hllj/quesmed huggingface dataset:
A 45-year-old construction worker visits a GP clinic for a routine check-up and is found to have high blood pressure (188/128 mmHg) without any symptoms. Subsequent measurements of the patient's blood pressure are similar. He has not been diagnosed with any other medical conditions.

As part of routine screening for potential damage to the patient's organs due to high blood pressure, which of the following would be performed?

Options:
explanation: Urine albumin:creatinine ratio and urine dipstick to check for proteinuria are recommended over 24-hour urine collection analysis.
name: 24-hour urine collection
label: b
answer: no
explanation: Liver function tests are not routinely offered to asses for target organ damage. Instead, renal function tests such as serum electrolytes, creatinine, and estimated glomerular filtration rate are advised to test for chronic kidney disease.
name: Liver function tests
label: d
answer: no
explanation: An ECG should be conducted on newly diagnosed hypertensive patients as part of a series of tests to check for evidence of damage to the patient's organs. ECG is one among them to further asses for cardiac function and detect left ventricular hypertrophy.
name: 12-lead electrocardiograph (ECG)
label: a
answer: yes
explanation: An echocardiogram is usually not recommended in the first instance. If any abnormalities are noted on ECG, then echocardiography would be the best choice to evaluate the underlying condition further.
name: Echocardiogram
label: c
answer: no
explanation: HbA1C is preferred over fasting blood glucose, as it is more convenient and reliable.
name: Fasting blood glucose
label: e
answer: no

Correct answer: a
A 70-year-old woman presents to a GP clinic complaining of dysuria, suprapubic pain, and urgency for the past week. Her past medical and surgical history is unremarkable. Her vital signs are:

 - Temperature: 37.1 °C
 - Pulse rate: 80/min
 - Blood pressure: 120/80 mmHg
 - Respiratory rate: 18/min

What is the most appropriate next course of action?

Options:
explanation: His clinical presentation is more consistent with UTI, which does not spontaneously resolve and requires antibiotics. Safety netting is offered irrespective of the diagnosis, as the symptoms can worsen. However, it must be accompanied by antibiotics in this scenario.
name: Reassure and discharge with safety netting
label: d
answer: no
explanation: A non-urgent referral to a specialist is only required if there are signs of bladder cancer and recurrent or persistent UTIs in people aged 60 years or over.
name: Urgent referral to a urologist
label: e
answer: no
explanation: A positive urine dipstick is not necessary to treat a UTI in those >65 years of age. This patient has clinical signs and symptoms of a UTI and therefore should have antibiotics started regardless of the urine dipstick result. This would have been the right choice if the patient was less than 65 years.
name: Perform urine dipstick and commence back-up antibiotic only if Nitrite negative and WBC positive
label: c
answer: no
explanation: A urine dipstick alone cannot confirm the diagnosis as around half of the elderly age group have asymptomatic bacteriuria and test positive on a dipstick without infection however this patient has clinical signs and symptoms of a urinary tract infection. It is therefore important to take a urine sample to culture and a urine dipstick as well as starting antibiotics.
name: Send off urine dipstick, urine culture and commence antibiotic immediately
label: a
answer: yes
explanation: A positive urine dipstick is not necessary to treat a UTI in those >65 years of age. This patient has clinical signs and symptoms of a UTI and therefore should have antibiotics started regardless of the urine dipstick result. This would have been the right choice if the patient was less than 65 years.
name: Perform urine dipstick and commence immediate antibiotic only if Nitrite positive and WBC positive
label: b
answer: no

Correct answer: a
A 60-year-old man presents to the GP with severe lower back pain for the past few days. He has a history of end-stage renal disease on haemodialysis, diabetes mellitus type 2, hypertension, and was recently diagnosed with prostate cancer. He further mentions that the pain (8/10) is severe in the lumbar region and has significant paraspinal muscle spasms. It does not radiate and denies any recent changes in bladder or bowel habits. His current medications include lisinopril, atenolol, insulin, and as needed, acetaminophen.

Physical examination is normal except for tenderness over the lumbar spine and an AV fistula in the left forearm. Vital signs are normal. A CT scan shows lytic lesions in the lumbar spine.

What is the most appropriate treatment for his pain?

