hllj/quesmed huggingface dataset:
A 18 year old patient presents to his GP with ongoing issues managing acne vulgaris. On examination he has open and closed comedones with papules, pustules but no scarring, and the acne is confined to his face and back. He has tried using benzoyl peroxide and adapalene (a topical retinoid) with no significant effect.

Which of the following treatments would be a suitable next step for managing this patient's acne vulgaris?

Options:
explanation: This is a topical steroid and is not indicated in acne vulgaris
name: Topical hydrocortisone 1%
label: d
answer: no
explanation: Oral antibiotics should be prescribed along with benzoyl peroxide and/or a topical retinoid to reduce the risk of antibiotic resistance
name: Stop current therapy and start oral lymecycline
label: b
answer: no
explanation: This is a topical antibiotic and is not indicated for acne vulgaris. It may be used to treat a skin infection however
name: Topical fusidic acid 2%
label: e
answer: no
explanation: Lymecycline is an antibiotic which will is active again the bacteria Propionebacterium acnes which is associated with acne vulgaris. The topical retinoid should be continued alongside this to reduce the risk of antibiotic resistance
name: Add in oral lymecycline, in addition to current therapy
label: a
answer: yes
explanation: According to NICE guidelines, referral to dermatology is only warranted if the acne is severe, there is scarring, and multiple treatments in primary care have failed
name: Refer to dermatology
label: c
answer: no

Correct answer: a


Learning point: Lymecycline is an antibiotic which will is active again the bacteria Propionebacterium acnes which is associated with acne vulgaris.
A 30 year old man is referred to the outpatient ENT clinic with gradual onset bilateral sensorineural hearing loss and tinnitus.

On examination, he has absent corneal reflexes bilaterally.

An MRI cerebellopontine angle confirms bilateral vestibular schwannomas.

What is the most likely underlying diagnosis?

Options:
explanation: This is not a cause of bilateral vestibular schwannomas
name: Benign paroxysmal positional vertigo (BPPV)
label: d
answer: no
explanation: There is no known association between HIV/acquired immune deficiency syndrome (AIDS) and vestibular schwannomas
name: HIV
label: c
answer: no
explanation: Neurofibromatosis type 1 is also a genetic condition characterised by tumour formation within nervous tissue, and is more common than NF2, however is not associated with bilateral vestibular schwannomas. NF1 is associated with optic gliomas
name: Neurofibromatosis type 1 (NF1)
label: b
answer: no
explanation: Neurofibromatosis type 2 is a genetic condition characterised by tumour formation within nervous tissue. It is associated with bilateral vestibular schwannomas. They normally present by this age, unlike unilateral vestibular schwannomas which tend to present in older people
name: Neurofibromatosis type 2 (NF2)
label: a
answer: yes
explanation: This is age-related sensorineural hearing loss. We can be fairly certain that the hearing loss are from his bilateral vestibular schwannomas which are shown on the MRI. This would not explain why he has bilateral vestibular schwannomas
name: Presbycusis
label: e
answer: no

Correct answer: a


Learning point: Neurofibromatosis type 2 is characterised by bilateral vestibular schwannomas, typically presenting in young adults with hearing loss and tinnitus.
An 88 year old woman presents to her GP with recurrent episodes of dizziness and vertigo which she says is often brought on when rolling over in bed. The GP performs the Dix-Hallpike manoeuvre which is positive. She is keen for something to manage her symptoms.

What is the next best step in managing this patient's dizziness?

Options:
explanation: NICE guidelines suggest that ENT referral is only warranted if the signs of symptoms are atypical or do not resolve in 4 weeks, or there have been at least 3 periods during which the patient has experienced episodes of vertigo
name: Refer to ENT
label: c
answer: no
explanation: Symptomatic drug treatment is of limited value in managing BPPV
name: Betahistine
label: b
answer: no
explanation: Drug treatment is of limited value in the management of BPPV. Prochlorperazine may sometimes be used in viral labyrinthitis to manage dizziness
name: Prochlorperazine
label: d
answer: no
explanation: This is correct. This patient has benign paroxysmal positional vertigo (BPPV), as confirmed by the Dix-Hallpike manoeuvre. The patient can be taught Brandt-Daroff exercises to do at home. The patient should be advised to return after 4 weeks if her dizzy spells have not resolved
name: Brandt-Daroff exercises
label: a
answer: yes
explanation: This is an anti-emetic to reduce vomiting.
name: Ondansetron
label: e
answer: no

