hllj/quesmed huggingface dataset:
A 73 year old female with poorly controlled type two diabetes mellitus has had a chronically infected foot ulcer for six weeks and it is not improving with oral antibiotics. She's become increasingly unable to weight bear over the past week.

Which investigation will be most useful to guide your management?

Options:
explanation: Arterial imaging would be of benefit if there was a concern about circulatory deficit preventing healing. The pathophysiology of diabetic foot ulcers is usually microvascular in nature and therefore arterial duplexes are not indicated
name: Arterial lower limb duplex
label: c
answer: no
explanation: Venous doppler scanning is predominantly used to look for venous thrombosis. Whilst haemostasis in the legs due to poor drainage can cause venous ulceration the vignette here indicates this is a diabetic foot ulcer and therefore dopplers are not indicated
name: Lower limb venous doppler
label: d
answer: no
explanation: Blood cultures would be indicated if this patient had presented acutely septic, however this is a chronic infection and therefore blood cultures are unlikely to be positive or helpful in this case
name: Blood cultures
label: b
answer: no
explanation: Given the chronicity of this infection and the relative immunosuppression of a patient with poorly controlled diabetes, it is important to rule out osteomyelitis which would require extended intravenous antibiotic therapy. The best modality for this is MRI
name: Magnetic resonance imaging (MRI) of the foot
label: a
answer: yes
explanation: Serum HbA1C is useful in determining both the initial diagnosis and long term control of diabetes. Whilst in this case we know the patient has poorly controlled diabetes and tighter diabetic control will lead to better outcomes it does not deal with the acute issue at hand
name: Serum haemoglobin A1C (HbA1C) measurement
label: e
answer: no

Correct answer: a


Learning point: In diabetic patients with chronic foot ulcers, MRI is essential to rule out osteomyelitis when infection fails to improve with oral antibiotics.
An 83 year old male with metastatic colorectal cancer presents to the emergency department with abdominal pain. He reports not passing urine for the last 12 hours. On examination he has moist mucous membranes, his JVP is not raised and his abdomen is diffusely tender without being peritonitic. Bladder scan shows a volume of 20ml.


His admission bloods are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|83  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|235x10<sup>9</sup>/L|150 - 400|
|Sodium|134 mmol/L|135 - 145|
|Potassium|5.4 mmol/L|3.5 - 5.3|
|Urea|14 mmol/L|2.5 - 7.8|
|Creatinine|300 µmol/L|60 - 120|
|C Reactive Protein|15 mg/L|< 5|


What is the most important next investigation?

Options:
explanation: Whilst a urine dip might be helpful in diagnosis if obstruction is not the cause, he has reported he has not passed urine for over 12 hours therefore obtaining a urine sample may not be possible without inserting a catheter
name: Urine dip
label: c
answer: no
explanation: This is not an unreasonable investigation, as patients with metastatic disease may present with cauda equina, however the bladder scan is not suggestive of urinary retention at a spinal level and therefore less likely than external compression of a ureter for example
name: Magnetic resonance imaging (MRI) of the spine
label: d
answer: no
explanation: Whilst a CT of his abdomen and pelvis would be useful in aiding diagnosis, at the moment his renal function is poor and contrast is best avoided
name: Computerised tomography (CT) of abdomen and pelvis with contrast
label: b
answer: no
explanation: A FAST scan is used to detect free fluid in the abdomen in a trauma situation and therefore is not indicated in this case
name: Focussed abdominal scanning in trauma (FAST) scanning
label: e
answer: no
explanation: This patient has a significant acute kidney injury, is anuric, and has a known intraabdominal malignancy. It is important to rule out a urological obstruction as cause for his presentation. The bladder scan does not show retention, however there may be an obstruction at the ureteric level
name: Ultrasound renal tract
label: a
answer: yes

Correct answer: a


Learning point: An ultrasound is performed in an anuric patient with a known intra-abdominal malignancy to assess for potential causes of urinary obstruction, such as tumor compression, hydronephrosis, or metastatic involvement of the urinary tract.
A 31 year old male presents to the general practice with rose coloured urine and fatigue. He reports that he had a recent upper respiratory tract infection, but otherwise has no past medical history of note. He undergoes a renal biopsy and is diagnosed with IgA nephropathy. During his follow up he is found to have hypertension on serial blood pressure measurements.

