hllj/quesmed huggingface dataset:
A 48-year-old man with no known medical history visits the GP clinic for a routine health check. His body mass index (BMI) is 27 kg/m2, and he has a family history of type 2 diabetes mellitus (T2DM). Physical examination is unremarkable. A random plasma glucose is found to be raised at 15.0 mmol/L (normal <6.1 mmol/L).


Which of the following is the most appropriate next step in management?

Options:
explanation: This is an incorrect answer. In persons with classic diabetic symptoms such as fatigue, polydipsia, polyuria, and blurred vision, a single abnormal blood test result, either HbA1c or fasting plasma glucose, is reliable. However, as this patient is asymptomatic, a second abnormal test on another day is required to confirm the diagnosis.
name: Confirm diagnosis of T2DM after an abnormal HbA1c result
label: b
answer: no
explanation: This is an incorrect answer. Random plasma glucose ≥11.1 mmol/L is a significant indication of underlying hyperglycaemia which should be further investigated. Moreover, the presence of risk factors (obesity and family history) increases the chance of developing T2DM in this scenario.
name: Reassure as no further action required
label: e
answer: no
explanation: This is an incorrect answer. Diagnosing T2DM based on a single abnormal test result in an asymptomatic patient is inappropriate as it depends on various other factors. Although metformin is considered the first-line agent, a confirmed diagnosis is mandatory first.
name: Confirm diagnosis of T2DM and commence treatment with metformin
label: c
answer: no
explanation: This is an incorrect answer. Diagnosing T2DM based on a single abnormal test result is inappropriate as it depends on various other factors. Insulin therapy is initiated if either oral hypoglycaemics are unsuitable or fail to control blood sugar levels despite maximum doses or there is an immediate risk of hyperglycaemia-associated complications.
name: Confirm diagnosis of T2DM and commence treatment with insulin
label: d
answer: no
explanation: This is the correct answer. NICE guidelines advise repeating, preferably with the same test, within two weeks in asymptomatic people. As in some cases, hyperglycaemia may be transient due to stress, infection, trauma, or recent surgery, which subsides spontaneously without further intervention. Additionally, HbA1c is more reliable and convenient as the patient does not need to fast before the test.
name: Confirm diagnosis of T2DM after an abnormal HbA1c result on two different days
label: a
answer: yes

Correct answer: a
A 10-year-old girl is brought to the GP clinic complaining of a sore throat, neck pain, headache and high-grade fever for the past five days. There are no similar complaints among her family or peers. Her vaccinations are up to date, and she is allergic to penicillin. Her vital signs are normal except for an elevated temperature (39.3°C). On examination, both tonsils are enlarged, hyperaemic tonsils with pus, and tender lymph nodes in the neck.

What is the most appropriate next step in management?

Options:
explanation: In cases where the patient has stridor, respiratory difficulty, dehydration, severe suppurative complications, severe systemic illness, or suspected Kawasaki disease or epiglottitis, an urgent same-day referral to an ENT specialist may be necessary. Referring the patient to a specialist may be required in these instances, but it is not the most appropriate next step in this case.
name: Urgent referral to a specialist
label: e
answer: no
explanation: The evaluation of patients with tonsillitis involves using the CENTOR score, a scoring system that includes:

- Fever
- Tonsillar exudate
- Tender cervical lymphadenopathy
- Abscence of cough

Each of these factors is assigned one point, and the total score is used to determine the likelihood of *streptococcal* *pharyngitis* or 'strep throat'. NICE guidelines advise commencing antibiotics immediately if the **CENTOR score is 3 or 4**. As her score is 3, and she is allergic to penicillins, clarithromycin is the most appropriate medication.
name: Clarithromycin
label: a
answer: yes
explanation: If the patient has a CENTOR score of 1 or 2, they are unlikely to benefit from an antibiotic, and an antibiotic prescription should not be offered. However, they may consider using the antibiotic if their sore throat has not started to improve within 3-5 days or if their symptoms worsen. They should be given the option of returning for reassessment and be advised to do so if their symptoms continue to worsen despite using the antibiotic prescription.
name: Review after 5-7 days
label: d
answer: no
explanation: Reassuring the patient may provide temporary relief, but it does not address the underlying cause of the patient's symptoms and would not be sufficient as a standalone treatment.
name: Reassure
label: c
answer: no
explanation: In cases of tonsillitis, NICE guidelines recommend prescribing antibiotics immediately if the CENTOR score is 3/4, and phenoxymethylpenicillin is the first-line medication as the positive predictive value for *streptococcal* pharyngitis or strep throat is between 32-56%. However, in this case, the patient is allergic to penicillin, so an alternative antibiotic, such as clarithromycin, would be more appropriate.
name: Phenoxymethylpenicillin
label: b
answer: no

