hllj/quesmed huggingface dataset:
An 81-year-old male with wet age-related macular degeneration (AMD) is reviewed in clinic. Twelve months ago, she had early-stage disease, initially managed with risk factor modification, although her vision has now deteriorated from 6/24 to 6/60 vision in both eyes. On fundoscopy, she has subretinal haemorrhages, lipid exudates, and fibrovascular scarring - corresponding to advanced-stage disease.

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

Options:
explanation: Thermal laser photocoagulation used to be the first-line treatment for wet AMD with extrafoveal choroidal neovascular membranes, although this has now largely been replaced by anti-VEGF treatment as treatment of subfoveal and juxtafoveal lesions often resulted in a dense scotoma with high recurrence rates
name: Thermal laser photocoagulation
label: e
answer: no
explanation: Anti-VEGF injections are the mainstay of management of wet AMD, reducing or eliminating macular oedema and reduce neovascularisation, which can reduce disease progression and reverse visual loss
name: Intravitreal injection with vascular endothelial growth factor inhibitors (anti-VEGF)
label: a
answer: yes
explanation: This patient has progressed to advanced wet AMD with significant deterioration in vision. Wet AMD can be treated initially with anti-VEGF intravitreal injections and so this should be trialled first, providing there are no contraindications
name: Observation
label: b
answer: no
explanation: Photodynamic therapy (PDT) is frequently used in wet AMD, although only as an adjunct as second-line treatment with anti-VEGF after anti-VEGF has already been tried
name: Photodynamic Therapy
label: c
answer: no
explanation: Intravitreal corticosteroids can be given for macular oedema in diabetes, uveitis, and retinal vein occlusion. It is not currently recommended as a treatment for wet AMD
name: Intravitreal corticosteroids
label: d
answer: no

Correct answer: a


Learning point: Intravitreal anti-VEGF injections, such as ranibizumab, aflibercept, and bevacizumab, are the primary treatment for wet age-related macular degeneration as they work by inhibiting vascular endothelial growth factor (VEGF) to reduce abnormal blood vessel growth and fluid leakage in the retina, helping to preserve vision.
A 67-year-old woman has presented to the GP with worsening left hip pain after a fall from standing height 2 days earlier after tripping on the carpet. Prior to this, she has been experiencing 12 months of worsening bilateral groin pain. The pain is worse later in the day and on prolonged exertion.

On examination, she has a painful straight leg raise bilaterally but a full range of motion. She can walk unaided but with an antalgic gait on her left side.

An X-ray of her left hip is shown below.

[lightgallery]

Which of the following is the most likely diagnosis?

Options:
explanation: The x-ray shows reduced joint space, osteophytes at the joint margin, and subchondral sclerosis. There is severe joint narrowing at the superior aspect of the acetabulum, although there is no fracture present on the x-ray. Patient's with acetabular fractures would unlikely be able to fully weight bear or straight leg raise and so is less likely based on the clinical history
name: Acetabular fracture
label: e
answer: no
explanation: The x-ray shows reduced joint space, osteophytes at the joint margin, and subchondral sclerosis. The joint space is severely narrowed, and the bones are osteopenic, although there is no fracture demonstrated in the image. The patient can fully weight bear and perform straight leg raise, so hip fracture is unlikely
name: Left neck of femur fracture
label: b
answer: no
explanation: Septic arthritis may present similarly in the history, although the examination findings would likely be different. In septic arthritis, the joint is warm, swollen, and very tender. The patient would unlikely be able to weight bear or perform straight leg raise and may present as more clinically unwell
name: Septic arthritis
label: c
answer: no
explanation: Slipped upper femoral epiphysis is a relatively common condition, although it presents in adolescents due to widening of the growth plate during limb growth. It would therefore be unlikely in a fully grown adult. The x-ray findings show an intact femoral epiphysis
name: Slipped upper femoral epiphysis
label: d
answer: no
explanation: The x-ray shows reduced joint space, osteophytes at the joint margin, and subchondral sclerosis. The joint space is severely narrowed, and the bones are osteopenic, although there is no fracture demonstrated in the image. This makes osteoarthritis of the hip without associated fracture the most likely diagnosis. The patient can be reassured that the pain from the fall should subside with analgesia over the next 2-4 weeks. Given the severe osteoarthritis, however, this patient should be referred to orthopaedics if her pain continues to not be controlled by analgesia and self-management strategies
name: Osteoarthritis of the hip
label: a
answer: yes

