hllj/quesmed huggingface dataset:
A four-year-old boy is taken to the emergency department by his mother with a 72-hour history of left ear pain. His mother reports that his left ear started to leak some purulent material this morning. He has no significant past medical history and no allergies. On examination, the external ear did not appear erythematous and the discharge was not obvious from external inspection. He had a pulse rate of 130bpm and a temperature of 38.5 degrees. Otoscopy revealed a red tympanic membrane with a perforation and white purulent discharge in the external auditory canal.

Which of the following is the most appropriate management of this patient?

Options:
explanation: For people who are allergic to, or intolerant of, penicillin, it would be appropriate to prescribe a five to seven-day course of clarithromycin.
name: Oral Clarithromycin
label: b
answer: no
explanation: This is a self-care measure for symptom relief and prevention of recurrent infection in otitis externa.
name: Acetic acid 2% ear drops
label: e
answer: no
explanation: Regular doses of paracetamol or ibuprofen are advised for pain but provided this patient is systemically unwell, antibiotics are most appropriate to prevent progression to sepsis.
name: Simple analgesia
label: c
answer: no
explanation: The most likely diagnosis here is otitis media. NICE guidance states that for people who do not require admission to hospital but are systemically very unwell as in this case, offer an immediate antibiotic prescription and if an antibiotic is required, prescribe a five to seven-day course of amoxicillin.
name: Oral amoxicillin
label: a
answer: yes
explanation: This is not advised when there is tympanic perforation.
name: Ear irrigation
label: d
answer: no

Correct answer: a
A 28-year-old woman with no significant past medical history presents with two days of right ear discomfort and discharge. Her observations are normal and she has not had a recent viral illness. On examination, the auditory canal appears erythematous and there is a small amount of debris present, but you can still see the tympanic membrane intact.

Which of the following is the most appropriate management of this patient?

Options:
explanation: The most likely diagnosis here is otitis externa. Mild to moderate otitis externa as in this case can be treated with topical drops including combined antibiotic/steroid drops (e.g. Gentamix), acetic acid and other preparations. It is vital that the patient is advised to keep the ear dry for the next 7-10 days too.
name: Combined topical antibiotic and steroid drops
label: a
answer: yes
explanation: Analgesia, ear irrigation and dry swabbing of secretions should be advised but they will not directly treat the infections per se and are therefore not as appropriate as combined topical antibiotic and steroid drops.
name: Supportive care
label: d
answer: no
explanation: Chloramphenicol ear drops are rarely used in practice.
name: Topical chloramphenicol
label: e
answer: no
explanation: Oral antibiotics would be considered when there is cellulitis extending beyond the external ear canal, when the ear canal is occluded by swelling and debris and a wick cannot be inserted, or in people with diabetes or compromised immunity. It is also recommended in cases of severe infection or high risk of severe infection, for example with Pseudomonas aeruginosa.
name: Oral amoxicillin
label: c
answer: no
explanation: Oral antibiotics would be considered when there is cellulitis extending beyond the external ear canal, when the ear canal is occluded by swelling and debris and a wick cannot be inserted, or in people with diabetes or compromised immunity. It is also recommended in cases of severe infection or high risk of severe infection, for example with Pseudomonas aeruginosa.
name: Oral ciprofloxacin
label: b
answer: no

Correct answer: a
A 78-year-old female smoker attends her optician with gradually worsening painless visual loss, especially for near objects. She also reports that her vision in dim light is especially worse. The optician performs fundoscopy, which reveals the presence of drusen.

Which of the following is the most likely diagnosis?

Options:
explanation: This is another cause of painless visual loss, but involves the cornea and typically presents with blurred vision first thing in the morning when a patient wakes up.
name: Fuch's endothelial dystrophy
label: c
answer: no
explanation: This is a typical presentation of dry age-related macular degeneration. Symptoms typically include reduced visual acuity, worse with near vision, variability in visual disturbance from day to day, poor vision at night, photopsia (perceived flickering of lights), and glare. Drusen is seen in dry ARMD as yellow pigmented spots on the retina that are collected around the macula.
name: Age-related macular degeneration (ARMD)
label: a
answer: yes
explanation: This is a potential cause of painless visual loss, but drusen would not be seen on fundoscopy.
name: Refractive error
label: b
answer: no
explanation: This is another cause of painless visual loss but usually presents with complaints of photopsia and floaters.
name: Vitreous haemorrhage
label: e
answer: no
explanation: This is another cause of painless visual loss but usually patients have no visual symptoms at presentation and glaucoma is mostly diagnosed through screening tests. Fundoscopic/slit-lamp assessment of patients with open-angle glaucoma may reveal a pale optic disc (indicating optic nerve atrophy), optic disc cupping (a cup:disc ratio of >0.7), or retinal vessel 'bayonetting' (when vessels appear to have a break as they enter the deep cup and then reappear at the base).
name: Primary open-angle glaucoma
label: d
answer: no

