hllj/quesmed huggingface dataset:
A 45-year-old woman develops a persistent headache of 4 days duration, not resolving with over the counter painkillers. She presented to Accident & Emergency with bilateral eye pain and blurred vision. At triage, she suffers a generalised tonic-clonic seizure which is terminated with one dose of IV lorazepam. Computed tomography (CT) brain was done immediately, which showed a large clot in the cavernous sinus.

Which is the next best step in acute management?

Options:
explanation: Evidence suggests that low molecular weight heparin results in better outcomes than unfractionated heparin (UFH) for initial anticoagulation in cerebral venous sinus thrombosis. UFH may be considered in patients with renal impairment or those requiring very rapid reversal of anticoagulation, e.g. imminent surgical intervention
name: Unfractionated heparin
label: c
answer: no
explanation: Direct oral anticoagulants can be considered for longer-term prophylaxis of venous thromboembolism
name: Dabigatran
label: e
answer: no
explanation: In cerebral venous sinus thrombosis, recurrent seizures are more likely to develop in those who present with seizures and in those with supratentorial brain lesions on imaging. This would not be appropriate in the initial management, but may be considered later on for seizure prophylaxis
name: Valproate
label: b
answer: no
explanation: This patient has presented with cerebral venous sinus thrombosis, for which the initial management would be subcutaneous low molecular weight heparin
name: Low molecular weight heparin
label: a
answer: yes
explanation: This may be considered after the acute stage for longer-term prophylaxis of further cerebral and extracerebral venous thrombosis (i.e. deep vein thrombosis, pulmonary embolism). It would not be appropriate to start warfarin acutely as it has prothrombotic activity on initiation
name: Warfarin
label: d
answer: no

Correct answer: a


Learning point: Cerebral venous sinus thrombosis is managed acutely with low molecular weight heparin to prevent further thrombus formation.
A 45-year-old woman presents to Accident & Emergency with a one-week history of persistent headache. She was worried as she started experiencing bilateral blurring of vision in the past day. She also reports hearing the sound of 'rushing water' in both ears. Fundoscopy reveals bilateral swelling of the optic discs.

The consultant reviews her and decides to start her on medication. What is the mechanism of action of the most likely drug used?

Options:
explanation: The most likely drug to be used here is acetazolamide, a carbonic anhydrase inhibitor. The patient has idiopathic intracranial hypertension, with the typical features of raised intracranial pressure (headache, tinnitus, papilloedema, visual loss). The treatment involves carbonic anhydrase inhibitors to decrease the rate of cerebrospinal fluid production
name: Carbonic anhydrase inhibitor
label: a
answer: yes
explanation: This is the mechanism of action of prednisolone. Steroids are not recommended for use in idiopathic intracranial hypertension as their withdrawal can cause severe rebound intracranial hypertension with visual loss, and may worsen weight gain, which is a risk factor for the condition. It may, however, be useful as a temporary measure prior to surgery in the setting of acute visual loss
name: Decreases inflammation via suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability
label: d
answer: no
explanation: This is the mechanism of action of ibuprofen, a nonsteroidal inflammatory drug that may be used for pain relief of migraines but would not be the treatment in this case
name: Reversible inhibitor of cyclooxygenase-1 and 2 (COX-1 and 2) enzymes
label: c
answer: no
explanation: This is the mechanism of action of sumatriptan, which may be used in the treatment of acute migraine. However, this would not be effective here as the headache is secondary to idiopathic intracranial hypertension
name: 5HT1 receptor agonist
label: e
answer: no
explanation: This is the mechanism of action of furosemide, which may be considered as an adjunct to acetazolamide
name: Inhibitor of the luminal Na-K-Cl cotransporter in the ascending loop of Henle
label: b
answer: no

Correct answer: a


Learning point: Carbonic anhydrase inhibitors, like acetazolamide, reduce cerebrospinal fluid production, aiding in the management of idiopathic intracranial hypertension.
A 75-year-old male presents to the Emergency Department with sudden vision loss in his right eye. His past medical history includes hypertension, and he is a smoker.

His right eye is painless, and there is no conjunctival redness. Fundoscopy reveals a red spot at the macula.

Which of the following tests are most appropriate in investigating the underlying cause?

