hllj/quesmed huggingface dataset:
A neonate is found to have a hearing impairment after being referred for an auditory brainstem response test. There is a desquamating rash on the feet and palms.

Which intervention would have prevented the vertical transmission of the infective agent causing these symptoms?

Options:
explanation: The MMR vaccine protects against measles, mumps, and rubella. Congenital rubella syndrome is a good differential as this can cause sensorineural deafness. However, there is no mention of the other features of CRS such as cataracts, a blueberry muffin rash, or heart defects (typically pulmonary stenosis).
name: MMR Vaccine
label: b
answer: no
explanation: Ganciclovir or aciclovir may be used in maternal HSV infection.
name: Ganciclovir
label: e
answer: no
explanation: This is used in the treatment of toxoplasmosis in pregnancy. Toxoplasmosis causes chorioretinitis, intracranial calcifications, and hydrocephalus. Treatment for toxoplasmosis in neonates includes sulfadiazine, pyrimethamine, and folate.
name: Spiramycin treatment
label: d
answer: no
explanation: The diagnosis is congenital syphilis, presenting with sensorineural deafness and a desquamating rash. Other features include Hutchinson's teeth, interstitial keratitis, and ostrochondritis visible on x-ray.
name: Benzathine benzylpenicillin
label: a
answer: yes
explanation: This is advice prevent neonatal listeriosis, as listeria can be present in raw (unpausturised) milk. The main presentations are neonatal sepsis and meningitis.
name: Avoidance of unpasturised dairy
label: c
answer: no

Correct answer: a


Learning point: Benzathine benzylpenicillin is the first-line treatment for congenital syphilis
A 31-year-old patient visits her GP as she is experiencing bilateral breast pain. Her mother had a mastectomy for breast cancer at the age of 58, and she is anxious that she may have breast cancer.

What is the most appropriate initial management step?

Options:
explanation: Mastalgia can be caused by hormonal changes, such as those experienced in pregnancy or menstruation. The initial step in management should be a pregnancy test to investigate this.
name: Urine beta-HCG
label: a
answer: yes
explanation: Mammography is less useful in younger women, as they have dense breast tissue. If imaging is required (e.g. due to a palpable mass on examination), ultrasound would be a better modality of imaging.
name: Mammography
label: c
answer: no
explanation: The COCP is not indicated in the management of cyclical mastalgia.
name: Combined oral contraceptive pill
label: e
answer: no
explanation: Danazol is used in mastalgia refractory to breast pain not responding to simple analgesia for at least 3 months. As this patient does not fit these criteria, danazol should not be prescribed.
name: Danazol
label: d
answer: no
explanation: This may be indicated if a lump is felt, or other investigations do not yield a cause of the pain.
name: Ultrasound breast
label: b
answer: no

Correct answer: a


Learning point: Mastalgia, which can be caused by hormonal changes like those in pregnancy or menstruation, should initially be evaluated with a pregnancy test.
A 30-year old woman has a massive pulmonary embolus requiring thrombolysis. She has a lace-like rash on her shins.

Which investigation is most likely to reveal the underlying diagnosis?

Options:
explanation: This may be ordered as part of a thrombophilia screen, however the history and examination findings are concerning for antiphospholipid syndrome, rather than hyperhomocystinaemia.
name: Homocysteine levels
label: c
answer: no
explanation: Serum triglyceride levels are unlikely to be helpful at this point.
name: Triglycerides
label: e
answer: no
explanation: This would be required if the patient suffered an ischaemic stroke. Patients with antiphospholipid syndrome are susceptible to both venous and arterial thrombosis.
name: Carotid doppler
label: b
answer: no
explanation: The history of an unprovoked pulmonary embolus, along with the finding of livedo reticularis (often described as a lace-like rash), is suspicious for a diagnosis of antiphospholipid syndrome. Lupus anticoagulant should be tested for as part of a screen for the syndrome, along with anti-cardiolipin antibodies and beta-2 glycoprotein antibodies.
name: Lupus anticoagulant
label: a
answer: yes
explanation: This may be ordered as part of a screen to investigate excessive bleeding, rather than a thrombophilia screen. It is not to be mistaken with the test for Factor V Leiden (an activated protein C test), which may be undertaken in this case.
name: Factor V activity
label: d
answer: no

