Physician Licensing Examination (Хүний их эмчийн мэргэжлийн үйл ажиллагаа эрхлэх зөвшөөрлийн шалгалт, Mongolia) Feed

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A 58-year-old male presents to the outpatient clinic with retrosternal crushing chest pain radiating to his left shoulder and jaw that began 45 minutes ago during physical exertion. An emergency 12-lead ECG reveals 2.5 mm ST-segment elevation in leads II, III, and aVF with reciprocal ST depression in leads I and aVL. Which coronary artery is most likely occluded?

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A 62-year-old female with a 10-year history of poorly controlled type 2 diabetes mellitus presents with worsening exertional dyspnea, orthopnea, and bilateral lower extremity pitting edema. Physical examination demonstrates an elevated jugular venous pressure (8 cm H2O) and a third heart sound (S3 gallop). Echocardiography reveals a left ventricular ejection fraction of 32%. Which initial pharmacologic regimen provides proven mortality benefit in chronic heart failure with reduced ejection fraction (HFrEF)?

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A 45-year-old male with persistent essential hypertension on amlodipine 10 mg daily presents for a follow-up. Blood pressure remains elevated at 154/96 mmHg. Laboratory testing shows serum potassium of 3.1 mmol/L (reference: 3.5–5.0 mmol/L) with no history of diuretic therapy. Plasma aldosterone concentration is elevated, and plasma renin activity is suppressed, resulting in an aldosterone-to-renin ratio (ARR) of 42. What is the most appropriate next diagnostic step?

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A 34-year-old female presents with palpitations, unintended weight loss of 6 kg over two months, heat intolerance, and frequent loose stools. Physical examination reveals fine resting hand tremors, a smooth, diffusely enlarged, non-tender thyroid gland with an audible systolic bruit, and mild bilateral proptosis. Serum TSH is <0.01 mIU/L and free T4 is 48 pmol/L (reference: 11.5–22.7 pmol/L). Which antibody is the primary pathogenic driver of this condition?

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A 52-year-old male with a 30-pack-year smoking history presents with a 4-day history of high fever, rigors, right-sided pleuritic chest pain, and productive cough with rust-colored sputum. Auscultation reveals bronchial breath sounds and inspiratory crackles over the right lower lung field, with dullness to percussion. Chest radiography shows dense lobar consolidation in the right lower lobe. What is the most likely causative pathogen?

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A 68-year-old male with severe chronic obstructive pulmonary disease (COPD, GOLD stage IV) is admitted with an acute exacerbation. Arterial blood gas (ABG) on room air shows: pH 7.28, PaCO2 62 mmHg, PaO2 52 mmHg, and HCO3- 29 mmol/L. The patient is alert, responsive, and hemodynamically stable, but shows marked tachypnea (respiratory rate 28/min) and accessory muscle use. What is the most appropriate next step in ventilatory support?

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A 26-year-old female presents to the emergency department with a 12-hour history of periumbilical pain that has now shifted and localized to the right lower quadrant. She reports nausea, one episode of non-bilious vomiting, and anorexia. Vital signs: temperature 38.1°C, pulse 96 bpm, BP 118/74 mmHg. Abdominal examination shows tenderness at McBurney's point with guarding, positive Rovsing's sign, and positive psoas sign. Laboratory evaluation reveals a leukocyte count of 14,200/mcL with 82% neutrophils. What is the most likely diagnosis?

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A 48-year-old obese female presents with severe, sharp right upper quadrant abdominal pain that radiates to her right shoulder and scapula, starting 1 hour after eating a fatty meal. She has had several similar milder episodes over the past 6 months. Physical examination demonstrates marked tenderness in the right subcostal margin, where deep inspiration causes sudden arrest of breathing due to severe pain. Vital signs: temperature 38.4°C, HR 102 bpm. What is the physical examination sign described, and which condition does it classically indicate?

