MMDC Medical Licensing Examination (Maldives) Feed

Question

A 58-year-old man with heavy smoking and alcohol use has progressive dysphagia, first to solids and now to liquids, and has lost 8 kg. Endoscopy shows an ulcerated circumferential mass 30 cm from the incisors, and biopsy confirms squamous cell carcinoma. Which anatomical feature of the esophagus most favors early local spread of this cancer into the mediastinum?

Anatomy

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A 23-year-old female presents with severe pain in her right lower leg following a minor sprain. Her right leg has normal motor function. When testing cutaneous sensation, you discover sensory loss over the lateral aspect of her leg and the entire dorsum of her foot, with intact sensation in the first web space between the great toe and second toe. Which nerve is injured?

Anatomy

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A 3.9 kg newborn delivered after a difficult shoulder dystocia holds the right arm adducted and internally rotated at the shoulder, with the elbow extended, the forearm pronated, and the wrist flexed (the 'waiter's tip' posture). The grasp reflex is present. Which part of the brachial plexus is most likely injured?

Anatomy

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During a left thyroid lobectomy, the surgeon identifies the left recurrent laryngeal nerve in the tracheoesophageal groove. Around which structure does the left recurrent laryngeal nerve hook before it ascends into the neck?

Anatomy

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A 64-year-old woman has a painful, irreducible groin lump below and lateral to the pubic tubercle, and a strangulated femoral hernia is suspected. Where does a femoral hernia pass in relation to the femoral vessels?

Anatomy

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A 45-year-old woman with carpal tunnel syndrome has numbness of the thumb, index finger, middle finger, and lateral half of the ring finger. On examination, which movement is most likely to be weak?

Anatomy

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Before an instrumental vaginal delivery, a medical officer performs a transvaginal pudendal nerve block. Toward which bony landmark is the needle guided to infiltrate the pudendal nerve?

Anatomy

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A 45-year-old male with chronic alcoholism is brought to the emergency department drowsy with deep, rapid breathing. An arterial blood gas (ABG) sample obtained on room air reveals: pH 7.20, PaCO₂ 25 mmHg, PaO₂ 88 mmHg, and HCO₃⁻ 11 mEq/L. Serum electrolytes are: sodium 138 mEq/L, chloride 98 mEq/L, and potassium 4.0 mEq/L. What is the primary acid-base disturbance and anion gap status?

Physiology

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An arterial blood gas (ABG) sample drawn from a patient breathing room air demonstrates the following values: pH 7.50, PaCO₂ 24 mmHg, PaO₂ 98 mmHg, and HCO₃⁻ 18 mEq/L. What is the primary acid-base disorder and the compensatory mechanism?

Physiology

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A 68-year-old male with a history of hypertension and osteoarthritis presents with acute kidney injury after taking high-dose naproxen for 2 weeks while taking enalapril. Serum creatinine has increased from a baseline of 1.0 mg/dL to 2.8 mg/dL. What physiological hemodynamic mechanism explains the synergistic reduction in glomerular filtration rate (GFR) caused by concurrent ACE inhibitor and NSAID administration?

Physiology

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A 25-year-old female presents with recurrent episodes of wheezing and shortness of breath. Pulmonary function testing (spirometry) demonstrates an FEV1 of 65% of predicted and an FEV1/FVC ratio of 60%. Following inhalation of 400 mcg of salbutamol (albuterol), repeat spirometry demonstrates an FEV1 improvement of 16% and an absolute increase of 260 mL. How is this spirometry result interpreted?

Physiology

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Which of the following changes shifts the oxyhemoglobin dissociation curve to the right, favoring oxygen unloading to the tissues?

Physiology

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After a head injury, a patient develops polyuria with dilute urine that concentrates after desmopressin is given. Where and how does antidiuretic hormone (vasopressin) normally increase water reabsorption in the kidney?

Physiology

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Which ionic current is responsible for the rapid upstroke (phase 0) of the action potential in ventricular myocytes?

Physiology

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A 50-year-old male undergoes a standard liver function panel. The results are as follows: Total bilirubin 1.0 mg/dL, Direct bilirubin 0.2 mg/dL, Alanine aminotransferase (ALT) 1,450 U/L (normal <45 U/L), and Aspartate aminotransferase (AST) 1,280 U/L (normal <40 U/L). Alkaline phosphatase and GGT are normal. What category of liver injury do transaminase levels >1,000 U/L with an ALT > AST pattern classically signify?

