Clinical Diagnosis & Management Flashcards

A 78-year-old woman on aspirin and NSAIDs presents with acute haematemesis. She is haemodynamically stable. What is the most appropriate next step?

Answer: Urgent upper GI endoscopy within 24 hours

Haematemesis requires urgent endoscopy (within 24 hours for stable patients, or immediately if haemodynamically unstable) for diagnosis and haemostasis. Intravenous PPI is given pre-endoscopy to reduce re-bleeding risk.

Which of the following is the most appropriate management of an acute ischaemic stroke presenting within 4.5 hours of onset?

Answer: IV alteplase (thrombolysis) if no contraindications

IV alteplase (tPA) within 4.5 hours of ischaemic stroke onset is the recommended thrombolytic therapy for eligible patients without contraindications. Mechanical thrombectomy may also be considered for large vessel occlusion.

A 55-year-old man with hypertension presents with acute severe headache, vomiting, and photophobia. CT brain is normal. What is the next most appropriate investigation?

Answer: Lumbar puncture for xanthochromia

A normal CT does not exclude subarachnoid haemorrhage (SAH). Lumbar puncture (ideally >12 hours after headache onset) is performed to look for xanthochromia (bilirubin from haemolysed red blood cells), which confirms SAH.

Which of the following is the most appropriate empirical antibiotic regimen for bacterial meningitis in an adult in New Zealand?

Answer: IV ceftriaxone 2 g 12-hourly plus IV dexamethasone

Empirical treatment for bacterial meningitis includes a third-generation cephalosporin (ceftriaxone) for broad coverage, plus IV dexamethasone to reduce inflammation and improve neurological outcomes. Do not delay antibiotics for imaging.

A 45-year-old woman with known rheumatoid arthritis presents with bilateral knee effusions and morning stiffness lasting 2 hours. Her DAS28 score is 5.8. What does this indicate?

Answer: High disease activity requiring treatment escalation

A DAS28 score above 5.1 indicates high disease activity in rheumatoid arthritis. This warrants treatment escalation (e.g., adding or switching a DMARD, or biologic therapy) to prevent joint damage.

Which of the following is NOT a red flag for low back pain requiring urgent investigation?

Answer: Pain that improves with rest and worsens with activity

Mechanical low back pain typically improves with rest and worsens with activity — this is a benign pattern and does not represent a red flag. Red flags (cauda equina syndrome, cancer, infection, fracture) require urgent investigation.