hllj/quesmed huggingface dataset:
A 36-year-old female presents for her 12-week scan after a positive pregnancy test at 6 weeks. She has had one previous pregnancy, during which she had hypertension with no proteinuria. She has felt well so far throughout this pregnancy. On examination, her blood pressure is 121/74 mmHg. Urine dipstick is negative and her fasting blood glucose is 5.5mmol/L.

What is the next best step in management?

Options:
explanation: This patient had hypertension during a previous pregnancy which puts her at high risk of pre-eclampsia. For women at high risk of pre-eclampsia, NICE recommend that aspirin 75—150 mg daily is prescribed from 12 weeks' gestation until birth. Women are considered to be high risk of pre-eclampsia if they have at least one of the following risk factors: a history of hypertensive disease during a previous pregnancy, chronic kidney disease, autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome, type 1 or type 2 diabetes, or chronic hypertension.
name: Aspirin
label: a
answer: yes
explanation: Folic acid supplementation should be started pre-conception in women who are planning a pregnancy, or in women who are in the early stages of pregnancy and should be continued until 12 weeks gestation. This is to reduce the risk of neural tube defects. The woman here is already at 12 weeks gestation so folic acid supplementation is no longer required.
name: Folic acid
label: e
answer: no
explanation: Insulin therapy should be considered in patients with gestational diabetes, guided by a specialist. Gestational diabetes is diagnosed if the woman has either a fasting plasma glucose level of 5.6 mmol/L or above or a 2‑hour plasma glucose level of 7.8 mmol/litre or above. This patient has a normal fasting plasma glucose.
name: Insulin therapy
label: b
answer: no
explanation: Labetalol is used in the management of women with hypertensive disease in pregnancy. This patient has a normal blood pressure at this visit so does not require anti-hypertensive therapy at this time.
name: Labetalol
label: c
answer: no
explanation: This patient is at high risk of pre-eclampsia, therefore she should be started on aspirin.
name: No medication required
label: d
answer: no

Correct answer: a


Learning point: Aspirin may be indicated in pregnancy to reduce the risk of preeclampsia, particularly in women with high-risk factors such as a history of preeclampsia, chronic hypertension, or certain medical conditions like diabetes.
A 14-year-old adolescent presents with a red-hot swollen knee joint after a chest infection last week. He has been unable to walk due to the pain in his knee despite analgesia. He has a background history of type 1 diabetes managed with an insulin pump. On examination there is erythema overlying the joint and pain whenever the joint is moved in any direction. His temperature is 38.3 °C.

What is the most important next step?

Options:
explanation: Gout or pseudogout can present with an acutely hot and painful joint. However, it is not typical for the paediatric age range. Moreover, given the presentation, septic arthritis is the most important diagnosis to exclude; thus, an aspirate for microscopy, culture and sensitivity is the best first test.
name: Joint aspiration and electron microscopy with polarised light
label: b
answer: no
explanation: The most important diagnosis to exclude is septic arthritis. This happens to be the most likely diagnosis in this case due to the fever, inability to bear weight and recent chest infection, which could have been the origin of the organism that has seeded haematologically to the joint. A joint aspirate should be done with cultures to isolate the organism. Empirical antibiotics should be commenced while awaiting the results.
name: Joint aspiration and microscopy, culture and sensitivities
label: a
answer: yes
explanation: This would be considered if a diagnosis of septic arthritis were confirmed. However, at this stage, the diagnosis is uncertain; thus, performing an aspirate in the first instance is the next best step.
name: Send to theatre for surgical washout
label: e
answer: no
explanation: A knee MRI would be a sensible investigation if there was a suspicion of an alternative diagnosis or if the joint aspiration were inconclusive. However, it would not represent an initial investigation.
name: Knee MRI
label: d
answer: no
explanation: A knee X-ray is often requested to assess for other differentials, such as chondrocalcinosis/fractures, or to assess if there has been any joint damage secondary to infection. However, this does not represent the most important initial investigation since a diagnosis of septic arthritis needs to be ruled out using a joint aspirate sent for microscopy, culture and sensitivity.
name: Knee X-ray
label: c
answer: no

Correct answer: a


Learning point: In cases of suspected septic arthritis, joint aspiration is crucial for diagnosis and guiding appropriate antibiotic therapy.
A 28-year-old woman was admitted to hospital overnight with severe left-sided loin-to-groin pain. A urine dipstick revealed blood, no nitrites or leukocytes. Due to claustrophobia, she declined a CT scan and she was subsequently diagnosed with kidney stones clinically and treated with analgesia. Today, she reports she no longer has any flank pain but has persistent pain in the left iliac fossa.