Biochemistry

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A 40-year-old male presents with deep jaundiced sclerae, dark tea-colored urine, and pale acholic stools. Laboratory investigations reveal: Total bilirubin 12.8 mg/dL, Direct bilirubin 10.4 mg/dL, Alkaline phosphatase 520 U/L (normal <120 U/L), GGT 410 U/L, AST 72 U/L, and ALT 85 U/L. Which pathophysiological mechanism explains why the patient has dark urine and pale stools?

Biochemistry

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A malnourished man with chronic alcohol use is confused and ataxic with nystagmus. The medical officer gives intravenous thiamine before starting a dextrose infusion. Which biochemical role of thiamine pyrophosphate explains this sequence?

Biochemistry

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A 28-year-old male presents with acute dyspnea, wheezing, and anxiety after receiving intravenous penicillin for cellulitis. He rapidly develops facial edema and stridor. Which immunological mechanism mediates this Type I hypersensitivity reaction?

Pathology

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A 52-year-old male is receiving intravenous gentamicin for complicated urosepsis. Five days into therapy, his serum creatinine rises from 0.9 mg/dL to 2.4 mg/dL with a non-oliguric urine output. Microscopic examination of the urine sediment demonstrates muddy brown granular casts and renal tubular epithelial cells. What is the mechanism and anatomical site of this drug-induced nephrotoxicity?

Pathology

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A 26-year-old male is brought to the emergency department after a single generalized tonic-clonic seizure. The seizure terminated 20 minutes ago, but he remains obtunded and combative. To confirm the diagnosis of true generalized epileptic convulsion rather than psychogenic non-epileptic seizure (PNES) or syncope, which serum marker is transiently elevated 10 to 20 minutes after a true generalized tonic-clonic seizure?

Pathology

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A 45-year-old male with severe methicillin-resistant Staphylococcus aureus (MRSA) bacteremia is treated with intravenous vancomycin. Which pharmacokinetic parameter best correlates with clinical efficacy and bacterial eradication for vancomycin, and what is the recommended therapeutic target monitoring parameter?

Pharmacology

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A 62-year-old male with chronic atrial fibrillation and ischemic cardiomyopathy is admitted for acute decompensated heart failure. He is taking digoxin, furosemide, and carvedilol. Two days later, he complains of nausea, vomiting, yellow-green halos around lights (xanthopsia), and palpitation. His serum potassium is 2.8 mEq/L (hypokalemia). What is the physiological mechanism explaining why hypokalemia increases the risk of digoxin toxicity?

Pharmacology

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A 40-year-old male is initiated on empirical broad-spectrum antibacterial therapy with intravenous piperacillin-tazobactam. What is the pharmacological rationale for combining tazobactam with piperacillin?

Pharmacology

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A 60-year-old female with severe rheumatoid arthritis is treated with low-dose oral methotrexate (15 mg once weekly). Which essential co-medication must be co-prescribed to reduce methotrexate-induced adverse effects such as stomatitis, oral ulcerations, gastrointestinal intolerance, and hematologic cytopenias?

Pharmacology

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Effective 10 December 2025, the Health Protection Agency added two vaccines to the Maldives National Immunization Schedule, given free of charge as a 3-dose series at 2, 4, and 6 months alongside the existing infant vaccines. Which two vaccines were added?

Preventive Social Medicine

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A medical officer working at an Atoll Health Center in the Maldives evaluates a 28-year-old male who has high fever, severe retro-orbital headache, thrombocytopenia, and a positive NS1 antigen test for dengue virus. Under the Public Health Protection Act and Ministry of Health communicable disease surveillance regulations, what is the mandatory reporting duty of the treating medical officer?

Preventive Social Medicine

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A new rapid test is evaluated in 1,000 people: 100 have the disease and 900 do not. The test is positive in 90 of the people with the disease and in 40 of the people without it. What is the positive predictive value (PPV) of the test in this population?

