MSRA MSRA Clinical Reasoning 1 — Questions and Answers
Question 1: A 45-year-old woman presents with sudden-onset severe headache described as 'the worst headache of her life.' What is the most important diagnosis to exclude?
- Migraine
- Subarachnoid hemorrhage (Correct answer)
- Tension headache
- Cluster headache
Correct answer: Subarachnoid hemorrhage
A sudden severe 'thunderclap' headache is the classic presentation of subarachnoid hemorrhage and must be excluded urgently with CT head and, if negative, lumbar puncture.
Question 2: A 62-year-old man with type 2 diabetes presents with a painless foot ulcer over the metatarsal head. Pulses are present. What is the most likely underlying mechanism?
- Peripheral arterial disease
- Peripheral neuropathy (Correct answer)
- Venous insufficiency
- Vasculitis
Correct answer: Peripheral neuropathy
Painless neuropathic ulcers at pressure points with preserved pulses are characteristic of peripheral diabetic neuropathy rather than ischemia.
Question 3: A 28-year-old woman in her third trimester presents with right upper quadrant pain, elevated liver enzymes, and thrombocytopenia. What syndrome should be considered?
- Acute fatty liver of pregnancy
- HELLP syndrome (Correct answer)
- Cholestasis of pregnancy
- Viral hepatitis
Correct answer: HELLP syndrome
HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets) is a severe complication of pre-eclampsia presenting with this triad in late pregnancy.
Question 4: A 70-year-old man on warfarin presents with an INR of 8.5 and minor bleeding from the gums. He is otherwise hemodynamically stable. What is the most appropriate management?
- IV vitamin K 10 mg
- Prothrombin complex concentrate
- Hold warfarin and give oral vitamin K 1–2 mg (Correct answer)
- Fresh frozen plasma
Correct answer: Hold warfarin and give oral vitamin K 1–2 mg
For minor bleeding with a markedly elevated INR, withholding warfarin and administering low-dose oral vitamin K is sufficient to bring the INR into a safe range.
Question 5: A 55-year-old male smoker presents with progressive dyspnea, barrel chest, and reduced breath sounds bilaterally. Spirometry shows FEV1/FVC of 0.55. What is the diagnosis?
- Asthma
- Pulmonary fibrosis
- COPD (Correct answer)
- Bronchiectasis
Correct answer: COPD
An obstructive spirometry pattern (FEV1/FVC < 0.7) combined with a smoking history, barrel chest, and reduced breath sounds is diagnostic of COPD.
Question 6: A 35-year-old woman presents with fatigue, weight gain, cold intolerance, and constipation. TSH is markedly elevated with low free T4. What is the first-line treatment?
- Carbimazole
- Levothyroxine (Correct answer)
- Propylthiouracil
- Radioactive iodine
Correct answer: Levothyroxine
Primary hypothyroidism confirmed by elevated TSH and low free T4 is treated with oral levothyroxine replacement therapy.
MSRA MSRA Clinical Reasoning 1
A 45-year-old woman presents with sudden-onset severe headache described as 'the worst headache of her life.' What is the most important diagnosis to exclude?