Medicine 10 clinical question

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I now have excellent material from authoritative textbooks (Goldman-Cecil, Tintinalli, Rosen's, Robbins, Katzung, Lippincott, Bradley & Daroff, Washington Manual) across Cardiology, Respiratory, Endocrinology, Neurology, Gastro, Nephrology, Infectious Disease, and Respiratory. Here are your 10 clinical MCQs:

10 Mixed Medicine Clinical MCQs

Medical Student Level | MCQ with Answer & Explanation

Q1 - Cardiology (STEMI)

A 58-year-old man presents to the emergency department with 2 hours of crushing central chest pain radiating to the left arm, diaphoresis, and nausea. His ECG shows 3mm ST elevation in leads II, III, and aVF with reciprocal changes in I and aVL. Troponin is elevated.

What is the most likely culprit vessel, and what is the primary treatment goal?

A. Left anterior descending artery; administer IV heparin only
B. Right coronary artery; urgent percutaneous coronary intervention (PCI) within 90 minutes
C. Left circumflex artery; thrombolysis is preferred over PCI regardless of centre availability
D. Right coronary artery; wait 24 hours for troponin trend before revascularisation
E. Left main stem; start IV nitrates and reassess

Correct Answer: B

Explanation: Inferior STEMI (ST elevation in II, III, aVF) is most commonly caused by occlusion of the right coronary artery (RCA). The standard of care is primary PCI, ideally within 90 minutes of first medical contact (door-to-balloon time). ST elevation in leads II, III, aVF with reciprocal ST depression in I and aVL is the classic pattern. Delaying revascularisation worsens outcomes. Thrombolysis is used only when PCI is not available within the time window. IV heparin alone does not restore flow in a totally occluded epicardial artery. (The Washington Manual of Medical Therapeutics - STEMI management)

Q2 - Respiratory (Community-Acquired Pneumonia)

A 45-year-old previously healthy man presents with 4 days of productive cough, fever (38.9°C), right-sided pleuritic chest pain, and a CXR showing right lower lobe consolidation. His CURB-65 score is 1.

What is the most appropriate management?

A. Admit to ICU and start IV vancomycin
B. Oral amoxicillin and manage as an outpatient
C. IV ceftriaxone + azithromycin; admit to hospital
D. CT chest before starting any antibiotic
E. No antibiotics; consolidation may be malignant

Correct Answer: B

Explanation: A CURB-65 score of 0-1 indicates low-severity community-acquired pneumonia (CAP), appropriate for outpatient management. Oral amoxicillin (or amoxicillin-clavulanate) is first-line for non-severe CAP in otherwise healthy adults in most guidelines (BTS/ATS). Hospital admission (CURB-65 ≥2) and IV antibiotics are reserved for moderate-to-severe disease. A CT scan prior to starting antibiotics is not routinely indicated when CXR findings and clinical features are consistent with CAP. Vancomycin is for MRSA-suspected pneumonia in the ICU setting. (Murray & Nadel's Textbook of Respiratory Medicine; Medical Microbiology 9e)

Q3 - Endocrinology (Diabetic Ketoacidosis)

A 19-year-old type 1 diabetic presents with vomiting, abdominal pain, polyuria, and Kussmaul breathing for 12 hours. Investigations: glucose 28 mmol/L, pH 7.1, bicarbonate 10 mmol/L, urine ketones 3+, anion gap 24.

Which of the following is the MOST important immediate step in management?

