hllj/quesmed huggingface dataset:
A 65 year old gentleman presents to Accident & Emergency with a 5 day history of persistent haematuria. He has a background of atrial fibrillation and is on warfarin.


Blood tests are as follows:

||||
|--------------|:-------:|---------------|
|Haemoglobin|115  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|9.1x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|210x10<sup>9</sup>/L|150 - 400|
|Neutrophils|5.5 x10<sup>9</sup>/L|2.0 - 7.5|
|Sodium|137 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Chloride|102 mmol/L|95 - 106|
|Urea|8 mmol/L|2.5 - 7.8|
|Creatinine|95 µmol/L|60 - 120|
|eGFR|85 mL/min/1.73m<sup>2</sup>|> 60|
|International Normalised Ratio (INR)|2.1|1.0|


Urinalysis showed red blood cells with no evidence of leucocytes or nitrites. Computed tomography (CT) of kidneys, ureters and bladder showed no stones.


Which is the next most appropriate investigation?

Options:
explanation: This may be useful in looking for metastases, but it would not be useful in diagnosing suspected renal or bladder cancer
name: CT abdomen pelvis
label: c
answer: no
explanation: This is usually indicated in nephrotic syndrome, acute nephritic syndrome or unexplained acute kidney injury, which is not the case here
name: Renal biopsy
label: e
answer: no
explanation: Guidelines state that any adult >45 years with unexplained visible haematuria without a urinary tract infection should have a 2 week referral for suspected renal or bladder cancer. Cystoscopy with biopsy is the gold standard for diagnosing bladder cancer, as it allows direct visualisation of the bladder
name: Flexible cystoscopy
label: a
answer: yes
explanation: This is best used for excluding urinary tract obstruction and can be used to visualise cysts, abscesses, hydronephrosis and other complications of pyelonephritis. It would not be the best in investigating suspected malignancy
name: Ultrasound of the kidneys, ureters and bladder
label: b
answer: no
explanation: This would be useful in looking for gastrointestinal cancer, which should be suspected in a patient with unexplained iron deficiency anaemia, change in bowel habit, melaena and other constitutional symptoms
name: Colonoscopy
label: d
answer: no

Correct answer: a


Learning point: In adults over 45 with unexplained visible haematuria, flexible cystoscopy is essential for diagnosing potential bladder cancer.
A 85 year old male is admitted with acute urinary retention. Over the past year, he has been having urinary hesitancy and poor stream with nocturia up to 5-6 times a night. He had an objective 3kg loss of weight in the last year.

Digital rectal examination (DRE) reveals a hard, asymmetrically enlarged prostate. Prostate specific antigen is elevated at 15ng/mL.

Which of the following is the next most appropriate investigation?

Options:
explanation: This would be most appropriate in patients with suspected prostate cancer after taking into account relevant risk factors including age, prostate specific antigen level, DRE findings and comorbidities. However, this method is invasive and may risk missing the cancer depending on the area biopsied
name: Transrectal ultrasound biopsy
label: b
answer: no
explanation: If there is a very high clinical suspicion of localised prostate cancer, clinicians should proceed directly to multiparametric MRI as a first-line investigation. This would reduce the risk of unnecessary prostate biopsies
name: Magnetic resonance imaging (MRI) scan of the prostate
label: a
answer: yes
explanation: This would be useful in investigating causes of obstructive uropathy. However, as prostate cancer is the most likely cause in this scenario given the DRE findings, it is better to proceed with an MRI prostate first
name: Ultrasound of the kidneys, ureters and bladder
label: d
answer: no
explanation: This would be useful in watchful waiting for asymptomatic patients in whom hormonal therapy is being deferred or as a staging scan for bone metastases. However, it is not the most useful in making a diagnosis of prostate cancer
name: Isotope bone scan
label: c
answer: no
explanation: This may be useful in investigating voiding dysfunction in patients with lower urinary tract symptoms that point towards chronic bladder outflow obstruction. However, it would not be useful in a patient which has a high clinical likelihood of prostate cancer
name: Urodynamic studies
label: e
answer: no

Correct answer: a


Learning point: In cases of suspected prostate cancer, multiparametric MRI is the preferred initial investigation to minimise unnecessary biopsies.
A 70 year old lady is admitted with a 1 month history of worsening lower back pain. She also reports feeling more fatigued and constipated recently.



