hllj/quesmed huggingface dataset:
A 29 year old woman has nausea and fatigue and appears jaundiced. She is 28 weeks pregnant with her first child. She appears confused. Her husband reports attending a family BBQ last month. She deteriorates over the next few days and unfortunately dies.

What is the most likely diagnosis?

Options:
explanation: Hepatitis C is more classically associated with chronic illness with most infected patients experiencing no acute symptoms within 6 months of infection. Hepatitis C may cause chronic liver disease, with corresponding signs such as spider naevi, ascites, caput medusae.
name: Hepatitis C
label: e
answer: no
explanation: Hepatocellular carcinoma is unlikely to present acutely and would classically be associated with a background of chronic hepatitis B, C, or alcoholism. Constitutional symptoms such as weight loss and night sweats may be present.
name: Hepatocellular carcinoma
label: c
answer: no
explanation: Pregnant women are at increased risk of contracting acute HEV infection after eating raw or undercooked meat, especially pork. These patients are at higher risk of developing severe complications including fulminant acute liver failure which can be fatal.
name: Hepatitis E
label: a
answer: yes
explanation: This is a sensible differential however the vignette points towards an infective picture with the recent BBQ. Pork in particular is a major reservoir of HEV. In addition, most cases would be unlikely to cause such a severe presentation.
name: Acute fatty liver of pregnancy
label: b
answer: no
explanation: Hepatitis A normally runs a self-limiting course. It is unlikely to cause such a severe clinical picture.
name: Hepatitis A
label: d
answer: no

Correct answer: a


Learning point: Pregnant women have an increased risk of severe complications and fulminant liver failure from Hepatitis E infection, especially following consumption of raw or undercooked meat.
A 75 year old man with no previous medical history presents with 7 kg of weight loss over the last three months. He has a tender palpable swelling in his left arm. He says that he has noticed a few similar swellings over the past few months. He appears jaundiced. His recent fasting blood glucose was 7.0 mmol/lL (normal range 3.5-5.5 mmol/L).

Which of the following investigations is most likely to reveal the underlying diagnosis?

Options:
explanation: Bone marrow biopsy and serum protein electrophoresis are investigations used to evaluate for haematological malignancies, such as multiple myeloma, which do not explain the patients new onset diabetes or arm swelling.
name: Serum protein electrophoresis
label: d
answer: no
explanation: While this may be useful in the context of symptoms suggestive of diabetes mellitus, it is not the single most important investigation here in view of the likely pancreatic cancer.
name: HbA1c
label: b
answer: no
explanation: Multiparametric MRI is used in the evaluation of prostate cancer, which can cause back pain and weight loss, but it is not the most appropriate investigation in this case as it does not explain the other symptoms.
name: Multiparametric MRI
label: e
answer: no
explanation: Bone marrow biopsy and serum protein electrophoresis are investigations used to evaluate for haematological malignancies, such as multiple myeloma, which do not explain the patients new onset diabetes or Trousseau's sign of malignancy.
name: Bone marrow biopsy
label: c
answer: no
explanation: This presentation is suspicious for pancreatic cancer, which a CT scan can detect. This will also show involvement of local anatomy such as blood vessels or lymph nodes. The swelling in his left arm would be consistent with the Trousseau sign of malignancy, also known as migratory thrombophlebilitis, which presents as a tender nodule under the skin.
name: CT scan of the abdomen
label: a
answer: yes

Correct answer: a


Learning point: A persistent, tender swelling in an arm, alongside unexplained weight loss and jaundice, warrants investigation with a CT scan, which may reveal underlying pancreatic cancer.
A 40-year-old man has had diarrhoea and widespread flushing for the last month. He gets dizzy when he stands up and his blood pressure is measured at 100/60mmHg. A pansystolic murmur is heard loudest over the fourth intercostal space.

Which of the following is most likely to alleviate his symptoms?

