hllj/quesmed huggingface dataset:
A 55-year-old man presents to the general practice after being invited for their 5-yearly NHS health check. They are currently asymptomatic with no past medical history. Their examination and blood results are normal, besides a BMI of 32 and a HbA1c of 53 mmol/mol.

Which of the following investigations is most likely to confirm the diagnosis?

Options:
explanation: In asymptomatic patients, two separate readings are required for diagnosis. As this patient has only had one reading, they cannot be diagnosed with type 2 diabetes at this point, but they should have a follow-up reading to confirm the diagnosis
name: No further investigations needed to confirm diagnosis
label: b
answer: no
explanation: The diagnosis of type 2 diabetes depends on whether the patient is symptomatic or asymptomatic. For symptomatic patients, only one positive HbA1c, fasting glucose or random glucose is used for diagnosis. In asymptomatic patients, two separate readings are required for diagnosis. As this patient has only had one reading, they cannot be diagnosed with type 2 diabetes at this point, but they should have a follow-up reading to confirm the diagnosis
name: Repeat HbA1c
label: a
answer: yes
explanation: In asymptomatic patients, two separate readings are required for diagnosis. NICE CKS recommends the same modality that was used for the original test is used, meaning HbA1c is the most appropriate answer, as this is the test that was originally used
name: Fasting glucose
label: d
answer: no
explanation: In asymptomatic patients, two separate readings are required for diagnosis. NICE CKS recommends the same modality that was used for the original test is used, meaning HbA1c is the most appropriate answer, as this is the test that was used initially
name: Random glucose
label: e
answer: no
explanation: This patient is 55 years old; it is very unlikely they will be presenting with type 1 diabetes at this age. This test is not recommended to distinguish between type 1 and type 2 diabetes unless there is diagnostic uncertainty
name: C-peptide
label: c
answer: no

Correct answer: a
A 73-year-old woman presents to the general practice to ask about 'weak bones', as her mother fractured her hip around her age. She has not had a previous hip fracture, and her BMI is 26.7. A FRAX® score is performed, which stratifies this patient as intermediate risk for a major fracture in the next ten years.

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

Options:
explanation: Denosumab is a monoclonal antibody therapy that is used for the treatment of osteoporosis. Denosumab is used second line for osteoporosis, so would only be initiated if bisphosphonates were not tolerated or are contraindicated
name: Start denosumab therapy
label: e
answer: no
explanation: The FRAX® score is used to risk stratify a patient for the probability of a major osteoporotic fracture over the next ten years.
As this patient has intermediate risk, the next most appropriate step is to get a DEXA scan
name: Lifestyle advice
label: b
answer: no
explanation: The FRAX® score is used to risk stratify a patient for the probability of a major osteoporotic fracture over the next ten years.

As this patient has intermediate risk, the next most appropriate step is to get a DEXA scan. They may need to start bisphosphonate therapy based on the result of the DEXA scan, but a DEXA scan should be performed first
name: Start oral bisphosphonate therapy
label: c
answer: no
explanation: Dental checkups are recommended before and during bisphosphonate therapy. This is because of the risk of osteonecrosis of the jaw while taking bisphosphonate therapy. As this patient is intermediate risk, they should have a DEXA scan before bisphosphonates are considered. Therefore, a dental checkup is not the next best step in management as they may not need to start bisphosphonate therapy
name: Dental checkup
label: d
answer: no
explanation: The FRAX® score is used to risk stratify a patient for the probability of a major osteoporotic fracture over the next ten years. In accordance with National Osteoporosis Guideline Group (NOGG) 2017 guidelines, they are stratified into:

- Low risk - give reassurance and lifestyle advice, reassess within the next five years.
- Intermediate risk - perform a DEXA scan to guide management.
- High risk - start bisphosphonate therapy; no need to perform a DEXA scan first.

A DEXA scan is used to measure bone mineral density. A T score of <-2.5 is diagnostic for osteoporosis.
As this patient has intermediate risk, the next most appropriate step is to get a DEXA scan
name: Dual-energy x-ray absorptiometry
label: a
answer: yes

Correct answer: a
A 55-year-old patient comes to the GP to discuss his recent blood tests. His latest eGFR was 61 ml/min/1.73m2, with his previous eGFR two years prior being 68 ml/min/1.73m<sup>2</sup>. His urine dipstick is normal.

