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MSRA Clinical Problem Solving Mock

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Question 1 of 50

1. Question

A 4-month-old infant presents with a 1-day history of sudden, severe, inconsolable crying episodes, drawing legs to chest, and passing ‘redcurrant jelly’ stools. Abdominal examination reveals a sausage-shaped mass in the right upper quadrant.

What is the most appropriate next step in the management of this infant?

A. Administer oral rehydration solution and observe for improvement.
Correct Incorrect Correct answer

B. Refer for urgent paediatric surgical review and consider air enema or surgical reduction for suspected intussusception.
Correct Incorrect Correct answer

C. Prescribe oral antibiotics for suspected gastroenteritis.
Correct Incorrect Correct answer

D. Advise strict fluid restriction.
Correct Incorrect Correct answer

E. Reassure parents that it's likely benign colic.
Correct Incorrect Correct answer
Question 2 of 50

2. Question

A 30-year-old female presents with a 6-month history of severe and persistent anxiety about her health, despite repeated negative medical investigations. She is preoccupied with the idea that she has a serious illness, frequently seeks reassurance from doctors, and experiences significant functional impairment.

What is the most likely diagnosis and the most appropriate initial management approach?

A. Prescribe antidepressant medication (e.g., SSRI) and refer for cognitive behavioural therapy (CBT) for illness anxiety disorder (hypochondriasis).
Correct Incorrect Correct answer

B. Arrange further extensive medical investigations to rule out rare diseases.
Correct Incorrect Correct answer

C. Reassure the patient that she is physically healthy and discharge her.
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D. Refer for urgent neurological investigation for organic cause.
Correct Incorrect Correct answer

E. Prescribe a sedative for anxiety.
Correct Incorrect Correct answer
Question 3 of 50

3. Question

A 25-year-old male presents with recurrent episodes of flank pain, haematuria, and recurrent urinary tract infections. His mother has a history of kidney disease. Ultrasound reveals multiple bilateral renal cysts.

What is the most likely diagnosis and the most appropriate initial management strategy?

A. Prescribe oral analgesia and advise fluids.
Correct Incorrect Correct answer

B. Optimize blood pressure control and refer for nephrology review for suspected Autosomal Dominant Polycystic Kidney Disease (ADPKD).
Correct Incorrect Correct answer

C. Arrange urgent renal biopsy for suspected glomerulonephritis.
Correct Incorrect Correct answer

D. Refer for urgent dialysis.
Correct Incorrect Correct answer

E. Advise strict fluid restriction.
Correct Incorrect Correct answer
Question 4 of 50

4. Question

A 50-year-old male presents with sudden onset of exertional chest pain, lightheadedness, and shortness of breath. His ECG shows non-specific ST-T wave changes. Troponin levels are normal. He reports recent excessive alcohol intake. On examination, his heart sounds are muffled, and JVP is elevated. Echocardiogram shows pericardial effusion with features of tamponade.

What is the most appropriate immediate intervention for this patient?

A. Administer Aspirin 300mg stat and Ticagrelor 180mg stat.
Correct Incorrect Correct answer

B. Perform urgent pericardiocentesis for cardiac tamponade.
Correct Incorrect Correct answer

C. Prescribe oral nitrates and a beta-blocker.
Correct Incorrect Correct answer

D. Advise strict fluid restriction and low-salt diet.
Correct Incorrect Correct answer

E. Reassure the patient and manage as anxiety.
Correct Incorrect Correct answer
Question 5 of 50

5. Question

A 30-year-old female presents with a 6-month history of a persistent, intensely itchy rash, characterized by multiple small, raised, fluid-filled blisters (vesicles) on her hands and feet, which are symmetrical. She reports episodes of severe itching, especially at night. There is no associated redness or scales.

What is the most likely diagnosis and the primary treatment approach?

A. Prescribe topical antifungal cream.
Correct Incorrect Correct answer

B. Prescribe potent topical corticosteroids (e.g., Clobetasol propionate) for suspected dyshidrotic eczema (pompholyx).
Correct Incorrect Correct answer

C. Advise applying cold compresses and observation only.
Correct Incorrect Correct answer

D. Prescribe oral antibiotics for presumed infection.
Correct Incorrect Correct answer

E. Reassure the patient it's likely a common allergic reaction.
Correct Incorrect Correct answer
Question 6 of 50

6. Question

A 60-year-old male presents with new onset of gradually increasing hand and foot size, coarse facial features, and excessive sweating. He also reports headaches and visual field defects. His IGF-1 levels are elevated.

What is the most likely diagnosis and the next best step in investigation?

A. Prescribe oral calcium and vitamin D supplements.
Correct Incorrect Correct answer

B. Arrange urgent pituitary MRI scan and refer for endocrinology review for suspected acromegaly.
Correct Incorrect Correct answer

C. Advise strict dietary changes and exercise.
Correct Incorrect Correct answer

D. Prescribe oral antidiabetic medication.
Correct Incorrect Correct answer

E. Reassure and observe, as symptoms are likely age-related.
Correct Incorrect Correct answer
Question 7 of 50

7. Question

A 50-year-old female presents with acute onset of sudden, painless unilateral hearing loss in her right ear. She has no associated dizziness or tinnitus. Audiometry confirms severe sensorineural hearing loss in the right ear.

