hllj/quesmed huggingface dataset:
An 18-year-old female presents to the GP with a three-year history of intermittent cramping abdominal pain and loose stools. She has decided to seek medical advice on this occasion as last week she noted some streaked fresh red blood, as well as some mucous, in her stool.

She undergoes a colonoscopy with results as follows: there are multiple, small, discrete areas of inflamed mucosa scattered throughout the large bowel, with interspersed regions of normal mucosal appearance. The most significant pathology was identified in the distal ileum, where there were multiple deep and discrete ulcers in a cobblestone appearance.

What is the most likely diagnosis?

Options:
explanation: Colonoscopy, including views of the ileum (which is the most common site of disease) is the definitive diagnostic test for Crohn's disease. Classic findings on colonoscopy include skip lesions and a cobblestone appearance. Other findings may include strictures and fistulae (due to transmural inflammation)
name: Crohn's disease
label: a
answer: yes
explanation: In IBS patients experience cramping abdominal pain, classically associated with bloating and relieved with defecation. Colonoscopy would show no abnormality
name: Irritable bowel syndrome (IBS)
label: d
answer: no
explanation: In UC the disease is isolated only in the large bowel, therefore the ileum would not affected (unless this is representing back-wash ileitis which can happen in patients with pancolitis). Additionally, inflammation in UC occurs in a continuous process – there would be no areas of separating normal bowel (skip lesions)
name: Ulcerative colitis (UC)
label: c
answer: no
explanation: Diverticulitis is a common disease of the older person. It would be rare to have developed in an 18-year-old, particularly to the extent of causing significant symptoms. Diverticular disease would also be easily identified on a colonoscopy. Of note – colonoscopy should not be performed where acute diverticulitis is suspected as this can increase fragility of the bowel and increase risk of perforation during the procedure (guidelines recommend waiting six weeks post-acute episode)
name: Diverticulitis
label: b
answer: no
explanation: Infectious colitis can be the cause of acute gastrointestinal upset, often in those returning from travel abroad. There is no history of other infective symptoms in this stem, such as fever, nor of recent travel. In addition, this patient has been experiencing these symptoms on and off for several years – too long a history for infectious colitis, which is acute in presentation
name: Infectious colitis
label: e
answer: no

Correct answer: a
A 52-year-old man presents to his GP complaining of feeling tired all the time. In recent months, he has been prescribed two courses of antibiotics for urinary tract infections, and has also been seen regarding erectile dysfunction. His past medical history includes hypercholesterolaemia and obesity.

What is the most likely unifying diagnosis?

Options:
explanation: T1DM most commonly develops in younger patients and does not share the same risk factors of obesity and hypercholesterolaemia as T2DM. Instead, it is autoimmune in nature
name: Type 1 diabetes mellitus (T1DM)
label: c
answer: no
explanation: Malignancy can certainly present with fatigue, as well as having the ability to suppress the immune system and make the patient more prone to infections. In addition, late in the course of prostate cancer - and more commonly, following prostate cancer treatments - erectile dysfunction can occur. However this diagnosis is not as common, nor as directly related to his metabolic risk factors, as T2DM
name: Prostate cancer
label: b
answer: no
explanation: Hypercholesterolaemia and obesity are risk factors for the development of T2DM. Common presentations leading to diagnosis include thirst, urinary frequency, propensity to develop urinary tract infections and fatigue. Poor glycaemic control causes damage to the small vessels and nerves, leading to diabetic complications, such as renal and retinal disease, and neuropathy. Erectile dysfunction can often be an early sign of such complications, and is very common in the diabetic population
name: Type 2 diabetes mellitus (T2DM)
label: a
answer: yes
explanation: Bladder cancer commonly presents with dysuria and haematuria, rather than urinary infections. In addition, bladder cancer is strongly related to tobacco exposure/exposure to other chemical carcinogens, such as those used in dyes
name: Bladder cancer
label: d
answer: no
explanation: Recurrent urinary tract infections can increase patients risk of developing CKD, however diabetes is a more likely unifying diagnosis to explain this collection of symptoms
name: Chronic kidney disease (CKD)
label: e
answer: no

Correct answer: a
A 19-year-old man presents to the GP with lethargy. After a period of investigation, a new diagnosis of type 1 diabetes mellitus (T1DM) is made.

