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abdominal pain

Practice targeted AMC-style multiple-choice questions on abdominal pain.

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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 45-year-old male presents with intermittent abdominal pain and melena. The provided image was obtained. What is the most likely underlying cause?

A. Henoch-Schönlein purpura
B. Cystic fibrosis
C. Meckel's diverticulum
D. Peutz-Jeghers syndrome
E. Blue rubber bleb nevus syndrome
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Elective abdominal ultrasonography of a 64 year old woman with past colicky pain but no current pain. It shows a mildly dilated common bile duct with what appears to be a gallstone (black arrow). The green and blue dots are blood flow, since the exam is done as a Doppler ultrasound to distinguish the bile duct from blood vessels.
Image by Mikael Häggström CC0 1.0 · Source

A 64-year-old woman presents for follow-up after experiencing intermittent episodes of right upper quadrant colicky pain over the past year, which have since resolved. She denies any current pain, fever, jaundice, or changes in bowel habits. Physical examination is unremarkable, and recent liver function tests are within normal limits. An elective abdominal ultrasound was performed, yielding the image shown. Considering the clinical context and the findings demonstrated, what is the most appropriate next step in her management?

A. Discharge with advice to return if symptoms recur
B. ERCP for stone extraction
C. Initiate ursodeoxycholic acid therapy
D. MRCP to further delineate the biliary anatomy
E. Elective laparoscopic cholecystectomy
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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 62-year-old male with a history of poorly controlled diabetes presents with fever, RUQ pain, and night sweats for 3 weeks. Initial blood cultures are negative. Imaging is performed, as shown. What is the MOST appropriate next step in management?

A. Albendazole therapy
B. Percutaneous drainage and culture of the lesion
C. Surgical resection of the affected liver segment
D. Empiric broad-spectrum antibiotics
E. Observation with serial imaging
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Inguinal hernia right view. Adult male with an inguinal hernia, showing bulging in the groin area.
Image by IkeTheSloth CC0 1.0 · Source

A 58-year-old male presents to your GP clinic complaining of a dragging sensation in his right groin, particularly when standing for long periods. He denies any pain, nausea, or vomiting. On examination, you note the finding in the image. Palpation reveals a soft, reducible mass. What is the MOST appropriate next step in management?

A. Referral to a general surgeon for elective repair
B. Referral to physiotherapy for core strengthening exercises
C. Urgent referral to the emergency department
D. Prescription of a truss for symptomatic relief
E. Reassurance and watchful waiting
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 35-year-old male with a history of multiple cutaneous vascular lesions presents with recurrent episodes of crampy abdominal pain and melena over the past month. His vital signs are stable. An abdominal CT scan is performed. Considering the clinical presentation and the findings demonstrated in the provided image, what is the most likely underlying pathology responsible for the patient's symptoms and the observed bowel findings?

A. Mesenteric adenitis triggering intussusception
B. Inflammatory strictures leading to obstruction
C. Lymphoid hyperplasia causing transient intussusception
D. Malignant polyps causing intussusception
E. Intestinal haemangiomas acting as lead points
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 3-year-old child is investigated for a 2-month history of increasing abdominal distension and intermittent pain. On examination, a firm, non-tender mass is palpable in the upper abdomen. Initial blood tests reveal mild anaemia. Vital signs are stable. The provided image was obtained as part of the diagnostic evaluation. Considering the clinical presentation and the findings demonstrated, which of the following investigations is most crucial for determining the extent of disease spread, a key factor in guiding subsequent management decisions for this paediatric patient?

A. 123I-MIBG scintigraphy
B. Urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels
C. MYCN gene amplification testing
D. Whole-body PET-CT scan
E. Bone marrow biopsy
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A previously well 3-year-old boy presents to the emergency department with a 12-hour history of sudden onset, intermittent, severe, colicky abdominal pain, associated with non-bilious vomiting. Between episodes, he appears lethargic and pale. His vital signs are stable: HR 110, BP 90/60, RR 24, Temp 37.2. Abdominal examination reveals mild distension and tenderness, but no guarding or rebound. Bowel sounds are present. A point-of-care ultrasound is performed by the emergency physician. Considering the clinical presentation, the patient's current stable vital signs, and the specific findings demonstrated in the provided ultrasound image, which of the following represents the single most appropriate immediate next step in the management of this patient in an Australian tertiary paediatric centre?

