hllj/quesmed huggingface dataset:
A 60-year-old lady is admitted with a three-day history of sudden onset epigastric pain, nausea and two episodes of vomiting.


On examination, her abdomen is soft and diffusely tender. There is no rigidity or guarding.


Observations: temperature 37.0°C, HR 110 bpm, BP 90/60 mmHg, RR 20 bpm, SpO2 99% on room air.


Her bloods show:

||||
|---------------------------|:-------:|--------------------|
|Albumin|40 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|21 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|32 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|110 IU/L|25 - 115|
|Bilirubin|7 µmol/L|< 17|
|Gamma Glutamyl Transferase (GGT)|20 U/L|9 - 40|
|Lipase|432 IU/L|< 101|
|Amylase|289 U/L|< 220|


She was recently started on a new medication. Which of the following is the most likely cause of her current presentation?

Options:
explanation: Another possible differential is peptic ulcer disease, which may have been caused by non-steroidal anti-inflammatory drugs such as ibuprofen. This is unlikely to cause elevated lipase. The patient also does not have signs of peritonism, which might suggest a perforation
name: Ibuprofen
label: c
answer: no
explanation: This woman has presented with acute pancreatitis secondary to valproate, which is a rare cause of pancreatitis. Lipase is more sensitive in patients with pancreatitis as it has a longer half-life than amylase; thus, lipase levels may remain elevated even after amylase levels have normalised
name: Valproate
label: a
answer: yes
explanation: This may cause gastrointestinal upset, including nausea and vomiting, diarrhoea and bloating. Rarely, it may cause lactic acidosis, usually in patients with impaired renal or hepatic function. However, it would not explain the elevated lipase levels
name: Metformin
label: d
answer: no
explanation: This is a known cause of cholestatic hepatitis, which is not the case here, given the normal liver function tests. It does not cause acute pancreatitis
name: Co-amoxiclav
label: b
answer: no
explanation: This may cause gastrointestinal upset, including nausea, vomiting and diarrhoea. It may also cause a metallic taste in the mouth. It is not associated with acute pancreatitis
name: Lithium
label: e
answer: no

Correct answer: a


Learning point: Valproate can cause drug-induced pancreatitis, and other drugs that can also lead to this condition include azathioprine, mercaptopurine, sulfonamides, tetracyclines, estrogens, calcium channel blockers, and furosemide.
A 50-year-old female presents with shortness of breath, dry cough and fatigue for the past two months. She also has bilateral knee pain. She is a non-smoker, does an office-based job and has no other past medical history of note.


Erythrocyte sedimentation rate (ESR) was raised at 66 mm/hour (normal <20 mm/h). Corrected calcium was 2.85 mmol/L (normal range 2.2-2.6 mmol/L). Blood results for full blood count, urea & electrolytes and liver function testing were all unremarkable.


Chest X-ray: bilateral mid to upper zone reticular opacities


Bronchoalveolar lavage (BAL): Increased lymphocytes, no bacterial growth seen, biopsy showing non-caseating granulomas


Which of the following investigation findings is most likely to correspond with her diagnosis?

Options:
explanation: This would occur with obstructive lung diseases such as asthma or chronic obstructive pulmonary disease. This is not likely given the clinical history and the fact she is a non-smoker. Sarcoidosis would typically present with a restrictive picture on lung function testing, although it may also be normal
name: Obstructive pattern on lung function testing
label: d
answer: no
explanation: This is a test used to detect tuberculosis (TB) infection and would be positive in the context of both latent and active TB. Bronchoalveolar lavage (BAL) may be used in the diagnosis of TB if there are difficulties obtaining induced sputum samples. In TB, BAL is more likely to show caseating (necrotising) granulomas, and cultures would be positive for acid-fast bacilli, which is not the case here
name: Interferon gamma release assay (IGRA) positivity
label: e
answer: no
explanation: This woman has sarcoidosis, which may present with non-specific respiratory symptoms, polyarthralgia and multiple other extrapulmonary manifestations. BAL is the most specific test for sarcoidosis. It would show non-necrotising granulomas, which are typical of non-infectious interstitial lung disease (ILD), rather than necrotising granulomas, which are usually seen with infections. Other differential causes of non-infectious ILD include drugs, environmental toxins, immunodeficiency, malignancy, vasculitis and inflammation
name: Raised serum angiotensin-converting enzyme (ACE) levels
label: a
answer: yes
explanation: This is most specific for rheumatoid arthritis, which may also present with pulmonary manifestations including interstitial, pleural and airway disease. It does not usually cause granulomatous lung disease
name: Anti-cyclic citrullinated peptide (CCP) antibody positivity
label: b
answer: no
explanation: Autoimmune vasculitides including granulomatosis with polyangiitis and eosinophilic granulomatosis with polyangiitis, would be possible differentials here given the respiratory symptoms and raised ESR, but it is less likely here given the normal renal function and the raised calcium level
name: Antineutrophil cytoplasmic antibody (ANCA) positivity
label: c
answer: no

