hllj/quesmed huggingface dataset:
During a primary care rotation, a 35-year-old man comes to the GP with burning pain during urination and urethral discharge and is diagnosed with a sexually transmitted infection. He asks if it is possible to prescribe him antibiotics without putting it on the records as his wife is friends with one of the GPs at the practice and he does not want his wife to know about his presentation.

What is the most appropriate next step?

Options:
explanation: This may be well-meaning but it does not involve the patient being treated and would be breaking confidentiality for an inappropriate reason.
name: Refuse and contact his wife to alert her of the presentation in the public interest
label: d
answer: no
explanation: Whilst this may be well-meaning, it does not address his concerns and will be perceived as inflammatory. His treating doctor should advise him to disclose his history to sexual partners but should not threaten the patient.
name: Refuse and remind him that he legally must tell his wife or face criminal charges
label: b
answer: no
explanation: If treatment is prescribed in a GP practice, it must be documented on the records and not doing so is a probity issue.
name: Accept and advise the patient that he must tell his wife
label: e
answer: no
explanation: This is correct. If treatment is prescribed in a GP practice, it must be documented on the records and not doing so is a probity issue. The patient can seek help from a sexual health clinic that is not connected to the GP practice if he is concerned. The patient should be reminded of the duty of confidentiality that all doctors must abide by.
name: Refuse and offer an appointment at a sexual health clinic
label: a
answer: yes
explanation: If treatment is prescribed in a GP practice, it must be documented on the records and not doing so is a probity issue.
name: Accept and prescribe the antibiotics without documentation
label: c
answer: no

Correct answer: a


Learning point: Doctors must document information in patient records to ensure accurate, consistent care, maintain legal and ethical standards, protect patient confidentiality, and prevent potential conflicts of interest
A 40-year-old man is brought to the emergency department after a head injury.

Which of the following features, if found in the medical history, would prompt an urgent CT head within an hour according to NICE guidelines?

Options:
explanation: This may inform whether a CT Head is needed within 8 hours but does not necessitate one needed within an hour.
name: On current anticoagulation treatment
label: e
answer: no
explanation: NICE guidance suggests CT head within one hour if more than one episode of vomiting occurs in adults.
name: One episode of vomiting since the injury
label: b
answer: no
explanation: Amnesia since the injury may require a CT head within one hour if combined with other features such as loss of consciousness and drowsiness but alone may either require a CT head within 8 hours or no imaging. Please see NICE CT Head guidelines for further clarity.
name: Amnesia since the injury
label: c
answer: no
explanation: This is correct. This is an extremely concerning sign of a basal skull fracture and requires urgent imaging.
name: Haemotympanum since the injury
label: a
answer: yes
explanation: It is a seizure following the head injury with no epilepsy diagnosis that requires a CT head within an hour.
name: One seizure occurred before the head injury
label: d
answer: no

Correct answer: a


Learning point: Haemotympanum refers to the presence of blood in the middle ear, often due to trauma, skull fractures, or barotrauma. Haemotympanum indicates potential basal skull fracture and necessitates urgent CT imaging to assess for intracranial injury.
A 25-year-old man is brought to the emergency department by ambulance after a head injury, after which he became unconscious. At present he is conscious and confused, complaining of nausea and headache. A CT head is performed:

[lightgallery]

What is the likely diagnosis?

Options:
explanation: There is nothing to suggest a stroke at present with no localising hemiparesis, no slurred speech and no higher dysfunction e.g. dysphasia.
name: Middle cerebral artery stroke
label: d
answer: no
explanation: This would likely present with severe thunderclap headache and CT appearance would show widespread blood in subarachnoid space and basal cisterns.
name: Subarachnoid haemorrhage.
label: c
answer: no
explanation: This is correct. The history of head trauma with subsequent lucid interval, headache, confusion and vomiting as well as the CT appearance of a bi-convex bleed limited by sutures.
name: Extradural haemorrhage
label: a
answer: yes
explanation: This is unlikely to cause so profound a presentation and would not cause the CT changes seen.
name: Concussion
label: e
answer: no
explanation: This tends to occur in elderly patients, especially those with alcohol dependence issues and has a different crescentic lentiform appearance on CT Head with often a longer clinical history.
name: Subdural haemorrhage
label: b
answer: no

Correct answer: a


Learning point: Extradural haemorrhage often presents with a lucid interval following head trauma, headache, confusion, and characteristic bi-convex CT findings.
A 32-year-old man comes to the GP due to longstanding lower back pain which has proved resistant to exercise and non-steroidal analgesia. He describes multiple episodes of diarrhoea and blurred vision in the past. He is referred to specialists and imaging investigations are performed.

