hllj/quesmed huggingface dataset:
A 65-year-old male undergoes an abdominal ultrasound scan as part of screening. His ultrasound report states that his abdominal aorta has a diameter of 3.3cm. He states that he currently has no symptoms, but he has a smoking history of 12 pack years.

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

Options:
explanation: This is because an abdominal aorta diameter of 3.3cm is considered to be small and so he would be offered annual ultrasound scans in this case. Note that all men in the UK are offered a one-off ultrasound scan at the age of 65 which determines the frequency of scanning if needed. Patients are usually asymptomatic unless the aneurysm has ruptured. Operative management is offered 5.5cm+. AAA's measuring 3-4.4cm are scanned every 12 months, and every 3 months between 4.5-5.4cm.
name: 12-monthly ultrasound scan
label: a
answer: yes
explanation: This would be indicated if the patient presented with a ruptured aneurysm, or as an elective procedure to repair large or rapidly expanding AAAs where anatomical considerations make EVAR's unsuitable. A ruptured AAA presents with shock and abdominal pain radiating to the back/back pain. This patient has no features of a ruptured AAA and he does not require repair at this stage due to the small size of the AAA. Open repair surgery is much more invasive than EVAR procedures, and some patients may not be fit enough for this procedure.
name: Open repair
label: d
answer: no
explanation: This is incorrect because ultrasound scanning is only repeated every 3 months or yearly. This would not be an option for this patient.
name: 6-monthly ultrasound scan
label: e
answer: no
explanation: This would be required if the aneurysm is of medium size, between 4.5 to 5.4cm. However, this is not required for this patient as the AAA is only 3.3cm. The indication for repair is when the aneurysm is above 5.5cm or expanding >1cm each year.
name: 3-monthly ultrasound scan
label: c
answer: no
explanation: This is a common surgical option to repair large or rapidly expanding aneurysms. It involves the insertion of a stent within the abdominal aorta. However, this is not required for this patient as the AAA is only 3.3cm. The indication for repair is when the aneurysm is above 5.5cm or expanding >1cm each year.
name: Endovascular aneurysm repair (EVAR)
label: b
answer: no

Correct answer: a


Learning point: An abdominal aortic aneurysm measuring 3.3cm requires annual ultrasound monitoring due to its small size and low risk of rupture.
A 74-year-old female presents to the memory clinic after referral by her GP. Her family report that her memory for recent events is worsening, and she is struggling to manage her finances, remember words, and recognise objects. Her childhood memories remain relatively preserved.

Given the most likely diagnosis, which of the following is the most likely pathological finding?

Options:
explanation: This is incorrect because this describes the finding in frontotemporal dementia. Frontotemporal dementia typically affects patients who are younger than 65 years and causes changes in their behaviour and personality. Memory and visuospatial skills are relatively preserved.
name: Frontal and temporal lobe atrophy
label: c
answer: no
explanation: This is incorrect because this describes the finding in normal pressure hydrocephalus. The classic symptoms for this condition can be remembered by wet, weird and wobbly: urinary incontinence, dementia, and recurrent falls. Note that this is a type of reversible dementia.
name: Enlarged ventricles
label: e
answer: no
explanation: Alpha-synuclein inclusions are found within the substantia nigra in Parkinson's disease and Lewy Body Dementia. These conditions are characterised by a typical triad of bradykinesia, rigidity and a resting tremor, which this patient does not have. Lewy Body Dementia is also classically associated with visual hallucinations, typically of Lilliputian bodies.
name: Alpha-synuclein
label: b
answer: no
explanation: This is incorrect because this describes the finding in vascular dementia. Patients typically have a step-wise decline in function following a cerebrovascular event. They usually have cardiovascular risk factors such as hypertension, hypercholesterolaemia or diabetes.
name: Multiple infarcts with white matter damage
label: d
answer: no
explanation: This patient has Alzheimer's disease. Histopathology would demonstrate beta amyloid plaques and neurofibrillary tangles made of tau protein.
name: Amyloid plaques
label: a
answer: yes

Correct answer: a


Learning point: Alzheimer's disease is characterised by the presence of amyloid plaques and neurofibrillary tangles in the brain.
A 15-year-old male presents to the GP with concerns regarding changes to his skin. He says this has occurred over the past year and he has used several over-the-counter facial washes which have not helped. On examination, there are widespread inflammatory papules and pustules, nodules, and scars on his face, neck, and shoulders. He is adamant that he wants to try a stronger medication.