Correct answer: a
A 50-year-old man presents to the emergency department with sudden onset severe headache. He describes the pain, which is on his left side, as behind his eye. He also reports a slight loss of vision in this eye and says it has been tearing an unusually large amount. On inspection of the left eye, there is significant conjunctival haemorrhage and the cornea looks hazy. Pupillary light reflexes on the right are normal; however, the left pupil is non-reactive and fixed-dilated.

Which of the following is the most likely diagnosis?

Options:
explanation: Anterior uveitis is inflammation of the anterior uvea, comprising the iris and/or ciliary body. Symptoms are typically a painful red eye that worsens over several days, photophobia, blurred vision
and headache. It would not cause a fixed dilated pupil.
name: Anterior uveitis
label: c
answer: no
explanation: Posterior uveitis is inflammation of the choroid and/or retina. Symptoms are classically blurred vision, progressive vision loss and flashes or floaters. It would not cause a fixed dilated pupil.
name: Posterior uveitis
label: d
answer: no
explanation: This is a classic description of a case of closed-angle glaucoma. Patients typically present systemically unwell with nausea and headaches. In some, but not all, there is severe ocular pain associated with blurred vision and halos around lights. The pupil is typically in a fixed-dilated position. Primary closed-angle glaucoma is an emergency. Patients must be referred to ophthalmology immediately to prevent the progression of visual loss.
name: Primary closed-angle glaucoma
label: a
answer: yes
explanation: Classically, a migraine is a unilateral throbbing headache preceded by an aura, such as visual (eg. lines, zigzags) or sensory (paraesthesia spreading from fingers to face) symptoms. The headache is associated with photophobia and phonophobia often and there may be identifiable triggers such as oral contraceptives or chocolate.
name: Migraine
label: e
answer: no
explanation: A cluster headache is a unilateral headache that is typically worse around the eye and can cause excessive tearing. It does not typically cause nausea or dilation of the pupil though.
name: Cluster headache
label: b
answer: no

Correct answer: a
A 50-year-old woman attends her optician complaining of gradual onset noticeable fading of her colour vision as well as glare from headlights when driving in the dark. She says her symptoms do not change day to day and are getting gradually worse. She has a past medical history of polymyalgia rheumatica for which she has been using long-term prednisolone to treat. Her pupils are dilated and ophthalmoscopy is undertaken which reveals a normal fundus and optic nerve.

Which of the following is the most likely diagnosis?

Options:
explanation: Usually, patients have no visual symptoms at presentation with open-angle glaucoma, and it is mostly diagnosed through screening tests. A small proportion of patients may notice peripheral vision loss.
name: Primary open-angle glaucoma
label: c
answer: no
explanation: Retinitis pigmentosa is a rare inherited condition causing retinal degeneration. Patients often present at a young age with 'tunnel vision' due to damage to the peripheral retina from pigment deposits.
name: Retinitis pigmentosa
label: e
answer: no
explanation: A cataract refers to an opacity in the lens due to denatured protein. Presenting symptoms vary according to the type of cataract, but the most common at presentation are painless loss of vision, difficulty reading/watching television, difficulty recognising faces, faded colour vision as well as haloes and glare around lights, particularly at night. Steroids are a specific risk factor for subcapsular cataracts.
name: Subcapsular cataract
label: a
answer: yes
explanation: This can also present with glare. However, other symptoms that are typically reported include photopsia (perceived flickering of lights) and variability in visual disturbance from day to day.
name: Age-related macular degeneration (ARMD)
label: b
answer: no
explanation: This would be very unusual to occur in someone with no past medical history of diabetes.
name: Diabetic retinopathy
label: d
answer: no

Correct answer: a
A 79-year-old woman is admitted to the geriatric ward for treatment of pneumonia. After 36 hours of admission, her bloods reveal a rise in her serum creatinine of 29 μmol/L (60-120 μmol/L).