Options:
explanation: This may be done to investigate ankylosing spondylitis. This may cause anterior uveitis, which leads to acute-onset painful vision loss with photophobia, red eye and a constricted pupil. Slit lamp may reveal a hypopyon in the anterior chamber and white precipitates on the cornea. This is not the case here, as the visual loss is painless with no red eye
name: MRI lumbosacral spine, including sacroiliac joints
label: d
answer: no
explanation: The patient has sudden onset painless monocular vision loss with a fundoscopy finding suggestive of central retinal artery occlusion. This is usually due to thromboembolism, obstructing blood flow to the retinal artery. Workup for cardiovascular risk factors and a possible thromboembolic cause should be done, including investigations for stroke. The patient is hypertensive and a current smoker, both of which are contributing risk factors as well
name: Carotid doppler
label: a
answer: yes
explanation: This may be done if suspecting multiple sclerosis, which is the top cause of optic neuritis. Patients usually have painless monocular vision loss over hours to days with colour desaturation. Fundoscopy may show a swollen, blurred optic disc. Lumbar puncture would demonstrate oligoclonal bands in the cerebrospinal fluid
name: Lumbar puncture
label: c
answer: no
explanation: HIV is one of the systemic causes of eye disease, including HIV retinopathy, cytomegalovirus (CMV) retinitis, herpes simplex virus (HSV) keratitis or retinitis and toxoplasmosis. CMV retinitis tends to be the most common HIV-related eye condition, causing loss of central vision, blind spots, floaters or flashing lights. Fundoscopy typically shows a "pizza pie" appearance due to haemorrhagic retinal necrosis
name: Human immunodeficiency virus (HIV) testing
label: e
answer: no
explanation: This would be appropriate if suspecting acute anterior ischaemic optic neuropathy, which may occur due to giant cell arteritis (arteritic) or atherosclerosis (non-arteritic). Presenting symptoms include a sudden onset painless monocular vision loss with deterioration of colour vision, and fundoscopy reveals unilateral optic disc oedema with flame-shaped haemorrhages. In giant cell arteritis, erythrocyte sedimentation rate (ESR) would be raised, and temporal artery biopsy is the gold standard investigation
name: Temporal artery biopsy
label: b
answer: no

Correct answer: a


Learning point: A carotid Doppler is an important diagnostic tool for evaluating sudden onset painless monocular vision loss, especially when fundoscopy findings suggest central retinal artery occlusion (CRAO). This test helps identify significant stenosis or emboli in the carotid artery, which can be a source of the arterial blockage leading to CRAO.
A 50-year-old woman presents to the Emergency Department with sudden onset severe pain in her right eye. Her past medical history includes severe asthma, sickle cell disease and depression. She only takes selegiline. She has nausea and vomited once on the way to the hospital. On inspection, she has right conjunctival redness, and her right pupil reacts poorly to light.

Which of the following medications should be started?

Options:
explanation: This is a beta-blocker that would be contraindicated in patients with asthma, COPD, heart block and severe heart failure, to name a few conditions. It may cause bronchoconstriction in a patient with asthma
name: Timolol
label: c
answer: no
explanation: This is an alpha agonist that reduces aqueous secretion and increases outflow through the trabecular meshwork. It is contraindicated in patients taking monoamine oxidase inhibitors (selegiline in this case) due to the risk of hypertensive crisis
name: Brimonidine
label: d
answer: no
explanation: This is a cycloplegic that dilates the pupil and is used in anterior uveitis to prevent the formation of posterior synechiae. It would worsen glaucoma as it exacerbates angle closure
name: Cyclopentolate
label: e
answer: no
explanation: This is a carbonic anhydrase inhibitor, which is contraindicated in those with sickle cell disease, as it may precipitate a vaso-occlusive crisis by exacerbating sickling of cells. In the absence of contraindications, IV acetazolamide may be given in acute glaucoma to lower intraocular pressure
name: Brinzolamide
label: b
answer: no
explanation: This patient is presenting with acute angle closure. The immediate management of this includes pilocarpine eye drops, acetazolamide (contraindicated in this case), analgesia and an anti-emetic if needed.
name: Pilocarpine
label: a
answer: yes

Correct answer: a


Learning point: Latanoprost is a prostaglandin analog used to treat glaucoma and ocular hypertension by increasing the outflow of aqueous humor, which lowers intraocular pressure (IOP).
A 60-year-old lady is admitted with a three-day history of sudden onset epigastric pain, nausea and two episodes of vomiting.


