hllj/quesmed huggingface dataset:
Case Presentation:


A 38-week pregnant lady is admitted to the Emergency Department with generalized tonic-clonic seizure. Prior to the onset of the seizure, her husband mentioned she had been complaining of headache and abdominal pain. PMH Gestational diabetes. DH Metformin 1g BD PO. Weight 60kg


 **On Examination**
BP 205/100 mmHg (on admission) (<140/90mmHg), HR 92/min, RR 22
BP 92/50 mmHg (at 25 weeks)


 **Investigations**
Urine dipstick ++ protein

||||
|--------------|:-------:|---------------|
|Haemoglobin|110   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|8x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|80x10<sup>9</sup>/L|150 - 400|
|Bilirubin|1.5 µmol/L|< 17|
|Aspartate Aminotransferase (AST)|80IU/L|10 - 40|
|Alanine Aminotransferase (ALT)|140 IU/L|10 - 50|
|Creatinine|123 µmol/L|60 - 120|
|Creatinine|0.66 mmol/L|0.19 - 0.36|


Question:
Select the most appropriate decision option with regard to the treatment of her eclampsia based on these data.

Options:
explanation: Antiepileptics including phenytoin should not be given, likewise for tocolytics, as this woman is 38 weeks pregnant and delivery would help with her eclampsia
name: Atosiban 6.75mg IV over 1 minute
label: e
answer: no
explanation: Antiepileptics including phenytoin should not be given, likewise for tocolytics, as this woman is 38 weeks pregnant and delivery would help with her eclampsia
name: Two doses of Lorazepam 6mg IV followed by phenytoin 1.2g IV
label: c
answer: no
explanation: This patient has a history of headache, abdominal pain and presented with generalized tonic clonic seizure. In addition, her blood pressure at 25 weeks was normal but is currently significantly elevated. Her signs and symptoms in combination with her investigation results of haemolytic anaemia, elevated liver transaminases and lower platelet count is suggestive of eclampsia with HELLP syndrome. Magnesium sulphate should be given to treat eclampsia alongside antihypertensive medications such as labetalol
name: Magnesium sulphate IV 4g over 5-15minutes, labetalol hydrochloride 20mg/hour IV
label: a
answer: yes
explanation: Magnesium sulphate should be given to treat eclampsia alongside antihypertensive medications such as labetalol. Dexamethasone is not necessary as this woman is currently 38 weeks pregnant
name: Magnesium sulphate IV 4g over 5-15minutes, labetalol hydrochloride 20mg/hour IV,
dexamethasone 8mg IV
label: b
answer: no
explanation: Antiepileptics including phenytoin should not be given, likewise for tocolytics, as this woman is 38 weeks pregnant and delivery would help with her eclampsia
name: Terbutaline 5 micrograms/minute for 20 minutes
label: d
answer: no

Correct answer: a
Case Presentation: A 34-year-old gentleman is admitted to ED with generalised abdominal pain.




 **PMH** Nil


 **DH** Nil


 **Investigations**


Observations: HR 112 bpm, RR 21, blood pressure 84/44 mmHg, temperature 38.4, O2 saturations 93% on RA


Abdominal examination: tender to palpation in RUQ, bowel sounds present.


Bloods: CRP 211 mg/L (<5 mg/L), WCC 18.9 x 10<sup>9</sup>)L (3.6 – 11.0 x 10<sup>9</sup>)L)


Question: Select the most appropriate decision option based on this data

Options:
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. 45 minutes would take too long to give the fluid in this type of scenario.
name: A fluid bolus of 500ml should be prescribed and given over 45 minutes
label: e
answer: no
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. 30 minutes would take too long to give the fluid in this type of scenario. A 250ml bolus is also not enough, this would typically be used in patients with pre-existing heart failure.
name: A fluid bolus of 250ml should be prescribed and given over 30 minutes
label: d
answer: no
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. 30 minutes would take too long to give the fluid in this type of scenario.
name: A fluid bolus of 500ml should be prescribed and given over 30 minutes
label: c
answer: no
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes.
name: A fluid bolus of 500ml should be prescribed and given over <15 minutes
label: a
answer: yes
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. Giving a 250ml bolus is preferred if the patient has pre-existing heart failure.
name: A fluid bolus of 250ml should be prescribed and given over <15 minutes
label: b
answer: no

Correct answer: a
Case Presentation:  A 48-year-old woman is attends her GP due to an ongoing cough. She has had this cough for the last 2 days. It is productive of green sputum. She has also been experiencing feverish symptoms since her cough started.


