hllj/quesmed huggingface dataset:
A 76 year old man comes to the GP practice worried about a skin change. He has been diagnosed with an actinic keratosis on his scalp 2 years ago and has had topical 5-fluorouracil treatment and imiquimod for it, with no resolution. He says it has gotten bigger in the last 2 months. Inspection shows a nodular hyperkeratotic lesion.

What is the most appropriate course of action?

Options:
explanation: This case describes an actinitc keratosis undergoing malignant transformation to a squamous cell cancer. Signs of malignant transformation include enlarging, becoming hyperkeratotic, nodular and showing a poor response to treatment.
name: 2 week referral to dermatology
label: a
answer: yes
explanation: This is not appropriate given the concerning presentation, lack of treatment response and patient's distress.
name: Discharge with reassurance
label: b
answer: no
explanation: This may be indicated in the treatment of the likely SCC, but in the first instance, a dermatology referral is needed to confirm the diagnosis and ascertain the best form of treatment.
name: Refer for excision
label: d
answer: no
explanation: This would not prove useful in the treatment of SCC.
name: Trial a oral course of low dose steroids
label: e
answer: no
explanation: This may be indicated in the treatment of the likely SCC, but in the first instance, a dermatology referral is needed to confirm the diagnosis and ascertain the best form of treatment.
name: Refer for cryotherapy
label: c
answer: no

Correct answer: a


Learning point: A persistent, enlarging, hyperkeratotic and nodular skin lesion following unsuccessful treatment for an actinic keratosis may indicate squamous cell carcinoma, necessitating urgent dermatology referral.
A 78 year old man has been admitted to the ICU following a diagnosis of severe urinary tract infection, resulting in urosepsis. He subsequently develops an AKI and is catheterised on the ward. The nurses are seriously concerned about fluctuations in his mood. Over the last few days, he has periods of being withdrawn, disorientated and apathetic and periods of agitation, hallucinations and delusions.

What is the most likely aetiology of the patient's symptoms?

Options:
explanation: Although the patient describes hallucinations and delusions, the mixed picture and acuity following a physical health illness, especially in elderly patients is more suggestive of a delirium.
name: Acute psychosis
label: e
answer: no
explanation: This case describes a mixed delirium with hyperactive features of agitation and hypoactive features such as withdrawing and appearing apathetic. The delirium may have been triggered by the infection, change in environment or due to pain or medications.
name: Delirium
label: a
answer: yes
explanation: Lewy body dementia is associated with long term cognitive decline, parkinsonism and fluctations in cognition. This presentation is too acute and the lability is not in keeping with LBD.
name: Lewy Body dementia
label: d
answer: no
explanation: Bipolar disorder is defined by periods of depression (lasting at least 2 weeks) and mania as opposed to intense emotional lability within a matter of days, there is additionally no mention of a psychiatric history.
name: Bipolar disorder
label: c
answer: no
explanation: Although EUPD may cause emotional lability and intense mood swings, there is nothing to suggest a long term psychiatric history in this patient and his presentation has arisen over the last few days due to physical health problems.
name: Emotionally unstable personality disorder
label: b
answer: no

Correct answer: a


Learning point: Delirium, characterised by fluctuations in consciousness and attention, can present with both hyperactive and hypoactive features and may be precipitated by various causes including infections and medications.
A 67 year old man has shortness of breath and a productive cough for 2 days. He is alert. His temperature is 38 degrees Celcius, his blood pressure is 118/79mmHg and his respiratory rate is 32. He has recently come back from visiting family in India. He has no allergies. A chest X ray is performed and shown below. Bloods show urea levels of 6.9mmol.

[lightgallery]

What is the most appropriate course of action?

