hllj/quesmed huggingface dataset:
A 37-year-old primigravida is established in the first stage of labour, and you notice some prolonged decelerations on the cardiotocograph. Foetal blood sampling is performed, and the results are as follows:


||||
|--------------|:-------:|------------------|
|pH|7.14|7.35 - 7.45|
|Lactate|5.3 mmol/L|0.6 - 1.4|



What should you do?

Options:
explanation: This is a concerning blood sample indicating that the foetus is acidotic, implying hypoxia and therefore needs urgent delivery
name: Urgent delivery
label: a
answer: yes
explanation: Asking the mother to lie in the left lateral position can shift weight off the maternal vessels and correct cord compression, however as the foetal blood sampling is abnormal, the foetus needs to be delivered. Therefore, this is not the right answer
name: Ask the mother to lie in the left lateral position
label: e
answer: no
explanation: This is an abnormal and very worrying result, and therefore time is of the essence. NICE guidance suggests that if pH < 7.20 or lactate is >4.9mmol/L, the foetus should be delivered immediately. If the pH were 7.21 - 7.24 or lactate were 4.2 -4.8mmol/L, it would be reasonable to retest in the first instance
name: Repeat the test in 30 minutes
label: b
answer: no
explanation: This is an abnormal and very worrying result, and therefore, time is of the essence, and the baby needs to be delivered urgently. Whilst it is important to stay calm and keep the mother reassured, it is important not to give false reassurance at the gravity of the situation
name: Reassure the mother that everything is normal
label: c
answer: no
explanation: The cardiotocograph will give you an accurate assessment of foetal heart rate (and, in this case, is showing abnormal decelerations). Auscultation would unlikely add anything in this scenario
name: Auscultate for foetal heart rate
label: d
answer: no

Correct answer: a


Learning point: Prolonged fetal heart rate decelerations accompanied by acidosis suggest fetal hypoxia, requiring immediate delivery to avoid potential complications.
A 63-year-old male has been admitted to hospital with sepsis following a recent total knee replacement. His knee is red, hot and swollen, and so he is started on broad-spectrum antibiotics. After 48 hours, he is still pyrexial, in significant pain, and his inflammatory markers continue to rise.

What is the next step in management?

Options:
explanation: Whilst it is important to obtain samples for microbiology to determine whether the knee is the source of infection and help guide antimicrobial therapy in a joint containing a prosthesis, this is best undertaken in the theatre environment. In suspected septic joints where there is no prosthesis involved, it would be reasonable to undertake aspiration in an aseptic manner in the ward or the Emergency Department prior to starting antibiotics
name: Aspiration of the joint on the ward
label: b
answer: no
explanation: This patient remains unwell despite broad-spectrum antibiotics. As a prosthesis is involved, he will likely need a surgical washout of the joint in theatres and may even need removal of the prosthesis to control his sepsis. Samples should be taken intraoperatively for microbiology. Aspiration of a septic joint where there is a prosthesis should never be undertaken outside of the sterile theatre environment, as by performing the aspiration, you run the risk of introducing infection
name: Surgical washout
label: a
answer: yes
explanation: A PCA may be of benefit in helping this patient with his pain; however, it would not help treat the underlying cause of his illness and therefore is not the next step in the management of his sepsis
name: Start a patient controlled analgesia (PCA)
label: d
answer: no
explanation: It may be worth speaking to the microbiologists and changing the antibiotics to a different combination; however, it would be difficult for them to provide advice without a causative organism or confirmed diagnosis. As this patient has been on broad-spectrum antibiotics for 48 hours and is not improving, it is important to get source control of his sepsis, and this is best done by a washout in theatres
name: Change antibiotics
label: c
answer: no
explanation: A CT of the knee would be beneficial if you were trying to determine whether there was osteomyelitis or bone involvement which would be a more chronic infection. Also, as this patient has had a recent prosthesis made of metal, there would likely be a significant artefact from this. So imaging would unlikely move you forward in management
name: CT of the knee
label: e
answer: no

