← Back to Topics

elderly patient

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

Related Topics

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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
Elective abdominal ultrasonography of a 64 year old woman with past colicky pain but no current pain. It shows a mildly dilated common bile duct with what appears to be a gallstone (black arrow). The green and blue dots are blood flow, since the exam is done as a Doppler ultrasound to distinguish the bile duct from blood vessels.
Image by Mikael Häggström CC0 1.0 · Source

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

A. Discharge with advice to return if symptoms recur
B. ERCP for stone extraction
C. Initiate ursodeoxycholic acid therapy
D. MRCP to further delineate the biliary anatomy
E. Elective laparoscopic cholecystectomy
Mark this as a high-quality question
Mark this as a poor-quality or problematic question

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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question

A 67-year-old man with a history of hypertension and type 2 diabetes is scheduled for elective cholecystectomy due to symptomatic gallstones. During the preoperative assessment, he mentions experiencing mild chest discomfort during exertion over the past few weeks. What is the most appropriate next step in his preoperative management?

A. Start the patient on aspirin and beta-blockers immediately
B. Order a preoperative chest X-ray
C. Refer for a cardiology evaluation and possible stress testing
D. Proceed with surgery as planned with close intraoperative monitoring
E. Schedule an urgent coronary angiogram
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 review in the outpatient clinic. She reports a history of intermittent, self-resolving episodes of right upper quadrant colicky pain over the past year, but is currently asymptomatic. She denies fever, jaundice, or other systemic symptoms. Her physical examination is unremarkable, and recent liver function tests are within the normal reference range. An elective abdominal ultrasound was performed, yielding the image shown. Based on the clinical presentation and the findings demonstrated, what is the most appropriate next step in her management?

A. Trial of ursodeoxycholic acid
B. Reassurance and discharge with advice to return if symptoms recur
C. Elective laparoscopic cholecystectomy
D. Further investigation with CT abdomen
E. Referral for endoscopic retrograde cholangiopancreatography (ERCP)
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 68-year-old woman presents with a persistent rash on her chest wall at the site of a previous mastectomy performed 8 years ago. She denies pain or itching. What is the MOST appropriate next step in management?

A. Reassurance and observation
B. Topical corticosteroid application
C. Skin biopsy
D. Referral to dermatology for cryotherapy
E. Excisional biopsy with wide margins
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 alcoholic cirrhosis presents for routine HCC screening. His AFP is 25 ng/mL. A CT scan with IV contrast is performed (image attached). What is the MOST appropriate next step in management?

A. MRI of the abdomen with contrast
B. Repeat AFP in 3 months
C. Initiate sorafenib
D. Surgical resection
E. Referral for liver transplant evaluation
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

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

A. Fresh frozen plasma (FFP)
B. Vitamin K
C. Tranexamic acid
D. Prothrombinex (PCC)
E. Recombinant Factor VIIa
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 70-year-old woman presents with a lesion on her chest wall at the site of a mastectomy performed 10 years prior. She reports it started as a small area of redness and has slowly enlarged. What is the MOST likely diagnosis?

A. Eczema
B. Radiation dermatitis
C. Paget's disease of the breast
D. Invasive ductal carcinoma
E. Herpes zoster
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 past colicky pain has the ultrasound shown. LFTs are normal. What is the MOST appropriate next investigation?

A. Hepatobiliary Iminodiacetic Acid (HIDA) scan
B. Endoscopic ultrasound (EUS)
C. MRCP
D. Repeat ultrasound in 3 months
E. CT Abdomen
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 72-year-old woman presents with 3 days of worsening right upper quadrant pain, nausea, and vomiting. She has a history of dyspepsia. On examination, she is afebrile (37.2°C), heart rate 95 bpm, blood pressure 130/80 mmHg. Abdominal examination reveals tenderness in the right upper quadrant without guarding or rebound. Bowel sounds are present. Her white cell count is 11 x 10^9/L, CRP 80 mg/L. Liver function tests are normal. The provided imaging was obtained. Considering the clinical presentation and the findings demonstrated in the provided imaging, which of the following complications is this patient at increased risk of developing?

A. Acute appendicitis
B. Acute pancreatitis
C. Diverticulitis
D. Gallstone ileus
E. Ascending cholangitis
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 75-year-old presents with a 4-month history of increasing dysphagia to solids, occasional regurgitation, and chronic cough, particularly at night. He denies significant weight loss or chest pain. Past medical history includes type 2 diabetes and hypertension. Medications are metformin and perindopril. Physical examination is unremarkable. A chest X-ray is performed as part of the initial assessment. Considering the clinical presentation and the radiographic findings, which of the following investigations is most appropriate at this stage?

