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elderly patient

Practice targeted AMC-style multiple-choice questions on elderly patient.

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An old man presents with 6 months of memory decline, falls, visual hallucinations, agitation, and confusion. Which of the following features is relevant to diagnosing his condition?

A. Parkinsonian features
B. Normal CSF markers for amyloid and tau.
C. Cerebellar signs
D. Significant early memory impairment.
E. Absence of motor symptoms.
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An 80-year-old woman is brought to the emergency department from a nursing home due to increased lethargy and confusion over the past 24 hours. Her history includes dementia, hypertension, and type 2 diabetes. Nursing staff report poor oral intake for 48 hours and a recent cough. On examination, she is drowsy but rousable. Her vital signs are: BP 85/50 mmHg, HR 110 bpm, RR 22 breaths/min, Temp 37.8°C, SpO2 94% on air. Capillary refill time is 4 seconds. Chest auscultation reveals decreased breath sounds at the bases. Abdomen is soft. Urine dipstick shows leukocytes and nitrites. She is on lisinopril and metformin. What is the most appropriate initial management step?

A. Administer intravenous fluid bolus (e.g., 500 mL crystalloid)
B. Administer oral rehydration solution
C. Obtain a chest X-ray and urine culture
D. Discontinue lisinopril and monitor blood pressure
E. Administer broad-spectrum intravenous antibiotics
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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 70-year-old male presents to his general practitioner complaining of mild, chronic lower back pain that has been present for several months. He describes the pain as a dull ache, worse with prolonged standing. He has a significant past medical history including hypertension, hyperlipidemia, and a 50-pack-year smoking history, all of which are currently managed with medications. He denies any acute abdominal pain, pulsatile sensation, or leg symptoms. On physical examination, his vital signs are stable: blood pressure 135/85 mmHg, heart rate 72 bpm, respiratory rate 14 breaths/min, and oxygen saturation 99% on room air. Abdominal examination is soft, non-tender, with no palpable masses. Peripheral pulses are symmetric and strong. As part of the investigation into his chronic back pain, a contrast-enhanced CT scan of the abdomen and pelvis is performed. An axial view from the scan is shown. Based on the clinical presentation and the findings demonstrated in the provided image, which of the following is the MOST appropriate next step in management?

A. Refer urgently to a vascular surgeon for consideration of immediate endovascular repair.
B. Initiate a program of regular surveillance imaging with ultrasound and aggressively manage cardiovascular risk factors.
C. Reassure the patient that the finding is incidental and benign, and focus solely on managing his chronic back pain.
D. Arrange for immediate admission to hospital for observation and further investigation.
E. Schedule a repeat CT scan with contrast within 3 months to assess for rapid expansion.
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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino CC BY-SA 2.0 · Source

A 72-year-old woman presents with a 6-month history of a non-healing rash on her chest wall at the site of a previous mastectomy performed 10 years prior for invasive ductal carcinoma. She completed adjuvant chemotherapy and radiation. Examination reveals the findings shown. What is the MOST appropriate next step in management?

A. Skin biopsy of the affected area
B. Empiric antibiotic therapy
C. Reassurance and observation
D. Referral for wide local excision
E. Topical corticosteroid application
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A 65-year-old man with a 20-year history of poorly controlled type 2 diabetes mellitus, hypertension, and dyslipidaemia presents with a 6-month history of burning pain in his feet, worse at night, often waking him from sleep. He also reports feeling lightheaded when standing up quickly and has noticed difficulty initiating urination and a weak stream. On examination, his blood pressure is 135/85 mmHg supine and 115/70 mmHg after standing for 3 minutes. Neurological examination reveals decreased sensation to pinprick and light touch in a stocking distribution up to the mid-calf bilaterally. Vibration sense is reduced at the ankles. Ankle reflexes are absent. The remainder of the examination is unremarkable. His most recent HbA1c is 8.9%. Which of the following is the most likely underlying cause of his constellation of symptoms?

A. Diabetic sensorimotor polyneuropathy with autonomic involvement
B. Charcot joint arthropathy
C. Peripheral arterial disease
D. Vitamin B12 deficiency
E. Lumbar spinal stenosis
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A 70-year-old woman with a history of diabetes presents with fever, cough, and weight loss. A chest X-ray shows a cavitary lesion in the right upper lobe. What is the most likely diagnosis?

