hllj/quesmed huggingface dataset:
A 23-year-old patient with sickle cell anaemia develops a fever and a red, hot swollen elbow. On examination, they are in excruciating pain on active and passive movement of the joint.

A radiograph of the elbow is normal. The patient's observations are as follows:

* Heart rate: 112 beats/minute
* Blood pressure: 102/69 mmHg
* Respiratory rate: 17 breaths/minute
* Temperature: 38.7 degrees
* Oxygen saturations (room air): 98%

What is the next most appropriate step?

Options:
explanation: It would be important to take blood cultures in a patient who is febrile with a suspected infection, however, the most urgent task to perform is a joint aspiration for diagnostic purposes.
name: Take blood cultures
label: c
answer: no
explanation: This patient likely has a septic joint. Colchicine may be used to help manage pain in an acute monoarthritis, but is not typically used in septic arthritis. The most important step to take is to obtain a joint aspirate.
name: Commence colchicine
label: e
answer: no
explanation: The likely diagnosis in this case is septic arthritis given the acute red hot swollen joint and fever. Patients with sickle cell anaemia are susceptible to overwhelming infections, and there is a link between sickle cell anaemia and septic arthritis caused by salmonella. An urgent joint aspirate should be obtained for diagnostic purposes and to ascertain microbial sensitivities.
name: Joint aspiration
label: a
answer: yes
explanation: This would be inappropriate; the patient has an acute monoarthritis with a fever and septic arthritis must be considered.
name: Discharge with NSAIDs
label: d
answer: no
explanation: The most likely diagnosis is septic arthritis. The first step that should be undertaken is a diagnostic joint aspirate. An arthroscopy and washout may be required further down the line if the infection is severe or is not responding to antibiotics.
name: Arthroscopy and washout
label: b
answer: no

Correct answer: a


Learning point: Patients with sickle cell anaemia are at increased risk of septic arthritis, often caused by Salmonella, requiring prompt joint aspiration for diagnosis.
A 30-year-old primigravida at 32 weeks gestation is discussing childbirth with her midwife. She is known to be HIV positive, and is taking antiretroviral therapy. Her latest blood tests show an undetectable HIV viral load and a normal CD4 count.

What is the best strategy to reduce vertical transmission of HIV?

Options:
explanation: Post-exposure prophylaxis for infants born to HIV-positive mothers is recommended in all cases. Raltegravir, however, is not recommended for this indication. Standard PEP for very low and low-risk babies is zidovudine monotherapy for 2-4 weeks. Combination antiretroviral therapy is recommended in high-risk babies (i.e. those born to mothers with a viral load >50 copies/mL)
name: Raltegravir administered to the baby (post-delivery)
label: d
answer: no
explanation: As this patient's HIV viral load is undetectable, a vaginal delivery is acceptable. Elective Caesarean section deliveries were more common before the introduction of highly active antiretroviral therapy.
name: Elective caesarean section
label: e
answer: no
explanation: The British HIV Association and Royal College of Obstetricians and Gynaecologists recommend women avoid breastfeeding post-partum, regardless of their viral load and CD4 count, to reduce the risk of vertical transmission. If a woman does decide to breastfeed with an undetectable viral load, they should stop doing so if they develop any nipple bleeding or infections.
name: Avoid breastfeeding
label: a
answer: yes
explanation: Intrapartum antiretrovirals are indicated for women with a viral load of >1000 RNA copies/mL plasma, untreated HIV-positive patients, and can be considered if the viral load is 50-100 copies/mL plasma. This does not apply in this case as the patient has an undetectable viral load. Further, the antiretroviral of choice for this situation would be zidovudine.
name: Intrapartum emtricitabine
label: b
answer: no
explanation: Intrapartum antiretrovirals are indicated for women with a viral load of >1000 RNA copies/mL plasma, untreated HIV-positive patients, and can be considered if the viral load is 50-100 copies/mL plasma. This does not apply in this case. Further, the antiretroviral of choice for this situation would be zidovudine.
name: Intrapartum tenofovir
label: c
answer: no

Correct answer: a


Learning point: To minimise vertical transmission of HIV, mothers should avoid breastfeeding, regardless of viral load or CD4 count.
A 23-year-old man visits a sexual health clinic with dysuria and purulent urethral discharge. He reports two episodes of unprotected sexual intercourse with a casual female partner three weeks ago.