Initial blood tests are as follows:



||||
|--------------|:-------:|---------------|
|Haemoglobin|102  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|9.1x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|210x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|85 fL|80 - 96|
|Sodium|137 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Chloride|102 mmol/L|95 - 106|
|Urea|8 mmol/L|2.5 - 7.8|
|Creatinine|181 µmol/L|60 - 120|
|Calcium|3.1 mmol/L|2.2 - 2.6|
|eGFR|43 mL/min/1.73m<sup>2</sup>|> 60|
|Albumin|40 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|21 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|32 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|266 IU/L|25 - 115|
|Bilirubin|7 µmol/L|< 17|
|Gamma Glutamyl Transferase (GGT)|20 U/L|9 - 40|





Thoracolumbar spine X-rays reveal multilevel compression fractures.



She is started on intravenous hydration.



Which of the following is the most appropriate treatment to initiate for her hypercalcaemia?

Options:
explanation: This may be considered as a second line to bisphosphonates. It works by increasing renal calcium excretion and reducing bone resorption by osteoclasts. It is useful in rapidly lowering calcium levels, but bisphosphonates would provide a more sustained effect
name: Calcitonin
label: c
answer: no
explanation: This is a parathyroid hormone analogue used as a second-line treatment for osteoporosis. It should not be used in this scenario as it will exacerbate hypercalcaemia
name: Furosemide
label: d
answer: no
explanation: This is a parathyroid hormone analogue used as a second-line treatment for osteoporosis. It should not be used in this scenario as it will exacerbate hypercalcaemia
name: Teriparatide
label: b
answer: no
explanation: This patient has a likely new diagnosis of multiple myeloma, as evidenced by the anaemia, renal impairment, pathologic fractures and hypercalcaemia. Bisphosphonates are used in hypercalcaemia of malignancy and renal impairment should be considered when choosing a particular agent for initiation
name: Bisphosphonates
label: a
answer: yes
explanation: This is a calcimimetic that works by increasing the sensitivity of the calcium-sensing receptor on the parathyroid gland, thereby lowering parathyroid hormone and calcium levels. It is typically used in medical therapy of primary hyperparathyroidism where surgery is not suitable. It would be a second-line agent in this scenario
name: Cinacalcet
label: e
answer: no

Correct answer: a

Bisphosphonates
A 75-year-old woman presents with worsening joint pain and swelling in her hands, wrists, and knees, along with deep bone aches that disrupt her sleep. She has lost 5kg over the past year with poor appetite. She has no significant medical history, occupational exposure, or smoking history.


On examination, she has clubbing bilaterally. She has symmetrical polyarthritis of the wrists, metacarpal joints and knees; with pain, swelling and reduced range of motion of the affected joints.


X-rays of her tibia and fibula are suggestive of periosteal bone formation.


Chest X-ray shows a left lower lobe mass. The medical team decides to arrange an interventional radiology guided biopsy of the mass lesion.


Which of the following histology findings are most likely?

