hllj/quesmed huggingface dataset:
A 65 year old man presents to his general practice for a routine blood pressure check. He does not appear confused and he denies chest pain or cough.

He has a blood pressure monitor at home and presents a piece of paper with his recordings on it:

- Monday AM: 132/95mmHg
- Monday PM: 136/92mmHg
- Tuesday AM: 142/105mmHg
- Tuesday PM: 135/95mmHg
- Wednesday AM: 143/105mmHg
- Wednesday PM: 139/101mmHg

The patient currently takes the following medications:

- Ramipril 10mg OD
- Amlodipine 10mg OD
- Metformin 500mg BD

A fundoscopy examination is normal. At the practice, his blood pressure is 155/100mmHg.

What is the next best step in the management of this patient?

Options:
explanation: According to NICE guidelines, specialist assessment on the same day is only indicated if the patient has a blood pressure of more than 180/120mmHg and either signs of retinal haemorrhage of papilloedema or life threatening symptoms such as a new onset confusion, chest pain, signs of heart failure or acute kidney injury
name: Refer for immediate specialist assessment for the same day
label: e
answer: no
explanation: Referral to hypertension clinic should only be required if the patient has resistant hypertension which remains uncontrolled when taking the optimal tolerated doses of 4 drugs. This patient is currently only taking 2 drugs
name: Refer to hypertension clinic
label: c
answer: no
explanation: An ACE inhibitor (eg. ramipril) can be switched to a angiotensin II receptor blocker (eg. candesartan) if the ACE inhibitor is causing adverse effects such as a cough. This does not appear to be the case in this patient
name: Stop ramipril and start candesartan
label: b
answer: no
explanation: This is correct. According to NICE guidelines, the third step after commencing an ACE inhibitor (ramipril) and calcium channel blocker (amlodipine) is a thiazide-like diuretic such as indapamide. This man's blood pressure is still not controlled, particularly his diastolic blood pressure values, as demonstrated by his home monitoring values and the clinic blood pressure and therefore the third medication is indicated
name: Commence indapamide
label: a
answer: yes
explanation: This is not appropriate as he is currently above the threshold for uncontrolled blood pressure
name: Continue current medication regimen and schedule next blood pressure check for 3 months time
label: d
answer: no

Correct answer: a


Learning point: In patients with resistant hypertension, adding a thiazide-like diuretic such as indapamide is recommended after an ACE inhibitor and calcium channel blocker.
A 85 year old man is seen at the neurology clinic with his daughter. The daughter reports that he has been increasingly forgetful, has a shortened attention span compared to his usual self and has become very clumsy. She says that this has been a gradual decline over several months. The patient denies any changes in mood or any suicidal ideation.

His only significant past medical history is chronic obstructive pulmonary disease (COPD) for which he takes salbutamol PRN. He has no significant psychiatric history.

On examination, he has normal tone of his upper and lower limbs, a normal gait, and normal power throughout.

The neurologist decides to start him on Donepazil. Which investigation should be performed prior to commencing this medication?

Options:
explanation: Although this patient has COPD, there is no requirement for spirometry testing prior to initiation of Donepazil
name: Perform spirometry testing
label: d
answer: no
explanation: Although Donepazil is primarily excreted renally, there is no indication this man has impaired renal function, and there is no routine requirement to check renal function prior to initiating Donepazil
name: Perform blood tests for baseline urea and electrolytes
label: e
answer: no
explanation: Although this patient has COPD, there is no requirement for a routine chest x-ray prior to initiation of Donepazil
name: Perform a chest x-ray
label: c
answer: no
explanation: This patient has no focal neurological signs so there is no indication for a CT head at this stage
name: Refer for a computed tomography (CT) scan of the head
label: b
answer: no
explanation: This patient likely has Alzheimer's disease. Donepazil is an acetylcholinesterase inhibitor which can prolong the QT-interval (QTc). Therefore it is important to perform a 12 lead ECG and document baseline heart rhythm and QTc interval prior to initiation
name: Electrocardiogram (ECG)
label: a
answer: yes

Correct answer: a


Learning point: Before starting Donepezil, an ECG is important to assess the baseline heart rhythm and QTc interval, as the medication can potentially prolong the QT interval and increase the risk of arrhythmias.
A 30 year old man with a past medical history of ulcerative colitis presents to the accident and emergency department. They report that they have been passing approximately six blood-stained stools per day. He denies nausea or vomiting at present.

