hllj/quesmed huggingface dataset:
Case Presentation: A 70 year old man is on the acute admissions unit being treated for exacerbation of congestive cardiac failure and new atrial fibrillation. **PMH** CCF, recurrent DVTs. **DH** lisinopril 15mg PO OD, carvedilol 25mg PO BD, spironolactone 50mg PO OD, isosorbide mononitrate 30mg PO BD, warfarin sodium 3mg PO OD. NKDA


On the morning drug round at 0800 hrs, he has been given his usual medications as well as 375 micrograms of digoxin in accordance with the rapid digitalisation protocol.

**Investigations**

U&Es: Na 144, K 3.9, Cl 99, Ur 4.2, Cr 117 (baseline 103), eGFR 52mL/min/1.73m^2

Question: Select the most appropriate monitoring option to assess the need for dose adjustments of digoxin in this patient.

Options:
explanation: Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels at 1000 hrs
label: b
answer: no
explanation: Taking digoxin levels more than 6 hours after the initial dose may lead to inaccurate dose adjustments being made from a falsely low level
name: Blood levels immediately before next dose
label: d
answer: no
explanation: Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels immediately post-dose
label: e
answer: no
explanation: Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels at 1200 hrs
label: c
answer: no
explanation: This is the correct time to take a digoxin level, which is 6 hours after the last dose
name: Blood levels at 1400 hrs
label: a
answer: yes

Correct answer: a
Case Presentation: A 62 year old man is sent to the rapid access chest pain clinic by his GP following the reported results of a 24 hour ECG holter monitor. **PMH** myocardial infarction with 100% LAD occlusion, hypertension. **DH** aspirin 75mg PO OD, bisoprolol fumarate 2.5mg PO OD, ramipril 5mg PO OD. NKDA


**Investigations**

24 hour ECG holter monitor: infrequent runs of ventricular tachycardia lasting 30-40 seconds

The cardiology consultant recommends starting amiodarone hydrochloride 200mg PO TDS whilst awaiting implantation of an ICD.

Question: Select the most appropriate monitoring option required before initiating amiodarone hydrochloride.

Options:
explanation: Amiodarone is a potassium channel blocker and as such imbalances in potassium should be corrected prior to starting this drug, rather than sodium
name: Serum sodium
label: d
answer: no
explanation: An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited usefulness with respect to starting this drug
name: Troponin
label: e
answer: no
explanation: A potentially severe side effect of amiodarone use is pulmonary fibrosis. Existing lung damage should be ruled out prior to starting this drug
name: Chest X-ray
label: a
answer: yes
explanation: While blood dyscrasias have been reported with use of amiodarone, these are very rare and as such a full blood count would be useful as a baseline but is not routinely done
name: Full blood count
label: c
answer: no
explanation: Amiodarone is metabolised and excreted by the liver. Renal function would be useful as a baseline but not with respect to starting this drug
name: Creatinine clearance
label: b
answer: no

Correct answer: a
Case Presentation: A 37 year old woman is referred to the anticoagulation clinic following a hospital admission for a pulmonary embolus. **PMH** systemic lupus erythematosus, antiphospholipid syndrome. **DH** hydroxychloroquine sulfate 300mg PO OD. NKDA **SH** ex-smoker (5 pack years).


Her consultant decides that it is appropriate to pursue lifelong anticoagulation with warfarin sodium at a starting dose of 5mg PO OD.

Question: Select the most appropriate option to monitor for adverse effects of this treatment in the first few months.

Options:
explanation: Dyspepsia is not a known adverse effect associated with warfarin
name: Patient reports new dyspepsia
label: b
answer: no
explanation: Vitamin K assays are not routinely done in patients taking warfarin as levels will almost certainly be lower and as such this is of negligible clinical usefulness
name: Vitamin K levels
label: e
answer: no
explanation: The prothrombin time has no role in monitoring either the dosing or adverse effects of warfarin
name: Prothrombin time
label: d
answer: no
explanation: Warfarin has no effect on platelets and thus they have no role in monitoring either the dosing or adverse effects of warfarin
name: Platelet count
label: c
answer: no
explanation: When starting anticoagulation treatment it is important for patients to report any new bruising or bleeding as they may be receiving too high a dose
name: Patient reports easy bruising
label: a
answer: yes

Correct answer: a
A 31-year-old woman presents to the general practitioner as she has failed to become pregnant after 18 months of regular intercourse.

