MSRA Clinical Problem Solving 1 — Questions and Answers
Question 1: A 65-year-old patient presents with acute chest pain, sweating, and shortness of breath. The ECG shows ST elevation in leads II, III, and aVF. What is the most likely diagnosis?
- Inferior ST-elevation myocardial infarction (Correct answer)
- Pulmonary embolism
- Pericarditis
- Aortic dissection
Correct answer: Inferior ST-elevation myocardial infarction
ST elevation in leads II, III, and aVF indicates an inferior STEMI, typically caused by right coronary artery occlusion, requiring urgent reperfusion therapy.
Question 2: What is the most appropriate initial management of a patient presenting with diabetic ketoacidosis?
- IV fluid resuscitation, IV insulin infusion, and potassium replacement (Correct answer)
- Oral hypoglycemic agents
- Subcutaneous insulin only
- Bicarbonate infusion as first-line treatment
Correct answer: IV fluid resuscitation, IV insulin infusion, and potassium replacement
DKA management priorities are fluid resuscitation (0.9% saline), IV insulin infusion, potassium monitoring and replacement, and identifying the precipitating cause. Bicarbonate is reserved for severe acidosis (pH <6.9).
Question 3: A 30-year-old woman presents with sudden-onset severe headache described as the worst headache of her life. What investigation should be performed urgently?
- CT head without contrast, followed by lumbar puncture if CT is negative (Correct answer)
- MRI brain with contrast
- Skull X-ray
- Blood tests only
Correct answer: CT head without contrast, followed by lumbar puncture if CT is negative
Thunderclap headache requires urgent CT head to rule out subarachnoid hemorrhage. If CT is negative but clinical suspicion remains, lumbar puncture should be performed to look for xanthochromia.
Question 4: What scoring system is used to assess stroke severity in MSRA clinical scenarios?
- NIH Stroke Scale (NIHSS) (Correct answer)
- Glasgow Coma Scale
- ABCD2 score
- CHA2DS2-VASc score
Correct answer: NIH Stroke Scale (NIHSS)
The NIHSS quantifies stroke severity by assessing consciousness, gaze, visual fields, facial palsy, motor function, ataxia, sensory function, language, dysarthria, and extinction/inattention.
Question 5: A patient on warfarin presents with an INR of 8.0 and minor bleeding. What is the most appropriate management?
- Stop warfarin and give oral vitamin K (Correct answer)
- Continue warfarin at a reduced dose
- Give IV vitamin K and fresh frozen plasma immediately
- Administer protamine sulfate
Correct answer: Stop warfarin and give oral vitamin K
For INR >5.0 with minor bleeding, warfarin should be stopped and oral vitamin K (1-5mg) administered. IV vitamin K and FFP are reserved for major or life-threatening bleeding.
Question 6: What is the Wells score used to assess?
- Clinical probability of pulmonary embolism or deep vein thrombosis (Correct answer)
- Severity of heart failure
- Risk of stroke in atrial fibrillation
- Likelihood of appendicitis
Correct answer: Clinical probability of pulmonary embolism or deep vein thrombosis
The Wells score is a clinical prediction rule that estimates the pre-test probability of PE or DVT based on clinical features, helping determine whether D-dimer testing or imaging is appropriate.
MSRA Clinical Problem Solving 1
A 65-year-old patient presents with acute chest pain, sweating, and shortness of breath.
The ECG shows ST elevation in leads II, III, and aVF.
What is the most likely diagnosis?