A. Proceed directly to surgical exploration.
B. Attempt pneumatic or hydrostatic reduction under fluoroscopic guidance.
C. Obtain a CT scan of the abdomen and pelvis.
D. Administer IV fluids and observe for resolution.
E. Discharge home with pain relief and follow-up.
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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 62-year-old male with a history of poorly controlled diabetes presents with right upper quadrant pain, fever, and night sweats for 3 weeks. He is on immunosuppressants following a renal transplant 5 years ago. Blood cultures are pending. Imaging is performed, as shown. What is the MOST appropriate next step in management?

A. Empiric antifungal therapy
B. Observation and serial imaging
C. Metronidazole and supportive care
D. Albendazole and surgical resection
E. Percutaneous drainage and antibiotics
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Inguinal hernia right view. Adult male with an inguinal hernia, showing bulging in the groin area.
Image by IkeTheSloth CC0 1.0 · Source

A 52-year-old man presents with right groin discomfort, worse with standing. Examination reveals the finding in the image. What is the MOST appropriate next step?

A. CT abdomen and pelvis
B. Reassurance and watchful waiting
C. Surgical referral for elective repair
D. Urgent surgical referral
E. Prescription of a truss
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

A 62-year-old male presents to the emergency department with right upper quadrant abdominal pain, weight loss, and increasing jaundice over the past month. He has a history of chronic hepatitis C infection and heavy alcohol use. His vital signs are stable. Physical examination reveals hepatomegaly and mild ascites. Laboratory investigations show elevated bilirubin, alkaline phosphatase, and gamma-glutamyl transferase (GGT). Alpha-fetoprotein (AFP) is significantly elevated. A CT scan of the abdomen with and without contrast is performed, as shown. Based on the clinical presentation and imaging findings, what is the MOST appropriate next step in management?

A. Administration of intravenous antibiotics for suspected cholangitis
B. Percutaneous liver biopsy for histological confirmation
C. Initiation of antiviral therapy for hepatitis C
D. Surgical resection of the identified lesion
E. Referral to a hepatologist for consideration of liver transplantation
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Acute cholecystitis with gallbladder wall thickening, a large gallstone, and a large gallbladder
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 55-year-old woman presents with 2 days of worsening right upper quadrant pain radiating to her back, nausea, and subjective fever. On examination, she is tender in the RUQ. Vitals are stable. Labs show WCC 15.0, CRP 120. This image is obtained. Based on the clinical presentation and imaging findings, what is the most appropriate next step in management?

A. Continue medical management with IV antibiotics and analgesia
B. Laparoscopic cholecystectomy within 24-72 hours
C. Urgent endoscopic retrograde cholangiopancreatography (ERCP)
D. Repeat abdominal ultrasound in 24 hours
E. Percutaneous cholecystostomy tube insertion
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

A 58-year-old male with cirrhosis secondary to alcohol abuse presents with new-onset ascites and RUQ pain. His AFP is markedly elevated. A CT abdomen with IV contrast is performed, as shown. What is the MOST appropriate next step in confirming the suspected diagnosis?

A. Initiate systemic chemotherapy
B. Referral for liver transplantation evaluation
C. Repeat CT scan in 3 months
D. MRI of the abdomen with hepatobiliary contrast
E. Liver biopsy
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 68-year-old man presents to the emergency department with a 2-day history of worsening left lower quadrant abdominal pain, associated with subjective fever, chills, and nausea. He reports some recent constipation. On examination, his temperature is 38.5°C, pulse 95 bpm, BP 130/80 mmHg. Abdominal examination reveals tenderness and guarding in the left iliac fossa. Bowel sounds are reduced. Blood tests show a white cell count of 15 x 10^9/L (neutrophils 85%) and C-reactive protein of 120 mg/L. Urea, electrolytes, and creatinine are within normal limits. A CT scan of the abdomen and pelvis is performed (image provided). Considering the clinical presentation and the findings demonstrated in the provided image, which of the following represents the most appropriate initial management strategy?

