hllj/quesmed huggingface dataset:
A 65 year old female is seen in the respiratory clinic to receive her most recent spirometry results. She has been experiencing a dry cough and shortness of breath which has been progressively worsening over the last 4 months.

patient has a past me dical history of rheumatoid arthritis and takes methotrexate. They have never smoked and have no allergies.

The spirometry results are as follows:

FEV1: 68%
FVC: 60%
FEV1/FVC ratio: 0.84

Diffusion Capacity of the Lungs for carbon monoxide (DLCO): reduced.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is incorrect. In bronchiectasis, an obstructive pattern would be seen on spirometry.
name: Bronchiectasis
label: c
answer: no
explanation: This is correct. The patient takes methotrexate which is a known risk factor for pulmonary fibrosis. Her spirometry also shows a restrictive pattern with both FEV1 and FVC below the predicted normal level and a ratio >0.7. The pattern is specific to pulmonary fibrosis as the DLCO is also reduced.
name: Pulmonary fibrosis
label: a
answer: yes
explanation: This is incorrect. In asthma, an obstructive pattern would be seen on spirometry.
name: Asthma
label: d
answer: no
explanation: This is incorrect. Although a restrictive pattern would also be seen in obesity hypoventilation syndrome, DLCO would not be expected to be affected.
name: Obesity hypoventilation syndrome
label: e
answer: no
explanation: This is incorrect. In COPD, an obstructive pattern would be seen on spirometry.
name: Chronic obstructive pulmonary disease (COPD)
label: b
answer: no

Correct answer: a
A 19 year old male patient presents to the GP for an asthma review. They were diagnosed with the condition at the age of 15 and the only medication they take is a salbutamol inhaler. They feel it is well-controlled and have never been admitted to hospital because of their asthma.

The patient reports using their salbutamol inhaler 5 times a week before football practice and waking up one night a week with a tight chest.

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

Options:
explanation: This is correct. According to the British thoracic guidelines (BTS) adding in an ICS such as beclomethasone is the next management step after a short-acting beta2 agonist. These would be used in combination and the patient counselled on how and when to use them.
name: Prescribe a low dose inhaled corticosteroid (ICS)
label: a
answer: yes
explanation: This is incorrect. Leukotriene receptor antagonists such as Montelukast can be trialled after low-dose inhaled corticosteroids and long-acting beta-2 agonists. According to the British thoracic guidelines (BTS) adding in an inhaled corticosteroid such as beclomethasone is the next management step after a short-acting beta2 agonist.
name: Oral leukotriene receptor antagonist
label: d
answer: no
explanation: This is incorrect. Although theophylline can be used in asthma management, it is not the next management step when only a beta2 agonist has been tried so far. According to the British thoracic guidelines (BTS) adding in an inhaled corticosteroid such as beclomethasone is the next management step after a short-acting beta2 agonist.
name: Oral theophylline
label: c
answer: no
explanation: This is incorrect. According to the British thoracic guidelines (BTS) adding in an inhaled corticosteroid such as beclomethasone is the next management step after a short-acting beta2 agonist.
name: Add long acting beta-2 agonist
label: e
answer: no
explanation: This is incorrect. Although the patient states their asthma is well managed they are still having to use their salbutamol inhaler several times a week and are experiencing nocturnal symptoms. Therefore a low dose inhaled corticosteroid inhaler should be added.
name: Review in 6 months
label: b
answer: no

Correct answer: a
A 17 year old girl attends her GP surgery for a review of her asthma symptoms. She undergoes spirometry to determine her lung volume.

Which of the following is the normal inspiratory reserve volume of a person without lung disease?

Options:
explanation: This is correct. The normal inspiratory reserve volume of a person without lung disease is approximately 3000ml, however, this can vary between patients.
name: Approximately 3000ml
label: a
answer: yes
explanation: This is incorrect. This is the inspiratory capacity
name: Approximately 3500ml
label: d
answer: no
explanation: This is incorrect. This is the normal expiratory reserve volume.
name: Approximately 1000ml
label: b
answer: no
explanation: This is incorrect. This is the total lung capacity.
name: Approximately 6000ml
label: e
answer: no
explanation: This is incorrect. This is the normal residual volume.
name: Approximately 1500ml
label: c
answer: no

Correct answer: a
A 33 year old female attends their GP to discuss the results of a recent blood test. They have been feeling more tired than usual and complain of a low-grade fever affecting their ability to concentrate. They also report widespread muscle and joint aches despite minimal physical exertion.

