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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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A 62-year-old man with a history of hypertension and type 2 diabetes mellitus presents to the emergency department complaining of palpitations and lightheadedness. He reports that the symptoms started suddenly about an hour ago. He denies any chest pain, shortness of breath, or syncope. His medications include metformin and lisinopril. On examination, he is alert and oriented. His blood pressure is 110/70 mmHg, heart rate is irregularly irregular at 140 bpm, respiratory rate is 18 breaths per minute, and oxygen saturation is 97% on room air. An ECG is performed, which shows an absence of P waves, irregularly irregular R-R intervals, and narrow QRS complexes. Which of the following is the most appropriate next step in the management of this patient?

A. Synchronized cardioversion
B. Vagal maneuvers
C. Administration of intravenous magnesium sulfate
D. Intravenous amiodarone
E. Rate control with intravenous diltiazem
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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 patient with community-acquired pneumonia has a CURB-65 score of 3. What is the most appropriate management setting?

A. Outpatient management
B. Outpatient management with daily review
C. Intensive care unit
D. Inpatient management on a general medical ward
E. Inpatient management, considering higher level care
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An 80-year-old woman is brought to the emergency department from a nursing home due to increased lethargy and confusion over the past 24 hours. Her history includes dementia, hypertension, and type 2 diabetes. Nursing staff report poor oral intake for 48 hours and a recent cough. On examination, she is drowsy but rousable. Her vital signs are: BP 85/50 mmHg, HR 110 bpm, RR 22 breaths/min, Temp 37.8°C, SpO2 94% on air. Capillary refill time is 4 seconds. Chest auscultation reveals decreased breath sounds at the bases. Abdomen is soft. Urine dipstick shows leukocytes and nitrites. She is on lisinopril and metformin. What is the most appropriate initial management step?

A. Administer intravenous fluid bolus (e.g., 500 mL crystalloid)
B. Administer oral rehydration solution
C. Obtain a chest X-ray and urine culture
D. Discontinue lisinopril and monitor blood pressure
E. Administer broad-spectrum intravenous antibiotics
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A 58-year-old man presents to the emergency department with chest pain radiating to his left arm. His ECG shows ST-segment elevation in leads II, III, and aVF. What is the most appropriate immediate management?

A. Administer thrombolytic therapy
B. Perform an echocardiogram to assess cardiac function
C. Administer sublingual nitroglycerin and observe
D. Start intravenous heparin and admit to the coronary care unit
E. Administer aspirin and initiate primary percutaneous coronary intervention (PCI)
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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. Vitals are stable. An ultrasound is performed, shown above. Based on the clinical presentation and the provided image, what is the most appropriate next step in the management of this patient?

A. Urgent surgical consultation for laparotomy
B. Administration of broad-spectrum antibiotics
C. CT scan of the abdomen and pelvis
D. Admission for observation and serial abdominal exams
E. Air enema reduction
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A 68-year-old man presents to the emergency department with 90 minutes of crushing chest pain radiating to his left arm. He is diaphoretic and anxious. ECG shows 3mm ST elevation in leads V2-V4. His blood pressure is 130/80 mmHg, heart rate 75 bpm. What is the most appropriate immediate next step in management?

A. Arrange urgent coronary CT angiography
B. Administer dual antiplatelet therapy and heparin
C. Prepare for intravenous fibrinolysis
D. Activate the cardiac catheterisation laboratory for primary PCI
E. Obtain serial cardiac biomarkers
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A 3-year-old boy is brought to the emergency department by his parents due to a high fever and irritability. He has had a runny nose and cough for the past two days. On examination, he is lethargic and has a bulging fontanelle. A lumbar puncture is performed, and the cerebrospinal fluid (CSF) analysis shows elevated protein, low glucose, and a high white cell count with a predominance of neutrophils. What is the most likely diagnosis?

A. Tuberculous meningitis
B. Bacterial meningitis
C. Subdural hematoma
D. Viral meningitis
E. Encephalitis
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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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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. Given the clinical scenario and the imaging findings, what is the MOST appropriate next step in management?

