emergency medicine
Practice targeted AMC-style multiple-choice questions on emergency medicine.
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A 32-year-old woman presents to the ED with acute lower abdominal pain and nausea. She reports her last menstrual period was 6 weeks ago, and home pregnancy test was negative yesterday. Vitals are stable. A CT scan of the abdomen and pelvis is performed, the relevant image is shown. What is the MOST appropriate next step in management?
A 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 55-year-old female presents to the emergency department with a 24-hour history of severe right upper quadrant pain radiating to her back, associated with nausea, vomiting, and subjective fever. On examination, she is febrile (38.5°C) and has marked tenderness and guarding in the right upper quadrant. Her vital signs are otherwise stable. 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 subsequently performed. Considering the patient's clinical presentation and the findings demonstrated in the provided imaging, what is the most appropriate definitive 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). Following successful management of this acute episode, what is the most appropriate next step regarding long-term assessment of the colon?
A 75-year-old male with a history of atrial fibrillation on warfarin presents to the emergency department with acute onset shortness of breath and right-sided chest pain. His vital signs are stable. His INR is found to be 7.2. A chest CT is performed (image attached). Based on the clinical presentation and imaging findings, what is the MOST appropriate immediate management step?
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 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 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, which of the following developments would most strongly necessitate urgent urological intervention?
A 78-year-old male on warfarin for atrial fibrillation presents 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 pharmacological agents is the most appropriate immediate intervention?
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 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 45-year-old male presents to the ED with left flank pain that started suddenly 6 hours ago. He describes the pain as a sharp, cramping sensation radiating to his groin. He also reports nausea and one episode of vomiting. His vital signs are stable: BP 120/80 mmHg, HR 78 bpm, RR 16 breaths/min, Temp 37.1°C. Urine dipstick shows 2+ blood. A renal ultrasound is performed, and the image is shown. Assuming the patient's pain is not controlled with oral analgesics, what is the MOST appropriate next step?
A 72-year-old male presents to the ED with increasing shortness of breath and epigastric pain, especially when lying down. He has a history of GORD, hypertension and COPD. His vitals are stable. An X-ray is performed. What is the MOST appropriate next step in 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 78-year-old man presents to the emergency department with acute, severe right groin pain and a palpable, non-reducible mass. He reports associated nausea but denies vomiting or changes in bowel habit. His vital signs are within normal limits, and bowel sounds are audible. A CT scan of the pelvis is performed, the findings of which are depicted in the image. Given the clinical context and the information revealed by the imaging study, what is the most appropriate immediate management strategy?
A 63-year-old man presents to the ED with increasing shortness of breath and epigastric discomfort, particularly after meals. He has a history of well-controlled hypertension and takes no regular medications. Physical examination reveals decreased breath sounds at the left lung base. An abdominal CT scan is performed, the axial view is shown. What is the MOST appropriate next step in management?
A 68-year-old male presents with abdominal pain, distension, and obstipation for 3 days, with a history of multiple abdominal surgeries. Vitals are HR 110, BP 110/70, T 37.8. Exam shows a distended abdomen with high-pitched bowel sounds. An upright abdominal X-ray is shown. Considering the clinical context and the imaging findings, which of the following is the MOST likely expected outcome with initial non-operative management?
A 72-year-old male presents to the ED with increasing shortness of breath and epigastric pain, especially when lying down. He has a history of GORD, hypertension and COPD. His vitals are stable. An X-ray is performed. What is the MOST likely underlying cause of his presentation?
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 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 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 32-year-old male, originally from a high-TB prevalence country, presents to the emergency department with a persistent cough for the past 3 weeks, night sweats, and a 5 kg weight loss. He denies any fever or shortness of breath. Physical examination reveals normal breath sounds bilaterally, with no wheezes or crackles. His vital signs are stable: temperature 37.2°C, heart rate 88 bpm, blood pressure 120/80 mmHg, and oxygen saturation 98% on room air. A chest X-ray was initially interpreted as showing a possible lung mass, prompting further investigation with a PET-CT scan, the axial view of which is shown. Sputum samples have been sent for microscopy and culture, but results are pending. Given the clinical presentation and the imaging findings, what is the MOST appropriate next step in management?
A 28-year-old woman presents with pelvic pain that started suddenly 2 days ago. Her periods are irregular. She denies fever or vomiting. The shown CT was performed. 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 subjective fever and chills. He denies nausea, vomiting, or change in bowel habits. On examination, he is afebrile, heart rate 85 bpm, blood pressure 130/80 mmHg. Abdominal examination reveals tenderness in the left iliac fossa without guarding or rebound. White cell count is 14 x 10^9/L, CRP 80 mg/L. A CT scan of the abdomen and pelvis is performed, the relevant axial image is shown. Considering the patient's presentation and the findings on the provided image, which of the following represents the most appropriate initial management strategy?