Correct answer: a
A 75-year-old man is admitted to the general medical ward with a 3 day history of worsening shortness of breath and a productive cough with green sputum. He has a past medical history of COPD.


On examination, he has visible accessory muscle use and has widespread coarse crepitations with an expiratory wheeze.


Observations:


 - Temperature 38.5°C
 - pulse 105
 - BP 140/70
 - SpO<sub>2</sub> 89% on 40% O<sub>2</sub> via Venturi mask


Arterial blood gas:

||||
|--------------|:-------:|------------------|
|pH|7.27|7.35 - 7.45|
|PaO₂|8 kPa|11 - 15|
|PaCO₂|7.1 kPa|4.6 - 6.4|
|Bicarbonate|15 mmol/L|22 - 30|



Which is the next most appropriate management?

Options:
explanation: This patient has a severe exacerbation of chronic obstructive pulmonary disease (COPD). BiPAP would be indicated in patients with acute respiratory acidosis and would be the most appropriate measure prior to considering intubation and mechanical ventilation
name: Bilevel positive airway pressure (BiPAP) machine
label: a
answer: yes
explanation: In patients with COPD, CPAP would not be preferred as the tidal volume cannot be effectively titrated unlike with BiPAP, hence it is not as suitable for patients with hypercapnia that would require increased alveolar ventilation. CPAP would be indicated in patients with acute cardiogenic pulmonary oedema
name: Continuous positive airway pressure (CPAP) machine
label: b
answer: no
explanation: Non-rebreather masks can deliver an inspired oxygen concentration of up to 90%, but as it is considered uncontrolled oxygen therapy, it would not be appropriate if the patient is known to retain carbon dioxide, as it may exacerbate hypercapnia and respiratory acidosis
name: High flow oxygen via non-rebreather mask
label: d
answer: no
explanation: This would be considered only if the patient is clinically deteriorating and has failed a trial of non-invasive ventilation, is unable to tolerate or has contraindications to it
name: Intubation and mechanical ventilation
label: c
answer: no
explanation: This would be able to provide oxygen of up to 6-10 L per minute, which would likely be insufficient for this patient's current requirements in view of the respiratory acidosis. It is also a form of uncontrolled oxygen therapy which would not be appropriate in carbon dioxide retaining patients
name: Simple face mask
label: e
answer: no

Correct answer: a
A 75 year old lady is admitted to the general medical ward with a 2 day history of worsening shortness of breath and a productive cough. She has a background of asthma since childhood and is known to be poorly compliant with her inhalers.


On examination, she is drowsy and has reduced breath sounds bilaterally.


Observations:


 - Temperature 38.5°C
 - pulse 115
 - BP 110/70
 - respiratory rate 16
 - SpO<sub>2</sub> 96% on 8L oxygen


Arterial blood gas:

||||
|--------------|:-------:|------------------|
|pH|7.37|7.35 - 7.45|
|PaO₂|11.5 kPa|11 - 15|
|PaCO₂|5.1 kPa|4.6 - 6.4|
|Bicarbonate|23 mmol/L|22 - 30|


She has been started on nebulised salbutamol and ipratropium, and has been given IV hydrocortisone and magnesium sulphate. Which is the next most appropriate management?

