hllj/quesmed huggingface dataset:
A 67-year-old woman with a history of advanced breast cancer presents to the oncology clinic for her follow-up appointment. She has been receiving palliative chemotherapy for the past nine months and reports having significant symptom control. Her past medical history is significant for diabetes and obesity.

On physical examination, the patient appears tired and anxious. She is able to speak in short sentences and is short of breath with any activity. She has difficulty with personal hygiene and requires assistance with dressing. She is unable to prepare meals or walk around her house and is confined to bed. You are writing a letter to her oncologist and want to include her WHO Performance Status.

What is the patient's WHO Performance Status?

Options:
explanation: This would correspond to a patient who is fully active, able to carry out all pre-disease performance without restriction. This does not match the description of the patient, as she is confined to bed, unable to perform any self-care activities or walk around her house, and requires assistance with dressing.
name: Status 0
label: e
answer: no
explanation: This would correspond to a patient who is able to walk and do light work, but is unable to do heavy work. This does not match the description of the patient, as she is unable to perform any self-care activities or walk around her house and is confined to bed.
name: Status 1
label: d
answer: no
explanation: This would correspond to a patient who is restricted in self-care and is unable to carry out any work activities. This does not match the description of the patient, as she is confined to bed, unable to perform any self-care activities or walk around her house, and requires assistance with dressing.
name: Status 3
label: b
answer: no
explanation: This would correspond to a patient who is restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature. This does not match the description of the patient, as she is confined to bed, unable to perform any self-care activities or walk around her house, and requires assistance with dressing.
name: Status 2
label: c
answer: no
explanation: The patient is confined to bed, unable to perform any self-care activities or walk around her house, and requires assistance with dressing. This corresponds to a WHO Performance Status of 4 (completely disabled, bedridden, and requiring active nursing care).
name: Status 4
label: a
answer: yes

Correct answer: a
Which of the following best describes the main mechanism of action of macrogol (polyethylene glycol) laxatives?

Options:
explanation: Correct. This is the mechanism of action of osmotic laxatives such as macrogols (e.g. MOVICOL) or lactulose.
name: Causes increased water retention in the lumen of the large bowel. This can in turn lead to distention which can stimulate peristalsis
label: a
answer: yes
explanation: This describes the mechanism of action of stimulant laxatives such as Senna.
name: Stimulation of colonic nerves to cause peristalsis
label: b
answer: no
explanation: This is the mechanism of action of Docusate, often described as a stool-softener
name: It acts as a surfactant, which causes reduction in surface tension and allows fat and water into the faeces to soften the stool
label: c
answer: no
explanation: This is the mechanism of action of Prucalopride
name: By stimulation of serotonin (5HT4) receptors, which stimulates intestinal motility
label: d
answer: no
explanation: This is the mechanism of action of bulk-forming laxatives such as isphagula husk
name: It increases the soluable fibre content of the stool thereby increasing water and stool mass in the bowel lumen. This in turn stimulates peristalsis
label: e
answer: no

Correct answer: a
A 67 year old female with pure stress urinary incontinence has gained no benefit from conservative management of this condition. She does not want any form of surgical management.

Assuming there are no contra-indications, which of the following pharmacological agent may be offered?

Options:
explanation: This is an anti-muscarinic agent which is used in the treatment of urge incontinence or overactive bladder.
name: Tolterodine
label: d
answer: no
explanation: This is an analogue of ADH (vasopressin) used to treat nocturia. It acts on the V2 receptors in the renal collecting ducts to cause re-absorption of water into the blood via aquaporin channels. This leads to reduced urine production.
name: Desmopressin
label: e
answer: no
explanation: This is an anti-muscarinic agent which is used in the treatment of urge incontinence or overactive bladder.
name: Oxybutynyn
label: c
answer: no
explanation: This is a sympathomimetic beta-3 adrenergic receptor agonist which relaxes the smooth muscle of the bladder. It is used to treat overactive bladder and urge incontinence.
name: Mirabegron
label: b
answer: no
explanation: Correct. Duloxetine is a serotonin and noradrenaline re-uptake inhibitor. Its central nervous system effects lead to increased tone of the  external urinary sphincter, thereby acting to reduce stress incontinence.
name: Duloxetine
label: a
answer: yes

Correct answer: a
Which of the following best describes the mechanism of action of oxybutynin in treatment of urge incontinence?

