hllj/quesmed huggingface dataset:
A 34-year-old man presents with a two-week history of a purple coloured rash on his lower limbs. He also reports approximately 5kg weight loss in the last two months. He is otherwise well, and his only significant past medical history is of recurrent episodes of sinusitis in the past year.

On examination, there is a widespread palpable purpuric rash on the anterior aspects of both legs. Examination and observations are otherwise normal.

Which of the following is the next best step in management?

Options:
explanation: Meningococcal septicaemia can present with a purpuric rash, similar to that seen in small vessel vasculitis. However, the absence of any infective symptoms, normal observations and chronicity of the history favour a diagnosis of vasculitis
name: Blood cultures
label: c
answer: no
explanation: This is an important test to look for any evidence of proteinuria (especially in a patient who is likely to have significant renal disease) but a simple urine dipstick should be done in the first instance
name: Urine Protein Creatinine ratio
label: b
answer: no
explanation: CRP levels are indicative of infective and inflammatory states and therefore are likely to be raised in vasculitis. However, it is a non-specific test. A urine dipstick is preferable as an initial test to exclude potentially life-threatening renal vasculitis
name: Measure C-reactive protein (CRP) levels
label: e
answer: no
explanation: Tryptase levels are increased in anaphylaxis. The rash in anaphylaxis is typically an urticarial rash, characterised by itchy weals and surrounding erythema. Also, there are no other signs or symptoms of anaphylaxis described
name: Serum tryptase levels
label: d
answer: no
explanation: The rash combined with systemic symptoms and recurrent sinusitis is suggestive of small vessel vasculitis. In this context, recurrent sinusitis, in particular, is indicative of granulomatosis with polyangiitis (GPA). Vasculitis, in general, is commonly associated with renal disease, which can manifest with proteinuria and haematuria. Therefore, it is important to do a urine dipstick in all patients with this presentation to exclude significant renal complications
name: Urine dipstick
label: a
answer: yes

Correct answer: a


Learning point: Recurrent sinusitis and a purpuric rash could suggest granulomatosis with polyangiitis, making urine dipstick testing important to evaluate potential renal involvement.
A 32-year-old woman presents with a three-day history of a worsening rash across her body.

On examination, there is an erythematous rash covering the majority of the patient's skin, both anteriorly and posteriorly. The skin is hot to touch, and there is associated scaling. Systemic examination is otherwise normal.

Blood tests reveal increased urea to creatinine ratio but no other significant findings.

Which of the following is the most likely cause of the rash described?

Options:
explanation: Haematological malignancies can cause erythroderma; however, the lack of systemic symptoms, largely normal blood tests and absence of lymphadenopathy would go against this
name: Haematological malignancy
label: e
answer: no
explanation: Around 30% of cases of erythroderma are idiopathic. Most cases of erythroderma are associated with a pre-existing skin condition
name: Idiopathic
label: b
answer: no
explanation: The rash is highly suggestive of erythroderma. Erythroderma is a dermatological emergency where there is widespread erythema affecting >90% of the skin surface. The increased urea level suggests dehydration, an important complication of erythroderma, and highlights the importance of the skin's function in fluid balance.

The most common cause of erythroderma is a pre-existing skin condition such as eczema or psoriasis
name: Pre-existing skin condition
label: a
answer: yes
explanation: Sezary syndrome is a type of cutaneous T-cell lymphoma and is a rare cause of erythroderma
name: Sezary syndrome
label: d
answer: no
explanation: Drug reactions can cause erythroderma; however, this is less likely than a pre-existing skin condition preceding erythroderma.
name: Drug-reaction
label: c
answer: no

Correct answer: a


Learning point: A pre-existing skin condition, such as psoriasis, atopic dermatitis, or seborrheic dermatitis, is a risk factor for erythroderma
A 65-year-old man presents to his general practitioner (GP) complaining that his voice has become more hoarse over the last three months. He denies any other symptoms.

His past medical history is significant for gastro-oesophageal reflux disease (GORD), for which he takes 20mg of omeprazole once a day.