A nucleic acid amplification test of his urine is negative for chlamydia and gonorrhoea. Microscopy performed on a sample of the discharge shows 19 neutrophils/high power microscopic field (normal < 5 neutrophils/high power microscopic field).

What is the most appropriate antimicrobial to prescribe?

Options:
explanation: The diagnosis in this case is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance. If NGU recurs, metronidazole may be prescribed with azithromycin.
name: Metronidazole
label: d
answer: no
explanation: Benzathine benzylpenicillin is the first-line antibiotic of choice for syphilis. The diagnosis in this case is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance.
name: Benzathine benzylpenicillin
label: c
answer: no
explanation: Fluconazole is usually used in the treatment of candidiasis. The diagnosis in this case is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance.
name: Fluconazole
label: e
answer: no
explanation: The diagnosis in this case is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance.
name: Doxycycline
label: a
answer: yes
explanation: The diagnosis, in this case, is non-gonococcal urethritis (NGU). Common organisms implicated are _Chlamydia_ and _Mycoplasma_ species. Doxycycline (or azithromycin as a 2nd line option) are recommended in the first instance.
name: Clarithromycin
label: b
answer: no

Correct answer: a


Learning point: Doxycycline is the first-line treatment for non-gonococcal urethritis, commonly caused by Chlamydia and Mycoplasma species.
A 31-year-old woman visits her GP after giving birth to discuss contraceptive options. She has done extensive reading and would like a highly effective method that does not involve hormonal therapy. A copper intrauterine device (IUD) is suggested.

What would be an absolute contraindication to IUD insertion?

Options:
explanation: Postpartum sepsis is an absolute contraindication (UKMEC 4) to IUD insertion due to infection risk.
name: Postpartum sepsis
label: a
answer: yes
explanation: Insertion of an IUD in a patient with fibroids NOT distorting the uterine cavity is UKMEC 1 (no restriction), however, if uterine distortion is present, this would be UKMEC category 3 (risks usually outweigh advantages). In both cases, fibroids are not an absolute contraindication to IUD use.
name: Uterine fibroids (not distorting uterine cavity)
label: e
answer: no
explanation: Insertion of an IUD in patients with sickle cell disease is UKMEC category 2 (advantages generally outweigh risks) rather than UKMEC 4 (contraindicated)
name: Sickle cell disease
label: d
answer: no
explanation: Obesity is not a contraindication to IUD insertion. It is, however, a consideration with hormonal methods.
name: BMI >35 kg/m^2
label: c
answer: no
explanation: Copper IUD insertion is UKMEC category 3 (risks usually outweigh advantages) between 48 hours and 4 weeks postpartum, rather than UKMEC 4 (contraindicated). Copper IUD insertion is UKMEC category 1 (no restriction) <48 hours and >4 weeks postpartum.
name: Vaginal delivery within 3 weeks
label: b
answer: no

Correct answer: a


Learning point: Postpartum sepsis is an absolute contraindication for copper intrauterine device insertion due to the increased risk of infection.
The mother of a 12-hour-old baby in the post-natal observation unit is concerned about a swelling on her baby's head. She had a vacuum-assisted delivery but suffered no intrapartum or postpartum complications.

On examination, there is a boggy diffuse swelling with poorly defined margins around the occiput. It appears to cross the suture lines.

What is the best next step to take?

Options:
explanation: The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. Attempting to aspirate any fluid/blood would be inappropriate.
name: Diagnostic aspiration
label: e
answer: no
explanation: The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. No further investigations are required in this case. Baseline blood tests should be considered for other causes of head swelling e.g. subgaleal haemorrhages.
name: Full blood count and clotting profile
label: b
answer: no
explanation: The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. No further investigations are required in this case.
name: Cranial ultrasound scan
label: c
answer: no
explanation: The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. No further investigations are required in this case. Imaging may be considered for other conditions e.g. craniosynostosis.
name: Skull x-ray
label: d
answer: no
explanation: The most likely diagnosis is caput succedaneum, a self-limiting and benign condition characterised by scalp oedema after childbirth. This can occur in unassisted deliveries due to external pressure from the birth canal but is made more likely by vacuum or forceps-assisted births.
name: No further investigations are required
label: a
answer: yes

Correct answer: a


Learning point: Caput succedaneum is a benign, self-limiting scalp swelling in newborns, often resulting from vacuum-assisted deliveries. It typically resolves within a few days without treatment.
A 41-year-old pregnant lady is referred to a materno-foetal medicine unit after a cardiovascular anomaly was found on a routine foetal ultrasound scan. A combined screening test in the first trimester showed increased nuchal thickness, a high serum beta-HCG level, and a low Pregnancy-associated plasma protein-A (PAPP-A) level. She opted not to proceed with further pre-natal diagnostics.