Correct answer: a


Learning point: In cases of septic arthritis involving a prosthesis, surgical washout is essential if symptoms persist despite broad-spectrum antibiotics.
A 14-year-old female is brought into the Emergency Department by her parents due to a reduced consciousness level. On examination, she is thin and appears dehydrated and drowsy. Her observations are as follows:


 - Temperature 36.5°C
 - Blood pressure 110/65 mmHg
 - Heart rate 120 bpm
 - Respiratory rate 32 bpm
 - Oxygen saturations 99% (on air)
 - Peripheral blood glucose 25mmol/L (normal <6.1 mmol/L)


Which of the following findings are you most likely to find on an arterial blood gas?

Options:
explanation: This blood gas demonstrates an alkalosis which may be caused by loss of electrolytes (commonly potassium) as seen in severe vomiting and diarrhoea. DKA cause an acidosis, demonstrated by a low pH
name: A pH of 7.49
label: d
answer: no
explanation: This patient has DKA, and you would therefore expect the blood gas to show hyperglycaemia. Patients can rarely have euglycaemic diabetic ketoacidosis but this is often associated with certain medications such as SGLT2 inhibitors
name: A glucose of 10.4mmol/L
label: e
answer: no
explanation: This blood gas shows a hypercapnoea. This is common in acute respiratory presentations such as an acute asthma attack. In DKA the carbon dioxide tends to be low due to compensatory hyperventilation for the acidosis
name: A PaCO2 5.4kPa
label: c
answer: no
explanation: Reduced conscious level in a young patient with high peripheral blood sugars should make you think of the first presentation of type 1 diabetes. This vignette is a classic example of a patient in diabetic ketoacidosis where she cannot utilise glucose for her energy needs and has therefore gone into a ketotic state. You would therefore expect her blood gas to show a metabolic acidosis. She has a high respiratory rate as she is trying to use hyperventilation to compensate for her acidosis by expelling her carbon dioxide
name: A pH of 7.20
label: a
answer: yes
explanation: This would indicate hypoxaemia, commonly seen respiratory failure in conditions such as chronic obstructive pulmonary disease (COPD). Hypoxaemia is not a common finding in DKA
name: A PaO2 of 7.1kPa
label: b
answer: no

Correct answer: a


Learning point: In diabetic ketoacidosis (DKA), an arterial blood gas (ABG) typically shows metabolic acidosis with a low pH (usually <7.35), decreased bicarbonate (HCO3-) levels, and an anion gap that is often elevated due to the accumulation of ketoacids.
A 5-year-old boy is brought to the Emergency Department after his parents witness a seizure at home. This has never happened before, and they are understandably very concerned. On review in the department, his observations are normal; he is well though slightly drowsy.

What is your next step in management?

Options:
explanation: This child may have had a first presentation of epilepsy and therefore needs to be followed up in a specialist clinic such as a first fit clinic
name: Reassure and discharge
label: d
answer: no
explanation: Levetiracetam is an antiepileptic medication that can be used in the treatment of childhood epilepsy. However, this child has only had one self-limiting episode and does not yet have a confirmed diagnosis of epilepsy; therefore, starting an antiepileptic medication is not indicated here
name: Start levetiracetam
label: b
answer: no
explanation: Paracetamol is one of the mainstays of treatment in febrile convulsions. This child is well, and no fever is reported; therefore, paracetamol is not currently indicated
name: Administer paracetamol
label: e
answer: no
explanation: Buccal midazolam is useful in the management of acute seizure and status epilepticus. This child is currently well and has recovered from the episode, so the use of benzodiazepines is not indicated here
name: Administer buccal midazolam
label: c
answer: no
explanation: This child may well be developing epilepsy and, therefore, should be followed up in a first fit clinic. The parents should be educated on what do to if it happens again and advised on when to present to the hospital (if seizures ongoing for an extended period of time or if having multiple seizures in quick succession). They should also be advised to try to record any further episodes
name: Refer to first fit clinic
label: a
answer: yes

Correct answer: a


Learning point: In a child experiencing their first seizure, referral to a first fit clinic is essential for further evaluation and management.
A 15-year-old female presents with her boyfriend, who is in the same year at school, to General Practice requesting the contraceptive implant. She and her boyfriend are already sleeping together, and she is adamant that she will not discuss this with her parents. She understands the risk of pregnancy and would like to discuss different types of contraception. She is able to weigh up the pros and cons of each.