What is the most appropriate first line treatment for this patient?

Options:
explanation: T1DM is characterised by an absolute lack of insulin, unlike Type 2 diabetes where there is insulin resistance. For this reason, the insulin that the body is lacking must be replaced directly with subcutaneous insulin injections
name: Insulin
label: a
answer: yes
explanation: Glucagon injections are used in the acute management of severe episodes of hypoglycaemia. It acts to raise sugar levels by triggering conversion of glycogen to glucose in the liver. It is not used to manage hyperglycaemia
name: Glucagon
label: d
answer: no
explanation: A pancreas transplant is not a first line treatment due to the significant risks of both transplants and major surgery in general. It is considered in some patients with T1DM who have severe renal disease (and may be carried out at the same time as a kidney transplant) or those with hypoglycaemic episodes that are unmanageable and pose significant risk to warrant the surgery
name: Pancreatic transplant
label: e
answer: no
explanation: Gliclazide is a sulphonylurea, which acts to enhance secretion of pancreatic insulin. In T1DM where there is an inherent lack of insulin (due to destruction of the secretory beta cells within the pancreas) Gliclazide would be ineffective and is not used - its role is in type 2 diabetes treatment
name: Gliclazide
label: c
answer: no
explanation: Metformin acts to reduce hyperglycaemia by reducing hepatic gluconeogenesis and over time, can help increase insulin sensitivity. It is the first line anti-diabetic medication for adults with type 2 diabetes where lifestyle measures are unable to control sugar levels. In T1DM the fundamental problem is an absolute lack of insulin, so without replacing this directly there would be little or no effect on glycaemic control
name: Metformin
label: b
answer: no

Correct answer: a
A 30-year-old woman attends to see her GP with concerns about her fertility. For the past two years, she has noted increasingly irregular menses. This is in addition to 15 kilograms of weight gain with notable purple striae across her abdomen.

On examination, the patient is noted to have hyperpigmentation in her palmar folds, multiple unexplained bruises across her arms and facial plethora.

What is the most appropriate first line test to investigate the cause of these symptoms?

Options:
explanation: This is an appropriate test for this patient as hypercortisolism can cause hyperglycaemia which may need treatment. However this test would not help to establish the **cause** of these symptoms
name: Fasting blood glucose levels
label: b
answer: no
explanation: This patient has many symptoms pointing towards hypercortisolism. The first step in investigation here would be to confirm this clinical suspicion. An overnight 1mg dexamethasone suppression test is a suitable first line investigation in patients with suspected Cushing's syndrome. 1mg of dexamethasone is given at midnight and cortisol levels are checked at 8 am. An 8 am cortisol result of <50 nmol/L is normal (as the axis should be suppressed) and >50 nmol/L is abnormal. This requires further investigation (to confirm the result and classify into ACTH dependent vs ACTH independent)
name: 1mg overnight dexamethasone suppression test
label: a
answer: yes
explanation: An adrenal CT may be appropriate further into this patients work up, if it is confirmed that she has ACTH-independent hypercortisolism - a solitary secretory adrenal adenoma is the most common cause
name: Computer tomography (CT) of the adrenal glands
label: e
answer: no
explanation: Before checking the ACTH level, it first needs to be established if the patient has hypercortisolism
name: Adrenocorticotrophic hormone (ACTH) level
label: d
answer: no
explanation: A pituitary MRI may be appropriate further into this patient's work up, if it is confirmed that she has ACTH-dependant hypercortisolism (suggestive of pituitary adenoma/**"Cushing's disease"** or an ectopic source of cortisol)
name: Pituitary magnetic resonance imaging (MRI)
label: c
answer: no

Correct answer: a
A 62-year-old Caucasian woman presents to the emergency department with a fracture of her distal radius. This is her third fracture in the last nine months. She has a past medical history of poorly controlled asthma and chronic kidney disease (CKD) stage 3.


