hllj/quesmed huggingface dataset:
A 74-year-old woman visits her GP as she has noticed a painless lump in her groin, which she has not experienced before. She has a history of chronic constipation and COPD.

On examination, she has a soft, reducible lump below and lateral to the pubic tubercle. It is not tender to palpation and has a cough impulse.

What is the most appropriate next step in management?

Options:
explanation: This patient likely has a femoral hernia based on examination findings. While imaging will likely be required, arranging this will delay a surgical opinion which is urgently needed due to the risk of strangulation. If further imaging is required, the surgical team can arrange this.
name: Arrange CT abdomen/pelvis
label: e
answer: no
explanation: This patient likely has a femoral hernia. These are very prone to strangulation, so observation and follow-up is inappropriate.
name: Careful observation and follow-up
label: c
answer: no
explanation: This patient likely has a femoral hernia based on examination findings. While an abdominal ultrasound will likely be required, arranging this will delay a surgical opinion which is urgently needed due to the risk of strangulation. If further imaging is required, the surgical team can arrange this.
name: Arrange an urgent abdominal ultrasound
label: d
answer: no
explanation: This patient likely has a femoral hernia - clinical examination findings are suggestive of this, and she has multiple risk factors (constipation causing increased intra-abdominal pressure, female sex, increasing age, and COPD potentially causing a chronic cough). She should be referred urgently, as these hernias are prone to strangulation and therefore require prompt investigation and management.
name: Urgent referral to surgical team
label: a
answer: yes
explanation: This patient likely has a femoral hernia. A referral to the emergency department for emergency surgery should be made if there are features of incarceration, strangulation, or obstruction. These would include an irreducible hernia, pain, features of bowel obstruction, or other clinical concerns. At present, an urgent referral to the surgical team is sufficient.
name: Refer to the emergency department
label: b
answer: no

Correct answer: a


Learning point: Femoral hernias are more common in elderly women and can lead to strangulation, requiring urgent surgical referral.
A 56-year-old man with multiple episodes of rectal bleeding undergoes a colonoscopy under the 2-week wait pathway. He reports a history of long-standing irritable bowel syndrome with constipation.

The following appearance is seen in the sigmoid colon:

[lightgallery]

What is the most likely cause of his symptoms?

Options:
explanation: This is the most important differential diagnosis to rule out. However, these endoscopy findings make colorectal carcinoma unlikely; no tumours are seen. The endoscopy image shows multiple outpouchings of the intestinal wall, consistent with diverticular disease. Constipation is a risk factor for this.
name: Colorectal carcinoma
label: b
answer: no
explanation: Angioectasias are common vascular lesions of the digestive tract and may cause chronic, recurrent lower GI bleeding. These appear as red 'coral reef' structures on endoscopy, and may be associated with aortic stenosis (this is called Heyde's syndrome). In this case, the endoscopy shows outpouchings of the intestinal wall, consistent with diverticular disease.
name: Angioectasia (angiodysplasia)
label: c
answer: no
explanation: There are no polyps demonstrated in this image. The endoscopy image shows multiple outpouchings of the intestinal wall, consistent with diverticular disease.
name: Bleeding polyp
label: e
answer: no
explanation: The endoscopy image shows multiple outpouchings of the intestinal wall, consistent with diverticular disease. Constipation is a risk factor for this. #
name: Diverticular disease
label: a
answer: yes
explanation: Inflammatory bowel disease would be a good differential in this case, however, the absence of systemic features makes this less likely. Endoscopy would show mucosal inflammation. In this case, the endoscopy image shows multiple outpouchings of the intestinal wall, consistent with diverticular disease.
name: Inflammatory bowel disease
label: d
answer: no

Correct answer: a


Learning point: Diverticular disease is characterised by the formation of outpouchings in the colon, often associated with constipation and rectal bleeding.
A 68-year-old previously fit and well woman is diagnosed with colorectal cancer at the hepatic flexure during a colonoscopy performed due to a positive bowel cancer screening (FIT) test.

Subsequent investigations show that the tumour has not metastasised or breached the intestinal wall.

Which of the following is the most suitable surgical approach?

