hllj/quesmed huggingface dataset:
A 12-month-old boy presents to the GP with his mother for his Measles, mumps, and rubella vaccination.

Which of the following class of immunoglobulins are made by the immune system initially?

Options:
explanation: IgM antibodies are made initially by the immune system after exposure to an antigen. The MMR vaccine is a live attenuated vaccine that will trigger the body's adaptive immune system to produce antibodies, with memory cells providing long lasting immunity.
name: IgM
label: a
answer: yes
explanation: IgG antibodies are produced in the latter stages of the adaptive immune response, and if the body is re-exposed to the antigen in the future.
name: IgG
label: b
answer: no
explanation: IgD antibodies do not form a significant part of the post-vaccine response. Their function remains unclear,  but they are present on immature B cells and make up part of the innate immune system.
name: IgD
label: d
answer: no
explanation: IgE antibodies are associated with atopy, parasitic infections, and allergic conditions. They do not form  significant part of the post-vaccine response.
name: IgE
label: e
answer: no
explanation: IgA antibodies are present in saliva, tears, and on mucosal surfaces to provide an immune 'shield', neutralising any pathogens before they have the opportunity to enter the body. They do not form a significant part of the post-vaccine response.
name: IgA
label: c
answer: no

Correct answer: a


Learning point: IgM antibodies are the first immunoglobulins produced by the immune system in response to an antigen.
A 71-year-old male presents to the GP for a follow-up appointment after conducting blood tests for fatigue. He says this has been going on for the past 8 months. He has a past medical history of warm autoimmune haemolytic anaemia. His blood tests reveal the following: 


||||
|--------------|:-------:|---------------|
|Haemoglobin|95 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|90x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|200x10<sup>9</sup>/L|150 - 400|
|Neutrophils|6.5x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|70x10<sup>9</sup>/L|1.5 - 4.0|

His thyroid function, vitamin B12, and folate levels are normal.


Which of the following investigations is most likely to confirm the underlying diagnosis?

Options:
explanation: This is incorrect because this is one of the investigations for hereditary spherocytosis, which presents in childhood with  jaundice, anaemia, and splenomegaly. There is typically a family history as the condition is inherited in an autosomal dominant pattern. It is a type of haemolytic anaemia, but this question stem ludes to warm autoimmune haemolytic anaemia caused by chronic lymphocytic leukaemia.
name: Osmotic fragility test
label: c
answer: no
explanation: Haptoglobin is a useful test when suspecting intravascular haemolysis. This patient has a past history of haemolytic anaemia but his haemaglobin at present is acceptable. There is no indication that he requires investigating for haemolysis at this stage.
name: Haptoglobin
label: d
answer: no
explanation: This is incorrect because bone marrow biopsies are rarely carried out as part of the initial work-up for CLL, since the diagnosis can be made on peripheral blood cytometry alone. It may be required further down the line, such as prior to initiating treatment, or to assess response to treatment.
name: Bone marrow biopsy
label: e
answer: no
explanation: This is incorrect because this is used to diagnose G6PD deficiency. This is an X-linked recessive disorder which usually presents with jaundice in neonates or during earlier years of life. It can be triggered by recent infections, fava beans, and medications such as primaquine, nitrafurantoin, and quinolones.  G6PD deficiency results in intravascular haemolysis, raised LDH, bilirubinuria, reticulocytosis, and bite cells/heinz bodies.
name: Glucose-6-Phosphate-Dehydrogenase enzyme assay
label: b
answer: no
explanation: Flow cytometry of peripheral blood is the first line investigation for chronic lymphocytic leukaemia, which this patient most likely has as indicated by the raised lymphocyte count and previous history of warm autoimmune haemolytic anaemia, which this patient has. CLL is often diagnosed incidentally since it remains asymptomatic for a prolonged period of time. Blood films show characteristic smudge/smear cells.
name: Flow cytometry of peripheral blood
label: a
answer: yes

Correct answer: a


Learning point: Chronic lymphocytic leukemia (CLL) is a type of cancer characterized by the accumulation of abnormal B cells, and flow cytometry of peripheral blood is a key diagnostic tool that identifies these cells based on their specific surface markers, confirming the presence of CLL.
A 68-year-old woman presents to the GP with a 3-day history of a cough productive of green phlegm, as well as exertional dyspnoea. She has no past medical history, takes no regular medications, and has no drug allergies. Her vital signs are: HR 89bpm, RR 14 breaths per minute, O2 saturation 99% on room air, BP 145/78mmHg. Her AMTS is 9/10. On examination, there are crepitations in the left lower zone of her chest.

