hllj/quesmed huggingface dataset:
A 34-year-old woman presents to her GP with amenorrhoea. She had normal periods up until the last year but has had no periods for the last 4 months. Apart from feeling tired, which she attributes to travelling a lot for work, she reports no other symptoms. Her examination is normal. Her pregnancy test is negative. She has an elevated FSH and LH, a low oestradiol level and a normal prolactin and testosterone level. 

What is the most likely cause of her amenorrhoea?

Options:
explanation: Premature ovarian failure refers to loss of normal ovarian function before the age of 40. It is confirmed by oligo/amenorrhoea for at least 4 months and an elevated FSH on two occasions at least 4 weeks apart. In premature ovarian insufficiency, there is hypergonadotrophic hypogonadism since loss of negative feedback of ovarian hormones results in raised gonadotrophic hormones (whereas these would be low in functional hypothalamic amenorrhea).
name: Premature ovarian insufficiency
label: a
answer: yes
explanation: Prolactinoma can result in secondary amenorrhoea as the elevated prolactin levels inhibit the release of FSH and LH. These patients would have a low oestradiol, low FSH/LH and high prolactin levels.
name: Prolactinoma
label: e
answer: no
explanation: Functional hypothalamic amenorrhoea is a common cause of secondary amenorrhoea. Stress, anorexia or intense exercise result in reduced hypothalamic secretion of gonadotropin-releasing hormone, leading to reduced follicle-stimulating hormone (FSH) and luteinising hormone (LH) and subsequently oestrogen. This is also termed hypogonadotrophic hypogonadism. In this patient, the high FSH and LH levels go against this diagnosis.
name: Functional hypothalamic amenorrhoea
label: b
answer: no
explanation: In patients under 40 who undergo ovarian failure, this is deemed as premature ovarian insufficiency. However, in women over 40 with menopause symptoms and a low FSH, this is deemed menopause.
name: Menopause
label: c
answer: no
explanation: Polycystic ovarian syndrome (PCOS) can result in amenorrhoea and often presents with evidence of hyperandrogenism, such as hirsutism, acne or elevated testosterone. These patients tend to have a normal FSH but an elevated LH:FSH ratio and can have a normal, low or high oestradiol. The patient in this case has a high FSH and LH and no signs of hyperandrogenism on examination, which goes against the diagnosis of PCOS.
name: Polycystic ovarian syndrome
label: d
answer: no

Correct answer: a
An 87-year-old man presents with a 3 day history of palpitations. On examination, his heart rate is 110 bpm. The remainder of the examination is unremarkable. A venous blood gas confirms a potassium of 7.2 mmol/L (3.5 - 5.3 mmol/L) and an ECG shows sinus tachycardia with peaked T waves. He is given calcium gluconate and insulin-dextrose.
 
Which of his regular medications should be held?

Options:
explanation: Lactulose is an osmotic laxative. Excessive use of lactulose can cause electrolyte abnormalities, such as hypokalaemia, instead of hyperkalaemia.
name: Lactulose
label: e
answer: no
explanation: Omeprazole is a proton pump inhibitor, which can cause hyponatraemia and hypomagnesaemia but is not known to cause hyperkalaemia.
name: Omeprazole
label: b
answer: no
explanation: Furosemide is a loop diuretic which blocks the reabsorption of sodium, potassium and chloride. It can cause hypokalaemia instead of hyperkalaemia.
name: Furosemide
label: c
answer: no
explanation: Losartan is an angiotensin-receptor blocker used for the treatment of hypertension, diabetic nephropathy and heart failure. As it works on the renin-angiotensin-aldosterone system as a blocker, it can cause a reduced sodium and a raised potassium.
name: Losartan
label: a
answer: yes
explanation: Indapamide is a thiazide-like diuretic which can cause hypokalaemia instead of hyperkalaemia.
name: Indapamide
label: d
answer: no

Correct answer: a
A 32-year-old woman is brought to A&E by ambulance accompanied by her mother. She was discharged from hospital 3 d ago after a total thyroidectomy for papillary thyroid cancer. Today, her mother witnessed her having a tonic-clonic seizure, which terminated after a single dose of lorazepam provided by paramedics. There have been no further seizures. On examination, gentle tapping over the facial nerve produces spasm of her face ipsilaterally.

