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elderly patient

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

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

A. Administer vitamin K and discontinue warfarin
B. Elevate the leg and apply compression bandages
C. Prescribe a broad-spectrum antibiotic
D. Apply topical corticosteroids
E. Increase the dose of warfarin
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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 GP with a 6-month history of increasing fatigue, generalised bone aches, and constipation. She has no significant past medical history and takes no regular medications. Physical examination is unremarkable. Initial laboratory investigations reveal a corrected 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 12 mmol/day (reference range: 2.5-7.5 mmol/day). She 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. Order genetic testing for MEN syndromes
B. Surgical parathyroidectomy
C. Repeat parathyroid localisation imaging
D. Initiate medical therapy with cinacalcet
E. Perform a bone mineral density scan
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

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

A. CT abdomen and pelvis with intravenous contrast
B. Repeat plain abdominal X-ray in 6 hours
C. MRI abdomen
D. Barium enema
E. Upper GI series with small bowel follow-through
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 70-year-old male with cirrhosis secondary to alcohol abuse presents with new-onset ascites and a palpable liver mass. His AFP is markedly elevated. A contrast-enhanced ultrasound is performed, as shown. What is the MOST appropriate next diagnostic step?

A. Quadruple-phase CT scan of the abdomen
B. Initiate systemic chemotherapy
C. Repeat ultrasound in 3 months
D. MRI of the abdomen with hepatobiliary contrast
E. Liver biopsy
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A 70-year-old man with severe COPD (FEV1 30% predicted), on triple inhaled therapy and supplemental oxygen, presents with a 3-day history of increased dyspnoea, productive cough with purulent sputum, and reduced exercise tolerance. He denies fever or chest pain. On examination, he is tachypnoeic (RR 24), saturating 88% on 2 L/min oxygen, with diffuse wheeze and prolonged expiration. His chest X-ray shows hyperinflation but no new infiltrates. His arterial blood gas on 2 L/min oxygen shows pH 7.32, pCO2 68 mmHg, pO2 55 mmHg, bicarbonate 35 mmol/L. Given this presentation, what is the most appropriate immediate management step?

A. Initiate non-invasive ventilation
B. Prescribe oral antibiotics
C. Administer intravenous corticosteroids
D. Increase supplemental oxygen flow rate
E. Perform a bronchoscopy
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 72-year-old woman presents with a long history of heartburn, regurgitation, and recently developed a chronic cough, particularly at night. Physical examination is unremarkable. A chest radiograph is obtained. Considering the radiographic findings in the context of the patient's presentation, what is the most likely pathophysiological mechanism contributing to her chronic cough?

A. Pulmonary oedema secondary to cardiac dysfunction
B. Interstitial lung disease causing restrictive ventilatory defect
C. Compression of the left main bronchus by an enlarged lymph node
D. Bronchial hyperreactivity triggered by inhaled allergens
E. Chronic aspiration of gastric contents
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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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A 65-year-old man undergoes successful coil embolization of a ruptured anterior communicating artery aneurysm. Two days post-procedure, he develops a temperature of 38.1°C, generalized malaise, and a headache unresponsive to paracetamol. Neurological exam is unchanged from baseline. CRP is 45 mg/L (normal <5). Which of the following is the most likely cause of his current symptoms?

A. Bacterial meningitis
B. Post-embolization syndrome
C. Re-rupture of the aneurysm
D. Vasospasm
E. Deep vein thrombosis
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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 routine follow-up. He is asymptomatic. Review the image. What is the most appropriate next step in management?

A. Commence dual antiplatelet therapy
B. Repeat imaging in 6-12 months
C. Prescribe a statin
D. Initiate beta-blocker therapy
E. Schedule elective surgical repair
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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 new onset ascites and elevated ALP has the imaging shown. What is the MOST likely primary malignancy?

