hllj/quesmed huggingface dataset:
A male and female couple in their 60's attend their GP surgery to discuss their alcohol intake. They both drink 18 units per week; one 175ml glass of red one each per night during the week and two each on a Saturday and Sunday.

Which of the following is the best next step in the management of these patients?

Options:
explanation: Both patients are drinking over the recommended 14 units with no alcohol free days per week. Therefore they should both be recommended to decrease their alcohol consumption.
name: Advise the patients that their alcohol intake is within current NHS guidelines and no further action is required
label: c
answer: no
explanation: Previous guidance suggested different limits for men and women, for men it was suggested 21 units per week maximum and women 14 units. However, this was changed in 2016 to the current maximum of 14 units for everyone.
Therefore both patients should be advised to cut down their alcohol intake to a maximum of 14 units per week.
name: Only advise the female patient to decrease her alcohol intake to 14 units
label: b
answer: no
explanation: The AUDIT questionnaire is used to measure the severity of chronic alcohol misuse. Whilst that may be helpful to assess the patients, most importantly is to recommend that they cut down their units to the recommeneded 14 units per week each.
name: Provide the patients with the AUDIT questionnaire
label: e
answer: no
explanation: It is recommended to drink no more than 14 units per week for men and women.
Previous guidance suggested different limits for men and women, for men it was suggested 21 units per week maximum and women 14 units. However, this was changed in 2016 to the current maximum of 14 units for everyone.
name: Advise both patients to limit alcohol to 14 units per week each with several alcohol free days per week
label: a
answer: yes
explanation: Indications for inpatient withdrawal are:

- Patients drinking >30 units per day
- Scoring over 30 on the SADQ score
- High risk of alcohol withdrawal seizures (previous alcohol withdrawal seizures or delirium tremens, or history of epilepsy)
- Concurrent withdrawal from benzodiazepines
- Significant medical or psychiatric comorbidity
- Vulnerable patients
- Patients under 18

Therefore these patients do not require admission for alcohol detoxification. They should be advised to decrease their alcohol intake to the recommended 14 units per week.
name: Arrange for inpatient alcohol detoxification for both patients
label: d
answer: no

Correct answer: a
A 24 year old female attends her GP surgery with bilateral breast tenderness for the past two weeks. Examination of the breasts shows no abnormalities.

Her past medical history includes asthma.

She currently takes a salbutamol inhaler and the combined oral contraceptive pill.

Which of the following is the most likely explanation for this patient’s symptoms?

Options:
explanation: Mastitis does cause breast pain, however, examination would reveal inflammatory changes such as erythema and warmth. Mastitis is common among those breastfeeding, but it can also occur in smokers.
name: Mastitis
label: b
answer: no
explanation: A patient under the age of 30 with bilateral breast pain and normal examination is unlikely to have breast cancer.
The guidance for urgent referral on the suspected cancer pathway is:

*  30 years or over with unexplained breast lump with or without pain, or
* 50 years and over with unilateral nipple changes such as discharge or retraction

A referral can be considered for those with skin changes to the breast or those 30 years and over with an unexplained lump in the axilla.
[Click here for NICE CKS on Breast cancer - recognition and referral] (https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/)
name: Breast malignancy
label: c
answer: no
explanation: Fat necrosis often occurs after trauma to the breast tissue. A lump with overlying bruising would be found on examination.
name: Fat necrosis of the breat
label: d
answer: no
explanation: Fibroadenomas are benign tumours of the breast originating from fibrous and epithelial tissue. Whilst this patient is a typical age for fibroadenomas, she does not present with a lump. Fibroadenomas present with a firm, non tender lump which is highly mobile.
name: Fibroadenoma of the breast
label: e
answer: no
explanation: Breast tenderness is a common side effect of the combined oral contraceptive pill. This can often be managed with simple analgesia such as paracetamol, however, alternative contraception can be offered if symptoms continue.
name: Side effect of the combined oral contraceptive pill
label: a
answer: yes

Correct answer: a
A 32 year old female attends her GP practice. She is sexually active and takes the combined oral contraceptive pill (COCP), however she had forgotten to take her pill last night. Prior to this she has had good adherence. She is currently in week three of her cycle.

