hllj/quesmed huggingface dataset:
A 57-year-old male has a hoarse voice.

He initially had symptoms of a cough, nasal discharge and sore throat but the hoarseness has persisted for more than a month after these symptoms resolved.

He has no other past medical history but smokes 30 cigarettes a day.

What is the most appropriate management option?

Options:
explanation: Whilst hypothyroidism can cause a hoarse voice, it is more important to exclude head and neck cancer in the initial sense. The patient also did not mention any other symptoms of hypothyroidism.
name: Arrange thyroid function tests
label: e
answer: no
explanation: Whilst an upper respiratory tract infection can cause a hoarse voice, the persistent nature of the hoarseness and smoking history is concerning and suggests the patient should be referred under a 2-week wait pathway.
name: Arrange a respiratory viral swab
label: b
answer: no
explanation: A persistent hoarse voice in patients aged 45 or over warrants a referral for suspected laryngeal cancer. It is also worth noting in a smoker that lung cancer is an important differential.
name: 2 week-wait referral under the suspected laryngeal cancer pathway
label: a
answer: yes
explanation: Whilst this is likely the investigation that will be carried out by ENT, the referral needs to be urgent to exclude laryngeal cancer.
name: Non-urgent referral to ENT for nasendoscopy
label: d
answer: no
explanation: This is an inappropriate management strategy as the persistent hoarseness in a patient aged 45 years or older merits an urgent referral for suspected laryngeal cancer.
name: Advise simple analgesia and throat lozenges
label: c
answer: no

Correct answer: a


Learning point: Persistent hoarseness lasting over three weeks in individuals over 45, especially smokers, requires urgent referral for suspected laryngeal cancer.
A 19-year-old male has multiple painful blisters on his penis and perineum. He also states he has had pain when passing urine for the last week. When asked about his recent sexual activity, he states he has had multiple male and female sexual partners in the past 3 months. He was previously well prior to this episode.

What is the most likely diagnosis?

Options:
explanation: Syphilis typically causes a single painless ulcer (chancre) rather than multiple painful ulcers.
name: Syphilis
label: c
answer: no
explanation: Whilst this can cause abscesses/ulcers, they are usually painless, and it also commonly presents with proctitis, which is not mentioned in this history.
name: Lymphogranuloma venerum
label: e
answer: no
explanation: These are normal physiological variants which have the appearance of white/yellow papules rather than painful ulcers.
name: Fordyce spots
label: d
answer: no
explanation: Multiple painful blisters suggest HSV. Dysuria is a common feature due to pain from blisters when passing urine.
name: Herpes simplex
label: a
answer: yes
explanation: Whilst chancroid can cause painful ulcers, it is much less common than genital herpes.
name: Chancroid
label: b
answer: no

Correct answer: a


Learning point: Herpes simplex virus typically presents with multiple painful blisters and can cause dysuria due to associated genital lesions.
A 32-year-old pregnant female complains of vulval itching and a yellow/white discharge. She is sexually active with one partner and is in a monogamous relationship.

Her vaginal pH is found to be <4.5.

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

Options:
explanation: This history is suggestive of thrush, given the pruritis and yellow-white discharge with an acidic vaginal pH. In a pregnant woman, oral fluconazole is contraindicated and so a clotrimazole pessary is the recommended option.
name: Clotrimazole pessary
label: a
answer: yes
explanation: This would be used to treat a Chlamydia trachomatis infection, which would present with dysuria and discharge, typically with no itching. It is also contraindicated in pregnancy as it is teratogenic.
name: Oral doxycycline
label: c
answer: no
explanation: This would be a first-line option in a non-pregnant patient but is contraindicated in pregnancy.
name: Oral fluconazole
label: b
answer: no
explanation: This would be used to treat a Neisseria gonorrhoea infection, which would present with dysuria and purulent discharge, typically with no itching.
name: IM ceftriaxone
label: d
answer: no
explanation: This is used to treat bacterial vaginosis, which causes an alkaline vaginal pH.
name: Oral metronidazole
label: e
answer: no

Correct answer: a


Learning point: Clotrimazole pessaries are commonly used to treat vaginal candidiasis during pregnancy, as they effectively target the fungal infection while being considered safe for use in the second and third trimesters.
A mother of a 12-year-old boy has refused any vaccines thus far as she is concerned about side effects. However, she agrees to have a further conversation with a doctor about the importance of vaccines.

