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geriatrics

Practice targeted AMC-style multiple-choice questions on geriatrics.

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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 female presents with right leg pain and skin changes after starting warfarin for atrial fibrillation. Her INR is 3.5. Examination reveals the findings in the image. What is the MOST appropriate next step in management?

A. Administer vitamin K and discontinue warfarin
B. Elevate the leg and apply compression bandages
C. Prescribe a broad-spectrum antibiotic
D. Apply topical corticosteroids
E. Increase the dose of warfarin
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An 85-year-old man from a nursing home presents with new confusion, mild cough, and temperature 37.9°C. Chest X-ray shows a right lower lobe infiltrate. He has dysphagia. Considering his presentation and risk factors, which initial antibiotic regimen is most appropriate?

A. Ceftriaxone
B. Azithromycin
C. Amoxicillin-clavulanate
D. Doxycycline
E. Amoxicillin
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Elective abdominal ultrasonography of a 64 year old woman with past colicky pain but no current pain. It shows a mildly dilated common bile duct with what appears to be a gallstone (black arrow). The green and blue dots are blood flow, since the exam is done as a Doppler ultrasound to distinguish the bile duct from blood vessels.
Image by Mikael Häggström CC0 1.0 · Source

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. Discharge with advice to return if symptoms recur
B. ERCP for stone extraction
C. Initiate ursodeoxycholic acid therapy
D. MRCP to further delineate the biliary anatomy
E. Elective laparoscopic cholecystectomy
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

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. Administer protamine sulfate
B. Perform a thoracentesis
C. Administer intravenous antibiotics
D. Order a ventilation/perfusion scan
E. Insert a chest tube
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 78-year-old male on warfarin for atrial fibrillation presents with acute dyspnea and pleuritic chest pain. His INR is 7.0. A chest CT is performed (image attached). After initial resuscitation, what is the MOST appropriate intervention?

A. Administer intravenous vitamin K and prothrombin complex concentrate
B. Perform needle thoracostomy
C. Administer intravenous protamine sulfate
D. Administer intravenous furosemide
E. Observe and repeat CT scan in 6 hours
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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. Administer oral sodium polystyrene sulfonate
B. Administer intravenous calcium gluconate
C. Initiate hemodialysis
D. Start intravenous insulin and glucose
E. Administer intravenous sodium bicarbonate
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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. Diuretic (e.g., hydrochlorothiazide)
B. Beta-blocker (e.g., metoprolol)
C. Angiotensin II receptor blocker (e.g., losartan)
D. Calcium channel blocker (e.g., amlodipine)
E. Nitrate (e.g., isosorbide mononitrate)
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 78-year-old male on warfarin 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. Observe and repeat CT chest in 6 hours
B. Administer intravenous vitamin K and prothrombin complex concentrate
C. Perform bronchoscopy with bronchoalveolar lavage
D. Administer intravenous protamine sulfate
E. Insert an intercostal chest drain
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 72-year-old male presents with increasing dyspnea. He has a history of GORD. The provided image was taken. What is the most appropriate next step?

A. Refer for surgical consultation for fundoplication.
B. Prescribe prokinetic agents to improve gastric emptying.
C. Initiate a trial of PPI therapy and lifestyle modifications.
D. Order a barium swallow study to further evaluate the anatomy.
E. Perform an upper endoscopy to assess for complications.
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A 72-year-old man presents to the clinic with progressive shortness of breath and a chronic cough producing white sputum. He has a 40-pack-year smoking history and worked in construction for most of his life. On examination, he has clubbing of the fingers and crackles at the lung bases. A chest X-ray shows diffuse reticular opacities, particularly at the lung bases. What is the most likely diagnosis?

A. Idiopathic pulmonary fibrosis
B. Lung cancer
C. Asbestosis
D. Congestive heart failure
E. Chronic obstructive pulmonary disease (COPD)
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A 70-year-old woman with a history of diabetes presents with fever, cough, and weight loss. A chest X-ray shows a cavitary lesion in the right upper lobe. What is the most likely diagnosis?

A. Sarcoidosis
B. Lung cancer
C. Tuberculosis
D. Lung abscess
E. Pneumocystis pneumonia
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A 68-year-old man presents to the emergency department with fatigue, pallor, and shortness of breath on exertion. His blood tests reveal a hemoglobin level of 7.5 g/dL, mean corpuscular volume (MCV) of 72 fL, and low serum ferritin. He has a history of osteoarthritis and takes ibuprofen regularly. What is the most likely cause of his anemia?