Correct answer: a


Learning point: Osteoarthritis of the hip presents with joint space narrowing, osteophytes, and pain exacerbated by activity, often leading to an antalgic gait.
A 65-year-old man has presented with 24 hours of worsening painful swelling of his right knee. He recently fell onto his right side while cycling 3 days earlier, sustaining some grazes on his right leg but no other acute injuries. He has type 2 diabetes but no other medical problems.

On examination, he is pyrexial and tachycardic. His right knee is hot to touch, erythematous, and markedly swollen. There is a reduced range of motion and he is not able to weight bear.

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

Options:
explanation: This patient has presented with an acute, hot, tender, swollen joint with suspicion of septic arthritis. This can destroy joints quickly with irreversible loss of joint function, and so knee aspiration and intravenous antibiotics should be started
name: Discharge with oral flucloxacillin
label: c
answer: no
explanation: This patient may benefit from intravenous fluids as he is pyrexial and tachycardic with likely septic arthritis, although it is not the immediate priority. A joint aspiration followed by intravenous antibiotics must be given first
name: Intravenous fluids
label: d
answer: no
explanation: This patient will require admission and intravenous flucloxacillin, although ideally a knee aspiration should be done prior to starting antibiotics if possible, to provide the best chance of growth of any pathogens
name: Intravenous flucloxacillin
label: b
answer: no
explanation: This patient would warrant a knee x-ray given the examination findings, although it is not the first priority. A joint aspiration followed by intravenous antibiotics must be given first for possible septic arthritis
name: Knee X-ray
label: e
answer: no
explanation: This patient has presented with an acute, hot, tender, swollen joint after a previous soft tissue injury around the knee. This raises concerns for septic arthritis. An urgent knee aspiration must be conducted, ideally prior to starting antibiotics. If there is an unavoidable delay in performing a knee aspiration or the patient is septic, then antibiotics can be given first
name: Knee aspiration
label: a
answer: yes

Correct answer: a


Learning point: Acute, hot, and swollen joints after an injury may suggest septic arthritis, requiring urgent knee aspiration for accurate diagnosis and treatment.
A 9-month-old child is brought to the GP with two days of pyrexia and worsening barking cough, worse at night time. She has prominent inspiratory high-pitched wheeze with mild intercostal recession at rest. There is no sialorrhoea and her oral mucosa is unremarkable.

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

Options:
explanation: Due to the association of aspirin with Reye's syndrome in children, it is very rarely given
name: Stat dose of aspirin
label: b
answer: no
explanation: This child has symptoms of croup - a viral infection most commonly associated with parainfluenza virus. Antibiotics would therefore not be indicated unless there was suspicion of superadded bacterial pneumonia
name: Give oral antibiotics
label: c
answer: no
explanation: This child is experiencing symptoms of croup with stridor and signs of increased respiratory effort. This is managed with a single dose of oral dexamethasone 0.15mg/kg immediately with consideration of admission to hospital, depending on their risk factors
name: Stat dose of oral dexamethasone
label: a
answer: yes
explanation: Nebulised adrenaline can be given for temporary improvement of symptoms with upper airway obstruction in croup, although it is not the _next_ best management option. Oral steroids should be given first here unless the child is critically unwell
name: Give nebulised adrenaline
label: e
answer: no
explanation: Nebulised salbutamol can be given in acute stridor, although in croup it would unlikely reverse the upper airway narrowing as it does not contain smooth muscle
name: Give nebulised salbutamol
label: d
answer: no

Correct answer: a


Learning point: Croup in children is effectively managed with a single dose of oral dexamethasone to reduce inflammation and improve respiratory symptoms.
A 2-year-old child presents with 2 days of right-sided otalgia and pyrexia. She is otherwise well and had a similar problem two weeks ago which initially self-resolved. She is currently taking immunosuppressants for a liver transplant she had as a neonate for extrahepatic biliary atresia. On otoscopy there is bulging of the tympanic membrane with surrounding erythema.