What is the most likely diagnosis and the most appropriate immediate action?

A. Prescribe oral antibiotics immediately.
Correct Incorrect Correct answer

B. Advise vocal rest and simple analgesia.
Correct Incorrect Correct answer

C. Prescribe oral corticosteroids (e.g., Prednisolone) immediately and refer for urgent ENT/audiology review for suspected sudden sensorineural hearing loss (SSNHL).
Correct Incorrect Correct answer

D. Prescribe topical nasal decongestants.
Correct Incorrect Correct answer

E. Reassure that hearing loss is common with age.
Correct Incorrect Correct answer
Question 8 of 50

8. Question

A 45-year-old male presents with acute onset of severe epigastric pain, radiating to his back, associated with nausea, vomiting, and abdominal distension. He has a history of heavy alcohol intake. His serum amylase and lipase are significantly elevated.

What is the most appropriate initial management step for this child?

A. Prescribe proton pump inhibitor (PPI) for suspected GORD.
Correct Incorrect Correct answer

B. Advise soft diet and small, frequent meals.
Correct Incorrect Correct answer

C. Administer aggressive intravenous fluids, analgesia, and nil by mouth (NBM) for suspected acute pancreatitis.
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D. Prescribe prokinetic medication (e.g., Metoclopramide).
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E. Reassure the patient that abdominal pain is common.
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Question 9 of 50

9. Question

A 60-year-old male presents with increasing fatigue, weight loss, night sweats, and painless generalized lymphadenopathy. Excisional lymph node biopsy shows Reed-Sternberg cells.

What is the most likely diagnosis and the most appropriate immediate investigation?

A. Prescribe oral iron supplements.
Correct Incorrect Correct answer

B. Refer for urgent haematology consultation for suspected Hodgkin Lymphoma.
Correct Incorrect Correct answer

C. Order a bone marrow biopsy.
Correct Incorrect Correct answer

D. Prescribe folic acid supplementation.
Correct Incorrect Correct answer

E. Arrange urgent blood transfusion.
Correct Incorrect Correct answer
Question 10 of 50

10. Question

A 30-year-old female presents with a new onset of recurrent oral ulcers, genital ulcers, and painful red nodules on her shins (erythema nodosum). She also reports eye inflammation (uveitis) and a positive pathergy test (skin lesion at site of minor trauma).

What is the most likely diagnosis and the most appropriate initial management step?

A. Prescribe oral antihistamines and advise avoidance of triggers.
Correct Incorrect Correct answer

B. Prescribe oral corticosteroids (e.g., Prednisolone) and refer to rheumatology for suspected Behçet's disease.
Correct Incorrect Correct answer

C. Prescribe high-dose oral corticosteroids immediately.
Correct Incorrect Correct answer

D. Refer for urgent allergy skin prick testing.
Correct Incorrect Correct answer

E. Reassure the patient it's likely a common viral infection.
Correct Incorrect Correct answer
Question 11 of 50

11. Question

A 50-year-old female presents with a 6-month history of widespread joint pain, morning stiffness lasting over an hour, and symmetrical swelling of her small joints of the hands and feet. She also reports fatigue and dry eyes. Her RF and anti-CCP antibodies are positive.

What is the most likely diagnosis and the most appropriate initial investigation?

A. Prescribe oral NSAIDs and advise rest.
Correct Incorrect Correct answer

B. Prescribe a disease-modifying anti-rheumatic drug (DMARD) (e.g., Methotrexate) and refer to rheumatology for suspected rheumatoid arthritis.
Correct Incorrect Correct answer

C. Advise activity modification and analgesia for suspected mechanical pain.
Correct Incorrect Correct answer

D. Administer intra-articular corticosteroid injection.
Correct Incorrect Correct answer

E. Reassure that it's likely age-related stiffness.
Correct Incorrect Correct answer
Question 12 of 50

12. Question

A 60-year-old male presents with a 6-month history of progressive difficulty with speech (dysarthria), swallowing (dysphagia), and widespread muscle weakness, twitching (fasciculations), and wasting, affecting both upper and lower limbs. Sensation and cognition are preserved.

What is the most appropriate next step in the management of this patient?

A. Prescribe oral corticosteroids.
Correct Incorrect Correct answer

B. Refer for urgent neurology review for suspected Motor Neuron Disease (MND).
Correct Incorrect Correct answer

C. Advise physiotherapy and occupational therapy only.
Correct Incorrect Correct answer

D. Arrange urgent MRI brain for suspected tumour.
Correct Incorrect Correct answer

E. Reassure the patient it's likely age-related muscle weakness.
Correct Incorrect Correct answer
Question 13 of 50

13. Question

A 38-year-old female presents with a 6-month history of heavy, prolonged menstrual bleeding (menorrhagia) and severe pelvic pain, particularly during her period. Her uterus is enlarged and tender on examination. Ultrasound shows a bulky, heterogeneous uterus with myometrial cysts.

