hllj/quesmed huggingface dataset:
A 50-year-old man presents with a 7-month history of a persistent dry cough and exertional dyspnoea. He has no chest pain, fever, or haemoptysis. He is a non-smoker. He has had occupational exposure to asbestos.

On lung auscultation, there are fine inspiratory crackles.

High-resolution CT shows a honeycomb pattern in the lungs.

What is the most appropriate initial diagnostic test for confirming the diagnosis in this patient?

Options:
explanation: Bronchoscopy allows for direct visualisation of the airways and collection of samples. It is often used to evaluate airway abnormalities, retrieve specimens for culture or biopsy, and assess for conditions like lung cancer.
name: Bronchoscopy
label: c
answer: no
explanation: An ABG is not typically the initial diagnostic test for pulmonary fibrosis.
name: ABG
label: d
answer: no
explanation: Echocardiography is a diagnostic tool for assessing heart function and structural abnormalities.
name: Echocardiography
label: e
answer: no
explanation: Pulmonary function tests (PFTs), including spirometry and lung volumes, are valuable tools for assessing lung function and identifying restrictive lung diseases, including pulmonary fibrosis. This patient's symptoms and radiological findings suggest the presence of pulmonary fibrosis. PFTs can help confirm the diagnosis by revealing restrictive lung patterns with decreased lung volumes and impaired gas exchange.
name: Pulmonary function tests
label: a
answer: yes
explanation: Sputum culture is typically used to identify respiratory infections, such as pneumonia. The symptoms and radiological findings here are more indicative of a chronic, non-infectious condition like pulmonary fibrosis.
name: Sputum culture
label: b
answer: no

Correct answer: a
A 25-year-old female presents with a 3-day history of abnormal vaginal discharge. She describes the discharge as thin and watery. She does not describe itchiness.

Microscopic examination of the discharge reveals the presence of clue cells.

What is the most appropriate management for this patient?

Options:
explanation: This presentation is highly suggestive of bacterial vaginosis (BV). Oral metronidazole is the first-line treatment for this condition.
name: Oral metronidazole
label: a
answer: yes
explanation: IM ceftriaxone is the recommended treatment for gonorrhoea - a sexually transmitted infection caused by the bacterium *Neisseria gonorrhoeae*. When viewed under microscopy, *Neisseria gonorrhoea* appears as gram-negative diplococci.
name: IM ceftriaxone
label: c
answer: no
explanation: Given the clinical presentation and presence of clue cells, this is unlikely to be a normal physiological variation. Appropriate treatment for suspected BV is indicated.
name: No treatment
label: e
answer: no
explanation: Hormonal therapy with progesterone is not indicated for the treatment of vaginal discharge.
name: Intravaginal progesterone therapy
label: d
answer: no
explanation: This treatment is used for vaginal yeast infections. This presents with symptoms such as itching and the presence of white, cottage cheese-like discharge.
name: Topical antifungal cream
label: b
answer: no

Correct answer: a
A 45-year-old man presents to his GP expressing concerns that he has swollen breasts. He has no other symptoms. His BMI is 23.

He has a past medical history of ascites and hypertension.

He is currently taking furosemide and spironolactone.

Which of the following is the most likely cause of this patient's symptoms?

Options:
explanation: Polycystic ovary syndrome is a condition that primarily affects females and is characterised by hormonal imbalances, ovarian cysts and features such as irregular menstrual cycles, hirsutism and acne.
name: Polycystic ovary syndrome
label: d
answer: no
explanation: Testicular cancer typically presents with masses in the testicles or pain and discomfort.
name: Testicular cancer
label: b
answer: no
explanation: Pseudogynecomastia refers to fat deposits in the breast area without glandular breast tissue enlargement. It can be caused by obesity, but this patient's BMI is 23, so obesity is not a likely cause of his breast swelling.
name: Pseudogynecomastia
label: e
answer: no
explanation: Gynaecomastia is the development of enlarged breast tissue in males. Spironolactone can cause gynecomastia as a side effect.
name: Gynaecomastia due to spironolactone
label: a
answer: yes
explanation: Gynaecomastia is not a common or specific feature of hypothyroidism. Given this patient's BMI of 23, hypothyroidism is quite unlikely.
name: Hypothyroidism
label: c
answer: no

Correct answer: a
A 38-year-old woman presents with a 2-month history of hoarseness and a rapidly enlarging neck lump.

