hllj/quesmed huggingface dataset:
A 79-year-old presents with progressively worsening vision. He reports that he struggles to drive at night, but cannot pinpoint when this all began. He has a past medical history of hypertension and hypercholesterolaemia. He takes amlodipine and atorvastatin, and has no allergies. He smokes 10 cigarrettes per day and drinks 10 units of alcohol a week.

His observations are within normal limits. Fundoscopy identifies yellow deposits.

Options:
explanation: A cataract is an opacity in the lens. They are more common in the elderly, but they would not cause drusen on fundoscopy. Classic presenting symptoms include 'haloes around lights', and there will be a loss of the red reflex on examination
name: Cataract
label: e
answer: no
explanation: This patient has dry age related macular degeneration (ARMD). In wet ARMD, one would see neovascularisation, bleeding and fluid leakage on fundoscopy. This presents more rapidly and has a poorer prognosis than dry ARMD.
name: Wet age related macular degeneration
label: b
answer: no
explanation: Central retinal vein occlusion (CRVO) typically causes **sudden** painless visual loss, whilst this patient's presentation is far more insidious in onset. Fundoscopy in CRVO will show: haemorrhages, cotton wool spots, retunal oedema and tortuous retinal veins. None of these are present here.
name: Central retinal vein occlusion
label: d
answer: no
explanation: Correct! This patient has dry age related macular degeneration (ARMD). The 'yellow deposits' on fundoscopy are drusen which are seen in the condition. Dry ARMD accounts for the vast majority of cases. All patients with ARMD should be encouraged to stop smoking.
name: Dry age related macular degeneration
label: a
answer: yes
explanation: Whilst this patient has known hypertension, this is well controlled (with normal BP on assessment) with one anti-hypertensive medication. Signs on fundoscopy of hypertensive retinopathy include: narrowing of the retinal arteries, retinal haemorrhages, hard exudates and cotton wool spots.
name: Hypertensive retinopathy
label: c
answer: no

Correct answer: a
Which of the following characteristics support diagnosis of Lewy Body Dementia (LBD) rather than Parkinson's disease dementia (PDD)?

Options:
explanation: Dementia symptoms can precede motor symptoms, but if motor symptoms are rapidly followed by dementia onset (within 1 year) this would indicate LBD.
name: Emergence of dementia 6 months after parkinsonian motor symptom onset
label: a
answer: yes
explanation: Lewy bodies are protein aggregates  (primarily alpha-synuclein) which are characteristic of both Parkinson's Disease and LBD and therefore not a distinguishing feature.
name: Histological finding of 'Lewy Bodies' in the brain on autopsy
label: e
answer: no
explanation: This is a motor sign suggestive of Progressive Supranuclear Palsy, a Parkinson's plus syndrome. It is not a feature of LBD.
name: Vertical gaze palsy
label: d
answer: no
explanation: Visual hallucinations are found in both LBD and PDD.
name: Visual hallucinations
label: b
answer: no
explanation: REM sleep behaviour disorder (acting out dreams) is found in both LBD and PDD
name: REM (rapid eye movement) sleep behaviour disorder
label: c
answer: no

Correct answer: a
A 53 year old male bus driver attends his GP practice, he has recently been discharged from hospital after having a stroke. He has attend to discuss his new medication. He mentions that he has not told the DVLA about the stroke as he is keen to return to work and does not want to lose his liscense. After discussing why he needs to inform the DVLA he continues to refuse.

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

Options:
explanation: Those with a lorry, bus or coach driving liscence who suffer a stroke must report this to the DVLA regardless of their ongoing symptoms or neurological defecit. Therefore, a neurological examination would not change the outcome of the consultation.
name: Conduct a full neurological examination to determine if he is safe to drive
label: d
answer: no
explanation: As the patient is a bus driver, it is therefore in the public's best interest to report the issue to the DVLA without the patient's consent. However, it is important to inform the patient of your intention to disclose this to the DVLA and explain your legal responsibility to do so.
name: Contact the DVLA and inform the patient
label: a
answer: yes
explanation: This would only be acceptable if the patient agrees to stop driving in the meantime whilst they consider reporting to the DVLA. If they do not agree to this then it is the doctor's responsibility to report it.
name: Review the patient again in 2 weeks to see if he has changed his mind
label: e
answer: no
explanation: This would be the case for a car or motorbike liscence, however, the patient is a bus driver and therefore there is a legal responsibility for the patient to inform the DVLA that they have had a stroke.
name: The patient only needs to inform the DVLA if he is still having problems 1 month after the stroke
label: c
answer: no
explanation: Whilst the patient may have capacity there is a legal responsibility for doctors to report to the DVLA in this situation if they have not been able to persuade the patient to stop driving.
name: Nothing as  the patient has capacity
label: b
answer: no

