hllj/quesmed huggingface dataset:
An 82-year-old woman falls onto her outstretched hands after not seeing a kerb. She immediately cradled her right arm and complained of severe pain. An X-ray in the accident and emergency department has revealed a fracture of the distal end of the radius with dorsal displacement.

What is the name of this kind of fracture?

Options:
explanation: A Galeazzi fracture is a fracture of the middle to distal-third of the radius associated with dislocation or subluxation of the distal radioulnar joint (DRUJ).
name: Galeazzi fracture
label: c
answer: no
explanation: This is also a distal radius fracture but with volar angulation of the distal fragment.
name: Smith fracture
label: e
answer: no
explanation: Colles' fracture normally follows a fall on an outstretched wrist and leads to a distal radial fracture with dorsal displacement of the distal fragment. It occurs mostly in older women with osteoporotic bones.
name: Colles' fracture
label: a
answer: yes
explanation: A Bennett fracture is a fracture of the base of the thumb resulting from forced abduction of the first metacarpal. It is defined as an intra-articular two-part fracture of the base of the first metacarpal bone.
name: Bennett fracture
label: d
answer: no
explanation: Monteggia fractures involve a fracture of the proximal third of the ulnar shaft and anterior dislocation of the radial head at the capitellum.
name: Monteggia fracture
label: b
answer: no

Correct answer: a
A 69-year-old woman who has been taking oral steroids for the last year for giant cell arteritis presents with progressive pain in her left groin. The pain started insidiously and has been getting worse for the past two months. On examination, movement of her hip is painful in all directions but there is no evidence of limb shortening or external rotation. A weight-bearing hip X-Ray shows a crescent sign.

Which of the following is the most likely diagnosis?

Options:
explanation: Transient osteoporosis of the hip is a rare condition that causes bone loss temporarily in the superior section of the femur. It is mostly found in young or middle-aged men between the ages of 30 and 60, and women in their later stages of pregnancy or early postpartum period (following childbirth). The majority of patients present with a sudden onset of pain in the groin area.
name: Transient osteoporosis
label: b
answer: no
explanation: X-ray signs associated with osteoarthritis are nonuniform joint space loss, osteophyte formation, cyst formation and subchondral sclerosis.
name: Osteoarthritis
label: e
answer: no
explanation: This causes lateral hip pain and is thought to be caused by inflammation of the trochanteric bursa. It often presents with pain which can radiate to the lateral knee when side-lying on the affected side or when sitting down for prolonged periods. It is investigated with ultrasound and then MRI if required.
name: Trochanteric bursitis
label: d
answer: no
explanation: This would be unusual to present initially in the hip region. It would also normally present with morning stiffness lasting over an hour and/or systemic symptoms of fatigue, fever or loss of appetite. The pain generally gets better after activity. X-ray features would include erosions or significant soft tissue swelling.
name: Rheumatoid Arthritis
label: c
answer: no
explanation: This is the death of the femoral head as a result of vascular disruption. Symptoms are often similar to osteoarthritis with progressive pain on activity. Risk factors include steroids, trauma and radiation. In mild-to-moderate AVN, radiographs may demonstrate sclerosis and changes in bone density. In advanced disease, bone deformities, such as flattening, subchondral radiolucent lines (crescent sign), and collapse of the femoral head, are evident.
name: Avascular necrosis
label: a
answer: yes

Correct answer: a
A 26-year-old type 1 diabetic male presents to the emergency department by ambulance. His bedside glucose is 22mmol/L (nromal <6.1 mmol/L). His ketones are 3.8mmol/L (normal <0.6 mmol/L) and bicarbonate 14mmol/L (normal 22-30 mmol/L) on a venous blood gas.

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

Options:
explanation: This patient is in diabetic ketoacidosis (DKA) by definition. There is universal agreement that the most important initial therapeutic intervention in DKA is appropriate fluid replacement followed by insulin administration. 0.9% sodium chloride solution (‘normal saline’) is the fluid resuscitation of choice according to the latest guidance from the joint British Diabetes Societies.
name: IV saline (0.9% NaCl)
label: a
answer: yes
explanation: Conversion to a subcutaneous regime should occur when the patient is biochemically stable (capillary ketones less than 0.6 mmol/L AND pH over 7.3) and the patient is ready and able to eat.
name: Subcutaneous insulin
label: c
answer: no
explanation: This should occur as step 2 following commencement of 0.9% NaCl. The IV insulin should be given at a rate of 0.1unit/kg/hour.
name: Intravenous insulin infusion
label: d
answer: no
explanation: There is universal agreement that the most important initial therapeutic intervention in DKA is appropriate fluid replacement followed by insulin administration. 0.9% sodium chloride solution (‘normal saline’) is the fluid resuscitation of choice according to the latest guidance from the Joint British Diabetes Societies.
name: IV Ringer's Lactate (Hartmann's solution)
label: b
answer: no
explanation: This is an oral medication used in the treatment of type 2 diabetes mellitus.
name: Gliclazide
label: e
answer: no