Options:
explanation: Transverse colectomies are not often undertaken due to this being a complex surgery, as the colon has a complicated blood supply. An extended right hemicolectomy is the best option.
name: Transverse colectomy
label: b
answer: no
explanation: This would be the most appropriate option. A right hemicolectomy involves the resection of a portion of the distal ileum, caecum, ascending colon, and proximal to mid-transverse colon. As the tumour is at the hepatic flexure, this would be resected. A primary anastomosis between the ileum and remaining colon is often made unless there are surgical complications necessitating temporary stoma formation.
name: Right hemicolectomy with ileocolic anastamosis
label: a
answer: yes
explanation: While an extended right hemicolectomy would remove the tumour (this is the same as a right hemicolectomy but extended to the splenic flexure), this would be more extensive than required as the patient's tumour is at the hepatic flexure, and therefore be a higher risk procedure. Formation of an ileostomy would not be ideal unless a surgical complication meant that a primary anastomosis was not possible.
name: Extended right hemicolectomy and temporary ileostomy
label: c
answer: no
explanation: There is no indication to remove the whole colon, which is a higher-risk procedure. The tumour is confined to the hepatic flexure, and therefore a right hemicolectomy would suffice.
name: Total colectomy
label: e
answer: no
explanation: A Hartmann's procedure involves surgical resection of the rectosigmoid colon with closure of the anorectal stump and formation of an end colostomy. This is typically an emergency procedure performed due to a sigmoid perforation (e.g. due to diverticulitis) or an obstructing sigmoid tumour. It is not suitable for right-sided colon cancer.
name: Hartmann's procedure
label: d
answer: no

Correct answer: a


Learning point: Right hemicolectomy is the standard surgical treatment for tumours located at the hepatic flexure of the colon.
A 19-year-old man attends the eye emergency department with a swelling of his eyelid. He is concerned that he has an eye infection as he admits to wearing his contact lenses in the shower. He has no visual disturbances.

On examination, his observations are within normal range, visual acuity (corrected) is normal, and eye movements are normal, as is fundoscopy. The following appearance is seen:

[lightgallery]

What is the most appropriate initial step in management?

Options:
explanation: The clinical history and image are suggestive of a chalazion, caused by the blockage of an oil-secreting (Meibomian) gland. The first step in managing this condition is encouraging massage and using warm compresses.
name: Warm compresses and massage
label: a
answer: yes
explanation: Intralesional steroid injections are considered in persistent, recurrent chalazia. As this has only been present for a day, conservative management should be tried first. Incision and drainage may be preferred to steroid injections in the first instance.
name: Triamcinolone injection
label: e
answer: no
explanation: Chalazia that do not respond to conservative management may require incision and drainage.
name: Incision and drainage
label: b
answer: no
explanation: Chalazia are usually caused by non-infective processes (in contrast to styes). Although topical antibiotics are commonly used (especially for styes), the first line management to encourage the gland to unblock is massage and use of warm compresses.
name: Topical chloramphenicol
label: d
answer: no
explanation: Chalazia are usually caused by non-infective processes (in contrast to styes). There are currently no indications for oral antibiotics. Flucloxacillin may be required if an infection develops.
name: Oral flucloxacillin
label: c
answer: no

Correct answer: a


Learning point: A chalazion is managed initially with warm compresses and massage to promote drainage of the blocked Meibomian gland.
An 18-month-old girl is referred to the paediatric ophthalmology clinic after her GP noticed leukocoria in her left eye.

Ophthalmoscopy under general anaesthesia and an MRI confirm a likely diagnosis of advanced retinoblastoma, confined to the eye.

What is the most likely next step in management?

