hllj/quesmed huggingface dataset:
A 76-year-old female is diagnosed with Alzheimer's dementia. Over the last few years, her cognition has declined, and her behaviour has become less manageable. She is now becoming aggressive towards staff and other residents in her care home. Her GP is considering starting risperidone to help manage her aggression as behavioural measures are failing.

Which of the following is a recognised risk of risperidone?

Options:
explanation: Patients started on risperidone should be monitored for prolactin concentration at the start of therapy, at six months, and then yearly. Clozapine can cause agranulocytosis and therefore requires differential white blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly. This is not the case for risperidone
name: Increased risk of agranulocytosis
label: d
answer: no
explanation: Risperidone has a lower risk of producing extrapyramidal side effects than typical antipsychotics such as chlorpromazine and haloperidol; however, there is still a risk of drug-induced Parkinsonism, particularly at higher doses. It does not, however, cause Parkinson's Disease
name: Increased risk of Parkinson's Disease
label: c
answer: no
explanation: Risperidone is associated with hypotension (usually dose-related) as opposed to hypertension
name: Increased risk of hypertension
label: e
answer: no
explanation: Antipsychotic medications can cause weight gain and a rise in blood sugar; therefore are associated with an increased risk of developing diabetes, though this is less likely to be relevant in this case as it is a long-term effect
name: Increased risk of hypoglycaemia
label: b
answer: no
explanation: There is a small increased risk of stroke when starting certain antipsychotic medications. The National Institute for Health and Care Excellence (NICE) quotes an absolute risk increase of 1.22% (an extra 12 strokes per 1000 people starting an antipsychotic)
name: Increased risk of stroke
label: a
answer: yes

Correct answer: a


Learning point: Risperidone use in elderly patients with dementia is associated with a small increased risk of stroke.
The police bring a 32-year-old male to the Emergency Department after being injured whilst resisting arrest for theft. On review, he has only minor injuries, but you notice that he is starting to shiver, sweat, retch and has a tremor. His pupils are dilated.

What is the most likely diagnosis?

Options:
explanation: This is a reasonable differential as the signs and symptoms of alcohol and opiate withdrawal are very similar, however, dilated pupils are more commonly associated with opiate withdrawal than alcohol
name: Alcohol withdrawal
label: c
answer: no
explanation: This patient may well be anxious as they have just been arrested, and anxiety can account for some of the symptoms described but would not account for the shivering or the dilated pupils
name: Anxiety attack
label: b
answer: no
explanation: Drug abuse can lead to drug-induced psychosis. However, this is not the clinical picture here
name: Acute psychosis
label: d
answer: no
explanation: Drug and alcohol abuse (particularly cocaine use) can raise the risk of myocardial infarction; however, this is not the most likely diagnosis
name: Acute myocardial infarction
label: e
answer: no
explanation: This patient is showing some of the classic signs and symptoms of early opiate withdrawal. Treatment in the first instance should be supportive, and patients may require fluid resuscitation to replace fluids lost through sweating and diarrhoea. Should they wish it, the patient can have withdrawal management with either buprenorphine or methadone; however, this should be managed by an experienced professional
name: Opiate withdrawal
label: a
answer: yes

Correct answer: a


Learning point: Opiate withdrawal presents with symptoms such as tremors, sweating, dilated pupils, and gastrointestinal disturbances.
A 76-year-old male is brought from his residential home to the Emergency Department with difficulty breathing. He is disorientated, breathing fast, and on auscultation of his chest, you note coarse crackles at the right base.

- Temperature 37.9°C
- Blood pressure 90/50 mmHg
- Heart rate 105 bpm
- Respiratory rate 32 breaths per minute
- Saturations 95% (on air)

What should your management be?

