hllj/quesmed huggingface dataset:
A 60-year-old man successfully underwent percutaneous coronary intervention and was discharged from the hospital a month ago after presenting with a myocardial infarction to the emergency department. His left ventricular ejection fraction (LVEF) was 50% at the time of discharge. He has now presented to the GP for a regular follow-up, has had no complaints since the procedure, and is feeling generally well.

He asks the GP if he needs to inform the Driver and Vehicle Licensing Agency (DVLA) about driving his car. Which of the following is the best advice?

Options:
explanation: He can resume driving a week after successful coronary intervention if there is no other urgent revascularization planned (within four weeks), the left ventricular ejection fraction (LVEF) is at least 40% before hospital discharge, and there are no other disqualifying conditions. He meets all of these criteria, and it has already been four weeks since the procedure. Therefore, **he can start driving immediately and does not need to notify the Driver and Vehicle Licensing Agency (DVLA)** about this.
name: Patient does not need to notify DVLA and resume driving now
label: a
answer: yes
explanation: The DVLA must be notified if the individual has symptoms that are likely to cause incapacity and/or if the arrhythmia is not controlled for at least four weeks and an underlying cause has not been identified.
name: Notify DVLA and resume driving after 4 weeks
label: d
answer: no
explanation: If the individual has not been treated with coronary intervention or, if they have undergone PCI, does not meet the specified criteria, they may resume driving only after four weeks from the acute event without notifying DVLA.
name: Patient does not need to notify DVLA and resume driving after 4 weeks
label: e
answer: no
explanation: This would have been the correct choice if he had just been discharged from the hospital, as the DVLA guidance states that he can resume driving without informing the DVLA after one week from the day of the procedure.
name: Patient does not need to notify DVLA and resume driving after 1 week
label: b
answer: no
explanation: This would have been the right choice if he had undergone pacemaker implantation or cardiac resynchronization therapy.
name: Notify DVLA and resume driving after 1 week
label: c
answer: no

Correct answer: a
An 18-year-old female who is 14 weeks pregnant has requested a termination of pregnancy as she is an emotionally abusive relationship and this is significantly affecting her mental health. She does not feel she would be able to raise this child. However, your religious belief does not align with the patient's intentions, and you do not wish to arrange the abortion.

What is the most appropriate action to take in this situation?

Options:
explanation: This is not an appropriate action to take as it goes against the patient's autonomy and confidentiality. In the United Kingdom, abortion is legal and whilst doctors are allowed to **conscientiously object**, it is not against our law and thus should not be referred to the police.
name: Refuse termination of pregnancy and inform the police
label: b
answer: no
explanation: The patient, in this case, is an 18-year-old female, which means she is a legal adult according to UK law and has the right to make her own healthcare decisions and provide consent for medical treatment. Informing her parents or seeking their consent is unnecessary in this situation, as the patient can understand the risks and benefits of the procedure and has clearly expressed her desire for an abortion. It is important for healthcare providers to respect the patient's autonomy and confidentiality in this situation, even if it goes against their personal beliefs or values.
name: Refuse termination of pregnancy and inform her parents
label: c
answer: no
explanation: Whilst termination of pregnancy is legal in the UK, doctors are allowed to refuse to offer this treatment if it goes agaist their personal values or belief. They **must** however refer patients seeking such interventions onto another doctor who can facilitate this. This is termed 'conscientious objecting'.
name: Perform surgical termination of pregnancy
label: e
answer: no
explanation: This is the most appropriate action to take in this situation as it respects the patient's autonomy and allows her to receive the care she desires while also acknowledging and respecting the healthcare provider's *conscientious objection*. **It is important to ensure that the patient's needs are met while also taking into consideration the healthcare provider's beliefs and values.** However, doctors are **obliged** to refer the patient on to an appropriate alternative, and cannot deny the care to this patient.
name: Refuse termination of pregnancy and refer to your colleague to carry out the procedure
label: a
answer: yes
explanation: Whilst termination of pregnancy is legal in the UK, doctors are allowed to refuse to offer this treatment if it goes agaist their personal values or belief. They **must** however refer patients seeking such interventions onto another doctor who can facilitate this. This is termed 'conscientious objecting'.
name: Perform medical termination of pregnancy
label: d
answer: no

Correct answer: a
A 26-year-old woman presents to the GP clinic with pain and multiple bruises on her arms and face. She tells the GP that she has been suffering from domestic abuse at the hands of her partner for the past year. She has two children, ages 5 and 7, who are currently at home with her. She has the capacity and understands the risks and benefits of seeking help and support. However, she declines a referral to social services or any other support services, saying that she fears what her partner might do if she seeks help.

