hllj/quesmed huggingface dataset:
A 68-year-old male presents to the respiratory clinic with symptoms of breathlessness and a persistent cough. He mentions that his breathlessness is usually apparent on exertion, but he does feel quite breathless at night as well. The patient has a past medical history of type 2 diabetes and hypercholesterolaemia, for which he takes metformin and atorvastatin respectively. He has a smoking history of 25 cigarettes per day for approximately 40 years.

Given the most likely diagnosis, what would be the most likely spirometry findings in this patient?

Options:
explanation: If the FEV1 is reduced and the FVC is increased, the FEV1:FVC ratio would be expected to be < 0.7, as opposed to > 0.7.
name: Reduced FEV1, increased FVC, FEV1:FVC ratio > 0.7
label: c
answer: no
explanation: The FEV1 is reduced in COPD due to inflammation of the airways, rather than being increased.
name: Increased FEV1, increased FVC, FEV1:FVC ratio < 0.7
label: e
answer: no
explanation: The FEV1 is reduced in COPD due to inflammation of the airways, resulting in a decreased FEV1:FVC ratio.
name: Increased FEV1, reduced FVC, FEV1:FVC ratio > 0.7
label: d
answer: no
explanation: This patient is presenting with signs and symptoms of chronic obstructive pulmonary disorder (COPD), as characterised by his extensive smoking history. As COPD is an obstructive respiratory condition, it results in a reduced forced expiratory volume (FEV1) as the airway inflammation allows less air to be exhaled in one second. However, the forced vital capacity (FVC) remains normal, which leads to a reduced FEV1:FVC ratio.
name: Reduced FEV1, normal FVC, FEV1:FVC ratio < 0.7
label: a
answer: yes
explanation: These spirometry results are more likely to be seen in restrictive respiratory conditions, as opposed to COPD.
name: Reduced FEV1, reduced FVC, FEV1:FVC ratio > 0.7
label: b
answer: no

Correct answer: a
A 50-year-old male presents to the respiratory clinic with symptoms of breathlessness and a persistent cough. His past medical history includes recurrent respiratory infections, but he takes no regular medications. He started smoking 10 cigarettes per day 2 years ago.

Spirometry is conducted for the patient and the results are shown below:

Forced expiratory volume (FEV1) pre-bronchodilator = 3.0 litres

Forced expiratory volume (FEV1) post-bronchodilator = 3.4 litres

Forced vital capacity = 4.8 litres

Initial FEV1:FVC ratio = 0.63

What is the most likely diagnosis?

Options:
explanation: Given the low FEV1 and reduced FEV1:FVC ratio, this patient is presenting with an obstructive lung disease picture. The history of recurrent respiratory infections and lack of extensive smoking history leads more towards a diagnosis of bronchiectasis. This is a condition in which the airways widen, leading to the accumulation of mucus which can result in breathlessness, cough and infections.
name: Bronchiectasis
label: a
answer: yes
explanation: Sarcoidosis is a restrictive lung disorder, as opposed to an obstructive lung disorder. It would therefore classically present with a FEV1:FVC ratio > 0.7.
name: Sarcoidosis
label: d
answer: no
explanation: Pulmonary fibrosis is a restrictive lung disorder, as opposed to an obstructive lung disorder. It would therefore classically present with a FEV1:FVC ratio > 0.7.
name: Pulmonary fibrosis
label: c
answer: no
explanation: COPD would typically present with a more extensive smoking history. Additionally, the spirometry results would not show the same level of reversibility after bronchodilator use in COPD.
name: Chronic obstructive pulmonary disorder (COPD)
label: b
answer: no
explanation: Asbestosis is a restrictive lung disorder, as opposed to an obstructive lung disorder. It would therefore classically present with a FEV1:FVC ratio > 0.7.
name: Asbestosis
label: e
answer: no

Correct answer: a
A 34-year-old male is found unconscious outside of the hospital. He has a normal pulse rate of 98 bpm but appears to be breathing very slowly (respiratory rate 6 breaths/minute). He is also noticed to have pinpoint pupils.

Given the most likely diagnosis, which treatment should be offered first-line to this patient?

