hllj/quesmed huggingface dataset:
A 65-year-old woman with known stress incontinence presents to her GP after having completed 6 months of pelvic floor exercises and lifestyle changes without significant improvement of her incontinence. She reports good compliance with her pelvic floor exercises. She has no significant past medical history or drug allergies. She does not want any surgical treatment at this stage.

What is the next most appropriate management to offer her?

Options:
explanation: An oestrogen pessary can improve vaginal dryness in postmenopausal women. It will not help in the case of an overactive bladder.
name: Oestrogen pessary
label: c
answer: no
explanation: Duloxetine is a serotonin-noradrenaline reuptake inhibitor, which works by increasing urethral tone and reducing urinary leaks. It is indicated as a second-line option to surgery where surgery is not a possible treatment (ie. if the patient is not fit for, or does not want to have, surgery, as in this case). Common side effects include gastrointestinal disturbance and drowsiness. It is used with caution in the elderly and may reduce the seizure threshold.
name: Duloxetine
label: a
answer: yes
explanation: Mirabegron is a beta 3 agonist approved for use in overactive bladder, otherwise known as urge incontinence. It has been shown to have equal efficacy to tolterodine and solifenacin for urge incontinence. Its side effects include raised blood pressure and increased risk of urinary tract infection. This would not be a treatment for stress incontinence.
name: Mirabegron
label: d
answer: no
explanation: This patient has committed to pelvic floor exercises for 6 months without improvement of her symptoms. National Institute for Health and Care Excellence guidelines state that at least 3 months of pelvic floor exercises should be trialled and further treatments considered if this fails. Therefore, it would be inappropriate to ask her to complete another 6 months of pelvic floor exercises and she should now be considered for pharmacological or surgical management.
name: Further 6 months of pelvic floor exercises
label: b
answer: no
explanation: This patient does not want surgical management. Colposuspension is a surgical treatment for stress urinary incontinence, which involves securing the bladder neck with stitches, so that it does not drop down and cause urinary leakage.
name: Referral for colposuspension
label: e
answer: no

Correct answer: a


Learning point: Duloxetine is an effective second-line treatment for stress incontinence, enhancing urethral tone when conservative measures fail.
A 28-year-old woman presents to A&E with 3 d of fever, lower abdominal pain and deep dyspareunia. She tells you she has recently had treatment 1 month ago for *Chlamydia*,* but did not complete the course of antibiotics. She has had at least 7 sexual partners in the last 3 months and has not used any barrier methods of contraception. She has no other medical history and has no drug allergies. On examination, she is vomiting and unable to tolerate any oral intake. She has a fever of 38.9 °C.

Which of the following is the best treatment?

Options:
explanation: This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement.
name: Oral doxycycline and metronidazole (for 14 d)
label: c
answer: no
explanation: This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement.
name: Oral doxycycline (for 7 d)
label: e
answer: no
explanation: This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole, plus intravenous ceftriaxone until there is a clinical improvement.
name: IM ceftriaxone (single dose)
label: b
answer: no
explanation: This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis, but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement.
name: IV ceftriaxone (until improving clinically), oral doxycycline and metronidazole (for 14 d)
label: a
answer: yes
explanation: This patient is presenting with features of severe pelvic inflammatory disease. The severity is a clinical diagnosis but fever, signs of pelvic peritonitis or tubo-ovarian abscess usually confer severe disease. These patients require 14 d of doxycycline and metronidazole plus IV ceftriaxone until there is a clinical improvement. Intramuscular benzylpenicillin is used for suspected syphilis infection. This patient lacks symptoms of syphilis, such as a rash or genital ulcer.
name: IM benzylpenicillin (single dose), oral doxycycline and metronidazole (for 14 d)
label: d
answer: no

Correct answer: a


Learning point: Severe pelvic inflammatory disease requires intravenous ceftriaxone initially, followed by a 14-day course of doxycycline and metronidazole for complete treatment.
A 32-year-old man presents to the Neurology Clinic with impaired sensation over his neck and upper back. He says he cannot feel pain over this region when he pinches the skin, as well as weakness in his hands. On examination, he has a loss of pain and temperature sensation over his neck, back and upper shoulders. There is some clawing of his hands bilaterally with atrophy of the muscles of the forearm. Fine touch, proprioception and vibration are spared. There are no sensory or motor abnormalities of the lower limbs.