What is the single most appropriate action in this situation?

Options:
explanation: Referring the woman to a domestic abuse support group may be a useful resource for her, but it does not address the key issue here, which is **child safeguarding**.
name: Refer her to a domestic abuse support group
label: c
answer: no
explanation: In this situation, the patient has disclosed that she is experiencing domestic abuse and that there are children present in the home. This raises safeguarding concern for both the adult and children. Capacitous adults can refuse referral for themselves, but they cannot refuse referrals for child safeguarding concerns. Therefore, the most appropriate course of action would be a child safeguarding referral.
name: Refer to child safeguarding service
label: a
answer: yes
explanation: While the woman may benefit from mental health support due to the domestic abuse she has experienced, it is important to also consider the issue of child safeguarding and take appropriate action. Referring to a mental health service alone is not sufficient in this situation.
name: Refer to mental health service
label: e
answer: no
explanation: While it is important to respect the woman's autonomy and decision-making capacity, it is also essential to consider the safety and well-being of the children in this situation. Failing to refer to social services for child safeguarding could put the children at risk of harm. Capacitous adults can refuse referral for themselves, but they cannot refuse referrals for child safeguarding concerns. Therefore, the most appropriate course of action would be a child safeguarding referral.
name: Respect her decision and do not refer
label: d
answer: no
explanation: While providing pain medication may be appropriate to address the woman's physical injuries, it is important to also address the issue of domestic abuse and consider the potential ongoing risk to the woman and her children.
name: Prescribe her analgesia and discharge her
label: b
answer: no

Correct answer: a
An 87-year-old woman with a past medical history of dementia dies at home. Two days prior, her GP had visited her and noted that her blood glucose levels were deteriorating. On the day of her death, the patient's daughter witnessed her last moments as she complained of chest pain and breathlessness and then suddenly collapsed and died. The daughter called for an ambulance, but the patient passed away before it arrived. She was not resuscitated as she wished not to attempt cardiopulmonary resuscitation.

Which of the following is the most likely cause of death to be included on the death certificate?

Options:
explanation: Dementia might have contributed to her death, but it is not the direct cause. Hence, it is not stated as the cause of death.
name: Dementia
label: b
answer: no
explanation: Cardiac, respiratory, liver, or kidney failure should not be included as causes of death on a death certificate. Instead, the underlying cause, such as ischemic heart disease, should be stated.
name: Heart failure
label: c
answer: no
explanation: Cardiac, respiratory, liver, or kidney failure should not be included as causes of death on a death certificate. Instead, the underlying cause, such as ischemic heart disease, should be stated.
name: Cardiac arrest
label: d
answer: no
explanation: In very limited circumstances, old age should only be given as the sole cause of death. A death certificate that lists "old age" or "senility" as the cause of death will usually be referred to the coroner unless the deceased is 80 years or older, only if the cause of death cannot be identified.
name: Old age
label: e
answer: no
explanation: In death certificates, it is appropriate to list the pathological cause, like ischemic heart disease, rather than modes of dying, like liver, heart, or respiratory failure.
name: Ischaemic heart disease
label: a
answer: yes

Correct answer: a
A 45-year-old man presents to the smoking cessation clinic requesting medication to help him quit smoking. He has tried behavioural therapy and counselling at his GP clinic, but they did not work for him. He is also under treatment for severe depression and binge eating disorder for the past few years. Otherwise, there is no other significant medical history. He currently smokes 25 cigarettes daily and has been smoking for the past 25 years.

Which of the following is the most appropriate next step?

