hllj/quesmed huggingface dataset:
A 22-year-old woman presents to the GP. She mentions that she is feeling depressed due to her extensive scarring acne and painful nodules.

What is the most appropriate management for her?

Options:
explanation: For this patient with severe acne vulgaris, once-daily oral lymecycline 408 mg or oral doxycycline 100 mg is the recommended first-line management. Topical therapy such as azelaic acid should also be co-prescribed.
name: Lymecycline with topical azelaic acid
label: a
answer: yes
explanation: This would be appropriate for patients with mild-moderate acne. This patient however has presented with severe nodular acne.
name: Combination of topical benzoyl peroxide with topical clindamycin
label: b
answer: no
explanation: Adequate courses of standard therapy with systemic antibiotics and topical therapy should be attempted before trialling oral isotretinoin. Additionally, this patient has presented in GP and isotretinoin can only be prescribed by a dermatologist.

It is standard practice to co-prescribe two forms of contraception prior to starting isotretinoin as it is a teratogen.

There is also a reported increased risk of depression and suicide associated with systemic retinoids; any changes in mood should be closely monitored. Given that this patient has self-reported depression, we would need to be cautious when prescribing isotretinoin.
name: Oral isotretinoin
label: d
answer: no
explanation: Adequate courses of standard therapy with systemic antibiotics and topical therapy should be attempted before trialling the COCP.
name: Combined Oral Contraceptive Pill (COCP)
label: e
answer: no
explanation: This regime is more likely to be used in patients with moderate acne. This patient however has presented with severe nodular acne. Furthermore, macrolides such as clindamycin are typically used for acne when patients cannot tolerate tetracyclines e.g. lymecycline or doxycycline. There is no indication of tetracycline intolerance in this case.
name: Clindamycin with topical benzyl peroxide
label: c
answer: no

Correct answer: a
A 39-year-old woman presents to A&E with a one-week history of dyspnoea and cough, bringing up increasing amounts of sputum.

She has a fever, a respiratory rate of 26 breaths per minute and is saturating 92% on room air.

A chest x-ray shows a cavitating lesion in the right middle zone. Microscopy shows Gram-positive cocci.

She has not been in contact with any unwell persons nor does she have a history of tuberculosis. She is a known IV drug user.

What is the most likely causative organism of this woman's symptoms?

Options:
explanation: Previously known as *Pneumocystis carinii*, this yeast-like fungus is an opportunistic agent and a common cause of pneumonia in patients who have HIV.
name: *Pneumocystis jirovecii*
label: c
answer: no
explanation: This is a Gram-negative rod-shaped bacterium associated with pneumonia. It typically causes pneumonia in patients at high risk of aspiration. Alcoholism is also a well-known risk factor.
name: *Klebsiella pneumoniae*
label: d
answer: no
explanation: This is a gram-negative cocci that can cause ear, upper respiratory tract, and lower respiratory tract infections. It is also known as *Branhamella catarrhalis*.
name: *Moraxella catarrhalis*
label: b
answer: no
explanation: This patient has developed a community–acquired pneumonia (CAP). Other potential differentials include pulmonary embolism, acute bronchitis and acute exacerbation of COPD. However, this patient's symptoms - particularly the fever, sputum, low oxygen saturations, cough and now a cavitating lesion - point towards a diagnosis of CAP with cavitation.

Furthermore, *Staphylococcus aureus* and *Streptococcus pneumoniae* are the only answer choices that are gram-positive cocci. However, of the two, *Staphylococcus aureus* is arranged in grape-like clusters or 'clumps', whereas Streptococci are arranged in chains or pairs (diplococci).
name: *Staphylococcus aureus*
label: a
answer: yes
explanation: This is a Gram-positive spherical bacteria, usually found in pairs (diplococci). *Streptococcus pneumoniae* is the most common cause of community-acquired pneumonia.
name: *Streptococcus pneumoniae*
label: e
answer: no

Correct answer: a
A 70-year-old male has a seven-month history of dry cough and increasing dyspnoea. He was previously fit and well and is an occasional smoker. His temperature is 36.3°C, pulse 60 bpm and oxygen saturations are 88% on air.

On examination, there is finger clubbing and on respiratory examination, you auscultate bibasal crepitations.