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A 55-year-old male with a history of long-standing duodenal ulcer disease suddenly experiences excruciating, generalized abdominal pain that began 2 hours ago. On physical examination, the patient lies completely still with shallow respirations. The entire abdomen is rigid and board-like, with diffuse rebound tenderness. Bowel sounds are absent. An upright chest radiograph demonstrates a thin crescent of free air beneath the right hemidiaphragm (pneumoperitoneum). What is the mandatory immediate management?

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A 70-year-old male presents with a 3-day history of obstipation, progressive abdominal distension, and colicky lower abdominal pain. He has had no previous abdominal surgeries. Physical examination reveals a tensely distended, tympanitic abdomen with high-pitched 'tinkling' bowel sounds. Plain abdominal radiography demonstrates a massive, dilated loop of large bowel without haustra, originating from the left lower quadrant and projecting towards the right upper quadrant, resembling a 'coffee bean' sign. What is the most likely diagnosis?

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A 42-year-old female presents with chronic fatigue, generalized pruritus that is worse at night, and dry eyes and mouth. Physical examination reveals mild jaundice, palmar erythema, and xanthelasma around the inner canthi of both eyes. The liver edge is palpable 3 cm below the right costal margin. Laboratory studies reveal: total bilirubin 45 mcmol/L, alkaline phosphatase (ALP) 620 U/L (reference: 40–130 U/L), ALT 65 U/L, and AST 58 U/L. Viral hepatitis serologies (HBsAg, anti-HCV) are negative. An antimitochondrial antibody (AMA) titer is strongly positive (1:320). What is the definitive first-line medical therapy for this disorder?

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A 50-year-old male with chronic hepatitis B cirrhosis presents with hematemesis of approximately 500 mL fresh blood followed by lightheadedness. Vital signs: BP 88/54 mmHg, HR 122 bpm, SpO2 96%. On physical exam, he appears pale and diaphoretic with mild ascites and spider angiomas. What are the essential initial pharmacological agents to administer alongside crystalloid/blood resuscitation while preparing for urgent endoscopy?

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A 24-year-old male presents with a 6-month history of lower back stiffness and dull buttock pain that is most severe in the morning and improves significantly with exercise and hot showers, but worsens with rest. He also notes heel pain at the insertion of the Achilles tendon. Spinal examination reveals reduced lumbar flexion on the modified Schober test (expansion < 3 cm) and bilateral sacroiliac joint tenderness. Plain radiography confirms bilateral grade 2 sacroiliitis. Which genetic marker is strongly associated with this condition?

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A 28-year-old female presents with persistent fatigue, migratory polyarthralgia involving her wrists and knees, an erythematous butterfly rash sparing the nasolabial folds across her cheeks and bridge of her nose, and pleuritic chest pain. Urinalysis demonstrates 3+ proteinuria and red blood cell casts. Laboratory tests reveal leukopenia (3,100/mcL), positive antinuclear antibodies (ANA, titer 1:640), and elevated anti-double-stranded DNA (anti-dsDNA) antibodies with hypocomplementemia (low C3 and C4). What is the primary diagnosis?

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A 46-year-old male with chronic alcohol use disorder is brought to the emergency department after being found unresponsive in the snow. On examination, he is stuporous, hypothermic (core temperature 34.2°C), and smells of alcohol. Laboratory results show: serum sodium 138 mmol/L, potassium 4.2 mmol/L, chloride 100 mmol/L, bicarbonate 12 mmol/L, BUN 8.5 mmol/L, creatinine 110 mcmol/L, blood glucose 4.2 mmol/L, serum osmolality 335 mOsm/kg. Calculated serum osmolality is 289 mOsm/kg, yielding an osmolal gap of 46 mOsm/kg. Serum anion gap is 26 mmol/L. Urinalysis reveals calcium oxalate crystals. What toxic ingestion is the most likely cause?