What single medication ought to be started in the first instance?

Options:
explanation: Whilst hypertension requires aggressive treatment in IgA nephropathy, 5mg is a high starting dose as patients are usually started at 1.25-2.5mg and then gradually increased at two weekly intervals
name: Commence ramipril 5mg once daily
label: c
answer: no
explanation: The National Institute of Clinical Excellence (NICE) states that calcium channel blocker is first line antihypertensive medication for those over the age of 55 or of African or Afro-Caribbean family origin. As this patient is young an ACEi is therefore first line
name: Commence amlodipine 5mg once daily
label: e
answer: no
explanation: High blood pressure should be treated aggressively in patients with IgA nephropathy, and the antihypertensive medication of choice is an angiotensin-converting enzyme inhibitor (ACEi) such as ramipril. They protect kidney function and may even be beneficial with normal blood pressure
name: Commence ramipril 1.25mg once daily
label: a
answer: yes
explanation: There is some role for steroids in the treatment of IgA nephropathy, however this does not address his hypertension
name: Commence prednisolone 5mg once daily
label: d
answer: no
explanation: A loop diuretic is not the first line diuretic in this instance and may lead to electrolyte imbalance
name: Commence furosemide 20mg once daily
label: b
answer: no

Correct answer: a


Learning point: Ramipril, an ACE inhibitor, is used in managing IgA nephropathy by reducing proteinuria and slowing disease progression through its effects on lowering blood pressure and decreasing intraglomerular pressure.
A 75-year-old male is seen in clinic and is noted to have renal and liver function off his usual baseline. His wife is concerned his memory isn't what it used to be, and he has been mixing up his medications of late. She has also noticed his hands are shaking. His past medical history includes autosomal dominant polycystic kidney (ADPKD) disease, for which he had a renal transplant ten years ago.

What is the most likely cause for this clinical picture?

Options:
explanation: Chronic rejection is a possibility in this case and should be considered in clinical practice. However, the picture of declining renal function in chronic rejection is more gradual in nature and would not account for the changes in his liver function
name: Chronic graft rejection
label: d
answer: no
explanation: Acute rejection is defined as rejection in the first few weeks to the first three months after transplantation
name: Acute graft rejection
label: c
answer: no
explanation: Those who suffer from ADPKD can also develop liver cysts, which can alter liver function; however, it is unusual to develop new cysts in a transplanted kidney
name: Progression of his ADPKD
label: e
answer: no
explanation: Tremor and headache are two well-known symptoms of tacrolimus toxicity which is also both nephrotoxic and hepatotoxic. The fact that this patient might be mixing up his medications raises the concern that he may be overdosing his tacrolimus
name: Calcineurin inhibitor toxicity
label: a
answer: yes
explanation: Whilst vascular dementia may be the precipitating factor for his cognitive decline; it would not account for the changes in his blood tests
name: Vascular dementia
label: b
answer: no

Correct answer: a


Learning point: Calcineurin inhibitor toxicity, caused by drugs like cyclosporine or tacrolimus, causes nephrotoxicity, hypertension, neurotoxicity, hyperkalemia, and infection risk, requiring regular drug level and kidney function monitoring.
A 24-year-old male is brought to the emergency department by ambulance after a witnessed generalised tonic-clonic seizure. He had initially appeared to recover but did not regain consciousness on his way to the hospital and has now started seizing again. Intravenous access is obtained, and he is given 4mg of lorazepam, but after 10 minutes, there is no response.

What is the next step in your management?