A. Colorectal
B. Cholangiocarcinoma
C. Gastric
D. Hepatocellular
E. Pancreatic
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An 82-year-old woman with dementia and COPD presents with increased confusion and mild cough. Temperature 37.8°C, HR 95, RR 24, BP 110/70, SpO2 90% on air. Chest sounds are diminished bilaterally. What is the most appropriate initial investigation?

A. Serum procalcitonin
B. Bronchoscopy
C. High-resolution CT chest
D. Chest X-ray
E. Sputum Gram stain and culture
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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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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 72-year-old female on warfarin for chronic atrial fibrillation presents with a 2-day history of increasing pain and a developing lesion on her right lower leg. She denies trauma. Her INR is therapeutic at 2.5. Vitals are stable. Considering the clinical presentation and the image provided, what is the most appropriate immediate management?

A. Continue warfarin at a reduced dose and monitor the lesion closely.
B. Switch anticoagulation to a direct oral anticoagulant (DOAC).
C. Discontinue warfarin, administer vitamin K, and initiate heparin.
D. Initiate broad-spectrum antibiotics and arrange surgical debridement.
E. Apply topical corticosteroids and compression bandaging.
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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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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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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 with right groin pain and a palpable mass. He reports constipation and mild nausea. Vitals are stable. The provided image was obtained. What is the MOST appropriate next step in management?

A. Manual reduction attempt
B. Stool softeners and observation
C. Broad-spectrum antibiotics
D. Surgical consultation for emergent repair
E. Increase oral fluid intake and monitor
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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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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 colicky abdominal pain, bloating, and occasional non-bilious vomiting, associated with a 3kg weight loss. She reports reduced stool frequency. She is currently managed with mesalazine and azathioprine. Her vital signs are stable (BP 120/75, HR 82, Temp 36.8), and physical examination reveals mild right lower quadrant tenderness without guarding or rebound. Bowel sounds are hyperactive. Imaging is performed. Considering the clinical presentation, her current therapy, and the findings suggested by the provided images, which of the following represents the most appropriate next step in this patient's management?

A. Performing a colonoscopy with attempted balloon dilation
B. Recommending a high-fibre diet and increased fluid intake
C. Initiating therapy with an anti-TNF agent such as infliximab
D. Increasing the dose of azathioprine and adding oral corticosteroids
E. Referral for surgical consultation regarding potential resection
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 68-year-old male presents to his general practitioner with a three-month history of progressive dysphagia to both solids and liquids, accompanied by postprandial regurgitation. He also reports experiencing early satiety and occasional episodes of nocturnal coughing. His past medical history is significant for well-controlled hypertension and a remote history of smoking (quit 20 years ago). Physical examination reveals mild epigastric fullness, but is otherwise unremarkable. His vital signs are within normal limits. An abdominal CT scan with contrast was performed, and a representative image is shown. Given the clinical presentation and the findings on the image, which of the following is the MOST appropriate next step in the management of this patient?

A. Referral to a gastroenterologist for surgical evaluation
B. Esophageal manometry to evaluate esophageal motility
C. Empiric treatment with antibiotics for possible aspiration pneumonia
D. Initiation of a proton pump inhibitor and lifestyle modifications
E. Barium swallow study to further delineate the anatomy
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 70-year-old male with known gastric MANEC presents with worsening jaundice and ascites. The provided CT scan was performed. Which of the following serum markers would be MOST useful in monitoring disease progression in this patient?

A. Amylase
B. Chromogranin A
C. CEA
D. Alpha-fetoprotein
E. CA 19-9
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An 82-year-old man is brought from an aged care facility with a 2-day history of increased confusion and a new cough. He has a history of dementia and hypertension. On examination, his temperature is 38.1°C, pulse 98 bpm, BP 130/80 mmHg, and oxygen saturation 92% on room air. Chest auscultation reveals crackles in the right lower lung field. What is the most appropriate initial investigation?