A. Barium swallow study
B. Oesophageal manometry
C. Oesophago-gastro-duodenoscopy
D. High-resolution CT chest
E. Ambulatory ECG monitoring
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 worsening abdominal pain, bloating, and occasional post-prandial vomiting. She is currently managed with mesalazine and budesonide. Physical examination reveals mild right lower quadrant tenderness. Laboratory tests show a slightly elevated CRP. Given her presentation and the provided imaging, what is the most appropriate next step in her management?

A. Perform an urgent colonoscopy with biopsies
B. Increase the dose of budesonide
C. Continue current medical therapy and monitor symptoms
D. Switch mesalazine to an oral corticosteroid like prednisone
E. Refer for surgical assessment for potential stricture or complication
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 70-year-old man presents with a 3-month history of worsening constipation, occasional bright red rectal bleeding, and unexplained fatigue. His GP notes mild pallor. Full blood count reveals a haemoglobin of 105 g/L and low ferritin. A colonoscopy is performed, and the image provided is a representative view of a finding in the sigmoid colon. Biopsies were taken. Considering the clinical context and the endoscopic appearance, which of the following is the most appropriate next step in the management pathway to determine the extent of disease?

A. Referral for immediate surgical resection
B. Repeat colonoscopy in 6 months to assess response to medical therapy
C. CT scan of chest, abdomen, and pelvis for staging
D. PET scan for metabolic activity assessment
E. Commencement of iron supplementation and review in 4 weeks
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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, constipation, and bone pain. Serum calcium is elevated. The images are obtained. What is the MOST appropriate next step in management?

A. Bisphosphonate therapy
B. Vitamin D supplementation
C. Observation with serial calcium monitoring
D. Surgical excision of the identified lesion
E. Cinacalcet administration
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old male presents with a painful, irreducible right groin mass. He reports vomiting and abdominal distension. His vitals are: HR 110, BP 100/60, RR 22, SpO2 96% RA. The provided image was obtained. What is the next step?

A. Attempt manual reduction with sedation
B. Surgical consultation for emergent repair
C. Order a repeat CT scan with contrast in 6 hours
D. Start a clear liquid diet
E. Administer intravenous antibiotics
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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, constipation, and bone pain. Serum calcium is elevated. The provided imaging was obtained. What is the MOST likely underlying cause of her presentation?

A. Parathyroid adenoma
B. Multiple myeloma
C. Thyroid carcinoma
D. Metastatic bone disease
E. Vitamin D deficiency
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 70-year-old male with known cirrhosis secondary to non-alcoholic fatty liver disease is undergoing routine surveillance. His recent surveillance ultrasound identified a new 3 cm lesion in segment VIII. His alpha-fetoprotein level is 45 ng/mL (previously normal). A contrast-enhanced ultrasound is performed, with representative images shown. Based on the clinical context and the findings demonstrated in the images, what is the most appropriate immediate next step in this patient's management?

A. Initiate systemic chemotherapy with sorafenib
B. Repeat the contrast-enhanced ultrasound in 3 months
C. Referral to a multidisciplinary liver tumour board for staging and treatment planning
D. Schedule a follow-up appointment with the GP in 4 weeks
E. Perform an immediate percutaneous biopsy of the lesion
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 68-year-old male on warfarin presents with pleuritic chest pain and mild dyspnea. INR is 4.5. The image was obtained. What is the MOST appropriate initial intervention?

A. Observation and serial chest X-rays
B. Urgent bronchoscopy
C. Vitamin K administration
D. Chest tube insertion
E. IV protamine sulfate
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 general practitioner with a several-year history of worsening symptoms. He describes significant heartburn and regurgitation, particularly when lying down, which is only partially relieved by high-dose proton pump inhibitors. He has also noticed increasing difficulty swallowing solid food and occasionally liquids, sometimes accompanied by coughing fits after eating. He reports feeling full very quickly after starting a meal and has lost approximately 5 kg unintentionally over the past year. His past medical history includes osteoarthritis and benign prostatic hyperplasia. He is a non-smoker and drinks alcohol occasionally. Physical examination is unremarkable. Routine blood tests, including full blood count, electrolytes, and liver function tests, are within normal limits. A CT scan of the chest and upper abdomen was performed as part of the workup for his symptoms, and a representative axial image is shown. Considering the clinical presentation and the findings demonstrated in the image, which of the following represents the MOST appropriate definitive management strategy for this patient?