There are no notable findings on examination.

Which of the following is the next best step in management?

Options:
explanation: This would not be appropriate as hoarseness could be a sign of underlying malignancy
name: Reassure and discharge
label: d
answer: no
explanation: Hoarseness is a red flag for laryngeal cancer. Guidelines suggest that all patients over 45 years old should be referred urgently to secondary care if they have unexplained and persistent hoarseness
name: Urgent referral for investigation of laryngeal cancer
label: a
answer: yes
explanation: Delay in investigations can affect prognosis, and it is therefore recommended that this patient be referred urgently under the 2-week wait pathway
name: Arrange a follow-up GP appointment in two weeks to monitor symptoms
label: e
answer: no
explanation: GORD can lead to voice changes due to the effect of acid on the vocal cords. However, this patients GORD symptoms appear to be well controlled on omeprazole. Regardless, persistent hoarseness is concerning, and he should be referred urgently to exclude laryngeal cancer
name: Increase omeprazole dosing to 20mg twice a day
label: b
answer: no
explanation: Apical lung cancer can compress the recurrent laryngeal nerve and lead to hoarseness. However, the lung cancer pathways require an abnormal chest X-ray or unexplained haemoptysis in patients over 40 before urgent referral
name: Urgent referral for investigation of lung cancer
label: c
answer: no

Correct answer: a


Learning point: All patients over 45 years old should be referred urgently to secondary care if they have unexplained and persistent hoarseness
A 19-year-old woman presents to her general practitioner (GP) with pain and discharge from her right ear. She reports the symptoms began two days ago after returning from a beach holiday in Spain.

She has no significant past medical history, and her observations are all normal.

On examination, there is tenderness on gentle movement of the right ear. Otoscopy reveals a mildly inflamed and erythematous ear canal with scant white discharge. The tympanic membrane remains intact.

Which of the following is the next best step in management?

Options:
explanation: Acetic acid can be used in the very early stages of infection. In this case, the inflammation, discharge and pain favour using a combination antibiotic/steroid ear drop
name: 2% acetic acid ear drops
label: e
answer: no
explanation: Uncomplicated otitis externa does not require referral to ENT. Persistent infection and infections in which there is concern about spread beyond the external ear canal would warrant referral
name: Urgent referral to ENT
label: b
answer: no
explanation: Oral antibiotics are usually not used in otitis externa due to poor penetration of the skin that lines the external ear canal. However, if there is spread beyond this (i.e. to bone or face), then oral antibiotics should be considered
name: Oral flucloxacillin
label: c
answer: no
explanation: Ribbon gauze can be used in severe otitis externa if there is significant inflammation of the ear canal that prevents ear drops from passing into the canal. There is only mild inflammation in this case, making topical antibiotics a better first-line option
name: Insert ribbon gauze (Pope wick)
label: d
answer: no
explanation: The likely diagnosis is acute otitis externa, given the ear pain and characteristic appearances on otoscopy. Swimming and water sports are common risk factors for this condition. Treatment is with topical antibiotic/steroid drops and keeping the ear dry for 7-10 days
name: Offer topical antibiotic/steroid drops and advise keeping the ear dry
label: a
answer: yes

Correct answer: a


Learning point: Patients with acute otitis externa require topical antibiotic/steroid drops and should be advised to keep the ear dry
A 40-year-old man with a history of recurrent right-sided otitis media presents with a one-month history of gradually worsening hearing loss in his right ear. He denies any other symptoms, and his past medical history is otherwise unremarkable.

On examination, otoscopy reveals chalky white patches on the tympanic membrane. Rinne's test is negative on the right, and Weber's test lateralises to the right ear.

Which of the following is the most likely diagnosis?

