hllj/quesmed huggingface dataset:
A 14-year-old boy presents to A&E with his dad complaining of abdominal pain. He describes it as crampy, which paracetamol has not relieved. Over the last 2 days, he is complaining of leg weakness, fever, and bloody diarrhoea. His dad is concerned that he may have ulcerative colitis. There is no travel history of note. They went to a barbecue 5 days ago where they ate chicken. On examination, the patient has a temperature of 39.8. A faecal sample is taken which shows a spiral shaped organism.

Which of the following organisms is the most likely cause?

Options:
explanation: Escherichia coli can present in a similar way to C. Jejuni with bloody diarrhoea, fever, and abdominal pain in the context of food poisoning. It is important to remember the 0157: H7 strain which can trigger haemolytic uraemic syndrome. However, E. Coli is a gram negative rod, as opposed to spiral/comma shaped.
name: Escherichia coli
label: c
answer: no
explanation: Bacillus cereus is a gram positive rod presenting with rapid onset, toxin mediated food poisoning (within hours.) It is classically associated with takeaways or reheating rice. It is not associated with bloody diarrhoea. The incubation period in this case, findings on stool culture, and bloody diarrhoea point against Bacillus cereus.
name: Bacillus cereus
label: e
answer: no
explanation: C. jejuni is a spiral or comma-shaped gram negative organism, which commonly presents with a flu-like prodrome, crampy abdominal pain, and bloody diarrhoea. It is a common cause of food poisoning and has a long incubation period of around 5 days. It is associated with Guillain Barre syndrome, which presents with ascending, bilateral weakness in the lower limbs; this child is complaining of lower limb weakness, so this should raise clinical suspicion of this complication.
name: Campylobacter jejuni
label: a
answer: yes
explanation: Entamoeba histolytica causes amoebic dysentery. It is associated with foreign travel and stool microscopy would show trophozoites.
name: Entamoeba histolytica
label: d
answer: no
explanation: Salmonella enteritidis can present in a similar way to C. Jejuni with bloody diarrhoea, fever, and abdominal pain in the context of food poisoning. However, it presents earlier than C. jejuni as the incubation period is shorter (around 12-48 hours.) Furthermore, Salmonella is a gram-negative rod rather than a spiral-shaped/comma-shaped organism.
name: Salmonella enteritidis
label: b
answer: no

Correct answer: a


Learning point: Campylobacter jejuni commonly causes food poisoning, presenting with crampy abdominal pain, bloody diarrhoea, and can lead to Guillain-Barré syndrome.
A 68-year-old male presents to A&E feeling generally unwell. He is unable to give a history as he is feeling light-headed. On examination, his abdomen is tender, and there is a pulsatile, expansile abdominal mass. Observations: HR 130bpm, RR 19 breaths per min, O2 saturations 98% on room air, BP 98/60mmHg, temperature 36.7. Blood tests show: 

||||
|--------------|:-------:|---------------|
|Haemoglobin|121 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|1.9x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|38x10<sup>9</sup>/L|150 - 400|

A CT scan is requested and he is prepared for immediate surgery.


Given the most likely diagnosis, which of the following will he require during his resuscitation?

