hllj/quesmed huggingface dataset:
A 52-year-old man with a background of asthma is being ventilated in the intensive care unit (ICU) following repair of a ruptured abdominal aortic aneurysm (AAA).

The medical team are called to assess the patient as his oxygen saturations have dropped to 90% on a fraction of inspired oxygen (FiO₂) of 50%. All other observations are within the normal range.

On assessment, the patient is not in respiratory distress. His trachea is central, and breath sounds are vesicular apart from an area of hyper-resonance at the apex of the left lung. There is associated reduced vocal resonance in this area.

Which of the following is the next best step in management?

Options:
explanation: A peak flow measurement would not be possible in a patient who is intubated and ventilated
name: Peak flow
label: c
answer: no
explanation: There are no features to suggest that infection is driving this patient's hypoxia; therefore IV antibiotics are not indicated
name: Broad-spectrum IV antibiotics
label: e
answer: no
explanation: Although recent surgery and immobility increase the risk of venous thromboembolism, the examination findings strongly suggest a pneumothorax
name: CT pulmonary angiogram (CTPA)
label: b
answer: no
explanation: There are no signs of tension pneumothorax (e.g. tracheal deviation, haemodynamic instability), hence an emergency thoracentesis is not indicated
name: Emergency thoracentesis
label: d
answer: no
explanation: The examination findings are suggestive of a left-sided apical pneumothorax. Mechanical ventilation is an important cause of iatrogenic pneumothorax, and should be considered as a cause of any acute drop in saturations in this context. CXR would be the best investigation to confirm the diagnosis
name: Chest X-ray (CXR)
label: a
answer: yes

Correct answer: a
A 43-year-old woman is recovering following a total thyroidectomy the previous day. The surgical notes reveal an uncomplicated operation, and all observations post-operatively have been normal.

The on-call doctor is called to see the patient urgently as her oxygen saturations have dropped acutely to 90% on room air. On assessment, the patient can speak in short sentences only and is using her accessory muscles. Examination of the lung fields are unremarkable; however, there is an intermittent high pitched sound heard on inspiration and an erythematous neck swelling.

Which of the following is the most appropriate definitive step in management?

Options:
explanation: Hypocalcemia is an important complication of thyroid surgery due to disruption of parathyroid gland function. However, there are no symptoms of hypocalcemia described
name: IV calcium gluconate
label: c
answer: no
explanation: High flow oxygen is an important immediate step in management given that the patient is desaturating due to airway obstruction. However, the most appropriate definitive management step is to relieve the obstruction by evacuating the haematoma
name: High flow oxygen
label: d
answer: no
explanation: This patient has acute airway obstruction secondary to a neck haematoma. Neck haematoma is a life-threatening complication of thyroid surgery and can present with signs of airway obstruction (e.g. stridor, respiratory distress), dysphagia, hoarseness and a painful neck mass. Definitive management is with an urgent return to theatre to open the stitches and evacuate the haematoma
name: Open stitches and evacuate haematoma
label: a
answer: yes
explanation: Steroids may be used as a supportive measure to reduce oedema that may be contributing to airway obstruction in this context; however, it is not the definitive step in management
name: IV methylprednisolone
label: e
answer: no
explanation: Although stridor is a feature of anaphylaxis, the clinical context suggests airway obstruction secondary to a neck haematoma
name: IM adrenaline
label: b
answer: no

Correct answer: a


Learning point: The definitive management of acute airway obstruction due to a neck hematoma is an urgent return to the operating theatre to open the stitches and evacuate the hematoma, relieving the obstruction.
A 68-year-old patient is assessed in the pre-operative clinic before an elective total hip replacement.

He is currently taking 75mg clopidogrel once daily following a transient ischaemic attack (TIA) two years ago.

How many days should he be advised to withhold clopidogrel before surgery?

