hllj/quesmed huggingface dataset:
A 24-year-old man presents to the Rheumatology Clinic reporting back pain and stiffness that gets better throughout the day. On examination, he has reduced range of movement of his lumbar spine and a positive Schober test.

What is the first-line management of this condition?

Options:
explanation: The diagnosis, in this case, is ankylosing spondylitis as this young man has presented with back pain, restricted spinal movement and a positive Schober's test. This condition is also associated with a "bamboo-spine" appearance on X-ray. The first-line management for ankylosing spondylitis is NSAIDs. Long-term NSAID use may cause gastric problems such as peptic ulcers, hence PPIs should be co-prescribed.
name: NSAID + PPI
label: a
answer: yes
explanation: The diagnosis, in this case, is ankylosing spondylitis as this young man has presented with back pain, restricted spinal movement and a positive Schober test. This condition is also associated with a "bamboo-spine" appearance on X-ray. Paracetamol has no role in the management of ankylosing spondylitis.
name: Paracetamol
label: d
answer: no
explanation: The diagnosis, in this case, is ankylosing spondylitis as this young man has presented with back pain, restricted spinal movement and a positive Schober test. This condition is also associated with a "bamboo-spine" appearance on X-ray. Infliximab is a TNF-alpha inhibitor and is normally given if symptoms have not been controlled effectively by NSAIDs or if a patient has severe disease.
name: Infliximab
label: e
answer: no
explanation: The diagnosis, in this case, is ankylosing spondylitis as this young man has presented with back pain, restricted spinal movement and a positive Schober test. This condition is also associated with a "bamboo-spine" appearance on X-ray. Local steroid injections can help ease the pain in ankylosing spondylitis, but cannot be injected into the spine making it unsuitable for this patient.
name: Steroid injections
label: c
answer: no
explanation: The diagnosis, in this case, is ankylosing spondylitis as this young man has presented with back pain, restricted spinal movement and a positive Schober test. This condition is also associated with a "bamboo-spine" appearance on X-ray. Methotrexate is a disease-modifying antirheumatic drug (DMARD) and tends to be more useful in patients with enthesitis as opposed to axial symptoms. It would also not improve spinal inflammation.
name: Methotrexate
label: b
answer: no

Correct answer: a
A 42-year-old woman presents to her GP as she is concerned that her fingers turn blue when is she outside, and red and painful when she comes back inside. She has also noticed that her fingers have looked more swollen and shiny recently, and there are several small hard lumps near her fingertips. She has a past medical history of GORD.

Which antibody is most associated with this condition?

Options:
explanation: The condition described here is limited cutaneous systemic sclerosis. Anti-Ro antibodies are associated with Sjogren's syndrome.
name: Anti-Ro
label: c
answer: no
explanation: The condition described here is limited cutaneous systemic sclerosis. Anti-dsDNA antibodies are primarily linked to systemic lupus erythematosus.
name: Anti-dsDNA
label: d
answer: no
explanation: The condition described here is limited cutaneous systemic sclerosis (CREST syndrome). Anti-Scl-70 antibodies are present in diffuse cutaneous systemic sclerosis.
name: Anti-Scl-70 antibodies
label: b
answer: no
explanation: The condition described here is limited cutaneous systemic sclerosis and is characterised by skin fibrosis which is limited to the hands and forearms, feet and legs, and the head and neck. CREST symptoms are present as she experiences calcinosis (small hard lumps near her fingertips), Raynaud's phenomenon (blue and red fingers according to temperature change), oesophageal dysmotility (demonstrated by her past medical history of GORD) and sclerodactyly (swollen and shiny skin over fingers). The antibody linked to limited cutaneous systemic sclerosis is anti-centromere - it is specific and present in 90% of cases.
name: Anti-centromere antibodies
label: a
answer: yes
explanation: The condition described here is limited cutaneous systemic sclerosis. Anti-Jo-1 antibodies are seen in polymyositis.
name: Anti-Jo-1
label: e
answer: no

Correct answer: a
A 55-year-old man with a past medical history of polymyalgia rheumatica presents to A&E with new onset scalp tenderness and a headache towards the left side of his head. Investigations show an elevated ESR.

