hllj/quesmed huggingface dataset:
A 19-year-old female with a background of anorexia nervosa is brought to the emergency department by her mother, who is concerned about her physical health. Her mother reports that she hasn't eaten anything in 5 days. On examination, she appears cachectic, has a heart rate of 55 beats per minute, and a blood pressure of 85/50mmHg. The patient refuses to be admitted to hospital.

The multi-disciplinary team are all in agreement that this patient should be admitted for artificial feeding. Under which section of the Mental Health Act should this be done?

Options:
explanation: Both section 2 and section 3 of the Mental Health Act can be used to treat a patient against their wishes
name: Section 2
label: a
answer: yes
explanation: Section 135 allows police to break into a property to take a person to a place of safety so that a mental health assessment can be carried out
name: Section 135
label: e
answer: no
explanation: Section 5(4) allows a qualified nurse to detain a patient in hospital for up to 6 hours until a fully registered doctor can assess the need for further detention. It cannot be used to treat patients against their wishes
name: Section 5(4)
label: d
answer: no
explanation: Section 5(2) gives doctors the ability to detain patients in hospital for up to 72 hours until a further assessment can be carried out to determine if further detention is necessary. It cannot be used to treat patients against their wishes
name: Section 5(2)
label: c
answer: no
explanation: Section 4 of the MHA is used in an emergency by a GP or Approved Mental Health Professional (AMHP) to allow 72 hours of assessment. It can later be switched to section 2 when admitted to hospital or later in admission at the end of the 72-hour window. It cannot be used to treat patients against their wishes
name: Section 4
label: b
answer: no

Correct answer: a


Learning point: Section 2 of the Mental Health Act allows detention for up to 28 days for the assessment of a person with a mental disorder, requiring two doctors' recommendations and an AMHP's involvement.
A 45-year-old male attends his GP. He is currently being investigated for a seizure that he had five days ago. He works as a lorry driver. He has been informed that he should notify the DVLA and stop driving. However, at his GP practice, he discloses that he has continued to drive and refuses to inform the DVLA.

Which of the following is the next best step?

Options:
explanation: This is one of the few circumstances in which a doctor can break patient confidentiality. In this circumstance, the wider risk to the public is deemed more important than the patient's right to confidentiality and, if the patient refuses to inform the DVLA themselves, the clinician is obliged to notify the DVLA
name: Only inform the DVLA if the patient gives you his permission
label: b
answer: no
explanation: This would be breaking patient confidentiality. The clinician should inform the DVLA but should not speak to a next of kin against the patient's wishes
name: Ring his next kin and insist they inform the DVLA on his behalf
label: d
answer: no
explanation: If the clinician has concerns that the patient has not informed the DVLA that they shouldn't be driving, then they should inform the DVLA as soon as reasonably possible. By delaying this for a week, they would be putting the wider public at risk
name: Arrange a follow-up appointment for one week and ensure then that he has informed the DVLA
label: e
answer: no
explanation: This is correct. This is one of the few circumstances where the clinician is obliged to break confidentiality and inform the DVLA if the patient refuses to, as the risk to the general public is more important than the patient's right to confidentiality. It is best practice to inform the patient that you will notify the DVLA before you do so
name: Inform the patient that you will have to inform the DVLA if he does not
label: a
answer: yes
explanation: There is no legal requirement to inform the police if patients are driving against advice
name: Report this to the police
label: c
answer: no

Correct answer: a


Learning point: Clinicians must prioritise public safety over patient confidentiality when a patient's medical condition poses a risk, such as driving after a seizure.
A 90-year-old is admitted to hospital from a care home with a two day history of dysuria, urinary incontinence and increased confusion. She is pyrexial and extremely drowsy and is unable to hold a conversation. She has a background of congestive heart failure, hypertension, dementia and recurrent urinary tract infection. On her electronic patient record, there is a discussion documented from an admission with a fall three months ago where she states that she would not like to be resuscitated in the event of a cardiac arrest. It was documented by the team at the time that she had capacity. 

Which of the following is the next best step?

