hllj/quesmed huggingface dataset:
A 65-year-old man presents to his GP with increased frequency. He has noticed that he has been getting up during the night to urinate more often. He reports having a poor stream, and having to try and force urine out because he often has a feeling of incomplete voiding. He has a past medical history of type 2 diabetes mellitus, obesity and postural hypotension. On digital rectal examination, the prostate was noted to be enlarged and smooth. A diagnosis of benign prostatic hypertrophy was made.

Which medication should the GP start this patient on?

Options:
explanation: Fenofibrate is prescribed for patients with hyperlipidaemia or hypertriglyceridaemia
name: Fenofibrate
label: e
answer: no
explanation: Doxazosin is an alpha-blocker. It is less selective than tamsulosin and so is only used when these selective effects are preferable, for example in a patient with hypertension
name: Doxazosin
label: c
answer: no
explanation: Finasteride is a 5-alpha reductase inhibitor. Usually these are prescribed 2nd-line after alpha-blockers. However, in this case the patient has postural hypotension and therefore, alpha-blockers are relatively contraindicated because of their potential adverse effects on the patients blood pressure
name: Finasteride
label: a
answer: yes
explanation: Tamsulosin is an alpha-blocker, usually used first line in treating BPH. However, here the patient has postural hypotension and so a 5-alpha reductase inhibitor would be preferable
name: Tamsulosin
label: b
answer: no
explanation: Alfuzosin is an alpha-blocker. It is less selective than tamsulosin and so is only used when these selective effects are preferable, for example in a patient with hypertension
name: Alfuzosin
label: d
answer: no

Correct answer: a


Learning point: Finasteride is a 5-alpha reductase inhibitor used to treat benign prostatic hypertrophy, particularly in patients with contraindications to alpha-blockers.
A 19-year-old patient visits her GP to talk about different types of contraception. She is keen to start the combined oral contraceptive pill (COCP).

Which of these would be a contraindication for this patient to start the COCP?

Options:
explanation: Ovarian cancer comes under category 1 in the UK Medical Eligibility criteria (UKMEC), therefore, they recommend unrestricted use
name: History of ovarian cancer
label: d
answer: no
explanation: This is not a contraindication because the patient is 19. Anyone under 35 who smokes comes under category 2 in the UK Medical Eligibility criteria (UKMEC), therefore, the "benefits generally outweigh the risks"
name: Current smoker, 20 a day
label: c
answer: no
explanation: Hypertension (with a systolic of more than 160 mmHg or diastolic of more than 95 mmHg) comes under category 4 in the UK Medical Eligibility criteria (UKMEC). However, hypotension is not a contraindication
name: Hypotension
label: e
answer: no
explanation: Stroke comes under category 4 in the UK Medical Eligibility criteria (UKMEC), which means that prescribing the COCP would lead to a "unacceptable health risk and should not be used". A patients' risk of stroke will increase slightly when prescribed the COCP, therefore, should be avoided in patients who have previously had a stroke
name: History of stroke
label: a
answer: yes
explanation: This is not a contraindication to starting the COCP. Women can in fact extend the cycling of the packets to reduce the number of bleeds they experience
name: Heavy menstrual periods
label: b
answer: no

Correct answer: a
An 18-year-old woman attends a GP appointment; she is worried because she missed the time for her progesterone only pill (POP) and she is now 22 hours late. She has not had sex in the meantime.

What should the GP advise?

