hllj/quesmed huggingface dataset:
A 49-year-old man presents to A&E with fever and myalgia. He denies any recent unwell contacts or coryzal symptoms. His past medical history includes chronic kidney disease stage 5, hypertension and a kidney transplant 6 weeks ago. On examination, he appears pale. He has a temperature of 38.5. His blood tests reveal deranged liver function.

Which of the following is the most likely causative organism?

Options:
explanation: This is incorrect because VZV can cause shingles in the later years of life when a patient is immunosuppressed. This would present as a painful, vesicular, dermatomal rash which this patient does not have. VZV is also screened for prior to a renal transplant.
name: Varicella Zoster Virus
label: d
answer: no
explanation: This is incorrect because Hepatitis C would present with fever,  malaise, and jaundice, with other risk factors in the history such as transmission through blood, birth, or sexual intercourse. Note that Hepatitis C would also cause deranged LFTs, but CMV infection is more likely in this patient following a renal transplant.
name: Hepatitis C
label: e
answer: no
explanation: This is incorrect because Hepatitis B would present with fever, malaise, and potentially jaundice, with other risk factors in the history such as transmission through blood, birth, or sexual intercourse. Note that acute Hepatitis B would also cause deranged LFTs with the AST and ALT possibly in the 1000s. However, CMV infection is more common in this patient following a renal transplant.
name: Hepatitis B
label: c
answer: no
explanation: This is incorrect because EBV would present with fever, lymphadenopathy and a sore throat. Hepatosplenomegaly may also be found on palpation. EBV infection in transplant patients typically occurs due to reactivation of latent EBV from donor tissue. It generally takes longer to present  (6 months+), and is often associated with post transplant lymphoproliferative disorder. As such, this case is too early post transplant to raise suspicion of an EBV mediated pathology.
name: Epstein-Barr Virus
label: b
answer: no
explanation: This is correct because this patient has recently undergone a renal transplant. These patients are at risk of reactivation of latent CMV from within donor tissue within the first 6 weeks after a transplant secondary to immunosuppression. Note that a fever and deranged LFTs are key features for identifying CMV infection. It is managed with ganciclovir.
name: Cytomegalovirus
label: a
answer: yes

Correct answer: a


Learning point: Cytomegalovirus reactivation from latent infection of the donor organ is a common complication in renal transplant patients, often presenting with symptoms such as fever, fatigue, and abnormal liver function tests, and may lead to more severe systemic illness if not promptly managed.
A 59-year-old man presents to A&E with a 3-hour history of chest pain. He says this came on suddenly whilst at work. He is currently taking amlodipine for hypertension and atorvastatin for hypercholesterolaemia. On examination, he appears clammy. His ECG shows ST depression and his blood tests reveal a raised troponin and a haemoglobin of 76. He has been initiated on treatment according to the Acute Coronary Syndrome (ACS) protocol.

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

Options:
explanation: Beta-blockers are usually indicated in the management of ACS, to reduce chest pain by reducing myocardial oxygen demand and also improve long-term outcomes. This question indicates that ACS management according to guidelines has already been commenced. As such, at this stage the priority should be to correct the anaemia.
name: Atenolol
label: e
answer: no
explanation: This is incorrect because this is the management for pericarditis. Pericarditis presents as pleuritic chest pain which improves on leaning forward and worsens on lying flat. Classical ECG findings are PR depression and widespread saddle-shaped ST elevation. It has many causes including viral infections. The first line treatment is usually an NSAID, and alternative treatments include colchicine.
name: Ibuprofen
label: c
answer: no
explanation: Cardiac patients at risk of myocardial ischaemia/with myocardial ischaemia, as in this case, should have a target haemoglobin level of above 80. Therefore, this patient requires a red blood cell transfusion as his haemoglobin is 76.  This is in order to maintain adequate myocardial perfusion. As he has already been initiated on ACS treatment, treating his haemoglobin should be the next priority.
name: Red blood cell transfusion
label: a
answer: yes
explanation: This is incorrect because this patient is having an NSTEMI and requires admission therefore, for treatment, cardiology review, monitoring, and a secondary percutaneous coronary intervention. Furthermore, his haemoglobin is low enough to meet the threshold for transfusion in a patient with cardiac ischaemia (<80.) It would be inappropriate to discharge him from A&E at this stage.
name: Discharge patient
label: b
answer: no
explanation: This is incorrect because FFP contains clotting factors which is used in the context of bleeding disorders or massive haemorrhage. This is not indicated in this patient because this would not help increase the haemoglobin level and there is no evidence of coagulopathy.
name: Fresh frozen plasma transfusion
label: d
answer: no

