MSRA - Exam Clinical Problem Solving 3

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?

Accepted Answer

IV broad-spectrum antibiotics, IV fluids, and high-flow oxygen

Answer

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?

Accepted Answer

CT pulmonary angiogram (CTPA)

Answer

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?

Accepted Answer

Urgent surgical referral for likely appendicectomy

Answer

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?

Accepted Answer

Admit urgently and use the ABCD² score to guide management

Answer

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?

Accepted Answer

Administer IV benzylpenicillin without waiting for investigations

Answer

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.

MSRA Exam (Multi-Specialty Recruitment Assessment) Practice Test

MSRA Exam (Multi-Specialty Recruitment Assessment) Practice Test

MSRA - Exam Clinical Problem Solving 3