hllj/quesmed huggingface dataset:
A 23-year-old man presents to his GP with a history of bloody stool. For the last week, he reports opening his bowel six times per day with associated blood. He also notes associated mild abdominal pain and the constant urge to open his bowels.


He has no significant past medical history; however, he has a family history of type 1 diabetes and rheumatoid arthritis.


On assessment, he is haemodynamically stable. Abdominal examination is unremarkable apart from some diffuse mild abdominal tenderness, and blood tests show a haemoglobin level of 102 g/L (130-170 g/L).


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

Options:
explanation: This patient has symptoms suggestive of severe colitis, which has the potential to deteriorate significantly. He should be admitted to hospital for investigation and management
name: Monitor symptoms and review in three days
label: e
answer: no
explanation: Treatment for UC should be started by a gastroenterologist, following confirmation of the diagnosis. It would not be appropriate to start treatment in primary care
name: Start oral steroids
label: c
answer: no
explanation: This patient has a history suggestive of inflammatory bowel disease (IBD). The significant rectal bleeding and tenesmus (urge to constantly open his bowels) are more suggestive of ulcerative colitis (UC) than Crohn's disease. Using the Truelove and Witts scoring system for UC, this patient has severe UC due to the number of bowel motions per day and anaemia. Hospital admission is recommended for patients with features suggestive of severe disease
name: Urgent hospital admission
label: a
answer: yes
explanation: Patients with symptoms suggestive of milder UC would be more appropriate for outpatient review. The patient is anaemic with significant symptoms, which means that he would be better managed as an inpatient in secondary care
name: Urgent outpatient gastroenterology referral
label: b
answer: no
explanation: Faecal calprotectin is an inflammatory marker that is useful in the diagnosis of IBD. However, given that the patient satisfied the criteria for severe colitis, this patient should be admitted to hospital for investigation and management
name: Check faecal calprotectin in primary care
label: d
answer: no

Correct answer: a


Learning point: Severe ulcerative colitis is characterised by frequent bloody stools, abdominal pain, and may require urgent hospital admission for management.
A 60-year-old man is referred for an outpatient gastroscopy following worsening reflux symptoms over the last six months.

Gastrosopcy shows a red, velvety appearance of the oesophageal mucosa and biopsies from this region show "metaplastic columnar epithelium replacing the oesophageal squamous epithelium". There are no areas of dysplasia identified.

Which of the following is the best step in management?

Options:
explanation: There is no role for oesophagectomy in Barrett's. Oesophagectomy is a treatment option for oesophageal carcinoma
name: Referral to the multi-disciplinary team (MDT) for consideration of an oesophagectomy
label: d
answer: no
explanation: RFA is a treatment option for Barrett's with high-grade dysplasia as there is a more significant risk of progressing to cancer
name: Radiofrequency ablation (RFA)
label: c
answer: no
explanation: High dose PPI alone should be combined with regular surveillance endoscopies to monitor for the development of dysplasia and adenocarcinoma
name: High dose PPI
label: e
answer: no
explanation: The histological appearances are consistent with a diagnosis of Barrett's oesophagus. This is usually a consequence of long-standing reflux disease and describes the abnormal, reversible change of the oesophageal epithelium from stratified squamous to simple columnar. The major risk factor of Barretts's is oesophageal adenocarcinoma. Treatment is with high dose PPI and regular endoscopies to screen for the development of dysplasia and adenocarcinoma
name: High dose proton-pump inhibitor (PPI) and surveillance endoscopies
label: a
answer: yes
explanation: EMR is a treatment option for Barrett's with high-grade dysplasia as there is a more significant risk of progressing to cancer
name: Endoscopic mucosal resection (EMR)
label: b
answer: no

Correct answer: a


Learning point: Barrett's oesophagus is characterized by metaplastic changes in the oesophageal lining resulting from chronic gastro-oesophageal reflux disease, requiring PPI therapy and regular surveillance.
A 35-year-old woman with a history of chronic pancreatitis presents with post-prandial vomiting and abdominal pain. She denies weight loss, fevers, pruritus and any family history of malignancy.