Options:
explanation: This would be useful in treating Addison's disease, which can cause hypotension and dizziness, but not the diarrhoea or murmur. There are no other autoimmune features or skin pigmentation mentioned which would make this diagnosis more likely.
name: Hydrocortisone and fludrocortisone
label: b
answer: no
explanation: This presentation is consistent with carcinoid syndrome, due to serotonin production from a tumour. The symptoms of carcinoid syndrome include diarrhoea, flushing, hypotension, and predominantly right sided heart murmurs, which are consistent with the symptoms described in the scenario.
name: Octreotide
label: a
answer: yes
explanation: This presentation is not consistent with coeliac disease.
name: Gluten free diet
label: d
answer: no
explanation: A low FODMAP diet may be used to treat irritable bowel syndrome, which would not explain any of the symptoms apart from diarrhoea and is a diagnosis of exclusion. There is no mention of bloating, abdominal pain or cramping, core features of IBS.
name: Low FODMAP diet
label: e
answer: no
explanation: Infective endocarditis is not an unreasonable differential, however the lack of a fever or risk factors for bacterial endocarditis make this less likely.
name: Broad-spectrum antibiotics
label: c
answer: no

Correct answer: a


Learning point: In gastroenterology, carcinoid syndrome is characterised by diarrhoea, flushing, hypotension, and right-sided heart valvular damage, which can be treated with octreotide to alleviate symptoms.
A 50-year-old woman has had heartburn, belching and coughing during meals for the last two months. She is overweight and drinks 16 units of alcohol a week. Imaging investigations demonstrate a sliding hiatus hernia.

What is the most appropriate management?

Options:
explanation: In the first instance, weight loss, avoiding large meals,avoiding acidic/spicy foods, avoiding caffeine/alcohol, and quitting smoking should be implemented along with a proton pump inhibitor or H2 blocker.
name: Lifestyle measures and symptomatic control
label: a
answer: yes
explanation: Urgent referral for surgical correction is only needed if the patient experiences acute complications such as severe chest pain or difficulty swallowing.
name: Urgent referral for surgical correction
label: c
answer: no
explanation: Routine referral for surgical correction is not necessary unless the patient experiences chronic and severe symptoms, or develops complications such as bleeding, narrowing of the oesophagus, or a strangulated hernia.
name: Routine referral for surgical correction
label: b
answer: no
explanation: Not addressing the patient's symptoms is not appropriate in this scenario.
name: Discharge with safety netting
label: d
answer: no
explanation: There is no role for endoscopic surveillance for simple hiatus hernias. This may be required if a patient has concurrent pathology such as Barrett's oesophagus.
name: Refer for 6 monthly endoscopic monitoring
label: e
answer: no

Correct answer: a


Learning point: In patients with a sliding hiatus hernia causing symptoms such as heartburn, belching and coughing during meals, initial management should include lifestyle modifications, weight loss, and acid suppressant therapy before considering surgical intervention.
A 28 year old man comes to the emergency department with severe upper chest pain which started after he went to the gym yesterday which he rates as 7/10. His neck and shoulders also feel very sore. He denies any other symptoms. His ECG is shown below. His troponin levels are normal. What is the most appropriate management option?

[lightgallery]

Options:
explanation: There is no evidence of an acute myocardial infarction.
name: Refer for Urgent PCI
label: d
answer: no
explanation: The diagnosis is costochondritis. There are no features of a pathology that can be treated surgically.
name: Urgently take to theatre for surgery
label: e
answer: no
explanation: There is no evidence of an acute myocardial infarction.
name: Initiate thrombolytic therapy
label: c
answer: no
explanation: This would be an appropriate treatment for pericarditis, which would commonly present following a viral illness. An ECG may show saddle-shaped ST elevation.
name: Discharge with colchicine
label: b
answer: no
explanation: This man's presentation suggests a diagnosis of costochondritis, due to the recent musculoskeletal injury.
name: Discharge with ibuprofen
label: a
answer: yes

Correct answer: a


Learning point: In young adults presenting with chest pain and normal ECG and troponin levels, consider alternative diagnoses such as costochondritis before assuming acute coronary syndrome.
A 56-year-old comes to the GP surgery with breathlessness while walking his dog for the last two months. He has peripheral oedema and a tanned complexion, the latter also having progressed over the past two months. He has been thirsty and urinating more over the same time frame.