She has an irregular menstrual cycle, which varies between 35-60 days.

On examination, she is overweight and has a papulopustular folliculitis on her face, particularly on the chin.

Which single test would most likely to confirm the probable diagnosis?

Options:
explanation: Whilst PCOS is associated with impaired glucose tolerance and type 2 diabetes, a fasting serum blood glucose would not aid in diagnosing PCOS.
name: Fasting serum blood glucose
label: d
answer: no
explanation: This woman has features of polycystic ovary syndrome (PCOS). The Rotterdam criteria are used to diagnose PCOS and include (1) oligo- or anovulatory cycles; (2) clinical or biochemical hyperandrogenism and (3) a polycystic appearance of the ovaries on ultrasound. A diagnosis of PCOS can be made if two of the above three criteria are met and other causes of the person's symptoms have been excluded.

The long and irregular menstrual cycles are likely to be anovulatory cycles. The papulo-pustular rash on her face is likely due to shaving, an indication of troublesome hirsutism caused by hyperandrogenism.
name: Transvaginal ultrasound scan
label: a
answer: yes
explanation: A 24-hour urinary cortisol would be indicated for the exclusion of Cushing's syndrome, but would not confirm the likely diagnosis of PCOS. Cushing's syndrome results in an excess of glucocorticoids (cortisol). It can present with similar signs such as obesity, acne and hirsutism but is much less common than PCOS.
name: 24-hour urinary cortisol
label: e
answer: no
explanation: Serum follicle-stimulating hormone can be measured in conjunction with luteinising hormone (LH). In PCOS, the ratio of LH to FSH is increased (>2). Serum FSH can also help diagnose premature ovarian failure or menopause and is elevated in these conditions. FSH alone would not aid in the diagnosis of PCOS.
name: Serum follicle-stimulating hormone (FSH)
label: b
answer: no
explanation: Mid-luteal serum progesterone is used to confirm ovulation. Whilst this may be useful in the workup for primary infertility, the history of long cycles already suggests anovulatory cycles. A mid-luteal serum progesterone may confirm or refute ovulation, but does not aid in confirming the likely diagnosis of PCOS.
name: Mid-luteal serum progesterone
label: c
answer: no

Correct answer: a
A 58-year-old woman presents to her general practitioner with a six-month history of incontinence.

She feels she needs to pass urine more often and cannot make it to the toilet in time. She often feels a burning sensation when voiding.

Her observations are normal, and a urine dipstick is clear.

She has a past medical history of well-controlled hypertension, osteoporosis and hypothyroidism. She has had a previous hysterectomy for menorrhagia. She is not sexually active.

On examination, her abdomen is soft and non-tender. Her vulval skin is pale, and there is a narrowing of the introitus. A single-digit vaginal examination does not reveal any significant pelvic organ prolapse. On coughing, there is a minor leakage of urine.

What is the most appropriate management?