Which of the following options is the most likely diagnosis?

Options:
explanation: Despite a history of smoking and the presence of clubbing, there are no further indications of lung cancer such as red flag symptoms or extrapulmonary features. Furthermore, this patient has a dry cough, crackles, clubbing and is a 70-year-old smoker: this is a typical presentation of IPF.
name: Lung carcinoma
label: d
answer: no
explanation: There are no risk factors for TB in this question (i.e. travel abroad, unwell contacts). Furthermore, this patient has a dry cough, crackles, clubbing and is a 70-year-old smoker: this is a typical presentation of IPF.
name: Pulmonary tuberculosis
label: e
answer: no
explanation: Patients with bronchiectasis often have a chronic mucopurulent cough, exertional dyspnoea and occasionally have haemoptysis.

They can also present with an acute infective exacerbation. If this patient did have an infection, his symptomatic history would be much shorter, he would be pyrexic, and be producing purulent sputum.
name: Bronchiectasis
label: b
answer: no
explanation: There is no indication of allergy or exposure to irritants (coal, dust, chemicals) in this question. Furthermore, this patient has a dry cough, crackles, clubbing, and is a 70-year-old smoker: this is a typical presentation of IPF.
name: Extrinsic allergic alveolitis
label: c
answer: no
explanation: This patient has a dry cough, crackles, clubbing and is a 70-year-old smoker. This is a typical presentation of IPF.
name: Idiopathic pulmonary fibrosis (IPF)
label: a
answer: yes

Correct answer: a
A 40-year-old female has a left lower lobe pneumonia. Blood cultures are positive for a penicillin-sensitive *Streptococcus pneumoniae*. She is managed with IV benzylpenicillin. She improves but on the fourth day of treatment, she becomes pyrexic and has increased dyspnoea.

A chest x-ray shows a left basal effusion. Purulent fluid is aspirated and analysis of the fluid shows a pH of 6.80 (reference range 7.35 – 7.45) and Gram-positive cocci.

What is the most appropriate next step in managing this patient?

Options:
explanation: The appropriate treatment is drainage to avoid empyema development. The streptococcus is sensitive to penicillin therefore a change in antibiotic or the way in which it is administered is very unlikely to yield any significant results.
name: Switch benzylpenicillin to ceftriaxone
label: e
answer: no
explanation: The streptococcus is sensitive to penicillin therefore a change in antibiotics or the way in which it is administered is very unlikely to yield any significant results.
name: Inject antibiotic into the effusion
label: c
answer: no
explanation: The appropriate treatment is drainage to avoid empyema development. The streptococcus is sensitive to penicillin therefore a change in antibiotic or the way in which it is administered is very unlikely to yield any significant results.
name: Increase the dose of penicillin
label: d
answer: no
explanation: This is because the Gram stain and low pH indicate a complex parapneumonic effusion (pleural effusion that develops next to a pneumonia). The appropriate treatment is drainage of the effusion as it is likely developing into an empyema. Streptococcus is sensitive to penicillin, therefore a change in antibiotics is very unlikely to yield any significant results.
name: Drainage of the effusion
label: a
answer: yes
explanation: The goal of pleurodesis is to try to adhere the linings of the lung (pleura) together in order to stop further fluid or air build-up. This is achieved by inserting sterile talc into the area between the lung and the inside of the chest wall. It is indicated in recurrent pleural effusions and persistent pneumothoraces.
name: Talc pleurodesis
label: b
answer: no

Correct answer: a
At what volume can pleural effusions be seen on a chest x-ray?

Options:
explanation: A pleural effusion is an excessive accumulation of fluid in the pleural space (between the visceral and parietal pleura). It can be detected on x-ray when ≥300 mL of fluid is present, and clinically, when ≥500 mL is present.
name: ≥100 mL
label: b
answer: no
explanation: A pleural effusion is an excessive accumulation of fluid in the pleural space (between the visceral and parietal pleura). It can be detected on x-ray when ≥300 mL of fluid is present, and clinically, when ≥500 mL is present.
name: ≥400 mL
label: d
answer: no
explanation: A pleural effusion is an excessive accumulation of fluid in the pleural space (between the visceral and parietal pleura). It can be detected on x-ray when ≥300 mL of fluid is present, and clinically, when ≥500 mL is present.
name: ≥300 mL
label: a
answer: yes
explanation: A pleural effusion is clinically noted when ≥500 mL is present. However, it can be noted on CXR with just 300ml.
name: ≥500 mL
label: e
answer: no
explanation: A pleural effusion is an excessive accumulation of fluid in the pleural space (between the visceral and parietal pleura). It can be detected on x-ray when ≥300 mL of fluid is present, and clinically, when ≥500 mL is present.
name: ≥200 mL
label: c
answer: no

Correct answer: a
A 71-year-old man with known COPD presents to A&E with increasing shortness of breath. He is alert.


