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emergency management

Practice targeted AMC-style multiple-choice questions on emergency management.

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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 68-year-old man presents to the emergency department with a 2-day history of worsening left lower quadrant abdominal pain, associated with subjective fever, chills, and nausea. He reports some recent constipation. His past medical history includes hypertension and hyperlipidaemia, both well-controlled on medication. On examination, his temperature is 38.5°C, pulse 95 bpm, BP 130/80 mmHg, respiratory rate 18/min, oxygen saturation 98% on room air. Abdominal examination reveals tenderness and guarding in the left iliac fossa, with mild rebound tenderness. Bowel sounds are reduced. Digital rectal examination is unremarkable. Blood tests show a white cell count of 15 x 10^9/L (neutrophils 85%), haemoglobin 145 g/L, platelets 250 x 10^9/L, C-reactive protein of 120 mg/L. Urea, electrolytes, and creatinine are within normal limits. Liver function tests are normal. A CT scan of the abdomen and pelvis is performed (image provided). Considering the clinical presentation and the findings demonstrated in the provided image, which of the following represents the most appropriate initial management strategy?

A. Administration of oral antibiotics and analgesia, followed by discharge home with instructions for follow-up with his general practitioner.
B. Percutaneous drainage of the identified collection under imaging guidance, in addition to intravenous antibiotics.
C. Urgent surgical consultation for consideration of immediate laparoscopic sigmoid colectomy.
D. Preparation for urgent colonoscopy to assess the extent and severity of the inflammatory process.
E. Commencement of intravenous broad-spectrum antibiotics and close clinical observation, deferring any intervention unless clinical deterioration occurs.
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset intermittent severe abdominal pain, vomiting, and lethargy. On examination, he is pale and has a palpable mass in the right upper quadrant. An ultrasound is performed (image provided). Based on this finding, what is the most appropriate next step in management?

A. Upper gastrointestinal endoscopy
B. Pneumatic or hydrostatic enema reduction
C. Immediate surgical exploration
D. Abdominal CT scan with contrast
E. Observation with serial abdominal exams
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A GP working in a hospital is observed getting into arguments with colleagues. Later, a colleague finds her disoriented and walking in the hallway. What is the most appropriate initial step?

A. Assume it is a personal matter and take no immediate action.
B. Advise the GP to go home and rest.
C. Talk to the GP privately to understand the issue.
D. Document the observations in the GP's personnel file.
E. Notify a superior or relevant authority (e.g., medical supervisor, head of department).
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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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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 55-year-old man presents with 2 days of left lower quadrant pain and mild constipation. He denies fever, nausea, or vomiting. On examination, he is afebrile, BP 120/70, HR 65, O2 sat 99% on air. There is mild LLQ tenderness without guarding or rebound. Bloods show WCC 11.5, CRP 30. 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. Urgent surgical consultation for potential colectomy
B. Discharge with analgesia and advice to return if symptoms worsen
C. Admission for intravenous antibiotics and observation
D. Colonoscopy within 24 hours to assess severity
E. Outpatient oral antibiotics and analgesia
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents to the emergency department with a 2-week history of progressively worsening non-bilious vomiting, which has become projectile over the past few days. His parents report he is feeding eagerly but vomits most feeds shortly after completion. He has had fewer wet nappies than usual and appears more lethargic. On examination, he is irritable but consolable. His weight is below the 3rd percentile, having dropped from the 10th percentile at birth. Vital signs are: Temperature 36.8°C, Heart Rate 155 bpm, Respiratory Rate 40 bpm, Blood Pressure 85/50 mmHg, Oxygen Saturation 98% on room air. Capillary refill time is 3 seconds. Abdominal examination reveals a soft, non-distended abdomen with active bowel sounds; no palpable masses are appreciated. Initial blood gas shows pH 7.52, pCO2 40 mmHg, Bicarbonate 32 mmol/L, Na+ 132 mmol/L, K+ 3.0 mmol/L, Cl- 88 mmol/L. A point-of-care ultrasound was performed, and the image provided was obtained. Considering the clinical presentation, the laboratory results, and the findings demonstrated in the image, which of the following represents the most appropriate immediate therapeutic intervention?