Options:
explanation: Whilst hypoglycaemia may be a cause for collapse, the patient's bradypnea and pinpoint pupils are more suggestive of an opioid overdose.
name: Intramuscular glucagon
label: d
answer: no
explanation: Intravenous flumazenil is used to reverse benzodiazepine overdoses, rather than opioid overdoses.
name: Intravenous flumazenil
label: e
answer: no
explanation: Intramuscular adrenaline should be administered in patients presenting with signs of anaphylactic shock, as opposed to signs of opioid overdose.
name: Intramuscular adrenaline
label: c
answer: no
explanation: This patient is presenting with signs characteristic of an opioid overdose, especially given the bradypnea and pinpoint pupils. The definitive management for opioid toxicity is to administer intramuscular (or intranasal) naloxone to reverse the effects of the opiates.
name: Intramuscular naloxone
label: a
answer: yes
explanation: Intravenous atropine can be considered in patients presenting with severe bradycardia, as opposed to opioid overdoses.
name: Intravenous atropine
label: b
answer: no

Correct answer: a
An 84-year-old female is admitted to the hospital with signs and symptoms of sepsis. She has a past medical history of hypertension and hypercholesterolaemia for which she is taking amlodipine, candesartan and atorvastatin. She is started on IV 0.9% sodium chloride and IV gentamicin for sepsis. Two days after being admitted, the patient's serum creatinine rises from 82 micromol/l to 170 micromol/l (normal range 60-120 micromol/L). Her urine is examined under microscopy and is found to contain brown granular casts.


What is the most likely diagnosis?

Options:
explanation: Acute interstitial nephritis would typically present with a fever or a rash alongside signs of acute kidney injury. Additionally, brown granular casts are quite specific for acute tubular necrosis.
name: Acute interstitial nephritis
label: b
answer: no
explanation: Whilst renal artery stenosis may lead to pre-renal acute kidney injury, the presence of brown granular casts in the urine is more suggestive of acute tubular necrosis secondary to gentamicin use.
name: Renal artery stenosis
label: e
answer: no
explanation: Whilst ureteric obstruction may lead to post-renal acute kidney injury, the presence of brown granular casts in the urine is more suggestive of acute tubular necrosis secondary to gentamicin use.
name: Ureteric obstruction
label: d
answer: no
explanation: Acute glomerulonephritis would classically present with protein or blood in the urine alongside other signs of acute kidney injury (e.g. peripheral oedema). The presence of brown granular casts in the urine is more specific for acute tubular necrosis.
name: Acute glomerulonephritis
label: c
answer: no
explanation: This patient is presenting with signs characteristic of acute kidney injury, given the rise in serum creatinine over a short period of time. This is most likely to have been triggered by gentamicin, which can be nephrotoxic. The presence of brown granular casts in the urine indicates that this is most likely to be acute tubular necrosis, as opposed to other causes of acute kidney injury.
name: Acute tubular necrosis
label: a
answer: yes

Correct answer: a
A 76-year-old male is admitted to the hospital following a fractured neck of femur. He has a past medical history of osteoarthritis and hypercholesterolaemia for which he is taking ibuprofen and atorvastatin. Two days after being admitted, the patient's serum creatinine rises from 74 micromol/l to 165 micromol/l (normal range 60-120 micromol/l). He also develops peripheral oedema and is passing less urine than usual.


Which of the following management steps should be considered first?

Options:
explanation: Naproxen is another NSAID medication and could further impair this patient's renal function. It is better to stop ibuprofen entirely than to switch it to naproxen.
name: Switch ibuprofen to naproxen
label: d
answer: no
explanation: This patient is presenting with signs characteristic of an acute kidney injury (AKI), given the rise in serum creatinine over a short period of time, as well as the oliguria. One of the key steps in managing acute kidney injury is to stop any nephrotoxic medications. Non-steroidal anti-inflammatory agents like ibuprofen can contribute towards AKIs and should therefore be stopped in this patient.
name: Stop ibuprofen
label: a
answer: yes
explanation: Statins are less likely to be nephrotoxic and therefore are not usually stopped in acute kidney injury.
name: Stop atorvastatin
label: b
answer: no
explanation: Dialysis would be considered in refractory cases of acute kidney injury where other treatment options have failed. The first step in this scenario is to stop any nephrotoxic medications.
name: Start dialysis
label: c
answer: no
explanation: Statins are less likely to be nephrotoxic and therefore are not usually stopped in acute kidney injury.
name: Switch atorvastatin to ezetimibe
label: e
answer: no

Correct answer: a
A 77-year-old male presents to A&E with left-sided hemiparesis, left-sided facial paralysis and slurred speech which started 3 hours ago. He has a past medical history of hypertension and type 2 diabetes for which he is taking amlodipine and metformin. A CT scan is performed which reveals a region of hypodensity over the right frontal lobe.

