hllj/quesmed huggingface dataset:
A 22-year-old woman attends her general practitioner with a 1-week history of left sided pelvic pain.

On examination, there is mild tenderness in the left iliac fossa, with no peritonism or guarding. Her observations are normal.

Her last menstrual period was 4 weeks prior.

A urinary pregnancy test is positive, to her surprise.

She is referred to the early pregnancy assessment unit where a transvaginal ultrasound scan is performed. There is no pregnancy visible within the uterus, and there is no free fluid identified in the pelvis. A serum B-hCG is 315 mIU/mL.

She wishes to proceed with a termination of pregnancy.

What is the most appropriate management?

Options:
explanation: Mifepristone is an antiprogestogenic steroid used in medical termination of pregnancy. Whilst this woman wishes to proceed with termination of pregnancy, the location of the pregnancy must be confirmed as intrauterine first.
name: Mifepristone
label: c
answer: no
explanation: This woman currently has a pregnancy of unknown location. Methotrexate is used in the medical management of ectopic pregnancy. Medical management is offered where a woman has an ectopic pregnancy, but there are no indications for surgical management.
name: Methotrexate
label: b
answer: no
explanation: Misoprostol, a synthetic prostaglandin analogue, is used in a medical termination of pregnancy. Whilst this woman wishes to proceed with termination of pregnancy, the location of the pregnancy must be confirmed as intrauterine first.
name: Misoprostol
label: e
answer: no
explanation: This woman has a pregnancy of unknown location. As she is haemodynamically stable with mild pelvic pain, she can be managed conservatively.

Serial serum B-hCGs 48 hours apart can help give an indication of the location and prognosis of the pregnancy.

- If the levels fall then it is suggested that the foetus will not develop or there has been a miscarriage.
- If there is only a slight increase or a plateau in B-hCG levels then this may indicate an ectopic pregnancy.
- A large increase in B-hCG suggests the foetus is growing normally intrauterine. In this case a repeat transvaginal scan may be performed, and if the pregnancy is confirmed as intrauterine, the woman may proceed with termination of pregnancy.
name: Repeat serum B-hCG in 48 hours
label: a
answer: yes
explanation: Whilst this woman may have an ectopic pregnancy, she is haemodynamically stable, therefore there is no indication for surgery. It may well be an intrauterine pregnancy which is too small to see on a transvaginal ultrasound scan.
name: Admit for an exploratory laparoscopy
label: d
answer: no

Correct answer: a
A 44-year-old woman attends the family planning clinic for insertion of a Mirena levonorgestrel-releasing intrauterine system; as she has read that this will help with her heavy periods. She currently takes the progestogen-only pill and is menstruating.

On routine bimanual examination before inserting the coil, the uterine fundus can be felt around the level of the umbilicus, and it is not possible to ascertain the position of the uterus.

What is the most appropriate next step?

Options:
explanation: This woman has an obvious abnormality. Although this is likely to be fibroids, intrauterine contraception should only be used in women with fibroids after seeking specialist advice. She has adequate contraception in the form of the progestogen-only pill at present.
name: Insert the Mirena coil and refer to gynaecology
label: b
answer: no
explanation: This woman has an obvious abnormality and requires referral to gynaecology. In addition, intrauterine contraception should not be inserted where there is a palpable uterus unless under specialist advice.
name: Insert the Mirena coil and advise the woman to return in one month for a repeat examination
label: d
answer: no
explanation: This woman has an obvious abnormality and requires referral to gynaecology. Whilst an endometrial biopsy may form part of the investigations, it would not be appropriate to perform this in the family planning clinic. In addition, intrauterine contraception should not be inserted where there is a palpable uterus unless under specialist advice.
name: Perform an endometrial biopsy before inserting the Mirena coil
label: c
answer: no
explanation: This woman has heavy menstrual bleeding and a palpable uterus. The most likely diagnosis is uterine fibroids, however she requires imaging to confirm this. Intrauterine contraception should only be used in women with fibroids after seeking specialist advice.
name: Refer to gynaecology without inserting the Mirena coil
label: a
answer: yes
explanation: While the likely diagnosis is fibroids, and GnRH analogues are a treatment strategy for the medical management of fibroids, the diagnosis is not confirmed. It would be inappropriate to commence this specialist treatment in a family planning setting.
name: Prescribe the woman a gonadotropin-releasing hormone (GnRH) analogue and ask her to return for her Mirena coil insertion in six months
label: e
answer: no

Correct answer: a
A 51-year-old woman attends the family planning clinic for a repeat supply of her combined oral contraceptive pill (COCP).

