MSRA: MULTI-SPECIALTY RECRUITMENT ASSESSMENT EXAM READY -
VERIFIED QUESTIONS AND ANSWERS - COMPREHENSIVE LATEST
VERSION 2026
MULTI-SPECIALTY RECRUITMENT ASSESSMENT (MSRA)
Q1: A 65-year-old man presents with central chest pain radiating to the jaw,
diaphoresis and nausea for 2 hours. ECG shows ST elevation in leads II, III and
aVF. What is the most appropriate immediate management?
Answer: This is an inferior STEMI. Immediate management: call for primary
PCI (PPCI) team, administer aspirin 300mg + ticagrelor 180mg (or
clopidogrel 300mg if ticagrelor not available), anticoagulate with
unfractionated heparin, and transfer urgently for PPCI within 120 minutes of
first medical contact. Do not thrombolyse if PPCI available within that
window.
Q2: A 72-year-old woman is found to have a BP of 175/100 mmHg on two
separate occasions. She has type 2 diabetes and a history of renal
impairment (eGFR 45). What is the first-line antihypertensive?
Answer: An ACE inhibitor (e.g. ramipril) is first-line for hypertensive patients
with diabetes and CKD due to renoprotective benefits. Monitor potassium
and eGFR after initiation. If ACE-intolerant (cough), use an ARB (e.g.
losartan). Target BP <130/80 mmHg in diabetics.
Q3: A 55-year-old man with known AF is on warfarin (INR 2.1 today). He is
admitted with haematemesis. How do you reverse warfarin urgently?
Answer: For life-threatening bleeding: give 4-factor prothrombin complex
concentrate (PCC, e.g. Beriplex) immediately plus IV vitamin K 5–10mg.
FFP is second-line if PCC unavailable. Do not wait for INR. Hold warfarin.
Involve haematology and GI/surgical teams urgently.
Q4: A 40-year-old woman with no cardiac history presents with sudden onset
palpitations, HR 170 bpm, BP 110/70, narrow complex regular tachycardia on
ECG. What is the first-line treatment?
, Answer: This is likely SVT (supraventricular tachycardia). First-line: vagal
manoeuvres (Valsalva manoeuvre or carotid sinus massage). If
unsuccessful, give IV adenosine 6mg rapid bolus (followed by 12mg, then
18mg if needed). Monitor continuously. If haemodynamically unstable,
proceed to synchronised DC cardioversion.
Q5: A patient on amlodipine develops peripheral oedema. They are well-
controlled hypertensive. What is the most appropriate action?
Answer: Peripheral oedema is a recognised side-effect of dihydropyridine
calcium channel blockers (e.g. amlodipine). If troublesome, switch to an
ACE inhibitor or ARB, or add an ACE inhibitor (which can reduce CCB-
induced oedema). Do not add a diuretic primarily to manage CCB oedema
— it may worsen renal function and is not addressing the cause.
Q6: What ECG changes are associated with hyperkalaemia and in what order
do they appear?
Answer: Hyperkalaemia ECG changes (in progressive order): 1) Tall,
peaked T waves (earliest), 2) Prolonged PR interval, 3) Widening QRS
complex, 4) Loss of P waves, 5) Sinusoidal/sine wave pattern, 6) Ventricular
fibrillation/asystole. Treat urgently with IV calcium gluconate (membrane
stabilisation), insulin/dextrose, salbutamol nebulisers, and definitive removal
(calcium resonium, dialysis).
Q7: A 68-year-old man has new-onset AF with a CHA₂DS₂-VASc score of 4.
He has no contraindications to anticoagulation. What is the recommended
treatment?
Answer: With CHA₂DS₂-VASc ≥2 in males (≥3 in females), anticoagulation
is recommended to reduce stroke risk. A DOAC (direct oral anticoagulant —
e.g. apixaban, rivaroxaban, edoxaban) is preferred over warfarin unless
there is a specific indication for warfarin (e.g. mitral stenosis, mechanical
heart valve). Antiplatelet therapy alone is NOT recommended for stroke
prevention in AF.
