hllj/quesmed huggingface dataset:
A 74-year-old male is referred to the falls clinic after he suffers three mechanical falls at home within two months. He has a past medical history that includes postural hypotension, urinary incontinence, recurrent chest infections and six months ago was diagnosed with Parkinson's disease. He currently takes, co-benyldopa and has just finished a course of amoxicillin. On examination, you note that he has hypomimia, rigidity and bradykinesia with a very mild tremor.

You suspect a Parkinson's Plus Syndrome. Which of the following would you perform next?

Options:
explanation: We know that this patient has postural hypotension, and therefore lying and standing blood pressure measurements would prove this to be true. However, there are many causes for postural hypotension in the elderly, and therefore this would not prove a Parkinson's plus syndrome
name: Lying and standing blood pressure measurement
label: b
answer: no
explanation: Parkinson's disease is closely linked to Lewy Body Dementia, and therefore in all patients with Parkinson's disease, it is important to assess cognitive function. However, this would not account for the recurrent falls and would not be likely to aid further diagnosis here.
name: Abbreviated Mental Test (AMT)
label: e
answer: no
explanation: This history is not suggestive of syncopal episodes as a cause for his falls. Whilst an ECG should always be performed in patients with recurrent falls to look for arrhythmias; a stand-alone ECG is unlikely to pick up a cause for falls. 24 hour Halter monitoring is more sensitive and would be a reasonable investigation if there were concerns about a cardiac cause for his falls
name: 12 lead ECG
label: c
answer: no
explanation: The two main differential diagnoses in this scenario are Progressive Supranuclear Palsy (PSP) and Multiple system atrophy (MSA). This patient likely has a Parkinson's plus syndrome as he has symptoms of autonomic instability (urinary incontinence, postural hypotension and recurrent chest infections, which raises a concern about poor swallow), and the co-benyldopa does not seem to have had much effect. It's important to test for vertical gaze palsy to help you narrow down your differential diagnosis. 
name: Testing vertical gaze
label: a
answer: yes
explanation: Infection is a common cause of falls in the elderly. Common sources are urine and chest; however, there is nothing in the history suggestive of infection; therefore, whilst this is always worth checking, it is unlikely to provide a diagnosis here
name: Urinalysis
label: d
answer: no

Correct answer: a


Learning point: In Parkinson's Plus Syndromes, vertical gaze testing reveals difficulty with downward gaze, impaired saccades, and smooth pursuit
A 40-year-old man with a history of recurrent right-sided otitis media presents with a one-month history of gradually worsening hearing loss in his right ear. He denies any other symptoms, and his past medical history is otherwise unremarkable.

On examination, otoscopy reveals chalky white patches on the tympanic membrane. Rinne's test is negative on the right, and Weber's test lateralises to the right ear.

Which of the following is the most likely diagnosis?

Options:
explanation: Cerumen (ear wax) in the ear canal is one of the most common causes of conductive hearing loss. It would not lead to a change in the appearance of the tympanic membrane
name: Cerumen impaction
label: d
answer: no
explanation: A vestibular schwannoma (acoustic neuroma) is usually a slow-growing tumour of the cerebellopontine angle. It can present with sensorineural hearing loss, vertigo and tinnitus
name: Vestibular schwannoma
label: e
answer: no
explanation: Tympanosclerosis refers to calcification of the middle ear and tympanic membrane. The aetiology is not fully understood, but the major risk factors are middle ear infections and grommet insertion. The condition is characterised by chalky white patches on the tympanic membrane and a conductive pattern of hearing loss
name: Tympanosclerosis
label: a
answer: yes
explanation: Otosclerosis is a condition in which there is abnormal bone growth in the middle ear. It is a cause of conductive hearing loss but would not explain the characteristic appearances of the tympanic membrane described
name: Otosclerosis
label: c
answer: no
explanation: Chronic otitis media presents with ear discharge for greater than six weeks. Often there will also be perforation of the tympanic membrane on examination
name: Chronic otitis media
label: b
answer: no

Correct answer: a


Learning point: Tympanosclerosis is characterised by chalky white patches on the tympanic membrane and can lead to conductive hearing loss.
A 75-year-old man presents to the Emergency Department (ED), having been found collapsed at his home by his wife. His wife tells you that they recently moved to a new house and had been moving things into the basement.

