geriatrics

A 64-year-old woman presents for follow-up after experiencing intermittent episodes of right upper quadrant colicky pain over the past year, which have since resolved. She denies any current pain, fever, jaundice, or changes in bowel habits. Physical examination is unremarkable, and recent liver function tests are within normal limits. An elective abdominal ultrasound was performed, yielding the image shown. Considering the clinical context and the findings demonstrated, what is the most appropriate next step in her management?

A 72-year-old male presents to the emergency department complaining of sudden onset shortness of breath and right-sided chest pain. He reports that the pain started acutely this morning and has been gradually worsening. He has a history of atrial fibrillation and has been taking warfarin for the past 5 years. He denies any recent trauma or injury. On examination, his vital signs are: heart rate 110 bpm, blood pressure 100/60 mmHg, respiratory rate 28 breaths per minute, oxygen saturation 88% on room air. Auscultation reveals decreased breath sounds on the right side. The patient is pale and diaphoretic. A chest X-ray was initially performed, followed by the image shown. Given the clinical presentation and the findings on the image, what is the MOST appropriate next step in management?

A 72-year-old man with a history of chronic kidney disease stage 4, hypertension, and type 2 diabetes presents to the emergency department with confusion and lethargy. His family reports that he has been increasingly drowsy over the past two days. On examination, he is disoriented to time and place, with a blood pressure of 150/90 mmHg, heart rate of 88 bpm, respiratory rate of 20 breaths per minute, and temperature of 36.5°C. Laboratory tests reveal: sodium 130 mmol/L, potassium 5.8 mmol/L, bicarbonate 18 mmol/L, urea 25 mmol/L, creatinine 450 µmol/L, and glucose 8 mmol/L. An ECG shows peaked T waves. What is the most appropriate immediate management step?

A 65-year-old male with a history of hypertension and type 2 diabetes presents with stable angina. He is currently on metformin, atorvastatin, and lisinopril. Which of the following medications is most appropriate to add to his regimen to reduce angina symptoms?

A 78-year-old male on warfarin presents with dyspnea and pleuritic chest pain after a fall. INR is 7.0. A chest CT is performed (image attached). After initial resuscitation, what is the MOST appropriate next step?

A 72-year-old male with a history of hypertension and hyperlipidemia presents for a routine follow-up. He is asymptomatic. A contrast-enhanced CT scan of the abdomen was performed as part of a screening protocol. An axial view is shown. What is the MOST appropriate next step?

A 72-year-old man with fatigue and a past myocardial infarction at 55 is breathless on stairs, has a 3 kg weight gain, and ankle marks. What is his likely NYHA functional class for chronic heart failure?

A 68-year-old woman presents with a 2-week history of progressive weakness in her right arm and leg, associated with a tremor in the right hand. She also reports feeling more tired than usual. Her general practitioner noted an elevated TSH (12 mIU/L, reference range 0.4-4.0 mIU/L) on routine blood tests done a month ago, but free T4 was within the normal range (15 pmol/L, reference range 10-20 pmol/L). On examination, she has mild right-sided hemiparesis (MRC grade 4/5) and a coarse tremor in the right hand, worse with action. Reflexes are brisk on the right. The rest of the neurological exam is unremarkable. She has mild bradycardia (55 bpm) but no other signs of overt hypothyroidism. What is the most appropriate initial investigation?

An 80-year-old presents with cough, fever, and new confusion. CXR shows right lower lobe consolidation. What is the most appropriate initial antibiotic regimen?

A 75-year-old presents with a 4-month history of increasing dysphagia to solids, occasional regurgitation, and chronic cough, particularly at night. He denies significant weight loss or chest pain. Past medical history includes type 2 diabetes and hypertension. Medications are metformin and perindopril. Physical examination is unremarkable. A chest X-ray is performed as part of the initial assessment. Considering the clinical presentation and the radiographic findings, which of the following investigations is most appropriate at this stage?

A 68-year-old man presents to the emergency department with a 3-day history of left lower quadrant abdominal pain, associated with mild fever (38.1°C) and constipation. On examination, he has localised tenderness in the left iliac fossa without guarding or rebound. His blood pressure is 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 bpm. Blood tests show a white cell count of 12.5 x 10^9/L (normal range 4-11). A CT scan of the abdomen and pelvis is performed (image provided). Considering the patient's presentation and the findings demonstrated in the image, which of the following represents the most appropriate initial management strategy?

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

An 82-year-old woman with dementia and COPD presents with increased confusion and mild cough. Temperature 37.8°C, HR 95, RR 24, BP 110/70, SpO2 90% on air. Chest sounds are diminished bilaterally. What is the most appropriate initial investigation?