Options:
explanation: This would be a reasonable choice if the patient did not have IV access, but as we have secured access in this patient, IV lorazepam is a better option as it is faster acting and does not run the risk of whoever is administering it being accidentally bitten by the patient while they seize
name: Give 10mg buccal midazolam
label: b
answer: no
explanation: This is the next step if two doses of benzodiazepines do not work and the patient continues to be in status epilepticus. Be aware that phenytoin infusions are likely to cause a drop in blood pressure
name: Start a phenytoin infusion
label: c
answer: no
explanation: This patient may well need a neurology review and further investigations; however, the acute issue is their seizures, and the patient needs to be stabilised before referring to a specialty
name: Refer to neurology
label: e
answer: no
explanation: This patient is in status epilepticus, defined as a seizure lasting >5 minutes; or repeated seizures without regaining consciousness. Initial management is basic life support alongside benzodiazepines.
name: Give a further intravenous (IV) 4mg lorazepam
label: a
answer: yes
explanation: Whilst airway protection is an important consideration and should be part of your initial and continuous assessment; we do not yet need to intubate in this instance. Other airway adjuncts may be better in the first instance, such as a nasopharyngeal airway
name: Intubate the patient
label: d
answer: no

Correct answer: a


Learning point: Status epilepticus requires immediate treatment with benzodiazepines, such as lorazepam.
A 58-year-old female presents to the Emergency Department concerned she has had a stroke. Her past medical history includes hypertension, gout, recurrent urinary tract infections, chronic kidney disease (CKD) stage three, type two diabetes on insulin, and a previous N-STEMI. On examination, she is GCS 15/15 and talking in complete and coherent sentences. She has normal power, tone, sensation, reflexes and coordination in all four limbs. She has double vision and a mild ptosis. Her pupils are both symmetrical and equal.

An MRI Head is performed which is normal.

Which of the following is the most likely underlying cause of her presentation?

Options:
explanation: Multiple Sclerosis is a definite cause of a medical third nerve palsy. However, the normal MRI Head, lack of any previous neurological history and significant vascular risk factors in her history point towards a more vasculopathic process
name: Multiple Sclerosis
label: d
answer: no
explanation: This is the cause of a 'surgical' third nerve palsy. Note that this is a medical third nerve palsy which is pupillary sparing rather than a 'surgical' third nerve palsy where aneurysms, tumours and raised intracranial pressure can push on the outer autonomic fibres of the nerve, causing the pupil to dilate. In a medical third palsy, only the inner motor fibres are affected so the pupils are spared
name: Cerebral artery Aneurysm
label: b
answer: no
explanation: This patient has an oculomotor nerve palsy (cranial nerve III), and one of the common medical causes of this presentation is due to vasculopathic ischaemia to the third nerve. Note that this is a medical third nerve palsy which is pupillary sparing rather than a 'surgical' third nerve palsy where aneurysms, tumours and raised intracranial pressure can push on the outer autonomic fibres of the nerve, causing the pupil to dilate. In a medical third palsy, only the inner motor fibres are affected so the pupils are spared
name: Diabetes
label: a
answer: yes
explanation: There are no real signs of raised intracranial pressure in this scenario. Also you would expect there to be pupillary dilatation secondary to pressure on the outer autonomic fibres of the third cranial nerve
name: Raised intracranial pressure
label: e
answer: no
explanation: Urinary tract infection is unlikely to be implicated in causing an isolated third nerve palsy
name: Urinary tract infection
label: c
answer: no

Correct answer: a


Learning point: Medical third nerve palsy, often caused by diabetes, involves damage to the oculomotor nerve, resulting in ptosis, ocular misalignment ("down and out" eye), and normal pupil reaction.
A 58-year-old male presents to the Emergency Department with painless visual loss that he describes as a curtain coming down over his vision. He has never had this happen before. His only past medical history is well-controlled diabetes, and he is short-sighted.

What is the most likely diagnosis?

Options:
explanation: A cataract is an opacity of the lens of the eye and is usually a gradual age-related process. Presentation is usually with gradual blurring of the vision. Whilst diabetes is a risk factor for cataracts; this history is too acute
name: Cataract
label: d
answer: no
explanation: This is a reasonable differential diagnosis; however, as he has never suffered with this before, this would need to be a diagnosis of exclusion given the patient's age and comorbidities
name: Ocular migraine
label: b
answer: no
explanation: This is a classic history suggestive of retinal detachment. Risk factors for exudative retinal detachment include hypertension, vasculitis and macular degeneration, whereas myopia is a cause for tractional detachment. Other causes of detachment may be traumatic in nature, allowing fluid to pass from the vitreous space into the subretinal space
name: Retinal detachment
label: a
answer: yes
explanation: This is the most prevalent degenerative condition of the retina and usually presents with night blindness followed by daytime peripheral and central visual loss. This does not fit with the acute clinical picture here
name: Retinitis pigmentosa
label: e
answer: no
explanation: This would be a differential and is important to exclude; however, it is less common, and the history is more suggestive of retinal detachment. Retinal artery occlusion usually presents with dramatic visual loss within seconds of occlusion. It should be considered a form of stroke as it is often thromboembolic in origin. Therefore the risk factors are similar to other causes of stroke (smoking, heart disease, atrial fibrillation, diabetes, hypercholesterolaemia)
name: Retinal artery occlusion
label: c
answer: no

