hllj/quesmed huggingface dataset:
A 63-year-old man presents to his GP with worsening pain in both knees over a period of 6 months. The pain is worse on physical activity and limits his independence as he lives in a second-floor flat and now struggles to get up and down the stairs. He has a past medical history of type 2 diabetes, hypercholesterolaemia and a body mass index (BMI) of 36.

What is the most likely diagnosis?

Options:
explanation: This patient does have some risk factors for gout, in that the condition is more common in men of an older age. However, gouty pain tends to have a more acute course of onset, often coming on over several hours - days rather than months. In addition, you would expect some mention of the joint being red or hot, as is the case in flares of crystal arthropathies. Gout can affect any joint, but it most commonly affects the first metatarsophalangeal joint (great toe)
name: Gout
label: d
answer: no
explanation: Osteoarthritis is a disease of "wear and tear". It is more common in those aged over 50 with risk factors that increase weight loading strain on the joint - these include obesity, sports/occupation and previous trauma to the joint. It most commonly affects the knees, hips, hands and spine. It can be differentiated from rheumatoid arthritis (RA) when occurring in the hands by its tendency to spare the metacarpophalangeal (MCP) joints
name: Osteoarthritis (OA)
label: a
answer: yes
explanation: Structural damage to the soft tissues in the knee are generally acute injuries associated with a trauma event. This is not the case in this history. Additionally, you would have to be unlucky to injure your menisci in both knees simultaneously!
name: Meniscal tear
label: e
answer: no
explanation: RA is an inflammatory arthritis and is, therefore, most classically associated with morning stiffness lasting longer than 1 hour. Additionally, RA tends to be distributed differently, having a strong propensity for affecting the hands, in particular, the metacarpophalangeal (MCP) joints, whilst sparing the distal interphalangeal (DIP) joints. This is compared to OA, which tends to occur more in weight-bearing joints, including the hips and knees, spine and hands (in a different distribution to RA)
name: Rheumatoid arthritis (RA)
label: b
answer: no
explanation: Psoriatic arthritis is again inflammatory in nature and associated with morning stiffness lasting longer than 1 hour. It is associated with psoriasis; however, arthritis can occur without any skin involvement - it would be important to look for associated family history also. It is also associated with nail changes not present in other forms of arthritis, including pitting of the nails and onycholysis
name: Psoriatic arthritis
label: c
answer: no

Correct answer: a
A 52-year-old woman presents to her GP with worsening pain and deformity in both her hands. The patient has recently moved to the UK and previously had poor access to healthcare. The pain first started 15 years ago and is worse in the morning, with associated stiffness which does not ease until the middle of the day.

A plain x-ray of her right hand is shown below:

[lightgallery]

What is the most likely diagnosis?

Options:
explanation: In early psoriatic arthritis, there may be no visible change on radiograph, except for some soft tissue swelling due to the inflammatory nature of the condition. Late in the disease course, there is classical osteolysis with new bone formation around the joint margins, which causes a "pencil-in-cup deformity". Over time the arthritis can progress into "arthritis mutilans"
name: Psoriatic arthritis
label: b
answer: no
explanation: SLE can cause arthritis, particularly of the hands and feet, however this is classically "non-deforming" which means you would not see these destructive changes on imaging
name: Systemic lupus erythematosus (SLE)
label: e
answer: no
explanation: X-rays of patients with RA may show loss of joint space with peri-articular osteopenia, bony erosions around the joint margins and associated soft tissue swelling. Late on in the disease course, they may reveal joint subluxation. In this radiograph, you can see evidence of all of these features - in keeping with the history of a delayed presentation and relatively advanced disease. Characteristic of rheumatoid, there is also resultant ulnar deviation at the metacarpophalangeal joints and Z thumb deformity
name: Rheumatoid arthritis (RA)
label: a
answer: yes
explanation: Ankylosing spondylitis tends to present with inflammatory **back pain** in young patients, usually in their late teens and early 20s. It is also more common in men, compared to RA which is more common in women
name: Ankylosing spondylitis
label: d
answer: no
explanation: X-rays in OA show **L**oss of joint space, **O**steophytes, **S**ubchondral cysts and **S**ubarticular sclerosis (helpful acronym to remember these features is **LOSS**). It does not cause the classic ulnar deviation or erosive changes as seen in rheumatoid arthritis
name: Osteoarthritis
label: c
answer: no

Correct answer: a
A 40-year-old man presents to his GP with pain in his left leg which has been progressively worsening for two days. He has recently returned from a diving holiday in Australia and wonders if he injured the leg during diving, although he does not recall any particular episode of trauma.