Options:
explanation: In low-risk patients, clopidogrel should be stopped for at least 7 days before surgery
name: 24 hours
label: c
answer: no
explanation: In low-risk patients, clopidogrel should be stopped for at least 7 days before surgery
name: 48 hours
label: d
answer: no
explanation: This patient is at comparatively low risk of thrombosis, and guidelines recommend that clopidogrel should be withheld for 7 days before surgery in this case. If he had had a stroke, TIA or acute coronary event within the last year, this would increase the risk of thrombosis. In this case, a decision would need to be taken on continuing clopidogrel for longer following consideration of the risk of thrombosis vs the risk of perioperative bleeding
name: 7 days
label: a
answer: yes
explanation: In low-risk patients, clopidogrel should be stopped for at least 7 days before surgery
name: 5 days
label: b
answer: no
explanation: There would be no need to stop clopidogrel for longer than 7 days in this case as it would unnecessarily increase the risk of thrombosis without reducing the risk of perioperative bleeding
name: 14 days
label: e
answer: no

Correct answer: a
A 24-year-old woman presents to her GP with abnormal, fishy-smelling vaginal discharge for the last three days. She denies any other genitourinary symptoms.

On examination, there is a white homogenous discharge visible on the walls of the vagina.

Which of the following is the next best step in management?

Options:
explanation: IM ceftriaxone is the first-line treatment for uncomplicated anogenital gonorrhoea infections in the community. The white discharge and absence of any other genito-urinary symptoms make BV the most likely diagnosis.
Doxycycline
name: IM ceftriaxone
label: d
answer: no
explanation: Microscopy of vaginal secretions may reveal "clue cells" in BV. However, testing is not required if the history and examination findings suggest the diagnosis in non-pregnant women at low risk of having a sexually transmitted infection (STI)
name: Send vaginal secretions for microscopy
label: b
answer: no
explanation: Doxycycline is the first-line treatment for Chlamydia. The white discharge and absence of any other genito-urinary symptoms make BV the most likely diagnosis
name: Oral doxycycline
label: e
answer: no
explanation: This patient's symptoms and examination findings are suggestive of bacterial vaginosis (BV). It is the most common cause of abnormal vaginal discharge in women of child-bearing age and is characterised by an overgrowth of anaerobic organisms in the vagina. In addition, there is an associated increase in vaginal pH to above 4.5. In most women with characteristic signs and symptoms, empirical treatment should be started without further investigations
name: Oral metronidazole
label: a
answer: yes
explanation: If measured, vaginal pH would be greater than 4.5 in BV. However, testing is not required if the history and examination findings suggest the diagnosis in non-pregnant women at low risk of having a sexually transmitted infection (STI)
name: Measure vaginal pH
label: c
answer: no

Correct answer: a


Learning point: Bacterial vaginosis is characterised by a fishy-smelling discharge and is treated with oral metronidazole.
A 24-year-old homosexual male presents with a two-week history of enlarging lumps in both sides of his groin. He reports noticing a painless penile ulcer around three weeks ago that resolved spontaneously.

He denies any other symptoms on questioning but reports having had multiple sexual partners over the last three months.

Examination of his groin is significant for the findings shown in the image below.

[lightgallery]

Given the likely diagnosis, which of the following is the most appropriate treatment option?

Options:
explanation: Conservative management would be the first-line treatment for genital herpes. Genital herpes would present with painful genital ulceration and it is not associated with buboes
name: Conservative management with analgesia
label: e
answer: no
explanation: Ceftriaxone is the first-line treatment for uncomplicated, anogenital gonorrhoea. The clinical vignette is suggestive of LGV which is caused by Chlamydia species
name: IM ceftriaxone
label: c
answer: no
explanation: This is the first-line treatment for syphilis. Although primary syphilis presents with a painless genital ulcer, secondary syphilis would present differently with features such as a maculopapular rash, generalised lymphadenopathy and constitutional symptoms
name: IM benzathine penicillin
label: b
answer: no
explanation: Aciclovir can be used for recurrent cases of genital herpes which is caused by Herpes simplex virus. Genital herpes would present with painful genital ulceration and it is not associated with buboes
name: Oral aciclovir
label: d
answer: no
explanation: The most likely diagnosis is lymphogranuloma venerum (LGV). This is a sexually transmitted infection that is caused by specific serovars of Chlamydia trachomatis. The primary infection of infection is characterised by painless genital ulceration. The secondary stage follows weeks later with painful, inguinal and/or femoral lymphadenopathy (buboes). The first-line treatment option is with a three-week course of doxycycline
name: Doxycycline
label: a
answer: yes

Correct answer: a


Learning point: Lymphogranuloma venereum, a sexually transmitted infection caused by Chlamydia trachomatis, is managed with doxycycline 100 mg twice daily for 21 days to eliminate the infection and prevent complications.
A 17 year old competitive triathlete presents to her GP concerned that her periods have stopped. She tells you she has been stressed recently as she is training intensively for an upcoming national competition.

