hllj/quesmed huggingface dataset:
A 56-year-old man with a background of type 2 diabetes and hypertension presents to his GP for a routine set of blood tests.


He reports regularly drinking approximately 14 Units of alcohol per week. His body mass index (BMI) is 30, and a set of routine observations are unremarkable.


The blood tests reveal an alanine transaminase (ALT) of 195 U/L (7-56 U/L) and a gamma-glutamyl transferase (GGT) level of 85 U/L (<10 U/L). Glycosylated haemoglobin levels (HBA1C) are noted to be 52 mmol/l (42-47 mmol/l).


Which of the following is the most likely explanation for the deranged liver function tests?

Options:
explanation: Haemochromatosis is a disorder of iron overload and can either be primary (an autosomal recessive disorder that results in an inability to regulate iron absorption) or secondary (due to frequent blood transfusions in conditions such as thalassaemia major). Haemochromatosis can cause liver disease and diabetes; however, the strong metabolic risk factors make NAFLD more likely in this case
name: Haemochromatosis
label: c
answer: no
explanation: This patient has diabetes, hypertension and obesity, which are three major risk factors for NAFLD. NAFLD is the most common cause of liver disease worldwide and is characterised by fatty infiltration of hepatocytes without a secondary cause. It is strongly linked to metabolic syndrome, and the most typical liver enzyme abnormality is a raised ALT and/or GGT
name: Non-alcoholic fatty liver disease (NAFLD)
label: a
answer: yes
explanation: Although this patient drinks regular alcohol, his consumption is not excessive. It is, therefore, unlikely that he has alcoholic liver disease
name: Alcoholic liver disease
label: b
answer: no
explanation: Autoimmune hepatitis is a rare cause of chronic liver disease that is more common in women and those with a background of other autoimmune diseases (e.g. type 1 diabetes, autoimmune thyroid disease, ulcerative colitis). NAFLD is more likely in this case
name: Autoimmune hepatitis
label: e
answer: no
explanation: Viral hepatitis is less likely as the patient has no risk factors (e.g. recent travel, history of intravenous drug use, recent tattoos/piercings, blood transfusion etc.) or symptoms. Viral hepatitis would also usually present with a more significant rise in transaminases (i.e. ALT and AST). It should, however be excluded by conducting a full viral screen
name: Viral hepatitis
label: d
answer: no

Correct answer: a


Learning point: Non-alcoholic fatty liver disease (NAFLD) is commonly associated with obesity, diabetes, and hypertension, leading to elevated liver enzymes.
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: 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: 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: 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.
An 81-year-old male with wet age-related macular degeneration (AMD) is reviewed in clinic. Twelve months ago, she had early-stage disease, initially managed with risk factor modification, although her vision has now deteriorated from 6/24 to 6/60 vision in both eyes. On fundoscopy, she has subretinal haemorrhages, lipid exudates, and fibrovascular scarring - corresponding to advanced-stage disease.

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

Options:
explanation: Anti-VEGF injections are the mainstay of management of wet AMD, reducing or eliminating macular oedema and reduce neovascularisation, which can reduce disease progression and reverse visual loss
name: Intravitreal injection with vascular endothelial growth factor inhibitors (anti-VEGF)
label: a
answer: yes
explanation: Intravitreal corticosteroids can be given for macular oedema in diabetes, uveitis, and retinal vein occlusion. It is not currently recommended as a treatment for wet AMD
name: Intravitreal corticosteroids
label: d
answer: no
explanation: This patient has progressed to advanced wet AMD with significant deterioration in vision. Wet AMD can be treated initially with anti-VEGF intravitreal injections and so this should be trialled first, providing there are no contraindications
name: Observation
label: b
answer: no
explanation: Photodynamic therapy (PDT) is frequently used in wet AMD, although only as an adjunct as second-line treatment with anti-VEGF after anti-VEGF has already been tried
name: Photodynamic Therapy
label: c
answer: no
explanation: Thermal laser photocoagulation used to be the first-line treatment for wet AMD with extrafoveal choroidal neovascular membranes, although this has now largely been replaced by anti-VEGF treatment as treatment of subfoveal and juxtafoveal lesions often resulted in a dense scotoma with high recurrence rates
name: Thermal laser photocoagulation
label: e
answer: no

Correct answer: a


Learning point: Intravitreal anti-VEGF injections, such as ranibizumab, aflibercept, and bevacizumab, are the primary treatment for wet age-related macular degeneration as they work by inhibiting vascular endothelial growth factor (VEGF) to reduce abnormal blood vessel growth and fluid leakage in the retina, helping to preserve vision.
A 32-year-old man is brought in by ambulance to A&E after a road traffic collision. On examination, he has a large wound at the back of his head. His Glasgow Coma Score is 3. A CT scan of the head shows no abnormalities. A rapid sequence induction of anaesthetic is performed to secure his airway. A week into his admission, extubation is attempted on the Intensive Care Unit but this is unsuccessful. A gag reflex is documented as being absent in his medical notes.

