hllj/quesmed huggingface dataset:
A 24-year-old woman is attending for labour induction for a large-for-dates baby at 38+2 weeks gestation.

Her observations are as follows:

- Heart rate: 66 beats per minute
- Blood pressure: 124/76 mmHg
- Respiratory rate: 18 breaths per minute
- Oxygen saturations: 100% on room air
- Temperature: 36.7°C

A cardiotocograph is performed, which is reassuring.

A midwife performs a vaginal examination and describes her cervix as long, closed, firm, and posterior. Her Bishops score is 0.

What is the most appropriate management?

Options:
explanation: An artificial rupture of membranes (ARM) can only be performed where the cervix is favourable, the foetus is well engaged, and there is space to access the cervical os.
name: Artificial rupture of membranes
label: e
answer: no
explanation: Intravenous oxytocin is not used alone for induction of labour, however may be required later in the process to facilitate effective contractions.
name: Intravenous oxytocin
label: b
answer: no
explanation: Intravaginal prostaglandin E2 analogues such as Propess and Prostin are the first-line treatment in the induction of labour where there are no contraindications. These aim to soften and ripen the cervix in preparation for labour.
name: Intravaginal prostaglandin E2 analogue e.g. Propess
label: a
answer: yes
explanation: Misoprostol, oral or vaginal, can be used to induce labour however is associated with an increased risk of uterine hyperstimulation
name: An oral prostaglandin E1 analogue, e.g. misoprostol every 4 hours
label: d
answer: no
explanation: This woman's cervix is described as very unfavourable, therefore insertion of a balloon catheter may be impossible. She has no contraindications to induction of labour using intravaginal prostaglandin E2 analogues such as Propress and Prostin.
name: Foley intracervical balloon catheter
label: c
answer: no

Correct answer: a
A 17-year-old woman presents to accident and emergency with a 4-hour history vaginal bleeding. She is approximately 11 weeks gestation. She describes the bleeding as bright red, and associated with lower abdominal cramps.

She does not complain of any unusual vaginal discharge, or any other symptoms.

On examination, her observations are normal. Her abdomen is soft and non-tender. On speculum examination, the cervical os is closed, however there is some red blood evident at the cervix.

An abdominal ultrasound scan reveals a foetus of approximately 11 weeks. A foetal heartbeat is present.

What is the diagnosis?

Options:
explanation: Implantation bleeding occurs in the two weeks following conception, as the embryo implants into the endometrium. This woman is approximately 11 weeks gestation, which is after any implantation bleeding should have settled.
name: Implantation bleeding
label: e
answer: no
explanation: There was an intrauterine pregnancy which has now fully miscarried, with all products of conception expelled, and the uterus is now empty. The os is usually closed. The patient may have been alerted to the miscarriage by pain and bleeding.
name: Complete miscarriage
label: c
answer: no
explanation: This is where there are some mild symptoms of bleeding with the foetus retained within the uterus as the cervical os is closed. Hence there is the 'threat' of a miscarriage, but it is not certain. There may be little or no pain. Ultrasound reveals that the foetus is present intrauterine.
name: Threatened miscarriage
label: a
answer: yes
explanation: The uterus still contains foetal tissue, but the foetus is no longer alive. The miscarriage is 'missed' as often the woman is asymptomatic so does not realise something is wrong. The cervical os is closed.
name: Missed miscarriage
label: d
answer: no
explanation: There is often heavy bleeding and pain, where the foetus is currently intrauterine but the cervical os is open. Hence it is inevitable that the foetus will be lost. Ultrasound reveals that the foetus is present intrauterine.
name: Inevitable miscarriage
label: b
answer: no

Correct answer: a
A 24-year-old woman attends her general practitioner worried about a rash. She is 35 weeks pregnant, and has noticed an itchy rash on her abdomen and thighs in the last few days. She says is started on her stomach, and initially wasn't itchy, however it has become itchy over the last day.

On examination, she has a widespread eczematous rash consisting of papules and plaques over her abdomen, thighs and buttocks. There is umbilical sparing. There is evidence of excoriation across her abdomen.

