hllj/quesmed huggingface dataset:
A 32-year-old woman presents with 12 months of infertility despite regular unprotected intercourse. She reports regular periods, though increasingly heavy in recent years. She had normal childhood development and menarche at age 11, with up-to-date negative cervical smears for HPV, and has no past medical history. She is in a monogamous relationship with a negative sexually transmitted infection screen 6 months ago.


On examination, she has a firm, palpable painless 10cm smooth mass in the suprapubic region. Abdomen is otherwise soft non-tender with no shifting dullness or fluid thrill.


Routine bloods reveal microcytic iron deficiency anaemia but are otherwise unremarkable.


Urine dip and beta HCG are negative.


What is the most appropriate next investigation?

Options:
explanation: This may help in confirming the aetiology of the anaemia, although the clinical information provides enough information to reasonably assume the anaemia was caused either by menorrhagia or from malignancy. The patient has presented with an abdominal mass which must be investigated first
name: Blood film
label: b
answer: no
explanation: This patient most likely has uterine fibroids which has resulted in her menorrhagia, subfertility, and anaemia. She has a smooth benign-feeling suprapubic mass; however this still needs to be formally assessed sonographically to be characterised and assessed for malignancy
name: Transvaginal ultrasound scan
label: a
answer: yes
explanation: This may help in confirming the aetiology of the anaemia, although the clinical information provides enough information to reasonably assume the anaemia was caused either by menorrhagia or from malignancy. The patient has presented with an abdominal mass which must be investigated first
name: Low vaginal swab for chlamydia and gonorrhoea
label: d
answer: no
explanation: These would be reasonable suggestions to investigate subfertility/infertility if the patient did not present with an abdominal mass and ultrasound scans were unremarkable
name: Mid luteal phase progesterone
label: c
answer: no
explanation: MRI Pelvis provides excellent anatomic delineation of gynaecological structures. It is the most _accurate_ modality for detecting, localising, and characterising uterine fibroids. It is, however, not generally required for diagnosis and would not be the _first_ investigation of choice
name: MRI Pelvis
label: e
answer: no

Correct answer: a

Transvaginal ultrasound scan

Learning point: A transvaginal ultrasound scan is a diagnostic imaging technique used to visualize uterine fibroids, providing detailed images of their size, number, and location within the uterus, aiding in diagnosis and treatment planning.
A 6-year-old boy presents with his father to the emergency department with two days of progressive shortness of breath on exertion and new visible jaundice. He is normally fit and well and has reached all his developmental milestones. On questioning regarding the patient's diet, his father reports the child has been eating fava beans with every meal for the past week.


On examination, he appears well but is jaundiced. His chest is clear, and he has a smooth, palpable mass in the left upper quadrant; the abdomen is soft and non-tender.  

Blood tests:

|Serum|Result|Reference Range|
|-------------------|------|------------|
|Haemoglobin|68|130 - 170 mg/dL|
|White Cell Count|5.1|3.0 - 10.0 x 10⁹ /L|
|Platelets|162|150 - 400 x 10⁹/L|
|Reticulocytes|220|25 - 100 x 10⁹/L|
|Haptoglobin|19|50-220 mg/dL|
|Lactate Dehydrogenase|636|70 - 250 IU/L|
|Creatinine|95|60 - 120 µmol/L|
|Bilirubin|85|< 17 µmol/L|
|Alanine Aminotransferase|35|10 - 40 IU/L|
|Alkaline Phosphatase|89|25 - 115 IU/L|
|Gamma glutamyl transferase|21|9 - 40 U/L|


Peripheral blood film shows polychromasia and bite cells.


Which of the following is the next best investigation?