During the conversation, she asks about notifiable diseases as she has read about them online.

Which of the following is a notifiable disease in the UK?

Options:
explanation: This is not a notifiable disease in the UK and is a common cause of URTIs.
name: Rhinovirus
label: e
answer: no
explanation: Of all the options listed, this is the only notifiable disease. There has been an increased number of cases in recent years due to decreased vaccine uptake.
name: Mumps
label: a
answer: yes
explanation: This is not a notifiable disease in the UK.
name: Gonorrhoea
label: d
answer: no
explanation: This is not a notifiable disease in the UK.
name: HIV infection
label: b
answer: no
explanation: This is not a notifiable disease in the UK and is the most common cause of sexually transmitted infection.
name: Chlamydia
label: c
answer: no

Correct answer: a


Learning point: Mumps is a notifiable disease in the UK, with rising cases linked to reduced vaccination coverage.
A 37-year-old female would like to discuss contraceptive options.
She would like an option which is readily reversible, as she is considering starting a family in the next year.

She has a past medical history of asthma and migraine with aura.

Which of the following is the most appropriate contraceptive option to offer?

Options:
explanation: Of all the options listed, this is the only readily reversible option which is not contraindicated due to the patient’s history of migraine with aura.
name: Progesterone-only pill
label: a
answer: yes
explanation: Although this option has no period after stopping with an impact on fertility, it is less effective than medical contraceptive options. The progesterone-only pill can therefore be offered to the patient.
name: Condoms alone
label: c
answer: no
explanation: This is a long-term contraceptive option that is not readily reversible, with regular menstrual cycles often resuming several months after stopping injections
name: Progesterone injection (Depo-provera)
label: d
answer: no
explanation: Whilst readily reversible, this is also contraindicated due to the patient’s history of migraine with aura.
name: Combined contraceptive patch
label: e
answer: no
explanation: Whilst readily reversible, this is contraindicated due to the patient’s history of migraine with aura.
name: Combined oral contraceptive pill
label: b
answer: no

Correct answer: a


Learning point: The progesterone-only pill is a good contraceptive option for women with a history of migraine with aura, as the combined pill is contraindicated in such cases.
A 27-year-old male smoker has painful pallor of his fingers in the cold, followed by cyanosis then erythema.

He denies joint pain or rashes, or any family history of connective tissue disease.

His recent blood tests including ANA and ESR were all negative.

What is the most appropriate initial management?

Options:
explanation: Nifedipine, rather than amlodipine, is the first-line calcium channel blocker for Raynaud’s phenomenon.
name: Prescribe amlodipine
label: c
answer: no
explanation: This is an inappropriate management strategy as the patient is finding symptoms troublesome, and Raynaud’s is not considered a typical physiological response despite it being fairly common.
name: Reassure the patient that this is a normal physiological variant
label: d
answer: no
explanation: This can be trialled if lifestyle factors and keeping warm are ineffective.
name: Prescribe nifedipine
label: b
answer: no
explanation: Keeping warm and managing lifestyle factors (e.g. smoking) is the correct first-line management of Raynaud’s phenomenon with no concerning features.
name: Advise smoking cessation and encourage using gloves to keep warm
label: a
answer: yes
explanation: This may be merited if the patient had joint pain, rashes, positive autoantibodies or raised inflammatory markers on their blood tests. In this case, conservative measures should be trialled before this is considered.
name: Refer the patient to Rheumatology
label: e
answer: no

Correct answer: a


Learning point: Raynaud's phenomenon management includes smoking cessation and keeping extremities warm to alleviate symptoms.
A 63-year-old woman experiences sudden urgency when needing to go to the toilet.

She denies any leaking of urine on coughing, laughing or sneezing.

She has no dysuria or haematuria.

Given the likely diagnosis, what is the most appropriate first-line management?