**PMH** Addison's disease

**DH** Hydrocortisone 20mg PO BD, Fludrocortisone 50 micrograms PO OD

Question: Select the most appropriate decision option based on this data

Options:
explanation: This patient has Addison's disease and will be steroid dependent. Her corticosteroid and mineralocorticosteroid medications must not be stopped.
name: Stop both her hydrocortisone and fludrocortisone immediately
label: e
answer: no
explanation: This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.
name: Make no changes to her medications
label: d
answer: no
explanation: This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.
name: Increase her hydrocortisone to 40mg PO BD and increase her fludrocortisone dose to 100 micrograms PO OD
label: c
answer: no
explanation: This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.
name: Increase her hydrocortisone to 40mg PO BD, don't change her fludrocortisone dose
label: a
answer: yes
explanation: This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.
name: Increase her fludrocortisone dose to 100 micrograms PO OD, do not change her hydrocortisone dose
label: b
answer: no

Correct answer: a
Case Presentation:


A 93-year-old inpatient on the Senior Health ward is commenced on palliative care, and his analgesia regimen needs to be converted from oral to a syringe driver.

**PMH** Small cell lung cancer, Osteoarthritis, COPD.

**DH** Morphine sulfate M/R 40mg PO BD, Morphine sulfate 10 mg/5 mL solution (Oramorph) 5 mL PO PRN. Paracetamol 1g PO QDS, Ibuprofen 400mg PO TDS, Salmeterol 50 micrograms INH BD. He has taken 4 doses of her Oramorph in the last 24 hours.

Question:
Select the most appropriate decision option with regard to his pain management based on these data.

Options:
explanation: Although Diamorphine is sometimes used in syringe drivers, this is the incorrect dose equivalence. With 120mg Morphine sulfate taken orally in the past 24 hours, this would be equivalent to 40mg s/c Diamorphine.
name: Switch to subcutaneous infusion of 30mg Diamorphine hydrochloride over 24 hours
label: e
answer: no
explanation: This patient has taken (40x2) + (10x4) = 120mg Morphine sulfate PO in the last 24 hours. To convert PO morphine to SC morphine you simply have to divide the total 24 hour dose by 2.
name: Switch to subcutaneous infusion of 60mg Morphine sulfate over 24 hours
label: a
answer: yes
explanation: This would be correct if the total oral intake of Morphine sulfate over the last 24 hours was 180mg.
name: Switch to subcutaneous infusion of 90mg Morphine sulfate over 24 hours
label: b
answer: no
explanation: Although this is the correct conversion, syringe drivers typically run over 24 hours, rather than every 12 hours.
name: Switch to subcutaneous infusion of 30mg Morphine sulfate over 12 hours
label: c
answer: no
explanation: When converting from oral to subcutaneous you cannot simply use the same dosage as the bioavailability is different. This would result in a overdose of morphine to the patient.
name: Switch to subcutaneous infusion of 120mg Morphine sulfate over 24 hours
label: d
answer: no

Correct answer: a
A 74-year-old woman is referred to the 2-week-wait breast clinic after finding a lump in the upper outer quadrant of her left breast on self-examination.

She is not keen to have any operative interventions.

Triple assessment outcome:

* Clinical examination - P4 (suspicious of malignancy)

* Imaging (mammography) - M5 (malignant)

* Biopsy - B5 (malignant). Invasive ductal carcinoma.

Immunohistochemistry:

* Oestrogen receptor: strongly positive

* Progesterone receptor: mildly positive

* Human epidermal growth factor receptor 2 (HER2): not expressed

Which of the following is most likely to be a part of her management?

