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computed tomography (CT)

Practice targeted AMC-style multiple-choice questions on computed tomography (CT).

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A contrast enhanced CT scan demonstrating an abdominal aortic aneurysm of 4.8 * 3.8 cm
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old male with a history of hypertension and hyperlipidemia presents for a routine follow-up. He is asymptomatic. A contrast-enhanced CT scan of the abdomen was performed as part of a screening protocol. An axial view is shown. What is the MOST appropriate next step?

A. Start aspirin therapy
B. Measure ankle-brachial index
C. Initiate statin therapy
D. Surgical repair
E. Repeat imaging in 6-12 months
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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 68-year-old male presents to the emergency department with a 12-hour history of severe, constant left groin pain. He reports a bulge in his groin that has been present for several years, which he can usually reduce himself. However, today he has been unable to push it back in, and the pain has become excruciating. He denies any fever, nausea, or vomiting. On examination, his vital signs are stable: temperature 37.0°C, heart rate 88 bpm, blood pressure 130/80 mmHg, respiratory rate 16 breaths/min, and oxygen saturation 98% on room air. Abdominal examination is unremarkable. Palpation of the left groin reveals a firm, tender mass that is non-reducible. The overlying skin is erythematous, but there is no crepitus. A CT scan of the abdomen and pelvis is performed, and an axial slice is shown. Given the clinical scenario and the imaging findings, what is the MOST appropriate next step in management?

A. Order a repeat CT scan with intravenous contrast in 6 hours to assess for bowel ischemia
B. Prescribe oral analgesics and instruct the patient to follow up with his general practitioner in 24 hours
C. Surgical consultation for emergent operative intervention
D. Attempt manual reduction with intravenous sedation and analgesia
E. Administer broad-spectrum antibiotics and observe for improvement
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A contrast enhanced CT scan demonstrating an abdominal aortic aneurysm of 4.8 * 3.8 cm
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 68-year-old male presents to the emergency department complaining of new onset left flank pain radiating to his groin. He reports a history of hypertension and hyperlipidemia, both managed with medications. He denies any recent trauma. His vital signs are stable: blood pressure 130/80 mmHg, heart rate 88 bpm, respiratory rate 16 breaths/min, and oxygen saturation 98% on room air. Physical examination reveals mild tenderness to palpation in the left flank, but no guarding or rebound tenderness. Peripheral pulses are normal and symmetric. A contrast-enhanced CT scan of the abdomen and pelvis is performed, the axial view is shown. Given the clinical context and the findings on the image, which of the following is the MOST appropriate next step in management?

A. Referral to vascular surgery for elective repair
B. Order a renal ultrasound to evaluate for hydronephrosis
C. Prescribe analgesics and schedule a repeat CT scan in 6 months
D. Start oral antibiotics for suspected pyelonephritis
E. Initiate intravenous heparin and consult vascular surgery for urgent repair
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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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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 78-year-old male on warfarin for atrial fibrillation presents with sudden onset of severe dyspnoea and right-sided pleuritic chest pain. He denies trauma. On examination, he is tachypnoeic, oxygen saturation is 92% on room air. Blood pressure 110/70 mmHg, heart rate 95 bpm. Chest examination reveals decreased breath sounds on the right. A CT scan of the chest is performed. Considering the patient's clinical presentation, medical history, and the findings demonstrated in the provided image, which of the following pharmacological agents is the most appropriate immediate intervention?

A. Fresh frozen plasma (FFP)
B. Vitamin K
C. Tranexamic acid
D. Prothrombinex (PCC)
E. Recombinant Factor VIIa
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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 man presents to the emergency department with a 3-day history of left lower quadrant abdominal pain, associated with mild fever (38.1°C) and constipation. On examination, he has localised tenderness in the left iliac fossa without guarding or rebound. His blood pressure is 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 bpm. Blood tests show a white cell count of 12.5 x 10^9/L (normal range 4-11). A CT scan of the abdomen and pelvis is performed (image provided). Considering the patient's presentation and the findings demonstrated in the image, which of the following represents the most appropriate initial management strategy?

