MSRA - Exam Clinical Problem Solving 2

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?

Accepted Answer

Pulmonary embolism

Answer

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?

Accepted Answer

Administer intravenous benzylpenicillin immediately

Answer

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?

Accepted Answer

Non-ST-elevation myocardial infarction (NSTEMI)

Answer

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?

Accepted Answer

Ruptured ectopic pregnancy

Answer

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?

Accepted Answer

Glasgow (Imrie) score

Answer

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.

MSRA Exam (Multi-Specialty Recruitment Assessment) Practice Test

MSRA Exam (Multi-Specialty Recruitment Assessment) Practice Test

MSRA - Exam Clinical Problem Solving 2