hllj/quesmed huggingface dataset:
A 29-year-old man is taken to a major trauma centre after a high-speed car accident. They are having a CT scan of the entire body, when they deteriorate.

Observations show:

* Heart rate 113 beats/minute

* Blood pressure 90/59 mmHg

* Respiratory rate 32 breaths/minute

* Oxygen saturations 88% on 15 litres/minute oxygen (non-rebreather mask)

On examination, he is cyanosed. There is absent air entry across the right side of the thorax.

What is the most appropriate next step to take?

Options:
explanation: The most likely diagnosis is a tension pneumothorax causing respiratory and circulatory compromise. Immediate needle decompression should be undertaken.
name: Needle decompression
label: a
answer: yes
explanation: This may be required eventually, however intubation and positive pressure ventilation should not take place until the pneumothorax is treated, as more air will be forced into the pleural cavity, worsening the situation.
name: Intubation and ventilation
label: d
answer: no
explanation: Cardiac tamponade is a differential, however the absence of air entry over the right hemithorax and the desaturation makes this less likely. If a focussed echocardiogram demonstrates a tamponade, thoracotomy may be used to drain the blood.
name: Emergency thoracotomy
label: e
answer: no
explanation: Cardiac tamponade is a differential, however the absence of air entry over the right hemithorax and the desaturation makes this less likely. A focussed echocardiogram would be useful after the patient is stabilised. In trauma, a thoracotomy is preferred to pericardiocentesis, as the tamponade will re-accumulate.
name: Pericardiocentesis
label: b
answer: no
explanation: Although the patient is hypotensive and tachycardic, this patient is likely in obstructive shock due to a tension pneumothorax. A fluid bolus will likely also be administered, but needle decompression is the priority.
name: Fluid bolus
label: c
answer: no

Correct answer: a


Learning point: The landmarks for needle decompression in tension pneumothorax are the second intercostal space at the midclavicular line or the fifth intercostal space at the anterior axillary line, with the needle inserted above the rib to avoid the neurovascular bundle.
A patient presents to his GP feeling generally unwell. He has a background of Burkitt's lymphoma, for which he received chemotherapy 8 days ago. Observations show:

* Heart rate 83 beats/minute

* Blood pressure 132/83 mmHg

* Respiratory rate 13 breaths/minute

* Temperature 38.2 degrees Celcius

On examination, he looks tired but has no other signs of note.

What is the most appropriate next step in management?

Options:
explanation: Fever in a patient undergoing chemotherapy should be taken seriously. This patient is at high risk for neutropenic sepsis, which suually presents 7-10 days after chemotherapy, when neutrophils are at their lowest. He requires urgent inpatient investigation and intravenous antibiotics through an emergency admission to hospital.
name: Emergency admission to hospital
label: a
answer: yes
explanation: The patient is at risk of neutropenic sepsis. Emergency admission to hospital should be arranged, rather than an urgent referral to haematology.
name: Urgent referral to haematology
label: d
answer: no
explanation: This is inappropriate. The patient is at high risk of neutropenic sepsis, and should be admitted to hospital for IV antibiotics and investigations that are only available in hospital (e.g. blood cultures).
name: Reassure this is likely a viral infection and discharge with safety-netting
label: e
answer: no
explanation: While an urgent full blood count will be required to check the neutrophil count, this should not be undertaken in the GP surgery. The priority should be admitting the patient to hospital for IV antibiotics. The GP is unlikely to be able to receive the results of blood tests in time to act on them in an emergency situation.
name: Urgent full blood count
label: b
answer: no
explanation: Fever in a patient undergoing chemotherapy should be taken seriously. This patient is at high risk for neutropenic sepsis, which suually presents 7-10 days after chemotherapy, when neutrophils are at their lowest. He requires urgent inpatient investigation and intravenous antibiotics. Local guidelines vary, but the antibiotic of choice is usually IV piparicillin/tazobactam (in patients without a penicillin allergy).
name: Prescribe oral co-amoxiclav
label: c
answer: no

Correct answer: a


Learning point: Fever in a chemotherapy patient may indicate neutropenic sepsis, necessitating urgent hospital admission for assessment and intravenous antibiotics.
A 55-year-old woman with a background of metastatic breast cancer is admitted to hospital due to severe abdominal pain. She is being treated with hormonal therapy (letrozole) and her disease has been stable for the past few years.