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A 65-year-old male with long-standing poorly controlled hypertension presents for a routine check-up. Serum creatinine is 165 mcmol/L (eGFR 38 mL/min/1.73m2, baseline 155 mcmol/L one year ago). Spot urine albumin-to-creatinine ratio (uACR) is 280 mg/g. Blood pressure is 148/92 mmHg. According to KDIGO clinical practice guidelines for chronic kidney disease (CKD), which class of antihypertensive medications is the first-line choice to slow CKD progression and reduce proteinuria?

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A 72-year-old male presents with worsening exertional fatigue, pallor, and paresthesias in his feet described as 'pins and needles'. Physical examination reveals conjunctival pallor, a smooth beefy-red tongue (atrophic glossitis), impaired vibration and proprioceptive sensation in both lower extremities, and positive Romberg sign. Complete blood count shows: hemoglobin 78 g/L, MCV 116 fL (reference: 80–100 fL), WBC 3,800/mcL, platelets 125,000/mcL. Peripheral blood smear displays hypersegmented neutrophils. What is the underlying pathophysiological cause of this patient's neurological symptoms?

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A 22-year-old male presents with sudden onset of severe right-sided flank pain that radiates anteriorly to his right groin and ipsilateral scrotum. The pain is colicky, episodic, and accompanied by nausea and gross hematuria. The patient cannot find a comfortable position and paces around the examination room. Abdominal examination is unremarkable with no peritoneal signs. What is the gold standard, first-line diagnostic imaging modality of choice to confirm the diagnosis and determine stone size and location?

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A 48-year-old male with a history of alcohol abuse presents with severe epigastric pain that radiates directly to the mid-back, relieved somewhat by leaning forward. He has had persistent vomiting for 12 hours. Vital signs: pulse 110 bpm, BP 105/70 mmHg, temperature 37.8°C. Abdominal exam shows marked epigastric tenderness with voluntary guarding. Serum amylase is 840 U/L and serum lipase is 1,250 U/L (reference: 10–60 U/L). Which of the following laboratory parameters within the first 48 hours is included in the Ranson criteria to predict the severity and mortality of acute pancreatitis?

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A 60-year-old female with long-standing rheumatoid arthritis treated with chronic oral prednisone (15 mg daily) undergoes an emergency open reduction and internal fixation for a fractured femur following a fall. Two hours postoperatively in the recovery room, she becomes acutely confused, nauseated, and hypotensive with BP 75/40 mmHg unresponsive to a 1,000 mL normal saline bolus. Heart rate is 115 bpm. Laboratory testing shows serum sodium 126 mmol/L, potassium 4.6 mmol/L, and blood glucose 3.2 mmol/L. What is the immediate life-saving medical intervention?

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A 32-year-old male with human immunodeficiency virus (HIV) infection and a CD4+ T-lymphocyte count of 85 cells/mcL presents with a 3-week history of worsening dry cough, low-grade fever, exertional dyspnea, and profound fatigue. Vital signs: RR 26/min, HR 104 bpm, SpO2 88% on room air. Chest auscultation reveals minimal bilateral crackles, but chest radiography demonstrates diffuse bilateral perihilar ground-glass interstitial infiltrates. Arterial blood gas shows a PaO2 of 56 mmHg on room air (room air alveolar-arterial oxygen gradient > 35 mmHg). What is the definitive first-line antimicrobial therapy and critical adjunctive treatment?

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A 56-year-old male with a history of alcohol-associated cirrhosis presents with worsening confusion, inverted sleep-wake cycle, and disorientation to time and place over the past 48 hours. On examination, when asked to extend his wrists with fingers separated and arms outstretched, bilateral jerky, flapping tremors of the hands are observed. He is afebrile and hemodynamically stable. What is the physical sign demonstrated, and what is the primary initial pharmacological treatment?

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A 67-year-old male smoker presents with painless gross hematuria accompanied by clots for three weeks. He reports no dysuria, fever, or flank pain. Urine dipstick confirms heavy blood with no nitrites or leukocytes. A complete blood count and renal function tests are normal. What is the most important and definitive diagnostic combination required to evaluate this presentation?