Her blood tests are significant for a cholestatic pattern of liver function tests.

Which of the following is the most likely diagnosis?

Options:
explanation: Pancreatic pseudocysts are a common complication of acute or chronic pancreatitis. They occur due to damage to the pancreatic ducts, which leads to cystic accumulation of pancreatic juices. Pseudocysts can be asymptomatic or present with signs of biliary obstruction (abdominal pain, jaundice) or gastric outlet obstruction (post-prandial vomiting) due to mass effect of an enlarging pseudocyst on adjacent structures. There is also the risk of secondary infection
name: Pancreatic pseudocyst
label: a
answer: yes
explanation: Cholangiocarcinoma is less likely given the age of the patient and lack of risk factors
name: Cholangiocarcinoma
label: c
answer: no
explanation: PBC is less likely as it would not explain the symptoms of gastric outlet obstruction. Also, there is no pruritus (present in around 70% of cases of PBC)
name: Primary biliary cholangitis (PBC)
label: e
answer: no
explanation: Choledocholithiasis refers to gallstone disease in the common bile duct. Although this is often associated with pain and cholestatic liver function tests, the post-prandial vomiting would be unusual and is more suggestive of gastric outlet obstruction
name: Choledocholithiasis
label: d
answer: no
explanation: Pancreatic cancer is unlikely given the age of the patient. It is also more common for pancreatic cancer to present without pain
name: Pancreatic cancer
label: b
answer: no

Correct answer: a


Learning point: Pancreatic pseudocysts are common complications of chronic pancreatitis, typically forming as fluid-filled sacs that develop in response to inflammation, necrosis, or ductal obstruction, and can lead to symptoms such as abdominal pain, nausea, and potential rupture or infection if left untreated.
A 32-year-old with type 1 diabetes presents to her GP with a 6-month history of diarrhoea, weight loss and bloating.

Examination reveals conjunctival pallor and a soft, non-tender abdomen.

Her blood tests show a microcytic anaemia, thrombocytopenia, normal anti-tissue transglutaminase (TTG) antibody levels and low serum immunoglobulin A (IgA).

Which of the following is the next best investigation given the likely diagnosis?

Options:
explanation: Faecal calprotectin is a measure of intestinal inflammation. It may be raised in coeliac disease and conditions such as inflammatory bowel disease, colorectal cancer and infectious colitis. The main use of faecal calprotectin is to exclude inflammatory bowel disease (IBD), given that it has a high specificity in this context
name: Measure faecal calprotectin
label: d
answer: no
explanation: A duodenal biopsy is the gold standard test to confirm the diagnosis of Coeliac disease. It would be performed if serological tests are positive or if there is high clinical suspicion following multiple negative results from different serological tests
name: Duodenal biopsy
label: c
answer: no
explanation: The history of autoimmune disease, symptoms and associated microcytic anaemia are suggestive of Coeliac disease. The most commonly used screening test for Coeliac disease is checking for the presence of auto-antibodies against tissue transglutaminase (TTG). This has a high specificity and sensitivity; however, false negatives may be found in patients with IgA deficiency. IgA deficiency is more common in patient's with coeliac disease, and therefore, all patients should have IgA levels measured alongside antibodies against TTG. The next step in patients with IgA deficiency would be to measure antibodies against TTG from the IgG class
name: Measure immunoglobulin G (IgG) TTG levels
label: a
answer: yes
explanation: Low levels of faecal elastase are suggestive of exocrine pancreatic insufficiency. Causes include cystic fibrosis, chronic pancreatitis and biliary obstruction. Although the patient's symptoms may be due to pancreatic insufficiency, Coeliac disease is more likely given the history of autoimmune disease and IgA deficiency
name: Measure faecal elastase
label: e
answer: no
explanation: This patient has IgA deficiency and likely has a false-negative IgA anti-TTG level. Repeating the anti-TTG levels using the same immunoglobulin class (i.e. IgA) is likely to give the same result
name: Repeat anti-TTG antibody levels
label: b
answer: no

Correct answer: a


Learning point: In patients with suspected Coeliac disease and low serum IgA, measure IgG anti-tissue transglutaminase (TTG) antibodies for accurate diagnosis.
A 2-year-old boy presents to the paediatric emergency department (ED) after his parents noted that he was struggling with his breathing. They note that for the last three days, he has had a dry cough and runny nose with mild temperature spikes.