A. Discharge with advice on a low-residue diet and follow-up in 6 months.
B. Admission for intravenous antibiotics and close observation.
C. Urgent colonoscopy to evaluate the affected segment.
D. Outpatient management with oral antibiotics and analgesia.
E. Urgent surgical consultation for Hartmann's procedure.
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents with increasing shortness of breath and epigastric discomfort, particularly after meals. He has a history of GERD. Physical examination reveals decreased breath sounds at the left lung base. An axial CT image is shown. Considering the clinical presentation and imaging findings, what is the MOST appropriate next step in management?

A. Arrange urgent upper gastrointestinal endoscopy
B. Request a barium swallow study
C. Referral for surgical repair
D. Discharge with advice on lifestyle modification and follow-up
E. Initiate high-dose proton pump inhibitor therapy
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 3-year-old child presents with 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. Based on the findings in the image and the clinical context, which of the following imaging modalities is most likely to provide critical information regarding potential metastatic disease, which is essential for accurate staging and treatment planning in this paediatric patient?

A. Bone scan with Technetium-99m
B. Contrast-enhanced ultrasound of the abdomen
C. PET-CT with 18F-FDG
D. 123I-MIBG scintigraphy
E. Whole-body MRI
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Ovarian Cyst
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 28-year-old female presents with right lower quadrant pain for 3 days. She denies fever, vomiting, or vaginal discharge. Her last menstrual period was 2 weeks ago. The shown CT was performed. What is the MOST likely diagnosis?

A. Endometrioma
B. Corpus luteum cyst
C. Mature cystic teratoma
D. Tubo-ovarian abscess
E. Ovarian torsion
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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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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 2-year-old with a palpable abdominal mass and periorbital ecchymoses has the shown CT. What is the MOST likely diagnosis?

A. Hepatoblastoma
B. Neuroblastoma
C. Rhabdomyosarcoma
D. Lymphoma
E. Wilms tumor
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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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Post-embolization arteriogram showing coiled aneurysm (indicated by yellow arrows) of the posteriorcerebral artery with a residual aneurysmal sac.
Image by Promod Pillai, Aftab Karim, Anil Nanda CC BY 2.0 · Source

A 68-year-old woman with a history of hypertension and hyperlipidemia presents to the emergency department with a sudden onset of left-sided hemianopia and mild right-sided weakness. Her symptoms began approximately 4 hours prior to arrival. Initial neurological examination reveals intact language function and no cognitive deficits. A CT angiogram was performed, followed by endovascular coiling. The provided image shows a post-operative angiogram. Despite the intervention, the patient's hemianopia persists, and her weakness has slightly worsened. What is the MOST appropriate next step in the management of this patient?

A. Administer intravenous thrombolysis with alteplase
B. Prescribe a course of high-dose corticosteroids to reduce cerebral edema
C. Repeat angiography to assess for recanalization or further aneurysm growth
D. Start the patient on nimodipine to prevent vasospasm
E. Initiate dual antiplatelet therapy with aspirin and clopidogrel
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 68-year-old male presents with dysphagia and weight loss. Gastroscopy and biopsy confirm gastric adenocarcinoma. Staging CT imaging is shown. His ECOG performance status is 1. Considering the clinical presentation and the findings demonstrated in the provided images, what is the most appropriate initial management strategy for this patient?

A. Proceed with total gastrectomy and D2 lymphadenectomy
B. Refer for liver transplantation assessment
C. Plan palliative radiotherapy to the gastric primary
D. Initiate systemic chemotherapy
E. Consider transarterial chemoembolisation for hepatic lesions
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 4-year-old presents with abdominal distension and back pain for 2 months. Exam reveals a firm, fixed abdominal mass. Vitals are normal. An abdominal CT is performed (axial view shown). Which lab finding would MOST strongly support the suspected diagnosis?

A. Elevated urine homogentisic acid
B. Elevated urine vanillylmandelic acid (VMA)
C. Elevated serum lactate dehydrogenase (LDH)
D. Elevated serum amylase
E. Elevated serum alpha-fetoprotein (AFP)
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 72-year-old male presents to the ED with sudden onset shortness of breath and right-sided chest pain. He has a history of atrial fibrillation and has been taking warfarin for the past 5 years. His INR is currently 6.0. A CT scan of the chest is performed (image attached). What is the MOST appropriate initial management step?

A. Administer intravenous vitamin K and prothrombin complex concentrate (PCC)
B. Administer intravenous tranexamic acid
C. Administer intravenous protamine sulfate
D. Perform a needle thoracostomy
E. Observe and monitor the patient's respiratory status
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 4-year-old with abdominal pain and hypertension has this CT. What is the MOST appropriate next step in management?

