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emergency management

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

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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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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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A 7-year-old boy is brought to the emergency department by his parents due to sudden onset wheezing and difficulty breathing. He has a history of asthma, for which he uses a salbutamol inhaler as needed. His parents report that he had a cold over the past few days, and today he started wheezing and became short of breath. On examination, he is in moderate respiratory distress, with a respiratory rate of 30 breaths per minute, oxygen saturation of 92% on room air, and widespread wheezing on auscultation. What is the most appropriate initial management step for this child?

A. Administer nebulized salbutamol
B. Provide supplemental oxygen
C. Initiate inhaled corticosteroids
D. Start oral corticosteroids
E. Administer intravenous magnesium sulfate
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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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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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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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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 55-year-old patient with a history of solid organ transplant on immunosuppressive therapy presents with a two-week history of intermittent fever, chills, and dull right upper quadrant pain. On examination, there is mild tenderness in the right upper quadrant. Blood tests reveal a white cell count of 14 x 10^9/L and CRP of 120 mg/L. Imaging is performed. Considering the clinical context and the provided images, what is the most appropriate immediate next step in the management of this patient?

A. Arrange for repeat cross-sectional imaging in 4-6 weeks to assess for interval change
B. Schedule surgical exploration and debridement of the lesion
C. Order serological tests for common parasitic infections, including Echinococcus species
D. Percutaneous aspiration and drainage of the lesion for microbiological and pathological analysis
E. Initiate empirical broad-spectrum intravenous antibiotics covering typical bacterial pathogens
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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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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. On examination, his temperature is 38.5°C, pulse 95 bpm, BP 130/80 mmHg. Abdominal examination reveals tenderness and guarding in the left iliac fossa. Bowel sounds are reduced. Blood tests show a white cell count of 15 x 10^9/L (neutrophils 85%) and C-reactive protein of 120 mg/L. Urea, electrolytes, and creatinine are within normal limits. 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. Conservative management with analgesia and observation.
B. Oral antibiotics and outpatient management.
C. Urgent surgical resection of the affected segment.
D. Colonoscopy to assess the severity of diverticular disease.
E. Intravenous antibiotics and consider percutaneous drainage.
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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 65-year-old male presents to the emergency department with 2 days of constant right upper quadrant pain radiating to the back, associated with nausea and subjective fever. On examination, he is febrile (38.5°C) with significant tenderness and a positive Murphy's sign in the right upper quadrant. His white cell count is elevated at 15 x 10^9/L, and CRP is 120 mg/L. Liver function tests are within normal limits. Considering the clinical findings and the provided imaging, what is the most appropriate next step in the management of this patient?

A. Laparoscopic cholecystectomy within 24-72 hours
B. Urgent endoscopic retrograde cholangiopancreatography (ERCP)
C. Percutaneous cholecystostomy insertion
D. Repeat abdominal CT scan in 24 hours
E. Continue medical management with intravenous antibiotics and analgesia only
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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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What is the recommended initial antibiotic regimen for severe community-acquired pneumonia in an Australian adult requiring ICU admission?

A. Ceftriaxone plus azithromycin
B. Azithromycin monotherapy
C. Ciprofloxacin monotherapy
D. Doxycycline monotherapy
E. Amoxicillin
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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 woman presents to the emergency department with right upper quadrant abdominal pain, fever, and jaundice. Her vital signs are: temperature 38.5°C, heart rate 110 bpm, blood pressure 110/70 mmHg, respiratory rate 20 breaths per minute, and oxygen saturation 97% on room air. Initial laboratory investigations reveal: white blood cell count 14,000/µL, total bilirubin 6.0 mg/dL, alkaline phosphatase 450 U/L, ALT 300 U/L, and AST 250 U/L. An ERCP is performed, and the image is obtained. Following successful intervention, what is the MOST appropriate next step in managing this patient's condition?

A. Continue intravenous antibiotics and perform a percutaneous cholecystostomy tube placement.
B. Observe the patient without antibiotics and schedule an outpatient laparoscopic cholecystectomy in 6-8 weeks.
C. Administer intravenous antibiotics and schedule a laparoscopic cholecystectomy during the same admission.
D. Discharge the patient home with oral antibiotics and schedule an outpatient laparoscopic cholecystectomy.
E. Perform an open cholecystectomy during the same admission.
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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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A 68-year-old man with hypertension presents with sudden onset right-sided weakness and slurred speech. GCS is 13. BP 190/110 mmHg. What is the most critical initial investigation to guide management?