What should you do?

Options:
explanation: This patient fulfils the Fraser Guidelines and therefore should be prescribed contraception. The Fraser Guidelines are as follows:

- They understand the doctor's advice
- The young person cannot be persuaded to inform their parents that they are seeking contraceptive advice
- They are likely to begin or continue having intercourse with or without the contraceptive treatment
- Unless they receive the contraception, their physical or mental health is likely to suffer
- It is in the young person's best interests to provide contraceptive advice and/or treatment without parental consent
name: Arrange for her to have the implant fitted
label: a
answer: yes
explanation: This would be a reasonable choice if you felt that she was being pressured into intercourse or if there was a suggestion that the intercourse was with someone older or otherwise inappropriate. She has attended her appointment with a partner who appears supportive, and there is no suggestion here that there is abuse in this case
name: Make a referral to safeguarding
label: e
answer: no
explanation: This patient has clearly stated that she is already having intercourse with her boyfriend and is requesting contraception. Refusing to provide her with treatment is unsafe and not in her best interests
name: Refuse her request
label: d
answer: no
explanation: This is a breach of confidentiality and would only be acceptable if you felt that she was putting herself or others at risk. It is important that you try to persuade her that involving her parents is a good idea however you cannot force her to tell them, nor can you tell them without her permission
name: Arrange a consultation with her and her parents
label: c
answer: no
explanation: This patient has fulfilled the Fraser Guidelines to be provided with contraception and has requested the implant, not the contraceptive pill. It is worth exploring her choice to make sure she is fully informed; however, she has requested the implant, and therefore this should be what you provide
name: Prescribe the contraceptive pill
label: b
answer: no

Correct answer: a


Learning point: Under Fraser Guidelines, competent minors can receive contraceptive advice and treatment without parental consent if it serves their best interests.
A newborn baby is examined as part of the routine 6-week baby check and the on gentle gentle forward pressure of the left there is movement palpable suggesting that the hip is dislocated or subluxed, but reducible. Ultrasound examination is undertaken at 4 weeks of age which is suspicious of developmental dysplasia of the hip joint.

What is the correct management?

Options:
explanation: This newborn has a positive Ortolani and therefore investigation and prompt treatment are indicated
name: Reassure and discharge
label: e
answer: no
explanation: Ultrasound examination is indicated in this baby, however serial ultrasounds are not of benefit, particularly if developmental dysplasia is detected as it does not treat the problem.
In babies where there is no clinical suspicion of developmental dysplasia, Public Health England does not recommend routine ultrasound examination unless specific risk factors are present:

1. There is a first-degree family history of hip problems in early life unless DDH was definitively excluded.
2. There is a breech presentation:

- At or after 36 completed weeks of pregnancy, irrespective of presentation at delivery or mode of delivery; or
- At delivery if this is earlier than 36 weeks.
- In the case of a multiple birth, if any of the babies fall into either of these categories, all babies in this pregnancy should have an ultrasound examination
name: Serial ultrasounds
label: c
answer: no
explanation: This baby has a positive Ortolani's test and an ultrasound suggestive of developmental dysplasia of the hip. Risk factors include: breech presentation, female gender, family history of developmental dysplasia.