Where is the lesion causing his clinical presentation?

Options:
explanation: The midbrain may be damaged as a consequence of head injury; however, the nuclei of CN IX and X are found in the medulla, not the midbrain. The midbrain contains the nuclei of CN III and IV. These are not involved in the gag reflex.
name: Midbrain
label: c
answer: no
explanation: The gag reflex is an evolutionary reflex with the primary role being to prevent foreign body inhalation. This reflex is made up of the glossopharyngeal nerve (CN IX) as the afferent limb and the vagus nerve (CN X) as the efferent. These two nerves have their nuclei in the brainstem medulla, alongside CN XI and XII. Compression may be as a result of raised intracranial pressure secondary to injury, given that no focal abnormalities were noted on his head scan.
name: Medulla oblongata
label: a
answer: yes
explanation: Skull fractures sustained during head injury can be a risk factor for septic cavernous sinus thrombosis. However, in this scenario, there is no fracture (the CT head is normal) and no clinical features of a septic cavernous sinus thrombosis, including involvement of nerves III, IV, Va, Vb and VI, which run through the cavernous sinus.
name: Cavernous sinus
label: d
answer: no
explanation: The pons may be damaged as a consequence of head injury; however, the nuclei of CN IX and X are found in the medulla, not the pons. The pons contains the nuclei of CN V, VI, VII and VIII. These are not involved in the gag reflex.
name: Pons
label: b
answer: no
explanation: The occipital lobe is involved in visuospatial processing, colour perception and facial recognition. It is not involved in the gag reflex. Occipital lobe damage may present with the above features, alongside a visual field defect of contralateral homonymous hemianopia with macular sparing.
name: Occipital lobe
label: e
answer: no

Correct answer: a


Learning point: Lesions in the medulla oblongata can impair the gag reflex, indicating potential brainstem injury or raised intracranial pressure.
A 42-year-old woman presents with a 2-d history of reduced sensation to the left side of her face. She also has double vision and is struggling with pain in her left eye. She has a past medical history of poorly controlled type 2 diabetes and underwent paranasal sinus surgery 4 d ago. On examination, there is extensive left-sided periorbital oedema and proptosis. Her temperature is 38.4 °C.

What additional finding might be present on physical examination?

Options:
explanation: Relative afferent pupillary defects are present when there are issues with the afferent pathway of the pupillary reflex, that is, retinal or optic nerve pathology. Neither are involved in cavernous sinus syndrome.
name: Relative afferent pupillary defect
label: c
answer: no
explanation: Sensorineural deafness occurs due to disorders of the vestibulocochlear (VIII) nerve. This nerve does not run through the cavernous sinus.
name: Sensorineural deafness on the left
label: d
answer: no
explanation: The facial nerve does not run through the cavernous sinus; therefore, this option is incorrect.
name: Facial nerve palsy
label: b
answer: no
explanation: This patient has a cavernous sinus syndrome, probably due to a thrombus secondary to cavernous sinus infection. She is at higher risk of infection due to her poorly controlled diabetes and her recent paranasal sinus surgery. The cavernous sinus houses cranial nerves III, IV, VI, Va and Vb, and the internal carotid artery. The changes are ipsilateral to the side of the lesion. There is also an issue with venous drainage from the facial vein leading to chemosis, periorbital oedema, orbital pain and proptosis. Associated complications include seizures, septic emboli, Horner syndrome and intracranial hypertension.
name: Abducens nerve palsy
label: a
answer: yes
explanation: Sensation to the skin overlying the chin is provided by Vc (the mandibular branch of the trigeminal nerve). This does not run through the cavernous sinus.
name: Loss of sensation over the chin
label: e
answer: no

Correct answer: a


Learning point: Cavernous sinus syndrome can present with cranial nerve palsies, particularly affecting the abducens nerve, leading to diplopia and ocular motility issues.
A 14-year-old adolescent is brought to A&E after a week-long history of painful left eye movements and diplopia. One week ago, she was struck in the face with a hockey stick and sustained an undisplaced fracture of the zygomatic bone. She was sent home with analgesia and clinic follow-up with ophthalmology. On examination, you note swelling and erythema around the left eye. She has a complex ophthalmoplegia but the remainder of her cranial nerve examination is unremarkable. Her temperature is 38.7 °C.

Which of the following is the next best investigation?