On examination, the boy is tachypnoeic and using his accessory muscles. His temperature is 38°C, and there is a high-pitched rasping sound audible during inspiration.

Given the likely diagnosis, which of the following is the most likely causative organism?

Options:
explanation: RSV can cause croup; however, parainfluenza is more common. RSV is the most common causative organism in bronchiolitis
name: Respiratory syncytial virus (RSV)
label: b
answer: no
explanation: Croup (acute laryngotracheobronchitis) is an upper airways disease that is most common in children aged between 6 months to 3 years. It usually presents with difficulty in breathing, fever, stridor and a seal or dog-like barking-cough on the background of a coryzal illness. Parainfluenza virus is the most common causative organism
name: Parainfluenza
label: a
answer: yes
explanation: Bordetella is the causative agent in pertussis (whooping cough). This is a bacterial infection that is rarer than croup due to effective vaccination. Pertussis can present with an inspiratory gasp; however, the high-pitching rasping sound described in the question is more suggestive of stridor
name: Bordetella pertussis
label: d
answer: no
explanation: Mycoplasma is a rare cause of croup
name: Mycoplasma pneumoniae
label: c
answer: no
explanation: Rhinovirus is a well-recognised cause of croup; however, it is less common than parainfluenza
name: Rhinovirus
label: e
answer: no

Correct answer: a


Learning point: Croup, characterised by stridor and a barking cough, is commonly caused by the parainfluenza virus in children aged 6 months to 3 years.
A 25-year-old woman presents to her GP with an 8 hour history of a red and swollen left breast. She is ten weeks post-partum and has been regularly breastfeeding with no complications.

On examination, she has a temperature of 37.6°C and an erythematous and tender left breast. The erythema is noted to extend in a wedge-shaped distribution.

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

Options:
explanation: Urgent breast clinic referral would be warranted if there are signs of a breast abscess. A breast abscess would present with a painful swollen lump in the breast, often with a history of recent mastitis
name: Urgent referral to the breast surgery clinic
label: c
answer: no
explanation: This woman has signs and symptoms consistent with mastitis. First-line management is with reassurance, simple analgesia and encouragement of breastfeeding
name: Encourage breastfeeding and provide simple analgesia
label: a
answer: yes
explanation: It is essential that breastfeeding continues to help prevent stasis of breast milk which can predispose to infection and worsening of symptoms
name: Advise against breastfeeding until symptoms resolve
label: d
answer: no
explanation: There are no signs that this patient is systemically unwell and in need of hospital admission. Oral antibiotics would be the next step if her symptoms do not respond to conservative management
name: Admit to hospital for IV antibiotics
label: e
answer: no
explanation: Antibiotics should be prescribed in cases that are likely to be due to infectious mastitis. These include the presence of a nipple fissure, symptoms not improving with continuous milk removal for 12-24 hours and a positive breast milk culture
name: Prescribe oral flucloxacillin
label: b
answer: no

Correct answer: a


Learning point: Mastitis in breastfeeding women is typically managed with reassurance, analgesia, and continued breastfeeding to promote drainage and healing.
A 23-year-old woman presents to her GP requesting emergency contraception after an episode of unprotected sexual intercourse (UPSI) five days ago. She does not use any regular contraception and is on day 13 of a regular 28-day menstrual cycle.

On questioning, she reveals some dysuria and abnormal vaginal discharge for the last 24 hours.

Which of the following is the most appropriate step with regards to the provision of emergency contraception?