Correct answer: a


Learning point: Brandt-Daroff exercises involve a series of head and body movements performed at home to help reposition the otoliths in the inner ear, reducing the frequency and severity of vertigo episodes in benign paroxysmal positional vertigo (BPPV).
A 24 year old male presents to the Emergency Department with epistaxis which started 1 hour prior to being seen. The nurse practitioner has already applied nasal pressure for 15 minutes. On examination using a nasal speculum, there is an obvious bleeding site in the anterior aspect of the septum. The patient is haemodynamically stable.

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

Options:
explanation: This is the next step in managing epistaxis if first aid measures have not worked and given that the appropriate expertise and facilities are available
name: Nasal cautery
label: a
answer: yes
explanation: This is only indicated if the patient has had nasal packing
name: Refer to ENT for admission for observation
label: d
answer: no
explanation: This would be the next step if the bleeding stopped with first aid measures
name: Naseptin cream
label: e
answer: no
explanation: This is not indicated at this stage as the patient is haemodynamically stable
name: Urgent transfer to ITU
label: c
answer: no
explanation: Nasal packing should only be considered in primary care if nasal cautery has been ineffective or the bleeding point cannot be seen
name: Nasal packing
label: b
answer: no

Correct answer: a


Learning point: Nasal cautery is indicated for managing anterior epistaxis when initial measures, such as nasal pressure, are ineffective.
A 75 year old is brought to the emergency department by his son who believes he has taken an intentional overdose of his bisoprolol. On arrival to the department he has a reduced GCS, a blood pressure of 88/58 mmHg, and a heart rate of 40 beats per minute. He is initially given atropine, but his heart rate only increases to 50 beats per minute and he remains hypotensive.

Which of the following is the next best step in the management of this patient's bisoprolol overdose?

Options:
explanation: This is a chelating agent used to reverse an overdose of iron
name: Desferrioxamine
label: e
answer: no
explanation: Glucagon can be used to manage beta blocker overdoses. Atropine may be tried when the patient is bradycardic and haemodynamically unstable (as in this case)
name: Glucagon
label: a
answer: yes
explanation: N-acetylcysteine is used in the management of paracetamol overdose
name: N-acetylcysteine
label: b
answer: no
explanation: IV bicarbonate is used in the management of salicylate (eg. aspirin) or tricyclic antidepressant overdose
name: IV bicarbonate
label: c
answer: no
explanation: Naloxone is used in the management of opioid overdose
name: Naloxone
label: d
answer: no

Correct answer: a


Learning point: Glucagon is an effective treatment for beta-blocker overdose, particularly in cases of bradycardia and hypotension.
A 55 year old presents to the emergency department with sudden onset of breathlessness. He is known to have chronic obstructive pulmonary disease (COPD) and has smoked 20 cigarettes per day for approximately 40 years. His chest x-ray shows a pneumothorax of approximately 3cm in size.

His observations are all normal and his saturations are 96% on air.

What is the next step in this patient's management?

Options:
explanation: High flow oxygen is not indicated at this stage. He has normal saturations on room air and, in addition to this, it is not unreasonable to suspect that this patient might be oxygen sensitive given his background of COPD
name: High flow oxygen
label: d
answer: no
explanation: This would be the case if the patient's pneumothorax was less than 1cm
name: Observe for 24h
label: c
answer: no
explanation: This would be the case if the patient's pneumothorax was an acceptable size without high-risk characteristics
name: Aspiration
label: b
answer: no
explanation: This is correct. As this man is over 50 and has a significant smoking history, and is known to have lung disease, this is a pneumothorax with high-risk characteristics. The pneumothorax is over 2cm in size and is therefore amenable to drainage, with chest drain the best option.
name: Admit to hospital for a chest drain
label: a
answer: yes
explanation: This patient has a pneumothorax with high-risk characteristics and so this patient requires admission and insertion of a chest drain
name: Discharge with safety netting advice
label: e
answer: no

Correct answer: a


Learning point: For a pneumothorax greater than 2 cm in a high-risk patient, management typically involves needle aspiration or chest tube insertion to relieve pressure, improve lung expansion, and prevent complications like tension pneumothorax.
A cardiac arrest is called to a medical ward. On arrival, the patient is unresponsive and not breathing. Nursing staff on the ward have already commenced cardiopulmonary resuscitation (CPR) at a rate of 30:2 and attached the defibrillator. An ECG shows normal sinus rhythm, but central pulses cannot be felt.