A. Give subcutaneous insulin immediately and send the patient home
B. Start IV 0.9% NaCl fluid resuscitation as the first priority
C. Give IV sodium bicarbonate to correct acidosis
D. Administer IV insulin bolus before starting fluids
E. Oral rehydration and monitoring in A&E

Correct Answer: B

Explanation: In diabetic ketoacidosis (DKA), fluid resuscitation with IV 0.9% NaCl is the FIRST priority - patients are typically 3-5 litres depleted. Fluid replacement restores circulating volume, improves renal perfusion, and begins to lower glucose and ketones. IV insulin infusion (not bolus) is started shortly after fluids begin, usually once potassium is confirmed ≥3.5 mmol/L. IV bicarbonate is not recommended routinely (pH >6.9 does not benefit) and can worsen hypokalaemia and intracellular acidosis. Subcutaneous insulin is inappropriate in acute DKA due to unreliable absorption. (Tintinalli's Emergency Medicine; Rosen's Emergency Medicine - DKA section)

Q4 - Neurology (Acute Ischaemic Stroke)

A 67-year-old woman is brought in with sudden right-sided weakness and dysphasia. Her symptoms began 2 hours ago. CT head shows no haemorrhage. BP is 165/90 mmHg. She has no recent surgery or active bleeding.

What is the most appropriate treatment?

A. IV labetalol to lower BP urgently before any intervention
B. IV recombinant tPA (alteplase) within the 3-4.5-hour window
C. Aspirin 300mg and discharge with outpatient neurology review
D. Oral clopidogrel; thrombolysis is not indicated
E. Heparin infusion to prevent clot propagation

Correct Answer: B

Explanation: IV alteplase (recombinant tPA) at 0.9 mg/kg is the standard of care for acute ischaemic stroke within 3 to 4.5 hours of symptom onset, provided no contraindications exist (haemorrhage on CT, recent surgery, active bleeding, etc.). The NINDS rtPA trial established this. BP should be kept below 185/110 mmHg before thrombolysis but should not be aggressively lowered prophylactically, as relative hypertension helps maintain perfusion to the ischaemic penumbra. Aspirin alone is not the correct first-line treatment when thrombolysis is eligible. Heparin is not indicated in the acute phase. (Bradley and Daroff's Neurology in Clinical Practice; Plum and Posner's Diagnosis and Treatment of Stupor and Coma)

Q5 - Gastroenterology (Peptic Ulcer / H. pylori)

A 42-year-old man with a 3-month history of epigastric pain relieved by eating is found on upper GI endoscopy to have a duodenal ulcer. CLO (campylobacter-like organism) test is positive.

What is the first-line treatment?

A. Long-term proton pump inhibitor (PPI) monotherapy alone
B. H2 receptor antagonist only
C. Triple therapy: PPI + amoxicillin + clarithromycin for 7-14 days
D. IV omeprazole for 5 days followed by surveillance endoscopy
E. Immediate surgical referral for ulcer oversewing

Correct Answer: C

Explanation: The discovery of H. pylori (positive CLO test) as the causative agent of most duodenal ulcers means eradication is the mainstay of treatment. Standard first-line triple therapy consists of a PPI (e.g. omeprazole) + amoxicillin + clarithromycin for 7-14 days. Successful eradication heals the ulcer and dramatically reduces recurrence. PPI monotherapy heals the ulcer with acid suppression but does not eradicate H. pylori and recurrence rates are high. H2 antagonists are less effective than PPIs. Surgery is reserved for complications (perforation, haemorrhage unresponsive to endoscopy). (Schwartz's Principles of Surgery; Katzung's Basic and Clinical Pharmacology - Acid-Peptic Diseases; Goldman-Cecil Medicine)

Q6 - Nephrology (Acute Kidney Injury)

A 72-year-old man is admitted with 2 days of vomiting and diarrhoea. His urine output has dropped to 200 mL over the last 24 hours. Investigations: creatinine 340 µmol/L (baseline 90), BUN 28 mmol/L, urine sodium 12 mmol/L, urine specific gravity 1.025. BP is 95/60 mmHg.

What is the most likely type of AKI and its immediate management?

