hllj/quesmed huggingface dataset:
A 37-year-old male has painful and swollen breast tissue and has noticed a milky discharge from his nipples. This has been occurring for the past 3 weeks and the patient is finding it to be troublesome and embarrassing. He has a past medical history of schizophrenia and takes haloperidol for this. He is aware that the symptoms he is experiencing are a side effect of his medication and asks whether there is an alternative which he can start taking.

Which of the below anti-psychotic medications is least likely to cause these symptoms?

Options:
explanation: This is an atypical antipsychotic, which has a stronger affinity for 5HT receptors than dopamine receptors, although the antagonistic effect on dopamine receptors still can cause hyperprolactinaemia.
name: Olanzapine
label: e
answer: no
explanation: As a partial dopamine agonist, Aripiprazole is least likely to cause galactorrhoea as dopamine normally inhibits prolactin production. All the other medications listed antagonise dopamine receptors and therefore have a greater risk of increasing prolactin production.
name: Aripiprazole
label: a
answer: yes
explanation: This is a typical antipsychotic which is a strong dopamine receptor antagonist, therefore greatly increasing the risk of hyperprolactinaemia.
name: Chlorpromazine
label: b
answer: no
explanation: This is a typical antipsychotic which is a strong dopamine receptor antagonist, therefore greatly increasing the risk of hyperprolactinaemia.
name: Prochlorperazine
label: c
answer: no
explanation: This is an atypical antipsychotic, which has a stronger affinity for 5HT receptors than dopamine receptors. However, the antagonistic effect on dopamine receptors still can cause hyperprolactinaemia.
name: Quetiapine
label: d
answer: no

Correct answer: a


Learning point: Aripiprazole, a partial dopamine agonist, is less likely to cause galactorrhoea compared to other antipsychotics that antagonise dopamine receptors.
A 23-year-old male has recently been diagnosed with moderate depression after experiencing low mood, anhedonia and fatigue for the past 4 months. He has also been noticing poor focus and sleep, often waking up at 4AM and unable to get back to sleep. He is awaiting an appointment for cognitive behavioural therapy but would like to trial medication and is therefore started on sertraline. The patient would like to know when he will start to see the positive effects of the medication.

What is the most appropriate advice to offer?

Options:
explanation: This is the correct answer. SSRIs do not always work for patients with depression but if they have a beneficial effect it will be seen within 4 weeks of starting treatment. It is vital to counsel patients that they may feel worse initially, including worsened suicidal ideation. They should be advised of how to seek urgent review if this is the case.
name: The medication usually will work within 4 weeks of commencing treatment, but the patient may experience worsening symptoms initially
label: a
answer: yes
explanation: SSRIs usually have a beneficial effect within 4 weeks of starting treatment but can make patients feel worse initially, especially within the first 2 weeks of starting treatment.
name: The medication will start to work immediately
label: b
answer: no
explanation: Although a beneficial effect is expected to be seen within the first 4 weeks of treatment, SSRIs must be taken daily.
name: The medication will be more effective if taken twice a week, with a beneficial effect seen within 4 weeks of starting treatment
label: e
answer: no
explanation: Although SSRIs can make patients feel worse initially, a beneficial effect should be seen within 4 weeks of starting treatment.
name: The medication will cause a worsening of symptoms for a month and a beneficial effect is normally seen within 6 months
label: c
answer: no
explanation: SSRIs usually have a beneficial effect within 4 weeks of starting treatment, a year is much too long to wait before trying alternative treatment options.
name: The medication must be taken for a year before a beneficial effect is seen
label: d
answer: no

Correct answer: a


Learning point: Selective serotonin reuptake inhibitors (SSRIs) like sertraline typically show effects within four weeks, though initial worsening of symptoms may occur.
A 65-year-old male believes that an imposter has replaced his wife. He states this started 4 weeks ago and is unsure who the ‘imposter’ is and their purpose or aim. He has not been engaging with his wife and has attempted to contact the police numerous times. On discussion, he refuses to accept evidence that his wife is the same person, including information that only his wife would know. The patient has a background of schizophrenia and takes olanzapine, although his wife is unsure of how compliant he is with his medication.

