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elderly patient

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

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An 85-year-old man from a nursing home presents with new confusion, mild cough, and temperature 37.9°C. Chest X-ray shows a right lower lobe infiltrate. He has dysphagia. Considering his presentation and risk factors, which initial antibiotic regimen is most appropriate?

A. Ceftriaxone
B. Azithromycin
C. Amoxicillin-clavulanate
D. Doxycycline
E. Amoxicillin
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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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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 75-year-old male presents with worsening dysphagia. An X-ray is performed (shown). What is the most appropriate initial investigation?

A. Esophageal manometry
B. 24-hour pH monitoring
C. Upper endoscopy
D. CT chest
E. Barium swallow
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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 with a history of intermittent, self-resolving right upper quadrant pain presents for evaluation. She denies fever, chills, or jaundice, and her physical examination is unremarkable. Routine blood tests, including liver function tests and amylase, are within normal limits. An abdominal ultrasound was performed, and a representative image is shown. Based on the findings in this image and her clinical presentation, what is the most appropriate next step in management?

A. Laparoscopic cholecystectomy alone
B. Prescribe oral analgesics and advise dietary modification
C. Elective endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction
D. Referral for urgent surgical common bile duct exploration
E. Observation with regular clinical review
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A 72-year-old man with fatigue and a past myocardial infarction at 55 is breathless on stairs, has a 3 kg weight gain, and ankle marks. What is his likely NYHA functional class for chronic heart failure?

A. NYHA Class 3
B. NYHA Class 2
C. NYHA Class 4
D. NYHA Class 1
E. Not enough information to classify.
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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 presents with a severe headache and altered mental status. Aneurysm coiling was performed. The image shows a post-operative angiogram. 6 hours later, she develops a fever of 38.5°C and worsening neurological deficits. What is the MOST likely cause?

A. Meningitis
B. Coil migration
C. Hemorrhagic conversion
D. Hydrocephalus
E. Vasospasm
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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 presents to his general practitioner for a routine check-up. He reports a history of hypertension, hyperlipidemia, and a 40-pack-year smoking history. He denies any abdominal pain, back pain, or lower extremity claudication. On physical examination, his vital signs are within normal limits. Auscultation of the abdomen is unremarkable, and peripheral pulses are palpable and symmetric. As part of his cardiovascular risk assessment, a contrast-enhanced CT scan of the abdomen and pelvis is performed. An axial view from the scan is shown. Based on the image and the patient's clinical presentation, which of the following is the MOST appropriate next step in management?

A. Prescribe a beta-blocker to reduce blood pressure and heart rate
B. Schedule a repeat CT scan in 6-12 months to monitor aneurysm size
C. Refer to vascular surgery for elective repair
D. Order an ultrasound of the abdomen to further evaluate the aorta
E. Initiate statin therapy and lifestyle modifications
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A 75-year-old obese man with a history of hypertension and chronic lower limb skin changes, swelling, tingling, and weakness presents with sudden onset inability to stand or move his legs, accompanied by a loss of sensation extending up to his waist. On examination, he has flaccid paralysis of both lower limbs, absent deep tendon reflexes in the legs, and a sensory level at the umbilicus. Which of the following is the most appropriate initial investigation?

A. Urgent MRI of the spine
B. Electromyography and nerve conduction studies
C. CT angiography of the aorta and iliac arteries
D. Lumbar puncture
E. Urgent CT scan of the spine
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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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A 68-year-old male with a history of hypertension and stable angina is prescribed amlodipine. He returns after two weeks complaining of significant ankle edema. What is the most appropriate initial management step?

A. Add a beta-blocker to counteract the effects of amlodipine.
B. Advise the patient to elevate his legs and wear compression stockings.
C. Reduce the dose of amlodipine.
D. Switch to an alternative antihypertensive such as an ACE inhibitor or ARB.
E. Prescribe a diuretic to manage the edema.
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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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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. Apply compression bandages and elevate the leg
B. Start heparin and continue warfarin at the same dose
C. Reduce warfarin dose and monitor INR daily
D. Stop warfarin and administer vitamin K and fresh frozen plasma
E. Continue warfarin at the same dose and apply topical corticosteroids
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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 to the emergency department 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 findings and the provided imaging, what is the most appropriate next step in the management of this patient?

