hllj/quesmed huggingface dataset:
A 32-year-old woman attends an appointment in the emergency surgery clinic due to persistent abdominal pain.

The patient is seen by a doctor and listed for an outpatient cholecystectomy following a review of the imaging she had the previous day.

However, it transpires that the doctor has mistakenly reviewed the imaging of a patient with the same name, having failed to check the patient's age and hospital number.

Which of the following principles is most pertinent following identification of this error?

Options:
explanation: Duty of candour states that "all healthcare professionals should be open and honest with patients when treatment or care causes, or has the potential to cause, harm or distress". In this situation, the doctor should contact the patient as soon as possible and inform them of the error. They should also report the incident so it can be investigated internally to reduce similar occurrences in the future
name: Professional duty of candour
label: a
answer: yes
explanation: Confidentiality is a legal right that all patients have. Although the doctor has inadvertently breached confidentiality by informing the patient of another patients test results, duty of candour is more pertinent given that a patient is likely to undergo an unnecessary operation
name: Confidentiality
label: b
answer: no
explanation: The doctrine of double effect states that if the primary intervention was in a patient's best interests, then an unintended adverse effect is not necessarily unlawful. It does not apply in this case
name: The doctrine of double effect
label: c
answer: no
explanation: Informed consent relies on the principles of the patient being fully informed, having mental capacity and not being coerced into a decision. It is not applicable in this case as the patient has consented to a surgery based on the wrong information
name: Informed consent
label: d
answer: no
explanation: Shared decision refers to a process where both the doctor and the patient contribute towards making a personalised decision on management
name: Shared decision making
label: e
answer: no

Correct answer: a


Learning point: Duty of candour states that "all healthcare professionals should be open and honest with patients when treatment or care causes, or has the potential to cause, harm or distress"
A 2-year-old boy presents to the paediatric emergency department (ED) after his parents noted that he was struggling with his breathing. They note that for the last three days, he has had a dry cough and runny nose with mild temperature spikes.

On examination, the boy is tachypnoeic and using his accessory muscles. His temperature is 38°C, and there is a high-pitched rasping sound audible during inspiration.

Given the likely diagnosis, which of the following is the most likely causative organism?

Options:
explanation: Croup (acute laryngotracheobronchitis) is an upper airways disease that is most common in children aged between 6 months to 3 years. It usually presents with difficulty in breathing, fever, stridor and a seal or dog-like barking-cough on the background of a coryzal illness. Parainfluenza virus is the most common causative organism
name: Parainfluenza
label: a
answer: yes
explanation: Bordetella is the causative agent in pertussis (whooping cough). This is a bacterial infection that is rarer than croup due to effective vaccination. Pertussis can present with an inspiratory gasp; however, the high-pitching rasping sound described in the question is more suggestive of stridor
name: Bordetella pertussis
label: d
answer: no
explanation: Rhinovirus is a well-recognised cause of croup; however, it is less common than parainfluenza
name: Rhinovirus
label: e
answer: no
explanation: RSV can cause croup; however, parainfluenza is more common. RSV is the most common causative organism in bronchiolitis
name: Respiratory syncytial virus (RSV)
label: b
answer: no
explanation: Mycoplasma is a rare cause of croup
name: Mycoplasma pneumoniae
label: c
answer: no

Correct answer: a


Learning point: Croup, characterised by stridor and a barking cough, is commonly caused by the parainfluenza virus in children aged 6 months to 3 years.
A 24-year-old homosexual male presents with a two-week history of enlarging lumps in both sides of his groin. He reports noticing a painless penile ulcer around three weeks ago that resolved spontaneously.

He denies any other symptoms on questioning but reports having had multiple sexual partners over the last three months.

Examination of his groin is significant for the findings shown in the image below.

[lightgallery]

Given the likely diagnosis, which of the following is the most appropriate treatment option?