Options:
explanation: Nicotine is a commonly used medication for smoking cessation and is available in various strengths. The recommended starting dose for **nicotine replacement therapy is 4 mg for people who smoke more than 20 cigarettes a day**, which is the case for this patient.
name: Nicotine 4 mg
label: a
answer: yes
explanation: Currently, e-cigarettes are not a treatment option that smoking cessation clinics can prescribe. However, they can be suggested to individuals who have not successfully quit with medication, but this should be done on a case-by-case basis and with clinical judgement.
name: E-cigarettes
label: e
answer: no
explanation: Varenicline is usually not preferred in this patient as he has a history of severe depression, which can exacerbate his depression.
name: Varenicline 500 micrograms
label: c
answer: no
explanation: It is incorrect because it is a lower dose than what is recommended for this patient based on the number of cigarettes he smokes per day. It would have been the right choice if he had smoked less than 20 cigarettes each day.
name: Nicotine 2 mg
label: b
answer: no
explanation: Bupropion is usually not preferred in this patient as he has a history of binge eating disorder, which can further worsen his mental health.
name: Bupropion 150 mg
label: d
answer: no

Correct answer: a
A 54-year-old man with a history of hypertension, osteoporosis, benign prostatic hyperplasia, and constipation comes to the clinic ten months after the death of his spouse. He reports decreased appetite and difficulty sleeping and performing daily activities. He is currently taking amlodipine, terazosin, alendronate, and over-the-counter fibre supplements and recently started sertraline for depression. He is now complaining of diarrhoea, nausea and vomiting.

Which of the following drugs would have led to his complaints?

Options:
explanation: The most common side effect of terazosin is dizziness, light-headedness, and orthostatic hypotension.
name: Terazosin
label: c
answer: no
explanation: The most common side effect of OTC fibre supplements is digestive discomfort, including bloating, gas, and diarrhoea. They are usually mild and can be relieved by drinking plenty of water.
name: Over the counter fibre supplements
label: e
answer: no
explanation: The most common side effect of amlodipine is swelling of the ankles and feet (peripheral oedema).
name: Amlodipine
label: b
answer: no
explanation: The most common side effect of alendronate is heartburn and difficulty swallowing. Rare but serious side effects include oesophageal irritation or ulcers, osteonecrosis of the jaw, and hypocalcaemia.
name: Alendronate
label: d
answer: no
explanation: Sertraline is a selective serotonin reuptake inhibitor used to treat depression and anxiety disorders. It is the most likely cause of his gastrointestinal symptoms, as nausea, vomiting, and diarrhoea are common side effects of SSRIs. Non-pharmacologic methods should be tried first in appropriate circumstances when treating the elderly. Behavioural therapy, relaxation techniques, and counselling should be tried first in a grief reaction.
name: Sertraline
label: a
answer: yes

Correct answer: a
A 70-year-old woman recently diagnosed with Crohn's disease is commenced on monotherapy with prednisolone. She was further assessed and found to be at high risk for fragility fractures. Although she is taking adequate calcium and vitamin D supplements, the GP prescribes a new medication which inhibits osteoclastic bone resorption.

What is the most crucial advice she should receive while taking this new medication?

Options:
explanation: Milk and milk products, orange juice, and meals can reduce oral bisphosphonate absorption, so they must only be taken on an empty stomach.
name: Take it with food
label: d
answer: no
explanation: Bisphosphonates cause adverse upper gastrointestinal effects such as nausea, reflux, oesophagitis, oesophageal ulcers, and gastritis. They are avoided at bedtime or before getting up in the morning.
name: Take it at bedtime
label: c
answer: no
explanation: Due to the risk of oropharyngeal ulcers, the tablet should be swallowed whole with plain water (200 mL); it should not be sucked or chewed.
name: Chew it before swallowing
label: e
answer: no
explanation: Patients should receive supplemental calcium and vitamin D if dietary intake is inadequate. However, taking both at the same time impairs bisphosphonate absorption. Between taking bisphosphonate and calcium supplements or antacids, a minimum interval of 30 minutes is advised.
name: Take it with a calcium supplement
label: b
answer: no
explanation: One of the extra-intestinal complications of Crohn's disease is secondary osteoporosis. On top of that, steroid therapy further increases its risk. Therefore, bisphosphonates are simultaneously started in elderly postmenopausal women to enhance bone mineral density. Oesophagal irritation or ulceration are adverse effects of bisphosphotes, so patients are instructed to stay upright and not lie down for at least 30 minutes or until the first meal of the day.
name: Stay upright for 30 minutes after taking the medication
label: a
answer: yes