According to the advanced life support (ALS) guidelines, what is the next step in this instance?

Options:
explanation: PEA is a non-shockable rhythm and therefore shocks are not indicated
name: Give 1 shock, immediately resume CPR and reassess rhythm in 2 minutes
label: c
answer: no
explanation: Rhythm should be reassessed in 2 minutes
name: Immediately resume CPR and then reassess rhythm in 5 minutes
label: b
answer: no
explanation: This patient has pulseless electrical activity (PEA), which is a non-shockable rhythm. The management should include immediate resumption of CPR, with a rhythm check in 2 minutes
name: Immediately resume CPR and then reassess rhythm in 2 minutes
label: a
answer: yes
explanation: This should only be attempted after ROSC
name: Examine the patient using an ABCDE approach
label: e
answer: no
explanation: This should only be done after return of spontaneous circulation (ROSC)
name: 12 lead ECG
label: d
answer: no

Correct answer: a


Learning point: In pulseless electrical activity (PEA), immediate CPR resumption is crucial, followed by rhythm reassessment after two minutes.
A known type 2 diabetic presents to the emergency department with generalised fatigue and vomiting. They have a reduced level of consciousness and are clinically dehydrated.


They are currently prescribed metformin 500mg once daily for their type 2 diabetes.


Their biochemical results may be seen below:

||||
|---------------------------|:-------:|------------------------------|
|Non-fasting Glucose|35 mmol/L|< 6.1|
|Sodium|144 mmol/L|135 - 145|
|Potassium|4.5 mmol/L|3.5 - 5.3|

 - Serum osmolarity: raised
 - Ketones: normal


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

Options:
explanation: This is the management for hyperkalaemia. This patient has a normal potassium level and likely has hyperosmolar hyperglycaemic state (HHS). There is evidence to suggest that patients with HHS actually tend to have worse outcomes if they are treated with the diabetic ketoacidosis (DKA) protocol such as with an insulin infusion
name: Insulin and dextrose infusion
label: c
answer: no
explanation: This is incorrect. This patient has hyperosmolar hyperglycaemic state (HHS) which should be treated with fluids. There is evidence to suggest that patients with HHS actually tend to have worse outcomes if they are treated with the diabetic ketoacidosis (DKA) protocol such as with an insulin infusion
name: Sliding scale insulin infusion
label: b
answer: no
explanation: This is the first line fluid for management of hyperosmolar hyperglycaemic state (HHS). Compared to the serum of a patient with HHS, 0.9% is relatively hypotonic so should restore serum osmolarity to a normal level
name: IV 0.9% NaCl
label: a
answer: yes
explanation: This patient has hyperosmolar hyperglycaemic state (HHS) which should be addressed and treated before consideration of adjusting their long term diabetic medication
name: Increase their metformin to 500mg twice daily
label: e
answer: no
explanation: This is the management of hyponatraemia in a euvolaemic patient. This patient has a normal sodium level and has is noted to be clinically dehydrated. This patient likely has hyperosmolar hyperglycaemic state (HHS) which leads to severe dehydration which is managed with IV fluids (not restricting)
name: Fluid restriction to 1L per day
label: d
answer: no

Correct answer: a


Learning point: In hyperosmolar hyperglycaemic state (HHS), intravenous 0.9% NaCl is the first-line treatment to restore fluid balance and serum osmolarity.
A 21 year old female presents to the emergency department. She claims she has taken an overdose of aspirin 90 minutes ago. She has a GCS of 15 and her blood tests reveal a salicylate concentration of 550 mg/L (normal therapeutic range 15-30 mg/dL).


Which of the following is the best management for this patient?