Core biopsy results reveal the lump is a well-differentiated thyroid cancer.

Which of the following is the most likely diagnosis?

Options:
explanation: Hurthle cell thyroid cancer is a subtype of follicular thyroid cancer. A rapidly enlarging neck lump is less typical for this subtype.
name: Hurthle cell thyroid cancer
label: e
answer: no
explanation: Papillary thyroid cancer is the most common type of well-differentiated thyroid cancer. It is more common in women and is more common in people in their 30s and 40s.
name: Papillary thyroid cancer
label: a
answer: yes
explanation: Anaplastic thyroid cancer is a poorly differentiated and highly aggressive type of thyroid cancer.
name: Anaplastic thyroid cancer
label: d
answer: no
explanation: Medullary thyroid cancer is a type of thyroid cancer arising from the parafollicular C cells and typically does not present with hoarseness.
name: Medullary thyroid cancer
label: c
answer: no
explanation: Follicular thyroid cancer is another type of well-differentiated thyroid cancer. It is more common in people aged between 40 and 60.
name: Follicular thyroid cancer
label: b
answer: no

Correct answer: a
A 3-year-old girl presents with a rash, red tongue and a fever lasting for the past 6 days.

What is the most appropriate investigation to assess for a potential complication of the likely diagnosis?

Options:
explanation: A stool culture can be used to diagnose gastrointestinal infections. It is not relevant for assessing complications of Kawasaki disease.
name: Stool culture
label: e
answer: no
explanation: An FBC can provide information about the presence of infection and inflammation but is not a primary investigation to assess for coronary artery aneurysms in Kawasaki disease.
name: Full blood count (FBC)
label: b
answer: no
explanation: A throat swab can be used to identify streptococcal throat infections such as streptococcal pharyngitis. Whilst streptococcal infections can cause a fever and red throat, this presentation is more consistent with Kawasaki disease.
name: Throat swab
label: c
answer: no
explanation: These symptoms are concerning for Kawasaki disease - an inflammatory condition that can affect the blood vessels, including the coronary arteries. One of the potential complications of this disease is coronary artery aneurysms. An echocardiogram is the most appropriate investigation to assess for this complication.
name: Echocardiogram
label: a
answer: yes
explanation: A chest X-ray is not the primary investigation to assess for coronary artery aneurysms, which are a specific concern in Kawasaki disease.
name: Chest X-ray
label: d
answer: no

Correct answer: a
A 35-year-old male presents to his general practitioner with pink lesions on his arm that have been present for the past 2 weeks. The lesions are not painful but are itchy. He tells the GP that he has noticed similar lesions on the trunk of his 3-year-old son.

**A photo of the lesions is shown below:**

[lightgallery]

What organism is the most likely cause of this condition?

Options:
explanation: *Staphylococcus aureus* is a bacterial pathogen which does not cause molluscum contagiosum.
name: *Staphylococcus aureus*
label: b
answer: no
explanation: HPV can cause various warts and skin lesions but does not cause molluscum contagiosum.
name: Human Papillomavirus (HPV)
label: e
answer: no
explanation: This presentation is consistent with molluscum contagiosum - a viral skin infection caused by the poxvirus. It typically presents with small, dome-shaped, pink or flesh-coloured lesions.
name: Poxvirus
label: a
answer: yes
explanation: *Streptococcus pyogenes* can cause streptococcal skin infections. It is not associated with molluscum contagiosum.
name: *Streptococcus pyogenes*
label: d
answer: no
explanation: HSV typically causes cold sores and genital herpes.
name: Herpes simplex virus (HSV)
label: c
answer: no

Correct answer: a
A 33-year-old woman presents with central chest pain. The pain is worse when she breathes in and when she is lying down.

She has no significant past medical history.

**Her ECG is shown below:**

[lightgallery]

Which is the most specific ECG finding associated with the underlying diagnosis?