A. Surgical resection
B. Observation with serial imaging
C. Alpha-blockade
D. Radiation therapy
E. Chemotherapy
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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 24 hours of severe right upper quadrant pain, fever, and nausea. Examination reveals RUQ tenderness and a positive Murphy's sign. Vitals: T 38.5°C, HR 105, BP 130/80, RR 18, SpO2 98% RA. Labs: WCC 16, CRP 120, LFTs normal. An urgent abdominal CT is performed. Considering the clinical presentation and the findings on the provided imaging, what is the most appropriate definitive management strategy for this patient?

A. Percutaneous cholecystostomy tube placement.
B. Urgent endoscopic retrograde cholangiopancreatography (ERCP).
C. Intravenous antibiotics and delayed laparoscopic cholecystectomy in 6-8 weeks.
D. Laparoscopic cholecystectomy within 72 hours.
E. Oral antibiotics and analgesia with outpatient surgical referral.
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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 presents for routine surveillance. His AFP is elevated. A CT scan with contrast is performed (image attached). What is the MOST appropriate next step to determine definitive management?

A. Percutaneous ethanol injection
B. Repeat CT scan in 3 months
C. Initiate sorafenib therapy
D. Systemic chemotherapy
E. Referral to hepatology for consideration of liver transplant
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A contrast enhanced CT scan demonstrating an abdominal aortic aneurysm of 4.8 * 3.8 cm
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old man presents to his GP with a 3-month history of intermittent lower back pain, which is worse with activity. He has a history of hypertension, hyperlipidaemia, and is a former smoker. Physical examination reveals normal vital signs and no abdominal tenderness or pulsatile mass. Routine blood tests are normal. An abdominal CT scan is performed as part of the workup. Considering the findings demonstrated in the image, what is the most appropriate next step in the management of this patient?

A. Prescribe analgesia and review in 3 months.
B. Advise no further imaging is necessary.
C. Schedule surveillance ultrasound in 12 months.
D. Refer for urgent vascular surgical consultation.
E. Arrange a repeat CT scan in 6 months.
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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. Considering the clinical presentation and the imaging findings, what is the MOST appropriate next step in the management of this patient?

A. Order a pelvic ultrasound
B. Administer intravenous fluids and observe for symptom resolution
C. Outpatient follow-up with repeat imaging in 6 weeks
D. Laparoscopic surgical exploration
E. Initiate broad-spectrum antibiotics
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 72-year-old patient presents with a 4-month history of tenesmus and occasional bright red rectal bleeding. Colonoscopy was performed, and a representative image is shown. Biopsies confirm adenocarcinoma. Considering the likely stage suggested by the endoscopic appearance, which investigation is MOST crucial for pre-operative staging?

A. PET scan
B. Endorectal ultrasound
C. Repeat colonoscopy to assess proximal colon
D. CT scan of the chest, abdomen, and pelvis
E. Bone scan
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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 bone pain. An abdominal CT is performed (image attached). Which of the following is the MOST appropriate initial investigation to confirm the suspected diagnosis?

A. Urine catecholamine metabolites
B. Liver function tests
C. Bone marrow biopsy
D. Alpha-fetoprotein level
E. Complete blood count
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old male presents with postprandial vomiting and persistent retrosternal discomfort. He reports feeling full quickly after eating only small amounts. An abdominal CT scan is performed, the axial view is shown. What is the MOST likely underlying mechanism contributing to this patient's symptoms?

A. Gastric malignancy
B. Pyloric stenosis
C. Esophageal dysmotility
D. Mechanical obstruction of the gastric outflow
E. Increased gastric acid production
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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 110, BP 130/80, Temp 38.5°C. An abdominal CT scan is performed (image attached). What is the MOST appropriate next step in management?

A. Surgical consultation for cholecystectomy
B. HIDA scan to confirm diagnosis
C. Start intravenous antibiotics and observe
D. ERCP for possible choledocholithiasis
E. Discharge home with oral antibiotics and analgesics
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 4-year-old presents with abdominal distension and back pain for 2 months. Exam reveals a firm, fixed abdominal mass. Vitals are normal. An abdominal CT is performed (axial view shown). Which lab finding would MOST strongly support the suspected diagnosis?