What is the most likely diagnosis and the most appropriate initial management approach?

A. Prescribe oral analgesia and advise rest.
Correct Incorrect Correct answer

B. Prescribe combined oral contraceptive pills (COCP) or progestogens, and consider GnRH analogues or hysterectomy if symptoms are severe and fertility is not desired for suspected adenomyosis.
Correct Incorrect Correct answer

C. Arrange urgent transvaginal ultrasound scan to rule out pregnancy.
Correct Incorrect Correct answer

D. Refer for urgent general surgical review for suspected appendicitis.
Correct Incorrect Correct answer

E. Reassure and observe for symptom resolution.
Correct Incorrect Correct answer
Question 14 of 50

14. Question

A 50-year-old male presents with acute onset of severe, painful, red eye, associated with blurred vision, headaches, nausea, and vomiting. On examination, the eye is ‘rock hard’ to palpation, and the pupil is semi-dilated and fixed. Fundoscopy is difficult due to corneal oedema.

What is the most likely diagnosis and the most appropriate initial pharmacological management?

A. Prescribe topical antibiotic eye drops.
Correct Incorrect Correct answer

B. Advise rest and observation, as it's likely a migraine aura.
Correct Incorrect Correct answer

C. Administer topical beta-blockers (e.g., Timolol), oral acetazolamide, and refer for urgent ophthalmology review for suspected acute angle-closure glaucoma.
Correct Incorrect Correct answer

D. Prescribe oral corticosteroids for inflammation.
Correct Incorrect Correct answer

E. Arrange urgent MRI brain scan for stroke.
Correct Incorrect Correct answer
Question 15 of 50

15. Question

A 2-year-old child presents with a 3-day history of low-grade fever, irritability, and a generalized vesicular rash, starting on the trunk and spreading to the face and limbs. The lesions are in different stages (macules, papules, vesicles, crusts).

What is the most likely diagnosis and the most appropriate initial pharmacological management?

A. Prescribe oral antibiotics for suspected bacterial infection.
Correct Incorrect Correct answer

B. Advise symptomatic relief with paracetamol, calamine lotion, and strict hygiene to prevent scratching for suspected chickenpox (varicella).
Correct Incorrect Correct answer

C. Administer nebulised salbutamol and oral prednisolone.
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D. Refer for urgent chest X-ray for suspected foreign body.
Correct Incorrect Correct answer

E. Prescribe antiviral medication (e.g., Oseltamivir).
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Question 16 of 50

16. Question

A 35-year-old male presents with a 6-month history of persistent low mood, loss of pleasure, severe fatigue, weight loss, and recurrent thoughts of death. He has significant functional impairment and social withdrawal. He expresses active suicidal ideation with a plan.

What is the most likely diagnosis and the most appropriate immediate management plan?

A. Prescribe a selective serotonin reuptake inhibitor (SSRI) and arrange psychotherapy (e.g., CBT).
Correct Incorrect Correct answer

B. Conduct immediate risk assessment, ensure patient safety (e.g., constant observation, removal of means), and arrange urgent inpatient psychiatric admission for major depressive disorder with suicidal ideation.
Correct Incorrect Correct answer

C. Advise a 'wait-and-see' approach.
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D. Refer for urgent neurological investigation for organic cause.
Correct Incorrect Correct answer

E. Prescribe a benzodiazepine for anxiety.
Correct Incorrect Correct answer
Question 17 of 50

17. Question

A 60-year-old male presents with new onset of flank pain, haematuria, and a palpable abdominal mass. He has a history of smoking. CT scan reveals a large renal mass.

What is the most likely diagnosis and the most appropriate immediate action?

A. Prescribe oral analgesia and advise fluids.
Correct Incorrect Correct answer

B. Refer for urgent urology review for suspected renal cell carcinoma and consider nephrectomy.
Correct Incorrect Correct answer

C. Arrange urgent renal biopsy for suspected glomerulonephritis.
Correct Incorrect Correct answer

D. Refer for urgent dialysis.
Correct Incorrect Correct answer

E. Advise strict fluid restriction.
Correct Incorrect Correct answer
Question 18 of 50

18. Question

A 70-year-old female presents with episodes of dizziness, presyncope, and shortness of breath. Her ECG shows a persistent sinus bradycardia with heart rate 40 bpm and occasional pauses. She is currently on a beta-blocker.

What is the most likely diagnosis and the most appropriate initial investigation?

A. Administer intravenous adenosine (rapid IV push).
Correct Incorrect Correct answer

B. Withhold beta-blocker, administer intravenous atropine if symptomatic, and consider temporary or permanent pacemaker insertion for symptomatic bradycardia.
Correct Incorrect Correct answer

C. Perform urgent synchronized cardioversion.
Correct Incorrect Correct answer

D. Advise vagal manoeuvres (e.g., Valsalva, carotid sinus massage).
Correct Incorrect Correct answer

E. Reassure the patient and manage as anxiety.
Correct Incorrect Correct answer
Question 19 of 50

19. Question

A 20-year-old female presents with a 6-month history of a persistent red rash and flushing on her face, particularly on her cheeks and nose. She also reports prominent telangiectasias and occasional papules/pustules. Triggers include hot drinks and spicy food.