A. Conservative management with analgesia and observation.
B. Oral antibiotics and outpatient management.
C. Urgent surgical resection of the affected segment.
D. Colonoscopy to assess the severity of diverticular disease.
E. Intravenous antibiotics and consider percutaneous drainage.
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A 45-year-old woman presents to the emergency department with severe right upper quadrant abdominal pain that started suddenly 3 hours ago. She describes the pain as sharp and radiating to her right shoulder. She has a history of gallstones but has never had surgery. On examination, she is febrile with a temperature of 38.5°C, her blood pressure is 110/70 mmHg, and her heart rate is 100 bpm. She has tenderness in the right upper quadrant with a positive Murphy's sign. Laboratory tests reveal leukocytosis and mildly elevated liver enzymes. An abdominal ultrasound shows gallstones and a thickened gallbladder wall with pericholecystic fluid. What is the most appropriate next step in the management of this patient?

A. Immediate endoscopic retrograde cholangiopancreatography (ERCP)
B. Discharge with outpatient follow-up for elective cholecystectomy
C. Intravenous antibiotics and surgical consultation for cholecystectomy
D. Observation and pain management with oral analgesics
E. Percutaneous cholecystostomy
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Acute cholecystitis with gallbladder wall thickening, a large gallstone, and a large gallbladder
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 58-year-old woman with poorly controlled diabetes presents with severe RUQ pain, fever, and vomiting for 3 days. The provided CT was performed. What is the MOST appropriate initial management strategy?

A. Urgent cholecystectomy
B. Oral ursodeoxycholic acid
C. IV antibiotics and bowel rest
D. Percutaneous cholecystostomy tube placement
E. ERCP with stone extraction
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Elective abdominal ultrasonography of a 64 year old woman with past colicky pain but no current pain. It shows a mildly dilated common bile duct with what appears to be a gallstone (black arrow). The green and blue dots are blood flow, since the exam is done as a Doppler ultrasound to distinguish the bile duct from blood vessels.
Image by Mikael Häggström CC0 1.0 · Source

A 64-year-old woman presents for a routine health check. She reports intermittent episodes of colicky abdominal pain over the past year, which have resolved spontaneously. She denies any current pain, jaundice, fever, or changes in bowel habits. Her physical examination is unremarkable, with a soft, non-tender abdomen. Liver function tests are within normal limits. An abdominal ultrasound, as shown, was performed. Given the clinical context and the ultrasound findings, what is the MOST appropriate next step in management?

A. Recommend a high-fibre diet and analgesics as needed
B. Referral for endoscopic retrograde cholangiopancreatography (ERCP)
C. Schedule a repeat ultrasound in 6 months
D. Prescribe ursodeoxycholic acid and monitor liver function tests
E. Order a hepatobiliary iminodiacetic acid (HIDA) scan
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 68-year-old male presents with a 2-day history of worsening left lower quadrant abdominal pain, fever (38.5°C), and nausea. He has a history of similar, milder pain episodes. Examination reveals left iliac fossa tenderness with guarding. Bloods show WCC 16, CRP 120. A CT scan is performed (image provided). Considering the clinical picture and the imaging findings, which of the following represents the most appropriate initial management strategy?

A. Administer intravenous fluids and analgesia, and observe in the emergency department for 12 hours.
B. Initiate intravenous broad-spectrum antibiotics and admit for inpatient care.
C. Arrange urgent surgical review for consideration of immediate operative intervention.
D. Prescribe oral antibiotics and arrange follow-up with his general practitioner.
E. Schedule an urgent colonoscopy to evaluate the severity and rule out malignancy.
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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 68-year-old woman presents with 3 days of left lower quadrant pain. She reports mild nausea but no vomiting or fever. On examination, she is afebrile, BP 130/80, HR 78, O2 sat 98% on air. There is localised tenderness in the LLQ. Bloods show WCC 13.2, CRP 45. A CT scan is performed. Considering the clinical presentation and the findings demonstrated in the image, what is the most appropriate initial management plan?

A. Discharge with analgesia and advice to return if symptoms worsen, without antibiotics.
B. Outpatient management with oral antibiotics and analgesia.
C. Admission for intravenous antibiotics and observation.
D. Urgent colonoscopy to assess the extent of disease.
E. Surgical consultation for potential colectomy.
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 68-year-old male presents to the emergency department complaining of abdominal pain, distension, and obstipation for the past 3 days. He reports a history of multiple abdominal surgeries for adhesions. His vital signs are: HR 110 bpm, BP 110/70 mmHg, RR 22 breaths/min, SpO2 97% on room air, and temperature 37.8°C. Physical examination reveals a distended abdomen with high-pitched bowel sounds. An upright abdominal X-ray is performed, as shown. Given the clinical context and the findings on the imaging, what is the MOST appropriate next step in management?

