NZREX CLINICAL SAMPLE QUESTIONS
NZREX Clinical is an examination that focuses on your professionalism, communication, cultural
safety; and the application of clinical knowledge and clinical decision making. The stations are
structured to examine your ability in these areas. In preparing for NZREX Clinical, you are encouraged
to focus on the management of common clinical conditions encountered at the level of a recent New
Zealand graduate (intern level). Please see the NZREX Clinical handbook for further explanation of
the stations, the exam blueprint and matrix of questions.
The following sample questions are typical examples of stations that you may encounter in NZREX
Clinical. These questions are provided to give you an understanding of what is expected of you
during the exam. The questions are intended as a guide only. You are advised not to focus
excessively on the clinical detail contained in the following questions as you prepare for NZREX
Clinical.
NZREX Clinical is assessing your ability at the level of a recent New Zealand graduate.
The sample questions to follow include:
Primary competency Primary Topic
Clinical reasoning Behavioural
Integrated Musculoskeletal
History taking Cardiovascular
Integrated Musculoskeletal
Integrated Musculoskeletal
It is important that you undertake the tasks outlined in the candidate instructions. You will be given
2 minutes to read the candidate instructions prior to entering the station. The same instructions are
also available inside the station should you need to refer to them again. You will have 10 minutes
inside each station. We recommend you prepare yourself for NZREX Clinical by practising
completing tasks within this timeframe.
In some stations, with 1, 2, or 3 minutes to go, the examiner will ask you to provide a differential
diagnosis, preferred investigations, or a management plan. A timer will alert you to this.
The marking sheet and competencies to be examined are to follow and are the same for each
station.
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NZREX CLINICAL MARK SHEET
Station # and type of case
Examiner Instructions
1. Greet the candidate and check their name and ID
2. Give them the written instructions.
Points of focus for this case:
• Takes focused history including…
• Physical exam includes checking for…
• Management includes…
• With 2 minutes to go, ask the candidate for their management plan.
The standard expected is that of recent New Zealand graduate (new intern)
Please see the competency skills sheet to guide your grading.
Domain Excellent Good Satisfactory Poor Very Poor
Communication Excellent Good Satisfactory Poor Very Poor
Professionalism Excellent Good Satisfactory Poor Very Poor
Cultural safety and Excellent Good Satisfactory Poor Very Poor
Cultural competence
History Taking Excellent Good Satisfactory Poor Very Poor
Physical Examination Excellent Good Satisfactory Poor Very Poor
Investigations and Excellent Good Satisfactory Poor Very Poor
Clinical Reasoning
Management Excellent Good Satisfactory Poor Very Poor
Overall rating of the candidate’s Pass Borderline Fail
performance
Were there any serious concerns?
(That the candidate was significantly below minimal expected standards) YES NO
Were there any critical incidents in the exam process? YES NO
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NZREX CLINICAL
COMPETENCY SKILLS
In considering which grade to award a candidate in this global marking sheet the following should be
used as a guide.
The candidate will:
Communication • Build and maintain rapport
• Listen
• Show empathy
• Be patient centred – exploring the patient’s ideas, concerns and
expectations
• Communicate in English that is understandable to the patient and
examiner
• Communicate clearly and use minimal medical jargon
• Manage complex communication interactions eg breaking bad
news, managing conflict, and consulting with youth.
Professionalism • Be respectful
• Attend to infection control
• Maintain professional boundaries and standards.
