hllj/quesmed huggingface dataset:
A 35-year-old male has recently had surgery to treat severe Crohn's disease. This surgery involved the resection of his terminal ileum.

Which of the following vitamins is he at risk of becoming deficient in?

Options:
explanation: Vitamin B3 (niacin) is absorbed throughout the small intestine and stomach therefore loss of the terminal ileum will not drastically affect absorption. A deficiency of vitamin B3 causes Pellagra.
name: Vitamin B3
label: c
answer: no
explanation: Vitamin B12 is actively absorbed in the terminal ileum bound to intrinsic factor. Resection of the terminal ileum can therefore result in a deficiency. A deficiency of vitamin B12 can cause megaloblastic anaemia and peripheral neuropathy.
name: Vitamin B12
label: a
answer: yes
explanation: Vitamin B6 (pyridoxine) is primarily absorbed in the jejunum so would be unaffected by this surgery. A deficiency of vitamin B6 can cause anaemia and neuropathy. Although individuals with IBD are more likely to suffer pyridoxine deficiency, resection of the terminal ileum is a major risk factor for vitamin B12 deficiency.
name: Vitamin B6
label: d
answer: no
explanation: Vitamin B9 (folic acid) is absorbed in the duodenum and jejunum. A deficiency of folic acid results in megaloblastic anaemia and can cause neural tube defects in the foetus.
name: Vitamin B9
label: e
answer: no
explanation: Vitamin B1 (thiamine) is absorbed in the ileum and jejunum. As resection of the terminal ileum leaves the remainder of the ileum intact, this patient is unlikely to struggle to absorb vitamin B1. A deficiency of vitamin B1 can cause polyneuropathy, Wernicke-Korsakoff syndrome, and heart failure.
name: Vitamin B1
label: b
answer: no

Correct answer: a
A 36-year-old male attends a GP appointment asking for advice. His father has recently passed away from colorectal cancer aged 72. The man would like some information regarding colorectal cancer screening.

Which of the following is the correct age range for bowel cancer screening in Scotland?

Options:
explanation: In Scotland, bowel cancer screening takes the form of the faecal immunochemical test (FIT) which is offered to everyone between the ages of 50-74.
name: 50 - 74 years old
label: a
answer: yes
explanation: Individuals aged 75 and over can still request FIT testing every 2 years but are not invited to screening.
name: 50 - 79 years old
label: d
answer: no
explanation: This is the age range for screening in England.
name: 60 - 74 years old
label: e
answer: no
explanation: Individuals under the age of 50 are not offered bowel screening. Individuals aged 75 and over can still request FIT testing every 2 years but are not invited to screening.
name: 45 - 75 years old
label: c
answer: no
explanation: Individuals aged 75 and over can still request FIT testing every 2 years but are not invited to screening.
name: 60 - 79 years old
label: b
answer: no

Correct answer: a
A 57-year-old female presents to General Practice with a 5-week history of painless jaundice, pale stools, and dark urine. She is referred for an abdominal CT scan which reveals the "double duct" sign. She reports a smoking history of 25 pack years.

Which of the following is the most likely diagnosis?

Options:
explanation: Hepatocellular carcinoma is another important differential but is unlikely in this case. HCC classically presents with signs of liver cirrhosis. These include jaundice, right upper quadrant pain, ascites, pruritis, and splenomegaly. Furthermore, the double duct sign is not seen in hepatocellular cancer.
name: Hepatocellular carcinoma
label: b
answer: no
explanation: Chronic pancreatitis is an important differential but is not the diagnosis in this case. Chronic pancreatitis is most commonly caused by alcohol abuse which is not present in this patient's history. Dull epigastric pain is also present in 80% of chronic pancreatitis cases and is typically worst after a meal or on sitting forward. Finally, a CT scan would likely reveal pancreatic calcifications that are not present in this case.
name: Chronic pancreatitis
label: d
answer: no
explanation: Acute cholangitis is an infection of the biliary tree and is an unlikely diagnosis in this case. Acute cholangitis often presents with fever, jaundice, and right upper quadrant pain. The absence of pain and fever and the 5-week history are strong factors against this diagnosis.
name: Acute cholangitis
label: c
answer: no
explanation: Choledocholithiasis is the presence of gallstones in the bile ducts and is an important differential for obstructive jaundice. This condition presents with colicky right upper quadrant/epigastric pain often worse after a meal. As there is no pain in this presentation and the double duct sign is present, pancreatic cancer is the most likely diagnosis.
name: Choledocholithiasis
label: e
answer: no
explanation: This patient is suffering from pancreatic cancer. Painless obstructive jaundice is a classical presentation of this disease. Smoking is also an important risk factor. Combined with dilatation of the common bile duct and pancreatic duct (double duct sign), these factors indicate a diagnosis of pancreatic cancer.
name: Pancreatic Cancer
label: a
answer: yes

