hllj/quesmed huggingface dataset:
A patient with a recent diagnosis of motor neurone disease is admitted to hospital with a suspected subarachnoid haemorrhage.

They were unconscious and were intubated as soon as they arrived in the emergency department.

The patient's wife arrives at the hospital and informs staff that her husband has made an advanced decision to refuse treatment (ADRT), which specifies that he is not to be intubated and ventilated under any circumstances. She asks that he be extubated.

Which of the following is required to ensure the ADRT is valid?

Options:
explanation: This is incorrect; the Mental Capacity Act requires people to specify (in lay or medical terms) the treatment they wish to refuse and they may specify the circumstances, if any, in which that treatment is to be refused.
name: It does not have to specify which treatments the patient wishes to refuse
label: e
answer: no
explanation: This is incorrect; while patients may want/benefit from the support of a clinician, there is no legal requirement for this to be the case.
name: It must be made in front of a doctor
label: b
answer: no
explanation: This is incorrect; advanced directives often concern life-sustaining treatment. It is important that the advanced decision is written down, signed, and witnessed if this is the case.
name: It is invalid, as the patient is refusing life-sustaining treatment
label: d
answer: no
explanation: This is incorrect; if the patient verbalises or indicates that they have changed their mind, their advanced decision no longer stands.
name: It stands, even if the patient verbally says they have changed their mind
label: c
answer: no
explanation: This is correct - advanced decisions to refuse treatment that concern life-sustaining measures must be signed by a witness, as well as the patient. Without this, the advanced decision is invalid in law, but this could be considered an advanced statement that could be used to help inform a best interests decision.
name: It must be signed by a witness
label: a
answer: yes

Correct answer: a


Learning point: An advanced decision to refuse treatment must be signed by a witness to be legally valid.
A 64-year-old lady is admitted to the hospital with severe abdominal pain and rigors. She is confused and is unable to elaborate on her history. On examination, she is exquisitely tender in the right upper quadrant.


Observations:

 * Heart rate: 112 beats/minute

 * Blood pressure: 102/69 mmHg

 * Respiratory rate: 17 breaths/minute

 * Temperature: 38.7 degrees

 * Oxygen saturations (room air): 98%


Bloods:


||||
|--------------|:-------:|---------------|
|Haemoglobin|121    g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|21x10<sup>9</sup>/L|3.0 - 10.0|
|Mean Cell Volume (MCV)|77.1 fL|80 - 96|
|Creatinine|100 µmol/L|60 - 120|
|Alanine Aminotransferase (ALT)|61 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|64 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|428 IU/L|25 - 115|
|Bilirubin|87 µmol/L|< 17|


Which of the following is the definitive management of her acute presentation?

Options:
explanation: The patient has a complication of gallstone disease, ascending cholangitis. While a cholecystectomy will eventually be required, this will not definitively manage the CURRENT issue. Laparoscopic cholecystectomy is usually preferred over the open approach. The obstructing, infected area needs to be decompressed by ERCP.
name: Open cholecystectomy
label: e
answer: no
explanation: This patient has ascending cholangitis and presents with the typical triad of jaundice, fever, and right upper quadrant pain. Antibiotics and fluids will be administered as supportive therapy, but this will not definitively control the source of the infection. An ERCP is required so that the biliary tree can be visualised, and the obstructing stone can be removed, relieving the obstruction and controlling the source of the infection.
name: Antibiotics and fluids
label: c
answer: no
explanation: This patient has ascending cholangitis and presents with the typical triad of jaundice (high bilirubin), fever, and right upper quadrant pain. She also has obstructive-pattern liver enzyme derangements. An ERCP is required so that the biliary tree can be visualised, and the obstructing stone can be removed, relieving the obstruction and controlling the source of the infection.
name: Endoscopic retrograde cholangiopancreatography (ERCP)
label: a
answer: yes
explanation: The patient has a complication of gallstone disease, ascending cholangitis. While a cholecystectomy will eventually be required, this will not definitively manage the CURRENT issue. The obstructing, infected area needs to be decompressed by ERCP.
name: Laparoscopic cholecystectomy
label: d
answer: no
explanation: This patient has ascending cholangitis and presents with the typical triad of jaundice (high bilirubin), fever, and right upper quadrant pain. A PTC is a way of assessing the biliary tree, however, an ERCP is less invasive and allows better access for decompression of the infected area and removal of stones.
name: Percutaneous transhepatic cholangiography (PTC)
label: b
answer: no

Correct answer: a


Learning point: Emergency endoscopic retrograde cholangiopancreatography (within 24 hours) is needed for adults with common bile duct stones and acute cholangitis or acute pancreatitis when indicated
A 77-year-old man has had severe progressive constipation for the past week and has started vomiting today. His GP referred him to the emergency department as he was in significant discomfort.