Options:
explanation: The most likely diagnosis is lymphogranuloma venerum (LGV). This is a sexually transmitted infection that is caused by specific serovars of Chlamydia trachomatis. The primary infection of infection is characterised by painless genital ulceration. The secondary stage follows weeks later with painful, inguinal and/or femoral lymphadenopathy (buboes). The first-line treatment option is with a three-week course of doxycycline
name: Doxycycline
label: a
answer: yes
explanation: This is the first-line treatment for syphilis. Although primary syphilis presents with a painless genital ulcer, secondary syphilis would present differently with features such as a maculopapular rash, generalised lymphadenopathy and constitutional symptoms
name: IM benzathine penicillin
label: b
answer: no
explanation: Aciclovir can be used for recurrent cases of genital herpes which is caused by Herpes simplex virus. Genital herpes would present with painful genital ulceration and it is not associated with buboes
name: Oral aciclovir
label: d
answer: no
explanation: Conservative management would be the first-line treatment for genital herpes. Genital herpes would present with painful genital ulceration and it is not associated with buboes
name: Conservative management with analgesia
label: e
answer: no
explanation: Ceftriaxone is the first-line treatment for uncomplicated, anogenital gonorrhoea. The clinical vignette is suggestive of LGV which is caused by Chlamydia species
name: IM ceftriaxone
label: c
answer: no

Correct answer: a


Learning point: Lymphogranuloma venereum, a sexually transmitted infection caused by Chlamydia trachomatis, is managed with doxycycline 100 mg twice daily for 21 days to eliminate the infection and prevent complications.
A 17 year old competitive triathlete presents to her GP concerned that her periods have stopped. She tells you she has been stressed recently as she is training intensively for an upcoming national competition.

Which is the most appropriate initial investigation?

Options:
explanation: This is a reasonable next step test if you are concerned that this is secondary amenorrhoea due to a hypothalamic or pituitary cause. In this case it's more likely to be due to intensive exercise
name: Serum FSH and LH measurement
label: b
answer: no
explanation: TVUS is an invasive examination and would therefore not be the initial investigation of choice. A TVUS may be indicated where the pregnancy test is negative and polycystic ovary syndrome is a possible cause of her amenorrhoea
name: Transvaginal ultrasound scan (TVUS)
label: d
answer: no
explanation: A high testosterone might indicate an androgen secreting tumour or polycystic ovary syndrome which is less likely in this example
name: Serum testosterone level
label: c
answer: no
explanation: Whilst the most likely cause is exercise induced amenorrhoea, a urinary pregnancy test is indicated in this patient in the first instance
name: Urinary pregnancy test
label: a
answer: yes
explanation: A random cortisol level is part of the investigation for adrenal insufficiency and therefore will not aid diagnosis here
name: Serum cortisol level
label: e
answer: no

Correct answer: a


Learning point: In young female athletes, exercise-induced amenorrhoea is common, but a urinary pregnancy test should be performed to rule out pregnancy first.
An 56 year old female with a known ovarian fibroma presents to accident and emergency with breathlessness and abdominal distension. On examination, she is breathless at rest with reduced air entry at the right base. Her abdomen is soft, non tender and distended with evidence of shifting dullness on percussion.

What is the most likely cause of her breathlessness?

Options:
explanation: This is unlikely in this case as there is nothing in the history to suggest that this patient has heart failure and she has no other features of heart failure (e.g. peripheral oedema, raised JVP). Heart failure may cause _bilateral_ reduced air entry
name: Heart failure
label: e
answer: no
explanation: An ovarian fibroma is a benign tumour and therefore less likely to provoke a pulmonary embolism. The history does not suggest any other risk factors for PE. She also doesn't have any other features of PE aside from breathlessness, e.g. chest pain, leg swelling, haemoptysis
name: Pulmonary embolism (PE)
label: b
answer: no
explanation: Whilst patients may feel anxious about new symptoms when they have an underlying health condition, it would not explain her abdominal distension or chest findings
name: Anxiety
label: c
answer: no
explanation: Depending on the level of abdominal distention some patients may experience breathlessness due to their inability to take deep breaths. In this case, this would not explain her unilateral reduced air entry on examination
name: Splinting of the diaphragm
label: d
answer: no
explanation: This patient has a known benign solid ovarian tumour and the case vignette points towards Meigs' syndrome. Meigs' syndrome is defined as the triad of benign ovarian tumour (most commonly a fibroma), pleural effusion and ascites
name: Pleural effusion
label: a
answer: yes

Correct answer: a


Learning point: Meigs' syndrome is characterised by the presence of a benign ovarian tumour, pleural effusion, and ascites.
A 27 year old male with known sickle cell disease presents to his local accident and emergency department with an eight hour history of a painful right knee. His triage observations are as follows: SpO<sub>2</sub> 97% on air, respiratory rate 18, pulse 108 (regular), blood pressure 90/60 mmHg, temperature 39.2°C.