Options:
explanation: Acute hepatitis would present with grossly deranged liver enzymes and raised bilirubin. A raised bilirubin with anaemia and normal liver enzymes is more typical for haemolytic anaemia
name: Hepatitis panel
label: e
answer: no
explanation: This patient likely has acute haemolytic anaemia from glucose-6-phosphate dehydrogenase deficiency following ingestion of fava beans. Direct antiglobulin test (direct Coombs test) is used to determine whether the patient has immune-mediated haemolytic anaemia
name: Direct antiglobulin test
label: a
answer: yes
explanation: G6PD enzyme assay is used to diagnose glucose-6-phosphate dehydrogenase deficiency. It is checked approximately 3 months following an episode of acute haemolysis, and so it would not be the next investigation
name: Screen for red blood cell pyruvate kinase activity
label: d
answer: no
explanation: This child is experiencing acute haemolytic anaemia, likely triggered ingestion of fava beans with underlying glucose-6-phosphate dehydrogenase deficiency. Bone marrow biopsy would not further aid in the diagnosis of the definitive cause of haemolytic anaemia
name: Bone marrow biopsy
label: c
answer: no
explanation: G6PD enzyme assay is used to diagnose glucose-6-phosphate dehydrogenase deficiency. It is checked approximately 3 months following an episode of acute haemolysis, and so it would not be the next investigation
name: G6PD enzyme assay
label: b
answer: no

Correct answer: a

Direct antiglobulin test

Learning point: Direct antiglobulin test (direct Coombs test) is used to determine whether the patient has immune-mediated haemolytic anaemia
A 32-year-old woman has presented to the GP for advice about fertility. She has had four miscarriages prior to 20 weeks gestation, following which tests revealed no anatomical, hormonal, or chromosomal precipitating causes. She is otherwise well. Tests are requested to screen for thrombophilia with the results shown below:

| Serum                           | Result   | Result at 12 weeks |
| ------------------------------- | -------- | ------------------ |
| Lupus anticoagulant (LA)        | positive | positive           |
| Anticardiolipin (aCL) antibody  | positive | positive           |
| Anti-b2-glycoprotein I antibody | negative | negative           |

Which of the following is the most likely diagnosis?

Options:
explanation: While aCL antibodies can be found in Behçet's syndrome, there would likely also be a history of recurrent aphthous ulcers and uveitis. With positive LA antibodies, this points to antiphospholipid syndrome
name: Behçet's syndrome
label: b
answer: no
explanation: Protein C deficiency is a rare cause of thrombosis, which can present with recurrent miscarriages. It is not, however, associated with LA, aCL, or anti-b2-glycoprotein I antibodies
name: Protein C deficiency
label: e
answer: no
explanation: The name lupus anticoagulant is a misnomer and has only a weak association with SLE. It is a prothrombotic antibody where most patients with positive antibodies do not have SLE, and only a small proportion proceeds to develop the disease. The patient is otherwise well with no other systemic features and so makes the diagnosis of SLE unlikely
name: Systemic lupus erythematosus (SLE)
label: d
answer: no
explanation: All three of the antibodies above can be present in antiphospholipid syndrome, resulting in thrombophilia. This can often present as either unexplained recurrent miscarriages or vascular thrombosis
name: Antiphospholipid syndrome
label: a
answer: yes
explanation: Factor V Leiden is a common cause of thrombosis, which can present with recurrent miscarriages. It is not, however, associated with LA, aCL, or anti-b2-glycoprotein I antibodies
name: Factor V Leiden
label: c
answer: no

Correct answer: a


Learning point: Lupus anticoagulant, anticardiolipin antibody, and anti-β2-glycoprotein I antibody are autoantibodies linked to antiphospholipid syndrome, which increases the risk of blood clots and pregnancy complications, indicating a higher risk of thrombotic events.
A 32-year-old man presents to the emergency department with 3 days of shortness of breath, productive cough with green sputum, and pyrexia. 5 years ago, he underwent an emergency splenectomy following a road traffic collision.

Which of the following organisms is he at greater risk of infection?

Options:
explanation: Splenectomy causes an increased risk of infection from encapsulated organisms with a 10-20 times greater risk of acquiring sepsis. P. jirovecii is a yeast-like fungus, and it does not have a capsule
name: Pneumocystis jirovecii
label: d
answer: no
explanation: Splenectomy causes an increased risk of infection from encapsulated organisms with a 10-20 times greater risk of acquiring sepsis. C. psittaci is not an encapsulated bacterium
name: Chlamydia psittaci
label: b
answer: no
explanation: Splenectomy causes an increased risk of infection from encapsulated organisms with a 10-20 times greater risk of acquiring sepsis. The most common encapsulated bacteria are Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria meningitidis. For this reason, patients are offered the pneumococcal vaccine, Hib vaccine, and the meningococcal vaccine post-operatively. Patients should also be offered annual flu vaccination and lifelong antibiotic prophylaxis
name: Haemophilus influenzae
label: a
answer: yes
explanation: Splenectomy causes an increased risk of infection from encapsulated organisms with a 10-20 times greater risk of acquiring sepsis. Mycoplasma pneumoniae is not an encapsulated bacterium
name: Mycoplasma pneumoniae
label: e
answer: no
explanation: Splenectomy causes an increased risk of infection from encapsulated organisms with a 10-20 times greater risk of acquiring sepsis. M. catarrhalis is not an encapsulated bacterium
name: Moraxella catarrhalis
label: c
answer: no

