hllj/quesmed huggingface dataset:
A 21-year-old male has a painful left knee. He has also noticed he has a left red eye and pain on urination in the last week. On examination, his knee is swollen and mildly tender, but he has a full range of motion and can weight bear. The patient is afebrile.

Given the likely diagnosis, what is the most appropriate management?

Options:
explanation: This is a classic presentation of reactive arthritis (triad arthritis, urethritis and conjunctivitis). It is usually caused by gastrointestinal/genituo-urinary infections. Given the urinary symptoms, arranging urinary NAAT testing is likely to be diagnostic of the causative organism.
name: Arrange urinary NAAT testing
label: a
answer: yes
explanation: Whilst gastrointestinal infections can trigger reactive arthritis, there is no mention of diarrhoea or other GI symptoms, whilst there is suspicion for urethral infection.
name: Obtain stool cultures for PCR and culture
label: e
answer: no
explanation: This would be appropriate management for a confirmed crystal arthropathy (e.g. gout/pseudogout). However, the symptoms are far more suggestive of a reactive arthritis with active underlying infection, which would need to be treated on top of symptomatic analgesia.
name: Commence colchicine and discharge with safety netting advice
label: c
answer: no
explanation: Whilst a red, hot and swollen joint should always raise suspicion for septic arthritis, this would likely lead to limited range of motion and be exquisitely tender on palpation. Although joint aspiration may be useful, this history (and lack of fever) is far more suggestive of a reactive arthritis.
name: Arrange urgent joint aspiration
label: b
answer: no
explanation: This would be more useful in a scenario with suspected meniscal or ligament injury following trauma. It additionally would be unlikely to be used as a first line investigation.
name: Arrange urgent knee MRI
label: d
answer: no

Correct answer: a


Learning point: Urinary NAAT (nucleic acid amplification test) is a highly sensitive test for detecting Chlamydia trachomatis and Neisseria gonorrhoeae infections, which can trigger reactive arthritis, an inflammatory joint condition often linked to urogenital or gastrointestinal infections.
A 47-year-old female has foul smelling discharge from her right ear with associated hearing loss. When assessing her hearing with a tuning fork, she hears the sound louder on the right, with the tuning fork placed in the middle of the forehead. On the right, the sound from the tuning fork is heard best when placed on the mastoid process, whilst it is heard best next to the external auditory meatus on the left. She denies any tinnitus or vertigo.

What is the most likely diagnosis?

Options:
explanation: This patient demonstrates conductive hearing loss on the right-hand side on Rinne’s and Weber’s testing. Combined with her history of foul-smelling discharge, this makes cholesteatoma (an abnormal collection of skin cells within the ear) the most likely of these options. All of the other options are causes of sensorineural hearing loss rather than conductive hearing loss.
name: Cholesteatoma
label: a
answer: yes
explanation: This would cause a sensorineural hearing loss and would present with clusters of unilateral hearing loss, vertigo and tinnitus.
name: Meniere’s disease
label: e
answer: no
explanation: This would cause a sensorineural hearing loss and may be expected to be seen in an older patient.
name: Presbycusis
label: c
answer: no
explanation: There is no mention of ototoxic drugs (e.g. aminoglycosides, loop diuretics) in the history and this would also cause a sensorineural hearing loss.
name: Ototoxicity from medication
label: d
answer: no
explanation: This would cause a sensorineural hearing loss, usually associated with unilateral tinnitus and vertigo.
name: Acoustic neuroma
label: b
answer: no

Correct answer: a


Learning point: Cholesteatoma presents with conductive hearing loss and foul-smelling ear discharge due to abnormal skin cell accumulation in the middle ear.
An 85-year-old male has a unilateral nosebleed. He denies any nasal trauma and does not take any anticoagulation.

What is the most appropriate initial management advice to provide?