Options:
explanation: Polymorphic eruption of pregnancy is also known as PUPPP (Pruritic Urticarial Papules and Plaques of Pregnancy). This usually starts on the abdomen, spares the umbilicus, and may spread to the thighs or buttocks. Symptomatic treatment includes emollients, topical corticosteroids, and antihistamines.
name: Polymorphic eruption of pregnancy
label: a
answer: yes
explanation: Atopic eruption of pregnancy presents similarly to eczema and is most common in women with a history of eczema. Typical sites include the face, neck, chest and flexor surfaces of the upper limbs. Treatment is with emollients and topical corticosteroids.
name: Atopic eruption of pregnancy
label: c
answer: no
explanation: Pemphigoid gestationis is rare, and causes itchy rash which typically forms around the umbilicus and progresses to form blisters. The condition is likely to flare up again throughout the pregnancy. Management is with emollients and topical corticosteroids.
name: Pemphigoid gestationis
label: d
answer: no
explanation: Contact dermatitis is a type of eczema occurring following exposure to a causative agent. It presents with a dry, painful and pruritic skin rash where the skin has been in contact with a certain irritant.
name: Contact dermatitis
label: e
answer: no
explanation: Obstetric cholestasis is caused by elevated bile acids, and does not cause a rash in itself but does cause intense pruritus, which can then develop into a rash. Cholestasis is treated with ursodeoxycholic acid, with emollients and antihistamines being useful for the itchy rash.
name: Obstetric cholestasis
label: b
answer: no

Correct answer: a
A 42-year-old woman attends her general practitioner after finding out she is pregnant. Her last menstrual period was six weeks ago. She is aware that having a pregnancy in her 40's is higher risk for Down syndrome and is keen to "get tested" as soon as possible.

She is offered the combined test at 11 weeks. Which of the following is a component of combined screening that, if raised, may indicate a higher risk of Down syndrome?

Options:
explanation: Oestradiol is not tested for as part of combined screening.
name: Oestradiol
label: e
answer: no
explanation: Alpha-fetoprotein (AFP) is performed as part of the triple screening test, which is performed later in pregnancy, after 13 weeks. AFP is reduced in pregnancies with Down syndrome.
name: Alpha-fetoprotein (AFP)
label: b
answer: no
explanation: Beta-hCG is tested as part of the combined screening test, alongside nuchal translucency and pregnancy-associated plasma protein-A (PAPP-A). The combined test gives an overall risk of Down syndrome.
name: Beta-hCG
label: a
answer: yes
explanation: Amniotic fluid level is not tested for as part of combined screening.
name: Amniotic fluid level
label: d
answer: no
explanation: Pregnancy-associated plasma protein-A (PAPP-A) is tested as part of the combined screening test, alongside beta-hCG and nuchal translucency. Pregnancy-associated plasma protein-A (PAPP-A) is reduced in pregnancies with Down syndrome.
name: Pregnancy-associated plasma protein-A (PAPP-A)
label: c
answer: no

Correct answer: a
A 14-year-old girl is brought into the general practice by her mother, who is concerned that she doesn't seem to be physically maturing like her peers.

On examination, the girl appears short, approximately 145cm in height. She reports that she has not started her periods. She has a broad flat chest with no evidence of breast budding. She reports that she has no pubic or axillary hair.

What is the most likely cause of this girl's primary amenorrhoea?

Options:
explanation: Imperforate hymen would not affect the development of secondary sexual characteristics and usually manifests with cyclical pain.
name: Imperforate hymen
label: c
answer: no
explanation: Androgen insensitivity syndrome occurs in people with an XY genotype; however, their body does not respond to androgens, so they fail to develop male secondary sexual characteristics.
name: Androgen insensitivity syndrome
label: e
answer: no
explanation: Primary amenorrhoea is diagnosed where there is absent menstruation and absent secondary sexual characteristics at age 13. Turner syndrome results from the chromosomal abnormality X0, where one X chromosome is missing. Affected individuals are phenotypically female, with short stature, webbed neck, widely spaced nipple and a wide carrying angle. They are also likely to have congenital heart defects, ovarian dysgenesis and delayed puberty.
name: Turner syndrome
label: a
answer: yes
explanation: Whilst excessive exercise can cause amenorrhoea, including primary amenorrhoea, there is no indication this is the case in this scenario. In addition, this girl has features of Turner syndrome.
name: Excessive exercise
label: d
answer: no
explanation: Constitutional delay is the most common cause of delayed puberty; however, this girl has several features of Turner syndrome, making this diagnosis more likely.
name: Constitutional delay
label: b
answer: no

