hllj/quesmed huggingface dataset:
A 26-year-old female presents to A&E with abdominal pain that began 2 days ago. She says it began as an ache but has become gradually more severe. There is also pain in the tip of her shoulder. She denies any urinary frequency or dysuria. Her bowels are opening normally.

On examination, her heart rate is 94 and her blood pressure 100/72. She appears clammy and pale.

Which of the following is the most important initial investigation?

Options:
explanation: In a female patient presenting with abdominal pain, it would be important to first do a pregnancy test to rule out ectopic pregnancy as a cause.
name: CT abdomen
label: e
answer: no
explanation: When a female presents with abdominal pain, it is important to rule out an ectopic pregnancy. A pregnancy test is essential to rule this out. An ectopic pregnancy is a pregnancy that implants outside the uterus, most commonly in the fallopian tube. It presents as pelvic pain that can radiate to the shoulder, abnormal vaginal bleeding and haemodynamic instability. All of these features are seen in this patient.
name: Urine hCG
label: a
answer: yes
explanation: This may be a useful investigation if you suspected this patient’s abdominal pain was caused by a bowel obstruction. However, as this patient's bowels have been opening normally, a bowel obstruction is less likely.
name: Abdominal X ray
label: b
answer: no
explanation: In a female patient presenting with abdominal pain it is important to rule out ectopic pregnancy as an initial cause, so a urine hCG would be the most important initial investigation.
name: Ultrasound Abdomen
label: c
answer: no
explanation: It may be useful to do a urine dipstick for this patient if you suspected cystitis. However, this patient does not have any urinary frequency or dysuria, so cystitis is less likely. The right iliac fossa pain that radiates to the shoulder tip points us in the direction of an ectopic pregnancy, therefore a urine hCG would be the best initial investigation.
name: Urine dipstick
label: d
answer: no

Correct answer: a
A 31-year-old female presents to A&E with severe lower abdominal pain that began earlier in the day. She describes it as a colicky pain. She has begun vomiting and noticed small amounts of blood in her urine.  She has a past medical history of gout, hypertension, hypothyroidism and GORD.

You suspect she has renal stones.

Which of the following is the most likely composition of this patient's renal stone?

Options:
explanation: These type of renal stones are radio-lucent, meaning they are often not visible on X-ray, ultrasound or CT scans.
name: Indinavir
label: d
answer: no
explanation: This is the correct answer. The patient has severe intermittent loin to groin pain, which suggests a diagnosis of renal stones. A past medical history of gout makes uric acid the most likely composition of these stones.
name: Uric acid
label: a
answer: yes
explanation: This type of renal stone occurs in patients with homocystinuria, an autosomal recessive inherited disorder that predisposes individuals to recurrent renal stones and urinary tract infections. This patient is more likely to have uric acid renal stones, as they have a past medical history of gout.
name: Cysteine
label: b
answer: no
explanation: This type of renal stone often results in large, staghorn calculi. They are more likely to occur if the patient has recurrent upper urinary tract infections.
name: Struvite
label: c
answer: no
explanation: Magnesium is not a significant component of most renal stones.
name: Magnesium
label: e
answer: no

Correct answer: a
An 18-year-old female presents to the GP with an increased urinary frequency for the past 10 days. She also reports some dysuria and pain in the suprapubic region. A urine dipstick is positive for leucocytes and nitrites.

Her observations are all within the normal range, and she is keen to get back to her university studies as soon as possible.

Which of the following is the most appropriate antimicrobial management?

Options:
explanation: This would not be a first-choice antimicrobial for cystitis. Instead, a course of trimethoprim would be the most appropriate management.
name: Clindamycin
label: d
answer: no
explanation: This patient has typical symptoms of cystitis. Intravenous cephalosporin would be an appropriate management option if the patent had pyelonephritis. This would be suspected if they presented with pyrexia and loin or flank tenderness.
name: IV cephalosporin
label: b
answer: no
explanation: This would not be first line in a presentation of cystitis. You may choose to use pivmecillinam as a second choice antibiotic if there is no improvement with a first choice antimicrobial or if a first choice isn’t suitable.
name: Pivmecillinam
label: c
answer: no
explanation: This would not be a first-choice antimicrobial for cystitis. You may choose to use fosfomycin as a second choice antimicrobial if trimethoprim were ineffective.
name: Fosfomycin
label: e
answer: no
explanation: This is the antibiotic treatment for suspected cystitis. This patient presents with urinary frequency, dysuria, urgency, foul-smelling urine, and suprapubic pain, all consistent with cystitis. Trimethoprim is therefore the most appropriate management option.
name: Trimethoprim
label: a
answer: yes

Correct answer: a
A 59-year-old male is found to have hyperkalaemia on a routine blood test. He has a past medical history of type 2 diabetes mellitus, hypertension and generalized anxiety disorder.