On examination, her abdomen is soft and diffusely tender. There is no rigidity or guarding.


Observations: temperature 37.0°C, HR 110 bpm, BP 90/60 mmHg, RR 20 bpm, SpO2 99% on room air.


Her bloods show:

||||
|---------------------------|:-------:|--------------------|
|Albumin|40 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|21 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|32 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|110 IU/L|25 - 115|
|Bilirubin|7 µmol/L|< 17|
|Gamma Glutamyl Transferase (GGT)|20 U/L|9 - 40|
|Lipase|432 IU/L|< 101|
|Amylase|289 U/L|< 220|


She was recently started on a new medication. Which of the following is the most likely cause of her current presentation?

Options:
explanation: This is a known cause of cholestatic hepatitis, which is not the case here, given the normal liver function tests. It does not cause acute pancreatitis
name: Co-amoxiclav
label: b
answer: no
explanation: This woman has presented with acute pancreatitis secondary to valproate, which is a rare cause of pancreatitis. Lipase is more sensitive in patients with pancreatitis as it has a longer half-life than amylase; thus, lipase levels may remain elevated even after amylase levels have normalised
name: Valproate
label: a
answer: yes
explanation: This may cause gastrointestinal upset, including nausea, vomiting and diarrhoea. It may also cause a metallic taste in the mouth. It is not associated with acute pancreatitis
name: Lithium
label: e
answer: no
explanation: This may cause gastrointestinal upset, including nausea and vomiting, diarrhoea and bloating. Rarely, it may cause lactic acidosis, usually in patients with impaired renal or hepatic function. However, it would not explain the elevated lipase levels
name: Metformin
label: d
answer: no
explanation: Another possible differential is peptic ulcer disease, which may have been caused by non-steroidal anti-inflammatory drugs such as ibuprofen. This is unlikely to cause elevated lipase. The patient also does not have signs of peritonism, which might suggest a perforation
name: Ibuprofen
label: c
answer: no

Correct answer: a


Learning point: Valproate can cause drug-induced pancreatitis, and other drugs that can also lead to this condition include azathioprine, mercaptopurine, sulfonamides, tetracyclines, estrogens, calcium channel blockers, and furosemide.
A 65 year old gentleman presents to Accident & Emergency with a 5 day history of persistent haematuria. He has a background of atrial fibrillation and is on warfarin.


Blood tests are as follows:

||||
|--------------|:-------:|---------------|
|Haemoglobin|115  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|9.1x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|210x10<sup>9</sup>/L|150 - 400|
|Neutrophils|5.5 x10<sup>9</sup>/L|2.0 - 7.5|
|Sodium|137 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Chloride|102 mmol/L|95 - 106|
|Urea|8 mmol/L|2.5 - 7.8|
|Creatinine|95 µmol/L|60 - 120|
|eGFR|85 mL/min/1.73m<sup>2</sup>|> 60|
|International Normalised Ratio (INR)|2.1|1.0|


Urinalysis showed red blood cells with no evidence of leucocytes or nitrites. Computed tomography (CT) of kidneys, ureters and bladder showed no stones.


Which is the next most appropriate investigation?

Options:
explanation: This would be useful in looking for gastrointestinal cancer, which should be suspected in a patient with unexplained iron deficiency anaemia, change in bowel habit, melaena and other constitutional symptoms
name: Colonoscopy
label: d
answer: no
explanation: This is usually indicated in nephrotic syndrome, acute nephritic syndrome or unexplained acute kidney injury, which is not the case here
name: Renal biopsy
label: e
answer: no
explanation: Guidelines state that any adult >45 years with unexplained visible haematuria without a urinary tract infection should have a 2 week referral for suspected renal or bladder cancer. Cystoscopy with biopsy is the gold standard for diagnosing bladder cancer, as it allows direct visualisation of the bladder
name: Flexible cystoscopy
label: a
answer: yes
explanation: This may be useful in looking for metastases, but it would not be useful in diagnosing suspected renal or bladder cancer
name: CT abdomen pelvis
label: c
answer: no
explanation: This is best used for excluding urinary tract obstruction and can be used to visualise cysts, abscesses, hydronephrosis and other complications of pyelonephritis. It would not be the best in investigating suspected malignancy
name: Ultrasound of the kidneys, ureters and bladder
label: b
answer: no

Correct answer: a


Learning point: In adults over 45 with unexplained visible haematuria, flexible cystoscopy is essential for diagnosing potential bladder cancer.
A 85 year old male is admitted with acute urinary retention. Over the past year, he has been having urinary hesitancy and poor stream with nocturia up to 5-6 times a night. He had an objective 3kg loss of weight in the last year.