Correct answer: a
A 60-year-old woman with a history of type 2 diabetes mellitus and hyperlipidaemia presents to the GP with worsening pain in both knees over the past year. The pain is exacerbated by walking and relieved by rest, and warm compresses have provided temporary relief in the past. On examination, a "crepitus" is heard while palpating over the knee joints bilaterally. Her body mass index is 32kgm<sup>2</sup>.

What is the most appropriate initial treatment for her condition?

Options:
explanation: Intra-articular corticosteroid injections are used to deliver a high dose of corticosteroids directly to the joint to reduce inflammation and provide short-term pain relief. They are used in managing acute flares of joint pain rather than the initial treatment of osteoarthritis.
name: Intra-articular corticosteroid
label: d
answer: no
explanation: Diclofenac is tyically given topically and is the most appropriate initial management option for this patient's knee pain. Osteoarthritis (OA) is the most likely diagnosis, based on her clinical presentation and examination findings. OA is a degenerative joint disease that results in the erosion of cartilage in the intra-articular joints, causing joint pain and stiffness. Topical NSAIDs are the the first-line treatment for mild to moderate OA. It is effective in reducing pain and improving function in people with OA.
name: Topical diclofenac
label: a
answer: yes
explanation: Allopurinol is used in gout prophylaxis. It decreases the production of uric acid and reduces the risk of kidney damage caused by high uric acid levels in the blood. Allopurinol is not used in the treatment of osteoarthritis.
name: Allopurinol
label: e
answer: no
explanation: Naproxen is a non-steroidal anti-inflammatory drug (NSAID) that is highly effective in treating osteoarthritis. However, oral NSAIDs are considered second-line agents in OA if both paracetamol and topical NSAIDs are ineffective.
name: Oral naproxen
label: b
answer: no
explanation: There is no role for oral corticosteroids in the management of osteoarthritis. Corticosteroids are potent anti-inflammatory medications that are used to treat a variety of autoimmune conditions, but they are not recommended for the treatment of OA due to the potential for serious side effects and the limited effectiveness in relieving OA symptoms.
name: Oral corticosteroid
label: c
answer: no

Correct answer: a
A 30-year-old woman presents to the GP clinic with a mildly itchy rash on her chest and abdomen, which consists of pink scaly patches. The patient reports that the rash appeared suddenly about a week ago and has not improved since. On examination, the rash is salmon-coloured, oval, and has a surrounding ring of scale. It has a characteristic "Christmas tree" distribution.

What is the most likely diagnosis?

Options:
explanation: While psoriasis may also present with scaly, itchy patches on the skin, it is typically more persistent and chronic than pityriasis rosea. It is also more likely to affect other areas of the body, such as the scalp, nails, and joints. In addition, psoriasis is typically accompanied by other physical findings, such as thickened, pitted nails and red, swollen joints.
name: Psoriasis
label: b
answer: no
explanation: Eczema, also known as atopic dermatitis, is a chronic skin condition that typically presents with red, itchy patches on the skin. However, eczema tends to affect areas of the body that are more prone to irritation, such as the face, neck, and inner elbow, rather than the chest and abdomen. Eczema is also more likely to be chronic and persists over time rather than resolving on its own within a few weeks as pityriasis rosea does.
name: Eczema
label: c
answer: no
explanation: Tinea corporis is a dermatophyte infection of the face, trunk, and extremities. It is often confused with the herald patch of pityriasis rosea. The distinguishing features of tinea corporis are a less severe involvement of the centre of the lesion, a more active edge and itching. In contrast, circular patches of scaling and erythema are clues to pityriasis rosea.
name: Tinea corporis
label: e
answer: no
explanation: The symptoms described in the clinical scenario are consistent with pityriasis rosea, a skin condition probably due to human Herpesviruses 6 and 7. It typically starts with a single patch (herald patch) on the trunk or neck, which is oval, 2-5cm in size, and has a central, salmon-coloured area and a dark-red peripheral zone separated by fine scales. A secondary rash of smaller patches follows, with a "Christmas tree" distribution on the trunk, neck, and upper limbs.
name: Pityriasis rosea
label: a
answer: yes
explanation: Allergic dermatitis, also known as contact dermatitis, is a skin reaction to an allergen or irritant. It is characterised by red, itchy patches on the skin that may be accompanied by swelling and blistering. Allergic dermatitis may be triggered by exposure to certain substances, such as chemicals, fragrances, or metals. However, the sudden onset and lack of other physical findings make allergic dermatitis less likely in this case.
name: Allergic dermatitis
label: d
answer: no