A. Intravenous administration of 5% dextrose in 0.45% sodium chloride.
B. Oral rehydration therapy with an electrolyte solution.
C. Urgent surgical consultation for pyloromyotomy without prior fluid resuscitation.
D. Placement of a nasogastric tube for continuous gastric drainage.
E. Intravenous administration of 0.9% sodium chloride with added potassium chloride.
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A patient with community-acquired pneumonia has a CURB-65 score of 3. What is the most appropriate management setting?

A. Outpatient management with IV antibiotics
B. Outpatient management with oral antibiotics
C. ICU management
D. Inpatient management
E. Observation unit
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 45-year-old male with a known history of Blue Rubber Bleb Naevus Syndrome, characterised by recurrent gastrointestinal bleeding and multiple cutaneous vascular lesions, presents to the emergency department with acute onset severe, colicky abdominal pain, nausea, and vomiting. On examination, his abdomen is distended and diffusely tender with reduced bowel sounds. Vital signs are within normal limits. An urgent abdominal CT scan is performed. Based on the clinical presentation and the findings demonstrated in the image, what is the most appropriate immediate next step in management?

A. Urgent surgical exploration and reduction/resection
B. Attempt air enema reduction under fluoroscopy
C. Urgent upper gastrointestinal endoscopy for reduction
D. Nasogastric tube insertion, intravenous fluids, and observation
E. Obtain an urgent abdominal MRI for further characterisation
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents to the emergency department with a 12-hour history of sudden onset, severe, colicky abdominal pain, drawing his legs up, and non-bilious vomiting. His parents report he has been listless between episodes and had a small amount of red jelly-like stool earlier. Vitals: T 37.2°C, HR 110, RR 24, BP 95/60, Sats 98% on air. Abdominal examination reveals tenderness in the right upper quadrant and a palpable mass. Bowel sounds are diminished. A point-of-care ultrasound is performed. Based on the clinical presentation and the findings demonstrated in the provided ultrasound image, what is the most appropriate initial management step for this patient?

A. Initiate intravenous antibiotics and observe for improvement.
B. Proceed directly to urgent surgical exploration.
C. Attempt pneumatic or hydrostatic reduction under fluoroscopic guidance.
D. Administer opioid analgesia and arrange for outpatient follow-up.
E. Obtain a contrast-enhanced CT scan of the abdomen and pelvis.
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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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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with a low-grade fever (38.1°C) and mild nausea. He denies vomiting, diarrhoea, or rectal bleeding. On examination, he has localised tenderness in the left iliac fossa. His vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, SpO2 98% on air. Blood tests show a white cell count of 12.5 x 10^9/L and CRP 45 mg/L. An abdominal CT scan is performed (image provided). Based on the clinical presentation and the provided image, what is the most appropriate setting for this patient's initial management?

A. Inpatient admission for intravenous antibiotics and observation.
B. Outpatient management with oral antibiotics and analgesia.
C. Admission for bowel rest and total parenteral nutrition.
D. Urgent surgical consultation for potential intervention.
E. Discharge home with only analgesia and dietary advice.
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 45-year-old male with a known history of Blue Rubber Bleb Naevus Syndrome, characterised by recurrent gastrointestinal bleeding and multiple cutaneous vascular lesions, presents to the emergency department with acute onset severe, colicky abdominal pain, nausea, and vomiting. On examination, his abdomen is distended and diffusely tender with reduced bowel sounds. Vital signs are within normal limits. An urgent abdominal CT scan is performed. Considering the patient's history, acute presentation, and the findings on the abdominal CT scan, what is the most appropriate immediate management strategy?

A. Urgent surgical consultation for operative management
B. Attempt non-operative reduction via hydrostatic or pneumatic enema
C. Perform urgent upper and lower endoscopy to identify bleeding lesions
D. Initiate conservative management with intravenous fluids and nasogastric tube insertion
E. Administer broad-spectrum antibiotics and observe closely
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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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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 68-year-old male presents with a 2-day history of worsening left lower quadrant abdominal pain, fever (38.5°C), and nausea. He has a history of similar, milder pain episodes. Examination reveals left iliac fossa tenderness with guarding. Bloods show WCC 16, CRP 120. A CT scan is performed (image provided). Considering the clinical picture and the imaging findings, which of the following represents the most appropriate initial management strategy?