Which is the most appropriate initial investigation?

Options:
explanation: TVUS is an invasive examination and would therefore not be the initial investigation of choice. A TVUS may be indicated where the pregnancy test is negative and polycystic ovary syndrome is a possible cause of her amenorrhoea
name: Transvaginal ultrasound scan (TVUS)
label: d
answer: no
explanation: A high testosterone might indicate an androgen secreting tumour or polycystic ovary syndrome which is less likely in this example
name: Serum testosterone level
label: c
answer: no
explanation: Whilst the most likely cause is exercise induced amenorrhoea, a urinary pregnancy test is indicated in this patient in the first instance
name: Urinary pregnancy test
label: a
answer: yes
explanation: A random cortisol level is part of the investigation for adrenal insufficiency and therefore will not aid diagnosis here
name: Serum cortisol level
label: e
answer: no
explanation: This is a reasonable next step test if you are concerned that this is secondary amenorrhoea due to a hypothalamic or pituitary cause. In this case it's more likely to be due to intensive exercise
name: Serum FSH and LH measurement
label: b
answer: no

Correct answer: a


Learning point: In young female athletes, exercise-induced amenorrhoea is common, but a urinary pregnancy test should be performed to rule out pregnancy first.
An 56 year old female with a known ovarian fibroma presents to accident and emergency with breathlessness and abdominal distension. On examination, she is breathless at rest with reduced air entry at the right base. Her abdomen is soft, non tender and distended with evidence of shifting dullness on percussion.

What is the most likely cause of her breathlessness?

Options:
explanation: Depending on the level of abdominal distention some patients may experience breathlessness due to their inability to take deep breaths. In this case, this would not explain her unilateral reduced air entry on examination
name: Splinting of the diaphragm
label: d
answer: no
explanation: This patient has a known benign solid ovarian tumour and the case vignette points towards Meigs' syndrome. Meigs' syndrome is defined as the triad of benign ovarian tumour (most commonly a fibroma), pleural effusion and ascites
name: Pleural effusion
label: a
answer: yes
explanation: Whilst patients may feel anxious about new symptoms when they have an underlying health condition, it would not explain her abdominal distension or chest findings
name: Anxiety
label: c
answer: no
explanation: An ovarian fibroma is a benign tumour and therefore less likely to provoke a pulmonary embolism. The history does not suggest any other risk factors for PE. She also doesn't have any other features of PE aside from breathlessness, e.g. chest pain, leg swelling, haemoptysis
name: Pulmonary embolism (PE)
label: b
answer: no
explanation: This is unlikely in this case as there is nothing in the history to suggest that this patient has heart failure and she has no other features of heart failure (e.g. peripheral oedema, raised JVP). Heart failure may cause _bilateral_ reduced air entry
name: Heart failure
label: e
answer: no

Correct answer: a


Learning point: Meigs' syndrome is characterised by the presence of a benign ovarian tumour, pleural effusion, and ascites.
A 27 year old male with known sickle cell disease presents to his local accident and emergency department with an eight hour history of a painful right knee. His triage observations are as follows: SpO<sub>2</sub> 97% on air, respiratory rate 18, pulse 108 (regular), blood pressure 90/60 mmHg, temperature 39.2°C.

His knee is erythematous and hot to the touch and he has very minimal active movement.

What test will give you the definitive diagnosis?