Correct answer: a
A 79-year-old man without any active complaints visits his GP because he worries about prostate cancer. His father was diagnosed with prostate cancer at the same age. His vital signs, blood tests and previous colonoscopy results are all normal. A digital rectal examination (DRE) reveals an asymmetrically enlarged, immobile, hard and indurated prostate gland.

What is the most appropriate next step in management?

Options:
explanation: Watchful waiting may be suitable for men with slowly progressing tumours or significant comorbidities who are likely to die of other causes and not suffer significant morbidity from prostate cancer. However, it is not the appropriate choice as the diagnosis of prostate carcinoma is not yet confirmed.
name: Watchful waiting
label: e
answer: no
explanation: PSA test is offered in individuals whose DRE findings are inconclusive. It is not an effective screening tool for prostate cancer because it is not sensitive or specific enough. Moreover, it is an inaccurate marker for prostate cancer as it is elevated in several non-cancerous conditions.
name: Order prostate-specific antigen (PSA) testing
label: b
answer: no
explanation: TURP is primarily indicated for treating benign prostatic hyperplasia (BPH), a non-malignant condition characterised by overgrowth of the prostate gland. TURP is not indicated for the treatment of prostate cancer due to its limited extent and inability to eradicate malignant cells.
name: Refer for transurethral resection of the prostate (TURP)
label: d
answer: no
explanation: Advanced age and a positive family history increase the likelihood of developing prostate cancer. The abnormal findings on the DRE are consistent with prostate carcinoma. **NICE guidelines suggest referring the person for further evaluation through a suspected cancer pathway referral (within two weeks) if there are signs of malignancy on DRE.**
name: Urgent two-week wait cancer referral
label: a
answer: yes
explanation: Transrectal ultrasonography can evaluate the prostate gland for abnormalities, such as cancer. However, transrectal ultrasonography has a high false-positive rate which makes it unsuitable as a screening tool for prostate cancer, as it would generate too many false positives and lead to unnecessary follow-up tests and treatment. It may still be helpful in directing prostatic biopsy.
name: Refer for transrectal ultrasonography
label: c
answer: no

Correct answer: a
A 58-year-old woman presents to the GP complaining of bleeding after having intercourse for the past year. She has had ten episodes of mild vaginal bleeding in the past six months. She had regular periods until nine years ago and has not had bleeding in the last six years. She is currently on hormone replacement therapy (HRT). Otherwise, her past medical history is insignificant. Her cervical smear was unremarkable three years ago. A speculum examination shows a normal cervix and vagina.

What is the most appropriate next step in management?

Options:
explanation: The patient is experiencing recurrent vaginal bleeding after many years of attaining menopause, which can be a sign of endometrial cancer. **NICE guidelines recommend a 2 week wait suspected cancer pathway referral for women aged 55 years and over with postmenopausal bleeding (unexplained vaginal bleeding more than 12 months after menstruation has stopped because of the menopause).**
name: Urgent two-week wait cancer referral
label: a
answer: yes
explanation: This patient's cervical smear was already performed three years ago and was unremarkable, which makes the possibility of cervical cancer less likely. Therefore, repeating the cervical smear would not be an appropriate next step in management.
name: Repeat cervical smear
label: b
answer: no
explanation: Although HRT helps with her postmenopausal symptoms (such as hot flushes, vaginal dryness, reduced sex drive, etc.,) which she might be currently experiencing, there isn't any evidence stating that it increases the chance of endometrial cancer, or otherwise causes post-menopausal bleeding. Hence, it is not the appropriate choice.
name: Stop HRT
label: c
answer: no
explanation: The patient is experiencing bleeding after intercourse, which is not a typical symptom of menopause and can be a sign of a more serious underlying condition such as endometrial cancer. Delaying the referral and treatment for six months would not be appropriate and could potentially allow the condition to progress.
name: Reassure and review after six months
label: e
answer: no
explanation: Tranexamic acid is a medication that is used to treat heavy menstrual bleeding (menorrhagia). However, in this case, the patient is experiencing bleeding after intercourse, which is not a typical symptom of menorrhagia. Additionally, the patient is postmenopausal and has not had a period in nine years. Therefore, prescribing tranexamic acid would not be an appropriate next step in management.
name: Prescribe tranexamic acid
label: d
answer: no

