MSRA - Exam Clinical Problem Solving 3 — Questions and Answers
Question 1: A 72-year-old man is admitted with confusion, fever of 38.9°C, heart rate 118 bpm, and a respiratory rate of 24/min. Blood cultures are taken and lactate returns at 2.8 mmol/L. He has a suspected urinary source of infection. According to the Sepsis-6 bundle, which of the following should be administered within the first hour?
- Oral co-amoxiclav and reassess in 4 hours
- IV broad-spectrum antibiotics, IV fluids, and high-flow oxygen (Correct answer)
- IV furosemide to manage fluid overload risk
- Withhold antibiotics until culture sensitivities are available
Correct answer: IV broad-spectrum antibiotics, IV fluids, and high-flow oxygen
This patient meets sepsis criteria with an elevated lactate suggesting tissue hypoperfusion. The Sepsis-6 bundle requires: high-flow oxygen, blood cultures, IV antibiotics, IV fluid resuscitation, urine output monitoring, and serial lactate measurement — all within one hour. Delaying antibiotics pending sensitivities significantly worsens mortality.
Question 2: A 55-year-old woman presents with sudden pleuritic chest pain and breathlessness 5 days after a long-haul flight. Her oxygen saturation is 93% on air, heart rate 105 bpm, and blood pressure 118/76 mmHg. A Wells score is calculated as 5. What is the most appropriate next step?
- D-dimer blood test
- CT pulmonary angiogram (CTPA) (Correct answer)
- Ventilation-perfusion (V/Q) scan
- Chest X-ray and discharge with follow-up
Correct answer: CT pulmonary angiogram (CTPA)
A Wells score ≥ 5 indicates a high clinical probability of pulmonary embolism. In high-probability patients, guidelines recommend proceeding directly to CTPA rather than D-dimer, as a negative D-dimer does not reliably exclude PE at this pretest probability and would not alter management.
Question 3: A 28-year-old man presents with a 3-day history of right iliac fossa pain that has worsened over 24 hours, nausea, and a temperature of 38.2°C. Examination reveals guarding and rebound tenderness at McBurney's point. His Alvarado score is 8. What is the most appropriate management?
- Discharge with oral antibiotics and review in 48 hours
- Urgent surgical referral for likely appendicectomy (Correct answer)
- CT abdomen and pelvis before any further action
- IV morphine and reassess after analgesia
Correct answer: Urgent surgical referral for likely appendicectomy
An Alvarado score of 7–10 indicates a high likelihood of acute appendicitis and warrants urgent surgical referral. While CT can help in equivocal cases (score 4–6), a score of 8 in a young man with classical signs makes surgical assessment the priority to prevent perforation.
Question 4: A 68-year-old woman with a known history of hypertension presents to the emergency department with a sudden-onset facial droop, left arm weakness, and slurred speech lasting 45 minutes, which then fully resolved. She is now asymptomatic. What is the most appropriate immediate management?
- Reassure and arrange GP follow-up in one week
- Start aspirin 75 mg and discharge with neurology outpatient referral
- Admit urgently and use the ABCD² score to guide management (Correct answer)
- Perform an MRI brain as an elective outpatient investigation
Correct answer: Admit urgently and use the ABCD² score to guide management
This presentation is consistent with a transient ischaemic attack (TIA). The ABCD² score stratifies short-term stroke risk and guides the urgency of admission and investigation. High-risk patients (score ≥ 4) require same-day specialist assessment, carotid imaging, and antiplatelet therapy to prevent an early stroke.
Question 5: A 19-year-old student is brought to the emergency department with a 6-hour history of worsening headache, fever, neck stiffness, and a non-blanching petechial rash on her legs. What is the most critical immediate action?
- Perform a lumbar puncture immediately to confirm diagnosis
- Administer IV benzylpenicillin without waiting for investigations (Correct answer)
- Order a CT head before considering any treatment
- Send blood cultures and delay antibiotics until results are available
Correct answer: Administer IV benzylpenicillin without waiting for investigations
The clinical picture — fever, meningism, and a non-blanching rash — is highly suggestive of meningococcal meningitis/septicaemia. IV benzylpenicillin must be given immediately on clinical suspicion, before lumbar puncture or CT, as even a 30-minute delay significantly increases mortality. Investigations should never delay treatment in this scenario.
Question 6: A 70-year-old man with type 2 diabetes and chronic kidney disease (baseline creatinine 130 µmol/L) is admitted following three days of vomiting and diarrhoea. Investigations show: creatinine 310 µmol/L, potassium 6.2 mmol/L, bicarbonate 16 mmol/L, and urine output 15 mL/hour. Which of the following is the most immediately life-threatening abnormality requiring urgent treatment?
- Elevated creatinine indicating acute-on-chronic kidney injury
- Metabolic acidosis with low bicarbonate
- Hyperkalaemia with potassium of 6.2 mmol/L (Correct answer)
- Oliguria with urine output below 0.5 mL/kg/hour
Correct answer: Hyperkalaemia with potassium of 6.2 mmol/L
Hyperkalaemia (K⁺ 6.2 mmol/L) is the most immediately life-threatening finding as it can cause fatal cardiac arrhythmias. Management includes an urgent ECG to assess for peaked T-waves or broad QRS, followed by IV calcium gluconate for cardiac membrane stabilisation, insulin-dextrose infusion to shift potassium intracellularly, and treatment of the underlying cause.
MSRA - Exam Clinical Problem Solving 3
A 72-year-old man is admitted with confusion, fever of 38.9°C, heart rate 118 bpm, and a respiratory rate of 24/min.
Blood cultures are taken and lactate returns at 2.8 mmol/L.
He has a suspected urinary source of infection.
According to the Sepsis-6 bundle, which of the following should be administered within the first hour?