Options:
explanation: This is the correct answer. Guidelines for progesterone only pills differ, depending on the pill. For the traditional POP you are not protected against pregnancy if it is more than 3 hours late, and with the desogestrel pill if you are more than 12 hours late. Therefore, whichever pill the patient was on in this scenario the advice remains the same. Take the missed pill as soon as possible, take that day's pill at the normal time, and use additional contraception for 48 hours
name: Take the missed pill as soon as possible and then continue taking the rest of the pills as normal. They should advise the patient to use additional contraception, such as condoms, for the next 48 hours
label: a
answer: yes
explanation: The advice is not to skip the missed pill but to take it as soon as possible. Only take one pill as soon as possible - if more than 1 pill was missed do not take multiple. Additional contraception is advised for the next 48 hours because this is the time it takes for the cervical mucus to re-thicken
name: Skip out the missed pill but continue to take the rest of the pills as normal. They should advise the patient to use additional contraception, such as condoms, for the next week
label: c
answer: no
explanation: Additional contraception is advised for the next 48 hours because this is the time it takes for the cervical mucus to re-thicken
name: Take the missed pill as soon as possible and then continue taking the rest of the pills as normal. They should advise the patient to use additional contraception, such as condoms, for the next week
label: d
answer: no
explanation: The advice is not to skip the missed pill but to take it as soon as possible. Only take one pill as soon as possible - if more than 1 pill was missed do not take multiple
name: Skip out the missed pill but continue to take the rest of the pills as normal. They should advise the patient to use additional contraception, such as condoms, for the next 48 hours
label: b
answer: no
explanation: The advice is not to skip the missed pill but to take it as soon as possible. Only take one pill as soon as possible - if more than 1 pill was missed do not take multiple. The patient will need additional contraception for the next 48 hours to allow time for the cervical mucus to re-thicken
name: Skip out the missed pill but continue to take the rest of the pills as normal. The patient does not need to take additional contraception
label: e
answer: no

Correct answer: a
An 18-year-old female sees her GP with an itchy rash. Two weeks previously the patient had a fever and noticed a 5cm diameter, oval, salmon pink patch near her umbilicus. On examination, the rash now covers the majority of her torso. It is made up of multiple millimetre to centimetre wide, salmon pink patches.

What is the most likely diagnosis?

Options:
explanation: Guttate psoriasis also presents with salmon pink plaques, most commonly on the torso. It is usually preceded by a respiratory infection 2-3 weeks previously. However, there is not usually a herald patch associated with guttate psoriasis
name: Guttate psoriasis
label: b
answer: no
explanation: Pityriasis rosea typically presents with a "herald patch". This can be preceded by prodromal symptoms such as fever or malaise. After 1-2 weeks, the secondary rash will appear, which is usually on the trunk and arms. This is symmetrical and classically described to be in the shape of a Christmas tree. Pityriasis rosea is usually self-limiting, is non-contagious and generally improves within 6 weeks. However, patients may require symptomatic treatment
name: Pityriasis rosea
label: a
answer: yes
explanation: Erythema multiforme is a hypersensitivity reaction, usually to an infection or drugs. The rash starts peripherally and moves centrally, therefore, is unlikely in this case. The rash is made up of "target lesions", which are made up of concentric rings
name: Erythema multiforme
label: c
answer: no
explanation: Lichen planus is a skin disease with an unknown origin. It comprises pruritic, papular eruptions, most commonly on the genitals, flexor surfaces or mucous membranes. Therefore, it is unlikely in this patient
name: Lichen planus
label: e
answer: no
explanation: Tinea corporis is a dermatophytosis (tinea) infection that affects the trunk and arms. Dermatophytes are a group of fungi causing lesions that are usually annular, scaly and have a raised edge. Herald patches are not associated with tinea corporis
name: Tinea corporis
label: d
answer: no

Correct answer: a
A 65-year-old woman attends her GP due to a persistent cough. As well as coughing up green sputum, she has been having difficulty with breathlessness on exertion. She has a past medical history of type 2 diabetes mellitus, hypertension and hypercholesterolaemia. She was treated for community acquired pneumonia 6 weeks ago with oral antibiotics. She drinks approximately 8 units of alcohol per week and smokes 10-a-day. On examination, there are crackles on the lower right zone. The GP requests a repeat chest X-ray which shows persistent areas of consolidation, in line with a previous chest X-ray 6 weeks earlier.

What is the correct next step?