Digital rectal examination (DRE) reveals a hard, asymmetrically enlarged prostate. Prostate specific antigen is elevated at 15ng/mL.

Which of the following is the next most appropriate investigation?

Options:
explanation: This may be useful in investigating voiding dysfunction in patients with lower urinary tract symptoms that point towards chronic bladder outflow obstruction. However, it would not be useful in a patient which has a high clinical likelihood of prostate cancer
name: Urodynamic studies
label: e
answer: no
explanation: This would be most appropriate in patients with suspected prostate cancer after taking into account relevant risk factors including age, prostate specific antigen level, DRE findings and comorbidities. However, this method is invasive and may risk missing the cancer depending on the area biopsied
name: Transrectal ultrasound biopsy
label: b
answer: no
explanation: If there is a very high clinical suspicion of localised prostate cancer, clinicians should proceed directly to multiparametric MRI as a first-line investigation. This would reduce the risk of unnecessary prostate biopsies
name: Magnetic resonance imaging (MRI) scan of the prostate
label: a
answer: yes
explanation: This would be useful in investigating causes of obstructive uropathy. However, as prostate cancer is the most likely cause in this scenario given the DRE findings, it is better to proceed with an MRI prostate first
name: Ultrasound of the kidneys, ureters and bladder
label: d
answer: no
explanation: This would be useful in watchful waiting for asymptomatic patients in whom hormonal therapy is being deferred or as a staging scan for bone metastases. However, it is not the most useful in making a diagnosis of prostate cancer
name: Isotope bone scan
label: c
answer: no

Correct answer: a


Learning point: In cases of suspected prostate cancer, multiparametric MRI is the preferred initial investigation to minimise unnecessary biopsies.
A 75-year-old woman presents with worsening joint pain and swelling in her hands, wrists, and knees, along with deep bone aches that disrupt her sleep. She has lost 5kg over the past year with poor appetite. She has no significant medical history, occupational exposure, or smoking history.


On examination, she has clubbing bilaterally. She has symmetrical polyarthritis of the wrists, metacarpal joints and knees; with pain, swelling and reduced range of motion of the affected joints.


X-rays of her tibia and fibula are suggestive of periosteal bone formation.


Chest X-ray shows a left lower lobe mass. The medical team decides to arrange an interventional radiology guided biopsy of the mass lesion.


Which of the following histology findings are most likely?

Options:
explanation: This has the highest association with smoking amongst the lung cancers. It typically presents with centrally located lung masses and tends to be associated with Cushing's syndrome due to ectopic production of adrenocorticotropic hormone. It is not likely here as it is very rare in patients who have never smoked
name: Large cell carcinoma
label: d
answer: no
explanation: This has the highest association with smoking amongst the lung cancers. It typically presents with centrally located lung masses and tends to be associated with Cushing's syndrome due to ectopic production of adrenocorticotropic hormone. It is not likely here as it is very rare in patients who have never smoked
name: Small cell lung carcinoma
label: b
answer: no
explanation: This is the second most common type of lung cancer and has a strong association with smoking compared to other non-small cell lung carcinomas. It is usually centrally located and originates in the bronchi. Associated paraneoplastic phenomena usually includes hypercalcaemia secondary to secretion of parathyroid hormone related peptide
name: Squamous cell carcinoma
label: c
answer: no
explanation: This is the most common type of lung cancer, especially in females and non-smokers. This patient has presented with hypertrophic osteoarthropathy, with clubbing and a painful arthropathy that can be quite similar to inflammatory arthritis. It is most frequently associated with adenocarcinoma
name: Adenocarcinoma
label: a
answer: yes
explanation: This is most commonly associated with asbestos exposure and would typically present with bilateral pleural thickening and plaques. This is not likely given her lack of occupational exposure
name: Mesothelioma
label: e
answer: no

Correct answer: a

Adenocarcinoma

Learning point: Hypertrophic osteoarthropathy, characterised by clubbing and joint pain, is commonly associated with lung adenocarcinoma, particularly in non-smoking females.
A 32-year-old man presents to his General Practitioner (GP) with a 3-day history of sharp, constant central chest pain. He reports the pain to be worse on inspiration and relieved by sitting forward. On questioning, he reveals a 1-week history of coryzal symptoms and myalgia, which are now improving. He denies cough, shortness of breath or palpitations.