A. Administer intravenous fluids and analgesia, and observe in the emergency department for 12 hours.
B. Initiate intravenous broad-spectrum antibiotics and admit for inpatient care.
C. Arrange urgent surgical review for consideration of immediate operative intervention.
D. Prescribe oral antibiotics and arrange follow-up with his general practitioner.
E. Schedule an urgent colonoscopy to evaluate the severity and rule out malignancy.
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents with increasing frequency of non-bilious vomiting after feeds for the past week. He is otherwise well, afebrile, and has wet nappies. On examination, he is alert and interactive. Abdominal examination is unremarkable. Vitals are stable. You order an ultrasound, which is shown. Based on the clinical presentation and the provided image, what is the most appropriate immediate next step in management?

A. Obtain an upper gastrointestinal barium study.
B. Discharge home with advice on feeding techniques and follow-up.
C. Proceed directly to surgical pyloromyotomy.
D. Initiate intravenous fluid resuscitation and correct electrolyte abnormalities.
E. Prescribe a proton pump inhibitor and trial smaller, more frequent feeds.
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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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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 male with acute cholangitis is undergoing ERCP for stone extraction. The image is obtained after cannulation. Based on the findings, what is the most appropriate immediate next step in the procedure?

A. Insert nasobiliary drain
B. Terminate procedure and give antibiotics
C. Attempt basket extraction
D. Endoscopic sphincterotomy
E. Perform mechanical lithotripsy
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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 65-year-old man presents with 2 days of left lower quadrant abdominal pain, fever, and nausea. On examination, he is afebrile, haemodynamically stable, with localised tenderness in the LLQ. Blood tests show a WCC of 14.5. A CT scan of the abdomen and pelvis is performed. Considering the clinical presentation and the findings demonstrated in the image, what is the most appropriate initial management plan?

A. Admission for IV antibiotics and observation
B. Colonoscopy within 24 hours
C. Urgent surgical consultation for laparotomy
D. Outpatient oral antibiotics and analgesia
E. Discharge with advice to return if symptoms worsen
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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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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 65-year-old patient recently started on warfarin for deep vein thrombosis presents with a painful, expanding skin lesion on their leg. They report the lesion appeared suddenly and has worsened over the past 24 hours. INR is 2.8. Considering the clinical presentation and the appearance of the lesion, what is the most appropriate immediate management step?

A. Apply topical corticosteroids and compression bandaging.
B. Administer broad-spectrum antibiotics and debride the lesion.
C. Obtain a tissue biopsy for histopathology and culture.
D. Stop warfarin and initiate heparin and vitamin K.
E. Increase the warfarin dose and monitor INR closely.
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Ovarian Cyst
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 28-year-old female presents to the ED with acute onset right lower quadrant pain. She reports nausea and vomiting. Her last menstrual period was 6 weeks ago, and she denies any vaginal bleeding. She is hemodynamically stable. A CT scan of the abdomen and pelvis is performed, with a relevant image shown. Considering the clinical presentation and the imaging findings, what is the MOST appropriate next step in the management of this patient?

A. Order a pelvic ultrasound
B. Administer intravenous fluids and observe for symptom resolution
C. Outpatient follow-up with repeat imaging in 6 weeks
D. Laparoscopic surgical exploration
E. Initiate broad-spectrum antibiotics
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An 80-year-old man with known severe COPD and stable ischaemic heart disease presents to the emergency department with a 2-day history of worsening shortness of breath, increased cough productive of yellow sputum, and ankle swelling. He is usually independent but now struggles to walk across a room. On examination: Alert but distressed. BP 130/85 mmHg, HR 110 bpm, RR 28 breaths/min, Temp 37.8°C, SpO2 88% on room air. Chest examination reveals diffuse wheezes and crackles bilaterally, reduced air entry at the bases. JVP is elevated to 5 cm above the sternal angle. Mild pitting edema to the knees. ECG shows sinus tachycardia, no acute ischaemic changes. Chest X-ray shows hyperinflation, flattened diaphragms, increased bronchial markings, and mild interstitial prominence. Given this presentation, what is the most appropriate initial management step?

