hllj/quesmed huggingface dataset:
A 67-year-old male complains of a 6-month history of urinary hesitancy and increased urinary frequency. He states he wakes up approximately 3 times every night to pass urine which he is finding increasingly troublesome. He denies any dysuria or haematuria. On digital rectal examination. a hard, irregular mass is felt on the posterior aspect of his prostate gland.

What is the most appropriate management of this patient?

Options:
explanation: Whilst this may explain increased urinary frequency, the chronic history, lack of dysuria/haematuria and the examination findings suggest a malignant process rather than a simple UTI.
name: Urine MCS
label: e
answer: no
explanation: This is not an appropriate option as although LUTS might be common in older patients, they have a variety of causes, some of which are serious. Even if caused by BPH, treatment may be considered. This is especially inappropriate based on the examination findings.
name: Reassure the patient that these are normal symptoms with age
label: c
answer: no
explanation: If a patient has a prostate which feels malignant on DRE, they should be referred under the suspected cancer pathway. A PSA should not be performed on a patient who had a DRE on the same day and the patient should be referred based on the examination findings alone.
name: 2-week wait referral under suspected cancer pathway
label: a
answer: yes
explanation: A PSA should not be performed on a patient who had a DRE on the same day and the patient should be referred based on the examination findings alone.
name: Offer same-day PSA testing
label: b
answer: no
explanation: This is not an appropriate choice as there is no history of haematuria and the examination findings suggest prostate cancer needs to be ruled out before investigating other urological causes.
name: Refer for cystoscopy
label: d
answer: no

Correct answer: a


Learning point: When a prostate feels suspicious for cancer on digital rectal exam (DRE), referral under the suspected cancer pathway should be made based on the examination alone, without performing a PSA on the same day, as the DRE findings take precedence
An 87-year-old male has significant acute penile pain. He lives in a care home and has a long-term catheter in situ, which was changed 4 hours ago. His carers report he was otherwise well before this incident and normally his catheter changes occur without any issues. On examination, he has an enlarged glans with a retracted, oedematous foreskin. The patient reports extreme pain on palpation of the glans and foreskin.

What is the most appropriate management?

Options:
explanation: This is a case of paraphimosis, which is a medical emergency as the blood flow to the glans is compromised. It may require surgical decompression if manual decompression fails or is inappropriate. In this case, it likely occurred as the individual who replaced the catheter forgot to replace the foreskin.
name: Arrange emergency medical admission
label: a
answer: yes
explanation: This is inappropriate as paraphimosis is a medical emergency, given the risk of ischaemia.
name: Advise this is normal in patients who have long-term catheters
label: e
answer: no
explanation: This would be useful in the case of bacterial balanitis, which would not present with acute pain or these examination findings.
name: Prescribe an oral antibiotic
label: c
answer: no
explanation: This would be useful in the case of fungal balanitis, which would not present with acute pain or these examination findings.
name: Prescribe a topical antifungal
label: b
answer: no
explanation: This is inappropriate as this is a medical emergency, which may require circumcision if surgical decompression is needed.
name: Non-urgent referral for consideration of circumcision
label: d
answer: no

Correct answer: a


Learning point: Paraphimosis is a medical emergency in which the foreskin is retracted behind the glans and cannot be returned to its normal position, leading to swelling and restricted blood flow that can cause pain and serious complications if not treated promptly.
A 67-year-old man has severe abdominal pain. He describes it as 7/10 pain which radiates from his right flank down towards his suprapubic area. The patient also states the last few times he has passed urine, it appeared tinged red. He has a past medical history of COPD and peptic ulcer disease, with a previous upper GI bleed 6 years ago.

What is the most appropriate analgesia to offer?