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

Options:
explanation: This child has acute otitis media, which would be managed with reassurance and analgesia in the well child. As they are on immunosuppressants, they should be prescribed oral antibiotics unless unwell, where it can be escalated to intravenous antibiotics and admission
name: Analgesia and reassurance
label: c
answer: no
explanation: Back-up antibiotics can be given to children whose signs of infection do not resolve within 3 days or worsen significantly or rapidly at any time. As this child is on immunosuppressants, they should receive antibiotics immediately
name: Prescribe a back-up antibiotics prescription to take if not improving after three days
label: d
answer: no
explanation: This child has presented with acute otitis media. It is very common in children and is often managed conservatively without antibiotics. Antibiotics should be prescribed if the symptoms last >4 days, they are systemically unwell, are immunocompromised, or have evidence of tympanic perforation. This child is well but on immunosuppression and so oral antibiotics should suffice with good safety netting
name: Oral antibiotics
label: a
answer: yes
explanation: While this patient is on immunosuppressants, they are systemically well with acute otitis media. This will require oral antibiotics at present, but should have a low threshold for admission and intravenous antibiotics if not resolving in the community
name: Admit for intravenous antibiotics
label: b
answer: no
explanation: This child is on immunosuppressants but is systemically well at present with only one previous episode of acute otitis media. A child should be referred to the local emergency department if unwell or have systemic complications of acute otitis media such as meningitis, mastoiditis, intracranial abscess sinus thrombosis, or facial nerve paralysis. A child can be referred to ENT if they have recurrent unexplained episodes or they have a craniofacial abnormality. In this case, she can be managed with oral antibiotics alone
name: Refer to ENT
label: e
answer: no

Correct answer: a


Learning point: In immunocompromised children, acute otitis media requires prompt antibiotic treatment, especially if accompanied by tympanic membrane bulging and erythema.
A 19-day-old baby is brought to accident and emergency by her parents with jaundice and poor feeding for the last three days. On further questioning, they report she has been passing pale stools and dark urine over the last week. On examination, the baby is visibly jaundiced and has a distended abdomen with hepatosplenomegaly.

Which of the following is the most likely diagnosis?

Options:
explanation: Physiological jaundice presents at day 2 or 3 of age, begins to disappear towards the end of the first week, and has usually resolved by day 10. Jaundice lasting longer than 14 days (prolonged jaundice) always warrants further investigation for more sinister pathology
name: Physiological jaundice
label: c
answer: no
explanation: Congenital rubella is a cause of early neonatal jaundice, with onset within less than 24 hrs, due to hepatic dysfunction by the rubella virus. This baby has presented with late jaundice and so this is less is unlikely
name: Congenital rubella
label: e
answer: no
explanation: G6PD is a cause of early neonatal jaundice, with onset within less than 24 hrs, due to haemolytic anaemia. This baby has presented with late jaundice and so G6PD is unlikely
name: Glucose-6-phosphate dehydrogenase deficiency (G6PD)
label: b
answer: no
explanation: Biliary atresia is the obliteration or blockage of the extrahepatic biliary system. It presents as prolonged jaundice in the neonate, lasting longer than 14 days in infants and 21 days in preterm infants. It is characterised by jaundice >14 days, dark urine, pale stools, and poor appetite
name: Biliary atresia
label: a
answer: yes
explanation: Crigler-Najjar syndrome is a cause of early neonatal jaundice, with onset within less than 24 hrs, due to inborn errors in bilirubin metabolism. This baby has presented with late jaundice and so this is less is unlikely
name: Crigler-Najjar syndrome
label: d
answer: no