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

Options:
explanation: To avoid pregnancy the patient should be advised to take the missed pill as soon as possible and the next pill at the usual time. This may mean taking two pills in 24 hours. No emergency contraception or extra contraceptive measures are needed if adherence has been good in the 7 days previously. Therefore, there is no extra indication to test for pregnancy.
name: Stop taking the pill and take a home urinary pregnancy test in two weeks
label: e
answer: no
explanation: As long as there has been consistent adherence for the 7 days prior, there is no need for emergency contraception if in week 3 of the cycle.
The missed pill should be taken as soon as possible and the next pill taken at the usual time. This may mean taking two pills in 24 hours.

If the patient is struggling with adherence, alternative forms of contraception can be offered such as the IUS.
name: Offer the intraunterine system
label: d
answer: no
explanation: As long as there has been consistent adherence for the 7 days prior, there is no need for emergency contraception if in week 3 of the cycle.
The missed pill should be taken as soon as possible and the next pill taken at the usual time. This may mean taking two pills in 24 hours.
name: Offer emergency contraception
label: b
answer: no
explanation: As long as there has been consistent adherence for the 7 days prior, there is no need for extra precautions. The missed pill should be taken as soon as possible and the next pill taken at the usual time. This may mean taking two pills in 24 hours.
name: Abstain from sexual intercorse for the next 7 days
label: c
answer: no
explanation: In week three (counted as the third week after the hormone-free interval) if one pill is missed (up to 48 hours since the last pill was taken) then the missed pill should be taken as soon as possible and the next pill taken at the usual time. This may mean taking two pills in 24 hours. No additional contraception is required if there has been consistent adherence for the 7 days prior.

[Click here for NICE guidance on contraceptive pills] (https://cks.nice.org.uk/topics/contraception-combined-hormonal-methods/management/combined-oral-contraceptive/)
name: Take the last pill that was missed, finish the current pack and start the next pack immediately after
label: a
answer: yes

Correct answer: a
A 21 year old female attends her GP surgery to discuss emergency contraception after having unprotected sexual intercourse (UPSI) 4 days ago. She does not currently use any method of contraception.

Her past medical history is of menorrhagia secondary to dysfunctional uterine bleeding.

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

Options:
explanation: Ullipristal acetate is a selective progesterone-receptor modulator.
It is liscensed as a form of emergency contraception when taken within 120 hours of UPSI.
It prevents the LH surge preventing ovulation for 5 days.
name: Ullipristal acetate (ellaOne®)
label: a
answer: yes
explanation: The copper IUD is the most effective emergency contraception, it can be utilised 5 days after UPSI. It prevents fertilisation, and also has anti-implantation effects by causing inflammation in the endometrial lining.
Whilst this would be an appropriate option, however, the patient has menorrhagia. The IUD is not a suitable option as it often increases symptoms of menorrhagia.
name: The copper intrauterine device (IUD)
label: e
answer: no
explanation: Ullipristal acetate should be offered, it is liscenced as emergency contraception for up to 120 hours after UPSI.
name: Advise her to take a pregnancy test in a weeks time as it is too late to take emergency contraception
label: c
answer: no
explanation: Levonorgestrel it is progesterone-only emergency contraception.
Levonorgestrel can be used as emergency contraception if the UPSI took place within 72 hours.
It delays ovulation by 5 days and thickens the cervical mucus.
For this patient, as it has been over 72 hours since UPSI, Levonorgestrel is not effective emergency contraception.
name: Levonorgestrel (Levonelle)
label: b
answer: no
explanation: This is called the Yuzpe regimen, it is when a high dose of a combined oral contraceptive pill is used as emergency contraception. Taken within 72 hours of UPSI it has a 75% reduction in the risk of pregnancy. However, this method is no longer used in the UK as it was demonstrated to be far less effective than levonorgestrel.
name: Two doses of the combined oral contraceptive pill
label: d
answer: no

Correct answer: a
A 22 year old female attends her GP surgery to discuss contraception. She decides to try a combined oral contraceptive pill (COCP).
She is currently menstruating and is on day 4 of her cycle. She is sexually active.

