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emergency management

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

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

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

A. Administration of oral antibiotics and analgesia, followed by discharge home with instructions for follow-up with his general practitioner.
B. Percutaneous drainage of the identified collection under imaging guidance, in addition to intravenous antibiotics.
C. Urgent surgical consultation for consideration of immediate laparoscopic sigmoid colectomy.
D. Preparation for urgent colonoscopy to assess the extent and severity of the inflammatory process.
E. Commencement of intravenous broad-spectrum antibiotics and close clinical observation, deferring any intervention unless clinical deterioration occurs.
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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old man presents to the emergency department with a 6-hour history of worsening pain in his right groin. He has a known right inguinal hernia that has been present for several years and was previously reducible, but he has been unable to push it back in today. The pain is now constant and severe, rated 8/10. He denies fever, chills, nausea, or vomiting. His vital signs are: temperature 37.2°C, heart rate 96 bpm, blood pressure 140/90 mmHg, respiratory rate 18 breaths/min, oxygen saturation 97% on room air. On examination, there is a firm, exquisitely tender, non-reducible mass in the right inguinal region. The overlying skin appears slightly erythematous. Bowel sounds are present and normal. An urgent CT scan of the abdomen and pelvis is performed, and a representative axial image is shown. Considering the clinical presentation and the findings demonstrated in the image, what is the MOST appropriate immediate next step in management?

A. Administer broad-spectrum intravenous antibiotics and observe for improvement.
B. Urgent surgical consultation for operative repair.
C. Order an urgent ultrasound of the groin to assess for vascular flow.
D. Arrange for elective outpatient surgical repair within the next week.
E. Attempt manual reduction of the hernia under sedation.
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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 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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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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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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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. Considering the patient's acute presentation, physical examination findings, and the specific anatomical relationship demonstrated in the image, what is the most critical potential complication requiring urgent surgical assessment?

A. Epididymo-orchitis
B. Deep vein thrombosis
C. Bowel strangulation
D. Peritonitis
E. Bowel obstruction
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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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An 82-year-old woman from an aged care facility presents with a 2-day history of increased confusion and lethargy. Her baseline is independent living with mild cognitive impairment. She has a chronic cough but no recent change in sputum. Vital signs: T 37.8°C, HR 95 bpm, BP 110/70 mmHg, RR 22 breaths/min, SpO2 92% on room air. Chest examination reveals decreased breath sounds at the right base. Given the clinical presentation and setting, which of the following is the most appropriate initial management step while awaiting the chest X-ray result?

A. Perform a CT scan of the chest to confirm the diagnosis.
B. Administer empiric broad-spectrum antibiotics covering typical and atypical pathogens.
C. Transfer to a tertiary hospital for specialist respiratory review.
D. Administer supplemental oxygen and monitor vital signs closely.
E. Obtain sputum culture and sensitivity before initiating 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 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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Diverticulitis in the left lower quadrant. There is outpouching of the colonic wall, wall thickening, and surrounding fat stranding.
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 65-year-old man presents with 2 days of left lower quadrant abdominal pain, fever, and nausea. On examination, he is afebrile, haemodynamically stable, with localised tenderness in the LLQ. Blood tests show a WCC of 14.5. A CT scan of the abdomen and pelvis is performed. Considering the clinical presentation and the findings demonstrated in the image, what is the most appropriate initial management plan?

A. Admission for IV antibiotics and observation
B. Colonoscopy within 24 hours
C. Urgent surgical consultation for laparotomy
D. Outpatient oral antibiotics and analgesia
E. Discharge with advice to return if symptoms worsen
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

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

A. Admission for intravenous antibiotics and observation.
B. Outpatient oral antibiotics and pain relief.
C. Elective colonoscopy in 6-8 weeks.
D. Percutaneous drainage of any fluid collection.
E. Urgent surgical consultation for laparotomy.
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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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A 60-year-old man presents to the emergency department with sudden onset of severe chest pain that radiates 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 heard best at the right sternal border. What is the most appropriate next step in management?

A. Administer sublingual nitroglycerin
B. Perform an ECG
C. Order a CT angiography of the chest
D. Administer aspirin
E. Start intravenous heparin
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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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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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A 10-year-old boy with a history of asthma presents to the emergency department with wheezing and shortness of breath. His mother reports that he has been using his salbutamol inhaler more frequently over the past two days. On examination, he has a respiratory rate of 28 breaths per minute, and his oxygen saturation is 92% on room air. What is the most appropriate initial management step?

A. Administer nebulized salbutamol
B. Administer intravenous magnesium sulfate
C. Provide supplemental oxygen
D. Increase the dose of inhaled corticosteroids
E. Start oral corticosteroids
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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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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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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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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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A 72-year-old man with a history of hypertension and atrial fibrillation presents to the emergency department with worsening shortness of breath and fatigue over the past two weeks. He reports occasional palpitations but denies chest pain or syncope. On examination, his blood pressure is 110/70 mmHg, heart rate is 130 bpm (irregularly irregular), respiratory rate is 22 breaths per minute, and oxygen saturation is 94% on room air. Jugular venous pressure is elevated, and there are bilateral lung crackles. An ECG shows atrial fibrillation with a rapid ventricular response. An echocardiogram reveals moderate mitral regurgitation and left atrial enlargement. Which of the following is the most appropriate initial management step?

