hllj/quesmed huggingface dataset:
A 61 year old woman presents to the GP with shortness of breath which is limiting her ability to care for herself independently. She is no longer able to wash or dress herself without significant breathlessness.

On examination, the GP identifies:

Tar staining on the right hand, cachexia, increased work of breathing at rest, reduced chest expansion bilaterally, hyper-resonance to percussion bilaterally and bilateral expiratory wheeze.

Which clinical diagnosis is most likely, given the examination findings?

Options:
explanation: Examination findings in patients with lung cancer may include clubbing and a monophonic or harsh sounding wheeze. COPD is significantly more common than lung cancer
name: Lung cancer
label: d
answer: no
explanation: Asthma is not as classically a disease of smokers compared with COPD. In addition, although asthma does cause wheeze (which tends to be polyphonic or "musical"), it does not cause hyper-expansion of the lungs
name: Asthma
label: c
answer: no
explanation: Typical examination findings in ILD include fine end-expiratory crackles in the affected area (bases or apices depending on the cause of the fibrosis). You may also find clubbing and reduced chest expansion. This is a restrictive lung condition and as such, does not cause hyper-expansion of the lungs
name: Interstitial lung disease (ILD)
label: b
answer: no
explanation: COPD is directly linked to exposure to tobacco smoke or other pollutants (including direct and passive smoke inhalation). It is an obstructive condition which causes air trapping, leading to hyper-expanded lungs. This manifests in reduced expansion and hyper-resonance to percussion. COPD also commonly causes wheeze, particularly in times of acute exacerbation when there may be additional mucus clogging the already obstructed airways
name: Chronic obstructive pulmonary disease (COPD)
label: a
answer: yes
explanation: Most patients with bronchiectasis will have crackles on examination due to the presence of excess mucus in the airways. COPD is significantly more common than bronchiectasis
name: Bronchiectasis
label: e
answer: no

Correct answer: a
A 31 year old woman presents to the emergency department (ED) with sudden onset breathlessness and one episode of haemoptysis. Last week she had a car accident, and she has spent the last 5 days resting in bed due to whiplash. She has no other past medical history. Her only regular medication is the combined oral contraceptive pill. Her observations are as follows:

Respiratory rate 22, oxygen saturations 96% on room air, pulse 110, blood pressure 110/73, temperature 36.5

The ED doctor suspects pulmonary embolism (PE). What is the definitive diagnostic investigation for PE in this patient?

Options:
explanation: A CXR is not a diagnostic test for a pulmonary embolism, and in fact, is usually normal in these patients. When signs are present on the CXR (such as wedge shaped consolidation representing pulmonary infarction), it can be difficult to directly determine the cause (pneumonia could also explain this change)
name: Chest X-ray (CXR)
label: b
answer: no
explanation: Spirometry does not have a role in the diagnosis of pulmonary embolism
name: Spirometry
label: e
answer: no
explanation: This is the main alternative diagnostic imaging for patients with a contraindication to CTPA, such as severe renal impairment or contrast allergy. It is also used in pregnancy due to the lower radiation dose
name: Ventilation perfusion scan
label: d
answer: no
explanation: This patient has a Wells score of 7: Heart rate of >100 (1.5), haemoptysis (1), recent immobilisation of at least 3 days in the last 4 weeks (1.5), PE is number one diagnosis, or equally likely (3). Haemodynamically stable patients with a high clinical probability of PE (more than 4 points) should be investigated with a CTPA unless contraindicated
name: Computed tomography pulmonary angiography (CTPA)
label: a
answer: yes
explanation: A D-dimer would the first line test in patients with a Wells score of less than or equal to 4 (low probability of PE) and who are haemodynamically stable
name: D-dimer
label: c
answer: no

Correct answer: a
A 22 year old male presents to the emergency department (ED) with right sided pleuritic chest pain. This came on suddenly with no identifiable trigger. He is a smoker with a 10 pack year history and is noted to be very tall. He has no past medical history. His observations follow:

Respiratory rate 22, oxygen saturations 97%, pulse rate 90, blood pressure, 114/70, temperature 36.8

A chest x-ray visualises the right lung margin 2 centimetres from the chest wall, with absence of lung markings within this space. There is no evidence of tracheal deviation.