Correct answer: a


Learning point: Painless visual loss described as a curtain falling is characteristic of retinal detachment, often associated with myopia and diabetic retinopathy.
A 28-year-old female presents to her GP complaining that she struggles to read and has discomfort with eye movement. She has never had issues with her vision before. On examination, she is very slim with protuberant eyes and is flushed despite it being cold in the practice. She has significantly reduced visual acuity. She has no past medical history of note.

What intervention is likely to be indicated?

Options:
explanation: Laser eye surgery can correct refractive errors in vision; however, that is not the diagnosis here
name: Laser eye surgery
label: e
answer: no
explanation: Eye taping at night is beneficial if unable to close the eyelid to help prevent drying and abrasions whilst sleeping. Some patients with severe thyroid eye disease and very protuberant eyes may need assistance with lid closure; however, this intervention would not address the patient's visual loss
name: Eye taping at night
label: d
answer: no
explanation: Whilst patients with thyroid eye disease are at risk of dry eyes and developing conjunctivitis and abrasions; there is no evidence in this history of active infection that would require topical treatment
name: Topical chloramphenicol
label: b
answer: no
explanation: This patient has untreated hyperthyroidism and has symptoms suggestive of thyroid eye disease that has gone untreated, and her symptoms suggest optic nerve compression. It is important to treat her underlying thyroid disease, but as she has developed visual disturbance, surgical decompression should be considered as part of the acute treatment here
name: Surgical decompression of the optic nerve
label: a
answer: yes
explanation: This patient has a history suggestive of thyroid eye disease and compression of the optic nerve; therefore, referring to an optician would not benefit her acute management
name: Referral to an optician
label: c
answer: no

Correct answer: a


Learning point: Thyroid eye disease can cause optic nerve compression, which may lead to vision impairment; surgical decompression is often required when visual disturbances or threat to vision become significant.
A 56-year-old man presents to the Emergency Department with headache, photophobia and a very painful, red eye that has gradually worsened over the past two days. He reports no noticeable discharge from the eye. His past medical history includes diabetes, high cholesterol and rheumatoid arthritis. On examination, the entire sclera is bright red, and there is discomfort on eye movements. On probing with a phenylephrine soaked cotton bud, the redness does not change.

What is the most likely diagnosis?

Options:
explanation: A foreign body may cause irritation and lead to inflammation of the eye; however, this history does not suggest trauma to the eye
name: Foreign body
label: d
answer: no
explanation: Scleritis is a generalised inflammation of the sclera itself and is strongly associated with systemic disease, commonly vasculitis and rheumatoid arthritis. Ocular movements are painful, and often headache and photophobia are present. As the vessels of the sclera are deeper, they will not blanch on probing. Management is guided by underlying cause and ranges from steroids and topical NSAIDs to immunosuppressive therapy such as cyclophosphamide and rituximab
name: Scleritis
label: a
answer: yes
explanation: Episcleritis is inflammation below the conjunctiva and often associated with an inflammatory nodule. As these vessels are more superficial, they will move and blanch on probing with a phenylephrine soaked cotton bud
name: Episcleritis
label: b
answer: no
explanation: Patients with acute closed angle glaucoma usually present with nausea and vomiting. However, they rarely have visual complaints, and only about 25% will have a headache and a painful red eye
name: Acute closed angle glaucoma
label: e
answer: no
explanation: This is harmless bleeding of blood behind the conjunctiva and is often associated with the use of anticoagulants. It is usually more alarming than anything else and would not normally cause pain and therefore is not the most likely diagnosis here
name: Subconjunctival haemorrhage
label: c
answer: no

Correct answer: a


Learning point: Scleritis presents with severe eye pain, redness, and is often associated with systemic conditions like rheumatoid arthritis.
A 34-year-old male presents to the sexual health clinic concerned about a lump he has found in his left testicle. He is sexually active but does not complain of any penile discharge or any urinary symptoms. On examination, there is a soft fleshy lump that is separate from the spermatic cord. It is only palpable when the patient is standing and not when lying down. It does not transilluminate.