A. Administer controlled oxygen therapy aiming for SpO2 88-92% and nebulised bronchodilators.
B. Administer intravenous broad-spectrum antibiotics.
C. Perform urgent echocardiogram.
D. Administer intravenous furosemide.
E. Administer high-flow oxygen via non-rebreather mask.
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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 78-year-old male presents to the emergency department with a 6-hour history of sudden onset, severe pain and swelling in his right groin. He reports nausea but no vomiting. On examination, there is a tender, firm, non-reducible lump in the right inguinal region. Bowel sounds are present. Vitals are stable: BP 130/80, HR 75, Temp 36.8°C. A CT scan of the pelvis is performed, shown in the image. Integrating the patient's symptoms, physical examination, and the findings shown in the image, what is the most appropriate immediate next step?

A. Attempt manual reduction under sedation
B. Discharge home with analgesia and follow-up in outpatient clinic
C. Order an urgent abdominal X-ray series
D. Administer broad-spectrum antibiotics and observe
E. Urgent surgical consultation and exploration
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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 58-year-old male presents to the emergency department complaining of right groin pain that started approximately 6 hours ago. He reports noticing a bulge in his groin for several months, which he could usually push back in. However, today he is unable to reduce it, and the pain has become progressively severe. He denies any fever, nausea, or vomiting. His past medical history includes hypertension and hyperlipidemia, both well-controlled with medications. On examination, his vital signs are stable: blood pressure 130/80 mmHg, heart rate 80 bpm, respiratory rate 16 bpm, and temperature 37.0°C. Abdominal examination is benign. Examination of the groin reveals the finding shown in the image. The area is tender to palpation. Which of the following is the MOST appropriate next step in the management of this patient?

A. Surgical consultation for emergent repair
B. Ultrasound of the groin to rule out testicular torsion
C. Prescription for a truss and referral to a general surgeon for elective repair
D. CT scan of the abdomen and pelvis with intravenous contrast
E. Trial of manual reduction with sedation and analgesia
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A 35-year-old man, recently arrived from a country with a high burden of tuberculosis, presents to the emergency department with a 2-week history of worsening headache, low-grade fever, and general malaise. Over the past 48 hours, he has become increasingly drowsy and confused. He denies cough, weight loss, or night sweats. His past medical history is unremarkable, and he is not on any regular medications. On examination, he is febrile (38.5°C), drowsy but rousable, with a Glasgow Coma Scale (GCS) of 13/15 (E3 V4 M6). His neck is stiff, and Kernig's sign is positive. Fundoscopy is normal. Chest auscultation is clear. Neurological examination reveals no focal deficits. Initial blood tests show a mild lymphocytosis, normal electrolytes, and normal renal and liver function. A non-contrast CT scan of the brain shows subtle basal meningeal enhancement. A lumbar puncture is performed. CSF Results: * Appearance: Slightly turbid * Opening pressure: 25 cm H2O (elevated) * White cell count: 150 cells/µL (normal <5), 80% lymphocytes * Red cell count: 5 cells/µL * Protein: 1.5 g/L (normal 0.15-0.45) * Glucose: 1.8 mmol/L (normal 2.5-4.5), simultaneous blood glucose 5.5 mmol/L Given the clinical presentation and investigation findings, what is the most appropriate immediate next step in management?