Options:
explanation: A knee x-ray may be helpful in showing a large effusion but the history is not suggestive of a bony injury therefore x-ray will not give you a definitive diagnosis in this case
name: Knee x-ray
label: b
answer: no
explanation: A blood film is useful in the initial diagnosis of sickle cell disease however this patient is already known to have sickle cell disease and this would not aid in the acute diagnosis
name: Blood film assessment
label: e
answer: no
explanation: This patient is septic and the most likely source is his knee. Patients with known sickle cell disease are more prone to septic arthritis and the way this is diagnosed is by aspiration of the joint in an aseptic manner and sending for culture
name: Joint aspiration
label: a
answer: yes
explanation: Whilst blood cultures should always be taken in patients who present with sepsis, a positive blood culture would not necessarily tell you the focus of the infection. As the knee is the presumed focus, an aspirate directly from the joint will likely yield the definitive diagnosis
name: Blood culture
label: c
answer: no
explanation: Ultrasound may be used in aiding joint aspiration if the joint space is narrow or the effusion present is small, but it would not provide the diagnosis
name: Knee ultrasound
label: d
answer: no

Correct answer: a


Learning point: Joint aspiration is crucial in patients with sickle cell disease who are at increased risk of septic arthritis, as it helps confirm the diagnosis, identify the causative organism, and guide targeted treatment.
A 62 year old female has recurrent deep vein thromboses (DVT) for which she takes rivaroxaban 20mg once a day. Unfortunately she develops a new unilateral leg swelling and ultrasound investigation confirms a further deep vein thrombosis. She has been investigated previously for underlying hypercoagulable conditions and all the tests have been negative.

How should you treat this patient?

Options:
explanation: This patient has failed anticoagulation with a direct oral anticoagulant (DOAC). The National Institute for Health Care Excellence (NICE) guidance therefore suggests confirming her adherence to the medication and then either increasing the dosage of the medication or changing for an anticoagulant with a different mode of action. As she is already on the maximum dose of rivaroxaban changing her anticoagulation to warfarin is reasonable
name: Commence warfarin
label: a
answer: yes
explanation: 20mg once a day is already the maximum dose for rivaroxaban and therefore a dose increase should only be undertaken in complex cases under the advice of a haematologist. The better option here is to change to a difference mode of anticoagulation
name: Increase her rivaroxaban dose
label: b
answer: no
explanation: Apixaban is a factor Xa inhibitor, the same as rivaroxaban. This patient has already failed this therapy and therefore an anticoagulant with a different mechanism of action is indicated here
name: Commence apixaban
label: d
answer: no
explanation: Inferior vena cava filters are only indicated in patients who cannot take blood thinning medications. Changing to a different oral anticoagulant is the preferred option here
name: Insert an inferior vena cava filter
label: c
answer: no
explanation: Venesection is a recognised treatment for some haematological conditions such as hereditary haemochromatosis and polycythaemia (both of which can increase the risk of DVT) however this woman has been investigated for these conditions previously, therefore this treatment is not indicated
name: Regular venesection
label: e
answer: no

Correct answer: a


Learning point: In patients with recurrent DVT despite optimal DOAC therapy, switching to warfarin may be necessary for effective anticoagulation management.
A 73 year old female with poorly controlled type two diabetes mellitus has had a chronically infected foot ulcer for six weeks and it is not improving with oral antibiotics. She's become increasingly unable to weight bear over the past week.

Which investigation will be most useful to guide your management?

Options:
explanation: Given the chronicity of this infection and the relative immunosuppression of a patient with poorly controlled diabetes, it is important to rule out osteomyelitis which would require extended intravenous antibiotic therapy. The best modality for this is MRI
name: Magnetic resonance imaging (MRI) of the foot
label: a
answer: yes
explanation: Venous doppler scanning is predominantly used to look for venous thrombosis. Whilst haemostasis in the legs due to poor drainage can cause venous ulceration the vignette here indicates this is a diabetic foot ulcer and therefore dopplers are not indicated
name: Lower limb venous doppler
label: d
answer: no
explanation: Arterial imaging would be of benefit if there was a concern about circulatory deficit preventing healing. The pathophysiology of diabetic foot ulcers is usually microvascular in nature and therefore arterial duplexes are not indicated
name: Arterial lower limb duplex
label: c
answer: no
explanation: Blood cultures would be indicated if this patient had presented acutely septic, however this is a chronic infection and therefore blood cultures are unlikely to be positive or helpful in this case
name: Blood cultures
label: b
answer: no
explanation: Serum HbA1C is useful in determining both the initial diagnosis and long term control of diabetes. Whilst in this case we know the patient has poorly controlled diabetes and tighter diabetic control will lead to better outcomes it does not deal with the acute issue at hand
name: Serum haemoglobin A1C (HbA1C) measurement
label: e
answer: no

