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

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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 28-year-old female presents with a chronic cough and fatigue. She has no significant past medical history but reports recent travel to Southeast Asia. A chest PET-CT was performed. What is the MOST appropriate next step in the management of this patient?

A. Order a bronchoscopy with biopsy
B. Start a trial of inhaled corticosteroids
C. Repeat the PET-CT scan in 3 months
D. Initiate anti-tuberculosis therapy
E. Prescribe a course of broad-spectrum antibiotics
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 68-year-old male presents with fatigue and weight loss. The provided image was obtained. Which of the following is the MOST appropriate next step in management?

A. Initiate palliative care consultation
B. Percutaneous ethanol ablation of selected lesions
C. Referral to medical oncology for systemic therapy
D. Surgical resection of the largest lesion
E. Repeat imaging in 3 months to assess progression
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 45-year-old male with Crohn's presents with persistent right lower quadrant pain. Stool studies are negative. Review the imaging. What is the MOST likely complication?

A. Toxic megacolon
B. Fistula formation
C. Appendicitis
D. Small bowel obstruction
E. Perforation
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Post-embolization arteriogram showing coiled aneurysm (indicated by yellow arrows) of the posteriorcerebral artery with a residual aneurysmal sac.
Image by Promod Pillai, Aftab Karim, Anil Nanda CC BY 2.0 · Source

A 68-year-old male presents with worsening headaches and blurred vision. He underwent endovascular coiling for a posterior cerebral artery aneurysm 6 months ago. The attached image was obtained. Which of the following is the MOST appropriate next step in management?

A. Increase the dose of his antihypertensive medication
B. Initiate aspirin therapy
C. Repeat angiography
D. Order a CT scan of the head without contrast
E. Reassure the patient and schedule a follow-up appointment in 6 months
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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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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 62-year-old presents with jaundice and RUQ pain. The image was obtained during ERCP. What is the MOST appropriate next step?

A. Observation with serial LFTs
B. Ursodeoxycholic acid administration
C. Sphincterotomy and stone extraction
D. Cholecystectomy
E. Percutaneous transhepatic cholangiography
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Mammogram microcalcifications in carcinoma in situ, CC, details
Image by Jmarchn CC BY-SA 3.0 · Source

A 62-year-old woman presents for routine mammography. She has no palpable lumps or skin changes. Her previous mammogram two years ago was normal. The current mammogram is shown. What is the MOST appropriate next step in management?

A. Excisional biopsy
B. Ultrasound of the breast
C. Reassurance and routine screening in 2 years
D. Stereotactic core biopsy
E. MRI of the breast
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A 75-year-old obese man with a history of hypertension and chronic lower limb skin changes, swelling, tingling, and weakness presents with sudden onset inability to stand or move his legs, accompanied by a loss of sensation extending up to his waist. On examination, he has flaccid paralysis of both lower limbs, absent deep tendon reflexes in the legs, and a sensory level at the umbilicus. Which of the following is the most appropriate initial investigation?

A. Urgent MRI of the spine
B. Electromyography and nerve conduction studies
C. CT angiography of the aorta and iliac arteries
D. Lumbar puncture
E. Urgent CT scan of the spine
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 3-year-old presents with a 2-month history of increasing abdominal distension and intermittent pain. Physical examination reveals a firm, non-tender mass in the upper abdomen. Blood tests show mild anaemia. Vitals are stable. This CT scan was performed as part of the initial workup. Considering the clinical presentation and the findings demonstrated in the provided image, which of the following investigations is the most critical next step for accurate staging and risk stratification to guide appropriate management in this paediatric patient?

A. Bone marrow aspirate and trephine biopsy
B. Repeat CT scan of the abdomen in 3 months
C. Urgent surgical resection of the mass
D. Genetic testing for WT1 gene mutation
E. Initiation of empirical chemotherapy
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

A 72-year-old woman presents with a long history of heartburn, regurgitation, and recently developed a chronic cough, particularly at night. Physical examination is unremarkable. A chest radiograph is obtained. Considering the radiographic findings in the context of the patient's presentation, what is the most likely pathophysiological mechanism contributing to her chronic cough?