Options:
explanation: Whilst this TCA has anti-muscarinic effects, it is not recommended by NICE to treat urge incontinence.
name: Prescribe imipramine
label: e
answer: no
explanation: This is an appropriate medication to trial if bladder training exercises and lifestyle measures are ineffective.
name: Prescribe tolterodine
label: b
answer: no
explanation: This is an appropriate medication to trial if bladder training exercises and lifestyle measures are ineffective.
name: Prescribe darifenacin
label: c
answer: no
explanation: This history is suggestive of urge incontinence. The first line management of urge incontinence is bladder training exercises whilst avoiding alcohol and caffeine which have a diuretic effect.
name: Advise avoiding alcohol and caffeine and offer referral for bladder training exercises
label: a
answer: yes
explanation: This is the first line management of stress incontinence rather than urge incontinence. Given the patient denies leaking urine on straining, urge incontinence is more likely to be the diagnosis.
name: Advise avoiding alcohol and caffeine and offer referral for pelvic floor muscle training exercises
label: d
answer: no

Correct answer: a


Learning point: Urge incontinence management includes bladder training exercises and avoiding diuretics like alcohol and caffeine to reduce urgency symptoms.
A 24-year-old woman visits her GP with severe menorrhagia, which she has suffered from for a number of years. She feels tired all the time and is considering starting the combined oral contraceptive pill to help with her symptoms.


She has no other past medical history.


On examination, she looks pale. Her abdomen is soft and non-tender, and she declines a vaginal examination. Her chest is clear. A soft, non-radiating systolic murmur is heard on auscultation.


Blood results:

||||
|--------------|:-------:|---------------|
|Haemoglobin|90 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|9.2x10<sup>9</sup>/L|3.0 - 10.0|
|Mean Cell Volume (MCV)|72 fL|80 - 96|


Which of the following is most likely causing her murmur?

 

Options:
explanation: This is a reasonable differential for a systolic murmur, however, there are no mentions of other symptoms (syncope, angina, dyspnoea) or radiation to the carotid region. Further, aortic stenosis is more common in older patients. A flow murmur is the most likely diagnosis, exacerbated by the anaemia.
name: Aortic stenosis
label: b
answer: no
explanation: This is a reasonable differential for a systolic murmur, however a flow murmur is most likely given the patient is young and anaemic. Mitral regurgitation is more common in older patients, unless there are risk factors for valvular disease (e.g. congenital abnormalities/rheumatic fever).
name: Mitral regurgitation
label: d
answer: no
explanation: This is a reasonable differential for a systolic murmur, however this is more common in older patients, and the murmur radiates to the carotid arteries. A flow murmur is the most likely diagnosis, exacerbated by the anaemia.
name: Aortic sclerosis
label: c
answer: no
explanation: This is a reasonable differential for a systolic murmur, however a flow murmur is most likely given the patient is young and anaemic. Further, they have no risk factors for valvular disease or tricuspid regurgitation (e.g. pulmonary hypertension).
name: Tricuspid regurgitation
label: e
answer: no
explanation: Soft, systolic, asymptomatic murmurs in young patients are often due to high flow across valves and vessels. These can be exaggerated when circulation is hyperdynamic (e.g. due to anaemia, which this patient has). An echocardiogram should be carried out to exclude structural/valvular pathology.
name: Anaemia
label: a
answer: yes

Correct answer: a


Learning point: Anaemia can cause a soft, systolic murmur due to increased blood flow across heart valves in a hyperdynamic circulation.
A 54-year-old man has been referred to the emergency department by his GP. He has been experiencing recurrent fevers and has been feeling generally unwell for the past three weeks. He reports no other symptoms.

He is febrile, tachycardic, and hypotensive. On examination, he is pale and looks unwell. Auscultation of his chest reveals a pan-systolic murmur.

Examination of his hands shows:

[lightgallery]

Which of the following is a significant risk factor for the condition he has developed?

Options:
explanation: Hepatitis C infection can be caused by intravenous drug use, which is a risk factor for endocarditis. However, hepatitis C infection alone is not a risk factor for developing endocarditis.
name: Hepatitis C infection
label: e
answer: no
explanation: This gentleman most likely has infective endocarditis given his presentation, new murmur, and splinter haemorrhages (a vasculitic complication of endocarditis). Previous valve surgery would place this patient at a high risk of developing infective endocarditis.
name: Previous aortic valve replacement
label: a
answer: yes
explanation: This gentleman most likely has infective endocarditis given his presentation, new murmur, and splinter haemorrhages (a vasculitic complication of endocarditis). Intravenous, rather than inhaled, drug use is a risk factor for infective endocarditis.
name: Inhaling cocaine
label: b
answer: no
explanation: Intravenous, rather than inhaled, drug use is a risk factor for infective endocarditis.
name: Smoking cannabis
label: c
answer: no
explanation: Alcohol use can place patients at risk of a multitude of infections, however, it is not a well-known risk factor for endocarditis.
name: Alcohol consumption
label: d
answer: no

Correct answer: a


Learning point: Previous heart valve surgery significantly increases the risk of developing infective endocarditis due to potential bacterial colonisation.
A medical emergency team attends to a patient with breathlessness a week after surgery. They report feeling very unwell and complain of central chest pain. Examination is unremarkable.