A spine X-ray shows:

[lightgallery]

Which of the following is the most appropriate management given the likely diagnosis?

Options:
explanation: This should be an adjunct to medical treatment, however, due to the severity of symptoms and spinal appearance, medical management is required.
name: Advise physiotherapy
label: b
answer: no
explanation: This is correct. The history of lower back pain with bamboo spine appearance on x-ray suggests ankylosing spondylitis with possible HLA B27 associated complications such as inflammatory bowel and uveitis. NSAIDs are first-line medical management, after which anti-TNF agents are used.
name: Infliximab
label: a
answer: yes
explanation: This is not appropriate given the symptoms and concerning appearance on imaging.
name: Discharge with reassurance
label: d
answer: no
explanation: Surgery may occasionally be required for severe joint deformity later down the line whereas medical management is the initial priority here.
name: Advise surgical correction
label: c
answer: no
explanation: This is a JAK inhibitor which is an option later down the line as it is extremely expensive and reserved for recalcitrant cases.
name: Upadacitinib
label: e
answer: no

Correct answer: a


Learning point: Infliximab, a TNF-alpha inhibitor, is commonly used as a second-line treatment for ankylosing spondylitis when NSAIDs and physical therapy are insufficient, helping reduce inflammation, pain, and improve mobility.
A 78-year-old male is found to have a positive faecal immunochemistry (FIT) test and undergoes colonoscopy.

A suspicious mass is found in the sigmoid colon. Biopsy samples are taken and confirm a colorectal adenocarcinoma.

What is the next most important investigation to perform?

Options:
explanation: Whilst active cancer greatly increases the risk of pulmonary embolism (PE), there is nothing in the history to suggest PE (e.g. oxygen requirement or tachycardia etc.). A CT CAP would therefore be better to assess for the presence of metastases.
name: CT pulmonary angiogram
label: e
answer: no
explanation: Whilst colorectal cancers often metastasise to the liver, a CT CAP is a preferable imaging study to perform as it can rule out metastases to other areas in the chest, abdomen and pelvis.
name: Liver ultrasound
label: b
answer: no
explanation: This is unlikely to be a useful imaging study unless the patient has symptoms to suggest obstruction or perforation secondary to their cancer. Even in these cases, a CT abdomen would be a much more appropriate imaging study to perform.
name: Abdominal X-ray
label: d
answer: no
explanation: Although colorectal cancers can metastasise to the liver and pancreas, this specific imaging is unlikely to be as useful as a CT CAP could assess for metastases in a wider range of areas.
name: Magnetic resonance cholangiopancreatography (MRCP)
label: c
answer: no
explanation: In the case of confirmed malignancy, a CT CAP is advised to check for metastatic spread and help stage disease. The other investigations would not be able to assess for this adequately.
name: CT scan of the chest, abdomen and pelvis (CT CAP)
label: a
answer: yes

Correct answer: a


Learning point: In colorectal adenocarcinoma, a CT scan of the chest, abdomen, and pelvis is essential for staging and detecting metastatic spread.
A 67-year-old female with metastatic breast cancer has a malignant pleural effusion.

Her observations deteriorate during her time in hospital and she is felt to be approaching the end of her life. After a discussion between the patient, her family and the medical team, the patient opts to stop all active treatment.

The palliative care team advises that the patient is written up for anticipatory medications, to help control any symptoms she may experience.

Which of the following medications is typically prescribed to help with secretions in patients who are end of life?