What is the most likely diagnosis?

Options:
explanation: Chronic kidney disease can only be diagnosed in someone with an eGFR ≤59 or in those with structural kidney disease. This patient has an eGFR of 61, a normal urine dipstick and no other evidence of any structural kidney disease. Therefore, they do not have chronic kidney disease
name: Chronic kidney disease stage 3b
label: e
answer: no
explanation: Chronic kidney disease (CKD) is diagnosed with a combination of estimated glomerular filtration rate (eGFR) readings and urine dipstick findings. eGFR is an estimation of the rate at which the kidneys filter the blood and is an approximation of how well the kidneys are functioning. The eGFR that determines chronic kidney disease depends on whether there is evidence of other structural damage, e.g. haematuria, proteinuria, imaging abnormalities or histological abnormalities. If there is structural damage present, CKD can be diagnosed at any eGFR, even in those greater than 90. If there is no structural damage, the eGFR must be ≤59 to diagnose a patient with CKD. In this patient, their eGFR was 61; they have a normal urine dipstick and no evidence of structural kidney disease. Therefore they do not have chronic kidney disease
name: No chronic kidney disease
label: a
answer: yes
explanation: Chronic kidney disease can only be diagnosed in someone with an eGFR ≤59 or in those with structural kidney disease. This patient has an eGFR of 61, a normal urine dipstick and no other evidence of any structural kidney disease. Therefore, they do not have chronic kidney disease
name: Chronic kidney disease stage 3a
label: b
answer: no
explanation: Chronic kidney disease can only be diagnosed in someone with an eGFR ≤59 or in those with structural kidney disease. This patient has an eGFR of 61, a normal urine dipstick and no other evidence of any structural kidney disease. Therefore, they do not have chronic kidney disease
name: Chronic kidney disease stage 2
label: c
answer: no
explanation: Chronic kidney disease can only be diagnosed in someone with an eGFR ≤59 or in those with structural kidney disease. This patient has an eGFR of 61, a normal urine dipstick and no other evidence of any structural kidney disease. Therefore, they do not have chronic kidney disease
name: Chronic kidney disease stage 1
label: d
answer: no

Correct answer: a
A 33-year-old female presents to their GP with a one-day history of left-sided back pain. This was preceded by a five-day history of dysuria and urinary frequency. On examination, her temperature is 38.7ºC, and there is suprapubic and renal-angle tenderness. Urine dipstick is positive for leukocyte esterase and nitrites.

What is the most likely diagnosis?

Options:
explanation: Renal calculi can present with back pain, which is typically "loin to groin". However, this patient has a fever, features of lower urinary tract infection (dysuria, frequency) and typical urine dipstick findings for urinary tract infection (leukocyte esterase and nitrites), which are not found in simple renal calculi. These features make an ascending urinary tract infection (pyelonephritis) more likely than renal calculus
name: Renal calculi
label: e
answer: no
explanation: Polycystic kidney disease is an autosomal dominant genetic disease leading to cyst formation on the kidneys, liver and pancreas. This can present with cyst rupture, which can cause back pain. However, this would usually be accompanied by haematuria. In addition, this would not explain the positive urine dipstick for nitrites and leukocyte esterase
name: Polycystic kidney disease
label: d
answer: no
explanation: There are some typical features of lower urinary tract infection in this question, including dysuria and urinary frequency. However, flank pain and fever are features that point towards a diagnosis of upper urinary tract infection, over a simple lower urinary tract infection
name: Lower urinary tract infection
label: b
answer: no
explanation: Renal cell carcinoma is an adenocarcinoma of the kidneys. Typical presenting features include haematuria, pain or mass in the flank and manifestations of metastatic disease. It is unlikely that a patient with renal cell carcinoma would develop symptoms this rapidly, combined with a clinical urinary tract infection
name: Renal cell carcinoma
label: c
answer: no
explanation: Pyelonephritis, also known as an upper urinary tract infection, is an ascending urinary tract infection that affects the kidneys. This is typically caused by E. coli and presents with fever, rigors and flank pain. They may also have signs of lower urinary tract infection (e.g. dysuria, frequency), but the presence of flank pain and/or fever are good differentiators between upper and lower urinary tract infection. Urine dipstick, bloods and midstream urine sample are typical investigations for pyelonephritis, with renal ultrasound scan considered if there is a risk of renal stones causing the infection (pyonephrosis). This condition is generally treated in an inpatient setting with broad-spectrum IV antibiotics
name: Pyelonephritis
label: a
answer: yes