Which of the following is the most important blood test to request?

Options:
explanation: BNP may be relevant in assessing heart-related conditions, such as heart failure, it might not be the most important test in this case, given theadditional symptoms the patient is experiencing.
name: B naturetic peptide
label: b
answer: no
explanation: These symptoms do not strongly suggest a thyroid issue as the primary cause.
name: Thyroid function tests
label: e
answer: no
explanation: While the symptoms could potentially be related to liver dysfunction e.g. pulmonary oedema/pleural effusions due to hypoalbuminaemia, other symptoms point to potential renal/cardiac/endocrine impairment.
name: Liver function tests
label: d
answer: no
explanation: While impaired kidney function can contribute to fluid retention and creatinine would be an important test to request, kidney disease does not explain the entire clinical picture.
name: Serum creatinine
label: c
answer: no
explanation: The mention of a "bronze tan" could indicate haemochromatosis, a condition characterized by excess iron absorption, leading to symptoms such as those described in the vignette. This is further suggested by heart failure-type symptoms and diabetes.
name: Transferrin saturation
label: a
answer: yes

Correct answer: a


Learning point: In gastroenterology, a prolonged tanned complexion with peripheral oedema, thirst, and urinary frequency could indicate hereditary haemochromatosis, making transferrin saturation a crucial diagnostic test.
A 31-year-old woman comes to her GP surgery worried about losing her hair. She describes hair thinning across her scalp for 3 months. Her only past medical history is menorrhagia.

Which investigations are most likely to reveal the diagnosis?

Options:
explanation: Androgen testing in hair loss is mainly indicated when virilising features are noted such as hirsutism, acne or irregular menses, which are not present.
name: Androgen levels
label: b
answer: no
explanation: These are less likely to be useful in investigating hair loss.
name: Vitamin D levels
label: d
answer: no
explanation: Thyroid disorders and iron deficiency may both cause alopecia and hair loss, and would also be reasonable first-line investigations.
name: Thyroid function tests and ferritin
label: a
answer: yes
explanation: These are less likely to be useful in investigating hair loss.
name: B12 levels
label: e
answer: no
explanation: Discoid lupus and other causes of scarring alopecia may be investigated with an ANA and other blood tests, however the scenario describes the patient being otherwise well with no obvious skin lesions.
name: Autoimmune panel
label: c
answer: no

Correct answer: a


Learning point: Investigate thyroid function and iron levels in women with unexplained hair loss to rule out hypothyroidism and anaemia as possible causes.
A 38-year-old HIV positive man comes to the emergency department with headache and fever for the last two days. He denies neck stiffness and photophobia. A CT Head shows multiple ring enhancing lesions with no mass effect.

What is the most appropriate course of action?

Options:
explanation: IVIG and plasmapharesis may be used to treat PML which does not typically cause ring enhancing lesions.
name: Treat with IVIG and plasmapheresis
label: d
answer: no
explanation: LP may be contraindicated due to increased intracranial pressure and in the context of HIV neurocomplications is more likely to be a part of the workup for cryptococcal meningitis.
name: Perform a therapeutic lumbar puncture
label: c
answer: no
explanation: Toxoplasmosis serology in the blood has no diagnostic bearing on whether cerebral toxoplasmosis exists and is often falsely positive.
name: Send off toxoplasma serology
label: e
answer: no
explanation: This case describes a most likely case of toxoplasmosis due to the neuroimaging findings as multiple ring enhancing lesions in HIV are virtually diagnostic of toxoplasmosis. This is the correct answer, as treating toxoplasmosis often involves medical management and monitoring to see whether imaging and symptoms improve. Folate is often co-adminstered with sulfadiazine as it can lead to folate deficiency.
name: Administer sulfadiazine and pyramethamine
label: a
answer: yes
explanation: Brain biopsies are very invasive and are associated with a host of complications, dexamathesone should be avoided for two reasons, there is very little mass effect and oedema in this case and it could cause an improvement in imaging and confoundthe picture of whether the treatment is working.
name: Administer dexamethasone and arrange urgent brain biopsy
label: b
answer: no