Correct answer: a
A 32-year-old male presents to General Practice with right upper quadrant pain, malaise and fatigue. On examination, he is jaundiced and has right upper quadrant tenderness. He also reported experiencing a flu-like illness 2 weeks ago.

Which of the following are the transmission methods of the most likely diagnosis?

Options:
explanation: Hepatitis B is not transmitted through respiratory droplets. Classically respiratory airborne diseases include conditions such as influenza.
name: Respiratory droplets
label: b
answer: no
explanation: Hepatitis B is not transmitted through any respiratory means but can be transmitted through blood-to-blood contact.
name: Droplet,  Aerosol, Bloodborne
label: e
answer: no
explanation: Although hepatitis B can be spread by both sexual transmission and blood-blood contact, it is not typically transmitted by the faecal-oral route. This method of transmission is more typical of hepatitis A which is a hepatic virus spread through faecal-oral exposure such as ingesting contaminated food or water.
name: Faecal-oral, Sexual transmission, Bloodborne
label: c
answer: no
explanation: Although hepatitis B can be transmitted through both vertical and sexual means, it is not transmitted faecal-orally. This is more typical of hepatitis A which is a hepatic virus spread through faecal-oral exposure such as ingesting contaminated food or water.
name: Faecal-oral, Vertical, Sexual transmission
label: d
answer: no
explanation: This man is suffering from Hepatitis B. Hepatitis B typically presents with fever, right upper quadrant pain, jaundice, fatigue, and malaise. A prodromal illness may occur ~2 weeks before the onset of jaundice. Hepatitis B is a viral infection transmitted through infected bodily fluids and is therefore transmitted through blood-to-blood contact (e.g. needle sharing), sexual transmission, and vertical transmission from mother to baby perinatally.
name: Bloodborne, Sexual transmission, Vertical transmission
label: a
answer: yes

Correct answer: a
An 8-year-old female is brought to General Practice by her mother who reports a history of pale, oily, foul-smelling stool. The mother also mentions her daughter has suffered from recurrent chest infections. You note the child is of short stature.

Which of the following is the most appropriate management of this child's gastrointestinal symptoms?

Options:
explanation: This child is suffering from cystic fibrosis, as indicated by the history of recurrent chest infections, short stature, and pancreatic insufficiency (causing steatorrhoea). The BMJ and NICE recommend the use of pancreatic enzyme replacement as well as a high-fat, high-calorie diet.
name: Pancreatic enzyme supplementation
label: a
answer: yes
explanation: This child is suffering from cystic fibrosis, as indicated by the history of recurrent chest infections, short stature, and pancreatic insufficiency (causing steatorrhoea).  Antibiotic therapy may feature in the management of respiratory cystic fibrosis but would not be used in pancreatic insufficiency.
name: Antibiotic therapy
label: c
answer: no
explanation: Reassurance is not appropriate management of cystic fibrosis.
name: Reassurance
label: e
answer: no
explanation: This child is suffering from cystic fibrosis, as indicated by the history of recurrent chest infections, short stature, and pancreatic insufficiency (causing steatorrhoea). Steroid therapy is not indicated in the management of pancreatic insufficiency in cystic fibrosis.
name: Prednisolone
label: b
answer: no
explanation: A gluten-free diet may be useful to manage coeliac disease but would not feature in cystic fibrosis management. Instead, a high-calorie, high-fat diet is recommended to treat pancreatic insufficiency, as well as pancreatic enzymes.
name: Gluten-free diet
label: d
answer: no

Correct answer: a
A 40-year-old female presents to General Practice with a 1 week history of vertigo that is worse on movement. She also complains of hearing loss. Examination reveals bilateral sensorineural hearing loss. She has no relevant past medical history but does report recently recovering from an upper respiratory tract infection.