What is the most likely diagnosis and the most appropriate next step in management?

A. Prescribe topical antifungal cream.
Correct Incorrect Correct answer

B. Advise avoidance of triggers (e.g., hot drinks, spicy food, sun), and prescribe topical metronidazole or azelaic acid for suspected rosacea.
Correct Incorrect Correct answer

C. Advise applying cold compresses and observation only.
Correct Incorrect Correct answer

D. Prescribe oral antibiotics for presumed infection.
Correct Incorrect Correct answer

E. Refer for urgent skin biopsy.
Correct Incorrect Correct answer
Question 20 of 50

20. Question

A 30-year-old female presents with a 6-month history of infertility, oligomenorrhoea, hirsutism, and acne. Her BMI is 32 kg/m². Pelvic ultrasound shows multiple small ovarian cysts. Her testosterone levels are elevated.

What is the most likely diagnosis and the most appropriate immediate management?

A. Prescribe oral calcium and vitamin D supplements.
Correct Incorrect Correct answer

B. Advise lifestyle modifications (weight loss, exercise), and consider combined oral contraceptive pills (COCP) for menstrual irregularities/hirsutism for suspected Polycystic Ovary Syndrome (PCOS).
Correct Incorrect Correct answer

C. Advise strict dietary changes and exercise.
Correct Incorrect Correct answer

D. Prescribe oral antidiabetic medication.
Correct Incorrect Correct answer

E. Reassure and observe, as symptoms are likely stress-related.
Correct Incorrect Correct answer
Question 21 of 50

21. Question

A 60-year-old male presents with a 6-month history of gradually worsening bilateral sensorineural hearing loss, worse with high frequencies. He also reports persistent tinnitus in both ears. He denies any associated dizziness or neurological symptoms.

What is the most likely diagnosis and the most appropriate immediate pharmacological management?

A. Prescribe oral antibiotics immediately.
Correct Incorrect Correct answer

B. Advise watchful waiting and simple analgesia.
Correct Incorrect Correct answer

C. Refer for audiology assessment and consider hearing aids for suspected presbycusis.
Correct Incorrect Correct answer

D. Prescribe topical nasal decongestants.
Correct Incorrect Correct answer

E. Reassure that hearing loss is common with age.
Correct Incorrect Correct answer
Question 22 of 50

22. Question

A 30-year-old female presents with chronic abdominal pain, bloating, and fatigue. She reports symptoms worsening after eating gluten-containing foods. Her anti-TTG antibodies and IgA levels are elevated. Duodenal biopsy shows villous atrophy.

What is the most likely diagnosis and the most appropriate immediate action?

A. Advise a clear fluid diet and observation at home.
Correct Incorrect Correct answer

B. Advise a strict lifelong gluten-free diet for suspected coeliac disease.
Correct Incorrect Correct answer

C. Arrange urgent colonoscopy.
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D. Prescribe broad-spectrum antibiotics for suspected small intestinal bacterial overgrowth.
Correct Incorrect Correct answer

E. Reassure and manage as irritable bowel syndrome.
Correct Incorrect Correct answer
Question 23 of 50

23. Question

A 70-year-old male presents with increasing fatigue, weight loss, and generalized bone pain. His full blood count shows normocytic anaemia. Serum protein electrophoresis shows a monoclonal M-protein spike, and urine Bence-Jones protein is positive. He has a history of recurrent infections.

What is the most likely diagnosis and the most appropriate initial investigation?

A. Prescribe oral iron supplements.
Correct Incorrect Correct answer

B. Refer for urgent haematology consultation for suspected Multiple Myeloma and consider chemotherapy/stem cell transplant.
Correct Incorrect Correct answer

C. Order a bone marrow biopsy.
Correct Incorrect Correct answer

D. Prescribe folic acid supplementation.
Correct Incorrect Correct answer

E. Arrange urgent blood transfusion.
Correct Incorrect Correct answer
Question 24 of 50

24. Question

A 40-year-old male presents with a 6-month history of increasing fatigue, shortness of breath, and dry cough. Chest X-ray shows bilateral hilar lymphadenopathy. Lung function tests show restrictive pattern. His ACE levels are elevated.

What is the most likely diagnosis and the most appropriate initial management approach?

A. Prescribe oral NSAIDs and advise rest.
Correct Incorrect Correct answer

B. Refer for urgent respiratory/rheumatology review for suspected sarcoidosis and consider corticosteroids if symptomatic/progressive.
Correct Incorrect Correct answer

C. Prescribe high-dose oral corticosteroids immediately.
Correct Incorrect Correct answer

D. Administer intravenous immunoglobulins.
Correct Incorrect Correct answer

E. Reassure the patient that fatigue is common.
Correct Incorrect Correct answer
Question 25 of 50

25. Question

A 70-year-old female presents with a 6-month history of increasing pain, stiffness, and crepitus in her right knee, worse with activity and relieved by rest. She reports difficulty with prolonged walking. X-rays show narrowing of the medial joint space, osteophytes, and subchondral sclerosis.