What is the most likely diagnosis?

Options:
explanation: A varicocele is caused by dilated veins of the pampiniform plexus and often may only be present on standing. 90% occur on the left. They are associated with subfertility, but surgical repair appears to have little effect on subsequent pregnancy rates. Treatment is with scrotal support or surgery (varicocelectomy)/embolisation
name: Varicocoele
label: a
answer: yes
explanation: This is infection/inflammation of the testis and epididymis. It is often caused by sexually transmitted infections such as chlamydia but also caused by viral causes such as mumps. Patients report a tender generalised swelling and may have other associated features of infection (temperature, dysuria, penile discharge). Treatment is with antibiotics depending on the likely source (NB if sexually transmitted infection deemed likely source then contact tracing and treatment of partners should be initiated)
name: Epididimo-orchitis
label: c
answer: no
explanation: This would be in the differential and are caused by fluid within the tunica vaginalis; however, the description and the lack of transillumination make varicocoele more likely
name: Hydrocoele
label: b
answer: no
explanation: This is unlikely but should be carefully considered in the differential as testicular tumours are the commonest malignancy in this age demographic. They usually present as a painless, firm lump in the testes found after trauma/infection and may have a secondary hydrocoele
name: Testicular tumour
label: d
answer: no
explanation: This presents as a painless nodule at the head of the epididymis adjacent to the inferior pole of the testis and will transilluminate. They may contain clear or milky (spermatocele) fluid
name: Epididymal cyst
label: e
answer: no

Correct answer: a


Learning point: A varicocele, often present only when standing and typically occurring on the left, is caused by dilated veins of the pampiniform plexus, associated with subfertility, and treated with scrotal support or surgery/embolization.
A 25-year-old female presents to the Emergency Department with right-sided loin to groin pain that she describes as coming in waves and is associated with nausea but no vomiting. Her observations at triage show she is pyrexial at 38.8, tachycardic and hypotensive. Her urine dip is positive for blood and nitrites and negative for pregnancy, and her blood tests reveal raised inflammatory markers.
A CT of kidneys, ureters and bladder (KUB) is performed, demonstrating a right-sided 6mm obstructing calculus associated with hydroureter and hydronephrosis.

What treatment is urgently required?

Options:
explanation: This patient has an infected obstructed system which requires urgent intervention. She is also septic, and therefore treatment with oral antibiotics is unlikely to be sufficient
name: Oral antibiotics
label: b
answer: no
explanation: If medical expulsion therapy does not work in stable patients with stones >5mm, then ESWL is a reasonable choice. This patient is septic and therefore requires urgent decompression with a nephrostomy or ureteric stenting
name: Extracorporeal shockwave lithotripsy (ESWL)
label: d
answer: no
explanation: This patient has an obstructed infected urinary system that needs urgent decompression. As her stone is 6mm and in the upper part of the urethra, decompression with a nephrostomy is indicated. She should also be managed in accordance with sepsis six and started on antibiotics
name: Urgent right nephrostomy
label: a
answer: yes
explanation: Analgesia is indicated in this patient's case; however, it will not treat her underlying condition
name: Analgesia
label: e
answer: no
explanation: Whilst the stone is 6mm and therefore unlikely to pass spontaneously, the main issue here is the infected obstructed system that requires urgent intervention. If she was not septic, then medical expulsive therapy with tamsulosin would be a reasonable choice
name: Tamsulosin
label: c
answer: no

Correct answer: a


Learning point: In cases of obstructed pyelonephritis, urgent nephrostomy is essential to relieve obstruction and prevent further renal damage.