Options:
explanation: This is used for pain relief at the end of life rather than to reduce secretions.
name: Oxycodone
label: b
answer: no
explanation: This medication is used to treat nausea and vomiting in end-of-life care, rather than to reduce secretions.
name: Haloperidol
label: e
answer: no
explanation: This is typically used for nausea and vomiting in end-of-life care, rather than to reduce secretions.
name: Ondansetron
label: c
answer: no
explanation: This medication is used as an anxiolytic and would not reduce secretions in end-of-life care.
name: Midazolam
label: d
answer: no
explanation: Of the options listed, this is the only anti-muscarinic medication which is used to reduce secretions in end-of-life care.
name: Glycopyrronium bromide
label: a
answer: yes

Correct answer: a


Learning point: Glycopyrronium bromide is commonly prescribed to manage excessive secretions in patients receiving end-of-life care.
A 73-year-old male has shortness of breath on exertion and palpitations.

He has a past medical history of Hodgkin's lymphoma, treated with chemotherapy.

He is found to have cardiomyopathy on further investigation. His doctor states this is possibly due to his previous chemotherapy medication.

Which medication is most likely to have caused cardiomyopathy?

Options:
explanation: Doxorubicin can be used to treat Hodgkin lymphoma and has a known side effect of cardiotoxicity. Of the medications listed, it is therefore most likely to have caused cardiomyopathy.
name: Doxorubicin
label: a
answer: yes
explanation: Cisplatin more commonly causes nephrotoxicity than cardiomyopathy.
name: Cisplatin
label: b
answer: no
explanation: Bleomycin more commonly causes lung fibrosis or pneumonitis than cardiomyopathy.
name: Bleomycin
label: d
answer: no
explanation: Cyclophosphamide more commonly causes cystitis and bladder irritation than cardiomyopathy.
name: Cyclophosphamide
label: e
answer: no
explanation: Vincristine more commonly causes peripheral neuropathy than cardiomyopathy.
name: Vincristine
label: c
answer: no

Correct answer: a


Learning point: Doxorubicin, a chemotherapy agent, can cause cardiotoxicity, particularly with prolonged use or high doses, leading to heart failure, arrhythmias, and myocardial damage due to its effects on cardiac muscle cells.
A 40-year-old male has weight loss, abdominal pain and bloody diarrhoea and is diagnosed with colorectal cancer after a positive FIT test and colonoscopy.

He has a significant family history of cancer. His father died of pancreatic cancer at the age of 57 and his aunt died of endometrial cancer at the age of 55.

Which genetic syndrome is the most likely cause of this patient’s presentation?

Options:
explanation: This is associated with parathyroid hyperplasia, phaeochromocytoma and medullary thyroid carcinoma. It is therefore unlikely to cause hereditary colorectal cancer.
name: MEN Type IIA
label: e
answer: no
explanation: This is associated with pancreatic tumours, pituitary adenomas and parathyroid hyperplasia. It is therefore unlikely to cause hereditary colorectal cancer.
name: MEN Type I
label: d
answer: no
explanation: This is a syndrome associated with dominant germline mutations of TSG STK11. It is associated with brown freckles on the oral mucosa, palms and soles. It greatly increases the risk of GI cancer due to the formation of multiple polyps. It is not as common as HNPCC and therefore less likely to be the underlying genetic syndrome in this scenario.
name: Peutz-Jegher’s syndrome
label: c
answer: no
explanation: This is a less common hereditary cause of colorectal cancer. It increases the risk of duodenal tumours in addition to colorectal cancer. As a part of Gardner’s syndrome, there is also an increased risk of osteomas of the mandible and skull as well as thyroid carcinoma. Lynch syndrome therefore is more likely to be the underpinning cause of this patient’s presentation.
name: Familial adenomatous polyposis
label: b
answer: no
explanation: Lynch syndrome (HNPCC) is the most common **hereditary** cause of colorectal cancer, which should be suspected given the young age of the patient. It also increases the risk of pancreatic and endometrial cancer.
name: Lynch syndrome
label: a
answer: yes

Correct answer: a


Learning point: Lynch syndrome is primarily caused by mutations in one of the mismatch repair (MMR) genes: MLH1, MSH2, MSH6, PMS2, or the EPCAM gene, leading to a higher risk of colorectal, endometrial, and other cancers.
A 23-year-old female with right iliac fossa pain is diagnosed with appendicitis and goes on to have a laparoscopic appendectomy.