Options:
explanation: This should only be offered if IV paracetamol has inadequate analgesic effect.
name: Oral tramadol
label: d
answer: no
explanation: NSAIDs are contraindicated in this patient due to his past medical history of peptic ulcer disease with a previous upper GI bleed.
name: IM diclofenac
label: b
answer: no
explanation: NICE recommends offering IV paracetamol rather than oral paracetamol if NSAIDs are contraindicated.
name: Oral paracetamol
label: e
answer: no
explanation: Whilst NSAIDs are usually recommended as first-line treatment for pain in renal colic, they are contraindicated due to the patient’s past medical history of peptic ulcer disease with a previous upper GI bleed. IV paracetamol is therefore a more appropriate initial analgesic agent to offer.
name: IV paracetamol
label: a
answer: yes
explanation: NSAIDs are contraindicated in this patient due to his past medical history of peptic ulcer disease with a previous upper GI bleed.
name: PR diclofenac
label: c
answer: no

Correct answer: a


Learning point: In patients with a history of peptic ulcer disease, intravenous paracetamol is a safer analgesic choice for managing renal colic pain.
A 5-year-old boy is brought to the emergency department after accidentally drinking a significant amount of antifreeze which he mistook for a soft drink. He appears significantly dehydrated and is hypotensive on examination. He is anuric for 6 hours.

What is the most likely diagnosis?

Options:
explanation: This typically presents a few weeks following a streptococcal infection with self resolving haematuria.
name: Post-streptococcal glomerulonephritis
label: c
answer: no
explanation: This clinical picture is more suggestive of renal damage. Acute liver failure would present with jaundice, ascities, abdominal pain and coagulation disturbance.
name: Acute liver failure
label: d
answer: no
explanation: Membranous nephropathy causes a nephrotic syndrome and can be triggered by medications such as gold and penicillamine but tends to present less acutely with symptoms of proteinuria and peripheral oedema.
name: Membranous nephropathy
label: e
answer: no
explanation: This is another cause of intrinsic renal AKI, which can also be triggered by medications. However, antifreeze consumption is more likely to cause an acute tubular necrosis picture and acute interstitial nephritis would present with a triad of fever, rash and eosinophilia.
name: Acute interstitial nephritis
label: b
answer: no
explanation: This is correct. This is suggestive of a diagnosis of acute kidney injury secondary to acute tubular necrosis which is an intrinsic cause of AKI, whereby ethylene glycol in antifreeze directly damages the cells in the renal tubules.
name: Acute tubular necrosis.
label: a
answer: yes

Correct answer: a


Learning point: Acute tubular necrosis can occur following exposure to nephrotoxins, such as ethylene glycol, leading to acute kidney injury and anuria.
A 64-year-old gentleman has recently been diagnosed with Hodgkin’s Lymphoma following lymphadenopathy and weight loss. He was admitted to the oncology ward, catheterised, and commenced on cyclophosphamide and cyclosporin. 3 days later, he complains of dysuria and a nurse notices frank haematuria in his catheter bag.

Which of the following is the most likely cause of the patient’s haematuria?

Options:
explanation: Malignancy within the bladder may present as painless/ painful haematuria, however, the acuity of the symptoms and the fact that the bladder is not a common site for metastases for NHL render this less likely ( common sites include head and neck and GI tract).
name: Bladder metastases
label: e
answer: no
explanation: This is correct. Cyclophosphamide is well documented to cause hemorrhagic cystitis whereby symptoms of haematuria, and dysuria may occur immediately or years after treatment and persist despite discontinuation.
name: Cyclophosphamide
label: a
answer: yes
explanation: This may cause haematuria, but it is likely to occur immediately post-catheterisation as opposed to 3 days later.
name: Traumatic catheterisation
label: b
answer: no
explanation: Side effects associated with ciclosporin are more commonly: gingival hyperplasia, hypertension, increased hair growth and peripheral neuropathy. Haematuria is not common.
name: Ciclosporin
label: d
answer: no
explanation: Renal TB may cause haematuria and treatment with rifampicin may cause red urine, however, the absence of any other general symptoms of infection or TB such as fever, cough, dyspnoea, night sweats etc render this less likely.
name: Opportunistic TB infection
label: c
answer: no

Correct answer: a


Learning point: Cyclophosphamide, a chemotherapy drug, can cause hemorrhagic cystitis, which typically presents with dysuria and haematuria shortly after starting treatment.
A 35-year-old attends the emergency department with central chest pain, weakness and lethargy. It is difficult to elicit a history as he is confused. ECG shows widespread saddle-shaped ST elevation and PR depression. Troponin is raised. Urea and electrolytes reveal an eGFR of 8 mmol (>90), a creatinine of 300μmol (59 - 104) and urea of 26mmol (2.5-7.8)

What is the most appropriate management?

