hllj/quesmed huggingface dataset:
A 13-year-old male presents to hospital after falling onto an outstretched hand while playing football.

On examination, there is pain in the anatomical snuffbox. A scaphoid fracture is suspected but x-rays are unremarkable.

Which of the following is the most appropriate next step in management?

Options:
explanation: The scaphoid fracture is not confirmed so it would be unnecessary to apply a plaster for 6 – 8 weeks - this is unnecessary immobilisation which could result in muscle atrophy.
name: Plaster for 6–8 weeks
label: d
answer: no
explanation: This would be indicated if the patient had a displaced scaphoid fracture, however, this is not evident in the x-rays.
name: Immediate screw fixation
label: c
answer: no
explanation: Scaphoid fractures may not be radiologically visible until 10 days after the injury so repeating the x-ray so quickly is unlikely to impact management.
name: Repeat x-ray within one hour
label: e
answer: no
explanation: The combination of falling on an outstretched hand and pain over the anatomical snuffbox is highly indicative of a scaphoid fracture. However, a scaphoid fracture may only become visible radiologically after 10 days. A scaphoid fracture must be treated, even if it is not confirmed radiologically, to prevent the development of avascular necrosis of the scaphoid bone.
name: Plaster for 10 days then repeat x-rays
label: a
answer: yes
explanation: Discharging the patient would put him at risk of avascular necrosis of the scaphoid bone secondary to a lack of treatment.
name: Discharge
label: b
answer: no

Correct answer: a
A 45-year-old male presents to clinic with a 5-day history of knee pain.

On examination, the joint is erythematous, hot and swollen. Aspiration of the knee shows calcium pyrophosphate dihydrate crystals.

Given the most likely diagnosis, which of the following is a risk factor?

Options:
explanation: Hypomagnesemia is a risk factor for the deposition of calcium pyrophosphate dihydrate crystals as opposed to hypermagnesemia.
name: Hypermagnesemia
label: c
answer: no
explanation: Primary (and tertiary) hyperparathyroidism leads to hypercalcaemia which leads to the deposition of calcium pyrophosphate dihydrate crystals in articular cartilage. This results in flares of pseudogout. Secondary hyperparathyroidism, on the other hand, leads to hypocalcaemia.
name: Primary hyperparathyroidism
label: a
answer: yes
explanation: This is a risk factor for gout as high purine foods raise uric acid levels which leads to the formation of uric acid crystals. These can build up in articular structures causing gout.
name: Diet high in purines
label: d
answer: no
explanation: This is a risk factor for gout as hyperuricemia leads to the formation of urate crystals which can be found in synovial fluid on aspiration.
name: Hyperuricemia
label: e
answer: no
explanation: Hypoparathyroidism results in hypocalcaemia which means there is less calcium available for synovial deposits to form.
name: Hypoparathyroidism
label: b
answer: no

Correct answer: a
A 45-year-old female presents to her GP with a 6-month history of proximal muscle weakness. She explains that she struggles to get up from her chair.


On examination, there are no abnormalities and vital signs are within normal range.


Bloods are unremarkable apart from a creatine kinase of 300U/L (normal range 25-175 U/L).


A diagnosis of polymyositis is suspected.


Which of the following is most associated with polymyositis?

Options:
explanation: These are most associated with SLE.
name: Anti–dsDNA antibodies
label: b
answer: no
explanation: These are most associated with systemic sclerosis.
name: Anticentromere antibodies
label: e
answer: no
explanation: These are most associated with Sjogren's syndrome.
name: Anti-Ro/La antibodies
label: c
answer: no
explanation: Anti Jo–1 antibodies are associated with both polymyositis and dermatomyositis but are more commonly found in polymyositis.
name: Anti Jo–1 Antibodies
label: a
answer: yes
explanation: These are most associated with antiphospholipid syndrome.
name: Anticardiolipin antibodies
label: d
answer: no

Correct answer: a
A 73-year-old woman presents to Accident & Emergency following a fall at home. Paramedics found her with a shortened and externally rotated right leg.

A right pelvis x-ray shows an intertrochanteric fracture with partial displacement.

What is the most appropriate management of this fracture?

