hllj/quesmed huggingface dataset:
A 19-year-old female with a background of anorexia nervosa is brought to the emergency department by her mother, who is concerned about her physical health. Her mother reports that she hasn't eaten anything in 5 days. On examination, she appears cachectic, has a heart rate of 55 beats per minute, and a blood pressure of 85/50mmHg. The patient refuses to be admitted to hospital.

The multi-disciplinary team are all in agreement that this patient should be admitted for artificial feeding. Under which section of the Mental Health Act should this be done?

Options:
explanation: Both section 2 and section 3 of the Mental Health Act can be used to treat a patient against their wishes
name: Section 2
label: a
answer: yes
explanation: Section 135 allows police to break into a property to take a person to a place of safety so that a mental health assessment can be carried out
name: Section 135
label: e
answer: no
explanation: Section 4 of the MHA is used in an emergency by a GP or Approved Mental Health Professional (AMHP) to allow 72 hours of assessment. It can later be switched to section 2 when admitted to hospital or later in admission at the end of the 72-hour window. It cannot be used to treat patients against their wishes
name: Section 4
label: b
answer: no
explanation: Section 5(2) gives doctors the ability to detain patients in hospital for up to 72 hours until a further assessment can be carried out to determine if further detention is necessary. It cannot be used to treat patients against their wishes
name: Section 5(2)
label: c
answer: no
explanation: Section 5(4) allows a qualified nurse to detain a patient in hospital for up to 6 hours until a fully registered doctor can assess the need for further detention. It cannot be used to treat patients against their wishes
name: Section 5(4)
label: d
answer: no

Correct answer: a


Learning point: Section 2 of the Mental Health Act allows detention for up to 28 days for the assessment of a person with a mental disorder, requiring two doctors' recommendations and an AMHP's involvement.
A 45-year-old male attends his GP. He is currently being investigated for a seizure that he had five days ago. He works as a lorry driver. He has been informed that he should notify the DVLA and stop driving. However, at his GP practice, he discloses that he has continued to drive and refuses to inform the DVLA.

Which of the following is the next best step?

Options:
explanation: This would be breaking patient confidentiality. The clinician should inform the DVLA but should not speak to a next of kin against the patient's wishes
name: Ring his next kin and insist they inform the DVLA on his behalf
label: d
answer: no
explanation: If the clinician has concerns that the patient has not informed the DVLA that they shouldn't be driving, then they should inform the DVLA as soon as reasonably possible. By delaying this for a week, they would be putting the wider public at risk
name: Arrange a follow-up appointment for one week and ensure then that he has informed the DVLA
label: e
answer: no
explanation: This is one of the few circumstances in which a doctor can break patient confidentiality. In this circumstance, the wider risk to the public is deemed more important than the patient's right to confidentiality and, if the patient refuses to inform the DVLA themselves, the clinician is obliged to notify the DVLA
name: Only inform the DVLA if the patient gives you his permission
label: b
answer: no
explanation: There is no legal requirement to inform the police if patients are driving against advice
name: Report this to the police
label: c
answer: no
explanation: This is correct. This is one of the few circumstances where the clinician is obliged to break confidentiality and inform the DVLA if the patient refuses to, as the risk to the general public is more important than the patient's right to confidentiality. It is best practice to inform the patient that you will notify the DVLA before you do so
name: Inform the patient that you will have to inform the DVLA if he does not
label: a
answer: yes

Correct answer: a


Learning point: Clinicians must prioritise public safety over patient confidentiality when a patient's medical condition poses a risk, such as driving after a seizure.
A 90-year-old is admitted to hospital from a care home with a two day history of dysuria, urinary incontinence and increased confusion. She is pyrexial and extremely drowsy and is unable to hold a conversation. She has a background of congestive heart failure, hypertension, dementia and recurrent urinary tract infection. On her electronic patient record, there is a discussion documented from an admission with a fall three months ago where she states that she would not like to be resuscitated in the event of a cardiac arrest. It was documented by the team at the time that she had capacity. 

Which of the following is the next best step?