Correct answer: a


Learning point: Biliary atresia is a condition involving the blockage or obliteration of the extrahepatic biliary system, presenting in neonates with prolonged jaundice lasting more than 14 days, dark urine, pale stools, and poor appetite.
A woman brings her newborn boy to A&E with signs of respiratory distress. He was born 36 hours ago at 39 weeks and is currently grunting, tachypnoeic, and pyrexial with nasal flaring and use of accessory muscles. You suspect he has neonatal sepsis.

The mother had not attended any of her pre-natal screening sessions and reports her waters breaking over 24 hours before she went into labour. She also had a temperature in labour

Which of the following is the most likely organism responsible for this early-onset neonatal sepsis?

Options:
explanation: Streptococcus pneumoniae is a rare cause of early-onset neonatal sepsis, and is more common in late-onset neonatal sepsis (7-28 days old). In early-onset disease, pneumococci may be transmitted transplacentally, secondary to maternal bacteraemia, or transmitted from the mother transvaginally during delivery, although is not commonly present in vaginal flora and colonisation is rare. In late-onset neonatal sepsis it is more common as horizontal transmission from colonised visitors or health care workers has more time to occur
name: Streptococcus pneumoniae
label: c
answer: no
explanation: E. coli is the second most common pathogen for early-onset neonatal sepsis, accounting for approximately 24% of all episodes. The overall incidence of E. coli neonatal sepsis has remained stable after introduction of intrapartum antibiotic prophylaxis, but the incidence has increased in very low birth weight infants alongside worsening antibiotic-resistant patterns
name: Escherichia coli
label: b
answer: no
explanation: Staphylococcus aureus is a less common cause of early-onset neonatal sepsis than GBS and E. coli. It is more associated with late-onset neonatal sepsis (7-28 days old) where horizontal transmission from colonised visitors or health care workers is common
name: Staphylococcus aureus
label: e
answer: no
explanation: Listeria monocytogenes accounts for approximately 5% of early-onset neonatal sepsis in premature neonates, although it is rare in those >35 weeks gestation. It is commonly transmitted by aspiration or swallowing of amniotic fluid or vaginal secretions from the mother, although can also be transmitted transplacentally. Pregnant women typically acquire listeria infection from contaminated foods such as contaminated meats, poultry, dairy products, and vegetables
name: Listeria monocytogenes
label: d
answer: no
explanation: GBS is harboured asymptomatically in various sites, including the genital tract. Early-onset neonatal sepsis (<72 hours from birth) is most commonly caused by transmission of pathogens from the mother's genital tract during delivery. Risk factors for neonatal sepsis include prolonged prelabour rupture of membranes, intrapartum fever and suspected or confirmed bacterial infection. The most common pathogen in early-onset neonatal sepsis is GBS, causing 38-43% of all cases
name: Group B streptococcus (GBS)
label: a
answer: yes

Correct answer: a


Learning point: Group B streptococcus is the most common cause of early-onset neonatal sepsis, particularly following prolonged rupture of membranes and maternal fever.
A 78-year-old woman has been seeing her GP for the last 4 months with symptoms of depression. She was started on sertraline a week ago and has presented for her 1 week follow-up appointment. She states she feels no different and would like to try another agent.

For how long should her treatment be continued before considering a switch to a different anti-depressant?