Which of the following is the next best step in the management of this patient?

Options:
explanation: Doxycycline is used instead of amoxicillin for patients with a penicillin allergy, which this patient does not have, in the management of community acquired pneumonia. An alternative medication is oral clarithromycin which is also taken for 5 days.
name: Oral doxycycline
label: e
answer: no
explanation: This is incorrect because this woman's CRB65 score of 1 does not currently warrant hospital admission. If her CRB65 score were 2 or above, hospital admission would be considered as intravenous antibiotics would be needed.
name: Admit to hospital
label: d
answer: no
explanation: This is correct because this woman has a CRB65 score of 1. She scores 1 point for her age as she is above 65 years old. Note that the CRB65 scoring system is used in the GP setting for pneumonia because the urea is not immediately available. A 5-day course of oral amoxicillin 500mg three times daily (since she has no known allergies) is suitable for this patient as she has a CRB65 score of 1.
name: Oral amoxicillin
label: a
answer: yes
explanation: This is incorrect because steroids are not used in the routine management of community-acquired pneumonia, unless they are complicating an exacerbation of an obstructive airways disease. This patient has no wheeze or past medical history of obstructive airway pathology, and as such steroids will not be required in her management.
name: Oral prednisolone
label: c
answer: no
explanation: This is incorrect because this woman has a CRB65 score of 1 and there is clinical evidence of a community-acquired pneumonia on examination. NICE guidelines clearly state that an antibiotic must be offered for people with community-acquired pneumonia.
name: No treatment
label: b
answer: no

Correct answer: a


Learning point: In patients over 65 with pneumonia, a CRB65 score of 1 indicates the need for oral antibiotics like amoxicillin.
A 14-year-old boy presents to A&E with his dad complaining of abdominal pain. He describes it as crampy, which paracetamol has not relieved. Over the last 2 days, he is complaining of leg weakness, fever, and bloody diarrhoea. His dad is concerned that he may have ulcerative colitis. There is no travel history of note. They went to a barbecue 5 days ago where they ate chicken. On examination, the patient has a temperature of 39.8. A faecal sample is taken which shows a spiral shaped organism.

Which of the following organisms is the most likely cause?

Options:
explanation: Escherichia coli can present in a similar way to C. Jejuni with bloody diarrhoea, fever, and abdominal pain in the context of food poisoning. It is important to remember the 0157: H7 strain which can trigger haemolytic uraemic syndrome. However, E. Coli is a gram negative rod, as opposed to spiral/comma shaped.
name: Escherichia coli
label: c
answer: no
explanation: Bacillus cereus is a gram positive rod presenting with rapid onset, toxin mediated food poisoning (within hours.) It is classically associated with takeaways or reheating rice. It is not associated with bloody diarrhoea. The incubation period in this case, findings on stool culture, and bloody diarrhoea point against Bacillus cereus.
name: Bacillus cereus
label: e
answer: no
explanation: C. jejuni is a spiral or comma-shaped gram negative organism, which commonly presents with a flu-like prodrome, crampy abdominal pain, and bloody diarrhoea. It is a common cause of food poisoning and has a long incubation period of around 5 days. It is associated with Guillain Barre syndrome, which presents with ascending, bilateral weakness in the lower limbs; this child is complaining of lower limb weakness, so this should raise clinical suspicion of this complication.
name: Campylobacter jejuni
label: a
answer: yes
explanation: Salmonella enteritidis can present in a similar way to C. Jejuni with bloody diarrhoea, fever, and abdominal pain in the context of food poisoning. However, it presents earlier than C. jejuni as the incubation period is shorter (around 12-48 hours.) Furthermore, Salmonella is a gram-negative rod rather than a spiral-shaped/comma-shaped organism.
name: Salmonella enteritidis
label: b
answer: no
explanation: Entamoeba histolytica causes amoebic dysentery. It is associated with foreign travel and stool microscopy would show trophozoites.
name: Entamoeba histolytica
label: d
answer: no

Correct answer: a


Learning point: Campylobacter jejuni commonly causes food poisoning, presenting with crampy abdominal pain, bloody diarrhoea, and can lead to Guillain-Barré syndrome.
A 23-year-old male presents to A&E via ambulance following a road traffic accident. On examination, there is bruising around the eyes and bleeding behind his tympanic membrane. There are no lacerations on his scalp and his skull has a smooth contour. His Glasgow Coma Score is 11. A CT head is requested.