His knee is erythematous and hot to the touch and he has very minimal active movement.

What test will give you the definitive diagnosis?

Options:
explanation: A knee x-ray may be helpful in showing a large effusion but the history is not suggestive of a bony injury therefore x-ray will not give you a definitive diagnosis in this case
name: Knee x-ray
label: b
answer: no
explanation: Whilst blood cultures should always be taken in patients who present with sepsis, a positive blood culture would not necessarily tell you the focus of the infection. As the knee is the presumed focus, an aspirate directly from the joint will likely yield the definitive diagnosis
name: Blood culture
label: c
answer: no
explanation: Ultrasound may be used in aiding joint aspiration if the joint space is narrow or the effusion present is small, but it would not provide the diagnosis
name: Knee ultrasound
label: d
answer: no
explanation: A blood film is useful in the initial diagnosis of sickle cell disease however this patient is already known to have sickle cell disease and this would not aid in the acute diagnosis
name: Blood film assessment
label: e
answer: no
explanation: This patient is septic and the most likely source is his knee. Patients with known sickle cell disease are more prone to septic arthritis and the way this is diagnosed is by aspiration of the joint in an aseptic manner and sending for culture
name: Joint aspiration
label: a
answer: yes

Correct answer: a


Learning point: Joint aspiration is crucial in patients with sickle cell disease who are at increased risk of septic arthritis, as it helps confirm the diagnosis, identify the causative organism, and guide targeted treatment.
A 62 year old female has recurrent deep vein thromboses (DVT) for which she takes rivaroxaban 20mg once a day. Unfortunately she develops a new unilateral leg swelling and ultrasound investigation confirms a further deep vein thrombosis. She has been investigated previously for underlying hypercoagulable conditions and all the tests have been negative.

How should you treat this patient?

Options:
explanation: This patient has failed anticoagulation with a direct oral anticoagulant (DOAC). The National Institute for Health Care Excellence (NICE) guidance therefore suggests confirming her adherence to the medication and then either increasing the dosage of the medication or changing for an anticoagulant with a different mode of action. As she is already on the maximum dose of rivaroxaban changing her anticoagulation to warfarin is reasonable
name: Commence warfarin
label: a
answer: yes
explanation: Apixaban is a factor Xa inhibitor, the same as rivaroxaban. This patient has already failed this therapy and therefore an anticoagulant with a different mechanism of action is indicated here
name: Commence apixaban
label: d
answer: no
explanation: Inferior vena cava filters are only indicated in patients who cannot take blood thinning medications. Changing to a different oral anticoagulant is the preferred option here
name: Insert an inferior vena cava filter
label: c
answer: no
explanation: Venesection is a recognised treatment for some haematological conditions such as hereditary haemochromatosis and polycythaemia (both of which can increase the risk of DVT) however this woman has been investigated for these conditions previously, therefore this treatment is not indicated
name: Regular venesection
label: e
answer: no
explanation: 20mg once a day is already the maximum dose for rivaroxaban and therefore a dose increase should only be undertaken in complex cases under the advice of a haematologist. The better option here is to change to a difference mode of anticoagulation
name: Increase her rivaroxaban dose
label: b
answer: no

Correct answer: a


Learning point: In patients with recurrent DVT despite optimal DOAC therapy, switching to warfarin may be necessary for effective anticoagulation management.
An 18 year old female with recurrent tonsillitis presents to her local accident and emergency with a four day history of sore throat, fever and inability to swallow her own saliva. She has a tender swelling over the lateral aspect of her neck and targetted ultrasound reveals a thrombus in her jugular vein.

What is the name of the likely condition?

