hllj/quesmed huggingface dataset:
A 34-year-old woman presents to her GP complaining of a mild fever, fatigue, and weight loss over the past two weeks. She is noted to be limping slightly and, when asked, she mentions that she has had pain in her left knee. She has a past medical history of Raynaud's syndrome, and her only medication is the combined oral contraceptive pill. On examination, the GP notes a malar rash on her cheeks. Systemic lupus erythematosus (SLE) is suspected.

Which of the following blood tests is most sensitive for the likely diagnosis?

Options:
explanation: ANA is the most sensitive test for SLE. However, is not the most specific test, as it is also present in a number of other connective tissue diseases. It is not diagnostic in itself but does make up a key part of the workup for an SLE diagnosis. A negative test can relatively reliably rule out SLE.
name: Antinuclear antibody (ANA)
label: a
answer: yes
explanation: Anti-TPO is the primary antibody detected in patients with Graves' disease. It prevents the breakdown of thyroid hormone resulting in excessive free T4/T3- leading to signs of thyrotoxicosis.
name: Anti-thyroperoxidase (anti-TPO) antibodies
label: e
answer: no
explanation: Anti-dsDNA is a highly specific test for SLE. However, it is only found in about 60% of patients with SLE. It can be used as a confirmatory blood test following a positive ANA result. High levels of anti-dsDNA have also been linked to greater disease activity, and therefore this test plays a role in determining the severity of the condition.
name: Anti-double-stranded DNA (anti-dsDNA)
label: b
answer: no
explanation: Anti-smith antigen is another highly specific test for SLE, but is not as sensitive. It has a role in confirming an SLE diagnosis following a positive ANA result.
name: Anti-smith antigen
label: d
answer: no
explanation: Anti-CCP is the primary blood marker used in the diagnosis of rheumatoid arthritis. However, it is less likely to be raised in SLE.
name: Anti-CCP
label: c
answer: no

Correct answer: a
A 62-year-old female patient on long-term warfarin for atrial fibrillation presents to the INR clinic. Her INR on this occasion is found to be raised at 4.6. She has a past medical history of osteoarthritis which she manages with over-the-counter medicines, and type 2 diabetes for which she has recently been started on metformin. She reports that she is currently being treated for cellulitis.

Which of the following is most likely to have increased this patient's INR?

Options:
explanation: Trauma is unlikely to increase INR and is absent in this patient. A patient with a raised INR may be at increased risk of bleeding as a result of trauma.
name: Trauma
label: d
answer: no
explanation: Metformin has been shown to reduce INR, not increase it.
name: Metformin
label: e
answer: no
explanation: A change in diet - specifically intake of more vitamin K-rich foods may result in a fall in INR, not a rise. This is because vitamin K acts as a natural reversal agent for warfarin - a vitamin K antagonist.
name: Increased green vegetable intake
label: b
answer: no
explanation: Antibiotics (most notably macrolides and metronidazole) can increase INR by inhibiting warfarin's metabolism, and affecting gut flora and therefore vitamin K absorption. This patient is currently being treated for cellulitis, which is frequently treated with metronidazole, clarithromycin or erythromycin. These antibiotics are known to delay the metabolism of warfarin and therefore enhance its anticoagulant effect. This would result in a raised INR.
name: Antibiotic use
label: a
answer: yes
explanation: Paracetamol use is considered safe when used in combination with warfarin and would not increase the patient's INR. However, other over-the-counter medicines, such as aspirin and ibuprofen, have been shown to increase the effects of warfarin, increasing the INR.
name: Paracetamol use
label: c
answer: no

Correct answer: a
A 58-year-old woman presents to her GP complaining of palpitations for the last three days. She describes this as feeling like her heart is beating out of her chest and skipping occasional beats. An ECG is ordered which shows atrial fibrillation. She has a past medical history of asthma, for which she takes a salbutamol inhaler. The patient is normally fit and active, and her current observations are stable.

Which of the following medications would be most appropriate for rate control in this patient?