Options:
explanation: Patients should be reviewed every 1-2 weeks at the start of anti-depressant treatment and should be continued for at least 4 weeks (6 weeks in the elderly) before considering switching agents
name: 2 weeks
label: c
answer: no
explanation: Patients should be reviewed every 1-2 weeks at the start of anti-depressant treatment and should be continued for at least 4 weeks (6 weeks in the elderly) before considering switching agents
name: 3 weeks
label: b
answer: no
explanation: Patients should be reviewed every 1-2 weeks at the start of anti-depressant treatment and should be continued for at least 4 weeks (6 weeks in the elderly) before considering switching agents. If there is partial response at these timepoints, continue for a further 2-4 weeks (elderly patients may take longer to respond). This patient should therefore receive minimum 6 weeks of treatment before consideration of switching agents
name: 6 weeks
label: a
answer: yes
explanation: Patients should be reviewed every 1-2 weeks at the start of anti-depressant treatment and should be continued for at least 4 weeks (6 weeks in the elderly) before considering switching agents. If patient has remission with an anti-depressant, they should be continued on the same dose for at least 6 months (12 months in the elderly). Patients with a history of recurrent depression should receive maintenance treatment for at least 2 years
name: 6 months
label: e
answer: no
explanation: Patients should be reviewed every 1-2 weeks at the start of anti-depressant treatment and should be continued for at least 4 weeks (6 weeks in the elderly) before considering switching agents
name: 12 weeks
label: d
answer: no

Correct answer: a


Learning point: Antidepressant treatment in elderly patients should generally be continued for at least six weeks before considering a switch to another medication
A 75-year-old woman with metastatic mesothelioma presents with progressive shortness of breath and uncontrolled pleuritic chest pain. Her eGFR is 85mL/min/1.73m<sup>2</sup> and her liver function tests are all within normal range.


She currently takes 900mg gabapentin TDS, 1g paracetamol QDS, 80mg modified standard release morphine sulfate (long acting) BD, and 75mg amitriptyline ON. S She is currently using all her prescribed as-needed oral morphine doses and frequently requests her next dose due to ongoing pain.


You decide to increase her modified standard release morphine sulfate dose to 90mg twice daily. Calculate the most appropriate breakthrough oral morphine sulfate immediate release dose for this new regime.

Options:
explanation: Always make sure in these questions, and in practice, to calculate the full 24 hour dose of oral morphine e.g. 2x90mg given the twice daily dosing
name: 30-40mg oral morphine sulfate immediate release as required, 4-hourly
label: d
answer: no
explanation: This would be an appropriate starting dose for a patient who is opioid-naïve, although this patient is already on high-strength long-acting morphine for her cancer pain and so breakthrough doses must be calculated appropriately
name: 5-10mg oral morphine sulfate immediate release as required, 4-hourly
label: c
answer: no
explanation: Breakthrough dose of morphine in adults with cancer is calculated by dividing the 24-hour dose of oral morphine by 6. Usually a range is required and so the range should be approximately 1/10th-1/6th of the 24-hour total morphine dose.
 

 The principal is the same for all opioids, although it is best practice to convert the full 24 hour dose of opioids to the corresponding _oral_ morphine dose, and then convert back to the desired drug and route. This is of use when the long-acting drug is different to the breakthrough drug e.g. oral oxycodone breakthrough with a buprenorphine patch.
 

 The total dose of oral morphine in this case is 180mg/24hrs. 1/6th of this is 30mg and 1/10th of this is 18mg. For practicality in administration, this has been rounded to 20-30mg
name: 20-30mg oral morphine sulfate immediate release as required, 4-hourly
label: a
answer: yes
explanation: This would be too large of an increment of as required oral morphine to increase to for the current long-acting morphine dose. This increases the risk of needless opioid toxicity/overdose and of systemic side-effects
name: 40-50mg oral morphine sulfate immediate release as required, 4-hourly
label: e
answer: no
explanation: Always make sure in these questions, and in practice, to calculate the full 24 hour dose of oral morphine e.g. 2x90mg given the twice daily dosing
name: 10-15mg oral morphine sulfate immediate release as required, 4-hourly
label: b
answer: no

Correct answer: a

20-30mg oral morphine sulfate immediate release as required, 4-hourly

Learning point: In cancer pain management, the breakthrough dose of oral morphine is typically 1/6th to 1/10th of the total daily morphine dose.