An 82-year-old woman is admitted to the hospital with increasing shortness of breath and intermittent chest discomfort over the past week. She reports some difficulty swallowing larger food boluses recently but denies significant heartburn. Her past medical history includes hypertension and osteoarthritis. On examination, her vital signs are stable: BP 135/85 mmHg, HR 78 bpm, RR 18/min, SpO2 94% on room air, Temp 36.8°C. Auscultation of the chest reveals decreased breath sounds at the left base. A central venous catheter is noted in the right subclavian vein. Initial blood tests show a mild normocytic anaemia (Hb 105 g/L) and normal inflammatory markers. An urgent imaging study is performed. Considering the clinical presentation and the provided imaging study, what is the most appropriate next step in the management of this patient?

A 72-year-old female on warfarin for chronic atrial fibrillation presents with a 2-day history of increasing pain and a developing lesion on her right lower leg. She denies trauma. Her INR is therapeutic at 2.5. Vitals are stable. Considering the clinical presentation and the image provided, what is the most appropriate immediate management?

A 68-year-old male on warfarin presents post-fall with dyspnea and pleuritic chest pain. INR is 4.8. Vitals: HR 115, BP 95/60, RR 26, SpO2 89% on air. The provided image was obtained. What is the MOST appropriate next step?

A 72-year-old male presents with new onset back pain. His CT is shown. What is the most appropriate initial management?

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 72-year-old male presents with vomiting and abdominal pain. An abdominal X-ray is performed. What is the MOST likely underlying cause?

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 70-year-old presents with iron deficiency anaemia and intermittent rectal bleeding. Colonoscopy was performed, and a representative image is shown. Biopsies are pending but malignancy is strongly suspected based on the endoscopic appearance. What is the MOST appropriate next investigation to guide definitive management?

A 78-year-old male presents with persistent vomiting and epigastric pain. He reports a history of NSAID use for chronic arthritis. An X-ray is performed. Which of the following is the MOST likely complication associated with this finding?

An elderly man presents with a 6-month history of memory decline, recurrent falls, visual hallucinations, agitation, and confusion. His wife reports he talks to people who are not visible. Which of the following clinical features is most helpful in diagnosing his condition?

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

A 60-year-old woman presents to the clinic with a 2-month history of progressive shortness of breath and a dry cough. She has a history of rheumatoid arthritis and is currently on methotrexate and low-dose prednisone. On examination, she has fine inspiratory crackles at the lung bases. A high-resolution CT scan of the chest shows reticular opacities and honeycombing predominantly in the lower lobes. What is the most likely diagnosis?

A 72-year-old man presents to the emergency department with confusion and difficulty walking. His family reports that he has been increasingly forgetful over the past few months and has had several falls. He has a history of hypertension and hyperlipidemia, for which he takes lisinopril and atorvastatin. On examination, he is disoriented to time and place, with a blood pressure of 140/85 mmHg, heart rate of 78 bpm, and a wide-based gait. Neurological examination reveals brisk reflexes and a positive Romberg sign. A CT scan of the head shows mild cortical atrophy but no acute lesions. Which of the following is the most likely diagnosis?

A 72-year-old woman presents with sudden onset shortness of breath and pleuritic chest pain. She had knee surgery 10 days ago. She has a history of hypertension. On examination, she is anxious, respiratory rate is 24, heart rate 105, BP 130/80, SpO2 92% on room air. Lungs are clear. ECG shows sinus tachycardia. There is mild swelling in the operated leg. Considering the likely diagnosis, which initial investigation is most appropriate?

An 80-year-old male with a history of smoking and hypertension presents for investigation of mild, intermittent lower back pain. Physical examination is unremarkable. Vital signs are stable. A CT scan of the abdomen is performed. Based on the provided image and clinical context, what is the most appropriate next step in the management of this patient?

A 68-year-old man with known alcoholic cirrhosis presents for routine surveillance. He reports mild fatigue. Liver function tests are within his baseline (Child-Pugh A). Alpha-fetoprotein is 150 ng/mL. The provided images are obtained. Considering the clinical context and the findings demonstrated in the images, which of the following treatment modalities is most likely to be considered first for this patient?

A 72-year-old male on warfarin presents with sudden onset shortness of breath and right-sided chest pain after a fall. His INR is 4.5. The provided image was obtained. What is the MOST appropriate next step in management?

A 68-year-old patient presents with chronic intermittent upper abdominal discomfort, postprandial fullness, and occasional regurgitation. Physical examination is unremarkable. A chest radiograph is performed as part of the workup. Considering the radiographic findings in the context of the patient's presentation, 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. Considering the patient's clinical presentation and the findings demonstrated in the provided image, which of the following represents the most appropriate immediate next step in her management?