Their observations are as follows:

- Respiratory rate: 18 breaths per minute
- Saturations: 99% on air
- Heart rate: 105 beats per minute
- Blood pressure: 110/85mmHg
- Temperature: 38.2 degrees Celsius

On examination, their abdomen is mildly distended with mild generalised tenderness. Bowel sounds are present.

Which of the following investigations should be first conducted in this patient?

Options:
explanation: This patient appears to be having a flare of his ulcerative colitis, a barium enema would not be an appropriate investigation, and in fact may increase risk of bowel perforation
name: Barium enema
label: d
answer: no
explanation: A plain abdominal x-ray should first be conducted in this patient to investigate for toxic megacolon. The symptoms that he presents with are consistent with this
name: Abdominal X-ray
label: a
answer: yes
explanation: Urgent endoscopy is not indicated in this patient at present, who appears to be having a flare of his ulcerative colitis. An urgent endoscopy may indicated in patients with haematemesis, melaena, or haemodynamic instability
name: Urgent endoscopy
label: e
answer: no
explanation: A CT abdomen/pelvis may be indicated later in his admission to look or any complications such as abscesses, but would first require an abdominal x-ray
name: CT abdomen/pelvis
label: b
answer: no
explanation: In this patient it is most important to investigate for toxic megacolon as they appear to be having a flare of their ulcerative colitis. An ultrasound abdomen would visualise investigate gallstones or free pelvic fluid
name: Ultrasound abdomen
label: c
answer: no

Correct answer: a
A 40 year old man is admitted to hospital following a road traffic accident. He has a pelvic x-ray which shows a stable pelvic fracture which is managed conservatively.

Approximately 48 hours later, he becomes acutely confused, drowsy and breathless.

His observations are as follows:

- Respiratory rate: 25 breaths per minute
- Saturations: 90% on room air
- Heart rate: 90 beats per minute
- Blood pressure: 95/65mmHg
- Temperature: 36.5 degrees Celsius

On examination, auscultation of his chest reveals bibasal coarse crackles. There is also a petechial rash on the anterior aspect of his chest.

What is the most likely diagnosis?

Options:
explanation: This is a sensible differential in a trauma patient with haemodynamic instability, although it would not explain the petechial rash and is unlikely to cause such significant respiratory compromise and neurological disturbance
name: Internal haemorrhage
label: b
answer: no
explanation: This would not explain his respiratory compromise or petechial rash. Although a subarachnoid haemorrhage is the most common type of brain haemorrhage secondary to trauma in the acute phase
name: Subarachnoid haemorrhage
label: d
answer: no
explanation: Although this may explain his respiratory compromise, it would not explain the petechial rash. It is unlikely to cause acute confusion and drowsiness in someone so young, and the normal temperature is also going against this diagnosis. Pneumonia would also typically cause unilateral crackles on auscultation
name: Hospital-acquired pneumonia
label: c
answer: no
explanation: Fat embolism classically presents with the triad of respiratory compromise, neurological disturbance and a petechial rash. It typically occurs 24-72 hours after a long bone injury or surgical procedure
name: Fat embolism
label: a
answer: yes
explanation: This may explain his acute respiratory distress but would not explain the petechial rash and is unlikely to cause such acute neurological disturbance
name: Acute respiratory distress syndrome (ARDS)
label: e
answer: no

Correct answer: a


Learning point: Fat embolism syndrome typically presents 24-72 hours post-injury with respiratory distress, neurological symptoms, and a petechial rash.
A 80 year old man presents to the accident and emergency department with sudden onset abdominal pain and feeling generally unwell for the last 2 hours. He has no significant past medical history.

An erect chest x-ray shows free air under the diaphragm, and a CT abdomen/pelvis confirms a bowel perforation.

What is the most likely underlying pathology in this patient?