Options:
explanation: An MRI is rarely done because a CT orbit is quicker to carry out and most often confirms the diagnosis. On T1, a low signal will be observed.
name: T1 MRI brain with orbits
label: d
answer: no
explanation: This patient likely has orbital cellulitis, as indicated by the presence of erythema and swelling surrounding the left eye, fever, diplopia (due to extraocular eye muscle involvement) and pain. The diplopia occurs due to complex ophthalmoplegia, which is when eye signs cannot be attributed to a single cranial nerve. The orbit is made up of seven bones, including the zygomatic, palatine and maxillary bones. Fractures of any of these bones are a risk factor for developing orbital cellulitis. This is a potentially sight-threatening emergency and can be further complicated by infective extension into the cavernous sinus. The best test is a CT orbit for this condition.
name: CT orbit
label: a
answer: yes
explanation: This is a highly sensitive imaging modality for evaluating thromboses within the venous sinuses, not for identifying orbital cellulitis.
name: CT venogram
label: c
answer: no
explanation: This is a reasonable option and a CT of the head is often performed alongside a dedicated scan of the orbit. However, a dedicated scan of the orbit is still required, so this is not the best investigation.
name: CT head with contrast
label: b
answer: no
explanation: An MRI is rarely done because a CT orbit is quicker to carry out and most often confirms the diagnosis. On T2, a high signal will be observed.
name: T2 MRI brain with orbits
label: e
answer: no

Correct answer: a


Learning point: A CT scan of the orbit is an essential imaging tool for evaluating orbital cellulitis, as it helps to identify the extent of infection, detect any associated complications such as orbital abscess or sinusitis, and distinguish it from other conditions that may affect the orbital structures.
A 33-year-old pregnant woman presents with persistent nausea and vomiting in the first trimester. She reports that she cannot keep any food down, and this has been the case for 5 d. She has managed small sips of water. On examination, she is tachycardic at 110 bpm, blood pressure 115/70 mmHg, respiratory rate 18 and is afebrile. A diagnosis of hyperemesis gravidarum is made by the admitting team and she is prescribed antiemetics and fluids. Two hours later the patient's head has rotated to one side and her eyes are periodically deviating upwards.

What is the most likely antiemetic to have caused this side effect?

Options:
explanation: This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Metoclopramide is primarily a D2 receptor antagonist and acts on the receptors in the chemoreceptor trigger zone in the central nervous system. It is also a prokinetic agent via its muscarinic activity. Due to antagonism at the D2 receptor, it may also cause blockade in the extrapyramidal circuits, leading to side effects including acute dystonia (such as oculogyric crises and cervical dystonias), and, with chronic use, tardive dyskinesias. The risk of acute dystonic reactions is increased with higher doses and younger patients.
name: Metoclopramide
label: a
answer: yes
explanation: This patient is presenting with acute dystonia, in the form of torticollis (cervical dystonia) and an oculogyric crisis. Cyclizine is a histamine H1 receptor antagonist. Side effects may include urinary retention but extrapyramidal side effects are not reported.
name: Cyclizine
label: b
answer: no
explanation: This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Ondansteron is an antiemetic particularly used in the case of nausea and vomiting caused by chemotherapy. It is a serotonin 5 HT3 receptor antagonist. It does not have any effect on the D2 receptors; therefore, acute dystonias are not a recognised side effect.
name: Ondansetron
label: e
answer: no
explanation: This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Promethazine is a first-generation antihistamine, antagonising the H1 receptor, and is generally used for its sedative effects, as opposed to its antiemetic effects. It has some antidopaminergic effects, which may lead to tardive dyskinesia, dystonias and akathisia but these are uncommon.
name: Promethazine
label: d
answer: no
explanation: This patient is presenting with acute dystonia in the form of torticollis (cervical dystonia) and an oculogyric crisis. Chlopromazine is an antipsychotic that antagonises the D2 receptor and would not ordinarily be used to treat nausea and vomiting. Less commonly, it causes acute dystonias but it is known to cause tardive dyskinesia and akathisia, which are more likely at higher doses.
name: Chlopromazine
label: c
answer: no

Correct answer: a


Learning point: Metoclopramide can cause acute dystonia, including torticollis and oculogyric crises, particularly in younger patients and with higher doses.
A 38-year-old woman is brought in by ambulance to A&E. She was having lunch with a friend when she complained of a headache and lost consciousness soon after. On examination, she has a Glasgow Coma Scale score of 3 and bilateral flank masses palpable on her abdomen. Her observations are otherwise within normal parameters.

What is the cause of her neurological presentation?