Options:
explanation: Oxybutynin inhibits muscarinic stimulation.
name: Stimulation of nicotinic receptors in the smooth muscle of the bladder
label: e
answer: no
explanation: Stimulation of muscarinic receptors would stimulate bladder contraction. Oxybutynin acts to inhibit muscarinic activity.
name: Stimulation of muscarinic receptors in  the smooth muscle of the bladder
label: c
answer: no
explanation: Correct. Normal bladder voiding is caused by activation of parasympathetic muscarinic receptors in the detrusor smooth muscle. Therefore anti-muscarinic agents can be used to to inhibit this process in cases of overactive bladder.
name: Inhibition of muscarinic receptors in  the smooth muscle of the bladder
label: a
answer: yes
explanation: Anti-cholinergics used in overactive baldder act at the muscarinic receptor.
name: Inhibition of nicotinic receptors in the smooth muscle of the bladder
label: b
answer: no
explanation: This is the mechanism of action of Mirabegron, which is not an anti-cholinergic agent.
name: Stimulation of beta-3 adrenergic receptors in the smooth muscle of the bladder
label: d
answer: no

Correct answer: a
A 76 year old male presents to the emergency department after multiple falls. He has a past medical history of irritable bowel syndrome, heart failure, chronic obstructive pulmonary disease and benign prostatic hypertrophy. His heart rate is 76bpm, and his blood pressure is 146/82 on lying and 124/79 upon standing (at 3 minutes). He is euvolaemic on examination.

Which of the following medication is most likely to be responsible for this presentation?

Options:
explanation: Aspirin is a COX-1 and COX-2 inhibitor. It does not commonly cause postural hypotension.
name: Aspirin 75mg
label: c
answer: no
explanation: Fludrocortisone is a mineralocorticoid which is sometimes used to boost blood pressure.
name: Fludrocortisone 50 micrograms
label: b
answer: no
explanation: Correct. Tamsulosin is an alpha adrenoceptor blocker. It therefore impairs reactive vasocontriction in response to a drop in blood pressure.
name: Tamsulosin 400micrograms
label: a
answer: yes
explanation: Prednisolone is a steroid which would not cause postural hypotension. Steroids may improve postural hypotension if the cause is mineralocorticoid deficiency (adrenal insufficiency).
name: Prednisolone 30mg OD
label: d
answer: no
explanation: This is an anti-spasmodic agent commonly used in treatment of irritable bowel syndrome. It would not commonly cause postural drop.
name: Hyoscine Butylbromide 20mg TDS
label: e
answer: no

Correct answer: a
A 67 year old male is suffering from worsening stable angina. The next step in management is to commence Isosorbide mononitrate.

Which of the following medications constitutes a severe interaction with isosorbide mononitrate (ISMN)?

Options:
explanation: These are both nitrates and therefore concurrent use would increase risk of side effects including hypotension, howvever GTN is often required for acute angina attacks; there is no contraindication.
name: Glyceryl Trinitrate (GTN)
label: b
answer: no
explanation: Sertraline is a serotonin reuptake inhibitor and does not interact with ISMN.
name: Sertraline
label: d
answer: no
explanation: Diltiazem is a calcium channel blocker. Concurrent use can increase risk of hypotension but is not a severe interaction.
name: Diltiazem
label: e
answer: no
explanation: Concurrent use increases the risk of hypotension and represents a severe interaction and manufacturer advises to avoid co-prescribing.
name: Sildenafil
label: a
answer: yes
explanation: Bisoprolol is a beta-blocker commonly used alongside ISMN in treatment of ischaemic heart disease. Concurrent use can increase risk of hypotension but is not a severe interaction and can usually be continued.
name: Bisoprolol
label: c
answer: no

Correct answer: a
A 65 year old female with pancreatic cancer is reviewed by the palliative care team. She currently takes 45mg of modified release morphine twice daily, with no other opioids currently prescribed. It is agreed that some additional analgaesia should be prescribed as required for acute episodes of pain during the day.