On assessment, he reports a severe headache and has a GCS of 14. On examination, there is significant accessory muscle usage, tachypnoea and vesicular breath sounds are heard throughout both lung fields. Oxygen saturations are 96% on room air. An arterial blood gas (ABG) shows a PaO<sub>2</sub> of 11.5kPa (>11kPa) and a PCO<sub>2</sub> of 5.1kPa (4.5-6kPa).

Which of the following is the most likely diagnosis?

Options:
explanation: Normal findings on auscultation and normal oxygen saturations would make a pneumothorax an unlikely explanation for the significant symptoms that this patient has presented with
name: Pneumothorax
label: c
answer: no
explanation: Poorly maintained gas and heating appliances are a common cause of carbon monoxide poisoning. Presenting symptoms can include headache, confusion, nausea, shortness of breath and chest pain. Carbon dioxide binds preferentially with haemoglobin to form carboxy-haemoglobin, thereby reducing haemoglobin's carrying capacity of oxygen. Saturation probes cannot differentiate between oxy-haemoglobin and carboxy-haemoglobin, meaning that oxygen saturations are misleadingly normal. Arterial oxygen levels are also normal as there is no ventilation-perfusion mismatch. Elevated carboxy-haemoglobin levels on an ABG can confirm the diagnosis
name: Carbon monoxide poisoning
label: a
answer: yes
explanation: Methaemoglobinaemia is a condition in which the iron in haemoglobin is oxidised from the ferrous to the ferric state, thereby rendering it unable to bind to oxygen. It usually presents with cyanosis, oxygen saturations between 85-90% and normal arterial oxygen levels. Cyanosis is not usually seen in carbon monoxide poisoning as carboxy-haemoglobin has a bright red colour
name: Methaemoglobinaemia
label: b
answer: no
explanation: A subarachnoid haemorrhage is an important differential in this context, given the history of severe headache and reduced GCS. However, he is not in the right age range for a subarachnoid haemorrhage. In any case, you will likely get a CT Head for this patient but this is not the single best answer
name: Subarachnoid haemorrhage
label: e
answer: no
explanation: A pulmonary embolism of the size needed to cause respiratory accessory muscle usage would be expected to cause a decrease in oxygen saturation and arterial oxygen levels
name: Pulmonary embolism
label: d
answer: no

Correct answer: a


Learning point: Carbon monoxide poisoning often presents with headache, confusion, and respiratory distress, despite normal oxygen saturation readings.
A 65-year-old patient with a background of chronic obstructive pulmonary disease (COPD) presents with acute onset chest pain and shortness of breath.

On assessment, he has decreased chest expansion in the left upper zones with associated hyper-resonance and reduced air entry. A chest x-ray confirms a 2.5 cm left sided apical pneumothorax.

Which of the following is the next best step in management.

Options:
explanation: Given his underlying COPD and age, this patient has high risk characteristics associated with his pneumothorax. As it is greater than 2cm (i.e. amenable to drainage), guidelines suggest that chest drain insertion is the best management
name: Chest drain insertion
label: a
answer: yes
explanation: Aspiration is not recommended for patients with a pneumothorax who have high risk characteristics
name: Aspiration
label: b
answer: no
explanation: This is not appropriate given this patient's age and underlying lung disease, which would be considered as high risk characterstics according to BTS guidelines, necessitating chest drain insertion
name: Discharge and review in ambulatory care clinic the next day
label: e
answer: no
explanation: Insertion of a large bore cannula into the second intercostal space on the affected side would be indicated if the patient had a tension pneumothorax
name: Emergency thoracentesis
label: d
answer: no
explanation: This would be indicated if the patient was not breathless, the pneumothorax was less than 2cm and the patient was not keen on interventional management
name: High flow oxygen and observation
label: c
answer: no

Correct answer: a


Learning point: In patients with a significant pneumothorax, especially those with COPD, chest drain insertion may be required.
A 56-year-old man has a cardiac arrest in hospital. Following prompt commencement of cardio-pulmonary resuscitation (CPR), he is found to have a regular broad-complex tachycardia at the first rhythm check.

