hllj/quesmed huggingface dataset:
A 7-year-old boy attends his General Practitioner for a routine asthma review. His regular inhalers include salbutamol and beclometasone 200 micrograms (mcg) daily. He was previously unable to tolerate a MART regimen. He has been compliant with his inhalers but has been using his salbutamol inhaler every other day for the past two months due to wheezing. He is an active boy at school and plays sports; however his symptoms limit his exercise tolerance. 

Which of the following is the next best management for his asthma?

Options:
explanation: This would only be indicated in an acute asthma attack, which is not the case here.
name: Oral prednisolone
label: e
answer: no
explanation: In children whose asthma is not well controlled on salbutamol and a low dose inhaled corticosteroid and who cannot tolerate a MART regimen, it is recommended to start montelukast. 
name: Add on montelukast
label: d
answer: yes
explanation: In children whose asthma is not well controlled on salbutamol and a low dose inhaled corticosteroid, it is recommended to start montelukast. However, salbutamol should not be stopped as it is the mainstay of reliever therapy. Instead, salmeterol might be stopped if it does not appear to be working.
name: Stop salbutamol and start montelukast
label: b
answer: no
explanation: This boy has poorly controlled asthma on his current regime, as evidenced by his symptoms and need for reliever inhaler use more than three times a week. The next step would be to add montelukast as he has already not been able to tolerate a MART regimen.
name: Switch to maintenance and reliever therapy (MART)
label: a
answer: no
explanation: The patient is currently on a low dose of inhaled corticosteroids (100-200mcg). It would be more appropriate to trial combined maintenance and reliever therapy first before moving on to an increased dose of steroids.
name: Increase beclometasone to 300mcg daily
label: c
answer: no

Correct answer: d


Learning point: In children aged 5-11 whose asthma is uncontrolled while on salbutamol and low-dose ICS, if they are unable to tolerate MART therapy, montelukast (LTRA) should be trialled.
A 50-year-old woman presents to her General Practitioner with a two-week history of intermittent tension headache. She describes having poor sleep and concentration for the past year and has had to leave her job as a result. She also has frequent episodes of palpitations accompanied by shortness of breath at rest.

Physical examination reveals no significant abnormalities. An electrocardiogram shows a normal sinus rhythm.

Which is the next best course of management?

Options:
explanation: This would only be appropriate to use in an acute anxiety attack. It is not recommended for long term use in patients with anxiety as it may result in benzodiazepine dependence
name: A short course of lorazepam
label: b
answer: no
explanation: This is a specialised form of cognitive behavioural therapy shown to be most effective in treating obsessive compulsive disorder. This would involve exposing patients to situations that provoke their obsessions whilst helping them overcome their compulsive responses. It would not be relevant in treating generalised anxiety disorder in this case
name: Refer for exposure and response prevention therapy
label: e
answer: no
explanation: This would provide pain relief for her tension headache but would not be addressing the root cause of her problem, which is generalised anxiety disorder
name: Start paracetamol and ibuprofen as required
label: d
answer: no
explanation: This is a selective serotonin reuptake inhibitor (SSRI), the class of drugs that would be recommended as first-line in the pharmacological treatment of generalised anxiety disorder. However, before escalating to pharmacotherapy, it would be more appropriate to try psychological interventions first
name: Start paroxetine
label: c
answer: no
explanation: The patient meets the diagnostic criteria for generalised anxiety disorder. CBT has been shown to be highly effective and should be trialled in all patients before moving on to pharmacotherapy. Other psychological interventions may include counselling, support groups and relaxation training
name: Refer for cognitive behavioural therapy (CBT)
label: a
answer: yes

Correct answer: a


Learning point: Cognitive behavioural therapy is an effective first-line treatment for generalised anxiety disorder, improving symptoms and functioning before considering medication.
An 80-year-old gentleman with a background of mixed dementia is admitted to the care of the elderly ward with a urinary tract infection. He has challenging behaviour on the ward, being aggressive to nursing staff and refusing to take his medications. Collateral history from his family reveals that he has also displayed such behaviour at home.

He is diagnosed as having behavioural and psychological symptoms of dementia and is started on quetiapine.

