emergency medicine

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 68-year-old male presents to the emergency department complaining of abdominal pain, distension, and obstipation for the past 3 days. He reports a history of multiple abdominal surgeries for adhesions. His vital signs are: HR 110 bpm, BP 110/70 mmHg, RR 22 breaths/min, SpO2 97% on room air, and temperature 37.8°C. Physical examination reveals a distended abdomen with high-pitched bowel sounds. An upright abdominal X-ray is performed, as shown. Given the clinical context and the findings on the imaging, what is the MOST appropriate next imaging investigation to guide management?

A 67-year-old man with a history of type 2 diabetes mellitus and hypertension presents to the emergency department with sudden onset of right-sided weakness and slurred speech that began 2 hours ago. He has no history of atrial fibrillation or previous strokes. On examination, his blood pressure is 180/95 mmHg, heart rate is 88 bpm, and he is afebrile. Neurological examination reveals right-sided hemiparesis and expressive aphasia. A non-contrast CT scan of the head shows no evidence of hemorrhage. Which of the following is the most appropriate next step in the management of this patient?

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 presents to the ED with left flank pain radiating to his groin. He reports nausea but denies fever or dysuria. Vitals are stable. A point-of-care ultrasound is performed, with the image shown. Assuming no contraindications, 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 previously well 3-year-old boy presents to the emergency department with a 12-hour history of sudden onset, intermittent, severe, colicky abdominal pain, associated with non-bilious vomiting. Between episodes, he appears lethargic and pale. His vital signs are stable: HR 110, BP 90/60, RR 24, Temp 37.2. Abdominal examination reveals mild distension and tenderness, but no guarding or rebound. Bowel sounds are present. A point-of-care ultrasound is performed by the emergency physician. Considering the clinical presentation, the patient's current stable vital signs, and the specific findings demonstrated in the provided ultrasound image, which of the following represents the single most appropriate immediate next step in the management of this patient in an Australian tertiary paediatric centre?

A 62-year-old woman presents to the emergency department with a 2-day history of right upper quadrant abdominal pain, nausea, and vomiting. She reports that the pain started gradually but has become increasingly severe and constant. She denies any fever or chills. Her past medical history is significant for hypertension and hyperlipidemia, both well-controlled with medications. On physical examination, she is afebrile, with a heart rate of 92 bpm, blood pressure of 140/85 mmHg, and an oxygen saturation of 98% on room air. Abdominal examination reveals marked tenderness to palpation in the right upper quadrant with guarding. Murphy's sign is positive. The provided image was obtained. Which of the following is the MOST appropriate next step in the management of this patient?

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 68-year-old man with a history of poorly controlled type 2 diabetes, hypertension, and chronic kidney disease (stage 3) presents to the emergency department with severe abdominal pain and vomiting. On examination, he has a distended abdomen with diffuse tenderness and guarding. His vital signs show a blood pressure of 90/60 mmHg, heart rate of 110 bpm, and a temperature of 38.5°C. Laboratory tests reveal leukocytosis, elevated serum lactate, and worsening renal function. A CT scan of the abdomen shows pneumoperitoneum and free fluid, suggesting perforated viscus. What is the most appropriate next step in the management of this patient?

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

A 55-year-old female presents to the emergency department with a 24-hour history of severe right upper quadrant pain radiating to the back, associated with nausea, vomiting, and subjective fever. On examination, she is tachycardic (HR 105 bpm) and febrile (38.5°C), with marked tenderness and guarding in the right upper quadrant. Blood tests reveal a white cell count of 15 x 10^9/L and C-reactive protein of 120 mg/L. Liver function tests, including bilirubin, are within normal limits. She is initiated on intravenous fluids and broad-spectrum antibiotics. Imaging is obtained. Considering the patient's clinical status and the findings on the provided imaging, which of the following represents the most appropriate definitive management strategy?

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

A 78-year-old man with a history of chronic atrial fibrillation and hypertension presents to the emergency department with sudden onset of severe pain, numbness, and coldness in his left leg, starting approximately 3 hours ago. He is currently taking aspirin 100mg daily. On examination, his left foot and lower calf are pale and cool to touch. Pedal pulses are absent, popliteal pulse is weak. Sensation is decreased below the ankle, and motor function is preserved but weak. Capillary refill in the toes is delayed. His heart rate is irregularly irregular at 95 bpm, blood pressure 140/85 mmHg. What is the most appropriate initial management step?

A 72-year-old male presents to the ED with sudden onset shortness of breath and right-sided chest pain. He has a history of atrial fibrillation and has been taking warfarin for the past 5 years. His INR is currently 6.0. A CT scan of the chest is performed (image attached). What is the MOST appropriate initial management step?

A 32-year-old man presents to the emergency department with severe abdominal pain that started suddenly 6 hours ago. The pain is located in the right lower quadrant and is associated with nausea and vomiting. On examination, he has rebound tenderness and guarding in the right lower quadrant. His temperature is 37.8°C, heart rate is 110 beats per minute, and blood pressure is 120/80 mmHg. A CT scan of the abdomen shows an inflamed appendix with surrounding fat stranding. What is the most appropriate next step in management?

A 68-year-old male presents to the ED with abdominal distension, obstipation, and vomiting. He reports a history of multiple abdominal surgeries. An upright abdominal X-ray is performed. Based on the image, what is the MOST appropriate next step in management?