A. Elevated urine vanillylmandelic acid (VMA)
B. Elevated serum lactate dehydrogenase (LDH)
C. Elevated alpha-fetoprotein (AFP)
D. Elevated urine urobilinogen
E. Elevated serum amylase
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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 45-year-old male presents with left flank pain radiating to the groin. Urinalysis shows microscopic hematuria. What is the MOST likely diagnosis based on the image?

A. Polycystic kidney disease
B. Pyelonephritis
C. Glomerulonephritis
D. Ureterolithiasis
E. Renal cell carcinoma
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 72-year-old male presents with a 4-month history of increasing fatigue, anorexia, and a 10 kg weight loss. He reports occasional nausea but no vomiting or abdominal pain. His vital signs are stable. Physical examination reveals mild jaundice and palpable hepatomegaly. Blood tests show Hb 105 g/L, elevated AST/ALT, and a mildly raised bilirubin. An upper endoscopy showed a large gastric mass, with histology pending. A CT scan of the abdomen and pelvis was performed. Considering the clinical context and the findings on the provided imaging, what is the most likely implication for this patient's overall management strategy?

A. Referral for liver transplantation assessment.
B. Planning for curative surgical resection of the primary tumour and liver lesions.
C. Urgent initiation of aggressive systemic chemotherapy with curative intent.
D. Focus on symptom control and quality of life measures.
E. Further investigation with MRI liver to characterise the lesions.
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 62-year-old male with LLQ pain and mild fever has the CT abdomen shown. What is the MOST appropriate next step in management?

A. Colonoscopy to rule out malignancy
B. Oral antibiotics and outpatient follow-up
C. Stool culture to rule out infectious colitis
D. IV antibiotics and admission for observation
E. Surgical consultation for possible resection
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents to the ED with increasing shortness of breath and epigastric discomfort, particularly after meals. He has a history of well-controlled hypertension and takes no regular medications. Physical examination reveals decreased breath sounds at the left lung base. An abdominal CT scan is performed, the axial view is shown. What is the MOST appropriate next step in management?

A. Discharge with reassurance and follow-up with a gastroenterologist in 6 months
B. Barium swallow study to further evaluate the anatomy
C. Surgical consultation for elective repair
D. Initiate a trial of proton pump inhibitors and lifestyle modifications
E. Esophageal manometry to assess esophageal motility
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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 68-year-old male presents to the ED with a painful lump in his groin that has been present for 3 days. He reports nausea but denies vomiting. His vital signs are stable. An abdominal CT is performed, and a slice is shown. What is the MOST appropriate next step in management?

A. Initiate broad-spectrum antibiotics
B. Trial of manual reduction in the ED
C. Administer analgesia and observe for spontaneous resolution
D. Surgical consultation for emergent repair
E. Increase dietary fiber and schedule outpatient follow-up
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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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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 68-year-old male presents with fatigue, weight loss, and vague abdominal discomfort. His past medical history includes a recent diagnosis of gastric mixed adenoneuroendocrine carcinoma (MANEC). A CT scan of the abdomen is performed. Based on the imaging, what is the MOST appropriate next step in management?

A. Surgical resection of the affected liver segments
B. Initiation of palliative care and symptom management
C. Percutaneous radiofrequency ablation of liver lesions
D. Observation with serial imaging in three months
E. Referral to medical oncology for systemic chemotherapy
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 32-year-old male, recent immigrant from a high-TB prevalence country, presents with a persistent cough and night sweats for the past two months. He denies fever or weight loss. Physical examination is unremarkable except for mild scattered rhonchi on auscultation. Sputum cultures are negative for acid-fast bacilli. A PET-CT scan of the chest is performed, the axial view is shown. Given the clinical context and imaging findings, what is the MOST appropriate next step in management?

A. Schedule a follow-up chest X-ray in 6 weeks to monitor for changes
B. Repeat sputum cultures for acid-fast bacilli with liquid media
C. Order a bronchoscopy with transbronchial biopsy of the lesion
D. Initiate a multi-drug anti-tuberculosis therapy regimen
E. Prescribe a course of broad-spectrum antibiotics for presumed bacterial pneumonia
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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 with a history of hepatitis C presents with new onset ascites and right upper quadrant pain. His AFP is elevated. A CT scan of the abdomen with and without contrast is performed, as shown. What is the MOST appropriate next step in management?

