hllj/quesmed huggingface dataset:
A new drug is developed that claims to prevent diabetes mellitus in patients with impaired glucose tolerance. A randomised control trial is undertaken in 100 patients with HbA1c of 42-47, where half the participants are given the new drug, and the other half are given a placebo.

In those who were given the new drug, 25 patients developed diabetes within five years; in the group who were not given the drug, 36 patients developed diabetes within five years.

What is the relative risk of developing diabetes if treated with the new drug?

Options:
explanation: This is incorrect as this is the risk of developing diabetes in the placebo group
name: 0.72
label: d
answer: no
explanation: The relative risk or risk ratio is the probability of an outcome occurring in a patient group exposed to a change (in this case, a new drug). Of those given the drug, 50% went on to develop diabetes compared to 72% in the placebo group.

Relative risk = risk in the group exposed to drug/risk in those not exposed to the drug.

50/72 = 0.69
name: 0.69
label: a
answer: yes
explanation: This is incorrect as this is the risk of not developing diabetes in the placebo group
name: 0.28
label: e
answer: no
explanation: This is incorrect as this is the risk of developing diabetes in the group given the drug
name: 0.50
label: c
answer: no
explanation: This is incorrect as the group that has been exposed to the change is those given the drug
name: 1.44
label: b
answer: no

Correct answer: a


Learning point: Relative risk compares the likelihood of an event occurring in an exposed group to an unexposed group, calculated as the ratio of incidence in the exposed group to the unexposed group.
An 83 year old male with metastatic colorectal cancer presents to the emergency department with abdominal pain. He reports not passing urine for the last 12 hours. On examination he has moist mucous membranes, his JVP is not raised and his abdomen is diffusely tender without being peritonitic. Bladder scan shows a volume of 20ml.


His admission bloods are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|83  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|235x10<sup>9</sup>/L|150 - 400|
|Sodium|134 mmol/L|135 - 145|
|Potassium|5.4 mmol/L|3.5 - 5.3|
|Urea|14 mmol/L|2.5 - 7.8|
|Creatinine|300 µmol/L|60 - 120|
|C Reactive Protein|15 mg/L|< 5|


What is the most important next investigation?

Options:
explanation: Whilst a CT of his abdomen and pelvis would be useful in aiding diagnosis, at the moment his renal function is poor and contrast is best avoided
name: Computerised tomography (CT) of abdomen and pelvis with contrast
label: b
answer: no
explanation: This patient has a significant acute kidney injury, is anuric, and has a known intraabdominal malignancy. It is important to rule out a urological obstruction as cause for his presentation. The bladder scan does not show retention, however there may be an obstruction at the ureteric level
name: Ultrasound renal tract
label: a
answer: yes
explanation: A FAST scan is used to detect free fluid in the abdomen in a trauma situation and therefore is not indicated in this case
name: Focussed abdominal scanning in trauma (FAST) scanning
label: e
answer: no
explanation: Whilst a urine dip might be helpful in diagnosis if obstruction is not the cause, he has reported he has not passed urine for over 12 hours therefore obtaining a urine sample may not be possible without inserting a catheter
name: Urine dip
label: c
answer: no
explanation: This is not an unreasonable investigation, as patients with metastatic disease may present with cauda equina, however the bladder scan is not suggestive of urinary retention at a spinal level and therefore less likely than external compression of a ureter for example
name: Magnetic resonance imaging (MRI) of the spine
label: d
answer: no

Correct answer: a


Learning point: An ultrasound is performed in an anuric patient with a known intra-abdominal malignancy to assess for potential causes of urinary obstruction, such as tumor compression, hydronephrosis, or metastatic involvement of the urinary tract.
A 31 year old male presents to the general practice with rose coloured urine and fatigue. He reports that he had a recent upper respiratory tract infection, but otherwise has no past medical history of note. He undergoes a renal biopsy and is diagnosed with IgA nephropathy. During his follow up he is found to have hypertension on serial blood pressure measurements.

What single medication ought to be started in the first instance?

