Free SMLE practice questions

Correct answer: D

• A. Begin bowel preparation and arrange colonoscopy within 24 hours

  Colonoscopy is not the appropriate initial investigation because hematemesis localizes the bleeding to the upper gastrointestinal tract, and variceal bleeding is strongly suspected.

• B. Start intravenous pantoprazole and arrange upper endoscopy within 24 hours

  This is insufficient for suspected variceal hemorrhage. Proton-pump inhibitor therapy does not replace vasoactive treatment and antibiotic prophylaxis, and the recommended endoscopic target is within 12 hours.

• C. Arrange contrast-enhanced CT angiography before any endoscopic evaluation

  CT angiography is not the initial test in a hemodynamically stabilized patient with suspected variceal upper gastrointestinal bleeding; treatment and timely endoscopy should not be delayed for it.

• D. Start intravenous octreotide and ceftriaxone, then arrange upper endoscopy within 12 hours

  This is correct because suspected acute variceal bleeding requires immediate vasoactive therapy and antibiotic prophylaxis, followed by endoscopy after resuscitation, ideally within 12 hours.

Baveno VII – Renewing consensus in portal hypertension, 2022 · Acute variceal bleeding, recommendations 6.1–6.7 (checked 9 August 2026)

Correct answer: A

• A. Activate the catheterization laboratory for immediate primary percutaneous coronary intervention

  This is an anterior ST-elevation myocardial infarction, and primary percutaneous coronary intervention is indicated because it can be delivered within the recommended 120-minute time window.

• B. Administer intravenous fibrinolytic therapy before arranging transfer for intervention

  Fibrinolysis is considered when timely primary PCI cannot be performed. In this patient, the hospital can provide primary PCI within 120 minutes, so fibrinolysis is not the preferred reperfusion strategy.

• C. Arrange an exercise stress test after serial cardiac biomarker measurements

  Stress testing is inappropriate in a patient with diagnostic ST-elevation myocardial infarction because urgent reperfusion is required rather than outpatient ischemia assessment.

• D. Obtain computed tomography coronary angiography before choosing reperfusion therapy

  Computed tomography coronary angiography is not appropriate when the ECG and clinical presentation establish an acute ST-elevation myocardial infarction requiring immediate reperfusion.

2023 European Society of Cardiology Guidelines for the Management of Acute Coronary Syndromes · Section 6.2.1, Reperfusion therapy in ST-segment elevation myocardial infarction (checked 9 August 2026)

Correct answer: C

• A. Continuous intravenous unfractionated heparin

  Intravenous heparin is indicated for selected thromboembolic conditions, not as routine treatment for uncomplicated acute pericarditis. Anticoagulation may also increase concern for hemorrhagic pericardial effusion in appropriate clinical settings.

• B. Intravenous thrombolytic therapy

  Thrombolytic therapy is used for selected acute coronary or pulmonary thromboembolic emergencies. It is not indicated for the diffuse inflammatory electrocardiographic pattern and characteristic pain of acute pericarditis.

• C. Ibuprofen plus colchicine

  This is the recommended initial therapy for uncomplicated acute pericarditis when there are no contraindications. An anti-inflammatory drug relieves symptoms, and colchicine reduces persistent or recurrent disease.

• D. Aspirin plus clopidogrel

  Dual antiplatelet therapy is used primarily for acute coronary syndromes or after coronary stenting. The positional pain and diffuse ST-segment changes indicate pericarditis rather than a focal coronary occlusion.

2015 ESC Guidelines for the Diagnosis and Management of Pericardial Diseases · Management of acute pericarditis (checked 9 August 2026)

Correct answer: A

• A. Ibuprofen

  Correct. This presentation is typical of primary dysmenorrhea. Nonsteroidal anti-inflammatory drugs, such as ibuprofen, are first-line treatment because they reduce prostaglandin production and menstrual pain.