Options:
explanation: Whilst this may be appropriate management after the bleeding had resolved, it is not appropriate initial treatment.
name: Prescribe Naseptin cream
label: e
answer: no
explanation: This increases the risk of aspiration and the pressure being applied to the bridge of the nose does not compress the likely source of the bleed.
name: Lean backwards and apply pressure to the bridge of their nose of 15 minutes
label: c
answer: no
explanation: Leaning backwards increases risk of aspirating blood. The patient should lean forwards rather backwards.
name: Lean backwards and apply pressure to outside of their nose just above the nostrils for 15 minutes
label: b
answer: no
explanation: Whilst leaning forwards is the correct advice to give, applying pressure to the bridge of the nose does not compress the likely source of the bleed.
name: Lean forwards and apply pressure to the bridge of their nose of 15 minutes
label: d
answer: no
explanation: This is the correct initial management of epistaxis. Leaning forwards reduces the risk of aspiration and pinching the outside of the nose just above the nostrils applies pressure to the likely source of bleeding.
name: Lean forward and apply pressure to pinching the outside of their nose just above the nostrils for 15 minutes
label: a
answer: yes

Correct answer: a


Learning point: For managing epistaxis, advise the patient to lean forward and pinch the nose for 15 minutes to control bleeding effectively.
A 28-year-old-male notices bright red blood in the toilet bowel after opening his bowels for the last 3 days. He experiences pain when passing stool. He denies any weight loss or abdominal pain. He usually opens his bowels once a day. There are no palpable masses on rectal examination.

What is the most likely diagnosis?

Options:
explanation: This is normally associated with crampy ano-rectal pain at night rather than rectal bleeding.
name: Proctalgia fugax
label: e
answer: no
explanation: This would be rare in a young patient and would likely present with a longer history of symptoms and weight loss. In addition, there may possibly be a palpable mass on examination.
name: Rectal cancer
label: c
answer: no
explanation: A short history of painful defecation with bright red blood passed is most likely to be an anal fissure rather than other more sinister pathology. Advice to increase dietary fibre and fluid intake as well as keeping the area clean and dry should be provided.
name: Anal fissure
label: a
answer: yes
explanation: Whilst this can present similarly to anal fissures, they are less likely to be associated with pain on defecation and there would likely masses that were palpable on rectal examination.
name: Haemorrhoids
label: d
answer: no
explanation: Whilst this may present with rectal bleeding, the short history of symptoms, lack of increased frequency of stool passage and the lack of constitutional symptoms point away from inflammatory bowel disease.
name: Inflammatory bowel disease
label: b
answer: no

Correct answer: a


Learning point: Anal fissures typically present with bright red blood and pain during defecation, often linked to constipation or straining.
A 45-year-old female has a fever and constant upper abdominal pain. She denies any diarrhoea or recent travel history. On general inspection, she has no scleral icterus. On palpation, she is extremely tender in the right upper quadrant pain on palpation, particularly when taking a deep breath in.

What is the most likely diagnosis?

Options:
explanation: Whilst this will present with fever and right upper quadrant pain, the absence of jaundice and presence of Murphy’s sign make this less likely.
name: Ascending cholangitis
label: b
answer: no
explanation: This classically presents with intermittent right upper quadrant pain after fatty meals rather than constant pain and a fever.
name: Biliary colic
label: e
answer: no
explanation: The patient demographics (middle aged female), presence of Murphy’s sign (pain on inspiration on palpation of the right upper quadrant on deep breathing) and history all suggest an acute cholecystitis is the most likely diagnosis.
name: Acute cholecystitis
label: a
answer: yes
explanation: This would typically present with epigastric pain rather than right upper quadrant pain and Murphy’s sign would not normally be present.
name: Acute gastritis
label: c
answer: no
explanation: Whilst this may present with fever and right upper quadrant pain, the absence of jaundice and diarrhoea make this less likely.
name: Acute hepatitis A infection
label: d
answer: no

Correct answer: a


Learning point: Acute cholecystitis typically presents with right upper quadrant pain, fever, and a positive Murphy's sign on examination.
A 45-year-old male with motor neuron disease would like to find out if it is possible to establish which medical treatments they do not want to have in future, if they were no longer able to make these decisions for themselves.

How can they do this in a way which is legally binding?