Correct answer: a


Learning point: Neurological presentations in HIV positive patients should prompt consideration of toxoplasmosis with characteristic neuroimaging features of multiple ring enhancing lesions.
A 70 year old female patient presents with sudden onset, painless visual loss. Examination reveals a relative afferent pupillary defect and a pale, swollen optic disc. Over the past month she had noted weight loss and discomfort in her jaw after talking for long periods on the phone, but had not sought medical input. 

What is the most likely diagnosis? 

Options:
explanation: Incorrect. Amaurosis fugax is a transient, painless loss of vision, often described as a curtain descending over the eye, usually lasting seconds to minutes. This patient’s visual loss is not transient, making amaurosis fugax unlikely.
name: Amaurosis fugax
label: c
answer: no
explanation: Incorrect. Optic neuritis is associated with painful vision loss, typically in younger patients, and is often linked to multiple sclerosis. The painless vision loss and systemic symptoms in this case make optic neuritis unlikely.
name: Optic neuritis
label: e
answer: no
explanation: Correct. This patient’s sudden, painless visual loss, along with a relative afferent pupillary defect and pale, swollen optic disc, is characteristic of arteritic AION, most often caused by giant cell arteritis (GCA). The patient’s weight loss and jaw discomfort (jaw claudication) further support this diagnosis. GCA is a medical emergency, requiring urgent treatment with corticosteroids to prevent further vision loss.
name: Arteritic anterior ischemic optic neuropathy (AION)
label: a
answer: yes
explanation: Incorrect. Vitreous haemorrhage typically presents with floaters or a sudden, painless loss of vision but would not cause a swollen optic disc or a relative afferent pupillary defect, which are seen in this case.
name: Vitreous haemorrhage
label: d
answer: no
explanation: Incorrect. Non-arteritic AION typically presents similarly but lacks systemic symptoms like weight loss or jaw claudication, which are seen in arteritic AION secondary to giant cell arteritis. The visual loss in non-arteritic AION is also usually less severe.
name: Non-arteritic anterior ischemic optic neuropathy (AION)
label: b
answer: no

Correct answer: a


Learning point: Arteritic anterior ischemic optic neuropathy (AION) in giant cell arteritis (GCA) is a vision-threatening condition caused by inflammation of the arteries supplying the optic nerve, leading to sudden, painless vision loss and potential permanent damage if not treated promptly.
A 25-year-old man comes to the GP as his skin has become yellow. He denies any other symptoms. He has returned from visiting family in Egypt a few weeks ago and is currently observing Ramadan.

What is the most appropriate management plan?

Options:
explanation: An urgent referral may be warranted if LFTs show evidence of hepatitis or the patient has concerning symptoms such as fever/abdominal pain.
name: Urgent referral to gastroenterology
label: c
answer: no
explanation: Not investigating jaundice is inappropriate.
name: Discharge with reassurance
label: b
answer: no
explanation: The most likely diagnosis is Gilbert's syndrome, a benign condition where hyperbilirubinaemia occurs in the absence of liver disease. LFTs are required to check for an acute hepatitis and confirm that there are no other derangements other than an isolated rise in unconjugated bilirubin.
name: Request liver functon tests
label: a
answer: yes
explanation: Antimalarials are not indicated empirically in this case. The patient has no symptoms of malaria and Egypt is not an endemic area.
name: Treat with chloroquine
label: e
answer: no
explanation: An urgent referral may be warranted if LFTs show evidence of hepatitis or the patient has concerning symptoms such as fever/abdominal pain.
name: Urgent referral to infectious diseases
label: d
answer: no

Correct answer: a


Learning point: In individuals presenting with yellow skin (icterus) but lacking other symptoms or signs of liver disease, consider conducting liver function tests to rule out alternative causes before diagnosing Gilbert's syndrome.
A 27 year old woman attends her routine screening cervical smear appointment at the practice. During the appointment, she asks you to define what the term 'screening test' actually means.