Options:
explanation: Although there are signs of consolidation on the chest X-ray, there is concern that this could be due to an underlying malignancy rather than a persistent infection, therefore, the patient should be urgently referred
name: Admittance to A&E for intravenous antibiotics
label: c
answer: no
explanation: The patient is at risk of developing chronic obstructive pulmonary disease (COPD). Therefore, salbutamol may be an appropriate treatment. However, there is concern that there is an underlying malignancy causing the patient's symptoms in this case. Therefore, the 2-week wait is the most appropriate next step at this stage
name: Salbutamol prescription
label: e
answer: no
explanation: The British Thoracic Society advise that all patients who have continuing symptoms of pneumonia or are at risk of an underlying malignancy should have a follow up chest X-ray after 6 weeks. In up to 10% of pneumonias, there is an underlying malignancy. If therefore, the consolidation has not cleared on chest X-ray after 6 weeks, the patient should be referred to respiratory via the 2 week wait pathway
name: 2 week-wait referral to respiratory
label: a
answer: yes
explanation: Although there are signs of consolidation on the chest X-ray, there is concern that this could be due to an underlying malignancy rather than a persistent infection; therefore, the patient should be urgently referred
name: A further course of oral antibiotics
label: b
answer: no
explanation: The patient is at risk of developing chronic obstructive pulmonary disease (COPD). Therefore, spirometry testing would be an appropriate investigation. However, in this case, there is concern that there is an underlying malignancy causing the patient's symptoms. Therefore, the 2-week wait is the most appropriate next step at this stage
name: Spirometry testing
label: d
answer: no

Correct answer: a
A 31-year-old woman attends her GP due to severe pain on defecation. She describes the pain as like passing hard shards of glass. After opening her bowels, she occasionally sees bright red blood when wiping. She opens her bowels once every 2 or 3 days.

What is the most likely diagnosis?

Options:
explanation: Proctalgia fugax leads to intermittent severe pain localised to the rectum. It will usually completely resolve within seconds to minutes. The cause is unknown. Proctalgia fugax would not lead to spots of bright red blood on wiping
name: Proctalgia fugax
label: d
answer: no
explanation: Internal haemorrhoids would be a differential in this case. The bright red blood on wiping and the constipation risk factor could suggest internal haemorrhoids. However, internal haemorrhoids are not severely painful, which makes anal fissure the more likely diagnosis
name: Internal haemorrhoids
label: b
answer: no
explanation: Ulcerative colitis would be a differential for this patient due to the bright red blood on wiping. However, the pain profile is usually different. For example, abdominal pain is much more common than pain on defecation, which is a classic feature of anal fissures
name: Ulcerative colitis
label: c
answer: no
explanation: Anal fissures are usually very painful when defecating and are classically described as like passing glass. This pain may persist for hours afterwards. Constipation is a risk factor for anal fissures. On examination, they are linear and have clear edges. Most will heal after a few weeks of conservative management; however, some will require surgical intervention
name: Anal fissure
label: a
answer: yes
explanation: Crohn's disease would be a differential for this patient. However, the pain profile is usually different. Abdominal pain is much more common than pain on defecation, which is a classic feature of anal fissures
name: Crohn's disease
label: e
answer: no

Correct answer: a
A 62-year-old man is about to undergo a pancreatectomy.

Which antibiotic regime should be considered before the surgery?

Options:
explanation: IV gentamicin is commonly used for perioperative prophylaxis in urological surgeries
name: IV gentamicin
label: d
answer: no
explanation: Oral antibiotics are less appropriate than the intravenous route as antibiotic prophylaxis before a major operation
name: Oral co-amoxiclav
label: b
answer: no
explanation: Intravenous antibiotic therpay is important for surgical prophylaxis in many major surgeries. Different health care systems may recommend different antibiotics for different surgeries however IV co-amoxiclav is a common regime for abdominal surgery
name: Intravenous co-amoxiclav
label: a
answer: yes
explanation: Nasal mupirocin 2% (Bactroban Nasal®) is often used for MRSA eradication prior to hospital admission
name: IV mupirocin
label: e
answer: no
explanation: This is the usual regime for suspected intra-abdominal sepsis
name: Intravenous amoxicillin, metronidazole and gentamicin
label: c
answer: no

Correct answer: a
A 55-year-old female attends her GP due to right upper quadrant pain. She has been vomiting and feels feverish. She has a past medical history of gallstones, hyperlipidaemia and obesity. On examination there is rebound tenderness over the right upper quadrant. Furthermore, when the GP rests two fingers over the right upper quadrant and asks the patient to inspire, this leads to acute tenderness and patient stopping her inspiration.