Given the most likely diagnosis, which of the following treatment options is most likely to be considered?

Options:
explanation: This patient is presenting with signs characteristic of a right-sided ischaemic stroke, which is confirmed by the region of hypodensity present on the CT scan. If a patient presents within 4.5 hours of stroke symptom onset, IV alteplase should be started as soon as possible for thrombolysis, assuming there are no contraindications.
name: Intravenous alteplase
label: a
answer: yes
explanation: For ischaemic strokes, intravenous alteplase is the preferred agent for thrombolysis, rather than intravenous apixaban. Apixaban also only comes in oral form.
name: Intravenous apixaban
label: c
answer: no
explanation: Whilst a mechanical thrombectomy may be considered in patients presenting late with ischaemic stroke, this patient has presented within the 4.5-hour threshold and is therefore a candidate for IV alteplase thrombolysis first.
name: Mechanical thrombectomy
label: e
answer: no
explanation: For ischaemic strokes, intravenous alteplase is the preferred agent for thrombolysis, rather than intravenous warfarin.
name: Intravenous warfarin
label: b
answer: no
explanation: Blood pressure control is a part of the management of haemorrhagic strokes, as opposed to ischaemic strokes.
name: Intravenous bisoprolol
label: d
answer: no

Correct answer: a
A 5-year-old male child presents to A&E with a headache and neck stiffness. His temperature is measured to be 39.1 degrees Celsius.

Given the most likely diagnosis, which of the following organisms is most likely to be present?

Options:
explanation: *Listeria monocytogenes* commonly causes meningitis in infants aged between 0-3 months and occasionally in adults older than 60 years of age.
name: *Listeria monocytogenes*
label: d
answer: no
explanation: *Escherichia coli* typically causes meningitis in infants aged between 0-3 months, as opposed to children beyond the age of 1 year.
name: *Escherichia coli*
label: c
answer: no
explanation: This patient is presenting with signs and symptoms characteristic of meningitis, given the triad of fever, headache and neck stiffness. The most likely causative organism of meningitis between the ages of 3 months to 6 years is *Neisseria meningitidis*, which is a gram-negative diplococci bacterium.
name: *Neisseria meningitidis*
label: a
answer: yes
explanation: Although *Haemophilus influenzae* can lead to meningitis in children between 3 months and 1 year of age, *Neisseria meningitidis* is far more common in this age range.
name: *Haemophilus influenzae*
label: e
answer: no
explanation: *Group B streptococcus* is the most common cause of bacterial meningitis in neonates, rather than in children beyond the age of 1 year.
name: *Group B streptococcus*
label: b
answer: no

Correct answer: a
A 14-year-old male is assessed by an ambulance team. He has stridor, wheeze, and a widespread urticarial rash. His mother states that his symptoms started after he was stung by a wasp.

Given the most likely diagnosis, which treatment option should be offered first?

Options:
explanation: 100 micrograms of intramuscular adrenaline may be considered for anaphylaxis in individuals less than 6 months of age.
name: 100 micrograms of intramuscular adrenaline
label: d
answer: no
explanation: Intravenous adrenaline should only be considered if no improvement is seen after 2 doses of intramuscular adrenaline. Expert help should be sought before starting IV adrenaline infusions for anaphylaxis.
name: 250 micrograms of intravenous adrenaline
label: e
answer: no
explanation: This patient is presenting with signs and symptoms characteristic of anaphylaxis, as demonstrated by the stridor and urticarial rash which started shortly after an external stimulus. The first-line treatment for individuals above the age of 12 years with anaphylaxis is to administer 500 micrograms of intramuscular adrenaline, usually via an EpiPen. Adrenaline can be repeated every 5 minutes, but expert help should be sought if symptoms do not improve after 2 doses.
name: 500 micrograms of intramuscular adrenaline
label: a
answer: yes
explanation: 300 micrograms of intramuscular adrenaline would be the first-line treatment for anaphylaxis in individuals between 6-12 years of age.
name: 300 micrograms of intramuscular adrenaline
label: b
answer: no
explanation: 150 micrograms of intramuscular adrenaline would be the first-line treatment for anaphylaxis in individuals between 6 months and 6 years of age.
name: 150 micrograms of intramuscular adrenaline
label: c
answer: no

Correct answer: a
A 75-year-old male on the respiratory ward develops shortness of breath and fever. He was initially diagnosed with pneumonia and started on IV amoxicillin, but his symptoms are continuing to worsen.