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

Options:
explanation: This is correct because this patient has severe acne vulgaris which is evident by the presence of widespread inflammatory lesions and scarring. This would be the best next step in management. Topical adapelene with topical benzoyl peroxide should be prescribed with an oral antibiotic such as lymecycline to prevent antibiotic resistance. Tetracyclines have anti-inflammatory effects, but note that these are contraindicated in pregnancy or breast-feeding which does not apply to this case.
name: Topical adapelene with topical benzoyl peroxide and oral lymecycline
label: a
answer: yes
explanation: This is incorrect because oral isotretinoin is prescribed for patients with severe acne vulgaris resistant to traditional topical and systemic antibiotic therapies. This patient has not tried topical medication or antibiotics yet. Although this patient wants stronger medication, isotretinoin is not prescribed within primary care due to its side effect profile. Some of these include deranged liver function, increased risk of suicide and depression, and teratogenicity.
name: Oral isotretinoin
label: e
answer: no
explanation: This is incorrect because this is the treatment for mild acne rosacea. In acne rosacea, patients typically present with papules, pustules and flushing of the nose, cheeks and forehead. It usually affects an older patient demographic and can present with telangiectasia. Topical metronidazole is not used for acne vulgaris.
name: Topical metronidazole
label: b
answer: no
explanation: This is incorrect because this is the treatment for impetigo which is an infection typically caused by Staphylococcus aureus and usually affects infants. It presents with golden crusted lesions which this patient does not have. Impetigo is usually managed in primary care with oral antibiotics and topical fusidic acid.
name: Oral flucloxacillin and topical fusidic acid
label: c
answer: no
explanation: This is incorrect because spironolactone is rarely used as a first-line treatment for acne vulgaris. It is also important to avoid prescribing this drug in males because it is an anti-androgen medication which works by reducing testosterone levels and can cause feminising side effects.
name: Spironolactone
label: d
answer: no

Correct answer: a


Learning point: Acne can be effectively managed with a combination of topical adapalene, which is a retinoid that helps to clear blocked pores and reduce inflammation, topical benzoyl peroxide, which has antimicrobial and anti-inflammatory properties, and oral lymecycline, an antibiotic that reduces bacteria and inflammation.
A 40-year-old man presents to A&E with a headache and itchy, red eyes for the past 8 days. He works as a water engineer and spends a lot of time in the sewers. He has no significant past medical history. On examination, his eyes are red and his liver edge is palpable. He has a low-grade fever of 37.7. Blood tests show a mildly raised AST and ALT, low platelets, and a high urea and creatinine.

Which of the following is the most likely diagnosis?

Options:
explanation: Leptospirosis is caused by Leptospira interrogans which can be transmitted by rats. Occupational exposure may occur through working in sewers. The key symptoms here are headache, fever, red eyes, deranged liver function tests, acute kidney injury, and reduced platelets. Note that patients with leptospirosis can also get diarrhoea, abdominal pain, and a rash. Liver and kidney failure may complicate its course.
name: Leptospirosis
label: a
answer: yes
explanation: This is incorrect because asbestosis presents with gradually worsening shortness of breath. Occupational exposure may occur in those who work in construction or on boilers.
name: Asbestosis
label: c
answer: no
explanation: This is incorrect because Bartonella henselae causes a condition known as Cat Scratch disease. This presents with painful local lymphadenopathy and fever. There is no mention of a cat scratch in this case.
name: Bartonella henselae
label: d
answer: no
explanation: This is incorrect because lead poisoning would present with abdominal pain, mood changes, motor neuropathy and memory loss. Lead poisoning can also cause a microcytic anaemia and Burton's lines in the gums which appear blue. This is a good differential as lead poisoning can also present with headaches and may relate to this patient's occupation. However, the presence of conjunctivitis, his deranged blood results, acute presentation, and occupation should point towards leptospirosis.
name: Lead poisoning
label: b
answer: no
explanation: This is incorrect because Cryptosporidium parvum typically presents with chronic watery, green diarrhoea in patients who are immunosuppressed (typically, those patients with HIV.)
name: Cryptosporidium parvum
label: e
answer: no

