hllj/quesmed huggingface dataset:
A 67 year old man is brought to the emergency department by ambulance with acute breathlessness. His oxygen saturation remains at 86% on 15 L of oxygen and he is admitted to the respiratory ward. Chest imaging reveals a left sided pneumothorax with widespread pleural plaques and a left sided mesothelioma. Despite treatment with a chest drain, he arrests on the ward and is unable to be resuscitated.

What is the most appropriate course of action?

Options:
explanation: This is the correct answer. The imaging findings heavily suggest an occupational exposure to asbestos with pleural plaques and mesothelioma. All deaths related to industrial disease must be reported to the coroner.
name: Refer death to the coroner
label: a
answer: yes
explanation: There is nothing to suggest that the circumstances of the death warrant an incident form. This may be required in cases where an incident (e.g. medication error) is thought to have contributed to an adverse outcome.
name: Submit a critical incident form
label: d
answer: no
explanation: There is nothing to suggest this patient is infectious at present.
name: Notify local microbiology lead
label: b
answer: no
explanation: To certify a death you must have seen the patient in the last 14 days before death or after death and must have provided care in the last illness before death. As this case needs a coroner referral, this is not appropriate and should not be handed over to a colleague who has likely not seen the patient.
name: Handover to night team doctor to verify and certify death
label: c
answer: no
explanation: This would be appropriate had a coroner referral not been warranted.
name: Verify and certify death and discharge the patient to funeral parlour
label: e
answer: no

Correct answer: a


Learning point: Deaths associated with industrial diseases, such as mesothelioma from asbestos exposure, must be reported to the coroner for further investigation.
An 88 year old woman has stage 4 breast cancer with metastases in the brain, liver and lungs. It is felt she may be nearing the end of her life, and is currently bedbound with a WHO performance status of 4. She is unable to demonstrate capacity to make treatment decisions. Her daughter requests her mother is given intravenous fluids and is NG tube fed as she has not been eating and drinking for the last few days. There is no formal lasting power of attorney in place.

What is the most appropriate course of action?

Options:
explanation: As the patient lacks capacity, decisions should be made in their best interests, involving the MDT and next of kin. It is important to remember that fluids and artifical nutrition are medical treatments and should be prescribed only when clinically indicated and when they are likely to help. Nausea and loss of appetite are common symptoms in the last days of life, which may warrant symptomatic management.
name: Discuss in the MDT as to whether fluids and nasogastric tube insertion are in her best interests
label: a
answer: yes
explanation: If the lack of eating is due to a possible swallowing difficulty, this will undoubtedly be useful, but there is no suggestion of that at present.
name: Refer to speech and language therapy for assessment
label: e
answer: no
explanation: This is inappropriate. A more detailed discussion needs to be had to ascertain if these interventions are likely to be helpful and in the patient's best interests, as well as what the goals of treatment are.
name: Advise IV fluids and NG tube will not be helpful at this stage
label: c
answer: no
explanation: This may be helpful but it does not address the daughter's concerns about artificial nutrition and hydration.
name: Encourage oral food and water
label: d
answer: no
explanation: At this stage, we do not have enough information as to whether these treatments are indicated or were previously by the patient, see above answer for MDT discussion for further information.
name: Administer IV fluids and insert NG tube
label: b
answer: no

Correct answer: a


Learning point: In patients nearing end-of-life, decisions about artificial nutrition and hydration should prioritize their best interests and overall quality of life, with input from an MDT (multidisciplinary team) to ensure comprehensive care and shared decision-making.
A 58 year old man is brought to A&E by police under section 136. They report he was screaming in the library about seeing and feeling insects crawling all over his skin. His past psychiatric history includes bipolar disorder and alcohol dependence. On inspection, he appears sweaty and confused and a coarse tremor is noted.

Which of the following is the most appropriate treatment?