Options:
explanation: This may rarely present with bowel perforation, but is not as common a cause for bowel perforation as diverticulosis. Advanced colon cancer may more likely present with bowel obstruction or PR bleeding
name: Colon cancer
label: c
answer: no
explanation: This may rarely present with bowel perforation, but is not as common a cause for bowel perforation as diverticulosis
name: Appendicitis
label: e
answer: no
explanation: This would cause perforation of the duodenum or stomach rather than bowel perforation
name: Peptic ulcer disease
label: b
answer: no
explanation: Diverticular disease is the most common underlying pathology found in cases of bowel perforation in elderly patients. Diverticulosis refers to the asymptomatic presence of diverticula in the large bowel
name: Diverticular disease
label: a
answer: yes
explanation: It is unlikely that a man of this age would present with ulcerative colitis for the first time. It may also rarely cause bowel perforation but is not as a common a cause as diverticulosis
name: Ulcerative colitis
label: d
answer: no

Correct answer: a
A 25 year old woman presents with pain in her throat on swallowing. She has no significant past medical history.

She has an endoscopy which shows the following:

[lightgallery]

Which of the following blood tests is best to do next in this patient?

Options:
explanation: There is no link with hepatitis B and oesophageal candidiasis or dysphagia
name: Hepatitis B antigen
label: d
answer: no
explanation: This would investigate systemic lupus erythematosus (SLE), which is a cause of dysphagia, but the endoscopy image above clearly shows oesophageal candidiasis, which would not be explained by SLE
name: Anti-nuclear antibodies (ANA)
label: c
answer: no
explanation: The endoscopy image above shows a severe case of oesophageal candidiasis. The most common cause of this includes HIV and topical steroid treatment such as steroid inhalers
name: HIV testing
label: a
answer: yes
explanation: This would investigate systemic lupus erythematosus (SLE), which is a cause of dysphagia, but the endoscopy image above clearly shows oesophageal candidiasis, which would not be explained by SLE
name: Anti-dsDNA
label: e
answer: no
explanation: This would investigate for myasthenia gravis which may be a cause of dysphagia. However, the endoscopy image above shows oesophageal candidiasis
name: Antibodies against acetylcholine receptor (AChR)
label: b
answer: no

Correct answer: a


Learning point: Oesophageal candidiasis often suggests underlying immunosuppression, such as HIV infection, and individuals presenting with this condition should be tested for HIV.
A 30 year old woman presents to her general practice with dysuria for the last 3 days. She denies blood in her urine, urinary frequency, or abdominal pain and her last period started 10 days ago, and has now finished.

A urine dipstick test is performed:

- Glucose: none
- Bilirubin: none
- Ketones: none
- Specific gravity: 1.020 (1.002-1.035mOsm/kg)
- pH 5 (4.5-8)
- Blood: none
- Protein: none
- Nitrites: none
- Leukocytes: none

What is the next best step to investigate this patient's dysuria?

Options:
explanation: There is no indication for an ultrasound of the kidneys at present
name: Ultrasound of kidneys
label: c
answer: no
explanation: This is only indicated if there is protein in the urine, which there is not
name: Send urine for PCR
label: e
answer: no
explanation: There is no need to send this urine for culture if it is negative for nitrites and leukocytes, it is unlikely to be due to an infection
name: Urine culture
label: d
answer: no
explanation: This is correct. This is a simple test to investigate the next most common cause of dysuria in a young female patient
name: Sexually transmitted disease (STD) screen
label: a
answer: yes
explanation: Simpler investigations should first be carried out before referral for consideration of cystoscopy
name: Refer for cystoscopy
label: b
answer: no

Correct answer: a


Learning point: In young women with dysuria and negative urine dipstick results, consider screening for sexually transmitted infections as a common underlying cause.
A 65 year old woman comes into A&E with a 2 week history of bloody spotting on her underwear. She is surprised to find this as she went through menopause 15 years ago. She has been married to her husband of 25 years and has no children. Past medical history includes type 2 diabetes and obesity.

What is the next best investigation?