A. Pulmonary oedema secondary to cardiac dysfunction
B. Interstitial lung disease causing restrictive ventilatory defect
C. Compression of the left main bronchus by an enlarged lymph node
D. Bronchial hyperreactivity triggered by inhaled allergens
E. Chronic aspiration of gastric contents
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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 62-year-old male with a history of poorly controlled diabetes presents with right upper quadrant pain, fever, and night sweats for 3 weeks. He is on immunosuppressants following a renal transplant 5 years ago. Blood cultures are pending. Imaging is performed, as shown. What is the MOST appropriate next step in management?

A. Empiric antifungal therapy
B. Observation and serial imaging
C. Metronidazole and supportive care
D. Albendazole and surgical resection
E. Percutaneous drainage and antibiotics
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 65-year-old patient with a history of smoking presents with a chronic cough and mild weight loss over three months. Physical examination is unremarkable, and vital signs are stable. Routine blood tests, including full blood count and inflammatory markers, are within normal limits. A chest X-ray revealed a solitary pulmonary nodule in the right upper lobe. Subsequent PET-CT imaging was performed as part of the diagnostic workup. Considering the findings demonstrated in the image provided, which of the following is the most appropriate next step in the management of this patient?

A. Refer for surgical resection
B. Bronchoscopy with biopsy or fine needle aspiration
C. Prescribe a course of inhaled corticosteroids
D. Initiate empirical broad-spectrum antibiotics
E. Repeat PET-CT scan in three months
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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 62-year-old male with a history of poorly controlled diabetes presents with right upper quadrant pain, fever, and night sweats for 3 weeks. He is on immunosuppressants following a renal transplant 5 years ago. Blood cultures are pending. Imaging is performed, as shown. What is the MOST appropriate next step in management?

A. Percutaneous drainage and antibiotics
B. Observation and serial imaging
C. Metronidazole and supportive care
D. Empiric amphotericin B
E. Albendazole and surgical resection
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 65-year-old male with new onset ascites and elevated ALP has the imaging shown. What is the MOST likely primary malignancy?

A. Colorectal
B. Cholangiocarcinoma
C. Gastric
D. Hepatocellular
E. Pancreatic
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Mammogram microcalcifications in carcinoma in situ, CC, details
Image by Jmarchn CC BY-SA 3.0 · Source

A 58-year-old woman presents for her scheduled screening mammogram. She reports no breast lumps, pain, or nipple discharge. Her past medical history includes well-controlled hypertension and osteoarthritis. She has no known family history of breast or ovarian cancer. Physical examination reveals no palpable abnormalities in either breast or axillae. The mammogram is performed, and the image provided is a detail from the craniocaudal view of the left breast. Considering the clinical presentation and the findings demonstrated in the provided image, what is the most appropriate immediate next step in the management of this patient?

A. Repeat mammography in 6 months
B. Ultrasound of the breast
C. Excisional biopsy
D. Referral for genetic counselling and testing
E. Stereotactic core biopsy of the suspicious area
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Neuroblastoma, CT of the abdomen
Image by RadsWiki CC BY-SA 3.0 · Source

A 3-year-old child presents with a 2-month history of increasing abdominal distension and intermittent pain. On examination, a firm, non-tender mass is palpable in the upper abdomen. Initial blood tests reveal mild anaemia. Vital signs are stable. The provided image was obtained as part of the diagnostic evaluation. Based on the findings in the image and the clinical context, which of the following imaging modalities is most likely to provide critical information regarding potential metastatic disease, which is essential for accurate staging and treatment planning in this paediatric patient?