Options:
explanation: This may well be done, however, initiating a benzodiazepine should be done in the first instance by the medical team.
name: Refer to liasion psychiatry team
label: d
answer: no
explanation: This is correct. This is a case of alcohol withdrawal and delirium tremens with common symptoms including formication (feeling like insects are crawling on your skin), visual hallucinations (possibly of the insects), diaphoresis, confusion and a coarse tremor.
name: Chlordiazepoxide
label: a
answer: yes
explanation: Lithium toxicity may well cause a similar coarse tremor, confusion and diaphoresis however is unlikely to cause visual hallucinations and formication. In any case, lithium levels would be required before stopping or withholding lithium.
name: Discontinue lithium
label: b
answer: no
explanation: This has no role in the acute treatment of alcohol withdrawal and delirium tremens which typically includes benzodiazepines and B vitamins in the first instance. Disulfiram may help with a later stage to quit drinking due to its role in aversion therapy.
name: Initiate disulfiram
label: e
answer: no
explanation: Lithium toxicity may well cause a similar coarse tremor, confusion and diaphoresis however is unlikely to cause visual hallucinations and formication. In any case, lithium levels would be required before stopping or withholding lithium. Haemodialysis may used to treat severe cases of lithium toxicity.
name: Initiate haemodialysis
label: c
answer: no

Correct answer: a


Learning point: Chlordiazepoxide, a benzodiazepine, manages acute alcohol withdrawal by reducing symptoms such as anxiety, agitation, and seizures through its GABAergic activity, providing a gradual, controlled sedative effect to prevent severe withdrawal complications.
A 26 year old man comes to the GP with low mood, fatigue, anhedonia, as well as feelings of worthlessness and guilt. You decide to start him on a selectrive serotonin reuptake inhibitor.

Which of the following should you advise him?

Options:
explanation: This is the correct answer. It is important to counsel patients on the sexual side effects as they can negatively impact quality of life and persist, even after stopping them.
name: SSRIs may cause sexual dysfunction
label: a
answer: yes
explanation: The recommendation is they should not be stopped until 6 months after symptomatic relief.
name: SSRIs may be discontinued 3 months following symptomatic relief
label: d
answer: no
explanation: This is incorrect. Sudden withdrawal can cause SSRI discontinuation syndrome which is characterised by flu like symptoms, insomnia, nausea, dizziness and sensory disturbances.
name: SSRIs may be stopped immediately with little side effects
label: e
answer: no
explanation: SSRIs typically start working within 4-6 weeks of initiation. If no improvement in symptoms has been noted by then, switching to an alternative agent may be considered.
name: SSRIs may take up to 6 months to alleviate symptoms
label: b
answer: no
explanation: In young adults (often local guidelines may quote under 30 years of age), SSRIs may cause an initial increase in suicidal ideation within the first 2 weeks and there is, therefore, a recommendation to inform patients about this and review them at 1 week point following initiation.
name: SSRIs are associated with an immediate reduction in suicidal ideation
label: c
answer: no

Correct answer: a


Learning point: Selective serotonin reuptake inhibitors (SSRIs) can cause persistent sexual dysfunction, which may continue even after discontinuation of the medication.
A 65 year old man is brought to the emergency department by ambulance following reports of a severe headache and subsequent loss of consiousness. His GCS is 7. He is intubated and admitted to the ICU.

A CT head shows

[lightgallery]

What is the most appropriate next step in the management of this patient?

Options:
explanation: This is typically used in the treatment of normal pressure hydrocephalus.
name: Ventriculoperitoneal shunt insertion
label: e
answer: no
explanation: Decompressive craniectomy is where a bone flap is permanently removed from the skull and is used to treat traumatic brain injuries, chiari malformationss, stroke and other conditions causing a raised ICP. This may become required in the future if cerebral oedema develops, however it is not currently the most appropriate management.
name: Decompressive craniectomy
label: d
answer: no
explanation: This is correct. The history and imaging suggests a case of subarachnoid haemmorhage. The immediate priority is to treat vasospasm using nimodipine and optimise blood pressure control (140-160mmHg) to prevent rebleeding.
name: Nimodipine and blood pressure control
label: a
answer: yes
explanation: Craniotomy is where a bone flap is temporarily removed from the skull and replaced. It is useful in the treatment of space occupying lesions, blood clots, traumatic brain injury (TBI), and can also facilitate implantation of deep brain stimulators for Parkinson's disease.
name: Craniotomy
label: c
answer: no
explanation: This is typically used in the treatment of subdural and extradural haematomas, to reduce pressure on the brain.
name: Burr hole
label: b
answer: no

Correct answer: a


Learning point: Nimodipine is essential in managing subarachnoid haemorrhage to prevent vasospasm and optimise blood pressure control.
A 46-year-old Caucasian woman complains of fatigue and joint pain. Antibody analysis shows positive anti-histone antibodies.