A. Referral for a barium swallow study and oesophageal manometry.
B. Long-term, high-dose proton pump inhibitor therapy and dietary modifications.
C. Endoscopic balloon dilation of the oesophagus.
D. Placement of a percutaneous endoscopic gastrostomy (PEG) tube for nutritional support.
E. Laparoscopic repair of the diaphragmatic defect with fundoplication and mesh reinforcement.
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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.
Mark this as a high-quality question
Mark this as a poor-quality or problematic question

A 65-year-old man with a history of hypertension and ischemic heart disease presents to the emergency department with worsening shortness of breath, orthopnea, and peripheral edema. On examination, he has elevated jugular venous pressure, bilateral basal crackles, and pitting edema in the lower limbs. An echocardiogram shows an ejection fraction of 35%. What is the most appropriate initial management step for this patient?

A. Initiate digoxin therapy
B. Perform coronary angiography
C. Start oral beta-blockers
D. Administer intravenous furosemide
E. Prescribe oral ACE inhibitors
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question

A 68-year-old man with known severe COPD presents with a 3-day history of increased cough, purulent sputum, and worsening dyspnoea. He uses salbutamol more frequently. On examination, he is afebrile, respiratory rate 24, SpO2 90% on air. Scattered wheezes are heard. Which of the following is the most appropriate initial management step?

A. Initiate oral corticosteroids and antibiotics.
B. Administer high-flow oxygen via nasal cannula.
C. Prepare for non-invasive ventilation.
D. Order an urgent chest X-ray.
E. Give intravenous salbutamol infusion.
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

An 82-year-old patient presents with a 6-month history of chronic cough, intermittent dyspnea, and occasional regurgitation, particularly when lying flat. They deny significant chest pain or weight loss. Past medical history includes well-controlled hypertension and mild asthma managed with salbutamol PRN. On examination, vital signs are stable, and lung sounds are clear with no wheeze. An outpatient chest X-ray was performed as part of the workup for the cough and dyspnea. Considering the radiographic findings in conjunction with the clinical history, which of the following investigations is most appropriate at this stage?

A. High-resolution CT chest
B. Oesophago-gastro-duodenoscopy (OGD)
C. Pulmonary function tests
D. 24-hour oesophageal pH monitoring
E. Cardiac stress test
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 to the emergency department with sudden onset of severe dyspnoea and right-sided pleuritic chest pain. He denies trauma. On examination, he is tachypnoeic, oxygen saturation is 92% on room air. Blood pressure 110/70 mmHg, heart rate 95 bpm. Chest examination reveals decreased breath sounds on the right. A CT scan of the chest is performed. Considering the patient's clinical presentation, medical history, and the findings demonstrated in the provided image, which of the following interventions is most critical to initiate *before* considering invasive drainage?

A. Insertion of a large-bore chest tube
B. Urgent surgical exploration of the chest
C. Administration of prothrombin complex concentrate (PCC) or Factor IX complex
D. Initiation of therapeutic heparin infusion
E. Intravenous administration of broad-spectrum antibiotics
Mark this as a high-quality question
Mark this as a poor-quality or problematic question

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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 68-year-old male with a history of reflux presents with epigastric pain and vomiting. An X-ray is performed (shown). What is the most likely complication?

A. Gastric volvulus
B. Pericarditis
C. Esophageal stricture
D. Aortic dissection
E. Pneumonia
Mark this as a high-quality question
Mark this as a poor-quality or problematic question

A 60-year-old woman presents to the emergency department with sudden onset of severe abdominal pain radiating to her back. She has a history of hypertension and hyperlipidemia. On examination, she is hypotensive and tachycardic. Her abdomen is distended and tender, with guarding and rebound tenderness. An abdominal ultrasound reveals a large abdominal aortic aneurysm. What is the most appropriate next step in the management of this patient?

A. Administer intravenous beta-blockers
B. Initiate intravenous antibiotics
C. Immediate surgical repair
D. Perform a CT angiography
E. Start anticoagulation therapy
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 for urgent liver transplant assessment
B. Repeat the contrast-enhanced ultrasound in 3 months to assess for interval change
C. Perform a percutaneous biopsy of the lesion for histological confirmation
D. Referral for discussion regarding locoregional therapy (e.g., ablation) or surgical resection
E. Initiate systemic therapy with sorafenib
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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. Referral for surgical parathyroidectomy
B. Repeat imaging with a different modality
C. Initiate medical therapy with cinacalcet
D. Schedule regular monitoring of serum calcium and PTH levels
E. Begin treatment with intravenous fluids and bisphosphonates
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 male presents with worsening headaches and blurred vision 3 months post-embolization. The attached image was obtained. Which of the following is the MOST appropriate next step in management?

A. Order an MRI of the brain to rule out other causes of headache
B. Initiate a course of high-dose corticosteroids
C. Refer for surgical clipping of the aneurysm
D. Repeat angiography to assess for recanalization
E. Prescribe analgesics and schedule a follow-up appointment in 6 months
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 to his GP with mild, intermittent lower back pain. Physical examination is unremarkable. Routine blood tests are normal. A CT scan of the abdomen is performed to investigate the back pain. Considering the findings demonstrated in the provided image in the context of this patient's presentation, what is the most appropriate next step in management?