Options:
explanation: Pelvic muscle retraining is a first-line management strategy for uncomplicated stress urinary incontinence. Whilst this woman has an element of stress incontinence (urine leakage on coughing), she predominantly has symptoms of urge incontinence, likely caused by vulvovaginal atrophy.
name: Refer for pelvic muscle retraining
label: d
answer: no
explanation: This postmenopausal woman likely has urge incontinence due to atrophic vulvovaginitis/urethritis caused by oestrogen deficiency. Atrophic vulvovaginitis often results in urinary frequency, urge incontinence and dysuria. Vulval atrophy is evidenced by pallor, and vaginal atrophy is evidenced by the narrowed introitus and inability to insert more than one digit. The treatment of choice is topical oestrogen therapy for at least 14 days. Symptoms can be reassessed at this point.
name: Topical oestrogen therapy for at least 14 days
label: a
answer: yes
explanation: Post-void residual urine volume should be measured in people with unexplained urge incontinence to assess for incomplete bladder emptying. This woman has features of vulvovaginal atrophy, so it would be prudent to treat this and reassess. If her symptoms were not resolved with topical oestrogen, an ultrasound scan might be used next.
name: Bladder ultrasound scan for post-void residual urine volume
label: c
answer: no
explanation: An urgent spinal MRI would be indicated in a patient with recent-onset urinary incontinence accompanied by lower limb weakness, altered perineal sensation or back pain to exclude cauda equina syndrome. This woman does not have an acute onset of urinary incontinence and does not have any other features of cauda equina.
name: Urgent magnetic resonance imaging (MRI) of the spine
label: e
answer: no
explanation: Whilst this woman has features of urinary tract infection (frequency, dysuria and incontinence), her urine dipstick is clear. She also has no fever, and it is unlikely she has had a urinary tract infection for six months.
name: Urine culture and sensitivity
label: b
answer: no

Correct answer: a
A 66-year-old woman presents with sharp pain on defecation and occasional blood on toilet paper. She denies weight loss or changes in bowel habits.


She has a past medical history of type 2 diabetes which is well-controlled on metformin, hypertension and eczema.

On examination, her abdomen is soft and non-tender. Genital exam reveals smooth, dry vulva with porcelain-white shiny areas, particularly on the left. The labia minora and clitoris are not visible, and the labia majora are thickened with red patches. Linear lacerations are present at the posterior fourchette and external anal sphincter.


Digital vaginal examination is not possible. Digital rectal examination reveals no masses and soft stool in the rectum.


What is the most appropriate next step?

Options:
explanation: This woman has features of lichen sclerosus, an inflammatory skin condition that often affects the vulva. It appears as hypopigmentation of the vulval and perianal skin, characteristically appearing in a "figure of eight" distribution. In severe cases, thickening and scarring occurs, which can completely obliterate vulval structures such as the labia minora and clitoris. Fissures are common, particularly around the posterior fourchette (the thin, v-shaped tissue joining the labia minora inferiorly). Fissures can easily tear and cause discomfort and bleeding.
 

 Vulval biopsy should be performed to confirm the diagnosis of lichen sclerosus. Lichen sclerosus carries an increased risk of vulval intraepithelial neoplasia (VIN) and squamous cell carcinoma. In this case in particular, the distribution of the hypopigmentation is not well-demarcated or symmetrical, raising a concern of pre-cancerous or cancerous changes.
name: Vulval biopsy
label: a
answer: yes
explanation: A vulvovaginal swab for culture and sensitivity would be indicated if there was any symptoms or signs of infection such as a new vaginal discharge or pelvic pain.
name: Low vulvovaginal swab for culture and sensitivity
label: e
answer: no
explanation: Topical oestrogen therapy is used to treat vulvovaginal atrophy. Whilst vulvovaginal atrophy presents in a similar way to this woman, the "figure of eight" pattern, the "porcelain white" appearance and the presence of scarring is more indicative of lichen sclerosus than vulvovaginal atrophy. Atrophy typically presents with thinning of the vulval tissues and does not often cause fusion of vulval structures.
name: Topical oestrogen therapy
label: c
answer: no
explanation: Topical ultrapotent steroid cream is the first-line management for lichen sclerosus; however, a biopsy should be performed first to confirm. The patient should have been off steroid therapy for at least three weeks prior to performing a biopsy.
name: Topical vaginal moisturiser
label: d
answer: no
explanation: Topical ultrapotent steroid cream is the first-line management for lichen sclerosus; however, a biopsy should be performed first to confirm. The patient should have been off steroid therapy for at least three weeks prior to performing a biopsy.
name: Topical ultrapotent steroid cream
label: b
answer: no

Correct answer: a

Vulval biopsy
A 22-year-old woman attends her general practitioner seeking contraception. She is entering her final year at university and does not wish to become pregnant while studying. She has read a little about contraception and thinks she would like to take a combined oral contraceptive pill. She is currently using condoms every time she has intercourse.