Options:
explanation: Rate-limiting calcium channel blockers (CCB) or beta-blockers are the first-line management option for rate control in patients with atrial fibrillation. Verapamil is more suitable for this patient due to her history of asthma. CCBs should be used with caution in patients with heart failure due to their negatively inotropic effects.
name: Verapamil
label: a
answer: yes
explanation: Atropine is a muscarinic agonist and is used in sinus bradycardia, not atrial fibrillation. It can cause atrial fibrillation and would not have a role in this patient's management.
name: Atropine
label: d
answer: no
explanation: Amiodarone is effective at controlling rate and rhythm in atrial fibrillation. However, it is associated with a large number of side effects, so is typically reserved for use in older, sedentary patients.
name: Amiodarone
label: e
answer: no
explanation: Beta-blockers are typically the first line option (along with CCBs) for rate control in patients with atrial fibrillation. However, it is contraindicated in this patient due to her history of asthma.
name: Bisoprolol
label: b
answer: no
explanation: Digoxin can be used for rate control in some patients. However, it is not as effective as beta-blockers or calcium channel blockers. It is not effective at controlling heart rate during exertion, and is typically reserved for sedentary patients with low blood pressure or co-existent heart failure.
name: Digoxin
label: c
answer: no

Correct answer: a
A patient presents to the emergency department with pain and swelling in her left calf which started earlier this morning. On examination, the left calf is warm and slightly tender on palpation. The left leg is approximately 3cm larger in circumference than the right. She has no significant past medical history and her only regular medication is the oral contraceptive pill.

Which of the following scoring systems would be most useful for determining the most appropriate next step?

Options:
explanation: The QRISK3 score calculates a person's risk of developing a heart attack or stroke over the next 10 years. Statin treatment is typically offered as primary cardiovascular disease prevention for individuals with a QRISK3 score of 10% or more. This tool would not be useful in the diagnosis of DVT.
name: QRISK3
label: c
answer: no
explanation: The FEVERPAIN score is used to predict the likelihood of the presence of a strep throat infection and thus the need for antibiotics in its treatment. It would not be useful in the diagnosis of DVT.
name: FEVERPAIN score
label: e
answer: no
explanation: Well's score lists a number of criteria which are used to determine the pretest clinical probability of a deep vein thrombosis (DVT). Zero points corresponds to a low DVT probability, and advises a D-dimer which, if negative, can reliably rule out the diagnosis. One to two points is classed as an intermediate probability, and the patient should be treated as having a DVT, and a compression USS should be performed. Scores above two are high probability and should be treated as a DVT, with a compression USS performed to confirm the diagnosis. An adapted Well's score also exists for pulmonary embolism.
name: Well's score
label: a
answer: yes
explanation: The ORBIT score is used to predict the bleeding risk in patients started on anticoagulation for atrial fibrillation. It would not be used in this case as there is no sign the patient suffers from atrial fibrillation and would not aid in the diagnosis of DVT.
name: ORBIT score
label: b
answer: no
explanation: The CHA2DS2-VASc score calculates the stroke risk in patients with atrial fibrillation. It would not be useful in the diagnosis of DVT.
name: CHA2DS2-VASc score
label: d
answer: no

Correct answer: a
A 33-year-old black woman presents to her GP complaining of a dry cough and worsening shortness of breath for the last two months. She reports feeling fatigued and that she has lost some weight recently. She denies chest pain. Upon examination, you note nodules on her shins bilaterally, and swollen lymph nodes in the patient's neck. She drinks approximately six units of alcohol each week, does not smoke, and denies any recent international travel.
Her temperature is 37.9 degrees, pulse 89 bpm, BP 126/78, and CRT < 2.
Blood tests show raised ESR, raised calcium, and reduced lymphocytes. Blood, urine and sputum cultures are all negative.
Given the likely diagnosis, what would most likely be present on a chest X-ray?