Options:
explanation: These are professionals who are consulted with to make best interest decisions, once a patient has already lost capacity and often if they lack family members/friends to aid with the best interest decision.
name: Consulting with an independent mental capacity advocate
label: c
answer: no
explanation: This a document in which a patient can express preferences for treatments they do want to have, if they are no longer able to make decisions for themselves. It is **not** legally binding.
name: An advance statement
label: b
answer: no
explanation: To refuse life sustaining treatment, an advance decision needs to be drawn up. This needs to clearly state which treatments are to be refused with acknowledgement of these being life sustaining treatments. They also need to be written, signed and witnessed.
name: Telling the doctor verbally that they do not want to be intubated, if they were to lose capacity in future
label: d
answer: no
explanation: An advance decision to refuse treatment is a way that people with capacity can establish which treatments they do not want in the future, were they to lose capacity. If patients wish to refuse life-sustaining treatments, the advance decisions need to be written down clearly stating what is to be refused, and must be signed and witnessed.
name: An advance decision to refuse treatment
label: a
answer: yes
explanation: This is incorrect, as advance decisions allow this to be done.
name: It is not possible to refuse future treatments in a way which is legally binding
label: e
answer: no

Correct answer: a


Learning point: An advance decision to refuse treatment allows individuals to specify unwanted medical interventions in the event they lose decision-making capacity.
A 6-year-old boy with a history of eczema and asthma has a fever and multiple monomorphic lesions on his face, arms and trunk. His dad mentions his classmate at school last week had a golden crusted rash on their face.

What is the next most appropriate management step?

Options:
explanation: This describes eczema herpeticum, which classically presents with a monomorphic rash, fever and affects patients with a history of atopy. It needs to be treated in hospital with IV antivirals. The history of possible impetigo contact should not distract from the presentation, as the patient’s rash is not consistent with impetigo.
name: Referral to local ED
label: a
answer: yes
explanation: This is a suitable treatment for widespread non-bullous impetigo/bullous impetigo, not eczema herpeticum.
name: Oral flucloxacillin
label: e
answer: no
explanation: This is an alternative treatment for non-bullous impetigo, not eczema herpeticum.
name: Topical fusidic acid
label: c
answer: no
explanation: Oral antivirals are insufficient for eczema herpeticum.
name: Oral aciclovir
label: d
answer: no
explanation: This is first line treatment for non-bullous impetigo, not eczema herpeticum.
name: Topical hydrogen peroxide
label: b
answer: no

Correct answer: a


Learning point: Eczema herpeticum presents with fever and monomorphic lesions in atopic individuals, requiring urgent hospital management with intravenous antivirals.
A 47-year-old woman with high grade non-Hodgkin’s lymphoma is treated with R-CHOP chemotherapy. 3 days after her first course of treatment, she has diarrhoea, paraesthesia, and decreased urine output.

Given the likely diagnosis, which of the following investigation results would you expect to see?

Options:
explanation: This would likely be raised in the setting of AKI.
name: Normal serum creatinine
label: e
answer: no
explanation: Phosphate would be raised in tumour lysis syndrome, due to increased cell breakdown.
name: Decreased serum phosphate
label: c
answer: no
explanation: Potassium would be raised in tumour lysis syndrome, due to the increased cell breakdown.
name: Decreased serum potassium
label: b
answer: no
explanation: Calcium is normally low in tumour lysis syndrome as phosphate binds to calcium. Hypocalcaemia may be contributing to this patient's paraesthesia.
name: Increased serum calcium
label: d
answer: no
explanation: The diagnosis is tumour lysis syndrome, which classically occurs 2-3 days after chemotherapy for high grade haematological malignancies. The increased uric acid is due to increased due to increased cancer cell breakdown, which would also increase potassium and phosphate. The oliguria described is due to AKI.
name: Raised serum uric acid
label: a
answer: yes

Correct answer: a


Learning point: Tumour lysis syndrome can occur after chemotherapy, leading to elevated serum uric acid, potassium, and phosphate levels, alongside acute kidney injury.
A 21-year-old man presents to his GP with a 3-day history of white urethral discharge and dysuria. He is sexually active and recently began a casual relationship. Nucleic acid amplification testing (NAAT) confirms that his condition is caused by an obligate intracellular bacterium.

What is the most likely causative organism?