Options:
explanation: This is indicated in femoral shaft fractures.
name: Intramedullary nail
label: d
answer: no
explanation: This is normally indicated in younger patients (who are medically fit enough for the procedure) with displaced intracapsular fractures to preserve mobility.
name: Total hip replacement
label: c
answer: no
explanation: This is indicated in older patients with displaced intracapsular fractures.
name: Hemi–arthroplasty
label: b
answer: no
explanation: Surgery is the treatment option for a hip fracture, simply reducing the fracture is not enough to fix it.
name: Reduce the fracture
label: e
answer: no
explanation: Extracapsular neck of femur fractures are treated with ORIF and a dynamic hip screw.
name: Open repair with internal fixation (ORIF) and a dynamic hip screw
label: a
answer: yes

Correct answer: a
A 70-year-old male with no past medical history presents to his GP with a slowly worsening dull aching pain in his hips. During the consultation, it is noted that the patient struggles to hear, and on observation of his gait, it is clear that he has a varus leg deformity.

He is referred to secondary care where bloodwork is done.

Based on the most likely diagnosis, which of the following results are you most likely to find on his blood tests?

Options:
explanation: This set of bloods might be seen in the early stages of Paget’s disease, but since this patient has hearing loss, he likely has advanced disease. Hence, we would expect his ALP to be raised.
name: Normal ALP, normal calcium, normal phosphate
label: e
answer: no
explanation: This is the typical blood test result in a patient with osteomalacia.
name: Raised ALP, low calcium, low phosphate
label: c
answer: no
explanation: This is the typical blood test result in a patient with multiple myeloma.
name: Normal ALP, raised calcium, normal phosphate
label: b
answer: no
explanation: These bloods are indicative of primary hyperparathyroidism.
name: Normal ALP, raised calcium, low phosphate
label: d
answer: no
explanation: This is a typical presentation of Paget’s disease of the bone. The elevated ALP is caused by increased levels of osteoblast activity due to the accelerated rate of bone remodelling and formation of new bone.
name: Raised ALP, normal calcium and normal phosphate levels
label: a
answer: yes

Correct answer: a
A 21-year-old male wakes up with his arm draped over his chair after a night out.

He has a right-sided wrist drop and loss of sensation over the posterior aspect of the right arm, forearm, and posterolateral aspect of the right hand.

Which nerve is most likely to be affected?

Options:
explanation: The median nerve is compressed in carpal tunnel syndrome and results in loss of sensation over the lateral three-and-a-half fingers on the palmar surface of the hand.
name: Median nerve
label: e
answer: no
explanation: The axillary nerve gives off the superior lateral cutaneous nerve which innervates the regimental badge area (inferior region of deltoid), therefore damage to this nerve causes a loss of sensation over the regimental badge area.
name: Axillary nerve
label: d
answer: no
explanation: The suprascapular nerve innervates the supraspinatus muscle. Damage to the suprascapular nerve leads to the loss of active shoulder abduction.
name: Suprascapular nerve
label: c
answer: no
explanation: The long thoracic nerve innervates the serratus anterior which protracts the scapula. Damage to the long thoracic nerve causes winging of the scapula.
name: Long thoracic nerve
label: b
answer: no
explanation: This patient is suffering from ‘Saturday night palsy’, which is a compressive neuropathy of the radial nerve that occurs due to prolonged, direct pressure on the upper medial axilla; the chair has compressed his axilla in this case.
name: Radial nerve
label: a
answer: yes

Correct answer: a
A 40-year-old female presents to the GP following 6 months of muscle aches and fatigue. She has also experienced difficulty climbing up the stairs in her home.


Her blood test results are as follows:

||||
|---------------------------|:-------:|--------------------|
|Calcium|2.0 mmol/L|2.2 - 2.6|
|Phosphate|0.52 mmol/L|0.8 - 1.5|
|Alkaline Phosphatase (ALP)|240 IU/L|25 - 115|


What is the most likely diagnosis?