Which of the following is most likely to be found in the patient’s current medical history?

Options:
explanation: The patient’s presentation suggests a case of drug-induced lupus. Common causes of drug induced lupus include isoniazid (used for TB), procainamide, hydralazine, minocycline and phenytoin.
name: Active pulmonary tuberculosis
label: a
answer: yes
explanation: Trigeminal neuralgia is typically treated with carbamazapine, which can rarely cause drug-induced lupus but not as commonly as isoniazid.
name: Trigeminal neuralgia
label: c
answer: no
explanation: The anti-histone antibodies and joint pain point towards drug-induced lupus.
name: Pulmonary Fibrosis
label: e
answer: no
explanation: The anti-histone antibodies and joint pain are suggestive of drug-induced lupus.
name: Metastatic breast cancer
label: b
answer: no
explanation: Atrial fibrillation can be treated in a variety of ways, none of which are likely to cause drug-induced lupus.
name: Atrial fibrillation
label: d
answer: no

Correct answer: a


Learning point: Drug-induced lupus erythematosus can occur with medications like isoniazid, commonly used for treating pulmonary tuberculosis.
An 86-year-old man is referred for a spinal MRI due to persistent back pain. The scan shows a lytic bone lesion at the T5 vertebrae. His past medical history includes CKD stage 4, pulmonary fibrosis, Alzheimer’s disease, heart failure, macular degeneration and osteoporosis. His WHO performance status is 3.

What is the most appropriate management?

Options:
explanation: This would be inappropriate as extensive investigation are unlikely to ultimately affect treatment decisions. NICE guidelines CG104 recommend not routinely investigating to find the primary cancer, which a PET scan may be used to do. The man's age and comorbidities mean he will likely not be a candidate for active treatment.
name: Whole body FDG PET scan
label: c
answer: no
explanation: This would be inappropriate as extensive investigation are unlikely to ultimately affect treatment decisions. The man's age and comorbidities mean he will likely not be a candidate for active treatment.
name: Staging CT CAP
label: b
answer: no
explanation: In patients with a likely malignancy of unknown primary, in whom extensive investigation is unlikely to ultimately affect treatment decisions, NICE guidelines CG104 recommend not routinely investigating to find the primary. The man's age and comorbidities mean he will likely not be a candidate for active treatment.
name: No further investigations
label: a
answer: yes
explanation: While prostate cancer is a likely diagnosis, Ffurther investigations to identify the primary cancer are unlikely to be helpful in this case. In patients with a likely malignancy of unknown primary, in whom extensive investigation is unlikely to ultimately affect treatment decisions, NICE guidelines CG104 recommend not routinely investigating to find the primary. The man's age and comorbidities mean he will likely not be a candidate for active treatment.
name: Multiparametric MRI of the prostate
label: e
answer: no
explanation: Bone scans are used to assess the spread of cancer to bones. In this case, the presence of a lytic lesion demonstrates that bony metastases are already present. Further scanning to locate other lesions is unlikely to be helpful, as this patient is unlikely to be a candidate for active treatment.
name: Technetium bone scan
label: d
answer: no

Correct answer: a


Learning point: In elderly patients with significant comorbidities and suspected malignancy, extensive investigations may be inappropriate if they won't alter management.
A 2-month-old boy is brought to hospital following periods of intense crying and irritability, followed by cyanosis and difficulty breathing. They report he has lost consciousness on two of these occasions. On auscultation, an ejection systolic murmur is heard.

Which of the following is the most appropriate advice to give his parents?