Which of her following medications should be stopped?

Options:
explanation: Pioglitazone has not been found to impair kidney function so can be continued in acute kidney injury. Metformin is the main diabetic drug that would need to be stopped.
name: Pioglitazone
label: c
answer: no
explanation: Thiamine has not been found to impair kidney function so can be continued in acute kidney injury.
name: Thiamine
label: d
answer: no
explanation: Sitagliptin has not been found to impair kidney function so can be continued in acute kidney injury. Metformin is the main diabetic drug that would need to be stopped.
name: Sitagliptin
label: b
answer: no
explanation: By definition, this woman has an acute kidney injury (AKI) stage 1. Ibuprofen is an NSAID drug which is nephrotoxic and should be stopped in AKI.
name: Ibuprofen
label: a
answer: yes
explanation: Amoxicillin has not been found to impair kidney function so can be continued in acute kidney injury.
name: Amoxicillin
label: e
answer: no

Correct answer: a
A 66-year-old female presents to the GP complaining of a two-day history of dysuria and foul-smelling urine. She is systemically otherwise well. Her urine dip reveals leucocytes +++ and nitrites ++ with a trace of blood.

Which of the following is the next best investigation for this patient?

Options:
explanation: NICE guidelines say a sample should be sent for urine culture in all women with suspected lower urinary tract infections who are older than 65 years.
name: Urine culture
label: a
answer: yes
explanation: This is an investigation carried out in those with diabetes, chronic kidney disease and certain patients with proteinuria on a dipstick.
name: Urine protein to creatinine ratio
label: b
answer: no
explanation: This is an endoscopy which visualises the urethra, certain areas of the prostate and the bladder. It is not indicated in suspected lower urinary tract infections.
name: Cystoscopy
label: e
answer: no
explanation: The primary indications for this scan are suspected urolithiasis and flank pain.
name: CT kidneys, ureter, bladder
label: d
answer: no
explanation: This is a scan often used to investigate suspected ureteral obstruction and/or hydronephrosis, urinary retention, and in the placement of Foley catheters in certain situations.
name: USS renal tract
label: c
answer: no

Correct answer: a
An 88-year-old female is brought to the emergency department after falling at home. On taking a history from the patient, you learn that she was lying on the floor for more than 24 hours before she was attended to by the ambulance service. She has no history of chronic kidney disease. She is however found to have an acute kidney injury (AKI) as a result of suspected rhabdomyolysis. Her urea and electrolytes are normal, apart from a mild hyponatraemia at 130mmol/L and elevated creatinine at 105μmol/L (normal range 60-120 μmol/L).

Which of the following serum investigation is the most appropriate to diagnose the cause of her AKI?

Options:
explanation: This test is not as specific or sensitive as creatine kinase for diagnosing rhabdomyloysis.
name: Full blood count
label: c
answer: no
explanation: This test is not as specific or sensitive as creatine kinase for diagnosing rhabdomyloysis.
name: C-reactive protein (CRP)
label: d
answer: no
explanation: Rhabdomyolysis is caused by skeletal muscle breakdown. Creatine kinase is the most reliable indicator of muscle damage. A five-fold rise from the upper limit of the reference range suggests rhabdomyolysis although the levels are often much higher.
name: Creatine kinase
label: a
answer: yes
explanation: This test is not as specific or sensitive as creatine kinase for diagnosing rhabdomyloysis.
name: Liver function tests
label: b
answer: no
explanation: This test is not as specific or sensitive as creatine kinase for diagnosing rhabdomyloysis. It may reveal a metabolic acidosis if rhabdomyolysis is present.
name: Venous blood gas
label: e
answer: no

Correct answer: a
A nine-year-old boy presents to the GP with his father. He reports blood in his urine over the last two days. He denies dysuria, frequency or urgency. He was last at the GP just three days ago complaining of cough and coryza, which was thought to be viral in origin. A urine dipstick reveals blood +++ only.

Which of the following is the most likely diagnosis?