A. Order a repeat CT scan with intravenous contrast in 6 hours to assess for bowel ischemia
B. Prescribe oral analgesics and instruct the patient to follow up with his general practitioner in 24 hours
C. Surgical consultation for emergent operative intervention
D. Attempt manual reduction with intravenous sedation and analgesia
E. Administer broad-spectrum antibiotics and observe for improvement
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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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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 55-year-old woman presents with 2 days of worsening right upper quadrant pain radiating to her back, nausea, and subjective fever. On examination, she is tender in the RUQ. Vitals are stable. Labs show WCC 15.0, CRP 120. This image is obtained. Based on the clinical presentation and imaging findings, what is the most appropriate next step in management?

A. Continue medical management with IV antibiotics and analgesia
B. Laparoscopic cholecystectomy within 24-72 hours
C. Urgent endoscopic retrograde cholangiopancreatography (ERCP)
D. Repeat abdominal ultrasound in 24 hours
E. Percutaneous cholecystostomy tube insertion
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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 68-year-old man presents to the emergency department with a 3-day history of left lower quadrant abdominal pain, associated with mild fever (38.1°C) and constipation. On examination, he has localised tenderness in the left iliac fossa without guarding or rebound. His blood pressure is 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 bpm. Blood tests show a white cell count of 12.5 x 10^9/L (normal range 4-11). A CT scan of the abdomen and pelvis is performed (image provided). Considering the patient's presentation and the findings demonstrated in the image, which of the following represents the most appropriate initial management strategy?

A. Discharge with advice on a low-residue diet and follow-up in 6 months.
B. Admission for intravenous antibiotics and close observation.
C. Urgent colonoscopy to evaluate the affected segment.
D. Outpatient management with oral antibiotics and analgesia.
E. Urgent surgical consultation for Hartmann's procedure.
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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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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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A 70-year-old male presents to the emergency department with severe abdominal and back pain. He has a history of hypertension and smoking. On examination, he is hypotensive and tachycardic. Palpation reveals a pulsatile abdominal mass. What is the most likely diagnosis?

A. Ruptured abdominal aortic aneurysm
B. Renal colic
C. Acute pancreatitis
D. Myocardial infarction
E. Diverticulitis
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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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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. Based on the clinical presentation and the findings demonstrated in the image, what is the most appropriate immediate next step in the management of this patient?

A. Order a follow-up ultrasound in 24 hours
B. Urgent surgical exploration and repair
C. Attempt manual reduction under sedation
D. Administer intravenous antibiotics and observe
E. Discharge home with analgesia and advice to return if symptoms worsen
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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 a 12-hour history of intermittent, severe abdominal pain, drawing his legs up to his chest. He has vomited several times. His vital signs are stable: HR 110, BP 95/60, RR 24, Temp 37.2°C. On examination, he is irritable but comfortable between episodes of pain. His abdomen is soft but mildly distended. A focused abdominal ultrasound is performed, yielding the image provided. Based on the clinical presentation and the findings shown, which of the following non-surgical interventions is typically attempted first to resolve the underlying issue?

A. Nasogastric tube insertion for decompression and bowel rest
B. Pneumatic reduction under fluoroscopic guidance
C. Administration of intravenous opioids for pain control followed by observation
D. Intravenous fluid resuscitation and broad-spectrum antibiotics
E. Urgent surgical exploration and manual reduction
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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 45-year-old male presents to the emergency department with sudden onset severe left flank pain radiating to the groin. He reports some nausea but no vomiting. His temperature is 37.5°C, pulse 88 bpm, BP 130/80 mmHg, respiratory rate 16/min, oxygen saturation 98% on room air. On examination, he has significant left costovertebral angle tenderness. Urinalysis shows microscopic haematuria and trace leukocytes. His creatinine is 90 µmol/L (baseline unknown). An ultrasound of the kidneys is performed, shown in the image. Based on the clinical presentation and the finding shown in the image, what is the most appropriate immediate next step in management?

A. Admit for observation, serial renal function tests, and pain management.
B. Arrange urgent non-contrast CT scan of the kidneys, ureters, and bladder.
C. Arrange urgent flexible cystoscopy and retrograde pyelography.
D. Administer intravenous fluids, opioid analgesia, and prescribe tamsulosin for medical expulsive therapy.
E. Urgent urology consultation for consideration of upper tract decompression.
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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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A patient is given an antiemetic and subsequently develops spasticity of the back. What is the most appropriate initial management?