Correct answer: a


Learning point: In acute coronary syndrome, patients with a haemoglobin level below 80 g/L require a red blood cell transfusion.
A 35-year-old female presents to the GP with a painless lump in her breast. She says she found the lump this morning whilst she was in the shower and is alarmed by its presence. She is currently 24 weeks pregnant. On examination, the breast lump measures 2cm in the left breast, in the 6 o'clock position. It appears fixed to the skin. There is no evidence of axillary lymphadenopathy.

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

Options:
explanation: This is incorrect because this patient clearly meets the guidelines for a 2-week-wait referral to the breast clinic. Her lump has not been proven as benign and as such it would be wrong to reassure her at this stage.
name: Reassure patient
label: d
answer: no
explanation: This is incorrect because this is the management for fibrocystic disease. This would present as bilateral breast lumps which are commonly found in the upper, outer quadrant and patients usually experience breast pain. This is generally related to menstruation due to the build-up of oestrogen. This patient does not have typical features of fibrocystic disease, and requires further investigation.
name: Analgesia and support bra
label: e
answer: no
explanation: This is correct because this patient is over the age of 30 with an unexplained breast lump. This satisfies the criteria for a 2 week wait referral to the breast clinic where she will undergo a triple assessment. Note that this involves history and examination, ultrasound scanning, and a tissue biopsy if required. Although this patient is pregnant, there is no evidence of inflammation in the question stem to suggest alternative diagnoses.
name: Referral to breast clinic under 2 week wait pathway
label: a
answer: yes
explanation: This is incorrect because incision and drainage is performed within the hospital setting by the surgical team if there is evidence of an abscess. There is nothing to indicate the presence of an abscess, such as fevers or erythema, in this case.
name: Incision and drainage
label: c
answer: no
explanation: This is incorrect because this is the management for mastitis, which is associated with breast-feeding. Mastitis usually presents as a painful breast lump with associated inflammatory skin changes, such as erythema. Oral flucloxacillin would be the correct management for mastitis as it is commonly caused by Staphylococcus aureus. Prior to prescribing antibiotics, supportive measures like analgesia and encouraging lactation is the first line treatment. Antibiotics are prescribed if there is evidence of an infected nipple fissure, if the breast milk culture is positive, or if symptoms do not improve despite supportive measures.
name: Oral flucloxacillin
label: b
answer: no

Correct answer: a


Learning point: A breast lump in a woman over 30 years old warrants a 2-week referral to a breast clinic for further assessment.
A 59-year-old man had an uncomplicated coronary artery bypass graft under general anaesthetic two days ago. During the ward round, he is found to be visibly short of breath. He is occasionally coughing clear, thick sputum, but is struggling to fully expectorate this. He has a 21 pack year smoking history. On examination, there is dullness to percussion and reduced breath sounds in the left lower zone of the lungs. His respiratory rate is 24 breaths per minute, heart rate 103bpm, and temperature 37.8. A chest X-ray shows lung collapse in the left lower zone.