Specific blood tests are shown below:


||||
|---------------------------|:-------:|------------------------------|
|Calcium|2.35 mmol/L|2.2 - 2.6|
|Phosphate|1.1 mmol/L|0.8 - 1.5|
|Alkaline Phosphatase (ALP)|63 IU/L|25 - 115|
|Parathyroid Hormone|4.8 pmol/L|1.6 - 8.5|
|Vitamin D|110 nmol/L|>50|



What is the most likely cause of these repeated fractures?

Options:
explanation: Bone mineral deficiency may occur as a late complication of renal failure that is unlikely to occur in someone with CKD stage 3 (GFR 30-59). In addition, her biochemical profile is normal
name: Bone mineral deficiency secondary to chronic kidney disease
label: d
answer: no
explanation: Paget's disease of the bone is a form of metabolic bone disease where there is excessive osteoclastic bone destruction alongside high levels of bone deposition (often with poor integrity). An isolated raised ALP is typically seen on blood testing
name: Paget's disease
label: b
answer: no
explanation: In osteoporosis, all of the above parameters are classically normal - the weakened bone is caused by low bone mineral **density** and atypical bone architecture, rather than any biochemical disturbance. This patient has risk factors for osteoporosis in both her demographic (older, white female, likely post-menopausal) and her history of poorly controlled asthma, which suggests she may have had a significant amount of steroid exposure
name: Osteoporosis
label: a
answer: yes
explanation: In normal metabolism, PTH is released in response to low calcium levels in the blood. In primary hyperparathyroidism excess production of PTH causes recruitment of excess calcium from bone, which can damage the bones integrity. There would be a raised PTH, hypercalcaemia, and resultant hypophosphataemia (via homeostatic control) on blood testing
name: Primary hyperparathyroidism
label: e
answer: no
explanation: Multiple myeloma can damage to bone integrity, however this is through the mechanism of calcium recruitment from bone (via osteoclast activation and bone destruction) and as a result you classically see hypercalcaemia on blood testing
name: Multiple myeloma
label: c
answer: no

Correct answer: a
A 41-year-old male presents to the emergency department with shortness of breath and high-grade fever. He is found to have sepsis secondary to a severe community acquired pneumonia. As part of his management, he is catheterised and noted to have low urine output.


Specific blood tests from today, and three months previously, are found below.


Today:

||||
|---------------------------|:-------:|--------------------|
|Sodium|147 mmol/L|135 - 145|
|Potassium|5.4 mmol/L|3.5 - 5.3|
|Urea|27.1 mmol/L|2.5 - 7.8|
|Creatinine|336 µmol/L|60 - 120|
|eGFR|17 mL/min/1.73m<sup>2</sup>|> 60|


 3 months previously:


||||
|---------------------------|:-------:|--------------------|
|Sodium|139 mmol/L|135 - 145|
|Potassium|4.1 mmol/L|3.5 - 5.3|
|Urea|7.1 mmol/L|2.5 - 7.8|
|Creatinine|104 µmol/L|60 - 120|
|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|


What is the most likely cause of this patient's low urine output?

Options:
explanation: When assessing a patient with low urine output, flushing the catheter to check patency is always a reasonable pragmatic step that should be taken. However, given that some urine is draining from the catheter, it does not appear to be completely blocked. Additionally, in the history there is a clear explanation for why the patient's urine output might be low, making a simple blocked catheter less likely to be responsible
name: Blocked catheter
label: b
answer: no
explanation: Intrinsic or "renal" causes of AKI include iatrogenic insult from nephrotoxic agents (commonly medications or intravenous contrast) or rarer causes such as rhabdomyolysis, interstitial nephritis or vasculitides
name: Intrinsic acute kidney injury
label: e
answer: no
explanation: Post-renal AKI refers to renal impairment secondary to obstruction of the urine drainage system, most commonly from renal stones, a very large prostate, ureteric strictures, or more rarely neurological causes such as an atonic bladder
name: Post-renal acute kidney injury
label: d
answer: no
explanation: This patient likely has an acute kidney injury (AKI) secondary to sepsis and associated hypotension/hypovolaemia. Dividing causes of AKI into pre-renal, renal/intrinsic and post-renal/obstructive causes is a helpful approach to a topic that can otherwise be daunting
name: Pre-renal acute kidney injury
label: a
answer: yes
explanation: In chronic kidney disease, there would be deranged renal function in the previous blood test results. However, here we can see that three months ago, the patient had normal renal function, indicating that this is an acute insult
name: Chronic kidney disease
label: c
answer: no