Options:
explanation: Recombinant factor VIII is used in the management of Haemophilia A, which is an X linked recessive disorder characterised by factor VIII deficiency. Haemophilia A is the most common inherited bleeding disorder which presents with recurrent haemarthroses and bruising. Blood tests reveal a prolonged APTT.
name: Recombinant clotting factor VIII
label: c
answer: no
explanation: Recombinant factor IX is used in the management of Haemophilia B, which is an X linked recessive disorder characterised by factor IX deficiency. Haeomophilia B is also known as Christmas disease.. Blood tests reveal a prolonged APTT.
name: Recombinant clotting factor IX
label: d
answer: no
explanation: Cryoprecipitate, which contains high levels of von Willebrand Factor and fibrinogen, may be required during massive haemorrhage, but it is not routinely provided, unlike packed red cells, platelets, and FFP. The decision to provide cryoprecipitate depends on close monitoring of bloods during the resuscitation efforts, and is usually required when the fibrinogen levels are less than 1. Treatment of massive haemorrhage should utilise the expertise of a haematologist since coagulopathy and complications can be extreme.
name: Cryoprecipitate
label: b
answer: no
explanation: This patient is presenting with a ruptured abdominal aortic aneurysm. He will need transfusing according to a major haemorrhage protocol, which involves providing platelets, fresh frozen plasma, and packed red cells in a 1:1:1 ratio. It will be incorrect to transfuse him packed red cells only since this will not correct/worsen any coagulopathy sustained because of the massive haemorrhage.
name: Packed red cells only
label: e
answer: no
explanation: This patient is presenting with a ruptured abdominal aortic aneurysm. He will need transfusing according to a major haemorrhage protocol, which involves providing platelets, fresh frozen plasma, and packed red cells in a 1:1:1 ratio. Once stabilised, he will be able to go to theatre for either endovascular or open abdominal aortic aneurysm repair.
name: Packed red cells, platelets and fresh frozen plasma (FFP)
label: a
answer: yes

Correct answer: a


Learning point: A ruptured abdominal aortic aneurysm requires immediate resuscitation with packed red cells, platelets, and fresh frozen plasma in a 1:1:1 ratio.
A 37-year-old female presents to the GP concerned about her recent diagnosis of liver cirrhosis secondary to chronic alcoholism. Her past medical history includes moderate depression and chronic fatigue syndrome. She is managing both conditions well. However, she does not have any support at home or at work and she lives alone. Her GP conducts a motivational interview and concludes that she is keen to quit alcohol but she is unsure about how to do this. Her GP measures her patient activation level as 3.

Which of the following is the next best step in the management of this patient?

Options:
explanation: Acamprosate is a medication prescribed to patients who have already successfully achieved abstinence, to prevent relapse through reducing cravings. This patient has not reached that stage yet.
name: Prescribe acamprosate
label: e
answer: no
explanation: Patients must first be assessed by community drug and alcohol services, who will try to aid abstinence in the community. If community support fails, referral may be made for intensive rehabilitation, and so this is not the next step.
name: Refer to intensive rehabilitation
label: c
answer: no
explanation: This is correct because this patient is willing to quit alcohol and she needs further advice on how to do so. A GP can either refer patients to local drug and alcohol services or offer treatment at the practice. Patients who are not comfortable approaching the GP also have the option to self-refer to the local drug and alcohol service. Patient activation measures assess the knowledge, skills and confidence of patients to manage their health and has been consistently used as an outcome measure of health interventions. In this case, level 3 suggests that this patient is willing to take action, that she has good self-management skills, and feels that she is part of the healthcare team.
name: Referral to local community drug and alcohol services
label: a
answer: yes
explanation: This patient may require cognitive behavioural therapy if she has problems with her mental health in terms of mood and anxiety. However, this is not her current priority, and she seems to be managing her mental health well. Cognitive behavioural therapy referral at this stage will not directly assist her desire to overcome her addiction to alcohol, and as such does not represent the best next step.
name: Refer for cognitive behavioural therapy
label: d
answer: no
explanation: Chlordiazepoxide is a short acting benzodiazepine drug used to aid alcohol detoxification since it ameliorates the side-effects of alcohol withdrawal and protects against life threatening delirium tremens. Detoxification programmes using chlordiazepoxide need careful planning with the support of local drug and alcohol services and as such the patient needs to be referred to see them first before this is commenced. Detox is usually done as an inpatient, but community detoxification programmes are being increasingly undertaken.
name: Prescribe chlordiazepoxide
label: b
answer: no

Correct answer: a


Learning point: Referral to community drug and alcohol services is essential for patients with liver cirrhosis seeking support to quit alcohol.
A 34-year-old woman presents to A&E with a three day history of fevers and joint pains. She denies any unwell contacts. She has a history of intravenous drug use but no other past medical history. Her vital signs are: HR 101bpm, RR 17 breaths per minute, O2 saturations of 98% on air, BP 157/61mmHg, and temperature 39.5. On examination, there is an early diastolic murmur on auscultation of the aortic area.