The patient's observations are currently as follows: heart rate 112 bpm regular, blood pressure 88/54 mmHg, respiratory rate 26 breaths/minute, SpO2 94% on 15-litre oxygen, temperature 39.1 degrees Celsius.

Which type of shock does this patient have?

Options:
explanation: Hypovolaemic shock would typically present with a history of trauma or blood loss, as opposed to a worsening pneumonia.
name: Hypovolaemic shock
label: b
answer: no
explanation: Although anaphylactic shock is a type of distributive shock, it would typically present with sudden onset stridor, wheezing and an urticarial rash.
name: Anaphylactic shock
label: d
answer: no
explanation: This patient has signs and symptoms characteristic of sepsis, as demonstrated by the fever, hypotension and tachycardia. Sepsis is a form of distributive shock, whereby systemic vasodilation leads to inadequate tissue perfusion and associated end-organ damage.
name: Distributive shock
label: a
answer: yes
explanation: Although neurogenic shock is a type of distributive shock, it is usually secondary to a spinal cord transection. This would typically present with bradycardia and hypotension, rather than tachycardia.
name: Neurogenic shock
label: e
answer: no
explanation: Cardiogenic shock would typically present with a weak pulse, hypotension and tachypnea on a background of myocardial ischaemia.
name: Cardiogenic shock
label: c
answer: no

Correct answer: a
A 65-year-old male presents to General Practice with a painful swelling of the first metatarsophalangeal joint. The patient mentions that this started yesterday and has become very painful, limiting the movement of the joint. He has a past medical history of peptic ulcer disease but does not currently take any medication. He does not have any allergies.

Which of the following medications should be considered first in the acute management of this patient?

Options:
explanation: This patient is presenting with signs and symptoms characteristic of gout. Whilst both NSAIDs and colchicine may be considered first-line in gout, this patient has a history of peptic ulcer disease which could worsen through NSAID use. Therefore, colchicine should be trialled first.
name: Colchicine
label: a
answer: yes
explanation: Ibuprofen is an NSAID which could potentially cause/worsen peptic ulcers given the patient's history of peptic ulcer disease.
name: Ibuprofen
label: b
answer: no
explanation: Naproxen is an NSAID which could potentially cause/worsen peptic ulcers, given the patient's history of peptic ulcer disease.
name: Naproxen
label: c
answer: no
explanation: Although allopurinol is used as a urate-lowering therapy after gout, it should not be started until 2 weeks after an acute attack.
name: Allopurinol
label: d
answer: no
explanation: Oral steroids may be considered in patients with gout if NSAIDs and colchicine are both contraindicated. However, in this case, there are no contraindications to colchicine use.
name: Prednisolone
label: e
answer: no

Correct answer: a
A 28-year-old male presents to General Practice with worsening back pain and tiredness. His symptoms started a few months ago and appear to be worst in the morning, often improving with exercise.

Which of the following investigations should be considered first-line to confirm the most likely diagnosis?

Options:
explanation: Plain x-ray of the sacroiliac joints is the preferred method for diagnosing ankylosing spondylitis, as opposed to ultrasound scans which may not provide enough detail.
name: Ultrasound of sacroiliac joints
label: d
answer: no
explanation: MRI spine may be considered in patients with suspected ankylosing spondylitis who show no signs of the disease on plain x-ray of the sacroiliac joints.
name: MRI spine
label: c
answer: no
explanation: This patient is presenting with signs and symptoms characteristic of ankylosing spondylitis, given his back pain of insidious onset. A plain x-ray of the sacroiliac joints is the first imaging modality that should be performed to confirm the diagnosis. Signs of ankylosing spondylitis on x-ray include sacroiliitis, subchondral erosions, sclerosis, squaring of the lumbar vertebrae and syndesmophytes.
name: Plain x-ray of sacroiliac joints
label: a
answer: yes
explanation: According to NICE guidelines, there is currently no role for CT scans in the diagnosis of ankylosing spondylitis.
name: Non-contrast CT scan of sacroiliac joints
label: e
answer: no
explanation: According to NICE guidelines, there is currently no role for CT scans in the diagnosis of ankylosing spondylitis.
name: Contrast CT scan of sacroiliac joints
label: b
answer: no

Correct answer: a
A 57-year-old female presents to General Practice with swollen, painful joints in the fingers and wrists of both hands. She mentions that her symptoms started a few months ago, and are usually worst in the morning. There do not appear to be any skin changes around the affected joints.