A. Laparoscopic cholecystectomy within 24-72 hours
B. Urgent endoscopic retrograde cholangiopancreatography (ERCP)
C. Percutaneous cholecystostomy insertion
D. Repeat abdominal CT scan in 24 hours
E. Continue medical management with intravenous antibiotics and analgesia only
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A 78M presents with cough, fever, confusion. BP 90/60, RR 30, Temp 38.5, SpO2 90% on air. CXR shows LUL consolidation. What is the most appropriate initial management?

A. Arrange urgent viral PCR testing
B. Initiate oral antibiotics and admit to general ward
C. Discharge home with oral antibiotics
D. Perform urgent bronchoscopy
E. Initiate IV antibiotics and assess for ICU 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 presents with a severe headache and altered mental status. Aneurysmal coiling was performed. The image shows a post-operative angiogram. 6 hours later, the patient's GCS decreases. What is the MOST likely cause?

A. Hydrocephalus
B. Post-operative delirium
C. Re-rupture of the aneurysm
D. Vasospasm
E. Cerebral salt wasting
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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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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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Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct.
Image by Samir धर्म at en.wikipedia CC BY-SA 3.0 · Source

A 72-year-old man with a history of cholelithiasis presents with a 2-day history of fever, jaundice, and severe right upper quadrant pain. His vital signs are stable, but laboratory tests show elevated bilirubin and alkaline phosphatase. He is undergoing urgent ERCP for management of suspected choledocholithiasis and cholangitis. Following successful cannulation and injection of contrast, the image is obtained. Considering the findings demonstrated in the image in the context of this patient's presentation, what is the most appropriate immediate next step during this procedure?

A. Placement of a biliary stent
B. Mechanical lithotripsy
C. Balloon dilation of the common bile duct
D. Endoscopic sphincterotomy
E. Attempt stone extraction with a basket
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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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Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct.
Image by Samir धर्म at en.wikipedia CC BY-SA 3.0 · Source

A 70-year-old male with ascending cholangitis undergoes ERCP. The image is obtained. What is the MOST appropriate next step in management?

A. Ursodeoxycholic acid administration
B. Sphincterotomy and stone extraction
C. Observation with serial LFTs
D. Percutaneous transhepatic biliary drainage
E. Cholecystectomy
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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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Inguinal hernia right view. Adult male with an inguinal hernia, showing bulging in the groin area.
Image by IkeTheSloth CC0 1.0 · Source

A 62-year-old man presents to his GP with a history of a bulge in his right groin that has been present for approximately 18 months. He reports it is more prominent with straining or standing and disappears completely when he lies down. He denies any associated pain, nausea, vomiting, or change in bowel habits. He has no significant past medical history. His physical examination reveals the finding depicted in the image. Vital signs are within normal limits. Based on this clinical picture, which of the following represents the most appropriate definitive management strategy for this patient?

A. Observation with regular follow-up.
B. Urgent surgical exploration.
C. Further imaging to confirm the diagnosis.
D. Elective surgical repair.
E. Non-surgical management with a supportive device.
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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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Inguinal hernia right view. Adult male with an inguinal hernia, showing bulging in the groin area.
Image by IkeTheSloth CC0 1.0 · Source

A 68-year-old man presents to the emergency department with sudden onset of severe pain and tenderness in his right groin, associated with nausea. He reports a long history of an intermittent swelling in this area, similar to the appearance shown, which he could previously push back. On examination, the swelling is firm, exquisitely tender, and irreducible. Vital signs are stable. What is the most appropriate immediate management?

A. Attempt manual reduction with sedation and analgesia
B. Order an urgent CT scan of the abdomen and pelvis
C. Prescribe oral analgesia and arrange outpatient surgical review
D. Administer broad-spectrum antibiotics and observe for signs of sepsis
E. Urgent surgical consultation for potential strangulation
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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 with abdominal distension and obstipation. An upright abdominal X-ray is performed. What is the MOST appropriate next step in management?

