hllj/quesmed huggingface dataset:
A 44-year-old female attends A&E after developing sudden onset breathing difficulties. Her lips are swollen and she has developed a widespread pruritic rash.

Which is the correct prescription?

Options:
explanation: IV adrenaline is not given during anaphylaxis unless it is performed by a specialist. This will usually require continuous monitoring
name: Adrenaline IV (1:10000) 500 micrograms
label: d
answer: no
explanation: This is the correct answer. The patient is experiencing anaphylaxis and therefore, requires IM adrenaline urgently. Note that the correct concentration for IM adrenaline is (1:1000) compared to IV adrenaline (1:10000) which is used during a cardiac arrest. The more concentrated form is therefore, the form that is injected into muscles whereas it would be inadvisable to inject such a dose directly into the vasculature
name: Adrenaline IM (1:1000) 500 micrograms
label: a
answer: yes
explanation: IV adrenaline is not given during anaphylaxis unless it is performed by a specialist. This will usually require continuous monitoring
name: Adrenaline IV (1:100000) 500 micrograms
label: e
answer: no
explanation: IV adrenaline is not given during anaphylaxis unless it is performed by a specialist. This will usually require continuous monitoring. (Also, this concentration of adrenaline would be inadvisable to administer IV)
name: Adrenaline IV (1:1000) 500 micrograms
label: c
answer: no
explanation: This is incorrect. The concentration of adrenaline is for an IV dose
name: Adrenaline IM (1:10000) 500 micrograms
label: b
answer: no

Correct answer: a


Learning point: Anaphylaxis is a severe, life-threatening allergic reaction treated with intramuscular (IM) adrenaline (1:1000) at a dose of 500 micrograms to rapidly counteract symptoms by stimulating alpha and beta-adrenergic receptors
A 56-year-old woman is brought in to A&E after a motorcycle accident. On examination her eyes open after administering a trapezius squeeze; she is able to say words but no clear sentences; her movement is described a "decorticate".

What is her Glasgow Coma Scale score?

Options:
explanation: This is incorrect. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate single words only and therefore, scores a 3 for verbal. Motor of 2 would be decerebrate rather than decorticate. Decorticate means abnormal flexion in response to pain, which is therefore, a 3. Decerebrate means abnormal extension in response to pain and would therefore, score a 2
name: 7 - Eyes 2, Verbal 3, Motor 2
label: d
answer: no
explanation: This is incorrect. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate words, rather than mumbling so scores at least a 3. However, because she is not able to form sentences, confused or otherwise, she only scores a 3. Motor of 2 would be decerebrate rather than decorticate. Decorticate means abnormal flexion in response to pain, which is therefore, a 3. Decerebrate means abnormal extension in response to pain and would therefore, score a 2
name: 6 - Eyes 2, Verbal 2, Motor 2
label: e
answer: no
explanation: This is the correct total score, but incorrect in the constituent parts. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate words, rather than mumbling so scores at least a 3. However, because she is not able to form sentences, confused or otherwise, she only scores a 3. Motor of 2 would be decerebrate rather than decorticate. Decorticate means abnormal flexion in response to pain, which is therefore, a 3. Decerebrate means abnormal extension in response to pain and would therefore, score a 2
name: 8 - Eyes 2, Verbal 4, Motor 2
label: b
answer: no
explanation: This is incorrect. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate words, rather than mumbling so scores at least a 3. However, because she is not able to form sentences, confused or otherwise, she only scores a 3. Decorticate means abnormal flexion in response to pain, which is therefore, a 3
name: 9 - Eyes 2, Verbal 4, Motor 3
label: c
answer: no
explanation: This is the correct answer. The patient's eyes only open to pain, therefore, this scores a 2. She is able to articulate words, rather than mumbling so scores at least a 3. However, because she is not able to form sentences, confused or otherwise, she only scores a 3. Decorticate means abnormal flexion in response to pain, which is therefore, a 3
name: 8 - Eyes 2, Verbal 3, Motor 3
label: a
answer: yes