A. Intrinsic (acute tubular necrosis); start renal replacement therapy
B. Pre-renal AKI; IV fluid resuscitation with 0.9% NaCl
C. Post-renal AKI; urgent urinary catheter
D. Intrinsic glomerulonephritis; IV methylprednisolone
E. Pre-renal AKI; restrict fluids to prevent fluid overload

Correct Answer: B

Explanation: This is pre-renal AKI. The key clues are: clinical dehydration (vomiting/diarrhoea), low BP, concentrated urine (high specific gravity 1.025), and low urine sodium (<20 mmol/L) indicating maximal tubular sodium reabsorption - the kidney is working hard to retain fluid. KDIGO classifies AKI into prerenal, intrinsic (renal), and postrenal. Pre-renal AKI is caused by reduced renal perfusion and is reversible with prompt fluid resuscitation. Intrinsic AKI (e.g. ATN) typically shows high urine sodium (>40) and isosthenuria. Post-renal requires obstruction (absent here). Withholding fluids would worsen the injury. (Miller's Anesthesia; Robbins & Kumar Basic Pathology - Acute Tubular Injury)

Q7 - Endocrinology (Hypothyroidism)

A 38-year-old woman presents with 6 months of fatigue, weight gain of 5 kg, constipation, dry skin, and cold intolerance. Investigations: TSH 18 mIU/L (normal 0.4-4.0), free T4 6 pmol/L (normal 9-24).

What is the diagnosis and drug of choice?

A. Hyperthyroidism; propranolol
B. Primary hypothyroidism; levothyroxine (T4)
C. Secondary hypothyroidism; hydrocortisone first
D. Subclinical hypothyroidism; no treatment required
E. Euthyroid sick syndrome; IV liothyronine (T3)

Correct Answer: B

Explanation: Primary hypothyroidism is defined by high TSH and low free T4, indicating primary gland failure. The most common cause is autoimmune (Hashimoto's) thyroiditis. Classic features include weight gain, fatigue, constipation, cold intolerance, and dry skin. Levothyroxine (synthetic T4) is the preferred replacement because it has a long half-life (~7 days), predictable absorption, and peripheral conversion to T3 mirrors physiology. Treatment is monitored by TSH normalisation. T3 (liothyronine) alone is not preferred due to short half-life and difficulty maintaining stable levels. Secondary hypothyroidism (low TSH + low T4) requires investigation for pituitary disease. (Lippincott Illustrated Reviews: Pharmacology; Goodman & Gilman's; Rosen's Emergency Medicine - Hypothyroidism)

Q8 - Infectious Disease (Bacterial Meningitis)

A 21-year-old university student presents with a 12-hour history of fever, severe headache, neck stiffness, and a non-blanching petechial rash. He is confused. CT head shows no mass lesion or raised ICP.

What is the most appropriate next step?

A. Await blood culture results before starting any antibiotics
B. Lumbar puncture followed by empirical IV ceftriaxone
C. IV dexamethasone alone; delay LP until fever settles
D. Empirical IV ceftriaxone + dexamethasone immediately; perform LP promptly
E. Oral ciprofloxacin and discharge with outpatient review

Correct Answer: D

Explanation: This is a classical presentation of bacterial meningitis (fever, neck stiffness, confusion, non-blanching rash - suggesting meningococcal septicaemia). Management should not be delayed for LP when clinical features are strongly suggestive. Guidelines recommend: blood cultures + immediate IV ceftriaxone + IV dexamethasone (to reduce inflammation and complications such as deafness), then LP as soon as it is safe. CSF abnormalities in bacterial meningitis (neutrophilic pleocytosis, low glucose, high protein) persist for hours after antibiotics start, so LP remains informative. In this case CT has cleared for LP, so LP should follow, not precede, the antibiotic. (Tintinalli's Emergency Medicine; Roberts and Hedges' Clinical Procedures - Lumbar Puncture section)

Q9 - Respiratory/Cardiology (Pulmonary Embolism)

A 55-year-old woman who returned from a 12-hour flight 3 days ago presents with sudden-onset dyspnoea, right-sided pleuritic chest pain, and haemoptysis. Heart rate is 118 bpm, O2 saturation 91% on air. ECG shows sinus tachycardia and S1Q3T3 pattern.