Options:
explanation: This patient should not be for resuscitation as there is a previously documented discussion where she has refused. It can be re-discussed if she regains capacity and can hold this conversation.
name: Leave for resuscitation until she is awake enough to have a formal discussion
label: d
answer: no
explanation: This is not necessary as there has been a clear formal discussion with the patient whilst she had capacity where she made her wishes clear.
name: Discuss with the hospital legal department
label: e
answer: no
explanation: As this patient clearly stated that they would not like to be resuscitated whilst she had capacity, a DNACPR form should be instigated. It it important to take into consideration the patient's prior wishes when considering DNACPR forms. 
name: Complete DNACPR form
label: a
answer: yes
explanation: The next of kin has no role in decision making about resuscitation. It is good practice to discuss resuscitation decisions with the next of kin; however, it is ultimately the patient and/or medical practitioner who decides, depending on the circumstances
name: Consider DNACPR based on wishes of next of kin
label: b
answer: no
explanation: This patient should not be for resuscitation as ultimately patients have a right to refuse resuscitation as long as they have capacity. When this patient discussed resuscitation, she did have capacity.
name: Document that this patient is for resuscitation
label: c
answer: no

Correct answer: a


Learning point: Respecting a patient's previously expressed wishes regarding resuscitation is crucial when determining the appropriateness of a DNACPR order.
A 60-year-old inpatient experiences rectal bleeding. A rectal examination is indicated, which is performed by a junior doctor at the bedside. There are no concerns about their capacity to make decisions.

In terms of consent, which of the following is required?

Options:
explanation: Verbal consent is required for an intimate examination, and this should be documented formally
name: Verbal consent and document this in the notes
label: a
answer: yes
explanation: Consent in writing is not required for a rectal examination; verbal consent will suffice. A formal consent form with the patient's signature is required for surgical procedures
name: Consent in writing before the rectal examination
label: c
answer: no
explanation: Consent in writing is not required for a rectal examination; verbal consent will suffice. Consent should be obtained before the examination
name: Consent in writing after rectal examination
label: d
answer: no
explanation: Consent is required for intimate examinations such as a rectal examination
name: No consent required
label: e
answer: no
explanation: Verbal consent should be documented in the notes
name: Verbal consent, no need to document this in the notes
label: b
answer: no

Correct answer: a


Learning point: Verbal consent is essential before performing intimate examinations, and it must be documented in the patient's medical notes.
A 25 year old man presents to his general practice with a sore throat which started 2 days ago. He also reports feeling feverish and unwell and denies a cough or coryza. He is still able to eat and drink. He has no allergies and does not take any regular medications.

His observations are as follows:

- Heart rate: 70 beats per minute
- Blood pressure: 115/80mmHg
- Respiratory rate: 14 breaths per minute
- Saturations: 99% on room air
- Temperature: 38.1 degrees Celsius

On examination, his tonsils are inflamed and purulent. He does not have any tender cervical lymphadenopathy.

What is the next best step in the management of this patient?

Options:
explanation: NICE recommend using either the FeverPAIN criteria or Centor criteria to identify which patients are more likely to benefit from antibiotics. This patient has a FeverPAIN score of 5 (for fever, purulence, attended rapidly, inflamed tonsils, and no cough or coryza) and a Centor score of 3 (tonsillar exudate, history of ever and s=absence of cough). Both of these mean that the patient should receive antibiotics. The first line for a patient not allergic or intolerant to penicillin is phenoxymethylpenicillin. In patients who are penicillin allergic or intolerant, alternative antibiotic choices include clarithromycin or erythromycin
name: Prescribe phenoxymethylpenicillin 500mg QDS for 5 days
label: a
answer: yes
explanation: Doxycycline is not indicated for use in tonsillitis. Doxycycline is most commonly used in respiratory tract infections particularly in those who are penicillin allergic or intolerant
name: Prescribe doxycycline 200mg for 1 dose, then maintenance 100mg OD for 5 days total
label: e
answer: no
explanation: Antibiotic are indicated in this patient as he has a FeverPAIN score of 5 or a Centor score of 3
name: Reassure and explain that there is no indication for antibiotics at present
label: c
answer: no
explanation: Amoxicillin is not indicated for use in tonsillitis. Common indications for amoxicillin include respiratory tract and urinary tract infections
name: Prescribe amoxicillin 500mg TDS for 5 days
label: d
answer: no
explanation: There is no indication that this patient would not, at present, be able to manage at home. Indications for referral to hospital would include stridor, clinical suspicion of acute epiglottitis, dehydration, or signs of any complications. He does not appear to be systemically unwell from his observations. Immunosuppression is another indication to urgently refer to hospital, which we have no reason to think that this patient is
name: Refer urgently to hospital
label: b
answer: no