She has been taking this since age 37 and queries when she should stop taking it. She has completed her family and has no symptoms of menopause.

What is the correct advice to give her?

Options:
explanation: Women should stop taking combined hormonal contraception over the age of 50.
name: She can continue to take it indefinitely
label: e
answer: no
explanation: She should stop taking it now, as it is contraindicated for women over the age of 50.
name: She should stop taking it in one year's time
label: d
answer: no
explanation: She should not be taking combined hormonal contraception as she is over 50 years of age. Menopause is defined as not having a menstrual period for over one year, however this is difficult to ascertain when using hormonal contraception.
name: She should stop taking it when she no longer has any menstrual bleeding for 1 year
label: c
answer: no
explanation: The Faculty of Sexual and Reproductive Health (FSRH) UK Medical Eligibility Criteria (UKMEC) state that combined hormonal contraception is contraindicated in women over the age of 50. She should be switched to an alternative method of contraception.
name: She should stop taking it now and switch to an alternative method of contraception
label: a
answer: yes
explanation: Contraception is no longer required after the age of 55, where natural fertility is assumed to have ceased. However, combined hormonal contraception should not be used by women over the age of 50.
name: She should stop taking it after the age of 55
label: b
answer: no

Correct answer: a
A 22-year-old woman has just delivered a live female infant via spontaneous vaginal delivery. She has opted for active management of the third stage of labour.

Which of the following is involved in active management of the third stage of labour?

Options:
explanation: In active management, the placenta is delivered by controlled cord traction.
name: Allowing the placenta to deliver via uterine contractions
label: c
answer: no
explanation: Active management of the third stage of labour includes:

1. Injection of a uterotonic drug such as oxytocin
2. Clamping of the cord between 1 and 5 minutes after delivery of the infant
3. Delivery of the placenta by controlled cord traction
name: Intramuscular administration of a uterotonic drug
label: a
answer: yes
explanation: Active management of the third stage of labour includes:

1. Injection of a uterotonic drug such as oxytocin
2. Clamping of the cord between 1 and 5 minutes after delivery of the infant
3. Delivery of the placenta by controlled cord traction
name: Allowing the cord to completely stop pulsing prior to clamping
label: b
answer: no
explanation: Tocolytic drugs would halt uterine contractions and would not be helpful in the active management of the third stage of labour.
name: Intramuscular administration of a tocolytic drug
label: d
answer: no
explanation: Immediate skin-to-skin of the infant and the mother is advocated in all uncomplicated deliveries, and does not specifically form part of the management of the third stage of labour.
name: Immediate skin-to-skin of the infant and the mother
label: e
answer: no

Correct answer: a
A 24-year-old primigravida at 36 weeks gestation presents with 5 days of vomiting and inability to tolerate oral fluids. Her past medical history includes hypothyroidism and gestational hypertension.
She takes the following medications:



  - Labetalol 200mg three times daily
  - Levothyroxine 175micrograms once daily
  - Ferrous fumarate 210mg twice daily



On examination, she looks clinically dehydrated and has a heart rate of 100 bpm.



A cardiotocograph is reassuring.



Her full blood count tests are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|101 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|6.5 x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|100x10<sup>9</sup>/L|150 - 400|





Her liver function tests are as follows:



||||
|---------------------------|:-------:|--------------------|
|Albumin|31 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|150IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|120 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|210 IU/L|25 - 115|
|Bilirubin|32 µmol/L|< 17|
|Gamma Glutamyl Transferase (GGT)|42 U/L|9 - 40|
|Lactate Dehydrogenase|642 IU/L|70 - 250|



She is unable to provide a urine sample for urinalysis.



What is the most likely diagnosis?

