1|Page
MSRA ( MEDICAL SPECIALTY
RECRUITMENT ASSESSMENT )– APPLIED
CLINICAL KNOWLEDGE EXAM 2026 |150
QUESTIONS AND CORRECT DETAILED
ANSWERS |RATED A+
1. A 67-year-old man presents with sudden onset right-sided
weakness and aphasia that began 90 minutes ago. CT head shows
no hemorrhage. His BP is 175/95 mmHg. What is the most
appropriate next step?
A. Start aspirin immediately
B. Lower blood pressure aggressively to <140/90
C. Administer intravenous alteplase
D. Arrange MRI brain before treatment
Early ischemic stroke within the thrombolysis window and no
contraindications warrants IV thrombolysis; BP is acceptable for
treatment.
2. A 45-year-old woman with type 1 diabetes presents with vomiting,
abdominal pain, and deep rapid breathing. Labs show glucose 28
mmol/L, ketones 6 mmol/L, pH 7.12. What is the first priority in
management?
A. Start insulin infusion
B. Begin intravenous 0.9% saline
C. Give sodium bicarbonate
D. Administer potassium chloride
Fluid resuscitation is the initial priority in diabetic ketoacidosis
before insulin therapy.
3. A 72-year-old man with COPD presents with worsening dyspnea
and productive cough. ABG shows pH 7.29, PaCO₂ 8.5 kPa, PaO₂
7.0 kPa on air. Best next step?
A. Intubation and ventilation
,2|Page
B. Non-invasive ventilation
C. High-flow oxygen via non-rebreather
D. Oral corticosteroids only
Acute hypercapnic respiratory failure in COPD with acidosis is
an indication for NIV.
4. A patient with atrial fibrillation is taking apixaban. He requires
urgent surgery for bowel obstruction. What is the most appropriate
perioperative management?
A. Continue apixaban
B. Switch to aspirin
C. Delay surgery for 72 hours
D. Stop apixaban and proceed with appropriate reversal if
needed
Urgent surgery may require cessation and reversal of
anticoagulation depending on bleeding risk.
5. A 23-year-old woman presents with fever, lower abdominal pain,
and cervical motion tenderness. Pregnancy test is negative. Most
likely diagnosis?
A. Appendicitis
B. Pelvic inflammatory disease
C. Ovarian torsion
D. Endometriosis
Classic triad suggests pelvic inflammatory disease.
6. A 58-year-old man presents with painless jaundice and weight loss.
Which investigation is most appropriate initially?
A. ERCP
B. Liver biopsy
C. CT abdomen with contrast
D. Ultrasound-guided drainage
CT imaging is first-line for suspected pancreatic malignancy.
7. A junior doctor prescribes morphine but mistakenly administers
ten times the intended dose. The patient is harmed. What is the
most appropriate professional action?
A. Do nothing unless asked
B. Alter the drug chart
,3|Page
C. Report the incident and disclose to the patient
D. Blame the nursing staff
Duty of candor requires reporting errors and open disclosure.
8. A 34-year-old man presents with severe headache, photophobia,
and neck stiffness. CT head is normal. Next step?
A. Discharge with analgesia
B. MRI brain
C. Lumbar puncture
D. Start antivirals only
Lumbar puncture is required to diagnose meningitis or
subarachnoid hemorrhage when CT is normal.
9. A patient with schizophrenia refuses treatment for pneumonia. He
lacks capacity. What is the correct approach?
A. Respect refusal absolutely
B. Seek family consent
C. Treat in best interests
D. Detain under the Mental Health Act for pneumonia
Physical illness without capacity is treated under best-interest
principles.
10. A 60-year-old woman presents with postmenopausal
bleeding. Most appropriate initial investigation?
A. Pap smear
B. Hysteroscopy immediately
C. Transvaginal ultrasound
D. CT pelvis
TVUS assesses endometrial thickness as first-line investigation.
11. A patient on long-term corticosteroids presents for elective
surgery. What perioperative adjustment is required?
A. Stop steroids
B. Double dose postoperatively only
C. Administer stress-dose steroids
D. No adjustment needed
Steroid-dependent patients require stress dosing to prevent
adrenal crisis.
, 4|Page
12. A 28-year-old man presents with urethral discharge. Gram
stain shows intracellular gram-negative diplococci. Best treatment?
A. Oral doxycycline alone
B. Intramuscular ceftriaxone
C. Oral azithromycin alone
D. Metronidazole
Neisseria gonorrhoeae is treated with IM ceftriaxone.
13. A patient with chest pain has ST elevation in leads II, III, and
aVF. Which artery is most likely occluded?
A. Left anterior descending
B. Circumflex
C. Right coronary artery
D. Left main
Inferior MI typically involves the RCA.
14. A 40-year-old woman presents with fatigue and pallor. Labs
show Hb 8 g/dL, MCV 68 fL. Most likely cause?
A. Thalassemia trait
B. Iron deficiency anemia
C. Vitamin B12 deficiency
D. Aplastic anemia
Microcytic anemia with low Hb commonly indicates iron
deficiency.
15. A patient collapses in the ward. No pulse, not breathing. First
action?
A. Defibrillate immediately
B. Check blood glucose
C. Start chest compressions
D. Secure airway
Immediate CPR is the priority in cardiac arrest.
16. A 52-year-old man presents with hematuria and weight loss.
Most concerning diagnosis?