Correct answer: a


Learning point: In antiphospholipid syndrome, lupus anticoagulant should be tested along with anti-cardiolipin antibodies and beta-2 glycoprotein antibodies as part of the diagnostic screening to identify the presence of antiphospholipid antibodies.
The parents of a 9-month old boy who has undergone cardiac surgery are concerned about his contact with his 1 year old cousin who has been admitted to hospital with a wheeze following a recent upper respiratory tract infection.

Which of the following is useful in preventing the child contracting this condition?

Options:
explanation: This is the agent used to confer passive immunity to respiratory syncytial virus, the pathogen causing bronchiolitis, which this patient's cousin likely has. It should be administered to children at risk of severe illness if infected with RSV, once a month, during RSV season.
name: Palivizumab
label: a
answer: yes
explanation: The MMR vaccine is used in children over a year old. It will not prevent bronchiolitis caused by RSV (the most common pathogen).
name: MMR vaccine
label: b
answer: no
explanation: This patient's cousin most likely has bronchiolitis caused by respiratory syncytial virus. The patient may have a flu vaccine given their medical history, but this would not prevent bronchiolitis.
name: Influenza vaccine
label: d
answer: no
explanation: This patient's cousin most likely has bronchiolitis caused by respiratory syncytial virus. The patient should have had multiple HiB vaccines as part of the routine schedule, but these would not prevent bronchiolitis.
name: Haemophilus influenzae vaccine
label: e
answer: no
explanation: Parainfluenza virus most commonly causes croup, characterised by upper airway obstruction. This patient's cousin most likely has bronchiolitis. A parainfluenza virus vaccine is not yet licenced.
name: Parainfluenza vaccine
label: c
answer: no

Correct answer: a


Learning point: Palivizumab is a monoclonal antibody given as an intramuscular injection to high-risk infants and young children, such as those with prematurity, congenital heart disease, or chronic lung disease, to prevent severe RSV infection during RSV season.
A  medication is being studied for the treatment of lung cancer. An ethics committee does not approve a randomised controlled trial of the medication, as they do not believe there is genuine uncertainty about whether the current standard of care is better or worse than this new medication.

What best describes the ethical concept the investigators are referring to?

Options:
explanation: This is when trial participants believe that everything that happens in a research trial is for their own benefit, rather than realising the goal is to produce data. While important to minimise, this is not the concept the question is referring to.
name: Therapeutic misconception
label: e
answer: no
explanation: This is the assumption that there is not one 'better' intervention present (for either the control or experimental group) during a trial. If there is no genuine uncertainty in whether one intervention is better/worse than another, then a trial should not be conducted.
name: Clinical equipoise
label: a
answer: yes
explanation: This is not an established ethical principle. The issue with this trial is that the ethics committee believe there is no genuine clinical equipoise. A non-inferiority trial is one that attempts to show that an intervention is not worse (but also not necessarily better) than another.
name: Non-inferiority
label: d
answer: no
explanation: This is not an established ethical principle. The issue with this trial is that the ethics committee believe there is no genuine clinical equipoise.
name: Proof of effect
label: b
answer: no
explanation: All trials require participants (or their proxies) to consent, in accordance with the Declaration of Helsinki. However, this is not the ethical principle that the committee are concerned about.
name: Informed consent
label: c
answer: no

Correct answer: a


Learning point: Clinical equipoise refers to a genuine uncertainty or balance of opinion within the medical community about the relative benefits and risks of two or more treatment options, which justifies conducting a clinical trial to determine which treatment is more effective.
A 54 year old woman attends her GP with an itchy nipple. On examination, she has a raised, scaly, red rash extending to the areola. There is no nipple inversion or discharge. Examination of both breasts is otherwise normal.