A. Insert a nasogastric tube and initiate intravenous fluid resuscitation
B. Prescribe oral laxatives and encourage increased fluid intake
C. Administer intravenous antibiotics and schedule an urgent CT scan with oral contrast
D. Order a barium enema to assess for colonic obstruction
E. Perform a flexible sigmoidoscopy to rule out sigmoid volvulus
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Umbilical hernia
Image by Ibrahim Husain Meraj CC BY-SA 4.0 · Source

A 9-month-old presents with the abdominal finding shown. It is soft and reducible. Parents are concerned. What counseling is most appropriate?

A. Reassurance and observation, as most resolve spontaneously by age 5
B. Application of an abdominal binder to prevent further enlargement
C. Immediate surgical referral due to risk of incarceration
D. Initiation of physiotherapy to strengthen abdominal muscles
E. Dietary changes to reduce intra-abdominal pressure
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Acute cholecystitis with gallbladder wall thickening, a large gallstone, and a large gallbladder
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 45-year-old woman presents to the ED with right upper quadrant pain, fever, and nausea for 24 hours. Her vital signs are: HR 105 bpm, BP 130/80 mmHg, Temp 38.5°C. Physical exam reveals marked tenderness on palpation of the right upper quadrant. An abdominal CT scan is performed, as shown. What is the MOST appropriate next step in management?

A. Initiate broad-spectrum antibiotics and observe
B. Discharge with analgesics and outpatient follow-up
C. ERCP to rule out choledocholithiasis
D. Surgical consultation for cholecystectomy
E. Start ursodeoxycholic acid for gallstone dissolution
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset, intermittent, severe abdominal pain, vomiting, and lethargy. On examination, he is pale but haemodynamically stable. An abdominal ultrasound is performed. Based on the clinical presentation and the provided image, what is the most appropriate next step in the management of this patient?

A. Urgent surgical consultation for laparotomy
B. Nasogastric tube insertion and IV fluids only
C. Air enema reduction
D. Observation with serial abdominal examinations
E. CT abdomen and pelvis
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Umbilical hernia
Image by Ibrahim Husain Meraj CC BY-SA 4.0 · Source

A 6-month-old male infant is brought to the emergency department by his parents. They report that they have noticed a bulge on his abdomen that seems to get larger when he cries. The infant is otherwise healthy, feeding well, and has normal bowel movements. On examination, the infant is afebrile, and his vital signs are within normal limits. The abdomen is soft and non-tender. Palpation reveals a soft, reducible mass at the umbilicus, as shown in the image. What is the MOST appropriate next step in the management of this patient?

A. Urgent ultrasound to rule out incarceration
B. Application of an abdominal binder
C. Reassurance and observation
D. Immediate surgical referral for elective repair
E. Initiation of a high-fiber diet to prevent constipation
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 3-week-old male infant presents with persistent, non-bilious projectile vomiting after each feed. He appears hungry and eagerly accepts the bottle, but vomits shortly after. On examination, mild dehydration is noted. An abdominal X-ray is ordered, the relevant image is attached. What is the MOST appropriate next step in management?

A. Perform an upper endoscopy
B. Administer intravenous ondansetron
C. Initiate a course of erythromycin
D. Surgical pyloromyotomy
E. Start a trial of thickened feeds
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A neonate is born at term following an uneventful pregnancy. Immediately after birth, the baby develops bilious vomiting. Abdominal examination reveals epigastric distension, but the rest of the abdomen is scaphoid. An abdominal X-ray is performed. Which of the following findings on the abdominal X-ray would be most consistent with the likely diagnosis?

A. Double-bubble sign
B. Multiple air-fluid levels throughout the abdomen
C. Free air under the diaphragm
D. Pneumatosis intestinalis
E. Ground glass appearance
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 45-year-old male presents with intermittent abdominal pain and melena. He has multiple cutaneous hemangiomas. The provided image was obtained. What is the MOST likely underlying cause of the patient's presentation?