Correct answer: a
A 45-year-old presents to the emergency department with a red, hot and swollen left leg. They have recently travelled back to the UK from Australia. On examination, their pulse is 88/min, and they are apyrexial. Their left lower leg is erythematous to the knee, there is pain on palpation of the leg, pitting oedema, and the left leg is 3.4cm larger than the right.

Which of the following is the next best investigation?

Options:
explanation: This patient presents with a typical history of deep vein thrombosis (DVT): a red, hot, swollen calf in the presence of risk factors for venous thrombosis (in this case, long haul flight). The next thing to do in the evaluation of this patient would be a Wells' 2-level DVT score. This patient's Wells' score is 3 points, scoring for: calf swelling >3cm, localised tenderness along the deep venous system and pitting oedema confined to the symptomatic leg. A Wells' score of ≥2 means the patient should have a doppler ultrasound scan of the entire leg to identify any thrombi or emboli in the venous system to confirm the diagnosis. As this patient has a Wells' score of 3, this should be the first investigation
name: Proximal leg vein ultrasound scan
label: a
answer: yes
explanation: Echocardiograms can be used to look for right heart strain associated with a pulmonary embolism, especially in massive pulmonary embolism. However, this patient does not have any signs of pulmonary embolism, so does not need an echocardiogram
name: Echocardiogram
label: e
answer: no
explanation: V/Q scan is used to diagnose PE in patients with symptoms of PE who are unable to have a CTPA. This patient has no features of PE
name: V/Q scan
label: d
answer: no
explanation: This patient presents with a history typical of deep vein thrombosis, and their Wells' score is 3. In patients with a Wells' score of ≥2, a doppler ultrasound should be performed first line. If their Wells' score was ≤1, then a d-dimer should be performed. D-dimer has a high sensitivity but low specificity for DVT. This makes it a good rule-out test, but it cannot confirm a DVT. A raised d-dimer can have many causes, including malignancy, infection, pregnancy and stroke
name: D-dimer test
label: b
answer: no
explanation: Deep vein thrombosis (DVT) is associated with pulmonary embolism, as the original clot in the leg can embolise and travel through the systemic vasculature, through the heart and into the pulmonary arteries. However, there are no features suggestive of pulmonary embolism in this case, including no history of breathlessness, chest pain or haemoptysis. A percentage of patients with DVT will have a silent PE, but asymptomatic patients should not receive a CT pulmonary angiography scan to diagnose a silent pulmonary embolism
name: CT pulmonary angiography
label: c
answer: no

Correct answer: a
A 67 year old man presents to the GP complaining of tiredness. Physical examination shows no abnormalities. He drinks 40 units of alcohol per week. He has some blood tests, which are shown below:

||||
|--------------|:-------:|---------------|
|Haemoglobin|115    g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|4.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|200x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|66 fL|80 - 96|
|Ferritin|56 μg/L|12 - 200|
|Serum Vitamin B12|800 ng/L|160 - 925|
|Serum Folate|8 μg/L|(3 - 15|


He had no abnormalities on his previous full blood count and haematinics, which were taken two years ago.


Which of the following is the most likely cause of this patient's blood results?