Options:
explanation: Chemotherapy can be considered in bilateral retinoblastoma or small tumours, however as this patient has advanced disease, enucleation is the best option.
name: Systemic chemotherapy
label: b
answer: no
explanation: Anti-VEGF therapy is usually used in patients with vaso-proliferative retinopathies, e.g. diabetic retinopathy. It is not indicated in retinoblastoma.
name: Intravitreal anti-vascular endothelial growth factor therapy
label: d
answer: no
explanation: Radiotherapy may be used to treat small tumours, or when the disease is bilateral, the most involved eye is enucleated and the less involved eye is irradiated. There are no indications for bilateral irradiation in this case. Enucleation of the left eye is the most appropriate choice.
name: Bilateral irradiation of the eyes
label: e
answer: no
explanation: Removal of the eye (and as little of the optic nerve as possible) and insertion of a prosthesis is recommended in cases of retinoblastoma that is confined to the eye.
name: Enucleation
label: a
answer: yes
explanation: Laser photocoagulation may be used to manage small tumours, however as this patient has advanced disease, the eye should be removed to prevent metastases and resect the diseased areas.
name: Photocoagulation
label: c
answer: no

Correct answer: a


Learning point: Enucleation is a surgical procedure in which the entire eyeball is removed to treat conditions like advanced retinoblastoma confined to the eye, aiming to prevent metastasis and preserve surrounding structures.
A 45-year-old African man is referred to the dermatology clinic for investigation of skin lesions that have appeared over the past year. He describes these as intensely itchy and notices that new lesions sometimes form at sites of injury.

On examination, multiple dark, polygonal plaques are seen over the arms. They are crossed by fine white lines.

What is the most appropriate next step?

Options:
explanation: This patient's presentation of polygonal plaques with fine white lines (Wickham's striae), and the development of lesions at sites of injury describes Koebner's phenomenon, all keeping in line with a diagnosis of lichen planus, which is primarily a clinical diagnosis. This is managed with topical corticosteroids.
name: Topical corticosteroids
label: b
answer: yes
explanation: The most likely diagnosis is lichen planus. Intralesional injections may be considered if the disease is refractory to other treatments. The next most appropriate step, however, is to carry out a biopsy to confirm the diagnosis and exclude malignant changes.
name: Intralesional steroid injections
label: d
answer: no
explanation: The clinical history and findings are suggestive of lichen planus, a chronic inflammatory skin condition. In people with coloured skin, lesions may appear dark rather than purple. The fine white lines on the lesions are Wickham's striae, and the development of lesions at sites of injury describes Koebner's phenomenon. This is primarily a clinical diagnosis and a skin biopsy would be undertaken to confirm the diagnosis and check for any malignant changes if there was any diagnostic uncertainty.
name: Skin biopsy
label: a
answer: no
explanation: Oral immunosuppressants may be considered in lichen planus refractory to topical therapy. This is not the most appropriate next step. A skin biopsy should be obtained first to confirm the diagnosis and exclude malignancy.
name: Oral azathioprine
label: e
answer: no
explanation: The most likely diagnosis is lichen planus. Tacrolimus may be commenced to spare steroid use, however this would not be the next most appropriate step.
name: Topical tacrolimus
label: c
answer: no

Correct answer: b


Learning point: A skin biopsy is often used to diagnose lichen planus by examining a sample of skin tissue for characteristic signs such as lymphocytic infiltration and basal cell degeneration.
A university student visits his GP with severe scalp itching that he has experienced for a few months. He is becoming self-conscious as he is also experiencing large volumes of dandruff and flaking of the skin at his hairline.

On examination, greasy white scales are present on the scalp and at the hairline. He has a past medical history of asthma and has no drug allergies.

Which of the following will most likely improve his symptoms?

Options:
explanation: An antihistamine may help reduce the pruritus, but will not address the disease process. A topical antifungal should be prescribed.
name: Cetirizine
label: d
answer: no
explanation: This is a treatment for seborrhoeic dermatitis in babies (cradle cap) as they have little hair. Antifungal preparations should be used in adults.
name: Scalp massage with emollients
label: b
answer: no
explanation: This may be considered for seborrhoeic dermatitis affecting the skin, however, applying a shampoo is most appropriate to treat the scalp and hair.
name: Clotrimazole cream
label: e
answer: no
explanation: The clinical history and findings are consistent with seborrhoeic dermatitis, an inflammatory skin condition thought to be caused by an overgrowth of Malassezia yeasts. Topical ketoconazole shampoo is recommended as a first-line treatment for diseases affecting the scalp. Topical steroids may be added to control pruritus.
name: Ketoconazole shampoo
label: a
answer: yes
explanation: There are no indications for systemic steroids in this case.
name: A short course of oral steroids
label: c
answer: no

Correct answer: a


Learning point: Ketoconazole shampoo is an effective first-line treatment for seborrhoeic dermatitis, characterised by greasy scales and itching on the scalp.
A 14-year-old male has had a sore throat for four days, which is causing him pain when eating. He visits his GP asking for antibiotics to treat his symptoms. He is allergic to penicillin and has a past medical history of recurrent otitis externa. He denies any other symptoms.