What is the next most important test to conduct?

Options:
explanation: This patient is unlikely to tolerate a CT abdomen since she has already declined one because of claustrophobia. Furthermore, an ultrasound examination is usually preferred in young female patients in the first instance. Before any imaging, a pregnancy test will be a sensible next step to guide the diagnostic process.
name: CT abdomen
label: c
answer: no
explanation: Since this patient did not have a CT kidneys, ureters and bladder, a pregnancy test may have been missed by the assessing doctor, who may have otherwise been prompted to do one before exposing a woman of child-bearing age to radiation. In any woman of child-bearing age presenting with abdominal pain, a pregnancy test should always be done to rule out life-threatening causes of abdominal pain, such as ectopic pregnancy.
name: Pregnancy test
label: a
answer: yes
explanation: A urinary tract infection may cause abdominal pain and may complicate kidney stones. However, this patient has seen some improvement in her pain without antibiotics and a urine dipstick yesterday was negative for leukocytes and nitrites. The persistent pain is in the left iliac fossa and so gynaecological causes should be excluded. Therefore, the next best step is a pregnancy test.
name: Urine microscopy, culture and sensitivity
label: e
answer: no
explanation: This may be a useful investigation to evaluate for any free fluid in the pelvis or ovarian cysts, without exposing her to the radiation of a CT scan. It is likely she will have this test further down the line if the pain persists but a pregnancy test is a quick, noninvasive, appropriate immediate next step to further guide diagnosis.
name: Pelvic ultrasound
label: b
answer: no
explanation: Abdominal X-rays provide limited information in the context of acute abdominal pain. They can help diagnose bowel obstruction, mega-colon, chronic inflammatory bowel disease changes and radio-opaque kidney stones. She requires a pregnancy test in the first instance to guide the diagnostic process.
name: Abdominal X-ray
label: d
answer: no

Correct answer: a


Learning point: Always perform a pregnancy test in women of child-bearing age presenting with abdominal pain to exclude life-threatening conditions like ectopic pregnancy.
A 45-year-old woman who is recovering from a recent wide local excision for an oestrogen receptor-positive breast cancer attends her outpatient follow-up appointment in the oncology department. She asks what the purpose is behind sending the breast tissue for histology.

What explanation should be offered to the patient?

Options:
explanation: Sentinel lymph nodes are identified intraoperatively using radioactive blue dye. The surgeon injects the dye under the nipple and identifies the sentinel lymph node using radioactive readings and colour change.
name: To help identify the sentinel lymph node
label: d
answer: no
explanation: For breast cancer, we know that the common sites of spread include the lungs, brain and bones. Histology, alongside other factors, may give us an idea of prognosis and the degree of aggression and therefore propensity to metastasise but it does not suggest where those sites will be.
name: Predicts likely sites of metastases
label: e
answer: no
explanation: Histology indicates which treatments would be effective for the cell types of breast cancer. Generally, positivity for the oestrogen receptor, progesterone receptor or HER2 allow specific therapies to be employed. However, the response to therapy is variable and other factors influence prognosis, most notably staging. The better and more direct answer is that histology helps guide treatment.
name: As a sole indicator of prognosis
label: b
answer: no
explanation: Histology is crucial for breast cancer management because cell type governs the chemotherapy or hormonal treatments offered. The main subtypes of clinical relevance include oestrogen receptor, progesterone receptor and human epidermal growth factor receptor 2 (HER2) status. For this patient, her breast cancer is oestrogen receptor-positive, meaning it could be susceptible to an aromatase inhibitor, such as anastrozole, or a selective oestrogen receptor modulator, such as tamoxifen. The other factors that influence the choice of chemotherapy or hormonal therapy include age, comorbidities and cancer stage.
name: To guide drug treatment
label: a
answer: yes
explanation: Certain hereditary cancer syndromes, such as *BRCA1*/*BRCA2*, are associated with triple-negative breast cancers (negative for the oestrogen and progesterone receptors and the HER2 receptor). However, patients who do not possess these mutations can also be triple-negative; therefore, diagnosis of hereditary cancer syndromes cannot be made on histology alone.
name: To diagnose hereditary cancer syndromes
label: c
answer: no