She has normal renal function.

Which of the following would be an appropriate additional morphine prescription in this case?

Options:
explanation: Although close to the calculated 15mg, dosing should align with standard prescribing practices, and 15mg is the more appropriate, rounded dose.
name: 14mg immediate release oral morphine
label: e
answer: no
explanation: While closer to 1/6th of the individual dose (45mg), it is not calculated based on the total daily dose (90mg), which is the correct basis for breakthrough dosing.
name: 6.6mg immediate-release oral morphine
label: c
answer: no
explanation: An appropriate breakthrough dose is 1/6th to 1/10th of the total daily dose of morphine. In this case she takes total 90mg/day, so 1/6th dose is 15mg of morphine for rapid analgesia control. 
name: 15mg immediate-release oral morphine
label: a
answer: yes
explanation: This dose is too low to provide effective breakthrough analgesia for a patient on a daily morphine dose of 90mg. It would likely be insufficient to manage acute pain episodes.
name: 4mg immediate-release oral morphine
label: b
answer: no
explanation: Modified-release morphine is inappropriate for breakthrough pain due to its delayed onset of action. Immediate-release formulations are preferred for rapid pain relief.
name: 13mg modified-release oral morphine
label: d
answer: no

Correct answer: a
Which of the following is a common early non-motor symptom of Parkinson's Disease (PD)?

Options:
explanation: Storage symptoms such as urinary urgency, frequency and nocturia are more commonly associated with PD
name: Acute Urinary retention???
label: d
answer: no
explanation: Freezing is a mid to late motor sign commonly experienced by people with PD, when they find they are transiently unable to move.
name: 'Freezing'
label: e
answer: no
explanation: Constipation is more commonly seen in PD, due to autonomic dysfunction and slowing of peristalsis.
name: Diarrhoea
label: b
answer: no
explanation: Depression, apathy and anxiety are common symptoms of PD
name: Hypo-mania
label: c
answer: no
explanation: Reduction in sense of smell is a common non-motor symptom of PD that often precedes motor symptom onset.
name: Anosmia
label: a
answer: yes

Correct answer: a
An 80 year old female is brought into hospital by her neighbour, who discovered she has been self-neglecting at home. She has had a poor diet for several months, related to Alzheimer's dementia and poor mobility.
Today, she is 167cm tall, 52kg. Her previous recorded weight was 60kg 5 months ago.
BMI = 18.6
She is otherwise well and happily accepts lunch on the ward.


 **STEP 1: BMI score**
 - Greater than 20kg/m2= 0 points
 - 18.5 - 20kg/m2 = +1 point
 - <18.5kg/m2 = +2 points


N.B. BMI = weight (kg)/(height)^2 (m)


 **STEP 2: Unintentional weight loss score**


 - <5% = 0 points
 - 5-10% = +1 point
 - Greater than 10% = +2 points


 **STEP 3: Patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days**
 - No = 0 points
 - Yes = +2 points


Total MUST score:
 - Low risk = 0
 - Medium Risk = 1
 - High risk  = 2+


Based on this patient's MUST score, which of the following represents the best nutritional management plan?