Options:
explanation: The raised ALP alongside low phosphate and low calcium is evidence of failed bone mineralisation; this is seen in osteomalacia, resulting in softer and more brittle bones,
name: Osteomalacia
label: a
answer: yes
explanation: The muscle weakness described in this patient is consistent with polymyositis, however, the calcium, phosphate and ALP levels would be normal in polymyositis. Creatine kinase would also be elevated.
name: Polymyositis
label: d
answer: no
explanation: The muscle aches align with fibromyalgia as a differential diagnosis, however, the abnormal blood test results do not. The calcium, phosphate and ALP levels would be normal in fibromyalgia.
name: Fibromyalgia
label: e
answer: no
explanation: In Paget’s disease, the ALP is very raised (more than in osteomalacia), but the calcium and phosphate are usually normal.
name: Paget’s disease
label: c
answer: no
explanation: Osteopenia would present with normal bloods and reduced bone density.
name: Osteopenia
label: b
answer: no

Correct answer: a
A 21-year-old male presents to clinic following a 5-month history of early morning back pain and stiffness that improves with activity. The patient also complains of an acutely red eye and sensitivity to light that has developed over 2 weeks.

On examination, there is a limited range of lumbar motion.

The patient was recently diagnosed with ankylosing spondylitis and has received NSAID treatment which has been unsuccessful in managing his symptoms.

What is the next most appropriate step in treatment?

Options:
explanation: It has been stated that NSAIDs have not been successful in managing this patient's symptoms. Paracetamol is at the bottom of the pain ladder, so it alone would not be appropriate in this case.
name: Paracetamol
label: d
answer: no
explanation: Disease-modifying anti-rheumatic drugs (DMARDs) are most useful in the treatment of ankylosing spondylitis with enthesitis and do not improve spinal inflammation. This patient is suffering from spinal inflammation and extra-articular involvement, therefore this is not the most appropriate next step.
name: Methotrexate
label: e
answer: no
explanation: NICE guidance suggests that TNF–alpha inhibitors should be used in cases of ankylosing spondylitis where NSAID treatment has failed. They should also be used in severe cases as demonstrated in this patient who has anterior uveitis (a complication of ankylosing spondylitis).
name: Etanercept
label: a
answer: yes
explanation: Oral steroids are not indicated in the treatment of ankylosing spondylitis; steroids must be given intra-articularly in ankylosing spondylitis.
name: Oral prednisolone
label: c
answer: no
explanation: Physiotherapy is indicated in ankylosing spondylitis for improving and maintaining posture, flexibility and mobility. However, physiotherapy alone would not be enough for this patient with extra-articular involvement who has experienced no relief from NSAID therapy.
name: Physiotherapy
label: f
answer: no

Correct answer: a
A 22-year-old female presents to her GP with weeping eczema along the margins of her hairline. She discloses that she dyed her hair 2 days ago and the skin irritation has only occurred since then. She is diagnosed with allergic contact dermatitis.

Which of the following best describes the type of hypersensitivity reaction that occurs in allergic contact dermatitis?

Options:
explanation: Type IV is a T-cell mediated delayed hypersensitivity reaction.
name: Type IV
label: a
answer: yes
explanation: Type II is known as a cell-bound hypersensitivity reaction in which IgG or IgM binds to antigens on the cell surface. Pemphigus Vulgaris and immune thrombocytopenic purpura are examples of type II hypersensitivity reactions.
name: Type II
label: c
answer: no
explanation: In Type V hypersensitivity reactions, antibodies are produced that recognise and bind to cell surface receptors, and either stimulate them or block ligand binding. Graves' disease and myasthenia gravis are examples of Type V hypersensitivity reactions.
name: Type V
label: e
answer: no
explanation: In Type I hypersensitivity reactions, an antigen reacts with IgE bound to mast cells. Anaphylaxis and asthma are examples of type I hypersensitivity reactions.
name: Type I
label: b
answer: no
explanation: Type III is known as an immune complex hypersensitivity reaction in which free antigen and antibody (IgG, IgA) combine. Systemic lupus erythematosus is an example of a type III hypersensitivity reactions
name: Type III
label: d
answer: no

Correct answer: a
A 27-year-old female presents to her GP with itchy, vesicular lesions on her elbows and knees in a symmetrical distribution. She discloses that she has also suffered from intermittent diarrhoea for the past 7 months along with abdominal pain and weight loss. Her vital signs are normal.

