MSRA - Exam Clinical Problem Solving 2 — Questions and Answers
Question 1: A 45-year-old woman presents to A&E five days after a total knee replacement with sudden-onset breathlessness, pleuritic chest pain, and haemoptysis. Her oxygen saturation is 91% on air and heart rate is 112 bpm. What is the most likely diagnosis?
- Community-acquired pneumonia
- Pulmonary embolism (Correct answer)
- Spontaneous pneumothorax
- Acute aortic dissection
Correct answer: Pulmonary embolism
Recent major orthopaedic surgery is a major VTE risk factor. Sudden dyspnoea, pleuritic chest pain, haemoptysis, tachycardia, and hypoxia in this context constitute a classic presentation of pulmonary embolism. Pneumonia typically has a more gradual onset with fever; pneumothorax would show absent breath sounds; aortic dissection presents with tearing back pain.
Question 2: A 22-year-old university student presents with high fever, severe headache, neck stiffness, photophobia, and a rapidly spreading non-blanching purpuric rash. What is the single most important immediate action?
- Perform a lumbar puncture to confirm diagnosis
- Request an urgent CT head before any treatment
- Administer intravenous benzylpenicillin immediately (Correct answer)
- Obtain blood cultures and await sensitivity results before treating
Correct answer: Administer intravenous benzylpenicillin immediately
A non-blanching purpuric rash with signs of meningism indicates probable meningococcal septicaemia — a life-threatening emergency. IV benzylpenicillin must be given immediately without waiting for investigations, as delay significantly increases mortality. Lumbar puncture and CT can follow once the patient is stabilised.
Question 3: A 58-year-old man with hypertension and type 2 diabetes presents with two hours of central chest pain radiating to his left arm. His ECG shows ST depression and T-wave inversion in leads V4–V6, and his high-sensitivity troponin is significantly elevated. What is the correct diagnosis?
- Unstable angina
- ST-elevation myocardial infarction (STEMI)
- Non-ST-elevation myocardial infarction (NSTEMI) (Correct answer)
- Acute pericarditis
Correct answer: Non-ST-elevation myocardial infarction (NSTEMI)
NSTEMI is defined by ischaemic symptoms plus elevated troponin in the absence of ST elevation. ST depression and T-wave inversion confirm ischaemia, and the raised troponin indicates myocardial necrosis. STEMI requires ST elevation; unstable angina has normal troponin; pericarditis typically produces diffuse saddle-shaped ST elevation with PR depression.
Question 4: A 29-year-old woman with a previous ectopic pregnancy presents with a 6-week history of amenorrhoea, left iliac fossa pain, and sudden onset of right shoulder tip pain. Her blood pressure is 78/50 mmHg and heart rate is 136 bpm. What is the most likely diagnosis?
- Acute appendicitis
- Ruptured ectopic pregnancy (Correct answer)
- Ovarian torsion
- Threatened miscarriage
Correct answer: Ruptured ectopic pregnancy
Shoulder tip pain results from diaphragmatic irritation caused by haemoperitoneum — blood collecting under the diaphragm after intra-abdominal haemorrhage. Combined with haemodynamic instability, amenorrhoea, and a prior ectopic pregnancy (a major risk factor), the diagnosis is a ruptured ectopic pregnancy until proven otherwise. This is a surgical emergency.
Question 5: A 52-year-old man presents with severe epigastric pain radiating to the back, nausea, and vomiting following a heavy alcohol binge. Serum amylase is five times the upper limit of normal. Which scoring system is used to stratify the severity of this condition?
- CURB-65 score
- Glasgow-Blatchford score
- Glasgow (Imrie) score (Correct answer)
- Wells score
Correct answer: Glasgow (Imrie) score
The Glasgow (Imrie) score uses eight clinical and laboratory parameters to predict severe acute pancreatitis within 48 hours of admission. CURB-65 stratifies pneumonia severity; the Glasgow-Blatchford score risk-stratifies upper GI bleeds; the Wells score estimates pre-test probability of PE or DVT.
Question 6: A 72-year-old man taking warfarin for atrial fibrillation develops sudden-onset left-sided facial droop, arm weakness, and slurred speech that resolves completely within 40 minutes. What is the most appropriate initial investigation?
- MRI brain with diffusion-weighted imaging
- Non-contrast CT head (Correct answer)
- Carotid Doppler ultrasound
- Transthoracic echocardiogram
Correct answer: Non-contrast CT head
This presentation is consistent with a TIA. In a patient on anticoagulation, a non-contrast CT head must be performed first to exclude intracranial haemorrhage before any management decisions are made. Although diffusion-weighted MRI is more sensitive for detecting early ischaemia, excluding a bleed takes priority, particularly in anticoagulated patients.
MSRA - Exam Clinical Problem Solving 2
A 45-year-old woman presents to A&E five days after a total knee replacement with sudden-onset breathlessness, pleuritic chest pain, and haemoptysis.
Her oxygen saturation is 91% on air and heart rate is 112 bpm.
What is the most likely diagnosis?