hllj/quesmed huggingface dataset:
A 43-year-old man visits his GP with a 3-week history of a cough. Recently, he has been bringing up yellow sputum. He has no chest pain and no significant medical history. He believes he may be allergic to penicillin.

On examination, he has crackles in the right basal zone of the lungs. Observations are as follows:

* Heart rate: 62 beats/minute
* Blood pressure: 140/66 mmHg
* Respiratory rate: 16 breaths/minute
* Temperature: 37.9 degrees
* Oxygen saturations (room air): 98%

What is the most appropriate course of action to take?

Options:
explanation: This is not appropriate as the patient has signs and symptoms of a community acquired pneumonia, which should be treated with appropriate antibiotics.
name: Advise a 'watch and wait' strategy
label: e
answer: no
explanation: There are no 'red flags' indicating hospital admission, e.g. hypoxia or evidence of respiratory distress. This patient's CRB-65 score is 0, indicating a low risk of mortality.
name: Arrange hospital admission
label: b
answer: no
explanation: This is the most appropriate course of action. This patient has signs of a community acquired pneumonia, with a CRB-65 score of 0, indicating a low risk of mortality. Antibiotics should be prescribed. As he reports a penicillin allergy, clarithromycin or doxycycline are appropriate agents.
name: Prescribe clarithromycin
label: a
answer: yes
explanation: This would not be an appropriate choice of antibiotic, not only as the patient reports a penicillin allergy, but also as amoxicllin/doxycycline/clarithromycin are the first choice antibiotics in community acquired pneumonia, not co-amoxiclav.
name: Prescribe co-amoxiclav
label: c
answer: no
explanation: This would not be an appropriate antibiotic combination. Either doxycycline OR clarithromycin should be prescribed for the treatment of community acquired pneumonia in penicillin allergy.
name: Prescribe doxycycline and clarithromycin
label: d
answer: no

Correct answer: a


Learning point: In community-acquired pneumonia, clarithromycin is a suitable antibiotic alternative for patients with a penicillin allergy.
A 47-year-old woman has sudden onset shortness of breath and pleuritic chest pain. She has a history of type II diabetes and obesity.
She medication history includes metformin and the combined oral contraceptive pill.
Her saturations are 98% on 4 litres of oxygen via nasal cannulae. Her chest X-ray and VBG are both normal.

Given the most likely diagnosis, what is the most likely finding on her ECG?

Options:
explanation: This vignette suggests a diagnosis of pulmonary embolism, with sudden onset pleuritic chest pain and oxygen requirement, combined with several risk factors for VTE (obesity and use of COCP). The most common finding on ECG for patients with a PE is sinus tachycardia.
Whilst S1Q3T3 is a specific finding, it is not the most common finding.
name: Sinus tachycardia
label: a
answer: yes
explanation: This may be seen if the history was suggestive of an infection e.g. pneumonia (which can commonly trigger AF) or if palpitations/pre-syncope were described.
name: An irregularly irregular rhythm with an absence of P waves
label: d
answer: no
explanation: This is normally seen in hyperkalaemia. There is nothing in the history to suggest hyperkalaemia as the admission VBG is normal.
name: Tall tented T waves
label: e
answer: no
explanation: This is concerning for myocardial infarction rather than PE. A right bundle branch block may be observed in unstable PE due to right heart strain.
name: New left bundle branch block
label: c
answer: no
explanation: Whilst this is a specific finding for a PE, it is much less commonly seen than sinus tachycardia.
name: S1Q3T3 pattern
label: b
answer: no

Correct answer: a


Learning point: The most likely ECG finding in pulmonary embolism (PE) is sinus tachycardia, while the most specific finding is the S1Q3T3 pattern, which indicates right heart strain and is highly specific but less common.
A 65-year-old businesswoman has a dry cough and flu-like symptoms on returning home from a trip to Spain. She stayed in an old hotel whilst there. On examination, she is febrile and has bibasal crackles.
A chest x-ray shows patchy bibasal consolidation.

Given the likely causative organism, which of the other below findings would be expected?

