emergency medicine

A 32-year-old woman presents to the ED with acute lower abdominal pain and nausea. She reports her last menstrual period was 6 weeks ago, and home pregnancy test was negative yesterday. Vitals are stable. A CT scan of the abdomen and pelvis is performed, the relevant image is shown. What is the MOST appropriate next step in management?

A 60-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. On examination, there is a new diastolic murmur. What is the most appropriate initial investigation?

A 45-year-old man presents to the emergency department with severe epigastric pain radiating to the back. He has a history of alcohol use disorder and has been drinking heavily over the past week. On examination, he is febrile, tachycardic, and has abdominal tenderness. Laboratory tests reveal elevated serum lipase and amylase levels. What is the most appropriate initial management for this patient?

A 3-year-old boy presents to the emergency department with a 24-hour history of intermittent, severe abdominal pain. His mother reports episodes where he cries inconsolably, draws his knees to his chest, and then seems to recover briefly before the pain returns. He has also passed a stool mixed with mucus and blood, described as 'red currant jelly'. On examination, the child is afebrile, but appears pale and lethargic. Abdominal palpation reveals a sausage-shaped mass in the right upper quadrant. An ultrasound is performed, and a representative image is shown. Assuming the diagnosis is confirmed, what is the MOST appropriate next step in management?

A 38-year-old male presents to the emergency department with a 2-day history of intermittent abdominal pain, nausea, and vomiting. He reports passing dark, tarry stools. He has a known history of multiple cutaneous hemangiomas since childhood. On examination, his abdomen is distended and tender to palpation, particularly in the periumbilical region. Bowel sounds are hyperactive. Vitals are: HR 110 bpm, BP 100/60 mmHg, RR 20 breaths/min, SpO2 97% on room air, Temp 37.2°C. A CT scan of the abdomen and pelvis is performed, and a representative image is shown. Given the clinical presentation and imaging findings, what is the MOST appropriate initial management strategy?

A 45-year-old woman presents to the ED with right upper quadrant pain, fever, and nausea for 2 days. Her vital signs are: BP 130/80 mmHg, HR 105 bpm, Temp 38.5°C, RR 18 bpm, SpO2 98% on room air. An abdominal CT scan with contrast is performed, and a slice is shown. What is the MOST appropriate next step in management?

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 25-year-old man presents to the emergency department with a 2-day history of severe headache, photophobia, and neck stiffness. He has no significant past medical history and is not on any medications. On examination, he is febrile with a temperature of 39°C, and there is a positive Brudzinski's sign. What is the most appropriate initial investigation to confirm the diagnosis?

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 45-year-old woman presents to the emergency department with severe right upper quadrant abdominal pain that started suddenly 3 hours ago. She describes the pain as sharp and radiating to her right shoulder. She has a history of gallstones but has never had surgery. On examination, she is febrile with a temperature of 38.5°C, her blood pressure is 110/70 mmHg, and her heart rate is 100 bpm. She has tenderness in the right upper quadrant with a positive Murphy's sign. Laboratory tests reveal leukocytosis and mildly elevated liver enzymes. An abdominal ultrasound shows gallstones and a thickened gallbladder wall with pericholecystic fluid. What is the most appropriate next step in the management of this patient?

A 62-year-old male presents to the emergency department complaining of left lower quadrant abdominal pain for the past three days. He describes the pain as constant and sharp, rating it an 8 out of 10. He also reports nausea, decreased appetite, and subjective fevers. His past medical history is significant for hypertension and hyperlipidemia, both well-controlled with medications. He denies any recent travel or sick contacts. On physical examination, his abdomen is tender to palpation in the left lower quadrant with guarding. Bowel sounds are present but diminished. The remainder of his examination is unremarkable. His vital signs are: Temperature 38.2°C, Heart Rate 98 bpm, Blood Pressure 140/90 mmHg, Respiratory Rate 18 breaths per minute, and Oxygen Saturation 98% on room air. Laboratory results show a white blood cell count of 14,000/µL with a neutrophilic predominance. A CT scan of the abdomen and pelvis with intravenous contrast is performed, and a representative image is shown. Assuming the patient has no allergies, what is the MOST appropriate initial management strategy?

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 78-year-old male on warfarin presents to the ED after a fall. He complains of dyspnea and right-sided chest pain. His INR is 5.0. Vitals: HR 110, BP 100/60, RR 28, SpO2 90% on room air. The provided image was obtained. What is the MOST appropriate next step?

A 32-year-old woman presents to the ED with acute lower abdominal pain. She reports nausea but denies fever or vaginal bleeding. Her last menstrual period was 3 weeks ago. A CT scan of the abdomen and pelvis is performed, the relevant image is shown. What is the MOST appropriate next step in management?