Correct answer: a


Learning point: Patients who have undergone splenectomy are at increased risk of infections from encapsulated organisms, particularly Haemophilus influenzae.
A 45-year-old Vietnamese man has presented to the emergency department with jaundice. A full liver screen is sent with the following results:

| Serum                                                   | Result   |
| ------------------------------------------------------- | -------- |
| Hepatitis B surface antigen (HBsAg)                     | positive |
| Hepatitis B surface antibody (anti-HBs)                 | negative |
| Total hepatitis B core antibody (anti-HBc)              | positive |
| IgM antibody to hepatitis B core antigen (IgM anti-HBc) | negative |

Options:
explanation: This would present with positive anti-HBc but negative HBsAg, anti-HBs, and IgM anti-HBc. These results could also indicate "low-level" chronic infection or resolved infection
name: Resolved hepatitis B infection
label: e
answer: no
explanation: This would present with positive HBsAg, anti-HBc, and IgM anti-HBc
name: Acute hepatitis B
label: b
answer: no
explanation: This would present as positive anti-HBc and anti-HBs but negative HBsAg and IgM anti-HBc
name: Immune to hepatitis B due to natural infection
label: d
answer: no
explanation: HBsAg is a protein on the surface of the hepatitis B virus. It can be detected during acute or chronic hepatitis B infection and indicates the person is infectious. Anti-HBs indicates recovery and immunity from hepatitis B infection and also appears in those who have been successfully vaccinated. Anti-HBc indicates previous or ongoing infection in an undefined timeframe. It appears at the onset of symptoms in acute hepatitis B and persists for life. IgM anti-HBc indicates recent acute infection within the last 6 months. In this case, positive HBsAg and anti-HBc indicate the patient is infectious of hepatitis B with previous/ongoing infection. Negative IgM anti-HBc shows the infection is chronic
name: Chronic hepatitis B
label: a
answer: yes
explanation: This would present with positive anti-HBs and negative for HBsAg, anti-HBc, and IgM anti-HBc
name: Immune due to hepatitis B vaccination
label: c
answer: no

Correct answer: a


Learning point: Chronic hepatitis B is characterised by positive HBsAg and anti-HBc, with negative IgM anti-HBc indicating no recent acute infection.
A novel screening test has been developed to detect breast cancer early in high-risk individuals. It is tested on 1000 individuals with risk factors for breast cancer:

|                   | Breast cancer present | Breast cancer absent |
| ----------------- | --------------------- | -------------------- |
| **Test positive** | 280                   | 70                   |
| **Test negative** | 10                    | 640                  |

What is the specificity of the new test?

Options:
explanation: The specificity is the proportion of patients without the condition with a negative test result. This is calculated as the true negative/(true negative + false positive) = 640/(640+70) = 90.1%
name: 69.6%
label: e
answer: no
explanation: This value corresponds to the negative predictive value - the chance that the patient does not have the condition if the test is negative. This is calculated as the true negative/(true negative + false negative) = 640/(640+10) = 98.5%
name: 98.5%
label: d
answer: no
explanation: Splitting the table up into true positive (280), false positive (70), false negative (10), and true negative (640) can make answering these tables easier to understand. The specificity is the proportion of patients without the condition with a negative test result. This is calculated as the true negative/(true negative + false positive) = 640/(640+70) = 90.1%
name: 90.1%
label: a
answer: yes
explanation: This value is the positive predictive value. Positive predictive value is the chance that the patient has the condition if the test is positive. This corresponds to true positive/(true positive + false positive) = 280/(280+70) = 80%
name: 80%
label: c
answer: no
explanation: This value is the sensitivity. The sensitivity is the proportion of patients with the condition who have a positive test result. This is calculated as the true positive/(true positive + false negative) = 280/(280+10) = 96.6%
name: 96.6%
label: b
answer: no

Correct answer: a


Learning point: Specificity is a measure of a diagnostic test's ability to correctly identify those without the condition (true negatives), calculated as the ratio of true negatives to the total number of individuals without the condition: Specificity = (True Negatives / (True Negatives + False Positives)) × 100.
A new treatment has been developed for ulcerative colitis. In a large randomised controlled trial, 20% of participants in the placebo arm had an acute flare within the next year. In the treatment arm, 12% of participants developed an acute flare within the next year.