She has a past medical history of asthma, atopic dermatitis and has recently recovered from a COVID-19 infection. She takes salbutamol as required. She does not appear overweight.

Her mother has type 2 diabetes and recently underwent a left mastectomy for a lobular breast cancer in situ. Her father recently died age 59 of bowel cancer.

Which of the following should be performed before prescribing the combined oral contraceptive pill?

Options:
explanation: BMI should be recorded and documented prior to initiating combined hormonal contraception in all women, even those who do not appear overweight. Women with a BMI ≥35 kg/m<sup>2</sup> generally should not use combined hormonal contraception.
name: Height and weight
label: a
answer: yes
explanation: Cervical screening starts at age 25 in the UK. Prior to age 25, cervical smears should not be performed.
name: Cervical smear test for primary screening for high-risk human papillomavirus infection
label: b
answer: no
explanation: As she has been using condoms reliably, there is no need to perform a pregnancy test prior to initiating combined hormonal contraception.
name: High-sensitivity urinary pregnancy test
label: e
answer: no
explanation: Routine checks for diabetes and impaired glucose tolerance are not required for initiation of combined hormonal contraception, even if there is a family history.
name: Check HbA1c level
label: c
answer: no
explanation: The use of combined hormonal contraception is acceptable for women with a family history of breast cancer, and genetic tests are not required.
name: Screening for BRCA1 and BRCA2 genes
label: d
answer: no

Correct answer: a
A 22-year-old woman attends her general practice troubled by acne and hirsutism. On examination, she has significant pustular facial acne and facial hair. She has trialled topical and oral antibiotics; however, she feels her acne has not improved.

She has been taking a combined oral contraceptive pill containing 30 micrograms ethinyloestradiol and 150 micrograms levonorgestrel for the past six months, which she started to regulate her menstrual cycle and alleviate menorrhagia. She feels her acne has worsened since starting this.

She asks if there is a different contraceptive that she can switch to, to improve her acne.

Which of the following contraceptive options is most likely to alleviate acne?

Options:
explanation: The progestogen-only subdermal implant contains etonogestrel, which, although is less androgenic than levonorgestrel, can also have the side effect of causing or worsening acne. In addition, a common side effect of the contraceptive implant is irregular bleeding, which may be unacceptable to this woman.
name: Progestogen-only subdermal implant
label: c
answer: no
explanation: There may be an increased risk of acne worsening with the levonorgestrel-releasing intrauterine system. In addition, the levonorgestrel-releasing intrauterine system is associated with irregular menstrual bleeding or spotting, which may be unacceptable for this woman.
name: Levonorgestrel-releasing intrauterine system
label: e
answer: no
explanation: Most women with acne find that their skin improves when they take the combined oral contraceptive pill, however different formulations have different effects. Co-cyprindiol (ethinylestradiol and cyproterone) has anti-androgenic properties, and is licenced for treating acne in women who have not responded to antibiotics. Levonorgestrel has androgenic properties and may worsen acne.
name: A combined oral contraceptive pill containing ethinyloestradiol and cyproterone acetate
label: a
answer: yes
explanation: Levonorgestrel has androgenic properties, so may make acne worse. In addition, progestogen-only pills can often result in irregular bleeding. The stem of the question states she started the combined oral contraceptive pill to regulate menstrual bleeding, so this side effect may be unacceptable.
name: A progestogen-only pill containing 30 micrograms levonorgestrel
label: b
answer: no
explanation: The copper intrauterine device will not have any effect on acne, as it does not contain any hormones. The copper intrauterine device is associated with increased menstrual blood flow, which may be an unacceptable side effect in a woman who had started the combined oral contraceptive pill for menorrhagia.
name: Copper intrauterine device
label: d
answer: no

Correct answer: a
An 18-year-old primigravida woman attends her general practitioner at 22 weeks gestation with a 1-day history of a headache. She describes the headache as a "tight band" around both sides of the head. There are no visual changes or other associated symptoms. She has not utilised any analgesia. She has no past medical history.