On examination, he has a tense, distended, uncomfortable abdomen. There are no signs of peritonism. His rectum is empty on PR examination, with no masses or faeces noted.

Observations are stable. Blood tests show hypernatraemia and a raised CRP.

An abdominal x-ray is performed:

[lightgallery]

What is the most likely underlying diagnosis?

Options:
explanation: The x-ray shows large bowel obstruction, as the dilated bowel loops are peripheral and show haustra (rather than the valvulae conniventes seen in small bowel obstruction). Adhesions usually cause small bowel obstruction, not large bowel obstruction.
name: Adhesional bowel obstruction
label: b
answer: no
explanation: The x-ray appearances are in keeping with large bowel obstruction, which is commonly caused by colorectal carcinoma. Mesenteric ischaemia would present more acutely, with severe pain and without these x-ray findings. The serum lactate may be raised.
name: Mesenteric ischaemia
label: e
answer: no
explanation: Pseudo-obstruction is a differential, however, it is a rare diagnosis and one that can only be made when cross-sectional imaging fails to demonstrate a mechanical obstruction. It is more likely that this patient has a mechanical large bowel obstruction, caused by an underlying carcinoma.
name: Pseudo-obstruction (Ogilve's Syndrome)
label: d
answer: no
explanation: The history, examination findings, and x-ray appearance of dilated peripheral bowel loops are in keeping with large bowel obstruction. The most common cause of large bowel obstruction (especially in this demographic) is an obstructing tumour. Hypernatraemia is due to dehydration due to poor oral intake.
name: Colorectal carcinoma
label: a
answer: yes
explanation: The appearance of the x-ray and the clinical presentation is suggestive of large bowel obstruction, likely secondary to a tumour. Inflammatory bowel disease can cause toxic megacolon (which has a different appearance), or classically small bowel obstruction (e.g. in Crohn's). The history does not mention a chronic course of events.
name: Inflammatory bowel disease
label: c
answer: no

Correct answer: a


Learning point: Colorectal carcinoma is a common cause of large bowel obstruction in elderly patients presenting with progressive constipation and abdominal distension.
A patient is admitted to hospital with a severe exacerbation of heart failure. They have a background of type 2 diabetes, hypertension, and hypercholesterolaemia.


An infusion of furosemide (10mg/hour) is commenced due to significant pulmonary oedema. A venous blood gas (VBG) shows:


||||
|--------------|:-------:|------------------|
|pH|7.32|7.35 - 7.45|
|PaO₂|4.9 kPa|11 - 15|
|PaCO₂|3.2 kPa|4.6 - 6.4|
|Bicarbonate|20.8 mmol/L|22 - 30|
|Lactate|3.4 mmol/L|0.6 - 1.4|
|Sodium|136 mmol/L|135 - 145|
|Potassium|4.3 mmol/L|3.5 - 5.3|
|Non-fasting Glucose|6.9 mmol/L|< 6.1|


Which medication is most important to stop in light of these results?