A. Thalassemia minor
B. Vitamin B12 deficiency
C. Chronic blood loss due to gastrointestinal bleeding
D. Anemia of chronic disease
E. Hemolytic anemia
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A 68-year-old woman is admitted to the hospital with confusion and muscle weakness. Her medications include hydrochlorothiazide for hypertension. Initial laboratory results show: Sodium 120 mmol/L (Normal: 135-145 mmol/L), Potassium 3.8 mmol/L (Normal: 3.5-5.0 mmol/L), Chloride 90 mmol/L (Normal: 95-105 mmol/L). What is the most likely cause of her hyponatremia?

A. Hyperglycemia
B. Thiazide-induced SIADH
C. Primary polydipsia
D. Renal failure
E. Adrenal insufficiency
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A 78M presents with cough, fever, confusion. BP 90/60, RR 30, Temp 38.5, SpO2 90% on air. CXR shows LUL consolidation. What is the most appropriate initial management?

A. Arrange urgent viral PCR testing
B. Initiate oral antibiotics and admit to general ward
C. Discharge home with oral antibiotics
D. Perform urgent bronchoscopy
E. Initiate IV antibiotics and assess for ICU admission
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

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. Barium swallow study
B. Oesophageal manometry
C. Oesophago-gastro-duodenoscopy
D. High-resolution CT chest
E. Ambulatory ECG monitoring
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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 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. Discharge with advice on a low-residue diet and follow-up in 6 months.
B. Admission for intravenous antibiotics and close observation.
C. Urgent colonoscopy to evaluate the affected segment.
D. Outpatient management with oral antibiotics and analgesia.
E. Urgent surgical consultation for Hartmann's procedure.
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 78-year-old male on warfarin 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?

A. Administer IV protamine sulfate
B. Tube thoracostomy
C. Administer IV vitamin K
D. Administer IV tranexamic acid
E. Observation with serial chest X-rays
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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?

A. Serum procalcitonin
B. Bronchoscopy
C. High-resolution CT chest
D. Chest X-ray
E. Sputum Gram stain and culture
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

An 82-year-old female presents with a 3-month history of intermittent retrosternal burning pain, worse after meals, and occasional shortness of breath on exertion. Vital signs are stable. Physical exam unremarkable. A chest X-ray is performed. Considering the findings on the image, what is the most appropriate initial management step?

A. Reassure the patient that the finding is benign and requires no further action.
B. Urgent surgical consultation for repair.
C. Initiate a trial of proton pump inhibitor therapy.
D. Proceed directly to oesophago-gastro-duodenoscopy (OGD).
E. Refer for a stress echocardiogram to rule out cardiac ischaemia.
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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. Initiate intravenous unfractionated heparin and consult vascular surgery urgently.
B. Administer a bolus of intravenous fluid and analgesia.
C. Start a continuous infusion of alteplase.
D. Order an urgent CT angiography of the left lower limb.
E. Arrange for an urgent venous duplex ultrasound to rule out deep vein thrombosis.
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A 62-year-old woman presents to the emergency department with confusion and lethargy. Her family reports she has been increasingly forgetful over the past week and has had a decreased appetite. She has a history of type 2 diabetes mellitus and hypertension, for which she takes metformin and lisinopril. On examination, she is disoriented to time and place, with dry mucous membranes and decreased skin turgor. Her blood pressure is 100/60 mmHg, heart rate is 110 bpm, and temperature is 37.2°C. Laboratory tests reveal a serum sodium level of 118 mmol/L, serum osmolality of 260 mOsm/kg, and urine osmolality of 500 mOsm/kg. Which of the following is the most appropriate initial management for this patient?

A. Furosemide administration
B. Normal saline infusion
C. Hypertonic saline infusion
D. Fluid restriction
E. Demeclocycline administration
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An 80-year-old presents with cough, fever, and new confusion. Vital signs: T 38.5°C, HR 110, BP 100/60, RR 28, SpO2 90% on air. Chest X-ray shows consolidation. What is the most appropriate initial management step?

A. Oral antibiotics and outpatient management
B. Chest CT scan
C. Bronchoscopy
D. Sputum culture and sensitivity testing
E. Intravenous antibiotics and hospital admission
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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 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. Obtain a groin ultrasound for further assessment
B. Attempt manual reduction under sedation
C. Arrange for elective surgical consultation
D. Administer analgesia and observe closely
E. Emergency surgical exploration and repair
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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?