She becomes increasingly confused and agitated on the ward. Her family also notice she has become more thirsty.

Which of the following is the next best investigation to perform?

Options:
explanation: The patient's presentation is suggestive of hypercalcaemia caused by malignancy, which is likely leading to abdominal pain. There are no specific examination findings (e.g. right upper quadrant pain) mentioned that immediately warrant an ultrasound scan.
name: Ultrasound abdomen
label: d
answer: no
explanation: While brain metastases may account for the confusion and these may be seen on CT, the next best investigation would be a bone profile to check whether the symptoms are due to hypercalcaemia. A simple blood test is both quicker and easier than performing imaging.
name: CT scan of the brain
label: c
answer: no
explanation: A CT of the urinary tract is the investigation of choice for renal colic. There is no mention of flank pain or haematuria, making this diagnosis unlikely. Hypercalcemia should be investigated for with a bone profile.
name: CT urinary tract (KUB)
label: e
answer: no
explanation: The patient's symptoms of abdominal pain, thirst, and confusion are suggestive of hypercalcaemia due to her malignancy. A bone profile would confirm this.
name: Bone profile
label: a
answer: yes
explanation: While brain metastases may account for the confusion and these may be seen on MRI, the next best investigation would be a bone profile to check whether the symptoms are due to hypercalcaemia.
name: MRI scan of the brain
label: b
answer: no

Correct answer: a


Learning point: In metastatic breast cancer, a bone profile, including calcium, phosphate, alkaline phosphatase (ALP), and albumin, is performed to assess bone involvement and detect complications such as bone metastases, hypercalcemia, or changes in bone density.
A 68-year-old woman visits her GP as she is concerned about her risk of having a stroke, as her brother has just suffered a transient ischaemic attack.

She currently takes no medication, and her QRISK 3 score is calculated as 13%. Blood tests show a mildly raised total cholesterol level, with a normal HbA1c and liver function tests.

What is the most appropriate next step to take?

Options:
explanation: NICE recommend lifestyle modification measures in the first instance for patients who have a QRISK score of over 10%. If these are ineffective in lowering cholesterol, a statin should be offered.
name: Encourage lifestyle modification
label: a
answer: yes
explanation: This is inappropriate as her QRISK score (which is a measure of the risk of a cardiovascular event) is over 10%. She should be encouraged to engage in lifestyle modification measures. If these are ineffective, a statin may be offered.
name: Reassure the patient she is at low risk of developing a stroke
label: c
answer: no
explanation: This is inappropriate. Aspirin has no role in the primary prevention of strokes.
name: Offer daily aspirin for stroke prevention
label: e
answer: no
explanation: This may well be required if lifestyle modification does not lower her cholesterol, however NICE recommend lifestyle measures in the first instance. Statins may be offered if the QRISK is above 10% and lifestyle modification is inappropriate/ineffective.
name: Prescribe a statin
label: b
answer: no
explanation: This would not be appropriate as the patient has had no symptoms of a stroke/TIA.
name: Arrange for a carotid artery doppler
label: d
answer: no

Correct answer: a


Learning point: For patients with a QRISK score over 10%, lifestyle modifications should be prioritised to reduce stroke risk before considering pharmacological interventions.
A 45-year old man is found to be hypertensive at 144/93 mmHg during a routine consultation. He has no significant past medical history and does not take any medications.

He is worried by this measurement as his father died of a heart attack when he was in his 50s.

What is the most appropriate next step to take?