Correct answer: a


Learning point: Leptospirosis, caused by Leptospira interrogans, presents with fever, headache, conjunctival suffusion, and can lead to liver and kidney dysfunction.
A 49-year-old man presents to A&E with fever and myalgia. He denies any recent unwell contacts or coryzal symptoms. His past medical history includes chronic kidney disease stage 5, hypertension and a kidney transplant 6 weeks ago. On examination, he appears pale. He has a temperature of 38.5. His blood tests reveal deranged liver function.

Which of the following is the most likely causative organism?

Options:
explanation: This is incorrect because Hepatitis C would present with fever,  malaise, and jaundice, with other risk factors in the history such as transmission through blood, birth, or sexual intercourse. Note that Hepatitis C would also cause deranged LFTs, but CMV infection is more likely in this patient following a renal transplant.
name: Hepatitis C
label: e
answer: no
explanation: This is incorrect because VZV can cause shingles in the later years of life when a patient is immunosuppressed. This would present as a painful, vesicular, dermatomal rash which this patient does not have. VZV is also screened for prior to a renal transplant.
name: Varicella Zoster Virus
label: d
answer: no
explanation: This is incorrect because Hepatitis B would present with fever, malaise, and potentially jaundice, with other risk factors in the history such as transmission through blood, birth, or sexual intercourse. Note that acute Hepatitis B would also cause deranged LFTs with the AST and ALT possibly in the 1000s. However, CMV infection is more common in this patient following a renal transplant.
name: Hepatitis B
label: c
answer: no
explanation: This is correct because this patient has recently undergone a renal transplant. These patients are at risk of reactivation of latent CMV from within donor tissue within the first 6 weeks after a transplant secondary to immunosuppression. Note that a fever and deranged LFTs are key features for identifying CMV infection. It is managed with ganciclovir.
name: Cytomegalovirus
label: a
answer: yes
explanation: This is incorrect because EBV would present with fever, lymphadenopathy and a sore throat. Hepatosplenomegaly may also be found on palpation. EBV infection in transplant patients typically occurs due to reactivation of latent EBV from donor tissue. It generally takes longer to present  (6 months+), and is often associated with post transplant lymphoproliferative disorder. As such, this case is too early post transplant to raise suspicion of an EBV mediated pathology.
name: Epstein-Barr Virus
label: b
answer: no

Correct answer: a


Learning point: Cytomegalovirus reactivation from latent infection of the donor organ is a common complication in renal transplant patients, often presenting with symptoms such as fever, fatigue, and abnormal liver function tests, and may lead to more severe systemic illness if not promptly managed.
A 59-year-old man presents to A&E with a 3-hour history of chest pain. He says this came on suddenly whilst at work. He is currently taking amlodipine for hypertension and atorvastatin for hypercholesterolaemia. On examination, he appears clammy. His ECG shows ST depression and his blood tests reveal a raised troponin and a haemoglobin of 76. He has been initiated on treatment according to the Acute Coronary Syndrome (ACS) protocol.