A. Bone scan with Technetium-99m
B. Contrast-enhanced ultrasound of the abdomen
C. PET-CT with 18F-FDG
D. 123I-MIBG scintigraphy
E. Whole-body MRI
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CT, ultrasonography, SPECT and scintigraphy of intra-thyroid parathyroid adenoma
Image by Mnahi Bin Saeedan, Ibtisam Musallam Aljohani, Ayman Omar Khushaim, Salwa Qasim Bukhari, Salahudin Tayeb Elnaas CC BY 4.0 · Source

A 58-year-old woman presents with persistent fatigue, muscle weakness, and vague abdominal pain. Investigations reveal serum calcium 3.2 mmol/L (2.1-2.6), PTH 190 pg/mL (10-65). Renal function is normal. She denies family history of endocrine disorders. Imaging studies are performed, as shown. Considering the clinical presentation and the findings from the imaging modalities, what is the definitive management strategy for this patient?

A. Initiation of bisphosphonate therapy
B. Surgical excision of the identified lesion
C. Observation with regular monitoring of calcium and PTH levels
D. Radiofrequency ablation of the lesion
E. Long-term medical management with cinacalcet
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 4-week-old male presents with non-bilious emesis. An upper GI series is performed (image shown). What acid-base abnormality is MOST likely?

A. Respiratory alkalosis
B. Hyperchloremic metabolic acidosis
C. Normal acid-base status
D. Respiratory acidosis
E. Hypochloremic metabolic alkalosis
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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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Post-embolization arteriogram showing coiled aneurysm (indicated by yellow arrows) of the posteriorcerebral artery with a residual aneurysmal sac.
Image by Promod Pillai, Aftab Karim, Anil Nanda CC BY 2.0 · Source

A 55-year-old female presents with new onset right homonymous hemianopia 3 months post-aneurysm coiling. Review the image. What is the MOST likely cause?

A. Aneurysm regrowth
B. Arteriovenous malformation
C. Vasospasm
D. Coil migration
E. New aneurysm formation
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 62-year-old male with a history of hepatitis C presents with new onset ascites and right upper quadrant pain. His AFP is markedly elevated. A contrast-enhanced ultrasound is performed, as shown. What is the MOST appropriate next step in management?

A. Surveillance with serial AFP measurements and ultrasound
B. Referral for liver transplant evaluation
C. Percutaneous ethanol ablation
D. Surgical resection
E. Initiation of systemic chemotherapy
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

A 68-year-old man with known alcoholic cirrhosis presents for routine surveillance. He reports mild fatigue but no other symptoms. Liver function tests are within his baseline. Alpha-fetoprotein is 150 ng/mL (normal <10). The provided images are obtained. Considering the clinical context and the findings demonstrated in the images, what is the most appropriate immediate next step in this patient's management?

A. Referral for liver transplant assessment
B. Initiate treatment with transarterial chemoembolisation (TACE)
C. Percutaneous biopsy of the lesion
D. Commence systemic therapy with Sorafenib
E. Repeat imaging with MRI liver in 4 weeks
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

A 65-year-old man with chronic hepatitis C and compensated cirrhosis (Child-Pugh A) presents for routine surveillance. His alpha-fetoprotein is 250 ng/mL. He feels well. The provided images are obtained. Considering the clinical context and the findings demonstrated in the images, which of the following management strategies is most likely to be the initial approach for this patient?

A. Liver transplantation
B. Radiofrequency ablation (RFA)
C. Palliative care
D. Systemic chemotherapy
E. Transarterial chemoembolisation (TACE)
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CT, ultrasonography, SPECT and scintigraphy of intra-thyroid parathyroid adenoma
Image by Mnahi Bin Saeedan, Ibtisam Musallam Aljohani, Ayman Omar Khushaim, Salwa Qasim Bukhari, Salahudin Tayeb Elnaas CC BY 4.0 · Source

A 62-year-old woman presents with fatigue, bone pain, and constipation. Laboratory investigations reveal serum calcium 3.1 mmol/L, parathyroid hormone 180 pg/mL, and elevated 24-hour urine calcium excretion. Imaging studies are performed for pre-operative localisation, the results of which are shown. Considering the clinical context and the findings demonstrated in the images, which surgical approach is MOST likely indicated for definitive management?

