hllj/quesmed huggingface dataset:
A 7-year-old boy is brought to the emergency department following a road traffic accident with a traumatic supracondylar fracture. The fracture is reduced and a cast is placed. A few hours later he appears anxious and in pain. Examination demonstrates pallor and paraesthesia.

Which of the following is most likely to be observed in this patient?

Options:
explanation: This would be expected in ulnar nerve injury. Supracondylar fractures tend to cause radial nerve injuries which may present with wrist drop and sensory deficits.
name: Ulnar claw on examination
label: d
answer: no
explanation: This would certainly be expected in cases of compartment syndrome in the lower limb, however, this child has sustained a supracondylar fracture, a common fracture in the upper limb in children therefore would not impact the lower limb.
name: Pain on passive flexion of toes
label: b
answer: no
explanation: This is more in keeping with a fat embolism following a long bone fracture in an orthopaedic context.
name: Petechial rash on examination
label: e
answer: no
explanation: This is correct. This is suggestive of a diagnosis of compartment syndrome in the arm. In children, anxiety associated with increasing analgesic requirements, often necessitating opioid medications, is a reliable indicator of compartment syndrome which most commonly occurs following trauma and presents with severe pain, pallor, paraesthesia and in severe cases paralysis.
name: Excessive use of breakthrough analgesia
label: a
answer: yes
explanation: This may well occur in the late stages of compartment syndrome in the lower limb but the injury here is in the upper limb.
name: Absence of dorsalis pedis pulse
label: c
answer: no

Correct answer: a


Learning point: Anxiety and increased analgesic requirements in a child after limb trauma may indicate compartment syndrome.
A 43-year-old diabetic woman attends the GP with a six-month history of left shoulder pain and stiffness with increasing difficulty in bathing and dressing on the left side, now requiring daily assistance. She denies trauma and works as a receptionist.

Which of the following is the most likely diagnosis?

Options:
explanation: This is incredibly unlikely in this chronic case of joint pain and stiffness with no systemic upset.
name: Septic arthritis
label: c
answer: no
explanation: This is correct. This is suggestive of a diagnosis of frozen shoulder with shoulder pain, stiffness and limitations in primarily external rotation in a middle-aged diabetic.
name: Adhesive capsulitis
label: a
answer: yes
explanation: This is an excellent differential producing pain and reduced range of motion over a similar timeframe to adhesive capsulitis. Rotator cuff injuries are more likely in occupations where the arm is likely to be overused e.g. carpenter. The key distinction is that patients with rotator cuff injuries can typically lift their arms by themselves whereas patients with frozen shoulders typically need assistance.
name: Supraspinatus tendinopathy
label: b
answer: no
explanation: An important differential to consider in chronic bone pain, however this typically occurs in younger patients and would not tend to cause such profound "freezing".
name: Osteosarcoma
label: e
answer: no
explanation: This would likely occur acutely and secondary to trauma and would present with intense pain and a visible deformity.
name: Anterior shoulder dislocation
label: d
answer: no

Correct answer: a


Learning point: Adhesive capsulitis, or frozen shoulder, commonly presents with pain and stiffness, particularly in diabetics, affecting daily activities such as dressing.
A 75-year-old woman attends the emergency department with severe pain in her right knee with fever, lethargy and nausea. On examination, the knee joint is warm and erythematous.

What is the most appropriate initial management?

Options:
explanation: This case is likely to require assessment by orthopaedics and will likely require surgical washout, but the initial priority is joint aspiration.
name: Surgical irrigation and debridement
label: c
answer: no
explanation: Septic arthritis is an orthopaedic emergency and can cause permanent and severe damage to joints. Oral antibiotics are not appropriate and intravenous ones are required.
name: Oral antibiotics
label: e
answer: no
explanation: This is a last resort and not indicated at present.
name: Above knee amputation
label: d
answer: no
explanation: This is correct. This is suggestive of a diagnosis of septic arthritis with an acute red hot swollen joint. The sample is sent for culture, microscopy, gram staining and sensitivities.
name: Joint aspirate
label: a
answer: yes
explanation: These will need to be initiated following joint aspirate.
name: Intravenous antibiotics
label: b
answer: no

Correct answer: a


Learning point: Septic arthritis presents with a warm, erythematous joint; joint aspiration is crucial for diagnosis and management.
A 24-year-old woman comes to the GP with a painful erythematous left breast. She is 2 weeks postpartum. Inspection shows erythema and a nipple fissure in the left breast.