After her operation, she complains of significant nausea and has three episodes of vomiting.

Which of the following is a risk factor for postoperative nausea and vomiting?

Options:
explanation: Non-smokers have a higher risk of post-operative nausea and vomiting when compared to smokers. The exact mechanism for this is not fully understood.
name: The patient is a smoker
label: b
answer: no
explanation: Female patients have a higher risk of post-operative nausea and vomiting than male patients.
name: The patient is a female
label: a
answer: yes
explanation: Longer operations pose a greater risk factor for postoperative nausea and vomiting.
name: Shorter length of operation
label: d
answer: no
explanation: Opioid analgesia increases the risk of postoperative nausea and vomiting, as is the case with opioid analgesia in any setting.
name: Use of non-opioid analgesia peri-operatively
label: e
answer: no
explanation: Younger patients have a higher risk of postoperative nausea and vomiting than older patients.
name: Old age
label: c
answer: no

Correct answer: a


Learning point: Women are more likely to experience postoperative nausea and vomiting than men.
A 57-year-old male is kept nil-by-mouth prior to an elective knee replacement.

The patient weighs 85 kilograms and he has no known heart failure or renal impairment.

Which of the following is the closest to his maintenance fluid requirements in a 24-hour period?

Options:
explanation: This is slightly too much water for one day as well as an insufficient amount of glucose for a 24-hour period.
name: 3.0L of water

80mmol potassium, sodium and chloride

25g of glucose
label: e
answer: no
explanation: This is an insufficient quantity of potassium, sodium and chloride as well as too much glucose for a 24-hour period.
name: 2.5L of water

40mmol of potassium, sodium and chloride

150g of glucose
label: d
answer: no
explanation: NICE guidance suggests for maintenance fluids alone patients should receive:

- 25 to 30ml/kg/day of water

- 1mmol/kg/day of potassium, sodium and chloride

- Approximately 50 to 100g/day of glucose to limit starvation ketosis

This therefore means this is the most accurate representation of the patient’s maintenance fluid requirements in a 24-hour period.
name: 2.5L of water

80mmol of potassium, sodium and chloride

50g of glucose
label: a
answer: yes
explanation: This is an insufficient quantity of potassium, sodium and chloride for an 85kg patient in one day.
name: 2.0L of water

20mmol of potassium, sodium and chloride

50g of glucose
label: c
answer: no
explanation: This is over the patient’s daily water requirement and the potassium amount is incorrect as potassium only comes in 20 and 40mmol bags, therefore the option has to be 60mmol or 80mmol.
name: 3.5L of water

70mmol of potassium, sodium and chloride

100g of glucose
label: b
answer: no

Correct answer: a


Learning point: Maintenance fluid requirements for adults are approximately 25-30 ml/kg/day of water, alongside electrolytes and glucose to prevent starvation ketosis.
A 47-year-old female is in a road traffic accident.

She requires emergency surgery for a ruptured spleen.

Shortly after she is sedated and intubated, she becomes extremely sweaty and her muscles become rigid. Her temperature is recorded at 38.6 degrees Celsius and her heart rate is 118.

Her partner recalls her mother had a similar experience when she had an emergency appendectomy.

What is the most likely diagnosis?

Options:
explanation: The combination of pyrexia, tachycardia and fasciculations in a patient with a family history of a similar presentation suggests malignant hyperthermia. This is a condition seen as a response to certain anaesthetic agents (e.g. suxamethonium or volatile inhaled agents) in genetically susceptible individuals. Suxamethanoium is commonly used in emergency scenarios for rapid sequence induction as in this scenario.
name: Malignant hyperthermia
label: a
answer: yes
explanation: This is prolonged paralysis which is seen as limited respiratory effort after extubation due to a lack of cholinesterase.
name: Suxamethonium apnoea
label: b
answer: no
explanation: This is unlikely to be a normal physiological response, due to the pyrexia, tachycardia and muscle rigidity.
name: Normal physiological response
label: e
answer: no
explanation: Whilst this may present with tachycardia after being given medication, it is more likely to present with hypotension and angioedema rather than pyrexia and muscle rigidity.
name: Anaphylaxis
label: d
answer: no
explanation: Although this can present with pyrexia and tachycardia, it would be unlikely to occur suddenly after the introduction of an anaesthetic agent and may take longer to occur after a road traffic accident.
name: Sepsis
label: c
answer: no