A. Start sorafenib therapy
B. Referral for liver transplant evaluation
C. Initiate systemic chemotherapy
D. Perform a percutaneous liver biopsy
E. Order a triple phase MRI of the liver
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Ovarian Cyst
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 32-year-old woman presents to her general practitioner with a 6-month history of worsening dysmenorrhea and pelvic pain, particularly on the left side. She reports no fever, weight loss, or abnormal vaginal bleeding. Her last menstrual period was 2 weeks ago and was normal. Physical examination reveals mild left adnexal tenderness. A CT scan of the pelvis was performed, the relevant image is shown. Given the clinical context and the imaging findings, what is the MOST appropriate next step in management?

A. Refer for diagnostic laparoscopy
B. Prescribe NSAIDs and schedule a follow-up appointment in 3 months
C. Initiate combined oral contraceptive pill
D. Repeat pelvic ultrasound in 6-12 weeks
E. Order serum CA-125 levels
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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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Ovarian Cyst
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 28-year-old female presents with sudden onset severe right lower quadrant pain, associated with nausea and one episode of vomiting. Her last menstrual period was 6 weeks ago. On examination, she is afebrile, heart rate 88, blood pressure 120/70. Abdominal examination reveals tenderness in the right iliac fossa. A CT scan of the abdomen and pelvis is performed, with a relevant axial image shown. Considering the clinical presentation and the findings demonstrated in the image, what is the MOST appropriate immediate next step in the management of this patient?

A. Perform a diagnostic laparoscopy to confirm appendicitis
B. Order a pelvic ultrasound for further characterisation
C. Arrange for outpatient follow-up with gynaecology
D. Laparoscopic surgical exploration
E. Administer broad-spectrum antibiotics
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 65-year-old presents with 2 days of left lower quadrant pain, fever (38.5°C), and nausea. On examination, there is localised tenderness in the LLQ. Vitals: BP 130/80, HR 90, RR 16, SpO2 98%. CRP is 150 mg/L, WCC 18 x 10^9/L. This image is obtained as part of the workup. Considering the clinical context and the findings on the image, which of the following represents the most appropriate initial management strategy?

A. Colonoscopy to assess the severity
B. Inpatient management with intravenous antibiotics
C. Percutaneous drainage of the collection
D. Urgent surgical consultation for laparotomy
E. Outpatient oral antibiotics and clear fluid diet
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 62-year-old male presents with acute onset of LLQ pain, fever, and vomiting. His WBC count is elevated. A CT scan of the abdomen and pelvis is performed. Based on the image, what is the most appropriate next step in management?

A. Flexible sigmoidoscopy
B. IV antibiotics and bowel rest
C. Stool softeners
D. Surgical resection
E. High-fiber diet
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 35-year-old male presents with hemoptysis and weight loss. PET-CT is shown. Bronchoscopy with biopsy is MOST likely to reveal which of the following?

A. Adenocarcinoma in situ
B. Squamous cell carcinoma
C. Granulomatous inflammation with caseous necrosis
D. Small cell carcinoma
E. Mesothelioma
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 55-year-old male presents with LLQ pain, fever, and increased WBC. A CT scan is performed, as shown. He is hemodynamically stable. What is the MOST appropriate initial management?

A. IV antibiotics and bowel rest
B. High-fiber diet and increased fluid intake
C. Surgical resection
D. Flexible sigmoidoscopy
E. Oral antibiotics and outpatient follow-up
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 65-year-old male presents with a 3-month history of unintentional weight loss and epigastric discomfort. Endoscopy revealed a gastric mass, and biopsy confirmed a mixed adenoneuroendocrine carcinoma. Staging imaging is shown. His ECOG performance status is 1. Considering the clinical presentation and the findings demonstrated in the provided images, what is the most appropriate initial management strategy for this patient?

A. Refer for surgical assessment for hepatic metastasectomy
B. Evaluate for potential liver transplantation
C. Plan for palliative external beam radiotherapy to the liver
D. Initiate systemic chemotherapy targeting the adenocarcinoma component
E. Commence treatment with a long-acting somatostatin analogue
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A 65-year-old patient with a history of DVT presents with sudden onset dyspnoea and pleuritic chest pain. Examination is unremarkable except for mild tachypnoea. Wells score is 4. Which initial investigation is most appropriate in the diagnostic pathway?