Which is the following potential side effects is he at increased risk of with this new medication?

Options:
explanation: Antipsychotics are usually associated with hyperprolactinaemia. This is due to their dopamine antagonist effect, which blocks the inhibitory effects of dopamine on the pituitary, thereby increasing its secretion of prolactin. Clinical consequences of elevated prolactin levels include gynaecomastia and galactorrhoea
name: Hypoprolactinaemia
label: c
answer: no
explanation: Antipsychotics are associated with an increased risk of ischaemic stroke. In general, they should be initiated with caution in elderly patients due to their many side effects and increased risk of mortality
name: Stroke
label: a
answer: yes
explanation: Antipsychotics are associated with QT interval prolongation, which may lead to ventricular arrhythmias. A baseline electrocardiogram should always be obtained prior to initiation
name: QT interval shortening
label: b
answer: no
explanation: Antipsychotics are more likely to cause postural hypotension, likely secondary to alpha-adrenergic blockade; hence they should be used with caution in the elderly who are at higher risk of falls
name: Hypertension
label: e
answer: no
explanation: Antipsychotics are associated with sedative effects and may help with insomnia
name: Insomnia
label: d
answer: no

Correct answer: a


Learning point: Antipsychotics like quetiapine can increase the risk of ischaemic stroke in elderly patients.
A 70-year-old man is admitted with sudden onset right ankle pain and swelling for 1 day, the third episode this year. His medical history includes type 2 diabetes and chronic kidney disease, likely from diabetic nephropathy.


On examination, his right ankle is erythematous, warm, and tender, with full range of movement.




Observations: Temperature 38.1°C, pulse 90, BP 110/70, respiratory rate 18, SpO<sub>2</sub> 100% on room air



Initial blood tests are as follows:

||||
|--------------|:-------:|---------------|
|Haemoglobin|142 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.1x10<sup>9</sup>/L|3.0 - 10.0|
|Neutrophils|5.5x10<sup>9</sup>/L|2.0 - 7.5|
|Platelets|210x10<sup>9</sup>/L|150 - 400|
|Sodium|137 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Chloride|102 mmol/L|95 - 106|
|Urea|8 mmol/L|2.5 - 7.8|
|Creatinine|151 µmol/L|60 - 120|
|eGFR|60 mL/min/1.73m<sup>2</sup>|> 60|





X-ray of the right ankle showed no acute fractures or bony erosions.



Which of the following is the next most appropriate treatment?

Options:
explanation: This would not be appropriate in a patient with chronic kidney disease as it may worsen renal function. Creatinine clearance should be calculated first. Proton pump inhibitor therapy should also be considered if initiating treatment with non-steroidal anti-inflammatory drugs
name: Naproxen
label: b
answer: no
explanation: This would be a second-line agent for urate lowering therapy if allopurinol is contraindicated, not tolerated or unable to achieve target serum uric acid
name: Febuxostat
label: e
answer: no
explanation: This may be considered if the patient has very poor renal function and is not able to take either non-steroidal anti-inflammatory drugs or colchicine. Blood glucose monitoring should be done whilst on prednisolone, especially since the patient is diabetic, as it usually causes elevated glucose levels in the evening or nighttime
name: Prednisolone
label: c
answer: no
explanation: This would not be appropriate in a patient with chronic kidney disease as it may worsen renal function. Creatinine clearance should be calculated first. Proton pump inhibitor therapy should also be considered if initiating treatment with non-steroidal anti-inflammatory drugs
name: Allopurinol
label: d
answer: no
explanation: This patient likely has an acute attack of crystal arthropathy. Septic arthritis should be ruled out, especially in a diabetic patient who may be immunocompromised. Joint aspiration should be considered for diagnosis. Colchicine would be suitable in a patient with chronic kidney disease, and renal adjustment considered if eGFR 10-50, below which it would be contraindicated
name: Colchicine
label: a
answer: yes

Correct answer: a

Colchicine

Learning point: Colchicine can be used for gout in chronic kidney disease, but doses must be reduced for an eGFR of 10-50 to avoid toxicity, with close monitoring
A 40 year old gentleman is admitted to the acute medical unit with a 1 day history of sudden onset right ankle pain and swelling. He has no other past medical history.