What is the likely diagnosis?

Options:
explanation: This is also known as erotomania, where an individual believes another person (whom they are often unable to interact with directly e.g. celebrities) is infatuated with them. It can be secondary to BPAD or schizophrenia.
name: De Clarembeut’s syndrome
label: d
answer: no
explanation: This is delusional misidentification syndrome, where an individual has a fixed delusion that a person close to them has been replaced by an identical imposter. It is associated with schizophrenia.
name: Capgras syndrome
label: a
answer: yes
explanation: This is a syndrome where the patient has a fixed delusion that multiple people are the same person (often a familiar person to the patient) in disguise. This is different to Capgras syndrome where they believe an individual close to them has been replaced by an imposter. De Fregoli syndrome is also associated with schizophrenia.
name: De Fregoli syndrome
label: b
answer: no
explanation: These describe nihilistic delusions, where the patient believes they are dead or rotten. It is common in psychotic depression in older patients.
name: Cotard syndrome
label: e
answer: no
explanation: Ekbom syndrome is also known as delusional parasitosis, where an individual believes they are infested with parasites and often have tactile hallucinations of insects crawling on them. It is associated with a range of conditions.
name: Ekbom syndrome
label: c
answer: no

Correct answer: a


Learning point: Capgras syndrome is a delusional misidentification disorder where individuals believe a close person has been replaced by an imposter.
A 27-year-old female often gets into disagreements with her colleagues. She believes herself to be the best employee in the company and thinks others have ideas which are unimportant or meaningless. She will constantly seek praise from her boss and enjoys having interns she can influence. She frequently lies about missing deadlines to ensure she is presented in the best possible way at work.

Which of the following is the most likely diagnosis?

Options:
explanation: This is associated with the individual holding unconventional beliefs and difficulty interacting with others due to social anxiety and paranoia.
name: Schizotypal personality disorder
label: b
answer: no
explanation: This is characterised by intense fluctuating emotions, inability to maintain relationships, feelings of emptiness and often self-harm.
name: Emotionally unstable personality disorder
label: d
answer: no
explanation: This is characterised by inappropriate attention-seeking behaviour and an excessive desire for approval and validation.
name: Histrionic personality disorder
label: e
answer: no
explanation: This is characterised by a lack of empathy and aggressive behaviour towards others and is associated with impulsive behaviour and often substance abuse.
name: Antisocial personality disorder
label: c
answer: no
explanation: This is a classic description of narcissistic personality disorder, where the individual believes themselves to be superior and acts in a manipulative manner, often to get admiration.
name: Narsicistic personality disorder
label: a
answer: yes

Correct answer: a


Learning point: Narcissistic personality disorder is characterised by an inflated sense of self-importance and a constant need for admiration from others.
A 32-year-old male complains of persistently distressing thoughts and images. This has been occurring for the last 6 months and he finds them worsening when he is stressed. He finds the only way to deal with the stress created by these thoughts is repeatedly turning his bedside lamp on and off, or doing the same with his phone torch. He would like to try medication to improve his symptoms.

Which of the following medications should be offered?

Options:
explanation: Clomipramine is the only TCA which is licencsed to treat OCD. Amitriptyline is therefore an incorrect answer.
name: Amitriptyline
label: b
answer: no
explanation: This is an antipsychotic which is not licensed for the treatment of OCD.
name: Aripiprazole
label: e
answer: no
explanation: This is the only medication listed here which is licensed to treat OCD, characterised by intrusive obsessions and ritualistic compulsions. It may be required at a higher dose than used when treating depression.
name: Sertraline
label: a
answer: yes
explanation: This is an antipsychotic which is not licensed for the treatment of OCD.
name: Olanzapine
label: c
answer: no
explanation: This is an antipsychotic which is not licensed for the treatment of OCD.
name: Haloperidol
label: d
answer: no

Correct answer: a


Learning point: Sertraline is an effective first-line medication for treating obsessive-compulsive disorder (OCD), targeting intrusive thoughts and compulsive behaviours.
A 57-year-old male with a background of bipolar disorder experiences palpitations. He said this commenced when he was walking his dog 30 minutes ago and he also feels lightheaded. He denies any chest pain, syncope or dyspnoea and states that the symptoms have not worsened or changed in the last 30 minutes. An urgent ECG is carried out which is seen below:

[lightgallery]

Given the likely diagnosis, what is the most appropriate management?