What is the most appropriate management?

Options:
explanation: This is the typical advice given for causes of postpartum mastitis not requiring antibiotics such as those not complicated by a nipple fissure.
name: Encourage breastfeeding and expressing milk
label: d
answer: no
explanation: This is correct. Cases of mastitis with a nipple fissure require antibiotic presentation.
name: Prescribe flucloxacillin
label: a
answer: yes
explanation: This scenario is one of mastitis and does not warrant a two-week wait referral for suspected cancer at present. If the mastitis fails to improve with antibiotic treatment, breast cancer should be considered.
name: Urgent two-week wait referral to a breast specialist
label: c
answer: no
explanation: This may form part of the management of a breast abscess. There is currently no evidence of an abscess developing.
name: Urgent hospital admission for drainage
label: b
answer: no
explanation: This is not appropriate as this case warrants treatment.
name: Reassure
label: e
answer: no

Correct answer: a


Learning point: Mastitis in postpartum women, especially with nipple fissures, is commonly treated with flucloxacillin to address potential bacterial infection.
A 24-year-old woman comes to the GP worried about a breast lump. Examination reveals a smooth, round 1cm lump in the left breast which is mobile and painless.

What is the most appropriate management?

Options:
explanation: This may form part of the management of suspected breast cancer. The NICE guidelines recommend a two-week wait referral for suspected breast cancer for an unexplained breast lump in patients aged 30 or above.
name: Urgent 2-week wait referral to a breast specialist
label: b
answer: no
explanation: Some large fibroadenomas may be excised as per the patient's wishes.
name: Refer for excision
label: e
answer: no
explanation: This is correct. Fibroadenomas are common benign tumours of breast duct tissue. They are typically small and mobile within the breast tissue, and are not concerning. [NICE guidance](https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/) advises to **consider** non-urgent referral in people aged under 30 years with an unexplained breast lump with or without pain, though not all lumps will be referred
name: Reassure
label: a
answer: yes
explanation: This may be required in cases of mastitis which do not self-resolve or in which a nipple fissure is present.
name: Prescribe oral antibiotics
label: d
answer: no
explanation: This may form part of the management of a breast abscess in primary care.
name: Urgent same-day referral for incision and drainage
label: c
answer: no

Correct answer: a


Learning point: According to NICE guidelines, fibroadenomas should be assessed with clinical examination and imaging, and if they are asymptomatic and stable, routine monitoring is usually recommended, while biopsy or surgical removal may be considered for large, painful, or uncertain cases.
A 48-year-old woman attends the GP worried about a swelling in her left breast which started a week ago. Inspection reveals a swollen painful left breast with significant skin dimpling and erythema with overlying oedema and nipple inversion.

What is the most likely diagnosis?

Options:
explanation: This is correct. This scenario describes rapid breast changes with a "peau d'orange" appearance most in keeping with inflammatory breast cancer, a fast-growing, aggressive form of breast cancer.
name: Inflammatory breast cancer
label: a
answer: yes
explanation: These are benign breast lumps which are small, mobile and painless.
name: Fibroadenoma
label: d
answer: no
explanation: Inflammatory breast cancer is often misdiagnosed as mastitis, which more typically affects younger lactating women. The appearances in the vignette are more in keeping with breast cancer as opposed to mastitis. In equivocal cases, inflammatory breast cancer should be considered in cases of mastitis which do not respond to antibiotics.
name: Mastitis
label: b
answer: no
explanation: This is breast pain that is associated with the menstrual cycle due to hormonal variation and can cause lumpiness and breast swelling but this would follow a menstrual history and would not cause the profound appearance changes that are described.
name: Cyclical mastalgia
label: c
answer: no
explanation: These are benign tumours of fat (adipose) tissue which can occur in the breasts and tend to be painless, and mobile with no skin changes.
name: Lipoma
label: e
answer: no

Correct answer: a


Learning point: Inflammatory breast cancer presents with rapid swelling, skin dimpling, erythema, and oedema, often resembling "peau d'orange".
A researcher is attempting to design a study which investigates gestational risk factors for the development of DiGeorge syndrome, which has an incidence of 1 in 6000.