Options:
explanation: Gabapentin is a medication that can effectively relieve neuropathic pain when combined with other pain medications. However, the dosage of gabapentin must be gradually increased to avoid side effects, so it may not be a suitable choice for a patient who needs rapid pain relief.
name: High dose gabapentin
label: d
answer: no
explanation: Morphine is a common opioid medication, but its active by-products can build up in the body when the kidneys are not functioning properly, which increases the risk of harmful neuroexcitatory effects if the medication is rapidly increased in dosage. Moreover, it is contraindicated in chronic kidney disease.
name: Morphine
label: b
answer: no
explanation: Oxycodone is a powerful opioid medication preferred in palliative care patients with severe renal impairment. It is often the **preferred opioid for treating cancer-related pain in patients with chronic kidney disease**. When managing end-of-life care for renal failure or disease patients, oxycodone 1.25 – 2.5 mg is prescribed to alleviate pain. However, it is important to exercise caution as there is a higher potential for opioid toxicity. Therefore, increasing the dosing intervals with the lowest possible dose is necessary to ensure safety.
name: Oxycodone
label: a
answer: yes
explanation: Codeine is contraindicated in patients with kidney failure. Therefore, it is not the best choice in this scenario.
name: Codeine
label: e
answer: no
explanation: A transdermal fentanyl patch is an effective pain medication for patients who are already taking opioids regularly. It does not produce any active by-products that can accumulate in the body and cause problems in patients with end-stage kidney disease. However, it should only be used in patients who are already tolerant to opioids.
name: Transdermal fentanyl patch
label: c
answer: no

Correct answer: a
A 85-year-old woman presents to the emergency department with severe pain in her left hip and difficulty walking and bearing weight on the left leg. She reports falling on her left side while getting out of bed this morning. She recently had a stroke a few months ago that left her with paralysis on the left side, and she is using a frame while walking. Past medical history includes hypothyroidism, osteoporosis, hypercholesterolaemia and heart failure.

Examination reveals a shortened and externally rotated left lower limb. X-ray shows a complete and partially displaced subcapital fracture of the neck of the femur.

Which of the following management option is the most appropriate choice?

Options:
explanation: According to the radiographic findings, which show a **Garden stage III hip fracture**, this patient requires immediate surgical intervention to repair the fracture and stabilise the joint. A hemiarthroplasty would be the safest choice due to her age and comorbidities, as it carries a relatively lower risk compared to a total hip replacement.
name: Hemiarthroplasty
label: a
answer: yes
explanation: Intramedullary nailing is the "gold standard" treatment for managing femoral shaft fractures.
name: Intramedullary nail
label: d
answer: no
explanation: Due to her current medical conditions, which are currently impairing her mobility, it would not be advisable for her to undergo a total hip replacement at this age.
name: Total hip replacement
label: b
answer: no
explanation: A Dynamic hip screw is regarded as the 'gold standard' implant for application in all extracapsular fractures. This is an intra-capsular fracture.
name: Dynamic hip screw
label: c
answer: no
explanation: The clinical scenario is a surgical emergency that requires prompt intervention to stabilise the fracture and restore function to the hip joint. While physiotherapy may be an important part of the patient's rehabilitation after the surgery, it is not an appropriate treatment for the fracture itself.
name: Physiotherapy
label: e
answer: no

Correct answer: a
A 70-year-old woman has been seen at the GP clinic for a review of her bloods. A week ago, she complained of burning micturition, dysuria, and lower pelvic pain. She was diagnosed with urinary tract infection and was started on trimethoprim. Past medical history includes chronic obstructive pulmonary disease, coronary artery disease, rheumatoid arthritis, and type 2 diabetes mellitus. She takes ipratropium bromide and salbuterol inhalers, aspirin, clopidogrel, atorvastatin, ciclosporin, and metformin.


Her vital signs and physical examination are unremarkable. A week ago,
Creatinine: 89 µmol/L (60-120 µmol/L)
Urinalysis: 0-1 RBCs, 0-2 WBCs, 5-10 hyaline casts.


Her recent blood tests reveal:
Creatinine: 140 µmol/L (60-120 µmol/L)


Given the blood results, what is the best course of action?

Options:
explanation: There are no worrying signs of any significant kidney injury, the patient's vital signs and physical examination are unremarkable, and the patient is otherwise stable. Therefore, referring the patient to a specialist for further review would not be necessary.
name: Refer to a specialist for further review
label: d
answer: no
explanation: This patient has only been taking paracetamol for the past week, so it is unlikely to have caused any kidney injury. Additionally, the patient has been diagnosed with osteoarthritis, and paracetamol is a safe and effective treatment for her pain. Analgesic nephropathy is due to the long-term use of paracetamol, aspirin or NSAIDs.
name: Discontinue paracetamol
label: e
answer: no
explanation: Regular monitoring of creatinine levels may not provide additional information, as there will be no evidence of renal damage. Moreover, it is an unnecessary burden on healthcare resources.
name: Monitor creatinine levels daily
label: c
answer: no
explanation: A transient increase in serum creatinine level is an expected effect of trimethoprim, which is not harmful as it returns to normal after stopping the medication. Switching antibiotics unnecessarily can lead to resistance. Therefore, replacing trimethoprim with another antibiotic is not recommended.
name: Replace trimethoprim with another antibiotic
label: b
answer: no
explanation: Trimethoprim causes a **transient rise in creatinine levels** by decreasing renal creatinine excretion rather than a sign of acute kidney injury. Moreover, there is a high chance of developing hyperkalaemia due to inhibition of the uptake of sodium in the distal tubule, leading to less urine potassium and an accumulation of potassium in the blood. Both of these changes are reversible, and the values return to normal after withdrawing the drug.
name: No action needed
label: a
answer: yes