A. Nystagmus
B. Parkinsonian gait/tremor
C. Ataxia
D. Aphasia
E. Hemiparesis
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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 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. Urgent surgical consultation for operative intervention.
B. Attempt manual reduction under adequate analgesia and sedation.
C. Request an urgent Doppler ultrasound to assess blood flow to the contents.
D. Initiate intravenous broad-spectrum antibiotics and monitor closely.
E. Arrange for elective hernia repair in the coming weeks.
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

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. An X-ray is performed. What is the MOST appropriate next step in management?

A. Perform an upper endoscopy
B. Refer for surgical consultation for fundoplication
C. Initiate a proton pump inhibitor and lifestyle modifications
D. Prescribe a prokinetic agent such as metoclopramide
E. Order a barium swallow study
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 72-year-old male presents with a 4-month history of increasing fatigue, anorexia, and a 10 kg weight loss. He reports occasional nausea but no vomiting or abdominal pain. His vital signs are stable. Physical examination reveals mild jaundice and palpable hepatomegaly. Blood tests show Hb 105 g/L, elevated AST/ALT, and a mildly raised bilirubin. An upper endoscopy showed a large gastric mass, with histology pending. A CT scan of the abdomen and pelvis was performed. Considering the clinical context and the findings on the provided imaging, what is the most likely implication for this patient's overall management strategy?

A. Referral for liver transplantation assessment.
B. Planning for curative surgical resection of the primary tumour and liver lesions.
C. Urgent initiation of aggressive systemic chemotherapy with curative intent.
D. Focus on symptom control and quality of life measures.
E. Further investigation with MRI liver to characterise the lesions.
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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 68-year-old man with a history of hypertension, type 2 diabetes, and stable angina is scheduled for elective hernia repair surgery. He is currently on aspirin, metformin, lisinopril, and atorvastatin. His last angina episode was over a year ago, and he has no history of myocardial infarction. What is the most appropriate preoperative management step to minimize his cardiovascular risk during surgery?

A. Discontinue aspirin therapy one week before surgery
B. Increase the dose of atorvastatin
C. Continue aspirin therapy
D. Order a preoperative stress test
E. Start beta-blocker therapy
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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 68-year-old woman recently started on warfarin for a pulmonary embolism presents with a painful, rapidly expanding purpuric lesion on her thigh, which developed two days ago. Her INR is 2.5. She has no history of trauma to the area. Considering the clinical presentation and the appearance of the lesion, what is the most likely underlying pathophysiological process?

A. Allergic vasculitis secondary to warfarin
B. Protein C deficiency leading to paradoxical thrombosis
C. Vitamin K deficiency exacerbating bleeding
D. Direct toxic effect of warfarin on dermal capillaries
E. Heparin-induced thrombocytopenia causing microthrombi
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A 70-80 year old lady being treated for pulmonary embolism with a therapeutic dose of subcutaneous Enoxaparin is found to have multiple new pulmonary emboli. What is the most appropriate next step?

A. Start streptokinase infusion.
B. Switch to intravenous unfractionated heparin.
C. Switch to oral warfarin.
D. Increase the dose of subcutaneous enoxaparin.
E. Insert an IVC filter.
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A contrast enhanced CT scan demonstrating an abdominal aortic aneurysm of 4.8 * 3.8 cm
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 70-year-old male undergoes a CT scan for investigation of chronic back pain. He has no history of abdominal pain or pulsatile mass. His blood pressure is 130/80 mmHg. The image provided is an axial view from this scan. Based on this finding and the patient's clinical status, what is the most appropriate next step in management according to current guidelines?

A. Schedule elective endovascular aneurysm repair (EVAR).
B. Arrange for surveillance ultrasound in 12 months.
C. Arrange for urgent surgical consultation.
D. Repeat CT angiography in 6 months.
E. No further follow-up is required.
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

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. Gastric malignancy
B. Esophageal dysmotility
C. Reduced lower esophageal sphincter tone
D. Aortic aneurysm
E. Pneumonia
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A contrast enhanced CT scan demonstrating an abdominal aortic aneurysm of 4.8 * 3.8 cm
Image by James Heilman, MD CC BY-SA 3.0 · Source

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. Repeat CT scan in 3 months
B. Urgent referral for surgical repair
C. Annual ultrasound surveillance
D. No further follow-up required
E. Initiate antiplatelet therapy and review in 1 year
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

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

A. Arrange for urgent bronchoscopy to investigate airway obstruction.
B. Increase warfarin dose and monitor INR.
C. Observe closely in the emergency department with serial chest X-rays.
D. Administer broad-spectrum antibiotics and arrange for thoracentesis.
E. Administer Vitamin K and Prothrombinex (PCC) and arrange for chest tube insertion.
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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?