Options:
explanation: NSAIDs should be avoided in such poor renal function and AKI, colchicine is recommended to be avoided in extremely low gfr (<10).
name: Administer NSAIDs and colchicine
label: c
answer: no
explanation: NSAIDs should be avoided in such poor renal function and AKI. IVF will undoubtedly form part of the initial management of this patient but he needs acute dialysis.
name: Administer NSAIDs and intravenous fluids
label: e
answer: no
explanation: This is correct. This patient has an acute kidney injury with features of pericarditis and encephalopathy, likely in the context of uraemia. He therefore needs acute dialysis. Other indications include refractory hyperkalaemia, acidosis, overload or toxin ingestion.
name: Refer for haemodialysis
label: a
answer: yes
explanation: There is no evidence of a Myocardial infarction at present. The ECG findings suggest pericarditis.
name: Refer for PCI
label: b
answer: no
explanation: This is inappropriate as the patient is very unwell with uraemic pericarditis and encephalopathy.
name: Discharge with paracetamol
label: d
answer: no

Correct answer: a


Learning point: Indications for acute dialysis include severe electrolyte imbalances, acute kidney failure with significant fluid overload, uremic symptoms (such as encephalopathy or pericarditis), and poisoning or drug overdose that cannot be managed with other treatments.
A 48-year-old man comes to the GP concerned about a white patch on the side of his tongue that he is not able to rub off. His past medical history consists of ulcerative colitis, hypertension and HIV.

What is the most appropriate management?

Options:
explanation: Chlorhexidine mouthwash is useful in a variety of conditions such as ulcers, mucositis and following oral surgery. This option however does not appreciate the urgency of the situation and the need for an HIV specialist.
name: Commence chlorhexidine mouthwash with topical analgesia
label: d
answer: no
explanation: This is very inappropriate given the patient's symptoms, concerns and history.
name: Discharge and advise improvement in dental hygiene
label: e
answer: no
explanation: Nystatin may be used in oral candidiasis (thrush) where we would expect white patches on gums, tongue and inside the mouth that can be peeled off leaving a raw area. Oesophageal candidiasis can occur in HIV as well but we would expect odynophagia and sometimes dysphagia.
name: Commence Nystatin suspension
label: b
answer: no
explanation: This is correct. The patient is presenting with oral hairy leukoplakia, an EBV infection of the tongue, suggestive of advanced immunocompromise likely on the background of HIV and ulcerative colitis here. This can be an AIDS-defining illness and he needs to be rapidly assessed by an HIV specialist.
name: Refer to secondary care
label: a
answer: yes
explanation: Antiretrovirals must never be stopped, started or withheld by anyone other than an HIV specialist. In addition, we do not know if the patient is established on them in this case.
name: Stop the patient’s antiretrovirals
label: c
answer: no

Correct answer: a


Learning point: Oral hairy leukoplakia, often associated with HIV, requires urgent referral to secondary care for assessment and management.
A 68-year-old man attends the GP practice with a 3-month history of progressive dysphagia and weight loss. He has smoked 20 cigarettes a day for the last 32 years, and used to suffer from alcoholism.

What is the most likely diagnosis?

Options:
explanation: This normally develops after longstanding GORD which is not described and predisposes to malignancy.
name: Barrett's oesophagus
label: d
answer: no
explanation: This is correct. The patient is presenting with signs and symptoms of oesophageal cancer and his smoking and alcohol history further increase the risk of squamous cell carcinoma.
name: Oesophageal squamous cell carcinoma
label: a
answer: yes
explanation: This is not in keeping with the clinical context with no heartburn, indigestion, belching or acid reflux.
name: Gastro-oesophageal reflux disease
label: e
answer: no
explanation: The progressive dysphagia, age and history are more in keeping with malignancy as opposed to achalasia which is dysphagia to solids and liquids from its onset with sputtering and regurgitation of food which are not described.
name: Achalasia
label: c
answer: no
explanation: The patient is presenting with signs and symptoms of oesophageal cancer, however adenocarcinoma tends to be associated with longstanding reflux/GORD. Smoking is very strongly associated with squamous cell carcinoma, as is chronic alcohol abuse.
name: Oesophageal adenocarcinoma
label: b
answer: no

Correct answer: a


Learning point: Oesophageal squamous cell carcinoma is associated with risk factors such as smoking and alcohol consumption, presenting with dysphagia and weight loss.
A 48-year-old man attends the GP due to troublesome reflux, heartburn and difficulty swallowing for the last three months.