He has no significant past medical history and examination and all observations are unremarkable.

An ECG shows widespread PR depression and concave ST elevation.

Given the likely diagnosis, which of the following is the first-line management?

Options:
explanation: The most likely diagnosis is acute pericarditis. This is inflammation of the pericardium that typically lasts for less than 4-6 weeks and is characterised by central chest pain relieved by sitting forward. The pain is also pleuritic, meaning that it is worse on inspiration. As described in this case, a prodromal viral illness may be associated with pericarditis as a viral infection is a common precipitant.

The most specific sign on ECG for acute pericarditis is PR depression. This can also be associated with widespread, concave ST elevation.

The first-line management of pericarditis is with a short course of a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen
name: Non-steroidal anti-inflammatory drug (NSAID)
label: a
answer: yes
explanation: Nebulised bronchodilators would be indicated in asthma. There are no features to suggest asthma such as shortness of breath, wheeze or a prior history of atopy
name: Nebulised bronchodilators
label: c
answer: no
explanation: Pleuritic chest pain can be a sign of pneumonia for which antibiotics would be indicated. However, the ECG findings in combination with the prodrome of coryzal prodrome is suggestive of acute pericarditis
name: Oral antibiotics
label: b
answer: no
explanation: Aspirin would be indicated in acute coronary syndrome (ACS). This patient's pain does not have any ischaemic characteristics and is pleuritic in nature. He also does not have any risk factors for ischaemic heart disease
name: Aspirin 300mg
label: d
answer: no
explanation: LMWH would be used for the treatment of a pulmonary embolus (PE). A PE is an important differential to consider in this case as it can present with pleuritic chest pain. However, pain relieved by sitting forward and a history of a recent viral illness favour a diagnosis of pericarditis more
name: Low molecular weight heparin (LMWH)
label: e
answer: no

Correct answer: a


Learning point: Acute pericarditis presents with pleuritic chest pain, often relieved by sitting forward, and is initially managed with NSAIDs.
A 61-year-old man with a background of type 1 diabetes and hypertension presents with a 30-minute history of chest pain radiating to the left jaw, which is unrelieved by rest or glyceryl trinitrate (GTN). He has anterolateral ST elevation on his ECG and is sent for urgent coronary angiography.

Coronary angiography shows significant stenosis of the left anterior descending, left circumflex and right coronary artery.

Which of the following is the best step in management?

Options:
explanation: A heart transplant would be reserved for patients with severe heart failure or coronary artery disease that is refractory to all medical and surgical management options. A CABG would be considered first for a patient with triple-vessel disease
name: Cardiac transplantation
label: d
answer: no
explanation: Urgent revascularisation has a prognostic benefit in patients with ST-elevation myocardial infarction (STEMI). Therefore it would not be appropriate to manage this patient with medical management alone
name: Medical management with dual antiplatelet therapy (DAPT)
label: e
answer: no
explanation: This patient has significant three-vessel coronary artery disease. This is the most severe form of coronary atherosclerosis and management is usually with a CABG. This is a surgical procedure that aims to divert blood flow away from the areas of stenosis by using a graft from the chest, arm or leg
name: Coronary artery bypass graft (CABG)
label: a
answer: yes
explanation: Drug-coated balloons only (i.e. without stents) are used in certain centres for the treatment of certain cases of de novo coronary artery disease. They have the advantage that they avoid the risk of stent thrombosis and thereby reduce the length of dual antiplatelet treatment. However, for 3 vessel disease, CABG would be a better option
name: Drug-coated balloon only angioplasty
label: c
answer: no
explanation: Coronary stenting is often used in the management of acute coronary syndrome (ACS); however, for three-vessel coronary disease, outcomes are better with the use of CABG
name: Insertion of drug-eluting coronary stents
label: b
answer: no

Correct answer: a


Learning point: Coronary artery bypass grafting (CABG) is indicated for patients with significant three-vessel coronary artery disease to improve blood flow and reduce ischaemia.