MSRA: MULTI-SPECIALTY RECRUITMENT ASSESSMENT - REAL QUESTIONS +
DETAILED ANSWERS - LATEST VERSION - TOP RATED (2026/2027)
Q1. A 65-year-old man presents with central crushing chest pain radiating to his left arm
for 2 hours. ECG shows ST elevation in leads II, III and aVF. Which coronary artery is
most likely occluded?
A. Left anterior descending
B. Right coronary artery
C. Left circumflex
D. Left main stem
Answer: B Inferior STEMI (ST elevation in II, III, aVF) is most commonly caused by
RCA occlusion.
Q2. A 55-year-old woman presents with dyspnoea and bilateral ankle oedema. BNP is
markedly elevated. Echo shows an EF of 25%. Which drug has been shown to reduce
mortality in this condition?
A. Digoxin
B. Amlodipine
C. Bisoprolol
D. Furosemide
Answer: C Beta-blockers (e.g. bisoprolol) reduce mortality in heart failure with reduced
ejection fraction (HFrEF).
Q3. A 45-year-old man is found to have a BP of 175/100 mmHg on three separate
occasions. He has no other comorbidities. What is the first-line antihypertensive
treatment?
A. ACE inhibitor
B. Beta-blocker
C. Thiazide diuretic
D. Alpha-blocker
Answer: A ACE inhibitors are first-line for hypertension in patients under 55 years
without specific contraindications (NICE guidelines).
Q4. A 70-year-old woman with known AF is found to have a CHA₂DS₂-VASc score of 3.
She has no contraindications. What is the most appropriate management?
A. Aspirin alone
, B. Warfarin or DOAC
C. No anticoagulation needed
D. Clopidogrel
Answer: B CHA₂DS₂-VASc ≥2 in women indicates anticoagulation is recommended to
reduce stroke risk.
Q5. A 60-year-old man presents with sudden severe chest pain radiating to the back. CT
shows a widened mediastinum. BP is 190/100 mmHg. What is the most likely diagnosis?
A. Pulmonary embolism
B. Aortic dissection
C. STEMI
D. Oesophageal rupture
Answer: B Aortic dissection presents with tearing back pain, widened mediastinum, and
hypertension.
Q6. A 72-year-old smoker presents with a 3-month history of haemoptysis and weight
loss. CXR shows a hilar mass. What is the most likely diagnosis?
A. Mesothelioma
B. Pulmonary embolism
C. Lung carcinoma
D. Pulmonary tuberculosis
Answer: C Central hilar mass in a smoker with haemoptysis and weight loss strongly
suggests lung carcinoma.
Q7. A 30-year-old asthmatic presents to A&E with wheeze, unable to complete
sentences. PEFR is 30% predicted. SpO₂ is 92%. What is the immediate treatment?
A. Oral prednisolone
B. IV magnesium sulphate
C. High-flow oxygen, nebulised salbutamol, IV hydrocortisone
D. Intubation
Answer: C Life-threatening asthma requires high-flow O₂, back-to-back nebulisers, and
IV steroids as initial management.
Q8. A 55-year-old man with COPD has FEV1/FVC of 0.60 and FEV1 of 45% predicted.
He is on a SABA. What is the most appropriate next step?
A. Add ICS
B. Add LABA
C. Add LAMA
D. Start LABA + ICS
Answer: C NICE recommends adding LAMA (e.g. tiotropium) as the next step for
symptomatic COPD after SABA.
,Q9. A 25-year-old woman presents with pleuritic chest pain and breathlessness 3 days
after a long-haul flight. D-dimer is elevated. What should be done next?
A. Start warfarin immediately
B. CTPA
C. V/Q scan
D. Reassure and discharge
Answer: B CTPA is the investigation of choice for suspected PE, especially with
elevated D-dimer and clinical risk factors.
Q10. A 40-year-old male with known sarcoidosis has worsening dyspnoea and bilateral
hilar lymphadenopathy on CXR. What is the most appropriate initial treatment?
A. Methotrexate
B. Oral prednisolone
C. Azathioprine
D. No treatment required
Answer: B Systemic corticosteroids (prednisolone) are first-line for symptomatic
pulmonary sarcoidosis.
Section 2: Clinical Problem Solving – Gastroenterology & Neurology (Q11–Q20)
Q11. A 45-year-old woman presents with right upper quadrant pain, fever and jaundice.
Murphy's sign is positive. LFTs show raised ALP and bilirubin. What is the most likely
diagnosis?
A. Acute pancreatitis
B. Cholangitis
C. Hepatitis A
D. Peptic ulcer disease
Answer: B Charcot's triad (RUQ pain, fever, jaundice) indicates ascending cholangitis,
a biliary emergency.