Options:
explanation: Although sarcoidosis may rarely cause a pleural effusion, it typically has little pleural involvement, making this finding unlikely. Patients with a pleural effusion are also likely to present with chest pain which is absent in this patient. CXR in pleural effusion would show blunting of the costophrenic angles or white-out of one hemifield if large.
name: Pleural effusion
label: b
answer: no
explanation: Kerley B lines are horizontal lines in the peripheries of the lung which extend to the pleura. They may be present in pulmonary/interstitial oedema, and represent thickened interlobular septa. They are not associated with sarcoidosis.
name: Kerley B lines
label: c
answer: no
explanation: This patient is likely suffering from sarcoidosis, which can present acutely with fever, polyarthralgia, erythema nodosum, and bilateral hilar lymphadenopathy (known collectively as Lofgren syndrome). It is a multisystem disease which is characterised by the formation of granulomas which result in widespread inflammation and complications. A tissue biopsy is diagnostic which would show non-caseating granulomas, however bilateral hilar lymphadenopathy is classically seen on chest X-ray.
name: Bilateral hilar lymphadenopathy
label: a
answer: yes
explanation: A lung nodule may be a sign of lung cancer, which may present with similar symptoms as this patient. However, the patient's age and lack of risk factors make this an unlikely diagnosis. It would also not explain the presence of erythema nodosum, which is a key feature of sarcoidosis.
name: Lung nodule
label: e
answer: no
explanation: Hyperinflation is a sign often seen in patients suffering from COPD. A patient with COPD may present with symptoms similar to this patient. However, the systemic involvement and age of this patient make this an unlikely diagnosis.
name: Lung hyperinflation
label: d
answer: no

Correct answer: a
An 81-year-old woman presents to her GP complaining of worsening breathlessness. She has a diagnosis of chronic obstructive pulmonary disease (COPD) and currently takes a salbutamol inhaler as needed. She is now having to take this multiple times each day, with little improvement in symptoms. She has a past medical history of atrial fibrillation, for which she has taken bisoprolol for two years. Spirometry reveals an FEV1/FVC 0.5. Oxygen saturations are 95%.
The GP decides to amend her current regime to improve her symptoms.
Which of the following medication changes would be most appropriate to make in this patient?

Options:
explanation: Long-term oxygen therapy is reserved for patients with severe resting hypoxaemia (resting O2 <93%) who are non-smokers. It would not be indicated in this patient at this time.
name: Initiate long-term oxygen therapy
label: d
answer: no
explanation: A LABA and ICS would be initiated in patients with asthmatic features or features suggesting steroid responsiveness when symptoms continue despite treatment with a SABA/SAMA. This patient does not have any asthmatic features or evidence of steroid responsiveness. Therefore, it is more appropriate to start this patient on a LABA and LAMA initially.
name: Add LABA + ICS
label: b
answer: no
explanation: A leukotriene receptor antagonist (LTRA) is used in the treatment of asthma following the use of an ICS and LABA. It does not currently have a role in the treatment of COPD.
name: Add leukotriene receptor antagonist
label: e
answer: no
explanation: According to NICE guidance, if a patient continues to be limited by symptoms of COPD or experiences exacerbations despite treatment with a SABA or SAMA, and no asthmatic features are present, the patient should be offered a LABA AND a LAMA. This patient has uncontrolled symptoms despite regular use of her salbutamol inhaler. She has no past medical history of asthma, and her use of bisoprolol - which is contraindicated in asthmatic patients - confirms this. The correct next step would be to commence the patient on a LABA and a LAMA. An ICS may be added to this regime later if symptoms continue despite treatment.
name: Add LABA + LAMA
label: a
answer: yes
explanation: Inhaled corticosteroids (ICS) make up the second-line treatment for asthma, and are used in addition to LABAs and LAMAs in COPD management, particularly in those with asthmatic features. It would not be appropriate to prescribe an ICS alone to this patient.
name: Add inhaled corticosteroid
label: c
answer: no

Correct answer: a
A 58-year-old farmer presents to his GP with a two-year history of progressive shortness of breath, particularly on exertion. Over this time, he has also had a cough productive of large volumes of green sputum. He has had five chest infections requiring antibiotics within the past year. He denies any weight loss, and his observations are normal. He has smoked 20 cigarettes per day for the last 35 years and does not drink alcohol. There is no past medical history of note and he has never travelled abroad.

Examination notes bilateral clubbing of the fingers. A chest X-ray shows tram-track opacities, and a CT scan demonstrates dilated airways throughout the lungs with no lesions.

What is the most likely diagnosis?