A. Renal stone
B. Renal cell carcinoma
C. UTI
D. Benign prostatic hyperplasia
MSRA ( MEDICAL SPECIALTY
RECRUITMENT ASSESSMENT )– APPLIED
CLINICAL KNOWLEDGE EXAM 2026 |150
QUESTIONS AND CORRECT DETAILED
ANSWERS |RATED A+
1. A 67-year-old man presents with sudden onset right-sided
weakness and aphasia that began 90 minutes ago. CT head shows
no hemorrhage. His BP is 175/95 mmHg. What is the most
appropriate next step?
A. Start aspirin immediately
B. Lower blood pressure aggressively to <140/90
C. Administer intravenous alteplase
D. Arrange MRI brain before treatment
Early ischemic stroke within the thrombolysis window and no
contraindications warrants IV thrombolysis; BP is acceptable for
treatment.
2. A 45-year-old woman with type 1 diabetes presents with vomiting,
abdominal pain, and deep rapid breathing. Labs show glucose 28
mmol/L, ketones 6 mmol/L, pH 7.12. What is the first priority in
management?
A. Start insulin infusion
B. Begin intravenous 0.9% saline
C. Give sodium bicarbonate
D. Administer potassium chloride
Fluid resuscitation is the initial priority in diabetic ketoacidosis
before insulin therapy.
3. A 72-year-old man with COPD presents with worsening dyspnea
and productive cough. ABG shows pH 7.29, PaCO₂ 8.5 kPa, PaO₂
7.0 kPa on air. Best next step?
A. Intubation and ventilation
,2|Page
B. Non-invasive ventilation
C. High-flow oxygen via non-rebreather
D. Oral corticosteroids only
Acute hypercapnic respiratory failure in COPD with acidosis is
an indication for NIV.
4. A patient with atrial fibrillation is taking apixaban. He requires
urgent surgery for bowel obstruction. What is the most appropriate
perioperative management?
A. Continue apixaban
B. Switch to aspirin
C. Delay surgery for 72 hours
D. Stop apixaban and proceed with appropriate reversal if
needed
Urgent surgery may require cessation and reversal of
anticoagulation depending on bleeding risk.
5. A 23-year-old woman presents with fever, lower abdominal pain,
and cervical motion tenderness. Pregnancy test is negative. Most
likely diagnosis?
A. Appendicitis
B. Pelvic inflammatory disease
C. Ovarian torsion
D. Endometriosis
Classic triad suggests pelvic inflammatory disease.
6. A 58-year-old man presents with painless jaundice and weight loss.
Which investigation is most appropriate initially?
A. ERCP
B. Liver biopsy
C. CT abdomen with contrast
D. Ultrasound-guided drainage
CT imaging is first-line for suspected pancreatic malignancy.
7. A junior doctor prescribes morphine but mistakenly administers
ten times the intended dose. The patient is harmed. What is the
most appropriate professional action?
A. Do nothing unless asked
B. Alter the drug chart
,3|Page
C. Report the incident and disclose to the patient
D. Blame the nursing staff
Duty of candor requires reporting errors and open disclosure.
8. A 34-year-old man presents with severe headache, photophobia,
and neck stiffness. CT head is normal. Next step?
A. Discharge with analgesia
B. MRI brain
C. Lumbar puncture
D. Start antivirals only
Lumbar puncture is required to diagnose meningitis or
subarachnoid hemorrhage when CT is normal.
9. A patient with schizophrenia refuses treatment for pneumonia. He
lacks capacity. What is the correct approach?
A. Respect refusal absolutely
B. Seek family consent
C. Treat in best interests
D. Detain under the Mental Health Act for pneumonia
Physical illness without capacity is treated under best-interest
principles.
10. A 60-year-old woman presents with postmenopausal
bleeding. Most appropriate initial investigation?
A. Pap smear
B. Hysteroscopy immediately
C. Transvaginal ultrasound
D. CT pelvis
TVUS assesses endometrial thickness as first-line investigation.
11. A patient on long-term corticosteroids presents for elective
surgery. What perioperative adjustment is required?
A. Stop steroids
B. Double dose postoperatively only
C. Administer stress-dose steroids
D. No adjustment needed
Steroid-dependent patients require stress dosing to prevent
adrenal crisis.
, 4|Page
12. A 28-year-old man presents with urethral discharge. Gram
stain shows intracellular gram-negative diplococci. Best treatment?
A. Oral doxycycline alone
B. Intramuscular ceftriaxone
C. Oral azithromycin alone
D. Metronidazole
Neisseria gonorrhoeae is treated with IM ceftriaxone.
13. A patient with chest pain has ST elevation in leads II, III, and
aVF. Which artery is most likely occluded?
A. Left anterior descending
B. Circumflex
C. Right coronary artery
D. Left main
Inferior MI typically involves the RCA.
14. A 40-year-old woman presents with fatigue and pallor. Labs
show Hb 8 g/dL, MCV 68 fL. Most likely cause?
A. Thalassemia trait
B. Iron deficiency anemia
C. Vitamin B12 deficiency
D. Aplastic anemia
Microcytic anemia with low Hb commonly indicates iron
deficiency.
15. A patient collapses in the ward. No pulse, not breathing. First
action?
A. Defibrillate immediately
B. Check blood glucose
C. Start chest compressions
D. Secure airway
Immediate CPR is the priority in cardiac arrest.
16. A 52-year-old man presents with hematuria and weight loss.
Most concerning diagnosis?
A. Renal stone
B. Renal cell carcinoma
C. UTI
D. Benign prostatic hyperplasia