Options:
explanation: Mycoplasma genitalium is a bacterium without a cell wall that can cause urethritis. While it is intracellular, it is less common than Chlamydia trachomatis and typically associated with persistent or recurrent urethritis rather than acute symptoms as seen in this case.
name: Mycoplasma genitalium
label: c
answer: no
explanation: Chlamydia trachomatis is the most common cause of sexually transmitted urethritis in young men. It is an obligate intracellular bacterium, which fits the NAAT findings. It typically presents with dysuria and a clear or white urethral discharge.
name: Chlamydia trachomatis
label: a
answer: yes
explanation: Treponema pallidum is the causative organism of syphilis, a sexually transmitted infection that can cause painless genital ulcers (primary syphilis) or systemic symptoms (secondary syphilis). It is a spirochete, not an obligate intracellular bacterium, and is not associated with urethritis.
name: Treponema pallidum
label: e
answer: no
explanation: Trichomonas vaginalis is a motile protozoan, not a bacterium. It is a rare cause of urethritis in men and is typically associated with frothy discharge and irritation, not the white discharge and dysuria seen here.
name: Trichomonas vaginalis
label: d
answer: no
explanation: Although Neisseria gonorrhoeae is another common cause of sexually transmitted urethritis, it is a Gram-negative diplococcus, not an obligate intracellular bacterium. Gonorrhoea typically causes a more severe presentation with purulent (yellow or green) urethral discharge and more pronounced dysuria.
name: Neisseria gonorrhoeae
label: b
answer: no

Correct answer: a


Learning point: Chlamydia trachomatis is an intracellular gram-negative bacterium that causes a range of infections, including sexually transmitted diseases, pelvic inflammatory disease, and eye infections such as trachoma.
A 5-year-old boy has facial swelling. His mother states he had a cough and runny nose the week prior to the swelling. His urine dipstick shows 3+ protein.

Given the likely diagnosis, which of the following investigation results would you expect to see?

Options:
explanation: Sodium would usually be low due to increased ADH levels leading to hypervolaemic hyponatraemia.
name: High serum sodium
label: d
answer: no
explanation: Serum triglycerides would likely be raised in nephrotic syndrome.
name: Low serum triglycerides
label: b
answer: no
explanation: Serum albumin is low in nephrotic syndrome.
name: High serum albumin
label: c
answer: no
explanation: This would likely be raised in nephrotic syndrome. This is due to a combination of increased production and impaired catabolism/clearance of LDLs.
name: Low serum cholesterol
label: e
answer: no
explanation: This describes a case of minimal change disease, a form of nephrotic syndrome. It commonly follows viral upper respiratory tract infections. This classically causes a low serum albumin and elevated serum triglycerides/cholesterol.
name: Low serum albumin
label: a
answer: yes

Correct answer: a


Learning point: Low serum albumin is commonly seen in minimal change disease, a type of nephrotic syndrome, due to increased urinary loss of protein, leading to hypoalbuminemia and subsequent oedema.
A 30-year-old PhD student is particularly stressed about her upcoming viva and would like to learn about therapy options.

On further history taking, she describes distressing images flashing into her mind and she often feels she is unable to leave the house without turning the lights on and off multiple times.

What is the most likely diagnosis?

Options:
explanation: This history does not suggest mania or any of the core features of depression.
name: Bipolar disorder
label: d
answer: no
explanation: This would be unlikely to result in ritualistic behaviour. None of the core features of depression are mentioned (low mood, anhedonia or fatigue).
name: Depression
label: b
answer: no
explanation: This also is unlikely to cause ritualistic behaviour in the same way, and intrusive thoughts would not necessarily lead to compulsions.
name: Generalised Anxiety
label: c
answer: no
explanation: This describes the obsessions (intrusive unwanted thoughts) and compulsions (ritualistic or repetitive actions) which are classically worsened when the patient is stressed.
name: Obsessive compulsive disorder
label: a
answer: yes
explanation: This history does not mention any of the main features of EUPD, including impulsive behaviour or difficulty maintaining relationships.
name: Emotionally unstable personality disorder
label: e
answer: no

Correct answer: a


Learning point: Obsessive Compulsive Disorder is characterised by intrusive thoughts and ritualistic behaviours, often exacerbated by stress.
A 21-year-old female would like to discuss contraceptive options. Her preference is for the combined oral contraceptive pill as she is aware it can be beneficial in the treatment of acne, and she wants a form of contraception which is readily reversible.