On examination, his pharynx is red and inflamed and there is no palpable lymphadenopathy. An ear examination is normal. Observations are within normal limits.

What is the most appropriate course of action?

Options:
explanation: NICE recommends a delayed/backup antibiotic prescription if the FeverPAIN score is 2 or 3. This patient's FeverPAIN score is 1, making supportive management more appropriate.
name: Delayed antibiotic prescription
label: d
answer: no
explanation: This patient likely has viral pharyngitis; his FeverPAIN score is 1 (for the absence of a cough), meaning that it is unlikely his symptoms are caused by a streptococcal infection. Clarithromycin would be a reasonable choice given his penicillin allergy if his FeverPAIN score was 4 or 5 (or his Centor score was 3 or 4)
name: Clarithromycin
label: c
answer: no
explanation: This patient likely has viral pharyngitis; his FeverPAIN score is 1 (for the absence of a cough), meaning that it is unlikely his symptoms are caused by a streptococcal infection. He should be advised to rest and use regular analgesia, but to seek medical advice if his symptoms worsen.
name: Supportive management
label: a
answer: yes
explanation: This patient likely has viral pharyngitis; his FeverPAIN score is 1 (for the absence of a cough), meaning that it is unlikely his symptoms are caused by a streptococcal infection. Antibiotics are not currently indicated as per NICE guidelines. Phenoxymethylpenicillin would be an appropriate first choice in most cases, however this patient has an allergy to penicillin.
name: Phenoxymethylpenicillin
label: b
answer: no
explanation: This patient likely has viral pharyngitis. There are no current indications for a referral to secondary care such as airway compromise or significant systemic upset.
name: Referral to secondary care
label: e
answer: no

Correct answer: a


Learning point: Viral pharyngitis is common in adolescents; supportive management with rest and analgesia is typically sufficient, as antibiotics are ineffective.
A 48-year-old man is brought into hospital by ambulance feeling generally unwell. He provides minimal history, however, his wife describes a 3-day period of fevers, headaches, and drowsiness. She says he has no medical problems and only takes over-the-counter vitamins. He has no drug allergies.

On examination, he appears to be extremely photophobic, with nuchal rigidity and a positive Kernig's sign. No rashes are noted. He is also febrile and tachycardic.

What is the most important medication to prescribe?

Options:
explanation: The most likely diagnosis is meningitis. Local guidelines should always be referred to, but the BNF (and most hospital trusts) recommend empirical treatment with third-generation cephalosporins immediately, as these cover the most common bacteria that cause meningitis.
name: Cefotaxime
label: a
answer: yes
explanation: The most likely diagnosis is meningitis given the features of meningism. It is not uncommon for aciclovir to be given along with antibiotics to cover for viral encephalitis, however, this is not the most important drug to prescribe.
name: Aciclovir
label: d
answer: no
explanation: The most likely diagnosis is meningitis. Amoxicillin (or ampicillin) should be added to cephalosporin therapy in patients susceptible to listeria infections (children under the age of 1 and adults over the age of 60).
name: Amoxicillin
label: b
answer: no
explanation: Most clinical guidelines recommend cephalosporin therapy for meningitis. Vancomycin can be used if there is a history of travel to an area with cephalosporin-resistant pneumococci, or if there is a history of prolonged antibiotic use that might make infection by a resistant organism more likely.
name: Vancomycin
label: e
answer: no
explanation: The most likely diagnosis is meningitis. Benzylpenicillin is recommended in the pre-hospital (i.e. GP or ambulance) setting for patients with suspected meningococcal meningitis. This patient is in hospital and should therefore receive a cephalosporin.
name: Benzylpenicillin
label: c
answer: no

Correct answer: a


Learning point: If meningitis is suspected, treatment should start with a third-generation cephalosporin, like cefotaxime, to target the most common bacterial causes.
An 18-year-old university student visits his GP feeling tired all the time. He describes a 2-week period of lethargy, myalgia, headache, and a sore throat.