A. Initiation of antiarrhythmic therapy with amiodarone
B. Rate control with intravenous diltiazem
C. Immediate electrical cardioversion
D. Initiation of oral anticoagulation
E. Referral for mitral valve surgery
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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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An ultrasound showing target sign which is a characteristic finding for intussusception on ultrasound, this ultrasound is for a 3 year old boy with intestinal intussusception.
Image by Frank Gaillard CC BY-SA 3.0 · Source

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

A. Administration of broad-spectrum antibiotics
B. Admission for observation and IV fluids
C. Abdominal CT scan with contrast
D. Immediate surgical exploration
E. Air or hydrostatic enema reduction
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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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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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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. Proceed with mechanical lithotripsy after sphincterotomy.
B. Place a biliary stent for decompression.
C. Attempt extraction with a balloon catheter after sphincterotomy.
D. Refer for urgent laparoscopic common bile duct exploration.
E. Terminate the procedure and manage medically.
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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 82-year-old man with a history of stroke presents with new onset confusion, a mild cough, and a temperature of 37.8°C. A chest X-ray reveals a right lower lobe infiltrate. Which of the following is the most appropriate initial management step?

A. Initiate empiric broad-spectrum antibiotics
B. Order urgent sputum culture
C. Administer IV fluids and monitor
D. Discharge home with oral paracetamol
E. Arrange urgent physiotherapy review
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A patient presents with severe community-acquired pneumonia. Which initial investigation is most crucial for guiding immediate management?

A. Blood cultures
B. Sputum culture
C. Full blood count
D. Chest X-ray
E. Arterial blood gas
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A 62-year-old woman with a 15-year history of type 2 diabetes mellitus presents to the emergency department with confusion, polyuria, and polydipsia over the past three days. She has been non-compliant with her medications and diet. On examination, she is lethargic and dehydrated, with a blood pressure of 100/60 mmHg, heart rate of 110 bpm, and respiratory rate of 20 breaths per minute. Laboratory tests reveal a blood glucose level of 38 mmol/L, serum sodium of 150 mmol/L, serum potassium of 4.0 mmol/L, serum bicarbonate of 22 mmol/L, and a serum osmolality of 340 mOsm/kg. Urinalysis shows no ketones. Which of the following is the most appropriate initial management step?

A. Intravenous potassium supplementation
B. Intravenous normal saline
C. Oral hypoglycemic agents
D. Intravenous sodium bicarbonate
E. Intravenous insulin infusion
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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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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, if outpatient management is deemed appropriate, which of the following antibiotic regimens is most consistent with current Australian guidelines?

A. Intravenous ceftriaxone and metronidazole for 5 days
B. Oral amoxicillin-clavulanate for 7-10 days
C. Oral metronidazole monotherapy for 14 days
D. Oral doxycycline for 7 days
E. Oral ciprofloxacin monotherapy for 5 days
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A 62-year-old man presents to the emergency department with a history of palpitations and dizziness that started suddenly 2 hours ago. He has a history of hypertension and is on lisinopril. He denies chest pain, shortness of breath, or syncope. On examination, his blood pressure is 110/70 mmHg, heart rate is 150 bpm (irregular), respiratory rate is 18 breaths per minute, and temperature is 36.7°C. An ECG is performed, showing an irregularly irregular rhythm with no distinct P waves and a narrow QRS complex. Which of the following is the most appropriate initial management step?

A. Initiation of anticoagulation therapy
B. Rate control with a beta-blocker
C. Immediate electrical cardioversion
D. Administration of adenosine
E. Rate control with digoxin
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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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A 68-year-old man with a history of diverticulosis presents with recurrent, large volume rectal bleeding. Initial colonoscopy failed to identify or control the source. He remains haemodynamically stable after resuscitation. What is the most appropriate next step in management?

A. Repeat colonoscopy with epinephrine injection
B. Administration of intravenous octreotide
C. Initiation of high-dose proton pump inhibitor therapy
D. Urgent surgical colectomy
E. Angiography with embolization
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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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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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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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A 45-year-old man presents to the emergency department with sudden onset of severe chest pain radiating to his back. He describes the pain as tearing in nature. He has a history of hypertension and is a smoker. On examination, his blood pressure is 180/110 mmHg in the right arm and 160/100 mmHg in the left arm. His heart rate is 110 bpm, and he has a new diastolic murmur. An ECG shows left ventricular hypertrophy but no ischemic changes. What is the most appropriate next step in management?

A. Immediate thrombolysis
B. Chest X-ray
C. Echocardiography
D. Coronary angiography
E. CT angiography of the chest
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Right leg affected by warfarin necrosis
Image by Bakoyiannis C, Karaolanis G, Patelis N, Maskanakis A, Tsaples G, Klonaris C, Georgopoulos S, Liakakos T CC BY 4.0 · Source

An 82-year-old woman with a history of paroxysmal atrial fibrillation and a recent hospitalisation for pneumonia was discharged 5 days ago on warfarin 5mg daily. She presents to the emergency department complaining of increasing pain and a rapidly evolving lesion on her right lower leg over the past 48 hours. She denies trauma. Her vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, Temp 36.8°C. Physical examination reveals the appearance shown in the image on her right anterior lower leg. Her INR today is 4.5. She has no known history of protein C or S deficiency. Considering the patient's history, current medication, laboratory result, and the clinical appearance depicted, which of the following represents the most appropriate immediate management strategy?

A. Administer subcutaneous low molecular weight heparin and continue warfarin.
B. Initiate broad-spectrum antibiotics and arrange for surgical debridement.
C. Reduce the dose of warfarin and monitor the lesion closely.
D. Administer fresh frozen plasma to correct the INR and continue warfarin at a lower dose.
E. Stop warfarin, administer intravenous Vitamin K, and initiate therapeutic dose unfractionated heparin.
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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 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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