Correct answer: a
You have just reviewed five different patients presenting with a primary complaint of diarrhoea and subsequently diagnosed them with the following conditions: *Amoebiasis, Norovirus, Cystoisosporiasis*, *Campylobacter* (food poisoning), and *Giardiasis*.

Which one of the following would have to be notified to the consultant responsible for infectious disease control?

Options:
explanation: Staphylococcal skin infections are not a notifiable disease.
name: Staphylococcal aureus skin infection
label: e
answer: no
explanation: Amoebiasis is not a notifiable disease.
name: Amoebiasis
label: b
answer: no
explanation: Food poisoning of any cause is a notifiable disease. It is a statutory obligation to notify UK Health Security Agency (formerly Public Health England). In the UK, notifiable diseases are a list of infectious and non-infectious conditions that healthcare professionals and laboratories are required to report. The purpose of this reporting system is to monitor the occurrence and spread of these diseases in the population and to take appropriate public health action to prevent and control their transmission.
name: Campylobacter (food poisoning)
label: a
answer: yes
explanation: Norovirus is not a notifiable disease.
name: Norovirus
label: c
answer: no
explanation: Cystoisosporiasis is not a notifiable disease.
name: Cystoisosporiasis
label: d
answer: no

Correct answer: a
A 52 year old male attends his GP surgery for a general review. As part of this his assessent, his QRISK2 score is calculated which is 20%.

The patient wants to know what this means.

Which of the following is the best description of the patient's QRISK2 score?

Options:
explanation: The QRISK2 is an online calculation to estimate the patient's chance of having a cardiovascular event in the next 10 years. If the risk is 10% or higher then the patient can be offered a statin to decrease the risk, known as primary prevention of cardiovascular events.

The amount the risk would fall by would be dependent on the effectiveness of the statin with the aim being a 40% reduction in non-HDL-C levels. A higher dose statin may be required as well as lifestyle modification to reduce this risk.
name: The patient's risk of having a cardiovascular event can be decreased by 20% by treatment with a statin
label: d
answer: no
explanation: The QRISK score specifically looks at the risk of cardiovascular events occuring for an individual over 10 years.
name: There is a 20% chance of this patient having a cardiovascular event in the next 20 years
label: b
answer: no
explanation: The QRISK score is used to predict the likelihood of someone having a cardiovascular event over the next 10 years, it does not predicit morbidity or mortality.
name: The patient an 80% of chance of surviving a cardiovascular event in the next 10 years
label: e
answer: no
explanation: The QRISK2 is an online calculation to estimate the patient's chance of having a cardiovascular event in the next 10 years. It is used for those under the age of 85 years, and who do not have type 1 diabetes, familial hypercholesterolaemia or chronic kidney disease as these are already considered higher risk for cardiovascular events.
Patients with a QRISK score of 10% or more should be offered lifestyle advice such as weight loss, smoking cessation and increased exercise. A statin (atorvastatin 20mg is first line) should be offered for primary prevention of cardiovascular disease if lifestyle modification is unsuccessful or inappropriate to offer.
name: There is a 20% chance of this patient having a cardiovascular event in the next 10 years
label: a
answer: yes
explanation: The QRISK score is used to predict the likelihood of someone having a cardiovascular event over the next 10 years, it does not predicit morbidity or mortality.
name: There is a 20% chance mortality risk in the next 10 years from a cardiovascular event
label: c
answer: no

Correct answer: a
A 62 year old female is prescribed a statin for primary prevention of cardiovascular disease.

Which of the following describes the main mechanism of action of statins?