Options:
explanation: This is normally seen in Klebsiella pneumoniae infection, which more commonly affects elderly patients or those with alcohol excess.
name: Redcurrant jelly sputum
label: d
answer: no
explanation: This can be associated with Streptococcus pneumoniae infection, the most common cause of community acquired pneumonia. The presence of flu-like symptoms as well as recent air conditioning exposure make this diagnosis less likely.
name: Presence of cold sores
label: c
answer: no
explanation: Anaemia (specifically cold autoimmune haemolytic anaemia) is a finding associated with Mycoplasma, rather than Legionella.
name: Anaemia
label: e
answer: no
explanation: This describes the erythema multiforme typically seen in Mycoplasma pneumonia, another cause of an atypical pneumonia which is less associated with exposure to air conditioning and foreign travel.
name: Presence of target lesions on examination
label: b
answer: no
explanation: The history of recent foreign travel (e.g. exposure to air conditioning) combined with the flu-like symptoms suggests a pneumonia caused by Legionella pneumophilia. This is thought to be due to syndrome of inappropriate ADH secretion.
name: Hyponatraemia
label: a
answer: yes

Correct answer: a


Learning point: Legionella pneumophila pneumonia often presents with hyponatraemia due to the syndrome of inappropriate antidiuretic hormone secretion.
A 35-year-old female has bilateral raised, tender nodules on her shins. She also complains of shortness of breath and a dry cough for the last 6 months.

She has no past medical history. A routine blood test shows hypercalcaemia.

Given the likely diagnosis, what is most likely to be seen on chest X-ray?

Options:
explanation: This describes a pneumothorax, which does not fit with the clinical presentation as it would typically cause sudden onset shortness of breath with pleuritic chest pain.
name: Absence of lung markings at the right apex
label: e
answer: no
explanation: This may be seen in a lung malignancy (some of which can also cause hypercalcaemia). This would be less common in a younger patient with no mention of smoking history and unlikely to cause erythema nodosum.
name: Unilateral spiculated mass
label: c
answer: no
explanation: This describes chest X-ray changes that may be seen in acute heart failure. Whilst this also may present with shortness of breath and a dry cough, it would be less likely to occur in a younger patient with no other past medical history, or cause erythema nodosum or hypercalcaemia.
name: Cardiomegaly and pleural effusions
label: d
answer: no
explanation: This question describes a case of sarcoidosis, a granulomatous disease which can affect multiple systems. It commonly affects women aged 20-40 and can present with progressive dyspnoea and a dry cough. The tender nodules mentioned describe erythema nodusum. Hypercalcaemia can also be seen in sarcoidosis, which is thought to be due to increased active vitamin D production. Bilateral hilar lymphadenopathy is a classic chest X-ray finding of sarcoidosis.
name: Bilateral hilar lymphadenopathy
label: a
answer: yes
explanation: Sarcoidosis typically causes an upper zone pulmonary fibrosis rather than lower zone.
name: Lower zone pulmonary fibrosis
label: b
answer: no

Correct answer: a


Learning point: Bilateral hilar lymphadenopathy is a characteristic chest X-ray finding in sarcoidosis, often associated with hypercalcaemia and respiratory symptoms.
A 21-year-old female with a past medical history of asthma has worsening shortness of breath and chest tightness after cold-water swimming.

She is found to have a diffuse wheeze on examination and is given back-to-back salbutamol nebulisers as initial treatment.

What is the most likely complication of this treatment?

Options:
explanation: As a β-2 agonist, salbutamol can cause tachycardia if given in high doses and is commonly seen in patients receiving back-to-back nebulisers.
name: Tachycardia
label: a
answer: yes
explanation: The patient may well be tachypnoeic due to respiratory distress, but this is not a side effect of salbutamol treatment.
name: Tachypnoea
label: b
answer: no
explanation: Salbutamol tends to cause hyperglycaemia rather than hypoglycaemia at high doses due to increased glycolysis.
name: Hypoglycaemia
label: e
answer: no
explanation: At very high doses, salbutamol can cause lactic acidosis. This is thought to be due to increased glycolysis and lipolysis from β-2 activation.
name: Low lactate
label: c
answer: no
explanation: Salbutamol toxicity tends to cause hypokalaemia rather than hyperkalaemia due to increased sodium/potassium pump activity.
name: Hyperkalaemia
label: d
answer: no

Correct answer: a


Learning point: Salbutamol, a β-2 agonist, can induce tachycardia as a side effect because it stimulates β-2 receptors in the lungs to cause bronchodilation, but it can also indirectly activate β-1 receptors in the heart, leading to an increased heart rate.
A 57-year-old diabetic patient has sudden loss of vision in their right eye

They deny any pain or a history of trauma to the eye.

They are poorly compliant with their diabetic medication and have not attended their scheduled eye checks.

