hllj/quesmed huggingface dataset:
An 18-year-old university student comes to the GP with a headache, fever and non-blanching rash. He is truly penicillin allergic.

What is the most appropriate course of action?

Options:
explanation: This would result in anaphylaxis which would likely worsen the clinical picture.
name: Arrange urgent hospital transfer and administer IM Benzylpenicillin
label: b
answer: no
explanation: This is not appropriate as bacterial meningitis with septicaemia is a life-threatening emergency. It is to be managed in an inpatient setting.
name: Arrange assessment in ID clinic within 24 hours
label: d
answer: no
explanation: This is not appropriate as bacterial meningitis with septicaemia is a life-threatening emergency. This may be advice given in some new suspected cases of TIA.
name: Arrange assessment in the neurology clinic within 24 hours
label: c
answer: no
explanation: Oral therapy has no role in meningitis, especially not in septicaemia. This advice is dangerous and not appropriate as this is an emergency.
name: Prescribe 7 days of oral ceftriaxone and re-book appointment for next week
label: e
answer: no
explanation: This is correct. The patient is presenting with signs and symptoms of bacterial meningitis with meningococcal septicaemia, a neurological emergency which requires ambulance transport to the nearest hospital. As he is allergic to penicillin, benzylpenicillin is not appropriate. IM Cefotaxime may be administered in GP based on local availability.
name: Arrange urgent hospital transfer
label: a
answer: yes

Correct answer: a


Learning point: Non-blanching rash, fever, and headache in a young adult may indicate meningococcal septicaemia, requiring urgent hospital transfer for immediate treatment.
A 73-year-old woman is admitted to the hospital with palpitations and new onset chest pain. She is normotensive and tachycardic on examination. An ECG demonstrates a narrow complex tachycardia of 150 with a new left bundle branch block in the inferior leads. An initial troponin I is 1200.

What is the most appropriate initial course of action?

Options:
explanation: This is correct. The patient is presenting with regular narrow complex tachycardia with adverse features, i.e. signs and symptoms of myocardial ischaemia, she therefore urgently requires DC Cardioversion.
name: Arrange urgent DC Cardioversion
label: a
answer: yes
explanation: This is not appropriate as this is used in broad complex tachycardias. In addition, the patient has adverse features.
name: Administer 300mg amiodarone
label: d
answer: no
explanation: This would be the correct second-line approach in the absence of adverse features.
name: Administer 6mg Adenosine
label: c
answer: no
explanation: This would be the correct first-line approach to acute narrow complex tachycardias in the absence of adverse features.
name: Attempt vagal manoeuvres
label: b
answer: no
explanation: The priority is proceeding down the advanced life support tachycardia algorithm, normalising the rate and then subsequently the patient will require a PCI.
name: Urgent PCI
label: e
answer: no

Correct answer: a


Learning point: In patients with narrow complex tachycardia and signs of myocardial ischaemia, urgent direct current cardioversion is often necessary.
A 58-year-old gentleman is brought into the emergency department by ambulance after losing the ability to walk over the last few days. He describes severe lower back pain, incontinence and profound leg weakness bilaterally. On examination, power in his legs is MRC Grade 1/5 bilaterally. He is known to have renal cell carcinoma and is undergoing chemotherapy.

What is the most appropriate initial course of action?

Options:
explanation: This is correct. The patient is presenting with signs and symptoms of metastatic spinal cord compression, an emergency which requires immobilisation, urgent high-dose steroids to limit oedema and urgent spinal imaging to characterise the level and nature of compression.
name: Immobilise the patient and administer 16mg of dexamethasone
label: a
answer: yes
explanation: This would certainly form part of managing this patient but is not the initial priority in the emergency department.
name: Arrange urgent oncology review
label: b
answer: no
explanation: A whole spine MRI is required urgently within 24 hours to assess for spinal cord compression and to characterise the levels of compression.
name: Request an emergency lumbar spine MRI
label: e
answer: no
explanation: Surgical options would likely be discussed in a multidisciplinary setting once imaging has characterised any spinal lesions.
name: Arrange urgent spinal surgical review
label: c
answer: no
explanation: This is not appropriate as patients with suspected cord compression must be immobilised to stabilise the spinal column after possible injury and thus prevent further spinal cord damage.
name: Encourage mobilisation and administer 8mg dexamethasone
label: d
answer: no

Correct answer: a


Learning point: Metastatic spinal cord compression presents with severe back pain, leg weakness, and incontinence, requiring urgent immobilisation and high-dose steroids.
A 28-year-old gentleman with poorly controlled epilepsy is brought into hospital by his family following a collapse at home. He was previously last seen by his neighbour a day ago.