Correct answer: a


Learning point: To score the Glasgow Coma Scale (GCS), assess the patient’s eye opening (4 points), verbal response (5 points), and motor response (6 points) separately, and sum the scores to obtain a total between 3 (deep coma) and 15 (fully alert).
A 35-year-old male is brought to A&E by his girlfriend. He has been complaining of a progressive, severe headache for the last two hours. He has become increasingly violent in the waiting area. He has a past medical history of HIV and intravenous drug use (IVDU). On examination, he has neck stiffness and reduced visual acuity. A lumbar puncture is done urgently due to suspected meningitis.

Cerebrospinal fluid (CSF) results:

- Appearance - Cloudy
- Protein - Elevated
- Glucose - Low
- White Cell Count - 25 cells/mL
- Opening pressure - Very high
- India ink stain - Positive

What is the likely cause of these symptoms?

Options:
explanation: Streptococcus pneumonia and Neisseria meningitidis are the two most common causes of meningitis in children and adults. They are both bacterial infections, so will typically show on CSF a cloudy appearance; elevated protein; low glucose; white cell count above 200 cells/mL mostly made up of neutrophils; and an elevated opening pressure. They will lead to a negative India ink stain
name: Streptococcus Pneumonia
label: e
answer: no
explanation: CSF examination in Mycobacterium Tuberculosis will most likely have a cloudy appearance; elevated protein; low glucose; white cell count of roughly 20 cells/ mL; and an elevated opening pressure. However, it will lead to a negative India ink stain
name: Mycobacterium Tuberculosis
label: c
answer: no
explanation: Viral meningitis tends to be milder clinically. On CSF examination, a viral infection typically produces CSF with a clear appearance; normal or mildly elevated protein; normal glucose; a raised white cell count up to 200 cells/mL with predominantly lymphocytes; and a slightly elevated opening pressure. Viral meningitis will lead to a negative India ink stain
name: Herpes simplex virus
label: b
answer: no
explanation: Neisseria meningitidis and streptococcus pneumonia are the two most common causes of meningitis in children and adults. They are both bacterial infections, so will typically show a cloudy CSF appearance, with elevated protein, low glucose, a white cell count above 200 cells/mL mostly made up of neutrophils, and an elevated opening pressure. They will lead to a negative India ink stain
name: Neisseria Meningitidis
label: d
answer: no
explanation: This is a typical fungal meningitis. Fungal meningitis is most common in immunosuppressed patients, particularly patients who are HIV positive. India ink staining is used to detect cryptococcal fungi, which are most associated with HIV patients
name: Cryptococcus
label: a
answer: yes

Correct answer: a


Learning point: Cryptococcal meningitis commonly occurs in immunocompromised individuals, particularly those with HIV, presenting with elevated protein and low glucose in CSF.
An 89-year-old woman attends A&E. She moved into a new ground-floor flat two weeks ago and calls her daughter as she says her heating appears to have broken. Her daughter finds her confused, and she is complaining of a headache, nausea, vertigo, and dizziness.

Which of these investigations is most likely to lead to the correct diagnosis?

Options:
explanation: Lung function tests are unlikely to be useful in this acute scenario
name: Lung function tests
label: d
answer: no
explanation: Alcohol intoxication is a common differential of carbon monoxide poisoning, and the two can occur concomitantly. However, the patient is unlikely to complain of vertigo, and there is no mention of alcohol use in the history
name: Blood ethanol levels
label: e
answer: no
explanation: A urine dipstick would be a reasonable investigation to perform in this case. However, based on the history, although delirium secondary to a urinary tract infection is a differential, it is not the most likely and would be unlikely to lead to headache or nausea
name: Urine dipstick
label: b
answer: no
explanation: A chest x-ray would be a reasonable investigation to perform in this case. However, based on the history, although delirium secondary to pneumonia is a differential, it is not the most likely
name: Chest x-ray
label: c
answer: no
explanation: Carboxyhaemaglobin levels can be taken when there is a clinical suspicion of carbon monoxide poisoning. This patient is displaying classic signs and symptoms. Other classic signs are cherry red lips and peripheral cyanosis, which are more common in textbooks than in practice
name: Carboxyhaemaglobin levels
label: a
answer: yes