Options:
explanation: The role of inhaled corticosteroids as an adjunct in asthma exacerbations has not been well established. As the patient has already received high dose IV steroids, this would not be of additional benefit
name: Inhaled corticosteroids
label: d
answer: no
explanation: The patient has features of a life-threatening asthma attack and would benefit from an early ICU review. Patients with a normal pCO2 are at risk of quick deterioration to type 2 respiratory failure due to exhaustion and hypoventilation. The patient should be assessed for consideration of intubation and mechanical ventilation
name: Intensive care unit (ICU) review
label: a
answer: yes
explanation: This would not be appropriate at this stage although the blood gas results seem relatively reassuring. As the patient has a normal pCO2, they are at risk of exhaustion and hypoventilation, and should be considered for early escalation and senior review
name: Watch and observe
label: b
answer: no
explanation: Uncontrolled oxygen delivery may be dangerous in the deteriorating asthmatic patient as it may cause over-oxygenation and worsening hypercapnia if the patient hypoventilates. Controlled supplementary oxygen should be given to maintain oxygen saturations above 94%, with close pulse oximetry monitoring
name: High flow oxygen via non-rebreathe mask
label: c
answer: no
explanation: This is not likely to result in an additional bronchodilator effect compared with inhaled bronchodilators and steroids. It should only be administered after consultation with a senior as it would require close monitoring of levels
name: IV theophylline
label: e
answer: no

Correct answer: a
A 75 year old lady is admitted to the general medical ward with a 3 day history of worsening shortness of breath and a productive cough.


Examination reveals bibasal coarse crepitations and purplish discoloration of her fingers and toes.  

The patient’s observations include a temperature of 38.5°C, pulse of 90, blood pressure of 110/70 mmHg, respiratory rate of 25, and SpO₂ of 98% on 2L oxygen.  




Full blood count:



||||
|--------------|:-------:|---------------|
|Haemoglobin|95 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.1x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|186x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|115 fL|80 - 96|
|Reticulocytes|5 %|0.2 - 2|
|Haptoglobin|12 mg/dL|41 - 165|



Liver function tests:


||||
|---------------------------|:-------:|--------------------|
|Albumin|40 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|21 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|32 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|110 IU/L|25 - 115|
|Bilirubin|58 µmol/L|< 17|
|Conjugated Bilirubin|3.2 µmol/L|0 – 8|
|Unconjugated Bilirubin|26.5 µmol/L|0.2 – 0.8|
|Lactate Dehydrogenase|910 IU/L|70 - 250|




Chest X-ray: Bilateral patchy consolidation



Given the most likely diagnosis and complication that has occurred, which of the following is the most appropriate diagnostic test to find out the causative organism?

Options:
explanation: This would not be useful as Mycoplasma lacks a cell wall and would not be visible on Gram stain. Culture would be of low yield as it is a fastidious organism and would take weeks to grow
name: Immunofluorescence staining
label: d
answer: no
explanation: This would not be useful as Mycoplasma lacks a cell wall and would not be visible on Gram stain. Culture would be of low yield as it is a fastidious organism and would take weeks to grow
name: Gram stain and culture
label: b
answer: no
explanation: This is more appropriate for detecting Legionella or Pneumococcal antigen, which is not the case here. These are not known to be associated with autoimmune haemolytic anaemia
name: Urinary antigen testing
label: c
answer: no
explanation: This may be used as an alternative to molecular testing for Mycoplasma. However, it is impractical as the gold standard for diagnosis would require comparison of acute and convalescent serum samples (approximately 4 weeks apart) to detect a rise in IgG titres
name: Serology testing
label: e
answer: no
explanation: The patient has Mycoplasma pneumonia complicated by cold agglutinin disease, a form of autoimmune haemolytic anaemia that is associated with Mycoplasma infection. This is shown by the raised reticulocyte count and LDH, raised unconjugated bilirubin and decreased haptoglobin level, which are byproducts of red blood cell breakdown. Mycoplasma is a fastidious organism and difficult to grow in culture, hence molecular testing would be advised
name: Nucleic acid amplification testing (NAAT)
label: a
answer: yes

Correct answer: a

Nucleic acid amplification testing (NAAT)
A 40 year old female is admitted to the general medical ward with a 2 week history of fever, worsening shortness of breath and a productive cough with yellow sputum. She has visited her General Practitioner and has completed a 5 day course of antibiotics with no improvement. She has no other past medical history of note.



On examination, she has right sided coarse crepitations with reduced air entry in the right lower zone.