Correct answer: a
A 22-year-old female presents to her local sexual health clinic with a 4 day history of abdominal cramps, similar to menstrual cramps.She has also noticed new thick thick, yellow vaginal discharge. She denies any vulval itching

She has had unprotected intercourse with multiple casual male partners in the last three months.

She has a Mirena coil in situ for contraception.

A bimanual examination reveals cervical tenderness, and on speculum examination, the cervix appears inflamed. Her coil threads are visible. There is a thick yellow-green discharge present in the vaginal vault. A sample is obtained from the upper vagina and cervix for near-patient microscopy.


What is the most likely finding on microscopy which would account for her symptoms?

Options:
explanation: Gram-negative rods
name: Gram-positive cocci on a vaginal specimen may indicate bacterial vaginosis.
label: e
answer: no
explanation: Gram-positive budding yeast cells
name: these are likely to be lactobacilli.
label: d
answer: no
explanation: Gram-positive cocci on a vaginal specimen may indicate bacterial vaginosis.
name: Gram-positive cocci
label: b
answer: no
explanation: Gram-positive bacilli are a normal finding on a vaginal sample
name: Gram positive bacilli
label: c
answer: no
explanation: This patient has signs and symptoms of pelvic inflammatory disease. Gram-negative diplococci inside cells on a vaginal specimen indicate gonorrhoea infection, one of the most common causes of pelvic inflammatory disease.
name: Intracellular gram-negative diplococci
label: a
answer: yes

Correct answer: a

Intracellular gram-negative diplococci
A 24-year-old female presents to accident and emergency with acute onset left iliac fossa pain.

She describes the pain as "stabbing" and of intensity 9/10. It came on suddenly while she was out for her daily jog approximately 1 hour ago. She thinks the pain has alleviated a little since then.

Her last menstrual period was 13 days ago. Her last sexual contact was 21 days ago. She has a copper intrauterine device in situ, which was inserted three months ago.

What is the most likely diagnosis?

Options:
explanation: Whilst ovarian torsion is a sensible differential, a ruptured ovarian cyst is more common. Combined with the fact she is mid-cycle and that the pain seems to have alleviated slightly, ovarian cyst rupture is the more likely diagnosis. Ovarian torsion often presents with worsening pain, sometimes associated with nausea and vomiting.
name: Ovarian torsion
label: d
answer: no
explanation: Whilst ectopic pregnancy is a possibility, this would be rare with a copper intrauterine device in situ.
name: Ectopic pregnancy
label: b
answer: no
explanation: Appendicitis typically presents with central periumbilical pain which localises to the right lower quadrant. This doesn't fit with her pain being on the left and sudden-onset.
name: Appendicitis
label: e
answer: no
explanation: Ovarian cyst rupture presents with a sudden-onset sharp unilateral pain.
name: Ovarian cyst rupture
label: a
answer: yes
explanation: Whilst perforation of an intrauterine device can cause unilateral pain; this is usually within the first few days following insertion.
name: Intrauterine device perforation
label: c
answer: no

Correct answer: a
A 38-year-old woman attends the antenatal clinic for a routine appointment at 36 weeks gestation. She is para 1, having had an emergency caesarean section 6 years prior for foetal distress.

Which of the following would contraindicate a vaginal birth?