Correct answer: a
A 70 year old man presented to his GP with several months of increasing tiredness. His examination was unremarkable. The GP carried out some blood tests which are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|87 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|10x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|140x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|78 fL|80 - 96|
|Serum Vitamin B12|532 ng/L|160 - 925|
|Serum Folate|3.0 μg/L|3 - 15|
|HbA1c (Glycated Haemoglobin)|47 mmol/mol or %|20 - 42 or 4-6%|


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

Options:
explanation: Given the patient's age he needs exclusion of malignancy before looking at a dietary cause for his iron-deficiency anaemia.
name: Iron tablets
label: c
answer: no
explanation: Whilst tiredness can be multi-factorial and social stressors or care needs may be a factor, the most important first step is ruling out malignancy
name: Discussion of social circumstances and mood
label: e
answer: no
explanation: Whilst a blood film can be helpful in determining the type of anaemia (eg hypochromic or microcytic), with the above results including the haematinics it is likely an iron deficiency anaemia. If there was a suspicion of a haematological malignancy or the blood results were suggestive of bone marrow failure, then a blood film would be helpful.
name: Blood film
label: d
answer: no
explanation: NICE guidance advises referral on the 2 week wait suspected cancer pathway for patients over the age of 60 with iron deficiency anaemia.
name: Urgent 2 week wait referral for lower gastrointestinal tract cancers
label: a
answer: yes
explanation: Whilst the patient is pre-diabetic and may benefit from some lifestyle modifications, given his age and iron deficiency anaemia the most important step is 2 week wait referral for suspected lower gastrointestinal cancer.
name: Diet and lifestyle modifcation
label: b
answer: no

Correct answer: a
A 2 year old presents to the GP surgery with her mother. She has had 2 days of a harsh cough, a low grade temperature and decreased oral intake.
On examination she has mild stridor, a bark like cough and subcostal recession.

Which organism is the most likely cause of her presentation?

Options:
explanation: The patient's presentation is classic of croup, caused by parainfluenza virus. Croup is also known as laryngotracheobronchitis, is an infection of the upper airway. It commonly occurs in children under the age of three, with a harsh 'barking' or 'seal-like' cough, increased work of breathing and fevers. Whilst parainfluenza is the primary cause for croup, other viruses can also cause croup e.g. adenovirus, influenza and RSV.
name: Parainfluenza virus
label: a
answer: yes
explanation: Respiratory syncytial virus (RSV) can also cause croup, but this is less common. RSV is the most common pathogen causing bronchiolitis. Bronchiolitis occurs most commonly in under 1 year-olds, and it also presents with respiratory distress but not the bark like cough seen in croup.
name: Respiratory syncytial virus
label: b
answer: no
explanation: This pathogen can cause Scarlet fever, which presents with a course ('sandpaper') red rash on the cheeks, a bright red inflamed tongue with fevers and a sore throat.
name: Streptococcus pyogenes
label: d
answer: no
explanation: Adenovirus can also cause croup, however it is not the most common causative pathogen. Adenovirus is the most common pathogen to cause bronchiolitis obliterans- a rare condition of airway obstruction due to scarring of the bronchioles from recurrent infections
name: Adenovirus
label: e
answer: no
explanation: This bacteria can cause bacterial tracheitis in children, which is a rare but very serious condition. It can present similarly to croup but with a quickly progressive airway obstruction and thick airway secretions
name: Staphylococcus aureus
label: c
answer: no

Correct answer: a
A 25 year old female attends her GP surgery with heavy periods for the past 6 months. Due to this she is struggling to go to work when menstruating. Her periods are regular with no intermenstrual bleeding.
She has a past medical history of migraines with aura for which she takes sumitriptain.