On examination, the left calf is swollen and measures 4.5cm greater in diameter than the right calf. The left calf also appears slightly red.

What is the most likely diagnosis?

Options:
explanation: Ischaemic leg pain or "claudication pain" is like angina of the leg, and classically would occur on walking and be alleviated by rest. There is no mention of the pain being exertional in the stem
name: Intermittent claudication
label: e
answer: no
explanation: In a ruptured popliteal cyst you would usually expect a more acute onset of symptoms following cyst rupture. Additionally, there may also be more localisation of the pain to the popliteal region, or some mention of a swelling within the popliteal region preceding the lower leg swelling
name: Ruptured popliteal cyst (Baker's cyst)
label: d
answer: no
explanation: In a simple muscular injury, the patient would experience pain but would be unlikely to have significant swelling or redness in the affected limb. There would also likely be a notable trauma associated with this, in that a certain movement or event would likely have happened, followed by sudden onset of the pain. This is not the case in DVT, where symptoms develop more slowly
name: Muscular injury to the calf
label: c
answer: no
explanation: Cellulitis can cause swelling and redness in the lower limb, however you would expect further evidence of infection. Examples of other features you may see to suggest cellulitis include fever, the leg being hot to touch, a mention of the redness spreading progressively or the patient feeling generally unwell
name: Cellulitis
label: b
answer: no
explanation: The patient has a risk factor for thrombus formation here in his history, in that he has recently returned from Australia, which would be via a long haul flight. The symptoms he is experiencing, of leg pain and swelling alongside some redness, are classic for DVT and must be identified promptly to avoid delay in treatment
name: Deep Vein Thrombosis (DVT)
label: a
answer: yes

Correct answer: a
A 19-year-old female with a history of severe depression presents to the Emergency Department at 7 pm after taking an overdose of paracetamol. She describes taking 36 500mg tablets of paracetamol over the course of the afternoon, between 2 pm and 6 pm.

What is the first line treatment for this patient?

Options:
explanation: In patients who have taken a staggered overdose first line treatment is with N-acetylcysteine regardless of the time from ingestion
name: N-acetylcysteine
label: a
answer: yes
explanation: Haemodialysis to remove the paracetamol and associated toxins from the blood may be needed rarely in very critical cases of extreme overdose
name: Haemodialysis
label: e
answer: no
explanation: This is the correct course of action in patients with an overdose of <150mg/kg that has been ingested within a 1 hour period - not staggered, as is the case in this patient. In these circumstances, you can wait until you have a blood paracetamol level and treat only if this is above the "treatment line" on the paracetamol overdose nomogram. If any doubt remains about the dosage or timescale of the overdose, the safest option is always to treat empirically with N-acetylcysteine
name: Take blood paracetamol level and wait for result before initiating treatment
label: c
answer: no
explanation: Activated charcoal can be considered in patients who present very soon following ingestion of their overdose (within 1 hour of ingestion); however it should not be given in patients where there is any concern regarding their airway (if they have a reduced Glasgow Coma Score of <8 this indicates they cannot protect their own airway, or if they present as very drowsy)
name: Activated charcoal
label: b
answer: no
explanation: As per the Kings College Criteria, a hyper-acute liver transplant is indicated in patients with significant acidosis of pH <7.30 **OR** all 3 of: coagulopathy with INR >6.5 **AND** creatinine of >300umol/L **AND** grade III or IV encephalopathy
name: Hyper-acute liver transplant
label: d
answer: no

Correct answer: a
A 23-year-old female presents to her GP with menorrhagia. She reports feeling exhausted and undergoes some blood tests, which reveal an iron deficiency anaemia.