Options:
explanation: Previous history of uterine rupture is a contraindication to vaginal birth after caesarean section. Other contraindications include a classical (vertical) caesarean section scar, and any other condition that would normally contraindicate a vaginal delivery (e.g. major placenta praevia).
name: Previous history of uterine rupture
label: a
answer: yes
explanation: BMI over 30 is not a contraindication to vaginal birth after caesarean section
name: BMI over 30
label: d
answer: no
explanation: There are no specific contraindications regarding previous gestational age at birth.
name: Previous preterm delivery
label: c
answer: no
explanation: Previous postpartum haemorrhage is not a contraindication to vaginal birth after caesarean section.
name: Previous postpartum haemorrhage
label: e
answer: no
explanation: There is no specific age limit for vaginal birth after caesarean section in the absence of any other contraindications.
name: Age over 35
label: b
answer: no

Correct answer: a
A 43-year-old female presents to her general practitioner with a 6-month history of bleeding between periods and post-coital bleeding. She is very nervous and has never attended her general practice for anything before. She is aware she should have been attending cervical smears, but was too scared. She has a regular male partner and always uses condoms for intercourse.

Which of the following is essential to perform in this patient?

Options:
explanation: Whilst a urinary pregnancy test may form part of this woman's investigations, she does not disclose any unprotected intercourse. Pregnancy is not a likely cause of a 6-month history of intermenstrual bleeding.
name: Urinary pregnancy test
label: c
answer: no
explanation: This woman has symptoms of cervical cancer, i.e. intermenstrual and post-coital bleeding. Therefore it is essential to perform a speculum examination. Alongside a speculum examination, she should have testing for sexually transmitted infection and if her cervix appears normal, a routine cervical smear can be obtained.
name: Speculum examination
label: a
answer: yes
explanation: Whilst endometrial pathology can cause intermenstrual and post-coital bleeding, and this may be seen on an ultrasound scan, the first-line investigation in primary care is a speculum examination to visualise the cervix.
name: Transvaginal ultrasound scan
label: e
answer: no
explanation: A digital rectal examination is not necessary in the absence of any rectal symptoms.
name: Digital rectal examination
label: d
answer: no
explanation: Vaccination for human papillomavirus should be given to unvaccinated individuals in certain groups e.g. men who have sex with men.
name: Vaccination for human papillomavirus
label: b
answer: no

Correct answer: a
A 53-year-old woman presents to accident and emergency with acute onset right iliac fossa pain. She is taken for an emergency laparoscopy which reveals acute ovarian torsion and a right ovarian mass. She undergoes a right oophorectomy and makes a good recovery postoperatively. Pathology of the ovary reveals a mass containing an invasive proliferation of mucin-producing signet-ring cells.

Which of the following cancers should now be screened for?

Options:
explanation: Signet ring cells seen within the ovary are most commonly metastasis from gastrointestinal cancer.
name: Endometrial cancer
label: b
answer: no
explanation: Signet ring cells seen within the ovary are most commonly metastasis from gastrointestinal cancer.
name: Osteosarcoma
label: e
answer: no
explanation: Signet ring cells seen within the ovary are most commonly metastasis from gastrointestinal cancer.
name: Lymphoma
label: d
answer: no
explanation: Krukenberg tumours of the ovary refer to a tumour containing "signet ring" cells. This is typically a gastrointestinal carcinoma, which has metastasised to the ovary.
name: Gastrointestinal cancers
label: a
answer: yes
explanation: Signet ring cells seen within the ovary are most commonly metastasis from gastrointestinal cancer, however can also occur from breast cancers.
name: Breast cancer
label: c
answer: no

Correct answer: a
A 55-year-old woman attends her general practitioner with a 1-year history of a lump in her vagina. She also complains of leaking urine when she coughs or sneezes, which has been ongoing for the past eight months. On examination, her abdomen is soft and non-tender. On digital vaginal examination, a small cystocele is felt at the anterior vaginal wall. She can contract her pelvic floor muscles voluntarily. She has no dysuria or increased urinary frequency. Urinalysis is positive for leucocytes but otherwise negative.

What is the most appropriate next step?

