MSRA Practice and Application 3 — Questions and Answers
Question 1: A 70-year-old patient with dementia is brought to the ED by family. She is in pain from a fractured hip and lacks capacity. The family insists on conservative management against medical advice. What governs the treatment decision?
- The family's decision as next of kin
- The patient's previously expressed wishes and best interests assessment (Correct answer)
- The most senior clinician's preference
- A court order must be obtained before any action
Correct answer: The patient's previously expressed wishes and best interests assessment
For an incapacitated adult, treatment decisions are based on best interests and any previously expressed wishes, not family authority alone.
Question 2: You discover a drug error was made by a colleague — the wrong dose of anticoagulant was given to a patient who is currently stable. What is the most appropriate next step?
- Monitor the patient and document it privately without telling the team
- Inform the treating team immediately, complete an incident report, and be transparent with the patient (Correct answer)
- Advise the colleague to self-report at a later time
- Only report if the patient develops complications
Correct answer: Inform the treating team immediately, complete an incident report, and be transparent with the patient
Patient safety, open disclosure, and duty of candour require immediate communication with the treating team and completion of a formal incident report.
Question 3: A 32-year-old woman presents at 28 weeks gestation with new-onset hypertension (BP 158/102) and proteinuria. What is the most likely diagnosis?
- Gestational hypertension
- Pre-eclampsia (Correct answer)
- Chronic hypertension
- HELLP syndrome
Correct answer: Pre-eclampsia
New hypertension after 20 weeks gestation with proteinuria is diagnostic of pre-eclampsia.
Question 4: A patient with a penicillin allergy label requires surgical prophylaxis. On further questioning, the reaction was a mild rash 20 years ago. What is the best approach?
- Avoid all beta-lactams regardless
- Use cefazolin, as cross-reactivity risk is low with a history of mild rash (Correct answer)
- Use vancomycin as the only safe option
- Perform formal allergy testing before any surgery
Correct answer: Use cefazolin, as cross-reactivity risk is low with a history of mild rash
A distant history of mild rash has a very low risk of true penicillin allergy; cephalosporins like cefazolin are generally safe and preferred for surgical prophylaxis.
Question 5: A 55-year-old man presents with a 2-week history of productive cough, night sweats, and weight loss. He was born in a high-prevalence TB country. What is the most appropriate initial investigation?
- Start empirical antibiotics and review in one week
- Chest X-ray and sputum AFB smear and culture (Correct answer)
- CT thorax with contrast
- Mantoux test alone
Correct answer: Chest X-ray and sputum AFB smear and culture
Chest X-ray and sputum AFB smear/culture are the initial investigations for suspected pulmonary tuberculosis.
Question 6: You are asked to countersign a prescription written by a medical student. You have not seen the patient. What should you do?
- Sign it as the student is supervised and you trust their assessment
- Review the patient yourself before countersigning the prescription (Correct answer)
- Ask a nurse to verify the prescription before signing
- Decline to sign and ask the student to find another doctor
Correct answer: Review the patient yourself before countersigning the prescription
Countersigning a prescription without personally reviewing the patient makes you clinically and legally responsible; independent assessment is required.
Question 7: A 28-year-old woman presents with right iliac fossa pain, nausea, and a positive pregnancy test. Her BP is 90/60 and HR 118. What is the most urgent priority?
- Arrange a pelvic ultrasound scan and review results
- Insert two large-bore IV cannulae, send bloods, and activate emergency gynecology (Correct answer)
- Administer analgesia and reassess in 30 minutes
- Perform a pelvic examination before any investigations
Correct answer: Insert two large-bore IV cannulae, send bloods, and activate emergency gynecology
Hemodynamic instability with a positive pregnancy test and RIF pain suggests a ruptured ectopic pregnancy requiring immediate resuscitation and emergency referral.
MSRA Practice and Application 3
A 70-year-old patient with dementia is brought to the ED by family.
She is in pain from a fractured hip and lacks capacity.
The family insists on conservative management against medical advice.
What governs the treatment decision?