Correct answer: a


Learning point: Elevated carboxyhemoglobin (COHb) levels in carbon monoxide poisoning occur as CO binds to hemoglobin, reducing oxygen delivery; levels above 3-4% in non-smokers or >20-30% indicate severe exposure and symptoms.
A 90-year-old woman attends A&E due to nausea and vomiting. She had visited her GP about it two days before, but she had thought it had settled. It has now become significantly worse. On examination, she has severe right subcostal tenderness and is visibly jaundiced. Her past medical history includes diabetes type 2 mellitus, hypothyroidism and osteoarthritis.

Her current medications are as follows:

- Paracetamol, 1000mg, oral, 4 times a day
- Ibuprofen 5% gel, topical, to be taken as required, up to 3 times a day
- Metformin modified release, 500mg, oral, once a day
- Linagliptin, 5mg, oral, once a day
- Levothyroxine, 25 micrograms, oral, once a day

Her eGFR is 60 mL/minute/1.73 m2 and her weight is 44kg.

Which of these medications is most likely the cause of her symptoms?

Options:
explanation: Linagliptin is a dipeptidylpeptidase-4 inhibitor. Liver damage is not a known side effect
name: Linagliptin, 5mg, oral, once a day
label: d
answer: no
explanation: This patient is displaying symptoms and signs of hepatocellular necrosis secondary to a staggered overdose of paracetamol. The patient's weight is only 44kg. Any patient less than 50kg is at increased risk of developing liver toxicity secondary to paracetamol overdose. Therefore, prescribing 500mg up to 4 times a day instead of 1000mg is advised. Early features of paracetamol poisoning can present initially and then improve within the first 24 hours. Recurrence of these features usually indicates the onset of hepatocellular necrosis
name: Paracetamol, 1000mg, oral, 4 times a day
label: a
answer: yes
explanation: The patient is displaying signs of hepatocellular necrosis. Liver disorders are a potential rare side effect of ibuprofen orally; however, there is little evidence that this can occur via the topical route
name: Ibuprofen 5% gel, topical, to be taken as required, up to 3 times a day
label: b
answer: no
explanation: A rare side effect of metformin is hepatitis. However, this is the lowest possible dose, and the clinical picture suggests hepatocellular necrosis. It would be important in this patient to consider withholding the metformin prescription because paracetamol poisoning can lead to renal necrosis, which may increase the likelihood of lactic acidosis secondary to the metformin. Lactic acidosis is not usually a concern unless the eGFR drops below 30 mL/minute/1.73 m2
name: Metformin modified release, 500mg, oral, once a day
label: c
answer: no
explanation: Liver damage is not a known side effect of levothyroxine. Caution should be taken when prescribing levothyroxine, even at this small dose, with diabetic medications as the dose of antidiabetic drugs may need to be increased
name: Levothyroxine, 25 micrograms, oral, once a day
label: e
answer: no

Correct answer: a


Learning point: Paracetamol overdose can cause hepatocellular necrosis, especially in patients weighing less than 50kg, necessitating careful dosage adjustments.
An 86-year-old woman attends A&E after her carers found her with slurred speech and pale skin. This is her ECG:

[lightgallery]

Atrial fibrillation is noted. What other abnormality can be seen on the ECG?