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

Options:
explanation: This is incorrect because FFP contains clotting factors which is used in the context of bleeding disorders or massive haemorrhage. This is not indicated in this patient because this would not help increase the haemoglobin level and there is no evidence of coagulopathy.
name: Fresh frozen plasma transfusion
label: d
answer: no
explanation: This is incorrect because this patient is having an NSTEMI and requires admission therefore, for treatment, cardiology review, monitoring, and a secondary percutaneous coronary intervention. Furthermore, his haemoglobin is low enough to meet the threshold for transfusion in a patient with cardiac ischaemia (<80.) It would be inappropriate to discharge him from A&E at this stage.
name: Discharge patient
label: b
answer: no
explanation: Beta-blockers are usually indicated in the management of ACS, to reduce chest pain by reducing myocardial oxygen demand and also improve long-term outcomes. This question indicates that ACS management according to guidelines has already been commenced. As such, at this stage the priority should be to correct the anaemia.
name: Atenolol
label: e
answer: no
explanation: This is incorrect because this is the management for pericarditis. Pericarditis presents as pleuritic chest pain which improves on leaning forward and worsens on lying flat. Classical ECG findings are PR depression and widespread saddle-shaped ST elevation. It has many causes including viral infections. The first line treatment is usually an NSAID, and alternative treatments include colchicine.
name: Ibuprofen
label: c
answer: no
explanation: Cardiac patients at risk of myocardial ischaemia/with myocardial ischaemia, as in this case, should have a target haemoglobin level of above 80. Therefore, this patient requires a red blood cell transfusion as his haemoglobin is 76.  This is in order to maintain adequate myocardial perfusion. As he has already been initiated on ACS treatment, treating his haemoglobin should be the next priority.
name: Red blood cell transfusion
label: a
answer: yes

Correct answer: a


Learning point: In acute coronary syndrome, patients with a haemoglobin level below 80 g/L require a red blood cell transfusion.
A 54-year-old woman presents to A&E with sudden, painless loss of vision. This has not happened to her before. There was no obvious trigger, since she was sitting at home when this happened. She has a past medical history of severe left temporal lobe epilepsy and recently underwent surgery for this. When asked to point out the numbers on a clock face, she is only able to see from number 4 to 11 in both eyes. Fundoscopic examination is unremarkable.

What is responsible for this patient's visual field defect?

Options:
explanation: Central retinal vein occlusion does result in sudden onset painless loss of vision. However, on fundoscopy, you would expect to find a stormy-sunset appearance with widespread haemorrhage, cotton wool spots, swollen optic discs, engorged veins, and chronically proliferative changes. This patient's fundoscopic examination is normal. Risk factors include pro-thrombotic stages as well as cardiac risk factors, which this patient does not have.
name: Central retinal vein occlusion
label: b
answer: no
explanation: This patient has a right superior homonymous quadrantanopia visual field defect caused by damage to the left inferior optic radiation. This is likely due to her recent temporal lobe surgery.  the left temporal lobe. Damage to the temporal optic radiation fibres (Meyer's loop) causes superior contralateral quadrantanopias. Damage to the parietal optic radiation fibres result in inferior contralateral quadrantanopias.
name: Lesion of the inferior optic radiation
label: a
answer: yes
explanation: Retinal detachment occurs when there is separation of the neuro-sensory retina from the retinal pigment epithelium. This also presents with painless visual loss, but patients complain of flashing lights and floaters, and possibly a 'curtain' obscuring their vision (which would be the detached flap of retina.) Fundoscopy can reveal a detached homogenous floating grey membrane. This patient has none of these clinical features.
name: Retinal detachment
label: e
answer: no
explanation: This is incorrect because damage to the superior optic radiation within the parietal lobne  would cause an inferior homonymous quadrantanopia.
name: Lesion of the superior optic radiation
label: d
answer: no
explanation: Branch retinal vein occlusion does result in sudden onset painless loss of vision. However, on fundoscopy, you would expect to find haemorrhage, cotton wool spots, swollen optic discs, and engorged veins within the area of occlusion. This patient's fundoscopic examination is normal. Risk factors include pro-thrombotic stages as well as cardiac risk factors, which this patient does not have.
name: Branch retinal vein occlusion
label: c
answer: no

Correct answer: a


Learning point: Damage to the left inferior optic radiation can cause right superior homonymous quadrantanopia, often following temporal lobe surgery.
A 52-year-old woman presents to her GP with a headache for a month. She has also been waking in the middle of the night feeling sweaty which is unusual for her, and has been feeling more anxious. She has reported no change to her physical appearance. On examination, her blood pressure is 167/98mmHg, and the remainder of her physical assessment is unremarkable. Blood tests show a normal white cell count, normal urea and electrolytes, and normal thyroid function.

Which of the following hormones is the most likely cause of this patient's presentation?

