Real clinical images, a full explanation for every option, and no account needed. Choose a case, pick an answer, then see why.
InspectRecorded example chest X-ray · CDC PHIL 5803CDC / Dr Thomas Hooten · Public domain
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RespiratoryPublic sample. Progress isn’t saved.
Fever and breathlessness
A 48-year-old has fever, productive cough, pleuritic left-sided pain, respiratory rate 32/min, oxygen saturation 88% on room air and blood pressure 92/58 mmHg. The chest radiograph shown is available.
The answer is E · Provide oxygen and initiate the local sepsis pathway
Why
The image shows focal left lower-zone air-space opacity in a patient with hypoxaemia and possible sepsis-related organ dysfunction, requiring concurrent respiratory and sepsis care.
The other options
ADischarge with oral antibiotics because the opacity is focal
Hypoxaemia, tachypnoea and hypotension make outpatient management unsafe.
BDelay oxygen until an arterial blood gas confirms hypoxaemia
Pulse oximetry and clinical distress already justify oxygen while further assessment proceeds.
CTreat the radiograph as pulmonary embolism and give anticoagulation without further assessment
The focal air-space opacity and infectious syndrome support pneumonia; anticoagulation is not justified by the image.
DRepeat the radiograph after hydration before giving antimicrobials
Imaging repetition should not delay time-critical treatment in possible sepsis.
What the image shows
Frontal chest radiograph showing focal left lower-zone air-space opacity.
A 19-year-old man was struck on the side of the head by a cricket ball. He briefly lost consciousness, recovered fully, then over the next hour became drowsy and confused. His non-contrast CT brain is shown.
The answer is D · Middle meningeal artery
Why
The biconvex, suture-limited hyperdense extra-axial collection with an overlying temporal fracture and a preceding lucid interval indicates an extradural (epidural) haematoma, classically caused by laceration of the middle meningeal artery at the pterion, where the thin bone overlies the vessel.
The other options
AArteriovenous malformation
Tends to cause intraparenchymal or subarachnoid bleeding, not a trauma-related biconvex collection with a lucid interval.
BBridging cortical veins
These cause subdural haematomas, which are crescentic and cross suture lines, typically in elderly/anticoagulated patients.
CCharcot-Bouchard microaneurysm
Cause hypertensive intraparenchymal bleeds in the basal ganglia, not extra-axial collections.
ERuptured berry aneurysm of the circle of Willis
Causes subarachnoid haemorrhage with blood in cisterns/sulci, not a biconvex extra-axial collection.
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DermatologyPublic sample. Progress isn’t saved.
A rash after a cold sore
A 26-year-old woman presents with a 2-day eruption that began on the backs of her hands and forearms and is now symmetrical. Ten days earlier she had a crop of painful blisters on her lip that crusted and resolved. She takes no medications. She feels systemically well; her temperature is 37.0 degrees C. Examination shows discrete lesions less than 3 cm across with a dusky centre, a surrounding pale ring and an outer red ring; less than 2% of her body surface shows any blistering and there is no mucosal ulceration. Her rash is shown.
The answer is E · Treat supportively, address the precipitant, and offer antiviral suppression if attacks recur
Why
The image shows typical three-zone target lesions in a symmetrical acral distribution following a herpes labialis episode, with minimal (<2%) detachment and no mucosal involvement — diagnostic of herpes-associated erythema multiforme, which is self-limiting (resolves over ~2 weeks). Management is supportive plus identifying and treating/preventing the precipitant; antiviral started after the eruption does not alter the current episode, but continuous HSV suppression (e.g. valaciclovir) is the correct strategy to prevent recurrent HSV-driven EM, so it is offered if attacks recur.
The other options
AReassure as acute urticaria and prescribe a non-sedating oral antihistamine
Urticarial weals are transient (each lasting <24 h), migratory and lack a fixed dusky/blistered centre; fixed concentric three-zone targets are not urticaria.
BStart high-dose oral prednisolone for presumed bullous pemphigoid, with a vesiculobullous-screen biopsy
Bullous pemphigoid affects older patients with tense bullae on urticarial plaques over flexures/trunk, not young adults with acral targets; the morphology, demographic and post-herpetic timing do not fit, and systemic steroids are not first-line for self-limiting EM minor.
CTake blood cultures and give intravenous ceftriaxone for presumed disseminated gonococcaemia
Gonococcaemia produces sparse pustular/haemorrhagic acral lesions with fever and arthralgia in a systemically unwell patient, not symmetrical concentric targets after herpes labialis; she is afebrile and well.
