hllj/quesmed huggingface dataset:
An 18-year-old female presents to the Dermatologist for a follow-up appointment regarding her treatment for acne vulgaris. She has already tried topical retinoid treatment, benzoyl peroxide and oral erythromycin but has not seen any improvement in her acne. The dermatologist prescribes a new medication.

Based on the most likely medication prescribed, which of the following side effects should the patient be counselled about?

Options:
explanation: It is most likely that oral isotretinoin has been prescribed. Isotretinoin is a systemic retinoid and is known to be teratogenic. As a woman of childbearing age, the patient is required to be on contraception (ideally 3 methods) before, during and after treatment. Retinoids are also contraindicated in breastfeeding and pregnancy.
name: Teratogenicity
label: a
answer: yes
explanation: Skin thinning is commonly associated with the prolonged use of topical corticosteroids. Corticosteroids are not indicated in the treatment of acne.
name: Skin thinning
label: b
answer: no
explanation: It is most likely that oral isotretinoin has been prescribed. Hence, this patient may experience dry skin as a side effect of the systemic retinoid. However, this is not harmful and it is more important that the patient is counselled on the teratogenicity associated with isotretinoin.
name: Dry skin
label: e
answer: no
explanation: Cushing's syndrome often occurs as a side effect of systemic steroid use. However, steroids are not indicated in the treatment of acne vulgaris.
name: Cushing's syndrome
label: d
answer: no
explanation: Photosensitivity is commonly associated with tetracycline use, and excessive sun exposure can result in blistering. However, this patient has already trialled oral antibiotics and seen no improvement, so it is unlikely that tetracyclines would be prescribed again by the dermatologist.
name: Photosensitivity
label: c
answer: no

Correct answer: a
A 42-year-old female presents to the GP with complaints of redness across her nose and her cheeks. She has spent a lot of time in the sun over the previous 7 days. On examination, you notice papules and pustules on these areas as well as rhinophyma. The patient is diagnosed with acne rosacea and wonders what can be done to treat the facial erythema.

Which of the following is the most appropriate treatment for facial erythema?

Options:
explanation: Brimonidine is specifically indicated for facial erythema in rosacea. It can be applied once daily and its effects last up to 12 hours.
name: Topical brimonidine
label: a
answer: yes
explanation: Topical metronidazole is indicated for the treatment of acne rosacea, however, it does not specifically target facial erythema.
name: Topical metronidazole
label: c
answer: no
explanation: Topical emollients can be used as a soap substitute to target dry, scaly skin in acne rosacea. However, it is not used to resolve symptoms or target facial erythema.
name: Topical emollient
label: e
answer: no
explanation: Topical benzoyl peroxide is the first-line treatment for acne vulgaris. It is not indicated in the treatment of acne rosacea.
name: Topical benzoyl peroxide
label: b
answer: no
explanation: PUVA is indicated for severe cases of psoriasis; there is no benefit in using PUVA to treat acne rosacea.
name: PUVA
label: d
answer: no

Correct answer: a
A 55-year-old man presents to his GP with a lesion on the pinna of his ear which appeared last month and has since increased in size. On examination, there is a 6mm lesion with irregular borders and an ulcerated core. Vital signs are normal and there is no significant past medical history.

What is the most likely diagnosis?

Options:
explanation: This is the most likely diagnosis based on the short history of a fast-growing lesion on an area that is frequently sun exposed. The ulcerated core is also characteristic of squamous cell carcinoma.
name: Squamous cell carcinoma
label: a
answer: yes
explanation: Seborrheic keratosis presents as brown lesions with a 'stuck on' appearance; they are benign skin growths and are very common.
name: Seborrheic keratosis
label: d
answer: no
explanation: Keratoacanthomas present as rapidly growing skin tumours with a dome shape and a central keratin-filled crater.
name: Keratoacanthoma
label: e
answer: no
explanation: Although basal cell carcinomas are found on sun-exposed areas, they are slower growing than squamous cell carcinomas. Also, basal cell carcinomas usually have a pearly rolled edge and surrounding telangiectasia.
name: Basal cell carcinoma
label: b
answer: no
explanation: Actinic keratoses are found on areas of sun-exposed skin, but are not malignant and do not present with an ulcerated core.
name: Actinic keratosis
label: c
answer: no

Correct answer: a
A 16-year-old male presents to A&E with chest pain and shortness of breath. He has a past medical history of sickle cell anaemia. On examination, he has an audible wheeze throughout both lungs.


