hllj/quesmed huggingface dataset:
A 70 year old lady is admitted with an acute polyarthritic flare of her hands and knees. She has a past medical history of rheumatoid arthritis and migraines. Her regular medications include methotrexate, prednisolone and ibuprofen.


Bloods on admission are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|101 g/L|(M) 130 - 170, (F) 115 - 155|
|Platelets|400x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|108 fL|80 - 96|
|Ferritin|170 μg/L|12 - 200|
|Iron|20 μmol/L|(M) 14 - 31, (F) 11 - 30|
|Transferrin saturation|28 %|(M) 16 - 50 (F) 16 - 40|


 - White cell count and neutrophils normal
 - Reticulocyte count normal


What is the most likely cause of her anaemia?

Options:
explanation: The iron panel is not suggestive of iron deficiency anaemia
name: Iron deficiency anaemia
label: d
answer: no
explanation: The patient has macrocytic anaemia and is taking methotrexate without regular folate. Methotrexate therapy is a common cause of macrocytic anaemia due to folate deficiency
name: Methotrexate
label: a
answer: yes
explanation: This is a rare cause of anaemia in rheumatoid arthritis. This is unlikely as reticulocyte count is not raised
name: Autoimmune haemolytic anaemia
label: e
answer: no
explanation: This is a common cause of anaemia in rheumatoid arthritis patients. This would typically present as normochromic normocytic anaemia
name: Anaemia of chronic disease
label: b
answer: no
explanation: Felty's syndrome is characterised by the triad of rheumatoid arthritis, neutropenia, and splenomegaly. The neutrophils are normal in this case
name: Felty's syndrome
label: c
answer: no

Correct answer: a


Learning point: Methotrexate can cause macrocytic anaemia due to folate deficiency, particularly in patients not receiving regular folate supplementation.
A 19 year old male is admitted with a 1 day history of sudden onset severe chest pain and productive cough. He has a known history of sickle cell disease.

Vitals on admission:

- T 38.5°C
- BP 100/60
- Pulse 105
- Respiratory rate 25
- SpO<sub>2</sub> 98% on 4L oxygen

CXR reveals bilateral lower zone shadowing. What is the next best step?

Options:
explanation: This would be indicated in severe hypoxaemia, progression of the crisis despite simple transfusion, multi-lobar disease or a previous history of severe chest crisis
name: Exchange transfusion
label: c
answer: no
explanation: This may be considered later down the line if the patient is failing to maintain oxygen saturations on increasing levels of oxygen. Frequent oxygen monitoring, incentive spirometry and arterial blood gases should be done to monitor progression in such patients
name: Non-invasive ventilation
label: d
answer: no
explanation: This patient has a productive cough and acute chest crisis in the context of sickle cell anaemia. Recommended treatment in acute chest crises would be intravenous broad spectrum empiric coverage with a third generation cephalosporin for bacterial coverage and a macrolide for atypical organism cover
name: Start oral amoxicillin
label: e
answer: no
explanation: Effective pain control is key in the management of acute chest crises. Opioid analgesia can be started and titrated according to the pain ladder
name: Start morphine
label: a
answer: yes
explanation: This would be useful in long-term management to prevent future acute chest crises
name: Start hydroxyurea
label: b
answer: no

Correct answer: a


Learning point: Effective pain management with opioids is crucial in treating acute chest crises in patients with sickle cell disease.
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: 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: 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 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.
Forest plots are often used to summarise the results of meta-analyses in a graphical form. An example is shown below:

[lightgallery]

Which of the following statements is true of a forest plot?

Options:
explanation: The diamond shows the pooled result of all the studies. The vertical line indicates the line of no effect, i.e. the point at which there is statistically no significant difference between the control and intervention group. The width of the diamond illustrates the length of the confidence interval. Therefore, if the diamond touches the vertical line, it means that the overall result is **not** statistically significant
name: If the diamond touches the solid vertical line, it indicates that the overall outcome is not statistically significant
label: a
answer: yes
explanation: Each box represents an individual study with the 95% confidence interval plotted as a horizontal line
name: Each box with a horizontal line represents the results of a collection of studies
label: d
answer: no
explanation: A larger box would indicate a greater weight of that particular study in the pooled result. The horizontal lines through the boxes illustrate the length of the confidence interval; the longer the line, the wider the interval
name: A larger box indicates a wider confidence interval for the study
label: c
answer: no
explanation: The interpretation would depend on whether the outcome of interest is desirable (e.g. cure) or adverse (e.g. death). If the outcome is desirable, results to the right of the vertical line will favour the treatment over the control
name: If the results are to the right of the vertical line, it would always indicate that they favour the treatment over the control group
label: e
answer: no
explanation: The horizontal lines through the boxes illustrate the length of the confidence interval. A shorter line means that the confidence interval is very narrow, hence implying that the study is more reliable as there is a more precise estimate of effects. This is more likely to happen in larger studies with greater numbers of participants
name: A shorter horizontal line suggests that the study is less reliable
label: b
answer: no

Correct answer: a


Learning point: In forest plots, if the diamond intersects the vertical line, the overall result is statistically non-significant.
A 38 year old pregnant female at 32 weeks gestation presents to Maternity Triage with mild upper abdominal pain, vomiting and blurred vision. Her observations are normal, and cardiotocograph reveals no abnormalities with the foetus. Urinalysis is normal.