Correct answer: a


Learning point: Malignant hyperthermia is a rare, life-threatening reaction to certain anesthetics, causing rapid muscle rigidity, high fever, and metabolic disturbances, requiring immediate treatment with dantrolene to prevent serious complications.
A 36-year-old female complains of dizziness.

She states it occurs mostly when she wakes up in the morning and turns her head to look at her phone. It has been occurring for the past 10 months.

It lasts for around 30 seconds at a time and she has no associated tinnitus or hearing loss.

Given the most likely diagnosis, what is the most appropriate management option?

Options:
explanation: This is a classic description of benign paroxysmal positional vertigo (BPPV), with short episodes of vertigo triggered by head movement. It can be treated by carrying out the Epley manoeuvre after diagnosing it using the Dix-Hallpike manoeuvre.
name: Epley manoeuvre
label: a
answer: yes
explanation: Whilst a posterior circulation stroke is an important differential for sudden-onset vertigo, it would typically come on acutely and be severe and persistent.
name: Advise the patient to attend A&E for an urgent CT head
label: e
answer: no
explanation: There are no concerning features to suggest a referral to ENT is required. If her vertigo remained persistent after the Epley manoeuvre, or if the patient developed hearing loss/tinnitus, a referral to ENT may be warranted.
name: Referral to ENT
label: c
answer: no
explanation: As the patient is not complaining of nausea, an anti-emetic is unlikely to be helpful.
name: Ondansetron
label: b
answer: no
explanation: The patient’s symptoms are not consistent with excessive ear wax and therefore prescribing olive oil drops is unlikely to be beneficial.
name: Prescribe olive oil drops
label: d
answer: no

Correct answer: a


Learning point: Benign paroxysmal positional vertigo (BPPV) causes brief dizziness with head movements. The Epley maneuver, a series of head movements, helps reposition displaced otoliths in the inner ear to relieve symptoms.
A 27-year-old male has an itchy right ear with associated watery discharge. He is finding the symptoms incredibly bothersome as he works as a music producer.

On examination, he has tenderness on palpation of his right tragus. His auditory canal is erythematous and the tympanic membrane is intact.

Which of the following is the most appropriate initial management option?

Options:
explanation: This is not an appropriate management option as the inflammation can be managed using topical steroids rather than systemic steroids which would be less effective at treating the condition and have a high risk of side effects.
name: Prescribe oral steroids
label: b
answer: no
explanation: This is typically only done if topical antibiotics are ineffective.
name: Prescribe oral antibiotics
label: c
answer: no
explanation: The tenderness of the tragus, combined with watery discharge and an erythematous auditory canal is a classic history of otitis externa. This is typically managed with topical ciprofloxacin/dexamethasone drops if the symptoms are troublesome.
name: Prescribe topical combined antibiotic/steroid drops
label: a
answer: yes
explanation: This would be an appropriate strategy for malignant otitis externa, suggested by severe pain which wakes the patient at night as well as cranial nerve palsies. It is more common in older diabetic or immunocompromised patients and does not seem to be suspected in this scenario.
name: Refer to hospital for IV antibiotics
label: d
answer: no
explanation: Whilst diabetes is a risk factor for otitis externa, it is reasonable to try basic topical management before investigating the patient further if the basic management is ineffective. Checking the patient’s HbA1c also does not address the patient’s symptoms in the meantime.
name: Check the patient’s HbA1c
label: e
answer: no

Correct answer: a


Learning point: Otitis externa presents with ear tenderness, discharge, and erythema; initial treatment often involves topical antibiotic-steroid drops for symptom relief.