Cultural Safety and • Attend to visual or verbal cues from the patient around the initial
Cultural Competence greeting
• Be intentional when engaging with the patient and their whānau
(family), taking care to pronounce their names correctly and to
understand their inter-relationships
• Be prepared to share some information about themselves to
generate a shared whakawhanaungatanga (with Māori patients) or
an enhanced rapport for all patients
• If appropriate, acknowledge to the patient that they may be from
a different culture
• Be open to understanding that issues may need a different
approach than your standard one
• Check in with the patient during the consult to see if the patient is
comfortable with how the consult is going
• Invite the patient to give their view on what the presenting issue is
• Invite the patient to share their views on what management
options might work for them before creating a shared
management plan
• Be aware of and mitigate appropriately their own biases
• Display knowledge of, and/or enquire about cultural beliefs,
protocols, or language, and work to accommodate the cultural
preferences of the patient and whānau
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- For example (to Māori patient) I am aware that some people
are not comfortable with having their head touched
unnecessarily. It would be very helpful if I could examine your
eardrum and I would need to handle your head a little to do
that. Are you OK for me to do that?
History Taking • Obtain an accurate, succinct, and focussed history from the
patient
• Consider other relevant information provided by others.
Physical Examination • Undertake an appropriately focussed clinical examination and/or
mental state examination
• Communicate with the patient while examining, attending to their
comfort and dignity.
Investigations and • Order appropriate investigations
Clinical Reasoning • Interpret common investigations – blood tests, X-rays, scan
reports, ECG, and lung function tests
• Display logical clinical reasoning
• Apply current knowledge and use of evidence-based practice.
Management • Address patient concerns and questions
• Provide appropriate information and advice
• Engage in shared decision making (power sharing)
• Prescribe appropriately, and/or refers to guidelines
• Refer appropriately
• Attend to safety planning.
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NZREX CLINICAL
SAMPLE 1 – CLINICAL REASONING
CANDIDATE INSTRUCTIONS
• You are an intern in the emergency department.
• You have been requested by a nurse to see a patient, Jane Oliver.
• The nurse has bandaged a laceration on Ms Oliver. The nurse is concerned that the patient may
have self-inflicted the wound and is concerned about the patient’s state of mental health. The
wound has been treated and requires no further care.
• Your tasks are to:
- take a focused history
- assess the patient’s mental state
- advise her on appropriate management.
• This station does not require a physical examination. No marks are awarded for physical
examination.
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NZREX CLINICAL
SAMPLE 1 – CLINICAL REASONING
ACTOR INSTRUCTIONS
SCENARIO
• Your name is Jane Oliver.
• You are 20 years of age. Your friends brought you to hospital as you have cut your arm.
• Although you told your friends that the injury was on a piece of broken glass, in fact you
deliberately cut yourself with a razor blade.
• The nurse who saw you seemed to think that you may have self-harmed. She has asked the
doctor to see you.
BACKGROUND
• You have had problems with your mood for the last 4 years, mostly remaining stable but
sometimes going into what feels like a deep depression.
• You found it very difficult to get out of these moods that seem to last for many weeks.
• The cause of the mood problems was probably a physically abusive and distant father and a
depressed mother who was totally unable to cope with him.
• Two years ago you saw a GP who put you on to an antidepressant. This seemed to work and you
continued taking them for 12 months. In the last year your mood has been reasonable but not
terrific.
• You are at a technical institute doing a tourism course. You really enjoy the course.
• About 6 weeks ago your boyfriend and you broke up. This has devastated you and your mood has
gone downhill ever since.
• You are now drinking lots of alcohol at night to sleep. The usual things you enjoy in life seem to
have lost their appeal.
• You have tried cannabis but don’t regularly do any recreational drugs. You have never used IV
drugs.
• A week ago you saw your GP and explained what has been happening. Between yourself and
your GP, you agreed that the previous problem of depression was resurfacing and that you would
be best back on medication. She warned you that it would take 2 – 3 weeks for the medication to
work.
• There are occasional thoughts of self-harm and you acted on impulse on them today. In the past
(2 years ago) you cut yourself on several occasions but not since being on the medication.
• You live in a flat with two very close friends who give you lots of support.
• Although you have occasionally thought of killing yourself, you don’t really want to do this and
certainly have not thought about how you would do it. Even in the past you never really seriously
considered killing yourself.
• You have not heard voices or had unusual experiences that other people wouldn’t understand.