A. Ramipril
B. Underlying heart failure
C. Amoxicillin
D. Digoxin
E. Furosemide
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

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. Arrange for an Oesophago-Gastro-Duodenoscopy (OGD)
B. Order a CT pulmonary angiogram
C. Advise on weight loss and elevate the head of the bed
D. Initiate treatment with a high-dose proton pump inhibitor
E. Perform a stress echocardiogram
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An 80-year-old man presents with new confusion, cough, and fever. He has a history of COPD. On exam, he is tachypnoeic and has crackles at the right base. His oxygen saturation is 88% on room air. What is the most appropriate initial investigation?

A. Bronchoscopy
B. C-reactive protein
C. Sputum Gram stain and culture
D. High-resolution CT chest
E. Chest X-ray
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A contrast enhanced CT scan demonstrating an abdominal aortic aneurysm of 4.8 * 3.8 cm
Image by James Heilman, MD CC BY-SA 3.0 · Source

An 80-year-old male with a history of smoking and hypertension presents to his GP with mild, intermittent lower back pain. Physical examination is unremarkable. Routine blood tests are normal. A CT scan of the abdomen is performed to investigate the back pain. Considering the findings demonstrated in the provided image in the context of this patient's presentation, what is the most appropriate next step in management?

A. Refer immediately for surgical consultation for elective repair.
B. Initiate aggressive blood pressure control and repeat imaging in 5 years.
C. Schedule regular surveillance imaging.
D. Perform urgent angiography to assess for rupture risk.
E. Discharge with advice to return if pain worsens significantly.
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Fluoroscopic image of common bile duct stone seen at the time of ERCP. The stone is impacted in the distal common bile duct.
Image by Samir धर्म at en.wikipedia CC BY-SA 3.0 · Source

A 68-year-old woman presents to the emergency department with 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. Repeat ERCP in 3 months to check for residual stones.
B. Discharge home with pain relief and follow-up in general practice.
C. Referral for medical dissolution therapy for gallstones.
D. Long-term antibiotic therapy to prevent recurrence.
E. Elective laparoscopic cholecystectomy during the same admission or shortly after discharge.
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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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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 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?

A. Increase the warfarin dose and monitor INR closely.
B. Switch warfarin to a direct oral anticoagulant (DOAC).
C. Obtain a skin biopsy and continue current management.
D. Apply topical antibiotics and continue warfarin.
E. Stop warfarin, administer Vitamin K, and initiate heparin.
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A contrast enhanced CT scan demonstrating an abdominal aortic aneurysm of 4.8 * 3.8 cm
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 72-year-old man with a history of hypertension and smoking presents to his GP with mild, intermittent abdominal discomfort. His vital signs are stable, and abdominal examination is soft and non-tender. As part of the workup, a contrast-enhanced CT scan of the abdomen and pelvis is performed. The provided image is an axial view from this study. Based on the clinical context and the findings in the provided image, what is the most appropriate next step in this patient's management?

A. Referral for urgent endovascular repair planning
B. No further action is required at this time
C. Referral to a vascular surgeon for ongoing surveillance
D. Urgent surgical consultation for immediate repair
E. Repeat CT scan in 3 months to assess for growth
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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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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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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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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 75-year-old male on warfarin for atrial fibrillation presents with acute dyspnoea and pleuritic chest pain. He is hypotensive with a BP of 90/60 mmHg and tachycardic at 110 bpm. His INR is 7.2. A chest CT is performed (image attached). Considering the clinical context and imaging findings, what is the MOST appropriate immediate management step?

A. Administer intravenous Vitamin K and Prothrombinex-VF
B. Initiate high-flow nasal cannula oxygen
C. Arrange for urgent surgical consultation for thoracotomy
D. Perform urgent tube thoracostomy
E. Administer intravenous furosemide
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A 70-year-old woman with a history of hypertension and chronic kidney disease (CKD) stage 3 is prescribed an ACE inhibitor for blood pressure control. Which of the following parameters requires the closest monitoring after initiating the ACE inhibitor?

A. Liver function tests
B. Thyroid stimulating hormone (TSH)
C. Serum creatinine and potassium
D. Serum calcium
E. Complete blood count
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CT scan showing hemothorax caused by warfarin use
Image by Cevik Y CC BY 3.0 · Source

A 72-year-old male on warfarin presents with sudden onset dyspnea. His INR is 6.0. The provided image was obtained. What is the MOST appropriate next step?

A. Administer IV vitamin K and prothrombin complex concentrate
B. Observe and repeat imaging in 24 hours
C. Perform needle thoracostomy
D. Administer IV protamine sulfate
E. Administer IV furosemide
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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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