Options:
explanation: PSGN is a type of glomerular nephritis that occurs one to two weeks after a streptococcal throat infection or two to six weeks after a streptococcal skin infection.
name: Post streptococcal glomerulonephritis (PSGN)
label: b
answer: no
explanation: Minimal change can be associated with a viral upper respiratory tract infection in the preceding weeks. Patients suffering from minimal change disease typically present with oedema, including facial swelling and frothy urine.
name: Minimal change disease
label: c
answer: no
explanation: Alport's does often present in childhood. It usually presents with microscopic haematuria though alongside bilateral sensorineural hearing loss and/or retinitis pigmentosa.
name: Alport's Syndrome
label: d
answer: no
explanation: Rhabdomyolysis typically occurs with a history of a long-lie or seizure. Patients often complain of dark brown-coloured urine (often described as "tea-coloured") rather than blood in their urine.
name: Rhabdomyolysis
label: e
answer: no
explanation: Typically patients with IgA nephropathy present with recurrent visible or microscopic haematuria following an upper respiratory tract infection (usually 12-72 hours later) as in this case.
name: IgA nephropathy
label: a
answer: yes

Correct answer: a
A 47-year-old male attends the acute medical unit following a referral from his GP. He presents with complaints of bilateral generalised oedema of his legs and foamy urine. He has a past medical history significant for T2DM. His BP is 145/98mmHg and his urine dip reveals +++ protein. His biochemistry results are all normal apart from low albumin levels.

Which of the following is the most likely underlying cause?

Options:
explanation: Nephrotic syndrome is a triad of proteinuria (> 3g/24hr) causing hypoalbuminaemia (< 30g/L) and oedema. These are all likely to be present here and this man has diabetes making diabetic nephropathy a highly likely cause of his syndrome.
name: Diabetic nephropathy
label: a
answer: yes
explanation: IgA nephropathy is a type of nephritic syndrome. Nephritic syndrome is a condition involving haematuria, mild to moderate proteinuria (typically less than 3.5g/L/day), hypertension, oliguria and red cell casts in the urine. Haematuria and oliguria are not mentioned here and this man's blood pressure is not significantly raised making this a less likely diagnosis. He more likely has a nephrotic syndrome, of which diabetic nephropathy is the only choice.
name: IgA nephropathy
label: e
answer: no
explanation: Post-streptococcal glomerulonephritis is a type of nephritic syndrome. Nephritic syndrome is a condition involving haematuria, mild to moderate proteinuria (typically less than 3.5g/L/day), hypertension, oliguria and red cell casts in the urine. Haematuria and oliguria are not mentioned here and this man's blood pressure is not significantly raised making this a less likely diagnosis. He more likely has a nephrotic syndrome, of which diabetic nephropathy is the only choice.
name: Post-streptococcal glomerulonephritis
label: b
answer: no
explanation: Alport's syndrome is a type of nephritic syndrome. Nephritic syndrome is a condition involving haematuria, mild to moderate proteinuria (typically less than 3.5g/L/day), hypertension, oliguria and red cell casts in the urine. Haematuria and oliguria are not mentioned here and this man's blood pressure is not significantly raised making this a less likely diagnosis. He more likely has a nephrotic syndrome, of which diabetic nephropathy is the only choice.
name: Alports syndrome
label: d
answer: no
explanation: Rapidly progressive glomerulonephritis is a type of nephritic syndrome. Nephritic syndrome is a condition involving haematuria, mild to moderate proteinuria (typically less than 3.5g/L/day), hypertension, oliguria and red cell casts in the urine. Haematuria and oliguria are not mentioned here and this man's blood pressure is not significantly raised making this a less likely diagnosis. He more likely has a nephrotic syndrome, of which diabetic nephropathy is the only choice.
name: Rapidly progressive glomerulonephritis
label: c
answer: no

Correct answer: a
A 68-year-old female attends the practice nurse for her annual review of her systemic lupus erythematous. On examination, it is found that her blood pressure is 195/97mmHg. On further questionning, she reveals that she has also been bothered with blood in her urine the last few days as well as feeling significantly fatigued. Urine dipstick reveals blood +++ and protein ++.

Which of the following is the most likely condition?