A 32-year-old male presents to the emergency department with a 3-day history of worsening abdominal pain, primarily localized to the right lower quadrant. He reports associated nausea and decreased appetite but denies vomiting or diarrhea. His past medical history is significant for Crohn's disease, diagnosed 8 years ago, managed with intermittent courses of oral corticosteroids and azathioprine. He admits to poor adherence to his azathioprine regimen over the past year. On examination, he is afebrile with a heart rate of 92 bpm, blood pressure of 120/80 mmHg, and oxygen saturation of 98% on room air. Abdominal examination reveals tenderness to palpation in the right lower quadrant with guarding. Bowel sounds are normoactive. Laboratory investigations reveal a white blood cell count of 11,500/µL with neutrophilia, a C-reactive protein (CRP) of 45 mg/L, and normal liver function tests. A CT scan of the abdomen and pelvis with IV contrast is performed, the relevant images of which are shown. Given the patient's presentation and imaging findings, which of the following is the MOST appropriate next step in management?

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

A 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 67-year-old man presents to the emergency department with sudden onset of severe headache, nausea, and vomiting. He has a history of hypertension and is currently on amlodipine. On examination, he is drowsy but arousable, with a blood pressure of 210/120 mmHg and a heart rate of 90 bpm. Neurological examination reveals a left-sided hemiparesis and a right-sided facial droop. A CT scan of the head shows a hyperdense lesion in the right basal ganglia with surrounding edema. Which of the following is the most appropriate initial management step?

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 45-year-old male presents to the ED with left flank pain radiating to his groin. He reports nausea but no vomiting. Vitals are stable. A focused ultrasound is performed, as shown. What is the MOST appropriate next step in management?

A 45-year-old man presents to the emergency department with sudden onset of severe headache, nausea, and vomiting. He describes the headache as the worst he has ever experienced. He has a history of hypertension but is otherwise healthy. On examination, he is alert but in distress due to the headache. His blood pressure is 180/110 mmHg, heart rate is 90 bpm, and he has no focal neurological deficits. A CT scan of the head shows no acute intracranial hemorrhage. What is the next best step in management?

A 32-year-old woman presents to the emergency department with sudden onset of severe headache, nausea, and photophobia. She has no significant past medical history and is not on any medications. On examination, she is alert but in distress due to the headache. Her vital signs are stable, and there is no neck stiffness. A CT scan of the head is performed and shows no abnormalities. What is the most appropriate next step in the management of this patient?

A 68-year-old male presents to the ED with colicky abdominal pain, nausea, and vomiting. He reports no bowel movements for 3 days. His abdomen is distended and tender. An X-ray is performed. Given the findings, what is the MOST likely underlying cause of this patient's condition?

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

A 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. What is the MOST appropriate next step in the management of this patient?

A 78-year-old man presents to the emergency department with acute, severe right groin pain and a palpable, non-reducible mass. He reports associated nausea but denies vomiting or changes in bowel habit. His vital signs are within normal limits, and bowel sounds are audible. A CT scan of the pelvis is performed, the findings of which are depicted in the image. Given the clinical context and the information revealed by the imaging study, what is the most appropriate immediate management strategy?

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 38-year-old male presents to the emergency department complaining of sudden onset, severe left flank pain that radiates to his groin. He reports associated nausea and vomiting. He denies any fever, dysuria, or hematuria. His vital signs are stable: blood pressure 120/80 mmHg, heart rate 88 bpm, respiratory rate 16 breaths/min, and temperature 37.0°C. A urinalysis reveals microscopic hematuria. A point-of-care ultrasound is performed, and the image is shown. Given the clinical presentation and ultrasound findings, what is the MOST appropriate next step in management?

A 58-year-old male presents to the emergency department complaining of severe, constant right upper quadrant pain for the past 12 hours. He reports associated nausea and several episodes of non-bilious vomiting. He denies any fever or chills. His past medical history includes type 2 diabetes mellitus and hypertension, both managed with oral medications. On examination, the patient is alert and oriented. His vital signs are: temperature 37.2°C, heart rate 105 bpm, blood pressure 150/90 mmHg, respiratory rate 20 breaths/min, and SpO2 97% on room air. Abdominal examination reveals significant tenderness to palpation in the right upper quadrant, with guarding. Murphy's sign is positive. Laboratory investigations reveal a white blood cell count of 14,000/µL with neutrophilic predominance, total bilirubin of 2.5 mg/dL, alkaline phosphatase of 250 U/L, ALT of 150 U/L, and AST of 120 U/L. The provided image was obtained. Given the clinical scenario and the findings on the image, which of the following is the MOST appropriate initial management strategy?

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

A patient with severe lower GI bleeding refractory to colonoscopy requires further management. Which intervention is most appropriate if the bleeding source is suspected in the small bowel or inaccessible colon?

A 45-year-old male presents to the ED with left flank pain radiating to his groin. He reports nausea but no vomiting. Vitals are stable. A focused ultrasound is performed, as shown. What is the MOST appropriate next step in management?

A 63-year-old man presents to the ED with increasing shortness of breath and epigastric discomfort, particularly after meals. He has a history of GERD managed with occasional antacids. Physical examination reveals decreased breath sounds at the left lung base. A CT scan of the abdomen and pelvis is performed, the axial view is shown. What is the MOST appropriate next step in management?