What is the most likely diagnosis and the most appropriate immediate management?

A. Prescribe high-dose oral corticosteroids for suspected inflammatory arthritis.
Correct Incorrect Correct answer

B. Advise weight loss (if overweight), regular exercise, analgesia (e.g., Paracetamol, NSAIDs), and physiotherapy for suspected osteoarthritis.
Correct Incorrect Correct answer

C. Arrange urgent MRI scan of the knee for suspected meniscal tear.
Correct Incorrect Correct answer

D. Refer for urgent orthopaedic surgical review for suspected fracture.
Correct Incorrect Correct answer

E. Reassure that it's likely age-related stiffness.
Correct Incorrect Correct answer
Question 26 of 50

26. Question

A 50-year-old male presents with acute onset of severe headache, stiff neck, photophobia, and vomiting. He has no focal neurological deficits. Lumbar puncture reveals xanthochromia and red blood cells in the CSF.

What is the most likely diagnosis and the most appropriate initial management plan?

A. Prescribe oral corticosteroids.
Correct Incorrect Correct answer

B. Arrange urgent CT head scan and refer for neurosurgical review for suspected subarachnoid haemorrhage (SAH).
Correct Incorrect Correct answer

C. Advise physiotherapy and occupational therapy only.
Correct Incorrect Correct answer

D. Arrange urgent MRI brain for suspected tumour.
Correct Incorrect Correct answer

E. Reassure the patient it's likely severe migraine.
Correct Incorrect Correct answer
Question 27 of 50

27. Question

A 22-year-old female presents with a 3-month history of amenorrhoea and galactorrhoea (milky breast discharge). Her prolactin levels are elevated. Pituitary MRI shows no significant abnormalities.

What is the most likely diagnosis and the most appropriate initial pharmacological management?

A. Prescribe oral analgesia and advise rest.
Correct Incorrect Correct answer

B. Prescribe combined oral contraceptive pills (COCP).
Correct Incorrect Correct answer

C. Prescribe dopamine agonists (e.g., Cabergoline) for suspected hyperprolactinaemia.
Correct Incorrect Correct answer

D. Advise a wait-and-see approach.
Correct Incorrect Correct answer

E. Refer for urgent general surgical review for suspected breast pathology.
Correct Incorrect Correct answer
Question 28 of 50

28. Question

A 5-year-old child presents with bilateral sticky eyes with purulent discharge, redness, and crusting of the eyelids, worse in the morning. His mother reports several other children at his daycare have similar symptoms.

What is the most likely diagnosis and the most appropriate initial investigation?

A. Prescribe topical antibiotic eye drops for suspected bacterial conjunctivitis.
Correct Incorrect Correct answer

B. Advise rest and observation, as it's likely a viral infection.
Correct Incorrect Correct answer

C. Administer topical beta-blockers (e.g., Timolol), oral acetazolamide, and refer for urgent ophthalmology review for suspected acute angle-closure glaucoma.
Correct Incorrect Correct answer

D. Prescribe oral corticosteroids for inflammation.
Correct Incorrect Correct answer

E. Arrange urgent MRI brain scan for stroke.
Correct Incorrect Correct answer
Question 29 of 50

29. Question

A 1-year-old infant is brought in with a 3-day history of low-grade fever, followed by a generalized blanching maculopapular rash, starting on the trunk and spreading to the face and limbs. He is otherwise well. The rash appeared after the fever subsided.

What is the most likely diagnosis and the most appropriate initial management?

A. Prescribe oral antibiotics for suspected bacterial infection.
Correct Incorrect Correct answer

B. Advise symptomatic relief with paracetamol and reassurance, as it's likely Roseola Infantum (Exanthem Subitum).
Correct Incorrect Correct answer

C. Arrange urgent blood tests for suspected sepsis.
Correct Incorrect Correct answer

D. Refer for urgent dermatology review.
Correct Incorrect Correct answer

E. Administer intravenous immunoglobulins.
Correct Incorrect Correct answer
Question 30 of 50

30. Question

A 25-year-old female presents with a 6-month history of severe body image dissatisfaction, fear of gaining weight, and restrictive eating patterns resulting in a BMI of 16 kg/m². She exercises excessively and denies any bingeing or purging behaviours. She has amenorrhoea.

What is the most likely diagnosis and the most appropriate immediate management?

A. Prescribe appetite stimulants and advise dietary changes.
Correct Incorrect Correct answer

B. Refer for urgent psychiatric assessment and consider family-based therapy (FBT) or cognitive behavioural therapy (CBT) for anorexia nervosa, with focus on nutritional rehabilitation.
Correct Incorrect Correct answer

C. Advise a 'wait-and-see' approach.
Correct Incorrect Correct answer

D. Refer for urgent neurological evaluation.
Correct Incorrect Correct answer

E. Reassure the patient that these are temporary stress-related behaviours.
Correct Incorrect Correct answer
Question 31 of 50

31. Question

A 60-year-old male presents with acute onset of generalized oedema, oliguria, and haematuria. He reports a recent upper respiratory tract infection. His creatinine is 300 µmol/L (elevated), and C3 levels are low. Renal biopsy shows diffuse proliferative glomerulonephritis with subepithelial humps.

