MSRA Clinical Problem Solving 2 — Questions and Answers
Question 1: A 24-year-old woman presents with sudden pleuritic chest pain and breathlessness 2 weeks after starting the combined oral contraceptive pill. What is the most likely diagnosis?
- Pulmonary embolism (Correct answer)
- Pneumonia
- Costochondritis
- Anxiety attack
Correct answer: Pulmonary embolism
Recent oestrogen-containing contraception plus pleuritic chest pain and dyspnoea strongly suggests pulmonary embolism.
Question 2: A 60-year-old man with type 2 diabetes has a foot ulcer with surrounding erythema, warmth and purulent discharge. What is the most appropriate initial management?
- Oral antibiotics and wound review (Correct answer)
- Reassurance only
- Topical steroid cream
- Immediate amputation
Correct answer: Oral antibiotics and wound review
An infected diabetic foot ulcer requires antibiotics and close wound review to prevent progression.
Question 3: A 35-year-old presents with a sudden severe occipital headache described as 'the worst of my life'. CT head is normal at 12 hours. What is the next best investigation?
- Lumbar puncture (Correct answer)
- Discharge home
- MRI brain
- EEG
Correct answer: Lumbar puncture
If CT is negative beyond 6 hours, lumbar puncture for xanthochromia is needed to exclude subarachnoid haemorrhage.
Question 4: A 70-year-old man on warfarin presents with melaena and an INR of 8.0 but no major bleeding. What is the most appropriate action?
- Stop warfarin and give oral vitamin K (Correct answer)
- Continue warfarin unchanged
- Give protamine sulphate
- Increase the warfarin dose
Correct answer: Stop warfarin and give oral vitamin K
For high INR with minor bleeding, withhold warfarin and give vitamin K to reverse anticoagulation.
Question 5: A 4-year-old child has a barking cough, stridor and hoarseness that is worse at night. What is the most likely diagnosis?
- Croup (Correct answer)
- Epiglottitis
- Asthma
- Foreign body aspiration
Correct answer: Croup
Barking cough with stridor and hoarse voice is the classic picture of croup (laryngotracheobronchitis).
Question 6: A 50-year-old woman reports fatigue, cold intolerance, weight gain and constipation. Which single test is most useful?
- Thyroid-stimulating hormone (TSH) (Correct answer)
- Random glucose
- Full blood count only
- Liver function tests
Correct answer: Thyroid-stimulating hormone (TSH)
These symptoms suggest hypothyroidism, best screened with TSH.
Question 7: A 22-year-old presents with right iliac fossa pain, anorexia and a low-grade fever. Which clinical sign supports appendicitis?
- Rovsing's sign (Correct answer)
- Murphy's sign
- Kernig's sign
- Trousseau's sign
Correct answer: Rovsing's sign
Rovsing's sign (RIF pain on left-sided palpation) supports a diagnosis of appendicitis.
MSRA Clinical Problem Solving 2
A 24-year-old woman presents with sudden pleuritic chest pain and breathlessness 2 weeks after starting the combined oral contraceptive pill.
What is the most likely diagnosis?