A. CT angiography
B. Lumbar puncture
C. Non-contrast CT head
D. ECG
E. MRI brain
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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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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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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 the clinical presentation and the image, what is the most appropriate next step in management?

A. Pneumatic reduction under fluoroscopy
B. Urgent surgical exploration
C. CT scan of the abdomen and pelvis
D. Admission for observation and IV fluids
E. Administration of broad-spectrum antibiotics
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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 32-year-old male presents to the emergency department complaining of intermittent abdominal pain, nausea, and vomiting for the past 24 hours. He reports passing a small amount of blood in his stool this morning. He denies any fever or chills. His past medical history is significant for multiple cutaneous hemangiomas, which he has had since childhood. On physical examination, his abdomen is mildly distended and tender to palpation in the periumbilical region. Bowel sounds are hyperactive. The patient is hemodynamically stable. A CT scan of the abdomen is performed, the results of which are shown. Given the clinical presentation and imaging findings, what is the MOST appropriate next step in the management of this patient?

A. Initiation of high-dose corticosteroids
B. Surgical exploration
C. Colonoscopy with biopsy
D. Barium enema
E. Observation with serial abdominal examinations
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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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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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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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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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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 patient with a known history of multiple cutaneous vascular lesions presents to the emergency department with a 2-day history of intermittent, colicky abdominal pain and nausea. They report chronic fatigue and have a history of iron deficiency anaemia requiring occasional transfusions. On physical examination, vital signs are stable (BP 120/80, HR 75, RR 16, Temp 36.8°C). There is mild diffuse abdominal tenderness without guarding or rebound. Cutaneous examination reveals multiple blue-purple papules and nodules scattered over the trunk and limbs. An abdominal CT scan is performed. Considering the patient's clinical presentation, known history, and the findings demonstrated in the provided image, what is the most appropriate initial management strategy?

A. Discharge home with oral analgesia and urgent outpatient gastroenterology follow-up.
B. Inpatient medical management with pain control, intravenous fluids, and close observation for signs of obstruction or bleeding.
C. Immediate referral for small bowel capsule endoscopy to identify bleeding sources.
D. Initiate empirical treatment with intravenous antibiotics for suspected enteritis.
E. Urgent surgical exploration for reduction of the identified findings.
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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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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 62-year-old male presents with acute onset of LLQ pain, fever, and vomiting. His WBC count is elevated. A CT scan of the abdomen and pelvis is performed. Based on the image, what is the most appropriate next step in management?

A. Flexible sigmoidoscopy
B. IV antibiotics and bowel rest
C. Stool softeners
D. Surgical resection
E. High-fiber diet
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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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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

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

A. Arrange for urgent bronchoscopy to investigate airway obstruction.
B. Increase warfarin dose and monitor INR.
C. Observe closely in the emergency department with serial chest X-rays.
D. Administer broad-spectrum antibiotics and arrange for thoracentesis.
E. Administer Vitamin K and Prothrombinex (PCC) and arrange for chest tube insertion.
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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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A 70-year-old man with severe COPD (FEV1 35%) presents with increased cough, purulent sputum, and dyspnoea over 48 hours. He uses salbutamol PRN and tiotropium daily. His oxygen saturation is 88% on room air. Chest X-ray shows hyperinflation but no new consolidation. What is the most appropriate initial management step?

A. Administer controlled oxygen therapy targeting SpO2 88-92%.
B. Perform arterial blood gas analysis.
C. Initiate intravenous antibiotics.
D. Prescribe high-dose inhaled corticosteroids.
E. Administer nebulised salbutamol and ipratropium bromide.
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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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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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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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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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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 intermittent severe abdominal pain, vomiting, and lethargy. On examination, he is afebrile with a soft but slightly distended abdomen. An ultrasound is performed (image provided). Based on the clinical presentation and the image findings, what is the most appropriate next step in the management of this patient?

A. Pneumatic reduction under fluoroscopy
B. Admission for observation and IV fluids
C. Discharge home with pain relief
D. CT abdomen and pelvis
E. Urgent surgical exploration
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An 80-year-old presents with CAP. CURB-65 score is 3. What is the most appropriate initial management?