Options:
explanation: Wellens syndrome is associated with critical stenosis of the left anterior descending coronary artery. Wellens syndrome patterns on ECG are deeply inverted T-waves in leads V2-V3.
name: Wellens syndrome pattern
label: e
answer: no
explanation: This is seen in pericarditis but is not the most specific ECG finding.
name: PR segment depression
label: c
answer: no
explanation: This is not associated with pericarditis but may be seen in other cardiac conditions or as a side effect of medications.
name: Prolonged QT interval
label: b
answer: no
explanation: Diffuse concave ST elevation is the most specific ECG finding associated with pericarditis. The widespread, concave ST segment elevation is typically seen in multiple leads on the ECG.
name: Diffuse concave ST elevation
label: a
answer: yes
explanation: This is more indicative of myocardial infarction and chronic myocardial damage.
name: Pathological Q waves
label: d
answer: no

Correct answer: a
A 45-year-old male presents to the emergency department with a severe occipital headache that started 3 hours ago. He has been experiencing vomiting but reports no sensitivity to light or neck stiffness.

He has no history of head trauma.

What is the most appropriate initial management option for this patient?

Options:
explanation: A lumbar puncture may be performed if the CT head scan is inconclusive, but clinical suspicion for the subarachnoid remains high. Lumbar punctures are also helpful when patients present a while after headache onset, as the breakdown of red blood cells in the CSF can be picked up as xanthochromia.
name: Lumbar puncture
label: c
answer: no
explanation: This may help alleviate the headache, but the first priority should be to rule out serious causes of the sudden headache.
name: Administer pain relief
label: d
answer: no
explanation: This presentation raises concern for a potential subarachnoid haemorrhage, which is a medical emergency. A non-contrast CT head scan is the gold standard for ruling out a subarachnoid haemorrhage, especially considering this patient has presented within 6 hours of headache onset (CT head is almost 100% sensitive and specific for subarachnoid haemorrhages if performed within 6 hours of headache onset). It can quickly detect blood in the subarachnoid space.
name: Non-contrast CT head scan
label: a
answer: yes
explanation: This may help to relieve the patient's nausea and vomiting, but it should not replace investigation with a CT head scan.
name: Adminster an antiemetric
label: e
answer: no
explanation: Waiting for reassessment is inappropriate in this case as it may delay the diagnosis and treatment of a potentially life-threatening condition.
name: Observation with reassessment
label: b
answer: no

Correct answer: a
A 72-year-old man who is an inpatient on a medical ward has become confused over the last 2 days.

He is agitated and can be seen walking around the ward, looking for his deceased wife.

Which of the following most likely explains this patient's condition?

Options:
explanation: Delirium is characterised by acute and fluctuating confusion, disorientation, agitation and impaired attention and cognition. In this case, the patient's abrupt onset of confusion and agitation suggests delirium, which is often reversible with appropriate management.
name: Delirium
label: a
answer: yes
explanation: Schizophrenia is a chronic psychiatric disorder characterised by hallucinations, delusions, disorganised thinking, and impaired social functioning. This patient's presentation is not typical of schizophrenia.
name: Schizophrenia
label: d
answer: no
explanation: Dementia can also cause confusion and cognitive impairment but has a more gradual onset.
name: Dementia
label: b
answer: no
explanation: Depression can lead to cognitive changes, including difficulty concentrating. It is less likely to cause acute agitation and confusion.
name: Depression
label: c
answer: no
explanation: Anxiety disorders can lead to heightened states of anxiety, restlessness and excessive worry, but this patient's presentation is more consistent with delirium.
name: Anxiety disorder
label: e
answer: no

Correct answer: a
A 18-year old woman visits her GP feeling 'tired all the time'. She has also had occasional diarrhoea and weight loss, but is not experiencing any other symptoms of note. Routine investigations show:


||||
|--------------|:-------:|---------------|
|Haemoglobin|101   g/L|(M) 130 - 170, (F) 115 - 155|
|Mean Cell Volume (MCV)|68.9 fL|80 - 96|
|Serum Vitamin B12|100 ng/L|160 - 925|
|Serum Folate|5.2 μg/L|(3 - 15|
|Ferritin|7 μg/L|12 - 200|
|Thyroid Stimulating Hormone|3.32 mU/L|0.3 - 4.2|
|Total IgA|0.23 g/L|0.8 - 4|


  * Serum IgA anti-tissue transglutaminase - NEGATIVE

What is the most likely diagnosis?