Options:
explanation: There is no evidence to suggest that this patient has an advanced directive or care plan in place stating that they do not want active treatment. Therefore, you should initiate treatment of all reversible causes of their deterioration, including antibiotics and managing sepsis. However, if they deteriorate and require more intensive treatment such as non-invasive ventilation or intubation, then it should be considered whether this is in their best interests
name: Symptom control
label: e
answer: no
explanation: This patient has a community acquired pneumonia and a CURB-65 score of at least 4 (confusion, respiratory rate, diastolic blood pressure, age) even without the blood results for urea and therefore should be treated as severe pneumonia and admitted for intravenous antibiotics. The CURB-65 score is as follows:

- Confusion +1
- Urea >19mg/dL (>7mmol/L) +1
- Respiratory rate >30 +1
- SBP <90 or DBP <60 +1
- Age >65 +1
name: Admission for intravenous antibiotics
label: a
answer: yes
explanation: This patient is unwell with a community-acquired pneumonia and a CURB 65 score of at least 4 and therefore has a high 30-day mortality risk. They should be admitted for intravenous antibiotics
name: Oral antibiotics
label: b
answer: no
explanation: This patient has a community-acquired pneumonia with localising signs pointing towards a bacterial cause (single-zone lung crackles). Therefore, though oxygen is indicated in this patient's treatment, the definitive management is antibiotics according to the hospital's microbiology policy
name: Admission for oxygen therapy alone
label: d
answer: no
explanation: Whilst this patient has severe pneumonia, they are maintaining their airway, and we do not have any evidence that they are tiring. They may eventually require further airway support, and it is important to have this in mind however, intubation is not currently indicated
name: Intubation
label: c
answer: no

Correct answer: a
A 67-year-old male smoker is noted to be hyponatraemic at 128 on routine bloods done at his general practice. All other bloods are normal. He is euvolaemic, and physical examination is normal. He also discloses that he has had some weight loss recently. He has no past medical history. He is a smoker with a 30 year pack history.

Which of the following investigations is most likely to provide a diagnosis?

Options:
explanation: An ABG would help determine if this patient has type one or type two respiratory failure; however, it would not provide an underlying diagnosis
name: Arterial blood gas (ABG)
label: c
answer: no
explanation: Spirometry would be useful in diagnosing the difference between different patterns of lung disease (restrictive vs obstructive patterns) and, therefore would be of use if you were concerned about smoking-associated diseases such as chronic obstructive pulmonary disease (COPD). Whilst COPD can occasionally lead to SIADH, it is more important to rule out cancer. Changes due to COPD would also be evident on a CT chest
name: Spirometry
label: b
answer: no
explanation: A number of lung diseases can cause SIADH. Serum ACE is a test for sarcoidosis. In this case, the significant smoking history, weight loss and lack of other features makes lung cancer more likely favouring a CT Chest as the most useful investigation
name: Serum ACE
label: e
answer: no
explanation: Paired urine and serum osmolalities are useful in determining whether this is a renal or other cause for hyponatraemia. In healthy individuals, if serum osmolality is low, urine osmolality should also be low as the kidneys should be working hard to retain solute. In SIADH, the excess of ADH results in water retention, but not solute retention. As a result, concentrated urine, which is relatively high in sodium is produced, despite low serum sodium. Whilst paired osmolalities would be useful in the workup of this patient; they are unlikely to provide a definitive diagnosis
name: Paired urine and serum osmolalities
label: d
answer: no
explanation: This patient is a smoker with weight loss and euvolaemic hyponatraemia, which should raise the concern of syndrome of inappropriate antidiuretic hormone secretion (SIADH) from a small cell lung cancer. The gold standard investigation for this would be a CT chest
name: CT Chest
label: a
answer: yes

Correct answer: a
A 72-year-old female is admitted to hospital and treated for a non-infective exacerbation of her chronic obstructive pulmonary disease (COPD). She clinically improves with a short period of non-invasive ventilation (NIV), nebulisers and steroids; however, she has an ongoing oxygen requirement of 1-2 litres via nasal cannula to maintain her saturations.

Which of the following statements is a criterion for starting long term oxygen therapy (LTOT)?