A. Sarcoidosis
B. Lung cancer
C. Tuberculosis
D. Lung abscess
E. Pneumocystis pneumonia
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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 63-year-old woman with a 20-year history of Crohn's disease presents with a one-month history of worsening abdominal pain, bloating, and occasional vomiting, associated with a 3kg weight loss. She is currently managed with mesalazine and azathioprine. Her vital signs are stable, and physical examination reveals mild right lower quadrant tenderness. Imaging is performed. Considering the clinical presentation and the provided images, which of the following represents the most appropriate next step in this patient's management?

A. Provide symptomatic relief and arrange follow-up in the outpatient clinic.
B. Surgical consultation for assessment of operative management.
C. Repeat cross-sectional imaging in three months to monitor disease progression.
D. Perform a colonoscopy to assess disease activity and extent.
E. Initiate a course of oral corticosteroids and optimise immunosuppression.
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CT, ultrasonography, SPECT and scintigraphy of intra-thyroid parathyroid adenoma
Image by Mnahi Bin Saeedan, Ibtisam Musallam Aljohani, Ayman Omar Khushaim, Salwa Qasim Bukhari, Salahudin Tayeb Elnaas CC BY 4.0 · Source

A 62-year-old woman presents with fatigue, bone pain, and constipation. Laboratory tests reveal serum calcium 3.1 mmol/L, PTH 180 pg/mL, and elevated 24-hour urine calcium. Imaging studies are shown. Considering the clinical presentation and investigation findings, what is the MOST appropriate next step in the management of this patient?

A. Further imaging with MRI of the neck
B. Surgical parathyroidectomy
C. Long-term observation with serial calcium and PTH measurements
D. Initiation of medical therapy with cinacalcet
E. Commencement of intravenous bisphosphonate therapy
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 68-year-old male with known Hepatitis B related cirrhosis and a history of alcohol excess presents for routine surveillance. His alpha-fetoprotein (AFP) level, which has been stable at 15 ng/mL for the past two years, is now noted to be 185 ng/mL. A screening ultrasound performed three months prior was reported as showing diffuse parenchymal changes consistent with cirrhosis but no focal lesions. Due to the elevated AFP, a repeat ultrasound was performed, which identified a 2.5 cm nodule in segment VIII. To further characterise this lesion, a contrast-enhanced ultrasound (CEUS) was performed, and the images provided are representative findings from this study. The patient has well-compensated cirrhosis (Child-Pugh A) and no significant comorbidities. His liver function tests are within normal limits except for a slightly elevated GGT. Given the clinical context and the findings demonstrated in the provided images, what is the most appropriate next step in the management of this patient?

A. Referral to a multidisciplinary liver tumour board for consideration of curative treatment options.
B. Proceed directly to percutaneous biopsy of the lesion for histological confirmation.
C. Refer the patient to a general gastroenterologist for further investigation.
D. Initiate systemic therapy with a tyrosine kinase inhibitor such as sorafenib.
E. Schedule a repeat contrast-enhanced ultrasound in three months to assess for interval change.
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CT, ultrasonography, SPECT and scintigraphy of intra-thyroid parathyroid adenoma
Image by Mnahi Bin Saeedan, Ibtisam Musallam Aljohani, Ayman Omar Khushaim, Salwa Qasim Bukhari, Salahudin Tayeb Elnaas CC BY 4.0 · Source

A 62-year-old woman with osteoporosis and a history of kidney stones presents with a serum calcium of 2.9 mmol/L (2.1-2.6 mmol/L) and PTH of 120 pg/mL (10-65 pg/mL). She denies neck pain or swelling. The provided imaging was obtained. What is the MOST appropriate next step?