Bloods demonstrate a Sodium of 134mmol (135-145), K 6.9mmol (3.5-5.2), Urea 19mmol (1.8-7), Creatinine 630μmol (59 - 104) and an adjusted calcium of 1.84mmol (2.2-2.6).

What is the most appropriate initial course of action?

Options:
explanation: This may be required in advanced refractory cases but is not immediately indicated at present. Indications for acute dialysis include refractory hyperkalaemia, fluid overload, toxin ingestion, and uraemia.
name: Arrange urgent haemodialysis
label: b
answer: no
explanation: This is likely to form part of the initial management of his hyperkalaemia but the priority is protecting the heart and administering plenty of fluids to improve the AKI and rhabdomyolysis.
name: Administer insulin dextrose
label: e
answer: no
explanation: This is correct. The patient is presenting with signs and symptoms of rhabdomyolysis as suggested by a long lie, hypocalcaemia and severe stage 3 acute kidney injury due to the release of myoglobin from dying muscle cells. Calcium gluconate protects the heart and stabilises the myocardium given the hyperkalaemia.
name: Aggressive fluid resuscitation and calcium gluconate
label: a
answer: yes
explanation: This may play a part later on in optimising AEDs to reduce the frequency of seizures (and possible subsequent long lies).
name: Arrange urgent nephrology review
label: c
answer: no
explanation: This is not appropriate as this patient is very unwell with a stage 3 AKI and severe hyperkalaemia and he could go into cardiac arrest without appropriate treatment.
name: Discharge with outpatient nephrology review
label: d
answer: no

Correct answer: a


Learning point: In rhabdomyolysis, aggressive fluid resuscitation and calcium gluconate are crucial to manage hyperkalaemia and protect cardiac function.
A 47-year-old gentleman attends the GP with burning pain on urination and an increased frequency of urination for the last two days. Urine dip is strongly positive for leucocytes and nitrites. He has rheumatoid arthritis and takes methotrexate.

What is the most appropriate course of action?

Options:
explanation: This should be avoided as the patient is on methotrexate. Combining trimethoprim and methotrexate increases the risk of haematological side effects (sometimes fatal).
name: Trimethoprim for 3 days
label: c
answer: no
explanation: In men, the recommended treatment is 7 days of oral nitrofurantoin. In non-pregnant women, the duration is a 3-day course.
name: Nitrofurantoin for 3 days
label: b
answer: no
explanation: This is not needed at present with no concerning features. This can safely be managed in the community.
name: Admit to hospital
label: e
answer: no
explanation: This should be avoided as the patient is on methotrexate. Combining trimethoprim and methotrexate increases the risk of haematological side effects (sometimes fatal).
name: Trimethoprim for 7 days
label: d
answer: no
explanation: This is correct. The patient is presenting with signs and symptoms of urinary tract infection. In men, the recommended treatment is 7 days of oral nitrofurantoin, trimethoprim or amoxicillin.
name: Nitrofurantoin for 7 days
label: a
answer: yes

Correct answer: a


Learning point: Urinary tract infections in men typically require a 7-day course of antibiotics, such as nitrofurantoin, trimethoprim, or amoxicillin.
A 25-year-old female presents to the emergency department after collapsing during a football game. She is currently haemodynamically stable. Her father passed away at the age of 42 after a collapse.

Which of the following investigations would confirm the diagnosis?

