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middle-aged man

Practice targeted AMC-style multiple-choice questions on middle-aged man.

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Gynaecomastia
Image by ProloSozz CC BY-SA 4.0 · Source

A 55-year-old man presents to his general practitioner with a six-month history of bilateral breast tenderness and swelling. He is otherwise asymptomatic, reporting no nipple discharge, skin changes, or palpable lumps. His medical history includes well-controlled hypertension on amlodipine. He denies illicit drug use or significant alcohol intake. On examination, the finding shown in the image is noted. Given this presentation, what is the most appropriate initial diagnostic step?

A. Advise lifestyle modification and review in three months.
B. Serum hormonal profile including testosterone, oestradiol, LH, FSH, prolactin, and hCG.
C. Referral for surgical consultation and potential biopsy.
D. Bilateral diagnostic mammography to rule out malignancy.
E. Ultrasound examination of the breast and axillary lymph nodes.
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A 45-year-old man presents to the general practice clinic with a 3-month history of fatigue, weight loss, and night sweats. He has a history of smoking and works as a construction worker. On examination, he has cervical lymphadenopathy and hepatosplenomegaly. Blood tests reveal anemia and elevated lactate dehydrogenase (LDH). A chest X-ray shows a mediastinal mass. What is the most appropriate next step in the management of this patient?

A. Initiate corticosteroid therapy
B. Start empirical antibiotic therapy
C. Order a CT scan of the chest and abdomen
D. Perform a lymph node biopsy
E. Refer for surgical excision of the mass
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Inguinal hernia right view. Adult male with an inguinal hernia, showing bulging in the groin area.
Image by IkeTheSloth CC0 1.0 · Source

A 48-year-old man presents to his GP reporting an intermittent swelling in his right groin over the past six months. He notes it is more prominent when he is upright or coughing and disappears when he lies down. He experiences occasional mild discomfort but denies any acute pain, nausea, or vomiting. His past medical history is unremarkable, and vital signs are stable. Physical examination reveals the finding shown in the image. Considering the patient's history and the physical examination finding depicted, what is the most appropriate recommendation regarding definitive management for this patient?

A. Prescription of a truss for support
B. Watchful waiting with regular review
C. Elective surgical repair
D. Referral for ultrasound imaging
E. Urgent surgical exploration
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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 night sweats for 3 weeks. Initial blood cultures are negative. Imaging is performed, as shown. What is the MOST appropriate next step in management?

A. Albendazole therapy
B. Percutaneous drainage and culture of the lesion
C. Surgical resection of the affected liver segment
D. Empiric broad-spectrum antibiotics
E. Observation with serial imaging
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A 45-year-old man presents with chronic cough, weight loss, and night sweats. Chest X-ray shows apical infiltrates. Sputum smear for AFB is negative. What is the most appropriate next step in management?

A. Perform a bronchoscopy with lavage.
B. Order a CT scan of the chest.
C. Start empirical anti-tuberculosis treatment.
D. Discharge with symptomatic treatment and review.
E. Repeat sputum smear and culture, including nucleic acid amplification test (NAAT).
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old male presents to his general practitioner complaining of a persistent, asymptomatic lesion on his nose that has been present for approximately 6 months. He denies any trauma to the area. He reports no other skin issues or systemic symptoms. Physical examination reveals the lesion shown. The patient is concerned about cosmetic appearance and potential for malignancy. What is the MOST appropriate initial management step?

A. Topical imiquimod
B. Referral to a dermatologist for biopsy and potential excision
C. Reassurance and observation
D. Cryotherapy
E. Topical corticosteroids
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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 58-year-old male presents with vague abdominal pain and unintentional weight loss. He has a history of working on a sheep farm. The provided imaging was obtained. Which of the following serological tests is MOST appropriate?

A. Amoebic serology
B. Hepatitis B surface antigen
C. Echinococcus IgG antibody
D. Strongyloides IgG antibody
E. Alpha-fetoprotein
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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 a history of chronic hepatitis C presents with right upper quadrant pain, weight loss, and jaundice. Vital signs are stable. Physical examination reveals hepatomegaly and mild ascites. Laboratory investigations include elevated alpha-fetoprotein (AFP). Imaging is performed as shown. Considering the clinical context and the findings demonstrated in the imaging, which of the following assessments is MOST crucial for determining the feasibility and type of definitive treatment for the identified lesion?