Which of the following is the most likely diagnosis?

Options:
explanation: This is a presentation of viral labyrinthitis (inflammation of the membranous labyrinth of the inner ear). Labyrinthitis may present with vertigo, sensorineural hearing loss, tinnitus, and nausea. Viral labyrinthitis is classically preceded by a recent history of a viral illness. Labyrinthitis can be differentiated from vestibular neuronitis as the latter does not feature hearing loss.
name: Labyrinthitis
label: a
answer: yes
explanation: Acoustic neuromas are benign tumours of the vestibular portion of the vestibulocochlear nerve and typically manifest in the cerebellopontine angle. They can present with vertigo, unilateral sensorineural hearing loss, tinnitus, and even facial palsy if the facial nerve is compressed. An acoustic neuroma is less likely here as these tumours typically present with gradual onset of symptoms and hearing loss is unilateral, whereas this patient suffers from bilateral symptoms.
name: Acoustic neuroma (vestibular schwannoma)
label: c
answer: no
explanation: Another important vertigo differential, Meniere's disease is an idiopathic inner ear condition. It is characterized by repeat acute episodes of vertigo, hearing loss, tinnitus, and a sensation of ear fullness. This diagnosis cannot be made here as this is a single isolated episode of vertigo and hearing loss.
name: Meniere's disease
label: d
answer: no
explanation: Although this is an important differential, it is not the case here. Vestibular neuronitis is an inflammation of the vestibular portion of the vestibulocochlear nerve and presents with vertigo but not hearing loss. It may also feature a recent history of viral illness.
name: Vestibular neuronitis
label: b
answer: no
explanation: A common vestibular disorder but unlikely in this case. Benign paroxysmal positional vertigo (BPPV) is characterised by vertigo caused by head movement, however, does not feature hearing loss and is therefore unlikely to be involved here. Diagnosis can be confirmed by a positive Dix-Hallpike manoeuvre (recreation of symptoms and rotational nystagmus) and BPPV can be treated with the Epley manoeuvre.
name: Benign paroxysmal positional vertigo
label: e
answer: no

Correct answer: a
A 10-year-old boy presents with his father to General Practice. He has a 3-week history of left-sided hearing loss and has been experiencing unpleasant discharge from the left ear. On examination, you note malodorous, purulent discharge from the left ear which has not responded to antibiotics. Rinne's test is negative in the left ear and positive in the right ear. Weber's test lateralizes to the left ear. Otoscopy reveals crusting at the top of the left tympanic membrane.

Which of the following is the most likely diagnosis?

Options:
explanation: Also known as malignant otitis externa, this is an unlikely cause of this young boy's symptoms. Malignant otitis externa typically occurs in immunocompromised patients (most commonly in diabetics). It is characterised by severe ear pain, and purulent discharge, and may feature osteomyelitis of the temporal bone. It is not the most likely diagnosis due to the absence of immunosuppression and no ear pain in the history.
name: Benign necrotising otitis externa
label: c
answer: no
explanation: Chronic suppurative otitis media (CSOM) is a complication of unresolved acute otitis media with perforation of the tympanic membrane. Classically CSOM presents with persistent ear discharge and conductive hearing loss. Although an important differential, CSOM would not reveal a crusting cholesteatoma in the tympanic membrane attic.
name: Chronic suppurative otitis media
label: b
answer: no
explanation: A common ear condition but not the most likely one in this case. Otitis externa classically presents with otalgia, ear pruritis, and ear discharge. Hearing loss is possible but uncommon in otitis externa. Otoscopy typically reveals ear canal erythema and swelling. A cholesteatoma in the tympanic membrane attic would not be observed in otitis externa and hearing loss is uncommon in this condition.
name: Otitis externa
label: e
answer: no
explanation: Tympanosclerosis is scarring/calcification of the tympanic membrane. It presents with conductive hearing loss and calcification of the tympanic membrane is visualized on otoscopy. It is an unlikely diagnosis here due to the history of discharge and absence of tympanic membrane calcification.
name: Tympanosclerosis
label: d
answer: no
explanation: This young boy has a cholesteatoma, which is a benign accumulation of squamous epithelium and keratin within the middle ear or mastoid air cell spaces. Symptoms include purulent discharge from the external acoustic meatus and hearing loss and/or tinnitus from the affected ear. Examination may reveal conductive hearing loss and the otoscopy typically reveals a crust of keratin in the attic of the tympanic membrane.
name: Cholesteatoma
label: a
answer: yes