Which of the following clinical signs is specific to his diagnosis?

Options:
explanation: Peripheral oedema is a non-specific finding for many conditions including heart failure, liver cirrhosis and nephrotic syndrome. Infective endocarditis may cause acute valvular heart failure and subsequently peripheral oedema, but it is not specific finding, which is what the question is asking.
name: Peripheral oedema
label: c
answer: no
explanation: A malar flush is a purple-red discolouration overlying the malar eminence, and in a cardiac examination, is associated with mitral stenosis and pulmonary hypertension secondary to this. Mitral stenosis presents as a mid-diastolic murmur over the mitral area, and is not usually caused by infective endocarditis, but rheumatic fever. Other features include a parasternal heave due to right ventricular hypertrophy and a loud second heart sound. This patient has no past medical history, and has clinical features of aortic regurgitation.
name: Malar flush
label: b
answer: no
explanation: Rheumatic fever is caused by group A beta-haemolytic streptococci (S. pyogenes), and one of the major Jones diagnostic criteria is that of painless subcutaneous nodules.
Rheumatic fever can cause permanent damage to heart valves (rheumatic heart disease); it is rare in the developed world due to effective antimicrobial treatment of beta-haemolytic group A streptococcal infections. This patient is presenting acutely with a new murmur and fever, and as such infective endocarditis is the most likely diagnosis.
name: Subcutaneous painless nodules
label: d
answer: no
explanation: A displaced apex beat can occur in a variety of conditions that result in left ventricular dilation, including a volume overloaded left ventricle as in mitral or aortic regurgitation, chronic right-left shunt, eventual decompensation in concentric hypertrophy secondary to pressure overload, or dilated cardiomyopathy. This patient may develop a displaced apex beat, but it is not specific.
name: Displaced apex beat
label: e
answer: no
explanation: This patient has aortic regurgitation caused by infective endocarditis, as indicated by the presence of fever and a new murmur. Her risk factors include current intravenous drug use. De Musset's sign is a rhythmic head nodding or bobbing in-sync with each heart beat, which is associated with aortic regurgitation. She also has a wide pulse pressure, which is also associated with aortic regurgitation. This patient should have an urgent echocardiogram.
name: De Musset's sign
label: a
answer: yes

Correct answer: a


Learning point: De Musset's sign, which is a rhythmic bobbing of the head, suggests severe aortic regurgitation.
A 59-year-old male presents to the GP for a follow-up appointment after his hypertension annual review. He is currently asymptomatic and takes amlodipine 10mg once daily. His average blood pressure reading is 151/98mmHg.

Which of the following is the next best step in the management of this patient?

Options:
explanation: This is incorrect because this patient's blood pressure is greater than his target, and so his antihypertensive management requires escalation. He is already on maximum dose amlodipine and continuing this is unlikely to achieve his target.
name: Continue amlodipine
label: b
answer: no
explanation: Beta-blockers are used in the management of hypertension after conventional therapies - ACEi, calcium channel blockers, and thiazide-like diuretics - have been considered. It is a 4th line agent, alongside spironolactone and alpha-blockers; spironolactone is used when the potassium is <4.5, and a beta-blocker/alpha-blocker >4.5. Side effects of atenolol include vivid dreams, erectile dysfunction, and fatigue.
name: Prescribe atenolol
label: d
answer: no
explanation: Anti-hypertensives should only be discontinued if they produce  unwanted side effects or if the patient refuses to take them, since adding additional agents is more likely to produce better control than substituting with novel agents. Indapamide is a thiazide-like diuretic which is used after calcium channel blockers and ACEi as a third step. Common side effects of indapamide include hyperuricaemia, postural hypotension, and hypokalaemia.
name: Discontinue amlodipine and prescribe indapamide
label: c
answer: no
explanation: This is the correct answer because this patient is already taking amlodipine hence the next step in management is to add an ACE-inhibitor such as ramipril. Step 2 in the management of hypertension involves combining an ACE-inhibitor with a calcium channel blocker. The blood pressure target for this patient (an adult under 80) should be 140/90mmHg in clinic and 135/85mmHg at home. Remember common side effects of ACE-inhibitors such as a dry cough, delayed angioedema, and a dry mouth.
name: Prescribe ramipril
label: a
answer: yes
explanation: Nifedipine is another dihydropyridine calcium channel blocker like amlodipine. It is unlikely he will respond to this when he has not responded to amlodipine, and the two would not be prescribed together. The next step is therefore to add an ACEi.
name: Prescribe nifedipine
label: e
answer: no