What is the most appropriate next step?

Options:
explanation: This would be an appropriate strategy to manage shingles. There is no suggestion of a rash present in a dermatomal distribution, or any vesicles. The unilateral nipple findings are concerning for Paget's disease of the nipple.
name: Oral aciclovir and steroids
label: d
answer: no
explanation: While the red, scaly rash may look eczematous, it is important to recognise that this is possibly Paget's disease of the nipple, associated with an underlying cancer. The patient requires triple assessment on a 2-week pathway.
name: Topical steroid ointment
label: b
answer: no
explanation: While the red, scaly rash may look like a fungal infection, it is important to recognise that this is possibly Paget's disease of the nipple, associated with an underlying cancer. The patient requires triple assessment on a 2-week pathway.
name: Topical miconazole cream
label: e
answer: no
explanation: While the red, scaly rash may look eczematous, it is important to recognise that this is possibly Paget's disease of the nipple, associated with an underlying cancer. The patient requires triple assessment on a 2-week pathway.
name: Topical emollient cream and follow-up in 2 weeks
label: c
answer: no
explanation: The patient's symptoms and examination findings suggest Paget's disease of the nipple, a condition that is frequently associated with ductal carcinoma of the breast. This should not be mistaken for eczema or an infection. NICE recommend a 2-week referral for women aged over 50 with unilateral nipple changes that are concerning. A triple assessment will involve imaging (likely a mammogram), examination, and biopsy.
name: Referral on 2-week-wait pathway for triple assessment
label: a
answer: yes

Correct answer: a


Learning point: Paget's disease of the nipple often indicates underlying breast cancer and requires a 2 week wait refferal
A 10-day-old baby is referred to the paediatric emergency department by her GP as her skin and sclerae look yellow. She was born at full term. There were no complications during pregnancy or birth. She is exclusively breastfed. Her parents report that she is feeding slightly less than normal and has a runny nose, but is wetting nappies as usual.


Blood results show:


 * Total bilirubin 120 micromoles/litre (refer to image of treatment graph)


Observations:


 * Heart rate 152 beats/minute (normal 140-160 beats/minute)


 * Blood pressure 63/42 mmHg (normal 50-70 / 25-45 mmHg)


 * Respiratory rate 72 breaths/minute (normal <60 breaths/minute)


 * Temperature 38.0 degrees Celcius


Jaundice treatment graphs:


 [lightgallery]


Which of the following is the most important next step?

Options:
explanation: Hypothyroidism can result in  an unconjugated hyperbilirubinaemia, however heel-prick testing would detect congenital hypothyroidism. Further TFTs may be undertaken, but this is not the most important next step given that the baby is febrile.
name: Thyroid function tests
label: e
answer: no
explanation: Neonatal jaundice can be precipitated by an infection. In this case, the baby is febrile, tachypnoeic, and has features of a respiratory infection. Their bilirubin level is under the treatment line for phototherapy or exchange transfusion. A full septic screen should be undertaken (including a lumbar puncture) to identify any infections that require treatment.
name: Perform a septic screen
label: a
answer: yes
explanation: A DIRECT (not indirect) DAT (Coomb's) test will be required in the work-up of this patient, however it is not the most important next step given that the baby is febrile. This will help to determine if there is a haemolytic component.
name: Perform an indirect antiglobulin (Coomb's) test
label: d
answer: no
explanation: IVIG is considered for babies undergoing phototherapy in cases of ABO or rhesus haemolytic disease, when bilirubin levels rise by more than 8.5 micromol/litre/hour. This is not the case.
name: Administer IV immunoglobulin
label: c
answer: no
explanation: At present, the baby's bilirubin level does not warrant phototherapy. This should be monitored in case it rises above the threshold.
name: Initiate phototherapy
label: b
answer: no

Correct answer: a


Learning point: In neonates with jaundice, a septic screen is crucial if there are signs of infection, such as fever or respiratory distress.
A 33-year-old woman is referred to gynaecology on the 2-week-wait cancer pathway after her GP felt a pelvic mass on bimanual examination, which was performed as she was experiencing severe menorrhagia and lower abdominal pain. A transvaginal ultrasound scan shows a fibroid measuring 4cm in the uterus. The patient states that she has been trying (unsuccessfuly) to conceive for 2 years and would like children.

