hllj/quesmed huggingface dataset:
A 75-year-old male presents to the Emergency Department with sudden vision loss in his right eye. His past medical history includes hypertension, and he is a smoker.

His right eye is painless, and there is no conjunctival redness. Fundoscopy reveals a red spot at the macula.

Which of the following tests are most appropriate in investigating the underlying cause?

Options:
explanation: HIV is one of the systemic causes of eye disease, including HIV retinopathy, cytomegalovirus (CMV) retinitis, herpes simplex virus (HSV) keratitis or retinitis and toxoplasmosis. CMV retinitis tends to be the most common HIV-related eye condition, causing loss of central vision, blind spots, floaters or flashing lights. Fundoscopy typically shows a "pizza pie" appearance due to haemorrhagic retinal necrosis
name: Human immunodeficiency virus (HIV) testing
label: e
answer: no
explanation: This may be done to investigate ankylosing spondylitis. This may cause anterior uveitis, which leads to acute-onset painful vision loss with photophobia, red eye and a constricted pupil. Slit lamp may reveal a hypopyon in the anterior chamber and white precipitates on the cornea. This is not the case here, as the visual loss is painless with no red eye
name: MRI lumbosacral spine, including sacroiliac joints
label: d
answer: no
explanation: The patient has sudden onset painless monocular vision loss with a fundoscopy finding suggestive of central retinal artery occlusion. This is usually due to thromboembolism, obstructing blood flow to the retinal artery. Workup for cardiovascular risk factors and a possible thromboembolic cause should be done, including investigations for stroke. The patient is hypertensive and a current smoker, both of which are contributing risk factors as well
name: Carotid doppler
label: a
answer: yes
explanation: This would be appropriate if suspecting acute anterior ischaemic optic neuropathy, which may occur due to giant cell arteritis (arteritic) or atherosclerosis (non-arteritic). Presenting symptoms include a sudden onset painless monocular vision loss with deterioration of colour vision, and fundoscopy reveals unilateral optic disc oedema with flame-shaped haemorrhages. In giant cell arteritis, erythrocyte sedimentation rate (ESR) would be raised, and temporal artery biopsy is the gold standard investigation
name: Temporal artery biopsy
label: b
answer: no
explanation: This may be done if suspecting multiple sclerosis, which is the top cause of optic neuritis. Patients usually have painless monocular vision loss over hours to days with colour desaturation. Fundoscopy may show a swollen, blurred optic disc. Lumbar puncture would demonstrate oligoclonal bands in the cerebrospinal fluid
name: Lumbar puncture
label: c
answer: no

Correct answer: a


Learning point: A carotid Doppler is an important diagnostic tool for evaluating sudden onset painless monocular vision loss, especially when fundoscopy findings suggest central retinal artery occlusion (CRAO). This test helps identify significant stenosis or emboli in the carotid artery, which can be a source of the arterial blockage leading to CRAO.
A 50-year-old woman presents to the Emergency Department with sudden onset severe pain in her right eye. Her past medical history includes severe asthma, sickle cell disease and depression. She only takes selegiline. She has nausea and vomited once on the way to the hospital. On inspection, she has right conjunctival redness, and her right pupil reacts poorly to light.

Which of the following medications should be started?

Options:
explanation: This is a beta-blocker that would be contraindicated in patients with asthma, COPD, heart block and severe heart failure, to name a few conditions. It may cause bronchoconstriction in a patient with asthma
name: Timolol
label: c
answer: no
explanation: This is a cycloplegic that dilates the pupil and is used in anterior uveitis to prevent the formation of posterior synechiae. It would worsen glaucoma as it exacerbates angle closure
name: Cyclopentolate
label: e
answer: no
explanation: This patient is presenting with acute angle closure. The immediate management of this includes pilocarpine eye drops, acetazolamide (contraindicated in this case), analgesia and an anti-emetic if needed.
name: Pilocarpine
label: a
answer: yes
explanation: This is an alpha agonist that reduces aqueous secretion and increases outflow through the trabecular meshwork. It is contraindicated in patients taking monoamine oxidase inhibitors (selegiline in this case) due to the risk of hypertensive crisis
name: Brimonidine
label: d
answer: no
explanation: This is a carbonic anhydrase inhibitor, which is contraindicated in those with sickle cell disease, as it may precipitate a vaso-occlusive crisis by exacerbating sickling of cells. In the absence of contraindications, IV acetazolamide may be given in acute glaucoma to lower intraocular pressure
name: Brinzolamide
label: b
answer: no

