NZREX Emergency Medicine 2 β Questions and Answers
Question 1: A 55-year-old presents with sudden onset severe headache, vomiting, and neck stiffness. CT brain is normal. Lumbar puncture shows xanthochromia. What is the diagnosis?
- Subarachnoid haemorrhage (Correct answer)
- Bacterial meningitis
- Viral meningitis
- Cerebral venous sinus thrombosis
Correct answer: Subarachnoid haemorrhage
Xanthochromia (yellow CSF discolouration due to bilirubin from haemolysed red blood cells) after a thunderclap headache confirms subarachnoid haemorrhage (SAH) when CT is normal. LP is most sensitive >12 hours after headache onset.
Question 2: A patient is brought in with a GCS of 8 after a road traffic accident. What is the GCS score threshold typically used to guide intubation?
- GCS β€8 (Correct answer)
- GCS β€10
- GCS β€12
- GCS <15
Correct answer: GCS β€8
A GCS of β€8 is the widely accepted threshold indicating the patient cannot protect their own airway, requiring intubation. 'GCS of 8 β intubate' is a clinical rule of thumb used in trauma and emergency medicine.
Question 3: Which of the following is the first-line treatment for hypoglycaemia in a conscious patient who can swallow?
- 15β20 g of fast-acting carbohydrate orally (e.g., glucose tablets or sugary drink) (Correct answer)
- IV dextrose 50% immediately
- IM glucagon
- IV thiamine followed by glucose
Correct answer: 15β20 g of fast-acting carbohydrate orally (e.g., glucose tablets or sugary drink)
Conscious patients with hypoglycaemia who can swallow safely should receive 15β20 g of fast-acting oral carbohydrate. IV dextrose and IM glucagon are reserved for unconscious patients or those unable to swallow.
Question 4: A 35-year-old woman presents with acute severe asthma not responding to initial bronchodilators. Her SpO2 is 88% despite oxygen. What is the next most appropriate intervention?
- IV magnesium sulphate 2 g over 20 minutes (Correct answer)
- Oral prednisolone 40 mg
- Repeat salbutamol nebuliser only
- Discharge with oral steroids
Correct answer: IV magnesium sulphate 2 g over 20 minutes
IV magnesium sulphate is recommended for acute severe asthma not responding to initial bronchodilators, as it causes bronchial smooth muscle relaxation. This should be given alongside IV corticosteroids, continuous salbutamol, and senior review.
Question 5: In a patient with suspected carbon monoxide poisoning, which intervention is most important?
- High-flow 100% oxygen via non-rebreather mask (Correct answer)
- Activated charcoal
- Hyperbaric oxygen as the immediate first step
- IV N-acetylcysteine
Correct answer: High-flow 100% oxygen via non-rebreather mask
High-flow 100% oxygen accelerates elimination of carbon monoxide (CO) from haemoglobin. It reduces the half-life of carboxyhaemoglobin from ~5 hours on room air to ~60β90 minutes. Hyperbaric oxygen is considered for severe cases but high-flow O2 is the immediate priority.
Question 6: A 70-year-old woman falls and presents with inability to bear weight on the right hip. The leg is shortened and externally rotated. What is the most likely diagnosis?
- Fractured neck of femur (Correct answer)
- Hip dislocation
- Pelvic fracture
- Greater trochanter avulsion
Correct answer: Fractured neck of femur
A shortened, externally rotated leg following a fall in an elderly person is the classic presentation of a fractured neck of femur (hip fracture). This requires orthopaedic review and surgical management (hemiarthroplasty or total hip replacement).
NZREX Emergency Medicine 2
A 55-year-old presents with sudden onset severe headache, vomiting, and neck stiffness.
CT brain is normal.
Lumbar puncture shows xanthochromia.
What is the diagnosis?