A. Stool softeners
B. Colonoscopy
C. Barium enema
D. Increase oral fluid intake
E. Surgical consultation
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An elderly man presents with a 6-month history of memory decline, recurrent falls, visual hallucinations, agitation, and confusion. His wife reports he talks to people who are not visible. Which of the following clinical features is most helpful in diagnosing his condition?

A. Nystagmus
B. Parkinsonian gait/tremor
C. Ataxia
D. Aphasia
E. Hemiparesis
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A 74-year-old lady presents with a 2-hour history of nosebleed. She is pale and clammy with ongoing bleeding despite digital pressure. Her blood pressure is 120/80 mmHg and her heart rate is 120/min. What is the most appropriate next step in management?

A. Posterior nasal packing.
B. Rapid Rhino and blood tests for VWD.
C. Cautery with silver nitrate.
D. Ribbon gauze with chloramphenicol, review in 2 hours.
E. Anterior nasal packing with Merocel.
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 62-year-old male presents with a 3-month history of worsening upper abdominal pain, significant fatigue, and a 10 kg unintentional weight loss. His medical history includes long-standing peptic ulcer disease managed with proton pump inhibitors. On examination, he has mild hepatomegaly and trace ascites. Initial blood tests show elevated alkaline phosphatase and gamma-glutamyl transferase, with normal serum bilirubin and transaminases. A contrast-enhanced CT scan of the abdomen and pelvis is performed, and representative images are provided. Considering the clinical presentation and the findings demonstrated on the imaging, which of the following represents the MOST appropriate immediate next step in the management of this patient?

A. Commencement of empirical systemic chemotherapy
B. Urgent upper endoscopy with gastric biopsies
C. Immediate referral to palliative care services
D. Image-guided biopsy of a liver lesion
E. Referral for surgical assessment for liver metastasectomy
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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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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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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

An 80-year-old male presents to the emergency department with sudden onset of severe right groin pain and a non-reducible bulge. He has a history of a reducible inguinal hernia. Vitals are stable. A CT scan of the pelvis is performed. Considering the clinical presentation and the provided imaging, what is the most appropriate immediate management step?

A. Discharge home with advice to see GP if symptoms worsen.
B. Urgent surgical consultation for potential operative intervention.
C. Administer analgesia and observe for spontaneous reduction.
D. Attempt manual reduction under sedation.
E. Order an urgent ultrasound of the groin.
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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. Schedule regular clinical follow-up and repeat imaging in 12 months.
B. Arrange for upper gastrointestinal endoscopy with biopsies.
C. Referral for surgical assessment and repair.
D. Initiate high-dose proton pump inhibitor therapy and review in 3 months.
E. Advise dietary modification, elevation of the head of the bed, and weight loss.
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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 for evaluation. Her calcium is 2.9 mmol/L (2.1-2.6 mmol/L), PTH 110 pg/mL (10-65 pg/mL), and creatinine is normal. She denies neck pain or swelling. Given the imaging, what is the MOST appropriate next step?

A. Vitamin D supplementation and repeat calcium level in 3 months
B. Bisphosphonate therapy
C. Kidney stone removal
D. Surgical exploration and parathyroidectomy
E. Cinacalcet administration
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A 70-80 year old lady being treated for pulmonary embolism with a therapeutic dose of subcutaneous Enoxaparin is found to have multiple new pulmonary emboli. What is the most appropriate next step?

A. Start streptokinase infusion.
B. Switch to intravenous unfractionated heparin.
C. Switch to oral warfarin.
D. Increase the dose of subcutaneous enoxaparin.
E. Insert an IVC filter.
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A 72-year-old man with a history of hypertension and atrial fibrillation presents to the emergency department with worsening shortness of breath and fatigue over the past two weeks. He reports occasional palpitations but denies chest pain or syncope. On examination, his blood pressure is 110/70 mmHg, heart rate is 130 bpm (irregularly irregular), respiratory rate is 22 breaths per minute, and oxygen saturation is 94% on room air. Jugular venous pressure is elevated, and there are bilateral lung crackles. An ECG shows atrial fibrillation with a rapid ventricular response. An echocardiogram reveals moderate mitral regurgitation and left atrial enlargement. Which of the following is the most appropriate initial management step?