Correct answer: a


Learning point: Latanoprost is a prostaglandin analog used to treat glaucoma and ocular hypertension by increasing the outflow of aqueous humor, which lowers intraocular pressure (IOP).
A 30-year-old male presents to his GP with a two-month history of persistent right elbow pain. He describes a tingling sensation in the 4th and 5th fingers. On examination, the pain is aggravated by wrist flexion and pronation of the arm.

Which single nerve is involved?

Options:
explanation: If median nerve injury occurs more proximally at the elbow (most commonly due to a supracondylar fracture of the humerus), this may result in a hand of benediction (inability to flex the 2nd and 3rd fingers when making a fist) and paralysis of the flexors and pronators of the forearm. Sensation to the palmar aspect of the lateral 3.5 fingers may also be affected
name: Median nerve
label: c
answer: no
explanation: Isolated musculocutaneous nerve lesions are rare. This would result in weakness of elbow flexion and forearm supination, weak biceps tendon reflex and sensory loss over the lateral surface of the forearm
name: Musculocutaneous nerve
label: d
answer: no
explanation: This is most commonly damaged by direct trauma to the shoulder or proximal humerus, such as in fracture of the surgical neck of the humerus or shoulder dislocation. It would result in regimental badge numbness (over the inferior portion of the deltoid) and inability to abduct the affected shoulder due to deltoid and teres minor muscle weakness
name: Axillary nerve
label: e
answer: no
explanation: This is golfer's elbow, which results from medial epicondylitis. The ulnar nerve may be compressed as it passes through the ulnar groove, which lies posterior and lateral to the medial epicondyle, resulting in numbness and/or tingling in the 4th and 5th fingers
name: Ulnar nerve
label: a
answer: yes
explanation: This is most likely to be affected in tennis elbow, which results from lateral epicondylitis as the radial nerve travels anterior to the lateral epicondyle to enter the forearm. Pain is exacerbated in resisted wrist extension or supination. It may lead to radial nerve entrapment syndrome, causing wrist drop, loss of sensation to the anatomical snuff box and radial 3.5 digits on the dorsum of the hand
name: Radial nerve
label: b
answer: no

Correct answer: a


Learning point: Ulnar nerve compression can cause tingling in the 4th and 5th fingers, often associated with medial epicondylitis or golfer's elbow.
A 40-year-old motorcyclist is involved in a road collision accident and sustains a displaced tibial shaft fracture. He undergoes closed reduction, and his leg is immobilised in a long cast. A few hours after the procedure, he complains of severe pain in the affected limb that seems disproportionate to clinical findings.

Given the most likely complication that has occurred, which of the following is considered a late finding in his condition?

Options:
explanation: This is an early finding in compartment syndrome
name: Burning pain in the affected limb
label: d
answer: no
explanation: The patient has developed compartment syndrome due to significant trauma causing bleeding and raised intracompartmental pressure within the limb. Late findings may also include the absence of distal pulses, and hypoesthesia. The patient would require an urgent fasciotomy to relieve the pressure within the compartment. It is important to remember always to have a high index of suspicion for compartment syndrome as clinical signs may be varied, and consider urgent referral for any patient with a tense, painful muscle compartment
name: Paralysis of the affected limb
label: a
answer: yes
explanation: This is an early and common finding in compartment syndrome
name: Severe pain in the limb out of proportion to clinical findings
label: e
answer: no
explanation: This is an early finding in compartment syndrome
name: Pain on passive muscle stretch
label: b
answer: no
explanation: Tingling sensations in the limb are an early finding in compartment syndrome and would suggest ischaemic nerve dysfunction. Sensory deficits would typically precede motor deficits, i.e. weakness of the limb
name: Paraesthesia of the affected limb
label: c
answer: no

Correct answer: a


Learning point: Compartment syndrome can lead to paralysis of the affected limb if not promptly diagnosed and treated.
A 10-year-old boy presents to A&E with a 3-day history of nosebleeds and palpable, non-blanching red spots on his arms and legs. (refer to image provided).