Where is the lesion responsible for his sensory symptoms?

Options:
explanation: The dorsal columns are responsible for fine touch, vibration and proprioception. The patient has no issues with these sensory modalities and so this is not responsible for his symptoms. Progression of the syrinx can, over time, impinge on the dorsal columns and cause deficiencies within these sensory modalities.
name: Dorsal columns
label: c
answer: no
explanation: This patient has evidence of corticospinal tract involvement since there is evidence of motor dysfunction with associated hand clawing. However, this would not explain his sensory symptoms, which is the question being asked.
name: Corticospinal tracts
label: b
answer: no
explanation: The description of loss of pain and temperature over the neck and back (in a cape-like distribution) and predominant upper-limb dysfunction with bilateral hand clawing fits with a diagnosis of syringomyelia. Syringomyelia is a fluid-filled cyst (syrinx) that forms within the centre of the spinal cord, initially compressing the decussation of the spinothalamic tract and leading to localised loss of pain and temperature sensation. Over time, it gets larger and can expand to multiple levels of the cord as well as other structures, such as the anterolateral corticospinal tracts, which this patient has evidence of due to the presence of motor symptoms, and the dorsal columns.
name: Spinothalamic tract
label: a
answer: yes
explanation: The motor cortex is a cerebral structure within the frontal lobe. A lesion in the motor cortex causes upper motor neurone pathology and spasticity (hyperreflexia, pyramidal distribution of weakness and a velocity-dependent increase in tone). Sensory involvement is spared. A lesion in the motor cortex will therefore not explain this patient's symptoms.
name: Motor cortex
label: d
answer: no
explanation: The somatosensory cortex is a cerebral structure within the parietal lobe. Depending on the precise location of the lesion in the somatosensory cortex, any sensory modality may be lost in the distribution as dictated by the sensory homunculus. However, sensory loss with cerebral lesions do not have such a defined pattern of presentation, with dorsal column sparing and a cape-like distribution. Loss of sensation in this pattern should raise clinical suspicion of a spinal lesion.
name: Somatosensory cortex
label: e
answer: no

Correct answer: a


Learning point: Syringomyelia causes a characteristic 'cape-like' distribution of pain and temperature loss due to compression of the spinothalamic tract in the spinal cord.
A 35-year-old female presents to the GP with a 6-month history of fatigue. During this time, she also describes feeling short of breath when running for the bus and recurrent episodes of tingling down her leg. On examination, she has swollen lymph nodes and crepitations on chest auscultation. She has a temperature of 37.7.

Which of the following is the next best investigation?

Options:
explanation: This scan can be requested later on by a specialist within the hospital setting. A CT chest is useful to further characterise how the sarcoidosis has affected the patient's lungs. This would be requested after a CXR, since starting with simple, least invasive/harmful investigations is most appropriate in the first instance.
name: CT chest
label: d
answer: no
explanation: Serum ACE levels are raised in sarcoidosis, however it would not be the next best investigation since ACE is neither specific to, nor diagnostic of, sarcoidosis.
name: Angiotensin-converting enzyme (ACE) levels
label: b
answer: no
explanation: This is a specialist investigation which would not be requested by the GP.  This investigation can be diagnostic for sarcoidosis, but it does not represent the next best investigation. Typically, you would find non-caseating granulomas on a biopsy.
name: Lung biopsy
label: e
answer: no
explanation: CRP can be raised in any infection or conditions that cause inflammation in the body. It is a non-specific marker which would not be helpful in determining the cause of this patient's symptoms, since it may be raised in conditions such as sarcoidosis,  but also other inflammatory conditions, including pneumonia.
name: C-reactive protein
label: c
answer: no
explanation: This patient has sarcoidosis which explains her long-term symptoms. In the early stages, a CXR may show evidence of bilateral hilar lymphadenopathy and fibrosis in the later stages. It can also rule out other causes of shortness of breath and crepitations, such as pneumonia.
name: Chest X-Ray
label: a
answer: yes