What is the most likely diagnosis and the most appropriate initial management?

A. Prescribe diuretics and advise strict fluid restriction.
Correct Incorrect Correct answer

B. Administer high-dose oral corticosteroids and consider cyclophosphamide, and refer for urgent nephrology review for suspected post-streptococcal glomerulonephritis or rapidly progressive glomerulonephritis.
Correct Incorrect Correct answer

C. Prescribe broad-spectrum antibiotics for suspected infection.
Correct Incorrect Correct answer

D. Refer for urgent dialysis.
Correct Incorrect Correct answer

E. Reassure the patient that oedema is common.
Correct Incorrect Correct answer
Question 32 of 50

32. Question

A 50-year-old male presents with new onset of gradually worsening exertional chest pain and shortness of breath. On examination, he has a wide, fixed split S2 and a systolic murmur loudest at the upper left sternal edge. His ECG shows incomplete right bundle branch block.

What is the most likely diagnosis and the most appropriate initial investigation?

A. Prescribe oral nitrates and a beta-blocker.
Correct Incorrect Correct answer

B. Refer for urgent cardiology review for suspected atrial septal defect (ASD) and consider surgical closure.
Correct Incorrect Correct answer

C. Arrange urgent cardiac catheterization.
Correct Incorrect Correct answer

D. Advise strict fluid restriction and low-salt diet.
Correct Incorrect Correct answer

E. Reassure the patient and manage as anxiety.
Correct Incorrect Correct answer
Question 33 of 50

33. Question

A 30-year-old female presents with a 6-month history of a persistent, intensely itchy, erythematous rash in her flexural folds (e.g., antecubital and popliteal fossae), associated with dryness and excoriations. She has a history of asthma and hay fever.

What is the most likely diagnosis and the most appropriate initial investigation?

A. Prescribe topical antifungal cream.
Correct Incorrect Correct answer

B. Prescribe topical corticosteroids (e.g., Hydrocortisone or Mometasone furoate) and emollients, and advise avoidance of irritants for suspected atopic dermatitis (eczema).
Correct Incorrect Correct answer

C. Advise applying cold compresses and observation only.
Correct Incorrect Correct answer

D. Prescribe oral antibiotics for presumed infection.
Correct Incorrect Correct answer

E. Refer for urgent skin biopsy.
Correct Incorrect Correct answer
Question 34 of 50

34. Question

A 50-year-old male presents with new onset of central obesity, ‘buffalo hump’, ‘moon face’, and easy bruising. He also reports new onset diabetes and hypertension. His 24-hour urinary free cortisol is elevated, and plasma ACTH is suppressed.

What is the most likely diagnosis and the most appropriate next step in management?

A. Prescribe oral calcium and vitamin D supplements.
Correct Incorrect Correct answer

B. Arrange urgent pituitary MRI or adrenal CT scan and refer for endocrinology review for suspected Cushing's syndrome.
Correct Incorrect Correct answer

C. Advise strict dietary changes and exercise.
Correct Incorrect Correct answer

D. Prescribe oral antidiabetic medication.
Correct Incorrect Correct answer

E. Reassure and observe, as symptoms are likely stress-related.
Correct Incorrect Correct answer
Question 35 of 50

35. Question

A 4-year-old child presents with a 2-day history of acute onset of fever, sore throat, and severe difficulty swallowing. He is drooling and sitting in a ‘tripod’ position. Laryngoscopy reveals a swollen, red epiglottis.

What is the most likely diagnosis and the most appropriate immediate definitive management?

A. Prescribe oral antibiotics immediately.
Correct Incorrect Correct answer

B. Advise vocal rest and simple analgesia.
Correct Incorrect Correct answer

C. Avoid disturbing the child, administer oxygen if tolerated, and urgently notify senior paediatric/anaesthetic/ENT staff for suspected epiglottitis.
Correct Incorrect Correct answer

D. Prescribe topical nasal decongestants.
Correct Incorrect Correct answer

E. Reassure that sore throats are common.
Correct Incorrect Correct answer
Question 36 of 50

36. Question

A 60-year-old male presents with a 6-month history of increasing fatigue, weight loss, and dark stools (melaena). His full blood count shows microcytic anaemia. Upper GI endoscopy reveals an ulcerated mass in the stomach.

What is the most likely diagnosis and the most appropriate initial investigation?

A. Advise a clear fluid diet and observation at home.
Correct Incorrect Correct answer

B. Prescribe a proton pump inhibitor (PPI) and arrange urgent oncology review for suspected gastric malignancy.
Correct Incorrect Correct answer

C. Arrange urgent colonoscopy.
Correct Incorrect Correct answer

D. Prescribe broad-spectrum antibiotics for suspected small intestinal bacterial overgrowth.
Correct Incorrect Correct answer

E. Reassure and manage as irritable bowel syndrome.
Correct Incorrect Correct answer
Question 37 of 50

37. Question

A 30-year-old male presents with chronic fatigue, exertional dyspnoea, and pallor. His full blood count shows Hb 9.0 g/dL (low) and MCV 110 fL (high). His serum B12 is very low, and serum folate is normal. He reports a history of gastric surgery.