Correct answer: a
A 25-year-old man has some routine blood tests through his GP when registering as a new patient. He is asymptomatic and has no past medical history. He describes his lifestyle as very healthy, and he works as a personal trainer. His body mass index (BMI) is 31.


His renal function is reported as deranged (see results below):

||||
|---------------------------|:-------:|--------------------|
|Sodium|142 mmol/L|135 - 145|
|Potassium|4.6 mmol/L|3.5 - 5.3|
|Urea|6.9 mmol/L|2.5 - 7.8|
|Creatinine|130 µmol/L|60 - 120|
|eGFR|58 mL/min/1.73m<sup>2</sup>|> 60|



What is the most likely explanation for these results?

Options:
explanation: Although the patient does work in fitness, there is no particular stressor identified in the history that would have caused severe enough dehydration to lead to AKI
name: Acute Kidney Injury (AKI) secondary to dehydration
label: e
answer: no
explanation: This would correspond to an eGFR or 60-89
name: Chronic Kidney Disease Stage 2
label: c
answer: no
explanation: The calculation for GFR is based on a patients gender, age and creatinine. Creatinine is ultimately a waste product from muscle turnover, so higher levels would naturally be found in people with increased muscle mass. This man has a raised BMI but describes a healthy lifestyle and works as a personal trainer - this should highlight that he is likely to be very muscular which is the most likely cause of his raised Creatinine. 
name: Increased muscle mass
label: a
answer: yes
explanation: CKD stage 1 is defined as a GFR of >90 with evidence of renal disease, either from a biopsy result, imaging, or urine testing (haematuria/ proteinuria). This patient is asymptomatic and it is unlikely that it has any underlying renal disease
name: Chronic Kidney Disease Stage 1
label: b
answer: no
explanation: The GFR listed in the patient's results _would_ correspond to CKD stage 3(a), providing the result was accurate. As discussed in the explanation, there are limitations to interpreting these results in this patient context. At present, the **most likely** explanation is due to patient factors rather than a disease process
name: Chronic Kidney Disease Stage 3
label: d
answer: no

Correct answer: a
A 35-year-old woman presents to her GP with no improvement in symptoms following a three day course of nitrofurantoin for a urinary tract infection (UTI). She has ongoing dysuria and urinary frequency. She is allergic to penicillin (rash).

A urine culture result is now available:

Moderate growth of E. Coli

- Amoxicillin - R
- Nitrofurantoin - R
- Cefalexin - S
- Co-amoxiclav - S
- Trimethoprim - S
- Ciprofloxacin - R

NB: R = Resistant and S = Sensitive

What is the most appropriate antibiotic choice to treat this woman's UTI?

Options:
explanation: The E. Coli grown is resistant to nitrofurantoin, which explains why the first course did not resolve the patient's symptoms. Extending the course will not alter the resistance and will not benefit the patient
name: Extend course of nitrofurantoin to 7 days duration
label: b
answer: no
explanation: Trimethoprim is the only sensitive result for this E. Coli that would be suitable for use alongside a penicillin allergy
name: Trimethoprim
label: a
answer: yes
explanation: Although the E. Coli is sensitive to the co-amoxiclav, this woman has an allergy to penicillin, so this would not be an appropriate choice
name: Co-amoxiclav
label: e
answer: no
explanation: The E. Coli grown is resistant to ciprofloxacin, so this would not be an appropriate choice
name: Ciprofloxacin
label: d
answer: no
explanation: Although the E. Coli is sensitive to the cefalexin, this woman has an allergy to penicillin. Cephalosporin antibiotics still confer risk of cross-reactivity in patients with penicillin allergy and so should be avoided where there is another reasonable option
name: Cefalexin
label: c
answer: no

Correct answer: a
A 25-year-old female presents to the Emergency Department feeling generally unwell, with nausea, vomiting and a high fever. She has no significant past medical history, but completed a 3 day course of antibiotics (trimethoprim) for a urinary tract infection yesterday.