Options:
explanation: Vasopressin, also known as anti-diuretic hormone, is essential for enabling the reabsorption of free water from the collecting duct in the nephron through aquaporin channels. Excess vasopressin results in excessive free water reabsorption, and a classical euvolaemic hyponatraemia as seen in SIADH. Low sodium results in non-specific symptoms, such as confusion and lethargy, and, if very low, seizures. This patient's bloods are normal, and there are no clinical features suggestive of low sodium.
name: Vasopressin
label: b
answer: no
explanation: Thyrotoxicosis can result in sweating, palpitations, anxiety, and hypertension. However, this patient has normal thyroid function tests, and no clinical features of hyperthyroidism, such as tremor, diarrhoea, or a goitre.
name: Thyroxine
label: d
answer: no
explanation: Excess growth hormone, usually from a pituitary adenoma, results in acromegaly. Pituitary tumours can cause headaches, and excessive growth hormone may result in hypertension, as seen in this case. However, acromegalous features are absent in this patient, such macroglossia, prognathism, changes in physical appearance, and growing hands/feet.
name: Growth hormone
label: c
answer: no
explanation: Excess cortisol leads to Cushing's syndrome, which is associated with hypertension. However, other features of Cushing's syndrome are notably absent, such as proximal weakness, striae, central adiposity, and thinning/bruising of the skin. Cushing's disease refers to Cushing's syndrome secondary to a pituitary tumour, whilst Cushing's syndrome is excess cortisol of any cause, including secondary to exogenous steroid use.
name: Cortisol
label: e
answer: no
explanation: This patient has likely got a pheochromocytoma which is a catecholamine-secreting tumour in the adrenal medulla. Excess of circulating catecholamines result in hypertension, headaches,  flushing, palpitations, and anxiety.
name: Adrenaline and noradrenaline
label: a
answer: yes

Correct answer: a


Learning point: Pheochromocytoma is a catecholamine-secreting tumour causing symptoms like hypertension, headaches, anxiety, and nocturnal sweating due to excess adrenaline and noradreanline.
A 68-year-old woman presents to the GP with a 3-day history of a cough productive of green phlegm, as well as exertional dyspnoea. She has no past medical history, takes no regular medications, and has no drug allergies. Her vital signs are: HR 89bpm, RR 14 breaths per minute, O2 saturation 99% on room air, BP 145/78mmHg. Her AMTS is 9/10. On examination, there are crepitations in the left lower zone of her chest.

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

Options:
explanation: This is incorrect because this woman has a CRB65 score of 1 and there is clinical evidence of a community-acquired pneumonia on examination. NICE guidelines clearly state that an antibiotic must be offered for people with community-acquired pneumonia.
name: No treatment
label: b
answer: no
explanation: This is correct because this woman has a CRB65 score of 1. She scores 1 point for her age as she is above 65 years old. Note that the CRB65 scoring system is used in the GP setting for pneumonia because the urea is not immediately available. A 5-day course of oral amoxicillin 500mg three times daily (since she has no known allergies) is suitable for this patient as she has a CRB65 score of 1.
name: Oral amoxicillin
label: a
answer: yes
explanation: This is incorrect because this woman's CRB65 score of 1 does not currently warrant hospital admission. If her CRB65 score were 2 or above, hospital admission would be considered as intravenous antibiotics would be needed.
name: Admit to hospital
label: d
answer: no
explanation: This is incorrect because steroids are not used in the routine management of community-acquired pneumonia, unless they are complicating an exacerbation of an obstructive airways disease. This patient has no wheeze or past medical history of obstructive airway pathology, and as such steroids will not be required in her management.
name: Oral prednisolone
label: c
answer: no
explanation: Doxycycline is used instead of amoxicillin for patients with a penicillin allergy, which this patient does not have, in the management of community acquired pneumonia. An alternative medication is oral clarithromycin which is also taken for 5 days.
name: Oral doxycycline
label: e
answer: no

Correct answer: a


Learning point: In patients over 65 with pneumonia, a CRB65 score of 1 indicates the need for oral antibiotics like amoxicillin.