hllj/quesmed huggingface dataset:
A 22-year-old man visits the emergency department with severe pain in his left ankle, after he twisted it during a fall while walking on a slippery surface.

On examination, his left ankle is swollen and extremely tender in the malleolar zone of the foot:

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Which of the following would suggest that an ankle X-ray is required?

Options:
explanation: Although bruising may occur in ankle fractures, this is not a criterion included in the Ottawa ankle rules.
name: Severe bruising in the mid-foot zone
label: c
answer: no
explanation: This is incorrect; according to the Ottawa ankle rules, pain at point D would qualify the patient for an ankle x-ray if there was pain in the mid-foot zone, rather than the malleolar zone.
name: Point-tenderness at point D on the diagram
label: d
answer: no
explanation: This is incorrect; the Ottawa ankle rules explicitly state that the criteria for an x-ray involve an inability to weight bear (for 4 steps) both immediately and in the emergency department. Simple pain on walking does not fall into this category.
name: Pain on walking
label: e
answer: no
explanation: This is correct. The Ottawa ankle rules state that an ankle X-ray is required if (with malleolar zone pain) there is either tenderness at point A, tenderness at point B, or an inability to weight bear for 4 steps both immediately AND in the emergency department.
name: Tenderness at point A on the diagram
label: a
answer: yes
explanation: This is incorrect; the Ottawa ankle rules state that an inability to weight bear (for 4 steps) should be present both immediately after the injury and also in the ED - i.e. the onset should not be gradual.
name: Gradual-onset inability to weight bear after the injury
label: b
answer: no

Correct answer: a


Learning point: Tenderness in the malleolar zone of the ankle indicates the need for an X-ray to rule out fractures, as per the Ottawa ankle rules.
A 5-day-old girl is brought to the paediatric emergency department with vomiting and poor feeding. Bloods show hyponatraemia and hyperkalaemia. She appears dehydrated with reduced skin turgor and dry mucous membranes.

Which of the following findings would most likely be found on examination?

Options:
explanation: This is correct. This is suggestive of a diagnosis of congenital adrenal hyperplasia (CAH) with symptoms of dehydration and vomiting developing soon after birth. The electrolyte derangements also suggest CAH, with hyponatraemia and hyperkalaemia caused by hypoaldosteronism.
name: Fused labia and urogenital sinus
label: a
answer: yes
explanation: This is suggestive of meningitis which can present vaguely in newborns. Meningitis does not explain the hyperkalaemia and may cause respiratory symptoms or drowsiness which are not mentioned.
name: Widespread petechial rash
label: d
answer: no
explanation: Physiological jaundice may occur up to two weeks post-birth in healthy breastfed babies. Persistent jaundice or jaundice in the first 24 hours of life is concerning for haematological/biliary conditions.
name: Jaundice
label: e
answer: no
explanation: This is suggestive of intussuception which tends to happen between the ages of three and 18 months. It presents with colicky abdominal pain, vomiting and red currant jelly stools.
name: Sausage-shaped mass in the abdomen
label: c
answer: no
explanation: This is suggestive of pyloric stenosis which can present with projectile vomiting, normally 2-6 weeks after birth. Electrolyte abnormalities include hypokalaemia and hypochloraemia with metabolic alkalosis.
name: Olive-shaped mass in the abdomen
label: b
answer: no

Correct answer: a


Learning point: In congenital adrenal hyperplasia, excess androgen production can cause fused labia and a urogenital sinus, where the urethra and vagina share an opening, leading to ambiguous genitalia in females.
A 35-week-old baby is born in the maternity ward. Five minutes after birth, the baby appears to be grunting and is cyanosed with an oxygen saturation of 80%. Inspection reveals a scaphoid abdomen and a barrel chest.

Which of the following features are likely to be present on auscultation of the chest?