At the start of ophthalmic examination, they are noted to have an absent red reflex on the right-hand side.

What is the most likely diagnosis?

Options:
explanation: This can cause sudden onset flashers and floaters, but would not cause complete visual loss unless it progressed to retinal detachment.
name: Posterior vitreous detachment
label: e
answer: no
explanation: Whilst this could cause an absent red reflex, it would be unlikely to present with sudden onset visual loss but rather progressive blurring of vision over time.
name: Right sided cataract
label: b
answer: no
explanation: This is more commonly seen in children and would be characteristically causes leukocoria (white reflex instead of red) instead of an absent red reflex.
name: Retinoblastoma
label: c
answer: no
explanation: In a patient with poorly controlled diabetes and sudden, painless visual loss, vitreous haemorrhage is a key differential. The classic sign on examination is an absent red reflex on the affected side.
name: Vitreous haemorrhage
label: a
answer: yes
explanation: Whilst his can cause visual difficulties if untreated, it would be painful and likely take a longer time to develop. Corneal scarring may cause a reduced or absent red reflex.
name: Corneal ulcer
label: d
answer: no

Correct answer: a


Learning point: Vitreous haemorrhage often presents with sudden, painless vision loss and an absent red reflex, particularly in poorly controlled diabetic patients.
A 21-year-old male has a red and painful left eye. He describes difficulty looking at bright lights and increased tearing of the eye.

On examination, his left pupil is irregular in shape.

He has no past medical history but takes ibuprofen regularly for early morning back pain.

Given the likely diagnosis, which treatment is most likely to be commenced?

Options:
explanation: This would be used in the treatment of bacterial conjunctivitis, which would also cause a red eye but would present with green/yellow discharge and a foreign body sensation rather than an irregular pupil and photophobia.
name: Topical chloramphenicol
label: b
answer: no
explanation: This scenario describes a case of anterior uveitis, an inflammation of the middle layer of the eye. The mainstay of treatment is typically steroids combined with drugs like atropine/cyclopentalone to prevent adhesions between the iris and the lens (posterior synechiae). The back pain mentioned may suggest this patient has anterior uveitis related to ankylosing spondylitis.
name: Topical steroids
label: a
answer: yes
explanation: Whilst this may help improve pain, it would not adequately address the underlying inflammation in the eye. The history of back pain responsive to NSAIDs suggests an underlying ankolysing spondylitis.
name: NSAIDs
label: e
answer: no
explanation: This is typically used in the treatment of a stye or chalazion and would be unlikely to help resolve the inflammation in a case of anterior uveitis.
name: Hot compress
label: c
answer: no
explanation: This is the surgical management of acute angle closure glaucoma. Whilst this can present with a painful red eye, it is less likely to affect this patient age group and more commonly causes a fixed mid-dilated pupil than an irregular one. Blurry vision and nausea are also common features of acute angle closure glaucoma.
name: Laser peripheral iridotomy
label: d
answer: no

Correct answer: a


Learning point: Anterior uveitis often presents with eye pain, photophobia, and irregular pupil, and is commonly treated with topical steroids.
A 53-year-old man has erectile dysfunction. He states it occurred gradually and has worsened over time.

He denies any symptoms of anxiety or depression and states he has no loss of libido. On examination, he has appropriate body hair and muscle mass.

He has a past medical history of obesity.

Which blood test would be most helpful in establishing the underlying diagnosis?

Options:
explanation: Prolactinomas can cause erectile dysfunction, however, vascular causes are more common (especially in a patient with risk factors such as obesity). There is an absence of other symptoms such loss of libido, headaches, or visual changes.
name: Serum prolactin levels
label: e
answer: no
explanation: This is unlikely to be helpful in establishing a cause for erectile dysfunction. There is also no mention of symptoms suggestive of anaemia.
name: Full blood count
label: b
answer: no
explanation: Whilst this is a recommended investigation for patients with erectile dysfunction, the presence of secondary sexual hair and muscle mass points away from it. Additionally, given the history of obesity, diabetes is a more likely cause for erectile dysfunction in this patient.
name: Testosterone levels
label: c
answer: no
explanation: Gradual onset erectile dysfunction in a middle-aged male with risk factors present should raise suspicion of diabetes mellitus. Vascular causes are the most common organic cause of erectile dysfunction.
name: HbA1c
label: a
answer: yes
explanation: Although prostatic issues can cause erectile dysfunction, this is less common than diabetes as a cause. Additionally, there are no mention of other symptoms associated with prostate cancer (e.g. lower urinary tract symptoms). PSA testing should not routinely be offered to asymptomatic patients.
name: Prostate specific antigen (PSA)
label: d
answer: no

Correct answer: a


Learning point: Gradual onset erectile dysfunction in middle-aged men may indicate underlying diabetes mellitus, particularly in those with obesity.
A 67-year-old male has noticed tenderness and swelling of his breast tissue in recent months

He has a past medical history of drug resistant hypertension and raised cholesterol.