A. Confirmation of hepatitis C viral load
B. Assessment of underlying liver synthetic function (e.g., Child-Pugh score)
C. Evaluation for extrahepatic metastatic disease
D. Assessment of portal vein patency
E. Measurement of the lesion's maximum diameter
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A 45-year-old man presents to the emergency department with sudden onset of severe abdominal pain radiating to the back. He is a smoker and has a history of hypertension. On examination, he is diaphoretic, with a heart rate of 120 bpm and blood pressure of 90/60 mmHg. Abdominal examination reveals a pulsatile mass in the midline. What is the most likely diagnosis?

A. Acute pancreatitis
B. Ruptured abdominal aortic aneurysm
C. Acute mesenteric ischemia
D. Perforated peptic ulcer
E. Renal colic
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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 denies fever or dysuria. Vitals are stable. A point-of-care ultrasound is performed, with the image shown. Assuming no contraindications, what is the MOST appropriate next step in management?

A. Prescribe oral tamsulosin and discharge home
B. Insert an indwelling urinary catheter
C. Consult urology for emergent stent placement
D. Order a non-contrast CT scan of the abdomen and pelvis
E. Administer intravenous ketorolac
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 45-year-old male with a known history of Blue Rubber Bleb Naevus Syndrome, characterised by recurrent gastrointestinal bleeding and multiple cutaneous vascular lesions, presents to the emergency department with acute onset severe, colicky abdominal pain, nausea, and vomiting. On examination, his abdomen is distended and diffusely tender with reduced bowel sounds. Vital signs are within normal limits. An urgent abdominal CT scan is performed. Based on the clinical presentation and the findings demonstrated in the image, what is the most appropriate immediate next step in management?

A. Urgent surgical exploration and reduction/resection
B. Attempt air enema reduction under fluoroscopy
C. Urgent upper gastrointestinal endoscopy for reduction
D. Nasogastric tube insertion, intravenous fluids, and observation
E. Obtain an urgent abdominal MRI for further characterisation
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Gynaecomastia
Image by ProloSozz CC BY-SA 4.0 · Source

A 58-year-old man presents to his general practitioner expressing concern about the appearance of his chest, which he feels has become more prominent over the past 18 months. He denies any pain, tenderness, or nipple discharge. His medical history includes well-controlled hypertension managed with perindopril and occasional use of ibuprofen for mild osteoarthritis. He reports no significant changes in weight, appetite, or energy levels. He is a non-smoker and drinks alcohol socially, approximately 5 standard drinks per week. He works as an accountant and reports no exposure to unusual chemicals or substances. On physical examination, his vital signs are within normal limits. Abdominal examination reveals no hepatosplenomegaly. Testicular examination is normal in size and consistency, with no palpable masses. The image provided shows the appearance of his chest. Considering the patient's presentation and the visual finding, what is the most appropriate initial investigation to pursue?

A. Genetic testing for Klinefelter syndrome.
B. Serum levels of testosterone, luteinising hormone (LH), follicle-stimulating hormone (FSH), oestradiol, and prolactin.
C. Liver function tests and renal function tests.
D. Mammography of the chest to assess for underlying malignancy.
E. Referral for psychological assessment and counselling regarding body image concerns.
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Endoscopy image of colon adenocarcinoma in sigmoid colon.
Image by Unknown CC BY-SA 3.0 · Source

A 62-year-old male presents with a three-month history of intermittent rectal bleeding and altered bowel habits. His past medical history is unremarkable. A colonoscopy was performed, and an image from the procedure is shown. What is the MOST appropriate next step in management?

A. Surgical resection
B. Administer intravenous antibiotics
C. Initiate a course of high-dose corticosteroids
D. Repeat colonoscopy in 1 year
E. Prescribe a high-fiber diet and monitor symptoms
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A 48-year-old sheep farmer presents to his GP with a two-week history of persistent fever, severe retro-orbital headache, and profound fatigue. He denies cough, shortness of breath, or rash. On examination, his temperature is 38.5°C, pulse 85 bpm, BP 120/80 mmHg. The remainder of the examination, including chest auscultation, is unremarkable. He has not travelled outside the region recently.

A. Acute Q fever
B. Atypical pneumonia
C. Leptospirosis
D. Brucellosis
E. Influenza
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A 55-year-old farmer presents with a week of high fever, severe retro-orbital headache, and profound muscle aches. He denies cough, sore throat, or rash. On examination, temperature is 39.5°C, pulse 90, BP 120/80. Lungs are clear to auscultation. Abdomen is soft, non-tender. Initial bloods show mildly elevated transaminases. What is the most likely diagnosis?