Correct answer: a


Learning point: Histological analysis of breast cancer tissue determines the appropriate hormonal or chemotherapy treatment based on receptor status and cancer subtype.
A 34-year-old primigravida woman who is 35 weeks pregnant presents with itchy skin for 5 d to A&E. There has been no response to antihistamines or creams. The itching is particularly intense on her palms and soles and at night. Her pregnancy has been unremarkable so far and she has no prior health conditions. She reports that her mother had a similar problem during her pregnancies. On examination, she has extensive scratch marks to her arms and abdomen. The remainder of the examination is normal.

Which investigation is most specific for her underlying diagnosis?

Options:
explanation: This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. There is a raised bilirubin in only a quarter of cases and raised bilirubin lacks specificity for this pathology.
name: Serum bilirubin
label: e
answer: no
explanation: This patient likely has intrahepatic cholestasis of pregnancy, which presents typically with persistent itching (especially on the hands/feet and nocturnally) in the third trimester and can run in families. Alanine transaminase (ALT)/aspartate transaminase (AST) may be mildly elevated, as well as bilirubin, but total serum bile acid is the most specific test and will be markedly raised in around 80% of cases. There is an increased risk of foetal compromise and stillbirth with this condition; therefore, early delivery may be indicated.
name: Bile acids
label: a
answer: yes
explanation: This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. ALT/AST may be raised mildly in 60% of cases and they lack specificity for this pathology.
name: Serum ALT
label: c
answer: no
explanation: This patient has presented with pruritus in the third trimester of pregnancy, which should raise the suspicion of intrahepatic cholestasis of pregnancy. The best test for this would be serum bile acids. ALT/AST may be raised mildly in 60% of cases and they lack specificity for this pathology.
name: Serum AST
label: d
answer: no
explanation: Uraemia can cause skin itching; however, this patient has no known risk factors for renal failure and no other signs consistent with it on history or examination, such as asterixis, confusion or pericarditis.
name: Serum urea
label: b
answer: no

Correct answer: a


Learning point: Intrahepatic cholestasis of pregnancy presents with intense itching, particularly on palms and soles, and is diagnosed by elevated serum bile acids.
A 35-year-old woman with a history of chronic pancreatitis presents with post-prandial vomiting and abdominal pain. She denies weight loss, fevers, pruritus and any family history of malignancy.

Her blood tests are significant for a cholestatic pattern of liver function tests.

Which of the following is the most likely diagnosis?

Options:
explanation: Cholangiocarcinoma is less likely given the age of the patient and lack of risk factors
name: Cholangiocarcinoma
label: c
answer: no
explanation: Pancreatic cancer is unlikely given the age of the patient. It is also more common for pancreatic cancer to present without pain
name: Pancreatic cancer
label: b
answer: no
explanation: Choledocholithiasis refers to gallstone disease in the common bile duct. Although this is often associated with pain and cholestatic liver function tests, the post-prandial vomiting would be unusual and is more suggestive of gastric outlet obstruction
name: Choledocholithiasis
label: d
answer: no
explanation: PBC is less likely as it would not explain the symptoms of gastric outlet obstruction. Also, there is no pruritus (present in around 70% of cases of PBC)
name: Primary biliary cholangitis (PBC)
label: e
answer: no
explanation: Pancreatic pseudocysts are a common complication of acute or chronic pancreatitis. They occur due to damage to the pancreatic ducts, which leads to cystic accumulation of pancreatic juices. Pseudocysts can be asymptomatic or present with signs of biliary obstruction (abdominal pain, jaundice) or gastric outlet obstruction (post-prandial vomiting) due to mass effect of an enlarging pseudocyst on adjacent structures. There is also the risk of secondary infection
name: Pancreatic pseudocyst
label: a
answer: yes

Correct answer: a


Learning point: Pancreatic pseudocysts are common complications of chronic pancreatitis, typically forming as fluid-filled sacs that develop in response to inflammation, necrosis, or ductal obstruction, and can lead to symptoms such as abdominal pain, nausea, and potential rupture or infection if left untreated.
A 32-year-old with type 1 diabetes presents to her GP with a 6-month history of diarrhoea, weight loss and bloating.