Which of the following represents an absolute contraindication for the combined oral contraceptive pill?

Options:
explanation: This is UKMEC Category 1 (no restriction on use) unless the patient is a known carrier of gene mutations associated with breast cancer.
name: Family history of breast cancer
label: c
answer: no
explanation: This is UKMEC Category 2 (but would be UKMEC Category 4 if the patient was over 35).
name: Smoking 20 cigarettes a day
label: e
answer: no
explanation: This is the only UKMEC Category 4 (absolute contraindication) option on the list for the combined oral contraceptive pill, due to the risk of thrombotic complications.
name: Antiphospholipid syndrome
label: a
answer: yes
explanation: This is UKMEC Category 1 (no restriction on use), although enzyme-inducing anti-epileptic drugs may reduce the effectiveness of oral contraceptives, so an alternative form of contraception (such as a patch) may be recommended.
name: Taking anti-epileptic medications
label: b
answer: no
explanation: This is UKMEC Category 2 (advantages generally outweigh risks) and is therefore not an absolute contraindication.
name: Rheumatoid arthritis
label: d
answer: no

Correct answer: a


Learning point: Antiphospholipid syndrome is an absolute contraindication for the combined oral contraceptive pill due to increased thrombotic risk.
You are a foundation year one doctor on a general surgery rotation and are reviewing the cases for the list for the next few days.

Which of the following cases should be placed at the start of the surgical list for the day?

Options:
explanation: Diabetic patients who are fasting should be placed at the beginning of the surgical list to minimise the duration of the fast and the complications of suboptimal glucose control, which include dizziness, sweating, palpitations and, if severe, loss of consciousness.
name: A 43 year old insulin-dependant diabetic lady undergoing a hernia repair
label: a
answer: yes
explanation: Although this case may prove difficult from an anaesthetics point of view due to the difficulties with controlling blood pressure and risk of catecholamine surge during surgery, limiting fasting duration in a patient with diabetes takes priority.
name: A 21 year old man undergoing an elective surgery to remove a pheochromocytoma
label: c
answer: no
explanation: Infectious patients should be placed at the end of the surgical list to reduce the risk of infecting other patients.
name: A 45 year old patient with miliary tuberculosis undergoing an elective lobectomy
label: d
answer: no
explanation: There is no particular reason why this patient should be placed at the start of the list.
name: An 88 year old man undergoing an elective hip replacement surgery
label: b
answer: no
explanation: There is no particular reason why this patient should be placed at the start of the list.
name: A 44 year old lady undergoing an elective laparoscopic cholecystectomy
label: e
answer: no

Correct answer: a


Learning point: Diabetic patients should be prioritised for surgery to reduce fasting duration and prevent complications from poor glucose control.
A 49 year old patient is scheduled to undergo an elective cholecystectomy next week for long standing biliary colic. She asks whether she can eat and drink prior to her surgery.

Which of the following is true regarding her pre-operative eating and drinking?

Options:
explanation: This is incorrect, she may drink water up to 2 hours before surgery.
name: She should not drink for 6 hours before surgery
label: d
answer: no
explanation: This is incorrect, orange juice with pulp does not constitute a clear fluid and therefore should not be consumed 2 hours before surgery. It can be consumed 6 hours before her operation, however.
name: She may have a glass of orange juice with pulp 2 hours before surgery
label: b
answer: no
explanation: This is incorrect, tomato soup does not constitute a clear fluid and therefore should be consumed at least 6 hours before surgery.
name: She may have tomato soup 2 hours before surgery
label: c
answer: no
explanation: This is correct, clear fluids (black coffee, black tea, water) can be drank up to 2 hours before surgery.
name: She may drink water 2 hours before surgery
label: a
answer: yes
explanation: The current recommendation is to abstain from eating for 6 hours before surgery and clear fluids 2 hours before.
name: She should fast overnight
label: e
answer: no

Correct answer: a


Learning point: Patients may consume clear fluids, such as water, up to two hours prior to elective surgery.