What is the first-line initial treatment for her diagnosis?

Options:
explanation: This patient likely has hypocalcaemia, secondary to parathyroid gland removal during total thyroidectomy. The sign elicited on examination is Chvostek sign, one of the two signs for hypocalcaemia, the other being Trousseau's. Trousseau's sign is carpopedal spasm when a blood pressure cuff is applied and inflated on the arm. The patient has also presented with a seizure, suggesting profound hypocalcaemia. An ECG would also be an important investigation due to these patients being at risk of prolonged QTc and subsequent torsades de pointes.
name: IV calcium gluconate
label: a
answer: yes
explanation: This patient is likely vitamin D-deficient due to parathyroid gland removal during total thyroidectomy surgery. Correcting the hypocalcaemia is the first port of call due to her having had a seizure. Vitamin D replacement is important for long-term management.
name: Oral high-dose vitamin D
label: c
answer: no
explanation: This patient has had a seizure, which has terminated with one dose of lorazepam. If she had another seizure then another dose may be given as part of the emergency management. However, given that there are no current seizures, treating the underlying cause to prevent further episodes is the best next step. Therefore, calcium gluconate is the best answer.
name: Lorazepam
label: e
answer: no
explanation: This patient has had a seizure, terminated by one dose of lorazepam. Phenytoin is given after multiple unsuccessful doses of lorazepam 10 min apart. The likely cause of the seizure is hypocalcaemia and therefore it is best to treat the underlying cause to prevent further seizures.
name: Phenytoin
label: d
answer: no
explanation: This would be the treatment of choice for mild hypocalcaemia. This patient likely has profound hypocalcaemia due parathyroid gland removal during total thyroidectomy surgery. This patient has had serious complication of hypocalcaemia, including a seizure, and therefore IV calcium gluconate is the most appropriate initial treatment.
name: Oral calcium carbonate
label: b
answer: no

Correct answer: a


Learning point: Hypocalcaemia can occur after total thyroidectomy, presenting with seizures and Chvostek's sign; immediate treatment includes intravenous calcium gluconate.
A 36-year-old female presents for her 12-week scan after a positive pregnancy test at 6 weeks. She has had one previous pregnancy, during which she had hypertension with no proteinuria. She has felt well so far throughout this pregnancy. On examination, her blood pressure is 121/74 mmHg. Urine dipstick is negative and her fasting blood glucose is 5.5mmol/L.

What is the next best step in management?

Options:
explanation: This patient had hypertension during a previous pregnancy which puts her at high risk of pre-eclampsia. For women at high risk of pre-eclampsia, NICE recommend that aspirin 75—150 mg daily is prescribed from 12 weeks' gestation until birth. Women are considered to be high risk of pre-eclampsia if they have at least one of the following risk factors: a history of hypertensive disease during a previous pregnancy, chronic kidney disease, autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome, type 1 or type 2 diabetes, or chronic hypertension.
name: Aspirin
label: a
answer: yes
explanation: Insulin therapy should be considered in patients with gestational diabetes, guided by a specialist. Gestational diabetes is diagnosed if the woman has either a fasting plasma glucose level of 5.6 mmol/L or above or a 2‑hour plasma glucose level of 7.8 mmol/litre or above. This patient has a normal fasting plasma glucose.
name: Insulin therapy
label: b
answer: no
explanation: This patient is at high risk of pre-eclampsia, therefore she should be started on aspirin.
name: No medication required
label: d
answer: no
explanation: Labetalol is used in the management of women with hypertensive disease in pregnancy. This patient has a normal blood pressure at this visit so does not require anti-hypertensive therapy at this time.
name: Labetalol
label: c
answer: no
explanation: Folic acid supplementation should be started pre-conception in women who are planning a pregnancy, or in women who are in the early stages of pregnancy and should be continued until 12 weeks gestation. This is to reduce the risk of neural tube defects. The woman here is already at 12 weeks gestation so folic acid supplementation is no longer required.
name: Folic acid
label: e
answer: no