Options:
explanation: Postmenopausal bleeding raises a high suspicion for endometrial cancer. An urgent transvaginal ultrasound is the most useful first-line test to determine endometrial thickness and assess for any uterine abnormality (e.g. fibroids). The ultrasound result would determine the need for further investigation such as endometrial biopsy, blood tests, hysteroscopy or further pelvic imaging
name: Transvaginal ultrasound
label: a
answer: yes
explanation: This is a diagnostic investigation for cervical cancer, which is typically found in younger females with a high-risk sexual history. Colposcopy would be indicated if a cervical abnormality was seen, or if infection with human papilloma virus (HPV) was found on a routine cervical smear
name: Colposcopy
label: d
answer: no
explanation: This might be useful later down the line as a staging scan for malignancy
name: Computed tomography (CT) scan of the pelvis
label: b
answer: no
explanation: CA-125 is commonly elevated in cases of ovarian cancer and is a useful screening test for ovarian malignancy. This woman is not presenting with symptoms of ovarian cancer (e.g. abdominal fullness, urinary frequency/urgency and changes in bowel habit) therefore this would not be an appropriate first-line test
name: CA-125
label: e
answer: no
explanation: This is a screening test for cervical cancer, and would not be first-line in a postmenopausal patient with red flag features for malignancy. However it would be useful to note in the history if the patient's smear tests are up to date and if she has had any treatment to the cervix
name: Cervical smear testing
label: c
answer: no

Correct answer: a


Learning point: Postmenopausal bleeding necessitates urgent investigation, with transvaginal ultrasound being the first-line test to assess for endometrial abnormalities.
A 20 year old female has been brought into A&E by her partner with sudden onset right lower abdominal pain and vomiting for the past day. She had also briefly fainted just prior to arrival. In triage, she was afebrile, BP 75/50, HR 115, SpO<sub>2</sub> 98%. A urine pregnancy test was positive but transvaginal ultrasound scan (US) showed an empty uterus.

What is the next most appropriate course of action?

Options:
explanation: Methotrexate is utilised for medical management of ectopic pregnancy under specific circumstances where the patient is haemodynamically stable. This patient is unstable and would therefore not be suitable for medical management
name: Methotrexate
label: d
answer: no
explanation: Ectopic pregnancy may result in hypovolaemia secondary to blood loss. A blood transfusion may be considered if there is a large volume of blood loss with a significant drop in haemoglobin. Bloods should be sent off for group and save, and 2-4 units crossmatched. However, in the acute setting, the patient should be resuscitated with IV fluids first
name: Blood transfusion
label: e
answer: no
explanation: Whilst the next investigation and definitive management of suspected ectopic pregnancy would be an emergency laparoscopy, this patient is currently unstable and requires fluid resuscitation first
name: Emergency laparoscopy
label: b
answer: no
explanation: There is high suspicion for an ectopic pregnancy in a young sexually active female with signs of tachycardia and hypotension suggesting blood loss. Up to half of transvaginal US scans may be inconclusive. As she is haemodynamically unstable, she should be resuscitated with IV fluids as a first priority
name: Intravenous (IV) fluid bolus
label: a
answer: yes
explanation: This patient is currently haemodynamically unstable and requires fluid resuscitation prior to the consideration of any surgery. Laparoscopy is usually the first-line diagnostic and therapeutic operation for ectopic pregnancy as it is less invasive and harbours a shorter recovery time than laparotomy. Emergency laparotomy would be indicated if the patient had an acute abdomen, or if other pathology e.g. bowel was suspected
name: Emergency laparotomy
label: c
answer: no

Correct answer: a


Learning point: In suspected ectopic pregnancy, immediate intravenous fluid resuscitation is crucial for managing haemodynamic instability.
An 80 year old woman is admitted to the ward with a one week history of confusion, dysuria and urinary incontinence. She lives alone with a carer coming in once weekly, who brought her into hospital upon realising she was "slightly muddled". She has a past medical history of ischaemic heart disease, atrial fibrillation and dementia and she currently takes warfarin. Her international normalised ratio (INR) is 6.5 on admission.

A CT head no evidence of acute intracranial abnormality.

Which of the following is the most appropriate management?