A 68-year-old male presents to the ED with left lower quadrant abdominal pain, fever, and leukocytosis. A CT scan of the abdomen and pelvis is performed. Based on the imaging, what is the MOST appropriate next step in management?
A 68-year-old male presents to the emergency department complaining of acute onset shortness of breath and right-sided chest pain. He reports that the pain started suddenly this morning and has been gradually worsening. He has a history of paroxysmal atrial fibrillation, for which he takes warfarin. He denies any recent trauma or injury. On examination, his vital signs are: heart rate 115 bpm, blood pressure 95/60 mmHg, respiratory rate 30 breaths per minute, oxygen saturation 87% on room air. Auscultation reveals decreased breath sounds on the right side. The patient appears pale and is diaphoretic. His INR is 6.5. A CT scan of the chest is performed, and the relevant image is shown. What is the MOST appropriate next step in the management of this patient?
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 75-year-old male is brought to the emergency department by ambulance with sudden onset severe shortness of breath and left-sided pleuritic chest pain that began approximately 4 hours ago. He reports feeling lightheaded and generally unwell. His past medical history includes chronic atrial fibrillation, hypertension, and type 2 diabetes mellitus. He is currently prescribed warfarin 5mg daily, metoprolol 50mg twice daily, perindopril 4mg daily, and metformin 1000mg twice daily. He denies any recent falls, trauma, or invasive procedures. On examination, he is visibly distressed and tachypnoeic. His vital signs are: temperature 36.8°C, heart rate 125 bpm (irregularly irregular), blood pressure 88/55 mmHg, respiratory rate 32 breaths per minute, oxygen saturation 85% on room air. Jugular venous pressure is not elevated. Cardiac auscultation reveals a rapid, irregular rhythm with no murmurs. Pulmonary auscultation reveals significantly diminished breath sounds over the entire left hemithorax, with dullness to percussion. The right lung field is clear. Abdominal examination is unremarkable. Peripheral pulses are weak but present. His capillary refill time is prolonged at 4 seconds. Initial laboratory results show haemoglobin 135 g/L (baseline 140 g/L three months ago), white cell count 9.2 x 10^9/L, platelets 250 x 10^9/L, creatinine 110 µmol/L, electrolytes within normal limits. His INR is 7.8. An urgent CT scan of the chest is performed, and a representative axial image is shown. Based on the clinical presentation and the findings demonstrated in the image, what is the single MOST appropriate immediate management step?
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 strategy?
A 68-year-old male presents to the emergency department with a 12-hour history of severe, constant left groin pain. He reports a bulge in his groin that has been present for several years, which he can usually reduce himself. However, today he has been unable to push it back in, and the pain has become excruciating. He denies any fever, nausea, or vomiting. On examination, his vital signs are stable: temperature 37.0°C, heart rate 88 bpm, blood pressure 130/80 mmHg, respiratory rate 16 breaths/min, and oxygen saturation 98% on room air. Abdominal examination is unremarkable. Palpation of the left groin reveals a firm, tender mass that is non-reducible. The overlying skin is erythematous, but there is no crepitus. A CT scan of the abdomen and pelvis is performed, and an axial slice is shown. Considering the clinical presentation and the findings demonstrated in the image, what is the MOST appropriate next step in management?
A 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 this finding, what is the most appropriate next step in management?
A 63-year-old man presents to the emergency department complaining of increasing shortness of breath and epigastric discomfort over the past several months. He reports feeling full quickly after eating only small amounts. He denies any chest pain, fever, or recent weight loss. His past medical history includes hypertension and well-controlled type 2 diabetes. He takes lisinopril and metformin daily. On examination, his vital signs are stable: blood pressure 130/80 mmHg, heart rate 82 bpm, respiratory rate 18 breaths/min, and oxygen saturation 96% on room air. Auscultation of the chest reveals decreased breath sounds at the left base. Abdominal examination reveals mild epigastric tenderness to palpation, but no rebound tenderness or guarding. The provided image was obtained. Which of the following is the MOST appropriate next step in management?
A 65-year-old man presents to the emergency department with a 2-day history of worsening left lower quadrant abdominal pain, associated with fever and chills. He reports a change in bowel habit with increased constipation. On examination, he is febrile at 38.6°C and has significant tenderness and guarding in the left iliac fossa. His white cell count is 18 x 10^9/L. A CT scan of the abdomen and pelvis is performed (image provided). Considering the patient's presentation and the findings on the provided image, which of the following represents the most appropriate initial management step in addition to intravenous antibiotics?