Options:
explanation: HELLP (Haemolysis, Elevated Liver enzymes and Low Platelets) syndrome is a severe life-threatening condition in pregnancy. This patient has evidence of haemolysis (low haemoglobin, elevated bilirubin), elevated liver enzymes and low platelets. She is not hypertensive, however this may be accounted for by the fact she is already on labetalol, and she is clinically dehydrated. HELLP syndrome can occur in the absence of hypertension and proteinuria.
name: HELLP syndrome
label: a
answer: yes
explanation: Gestational hypertension is diagnosed where there is new-onset hypertension, without proteinuria or evidence of pre-eclampsia. Whilst this woman does have gestational hypertension, the diagnosis which encompasses all of her findings is HELLP syndrome.
name: Gestational hypertension
label: c
answer: no
explanation: Pre-eclampsia is defined as new-onset hypertension in pregnancy accompanied by proteinuria. Pre-eclampsia is not associated with thrombocytopenia.
name: Acute hepatitis
label: d
answer: no
explanation: Pre-eclampsia is defined as new-onset hypertension in pregnancy accompanied by proteinuria. Pre-eclampsia is not associated with thrombocytopenia.
name: Pre-eclampsia
label: b
answer: no
explanation: Hyperemesis gravidarum typically occurs in the first trimester, and whilst it may present with tachycardia and hypotension if profound dehydration, it does not cause thrombocytopenia or deranged liver function tests.
name: Hyperemesis gravidarum
label: e
answer: no

Correct answer: a

HELLP syndrome
A 48-year-old woman attends her general practitioner troubled with waking up at night drenched in sweat. She also finds it difficult to concentrate on her work as a statistics professor. She has not had sex with her husband since her hysterectomy as she struggled with low libido postoperatively and now finds it too painful to attempt intercourse.

Her past medical history is significant for a hysterectomy with ovarian preservation age 44 for a large fibroid. She also has Ehlers-Danlos syndrome, which manifests as joint hypermobility with frequent dislocations.

Which of the following medication regimes is most appropriate?

Options:
explanation: Sequential therapy is suitable for women with a uterus. These women require endometrial protection in the form of a progestogen (either oral or via a Mirena coil). This woman does not have a uterus, so she does not require a progestogen.
name: Evorel Sequi (sequential transdermal oestrogen-only hormone replacement therapy) and oral utrogestan for 14 days per month
label: c
answer: no
explanation: Testosterone gel is not first-line therapy for treating symptoms of menopause, and this woman does not require a progestogen as she does not have a uterus.
name: Testogel (transdermal testosterone gel) and oral utrogestan
label: e
answer: no
explanation: Whilst continuous transdermal oestrogen-only hormone replacement therapy is the correct option, this would be trialled alone before thinking about adding in other options such as testosterone gel.
name: Evorel conti (continuous transdermal oestrogen-only hormone replacement therapy) and Testogel (transdermal testosterone gel)
label: d
answer: no
explanation: Women who have had a hysterectomy should be offered continuous oestrogen-only hormone replacement therapy. Sequential therapy is offered to women with a uterus who are still having menstrual periods, or are within a year of their last menstrual period. Topical vaginal oestrogen pessaries, however, would be a sensible addition to the correct regime.
name: Evorel Sequi (sequential transdermal oestrogen-only hormone replacement therapy) and topical vaginal oestrogen pessaries
label: b
answer: no
explanation: This woman has symptoms of menopause - hot flushes, night sweats, reduced concentration and vulvovaginal symptoms. She would therefore benefit from a trial of hormone replacement therapy. Since she has had her uterus removed, is it is most appropriate to prescribe her a continuous oestrogen-only regime.
name: Evorel Conti (continuous transdermal oestrogen-only hormone replacement therapy)
label: a
answer: yes

Correct answer: a
A 24-year-old woman is asked to provide a repeat urine sample after attending her booking appointment at 12 weeks gestation. Her midwife explains that her first urine sample had grown an e-coli in the culture.

The woman has no urinary symptoms and is otherwise entirely well.

What is the most appropriate management plan if the second sample also shows bacteriuria?