Given the most likely diagnosis, which rash is she most likely experiencing?

Options:
explanation: This disease presents with pearly white papules with central umbilication. Molluscum contagiosum is caused by the molluscum contagiosum virus and is not linked to GI upset.
name: Molluscum contagiosum
label: b
answer: no
explanation: Eczema herpeticum usually presents with a widespread vesicular rash and systemic symptoms such as fever and lethargy. In addition, eczema herpeticum is usually secondary to a pre-existing skin condition, which this patient does not have.
name: Eczema herpeticum
label: c
answer: no
explanation: Pemphigus vulgaris presents with superficial blisters and vesicles. Patients with pemphigus vulgaris tend to also experience blistering in their mouths as well as their skin. Pemphigus vulgaris is normally triggered by drug treatment as opposed to gastrointestinal upset.
name: Pemphigus Vulgaris
label: d
answer: no
explanation: Erythema multiforme presents with target lesions and is usually triggered by an infection, most commonly a herpes simplex infection.
name: Erythema multiforme
label: e
answer: no
explanation: This patient is most likely suffering from coeliac disease and is experiencing dermatitis herpetiformis as a complication of this. This can be relieved by complying with a gluten-free diet.
name: Dermatitis herpetiformis
label: a
answer: yes

Correct answer: a
A 32-year-old male presents to his GP for a review of his chronic plaque psoriasis treatment. On examination, there are well-demarcated, red, scaly patches on his elbows and knees. He describes the rash as being extremely itchy but not painful.

His psoriasis has already been treated with topical betamethasone and topical calcipotriol, however, there has been no improvement.

What is the most appropriate next step in treatment for his psoriasis?

Options:
explanation: This may be a treatment option further down the line but must be started in secondary care.
name: Methotrexate
label: d
answer: no
explanation: This is indicated when both topical vitamin D analogue monotherapy and topical steroid have been trialled and failed.
name: Coal tar
label: c
answer: no
explanation: The second-line treatment for chronic plaque psoriasis is vitamin D analogue monotherapy.
name: Topical calcipotriol twice daily
label: a
answer: yes
explanation: This is the third-line treatment for chronic plaque psoriasis; very potent steroids must be prescribed in a secondary care setting.
name: Topical Dermovate twice daily
label: b
answer: no
explanation: Smoking cessation is good advice to prevent psoriasis from worsening, but it is not enough in this case to treat the severity of the patient's psoriasis.
name: Smoking cessation
label: e
answer: no

Correct answer: a
A 54-year-old female presents to her GP with a one-week history of a rash. On examination, there is a papular rash in the finger webs which she describes as being extremely itchy. The rash is diagnosed as scabies.

Which of the following is the most appropriate advice to give?

Options:
explanation: Steroids are not indicated in the curative treatment of scabies. Permethrin 5% is the first-line treatment and malathion 0.5% is the second-line treatment.
name: Apply topical hydrocortisone 0.5% on cool dry skin all over the body
label: e
answer: no
explanation: Malathion 0.5% is the second-line treatment for scabies, so it is more appropriate to treat with permethrin first and assess its effectiveness.
name: Apply topical malathion 0.5% on cool dry skin all over the body
label: d
answer: no
explanation: Members of a household are required to start treatment at the same time as the patient
name: Members of the household can start treatment 24 hours later
label: c
answer: no
explanation: Topical permethrin 5% is the first-line treatment for scabies and it is important that it is not only applied to the itchy areas with a rash, but to the entire body.
name: Apply topical permethrin on cool dry skin all over the body
label: a
answer: yes
explanation: Individuals can return to work/school 24 hours after the treatment is initiated.
name: She cannot return to work until the rash has completely disappeared
label: b
answer: no

Correct answer: a
A 57-year-old male presents to his GP concerned about a strange mole on his back which she noticed 6 months ago. On examination, you notice the lesion is brown with irregular borders. The patient explains that over the past 6 months, the lesion has noticeably increased in size. You measure the lesion to be 8mm. He denies any itchiness, inflammation, oozing or change in colour. Further investigation leads to a diagnosis of malignant melanoma.