On examination, his right ankle is erythematous, warm and tender on palpation. There is limited active and passive range of movement in the ankle joint due to pain.



Observations:



  - Temperature 38.5°C
  - pulse 90
  - BP 110/70
  - respiratory rate 18
  - SpO<sub>2</sub> 100% on room air



Initial blood tests are as follows:



||||
|--------------|:-------:|---------------|
|Haemoglobin|142  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.1x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|210x10<sup>9</sup>/L|150 - 400|
|Neutrophils|13x10<sup>9</sup>/L|2.0 - 7.5|



Joint aspiration is done which shows a cloudy yellow fluid with a predominance of neutrophils. The following is seen on Gram stain:



  [lightgallery]



Which is the most likely causative organism?

Options:
explanation: This would appear as Gram-positive elongated diplococci
name: Streptococcus pneumoniae
label: c
answer: no
explanation: This would appear as Gram-negative intracellular diplococci. It is associated with young sexually active adults
name: Neisseria gonorrhoeae
label: b
answer: no
explanation: This would appear as Gram-negative intracellular diplococci. It is associated with young sexually active adults
name: Escherichia coli
label: d
answer: no
explanation: This would appear as Gram-negative bacilli. It is an uncommon cause of septic arthritis
name: Pseudomonas aeruginosa
label: e
answer: no
explanation: This would appear as Gram-positive diplococci in clusters. This is seen as purple staining cocci that appear similar to "bunches of grapes". S. aureus is a common cause of septic arthritis in otherwise healthy adults and may be associated with prosthetic joint infections
name: Staphylococcus aureus
label: a
answer: yes

Correct answer: a

Staphylococcus aureus

Learning point: Staphylococcus aureus is the most common causative organism of septic arthritis.
A 50 year old woman presents with an episode of sudden painless visual loss in her right eye this morning. She also complains of a 2 week history of persistent frontal headache and morning stiffness of the shoulders and hips worse in the past year.

Physical examination is otherwise unremarkable.

Computed tomography (CT) brain showed no acute intracranial abnormalities.

Which of the following findings is most likely associated with her condition?

Options:
explanation: This is classically found in ankylosing spondylitis, which may present with neck or back pain with morning stiffness that improves on exercise. However, this is more likely associated with anterior uveitis, which would cause painful visual loss
name: Inflammation of the sacroiliac joints
label: c
answer: no
explanation: This is highly specific for rheumatoid arthritis (RA), which is an inflammatory arthritis that may also present with pain and morning stiffness in joints. However, RA is more likely to have peripheral joint involvement, as opposed to axial involvement in polymyalgia rheumatica
name: Anticyclic citrullinated peptide (anti-CCP) antibody positivity
label: e
answer: no
explanation: This may be found in transient ischaemic attack (TIA) due to carotid thromboembolism, which may result in transient monocular visual loss or amaurosis fugax. A TIA would not explain the frontal headache and joint stiffness
name: Carotid artery stenosis on ultrasound Doppler
label: b
answer: no
explanation: This patient has giant cell arteritis and polymyalgia rheumatica, which are closely associated. Raised ESR is a characteristic finding. Sudden onset vision loss is a red flag and requires urgent steroid treatment to avoid permanent vision loss
name: Raised erythrocyte sedimentation rate (ESR)
label: a
answer: yes
explanation: Headache may be a symptom of raised intracranial pressure. This may occur due to a wide range of aetiologies, including intracranial haemorrhage, neoplasm, stroke, infections, hydrocephalus. However, the patient does not have any neurological abnormalities so this would be less likely. Idiopathic intracranial hypertension may present with headache and vision loss but this is less likely to be unilateral
name: Raised cerebrospinal fluid (CSF) pressure
label: d
answer: no

Correct answer: a


Learning point: Giant cell arteritis is associated with polymyalgia rheumatica and typically presents with a raised erythrocyte sedimentation rate (ESR).
A 90 year old gentleman is admitted to the medical ward with an infected sacral sore. He has a background of advanced dementia and previous stroke. During his stay, he develops aspiration pneumonia and his condition begins to deteriorate.