Q12. A 30-year-old man presents with bloody diarrhoea, abdominal pain and weight loss
for 3 months. Colonoscopy shows continuous colonic inflammation from rectum to
splenic flexure. What is the most likely diagnosis?
A. Crohn's disease
B. Ulcerative colitis
C. Coeliac disease
D. Irritable bowel syndrome
Answer: B UC characteristically shows continuous inflammation starting from rectum;
Crohn's shows skip lesions.
Q13. A 55-year-old man with known liver cirrhosis develops confusion and asterixis.
Ammonia level is elevated. What is the immediate treatment?
, A. IV flumazenil
B. Lactulose
C. Rifaximin
D. IV N-acetylcysteine
Answer: B Lactulose is first-line treatment for hepatic encephalopathy, reducing
ammonia absorption from the gut.
Q14. A 60-year-old man presents with dysphagia to solids initially then liquids, and 10
kg weight loss over 3 months. What is the most likely diagnosis?
A. Oesophageal carcinoma
B. Achalasia
C. GORD
D. Pharyngeal pouch
Answer: A Progressive dysphagia (solids before liquids) with significant weight loss
strongly suggests oesophageal carcinoma.
Q15. A 50-year-old man taking NSAIDs presents with epigastric pain and melaena. OGD
reveals a duodenal ulcer with a visible vessel. What is the Rockford score indicating?
A. Low risk – discharge
B. High risk – endoscopic treatment needed
C. Intermediate risk – observation
D. Immediate surgery required
Answer: B Visible vessel at OGD is Forrest class IIa, indicating high re-bleeding risk
requiring endoscopic haemostasis.
Q16. A 70-year-old man presents with sudden onset left-sided weakness and facial droop
lasting 20 minutes, now resolved. What is the most appropriate immediate investigation?
A. CT head with contrast
B. MRI brain with DWI
C. Carotid Doppler
D. ECG and echocardiogram
Answer: B MRI with DWI is most sensitive for TIA/early stroke; urgent imaging within
24h is recommended by NICE.
Q17. A 25-year-old woman presents with bilateral lower limb weakness that started in
her feet 2 weeks after a diarrhoeal illness and is ascending. Reflexes are absent. What is
the most likely diagnosis?
A. Multiple sclerosis
B. Guillain-Barré syndrome
C. Transverse myelitis
D. Motor neuron disease
DETAILED ANSWERS - LATEST VERSION - TOP RATED (2026/2027)
Q1. A 65-year-old man presents with central crushing chest pain radiating to his left arm
for 2 hours. ECG shows ST elevation in leads II, III and aVF. Which coronary artery is
most likely occluded?
A. Left anterior descending
B. Right coronary artery
C. Left circumflex
D. Left main stem
Answer: B Inferior STEMI (ST elevation in II, III, aVF) is most commonly caused by
RCA occlusion.
Q2. A 55-year-old woman presents with dyspnoea and bilateral ankle oedema. BNP is
markedly elevated. Echo shows an EF of 25%. Which drug has been shown to reduce
mortality in this condition?
A. Digoxin
B. Amlodipine
C. Bisoprolol
D. Furosemide
Answer: C Beta-blockers (e.g. bisoprolol) reduce mortality in heart failure with reduced
ejection fraction (HFrEF).
Q3. A 45-year-old man is found to have a BP of 175/100 mmHg on three separate
occasions. He has no other comorbidities. What is the first-line antihypertensive
treatment?
A. ACE inhibitor
B. Beta-blocker
C. Thiazide diuretic
D. Alpha-blocker
Answer: A ACE inhibitors are first-line for hypertension in patients under 55 years
without specific contraindications (NICE guidelines).
Q4. A 70-year-old woman with known AF is found to have a CHA₂DS₂-VASc score of 3.
She has no contraindications. What is the most appropriate management?
A. Aspirin alone
, B. Warfarin or DOAC
C. No anticoagulation needed
D. Clopidogrel
Answer: B CHA₂DS₂-VASc ≥2 in women indicates anticoagulation is recommended to
reduce stroke risk.
Q5. A 60-year-old man presents with sudden severe chest pain radiating to the back. CT
shows a widened mediastinum. BP is 190/100 mmHg. What is the most likely diagnosis?
A. Pulmonary embolism
B. Aortic dissection
C. STEMI
D. Oesophageal rupture
Answer: B Aortic dissection presents with tearing back pain, widened mediastinum, and
hypertension.
Q6. A 72-year-old smoker presents with a 3-month history of haemoptysis and weight
loss. CXR shows a hilar mass. What is the most likely diagnosis?