His observations are: Temp 38.0°C, pulse 101, BP 98/77mmHg, RR 31 and saturations 88% SpO2 on a 15 L non-rebreather mask (NRB).


The results from the patient's arterial blood gas are shown below:


||||
|--------------|:-------:|------------------|
|pH|7.30|7.35 - 7.45|
|PaO₂|6.9 kPa|11 - 15|
|PaCO₂|9.3 kPa|4.6 - 6.4|
|Bicarbonate|32 mmol/L|22 - 30|


What is the most important initial management?

Options:
explanation: This choice would not solve this patient's respiratory acidosis, which is an immediate concern that needs to be corrected with non-invasive ventilation. Furthermore, this patient is alert and unlikely to tolerate an OP airway.

BiPAP is used in patients with type II respiratory failure and pH <7.35.
name: Oesopharngeal airway (OP)
label: d
answer: no
explanation: Invasive ventilation is not indicated in this patient who is alert and has a raised respiratory rate. His respiratory acidosis should instead be managed less aggressively with non-invasive ventilation.

BiPAP is used in patients with type II respiratory failure and pH <7.35.
name: Invasive ventilation
label: b
answer: no
explanation: CPAP is commonly used in patients with type I respiratory failure.
This patient has type II respiratory failure with respiratory acidosis secondary to his COPD exacerbation and requires BiPAP.
name: Continuous positive airway pressure (CPAP)
label: e
answer: no
explanation: The patient is already on 15L NRB, therefore this choice represents a step down in this patient's management, which is not appropriate given his signs and symptoms.
name: Nasal high-flow oxygen
label: c
answer: no
explanation: Respiratory acidosis is an immediate concern that needs to be corrected with non-invasive ventilation (NIV). This patient is alert with a pH of less than 7.35 and is in type II respiratory failure, making NIV the optimal initial management.

BiPAP is used in patients with type II respiratory failure, with two different levels of positive pressure on inspiration and expiration.
name: Bilevel-positive airway pressure (BiPAP)
label: a
answer: yes

Correct answer: a
A 71-year-old man has increasing breathlessness. He had a carotid artery bypass 9 days ago. He reports chest pain and mild abdominal pain. He has a past medical history of hypertension and stroke.

His observations are: Temp 37.6°C, pulse 107 bpm, BP 121/78 mmHg, RR 26, and oxygen saturations of 93% SpO2 on room air.

There are no crackles on auscultation, and he complains of some mild abdominal pain which is improving.

What is the most likely diagnosis?

Options:
explanation: Pancreatitis typically presents with severe epigastric pain radiating to the back. This patient has mild abdominal pain, which is likely related to his recent surgery.
name: Pancreatitis
label: b
answer: no
explanation: Pneumonia would present with a cough, purulent sputum and chest pain which could be pleuritic in nature.
name: Pneumonia
label: c
answer: no
explanation: This patient has had a prolonged period of immobilisation and likely has a history of atherosclerosis, given the nature of his recent surgery (carotid artery bypass). This alongside his tachypnoea and tachycardia makes pulmonary embolism the most likely diagnosis.
name: Pulmonary embolism
label: a
answer: yes
explanation: Myocardial infarction would present with severe, crushing central chest pain, which may radiate to the jaw. This choice is a reasonable differential given his recent carotid endarterectomy.
name: Myocardial infarction
label: d
answer: no
explanation: The risk of stroke is around 2% following carotid endarterectomy and is higher in people who have had a stroke before the operation. However, this patient's clinical picture is more suggestive of a pulmonary embolism.
name: Stroke
label: e
answer: no

Correct answer: a
A 51-year-old man presents to the critical care unit with new-onset confusion and chest pain. An ECG shows no ST changes or T wave inversion, but you are unsure if the PR interval is prolonged.