What is the most likely diagnosis?

Options:
explanation: This pneumothorax has occurred in a patient with no prior lung disease and without a trigger. Additionally, this patient has many risk factors for pneumothorax, including smoking, his height and his age/gender combination
name: Primary spontaneous pneumothorax
label: a
answer: yes
explanation: A secondary spontaneous pneumothorax happens without a trigger in a patient with known underlying lung disease
name: Secondary spontaneous pneumothorax
label: b
answer: no
explanation: No trauma occurred in this patient's history
name: Traumatic pneumothorax
label: c
answer: no
explanation: In this patient's demographic, in the absence of any risk factors for thrombus formation, a pneumothorax would be a more likely cause for sudden onset pleuritic chest pain
name: Pulmonary embolism
label: e
answer: no
explanation: A patient with a tension pneumothorax would be clinically more unwell than this patient, whose observations are not significantly deranged. The lack of tracheal deviation makes this unlikely
name: Tension pneumothorax
label: d
answer: no

Correct answer: a
A 59-year-old woman presents to the GP with a 3-day history of worsening cough, productive of green sputum, and notable fatigue. She diagnosed with a community acquired pneumonia (CAP).

Her observations are as follows:

- Respiratory rate 22
- Oxygen saturations 97% on room air
- Pulse 109
- Blood pressure 109/67
- Temperature 37.9°C

What other factor needs to be considered to allow for evidenced-based severity grading of the pneumonia in this context?

Options:
explanation: An AMTS forms part of CRB-65 assessment which is part of the recommended pathway for assessing severity of CAP in the GP context (recommended by both British Thoracic Society and National Institute for Health and Care Excellence (NICE)).

CRB-65 is calculated as follows, scoring one point for each of the following:

- C = confusion (defined as a AMTS score of ≤ 8, or new disorientation in person, place or time)
- R = respiratory rate ≥ 30
- B = systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg
- 65 = age ≥ 65 years

A score of:

- 0 = likely suitable for outpatient management
- 1-2 = consider hospital referral
- 3 or 4 = urgent hospital admission

Therefore, the score helps to inform whether a patient should be referred to hospital or if management in the community is appropriate. Other patient factors should also be considered alongside the score, including the patient's age, previous and concurrent health conditions and oxygen saturations
name: Abbreviated mental test score (AMTS)
label: a
answer: yes
explanation: A CXR would demonstrate the proportion of lung impacted by the infection, an important indicator of pneumonia severity. However, in the context of GP assessment this test is not routinely available, nor does it form part of the evidence-based scoring system for pneumonia severity assessment
name: Chest x-ray (CXR)
label: b
answer: no
explanation: A sputum culture may help to determine specific anti-microbial management of the pneumonia further down the line; however, it does not affect severity of the condition acutely. Additionally, this investigation can take several days to come back. In the interim, empirical management of the pneumonia is indicated
name: Sputum culture
label: d
answer: no
explanation: This forms part of the CURB-65 score, used for hospital assessment of CAP severity. In the community, when blood testing is not as accessible, the score system becomes modified to the CRB-65
name: Blood testing for urea levels
label: c
answer: no
explanation: Blood testing for markers of inflammation can be helpful in hospital assessment, as well as in monitoring patient's recovery trajectory. However, in the community (GP) setting this test may take several days for a result. It also does not form part of the evidence-based scoring system for pneumonia severity assessment
name: Blood testing for inflammatory markers
label: e
answer: no

Correct answer: a
A 73-year-old woman with a history of chronic obstructive pulmonary disease (COPD) comes in via ambulance to the emergency department with worsening shortness of breath.


An arterial blood gas (ABG) is performed as part of her assessment:


||||
|--------------|:-------:|------------------|
|pH|7.27|7.35 - 7.45|
|PaO₂|7.1 kPa|11 - 15|
|PaCO₂|9.47 kPa|4.6 - 6.4|
|Bicarbonate|43 mmol/L|22 - 30|
|Lactate|1.1 mmol/L|0.6 - 1.4|

 - Inspired oxygen 28%


What is the most likely explanation for this blood gas result?