Options:
explanation: The criteria for LTOT in COPD are patients either a PaO2 <7.3 when stable or PaO2 7.3–8 kPa when stable and also have either secondary polycythaemia, peripheral oedema, or evidence of pulmonary hypertension (minimum of 15 hours per day). A haemoglobin of >160g/L in women is considered polycythaemia
name: An arterial blood gas demonstrating PaO2 7.5 kPa and a Hb 170g/L in a stable patient who is no longer smoking
label: a
answer: yes
explanation: LTOT can be considered in the treatment of obstructive sleep apnoea in symptomatic patients despite continuous positive airways pressure therapy after specialist assessment
name: A patient newly diagnosed with sleep apnoea
label: c
answer: no
explanation: Smoking is an absolute contraindication for starting LTOT
name: An arterial blood gas demonstrating PaO2 7.5 kPa and a Hb 170g/L in a stable patient who has reduced their smoking
label: b
answer: no
explanation: NICE guidance states that LTOT should be considered in patients with heart failure with daytime PaO2<7.3 kPa when breathing air or with nocturnal hypoxaemia
name: A patient with heart failure with daytime PaO2 of 7.4 kPa on air
label: d
answer: no
explanation: In COPD, patients with PaO2 <7.3 kPa when stable and who do not smoke should be considered for LTOT, even without any other secondary sequelae of COPD (minimum of 15 hours per day)
name: An arterial blood gas demonstrating PaO2 7.4 kPa in an otherwise well patient who is no longer smoking
label: e
answer: no

Correct answer: a
A 34-year-old female presents to GP with a mild persistent dry cough and rash. Observations and routine bloods are normal other than a raised erythrocyte sedimentation rate (ESR); her doctor refers her for a chest x-ray which shows bilateral hilar lymphadenopathy.

What is the most appropriate treatment?

Options:
explanation: Oral steroids are reasonable in symptomatic sarcoid; however, intravenous pulsed steroids are rarely indicated in sarcoidosis
name: Pulsed high dose intravenous steroids
label: b
answer: no
explanation: For patients who cannot be treated with low-dose glucocorticoids and an antimetabolite, anti-tumour necrosis factor (TNF) monoclonal antibodies have been shown to control disease. However, anti-TNF drugs are associated with substantial toxic effects and, in some cases, are ineffective
name: Intravenous infliximab
label: e
answer: no
explanation: Oral steroids are often used to treat stage two and above or in symptomatic stage one sarcoidosis; however, as this patient is otherwise well and asymptomatic, it is reasonable to watch and wait in the first instance
name: Oral steroids
label: c
answer: no
explanation: In patients with stage one sarcoid who are otherwise asymptomatic, many will spontaneously resolve without the need for any treatment
name: Watch and wait
label: a
answer: yes
explanation: Antimetabolites such as methotrexate, azathioprine and mycophenolate may be used to treat symptomatic sarcoidosis as an alternative to steroids; however, as this patient is otherwise well and asymptomatic, it is reasonable to watch and wait in the first instance
name: Oral methotrexate
label: d
answer: no

Correct answer: a
A 45-year-old male presents to General Practice requesting help and advice on quitting smoking.

What is the most appropriate treatment?

Options:
explanation: The National Institute for Health and Care Excellence (NICE) recommends that nicotine replacement therapy (NRT) with varenicline OR bupropion, as appropriate, to people planning to stop smoking; however, these medications should not be used in combination. In addition, patients should be advised not to smoke whilst on NRT
name: Offer nicotine replacement therapy (NRT) with varenicline AND bupropion
label: e
answer: no
explanation: Some patients may find acupuncture beneficial; however, it has not been shown to be effective in clinical trials and therefore is not currently recommended
name: Acupuncture
label: d
answer: no
explanation: Some patients may find hypnotherapy beneficial; however, it has not been shown to be effective in clinical trials and, therefore, is not recommended
name: Referral for hypnotherapy
label: c
answer: no
explanation: Whilst behavioural therapy can be helpful in stopping smoking in identifying triggers and craving coping strategies, behavioural therapy alone has a lower success rate than when used in conjunction with NRT
name: Cognitive behavioural therapy alone
label: b
answer: no
explanation: The National Institute for Health and Care Excellence (NICE) recommends that nicotine replacement therapy (NRT) with varenicline or bupropion, as appropriate, to people planning to stop smoking. Patients should be advised not to smoke whilst on NRT
name: Offer nicotine replacement therapy (NRT) with varenicline OR bupropion
label: a
answer: yes

Correct answer: a
A 48-year-old female presents to General Practice complaining of cold, painful fingers. She reports that her fingers go blue after being outside (particularly if she forgets her gloves) but that they regain their colour when she comes inside. Her only past medical history is significant for rheumatoid arthritis, for which she takes methotrexate.