  [lightgallery]



He has no past medical history of note. He has otherwise been well apart from a recent cold two weeks ago. His mother says that he has not had any recent trauma and does not play any contact sports.



Investigations are as follows:



Full blood count:

||||
|--------------|:-------:|---------------|
|Haemoglobin|140 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|9x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|55x10<sup>9</sup>/L|150 - 400|
|Reticulocytes|1 %|0.2 - 2|




Coagulation screen:


||||
|---------------|:-------:|------------------------|
|Activated Partial Thromboplastin Time (APTT)|30  seconds|22 - 41|
|Prothrombin Time (PT)|12  seconds|10 - 12|
|Fibrinogen|0.4 g/dL|1.5 - 4.0|





Peripheral blood film:



  - Normal sized platelets, no clumping seen



Direct antiglobulin test (DAT): Negative



Which is the most appropriate management of his condition?

Options:
explanation: This would only be considered in patients with life-threatening haemorrhage, persistent bleeding refractory to treatment or those requiring surgery. The patient is stable; hence this would not be required
name: Intravenous immunoglobulin
label: c
answer: no
explanation: Platelet transfusions are generally reserved for patients with active life-threatening haemorrhage, persistent bleeding refractory to treatment or those requiring surgery. The patient is stable, and hence this would not be required
name: Oral vitamin K
label: d
answer: no
explanation: Platelet transfusions are generally reserved for patients with active life-threatening haemorrhage, persistent bleeding refractory to treatment or those requiring surgery. The patient is stable, and hence this would not be required
name: Platelet transfusion
label: b
answer: no
explanation: Glucocorticoids may be given to raise the platelet count if it needs to be raised acutely. However, in the absence of any clinically significant bleeding, there is no need for this
name: Oral prednisolone
label: e
answer: no
explanation: The patient has immune thrombocytopenic purpura (ITP). Patients usually present with an isolated low platelet count with normal coagulation profile, peripheral blood film and reticulocyte count. The negative DAT rules out autoimmune haemolytic anaemia, which may occur in conjunction with ITP (Evans syndrome). The general approach in stable patients without clinically significant bleeding would be to wait and observe, with safety net advice given to avoid contact sports, blood-thinning medications and to monitor for signs of worsening bleeding
name: Wait and observe
label: a
answer: yes

Correct answer: a

Wait and observe

Learning point: In stable patients with immune thrombocytopenic purpura (ITP) without significant bleeding, the general approach is to observe and monitor, providing safety net advice to avoid contact sports, blood-thinning medications, and watch for signs of worsening bleeding.
A 10-year-old boy collapses in the Emergency Department after being administered a dose of amoxicillin for otitis media. He has no other past medical history of note.

He develops a sudden onset wheeze and shortness of breath.

Observations:

- Temperature 37.5°C
- pulse 150
- BP 80/60
- SpO<sub>2</sub> 88% room air

What is the next most important medication to administer?

