management
Practice targeted AMC-style multiple-choice questions on management.
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A 68-year-old male with known Hepatitis B related cirrhosis and a history of alcohol excess presents for routine surveillance. His alpha-fetoprotein (AFP) level, which has been stable at 15 ng/mL for the past two years, is now noted to be 185 ng/mL. A screening ultrasound performed three months prior was reported as showing diffuse parenchymal changes consistent with cirrhosis but no focal lesions. Due to the elevated AFP, a repeat ultrasound was performed, which identified a 2.5 cm nodule in segment VIII. To further characterise this lesion, a contrast-enhanced ultrasound (CEUS) was performed, and the images provided are representative findings from this study. The patient has well-compensated cirrhosis (Child-Pugh A) and no significant comorbidities. His liver function tests are within normal limits except for a slightly elevated GGT. Given the clinical context and the findings demonstrated in the provided images, what is the most appropriate next step in the management of this patient?
A 35-year-old male presents to his general practitioner with a lesion on his nose that has been present for approximately 3 months. He initially thought it was a persistent pimple but it has not resolved and seems to be slowly growing. He denies pain, itching, or bleeding from the lesion. He has no significant past medical history and takes no regular medications. He works outdoors but reports using sunscreen inconsistently. On examination, vital signs are stable. The lesion is as shown in the image. There are no other skin lesions noted elsewhere. Regional lymph nodes are not palpable. Based on the appearance of the lesion shown, what is the most appropriate next step in the management of this patient?
A 68-year-old man with a history of smoking, hypertension, and dyslipidaemia presents for investigation of intermittent flank pain. Physical examination is unremarkable. Routine blood tests are normal. A CT scan of the abdomen is performed. Considering the findings demonstrated in the image, what is the most appropriate next step in the management of this patient?
A 3-year-old child is brought to the GP by their parents who are worried about the appearance of their child's abdomen, as shown in the image. The child is otherwise well, active, and has no pain, vomiting, or changes in bowel habits. On examination, the finding is soft and easily reducible. Vital signs are normal. Based on this presentation and the image, what is the most appropriate initial management?
A 1-year-old child is presented to the general practitioner by their parents who are concerned about the appearance of their child's umbilicus, as depicted in the accompanying image. The parents report the bulge is more prominent with crying but is easily reducible. The child is otherwise well, feeding normally, and has no history of pain, vomiting, or constipation. Physical examination reveals normal vital signs and a soft, non-tender abdomen. Considering the clinical presentation and the finding shown, what is the most appropriate advice to give the parents regarding initial management?
A 64-year-old woman presents for review in the outpatient clinic. She reports a history of intermittent, self-resolving episodes of right upper quadrant colicky pain over the past year, but is currently asymptomatic. She denies fever, jaundice, or other systemic symptoms. Her physical examination is unremarkable, and recent liver function tests are within the normal reference range. An elective abdominal ultrasound was performed, yielding the image shown. Based on the clinical presentation and the findings demonstrated, what is the most appropriate next step in her management?
A 3-year-old child is presented to the general practitioner by their parents who are concerned about the appearance of their child's umbilicus, as depicted in the accompanying image. The child is reported to be entirely asymptomatic, feeding and playing normally, with no history of pain, discomfort, or vomiting. Physical examination reveals normal vital signs and a soft, non-tender abdomen with no signs of obstruction. Considering the clinical presentation and the finding shown, what is the most appropriate initial management plan for this child?
A 62-year-old woman presents with fatigue, bone pain, and constipation. Laboratory tests reveal serum calcium 3.1 mmol/L, PTH 180 pg/mL, and elevated 24-hour urine calcium. Imaging studies are shown. Considering the clinical presentation and investigation findings, what is the MOST appropriate next step in the management of this patient?
A 68-year-old former smoker with a 30 pack-year history presents to their GP with a 2-month history of persistent cough and increasing fatigue, noting a 3kg unintentional weight loss. 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 reveals a solitary pulmonary nodule in the right upper lobe. Subsequent PET-CT imaging is performed as part of the diagnostic workup. Considering the findings demonstrated in the image provided in the context of this patient's presentation, which of the following is the most appropriate next step in the management of this patient?
A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?