Correct answer: a


Learning point: Sarcoidosis commonly presents with fatigue, shortness of breath, and lymphadenopathy; a chest X-ray is essential for diagnosis and assessment.
A 65-year-old male undergoes an abdominal ultrasound scan as part of screening. His ultrasound report states that his abdominal aorta has a diameter of 3.3cm. He states that he currently has no symptoms, but he has a smoking history of 12 pack years.

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

Options:
explanation: This is because an abdominal aorta diameter of 3.3cm is considered to be small and so he would be offered annual ultrasound scans in this case. Note that all men in the UK are offered a one-off ultrasound scan at the age of 65 which determines the frequency of scanning if needed. Patients are usually asymptomatic unless the aneurysm has ruptured. Operative management is offered 5.5cm+. AAA's measuring 3-4.4cm are scanned every 12 months, and every 3 months between 4.5-5.4cm.
name: 12-monthly ultrasound scan
label: a
answer: yes
explanation: This is a common surgical option to repair large or rapidly expanding aneurysms. It involves the insertion of a stent within the abdominal aorta. However, this is not required for this patient as the AAA is only 3.3cm. The indication for repair is when the aneurysm is above 5.5cm or expanding >1cm each year.
name: Endovascular aneurysm repair (EVAR)
label: b
answer: no
explanation: This is incorrect because ultrasound scanning is only repeated every 3 months or yearly. This would not be an option for this patient.
name: 6-monthly ultrasound scan
label: e
answer: no
explanation: This would be required if the aneurysm is of medium size, between 4.5 to 5.4cm. However, this is not required for this patient as the AAA is only 3.3cm. The indication for repair is when the aneurysm is above 5.5cm or expanding >1cm each year.
name: 3-monthly ultrasound scan
label: c
answer: no
explanation: This would be indicated if the patient presented with a ruptured aneurysm, or as an elective procedure to repair large or rapidly expanding AAAs where anatomical considerations make EVAR's unsuitable. A ruptured AAA presents with shock and abdominal pain radiating to the back/back pain. This patient has no features of a ruptured AAA and he does not require repair at this stage due to the small size of the AAA. Open repair surgery is much more invasive than EVAR procedures, and some patients may not be fit enough for this procedure.
name: Open repair
label: d
answer: no

Correct answer: a


Learning point: An abdominal aortic aneurysm measuring 3.3cm requires annual ultrasound monitoring due to its small size and low risk of rupture.
A 23-year-old male presents to A&E with a 2 hour history of chest pain. He has no significant past medical history. He trains as a basketball player and has a smoking history of 7 pack years. On examination, he appears distressed and he is working hard to breathe. There is no evidence of tracheal deviation. His respiratory rate is 27, and his saturations are 98% on air.  A Chest X-ray shows 3cm rim of air between the lung and chest wall.