What is the most appropriate management?

Options:
explanation: This presentation does not appear cardiac in origin.
name: Urgent two-week wait referral to cardiology
label: e
answer: no
explanation: This is a recommendation in general practice for the treatment of possible peptic ulcer, however, the priority here is to exclude an upper GI malignancy.
name: Advise 8-week trial of oral PPI
label: b
answer: no
explanation: This is correct. NICE recommends anyone with dysphagia requires urgent assessment to exclude upper GI malignancy.
name: Urgent two-week wait referral to gastro-enterology
label: a
answer: yes
explanation: This is a recommendation in general practice for the treatment of possible peptic ulcer, however, the priority here is to exclude an upper GI malignancy.
name: Test and treat for H.Pylori
label: c
answer: no
explanation: Lifestyle measures such as weight loss and avoiding certain foods may be helpful in dyspepsia but this does not address his dysphagia, which is a red flag symptom for upper GI malignancy.
name: Reassure and advise lifestyle measures
label: d
answer: no

Correct answer: a


Learning point: Dysphagia warrants urgent referral to gastroenterology to rule out potential upper gastrointestinal malignancy, as per NICE guidelines.
A 35-year-old man attends the GP due to skin yellowing. On examination, he has hepatomegaly with jaundiced skin and spider naevi. He reports troublesome cough, breathlessness and wheezing over the last year. He is not a smoker and is obese.

What is the most likely underlying diagnosis?

Options:
explanation: The vignette does mention an alcohol history in this case. This should however be explored. Alcohol abuse would not explain the respiratory symptoms.
name: Alcoholic cirrhosis
label: c
answer: no
explanation: This is a disorder of sleep breathing in obese patients which results in daytime hypercapnia and is associated with obstructive sleep apnoea. It would not produce the liver or respiratory findings in this case.
name: Obesity hypoventilation syndrome
label: d
answer: no
explanation: This is correct. The patient has features of chronic liver disease and respiratory symptoms in keeping with obstructive pulmonary disease. The combination in a young non-smoker is typical of alpha 1 anti-trypsin deficiency.
name: Alpha-1 Antitrypsin Deficiency
label: a
answer: yes
explanation: Chronic myeloid leukaemia may result in hepatomegaly and recurrent respiratory infections. However, it does not explain the other symptoms of chronic liver disease and the patient describes no other symptoms of chronic myeloid leukaemia e.g. pallor, fatigue, easy bleeding and bruising.
name: Chronic myeloid leukaemia
label: e
answer: no
explanation: This may cause chronic liver disease, with obesity commonly predisposing. The patient is however quite young to develop non-alcoholic fatty liver disease and it does not explain the respiratory symptoms.
name: Non-alcoholic fatty liver disease
label: b
answer: no

Correct answer: a


Learning point: Alpha-1 Antitrypsin Deficiency can present with liver disease and respiratory symptoms, particularly in young, non-smoking individuals.
A 47-year-old woman attends the emergency department with severe right upper abdominal pain. She is hypotensive, tachycardic, jaundiced and febrile on examination. She is fluid resuscitated and initiated on intravenous antibiotics.

What is the most appropriate management?

