hllj/quesmed huggingface dataset:
A 78-year-old male patient is on the surgical wards after an oesophagectomy. Several hours postoperatively, he develops shortness of breath. He has a chest drain in-situ, which has started to leak large amounts of milky fluid.

Which of these would be the most appropriate initial management?

Options:
explanation: This is a difficult question. This patient has developed chylothorax, which is leaking through his chest drain. Traumatic chylothoraces are the most common type, and they can occur in up to 4% of oesophagectomies. Lymph leaks from the thoracic duct into the chest cavity. In large leaks, the most effective initial management is to allow the lymph to drain and to support the patient with adequate nutritional support
name: Allow the fluid to drain and prescribe total parenteral nutrition
label: a
answer: yes
explanation: The fluid moving coming out of the chest drain is lymph. The patient has a chylothorax which needs to drain from the chest cavity. Drainage may reduce pressure on the lungs and improve the patient's breathing. Nutritional support is important to remember in these patients, although they may require additional IV fluids
name: Clamp the chest drain and prescribe IV fluids
label: b
answer: no
explanation: Readmission to ITU is the most appropriate initial management. This patient has developed a chyle leak and needs to be managed in ITU given the serious nature of the complication. The chylothorax will need to be drained from the chest cavity. Drainage may reduce pressure on the lungs and improve the patient's breathing.
name: Readmit to ITU as soon as possible
label: e
answer: no
explanation: The fluid moving coming out of the chest drain is lymph. The patient has a chylothorax which needs to drain from the chest cavity. Drainage may reduce pressure on the lungs and improve the patient's breathing. IV furosemide is not require
name: Clamp the chest drain and prescribe IV furosemide
label: d
answer: no
explanation: The fluid moving coming out of the chest drain is lymph. The patient has a chylothorax which needs to drain from the chest cavity. Drainage may reduce pressure on the lungs and improve the patient's breathing. It may be necessary to call the intensive care unit depending on the vital signs of the patient
name: Clamp the chest drain and call the intensive care unit
label: c
answer: no

Correct answer: a


Learning point: A chylothorax is a condition where lymph leaks from the thoracic duct into the chest cavity, often occurring after trauma like oesophagectomy, and is typically managed by draining the lymph and ensuring adequate nutritional support.
A 17-year-old male patient attends A&E due to decreasing responsiveness. On examination, his breath smells like pear drops, and he has developed deep, rapid inspiration.

His observations are as follows:

Pulse 90bpm
Blood pressure 85/55mmHg
Respiratory rate 30bpm
SpO2 98% on air
Temperature 36.7°C
What is the initial management?

Options:
explanation: It is important to first restore circulatory volume and start a fixed-rate IV insulin infusion
name: IV IV 0.9% sodium chloride 1L with potassium chloride over 2 hours
label: d
answer: no
explanation: It is important to restore circulatory volume first by giving fast fluids. Once circulatory volume has been restored, IV insulin can be commenced
name: IV insulin with 0.9% sodium chloride at a concentration of 1 unit/mL; infused at a fixed rate of 0.1 units/kg/hour
label: b
answer: no
explanation: The patient is hypotensive and requires fluid resuscitation with an IV bolus
name: 1L IV sodium chloride 0.9% over 1 hour
label: c
answer: no
explanation: Whilst ongoing fluid and potassium replacement is important, the priority here is to restore circulatory volume with an IV fluid bolus
name: 1L IV 0.9% sodium chloride with 40 mmol KCl over 6 hours
label: e
answer: no
explanation: The patient has presented with signs of diabetic ketoacidosis and is hypotensive. The correct initial management is to restore circulatory volume by giving a rapid bolus of IV fluid
name: 500 mL IV sodium chloride 0.9% over 10–15 minutes
label: a
answer: yes

Correct answer: a


Learning point: In diabetic ketoacidosis, initial management includes administering intravenous fluids to restore circulatory volume and address hypotension.
A Foundation Year 1 doctor is on their first rotation in urology. They are asked by the urology consultant to consent a 67-year-old male patient for a trans urethral resection of a bladder tumour. The patient is due to go to theatre that afternoon. The Foundation Year 1 doctor has never seen this surgery performed before and does not have a clear idea about what it entails.