Which of the following medications is most likely to be causing his hyperkalaemia?

Options:
explanation: Nicorandil is used as a vasodilatory drug in the treatment of angina. It does not cause hyperkalaemia but can, however, have a range of other side effects including: headaches, flushing, and skin and eye ulceration.
name: Nicorandil
label: b
answer: no
explanation: ACE inhibitors work by inhibiting the conversion of angiotensin I to angiotensin II, preventing the secretion of aldosterone. Aldosterone usually acts to cause sodium reabsorption and consequently, secretion of potassium into the urine. Inhibition of this process through an ACE inhibitor can therefore lead to hyperkalaemia in some patients. Other side effects of ACE inhibitors to be aware of include: cough, angioedema, and first-dose hypotension.
name: Ramipril
label: a
answer: yes
explanation: Statins work by inhibiting the actions of HMG-CoA reductase in the liver, which is an enzyme involved in cholesterol synthesis. Statins do not commonly cause hyperkalaemia. However, they can cause myopathy, and liver impairment and they can increase the risk of intracerebral haemorrhage in some patients.
name: Atorvastatin
label: e
answer: no
explanation: Loop diuretics work by inhibiting the Na-K-Cl cotransporter in the loop of Henle, which reduces the absorption of NaCl. This means that loop diuretics cause hypokalaemia, not hyperkalaemia.
name: Furosemide
label: c
answer: no
explanation: Beta-blockers such as propranolol can cause a number of side effects including bronchospasm, fatigue, sleep disturbances, and erectile dysfunction. They do not commonly cause hyperkalaemia.
name: Propranolol
label: d
answer: no

Correct answer: a
A 55-year-old female attends an oncology clinic appointment for a discussion of her newly diagnosed bladder cancer. She is keen to explore surgical treatment options.

Which of the following structures form the trigone of the bladder?

Options:
explanation: This is incorrect. The trigone of the bladder is formed of two ureteric orifices and the internal urethral meatus.
name: Ureteric orifice, internal urethral sphincter and internal urethral meatus
label: c
answer: no
explanation: This is incorrect. The trigone of the bladder is formed of two ureteric orifices and the internal urethral meatus.
name: Ureteric orifice and internal urethral sphincter
label: e
answer: no
explanation: The trigone is located on the posterior wall of the bladder. It is a triangle shape and is defined by three structures: two ureteric orifices and the internal urethral meatus. It is the least mobile part of the bladder.
name: Two ureteric orifices and the internal urethral meatus
label: a
answer: yes
explanation: This is incorrect. The trigone of the bladder is formed of two ureteric orifices and the internal urethral meatus.
name: Ureteric orifice, pubic symphysis, and internal urethral meatus
label: d
answer: no
explanation: This is incorrect. The Trigone of the bladder is formed of two ureteric orifices and the internal urethral meatus.
name: Fundus and two inferolateral surfaces
label: b
answer: no

Correct answer: a
A 64-year-old female presents to the GP with a headache just lateral to her left eye that began a day ago. She has also noticed some pain on chewing food and scalp tenderness on the left-hand side. She reports normal vision in both eyes.

Which of the following can definitively diagnose the most likely diagnosis?

Options:
explanation: A temporal artery biopsy is the definitive investigation for giant cell arteritis. A temporal headache, scalp tenderness, and jaw claudication are strongly indicative of giant cell arteritis. Steroid treatment should be commenced promptly to prevent visual loss.
name: Temporal artery biopsy
label: a
answer: yes
explanation: This patient demonstrates a classic presentation of giant cell arteritis: temporal headache, jaw claudication, and scalp tenderness. ESR is the most sensitive test to diagnose this condition. However, the definitive investigation would be a temporal artery biopsy.
name: Erythrocyte sedimentation rate (ESR)
label: c
answer: no
explanation: This patient is presenting with symptoms of giant cell arteritis: a temporal headache, jaw claudication, and scalp tenderness. The most appropriate investigation to diagnose this condition would be a temporal artery biopsy.
name: Full blood count (FBC)
label: b
answer: no
explanation: This patient demonstrates a classic presentation of giant cell arteritis. It may be useful to also conduct a CT head if you suspected large vessel involvement. However, you should first conduct a temporal artery biopsy as the definitive investigation for this condition.
name: CT head
label: e
answer: no
explanation: This patient demonstrates a classic presentation of giant cell arteritis. Therefore the definitive investigation is a temporal artery biopsy, not a lumbar puncture.
name: Lumbar puncture
label: d
answer: no