Options:
explanation: This is typically delayed until all symptoms have resolved and ERCP has confirmed that the bile duct is clear of gallstones.
name: Cholecystectomy
label: b
answer: no
explanation: This is correct. The patient has features of ascending cholangitis with Charcot's triad of fever, jaundice and right upper quadrant pain. She has presented in shock and will likely require biliary drainage via ERCP alongside IV antibiotics.
name: Endoscopic retrograde cholangiopancreatography
label: a
answer: yes
explanation: This may be required as cases of ascending cholangitis are associated with high morbidity and mortality but the priority is in providing relief of biliary obstruction.
name: Admit to the intensive care unit
label: d
answer: no
explanation: This is inappropriate as the patient is extremely unwell and requires intravenous antibiotics and relief of biliary obstruction.
name: Reassurance and discharge with oral antibiotics
label: e
answer: no
explanation: The preferred approach is endoscopic as opposed to surgical.
name: Urgent laparotomy
label: c
answer: no

Correct answer: a


Learning point: Emergency endoscopic retrograde cholangiopancreatography (within 24 hours) is needed for adults with common bile duct stones and acute cholangitis or acute pancreatitis when indicated
A 24-year-old obese woman comes to the GP describing a 4-month history of right-sided headaches and blurry vision, worst in the morning.

Fundoscopy reveals bilateral papilloedema and a CT Head is reported as normal.

Which of the following is most likely to be present in her past medical history?

Options:
explanation: Seizures may be seen in cases of brain tumours but are not common in cases of idiopathic intracranial hypertension.
name: Generalised tonic-clonic seizures
label: c
answer: no
explanation: This is more suggestive of a gynaecological pathology or antiphospholipid syndrome.
name: Recurrent miscarriages
label: b
answer: no
explanation: This finding is not in keeping with a diagnosis of idiopathic intracranial hypertension. Anosmia can be associated with infections and congenital causes.
name: Loss of sense of smell
label: d
answer: no
explanation: This is correct. The patient is presenting with signs and symptoms of idiopathic intracranial hypertension, with a space-occupying lesion excluded. The biggest risk factors for this condition are obesity and the use of tetracyclines, common in the treatment of acne.
name: Poorly controlled acne vulgaris
label: a
answer: yes
explanation: This is not in keeping with the clinical story with persistent daily headaches and features of focal neurology described as opposed to nasal congestion and discharge and short-lived episodes of intense agony.
name: Cluster headaches
label: e
answer: no

Correct answer: a


Learning point: Tetracyclines, especially doxycycline, are associated with an increased risk of idiopathic intracranial hypertension (IIH), which can cause symptoms like headaches and vision changes, and other risk factors include obesity, certain medications, medical conditions like PCOS, and hormonal changes,
A 29-year-old woman comes to the GP describing two separate instances over the last few months of pins and needles in her left arm and right leg, respectively.  She says both of these episodes came on shortly after a gym workout and lasted a few days. In addition, she also experienced weakness in her left leg for almost a day, two weeks ago.

What is the most likely diagnosis?

Options:
explanation: Guillan-Barre typically presents with an ascending weakness and paralysis following viral infection, neither of which is described here.
name: Guillan-Barre syndrome
label: e
answer: no
explanation: This is correct. The patient is presenting with signs and symptoms of multiple sclerosis with multiple demyelinating lesions in space and time. The story is in keeping with Uthoff's phenomenon where symptoms worsen in the heat, i.e. during exercising.
name: Multiple sclerosis
label: a
answer: yes
explanation: Syringomyelia tends to present with loss of pain and temperature sensation, weakness and reflex changes due to damage to the spinothalamic tract. Symptoms vary depending on where the syrinx occurs but are more likely to affect the upper extremities. Syringomyelia would cause a progressively worsening clinical history as opposed to distinct events.
name: Syringomyelia
label: c
answer: no
explanation: This is not in keeping with the vignette with no mention of fatigability, eye drooping, or muscle weakness. The incidences appear distinct in time correlating with different lesions in the nervous system more in keeping with multiple sclerosis as opposed to continuously present as would be expected in myasthenia gravis.
name: Myasthenia Gravis
label: b
answer: no
explanation: This tends to present with bilateral numbness, neck stiffness, and loss of manual dexterity in hands generally in older patients. It would not explain the leg weakness here.
name: Degenerative cervical myelopathy
label: d
answer: no

Correct answer: a


Learning point: Multiple sclerosis can present with transient neurological symptoms, often exacerbated by heat, as seen in Uthoff's phenomenon.