Options:
explanation: Oral bicarbonate is not advisable as raising the pH of the gastrointestinal lumen can lead to remaining salicylate tablets in the gastrointestinal tract to dissolve and increase absorption of salicylates
name: Oral bicarbonate
label: b
answer: no
explanation: This is correct. This patient should be considered for urinary alkalinisation with IV sodium bicarbonate, although local protocols should be consulted
name: IV sodium bicarbonate
label: a
answer: yes
explanation: Gastric lavage should only be considered within 1 hour of a potentially life threatening overdose
name: Gastric lavage
label: d
answer: no
explanation: This is the management for opioid overdose
name: Naloxone
label: e
answer: no
explanation: This is only indicated in patients with plasma salicylate concentration >700mg/L, severe acidosis, acute kidney injury, congestive cardiac failure or pulmonary oedema
name: Emergency haemodialysis
label: c
answer: no

Correct answer: a


Learning point: Urinary alkalinisation with intravenous sodium bicarbonate is a key treatment for severe salicylate toxicity.
A patient self presents after taking an overdose of their amitriptyline approximately two and a half hours ago. An ECG shows a ventricular arrhythmia.

Which of the following is indicated in this patient?

Options:
explanation: Vitamin K may be used to reverse warfarin ovedose
name: Vitamin K
label: b
answer: no
explanation: This is a tertiary option after IV sodium bicarbonate and IV benzodiazepine
name: Phenobarbital
label: d
answer: no
explanation: This is used in the management of paracetamol overdose
name: N-acetylcysteine
label: e
answer: no
explanation: This, or IV lorazepam, is a second line option after IV sodium bicarbonate
name: Diazepam
label: c
answer: no
explanation: Sodium bicarbonate is indicated in patients with a tricyclic antidepressant (TCA) overdose who have an arrhythmia. This should be bolused, and once narrowing of the QRS is shown, this should be switched to an infusion
name: Sodium bicarbonate
label: a
answer: yes

Correct answer: a


Learning point: Sodium bicarbonate is the treatment of choice for ventricular arrhythmias in tricyclic antidepressant overdose, particularly to narrow the QRS complex.
A 30-year-old female presents to the Emergency Department with a one-week history of polyuria, reduced appetite, nausea and vomiting. On examination, her abdomen is soft and non-tender. She has the following blood tests:

||||
|---------------------------|:-------:|------------------------------|
|Non-fasting Glucose|5.8 mmol/L|< 6.1|
|Bicarbonate|17.5 mmol/L|22 - 29|
|pH|7.26|7.35 - 7.45|
|Anion gap|20 mEq/L|6 - 12|


She has a background of type 2 diabetes, for which she takes dapagliflozin and metformin.


Which of the following is the most likely diagnosis in this patient?

Options:
explanation: HHS leads to a significantly elevated glucose and not such a significant acidosis
name: Hyperosmolar hyperglycaemic state (HHS)
label: b
answer: no
explanation: This is likely euglycaemic DKA. Although this is a rare phenomenon, one of the most known causes is SGLT2 inhibitors. These are typical symptoms associated with DKA, and her blood tests are all typical of DKA, with the exception of the normal glucose. Therefore, this is euglycaemic DKA. She should be treated with the local DKA protocol
name: Diabetic ketoacidosis (DKA)
label: a
answer: yes
explanation: Gastroenteritis is unlikely to cause polyuria and acidosis such as this
name: Gastroenteritis
label: c
answer: no
explanation: Pyelonephritis is associated with dysuria and urinary frequency, not polyuria. It may cause nausea and vomiting. It would not normally cause an acidosis such as this
name: Pyelonephritis
label: e
answer: no
explanation: This is unlikely if her abdomen is soft and non-tender. Metabolic acidosis may occur in patients with peritonitis secondary to a perforated appendix, but they would almost certainly have a tender and rigid abdomen if this was the case
name: Appendicitis
label: d
answer: no

Correct answer: a


Learning point: Euglycaemic diabetic ketoacidosis can occur in patients on SGLT2 inhibitors, presenting with typical DKA symptoms despite normal glucose levels.
A 70-year-old female presents with acute back pain, and an x-ray spine reveals a fracture of the 4th lumbar vertebra.


She has the following blood tests:


||||
|---------------------------|:-------:|--------------------|
|Alkaline Phosphatase (ALP)|110 IU/L|25 - 115|
|Vitamin D|45 nmol/L|>50|
|Calcium|2.4 mmol/L|2.2 - 2.6|
|Phosphate|1.0 mmol/L|0.8 - 1.5|


A DEXA scan is later performed, which produces a T-score of -2.3.