Options:
explanation: This is the management of regular, broad complex tachycardias without life-threatening features. The rhythm seen here is an irregular, broad complex tachycardia.
name: IV amiodarone
label: b
answer: no
explanation: This is the management of irregular, narrow complex tachycardias without life-threatening features. The rhythm seen here is an irregular, broad complex tachycardia.
name: IV diltiazem
label: e
answer: no
explanation: This is an irregular, broad complex rhythm in keeping with Torsades des Pointes (polymorphic ventricular tachycardia). Lithium is a risk factor for QTc prolongation which can predispose to Torsades des Pointes. Magnesium is the correct medical treatment for this if no life-threatening features are present.
name: IV magnesium
label: a
answer: yes
explanation: This is the second line management of regular, narrow complex tachycardias without life-threatening features after vagal manoeuvres have been tried. The rhythm seen here is an irregular, broad complex tachycardia.
name: IV adenosine
label: c
answer: no
explanation: This is the first line of management of regular, narrow complex tachycardias without life-threatening features. The rhythm seen here is an irregular, broad complex tachycardia.
name: Vagal manoeuvres
label: d
answer: no

Correct answer: a


Learning point: Torsades de Pointes is a polymorphic ventricular tachycardia often associated with QTc prolongation, and IV magnesium is the first-line treatment.
A 25-year-old male is found collapsed. The only collateral history was provided by a passerby who found the patient was unresponsive and called an ambulance.

On assessment:

* A: No obvious angioedema, trachea central. Patient groaning occasionally
* B: Equal but slow chest expansion, no added sounds. RR 6, SpO2 91% on room air
* C: Regular pulse with warm peripheries. HS I + II + 0. HR 112, BP 108/60, Temperature 37.3 degrees, Urine Output unknown.
* D: GCS 7/15. Pinpoint pupils. Glucose within normal limits.
* E: No obvious rashes. Abdomen soft and non-tender

Which of the following is the most appropriate medication to prescribe?

Options:
explanation: Although naloxone is the correct treatment for opioid toxicity, it is given IV, IM or via intranasal administration.
name: Oral naloxone
label: b
answer: no
explanation: This is the reversal agent for ethylene glycol toxicity rather than opioid overdose. Opioid overdose is suggested here by low GCS, low RR and pinpoint pupils.
name: Fomepizil
label: d
answer: no
explanation: This is the reversal agent for benzodiazepine toxicity. Although benzodiazepine toxicity also would present with a reduced GCS, dilated pupils are more likely than pinpoint pupils. Additionally, flumazenil is only licensed for reversal in anaesthesia or ICU, rather than overdoses in the community.
name: IV flumazenil
label: c
answer: no
explanation: This is a likely case of opioid toxicity; suggested by the low respiratory rate, pinpoint pupils and low GCS. The correct treatment for opioid toxicity is naloxone. This is given IV, IM or via intranasal administration.
name: IV naloxone
label: a
answer: yes
explanation: This is used for paracetamol overdose rather than opioid overdose. Paracetamol toxicity would instead likely present with nausea, vomiting, headache and jaundice (in some severe or cases of delayed presentation).
name: N-acetyl cysteine
label: e
answer: no

Correct answer: a


Learning point: Opioid toxicity presents with respiratory depression, pinpoint pupils, and altered consciousness; naloxone is the antidote of choice.
A 47-year-old female is out for a steak dinner with her colleagues. She starts gesturing towards her throat and cannot answer when asked what is wrong. Her colleagues believe she is choking and start performing abdominal thrusts. After a few minutes of abdominal thrusts, she falls unconscious, with no response to voice or pain.

What is the appropriate management?