A. Peutz-Jeghers syndrome
B. Blue rubber bleb nevus syndrome
C. Gardner syndrome
D. Henoch-Schönlein purpura
E. Osler-Weber-Rendu syndrome
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Ovarian Cyst
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 28-year-old female presents to the ED with acute onset right lower quadrant pain. She reports nausea and vomiting. Her last menstrual period was 6 weeks ago, and she denies any vaginal bleeding. She is hemodynamically stable. A CT scan of the abdomen and pelvis is performed, with a relevant image shown. What is the MOST appropriate next step in the management of this patient?

A. Emergency hysterectomy
B. Laparoscopic cystectomy
C. Administration of broad-spectrum antibiotics
D. Initiate anticoagulation therapy
E. Expectant management with analgesia
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A 45-year-old man presents to the clinic with a 3-month history of fatigue, weight loss, and abdominal pain. He has a history of type 2 diabetes and hypertension. On examination, he has a palpable mass in the left upper quadrant of the abdomen. Laboratory tests reveal anemia and elevated serum lactate dehydrogenase (LDH). A CT scan of the abdomen shows splenomegaly and multiple hypodense lesions in the spleen. What is the most likely diagnosis?

A. Splenic lymphoma
B. Renal cell carcinoma with splenic metastasis
C. Chronic pancreatitis
D. Infectious mononucleosis
E. Portal hypertension
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 32-year-old male with a history of Crohn's disease presents with worsening abdominal pain, diarrhea, and a low-grade fever. He reports that his symptoms have been progressively worsening over the past few weeks despite being compliant with his prescribed mesalamine. A CT scan of the abdomen and pelvis is performed, as shown. What is the MOST appropriate next step in management?

A. Schedule a colonoscopy with biopsy
B. Start a course of oral prednisone
C. Initiate infliximab therapy
D. Increase the dose of mesalamine
E. Prescribe a course of oral ciprofloxacin and metronidazole
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 3-year-old presents with abdominal distension and vague pain. Vitals are stable. An abdominal CT is performed (image attached). Elevated levels of HVA and VMA are noted in the urine. What is the MOST likely origin of the primary lesion?

A. Spleen
B. Pancreas
C. Liver
D. Adrenal gland
E. Kidney
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 28-year-old female presents to her general practitioner with a 6-month history of intermittent abdominal pain, predominantly in the right lower quadrant. She describes the pain as cramping and associated with occasional episodes of non-bloody diarrhea. She denies fever, weight loss, or recent travel. Her past medical history is significant for well-controlled asthma, for which she uses an inhaled corticosteroid as needed. Physical examination reveals mild tenderness to palpation in the right lower quadrant, but is otherwise unremarkable. Bowel sounds are normal. Initial laboratory investigations, including a complete blood count and comprehensive metabolic panel, are within normal limits. Stool studies for ova and parasites, bacterial culture, and Clostridium difficile toxin are negative. Given her persistent symptoms, the GP refers her for further evaluation. A CT enterography is performed, and relevant images are shown. Based on the clinical presentation and imaging findings, which of the following is the MOST likely long-term complication this patient is at increased risk of developing?

A. Toxic megacolon
B. Fulminant colitis
C. Small bowel obstruction
D. Erosive esophagitis
E. Primary sclerosing cholangitis
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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 65-year-old male presents with left lower quadrant abdominal pain for 3 days, associated with constipation. He denies fever. An abdominal CT scan is performed, the axial view is shown. What dietary advice is MOST appropriate at discharge?

A. Strictly liquid diet for 2 weeks
B. Low-residue diet until symptoms resolve
C. High-fiber diet with adequate fluid intake
D. Gluten-free diet
E. Avoidance of nuts and seeds
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 32-year-old male with Crohn's disease presents with worsening abdominal pain and diarrhea despite being on maintenance infliximab. He denies fever or blood in his stool. An abdominal CT and MRI are performed. Based on the imaging, what is the MOST appropriate next step in management?

A. Initiate treatment with ustekinumab
B. Perform a colonoscopy with biopsy
C. Prescribe a course of oral metronidazole
D. Start a course of oral budesonide
E. Increase the dose of infliximab
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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with a low-grade fever (38.1°C) and mild nausea. He denies vomiting, diarrhoea, or rectal bleeding. On examination, he has localised tenderness in the left iliac fossa. His vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, SpO2 98% on air. Blood tests show a white cell count of 12.5 x 10^9/L and CRP 45 mg/L. An abdominal CT scan is performed (image provided). Based on the clinical presentation and the provided image, what is the most appropriate initial management plan?