Options:
explanation: This patient has a mild lactic (metabolic) acidosis. This is likely due to organ hypoperfusion caused by heart failure. Metformin has been linked to the development/exacerbation of lactic acidosis, and therefore is the most important medication to hold.
name: Metformin
label: a
answer: yes
explanation: There is no indication to hold atorvastatin in this case, such as rhabdomyolysis or statin-induced myopathy. Metformin has been linked to the development/exacerbation of lactic acidosis, and therefore is the most important medication to hold.
name: Atorvastatin
label: c
answer: no
explanation: Furosemide will be required to treat this patient's pulmonary oedema and heart failure. Metformin has been linked to the development/exacerbation of lactic acidosis, and therefore is the most important medication to hold.
name: Furosemide
label: b
answer: no
explanation: Ramipril increases life expectancy in patients with heart failure. There is no current indication to hold it, e.g. an acute kidney injury or hypotension. Metformin has been linked to the development/exacerbation of lactic acidosis, and therefore is the most important medication to hold.
name: Ramipril
label: e
answer: no
explanation: The patient's blood sugar is within range, and there is no reason at present to hold gliclazide. It may be held or reduced if the patient is commenced on a variable rate insulin infusion, however. Metformin has been linked to the development/exacerbation of lactic acidosis, and therefore is the most important medication to hold.
name: Gliclazide
label: d
answer: no

Correct answer: a


Learning point: Metformin-associated lactic acidosis is a rare but serious complication, typically occurring in patients with renal impairment or conditions causing hypoxia. It results from lactate accumulation due to impaired gluconeogenesis and metabolism
A patient is brought to the resuscitation room in the emergency department after being found collapsed on the street. No medical history is available.

On examination, they have small pupils, which are minimally reactive to light. They are rousable to pain but not to voice. The airway appears patent.

Observations:

* Heart rate: 139 beats/minute

* Blood pressure: 120/76 mmHg

* Respiratory rate: 6 breaths/minute

* Temperature: 36.8 degrees

* Oxygen saturations (room air): 89%

What is the most important next step to take?

Options:
explanation: This is inappropriate. The patient is showing signs of opioid toxicity that must be treated. Supportive management is more appropriate for benzodiazepine overdoses that do not cause airway/respiratory compromise.
name: Supportive management only
label: b
answer: no
explanation: Naloxone will be required as this is a likely opioid overdose, however, it will take time to locate, draw up, and administer this. Following the A-E approach, it is most important (assuming the airway is patent) to support this patient's breathing with a bag-valve mask connected to oxygen, until naloxone can be administered. Not doing this could lead to respiratory, and then cardiac, arrest.
name: Administer naloxone
label: c
answer: no
explanation: This patient is showing signs of opioid toxicity, potentially secondary to recreational use. Following the A-E approach, it is most important (assuming the airway is patent) to support this patient's breathing with a bag-valve mask connected to oxygen, until naloxone can be administered. Not doing this could lead to respiratory, and then cardiac, arrest.
name: Bag-valve mask ventilation
label: a
answer: yes
explanation: This patient is showing signs of opioid toxicity, potentially secondary to recreational use. There is no mention of airway compromise in the information given. Following the A-E approach, it is most important (assuming the airway is patent) to support this patient's breathing with a bag-valve mask connected to oxygen, until naloxone can be administered. Not doing this could lead to respiratory, and then cardiac, arrest. Intubation may be considered further down the line, but is not the next best step.
name: Intubation
label: d
answer: no
explanation: This patient is showing signs of an opiate overdose. Naloxone, rather than naloxegol, is used in these situations. First, however, the patient's breathing must be supported with bag valve mask ventilation.
name: Administer naloxegol
label: e
answer: no

Correct answer: a


Learning point: In cases of suspected opioid toxicity, immediate bag-valve mask ventilation is crucial to support respiration and prevent respiratory arrest.
A 43-year-old man is referred to the rheumatology clinic by his GP for investigation of joint stiffness and pain, mainly involving the hands (left more than the right)

On examination, he has marked dactylitis of the left index finger. He also has a scaly rash on his right elbow. His distal interphalangeal joints are tender to palpation.

Given the most likely diagnosis, which other finding is likely to be elicited?