Options:
explanation: An abdominal aortic aneurysm rupture may present with shock due to bleeding and subsequent reduced consciousness. Headache is not a typical component of the presentation and there is no evidence of haemodynamic instability here. Abdominal aortic aneurysms are also more likely in older male patients.
name: Abdominal aortic aneurysm rupture
label: c
answer: no
explanation: A myocardial infarction (MI) typically presents with chest pain, breathlessness or syncope. Patients are typically older with cardiovascular risk factors. Younger patients may present with MIs, especially if there are strong risk factors such as use of cocaine or hereditary hypercholesterolaemia. ADPKD does not typically increase the risk of MI until there is a significant degree of renal impairment. The most likely cause of this presentation is a berry aneurysm rupture.
name: Myocardial infarction
label: d
answer: no
explanation: Meningitis can cause headache and reduced consciousness. However, the natural history in this case is hyperacute, and therefore a haemorrhage is more likely since meningitis tends to have a more insidious onset. There are also no clinical features of infection, such as fever, or other features of meningism, such as neck stiffness. Furthermore, in this case the presence of bilateral flank masses should also raise suspicion of autosomal dominant polycystic kidney disease and the presence of a ruptured berry aneurysm.
name: Meningitis
label: b
answer: no
explanation: Berry aneurysms are a recognised feature of autosomal dominant polycystic kidney disease (ADPCKD), which is an inherited cause of end-stage renal failure. The palpable bilateral flank masses should raise suspicion of underlying ADPCKD. Berry aneurysms have a propensity to rupture leading to a subarachnoid haemorrhage, presenting with a traditional sudden-onset 'thunderclap' headache and rapid neurological deterioration.
name: Subarachnoid haemorrhage
label: a
answer: yes
explanation: An extradural haematoma typically presents after a traumatic head injury with a brief loss of consciousness followed by recovery (lucid interval) and subsequent rapid deterioration in conscious level. It occurs typically due to a blow to the temples and rupture of the middle meningeal branch of the maxillary artery (a branch of the external carotid). There is no history of trauma in this patient and the clinical features of a lucid interval are not present.
name: Extradural haematoma
label: e
answer: no

Correct answer: a


Learning point: Autosomal dominant polycystic kidney disease is associated with berry aneurysms, which can rupture and cause subarachnoid haemorrhage.
A 20-year-old female presents to general practice with questions regarding her ongoing acne. She has extensive pustules and erythematous papules across her face and upper back. She is embarrassed of her skin but denies any low mood. She has previously tried combinations of topical Differin, topical benzoylperoxide and topical clindamycin with no improvement. She has had a previous deep vein thrombosis (DVT) after surgery. She takes no regular medications currently and has no drug allergies.

What is the most appropriate next step in management?

Options:
explanation: Co-cyprindiol is an oral contraceptive pill with antiandrogenic effects. It contains cyproterone acetate (antiandrogenic) and ethinyloestradiol. NICE guidelines recommend this medication in patients with polycystic ovary syndrome and acne not responding to conventional first-line topical and oral antibiotic therapies. Therefore, this patient does not qualify for this treatment and would be contraindicated anyway due to the presence of previous DVT.
name: Co-cyprindiol
label: e
answer: no
explanation: This could be a service to offer this patient in conjunction with acne treatment if her mental health were significantly affected: symptoms of depression, anxiety, body dysmorphia, suicidal ideation or self-harm. This is not the case here. Furthermore, it would not treat her condition alone since psychological support would not address the root cause (ie. the acne) of any mood disorder if present.
name: Referral to psychological services
label: b
answer: no
explanation: Short courses of prednisolone can be used to treat some severe acne flares, such as acne fulminans. It has no place in the routine or long-term management of most acne presentations.
name: Prednisolone
label: d
answer: no
explanation: This drug is reserved for initiation by a dermatologist for patients with severe acne who are unresponsive to two courses of oral antibiotic therapy. This patient does not currently fulfil these criteria.
name: Oral isotretinoin
label: c
answer: no
explanation: This patient has moderate acne indicated by the presence of many inflammatory lesions (pustules and inflammatory papules). Mild acne is defined by the presence of mostly comedones with few inflammatory lesions. There are no markers of severe acne (nodules, cysts and scars). She has not responded to topical agents, so as per National Institute for Health and Care Excellence (NICE) guidelines oral antibiotics are indicated. This is usually doxycycline or lymecycline but alternatives include clarithromycin or trimethoprim. Topical agents should be continued while on oral antibiotics. Combined oral contraceptives with antiandrogenic effects (such as co-cyprindiol) could be considered in some patients but this would not be an option in the context of previous deep vein thrombosis.
name: Oral lymecycline
label: a
answer: yes

Correct answer: a


Learning point: Oral antibiotics like lymecycline are recommended for moderate acne unresponsive to topical treatments.