Options:
explanation: An ABG performed in a patient with simple hyperventilation would likely show low PaCO<sub>2</sub> levels (due to losses in expiration) with normal PaO<sub>2</sub> (no pathology present to cause hypoxia). This may cause a respiratory alkalosis if hyperventilation is maintained for long enough, not an acidosis. Additionally, there would be a change in the metabolic axis (i.e. bicarbonate) due to the acuity of the respiratory derangement
name: Hyperventilation
label: c
answer: no
explanation: This patient is acidotic, however a low bicarbonate level would be expected if this were metabolic in origin. Additionally, respiratory compensation for a metabolic acidosis would involve hyperventilation in order to reduce PaCO<sub>2</sub> levels - in this ABG example both the bicarbonate and PaCO<sub>2</sub> are elevated
name: Metabolic acidosis with partial respiratory compensation
label: d
answer: no
explanation: In chronic type 2 respiratory failure there is hypoxia with hypercapnia (as is the case here) - however, as this is a chronic process you would expect the pH to be largely corrected by metabolic compensatory processes (pH normal/close to normal with elevated bicarbonate)
name: Chronic type 2 respiratory failure
label: b
answer: no
explanation: In type 1 respiratory failure there is hypoxia without hypercapnia. In this example, the PaCO<sub>2</sub> is raised
name: Type 1 respiratory failure
label: e
answer: no
explanation: In acute-on-chronic type 2 respiratory failure the usual compensatory metabolic processes have been overwhelmed by the additional acute respiratory insult. The resultant pattern on ABG is a marked increase in PaCO<sub>2</sub> with significant respiratory acidosis, alongside a highly elevated HCO3 that is not adequate to normalise/nearly normalise the pH. Therefore, this patient is likely to need bilevel positive airway pressure (BiPaP) non-invasive ventilation to aid clearance of the CO<sub>2</sub> and improve the acidosis as part of their treatment plan
name: Acute-on-chronic type 2 respiratory failure
label: a
answer: yes

Correct answer: a
A 23-year-old female presents to the emergency department with severe abdominal pain. This started 24 hours ago and was generalised in location but has now become markedly worse overnight, alongside migration of the pain to be more focussed in her right iliac fossa. She also reports some associated nausea, but no vomiting.

Which of the following is the next best step in the management of this patient?

Options:
explanation: Once an ectopic pregnancy has been ruled out, this patient's history is strongly suggestive of appendicitis. An abdominal CT scan can be a valuable investigation, particularly in patients with a longer history of pain or a palpable mass in the right iliac fossa (where there may be concern of an appendicular abscess or underlying malignancy), as well as in cases where a previous ultrasound has been indeterminate. However, it is important to remember that appendicitis can also be a clinical diagnosis and many patients go straight to theatre without any confirmatory imaging
name: Computed tomography (CT) abdomen
label: c
answer: no
explanation: An erect CXR can play a role in assessment of patients presenting with acute abdominal pain – if the x-ray demonstrates pneumoperitoneum (air under the diaphragm) this is in keeping with a perforated viscus. However, this finding is not that sensitive - many cases of perforation occur in the absence of any identifiable pneumoperitoneum. There are other more valuable investigations at the stage of the patient's assessment
name: Erect chest x-ray (CXR)
label: b
answer: no
explanation: This would play an important role in determining the severity of any infection, as well as the patient's response to any antibiotic treatment. However, this is a relatively non-specific test and there are other more urgent considerations to be addressed, particularly the patient's pregnancy status
name: Blood tests for inflammatory markers
label: d
answer: no
explanation: In women of child-bearing age a urine pregnancy test should be prioritised to rule out the possibility of an ectopic pregnancy. This is a priority in early stages of patient assessment as the rupture of an ectopic is a surgical emergency, with high levels of mortality if not rapidly identified and treated. Additionally, it would be important to know about a viable pregnancy too, as this may alter the plan for further investigation and treatment of the pain
name: Urinary beta-HCG
label: a
answer: yes
explanation: Once an ectopic pregnancy has been ruled out, this patient's history is strongly suggestive of appendicitis. An abdominal ultrasound is an important diagnostic investigation in appendicitis, particularly if there are concerns regarding radiation dose for the patient, i.e. in pregnancy or childhood/for young adults. However, it is important to remember that appendicitis can also be a clinical diagnosis and many patients go straight to theatre without any confirmatory imaging
name: Abdominal ultrasound
label: e
answer: no