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

Options:
explanation: This is incorrect because needle decompression is required for a tension pneumothorax. The stem clearly states that there is no evidence of tracheal deviation and although he is slightly tachypnoeic, he is not unstable. This patient has a 3cm primary spontaneous pneumothorax. Aspiration should be tried in the first instance. Note that needles must be inserted just above ribs to avoid neurovascular damage.
name: Needle decompression in the left 2nd intercostal space, mid-clavicular line, below the third rib
label: e
answer: no
explanation: Although it is recommended to provide high flow oxygen to patients with pneumothoraces in order to facilitate lung re-expansion, the next best step is aspiration.  He is oxygenating well on air and at this stage, applying high flow oxygen is not a priority.
name: High flow oxygen
label: c
answer: no
explanation: This patient is presenting with a symptomatic, large (>2cm) primary spontaneous pneumothorax. Smoking is a known risk factor. As per the British Thoracic Society guidelines, the pneumothorax should be aspirated initially. If aspiration is successful, he can be discharged with follow up. If unsuccessful, a chest drain must be inserted.
name: Aspirate
label: a
answer: yes
explanation: This is incorrect because this patient has a primary spontaneous pneumothorax. A chest drain is indicated once an aspiration is performed and deemed unsuccessful. Patients with underlying respiratory conditions such as asthma or COPD are classed as having a secondary pneumothorax, and if they have additional high risk factors, can necessitate a chest drain without the need for aspiration in the first instance.
name: Chest drain
label: b
answer: no
explanation: This is incorrect because needle decompression is required for a tension pneumothorax. The stem clearly states that there is no evidence of tracheal deviation and although he is slightly tachypnoeic, he is not unstable. This patient has a 3cm primary spontaneous pneumothorax. Aspiration should be tried in the first instance. Note that needles must be inserted just above ribs to avoid neurovascular damage.
name: Needle decompression in the left 2nd intercostal space, mid-clavicular line, above the third rib
label: d
answer: no

Correct answer: a


Learning point: A primary spontaneous pneumothorax in young smokers often requires initial aspiration, especially if symptomatic and larger than 2cm.
A 74-year-old female presents to the memory clinic after referral by her GP. Her family report that her memory for recent events is worsening, and she is struggling to manage her finances, remember words, and recognise objects. Her childhood memories remain relatively preserved.

Given the most likely diagnosis, which of the following is the most likely pathological finding?

Options:
explanation: This is incorrect because this describes the finding in vascular dementia. Patients typically have a step-wise decline in function following a cerebrovascular event. They usually have cardiovascular risk factors such as hypertension, hypercholesterolaemia or diabetes.
name: Multiple infarcts with white matter damage
label: d
answer: no
explanation: This is incorrect because this describes the finding in normal pressure hydrocephalus. The classic symptoms for this condition can be remembered by wet, weird and wobbly: urinary incontinence, dementia, and recurrent falls. Note that this is a type of reversible dementia.
name: Enlarged ventricles
label: e
answer: no
explanation: This patient has Alzheimer's disease. Histopathology would demonstrate beta amyloid plaques and neurofibrillary tangles made of tau protein.
name: Amyloid plaques
label: a
answer: yes
explanation: Alpha-synuclein inclusions are found within the substantia nigra in Parkinson's disease and Lewy Body Dementia. These conditions are characterised by a typical triad of bradykinesia, rigidity and a resting tremor, which this patient does not have. Lewy Body Dementia is also classically associated with visual hallucinations, typically of Lilliputian bodies.
name: Alpha-synuclein
label: b
answer: no
explanation: This is incorrect because this describes the finding in frontotemporal dementia. Frontotemporal dementia typically affects patients who are younger than 65 years and causes changes in their behaviour and personality. Memory and visuospatial skills are relatively preserved.
name: Frontal and temporal lobe atrophy
label: c
answer: no

Correct answer: a


Learning point: Alzheimer's disease is characterised by the presence of amyloid plaques and neurofibrillary tangles in the brain.
A 15-year-old male presents to the GP with concerns regarding changes to his skin. He says this has occurred over the past year and he has used several over-the-counter facial washes which have not helped. On examination, there are widespread inflammatory papules and pustules, nodules, and scars on his face, neck, and shoulders. He is adamant that he wants to try a stronger medication.