Options:
explanation: Cerumen (ear wax) in the ear canal is one of the most common causes of conductive hearing loss. It would not lead to a change in the appearance of the tympanic membrane
name: Cerumen impaction
label: d
answer: no
explanation: Tympanosclerosis refers to calcification of the middle ear and tympanic membrane. The aetiology is not fully understood, but the major risk factors are middle ear infections and grommet insertion. The condition is characterised by chalky white patches on the tympanic membrane and a conductive pattern of hearing loss
name: Tympanosclerosis
label: a
answer: yes
explanation: Chronic otitis media presents with ear discharge for greater than six weeks. Often there will also be perforation of the tympanic membrane on examination
name: Chronic otitis media
label: b
answer: no
explanation: A vestibular schwannoma (acoustic neuroma) is usually a slow-growing tumour of the cerebellopontine angle. It can present with sensorineural hearing loss, vertigo and tinnitus
name: Vestibular schwannoma
label: e
answer: no
explanation: Otosclerosis is a condition in which there is abnormal bone growth in the middle ear. It is a cause of conductive hearing loss but would not explain the characteristic appearances of the tympanic membrane described
name: Otosclerosis
label: c
answer: no

Correct answer: a


Learning point: Tympanosclerosis is characterised by chalky white patches on the tympanic membrane and can lead to conductive hearing loss.
A 75-year-old man presents to the Emergency Department (ED), having been found collapsed at his home by his wife. His wife tells you that they recently moved to a new house and had been moving things into the basement.

On assessment, he reports a severe headache and has a GCS of 14. On examination, there is significant accessory muscle usage, tachypnoea and vesicular breath sounds are heard throughout both lung fields. Oxygen saturations are 96% on room air. An arterial blood gas (ABG) shows a PaO<sub>2</sub> of 11.5kPa (>11kPa) and a PCO<sub>2</sub> of 5.1kPa (4.5-6kPa).

Which of the following is the most likely diagnosis?

Options:
explanation: A pulmonary embolism of the size needed to cause respiratory accessory muscle usage would be expected to cause a decrease in oxygen saturation and arterial oxygen levels
name: Pulmonary embolism
label: d
answer: no
explanation: Poorly maintained gas and heating appliances are a common cause of carbon monoxide poisoning. Presenting symptoms can include headache, confusion, nausea, shortness of breath and chest pain. Carbon dioxide binds preferentially with haemoglobin to form carboxy-haemoglobin, thereby reducing haemoglobin's carrying capacity of oxygen. Saturation probes cannot differentiate between oxy-haemoglobin and carboxy-haemoglobin, meaning that oxygen saturations are misleadingly normal. Arterial oxygen levels are also normal as there is no ventilation-perfusion mismatch. Elevated carboxy-haemoglobin levels on an ABG can confirm the diagnosis
name: Carbon monoxide poisoning
label: a
answer: yes
explanation: Methaemoglobinaemia is a condition in which the iron in haemoglobin is oxidised from the ferrous to the ferric state, thereby rendering it unable to bind to oxygen. It usually presents with cyanosis, oxygen saturations between 85-90% and normal arterial oxygen levels. Cyanosis is not usually seen in carbon monoxide poisoning as carboxy-haemoglobin has a bright red colour
name: Methaemoglobinaemia
label: b
answer: no
explanation: Normal findings on auscultation and normal oxygen saturations would make a pneumothorax an unlikely explanation for the significant symptoms that this patient has presented with
name: Pneumothorax
label: c
answer: no
explanation: A subarachnoid haemorrhage is an important differential in this context, given the history of severe headache and reduced GCS. However, he is not in the right age range for a subarachnoid haemorrhage. In any case, you will likely get a CT Head for this patient but this is not the single best answer
name: Subarachnoid haemorrhage
label: e
answer: no

Correct answer: a


Learning point: Carbon monoxide poisoning often presents with headache, confusion, and respiratory distress, despite normal oxygen saturation readings.
A 65-year-old patient with a background of chronic obstructive pulmonary disease (COPD) presents with acute onset chest pain and shortness of breath.

On assessment, he has decreased chest expansion in the left upper zones with associated hyper-resonance and reduced air entry. A chest x-ray confirms a 2.5 cm left sided apical pneumothorax.

Which of the following is the next best step in management.