Which description best fits with an iron deficiency anaemia?

Options:
explanation: Anaemia of chronic disease refers simply to anaemia which occurs in the context of long term illness. This includes chronic infections, many inflammatory conditions and some malignancies. The underlying process is related to reduced red blood cell production, which is felt to be mediated by inflammation - on differential blood count, you would see a relatively low reticulocyte count reflecting this
name: Anaemia of chronic disease
label: c
answer: no
explanation: Pernicious anaemia is a form of autoimmune disease which results in antibodies forming against gastric parietal cells and ultimately causes a lack of intrinsic factor - this means that B12 cannot be absorbed from the diet. The resultant anaemia would be macrocytic, as per other forms of B12 deficiency anaemia
name: Pernicious anaemia
label: e
answer: no
explanation: Haemolysis is the breakdown of red blood cells - it can cause anaemia when this process is happening more rapidly than the red cells can be replaced. This is classically a normocytic anaemia, as there is nothing wrong with the red cells themselves (no deficiencies etc.), simply that they are being broken down more rapidly than intended. If you were to perform a blood film in a haemolytic anaemia, you would likely see schistocytes (broken/fragmented red cells). On differential blood count, you may also see a raised reticulocyte count, as the body works hard to rapidly replace the red cells that have been lost
name: Haemolytic anaemia
label: d
answer: no
explanation: Macrocytic anaemias are most commonly caused by simple dietary B12 or folate deficiency, or more rarely, pernicious anaemia. A macrocytosis (with or without associated anaemia) also commonly occurs in chronic alcoholism
name: Macrocytic anaemia
label: b
answer: no
explanation: Iron deficiency causes a microcytic, hypochromic anaemia. Iron is an important component for the production of haemoglobin - the molecule responsible for the oxygen carrying capacity of red blood cells
name: Microcytic anaemia
label: a
answer: yes

Correct answer: a
A 23-year-old female presents to the GP with fatigue. She describes herself as very healthy, following a vegan diet and exercising four times a week - although the fatigue is now making this more challenging to maintain. She has no past medical history.

Blood tests reveal:

- Hb 94 (135-175g/dL)
- MCV 106 (80-96 fl)

What is the most likely cause of the patient's anaemia?

Options:
explanation: Inherited causes of anaemia such as thalassaemia or sickle cell are unlikely to present for the first time in adulthood, usually being identified at a young age (most commonly through screening programmes). Screening for thalassaemia trait is offered to all pregnant women in England. Additionally, the newborn blood spot test includes haemoglobinopathy testing for both thalassaemia and sickle cell disease
name: Thalassaemia
label: e
answer: no
explanation: There is no mention of menorrhagia in the stem, although this is an important potential cause of anaemia to consider in people who menstruate. Anaemia from menorrhagia would usually be normocytic or microcytic
name: Menorrhagia
label: c
answer: no
explanation: Conditions of the gastrointestinal (GI) tract such as coeliac disease or inflammatory conditions can cause malabsorption of multiple nutrients which can result in anaemia. However, in this stem there is no mention of any GI symptoms and given the patients vegan diet, dietary insufficiency is more likely to be responsible for any deficiencies than malabsorption
name: Malabsorption
label: d
answer: no
explanation: B12 deficiency can cause a macrocytic anaemia. People with strict vegetarian or vegan diets can be at higher risk of B12 deficiency as this nutrient is mainly sourced from meat and dairy products. It is therefore recommended that those choosing a vegetarian or vegan diet take dietary supplements
name: B12 deficiency anaemia
label: a
answer: yes
explanation: Iron deficiency causes a microcytic anaemia
name: Iron deficiency anaemia
label: b
answer: no

Correct answer: a
A 40-year-old male presents to the Emergency Department. He appears unkempt, cachectic and on questioning it is identified that he is experiencing homelessness. He describes a very poor diet consisting of donated food when this is available, and otherwise mainly eats scraps from bins. He is noted to be very pale and his full blood count results demonstrate a normocytic anaemia.