Correct answer: a


Learning point: In cases of acute pharyngitis with purulent tonsillitis, phenoxymethylpenicillin is the first-line antibiotic treatment if the patient is not penicillin allergic.
A 25 year old female presents to her general practice for her first routine cervical screening. She has no gynaecological symptoms.

On speculum examination, her cervix appears normal.

The sample returns as negative for human papillomavirus (HPV).

What is the next best step?

Options:
explanation: This is correct. All women aged 25 to 49 are invited for "routine recall" if a cervical sample is negative for high-risk HPV
name: Return for cervical screening in 3 years
label: a
answer: yes
explanation: The NHS employ a "HPV first" system whereby a the sample is first tested for high risk strains of HPV, and cytological examination is only performed if this is positive
name: Cytological examination of the sample
label: e
answer: no
explanation: All women aged 25 to 49 are invited for routine cervical screening every 3 years. Between the ages of 50 and 64 this becomes every 5 years
name: Return for cervical screening in 5 years
label: b
answer: no
explanation: Colposcopy is only indicated if the cytology of the cells is abnormal, or there are two consecutive inadequate samples. In the current "HPV first" system in the NHS screening programme, the sample is only tested for cytology if it is positive for high risk strains of HPV. As this patient's sample was negative, it was not tested for cytology
name: Refer for colposcopy
label: d
answer: no
explanation: All women aged 25 to 49 are invited for screening every 3 years, even if their previous screening was normal
name: Discharge from national screening programme
label: c
answer: no

Correct answer: a


Learning point: Women aged 25 to 49 should return for cervical screening every three years if their HPV test is negative.
A 40 year old man is admitted to hospital following a road traffic accident. He has a pelvic x-ray which shows a stable pelvic fracture which is managed conservatively.

Approximately 48 hours later, he becomes acutely confused, drowsy and breathless.

His observations are as follows:

- Respiratory rate: 25 breaths per minute
- Saturations: 90% on room air
- Heart rate: 90 beats per minute
- Blood pressure: 95/65mmHg
- Temperature: 36.5 degrees Celsius

On examination, auscultation of his chest reveals bibasal coarse crackles. There is also a petechial rash on the anterior aspect of his chest.

What is the most likely diagnosis?

Options:
explanation: This is a sensible differential in a trauma patient with haemodynamic instability, although it would not explain the petechial rash and is unlikely to cause such significant respiratory compromise and neurological disturbance
name: Internal haemorrhage
label: b
answer: no
explanation: Although this may explain his respiratory compromise, it would not explain the petechial rash. It is unlikely to cause acute confusion and drowsiness in someone so young, and the normal temperature is also going against this diagnosis. Pneumonia would also typically cause unilateral crackles on auscultation
name: Hospital-acquired pneumonia
label: c
answer: no
explanation: This may explain his acute respiratory distress but would not explain the petechial rash and is unlikely to cause such acute neurological disturbance
name: Acute respiratory distress syndrome (ARDS)
label: e
answer: no
explanation: This would not explain his respiratory compromise or petechial rash. Although a subarachnoid haemorrhage is the most common type of brain haemorrhage secondary to trauma in the acute phase
name: Subarachnoid haemorrhage
label: d
answer: no
explanation: Fat embolism classically presents with the triad of respiratory compromise, neurological disturbance and a petechial rash. It typically occurs 24-72 hours after a long bone injury or surgical procedure
name: Fat embolism
label: a
answer: yes

Correct answer: a


Learning point: Fat embolism syndrome typically presents 24-72 hours post-injury with respiratory distress, neurological symptoms, and a petechial rash.
A 25 year old woman presents with pain in her throat on swallowing. She has no significant past medical history.

She has an endoscopy which shows the following:

[lightgallery]

Which of the following blood tests is best to do next in this patient?