A. Typhoid fever
B. Leptospirosis
C. Influenza
D. Dengue fever
E. Q fever
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 55-year-old man presents to his GP with a lesion on his nose that he first noticed about 6 months ago. It has gradually increased in size but is not painful or itchy. He has no significant past medical history and takes no regular medications. On examination, vital signs are stable. The image shows the lesion. Based on the appearance of this lesion, what is the most appropriate next step in management?

A. Advise observation and review in 6 months.
B. Perform an excisional biopsy for histological examination.
C. Refer urgently to a dermatologist for Mohs surgery.
D. Prescribe a course of topical antibiotic cream.
E. Arrange for cryotherapy in the clinic.
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old male with a history of mild dysphagia and iron deficiency anemia presents for further evaluation. He denies any recent weight loss or hematemesis. An abdominal CT scan with contrast is performed, the axial view is shown. What is the MOST likely underlying cause of his anemia?

A. Angiodysplasia
B. Cameron lesions
C. Gastric malignancy
D. Duodenal ulcer
E. Esophageal varices
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An incarcerated inguinal hernia as seen on CT
Image by James Heilman, MD CC BY-SA 3.0 · Source

A 59-year-old male presents with a painful right groin bulge that has progressively worsened over the past week. He denies fever, chills, nausea, or vomiting. Vitals are stable. The provided image was obtained. What is the MOST appropriate next step?

A. Prescribe analgesics and discharge with surgical follow-up
B. Order a bowel preparation
C. Attempt manual reduction with sedation
D. Initiate broad-spectrum antibiotics
E. Surgical consultation for operative management
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Contrast-enhanced ultrasound of encephaloid hepatocellular carcinoma
Image by R. Badea, Simona Ioanitescu CC BY 3.0 · Source

A 58-year-old male with cirrhosis secondary to alcohol abuse presents for routine surveillance. His AFP is 25 ng/mL. A contrast-enhanced ultrasound is performed, as shown. What is the MOST appropriate next step in management?

A. MRI of the abdomen with contrast
B. Repeat AFP in 3 months
C. CT of the abdomen with contrast
D. Liver biopsy
E. Initiate sorafenib
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A 62-year-old male presents to the emergency department with a 2-day history of right flank pain, fever, and nausea. He reports a history of recurrent urinary tract infections. On examination, he has right costovertebral angle tenderness. Urinalysis reveals pyuria and leukocyte esterase. Which of the following is the most likely underlying condition related to the organ primarily affected in the right lumbar region?

A. Cholecystitis with referred pain
B. Appendicitis with atypical presentation
C. Musculoskeletal strain
D. Pyelonephritis secondary to ascending urinary tract infection
E. Diverticulitis of the ascending colon
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A 45-year-old man presents to the general practice clinic with a 6-month history of progressive shortness of breath and a persistent dry cough. He works as a construction worker and has a 20-pack-year smoking history. On examination, he has clubbing of the fingers and fine inspiratory crackles at the lung bases. Pulmonary function tests show a restrictive pattern. A high-resolution CT scan of the chest reveals reticular opacities and honeycombing predominantly in the lower lobes. Which of the following is the most likely diagnosis?

A. Sarcoidosis
B. Hypersensitivity pneumonitis
C. Idiopathic pulmonary fibrosis
D. Asbestosis
E. Chronic obstructive pulmonary disease
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A 55-year-old man with a history of type 2 diabetes presents for a routine check-up. His last HbA1c level, measured three months ago, was 8.2%. He reports no new symptoms and is currently on metformin. What is the most appropriate next step in managing his diabetes?

A. Start insulin therapy
B. Add a sulfonylurea
C. Increase the dose of metformin
D. Order a fasting blood glucose test
E. Refer to a diabetes educator
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents with increasing postprandial fullness and epigastric discomfort. He reports occasional regurgitation of undigested food. A CT scan of the abdomen is performed. Based on the image, what is the MOST appropriate next step in management?