Based on the findings, what is the Glasgow score for his lesion?

Options:
explanation: This patient scores 2 points each for change in size and irregular borders, and 1 point for a diameter of 8mm, giving a total of 5.
name: 4
label: d
answer: no
explanation: In the Glasgow 7-point checklist, 2 points are awarded for major features: change in shape, irregular shape, irregular colour; and 1 point is awarded for minor features: diameter > 7mm, inflammation, oozing or crusting, change in sensation. Therefore, this patient scores 2 points each for change in size and irregular borders and 1 point for a diameter of 8mm.
name: 5
label: a
answer: yes
explanation: This patient scores 2 points each for change in size and irregular borders, and 1 point for a diameter of 8mm, giving a total of 5.
name: 3
label: c
answer: no
explanation: This patient scores 2 points each for change in size and irregular borders, and 1 point for a diameter of 8mm, giving a total of 5.
name: 2
label: b
answer: no
explanation: This patient scores 2 points each for change in size and irregular borders, and 1 point for a diameter of 8mm, giving a total of 5.
name: 6
label: e
answer: no

Correct answer: a
A 55-year-old male presents to clinic following the onset of oral blisters. On examination, the patient has a widespread erythematous rash with blisters. The patient explains that the rash is extremely itchy and painful and that his skin peels off when he applies pressure.

Based on the most likely diagnosis, what is the most appropriate treatment?

Options:
explanation: Doxycycline is a tetracycline antibiotic which is indicated for the management of Acne vulgaris but has no role in the treatment of pemphigus vulgaris.
name: Oral doxycycline
label: b
answer: no
explanation: Topical steroids are more likely to be used in the treatment of bullous pemphigoid.
name: Topical corticosteroids
label: c
answer: no
explanation: Aciclovir is an antiviral medication used in the treatment of eczema herpeticum which is caused by the herpes simplex virus.
name: Oral aciclovir
label: e
answer: no
explanation: The most likely diagnosis is pemphigus vulgaris. Oral corticosteroids are indicated in pemphigus vulgaris to control the symptoms, however, they are not curative.
name: Oral corticosteroids
label: a
answer: yes
explanation: Dressing wounds is useful as part of the supportive management of pemphigus vulgaris, but oral corticosteroids are most useful for controlling symptoms and are therefore the most appropriate treatment.
name: Wound dressing
label: d
answer: no

Correct answer: a
A 4-year-old girl presents to A&E with a 24-hour history of widespread large superficial blisters. On examination, there is widespread erythema and patches of desquamation. The oral mucosa is unaffected and Nikolsky sign is positive. Vital signs are normal apart from a temperature of 38 degrees. The patient has no significant past medical history.

What is the most likely diagnosis?

Options:
explanation: Although pemphigus vulgaris also presents with blisters, desquamation and a positive Nikolsky sign, it is not the most likely diagnosis as the fact that the oral mucosa is not affected in this patient. Furthermore, pemphigus vulgaris tends to present in adults and would not present with a fever as it is not an infectious disease.
name: Pemphigus Vulgaris
label: b
answer: no
explanation: Bullous pemphigoid is not Nikolsky sign positive and presents with tense, rather than superficial, blisters
name: Bullous pemphigoid
label: c
answer: no
explanation: This is the most likely diagnosis based on the sparing of the oral mucosa, the positive Nikolsky sign and the patient's age. Staphylococcal scalded skin syndrome normally occurs in young children.
name: Staphylococcal scalded skin syndrome
label: a
answer: yes
explanation: Eczema herpeticum presents with a widespread painful vesicular rash, rather than blisters. Also, eczema herpeticum is caused by the herpes simplex virus whereas pemphigus vulgaris is an autoimmune disease.
name: Eczema herpeticum
label: d
answer: no
explanation: TEN presents similarly to pemphigus vulgaris with widespread erythema, desquamation and a positive Nikolsky sign. However, TEN is more likely to present with involvement of the oral mucosa and usually occurs as a reaction to a newly initiated drug.
name: Toxic epidermal necrolysis (TEN)
label: e
answer: no

Correct answer: a