Correct answer: a
A 59-year-old female attends the GP with a 10-day history of upper abdominal pain. She also reports having some difficulty swallowing and a burning sensation in the middle of her chest.

She has no other medical conditions aside from hay fever and osteoporosis.

Which of the following medications is the most likely cause of her symptoms?

Options:
explanation: This is a disease modifying anti-rheumatic drug (DMARD) that can be used for treatment of inflammatory conditions like rheumatoid arthritis. Its side effects include retinopathy and rash in some patients. It would not cause the symptoms that this patient is experiencing.
name: Hydroxychloroquine
label: c
answer: no
explanation: This can cause myelosuppression, nausea, rash, oral ulcers and a decreased sperm count. It would not be responsible of causing symptoms of dysphagia and dyspepsia.
name: Sulfasalazine
label: b
answer: no
explanation: Phenytoin is used for the management of status epilepticus. It has a range of side effects that include: acne, anorexia, constipation, paraesthesia, rashes, and tremors. It would not cause dysphagia and dyspepsia.
name: Phenytoin
label: e
answer: no
explanation: Amiodarone can be used for management of atrial fibrillation and cardiac arrhythmias. Its side effects can include hypo- or hyperthyroidism as well as corneal deposits, grey skin discolouration, and occasionally liver failure. It would not cause this patient’s presentation.
name: Amiodarone
label: d
answer: no
explanation: Bisphosphonates like alendronic acid can cause oesophagitis, oesophageal ulcers, dysphagia and dyspepsia. To reduce the risk of these side effects occurring, there are specific guidelines that patients can follow. These include: taking tablets on an empty stomach 30 minutes before food, sitting upright for 30 minutes after taking the medication, and swallowing tablets whole with plenty of water.
name: Alendronic acid
label: a
answer: yes

Correct answer: a
A 20-year-old female presents to the GP with bone pain that began 6 months ago. The GP conducts some blood tests which come back as follows: normal serum calcium, normal serum phosphate, normal PTH, and high ALP.

Which of the following is the most likely diagnosis?

Options:
explanation: This would typically cause shoulder and hip girdle stiffness alongside systemic symptoms such as fever, anorexia, weight loss and malaise. ESR and CRP are typically raised, as this is an inflammatory condition.  Polymyalgia rheumatica would not account for the raised ALP seen in this patient.
name: Polymyalgia Rheumatica
label: c
answer: no
explanation: This would present as inflammation and pain in one joint, most commonly the wrist or shoulder. It would not account for this patient’s high ALP.
name: Pseudogout
label: e
answer: no
explanation: Gout typically presents with a red, hot and swollen joint. It would not account for the raised ALP, so is not the most likely diagnosis in this case.
name: Gout
label: d
answer: no
explanation: This patient is presenting with bone pain and an isolated raised ALP which points us to the diagnosis of Paget’s disease. Paget’s disease can also be picked up on X ray where you may find osteolysis, increased bone size and sclerosis or pathological fractures.
name: Paget’s disease
label: a
answer: yes
explanation: Osteoporosis would have a normal bone profile, so would not explain this patient’s raised ALP.
name: Osteoporosis
label: b
answer: no

Correct answer: a
A 62-year-old female presents to the GP with lower back pain that began 11 hours ago. On further questioning, she tells you she cannot feel the toilet paper when wiping. She has not opened her bowels or urinated since yesterday afternoon.

Which of the following is the next best step?