A 70-year-old male with a history of hypertension and smoking undergoes a CT scan for investigation of chronic back pain. He denies any abdominal pain, pulsatile mass, or leg ischaemia. His blood pressure is 130/80 mmHg, pulse 72 bpm. The image provided is an axial view from this scan. Based on this finding, what is the most appropriate next step in his management?
A 62-year-old man presents to his GP reporting a swelling in his right groin that has been present for approximately 18 months. He describes it as intermittent, appearing when he stands or strains, and disappearing when he lies down. He occasionally experiences a mild, dull ache in the area, but denies any severe pain, nausea, vomiting, or change in bowel habits. His past medical history includes hypertension controlled with medication. On examination, vital signs are stable, and the finding shown in the image is noted. It is easily reducible. Considering the patient's history, the absence of acute symptoms, and the physical examination finding depicted, what is the most appropriate next step in the management of this patient?
A 55-year-old patient with a history of solid organ transplant on immunosuppressive therapy presents with a 2-week history of low-grade fever, malaise, and dull right upper quadrant discomfort. Physical examination is unremarkable except for mild tenderness in the right upper quadrant. Blood tests reveal a CRP of 85 mg/L (normal <5), WCC 11.5 x 10^9/L (normal 4-11), and mildly elevated alkaline phosphatase. Imaging is performed as shown. What is the most appropriate next step in management?
A 55-year-old renal transplant recipient on long-term immunosuppression presents with a 2-week history of low-grade fever, malaise, and dull right upper quadrant discomfort. Physical exam is unremarkable except for mild tenderness. Labs show mild leucocytosis and elevated CRP. Imaging is shown. Based on these findings, what is the most appropriate immediate management step?
A 62-year-old woman presents with a 4-month history of increasing abdominal distension, bloating, and a sensation of early fullness after eating. She has also noticed a gradual increase in her waist circumference and reports feeling more fatigued than usual. Her medical history includes well-controlled type 2 diabetes mellitus and hypercholesterolaemia, managed with metformin and atorvastatin respectively. She is post-menopausal, having completed menopause 10 years ago. On physical examination, her vital signs are stable: blood pressure 128/78 mmHg, heart rate 68 bpm, respiratory rate 14/min, and temperature 36.6°C. Abdominal examination reveals moderate distension and a firm, irregular mass is palpable extending from the pelvis into the lower abdomen. Bowel sounds are present and normal. A recent transvaginal ultrasound was inconclusive due to the size of the mass, prompting a CT scan of the abdomen and pelvis, an axial image from which is shown. Given the clinical presentation and the findings on the image, what is the most appropriate immediate next step in the management of this patient?
A 48-year-old man presents with a 2-year history of progressive, tender breast enlargement causing significant distress. Initial investigations including liver function tests, renal function tests, and basic hormonal assays (LH, FSH, testosterone, oestradiol) were largely within normal limits, except for a mildly elevated oestradiol. He takes no regular medications and denies recreational drug use. He is otherwise well and his physical examination is unremarkable apart from the findings shown in the image. Considering the clinical presentation and the findings, what is the most appropriate next step in his management?
A 62-year-old man presents to his GP with a history of a bulge in his right groin that has been present for approximately 18 months. He reports it is more prominent with straining or standing and disappears completely when he lies down. He denies any associated pain, nausea, vomiting, or change in bowel habits. He has no significant past medical history. His physical examination reveals the finding depicted in the image. Vital signs are within normal limits. Based on this clinical picture, which of the following represents the most appropriate definitive management strategy for this patient?
A 72-year-old man presents to his GP with a 3-month history of intermittent lower back pain, which is worse with activity. He has a history of hypertension, hyperlipidaemia, and is a former smoker. Physical examination reveals normal vital signs and no abdominal tenderness or pulsatile mass. Routine blood tests are normal. An abdominal CT scan is performed as part of the workup. Considering the findings demonstrated in the image, what is the most appropriate next step in the management of this patient?
A 3-year-old boy presents with a 12-hour history of intermittent, severe abdominal pain, non-bilious vomiting, and decreased activity. Parents report redcurrant jelly stool. On exam, a palpable mass is noted. Vitals are stable. An ultrasound is performed (shown above). Considering the clinical picture and the image findings, which non-surgical intervention is indicated?