• B. Combined oral contraceptive pill

  Combined oral contraceptives can improve dysmenorrhea, but they are generally considered when symptoms persist, when contraception is desired, or when NSAIDs are ineffective or contraindicated.

• C. Doxycycline

  Doxycycline is used for selected bacterial infections, including some causes of pelvic inflammatory disease. The absence of fever, discharge, cervical motion tenderness, and pelvic abnormalities makes infection unlikely.

• D. Leuprolide

  Leuprolide is a gonadotropin-releasing hormone agonist used in selected cases of endometriosis or other hormone-dependent conditions. It is not an appropriate initial treatment for uncomplicated primary dysmenorrhea.

American College of Obstetricians and Gynecologists, Committee Opinion No. 760: Dysmenorrhea and Endometriosis in Adolescents, reaffirmed 2025 · Dysmenorrhea: Initial treatment (checked 8 August 2026)

Correct answer: A

• A. Stabilize the mother with magnesium sulfate and urgent blood-pressure treatment, then proceed with delivery

  This patient has preeclampsia with severe features at 35 weeks, including severe hypertension, neurologic symptoms, thrombocytopenia, and elevated liver enzymes. At 34 weeks or later, delivery is recommended after maternal stabilization; magnesium sulfate provides seizure prophylaxis and severe hypertension requires urgent treatment.

• B. Continue expectant management with frequent maternal and fetal surveillance until 37 weeks

  Expectant management may be considered in selected patients with severe features before 34 weeks when maternal and fetal conditions are stable. This patient is already beyond 34 weeks and has severe neurologic and laboratory abnormalities, so prolonging the pregnancy is not appropriate.

• C. Perform an immediate cesarean birth without treating the severe hypertension or giving seizure prophylaxis

  Delivery is indicated, but maternal stabilization must begin first. Severe hypertension should be treated promptly, and magnesium sulfate should be given for seizure prophylaxis; the route of delivery depends on obstetric factors rather than preeclampsia alone.

• D. Administer antenatal corticosteroids and delay delivery for 48 hours

  Corticosteroids are recommended when preterm delivery is anticipated, particularly before 34 weeks, but they should not delay indicated delivery in a woman at or beyond 34 weeks with severe preeclampsia and maternal complications.

American College of Obstetricians and Gynecologists, Practice Bulletin No. 222: Gestational Hypertension and Preeclampsia, 2020 (reaffirmed 2023) · Management of Preeclampsia With Severe Features (checked 9 August 2026)

Correct answer: C

• A. Retained placental tissue

  Retained placental tissue can cause postpartum hemorrhage, but the placenta is described as complete. It more often causes persistent uterine subinvolution and bleeding rather than the immediate boggy uterus described here.

• B. Uterine inversion

  Uterine inversion typically causes sudden severe pain, shock that may be disproportionate to visible blood loss, and a fundal depression or mass protruding through the vagina. These findings are not present in this case.

• C. Uterine atony

  This is the most likely diagnosis. Early postpartum hemorrhage with a large, boggy uterus after delivery, in the absence of retained placental tissue or genital tract trauma, is characteristic of uterine atony.

• D. Uterine rupture

  Uterine rupture usually presents during labour or immediately after delivery with severe abdominal pain, maternal instability, and often an abnormal fetal heart-rate pattern before delivery. A boggy uterus with no stated risk factors is more consistent with atony.

Williams Obstetrics, 26th edition, 2022 · Chapter 36: Postpartum Hemorrhage (checked 9 August 2026)

Correct answer: C

• A. Start chest compressions

  Chest compressions are indicated only when the heart rate remains below 60 beats/min after effective positive-pressure ventilation, not as the initial intervention for a heart rate of 80 beats/min.

• B. Apply continuous positive airway pressure

  Continuous positive airway pressure is used for a spontaneously breathing newborn with respiratory distress or persistent cyanosis; this newborn is apneic and requires assisted ventilation.