Options:
explanation: Capture beats occur when the sinoatrial node "captures" current from the ventricles during atrioventricular dissociation. This produces a normal QRS complex during ventricular tachycardia. They can help differentiate between VT and supraventricular tachycardia (SVT) with aberrancy rhythms as they are more likely to occur in VT
name: Capture beats
label: e
answer: no
explanation: Pathological Q waves usually indicate ongoing or historic myocardial infarction. Q waves are considered pathological if they are wider or deeper than normal
name: Pathological Q waves
label: b
answer: no
explanation: Brugada syndrome is due to an abnormality in a cardiac sodium channel which can lead to sudden death. Brugada sign is potentially diagnostic but does not necessarily lead to Brugada syndrome. There is ST elevation in more than one lead, followed by a negative T wave
name: Brugada sign
label: d
answer: no
explanation: These occur when sinus and ventricular rhythms coincide. They can help differentiate between Ventricular Tachycardia (VT) and Supraventricular Tachycardia (SVT) with aberrancy rhythms as they are more likely to occur in VT
name: Fusion beats
label: c
answer: no
explanation: This patient has presented with signs and symptoms of hypothermia. J waves can be seen in hypothermic patients, often at a temperature of less than 30 degrees. The height of the J wave is thought to be approximate to the degree of hypothermia. They are positive deflections between the QRS and the ST segment
name: J waves
label: a
answer: yes

Correct answer: a


Learning point: J waves on ECG are indicative of hypothermia, typically appearing when body temperature falls below 30 degrees Celsius.
A Foundation Year 1 doctor is on their first rotation in urology. They are asked by the urology consultant to consent a 67-year-old male patient for a trans urethral resection of a bladder tumour. The patient is due to go to theatre that afternoon. The Foundation Year 1 doctor has never seen this surgery performed before and does not have a clear idea about what it entails.

Which of the following is the most appropriate action for the Foundation Year 1 doctor?

Options:
explanation: This is the second best choice. You should not practice outside your boundaries of competence. (Even consultants need to ask others for help occasionally). However, explaining why they have refused would be best
name: Refuse to consent the patient
label: c
answer: no
explanation: This is a poor choice, even if the doctor has mitigated the scenario slightly by looking up the details of the surgery. This consent requires a complex understanding of the operation that only someone who has performed the surgery will have
name: Consent the patient after looking up the details of the surgery in more detail
label: e
answer: no
explanation: This is a poor choice as the doctor is also involving a second underqualified doctor. It is up to interpretation whether this option is worse the consenting the patient after looking up the details first. Ultimately, both should not happen
name: Ask another Foundation Year 1 doctor, who has seen the surgery performed before, to consent the patient
label: d
answer: no
explanation: This is the best answer. As a Foundation Year 1 doctor, they should not be consenting a patient for a procedure which is unknown to them as they would be unable to sufficiently explain the risks and benefits for the surgery to the patient. They would also be unlikely to answer any further questions from the patient. A good general rule that can be used is: if you can do the procedure yourself then you can ascertain consent. If you cannot, then it may not be appropriate to be obtaining consent
name: Explain to the consultant that they are unable to consent the patient as they do not have enough experience
label: a
answer: yes
explanation: This is the worst choice as the doctor is unlikely to be able to provide clear guidance, and the patient would have reasonable grounds to complain as it would negatively affect their care
name: Consent the patient as best they can on their own
label: b
answer: no

Correct answer: a


Learning point: Foundation Year doctors should not consent for procedures they are unfamiliar with, as they cannot adequately explain risks and benefits to patients.
A 95-year-old female is an inpatient on the acute medical unit. She has been treated for a urinary tract infection with antibiotics and is due to be discharged home. Before discharge, the patient agreed with the consultant to complete a Do Not Attempt Resuscitation (DNAR) form. The patient had capacity to make this decision. The patient's daughter (her next of kin) visits the ward and demands to know whether or not her mother has a DNAR form. She is very upset because she says it has been so difficult to contact the ward to find out how her mother has been doing.

Which is the best next step for you, as the ward resident doctor, to take?