A. Blood cultures
B. Sputum culture
C. ECG
D. Chest X-ray
E. CT scan of the head
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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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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old man presents with sudden onset of severe right groin pain and a firm, non-reducible bulge. He reports mild nausea but denies vomiting or change in bowel habit. Vital signs are stable. A CT scan of the pelvis is performed, as shown. Considering the clinical context and the imaging findings, what is the most appropriate immediate management?

A. Obtain a groin ultrasound for further assessment
B. Attempt manual reduction under sedation
C. Arrange for elective surgical consultation
D. Administer analgesia and observe closely
E. Emergency surgical exploration and repair
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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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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 and a recent hospitalisation for pneumonia was discharged 5 days ago on warfarin 5mg daily. She presents to the emergency department complaining of increasing pain and a rapidly evolving lesion on her right lower leg over the past 48 hours. She denies trauma. Her vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, Temp 36.8°C. Physical examination reveals the appearance shown in the image on her right anterior lower leg. Her INR today is 4.5. She has no known history of protein C or S deficiency. Considering the patient's history, current medication, laboratory result, and the clinical appearance depicted, which of the following represents the most appropriate immediate management strategy?

A. Prescribe oral flucloxacillin and review in 24 hours for suspected bacterial cellulitis.
B. Increase the daily dose of warfarin to achieve a target INR of 2.5-3.0 more rapidly.
C. Arrange for urgent surgical consultation for debridement of the necrotic tissue.
D. Discontinue warfarin, administer intravenous vitamin K, and initiate therapeutic dose unfractionated heparin or low molecular weight heparin.
E. Switch warfarin to rivaroxaban 20mg daily and monitor the lesion.
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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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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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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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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. Prescribe a course of high-dose corticosteroids to reduce peri-aneurysmal edema
B. Order an MRI of the brain to evaluate for ischemic changes
C. Initiate dual antiplatelet therapy with aspirin and clopidogrel
D. Repeat angiography to assess for recanalization or further aneurysm growth
E. Administer intravenous thrombolysis with alteplase
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A 60-year-old man presents to the clinic with a 6-month history of progressive difficulty in swallowing both solids and liquids. He also reports unintentional weight loss and occasional regurgitation of undigested food. On examination, there is no lymphadenopathy or abdominal masses. A barium swallow study shows a 'bird-beak' appearance of the lower esophagus. What is the most likely diagnosis?

A. Hiatal hernia
B. Esophageal stricture
C. Achalasia
D. Gastroesophageal reflux disease (GERD)
E. Esophageal cancer
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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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A 70-year-old woman with a history of hypertension presents with fatigue, shortness of breath, and bilateral leg swelling. Echocardiography shows an ejection fraction of 30%. What is the most appropriate first-line treatment?

A. Calcium channel blocker
B. Nitrate therapy
C. ACE inhibitor and beta-blocker
D. Digoxin
E. Diuretic therapy alone
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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 68-year-old presents with a 3-day history of fever, jaundice, and severe RUQ pain radiating to the back. Vitals: T 38.5°C, BP 110/70, HR 95. LFTs show bilirubin 150, ALP 450, ALT 120. An ERCP is performed for stone extraction. The image is captured during the procedure after cannulation. Considering the findings demonstrated in the image, what is the most appropriate immediate next step in management during the current procedure?

A. Proceed with mechanical lithotripsy after sphincterotomy.
B. Place a biliary stent for decompression.
C. Attempt extraction with a balloon catheter after sphincterotomy.
D. Refer for urgent laparoscopic common bile duct exploration.
E. Terminate the procedure and manage medically.
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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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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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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old male with a history of diverticulitis presents with severe abdominal pain, vomiting, and inability to pass flatus for 24 hours. An upright abdominal X-ray is performed. Based on the image, what is the MOST likely underlying cause?