A 70-year-old male undergoes a CT scan for investigation of chronic back pain. He is otherwise asymptomatic with stable vital signs. The image provided is an axial view from this scan. Based on this finding, what is the most appropriate next step in the patient's management according to current guidelines?
A 14-month-old child is brought to the general practitioner for a routine check-up and immunisations. The parents express mild concern about a bulge they have noticed around the child's navel, which seems more prominent when the child is crying or straining. They report it is easily pushed back in and does not appear to cause the child any pain or discomfort. The child is otherwise thriving, with normal feeding, bowel movements, and developmental progress. On physical examination, the child is alert and interactive. Vital signs are within normal limits for age. Abdominal examination reveals no distension or tenderness. The finding illustrated in the image is noted. Based on this clinical presentation and examination finding, what is the most appropriate initial management plan?
A 55-year-old woman presents to her general practitioner with a 3-month history of increasing abdominal bloating, early satiety, and a vague, intermittent dull ache in her lower abdomen. She reports a 5 kg weight loss over the same period, which she attributes to reduced appetite. Her last menstrual period was 5 years ago. She has a past medical history of well-controlled hypertension and osteoarthritis. She is on perindopril and paracetamol as needed. On physical examination, her vital signs are stable (BP 130/80 mmHg, HR 72 bpm, RR 16/min, Temp 36.8°C). Abdominal examination reveals mild distension and a firm, non-tender mass palpable in the suprapubic and left iliac fossa regions, estimated to be about 8 cm in size. Bowel sounds are normal. Pelvic examination is deferred due to patient discomfort and preference for imaging first. Routine blood tests, including full blood examination, urea and electrolytes, liver function tests, and C-reactive protein, are all within normal reference ranges. A CT scan of the abdomen and pelvis is performed to investigate her symptoms, an axial image from which is shown. Considering the clinical presentation and the findings on the image, what is the most appropriate immediate next step in the management of this patient?
A 1-year-old child presents to the GP with parental concern about a bulge on the abdomen, as shown in the image. The child is asymptomatic, feeding well, and has normal bowel movements. Examination reveals a soft, reducible finding at the umbilicus; the abdomen is non-tender with normal bowel sounds. Based on this presentation and the image, what is the most appropriate initial management?
A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history. Her vital signs are stable. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?
A 65-year-old woman presents with a several-month history of a slowly enlarging, mildly pruritic skin lesion on her left chest wall. She underwent a simple mastectomy on the left side for invasive ductal carcinoma 8 years ago. She denies systemic symptoms. Physical examination reveals the appearance shown. What is the most appropriate next step in management?
A 55-year-old man presents to his GP complaining of a long-standing, intermittent swelling in his right groin that becomes more noticeable when he coughs or lifts heavy objects. It is usually painless and he can push it back in. His vital signs are normal. Considering the clinical presentation and the appearance shown, what is the most appropriate initial management?
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 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 72-year-old male presents with a 4-month history of increasing constipation and occasional streaks of blood on stool. He denies significant weight loss. Physical exam is unremarkable. A colonoscopy was performed, and the image is shown. Biopsies are taken from the lesion. Assuming the biopsy confirms adenocarcinoma, what is the MOST appropriate initial investigation to guide further management?
A 62-year-old woman presents to her general practitioner complaining of fatigue, bone pain, and constipation for the past several months. She denies any significant past medical history. Initial laboratory investigations reveal an elevated serum calcium level of 3.1 mmol/L (reference range: 2.1-2.6 mmol/L) and an elevated parathyroid hormone (PTH) level of 180 pg/mL (reference range: 10-65 pg/mL). A 24-hour urine calcium excretion is also elevated. The patient is referred for further imaging, the results of which are shown. Based on the available information, what is the MOST appropriate next step in the management of this patient?
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?
An 68-year-old man attends his GP for a routine check-up. He has a history of well-controlled type 2 diabetes, hypertension, and smoked for 30 years, quitting 5 years ago. He denies any abdominal pain, back pain, or pulsatile sensation. Physical examination is unremarkable. As part of a cardiovascular risk assessment, an abdominal ultrasound is initially performed, which is inconclusive due to bowel gas. A follow-up contrast-enhanced CT scan is arranged. Considering the findings demonstrated in the image, what is the most appropriate next step in the management of this patient?