On examination her abdomen is soft, but there is significant tenderness in her left flank.

What is the most likely diagnosis?

Options:
explanation: Muscular back pain would not be expected to cause infective symptoms, such as a high fever
name: Muscular back pain
label: c
answer: no
explanation: Although kidney stones can act as a focus for infection, they more commonly present with **pain as the primary symptom**. The pain is characteristically very severe and radiates in a "loin to groin" pattern
name: Kidney stone
label: b
answer: no
explanation: This patient has recently been treated for a urinary tract infection. This treatment was likely insufficient, and she has now gone on to develop pyelonephritis - an upper urinary tract infection that involves infection/ inflammation of the kidney itself. This commonly presents with nausea, vomiting, fever and flank pain
name: Urinary tract infection
label: d
answer: no
explanation: Pyelonephritis is an upper urinary tract infection involving infection/ inflammation of the kidney itself. This commonly presents with nausea, vomiting, fever and flank pain - this patient has all of the classic symptoms. There is also the additional clue of recent treatment for UTI via the GP - this treatment was likely insufficient, and the infection has now tracked up the urinary tract to the kidney
name: Pyelonephritis
label: a
answer: yes
explanation: A psoas abscess would also present with flank pain and fever, however, this patient has none of the classic risk factors (underlying immunosuppression, intravenous drug use, recent local surgery or trauma). Additionally, the recent history of urinary tract infection is more suggestive of pyelonephritis. A psoas abscess may also present with a limp, or pain that is exacerbated by movement of the ipsilateral limb
name: Psoas abscess
label: e
answer: no

Correct answer: a
A 59-year-old woman presents to the GP with two weeks of stiffness in her shoulders and hips which she describes as worse in the morning. Initially, she recalls thinking she had the flu, as she had myalgia, a low-grade fever and significant fatigue. However, these symptoms have not improved, and she is now anxious that there may be something more sinister going on. The stiffness and muscle pain is so severe she can no longer stand from sitting independently, or open the top cupboards in her kitchen.

What is the most likely diagnosis?

Options:
explanation: Pain in fibromyalgia is generally more diffuse than the pain experienced in polymyalgia rheumatica. In addition, there is not usually the characteristic shoulder stiffness
name: Fibromyalgia
label: e
answer: no
explanation: Osteoarthritis is not an inflammatory condition. The associated stiffness does not follow this classic "worse in the morning for more than 1 hour" pattern - there still tends to be morning stiffness, but this resolves more quickly, and the pain is often described as being worse after periods of physical activity. Additionally, this patient has had a relatively acute onset of these symptoms, whereas symptoms related to OA tend to be more insidious in onset over many months - years
name: Osteoarthritis (OA)
label: b
answer: no
explanation: Adrenal insufficiency is associated with long term steroid use. PMR is treated with steroids, and therefore, these patients are at high risk of developing insufficiency during periods of intercurrent illness. However, at this point, the patient is yet to be diagnosed and commenced on any treatment
name: Adrenal insufficiency
label: c
answer: no
explanation: PMR most commonly occurs in women over 50. The most characteristic symptoms include shoulder and hip girdle **stiffness and pain** - both of which can affect patients ability to do their daily activities - and which classically inhibit a patient from standing from a seated position. Other common features of the condition which are mentioned in this stem include fatigue and low-grade fever. PMR is a systemic inflammatory condition - the associated stiffness is worse in the morning (lasting for 1 hour or more) - as is the case for most inflammatory rheumatological conditions
name: Polymyalgia rheumatica (PMR)
label: a
answer: yes
explanation: GCA is an _associated condition_ often co-occurring in patients with polymyalgia. It presents with unilateral symptoms of jaw claudication, headache and scalp tenderness which can progress to visual loss if not identified and treated
name: Giant cell arteritis (GCA)
label: d
answer: no

Correct answer: a