Correct answer: a


Learning point: Aspirin may be indicated in pregnancy to reduce the risk of preeclampsia, particularly in women with high-risk factors such as a history of preeclampsia, chronic hypertension, or certain medical conditions like diabetes.
A 42-year-old woman presents to her GP with frequent leaking of small volumes of urine. This is worse when she drinks coffee, coughs or eats a large meal. She denies urinary urgency or any other urinary symptoms. She is a current smoker and on examination her body mass index is 30.

Apart from lifestyle advice, what is the next best step in management?

Options:
explanation: Duloxetine is a serotonin-noradrenaline reuptake inhibitor used to manage stress incontinence by increasing urethral tone. However, this is after lifestyle changes and pelvic floor exercises for at least 3 months.
name: Duloxetine
label: b
answer: no
explanation: This woman gives a typical history of stress incontinence. She passes small amounts of urine involuntarily when her abdominal pressure is increased, such as when coughing or after eating a large meal. She has risk factors for stress incontinence such as being female, overweight, smoking and drinking coffee. She would be advised to limit her alcohol and coffee intake and be offered help to lose weight and quit smoking. She would also be referred for pelvic floor exercises.
name: Pelvic floor exercises
label: a
answer: yes
explanation: This patient is yet to try lifestyle changes and pelvic floor exercises. Failure to respond to medical therapy may prompt surgical management.
name: Referral for mesh repair surgery
label: c
answer: no
explanation: This is a beta 3 agonist used for the management of urge (overactive bladder) incontinence. The history here is not consistent with urge incontinence.
name: Mirabegron
label: d
answer: no
explanation: This patient is yet to try lifestyle changes and pelvic floor exercises. Failure to respond to medical therapy may prompt surgical management. In this procedure, a bulking agent is injected into the bladder neck (usually under local anaesthetic) to improve its contraction and reducing urine leakage.
name: Intramural urethral bulking
label: e
answer: no

Correct answer: a


Learning point: Pelvic floor exercises are the first-line management for stress incontinence, particularly in women with risk factors like obesity and smoking.
A 14-year-old adolescent presents with a red-hot swollen knee joint after a chest infection last week. He has been unable to walk due to the pain in his knee despite analgesia. He has a background history of type 1 diabetes managed with an insulin pump. On examination there is erythema overlying the joint and pain whenever the joint is moved in any direction. His temperature is 38.3 °C.

What is the most important next step?

Options:
explanation: A knee X-ray is often requested to assess for other differentials, such as chondrocalcinosis/fractures, or to assess if there has been any joint damage secondary to infection. However, this does not represent the most important initial investigation since a diagnosis of septic arthritis needs to be ruled out using a joint aspirate sent for microscopy, culture and sensitivity.
name: Knee X-ray
label: c
answer: no
explanation: Gout or pseudogout can present with an acutely hot and painful joint. However, it is not typical for the paediatric age range. Moreover, given the presentation, septic arthritis is the most important diagnosis to exclude; thus, an aspirate for microscopy, culture and sensitivity is the best first test.
name: Joint aspiration and electron microscopy with polarised light
label: b
answer: no
explanation: The most important diagnosis to exclude is septic arthritis. This happens to be the most likely diagnosis in this case due to the fever, inability to bear weight and recent chest infection, which could have been the origin of the organism that has seeded haematologically to the joint. A joint aspirate should be done with cultures to isolate the organism. Empirical antibiotics should be commenced while awaiting the results.
name: Joint aspiration and microscopy, culture and sensitivities
label: a
answer: yes
explanation: This would be considered if a diagnosis of septic arthritis were confirmed. However, at this stage, the diagnosis is uncertain; thus, performing an aspirate in the first instance is the next best step.
name: Send to theatre for surgical washout
label: e
answer: no
explanation: A knee MRI would be a sensible investigation if there was a suspicion of an alternative diagnosis or if the joint aspiration were inconclusive. However, it would not represent an initial investigation.
name: Knee MRI
label: d
answer: no