Options:
explanation: With a CURB 65 score of 2, at this moment in time, he can be managed on the general medical/respiratory ward and does not need ICU, which is normally indicated at CURB 65 score over 3.
name: Admit to ICU and adminster IV Tazocin
label: c
answer: no
explanation: This man has a community acquired pneumonia with a CURB 65 Score of 2. He needs admission to the general medical/respiratory ward to be commenced on combination antibiotic therapy.
name: Admit to respiratory ward and adminster amoxicillin + clarithomycin
label: a
answer: yes
explanation: This is inappropriate as the patient is unwell and requires intravenous antibiotics in hospital.
name: Discharge with outpatient follow up
label: e
answer: no
explanation: Alteplase may be indicated in the treatment of massive PE, however the CXR and clinical picture point towards a pneumonia.
name: Thrombolyse with alteplase
label: b
answer: no
explanation: This is the management for tuberculosis. Although he has returned from India, the absence of night sweats, haemoptysis and acuity of symptoms are more typical of pneumonia.
name: Admit to infectious diseases ward, isolate in a negative pressure room and adminster rifampicin, isionazid, pyrizanamide and ethambutol
label: d
answer: no

Correct answer: a


Learning point: Elderly patients with shortness of breath, productive cough, fever, and an abnormal chest X-ray require admission for antibiotic treatment to manage community-acquired pneumonia.
A 35 year old woman has shortness of breath and joint pain for the last month. Her GP has referred her for a chest X ray which shows:

[lightgallery]

What is the most likely diagnosis?

Options:
explanation: Although this causes BHL on CXR, there is no occupational mention or reason to suspect it in this instance.
name: Silocosis
label: e
answer: no
explanation: Although this may cause BHL and arthritis, the absence of other typical symptoms such as fever, night sweats, cough and lack of travel history make it less likely.
name: Tuberculosis
label: b
answer: no
explanation: Although this causes BHL on CXR, the absence of B symptoms and cervical lymphadenopathy renders it less likely.
name: Non-Hodgkin's Lymphoma
label: d
answer: no
explanation: Although this causes BHL on CXR, the absence of B symptoms and cervical lymphadenopathy renders it less likely.
name: Hodgkin's Lymphoma
label: c
answer: no
explanation: The age, gender, symptomatology and bilateral hilar lympadenopathy (BHL) findings all point to sarcoidosis.
name: Sarcoidosis
label: a
answer: yes

Correct answer: a


Learning point: In younger adults with unexplained shortness of breath and joint pain, the presence of bilateral hilar lymphadenopathy on a chest X-ray raises strong suspicion for sarcoidosis.
A 78-year-old woman was brought in by ambulance following a fall at home. She describes recently feeling unsteady on her feet and dizzy with the room spinning, when tying her shoelaces. She has hypertension, type 2 diabetes, knee osteoarthritis and COPD. On examination, her gait and balance were normal, with no focal neurology.

Which of the following is likely to diagnose the underlying cause of her fall?

Options:
explanation: This woman describes vertigo and dizziness on sudden head movements characteristic of benign paroxysmal positional vertigo, for which Dix-Hallpike is diagnostic.
name: Dix-Hallpike manoeuvre
label: a
answer: yes
explanation: This may be useful to assess the extent of degenerative changes within the knee or characterise any ligamentous or soft tissue injury however the fall does not seem related to the OA and her gait is normal.
name: MRI Knee
label: d
answer: no
explanation: This may prove useful if suspecting a stroke secondary to carotid artery stenosis but as per the explanation for why non contrast CT head was not correct, it is not the best choice in this case.
name: Carotid artery doppler
label: e
answer: no
explanation: This may be useful to assess for C-spine fracture in trauma or to assess whether cervical myelopathy caused the fall. Degenerative Cervical myelopathy would have more likely caused sensory changes and loss of fine motor function of the hands.
name: CT Cervical Spine
label: b
answer: no
explanation: This would be diagnostic for a stroke, for which she has vascular risk factors for. However the absence of focal neurology and the fact that symptoms occur on head turning point away from stroke.
name: Non-contrast CT head
label: c
answer: no

Correct answer: a


Learning point: Suspected Benign Paroxysmal Positional Vertigo (BPPV) should be diagnosed through performing the Dix-Hallpike manoeuvre.
A 10-month old girl is rushed into the Emergency Department with sudden onset cough, respiratory distress, and noisy breathing. This started 20 minutes ago whilst at a playdate, and she had previously been well. On examination she is making a high-pitched inspiratory sound whilst breathing and is coughing ineffectively. There is no wheeze, rash, or angioedema. Her respiratory rate is elevated at 48 (30-40) and she is tachycardic at 152 bpm (80-140), her other vital signs are normal.