Which of the following is the most appropriate action for the Foundation Year 1 doctor?

Options:
explanation: This is a poor choice, even if the doctor has mitigated the scenario slightly by looking up the details of the surgery. This consent requires a complex understanding of the operation that only someone who has performed the surgery will have
name: Consent the patient after looking up the details of the surgery in more detail
label: e
answer: no
explanation: This is the worst choice as the doctor is unlikely to be able to provide clear guidance, and the patient would have reasonable grounds to complain as it would negatively affect their care
name: Consent the patient as best they can on their own
label: b
answer: no
explanation: This is the second best choice. You should not practice outside your boundaries of competence. (Even consultants need to ask others for help occasionally). However, explaining why they have refused would be best
name: Refuse to consent the patient
label: c
answer: no
explanation: This is the best answer. As a Foundation Year 1 doctor, they should not be consenting a patient for a procedure which is unknown to them as they would be unable to sufficiently explain the risks and benefits for the surgery to the patient. They would also be unlikely to answer any further questions from the patient. A good general rule that can be used is: if you can do the procedure yourself then you can ascertain consent. If you cannot, then it may not be appropriate to be obtaining consent
name: Explain to the consultant that they are unable to consent the patient as they do not have enough experience
label: a
answer: yes
explanation: This is a poor choice as the doctor is also involving a second underqualified doctor. It is up to interpretation whether this option is worse the consenting the patient after looking up the details first. Ultimately, both should not happen
name: Ask another Foundation Year 1 doctor, who has seen the surgery performed before, to consent the patient
label: d
answer: no

Correct answer: a


Learning point: Foundation Year doctors should not consent for procedures they are unfamiliar with, as they cannot adequately explain risks and benefits to patients.
A 95-year-old female is an inpatient on the acute medical unit. She has been treated for a urinary tract infection with antibiotics and is due to be discharged home. Before discharge, the patient agreed with the consultant to complete a Do Not Attempt Resuscitation (DNAR) form. The patient had capacity to make this decision. The patient's daughter (her next of kin) visits the ward and demands to know whether or not her mother has a DNAR form. She is very upset because she says it has been so difficult to contact the ward to find out how her mother has been doing.

Which is the best next step for you, as the ward resident doctor, to take?

Options:
explanation: Although the mother is upset about the lack of information that she has received it is still not acceptable to break patient-doctor confidentiality
name: Tell the daughter that her mother does have a DNAR form and update her about her current care
label: e
answer: no
explanation: Just because the daughter is the next of kin does not automatically mean that you can break patient-doctor confidentiality
name: Tell the daughter that her mother does have a DNAR form as she is the next of kin
label: b
answer: no
explanation: You should not break patient-doctor confidentiality by disclosing this information without the patient's permission. Instead you must ask the mother whether it is acceptable to relay this information to her daughter. Whilst a DNACPR is a medical decision, this antagonistic response is likely to create further tension
name: Tell the daughter that their mother does have a DNAR form and explain that this is a medical decision and that her opinion will not change anything
label: d
answer: no
explanation: This is the correct answer. The patient had capacity to make the decision about resuscitation, therefore, it is likely that she will have capacity to make the decision about whether to communicate this decision to her daughter. If you did not ask permission, you would be breaking patient-doctor confidentiality
name: Check with the patient whether you can share this information with their daughter
label: a
answer: yes
explanation: This is the next best answer, as you cannot tell the daughter any information about her mother without her mother's consent
name: Refuse to tell the daughter anything
label: c
answer: no

Correct answer: a


Learning point: Always seek patient consent before disclosing medical information to relatives to uphold confidentiality and respect patient autonomy.
A 54-year-old woman presents to A&E with abdominal pain. The pain is generalised across the abdomen, which appears distended. She feels feverish and has been experiencing diarrhoea and vomiting. She has known liver cirrhosis.