• C. Begin positive-pressure ventilation

  This is correct because apnea and a heart rate below 100 beats/min after the initial steps are indications for immediate positive-pressure ventilation.

• D. Give supplemental oxygen by face mask alone

  Supplemental oxygen alone does not provide the ventilatory support required for an apneic newborn with a heart rate below 100 beats/min.

Neonatal Resuscitation Program, Textbook of Neonatal Resuscitation, 8th edition · Initial Steps of Newborn Care and Positive-Pressure Ventilation (checked 9 August 2026)

Correct answer: C

• A. Early-onset neonatal pneumonia

  This is less likely in an otherwise well-appearing newborn without fever, maternal infectious risk factors, or focal infiltrates. Pneumonia may clinically resemble respiratory distress syndrome but is not suggested by this presentation.

• B. Neonatal respiratory distress syndrome

  This is less likely in a term infant without severe respiratory distress. Respiratory distress syndrome is more typical in preterm infants and usually shows diffuse reticulogranular opacities with low lung volumes.

• C. Transient tachypnea of the newborn

  Correct. Early tachypnea after cesarean delivery, mild oxygen requirement, and radiographic fluid retention are characteristic of delayed clearance of fetal lung fluid.

• D. Meconium aspiration syndrome

  This is less likely because the vignette does not describe meconium-stained amniotic fluid or coarse, patchy pulmonary opacities. Meconium aspiration can also cause more significant hypoxemia.

Cloherty and Stark's Manual of Neonatal Care 2023 · Respiratory Distress in the Newborn (checked 9 August 2026)

Correct answer: A

• A. Perform emergency exploratory laparotomy

  This is the best next step because the patient has persistent hemodynamic instability and a positive FAST examination, indicating major intra-abdominal hemorrhage requiring immediate operative control.

• B. Proceed to pelvic arterial embolization

  Pelvic arterial embolization is used for selected pelvic arterial bleeding, particularly when there is no indication for immediate laparotomy. Positive intraperitoneal fluid with persistent shock indicates a need for abdominal exploration.

• C. Perform diagnostic peritoneal lavage

  Diagnostic peritoneal lavage is an alternative diagnostic test when FAST is unavailable or indeterminate. In this patient, FAST has already demonstrated free fluid and immediate laparotomy is indicated.

• D. Obtain contrast-enhanced abdominal CT

  CT is appropriate for a hemodynamically stable trauma patient. It should not delay operative hemorrhage control in a persistently unstable patient with free intraperitoneal fluid.

American College of Surgeons, Advanced Trauma Life Support (ATLS) Student Course Manual, 11th edition, 2025 · Abdominal and Pelvic Trauma (checked 9 August 2026)

Correct answer: A

• A. Apply a pelvic binder centered over the greater trochanters

  This is the immediate mechanical intervention for suspected unstable pelvic-ring injury with hemodynamic instability. It reduces pelvic volume and helps tamponade venous and cancellous-bone bleeding while definitive hemorrhage control is arranged.

• B. Transfer directly to angiography for pelvic embolization

  Angiographic embolization may be required for ongoing arterial bleeding, but it is not the first immediate maneuver. Mechanical stabilization and continued damage-control resuscitation should occur before definitive angioembolization.

• C. Perform diagnostic peritoneal lavage

  Diagnostic peritoneal lavage is not the preferred initial test when focused ultrasonography is negative and the clinical findings strongly suggest pelvic hemorrhage. Immediate pelvic stabilization is more appropriate.

• D. Obtain contrast-enhanced CT of the abdomen and pelvis

  CT is useful in a hemodynamically stable patient for defining injuries, but transporting this unstable patient for imaging would delay immediate pelvic stabilization and hemorrhage control.

Advanced Trauma Life Support (ATLS) Student Course Manual, 11th edition · Pelvic Trauma and Genitourinary Trauma, 2025 (checked 9 August 2026)