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

Options:
explanation: This patient may have an underlying diagnosis of COPD given his extensive smoking history and the presence of a productive cough. However, there is no wheeze at present, and his shortness of breath can be explained by the X-ray findings of collapse. As such, it does not seem necessary to treat him as an exacerbation of COPD at present. Bronchodilators are often prescribed to help encourage clearance of secretions, and so whilst this may be an appropriate option, the best initial treatment is chest physiotherapy, and the addition of oral steroids is not necessary.
name: Nebulised salbutamol and oral prednisolone
label: c
answer: no
explanation: Carbocisteine is a mucolytic sometimes provided to help loosen secretions and allow them to be coughed up. However, in the first instance, chest physiotherapy remains the best treatment option.
name: Carbocisteine
label: d
answer: no
explanation: This is correct because the goal in atelectasis is to re-expand the collapsed lung, and chest physiotherapy helps to clear the thick sputum and secretions, which are likely contributing to the collapse in this case. Atelectasis is a very common cause of post-operative pyrexia.
name: Chest physiotherapy
label: a
answer: yes
explanation: Bronchoscopy may be used to help remove secretions at a later stage, if initial medical management has failed. As such, this option does not represent the best, next step.
name: Bronchoscopy
label: e
answer: no
explanation: This is incorrect because this is the management for mild, community-acquired pneumonia. Patients with pneumonia typically present with fever, productive cough with green sputum, and shortness of breath. On auscultation, you would hear crackles. You would also expect the chest X-ray to show consolidation. This patient is at risk of pneumonia, but at present does not display the clinical features suggestive of this. Oral amoxicillin would not be the best choice even if a diagnosis of pneumonia were made, as this would not be  the treatment for a hospital acquired pneumonia.
name: Oral amoxicillin
label: b
answer: no

Correct answer: a
A 54-year-old woman presents to A&E with sudden, painless loss of vision. This has not happened to her before. There was no obvious trigger, since she was sitting at home when this happened. She has a past medical history of severe left temporal lobe epilepsy and recently underwent surgery for this. When asked to point out the numbers on a clock face, she is only able to see from number 4 to 11 in both eyes. Fundoscopic examination is unremarkable.

What is responsible for this patient's visual field defect?

Options:
explanation: Retinal detachment occurs when there is separation of the neuro-sensory retina from the retinal pigment epithelium. This also presents with painless visual loss, but patients complain of flashing lights and floaters, and possibly a 'curtain' obscuring their vision (which would be the detached flap of retina.) Fundoscopy can reveal a detached homogenous floating grey membrane. This patient has none of these clinical features.
name: Retinal detachment
label: e
answer: no
explanation: Central retinal vein occlusion does result in sudden onset painless loss of vision. However, on fundoscopy, you would expect to find a stormy-sunset appearance with widespread haemorrhage, cotton wool spots, swollen optic discs, engorged veins, and chronically proliferative changes. This patient's fundoscopic examination is normal. Risk factors include pro-thrombotic stages as well as cardiac risk factors, which this patient does not have.
name: Central retinal vein occlusion
label: b
answer: no
explanation: Branch retinal vein occlusion does result in sudden onset painless loss of vision. However, on fundoscopy, you would expect to find haemorrhage, cotton wool spots, swollen optic discs, and engorged veins within the area of occlusion. This patient's fundoscopic examination is normal. Risk factors include pro-thrombotic stages as well as cardiac risk factors, which this patient does not have.
name: Branch retinal vein occlusion
label: c
answer: no
explanation: This is incorrect because damage to the superior optic radiation within the parietal lobne  would cause an inferior homonymous quadrantanopia.
name: Lesion of the superior optic radiation
label: d
answer: no
explanation: This patient has a right superior homonymous quadrantanopia visual field defect caused by damage to the left inferior optic radiation. This is likely due to her recent temporal lobe surgery.  the left temporal lobe. Damage to the temporal optic radiation fibres (Meyer's loop) causes superior contralateral quadrantanopias. Damage to the parietal optic radiation fibres result in inferior contralateral quadrantanopias.
name: Lesion of the inferior optic radiation
label: a
answer: yes

Correct answer: a


Learning point: Damage to the left inferior optic radiation can cause right superior homonymous quadrantanopia, often following temporal lobe surgery.
A 62-year-old woman presents to A&E with a 2-day history of abdominal pain and nausea. She has also experienced some rectal bleeding but she thinks this is due to straining. She last opened her bowels earlier this morning. Her diet has been poor since her husband recently passed away. On examination, there is tenderness in the left lower quadrant and her abdomen is non-distended. Her vital signs are: HR 102 bpm, RR 15 breaths per minute, BP 139/97mmHg, temperature of 39.2.