Options:
explanation: If the patient was pre-menopausal, tamoxifen would be an appropriate anti-oestrogen medication to use, given that the cancer is oestrogen receptor-positive. However, as the patient is post-menopausal, an aromatase inhibitor should be used in preference.
name: Tamoxifen
label: b
answer: no
explanation: A sentinel lymph node biopsy is a surgical procedure that often occurs at the time of a wide local excision or mastectomy, depending on the invasiveness of the cancer. In this case, the patient has expressed a wish to not undergo operative intervention, so this is not a suitable choice. Oral anti-oestrogen medications are likely to be offered.
name: Sentinel lymph node biopsy
label: e
answer: no
explanation: This could be an option, however, the patient has expressed she is not keen on surgical management. Anti-oestrogen therapy (letrozole/anastrozole) will likely be offered to slow tumour growth, as the tumour is oestrogen receptor-positive.
name: Wide local excision
label: d
answer: no
explanation: Trastuzumab (brand name Herceptin) is a HER-2-directed monoclonal antibody, which may be used by itself or with other chemotherapy. As this cancer is HER-2 negative, it is not an appropriate choice.
name: Trastuzumab
label: c
answer: no
explanation: This woman has an oestrogen receptor-positive breast carcinoma. Anti-oestrogen therapy is likely to be used in this case. As the patient is post-menopausal, an aromatase inhibitor (like anastrozole or letrozole) would be used instead of a selective oestrogen receptor modulator. This is because the majority of oestrogen production in post-menopausal females is due to the aromatisation of androgens in the fatty tissues, muscles, and skin.
name: Letrozole
label: a
answer: yes

Correct answer: a


Learning point: Letrozole, an aromatase inhibitor, is the preferred treatment for post-menopausal women with oestrogen receptor-positive invasive ductal carcinoma.
A 31-year-old woman is experiencing tenderness and pain in her right breast 10 weeks after giving birth. Her baby has been bottle-fed for the past few weeks. She has not experienced this issue before, is feeling unwell and is in significant pain. 

On examination, she has a warm, tender, wedge-shaped erythematous patch on the right breast, with no palpable masses and no visible discharge.

What is the single best course of management?

Options:
explanation: The question does not mention breastfeeding. The management of lactational mastitis is to encourage breastfeeding for 12-24 hours and review the need for antibiotics.
name: Encourage breastfeeding and review
label: b
answer: no
explanation: There are no signs of a breast abscess at present. The diagnosis is non-lactational mastitis, for which co-amoxiclav should be prescribed.
name: Incision and drainage
label: c
answer: no
explanation: Warm compresses may provide symptomatic relief, however, antibiotic treatment is required in all cases of non-lactational mastitis.
name: Warm compresses
label: d
answer: no
explanation: This patient has signs of non-lactational mastitis, which usually presents in a wedge-shaped distribution. NICE recommends all patients with this condition receive co-amoxiclav (or erythromycin/clarithromycin + metronidazole), with a review at 48 hours.
name: Oral co-amoxiclav
label: a
answer: yes
explanation: This is not appropriate; the patient is in pain and requires antibiotic treatment. The first choice antibiotic in non-lactational mastitis is co-amoxiclav.
name: Watch and wait
label: e
answer: no

Correct answer: a


Learning point: Non-lactational mastitis presents with a warm, tender, wedge-shaped erythematous patch and is typically treated with oral co-amoxiclav.
A 32-year-old man has a PET-CT scan after being referred to the haematology 2-week wait clinic. He initially visited his GP as he had been experiencing weight loss, night sweats, and fevers.

On examination, he has axillary lymphadenopathy, but no splenomegaly. No other lymph node groups are palpable. A diagnosis of lymphoma is made from a lymph node biopsy.

A PET-CT shows avidity in the para-aortic nodes, as well as the axilla.

Which of the following best describes the stage of the patient's lymphoma?

Options:
explanation: This is incorrect - stage IV lymphoma implies there is disease above and below the diaphragm, as well as organ involvement. The 'B' after the numerical stage is correct, however, as the patient is suffering from B symptoms.
name: Stage IV B
label: c
answer: no
explanation: This is the correct answer as the patient has two sites of disease on either side of the diaphragm (above - axillary and below - para-aortic nodes), as well as B symptoms (weight loss, night sweats, fevers).
name: Stage III B
label: a
answer: yes
explanation: This is incorrect - B symptoms (weight loss, night sweats, fevers) are present, so the letter following the numerical stage would be 'B', rather than 'A'.
name: Stage III A
label: b
answer: no
explanation: This is incorrect - stage I lymphoma implies there is disease in just one group of lymph nodes, or a single organ. Furthermore, B symptoms (weight loss, night sweats, fevers) are present, so the letter following the numerical stage would be 'B', rather than 'A'.
name: Stage I A
label: d
answer: no
explanation: This is incorrect - stage I lymphoma implies there is disease in just one group of lymph nodes, or a single organ. The 'B' after the numerical stage is correct, however, as the patient is suffering from B symptoms.
name: Stage I B
label: e
answer: no