Which complication is this gentleman's disease linked to?

Options:
explanation: This man's diagnosis is giant cell/temporal arteritis due to him experiencing scalp tenderness and headache as well as his past medical history of polymyalgia rheumatica. Encephalitis is not a complication of these conditions as they do not directly affect the brain, but they can increase the likelihood of stroke.
name: Encephalitis
label: c
answer: no
explanation: This man's diagnosis is giant cell/temporal arteritis due to him experiencing scalp tenderness and headache as well as his past medical history of polymyalgia rheumatica. This is treated with high-dose steroids which if taken for a prolonged period without PPI cover for gastric protection, could result in the development of gastric ulcers as a complication of treatment. However, gastric ulcers are not a complication of temporal arteritis itself.
name: Gastric ulcers
label: d
answer: no
explanation: This man's diagnosis is giant cell/temporal arteritis due to him experiencing scalp tenderness and headache as well as his past medical history of polymyalgia rheumatica. It is important to treat giant cell/temporal arteritis as quickly as possible with high-dose prednisolone to prevent permanent monocular blindness.
name: Permanent monocular blindness
label: a
answer: yes
explanation: This man's diagnosis is giant cell/temporal arteritis due to him experiencing scalp tenderness and headache as well as his past medical history of polymyalgia rheumatica. Several rheumatological conditions increase the likelihood of developing septic arthritis, but giant cell/temporal arteritis and polymyalgia rheumatica do not.
name: Septic arthritis
label: b
answer: no
explanation: This man's diagnosis is giant cell/temporal arteritis due to him experiencing scalp tenderness and headache as well as his past medical history of polymyalgia rheumatica. This is treated with high-dose steroids which if taken for a prolonged period without bisphosphonates for bone protection, could result in the development of osteoporosis as a complication of treatment. However, osteoporosis is not a complication of temporal arteritis itself.
name: Osteoporosis
label: e
answer: no

Correct answer: a
A 51-year-old woman experiences shortness of breath and feelings of chest tightness following the administration of 1 unit of blood.

On examination, she is tachypnoeic, tachycardic, and has an audible wheeze at her lung bases. Her blood pressure is 180/110.

What is the best course of management for this transfusion reaction?

Options:
explanation: This patient is experiencing transfusion-associated circulatory overload, evidenced by her shortness of breath and signs of pulmonary oedema as well as hypertension and widened pulse pressure. This is best managed by slowing the blood transfusion and concurrently giving furosemide.
name: Slow transfusion + give furosemide
label: a
answer: yes
explanation: This patient is experiencing transfusion-associated circulatory overload, evidenced by her shortness of breath and signs of pulmonary oedema as well as hypertension and widened pulse pressure. This answer choice would work if the patient was experiencing an allergic reaction to the transfusion.
name: Stop the transfusion + give saline, adrenaline, chlorphenamine, and hydrocortisone
label: b
answer: no
explanation: This patient is experiencing transfusion-associated circulatory overload, evidenced by her shortness of breath and signs of pulmonary oedema as well as hypertension and widened pulse pressure. This answer choice would work if the patient was experiencing a febrile non-haemolytic transfusion reaction.
name: Slow the transfusion + give paracetamol
label: c
answer: no
explanation: This patient is experiencing transfusion-associated circulatory overload, evidenced by her shortness of breath and signs of pulmonary oedema as well as hypertension and widened pulse pressure. The transfusion should not be stopped; it should be slowed and a loop diuretic like furosemide should be administered to combat the symptoms of fluid overload.
name: Stop the transfusion
label: e
answer: no
explanation: This patient is experiencing transfusion-associated circulatory overload, evidenced by her shortness of breath and signs of pulmonary oedema as well as hypertension and widened pulse pressure. Whilst slowing the transfusion is correct, the patient's fluid overload should be managed using a loop diuretic. Indapamide is a thiazide-like diuretic which has no role in managing this transfusion reaction.
name: Slow the transfusion + give indapamide
label: d
answer: no

Correct answer: a
A 35-year-old man who has recently immigrated from Senegal presents to the GP with abdominal pain, constipation, muscle pain and fatigue.