What is the most appropriate management to suggest?

Options:
explanation: This is an option for patients for a short period of time, to induce a 'pseudo-menopause' and shrink the size of the fibroids. This is not appropriate in somebody who would like to become pregnant.
name: GnRH analogues
label: d
answer: no
explanation: There is some evidence that removing fibroids in cases of subfertility may increase the chance of pregnancy. Further, it is clear that the patient is suffering with symptoms from the fibroids. Intervention should be offered.
name: Myomectomy
label: a
answer: yes
explanation: This is likely to alleviate some of the symptoms, but perhaps not her menorrhagia. Further, this does not address the element of subfertility that may be caused by the fibroids.
name: Symptomatic relief with NSAIDs
label: b
answer: no
explanation: This is clearly contraindicated as pregnancy is desired.
name: Hysterectomy
label: e
answer: no
explanation: This is an option for patients who have no contraindications to hormonal contraceptives, and who do not want to become pregnant.
name: Hormonal contraceptives to control menorrhagia
label: c
answer: no

Correct answer: a


Learning point: Myomectomy is a surgical procedure to remove fibroids from the uterus, preserving the uterine structure and function, and is often recommended for women who wish to maintain fertility or experience significant symptoms such as heavy bleeding or pain.
A 23-year-old woman with a history of recurrent sexually transmitted infections visits a genitourinary medicine clinic with increasing vaginal discharge. She also has right upper quadrant pain and deep dyspareunia.

Observations are stable and a urine pregnancy test is negative. There is minimal tenderness to palpation of the abdomen.

High vaginal swabs and a urine NAAT for chlamydia, gonorrhoea, and mycoplasma are sent.

What is the most appropriate course of management?

Options:
explanation: The gold standard test for pelvic inflammatory disease is a diagnostic laparoscopy, however this may be considered if symptoms do not resolve with antibiotic treatment, or another differential is being considered.
name: Arrange a diagnostic laparoscopy
label: e
answer: no
explanation: This is clearly inappropriate; the likely diagnosis is pelvic inflammatory disease, which can progress to sepsis and lead to complications such as subfertility.
name: Administer analgesia and discharge
label: d
answer: no
explanation: Contact tracing is required, but this should encompass a period of six months according to NICE, not one.
name: Trace sexual partners in the last month and inform them to undergo STI screening
label: c
answer: no
explanation: The most likely diagnois is pelvic inflammatory disease (PID), as evidenced by dyspareunia, discharge, and right upper quadrant pain (Fitz-Hugh-Curtis syndrome). This should be treated empirically to limit the infection and reduce the risk of complications.
name: Await results of swabs and follow up in a week
label: b
answer: no
explanation: The most likely diagnois is pelvic inflammatory disease (PID), as evidenced by dyspareunia, discharge, and right upper quadrant pain (Fitz-Hugh-Curtis syndrome). There are currently no indications for hospital admission as observations are stable and there are no concerns for another intra-abdominal pathology such as an ectopic pregnancy or appendicitis. Once PID is suspected, it should be treated empirically with a combination of antibiotics.
name: Administer IM ceftriaxone, PO doxycycline, PO metronidazole for 14 days
label: a
answer: yes

Correct answer: a


Learning point: The treatment for pelvic inflammatory disease (PID) typically includes IM ceftriaxone for gonorrhea, PO doxycycline for chlamydia and other pathogens, and PO metronidazole for anaerobic coverage, usually over 14 days.
A patient admitted to the resuscitation room of the emergency department is being examined when the cardiac monitor alarms. The trace monitor shows new ventricular tachycardia (previously sinus rhythm). There is no pulse present.

What is the most appropriate action to take?