An ascitic tap is performed:


 - Appearance cloudy


||||
|---------------------------------|:-------------------------:|-------|
|RBC|80|none|
|WBC|550 /mm<sup>3</sup>|< 300|
|Albumin|5.2 g/L|< 40|
|Glucose|4.5 mmol/L|3.5 - 5.5|
|Amylase|350 U/L|< 100|


What is the most likely diagnosis?

Options:
explanation: The history, combined with the ascitic tap results, point towards a diagnosis of spontaneous bacterial peritonitis. Ascitic fluid is likely to appear cloudy in spontaneous bacterial peritonitis, with a high neutrophil and protein count. Spontaneous bacterial peritonitis is most commonly seen in patients with end-stage liver disease
name: Spontaneous bacterial peritonitis
label: a
answer: yes
explanation: Tuberculosis can lead to ascites, especially when granulomas spread to the peritoneum. However, tuberculosis is more likely to lead to a milky coloured ascitic tap along with raised protein levels. It is much rarer than spontaneous bacterial peritonitis
name: Tuberculosis
label: c
answer: no
explanation: Pancreatic carcinoma may lead to feverish symptoms, but they classically present without pain. Those that do have abdominal pain are more likely to experience epigastric rather than generalised pain. It is more likely to lead to a milky or bloody ascitic tap with mildly elevated red cell count and reduced glucose levels
name: Pancreatic carcinoma
label: e
answer: no
explanation: Liver cirrhosis is unlikely to be the sole cause of these symptoms; for example, cirrhotic patients will not become feverish without a secondary cause. Patients with liver cirrhosis are more likely to have clear or sometimes straw-coloured ascitic taps. They would also normally have a normal absolute neutrophil count
name: Cirrhosis
label: b
answer: no
explanation: Hepatocellular carcinoma may lead to feverish symptoms with abdominal pain. However, hepatocellular carcinoma is more likely to lead to a milky or bloody ascitic tap with mildly elevated red cell count and reduced glucose levels
name: Hepatocellular carcinoma
label: d
answer: no

Correct answer: a


Learning point: Spontaneous bacterial peritonitis commonly occurs in patients with liver cirrhosis and is characterised by cloudy ascitic fluid and elevated white blood cell counts.
A 21-year-old female presents to her GP because she has been feeling increasingly anxious. She has recently moved house and broken up with her partner. She has also been experiencing intermittent diarrhoea and diffuse abdominal pain. Her GP decides to send her for an ileocolonoscopy where biopsies are taken. These biopsies show granulomas and inflammation of the serous membrane.

What is the most likely diagnosis?

Options:
explanation: Irritable bowel syndrome may present with similar symptoms, which can become worse in periods of stress. However, the histology findings point towards an inflammatory cause
name: Irritable bowel syndrome
label: c
answer: no
explanation: Serositis is absent in most ulcerative colitis histology, except in fulminant colitis and granulomas are absent, except in the case of ruptured crypts. Ulcerative colitis is more likely to present with bloody diarrhoea and colicky abdominal pain, urgency and tenesmus
name: Ulcerative colitis
label: b
answer: no
explanation: Anxiety may present with abdominal pain, which is sometimes described as "churning". However, it will not lead to the histological findings seen in this patient
name: Anxiety
label: d
answer: no
explanation: Coeliac disease is likely to show subtotal villus atrophy on histology rather than serositis and granulomas. Serological testing whilst the patient is having gluten in their diet is usually done before biopsies
name: Coeliac disease
label: e
answer: no
explanation: The histology is highly specific for Crohn's disease. Serositis and granulomas are often present in Crohn's, whereas they are absent in ulcerative colitis. Crohn's disease can present with variable symptoms, including diarrhoea, which may or may not contain blood, as well as generalised abdominal pain
name: Crohn's disease
label: a
answer: yes

Correct answer: a


Learning point: Histology in Crohn's disease typically shows transmural inflammation, granulomas, crypt abscesses, and mucosal ulceration, often involving any part of the gastrointestinal tract and characterized by skip lesions and fibrosis.
A 25-year-old woman presents to her GP with bloody diarrhoea. This has been going on for the last week. She has also been experiencing fevers and malaise. She states that she has recently visited India to see her family.

