hllj/quesmed huggingface dataset:
A 76-year-old gentleman with metastatic colon cancer is dying in the oncology ward and in his last few days of life. He has poorly controlled type 2 diabetes mellitus and takes multiple medications including insulin and asks if his diabetic medications can be stopped.

What is the most appropriate management?

Options:
explanation: This is not appropriate or required here. Variable rate infusion is typically used peri-operatively or in medical patients who are not eating and drinking with erratic blood sugars.
name: Switch to variable rate insulin infusion
label: e
answer: no
explanation: Insulin may need to be continued depending on his blood sugar control, this should be explored as opposed to immediately stopped.
name: Stop all diabetic medications
label: b
answer: no
explanation: This is correct. The guidance related to diabetic management in end-of-life is primarily focused on symptom control as opposed to preventing long-term complications. Therefore, oral hypoglycaemics can be stopped and stopping insulin should be considered based on how erratic the control is. It is important to avoid symptomatic hyperglycaemia in end-of-life patients as this can be bothersome.
name: Stop all oral hypoglycaemics and consider whether insulin can be stopped
label: a
answer: yes
explanation: It is important to endeavour to honour patient wishes when the guidelines allow you to, particularly in palliative patients at the end of their life.
name: Continue all diabetic medications
label: d
answer: no
explanation: This is not in keeping with guidance related to diabetes management at the end of life which advises stopping oral hypoglycaemics.
name: Stop insulin but continue oral hypoglycaemics
label: c
answer: no

Correct answer: a


Learning point: In palliative care, it is often recommended to stop all oral hypoglycemics and consider whether insulin therapy can be discontinued, as the focus shifts to comfort and quality of life rather than strict blood glucose control.
A 79-year-old man visits his general practitioner with fevers and significant weight loss after returning from a prolonged stay in Asia. He reports that he was diagnosed with a type of 'blood cancer' three years ago after a routine blood test, but has been very well and has not received any treatment for his condition.

On examination, he looks unwell and is cachectic. Firm, rubbery lymph nodes are palpated in the mandible and his spleen is enlarged.

Which haematological malignancy is he most likely to have been initially diagnosed with?

Options:
explanation: This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to non-Hodgkin lymphoma (typically diffuse large B cell lymphoma). The history of being diagnosed with a haematological malignancy incidentally that was not actively treated is not typical of an initial diagnosis of acute leukaemia.
name: Acute Lymphocytic Leukaemia (ALL)
label: c
answer: no
explanation: While hairy cell leukaemia is indolent and is usually not actively treated, it rarely transforms into an acute lymphoma/leukaemia. This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to a non-Hodgkin lymphoma (typically diffuse large B cell lymphoma).
name: Hairy cell leukaemia
label: e
answer: no
explanation: This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to a non-Hodgkin lymphoma (typically diffuse large B cell lymphoma). The history of being diagnosed with a haematological malignancy incidentally that was not actively treated is not typical of an initial diagnosis of acute leukaemia.
name: Acute Myeloid Leukaemia (AML)
label: d
answer: no
explanation: This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to a non-Hodgkin lymphoma (typically diffuse large B cell lymphoma). This patient requires hospital admission and treatment with chemotherapy.
name: Chronic Lymphocytic Leukaemia (CLL)
label: a
answer: yes
explanation: While CML can enter the blast phase and transform into acute myeloid leukaemia, it would not be typical for a patient with CML to receive no treatment; a JAK inhibitor such as imatinib would usually be prescribed. This presentation of an indolent, incidentally-diagnosed haematological malignancy presenting with an acute illness is characteristic of Richter's transformation of CLL to a non-Hodgkin lymphoma (typically diffuse large B cell lymphoma). This patient requires hospital admission and treatment with chemotherapy.
name: Chronic Myeloid Leukaemia (CML)
label: b
answer: no

Correct answer: a


Learning point: Chronic Lymphocytic Leukaemia can transform into aggressive non-Hodgkin lymphoma, presenting with acute symptoms like fever and weight loss.
A 43-year-old female is seen in an outpatient clinic for a follow-up of her alcohol-related liver disease. She reports being abstinent from alcohol for three months and has not experienced any episodes of decompensation. However, she reports feeling tired all the time.