Which of the following medications is the most likely cause of his symptoms?

Options:
explanation: This potassium-sparing diuretic is commonly associated with gynaecomastia. It is thought to have anti-androgenic effects by preventing testosterone binding to androgen receptors in breast tissue and causing increased clearance of testosterone.
name: Spironolactone
label: a
answer: yes
explanation: ACE inhibitors are not associated with gynaecomastia.
name: Ramipril
label: b
answer: no
explanation: This is typically prescribed as an alternative in patients who experience spironolactone-induced gynaecomastia. The patient would be unlikely to be taking the two drugs simultaneously.
name: Amiloride
label: c
answer: no
explanation: Whilst 5 alpha-reductase inhibitors can cause gynaecomastia, the patient has no history of BPH mentioned and would therefore be unlikely to be taking this medication.
name: Finasteride
label: e
answer: no
explanation: Statins are not typically associated with gynaecomastia.
name: Atorvastatin
label: d
answer: no

Correct answer: a


Learning point: Spironolactone can cause gynaecomastia due to its anti-androgenic effects, as it blocks androgen receptors and inhibits the conversion of testosterone to its more active form, leading to an imbalance that promotes breast tissue growth in males
A 67-year-old male has a routine HbA1c check as part of his diabetes management. He was started on metformin 12 months ago.

He has a past medical history of ischaemic heart disease.

* HbA1c: 67mmol/mol (patient target 48mmol/mol)

Given this result, which additional medication should he be offered in conjunction with metformin?

Options:
explanation: As the patient has established cardiovascular disease, a SGLT-2 inhibitor is preferable. Pioglitazone has been linked to worsened outcomes in patients with heart disease and therefore should not be used in this circumstance.
name: Pioglitazone
label: b
answer: no
explanation: As the patient has established cardiovascular disease, a SGLT-2 inhibitor is preferable. A DPP-4 inhibitor would have otherwise been an appropriate agent to commence for second-line treatment.
name: Sitagliptin
label: e
answer: no
explanation: Given this patient has a history of ischaemic heart disease, they should be offered a SGLT-2 inhibitor in conjunction with metformin given the proven cardiovascular benefits of this class of medication.
name: Dapagliflozin
label: a
answer: yes
explanation: As the patient has established cardiovascular disease, a SGLT-2 inhibitor is preferable. A sulfonylurea would have otherwise been an appropriate agent to commence for second-line treatment.
name: Gliclazide
label: c
answer: no
explanation: This may be considered if second line therapy (combination of two anti-diabetic medication) fails, however, it would not be routinely offered after just metformin was trialled.
name: Insulin
label: d
answer: no

Correct answer: a


Learning point: In patients with diabetes and ischaemic heart disease, SGLT-2 inhibitors like dapagliflozin provide significant cardiovascular benefits alongside metformin.
A 23-year-old female has flank pain and haematuria. She mentions she has been experiencing fatigue, bony pain and generalised abdominal pain for the last year.


Her blood results show:

||||
|---------------------------|:-------:|------------------------------|
|Calcium|3.2 mmol/L|2.2 - 2.6|
|Phosphate|0.55 mmol/L|0.8 - 1.5|
|Parathyroid Hormone|62 pmol/L|1.6 - 8.5|


What is the most likely underlying diagnosis?