Preventive Social Medicine

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A 30-year-old farm worker is brought in after deliberately drinking an organophosphate insecticide. He has pinpoint pupils, profuse salivation and bronchorrhea, bradycardia, and muscle fasciculations. Intravenous atropine is given in doubling doses. Which clinical end-point indicates adequate atropinization?

Forensic Medicine

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A 45-year-old competent adult male is diagnosed with acute appendicitis. The surgical team explains the diagnosis, the risks, benefits, and alternatives of laparoscopic appendectomy, as well as the risks of refusing surgery (perforation, peritonitis, sepsis). The patient demonstrates full capacity and firmly refuses surgical intervention, choosing instead to be discharged. What is the most legally and ethically sound action for the attending physician?

Medical Ethics Medico Legal

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A 45-year-old woman undergoes an uncomplicated open cholecystectomy. Three months later she has persistent pain and a discharging sinus, and imaging shows a surgical swab retained in the gallbladder bed. She was anaesthetised and under the exclusive control of the surgical team throughout the operation. In a negligence claim, which legal doctrine allows negligence to be inferred from these facts themselves?

Medical Ethics Medico Legal

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A 24-year-old man has purulent urethral discharge and dysuria for 3 days. A Gram-stained smear of the discharge shows many polymorphs containing Gram-negative intracellular diplococci. Which organism is most likely responsible?

Microbiology

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A 40-year-old fisherman who stepped on a rusty nail 8 days earlier develops trismus, risus sardonicus, and painful generalized spasms. By which mechanism does the toxin of the causative organism produce these features?

Microbiology

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A 58-year-old male with a history of hypertension and smoking presents to the emergency department with severe, crushing retrosternal chest pain radiating to his left arm and jaw for 90 minutes. His blood pressure is 145/90 mmHg and heart rate is 88 bpm. An electrocardiogram (ECG) reveals 2.5 mm ST-segment elevation in leads II, III, and aVF with reciprocal depression in leads I and aVL. Which coronary artery is most likely occluded?

Internal Medicine

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A 62-year-old female with long-standing type 2 diabetes mellitus and chronic kidney disease presents with progressive dyspnea on exertion, orthopnea, and bilateral lower extremity edema. On examination, elevated jugular venous pressure and bilateral basilar crackles are noted. Echocardiography demonstrates a left ventricular ejection fraction (LVEF) of 32%. Which of the following guideline-directed medical therapy regimens is proven to provide a mortality benefit in this patient with heart failure with reduced ejection fraction (HFrEF)?

Internal Medicine

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A 45-year-old male presents with palpitations, tremors, heat intolerance, and unintended weight loss of 6 kg over the past two months. On examination, he has bilateral exophthalmos, lid lag, pretibial myxedema, and a diffusely enlarged, non-tender thyroid gland with an audible bruit. Laboratory evaluation reveals a serum thyroid-stimulating hormone (TSH) of <0.01 mIU/L and elevated free thyroxine (FT4). Which autoantibody is most specific for confirming this etiology?

Internal Medicine

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A 35-year-old male agricultural worker in the Southern Atolls presents with a 6-day history of high spiking fevers, chills, severe frontal headache, conjunctival suffusion, and myalgias. On physical examination, a characteristic black, painless crusted lesion with an erythematous halo (eschar) is discovered in his left groin along with regional lymphadenopathy. A presumptive diagnosis of scrub typhus is made. What is the first-line antimicrobial therapy of choice?

Internal Medicine

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A 52-year-old male with chronic hepatitis B cirrhosis presents with increasing abdominal distension and mild diffuse abdominal tenderness for 3 days. His temperature is 38.2°C, blood pressure is 110/70 mmHg, and pulse is 96 bpm. Abdominal paracentesis is performed. The ascitic fluid analysis demonstrates a yellow, cloudy fluid with a total leukocyte count of 850/mm³ with 72% polymorphonuclear neutrophils (PMNs), a total protein of 0.9 g/dL, and an albumin of 0.8 g/dL. His serum albumin is 2.5 g/dL. What is the definitive diagnosis and recommended immediate antimicrobial therapy?

