NZREX Clinical History-Taking & Examination 3 — Questions and Answers
Question 1: Which of the following is the most appropriate first step when approaching a systemically unwell patient?
- ABCDE assessment (Correct answer)
- Full history and examination
- Ordering blood tests
- Calling the senior doctor
Correct answer: ABCDE assessment
The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is the internationally recognised framework for assessing and managing the acutely unwell patient in a structured, prioritised manner.
Question 2: A patient reports productive cough, fever, and right-sided pleuritic chest pain. On examination there is dullness to percussion and bronchial breathing at the right base. What is the most likely diagnosis?
- Right lower lobe pneumonia (Correct answer)
- Right-sided pleural effusion
- Pulmonary embolism
- Spontaneous pneumothorax
Correct answer: Right lower lobe pneumonia
Dullness to percussion with bronchial breathing indicates consolidation, consistent with lobar pneumonia. A pleural effusion would cause absent (not bronchial) breath sounds and stony dullness.
Question 3: Which clinical sign is used to assess for hepatomegaly during abdominal examination?
- Begin percussion in the right iliac fossa and move superiorly until dullness is detected (Correct answer)
- Percuss from the left iliac fossa toward the right upper quadrant
- Palpate deeply in the left hypochondrium
- Auscultate over the right upper quadrant for a bruit
Correct answer: Begin percussion in the right iliac fossa and move superiorly until dullness is detected
Hepatomegaly is assessed by starting percussion in the right iliac fossa (where the liver is absent) and moving upward to detect the superior border of liver dullness, then palpating to confirm the inferior border.
Question 4: What is the primary purpose of the 'systems review' component of a clinical history?
- To identify symptoms not covered in the presenting complaint that may be relevant (Correct answer)
- To repeat the presenting complaint in organ-specific terms
- To document the patient's surgical history
- To record current medications
Correct answer: To identify symptoms not covered in the presenting complaint that may be relevant
The systems review (or review of systems) systematically screens for symptoms in each organ system that the patient may not have volunteered, ensuring no relevant information is missed.
Question 5: When examining cranial nerve VII (facial nerve), which movement tests the upper motor neurone versus lower motor neurone?
- Forehead sparing (UMN) versus forehead involvement (LMN) (Correct answer)
- Eye closure (UMN) versus mouth movement (LMN)
- Taste on anterior tongue (LMN) versus posterior tongue (UMN)
- Corneal reflex (UMN) versus blink reflex (LMN)
Correct answer: Forehead sparing (UMN) versus forehead involvement (LMN)
In upper motor neurone facial palsy (e.g., stroke), the forehead is spared due to bilateral cortical representation. In lower motor neurone palsy (e.g., Bell's palsy), the entire ipsilateral face including the forehead is affected.
Question 6: A 70-year-old patient presents with confusion. Which validated tool is most appropriate for brief cognitive assessment in the acute setting?
- Abbreviated Mental Test Score (AMTS) (Correct answer)
- Mini-Mental State Examination (MMSE)
- Montreal Cognitive Assessment (MoCA)
- Clock Drawing Test alone
Correct answer: Abbreviated Mental Test Score (AMTS)
The AMTS (10 questions, score 0–10) is rapid and validated for use in acute settings to screen for cognitive impairment. The MMSE and MoCA are more detailed and better suited to outpatient cognitive assessment.
NZREX Clinical History-Taking & Examination 3
Which of the following is the most appropriate first step when approaching a systemically unwell patient?