Options:
explanation: A parapharyngeal abscess is another recognised complication of under-treated bacterial throat infections. It may present with a neck swelling and can lead to Lemierre's syndrome, but not all parapharyngeal abscesses have an associated thrombus, therefore this is not the correct answer. It can be life threatening as it may lead to airway compromise and thus must be surgically drained under general anaesthetic
name: Parapharyngeal abscess
label: b
answer: no
explanation: A quinsey is another term for a peritonsillar abscess. This is a more common complication of under-treated bacterial throat infections and often requires incision and drainage. A quinsey can develop into a parapharyngeal abscess if left untreated, but as with parapharyngeal abscess it does not always have an associated thrombosis and therefore is not the correct answer here
name: Quinsey
label: c
answer: no
explanation: This is a combination of symptoms that arise from damage to the sympathetic trunk. The classical signs are of miosis (constricted pupil), partial ptosis (weak droopy eyelid) and anhydrosis (reduced sweating). This presentation is more in keeping with an acute inflammatory/infective process as opposed to disruption of nerve signals
name: Horner's syndrome
label: e
answer: no
explanation: Lemierre's syndrome is an infective thrombophlebitis that can develop as a result of untreated bacterial throat infections in otherwise healthy young adults. It can lead to other further systemic complications such as bacteraemia and septic emboli
name: Lemeirre's syndrome
label: a
answer: yes
explanation: Reye's syndrome is acute encephalopathy and liver failure after a febrile viral illness such as influenza and upper respiratory tract infections. It does not present with neck swelling and liver failure is more commonly associated with bleeding as opposed to thrombosis. This is therefore not the correct answer
name: Reye's syndrome
label: d
answer: no

Correct answer: a


Learning point: Lemierre's syndrome is a serious condition arising from untreated bacterial throat infections, leading to jugular vein thrombosis.
A company develops a new coronavirus test. They trial it on 1000 people and have 83 positive tests, of which 80 were later confirmed to be positive through alternative means of testing. Of those who tested negative, 15 were later confirmed positive through alternative testing.

What is the sensitivity of the new test?

Options:
explanation: Sensitivity of a test is the ability of a test to correctly identify those with a disease.

Sensitivity = true positives / (true positives + false negatives)

So in this case 80/(80+15) = 84.2%
name: 84.2%
label: a
answer: yes
explanation: This is the specificity of the test, not the sensitivity. Specificity of a test is the ability of the test to correctly identify those without a disease.

Specificity = true negatives / (true negatives + false positives).
In this case = 920/(920+3) = 99.7%
name: 99.7%
label: d
answer: no
explanation: This is the number of true negatives expressed as a percentage, not the sensitivity
name: 90.2%
label: e
answer: no
explanation: This is the number of true negatives expressed as a percentage, not the sensitivity
name: 92.0%
label: b
answer: no
explanation: This is the number of true positives expressed as a percentage, not the sensitivity
name: 80.0%
label: c
answer: no

Correct answer: a


Learning point: Sensitivity measures a test's ability to correctly identify individuals with a disease, calculated as true positives divided by the sum of true positives and false negatives.
A new drug is developed that claims to prevent diabetes mellitus in patients with impaired glucose tolerance. A randomised control trial is undertaken in 100 patients with HbA1c of 42-47, where half the participants are given the new drug, and the other half are given a placebo.

In those who were given the new drug, 25 patients developed diabetes within five years; in the group who were not given the drug, 36 patients developed diabetes within five years.

What is the relative risk of developing diabetes if treated with the new drug?

Options:
explanation: This is incorrect as this is the risk of developing diabetes in the placebo group
name: 0.72
label: d
answer: no
explanation: This is incorrect as this is the risk of developing diabetes in the group given the drug
name: 0.50
label: c
answer: no
explanation: The relative risk or risk ratio is the probability of an outcome occurring in a patient group exposed to a change (in this case, a new drug). Of those given the drug, 50% went on to develop diabetes compared to 72% in the placebo group.

Relative risk = risk in the group exposed to drug/risk in those not exposed to the drug.

