hllj/quesmed huggingface dataset:
A 45-year-old woman who is recovering from a recent wide local excision for an oestrogen receptor-positive breast cancer attends her outpatient follow-up appointment in the oncology department. She asks what the purpose is behind sending the breast tissue for histology.

What explanation should be offered to the patient?

Options:
explanation: Histology indicates which treatments would be effective for the cell types of breast cancer. Generally, positivity for the oestrogen receptor, progesterone receptor or HER2 allow specific therapies to be employed. However, the response to therapy is variable and other factors influence prognosis, most notably staging. The better and more direct answer is that histology helps guide treatment.
name: As a sole indicator of prognosis
label: b
answer: no
explanation: Histology is crucial for breast cancer management because cell type governs the chemotherapy or hormonal treatments offered. The main subtypes of clinical relevance include oestrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 (HER2) status. For this patient, her breast cancer is oestrogen receptor-positive, meaning it could be susceptible to an aromatase inhibitor, such as anastrozole, or a selective oestrogen receptor modulator, such as tamoxifen. The other factors that influence the choice of chemotherapy or hormonal therapy include age, comorbidities and cancer stage.
name: To guide drug treatment
label: a
answer: yes
explanation: For breast cancer, we know that the common sites of spread include the lungs, brain and bones. Histology, alongside other factors, may give us an idea of prognosis and the degree of aggression and therefore propensity to metastasise but it does not suggest where those sites will be.
name: Predicts likely sites of metastases
label: e
answer: no
explanation: Sentinel lymph nodes are identified intraoperatively using radioactive blue dye. The surgeon injects the dye under the nipple and identifies the sentinel lymph node using radioactive readings and colour change.
name: To help identify the sentinel lymph node
label: d
answer: no
explanation: Certain hereditary cancer syndromes, such as *BRCA1*/*BRCA2*, are associated with triple-negative breast cancers (negative for the oestrogen and progesterone receptors and the HER2 receptor). However, patients who do not possess these mutations can also be triple-negative; therefore, diagnosis of hereditary cancer syndromes cannot be made on histology alone.
name: To diagnose hereditary cancer syndromes
label: c
answer: no

Correct answer: a


Learning point: Histological analysis of breast cancer tissue determines the appropriate hormonal or chemotherapy treatment based on receptor status and cancer subtype.
A 34-year-old primigravida woman who is 35 weeks pregnant presents with itchy skin for 5 d to A&E. There has been no response to antihistamines or creams. The itching is particularly intense on her palms and soles and at night. Her pregnancy has been unremarkable so far and she has no prior health conditions. She reports that her mother had a similar problem during her pregnancies. On examination, she has extensive scratch marks to her arms and abdomen. The remainder of the examination is normal.

Which investigation is most specific for her underlying diagnosis?

Options:
explanation: This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. There is a raised bilirubin in only a quarter of cases and raised bilirubin lacks specificity for this pathology.
name: Serum bilirubin
label: e
answer: no
explanation: Uraemia can cause skin itching; however, this patient has no known risk factors for renal failure and no other signs consistent with it on history or examination, such as asterixis, confusion or pericarditis.
name: Serum urea
label: b
answer: no
explanation: This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. ALT/AST may be raised mildly in 60% of cases and they lack specificity for this pathology.
name: Serum ALT
label: c
answer: no
explanation: This patient likely has intrahepatic cholestasis of pregnancy, which presents typically with persistent itching (especially on the hands/feet and nocturnally) in the third trimester and can run in families. Alanine transaminase (ALT)/aspartate transaminase (AST) may be mildly elevated, as well as bilirubin, but total serum bile acid is the most specific test and will be markedly raised in around 80% of cases. There is an increased risk of foetal compromise and stillbirth with this condition; therefore, early delivery may be indicated.
name: Bile acids
label: a
answer: yes
explanation: This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. ALT/AST may be raised mildly in 60% of cases and they lack specificity for this pathology.
name: Serum AST
label: d
answer: no

Correct answer: a


Learning point: Intrahepatic cholestasis of pregnancy presents with intense itching, particularly on palms and soles, and is diagnosed by elevated serum bile acids.
A 30-year-old woman presents to her GP after a positive pregnancy test. She is happy about the pregnancy and wants antenatal advice and referral to the relevant secondary care services. She says the first day of her last menstrual period was the 25 August 2022. She has a regular 28-d cycle normally.