Options:
explanation: Intrapartum antibiotics would be indicated if this person's urine had grown a group B streptococcus.
name: Advise intrapartum antibiotics
label: c
answer: no
explanation: This would be the first-line treatment for symptomatic urinary tract infection in the non-pregnant person. Trimethoprim is not recommended in pregnancy, particularly in the first trimester.
name: Trimethoprim 200mg twice daily for three days
label: d
answer: no
explanation: Unless sensitivities dictate otherwise, oral nitrofurantoin is the first-line antibiotic for asymptomatic bacteriuria in pregnant women.
name: Treat with oral nitrofurantoin 100 mg modified-release tablets twice a day for seven days
label: a
answer: yes
explanation: Asymptomatic bacteriuria should be treated in pregnancy. Without treatment, up to 35% of pregnant women with asymptomatic bacteriuria will develop a symptomatic urinary tract infection or pyelonephritis.
name: Reassure if not symptomatic, the bacteria is a likely contaminant and does not require treatment
label: e
answer: no
explanation: Unless sensitivities dictate otherwise, oral nitrofurantoin is the first-line antibiotic for asymptomatic bacteriuria in pregnant women. A seven-day course is required in pregnancy.
name: Treat with amoxicillin 500 mg three times a day for five days
label: b
answer: no

Correct answer: a
A 17-year-old female attends the drop-in clinic at her local sexual health clinic with irregular menstrual bleeding.

She has a progestogen-only subdermal implant in situ for contraception, inserted when she was 16. She was initially entirely amenorrhoeic with the implant, however in the past six months has had irregular bleeding, occurring every 4-7 weeks and lasting for 2-9 days.

What is the most appropriate management plan?

Options:
explanation: The subdermal implant appears to have been in situ for less than three years, therefore does not require replacement unless requested by the patient. Whilst irregular bleeding can occur with the implant, it is rarely a reason for early replacement.
name: Replace her subdermal contraceptive implant
label: c
answer: no
explanation: Whilst chlamydia infection is common in this age group, a swab should be obtained for NAAT/PCR testing first rather than blindly treating.
name: Treat empirically for chlamydia infection with doxycycline 200mg twice daily for one week
label: e
answer: no
explanation: While this is a valid option for managing irregular bleeding with progestogen-only contraception, STIs should be ruled out first.
name: Commence a combined oral contraceptive pill to regulate bleeding
label: d
answer: no
explanation: One of the most common causes of irregular menstrual bleeding in people under the age of 25 is sexually transmitted infections (STI) such as chlamydia. Whilst the implant can cause irregular bleeding, it is important to rule out STIs.
name: Ask her to do a self-obtained lower vaginal swab for chlamydia and gonorrhoea
label: a
answer: yes
explanation: Whilst the implant can cause irregular bleeding, it is important to rule out STIs.
name: Reassure her this is a known side effect of the contraceptive implant and does not require any investigation. She should return at three years to have the implant replaced
label: b
answer: no

Correct answer: a
A 56-year-old woman attends her general practitioner complaining of weight loss. She states she has lost around 7kg in the past six months and attributes this to just not being able to eat proper meals the way she used to. She feels she becomes full quickly and always feels bloated. Her last menstrual period was age 54, and she has no menopausal symptoms.

She has a past medical history of gastroesophageal reflux disease, obesity and type 2 diabetes. She takes omeprazole and metformin.

On examination, the woman is obese with a BMI of approximately 40. The abdomen is soft and non-tender; however, there is a fullness felt in the left iliac fossa. Bimanual examination also reveals a potential mass in the left adnexa.

What is the most appropriate management?

Options:
explanation: Whilst an abdominal or transvaginal ultrasound scan is likely to form part of the investigation of this woman, it is usually requested following urgent gynaecology referral.
name: Order an abdominal ultrasound scan
label: c
answer: no
explanation: This woman is over the age of 50 and has several symptoms which may suggest an ovarian malignancy - early satiety, bloating, weight loss and a pelvic mass.
name: Urgent referral to gynaecology
label: a
answer: yes
explanation: Whilst a CA-125 blood test may help in the diagnosis of ovarian malignancy, the most appropriate management is to refer to gynaecology urgently. A reassuring CA-125 level would not change this.
name: Perform a CA-125 blood test
label: b
answer: no
explanation: This woman does not have any symptoms of upper gastrointestinal malignancy. Whilst having gastrointestinal reflux disease may place her at a higher risk of Barratt's oesophagus and malignant transformation, her symptoms point toward a pelvic malignancy.
name: Order an urgent upper gastrointestinal endoscopy
label: e
answer: no
explanation: Whilst this woman is obese, she complains of unintentional weight loss, which is a red flag for malignancy. Suggesting she lose more weight is not appropriate at this stage.
name: Advise weight loss in the form of dietary change and increasing exercise
label: d
answer: no