His basic observations show the following:
Respiratory rate: 27 breaths per minute
Oxygen saturation: 85%
Heart rate: 112 beats per minute
Temperature: 37.8
Blood pressure: 110/80mmHg


His haemoglobin is 83g/L and was 84g/L 6 months prior (normal range 103-170 g/L). A chest x-ray is done which shows pulmonary infiltrates.


What complication of sickle cell anaemia is most likely occurring in this patient?

Options:
explanation: This is a complication of sickle cell anaemia which normally occurs in children (the spleen in sickle cell patients is normally atrophied by adulthood) and is caused by the pooling of blood in the spleen. Patients typically present with shock, abdominal pain and severe anaemia.
name: Splenic sequestration crisis
label: d
answer: no
explanation: Asthma would also present with a wheeze, however, it would not cause pulmonary infiltrates on chest x-ray and is not a complication of sickle cell disease.
name: Asthma
label: c
answer: no
explanation: Aplastic crisis is a complication of sickle cell disease in which there is a sudden reduction in bone marrow production due to parvovirus B19 infection, resulting in the temporary cessation of new red blood cell production. A patient experiencing an aplastic crisis would have a sudden drop in haemoglobin and no respiratory changes.
name: Aplastic crisis
label: b
answer: no
explanation: Acute chest syndrome presents with chest pain, fever, tachypnoea and wheeze. It is characterised by pulmonary infiltrates on chest x-ray and is treated with antibiotics, oxygen and analgesia.
name: Acute chest syndrome
label: a
answer: yes
explanation: Vaso-occlusive crisis is caused by the occlusion of small vessels causing distal limb ischaemia. Patients present with severe sudden onset pain but do not experience pyrexia or respiratory symptoms such as wheeze or low oxygen saturations.
name: Vaso-occlusive crisis
label: e
answer: no

Correct answer: a
An 84-year-old male presents to his GP with a sore throat. He explains that he has felt fatigued over the past 4 months, and intermittently feels his heart beating hard and fast. He also mentions that he has lost a large amount of weight. On examination, he appears cachexic and has hepatomegaly.



Blood results show the following:


||||
|--------------|:-------:|---------------|
|Haemoglobin|68 g/L|(M) 130 - 170, (F) 115 - 155|
|Mean Cell Volume (MCV)|89 fL|80 - 96|
|White Cell Count|24x10<sup>9</sup>/L|3.0 - 10.0|
|Neutrophils|1.2x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|2x10<sup>9</sup>/L|1.5 - 4.0|
|Monocytes|0.4x10<sup>9</sup>/L|0.2 - 1.0|
|Eosinophils|0.1x10<sup>9</sup>/L|0 - 0.4|
|Basophils|0.1x10<sup>9</sup>/L|0 - 0.1|
|Platelets|80x10<sup>9</sup>/L|150 - 400|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|110 µmol/L|60 - 120|
|Calcium|2.3 mmol/L|2.2 - 2.6|


A blood film shows Auer rods.



Based on the clinical history and the above findings, what is the most likely diagnosis?

Options:
explanation: ALL is caused by the proliferation of lymphoid precursor cells. ALL presents similarly to AML, but Auer rods are specifically associated with AML which makes it the most likely diagnosis.
name: Hodgkin's lymphoma
label: d
answer: no
explanation: AML causes anaemia and thrombocytopenia as a result of myeloid blast cells infiltrating the bone marrow. It normally presents in patients over 65 with lymphadenopathy, splenomegaly, features of anaemia (e.g. palpitations and breathlessness), neutropenia and thrombocytopenia. Auer rods are a classic finding on blood film in AML.
name: Acute myeloblastic leukaemia (AML)
label: a
answer: yes
explanation: Myeloma is a blood disorder which occurs as a result of the proliferation of plasma cells. It presents with anaemia, acute kidney injury, hypercalcaemia and bone pain. Therefore, it does not fit the clinical picture of this patient. Furthermore, the blood film in multiple myeloma would show rouleaux formation.
name: Multiple myeloma
label: e
answer: no
explanation: ALL is caused by the proliferation of lymphoid precursor cells. ALL presents similarly to AML, but Auer rods are specifically associated with AML which makes it the most likely diagnosis.
name: Acute lymphoblastic leukaemia (ALL)
label: b
answer: no
explanation: Aplastic anaemia is characterised by pancytopenia and hypoplastic bone marrow. Although aplastic anaemia is a valid differential for the signs of anaemia (e.g. fatigue, palpitations), it would not explain the high white cell count in this case.
name: Aplastic anaemia
label: c
answer: no

Correct answer: a

Acute myeloblastic leukaemia (AML)
A 55-year-old female presents to her GP with back pain. The patient undergoes serum electrophoresis and an IgG paraprotein spike is found.