Correct answer: a


Learning point: In cases of suspected septic arthritis, joint aspiration is crucial for diagnosis and guiding appropriate antibiotic therapy.
A 72-year-old female presents to her GP with leakage of urine. She says that urine leaks continuously throughout the day and is affecting her ability to leave the house since she frequently has to change her underwear. She does not report her symptoms worsening with alcohol, caffeine, straining or coughing. She does not report any urinary urgency or any other urinary symptoms. She underwent radiotherapy after resection of a rectal tumour 4 months ago. There has been no signs of recurrence from her most recent follow-up. She is otherwise well, has never smoked and has a body mass index of 25. She had one child via caesarian section 40 years ago.

What is the most likely diagnosis?

Options:
explanation: This patient has recently undergone radiotherapy to the pelvis for the treatment of a rectal tumour. This has likely caused a vesicovaginal fistula, which would mean a constant leakage of urine from the bladder through to the vagina. There are no clinical features suggestive or urge or stress incontinence, such as urgency or leakage on coughing respectively.
name: Vesicovaginal fistula
label: a
answer: yes
explanation: Chronic cystitis would more typically give a history of dysuria, pelvic pain, urinary urgency and frequency. This patient describes urinary leakage throughout the day with no mention of pain in the history. The most likely diagnosis is a vesicovaginal fistula given the painless continuous leakage of urine plus recent pelvic radiotherapy.
name: Chronic cystitis
label: e
answer: no
explanation: This patient denies any symptoms of urgency. The urine leakage is consistent throughout the day, which is most in keeping with a vesicovaginal fistula, especially in the context of recent radiotherapy to the pelvis.
name: Urge incontinence
label: b
answer: no
explanation: This patient denies any symptoms of leakage following raised abdominal pressure, for example, with coughing or sneezing. Urine leakage is consistent throughout the day, which is most in keeping with a vesicovaginal fistula, especially in the context of recent radiotherapy to the pelvis.
name: Stress incontinence
label: c
answer: no
explanation: A rectovaginal fistula would cause the passage of faeces through the vagina, with an increased risk of urinary tract infections. This patient describes a continuous urine leakage throughout the day, with recent pelvic radiotherapy, making a vesicovaginal fistula the most likely diagnosis.
name: Rectovaginal fistula
label: d
answer: no

Correct answer: a


Learning point: Vesicovaginal fistula can occur post-radiotherapy, leading to continuous urinary leakage without urgency or stress-related symptoms.
A 28-year-old woman was admitted to hospital overnight with severe left-sided loin-to-groin pain. A urine dipstick revealed blood, no nitrites or leukocytes. Due to claustrophobia, she declined a CT scan and she was subsequently diagnosed with kidney stones clinically and treated with analgesia. Today, she reports she no longer has any flank pain but has persistent pain in the left iliac fossa.

What is the next most important test to conduct?

Options:
explanation: A urinary tract infection may cause abdominal pain and may complicate kidney stones. However, this patient has seen some improvement in her pain without antibiotics and a urine dipstick yesterday was negative for leukocytes and nitrites. The persistent pain is in the left iliac fossa and so gynaecological causes should be excluded. Therefore, the next best step is a pregnancy test.
name: Urine microscopy, culture and sensitivity
label: e
answer: no
explanation: This may be a useful investigation to evaluate for any free fluid in the pelvis or ovarian cysts, without exposing her to the radiation of a CT scan. It is likely she will have this test further down the line if the pain persists but a pregnancy test is a quick, noninvasive, appropriate immediate next step to further guide diagnosis.
name: Pelvic ultrasound
label: b
answer: no
explanation: This patient is unlikely to tolerate a CT abdomen since she has already declined one because of claustrophobia. Furthermore, an ultrasound examination is usually preferred in young female patients in the first instance. Before any imaging, a pregnancy test will be a sensible next step to guide the diagnostic process.
name: CT abdomen
label: c
answer: no
explanation: Abdominal X-rays provide limited information in the context of acute abdominal pain. They can help diagnose bowel obstruction, mega-colon, chronic inflammatory bowel disease changes and radio-opaque kidney stones. She requires a pregnancy test in the first instance to guide the diagnostic process.
name: Abdominal X-ray
label: d
answer: no
explanation: Since this patient did not have a CT kidneys, ureters and bladder, a pregnancy test may have been missed by the assessing doctor, who may have otherwise been prompted to do one before exposing a woman of child-bearing age to radiation. In any woman of child-bearing age presenting with abdominal pain, a pregnancy test should always be done to rule out life-threatening causes of abdominal pain, such as ectopic pregnancy.
name: Pregnancy test
label: a
answer: yes