Q8: A 50-year-old man presents with sharp chest pain worse on inspiration
and leaning forward. He had a viral illness 2 weeks ago. ECG shows
widespread saddle-shaped ST elevation. What is the diagnosis and
treatment?
Answer: Acute pericarditis. Typical features: sharp pleuritic chest pain
relieved by leaning forward, pericardial rub on auscultation, widespread
saddle-shaped ST elevation (without reciprocal changes) on ECG, and
recent viral illness. Treatment: NSAIDs (e.g. ibuprofen 600mg TDS) for 2–4
weeks plus colchicine 0.5mg BD for 3 months. Restrict strenuous physical
activity until symptom-free.
,Q9: A 35-year-old woman presents with acute shortness of breath, HR 120
bpm, BP 90/60 mmHg. Neck veins are raised. Heart sounds reveal a new
murmur. ECG shows sinus tachycardia. Chest X-ray shows enlarged cardiac
silhouette. What is the most likely diagnosis?
Answer: Cardiac tamponade. Beck's triad: hypotension, raised JVP, muffled
heart sounds. The enlarged cardiac silhouette on CXR suggests pericardial
effusion. Management: urgent pericardiocentesis. While preparing: IV fluid
resuscitation to maintain preload. Avoid vasodilators. Cardiothoracic surgery
input required for traumatic or recurrent causes.
Q10: Which class of drug is used as first-line for stable angina symptom relief
and what is its mechanism?
Answer: Short-acting nitrates (e.g. GTN sublingual spray/tablet) are first-
line for acute angina relief. Mechanism: nitric oxide release → venodilation
→ reduced preload → reduced myocardial oxygen demand. Also causes
coronary vasodilation. For prophylaxis: beta-blockers are first-line to prevent
angina episodes by reducing heart rate and myocardial oxygen demand.
SECTION 2: CLINICAL PROBLEM SOLVING — RESPIRATORY
Q1: A 70-year-old smoker presents with progressive dyspnoea, productive
cough, and wheeze. Spirometry shows FEV1/FVC ratio of 0.62 (post-
bronchodilator). FEV1 is 55% predicted. What is the diagnosis and GOLD
stage?
Answer: Diagnosis: COPD. Post-bronchodilator FEV1/FVC <0.7 confirms
obstruction. FEV1 55% predicted = GOLD Stage 2 (Moderate, FEV1 50–
79%). Management: SABA (salbutamol) PRN, add LAMA (tiotropium) or
LABA (salmeterol). If frequent exacerbations, add ICS. Smoking cessation is
the single most important intervention. Consider pulmonary rehabilitation.
Q2: A 28-year-old woman with known asthma presents to A&E with severe
wheeze and dyspnoea. She cannot complete sentences. RR 28, SpO2 91%,
PEFR 40% of best. What is the severity and immediate management?
Answer: This is a severe asthma attack (PEFR 33–50% best, RR>25, can't
complete sentences). Immediate: high-flow O2 to maintain SpO2 94–98%,
nebulised salbutamol 5mg back-to-back, ipratropium 0.5mg nebulised, IV
hydrocortisone 100mg or oral prednisolone 40–50mg. If SpO2 <92% or life-
threatening features (silent chest, cyanosis, PEFR <33%), call anaesthetics
for possible intubation.
Q3: A 65-year-old man presents with haemoptysis, weight loss and a 2-cm
spiculated mass on CXR. He smokes 30 pack-years. What investigations are
required?
, Answer: Suspected lung cancer: arrange urgent CT thorax/abdomen/pelvis
with contrast (within 2 weeks). Refer urgently to lung cancer MDT.
Bronchoscopy with BAL/biopsy if central lesion; CT-guided biopsy if
peripheral. PET-CT for staging. Brain MRI if symptoms suggest CNS
involvement. Lung function tests (FEV1) pre-operatively. Histology
determines treatment (NSCLC vs SCLC).
Q4: What are the CURB-65 criteria and what score indicates hospital
admission for community-acquired pneumonia?