She appears well, and her observations are as follows:

- Heart rate: 66 beats per minute
- Blood pressure: 144/98 mmHg
- Respiratory rate: 18 breaths per minute
- Oxygen saturations: 100% on room air
- Temperature: 36.7°C

Urinalysis is normal.

What is the most likely diagnosis?

Options:
explanation: Gestational (or pregnancy-induced) hypertension is defined by two blood pressure readings of ≥140/90 mmHg on two occasions (at least 4 hours apart) after 20 weeks gestation in a previously normotensive patient. Gestational hypertension does not have associated proteinuria or other clinical features of pre-eclampsia.
name: Gestational hypertension
label: a
answer: yes
explanation: Pre-eclampsia is defined as new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement. Whilst headache can be a symptom of pre-eclampsia, the headache this woman is describing sounds more like a tension headache than the classic frontal headache seen in pre-eclampsia.
name: Pre-eclampsia
label: c
answer: no
explanation: Eclampsia is the presence of tonic-clonic seizures on a background of pre-eclampsia (new-onset, persistent hypertension with either proteinuria or evidence of systemic involvement).
name: Eclampsia
label: d
answer: no
explanation: HELLP syndrome is a subtype of severe pre-eclampsia characterised by haemolysis (H), elevated liver enzymes (EL), and low platelets (LP). It is much rarer than gestational hypertension, and there is no suggestion of any of these manifestations.
name: HELLP syndrome
label: e
answer: no
explanation: The patient is hypertensive but has no past medical history, which suggests the hypertension is new, indicating gestational hypertension rather than chronic hypertension.
name: Chronic hypertension
label: b
answer: no

Correct answer: a
A 16-year-old primiparous woman attends her general practitioner with a 2-week history of unusual vaginal discharge, which started the day after unprotected intercourse with her regular male partner. She describes the discharge as white and associated with vulval discomfort and itch. She is approximately 10 weeks pregnant.

On examination, the labia minora are coated with a white discharge, and a lumpy white discharge can be observed inside the vaginal vault on speculum examination. There is no noticeable odour.

Litmus paper, applied to the lateral vaginal wall, indicates a pH of around 4.0.

What is the most likely causative organism?

Options:
explanation: Whilst chlamydia trachomatis is the most common sexually transmitted infection; it typically does not present with a vulval itch. In most women, chlamydia infection is asymptomatic; however, it can cause an unusual vaginal discharge.
name: Chlamydia trachomatis
label: c
answer: no
explanation: Lactobacilli are part of the normal vaginal flora. Lack of lactobacilli results in bacterial vaginosis, which presents with a smelly discharge and increased vaginal pH.
name: Lactobacillus crispatus
label: e
answer: no
explanation: Trichomonas vaginalis (TV) causes trichomoniasis, which typically presents with a profuse frothy discharge, vaginitis and a raised pH.
name: Trichomonas vaginalis
label: b
answer: no
explanation: This woman is presenting with symptoms typical of vulvovaginal candidiasis (thrush). Checking pH can often help in the diagnosis; normal vaginal pH is between 3.8 and 4.5. Higher pH (i.e. >4.5 usually indicates conditions such as bacterial vaginosis or trichomoniasis). Vulvovaginal candidiasis can be triggered by intercourse, and is more common during pregnancy.
name: Candida albicans
label: a
answer: yes
explanation: Mycoplasma genitalium can also cause an unusual vaginal discharge and is sexually transmitted. However, it does not tend to cause an itch, so this is less likely to be the causative organism.
name: Mycoplasma genitalium
label: d
answer: no

Correct answer: a