Options:
explanation: Whilst hypertension requires aggressive treatment in IgA nephropathy, 5mg is a high starting dose as patients are usually started at 1.25-2.5mg and then gradually increased at two weekly intervals
name: Commence ramipril 5mg once daily
label: c
answer: no
explanation: High blood pressure should be treated aggressively in patients with IgA nephropathy, and the antihypertensive medication of choice is an angiotensin-converting enzyme inhibitor (ACEi) such as ramipril. They protect kidney function and may even be beneficial with normal blood pressure
name: Commence ramipril 1.25mg once daily
label: a
answer: yes
explanation: A loop diuretic is not the first line diuretic in this instance and may lead to electrolyte imbalance
name: Commence furosemide 20mg once daily
label: b
answer: no
explanation: The National Institute of Clinical Excellence (NICE) states that calcium channel blocker is first line antihypertensive medication for those over the age of 55 or of African or Afro-Caribbean family origin. As this patient is young an ACEi is therefore first line
name: Commence amlodipine 5mg once daily
label: e
answer: no
explanation: There is some role for steroids in the treatment of IgA nephropathy, however this does not address his hypertension
name: Commence prednisolone 5mg once daily
label: d
answer: no

Correct answer: a


Learning point: Ramipril, an ACE inhibitor, is used in managing IgA nephropathy by reducing proteinuria and slowing disease progression through its effects on lowering blood pressure and decreasing intraglomerular pressure.
A 75-year-old male is seen in clinic and is noted to have renal and liver function off his usual baseline. His wife is concerned his memory isn't what it used to be, and he has been mixing up his medications of late. She has also noticed his hands are shaking. His past medical history includes autosomal dominant polycystic kidney (ADPKD) disease, for which he had a renal transplant ten years ago.

What is the most likely cause for this clinical picture?

Options:
explanation: Whilst vascular dementia may be the precipitating factor for his cognitive decline; it would not account for the changes in his blood tests
name: Vascular dementia
label: b
answer: no
explanation: Those who suffer from ADPKD can also develop liver cysts, which can alter liver function; however, it is unusual to develop new cysts in a transplanted kidney
name: Progression of his ADPKD
label: e
answer: no
explanation: Acute rejection is defined as rejection in the first few weeks to the first three months after transplantation
name: Acute graft rejection
label: c
answer: no
explanation: Chronic rejection is a possibility in this case and should be considered in clinical practice. However, the picture of declining renal function in chronic rejection is more gradual in nature and would not account for the changes in his liver function
name: Chronic graft rejection
label: d
answer: no
explanation: Tremor and headache are two well-known symptoms of tacrolimus toxicity which is also both nephrotoxic and hepatotoxic. The fact that this patient might be mixing up his medications raises the concern that he may be overdosing his tacrolimus
name: Calcineurin inhibitor toxicity
label: a
answer: yes

Correct answer: a


Learning point: Calcineurin inhibitor toxicity, caused by drugs like cyclosporine or tacrolimus, causes nephrotoxicity, hypertension, neurotoxicity, hyperkalemia, and infection risk, requiring regular drug level and kidney function monitoring.
A 24-year-old male is brought to the emergency department by ambulance after a witnessed generalised tonic-clonic seizure. He had initially appeared to recover but did not regain consciousness on his way to the hospital and has now started seizing again. Intravenous access is obtained, and he is given 4mg of lorazepam, but after 10 minutes, there is no response.

What is the next step in your management?

Options:
explanation: This is the next step if two doses of benzodiazepines do not work and the patient continues to be in status epilepticus. Be aware that phenytoin infusions are likely to cause a drop in blood pressure
name: Start a phenytoin infusion
label: c
answer: no
explanation: This patient may well need a neurology review and further investigations; however, the acute issue is their seizures, and the patient needs to be stabilised before referring to a specialty
name: Refer to neurology
label: e
answer: no
explanation: This would be a reasonable choice if the patient did not have IV access, but as we have secured access in this patient, IV lorazepam is a better option as it is faster acting and does not run the risk of whoever is administering it being accidentally bitten by the patient while they seize
name: Give 10mg buccal midazolam
label: b
answer: no
explanation: This patient is in status epilepticus, defined as a seizure lasting >5 minutes; or repeated seizures without regaining consciousness. Initial management is basic life support alongside benzodiazepines.
name: Give a further intravenous (IV) 4mg lorazepam
label: a
answer: yes
explanation: Whilst airway protection is an important consideration and should be part of your initial and continuous assessment; we do not yet need to intubate in this instance. Other airway adjuncts may be better in the first instance, such as a nasopharyngeal airway
name: Intubate the patient
label: d
answer: no