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

Options:
explanation: 300mg of amiodarone is used in cardiac arrest secondary to VF or VT. However, it is only given after the 3rd shock
name: Administer 300mg of amiodarone (IV)
label: d
answer: no
explanation: Along with amiodarone, adrenaline is given after the 3rd shock in patients with cardiac arrest secondary to VF or pVT
name: Administer 10mg of 1 in 10,000 adrenaline (IV)
label: c
answer: no
explanation: Amiodarone and adrenaline are given in cases of cardiac arrest secondary to VF or VT; however, only after the 3rd shock
name: Administer 300mg of amiodarone (IV) and 10mg of 1 in 10,000 adrenaline (IV)
label: e
answer: no
explanation: This patient has a shockable rhythm, so it is important to administer a shock before recommencing chest compression
name: Continue CPR for 2 minutes
label: b
answer: no
explanation: In the context of a patient in cardiac arrest, a regular broad-complex tachycardia is suggestive of pulseless ventricular tachycardia (pVT). Along with ventricular fibrillation (VF), pVT is an indication for defibrillation (unsynchronised cardioversion) at a setting of 200J
name: Unsynchronised cardioversion at an energy setting of 200J
label: a
answer: yes

Correct answer: a


Learning point: Pulseless ventricular tachycardia (VT) is a shockable cardiac arrest rhythm, and defibrillation with unsynchronized cardioversion at an energy setting of 200J is used to deliver an electrical shock to attempt to restore a normal heart rhythm.
A 56-year-old man is being treated for Escherichia coli septicaemia secondary to pyelonephritis. He is currently on day three of treatment with gentamicin but continues to have fevers and rising inflammatory markers. In addition, his most recent blood tests show a low platelet count, low fibrinogen and raised prothrombin (PT) and activated partial thromboplastin (aPTT) times.

Which of the following is the most likely explanation for the patient's blood test results?

Options:
explanation: Sepsis and trauma can lead to low platelets due to a 'consumptive state'. However, this would not be associated with clotting abnormalities
name: Consumptive thrombocytopaenia due to infection
label: e
answer: no
explanation: TMA is characterised by the formation of thrombi in the small vasculature and associated microangiopathic haemolytic anaemia (MAHA) due to fragmentation of red blood cells. TMA alone would not be associated with clotting abnormalities (i.e. raised PT and APTT)
name: Secondary thrombotic microangiopathy (TMA) due to infection
label: b
answer: no
explanation: DIC is a life-threatening complication of sepsis. It results from over-activation of the coagulation pathway leading to increased risk of thrombosis and subsequent risk of bleeding due to depletion of clotting factors and platelets. It is characterised by raised PT, APTT and D-Dimer, and low platelet count and fibrinogen level. Treatment is supportive with blood products and treatment of the underlying cause
name: Disseminated intravascular coagulation (DIC)
label: a
answer: yes
explanation: MAHA is associated with intravascular haemolysis and can be seen in conjunction with a thrombotic microangiopathy (TMA) or disseminated intravascular coagulation (DIC). MAHA alone (e.g. due to haemolysis secondary to prosthetic heart valves) is not associated with low platelets or clotting abnormalities
name: Microangiopathic haemolytic anaemia (MAHA)
label: c
answer: no
explanation: ITP is characterised by an isolated thrombocytopenia in the absence of an identifiable cause. Therefore, clotting would be normal
name: Immune thrombocytopenic purpura (ITP)
label: d
answer: no

Correct answer: a


Learning point: Disseminated intravascular coagulation (DIC) is a severe complication of sepsis, characterised by coagulopathy and multi-organ dysfunction.
A 16-year-old patient with type 1 diabetes mellitus is admitted after a short history of lethargy, vomiting and confusion. He is found to be in diabetic ketoacidosis (DKA) and is treated with IV fluids and a fixed rate insulin infusion.