Options:
explanation: This has the highest association with smoking amongst the lung cancers. It typically presents with centrally located lung masses and tends to be associated with Cushing's syndrome due to ectopic production of adrenocorticotropic hormone. It is not likely here as it is very rare in patients who have never smoked
name: Small cell lung carcinoma
label: b
answer: no
explanation: This is most commonly associated with asbestos exposure and would typically present with bilateral pleural thickening and plaques. This is not likely given her lack of occupational exposure
name: Mesothelioma
label: e
answer: no
explanation: This has the highest association with smoking amongst the lung cancers. It typically presents with centrally located lung masses and tends to be associated with Cushing's syndrome due to ectopic production of adrenocorticotropic hormone. It is not likely here as it is very rare in patients who have never smoked
name: Large cell carcinoma
label: d
answer: no
explanation: This is the second most common type of lung cancer and has a strong association with smoking compared to other non-small cell lung carcinomas. It is usually centrally located and originates in the bronchi. Associated paraneoplastic phenomena usually includes hypercalcaemia secondary to secretion of parathyroid hormone related peptide
name: Squamous cell carcinoma
label: c
answer: no
explanation: This is the most common type of lung cancer, especially in females and non-smokers. This patient has presented with hypertrophic osteoarthropathy, with clubbing and a painful arthropathy that can be quite similar to inflammatory arthritis. It is most frequently associated with adenocarcinoma
name: Adenocarcinoma
label: a
answer: yes

Correct answer: a

Adenocarcinoma

Learning point: Hypertrophic osteoarthropathy, characterised by clubbing and joint pain, is commonly associated with lung adenocarcinoma, particularly in non-smoking females.
A 90 year old gentleman is admitted to the medical ward with an infected sacral sore. He has a background of advanced dementia and previous stroke. During his stay, he develops aspiration pneumonia and his condition begins to deteriorate.

He is reviewed by the Palliative team who plan to start him on end of life medications via a syringe driver. He is currently on oral morphine 10mg TDS and has required three breakthrough doses of oral morphine 2mg in the past day. What is the most appropriate subcutaneous breakthrough dose he should be prescribed?

Options:
explanation: Syringe drivers are given as continuous subcutaneous infusions over 24 hours. The oral morphine dose needs to be halved for subcutaneous (SC) administration via the syringe driver. The total daily oral morphine dose is (10mg x 3) + (2mg x 3) = 36mg. This would be SC morphine 18mg. As breakthrough doses should be one-sixth to one-tenth of the total daily dose, you should therefore prescribe him 2-3mg every hourly as required. The lower limit of the dose range may be prescribed to avoid concerns of toxicity. If more than 6 doses are required in 24 hours, consider seeking senior advice or review
name: 2mg hourly as required
label: a
answer: yes
explanation: Both the regular and breakthrough doses of oral morphine should be added together to obtain the total daily dose of oral morphine required. Furthermore, a shorter dosing interval between breakthrough doses would be required to allow for adequate pain relief
name: 5mg 6-8 hourly
label: d
answer: no
explanation: Both the regular and breakthrough doses of oral morphine should be added together to obtain the total daily dose of oral morphine required
name: 5mg hourly as required
label: e
answer: no
explanation: This breakthrough dose would be too high for his current pain requirements. The conversion ratio from oral to subcutaneous morphine is 2:1
name: 10mg hourly as required
label: c
answer: no
explanation: A shorter dosing interval between breakthrough doses would be required to allow for adequate pain relief
name: 2mg 6-8 hourly
label: b
answer: no

Correct answer: a


Learning point: In palliative care, subcutaneous breakthrough doses of morphine should be one-sixth to one-tenth of the total daily oral morphine dose.
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: This is typically an X-linked recessive disorder
name: Androgen insensitivity syndrome
label: c
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 an autosomal recessive disorder that may also cause premature ovarian failure
name: Galactosemia
label: d
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

Correct answer: a


Learning point: Fragile X syndrome and Rett syndrome both exhibit X-linked dominant inheritance patterns, affecting primarily females.
A 55 year old man presents to his GP with a 6 month history of multiple hypopigmented patches over his torso. He also has multiple burn marks on his hands from accidentally touching hot pans whilst cooking. Nerve conduction studies reveal reduced conduction velocity in the ulnar and median nerves. He is diagnosed with leprosy and started on dapsone.

Which one of the following tests should be performed before starting treatment?