Correct answer: a


Learning point: Stage III B lymphoma indicates extensive lymph node involvement on both sides of the diaphragm, with systemic B symptoms like fever, night sweats, and weight loss.
A patient is called by his GP with concerns about his blood test results. He has had routine investigations as he has been feeling very fatigued recently. He has a background of rheumatoid arthritis which he has just experienced a severe flare of.


On examination, he looks well and observations are within normal limits.


Blood test results:

||||
|--------------|:-------:|---------------|
|Haemoglobin|121 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|23.2x10<sup>9</sup>/L|3.0 - 10.0|
|Mean Cell Volume (MCV)|77.1 fL|80 - 96|
|Neutrophils|17.8x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|2.9x10<sup>9</sup>/L|1.5 - 4.0|
|Eosinophils|0.1x10<sup>9</sup>/L|0 - 0.4|
|Basophils|0.1x10<sup>9</sup>/L|0 - 0.1|
|C Reactive Protein|15.2 mg/L|< 5|

What is the most likely explanation for this abnormality?

Options:
explanation: A bacterial infection causing reactive neutrophilia is the second most likely diagnosis and should be excluded. His observations being within normal limits (e.g. him being afebrile) and being otherwise well suggests infection is less likely. He has likely received prednisolone for his RA flare, resulting in neutrophilia.
name: Infection
label: c
answer: no
explanation: This is unlikely given the clinical history. Leukaemias such as CML may result in a leukocytosis/neutrophilia, but there are no other cell lines affected, nor is there a compatible clinical history.
name: Leukaemia
label: b
answer: no
explanation: Methotrexate can cause bone marrow suppression and pancytopenia, rather than neutrophilia. It is more likely that this patient has received a course of prednisolone for his RA flare.
name: Methotrexate use
label: d
answer: no
explanation: Neutrophilia can be caused by infections (particularly bacterial), medications (steroids and lithium predominantly), inflammation, stress, and malignancies. In this case, the patient has likely received steroids for their flare of rheumatoid arthritis, resulting in neutrophilia.
name: Prednisolone
label: a
answer: yes
explanation: NSAIDs are not known to cause neutrophilia. It is more likely that this patient has received a course of prednisolone for his RA flare, causing neutrophilia.
name: NSAID use
label: e
answer: no

Correct answer: a


Learning point: Prednisolone can cause neutrophilia, often seen in patients with inflammatory conditions like rheumatoid arthritis.
A 68-year-old lady is admitted to hospital with severe bleeding after a tooth extraction. She has a history of diabetes, hypertension, and heart failure with a reduced ejection fraction (HFpEF). Investigations showed a haemoglobin concentration of 34 g/L (normal range 115-155 g/L), with fragments on the blood film. Her D-dimer was raised, and clotting was significantly deranged, in keeping with disseminated intravascular coagulation (DIC).


She receives 5 units of packed red cells and 3 pools of fresh frozen plasma (FFP) as part of the major haemorrhage protocol.


She becomes acutely breathless and hypoxaemic, with saturations of 84% on air. A chest x-ray shows:


 [lightgallery]


Which of the following is the most likely diagnosis?