Options:
explanation: Alcohol abuse can cause a macrocytosis. This patient is drinking above the recommended weekly limit for alcohol consumption; however, he presents with a microcytic anaemia, making alcohol an unlikely cause for his anaemia
name: Alcoholism
label: e
answer: no
explanation: This patient is presenting with a microcytic anaemia. The most common cause of microcytic anaemia is iron-deficiency anaemia. In any patient >60 years old presenting with iron deficiency anaemia, they must be referred as an urgent 2-week wait referral for colonoscopy for colorectal cancer, unless their history suggests an alternative, more likely diagnosis. This patient may have a falsely normal ferritin, as ferritin is an acute phase reactant, elevated in inflammatory states such as infection or malignancy
name: Colorectal cancer
label: a
answer: yes
explanation: Thalassaemia is a haemoglobinopathy related to faulty production of haemoglobin. This becomes apparent a few months after birth when the body stops producing foetal haemoglobin (HbF). This can present as a microcytic anaemia; however, this patient has previously had a normal full blood count, making thalassaemia highly unlikely
name: Thalassaemia
label: b
answer: no
explanation: Megaloblastic anaemia is a macrocytic anaemia caused by folate or vitamin B12 deficiency. This patient is presenting with microcytic anaemia, making megaloblastic anaemia unlikely
name: Megaloblastic anaemia
label: d
answer: no
explanation: Autoimmune haemolytic anaemia (AIHA) usually presents as a normocytic or macrocytic anaemia. This patient is presenting with a microcytic anaemia, making AIHA unlikely
name: Autoimmune haemolytic anaemia
label: c
answer: no

Correct answer: a
A 33 year old patient presents to the GP with a four-month history tiredness and a one-month history of pins and needles in their legs. They have a past medical history of type 1 diabetes and hypothyroidism. They drink 6 units of alcohol per week. Their blood results are shown below:


||||
|--------------|:-------:|---------------|
|Haemoglobin|105  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|7x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|303x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|105 fL|80 - 96|
|HbA1c (Glycated Haemoglobin)|47 mmol/mol|20 - 42 or 4-6%|
|Thyroid Stimulating Hormone|3.6 mU/L|0.3 - 4.2|
|Free T4|14 pmol/L|9 - 25|


Which of the following is the most likely cause of this patient's blood results?

Options:
explanation: Alcoholism is a cause of macrocytosis. It can also be associated with alcoholic neuropathy. However, this patient reports only drinking four units a week, which is within the recommended weekly intake for alcohol. Patients are not always honest about their alcohol intake, but given their history of autoimmune disease and current neurological signs, vitamin B12 deficiency secondary to pernicious anaemia is the more likely diagnosis
name: Alcoholism
label: c
answer: no
explanation: Hypothyroidism can cause macrocytosis. This patient has hypothyroidism; however, their thyroid function tests are normal. As their thyroid disease is well controlled, it is unlikely that this is causing their macrocytosis. In addition, autoimmune hypothyroidism (the most common cause of hypothyroidism in the UK) is associated with other autoimmune diseases, including pernicious anaemia. Hypothyroidism is unlikely to cause this patient's neurological signs
name: Hypothyroidism
label: b
answer: no
explanation: Pernicious anaemia is an autoimmune condition with antibodies targeting intrinsic factor and/or gastric parietal cells. Intrinsic factor is a cofactor produced by gastric parietal cells essential for the absorption of vitamin B12 in the terminal ileum. Therefore, pernicious anaemia can cause a vitamin B12 deficiency. This presents as a macrocytic anaemia with other signs of anaemia, including tiredness and pallor. In addition, B12 deficiency can cause neurological symptoms including paraesthesia, weakness and acute degeneration of the cord in severe cases. As pernicious anaemia is an autoimmune condition, it is associated with other autoimmune disorders, including type 1 diabetes and autoimmune thyroid disorders
name: Pernicious anaemia
label: a
answer: yes
explanation: Type 1 diabetes is associated with diabetic neuropathy and can cause tiredness when the patient is hyperglycemic. However, this patient's type 1 diabetes is well controlled (HbA1c <48 mmol/mol), and this would not explain the macrocytosis in his blood results. Therefore, vitamin B12 deficiency secondary to pernicious anaemia is the more likely diagnosis
name: Diabetic neuropathy
label: e
answer: no
explanation: Iron deficiency anaemia presents with a microcytic anaemia. This patient has a macrocytic anaemia, making iron deficiency anaemia less likely
name: Iron deficiency anaemia
label: d
answer: no

Correct answer: a
A 23-year-old female is receiving a blood transfusion in the respiratory ward. After 10 minutes, she reports that she feels cold. Her observations are as follows: heart rate 70/min, blood pressure 123/81 mmHg, respiratory rate 13/min, oxygen saturations 97% and temperature 38.6ºC.