Options:
explanation: This is not required
name: HIV testing
label: e
answer: no
explanation: Dapsone inhibits folic acid synthesis and should be given with folate supplementation. It does not affect B12 levels
name: Vitamin B12 levels
label: d
answer: no
explanation: Dapsone does not cause arrhythmias or cardiovascular events
name: Electrocardiogram (ECG)
label: c
answer: no
explanation: Dapsone undergoes hepatic metabolism and does not require dosage adjustment in renal impairment
name: Renal function testing
label: b
answer: no
explanation: Dapsone carries the risk of severe haemolytic anaemia in patients with severe G6PD deficiency
name: Glucose-6-phosphate dehydrogenase (G6PD) levels
label: a
answer: yes

Correct answer: a


Learning point: Dapsone carries the risk of severe haemolytic anaemia in patients with severe G6PD deficiency
A 70-year-old retired statistician attends his General Practitioner's surgery for a routine medical checkup. He has done some reading online and would like to ask for advice on the utility of prostate specific antigen (PSA) testing to determine his likelihood of prostate cancer.

He has found a study in a population of 2000 males above 60 years old evaluating the prostate cancer detection rate using a PSA cut off of 4.0ng/mL. The data are as follows:

|               | Disease present | Disease absent |
| ------------- | --------------- | -------------- |
| Positive test | 100             | 300            |
| Negative test | 400             | 1200           |

Which of the following is true based on the evidence above?

Options:
explanation: Based on the evidence given, the sensitivity of PSA testing is only 20%, which is not high. This means that some men with low PSA levels might still have prostate cancer. However, lowering the PSA cutoff level may worsen specificity and result in overdiagnosis
name: The PSA level is a very sensitive test in diagnosing prostate cancer
label: e
answer: no
explanation: The PPV is calculated as (True positives)/(True positives + False positives) = 100/ (100 + 300) = 25%. The value of 75% is referring to the negative predictive value
name: The positive predictive value (PPV) of the PSA test is 75%
label: c
answer: no
explanation: There aree 100 true positives and 300 false positives = 400 total.The proportion of those men who actually have prostate cancer is 100 out of that 400 total, or 25%, which is the positive predictive value.

name: 1 in 5 people who test positive actually turn out to have prostate cancer
label: d
answer: no
explanation: The specificity is defined as the proportion of people who test negative among all those who actually do not have the disease. It is calculated as (True negatives)/ (True negatives + False positives) = 1200/ (1200 + 300) = 80%.

The value of 20% is referring to the sensitivity of the test
name: The specificity of the PSA test is 20%
label: b
answer: no
explanation: There aree 100 true positives and 300 false positives = 400 total.The proportion of those men who actually have prostate cancer is 100 out of that 400 total, or 25%, which is the positive predictive value.

name: 1 in 4 people who test positive actually turn out to have prostate cancer
label: a
answer: yes

Correct answer: a


Learning point: Positive Predictive Value (PPV) is the probability that a positive test result accurately reflects the presence of a disease, calculated as TP/(TP + FP). Higher PPV indicates greater test reliability.
A 21-day old baby boy is brought into the Emergency Department by his worried mother as he has been having shortness of breath and irritability during feeds. His weight is on the 5th percentile for his age.

His mother has diabetes mellitus, but otherwise had an uncomplicated pregnancy and spontaneous vaginal delivery at 38 weeks.

He is tachypnoeic with accessory muscle use. On examination, there is a pansystolic murmur at the lower left sternal border and hepatomegaly.

An electrocardiogram shows right axis deviation. Chest X-ray (CXR) reveals a narrow mediastinum and an enlarged heart.

Which is the most definitive management of his condition?