Options:
explanation: Bronchiectasis is the permanent dilation of the airways within the lung secondary to chronic inflammation or infection. It presents with a persistent productive cough (often with large volumes of sputum), shortness of breath, and sometimes haemoptysis. Coarse crackles are heard on auscultation and patients may also have finger clubbing. Patients are prone to repeated chest infections. 'Tram-track' opacities are a characteristic chest X-ray finding in bronchiectasis, and a CT scan would show dilated airways.
name: Bronchiectasis
label: a
answer: yes
explanation: Asthma is an appropriate differential diagnosis in this patient. However, the productive cough and lack of a wheeze described by the patient make it less likely. Asthma patients are also more likely to have a family history, other atopic disease, or diurnal variation in their symptoms - all of which are absent in this patient.
name: Asthma
label: e
answer: no
explanation: Tuberculosis (TB) is the most common cause of bronchiectasis worldwide, but is unlikely in this patient. Tuberculosis is uncommon in the UK, and this patient has no history of travelling to TB-prevalent countries. Although TB may cause a persistent cough, it would typically present with systemic symptoms such as night sweats, weight loss, and a fever. A CT/CXR would also show signs of TB.
name: Tuberculosis
label: c
answer: no
explanation: Lung cancer may cause a chronic cough and finger clubbing. However, it is unlikely here given the lack of systemic symptoms such as weight loss, and no lesions being found on chest X-ray or CT.
name: Lung cancer
label: b
answer: no
explanation: Cystic fibrosis is a common cause of bronchiectasis. However, it is an unlikely cause in this patient. A patient with cystic fibrosis would typically have signs much earlier in life (e.g. meconium ileus) which would lead to a pre-existing diagnosis- which is absent in this patient. They may present with clubbing, but also commonly have pancreatic damage.
name: Cystic fibrosis
label: d
answer: no

Correct answer: a
A 24-year-old woman presents to A&E with severe shortness of breath. She has a past medical history of asthma and has taken 20 puffs of her salbutamol inhaler today, which has not relieved her symptoms. On examination, there is an audible wheeze. Her observations show HR 122, RR 24, BP 142/74, O2 90%. An arterial blood gas is performed, and she is found to be in type 1 respiratory failure.

Which of the following arterial blood gas results would you most expect to see in this patient?

Options:
explanation: This is an example of type 2 respiratory failure, which is caused by alveolar hypoventilation. In type 2 respiratory failure, the lungs are unable to effectively oxygenate the blood and cannot effectively excrete carbon dioxide. This leads to low oxygen, with high carbon dioxide levels.
name: PaO2 - 6.2 kPa, PaCO2 - 8 kPa
label: b
answer: no
explanation: This is a normal arterial blood gas result.
name: PaO2 - 10.9 kPa, PaCO2 - 3.4
label: c
answer: no
explanation: This patient is experiencing an exacerbation of asthma, which would cause a type 1 respiratory failure. Type 1 respiratory failure is caused by a V/Q mismatch in the lungs, where the volume of air entering and exiting the lungs is comparatively smaller than the volume of blood perfusing the lungs. This typically results in low oxygen, with normal/low carbon dioxide levels.
name: PaO2 - 6.2 kPa, PaCO2 - 4.8 kPa
label: a
answer: yes
explanation: This is a normal arterial blood gas result, with oxygen and carbon dioxide levels both at the extremes of the normal ranges.
name: PaO2 - 8.0 kPa, PaCO2 - 5.9 kPa
label: e
answer: no
explanation: These results show a normal PaO2, with a raised PaCO2. This may be present in patients with long-term COPD where, due to hypoventilation, the body produces more CO2 than it can eliminate, resulting in a net retention of CO2. In type 1 respiratory failure, the PaO2 would be expected to be low, with low or normal PaCO2.
name: PaO2 - 8.0 kPa, PaCO2 - 7.5 kPa
label: d
answer: no

Correct answer: a
A 73-year-old woman presents with a two-month history of shortness of breath, productive cough and chest pain. For the past six months, she has been feeling progressively more tired and has had 10kg of unintentional weight loss. She has a past medical history of hypertension, for which she takes amlodipine. She is retired, although previously worked as an accountant, and has a 45 pack-year history of smoking. A chest X-ray is ordered which shows a right hilar mass. Blood tests demonstrate hypercalcaemia.

What is the most likely diagnosis?