What is the most likely cause of this anaemia?

Options:
explanation: Anaemia of chronic disease does cause a normocytic anaemia. However, this often occurs in elderly patients or those with significant underlying physical health problems. Whilst this patient is clearly not in a good physical condition, from the information given in the stem there is no evidence to suggest any long term illnesses
name: Anaemia of chronic disease
label: e
answer: no
explanation: This patient likely does have an element of folate deficiency contributing to his anaemia, however folate deficiency alone would cause a macrocytic picture, therefore something else must also be contributing. In this patient where their diet is very poor **overall**, it is unlikely that he would be lacking in one specific nutrient alone
name: Folate deficiency anaemia
label: d
answer: no
explanation: Additionally, there are no risk factors for autoimmune haemolytic anaemias identified in this stem (such as a history of/signs on examination suggestive of other autoimmune disease)
name: Autoimmune haemolytic anaemia
label: b
answer: no
explanation: This patient likely does have an element of iron deficiency contributing to his anaemia, however iron deficiency alone would cause a microcytic picture, therefore something else must also be contributing. In this patient where their diet is very poor **overall**, it is unlikely that he would be lacking in one specific nutrient alone
name: Iron deficiency anaemia
label: c
answer: no
explanation: In patients with marked generalised malnutrition (as is clear from this patient's history) a normocytic anaemia can prevail. This is due to mixed effects of iron deficiency (which normally causes a microcytic anaemia) and B12 +/- folate deficiency (which normally causes a macrocytic anaemia)
name: Generalised malnutrition
label: a
answer: yes

Correct answer: a
A 69-year-old male requires a 3 unit blood transfusion following a road traffic accident. He has no past medical history but appears physically very frail, weighing 49 kilograms with a body mass index of 17.

Two hours after the transfusion, he becomes increasingly short of breath and develops an oxygen requirement, needing 2 litres to maintain saturations of 96%.

What is the most likely cause of his respiratory symptoms?

Options:
explanation: Anaemia can cause shortness of breath and hypoxia, but it is unlikely that this would develop only after the transfusion - if the anaemia were significant enough to cause these symptoms, you would expect them to have been present both **before** _and after_ the transfusion
name: Persistent anaemia requiring further transfusion
label: d
answer: no
explanation: In older, more frail patients, extra care and caution must be taken to avoid fluid overload when giving any infusion. We are used to considering this and adapting our prescriptions accordingly when giving simple fluids, but this can be overlooked when giving blood products. It is important to remember that blood products can have similar effects to fluids, particularly when multiple units are required. You can reduce the risk of transfusion associated circulatory overload by giving the blood products more slowly (i.e. giving 1 unit over 4 or 5 hours, instead of 2 or 3) or by giving a small dose of furosemide between each unit
name: Transfusion associated circulatory overload
label: a
answer: yes
explanation: Complications of transfusions that are classified as "delayed" occur days to weeks following the transfusion event. As the onset of the patient's symptoms started only 2 hours after completing the transfusion, this would not be classified as a 'delayed' reaction. Additionally, there is no evidence in the stem to point you towards haemolysis (features of a haemolytic reaction may include jaundice, fever, elevated lactate dehydrogenase +/- bilirubin, a newly positive direct antiglobulin test on blood testing and haemoglobinuria)
name: Delayed haemolytic transfusion reaction
label: e
answer: no
explanation: There is no mention in the stem of infective symptoms to meet criteria for sepsis, such as fever, tachycardia or hypotension. With modern screening of blood products, acquiring an infection from a transfusion is rare. Although it is always important to consider when reviewing a patient with complications from a transfusion, it is not the most likely cause of this patients symptoms
name: Transfusion associated sepsis
label: b
answer: no
explanation: Anaphylactic reactions to blood products are rare. If this were to be the case, you would expect more of a focus on key anaphylactic symptoms, including the airway being affected (new wheeze, stridor, airway swelling) or features of anaphylactic shock, including significant hypotension. The biggest risk factor for transfusion associated anaphylaxis is IgA deficiency, following receipt of transfused plasma containing normal IgA levels
name: Anaphylactic reaction
label: c
answer: no

Correct answer: a
A 71-year-old female patient is brought into the Emergency Department from a care home with worsening confusion and vomiting. She has not opened her bowels in 7 days and has been increasingly agitated, disorientated and difficult to engage in conversation for the past 5 days.