What medication should you consider starting?

Options:
explanation: Warfarin is an anticoagulant that is sometimes used in patients who are pro-coagulant or who have venous thrombosis, particularly if they have failed treatment with a direct oral anticoagulant (DOAC). It is also used in patients with metal heart valves. It is not of benefit in this patient's case
name: Warfarin
label: c
answer: no
explanation: This patient most likely has Raynaud's phenomenon as she is experiencing paroxysmal digital ischaemia when exposed to the cold. It is often associated with underlying rheumatological conditions, including systemic sclerosis, rheumatoid arthritis and systemic lupus erythematosus (SLE). Treatment is mostly trigger management - keeping fingers warm, smoking cessation and avoiding stress - however in some cases, nifedipine may help symptoms
name: Nifedipine
label: a
answer: yes
explanation: Aspirin is an antiplatelet medication often used in peripheral vascular disease. While this patient has digital ischaemia, it is paroxysmal; therefore, aspirin is not the treatment of choice
name: Aspirin
label: b
answer: no
explanation: Epoprostenol is also known as prostaglandin I2 and is an effective vasodilator. It is sometimes used to treat severe attacks of Raynaud's, e.g. where there are concerns about digital gangrene or the development of digital necrosis. It is a rescue therapy and is not used routinely. Relapse is common after infusion, and some patients with severe disease require regular infusions, particularly in the winter months
name: Epoprostenol
label: e
answer: no
explanation: Apixaban is an anticoagulant (in the DOAC category) that is often used in the treatment of deep vein thrombosis and in patients who are pro-coagulant. It is not currently used in the treatment of Raynaud's phenomenon
name: Apixaban
label: d
answer: no

Correct answer: a


Learning point: Nifedipine, a calcium channel blocker, is commonly used to treat Raynaud's disease by relaxing blood vessels and improving blood flow, reducing the frequency and severity of episodes of vasoconstriction and color changes in the fingers.
A 46-year-old female presents to General Practice with bilateral knee pain that has been present for six months. She currently works part-time as a cleaner. Her past medical history includes type two diabetes mellitus, hypertension, gastro-oesophageal reflux (GORD) and morbid obesity.
Knee x-rays are requested and show loss of joint space with some subchondral sclerosis.

What is your initial management?

Options:
explanation: Steroid injections may be of benefit in reducing her symptoms but are not always effective and carry risks, including that of introducing infection; as she has diabetes, this risk is even more of a concern. Other interventions should be considered first in this case
name: Steroid injection
label: b
answer: no
explanation: This patient has the start of osteoarthritis as seen in her x-ray changes and therefore should be advised on lifestyle modifications to prevent the progression of symptoms
name: Watch and wait
label: d
answer: no
explanation: TKR is often the best way to deal with severe arthritis when it impacts the quality of life; however, this patient has a short history and has yet to attempt any non-surgical management. In addition, TKRs only last around 15 years, and as this patient is young, this is best avoided at present
name: Total knee replacement (TKR)
label: e
answer: no
explanation: Non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen are beneficial in treating the pain associated with osteoarthritis; however, this patient already has a degree of reflux, which would be exacerbated by NSAID use. If NSAIDs were required, topical would be first-line, or if that was ineffective, ibuprofen would likely be the first-line oral option as it is not as strong. She would require gastric protection, for example, with a proton pump inhibitor (PPI). She has a relatively short history, and therefore lifestyle interventions would be of benefit in the first instance in this case
name: Naproxen
label: c
answer: no
explanation: This patient has osteoarthritis. As she is morbidly obese and young, one of the first interventions should be lifestyle advice and weight loss, particularly as she also has diabetes and hypertension. Weight loss would reduce the stress on her load-bearing joints and also improve her health generally as well as her diabetes and hypertension
name: Advise the patient to lose weight
label: a
answer: yes

Correct answer: a


Learning point: Weight loss is a crucial initial management strategy for osteoarthritis, particularly in morbidly obese patients, to reduce joint stress and improve overall health.
A 63-year-old female presents to Accident and Emergency with sudden right-sided blindness associated with a headache. She has never had issues with headaches before. On further questioning, she reveals that she has tenderness on brushing her hair and has been to the dentist recently with toothache but did not need any dental work done.