A. H. pylori testing and eradication if positive
B. Surgical repair
C. Trial of proton pump inhibitors
D. Endoscopic surveillance
E. Dietary modification and lifestyle advice
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Inguinal hernia right view. Adult male with an inguinal hernia, showing bulging in the groin area.
Image by IkeTheSloth CC0 1.0 · Source

A 58-year-old male presents to the emergency department complaining of right groin pain that started approximately 6 hours ago. He reports noticing a bulge in his groin for several months, which he could usually push back in. However, today he is unable to reduce it, and the pain has become progressively severe. He denies any fever, nausea, or vomiting. His past medical history includes hypertension and hyperlipidemia, both well-controlled with medications. On examination, his vital signs are stable: blood pressure 130/80 mmHg, heart rate 80 bpm, respiratory rate 16 bpm, and temperature 37.0°C. Abdominal examination is benign. Examination of the groin reveals the finding shown in the image. The area is tender to palpation. Which of the following is the MOST appropriate next step in the management of this patient?

A. Surgical consultation for emergent repair
B. Ultrasound of the groin to rule out testicular torsion
C. Prescription for a truss and referral to a general surgeon for elective repair
D. CT scan of the abdomen and pelvis with intravenous contrast
E. Trial of manual reduction with sedation and analgesia
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 45-year-old male presents with intermittent abdominal pain and melena. He has multiple cutaneous hemangiomas. The provided image was obtained. What is the MOST likely underlying cause of the patient's presentation?

A. Peutz-Jeghers syndrome
B. Blue rubber bleb nevus syndrome
C. Gardner syndrome
D. Henoch-Schönlein purpura
E. Osler-Weber-Rendu syndrome
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old male presents with postprandial vomiting and persistent retrosternal discomfort. He reports feeling full quickly after eating only small amounts. An abdominal CT scan is performed, the axial view is shown. What is the MOST likely underlying mechanism contributing to this patient's symptoms?

A. Gastric malignancy
B. Pyloric stenosis
C. Esophageal dysmotility
D. Mechanical obstruction of the gastric outflow
E. Increased gastric acid production
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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 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with a low-grade fever (38.1°C) and mild nausea. He denies vomiting, diarrhoea, or rectal bleeding. On examination, he has localised tenderness in the left iliac fossa. His vital signs are stable: BP 130/80 mmHg, HR 78 bpm, RR 16/min, SpO2 98% on air. Blood tests show a white cell count of 12.5 x 10^9/L and CRP 45 mg/L. An abdominal CT scan is performed (image provided). Considering the clinical presentation and the findings on the provided image, which of the following investigations is most appropriate to recommend for this patient *after* resolution of the acute episode?

A. Colonoscopy in 6-8 weeks
B. Repeat CT scan of the abdomen and pelvis
C. Urgent colonoscopy within 48 hours
D. Faecal occult blood test
E. Barium enema
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A 45-year-old farmer presents with a 10-day history of fever, severe retro-orbital headache, and myalgia. He denies cough or dyspnoea. Physical examination is unremarkable. What is the most appropriate initial investigation?

A. Liver function tests
B. Serology for Coxiella burnetii
C. Chest X-ray
D. Blood culture
E. PCR for Coxiella burnetii
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 62-year-old male with LLQ pain and mild fever has the CT abdomen shown. What is the MOST appropriate next step in management?

A. Colonoscopy to rule out malignancy
B. Oral antibiotics and outpatient follow-up
C. Stool culture to rule out infectious colitis
D. IV antibiotics and admission for observation
E. Surgical consultation for possible resection
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 62-year-old man presents with a painless lesion on his nose, present for 8 months. He denies trauma or fever. Examination reveals the image shown. Histopathology is MOST likely to show which of the following?

A. Nodular basaloid cells with peripheral palisading
B. Granulomatous inflammation with eosinophils
C. Keratin pearls and intercellular bridges
D. Atypical melanocytes with pagetoid spread
E. Spindle cells arranged in a storiform pattern
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A 45-year-old man with a history of hypertension presents to the emergency department with palpitations and lightheadedness. His ECG shows a regular narrow-complex tachycardia at a rate of 180 bpm. There are no visible P waves, and the QRS duration is 0.08 seconds. He is hemodynamically stable. Which of the following is the most appropriate initial management?

A. Synchronized cardioversion
B. Observation without intervention
C. Intravenous adenosine
D. Vagal maneuvers
E. Intravenous metoprolol
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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 55-year-old man with a history of renal transplant on long-term immunosuppressive therapy presents with a 3-month history of intermittent right upper quadrant pain and unintentional weight loss. He denies fever or chills. Physical examination is unremarkable. Liver function tests show mild elevation of alkaline phosphatase and gamma-GT. Inflammatory markers (CRP, ESR) are slightly elevated. Imaging is performed. Considering the clinical context and the findings on imaging, what is the most appropriate next diagnostic step?