Answer: CURB-65 criteria (1 point each): Confusion (new onset, AMT ≤8),
Urea >7 mmol/L, Respiratory rate ≥30/min, Blood pressure <90 systolic or
≤60 diastolic, Age ≥65. Score 0–1: treat at home. Score 2: consider short
admission. Score 3–5: hospital admission, consider ICU if score 4–5. High-
severity CAP: IV co-amoxiclav + clarithromycin. Low-severity: amoxicillin
500mg TDS or doxycycline.
Q5: A 45-year-old woman post-hip replacement develops sudden dyspnoea
and pleuritic chest pain. Her Wells score is 5. D-dimer is elevated. CT
pulmonary angiogram shows filling defect in the right pulmonary artery. What
is the treatment?
Answer: Confirmed PE. Haemodynamically stable: anticoagulate with a
DOAC (apixaban 10mg BD for 7 days then 5mg BD, or rivaroxaban 15mg
BD for 21 days then 20mg OD). If massive PE (haemodynamically
unstable): systemic thrombolysis (alteplase 100mg IV), or catheter-directed
thrombolysis/surgical embolectomy. Duration of anticoagulation: 3 months
(provoked) or 6 months+ (unprovoked).
Q6: A 55-year-old man presents with progressive breathlessness, dry cough,
and bilateral basal crackles on examination. CXR shows bilateral lower zone
infiltrates. He is a bird keeper. What is the likely diagnosis?
Answer: Extrinsic allergic alveolitis (hypersensitivity pneumonitis) —
specifically Bird Fancier's Lung. Caused by inhaled organic antigens (avian
proteins in bird droppings/feathers). Features: bilateral crackles, restrictive
spirometry, ground-glass opacity on HRCT. Treatment: avoid antigen
exposure (primary), oral corticosteroids for acute/subacute disease. HRCT
and serum precipitins (avian antibodies) confirm diagnosis.
Q7: A 30-year-old man presents with left-sided pleuritic chest pain and
dyspnoea. CXR shows a 2.5 cm rim of air on the left. He is a tall, thin male
with no prior lung disease. What is the diagnosis and management?
Answer: Primary spontaneous pneumothorax. Rim of air >2cm on PA CXR
= large pneumothorax. Management (BTS 2023 guidelines): if symptomatic
and large (>2cm), aspirate with 16–18G cannula in 2nd intercostal space,
VERIFIED QUESTIONS AND ANSWERS - COMPREHENSIVE LATEST
VERSION 2026
MULTI-SPECIALTY RECRUITMENT ASSESSMENT (MSRA)
Q1: A 65-year-old man presents with central chest pain radiating to the jaw,
diaphoresis and nausea for 2 hours. ECG shows ST elevation in leads II, III and
aVF. What is the most appropriate immediate management?
Answer: This is an inferior STEMI. Immediate management: call for primary
PCI (PPCI) team, administer aspirin 300mg + ticagrelor 180mg (or
clopidogrel 300mg if ticagrelor not available), anticoagulate with
unfractionated heparin, and transfer urgently for PPCI within 120 minutes of
first medical contact. Do not thrombolyse if PPCI available within that
window.
Q2: A 72-year-old woman is found to have a BP of 175/100 mmHg on two
separate occasions. She has type 2 diabetes and a history of renal
impairment (eGFR 45). What is the first-line antihypertensive?
Answer: An ACE inhibitor (e.g. ramipril) is first-line for hypertensive patients
with diabetes and CKD due to renoprotective benefits. Monitor potassium
and eGFR after initiation. If ACE-intolerant (cough), use an ARB (e.g.
losartan). Target BP <130/80 mmHg in diabetics.
Q3: A 55-year-old man with known AF is on warfarin (INR 2.1 today). He is
admitted with haematemesis. How do you reverse warfarin urgently?
Answer: For life-threatening bleeding: give 4-factor prothrombin complex
concentrate (PCC, e.g. Beriplex) immediately plus IV vitamin K 5–10mg.
FFP is second-line if PCC unavailable. Do not wait for INR. Hold warfarin.
Involve haematology and GI/surgical teams urgently.
Q4: A 40-year-old woman with no cardiac history presents with sudden onset
palpitations, HR 170 bpm, BP 110/70, narrow complex regular tachycardia on
ECG. What is the first-line treatment?