Correct answer: a
A 57-year-old male presents to the Emergency Department with confusion and abdominal pain. He is unable to give any information about his medical history, due to his confusion. Blood tests identify significantly deranged liver function tests.

On examination, what clinical sign may suggest that this is an acute rather than chronic form of liver disease?

Options:
explanation: Ascites can develop in patients with decompensated chronic liver disease and is primarily due to portal hypertension. It presents with abdominal distension, with evidence of shifting dullness, reflecting excess fluid within the abdominal cavity. In acute liver failure these mechanisms have not taken place, so ascites is significantly less common
name: Ascites
label: c
answer: no
explanation: Gynaecomastia develops in chronic liver disease because of impaired testosterone breakdown within the liver, leading to a rise in oestrogen levels (more testosterone is converted to oestrogen) which can stimulate breast tissue development
name: Gynaecomastia
label: b
answer: no
explanation: Splenomegaly can develop in chronic liver disease because of blood pooling in the spleen, secondary to portal hypertension
name: Splenomegaly
label: e
answer: no
explanation: Tender, smooth hepatomegaly suggests an acute liver pathology, with potential causes including acute viral hepatitis, hepatic vein thrombosis (Budd Chiari syndrome) and right heart failure with portal congestion. In chronic liver disease there is usually a degree of liver cirrhosis over time, which causes a reduction in organ size because of fibrosis. The caveat to this is in cases of malignancy where they may be hepatomegaly due to presence of a mass, but this is usually irregular in nature and not classically tender
name: Tender, smooth hepatomegaly
label: a
answer: yes
explanation: Spider naevi (sometimes also called spider angiomas) are a particular form of telangiectasia representing another manifestation of the imbalance of testosterone and oestrogen occurring in chronic liver disease. On examination, spider naevi can be identified as spider-like vessels, which fill from a central arteriole (i.e. when you apply pressure, they blanch (fade), and refill from the centre)
name: Spider naevi
label: d
answer: no

Correct answer: a
A 22-year-old male presents to the emergency department (ED) with severe fatigue and shortness of breath on exertion. On review of symptoms he also reports some associated nausea and a change in bowel habit to darker stools over the past five days.

He was recently diagnosed with ankylosing spondylitis and three weeks ago was started on 500mg twice daily of naproxen from his GP for this reason. He is otherwise well with no regular medications.

What is the most likely diagnosis?

Options:
explanation: Aortitis is a form of vasculitis and is a **rare** but serious complication that can arise **late** in the disease course of ankylosing spondylitis. It can cause severe fatigue and shortness of breath, but is more classically associated with symptoms of fever or chest pain
name: Aortitis
label: d
answer: no
explanation: A recent course of non-steroidal anti-inflammatory (NSAID) medication, alongside a change in bowel habit to dark stool and symptoms of anaemia (fatigue and shortness of breath) is concerning for an upper GI bleed, likely from a peptic ulcer. The dark stool likely represents melaena. NSAIDs are gastric irritants and when prescribed at higher doses or in longer courses, a proton pump inhibitor (PPI) or other gastro-protective medication should be given in addition to prevent this
name: Upper gastrointestinal (GI) bleeding
label: a
answer: yes
explanation: In lower GI bleeding the blood has less transit time in the digestive tract which classically causes it to have a brighter/more red appearance, compared to the darker blood that is seen from bleeding at more proximal locations. In addition, this patient's recent NSAID use is a risk factor for the development of peptic ulcers, which is the likely source of bleeding in this case
name: Lower gastrointestinal bleeding
label: b
answer: no
explanation: Autoimmune conditions such as ankylosing spondylitis are risk factors for other autoimmune conditions (e.g. haemolytic anaemia). A marked anaemia can present with fatigue and shortness of breath - as is the case here from the acute blood loss. However in this instance the history is more acute with a clear identifiable trigger - as well as other signs in the history pointing to GI bleeding (dark stools) - which makes haemolytic anaemia significantly less likely
name: Haemolytic anaemia
label: c
answer: no
explanation: Ankylosing spondylitis can present with marked fatigue, but is not expected to cause shortness of breath, nausea or dark stools. These symptoms should be taken seriously and investigated urgently to identify the cause
name: Symptoms to be expected in ankylosing spondylitis
label: e
answer: no