Options:
explanation: This is not necessary as there has been a clear formal discussion with the patient whilst she had capacity where she made her wishes clear.
name: Discuss with the hospital legal department
label: e
answer: no
explanation: The next of kin has no role in decision making about resuscitation. It is good practice to discuss resuscitation decisions with the next of kin; however, it is ultimately the patient and/or medical practitioner who decides, depending on the circumstances
name: Consider DNACPR based on wishes of next of kin
label: b
answer: no
explanation: This patient should not be for resuscitation as there is a previously documented discussion where she has refused. It can be re-discussed if she regains capacity and can hold this conversation.
name: Leave for resuscitation until she is awake enough to have a formal discussion
label: d
answer: no
explanation: As this patient clearly stated that they would not like to be resuscitated whilst she had capacity, a DNACPR form should be instigated. It it important to take into consideration the patient's prior wishes when considering DNACPR forms. 
name: Complete DNACPR form
label: a
answer: yes
explanation: This patient should not be for resuscitation as ultimately patients have a right to refuse resuscitation as long as they have capacity. When this patient discussed resuscitation, she did have capacity.
name: Document that this patient is for resuscitation
label: c
answer: no

Correct answer: a


Learning point: Respecting a patient's previously expressed wishes regarding resuscitation is crucial when determining the appropriateness of a DNACPR order.
A 60-year-old inpatient experiences rectal bleeding. A rectal examination is indicated, which is performed by a junior doctor at the bedside. There are no concerns about their capacity to make decisions.

In terms of consent, which of the following is required?

Options:
explanation: Consent is required for intimate examinations such as a rectal examination
name: No consent required
label: e
answer: no
explanation: Verbal consent should be documented in the notes
name: Verbal consent, no need to document this in the notes
label: b
answer: no
explanation: Consent in writing is not required for a rectal examination; verbal consent will suffice. Consent should be obtained before the examination
name: Consent in writing after rectal examination
label: d
answer: no
explanation: Consent in writing is not required for a rectal examination; verbal consent will suffice. A formal consent form with the patient's signature is required for surgical procedures
name: Consent in writing before the rectal examination
label: c
answer: no
explanation: Verbal consent is required for an intimate examination, and this should be documented formally
name: Verbal consent and document this in the notes
label: a
answer: yes

Correct answer: a


Learning point: Verbal consent is essential before performing intimate examinations, and it must be documented in the patient's medical notes.
A 30-year-old female presents feeling unwell for the last 12 hours.


She has a background of Crohn's disease, for which she takes infliximab.


Her observations are as follows:


 - Heart rate 90 beats per minute
 - Blood pressure 110/90 mmHg
 - Temperature 38.1 °C


Her blood tests return as follows:

||||
|--------------|:-------:|---------------|
|Haemoglobin|120  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|
|C Reactive Protein|<5 mg/L|< 5|


What is the best next step in the management of this patient?

Options:
explanation: Although this patient has normal inflammatory markers, she is on a monoclonal antibody which can hide an inflammatory response, and so she should be admitted for further investigations +/- IV antibiotics. Those on biologics such as infliximab are at higher risk of more severe infection. CRP can often remain normal in patients with Crohn's disease, and serious complications such as an abscess or collection may not cause a rise in CRP
name: Admit for further investigations
label: a
answer: yes
explanation: This patient is not suitable for discharge as her biologic may be hiding her inflammatory response, and she is more at risk of having a serious infection. However, sending urine for culture would be sensible if her urine is positive for leucocytes or nitrites when a dipstick test is performed
name: Discharge home after sending urine for culture
label: d
answer: no
explanation: There are no specific guidelines about stopping, continuing or restarting biologics whilst pyrexial. She is not suitable for discharge as her infliximab may be hiding her inflammatory response, and she is more likely to have a serious infection
name: Discharge home with advice to withhold infliximab whilst pyrexial
label: c
answer: no
explanation: This is not appropriate as she is on infliximab and is therefore at higher risk of serious infection
name: Discharge home with GP follow up in one week
label: b
answer: no
explanation: This patient is not suitable for discharge as her biologic may be hiding her inflammatory response, and she is more at risk of having a serious infection. However, sending a stool sample is sensible if this the suspected source of infection, e.g. if she has diarrhoea
name: Discharge home after sending stool sample
label: e
answer: no

Correct answer: a


Learning point: Patients on infliximab for Crohn's disease may have normal inflammatory markers despite serious infections
A 20-year-old female presents to the emergency department with fever and jaundice. Their LFTs are deranged, and their liver viral screen is negative. Autoimmune hepatitis (AIH) is suspected.