, Answer: This is likely SVT (supraventricular tachycardia). First-line: vagal
manoeuvres (Valsalva manoeuvre or carotid sinus massage). If
unsuccessful, give IV adenosine 6mg rapid bolus (followed by 12mg, then
18mg if needed). Monitor continuously. If haemodynamically unstable,
proceed to synchronised DC cardioversion.
Q5: A patient on amlodipine develops peripheral oedema. They are well-
controlled hypertensive. What is the most appropriate action?
Answer: Peripheral oedema is a recognised side-effect of dihydropyridine
calcium channel blockers (e.g. amlodipine). If troublesome, switch to an
ACE inhibitor or ARB, or add an ACE inhibitor (which can reduce CCB-
induced oedema). Do not add a diuretic primarily to manage CCB oedema
— it may worsen renal function and is not addressing the cause.
Q6: What ECG changes are associated with hyperkalaemia and in what order
do they appear?
Answer: Hyperkalaemia ECG changes (in progressive order): 1) Tall,
peaked T waves (earliest), 2) Prolonged PR interval, 3) Widening QRS
complex, 4) Loss of P waves, 5) Sinusoidal/sine wave pattern, 6) Ventricular
fibrillation/asystole. Treat urgently with IV calcium gluconate (membrane
stabilisation), insulin/dextrose, salbutamol nebulisers, and definitive removal
(calcium resonium, dialysis).
Q7: A 68-year-old man has new-onset AF with a CHA₂DS₂-VASc score of 4.
He has no contraindications to anticoagulation. What is the recommended
treatment?
Answer: With CHA₂DS₂-VASc ≥2 in males (≥3 in females), anticoagulation
is recommended to reduce stroke risk. A DOAC (direct oral anticoagulant —
e.g. apixaban, rivaroxaban, edoxaban) is preferred over warfarin unless
there is a specific indication for warfarin (e.g. mitral stenosis, mechanical
heart valve). Antiplatelet therapy alone is NOT recommended for stroke
prevention in AF.
Q8: A 50-year-old man presents with sharp chest pain worse on inspiration
and leaning forward. He had a viral illness 2 weeks ago. ECG shows
widespread saddle-shaped ST elevation. What is the diagnosis and
treatment?
Answer: Acute pericarditis. Typical features: sharp pleuritic chest pain
relieved by leaning forward, pericardial rub on auscultation, widespread
saddle-shaped ST elevation (without reciprocal changes) on ECG, and
recent viral illness. Treatment: NSAIDs (e.g. ibuprofen 600mg TDS) for 2–4
weeks plus colchicine 0.5mg BD for 3 months. Restrict strenuous physical
activity until symptom-free.
,Q9: A 35-year-old woman presents with acute shortness of breath, HR 120
bpm, BP 90/60 mmHg. Neck veins are raised. Heart sounds reveal a new
murmur. ECG shows sinus tachycardia. Chest X-ray shows enlarged cardiac
silhouette. What is the most likely diagnosis?
Answer: Cardiac tamponade. Beck's triad: hypotension, raised JVP, muffled
heart sounds. The enlarged cardiac silhouette on CXR suggests pericardial
effusion. Management: urgent pericardiocentesis. While preparing: IV fluid
resuscitation to maintain preload. Avoid vasodilators. Cardiothoracic surgery
input required for traumatic or recurrent causes.
Q10: Which class of drug is used as first-line for stable angina symptom relief
and what is its mechanism?
Answer: Short-acting nitrates (e.g. GTN sublingual spray/tablet) are first-
line for acute angina relief. Mechanism: nitric oxide release → venodilation
→ reduced preload → reduced myocardial oxygen demand. Also causes
coronary vasodilation. For prophylaxis: beta-blockers are first-line to prevent
angina episodes by reducing heart rate and myocardial oxygen demand.
SECTION 2: CLINICAL PROBLEM SOLVING — RESPIRATORY
Q1: A 70-year-old smoker presents with progressive dyspnoea, productive
cough, and wheeze. Spirometry shows FEV1/FVC ratio of 0.62 (post-
bronchodilator). FEV1 is 55% predicted. What is the diagnosis and GOLD
stage?