Options:
explanation: Nephritic syndrome is a condition involving haematuria, mild to moderate proteinuria (typically less than 3.5g/L/day), hypertension, oliguria and red cell casts in the urine. Numerous of these are present here making a nephritic syndrome the most likely condition. Due to the rapid onset, rapidly progressive glomerulonephritis is a good differential. It is also the only nephritic syndrome in the answer set- the rest are examples of nephrotic syndrome.
name: Rapidly progressive glomerulonephritis
label: a
answer: yes
explanation: Minimal change disease is an example of a nephrotic syndrome. Nephrotic syndrome is a triad of proteinuria (> 3g/24hr) causing hypoalbuminaemia (< 30g/L) and oedema. Despite proteinuria being present, oedema is not mentioned and there is no albumin result making this a less likely diagnosis. This woman is more likely to have a nephritic syndrome, of which rapidly progressive glomerulonephritis is the most likely cause.
name: Minimal change disease
label: b
answer: no
explanation: Membranous glomerulonephritis is an example of a nephrotic syndrome. Nephrotic syndrome is a triad of proteinuria (> 3g/24hr) causing hypoalbuminaemia (< 30g/L) and oedema. Despite proteinuria being present, oedema is not mentioned and there is no albumin result making this a less likely diagnosis. This woman is more likely to have a nephritic syndrome, of which rapidly progressive glomerulonephritis is the most likely cause.
name: Membranous glomerulonephritis
label: e
answer: no
explanation: Amyloidosis is an example of a nephrotic syndrome. Nephrotic syndrome is a triad of proteinuria (> 3g/24hr) causing hypoalbuminaemia (< 30g/L) and oedema. Despite proteinuria being present, oedema is not mentioned and there is no albumin result making this a less likely diagnosis. This woman is more likely to have a nephritic syndrome, of which rapidly progressive glomerulonephritis is the most likely cause.
name: Amyloidosis
label: c
answer: no
explanation: FSGS is an example of a nephrotic syndrome. Nephrotic syndrome is a triad of proteinuria (> 3g/24hr) causing hypoalbuminaemia (< 30g/L) and oedema. Despite proteinuria being present, oedema is not mentioned and there is no albumin result making this a less likely diagnosis. This woman is more likely to have a nephritic syndrome, of which rapidly progressive glomerulonephritis is the most likely cause.
name: Focal segmental glomerulosclerosis (FSGS)
label: d
answer: no

Correct answer: a
A 40-year-old woman with episodes of recurrent Proteus mirabilis urinary tract sepsis presents with a suspected staghorn calculus of her right kidney. Her urinary pH is 7.2. An x-ray of the kidneys, ureter and bladder shows branching calcific densities overlying the renal outline in keeping with a staghorn calculus.

Which of the following is the most likely type of stone?

Options:
explanation: This accounts for around 5-10% of renal stones and is radio-lucent.
name: Uric acid
label: c
answer: no
explanation: This is the most common type of renal stone and has an opaque radiographic appearance.
name: Calcium oxalate
label: b
answer: no
explanation: This is a rare type of stone accounting for just 1% and is semi-opaque with a 'ground-glass' radiographic appearance.
name: Cystine
label: e
answer: no
explanation: Staghorn calculi involve the renal pelvis and extend into at least two calyces. They develop in alkaline urine as in this case and are composed of struvite (ammonium magnesium phosphate, triple phosphate). Ureaplasma urealyticum and Proteus infections predispose to their formation.
name: Struvite
label: a
answer: yes
explanation: This accounts for 10% of renal stones and has an opaque radiographic appearance.
name: Calcium phosphate
label: d
answer: no

Correct answer: a
A 78-year-old male presents to the emergency department with a 24-hour history of inability to pass urine and significant suprapubic pain. On examination, he has a palpably distended bladder, with suprapubic tenderness. A catheter is inserted and 800mls is drained from his bladder.

Which of the following is the most common cause of this condition?

Options:
explanation: This is a cause of acute urinary retention, but less common than BPH.
name: Urethral stricture
label: c
answer: no
explanation: This is a cause of acute urinary retention, most typically in those with high anticholinergic activity, but is less common than BPH.
name: Medication
label: d
answer: no
explanation: This patient presents with classic acute urinary retention. BPH accounts for up to 80% of acute urinary retention and up to one-third of patients undergoing surgical treatment for BPH present with acute urinary retention. The immediate treatment is bladder decompression using urethral or suprapubic catheterisation.
name: Benign prostatic hypertrophy (BPH)
label: a
answer: yes
explanation: This is a cause of acute urinary retention, but less common than BPH.
name: Detrusor muscle dysfunction
label: e
answer: no
explanation: This is a cause of acute urinary retention, but less common than BPH. It is less common because BPH is more likely to affect the central part of the prostate (where the urethra passes through) whereas prostate cancer is more likely to affect the peripheral zone.
name: Prostate cancer
label: b
answer: no

Correct answer: a