NOTE: It is important to balance scene realism with the time limitations of the candidates. If a candidate takes
a wrong turn and upsets you, convey this. When a candidate makes an effort to put things right, allow the
situation to improve so that the interview can continue. Don’t force an upset reaction to drag on for minutes
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at a time unless the candidate is behaving in a way that would make you continue to be upset as the only
option.
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NZREX CLINICAL
SAMPLE 2 – INTEGRATED
CANDIDATE INSTRUCTIONS
• You are a house officer on an orthopaedic attachment.
• You are seeing Mr Colin Brown, who is 55 years old, in outpatients.
• Your tasks are:
- to take a focused history
- to undertake a physical examination of his left shoulder.
• Please explain to the examiner what you are doing.
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NZREX CLINICAL
SAMPLE 2 – INTEGRATED
ACTOR INSTRUCTIONS
Your name is Colin Brown, age 55 years. You are here today to see a doctor about some pain in your
left shoulder. Please expect the doctor to ask you focused questions and take an examination of your
shoulder.
You have your own dairy farm. You were lifting a sack of fertiliser 10 days ago and at that time you
experienced a sudden severe pain in the left shoulder. Since that time, whenever you have lifted
things, the pain comes back on. Apart from that you have no other major issues with your shoulder.
Only if asked:
• You experience some minor discomfort during the day and night time.
• You also have a little discomfort when reaching up.
• There is no radiation of the pain.
• You have no pins and needles sensation in your arm.
• You have no chest tightness, chest pain or jaw pain.
• You have no weakness in your arm (you can still lift things but it causes some discomfort). There
is no pain in the elbow or neck.
• You’ve never had any major issues with your shoulder before. You have had no other joint pain
before. Your father had hip replacements because of osteoarthritis.
• Medications:
- You take medication for high cholesterol and you know that high cholesterol runs in your family.
You are not allergic to any medications.
• Social history:
- You live with your wife on the farm and you have two late teenage children.
- You do not smoke and you are an occasional social drinker.
- The pain in your shoulder is now starting to affect your ability to run the farm.
Please do as the candidate asks you to do.
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NZREX CLINICAL
SAMPLE 3 – HISTORY TAKING
CANDIDATE INSTRUCTIONS
• You are seeing Harry Patterson, aged 65, in outpatients who has been referred by his general
practitioner because of leg pain.
• Your task is to take a focused history from the patient and undertake a focused examination.
• During your physical examination, please tell the examiner what you are doing.
• The examiner will give you information on clinical findings if your examination is relevant to the
presenting problem.
• With 1 minute to go the examiner will ask you for your preferred diagnosis.
Do not discuss treatment options. No marks available for either of these.
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NZREX CLINICAL
SAMPLE 3 – HISTORY TAKING
EXAMINER INSTRUCTIONS
If the candidate examines the following, please inform them of the results as they proceed. Only give
the results pertinent to what they are examining at the time.
• Popliteal pulses are 2/3 on both sides
• Posterior tibial pulses 1/3 on both sides
• Tibialis anterior pulses 1/3 on both sides
• Capillary refill time of 5 seconds
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NZREX CLINICAL
SAMPLE 3 – HISTORY TAKING
ACTOR INSTRUCTIONS
Your name is Harry Patterson, age 65 years. Your general practitioner has referred you to hospital
outpatients for an opinion.
You have had increasing pain in your right leg for 9 months now. It started as an ache when walking
that you felt mainly in your right calf. If you stopped walking the pain would go in a couple of
minutes. Although you used to be able to walk about a kilometre, the pain seems to come on much
sooner now and you find that walking more than 100 metres will bring the pain on. Over the last
month or so you have noticed that your foot feels very cold at night. You have not had any pain in
your leg or foot when resting.
Past history:
You have had high blood pressure for about 10 years. You take bendrofluazide for this. More recently
your general practitioner put you on medication called felodipine to assist with your blood pressure
and to help with the leg pain. It seems to have made little difference to the pain.