Which of the following is consistent with the most likely diagnosis??

Options:
explanation: Patients can experience renal failure in multiple myeloma. Renal failure can result in increased thirst as the kidneys fail to concentrate urine and thus excrete more water.
name: Decreased thirst
label: d
answer: no
explanation: Multiple myeloma results in thrombocytopenia due to the proliferation of plasma cells in the bone marrow which overcrowds it. Thrombocytopenia leads to an increased risk of bruising and bleeding.
name: Decreased risk of bleeding
label: e
answer: no
explanation: Hypercalcaemia is seen in multiple myeloma, the symptoms of which can be remembered using 'bones, stones, abdominal groans and psychiatric moans'. Abdominal pain can be experienced with hypercalcaemia as a result of constipation.
name: Hypocalcaemia
label: c
answer: no
explanation: Weight loss is observed in multiple myeloma, not weight gain.
name: Weight gain
label: b
answer: no
explanation: Patients with multiple myeloma are anaemic. Fatigue is a manifestation of anaemia.
name: Fatigue
label: a
answer: yes

Correct answer: a
A 22-year-old female presents to her GP with complaints of heavy periods since the onset of menarche. She also reports lightheadedness and fatigue. She explains that her father has previously had episodes of prolonged bleeding and her twin sister also suffers from heavy periods.

Which of the following investigation findings is consistent with the most likely diagnosis?

Options:
explanation: These findings are indicative of haemophilia A, an X-linked inherited bleeding disorder caused by a deficiency in factor VIII. The bleeding time is normal because it measures the response of platelets to vascular injury which is not affected in Haemophilia A.
name: PT normal, APTT increased, factor VIII activity decreased, bleeding time normal
label: d
answer: no
explanation: Normally, Von Willebrand factor (VWF) protects factor VIII from proteolysis and enables contact between platelets and an injured vessel wall. In Von Willebrand disease (VWD), there are abnormalities in VWF which prevent this process from taking place. This results in reduced factor VIII activity.
name: PT normal, APTT increased, factor VIII activity normal, bleeding time prolonged
label: b
answer: no
explanation: This is indicative of DIC in which there is dysregulated blood clotting, resulting in increased PT, APTT and bleeding time.
name: PT increased, APTT increased, factor VIII activity normal, bleeding time prolonged
label: c
answer: no
explanation: In Von Willebrand disease (VWD), the prothrombin time is normal because the extrinsic pathway of the clotting cascade is unaffected.
name: PT increased, APTT increased, factor VIII activity decreased, bleeding time prolonged
label: e
answer: no
explanation: This patient is presenting with Von Willebrand disease (VWD). Patients with VWD have abnormalities in Von Willebrand factor (VWF) which normally aids the clotting process. In VWD, there is decreased factor VIII activity which results in a normal prothrombin time (PT) and prolonged activated partial thromboplastin time (APTT). Bleeding time is also prolonged because VWF normally enables platelets to bind to exposed epithelium, and the abnormal/absent VWF in VWD prevents this.
name: PT normal, APTT increased, factor VIII activity decreased, bleeding time prolonged
label: a
answer: yes

Correct answer: a
A 4-year-old boy presents to A&E with a painful, hot, swollen left knee. His parents explain that he gets recurrent nosebleeds and often bruises easily. Blood results show an increased PT, increased APTT and normal bleeding time.

What is the most likely diagnosis?