What should your initial management be?

Options:
explanation: 300mg of aspirin would be the treatment of choice if this patient were suspected of having a transient ischaemic attack (TIA); however, whilst TIAs can present with blindness, they do not usually cause headache and would not explain the scalp or jaw pain
name: Stat dose 300mg aspirin
label: b
answer: no
explanation: Low dose amitriptyline may be used in neuropathic pain and migraine prophylaxis; however, whilst migraine can cause headache and visual loss/disturbance in some cases, it is unlikely for a patient to have a new diagnosis of migraine at the age of 63 and therefore other causes should be considered
name: Start 10mg amitriptyline
label: c
answer: no
explanation: This history is suspicious for temporal arteritis, aka giant cell arteritis (GCA). As she has experienced vision loss, it is important to start high dose steroid treatment immediately; otherwise, she may have permanent loss. Symptoms of GCA include scalp tenderness, jaw claudication and headache. Patients usually require steroids for a two-year course then have complete remission, and steroids can be reduced once symptoms have resolved. The main cause of death and morbidity in GCA are related to long term steroid use, so risks and benefits of treatment should be considered carefully, and gastric and bone protection should be considered
name: Start high dose steroids
label: a
answer: yes
explanation: Thrombolysis with alteplase would be an appropriate treatment for an ischaemic stroke within 4.5 hours of the onset of symptoms. Whilst ischaemic stroke can cause blindness, it would not usually cause headaches and would not explain the scalp or jaw pain
name: Stat dose 900mcg/kg altepalase
label: e
answer: no
explanation: Carbemazipine is the first line treatment for trigeminal neuralgia. This would be in the differential for unilateral facial pain; however, it would not account for the blindness, and the pain she describes does not sound neuropathic
name: Start 100mg carbamazepine
label: d
answer: no

Correct answer: a


Learning point: Giant cell arteritis (GCA) is an inflammatory condition affecting large blood vessels, often presenting with symptoms like headache and vision changes; it requires prompt treatment with high-dose steroids to prevent complications such as vision loss and reduce inflammation.
A 34-year-old male presents to the sexual health clinic concerned about a lump he has found in his left testicle. He is sexually active but does not complain of any penile discharge or any urinary symptoms. On examination, there is a soft fleshy lump that is separate from the spermatic cord. It is only palpable when the patient is standing and not when lying down. It does not transilluminate.

What is the most likely diagnosis?

Options:
explanation: This is infection/inflammation of the testis and epididymis. It is often caused by sexually transmitted infections such as chlamydia but also caused by viral causes such as mumps. Patients report a tender generalised swelling and may have other associated features of infection (temperature, dysuria, penile discharge). Treatment is with antibiotics depending on the likely source (NB if sexually transmitted infection deemed likely source then contact tracing and treatment of partners should be initiated)
name: Epididimo-orchitis
label: c
answer: no
explanation: This is unlikely but should be carefully considered in the differential as testicular tumours are the commonest malignancy in this age demographic. They usually present as a painless, firm lump in the testes found after trauma/infection and may have a secondary hydrocoele
name: Testicular tumour
label: d
answer: no
explanation: A varicocele is caused by dilated veins of the pampiniform plexus and often may only be present on standing. 90% occur on the left. They are associated with subfertility, but surgical repair appears to have little effect on subsequent pregnancy rates. Treatment is with scrotal support or surgery (varicocelectomy)/embolisation
name: Varicocoele
label: a
answer: yes
explanation: This would be in the differential and are caused by fluid within the tunica vaginalis; however, the description and the lack of transillumination make varicocoele more likely
name: Hydrocoele
label: b
answer: no
explanation: This presents as a painless nodule at the head of the epididymis adjacent to the inferior pole of the testis and will transilluminate. They may contain clear or milky (spermatocele) fluid
name: Epididymal cyst
label: e
answer: no

Correct answer: a


Learning point: A varicocele, often present only when standing and typically occurring on the left, is caused by dilated veins of the pampiniform plexus, associated with subfertility, and treated with scrotal support or surgery/embolization.