Correct answer: a
A 24-year-old female presents to General Practice after experiencing sudden onset hearing loss in her left ear over the last 24 hours. On examination, Rinne's test is positive in both ears and Weber's test lateralizes to the right side. Otoscopy is unremarkable. She has never experienced anything like this before and has no relevant past medical or family history.

Which of the following is the most appropriate next step?

Options:
explanation: NICE states that any adult experiencing a sudden-onset sensorineural hearing loss (SSNHL) manifesting over 3 days or less should be immediately (less than 24 hours) referred to ENT or the emergency department. This is because SSNHL carries a major risk of progressing to permanent deafness without prompt expert intervention. ENT typically treat with oral corticosteroids but these should not be prescribed in general practice for SSNHL.
name: Immediate referral to ENT
label: a
answer: yes
explanation: Due to the risk of permanent hearing loss if left untreated, SSNHL warrants an immediate referral (less than 24 hours). A routine referral is therefore incorrect due to the increased risk of permanent disability.
name: Routine referral to ENT
label: e
answer: no
explanation: Although oral corticosteroids form the basis of treatment for SSNHL, the setting is important in this question. In general practice, all cases of SSNHL should be urgently referred to the nearest emergency department or ENT department. SSNHL should only be treated by hospital specialists.
name: Prescribe an oral corticosteroid
label: b
answer: no
explanation: ENT may decide to perform audiology testing but a referral should be made to them first. Audiology testing should not be arranged by general practice in the case of SSNHL.
name: Arrange outpatient audiology testing
label: d
answer: no
explanation: This is incorrect. NSAIDs have no place in the management of SSNHL. In general practice, an immediate referral to ENT or ED should be made where the patient is likely to be managed with oral corticosteroids.
name: Prescribe a non-steroidal anti-inflammatory
label: c
answer: no

Correct answer: a
A 12-year-old female presents to the ENT clinic with a unilateral, left-sided neck swelling that has been slowly increasing in size over the past 10 days. On examination, there is a left-sided neck swelling lying anterior to the sternocleidomastoid muscle that does not move on swallowing. On palpation, you identify a 4cm well-circumscribed, soft, non-tender, smooth, and fluctuant swelling. Fine needle aspiration reveals acellular fluid with cholesterol crystals. Blood results are normal.

Which of the following is the most likely diagnosis?

Options:
explanation: A very important consideration in any neck swelling but in this case is highly unlikely to be malignant. The most likely malignant cause of lymphadenopathy in a 12-year-old would be acute lymphoblastic leukaemia (ALL). This is not the case here as the patient is otherwise asymptomatic and, most importantly, blood tests are normal. Furthermore, fine needle aspiration reveals acellular fluid with cholesterol crystals which would not be found in a malignant node.
name: Malignancy
label: e
answer: no
explanation: Branchial cleft cysts are common developmental defects of the branchial arches (most commonly the second branchial arch). They present in late childhood/adolescence and early adulthood and characteristically contain acellular fluid with cholesterol crystals.
name: Branchial cleft cyst
label: a
answer: yes
explanation: Another important "neck lump" differential, cervical lymphadenopathy is an important diagnosis to consider but this is not the case here. Cervical lymphadenopathy is characteristically firm and rubbery whereas this swelling is soft and fluctuant. Furthermore, an enlarged lymph node would not be acellular on fine needle aspiration.
name: Cervical lymphadenopathy
label: d
answer: no
explanation: A cystic hygroma is a type of lymphangioma that forms in children. This example is unlikely to be a cystic hygroma as these masses typically present in the first 2 years of life. Additionally, although they can manifest anywhere on the body, the posterior triangle (i.e. posterior to the sternocleidomastoid muscle) is the most common location, whereas this mass is located anterior to the SCM muscle.
name: Cystic hygroma
label: c
answer: no
explanation: Although an important differential, this case is not a thyroglossal cyst. Thyroglossal cysts classically move on swallowing whereas this mass does not. Furthermore, thyroglossal cysts are typically midline masses whereas this mass lies laterally, on the left side.
name: Thyroglossal cyst
label: b
answer: no

Correct answer: a
A 66-year-old man presents to the emergency department with painless complete vision loss in his right eye. This occurred spontaneously 2 hours ago and has not resolved. After further investigation, you diagnose central retinal vein occlusion.