Their blood results are as follows:

Anti-dsDNA: positive.
Anti-sm: positive.
ANA: positive.

All other auto-antibody tests were negative.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is incorrect. Sjogren's syndrome is associated with a positive anti-Ro and anti-La. Symptoms of fatigue, fever and myalgia, although non-specific are all congruent with a diagnosis of SLE. The positive antibodies confirm this diagnosis.
name: Sjogren's syndrome
label: c
answer: no
explanation: This is correct. Symptoms of fatigue, fever and myalgia, although non-specific are all congruent with a diagnosis of SLE. The positive antibodies confirm this diagnosis.
name: Systemic lupus erythematous (SLE)
label: a
answer: yes
explanation: This is incorrect. Approximately 50-90% of patients with rheumatoid arthritis present with a positive rheumatoid factor and >95% present with a positive anti-CCP. Symptoms of fatigue, fever and myalgia, although non-specific are all congruent with a diagnosis of SLE. The positive antibodies confirm this diagnosis.
name: Rheumatoid arthritis
label: b
answer: no
explanation: This is incorrect. Wegener's granulomatosis is associated with a positive cANCA. Symptoms of fatigue, fever and myalgia, although non-specific are all congruent with a diagnosis of SLE. The positive antibodies confirm this diagnosis.
name: Wegener's granulomatosis
label: d
answer: no
explanation: This is incorrect. Diffuse cutaneous systemic sclerosis is associated with a positive Anti-Scl-70. Symptoms of fatigue, fever and myalgia, although non-specific are all congruent with a diagnosis of SLE. The positive antibodies confirm this diagnosis.
name: Diffuse cutaneous systemic sclerosis
label: e
answer: no

Correct answer: a
A 45 year old male patient attends the GP as they have begun to feel wheezy and short of breath with a nocturnal cough. It worsens when pollen is high. He has also been suffering from chronic sinusitis for the last 4 months. They have also experienced some pins and needles in their legs.


On examination, bilateral nasal polyps can be seen and a global wheeze can be heard on auscultation.


Blood test results are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|110   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|7.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|250x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|85 fL|80 - 96|
|Neutrophils|5x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|3.5x10<sup>9</sup>/L|1.5 - 4.0|
|Eosinophils|0.9x10<sup>9</sup>/L|0 - 0.4|
|Basophils|0.05x10<sup>9</sup>/L|0 - 0.1|


Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is incorrect. This presents as a rapidly progressive glomerulonephritis with pulmonary haemorrhage.
name: Microscopic polyangiitis
label: e
answer: no
explanation: This is incorrect. Although the patient is presenting with nasal polyps this is not the underlying condition and does not account for the lower respiratory tract symptoms or blood results.
name: Nasal polyps
label: d
answer: no
explanation: This is incorrect. Although the patient is presenting with an allergic clinical picture, allergic rhinitis would not have a positive ANCA and would not present with symptoms of neuropathy.
name: Allergic rhinitis
label: c
answer: no
explanation: This is incorrect. GPA (Wegener's Granulomatosis) is also a small and medium vessel vasculitis. However, as well as upper and lower respiratory tract symptoms it is characterised by pauci-immune glomerulonephritis. Additional symptoms such as haematuria or frothy urine may be seen, associated with a positive p and c-ANCA.
name: Granulomatosis with polyangiitis (GPA)
label: b
answer: no
explanation: This is correct. The patient is suffering from asthma with nasal polyps, symptoms of neuropathy and eosinophilia along with a positive pANCA. EGPA is an inflammatory small and medium vessel vasculitis.
name: Eosinophilic granulomatosis with polyangiitis (EGPA)
label: a
answer: yes

Correct answer: a
An 83 year old female attends her GP practice for a medication review. She has been struggling with reflux and dyspepsia since starting a new medication. She past medical history includes hypertension, osteoporosis, asthma and high cholesterol.