Options:
explanation: Diarrhoea, weight loss, and iron deficiency anaemia are all suggestive of a diagnosis of coeliac disease, due to malabsorption. This also explains the slightly low serum vitamin B12 level. While the IgA anti-TTG is the most specific blood marker for coeliac disease, it is unreliable in the case of IgA deficiency (as seen in this case). Measurement of IgG antibodies is necessary in this case. The gold standard diagnostic test for coeliac disease is a duodenal biopsy.
name: Coeliac disease
label: a
answer: yes
explanation: Irritable bowel syndrome is common and could account for the occasional diarrhoea, but not the iron/B12 deficiency or weight loss.
name: Irritable bowel syndrome
label: e
answer: no
explanation: A change in bowel habit and iron deficiency anaemia does raise suspicions for colorectal carcinoma, however this is not the most likely diagnosis in an 18-year-old patient.
name: Colorectal carcinoma
label: c
answer: no
explanation: Menorrhagia is a common cause of iron deficiency anaemia in the young female population, however a history of heavy periods has not been provided. Menorrhagia would also not account for the weight loss, diarrhoea, and B12 deficiency.
name: Menorrhagia
label: b
answer: no
explanation: A change in bowel habit, weight loss, and iron and B12 deficiency do raise suspicions for inflammatory bowel disease and this should remain within the differential. However, this is not the most likely diagnosis given an equivocal test for coeliac disease and the absence of other symptoms (bloody stools, extra-intestinal manifestations, severe diarrhoea).
name: Inflammatory bowel disease
label: d
answer: no

Correct answer: a


Learning point: Coeliac disease can present with fatigue, diarrhoea, weight loss, and iron deficiency anaemia due to malabsorption.
A 57-year-old man with a diagnosis of cirrhosis due to alcoholic liver disease is brought to ED by his wife, who is concerned that he is more confused than normal. He has been drinking 8 cans of beer a day for the past 7 years.

On examination, he has multiple spider naevi and asterixis is present. His abdomen is tense, distended and tender.

Observations:

* Heart rate: 98 beats/minute
* Blood pressure: 97/68 mmHg
* Respiratory rate: 18 breaths/minute
* Temperature: 38.2 degrees
* Oxygen saturations (room air): 96%
* GCS: 13/15

What is the most important investigation to perform?

Options:
explanation: A 'confusion screen' - i.e. blood tests measuring B12, folate, ferritin, and potentially a head CT, are important investigations in patients presenting with altered mental status. However, the most important diagnosis to exclude in this case is SBP, so abdominal paracentesis is the next most appropriate investigation.
name: Confusion screen
label: c
answer: no
explanation: The combination of a fever and altered GCS do raise suspicions for meningitis, however the patient is encephalopathic (as evidenced by asterixis) and there are no features of meningism mentioned. The most likely source of infection is spontaneous bacterial peritonitis, which must be investigated for using a diagnostic paracentesis.
name: Lumbar puncture
label: d
answer: no
explanation: Ammonia has very limited utility in liver disease. This patient is clinically encephalopathic, so measuring the ammonia does not add any additional information.
name: Serum ammonia level
label: b
answer: no
explanation: Any patient presenting with ascites in hospital should have this 'tapped' to check for spontaneous bacterial peritonitis, which has an extremely high mortality rate. The degree of suspicion for SBP in this case is increased by the fact the patient is febrile and has a tender abdomen. A white cell count of >250 with 90% neutrophils would confirm the diagnosis.
name: Diagnostic paracentesis
label: a
answer: yes
explanation: This will add limited information in the acute setting. Once the patient is stable, an ultrasound may help assess the liver and volume of ascites, however it is not the next most appropriate investigation.
name: Ultrasound abdomen
label: e
answer: no

Correct answer: a


Learning point: Spontaneous bacterial peritonitis (SBP) is a bacterial infection of the ascitic fluid in patients with liver disease, and diagnostic paracentesis is performed to analyze the fluid for elevated white blood cell count and the presence of bacteria, confirming the diagnosis and guiding treatment.
A 53-year-old woman is referred on the two-week-wait pathway for an oesophagogastroduodenoscopy (OGD) for persistent reflux symptoms, which have not responded to lifestyle modification.

The OGD reports appearances consistent with a sliding hiatus hernia, with no concerns for malignancy.

What is the next most appropriate step?