What is her estimated delivery date?

Options:
explanation: The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this.
name: 1 June 2023
label: a
answer: yes
explanation: The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this. The 1 May is 36 weeks of pregnancy.
name: 1 May 2023
label: c
answer: no
explanation: The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this. The 18 May is 38 weeks of pregnancy.
name: 18 May 2023
label: e
answer: no
explanation: The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this. The 25 May is incorrect since this does not include the 1 week added to reach the 40th week of pregnancy.
name: 25 May 2023
label: b
answer: no
explanation: The formula for the calculation of the estimated delivery date is: first day of last menstrual period + 1 year − 3 months + 7 d. To calculate this with some accuracy, the patient needs to have had a regular cycle before this. The 25 June is 3 weeks after the estimated delivery date.
name: 25 June 2023
label: d
answer: no

Correct answer: a


Learning point: The estimated delivery date can be calculated by adding one year, subtracting three months, and adding seven days to the first day of the last menstrual period.
A 62-year-old patient is 3 d post-open hysterectomy and recovering on the surgical ward. The operation was without complications and she is recovering well. The patient would like to know when she can return to work. Her job involves lifting heavy boxes and operating heavy machinery in a warehouse.

What is the advised recovery period for this patient before they return to work?

Options:
explanation: Six-to-eight weeks is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal. Returning to heavy lifting earlier than this risks wound dehiscence.
name: 1–2 weeks
label: c
answer: no
explanation: Six-to-eight weeks is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal.
name: 5–7 d
label: e
answer: no
explanation: Six-to-eight weeks is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal. Returning to heavy lifting earlier than this risks wound dehiscence.
name: 2–4 weeks
label: b
answer: no
explanation: Six-to-eight weeks is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal. Delaying return to work beyond this is not usually necessary. Furthermore, remaining stationary for prolonged periods, as may be the case if you are off work, increases the risk of certain postoperative complications, such as deep vein thrombosis.
name: 12–16 weeks
label: d
answer: no
explanation: This is the typical period of time needed for open abdominal wounds to heal fully. During this time, patients are advised to rest and not do any heavy lifting for the abdominal muscles and surrounding tissues to heal. Other complications of hysterectomy include temporary bowel, vaginal and bladder disturbances, such as constipation, urinary retention and vaginal bleeding. If the ovaries have been removed, they will experience severe menopausal symptoms, such as hot flushes and emotional disturbance.
name: 6–8 weeks
label: a
answer: yes

Correct answer: a


Learning point: Patients recovering from open hysterectomy should avoid heavy lifting for 6–8 weeks to ensure proper healing of abdominal wounds.
A 34-year-old woman undergoes a large loop excision of the transformation zone (LLETZ) for cervical intraepithelial neoplasia 2 cervical cancer. The procedure is completed successfully. The patient asks how long it will be before her next smear is due after the procedure.

When will her next smear be scheduled for?

Options:
explanation: National guidance states that follow-up post-LLETZ should be at 6 months. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt an HPV test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.
name: 12 months
label: d
answer: no
explanation: A follow-up smear is performed 6 months after a LLETZ procedure to determine if any further treatment is required, provided the histology sent from the LLETZ does not confirm a diagnosis of cancer. Of those women post-LLETZ procedure, typically 20% need further treatment. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt a human papillomavirus (HPV) test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.
name: 6 months
label: a
answer: yes
explanation: National guidance states that follow-up post-LLETZ should be at 6 months. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt an HPV test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.
name: 6 weeks
label: b
answer: no
explanation: National guidance states that follow-up post-LLETZ should be at 6 months. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt an HPV test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.
name: 3 months
label: e
answer: no
explanation: National guidance states that follow-up post-LLETZ should be at 6 months. At the 6-month repeat smear, normal/borderline/mild dyskariotic cells prompt an HPV test of cure, where high-risk HPV is looked for. If positive for high-risk HPV, or if there are moderate/severe dyskariotic cells, the patient is sent back to colposcopy. If the test of cure is negative, then they return to a 3-year recall.
name: 12 weeks
label: c
answer: no