Correct answer: a
An 82-year-old type 2 diabetic male complains of feeling lightheaded on the geriatric ward. The foundation doctor reviews him and requests his nurse to check his bedside blood glucose which reads 3.5mmol/L (normal <6.1 mmol/L). He is orientated to time and place, and able to swallow.

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

Options:
explanation: This would be an appropriate treatment once the patient;s blood glucose was above 4mmol/L. It equates to 20g of long-acting carbohydrate.
name: One piece of toast
label: c
answer: no
explanation: This would be appropriate if the patient was unconscious/fitting, very aggressive, or nil by mouth (NBM).
name: IV 200ml 10% glucose over 15 minutes
label: e
answer: no
explanation: This would be an appropriate treatment if the patient was conscious and able to swallow, but confused, disorientated or aggressive i.e. moderate hypoglycaemia.
name: 40% glucose oral gel (2 tubes)
label: b
answer: no
explanation: The Joint British Diabetes Societies have produced an algorithm for the treatment and management of hypoglycaemia in adults with diabetes mellitus in hospital. It states that if the patient is conscious, orientated, and able to swallow, they have mild hypoglycaemia. This should be treated with 15-20g of quick-acting carbohydrate, such as five to seven Dextrosol tablets, four to five Glucotabs or 150-200ml pure fruit juice.
name: Four to five Glucotabs
label: a
answer: yes
explanation: This would be appropriate if the patient was unconscious/fitting, very aggressive or nil by mouth (NBM).
name: 1mg IM glucagon
label: d
answer: no

Correct answer: a
A 62-year-old male visits an advanced nurse practitioner for a review of his type 2 diabetes. He has currently been taking metformin at his maximum tolerated dose for the last 6 months. His latest HbA1c result is 63mmol/mol and his individually agreed aim is 50mmol/mol. He has suffered from stable angina for the last 3 years but is otherwise well.

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

Options:
explanation: This would be considered when dual therapy with metformin and another oral drug has not continued to control HbA1c to below the person's individually agreed threshold.
name: Start insulin-based treatment
label: b
answer: no
explanation: You could consider adding this drug as a second-line. However, NICE guidance suggests as this man has established atherosclerotic cardiovascular disease, an SGLT2 is preferred first.
name: Add pioglitazone
label: c
answer: no
explanation: You could consider adding this drug as a second-line. However, NICE guidance suggests as this man has established atherosclerotic cardiovascular disease, an SGLT2 is preferred first.
name: Add gliclazide
label: d
answer: no
explanation: Exenatide is a GLP‑1 mimetic. This would only be considered in special circumstances where triple therapy with metformin and 2 other oral drugs is not effective, not tolerated or contraindicated.
name: Add Exenatide
label: e
answer: no
explanation: Dapagliflozin is an oral hypoglycaemic drug of the class SGLT2 inhibitor. NICE recomemnds for adults with type 2 diabetes at any stage after they have started first-line treatment if they have or develop chronic heart failure or established atherosclerotic cardiovascular disease, to offer an SGLT2 inhibitor in addition to current treatment.
name: Add dapagliflozin
label: a
answer: yes

Correct answer: a
A 55-year-old male presents to the GP with gradual onset perioral paraesthesia which developed over the last three days. On examination, Trousseau's sign is present and an urgent ECG reveals a prolonged QT interval.

Which of the following is the most likely electrolyte abnormality?