Options:
explanation: A contrast study may help to clarify the diagnosis and show strictures or dysmotility, but is not indicated as the OGD has showed a simple sliding hernia.
name: Arrange for a barium contrast study
label: e
answer: no
explanation: Initiating a proton pump inhibitor (e.g. Omeprazole) would be the most appropriate next step, as the patient has already tried conservative management for her reflux symptoms. PPIs provide symptomatic relief and help prevent complications e.g. stricturing and Barrett's oesophagus.
name: Prescribe a proton pump inhibitor
label: a
answer: yes
explanation: Oesophageal manometry studies may help to provide more information regarding oesophageal manometry, but would usually take place if surgery is being considered. In the first instance, medical management should be attempted.
name: Arrange oesophageal manometry studies
label: d
answer: no
explanation: A surgical procedure may be required if symptoms are refractory to medical management, but this should be tried first.
name: Refer for Nissen fundoplication
label: b
answer: no
explanation: A Heller cardiomyotomy is used in the management of achalasia, not hiatus hernias.
name: Refer for Heller cardiomyotomy
label: c
answer: no

Correct answer: a


Learning point: A sliding hiatus hernia occurs when part of the stomach pushes up through the diaphragm into the chest, and PPIs (proton pump inhibitors) are often used to reduce stomach acid, alleviating symptoms such as heartburn and reflux associated with this condition.
A patient admitted with acute severe ulcerative colitis has not responded to a prolonged course of intravenous hydrocortisone. Treatment with biologics is being considered.

Which of the following investigations should be undertaken before biologics can be administered?

Options:
explanation: Anti-infliximab antibodies can be generated in response to therapy with the drug. Measuring these may be indicated if patients have an inadequate response to infliximab. They are not routinely measured at the start of therapy.
name: Anti-infliximab antibodies
label: e
answer: no
explanation: The majority of the adult population have been infected with EBV. Serology is only useful if an acute infection is suspected. Excluding latent TB is more important.
name: Epstein Barr virus serology
label: b
answer: no
explanation: Reactivation of latent TB infection is a concern with the use of biologics such as infliximab. Screening with an IGRA (e.g. the Quantiferon test) should be carried out. This is supported by NICE guidelines and the BNF.
name: Tuberculosis inteferon gamma release assay (IGRA)
label: a
answer: yes
explanation: Hepatitis A virus causes an acute hepatitis. If there is no suspicion of infection, testing is not appropriate. Hepatitis B virus should be tested for, however, as biologics can cause virus reactivation (due to immunosuppression).
name: Hepatitis A virus serology
label: c
answer: no
explanation: While it is useful to confirm that patients receiving biologics have received all of their routine immunisations, testing for mumps immunity is not routine before starting biologics.
name: Mumps antibodies
label: d
answer: no

Correct answer: a


Learning point: A chest X-ray is recommended before starting biologic therapy to check for active tuberculosis, as these medications suppress the immune system and can increase the risk of latent TB reactivation and severe infection.
A 75-year-old man is admitted to hospital from a nursing home as his carers think she is significantly more confused than normal. She has a history of Alzheimer's disease and multiple strokes.

On examination, the patient is agitated and is shouting. There is no obvious focal neurology and the patient is moving all four limbs. The patient resists examination of the suprapubic region, pushing the doctor's hands away forcefully.

What is the next most appropriate investigation?

Options:
explanation: The patient likely has hyperactive delirium. Urinary retention is a common cause of delirium in the elderly. Resistance of examination of the suprapubic region suggests there may be a tender, enlarged bladder. A bladder scan will confirm whether this is the case.
name: Bedside bladder scan
label: a
answer: yes
explanation: An abdominal x-ray may show faecal loading/constipation, another common cause of hyperactive delirium in older patients. However, this would not be the most appropriate next investigation as a bladder scan can be done at the bedside.
name: X-ray abdomen
label: b
answer: no
explanation: A CT head may be carried out given that this patient is acutely confused, however, considering the history and examination findings, it is not the next most appropriate investigation. A bedside bladder scan can be done extremely quickly and may reveal the underlying cause for the delirium.
name: CT head
label: e
answer: no
explanation: If a bladder scan does not demonstrate retention and the patient is still resisting examination of the abdomen (suggesting pain), a CT abdomen may be required. This is not currently the case.
name: CT abdomen (with contrast)
label: d
answer: no
explanation: This would be a useful investigation to look for renal calculi or hydronephrosis. The history is not suggestive of this at present. The most pressing issue is investigating the cause of the patient's hyperactive delirium, which can be done in the first instance with a bladder scan.
name: CT Kidneys, Ureters, Bladder (non-contrast)
label: c
answer: no

Correct answer: a


Learning point: A bladder scan is a non-invasive tool used to assess urinary retention in the elderly by measuring post-void residual urine volume to determine if there is incomplete bladder emptying.