What is the most appropriate management?

Options:
explanation: NICE guidelines states that any patient with suspected acute cholecystitis should be urgently admitted to hospital. This patient has signs and symptoms highly suspicious of acute cholecystitis. They have a positive Murphy's sign (the patient stops in their inspiration due to tenderness over the right upper quadrant when palpated by the GP)
name: Urgent admission
label: a
answer: yes
explanation: Liver Function Tests may be useful in aiding the diagnosis. However, there is high clinical suspicion of acute cholecystitis. Therefore, the patient requires urgent admission as they may need an urgent cholecystectomy
name: Urgent Liver Function Tests
label: d
answer: no
explanation: This patient has signs and symptoms highly suspicious of acute cholecystitis. They have a positive Murphy's sign (the patient stops in their inspiration due to tenderness over the right upper quadrant when palpated by the GP). Although abdominal ultrasound is highly sensitive and specific for gallstones, the patient requires urgent admission for possible surgical treatment
name: Urgent outpatient abdominal ultrasound
label: b
answer: no
explanation: This patient has signs and symptoms highly suspicious of acute cholecystitis. Although they do require antibiotic therapy and analgesia, the antibiotics will need to be intravenous and accompanied by intravenous fluids. The patient may also require urgent surgery. Therefore, this cannot be treated in the outpatient environment
name: Oral antibiotics, analgesia and urgent outpatient abdominal ultrasound
label: e
answer: no
explanation: This patient has signs and symptoms highly suspicious of acute cholecystitis. Although they do require antibiotic therapy and analgesia, the antibiotics will need to be intravenous and accompanied by intravenous fluids. The patient may also require urgent surgery. Therefore, they require urgent admission
name: Oral antibiotics and analgesia
label: c
answer: no

Correct answer: a
An 48-year-old female was admitted to hospital due to central umbilical pain, which then moved to the right iliac fossa. She underwent an appendectomy. She has a past medical history of obesity, hypertension and type 2 diabetes mellitus. After the operation, she is started on an insulin-glucose infusion.

When should she re-start her usual insulin medication?

Options:
explanation: After an operation, a patient should continue with an insulin-glucose infusion until they can tolerate at least 50% of their usual diet
name: When she starts to eat normal meals
label: a
answer: yes
explanation: There is no timed cut-off period for re-starting insulin postoperatively
name: 24 hours postoperatively
label: d
answer: no
explanation: Insulin-glucose infusions should be continued whilst the patient is only able to tolerate clear fluids. The patient's normal insulin regimen should be re-started once they can tolerate at least 50% of their usual diet
name: When she starts to drink small amounts of fizzy drinks
label: b
answer: no
explanation: There is no timed cut-off period for re-starting insulin postoperatively. Each patient will be different, for example, they may experience a post-operative infection or post-operative ileus, or they may be taking opioids postoperatively. All of these may affect their appetite, which will, in turn, affect when they should re-start their insulin
name: 12 hours postoperatively
label: c
answer: no
explanation: There is no timed cut-off period for re-starting insulin postoperatively. Patients may be able to tolerate at least 50% of their usual diet before they are discharged. This should, therefore, not affect when they re-start their insulin
name: On discharge
label: e
answer: no

Correct answer: a
A 65-year-old woman presents to A&E due to vomiting. The vomit has a greenish tinge. She also complains of diffuse abdominal pain. She has a past medical history of diabetes type 2 mellitus, hypertension, obesity, Crohn's disease, and a previous hemicolectomy 6 years ago. On examination, her abdomen appears to be distended and it's difficult to hear bowel sounds. Her observations are satisfactory.

She undergoes an abdominal x-ray:

[lightgallery]

What is the most appropriate initial management?