Which of the following medications is most likely to be causing her symptoms?

Options:
explanation: This is correct. Dyspepsia is a known side effect of bisphosphonates. Patients are advised to take the medication on an empty stomach with plenty of water while sitting or standing and should stay upright for at least 30 minutes afterwards.
name: Alendronic acid
label: a
answer: yes
explanation: This is incorrect. Statin medications are less likely to cause reflux or dyspepsia compared to bisphosphonates.
name: Atorvastatin
label: b
answer: no
explanation: This is incorrect. Calcium channel blockers are more likely to cause peripheral oedema than dyspepsia symptoms.
name: Amlodipine
label: d
answer: no
explanation: This is incorrect. Although thiazide diuretics can cause gastric side effects such as diarrhoea and nausea, they are unlikely to cause reflux or dyspepsia.
name: Indapamide
label: e
answer: no
explanation: This is incorrect. Although corticosteroid inhaler can cause oral issues such as candidiasis, they do not cause reflux or dyspepsia.
name: Beclomethasone inhaler
label: c
answer: no

Correct answer: a
A 76 year old male has recently been diagnosed with lung cancer. He has been thoroughly researching his condition and is keen to learn more about the process of apoptosis.

Which of the following are the appropriate steps in apoptosis?

Options:
explanation: This is incorrect. Apoptosis, or programmed cell death, allows for the safe removal of virally infected or mutated cells. It ultimately ends with phagocytosis by macrophages.
name: Phagocytosis - chromatin compaction - cell shrinkage - cell fragmentation - apoptotic blebbing
label: e
answer: no
explanation: This is incorrect. Apoptosis, or programmed cell death, allows for the safe removal of virally infected or mutated cells. The first stage is cell shrinkage.
name: Apoptotic blebbing - cell shrinkage - chromatin compaction - cell fragmentation - phagocytosis
label: d
answer: no
explanation: This is incorrect. Apoptosis, or programmed cell death, allows for the safe removal of virally infected or mutated cells. It ultimately ends with phagocytosis by macrophages.
name: Cell shrinkage - chromatin compaction - phagocytosis - apoptotic blebbing - cell fragmentation
label: c
answer: no
explanation: This is correct. Apoptosis, or programmed cell death, allows for the safe removal of virally infected or mutated cells. It ultimately ends with phagocytosis by macrophages.
name: Cell shrinkage - chromatin compaction - apoptotic blebbing - cell fragmentation - phagocytosis
label: a
answer: yes
explanation: This is incorrect. Apoptosis, or programmed cell death, allows for the safe removal of virally infected or mutated cells. The first stage is cell shrinkage.
name: Chromatin compaction - cell shrinkage - cell fragmentation - apoptotic blebbing - phagocytosis
label: b
answer: no

Correct answer: a
A 36 year old woman with chronic obesity consults her GP regarding some weight loss advice. She is highly informed and has been researching the biochemical pathways involved in metabolism. The clinician explains that glycolysis is an important cellular pathway that converts glucose into pyruvate for energy.

In which of the following parts of the cell does glycolysis occur?

Options:
explanation: This is incorrect. The rough endoplasmic reticulum is responsible for the manufacturing of lysosomal enzymes and secreted proteins as well as N-linked glycosylation. Glycolysis occurs in the cytosol of the cell. The energy created from this process is used to form adenosine triphosphate (ATP).
name: Rough endoplasmic reticulum
label: d
answer: no
explanation: This is correct. Glycolysis occurs in the cytosol of the cell. The energy created from this process is used to form adenosine triphosphate (ATP).
name: The cytosol
label: a
answer: yes
explanation: This is incorrect. Ribosomes are responsible for mRNA translation. Glycolysis occurs in the cytosol of the cell. The energy created from this process is used to form adenosine triphosphate (ATP).
name: The ribosomes
label: c
answer: no
explanation: This is incorrect. The golgi apparatus packages proteins into vesicles before they are sent to their destination. Glycolysis occurs in the cytosol of the cell. The energy created from this process is used to form adenosine triphosphate (ATP).
name: Golgi apparatus
label: e
answer: no
explanation: This is incorrect. Glycolysis occurs in the cytosol of the cell. The energy created from this process is used to form adenosine triphosphate (ATP).
name: The mitochondrion
label: b
answer: no