What is the most likely diagnosis?

Options:
explanation: Sjogren's syndrome is an autoimmune disorder which is typically characterised by dry eyes and dry mouth.
name: Sjogren's syndrome
label: e
answer: no
explanation: Osteoarthritis usually affects large weight-bearing joints (hip/knee), as opposed to smaller joints in the hands. Additionally, osteoarthritis typically presents with unilateral symptoms which are worst at the end of the day.
name: Osteoarthritis
label: b
answer: no
explanation: Psoriatic arthritis typically presents with joint pain associated with skin changes and/or nail pitting.
name: Psoriatic arthritis
label: c
answer: no
explanation: This patient is presenting with signs and symptoms characteristic of rheumatoid arthritis, given the bilateral swelling of the small joints in her hands. Rheumatoid arthritis is an autoimmune disorder where autoantibodies (e.g. anti-cyclic citrullinated peptides) are produced against cells surrounding the joints.
name: Rheumatoid arthritis
label: a
answer: yes
explanation: Reactive arthritis usually involves joint pain which presents following an infection.
name: Reactive arthritis
label: d
answer: no

Correct answer: a
A 30-year-old female presents with generalised fatigue, recurrent mouth ulcers and joint pains. On examination, she is noted to have a red rash on her face which spares the nasolabial folds.

Which of the following investigations is most specific at confirming the most likely diagnosis?

Options:
explanation: Whilst ANA can be used to assist in the diagnosis of lupus, it has a high sensitivity, rather than a high specificity.
name: Anti-nuclear antibody (ANA)
label: b
answer: no
explanation: This patient is presenting with signs and symptoms characteristic of systemic lupus erythematosus (SLE), given the generalised systemic symptoms and the presence of a butterfly rash. One of the most specific investigations for SLE is the anti-dsDNA test which can be used to help confirm the diagnosis.
name: Anti-double-stranded DNA (anti-dsDNA)
label: a
answer: yes
explanation: ESR may be used as an inflammatory marker to monitor the progression of lupus. However, it is not used as a specific investigation to confirm the initial diagnosis.
name: Erythrocyte sedimentation rate (ESR)
label: e
answer: no
explanation: Whilst rheumatoid factor may be positive in lupus, it is not a very specific investigation for the condition.
name: Rheumatoid factor
label: c
answer: no
explanation: Anti-CCP is a specific investigation for the diagnosis of rheumatoid arthritis, as opposed to lupus.
name: Anti-cyclic citrullinated peptide (anti-CCP)
label: d
answer: no

Correct answer: a
A 64-year-old male presents to General Practice for a routine health check. As part of his routine investigations, a glycated haemoglobin (HbA1c) test is conducted and found to be elevated at 54 mmol/L (normal range 20-42 mmol/L). The patient is currently asymptomatic and does not have any other medical conditions.


What should be the next step in the management of this patient?

Options:
explanation: In asymptomatic patients with a raised HbA1c level, a repeat test should be conducted before commencing treatment.
name: Start metformin
label: b
answer: no
explanation: Although the patient is currently asymptomatic, a repeat HbA1c test is still warranted to check for the development of type 2 diabetes.
name: No further management required
label: c
answer: no
explanation: In asymptomatic patients with a raised HbA1c level, a repeat test should be conducted before commencing treatment.
name: Start sulfonylurea
label: d
answer: no
explanation: In asymptomatic patients with a raised HbA1c level, a repeat test should be conducted before commencing treatment. Additionally, insulin therapy is usually considered much later in the management of type 2 diabetes.
name: Start insulin
label: e
answer: no
explanation: This patient is presenting with a raised HbA1c level without any symptoms of diabetes. According to NICE guidelines, a repeat HbA1c test should be conducted in all patients with an incidentally raised HbA1c before commencing any treatment.
name: Repeat HbA1c test
label: a
answer: yes

Correct answer: a