Options:
explanation: In Von Willebrand disease, the prothrombin time (PT) is normal and activated partial thromboplastin time (APTT) and bleeding time are prolonged. The PT is normal because the extrinsic pathway of the clotting cascade is unaffected.
name: Von Willebrand disease
label: e
answer: no
explanation: Haemophilia A is an X-linked recessive bleeding disorder, hence is primarily seen in males. It results in a deficiency in factor VIII which is involved in the intrinsic pathway of the clotting cascade, measured using activated partial thromboplastin time (APTT). It often presents in young males with haemarthrosis, as demonstrated by this patient.
name: Haemophilia A
label: a
answer: yes
explanation: Trauma is a good differential for bleeding in joints. However, the coagulation screen suggests an underlying bleeding disorder.
name: Trauma
label: c
answer: no
explanation: The hot, swollen, painful joint in this case could suggest septic arthritis. However, a patient with septic arthritis would also present with systemic symptoms such as fever and lethargy.
name: Septic arthritis
label: d
answer: no
explanation: Haemophilia B is an X-linked recessive bleeding disorder that results in a deficiency in clotting factor IX. Factor IX is involved in the extrinsic pathway of the clotting cascade, which is measured using prothrombin time (PT). Haemophilia B is less common than Haemophilia A, so it is not the most likely diagnosis.
name: Haemophilia B
label: b
answer: no

Correct answer: a
A 50-year-old male presents to his GP with headaches and dizziness. On further questioning, he reports feeling itchy after taking hot showers. On examination, you notice he has a plethoric face.

Based on the most likely diagnosis, which of the following gene mutations would confirm the diagnosis?

Options:
explanation: This is a gene mutation associated with acute myeloid leukaemia.
name: DNA (cytosine-5)-methyltransferase 3A (DNMT3A) mutation
label: d
answer: no
explanation: This patient has polycythaemia rubra vera. Nearly 100% of patients with polycythaemia rubra vera have a JAK2 mutation.
name: JAK2
label: a
answer: yes
explanation: The c-myc gene is associated with Burkitt's lymphoma.
name: C-myc gene translocation
label: c
answer: no
explanation: This gene mutation is associated with chronic myeloid leukaemia as there is a translocation between the BCR and ABL genes.
name: BCR-ABL
label: b
answer: no
explanation: This is associated with sickle cell disease, as a mutation in the haemoglobin subunit beta (HBB) gene leads to the formation of haemoglobin S instead of beta-globin.
name: HBB gene mutation
label: e
answer: no

Correct answer: a
A 60-year-old female presents to her GP with fatigue. She reports having palpitations and has conjunctival pallor on examination.


Her blood results are the following:


||||
|--------------|:-------:|---------------|
|Haemoglobin|80  g/L|(M) 130 - 170, (F) 115 - 155|
|Mean Cell Volume (MCV)|70 fL|80 - 96|
|White Cell Count|6x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|420x10<sup>9</sup>/L|150 - 400|


Her last blood results 1 year ago were normal.


What is the most appropriate next step in the management of this patient?

Options:
explanation: Blood transfusions are indicated when haemoglobin is < 75g/L (< 80g/l in patients with a history of acute coronary syndrome)
name: Red blood cell transfusion
label: d
answer: no
explanation: The blood results suggest iron deficiency anaemia. In a patient 60 or over, a new iron deficiency anaemia may suggest colorectal cancer, so the 2-week wait pathway should be initiated. Thrombocytosis also suggests underlying inflammation which could be caused by malignancy.
name: 2 week wait colonoscopy
label: a
answer: yes
explanation: This would be useful for staging malignancies such as colorectal cancer, however, it is more appropriate to carry out a colonoscopy first to confirm the diagnosis.
name: CT abdomen + pelvis
label: c
answer: no
explanation: Colonoscopy is the first-line investigation in patients aged 60 or over with new onset iron deficiency anaemia. Investigations must be initiated under the 2-week wait pathway so that malignancies can be excluded or treated quickly.
name: Non-urgent colonoscopy
label: e
answer: no
explanation: Iron deficiency anaemia can be treated with ferrous fumarate, however, it is more prudent to exclude malignancy in a patient aged 60 or over with new iron deficiency anaemia.
name: Oral ferrous fumarate 210mg OD
label: b
answer: no

Correct answer: a
A 60-year-old female presents to A&E with pain and swelling in her right leg. She had a hip replacement 5 weeks ago. On examination, her left calf measures 45cm whilst her right calf measures 41cm, and there is pitting oedema in her right shin. She has a history of stable angina. Her vital signs are normal.