He is a known IV drug user and has needle track marks on his arms. His hands are clammy and have painful nodules. He also has non-tender macules on his soles. Exudative haemorrhagic retinal lesions with pale centres are seen on ophthalmoscopy. He is mildly confused.

His observations are: BP 100/75mmHg, HR 116 bpm, Temp 38.3 degrees Celsius.

A urine dip shows raised protein and blood.

What is the most appropriate next investigation?

Options:
explanation: The transoesophageal echocardiogram is the most sensitive diagnostic test for infective endocarditis. However, the first-line imaging modality performed should be a transthoracic echocardiogram, and whilst it is an important investigation in the work-up of suspected infective endocarditis, this patient's clinical features are highly suggestive of acute sepsis. Indeed, the patient has clammy hands, is hypotensive and tachycardic, and has new onset confusion. This should ring alarm bells for sepsis and should therefore prompt you to order blood cultures before any other investigation. This can be followed by IV antibiotics and fluid resuscitation.
name: Transoesophageal echocardiogram
label: b
answer: no
explanation: This patient meets the threshold for a sepsis screen, hence blood cultures should be performed. Blood cultures are also important in the investigation of infective endocarditis, which is the most likely diagnosis in this case.
name: Blood cultures
label: a
answer: yes
explanation: Whilst you are unsure if the PR interval is prolonged, which could indicate infective endocarditis secondary to aortic root abscess, it would still be more appropriate to order blood cultures at this stage to investigate his sepsis.
name: Repeat ECG
label: c
answer: no
explanation: Although a sputum culture is part of the investigative workup for suspected infective endocarditis, it would be more appropriate to order blood cultures at this stage to investigate his sepsis.
name: Sputum culture
label: e
answer: no
explanation: Although a 'Urea and Electrolytes' blood test is part of the diagnostic workup for suspected infective endocarditis, it would be more appropriate to order blood cultures at this stage to investigate his sepsis.
name: Urea and Electrolytes
label: d
answer: no

Correct answer: a
A 59-year-old female presents to A&E with a 6-week history of shortness of breath and a dry cough which she noticed 1 month ago. She has a 40-pack-year smoking history and works as a comedian.

She has a history of rheumatoid arthritis which has improved with treatment. Her spirometry results are FEV1: 2.3 and FVC: 2.6. She also has a history of hypertension and hypercholesterolaemia.

What is the most likely diagnosis?

Options:
explanation: This patient has drug-induced pulmonary fibrosis secondary to her extensive use of methotrexate for her rheumatoid arthritis, which has caused pneumonitis and subsequent pulmonary fibrosis.
name: Pulmonary fibrosis
label: a
answer: yes
explanation: Chronic obstructive pulmonary disease (COPD) is characterised by an obstructive picture on spirometry. This patient has an FEV1/FVC ratio of 0.88, which is indicative of a restrictive lung pathology.
name: Chronic obstructive pulmonary disease (COPD)
label: b
answer: no
explanation: Asthma is a type of obstructive lung disease characterised by paroxysmal and reversible airway bronchoconstriction. This patient has an FEV1/FVC ratio of 0.88, indicative of restrictive lung pathology.
name: Asthma
label: c
answer: no
explanation: Tuberculosis is transmitted via the inhalation of droplets infected with *Mycobacterium tuberculosis*. There are no risk factors here suggesting tuberculosis such as homelessness, immunosuppression or foreign travel. Furthermore, tuberculosis usually causes a productive and purulent cough, whereas this patient has a dry cough.
name: Tuberculosis
label: d
answer: no
explanation: Bronchiectasis is the permanent dilation of the bronchi and bronchioles due to chronic infection. It usually causes a productive, purulent cough with lots of sputum. This patient has a dry cough. Finally, bronchiectasis is an obstructive lung disease. This patient has an FEV1/FVC ratio of 0.73, indicative of restrictive lung pathology.
name: Bronchiectasis
label: e
answer: no

Correct answer: a
A 38-year-old female presents to A&E with a massive haemorrhage following a road traffic accident. A group and save (G&S) has been ordered but is not yet available.