A. Schedule a PET scan to assess metabolic activity
B. Perform an MRI of the abdomen for further characterisation
C. Order serological tests for Echinococcus and fungal markers
D. Ultrasound-guided aspiration or biopsy of the lesion for microscopy, culture, and histology
E. Initiate empirical broad-spectrum intravenous antibiotics
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Gynaecomastia
Image by ProloSozz CC BY-SA 4.0 · Source

A 58-year-old man presents with concerns about breast enlargement. Examination reveals the findings in the image. Which of the following is the MOST appropriate initial investigation?

A. Liver function tests
B. Medication review
C. Serum prolactin
D. Mammogram
E. Testicular ultrasound
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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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A 45-year-old Aboriginal man from a remote community presents to the clinic for a routine health check. He has a history of smoking (20 pack-years) and reports drinking alcohol occasionally (3-4 standard drinks per week). He denies any chronic medical conditions. His blood pressure is 145/95 mmHg. BMI is 32 kg/m2. Fasting blood glucose is 6.5 mmol/L. Which of the following is the MOST appropriate initial management strategy, considering the principles of culturally safe care?

A. Prescribe an antihypertensive medication (e.g., ACE inhibitor) and metformin to address the elevated blood pressure and glucose levels immediately.
B. Initiate lifestyle modification counseling, including smoking cessation, dietary advice, and encourage increased physical activity, while also arranging a follow-up appointment to reassess blood pressure and glucose levels.
C. Provide him with written information about hypertension and diabetes and instruct him to follow up with the clinic if he develops any symptoms.
D. Refer him to a specialist physician for further evaluation and management of his hypertension and pre-diabetes.
E. Advise him to reduce his alcohol consumption and schedule a follow-up appointment in six months to monitor his blood pressure and glucose levels.
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Facial eosinophilic granuloma. Red-brown nodule on the nose. Clearly visible follicular structures ("peau d'orange").
Image by Sand, Michael, et al. CC BY 2.0 · Source

A 35-year-old male presents with a painless lesion on his nose that has been present for several months. He denies any trauma or previous skin conditions. Examination reveals the image shown. What is the MOST appropriate initial management step?

A. Topical antifungal cream
B. Topical corticosteroid application
C. Biopsy of the lesion
D. Cryotherapy
E. Observation with regular follow-up
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A 55-year-old man with a history of hypertension and smoking presents for a routine check-up. He is concerned about his risk of cardiovascular disease and asks for advice on lifestyle modifications. Which of the following lifestyle changes would most significantly reduce his risk of cardiovascular events?

A. Adopting a Mediterranean diet
B. Smoking cessation
C. Increasing physical activity
D. Limiting alcohol consumption
E. Reducing dietary salt intake
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A 45-year-old man presents to the emergency department with sudden onset of severe headache, described as the worst headache of his life. He also reports nausea and photophobia. On examination, he is alert but in distress, with a blood pressure of 160/100 mmHg, heart rate of 90 bpm, and no focal neurological deficits. A CT scan of the head is performed and shows no acute intracranial hemorrhage. What is the most appropriate next step in management?

A. MRI of the brain
B. Administer analgesics and observe
C. Start antihypertensive therapy
D. Lumbar puncture
E. Repeat CT scan with contrast
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Diverticular disease
Image by James Heilman, MD CC BY-SA 4.0 · Source

A 55-year-old male presents with LLQ pain, fever, and increased WBC. A CT scan is performed, as shown. He is hemodynamically stable. What is the MOST appropriate initial management?

A. IV antibiotics and bowel rest
B. High-fiber diet and increased fluid intake
C. Surgical resection
D. Flexible sigmoidoscopy
E. Oral antibiotics and outpatient follow-up
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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 assessment with sonography for trauma (FAST) exam is performed, with a view obtained as shown. What is the MOST appropriate next step in management?

A. Perform a cystoscopy
B. Discharge with analgesics and follow-up with urology
C. Non-contrast CT of the abdomen and pelvis
D. Order serum lipase and amylase
E. Administer intravenous antibiotics
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A 55-year-old man presents to the emergency department with crushing chest pain radiating to his left arm and jaw. He is diaphoretic and appears anxious. An ECG shows ST-segment elevation in leads II, III, and aVF. What is the most appropriate immediate management?