Correct answer: a


Learning point: For patients with persistent hypertension who are already taking a calcium channel blocker (CCB), adding a second-line medication like an ACE inhibitor such as ramipril can be an effective to acheive an acceptable blood pressure.
A 55-year-old woman presents to the GP clinic with pain on passing urine for the past three days. She is otherwise well in herself. She has a past medical history of G6PD deficiency and rheumatoid arthritis, for which she takes methotrexate. She does not take any other medication and has no known drug allergies.

She has a temperature of 36.5 degrees Celsius, pulse 65 bpm, BP 125/86 mmHg.

Urine dipstick shows 2+ leukocytes and 3+ nitrites.

The GP decides to prescribe a course of antibiotics for this patient. Which is the most appropriate regimen to prescribe?

Options:
explanation: According to [NICE CKS guidelines](https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/management/acute-uti-no-visible-haematuria-not-pregnant-or-catheterized/), this is the second-line antibiotic regimen where nitrofurantoin and trimethoprim are contraindicated (see other explanations), or where there is no improvement in symptoms.
name: PO Pivmecillinam 400mg initial dose, then 200 mg TDS for three days
label: a
answer: yes
explanation: The BNF advises that ciprofloxacin be used with caution in patients with G6PD deficiency. Furthermore, this medication would be more appropriate for patients with acute pyelonephritis managed in the community. The lack of additional symptoms in this patient i.e. flank pain or features of sepsis makes acute pyelonephritis unlikely. 
name: PO Ciprofloxacin 1g for seven days
label: d
answer: no
explanation: Methotrexate is listed as a severe interaction with trimethoprim in the BNF, due to the increased risk of haematological side effects that can be fatal. This is a very important drug interaction to remember.
name: PO Trimethoprim 200mg BD for three days
label: c
answer: no
explanation: G6PD deficiency is listed as a contra-indication to nitrofurantoin in the BNF.
name: PO Nitrofurantoin 100mg BD for three days
label: b
answer: no
explanation: This would be appropriate for patients with suspected urosepsis. This patient does not present with any features of sepsis e.g. hypotension and therefore does not require a stat dose of gentamicin.
name: STAT dose IV gentamicin 5mg/kg
label: e
answer: no

Correct answer: a


Learning point: In women with urinary tract infections, pivmecillinam is a suitable second-line antibiotic when nitrofurantoin and trimethoprim are contraindicated.
A 62-year-old man presents to the Emergency Department with a 2-day history of fever, a productive cough and cold sores around his mouth. He has a past medical history of type 2 diabetes, hypertension and rheumatoid arthritis. He is a current smoker and drinks 20 units of alcohol per week on average. The doctor suspects a community-acquired pneumonia and sends off a series of investigations.

Which of the following would confirm the most likely cause of this patient's pneumonia?