Options:
explanation: The likely diagnosis is psoriatic arthritis, given the asymmetrical distribution, dactylitis, rash, and involvement of the distal interphalangeal joints. Livedo reticularis is a rash seen in some vasculitides, as well as anti-phospholipid syndrome.
name: Livedo reticularis
label: e
answer: no
explanation: The likely diagnosis is psoriatic arthritis, given the asymmetrical distribution, dactylitis, rash, and involvement of the distal interphalangeal joints. Onycholysis and nail pitting are common features of the condition.
name: Onycholysis
label: a
answer: yes
explanation: The likely diagnosis is psoriatic arthritis, given the asymmetrical distribution, dactylitis, rash, and involvement of the distal interphalangeal joints. Paronychia is an infection of the nail fold.
name: Paronychia
label: d
answer: no
explanation: The likely diagnosis is psoriatic arthritis, given the asymmetrical distribution, dactylitis, rash, and involvement of the distal interphalangeal joints. Nodules are a feature of rheumatoid, rather than psoriatic, arthritis.
name: Nodules
label: c
answer: no
explanation: The likely diagnosis is psoriatic arthritis, given the asymmetrical distribution, dactylitis, rash, and involvement of the distal interphalangeal joints. Tophi are usually found in gout - these are depositions of urate crystals that are often visible and palpable.
name: Tophi
label: b
answer: no

Correct answer: a


Learning point: Onycholysis, the painless separation of the nail from its bed, is a common nail manifestation in psoriatic arthritis. It occurs due to inflammation, often accompanied by pitting and subungual hyperkeratosis.
A 30-year-old woman with a history of poorly controlled ulcerative colitis is referred to the musculoskeletal clinic due to severe left groin and buttock pain that is stopping her from being able to mobilise as usual. She says this has developed gradually.

On examination of her legs, she has restricted, painful active and passive movement in the left hip joint, especially on internal rotation.

What is the most likely diagnosis?

Options:
explanation: The involvement of a large, isolated joint is not classical of rheumatoid arthritis (RA). RA usually causes multiple small-joint arthritis. The most likely diagnosis here is avascular necrosis.
name: Rheumatoid arthritis
label: b
answer: no
explanation: No history of trauma has been given. The most likely diagnosis in this case is avascular necrosis, likely due to steroid use for ulcerative colitis.
name: Trauma
label: e
answer: no
explanation: The pattern of single large joint involvement is not typical of psoriatic arthritis. There are no features in the history (e.g. DIP joint involvement, psoriasis, asymmetrical arthritis, dactylitis) to suggest this as the diagnosis. The most likely diagnosis in this case is avascular necrosis, likely due to steroid use for ulcerative colitis.
name: Psoriatic arthritis
label: d
answer: no
explanation: This patient likely has avascular necrosis of the femoral head, contributed to by long-term steroid use for ulcerative colitis. Other risk factors for this condition include smoking, alcohol use, and sickle cell anaemia. The insidious onset and pain in the groin/buttock region, as well as painful internal rotation, are classic findings in this condition. X-rays and an MRI scan will most likely be required.
name: Avascular necrosis
label: a
answer: yes
explanation: While osteoarthritis often affects the hips and has a gradual onset, this is a more likely diagnosis in an older patient. The most likely diagnosis in this case is avascular necrosis, likely due to prolonged steroid use for ulcerative colitis.
name: Osteoarthritis
label: c
answer: no

Correct answer: a


Learning point: Avascular necrosis often presents with gradual hip pain and restricted movement, commonly associated with long-term steroid use.
A patient with long-standing rheumatoid arthritis visits her rheumatologist for a routine appointment. On systemic enquiry, she reports feeling well in herself with well-controlled symptoms. She does mention, however, that she has had trouble reading recently and is seeing colours less vividly than she used to.

Which medication may account for these symptoms?

Options:
explanation: Retinal toxicity is a rare, but extremely important, side effect of hydroxychloroquine therapy. This patient's symptoms may signify the development of a scotoma (visual blind spot), which is a typical presentation of hydroxychloroquine retinopathy, along with colour vision loss. Patients taking the drug should be regularly screened with retinal photography and optical coherence tomography.
name: Hydroxychloroquine
label: a
answer: yes
explanation: Visual symptoms are not typical side effects of sulfasalazine therapy. More likely is retinopathy caused by hydroxychloroquine use.
name: Sulfasalazine
label: e
answer: no
explanation: Visual symptoms are not typical side effects of azathioprine therapy. More likely is retinopathy caused by hydroxychloroquine use.
name: Azathioprine
label: d
answer: no
explanation: Visual symptoms are not typical side effects of infliximab therapy. More likely is retinopathy caused by hydroxychloroquine use.
name: Infliximab
label: c
answer: no
explanation: Visual symptoms are not typical side effects of methotrexate therapy. More likely is retinopathy caused by hydroxychloroquine use.
name: Methotrexate
label: b
answer: no

Correct answer: a


Learning point: Hydroxychloroquine can cause retinal toxicity, leading to symptoms like colour vision loss and scotomas; regular eye screening is essential for patients.
A 19-year-old woman has been referred to the rheumatology clinic for investigation of polyarthralgia, recurrent mouth ulcers, and a butterfly-shaped rash on her face. She describes the symptoms developing over a few months and has a strong family history of autoimmune disorders.