Correct answer: a
A 45-year-old woman presents to her GP complaining of recurrent episodes of dizziness. Upon further questioning, she describes episodes of "the room spinning" which lasts 30-60 seconds at a time. She has noticed that getting out of bed can be a trigger. There is no tinnitus or hearing loss associated with this episode, however, she does state that she often feels very nauseous and has vomited on one occasion.

What is the most likely diagnosis?

Options:
explanation: While the description of vertigo would fit with acute labyrinthitis, the fact there is no hearing loss or tinnitus makes this less likely.
name: Acute Labyrinthitis
label: b
answer: no
explanation: This is a classical description of BPPV; the otoconia in the inner ear become dislodged by head movements such as getting out of bed. This stimulates the hair cells which causes the vertigo or the sensation of the room spinning.
name: Benign paroxysmal positional vertigo (BPPV)
label: a
answer: yes
explanation: This is an important differential for vertigo as there may be ischaemia in the cerebellum causing her symptoms. However, this is less likely in this case. In particular, the fact there are no neurological findings mentioned makes BPPV most likely.
name: Transient ischaemic attack (TIA)
label: e
answer: no
explanation: This is a reactivation of the varicella-zoster virus along the facial nerve (CN VII). Whilst some vertigo may be associated, the presenting complaint is likely to be facial droop due to facial nerve palsy.
name: Ramsay-Hunt syndrome
label: d
answer: no
explanation: Typically vestibular schwannomas cause unilateral sensorineural hearing loss and progressive tinnitus. This is because they affect the conductivity of the vestibulocochlear nerve (CN VIII).
name: Vestibular schwannoma
label: c
answer: no

Correct answer: a
A 21-year-old is asking for advice about her oral contraceptive pill. For the past few days, she has been vomiting. She thinks this started after eating a "dodgy" takeaway. As she has been vomiting she has not been able to keep any food or drink down, including her combined oral contraceptive pill. Further questioning reveals she has missed three days of her pill. She also tells you she has only five pills left in the current pack and has taken the pills correctly for this cycle. She has not had any intercourse since her last withdrawal bleed, and now feels recovered and no longer feels nauseous. 

What is the most appropriate advice to give her?

Options:
explanation: As this woman is in the last week of her cycle, likely, ovulation has already been prevented. Furthermore, no history of unprotected sexual intercourse (UPSI) is mentioned.
name: Offer an emergency contraception such as the Ella one pill
label: b
answer: no
explanation: This is the best option to prevent pregnancy for this woman as she is in the final week of her cycle (as she only has five pills left in the packet). Likely, ovulation has already been prevented for this cycle. However, it is important for the next cycle, hence starting the next pack immediately after.
name: Take the last pill that was missed, finish the current pack and start the next pack immediately after
label: a
answer: yes
explanation: There is no mention of unprotected sexual intercourse (UPSI) in this time of missed pills. Furthermore, ovulation was likely already prevented as this woman is in the last week of her cycle.
name: Offer an immediate pregnancy test
label: d
answer: no
explanation: The priority for this woman is maintaining the pill's effectiveness for her next cycle. Ovulation was likely already prevented before her sickness so barrier contraception is not needed. However, to maintain the effectiveness for her next cycle, it is important she takes the last missed pill as soon as possible and then starts the next pack immediately after finishing this one.
name: Carry on with pills as normal and use barrier contraception in the pill-free week
label: c
answer: no
explanation: This is a form of emergency contraception, which is not needed in this case. Ovulation was likely already prevented before the missed pills. It is more important to maintain effective contraception for the next cycle. This woman may want to switch to another form of contraception if she is consistently struggling to take pills at the same time each day but this is not the most important step at the moment.
name: Switch to a copper IUD
label: e
answer: no

Correct answer: a
Prostate-specific antigen (PSA) can be used to help identify potential cases of prostate cancer.

| PSA test result | Patients with prostate cancer | Patients without prostate cancer |
| --- | --- | --- |
| Positive | 105 | 30 |
| Negative | 395 | 470 |

Using the information in the table, what is the specificity of the PSA test?