Correct answer: a


Learning point: In diabetic patients with chronic foot ulcers, MRI is essential to rule out osteomyelitis when infection fails to improve with oral antibiotics.
An 18 year old female with recurrent tonsillitis presents to her local accident and emergency with a four day history of sore throat, fever and inability to swallow her own saliva. She has a tender swelling over the lateral aspect of her neck and targetted ultrasound reveals a thrombus in her jugular vein.

What is the name of the likely condition?

Options:
explanation: A quinsey is another term for a peritonsillar abscess. This is a more common complication of under-treated bacterial throat infections and often requires incision and drainage. A quinsey can develop into a parapharyngeal abscess if left untreated, but as with parapharyngeal abscess it does not always have an associated thrombosis and therefore is not the correct answer here
name: Quinsey
label: c
answer: no
explanation: Reye's syndrome is acute encephalopathy and liver failure after a febrile viral illness such as influenza and upper respiratory tract infections. It does not present with neck swelling and liver failure is more commonly associated with bleeding as opposed to thrombosis. This is therefore not the correct answer
name: Reye's syndrome
label: d
answer: no
explanation: A parapharyngeal abscess is another recognised complication of under-treated bacterial throat infections. It may present with a neck swelling and can lead to Lemierre's syndrome, but not all parapharyngeal abscesses have an associated thrombus, therefore this is not the correct answer. It can be life threatening as it may lead to airway compromise and thus must be surgically drained under general anaesthetic
name: Parapharyngeal abscess
label: b
answer: no
explanation: This is a combination of symptoms that arise from damage to the sympathetic trunk. The classical signs are of miosis (constricted pupil), partial ptosis (weak droopy eyelid) and anhydrosis (reduced sweating). This presentation is more in keeping with an acute inflammatory/infective process as opposed to disruption of nerve signals
name: Horner's syndrome
label: e
answer: no
explanation: Lemierre's syndrome is an infective thrombophlebitis that can develop as a result of untreated bacterial throat infections in otherwise healthy young adults. It can lead to other further systemic complications such as bacteraemia and septic emboli
name: Lemeirre's syndrome
label: a
answer: yes

Correct answer: a


Learning point: Lemierre's syndrome is a serious condition arising from untreated bacterial throat infections, leading to jugular vein thrombosis.
A company develops a new coronavirus test. They trial it on 1000 people and have 83 positive tests, of which 80 were later confirmed to be positive through alternative means of testing. Of those who tested negative, 15 were later confirmed positive through alternative testing.

What is the sensitivity of the new test?

Options:
explanation: Sensitivity of a test is the ability of a test to correctly identify those with a disease.

Sensitivity = true positives / (true positives + false negatives)

So in this case 80/(80+15) = 84.2%
name: 84.2%
label: a
answer: yes
explanation: This is the number of true negatives expressed as a percentage, not the sensitivity
name: 92.0%
label: b
answer: no
explanation: This is the number of true positives expressed as a percentage, not the sensitivity
name: 80.0%
label: c
answer: no
explanation: This is the specificity of the test, not the sensitivity. Specificity of a test is the ability of the test to correctly identify those without a disease.

Specificity = true negatives / (true negatives + false positives).
In this case = 920/(920+3) = 99.7%
name: 99.7%
label: d
answer: no
explanation: This is the number of true negatives expressed as a percentage, not the sensitivity
name: 90.2%
label: e
answer: no

Correct answer: a


Learning point: Sensitivity measures a test's ability to correctly identify individuals with a disease, calculated as true positives divided by the sum of true positives and false negatives.