Following treatment, he meets the criteria for resolution of DKA and is safely bridged onto his normal regime of subcutaneous insulin. However, he remains confused with a GCS of 13.

Other observations are as follows: heart rate 68bpm, blood pressure 110/55, respiratory rate 16, SpO2 99% on air, temperature 36.9.

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

Options:
explanation: Ongoing confusion in a paediatric patient who has been treated for DKA is concerning for the development of cerebral oedema. A CT head is the best investigation to exclude this
name: Computed tomography (CT) head
label: a
answer: yes
explanation: Hypothyroidism is an important cause of acute confusion and would be part of a routine confusion screen. However, in this case, it is most vital to exclude cerebral oedema given the history of recently treated DKA in a paediatric patient
name: Check thyroid function
label: d
answer: no
explanation: This patient is not hypoxic or in respiratory distress so there is no indication for an ABG
name: Arterial blood gas (ABG)
label: e
answer: no
explanation: There is no indication to restart a VRII if the patient's blood glucose is well controlled following conversion to their usual subcutaneous insulin regime
name: Start variable rate insulin infusion (VRII)
label: c
answer: no
explanation: There is no indication to restart a FRII if the patient's blood glucose is well controlled following conversion to their usual subcutaneous insulin regime
name: Restart fixed rate insulin infusion (FRII)
label: b
answer: no

Correct answer: a


Learning point: A CT scan can be used to diagnose cerebral oedema secondary to diabetic ketoacidosis (DKA), as it helps identify signs of swelling in the brain and rule out other potential complications or causes of altered mental status.
An 80-year-old woman presents to the Emergency Department (ED) with confusion.

On assessment, her GCS is 13, and a neurological examination reveals reduced power and sensation in the right upper and lower limbs. No external injuries are evident.

An urgent CT head shows a haemorrhagic stroke affecting the thalamus.

Which of the following is the most likely aetiology of the stroke?

Options:
explanation: Vasculitis can cause stroke, but it is rare and most commonly seen in younger patients
name: Vasculitis
label: e
answer: no
explanation: Trauma can lead to intracerebral haemorrhage; however, the absence of any external injuries on examination would go against this as the most likely cause
name: Trauma
label: d
answer: no
explanation: Hypertension is the most common cause of spontaneous intracerebral haemorrhage. The pathogenesis is due to hypertension leading to the formation, and subsequent rupture, of Charcot-Bouchard aneurysms in the small penetrating blood vessels of the brain
name: Hypertensive vasculopathy
label: a
answer: yes
explanation: AVM are an important but less common cause of intracerebral haemorrhage
name: Arteriovenous malformation (AVM)
label: b
answer: no
explanation: Cerebral amyloid angiopathy is the most common cause of lobar intracerebral haemorrhage in older adults. A thalamic stroke is more likely to be due to hypertensive vasculopathy
name: Cerebral amyloid angiopathy
label: c
answer: no

Correct answer: a


Learning point: Hypertension is the most common cause of spontaneous intracerebral haemorrhage.
A 56-year-old man with progressive motor neurone disease is assessed by the speech and language team due to concerns about his swallowing.

Following the assessment, the recommendation is that he would benefit from a pureed diet to reduce the risk of aspiration.

Having explained the recommendation and the risks associated with continuing with a normal diet, the patient refuses and states that he wishes to continue with a normal diet. He can understand, retain and weigh up the decision but only able to communicate in writing.