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

Options:
explanation: This would unnecessarily delay contraception. The COCP can be started at any time during the menstrual cycle, provided additional precautions are taken if started after day 5.
name: To wait until day 1 of her next cycle to start the COCP
label: c
answer: no
explanation: Immediate protection only applies if the COCP is started within the first 5 days of the menstrual cycle. Since the patient is on day 4 and sexually active, additional precautions are required for 7 days to ensure she is protected.
name: Start the COCP immediately, with no further precautions needed
label: b
answer: yes
explanation: When the COCP is started between day 1-5, FSRH states that no further precautions are required.
name: Start the COCP and advise the use of additional precautions for the next 7 days
label: a
answer: no
explanation: This does not align with FSRH guidelines, which recommend 7 days of additional contraception for maximum protection when starting the COCP outside the first 5 days of the menstrual cycle.
name: Start the COCP and advise the use of additional precautions for the next 3 days
label: d
answer: no
explanation: This is not a standard recommendation for starting the COCP and would not address the need for additional contraception during the initial 7-day window when the COCP is not yet effective.
name: Start the COCP immediately but omit the hormone free week of this cycle
label: e
answer: no

Correct answer: b
A 24 year old attends her GP surgery to discuss contraception. She currently takes a combined oral contraceptive pill (COCP). She has had to take emergency contraception twice this year due to forgetting to take the pill multiple days in a row. She wants to discuss alterantive methods of contraception.

Her past medical history includes menorrhagia, which was previously investigated and is secondry to dysfunctional uterine bleeding.

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

Options:
explanation: This would not be a suitable form of contraception for this patient. She has already reported to struggle with adherence to her current COCP, therefore is likely to have the same problem with the POP. Furthermore, the POP is not currently recommended as treatment for menorrhagia.
name: Progesterone only pill (POP)
label: e
answer: no
explanation: Patients with menorrhagia who want contraception can be offered the IUS, e.g. Mirena coil. The IUS is Levonorgestrel-releasing, it prevents fertilisation, thickens cervical mucus and thins the endometrial lining. It can cause irregular vaginal bleeding or spotting for the first few months, however, it decreases the amount of menstrual blood loss and therefore is first line treatment for menorrhagia.
name: The intrauterine system (IUS)
label: a
answer: yes
explanation: The SDI is a progesterone-only form of contraception.
Whilst the SDI may be a good option for patients who struggle to remember to take a pill everyday, it is not a currently recommended treatment of menorrhagia.
name: Subdermal implant (SDI)
label: c
answer: no
explanation: The IUD, also known as the copper coil, would not be an appropriate choice of contraception for this patient as she had menorrhagia which the IUD is likely to make worse.
name: The intrauterine device (IUD)
label: b
answer: no
explanation: The IUS should be offered first line, especially to a patient wanting contraception. However, non-hormonal treatment options for menorrhagia imclude the use of tranexamic acid.
name: Barrier method contraception and tranexamic acid
label: d
answer: no

Correct answer: a
A 26 year old female attends her GP surgery to discuss contraception. She decides to try the progesterone only pill (POP).

Which of the following is the primary mechanism of action of this medication?

Options:
explanation: The POP thins the lining of the endometrium to prevent implantation into the endometrium. It also thickens the cervical mucus to prevent sperm reaching the egg.
name: Shedding of the lining of the endometrium
label: e
answer: no
explanation: Whilst some POPs do inhibit ovulation, the primary mechanism of action is by thickening of the cervical mucus and thinning of the endometrium. The progesterone only implant's primary mechanism of action is by preventing ovulation.
This is, however, the primary mechanism of action of the combined contraceptive pill.
name: Inhibit ovulation by negative feedback to the hypothalamic-pituitary gland
label: b
answer: no
explanation: The POP thins the endometrium, preventing implantation. It also thickens cervical mucus to prevent sperm reaching the egg.
name: Thickening of the endometrium
label: c
answer: no
explanation: This is the mechanism of action of the copper intrauterine device (IUD), which releases copper ions which is toxic to sperm, preventing fertilisation.
The POP's mechanism of action to prevent pregnancy is primrily thickening of the cervical mucus and thinning of the endometrium. Some POPs also prevent ovulation.
The thickening of the cervical mucus prevents sperm reaching the egg, the thinning of the endometrium prevents implantation.
name: Makes the uterus toxic to sperm
label: d
answer: no
explanation: The progesterone only pill's mechanism of action to prevent pregnancy is primarily thickening of the cervical mucus and thinning of the endometrium. Some POPs also prevent ovulation.
The thickening of the cervical mucus prevents sperm reaching the egg, whilst the thinning of the endometrium prevents implantation.
name: Thickening of the cervical mucus and thinning of the endometrium
label: a
answer: yes