A. Start empirical broad-spectrum antibiotics (e.g., ceftriaxone and vancomycin).
B. Wait for the results of CSF Gram stain, bacterial culture, and mycobacterial culture before initiating specific therapy.
C. Perform an urgent MRI of the brain to better delineate meningeal involvement.
D. Administer intravenous acyclovir for possible viral encephalitis/meningitis.
E. Initiate empirical anti-tuberculosis therapy including rifampicin, isoniazid, pyrazinamide, and ethambutol, along with adjunctive corticosteroids.
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A 62-year-old man presents to the emergency department with acute onset chest pain radiating to his left arm and jaw, accompanied by diaphoresis and nausea. He has a history of hypertension, type 2 diabetes mellitus, and hyperlipidemia. On examination, his blood pressure is 160/95 mmHg, heart rate is 95 bpm, respiratory rate is 20 breaths per minute, and oxygen saturation is 96% on room air. An ECG shows ST-segment elevation in leads II, III, and aVF. Initial troponin levels are elevated. He is given aspirin and clopidogrel in the emergency department. Which of the following is the most appropriate next step in management?

A. Urgent percutaneous coronary intervention (PCI)
B. Intravenous nitroglycerin
C. Coronary artery bypass grafting (CABG)
D. Intravenous thrombolysis
E. Beta-blocker administration
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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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A 43-year-old is unconscious with low blood glucose (1.8 mmol/L), has a history of insulin use and alcohol intake. What is the next step?

A. 16G IV + 10% glucose, 150-200 ml over 15 minutes.
B. Give oral glucose.
C. Give 1 mg of glucagon intramuscularly.
D. Give IV 50% glucose.
E. Give subcutaneous insulin.
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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
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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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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset, intermittent, severe abdominal pain, vomiting, and lethargy. Examination reveals a palpable mass. Vitals stable. Ultrasound performed. Based on the clinical presentation and the provided image, what is the most appropriate next step in management?

A. Urgent surgical exploration
B. Pneumatic reduction under fluoroscopy
C. Abdominal CT scan with contrast
D. Admission for observation and IV fluids
E. Administration of broad-spectrum antibiotics
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset intermittent severe abdominal pain, vomiting, and lethargy. On examination, he is pale but haemodynamically stable. Abdominal examination reveals a palpable mass in the right upper quadrant. An ultrasound is performed (image provided). What is the most appropriate next step in management?

A. Administration of broad-spectrum antibiotics
B. Admission for observation and IV fluids
C. Abdominal CT scan with contrast
D. Immediate surgical exploration
E. Air or hydrostatic enema reduction
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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with a low-grade fever (38.1°C) and mild nausea. He denies vomiting, diarrhoea, or rectal bleeding. On examination, he has localised tenderness in the left iliac fossa. His vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, SpO2 98% on air. Blood tests show a white cell count of 12.5 x 10^9/L and CRP 45 mg/L. An abdominal CT scan is performed (image provided). Based on the clinical presentation and the provided image, what is the most appropriate initial management plan?

A. Intravenous antibiotics and hospital admission for observation.
B. Urgent surgical consultation for Hartmann's procedure.
C. Immediate colonoscopy to evaluate the colonic mucosa.
D. Discharge with advice on dietary modification and follow-up in 6 weeks.
E. Outpatient oral antibiotics and analgesia.
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

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

A. Colonoscopy to assess the severity
B. Inpatient management with intravenous antibiotics
C. Percutaneous drainage of the collection
D. Urgent surgical consultation for laparotomy
E. Outpatient oral antibiotics and clear fluid diet
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A 10-year-old boy with a known history of asthma presents to the emergency department. He developed symptoms three days after a viral upper respiratory tract infection. On examination, he is tachypnoeic (respiratory rate 48 breaths/min), tachycardic (heart rate 130 bpm), and hypoxic with an oxygen saturation of 91% on room air. He is speaking only in short phrases but remains alert and is afebrile. Auscultation reveals a widespread wheeze throughout his chest. A COVID swab performed yesterday was negative. Which investigation is the most appropriate next step in the immediate management of this patient?