Which one of the following laboratory findings is most likely in HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome?

Options:
explanation: This is a normal physiologic finding in pregnancy. In HELLP syndrome, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are typically elevated ≥2 times the upper limit of normal
name: Elevated ALP 2 times the upper limit of normal
label: b
answer: no
explanation: In HELLP syndrome, LDH is typically elevated ≥600 IU/L, a non-specific marker associated with severe haemolysis or acute hepatocellular injury
name: Normal lactate dehydrogenase (LDH)
label: e
answer: no
explanation: In HELLP syndrome, the PT, APTT and coagulation screen are normal. If prolonged, this may suggest disseminated intravascular coagulation, which is one complication of HELLP syndrome
name: Prolonged prothrombin time (PT)/activated partial thromboplastin clotting time (APTT)
label: c
answer: no
explanation: Haptoglobin level is a specific marker of haemolysis, and a level of ≤25mg/dL would suggest haemolysis which occurs in HELLP syndrome
name: Low serum haptoglobin
label: a
answer: yes
explanation: This is typical of glucose-6-phosphate dehydrogenase (G6PD) deficiency. In HELLP syndrome, the usual finding is schistocytes and burr cells, which are fragmented red blood cells indicating microangiopathic haemolytic anaemia
name: Peripheral blood film showing blister and bite cells
label: d
answer: no

Correct answer: a


Learning point: In HELLP syndrome, low serum haptoglobin levels indicate haemolysis.
A 30-year-old male presents to his GP with a two-month history of persistent right elbow pain. He describes a tingling sensation in the 4th and 5th fingers. On examination, the pain is aggravated by wrist flexion and pronation of the arm.

Which single nerve is involved?

Options:
explanation: This is most likely to be affected in tennis elbow, which results from lateral epicondylitis as the radial nerve travels anterior to the lateral epicondyle to enter the forearm. Pain is exacerbated in resisted wrist extension or supination. It may lead to radial nerve entrapment syndrome, causing wrist drop, loss of sensation to the anatomical snuff box and radial 3.5 digits on the dorsum of the hand
name: Radial nerve
label: b
answer: no
explanation: This is golfer's elbow, which results from medial epicondylitis. The ulnar nerve may be compressed as it passes through the ulnar groove, which lies posterior and lateral to the medial epicondyle, resulting in numbness and/or tingling in the 4th and 5th fingers
name: Ulnar nerve
label: a
answer: yes
explanation: If median nerve injury occurs more proximally at the elbow (most commonly due to a supracondylar fracture of the humerus), this may result in a hand of benediction (inability to flex the 2nd and 3rd fingers when making a fist) and paralysis of the flexors and pronators of the forearm. Sensation to the palmar aspect of the lateral 3.5 fingers may also be affected
name: Median nerve
label: c
answer: no
explanation: Isolated musculocutaneous nerve lesions are rare. This would result in weakness of elbow flexion and forearm supination, weak biceps tendon reflex and sensory loss over the lateral surface of the forearm
name: Musculocutaneous nerve
label: d
answer: no
explanation: This is most commonly damaged by direct trauma to the shoulder or proximal humerus, such as in fracture of the surgical neck of the humerus or shoulder dislocation. It would result in regimental badge numbness (over the inferior portion of the deltoid) and inability to abduct the affected shoulder due to deltoid and teres minor muscle weakness
name: Axillary nerve
label: e
answer: no

Correct answer: a


Learning point: Ulnar nerve compression can cause tingling in the 4th and 5th fingers, often associated with medial epicondylitis or golfer's elbow.
A 10-year-old boy presents to A&E with a 3-day history of nosebleeds and palpable, non-blanching red spots on his arms and legs. (refer to image provided).



  [lightgallery]



He has no past medical history of note. He has otherwise been well apart from a recent cold two weeks ago. His mother says that he has not had any recent trauma and does not play any contact sports.



Investigations are as follows:



Full blood count:

||||
|--------------|:-------:|---------------|
|Haemoglobin|140 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|9x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|55x10<sup>9</sup>/L|150 - 400|
|Reticulocytes|1 %|0.2 - 2|




Coagulation screen:


||||
|---------------|:-------:|------------------------|
|Activated Partial Thromboplastin Time (APTT)|30  seconds|22 - 41|
|Prothrombin Time (PT)|12  seconds|10 - 12|
|Fibrinogen|0.4 g/dL|1.5 - 4.0|





Peripheral blood film:



  - Normal sized platelets, no clumping seen



Direct antiglobulin test (DAT): Negative



Which is the most appropriate management of his condition?