A. Intravenous antibiotics and hospital admission for observation.
B. Urgent surgical consultation for Hartmann's procedure.
C. Immediate colonoscopy to evaluate the colonic mucosa.
D. Discharge with advice on dietary modification and follow-up in 6 weeks.
E. Outpatient oral antibiotics and analgesia.
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 48-year-old man with multiple cutaneous hemangiomas presents with crampy abdominal pain and guaiac-positive stools. The provided image was obtained. What is the MOST appropriate initial diagnostic test to identify the source of bleeding?

A. Tagged red blood cell scan
B. Upper endoscopy
C. Barium swallow
D. Colonoscopy
E. Capsule endoscopy
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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with a low-grade fever (38.1°C) and mild nausea. He denies vomiting, diarrhoea, or rectal bleeding. On examination, he has localised tenderness in the left iliac fossa. His vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, SpO2 98% on air. Blood tests show a white cell count of 12.5 x 10^9/L and CRP 45 mg/L. An abdominal CT scan is performed (image provided). Considering the clinical context and the findings demonstrated in the provided image, what is the most appropriate recommendation regarding subsequent investigation of the colon following resolution of the acute symptoms?

A. Barium enema within 3 months.
B. Flexible sigmoidoscopy within 1 week.
C. Urgent colonoscopy within 24 hours.
D. No further colonic investigation is necessary.
E. Colonoscopy within 6-8 weeks.
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 78-year-old male presents to the emergency department with a 2-day history of intermittent upper abdominal pain radiating to the chest and mild dysphagia. He denies shortness of breath or fever. Vital signs are stable. A chest X-ray is obtained. Considering the radiographic findings in the context of the patient's presentation, what is the most appropriate immediate management plan?

A. Admit for observation and serial cardiac enzymes.
B. Perform a bedside echocardiogram to assess cardiac function.
C. Order a contrast-enhanced CT scan of the abdomen and pelvis.
D. Referral for urgent surgical consultation.
E. Initiate high-dose proton pump inhibitor therapy and arrange outpatient follow-up.
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Ultrasonographic picture taken from a patient with left ureteral stone with hydronephrosis, created in Taiwan
Image by morning2k CC BY 2.5 · Source

A 40-year-old male presents with acute, severe left flank pain. An ultrasound is performed. What is the MOST likely underlying cause of the finding on the image?

A. Polycystic kidney disease
B. Renal cell carcinoma
C. Acute pyelonephritis
D. Ureteral obstruction
E. Renal vein thrombosis
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 32-year-old male with a 10-year history of Crohn's disease presents with worsening abdominal pain and diarrhea despite being on maintenance infliximab. He denies fever or blood in his stool. Physical exam reveals mild tenderness in the right lower quadrant. The provided imaging was obtained. What is the MOST appropriate next step in management?

A. Start a course of oral budesonide
B. Initiate treatment with vedolizumab
C. Perform a colonoscopy with biopsy
D. Prescribe a course of oral metronidazole and ciprofloxacin
E. Increase the dose of infliximab
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A 55-year-old man presents to the emergency department with sudden onset severe abdominal pain radiating to the back. He has a history of hypertension and is a smoker. On examination, he is diaphoretic and in distress, with a blood pressure of 90/60 mmHg and a heart rate of 110 bpm. Abdominal examination reveals a pulsatile mass in the midline. What is the most likely diagnosis?

A. Acute myocardial infarction
B. Acute pancreatitis
C. Perforated peptic ulcer
D. Renal colic
E. Ruptured abdominal aortic aneurysm
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Elective abdominal ultrasonography of a 64 year old woman with past colicky pain but no current pain. It shows a mildly dilated common bile duct with what appears to be a gallstone (black arrow). The green and blue dots are blood flow, since the exam is done as a Doppler ultrasound to distinguish the bile duct from blood vessels.
Image by Mikael Häggström CC0 1.0 · Source

A 64-year-old woman presents with a history of colicky pain. An ultrasound was performed. What is the MOST appropriate next step in management?