Correct answer: a
After commencing antihypertensive medication, a 70-year-old man returns to the GP clinic with bilateral ankle swelling. Previously, on examination, his blood pressure was 160/100 mmHg. It was further confirmed on repeat ambulatory blood pressure monitoring at home over the following seven days.

Which medication could account for his complaint?

Options:
explanation: A dry cough is the most common adverse effect reported to ACE inhibitor use. Other complaints include angioedema, hair loss, hypotension, dysgeusia, and vertigo.
name: Enalapril
label: d
answer: no
explanation: Thiazide diuretics commonly cause electrolyte imbalances, such as hypokalemia, hyponatremia, hyperuricemia, hypomagnesemia and postural hypotension.
name: Bendroflumethiazide
label: b
answer: no
explanation: Amlodipine is a dihydropyridine calcium channel blocker (CCB) used to manage hypertension and coronary artery disease. CCBs cause vasodilation leading to a redistribution of fluid from capillaries to interstitial space, in contrast to peripheral oedema caused by fluid retention. Ankle oedema occurs in a dose-dependent manner. Other adverse effects include palpitations, dizziness, headache, and flushing.
name: Amlodipine
label: a
answer: yes
explanation: Common side effects of beta-blockers are bradycardia, bronchospasm, constipation, depression, erectile dysfunction, hypo/hyperglycemia, and a flare-up of psoriasis and Raynaud syndrome.
name: Atenolol
label: c
answer: no
explanation: Alpha-blockers are associated with complaints of lack of energy and strength, orthostatic hypotension, nasal congestion, dizziness, headache and insomnia.
name: Prazosin
label: e
answer: no

Correct answer: a
A 50-year-old woman visits the GP for a routine health checkup. She was diagnosed with type 2 diabetes a few months ago (well-controlled on oral hypoglycemics). Examination is unremarkable, with normal vital signs. Blood tests reveal very high serum cholesterol and low-density lipoprotein levels. She is advised to take Simvastatin 20mg once daily.

Which of the following are patients told to avoid whilst taking statins?

Options:
explanation: Cranberry juice potentially increases the anticoagulant effect of warfarin.
name: Cranberry juice
label: b
answer: no
explanation: Grapefruit juice/pulp is proven to have interactions with more than 40 drugs. By interacting with statins (atorvastatin, simvastatin, lovastatin), it inhibits CYP3A4 activity leading to the development of unwanted side effects such as myopathy and rhabdomyolysis.
name: Grapefruit juice
label: a
answer: yes
explanation: Apple juice and orange juice inhibit fexofenadine absorption and decrease aliskiren concentration and renin activity.
name: Orange juice
label: d
answer: no
explanation: Apple juice and orange juice inhibit fexofenadine absorption and decrease aliskiren concentration and renin activity.
name: Apple juice
label: e
answer: no
explanation: Pomegranate juice increases the INR in response to warfarin.
name: Pomegranate juice
label: c
answer: no

Correct answer: a
A 75-year-old woman was started on oral morphine following a pathological fracture. After a week, she returns complaining of constipation. She has been straining, and her stools are rock-hard. Moreover, she mentions the feeling of incomplete evacuation of stools. A diagnosis of opioid-induced constipation is suspected. She is advised to take an over-the-counter laxative to soften her stool.

Which laxative acts by this mechanism?