Which of the following is the most likely diagnosis?

Options:
explanation: An open skull fracture is when the fracture has led to skin breakage, resulting in bone protruding. This patient has no scalp lacerations and there is no evidence of a compound fracture, therefore.
name: Open skull fracture
label: b
answer: no
explanation: Diastatic skull fractures are fractures that occur along suture lines, resulting in widening. They are usually seen in newborns and infants as their skull bones take time to develop.
name: Diastatic skull fracture
label: e
answer: no
explanation: A linear skull fracture is when there is a fracture without any movement or distortion of the bone. Hence, the fracture just appears as a thin line/crack in the skull. These are less serious than basal skull fractures, require observation only and do not usually require any surgical management. They are not associated with the characteristic features as in this case of a basal skull fracture, and rarely develop any complications.
name: Linear skull fracture
label: c
answer: no
explanation: Fractures of the skull base can occur following head injury sustained during road traffic accidents. The commonest location of these fractures is the petrous part of the temporal bone. Classical features are haemotympanum (bleeding behind the tympanic membrane), periorbital ecchymoses (raccoon eyes), bruising of the mastoid (Battle's sign) and rhinorrhea (due to CSF leakage.) Most require observation only, but in some cases surgical correction may be required, such as in the case of persistent CSF risk. Complications are serious, including meningo-encephalitis and cavernous sinus thrombosis.
name: Basal skull fracture
label: a
answer: yes
explanation: A depressed skull fracture is when the bone sinks downwards towards the brain. These may require surgical intervention, especially if the underlying brain tissue is compressed. This patient is displaying classical features of a basal skull fracture, however, and so this is the most likely diagnosis at this stage. Furthermore, this patient's skull is reported as having a smooth contour, making any depressions unlikely.
name: Depressed skull fracture
label: d
answer: no

Correct answer: a
A 68-year-old male presents to A&E feeling generally unwell. He is unable to give a history as he is feeling light-headed. On examination, his abdomen is tender, and there is a pulsatile, expansile abdominal mass. Observations: HR 130bpm, RR 19 breaths per min, O2 saturations 98% on room air, BP 98/60mmHg, temperature 36.7. Blood tests show: 

||||
|--------------|:-------:|---------------|
|Haemoglobin|121 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|1.9x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|38x10<sup>9</sup>/L|150 - 400|

A CT scan is requested and he is prepared for immediate surgery.


Given the most likely diagnosis, which of the following will he require during his resuscitation?

Options:
explanation: Recombinant factor IX is used in the management of Haemophilia B, which is an X linked recessive disorder characterised by factor IX deficiency. Haeomophilia B is also known as Christmas disease.. Blood tests reveal a prolonged APTT.
name: Recombinant clotting factor IX
label: d
answer: no
explanation: This patient is presenting with a ruptured abdominal aortic aneurysm. He will need transfusing according to a major haemorrhage protocol, which involves providing platelets, fresh frozen plasma, and packed red cells in a 1:1:1 ratio. Once stabilised, he will be able to go to theatre for either endovascular or open abdominal aortic aneurysm repair.
name: Packed red cells, platelets and fresh frozen plasma (FFP)
label: a
answer: yes
explanation: Recombinant factor VIII is used in the management of Haemophilia A, which is an X linked recessive disorder characterised by factor VIII deficiency. Haemophilia A is the most common inherited bleeding disorder which presents with recurrent haemarthroses and bruising. Blood tests reveal a prolonged APTT.
name: Recombinant clotting factor VIII
label: c
answer: no
explanation: Cryoprecipitate, which contains high levels of von Willebrand Factor and fibrinogen, may be required during massive haemorrhage, but it is not routinely provided, unlike packed red cells, platelets, and FFP. The decision to provide cryoprecipitate depends on close monitoring of bloods during the resuscitation efforts, and is usually required when the fibrinogen levels are less than 1. Treatment of massive haemorrhage should utilise the expertise of a haematologist since coagulopathy and complications can be extreme.
name: Cryoprecipitate
label: b
answer: no
explanation: This patient is presenting with a ruptured abdominal aortic aneurysm. He will need transfusing according to a major haemorrhage protocol, which involves providing platelets, fresh frozen plasma, and packed red cells in a 1:1:1 ratio. It will be incorrect to transfuse him packed red cells only since this will not correct/worsen any coagulopathy sustained because of the massive haemorrhage.
name: Packed red cells only
label: e
answer: no