The presence of which of the following antibodies is classically associated with Type I AIH?

Options:
explanation: This is associated with type II AIH which only affects children
name: Anti-liver kidney microsomal type 1 (anti-LKM-1)
label: b
answer: no
explanation: This antibody is associated with rheumatoid arthritis
name: Anti-cyclic citrullinated peptide antibody
label: d
answer: no
explanation: This is associated with myositis (e.g. dermatomyositis)
name: Anti-mi-2
label: e
answer: no
explanation: This is associated with type III AIH
name: Soluble liver-kidney antigen
label: c
answer: no
explanation: This is associated with type I AIH. Anti-smooth muscle antibodies are also associated with type I AIH
name: Anti-nuclear antibodies (ANA)
label: a
answer: yes

Correct answer: a


Learning point: Anti-nuclear antibodies (ANA) are classically associated with Type I autoimmune hepatitis (AIH).
A 50-year-old female with known non-alcoholic fatty liver disease (NAFLD) and associated ascites presents to the emergency department unwell. She is pyrexial and has generalised abdominal pain. Paracentesis is performed.

Which of the following results from the ascitic fluid would confirm a diagnosis of spontaneous bacterial peritonitis (SBP)?

Options:
explanation: Ascitic glucose is typically normal in SBP and low in secondary bacterial peritonitis. However, a normal glucose would not **confirm** a diagnosis of SBP
name: Low glucose
label: c
answer: no
explanation: An ascitic pH of <7.0 suggests bacterial infection but will not confirm a diagnosis
name: pH 7.1
label: d
answer: no
explanation: This is correct. Neutrophils will be raised in bacterial peritonitis due to the localised inflammatory response. Positive ascitic fluid bacterial cultures will also confirm. E.coli is the most common bacteria grown
name: Neutrophil count of more than 250/mm3
label: a
answer: yes
explanation: Ascitic amylase is typically raised in pancreatic ascites and is usually normal in SBP
name: Raised amylase
label: e
answer: no
explanation: This is associated with malignancy or haemorrhagic pancreatitis. In SBP, the ascitic fluid may appear cloudy, but there should not be any visible blood
name: Bloody appearance to ascitic fluid
label: b
answer: no

Correct answer: a


Learning point: A neutrophil count exceeding 250/mm³ in ascitic fluid indicates spontaneous bacterial peritonitis in patients with liver disease.
A 25-year-old female presents to the emergency department with a paracetamol overdose. She has hepatic encephalopathy grade II.


She has the following blood tests:


||||
|--------------|:-------:|------------------|
|pH|7.2|7.35 - 7.45|
|Creatinine|200 µmol/L|60 - 120|
|Prothrombin Time (PT)|80   seconds|10 - 12|
|Lactate|3.1 mmol/L|0.6 - 1.4|


Which of the following means that she is a candidate for liver transplantation according to the modified King's College Criteria (KCC)?

Options:
explanation: According to the modified KCC, hepatic encephalopathy grade III or IV and serum creatinine concentration >300umol/L and prothrombin time >100 seconds meets the criteria for possible liver transplantation
name: Prothrombin time of 80 seconds
label: d
answer: no
explanation: According to the modified KCC, an arterial lactate of >3.5mmol/L on admission or >3.0mmol/L 24 hours after paracetamol ingestion or after fluid resuscitation meets the criteria for possible liver transplantation
name: Arterial lactate of 3.1mmol/L
label: e
answer: no
explanation: According to the modified KCC, hepatic encephalopathy grade III or IV and serum creatinine concentration >300umol/L and prothrombin time >100 seconds meets the criteria for possible liver transplantation
name: Serum creatinine of 200umol/L
label: c
answer: no
explanation: According to the modified KCC, hepatic encephalopathy grade III or IV and serum creatinine concentration >300umol/L and prothrombin time >100 seconds meets the criteria for possible liver transplantation
name: Hepatic encephalopathy grade II
label: b
answer: no
explanation: According to the modified KCC, an arterial pH of <7.3 is criteria for possible liver transplantation
name: Arterial pH of 7.2
label: a
answer: yes