Examination of her gastrointestinal system is normal. Routine blood tests show:

|                |         |                   |
| -------------- | :-------: | --------------- |
| Haemoglobin    |        98 g/L   | (M) 130 - 170, (F) 115 - 155 |
| White Cell Count   |     4.3 x10<sup>9</sup>/L   | 3.0 - 10.0      |
| Platelets          |     72 x10<sup>9</sup>/L            | 150 - 400     |
| Mean Cell Volume (MCV)     | 112 fL                  | 80 - 96       |

|                    |    |                  |
| --------------------------- | :-------: | ------------------------------ |
| Serum Vitamin B12           | 50 ng/L            | 160 - 925              |
| Serum Folate                | 1.9 μg/L            | (3 - 15                 |
| Ferritin                    | 173 μg/L            | 12 - 200                  |

What is the most appropriate next step in management?

Options:
explanation: This patient has a macrocytic anaemia that is likely multifactorial given her B12 deficiency, folate deficiency, history of alcohol use, and liver disease. She requires correction of her B12 and folate levels to help with her symptoms. B12 should be repleted before folic acid is administered due to the small risk of precipitating subacute combined degeneration of the spinal cord or worsening peripheral neuropathy.
name: Start B12 supplements
label: a
answer: yes
explanation: Macrocytosis and haematinic deficiencies are common in gastroenterology/hepatology settings. Unless the patient fails to respond to therapy or there are other concerns, a haematology referral is not warranted.
name: Refer to haematology
label: e
answer: no
explanation: This may be a useful step in the holistic management of her chronic liver disease, but is not the most appropriate next step.
name: Refer to dieticians
label: d
answer: no
explanation: While the patient is anaemic, she has multifactorial macrocytic anaemia and normal ferritin levels. There is currently no evidence of iron deficiency. She should be prescribed vitamin B12, followed by folic acid.
name: Start iron supplements
label: c
answer: no
explanation: This patient has a macrocytic anaemia that is likely multifactorial given her B12 deficiency, folate deficiency, history of alcohol use, and liver disease. She requires correction of her B12 and folate levels to help with her symptoms. B12 should be repleted before folic acid is administered due to the small risk of precipitating subacute combined degeneration of the spinal cord or worsening peripheral neuropathy.
name: Start folate supplements
label: b
answer: no

Correct answer: a


Learning point: Macrocytic anaemia in patients with alcohol-related liver disease often indicates deficiencies in vitamin B12 and folate, necessitating appropriate supplementation.
An 82-year-old man is admitted to hospital with right upper quadrant pain, jaundice, and fevers. A CT abdomen shows evidence of cholangitis and he is admitted for antibiotics and a planned ERCP.

Routine clotting studies show a mildly prolonged prothrombin time and mild thrombocytopenia.

Over the day, he becomes profoundly septic and it is noted that he is bleeding from his cannula site. Repeat blood tests show worsening thrombocytopenia and coagulopathy, as well as new anaemia.

What is the most likely diagnosis?

Options:
explanation: Acute cholangitis may rarely cause a mild coagulopathy due to cholestasis, however, the history of an infection causing sepsis and profound coagulopathy is more in keeping with DIC.
name: Liver dysfunction
label: e
answer: no
explanation: HELLP (Haemolysis, Elevated Liver enzymes and Low Platelets) syndrome is a life-threatening pregnancy complication that may occur in the late second/third trimesters of pregnancy. It is often associated with pre-eclampsia/eclampsia.
name: HELLP syndrome
label: d
answer: no
explanation: Evolving coagulopathy and oozing at line sites/mucosal bleeding in the context of an acute illness should raise suspicions of DIC. A blood film, d-dimer, and fibrinogen levels would be useful to confirm the diagnosis.
name: Disseminated intravascular coagulation (DIC)
label: a
answer: yes
explanation: HUS causes microangiopathic haemolytic anaemia like DIC, however, it often presents after infection with a Shiga-toxin-associated E. coli strain. Patients with HUS may present with bloody diarrhoea. Sepsis followed by coagulopathy is more typical of DIC than HUS.
name: Haemolytic uraemic syndrome (HUS)
label: c
answer: no
explanation: TTP causes microangiopathic haemolytic anaemia like DIC, however it often presents with renal dysfunction and neurological signs. Intercurrent sepsis makes DIC a more likely diagnosis. Further, deranged PT/APTT are more commonly seen in DIC than TTP.
name: Thrombotic thrombocytopenic purpura (TTP)
label: b
answer: no