Options:
explanation: Given his underlying COPD and age, this patient has high risk characteristics associated with his pneumothorax. As it is greater than 2cm (i.e. amenable to drainage), guidelines suggest that chest drain insertion is the best management
name: Chest drain insertion
label: a
answer: yes
explanation: Insertion of a large bore cannula into the second intercostal space on the affected side would be indicated if the patient had a tension pneumothorax
name: Emergency thoracentesis
label: d
answer: no
explanation: This would be indicated if the patient was not breathless, the pneumothorax was less than 2cm and the patient was not keen on interventional management
name: High flow oxygen and observation
label: c
answer: no
explanation: Aspiration is not recommended for patients with a pneumothorax who have high risk characteristics
name: Aspiration
label: b
answer: no
explanation: This is not appropriate given this patient's age and underlying lung disease, which would be considered as high risk characterstics according to BTS guidelines, necessitating chest drain insertion
name: Discharge and review in ambulatory care clinic the next day
label: e
answer: no

Correct answer: a


Learning point: In patients with a significant pneumothorax, especially those with COPD, chest drain insertion may be required.
A 56-year-old man has a cardiac arrest in hospital. Following prompt commencement of cardio-pulmonary resuscitation (CPR), he is found to have a regular broad-complex tachycardia at the first rhythm check.

Which of the following is the next best step in management?

Options:
explanation: 300mg of amiodarone is used in cardiac arrest secondary to VF or VT. However, it is only given after the 3rd shock
name: Administer 300mg of amiodarone (IV)
label: d
answer: no
explanation: This patient has a shockable rhythm, so it is important to administer a shock before recommencing chest compression
name: Continue CPR for 2 minutes
label: b
answer: no
explanation: In the context of a patient in cardiac arrest, a regular broad-complex tachycardia is suggestive of pulseless ventricular tachycardia (pVT). Along with ventricular fibrillation (VF), pVT is an indication for defibrillation (unsynchronised cardioversion) at a setting of 200J
name: Unsynchronised cardioversion at an energy setting of 200J
label: a
answer: yes
explanation: Along with amiodarone, adrenaline is given after the 3rd shock in patients with cardiac arrest secondary to VF or pVT
name: Administer 10mg of 1 in 10,000 adrenaline (IV)
label: c
answer: no
explanation: Amiodarone and adrenaline are given in cases of cardiac arrest secondary to VF or VT; however, only after the 3rd shock
name: Administer 300mg of amiodarone (IV) and 10mg of 1 in 10,000 adrenaline (IV)
label: e
answer: no

Correct answer: a


Learning point: Pulseless ventricular tachycardia (VT) is a shockable cardiac arrest rhythm, and defibrillation with unsynchronized cardioversion at an energy setting of 200J is used to deliver an electrical shock to attempt to restore a normal heart rhythm.
A 56-year-old man is being treated for Escherichia coli septicaemia secondary to pyelonephritis. He is currently on day three of treatment with gentamicin but continues to have fevers and rising inflammatory markers. In addition, his most recent blood tests show a low platelet count, low fibrinogen and raised prothrombin (PT) and activated partial thromboplastin (aPTT) times.

Which of the following is the most likely explanation for the patient's blood test results?

Options:
explanation: TMA is characterised by the formation of thrombi in the small vasculature and associated microangiopathic haemolytic anaemia (MAHA) due to fragmentation of red blood cells. TMA alone would not be associated with clotting abnormalities (i.e. raised PT and APTT)
name: Secondary thrombotic microangiopathy (TMA) due to infection
label: b
answer: no
explanation: ITP is characterised by an isolated thrombocytopenia in the absence of an identifiable cause. Therefore, clotting would be normal
name: Immune thrombocytopenic purpura (ITP)
label: d
answer: no
explanation: Sepsis and trauma can lead to low platelets due to a 'consumptive state'. However, this would not be associated with clotting abnormalities
name: Consumptive thrombocytopaenia due to infection
label: e
answer: no
explanation: MAHA is associated with intravascular haemolysis and can be seen in conjunction with a thrombotic microangiopathy (TMA) or disseminated intravascular coagulation (DIC). MAHA alone (e.g. due to haemolysis secondary to prosthetic heart valves) is not associated with low platelets or clotting abnormalities
name: Microangiopathic haemolytic anaemia (MAHA)
label: c
answer: no
explanation: DIC is a life-threatening complication of sepsis. It results from over-activation of the coagulation pathway leading to increased risk of thrombosis and subsequent risk of bleeding due to depletion of clotting factors and platelets. It is characterised by raised PT, APTT and D-Dimer, and low platelet count and fibrinogen level. Treatment is supportive with blood products and treatment of the underlying cause
name: Disseminated intravascular coagulation (DIC)
label: a
answer: yes