Options:
explanation: The abdominal viscera and bowel tend to push the heart from its normal anatomic location with heart sounds often better auscultated on the right side.
name: Normal heart sounds in the expected location
label: d
answer: no
explanation: This is suggestive of patent ductus arteriosus whereby the abnormal connection between the aorta and the pulmonary artery fails to close after birth which can present asymptomatically with a 'machinery murmur' or with symptoms of shortness of breath, poor feeding, poor weight gain and respiratory infections.
name: Continuous machinery murmur
label: c
answer: no
explanation: This is suggestive of neonatal respiratory distress syndrome caused by a lack of lung surfactant in premature babies associated with high morbidity and mortality.
name: Diffuse crackles with globally decreased air entry
label: b
answer: no
explanation: Children with congenital diaphragmatic hernias are extremely unlikely to have normal lung sounds on auscultation.
name: Normal lung sounds
label: e
answer: no
explanation: This is correct. This vignette is suggestive of a diagnosis of congenital diaphragmatic hernia which is associated with an extremely high mortality with the bowel, stomach and possibly liver moving into the chest cavity. Auscultating the bowel in the thoracic cavity would result in tinkling sounds.
name: Tinkling sounds
label: a
answer: yes

Correct answer: a


Learning point: Congenital diaphragmatic hernia can cause bowel sounds in the thorax, leading to characteristic tinkling sounds on chest auscultation.
A number of children are seen over the day in a specialised developmental clinic.

Which of the following presentations is most concerning?

Options:
explanation: A healthy child should respond to their name by 9 months.
name: A 1-year-old who responds to her name
label: e
answer: no
explanation: 18 months is the cut-off for concern about children walking.
name: A 16-month-old not walking
label: c
answer: no
explanation: It is not recommended to use crawling as a developmental milestone due to variation in healthy children with different crawling styles with some children never crawling before walking.
name: A 14-month-old walking who never learned to crawl
label: d
answer: no
explanation: This is correct. Palmar grasp develops at 3-6 months and pincer grip at 9-12 months therefore this case demonstrates regression in developmental milestones, a universally concerning feature which warrants further assessment by a paediatrician.
name: A 12-month-old with a palmar grasp with a previously good pincer grip
label: a
answer: yes
explanation: The absence of a social smile at **6 weeks** is concerning for a potential visual problem and requires further work up.
name: A 5-week-old without a social smile
label: b
answer: no

Correct answer: a


Learning point: Regression in developmental milestones, such as loss of a previously acquired pincer grip, is a significant concern in paediatric assessments.
A two-year-old boy is brought to the emergency department with pain in his arm. His mother reports he was injured falling off his tricycle yesterday. Neurovascular assessment of the upper limb is unremarkable.

Which of the following is the most appropriate next step?

Options:
explanation: This is well-meaning but premature, a senior with experience needs to be involved in the case first.
name: Call the police
label: d
answer: no
explanation: This is inappropriate given the safeguarding concerns in this case.
name: Discharge with analgesia and safety netting
label: b
answer: no
explanation: At present, there are no specific concerns with the upper limb warranting radiation exposure. A full non-accidental injury workup may be performed which includes a skeletal survey, photography and possible ophthalmology review for retinal haemorrhages.
name: Refer for upper limb X-ray
label: c
answer: no
explanation: There are no concerns over the upper limb that warrant orthopaedic review.
name: Refer to orthopaedics
label: e
answer: no
explanation: This is correct. This scenario is concerning due to the delay in presentation to the ED and the mechanism of injury not being possible in a two-year-old (riding a tricycle is a skill expected in a three-year-old). Therefore, this child should be admitted and discussed with the local safeguarding lead/consultant paediatrician on-call due to possible non-accidental injury.
name: Admit for observations and safeguarding review
label: a
answer: yes

Correct answer: a


Learning point: When non-accidental injury is suspected, admission for observation allows monitoring of the child's condition. A safeguarding review ensures the child's safety, with a thorough assessment by social services and medical professionals.
A 3-day-old baby is recovering in the labour ward. On the last day, he has become irritable and has been constantly crying and frequently yawning. He was born via vaginal delivery at 34 weeks and was 1.6kg at birth. He is afebrile. He was well in his first 2 days of life.

