NZREX Clinical Diagnosis & Management 4 β Questions and Answers
Question 1: Which of the following is a contraindication to the use of metformin?
- eGFR below 30 mL/min/1.73mΒ² (Correct answer)
- BMI above 30 kg/mΒ²
- HbA1c above 70 mmol/mol
- Age over 65 years
Correct answer: eGFR below 30 mL/min/1.73mΒ²
Metformin is contraindicated in significant renal impairment (eGFR <30) due to the risk of lactic acidosis from metformin accumulation. It is dose-reduced at eGFR 30β45 and should be temporarily withheld before contrast procedures.
Question 2: A 5-year-old presents with a 2-day history of high fever, sore throat, and a fine sandpaper-like erythematous rash. Throat swab grows Group A Streptococcus. What is the diagnosis?
- Scarlet fever (Correct answer)
- Roseola infantum
- Kawasaki disease
- Infectious mononucleosis
Correct answer: Scarlet fever
Scarlet fever is caused by Group A Streptococcus and presents with fever, pharyngitis, and a diffuse erythematous 'sandpaper' rash, often with strawberry tongue. It is treated with penicillin/amoxicillin.
Question 3: Which radiological finding on a plain chest X-ray is characteristic of pulmonary oedema?
- Bilateral perihilar ('bat wing') shadowing with upper lobe venous diversion (Correct answer)
- Unilateral homogeneous opacification with tracheal deviation
- Hyperinflation with flattened hemidiaphragms
- Apical consolidation with hilar lymphadenopathy
Correct answer: Bilateral perihilar ('bat wing') shadowing with upper lobe venous diversion
Pulmonary oedema produces bilateral perihilar ('bat wing' or 'butterfly') shadowing, upper lobe blood diversion (cephalisation), Kerley B lines, and pleural effusions, reflecting elevated left atrial pressure.
Question 4: A 22-year-old woman presents with dysuria and vaginal discharge. High vaginal swab grows Neisseria gonorrhoeae. Which treatment regimen is most appropriate per New Zealand guidelines?
- IM ceftriaxone 500 mg stat plus azithromycin 1 g orally stat (Correct answer)
- Oral ciprofloxacin 500 mg stat
- Oral doxycycline 100 mg twice daily for 7 days
- IM penicillin G alone
Correct answer: IM ceftriaxone 500 mg stat plus azithromycin 1 g orally stat
New Zealand guidelines recommend dual therapy for gonorrhoea: IM ceftriaxone (to address increasing fluoroquinolone resistance) plus azithromycin (to provide additional coverage and reduce resistance development). Contact tracing is mandatory.
Question 5: Which of the following most accurately describes the management of stable angina?
- Short-acting nitrate PRN, regular antiplatelet, statin, and beta-blocker or calcium channel blocker (Correct answer)
- Immediate PCI
- Anticoagulation with warfarin
- IV thrombolysis
Correct answer: Short-acting nitrate PRN, regular antiplatelet, statin, and beta-blocker or calcium channel blocker
Stable angina is managed with sublingual GTN for acute episodes, aspirin, a statin, and an anti-anginal agent (beta-blocker first-line, or calcium channel blocker). Revascularisation is considered if symptoms are not controlled.
Question 6: A patient on warfarin presents with an INR of 9.2 and minor bleeding from the gums. What is the most appropriate management?
- Withhold warfarin and give oral vitamin K 1β3 mg (Correct answer)
- Continue warfarin and monitor
- Give IV vitamin K 10 mg immediately
- Give fresh frozen plasma immediately
Correct answer: Withhold warfarin and give oral vitamin K 1β3 mg
For a supratherapeutic INR with minor bleeding, warfarin is withheld and low-dose oral vitamin K (1β3 mg) is given to allow gradual INR correction without over-reversal. IV vitamin K and FFP are reserved for serious or life-threatening bleeding.
NZREX Clinical Diagnosis & Management 4
Which of the following is a contraindication to the use of metformin?