Options:
explanation: This would only be considered in patients with life-threatening haemorrhage, persistent bleeding refractory to treatment or those requiring surgery. The patient is stable; hence this would not be required
name: Intravenous immunoglobulin
label: c
answer: no
explanation: Platelet transfusions are generally reserved for patients with active life-threatening haemorrhage, persistent bleeding refractory to treatment or those requiring surgery. The patient is stable, and hence this would not be required
name: Oral vitamin K
label: d
answer: no
explanation: Glucocorticoids may be given to raise the platelet count if it needs to be raised acutely. However, in the absence of any clinically significant bleeding, there is no need for this
name: Oral prednisolone
label: e
answer: no
explanation: The patient has immune thrombocytopenic purpura (ITP). Patients usually present with an isolated low platelet count with normal coagulation profile, peripheral blood film and reticulocyte count. The negative DAT rules out autoimmune haemolytic anaemia, which may occur in conjunction with ITP (Evans syndrome). The general approach in stable patients without clinically significant bleeding would be to wait and observe, with safety net advice given to avoid contact sports, blood-thinning medications and to monitor for signs of worsening bleeding
name: Wait and observe
label: a
answer: yes
explanation: Platelet transfusions are generally reserved for patients with active life-threatening haemorrhage, persistent bleeding refractory to treatment or those requiring surgery. The patient is stable, and hence this would not be required
name: Platelet transfusion
label: b
answer: no

Correct answer: a

Wait and observe

Learning point: In stable patients with immune thrombocytopenic purpura (ITP) without significant bleeding, the general approach is to observe and monitor, providing safety net advice to avoid contact sports, blood-thinning medications, and watch for signs of worsening bleeding.
A 10-year-old boy collapses in the Emergency Department after being administered a dose of amoxicillin for otitis media. He has no other past medical history of note.

He develops a sudden onset wheeze and shortness of breath.

Observations:

- Temperature 37.5°C
- pulse 150
- BP 80/60
- SpO<sub>2</sub> 88% room air

What is the next most important medication to administer?

Options:
explanation: This is the dose that should be given in anaphylaxis in adults or children >12 years old
name: IM Adrenaline (1:1000) 500 micrograms
label: b
answer: no
explanation: This may be considered in cases of anaphylaxis with severe or persistent bronchospasm. However, adrenaline takes priority in this situation
name: Salbutamol nebulisers
label: d
answer: no
explanation: This is the dose that should be given in a cardiac arrest as part of the paediatric advanced life support algorithm
name: IV Adrenaline (1:10,000) 10 micrograms per kg
label: c
answer: no
explanation: The patient has developed anaphylaxis, most likely to amoxicillin. Warning signs in this scenario include stridor, wheeze, hypotension and desaturation. The single most important medication to administer is adrenaline, which should be done as soon as possible. This is the dose that should be given in children 6-12 years old. IV adrenaline for anaphylaxis should only be given by experienced specialists in an appropriate setting
name: IM Adrenaline (1:1000) 300 micrograms
label: a
answer: yes
explanation: This may be given if the patient has hypotension due to anaphylactic shock. However, adrenaline takes priority in this situation
name: IV Hartmann's bolus 10ml/kg
label: e
answer: no

Correct answer: a


Learning point: In children aged 6-12 years old, the recommended dose of intramuscular (IM) adrenaline (1:1000) for anaphylaxis is 300 micrograms (0.3 mg). This dose can be repeated every 5-15 minutes if necessary, depending on the severity of the reaction and clinical response.
A 12-month-old girl is brought in by her worried parents to the children's Accident & Emergency department with a three-day history of persistent cough, hoarse voice and shortness of breath.

Observations:

- Temperature 38.5°C
- pulse 150
- BP 80/60
- respiratory rate 40
- SpO<sub>2</sub> 95% room air

A posterior-anterior chest X-ray is done and is shown below.

[lightgallery]

Given her most likely diagnosis, which single therapy has been shown to improve disease outcomes?

Options:
explanation: Antibiotics have no role in the routine management of uncomplicated croup, as most cases are caused by viruses. They should only be used to treat cases of bacterial superinfection, such as pneumonia or bacterial tracheitis
name: Antibiotics
label: c
answer: no
explanation: Salbutamol does not play a role in the management of croup. It would be useful as a bronchodilator in asthma
name: Salbutamol
label: e
answer: no
explanation: Dexamethasone is the preferred glucocorticoid in the management of croup due to its longer half-life and anti-inflammatory effects. It works by reducing laryngeal mucosal oedema. It has been shown to reduce the overall severity of croup, length of hospital stay and the need for nebulised adrenaline
name: Dexamethasone
label: a
answer: yes
explanation: This may be used as supplemental therapy in hypoxaemic children, but would not alter the disease course
name: Oxygen
label: d
answer: no
explanation: Nebulised adrenaline may be used in acute symptom relief of croup by reducing stridor and work of breathing, as it works by decreasing airway oedema and relieving airway obstruction. However, it would not alter the natural clinical course of croup
name: Nebulised adrenaline
label: b
answer: no

Correct answer: a


Learning point: Dexamethasone is the first-line treatment for croup, effectively reducing laryngeal inflammation.
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 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
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 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 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 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

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.