A 63-year-old woman with a 20-year history of Crohn's disease presents with a one-month history of worsening abdominal pain, bloating, and occasional vomiting, associated with a 3kg weight loss. She is currently managed with mesalazine and azathioprine. Her vital signs are stable, and physical examination reveals mild right lower quadrant tenderness. Imaging is performed. Considering the clinical presentation and the findings demonstrated in the provided images, which of the following management approaches is most likely indicated?
Mrs. Eleanor Vance, a 62-year-old retired teacher, presents for her routine biennial screening mammogram through the BreastScreen Australia program. She has no personal history of breast disease, and her family history is negative for breast or ovarian cancer in first-degree relatives. She is otherwise healthy, with a history of diet-controlled type 2 diabetes and osteoarthritis managed with paracetamol. She denies any breast pain, lumps, nipple discharge, or skin changes. Her last mammogram two years ago was reported as normal (BIRADS 1). Physical examination of both breasts and axillae is unremarkable. The current screening mammogram is performed. The image provided is a magnified view from the craniocaudal projection of the left breast, specifically highlighting an area that has been flagged for further assessment by the reporting radiologist due to a change from the previous study. Based on the clinical presentation, the patient's history, and the specific finding demonstrated in the provided image from her screening mammogram, what is the most appropriate immediate next step in the management pathway for this patient?
A 14-month-old child is brought to the general practitioner for a routine check-up and immunisations. The parents express mild concern about a bulge they have noticed around the child's navel, which seems more prominent when the child is crying or straining. They report it is easily pushed back in and does not appear to cause the child any pain or discomfort. The child is otherwise thriving, with normal feeding, bowel movements, and developmental progress. On physical examination, the child is alert and interactive. Vital signs are within normal limits for age. Abdominal examination reveals no distension or tenderness. The finding shown in the image is noted. Based on this clinical presentation and examination finding, what is the most appropriate initial management plan?
A 65-year-old male with known cirrhosis secondary to chronic hepatitis B presents with increasing abdominal distension and fatigue. He has mild ascites. Liver function tests show bilirubin 35 umol/L, INR 1.3, albumin 30 g/L. AFP is 850 ng/mL. Imaging is performed as shown. Based on the imaging findings and clinical presentation, which of the following treatment modalities is MOST likely to be considered for this patient?
An asymptomatic 70-year-old male undergoes a CT scan of the abdomen as part of an investigation for mild, intermittent lower back pain. His vital signs are stable, and physical examination is unremarkable. Considering the findings on the provided image, what is the most appropriate next step in this patient's management?
Mrs. Eleanor Vance, a 62-year-old retired teacher, presents for her routine biennial screening mammogram through the BreastScreen Australia program. She has no personal history of breast disease, and her family history is negative for breast or ovarian cancer in first-degree relatives. She is otherwise healthy, with a history of diet-controlled type 2 diabetes and osteoarthritis managed with paracetamol. She denies any breast pain, lumps, nipple discharge, or skin changes. Her last mammogram two years ago was reported as normal (BIRADS 1). Physical examination of both breasts and axillae is unremarkable. The current screening mammogram is performed. The image provided is a magnified view from the craniocaudal projection of the left breast, specifically highlighting an area that has been flagged for further assessment by the reporting radiologist due to a change from the previous study. Assuming that subsequent investigation of the area highlighted in the image confirms a diagnosis of ductal carcinoma in situ (DCIS) and the patient undergoes breast-conserving surgery, which of the following factors is most important in determining the need for adjuvant radiotherapy?
A 63-year-old man presents to his GP with a 6-month history of intermittent postprandial fullness and mild dysphagia, particularly with solid foods. He reports occasional regurgitation but denies significant heartburn or chest pain. His vital signs are stable, and physical examination is unremarkable. Recent blood tests show mild iron deficiency anaemia. The provided image is from a CT scan of the chest and upper abdomen performed as part of his investigation. Considering the clinical presentation and the significant anatomical finding demonstrated in the image, what is the most appropriate next step in the management of this patient?