Options:
explanation: Women with stress urinary incontinence should be referred for a trial of at least three months of supervised pelvic floor muscle training (PFMT).
name: Refer the woman for pelvic floor muscle training (PFMT)
label: a
answer: yes
explanation: Duloxetine can be used as a second-line option for women with stress urinary incontinence where conservative management options have failed.
name: Trial of duloxetine
label: d
answer: no
explanation: Where a woman does not have symptoms of urinary tract infection (UTI) and urinalysis is negative for either leucocytes or nitrites, a urine samples should not be sent for culture as she is unlikely to have a UTI.
name: Send a urine sample for culture
label: c
answer: no
explanation: Antibiotics should not be prescribed for leukocytes on urinalysis in the absence of symptoms of urinary tract infection (e.g. dysuria, frequency or urgency).
name: Prescribe a three-day course of oral trimethoprim
label: b
answer: no
explanation: Referral for surgical management may be considered where conservative options have failed.
name: Refer to urogynaecology for consideration of colposuspension
label: e
answer: no

Correct answer: a
A 30-year-old woman attends for her 20-week foetal anomaly scan. The scan notes microcephaly with periventricular calcification, hyperechogenic bowel, splenomegaly and hepatomegaly.

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

Options:
explanation: Foetal MRI is indicated in very specific cases where ultrasound findings are equivocal e.g. spina bifida, suspicious masses. In this case the ultrasound findings are common to congenital CMV infection, so testing for this is the next step.
name: Foetal MRI
label: b
answer: no
explanation: These are ultrasound findings common to congenital cytomegalovirus (CMV) infection, which can be tested for using amniocentesis.
name: Amniocentesis
label: a
answer: yes
explanation: Chorionic villus sampling is performed to assess for genetic or chromosomal conditions, and is usually performed between 11 and 14 weeks of pregnancy. In this case, the pregnancy is already 20 weeks, so this is not an appropriate investigation.
name: Chorionic villus sampling
label: c
answer: no
explanation: Repeating the ultrasound scan in two weeks is unlikely to yield a different result. The more important issue is the diagnosis of potential CMV infection.
name: Repeat ultrasound scan at 22 weeks gestation
label: d
answer: no
explanation: The combined test is performed between weeks 11 and 13 of pregnancy and aims to give a risk of Down syndrome. The pregnancy is already 20 weeks, and there is no a suspicion of Down syndrome here.
name: The combined test including nuchal translucency, PAPP-A hormone and beta-hCG
label: e
answer: no

Correct answer: a
A 25-year-old parous woman attends her local maternity unit in established labour at 39+7 weeks. She had a spontaneous vaginal delivery 2 years prior and has had no problems during either pregnancy. She is experiencing regular, painful contractions. She has not experienced any vaginal loss.

A cardiotocograph is performed upon admission, which reveals a foetal heart rate of 110 beats per minute, with deep decelerations with contractions that are slow to recover.

The woman is transferred to theatre for an emergency caesarean section, and a live male infant is delivered.

As the midwife examines the placenta to check the membranes are complete, she describes the umbilical cord as "velamentous".

What is the most likely cause of the intrapartum foetal distress?

Options:
explanation: Whilst uterine rupture is a cause of foetal distress, this usually presents with sudden onset and continuous abdominal pain. There is often a history of previous caesarean section.
name: Uterine rupture
label: d
answer: no
explanation: Whilst umbilical cord prolapse is a cause of foetal distress, this occurs after the membranes have ruptured. This woman reports no history of vaginal loss on admission.
name: Umbilical cord prolapse
label: e
answer: no
explanation: Whilst placental abruption is a cause of foetal distress, this condition usually presents with sudden and severe abdominal pain, accompanied by a "woody" hard uterus and foetal distress.
name: Placental abruption
label: c
answer: no
explanation: Placenta praevia occurs where part of the placenta overlies the cervical os. This can lead to brisk antepartum haemorrhage before or during labour. This is less likely in this case as there was no visible antepartum haemorrhage, and the description of the placenta fits a type 1 vasa praevia.
name: Placenta praevia
label: b
answer: no
explanation: Vasa praevia occurs when the vessels in the umbilical cord run within the foetal membranes. These vessels may rupture spontaneously in early labour. Vasa praevia can be divided into types; in type 1 vasa praevia, the umbilical cord is inserted into the membranes rather than directly into the placenta (also known as a velamentous insertion) and in type 2 vasa praevia, the umbilical vessels run from the placenta to a succenturiate placental lobe.
name: Vasa praevia
label: a
answer: yes

Correct answer: a