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A 35-year-old female presents with recurrent, severe throbbing headaches that are strictly unilateral, last between 12 and 24 hours, and are accompanied by prominent photophobia, phonophobia, and nausea. She reports that prior to headache onset, she sees jagged shimmering lines in her visual field for about 20 minutes that completely resolve. Physical and neurological examinations are entirely normal. What is the diagnosis and the most appropriate first-line acute abortive therapy for moderate-to-severe attacks?

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A 54-year-old male with a history of hypertension and hyperlipidemia presents with sudden-onset weakness of his right face, arm, and leg that began 75 minutes ago. Neurological examination confirms a dense right-sided hemiplegia and expressive motor aphasia (NIHSS score: 14). Vital signs: BP 168/94 mmHg, HR 82 bpm, blood glucose 6.4 mmol/L. An immediate non-contrast brain CT scan rules out intracranial hemorrhage and reveals no early ischemic changes. There are no contraindications to thrombolytic therapy. What is the most appropriate next step in acute stroke management?

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A 30-year-old unrestrained driver is brought to the trauma bay following a high-speed motor vehicle collision. On arrival, he is in severe respiratory distress, tachypneic (RR 34/min), cyanotic, and diaphoretic. Vital signs: BP 70/40 mmHg, HR 138 bpm, SpO2 78% on high-flow oxygen. Physical examination reveals absent breath sounds over the entire right hemithorax, marked hyperresonance to percussion on the right, and the trachea is visibly deviated to the left side. Distended neck veins are noted. What is the immediate, life-saving next step?

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A 28-year-old male is evaluated 4 hours after a motorcycle crash in which he sustained a closed mid-shaft fracture of the right tibia. The limb was temporarily immobilized in a posterior splint. He now complains of excruciating, worsening pain in his right lower leg that is completely refractory to repeated doses of intravenous morphine. On physical examination, the anterior compartment of the right lower leg is tense and woody to palpation. Active dorsiflexion of the ankle is weak, and passive plantarflexion of the toes produces agonizing pain. Distal dorsalis pedis pulses are still palpable. What is the definitive emergency treatment?

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A 62-year-old male with known coronary artery disease and chronic atrial fibrillation presents with sudden onset of severe, diffuse abdominal pain that began 4 hours ago. Physical examination reveals an abdomen that is soft, non-distended, and only mildly tender to deep palpation, with no guarding or rigidity, creating a striking disparity between the patient's subjective agony and the physical findings. Rectal examination demonstrates stool that is positive for occult blood. Arterial blood gas shows a metabolic acidosis with an elevated serum lactate of 4.8 mmol/L. What is the most likely diagnosis?

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A 45-year-old male undergoes an uncomplicated elective open inguinal hernia repair under general anesthesia. On postoperative day 2 he has a temperature of 38.1°C, HR 88 bpm, BP 124/78 mmHg, RR 18/min and SpO2 96% on room air. The incision is clean and dry and the calves are soft and non-tender. Chest auscultation reveals decreased breath sounds and fine crackles at both lung bases, and a chest radiograph shows bibasal plate atelectasis without consolidation. What is the most appropriate first-line management?

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A 68-year-old male presents with a persistent, non-healing ulcer on the lower lip that has been slowly enlarging over the past 8 months. He has worked outdoors as a nomadic herder in the Mongolian countryside for over 40 years. Physical examination reveals a 1.5 cm indurated, crater-like ulcer with rolled, everted margins on the vermilion border of the lower lip. A single, firm, non-tender 1.5 cm submandibular lymph node is palpable. What is the most likely histological diagnosis?

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A 70-year-old female presents to the emergency department with a 2-day history of crampy lower abdominal pain, marked abdominal distension, and failure to pass flatus or stool. She has a history of chronic constipation. On examination, a painful, tender, irreducible, walnut-sized swelling is palpated in the right groin, located below and lateral to the pubic tubercle. Overlying skin is mildly erythematous. Abdominal X-ray shows multiple small bowel air-fluid levels. What type of hernia is responsible for this bowel obstruction?