Which of the following is the most likely aetiology of the underlying condition?

Options:
explanation: This is an extremely important differential which would need to be excluded, but the timeframe, yawning, lack of fever and prematurity are more in keeping with maternal drug use.
name: Neonatal sepsis
label: b
answer: no
explanation: This may explain the low birth weight as it can cause both macrosomia and intrauterine growth restriction but does not explain the current presentation.
name: Maternal gestational diabetes mellitus
label: d
answer: no
explanation: This is correct. The likely diagnosis is maternal opiate use and subsequent neonatal withdrawal. Yawning is a specific sign for opioid withdrawal and being well for the first few days suggests withdrawal over other differentials such as infection. The low birth weight and prematurity also suggest maternal drug use.
name: Maternal drug use
label: a
answer: yes
explanation: This is less likely to affect babies born at 34 weeks when most babies would have produced surfactant. It would also have been present since birth and does not explain the yawning.
name: Neonatal respiratory distress syndrome
label: c
answer: no
explanation: This presents later in life with cyanosis and cardiac signs that are not described in this scenario.
name: Tetralogy of Fallot
label: e
answer: no

Correct answer: a


Learning point: Neonatal withdrawal symptoms, such as irritability and yawning, often indicate maternal opiate use during pregnancy.
A 23-year-old woman comes to the emergency department complaining of fever and sweating. Examination reveals hyperreflexia, hypertension and muscle rigidity. She has a background of depression and describes partying last night, admitting to recreational drug use but is unsure of the name of the drug.

What is the most likely agent causing this presentation?

Options:
explanation: Neither opioid intoxication, which presents with reduced GCS, pinpoint pupils and slow breathing nor withdrawal, which presents with insomnia, yawning, diarrhoea, piloerection and lacrimation, would explain the presentation.
name: Heroin
label: d
answer: no
explanation: In overdose, hallucinogenic mushrooms tend to cause psychosis, renal failure, seizures and coma.
name: Hallucinogenic mushrooms
label: c
answer: no
explanation: In high doses and with extensive use, marijuana can induce temporary psychotic symptoms such as paranoia, delusions, anxiety and hallucination.
name: Marijuana
label: e
answer: no
explanation: This is correct. This scenario describes serotonin syndrome due to time of onset, fever, sweating and hyperreflexia. Concomitant use of SSRIs and  ecstasy can precipitate serotonin syndrome with the increasing incidence of ecstasy usage amongst adolescents with depressive disorders making this important knowledge for healthcare professionals.
name: Ecstasy
label: a
answer: yes
explanation: Neither alcohol intoxication, which presents with slurred speech, vomiting, possible loss of consciousness and mental confusion, nor alcohol withdrawal, which presents with tremors, hallucination and possible seizures, explains this presentation.
name: Alcohol
label: b
answer: no

Correct answer: a


Learning point: Serotonin syndrome can occur with the use of ecstasy, especially in patients on SSRIs, presenting with hyperreflexia, muscle rigidity, and autonomic instability.
A 67-year-old man with treatment-resistant schizophrenia has been transferred from the psychiatric intensive care unit to the acute medical unit at the local hospital due to a productive cough with tachypnoea and hypotension.

Which of the following investigations is it most important to order?

Options:
explanation: Several antipsychotics increase the risk of developing diabetes and elevating HbA1c but this is not a priority at the moment.
name: HbA1c
label: e
answer: no
explanation: Whilst useful to stage the likely pneumonia using a CURB-65 score and assess for acute kidney injury, it is not as important as excluding agranulocytosis here. In reality, these tests would be ordered together.
name: Urea and electrolytes
label: b
answer: no
explanation: Clozapine can cause myocarditis with an elevated troponin but the clinical picture is in keeping with pneumonia.
name: Troponin
label: c
answer: no
explanation: Antipsychotics are known to worsen cholesterol levels causing them to rise but this is not a priority at the moment.
name: LDL levels
label: d
answer: no
explanation: This is correct. This scenario suggests this man is on clozapine as it is the only licensed option for treatment-resistant schizophrenia which can cause profound agranulocytosis, which can result in overwhelming sepsis and death.
name: Full blood count
label: a
answer: yes

Correct answer: a


Learning point: Clozapine can cause agranulocytosis, so regular blood tests are needed to monitor white blood cell levels and prevent serious infections and complications.
A 75-year-old woman with a history of Lewy Body Dementia has been admitted to the care of the elderly ward following agitation and restlessness with a recent urinary tract infection. Her ward is finding her aggression difficult to manage as she is attempting to assault staff.