A. Cinacalcet to lower PTH levels
B. Vitamin D and calcium supplementation
C. Surgical excision of the identified lesion
D. Bisphosphonate therapy and observation
E. Thyroidectomy
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A 68-year-old woman with a history of hypertension and heart failure is admitted to the hospital with increasing shortness of breath and peripheral edema. She is currently taking furosemide 40mg daily. Her blood tests reveal the following: Na+ 130 mmol/L (135-145 mmol/L), K+ 3.1 mmol/L (3.5-5.0 mmol/L), Cl- 95 mmol/L (98-107 mmol/L), HCO3- 32 mmol/L (22-29 mmol/L). What is the most appropriate initial management?

A. Administer intravenous normal saline and continue furosemide at the same dose.
B. Administer an ACE inhibitor and monitor sodium levels.
C. Administer intravenous sodium bicarbonate and increase the dose of furosemide.
D. Hold furosemide, administer intravenous potassium chloride, and restrict free water intake.
E. Administer intravenous calcium gluconate and monitor potassium levels.
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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 presents to the ED after a fall. He complains of dyspnea and right-sided chest pain. His INR is 5.0. Vitals: HR 110, BP 100/60, RR 28, SpO2 90% on room air. The provided image was obtained. What is the MOST appropriate next step?

A. Administer IV protamine sulfate
B. Tube thoracostomy
C. Administer IV vitamin K
D. Administer IV tranexamic acid
E. Observation with serial chest X-rays
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A 68-year-old man with a history of severe chronic obstructive pulmonary disease (COPD) and known secondary pulmonary hypertension presents with increasing dyspnoea and peripheral oedema. His arterial blood gas on room air shows pH 7.31, PaCO2 68 mmHg, PaO2 48 mmHg, and SaO2 80%. His chest X-ray shows hyperinflation and prominent pulmonary arteries. Which of the following interventions is most likely to acutely decrease his pulmonary vascular resistance?

A. Application of positive pressure ventilation with high PEEP
B. Administration of inhaled bronchodilators
C. Administration of supplemental oxygen
D. Initiation of intravenous diuretic therapy
E. Aggressive intravenous fluid resuscitation
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A 65-year-old lady weighing 70 kg has an enlarging papule on her right neck, measuring 8 mm, raised with a keratotic horn. A keratinocytic tumor is suspected. What is the maximum safe dose of 1% lidocaine with adrenaline for local anesthesia in this patient?

A. 490 mg
B. e/ 1000 mg
C. 140 mg
D. 70 mg
E. 210 mg
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A 70-year-old male presents to the emergency department with severe abdominal and back pain. He has a history of hypertension and smoking. On examination, he is hypotensive and tachycardic. Palpation reveals a pulsatile abdominal mass. What is the most likely diagnosis?

A. Ruptured abdominal aortic aneurysm
B. Renal colic
C. Acute pancreatitis
D. Myocardial infarction
E. Diverticulitis
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CT, ultrasonography, SPECT and scintigraphy of intra-thyroid parathyroid adenoma
Image by Mnahi Bin Saeedan, Ibtisam Musallam Aljohani, Ayman Omar Khushaim, Salwa Qasim Bukhari, Salahudin Tayeb Elnaas CC BY 4.0 · Source

A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?

A. Surgical excision of the identified lesion
B. Vitamin D supplementation
C. Cinacalcet administration
D. Initiation of bisphosphonate therapy
E. Observation with serial calcium and PTH monitoring
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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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A 62-year-old woman presents with tiredness and is found to have B12 deficiency. What is the likely associated condition?

A. Pernicious anemia
B. Recent viral infection
C. Sulphonylurea use
D. Low vegetable, high meat diet.
E. Iron deficiency anemia
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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, managed with lisinopril. 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. Order a D-dimer to rule out acute aortic dissection
B. Referral to vascular surgery for elective repair
C. Initiate beta-blocker therapy to reduce wall stress
D. Repeat imaging in 6-12 months to monitor growth
E. Prescribe a statin to stabilize atherosclerotic plaques
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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 65-year-old male presents with groin pain and vomiting. The provided image was taken. What is the most appropriate next step in management?

A. Discharge with stool softeners
B. Administer intravenous antibiotics
C. Apply ice packs to the groin
D. Start a clear liquid diet
E. Surgical consultation for possible bowel resection
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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. Based on the clinical presentation and imaging findings, what is the most appropriate initial management step?