Correct answer: a


Learning point: Disseminated intravascular coagulation (DIC) is a severe complication of sepsis, characterised by coagulopathy and multi-organ dysfunction.
A 16-year-old patient with type 1 diabetes mellitus is admitted after a short history of lethargy, vomiting and confusion. He is found to be in diabetic ketoacidosis (DKA) and is treated with IV fluids and a fixed rate insulin infusion.

Following treatment, he meets the criteria for resolution of DKA and is safely bridged onto his normal regime of subcutaneous insulin. However, he remains confused with a GCS of 13.

Other observations are as follows: heart rate 68bpm, blood pressure 110/55, respiratory rate 16, SpO2 99% on air, temperature 36.9.

Which of the following is the next best step in management?

Options:
explanation: There is no indication to restart a VRII if the patient's blood glucose is well controlled following conversion to their usual subcutaneous insulin regime
name: Start variable rate insulin infusion (VRII)
label: c
answer: no
explanation: This patient is not hypoxic or in respiratory distress so there is no indication for an ABG
name: Arterial blood gas (ABG)
label: e
answer: no
explanation: Ongoing confusion in a paediatric patient who has been treated for DKA is concerning for the development of cerebral oedema. A CT head is the best investigation to exclude this
name: Computed tomography (CT) head
label: a
answer: yes
explanation: Hypothyroidism is an important cause of acute confusion and would be part of a routine confusion screen. However, in this case, it is most vital to exclude cerebral oedema given the history of recently treated DKA in a paediatric patient
name: Check thyroid function
label: d
answer: no
explanation: There is no indication to restart a FRII if the patient's blood glucose is well controlled following conversion to their usual subcutaneous insulin regime
name: Restart fixed rate insulin infusion (FRII)
label: b
answer: no

Correct answer: a


Learning point: A CT scan can be used to diagnose cerebral oedema secondary to diabetic ketoacidosis (DKA), as it helps identify signs of swelling in the brain and rule out other potential complications or causes of altered mental status.
An 80-year-old woman presents to the Emergency Department (ED) with confusion.

On assessment, her GCS is 13, and a neurological examination reveals reduced power and sensation in the right upper and lower limbs. No external injuries are evident.

An urgent CT head shows a haemorrhagic stroke affecting the thalamus.

Which of the following is the most likely aetiology of the stroke?

Options:
explanation: Cerebral amyloid angiopathy is the most common cause of lobar intracerebral haemorrhage in older adults. A thalamic stroke is more likely to be due to hypertensive vasculopathy
name: Cerebral amyloid angiopathy
label: c
answer: no
explanation: Trauma can lead to intracerebral haemorrhage; however, the absence of any external injuries on examination would go against this as the most likely cause
name: Trauma
label: d
answer: no
explanation: Vasculitis can cause stroke, but it is rare and most commonly seen in younger patients
name: Vasculitis
label: e
answer: no
explanation: Hypertension is the most common cause of spontaneous intracerebral haemorrhage. The pathogenesis is due to hypertension leading to the formation, and subsequent rupture, of Charcot-Bouchard aneurysms in the small penetrating blood vessels of the brain
name: Hypertensive vasculopathy
label: a
answer: yes
explanation: AVM are an important but less common cause of intracerebral haemorrhage
name: Arteriovenous malformation (AVM)
label: b
answer: no

Correct answer: a


Learning point: Hypertension is the most common cause of spontaneous intracerebral haemorrhage.