Correct answer: a


Learning point: Status epilepticus requires immediate treatment with benzodiazepines, such as lorazepam.
A 16-year-old female presents to the emergency department after an episode of loss of consciousness witnessed by her mother. Her mother reports that her daughter fell to the floor without warning then started shaking and making grunting noises. Her eyes were closed throughout, and her main movements were back arching and pelvic thrusting. She reports that she has bitten the tip of her tongue but retained continence. The episode lasted about 5-10 minutes in total.
Blood tests, urinalysis and examination findings are all normal.
What is the most likely diagnosis?

Options:
explanation: This is less likely to be the case here as the movements described are not typical of a tonic-clonic seizure where the movements are more synchronous jerking of the limbs, with the head often remaining still. Tongue biting in epileptic seizure is more commonly a lateral bite, and incontinence is frequently reported
name: Tonic-clonic seizure
label: b
answer: no
explanation: This is a relatively typical description of non-epileptic attack disorder. The more informal term for this condition is a pseudoseizure. The movements described in terms of back arching and pelvic thrusting are less in keeping with a tonic-clonic seizure. The eyes tend to remain open, and making noise is less likely in true epileptic seizures. Tongue biting may occur in both true seizures and non-epileptic attacks; however in epileptic seizures, it is usually the sides of the tongue that are bitten as opposed to the tip. Other signs that would point towards non-epileptic attacks are if they always occur in the company of others or if stressful or highly emotional situations induce them
name: Non-Epileptic Attack Disorder
label: a
answer: yes
explanation: Whilst vasovagal syncope is common in young females, the description above is more in keeping with a non-epileptic attack than a vasovagal syncope as syncopal episodes usually only last 30 seconds to 2 minutes, and any movements are also short-lived. Tongue biting is also rare in syncope, and the patient usually reports more prodromal symptoms such as disturbed vision, palpitations and feeling warm
name: Vasovagal syncope
label: d
answer: no
explanation: Absence seizures are a form of epilepsy most common in children and are commonly associated with being very still, fluttering of the eyelids and suddenly stopping activity. They can occur with muscle jerking and shaking, though this is less common than with other forms of epileptic seizure
name: Absence seizure
label: e
answer: no
explanation: There is no evidence in the case vignette that this episode is related to low blood sugar, and the blood tests are reported to be normal. It is always good to bear in mind hypoglycaemia in young women and, in particular, in diabetic patients on insulin or sulfonylureas such as gliclazide.
Symptoms of low blood sugars include sweating, dizziness, tingling lips and can cause unusual behaviour, seizures and collapse if untreated
name: Hypoglycaemic episode
label: c
answer: no

Correct answer: a


Learning point: Non-Epileptic Attack Disorder, or pseudoseizures, often presents with unusual movements and can be triggered by emotional stress.
A 65-year-old male attends the Emergency Department complaining of progressive numbness and weakness that started in his legs and moved slowly up his body. He has recently had an episode of diarrhoea and vomiting after eating a "dodgy takeaway".

He has been transferred to the hospital's adjoining tertiary neurology centre with a presumed diagnosis of Guillain-Barré Syndrome (GBS). On arrival in the neurology ward, he appears breathless.

What is the most appropriate investigation to help predict the need for intubation?