Options:
explanation: Whilst many patients are treated with decompression via sigmoidoscopy, the first priority is to ensure the patient is nil by mouth and is given appropriate IV fluid replacement
name: Sigmoidoscopic decompression
label: b
answer: no
explanation: If there was signs of sepsis, or if perforation was suspected, IV antibiotics may be indicated. This is suggested in the history, so the most appropriate immediate step is to administer IV fluids
name: IV antibiotics
label: d
answer: no
explanation: Metoclopramide is a pro-kinetic antiemetic drug which may be used in the management of symptomatic partial small bowel obstruction. This patient has a large bowel obstruction
name: IV metoclopramide
label: e
answer: no
explanation: The patient has a bowel obstruction, most likely secondary to adhesions. If there was signs of perforation, a CTAP may be indicated to delineate the site of perforation prior to surgical management
name: Computed tomography abdomen and pelvis (CTAP)
label: c
answer: no
explanation: This x-ray shows the "coffee bean" sign indicating a sigmoid volvulus. This is typically managed using the "drip and suck" approach, whereby the patient is placed as nil by mouth, given IV fluids, and a nasogastric tube inserted to drain any stomach contents.
name: IV 0.9% sodium chloride
label: a
answer: yes

Correct answer: a
A 46-year-old woman presents to her GP. She has been experiencing a non-productive cough for the last week. She has become short of breath of exercise and has felt intermittently feverish. On examination you notice oral thrush, a raised heart rate and widespread, scattered crackles. She is human immunodeficiency virus (HIV) positive.

What is the most appropriate management?

Options:
explanation: Although paracetamol may be helpful as an antipyretic and analgesia, it would not help treat the underlying infective cause
name: Paracetamol
label: e
answer: no
explanation: The patient has a non-productive cough and has been short of breath, which may suggest an asthma diagnosis. However, the fever and widespread scattered crackles point to an infective cause
name: Salbutamol
label: b
answer: no
explanation: The patient is showing signs of an infection, therefore, prednisolone is not appropriate at this stage
name: Prednisolone
label: d
answer: no
explanation: This may be appropriate for a bacterial pneumonia. However, the patient is HIV positive and has signs of oral thrush. These greatly increase the risk of an atypical infection. Pneumoncystis jirovecci is a common cause of pneumonia in immunocompromised patients
name: Co-amoxiclav
label: c
answer: no
explanation: The patient is suffering from a pneumocystis jirovecii infection. This is a fungus that can cause pneumonia in at-risk patients. It is an acquired immune deficiency syndrome (AIDs)-defining infection in individuals who are HIV positive. The most appropriate treatment is high dose co-trimoxazole (trimethoprim and sulfamethoxazole)
name: Co-trimoxazole
label: a
answer: yes

Correct answer: a


Learning point: Pneumocystis jirovecii pneumonia is an AIDS-defining illness in HIV-positive patients, typically treated with high-dose co-trimoxazole.
A 19-year-old man visits his GP due to urethral discharge and dysuria. This has been ongoing for the last week. He states that he had unprotected vaginal sex with two female partners and unprotected insertive anal sex with one male partner with over the last month.

His GP arranges for microscopy of the discharge. This showed gram-negative diplococci.

What is the diagnosis?

Options:
explanation: Penile discharge is common in trichomoniasis. However, it is caused by a protozoan rather than a bacterium
name: Trichomoniasis
label: d
answer: no
explanation: Chlamydia is likely to present with similar symptoms to gonorrhoea however is a rod-shaped gram-negative bacteria
name: Chlamydia
label: b
answer: no
explanation: Syphilis does not usually present in this way. Instead, there will most often be an initial chancre, a small painless ulcer, found on the glans of the penis
name: Syphilis
label: c
answer: no
explanation: Zoon's balanitis is an inflammation around the head of the penis and the foreskin. It leads to well-defined, itchy, red patches. Histology shows increased plasma cells on skin samples
name: Zoon's balanitis
label: e
answer: no
explanation: Urethral discharge is a common symptom in males with gonorrhoea. Gonorrhoea is a gram-negative diplococcus
name: Gonorrhoea
label: a
answer: yes

Correct answer: a


Learning point: Urethral discharge is a common symptom in males with gonorrhoea