Options:
explanation: This patient is at high risk of malnutrition and action should be taken.
name: No action required
label: e
answer: no
explanation: 1. BMI 18.6 = +1
 2. Weight loss >10% = +2
 3. No = 0
 4. Total = 3 points = high risk
name: Refer to dietician, increase and document overall nutritional intake. Monitor and review care plan at least weekly
label: a
answer: yes
explanation: This is an appropriate plan for someone at 'Medium risk'.
name: Refer to dietician. Increase and document overall nutritional intake. Monitor and review care plan at least weekly. Refer to eating disorder service
label: d
answer: no
explanation: This is an appropriate plan for someone at 'Low risk'.
name: Routine repeat screening
label: c
answer: no
explanation: This is an appropriate plan for someone at 'Medium risk'.
name: Formally document dietary intake for 3 days if patient in hospital or care home
label: b
answer: no

Correct answer: a

Refer to dietician, increase and document overall nutritional intake. Monitor and review care plan at least weekly
A 92 year old female is admitted after feeling generally unwell, with a one day history of left iliac fossa pain and bloody diarrhoea. A computed topography (CT) scan of her abdomen shows evidence of acute diverticulitis. However, it also shows a thickening of the ascending colon which is highly suspicious for malignancy.

The patient's daughter has Lasting Power of Attorney (LPA). She believes it is not in the patient's best interests to be told about the possible cancer diagnosis as it would cause too much distress. She asks you not to reveal the full scan result to the patient.
The patient had shown evidence of capacity at the time of your initial review.

Which of the following would be the most appropriate next course of action?

Options:
explanation: It would be inappropriate for a family member to break bad news, especially without an appropriate clinician present to ensure accurate information sharing. It is also doubtful whether the daughter would tell the patient at all.
name: Agree to let the daughter tell the patient once she has recovered and is at home in her own environment
label: c
answer: no
explanation: LPA is only applicable in patients who have lost capacity. Therefore the patient currently has full power to decide regarding her care, provided she has capacity to do so.
name: You cannot disclose, as the daughter has Legal Power of Attorney and therefore has the right to decide on the patient's behalf
label: d
answer: no
explanation: You must assess capacity before deciding whether to follow or override the daughter's wishes. Secondly, even if there is capacity the patient herself has 'the right not to know'- ask first.
name: Tell the patient everything
label: b
answer: no
explanation: LPA is only applicable in patients who have lost capacity. Therefore the capacitous patient can currently override the daughter's wishes. If the patient does/does not want to know, that is her decision to make.
name: Assess capacity: if the patient has capacity, tell her whatever she would like to know
label: a
answer: yes
explanation: A best interests meeting would not be appropriate if the patient has capacity to make her own decisions.
name: Call a Best Interests Meeting, with other healthcare professionals and Next of Kin
label: e
answer: no

Correct answer: a
A 87 year old female presents to A&E with confusion and sepsis. She is critically unwell. She has an Advance Statement document by her bedside.

Which of the following answers best describes an Advance Statement?

Options:
explanation: Advance Statements are not a legally binding document, wheras Advance DIrectives are.
name: An Advance Statement is a legally binding document outlining specific treatments a patient would and would not wish to receive in their future care
label: d
answer: no
explanation: This is the definition of an advance statement
name: An Advance Statement is a document outlining general wishes, feelings, beliefs and values surrounding a patient's future care, to which decision-makers can refer when making best-interests decisions in the event of loss of capacity
label: a
answer: yes
explanation: This is a Do Not Attempt CPR form. Advance Statements are not standardised and cover more than just wishes regarding CPR, although this could be included in an Advance Statement.
name: An Advance Statement is a standardised document that indicates that the patient is not for cardiopulmonary resuscitation (CPR) in the event of cardiac arrest
label: e
answer: no
explanation: They are two disctinct documents.
name: An Advance Statement is another interchangable term for an Advance Decision
label: b
answer: no
explanation: Advance Statements are not a legally binding document, wheras Advance DIrectives are.
name: An Advance Statement is a legally binding document refusing specific future treatments
label: c
answer: no

Correct answer: a
A 76-year-old man is admitted to the geriatrics ward with a urinary tract infection. He past medical history includes only COPD and hypertension. He has delirium but no background of cognitive impairment. He remains on IV antibiotics and requires further management.

He appears confused and states that he would like to be discharged and is planning to leave. He does is not able to understand the risks of leaving hospital and make an informed decision.

Which of the following is the best course of action?