What is the most likely cardiovascular anomaly detected?

Options:
explanation: The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect. Tetralogy of Fallot has a weaker association with Down's syndrome, and is also associated with Alagille syndrome and DiGeorge syndrome.
name: Tetralogy of Fallot
label: c
answer: no
explanation: The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect.
name: Patent foramen ovale
label: b
answer: no
explanation: The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect.
name: Total anomalous pulmonary venous return
label: d
answer: no
explanation: The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect. Aortic coarctation is commonly associated with Turner syndrome.
name: Coarctation of the aorta
label: e
answer: no
explanation: The combination of advanced maternal age and the findings of the combined test suggest that the foetus may have Down's syndrome (trisomy 21). The most common cardiovascular anomaly occurring in Down's syndrome is atrioventricular septal defect.
name: Atrioventricular septal defect
label: a
answer: yes

Correct answer: a


Learning point: Atrioventricular septal defect is the most common cardiac anomaly associated with Down's syndrome.
An 8-month-old girl is brought to the emergency department by her parents after developing a loud cough on a background of coryzal symptoms. They have also noticed a harsh high-pitched sound when she breathes in. Her observations are within normal limits except for a mild fever. She has mild stridor at rest. Her parents have given her oral paracetamol.

What is the best next step in management?

Options:
explanation: The most likely diagnosis is croup, for which steroids should be administered in the first instance. Nebulised (not injected) adrenaline can be considered as a second-line treatment until steroids take effect.
name: Intramuscular adrenaline
label: c
answer: no
explanation: The most likely diagnosis is croup, which is generally caused by a viral infection. Steroids should be administered immediately to help reduce airway oedema.
name: Intravenous antibiotics
label: d
answer: no
explanation: Given that croup primarily affects the upper respiratory tract (which does not contain smooth muscle), salbutamol is unlikely to be of benefit. Oral dexamethasone should be administered immediately.
name: Inhaled salbutamol
label: b
answer: no
explanation: The most likely diagnosis is croup, for which steroids should be administered in the first instance. Nebulised adrenaline can be considered as a second-line treatment until steroids take effect.
name: Nebulised adrenaline
label: e
answer: no
explanation: The most likely diagnosis is croup. The next best step to take is to administer steroids to help control inflammation. First-line treatment is oral dexamethasone (0.15 mg/kg), however, if the child is too unwell to take this, they can be given inhaled budesonide or parenteral dexamethasone.
name: Oral dexamethasone
label: a
answer: yes

Correct answer: a


Learning point: Croup is characterised by a barking cough and stridor, often requiring oral dexamethasone for inflammation management.
An 8-year-old boy weighing 32kg is admitted to the paediatric ward with acute appendicitis. He is awaiting an appendectomy and has been made nil by mouth so requires maintenance fluids.

What is the most appropriate 24hr fluid regime to prescribe?

Options:
explanation: This child requires 1740ml fluid/day (i.e. 72 ml/hour) according to the Holliday-Segar formula ( (100x10) + (50x10) + 20x12) ). NICE recommends administering isotonic crystalloids that contain sodium in the range of 131–154 mmol/litre in the first instance. Glucose may also be included.
name: 72 ml/hour 0.9% sodium chloride with 5% glucose
label: a
answer: yes
explanation: Although this child requires 1740ml fluid/day according to the Holliday-Segar formula, NICE recommends administering isotonic crystalloids that contain sodium in the range of 131–154 mmol/litre in the first instance. Administering only 5% glucose may result in hyponatraemia.
name: 1740 ml/day 5% glucose solution
label: b
answer: no
explanation: This would be an inappropriate choice; while a fluid bolus of 10-20 ml/kg can be considered for resuscitation in shocked patients, there is no indication that this is currently the case.
name: 640 ml over 15 minutes 0.9% sodium chloride solution
label: e
answer: no
explanation: This child requires 1740ml fluid/day (i.e. 72 ml/hour) according to the Holliday-Segar formula. NICE recommends administering isotonic crystalloids that contain sodium in the range of 131–154 mmol/litre in the first instance. Glucose may also be included.
name: 145 ml/hour Hartmann's solution
label: c
answer: no
explanation: This would be an inappropriate choice; while a fluid bolus of 10-20 ml/kg can be considered for resuscitation in shocked patients, there is no indication that this is currently the case. Furthermore, 5% glucose is an inappropriate choice for fluid resuscitation.
name: 320 ml over 15 minutes 5% glucose solution
label: d
answer: no

Correct answer: a


Learning point: For children requiring maintenance fluids, use the Holliday-Segar formula to calculate daily fluid needs and consider isotonic crystalloids.
A neonate born at 39 weeks gestation by elective Caesarean section is noted to be tachypnoeic and in respiratory distress shortly after delivery.