A 78-year-old woman with a history of heart failure (reduced ejection fraction), type 2 diabetes, and recent hospitalisation for pneumonia presents to her GP with increasing fatigue and a single episode of dizziness leading to a fall without loss of consciousness. Her current medications are Digoxin 125 mcg daily, Furosemide 40 mg daily, Ramipril 5 mg daily, Metformin 500 mg BD, and Amoxicillin 500 mg TDS (started 5 days ago for pneumonia). An ECG in clinic shows sinus rhythm, rate 70 bpm, and a QTc of 530 ms. An ECG from 6 months prior had a QTc of 440 ms. Recent laboratory tests show Na 138 mmol/L, K 4.2 mmol/L, Mg 0.9 mmol/L, Ca 2.3 mmol/L, Creatinine 90 µmol/L, and Digoxin level 1.1 ng/mL. Considering the clinical context and investigations, which of the following is the most likely significant contributor to the observed QTc prolongation?

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 72-year-old patient presents with intermittent chest discomfort and increasing shortness of breath, particularly after meals. Vitals are stable. Physical examination is unremarkable. A chest X-ray is performed. Considering the radiographic findings in the context of the patient's symptoms, what is the most appropriate next step in management?

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

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?

An 82-year-old woman with a history of paroxysmal atrial fibrillation was recently discharged from hospital following treatment for community-acquired pneumonia. Five days ago, she was commenced on warfarin 5mg daily for stroke prevention. She presents to the emergency department today complaining of severe, rapidly worsening pain and a dark, blistering lesion on her right lower leg that developed over the past 48 hours. She denies any recent trauma to the leg. Her vital signs are stable: blood pressure 132/82 mmHg, heart rate 76 bpm, respiratory rate 18/min, temperature 37.0°C. Physical examination reveals the appearance shown in the image on her right anterior lower leg. Laboratory results show an INR of 4.8, haemoglobin 125 g/L, white cell count 8.5 x 10^9/L, and platelets 250 x 10^9/L. She has no known personal or family history of thrombophilia. Considering the clinical presentation, recent medication changes, and the appearance depicted, which of the following is the most appropriate immediate management strategy?

A 70-year-old woman presents with a persistent, slowly enlarging skin lesion on her left chest wall, which she first noticed several months ago. She underwent a left simple mastectomy for invasive ductal carcinoma 12 years prior. Physical examination reveals the findings depicted. A recent biopsy of the lesion confirmed the presence of Paget cells. She has no other new symptoms. Her vital signs are stable. Considering the patient's history and the biopsy findings, which of the following investigations is the most appropriate next step in her management?

A 70-year-old man presents for a routine check-up. He reports occasional mild, non-radiating abdominal discomfort over the past few months, which he attributes to indigestion. He has a history of well-controlled hypertension and hyperlipidaemia, and quit smoking 10 years ago. Physical examination is unremarkable, with no palpable abdominal masses. Routine blood tests are within normal limits. An abdominal CT scan is performed to investigate the abdominal discomfort. Considering the findings demonstrated in the image, what is the most appropriate next step in the management of this patient?

A 72-year-old male presents with increasing shortness of breath and epigastric discomfort, particularly after meals. He has a history of well-controlled hypertension and takes aspirin daily. An X-ray is performed. What is the most appropriate next step in management?

A 68-year-old woman presents to the emergency department with a 2-day history of right upper quadrant abdominal pain, fever, and yellowing of her eyes. Her vital signs are stable, but laboratory investigations reveal elevated inflammatory markers and liver function tests consistent with biliary obstruction and infection. An ERCP is performed, and the image is obtained. Following successful intervention to relieve the obstruction, the patient's symptoms begin to improve. Considering the likely underlying cause of this presentation and the findings during the procedure, what is the MOST appropriate next step in managing this patient's condition?

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

A 68-year-old patient on warfarin for a recent DVT presents with a painful, rapidly expanding skin lesion on their leg that started 48 hours ago. Their INR is 2.9. Given the clinical context and the appearance of the lesion, what is the most appropriate immediate management step?

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 78-year-old male on warfarin presents with acute shortness of breath. INR is 5.0. The provided image was obtained. What is the MOST likely underlying cause?

A 66-year-old man, active with a good diet, whose mother had osteoporosis at age 91, wants to check his osteoporosis risk. What risk factors prompt a bone mineral density (BMD) test?

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 75-year-old woman on warfarin for chronic atrial fibrillation presents to the emergency department with a 24-hour history of rapidly worsening pain and discolouration in her right lower leg. She denies trauma. Her INR is 2.8. Physical examination reveals the findings shown in the image. Peripheral pulses are palpable. What is the most appropriate immediate management step?