Options:
explanation: Docusate is a stool softener with emollient properties (surfactant laxatives). It enables the flow of water and lipids into the stool mass by reducing the surface tension of the oil-water interface of the stool. As a result, the faeces softens and moves more readily through the intestine.
name: Docusate sodium
label: a
answer: yes
explanation: Bisacodyl is a stimulant laxative that improves intestinal secretions and motility by stimulating the myenteric and Auerbach plexuses. They also reduce the absorption of water from the intestinal lumen.
name: Bisacodyl
label: c
answer: no
explanation: Linaclotide is a guanylate cyclase-C agonist that stimulates peristalsis by increasing fluid secretion and reducing visceral hypersensitivity. It is mainly used in irritable bowel syndrome associated with constipation.
name: Linaclotide
label: e
answer: no
explanation: Lactulose is an osmotic laxative which increases the volume of water in the large intestine by either drawing fluid from the body or retaining the liquid with which they are consumed at the time of administration.
name: Lactulose
label: d
answer: no
explanation: Methylcellulose is a bulk-forming laxative. It improves stool weight and consistency by retaining fluid in the stool.
name: Methylcellulose
label: b
answer: no

Correct answer: a
A 43-year-old woman presents to the GP with painful swelling on her right elbow. Her past medical history includes psoriatic arthritis. She denies any trauma but mentions she is often crawling and leaning on her elbow while doing her desk job as a clerk. On examination, there is a fluctuant swelling the size of a golf ball, tenderness, and erythema over the posterior aspect of the elbow.

What is the most likely diagnosis?

Options:
explanation: A history of recent trauma with unusual limitation of both active and passive movements on examination is most likely due to a fracture of the olecranon process.
name: Fracture of the olecranon process
label: e
answer: no
explanation: Olecranon bursitis (student's elbow) is usually caused by constant friction and irritation of the elbow while repetitively leaning and working on the table for various reasons. In this clinical vignette, her occupation raises suspicion of this condition.
name: Olecranon bursitis
label: a
answer: yes
explanation: In rheumatoid arthritis, the whole joint is inflamed instead of localised, fluctuant swelling. Characteristic rheumatic nodules, which are firm without fluctuation, can cause swelling over the olecranon region.
name: Rheumatoid arthritis
label: b
answer: no
explanation: Septic arthritis presents with fever, severe excruciating pain and swelling of the whole joint rather than the bursa. A painful and limited range of movements on examination characterises it.
name: Septic arthritis
label: c
answer: no
explanation: Lateral epicondylitis (tennis elbow) is due to micro-tearing of the fibres and resultant inflammation of the extensor tendons in the forearm. It can be differentiated from olecranon bursitis by the presence of tenderness to palpation over the origin of the extensor carpi radialis brevis tendon.
name: Lateral epicondylitis
label: d
answer: no

Correct answer: a
A 45-year-old man with a history of type 2 diabetes mellitus presents to the GP for an annual review. He has been on metformin for the past year and mentions being compliant with it. He has recently noticed consistently high blood sugars ranging between 11-14 mmol/L before meals (normal range 3.5-5.5 mmol/L). His physical examination is notable for a body mass index (BMI) of 38 kg/m2 and acanthosis nigricans. His current HbA1c is 60 mmol/mol (normal range 20-42 mmol/mol).

Which of the following medication is the most appropriate option?

Options:
explanation: DPP-4 inhibitors such as Sitagliptin would be the most appropriate second line therapy as they are not known to cause weight gain
name: Sitagliptin
label: c
answer: yes
explanation: The main side effect of thiazolidinediones (rosiglitazone and pioglitazone) is water retention, leading to oedema and weight gain. Hence, they are not the best choice as an additional drug.
name: Pioglitazone
label: d
answer: no
explanation: Insulin will help improve glycaemic control but is associated with weight gain and hypoglycaemia. Moreover, insulin is usually commenced if a trial of multiple oral hypoglycaemic agents fails to control his condition.
name: Insulin
label: e
answer: no
explanation: Although sulfonylureas such as glipizide and glimepiride are the most preferred options as an add-on medication to metformin. However, their side effects (weight gain and hypoglycaemia) make them less likely a suitable choice in this scenario.
name: Glimepiride
label: b
answer: no
explanation: Glucagon-like peptide-1 (GLP-1) receptor agonists such as exenatide can be used as fourth line agents. In patients with BMI >= 35 kg/m² they have been known to cause weight loss.
name: Exenatide
label: a
answer: no

Correct answer: c