A. Refer immediately for surgical consultation for elective repair.
B. Initiate aggressive blood pressure control and repeat imaging in 5 years.
C. Schedule regular surveillance imaging.
D. Perform urgent angiography to assess for rupture risk.
E. Discharge with advice to return if pain worsens significantly.
Mark this as a high-quality question
Mark this as a poor-quality or problematic question

A 65-year-old patient with a history of DVT presents with sudden onset dyspnoea and pleuritic chest pain. Examination is unremarkable except for mild tachypnoea. Wells score is 4. Which initial investigation is most appropriate in the diagnostic pathway?

A. D-dimer
B. Lower limb ultrasound
C. V/Q scan
D. CT Pulmonary Angiogram (CTPA)
E. Chest X-ray
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

An 82-year-old woman is admitted to the hospital with increasing shortness of breath and intermittent chest discomfort over the past week. She reports some difficulty swallowing larger food boluses recently but denies significant heartburn. Her past medical history includes hypertension and osteoarthritis. On examination, her vital signs are stable: BP 135/85 mmHg, HR 78 bpm, RR 18/min, SpO2 94% on room air, Temp 36.8°C. Auscultation of the chest reveals decreased breath sounds at the left base. A central venous catheter is noted in the right subclavian vein. Initial blood tests show a mild normocytic anaemia (Hb 105 g/L) and normal inflammatory markers. An urgent imaging study is performed. Considering the clinical presentation and the findings on the imaging study, which of the following is the most likely underlying cause of the patient's anaemia?

A. Chronic mucosal erosion within the displaced viscus
B. Vitamin B12 deficiency secondary to impaired absorption from dysphagia
C. Anaemia of chronic disease exacerbated by her underlying osteoarthritis
D. Acute blood loss from a peptic ulcer distal to the pylorus
E. Microangiopathic haemolytic anaemia associated with the indwelling central venous catheter
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

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

A. Insert an intercostal chest drain
B. Administer intravenous vitamin K and prothrombin complex concentrate (PCC)
C. Perform a diagnostic thoracentesis
D. Observe and repeat INR in 6 hours
E. Administer intravenous protamine sulfate
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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 woman on warfarin for chronic atrial fibrillation presents with increasing pain in her right leg over the past 48 hours. Her INR is 4.0. Examination reveals the findings in the image. What is the MOST likely underlying cause?

A. Protein S deficiency
B. Prothrombin gene mutation
C. Antithrombin III deficiency
D. Factor V Leiden mutation
E. Protein C deficiency
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 68-year-old man presents with a 4-month history of increasing constipation alternating with loose stools, occasional rectal bleeding, and fatigue. He denies significant weight loss. Physical examination is unremarkable. Full blood count shows a haemoglobin of 115 g/L with low ferritin. A colonoscopy was performed, and the image provided is a representative view. Biopsies were taken from the observed lesion. Considering the clinical presentation and the endoscopic finding, what is the most appropriate next investigation to determine the extent of disease and inform definitive management planning?

A. PET scan
B. CT scan of chest, abdomen, and pelvis
C. Bone scan
D. Endoscopic ultrasound
E. MRI of the pelvis
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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. Assuming that subsequent investigation of the area highlighted in the image confirms a diagnosis of ductal carcinoma in situ (DCIS) and the patient undergoes breast-conserving surgery, which of the following factors is most important in determining the need for adjuvant radiotherapy?

A. Patient's body mass index (BMI)
B. Margin status of the surgical excision specimen
C. Oestrogen receptor status of the DCIS cells
D. Ki-67 proliferation index of the DCIS cells
E. Presence of metastatic disease on staging scans
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 65-year-old man presents to the emergency department with a 2-day history of worsening left lower quadrant abdominal pain, associated with fever and chills. He reports a change in bowel habit with increased constipation. On examination, he is febrile at 38.6°C and has significant tenderness and guarding in the left iliac fossa. His white cell count is 18 x 10^9/L. A CT scan of the abdomen and pelvis is performed (image provided). Considering the patient's presentation and the findings on the provided image, which of the following represents the most appropriate initial management step in addition to intravenous antibiotics?

A. Percutaneous drainage of the identified collection.
B. Urgent laparoscopic sigmoid colectomy.
C. Close observation with serial abdominal examinations.
D. Commencement of oral metronidazole and discharge home.
E. Flexible sigmoidoscopy to assess mucosal inflammation.
Mark this as a high-quality question
Mark this as a poor-quality or problematic question
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.
Mark this as a high-quality question
Mark this as a poor-quality or problematic question