Correct answer: a


Learning point: Disseminated intravascular coagulation (DIC) presents with coagulopathy and bleeding in the context of severe systemic illness.
A 14-year-old girl is sent to the emergency department by her GP with a continuous nosebleed. She is advised to apply pressure on the way to the hospital and an ice pack is also applied in the waiting area, but she is still bleeding 30 minutes later.

She looks well and observations are normal. She has no past medical history, and takes no regular medications.

On examination with a nasal speculum, a bleeding point cannot be confidently identified.

What is the most appropriate next step to take?

Options:
explanation: As direct pressure and ice packs have not resolved the bleeding, the next step would be to insert a nasal pack to tamponade the bleeding. As a bleeding point cannot be visualised, direct cautery is not appropriate. If packing fails to stem the bleeding or the patient becomes unstable, more invasive management (e.g. arterial ligation/embolisation) may be required.
name: Anterior nasal packing
label: a
answer: yes
explanation: As direct pressure and ice packs have not resolved the bleeding, the next step would be to insert a nasal pack to tamponade the bleeding. If packing fails to stem the bleeding or the patient becomes unstable, more invasive management (e.g. arterial ligation/embolisation) may be required.
name: Embolisation of the sphenopalatine artery
label: b
answer: no
explanation: As no bleeding point can be identified, there is currently no target to cauterise. A nasal pack should be inserted to tamponade the bleeding.
name: Silver nitrate cautery
label: c
answer: no
explanation: As direct pressure and ice packs have not resolved the bleeding, the next step would be to insert a nasal pack to tamponade the bleeding. If packing fails to stem the bleeding or the patient becomes unstable, more invasive management (e.g. arterial ligation/embolisation) may be required.
name: Ligation of the anterior ethmoidal artery
label: e
answer: no
explanation: This is unlikely to help as she has already applied pressure for over 30 minutes. A nasal pack should be inserted to tamponade the bleeding.
name: Apply increased pressure for 30 minutes
label: d
answer: no

Correct answer: a


Learning point: In cases of persistent epistaxis where the bleeding point is not visible, anterior nasal packing is the appropriate management step.
A 46-year-old man is referred to the emergency ENT clinic as he has been struggling to hear in his right ear for the past 3 days. He has no past medical history and takes no medications. He cannot think of any events that have precipitated this episode.

A full neurological examination and otoscopy are normal. He does not report any other symptoms.

The results of the initial screening are as follows:

Weber's test: Lateralises to the left ear
Rinne's test: Positive (air conduction > bone conduction) bilaterally.

What is the most appropriate next step in management?

Options:
explanation: While imaging is required to exclude a more sinister cause of sensorineural hearing loss, the most appropriate modality would be an MRI. In the first instance, however, steroids should be prescribed, and this is therefore the most appropriate first step to take.
name: Arrange a CT scan of the brain
label: c
answer: no
explanation: This gentleman's clinical presentation and examination findings are consistent with sudden idiopathic sensorineural hearing loss. Imaging (an MRI of the cerebellopontine angle/acoustic meatus) should be undertaken to exclude a more serious pathology e.g. a space-occupying mass, however, the most appropriate next step is to initiate high-dose oral steroids as arranging a scan can take some time.
name: Arrange an MRI scan of the cerebellopontine angle and auditory meatus
label: d
answer: no
explanation: This is inappropriate; the patient requires further work-up and management of his sensorineural hearing loss.
name: Discharge with reassurance and follow-up
label: b
answer: no
explanation: This gentleman's clinical presentation and examination findings are consistent with sudden idiopathic sensorineural hearing loss. Imaging (an MRI of the cerebellopontine angle/acoustic meatus) should be undertaken to exclude a more serious pathology e.g. a mass, however the most appropriate next step is to initiate high-dose oral steroids.
name: Oral prednisolone
label: a
answer: yes
explanation: Pure tone audiometry would be more appropriate to assess this patient's hearing quantitatively; the otoacoustic emissions test is usually used in newborn hearing screening. In this scenario, the patient is likely suffering from idiopathic sudden-onset sensorineural hearing loss, for which steroids should be commenced.
name: Arrange an otoacoustic emissions test
label: e
answer: no