What is the relative risk reduction of the new treatment?

Options:
explanation: 8% corresponds to the absolute relative risk, calculated as 20%-12%. This means that if you treated 100 people with this drug, 8 would be prevented from having a colitic flare in the next year. The number needed to treat (NNT) is calculated from this figure as 100/8 = 12.5, i.e. 12.5 people would need to be treated with this drug to prevent one episode
name: 8%
label: b
answer: no
explanation: Relative risk reduction shows how much the treatment has reduced the risk of bad outcomes relative to the control. The risk reduction is (20-12%)/20% = 0.4 or 40%, i.e. a patient is 40% less likely to develop a colitic flair within the next year by taking the drug vs taking a placebo
name: 40%
label: a
answer: yes
explanation: If the treatment causes an increased risk of bad outcome, then it is termed the "relative risk increase". 66.7% would be the relative risk increase if the treatment arm resulted in 20% of colitic flares within 1 year and the placebo arm resulted in 12%
name: 66.7%
label: c
answer: no
explanation: 140% relative risk reduction cannot exist as the maximum reduction of any bad outcome is 100%
name: 140%
label: e
answer: no
explanation: 60% is the value of the relative risk (in percentage form). Relative risk is a proportional measure to determine the size of effect of a treatment compared to other interventions or a control. It is the proportion of bad outcomes in the intervention group divided by the proportion of bad outcomes in the control group. In this case 12%/20% = 0.6
name: 60%
label: d
answer: no

Correct answer: a


Learning point: Relative risk reduction (RRR) is a measure of how much the risk of an event is reduced in the treatment group compared to the control group, calculated as 1 minus the relative risk (RR) and expressed as a percentage: RRR = (1 - RR) × 100, where RR is the risk in the treatment group divided by the risk in the control group.
The following diagram is a forest plot from a systematic review by Crowley et al. showing the results of seven studies looking at the effect of corticosteroids on hastening neonatal lung development when given to women about to give birth prematurely.

[lightgallery]

Which of the following statements is correct?

Options:
explanation: The summary measure of the meta-analysis is portrayed as a diamond, with the vertical points lying on the mean effect and the horizontal points measuring the confidence intervals
name: The width of the diamond corresponds to the 95% confidence interval of the summary measure
label: a
answer: yes
explanation: The 95% confidence intervals, represented as the horizontal edges of the summary measure diamond, do not overlap with the odds ratio of 1 and therefore, there is a significant effect of corticosteroids on neonatal mortality (mean odds ratio 0.53)
name: There is no significant effect of corticosteroids on neonatal mortality
label: b
answer: no
explanation: The heterogeneity, or I squared, is often used in forest plots, but it is not shown in the data set here. Heterogeneity is the degree to which data from multiple studies displaying the same effect overlap each other. The more heterogeneous the studies are within the met-analysis, the less conclusive the data is
name: The heterogeneity of the study is 0.53
label: d
answer: no
explanation: The area of the squares correspond to the proportional study's weight in the meta-analysis and is unrelated to the p-value
name: The area of the square corresponds inversely to the study's p-value
label: c
answer: no
explanation: The forest plot will include all studies investigated, regardless of their outcomes, analysed to determine the standardised mean difference, represented as the diamond in the bottom right of the image
name: Only the Auckland study showed significance, and so the other studies' results can be discounted
label: e
answer: no

Correct answer: a


Learning point: The summary measure of the meta-analysis is portrayed as a diamond, with the vertical points lying on the mean effect and the horizontal points measuring the confidence intervals
A new blood test to help diagnose acute myocardial infarction (MI) has been developed. It is tested on 1000 individuals with suspected myocardial infarction in the emergency department :

|                   | MI present | MI absent |
| ----------------- | ---------- | --------- |
| **Test positive** | 600        | 60        |
| **Test negative** | 50         | 290       |

What is the positive predictive value of the new test?