Correct answer: a
A 30-year-old man presents to his GP complaining of 2 weeks of burning chest pain which he experiences only when laying down in bed at night. His partner has also told him he has notable halitosis in recent months, which he finds embarrassing.

What is the most likely diagnosis?

Options:
explanation: Pain from pericarditis is worse when laying flat, with most patients noting significant relief from positional adjustment to sitting forwards. However, it would not only occur at night, nor would it explain the halitosis
name: Pericarditis
label: e
answer: no
explanation: This patient would be quite young to have developed coronary disease significant enough to cause an MI. In addition, the pain has been ongoing for two weeks and does not sound cardiac in nature (burning rather than crushing pain and no mention of it being related to exertion)
name: Myocardial infarction (MI)
label: d
answer: no
explanation: With a PE, chest pain is expected to be more pleuritic in nature, and not affected by position. Additionally, there is no mention of any risk factors for thrombus formation
name: Pulmonary embolism (PE)
label: b
answer: no
explanation: In PUD, there is often a more direct relationship of the pain to food – worse when hungry/relieved by food for duodenal ulcers, pain exacerbated by eating for gastric ulcers
name: Peptic ulcer disease (PUD)
label: c
answer: no
explanation: Patients with reflux may present with "chest pain" which is burning in nature ("heartburn"). Nocturnal symptoms or symptoms exacerbated by laying down or bending over are classical. Other associated symptoms may include halitosis, dysphagia, globus (the sensation of having a lump in the throat) and an unpleasant taste in the mouth
name: Gastro-oesophageal reflux
label: a
answer: yes

Correct answer: a
A 22-year-old female presents to her GP with a three month history of sharp upper abdominal pain occurring shortly after eating. She has lost 5 kilograms in the last month due to limiting her food intake to minimise her pain. She has also tried to cut out various foods from her diet, including gluten, lactose, spicy foods and fatty foods, but has not managed to identify any triggers.

She was previously referred for an abdominal ultrasound, which has come back with no abnormality detected.

What is the most likely diagnosis?

Options:
explanation: GORD would usually be described as causing more of a burning epigastric/chest pain, rather than a sharp pain. It would also usually be improved with dietary modification such as eating smaller meals or cutting out spicy foods
name: Gastro-oesophageal reflux disease (GORD)
label: c
answer: no
explanation: Pain from gastric ulcers is classically exacerbated by food, and maximal within 30 minutes to an hour of eating a meal. In addition, this pathology is not easily identified on ultrasound, and would usually require an oesophageal-gastroduodenoscopy (OGD)
name: Gastric ulcer
label: a
answer: yes
explanation: In biliary colic the pain is more cramping/"colic-y" in nature and is exacerbated specifically by fatty foods. In addition, patients may have a history of gallstones, most of which can be visualised on ultrasound
name: Biliary colic
label: e
answer: no
explanation: Pain from pancreatitis may radiate to the back and is also frequently accompanied by vomiting. In addition, most patients have a history that can identify a potential trigger, such as known gallstones, alcohol excess or pregnancy etc. (although it can be idiopathic!)
name: Pancreatitis
label: d
answer: no
explanation: Pain from duodenal ulcers is classically exacerbated by hunger and alleviated by food. This is thought to be due to acid levels in the duodenum, which is effectively "diluted" by the presence of food
name: Duodenal ulcer
label: b
answer: no

Correct answer: a