Which of the following is the next best investigation to confirm the most likely diagnosis?

Options:
explanation: Abdominal x-rays may be useful to rule out bowel obstruction (dilated bowel loops) and perforation (Rigler sign) if these were within the differentials. It would not be able to identify the cause of this patient's presentation, however, with no clinical features to suggest perforation or obstruction in this case.
name: Abdominal X-Ray
label: b
answer: no
explanation: This patient is at high risk of diverticulitis given the presence of left lower quadrant pain, fever, and history of constipation. CT abdomen is the gold standard for diagnosis. Diverticulitis occurs when diverticulae (outpouchings of bowel) become inflamed, causing nausea, vomiting, fever, and abdominal pain.
name: CT abdomen
label: a
answer: yes
explanation: A flexible sigmoidoscopy is used to view the rectum, sigmoid and descending colon to aid with diagnosis of diverticular disease; diverticulae especially affect the recto-sigmoid colon so a flexible sigmoidoscopy is an adequate technique to diagnose most cases. However, this is not performed in the acute setting due to risk of perforation.
name: Flexible sigmoidoscopy
label: c
answer: no
explanation: Colonoscopy is usually performed after acute diverticulitis to fully investigate the bowel for any underlying disease, such as cancer leading to constipation. It is not useful in the acute setting, and may risk perforation.
name: Colonoscopy
label: d
answer: no
explanation: Blood cultures will be indicated in this febrile patient. However, it will not be the best next test to confirm the diagnosis; a CT scan will be required to do this.
name: Blood cultures
label: e
answer: no

Correct answer: a
A 68-year-old male attends a pre-assessment clinic for a diagnostic knee arthroscopy. His past medical history includes hypertension, hypothyroidism, hypercholesterolaemia, and heart failure.

Which of the following medications must be stopped on the day of surgery?

Options:
explanation: Furosemide does not need to be routinely stopped prior to a surgical procedure. Stopping may precipitate fluid overload and render the patient unfit for a general anaesthetic.
name: Furosemide
label: d
answer: no
explanation: Bisoprolol does not need to be stopped prior to a surgical procedure. Stopping this may precipitate tachyarrythmia and render the patient unfit for a general anaesthetic.
name: Bisoprolol
label: e
answer: no
explanation: Atorvastatin does not need to be stopped prior to a surgical procedure.
name: Atorvastatin
label: c
answer: no
explanation: This is correct because ramipril must be stopped prior to surgery as it causes profound hypotension and haemodynamic instability in anaesthesia. A useful mnemonic to remember which drugs to stop prior to surgery is ILACKOP which includes insulin, lithium, anti-platelets and anti-coagulants, COCP, potassium-sparing diuretics, oral hypoglycaemic drugs and ACE inhibitors.
name: Ramipril
label: a
answer: yes
explanation: Levothyroxine does not need to be stopped prior to a surgical procedure.
name: Levothyroxine
label: b
answer: no

Correct answer: a
A 52-year-old woman presents to her GP with a headache for a month. She has also been waking in the middle of the night feeling sweaty which is unusual for her, and has been feeling more anxious. She has reported no change to her physical appearance. On examination, her blood pressure is 167/98mmHg, and the remainder of her physical assessment is unremarkable. Blood tests show a normal white cell count, normal urea and electrolytes, and normal thyroid function.

Which of the following hormones is the most likely cause of this patient's presentation?