Options:
explanation: Hyponatraemia is defined as serum sodium concentration <135mmol/L. Clinical features include nausea or vomiting, headache, confusion, fatigue, low blood pressure, loss of energy, muscle weakness, twitching, muscle cramps, seizures and coma. Hyponatraemia does not have any effect on the ECG, cardiac rhythm, or impulse conduction.
name: Hyponatraemia
label: e
answer: no
explanation: Hypercalcaemia is defined as corrected calcium >2.65mmol/L. There are often clinical features such as bone pain, osteoporosis, fatigue, confusion, memory problems, depression, nausea, vomiting, abdominal pain, weight loss, thirst, polyuria, constipation, abdominal pain, renal colic, or renal impairment. ECG changes include shortening of the QT interval. In severe hypercalcaemia, Osborn waves (J waves) may be seen.
name: Hypercalcaemia
label: b
answer: no
explanation: Hypokalaemia is defined as serum potassium concentration <3.5mmol/L. Clinical features include muscle cramps and pain with rhabdomyolysis, weakness, fatigue, palpitations, syncope, or cardiac arrhythmias. An ECG can show dynamic changes in T-wave morphology, ST-segment depression, and U waves, which are often best seen in the mid-precordial leads (V2–V4). The PR interval can also be prolonged along with an increase in the amplitude of the P wave.
name: Hypokalaemia
label: d
answer: no
explanation: Hypocalcaemia is a state of electrolyte imbalance in which the circulating serum calcium level is <2.1mmol/L. Clinical signs include Trousseau's sign where there is carpopedal spasm on inflation of a blood pressure cuff and Chvostek's sign where contraction of the ipsilateral facial muscles is elicited by tapping the facial nerve just anterior to the ear. The ECG hallmark of hypocalcaemia is QT interval prolongation secondary to a prolonged ST segment.
name: Hypocalcaemia
label: a
answer: yes
explanation: Hyperkalaemia is defined as serum potassium concentration >5.5mmol/L. Clinical features include lethargy, nausea, muscle weakness or paraesthesia. ECG changes (in order of severity) include:t all tented T-waves, flattened P-waves, prolonged PR interval, widened QRS complexes, idioventricular rhythms, sine wave patterns and VF/asystole.
name: Hyperkalaemia
label: c
answer: no

Correct answer: a
A 44-year-old woman is seen in the endocrinology clinic with a five-week history of fatigue and weight gain. She has a past medical history of reflux and she denies recent infectious symptoms. On examination, she has a heart rate of 95 bpm and blood pressure of 158/98mmHg. Her skin appears thinned and there are numerous prominent bruises across her upper arms.

Which of the following initial tests is most likely to make the diagnosis?

Options:
explanation: This is a test used in suspected Addison's disease. Patients presenting with Addison's disease usually appear tanned, lean, fatigued, and notice significant weight loss.
name: Short ACTH stimulation test
label: d
answer: no
explanation: This is a test used in suspected acromegaly. The clinical presentation would be with increasing size of hands and feet, frontal bossing, headache, macroglossia, and proximal myopathy.
name: Oral glucose tolerance test
label: c
answer: no
explanation: The most likely diagnosis in this case is Cushing's syndrome. The low-dose (overnight) dexamethasone suppression test is the most sensitive test to diagnose Cushing's syndrome and is now used first-line. In patients with Cushing's disease, there would be no change in cortisol levels. Patients without Cushing's disease will have reduced cortisol levels.
name: Low-dose (overnight) dexamethasone suppression test
label: a
answer: yes
explanation: The high-dose dexamethasone suppression test is a localisation test once Cushing's syndrome has been diagnosed. If cortisol and ACTH are both suppressed, this is indicative of Cushing's disease. If both are NOT suppressed this indicates an ectopic ACTH syndrome. Finally, if cortisol is not suppressed but ACTH is then this is Cushing's syndrome due to other causes- for example an adrenal adenoma.
name: High-dose dexamethasone suppression test
label: e
answer: no
explanation: This is a localisation test. CRH (Corticotrophin Releasing hormone) is given to test the responsiveness of the pituitary in producing ACTH and then cortisol. If the syndrome is of a pituitary source, cortisol rises. If it is of ectopic/adrenal source, there is no change in cortisol.
name: CRH stimulation test
label: b
answer: no

Correct answer: a
An unvaccinated two-year-old toddler presents to the paediatric assessment unit with his mother following a referral from his GP. He is in obvious distress and presents with a fever of 40.5 degrees, as well as soft stridor. His mother says that, over that last few hours, he has been unusually drooling a lot and resting in a tripod position.

Which of the following is the most likely diagnosis?