What is the most optimal study design in this case?

Options:
explanation: This is correct. Case-control studies are the most efficient design for rare diseases to investigate exposures as known cases of DiGeorge syndrome can be matched to controls and retrospectively investigated.
name: Case-Control study
label: a
answer: yes
explanation: Cohort studies are not efficient as they involve splitting people by exposures and following them up over time to assess whether a given outcome occurs. If a disease occurs very infrequently, you would have to follow a large group of people for a long period to accrue enough incident cases to study, which is both very time- and resource-intensive.
name: Cohort study
label: b
answer: no
explanation: This study design involves surveying people at a particular point in time to gather a range of opinions on a particular topic and would not be suitable for assessing temporal exposures.
name: Cross-sectional study
label: d
answer: no
explanation: This is an interventional study design which splits cases of interest into treatment and control groups and follows them over time to assess outcomes. This study design is not an observational study.
name: Randomised controlled trial
label: c
answer: no
explanation: Expert opinions may well prove valuable in guiding study design but are very low down the hierarchy of evidence and there may exist significant disagreement before the development of rigorous studies.
name: Expert witness interviewing
label: e
answer: no

Correct answer: a


Learning point: Case-control studies are ideal for investigating rare diseases like DiGeorge syndrome by comparing known cases with matched controls for exposure history.
A 54-year-old woman attends the GP with abdominal bloating, pelvic pain and urinary frequency. She reports these symptoms have been bothersome for the last two months. Examination reveals abdominal distension with shifting dullness, with no masses felt.

What is the most appropriate management?

Options:
explanation: NICE advises sending an urgent CA-125 and/or performing ultrasound in cases of new onset IBS, early satiety, abdominal bloating, pelvic pain and urinary frequency. In cases of ascites, an urgent two-week wait referral is the priority as the likelihood of cancer is increased.
name: Urgent CA-125
label: b
answer: no
explanation: This is correct. This scenario is suspicious for ovarian cancer with abdominal bloating and pelvic pain. The presence of ascites on initial examination circumvents the need for an initial CA-125 before referral (although it would likely be performed alongside the referral in practice).
name: Urgent 2-week wait gynaecology referral
label: a
answer: yes
explanation: This scenario is more suspicious for ovarian pathology than malignancy within the renal tract which is more likely to present with haematuria.
name: Urgent renal tract imaging
label: d
answer: no
explanation: This is very inappropriate as the patient has signs and symptoms which are concerning of possible metastatic ovarian malignancy and needs urgent investigation.
name: Reassure
label: e
answer: no
explanation: NICE advises sending an urgent CA-125 and/or performing ultrasound in cases of new onset IBS, early satiety, abdominal bloating, pelvic pain and urinary frequency. In cases of ascites, an urgent two-week wait referral is the priority as the likelihood of cancer is increased.
name: Urgent abdominal ultrasound
label: c
answer: no

Correct answer: a


Learning point: Abdominal bloating, pelvic pain, and ascites in women over 50 warrant urgent gynaecology referral due to potential ovarian cancer.
A 30-year-old primigravida woman goes into labour in the delivery suite. The delivery is difficult and the labour is prolonged. The head is delivered but, shortly thereafter, the anterior shoulder is stuck.

Which of the following is the baby at risk of developing?