Options:
explanation: This advice is usually given to parents of children suffering febrile convulsions.
name: If the episodes last for more than 5 minutes, call an ambulance
label: e
answer: no
explanation: The presentation is consistent with Tetralogy of Fallot, which causes periods of cyanosis and may cause syncope commonly presenting a few months after birth.  This manoeuvre compresses the femoral arteries and increases peripheral vascular resistance, reducing the magnitude of the shunt.
name: During the episode, pick the child up and bring his knees towards the chest
label: a
answer: yes
explanation: Tetralogy of Fallot does not resolve without surgical intervention.
name: The episodes will self-resolve by the time he is 6 months old
label: b
answer: no
explanation: This will not help.
name: During the episode, do not move the child
label: d
answer: no
explanation: This advice is usually given to parents of children who suffer breath holding attacks or reflex anoxic seixures.
name: Avoid upsetting or triggering the child to prevent the episodes
label: c
answer: no

Correct answer: a


Learning point: In Tetralogy of Fallot, bringing the knees to the chest during a cyanotic episode increases systemic vascular resistance, alleviating hypoxia.
A 50 year old man with type 2 diabetes comes to the GP with scleral icterus. He describes severe pain in his knees and breathlessness on minimal exertion, over the last month. His past medical history is remarkable for beta thalassemia major.

What is the most likely aetiology of his condition?

Options:
explanation: This is the defect found in Gilbert's syndrome, causing benign jaundice.
name: Inherited defect in UDP glucuronyltransferase levels
label: d
answer: no
explanation: This is the defect found in Wilson's disease, which usually presents with hepatic impairment and neuropsychiatric features.
name: Inherited defect of ATP7B gene
label: c
answer: no
explanation: The features are those of iron overload which can be inherited as in the case of haemochromatosis, but the patient's medical history makes an iatrogenic cause more likely.
name: Inherited defect of the HFE gene
label: b
answer: no
explanation: This causes Lynch syndrome, causing colorectal, ovarian, gastric and endometrial cancers.
name: Inherited defect of MSH2 gene
label: e
answer: no
explanation: This patient is likely to be suffering from iatrogenic iron overload from repeated blood transfusions for his thalassemia major. This causes symptoms similar to hereditary haemochromatosis, such as cardiac failure, liver impairment, and endocrine issues like diabetes.
name: Blood transfusions
label: a
answer: yes

Correct answer: a


Learning point: Iatrogenic iron overload from repeated blood transfusions can lead to severe complications, including liver dysfunction and diabetes in patients with thalassemia major.
A 15-year-old boy comes to the ED after getting hit in the face by the ball.  On inspection of the nose, a bilateral red swelling can be observed.

Given the likely diagnosis, which of the following is the definitive management plan?

Options:
explanation: This is the correct course of action. Septal haematomas must be evacuated to preserve blood supply to the nasal cartilage, as the septal cartilage relies on nutrient and oxygen delivery from the perichondrium. Untreated, the septum may collapse, causing a saddle-nose deformity.
name: Refer to ENT for incision and drainage under general anaesthetic
label: a
answer: yes
explanation: This is not appropriate - a septal haematoma is an emergency requiring intervention to prevent damage to the nasal septal cartilage.
name: Reassurance and discharge
label: b
answer: no
explanation: ENT referral is required, however needle aspiration is likely to be insufficient to drain the haematoma, which is required to ensure that the nasal septum continues receiving oxygen and nutrients.
name: Refer to ENT for antibiotics and needle aspiration
label: e
answer: no
explanation: This is the correct management for epistaxis, not for a septal haematoma.
name: Cauterisation and packing
label: c
answer: no
explanation: This will not resolve the septal haematoma, and will delay urgent intervention.
name: Give topical corticosteroids and refer to ENT
label: d
answer: no

Correct answer: a


Learning point: Bilateral nasal swelling after trauma may indicate a septal haematoma, requiring urgent drainage to prevent complications such as saddle-nose deformity.
A 59 year old woman has intermittent abdominal pain, accompanied by bloating and occasional diarrhoea. No other symptoms are present, and a diagnosis of irritable bowel syndrome is suspected. Her medical history is otherwise unremarkable.

Which is the most important investigation to request?