A. Start a low-fat diet
B. Surgical consultation for cholecystectomy
C. Endoscopic retrograde cholangiopancreatography (ERCP)
D. Administer ursodeoxycholic acid
E. Repeat ultrasound in 6 months
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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 62-year-old male with a history of poorly controlled diabetes presents with fever, RUQ pain, and recent travel to a rural area. Lab results show elevated ALP and GGT. Imaging is performed. What is the MOST appropriate next step in management?

A. Metronidazole
B. Observation and serial imaging
C. Percutaneous drainage and antibiotics
D. Albendazole and surgical resection
E. Ceftriaxone and doxycycline
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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 65-year-old male presents with acute LLQ pain. The provided image was obtained. What dietary advice is most appropriate upon resolution of acute symptoms?

A. Low-residue diet
B. Gluten-free diet
C. Lactose-free diet
D. Elemental diet
E. High-fibre diet
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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 58-year-old male, on chronic immunosuppressants, presents with vague abdominal pain. The images are shown. What is the MOST likely causative organism?

A. Klebsiella pneumoniae
B. Echinococcus multilocularis
C. Escherichia coli
D. Staphylococcus aureus
E. Entamoeba histolytica
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A 3-month-old baby presents with abdominal swelling and constipation. A rectal biopsy shows the absence of ganglion cells. What is the most likely diagnosis?

A. Hirschsprung disease
B. Meconium ileus
C. Intussusception
D. Cystic fibrosis
E. Volvulus
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Elective abdominal ultrasonography of a 64 year old woman with past colicky pain but no current pain. It shows a mildly dilated common bile duct with what appears to be a gallstone (black arrow). The green and blue dots are blood flow, since the exam is done as a Doppler ultrasound to distinguish the bile duct from blood vessels.
Image by Mikael Häggström CC0 1.0 · Source

A 64-year-old woman presents for a routine health check. She reports intermittent episodes of colicky abdominal pain over the past year, but denies any current pain, jaundice, or fever. An abdominal ultrasound is performed, the image is shown. What is the MOST appropriate next step in management?

A. Administer ursodeoxycholic acid
B. Discharge with reassurance
C. Initiate a low-fat diet
D. Referral for elective cholecystectomy
E. Order a HIDA scan
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 50-year-old man with multiple cutaneous lesions presents with recurrent episodes of abdominal pain and iron deficiency anemia. The provided image was obtained. What is the MOST appropriate next step in management?

A. Colonoscopy with polypectomy
B. Initiation of high-dose corticosteroids
C. Surgical resection of the affected bowel segment
D. Observation with serial abdominal exams
E. Empiric treatment for Helicobacter pylori
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset, intermittent, severe abdominal pain, vomiting, and lethargy. Examination reveals a pale child with a soft abdomen. Vitals are stable. An abdominal ultrasound is performed (image provided). What is the most appropriate next step in management?

A. Admission for observation and serial abdominal exams
B. Intravenous antibiotics and fluid resuscitation
C. CT abdomen/pelvis with contrast
D. Pneumatic reduction under fluoroscopy
E. Urgent surgical exploration
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A 72-year-old man with a history of a reducible inguinal hernia presents to the emergency department with severe groin pain and a firm, tender mass in the right inguinal region. He reports that he has been unable to reduce the hernia despite his usual maneuvers. He also reports nausea and vomiting for the past 6 hours. On examination, his vital signs are stable, but he appears uncomfortable. The mass in his groin is erythematous and exquisitely tender to palpation. Which of the following is the most appropriate next step in management?

A. Administration of intravenous antibiotics and observation
B. Surgical exploration
C. CT scan of the abdomen and pelvis with intravenous contrast
D. Attempt manual reduction with sedation and analgesia
E. Ultrasound of the groin to assess blood flow
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Inguinal hernia right view. Adult male with an inguinal hernia, showing bulging in the groin area.
Image by IkeTheSloth CC0 1.0 · Source

A 60-year-old man presents with a 6-month history of intermittent aching discomfort in his right groin, exacerbated by standing and lifting. He reports noticing a bulge in the area, similar to the appearance shown, which usually disappears when he lies down. On examination, the bulge is reducible. Vital signs are normal. Considering the clinical presentation and the image, which anatomical structure is the most likely primary site of the fascial defect?

A. External oblique aponeurosis
B. Femoral canal
C. Superficial inguinal ring
D. Hesselbach's triangle
E. Deep inguinal ring
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