Examination reveals conjunctival pallor and a soft, non-tender abdomen.

Her blood tests show a microcytic anaemia, thrombocytopenia, normal anti-tissue transglutaminase (TTG) antibody levels and low serum immunoglobulin A (IgA).

Which of the following is the next best investigation given the likely diagnosis?

Options:
explanation: The history of autoimmune disease, symptoms and associated microcytic anaemia are suggestive of Coeliac disease. The most commonly used screening test for Coeliac disease is checking for the presence of auto-antibodies against tissue transglutaminase (TTG). This has a high specificity and sensitivity; however, false negatives may be found in patients with IgA deficiency. IgA deficiency is more common in patient's with coeliac disease, and therefore, all patients should have IgA levels measured alongside antibodies against TTG. The next step in patients with IgA deficiency would be to measure antibodies against TTG from the IgG class
name: Measure immunoglobulin G (IgG) TTG levels
label: a
answer: yes
explanation: Faecal calprotectin is a measure of intestinal inflammation. It may be raised in coeliac disease and conditions such as inflammatory bowel disease, colorectal cancer and infectious colitis. The main use of faecal calprotectin is to exclude inflammatory bowel disease (IBD), given that it has a high specificity in this context
name: Measure faecal calprotectin
label: d
answer: no
explanation: Low levels of faecal elastase are suggestive of exocrine pancreatic insufficiency. Causes include cystic fibrosis, chronic pancreatitis and biliary obstruction. Although the patient's symptoms may be due to pancreatic insufficiency, Coeliac disease is more likely given the history of autoimmune disease and IgA deficiency
name: Measure faecal elastase
label: e
answer: no
explanation: A duodenal biopsy is the gold standard test to confirm the diagnosis of Coeliac disease. It would be performed if serological tests are positive or if there is high clinical suspicion following multiple negative results from different serological tests
name: Duodenal biopsy
label: c
answer: no
explanation: This patient has IgA deficiency and likely has a false-negative IgA anti-TTG level. Repeating the anti-TTG levels using the same immunoglobulin class (i.e. IgA) is likely to give the same result
name: Repeat anti-TTG antibody levels
label: b
answer: no

Correct answer: a


Learning point: In patients with suspected Coeliac disease and low serum IgA, measure IgG anti-tissue transglutaminase (TTG) antibodies for accurate diagnosis.
A 65-year-old Caucasian patient registers with a GP in the UK, having emigrated from Italy.


Following a set of initial investigations, it is found that his ambulatory blood pressure is 145/90 mmHg. He also has a glycosylated haemoglobin (HBA1C) level of 52 mmol/mol (normal range 20-42 mmol/mol) and a fasting blood glucose of 7.2 mmol/L (normal <6.1 mmol/L).


He notes that he was recently diagnosed with type 2 diabetes but has not started any treatment.


Which of the following is the most appropriate next step in the management of this patient's hypertension?

Options:
explanation: Nifedipine is a calcium-channel blocker. It would be indicated if this patient did not have co-existing type 2 diabetes
name: Start nifedipine
label: b
answer: no
explanation: This patient has stage 1 hypertension and type 2 diabetes. Therefore, the recommended first-line management of hypertension is with an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors are renoprotective in type 2 diabetes and are therefore recommended for the management of hypertension regardless of age or ethnicity
name: Start lisinopril
label: a
answer: yes
explanation: Bendroflumethiazide is not an initial treatment option for hypertension. It can be considered if the patient is intolerant to lisinopril or if blood pressure is not controlled after the dose has been up-titrated
name: Start bendroflumethiazide
label: e
answer: no
explanation: Metformin would be the first-line management option for this patient's type 2 diabetes, but it would not be used for treating hypertension
name: Start metformin
label: c
answer: no
explanation: Home blood pressure monitoring (HBPM) is an alternative to ambulatory blood pressure monitoring. HBPM is not indicated if a diagnosis of hypertension has been confirmed with ambulatory monitoring
name: Offer home blood pressure monitoring
label: d
answer: no

Correct answer: a


Learning point: In patients with type 2 diabetes and hypertension, starting an ACE inhibitor is essential for cardiovascular protection and renal health.
A 56-year-old man with a background of type 2 diabetes, hypertension and ischaemic heart disease presents with a cold and painful left foot.

