hllj/quesmed huggingface dataset:
An 83-year-old man with mild vascular dementia is brought to A&E by one of his carers. They report that he has not been himself for the past few weeks. He was previously independent with his activities of daily living but is now unable to feed or dress himself due to increasing confusion. This morning he was found to be very drowsy and withdrawn during breakfast. The carer admits that over the past few weeks they have been understaffed due to staff sickness. On examination, there is fading bruising along his left arm and shoulder. 

What is the most likely explanation for his presentation?

Options:
explanation: There should be suspicion of a previously unwitnessed fall due to the presence of bruising along the patient's arm and reported low staffing levels by the carer. Unwitnessed falls can lead to head injury. The elderly are at higher risk of subdural haematomas after head injury due to brain atrophy stretching the bridging veins within the subdural space. Therefore, this presentation likely represents a subdural haematoma. A CT head can be used to confirm the diagnosis; the patient will have a crescent-shaped mass.
name: Subdural haematoma
label: a
answer: yes
explanation: Extradural haematomas typically present after a head injury with a blow to the temples resulting in rupture of the middle meningeal artery. There is typically an initial loss of consciousness, followed by a period of lucidity then rapid decline in conscious level. There are no clinical features to suggest an extradural haematoma. The CT head would show a convex-shaped mass.
name: Extradural haematoma
label: c
answer: no
explanation: A subarachnoid haemorrhage would typically present with sudden-onset thunderclap headache and rapid clinical deterioration. Given the suspicion of a fall and the subacute presentation, a subdural haematoma is more likely in this age group due to brain atrophy and bridging vein tethering.
name: Subarachnoid haemorrhage
label: d
answer: no
explanation: Urinary tract infections (UTIs) can cause acute confusional states (delirium). This patient is presenting acutely confused; therefore, it is a diagnosis worth considering. However, there are no clinical features of UTI in either the history (such as dysuria, frequency or urgency), or examination (such as fever or suprapubic pain). This makes a UTI unlikely.
name: Urinary tract infection
label: b
answer: no
explanation: Normal pressure hydrocephalus is a possible differential for the falling and confused patient. These patients are typically described as 'wet, wobbly and weird', relating to urinary incontinence, ataxia and confusion respectively. However, there is an absence of these features in the clinical history and a subdural haematoma is a diagnosis to exclude first.
name: Normal pressure hydrocephalus
label: e
answer: no

Correct answer: a


Learning point: Elderly patients are at increased risk of subdural haematomas due to brain atrophy, often following unwitnessed falls and resulting head injuries.
A 42-year-old woman presents with a 2-d history of reduced sensation to the left side of her face. She also has double vision and is struggling with pain in her left eye. She has a past medical history of poorly controlled type 2 diabetes and underwent paranasal sinus surgery 4 d ago. On examination, there is extensive left-sided periorbital oedema and proptosis. Her temperature is 38.4 °C.

What additional finding might be present on physical examination?

Options:
explanation: This patient has a cavernous sinus syndrome, probably due to a thrombus secondary to cavernous sinus infection. She is at higher risk of infection due to her poorly controlled diabetes and her recent paranasal sinus surgery. The cavernous sinus houses cranial nerves III, IV, VI, Va and Vb, and the internal carotid artery. The changes are ipsilateral to the side of the lesion. There is also an issue with venous drainage from the facial vein leading to chemosis, periorbital oedema, orbital pain and proptosis. Associated complications include seizures, septic emboli, Horner syndrome and intracranial hypertension.
name: Abducens nerve palsy
label: a
answer: yes
explanation: Sensation to the skin overlying the chin is provided by Vc (the mandibular branch of the trigeminal nerve). This does not run through the cavernous sinus.
name: Loss of sensation over the chin
label: e
answer: no
explanation: Sensorineural deafness occurs due to disorders of the vestibulocochlear (VIII) nerve. This nerve does not run through the cavernous sinus.
name: Sensorineural deafness on the left
label: d
answer: no
explanation: Relative afferent pupillary defects are present when there are issues with the afferent pathway of the pupillary reflex, that is, retinal or optic nerve pathology. Neither are involved in cavernous sinus syndrome.
name: Relative afferent pupillary defect
label: c
answer: no
explanation: The facial nerve does not run through the cavernous sinus; therefore, this option is incorrect.
name: Facial nerve palsy
label: b
answer: no

Correct answer: a


Learning point: Cavernous sinus syndrome can present with cranial nerve palsies, particularly affecting the abducens nerve, leading to diplopia and ocular motility issues.
A 14-year-old adolescent is brought to A&E after a week-long history of painful left eye movements and diplopia. One week ago, she was struck in the face with a hockey stick and sustained an undisplaced fracture of the zygomatic bone. She was sent home with analgesia and clinic follow-up with ophthalmology. On examination, you note swelling and erythema around the left eye. She has a complex ophthalmoplegia but the remainder of her cranial nerve examination is unremarkable. Her temperature is 38.7 °C.