Which is the most appropriate initial investigation to confirm the diagnosis?

A. ABG only
B. Chest X-ray (CXR)
C. CT pulmonary angiography (CTPA)
D. Echocardiogram
E. V/Q scan as first-line in all cases

Correct Answer: C

Explanation: CTPA is the gold-standard investigation for diagnosing pulmonary embolism (PE) and is the first-line imaging modality in most clinical settings. This patient has multiple risk factors (recent long-haul flight = prolonged immobility), classic symptoms (dyspnoea, pleuritic pain, haemoptysis), and signs (tachycardia, hypoxia, S1Q3T3 on ECG). CXR is typically normal or shows non-specific changes (Westermark sign, Hampton's hump) and cannot confirm PE. ABG is supportive (hypoxia, hypocapnia) but not diagnostic. V/Q scan is an alternative when CTPA is contraindicated (e.g. contrast allergy, significant renal impairment, pregnancy). Anticoagulation with LMWH or heparin is started as soon as PE is clinically suspected. (Goldman-Cecil Medicine - Venous Thromboembolism)

Q10 - Cardiology (Heart Failure)

A 70-year-old man with a history of ischaemic heart disease presents with progressive breathlessness on exertion, orthopnoea, paroxysmal nocturnal dyspnoea, and ankle oedema. Echo: ejection fraction 32%. BNP is markedly elevated.

Which combination of medications has the strongest evidence for reducing mortality in this patient?

A. Digoxin + furosemide
B. Furosemide + calcium channel blocker (e.g. amlodipine)
C. ACE inhibitor + beta-blocker + aldosterone antagonist (e.g. spironolactone)
D. Aspirin + statin alone
E. Long-acting nitrate monotherapy

Correct Answer: C

Explanation: This is heart failure with reduced ejection fraction (HFrEF, EF <40%). The triple neurohormonal blockade - ACE inhibitor (or ARB/ARNI), beta-blocker, and aldosterone antagonist (mineralocorticoid receptor antagonist such as spironolactone or eplerenone) - forms the cornerstone of disease-modifying therapy with proven mortality benefit from landmark trials (CONSENSUS, MERIT-HF, RALES). Furosemide (a loop diuretic) relieves symptoms of fluid overload but has not been shown to reduce mortality. Calcium channel blockers (especially verapamil/diltiazem) are generally avoided in HFrEF. Digoxin reduces hospitalisation but not mortality. Current guidelines also support adding SGLT2 inhibitors (dapagliflozin/empagliflozin) as a fourth pillar of HFrEF therapy. (The Washington Manual of Medical Therapeutics; Goldman-Cecil Medicine - Heart Failure)

Summary Table

Q	System	Topic	Answer
1	Cardiology	Inferior STEMI - culprit vessel & management	B
2	Respiratory	CAP - CURB-65 & antibiotic choice	B
3	Endocrinology	DKA - immediate management	B
4	Neurology	Ischaemic stroke - thrombolysis	B
5	Gastroenterology	H. pylori peptic ulcer - eradication	C
6	Nephrology	Pre-renal AKI - diagnosis & management	B
7	Endocrinology	Hypothyroidism - treatment	B
8	Infectious Disease	Bacterial meningitis - emergency management	D
9	Respiratory	Pulmonary embolism - investigation	C
10	Cardiology	HFrEF - evidence-based pharmacotherapy	C

All 10 questions are grounded in authoritative textbooks including Goldman-Cecil Medicine, Tintinalli's Emergency Medicine, Rosen's Emergency Medicine, Robbins & Kumar Pathology, Katzung's Pharmacology, Lippincott Pharmacology, Bradley & Daroff's Neurology, Murray & Nadel's Respiratory Medicine, and The Washington Manual of Medical Therapeutics. Let me know if you want questions focused on any specific system, or if you'd like an explanation expanded.

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