Options:
explanation: Ovarian cancer is a diagnosis that must be excluded in this demographic. NICE recommend CA-125 testing in women >50 experiencing IBS-like symptoms in the previous 12 months.
name: CA-125 level
label: a
answer: yes
explanation: This would be a useful test to exclude IBD, but is not the most important in this case.
name: Faecal calprotectin
label: d
answer: no
explanation: This is not routinely used in the assessment of IBS or colorectal cancer (another differential). It may be used in ovarian cancer, along with a transvaginal ultrasound, however it is not currently the most important investigation.
name: Ultrasound of the abdomen
label: e
answer: no
explanation: This would not be a first-line investigation for ovarian cancer, or for colorectal cancer (which is another differential).
name: Flexible sigmoidoscopy
label: b
answer: no
explanation: While this is a useful test to request, it is not the most important investigation in this case. The patient's age and symptomos are concerning for ovarian cancer.
name: Full blood count
label: c
answer: no

Correct answer: a


Learning point: In women over 50 with IBS-like symptoms, CA-125 testing is essential to exclude ovarian cancer.
A 34-year-old primigravida attends hosptial after her membranes have ruptured at 32 weeks. Her medical history is unremarkable. A CTG shows no contractions and no features of foetal distress.

What is the most appropriate management?

Options:
explanation: Tocolytic agents (such as nifedipine) are used in pre-term labour in order to buy time so that steroids can be administered to encourage foetal lung maturation. The patient is not in labour as evidenced by the CTG showing no contractions, meaning tocolysis is not indicated.
name: Tocolytic agents
label: e
answer: no
explanation: There are no current indications for an elective caesarean, such as malpresentation or placenta praevia. Elective caesarean sections often are planned at 39 weeks. An emergency caesarean section may be indicated if there are features of foetal distress.
name: Elective caesarean section at 36 weeks
label: d
answer: no
explanation: IV benzylpenicillin may be used if the woman is in established labour and is febrile (material sepsis), or during delivery if there is a history of group B streptococcus colonisation. While antibiotics are required, oral erythromycin is the first choice for PPROM.
name: Intravenous benzylpenicillin
label: c
answer: no
explanation: This is not appropriate. There are no features of foetal distress. Inducing labour this early poses risks to the foetus.
name: Immediate induction of labour
label: b
answer: no
explanation: This patient has experienced a pre-term premature rupture of membranes. RCOG guidelines suggest antibiotics (preferably erythromycin) should be given for 10 days or until the woman is in established labour (whichever is sooner). They also recommend steroids are given until 33 weeks' 6 days' gestation.
name: Erythromycin and steroids
label: a
answer: yes

Correct answer: a


Learning point: In cases of preterm prelabor rupture of membranes (PPROM), erythromycin is often given as an antibiotic prophylaxis to reduce the risk of infection, while steroids are administered to accelerate fetal lung maturation and reduce the risk of lung complications related to prematurity.
A 24-year-old man with a long history of treatment-refractory psychosis is commenced on clozapine. He is poorly-compliant with monitoring. He presents to hospital with a fever and general malaise.

Which is the next most important investigation?

Options:
explanation: This is an important investigation as part of a septic screen, but results take 48 hours. A FBC is more important at this stage.
name: Blood cultures
label: d
answer: no
explanation: There are no neurological signs at present to warrant a CT head.
name: CT scan of brain
label: b
answer: no
explanation: At present, there are no concerns indicative of meningitis, encephalitis, or a subarachnoid haemorrhage.
name: Lumbar puncture
label: c
answer: no
explanation: There is no suggestion of neuroleptic malignant syndrome, which is a rare side effect of clozapine. This may present with lead-pipe rigidity, tachycardia, hypertension, and diaphoresis, along with other symptoms.
name: Creatine kinase levels
label: e
answer: no
explanation: Clozapine may cause agranulocytosis, making patients more susceptible to overwhelming infections. The most important investigation is a full blood count to ascertain if this has happened.
name: Full blood count
label: a
answer: yes

Correct answer: a


Learning point: Clozapine can cause agranulocytosis, so patients require regular full blood count monitoring to detect potential neutropenia and prevent severe infections.