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

Options:
explanation: This is incorrect because spironolactone is rarely used as a first-line treatment for acne vulgaris. It is also important to avoid prescribing this drug in males because it is an anti-androgen medication which works by reducing testosterone levels and can cause feminising side effects.
name: Spironolactone
label: d
answer: no
explanation: This is incorrect because this is the treatment for impetigo which is an infection typically caused by Staphylococcus aureus and usually affects infants. It presents with golden crusted lesions which this patient does not have. Impetigo is usually managed in primary care with oral antibiotics and topical fusidic acid.
name: Oral flucloxacillin and topical fusidic acid
label: c
answer: no
explanation: This is correct because this patient has severe acne vulgaris which is evident by the presence of widespread inflammatory lesions and scarring. This would be the best next step in management. Topical adapelene with topical benzoyl peroxide should be prescribed with an oral antibiotic such as lymecycline to prevent antibiotic resistance. Tetracyclines have anti-inflammatory effects, but note that these are contraindicated in pregnancy or breast-feeding which does not apply to this case.
name: Topical adapelene with topical benzoyl peroxide and oral lymecycline
label: a
answer: yes
explanation: This is incorrect because oral isotretinoin is prescribed for patients with severe acne vulgaris resistant to traditional topical and systemic antibiotic therapies. This patient has not tried topical medication or antibiotics yet. Although this patient wants stronger medication, isotretinoin is not prescribed within primary care due to its side effect profile. Some of these include deranged liver function, increased risk of suicide and depression, and teratogenicity.
name: Oral isotretinoin
label: e
answer: no
explanation: This is incorrect because this is the treatment for mild acne rosacea. In acne rosacea, patients typically present with papules, pustules and flushing of the nose, cheeks and forehead. It usually affects an older patient demographic and can present with telangiectasia. Topical metronidazole is not used for acne vulgaris.
name: Topical metronidazole
label: b
answer: no

Correct answer: a


Learning point: Acne can be effectively managed with a combination of topical adapalene, which is a retinoid that helps to clear blocked pores and reduce inflammation, topical benzoyl peroxide, which has antimicrobial and anti-inflammatory properties, and oral lymecycline, an antibiotic that reduces bacteria and inflammation.
A 40-year-old man presents to A&E with a headache and itchy, red eyes for the past 8 days. He works as a water engineer and spends a lot of time in the sewers. He has no significant past medical history. On examination, his eyes are red and his liver edge is palpable. He has a low-grade fever of 37.7. Blood tests show a mildly raised AST and ALT, low platelets, and a high urea and creatinine.

Which of the following is the most likely diagnosis?

Options:
explanation: This is incorrect because Cryptosporidium parvum typically presents with chronic watery, green diarrhoea in patients who are immunosuppressed (typically, those patients with HIV.)
name: Cryptosporidium parvum
label: e
answer: no
explanation: Leptospirosis is caused by Leptospira interrogans which can be transmitted by rats. Occupational exposure may occur through working in sewers. The key symptoms here are headache, fever, red eyes, deranged liver function tests, acute kidney injury, and reduced platelets. Note that patients with leptospirosis can also get diarrhoea, abdominal pain, and a rash. Liver and kidney failure may complicate its course.
name: Leptospirosis
label: a
answer: yes
explanation: This is incorrect because lead poisoning would present with abdominal pain, mood changes, motor neuropathy and memory loss. Lead poisoning can also cause a microcytic anaemia and Burton's lines in the gums which appear blue. This is a good differential as lead poisoning can also present with headaches and may relate to this patient's occupation. However, the presence of conjunctivitis, his deranged blood results, acute presentation, and occupation should point towards leptospirosis.
name: Lead poisoning
label: b
answer: no
explanation: This is incorrect because Bartonella henselae causes a condition known as Cat Scratch disease. This presents with painful local lymphadenopathy and fever. There is no mention of a cat scratch in this case.
name: Bartonella henselae
label: d
answer: no
explanation: This is incorrect because asbestosis presents with gradually worsening shortness of breath. Occupational exposure may occur in those who work in construction or on boilers.
name: Asbestosis
label: c
answer: no

Correct answer: a


Learning point: Leptospirosis, caused by Leptospira interrogans, presents with fever, headache, conjunctival suffusion, and can lead to liver and kidney dysfunction.