Options:
explanation: Amiodarone is not yet indicated. This may be administered after the third shock.
name: Administer amiodarone
label: c
answer: no
explanation: As cardiac arrest was witnessed and monitored with a defibrillator immediately available, up to 3 consecutive (stacked) shocks should be delivered.
name: Administer up to 3 (stacked) shocks
label: a
answer: yes
explanation: This will not be possible as the patient does not have a pulse. Vagal manoeuvres should be attempted in cases of supraventricular tachycardia with no adverse features. This patient is in pulselsess ventricular tachycardia.
name: Initially, attempt vagal manoeuvres
label: e
answer: no
explanation: There is no indication for adrenaline at present. This is administered immediately in cardiac arrest with a non-shockable rhythm, or after the 3rd shock (and then every 3-5 minutes) in a cardiac arrest with a shockable rhythm.
name: Administer adrenaline
label: b
answer: no
explanation: Adenosine is indicated in supraventricular tachycardia with no adverse features. This patient is in pulseless ventricular tachycardia.
name: Administer adenosine
label: d
answer: no

Correct answer: a


Learning point: In witnessed cardiac arrest with ventricular tachycardia and no pulse, resuscitation involves immediate administration of up to three stacked shocks.
A homeless man with no identification is conveyed to the emergency department by ambulance after suffering mutliple seizures. He has been given a dose of buccal midazolam and intravenous lorazepam with the ambulance service. He smells of alcohol and is intermittently twitching.

What is the most important next step?

Options:
explanation: This likely will be requested to detect any signs of a head injury given the lack of a history, however it is not the most important next step.
name: CT scan of the head
label: d
answer: no
explanation: This may be necessary as he is twitching which may represent seizure activity, but hypoglycaemia must be excluded first.
name: Start phenytoin infusion
label: c
answer: no
explanation: Seizures can be precipitated by hypoglycaemia, especially in patients at risk of malnutrition (such as this gentleman who is homeless and has a history of alcohol use). This should be done immediately.
name: Measure capillary blood glucose
label: a
answer: yes
explanation: The patient has had 2 doses of a benzodiazepine (1 of midazolam and 1 of lorazepam). If he continues seizing and hypoglycaemia is excluded, he will require second line treatment (levetiracetam, phenytoin, or valproate)
name: Administer another dose of lorazepam
label: b
answer: no
explanation: This may be necessary as he is twitching which may represent seizure activity, but hypoglycaemia must be excluded first.
name: Start levetiracetam infusion
label: e
answer: no

Correct answer: a


Learning point: Always measure capillary blood glucose in seizure patients, particularly those at risk of hypoglycaemia due to malnutrition or alcohol use.
A patient who has sustained a traumatic brain injury is intubated and ventilated on the intensive care unit, awaiting a neurosurgical opinion.

What is the most appropriate management?

Options:
explanation: There is little high quality evidence for therapeutic hypothermia, and some evidence of harm. Normothermia should be promoted.
name: Cool the head (therapeutic hypothermia)
label: e
answer: no
explanation: A higher blood pressure should be maintained to ensure the brain is adequately perfused.
name: Reduce systolic blood pressure to <100mmHg
label: d
answer: no
explanation: Patients with brain injuries should be deeply sedated to reduce metabolic demands and reduce distress, which helps lower intracranial pressure and thus the risk of brain herniation.
name: Use as little sedation as possible
label: b
answer: no
explanation: This is the correct answer. This position helps to reduce intracranial pressure, and thus the risk of brain herniation.
name: Position head up at 30 degrees
label: a
answer: yes
explanation: A lower PaCO2 is usually achieved through hyperventilation. A lower PaCO2 causes vasoconstriction in the cerebral arterioles, moderately reducing cerebral perfusion, and thus ICP.
name: Aim for a PaCO2 of 6 mmHg
label: c
answer: no

Correct answer: a


Learning point: Elevating the head to 30 degrees in traumatic brain injury patients reduces intracranial pressure and lowers the risk of brain herniation.