He reports that the symptoms came on suddenly around two hours ago. On examination, the left foot is pale and cold with absent dorsalis pedis and posterior tibial pulses; however, a prominent popliteal pulse is detected. Sensation and movement of the foot are preserved.

Which of the following is the most appropriate intervention whilst awaiting diagnostic imaging?

Options:
explanation: Warfarin is not used in acute limb ischaemia. Commencement of warfarin would delay any surgical intervention that may be necessary due to its long half-life
name: Warfarin
label: d
answer: no
explanation: Fondaparinux is not used in acute limb ischaemia. It is commonly used for the management of non-ST elevation myocardial infarctions (NSTEMIs)
name: Fondaparinux
label: e
answer: no
explanation: An unfractionated heparin infusion is preferable to treatment dose LMWH in the management of acute limb ischaemia. As unfractionated heparin has a shorter half-life than LMWH, patients can be taken to theatre more promptly with reduced bleeding risk
name: Low molecular weight heparin (LMWH)
label: c
answer: no
explanation: This patient has signs and symptoms consistent with acute limb ischaemia. The prominent popliteal pulsation suggests that the aetiology may be embolic disease from a popliteal aneurysm. Medical management of acute limb ischaemia is with high flow oxygen and initiation of an unfractionated heparin infusion. Surgical intervention may be necessary depending on classification using the Rutherford system
name: Unfractionated heparin
label: a
answer: yes
explanation: Clopidogrel is not used in acute limb ischaemia. Commencement of clopidogrel would delay any surgical intervention that may be necessary due to its long half-life
name: Clopidogrel
label: b
answer: no

Correct answer: a


Learning point: Medical management of acute limb ischaemia is with high flow oxygen and initiation of an unfractionated heparin infusion.
A 43-year-old woman is recovering following a total thyroidectomy the previous day. The surgical notes reveal an uncomplicated operation, and all observations post-operatively have been normal.

The on-call doctor is called to see the patient urgently as her oxygen saturations have dropped acutely to 90% on room air. On assessment, the patient can speak in short sentences only and is using her accessory muscles. Examination of the lung fields are unremarkable; however, there is an intermittent high pitched sound heard on inspiration and an erythematous neck swelling.

Which of the following is the most appropriate definitive step in management?

Options:
explanation: Steroids may be used as a supportive measure to reduce oedema that may be contributing to airway obstruction in this context; however, it is not the definitive step in management
name: IV methylprednisolone
label: e
answer: no
explanation: Hypocalcemia is an important complication of thyroid surgery due to disruption of parathyroid gland function. However, there are no symptoms of hypocalcemia described
name: IV calcium gluconate
label: c
answer: no
explanation: Although stridor is a feature of anaphylaxis, the clinical context suggests airway obstruction secondary to a neck haematoma
name: IM adrenaline
label: b
answer: no
explanation: High flow oxygen is an important immediate step in management given that the patient is desaturating due to airway obstruction. However, the most appropriate definitive management step is to relieve the obstruction by evacuating the haematoma
name: High flow oxygen
label: d
answer: no
explanation: This patient has acute airway obstruction secondary to a neck haematoma. Neck haematoma is a life-threatening complication of thyroid surgery and can present with signs of airway obstruction (e.g. stridor, respiratory distress), dysphagia, hoarseness and a painful neck mass. Definitive management is with an urgent return to theatre to open the stitches and evacuate the haematoma
name: Open stitches and evacuate haematoma
label: a
answer: yes

Correct answer: a


Learning point: The definitive management of acute airway obstruction due to a neck hematoma is an urgent return to the operating theatre to open the stitches and evacuate the hematoma, relieving the obstruction.