A. Initiation of antiarrhythmic therapy with amiodarone
B. Rate control with intravenous diltiazem
C. Immediate electrical cardioversion
D. Initiation of oral anticoagulation
E. Referral for mitral valve surgery
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A 70-80 year old lady, currently managed for pulmonary embolism with Enoxaparin 40 mg daily, is found to have multiple pulmonary emboli. Her vitals are within normal limits. What would be the most appropriate next step?

A. Insert an IVC filter.
B. Switch to apixaban.
C. Switch to oral warfarin.
D. Increase Enoxaparin to therapeutic dose.
E. Start streptokinase infusion.
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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 80-year-old male with a history of smoking and hypertension presents for investigation of mild, intermittent lower back pain. Physical examination is unremarkable. Vital signs are stable. A CT scan of the abdomen is performed. Based on the provided image and clinical context, what is the most appropriate next step in the management of this patient?

A. Repeat CT scan in 3 months
B. Urgent referral for surgical repair
C. Annual ultrasound surveillance
D. No further follow-up required
E. Initiate antiplatelet therapy and review in 1 year
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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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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. Considering the clinical presentation and the provided images, which of the following represents the most appropriate adjustment to her medical therapy?

A. Increase the dose of azathioprine.
B. Initiate treatment with an anti-TNF agent.
C. Discontinue azathioprine and switch to methotrexate.
D. Add a course of oral prednisolone.
E. Switch mesalazine to sulfasalazine.
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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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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

An 82-year-old woman with a history of paroxysmal atrial fibrillation was recently discharged from hospital following treatment for community-acquired pneumonia. Five days ago, she was commenced on warfarin 5mg daily for stroke prevention. She presents to the emergency department today complaining of severe, rapidly worsening pain and a dark, blistering lesion on her right lower leg that developed over the past 48 hours. She denies any recent trauma to the leg. Her vital signs are stable: blood pressure 132/82 mmHg, heart rate 76 bpm, respiratory rate 18/min, temperature 37.0°C. Physical examination reveals the appearance shown in the image on her right anterior lower leg. Laboratory results show an INR of 4.8, haemoglobin 125 g/L, white cell count 8.5 x 10^9/L, and platelets 250 x 10^9/L. She has no known personal or family history of thrombophilia. Considering the clinical presentation, recent medication changes, and the appearance depicted, which of the following is the most appropriate immediate management strategy?

A. Discontinue warfarin, administer Vitamin K, and initiate therapeutic dose low molecular weight heparin.
B. Reduce the dose of warfarin and monitor the INR closely.
C. Discontinue warfarin and administer Vitamin K only.
D. Initiate broad-spectrum intravenous antibiotics and arrange urgent surgical review for debridement.
E. Continue warfarin at the current dose and administer fresh frozen plasma to correct the INR.
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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 reports intermittent RUQ pain. She denies jaundice or fever. An abdominal ultrasound was performed, image shown. Besides referral for surgery, what is the MOST appropriate next step in management?

A. Start prophylactic antibiotics
B. Repeat ultrasound in 6 months
C. Administer ursodeoxycholic acid
D. Prescribe a low-fat diet
E. Arrange an MRCP
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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 with a 4-month history of increasing constipation and occasional streaks of blood on stool. He denies significant weight loss. Physical exam is unremarkable. A colonoscopy was performed, and the image is shown. Biopsies are taken from the lesion. Assuming the biopsy confirms adenocarcinoma, what is the MOST appropriate initial investigation to guide further management?

A. Referral for neoadjuvant chemotherapy
B. CT scan of chest, abdomen, and pelvis
C. Repeat colonoscopy in 3 months
D. PET scan for distant metastases
E. Endoscopic ultrasound for local staging
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A 65-year-old man presents to the emergency department with sudden onset of severe headache, nausea, and vomiting. He has a history of hypertension and is currently on antihypertensive medication. On examination, he is alert but in distress due to the headache. His blood pressure is 180/110 mmHg, heart rate is 90 bpm, and he has no focal neurological deficits. A CT scan of the head shows a subarachnoid hemorrhage. Which of the following is the most appropriate initial management step in this patient?