He is reviewed by the Palliative team who plan to start him on end of life medications via a syringe driver. He is currently on oral morphine 10mg TDS and has required three breakthrough doses of oral morphine 2mg in the past day. What is the most appropriate subcutaneous breakthrough dose he should be prescribed?

Options:
explanation: This breakthrough dose would be too high for his current pain requirements. The conversion ratio from oral to subcutaneous morphine is 2:1
name: 10mg hourly as required
label: c
answer: no
explanation: Both the regular and breakthrough doses of oral morphine should be added together to obtain the total daily dose of oral morphine required. Furthermore, a shorter dosing interval between breakthrough doses would be required to allow for adequate pain relief
name: 5mg 6-8 hourly
label: d
answer: no
explanation: A shorter dosing interval between breakthrough doses would be required to allow for adequate pain relief
name: 2mg 6-8 hourly
label: b
answer: no
explanation: Both the regular and breakthrough doses of oral morphine should be added together to obtain the total daily dose of oral morphine required
name: 5mg hourly as required
label: e
answer: no
explanation: Syringe drivers are given as continuous subcutaneous infusions over 24 hours. The oral morphine dose needs to be halved for subcutaneous (SC) administration via the syringe driver. The total daily oral morphine dose is (10mg x 3) + (2mg x 3) = 36mg. This would be SC morphine 18mg. As breakthrough doses should be one-sixth to one-tenth of the total daily dose, you should therefore prescribe him 2-3mg every hourly as required. The lower limit of the dose range may be prescribed to avoid concerns of toxicity. If more than 6 doses are required in 24 hours, consider seeking senior advice or review
name: 2mg hourly as required
label: a
answer: yes

Correct answer: a


Learning point: In palliative care, subcutaneous breakthrough doses of morphine should be one-sixth to one-tenth of the total daily oral morphine dose.
A 32-year-old woman presents to her General Practitioner (GP) with a right-sided breast lump. She first noticed it one week ago and denies any other symptoms including breast pain, discharge, skin or nipple changes. She has no personal or family history of any cancers.

On examination, there is a smooth 1cm lump in the upper inner quadrant of the left breast. The borders are well defined, and the lump moves under the skin on palpation. There is no associated lymphadenopathy.

Which of the following is the best step in management?

Options:
explanation: Although this is likely a benign breast lump, guidelines recommended an urgent referral to secondary care
name: Follow up assessment in primary care in 12 months
label: e
answer: no
explanation: The breast lump is likely to be a fibroadenoma based on its characteristics and the patient's age. This is a common, benign breast lump that is common in younger women due to increased sensitivity to oestrogen. However, all women over 30 with an unexplained breast lump should be urgently referred to the breast clinic for further assessment. This is likely to include further clinical assessment, imaging and biopsy or fine-needle aspiration (FNA)
name: Urgent referral to secondary care
label: a
answer: yes
explanation: An urgent (two-week wait) referral is recommended for all women over 30 with an unexplained breast lump. For younger patients with no worrying features, a non-urgent referral is indicated
name: Non-urgent referral to secondary care
label: c
answer: no
explanation: Although this is likely a benign breast lump, guidelines recommended an urgent referral to secondary care
name: Follow up assessment in primary care in 6 months
label: d
answer: no
explanation: Although this is likely a fibroadenoma, the patient should be referred for further investigations
name: Reassure the patient that this is a benign breast lump
label: b
answer: no

Correct answer: a


Learning point: All women over 30 with an unexplained breast lump should be urgently referred for further assessment, regardless of lump characteristics.
A 56-year-old woman is diagnosed with HER2 (human epidermal growth factor receptor 2) positive breast cancer. Her case is discussed at the breast cancer multidisciplinary team (MDT) meeting, and it is decided that she would benefit from neoadjuvant therapy before surgery.

Which of the following is the most important investigation to perform before starting treatment?