Options:
explanation: Back blows and abdominal thrusts should be carried out when the patient is conscious, with severe airway obstruction (e.g. ineffective cough). If the patient falls unconscious, CPR should be carried out.
name: A further cycle of 5 abdominal thrusts and 5 back blows
label: e
answer: no
explanation: This is not an appropriate choice, in the scenario of choking where the patient falls unconscious, CPR should be started.
name: Lay the patient in the recovery position
label: d
answer: no
explanation: As outlined by the BLS choking algorithm, once the patient is unconscious then CPR should be started rather than abdominal thrusts or back blows.
name: 5 further abdominal thrusts
label: c
answer: no
explanation: As per the BLS choking algorithm, if the patient falls unconscious then CPR should be started. Ideally, help should be sought early but if an ambulance had not already been called it should be now.
name: Call an ambulance and start CPR
label: a
answer: yes
explanation: As outlined by the BLS choking algorithm, once the patient is unconscious then CPR should be started rather than abdominal thrusts or back blows.
name: 5 back blows
label: b
answer: no

Correct answer: a


Learning point: In cases of suspected choking leading to unconsciousness, initiate CPR immediately and call for emergency medical assistance.
A 27-year-old female has a frequent severe headache, often worse on waking. She describes the pain as 9/10 and ‘pressure-like’ in nature. Since the headaches started 1 month ago, she has experienced dizziness and blurry vision. She denies any fevers, photophobia or neck stiffness. She is very concerned she has a brain tumour. She has a past medical history of type 2 diabetes, obesity and acne (for which she takes lymecycline).

She has a CT head which is reported as normal.

What is the most appropriate next step?

Options:
explanation: This is incorrect as the history is highly suggestive of idiopathic intracranial hypertension, the LP would help confirm the diagnosis whilst potentially also improving symptoms. The patient should be advised on weight loss, a low-sodium diet and stopping antibiotics. They may also be given acetazolamide.
name: Discharge with simple analgesia, no investigations required
label: b
answer: no
explanation: This patient had idiopathic intracranial hypertension; as classically described by signs of raised ICP (vomiting, blurry vision and severe headaches). She also has some significant risk factors for this condition (obesity and use of tetracycline antibiotics). As her CT head is normal, carrying out an LP to show raised opening pressure is the next most appropriate step.
name: Lumbar puncture
label: a
answer: yes
explanation: EEG is usually used in the diagnosis of epilepsy or other seizure disorders. The history here is suggestive of idiopathic intracranial hypertension (morning headaches and blurred vision) and the patient has significant risk factors for this condition (obesity and use of tetracycline antibiotics).
name: EEG
label: d
answer: no
explanation: Whilst meningitis is an important differential for severe headaches, the month-long history and absence of photophobia, neck stiffness and fevers make an infective cause much less likely.
name: Commence IV ceftriaxone
label: c
answer: no
explanation: This is usually used in the diagnosis of neuromuscular abnormalities such as MND, myasthenia gravis or myositis. The history here is suggestive of idiopathic intracranial hypertension (morning headaches and blurred vision) and the patient has significant risk factors for this condition (obesity and use of tetracycline antibiotics).
name: EMG
label: e
answer: no

Correct answer: a


Learning point: A lumbar puncture is performed in cases of idiopathic intracranial hypertension (IIH) to measure the opening pressure of the cerebrospinal fluid (CSF) and to analyze the fluid for abnormalities
A 6-year-old boy has difficulty breathing after eating cake at a friend’s birthday party.

On examination, his lips and tongue are swollen and he has a diffuse urticarial rash.

Which of the following medications should be given initially?