Correct answer: a


Learning point: A ruptured abdominal aortic aneurysm requires immediate resuscitation with packed red cells, platelets, and fresh frozen plasma in a 1:1:1 ratio.
A 32-year-old female presents to A&E following a seizure. She is post-ictal and unable to give a history. On examination, she has a low grade fever and has multiple purpura across her body. There is no evidence of meningism. Her blood tests show the following: 

||||
|--------------|:-------:|---------------|
|Haemoglobin|54 g/L|(M) 130 - 170, (F) 115 - 155|
|Platelets|22x10<sup>9</sup>/L|150 - 400|

Her creatinine is raised, but no baseline is available. A blood film reveals schistocytes. Her PT, APTT, fibrinogen, and d-dimers are within normal range.


What is is the definitive treatment for this presentation?

Options:
explanation: This patient has thrombotic thrombocytopenic purpura (TTP), presenting with the classic pentad of symptoms: acute kidney injury, neurological features, microangiopathic haemolytic anaemia, low platelets, and fever. It is usually an acquired disorder of ADAMTS13, where neutralising antibodies against this metalloprotease results in accummulation of high molecular weight multimeters of Von Willebrand Factor, which are highly active. ADAMTS13 usually cleaves these HMW multimers. This leads to excess platelet activation and clumping, leading to microangiopathic haemolytic anaemia. The clotting cascade is not activated, and so clotting factors are not consumed, resulting in a normal PT, APTT, fibrinogen, and d-dimers. Definitive treatment is plasma exchange to remove circulating antibodies.
name: Plasma exchange
label: a
answer: yes
explanation: Rituximab an anti-CD20 monoclonal antibody that depletes B cells, which produce antibodies that neutralise the ADAMTS13 protein. It may be considered in the management of TTP resistant to plasma exchange.
name: Rituximab
label: e
answer: no
explanation: This is a monoclonal antibody that inhibits Von Willebrand Factor, and may be considered in the management of TTP resistant to plasma exchange.
name: Caplacizumab
label: d
answer: no
explanation: Splenectomy may be considered in the management of TTP resistant to medical management.  The spleen is responsible for making antibodies which block the ADAMTS13 protein. Removing the spleen means that antibodies are no longer made against the ADAMTS13 protein.
name: Splenectomy
label: c
answer: no
explanation: Steroids may be considered in the management of TTP resistant to plasma exchange.
name: Steroids
label: b
answer: no

Correct answer: a


Learning point: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening blood disorder treated primarily with plasma exchange, which removes harmful substances and restores functional ADAMTS13
A 37-year-old female presents to the GP concerned about her recent diagnosis of liver cirrhosis secondary to chronic alcoholism. Her past medical history includes moderate depression and chronic fatigue syndrome. She is managing both conditions well. However, she does not have any support at home or at work and she lives alone. Her GP conducts a motivational interview and concludes that she is keen to quit alcohol but she is unsure about how to do this. Her GP measures her patient activation level as 3.

Which of the following is the next best step in the management of this patient?