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

Options:
explanation: As long as the patient has retained, understood, weighed up and communicated a decision, there is no need for further justification unless you are unsure of the patient's understanding
name: Ask the patient to justify his decision
label: e
answer: no
explanation: The three key components for informed consent are capacity, provision of adequate information and non-coercion. The patient has the capacity to decide about his feeding as he can understand, retain, weigh up, and communicate a decision. Therefore, his wishes should be accepted
name: Accept the patient's decision and continue with risk-feeding
label: a
answer: yes
explanation: The patient has the capacity to make this decision as he can understand, retain, weigh up, and communicate his wishes
name: Start a pureed diet as the patient lacks capacity
label: b
answer: no
explanation: The patient has capacity and can communicate his decision. There's no indication of psychiatric illness here so a referral to psychiatry is not indicated or appropriate
name: Refer to psychiatry for a full psychiatric assessment
label: c
answer: no
explanation: As the patient has met the criteria for having the capacity to make a decision regarding his feeding, there is no need to reassess
name: Reassess capacity the following day
label: d
answer: no

Correct answer: a


Learning point: Patients with capacity have the right to refuse medical recommendations, even if it poses risks to their health.
A junior medical student has learnt that all patients have a legal right to confidentiality. However, he is unsure of the circumstances in which confidentiality can be breached.

In which of the following situations does a doctor have a legal duty to breach confidentiality?

Options:
explanation: Drivers have a legal duty to inform the Driver and Vehicle Licensing Agency (DVLA) if they have a condition that impairs their ability to drive. A doctor should inform the patient of this duty and make every reasonable effort to make sure they do this. However, if a patient continues not to disclose the information, doctors have a **_professional duty_** to break confidentiality in the public's best interests
name: Conditions that impair the ability to drive
label: b
answer: no
explanation: In these cases, the doctor should first try and convince the patient to make the disclosure themselves. If this is not possible, a doctor should disclose the necessary information only and try and avoid identifying the patient where possible. This would be considered a case where a doctor may have a **legal defence** for breaching confidentiality in the public's best interests
name: Disclosing personal information to a sexual partner
label: e
answer: no
explanation: Identification of patients who are suspected of committing a road traffic offence is one of the specific statutory requirements where doctors have a legal duty to break confidentiality
name: Identification of a patient who committed a road traffic offence
label: a
answer: yes
explanation: General Medical Council (GMC) guidance in 2017 has highlighted that there is no duty to inform the police in the case of serious crime. However, a doctor may still break confidentiality if they believe that it is in the public's best interests. In these cases, there may be a **legal defence** for breaching confidentiality
name: Gunshot/knife wounds
label: d
answer: no
explanation: If the harm is only to the patient, a doctor should accept a competent adult's refusal to disclose information. However, if there are any children involved, a referral to social services is mandated
name: Domestic violence involving a young couple
label: c
answer: no

Correct answer: a


Learning point: Doctors have a legal duty to breach confidentiality when a patient is suspected of committing a road traffic offence.
An 85-year-old man with a background of metastatic prostate cancer is admitted to hospital with a stroke. On examination, he has significant left-sided weakness and sensory loss but no disturbance in cognition or speech.

Which of the following is the most appropriate next step in regards to advanced care planning?

Options:
explanation: It is good practice to discuss patients' wishes regarding CPR even in cases such as this where it is unlikely to be successful. This is important to maintain an honest and transparent patient-doctor relationship
name: Explore the patient's wishes regarding CPR
label: a
answer: yes
explanation: Although CPR is unlikely to be successful, it would be inappropriate to complete a DNACPR form without a discussion regarding the matter with the patient
name: Complete a do not attempt cardiopulmonary resuscitation (DNACPR) as CPR is not likely to be successful
label: c
answer: no
explanation: CPR should be discussed with the patient prior to making a decision on whether they should be for it or not.
name: Proceed with full treatment and keep the patient for CPR
label: e
answer: no
explanation: It would not be appropriate to ask the patient's family for their opinion without the patient's prior consent unless this was done in the patient's best interest. There are no signs to suggest that the patient lacks capacity in this case so it would be worth speaking to the patient first
name: Ask the patient's family about their thoughts on CPR
label: d
answer: no
explanation: Although CPR is unlikely to be successful, there is no reason why active treatment for the patient's stroke and cancer should not continue
name: Explain to the patient why active treatment will not be offered
label: b
answer: no

Correct answer: a


Learning point: In advanced care planning, it is essential to discuss patients' wishes regarding CPR, regardless of their prognosis.