Options:
explanation: Non-small cell lung cancers are the most common overall forms of lung cancer. Squamous cell carcinoma is one type of non-small cell lung cancer, and has a strong association with smoking. The presence of a hilar mass makes a lung lesion most likely, and the associated symptoms of weight loss and fatigue support a diagnosis of cancer. Squamous cell cancers develop in the cells lining the airways and are typically found near the hilum/main bronchi. These lesions can sometimes obstruct the airways and may press on nearby structures causing dysphagia and hoarseness. Squamous cell lung cancer is associated with parathyroid-related peptide (PTHrP), which would explain the hypercalcaemia in this patient.
name: Squamous cell lung cancer
label: a
answer: yes
explanation: Patients with sarcoidosis typically present with a dry cough, shortness of breath and non-pulmonary features such as erythema nodosum and fever. A chest X-ray would demonstrate bilateral hilar lymphadenopathy and patients are typically significantly younger than this patient. Sarcoidosis is associated with weight loss and hypercalcaemia.
name: Sarcoidosis
label: d
answer: no
explanation: Small cell lung cancers make up a relatively small portion of all lung cancers (10-20%), and are considered a highly aggressive form of lung cancer. Patients typically present in the advanced stage of the disease, with metastases seen in the majority of presenting patients. This patient has had non-specific symptoms for six months which would make small-cell lung cancer less likely. It is also associated with neuroendocrine cells resulting in paraneoplastic syndromes such as SIADH (ectopic ADH secretion).
name: Small cell lung cancer
label: b
answer: no
explanation: Infection within the lung can cause the appearance of a mass in the lung. However, the prolonged history of shortness of breath and cough, the presence of red-flag symptoms such as unintentional weight loss, and the lack of fever make the diagnosis of pneumonia unlikely.
name: Pneumonia
label: e
answer: no
explanation: Adenocarcinoma is the most common lung cancer in non-smokers and is often associated with asbestos exposure. It is less likely to present as a paraneoplastic syndrome.
name: Adenocarcinoma
label: c
answer: no

Correct answer: a
A 54-year-old man presents to his GP complaining of diarrhoea, facial flushing, and abdominal pain. Examination reveals a slight wheeze bilaterally. He has a two-year history of irritable bowel syndrome (IBS). A colonoscopy is performed which identifies a polyp. A biopsy confirms a carcinoid neuroendocrine tumour.

Which of the following hormones is responsible for the patient's symptoms?

Options:
explanation: Noradrenaline is the primary neurotransmitter of the sympathetic nerves in the cardiovascular system. High levels of noradrenaline may cause anxiety, hypertension, tachycardia, disturbed sleep, hyperglycaemia, and headaches. It would not be raised due to a carcinoid tumour.
name: Noradrenaline
label: d
answer: no
explanation: ACTH is not produced by a carcinoid tumour and excess levels would not result in the symptoms described above. ACTH is produced by the pituitary gland and stimulates the release of cortisol from the adrenal glands. ACTH may be raised in Cushing's disease, Addison's disease, multiple endocrine neoplasia, or ectopic ACTH-secreting tumours (e.g. small cell lung cancers).
name: Adrenocorticotrophic hormone (ACTH)
label: c
answer: no
explanation: TSH is produced by the anterior pituitary gland and stimulates thyroid hormone production by the thyroid gland. It is typically raised in hypothyroidism, accompanied by symptoms of weight gain, depression, constipation, and fatigue among others.
name: Thyroid-stimulating hormone (TSH)
label: e
answer: no
explanation: This patient has a carcinoid tumour, which is a slow-growing malignant tumour which develops within the neuroendocrine system. A small portion of these tumours secrete hormones, most commonly serotonin. Excess serotonin secretion results in the symptoms of abdominal pain, diarrhoea, flushing and wheeze often seen in these patients. Diarrhoea is a common presenting symptom and may present on its own, so is often misdiagnosed as IBS.
name: Serotonin
label: a
answer: yes
explanation: Octreotide - a radiolabelled somatostatin analogue - is often used to investigate for and treat carcinoid tumours, as it inhibits the release of tumour products, but would not cause the symptoms of this patient as it is not released by the tumour. Somatostatin produces neuroendocrine inhibitory effects, regulates the activity of the gastrointestinal tract, and prevents rapid cell proliferation.
name: Somatostatin
label: b
answer: no

Correct answer: a