Options:
explanation: 'Flash' pulmonary oedema can occur after an acute myocardial event or acute kidney injury. This is a possibility, however, the most likely diagnosis is TACO, caused by the infusion of large volumes of fluid in a patient with a background of heart failure.
name: Acute myocardial infarction causing flash pulmonary oedema
label: c
answer: no
explanation: Pulmonary oedema caused by circulatory overload is the most likely diagnosis. The x-ray shows 'bat wing' alveolar oedema and fluid in the right horizontal fissure. The patient has received a significant amount of fluid via blood transfusions; each unit of packed red cells contains around 300ml, and each pool of FFP contains 200-250ml. The patient's background of HFpEF puts them at risk of this condition.
name: Transfusion-associated circulatory overload (TACO)
label: a
answer: yes
explanation: Anaphylaxis can occur following blood transfusion, however, it would usually present with hypotension and airway compromise (i.e. a mention of stridor). It would not typically cause the appearance of pulmonary oedema on a chest x-ray.
name: Anaphylaxis
label: d
answer: no
explanation: Pulmonary haemorrhage is a rare (and often fatal) consequence of DIC. It is rare and may present with haemoptysis. The most likely diagnosis is TACO, caused by the infusion of large volumes of fluid in a patient with known HFpEF. Additionally, the infiltrates of diffuse pulmonary haemorrhage are usually described as 'fluffy', in contrast to the typical 'bat-wing' opacification seen in pulmonary oedema (and in this x-ray).
name: Pulmonary haemorrhage
label: e
answer: no
explanation: While TRALI is a differential, it is rare, and TACO is the most likely diagnosis given the patient's background of HFpEF. Patients with TRALI may become hypotensive and febrile, as the pulmonary oedema is caused by neutrophil activation causing leakage in capillaries. TRALI may be considered more likely if there is an inadequate response to diuresis with furosemide.
name: Transfusion-associated lung injury (TRALI)
label: b
answer: no

Correct answer: a


Learning point: Transfusion-associated circulatory overload (TACO) can occur in patients with heart failure after significant fluid administration, leading to pulmonary oedema.
An 89-year-old woman has been admitted to a hospice with malignant bowel obstruction as she is not suitable for operative management.

She is awake and alert, but reports being troubled by severe pain in her abdomen that comes and goes in waves. She says that when present, this pain reaches 9/10 in intensity.

Which of the following medications would be most helpful in managing the cause of her pain?

Options:
explanation: This patient is experiencing colicky pain due to peristalsis against the malignant obstruction. Opiates are very likely to be helpful in this situation, however, they will not treat the cause of the pain. Hyoscine is an antispasmodic and antimuscarinic, which will suppress peristalsis and help to relieve this colicky pain, and would therefore be the most useful medication. It can be added to a syringe driver if regular PRN doses are helpful.
name: Morphine
label: b
answer: no
explanation: This patient is experiencing colicky pain due to peristalsis against the malignant obstruction. Opiates are very likely to be helpful in this situation, however, they will not treat the cause of the pain. Further, codeine can only be taken orally and therefore is likely not suitable in this case. Hyoscine is an antispasmodic and antimuscarinic, which will suppress peristalsis and help to relieve this colicky pain, and would therefore be the most useful medication. It can be added to a syringe driver if regular PRN doses are helpful.
name: Codeine
label: d
answer: no
explanation: This patient is experiencing colicky pain due to peristalsis against the malignant obstruction. Opiates are very likely to be helpful in this situation, however, they will not treat the cause of the pain. Hyoscine is an antispasmodic and antimuscarinic, which will suppress peristalsis and help to relieve this colicky pain, and would therefore be the most useful medication. It can be added to a syringe driver if regular PRN doses are helpful.
name: Oxycodone
label: e
answer: no
explanation: This patient is experiencing colicky pain due to peristalsis against the malignant obstruction. Hyoscine is an antispasmodic and antimuscarinic, which will suppress peristalsis and help to relieve this colicky pain. It can be added to a syringe driver if regular PRN doses are helpful. Opiates may be helpful in addition, however, they will not treat the cause of the pain.
name: Hyoscine butylbromide
label: a
answer: yes
explanation: This patient is experiencing colicky pain due to peristalsis against the malignant obstruction. Opiates are very likely to be helpful in this situation, however, they will not treat the cause of the pain. Hyoscine is an antispasmodic and antimuscarinic, which will suppress peristalsis and help to relieve this colicky pain, and would therefore be the most useful medication. It can be added to a syringe driver if regular PRN doses are helpful.
name: Diamorphine
label: c
answer: no

Correct answer: a


Learning point: Hyoscine butylbromide is effective for managing colicky abdominal pain by suppressing peristalsis in cases of malignant bowel obstruction.