50/72 = 0.69
name: 0.69
label: a
answer: yes
explanation: This is incorrect as the group that has been exposed to the change is those given the drug
name: 1.44
label: b
answer: no
explanation: This is incorrect as this is the risk of not developing diabetes in the placebo group
name: 0.28
label: e
answer: no

Correct answer: a


Learning point: Relative risk compares the likelihood of an event occurring in an exposed group to an unexposed group, calculated as the ratio of incidence in the exposed group to the unexposed group.
Your colleague has a particular way of performing inguinal hernia repairs that is less commonly used. She wants to know whether her technique has a higher or lower rate of recurrence. She finds five studies that use her method compared to the routine method and plots them in a forest plot (x-axis represents the relative risk of recurrence in your colleague's method compared to the routine method).

[lightgallery]

Which of these statements about her findings is true?

Options:
explanation: This is incorrect as the ratio here is very close to 1, indicating that the risk of recurrence from her technique is very similar to the risk of recurrence from other techniques
name: Edwards et al. show the biggest difference in the risks of hernia recurrence between her technique and other techniques
label: c
answer: no
explanation: This is false as all of the forest plot lines are above 1. In risk ratios or relative risk, if the ratio is >1, then this means that the intervention has a less favourable risk than in the group not subject to the intervention, i.e. greater risk of hernia recurrance.
name: All the studies suggest that her method has a lower risk of hernia recurrence
label: e
answer: no
explanation: This is incorrect as the horizontal line is a representation of the confidence intervals. A wide confidence interval is more likely to be representative of a smaller data set
name: James et al. likely had the most participants in their study
label: d
answer: no
explanation: This is incorrect as the horizontal line on a forest plot indicates the confidence intervals as opposed to the range of the data sets. A wide confidence interval indicates instability of results, for example, due to a very small data set
name: James et al. have the largest range of results
label: b
answer: no
explanation: This is true as all of the forest plot lines are at or above 1. In risk ratios or relative risk, if the ratio is >1, then this means that the intervention has a less favourable risk than in the group not subject to the intervention, i.e. greater risk of hernia recurrance.
name: None of the studies suggest that her method has a lower risk of hernia recurrence
label: a
answer: yes

Correct answer: a


Learning point: A forest plot visually displays results from multiple studies, showing effect sizes with confidence intervals; points crossing the line of no effect indicate non-significance
A 28-year-old female gives birth to her second child at full term following an uneventful pregnancy. You check on the baby three hours after delivery, and you notice that the neonate is jaundiced. Observations are otherwise normal.

What test would confirm your diagnosis?

Options:
explanation: A liver ultrasound would be useful in diagnosing biliary atresia, serious but rare cause of neonatal jaundice. However, biliary atresia usually develops around three weeks after birth. This history is more in keeping with an acute haemolytic cause for jaundice than a structural issue
name: Liver ultrasound
label: d
answer: no
explanation: This history suggests rhesus haemolytic disease of the newborn, as this is a woman in her second pregnancy, and the jaundice is apparent in the first 24 hours after birth. You would therefore expect a positive direct Coombs test. A direct Coombs test is used to test for autoimmune haemolytic anaemia where the immune system breaks down red blood cells, leading to anaemia. The direct Coombs test is used to detect antibodies or complement proteins attached to the surface of red blood cells
name: Direct Coombs test
label: a
answer: yes
explanation: An indirect Coombs test looks at antibodies floating freely in the blood and, therefore, can be used in prenatal testing for pregnant women or in testing prior to blood transfusion. A positive indirect Coombs would not diagnose the cause for haemolysis in this case
name: Indirect Coombs test
label: b
answer: no
explanation: Breastfeeding is a common cause for prolonged jaundice in newborns; however, it would not develop in the first few hours of life. Visible jaundice in the first 24 hours of life is always abnormal
name: Withdrawal of breastfeeding
label: e
answer: no
explanation: Whilst liver function tests would help confirm whether this was true jaundice, they would not help diagnose the underlying cause
name: Liver function tests
label: c
answer: no

Correct answer: a


Learning point: Rhesus haemolytic disease of the newborn typically presents with jaundice within 24 hours of birth and is confirmed by a positive direct Coombs test.