Options:
explanation: Acute epiglottitis is a life-threatening cause of respiratory distress in children due to the risk of airway obstruction. It is typically caused by Haemophilus influenzae type b. Conjugate vaccines to Hib mean the disease is now much less common. However, children who are not up-to-date with their vaccinations, or in households who refuse vaccination, are at greater risk. Clinical features include rapid onset, high temperature, generally unwell, stridor, drooling of saliva and presenting in a 'tripod' position: leaning forward and extending their neck in a seated position to maximise airway opening.
name: Acute Epiglottitis
label: a
answer: yes
explanation: Subglottic stenosis can be defined as the narrowing of the upper airway, which lies between the vocal folds and the lower border of the cricoid cartilage. It can be congenital or acquired. In congenital subglottic stenosis, symptoms usually appear shortly after birth. The main symptoms are biphasic stridor, dyspnoea, air hunger, and suprasternal, intercostal, and diaphragmatic retractions. Abnormal cry, aphonia, or hoarseness occur when the vocal cords are affected. In acquired subglottic stenosis, there is a history of laryngeal insult often by trauma, and symptoms usually occur three to four weeks after the insult.
name: Subglottic stenosis
label: d
answer: no
explanation: This is a condition which can present at any age. It is an acute swelling of the upper airway that may cause dyspnoea and stridor. Fever is uncommon though. Swelling of the face, tongue, or pharynx are often also present.
name: Angioneurotic oedema
label: e
answer: no
explanation: This may present with sudden onset dyspnoea and stridor but there is usually a clear history of foreign body inhalation or ingestion and no prodrome or symptoms of viral illness as well as no fever (unless secondary infection).
name: Foreign body obstruction
label: c
answer: no
explanation: Croup should be suspected in a child with a sudden onset of a seal-like barking cough. Hoarse voice is also common. Symptoms are typically worse at night and increase with agitation.
name: Croup (Laryngotracheobronchitis)
label: b
answer: no

Correct answer: a
A six-month-old child with suspected bronchiolitis is reviewed on the ward round in the paediatric ward.

Which one of the following is the most likely pathogen causing this disease?

Options:
explanation: This virus can cause bronchiolitis but less often so than RSV.
name: Adenovirus
label: c
answer: no
explanation: Respiratory syncytial virus (RSV) is responsible for 80% of cases of bronchiolitis.
name: Respiratory syncytial virus (RSV)
label: a
answer: yes
explanation: This bacterial pathogen causes whooping cough, not bronchiolitis.
name: Bordetella pertussis
label: e
answer: no
explanation: This virus can cause bronchiolitis but less often so than RSV.
name: Bocavirus
label: b
answer: no
explanation: This virus can cause bronchiolitis but less often so than RSV. It is the most common cause of croup, however.
name: Parainfluenza virus
label: d
answer: no

Correct answer: a
A two-year-old infant presents to the GP with her father. He reports his daughter has had a persistent barking cough over the last five days. On examination, there is an easily audible stridor and sternal wall retraction at rest, but she appears in no distress or agitation. She is interested in the stethoscope you gave her to play with and is able to speak back to you.

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

Options:
explanation: This is an antibiotic. Parainfluenza virus (among other viruses) is the primary cause accounting for the vast majority of cases of croup. As such, antibiotics are not indicated in the management of croup at this stage.
name: Amoxicillin
label: d
answer: no
explanation: This is a short-acting beta-agonist often used in the treatment of asthma and bronchospasm. It is not indicated in the management of croup at this stage.
name: Salbutamol
label: c
answer: no
explanation: The most likely diagnosis here is croup. NICE guideline on the management of croup states to administer a dose of oral dexamethasone (0.15 mg/kg) either while awaiting admission to hospital or if hospital admission is not indicated in mild disease.
name: Dexamethasone
label: a
answer: yes
explanation: This would be indicated where are there significant concerns about the airway of a child, certainly not in this case if they are speaking comfortably.
name: Nebulised adrenaline
label: e
answer: no
explanation: Prednisolone is a steroid drug. However, regarding anti‐inflammatory potential, dexamethasone is five to six times more potent than prednisolone. Therefore, it is preferred in treatment of croup. In addition, dexamethasone is a long-acting drug whereas prednisolone is intermediate-acting.
name: Prednisolone
label: b
answer: no

Correct answer: a
An eight-year-old boy attends the GP surgery with abdominal pain for the last six days. He is eating and drinking normally. He has no urinary symptoms and no change in bowel habit. He had experienced some upper respiratory symptoms one week ago which the advanced nurse practitioner thought was viral, but these have since subsided. Aside from this, he is generally a fit and well child with no past medical history. On examination, the abdomen is soft but mildly tender throughout. His temperature is 37.5 degrees. His chest is clear and heart sounds are normal.