Options:
explanation: This is inappropriate as the diagnosis of hypertension (and need for treatment) should be established first. A thiazide-like diuretic would not be the first-line medication to prescribe in this case, if drug treatment is required.
name: Prescribe indapamide
label: c
answer: no
explanation: A diagnosis of hypertension should not be made based on blood pressure measurements taken during a single consultation. NICE recommend ambulatory blood pressure monitoring (or home blood pressure monitoring if this is not possible), to confirm the diagnosis in patients whose blood pressure falls between 140/90 and 180/120 mmHg.
name: Arrange for ambulatory blood pressure monitoring
label: a
answer: yes
explanation: This is inappropriate as the diagnosis of hypertension (and need for treatment) should be established first. A calcium channel blocker would not be the first-line medication to prescribe in this case, as the patient is under 55 and is not of black AFrican/African Caribbean family origin.
name: Prescribe amlodipine
label: d
answer: no
explanation: This is inappropriate as the diagnosis of hypertension (and its stage) should be established first. Secondary causes should be considered if there are signs/symptoms of an underlying condition, the patient is young (<40 years old), hypertension is severe, or if it fails to respond to drug therapy.
name: Refer for investigation of secondary hypertension
label: e
answer: no
explanation: Ramipril would be the first choice antihypertensive in this patient if treatment is warranted, as he is under 55 and is not of black African/African-Caribbean family origin. However, the diagnosis of hypertension (and its stage) should be confirmed before initiating treatment. If the patient has stage 1 hypertension, drug treatment may be started if they have other comorbidities. Otherwise, lifestyle measures may be tried first.
name: Prescribe ramipril
label: b
answer: no

Correct answer: a


Learning point: Ambulatory blood pressure monitoring, or home blood pressure monitoring if ambulatory monitoring is not possible, is used to confirm the diagnosis of hypertension in patients with blood pressure readings between 140/90 and 180/120 mmHg.
A 10-month old girl is rushed into the Emergency Department with sudden onset cough, respiratory distress, and noisy breathing. This started 20 minutes ago whilst at a playdate, and she had previously been well. On examination she is making a high-pitched inspiratory sound whilst breathing and is coughing ineffectively. There is no wheeze, rash, or angioedema. Her respiratory rate is elevated at 48 (30-40) and she is tachycardic at 152 bpm (80-140), her other vital signs are normal.

What is the most appropriate management?

Options:
explanation: The sudden onset and lack of temperature in this patient is not consistent with an infectious cause of respiratory distress. The history and examination is more consistent with an inhaled foreign body.
name: Amoxicillin
label: e
answer: no
explanation: Croup is a common cause of stridor in children and can also cause respiratory distress, this would be treated with steroids. However, the onset would not be so sudden and there is usually a history of low grade fever and coryzal illness. The history and examination is more consistent with an inhaled foreign body.
name: Dexamethasone, STAT dose
label: c
answer: no
explanation: Anaphylaxis is an important differential for respiratory distress and stridor, however is is accompanied by hypotension, and allergic symptoms such as angioedema. The history and examination is more consistent with an inhaled foreign body.
name: 150 micrograms IM adrenaline
label: d
answer: no
explanation: Bronchoconstriction can cause respiratory distress in infants, however a wheeze rather than stridor would be found on examintation. The history and examination is more consistent with an inhaled foreign body.
name: Nebulised salbutamol
label: b
answer: no
explanation: The history and examination is consistent with an inhaled foreign body. The immediate management is a rigid bronchoscopy to remove it. Foreign body inhalations are often unwitnessed in children and it is an important differential for anyone presenting with stridor and respiratory distress. Although not common practice, this question has appeared in previous writers' MLA AKT exams so we have included it in our bank.
name: Rigid bronchoscopy
label: a
answer: yes

Correct answer: a


Learning point: Inhaled foreign bodies in children can cause sudden respiratory distress and stridor, necessitating immediate rigid bronchoscopy for removal.
A 13-year-old boy presents to General Practice complaining of a sore throat for the last four days with no cough. He is able to eat and drink. He has no past medical history, is not taking any medications and has no allergies. Examination reveals no lymphadenopathy but there is swelling of the tonsils bilaterally with exudate. His observations are:

- Temperature 37.4 degrees Celsius
- Pulse 78 bpm
- Respiratory rate 15
- Oxygen saturation 98% on room air.