Options:
explanation: A lumbar puncture in Guillain-Barré Syndrome typically shows an elevated cerebrospinal fluid (CSF) protein with a normal cell count. LP findings do not correlate with severity of illness or need for intubation
name: Lumbar puncture (LP)
label: c
answer: no
explanation: Whilst a chest x-ray would rule out other causes of breathlessness, this patient is presumed to have Guillain-Barré Syndrome, and a chest x-ray is likely to be normal, and would not help to predict the need for intubation
name: Chest x-ray
label: b
answer: no
explanation: In the absence of signs and symptoms of pulmonary embolism, CTPA is unlikely to be of value in this case. A normal CTPA does not preclude the need for intubation in Guillain-Barré Syndrome
name: CT pulmonary angiogram (CTPA)
label: e
answer: no
explanation: An arterial blood may be normal in Guillain-Barré Syndrome, with hypoxia or hypercapnoea being a late sign of impending neuromuscular respiratory failure. Spirometry is recommended as a more accurate reflection of a patients requirement for respiratory support
name: Arterial blood gas (ABG)
label: d
answer: no
explanation: This patient has Guillain-Barré Syndrome (GBS), characterised by the preceding gastrointestinal illness and the pattern of bilateral ascending weakness. Bedside spirometry, particularly forced vital capacity (FVC) has a significant correlation with the risk of respiratory failure and need for intubation. If the FVC < 20mL/Kg, the patient likely needs intensive care, and if <15mL/Kg, likely requires intubation
name: Bedside spirometry
label: a
answer: yes

Correct answer: a


Learning point: In Guillain-Barré Syndrome (GBS), bedside spirometry is used to assess respiratory function, detecting weakness in respiratory muscles. Reduced vital capacity and peak flow suggest the need for respiratory support or monitoring.
A 74-year-old male is referred to the falls clinic after he suffers three mechanical falls at home within two months. He has a past medical history that includes postural hypotension, urinary incontinence, recurrent chest infections and six months ago was diagnosed with Parkinson's disease. He currently takes, co-benyldopa and has just finished a course of amoxicillin. On examination, you note that he has hypomimia, rigidity and bradykinesia with a very mild tremor.

You suspect a Parkinson's Plus Syndrome. Which of the following would you perform next?

Options:
explanation: Infection is a common cause of falls in the elderly. Common sources are urine and chest; however, there is nothing in the history suggestive of infection; therefore, whilst this is always worth checking, it is unlikely to provide a diagnosis here
name: Urinalysis
label: d
answer: no
explanation: We know that this patient has postural hypotension, and therefore lying and standing blood pressure measurements would prove this to be true. However, there are many causes for postural hypotension in the elderly, and therefore this would not prove a Parkinson's plus syndrome
name: Lying and standing blood pressure measurement
label: b
answer: no
explanation: The two main differential diagnoses in this scenario are Progressive Supranuclear Palsy (PSP) and Multiple system atrophy (MSA). This patient likely has a Parkinson's plus syndrome as he has symptoms of autonomic instability (urinary incontinence, postural hypotension and recurrent chest infections, which raises a concern about poor swallow), and the co-benyldopa does not seem to have had much effect. It's important to test for vertical gaze palsy to help you narrow down your differential diagnosis. 
name: Testing vertical gaze
label: a
answer: yes
explanation: This history is not suggestive of syncopal episodes as a cause for his falls. Whilst an ECG should always be performed in patients with recurrent falls to look for arrhythmias; a stand-alone ECG is unlikely to pick up a cause for falls. 24 hour Halter monitoring is more sensitive and would be a reasonable investigation if there were concerns about a cardiac cause for his falls
name: 12 lead ECG
label: c
answer: no
explanation: Parkinson's disease is closely linked to Lewy Body Dementia, and therefore in all patients with Parkinson's disease, it is important to assess cognitive function. However, this would not account for the recurrent falls and would not be likely to aid further diagnosis here.
name: Abbreviated Mental Test (AMT)
label: e
answer: no

Correct answer: a


Learning point: In Parkinson's Plus Syndromes, vertical gaze testing reveals difficulty with downward gaze, impaired saccades, and smooth pursuit
A 58-year-old female presents to the Emergency Department concerned she has had a stroke. Her past medical history includes hypertension, gout, recurrent urinary tract infections, chronic kidney disease (CKD) stage three, type two diabetes on insulin, and a previous N-STEMI. On examination, she is GCS 15/15 and talking in complete and coherent sentences. She has normal power, tone, sensation, reflexes and coordination in all four limbs. She has double vision and a mild ptosis. Her pupils are both symmetrical and equal.