Options:
explanation: The patient's next of kin's advice should always be sought and considered. However, if the patient does not have capacity, we must act in their best interest. In this case it would be to prevent the patient from leaving hospital.
name: Ask the next of kin if they will allow the patient to leave
label: d
answer: no
explanation: The Mental Health Act (MHA) is used to detain patients in their best interest if they **have a mental health disorder**, and are at **risk to themselves or others**.

Section 2 of the MHA is for assessment and treatment, and lasts 28 days.

This patient has acute, organic, lack of capacity secondary to delirium. He does not have a mental health disorder and therefore it would be inappropriate to detain him under the MHA.
name: Detain the patient under the Mental Health Act Section 2
label: b
answer: no
explanation: The Mental Health Act (MHA) is used to detain patients in their best interest if they **have a mental health disorder**, and are at **risk to themselves or others**.

Section 3 of the MHA is for treatment, and can last up to 3 months.

This patient has acute, organic, lack of capacity secondary to delirium. He does not have a mental health disorder and therefore it would be inappropriate to detain him under the MHA.
name: Detain the patient under the Mental Health Act Section 3
label: c
answer: no
explanation: A patient with capacity is allowed to make an 'unwise' decision. If a patient is deemed to have capacity they can of course leave hospital, but we asked them to sign s form declaring that they are doing so against medical advice - a 'self-discharge' form. This patient does not have capacity and it would be in his best interest to prevent him leaving hospital.
name: Allow the patient to leave after signing a self-discharge form
label: e
answer: no
explanation: Correct! The Deprivation of Liberty Safeguards is the procedure in law used where it is necessary to deprive a patient or resident of their liberty as they lack capacity to consent to treatment or care to keep them safe from harm. This patient lacks capacity so can be detained for their best interest. Mental capacity is guided by the principles of the Mental Capacity Act.
name: Detain the patient using a Deprivation of Liberty Safeguard
label: a
answer: yes

Correct answer: a
A 76-year-old patient is on the geriatrics ward following a fall at home. They have a 75 pack year smoking history and a recent diagnosis of lung cancer. Investigations identify multiple bony metastases. The patient is not for active management and is being reviewed by the palliative care team.

She is not confused and clearly has capacity to make decisions about her care. She is aware of her condition and poor prognosis. She currently lives alone, but will require support at home on discharge. She tells you she has one daughter who lives abroad, who does not know about her diagnosis.

Her daughter calls the ward and asks to know all of the details of her Mother's condition.

Which of the following is the next best step?

Options:
explanation: Patients have a legal right to confidentiality (under both Common Law and Human Rights Law), and doctors have the corresponding legal duty to provide this right to confidentiality. As the patient has capacity, you must gain their consent before discussing their case with the patient's relative.
name: Ask the patient if they allow you to discuss her case with her daughter
label: a
answer: yes
explanation: Patients have a legal right to confidentiality (under both Common Law and Human Rights Law), and doctors have the corresponding legal duty to provide this right to confidentiality. As the patient has capacity, you must gain **their** **consent** before discussing their case with the patient's relative. The consultant may offer valuable guidance, but it is the patient's decision to give permission or not.
name: Ask the consultant if you can discuss the patient's case with her daughter
label: d
answer: no
explanation: Patient's have a legal right to confidentiality. However, you may take steps to obtain consent (asking the patient!). Family discussions may often be helpful in providing best care to your patients.
name: Refuse to disclose details with the daughter over the phone
label: c
answer: no
explanation: Patients have a legal right to confidentiality (under both Common Law and Human Rights Law), and doctors have the corresponding legal duty to provide this right to confidentiality. As the patient has capacity, you must gain their consent before discussing their case with the patient's relative.
name: Discuss the details with the daughter as her Mother will need more care at home
label: b
answer: no
explanation: Patients have a legal right to confidentiality (under both Common Law and Human Rights Law), and doctors have the corresponding legal duty to provide this right to confidentiality. As the patient has capacity, you must gain their **consent** before discussing their case with the patient's relative, not just to inform them. This patient has capacity and can therefore refuse this.
name: Inform the patient that you will update her daughter
label: e
answer: no

Correct answer: a