A. Admission for intravenous antibiotics and observation.
B. Outpatient oral antibiotics and pain relief.
C. Elective colonoscopy in 6-8 weeks.
D. Percutaneous drainage of any fluid collection.
E. Urgent surgical consultation for laparotomy.
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old male presents with vomiting and abdominal pain. An abdominal X-ray is performed. What is the MOST likely underlying cause?

A. Appendicitis
B. Diverticulitis
C. Volvulus
D. Adhesions from prior surgery
E. Pancreatitis
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An 80-year-old presents with cough, fever, and new confusion. Vital signs: T 38.5°C, HR 110, BP 100/60, RR 28, SpO2 90% on air. Chest X-ray shows consolidation. What is the most appropriate initial management step?

A. Oral antibiotics and outpatient management
B. Chest CT scan
C. Bronchoscopy
D. Sputum culture and sensitivity testing
E. Intravenous antibiotics and hospital admission
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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 presented 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 revealed a left homonymous hemianopia, mild right hemiparesis (4/5 strength), and intact sensation. A CT angiogram was performed, identifying a cerebral aneurysm, and the patient subsequently underwent endovascular coiling. The provided image was obtained immediately following the procedure. Despite the intervention, the patient's left homonymous hemianopia persists, and her right hemiparesis has not improved. Considering the findings on the post-procedure imaging in the context of her ongoing neurological deficits, which of the following is the MOST appropriate immediate management step?

A. Administer intravenous thrombolysis given the persistent neurological deficits.
B. Perform an urgent brain MRI with diffusion-weighted imaging to assess for extent of infarction.
C. Initiate or optimise dual antiplatelet therapy to mitigate the risk of thromboembolism from the residual sac.
D. Continue current medical management and arrange for routine outpatient follow-up angiography in 3-6 months.
E. Arrange for urgent repeat endovascular coiling of the aneurysm to achieve complete occlusion.
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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 man presents with a 3-month history of progressive dysphagia, early satiety, and unintentional weight loss of 8 kg. He has a background of well-controlled hypertension. Physical examination reveals mild epigastric tenderness. Initial blood tests show a normocytic anaemia. An urgent upper endoscopy identified a large, ulcerated mass in the gastric body, and biopsies were taken. A staging CT scan of the abdomen and pelvis was subsequently performed. Considering the clinical presentation and the findings demonstrated in the provided imaging, which of the following statements best reflects the likely prognosis and primary management strategy for this patient?

A. Curative surgical resection of the gastric mass is the priority, followed by adjuvant chemotherapy.
B. The findings suggest a benign process, and symptomatic management is sufficient.
C. Liver transplantation should be considered given the extent of hepatic involvement.
D. The disease is likely incurable, and management will primarily focus on systemic therapy and palliative care.
E. Further investigation with a PET-CT scan is mandatory before determining the management plan.
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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 male presents to his general practitioner with a 3-month history of progressively worsening constipation alternating with episodes of loose stools, associated with occasional bright red blood per rectum and an unintentional weight loss of 4 kilograms over the same period. He denies any significant past medical history or family history of bowel disease. His vital signs are stable, and physical examination, including abdominal palpation and digital rectal examination, is unremarkable. Routine blood investigations reveal a haemoglobin of 105 g/L with a mean corpuscular volume of 78 fL, and normal inflammatory markers. Given the clinical presentation, a colonoscopy is performed. The image provided is a representative view obtained during this procedure. Based on the findings demonstrated in the image, what is the most appropriate immediate next step in the management of this patient?

A. Refer for urgent surgical resection without further investigation.
B. Obtain biopsies from the lesion and arrange for CT staging of the chest, abdomen, and pelvis.
C. Initiate a course of broad-spectrum antibiotics for presumed infectious colitis.
D. Schedule a repeat colonoscopy in 6 months to monitor the lesion's progression.
E. Prescribe a high-fibre diet and laxatives to manage the constipation.
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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 acute severe dyspnoea and right-sided pleuritic chest pain. Vitals: T 36.8°C, HR 95, BP 110/70, RR 24, SpO2 92% RA. Exam: decreased breath sounds, dullness right hemithorax. A CT scan of the chest is performed. Considering the patient's presentation, history, and the imaging findings, which is the most appropriate immediate management?