A. Targeted parathyroidectomy via hemithyroidectomy
B. Medical management with cinacalcet
C. Minimally invasive parathyroidectomy
D. Bilateral neck exploration
E. Observation with regular calcium monitoring
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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 male presents with new onset back pain. His CT is shown. What is the most appropriate initial management?

A. Lifestyle modification advice
B. Commence beta-blocker therapy
C. Repeat imaging in 12 months
D. Prescribe a statin
E. Referral to vascular surgery
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 70-year-old male with known cirrhosis secondary to non-alcoholic fatty liver disease is undergoing routine surveillance. His recent surveillance ultrasound identified a new 3 cm lesion in segment VIII. His alpha-fetoprotein level is 45 ng/mL (previously normal). A contrast-enhanced ultrasound is performed, with representative images shown. Based on the clinical context and the findings demonstrated in the images, what is the most appropriate immediate next step in this patient's management?

A. Initiate systemic chemotherapy with sorafenib
B. Repeat the contrast-enhanced ultrasound in 3 months
C. Referral to a multidisciplinary liver tumour board for staging and treatment planning
D. Schedule a follow-up appointment with the GP in 4 weeks
E. Perform an immediate percutaneous biopsy of the lesion
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 65-year-old male with recently diagnosed gastric mixed adenoneuroendocrine carcinoma presents with unintentional weight loss. Endoscopy confirmed the diagnosis. Staging imaging is provided. His ECOG performance status is 1. Based on the clinical context and the findings demonstrated, what is the primary goal of initial management for this patient?

A. Observation with regular follow-up imaging
B. Referral for consideration of liver transplantation
C. Surgical resection of the primary gastric tumour
D. Liver directed therapy such as radioembolisation or ablation
E. Palliative systemic therapy to control symptoms and prolong survival
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 65-year-old male with known alcoholic cirrhosis undergoes surveillance. The provided contrast-enhanced ultrasound was obtained. What is the MOST appropriate next step?

A. Repeat ultrasound in 3 months
B. Liver biopsy
C. Initiate sorafenib
D. Ablation therapy
E. Triphasic CT or MRI
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Ultrasonographic picture taken from a patient with left ureteral stone with hydronephrosis, created in Taiwan
Image by morning2k CC BY 2.5 · Source

A 45-year-old male presents to the 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. Discharge with analgesics and follow-up with urology
B. Administer IV antibiotics
C. Non-contrast CT of the abdomen and pelvis
D. Increase oral fluid intake and reassess in 2 hours
E. Refer for immediate surgical intervention
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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 male with a history of hypertension and hyperlipidemia presents for a routine follow-up. He is asymptomatic. A contrast-enhanced CT abdomen, axial view shown, was performed as part of a screening protocol. What is the MOST appropriate next step?

A. Initiate beta-blocker therapy
B. Prescribe a statin for lipid management
C. Start aspirin for antiplatelet therapy
D. Repeat imaging in 6-12 months
E. Refer for immediate surgical repair
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Upright X-ray demonstrating small bowel obstruction
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 68-year-old male presents with abdominal distension and obstipation. An upright abdominal X-ray is performed. What is the MOST appropriate next step in management?

A. Stool softeners
B. Colonoscopy
C. Barium enema
D. Increase oral fluid intake
E. Surgical consultation
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Mammogram microcalcifications in carcinoma in situ, CC, details
Image by Jmarchn CC BY-SA 3.0 · Source

A 62-year-old woman presents for her routine mammogram. She has no personal or family history of breast cancer. She denies any breast pain, nipple discharge, or palpable lumps. Clinical breast exam is unremarkable. Her previous mammograms have been negative. The current mammogram reveals findings as shown in the image. What is the MOST appropriate next step in management?