Which of the following is the most appropriate pharmacological treatment option?

Options:
explanation: SSRIs are not an option to manage acute aggression.
name: Sertraline
label: e
answer: no
explanation: This scenario describes hyperactive delirium. In cases when pharmacological management is needed where there are acute risk concerns, lorazepam is preferred and haloperidol should avoided if there are Parkinsonian features such as in dementia with Lewy bodies as this can severely worsen their Parkinsonism.
name: Lorazepam
label: a
answer: yes
explanation: This may be an option later down the line, necessitating an ECG before administration to assess QT, but is not the first line.
name: Risperidone
label: c
answer: no
explanation: This should be avoided in patients with Parkinsonism as it will worsen it.
name: Haloperidol
label: b
answer: no
explanation: This should be avoided due to its anticholinergic properties which may worsen delirium and confusion.
name: Promethazine
label: d
answer: no

Correct answer: a


Learning point: In Lewy body dementia, lorazepam is preferred over haloperidol for managing delirium due to a lower risk of exacerbating Parkinsonism and neuroleptic sensitivity
A 36-year-old G3P2 who is 27 weeks pregnant comes to the maternal assessment unit with lower back pain and light vaginal bleeding which started a few hours ago. On examination, a tender uterus is palpated. She is haemodynamically stable.

Which of the following investigations will prove most useful to guide management?

Options:
explanation: This may be useful if we are considering disseminated intravascular coagulation but there is nothing to suggest this at present.
name: INR, Fibrinogen and Fibrinogen degradation products
label: d
answer: no
explanation: This is useful as the patient is actively bleeding and may require transfusion if the haemoglobin drops but the bleeding is light at present and this is not the priority at present as the mother is haemodynamically stable.
name: Full blood count
label: c
answer: no
explanation: Whilst this most certainly would be performed to assess the bleed, it is less useful (and insensitive) in cases where there is concealed abruption or retroplacental abruption (up to 25%) which is out of proportion with blood loss and therefore must be considered with CTG and in the overall clinical picture.
name: Transabdominal ultrasound
label: b
answer: no
explanation: This is correct. This scenario describes placental abruption with painful antepartum haemorrhage. Management depends on the stability of the mother and foetus and gestational age. If the pregnancy is over 34 weeks and the mother is contracting or bleeding, vaginal delivery is recommended (with possible induction). If the gestation is less than 34 weeks, the mother should be admitted with regular ultrasonography and CTG with steroids considered. CTG is the most useful measure of the stability of the baby here and can inform management thereafter.
name: Continuous foetal heart rate monitoring
label: a
answer: yes
explanation: CT tends to be avoided in pregnancy as much as possible due to the radiation exposure. It may however be required in cases of traumatic abruption when an ultrasound is inconclusive.
name: Abdominal CT
label: e
answer: no

Correct answer: a


Learning point: Continuous fetal heart rate monitoring is essential in assessing the wellbeing of the fetus in cases of suspected placental abruption.
A 20-year-old caucasian nulligravida comes to the GP surgery complaining of dysmenorrhoea and heavy periods. She further reports dyspareunia and occasionally passing fresh red blood per rectum. She reports her mother suffering from similar issues in her youth.

What is the most likely diagnosis?