Options:
explanation: Although the mother is upset about the lack of information that she has received it is still not acceptable to break patient-doctor confidentiality
name: Tell the daughter that her mother does have a DNAR form and update her about her current care
label: e
answer: no
explanation: You should not break patient-doctor confidentiality by disclosing this information without the patient's permission. Instead you must ask the mother whether it is acceptable to relay this information to her daughter. Whilst a DNACPR is a medical decision, this antagonistic response is likely to create further tension
name: Tell the daughter that their mother does have a DNAR form and explain that this is a medical decision and that her opinion will not change anything
label: d
answer: no
explanation: This is the next best answer, as you cannot tell the daughter any information about her mother without her mother's consent
name: Refuse to tell the daughter anything
label: c
answer: no
explanation: Just because the daughter is the next of kin does not automatically mean that you can break patient-doctor confidentiality
name: Tell the daughter that her mother does have a DNAR form as she is the next of kin
label: b
answer: no
explanation: This is the correct answer. The patient had capacity to make the decision about resuscitation, therefore, it is likely that she will have capacity to make the decision about whether to communicate this decision to her daughter. If you did not ask permission, you would be breaking patient-doctor confidentiality
name: Check with the patient whether you can share this information with their daughter
label: a
answer: yes

Correct answer: a


Learning point: Always seek patient consent before disclosing medical information to relatives to uphold confidentiality and respect patient autonomy.
A 46-year-old woman presents to her GP. She has been experiencing a non-productive cough for the last week. She has become short of breath of exercise and has felt intermittently feverish. On examination you notice oral thrush, a raised heart rate and widespread, scattered crackles. She is human immunodeficiency virus (HIV) positive.

What is the most appropriate management?

Options:
explanation: Although paracetamol may be helpful as an antipyretic and analgesia, it would not help treat the underlying infective cause
name: Paracetamol
label: e
answer: no
explanation: The patient is suffering from a pneumocystis jirovecii infection. This is a fungus that can cause pneumonia in at-risk patients. It is an acquired immune deficiency syndrome (AIDs)-defining infection in individuals who are HIV positive. The most appropriate treatment is high dose co-trimoxazole (trimethoprim and sulfamethoxazole)
name: Co-trimoxazole
label: a
answer: yes
explanation: The patient has a non-productive cough and has been short of breath, which may suggest an asthma diagnosis. However, the fever and widespread scattered crackles point to an infective cause
name: Salbutamol
label: b
answer: no
explanation: The patient is showing signs of an infection, therefore, prednisolone is not appropriate at this stage
name: Prednisolone
label: d
answer: no
explanation: This may be appropriate for a bacterial pneumonia. However, the patient is HIV positive and has signs of oral thrush. These greatly increase the risk of an atypical infection. Pneumoncystis jirovecci is a common cause of pneumonia in immunocompromised patients
name: Co-amoxiclav
label: c
answer: no

Correct answer: a


Learning point: Pneumocystis jirovecii pneumonia is an AIDS-defining illness in HIV-positive patients, typically treated with high-dose co-trimoxazole.
A 19-year-old man visits his GP due to urethral discharge and dysuria. This has been ongoing for the last week. He states that he had unprotected vaginal sex with two female partners and unprotected insertive anal sex with one male partner with over the last month.

His GP arranges for microscopy of the discharge. This showed gram-negative diplococci.

What is the diagnosis?

Options:
explanation: Syphilis does not usually present in this way. Instead, there will most often be an initial chancre, a small painless ulcer, found on the glans of the penis
name: Syphilis
label: c
answer: no
explanation: Penile discharge is common in trichomoniasis. However, it is caused by a protozoan rather than a bacterium
name: Trichomoniasis
label: d
answer: no
explanation: Zoon's balanitis is an inflammation around the head of the penis and the foreskin. It leads to well-defined, itchy, red patches. Histology shows increased plasma cells on skin samples
name: Zoon's balanitis
label: e
answer: no
explanation: Chlamydia is likely to present with similar symptoms to gonorrhoea however is a rod-shaped gram-negative bacteria
name: Chlamydia
label: b
answer: no
explanation: Urethral discharge is a common symptom in males with gonorrhoea. Gonorrhoea is a gram-negative diplococcus
name: Gonorrhoea
label: a
answer: yes

Correct answer: a


Learning point: Urethral discharge is a common symptom in males with gonorrhoea