What is the most likely diagnosis in this patient?

Options:
explanation: Advanced osteoarthritis can, in fact, produce a higher than normal T-score on DEXA scan due to osteophytes and disc narrowing, making the bone appear denser than it is. This patient has a low T-score
name: Osteoarthritis
label: c
answer: no
explanation: A T-score of <-2.5 is the threshold for a diagnosis of osteoporosis
name: Osteoporosis
label: b
answer: no
explanation: Osteomalacia classically causes low vitamin D levels, low calcium, low phosphate, and a raised alkaline phosphate. This is not the case in this patient who has normal levels for all of these investigations
name: Osteomalacia
label: d
answer: no
explanation: A T-score between -1.0 and -2.5 is consistent with a diagnosis of osteopenia
name: Osteopenia
label: a
answer: yes
explanation: Paget's disease classically causes a raised ALP level
name: Paget's disease
label: e
answer: no

Correct answer: a


Learning point: Osteopenia is diagnosed when a DEXA scan shows a T-score between -1.0 and -2.5, indicating reduced bone density.
A 40-year-old type 1 diabetic presents to her GP for a routine check-up. She has poor glycaemic control, her renal function has been deteriorating over the last few years, and she now has end-stage renal disease. She has a renal biopsy, and the histology is displayed below.

[lightgallery]

Which of the following is the most likely diagnosis?

Options:
explanation: The histology above displays Kimmelstiel-Wilson nodules which are the spherical, eosinophilic, sclerotic nodules characteristic of nodular diabetic glomerulosclerosis
name: Nodular glomerulosclerosis
label: a
answer: yes
explanation: This is a genetic condition that produces the characteristic biopsy finding of longitudinal splitting of the glomerular basement membrane, which resembles a "basket weave" appearance
name: Alport syndrome
label: d
answer: no
explanation: In minimal change disease the histology is normal, which is not seen on this slide. Minimal change disease is the most common cause of nephrotic syndrome in children.
name: Minimal change disease
label: b
answer: no
explanation: Histologically, IgA nephropathy is associated with proliferation and hypercellularity of the mesangium of the glomerulus. Immunostaining would reveal IgA deposits
name: IgA nephropathy
label: e
answer: no
explanation: Renal amyloidosis would histologically demonstrate amyloid deposits, which this slide does not
name: Amyloidosis
label: c
answer: no

Correct answer: a


Learning point: Nodular glomerulosclerosis, characterised by Kimmelstiel-Wilson nodules, is a common complication of long-standing type 1 diabetes leading to end-stage renal disease.
A 70-year-old patient is admitted to hospital with a stroke. During their hospital stay, they are started on enteral feeding via a nasogastric tube. They are persistently hyperglycaemic with their blood glucose monitoring as follows:


 - Monday AM: 14mmol/l
 - Monday PM: 13mmol/l
 - Tuesday AM: 15mmol/l
 - Tuesday PM: 16mmol/l
 (normal <6.1 mmol/l)

Their glucose levels were stable and consistently below 10mmol/l before enteral feeding was commenced. They have no past medical history of diabetes mellitus.


Which of the following is the best medication to start in this patient?

Options:
explanation: This is a GLP-1 analogue. It is recommended that patients who are hyperglycaemic after commencing enteral feeding should be started on insulin
name: Dulaglutide
label: e
answer: no
explanation: This is a DPP-4 inhibitor. It is recommended that patients who are hyperglycaemic after commencing enteral feeding should be started on insulin
name: Sitagliptin
label: d
answer: no
explanation: This is a sulphonylurea. It is recommended that patients who are hyperglycaemic after commencing enteral feeding should be started on insulin
name: Gliclazide
label: c
answer: no
explanation: This would be the first-line drug of choice in type 2 diabetes mellitus. However, as it would seem that the hyperglycaemia is a consequence of commencing enteral feeding, it is recommended that this patient is managed with insulin
name: Metformin
label: b
answer: no
explanation: According to the Joint British Diabetes Societies guideline, insulin should be commenced in those with persistent hyperglycaemia who have recently started enteral feeding
name: Insulin
label: a
answer: yes

Correct answer: a


Learning point: In patients with persistent hyperglycaemia following enteral feeding, insulin therapy is recommended to manage blood glucose levels effectively.