A 40-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, with a blood pressure of 180/110 mmHg, heart rate of 90 bpm, and respiratory rate of 18 breaths per minute. Neurological examination reveals neck stiffness but no focal neurological deficits. A CT scan of the head shows no acute intracranial hemorrhage. What is the most appropriate next step in the management of this patient?

A 62-year-old male presents to the emergency department with a 2-day history of right flank pain, fever, and nausea. He reports a history of recurrent urinary tract infections. On examination, he has right costovertebral angle tenderness. Urinalysis reveals pyuria and leukocyte esterase. Which of the following is the most likely underlying condition related to the organ primarily affected in the right lumbar region?

A 3-year-old boy presents with a 12-hour history of intermittent, severe abdominal pain, non-bilious vomiting, and decreased activity. Parents report redcurrant jelly stool. On exam, a palpable mass is noted. Vitals are stable. An ultrasound is performed (shown above). Considering the clinical picture and the image findings, which non-surgical intervention is indicated?

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 72-year-old male presents to the ED with sudden onset shortness of breath and right-sided chest pain. He reports a recent fall but denies any significant trauma. He has a history of atrial fibrillation and is currently taking warfarin. His INR is 6.5. A CT scan of the chest is performed (image attached). What is the MOST appropriate immediate next step in management?

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 70-year-old man with known atrial fibrillation presents with sudden onset of severe pain, pallor, and coldness in his left leg. Pulses are absent below the femoral artery. What is the most likely source of the embolus causing this presentation?

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 45-year-old woman presents to the ED with right upper quadrant pain, fever, and nausea for 24 hours. Her vital signs are: HR 110, BP 130/80, Temp 38.5°C. An abdominal CT scan is performed (image attached). What is the MOST appropriate next step in management?

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 30-year-old man presents to the emergency department with severe right lower quadrant abdominal pain, nausea, and vomiting. The pain started around the umbilicus and then localized to the right lower quadrant. On examination, he has tenderness and guarding in the right lower quadrant. His temperature is 38.3°C, heart rate is 100 bpm, and blood pressure is 120/80 mmHg. What is the most likely diagnosis?

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 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 68-year-old male presents to the ED with abdominal distension, obstipation, and vomiting. He reports a history of multiple abdominal surgeries. An upright abdominal X-ray is performed. Based on the image, what is the MOST appropriate next step in management?

A 78-year-old male presents to the emergency department with a 2-day history of intermittent upper abdominal pain radiating to the chest and mild dysphagia. He denies shortness of breath or fever. Vital signs are stable. A chest X-ray is obtained. Considering the radiographic findings in the context of the patient's presentation, what is the most appropriate immediate 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 45-year-old woman presents to the emergency department with acute onset of severe right upper quadrant abdominal pain radiating to the back, accompanied by nausea and vomiting. She has a history of gallstones but no previous surgeries. On examination, she is febrile with a temperature of 38.5°C, her heart rate is 110 bpm, and she has tenderness in the right upper quadrant with a positive Murphy's sign. Laboratory tests reveal elevated white blood cell count, elevated liver enzymes, and elevated serum amylase. An abdominal ultrasound shows gallstones and a thickened gallbladder wall. Which of the following is the most appropriate next step in management?

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?

An 82-year-old patient presents to the emergency department with a 3-month history of intermittent retrosternal chest discomfort, worse after meals, and mild shortness of breath on exertion. They report occasional regurgitation but deny significant dysphagia. Past medical history includes hypertension and osteoarthritis. Medications are perindopril and paracetamol. On examination, vital signs are stable, and lung sounds are clear. A chest X-ray is performed. Based on the findings in the image, what is the most appropriate next step in management or investigation?

A 62-year-old male presents to the ED with left lower quadrant abdominal pain, fever, and nausea for 3 days. His WBC count is 14,000. 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 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. Given the clinical presentation and the findings demonstrated in the provided image, which of the following is the most appropriate *next* investigation to guide definitive management?

A 72-year-old man with a history of hypertension and type 2 diabetes mellitus is being managed with lisinopril. He presents to the emergency department complaining of lip swelling and difficulty breathing. On examination, his tongue appears swollen. What is the most appropriate immediate management?

A 68-year-old male presents to the ED with left lower quadrant abdominal pain, fever, and nausea for 3 days. His WBC count is 14,000. 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 72-year-old male presents with abdominal distension, vomiting, and inability to pass flatus for 48 hours. He has a history of prior bowel resection. Examination reveals a tympanitic abdomen and tenderness to palpation. His vitals are stable. An abdominal X-ray is performed, as shown. Considering the clinical context and the radiographic findings, what is the primary purpose of inserting a nasogastric tube in this patient?

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?

An 98-year-old lady with cognitive impairment has had 2 episodes of acute delirium, is pacing, and is vomiting blood. What is the immediate 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 55-year-old man presents to the emergency department with sudden onset severe abdominal pain radiating to the back. He has a history of hypertension and is a smoker. On examination, he is diaphoretic and in distress, with a blood pressure of 90/60 mmHg and a heart rate of 110 bpm. Abdominal examination reveals a pulsatile mass in the midline. What is the most likely diagnosis?

A 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with fever (38.2°C) and mild nausea. He denies vomiting, diarrhoea, or rectal bleeding. On examination, he has localised tenderness in the left iliac fossa. His blood pressure is 130/80 mmHg, heart rate 85 bpm, respiratory rate 16 bpm. Blood tests show a white cell count of 14 x 10^9/L and CRP 80 mg/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 is the most appropriate initial management strategy?

Adult with suspected aspiration pneumonia. Initial antibiotic?