A. Arrange for urgent bronchoscopy to rule out airway obstruction
B. Observe the patient closely in the intensive care unit without specific intervention
C. Increase the dose of warfarin and monitor INR
D. Administer broad-spectrum antibiotics and arrange for thoracentesis
E. Administer Vitamin K and Prothrombinex (PCC) and arrange for chest tube insertion
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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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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

Mr. Arthur Jenkins, a 72-year-old retired accountant, presents to his GP complaining of a change in bowel habit over the past 4 months, now experiencing increased frequency and occasional loose stools mixed with some mucus. He also reports intermittent small amounts of bright red blood on the toilet paper, which he initially attributed to haemorrhoids. He denies significant weight loss or abdominal pain. His past medical history includes hypertension well-controlled on medication and osteoarthritis. On examination, his abdomen is soft and non-tender, and digital rectal examination is unremarkable. Routine blood tests, including FBE and LFTs, are within normal limits. A faecal occult blood test is positive. Given these findings, a colonoscopy is arranged. The image provided was captured during the procedure. Considering the patient's presentation and the findings observed during the colonoscopy as depicted in the image, what is the most appropriate immediate next step in the management plan?

A. Attempt endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of the lesion.
B. Advise the patient on dietary modifications to increase fibre intake and schedule a follow-up appointment in 3 months.
C. Prescribe a course of antibiotics for presumed infectious colitis and repeat colonoscopy in 6 weeks.
D. Refer the patient directly for urgent surgical consultation for a potential sigmoid colectomy.
E. Obtain multiple biopsies from the lesion for histological examination and arrange for CT staging of the chest, abdomen, and pelvis.
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A 65-year-old man with a history of type 2 diabetes mellitus and hypertension presents with exertional dyspnea and fatigue. His physical examination reveals a blood pressure of 150/90 mmHg, a heart rate of 88 bpm, and a soft S4 gallop. There is no peripheral edema. An electrocardiogram shows left ventricular hypertrophy with repolarization abnormalities. Which of the following diagnostic tests would be most appropriate to evaluate for underlying coronary artery disease in this patient?

A. Coronary angiography
B. Cardiac MRI
C. 24-hour Holter monitoring
D. Transthoracic echocardiography without stress
E. Exercise stress echocardiography
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 75-year-old female presents to the emergency department with a 24-hour history of worsening colicky abdominal pain, nausea, and multiple episodes of bilious vomiting. She reports no passage of flatus or stool for the past 18 hours. Her past medical history includes an open appendectomy 30 years ago and a hysterectomy 10 years ago. On examination, she is afebrile, heart rate 92 bpm, blood pressure 130/80 mmHg, respiratory rate 18/min, oxygen saturation 98% on room air. Her abdomen is distended and diffusely tender to palpation, with high-pitched tinkling bowel sounds on auscultation. A plain abdominal X-ray series, including the image provided, was obtained. Considering the patient's clinical presentation and the findings demonstrated in the provided image, which of the following represents the most appropriate immediate next step in her management?

A. Administer a large volume enema
B. Administer broad-spectrum intravenous antibiotics
C. Order a CT scan of the abdomen and pelvis with intravenous contrast
D. Proceed directly to exploratory laparotomy
E. Insert a nasogastric tube for decompression
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CT, ultrasonography, SPECT and scintigraphy of intra-thyroid parathyroid adenoma
Image by Mnahi Bin Saeedan, Ibtisam Musallam Aljohani, Ayman Omar Khushaim, Salwa Qasim Bukhari, Salahudin Tayeb Elnaas CC BY 4.0 · Source

A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history. Her vital signs are stable. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?