Options:
explanation: There is no link with hepatitis B and oesophageal candidiasis or dysphagia
name: Hepatitis B antigen
label: d
answer: no
explanation: The endoscopy image above shows a severe case of oesophageal candidiasis. The most common cause of this includes HIV and topical steroid treatment such as steroid inhalers
name: HIV testing
label: a
answer: yes
explanation: This would investigate for myasthenia gravis which may be a cause of dysphagia. However, the endoscopy image above shows oesophageal candidiasis
name: Antibodies against acetylcholine receptor (AChR)
label: b
answer: no
explanation: This would investigate systemic lupus erythematosus (SLE), which is a cause of dysphagia, but the endoscopy image above clearly shows oesophageal candidiasis, which would not be explained by SLE
name: Anti-dsDNA
label: e
answer: no
explanation: This would investigate systemic lupus erythematosus (SLE), which is a cause of dysphagia, but the endoscopy image above clearly shows oesophageal candidiasis, which would not be explained by SLE
name: Anti-nuclear antibodies (ANA)
label: c
answer: no

Correct answer: a


Learning point: Oesophageal candidiasis often suggests underlying immunosuppression, such as HIV infection, and individuals presenting with this condition should be tested for HIV.
A 65 year old woman comes into A&E with a 2 week history of bloody spotting on her underwear. She is surprised to find this as she went through menopause 15 years ago. She has been married to her husband of 25 years and has no children. Past medical history includes type 2 diabetes and obesity.

What is the next best investigation?

Options:
explanation: This might be useful later down the line as a staging scan for malignancy
name: Computed tomography (CT) scan of the pelvis
label: b
answer: no
explanation: CA-125 is commonly elevated in cases of ovarian cancer and is a useful screening test for ovarian malignancy. This woman is not presenting with symptoms of ovarian cancer (e.g. abdominal fullness, urinary frequency/urgency and changes in bowel habit) therefore this would not be an appropriate first-line test
name: CA-125
label: e
answer: no
explanation: This is a screening test for cervical cancer, and would not be first-line in a postmenopausal patient with red flag features for malignancy. However it would be useful to note in the history if the patient's smear tests are up to date and if she has had any treatment to the cervix
name: Cervical smear testing
label: c
answer: no
explanation: This is a diagnostic investigation for cervical cancer, which is typically found in younger females with a high-risk sexual history. Colposcopy would be indicated if a cervical abnormality was seen, or if infection with human papilloma virus (HPV) was found on a routine cervical smear
name: Colposcopy
label: d
answer: no
explanation: Postmenopausal bleeding raises a high suspicion for endometrial cancer. An urgent transvaginal ultrasound is the most useful first-line test to determine endometrial thickness and assess for any uterine abnormality (e.g. fibroids). The ultrasound result would determine the need for further investigation such as endometrial biopsy, blood tests, hysteroscopy or further pelvic imaging
name: Transvaginal ultrasound
label: a
answer: yes

Correct answer: a


Learning point: Postmenopausal bleeding necessitates urgent investigation, with transvaginal ultrasound being the first-line test to assess for endometrial abnormalities.
A 20 year old female has been brought into A&E by her partner with sudden onset right lower abdominal pain and vomiting for the past day. She had also briefly fainted just prior to arrival. In triage, she was afebrile, BP 75/50, HR 115, SpO<sub>2</sub> 98%. A urine pregnancy test was positive but transvaginal ultrasound scan (US) showed an empty uterus.

What is the next most appropriate course of action?