An examination reveals no abnormalities. Blood tests are carried out which show a mild anaemia and a normal clotting screen.

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

Options:
explanation: A levonorgestrel-releasing intrauterine system (IUS) such as Mirena® is a coil that elutes levongesterel. It is used as contraception as well as a treatment for menorrhagia when dysfunctional intrauterine bleeding has been diagnosed. NICE guidance suggests initiating treatment for heavy menstrual bleeding without further investigation when the patient is low risk for fibroids or uterine cavity abnormalities, such as this patient.
The coil should be offered first line and disucssed with the patient to see if it aligns with their wishes in terms of contraception. The patient should also be counselled on the IUS causing menstrual irregularities for the first 6 months.
name: A Levonorgestrel-releasing intrauterine system
label: a
answer: yes
explanation: An intrauterine device (IUD) is also known as the copper coil. It is a form of contraception. It is not recommended in menorrhagia as the IUD can cause periods to be heavier.
name: Intrauterine device
label: e
answer: no
explanation: An ultrasound is recommended if there is a suspicion of fibroids eg a mass felt on examination, age of over 30 or dysmenorrhea.
name: Pelvic ultrasound
label: b
answer: no
explanation: Whilst this can be used as a treatment option for menorrhagia secondary to dysfunctional uterine bleeding, it is contraindicated for this patient due to her history of migraines with aura.
name: Combined oral contraceptive pill
label: c
answer: no
explanation: Tranexamic acid can be offered to treat menorrhagia for those who find the IUS unsuitable. It can also be beneficial to those who are suspected to have fibroids as it can be used in the interim before investigations have been arranged.
name: Tranexamic acid
label: d
answer: no

Correct answer: a
A 36 year old female attends her GP practice to discuss contraception. She is 4 weeks post partum and is currently breast feeding. She is on day 2 of her first period since giving birth.
She has a past medical history of menorrhagia, she does not take any regular medication.
She previously took a combined oral contraceptive pill (COCP).

Which of the following is most appropriate next step in managing this patient?

Options:
explanation: Combined hormonal contraceptive patches such as Evra are contraindicated when less than 6 weeks post partum and breastfeeding. This is because of the increased risk for VTE post natally which would be increased further with the use of a combined hormonal contraceptive patch.
name: Combined hormonal contraceptive patch
label: e
answer: no
explanation: Contraception is not required for the first 21 days post partum, however, beyond that contraception is recommended even if still breastfeeding. Lactational amenorrhea is a temporary lack of fertility whilst breast feeding. Lactational amenorrhea method (LAM) is sometimes used as a form of 'natural' contraception. If used correctly it is effective with only 2 in 100 people becoming pregnant in the first 6 months post partum. However, it requires consistent and exclusive breast feeding and amenorrhoea. It is only effective for the first 6 months post-partum. It is therefore recommended by the Faculty of Sexual and Reproductive Healthcare to implement contraception before 21 days.
name: Reassure her that no contraception is needed when breastfeeding
label: b
answer: no
explanation: The IUD, also known as the copper coil, can commonly cause periods to be heavier. As this patient has a history of menorrhagia it is not a suitable option for her.
name: Intrauterine device (IUD)
label: d
answer: no
explanation: The POP has no adverse affects on lactation or infant outcomes such as growth and development. Very small amounts of progesterone can be found in breast milk of those taking the POP.
name: Progesterone only pill (POP)
label: a
answer: yes
explanation: The COCP is contraindicated less than 6 weeks post partum and breast feeding. There is an increased risk for VTE post-natally, this would be increased by use of COCP.
name: Restart the COCP
label: c
answer: no

Correct answer: a
A 69 year old caucasion male attends his GP surgery for a medication review. His blood pressure is measured at 162/92 mmHg. This is repeated in the consultation and measures 160/90 mmHg.

Which of the following is most appropriate next step in managing this patient?