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

A 75-year-old female presents to the emergency department with a 24-hour history of worsening colicky abdominal pain, nausea, and multiple episodes of bilious vomiting. She reports no passage of flatus or stool for the past 18 hours. Her past medical history includes an open appendectomy 30 years ago and a hysterectomy 10 years ago. On examination, she is afebrile, heart rate 92 bpm, blood pressure 130/80 mmHg, respiratory rate 18/min, oxygen saturation 98% on room air. Her abdomen is distended and diffusely tender to palpation, with high-pitched tinkling bowel sounds on auscultation. A plain abdominal X-ray series, including the image provided, was obtained. Considering the patient's clinical presentation and the findings demonstrated in the provided image, which of the following represents the most appropriate immediate next step in her management?

A 68-year-old male presents to the ED with left lower quadrant abdominal pain, fever, and leukocytosis. A CT scan of the abdomen and pelvis is performed. Based on the image, what is the MOST appropriate next step in management?

A 68-year-old male presents with a 3-day history of abdominal pain, distension, and obstipation, with a background of multiple abdominal surgeries. Vitals show HR 110, BP 110/70, T 37.8°C. Physical exam reveals a distended abdomen with high-pitched bowel sounds. An upright abdominal X-ray is shown. Considering the clinical findings and the radiographic appearance, which of the following potential complications is the MOST critical to evaluate for urgently?

A 45-year-old man presents to the emergency department with sudden onset of severe headache, described as the worst headache of his life. He also reports nausea and photophobia. On examination, he is alert but in distress, with a blood pressure of 160/100 mmHg, heart rate of 90 bpm, and no focal neurological deficits. A CT scan of the head is performed and shows no acute intracranial hemorrhage. What is the most appropriate next step in management?

A 55-year-old male presents with LLQ pain, fever, and increased WBC. A CT scan is performed. He is hemodynamically stable. Based on the image, which of the following is the MOST appropriate initial management strategy?

A 45-year-old male presents to the ED with left flank pain radiating to his groin. He reports nausea but no vomiting. Vitals are stable. A focused assessment with sonography for trauma (FAST) exam is performed, with a view obtained as shown. What is the MOST appropriate next step in management?

A 32-year-old male, originally from a high-TB prevalence country, presents to the emergency department with a persistent cough for the past 3 weeks, night sweats, and a 5 kg weight loss. He denies any fever or shortness of breath. Physical examination reveals normal breath sounds bilaterally, with no wheezes or crackles. His vital signs are stable: temperature 37.2°C, heart rate 88 bpm, blood pressure 120/80 mmHg, and oxygen saturation 98% on room air. A chest X-ray was initially interpreted as showing a possible lung mass, prompting further investigation with a PET-CT scan, the axial view of which is shown. Sputum samples have been sent for microscopy and culture, but results are pending. Given the clinical presentation and the imaging findings, what is the MOST appropriate next step in management?

A 68-year-old male presents to the ED with left lower quadrant abdominal pain, fever, and leukocytosis. A CT scan of the abdomen and pelvis is performed. Based on the imaging, what is the MOST appropriate next step in management?

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 28-year-old woman presents to the emergency department with severe lower abdominal pain and vaginal bleeding. She is 8 weeks pregnant by last menstrual period. She reports no fever or chills. On examination, her blood pressure is 100/60 mmHg, heart rate is 110 bpm, and she appears pale and diaphoretic. Abdominal examination reveals tenderness in the lower quadrants without rebound tenderness or guarding. A pelvic examination shows a closed cervical os with moderate bleeding. A bedside transvaginal ultrasound reveals an empty uterus. Which of the following is the most appropriate next step in management?

A 68-year-old male presents to the ED with left lower quadrant abdominal pain, fever, and leukocytosis. A CT scan of the abdomen and pelvis is performed. Based on the imaging, what is the MOST appropriate next step in management?

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

A 62-year-old woman presents to the emergency department with acute onset of chest pain and shortness of breath. She describes the pain as sharp and worse with inspiration. She has a history of deep vein thrombosis and is currently on warfarin. On examination, her blood pressure is 110/70 mmHg, heart rate is 110 bpm, respiratory rate is 24 breaths per minute, and oxygen saturation is 88% on room air. Her jugular venous pressure is elevated, and she has clear lung fields on auscultation. An ECG shows sinus tachycardia with right axis deviation. Which of the following is the most likely diagnosis?

A 42-year-old male presents to the emergency department with a 3-day history of colicky abdominal pain, nausea, and vomiting. He reports that he has not had a bowel movement in 2 days and has noticed some blood in his vomit. He has a known history of multiple cutaneous hemangiomas since childhood. On examination, his abdomen is distended and tympanic, with tenderness to palpation in all quadrants. Bowel sounds are high-pitched and infrequent. Vitals are stable. A CT scan of the abdomen and pelvis is performed, and a representative image is shown. What is the MOST likely underlying cause of the patient's acute presentation, considering his history and the imaging findings?