Options:
explanation: The results in this case would show an elevated calcium, phosphate and PTH. Tertiary hyperparathyroidism often results from secondary hyperparathyroidism, as the parathyroid glands are chronically hyper-stimulated.
name: Tertiary hyperparathyroidism
label: c
answer: no
explanation: The history is describing symptoms suggestive of hypercalcaemia. In most people with Primary Hyperparathyroidism, both calcium and parathyroid are higher than normal. Occasionally, a patient may have an elevated calcium level and a normal or minimally elevated PTH level. Since PTH should be low when calcium is elevated, a normal or minimally elevated PTH is considered abnormal and usually indicates Primary hyperparathyroidim as if the normal feedback loop was maintained, the PTH should be suppressed.
name: Primary hyperparathyroidism
label: a
answer: yes
explanation: Osteomalacia is a defect of bone mineralisation secondary to vitamin D deficiency. A low calcium and low phosphate would be seen in osteomalacia, and it would be unlikely to present with renal stones.
name: Osteomalacia
label: e
answer: no
explanation: The results in this case would show hypocalcaemia and a raised phosphate and an (appropriately) raised PTH. This is usually due to decreased production of active vitamin D (e.g. in CKD).
name: Secondary hyperparathyroidism
label: b
answer: no
explanation: This would be rare to see in this patient age group and would not present with any of the symptoms of hypercalcaemia listed above. Additionally, the bone profile is typically normal in osteoporosis.
name: Osteoporosis
label: d
answer: no

Correct answer: a


Learning point: Primary hyperparathyroidism is a condition where one or more parathyroid glands produce excess parathyroid hormone (PTH), leading to elevated calcium levels in the blood (hypercalcemia), low phosphate levels, and associated symptoms such as fatigue, kidney stones, and bone pain.
A 23-year-old male has a lump on his right testis.

On examination, there is a 3mm fixed and irregular mass on the anterior aspect of the right testis. It is non-tender.

He has no other past medical history.

What is the most appropriate initial management?

Options:
explanation: This is inappropriate management as the history of an irregular, fixed and non-tender lump in a young male is highly suspicious for testicular cancer and they should therefore be referred as part of a two week wait pathway.
name: Reassure the patient and advise them to return in 3 months if the mass has not resolved
label: d
answer: no
explanation: This would be inappropriate management as the patient’s history is more concerning for testicular cancer. They also have no symptoms suggesting epididymo-orchitis (e.g. dysuria, urethral discharge or fever).
name: Refer to the local sexual health clinic for probable epididymo-orchitis
label: e
answer: no
explanation: Biopsy is rarely done in the case of suspected testicular cancer as it can increase risk of spread by seeding.
name: Arrange biopsy of the mass
label: c
answer: no
explanation: This scenario is concerning for testicular cancer as there is a fixed, irregular and non-tender swelling. The most appropriate management is therefore a two-week wait referral to Urology and potentially taking blood tests for tumour markers (e.g. AFP, hCG and LDH).
name: Two week wait referral
label: a
answer: yes
explanation: Whilst this might be arranged if the patient is found to have testicular cancer, it would be inappropriate to carry out before a diagnosis of cancer was confirmed.
name: Arrange CT CAP
label: b
answer: no

Correct answer: a


Learning point: A fixed, irregular, non-tender testicular mass in a young male warrants a two-week wait referral for suspected testicular cancer.
A 57-year-old male has pain which radiates from his flank towards his groin and has also noticed a dark red tinge to his urine in recent days.

On examination, he has extreme tenderness in the renal angle and is constantly fidgeting.

A CT KUB confirms the presence of a 6mm renal calculus on the left side.

What is the most likely mineral composition of this stone?

Options:
explanation: These are again rarer than calcium oxalate stones and are usually seen in patients with excessive dietary protein intake or gout.
name: Uric acid
label: d
answer: no
explanation: This is a much rarer composition of a renal stone than calcium oxalate and is usually associated with conditions such as renal tubular acidosis.
name: Calcium phosphate
label: c
answer: no
explanation: These are a rare cause of renal stones and usually seen in patients with a rare heritable condition called cystinuria. It can cause recurrent renal stones in affected patients.
name: Cystine
label: e
answer: no
explanation: These are typically seen following Proteus mirabalis infection and may cause staghorn calculi. There is no mention of preceding dysuria or increased urinary frequency to suggest preceding UTI.
name: Ammonium magnesium phosphate
label: b
answer: no
explanation: This is the most common type of renal stone. It is much more common than calcium phosphate stone formation. Hyercalciuria has many possible causes; including hypercalcaemia or poor fluid intake. Increased dietary oxalate intake (e.g. chocolate and nuts) or having conditions such as IBD also represent risk factors for formation of calcium oxalate stones.
name: Calcium oxalate
label: a
answer: yes

Correct answer: a


Learning point: Calcium oxalate stones are the most prevalent type of renal calculi, often associated with hypercalciuria.