Options:
explanation: Amlodopine is a calcium channel blocker, it is first line pharmacological treatment for hypertension in those over the of 55 years old. It is therefore appropriate for this patient after diagnosis of hypertension, which first requires ambulatory blood pressure monitoring to confirm the diagnosis.
name: Commence amlodopine
label: d
answer: no
explanation: Whilst these measures are helpful in treating hypertension and should be recommended alongside pharmacological treatment, a diagnosis of hypertension first needs to be made with ambulatory blood pressure monitoring.
name: Advise lifestyle changes such as weight loss and increase exercise
label: b
answer: no
explanation: Ramipril is an ACE-inhibitor, it is first line for primary hypertension in those under 55 years of age. The patient is 69 years old, therefore ramipril would not be first line.
name: Commence ramipril
label: c
answer: no
explanation: Patients with two measured blood pressures >140/90 mmHg should be offered either ABPM or home blood pressure monitoring. ABPM involves wearing a device that checks the blood pressure regularly over a 24 hour period. Patients are instructed to continue their usual activities throughout the day. This also help eliminate any 'white coat hypertension' which is when a patient's blood pressure increases due to the anxiety of being in a health care setting.
name: Ambulatory blood pressure monitoring (ABPM)
label: a
answer: yes
explanation: Whilst it is important to get multiple blood pressure readings, it is recommended to arrange ambulatory blood pressure monitoring and diagnose hypertension from an average of those readings.
name: Recheck the blood pressure in 2 weeks time
label: e
answer: no

Correct answer: a
A 17 year old male presents to the GP with acne vulgaris.
On examination he has open and closed comedones with a few cystic lesions on his face, back and chest.

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

Options:
explanation: Topical preparations of adapalene (a retinoid) and benzoyl peroxide (an anti-septic) is a first line option for any severity of acne. A 12 week course is recommended. It should be discussed that this medication can cause skin irritation and photosensitivity.
There are other topical combinations that can be used first-line, including topical tretinoin with topical clindamycin.
name: Topical adapalene with benzoyl peroxide
label: a
answer: yes
explanation: Spironolactone can be used as a treatment for acne due to its anti-andronergic affects. However, this is prescribed only by specialists. It is also contraindicated in men.
name: Spironolactone
label: d
answer: no
explanation: Doxycycline is used for the treatment of acne, however it is second line after the trial of topical preparations such as adapalene and benzoyl peroxide.
name: Doxycycline
label: b
answer: no
explanation: Oral isotretinoin, commonly known by its brand name Roaccutane, can be considered for those with acne that has not responded to systemic antibiotics and topical therapy. It is therefore not a first-line option.
name: Isotretinoin
label: e
answer: no
explanation: Whilst reassurance that acne is very common may be helpful due to the psychological distress that acne can cause, it is also very treatable. Treatment should be offered promptly to avoid scarring.
name: Reassure the patient that acne is common
label: c
answer: no

Correct answer: a
A 68 year old female attends her GP practice with symptoms of vaginal dryness associated with itching.
On speculum examination it is noted that the vaginal skin is thin.

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

Options:
explanation: As this patient does not present with post menopausal bleeding she does not require a 2 week wait referral.
name: Two week wait referral for endometrial cancer
label: c
answer: no
explanation: Whilst chemical irritants found in some washing poweders, soaps, panty liners or condoms may cause vulva or vaginal irritation which could present with similar symptoms, atrophic vaginitis is the most likely cause given the patient's age. Therefore, these may be helpful changes to make but topical oestrogen would be the first-line choice.
name: Recommend changing washing powder and soap
label: d
answer: no
explanation: Whilst systemic HRT would be helpful in treating atrophic vaginitis due to the affects of oestrogen, it is not first line treatment to those presenting solely with atrophic vaginitis. It would be appropriate if the patient presents with other menopausal symptoms. 10-25% of those recieving HRT will still have symptoms of atrophic vaginitis which require additional topical oestrogen.
name: Systemic hormone replacement therapy (HRT)
label: e
answer: no
explanation: The history is more suggestive of atrophic vaginitis rather than a UTI. However, having atrophic vaginitis can predispose to UTIs, therefore it is important to screen for symptoms of one such as dysuria or increased urinary frequency.
name: Antibiotics for a urinary tract infection (UTI)
label: b
answer: no
explanation: Atrophic vaginitis is caused by a fall in oestrogen, it is therefore most common in post-menopausal people. Common symptoms include vaginal dryness, pain and itching. It can also cause urinary symptoms and UTIs. Topical oestrogen is a first line treatment option.
name: Topical oestrogen
label: a
answer: yes

Correct answer: a
A 24 year old male attends his GP practice with 4 weeks of low mood. He has been struggling to sleep, has lost interest in his hobbies and is struggling to concentrate at work.