What is the most likely diagnosis and the most appropriate next step in management?

A. Prescribe oral iron supplements.
Correct Incorrect Correct answer

B. Administer intramuscular Vitamin B12 injections and investigate for pernicious anaemia or malabsorption.
Correct Incorrect Correct answer

C. Order a bone marrow biopsy.
Correct Incorrect Correct answer

D. Prescribe folic acid supplementation.
Correct Incorrect Correct answer

E. Arrange urgent blood transfusion.
Correct Incorrect Correct answer
Question 38 of 50

38. Question

A 50-year-old female presents with acute onset of painful, red eye, associated with sensitivity to light and reduced vision. She has a history of rheumatoid arthritis. On examination, the eye is diffusely red, and slit lamp examination shows inflammatory cells in the anterior chamber. The pupil is constricted.

What is the most likely diagnosis and the most appropriate immediate diagnostic investigation?

A. Prescribe oral NSAIDs and advise rest.
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B. Administer topical corticosteroids (e.g., Prednisolone acetate) and cycloplegics (e.g., Cyclopentolate) and refer for urgent ophthalmology review for suspected acute anterior uveitis.
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C. Prescribe high-dose oral corticosteroids immediately.
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D. Refer for urgent rheumatology review for suspected inflammatory arthritis flare.
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E. Reassure the patient that joint pain is common in rheumatoid arthritis.
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Question 39 of 50

39. Question

A 30-year-old male presents with acute onset of severe low back pain radiating down his left leg to his foot (sciatica), associated with saddle anaesthesia and new onset urinary retention. He reports recent heavy lifting.

What is the most likely diagnosis and the most appropriate initial management?

A. Prescribe high-dose oral corticosteroids for suspected inflammatory arthritis.
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B. Advise activity modification, analgesia (e.g., NSAIDs, neuropathic agents), and physiotherapy for suspected lumbar disc prolapse with radiculopathy.
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C. Arrange urgent MRI scan of the lumbar spine for suspected cauda equina syndrome and urgent neurosurgical review.
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D. Refer for urgent orthopaedic surgical review for suspected disc prolapse.
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E. Reassure that it's likely mechanical back pain.
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Question 40 of 50

40. Question

A 70-year-old male presents with acute onset of right-sided weakness, facial droop, and speech disturbance. Symptoms started 4 hours ago. CT head is normal. He has a history of hypertension and atrial fibrillation.

What is the most likely diagnosis and the most appropriate initial pharmacological management?

A. Prescribe oral corticosteroids.
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B. Administer intravenous thrombolysis (alteplase) if within thrombolysis window and no contraindications, and organize stroke unit admission.
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C. Advise physiotherapy and occupational therapy only.
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D. Arrange urgent MRI brain for suspected tumour.
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E. Reassure the patient it's likely a temporary viral infection.
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Question 41 of 50

41. Question

A 30-year-old pregnant female (G1P0, 36 weeks gestation) presents with sudden onset of severe, continuous abdominal pain and vaginal bleeding. Her uterus is tense and tender. Fetal heart rate is abnormal. She has a history of pre-eclampsia.

What is the most likely diagnosis and the most appropriate initial management?

A. Prescribe oral analgesia and advise rest.
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B. Arrange urgent ultrasound scan to localize placenta for suspected placenta praevia.
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C. Initiate immediate resuscitation (IV fluids, blood products), prepare for emergency Caesarean section, and notify senior obstetric/anaesthetic team for suspected placental abruption.
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D. Advise a wait-and-see approach.
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E. Refer for urgent general surgical review for suspected appendicitis.
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Question 42 of 50

42. Question

A 60-year-old male presents with gradual, painless vision loss in both eyes, described as a ‘tunnel vision’. He also reports headaches and occasional eye pain. On examination, intraocular pressure is elevated, and fundoscopy shows optic disc cupping.

What is the most likely diagnosis and the most appropriate initial management approach?

A. Prescribe topical antibiotic eye drops.
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B. Advise rest and observation, as it's likely a migraine aura.
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C. Administer topical prostaglandin analogues (e.g., Latanoprost) or beta-blockers (e.g., Timolol) and refer for urgent ophthalmology review for suspected chronic open-angle glaucoma.
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D. Prescribe oral corticosteroids for inflammation.
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E. Arrange urgent MRI brain scan for stroke.
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Question 43 of 50

43. Question

A 6-month-old infant is brought in with a 2-day history of increasing respiratory distress, wheezing, and nasal flaring. He has poor feeding and a productive cough. On examination, he has widespread fine crackles and expiratory wheeze. Oxygen saturations are 89% on air.

What is the most likely diagnosis and the most appropriate management?