Chest X-ray: Right sided pleural effusion



The respiratory registrar performs a diagnostic pleural tap. The results are as follows:



Appearance - Purulent
Microscopy - Neutrophil predominant
pH - 7.28



||Pleural fluid|Serum|
|---------------------------|-------------|----------|
|Protein|11 g/L|28 g/L|
|Lactate dehydrogenase (LDH)|358 U/L|465 U/L|
|Glucose|2.8 mmol/L|6.9 mmol/L|



Given the pleural fluid results, which is the most likely cause of her pleural effusion?

Options:
explanation: Pulmonary embolism tends to cause a transudative pleural effusion, and this history here does not indicate PE
name: Pulmonary embolism (PE)
label: b
answer: no
explanation: This patient has an exudative effusion fulfilling Light's criteria, with pleural fluid/serum LDH ratio >0.6 and pleural fluid LDH >2/3 the upper limit of normal serum LDH. Parapneumonic effusions may occur with bacterial pneumonia, and may cause either simple or complicated effusions (including empyema). This would usually show up on pleural tap as purulent pleural fluid with neutrophil predominance, pH <7.3, low glucose and raised LDH. Clinical presentation may be similar to that of pneumonia
name: Bacterial pneumonia
label: a
answer: yes
explanation: Whilst malignancy often causes a exudative effusion, this is unlikely given her young age and more recent onset of symptoms
name: Malignancy
label: c
answer: no
explanation: In rheumatoid pleurisy, pleural fluid is likely to be low in glucose with raised LDH and pH <7.3, which is rather similar to the pleural fluid results in this patient. However, the history is not suggestive of rheumatoid arthritis
name: Rheumatoid arthritis
label: e
answer: no
explanation: Pulmonary embolism tends to cause a transudative pleural effusion, and this history here does not indicate PE
name: Heart failure
label: d
answer: no

Correct answer: a

Bacterial pneumonia
A 70-year-old man is admitted with sudden onset right ankle pain and swelling for 1 day, the third episode this year. His medical history includes type 2 diabetes and chronic kidney disease, likely from diabetic nephropathy.


On examination, his right ankle is erythematous, warm, and tender, with full range of movement.




Observations: Temperature 38.1°C, pulse 90, BP 110/70, respiratory rate 18, SpO<sub>2</sub> 100% on room air



Initial blood tests are as follows:

||||
|--------------|:-------:|---------------|
|Haemoglobin|142 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.1x10<sup>9</sup>/L|3.0 - 10.0|
|Neutrophils|5.5x10<sup>9</sup>/L|2.0 - 7.5|
|Platelets|210x10<sup>9</sup>/L|150 - 400|
|Sodium|137 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Chloride|102 mmol/L|95 - 106|
|Urea|8 mmol/L|2.5 - 7.8|
|Creatinine|151 µmol/L|60 - 120|
|eGFR|60 mL/min/1.73m<sup>2</sup>|> 60|





X-ray of the right ankle showed no acute fractures or bony erosions.



Which of the following is the next most appropriate treatment?

Options:
explanation: This may be considered if the patient has very poor renal function and is not able to take either non-steroidal anti-inflammatory drugs or colchicine. Blood glucose monitoring should be done whilst on prednisolone, especially since the patient is diabetic, as it usually causes elevated glucose levels in the evening or nighttime
name: Prednisolone
label: c
answer: no
explanation: This patient likely has an acute attack of crystal arthropathy. Septic arthritis should be ruled out, especially in a diabetic patient who may be immunocompromised. Joint aspiration should be considered for diagnosis. Colchicine would be suitable in a patient with chronic kidney disease, and renal adjustment considered if eGFR 10-50, below which it would be contraindicated
name: Colchicine
label: a
answer: yes
explanation: This would not be appropriate in a patient with chronic kidney disease as it may worsen renal function. Creatinine clearance should be calculated first. Proton pump inhibitor therapy should also be considered if initiating treatment with non-steroidal anti-inflammatory drugs
name: Naproxen
label: b
answer: no
explanation: This would not be appropriate in a patient with chronic kidney disease as it may worsen renal function. Creatinine clearance should be calculated first. Proton pump inhibitor therapy should also be considered if initiating treatment with non-steroidal anti-inflammatory drugs
name: Allopurinol
label: d
answer: no
explanation: This would be a second-line agent for urate lowering therapy if allopurinol is contraindicated, not tolerated or unable to achieve target serum uric acid
name: Febuxostat
label: e
answer: no

Correct answer: a

Colchicine

Learning point: Colchicine can be used for gout in chronic kidney disease, but doses must be reduced for an eGFR of 10-50 to avoid toxicity, with close monitoring
A 40 year old gentleman is admitted to the acute medical unit with a 1 day history of sudden onset right ankle pain and swelling. He has no other past medical history.