Correct answer: a


Learning point: Following a LLETZ procedure for cervical intraepithelial neoplasia, a follow-up smear is scheduled for 6 months to assess further treatment needs.
A 27-year-old woman attends her GP with difficulty conceiving. She has been having frequent vaginal intercourse without contraception for 3 months with no subsequent pregnancy. She has never been pregnant before and has a regular 29-d cycle. She is not related to her partner and neither of them have any past medical history. They have never received investigation for infertility. On examination, her body mass index is 28.

How much longer should they keep trying to conceive before a referral is made to a local fertility service?

Options:
explanation: Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests. Neither party has any known risk factors for infertility at the moment, which could have otherwise prompted consideration for earlier referral.
name: 9 months
label: a
answer: yes
explanation: Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests. Neither party has any known risk factors for infertility at the moment, which could have otherwise prompted consideration for earlier referral.
name: 3 months
label: c
answer: no
explanation: Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests. Neither party has any known risk factors for infertility at the moment, which could have otherwise prompted consideration for earlier referral.
name: 6 months
label: e
answer: no
explanation: Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests.
name: 21 months
label: b
answer: no
explanation: Regular unprotected intercourse for 1 year, without a successful pregnancy, should lead to a referral for further investigations at a fertility service. There, they may undergo semen analysis and serum hormone levels may be taken, alongside other tests.
name: 12 months
label: d
answer: no

Correct answer: a


Learning point: Couples under 35 should seek fertility evaluation after one year of regular unprotected intercourse without conception.
A 30-year-old woman presents to secondary care for her second antenatal ultrasound scan. The scan shows two foetuses and the presence of the lambda sign.

Which of the following will be the advised delivery period?

Options:
explanation: This would be a very early delivery and would only be considered if there were concerns over foetal compromise and a careful discussion as part of a multidisciplinary team regarding the benefits and risks. There is no history suggesting this; therefore, the current recommendation for dichorionic diamniotic twins would be a delivery around 37  weeks.
name: 35–36 weeks
label: e
answer: no
explanation: The lambda sign on ultrasound indicates a dichorionic diamniotic twin pregnancy. They each have their own placenta and amnion. The [current guidance](https://www.nice.org.uk/guidance/ng137/resources/twin-and-triplet-pregnancy-pdf-66141724389829) recommends delivery around 37 for this type of twin pregnancy. Earlier delivery may be necessary depending on how the pregnancy progresses but this is not routinely performed.
name: 37 weeks
label: a
answer: yes
explanation: The lambda sign on ultrasound indicates a dichorionic diamniotic twin pregnancy. They each have their own placenta and amnion; 39–40 weeks would be preferred gestation period for a medically unremarkable singleton pregnancy.
name: 39–40 weeks
label: c
answer: no
explanation: As the gestation of a singleton passes 40 weeks, there can be concerns regarding the risk of foetal compromise and stillbirth; therefore, induction is discussed and offered. These risks would be higher in a twin pregnancy; therefore, induction would be offered even earlier.
name: 41 weeks
label: d
answer: no
explanation: The lambda sign on ultrasound indicates a dichorionic diamniotic twin pregnancy. They each have their own placenta and amnion. The current guidance recommends delivery at around 37 for this type of twin pregnancy. Earlier delivery may be necessary depending on how the pregnancy progresses but this is not routinely performed. Women with monochorionic diamniotic pregnancies are offered delivery at 36–36+6 weeks due to these pregnancies being at higher risk, such as of twin–twin transfusion syndrome.
name: 36 weeks
label: b
answer: no

Correct answer: a


Learning point: In dichorionic diamniotic twin pregnancies, delivery is typically advised around 37 weeks to optimise outcomes for both foetuses.
A primiparous 30-year-old woman is 39 + 6 weeks pregnant. She is in stage 2 of labour and has been pushing for 30 min. The midwife supports the foetus' head as it descends through the birth canal and becomes visible. At this moment, the cardiotocography shows a heart rate of 100 bpm for 1 min, before returning to a heart rate of 140–150 bpm.