Which of the following is the next best investigation?

Options:
explanation: This patient likely has orbital cellulitis, as indicated by the presence of erythema and swelling surrounding the left eye, fever, diplopia (due to extraocular eye muscle involvement) and pain. The diplopia occurs due to complex ophthalmoplegia, which is when eye signs cannot be attributed to a single cranial nerve. The orbit is made up of seven bones, including the zygomatic, palatine and maxillary bones. Fractures of any of these bones are a risk factor for developing orbital cellulitis. This is a potentially sight-threatening emergency and can be further complicated by infective extension into the cavernous sinus. The best test is a CT orbit for this condition.
name: CT orbit
label: a
answer: yes
explanation: This is a highly sensitive imaging modality for evaluating thromboses within the venous sinuses, not for identifying orbital cellulitis.
name: CT venogram
label: c
answer: no
explanation: An MRI is rarely done because a CT orbit is quicker to carry out and most often confirms the diagnosis. On T1, a low signal will be observed.
name: T1 MRI brain with orbits
label: d
answer: no
explanation: This is a reasonable option and a CT of the head is often performed alongside a dedicated scan of the orbit. However, a dedicated scan of the orbit is still required, so this is not the best investigation.
name: CT head with contrast
label: b
answer: no
explanation: An MRI is rarely done because a CT orbit is quicker to carry out and most often confirms the diagnosis. On T2, a high signal will be observed.
name: T2 MRI brain with orbits
label: e
answer: no

Correct answer: a


Learning point: A CT scan of the orbit is an essential imaging tool for evaluating orbital cellulitis, as it helps to identify the extent of infection, detect any associated complications such as orbital abscess or sinusitis, and distinguish it from other conditions that may affect the orbital structures.
A 33-year-old pregnant woman presents with persistent nausea and vomiting in the first trimester. She reports that she cannot keep any food down, and this has been the case for 5 d. She has managed small sips of water. On examination, she is tachycardic at 110 bpm, blood pressure 115/70 mmHg, respiratory rate 18 and is afebrile. A diagnosis of hyperemesis gravidarum is made by the admitting team and she is prescribed antiemetics and fluids. Two hours later the patient's head has rotated to one side and her eyes are periodically deviating upwards.

What is the most likely antiemetic to have caused this side effect?

Options:
explanation: This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Ondansteron is an antiemetic particularly used in the case of nausea and vomiting caused by chemotherapy. It is a serotonin 5 HT3 receptor antagonist. It does not have any effect on the D2 receptors; therefore, acute dystonias are not a recognised side effect.
name: Ondansetron
label: e
answer: no
explanation: This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Metoclopramide is primarily a D2 receptor antagonist and acts on the receptors in the chemoreceptor trigger zone in the central nervous system. It is also a prokinetic agent via its muscarinic activity. Due to antagonism at the D2 receptor, it may also cause blockade in the extrapyramidal circuits, leading to side effects including acute dystonia (such as oculogyric crises and cervical dystonias), and, with chronic use, tardive dyskinesias. The risk of acute dystonic reactions is increased with higher doses and younger patients.
name: Metoclopramide
label: a
answer: yes
explanation: This patient is presenting with acute dystonia, in the form of torticollis (cervical dystonia) and an oculogyric crisis. Cyclizine is a histamine H1 receptor antagonist. Side effects may include urinary retention but extrapyramidal side effects are not reported.
name: Cyclizine
label: b
answer: no
explanation: This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Chlopromazine is an antipsychotic that antagonises the D2 receptor and would not ordinarily be used to treat nausea and vomiting. Less commonly, it causes acute dystonias but it is known to cause tardive dyskinesia and akathisia, which are more likely at higher doses.
name: Chlopromazine
label: c
answer: no
explanation: This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Promethazine is a first-generation antihistamine, antagonising the H1 receptor, and is generally used for its sedative effects, as opposed to its antiemetic effects. It has some antidopaminergic effects, which may lead to tardive dyskinesia, dystonias and akathisia but these are uncommon.
name: Promethazine
label: d
answer: no

Correct answer: a


Learning point: Metoclopramide can cause acute dystonia, including torticollis and oculogyric crises, particularly in younger patients and with higher doses.
A 38-year-old woman is brought in by ambulance to A&E. She was having lunch with a friend when she complained of a headache and lost consciousness soon after. On examination, she has a Glasgow Coma Scale score of 3 and bilateral flank masses palpable on her abdomen. Her observations are otherwise within normal parameters.