Options:
explanation: Acamprosate is a medication prescribed to patients who have already successfully achieved abstinence, to prevent relapse through reducing cravings. This patient has not reached that stage yet.
name: Prescribe acamprosate
label: e
answer: no
explanation: This is correct because this patient is willing to quit alcohol and she needs further advice on how to do so. A GP can either refer patients to local drug and alcohol services or offer treatment at the practice. Patients who are not comfortable approaching the GP also have the option to self-refer to the local drug and alcohol service. Patient activation measures assess the knowledge, skills and confidence of patients to manage their health and has been consistently used as an outcome measure of health interventions. In this case, level 3 suggests that this patient is willing to take action, that she has good self-management skills, and feels that she is part of the healthcare team.
name: Referral to local community drug and alcohol services
label: a
answer: yes
explanation: Patients must first be assessed by community drug and alcohol services, who will try to aid abstinence in the community. If community support fails, referral may be made for intensive rehabilitation, and so this is not the next step.
name: Refer to intensive rehabilitation
label: c
answer: no
explanation: Chlordiazepoxide is a short acting benzodiazepine drug used to aid alcohol detoxification since it ameliorates the side-effects of alcohol withdrawal and protects against life threatening delirium tremens. Detoxification programmes using chlordiazepoxide need careful planning with the support of local drug and alcohol services and as such the patient needs to be referred to see them first before this is commenced. Detox is usually done as an inpatient, but community detoxification programmes are being increasingly undertaken.
name: Prescribe chlordiazepoxide
label: b
answer: no
explanation: This patient may require cognitive behavioural therapy if she has problems with her mental health in terms of mood and anxiety. However, this is not her current priority, and she seems to be managing her mental health well. Cognitive behavioural therapy referral at this stage will not directly assist her desire to overcome her addiction to alcohol, and as such does not represent the best next step.
name: Refer for cognitive behavioural therapy
label: d
answer: no

Correct answer: a


Learning point: Referral to community drug and alcohol services is essential for patients with liver cirrhosis seeking support to quit alcohol.
A 43-year-old male presents to A&E with muscle weakness and tingling. He says this has occurred intermittently for the past 2 months but he has never consulted a doctor about it. His vitals show a blood pressure of 160/95 mmHg. Blood tests show: 


||||
|---------------------------|:-------:|--------------------|
|Sodium|148 mmol/L|135 - 145|
|Potassium|2.0 mmol/L|3.5 - 5.3|
|Calcium|2.4 mmol/L|2.2 - 2.6|


Which of the following is the most likely diagnosis?

Options:
explanation: Diabetes insipidus presents with polyuria and polydipsia. The patients are at risk of dehydration, and sodium levels tend to trend towards the upper limit of normal. Potassium and blood pressure are spared (unless there is profound dehydration.) Therefore, diabetes insipidus is not in keeping with the clinical picture of this question.
name: Cranial diabetes insipidus
label: c
answer: no
explanation: Cushing's syndrome, which occurs due to cortisol excess, may be associated with hypertension, alongside the other classical clinical features of Cushing's such as striae, bruising, and central adiposity (which are absent in this case.) Cortisol has a mild mineralocorticoid effect, which can cause similar changes with a high sodium and low potassium. However, these changes are usually more mild, and in the absence of clinical feature's of Cushing's, this diagnosis remains unlikely.
name: Cushing's syndrome
label: e
answer: no
explanation: This patient is presenting with hypertension, raised sodium, and low potassium levels, and so the most likely diagnosis is hyperaldosteronism, which results in excess sodium absorption at the expense of potassium and is a secondary cause of hypertension. Muscle weakness and paraesthesiae are precipitated by the electrolyte abnormalities. Conn's syndrome refers to hyperaldosteronism secondary to an adrenal adenoma.
name: Primary hyperaldosteronism
label: a
answer: yes
explanation: Addison's disease is primary adrenal insufficiency, resulting in deficiencies of cortisol and mineralocorticoids. This results in hypotension, low sodium, and raised potassium, which is opposite to the current clinical picture.
name: Addison's disease
label: b
answer: no
explanation: Secondary hyperparathyroidism is an appropriate response of the parathyroid glands to hypocalcaemia. This patient's calcium levels are within normal range, but this would not necessarily exclude secondary hyperparathyroidism since the PTH may have successfully returned the calcium to normal. A PTH level will be required (which will be inappropriately raised despite the normal calcium) to confirm the diagnosis. However, secondary hyperparathyroidism would not explain the hypertension, the low potassium, or the raised sodium.
name: Secondary hyperparathyroidism
label: d
answer: no

Correct answer: a