Options:
explanation: The vignette suggests a diagnosis of hypertrophic cardiomyopathy and chest X-ray does not play any role in its diagnosis.
name: Chest X-ray
label: d
answer: no
explanation: Myocardial scintigraphy is used to diagnose coronary artery disease (CAD). The purpose of myocardial scintigraphy is to detect myocardial ischaemia. It does not play any role in diagnosing HOCM.
name: Myocardial Scintography
label: e
answer: no
explanation: Holter monitoring is an important investigation that is warranted when arrhythmia is suspected but it cannot confirm the diagnosis of HOCM.
name: Holter monitoring
label: b
answer: no
explanation: ECG would be the first line of investigation in the aforementioned scenario and even though there are ECG changes associated with HOCM such as septal Q waves (deep narrow dagger-like Q waves seen in lateral and inferior leads), it cannot confirm the given diagnosis and further investigation is imperative.
name: ECG
label: c
answer: no
explanation: Cardiac MRI helps in the diagnosis of hypertrophic cardiomyopathy (HOCM) by identifying areas of hypertrophy, which are often not well visualised by echocardiography, providing more accurate wall thickness measurements and differentiating HOCM from other causes of left ventricular hypertrophy.
name: Cardiac MRI
label: a
answer: yes

Correct answer: a


Learning point: Cardiac MRI is essential for diagnosing hypertrophic cardiomyopathy by accurately assessing wall thickness and identifying hypertrophy not visible on echocardiography.
A 55-year-old woman presents to the GP clinic with pain on passing urine for the past three days. She is otherwise well in herself. She has a past medical history of G6PD deficiency and rheumatoid arthritis, for which she takes methotrexate. She does not take any other medication and has no known drug allergies.

She has a temperature of 36.5 degrees Celsius, pulse 65 bpm, BP 125/86 mmHg.

Urine dipstick shows 2+ leukocytes and 3+ nitrites.

The GP decides to prescribe a course of antibiotics for this patient. Which is the most appropriate regimen to prescribe?

Options:
explanation: This would be appropriate for patients with suspected urosepsis. This patient does not present with any features of sepsis e.g. hypotension and therefore does not require a stat dose of gentamicin.
name: STAT dose IV gentamicin 5mg/kg
label: e
answer: no
explanation: The BNF advises that ciprofloxacin be used with caution in patients with G6PD deficiency. Furthermore, this medication would be more appropriate for patients with acute pyelonephritis managed in the community. The lack of additional symptoms in this patient i.e. flank pain or features of sepsis makes acute pyelonephritis unlikely. 
name: PO Ciprofloxacin 1g for seven days
label: d
answer: no
explanation: According to [NICE CKS guidelines](https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/management/acute-uti-no-visible-haematuria-not-pregnant-or-catheterized/), this is the second-line antibiotic regimen where nitrofurantoin and trimethoprim are contraindicated (see other explanations), or where there is no improvement in symptoms.
name: PO Pivmecillinam 400mg initial dose, then 200 mg TDS for three days
label: a
answer: yes
explanation: Methotrexate is listed as a severe interaction with trimethoprim in the BNF, due to the increased risk of haematological side effects that can be fatal. This is a very important drug interaction to remember.
name: PO Trimethoprim 200mg BD for three days
label: c
answer: no
explanation: G6PD deficiency is listed as a contra-indication to nitrofurantoin in the BNF.
name: PO Nitrofurantoin 100mg BD for three days
label: b
answer: no

Correct answer: a


Learning point: In women with urinary tract infections, pivmecillinam is a suitable second-line antibiotic when nitrofurantoin and trimethoprim are contraindicated.
A 65-year-old female has a 6-month history of feeling bloated after meals. She has lost 6kg in this period due to decreased appetite and has also experienced fluctuating diarrhoea and constipation. She has a past medical history of hypercholesterolaemia and has two children, born via uncomplicated vaginal delivery. Her last menstrual period was 10 years ago.

On examination, her abdomen is soft and non-tender, with no evidence of obvious distension, ascites or any palpable masses.

What is the most appropriate initial investigation?