What is most appropriate management plan?

Options:
explanation: This is only indicated in tonsillitis that is very severe and impairs the patient's ability to swallow which is not the case here.
name: IV maintenance fluids
label: e
answer: no
explanation: This patient is presenting with features of tonsillitis. As his Centor score is only 2 (tonsillar exudate and absence of a cough) antibiotics are not warranted currently. Antibiotics are only given if the Centor score is 3 or above. Therefore, this patient requires analgesia and appropriate safety netting to return in case the symptoms do not resolve. 

[NICE guidelines](https://www.nice.org.uk/guidance/ng84/chapter/Recommendations) currently advise using the **original** Centor scoring criteria, which **does not include age.** The modified/McIsaac Centor score, which is available via MDCalc however, does include age, which is why some users may have calculated this patient's score as 3.

name: Encourage regular paracetamol and fluid intake
label: a
answer: yes
explanation: This patient has a Centor score of 2 and therefore, they do not warrant antibiotics. Oral clarithromycin would be an option if they had a Centor score of 3 or more and a penicillin allergy.
name: Oral clarithromycin
label: d
answer: no
explanation: This patient has a Centor score of 2. Therefore, antibiotics are not warranted. IV antibiotics would be used if the patient were septic or had severe consequences from the tonsillitis that impaired their ability to swallow safely.
name: IV co-amoxiclav
label: b
answer: no
explanation: This patient has a Centor score of 2 and therefore, does not warrant antibiotics. Oral penicillin V would be used if they had a Centor score of 3 or more.
name: Oral penicillin V
label: c
answer: no

Correct answer: a


Learning point: In cases of tonsillitis with a Centor score of 2, supportive care with analgesia and hydration is the primary management approach.
A 29 year old woman presents to the GP with a new rash that has developed over the past week. It started as a single patch on her thigh but over the past 48 hours the rash is now all over her back and abdomen. Other than suffering influenza 2 weeks ago, she has no other past medical history. On examination, there is a red, discoid plaque with a scaly periphery on her right thigh, with multiple smaller lesions over her abdomen and back. The rash is very itchy and it is starting to interfere with her job as a nail technician.

Given the most likely diagnosis, what is the most appropriate management?

Options:
explanation: Systemic corticosteroids are not recommended for mild, uncomplicated pityriasis rosea. Their use is generally reserved for severe or refractory cases and would be prescribed by a Dermatologist, rather than in primary care.
name: Prescribe oral prednisolone
label: d
answer: no
explanation: Topical antifungal agents like clotrimoxazole are not appropriate as pityriasis rosea is not a fungal infection. The scaly plaques may mimic tinea corporis, but the clinical presentation (herald patch, secondary rash, history of viral illness) is inconsistent with a fungal cause.
name: Prescribe topical clotrimoxazole
label: e
answer: no
explanation: This is the correct answer. The patient's presentation of a herald patch followed by smaller secondary lesions distributed in a "Christmas tree" pattern on the trunk is classic for pityriasis rosea. Common triggers for the rash include viral illnesses such as influenza. Although the condition is self-limiting and usually resolves in 6-12 weeks, the pruritus can significantly impact quality of life. NICE guidelines recommend topical corticosteroids for symptomatic relief of itching.
name: Prescribe topical mild corticosteroid
label: a
answer: yes
explanation: While pityriasis rosea is a self-limiting condition, the itching is causing functional impairment for the patient, so management should address her symptoms. Simply reassuring her without treatment would not address the impact on her job.
name: Reassure and advise the rash will resolve on its own
label: b
answer: no
explanation: Antihistamines like chlorphenamine can reduce itching, but oral sedating antihistamines are not first-line treatment, particularly when the patient reports that the rash is interfering with her ability to work. Non-sedating alternatives or topical treatment are preferable. This would have been an appropriate option if the patient complained that the itch was interfering with her sleep.
name: Prescribe oral chlorphenamine
label: c
answer: no

Correct answer: a


Learning point: NICE recommend prescribing a mild topical corticosteroid for pityriasis rosea to alleviate pruritus.
A 46-year-old female comes into the ED with a fever of 39.6 degrees. The ED doctor wants to give a targeted therapy for the specific molecules which cause this high fever.