Early detection and management are key, with bracing as the first-line treatment. Surgery is reserved for those who do not respond to bracing or are diagnosed later (after six months of age) and where bracing is contraindicated (for example, if the hip is irreducible). Harness or splint treatment is much less successful if it is started after 6-8 weeks
name: Hip bracing
label: a
answer: yes
explanation: Bracing is the first line treatment in newborns when developmental dysplasia. Whilst physiotherapy may be of benefit in older children who are not diagnosed in childhood in a newborn this is not the correct management
name: Physiotherapy
label: d
answer: no
explanation: Surgery is reserved for those who do not respond to bracing or are diagnosed later (after six months of age) and where bracing is contraindicated (for example, if the hip is irreducible). Harness or splint treatment is much less successful if it is started after 6-8 weeks
name: Surgical fixation
label: b
answer: no

Correct answer: a


Learning point: Developmental dysplasia of the hip (DDH) is a condition where an infant's hip joint develops abnormally, leading to instability or dislocation, and is often treated with hip bracing, such as the Pavlik harness, to promote proper alignment and development.
A five-month-old baby is brought to the Emergency Department with laboured breathing and a raised temperature following a short coryzal illness. On examination, he has subcostal recession and audible, widespread crackles on chest auscultation.

What is the likely causative organism for this presentation?

Options:
explanation: Pseudomonal pneumonia is not a common pathogen as a cause of pneumonia and should prompt consideration of underlying conditions such as cystic fibrosis or immunodeficiency
name: Pseudomonas aeruginosa
label: d
answer: no
explanation: Parainfluenza virus can be a cause of bronchiolitis but is more commonly implicated in croup. Croup usually affects young children aged between six months and three years, with most cases occurring in one-year-olds and presents with a distinctive barking cough
name: Parainfluenza virus
label: b
answer: no
explanation: Streptococcus pneumonia is a common cause for bacterial pneumonia and should be considered in the differential diagnosis; however, as this child had a preceding coryzal illness and the crackles are widespread, this leans more towards a viral diagnosis such as bronchiolitis. In bacterial pneumonia, crackles are more likely to be localised to one zone
name: Streptococcus pneumoniae
label: c
answer: no
explanation: Group B streptococcal infections are a potentially life-threatening cause of sepsis in neonates. One in four women carry group B streptococci vaginally, which can infect the amniotic fluid before delivery or infect the baby during delivery, causing sepsis, pneumonia, or meningitis. Early-onset infections usually occur in the first seven days of life, and late-onset infections are usually from seven to 90 days of life. Pneumonia is more commonly associated with early-onset infection, as the baby swallows infected amniotic fluid during the delivery. This case vignette is not likely to be due to Group B streptococcus
name: Group B streptococcus
label: e
answer: no
explanation: This is a case of bronchiolitis, the most common respiratory presentation in children under the age of two years old, peaking between the ages of three and six months. It is usually commonly viral in origin and most often due to RSV. Other viral causative agents include human metapneumovirus (hMPV), adenovirus, rhinovirus, and parainfluenza and influenza viruses
name: Respiratory syncytial virus (RSV)
label: a
answer: yes

Correct answer: a


Learning point: Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis in infants, particularly those under six months old.
A 76-year-old female is diagnosed with Alzheimer's dementia. Over the last few years, her cognition has declined, and her behaviour has become less manageable. She is now becoming aggressive towards staff and other residents in her care home. Her GP is considering starting risperidone to help manage her aggression as behavioural measures are failing.

Which of the following is a recognised risk of risperidone?

Options:
explanation: Risperidone is associated with hypotension (usually dose-related) as opposed to hypertension
name: Increased risk of hypertension
label: e
answer: no
explanation: Risperidone has a lower risk of producing extrapyramidal side effects than typical antipsychotics such as chlorpromazine and haloperidol; however, there is still a risk of drug-induced Parkinsonism, particularly at higher doses. It does not, however, cause Parkinson's Disease
name: Increased risk of Parkinson's Disease
label: c
answer: no
explanation: Antipsychotic medications can cause weight gain and a rise in blood sugar; therefore are associated with an increased risk of developing diabetes, though this is less likely to be relevant in this case as it is a long-term effect
name: Increased risk of hypoglycaemia
label: b
answer: no
explanation: There is a small increased risk of stroke when starting certain antipsychotic medications. The National Institute for Health and Care Excellence (NICE) quotes an absolute risk increase of 1.22% (an extra 12 strokes per 1000 people starting an antipsychotic)
name: Increased risk of stroke
label: a
answer: yes
explanation: Patients started on risperidone should be monitored for prolactin concentration at the start of therapy, at six months, and then yearly. Clozapine can cause agranulocytosis and therefore requires differential white blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly. This is not the case for risperidone
name: Increased risk of agranulocytosis
label: d
answer: no

Correct answer: a


Learning point: Risperidone use in elderly patients with dementia is associated with a small increased risk of stroke.
The police bring a 32-year-old male to the Emergency Department after being injured whilst resisting arrest for theft. On review, he has only minor injuries, but you notice that he is starting to shiver, sweat, retch and has a tremor. His pupils are dilated.