A. Mesothelioma
B. Pulmonary embolism
C. Lung carcinoma
D. Pulmonary tuberculosis
Answer: C Central hilar mass in a smoker with haemoptysis and weight loss strongly
suggests lung carcinoma.
Q7. A 30-year-old asthmatic presents to A&E with wheeze, unable to complete
sentences. PEFR is 30% predicted. SpO₂ is 92%. What is the immediate treatment?
A. Oral prednisolone
B. IV magnesium sulphate
C. High-flow oxygen, nebulised salbutamol, IV hydrocortisone
D. Intubation
Answer: C Life-threatening asthma requires high-flow O₂, back-to-back nebulisers, and
IV steroids as initial management.
Q8. A 55-year-old man with COPD has FEV1/FVC of 0.60 and FEV1 of 45% predicted.
He is on a SABA. What is the most appropriate next step?
A. Add ICS
B. Add LABA
C. Add LAMA
D. Start LABA + ICS
Answer: C NICE recommends adding LAMA (e.g. tiotropium) as the next step for
symptomatic COPD after SABA.
,Q9. A 25-year-old woman presents with pleuritic chest pain and breathlessness 3 days
after a long-haul flight. D-dimer is elevated. What should be done next?
A. Start warfarin immediately
B. CTPA
C. V/Q scan
D. Reassure and discharge
Answer: B CTPA is the investigation of choice for suspected PE, especially with
elevated D-dimer and clinical risk factors.
Q10. A 40-year-old male with known sarcoidosis has worsening dyspnoea and bilateral
hilar lymphadenopathy on CXR. What is the most appropriate initial treatment?
A. Methotrexate
B. Oral prednisolone
C. Azathioprine
D. No treatment required
Answer: B Systemic corticosteroids (prednisolone) are first-line for symptomatic
pulmonary sarcoidosis.
Section 2: Clinical Problem Solving – Gastroenterology & Neurology (Q11–Q20)
Q11. A 45-year-old woman presents with right upper quadrant pain, fever and jaundice.
Murphy's sign is positive. LFTs show raised ALP and bilirubin. What is the most likely
diagnosis?
A. Acute pancreatitis
B. Cholangitis
C. Hepatitis A
D. Peptic ulcer disease
Answer: B Charcot's triad (RUQ pain, fever, jaundice) indicates ascending cholangitis,
a biliary emergency.
Q12. A 30-year-old man presents with bloody diarrhoea, abdominal pain and weight loss
for 3 months. Colonoscopy shows continuous colonic inflammation from rectum to
splenic flexure. What is the most likely diagnosis?
A. Crohn's disease
B. Ulcerative colitis
C. Coeliac disease
D. Irritable bowel syndrome
Answer: B UC characteristically shows continuous inflammation starting from rectum;
Crohn's shows skip lesions.
Q13. A 55-year-old man with known liver cirrhosis develops confusion and asterixis.
Ammonia level is elevated. What is the immediate treatment?
, A. IV flumazenil
B. Lactulose
C. Rifaximin
D. IV N-acetylcysteine
Answer: B Lactulose is first-line treatment for hepatic encephalopathy, reducing
ammonia absorption from the gut.
Q14. A 60-year-old man presents with dysphagia to solids initially then liquids, and 10
kg weight loss over 3 months. What is the most likely diagnosis?
A. Oesophageal carcinoma
B. Achalasia
C. GORD
D. Pharyngeal pouch
Answer: A Progressive dysphagia (solids before liquids) with significant weight loss
strongly suggests oesophageal carcinoma.
Q15. A 50-year-old man taking NSAIDs presents with epigastric pain and melaena. OGD
reveals a duodenal ulcer with a visible vessel. What is the Rockford score indicating?
A. Low risk – discharge
B. High risk – endoscopic treatment needed
C. Intermediate risk – observation
D. Immediate surgery required
Answer: B Visible vessel at OGD is Forrest class IIa, indicating high re-bleeding risk
requiring endoscopic haemostasis.
Q16. A 70-year-old man presents with sudden onset left-sided weakness and facial droop
lasting 20 minutes, now resolved. What is the most appropriate immediate investigation?
A. CT head with contrast
B. MRI brain with DWI
C. Carotid Doppler
D. ECG and echocardiogram
Answer: B MRI with DWI is most sensitive for TIA/early stroke; urgent imaging within
24h is recommended by NICE.
Q17. A 25-year-old woman presents with bilateral lower limb weakness that started in
her feet 2 weeks after a diarrhoeal illness and is ascending. Reflexes are absent. What is
the most likely diagnosis?
A. Multiple sclerosis
B. Guillain-Barré syndrome
C. Transverse myelitis
D. Motor neuron disease