A. Initiate medical management with cinacalcet
B. Repeat serum calcium and PTH in 3 months
C. Order a bone mineral density scan
D. Surgical parathyroidectomy
E. Refer for genetic testing for multiple endocrine neoplasia
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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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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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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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Clinical aspects of mammary Paget's disease occurred on the thoracic wall where simple mastectomy was performed some years before.
Image by Monica Giovannini, Carmelo D'Atri, Quirino Piubello, Annamaria Molino CC BY-SA 2.0 · Source

A 62-year-old woman presents for a routine follow-up appointment several years after undergoing a simple mastectomy for pT1N0M0 invasive ductal carcinoma of the left breast. She completed adjuvant endocrine therapy and has been well since. During the consultation, she mentions that she has noticed a persistent area of skin change on her left chest wall, near the mastectomy scar, over the past few months. She describes it as occasionally itchy and slightly raised, but denies pain, discharge, or systemic symptoms such as weight loss or fever. Her vital signs are stable, and physical examination reveals no palpable axillary or supraclavicular lymphadenopathy. The appearance of the affected area is shown in the image. Considering the patient's history and the clinical presentation, what is the most appropriate initial diagnostic step?

A. Arrange for a PET-CT scan to assess for metastatic disease
B. Perform fine needle aspiration cytology of the lesion
C. Prescribe a course of topical antifungal cream and review in two weeks
D. Excisional or incisional biopsy of the lesion
E. Reassure the patient that this is likely post-surgical scarring and review in six months
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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 woman presents with iron deficiency anaemia and a 4-month history of intermittent lower abdominal pain and tenesmus. Colonoscopy was performed, and the image shows a finding in the sigmoid colon. Biopsies are pending but highly suspicious for malignancy. What is the MOST appropriate initial staging investigation?

A. CT scan of chest, abdomen, and pelvis
B. Endoscopic ultrasound
C. PET scan
D. MRI pelvis
E. Bone scan
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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 with recently diagnosed gastric mixed adenoneuroendocrine carcinoma presents with unintentional weight loss. Endoscopy confirmed the diagnosis. Staging imaging is provided. His ECOG performance status is 1. Considering the extent of disease demonstrated, which of the following represents the most appropriate initial therapeutic approach?

A. Gastrectomy with D2 lymphadenectomy
B. Observation with regular imaging surveillance
C. Palliative radiotherapy to the gastric primary
D. Liver resection of dominant lesions
E. Systemic chemotherapy or targeted therapy
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 68-year-old patient presents with chronic intermittent upper abdominal discomfort, postprandial fullness, and occasional regurgitation. Physical examination is unremarkable. A chest radiograph is performed as part of the workup. Considering the radiographic findings in the context of the patient's presentation, what is the most appropriate next step in management?

A. Initiate a trial of high-dose proton pump inhibitor therapy.
B. Advise dietary modifications and schedule follow-up in 3 months.
C. Referral for upper gastrointestinal endoscopy.
D. Arrange urgent surgical consultation for repair.
E. Request a barium swallow study to assess anatomy.
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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 with a history of multiple abdominal surgeries presents to the emergency department complaining of abdominal pain, distension, and obstipation for the past 3 days. 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 radiographic findings, which demonstrate significant intraluminal gas accumulation proximal to the likely site of obstruction, what is the predominant source of this gas?

A. Diffusion from blood
B. Swallowed atmospheric air
C. Pancreatic enzyme activity
D. Biliary secretion
E. Bacterial fermentation
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A 72-year-old man with fatigue, a past myocardial infarction at age 55, breathlessness on stairs, and ankle marks has an LVEF < 40% on echocardiogram. Which of the following medications is known to improve outcomes in Heart Failure with Reduced Ejection Fraction (HFrEF)?

A. Digoxin
B. Verapamil
C. Frusemide
D. Amlodipine
E. Eplerenone
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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 65-year-old male presents with 2 days of constant right upper quadrant pain radiating to the back, associated with nausea and subjective fever. On examination, he is febrile (38.5°C) with significant tenderness and a positive Murphy's sign in the right upper quadrant. His white cell count is elevated at 15 x 10^9/L, and CRP is 120 mg/L. Liver function tests are within normal limits. Considering the clinical presentation and the provided imaging, what is the most appropriate timing for definitive surgical management?

A. Within 72 hours of admission
B. Only if symptoms fail to resolve with antibiotics
C. Following a trial of percutaneous drainage
D. Urgently, within 6 hours
E. After 6-8 weeks of medical management
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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 65-year-old male with known cirrhosis secondary to chronic hepatitis B presents with increasing abdominal distension and fatigue. He has mild ascites. Liver function tests show bilirubin 35 umol/L, INR 1.3, albumin 30 g/L. AFP is 850 ng/mL. Imaging is performed as shown. Based on the imaging findings and clinical presentation, which of the following treatment modalities is MOST likely to be considered for this patient?