What is the most likely cause of this patients confusion?

Options:
explanation: Delirium is a reversible form of cognitive impairment characterised by its **acute** onset, **fluctuating** course and propensity to cause **inattention**. PINCH ME is a helpful acronym to remember common causes of delirium - Pain, Infection, Nutrition, Constipation, Hydration, Medication and Environment (unfamiliar). In this patient, there is a clearly identifiable trigger preceding the onset of the confusion - constipation
name: Delirium
label: a
answer: yes
explanation: Hypoglycaemia in this patient is a valid concern - with her confusion, constipation and vomiting, she may be having very minimal oral intake. Hypoglycaemia can cause confusion and vomiting; however, it would not be in keeping with this patients 5-day history of agitation and disorientation - it would present much more acutely, coming on over minutes to hours, not days
name: Hypoglycaemia
label: b
answer: no
explanation: Though bowel cancer can present for the first time with bowel obstruction, which may be the case here with the patients marked constipation and subsequent vomiting, it would not explain the rapid onset of the confusion. You may also experience other associated red flag symptoms to be present such as a change in bowel habit for more than 6 weeks, blood in the stool or weight loss
name: Malignancy
label: e
answer: no
explanation: In the elderly, depression can often manifest with cognitive impairment. Additionally, depression and dementia are common co-existing conditions. However, the very acute nature of this confusion and the lack of any affective symptoms points away from depression as the cause
name: Depression
label: d
answer: no
explanation: Cognitive impairment in dementia is gradual in onset, over many months to years. It would not progress suddenly over the course of 5 days. Additionally, the clear trigger of constipation here makes a primary neurological cause much less likely
name: Dementia
label: c
answer: no

Correct answer: a
A 74-year-old man is brought to the GP by his wife, concerned about his deteriorating memory over the past 3 years. She reports several episodes of marked decline, with the most recent occurring when he woke up and failed to recognize his children. 

He has a past medical history of hypertension and atrial fibrillation, for which he takes amlodipine, ramipril and apixaban. He also had a stroke ten years previously and has some residual visual deficit and right arm weakness from this.


What is the most likely diagnosis?

Options:
explanation: In FTLD, the first symptoms are often personality change or inappropriate social behaviour, prior to any significant impact in memory (cognitive decline comes later in the disease course). As the name suggests, this is due to the specific area of the brain that is affected. FTLD tends to develop in younger patients, classically <65 years of age, compared with the other forms of dementia which increase in incidence with increasing age
name: Frontotemporal lobe dementia (FTLD)
label: c
answer: no
explanation: Alzheimer's dementia follows a much more gradual course and would not cause these distinct episodes of sudden, marked deterioration in memory
name: Delirium
label: d
answer: no
explanation: This patient has had a previous stroke, as well as comorbidities that together indicate pre-existing vascular disease. In vascular dementia, the deterioration in memory is classically "step-wise" as mini-infarcts occur, compared to other forms of dementia where there is a very gradual and insidious decline
name: Vascular dementia
label: a
answer: yes
explanation: In some elderly patients, depression can present by causing cognitive impairment, which can mask as a neurodegenerative disorder. Once treated, the cognitive impairment is often reversible. It is always important to consider and address mood in a patient presenting with memory loss, as **depression rates are very high in patients experiencing true forms of dementia**, and identifying and treating this appropriately can improve cognition and quality of life
name: Pseudo-dementia
label: e
answer: no
explanation: Alzheimer's dementia follows a much more gradual course and would not cause these distinct episodes of sudden, marked deterioration in memory
name: Alzheimer's dementia
label: b
answer: no

Correct answer: a

Vascular dementia