Options:
explanation: This is the dose that should be given in anaphylaxis in adults or children >12 years old
name: IM Adrenaline (1:1000) 500 micrograms
label: b
answer: no
explanation: This may be considered in cases of anaphylaxis with severe or persistent bronchospasm. However, adrenaline takes priority in this situation
name: Salbutamol nebulisers
label: d
answer: no
explanation: This is the dose that should be given in a cardiac arrest as part of the paediatric advanced life support algorithm
name: IV Adrenaline (1:10,000) 10 micrograms per kg
label: c
answer: no
explanation: This may be given if the patient has hypotension due to anaphylactic shock. However, adrenaline takes priority in this situation
name: IV Hartmann's bolus 10ml/kg
label: e
answer: no
explanation: The patient has developed anaphylaxis, most likely to amoxicillin. Warning signs in this scenario include stridor, wheeze, hypotension and desaturation. The single most important medication to administer is adrenaline, which should be done as soon as possible. This is the dose that should be given in children 6-12 years old. IV adrenaline for anaphylaxis should only be given by experienced specialists in an appropriate setting
name: IM Adrenaline (1:1000) 300 micrograms
label: a
answer: yes

Correct answer: a


Learning point: In children aged 6-12 years old, the recommended dose of intramuscular (IM) adrenaline (1:1000) for anaphylaxis is 300 micrograms (0.3 mg). This dose can be repeated every 5-15 minutes if necessary, depending on the severity of the reaction and clinical response.
A 12-month-old girl is brought in by her worried parents to the children's Accident & Emergency department with a three-day history of persistent cough, hoarse voice and shortness of breath.

Observations:

- Temperature 38.5°C
- pulse 150
- BP 80/60
- respiratory rate 40
- SpO<sub>2</sub> 95% room air

A posterior-anterior chest X-ray is done and is shown below.

[lightgallery]

Given her most likely diagnosis, which single therapy has been shown to improve disease outcomes?

Options:
explanation: Nebulised adrenaline may be used in acute symptom relief of croup by reducing stridor and work of breathing, as it works by decreasing airway oedema and relieving airway obstruction. However, it would not alter the natural clinical course of croup
name: Nebulised adrenaline
label: b
answer: no
explanation: Salbutamol does not play a role in the management of croup. It would be useful as a bronchodilator in asthma
name: Salbutamol
label: e
answer: no
explanation: This may be used as supplemental therapy in hypoxaemic children, but would not alter the disease course
name: Oxygen
label: d
answer: no
explanation: Dexamethasone is the preferred glucocorticoid in the management of croup due to its longer half-life and anti-inflammatory effects. It works by reducing laryngeal mucosal oedema. It has been shown to reduce the overall severity of croup, length of hospital stay and the need for nebulised adrenaline
name: Dexamethasone
label: a
answer: yes
explanation: Antibiotics have no role in the routine management of uncomplicated croup, as most cases are caused by viruses. They should only be used to treat cases of bacterial superinfection, such as pneumonia or bacterial tracheitis
name: Antibiotics
label: c
answer: no

Correct answer: a


Learning point: Dexamethasone is the first-line treatment for croup, effectively reducing laryngeal inflammation.
A 7-year-old boy attends his General Practitioner for a routine asthma review. His regular inhalers include salbutamol and beclometasone 200 micrograms (mcg) daily. He was previously unable to tolerate a MART regimen. He has been compliant with his inhalers but has been using his salbutamol inhaler every other day for the past two months due to wheezing. He is an active boy at school and plays sports; however his symptoms limit his exercise tolerance. 

Which of the following is the next best management for his asthma?

Options:
explanation: In children whose asthma is not well controlled on salbutamol and a low dose inhaled corticosteroid and who cannot tolerate a MART regimen, it is recommended to start montelukast. 
name: Add on montelukast
label: d
answer: yes
explanation: The patient is currently on a low dose of inhaled corticosteroids (100-200mcg). It would be more appropriate to trial combined maintenance and reliever therapy first before moving on to an increased dose of steroids.
name: Increase beclometasone to 300mcg daily
label: c
answer: no
explanation: This boy has poorly controlled asthma on his current regime, as evidenced by his symptoms and need for reliever inhaler use more than three times a week. The next step would be to add montelukast as he has already not been able to tolerate a MART regimen.
name: Switch to maintenance and reliever therapy (MART)
label: a
answer: no
explanation: This would only be indicated in an acute asthma attack, which is not the case here.
name: Oral prednisolone
label: e
answer: no
explanation: In children whose asthma is not well controlled on salbutamol and a low dose inhaled corticosteroid, it is recommended to start montelukast. However, salbutamol should not be stopped as it is the mainstay of reliever therapy. Instead, salmeterol might be stopped if it does not appear to be working.
name: Stop salbutamol and start montelukast
label: b
answer: no