Correct answer: a


Learning point: An arterial pH of less than 7.3 indicates a candidate for liver transplantation in paracetamol overdose according to modified King's College Criteria.
A 25 year old man presents to his general practice with a sore throat which started 2 days ago. He also reports feeling feverish and unwell and denies a cough or coryza. He is still able to eat and drink. He has no allergies and does not take any regular medications.

His observations are as follows:

- Heart rate: 70 beats per minute
- Blood pressure: 115/80mmHg
- Respiratory rate: 14 breaths per minute
- Saturations: 99% on room air
- Temperature: 38.1 degrees Celsius

On examination, his tonsils are inflamed and purulent. He does not have any tender cervical lymphadenopathy.

What is the next best step in the management of this patient?

Options:
explanation: There is no indication that this patient would not, at present, be able to manage at home. Indications for referral to hospital would include stridor, clinical suspicion of acute epiglottitis, dehydration, or signs of any complications. He does not appear to be systemically unwell from his observations. Immunosuppression is another indication to urgently refer to hospital, which we have no reason to think that this patient is
name: Refer urgently to hospital
label: b
answer: no
explanation: Antibiotic are indicated in this patient as he has a FeverPAIN score of 5 or a Centor score of 3
name: Reassure and explain that there is no indication for antibiotics at present
label: c
answer: no
explanation: Doxycycline is not indicated for use in tonsillitis. Doxycycline is most commonly used in respiratory tract infections particularly in those who are penicillin allergic or intolerant
name: Prescribe doxycycline 200mg for 1 dose, then maintenance 100mg OD for 5 days total
label: e
answer: no
explanation: Amoxicillin is not indicated for use in tonsillitis. Common indications for amoxicillin include respiratory tract and urinary tract infections
name: Prescribe amoxicillin 500mg TDS for 5 days
label: d
answer: no
explanation: NICE recommend using either the FeverPAIN criteria or Centor criteria to identify which patients are more likely to benefit from antibiotics. This patient has a FeverPAIN score of 5 (for fever, purulence, attended rapidly, inflamed tonsils, and no cough or coryza) and a Centor score of 3 (tonsillar exudate, history of ever and s=absence of cough). Both of these mean that the patient should receive antibiotics. The first line for a patient not allergic or intolerant to penicillin is phenoxymethylpenicillin. In patients who are penicillin allergic or intolerant, alternative antibiotic choices include clarithromycin or erythromycin
name: Prescribe phenoxymethylpenicillin 500mg QDS for 5 days
label: a
answer: yes

Correct answer: a


Learning point: In cases of acute pharyngitis with purulent tonsillitis, phenoxymethylpenicillin is the first-line antibiotic treatment if the patient is not penicillin allergic.
A 65 year old man with a past medical history of chronic obstructive pulmonary disease (COPD) presents to his general practice with a worsening cough and increased breathlessness on exertion over the last week. He is currently producing the same amount of sputum as normal, which remains transparent. He says he is currently coping at home.

His observations are as follows:

- Heart rate: 80 beats per minute
- Respiratory rate: 15 breaths per minute
- Saturations: 95% on room air
- Blood pressure: 140/100mmHg
- Temperature: 37.1 degrees Celsius

On examination, there is mild expiratory wheeze globally but no added crepitations. He does not appear confused.

What is the next best step in the management of this patient?