Options:
explanation: This is a deformity of the hand due to thickening and fibrosis of the palmar aponeurosis and eventual contracture of the 4th and 5th digits. It is not associated with brachial plexus injury but is more commonly associated with alcoholism.
name: Duputyren's contracture
label: c
answer: no
explanation: This is characterised by the extension of the second and third fingers and the abduction of the first finger, typically resulting from a median nerve injury affecting finger flexion. Shoulder dystocia is most commonly associated with Erb's palsy.
name: Hand of benediction
label: d
answer: no
explanation: This is correct. The most common kind of brachial plexus injury in shoulder dystocia is Erb's Palsy, an upper brachial plexus injury affecting C5/6. Erb's palsy presents with a flexed and adducted wrist and, extended and internally rotated arm, due to loss of the lateral rotators of the shoulder, arm flexors, and hand extensor muscles.
name: Waiter's tip appearance
label: a
answer: yes
explanation: In partial ulnar claw, only certain fingers exhibit the characteristic claw-like deformity, typically the fourth and fifth fingers. This occurs due to weakness or paralysis of the intrinsic hand muscles supplied by the ulnar nerve, leading to the inability to extend these fingers fully.
name: Partial claw hand
label: b
answer: no
explanation: Wrist drop is a condition characterised by the inability to extend the wrist and fingers due to radial nerve palsy, resulting in a partially flexed wrist and difficulty with hand movements. Shoulder dystocia is most commonly associated with Erb's palsy.
name: Wrist drop
label: e
answer: no

Correct answer: a


Learning point: Erb's Palsy, a common complication of shoulder dystocia, results in a characteristic 'waiter's tip' arm position due to upper brachial plexus injury.
A 30-year-old woman attends the GP enquiring about postpartum contraception as she gave birth three weeks ago. She is breastfeeding and does not want any long-term contraceptive options. She was on the combined oral contraceptive pill before conceiving and tolerated it well and would like to restart it.

What is the most appropriate management?

Options:
explanation: The patient would like oral contraceptives which have higher success rates than barrier methods.
name: Advise barrier methods
label: e
answer: no
explanation: The patient does not want long-term options. IUC can be safely inserted immediately after birth (within 10 minutes of delivery of the placenta) or within the first 48 hours after uncomplicated caesarean section or vaginal birth as per the FSRH.
name: Offer intrauterine device insertion
label: d
answer: no
explanation: The Lactational Amenorrhea Method is suitable for fully or almost fully breastfeeding mothers who experience amenorrhea. It relies on exclusive breastfeeding to suppress ovulation. It can be highly effective but relies on factors such as strict adherence to breastfeeding alone. In this case, this patient has asked for contraception.
name: Advise no contraception is needed until 6 months due to breastfeeding
label: c
answer: no
explanation: As per the FSRH, the combined hormonal contraceptive pill should not be restarted until 6 weeks postpartum in breastfeeding women.
name: Offer the combined hormonal contraceptive pill
label: b
answer: no
explanation: This is correct. According to the FSRH, the progesterone-only pill can be started at any time after childbirth, including immediately after delivery. No contraception is required in the first three weeks after birth.
name: Offer the progesterone-only pill
label: a
answer: yes

Correct answer: a


Learning point: The progesterone-only pill is the recommended contraceptive method for breastfeeding women postpartum, as it can be initiated anytime after childbirth.
A 32-year-old G2P1 pregnant woman, at 39 weeks gestation, presents to the maternity assessment unit ward with sudden onset severe vaginal discomfort. On examination, the umbilical cord is palpable alongside the presenting part of the foetus. CTG reveals sudden onset foetal bradycardia.

What is the most appropriate management?

Options:
explanation: Cases of cord prolapse require emergency caesarean section due to the risk of foetal compromise.
name: Take to theatre for assisted delivery
label: b
answer: no
explanation: This is correct. This is a case of cord prolapse which has a high morbidity and mortality with potential foetal compromise. The presenting part should be elevated to relieve cord compression and an immediate C-section performed.
name: Emergency caesarean section
label: a
answer: yes
explanation: This is an option for induction of labour and is not appropriate here when urgent intervention is required.
name: Insert prostaglandin pessary
label: d
answer: no
explanation: This is incredibly inappropriate in this maternal and foetal emergency.
name: Reassure and discharge
label: e
answer: no
explanation: This is inappropriate. The CTG findings are extremely concerning and this is an obstetric emergency which needs to be acted upon promptly to minimise risk to the foetus.
name: Continue CTG monitoring and await events
label: c
answer: no

Correct answer: a


Learning point: Cord prolapse occurs when the umbilical cord slips ahead of or alongside the baby during delivery, which can compress the cord and reduce blood and oxygen supply to the baby, making an emergency C-section necessary to prevent complications.
A 45-year-old multigravida presents to the antenatal clinic worried about the risk of her child developing Down’s Syndrome. She would like a definitive test performed. She is 13 weeks pregnant.