What is the most likely diagnosis?

Options:
explanation: This patient is showing some of the classic signs and symptoms of early opiate withdrawal. Treatment in the first instance should be supportive, and patients may require fluid resuscitation to replace fluids lost through sweating and diarrhoea. Should they wish it, the patient can have withdrawal management with either buprenorphine or methadone; however, this should be managed by an experienced professional
name: Opiate withdrawal
label: a
answer: yes
explanation: This patient may well be anxious as they have just been arrested, and anxiety can account for some of the symptoms described but would not account for the shivering or the dilated pupils
name: Anxiety attack
label: b
answer: no
explanation: This is a reasonable differential as the signs and symptoms of alcohol and opiate withdrawal are very similar, however, dilated pupils are more commonly associated with opiate withdrawal than alcohol
name: Alcohol withdrawal
label: c
answer: no
explanation: Drug abuse can lead to drug-induced psychosis. However, this is not the clinical picture here
name: Acute psychosis
label: d
answer: no
explanation: Drug and alcohol abuse (particularly cocaine use) can raise the risk of myocardial infarction; however, this is not the most likely diagnosis
name: Acute myocardial infarction
label: e
answer: no

Correct answer: a


Learning point: Opiate withdrawal presents with symptoms such as tremors, sweating, dilated pupils, and gastrointestinal disturbances.
A 48-year-old female presents to General Practice complaining of cold, painful fingers. She reports that her fingers go blue after being outside (particularly if she forgets her gloves) but that they regain their colour when she comes inside. Her only past medical history is significant for rheumatoid arthritis, for which she takes methotrexate.

What medication should you consider starting?

Options:
explanation: Apixaban is an anticoagulant (in the DOAC category) that is often used in the treatment of deep vein thrombosis and in patients who are pro-coagulant. It is not currently used in the treatment of Raynaud's phenomenon
name: Apixaban
label: d
answer: no
explanation: This patient most likely has Raynaud's phenomenon as she is experiencing paroxysmal digital ischaemia when exposed to the cold. It is often associated with underlying rheumatological conditions, including systemic sclerosis, rheumatoid arthritis and systemic lupus erythematosus (SLE). Treatment is mostly trigger management - keeping fingers warm, smoking cessation and avoiding stress - however in some cases, nifedipine may help symptoms
name: Nifedipine
label: a
answer: yes
explanation: Warfarin is an anticoagulant that is sometimes used in patients who are pro-coagulant or who have venous thrombosis, particularly if they have failed treatment with a direct oral anticoagulant (DOAC). It is also used in patients with metal heart valves. It is not of benefit in this patient's case
name: Warfarin
label: c
answer: no
explanation: Epoprostenol is also known as prostaglandin I2 and is an effective vasodilator. It is sometimes used to treat severe attacks of Raynaud's, e.g. where there are concerns about digital gangrene or the development of digital necrosis. It is a rescue therapy and is not used routinely. Relapse is common after infusion, and some patients with severe disease require regular infusions, particularly in the winter months
name: Epoprostenol
label: e
answer: no
explanation: Aspirin is an antiplatelet medication often used in peripheral vascular disease. While this patient has digital ischaemia, it is paroxysmal; therefore, aspirin is not the treatment of choice
name: Aspirin
label: b
answer: no

Correct answer: a


Learning point: Nifedipine, a calcium channel blocker, is commonly used to treat Raynaud's disease by relaxing blood vessels and improving blood flow, reducing the frequency and severity of episodes of vasoconstriction and color changes in the fingers.