Options:
explanation: The presence of a productive cough and herpes labialis makes a bacterial cause of pneumonia more likely than viral. A virus PCR screen may be helpful in this scenario, but certainly not the test that would confirm the diagnosis. Depending on the hospital, a virus screen will usually include influenza A & B, parainfluenza viruses, RSV, adenovirus and rhinovirus.
name: Sputum culture for respiratory virus PCR screen
label: c
answer: no
explanation: This would be the confirmatory test for *Mycoplasma pneumoniae*. This is more commonly associated with a dry cough, erythema multiforme, and cold autoimmune haemolytic anaemia (AIHA).
name: Mycoplasma serology
label: e
answer: no
explanation: This is the diagnostic test for *Streptococcus pneumonia*, which is the most likely cause of this patient's pneumonia. The key feature in this scenario are the cold sores, also known as herpes labialis. Other common characteristics include rust-coloured sputum and pleuritic chest pain.
name: Urinary antigen test
label: a
answer: yes
explanation: These are also important investigations to send off, but will not confirm the most likely diagnosis of *Streptococcus pneumonia* in this patient. Gram-stain will be useful to confirm Staphylococcus and other Streptococcus species, while silver-stain is used for *Pneumocystis jirovecii* pneumonia.
name: Sputum culture for gram-stain and silver-stain
label: b
answer: no
explanation: A CXR will not be able to confirm the microbial cause of the pneumonia. It is however an important step in the management of pneumonia to look for any consolidation. A follow-up CXR 6 weeks later is also needed to rule out any underlying malignancies which may be hidden by the original consolidations.
name: Chest X-ray (CXR)
label: d
answer: no

Correct answer: a


Learning point: Streptococcus pneumoniae is a common cause of community-acquired pneumonia, often confirmed by a urinary antigen test.
A 19-year-old man presents to the GP clinic with redness in both eyes that developed over the past week. He also complains of tearing and an itchy sensation around his eyes. He has never experienced these symptoms before. He has a past medical history of eczema as a child and takes over-the-counter antihistamines for hay fever. He is otherwise well in himself.

Given the most likely diagnosis, what is the most appropriate course of action?

Options:
explanation: This would be the appropriate management for blepharitis, which usually presents with dry eye. In allergic conjunctivitis, cold compresses (instead of hot) are advised to relieve symptoms of itchiness.
name: Advise gentle cleaning of the eyelid margins and hot compresses
label: d
answer: no
explanation: This is an antibiotic eye drop used to treat bacterial conjunctivitis, which is more likely to present with purulent 'sticky' discharge. This patient's symptom of tearing suggests a more watery discharge. Even if bacterial conjunctivitis was suspected, most cases resolve spontaneously within 5-7 days without treatment. Antibiotic eye drops such as chloramphenicol are only indicated in severe cases or situations that require rapid resolution.
name: Prescribe chloramphenicol 0.5% QDS for 7 days
label: c
answer: no
explanation: The most likely diagnosis in this scenario is allergic conjunctivitis given the patient's symptoms of red eye, watery discharge and itching. It is also commonly associated with other atopic conditions such as eczema, hay fever and asthma. According to [NICE guidelines](https://cks.nice.org.uk/topics/conjunctivitis-allergic/management/management-in-primary-care/#management-in-primary-care), the 1st line treatment is a topical mast cell stabilizer (sodium cromoglycate) and topical antihistamine (antazoline).
name: Prescribe topical sodium cromoglycate and antazoline drops
label: a
answer: yes
explanation: Given the most likely diagnosis of allergic conjunctivitis in this scenario, this can be managed in primary care in the first instance. There are no concerning symptoms or adverse features in the patient's history that would warrant an urgent same-day referral. NICE CKS provides some useful guidelines on [when to refer to secondary care in allergic conjunctivitis.](https://cks.nice.org.uk/topics/conjunctivitis-allergic/management/referral/)
name: Urgent referral for same-day ophthalmology assessment
label: b
answer: no
explanation: Lubricating eye drops are used to relieve symptoms of dry eyes. It will not relieve the itchiness that this patient is presenting with.
name: Prescribe lubricating eye drops such as hypromellose to relieve symptoms
label: e
answer: no

Correct answer: a


Learning point: For allergic conjunctivitis, prescribe sodium cromoglycate (1 drop, 2-4 times/day) to stabilize mast cells, and antazoline (1 drop, up to 3 times/day) to block histamine and relieve itching and redness.