What is the most appropriate management?

Options:
explanation: Bronchoconstriction can cause respiratory distress in infants, however a wheeze rather than stridor would be found on examintation. The history and examination is more consistent with an inhaled foreign body.
name: Nebulised salbutamol
label: b
answer: no
explanation: Anaphylaxis is an important differential for respiratory distress and stridor, however is is accompanied by hypotension, and allergic symptoms such as angioedema. The history and examination is more consistent with an inhaled foreign body.
name: 150 micrograms IM adrenaline
label: d
answer: no
explanation: The history and examination is consistent with an inhaled foreign body. The immediate management is a rigid bronchoscopy to remove it. Foreign body inhalations are often unwitnessed in children and it is an important differential for anyone presenting with stridor and respiratory distress. Although not common practice, this question has appeared in previous writers' MLA AKT exams so we have included it in our bank.
name: Rigid bronchoscopy
label: a
answer: yes
explanation: Croup is a common cause of stridor in children and can also cause respiratory distress, this would be treated with steroids. However, the onset would not be so sudden and there is usually a history of low grade fever and coryzal illness. The history and examination is more consistent with an inhaled foreign body.
name: Dexamethasone, STAT dose
label: c
answer: no
explanation: The sudden onset and lack of temperature in this patient is not consistent with an infectious cause of respiratory distress. The history and examination is more consistent with an inhaled foreign body.
name: Amoxicillin
label: e
answer: no

Correct answer: a


Learning point: Inhaled foreign bodies in children can cause sudden respiratory distress and stridor, necessitating immediate rigid bronchoscopy for removal.
A 13-year-old boy presents to General Practice complaining of a sore throat for the last four days with no cough. He is able to eat and drink. He has no past medical history, is not taking any medications and has no allergies. Examination reveals no lymphadenopathy but there is swelling of the tonsils bilaterally with exudate. His observations are:

- Temperature 37.4 degrees Celsius
- Pulse 78 bpm
- Respiratory rate 15
- Oxygen saturation 98% on room air.

What is most appropriate management plan?

Options:
explanation: This is only indicated in tonsillitis that is very severe and impairs the patient's ability to swallow which is not the case here.
name: IV maintenance fluids
label: e
answer: no
explanation: This patient has a Centor score of 2 and therefore, does not warrant antibiotics. Oral penicillin V would be used if they had a Centor score of 3 or more.
name: Oral penicillin V
label: c
answer: no
explanation: This patient has a Centor score of 2. Therefore, antibiotics are not warranted. IV antibiotics would be used if the patient were septic or had severe consequences from the tonsillitis that impaired their ability to swallow safely.
name: IV co-amoxiclav
label: b
answer: no
explanation: This patient is presenting with features of tonsillitis. As his Centor score is only 2 (tonsillar exudate and absence of a cough) antibiotics are not warranted currently. Antibiotics are only given if the Centor score is 3 or above. Therefore, this patient requires analgesia and appropriate safety netting to return in case the symptoms do not resolve. 

[NICE guidelines](https://www.nice.org.uk/guidance/ng84/chapter/Recommendations) currently advise using the **original** Centor scoring criteria, which **does not include age.** The modified/McIsaac Centor score, which is available via MDCalc however, does include age, which is why some users may have calculated this patient's score as 3.

name: Encourage regular paracetamol and fluid intake
label: a
answer: yes
explanation: This patient has a Centor score of 2 and therefore, they do not warrant antibiotics. Oral clarithromycin would be an option if they had a Centor score of 3 or more and a penicillin allergy.
name: Oral clarithromycin
label: d
answer: no

Correct answer: a


Learning point: In cases of tonsillitis with a Centor score of 2, supportive care with analgesia and hydration is the primary management approach.
A 65-year-old lady presents to the GP with joint pain affecting both of her hands for the last three months. She also reports stiffness in her hands that lasts for 10 minutes when she wakes up. Her hands feel worse towards the end of the day. She has no relevant past medical history.

Which of the following is the most likely examination finding in this patient?

