% Total Body Surface Area (TBSA). According to the Parkland formula (4 mL x kg x % TBSA), what is the total volume of Ringer's lactate required in the first 24 hours, and how should it be scheduled?

General Surgery

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A 45-year-old male presents with a painless bulge in the right groin that appears on standing and coughing and disappears when lying flat. On examination, the examining finger is invaginated into the external inguinal ring; upon coughing, a sustained impulse is felt pushing against the side (medial wall) of the finger rather than the tip. The mass is medial to the inferior epigastric vessels through Hesselbach's triangle. What type of hernia is this?

General Surgery

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A 50-year-old female presents with a painless, hard, irregular 2.5 cm solitary lump in the upper outer quadrant of her left breast with overlying skin tethering (peau d'orange) and non-tender, fixed left axillary lymphadenopathy. What is the standard diagnostic approach to evaluate suspected breast carcinoma before treatment planning?

General Surgery

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A 62-year-old male presents with progressive iron deficiency anemia, unexplained weight loss, and altered bowel habits over 5 months. Colonoscopy reveals an ulcerated, circumferential mass in the sigmoid colon. Biopsy confirms invasive moderately differentiated adenocarcinoma. What baseline staging imaging investigations are mandatory before surgery?

General Surgery

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On the 5th postoperative day following an elective open hemicolectomy, a 58-year-old female develops a fever of 38.6°C. On examination of the surgical wound, there is marked erythema extending 4 cm beyond the incision margin, local warmth, severe tenderness, and foul-smelling purulent discharge between skin staples. What is the most appropriate immediate surgical wound management?

General Surgery

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A 35-year-old male with a history of untreated peptic ulcer disease presents with persistent vomiting of undigested food eaten hours earlier, without bile. On physical examination, he appears dehydrated and cachectic; a visible gastric peristaltic wave is seen in the epigastrium and a prominent succussion splash is audible 4 hours after a meal. Arterial blood gas shows: pH 7.52, pCO2 48 mmHg, HCO3 36 mEq/L, serum chloride 86 mEq/L, and potassium 2.9 mEq/L. What is this classic metabolic derangement associated with gastric outlet obstruction?

General Surgery

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A 68-year-old male with atrial fibrillation presents with sudden onset of severe, excruciating periumbilical abdominal pain. On physical examination, the abdomen is soft and non-distended with mild non-specific tenderness but no guarding or rebound ('pain out of proportion to physical examination'). Bowel sounds are diminished. Laboratory tests reveal marked leukocytosis (22,000/mm3) and severe lactic acidosis (serum lactate 5.4 mmol/L). What is the definitive diagnostic imaging modality of choice?

General Surgery

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A 28-year-old female presents with a painless, solitary 2 cm nodule in the right lobe of her thyroid gland. Serum TSH is normal (1.8 mIU/L). Thyroid ultrasound reveals a solid, hypoechoic nodule with microcalcifications, irregular margins, and taller-than-wide shape. What is the most appropriate next diagnostic step?

General Surgery

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A 48-year-old male with a history of gallstones presents with severe upper abdominal pain, high spiking fevers with chills, and visible jaundice (Charcot's triad). His blood pressure is 85/50 mmHg and he is drowsy and confused (Reynolds' pentad). Total bilirubin is 6.8 mg/dL and alkaline phosphatase is 480 U/L. Ultrasound demonstrates a dilated common bile duct (14 mm) with choledocholithiasis. What is the most urgent life-saving intervention?

General Surgery

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A 22-year-old male is evaluated in the trauma bay following a high-speed motorcycle crash. He has a pelvic fracture and blood is noted at the external urethral meatus. On rectal examination, a high-riding, non-palpable prostate is noted. What mandatory investigation must be performed before any attempt at urethral catheterization?

General Surgery

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A 30-year-old male sustains a closed comminuted fracture of the right mid-shaft tibia in an athletic collision. Four hours after cast application, he complains of excruciating right leg pain that is unresponsive to increasing doses of parenteral opioids. On examination, the anterior compartment of the right lower leg is tense, wood-like, and swollen. Passive stretching of the toes produces agonizing pain. Distal dorsalis pedis pulses remain palpable. What is the diagnosis and immediate management?

General Surgery

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A 25-year-old male is struck on the right side of the head with a cricket bat. He experienced a brief loss of consciousness for 2 minutes, followed by a 'lucid interval' of 1 hour during which he felt completely normal. He then rapidly deteriorated, developing a severe headache, vomiting, progressive unresponsiveness, and a dilated, unreactive right pupil. What is the classic intracranial lesion and its source of bleeding?

General Surgery

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A 55-year-old male presents with intermittent, painless bright red rectal bleeding coating the outside of formed stools, accompanied by anal itching and a sensation of tissue prolapse during defecation that reduces spontaneously. Digital rectal examination and anoscopy reveal non-thrombosed vascular mucosal cushions protruding above the dentate line. What is the diagnosis?

General Surgery

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A full-term male infant born to an O-positive mother develops visible jaundice at 16 hours of life. Total serum bilirubin is 14.5 mg/dL (predominantly unconjugated/indirect). The infant's blood group is A-positive, and direct antiglobulin test (Coombs test) is strongly positive. Hemoglobin is 11.2 g/dL with reticulocytosis (8%). What is the diagnosis and primary concern if untreated?

Pediatrics

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A 4-day-old full-term infant presents with poor feeding, lethargy, hypothermia (rectal temperature 35.8°C), respiratory grunting, and mottled skin. Maternal history reveals prolonged rupture of membranes for 24 hours prior to delivery without intrapartum antibiotic prophylaxis. What is the most common causative organism of early-onset neonatal sepsis, and what is the standard empiric antibiotic regimen?

Pediatrics

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