According to the Wilson and Jungner criteria of screening tests, which of the following answers makes up part of the criteria?

Options:
explanation: This is incorrect. Screening is often aimed at conditions that can significantly impact health and quality of life, not necessarily those that are terminal.
name: The condition screened for must be eventually terminal
label: b
answer: no
explanation: The Wilson and Jungner criteria were established in 1968 by James Wilson and Gunnar Jungner, and they set forth principles for evaluating the suitability of a screening program for a disease. These criteria include several important aspects that a condition must meet for a screening program to be effective. This is one of the key criteria, as it is crucial to understand the progression of a disease to determine the optimal point for screening and intervention.
name: The untreated natural history of the disease must be known
label: a
answer: yes
explanation: Treatment options do not need to be surgical. They can be medical, lifestyle changes, or other forms of intervention.
name: There must be an acceptable surgical treatment for the disease
label: e
answer: no
explanation: While recognizing symptomatic stages can be useful, the criteria emphasize early detection before symptoms appear, rather than focusing on late stages.
name: There must be a recognisable late symptomatic stage of the disease
label: d
answer: no
explanation: Screening programs can be periodic rather than one-time events. The frequency depends on the natural history of the disease and the effectiveness of early detection, eg, breast and cervical cancer screening tests are performed every 5-years typically.
name: Screening must be one off
label: c
answer: no

Correct answer: a


Learning point: To effectively implement a cervical cancer screening program, it's crucial to first have a thorough understanding of the natural progression of the disease.
A 25 year old woman comes to the GP asking for help quitting smoking as she has recently discovered she is pregnant.

What is the most appropriate management?

Options:
explanation: Pregnant women should be advised to quit smoking in its entirety and helped to do so, there is no evidence switching to e-cigarettes is beneficial.
name: Advise to switch to e-cigarettes
label: e
answer: no
explanation: Vareniciline may be useful in smoking cessation but is contraindicated in pregnancy.
name: Offer Varenicline
label: c
answer: no
explanation: Bupropion may be useful in smoking cessation but is contraindicated in pregnancy.
name: Offer Bupropion
label: b
answer: no
explanation: This is inappropriate as maternal smoking is associated with a host of adverse birth outcomes including infant death, preterm birth, low birth weight and poor intrauterine growth.
name: Advise to quit after delivery
label: d
answer: no
explanation: All pregnant woman should be advised to stop smoking immediately and assisted with nicotine replacement therapy to help them quit.
name: Offer nicotine replacement therapy
label: a
answer: yes

Correct answer: a


Learning point: Nicotine replacement therapy is recommended for pregnant women seeking to quit smoking, as it aids in cessation while minimising risks to the fetus.
A 35 year old man comes to the GP with widespread raised papules with a central umbilication on his trunk, face, hands, legs and feet. He reports they have been present for the last 2 years without improvement and he is worried about them.

What is the most appropriate course of action?

Options:
explanation: Aciclovir is not used to treat molluscum contagiosum, steroid creams are used, whilst antibiotics may be indicated if secondary infection occurs.
name: Trial a course of aciclovir
label: d
answer: no
explanation: Whilst cryotherapy may be used for molluscum contagiosum, this option does not address the possible immunocompromise.
name: Refer for excision and cryotherapy
label: c
answer: no
explanation: The history and examination describe molluscum contagiosum, caused by the poxvirus. Whilst harmless in children, in adults when they persist and are widespread in the manner described they are suggestive of underlying immunocompromise, therefore HIV testing is indicated.
name: Arrange HIV testing
label: a
answer: yes
explanation: This is inappropriate due to widespread nature of the rash and lengthy duration.
name: Discharge with reassurance
label: b
answer: no
explanation: This is not appropriate as we are not concerned about a dermatological malignancy.
name: 2 week referral to dermatology
label: e
answer: no

Correct answer: a


Learning point: Persistent and widespread molluscum contagiosum in an adult may indicate underlying immunosuppression, requiring consideration for HIV testing.