What is the cause of her neurological presentation?

Options:
explanation: Berry aneurysms are a recognised feature of autosomal dominant polycystic kidney disease (ADPCKD), which is an inherited cause of end-stage renal failure. The palpable bilateral flank masses should raise suspicion of underlying ADPCKD. Berry aneurysms have a propensity to rupture leading to a subarachnoid haemorrhage, presenting with a traditional sudden-onset 'thunderclap' headache and rapid neurological deterioration.
name: Subarachnoid haemorrhage
label: a
answer: yes
explanation: An abdominal aortic aneurysm rupture may present with shock due to bleeding and subsequent reduced consciousness. Headache is not a typical component of the presentation and there is no evidence of haemodynamic instability here. Abdominal aortic aneurysms are also more likely in older male patients.
name: Abdominal aortic aneurysm rupture
label: c
answer: no
explanation: An extradural haematoma typically presents after a traumatic head injury with a brief loss of consciousness followed by recovery (lucid interval) and subsequent rapid deterioration in conscious level. It occurs typically due to a blow to the temples and rupture of the middle meningeal branch of the maxillary artery (a branch of the external carotid). There is no history of trauma in this patient and the clinical features of a lucid interval are not present.
name: Extradural haematoma
label: e
answer: no
explanation: A myocardial infarction (MI) typically presents with chest pain, breathlessness or syncope. Patients are typically older with cardiovascular risk factors. Younger patients may present with MIs, especially if there are strong risk factors such as use of cocaine or hereditary hypercholesterolaemia. ADPKD does not typically increase the risk of MI until there is a significant degree of renal impairment. The most likely cause of this presentation is a berry aneurysm rupture.
name: Myocardial infarction
label: d
answer: no
explanation: Meningitis can cause headache and reduced consciousness. However, the natural history in this case is hyperacute, and therefore a haemorrhage is more likely since meningitis tends to have a more insidious onset. There are also no clinical features of infection, such as fever, or other features of meningism, such as neck stiffness. Furthermore, in this case the presence of bilateral flank masses should also raise suspicion of autosomal dominant polycystic kidney disease and the presence of a ruptured berry aneurysm.
name: Meningitis
label: b
answer: no

Correct answer: a


Learning point: Autosomal dominant polycystic kidney disease is associated with berry aneurysms, which can rupture and cause subarachnoid haemorrhage.
A 64-year-old man undergoes a flexible sigmoidoscopy after a 4-month change to his bowel habit, where he reports intermittent constipation and loose stools. He denies any blood in the stool or any systemic symptoms. On flexible sigmoidoscopy no abnormality is found.

What is the next best step in his management?

Options:
explanation: A flexible sigmoidoscopy only passes through the rectum, sigmoid colon and proximal parts of the descending colon. Therefore, colon cancer could be missed further up in the ascending or transverse sections. Thus, a colonoscopy should be conducted. This patient has symptoms that are concerning for an underlying colon malignancy. The National Institute for Health and Care Excellence (NICE) guidelines state that patients over 60 with iron deficiency anaemia or changes in their bowel habit should be referred for investigation under a 2-week wait pathway.
name: Colonoscopy
label: a
answer: yes
explanation: A positron emission tomography scan can be useful for the evaluation of metastases, particularly in the case of bowel cancer to nearby lymph nodes and the liver. However, the primary site of malignancy has not been confirmed; therefore, it would be inappropriate to expose a patient to radiation at this stage.
name: Fluorodeoxyglucose-positron emission tomography scan
label: e
answer: no
explanation: This patient is presenting with chronic symptoms and there is nothing in the history suggestive of infection. A colorectal malignancy should therefore be ruled out.
name: Stool cultures
label: c
answer: no
explanation: A flexible sigmoidoscopy can only evaluate part of the colon for malignancy and therefore this is insufficient to rule out a malignancy of the colon. In the context of his age and the recent change in bowel habit, the NICE guidelines state this patient needs evaluation for colorectal malignancy. A colonoscopy is required.
name: Discharge with lifestyle advice
label: d
answer: no
explanation: Carcinoembryonic antigen (CEA) is only used when monitoring response to treatment for a confirmed colorectal malignancy. It is not a good screening or diagnostic test because its specificity is low. Furthermore, a negative result does not exclude malignancy; therefore, it does not exclude the need for colonoscopy.
name: Measure carcinoembryonic antigen
label: b
answer: no

Correct answer: a
A 20-year-old female presents to general practice with questions regarding her ongoing acne. She has extensive pustules and erythematous papules across her face and upper back. She is embarrassed of her skin but denies any low mood. She has previously tried combinations of topical Differin, topical benzoylperoxide and topical clindamycin with no improvement. She has had a previous deep vein thrombosis (DVT) after surgery. She takes no regular medications currently and has no drug allergies.