Options:
explanation: Whilst it would be important to investigate the possibility of Coeliac disease if the CA-125 was normal, Ovarian cancer should be ruled out urgently before investigating other differentials of these symptoms.
name: Arrange IgA TTG and total IgA antibody testing
label: d
answer: no
explanation: These symptoms in a woman >50 years old are concerning for ovarian cancer. NICE recommends measuring a serum CA-125 if an abdominal examination is normal. If the abdominal examination was abnormal, an urgent 2-week wait referral should be carried out.
name: Measure serum CA-125
label: a
answer: yes
explanation: Whilst early satiety and bloating can be associated with gastroparesis which is strongly linked to diabetes mellitus, the fluctuating diarrhoea and constipation, in conjunction with weight loss are more concerning for ovarian cancer.
name: Arrange HbA1c testing
label: e
answer: no
explanation: This should only be done once the CA-125 is found to be raised. If the initial abdominal examination is abnormal an urgent 2-week wait referral should be carried out.
name: Arrange an urgent ultrasound of the abdomen and pelvis
label: b
answer: no
explanation: Whilst fluctuating diarrhoea and constipation in conjunction with bloating can be seen in IBS, it is vital to rule out any other conditions before this is diagnosed. Specifically, any post-menopausal female with IBS-like symptoms should raise suspicion of ovarian cancer
name: No investigation is required, advise following a low FODMAP diet
label: c
answer: no

Correct answer: a


Learning point: In women over 50 with unexplained abdominal symptoms, measuring serum CA-125 is essential for evaluating potential ovarian cancer.
A 62-year-old male has an 8-month history of cough, haemoptysis and weight loss. He has a background of COPD and a 45-pack-year smoking history. Due to these symptoms, he is referred urgently under the 2-week wait cancer pathway and is subsequently diagnosed with adenocarcinoma of the lung. The patient would like to find out more about his new diagnosis as he is confused by the information he has read online.

Which of the following statements about adenocarcinoma of the lung is the correct advice to provide?

Options:
explanation: This is incorrect as adenocarcinomas are a type of non-small cell lung cancer rather than small-cell lung cancer.
name: Lung adenocarcinomas are a type of small-cell lung cancer
label: b
answer: no
explanation: Adenocarcinomas are the most common type of non-small lung cancer and are more prevalent than squamous cell and large cell lung cancers, which together are the three main types of non-small cell lung cancer.
name: Adenocarcinomas are the most common type of non-small cell lung cancers
label: a
answer: yes
explanation: This is incorrect as a smoking history increases the risk of developing non-small cell lung cancers, although some patients with no smoking history still can develop non-small cell lung cancer.
name: A smoking history does not increase the risk of developing adenocarcinoma of the lung
label: e
answer: no
explanation: This is incorrect as small cell lung cancers are classed as neuroendocrine tumours, adenocarcinomas are a type of non-small cell lung cancer.
name: Lung adenocarcinomas are classed as neuroendocrine tumours
label: c
answer: no
explanation: This is incorrect as it describes squamous cell carcinoma, which arises from the flat cells that line the surface of the airways. Adenocarcinomas arise from mucus-producing glands.
name: Lung adenocarcinomas arise from the flat cells that cover the surface of the airways
label: d
answer: no

Correct answer: a


Learning point: Adenocarcinoma is the most common type of non-small cell lung cancer, more common than squamous and large cell types.
A 17-year-old female has recently been diagnosed with acute lymphoblastic leukaemia (ALL) after a 4-week history of extreme fatigue, easy bruising and lymphadenopathy. She is due to undergo induction chemotherapy for her ALL and is concerned about the possibility of nausea and vomiting. The patient would like to know if it is possible to avoid these symptoms and asks if anything increases the risk of nausea and vomiting related to chemotherapy.

Which of the following is a risk factor for chemotherapy-related nausea and vomiting?

Options:
explanation: Patients are more likely to experience chemotherapy-related nausea and vomiting in the first cycle of chemotherapy.
name: Undergoing a later cycle of a chemotherapy regimen
label: c
answer: no
explanation: Younger patients are at a greater risk of chemotherapy-related nausea and vomiting.
name: Younger age
label: a
answer: yes
explanation: Whilst previously experiencing severe morning sickness is a risk factor for chemotherapy-related nausea and vomiting, history of pregnancy alone is not itself a risk factor.
name: History of pregnancy
label: e
answer: no
explanation: Female patients are at higher risk of chemotherapy-related nausea and vomiting than male patients.
name: Male sex
label: b
answer: no
explanation: This is incorrect, as these medications are used to treat chemotherapy-related nausea and vomiting.
name: Use of anti-emetic medications during chemotherapy
label: d
answer: no