He has bilateral posterior cervical lymphadenopathy and a red pharynx with some palatal petechiae. He is slightly tachycardic, but observations are otherwise normal.

Which feature would be most consistent with the most likely diagnosis?

Options:
explanation: The most likely diagnosis is glandular fever; an infection caused by the Epstein-Barr Virus. This is a common infection in people aged 15-24 and can be transmitted through contact with saliva. Splenomegaly is extremely common, and patients should be advised to avoid contact sports for a month to reduce the risk of splenic rupture.
name: Splenomegaly
label: a
answer: yes
explanation: The most likely diagnosis given the clinical history and sore throat is glandular fever, an infection caused by the Epstein-Barr virus. Drenching night sweats would suggest a diagnosis of lymphoma, which is also possible given the lymphadenopathy but is less likely with the infectious symptoms. EBV infections may cause sweats but they would typically not be drenching.
name: Drenching night sweats
label: b
answer: no
explanation: The most likely diagnosis given the clinical history and sore throat is glandular fever, an infection caused by the Epstein-Barr virus. Significant weight loss would suggest a diagnosis of lymphoma, which is also possible given the lymphadenopathy but is less likely with the infectious symptoms.
name: More than 10% weight loss in 1 month
label: c
answer: no
explanation: The most likely diagnosis given the clinical history and sore throat is glandular fever, an infection caused by the Epstein-Barr virus. A lymph node biopsy would not routinely be performed unless there is a high suspicion of lymphoma. 'Mirror image nuclei', also known as Reed-Sternberg cells, are seen in Hodgkin lymphoma.
name: 'Mirror-image nuclei' on lymph node biopsy
label: e
answer: no
explanation: The most likely diagnosis given the clinical history and sore throat is glandular fever, an infection caused by the Epstein-Barr virus. A lymph node biopsy would not routinely be performed unless there is a high suspicion of lymphoma. 'Owl's eye' inclusions are seen in cytomegalovirus infection, rather than EBV infection.
name: 'Owl's eye' inclusions seen on lymph node biopsy
label: d
answer: no

Correct answer: a


Learning point: Glandular fever, caused by Epstein-Barr Virus, commonly presents with splenomegaly and requires avoidance of contact sports to prevent splenic rupture.
An 87-year-old care home resident is admitted to hospital after a fall. During her stay, she develops watery diarrhoea (type 7 on the Bristol Stool Chart) and a fever.

She feels mildly unwell but has no abdominal pain or other symptoms. A rectal examination is unremarkable and her abdomen is soft and non-tender.

Stool samples are positive for C.difficile toxin.

What is the most appropriate antibiotic to prescribe?

Options:
explanation: Oral vancomycin is first-line for mild, moderate, or severe C. difficile infections. Metronidazole can be used in life-threatening or complicated infections, however this would be prescribed intravenously.
name: Oral metronidazole
label: c
answer: no
explanation: Fidaxomicin (200mg BD for 10 days) is the second-line treatment for C. difficile infections if vancomycin is contraindicated or ineffective. It is also recommended if a patient has a further infection with C. difficile after vancomycin treatment.
name: Oral fidaxomicin
label: e
answer: no
explanation: Oral vancomycin is first-line for mild, moderate, or severe C. difficile infections. Intravenous metronidazole can be added to vancomycin in life-threatening or complicated infections.
name: Intravenous metronidazole
label: d
answer: no
explanation: As per NICE guidelines, oral vancomycin (125mg QDS for 10 days) is first-line for mild, moderate, or severe C. difficile infections.
name: Oral vancomycin
label: a
answer: yes
explanation: Intravenous vancomycin is not used to treat C. difficile infections; the advantage of the oral route is that it acts directly in the gastrointestinal tract.
name: Intravenous vancomycin
label: b
answer: no

Correct answer: a


Learning point: Clostridioides difficile (C. diff) is a bacterial infection that causes severe diarrhea and colitis, and it is managed with oral vancomycin as the first-line treatment