Correct answer: a
An 80-year-old woman presents with a complaint of forgetfulness for the past three months. She used to live with her husband but has been living alone since his passing two years ago. Recently, she has become increasingly forgetful and socially withdrawn. She contacts her children less frequently than she used to and has been late paying her bills. She blames her recent memory impairment on tiredness. Her medical history includes being treated for depression as a teenager. Her physical examination is unremarkable, and the Mini-Mental State Examination score is 27/30, but she declines to answer some questions and needs to be urged to participate in the assessment.

What is the single most likely diagnosis?

Options:
explanation: The most common first manifestation of Alzheimer's dementia is short-term memory loss. The disease progresses gradually, with periods of a plateau, and may cause behaviour disorders such as wandering, agitation, and persecutory ideation.
name: Alzheimer's dementia
label: d
answer: no
explanation: Frontotemporal dementia is a type of neurodegenerative disorder that affects intellectual functions such as abstract thinking, reasoning, and executive function, leading to difficulties with activities of daily living. It is characterised by changes in behaviour, dietary habits, empathy, apathy, and executive function and may initially present with intact memory.
name: Frontotemporal dementia
label: b
answer: no
explanation: Normal pressure hydrocephalus causes a classical triad of symptoms: urinary incontinence, dementia and Parkinsonian-like gait abnormality. This is secondary to reduced CSf absorption and is reversible. Whilst this patient has dementia, and is in the right demographic category for this condition, she does not exihibit the other features.
name: Normal pressure hydrocephalus
label: e
answer: no
explanation: Pseudodementia (depressive dementia) is often **short and abrupt in onset**, while dementia is more often gradual. Suspect pseudodementia in older people with predominantly cognitive symptoms (memory loss, prominent slowing of movement, and slowed speech) with a relatively acute onset in whom a major life event has occurred as they are more likely to be suffering from a simultaneous major depressive episode as opposed to true dementia.
name: Pseudodementia
label: a
answer: yes
explanation: Vascular dementia tends to affect executive function earlier and cause memory loss later. It tends to progress in steps, with each episode causing intellectual decline that may be followed by modest recovery. Cognitive loss may be focal, making them more aware of their deficits and more prone to depression.
name: Vascular dementia
label: c
answer: no

Correct answer: a
A 70-year-old man presents with dizziness, headache, light-headedness, and frequent falls over the past month, often feeling faint after standing up from sitting for long periods. His past medical history is significant for depression and hypertension, and he has been taking sertraline and amlodipine for the past two years without any reported side effects. Recently, chlorthalidone was added for hypertension six months ago. 

The patient's blood pressure is 160/90 mmHg while sitting, 130/69 mmHg after standing for 3 minutes, with a pulse rate of 78 beats per minute.
On examination, no other significant findings are noted. Laboratory investigations of complete blood count and serum electrolytes are unremarkable.


Which among the following is the next best step in managing his complaints?

Options:
explanation: Non-pharmacological treatments include increasing water and salt intake, wearing compression garments or bandages, and physical manoeuvres to counter the drop in BP. However, as the question asked for the next best step, reviewing the medication is the most appropriate choice, which can be followed by providing non-pharmacological advice.
name: Advice high salt diet
label: e
answer: no
explanation: Pyridostigmine is primarily used to treat myasthenia gravis. It significantly improves standing BP, with the most significant effect on diastolic BP in patients with postural hypotension without worsening supine hypertension. However, it is considered a second-line medication and inappropriate in this scenario.
name: Prescribe pyridostigmine
label: c
answer: no
explanation: Orthostatic hypotension is a sudden and sustained **drop in systolic blood pressure of at least 20 mmHg (at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure of at least 10 mmHg within 3 minutes of standing** from a seated/lying down position. This patient is taking multiple medications: antidepressant (SSRI), calcium channel blockers, and notably, the addition of chlorthalidone (thiazide-like diuretic) six months ago might have most probably resulted in his complaints. Treatment depends on the cause, and non-pharmacological methods should be tried before resorting to medication. If the cause is related to polypharmacy, optimising the patient's treatment plan by removing or replacing the offending drug will be helpful.
name: Stop clorthalidone
label: a
answer: yes
explanation: Fludrocortisone is a synthetic mineralocorticoid hormone that is used to treat orthostatic hypotension by increasing blood volume and blood pressure. It is the first-line medication to treat postural hypotension if all other methods fail and symptoms and BP readings persist the same.
name: Prescribe cyclizine
label: d
answer: no
explanation: Fludrocortisone is a synthetic mineralocorticoid hormone that is used to treat orthostatic hypotension by increasing blood volume and blood pressure. It is the first-line medication to treat postural hypotension if all other methods fail and symptoms and BP readings persist the same.
name: Prescribe fludrocortisone
label: b
answer: no