A. Administer nimodipine to prevent cerebral vasospasm
B. Perform immediate surgical clipping of the aneurysm
C. Administer mannitol to reduce intracranial pressure
D. Start intravenous labetalol to control blood pressure
E. Initiate anticonvulsant therapy to prevent seizures
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Mammogram microcalcifications in carcinoma in situ, CC, details
Image by Jmarchn CC BY-SA 3.0 · Source

Mrs. Eleanor Vance, a 62-year-old retired teacher, presents for her routine biennial screening mammogram through the BreastScreen Australia program. She has no personal history of breast disease, and her family history is negative for breast or ovarian cancer in first-degree relatives. She is otherwise healthy, with a history of diet-controlled type 2 diabetes and osteoarthritis managed with paracetamol. She denies any breast pain, lumps, nipple discharge, or skin changes. Her last mammogram two years ago was reported as normal (BIRADS 1). Physical examination of both breasts and axillae is unremarkable. The current screening mammogram is performed. The image provided is a magnified view from the craniocaudal projection of the left breast, specifically highlighting an area that has been flagged for further assessment by the reporting radiologist due to a change from the previous study. Based on the clinical presentation, the patient's history, and the specific finding demonstrated in the provided image from her screening mammogram, what is the most appropriate immediate next step in the management pathway for this patient?

A. Stereotactic vacuum-assisted core biopsy of the suspicious calcifications.
B. Proceed directly to surgical excision of the area under wire localisation.
C. Repeat the mammogram in 3-6 months with spot compression and magnification views.
D. Request a breast MRI with contrast to better delineate the extent of the abnormality.
E. Perform a targeted ultrasound of the area of concern.
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A 68-year-old man with a history of smoking and hypertension presents with intermittent claudication in his right leg. Ankle-brachial index (ABI) is 0.6 on the right and 0.9 on the left. He has been on a supervised exercise program and optimal medical therapy for 6 months with no improvement in symptoms. What is the most appropriate next step in management?

A. Continue with the current exercise program and medical therapy
B. Consideration for revascularization with angioplasty or bypass surgery
C. Start a trial of cilostazol
D. Increase the dose of his antihypertensive medication
E. Refer for a vascular ultrasound to reassess the ABI
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 68-year-old man presents with 3 days of worsening left lower quadrant pain, fever, and nausea. He has a history of diverticulosis. On examination, he is tachycardic (HR 105), afebrile (37.5°C), and has localised tenderness with guarding in the left iliac fossa. His blood tests show a WCC of 16 x 10^9/L and CRP 150 mg/L. He is commenced on intravenous antibiotics. A CT scan is performed (image provided). Considering the clinical context and the findings on the image, what is the most appropriate next step in management?

A. Arrange for percutaneous drainage of the collection.
B. Prepare for urgent surgical resection of the affected bowel segment.
C. Transition to oral antibiotics and discharge home.
D. Request a repeat CT scan in 24 hours to assess for changes.
E. Continue intravenous antibiotics and monitor clinical progress.
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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 78-year-old male on warfarin presents with acute shortness of breath. INR is 5.0. The provided image was obtained. What is the MOST likely underlying cause?

A. Pneumonia
B. Anticoagulation-related bleeding
C. Heart failure exacerbation
D. Pulmonary embolism
E. Spontaneous pneumothorax
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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 episodes of right upper quadrant pain several months ago, which resolved spontaneously. She denies fever, jaundice, or current abdominal discomfort. Routine blood tests including LFTs are within normal limits. An abdominal ultrasound was performed, with a representative image provided. Considering her history and the imaging findings, what is the most appropriate next step in management?

A. Observation with repeat imaging if symptoms recur.
B. Elective laparoscopic cholecystectomy.
C. Endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction.
D. Urgent open surgical exploration of the common bile duct.
E. Medical dissolution therapy with ursodeoxycholic acid.
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