Internal Medicine

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A 70-year-old male with severe chronic obstructive pulmonary disease (COPD) is brought to the emergency department with worsening dyspnea, increased sputum volume, and purulence. He is alert but tachypneic at 28 breaths/min with pursed-lip breathing. Arterial blood gas (ABG) analysis on room air shows: pH 7.28, PaCO₂ 62 mmHg, PaO₂ 54 mmHg, and HCO₃⁻ 29 mEq/L. Which target oxygen saturation (SpO₂) range should be maintained during oxygen delivery?

Internal Medicine

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A 42-year-old male with a history of alcohol abuse presents with severe, boring epigastric pain radiating directly to his back, accompanied by nausea and repeated vomiting. On physical examination, he has epigastric tenderness with voluntary guarding and hypoactive bowel sounds. Serum lipase is 1,450 U/L (reference <60 U/L). According to the revised Atlanta classification, which criteria are required to establish the diagnosis of acute pancreatitis?

Internal Medicine

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A 32-year-old male presents to the clinic with persistent watery diarrhea, fatigue, and a 10 kg weight loss over 4 months. He reports recurrent oral candidiasis and generalized lymphadenopathy. A rapid HIV antibody/antigen screening test is positive. His CD4+ T-lymphocyte count is 140 cells/µL. In addition to initiating combination antiretroviral therapy (ART), which primary chemoprophylaxis regimen must be started immediately?

Internal Medicine

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A 23-year-old female presents with joint pain in her hands, wrists, and knees, accompanied by an erythematous facial rash over her malar eminences sparing the nasolabial folds, which worsens after sun exposure. Urinalysis demonstrates 3+ proteinuria and microscopic hematuria with red blood cell casts. Serum complement levels (C3 and C4) are markedly depressed. Which laboratory test has the highest diagnostic specificity for systemic lupus erythematosus (SLE)?

Internal Medicine

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A 50-year-old male presents with sudden-onset excruciating pain, redness, and swelling in his right first metatarsophalangeal (MTP) joint after attending a celebratory feast with heavy seafood and alcohol intake. On examination, the joint is warm, swollen, and exquisitely tender to light touch. Arthrocentesis is performed. What polarized light microscopy finding confirms the diagnosis of acute gouty arthritis?

Internal Medicine

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A 60-year-old female with long-standing poorly controlled hypertension presents to the clinic. Her in-office blood pressure readings on three separate occasions average 168/102 mmHg. Laboratory testing shows a serum creatinine of 1.1 mg/dL, potassium of 4.2 mEq/L, and a spot urine albumin-to-creatinine ratio of 180 mg/g (microalbuminuria). According to current international hypertension guidelines, which initial pharmacotherapy strategy is most appropriate?

Internal Medicine

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A 30-year-old male presents with a 3-week history of productive cough with blood-streaked sputum, afternoon low-grade fevers, drenching night sweats, and a 4 kg weight loss. A chest radiograph demonstrates an apical cavitary lesion in the right upper lobe. Sputum smear microscopy is positive for acid-fast bacilli (AFB). What is the standard first-line intensive phase regimen for drug-susceptible pulmonary tuberculosis under WHO guidelines?

Internal Medicine

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A 22-year-old male presents with a 14-hour history of abdominal pain that initially began periumbilically and has now localized to the right lower quadrant. He has anorexia, nausea, and a low-grade fever of 37.9°C. On examination, there is marked tenderness and involuntary guarding at McBurney's point. Rovsing's sign and the psoas sign are positive. His white blood cell count is 14,800/mm³ with 85% neutrophils. What is the most definitive management?

Surgery

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A 70 kg male sustains second- and third-degree thermal burns to his entire anterior torso (18%), entire right arm (9%), and anterior surface of both legs (18%), totaling 45% total body surface area (TBSA). Using the Parkland formula, calculate the total volume of Ringer's lactate fluid required during the first 24 hours from the time of injury, and state how much must be infused during the first 8 hours.

Surgery

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A 48-year-old female presents to the emergency department with severe, constant right upper quadrant pain radiating to the right infrascapular region, low-grade fever (38.3°C), and nausea following a fatty meal. On physical examination, there is marked tenderness and sudden cessation of inspiration upon deep palpation of the right upper quadrant (positive Murphy's sign). Laboratory tests show a white blood cell count of 13,500/mm³. What is the initial imaging modality of choice?

Surgery

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