Options:
explanation: Positive predictive value is the chance that the patient has the condition if the test is positive. This corresponds to true positive/(true positive + false positive) = 600/(600+60) = 90.9%
name: 67.4%
label: e
answer: no
explanation: This value corresponds to the specificity - the proportion of patients without the condition with a negative test result. This is calculated as the true negative/(true negative + false positive) = 290 / (290+60) =82.9%
name: 82.9%
label: c
answer: no
explanation: Splitting the table up into true positive (600), false positive (60), false negative (50), and true negative (290) can make answering these tables easier to understand. Positive predictive value is the chance that the patient has the condition if the test is positive. This corresponds to true positive/(true positive + false positive) = 600/(600+60) = 90.9%
name: 90.9%
label: a
answer: yes
explanation: This value corresponds to the negative predictive value - the chance that the patient does not have the condition if the test is negative. This is calculated as the true negative/(true negative + false negative) = 290/(290+50) = 85.3%
name: 85.3%
label: d
answer: no
explanation: This value corresponds to sensitivity - the proportion of patients with the condition who have a positive test result. This is calculated as the true positive/(true positive + false negative) = 600/(600+50) = 92.3%
name: 92.3%
label: b
answer: no

Correct answer: a


Learning point: Positive predictive value (PPV) is the probability that individuals with a positive test result truly have the condition, calculated as the ratio of true positives to the total number of positive test results (true positives + false positives).
A 32-year-old man with HIV-associated nephropathy (HIVAN) and end-stage kidney disease (ESKD) presents to the emergency department with an oozing arteriovenous (AV) fistula following dialysis earlier that afternoon. He is referred to the vascular surgeons for ultrasound, review, and for consideration of surgical exploration.


Bloods are taken at the time with a venous blood gas, revealing the following:


||||
|--------------|:-------:|------------------|
|pH|7.32|7.35 - 7.45|
|PaO₂|14.3 kPa|11 - 15|
|PaCO₂|3.6 kPa|4.6 - 6.4|
|Bicarbonate|16 mmol/L|22 - 30|
|Base Excess|-4 mmol/L|-2 to +2|
|Lactate|1.1 mmol/L|0.6 - 1.4|


Which of the following is the most likely cause for the patient's low bicarbonate level?

Options:
explanation: As functioning nephrons decline in CKD, acid secretion is initially compensated by ammonium excretion (up to 40-50mL/min glomerular filtration rate). Beyond this, CKD leads to the retention of hydrogen ions which is buffered by bicarbonate in the extracellular tissue. As the patient approaches ESKD, the plasma bicarbonate stabilises between 12 and 20 mmol/L, and can be partially compensated by increased respiratory rate and hypocarbia
name: Chronic kidney disease (CKD)
label: a
answer: yes
explanation: Severe hypovolaemia can result in reduced renal perfusion and acute kidney injury, resulting in increased bicarbonate buffering of retained hydrogen ions by damaged nephrons and thus a decreased serum bicarbonate. This patient is not experiencing other signs of hypovolaemia and has not described any large volume haemorrhage from his fistula site
name: Hypovolaemia
label: c
answer: no
explanation: Hyperventilation from anxiety would result in hypocarbia (low paCO2) but would not affect serum bicarbonate levels
name: Anxiety
label: b
answer: no
explanation: Type 2 renal tubular acidosis (RTA) is a failure of proximal tubular cells to reabsorb bicarbonate from the urine. It would result in a metabolic acidosis and reduced serum bicarbonate. Type 2 RTA is primarily a complication of genetic disorders such as Fanconi syndrome, cystinosis, and Lowe syndrome. It can be acquired in amyloidosis, multiple myeloma, and with HAART medication, but it is not linked directly to HIV or ESKD
name: Type 2 renal tubular acidosis
label: d
answer: no
explanation: This patient is experiencing metabolic acidosis (low pH and low bicarbonate) with partial respiratory compensation (hypocarbia from increased respiratory rate) as a result of chronic kidney disease
name: Acute respiratory acidosis with partial metabolic compensation
label: e
answer: no

Correct answer: a


Learning point: In chronic kidney disease (CKD), as nephrons decline, acid retention occurs when ammonium excretion is insufficient, leading to lower plasma bicarbonate levels that stabilize between 12-20 mmol/L in end-stage kidney disease (ESKD), partially compensated by an increased respiratory rate and hypocarbia.