A. Initiation of systemic targeted therapy
B. Referral for liver transplantation assessment
C. Percutaneous radiofrequency ablation
D. Transarterial chemoembolisation
E. Surgical resection
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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 with a history of hypertension and smoking presents to his GP with mild, intermittent abdominal discomfort. His vital signs are stable, and abdominal examination is soft and non-tender. As part of the workup, a contrast-enhanced CT scan of the abdomen and pelvis is performed. The provided image is an axial view from this study. Based on the clinical context and the findings in the provided image, what is the most appropriate next step in this patient's management?

A. Referral for urgent endovascular repair planning
B. No further action is required at this time
C. Referral to a vascular surgeon for ongoing surveillance
D. Urgent surgical consultation for immediate repair
E. Repeat CT scan in 3 months to assess for growth
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A 70-year-old man with a history of hypertension and heart failure is being managed with an ACE inhibitor. He presents to the emergency department complaining of dizziness, especially when standing up. His blood pressure is 90/60 mmHg, and his other vital signs are stable. Which of the following is the most appropriate initial step in managing this patient?

A. Order an ECG to rule out cardiac arrhythmia
B. Prescribe compression stockings
C. Review and potentially reduce the dose of the ACE inhibitor
D. Administer an intravenous bolus of normal saline
E. Start fludrocortisone
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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 70-year-old male with a history of smoking presents for a routine check-up. The image is taken. What is the recommended surveillance interval?

A. No further imaging required
B. Initiate statin therapy and monitor annually
C. Repeat imaging in 6-12 months
D. Immediate surgical consultation
E. Repeat imaging in 3 years
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

A 68-year-old female presents with right leg pain and skin changes after starting warfarin for atrial fibrillation 5 days ago. Her INR is currently 3.5. Examination reveals the findings in the image. What is the MOST appropriate next step in management?

A. Increase the dose of warfarin to achieve a higher INR
B. Start intravenous heparin and continue warfarin
C. Apply compression bandages and elevate the leg
D. Continue warfarin at the same dose and apply topical corticosteroids
E. Stop warfarin, administer vitamin K and start a direct oral anticoagulant
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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

An asymptomatic 70-year-old male undergoes a CT scan of the abdomen as part of an investigation for mild, intermittent lower back pain. His vital signs are stable, and physical examination is unremarkable. Considering the findings on the provided image, what is the most appropriate next step in this patient's management?

A. No further imaging required; manage back pain symptomatically.
B. Annual abdominal ultrasound surveillance.
C. Urgent referral for vascular surgical assessment.
D. Referral for a follow-up CT angiogram in 2 years.
E. Repeat CT scan in 6 months.
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 68-year-old man presents to his GP with a 4-month history of increasing constipation alternating with loose stools, occasional rectal bleeding, and a feeling of incomplete evacuation. He reports fatigue but denies significant weight loss. His physical examination, including digital rectal examination, is normal. Full blood count shows a haemoglobin of 115 g/L with low ferritin. A colonoscopy is performed, and the image provided is a representative view from the procedure. Considering the clinical presentation and the finding observed during the colonoscopy, what is the most appropriate immediate next step in the management of this patient?

A. Obtain biopsies from the lesion for histological assessment and arrange for staging investigations.
B. Schedule a repeat colonoscopy in 6 months to assess for changes in the appearance of the lesion.
C. Prescribe a course of oral corticosteroids for presumed inflammatory bowel disease.
D. Recommend dietary modification and bulk-forming laxatives to manage the change in bowel habit.
E. Refer the patient directly for urgent surgical consultation and resection planning.
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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 on warfarin presents with sudden onset dyspnea. His INR is 6.0. The provided image was obtained. What is the MOST appropriate next step?

A. Administer IV vitamin K and prothrombin complex concentrate
B. Observe and repeat imaging in 24 hours
C. Perform needle thoracostomy
D. Administer IV protamine sulfate
E. Administer IV furosemide
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