Options:
explanation: As this patient has symptoms of an untreated sexually transmitted infection, the IUD is contraindicated
name: Offer the copper intrauterine device (IUD)
label: b
answer: no
explanation: Ulipristal acetate is a form of emergency contraception that can be given up to five days after UPSI. It is more effective than levonorgestrel but less effective than the copper intrauterine device (IUD). As there is a risk of pregnancy in this scenario, ulipristal is the most appropriate management option
name: Offer ulipristal acetate
label: a
answer: yes
explanation: The earliest this woman could ovulate is day 14 in her cycle (shortest cycle length - 14 days). As she had UPSI on day 8, there is a risk of sperm meeting egg and therefore pregnancy, so emergency contraception is indicated
name: Reassure that emergency contraception is not needed
label: d
answer: no
explanation: The COCP cannot be used as a form of emergency contraception
name: Offer the combined oral contraceptive pill (COCP)
label: e
answer: no
explanation: Levonorgestrel can only be taken up to three days after UPSI. It is also less effective than ulipristal
name: Offer levonorgestrel
label: c
answer: no

Correct answer: a
A 65-year-old Caucasian patient registers with a GP in the UK, having emigrated from Italy.


Following a set of initial investigations, it is found that his ambulatory blood pressure is 145/90 mmHg. He also has a glycosylated haemoglobin (HBA1C) level of 52 mmol/mol (normal range 20-42 mmol/mol) and a fasting blood glucose of 7.2 mmol/L (normal <6.1 mmol/L).


He notes that he was recently diagnosed with type 2 diabetes but has not started any treatment.


Which of the following is the most appropriate next step in the management of this patient's hypertension?

Options:
explanation: Home blood pressure monitoring (HBPM) is an alternative to ambulatory blood pressure monitoring. HBPM is not indicated if a diagnosis of hypertension has been confirmed with ambulatory monitoring
name: Offer home blood pressure monitoring
label: d
answer: no
explanation: Metformin would be the first-line management option for this patient's type 2 diabetes, but it would not be used for treating hypertension
name: Start metformin
label: c
answer: no
explanation: Nifedipine is a calcium-channel blocker. It would be indicated if this patient did not have co-existing type 2 diabetes
name: Start nifedipine
label: b
answer: no
explanation: This patient has stage 1 hypertension and type 2 diabetes. Therefore, the recommended first-line management of hypertension is with an angiotensin-converting enzyme (ACE) inhibitor. ACE inhibitors are renoprotective in type 2 diabetes and are therefore recommended for the management of hypertension regardless of age or ethnicity
name: Start lisinopril
label: a
answer: yes
explanation: Bendroflumethiazide is not an initial treatment option for hypertension. It can be considered if the patient is intolerant to lisinopril or if blood pressure is not controlled after the dose has been up-titrated
name: Start bendroflumethiazide
label: e
answer: no

Correct answer: a


Learning point: In patients with type 2 diabetes and hypertension, starting an ACE inhibitor is essential for cardiovascular protection and renal health.
A 35-year-old man with presents to the Emergency Department with persistent dizziness since waking up four hours ago. He reports the room spinning around him and associated nausea but no vomiting.

Full systems review is otherwise unremarkable; however, the patient does reveal having some mild coryzal symptoms a few days ago. On examination, there is a positive head impulse test, unidirectional nystagmus and no abnormal test of skew.

Given the likely diagnosis, which of the following is the most appropriate management?

Options:
explanation: A CT head would be indicated if a central cause of vertigo (e.g. stroke) was suspected. Signs of central vertigo on a HINTS exam are a negative head impulse test, bidirectional nystagmus and an abnormal test of skew. The fact he is young and has no cardiac risk factors makes the diagnosis of stroke less likely
name: Urgent CT head
label: b
answer: no
explanation: Aspirin would be indicated if an ischaemic stroke was suspected as the cause of vertigo following exclusion of haemorrhage on a CT head
name: Start aspirin 300mg
label: c
answer: no
explanation: There is no indication for treatment with antibiotics. Vestibular neuronitis is often a sequelae of a viral upper respiratory tract infection
name: Start amoxicillin
label: e
answer: no
explanation: Vestibular neuronitis usually self-resolves spontaneously; however, the symptoms can be debilitating. Treatment is therefore recommended if symptoms are troublesome
name: Reassure with safety-net advice
label: d
answer: no
explanation: The likely diagnosis is vestibular neuronitis. This is a peripheral cause of vertigo, and the findings described on the HINTS (head impulse, nystagmus and test of skew) examination are suggestive of this. Vestibular neuronitis is characterised by inflammation of the vestibular nerve, often after a viral infection. Common symptoms include acute, spontaneous vertigo, nausea, vomiting and unsteadiness. Prochlorperazine is often used for symptomatic treatment
name: Oral prochlorperazine
label: a
answer: yes