Examination shows icteric sclera and a blood pressure reading of 150/90. He does not have any significant past medical or family history.


Investigations show:

||||
|--------------|:-------:|---------------|
|Haemoglobin|111  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5.0x10<sup>9</sup>/L|3.0 - 10.0|
|Mean Cell Volume (MCV)|70 fL|80 - 96|


What is the most likely diagnosis?

Options:
explanation: Iron-deficiency anaemia would also present with fatigue and a microcytic anaemia, but not with scleral icterus. They would also have other signs and symptoms such as conjunctival pallor, brittle nails and aphthous ulcers.
name: Iron-deficiency anaemia
label: b
answer: no
explanation: Anaemia of chronic disease can cause either a microcytic or normocytic anaemia and would explain some of this patient's symptoms such as fatigue. However, this patient does not have any chronic medical conditions.
name: Anaemia of chronic disease
label: c
answer: no
explanation: The patient has recently immigrated from Senegal where there is increased exposure to lead-contaminated soil and dust. The symptoms and signs he is experiencing, alongside his microcytic anaemia, correlate with a diagnosis of lead poisoning.
name: Lead poisoning
label: a
answer: yes
explanation: This is an inherited condition which commonly affects those of Mediterranean, South Asian, Southeast Asian and Middle Eastern origin. The patient in this question has no significant family history and is not exhibiting any of the other features of thalassaemia like facial bone deformities or abdominal swelling/enlargement.
name: Beta thalassaemia
label: e
answer: no
explanation: Chronic alcohol abuse would result in a macrocytic anaemia. The anaemia in this case is microcytic.
name: Chronic alcohol abuse
label: d
answer: no

Correct answer: a
A 27-year-old man presents to the GP with an intensely itchy rash in-between his fingers on both hands. He describes it to be very disruptive to his sleep as the itchiness is worse at night. He has no significant past medical history or family history. He lives in a hostel and recalls that several of the other tenants have been experiencing the same symptoms over the last week.

What type of hypersensitivity reaction is he experiencing?

Options:
explanation: The condition described here is scabies which typically presents as an itchy rash that worsens during the night and is spread through contact with other infected people. Type II hypersensitivity reactions are mediated by antibodies like IgG or IgM (e.g. blood transfusion reactions).
name: Type II
label: c
answer: no
explanation: The condition described here is scabies which typically presents as an itchy rash that worsens during the night and is spread through contact with other infected people. Type I hypersensitivity reactions include allergic reactions and atopic diseases like eczema or asthma.
name: Type I
label: b
answer: no
explanation: The condition described here is scabies which typically presents as an itchy rash that worsens during the night and is spread through contact with other infected people. Type III hypersensitivity reactions are mediated by immune complexes that are not cleared from the circulation (e.g. systemic lupus erythematosus).
name: Type III
label: d
answer: no
explanation: The condition described here is scabies which typically presents as an itchy rash that worsens during the night and is spread through contact with other infected people. This makes it a delayed Type IV hypersensitivity reaction. Type IV hypersensitivity reactions are cell-mediated reactions that occur in response to contact with certain allergens.
name: Type IV
label: a
answer: yes
explanation: The condition described here is scabies which typically presents as an itchy rash that worsens during the night and is spread through contact with other infected people. Type V hypersensitivity reactions occur when an antibody targets specific receptors on a cell (e.g.  Graves disease).
name: Type V
label: e
answer: no

Correct answer: a
A 41-year-old woman presents to the Dermatology clinic with peeling blistering skin over both her legs.

On examination, the top layers of the skin seem to lift away when pressure is applied, and there are signs of oral mucosa ulceration. She has no significant past medical history or family history. A biopsy + immunofluorescence shows deposition of IgG auto-antibodies within the epidermis.

What is the most likely diagnosis?