A. Full Blood Count (FBC)
B. No further diagnostics are required immediately.
C. Chest X-ray
D. Peak Expiratory Flow (PEF) measurement
E. Arterial Blood Gas (ABG)
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 5-week-old male infant presents with a 10-day history of non-bilious, forceful vomiting after every feed. His parents report decreased wet nappies and lethargy. On examination, he is pale, weighs 3.2 kg (birth weight 3.5 kg), has sunken eyes, and poor skin turgor. Vital signs: HR 170, RR 45, Temp 37.0, BP 80/50. Initial bloods show Na 132, K 3.1, Cl 88, HCO3 30. An imaging study is performed, shown in the image. Considering the clinical presentation and the findings demonstrated in the imaging study, what is the most appropriate immediate management priority for this infant?

A. Administer intravenous ondansetron to control vomiting.
B. Arrange urgent surgical consultation for definitive operative management.
C. Initiate intravenous fluid resuscitation with 0.9% sodium chloride and potassium supplementation.
D. Obtain a repeat imaging study using abdominal ultrasound.
E. Insert a nasogastric tube for gastric decompression and feeding.
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An 80-year-old man presents with new confusion, cough, and fever. He has a history of COPD. On exam, he is tachypnoeic and has crackles at the right base. His oxygen saturation is 88% on room air. What is the most appropriate initial investigation?

A. Bronchoscopy
B. C-reactive protein
C. Sputum Gram stain and culture
D. High-resolution CT chest
E. Chest X-ray
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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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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
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Ultrasonographic picture taken from a patient with left ureteral stone with hydronephrosis, created in Taiwan
Image by morning2k CC BY 2.5 · Source

A 55-year-old man presents to the emergency department with sudden onset, severe left flank pain radiating to his groin, associated with nausea. He is afebrile, blood pressure 130/80 mmHg, heart rate 85 bpm. Urinalysis shows 20-30 red blood cells per high-power field. Serum creatinine is within normal limits. An ultrasound is performed. Considering the clinical context and the findings demonstrated in the provided image, which of the following is the most appropriate immediate management step?

A. Initiate empirical broad-spectrum intravenous antibiotics.
B. Prescribe oral tamsulosin and diclofenac and discharge home.
C. Urgent urology consultation for potential decompression.
D. Administer intravenous fluids and opioid analgesia and observe for spontaneous stone passage.
E. Arrange a non-contrast CT KUB as the definitive imaging modality.
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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 a left homonymous hemianopia, mild right hemiparesis (4/5 strength), and intact sensation. A CT angiogram was performed, and the patient underwent endovascular coiling. The image shows a follow-up angiogram post-procedure. Despite the intervention, the patient's left homonymous hemianopia persists, and her right hemiparesis has not improved. What is the MOST appropriate next step in the management of this patient?

A. Repeat angiography to assess for recanalization or further aneurysm growth
B. Start rehabilitation therapy and monitor for improvement
C. Order an MRI of the brain to evaluate for ischemic changes
D. Prescribe a course of high-dose corticosteroids to reduce peri-aneurysmal edema
E. Initiate dual antiplatelet therapy with aspirin and clopidogrel
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A 58-year-old man presents to the emergency department with severe epigastric pain radiating to the back, which started suddenly 6 hours ago. He has a history of alcohol use disorder and has been consuming large amounts of alcohol daily for the past 10 years. On examination, he is diaphoretic and in distress, with a blood pressure of 100/60 mmHg, heart rate of 120 bpm, and respiratory rate of 22 breaths per minute. Abdominal examination reveals tenderness in the epigastric region with guarding. Laboratory tests show elevated serum amylase and lipase levels. Which of the following is the most appropriate initial management step?

A. Intravenous fluid resuscitation
B. Immediate surgical consultation
C. Administration of proton pump inhibitors
D. Initiation of broad-spectrum antibiotics
E. Nasogastric tube insertion
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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with subjective fever and chills. He denies nausea, vomiting, or change in bowel habits. On examination, he is afebrile, heart rate 85 bpm, blood pressure 130/80 mmHg. Abdominal examination reveals tenderness in the left iliac fossa without guarding or rebound. White cell count is 14 x 10^9/L, CRP 80 mg/L. A CT scan of the abdomen and pelvis is performed, the relevant axial image is shown. Considering the patient's presentation and the findings on the provided image, which of the following represents the most appropriate initial management strategy?