Options:
explanation: This is a common presentation and examination finding in ankylosing spondylitis.
name: Tenderness at the sacroiliac joints
label: c
answer: no
explanation: Heberden's nodes are common findings in patients presenting with osteoarthritis. They present as prominent bony outgrowths that can be palpated on the outer aspect of the distal interphalangeal joints. This patient likely has osteoarthritis due to her age and the fact that her symptoms appear to be activity-related, and are therefore worse in the evening. As the stiffness in her joints lasts less than 30 minutes in the morning it is unlikely to be an inflammatory arthropathy.
name: Heberden's nodes
label: a
answer: yes
explanation: Episcleritis is a finding in many rheumatological conditions, including rheumatoid arthritis and enteropathic arthritis.
name: Episcleritis
label: e
answer: no
explanation: This is a feature of rheumatoid arthritis (RA). The other features of RA are swan neck and boutonniere deformities, as well as ulnar deviation of the wrist. RA is the most common inflammatory arthropathy but usually affects younger patients.
name: Z-shaped deformity of the thumb
label: b
answer: no
explanation: This is a feature of rheumatoid arthritis (RA). Other features include z-shaped deformities of the thumbs, boutonniere's deformities, and ulnar deviation of the wrist. RA is the most common inflammatory arthropathy but usually affects younger patients.
name: Swan neck deformity of the fingers
label: d
answer: no

Correct answer: a


Learning point: Heberden's nodes are indicative of osteoarthritis, presenting as bony outgrowths on the distal interphalangeal joints, often worsening with activity.
A 55-year-old woman presents to the GP clinic with pain on passing urine for the past three days. She is otherwise well in herself. She has a past medical history of G6PD deficiency and rheumatoid arthritis, for which she takes methotrexate. She does not take any other medication and has no known drug allergies.

She has a temperature of 36.5 degrees Celsius, pulse 65 bpm, BP 125/86 mmHg.

Urine dipstick shows 2+ leukocytes and 3+ nitrites.

The GP decides to prescribe a course of antibiotics for this patient. Which is the most appropriate regimen to prescribe?

Options:
explanation: This would be appropriate for patients with suspected urosepsis. This patient does not present with any features of sepsis e.g. hypotension and therefore does not require a stat dose of gentamicin.
name: STAT dose IV gentamicin 5mg/kg
label: e
answer: no
explanation: According to [NICE CKS guidelines](https://cks.nice.org.uk/topics/urinary-tract-infection-lower-women/management/acute-uti-no-visible-haematuria-not-pregnant-or-catheterized/), this is the second-line antibiotic regimen where nitrofurantoin and trimethoprim are contraindicated (see other explanations), or where there is no improvement in symptoms.
name: PO Pivmecillinam 400mg initial dose, then 200 mg TDS for three days
label: a
answer: yes
explanation: Methotrexate is listed as a severe interaction with trimethoprim in the BNF, due to the increased risk of haematological side effects that can be fatal. This is a very important drug interaction to remember.
name: PO Trimethoprim 200mg BD for three days
label: c
answer: no
explanation: G6PD deficiency is listed as a contra-indication to nitrofurantoin in the BNF.
name: PO Nitrofurantoin 100mg BD for three days
label: b
answer: no
explanation: The BNF advises that ciprofloxacin be used with caution in patients with G6PD deficiency. Furthermore, this medication would be more appropriate for patients with acute pyelonephritis managed in the community. The lack of additional symptoms in this patient i.e. flank pain or features of sepsis makes acute pyelonephritis unlikely. 
name: PO Ciprofloxacin 1g for seven days
label: d
answer: no

Correct answer: a


Learning point: In women with urinary tract infections, pivmecillinam is a suitable second-line antibiotic when nitrofurantoin and trimethoprim are contraindicated.
A 19-year-old female inverts her right ankle whilst playing football. Immediately after the injury she is only able to take two steps using her right foot. On examination, her foot is swollen and bruised and she is extremely tender over her right lateral malleolus. Her foot is warm and well perfused and her dorsalis pedis pulse is palpable. She is unable to weight bear at the time of examination.

What is the most appropriate way to manage this injury?