Options:
explanation: Atopic dermatitis would present with dry skin and areas of erythematous, poorly demarcated itchy patches. It typically affects the flexural regions, such as the antecubital and popliteal fossas.
name: Atopic dermatitis
label: d
answer: no
explanation: This patient is experiencing blistering of the skin which is Nikolsky sign positive and oral mucosa ulceration which points toward a diagnosis of pemphigus vulgaris. This is supported by the biopsy and immunofluorescence showing IgG auto-antibody deposits within the epidermis.
name: Pemphigus Vulgaris
label: a
answer: yes
explanation: Bullous pemphigoid would present with deep, tense blisters which are Nikolsky sign negative. There would also not be any oral mucosa involvement. The biopsy and immunofluorescence would show IgG auto-antibodies deposited on the basement membrane.
name: Bullous Pemphigoid
label: b
answer: no
explanation: Patients with chronic plaque psoriasis have symmetrical plaques on extensor surfaces (elbows and knees, scalp, lower back) which are itchy, erythematous and well-demarcated. They do not have blistering.
name: Chronic plaque psoriasis
label: c
answer: no
explanation: This would present with pruritic papulovesicular lesions over the legs, but there is no blistering or peeling. It would be Nikolsky sign negative as well. This diagnosis is commonly linked to Coeliac disease.
name: Dermatits herpetiformis
label: e
answer: no

Correct answer: a
A 61-year-old overweight man presents to A&E with severe pain at the base of his right big toe which has been present for 2 days. He says that nothing makes it better, and even slight pressure makes it worse. He has a past medical history of hypertension and chronic kidney disease.

On examination, his right big toe is erythematous and swollen.

Arthrocentesis with synovial fluid analysis shows needle-shaped monosodium urate crystals with negative birefringence.

What is the most appropriate management for this man?

Options:
explanation: This is a classic history of an acute gout attack: the patient has a painful big toe as well as risk factors for gout including being an older overweight male with a history of hypertension and CKD. The investigation findings also point towards a diagnosis of gout. Methotrexate is a disease-modifying anti-rheumatic drug (DMARD), and it is used in the management of rheumatoid arthritis. It has no role in the management of acute gout.
name: Methotrexate
label: e
answer: no
explanation: This is a classic history of an acute gout attack: the patient has a painful big toe as well as risk factors for gout including being an older overweight male with a history of hypertension and CKD. The investigation findings also point towards a diagnosis of gout. Allopurinol should be commenced at a low dose at least 2 weeks following an attack of gout; it is not used in the acute setting.
name: Allopurinol
label: c
answer: no
explanation: This is a classic history of an acute gout attack: the patient has a painful big toe as well as risk factors for gout including being an older overweight male with a history of hypertension and CKD. The investigation findings also point towards a diagnosis of gout. The NSAID indomethacin is traditionally used first-line, but because this patient has CKD, NSAIDs should be avoided. Hence, colchicine is the most appropriate therapy.
name: Colchicine
label: a
answer: yes
explanation: This is a classic history of an acute gout attack: the patient has a painful big toe as well as risk factors for gout including being an older overweight male with a history of hypertension and CKD. The investigation findings also point towards a diagnosis of gout. The NSAID indomethacin is traditionally used first-line, but because this patient has CKD, NSAIDs should be avoided.
name: Indomethacin
label: b
answer: no
explanation: This is a classic history of an acute gout attack: the patient has a painful big toe as well as risk factors for gout including being an older overweight male with a history of hypertension and CKD. The investigation findings also point towards a diagnosis of gout. Febuxostat is used if allopurinol fails or is contraindicated in the prophylactic management of gout. It is not used in the management of acute gout.
name: Febuxostat
label: d
answer: no

Correct answer: a
A 25-year-old woman with recently diagnosed rheumatoid arthritis is put on methotrexate 2.5mg weekly. She has no other medical conditions and she takes no other medication, except for folic acid.

Which of the following medications should be avoided in this patient?