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A 38-year-old female presents with a painless, solitary lump in the right lobe of her thyroid gland, discovered incidentally during a health checkup. She has no hoarseness, dysphagia, or systemic symptoms. Serum TSH is normal (1.8 mIU/L). Thyroid ultrasound reveals a 1.8 cm solid, hypoechoic nodule with irregular margins, microcalcifications, and increased intranodular vascularity. Fine-needle aspiration biopsy (FNAB) demonstrates ground-glass nuclei with clearing ('Orphan Annie eyes'), nuclear pseudoinclusions, and longitudinal nuclear grooves. What is the diagnosis?

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A 40-year-old male pedestrian is struck by an automobile and arrives in the emergency department in shock. Primary survey reveals a patent airway and clear bilateral breath sounds. Pelvic examination demonstrates gross mechanical instability with pain and mobility on gentle anteroposterior compression. Vital signs: BP 78/46 mmHg, HR 134 bpm. FAST examination is negative for free intraperitoneal fluid. What is the immediate, life-saving orthopedic maneuver to control pelvic hemorrhage while initiating balanced blood product resuscitation?

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A 52-year-old male with chronic hepatitis B-related cirrhosis undergoes routine surveillance. Serum alpha-fetoprotein (AFP) is elevated at 340 ng/mL (reference: < 10 ng/mL). Multiphase contrast-enhanced abdominal CT demonstrates a 3.2 cm solitary liver lesion in segment VI that exhibits intense arterial phase hyperenhancement ('wash-in') followed by rapid contrast washout in the portal venous and delayed phases ('wash-out') with an enhancing pseudocapsule. What is the diagnosis?

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A 23-year-old male is evaluated in the emergency room 30 minutes after suffering a stab wound to the left anterior chest at the 4th intercostal space, just lateral to the sternal border. Vital signs: BP 80/50 mmHg, HR 126 bpm, RR 22/min. Physical examination reveals distended jugular neck veins, distant and muffled heart sounds on cardiac auscultation, and clear bilateral breath sounds. Pulsus paradoxus (a drop in systolic blood pressure > 10 mmHg during normal inspiration) is measured. What clinical triad is present, and what is the underlying condition?

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A 58-year-old male presents with intermittent, painless bright red rectal bleeding coating his stool, progressive narrowing of his stool caliber ('pencil stools') over the past 4 months, and a 5 kg weight loss. Digital rectal examination palpates an indurated, circumferential, ulcerated mass 5 cm from the anal verge. Colonoscopy and biopsy confirm moderately differentiated adenocarcinoma. What is the most important serum tumor marker used for monitoring disease recurrence and therapeutic response in colorectal cancer?

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A 45-year-old male presents with recurrent, severe heartburn, acid regurgitation, and progressive dysphagia to solid foods over the past 6 months. Upper gastrointestinal endoscopy reveals severe distal esophagitis and salmon-pink, velvety epithelial tongues extending 4 cm proximal to the gastroesophageal junction. Biopsies of this salmon-colored mucosa demonstrate columnar-lined epithelium with prominent intestinal goblet cells. What is this premalignant condition called, and which malignancy is it a precursor for?

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A 32-year-old female presents to the surgical clinic with a painful, erythematous, fluctuant 4 cm swelling in the upper outer quadrant of her left breast. She is currently breastfeeding her 4-week-old infant. Vital signs: temperature 38.6°C, HR 100 bpm. Ultrasonography demonstrates a well-circumscribed, thick-walled hypoechoic fluid collection consistent with an acute breast abscess. What is the most common causative bacterial organism, and what is the definitive initial surgical management?