What is the most likely diagnosis?

Options:
explanation: Transfusion-associated circulatory overload presents with features of fluid overload, e.g. peripheral oedema, coarse inspiratory crackles on auscultation. This patient is well and not presenting with any examination or auscultation findings, so it is unlikely to be transfusion-related circulatory overload
name: Transfusion-associated circulatory overload
label: e
answer: no
explanation: Anaphylaxis typically presents with angiooedema, urticaria, stridor, wheeze and hypotension. This patient is very well, so this is unlikely to be anaphylaxis
name: Anaphylaxis
label: c
answer: no
explanation: Transfusion-related acute lung injury typically presents with signs of pulmonary oedema, e.g. coarse inspiratory crackles on auscultation. This patient is well and not presenting with auscultation findings, so it is unlikely to be transfusion-related acute lung injury
name: Transfusion-related acute lung injury
label: d
answer: no
explanation: Febrile non-haemolytic transfusion reaction typically presents with fever (with or without chills and rigors) only, with otherwise normal observations. This is the case with this patient. Typical management would be to stop transfusion, give paracetamol and reintroduce the transfusion at a slower rate
name: Febrile non-haemolytic transfusion reaction
label: a
answer: yes
explanation: Acute haemolytic transfusion reaction typically presents with other symptoms, e.g. hypotension, back pain, disseminated intravascular coagulation. This typically occurs as a result of ABO incompatibility. This patient is very well, so this is unlikely to be an acute haemolytic transfusion reaction
name: Acute haemolytic transfusion reaction
label: b
answer: no

Correct answer: a
An 88-year-old female presents to the emergency department, where she is diagnosed and treated for a neck of femur fracture and admitted to the orthopaedic ward. The next day, she does not engage with the medical staff and seems withdrawn and distractible. She does not know where she is and has not eaten her food as she thinks it has been poisoned.

What is the most likely diagnosis?

Options:
explanation: Paranoid schizophrenia is a psychiatric disorder associated with paranoid delusions and auditory hallucinations. It is more common in patients between 20-30 years old (some female patients may also present in their 40s). This condition does not develop overnight, so there would likely be some mention of these symptoms when initially presenting to the emergency department. Although they have paranoid delusions, there is no evidence of any auditory hallucinations
name: Paranoid schizophrenia
label: e
answer: no
explanation: Delirium tremens is a condition associated with acute withdrawal from alcohol in an alcohol-dependent person. This typically occurs 72 hours after alcohol cessation and presents with confusion, agitation, cravings, visual hallucinations and tremor. This patient is presenting too early for this (assuming their last drink would be just before admission), and they do not have any tremor or visual hallucinations
name: Delirium tremens
label: d
answer: no
explanation: Alzheimer's disease generally presents with a long history of cognitive decline. This patient presents with an acute onset of disorientation, behavioural change and delusions after a hip fracture. This is not typical for dementia, making delirium the more appropriate diagnosis. Dementia is, however, a risk factor for delirium and having delirium in the past increases a patient's risk of developing dementia
name: Alzheimer's disease
label: b
answer: no
explanation: Delirium is an acute confusional state with a variety of causes. The two most significant risk factors are trauma/severe illness and being elderly, both present in this case. This woman is presenting with hypoactive delirium, as she is withdrawn. In addition, she is presenting with distractibility and disorientation, which are other characteristic features of delirium. Patients with delirium may also present with persecutory delusions, as in this case. This patient should be managed conservatively initially by reorientating them to the environment and addressing reversible causes, e.g. pain management, eating and drinking, urinary retention and constipation, managing infection and reviewing medications
name: Delirium
label: a
answer: yes
explanation: Vascular dementia generally presents with a long history of stepwise cognitive decline. This patient presents with an acute onset of disorientation, behavioural change and delusions after a hip fracture. This is not typical for dementia, making delirium the more appropriate diagnosis. Dementia is, however, a risk factor for developing delirium
name: Vascular dementia
label: c
answer: no

Correct answer: a