Options:
explanation: Resus council guidance now states IM adrenaline alone should be given initially in anaphylaxis. Steroids and antihistamines are no longer mentioned in the guidance. Antihistamines may help with an urticarial rash although this is often only given once the patient has been stabilised.
name: IM adrenaline and chlorphenamine
label: d
answer: no
explanation: PO adrenaline cannot be used in anaphylaxis as it is broken down and digested and does not have any systemic beneficial effects.
name: PO adrenaline alone
label: c
answer: no
explanation: Resus council guidance now states IM adrenaline alone should be given initially in anaphylaxis. Steroids and antihistamines are no longer mentioned in the guidance.
name: IM adrenaline alone
label: a
answer: yes
explanation: An IV adrenaline infusion is given in the treatment of refractory anaphylaxis (no response after 2 x IM adrenaline) and can only be initiated in a critical care setting.
name: IV adrenaline alone
label: b
answer: no
explanation: Resus council guidance now states IM adrenaline alone should be given initially in anaphylaxis. Steroids and antihistamines are no longer mentioned in the guidance. Antihistamines may help with an urticarial rash although this is often only given once the patient has been stabilised.
name: IM adrenaline and IV hydrocortisone
label: e
answer: no

Correct answer: a


Learning point: In cases of anaphylaxis, administer intramuscular adrenaline as the first-line treatment to rapidly counteract severe allergic reactions; steroids and antihistamines are not first-line treatments and should not replace adrenaline.
A 67-year-old man with poorly controlled diabetes attends the emergency department with fever and severe pain overlying his left first toe. A diabetic foot ulcer is noted on inspection with surrounding erythema.

What is the most appropriate imaging modality in this case?

Options:
explanation: This is a nuclear medicine scan primarily used to diagnose neuroendocrine tumours. Nuclear medicine scans have a role in diagnosing osteomyelitis and technetium and indium scintigraphy scans may be used in the workup of osteomyelitis.
name: PET-CT Ga-68 Dotatate scan
label: e
answer: no
explanation: This is less accurate in diagnosing osteomyelitis with reduced sensitivity and specificity compared to MRI.
name: Plain radiograph
label: b
answer: no
explanation: This has low overall sensitivity and specificity in diagnosing osteomyelitis but is superior in delineating the bony margins of the foot.
name: CT
label: c
answer: no
explanation: This is correct. This is suggestive of a diagnosis of osteomyelitis which is much more common in diabetic patients with non-healing foot ulcers. MRI is the most sensitive imaging modality to confirm osteomyelitis.
name: Magnetic resonance imaging
label: a
answer: yes
explanation: This has little role in the direct assessment of osteomyelitis, as it is unable to visualise within the bone.
name: Ultrasound
label: d
answer: no

Correct answer: a


Learning point: Osteomyelitis frequently complicates diabetic foot ulcers, and MRI is the most sensitive imaging modality for its diagnosis.
A 23-year-old man is brought in by ambulance following a road traffic accident during which he fractured both femurs. He undergoes surgical fixation and is admitted to the orthopaedic ward where two days later he becomes suddenly dyspneoic and hypoxic, profoundly confused with a widespread petechial rash.

What is the most likely diagnosis?

Options:
explanation: Osteomyelitis may present with severe systemic upset and it is possible the procedure introduced an infection, however, the absence of focal pain, fever, tachycardia and hypotension render septic shock secondary to osteomyelitis a less likely differential in this case.
name: Osteomyelitis
label: e
answer: no
explanation: This is an excellent differential in this case with acute onset breathlessness following surgery but the acute onset confusion and rash render this less likely. Some massive pulmonary emboli are associated with consumptive coagulopathy presenting as disseminated intravascular coagulation which could present as a diffuse petechial rash. The absence of bleeding and chest pain makes this less likely.
name: Pulmonary embolism
label: b
answer: no
explanation: This is unlikely in this young gentleman with the absence of any chest pain and would not commonly present with any of the symptoms described in the vignette.
name: ST Elevation Myocardial Infarction
label: d
answer: no
explanation: This is correct. This is suggestive of a diagnosis of fat embolism which may occur following trauma to the long bones and presents with a triad of hypoxia, confusion and petechial rash. It is treated with urgent thrombectomy.
name: Fat embolism
label: a
answer: yes
explanation: This may well have occurred in the road traffic accident but should have been picked up in the primary survey and would not explain the confusion or rash.
name: Traumatic pneumothorax
label: c
answer: no

Correct answer: a


Learning point: Fat embolism syndrome typically presents with hypoxia, confusion, and a petechial rash following long bone fractures.