Given the most likely diagnosis, which of the following autoantibodies is most likely to be positive?

Options:
explanation: The question asks which is the most sensitive test (i.e. which would most likely be positive) for lupus, which is the most likely diagnosis. Anti-CCP antibodies are extremely specific for rheumatoid arthritis, rather than lupus.
name: Anti-CCP antibodies
label: c
answer: no
explanation: The question asks which is the most sensitive test (i.e. which would most likely be positive) for lupus, which is the most likely diagnosis. Anti-Smith antibodies are extremely specific for lupus, however, they are not the most likely antibody to be found.
name: Anti-Smith antibodies
label: b
answer: no
explanation: The question asks which is the most sensitive test (i.e. which would most likely be positive) for lupus, which is the most likely diagnosis. Anti-smooth muscle antibodies are more strongly associated with autoimmune hepatitis, rather than lupus.
name: Anti-smooth muscle antibodies
label: d
answer: no
explanation: Anti-nuclear antibodies are found in around 99% of patients with lupus, which is the most likely diagnosis. The question asks which is the most **sensitive** test (i.e. which would most likely be positive), and so this is the correct answer.
name: Anti-nuclear antibodies
label: a
answer: yes
explanation: The question asks which is the most sensitive test (i.e. which would most likely be positive) for lupus, which is the most likely diagnosis. Anti-dsDNA antibodies are extremely specific for lupus, however, they are not the most likely antibody to be found.
name: Anti-double-stranded DNA antibodies
label: e
answer: no

Correct answer: a


Learning point: Anti-nuclear antibodies (ANAs) are autoantibodies produced by the immune system that target components of the cell nucleus, such as DNA, RNA, histones, and nuclear proteins. .
A 66-year-old woman is admitted to hospital after suffering a fall at home. She has severe pain around the left hip region and says she cannot move her leg.

On examination, her left leg is shortened and externally rotated. A pelvic X-ray shows a Garden IV intracapsular neck of femur fracture.

The patient has no significant past medical history and reports being completely independent with all activities of daily living, without the need for any walking aids.

What is the most appropriate course of management?

Options:
explanation: This is not appropriate; the patient has an intracapsular fracture. Dynamic hip screws are used in cases of intertrochanteric fractures. This patient requires a total hip replacement.
name: Dynamic hip screw
label: d
answer: no
explanation: This is not appropriate; intramedullary nails are used for subtrochanteric fractures, to fix the femoral shaft. This patient requires a total hip replacement.
name: Intramedullary nail
label: c
answer: no
explanation: ORIF can be considered for patients with minimally displaced (i.e. Garden I/II) fractures. This option is generally considered in younger patients, as it minimises the risk of a re-operation due to failure of a prosthetic. This patient may have been a candidate for an ORIF if their fracture was less displaced, however it has been classified Garden IV. They require a total hip replacement.
name: Open reduction, internal fixation (ORIF)
label: e
answer: no
explanation: This would be an appropriate course of treatment if the patient was older, frailer, or had poor baseline mobility. This is because while a hemiarthroplasty is less complex than a total hip replacement, the improvement in quality of life provided is not as good, and the rates of revision operations are higher.
name: Hemiarthroplasty
label: b
answer: no
explanation: This is the most appropriate course of management of the options provided, as the patient has good mobility at baseline and has an intracapsular fracture. A total hip replacement is more appropriate given the patient is relatively young, as this procedure has been shown to provide patients with a better quality of life and a lower rate of needing a revision operation.
name: Total hip replacement
label: a
answer: yes

Correct answer: a


Learning point: In patients with intracapsular neck of femur fractures and good pre-injury mobility, total hip replacement is often the preferred management option.