Which of the following is the most appropriate next investigation?

Options:
explanation: This patient is suffering from a deep vein thrombosis (DVT). Her Wells' score is 3: 1 point each for major surgery within the past 12 weeks, the symptomatic calf measuring >3cm more than the asymptomatic calf, and pitting oedema in the symptomatic calf. It is therefore likely that this patient has a DVT, and they should undergo a doppler ultrasound scan within 4 hours.
name: Venous doppler ultrasound
label: a
answer: yes
explanation: This is the gold-standard investigation to diagnose a pulmonary embolism (PE). This patient does not appear to be suffering from a PE as they do not have pleuritic chest pain, dyspnoea or haemoptysis.
name: CTPA
label: d
answer: no
explanation: An x-ray would not be able to visualise a thrombus, and this is not a useful investigation for DVT.
name: X-ray of the leg
label: e
answer: no
explanation: This could be an appropriate treatment but is not the most appropriate investigation.
name: Warfarin for 3 months
label: c
answer: no
explanation: D-dimer is the best initial investigation for patients with a low risk of DVT (Wells' score <2). This patient has a high DVT risk, so a d-dimer would not be sufficient.
name: D-dimer
label: b
answer: no

Correct answer: a
A 70-year-old female with a deep vein thrombosis (DVT) is prescribed warfarin as treatment.

What is the mechanism of action of warfarin?

Options:
explanation: Warfarin only affects the extrinsic pathway by inhibiting factors II, VII, IX and X.
name: Inhibits the intrinsic pathway
label: b
answer: no
explanation: Examples of antiplatelet drugs include clopidogrel and aspirin.
name: Inhibits platelet aggregation
label: e
answer: no
explanation: Anticoagulants such as apixaban inhibit Factor Xa in the common pathway.
name: Factor Xa inhibitor
label: c
answer: no
explanation: Examples of direct thrombin inhibitors include dabigatran.
name: Inhibits thrombin
label: d
answer: no
explanation: Warfarin acts on the extrinsic pathway by inhibiting factors II, VII, IX and X. This is because warfarin inhibits vitamin K epoxide reductase, reducing the levels of vitamin K available to activate factors II, VII, IX and X. A useful mnemonic is 1972 WEPT where 1972 refers to factors 10, 9, 7 and 2 being inhibited, and W = Warfarin, E = extrinsic pathway affected, PT = PT prolonged.
name: Factor II, VII, IX, X inhibitor
label: a
answer: yes

Correct answer: a
A 52-year-old female is in hospital following surgery for renal cell carcinoma. Bloods showed Hb levels of 69g/L (normal range 115 - 155 g/L), so 1 unit of blood is transfused. Following the blood transfusion, she develops progressively worsening shortness of breath. On auscultation, bilateral crackles are heard at the lung bases. She has a past medical history of stable angina. Vital signs are normal apart from a blood pressure of 147/81.


What is the most appropriate management for this patient?

Options:
explanation: The transfusion must be stopped or slowed to prevent the progression of fluid overload into pulmonary oedema. A chest x-ray might help show pulmonary oedema but is not an appropriate first-line management as the fluid overload needs to be reversed with furosemide.
name: Stop the transfusion and order a chest x-ray
label: e
answer: no
explanation: Continuing the transfusion might worsen the fluid overload, increasing the risk of pulmonary oedema and worsening symptoms. The transfusion should be stopped and fluid overload treated with IV furosemide.
name: Continue the transfusion and review in 30 minutes
label: b
answer: no
explanation: This patient is suffering from transfusion-associated circulatory overload(TACO) as a complication of the blood transfusion. This is more likely to occur in patients with a history of cardiovascular disease. The aim of TACO treatment is to reverse the fluid overload through the use of diuretics.
name: Stop the transfusion and administer 30mg IV furosemide
label: a
answer: yes
explanation: This is the treatment for anaphylaxis which can also be a complication of blood transfusions. A patient with anaphylaxis would present with dyspnoea, wheeze, angioedema and hypotension.
name: Stop the transfusion and administer IM adrenaline
label: c
answer: no
explanation: Furosemide is indicated to treat the fluid overload, but the IV route is favoured over oral as it has a higher bioavailability and faster onset.
name: Stop the transfusion and administer 30g oral furosemide
label: d
answer: no

Correct answer: a