Options:
explanation: You may wish to give an NSAID with gastric protection if you suspected this back pain was mechanical. However, this patient has some red flags, like saddle anesthesia and bowel disturbance and therefore this would not be the most appropriate action.
name: Ibuprofen and omeprazole
label: b
answer: no
explanation: It may be appropriate to look at inflammatory markers if you suspect an inflammatory cause of back pain such as ankylosing spondylitis. This would present as back pain with early morning stiffness, peripheral enthesitis or arthritis and tenderness of the sacroiliac joints. It would not cause saddle anesthesia or bowel disturbance.
name: Measure ESR and CRP
label: c
answer: no
explanation: You wish to do an X-ray of the spine if you suspect a vertebral fracture. This would be more likely if there was a history of trauma, such as involvement in a road traffic collision. However, the clinical picture here is more likely to be cauda equina syndrome, and therefore a full spine MRI is the best investigation.
name: Spinal X-ray
label: d
answer: no
explanation: This patient is presenting with the clinical features of cauda equina syndrome. Back pain associated with saddle anaesthesia (inability to feel toilet paper when wiping), and bladder or bowel disturbance (constipation or incontinence). Patients with these symptoms should receive a full spine MRI. If evidence of cauda equina is found, surgical decompression of the spine should be performed where appropriate within 48 hours of presentation.
name: Whole spine MRI
label: a
answer: yes
explanation: This acute nature of this patient's pain and neurological changes makes a diagnosis of cauda equina more likely than multiple myeloma. Therefore, a myeloma screen would not be the best investigation for this patient.
name: Myeloma screen
label: e
answer: no

Correct answer: a
A 30-year-old female attends the GP practice complaining of episodes of pain around her left eye and forehead. She tells you that during these episodes she gets a red and watery eye and feels 'stuffy' with a runny nose. The episodes of pain last around an hour and have occurred at random, several times during the last week. Her physical examination is unremarkable.

Which of the following is the most likely diagnosis?

Options:
explanation: This is a typical presentation of cluster headaches. The question describes a unilateral headache, worse around the eye and occurring in episodes/clusters over time. Cluster headaches are associated with a bloodshot eye, rhinorrhoea, lid swelling, and facial flushing. Attacks typically last from 15 minutes to 3 hours.
name: Cluster headaches
label: a
answer: yes
explanation: Tension headaches present as bilateral and non-pulsatile in nature. They are often described as feeling like a tight band around the head. Although they can be associated with tenderness of the scalp, tension headaches do not cause a painful or red and watery eye. Cluster headache is the most likely diagnosis.
name: Tension headache
label: c
answer: no
explanation: Migraines typically present as a unilateral throbbing headache associated with photophobia and phonophobia. Episodes of migraine last longer than cluster headaches, typically ranging from 4-72 hours. Migraines are commonly preceded by an aura, such as visual (e.g lines zigzags) or sensory (paraesthesia) symptoms. You can also look out for migraine triggers, such as oral contraceptives or chocolate.
name: Migraine
label: e
answer: no
explanation: This classically presents as a temporal headache alongside jaw claudication (pain on chewing food), scalp tenderness, and sometimes visual impairment. Examination may reveal a thickened tender temporal artery. You should also look out for a patient with symmetrical proximal muscle weakness and oligoarthritis, as giant cell arteritis is often associated with polymyalgia rheumatica.
name: Giant cell arteritis
label: d
answer: no
explanation: Trigeminal neuralgia presents as short episodes of sharp, stabbing pain. It affects one side of the face in the trigeminal nerve distribution. They are triggered by talking, eating, or touching the face. By contrast, the headache in this question is not described as following the trigeminal nerve distribution, and it is accompanied by autonomic symptoms more suggestive of a cluster headache.
name: Trigeminal Neuralgia
label: b
answer: no

Correct answer: a
A 20-year-old university student is bought into A&E after being found collapsed at home. The previous day she had complained of a headache and neck stiffness. On examination, there is a purpuric rash across her abdomen that does not disappear when pressure is applied.

A lumbar puncture is conducted. Cerebral spinal fluid analysis shows low levels of glucose, high white cell counts, and high protein levels.

Which of the following is the most likely causative organism?