Which of the following best describes fundoscopy findings in this condition?

Options:
explanation: These are the classical fundoscopy findings of central retinal artery occlusion. The retina is pale due to oedema from ischaemia and the cherry red spot represents the fovea, which remains red as it is the thinnest part of the retina and therefore is spared the oedematous whitening.
name: Pale retina and a central cherry-red spot
label: b
answer: no
explanation: Central retinal vein occlusion occurs when blood flow in the central retinal vein is obstructed, disrupting venous drainage of the eye. This results in congestion of blood within the retinal venous system which results in veins becoming dilated and tortuous. These veins can rupture, resulting in retinal haemorrhages.
name: Severe, widespread retinal haemorrhages and venous tortuosity
label: a
answer: yes
explanation: These findings are most associated with proliferative diabetic retinopathy. Microaneurysms are tiny aneurysms of the retinal capillaries. Dot and blot haemorrhages arise from bleeding capillaries. Cotton wool spots represent ischaemia of the retinal nerve fibres, which, in diabetic retinopathy, occurs due to vessel wall dysfunction. Proliferative diabetic retinopathy is defined by the formation of new vessels (neovascularisation) which occurs due to the increased retinal production of vascular endothelial growth factor, which is the retina's response to insufficient perfusion.
name: Microaneurysms, dot and blot haemorrhages, cotton wool spots, neovascularisation
label: d
answer: no
explanation: These findings would be most typical of dry age-related macular degeneration. Drusen are deposits of lipid and protein underneath the retina that occurs with age. Geographic atrophy represents the degeneration of the retina, which appears as localized, sharply demarcated atrophy on fundoscopy.
name: Drusen and geographic atrophy
label: e
answer: no
explanation: These fundoscopy findings would indicate hypertensive retinopathy. Arteriovenous nipping occurs due to the compression of veins at arteriovenous crossing sites. Flame haemorrhages represent bleeding in the superficial layer and occur as a result of vessel wall breakdown due to increased pressure. Cotton wool spots occur as a result of ischaemia of the nerve fibre layer.
name: Arteriovenous nipping, flame haemorrhages, cotton wool spots
label: c
answer: no

Correct answer: a
A 17-year-old male presents to the ENT clinic with a history of recurrent tonsillitis. He wants to know more about tonsillectomy and if this would be an option for him.

Which of the following is an indication for tonsillectomy?

Options:
explanation: NICE tonsillectomy guidelines indicate at least 7 episodes in 1 year are required to justify a tonsillectomy.
name: 5 episodes in 1 year
label: d
answer: no
explanation: NICE guidelines indicate that for a tonsillectomy to be indicated, the following criteria must be met: sore throats must be due to tonsillitis AND there have been 7 episodes in 1 year OR 5 episodes per year for 2 years OR 3 episodes per year for 3 years.
name: 5 episodes per year for 2 years
label: a
answer: yes
explanation: NICE guidelines on tonsillectomy indicate that 3 episodes per year for 3 years would be an indication for tonsillectomy, but 2 per year for 3 years does not meet the criteria for surgical intervention.
name: 2 episodes per year for 3 years
label: e
answer: no
explanation: Although NICE tonsillectomy criteria require recurrent episodes of tonsillitis, 3 episodes per year for 2 years is inadequate to justify surgical intervention. 5 episodes per year for 2 years would be an indication.
name: 3 episodes per year for 2 years
label: c
answer: no
explanation: This is incorrect. The first episode of tonsillitis is not an indication for tonsillectomy due to the risks of complications (including haemorrhage and pain). Therefore there must be a history of recurrent episodes of tonsillitis to justify surgery: 7 in 1 year, 5 per year for 2 years, or 3 per year for 3 years.
name: First episode of tonsillitis
label: b
answer: no

Correct answer: a