Which of the following is the most appropriate investigation to order?

Options:
explanation: These are screening blood tests which can help inform whether invasive test is needed. AFP and PAPP-a are typically lower in Down's Syndrome pregnancies and serum HCG is typically higher.
name: AFP, PAPP-a and serum HCG
label: e
answer: no
explanation: This is a screening test which measures the thickness of a fluid-filled space at the back of the baby's neck during the first-trimester ultrasound. An increased translucency measurement may indicate a higher risk of certain chromosomal abnormalities, prompting further diagnostic testing such as chorionic villus sampling (CVS) or amniocentesis for confirmation.
name: Nuchal translucency scan
label: d
answer: no
explanation: Later in pregnancy, this may give evidence related to congenital heart defects related to Down's Syndrome, but would not be diagnostic in and of itself.
name: Echocardiogram
label: c
answer: no
explanation: This is correct. This an invasive test to definitively diagnose Down's Syndrome by taking a small sample of placental tissue (chorionic villi) from the uterus, usually through the cervix or the abdomen. It is performed between 11 and 14 weeks.
name: Chorionic villous sampling
label: a
answer: yes
explanation: This is an invasive test to definitively diagnose Down's Syndrome by inserting a thin needle through the abdomen into the uterus to withdraw a small amount of amniotic fluid surrounding the foetus, which is then analysed. It is performed after 15 weeks of gestation.
name: Amniocentesis
label: b
answer: no

Correct answer: a


Learning point: Chorionic villus sampling is an invasive procedure used for definitive prenatal diagnosis of Down's Syndrome between 11 and 14 weeks of gestation.
A 69-year-old woman with metastatic breast cancer is admitted to the oncology ward due to new bony metastases causing her an incredible degree of pain. She is commenced on co-codamol, ibuprofen and morphine sulfate (Continus) 30mg BD. She has used 6 breakthrough doses in the last 24 hours.

What is the most appropriate management of her pain relief?

Options:
explanation: Whilst bisphosphonates may well be used in the treatment of bone metastases, stopping the patient's pain relief is unnecessary and agonising for the patient
name: Stop all pain relief and start pamidronate
label: d
answer: no
explanation: The current regimen is not sufficient to control her pain as she has used 5 breakthrough doses in a day, it needs to be increased.
name: Continue with the same dose of morphine
label: e
answer: no
explanation: Whilst radiotherapy is a treatment option for bone metastases, this will likely require careful planning and may not occur immediately, stopping the patient's pain relief is unnecessary and agonising for the patient.
name: Stop all pain relief and refer for radiotherapy
label: c
answer: no
explanation: This may be overzealous at this stage as we are more than doubling her current pain relief and we must titrate up to find the optimal regimen for the patient. High doses of opioids can be associated with greater side effects profile including respiratory depression.
name: Increase morphine sulfate to 120mg BD with 40mg oramorph breakthrough dose
label: b
answer: no
explanation: This is correct. The patient's regular analgesia regimen is not strong enough. The patient has used 60mg + 6(10mg = 1/6th of her total 120mg for breakthrough dose)= 120mg in a day. Therefore her new regimen should include 120mg as regular pain relief with a breakthrough dose of 1/6th of 120=20mg of oramorph.
name: Increase morphine sulfate to 60mg BD with 20mg oramorph breakthrough dose
label: a
answer: yes

Correct answer: a


Learning point: Breakthrough analgesia should typically be dosed at 1/6th of the total daily dose of the patient’s regular pain medication to provide relief for episodes of severe pain between regular doses.