Which molecule causes this fever and where does it act upon?

Options:
explanation: IL-6 is a pro-inflammatory cytokine which has numerous functions; one of them being to act on the hypothalamus to increase the body's temperature. It also causes the stimulation of bone marrow to produce leukocytes.
name: IL-6 on the hypothalamus
label: a
answer: yes
explanation: IL-6 is a molecule which affects the temperature of the body but it does not act on prostaglandin synthesis, this is the way that COX-inhibitors (such as aspirin) work.
name: IL-6 preventing prostaglandin synthesis
label: b
answer: no
explanation: IL-4 stimulates B and T cell proliferation, which does happen in the bone marrow. It plays no role in increasing the body's temperature.
name: IL-4 on the bone marrow
label: e
answer: no
explanation: IL-3 does not cause fever and does not act on the hypothalamus. IL-3 is used to regulate haematopoiesis.
name: IL-3 on the hypothalamus
label: d
answer: no
explanation: TNF-alpha does increase the body's temperature, however, it does not do this by acting on the skin. It does it by acting on the hypothalamus, liver and bone marrow.
name: TNF-alpha on the skin
label: c
answer: no

Correct answer: a
A 59-year-old patient is transferred to the renal ward due to a renal infarct. A biopsy is taken and looked at under the microscope. Coagulative necrosis of the kidney is seen.

Which of the following features will the pathologist find under the microscope when looking at these cells?

Options:
explanation: This occurs in a normal cell cycle during the M phase. This will not be seen in this patient as they are experiencing necrosis.
name: Metaphase of cells
label: e
answer: no
explanation: This happens in apoptosis, not necrosis. It is when the cell membrane bulges from the cell and breaks into fragments in the process of cell budding.
name: Cell blebbing
label: d
answer: no
explanation: This is when there is calcification of a tissue due to previous necrosis. As this patient has ongoing tissue necrosis, dystrophic calcification will not be present.
name: Dystrophic calcification
label: b
answer: no
explanation: Pyknosis is when the nucleus shrinks and becomes darker during the process of coagulative necrosis.
name: Pyknosis
label: a
answer: yes
explanation: This is formed when there is liquefactive necrosis and there is disintegrating tissue. As this patient has coagulative necrosis, this will not be found.
name: Loose pale zone
label: c
answer: no

Correct answer: a
During T cell maturation, what happens if there is MHCII positive selection and a low affinity for negative selection?

Options:
explanation: This happens when a T cell has MHCI positive selection, not MHCII positive selection. These cells have no affinity for self-peptides.
name: CD8+ cells are released into the periphery
label: d
answer: no
explanation: This occurs if a T cell has MHCII positive selection, however, these cells have no affinity for self-peptides. This means that they won't get activated in the periphery against our own cells and potentially cause an autoimmune disease.
name: CD4+ cells are released into the periphery
label: b
answer: no
explanation: If a T cell has MHCII positive selection, then it becomes a CD4+ cell. If there is also a low affinity for a self-peptide, this cell becomes a natural T reg cell. T reg cells have upregulated CD25.
name: CD4+ cells become natural T-reg cells
label: a
answer: yes
explanation: This happens when a T cell has MHCI positive selection, not MHCII positive selection, and also has a high affinity for self-peptides.
name: CD8+ cells undergo apoptosis
label: e
answer: no
explanation: This happens if a T cell has MHCII positive selection but has a very strong affinity for self-peptides. If this cell gets into the periphery, it will bind to self-cells, causing inflammation and damage. This is why it gets apoptosed.
name: CD4+ cells undergo apoptosis
label: c
answer: no

Correct answer: a