You had your appendix removed as a young man and had fractured an ankle many years ago that
required you to be in a cast for 6 weeks. You smoke 20 cigarettes a day and have done so since you
were about 20 years of age. You go to the RSA club on a Friday night and have about 3-4 glasses of
beer, but do not drink alcohol apart from this. You are retired from your job as an electrician and live
with your wife, she keeps in good health.
The candidate will examine your legs and may take your blood pressure.
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NZREX CLINICAL
SAMPLE 4 – INTEGRATED
CANDIDATE INSTRUCTIONS
• You are an intern in the Accident and Emergency Department.
• You have been requested to see a patient John Smith who has injured his ankle.
Your task is to
• Take a focused history relevant to the presenting complaint.
• Undertake a focused examination relevant to the presenting complaint.
• Describe the x-rays presented to you.
• Describe to John what your management plan will be.
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NZREX CLINICAL
SAMPLE 4 – INTEGRATED
ACTOR INSTRUCTIONS
• Your name is John Smith and you are 50 years old. You are seeing a doctor in the Accident
and Emergency Department.
• You have had an x-ray taken of your ankle.
• Five days ago, you were playing soccer on a wet field; you slipped and rolled your right ankle.
You think that your foot went inwards.
• You could not play on because of the pain. You iced it immediately and then every 2 hours
for the remainder of that day. The ankle became swollen on the outside within an hour of
injuring it.
• You strapped the ankle which seemed to help a little.
• You are an architect. Because you have been busy, you didn’t get your ankle seen by a doctor
at the time.
• The swelling has mostly gone but the ankle is still quite sore.
• You can walk reasonably comfortably but get increased pain with running.
• You want to get back to playing soccer and so you decided to have your ankle seen at the
Accident and Emergency Department.
• You wonder if you need a cast or a splint of some sort.
• You are otherwise fit and healthy. You have never damaged your ankle before. You take no
medications.
The specific questions you have for the doctor are:
1. What is wrong with your ankle?
2. What therapy is needed?
3. When can you get back to playing soccer?
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NZREX CLINICAL
SAMPLE 4 – INTEGRATED
X-ray
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NZREX CLINICAL
SAMPLE 4 – INTEGRATED
X-ray
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NZREX CLINICAL
SAMPLE 5 – INTEGRATED
CANDIDATE INSTRUCTIONS
• You are an intern working in an outpatient clinic.
• You have been requested to see a 30 year old patient, Hollie Stabler.
• She works as a bartender in a busy nightclub. She has had 6 weeks of increasing pain in her
right elbow when opening bottles.
• Your task is to undertake a focused history of her elbow pain and undertake an appropriate
focused physical examination. You will be asked to provide a probable diagnosis.
• Please tell the examiner what you are doing and what your findings are.
• With 1 minute to go you will be asked for the most likely diagnosis and your treatment
recommendation.
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NZREX CLINICAL
SAMPLE 5 – INTEGRATED
ACTOR INSTRUCTIONS
Your name is Hollie Stabler. You are 30 years of age.
You work as a bartender. A large amount of the work is opening bottles, which means repetitive
twisting of caps of bottles. For the last 6 weeks, you have experienced pain around the outside of
your right elbow when opening bottles. For the last 2 weeks, the aching pain has been present even
at rest but is much worse while you are at work opening bottles. At times when working this pain can
be quite severe (7 out of 10 rating). Other activities that require you to bend your wrist backwards
also cause significant discomfort. You have not seen a doctor or physio for this. You have taken some
ibuprofen which seemed to help. The pain does not radiate up or down your arm.
Your health is otherwise good. You have no other joint pains. There is no family history of arthritis.
You have no tingling or strange sensations in your arm. You have no history of injuries. You have no
rashes. You have been feeling well and not had any fevers.
The candidate will be performing a physical exam and taking a focused history.
There is tenderness if the doctor presses on the outer part of the elbow. Examiner will demonstrate.
There is pain on resisted wrist extension. Examiner will explain.
There is marked pain on resisted middle finger extension with the arms straight.
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