Correct answer: d


Learning point: In children aged 5-11 whose asthma is uncontrolled while on salbutamol and low-dose ICS, if they are unable to tolerate MART therapy, montelukast (LTRA) should be trialled.
A 50-year-old woman presents to her General Practitioner with a two-week history of intermittent tension headache. She describes having poor sleep and concentration for the past year and has had to leave her job as a result. She also has frequent episodes of palpitations accompanied by shortness of breath at rest.

Physical examination reveals no significant abnormalities. An electrocardiogram shows a normal sinus rhythm.

Which is the next best course of management?

Options:
explanation: The patient meets the diagnostic criteria for generalised anxiety disorder. CBT has been shown to be highly effective and should be trialled in all patients before moving on to pharmacotherapy. Other psychological interventions may include counselling, support groups and relaxation training
name: Refer for cognitive behavioural therapy (CBT)
label: a
answer: yes
explanation: This is a selective serotonin reuptake inhibitor (SSRI), the class of drugs that would be recommended as first-line in the pharmacological treatment of generalised anxiety disorder. However, before escalating to pharmacotherapy, it would be more appropriate to try psychological interventions first
name: Start paroxetine
label: c
answer: no
explanation: This would only be appropriate to use in an acute anxiety attack. It is not recommended for long term use in patients with anxiety as it may result in benzodiazepine dependence
name: A short course of lorazepam
label: b
answer: no
explanation: This would provide pain relief for her tension headache but would not be addressing the root cause of her problem, which is generalised anxiety disorder
name: Start paracetamol and ibuprofen as required
label: d
answer: no
explanation: This is a specialised form of cognitive behavioural therapy shown to be most effective in treating obsessive compulsive disorder. This would involve exposing patients to situations that provoke their obsessions whilst helping them overcome their compulsive responses. It would not be relevant in treating generalised anxiety disorder in this case
name: Refer for exposure and response prevention therapy
label: e
answer: no

Correct answer: a


Learning point: Cognitive behavioural therapy is an effective first-line treatment for generalised anxiety disorder, improving symptoms and functioning before considering medication.
An 80-year-old gentleman with a background of mixed dementia is admitted to the care of the elderly ward with a urinary tract infection. He has challenging behaviour on the ward, being aggressive to nursing staff and refusing to take his medications. Collateral history from his family reveals that he has also displayed such behaviour at home.

He is diagnosed as having behavioural and psychological symptoms of dementia and is started on quetiapine.

Which is the following potential side effects is he at increased risk of with this new medication?

Options:
explanation: Antipsychotics are more likely to cause postural hypotension, likely secondary to alpha-adrenergic blockade; hence they should be used with caution in the elderly who are at higher risk of falls
name: Hypertension
label: e
answer: no
explanation: Antipsychotics are associated with sedative effects and may help with insomnia
name: Insomnia
label: d
answer: no
explanation: Antipsychotics are associated with an increased risk of ischaemic stroke. In general, they should be initiated with caution in elderly patients due to their many side effects and increased risk of mortality
name: Stroke
label: a
answer: yes
explanation: Antipsychotics are associated with QT interval prolongation, which may lead to ventricular arrhythmias. A baseline electrocardiogram should always be obtained prior to initiation
name: QT interval shortening
label: b
answer: no
explanation: Antipsychotics are usually associated with hyperprolactinaemia. This is due to their dopamine antagonist effect, which blocks the inhibitory effects of dopamine on the pituitary, thereby increasing its secretion of prolactin. Clinical consequences of elevated prolactin levels include gynaecomastia and galactorrhoea
name: Hypoprolactinaemia
label: c
answer: no

Correct answer: a


Learning point: Antipsychotics like quetiapine can increase the risk of ischaemic stroke in elderly patients.