NZREX Common Clinical Conditions 2 — Questions and Answers
Question 1: What is the NZ guideline for investigating a patient with iron deficiency anaemia?
- Full blood count, iron studies, and investigation for the source of blood loss (coeliac serology, upper and lower GI investigation if appropriate) (Correct answer)
- Full blood count and iron tablets only
- No investigation needed — just prescribe iron supplements
- Bone marrow biopsy as the first investigation
Correct answer: Full blood count, iron studies, and investigation for the source of blood loss (coeliac serology, upper and lower GI investigation if appropriate)
In NZ, iron deficiency anaemia requires investigation for the underlying cause, not just iron replacement. This includes coeliac serology, and for appropriate patients (especially males and postmenopausal females), upper and lower GI investigation to exclude malignancy or other GI pathology.
Question 2: A patient in NZ presents with sudden onset severe headache — the 'worst headache of my life'. What is the most important diagnosis to exclude?
- Subarachnoid haemorrhage (SAH) — investigate with CT brain (within 6 hours) and lumbar puncture if CT is normal (Correct answer)
- Migraine — treat with triptans
- Tension headache — treat with paracetamol
- Sinusitis — prescribe nasal decongestants
Correct answer: Subarachnoid haemorrhage (SAH) — investigate with CT brain (within 6 hours) and lumbar puncture if CT is normal
A sudden-onset, severe headache (thunderclap headache) must be investigated urgently to exclude subarachnoid haemorrhage. In NZ, the standard approach is CT brain (highly sensitive within 6 hours of onset). If CT is negative and clinical suspicion remains, a lumbar puncture should be performed.
Question 3: In NZ, what is the recommended approach to managing a patient presenting with deep vein thrombosis (DVT)?
- Confirm with compression ultrasound, start anticoagulation (usually a DOAC such as rivaroxaban), and investigate for underlying cause if unprovoked (Correct answer)
- Prescribe aspirin and elevate the leg only
- Immediate surgical removal of the clot
- No treatment needed if the patient is asymptomatic
Correct answer: Confirm with compression ultrasound, start anticoagulation (usually a DOAC such as rivaroxaban), and investigate for underlying cause if unprovoked
NZ DVT management involves confirming the diagnosis with compression ultrasound, starting anticoagulation (DOACs such as rivaroxaban are increasingly first-line), and investigating for underlying causes (malignancy screen, thrombophilia testing) if the DVT is unprovoked.
Question 4: What is the NZ screening recommendation for cervical cancer?
- HPV screening test every 5 years for people aged 25-69 with a cervix (changed from cytology-based screening) (Correct answer)
- Annual cervical smear for all women from age 18
- Screening only recommended after age 40
- No cervical screening programme exists in NZ
Correct answer: HPV screening test every 5 years for people aged 25-69 with a cervix (changed from cytology-based screening)
NZ transitioned to HPV-based primary screening. The National Cervical Screening Programme recommends HPV screening every 5 years for eligible people aged 25-69 with a cervix, replacing the previous 3-yearly cytology (smear) programme.
Question 5: A NZ patient presents with symptoms of hypothyroidism. What investigations should be ordered?
- TSH (thyroid-stimulating hormone) as the initial screening test, followed by free T4 if TSH is abnormal (Correct answer)
- Free T3 and free T4 only — TSH is not useful
- Thyroid ultrasound as the first investigation
- No investigation needed — diagnose based on clinical symptoms alone
Correct answer: TSH (thyroid-stimulating hormone) as the initial screening test, followed by free T4 if TSH is abnormal
In NZ, TSH is the most sensitive initial screening test for thyroid dysfunction. An elevated TSH suggests hypothyroidism, which should be followed up with a free T4 level. Thyroid antibodies (anti-TPO) may be checked to determine the cause (e.g., Hashimoto's thyroiditis).
Question 6: In NZ, what is the recommended first-line treatment for Helicobacter pylori eradication?
- Triple therapy: proton pump inhibitor, amoxicillin, and clarithromycin for 14 days (Correct answer)
- A single dose of metronidazole
- Proton pump inhibitor alone for 8 weeks
- No treatment — H. pylori is harmless
Correct answer: Triple therapy: proton pump inhibitor, amoxicillin, and clarithromycin for 14 days
NZ guidelines recommend triple therapy for H. pylori eradication: a proton pump inhibitor (e.g., omeprazole), amoxicillin, and clarithromycin for 14 days. If penicillin-allergic, metronidazole replaces amoxicillin. Eradication should be confirmed by re-testing.
NZREX Common Clinical Conditions 2
What is the NZ guideline for investigating a patient with iron deficiency anaemia?