On examination, his right ankle is erythematous, warm and tender on palpation. There is limited active and passive range of movement in the ankle joint due to pain.



Observations:



  - Temperature 38.5°C
  - pulse 90
  - BP 110/70
  - respiratory rate 18
  - SpO<sub>2</sub> 100% on room air



Initial blood tests are as follows:



||||
|--------------|:-------:|---------------|
|Haemoglobin|142  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.1x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|210x10<sup>9</sup>/L|150 - 400|
|Neutrophils|13x10<sup>9</sup>/L|2.0 - 7.5|



Joint aspiration is done which shows a cloudy yellow fluid with a predominance of neutrophils. The following is seen on Gram stain:



  [lightgallery]



Which is the most likely causative organism?

Options:
explanation: This would appear as Gram-negative intracellular diplococci. It is associated with young sexually active adults
name: Escherichia coli
label: d
answer: no
explanation: This would appear as Gram-positive diplococci in clusters. This is seen as purple staining cocci that appear similar to "bunches of grapes". S. aureus is a common cause of septic arthritis in otherwise healthy adults and may be associated with prosthetic joint infections
name: Staphylococcus aureus
label: a
answer: yes
explanation: This would appear as Gram-negative bacilli. It is an uncommon cause of septic arthritis
name: Pseudomonas aeruginosa
label: e
answer: no
explanation: This would appear as Gram-positive elongated diplococci
name: Streptococcus pneumoniae
label: c
answer: no
explanation: This would appear as Gram-negative intracellular diplococci. It is associated with young sexually active adults
name: Neisseria gonorrhoeae
label: b
answer: no

Correct answer: a

Staphylococcus aureus

Learning point: Staphylococcus aureus is the most common causative organism of septic arthritis.
A 50 year old woman presents with an episode of sudden painless visual loss in her right eye this morning. She also complains of a 2 week history of persistent frontal headache and morning stiffness of the shoulders and hips worse in the past year.

Physical examination is otherwise unremarkable.

Computed tomography (CT) brain showed no acute intracranial abnormalities.

Which of the following findings is most likely associated with her condition?

Options:
explanation: This may be found in transient ischaemic attack (TIA) due to carotid thromboembolism, which may result in transient monocular visual loss or amaurosis fugax. A TIA would not explain the frontal headache and joint stiffness
name: Carotid artery stenosis on ultrasound Doppler
label: b
answer: no
explanation: This patient has giant cell arteritis and polymyalgia rheumatica, which are closely associated. Raised ESR is a characteristic finding. Sudden onset vision loss is a red flag and requires urgent steroid treatment to avoid permanent vision loss
name: Raised erythrocyte sedimentation rate (ESR)
label: a
answer: yes
explanation: Headache may be a symptom of raised intracranial pressure. This may occur due to a wide range of aetiologies, including intracranial haemorrhage, neoplasm, stroke, infections, hydrocephalus. However, the patient does not have any neurological abnormalities so this would be less likely. Idiopathic intracranial hypertension may present with headache and vision loss but this is less likely to be unilateral
name: Raised cerebrospinal fluid (CSF) pressure
label: d
answer: no
explanation: This is highly specific for rheumatoid arthritis (RA), which is an inflammatory arthritis that may also present with pain and morning stiffness in joints. However, RA is more likely to have peripheral joint involvement, as opposed to axial involvement in polymyalgia rheumatica
name: Anticyclic citrullinated peptide (anti-CCP) antibody positivity
label: e
answer: no
explanation: This is classically found in ankylosing spondylitis, which may present with neck or back pain with morning stiffness that improves on exercise. However, this is more likely associated with anterior uveitis, which would cause painful visual loss
name: Inflammation of the sacroiliac joints
label: c
answer: no

Correct answer: a


Learning point: Giant cell arteritis is associated with polymyalgia rheumatica and typically presents with a raised erythrocyte sedimentation rate (ESR).