A. Order a chest X-ray to rule out other causes
B. Start intravenous beta-blockers
C. Administer sublingual nitroglycerin
D. Provide oxygen therapy
E. Administer aspirin and initiate reperfusion therapy
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Synchronous multiple small bowel intussusceptions in an adult with blue rubber bleb naevus syndrome. CT scan of abdomen showing i) multiple intussusceptions demonstrating doughnut signs (white arrows), intussusceptiens [A], intussusceptum [B], distended loop of small

bowel [C] and ii) haemangioma of right quadratus lumborum muscle (dark arrow).
Image by Lee C, Debnath D, Whitburn T, Farrugia M, Gonzalez F CC BY 2.0 · Source

A 35-year-old male presents to the ED with intermittent abdominal pain, nausea, and melena. He has multiple cutaneous hemangiomas. A CT scan is performed, as shown. What is the MOST appropriate next step in management?

A. Initiation of high-dose corticosteroids
B. Surgical resection
C. Observation with serial abdominal exams
D. Empiric antibiotic therapy
E. Colonoscopy with polypectomy
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A 45-year-old male presents to the emergency department with severe chest pain radiating to his left arm, shortness of breath, and diaphoresis. He has a history of hypertension and hyperlipidemia. On examination, he is diaphoretic, and his blood pressure is 90/60 mmHg. An ECG shows ST-segment elevation in leads II, III, and aVF. What is the most appropriate initial management for this patient?

A. Administer intravenous fluids to address hypotension
B. Administer beta-blockers to reduce myocardial oxygen demand
C. Administer morphine for pain management
D. Administer aspirin and initiate reperfusion therapy
E. Administer nitroglycerin for chest pain relief
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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 a 10-year history of Crohn's disease presents with worsening abdominal pain and increased frequency of bowel movements. He reports no fever or weight loss. Physical examination reveals mild tenderness in the right lower quadrant. His inflammatory markers are elevated. Review the provided imaging. What is the MOST appropriate next step in management?

A. Initiate anti-TNF therapy
B. Perform a colonoscopy with biopsy
C. Recommend a low-FODMAP diet
D. Start a trial of antibiotics for possible infection
E. Prescribe a course of oral corticosteroids
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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 55-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, associated with subjective fever and chills. He denies nausea, vomiting, or change in bowel habits. On examination, he is afebrile, heart rate 85 bpm, blood pressure 130/80 mmHg. Abdominal examination reveals tenderness in the left iliac fossa without guarding or rebound. White cell count is 14 x 10^9/L, CRP 80 mg/L. A CT scan of the abdomen and pelvis is performed, the relevant axial image is shown. Considering the patient's presentation and the findings on the provided image, which of the following represents the most appropriate initial management strategy?

A. Discharge with only analgesia and advice to return if symptoms worsen
B. Urgent colonoscopy to assess the affected segment
C. Urgent surgical consultation for potential colectomy
D. Immediate inpatient admission for intravenous antibiotics
E. Outpatient management with oral antibiotics and analgesia
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A 50-year-old man presents to the general practice with a 3-month history of persistent heartburn and regurgitation, especially after meals. He has tried over-the-counter antacids with minimal relief. He denies any weight loss, dysphagia, or gastrointestinal bleeding. What is the most appropriate next step in the management of this patient?

A. Prescribe H2 receptor antagonists
B. Refer to a gastroenterologist
C. Order an upper endoscopy
D. Advise dietary modifications only
E. Start a proton pump inhibitor
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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 58-year-old male, on chronic immunosuppressants, presents with vague abdominal pain. The images are shown. What is the MOST likely causative organism?

A. Klebsiella pneumoniae
B. Echinococcus multilocularis
C. Escherichia coli
D. Staphylococcus aureus
E. Entamoeba histolytica
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Giant hiatal hernia, CT image. 63 year old man.
Image by Jmarchn CC BY 4.0 · Source

A 63-year-old man presents with increasing postprandial fullness and epigastric discomfort. A CT scan of the abdomen is performed. Based on the image, what is the MOST appropriate next step in management?

A. Initiate a trial of high-dose proton pump inhibitors
B. Esophageal manometry to assess esophageal motility
C. Surgical consultation for consideration of fundoplication
D. Reassurance and dietary modification
E. Barium swallow study to evaluate for esophageal strictures
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A 50-year-old man presents with a deformity of his right arm. On examination, there is a bulge in the mid-arm, and the shoulder appears flattened. He reports weakness when flexing his elbow. What is the most likely diagnosis?

A. Rupture of the long head of the biceps tendon.
B. Acromioclavicular joint injury
C. Glenohumeral arthritis
D. Anterior shoulder dislocation
E. Rotator cuff tear
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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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