A. Ultrasound-guided core biopsy
B. MRI of the breast
C. Stereotactic core biopsy
D. Excisional biopsy
E. Reassurance and routine screening mammography in 1 year
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CT, ultrasonography, SPECT and scintigraphy of intra-thyroid parathyroid adenoma
Image by Mnahi Bin Saeedan, Ibtisam Musallam Aljohani, Ayman Omar Khushaim, Salwa Qasim Bukhari, Salahudin Tayeb Elnaas CC BY 4.0 · Source

A 58-year-old woman presents with persistent fatigue, muscle weakness, and vague abdominal pain. Her serum calcium is 3.2 mmol/L (2.1-2.6 mmol/L), and PTH is 190 pg/mL (10-65 pg/mL). Renal function is normal. She denies any family history of endocrine disorders. Imaging studies are performed, as shown. Based on the clinical context and the imaging findings presented, which of the following represents the definitive management strategy for this patient?

A. Repeat serum calcium and PTH in three months.
B. Surgical excision of the identified lesion.
C. Order a skeletal survey to assess for osteitis fibrosa cystica.
D. Initiate treatment with cinacalcet and monitor calcium levels.
E. Perform a fine needle aspiration biopsy of the lesion.
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 70-year-old male with known cirrhosis secondary to non-alcoholic fatty liver disease presents for routine surveillance. He has Child-Pugh class A cirrhosis and ECOG performance status 0. His recent surveillance ultrasound showed a new 3 cm lesion in segment VIII. Serum alpha-fetoprotein is elevated at 450 ng/mL. A contrast-enhanced ultrasound was performed, and representative images are shown. Considering the patient's history, clinical status, laboratory results, and the findings demonstrated in the contrast-enhanced ultrasound images, what is the MOST appropriate immediate next step in the management of this patient?

A. Referral to a multidisciplinary liver tumour board for treatment planning
B. Start systemic chemotherapy with Sorafenib
C. Repeat the contrast-enhanced ultrasound in 3 months
D. Initiate palliative care referral
E. Perform an urgent liver biopsy of the lesion
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Post-embolization arteriogram showing coiled aneurysm (indicated by yellow arrows) of the posteriorcerebral artery with a residual aneurysmal sac.
Image by Promod Pillai, Aftab Karim, Anil Nanda CC BY 2.0 · Source

A 60-year-old female with a history of a posterior cerebral artery aneurysm presents for routine follow-up. Review the image. What is the MOST appropriate management?

A. Prescribe a course of corticosteroids
B. Increase dose of statin
C. Initiate dual antiplatelet therapy
D. Start aspirin
E. Repeat angiography in 6 months
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 30-year-old recent immigrant from a high-TB prevalence country presents with a persistent cough and night sweats for 2 months. Sputum cultures are negative for acid-fast bacilli. A PET-CT scan was performed, and an image is shown. What is the MOST appropriate next step in management?

A. Repeat sputum cultures in one week
B. Initiate anti-tuberculosis therapy
C. Prescribe a course of broad-spectrum antibiotics
D. Order a bronchoscopy with biopsy
E. Start the patient on corticosteroids
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Post-embolization arteriogram showing coiled aneurysm (indicated by yellow arrows) of the posteriorcerebral artery with a residual aneurysmal sac.
Image by Promod Pillai, Aftab Karim, Anil Nanda CC BY 2.0 · Source

A 72-year-old male with a history of atrial fibrillation and well-controlled hypertension presents with acute onset expressive aphasia and right-sided facial droop. A CT angiogram reveals a posterior cerebral artery aneurysm, which was promptly treated with endovascular coiling. The provided image shows the post-operative angiogram. Despite the intervention, the patient's aphasia persists, and the facial droop has worsened. What is the MOST likely cause of the patient's continued and worsening symptoms?

A. Intracranial pressure elevation due to edema
B. Reperfusion injury following aneurysm coiling
C. Underlying progressive neurodegenerative disease
D. Thromboembolic complication during the coiling procedure
E. Vasospasm of the posterior cerebral artery
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Ileitis terminalis bei langjaehrigem Morbus Crohn 63W - CT und MRT - 001
Image by Hellerhoff CC BY-SA 4.0 · Source

A 32-year-old male with Crohn's disease presents with worsening abdominal pain and diarrhea despite being on maintenance infliximab. He denies fever or blood in his stool. An abdominal CT and MRI are performed. Based on the imaging, what is the MOST appropriate next step in management?