A. D-dimer
B. Lower limb ultrasound
C. V/Q scan
D. CT Pulmonary Angiogram (CTPA)
E. Chest X-ray
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 68-year-old male presents to the ED with left lower quadrant abdominal pain, fever, and leukocytosis. A CT scan of the abdomen and pelvis is performed. Based on the image, what is the most appropriate next step in management?

A. Increase dietary fiber intake
B. Surgical resection of the affected bowel segment
C. Flexible sigmoidoscopy
D. IV antibiotics and bowel rest
E. Stool culture for C. difficile
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A contrast enhanced CT scan demonstrating an abdominal aortic aneurysm of 4.8 * 3.8 cm
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 68-year-old male presents for a routine check-up. He has a history of smoking and hypertension, well-controlled with medication. He denies any abdominal pain, back pain, or lower extremity claudication. Physical exam is unremarkable. A contrast-enhanced CT scan of the abdomen is performed, the axial view is shown. What is the MOST appropriate next step in management?

A. Referral for immediate surgical repair
B. Repeat imaging in 6-12 months
C. Start aspirin for secondary prevention
D. Initiate beta-blocker therapy
E. Prescribe a statin for lipid management
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 72-year-old male presents to the ED with sudden onset shortness of breath and right-sided chest pain. He has a history of atrial fibrillation and has been taking warfarin for the past 5 years. His INR is currently 6.5. A CT scan of the chest is performed (image attached). What is the MOST appropriate immediate next step in the management of this patient?

A. Insert an intercostal chest drain
B. Administer intravenous vitamin K and prothrombin complex concentrate (PCC)
C. Perform a diagnostic thoracentesis
D. Observe and repeat INR in 6 hours
E. Administer intravenous protamine sulfate
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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 patient with a long history of recurrent gastrointestinal bleeding and multiple cutaneous vascular lesions presents with acute onset severe abdominal pain, nausea, and distension. Physical examination reveals a distended, mildly tender abdomen. Bowel sounds are reduced. Vital signs are stable. Imaging is performed. Considering the patient's presentation and the findings demonstrated in the image, which of the following represents the most appropriate initial management approach?

A. Urgent upper and lower endoscopy to identify bleeding source.
B. Initiation of systemic medical therapy targeting vascular malformations.
C. Further imaging with mesenteric angiography.
D. Laparotomy for reduction or resection of affected bowel segments.
E. Non-operative management with nasogastric tube decompression and intravenous fluids.
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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 68-year-old male presents to the emergency department with a 12-hour history of severe, constant left groin pain. He reports a bulge in his groin that has been present for several years, which he can usually reduce himself. However, today he has been unable to push it back in, and the pain has become excruciating. He denies any fever, nausea, or vomiting. On examination, his vital signs are stable: temperature 37.0°C, heart rate 88 bpm, blood pressure 130/80 mmHg, respiratory rate 16 breaths/min, and oxygen saturation 98% on room air. Abdominal examination is unremarkable. Palpation of the left groin reveals a firm, tender mass that is non-reducible. The overlying skin is erythematous, but there is no crepitus. A CT scan of the abdomen and pelvis is performed, and an axial slice is shown. Considering the clinical presentation and the findings demonstrated in the image, what is the MOST appropriate next step in management?

A. Attempt manual reduction of the mass under conscious sedation
B. Order an urgent ultrasound of the groin to assess for vascular compromise
C. Administer intravenous fluids and analgesia, then observe for signs of spontaneous reduction over 24 hours
D. Urgent surgical consultation for operative management
E. Prescribe oral antibiotics and arrange for outpatient surgical review within one week
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents to his GP with a 6-month history of intermittent postprandial fullness and mild dysphagia, particularly with solid foods. He reports occasional regurgitation but denies significant heartburn or chest pain. His vital signs are stable, and physical examination is unremarkable. Recent blood tests show mild iron deficiency anaemia. The provided image is from a CT scan of the chest and upper abdomen performed as part of his investigation. Considering the clinical presentation and the significant anatomical finding demonstrated in the image, what is the most appropriate next step in the management of this patient?

A. Urgent upper gastrointestinal endoscopy to assess for malignancy.
B. Initiation of high-dose proton pump inhibitor therapy.
C. Prescription of iron supplements and dietary advice.
D. Barium swallow study to further characterise the anatomy.
E. Referral for surgical assessment and consideration of operative repair.
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