A. Outpatient management with observation only
B. Inpatient management with IV antibiotics
C. Outpatient management with oral antibiotics
D. Inpatient management with oral antibiotics
E. Admission to ICU
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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 patient with a long history of recurrent gastrointestinal bleeding and multiple cutaneous vascular lesions presents with acute onset severe abdominal pain, nausea, and distension. Physical examination reveals a distended, mildly tender abdomen. Bowel sounds are reduced. Vital signs are stable. Imaging is performed. Considering the patient's presentation and the findings demonstrated in the image, which of the following represents the most appropriate initial management approach?

A. Urgent upper and lower endoscopy to identify bleeding source.
B. Initiation of systemic medical therapy targeting vascular malformations.
C. Further imaging with mesenteric angiography.
D. Laparotomy for reduction or resection of affected bowel segments.
E. Non-operative management with nasogastric tube decompression and intravenous fluids.
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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 woman on warfarin for chronic atrial fibrillation presents with a painful, rapidly expanding lesion on her right lower leg that began two days ago, shortly after her warfarin dose was increased. Her vital signs are stable, and her INR is within the therapeutic range. Considering the clinical presentation and the appearance of the lesion shown, what is the most appropriate immediate management?

A. Administer broad-spectrum antibiotics and arrange urgent surgical debridement.
B. Switch warfarin to a direct oral anticoagulant (DOAC).
C. Discontinue warfarin, administer vitamin K, and initiate heparin.
D. Continue warfarin at the current dose and monitor closely.
E. Reduce the warfarin dose and add aspirin.
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

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

A. Percutaneous drainage of the identified collection.
B. Urgent laparoscopic sigmoid colectomy.
C. Close observation with serial abdominal examinations.
D. Commencement of oral metronidazole and discharge home.
E. Flexible sigmoidoscopy to assess mucosal inflammation.
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An 82-year-old man with a history of COPD and mild dementia is brought to the emergency department by his family due to increased confusion over 24 hours. He has had a low-grade fever (37.8°C) and a mild cough for 3 days. On examination, he is drowsy but rousable. His oxygen saturation is 90% on room air. Chest auscultation reveals decreased breath sounds at the bases. A chest X-ray shows bilateral lower lobe infiltrates. His CURB-65 score is 3. Considering the patient's presentation and CURB-65 score, what is the most appropriate initial management plan?

A. Admission to hospital for observation and oral antibiotics.
B. Discharge home with supportive care and review in 24 hours.
C. Admission to ICU for mechanical ventilation and broad-spectrum antibiotics.
D. Outpatient management with oral antibiotics and close follow-up.
E. Admission to hospital with intravenous 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. Examination reveals a pale child with a soft abdomen. Vitals are stable. An abdominal ultrasound is performed (image provided). What is the most appropriate next step in management?

A. Admission for observation and serial abdominal exams
B. Intravenous antibiotics and fluid resuscitation
C. CT abdomen/pelvis with contrast
D. Pneumatic reduction under fluoroscopy
E. Urgent surgical exploration
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A 72-year-old man with a history of a reducible inguinal hernia presents to the emergency department with severe groin pain and a firm, tender mass in the right inguinal region. He reports that he has been unable to reduce the hernia despite his usual maneuvers. He also reports nausea and vomiting for the past 6 hours. On examination, his vital signs are stable, but he appears uncomfortable. The mass in his groin is erythematous and exquisitely tender to palpation. Which of the following is the most appropriate next step in management?

A. Administration of intravenous antibiotics and observation
B. Surgical exploration
C. CT scan of the abdomen and pelvis with intravenous contrast
D. Attempt manual reduction with sedation and analgesia
E. Ultrasound of the groin to assess blood flow
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An 80-year-old with COPD presents with fever, cough, and increased sputum. CXR shows consolidation. BP 85/50, HR 110, RR 28, SpO2 88% on air. Confused. What is the most appropriate initial management step?

A. Initiate high-flow oxygen therapy
B. Administer intravenous fluids and broad-spectrum antibiotics
C. Prescribe oral amoxicillin
D. Obtain blood cultures and sputum for microscopy/culture
E. Assess for immediate intubation and ventilation
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