A. Initiate treatment with ustekinumab
B. Perform a colonoscopy with biopsy
C. Prescribe a course of oral metronidazole
D. Start a course of oral budesonide
E. Increase the dose of infliximab
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Hepatic metastases from a gastric mixed adenoneuroendocrine carcinoma (MANEC).
Image by Hellerhoff CC BY-SA 3.0 · Source

A 58-year-old male presents with a 3-month history of dyspepsia, early satiety, and unintentional weight loss. Upper endoscopy revealed a large, ulcerated mass in the gastric antrum. Biopsy confirmed adenocarcinoma. Staging investigations were performed, including the provided imaging. His ECOG performance status is 1. Blood tests show mild anaemia and normal liver function tests. Given the clinical presentation and the findings on the provided imaging, which of the following is the most appropriate primary goal of management for this patient?

A. Curative surgical resection of the primary gastric tumour
B. Radiation therapy to the gastric mass
C. Palliation of symptoms and improvement of quality of life
D. Neoadjuvant chemotherapy followed by reassessment for surgery
E. Liver transplantation
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A patient presents with severe community-acquired pneumonia. Which initial investigation is most crucial for guiding immediate management?

A. Blood cultures
B. Sputum culture
C. Full blood count
D. Chest X-ray
E. Arterial blood gas
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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 60-year-old man, post-chemotherapy, presents with fever and abdominal pain. The images are shown. What is the MOST appropriate initial therapy?

A. Surgical resection
B. Amphotericin B
C. Albendazole
D. Broad-spectrum antibiotics
E. Percutaneous drainage
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

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. Order a bronchoscopy with bronchoalveolar lavage and transbronchial biopsy
B. Schedule a follow-up PET-CT scan in 3 months to monitor for changes in size and metabolic activity
C. Prescribe a course of broad-spectrum antibiotics to cover community-acquired pneumonia
D. Perform a CT-guided needle biopsy of the lesion for definitive diagnosis
E. Initiate a multi-drug anti-tuberculosis therapy regimen
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X-ray of hiatal hernia
Image by Ahmed Farhat, Daryn Towle CC BY 4.0 · Source

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 findings on the imaging study, which of the following is the most likely underlying cause of the patient's anaemia?

A. Chronic mucosal erosion within the displaced viscus
B. Vitamin B12 deficiency secondary to impaired absorption from dysphagia
C. Anaemia of chronic disease exacerbated by her underlying osteoarthritis
D. Acute blood loss from a peptic ulcer distal to the pylorus
E. Microangiopathic haemolytic anaemia associated with the indwelling central venous catheter
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PET-CT of a tuberculoma
Image by Annemie Snoeckx, Pieter Reyntiens, Damien Desbuquoit, Maarten J. Spinhoven, Paul E. Van Schil, Jan P. van Meerbeeck, Paul M. Parizel CC BY 4.0 · Source

A 45-year-old male, who recently immigrated from India, presents to his primary care physician with a two-month history of progressive fatigue, unintentional weight loss of 7 kg, and intermittent night sweats. He denies any cough, chest pain, or shortness of breath. He has no significant past medical history and is not currently taking any medications. Physical examination reveals normal vital signs, including a temperature of 37.1°C, and clear breath sounds bilaterally. However, mild cervical lymphadenopathy is noted. Initial laboratory investigations, including a complete blood count and comprehensive metabolic panel, are unremarkable. A chest X-ray reveals a solitary pulmonary nodule in the right upper lobe, which prompts a PET-CT scan for further evaluation. An axial slice from the PET-CT is shown. Given the patient's clinical presentation, immigration history, and the PET-CT findings, which of the following is the MOST appropriate next step in establishing a definitive diagnosis?