Options:
explanation: This is not a first-line investigation for possible ankle fractures and would be more suited for assessing ligament damage.
name: Arrange an ankle MRI
label: c
answer: no
explanation: The Ottawa rules recommend an ankle X-ray if following an ankle injury, a patient has pain in the malleolar zone and one of the following; 1) Inability to weight bear immediately after the injury and on examination, 2) Bony tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, or 3) Bony tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus. As this patient meets these criteria, an ankle X-ray should be carried out in order to rule out ankle fracture.
name: Arrange an immediate ankle X-ray
label: a
answer: yes
explanation: As there is no evidence of an open fracture on examination and fracture is yet to be confirmed on X-ray, this would not be a reasonable first step in management.
name: Immediate surgical reduction and fixation
label: d
answer: no
explanation: This would not be appropriate as the patient meets the criteria for an ankle X-ray.
name: Discharge home with advice for elevation, compression, and analgesia
label: b
answer: no
explanation: Whilst in some injuries, a watch and wait approach can be useful, the patient clearly meets the ankle X-ray criteria listed above and as such, imaging should not be delayed.
name: Arrange an ankle X-ray in 14 days if symptoms have not improved
label: e
answer: no

Correct answer: a


Learning point: In ankle injuries, the Ottawa rules indicate an X-ray is necessary if there is malleolar zone pain and inability to weight bear.
A 46-year-old male has thickening of tissue and palpable nodules over the fourth and fifth digits on the palm of his right hand. The fingers are slightly flexed, and the patient is unable to flatten his right hand on the table.

Given the likely diagnosis, which of the following is a risk factor for the development of this condition?

Options:
explanation: This is incorrect. Patients >40 years old are at a greater risk of developing Dupuytren’s contracture.
name: Age <20 years old
label: b
answer: no
explanation: This is incorrect. Patients who smoke are at greater risk of developing Dupuytren’s contracture.
name: Negative smoking history
label: e
answer: no
explanation: This is incorrect. Patients of Northern European descent are at greater risk of developing Dupuytren’s contracture.
name: Mediterranean descent
label: d
answer: no
explanation: The condition described here is Dupuytren’s contracture, which is a progressive flexion contracture of the fingers due to connective tissue proliferation and nodule formation in the palm. Positive family history is a significant risk factor for the development of Dupuytren’s contracture.
name: Positive family history
label: a
answer: yes
explanation: This is incorrect. Male patients are at a greater risk of developing Dupuytren’s contracture.
name: Female sex
label: c
answer: no

Correct answer: a


Learning point: Dupuytren’s contracture is characterised by progressive flexion of the fingers due to palmar fascia thickening, often associated with a positive family history.
A 14-year-old boy has a painful swelling just above his right knee, which is growing in size. A knee X-ray shows a ‘sunburst appearance’ of the distal right femur. He has a past medical history of retinoblastoma.

What is the most likely diagnosis?

Options:
explanation: This history is more concerning for malignancy given the development of a growing, painful bony lesion in an adolescent. Patients would be less likely to develop pseudogout at this age and X-ray would be more likely to show chondrocalcinosis (calcification of cartilage).
name: Pseudogout
label: c
answer: no
explanation: This more commonly affects patients over the age of 40. Lytic lesions with ‘fluffy popcorn calcification’ are the characteristic X-ray findings.
name: Chondrosarcoma
label: b
answer: no
explanation: This is the most common primary bone malignancy which typically affects adolescent males. A history of retinoblastoma is a risk factor for the development of osteosarcoma and the ‘sunburst appearance’ (formation of new bone in a specific pattern) is a classic finding on X-ray.
name: Osteosarcoma
label: a
answer: yes
explanation: Whilst trauma can present with pain and swelling, the developing size of the swelling means malignancy is more likely and needs to be excluded.
name: Trauma to the distal femur
label: e
answer: no
explanation: This is a disease which causes inflammation of the growth plate and presents with pain and swelling of the tibial tuberosity rather than distal femur. This history and the X-ray findings are much more suggestive of malignancy.
name: Osgood-Schlatter disease
label: d
answer: no

Correct answer: a


Learning point: Osteosarcoma is the most common primary bone malignancy in adolescents, often presenting with a 'sunburst appearance' on X-ray.