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A 40-year-old female presents with severe, progressive fatigue, cold intolerance, constipation, weight gain of 5 kg, and heavy menstrual bleeding. Physical examination reveals dry, coarse skin, periorbital puffiness, diffuse alopecia, bradycardia (HR 52 bpm), and delayed relaxation of deep tendon reflexes (hung-up knee jerk). Laboratory testing reveals: TSH 34.5 mIU/L (reference: 0.4–4.0 mIU/L) and free T4 5.2 pmol/L (reference: 11.5–22.7 pmol/L). What is the standard definitive replacement therapy?

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A 65-year-old male with a history of heavy smoking and peripheral vascular disease presents with sudden-onset, severe 'tearing' retrosternal chest pain that radiates directly between his scapulae into his mid-back. Vital signs: BP in right arm is 178/100 mmHg, while BP in left arm is 112/68 mmHg. Radial pulse on the left wrist is faint compared to the right. Auscultation reveals a new high-pitched early diastolic decrescendo murmur at the right sternal border. Chest radiograph shows marked widening of the superior mediastinum. What is the most likely diagnosis?

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A 9-month-old infant is brought to the primary care clinic for a routine well-child checkup. The mother asks whether her child is developing normally. On developmental milestone screening, the infant sits steadily without support, transfers a block from one hand to the other, uses a crude pincer grasp, babbling with repetitive consonant-vowel sounds ('da-da', 'ba-ba'), and exhibits stranger anxiety. Which of the following developmental milestones is expected to appear next around 12 months of age?

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According to the WHO Integrated Management of Childhood Illness (IMCI / ХӨЦМ) guidelines utilized across primary healthcare centers in Mongolia, a 14-month-old child presents with a 2-day history of cough and fever. Which of the following clinical findings indicates 'fast breathing' (tachypnea) in a child aged 12 months up to 5 years?

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A 3-year-old child is brought to the outpatient clinic with watery diarrhea and vomiting for 2 days. On assessment according to IMCI (ХӨЦМ) diarrhea assessment protocols, the child is irritable and restless, drinks eagerly when offered a cup of water, has sunken eyes, and a skin pinch on the abdomen goes back slowly (< 2 seconds). How is the child's hydration status classified, and what is the appropriate management plan?

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A 2-year-old boy is brought to the emergency department in the middle of a winter night with sudden onset of a harsh, barking, seal-like cough, hoarseness, and inspiratory stridor. Symptoms were preceded by mild rhinorrhea and low-grade fever (37.9°C) for two days. On examination, the child is agitated, with audible inspiratory stridor at rest and suprasternal retractions. An anteroposterior neck radiograph demonstrates subglottic narrowing known as the 'steeple sign'. What is the most appropriate immediate medical management?

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A full-term male infant is born via spontaneous vaginal delivery with clear amniotic fluid. At 1 minute after birth, the heart rate is 110 bpm, he has a vigorous cry with regular respirations, active movement of all extremities, grimaces and coughs upon suctioning of the nares, but his body is pink with blue hands and feet (acrocyanosis). What is this infant's 1-minute APGAR score?

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A healthy term male infant develops visible yellowish discoloration of his face and trunk at 60 hours of life (Day 3). He is exclusively breastfeeding well, passes normal yellow seedy stools, and voids pale urine 6 times daily. Vital signs are normal. Total serum bilirubin is 165 mcmol/L (9.6 mg/dL) with a direct (conjugated) bilirubin of 8 mcmol/L (0.5 mg/dL). Hemoglobin is 175 g/L and maternal and infant blood groups are both O Rh-positive. What is the most likely diagnosis?

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An 8-month-old infant is brought to the clinic because of a high fever of 39.8°C that has persisted for 4 days without any focal symptoms. The infant was irritable during the fevers but otherwise drank fluids well. On day 4, the fever abruptly breaks and resolves completely. Concurrently, a blanching, rose-pink, discrete maculopapular rash appears on the neck and trunk, spreading slightly to the extremities. The child is now active and smiling. What is the causative pathogen of this classic childhood exanthem?

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