Options:
explanation: There is no clear evidence of decreased lung function with trastuzumab, and pulmonary function testing is not usually indicated
name: Pulmonary function testing
label: b
answer: no
explanation: An ETT may be useful as part of an anaesthetic assessment before surgery; however, the most important investigation before neoadjuvant therapy with trastuzumab is an ECHO
name: Exercise tolerance test (ETT)
label: c
answer: no
explanation: There is no indication for fundoscopy before starting neoadjuvant therapy in a patient with breast cancer
name: Fundoscopy
label: e
answer: no
explanation: Neoadjuvant therapy for a patient with HER2 positive breast cancer is likely to involve the monoclonal antibody trastuzumab (Herceptin). Cardiomyopathy is an important risk of trastuzumab treatment and therefore all patients should have a baseline ECHO before treatment
name: Echocardiogram (ECHO)
label: a
answer: yes
explanation: A DEXA scan is used to assess for osteoporosis. It would not routinely be performed before starting neoadjuvant therapy in breast cancer in a patient without any clear risk factors for osteoporosis
name: Dual-energy X-ray absorptiometry (DEXA) scan
label: d
answer: no

Correct answer: a


Learning point: Baseline echocardiogram is essential before initiating neoadjuvant therapy in HER2 positive breast cancer to assess the risk of trastuzumab-induced cardiomyopathy.
A 65-year-old man presents to his general practitioner (GP) complaining that his voice has become more hoarse over the last three months. He denies any other symptoms.

His past medical history is significant for gastro-oesophageal reflux disease (GORD), for which he takes 20mg of omeprazole once a day.

There are no notable findings on examination.

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

Options:
explanation: This would not be appropriate as hoarseness could be a sign of underlying malignancy
name: Reassure and discharge
label: d
answer: no
explanation: Delay in investigations can affect prognosis, and it is therefore recommended that this patient be referred urgently under the 2-week wait pathway
name: Arrange a follow-up GP appointment in two weeks to monitor symptoms
label: e
answer: no
explanation: Hoarseness is a red flag for laryngeal cancer. Guidelines suggest that all patients over 45 years old should be referred urgently to secondary care if they have unexplained and persistent hoarseness
name: Urgent referral for investigation of laryngeal cancer
label: a
answer: yes
explanation: GORD can lead to voice changes due to the effect of acid on the vocal cords. However, this patients GORD symptoms appear to be well controlled on omeprazole. Regardless, persistent hoarseness is concerning, and he should be referred urgently to exclude laryngeal cancer
name: Increase omeprazole dosing to 20mg twice a day
label: b
answer: no
explanation: Apical lung cancer can compress the recurrent laryngeal nerve and lead to hoarseness. However, the lung cancer pathways require an abnormal chest X-ray or unexplained haemoptysis in patients over 40 before urgent referral
name: Urgent referral for investigation of lung cancer
label: c
answer: no

Correct answer: a


Learning point: All patients over 45 years old should be referred urgently to secondary care if they have unexplained and persistent hoarseness
A 16-year-old woman attends her GP due to otalgia in her right ear. She has had the pain for the last 2 days. On otoscopic examination the GP identifies a cloudy and slightly bulging tympanic membrane.

What is the correct management?

Options:
explanation: The patient has acute otitis media. Regular paracetamol or ibuprofen is the advised treatment for those who present with no acute complications or systemic illness
name: Regular analgesia
label: a
answer: yes
explanation: There is no evidence to support the use of decongestants or antihistamines in acute otitis media
name: Regular analgesia, a decongestant and an antihistamine
label: c
answer: no
explanation: There is no evidence to support the use of antihistamines in acute otitis media
name: Regular analgesia and an antihistamine
label: d
answer: no
explanation: There is no evidence to support the use of decongestants in acute otitis media
name: Regular analgesia and a decongestant
label: b
answer: no
explanation: Antibiotics are advised for those who are suspected to have acute otitis media and a systemic infection. Also, those with otorrhoea or those aged less than 2 with a bilateral infection may benefit from a short course of antibiotics, usually amoxicillin. Acute otitis media will normally improve within 3 days without the need for antibiotic treatment so they should not be used in this case
name: Regular analgesia and a short course of antibiotics
label: e
answer: no

Correct answer: a


Learning point: Acute otitis media in children without complications or systemic illness is usually managed with regular analgesia, such as paracetamol or ibuprofen, to relieve pain.