A. Prescribe oral antibiotics for suspected pneumonia.
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B. Administer oxygen, nasal suctioning, and ensure adequate hydration for suspected bronchiolitis.
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C. Administer nebulised salbutamol and oral prednisolone.
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D. Refer for urgent chest X-ray for suspected foreign body.
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E. Prescribe antiviral medication (e.g., Oseltamivir).
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Question 44 of 50

44. Question

A 28-year-old female presents with a 2-week history of significant weight gain (5kg), increased appetite, hypersomnia, and a pervasive low mood. She denies suicidal ideation. She has a history of seasonal affective disorder, with symptoms typically improving in summer.

What is the most likely diagnosis and the most appropriate immediate management?

A. Prescribe a selective serotonin reuptake inhibitor (SSRI) and arrange psychotherapy (e.g., CBT) for major depressive episode with atypical features.
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B. Prescribe a benzodiazepine for anxiety.
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C. Advise a 'wait-and-see' approach.
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D. Refer for urgent neurological evaluation.
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E. Reassure the patient that these are temporary stress-related behaviours.
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Question 45 of 50

45. Question

A 30-year-old male presents with new onset of gradually worsening fatigue, polyuria, polydipsia, and a history of recurrent kidney stones. His blood calcium is elevated, and PTH is high. DXA scan shows osteoporosis.

What is the most likely diagnosis and the most appropriate initial management?

A. Prescribe calcium and vitamin D supplements.
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B. Refer for urgent parathyroidectomy for suspected primary hyperparathyroidism.
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C. Advise strict fluid restriction.
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D. Prescribe bisphosphonates for osteoporosis.
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E. Reassure the patient that polyuria is common.
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Question 46 of 50

46. Question

A 60-year-old female presents with episodes of exertional chest pain and palpitations. Her ECG shows frequent premature ventricular contractions (PVCs) and non-sustained ventricular tachycardia. She has a history of ischaemic heart disease.

What is the most likely diagnosis and the most appropriate initial management?

A. Administer Aspirin 300mg stat and Ticagrelor 180mg stat.
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B. Prescribe a beta-blocker (e.g., Bisoprolol) and refer for urgent cardiology review for suspected ventricular arrhythmias and risk stratification (e.g., ICD consideration).
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C. Perform urgent synchronized cardioversion.
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D. Advise strict fluid restriction and low-salt diet.
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E. Reassure the patient and manage as anxiety.
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Question 47 of 50

47. Question

A 40-year-old female presents with a 6-month history of a persistent, intensely itchy, erythematous rash with burrows on her finger webs, wrists, and nipples. She reports severe itching, worse at night, and affecting other family members.

What is the most likely diagnosis and the most appropriate initial investigation?

A. Prescribe topical antifungal cream.
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B. Prescribe topical permethrin cream (or oral ivermectin) for suspected scabies, and treat all close contacts simultaneously.
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C. Advise applying cold compresses and observation only.
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D. Prescribe oral antibiotics for presumed infection.
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E. Refer for urgent skin biopsy.
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Question 48 of 50

48. Question

A 30-year-old female presents with a 6-month history of headaches, dizziness, palpitations, and episodic sweating, anxiety, and tremors. Her blood pressure is labile, with paroxysms of hypertension. Her 24-hour urinary metanephrines are elevated.

What is the most likely diagnosis and the most appropriate long-term management strategy?

What is the most likely diagnosis and the most appropriate long-term management strategy?

A. Prescribe oral combined oral contraceptive pills (COCP).
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B. Administer alpha-blockers (e.g., Phenoxybenzamine) prior to beta-blockers, and refer for urgent endocrinology/surgical review for suspected phaeochromocytoma.
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C. Advise lifestyle modifications for stress management.
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D. Prescribe levothyroxine for suspected hypothyroidism.
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E. Reassure the patient and manage as stress-related symptoms.
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Question 49 of 50

49. Question

A 40-year-old male presents with acute onset of painful, red eye, associated with photophobia and blurred vision. He has a history of rheumatoid arthritis. On examination, the eye is diffusely red, and slit lamp examination shows inflammatory cells in the anterior chamber with a hypopyon.

What is the most likely diagnosis and the most appropriate immediate management?

A. Prescribe oral antibiotics immediately.
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B. Administer topical corticosteroids (e.g., Prednisolone acetate) and cycloplegics (e.g., Cyclopentolate) and refer for urgent ophthalmology review for suspected acute anterior uveitis.
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C. Advise keeping the eye dry and simple analgesia.
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D. Prescribe topical antihistamine eye drops.
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E. Reassure that it's likely conjunctivitis.
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Question 50 of 50

50. Question

A 50-year-old male presents with new onset dysphagia for solids, followed by liquids, and significant weight loss over 3 months. He has a history of smoking and alcohol misuse. Barium swallow shows an irregular stricture in the oesophagus.

What is the most likely diagnosis and the most appropriate immediate investigation?

A. Prescribe a proton pump inhibitor (PPI) for suspected GORD.
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B. Advise soft diet and small, frequent meals.
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C. Arrange urgent upper gastrointestinal endoscopy with biopsy for suspected oesophageal malignancy.
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D. Prescribe prokinetic medication (e.g., Metoclopramide).
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E. Reassure the patient that dysphagia can be due to anxiety.
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