hllj/quesmed huggingface dataset:
A 16-year-old woman attends her GP due to otalgia in her right ear. She has had the pain for the last 2 days. On otoscopic examination the GP identifies a cloudy and slightly bulging tympanic membrane.

What is the correct management?

Options:
explanation: There is no evidence to support the use of antihistamines in acute otitis media
name: Regular analgesia and an antihistamine
label: d
answer: no
explanation: Antibiotics are advised for those who are suspected to have acute otitis media and a systemic infection. Also, those with otorrhoea or those aged less than 2 with a bilateral infection may benefit from a short course of antibiotics, usually amoxicillin. Acute otitis media will normally improve within 3 days without the need for antibiotic treatment so they should not be used in this case
name: Regular analgesia and a short course of antibiotics
label: e
answer: no
explanation: The patient has acute otitis media. Regular paracetamol or ibuprofen is the advised treatment for those who present with no acute complications or systemic illness
name: Regular analgesia
label: a
answer: yes
explanation: There is no evidence to support the use of decongestants or antihistamines in acute otitis media
name: Regular analgesia, a decongestant and an antihistamine
label: c
answer: no
explanation: There is no evidence to support the use of decongestants in acute otitis media
name: Regular analgesia and a decongestant
label: b
answer: no

Correct answer: a


Learning point: Acute otitis media in children without complications or systemic illness is usually managed with regular analgesia, such as paracetamol or ibuprofen, to relieve pain.
A 79-year-old male was admitted to hospital with nausea and increased tiredness. His investigation results are as follows:


||||
|---------------------------|:-------:|--------------------|
|Sodium|125 mmol/L|135 - 145|
|Potassium|3.9 mmol/L|3.5 - 5.3|
|Urea|5.6 mmol/L|2.5 - 7.8|
|Creatinine|64 µmol/L|60 - 120|
|Urinary Sodium (random)|60 mmol|20|
|Urine Osmolality|145 mOsmol/kg|50 - 1200|


The patient is euvolaemic.


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

Options:
explanation: Tolvaptan is a V2 receptor agonist. It can be used as a second line treatment for patients with SIADH, it should be prescribed after specialist consultation
name: Tolvaptan
label: d
answer: no
explanation: Hypertonic fluids is the treatment for patients who are experiencing CNS related hyponatraemia symptoms. Usually this will involve a small bolus of 3% saline in a monitored environment
name: Hypertonic fluids
label: b
answer: no
explanation: This patient has syndrome of inappropriate ADH release (SIADH). Fluid restriction is the first line treatment for SIADH. Depending on their electrolyte free water clearance, which can be calculated using the Furst formula, depends on how much a patient is fluid restricted by
name: Fluid restriction
label: a
answer: yes
explanation: Steroid treatments may be recommended in certain causes of hyponatraemia, for example, Addison's disease (where a hyperkalaemia would also be expected). It is not the first line treatment for SIADH
name: Hydrocortisone
label: e
answer: no
explanation: This is more commonly used as a treatment for hypovolaemic, hyponatraemia patients. Therefore, it is imperative that a patient's fluid status is always taken into account
name: Isotonic fluids
label: c
answer: no

Correct answer: a
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: 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 (1:10000) 500 micrograms
label: d
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
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

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 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 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
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. 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 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

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: 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: 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: 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
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: 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

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: 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: 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: 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: 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: 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
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: 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

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: 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
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: 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: 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: 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

Correct answer: a


Learning point: J waves on ECG are indicative of hypothermia, typically appearing when body temperature falls below 30 degrees Celsius.
A 56-year-old woman visits her GP due to the development of new mouth ulcers. She also complains about a sore throat. On examination, she is warm to the touch. She has started a new medication due to a recent diagnosis of hyperthyroidism.


Her bloods are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|101      g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|2.2x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|90x10<sup>9</sup>/L|150 - 400|


Which of these medications is most likely to be the cause?

Options:
explanation: This patient has pancytopenia on their blood film and is displaying signs and symptoms of bone marrow depression. Bone marrow depression occurs in roughly 1 in 1000 patients who take carbimazole. The suppression is usually temporary and should improve within weeks if the carbimazole is stopped. More common side effects include headache, nausea and rashes
name: Carbimazole
label: a
answer: yes
explanation: Beta-blockers can lead to thrombocytopenia; however, pancytopenia is less common. Other side effects include fatigue, cold extremities and bronchospasm
name: Metoprolol
label: d
answer: no
explanation: Beta-blockers can lead to thrombocytopenia; however, pancytopenia is less common. Other side effects include fatigue, cold extremities and bronchospasm
name: Nadolol
label: e
answer: no
explanation: Beta-blockers can lead to thrombocytopenia; however, pancytopenia is less common. Other side effects include fatigue, cold extremities and bronchospasm
name: Propranolol
label: b
answer: no
explanation: Propylthiouracil is usually only prescribed by a specialist for hyperthyroidism. Propylthiouracil can lead to pancytopenia as well as hepatic disorders and hypersensitivity reactions. It is not first line because of the slightly increased likelihood of severe liver damage. Therefore, it is unlikely to have been prescribed to this patient
name: Propylthiouracil
label: c
answer: no

Correct answer: a


Learning point: Pancytopenia, a condition characterized by the reduction of all blood cell types, can be a rare side effect of carbimazole, a medication used to treat hyperthyroidism, due to its impact on bone marrow function.
A 62-year-old male patient presents to A&E due to a history of intermittent confusion, sweating and dizziness. These often improved towards the end of the day. His bloods are as follows:


 - Fasting glucose 1.2 (normal range 3.5-5.5 mmol/L)
 - Proinsulin raised
 - C-peptide raised


A diagnosis of insulinoma is made. What is the most appropriate initial management?

Options:
explanation: This patient requires immediate glucose replacement. However, they are more likely to require potassium replacement rather than sodium. This is due to the effect that insulin has on increasing potassium uptake within cells
name: IV dextrose and sodium replacement
label: c
answer: no
explanation: This patient will need immediate glucose replacement most urgently. They may require alternative fluid therapy later on in their treatment, but the low glucose levels require correction first. They will also likely require potassium replacement because increased circulating insulin levels will lead to an increase in potassium being transported intracellularly
name: IV 0.9% sodium chloride and potassium replacement
label: b
answer: no
explanation: This patient requires immediate glucose replacement. They will also likely require potassium replacement because increased circulating insulin levels will lead to an increase in potassium being transported intracellularly
name: IV dextrose and potassium replacement
label: a
answer: yes
explanation: This patient requires immediate glucose replacement. However, they are more likely to require potassium replacement rather than calcium. This is due to the effect that insulin has on increasing potassium uptake within cells
name: IV dextrose and calcium replacement
label: d
answer: no
explanation: This patient will need immediate glucose replacement most urgently. They may require alternative fluid therapy later on in their treatment, but the low glucose levels require correction first. They are more likely to require potassium replacement rather than calcium. This is due to the effect that insulin has on increasing potassium uptake within cells
name: IV 0.9% sodium chloride and calcium replacement
label: e
answer: no

Correct answer: a


Learning point: An insulinoma is a pancreatic tumor that causes excessive insulin secretion and hypoglycemia. IV dextrose quickly raises blood glucose, and potassium replacement may be needed due to insulin-induced cellular potassium shifts.