Options:
explanation: Thyrotoxicosis can result in sweating, palpitations, anxiety, and hypertension. However, this patient has normal thyroid function tests, and no clinical features of hyperthyroidism, such as tremor, diarrhoea, or a goitre.
name: Thyroxine
label: d
answer: no
explanation: This patient has likely got a pheochromocytoma which is a catecholamine-secreting tumour in the adrenal medulla. Excess of circulating catecholamines result in hypertension, headaches,  flushing, palpitations, and anxiety.
name: Adrenaline and noradrenaline
label: a
answer: yes
explanation: Vasopressin, also known as anti-diuretic hormone, is essential for enabling the reabsorption of free water from the collecting duct in the nephron through aquaporin channels. Excess vasopressin results in excessive free water reabsorption, and a classical euvolaemic hyponatraemia as seen in SIADH. Low sodium results in non-specific symptoms, such as confusion and lethargy, and, if very low, seizures. This patient's bloods are normal, and there are no clinical features suggestive of low sodium.
name: Vasopressin
label: b
answer: no
explanation: Excess growth hormone, usually from a pituitary adenoma, results in acromegaly. Pituitary tumours can cause headaches, and excessive growth hormone may result in hypertension, as seen in this case. However, acromegalous features are absent in this patient, such macroglossia, prognathism, changes in physical appearance, and growing hands/feet.
name: Growth hormone
label: c
answer: no
explanation: Excess cortisol leads to Cushing's syndrome, which is associated with hypertension. However, other features of Cushing's syndrome are notably absent, such as proximal weakness, striae, central adiposity, and thinning/bruising of the skin. Cushing's disease refers to Cushing's syndrome secondary to a pituitary tumour, whilst Cushing's syndrome is excess cortisol of any cause, including secondary to exogenous steroid use.
name: Cortisol
label: e
answer: no

Correct answer: a


Learning point: Pheochromocytoma is a catecholamine-secreting tumour causing symptoms like hypertension, headaches, anxiety, and nocturnal sweating due to excess adrenaline and noradreanline.
A 35-year-old male presents to A&E with extensive burns from a house fire. His burns are widely disseminated over his back, left leg, and left arm. He is rapidly resuscitated with 13L of 0.9% normal saline over the next 8 hours as he awaits transfer within the department to the local burns unit. He weighs 72kg. On the following day, he appears confused and complains of a headache and fatigue. An ABG shows metabolic acidosis.

Which of the following electrolyte imbalances is the most likely cause of his acid-base disturbance?

Options:
explanation: This patient has been given excessive volumes of normal saline in a short period of time which has led to high levels of chloride and a hyperchloraemic metabolic acidosis. In this stem, the patient has been managed in A&E rather than a dedicated burns unit, which may have resulted in this error. Parkland's formula is used to calculate resuscitation fluid required over the first 24 hours according to the estimated % of burn and the patient's weight. This patient should have received 6.5L of fluid over the first 8 hours and 6.5L over the next 16 hours. Aggressive fluid resuscitation can cause electrolyte imbalances. He would also be at risk of hypernatraemia in this case, and subsequent cerebral oedema. Some patients experience no symptoms with high levels of chloride whilst others may have muscle weakness, excessive thirst, and confusion.
name: Hyperchloraemia
label: a
answer: yes
explanation: This patient has had high volumes of normal saline and is therefore likely to be hypernatremic as opposed to hyponatraemic, and abnormalities in the sodium alone are unlikely to explain any acid-base disturbance.
name: Hyponatraemia
label: e
answer: no
explanation: Hypercalcaemia typically presents with 'stones, bones, abdominal groans, thrones and psychiatric overtones'. This refers to kidney stones bone pain, constipation, excessive thirst and mood changes. Hypercalcaemia can be caused by multiple myeloma, paraneoplastic conditions, medication, sarcoidosis and over-active parathyroid glands. Patients with burns are at risk of tissue breakdown and rhabdomyolysis, which may actually result in initial hypocalcaemia. Hypercalcaemia is not associated with a metabolic acidosis but has been associated with a metabolic alkalosis.
name: Hypercalcaemia
label: d
answer: no
explanation: This patient is unlikely to be hypokalaemic, since in fact burns lead to tissue breakdown and potential rhabdomyolysis, which may cause hyperkalaemia. Hyperkalaemia can also cause a metabolic acidosis due to displacement of intracellular hydrogen ions and competition for excretion in the distal tubule. Hypokalaemia would actually be associated with a metabolic alkalosis.
name: Hypokalaemia
label: c
answer: no
explanation: This is incorrect because this patient has received a large volume of normal saline, which would lead to hyperchloraemia. Hypochloraemia is usually associated with diarrhoea and vomiting. This is not associated with a metabolic acidosis.
name: Hypochloraemia
label: b
answer: no

Correct answer: a