Correct answer: a

Stop clorthalidone
A 60-year-old woman has presented with severe low back pain for the past three months. She has been a chronic smoker since childhood and had premature menopause at the age of 38 years. A dual-energy x-ray absorptiometry (DXA) scan, which assesses her bone density, revealed a T-score below −2.5.

Given the likely diagnosis, what receptor is overactive at the molecular level in the patient's condition?

Options:
explanation: CCR5 is a chemokine receptor that is expressed on the surface of immune cells, including T cells, monocytes, and macrophages. The HIV-1 virus uses CCR5 as a co-receptor to enter and infect immune cells. Antiretroviral drugs (maraviroc) that block the activity of CCR5 are used to treat HIV/AIDS.
name: CCR5
label: c
answer: no
explanation: The NMDA (N-methyl-D-aspartate) receptor is a glutamate receptor essential for normal brain function. Dysfunction of the NMDA receptor has been implicated in several neuropsychiatric conditions (schizophrenia, Alzheimer's disease, and stroke). NMDA receptor antagonists, such as ketamine and dextromethorphan, have been used as anaesthetics and have been shown to have antidepressant effects.
name: NMDA
label: d
answer: no
explanation: Osteoporosis is fairly common in post-menopausal women, primarily due to diminished oestrogen levels in the body, which is critical for maintaining bone homeostasis.
 - **Receptor activator of nuclear factor-kappa B (RANK)** is expressed on the surface of osteoclast precursors, which are cells responsible for bone resorption.
 - **RANK ligand (RANKL)** is expressed on the surface of osteoblast precursors, which are cells responsible for bone formation, and activates RANK on osteoclast precursors.
In normal bone homeostasis, the balance between RANKL and its inhibitor, osteoprotegerin is essential for maintaining bone mass. However, in osteoporosis, there is an imbalance in favour of RANKL, resulting in increased RANK activation and bone resorption. This leads to decreased bone density and an increased risk of fractures.
name: RANK
label: a
answer: yes
explanation: The acetylcholine receptor (AChR) is a protein found in the membrane of nerve cells that is responsible for the transmission of the nerve impulse across the synapse from one neuron to another. Overactivation of AChRs can lead to the development of myasthenia gravis, a chronic autoimmune disorder that causes muscle weakness and fatigue.
name: AChR
label: e
answer: no
explanation: CXCL13 is a B and T lymphocyte chemokine that mediates neuroinflammation through its receptor CXCR5. They are implicated in the pathogenesis of several autoimmune diseases, such as rheumatoid arthritis, myasthenia gravis, multiple sclerosis, and systemic lupus erythematosus.
name: CXCR5
label: b
answer: no

Correct answer: a
A 55-year-old woman, a baker by profession, was brought to the emergency department after falling while at work, resulting in a hip fracture. Her past medical history is significant for anorexia nervosa, and a family history of osteoporosis in a second-degree relative. She is a chronic smoker and alcoholic. Her BMI is 17.9 kg/m2. A complete physical examination, including the systems, is unremarkable.

Given the likely diagnosis, what is the standard deviation threshold for commencing bisphosphonate therapy?

Options:
explanation: A T-score of less than -1 indicates that the patient has low bone mass, also known as osteopenia. While this level of bone loss does not meet the criteria for osteoporosis, it does put the patient at increased risk for fractures and may warrant further evaluation and preventive measures.
name: T-score <−1
label: b
answer: no
explanation: This option is incorrect. A T-score of less than -3.5 would indicate very severe osteoporosis, a more advanced stage of bone loss. However, it is not the threshold for initiating bisphosphonate therapy.
name: T-score <−3.5
label: e
answer: no
explanation: Treatment with bisphosphonates (such as alendronate) is typically started if the T-score is −2.5 standard deviations below the mean. T-score is defined as the bone mineral density (BMD) at the site when compared to the young normal reference mean (healthy 30-year-old).
name: T-score <−2.5
label: a
answer: yes
explanation: This option is incorrect. A T-score of less than -3 would also indicate osteoporosis, however it is not the threshold for initiating bisphosphonate therapy.
name: T-score <−3
label: d
answer: no
explanation: This option is incorrect. A T-score of less than -1.5 would fall within the range of osteopenia and would not meet the criteria for initiating bisphosphonate therapy.
name: T-score <−1.5
label: c
answer: no

Correct answer: a