What is the next best step in management?

Options:
explanation: Oxytocin has multiple obstetric uses, including as an induction agent, to accelerate stage 2 of labour and reduce the risk of postpartum haemorrhage. There is no current indication for requiring oxytocin at this stage. The patient's labour is progressing well and the baby has descended into the birth canal with the head now visible.
name: Oxytocin infusion
label: c
answer: no
explanation: Forceps delivery may be required where the labour is not progressing or delivery requires expediting. This is not required for this case. The patient's labour is progressing well and the baby has descended into the birth canal with the head now visible; transient bradycardia is not significant in this context.
name: Attempt forceps delivery
label: d
answer: no
explanation: The labour is progressing well with the head now in the birth canal and visible. The cardiotocography trace does not represent any significant pathology. Therefore, an emergency caesarian section is not required at this stage.
name: Emergency caesarian section
label: b
answer: no
explanation: Foetal bradycardia is defined as a heart rate of less than 110 bpm sustained for over 5–10 min. Upon pressure to the foetal head, mild, transient bradycardia is common due to a vagal response and will improve spontaneously after the pressure is relieved. The labour is otherwise progressing well with no other abnormalities described on the cardiotocography. The foetus has now descended into the birth canal with the head visible and so vaginal delivery can continue at present.
name: Continue with vaginal delivery
label: a
answer: yes
explanation: Ventouse delivery may be required where labour is not progressing or delivery requires expediting. This is not required for this case. The patient's labour is progressing well and the baby has descended into the birth canal with the head now visible; transient bradycardia is not significant in this context.
name: Attempt ventouse delivery
label: e
answer: no

Correct answer: a


Learning point: Transient foetal bradycardia during labour can occur due to vagal stimulation and typically resolves spontaneously, allowing for continued vaginal delivery.
A 22-year-old woman attends her GP for contraceptive advice. She is going abroad for 4 months and would like to have a reliable form of contraception, which will also prevent her having any periods or bleeding while away. She has known endometriosis with chronic menstrual pain and adhesions. She takes no regular medications and has never smoked. On examination, her body mass index is 20.

Which of the following is the most appropriate option for this patient?

Options:
explanation: This injection must be provided every 3 months; therefore, for contraceptive cover this would be impractical due to the patient going abroad for 4 months. Moreover, it does not necessarily stop periods in all patients, with some patients having spotting and irregular bleeding.
name: Intramuscular progesterone injection
label: e
answer: no
explanation: The progesterone-only pill could provide reliable contraceptive cover if taken daily and may also help with endometriosis. However, it does not protect against irregular bleeding or reliably stop periods and so it would not be the best choice in this patient.
name: Progesterone-only pill
label: b
answer: no
explanation: The combined oral contraceptive pill provides reliable contraceptive cover and can be taken back to back to prevent bleeding. It can also help with endometriosis-related pain. This patient has no contraindications for the combined oral contraceptive pill such as migraine with aura or smoking and so can be offered this.
name: Combined oral contraceptive pill
label: a
answer: yes
explanation: Intrauterine devices are copper-based systems that do not stop periods and can in fact make them heavier and more prolonged. They will not help with endometriosis-related pain although will offer good contraception. Therefore, it does not fulfil all of the patient's criteria.
name: Intrauterine device
label: c
answer: no
explanation: Intrauterine systems release local progestogens and help thin the lining of the uterus, reducing bleeding and providing effective contraception. They can help with endometriosis pain. However, they do not reliably stop periods or breakthrough bleeding; therefore, they are not a suitable option for the patient.
name: Intrauterine system
label: d
answer: no

Correct answer: a


Learning point: The combined oral contraceptive pill is effective for contraception and can alleviate endometriosis-related pain while suppressing menstrual bleeding.