Observations:

* Heart rate: 187 beats/minute (100 - 205 beats/minute)
* Respiratory rate: 67 breaths/minute (30 - 50 breaths/minute)
* Oxygen saturations (room air): 98%

A chest x-ray was performed:

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Given the most likely diagnosis, which of the following is the greatest risk factor for this condition in this case?

Options:
explanation: The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. The chest radiograph shows features of fluid congestion in the lungs with a trace seen within the right horizontal fissure. Caesarean section is a significant risk factor for transient tachypnoea of the newborn, as the neonate is not subject to the compressive forces of the vaginal canal during delivery which would aid in fluid absorption.
name: Caesarean section delivery
label: a
answer: yes
explanation: The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. Maternal sepsis may predispose the newborn to neonatal sepsis, however this would not present immediately after delivery.
name: Maternal sepsis
label: b
answer: no
explanation: Meconium aspiration syndrome is a differential in this case, however, The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. This is due to the clinical history (Caesarean section delivery and no mention of meconium staining) and the radiographic findings of fluid overload.
name: Meconium stained liquor
label: c
answer: no
explanation: The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. Prematurity is a risk factor for the condition, however, in this case, the baby has been delivered at 39 weeks' gestation. Caesarean section is a significant risk factor for transient tachypnoea of the newborn, as the neonate is not subject to the compressive forces of the vaginal canal during delivery which would aid in fluid absorption.
name: Prematurity
label: d
answer: no
explanation: The most likely diagnosis is transient tachypnoea of the newborn, which is the most common aetiology of neonatal respiratory distress. Caesarean section delivery is the greatest risk factor in this particular case. Maternal cardiac disorders are not linked to the development of the condition.
name: Maternal cardiac disease
label: e
answer: no

Correct answer: a


Learning point: Transient tachypnoea of the newborn commonly occurs after Caesarean section due to inadequate clearance of pulmonary fluid.
A 10-month old girl is rushed into the Emergency Department with sudden onset cough, respiratory distress, and noisy breathing. This started 20 minutes ago whilst at a playdate, and she had previously been well. On examination she is making a high-pitched inspiratory sound whilst breathing and is coughing ineffectively. There is no wheeze, rash, or angioedema. Her respiratory rate is elevated at 48 (30-40) and she is tachycardic at 152 bpm (80-140), her other vital signs are normal.

What is the most appropriate management?

Options:
explanation: The history and examination is consistent with an inhaled foreign body. The immediate management is a rigid bronchoscopy to remove it. Foreign body inhalations are often unwitnessed in children and it is an important differential for anyone presenting with stridor and respiratory distress. Although not common practice, this question has appeared in previous writers' MLA AKT exams so we have included it in our bank.
name: Rigid bronchoscopy
label: a
answer: yes
explanation: Bronchoconstriction can cause respiratory distress in infants, however a wheeze rather than stridor would be found on examintation. The history and examination is more consistent with an inhaled foreign body.
name: Nebulised salbutamol
label: b
answer: no
explanation: Croup is a common cause of stridor in children and can also cause respiratory distress, this would be treated with steroids. However, the onset would not be so sudden and there is usually a history of low grade fever and coryzal illness. The history and examination is more consistent with an inhaled foreign body.
name: Dexamethasone, STAT dose
label: c
answer: no
explanation: The sudden onset and lack of temperature in this patient is not consistent with an infectious cause of respiratory distress. The history and examination is more consistent with an inhaled foreign body.
name: Amoxicillin
label: e
answer: no
explanation: Anaphylaxis is an important differential for respiratory distress and stridor, however is is accompanied by hypotension, and allergic symptoms such as angioedema. The history and examination is more consistent with an inhaled foreign body.
name: 150 micrograms IM adrenaline
label: d
answer: no

Correct answer: a


Learning point: Inhaled foreign bodies in children can cause sudden respiratory distress and stridor, necessitating immediate rigid bronchoscopy for removal.