Options:
explanation: There is no indication for antibiotics at present at they are producing the same amount of sputum and it has not changed colour. NICE guidelines advise other indications for considering antibiotics in exacerbations of COPD include risk of complications
name: Prescribe prednisolone 30mg OD for 5 days and doxycycline for 5 days
label: b
answer: no
explanation: Steroids are indicated for this patient as they are having increased breathlessness on exertion and increased cough. This is likely an exacerbation of his COPD
name: Reassure that there is no indication for antibiotics or steroids at present
label: e
answer: no
explanation: This patient is systemically well and there is no indication from the question stem that this patient currently requires a hospital admission. NICE guidelines suggest consideration of emergency admission in the following cases: severe breathlessness, inability to cope at home, rapid onset of symptoms, cyanosis, acute confusion, saturations of less than 90% on pulse oximetry, changes on chest x-ray, or already receiving long term oxygen therapy
name: Refer urgently to hospital
label: c
answer: no
explanation: NICE guidelines recommend only considering chest x-rays in those with an exacerbation of COPD if the person has recurrent chest infections or to exclude other conditions
name: Chest x-ray
label: d
answer: no
explanation: This is correct. This patient is likely having a non-infective exacerbation of their COPD. No antibiotics are indicated at present as they are not producing more sputum than normal and it hasn't changed colour. They should be counselled on the effects of prolonged steroid therapy
name: Prescribe prednisolone 30mg OD for 5 days
label: a
answer: yes

Correct answer: a
A 25 year old female presents to her general practice for her first routine cervical screening. She has no gynaecological symptoms.

On speculum examination, her cervix appears normal.

The sample returns as negative for human papillomavirus (HPV).

What is the next best step?

Options:
explanation: This is correct. All women aged 25 to 49 are invited for "routine recall" if a cervical sample is negative for high-risk HPV
name: Return for cervical screening in 3 years
label: a
answer: yes
explanation: Colposcopy is only indicated if the cytology of the cells is abnormal, or there are two consecutive inadequate samples. In the current "HPV first" system in the NHS screening programme, the sample is only tested for cytology if it is positive for high risk strains of HPV. As this patient's sample was negative, it was not tested for cytology
name: Refer for colposcopy
label: d
answer: no
explanation: All women aged 25 to 49 are invited for routine cervical screening every 3 years. Between the ages of 50 and 64 this becomes every 5 years
name: Return for cervical screening in 5 years
label: b
answer: no
explanation: The NHS employ a "HPV first" system whereby a the sample is first tested for high risk strains of HPV, and cytological examination is only performed if this is positive
name: Cytological examination of the sample
label: e
answer: no
explanation: All women aged 25 to 49 are invited for screening every 3 years, even if their previous screening was normal
name: Discharge from national screening programme
label: c
answer: no

Correct answer: a


Learning point: Women aged 25 to 49 should return for cervical screening every three years if their HPV test is negative.
A 20 year old female presents to her general practice to discuss contraception options. She has had the same regular partner for the last 2 years. Her periods are normally regular. Her past medical history includes migraine with aura. She does not smoke and drinks on average 3 units of alcohol per week.

A sexually transmitted disease screen returns negative, as does a urine beta-HCG.

Which of the following contraception options is contraindicated in this patient?

Options:
explanation: The only relative contraindication for an IUS in an active sexually transmitted infection (which this patient does not have) as this increases the risk of pelvic inflammatory disease. It is also contraindicated in current pregnancy
name: Intrauterine System (IUS)
label: b
answer: no
explanation: The most important contraindications for DMPA is current or history of breast cancer. It is also contraindicated in current pregnancy and undiagnosed abnormal vaginal bleeding
name: Depot medroxyprogesterone acetate (DMPA)
label: d
answer: no
explanation: The only relative contraindication for an IUD in an active sexually transmitted infection (which this patient does not have) as this increases the risk of pelvic inflammatory disease. It is also contraindicated in current pregnancy
name: Intrauterine Device (IUD)
label: c
answer: no
explanation: The most important contraindications to the contraceptive implant is pregnancy, liver disease, personal history of breast cancer or undiagnosed vaginal bleeding
name: Contraceptive Implant (etonogestrel)
label: e
answer: no
explanation: According to the UK Medical Eligibility Criteria (UKMEC), migraine with aura is categorised as "UKMEC 4" which represents an unacceptable health risk and therefore the combined oral contraceptive pill should not be started in these patients. This is because migraine with aura combined with the combined oral contraceptive pill causes a slight increase in risk of ischaemic stroke
name: Combined oral contraceptive pill
label: a
answer: yes

Correct answer: a