Options:
explanation: Methotrexate is utilised for medical management of ectopic pregnancy under specific circumstances where the patient is haemodynamically stable. This patient is unstable and would therefore not be suitable for medical management
name: Methotrexate
label: d
answer: no
explanation: Ectopic pregnancy may result in hypovolaemia secondary to blood loss. A blood transfusion may be considered if there is a large volume of blood loss with a significant drop in haemoglobin. Bloods should be sent off for group and save, and 2-4 units crossmatched. However, in the acute setting, the patient should be resuscitated with IV fluids first
name: Blood transfusion
label: e
answer: no
explanation: This patient is currently haemodynamically unstable and requires fluid resuscitation prior to the consideration of any surgery. Laparoscopy is usually the first-line diagnostic and therapeutic operation for ectopic pregnancy as it is less invasive and harbours a shorter recovery time than laparotomy. Emergency laparotomy would be indicated if the patient had an acute abdomen, or if other pathology e.g. bowel was suspected
name: Emergency laparotomy
label: c
answer: no
explanation: There is high suspicion for an ectopic pregnancy in a young sexually active female with signs of tachycardia and hypotension suggesting blood loss. Up to half of transvaginal US scans may be inconclusive. As she is haemodynamically unstable, she should be resuscitated with IV fluids as a first priority
name: Intravenous (IV) fluid bolus
label: a
answer: yes
explanation: Whilst the next investigation and definitive management of suspected ectopic pregnancy would be an emergency laparoscopy, this patient is currently unstable and requires fluid resuscitation first
name: Emergency laparoscopy
label: b
answer: no

Correct answer: a


Learning point: In suspected ectopic pregnancy, immediate intravenous fluid resuscitation is crucial for managing haemodynamic instability.
A 30 year old female presents to the GP surgery with a 6 month history of amenorrhoea. She is not sexually active and has had no previous pregnancies. Laboratory testing revealed elevated follicle stimulating hormone (FSH) and luteinising hormone (LH). Genetic testing reveals a mutation in the FMR1 gene causing an expansion of a trinucleotide repeat sequence "CGG".

Which of the following diseases is most likely to share the same mode of inheritance?

Options:
explanation: This is an X-linked recessive disorder
name: Duchenne muscular dystrophy
label: b
answer: no
explanation: The disease in question is fragile X syndrome, which is one of the genetic causes of premature ovarian failure and has **X-linked dominant inheritance**. Rett syndrome is another X-linked dominant neurodevelopmental disorder that occurs almost exclusively in females
name: Rett syndrome
label: a
answer: yes
explanation: This is an autosomal recessive disorder that may also cause premature ovarian failure
name: Galactosemia
label: d
answer: no
explanation: This is a chromosomal disorder due to the loss of part or all of an X chromosome, the most common karyotype being 45X. Most cases of Turner syndrome are not inherited. However, it is a major genetic cause of premature ovarian failure
name: Turner syndrome
label: e
answer: no
explanation: This is typically an X-linked recessive disorder
name: Androgen insensitivity syndrome
label: c
answer: no

Correct answer: a


Learning point: Fragile X syndrome and Rett syndrome both exhibit X-linked dominant inheritance patterns, affecting primarily females.
An 80 year old woman is admitted to the ward with a one week history of confusion, dysuria and urinary incontinence. She lives alone with a carer coming in once weekly, who brought her into hospital upon realising she was "slightly muddled". She has a past medical history of ischaemic heart disease, atrial fibrillation and dementia and she currently takes warfarin. Her international normalised ratio (INR) is 6.5 on admission.

A CT head no evidence of acute intracranial abnormality.

Which of the following is the most appropriate management?

Options:
explanation: This would be indicated in any serious or life-threatening bleeding requiring immediate reversal, regardless of the INR
name: Stop warfarin, administer prothrombin complex concentrate (PCC)
label: e
answer: no
explanation: This woman has a background of dementia and has been admitted with delirium, suggesting possible issues with medication compliance or overdosing. As the INR is between 5-8 with no active sources of bleeding, it is safe to withhold warfarin and recheck the INR the next day
name: Withhold one or two doses of warfarin, assess medication compliance and recheck INR
label: a
answer: yes
explanation: This would be indicated if the patient has active bleeding
name: Stop warfarin, administer IV phytomenadione
label: d
answer: no
explanation: This would be indicated if the INR is >8 without bleeding
name: Stop warfarin, administer oral vitamin K
label: c
answer: no
explanation: The patient has a supratherapeutic INR and further administration of warfarin even at a reduced dose would likely drive the INR higher and put her at increased risk of bleeding
name: Continue warfarin at a reduced dose
label: b
answer: no

Correct answer: a


Learning point: If the INR is between 5-8 and there are no active sources of bleeding, it is generally safe to withhold warfarin and recheck the INR the following day.