Her GP requests a colonoscopy where biopsies are taken. The biopsies show inflammation of the mucosa and the superficial submucosa. Neutrophilic infiltrates were seen, along with irregular, dilated crypts, pseudopolyps and lamina propria fibrosis.

What is the most likely diagnosis?

Options:
explanation: Shigellosis is associated with foreign travel. It usually leads to watery diarrhoea, however, blood and mucus can also be seen in the stool. It is a self-limiting disease that usually improves over a few days. It is less likely in this case because the biopsy results suggest chronic inflammation due to the irregular, dilated crypts seen
name: Shigellosis
label: e
answer: no
explanation: Irritable bowel syndrome is common in younger adults. However, it is unlikely to present with bloody diarrhoea, and would not show inflammation on biopsy
name: Irritable bowel syndrome
label: c
answer: no
explanation: Giardiasis is associated with foreign travel. It can lead to prolonged diarrhoea for more than one week. However, it is unlikely to lead to bloody diarrhoea. Plus, the biopsy results suggest chronic inflammation due to the irregular, dilated crypts seen. This makes giardiasis less likely
name: Giardiasis
label: d
answer: no
explanation: Crohn's disease can present with bloody diarrhoea, however, the histology would be unlikely to show pseudopolyps. Increased thickness of the bowel wall would also be likely as well as more diffuse inflammation
name: Crohn's disease
label: b
answer: no
explanation: Bloody diarrhoea is the cardinal symptom of ulcerative colitis. Although the initial history suggests a short time-line, the biopsy results suggest chronic bowel inflammation due to the irregular, dilated crypts. Therefore, ulcerative colitis is the most likely diagnosis. An ulcerative colitis history may mimic that of a gastrointestinal infection. Therefore, attention should be given to the biopsy results
name: Ulcerative colitis
label: a
answer: yes

Correct answer: a


Learning point: Bloody diarrhea is the cardinal symptom of ulcerative colitis, an inflammatory bowel disease that causes chronic inflammation and ulcers in the colon and rectum, often accompanied by abdominal pain, urgency, and weight loss.
A 56-year-old woman presents to her GP because her friends tell her that she looks tanned but hasn't been on holiday recently. On further questioning, she admits to some mild back pain, on and off for the last few months, which she has put down to her new exercise regime. She smokes 20-a-day and drinks alcohol "at weekends". On examination, she has scleral icterus and appears to be tanned.

What is the most likely diagnosis?

Options:
explanation: Pancreatic cancer classically presents as painless jaundice. There can be some accompanying generalised, nonspecific signs of epigastric or back pain. Painless obstructive jaundice is more likely to occur in tumours of the head of the pancreas. Risk factors for pancreatic cancer include smoking and high alcohol intake, as well as poor diet, diabetes and family history
name: Pancreatic cancer
label: a
answer: yes
explanation: Liver cirrhosis occurs when the liver tissue because nodules surrounded by widespread fibrosis. This usually occurs over a number of years rather than months. Jaundice is a symptom of liver cirrhosis, but it is often accompanied by ascites and muscle wasting
name: Liver cirrhosis
label: b
answer: no
explanation: Primary biliary cholangitis is often found incidentally. It is an autoimmune disease of the biliary system which eventually leads to scarring, fibrosis and cirrhosis over years or decades. (In its late stages, it can also be called primary biliary cirrhosis). The first symptoms are often fatigue, pruritis and right upper quadrant pain
name: Primary biliary cholangitis
label: d
answer: no
explanation: Nonspecific lower back pain can only be diagnosed when no other cause of the back pain can be found. Therefore, it is a diagnosis of exclusion. Nonspecific lower back pain would not lead to jaundice
name: Nonspecific lower back pain
label: c
answer: no
explanation: Hepatocellular carcinoma is the most common cancer of the liver. Patients with cirrhosis are at high risk of developing hepatocellular carcinoma. It usually presents with pruritis, jaundice, abdominal distension and right upper quadrant pain
name: Hepatocellular carcinoma
label: e
answer: no

Correct answer: a


Learning point: Pancreatic cancer typically presents with painless jaundice, often accompanied by nonspecific symptoms like epigastric or back pain, and is more common in tumors of the pancreas head, with risk factors including smoking, high alcohol intake, poor diet, diabetes, and family history.
A 66-year-old woman presents to her GP with increasing fatigue and pruritus. On examination, hepatomegaly is present. She has a past medical history of obesity, hyperthyroidism and coeliac disease. 