Options:
explanation: This would represent the sensitivity of the test. In other words, the proportion of people with the disease with a positive test result.
name: 21%
label: c
answer: no
explanation: This would represent the negative predictive value. This describes the proportion of people with a negative test result who truly do not have the disease.
name: 54%
label: b
answer: no
explanation: The specificity of a test is the proportion of people without the disease who test negative. In this example that is 470 out of 500 total patients without the disease, or 94%.
name: 94%
label: a
answer: yes
explanation: This represents the false positive rate. Which is the proportion of those without the condition who will test positive. It is calculated with this equation: false positive rate = 1 - specificity
name: 6%
label: e
answer: no
explanation: This would represent the positive predictive value or the proportion of people with a positive test result who actually have the disease.
name: 78%
label: d
answer: no

Correct answer: a
A 56-year-old man presents for a review. He was diagnosed with chronic obstructive pulmonary disorder (COPD) last year. He feels his breathlessness is getting worse despite the use of his salbutamol inhaler. He is currently still smoking and has a 30-pack-year smoking history.

Which management option is the most important?

Options:
explanation: This would be inappropriate for a few reasons. Firstly, the patient is still smoking which creates a risk of fire. Secondly, we do not know if this patient would benefit from additional oxygen. They have airway obstruction but no signs of hypoxia such as cyanosis or chronically low oxygen saturations.
name: Refer to receive long-term oxygen therapy
label: d
answer: no
explanation: This is a very invasive procedure which should not be used so early in this patient's journey. Trialling non-pharmacological and medical management options first is more appropriate.
name: Refer to thoracic surgeons for lung volume reduction surgery
label: b
answer: no
explanation: This may be considered as a next step in pharmacological management, as the patient is not benefiting from salbutamol alone. However, offering smoking cessation advice and services is more important.
name: Add in a tiotropium inhaler once daily
label: c
answer: no
explanation: This is the single most important management step as smoking cessation is the most effective way of reducing the decreasing lung function in these patients.
name: Offer smoking cessation advice
label: a
answer: yes
explanation: This may be a good next step for the pharmacological management of this patient's COPD. However, smoking cessation is more important in the first instance as it will slow the progression of the disease.
name: Add in an inhaled corticosteroid inhaler (e.g. Beclomethasone)
label: e
answer: no

Correct answer: a
A 62-year-old woman presents to her GP with episodes of incontinence. She describes episodes of waking up in the night feeling desperate to pass urine. She states that she never makes it on time so is leaking urine into the bed almost every night. On further questioning, she tells you that there is no leaking of urine on coughing or laughing. She also tells you she has had three vaginal deliveries previously.

What is the most likely form of urinary incontinence in this patient?

Options:
explanation: There are no features of stress incontinence alongside the urgency symptoms. These features could include urine leakage when laughing and coughing.
name: Mixed incontinence
label: e
answer: no
explanation: This description of incontinence could represent overflow incontinence, however, the absence of risk factors such as prostatism or structural abnormalities makes this less likely.
name: Overflow incontinence
label: c
answer: no
explanation: This describes the sudden and involuntary loss of urine associated with urinary incontinence.
name: Urge incontinence
label: a
answer: yes
explanation: This woman has some risk factors for stress incontinence due to three vaginal deliveries of her children. However, the fact that there is no urine leakage when coughing or laughing makes this less likely.
name: Stress incontinence
label: b
answer: no
explanation: There is an abnormality with this patient's bladder making it overactive. She should not be consistently waking in the night with urgency symptoms. Therefore, we can rule out functional incontinence.
name: Functional incontinence
label: d
answer: no

Correct answer: a