Correct answer: a
A 55 year old female attends her GP surgery to discuss her menopausal symptoms. Her last period was 18 months ago. She has noticed that she is having hot flushes, lethargy and loss of libido.

Her past medical history is of asthma.

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

Options:
explanation: Whilst the preparation of the HRT (containing both oestrogen and progesterone for patients with a uterus) is appropriate, patients who are post menopausal should be prescribed continuous rather than cyclical preparations.
This patient has been amenorrhoic for over 12 months.
name: Combined cyclical oral HRT
label: d
answer: no
explanation: Vaginal oestrogen gel can be prescribed to patients with a uterus without also prescribing progesterone as systemic absorption of the oestrogen is minimal.  As the systemic absorption is minimal, this route does not help with systemic symptoms such as the hot flushes experienced by this patient. Topical oestrogen helps locally with symptoms such as vaginal dryness.
name: Vaginal oestrogen gel
label: c
answer: no
explanation: Patients can be reffered for cognitive behaviour therapy (CBT) to help with the symptoms of low mood and stress associated with menopause.
However, it would also be appropriate to offer hormonal HRT to this patient to help with the symptoms she has presented with hot flushes, lethargy and loss of libido.
name: Referral for cognitive behaviour therapy
label: e
answer: no
explanation: Transdermal oestrogen patches can be prescribed for those who have had troublesome side effects with oral HRT.
The oestrogen patch is only suitable for those without a uterus. Oestrogen without progesterone ('unopposed oestrogen) causes hyperplasia of the endometrium, increasing the risk of endometrial cancer. If the patient has a intrauterine system with progesterone in situ then an oestrogen only HRT can be prescribed.
name: Oestrogen patch
label: b
answer: no
explanation: Combined HRT contains both oestrogen and progesterone. Oestrogen cannot be given on its own if the person still has a uterus. Oestrogen without progesterone ('unopposed oestrogen') causes hyperplasia of the endometrium, increasing the risk of endometrial cancer.
A continuous regimen is usually preferred for patients who are postmenopausal, whereas a cyclical regimen is preferred in perimenopausal patients. Perimenopausal is when symptoms of the menopause emerge with irregular menstruation, menopause is defined by the absence of menstruation for 12 months.
name: Combined continuous oral HRT
label: a
answer: yes

Correct answer: a
A 52 year old female attends her GP surgery to discuss Her menopausal symptoms. Her last period was 18 months ago. She has been more anxious and lethargic as of recently with episodes of hot flushes.
Her past medical history include eczema and fibroids for which she has had a hysterectomy.

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

Options:
explanation: This patient can be prescribed oestrogen without progesterone ('unopposed oestrogen') as she has had a hysterectomy. Unopposed oestrogen causes hyperplasia of the endometrium, increasing the risk of endometrial cancer. Oestrogen can be prescribed as a tablet or a transdermal patch.
First line treatment would be oral oestrogen.
name: Oral oestrogen
label: a
answer: yes
explanation: Whilst this could be offered to help with the symptoms of anxiety, the patient also presents with hot flushes.
A trial of HRT would be the first step, referral for CBT could be offered concurrently.
name: Refer for cognitive behavioural therapy (CBT)
label: e
answer: no
explanation: As this patient has had a hysterectomy she does not require progesterone alongside the oestrogen. Preparations of combined HRT are required when the patient has a uterus. This is because oestrogen on its own (unopposed) causes hypertrophy of the endometrium, leading to a risk of endometrial cancer.
name: Combined oral HRT
label: b
answer: no
explanation: FSH levels are not required to diagnose menopause in patients over the age of 45.
Patients between the age of 40 and 45 with menstrual cycle changes can have their FSH levels checked to confirm menopause. Patients under the age of 40 with menopausal symptoms can have their FSH levels checked to diagnose premature ovarian failure.
name: A blood test for FSH levels before commencing HRT
label: c
answer: no
explanation: Gabapentin can be prescribed for hot flushes, however, this patient has presented with anxiety and lethargy as well. Therefore, an HRT option would be most suitable.
name: Gabapentin
label: d
answer: no