An MRI Head is performed which is normal.

Which of the following is the most likely underlying cause of her presentation?

Options:
explanation: Multiple Sclerosis is a definite cause of a medical third nerve palsy. However, the normal MRI Head, lack of any previous neurological history and significant vascular risk factors in her history point towards a more vasculopathic process
name: Multiple Sclerosis
label: d
answer: no
explanation: Urinary tract infection is unlikely to be implicated in causing an isolated third nerve palsy
name: Urinary tract infection
label: c
answer: no
explanation: This is the cause of a 'surgical' third nerve palsy. Note that this is a medical third nerve palsy which is pupillary sparing rather than a 'surgical' third nerve palsy where aneurysms, tumours and raised intracranial pressure can push on the outer autonomic fibres of the nerve, causing the pupil to dilate. In a medical third palsy, only the inner motor fibres are affected so the pupils are spared
name: Cerebral artery Aneurysm
label: b
answer: no
explanation: There are no real signs of raised intracranial pressure in this scenario. Also you would expect there to be pupillary dilatation secondary to pressure on the outer autonomic fibres of the third cranial nerve
name: Raised intracranial pressure
label: e
answer: no
explanation: This patient has an oculomotor nerve palsy (cranial nerve III), and one of the common medical causes of this presentation is due to vasculopathic ischaemia to the third nerve. Note that this is a medical third nerve palsy which is pupillary sparing rather than a 'surgical' third nerve palsy where aneurysms, tumours and raised intracranial pressure can push on the outer autonomic fibres of the nerve, causing the pupil to dilate. In a medical third palsy, only the inner motor fibres are affected so the pupils are spared
name: Diabetes
label: a
answer: yes

Correct answer: a


Learning point: Medical third nerve palsy, often caused by diabetes, involves damage to the oculomotor nerve, resulting in ptosis, ocular misalignment ("down and out" eye), and normal pupil reaction.
A 28-year-old female gives birth to her second child at full term following an uneventful pregnancy. You check on the baby three hours after delivery, and you notice that the neonate is jaundiced. Observations are otherwise normal.

What test would confirm your diagnosis?

Options:
explanation: Whilst liver function tests would help confirm whether this was true jaundice, they would not help diagnose the underlying cause
name: Liver function tests
label: c
answer: no
explanation: A liver ultrasound would be useful in diagnosing biliary atresia, serious but rare cause of neonatal jaundice. However, biliary atresia usually develops around three weeks after birth. This history is more in keeping with an acute haemolytic cause for jaundice than a structural issue
name: Liver ultrasound
label: d
answer: no
explanation: Breastfeeding is a common cause for prolonged jaundice in newborns; however, it would not develop in the first few hours of life. Visible jaundice in the first 24 hours of life is always abnormal
name: Withdrawal of breastfeeding
label: e
answer: no
explanation: This history suggests rhesus haemolytic disease of the newborn, as this is a woman in her second pregnancy, and the jaundice is apparent in the first 24 hours after birth. You would therefore expect a positive direct Coombs test. A direct Coombs test is used to test for autoimmune haemolytic anaemia where the immune system breaks down red blood cells, leading to anaemia. The direct Coombs test is used to detect antibodies or complement proteins attached to the surface of red blood cells
name: Direct Coombs test
label: a
answer: yes
explanation: An indirect Coombs test looks at antibodies floating freely in the blood and, therefore, can be used in prenatal testing for pregnant women or in testing prior to blood transfusion. A positive indirect Coombs would not diagnose the cause for haemolysis in this case
name: Indirect Coombs test
label: b
answer: no

Correct answer: a


Learning point: Rhesus haemolytic disease of the newborn typically presents with jaundice within 24 hours of birth and is confirmed by a positive direct Coombs test.