A. Hernia
B. Volvulus
C. Intussusception
D. Adhesions
E. Neoplasm
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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, reporting no new systemic symptoms such as unexplained weight loss, fatigue, or bone pain. Her last mammogram of the contralateral breast and clinical examination at her previous visit six months ago were unremarkable. During the current 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 significant discomfort. Her vital signs are stable (BP 130/80 mmHg, HR 72 bpm, RR 16/min, Temp 36.8°C). 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, the duration and nature of the symptoms, and the clinical presentation, what is the most appropriate initial diagnostic step to investigate this new finding?

A. Prescribe a course of topical antifungal cream and review in two weeks.
B. Perform a punch biopsy of the affected skin area.
C. Arrange for a repeat mammogram of the contralateral breast and ultrasound of the axilla.
D. Order a CT scan of the chest, abdomen, and pelvis to rule out metastatic disease.
E. Reassure the patient that this is likely a benign inflammatory reaction related to the scar and monitor clinically.
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A 72-year-old man with a history of hypertension, hyperlipidemia, and type 2 diabetes mellitus presents to the emergency department complaining of exertional chest pain that has been increasing in frequency and severity over the past month. He describes the pain as a pressure-like sensation in the center of his chest, radiating to his left arm, and associated with shortness of breath. The pain typically occurs after walking two blocks and resolves with rest. He denies any recent changes in his medications or lifestyle. On examination, his blood pressure is 150/90 mmHg, heart rate is 78 bpm, and oxygen saturation is 96% on room air. An ECG shows normal sinus rhythm with no acute ST-segment changes. Troponin levels are within normal limits. Which of the following is the MOST appropriate next step in the management of this patient?

A. Stress echocardiography
B. Discharge home with instructions to follow up with his general practitioner
C. Initiate a trial of increased anti-anginal medications and lifestyle modifications
D. Coronary angiography
E. CT angiography of the chest
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 72-year-old male presents with increasing shortness of breath and epigastric discomfort, particularly after meals. He has a history of well-controlled hypertension and takes aspirin daily. An X-ray is performed. What is the most appropriate next step in management?

A. Prescribe a H2 receptor antagonist
B. Order a barium swallow study
C. Initiate a proton pump inhibitor and lifestyle modifications
D. Perform an upper endoscopy
E. Refer for surgical consultation for fundoplication
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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 68-year-old man attends his GP for a routine check-up. He has a history of well-controlled type 2 diabetes, hypertension, and smoked for 30 years, quitting 5 years ago. He denies any abdominal pain, back pain, or pulsatile sensation. Physical examination is unremarkable. As part of a cardiovascular risk assessment, an abdominal ultrasound is initially performed, which is inconclusive due to bowel gas. A follow-up contrast-enhanced CT scan is arranged. Considering the findings demonstrated in the image, what is the most appropriate next step in the management of this patient?

A. No further action required, reassure the patient
B. Immediate admission for urgent surgical assessment
C. Referral for elective surgical repair
D. Repeat CT scan in 3 months
E. Six-monthly abdominal ultrasound surveillance
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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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66-year-old man, smoker with mild COPD, on salbutamol and tiotropium, confused regarding usage. Back for GPMP. Care plan?

A. Recommend zoster and pneumococcal vaccines.
B. Increase salbutamol dose.
C. Advise to cut down on smoking.
D. Recommend flu, COVID, and pneumococcal vaccines.
E. Refer for pulmonary function tests.
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An 80-year-old presents with CAP. CURB-65 score is 3. What is the most appropriate initial management?

A. Outpatient management with observation only
B. Inpatient management with IV antibiotics
C. Outpatient management with oral antibiotics
D. Inpatient management with oral antibiotics
E. Admission to ICU
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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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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 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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A 66-year-old man, active with a good diet, whose mother had osteoporosis at age 91, wants to check his osteoporosis risk. What risk factors prompt a bone mineral density (BMD) test?

A. Asthma
B. Rheumatoid arthritis
C. Generalized anxiety disorder
D. Type 2 Diabetes Mellitus
E. Hypertension
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