A. Bronchoscopy with transbronchial needle aspiration of the lesion
B. Administer a purified protein derivative (PPD) skin test
C. Order a CT-guided percutaneous needle biopsy of the lung nodule
D. Repeat PET-CT scan in three months to assess for interval growth
E. Initiate empiric antibiotic therapy with a broad-spectrum antibiotic
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Mammogram microcalcifications in carcinoma in situ, CC, details
Image by Jmarchn CC BY-SA 3.0 · Source

A 62-year-old woman presents for routine mammography. The image is shown. What is the MOST appropriate next step?

A. Reassurance and routine screening
B. Stereotactic core biopsy
C. Ultrasound of the breast
D. MRI of the breast
E. Excisional biopsy
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Figure 3 of paper: Alveolar echinococcosis in a patient with immunosuppression.

(a) Abdominal gray-scale US shows an abscess-like hepatic image.
(b) Axial unenhanced CT shows a typical aspect of pyogenic liver abscess.
Image by Wenya Liu, Éric Delabrousse, Oleg Blagosklonov, Jing Wang, Hongchun Zeng, Yi Jiang, Jian Wang, Yongde Qin, Dominique Angèle Vuitton, Hao Wen CC BY 4.0 · Source

A 62-year-old male with a history of poorly controlled diabetes presents with fever, RUQ pain, and recent travel to a rural area. Lab results show elevated ALP and GGT. Imaging is performed. What is the MOST appropriate next step in management?

A. Metronidazole
B. Observation and serial imaging
C. Percutaneous drainage and antibiotics
D. Albendazole and surgical resection
E. Ceftriaxone and doxycycline
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Gynaecomastia
Image by ProloSozz CC BY-SA 4.0 · Source

A 55-year-old male presents to his GP with bilateral breast tenderness and swelling over six months. He denies nipple discharge or other systemic symptoms. Past medical history is unremarkable, and he takes no regular medications. Physical examination reveals the findings shown in the image. Vital signs are normal. Initial investigations including liver function tests, renal function tests, thyroid function tests, LH, FSH, prolactin, and testosterone are all within normal limits. Considering the clinical presentation, image findings, and normal initial investigations, which of the following is the most appropriate next step in the evaluation of this patient?

A. CT scan of the chest, abdomen, and pelvis
B. Referral for genetic testing for Klinefelter syndrome
C. Breast ultrasound and mammography
D. Initiate a trial of tamoxifen
E. Scrotal ultrasound
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CT scan of hepatocellular carcinoma, without and with IV contrast
Image by Zhenyu Pan, Guozi Yang, Tingting Yuan, Lihua Dong, Lihua Dong CC BY 4.0 · Source

A 62-year-old male with chronic hepatitis C presents with right upper quadrant pain, weight loss, and mild ascites. Laboratory tests show elevated alpha-fetoprotein. Imaging is performed. Based on the clinical context and the findings depicted in the provided imaging, which of the following factors is MOST important in assessing this patient's suitability for potentially curative surgical management?

A. Evidence of portal venous thrombosis or invasion.
B. Absolute level of serum alpha-fetoprotein.
C. Patient's body mass index.
D. Maximum diameter of the hepatic lesion.
E. Specific viral load of hepatitis C RNA.
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 70-year-old male with cirrhosis secondary to NAFLD presents for routine surveillance. A new 3 cm lesion was found in segment VIII on ultrasound, with AFP 45. Contrast-enhanced ultrasound was performed, with representative images shown. Considering the clinical context and the findings demonstrated, what is the most appropriate immediate next step in this patient's management?

A. Schedule repeat surveillance ultrasound in 3 months.
B. Referral to a multidisciplinary liver tumour board for staging and treatment planning.
C. Referral for immediate liver transplantation assessment.
D. Proceed directly to percutaneous biopsy of the lesion.
E. Initiate systemic therapy with a tyrosine kinase inhibitor.
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A middle-aged man with a 20% estimated cardiovascular risk is already on lifestyle modifications and statin therapy. Which of the following investigations can help further assess or reclassify his cardiovascular risk?

A. Coronary artery angiogram
B. Echocardiogram
C. Stress echocardiogram
D. Coronary artery calcium score
E. Exercise ECG
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