Options:
explanation: Azathioprine is an immunosuppressant which can be taken safely and effectively with methotrexate.
name: Azathioprine
label: b
answer: no
explanation: Lamotrigine is an anticonvulsant that is safe to take whilst on methotrexate.
name: Lamotrigine
label: c
answer: no
explanation: Haloperidol is a typical antipsychotic that is safe to take whilst on methotrexate.
name: Haloperidol
label: e
answer: no
explanation: Levetiracetam is an anticonvulsant that is safe to take whilst on methotrexate.
name: Levetiracetam
label: d
answer: no
explanation: Trimethoprim is an antibiotic commonly used to treat urinary tract infections. Methotrexate and trimethoprim both work by inhibiting dihydrofolate reductase. It can be dangerous to give both medications at the same time as it increases the risk of bone marrow suppression.
name: Trimethoprim
label: a
answer: yes

Correct answer: a
A 9-year-old boy presents to the GP with a painful right hip and a limp. His mother states that it started 4 days ago and that he also had a cold 2 weeks ago. He does not have a fever now.

On examination, he has pain on palpation of the right hip, but there are no other signs of inflammation.

What is the most likely diagnosis?

Options:
explanation: Transient synovitis commonly affects boys aged 3-11 and is usually preceded by a viral infection 1-2 weeks before the onset of pain and the limp.
name: Transient synovitis
label: a
answer: yes
explanation: Transient synovitis commonly affects boys aged 3-11 and is usually preceded by a viral infection 1-2 weeks before the onset of pain and the limp. DDH is a condition that affects babies in the first few months. It is more common in female babies.
name: Developmental dysplasia of the hip (DDH)
label: e
answer: no
explanation: Transient synovitis commonly affects boys aged 3-11 and is usually preceded by a viral infection 1-2 weeks before the onset of pain and the limp. Perthes disease affects children aged 4-8 and presents with a similar hip pain and limp to transient synovitis. With Perthes however, the symptoms tend to last for more than 4 weeks, whereas in transient synovitis the symptoms usually do not last for longer than 2 weeks.
name: Perthes disease
label: d
answer: no
explanation: Transient synovitis commonly affects boys aged 3-11 and is usually preceded by a viral infection 1-2 weeks before the onset of pain and the limp. It can be difficult to distinguish between transient synovitis and early septic arthritis, but the symptoms of transient synovitis are generally milder.
name: Septic arthritis
label: b
answer: no
explanation: Transient synovitis commonly affects boys aged 3-11 and is usually preceded by a viral infection 1-2 weeks before the onset of pain and the limp. SUFE is the most common hip disorder in adolescents; many of the children who develop it are overweight. This does not correlate with this patient's history.
name: Slipped upper femoral epiphyses (SUFE)
label: c
answer: no

Correct answer: a
A 31-year-old man presents to A&E following a fall onto his left hand whilst playing football.

On examination, there is swelling on inspection around the wrist, and there is pain on palpation of the anatomical snuffbox. An x-ray is ordered which shows no evidence of a fracture.

How should this patient be managed?

Options:
explanation: Although there is currently no radiological evidence of a fracture, the history and examination findings are highly suspicious for a scaphoid fracture. Ibuprofen can be useful in managing the pain associated with this fracture, but it should also be immobilised in a cast before the patient is discharged.
name: Give ibuprofen and discharge patient
label: b
answer: no
explanation: Although there is currently no radiological evidence of a fracture, the history and examination findings are highly suspicious for a scaphoid fracture. Internal fixation surgery should be done if there is radiological evidence of a displaced fracture. At this current point in time, the best course of action is to cast the wrist and repeat X-rays after 10 days.
name: Internal fixation surgery
label: c
answer: no
explanation: Although there is currently no radiological evidence of a fracture, the history and examination findings are highly suspicious for a scaphoid fracture. Scaphoid fractures can take some time to show up on x-rays, which is why all suspected fractures should be immobilised in a cast and have a follow-up x-ray arranged.
name: Apply a cast + repeat X-ray after 10 days
label: a
answer: yes
explanation: Although there is currently no radiological evidence of a fracture, the history and examination findings are highly suspicious for a scaphoid fracture. This means that the patient should have a cast and the x-rays should be repeated after 10 days.
name: Reassure the patient and discharge
label: e
answer: no
explanation: Although there is currently no radiological evidence of a fracture, the history and examination findings make this highly suspicious of a scaphoid fracture. Reduction surgery should be done if there is radiological evidence of a displaced fracture. At this current point in time, the best course of action is to cast the wrist and repeat X-rays after 10 days.
name: Reduction surgery
label: d
answer: no

Correct answer: a