A. Discharge with only analgesia and advice to return if symptoms worsen
B. Urgent colonoscopy to assess the affected segment
C. Urgent surgical consultation for potential colectomy
D. Immediate inpatient admission for intravenous antibiotics
E. Outpatient management with oral antibiotics and analgesia
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For severe community-acquired pneumonia requiring ICU admission, which adjunctive therapy is recommended?

A. High-dose Vitamin C
B. IV Immunoglobulin
C. Prophylactic Antifungals
D. Corticosteroids
E. Nebulised Saline
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 45-year-old male with a known history of Blue Rubber Bleb Naevus Syndrome, characterised by recurrent gastrointestinal bleeding and multiple cutaneous vascular lesions, presents to the emergency department with acute onset severe, colicky abdominal pain, nausea, and vomiting. On examination, his abdomen is distended and diffusely tender with reduced bowel sounds. Vital signs are within normal limits. An urgent abdominal CT scan is performed. Based on the clinical presentation and the findings demonstrated in the image, what is the most appropriate immediate next step in management?

A. Initiate broad-spectrum antibiotics for suspected peritonitis
B. Endoscopic evaluation of the small bowel
C. Barium enema for hydrostatic reduction
D. Laparotomy for reduction and resection of affected segments
E. Conservative management with nasogastric tube decompression and observation
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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

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

A. Attempt manual reduction of the mass under conscious sedation
B. Order an urgent ultrasound of the groin to assess for vascular compromise
C. Administer intravenous fluids and analgesia, then observe for signs of spontaneous reduction over 24 hours
D. Urgent surgical consultation for operative management
E. Prescribe oral antibiotics and arrange for outpatient surgical review within one week
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A 45-year-old man presents to the emergency department with sudden onset of severe chest pain radiating to his back. He describes the pain as tearing in nature. He has a history of hypertension and is a smoker. On examination, his blood pressure is 180/110 mmHg in the right arm and 160/100 mmHg in the left arm. His heart rate is 110 bpm, and he has a new diastolic murmur. An ECG shows left ventricular hypertrophy but no ischemic changes. What is the most appropriate next step in management?

A. Immediate thrombolysis
B. Chest X-ray
C. Echocardiography
D. Coronary angiography
E. CT angiography of the chest
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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. Administer subcutaneous low molecular weight heparin and continue warfarin.
B. Initiate broad-spectrum antibiotics and arrange for surgical debridement.
C. Reduce the dose of warfarin and monitor the lesion closely.
D. Administer fresh frozen plasma to correct the INR and continue warfarin at a lower dose.
E. Stop warfarin, administer intravenous Vitamin K, and initiate therapeutic dose unfractionated heparin.
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A 62-year-old man presents to the emergency department with sudden onset chest pain and shortness of breath that started 2 hours ago while he was gardening. He describes the pain as a tightness across his chest, radiating to his left arm. He has a history of hypertension and hyperlipidemia, and he is a current smoker. On examination, his blood pressure is 150/90 mmHg, heart rate is 110 bpm, respiratory rate is 22 breaths per minute, and oxygen saturation is 94% on room air. He appears anxious and diaphoretic. An ECG shows ST-segment elevation in leads II, III, and aVF. Which of the following is the most appropriate immediate management step?

A. Administer intravenous morphine for pain relief
B. Administer beta-blockers to control heart rate
C. Administer oxygen to maintain saturation above 95%
D. Administer aspirin and initiate primary percutaneous coronary intervention (PCI)
E. Administer sublingual nitroglycerin and observe for response
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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

A 3-year-old boy presents with sudden onset, intermittent, severe abdominal pain, vomiting, and lethargy. His vital signs are stable. On examination, he is pale. An abdominal ultrasound is performed, shown in the image. Based on the clinical presentation and imaging findings, what is the most appropriate next step in management?

A. Admission for intravenous fluids and observation
B. Urgent laparotomy for surgical reduction
C. Administer intravenous broad-spectrum antibiotics
D. Pneumatic reduction under fluoroscopic guidance
E. Obtain a CT scan of the abdomen and pelvis
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