Correct answer: a


Learning point: Younger patients undergoing chemotherapy have an increased risk of experiencing nausea and vomiting.
A 57-year-old male patient has severe malnutrition. He has a history of alcoholism and drinks 1 litre of vodka a day, with minimal solid food intake. He is treated for alcohol withdrawal with a weaning regimen of oxazepam and vitamin B supplementation. He is reviewed by dieticians who suggest controlled NG feed regimens and daily blood monitoring whilst the patient is at risk of re-feeding syndrome. The patient had an NG tube placed but the staff were unable to obtain aspirate at the time of insertion. A CXR is taken to confirm its position. The X-ray is seen below:

[lightgallery]

Based on the CXR, what is the most appropriate course of action?

Options:
explanation: The NG tube is sited in the right lower lobe of the lung. Waiting for a day would risk serious consequences without any benefit, as the NG tube will not re-site itself. The appropriate choice in this scenario is to remove the NG tube immediately.
name: Repeat the CXR the next day before starting the feed
label: e
answer: no
explanation: An NG tube should go down the midline, along the route of the oesophagus and bisect the carina. It should then cross the diaphragm and have the tip visible below the left hemidiaphragm (i.e. in the stomach). In this X-ray the NG tube does not bisect the carina and the tip is seen in the right lower lobe of the lung. It needs to be removed immediately before causing any further lung damage and before anything is given via the NG.
name: Remove the NG tube
label: a
answer: yes
explanation: This is typically used as a technique to try and obtain NG tube aspirate. In this case, the CXR shows the NG tube is already incorrectly sited and trying to obtain aspirate would therefore be limited in use.
name: Turn the patient on their left side to try and obtain aspirate
label: d
answer: no
explanation: This would be incredibly dangerous as the NG tube is seen in the right lower lobe of the lung. Commencing feeding in this scenario could be fatal.
name: Commence feeding
label: b
answer: no
explanation: This is typically used as a technique to try and obtain NG tube aspirate. In this case, the CXR shows the NG tube is incorrectly sited and trying to obtain aspirate would therefore be limited in use.
name: Inject 10ml of air into the tube
label: c
answer: no

Correct answer: a


Learning point: An incorrectly positioned nasogastric tube can lead to serious complications, including aspiration pneumonia, necessitating immediate removal.
A 57-year-old female is scheduled for an elective laparoscopic cholecystectomy at 12:00 PM. She attends her pre-operative assessment at 8:00 AM, at which she reveals she drank black coffee at 7:00 AM the same morning. She apologises and states she was aware she needed to remain 'nil by mouth' and is now concerned that the operation will need to be cancelled.

What is the most appropriate course of action to take?

Options:
explanation: The patient followed fasting rules correctly (no solid food for at least 6 hours before the operation, clear fluids up to 2 hours before the operation) and therefore there is no reason to delay the operation.
name: Delay the operation until 6:00 PM
label: b
answer: no
explanation: Fasting rules outline that a patient should not eat for at least 6 hours before the operation but can have clear fluids (water, black tea/coffee) up to 2 hours before the operation. As the patient had clear fluids 5 hours before the operation, she is completely safe to proceed.
name: Continue with the operation as planned
label: a
answer: yes
explanation: This would be incorrect as solid food should be consumed at the latest 6 hours before the operation.
name: Encourage the patient to keep eating and drinking up until 10:00 AM
label: e
answer: no
explanation: The patient followed fasting rules correctly (no solid food for at least 6 hours before the operation, clear fluids up to 2 hours before the operation) and therefore there is no reason to delay the operation.
name: Delay the operation until the following morning
label: c
answer: no
explanation: This would be incorrect as clear fluids can be consumed up until 2 hours before the operation, this would only allow 1.5 hours after consumption of clear fluids.
name: Bring the operation forward to 8:30 AM
label: d
answer: no

Correct answer: a


Learning point: Patients can consume clear fluids, such as black coffee, up to two hours before elective surgery without increasing aspiration risk.