Which of the following tools is most appropriate to use in aiding the diagnosis?

Options:
explanation: The AQ-10 is the autism spectrum quotient, used to screen adults for autism. The patient is presenting with symptoms of depression. Autistic spectrum disorders (ASDs) are characterised by a spectrum of social, language and behavioural deficits. Whilst the history mentions loss of interest in social activities like hobbies or work it has been over a 4 week period, it is therefore less suggestive of autism.
name: AQ-10
label: d
answer: no
explanation: CIWA (clinical institute withdrawal assessment) is used to monitor symptoms of alcohol withdrawal. As the patient is presenting with symptoms of depression the most helpful tool would be the PHQ-9 to measure the severity of depression. Alcohol use is important to discuss with the patient as well.
name: CIWA score
label: c
answer: no
explanation: AUDIT-test (Alcohol use disorders indentification test) is used as a screening tool for alcohol harm. Discussing alcohol use with the patient is helpful, but they are presenting with symptoms of depression, therefore the PHQ-9 would be the most useful.
name: AUDIT-test
label: b
answer: no
explanation: The mini-mental state examination is a 30 point test used to assess cognitive function. It can be used as a screening tool for dementia, however it is not a diagnostic test. Whilst this patient presents with poor concetration, dementia is very unlikely due to his age as well as low mood being a presenting complaint, this is more suggestive of depression.
name: MMSE
label: e
answer: no
explanation: The PHQ-9 is a self tested questionnaire that examines the nine DSM-5 criteria for depression (depressed mood, loss of interest or pleasure, weight change, change in sleep, change in activity, fatigue, concentration and suicidality) which the patient has presented with. It can be used to measure the severity of depression and monitor treatment response.
name: PHQ-9
label: a
answer: yes

Correct answer: a
A 45-year-old Nigerian man presents to the GP clinic complaining of persistent headaches and fatigue. He has no significant medical history and has never been diagnosed with hypertension before. On physical examination, his clinic blood pressure is 170/110 mmHg. A diagnosis of hypertension is confirmed as his ambulatory blood pressure monitoring reveals similar BP reading of 168/112 mmHg.

What is the first-line management of his condition?

Options:
explanation: Lisinopril is an angiotensin-converting enzyme inhibitor (ACEi) which would be the first choice medication in newly diagnosed hypertensive individuals with type 2 diabetes mellitus and in those who are less than 55 years of age and not of black African or African–Caribbean family origin.
name: Lisinopril
label: c
answer: no
explanation: Metoprolol is a beta-blocker, usually prescribed following a specialist referral if resistant hypertension is unresponsive to maximum tolerable doses of ACEi/ARB + CCB + thiazide-like diuretic (step-3 treatment).
name: Metoprolol
label: d
answer: no
explanation: Indapamide, a thiazide-like diuretic, is added in step 2 management of hypertension if it is not controlled with step 1 treatment with either ACEi or ARB; or CCB.
name: Indapamide
label: e
answer: no
explanation: **Calcium channel blockers (CCB) are the preferred step-1 medication for newly diagnosed hypertension in black African or African-Caribbean ethnicities**, irrespective of age. They tend to develop low renin, salt-sensitive type hypertension for which monotherapy with beta-blockers or ACE inhibitors is less effective than calcium channel blockers in this particular ethnicity.
name: Amlodipine
label: a
answer: yes
explanation: Telmisartan is an angiotensin receptor blocker (ARB) which would be the first choice medication in newly diagnosed hypertensive individuals of any age with type 2 diabetes mellitus. Moreover, an ARB is preferred over an ACE inhibitor in black African or African-Caribbean family origin.
name: Telmisartan
label: b
answer: no

Correct answer: a