Observations:
* Heart rate: 134 beats/minute
* Blood pressure: 102/69 mmHg
* Respiratory rate: 17 breaths/minute
* Temperature: 36.7 degrees
* Oxygen saturations (room air): 89%

ECG:

[lightgallery]

Options:
explanation: Chest pain, hypoxia, and breathlessness should raise suspicions of myocardial infarction. However, in the absence of ischaemic changes and the presence of right heart strain make pulmonary embolism more likely.
name: Non-ST elevation myocardial infarction (NSTEMI)
label: b
answer: no
explanation: Chest pain, hypoxia, and breathlessness should raise suspicions of myocardial infarction. However, in the absence of ischaemic changes (such as ST-segment elevation) and the presence of right heart strain make pulmonary embolism more likely.
name: ST-elevation myocardial infarction (STEMI)
label: c
answer: no
explanation: The ECG shows right bundle branch block and right axis deviation, suggestive of right heart strain. This, combined with the patient's hypoxia, chest pain, and recent surgery, makes pulmonary embolism the most likely diagnosis.
name: Pulmonary embolism
label: a
answer: yes
explanation: Pneumonia is an important differential, however, this does not account for the ECG features of right heart strain or the lack of examination findings; pneumonia would usually cause focal crackles. Pulmonary embolism is the most likely diagnosis.
name: Hospital-acquired pneumonia
label: e
answer: no
explanation: While atelectasis can cause post-operative hypoxia, this is usually present earlier in the postoperative course and is milder/less acute. The ECG findings of right heart strain, along with chest pain and hypoxia, make pulmonary embolism the most likely diagnosis.
name: Atelectasis
label: d
answer: no

Correct answer: a


Learning point: Pulmonary embolism should be suspected in post-operative patients presenting with hypoxia, chest pain, and signs of right heart strain on ECG.
A 67-year-old Caucasian woman with heart failure due to ischaemic heart disease is seen in an outpatient clinic. Her most recent echocardiogram shows an ejection fraction of 32% and an ECG shows sinus rhythm with broad QRS complexes.

Her current cardiac medications include:
* Bisoprolol 5mg PO OD
* Sacubitril-valsartan 24/26 mg PO OD
* Eplerenone 25mg PO OD
* Furosemide 20mg PO OD

On examination, she is visibly breathless on mobilising to the clinic room and has mild pitting oedema to both calves. Her observations are normal and her pulse is regular at 70 bpm.

What is the most appropriate next step to improve her prognosis?

Options:
explanation: Digoxin may help to control symptoms, however it does not provide a prognostic (i.e. mortality) benefit.
name: Add digoxin
label: b
answer: no
explanation: This may be considered but is mostly used in African-Caribbean patients. From the options provided, cardiac resynchronisation therapy is the best intervention to choose that would provide a mortality benefit.
name: Add hydralazine and nitrate
label: d
answer: no
explanation: This patient is clearly experiencing significant symptoms of dyspnoea due to heart failure with reduced ejection fraction. It would be inappropriate to leave her management unchanged unless the patient wished for this to be the case.
name: No changes to current management
label: c
answer: no
explanation: This is not appropriate; sacubitril-valsartan (Entresto) is recommended INSTEAD of an ACE inhibitor/ARB in patients with an ejection fraction of less than 35%. The formulation includes an angiotensin receptor blocker (valsartan).
name: Substitute sacubitril-valsartan for an ACE inhibitor
label: e
answer: no
explanation: This patient is clearly experiencing significant symptoms of dyspnoea due to heart failure with reduced ejection fraction. She is now at maximal medical therapy, including a beta blocker, mineralocorticoid receptor antagonist, and sacubitril-valsartan (which contains an angiotensin receptor blocker). The next step to improve her prognosis would addition of an SGLT-2 inhibitor such as empagliflozin or dapagliflozin, which are known to reduce mortality in patients with heart failure with reduced ejection fraction.
name: Add dapagliflozin
label: a
answer: yes