A. Administer parenteral benztropine.
B. Increase the dose of the antiemetic.
C. Administer oral diazepam.
D. Refer for physiotherapy.
E. Stop all medications.
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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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Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct.
Image by Samir धर्म at en.wikipedia CC BY-SA 3.0 · Source

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

A. Attempt balloon dilation of the distal duct without sphincterotomy
B. Place a biliary stent and schedule follow-up ERCP
C. Perform endoscopic sphincterotomy
D. Attempt stone fragmentation with lithotripsy before sphincterotomy
E. Abandon the procedure and refer for surgical exploration
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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 78-year-old female on warfarin for chronic atrial fibrillation presents to the emergency department with a 24-hour history of increasing pain and discolouration in her right lower leg. She denies trauma or recent falls. Her INR this morning was 2.5 (target 2.0-3.0). Vital signs are stable: BP 130/80, HR 75, RR 16, Temp 36.8°C. Examination reveals the findings shown in the image. Considering the patient's history, current medication, and the clinical appearance depicted, what is the most appropriate immediate management?

A. Discontinue warfarin, administer Vitamin K, and initiate heparin or LMWH.
B. Arrange urgent surgical debridement of the affected area.
C. Increase the dose of warfarin and monitor INR closely.
D. Initiate broad-spectrum intravenous antibiotics.
E. Perform a Doppler ultrasound of the leg veins.
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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 and the findings demonstrated in the image, what is the most appropriate immediate next step in the management of this infant?

A. Administer intravenous ondansetron and observe for improvement in vomiting.
B. Discharge home with instructions for smaller, more frequent feeds and review by the general practitioner in 24 hours.
C. Insert a nasogastric tube for continuous drainage and commence total parenteral nutrition.
D. Obtain an urgent upper gastrointestinal contrast study to confirm the diagnosis and assess for malrotation.
E. Initiate intravenous fluid resuscitation with 0.9% sodium chloride and potassium chloride supplementation, and arrange urgent surgical consultation.
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A 70-year-old man with a history of atrial fibrillation presents with sudden onset of severe pain, pallor, and coldness in his left leg. On examination, the leg is cool below the knee, distal pulses are absent, and sensation is diminished. Which of the following is the most appropriate initial diagnostic investigation?

A. Venous duplex ultrasound of the limb
B. Serum lactate level
C. CT angiography of the limb
D. Arterial duplex ultrasound of the limb
E. ECG
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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.
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 6-week-old male infant presents to the emergency department with a 5-day history of progressively worsening non-bilious vomiting, which has become projectile over the past 48 hours. He is exclusively formula-fed and his parents report decreased wet nappies and increased irritability. On examination, he is alert but appears slightly lethargic. His weight is below his birth weight. Capillary refill time is 3 seconds. Vitals are: HR 150 bpm, RR 40 bpm, T 37.2°C, BP 85/50 mmHg. Abdominal examination is soft, non-distended, and no masses are definitely palpable. Initial blood gas shows pH 7.52, pCO2 40 mmHg, HCO3 32 mmol/L, Na+ 130 mmol/L, K+ 3.0 mmol/L, Cl- 85 mmol/L. Urea and creatinine are mildly elevated. An imaging study was performed, shown above. Considering the clinical presentation and the findings on the imaging study, which of the following is the most critical immediate management step?

A. Initiate intravenous fluid resuscitation with 0.9% sodium chloride and potassium supplementation.
B. Insert a nasogastric tube for gastric decompression.
C. Administer intravenous ondansetron to control vomiting.
D. Arrange for urgent surgical consultation for pyloromyotomy.
E. Obtain a paediatric surgical ultrasound of the abdomen.
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A 45-year-old man with a history of hypertension presents to the emergency department with palpitations and lightheadedness. His ECG shows a regular narrow-complex tachycardia at a rate of 180 bpm. There are no visible P waves, and the QRS duration is 0.08 seconds. He is hemodynamically stable. Which of the following is the most appropriate initial management?

A. Synchronized cardioversion
B. Observation without intervention
C. Intravenous adenosine
D. Vagal maneuvers
E. Intravenous metoprolol
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A 34-year-old man presents to the Emergency Department with acute-onset shortness of breath. A CT pulmonary angiogram (CTPA) is ordered, shown in the photograph, confirming a diagnosis of pulmonary embolism. Which of the following is the most appropriate initial treatment option for this patient?