Correct answer: a


Learning point: Always perform a pregnancy test in women of child-bearing age presenting with abdominal pain to exclude life-threatening conditions like ectopic pregnancy.
A 28-year-old man presents to A&E after an overdose of paracetamol. He said he took 40 tablets over a 6-h period yesterday evening. It is now 11 a.m.

Which of the following tests provides the best prognostic indicator?

Options:
explanation: The liver produces albumin, the main component of the blood-maintaining oncotic pressure. When albumin levels drop, fluid moves from the intravascular space to the interstitial space, causing peripheral oedema and ascites. The half-life of albumin is 3 weeks; therefore, it is not a good measure of liver function in the acute setting.
name: Albumin
label: e
answer: no
explanation: This will be raised in hepatitis but it is not a measure of synthetic liver function or a good prognosticator for fulminant hepatic failure.
name: Aspartate transaminase
label: c
answer: no
explanation: This will be raised in hepatitis but it is not a measure of synthetic liver function or a good prognosticator for fulminant hepatic failure.
name: Alanine transaminase
label: b
answer: no
explanation: Liver injury typically causes prolongation of the prothrombin time and therefore the international normalised ratio. The activated partial thromboplastin time is usually spared.
name: Activated partial thromboplastin time
label: d
answer: no
explanation: The international normalised ratio is the best prognostic indicator for patients who have sustained hepatic injury due to paracetamol overdose. This is because it represents the synthetic function of the liver.
name: International normalised ratio
label: a
answer: yes

Correct answer: a


Learning point: In paracetamol overdose, an elevated International Normalised Ratio (INR) is an important prognostic indicator, as it signifies liver dysfunction and a higher risk of severe complications, including bleeding and potential liver failure
A 42-year-old man has some blood tests conducted by his hepatology team in the outpatient department. The results are shown below:

Hepatitis B surface antigen - negative
Anti-hepatitis B surface antibody - positive
IgM anti-HBc - negative
IgG anti-HBc - positive

Which of the following is the most likely explanation for these results?

Options:
explanation: This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. If this were an acute infection, we would expect positive IgM antibodies to the core antigen, as well as positive surface antigen due to the presence of virus particle production.
name: Acute infection with hepatitis B
label: c
answer: no
explanation: This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. Early acute infection would have a positive surface antigen present, without presence of antibodies. The first type of antibody to appear would then be IgM.
name: Early acute hepatitis B virus infection
label: e
answer: no
explanation: This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. This is in keeping with previous exposure to hepatitis B virus with recovery and the presence of current antibodies.
name: Previous exposure and recovery to hepatitis B
label: a
answer: yes
explanation: This patient has positive IgG antibodies to the core antigen of the hepatitis B virus and positive surface antigen antibodies. Previous vaccination would mean only antibodies for the surface antigen would be present since there is no core antigen present in the vaccine. This patient has antibodies to both, indicating previous infection with immunity.
name: Vaccination against hepatitis B
label: d
answer: no
explanation: This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. If the infection were chronic, we would expect a positive surface antigen to be present due to ongoing virus particle production. The surface antigen is currently negative, indicating recovery from the infection.
name: Chronic infection with hepatitis B
label: b
answer: no

Correct answer: a


Learning point: Positive IgG anti-HBc and positive anti-HBs indicate previous hepatitis B infection with subsequent recovery and immunity.