The patient has been transfused with 6 packs of red cells and the haematologist now requires fresh frozen plasma (FFP).

Which type of FFP is most appropriate for this patient?

Options:
explanation: Group AB blood does not have any anti-B or anti-A antibodies in the plasma, making it the universal FFP donor.

FFP is used in patients with a coagulopathy who need replacement of their clotting factors. As this patient has no G&S available, she should be given the universal FFP donor, which is group AB plasma (as this plasma has no antibodies). As the patient has childbearing potential, it would be best to give her rhesus-negative blood until her rhesus group is known.
name: AB RhD negative
label: a
answer: yes
explanation: Group O blood donors produce anti-A and anti-B antibodies in their plasma. The universal donor for FFP is group AB blood. The universal donor for red cells is group O blood.

As this patient has no G&S available, she should be given the universal FFP donor, which is group AB plasma (as this plasma has no antibodies). As the patient has childbearing potential, it would be best to give her rhesus-negative blood until her rhesus group is known.
name: O RhD positive
label: c
answer: no
explanation: Group A blood donors produce anti-B antibodies in their plasma. The universal donor for FFP is group AB blood. The universal donor for red cells is group O blood.

As this patient has no G&S available she should be given the universal FFP donor, which is group AB plasma (as this plasma has no antibodies). As the patient has childbearing potential, it would be best to give her rhesus-negative blood until her rhesus group is known.
name: A RhD negative
label: e
answer: no
explanation: Group O blood donors produce anti-A and anti-B antibodies in their plasma. The universal donor for FFP is group AB blood. The universal donor for red cells is group O blood.

As this patient has no G&S available, she should be given the universal FFP donor, which is group AB plasma (as this plasma has no antibodies). As the patient has childbearing potential, it would be best to give her rhesus-negative blood until her rhesus group is known.
name: O RhD negative
label: b
answer: no
explanation: Whilst group AB blood is the universal donor for FFP, this patient is of reproductive age, and if available, should receive RhD-negative blood to avoid the issue of a future fetus being RhD-positive and her being RhD-negative.

If a rhesus-negative mother becomes sensitised to rhesus-positive blood, she will form anti-RhD antibodies (this is called sensitisation). This can cause anaemia, hydrops fetalis and kernicterus in a future pregnancy if the foetus' blood is RhD-positive.
name: AB RhD positive
label: d
answer: no

Correct answer: a
A 67-year-old lawyer has a productive cough which started yesterday. She has also had a flare-up of her psoriasis over the last month. Her repeat medications have recently been altered following a diagnosis of angina pectoris 2 months ago. She has a 50-pack-year smoking history and also takes sertraline for depression. She is allergic to penicillin and sulphonamides.

Which of the following drugs is most likely to be contributing to her flare-up of psoriasis?

Options:
explanation: Although ivabradine can be used in the management of angina pectoris they are not known to exacerbate psoriasis.
name: Ivabradine (Procoralan)
label: c
answer: no
explanation: Macrolides are the first-line medication in penicillin-allergic patients who have mild community-acquired pneumonia. However, this question is about her psoriasis, not her new respiratory symptoms.

Statins are metabolised via the cytochrome P450 system. P450 inhibitors such as clarithromycin, a macrolide, can increase the risk of myalgia and rhabdomyolysis, and therefore both medications should not be co-prescribed. However, this combination is unlikely to have exacerbated this patient's psoriasis.
name: Atorvastatin & Clarithromycin
label: e
answer: no
explanation: Beta-blockers are known to exacerbate psoriasis. Drugs ending -lol are typically beta blockers.

To remember the drugs which may exacerbate psoriasis, use the memory aid 'BALI':

* Beta-blockers
* Anti-malarials (e.g. chloroquine), ACE inhibitors and Alcohol
* Lithium
* Ibuprofen (NSAIDs) and Infliximab.
name: Carvedilol
label: a
answer: yes
explanation: Dithranol is a topical agent commonly used in the management of psoriasis. This would be beneficial for this patient.
name: Dithranol (Anthralin)
label: d
answer: no
explanation: Although calcium channel blockers are used in the management of angina pectoris they are not known to exacerbate psoriasis.
name: Amlodipine
label: b
answer: no

Correct answer: a