Options:
explanation: Statins inhibit of HMG-CoA reductase, the enzyme responsible for cholesterol synthesis as well as lipid and low density lipoprotein (LDL) metabolism and transport.
name: Activation of HMG-CoA reductase
label: c
answer: no
explanation: HMG-CoA reductase is the key enzyme in cholesterol production in the liver, as well as lipid and low density lipoprotein (LDL) metabolism and transport.
Hyperlipidaemia is associated with increased risk of cardiovasculardisease.
name: Inhibition of HMG-CoA reductase
label: a
answer: yes
explanation: A statin lowers cholesterol by inhibiting HMG-CoA reductase, the key enzyme in cholesterol production in the liver, as well as lipid and low density lipoprotein (LDL) metabolism and transport.
Lipase inhibitors such as Orlistat can be used in weight loss management. It is an inhibitor of gastrointestinal lipase, therefore inhibiting the hydrolysis of triglycerides, therefore prevening their absorption and helping weight loss.
name: Lipase inhibitor
label: e
answer: no
explanation: A statin lowers cholesterol by inhibiting HMG-CoA reductase, the key enzyme in cholesterol production in the liver, as well as lipid and low density lipoprotein (LDL) metabolism and transport.
name: Binds to cholesterol
label: d
answer: no
explanation: ACE inhibitors such as ramipril are used in the treatment of hypertension.
Statins are HMG-CoA reductase inhibitors.
name: Competitive inhibition of ACE
label: b
answer: no

Correct answer: a
A 58 year old female attends her GP surgery for a diabetic review. She has had type 2 diabetes for 2 years and takes metformin. She has no other past medical history.

Her most recent HbA1c is 53 mmol/mol.

What should her target HbA1c be?

Options:
explanation: Type 2 diabetics on drug therapy that is not associated with hypoglycaemia (such as metformin, like in this case) should aim for an HbA1c of 48mmol/mol.
name: 50 mmol/mol
label: d
answer: no
explanation: Type 2 diabetics on drug therapy that is not associated with hypoglycaemia (such as metformin) should aim for an HbA1c of 48mmol/mol.

In this case, the patient should be offered further diet and lifestyle support, as well as an increase in their medication; an increase in the dose of metformin or the addition of another drug.
name: 48mmol/mol
label: a
answer: yes
explanation: Whilst targets should be discussed and agreed with the patient to form an individualised target, in general the HbA1c should be 48mmol/mol for those on drug therapy not associated with hypoglycaemia, and 53 mmol/mol for those on drug therapy which is associated with hypoglycaemia.
name: There is no specific target
label: c
answer: no
explanation: HbA1c should be measured every 3 to 6 months until stable on established therapy, and then every 6 months after that.
name: HbA1c does not need to be monitored after diagnosis
label: e
answer: no
explanation: Type 2 diabetics who are on treatment associated with hypoglycaemia (such as insulin and solfonylureas) should be aiming for 53 mmol/mol, however, this patient is taking metformin only, therefore their aim should be 48mmol/mol.
name: 53 mmol/mol
label: b
answer: no

Correct answer: a
A 57 year old male attends his GP surgery to discuss his alcohol intake.
He drinks four 125ml glasses of 13% red wine a week.
How many units, to the nearest whole unit, of alcohol per week does this patient drink?

Options:
explanation: This is the recommended upper normal limit of weekly alcohol intake for males and females.
name: 14 units
label: b
answer: no
explanation: Alcohol units are calculated multiplying the total volume of a drink (in ml) by its ABV (measured as a percentage) and dividing the result by 1,000. In this case, 4 x 125 = 500ml, 500ml x 13 (% of ABV) divided by 1000 = 6.5 units, rounded to 7. 
name: 2 units
label: c
answer: no
explanation: Alcohol units are calculated multiplying the total volume of a drink (in ml) by its ABV (measured as a percentage) and dividing the result by 1,000. In this case, 4 x 125 = 500ml, 500ml x 13 (% of ABV) divided by 1000 = 6.5 units, rounded to 7. 
name: 7 units
label: a
answer: yes
explanation: Alcohol units are calculated multiplying the total volume of a drink (in ml) by its ABV (measured as a percentage) and dividing the result by 1,000. In this case, 4 x 125 = 500ml, 500ml x 13 (% of ABV) divided by 1000 = 6.5 units, rounded to 7. 
name: 5 units
label: d
answer: no
explanation: Alcohol units are calculated multiplying the total volume of a drink (in ml) by its ABV (measured as a percentage) and dividing the result by 1,000. In this case, 4 x 125 = 500ml, 500ml x 13 (% of ABV) divided by 1000 = 6.5 units, rounded to 7. 
name: 65 units
label: e
answer: no

Correct answer: a