Correct answer: a


Learning point: First-line treatment options for idiopathic sudden idiopathic sensorineural hearing loss can include oral steroids, intra-tympanic steroid injections or a combination of both.
An 89-year-old patient with a history of Alzheimer's dementia is admitted to hospital after sustaining a fall at home. A trauma-protocol CT scan shows a displaced left humeral fracture.

The patient is adamant that they do not want to be operated on despite the orthopaedic team's recommendations. They express a strong wish for conservative management and appear to understand the consequences of not having surgery.

What is the most appropriate next step to take?

Options:
explanation: The patient appears to have the capacity to make decisions in this case. Seeking consent from the patient's next of kin is not the best course of action in this case.
name: Seek consent to proceed from the patient's next of kin
label: c
answer: no
explanation: This may be required if there are disagreements regarding whether the patient has capacity, but is unlikely to be the next best step to take.
name: Seek advice from the hospital's legal department
label: e
answer: no
explanation: While this would be useful to establish, a lasting power of attorney's decision-making role is only invoked if a patient lacks the capacity to make decisions about their medical treatment. In this case, the patient appears to have the capacity to refuse surgery, so the best course of action is to respect their wishes.
name: Establish if a lasting power of attorney has been appointed
label: d
answer: no
explanation: A DOLS application is required when a patient who lacks capacity is being deprived of their liberty (e.g. kept in hospital, subjected to 1-1 nursing or physical restraints) in their best interests. This is not applicable in this case.
name: Apply for a deprivation of liberty safeguard (DOLS)
label: b
answer: no
explanation: Despite the patient's Alzheimer's disease, the question stem suggests they have the capacity to decide to not undergo surgery. A detailed assessment would of course be required to confirm this is the case. It is important to remember that capacity is decision and time-specific and that a disorder of the mind/brain does not automatically mean a patient lacks capacity.
name: Respect the patient's choice
label: a
answer: yes

Correct answer: a


Learning point: Respecting a patient's autonomy is crucial, even in the presence of cognitive impairment, provided they demonstrate understanding and capacity regarding their treatment choices.
A 14-year-old girl visits her GP complaining of heavy, painful periods. She is otherwise well with no past medical or surgical history.

On examination, the GP is concerned that there are signs of previous female genital mutilation (FGM).

Which statement best describes the current legal position on disclosing this information to the police?

Options:
explanation: Since 2015, there has been a legal duty for healthcare professionals to report suspected cases of FGM in girls under the age of 18 to the police for further investigation within 28 days of discovery. This should, of course, be done sensitively, and safeguarding processes (if relevant) should also be commenced.
name: The doctor has a legal duty to inform the police of their findings
label: a
answer: yes
explanation: When considering whether to breach confidentiality, it is always best to discuss reasoning with the patient and gain consent to do so. However, there is a legal duty for doctors to disclose possible FGM to the police, and they do not need consent to do so.
name: The doctor must have the patient's consent to disclose this information to the police
label: d
answer: no
explanation: This is incorrect. While there would be a plausible defence to disclose this information (e.g. protecting any siblings of the patient), since 2015, there has been a legal duty for healthcare professionals to report suspected cases of FGM in girls under the age of 18 to the police for further investigation within 28 days of discovery. This should, of course, be done sensitively, and safeguarding processes (if relevant) should also be commenced.
name: The doctor does not have a legal duty to inform the police but should do so as they have a legal defence
label: b
answer: no
explanation: When considering whether to breach confidentiality, it is always best to discuss reasoning with the patient (and their families if appropriate/if there are no safeguarding concerns) and gain consent to do so. However, there is a legal duty for doctors to disclose possible FGM to the police, and they do not need consent to do so.
name: The doctor must have the patient's parent/guardian's consent to disclose this information to the police
label: e
answer: no
explanation: This is incorrect; since 2015, there has been a legal duty for healthcare professionals to report suspected cases of FGM in girls under the age of 18 to the police for further investigation within 28 days of discovery. This should, of course, be done sensitively, and safeguarding processes (if relevant) should also be commenced.
name: The doctor should not provide the requested information to the police as there is no legal duty to do so
label: c
answer: no