Answer: Diagnosis: COPD. Post-bronchodilator FEV1/FVC <0.7 confirms
obstruction. FEV1 55% predicted = GOLD Stage 2 (Moderate, FEV1 50–
79%). Management: SABA (salbutamol) PRN, add LAMA (tiotropium) or
LABA (salmeterol). If frequent exacerbations, add ICS. Smoking cessation is
the single most important intervention. Consider pulmonary rehabilitation.
Q2: A 28-year-old woman with known asthma presents to A&E with severe
wheeze and dyspnoea. She cannot complete sentences. RR 28, SpO2 91%,
PEFR 40% of best. What is the severity and immediate management?
Answer: This is a severe asthma attack (PEFR 33–50% best, RR>25, can't
complete sentences). Immediate: high-flow O2 to maintain SpO2 94–98%,
nebulised salbutamol 5mg back-to-back, ipratropium 0.5mg nebulised, IV
hydrocortisone 100mg or oral prednisolone 40–50mg. If SpO2 <92% or life-
threatening features (silent chest, cyanosis, PEFR <33%), call anaesthetics
for possible intubation.
Q3: A 65-year-old man presents with haemoptysis, weight loss and a 2-cm
spiculated mass on CXR. He smokes 30 pack-years. What investigations are
required?
, Answer: Suspected lung cancer: arrange urgent CT thorax/abdomen/pelvis
with contrast (within 2 weeks). Refer urgently to lung cancer MDT.
Bronchoscopy with BAL/biopsy if central lesion; CT-guided biopsy if
peripheral. PET-CT for staging. Brain MRI if symptoms suggest CNS
involvement. Lung function tests (FEV1) pre-operatively. Histology
determines treatment (NSCLC vs SCLC).
Q4: What are the CURB-65 criteria and what score indicates hospital
admission for community-acquired pneumonia?
Answer: CURB-65 criteria (1 point each): Confusion (new onset, AMT ≤8),
Urea >7 mmol/L, Respiratory rate ≥30/min, Blood pressure <90 systolic or
≤60 diastolic, Age ≥65. Score 0–1: treat at home. Score 2: consider short
admission. Score 3–5: hospital admission, consider ICU if score 4–5. High-
severity CAP: IV co-amoxiclav + clarithromycin. Low-severity: amoxicillin
500mg TDS or doxycycline.
Q5: A 45-year-old woman post-hip replacement develops sudden dyspnoea
and pleuritic chest pain. Her Wells score is 5. D-dimer is elevated. CT
pulmonary angiogram shows filling defect in the right pulmonary artery. What
is the treatment?
Answer: Confirmed PE. Haemodynamically stable: anticoagulate with a
DOAC (apixaban 10mg BD for 7 days then 5mg BD, or rivaroxaban 15mg
BD for 21 days then 20mg OD). If massive PE (haemodynamically
unstable): systemic thrombolysis (alteplase 100mg IV), or catheter-directed
thrombolysis/surgical embolectomy. Duration of anticoagulation: 3 months
(provoked) or 6 months+ (unprovoked).
Q6: A 55-year-old man presents with progressive breathlessness, dry cough,
and bilateral basal crackles on examination. CXR shows bilateral lower zone
infiltrates. He is a bird keeper. What is the likely diagnosis?
Answer: Extrinsic allergic alveolitis (hypersensitivity pneumonitis) —
specifically Bird Fancier's Lung. Caused by inhaled organic antigens (avian
proteins in bird droppings/feathers). Features: bilateral crackles, restrictive
spirometry, ground-glass opacity on HRCT. Treatment: avoid antigen
exposure (primary), oral corticosteroids for acute/subacute disease. HRCT
and serum precipitins (avian antibodies) confirm diagnosis.
Q7: A 30-year-old man presents with left-sided pleuritic chest pain and
dyspnoea. CXR shows a 2.5 cm rim of air on the left. He is a tall, thin male
with no prior lung disease. What is the diagnosis and management?
Answer: Primary spontaneous pneumothorax. Rim of air >2cm on PA CXR
= large pneumothorax. Management (BTS 2023 guidelines): if symptomatic
and large (>2cm), aspirate with 16–18G cannula in 2nd intercostal space,