A. Thrombolytic therapy.
B. Caval filter.
C. Unfractionated heparin or low-molecular weight heparin (LMWH).
D. Dabigatran.
E. Warfarin.
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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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Ovarian Cyst
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 28-year-old female presents with sudden onset severe right lower quadrant pain, associated with nausea and one episode of vomiting. Her last menstrual period was 6 weeks ago. On examination, she is afebrile, heart rate 88, blood pressure 120/70. Abdominal examination reveals tenderness in the right iliac fossa. A CT scan of the abdomen and pelvis is performed, with a relevant axial image shown. Considering the clinical presentation and the findings demonstrated in the image, what is the MOST appropriate immediate next step in the management of this patient?

A. Perform a diagnostic laparoscopy to confirm appendicitis
B. Order a pelvic ultrasound for further characterisation
C. Arrange for outpatient follow-up with gynaecology
D. Laparoscopic surgical exploration
E. Administer broad-spectrum antibiotics
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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 specific findings demonstrated in the provided image, which of the following interventions is most likely to be required in addition to intravenous antibiotics and supportive care?

A. Administration of oral laxatives to relieve constipation
B. Urgent surgical resection of the affected bowel segment
C. Percutaneous drainage of a fluid collection
D. Placement of a nasogastric tube for bowel decompression
E. Endoscopic stenting of a colonic stricture
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An electrocardiogram (ECG) shows a supraventricular tachycardia (SVT). What is the first-line treatment?

A. Adenosine
B. Verapamil
C. Valsalva maneuver
D. Synchronized cardioversion.
E. Beta-blockers
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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 55-year-old man presents to the emergency department with crushing chest pain radiating to his left arm and jaw. He is diaphoretic and appears anxious. An ECG shows ST-segment elevation in leads II, III, and aVF. What is the most appropriate immediate management?

A. Order a chest X-ray to rule out other causes
B. Start intravenous beta-blockers
C. Administer sublingual nitroglycerin
D. Provide oxygen therapy
E. Administer aspirin and initiate reperfusion therapy
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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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A 67-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. His blood pressure is 180/100 mmHg in the right arm and 160/90 mmHg in the left arm. He has a history of hypertension and is a smoker. An ECG shows no acute ischemic changes. What is the most appropriate next step in the management of this patient?

A. Start intravenous heparin
B. Administer sublingual nitroglycerin
C. Administer aspirin and clopidogrel
D. Order a CT angiography of the chest
E. Perform an urgent coronary angiogram
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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 a 12-hour history of intermittent, severe abdominal pain, drawing his legs up to his chest. He has vomited several times. His vital signs are stable: HR 110, BP 95/60, RR 24, Temp 37.2°C. On examination, he is irritable but comfortable between episodes of pain. His abdomen is soft but mildly distended. A focused abdominal ultrasound is performed, yielding the image provided. Based on the clinical presentation and the findings shown, what is the most appropriate initial therapeutic intervention?

A. Intravenous fluid resuscitation and pain control
B. Administer a nasogastric tube for decompression and observe
C. Air or hydrostatic enema under fluoroscopic guidance
D. Obtain a CT scan of the abdomen
E. Urgent surgical exploration
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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. Admission for observation and IV fluids
B. Air or hydrostatic enema reduction
C. Urgent surgical exploration
D. Abdominal CT scan with contrast
E. Intravenous antibiotics
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

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

A. Arrange for percutaneous drainage of the collection.
B. Prepare for urgent surgical resection of the affected bowel segment.
C. Transition to oral antibiotics and discharge home.
D. Request a repeat CT scan in 24 hours to assess for changes.
E. Continue intravenous antibiotics and monitor clinical progress.
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A 70-year-old man with a history of hypertension and heart failure is being managed with an ACE inhibitor. He presents to the emergency department complaining of dizziness, especially when standing up. His blood pressure is 90/60 mmHg, and his other vital signs are stable. Which of the following is the most appropriate initial step in managing this patient?

A. Order an ECG to rule out cardiac arrhythmia
B. Prescribe compression stockings
C. Review and potentially reduce the dose of the ACE inhibitor
D. Administer an intravenous bolus of normal saline
E. Start fludrocortisone
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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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