Which of the following is the most likely diagnosis?

Options:
explanation: Mesenteric adenitis describes inflamed mesenteric lymph nodes. It is often preceded by a previous upper respiratory tract infection as in this case. Its' presentation is described typically here too with low-grade fever and generalised abdominal tenderness.
name: Mesenteric adenitis
label: a
answer: yes
explanation: Classically, acute appendicitis presents as progressive peri-umbilical pain that moves to the right iliac fossa, and not as generalised tenderness. Nausea and one to two episodes of vomiting are also common, and not present in this case.
name: Acute appendicitis
label: c
answer: no
explanation: Meckel's would present similarly to appendicitis with severe pain and most commonly affects children aged approximately two years old. It can also present as painless rectal bleeding.
name: Meckel's diverticulum
label: d
answer: no
explanation: Intussusception usually affects infants between 6-18 months old. It features intermittent, severe, crampy, progressive abdominal pain. There will also most likely be a palpable mass, often described as "sausage-shaped".
name: Intussusception
label: e
answer: no
explanation: He is not vomiting or had a change in bowel habit, which would be expected in gastroenteritis.
name: Gastroenteritis
label: b
answer: no

Correct answer: a
An eight-week-old baby is visited by the health visitor with projectile vomiting after feeds for the last few days. The vomit is profuse but not green and occurs within minutes of a feed. The baby remains otherwise well and still appears to have an appetite. On examination, there is a palpable mass in the upper abdomen.

Which of the following is the most likely diagnosis?

Options:
explanation: This is a rare condition, which typically presents as bilious vomiting within the first day of life.
name: Malrotation
label: d
answer: no
explanation: Pyloric stenosis is a condition resulting from the hypertrophy of the pyloric sphincter. It typically occurs in babies aged 6-8 weeks old. The classic presentation is of projectile vomiting as in this case. The palpable mass, often described as a smooth olive-sized mass, is the hypertrophic pyloric sphincter.
name: Pyloric stenosis
label: a
answer: yes
explanation: Gastro-oesophageal reflux affects up to 40% of children during the first 6 months of life. It can present as vomit after feeds, but is not normally projectile. There is often associated crying/irritability, arching of the back or drawing up of the knees into the chest.
name: Gastro-oesophageal reflux disease
label: b
answer: no
explanation: Intussusception usually affects infants between 6-18 months old. It features intermittent, severe, crampy, progressive abdominal pain. There might be a palpable mass, but the key presenting feature is usually bloody stools.
name: Intussusception
label: e
answer: no
explanation: Volvulus presents with bilious vomiting, abdominal pain (if old enough to complain of) and somnolence.
name: Volvulus
label: c
answer: no

Correct answer: a
An 18-year-old university student attends his GP. He complains he has had a sore throat for the past six days. He denies having a cough, but does report a fever yesterday. On examination, his right tonsil appears to have exudate on its surface and tender cervical lymphadenopathy is noted. He is otherwise well and currently apyrexial. He denies having any allergies.

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

Options:
explanation: This would be an appropriate prescription for a non-pregnant person with a penicillin allergy with these symptoms and signs.
name: Clarithromycin
label: c
answer: no
explanation: This is a treatment when candidal pharyngitis is suspected in more widespread areas.
name: Fluconazole
label: d
answer: no
explanation: This is an appropriate action that can be taken by the ENT specialists in secondary care when there is evidence of peri-tonsillar abscess, parapharyngeal abscess or retropharyngeal abscess.
name: Aspiration of exudate
label: b
answer: no
explanation: This patient has a Centor score of 4 for his fever, absent cough, lymphadenopathy and tonsillar exudate. According to the NICE guidelines on acute sore throats, those with a Centor score of 3 or 4 should be prescribed phenoxymethylpenicillin first-line.
name: Phenoxymethylpenicillin
label: a
answer: yes
explanation: This would be appropriate if the Centor score was less than 3.
name: Supportive care
label: e
answer: no

Correct answer: a