Correct answer: a


Learning point: Healthcare professionals must report suspected cases of female genital mutilation in under-18s to the police within 28 days of discovery.
A 78-year-old man is referred to the acute medical unit with a red, warm, swollen right knee. He is systemically well; observations and blood test results are all within normal limits.

An x-ray taken of the knee is shown below:

[lightgallery]

Which of the following conditions is a risk factor for this presentation?

Options:
explanation: This knee radiograph shows chondrocalcinosis. The likely diagnosis given this finding and the clinical information given is pseudogout (calcium pyrophosphate dihydrate crystal deposition). Osteoarthritis is a risk factor for this condition. Other risk factors include hyperparathyroidism, haemochromatosis, hypercalcaemia, and osteoporosis.
name: Osteoarthritis of the knee
label: a
answer: yes
explanation: The most likely diagnosis is pseudogout given the clinical history and chondrocalcinosis evident on the knee radiograph. Kidney disease is more of a risk factor for gout (due to reduced urate clearance) than pseudogout.
name: Chronic kidney disease
label: b
answer: no
explanation: The most likely diagnosis is pseudogout given the clinical history and chondrocalcinosis evident on the knee radiograph. Thiazide use is more of a risk factor for gout (due to reduced urate clearance) than pseudogout.
name: Thiazide diuretic use
label: d
answer: no
explanation: The most likely diagnosis is pseudogout given the clinical history and chondrocalcinosis evident on the knee radiograph. NSAIDs are used to treat pseudogout and are not a risk factor for developing the condition.
name: NSAID use
label: e
answer: no
explanation: The most likely diagnosis is pseudogout given the clinical history and chondrocalcinosis evident on the knee radiograph. Increased, rather than decreased, levels of vitamin D are a risk factor for ectopic calcium deposition.
name: Hypovitaminosis D
label: c
answer: no

Correct answer: a


Learning point: Osteoarthritis increases the risk of pseudogout due to calcium pyrophosphate crystal deposition in damaged/ degenerated joints.
A 32-year-old woman is referred to the urgent rheumatology clinic with dactylitis and a one month history of early-morning joint pain. X-rays of the hands are performed, which show:

[lightgallery]

Given the most likely diagnosis, which other medical condition is she most likely to have?

Options:
explanation: While antiphospholipid syndrome can be associated with inflammatory arthropathies and other autoimmune conditions, this is not the most likely association of the options presented.
name: Antiphospholipid syndrome
label: c
answer: no
explanation: This patient's radiograph shows the classic 'pencil in cup' appearance, which along with the dactylitis and involvement of the distal interphalangeal joints suggests a diagnosis of psoriatic arthritis. Rheumatoid arthritis would usually show features of proximal interphalangeal and metacarpophalangeal joint (especially those of the index and middle fingers) involvement.
name: Rheumatoid arthritis
label: b
answer: no
explanation: This patient's radiograph shows the classic 'pencil in cup' appearance, which along with the dactylitis and involvement of the distal interphalangeal joints suggests a diagnosis of psoriatic arthritis, which may be associated with cutaneous psoriasis.
name: Psoriasis
label: a
answer: yes
explanation: While lupus can be associated with inflammatory arthropathies and other autoimmune conditions, this is not the most likely association of the options presented. Psoriasis would be a more likely association.
name: Systemic lupus erythematosus
label: e
answer: no
explanation: While some patients with psoriatic arthritis may develop Sjögren's syndrome, this is not the most likely association of the options presented. Psoriasis would be a more likely association.
name: Sjögren's syndrome
label: d
answer: no

Correct answer: a


Learning point: Psoriatic arthritis often presents with dactylitis and distal interphalangeal joint involvement, commonly associated with cutaneous psoriasis.