Options:
explanation: This is the most common cause in neonates, so would be unlikely to be the cause of this 20 year old’s meningitis. The rash described is more typical of Neisseria meningitis, rather than Group B streptococcus.
name: Group B Streptococcus
label: d
answer: no
explanation: This would cause a viral meningitis, meaning the cerebral fluid analysis would show a high glucose and low protein content. By contrast, this patient is presenting with meningococcal septicaemia. Neisseria meningitidis is the most likely causative organism.
name: Coxsackie Virus A
label: b
answer: no
explanation: This would cause a viral meningitis, meaning the cerebral spinal fluid would show a high glucose and low protein. By contrast, this patient is presenting with meningococcal septicaemia. Neisseria meningitidis is the most likely causative organism.
name: Herpes simplex virus 2
label: c
answer: no
explanation: This patient is presenting with meningococcal septicaemia. Neisseria meningitidis is the most likely causative organism. Typical features include fever, headache, neck stiffness, and photophobia. The presence of a non-blanching rash indicates the infection has spread into the bloodstream.
name: Neisseria Meningitidis
label: a
answer: yes
explanation: This is cause found in immunosuppressed patients and often found in patients at the extremes of age, like newborns or the elderly. The non-blanching rash in the question is more likely to be caused by neisseria meningitis.
name: Listeria monocytogenes
label: e
answer: no

Correct answer: a
A 21-year-old patient is brought to the emergency department following a road traffic collision. His eyes are shut but they open when you squeeze his trapezius muscles. He makes incomprehensible sounds and flexes to withdraw from pain.

What is his Glasgow Coma Scale score?

Options:
explanation: This patient has a GCS of 8, not 5. He opens his eyes to pain, scoring a 2 for eye-opening response. He is making incomprehensible sounds, meaning he scored a 2 for a verbal response. He flexes to withdraw from pain, meaning he scores a 4 in motor response.
name: 5
label: c
answer: no
explanation: This patient has a GCS of 8, not 4. He opens his eyes to pain, scoring a 2 for eye-opening response. He is making incomprehensible sounds, meaning he scored a 2 for a verbal response. He flexes to withdraw from pain, meaning he scores a 4 in motor response.
name: 4
label: b
answer: no
explanation: This patient has a GCS of 8, not 7. He opens his eyes to pain, scoring a 2 for eye-opening response. He is making incomprehensible sounds, meaning he scored a 2 for a verbal response. He flexes to withdraw from pain, meaning he scores a 4 in motor response.
name: 7
label: e
answer: no
explanation: This patient’s GCS is 8. He opens his eyes to pain, scoring a 2 for eye-opening response. He is making incomprehensible sounds, meaning he scored a 2 for a verbal response. He flexes to withdraw from pain, meaning he scores a 4 in motor response.
name: 8
label: a
answer: yes
explanation: This patient has a GCS of 8, not 6. He opens his eyes to pain, scoring a 2 for eye-opening response. He is making incomprehensible sounds, meaning he scored a 2 for a verbal response. He flexes to withdraw from pain, meaning he scores a 4 in motor response.
name: 6
label: d
answer: no

Correct answer: a
A 19-year-old female is brought to the emergency department after a sudden collapse at home. She has no diagnosed medical conditions, but has been undergoing investigations in her GP surgery for unexplained palpitations.

Her ECG demonstrates a normal sinus rhythm, with the presence of delta waves.

Which of the following is the most likely cause of her collapse?

Options:
explanation: This could be identified on an ECG as a PR interval of over 200ms. This patient has delta waves on their ECG which is suggestive of Wolff-Parkinson White syndrome.
name: First degree heart Block
label: d
answer: no
explanation: Atrial fibrillation is uncoordinated contraction, which causes a heart beat of 300-600 beats per minute. An ECG would show an irregularly irregular pulse rate. This patient has delta waves on their ECG which is suggestive of Wolff-Parkinson White syndrome.
name: Atrial Fibrillation
label: e
answer: no
explanation: On ECG, 3rd degree heart block would show bradycardia and complete dissociation between the P waves and QRS complexes. This patient has delta waves on their ECG which is suggestive of Wolff-Parkinson White syndrome.
name: 3rd degree heart block
label: c
answer: no
explanation: Atrial flutter is caused by an aberrant macro-circuit within the right atrium. The heart can beat at up to 300 beats per minute. An ECG of atrial flutter would show a saw-tooth pattern and narrow QRS complexes. This patient has delta waves on their ECG which is suggestive of Wolff-Parkinson White syndrome.
name: Atrial flutter
label: b
answer: no
explanation: This presentation is most likely to be Wolff-Parkinson White syndrome. Delta waves (which are slurred upstrokes of QRS) indicate Wolff-Parkinson White syndrome. ECGs may also show a shortened PR interval, broad QRS complex, or narrow complex tachycardia. This condition is caused by an extra accessory pathway that bypasses the AV node.
name: Wolff Parkinson- White syndrome
label: a
answer: yes

Correct answer: a