DTransfer to a burns unit and manage as Stevens-Johnson syndrome with intensive supportive care
SJS shows atypical FLAT targets plus purpuric macules, near-universal mucosal ulceration (92-100%), painful detaching skin with a positive Nikolsky sign, and a drug trigger in a systemically unwell patient. The well-formed RAISED acral three-zone targets, absent mucosal involvement, minimal detachment and a viral trigger in a well, afebrile patient defeat the SJS diagnosis.
What the image shows
Erythema multiforme: symmetrical acral typical target lesions with a central dusky/blistered zone, a pale oedematous ring and an outer erythematous ring
The peripheral blood film of an 18-month-old boy is shown. He was brought to the general practitioner because of increasing pallor and irritability. He drinks around one litre of cow's milk each day, eats little solid food, and is otherwise well. His haemoglobin is 78 g/L (105–135).
The answer is A · A low serum ferritin
Why
The history of excessive cow's milk intake with poor solid intake and the film together indicate iron-deficiency anaemia; a low serum ferritin, reflecting depleted iron stores, is the expected confirmatory finding.
The other options
BA positive direct antiglobulin test
A positive DAT indicates immune haemolysis, which produces a normocytic or macrocytic picture with spherocytes, not the microcytic hypochromic film driven by dietary iron deficiency.
CA raised reticulocyte count
Iron deficiency impairs erythropoiesis, so the reticulocyte response is inappropriately low rather than raised; a brisk reticulocytosis would suggest haemolysis or blood loss with intact iron stores.
DAn elevated haemoglobin A2 on electrophoresis
A raised HbA2 indicates beta-thalassaemia trait; while it also causes microcytosis, the dietary history points to iron deficiency, in which HbA2 is normal or even low.
EAn elevated serum lead concentration
Lead poisoning can cause microcytic anaemia with basophilic stippling, but it is uncommon in this setting and the dietary story makes simple iron deficiency far more likely; ferritin is the targeted next test.
What the image shows
Microcytic, hypochromic red cells with variation in size and shape and occasional pencil-shaped cells.
A 74-year-old man is brought to the emergency department after two episodes of collapse. He is pale and diaphoretic. His blood pressure is 78/45 mmHg, heart rate 32/min and regular, and he is confused. He takes no nodal-blocking medication, his potassium is 4.3 mmol/L and a recent troponin is not raised. His 12-lead ECG is shown. Transcutaneous pacing pads are applied and intravenous access is secured.
The answer is B · Commence transcutaneous pacing now and arrange urgent transvenous pacing
Why
The ECG shows complete (third-degree) AV block — regular P waves at a faster rate marching independently through a slower, regular, broad-complex ventricular escape with no consistent PR relationship. A wide escape localises the block below the AV node (infranodal/His-Purkinje), where vagolytic atropine has little effect because the escape pacemaker is not vagally innervated. In an unstable patient (hypotension, syncope, confusion), ANZCOR Guideline 11.9 lists complete AV block with a broad QRS or rate <40/min as an indication for pacing, and the ACLS bradycardia algorithm directs immediate transcutaneous pacing as a bridge to definitive transvenous pacing.
The other options
ACommence an isoprenaline infusion and continue to observe the rhythm
A chronotropic infusion (isoprenaline/adrenaline/dopamine) is only a temporising measure and is second-line to pacing in unstable high-degree block; 'continue to observe' is unsafe when the patient is hypotensive and confused and pacing pads are already in place. Pacing should be initiated now rather than waiting on a drip to take effect.
CIntravenous adenosine 6 mg as a rapid push
Adenosine blocks AV nodal conduction to terminate re-entrant SVT; in established complete heart block it would worsen the bradycardia and has no role.
DIntravenous atropine 600 micrograms, repeated every 3 minutes to a total of 3 mg
The dose itself is correct per ANZCOR (500–600 mcg, up to 3 mg), and atropine is the reflex first-line drug for symptomatic bradycardia — which makes this the strongest distractor. However, the broad escape QRS signals an infranodal lesion; in third-degree block with a new wide-complex escape, atropine is unlikely to work, may paradoxically slow the ventricular rate, and must not delay pacing in an already-unstable patient with pads applied.
ESynchronised direct-current cardioversion
Cardioversion treats unstable tachyarrhythmias with a shockable organised rhythm; the patient is profoundly bradycardic, so a shock is inappropriate and could induce asystole.
What the image shows
The clinical ECG photograph shows complete atrioventricular block with a slow ventricular escape rhythm.
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