Correct answer: a


Learning point: Cardiac resynchronization therapy (CRT) is used in heart failure with reduced ejection fraction (EF) to improve ventricular coordination, enhance cardiac output, and reduce symptoms in patients with dyssynchrony.
A 56-year-old man is admitted to hospital with right upper quadrant pain and fevers. An ultrasound is performed which shows multiple gallstones present within a thickened gallbladder. Has localised peritonism in the right upper quadrant and is Murphy's sign positive.

What is the most appropriate definitive management for this patient?

Options:
explanation: This patient has acute cholecystitis. As per NICE Guidelines, they should have a 'hot' cholecystectomy; i.e. gallbladder removal within a week of diagnosis. Delayed or 'interval' cholecystectomies are sometimes carried out as 'hot' cholecystectomies are more technically challenging and require more expertise. This may also be required if the patient requires medical stabilisation (e.g. if they are in septic shock), or optimisation of other comorbidities.
name: Cholecystectomy in 2 months' time
label: b
answer: no
explanation: These will be required, however, the question asks what the definitive management for acute cholecystitis is, which is a cholecystectomy.
name: Antibiotics, fluids, and analgesia
label: e
answer: no
explanation: ERCP is a useful diagnostic and therapeutic procedure for disorders of the biliary tree, e.g. ascending cholangitis. This patient has acute cholecystitis, which an ERCP will not be able to treat. They require a cholecystectomy.
name: Endoscopic retrograde cholangiopancreatography (ERCP)
label: d
answer: no
explanation: This patient has acute cholecystitis. Cholecystostomy (a drain placed into the gallbladder) can be considered in patients who are not fit for surgery and do not respond to conservative management (e.g. antibiotics). This patient has no contraindications to having a cholecystectomy, and therefore this would be the best definitive management.
name: Cholecystostomy
label: c
answer: no
explanation: This patient has acute cholecystitis. As per NICE Guidelines, they should have a 'hot' cholecystectomy; i.e. gallbladder removal within a week of diagnosis.
name: Cholecystectomy within 1 week
label: a
answer: yes

Correct answer: a


Learning point: Laparoscopic cholecystectomy should be performed within 1 week of acute cholecystitis diagnosis; if not possible, surgery should be delayed until the acute episode resolves, usually more than 4 weeks after diagnosis.
A 7-year-old boy is admitted to hospital with persistent fevers. His parents report him experiencing an episode of severe right iliac fossa pain lasting four days that ended a week ago.

He is started on antibiotics and an ultrasound scan is carried out, which shows an appendix mass but no associated abscess.

What is the most appropriate course of management?

Options:
explanation: This patient has developed an appendiceal mass; a contained area of small bowel and omentum which has become inflamed and encases the appendix. He should undergo an appendectomy, but it is unsafe to attempt this until the inflammation of the appendix has resolved. He should receive antibiotics and then have an appendectomy in 6-8 weeks' time.
name: Proceed to appendectomy
label: c
answer: no
explanation: This is inappropriate; the patient requires definitive management.
name: Observation in hospital
label: e
answer: no
explanation: This patient has developed an appendiceal mass; a contained area of small bowel and omentum which has become inflamed and encases the appendix. He should undergo an appendectomy, but it is unsafe to attempt this until the inflammation of the appendix has resolved. He should receive antibiotics and then have an appendectomy in 6-8 weeks' time.
name: Interval appendectomy in 6-8 weeks' time
label: a
answer: yes
explanation: Antibiotics will be required, however the patient will still likely require an appendectomy.
name: A 2-week course of antibiotics
label: b
answer: no
explanation: If an associated abscess was present, drainage may have been an option to control the source of infection. In this case, there is no drainable collection. The patient should receive antibiotics until the inflammation settles, and then can proceed to an appendectomy.
name: Ultrasound-guided drainage
label: d
answer: no

Correct answer: a


Learning point: In cases of appendiceal mass, initial management includes antibiotics followed by interval appendectomy after inflammation resolves, typically within 6-8 weeks.