Options:
explanation: A sensible differential. Polycystic ovarian syndrome may present with irregular or missed periods, however core features are weight gain, acne and hirsutism, making it less likely.
name: Polycystic ovarian syndrome
label: d
answer: no
explanation: This is not likely in this case as bloating and changes in bowel motion are not mentioned and the difficulties are primarily gynaecological.
name: Irritable bowel syndrome
label: c
answer: no
explanation: A sensible differential which shares many symptoms with endometriosis. The patient's ethnicity and age render this less common as fibroids tend to develop in Afro-Caribbean women over 40 years of age. In addition, the family history and PR bleeding are more in keeping with endometriosis.
name: Fibroids
label: b
answer: no
explanation: This may cause heavy bleeding with a family history but none of the other listed symptoms.
name: Von Willebrand Disease
label: e
answer: no
explanation: This is correct. The family history, dyspareunia, dysmenorrhea and rectal bleeding are all in keeping with endometriosis.
name: Endometriosis
label: a
answer: yes

Correct answer: a


Learning point: Endometriosis is a condition characterized by the growth of endometrial-like tissue outside the uterus, leading to pelvic pain, dysmenorrhea, menorrhagia, dyspareunia, and potentially infertility. Gastrointestinal symptoms are also common.
A 31-year-old G3P2 comes to the emergency department with a fever and foul-smelling vaginal discharge. She is 12 weeks pregnant and recently underwent invasive testing following a finding of thickened nuchal translucency. No PV bleeding is noted on examination and the cervical os is closed.

What is the most likely diagnosis?

Options:
explanation: This classically presents with thick white cottage cheese-like discharge which is not described.
name: Candida Albicans infection
label: d
answer: no
explanation: This presents with grey discharge, burning pain and fish-like odour which are not described.
name: Bacterial vaginosis
label: e
answer: no
explanation: This is correct. This placental infection can occur following invasive testing and typically presents with fever and foul-smelling vaginal discharge.
name: Chorioamnionitis
label: a
answer: yes
explanation: A sensible differential, however, given the closed cervical os, absence of PV bleeding and the absence of systemic features of sepsis, chorioamnionitis is more likely.
name: Septic Miscarriage
label: b
answer: no
explanation: This classically presents with fishy green-yellow discharge and dyspareunia and is a sexually transmitted disease. The clinical picture is not in keeping with this due to recent invasive testing.
name: Trichomonas Vaginalis infection
label: c
answer: no

Correct answer: a


Learning point: Chorioamnionitis is a placental infection characterised by fever and foul-smelling vaginal discharge, often following invasive procedures during pregnancy.
A 26-year-old man is an inpatient in the psychiatry ward under Section 2 due to a manic relapse of bipolar disorder. Whilst on the ward, he develops a fever and a new pan-systolic murmur can be heard. He refuses treatment for infective endocarditis despite being informed of its sequelae.

What is the most appropriate next step?

Options:
explanation: This is correct. The Mental Health Act cannot be used to treat physical health symptoms apart from a few exceptions including severe anorexia nervosa. The patient's capacity needs to be assessed to refuse this treatment and if present, even if this decision were to be deemed unwise, is his to make. If absent, action should be taken to treat him in his best interests.
name: Assess his capacity to refuse treatment
label: a
answer: yes
explanation: His capacity needs to be established first before considering best interests discussions including the opinions of any appointed attornies, least restrictive options, what the patient wants now and what they wanted in the past.
name: Obtain consent from a family member to treat his infective endocarditis
label: d
answer: no
explanation: This may well be the course of action if the patient is found to have capacity with regards to deciding to accept/reject treatment for infective endocarditis but given that it is potentially unwise, a capacity assessment should be performed.
name: Do not treat his infective endocarditis as he has refused
label: e
answer: no
explanation: Physical health symptoms are generally not treated under the Mental Health Act.
name: Treat his infective endocarditis under the Mental Health Act
label: b
answer: no
explanation: His capacity needs to be established first. If the patient lacks capacity, a best interests decision can be made.
name: Treat his infective endocarditis as it is in his best interests
label: c
answer: no

Correct answer: a


Learning point: Assessing capacity to refuse treatment involves evaluating the person's ability to understand the situation, weigh the benefits and risks, communicate a decision, and make a choice based on rational reasoning.