Options:
explanation: This would be part of initial management to maintain patency of the ductus arteriosus, allowing blood to travel from the left to the right side of the heart. However, in this case, the presence of a ventricular septal defect would already allow for left to right shunting of blood
name: Prostaglandin infusion
label: c
answer: no
explanation: This is a prostaglandin antagonist that is used in the treatment of patent ductus arteriosus. Anatomical closure would likely already have occurred at this age. Furthermore, it should not be used in cyanotic heart disease as it would worsen hypoxaemia by closing off the left to right shunt
name: Indomethacin
label: b
answer: no
explanation: This is a surgical procedure done to stabilise patients with severe hypoxaemia due to inadequate mixing between the two parallel circuits in transposition of the great arteries (TGA). A balloon is placed across the atrial septum and used to enlarge the foramen ovale or existing atrial septal defect. However, it is only a temporary measure before corrective surgery for TGA
name: Balloon atrial septostomy
label: e
answer: no
explanation: This neonate has transposition of the great arteries (TGA) and has presented in heart failure. He has not developed rapid cyanosis on day 2 of birth (with closure of the ductus arteriosus) but has presented later at a few weeks of age, as the presence of a ventricular septal defect (VSD) has allowed for improved inter-circulatory mixing. The classical finding on CXR would be an "egg on string" appearance. The definitive treatment would be an operation to translocate both the great arteries to the opposite root, establishing ventriculoarterial concordance
name: Arterial switch operation
label: a
answer: yes
explanation: This would be an initial surgical procedure done in Tetralogy of Fallot to create a pathway between the subclavian and pulmonary arteries, thus relieving cyanosis whilst awaiting definitive corrective surgery
name: Blalock-Taussig shunt
label: d
answer: no

Correct answer: a


Learning point: The arterial switch operation is the standard surgical treatment for transposition of the great arteries (TGA), a congenital heart defect where the aorta and pulmonary artery are swapped. This procedure involves switching the positions of the aorta and pulmonary artery, reattaching the coronary arteries to the new aorta, and correcting the alignment to restore normal circulation.
A 32-year-old man presents to his General Practitioner (GP) with a 3-day history of sharp, constant central chest pain. He reports the pain to be worse on inspiration and relieved by sitting forward. On questioning, he reveals a 1-week history of coryzal symptoms and myalgia, which are now improving. He denies cough, shortness of breath or palpitations.

He has no significant past medical history and examination and all observations are unremarkable.

An ECG shows widespread PR depression and concave ST elevation.

Given the likely diagnosis, which of the following is the first-line management?

Options:
explanation: Nebulised bronchodilators would be indicated in asthma. There are no features to suggest asthma such as shortness of breath, wheeze or a prior history of atopy
name: Nebulised bronchodilators
label: c
answer: no
explanation: The most likely diagnosis is acute pericarditis. This is inflammation of the pericardium that typically lasts for less than 4-6 weeks and is characterised by central chest pain relieved by sitting forward. The pain is also pleuritic, meaning that it is worse on inspiration. As described in this case, a prodromal viral illness may be associated with pericarditis as a viral infection is a common precipitant.

The most specific sign on ECG for acute pericarditis is PR depression. This can also be associated with widespread, concave ST elevation.

The first-line management of pericarditis is with a short course of a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen
name: Non-steroidal anti-inflammatory drug (NSAID)
label: a
answer: yes
explanation: LMWH would be used for the treatment of a pulmonary embolus (PE). A PE is an important differential to consider in this case as it can present with pleuritic chest pain. However, pain relieved by sitting forward and a history of a recent viral illness favour a diagnosis of pericarditis more
name: Low molecular weight heparin (LMWH)
label: e
answer: no
explanation: Pleuritic chest pain can be a sign of pneumonia for which antibiotics would be indicated. However, the ECG findings in combination with the prodrome of coryzal prodrome is suggestive of acute pericarditis
name: Oral antibiotics
label: b
answer: no
explanation: Aspirin would be indicated in acute coronary syndrome (ACS). This patient's pain does not have any ischaemic characteristics and is pleuritic in nature. He also does not have any risk factors for ischaemic heart disease
name: Aspirin 300mg
label: d
answer: no

Correct answer: a


Learning point: Acute pericarditis presents with pleuritic chest pain, often relieved by sitting forward, and is initially managed with NSAIDs.