Correct answer: a
A 65 year old male presents to his GP for a general health check. As part of this, the GP calculates the patient's QRISK2 score, which is 20%.

He has no past medical history.

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

Options:
explanation: The QRISK2 is a score used to estimate the 10-year risk of cardiovascular disease in patients under the age of 85 years who do not have heart disease.
The risk score helps guide **primary prevention** of cardiovascular disease with lifestyle and pharmacological intervention. Patients with a **QRISK2 score of 10% or more** should be **offered a statin** to reduce the risk of cardiovascular disease. First line choice is atorvastatin 20mg.
name: Atorvastatin 20mg
label: a
answer: yes
explanation: The patient shoukd be offered lifestyle advice such as increased exercise, stopping smoking and decreased alcohol intake as part of the primary prevention of cardiovascular disease. However, the patient should also be offered a statin.
name: Recommend an increase in weekly exercise only
label: c
answer: no
explanation: The QRISK2 is a score used to estimate the 10-year risk of cardiovascular disease in patients under the age of 85 years who do not have heart disease.
The risk score helps guide primary prevention of cardiovascular disease with lifestyle and pharmacological intervention. Patients with a 10% or more QRISK2 score should be offered a statin to reduce the risk of cardiovascular disease. First line choice is atorvastatin 20mg.
If atorvastatin 20mg is commenced and there has not been a 40% or greater reduction in non-HDL cholesterol, then the dose can be increased up to 80mg. For **secondary prevention**, atorvastatin 80mg would be appropriate.
name: Atorvastatin 80mg
label: f
answer: no
explanation: This patient should be offered a statin and lifestyle advice as part of primary prevention of cardiovascular disease. There is no need to recalculate his QRISK2 score.
name: Recalculate QRISK2 score in 3 months time
label: d
answer: no
explanation: Whilst a statin is recommended for this patient, atorvastatin is now the first line choice. Atorvastatin is more effective at lowering cholesterol than simvastatin.
name: Simvastatin 40mg
label: b
answer: no

Correct answer: a
A 68-year-old male attends the GP practice complaining of an irritating dry cough and fever. He has been a smoker for 55 years and has a pet parrot.

In which of the following conditions would you expect to find clubbing of the fingers?

Options:
explanation: This is a type 3 and type 4 immune-mediated hypersensitivity reaction and is a form of pulmonary fibrosis. Clubbing of the fingers is commonly seen in pulmonary fibrosis. The answer is specifically hypersensitivity pneumonitis as this patient has a pet bird, from which antigens can be inhaled in the air from their faeces.
name: Hypersensitivity Pneumonitis
label: a
answer: yes
explanation: Chronic obstructive pulmonary disease (COPD) is an obstructive lung condition typically comprising of chronic bronchitis and/or emphysema. It often occurs in smokers although does not present with finger clubbing.
name: COPD
label: b
answer: no
explanation: A pneumothorax is the accumulation of air within the pleural space. It can be spontaneous, typically occurring in young men, or may be due to an underlying lung condition like COPD or tuberculosis.
name: Pneumothorax
label: e
answer: no
explanation: A pleural effusion is the accumulation of fluid in the pleural space of the lungs and can be categorised as transudative or exudative. The patient may be asymptomatic or have pleuritic chest pain. Stony dull percussion and decreased breath sounds would be present on examination but finger clubbing is not seen in this condition.
name: Pleural Effusion
label: d
answer: no
explanation: This is an acute lower respiratory tract infection that can arise from the community, hospital or aspiration among other causes. The patient would present with fever, cough and occasionally pleuritic chest pain. It does not present with finger clubbing.
name: Pneumonia
label: c
answer: no

Correct answer: a