Options:
explanation: This would be indicated if the patient has active bleeding
name: Stop warfarin, administer IV phytomenadione
label: d
answer: no
explanation: This would be indicated if the INR is >8 without bleeding
name: Stop warfarin, administer oral vitamin K
label: c
answer: no
explanation: The patient has a supratherapeutic INR and further administration of warfarin even at a reduced dose would likely drive the INR higher and put her at increased risk of bleeding
name: Continue warfarin at a reduced dose
label: b
answer: no
explanation: This would be indicated in any serious or life-threatening bleeding requiring immediate reversal, regardless of the INR
name: Stop warfarin, administer prothrombin complex concentrate (PCC)
label: e
answer: no
explanation: This woman has a background of dementia and has been admitted with delirium, suggesting possible issues with medication compliance or overdosing. As the INR is between 5-8 with no active sources of bleeding, it is safe to withhold warfarin and recheck the INR the next day
name: Withhold one or two doses of warfarin, assess medication compliance and recheck INR
label: a
answer: yes

Correct answer: a


Learning point: If the INR is between 5-8 and there are no active sources of bleeding, it is generally safe to withhold warfarin and recheck the INR the following day.
A 70 year old lady is admitted with an acute polyarthritic flare of her hands and knees. She has a past medical history of rheumatoid arthritis and migraines. Her regular medications include methotrexate, prednisolone and ibuprofen.


Bloods on admission are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|101 g/L|(M) 130 - 170, (F) 115 - 155|
|Platelets|400x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|108 fL|80 - 96|
|Ferritin|170 μg/L|12 - 200|
|Iron|20 μmol/L|(M) 14 - 31, (F) 11 - 30|
|Transferrin saturation|28 %|(M) 16 - 50 (F) 16 - 40|


 - White cell count and neutrophils normal
 - Reticulocyte count normal


What is the most likely cause of her anaemia?

Options:
explanation: This is a rare cause of anaemia in rheumatoid arthritis. This is unlikely as reticulocyte count is not raised
name: Autoimmune haemolytic anaemia
label: e
answer: no
explanation: This is a common cause of anaemia in rheumatoid arthritis patients. This would typically present as normochromic normocytic anaemia
name: Anaemia of chronic disease
label: b
answer: no
explanation: Felty's syndrome is characterised by the triad of rheumatoid arthritis, neutropenia, and splenomegaly. The neutrophils are normal in this case
name: Felty's syndrome
label: c
answer: no
explanation: The patient has macrocytic anaemia and is taking methotrexate without regular folate. Methotrexate therapy is a common cause of macrocytic anaemia due to folate deficiency
name: Methotrexate
label: a
answer: yes
explanation: The iron panel is not suggestive of iron deficiency anaemia
name: Iron deficiency anaemia
label: d
answer: no

Correct answer: a


Learning point: Methotrexate can cause macrocytic anaemia due to folate deficiency, particularly in patients not receiving regular folate supplementation.
A 19 year old male is admitted with a 1 day history of sudden onset severe chest pain and productive cough. He has a known history of sickle cell disease.

Vitals on admission:

- T 38.5°C
- BP 100/60
- Pulse 105
- Respiratory rate 25
- SpO<sub>2</sub> 98% on 4L oxygen

CXR reveals bilateral lower zone shadowing. What is the next best step?

Options:
explanation: Effective pain control is key in the management of acute chest crises. Opioid analgesia can be started and titrated according to the pain ladder
name: Start morphine
label: a
answer: yes
explanation: This patient has a productive cough and acute chest crisis in the context of sickle cell anaemia. Recommended treatment in acute chest crises would be intravenous broad spectrum empiric coverage with a third generation cephalosporin for bacterial coverage and a macrolide for atypical organism cover
name: Start oral amoxicillin
label: e
answer: no
explanation: This would be useful in long-term management to prevent future acute chest crises
name: Start hydroxyurea
label: b
answer: no
explanation: This would be indicated in severe hypoxaemia, progression of the crisis despite simple transfusion, multi-lobar disease or a previous history of severe chest crisis
name: Exchange transfusion
label: c
answer: no
explanation: This may be considered later down the line if the patient is failing to maintain oxygen saturations on increasing levels of oxygen. Frequent oxygen monitoring, incentive spirometry and arterial blood gases should be done to monitor progression in such patients
name: Non-invasive ventilation
label: d
answer: no

Correct answer: a


Learning point: Effective pain management with opioids is crucial in treating acute chest crises in patients with sickle cell disease.