What is the most appropriate next step in management?

Options:
explanation: Co-cyprindiol is an oral contraceptive pill with antiandrogenic effects. It contains cyproterone acetate (antiandrogenic) and ethinyloestradiol. NICE guidelines recommend this medication in patients with polycystic ovary syndrome and acne not responding to conventional first-line topical and oral antibiotic therapies. Therefore, this patient does not qualify for this treatment and would be contraindicated anyway due to the presence of previous DVT.
name: Co-cyprindiol
label: e
answer: no
explanation: This drug is reserved for initiation by a dermatologist for patients with severe acne who are unresponsive to two courses of oral antibiotic therapy. This patient does not currently fulfil these criteria.
name: Oral isotretinoin
label: c
answer: no
explanation: This could be a service to offer this patient in conjunction with acne treatment if her mental health were significantly affected: symptoms of depression, anxiety, body dysmorphia, suicidal ideation or self-harm. This is not the case here. Furthermore, it would not treat her condition alone since psychological support would not address the root cause (ie. the acne) of any mood disorder if present.
name: Referral to psychological services
label: b
answer: no
explanation: This patient has moderate acne indicated by the presence of many inflammatory lesions (pustules and inflammatory papules). Mild acne is defined by the presence of mostly comedones with few inflammatory lesions. There are no markers of severe acne (nodules, cysts and scars). She has not responded to topical agents, so as per National Institute for Health and Care Excellence (NICE) guidelines oral antibiotics are indicated. This is usually doxycycline or lymecycline but alternatives include clarithromycin or trimethoprim. Topical agents should be continued while on oral antibiotics. Combined oral contraceptives with antiandrogenic effects (such as co-cyprindiol) could be considered in some patients but this would not be an option in the context of previous deep vein thrombosis.
name: Oral lymecycline
label: a
answer: yes
explanation: Short courses of prednisolone can be used to treat some severe acne flares, such as acne fulminans. It has no place in the routine or long-term management of most acne presentations.
name: Prednisolone
label: d
answer: no

Correct answer: a


Learning point: Oral antibiotics like lymecycline are recommended for moderate acne unresponsive to topical treatments.
A 42-year-old man attends his GP after a 6-month history of difficulty sleeping. He reports waking up multiple times a night gasping for breath and then napping more regularly in the day. His wife has also noticed that he tends to act out his dreams while asleep and snores heavily. On examination, his body mass index is 35 and otherwise unremarkable.

What is the best next investigation for his poor sleep?

Options:
explanation: Enlarged tonsils, adenoids or a narrowed airway can be risk factors for OSA. A laryngoscopy could be used to evaluate any structural abnormalities narrowing the airway. However, this is not first line and is generally reserved for patients undergoing potential surgical treatment, where standard medical therapy such as continuous positive airway pressure has failed or not been tolerated.
name: Laryngoscopy
label: d
answer: no
explanation: The history of snoring and daytime somnolence in a patient who is obese points towards a diagnosis of obstructive sleep apnoea (OSA). Acting out dreams can be a rapid eye movement (REM) disorder, which can also be seen in a small number of these patients. The first-line investigation for OSA would be polysomnography.
name: Polysomnography
label: a
answer: yes
explanation: A sleep diary is unlikely to yield much additional information since the patient and his wife have already given detailed accounts of his sleep patterns. Their accounts point towards a diagnosis of OSA; therefore, he should be referred for polysomnography.
name: Sleep diary
label: c
answer: no
explanation: Waking in the middle of the night can occur in the context of heart failure, where the patient reports waking up breathless and coughing pink, frothy sputum (paroxysmal nocturnal dyspnoea (PND)). In this case, there are no reported heart failure symptoms, such as shortness of breath, PND, orthopnoea or ankle swelling. The clinical presentation is more in keeping with OSA.
name: Brain natriuretic peptide
label: e
answer: no
explanation: Acting out dreams can indicate a REM disorder. This can be an early feature of Parkinson's disease, where a DaTscan can illustrate loss of dopaminergic neurones in the basal ganglia. However, given the patient demographics and the absence of any parkinsonian features, the more likely underlying cause of the REM sleep disorder is OSA. The first-line investigation would be polysomnography.
name: DaTscan
label: b
answer: no

Correct answer: a


Learning point: Polysomnography is the gold standard investigation for diagnosing obstructive sleep apnoea, it simultaneously records brain activity, eye movement, muscle activity, heart rate, respiratory effort, airflow, and oxygen saturation during sleep to identify apneic episodes and assess their severity.