You suspect a diagnosis of Primary Biliary Cholangitis. Which of the following blood tests will be most specific to this condition?

Options:
explanation: Anticentromere antibodies are found to be positive in approximately 80% of patients with CREST syndrome. (CREST syndrome stands for calcinosis, Raynaud's phenomenon, (o)esophageal dysfunction, sclerodactyly and telangiectasia). This patient is displaying symptoms, signs and risk factors of primary biliary cholangitis, therefore, anticentromere antibodies are unlikely to be positive. However, CREST syndrome is a common risk factor for developing primary biliary cholangitis
name: Anticentromere antibodies
label: c
answer: no
explanation: Roughly 35% of primary biliary cholangitis patients will be positive for antinuclear antibodies, however these are less specific than antimitochondrial antibodies
name: Antinuclear antibodies
label: b
answer: no
explanation: This patient is presenting with symptoms, signs and risk factors of primary biliary cholangitis. This is an autoimmune disease that can lead to primary biliary cirrhosis (which primary biliary cholangitis used to be called but is now only used in the late stages). It is often found incidentally, as it is often asymptomatic in the early phases. Approximately 90% of affected individuals will be positive for antimitochondrial antibodies
name: Antimitochondrial antibodies
label: a
answer: yes
explanation: Anti-Jo antibodies are most likely to be positive in polymyositis and dermatomyositis. These both lead to problems predominantly of the connective tissues. Therefore, anti-Jo antibodies are unlikely to be positive in this case
name: Anti-Jo antibodies
label: e
answer: no
explanation: Anti-Ro antibodies are most likely to be positive in Sjogren's syndrome, or less commonly Systemic Lupus Erythematosus (SLE). Sjogren's syndrome is a common feature of the history of individuals who present with primary biliary cholangitis. However, in this case, the patient has fatigue, pruritus and hepatomegaly, which all suggest primary biliary cholangitis rather than Sjogren's syndrome
name: Anti-Ro antibodies
label: d
answer: no

Correct answer: a


Learning point: Antimitochondrial antibodies are highly specific for Primary Biliary Cholangitis, present in approximately 90% of affected individuals.
A 23-year-old woman visits her GP due to headaches. They are unilateral, severe (8/10), last several hours and are associated with nausea. She has noticed that they are worst when she does not do any exercise.

What medication should the GP prescribe for pain relief during acute episodes?

Options:
explanation: Opiates should be avoided in migraine headache
name: Co-codamol 30/500mg
label: e
answer: no
explanation: This is the correct answer. First line treatment for migraines include: 1. Simple analgesia. 2. An anti-emetic if required. 3. Triptans (usually prescribed if moderate to severe symptoms)
name: Ibuprofen 400mg
label: a
answer: yes
explanation: Whilst nausea is common with migraine, and prochlorperazine is a correct treatment, this will not directly relieve the migraine
name: Prochlorperazine 3mg
label: b
answer: no
explanation: Propranolol is used for migraine prophylaxis, with a target dose of 80mg twice daily
name: Propranolol 80mg
label: d
answer: no
explanation: Aspirin is an option in migraine but the dose is usually 900mg. Please don't despair and worry that you have to memorise drug doses! This choice was left in to teach you that an option for migraine is 900mg Aspirin which is one of the rare instances where a larger dose than 300mg is used
name: Aspirin 300mg
label: c
answer: no

Correct answer: a


Learning point: First line treatment for migraines include: 1. Simple analgesia. 2. An anti-emetic if required. 3. Triptans (usually prescribed if moderate to severe symptoms)