Correct answer: a


Learning point: Oral prochlorperazine is used to manage the vertigo and nausea in vestibular neuronitis by blocking dopamine receptors, typically for short-term symptom relief.
A 56-year-old man with a background of type 2 diabetes, hypertension and ischaemic heart disease presents with a cold and painful left foot.

He reports that the symptoms came on suddenly around two hours ago. On examination, the left foot is pale and cold with absent dorsalis pedis and posterior tibial pulses; however, a prominent popliteal pulse is detected. Sensation and movement of the foot are preserved.

Which of the following is the most appropriate intervention whilst awaiting diagnostic imaging?

Options:
explanation: Warfarin is not used in acute limb ischaemia. Commencement of warfarin would delay any surgical intervention that may be necessary due to its long half-life
name: Warfarin
label: d
answer: no
explanation: Fondaparinux is not used in acute limb ischaemia. It is commonly used for the management of non-ST elevation myocardial infarctions (NSTEMIs)
name: Fondaparinux
label: e
answer: no
explanation: An unfractionated heparin infusion is preferable to treatment dose LMWH in the management of acute limb ischaemia. As unfractionated heparin has a shorter half-life than LMWH, patients can be taken to theatre more promptly with reduced bleeding risk
name: Low molecular weight heparin (LMWH)
label: c
answer: no
explanation: Clopidogrel is not used in acute limb ischaemia. Commencement of clopidogrel would delay any surgical intervention that may be necessary due to its long half-life
name: Clopidogrel
label: b
answer: no
explanation: This patient has signs and symptoms consistent with acute limb ischaemia. The prominent popliteal pulsation suggests that the aetiology may be embolic disease from a popliteal aneurysm. Medical management of acute limb ischaemia is with high flow oxygen and initiation of an unfractionated heparin infusion. Surgical intervention may be necessary depending on classification using the Rutherford system
name: Unfractionated heparin
label: a
answer: yes

Correct answer: a


Learning point: Medical management of acute limb ischaemia is with high flow oxygen and initiation of an unfractionated heparin infusion.
A 78-year-old lady with a background of atrial fibrillation and hypertension presents with a two-hour history of severe abdominal pain. She reports no other symptoms, and abdominal examination is unremarkable apart from some generalised abdominal tenderness.


A venous blood gas reveals a lactate of 7mmol/L (normal range 0.6-1.4 mmol/L), and an urgent CT abdomen and pelvis (CTAP) shows no acute pathology.


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

Options:
explanation: Endovascular intervention, including thrombolysis, may be indicated in this patient; however, a diagnosis of acute mesenteric ischaemia should first be confirmed by CT angiography
name: Endovascular thrombolysis
label: d
answer: no
explanation: Steroids are not used in the management of acute mesenteric ischaemia
name: IV methylprednisolone
label: c
answer: no
explanation: An erect abdominal X-Ray is important to look for signs of perforation. However, a CT has higher sensitivity and has already been reported as normal in this scenario
name: Erect abdominal X-Ray
label: e
answer: no
explanation: Acute, severe abdominal pain, atrial fibrillation and pain out of proportion to findings on an examination suggest acute mesenteric ischaemia. The high lactate level is also highly suggestive. Although CTAP is normal, the most sensitive imaging modality is a CT angiogram, which would be indicated in this scenario given the high index of suspicion
name: CT angiography
label: a
answer: yes
explanation: A laparotomy is not indicated as there are no signs of peritonitis, perforation or infraction at this stage. We are also not sure if this woman would be a candidate for surgery given her co-morbidities
name: Laparotomy
label: b
answer: no

Correct answer: a