Correct answer: a
A 23-year-old woman presents to accident and emergency at 19 weeks gestation with severe abdominal pain and vomiting.


Her observations are as follows:


 - Heart rate: 140 beats per minute
 - Blood pressure: 108/72mmHg
 - Respiratory rate: 20 breaths per minute
 - SpO2: 99% on room air
 - Temperature 38.1°C


Her full blood count tests are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|126 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.7x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|450x10<sup>9</sup>/L|150 - 400|



An abdominal examination reveals a gravid uterus with diffuse abdominal tenderness. There is sporadic uterine activity.


A midwife attends who is unable to auscultate the foetal heart.


A transabdominal ultrasound scan confirms a non-viable pregnancy with no foetal heart.


What is the most likely cause for this foetal demise?

Options:
explanation: Whilst chromosomal abnormalities are a common cause of spontaneous miscarriage, this mother has other features that point toward an infective cause.
name: Chromosomal abnormality
label: e
answer: no
explanation: Despite the maternal vomiting, gastroenteritis is a less likely cause of foetal demise. Gastroenteritis rarely causes sepsis or uterine activity.
name: Gastroenteritis
label: b
answer: no
explanation: Chorioamnionitis is a common cause of second trimester miscarriage and typically occurs due to ascending infection from the vagina. Chorioamnionitis typically presents with maternal fever, tachycardia and abdominal pain. There may be an offensive vaginal discharge or preterm prelabour rupture of membranes. In some cases, it leads to foetal demise.
name: Chorioamnionitis
label: a
answer: yes
explanation: Whilst urinary tract infection is the most common type of infection in pregnancy, there are no signs or symptoms of urinary tract infection.
name: Urinary tract infection
label: c
answer: no
explanation: Preterm rupture of membranes at 19 weeks would likely result in foetal demise, however in this scenario there is no indication that the membranes have ruptured.
name: Preterm rupture of membranes
label: d
answer: no

Correct answer: a
A 54-year-old woman presents to her general practitioner with intermittent vaginal bleeding. She describes bleeding almost every day, of varying severity. There is no associated pain. She had her last menstrual period at age 51 and does not complain of any menopausal symptoms. She has a copper coil in situ, which was inserted when she was 48.

She has a past medical history of type 2 diabetes and rheumatoid arthritis.

She takes the following medications:

- Metformin 1g twice daily
- Sulfazalazine 500mg four times a day
- Co-codamol 30/500mg as required
- Estradiol intravaginal pessary 10 micrograms twice weekly

What is the most appropriate management?

Options:
explanation: Sulfasalazine is unlikely to be contributing to her vaginal bleeding and should not be suddenly stopped in a patient with inflammatory arthritis.
name: Stop sulfasalazine for a period of four weeks
label: e
answer: no
explanation: If her bleeding appeared to be due to vulvovaginal atrophy, increasing her estradiol may be beneficial, but this is not the case here.
name: Increase estradiol pessaries to one 10 microgram pessary daily for two weeks
label: b
answer: no
explanation: Whilst Mirena coils are licenced for managing heavy menstrual bleeding, this does not appear to be menstrual bleeding here, so this would be inappropriate.
name: Swap her copper coil for a Mirena coil
label: d
answer: no
explanation: Whilst this woman no longer requires contraception and could have her copper coil removed, this would be unlikely to address the issue of her new postmenopausal bleeding, which requires investigation.
name: Remove her copper coil
label: c
answer: no
explanation: This woman has postmenopausal bleeding, which requires urgent referral to gynaecology for investigation of endometrial cancer.
name: Urgent referral to gynaecology
label: a
answer: yes

Correct answer: a