hllj/quesmed huggingface dataset:
A 46-year-old female presents to General Practice with bilateral knee pain that has been present for six months. She currently works part-time as a cleaner. Her past medical history includes type two diabetes mellitus, hypertension, gastro-oesophageal reflux (GORD) and morbid obesity.
Knee x-rays are requested and show loss of joint space with some subchondral sclerosis.

What is your initial management?

Options:
explanation: This patient has osteoarthritis. As she is morbidly obese and young, one of the first interventions should be lifestyle advice and weight loss, particularly as she also has diabetes and hypertension. Weight loss would reduce the stress on her load-bearing joints and also improve her health generally as well as her diabetes and hypertension
name: Advise the patient to lose weight
label: a
answer: yes
explanation: Non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen are beneficial in treating the pain associated with osteoarthritis; however, this patient already has a degree of reflux, which would be exacerbated by NSAID use. If NSAIDs were required, topical would be first-line, or if that was ineffective, ibuprofen would likely be the first-line oral option as it is not as strong. She would require gastric protection, for example, with a proton pump inhibitor (PPI). She has a relatively short history, and therefore lifestyle interventions would be of benefit in the first instance in this case
name: Naproxen
label: c
answer: no
explanation: This patient has the start of osteoarthritis as seen in her x-ray changes and therefore should be advised on lifestyle modifications to prevent the progression of symptoms
name: Watch and wait
label: d
answer: no
explanation: TKR is often the best way to deal with severe arthritis when it impacts the quality of life; however, this patient has a short history and has yet to attempt any non-surgical management. In addition, TKRs only last around 15 years, and as this patient is young, this is best avoided at present
name: Total knee replacement (TKR)
label: e
answer: no
explanation: Steroid injections may be of benefit in reducing her symptoms but are not always effective and carry risks, including that of introducing infection; as she has diabetes, this risk is even more of a concern. Other interventions should be considered first in this case
name: Steroid injection
label: b
answer: no

Correct answer: a


Learning point: Weight loss is a crucial initial management strategy for osteoarthritis, particularly in morbidly obese patients, to reduce joint stress and improve overall health.
A 63-year-old female presents to Accident and Emergency with sudden right-sided blindness associated with a headache. She has never had issues with headaches before. On further questioning, she reveals that she has tenderness on brushing her hair and has been to the dentist recently with toothache but did not need any dental work done.

What should your initial management be?

Options:
explanation: Low dose amitriptyline may be used in neuropathic pain and migraine prophylaxis; however, whilst migraine can cause headache and visual loss/disturbance in some cases, it is unlikely for a patient to have a new diagnosis of migraine at the age of 63 and therefore other causes should be considered
name: Start 10mg amitriptyline
label: c
answer: no
explanation: 300mg of aspirin would be the treatment of choice if this patient were suspected of having a transient ischaemic attack (TIA); however, whilst TIAs can present with blindness, they do not usually cause headache and would not explain the scalp or jaw pain
name: Stat dose 300mg aspirin
label: b
answer: no
explanation: This history is suspicious for temporal arteritis, aka giant cell arteritis (GCA). As she has experienced vision loss, it is important to start high dose steroid treatment immediately; otherwise, she may have permanent loss. Symptoms of GCA include scalp tenderness, jaw claudication and headache. Patients usually require steroids for a two-year course then have complete remission, and steroids can be reduced once symptoms have resolved. The main cause of death and morbidity in GCA are related to long term steroid use, so risks and benefits of treatment should be considered carefully, and gastric and bone protection should be considered
name: Start high dose steroids
label: a
answer: yes
explanation: Thrombolysis with alteplase would be an appropriate treatment for an ischaemic stroke within 4.5 hours of the onset of symptoms. Whilst ischaemic stroke can cause blindness, it would not usually cause headaches and would not explain the scalp or jaw pain
name: Stat dose 900mcg/kg altepalase
label: e
answer: no
explanation: Carbemazipine is the first line treatment for trigeminal neuralgia. This would be in the differential for unilateral facial pain; however, it would not account for the blindness, and the pain she describes does not sound neuropathic
name: Start 100mg carbamazepine
label: d
answer: no

Correct answer: a


Learning point: Giant cell arteritis (GCA) is an inflammatory condition affecting large blood vessels, often presenting with symptoms like headache and vision changes; it requires prompt treatment with high-dose steroids to prevent complications such as vision loss and reduce inflammation.
A 24-year-old male is treated for Hodgkin's lymphoma with chemotherapy.

As he has a high tumour burden, he is deemed at high risk of tumour lysis syndrome (TLS); which of the following blood tests would suggest tumour lysis syndrome?

Options:
explanation: Breakdown of cells includes the breakdown of their nucleic acid, which has a phosphate group, and therefore a high phosphate is expected in TLS. As phosphate leads to calcium chelation, patients will also have low calcium rather than high calcium. High calcium is associated with malignancy with boney metastasis, for example, lung cancer, breast cancer and renal cancer
name: Adjusted Calcium 3.70 mmol/L
label: c
answer: no
explanation: Hyponatreamia can be a sign of paraneoplastic syndromes such as syndrome of inappropriate ADH. It is not in keeping with tumour lysis syndrome
name: Sodium 128 mmol/L
label: d
answer: no
explanation: As rapid cell breakdown releases potassium, a low potassium would be unusual in TLS
name: Potassium 2.9 mmol/L
label: b
answer: no
explanation: TLS is a severe metabolic disturbance caused by the abrupt release of cellular components following the rapid lysis of malignant cells upon initiation of treatment. Therefore high potassium, high urea, high phosphate and low calcium are expected.

Lactate, urate and LDH may also be increased and so should be monitored, but are not diagnostic.

It is usually within 1-5 days of starting chemotherapy and can cause seizures, cardiac arrhythmias, kidney injury and even death. Management is through prevention and careful monitoring and treatment of any complications should they occur
name: Urea 22 mmol/L
label: a
answer: yes
explanation: This is a normal potassium level. A high potassium level would be associated with TLS
name: Potassium 4.2 mmol/L
label: e
answer: no

Correct answer: a


Learning point: Tumor lysis syndrome occurs when cancer cells rapidly die, releasing nucleic acids that break down into uric acid, overwhelming the kidneys, causing hyperuricemia, renal dysfunction, and elevated blood urea levels.
A 74-year-old male diagnosed with Non-Hodgkin's lymphoma and started on bleomycin. He presents to General Practice complaining about progressive breathlessness. On auscultation of his chest, you notice bilateral fine crackles.

What is the likely diagnosis?

Options:
explanation: Asthma can cause breathlessness, but this is not usually progressive in nature. Auscultation of the chest would reveal polyphonic wheeze or, in a severe attack, may be silent
name: Asthma
label: e
answer: no
explanation: Pulmonary fibrosis is a recognised side effect of bleomycin, and fine crackles on auscultation should prompt this diagnosis. A chest x-ray should be performed, and the medication may need to be stopped
name: Pulmonary fibrosis
label: a
answer: yes
explanation: Transudative pleural effusions are usually caused by fluid overload, such as organ failure (kidney, liver, heart) or through iatrogenic causes. Pleural effusions are usually associated with reduced air entry and dull percussion notes as opposed to fine crackles
name: Transudative pleural effusion
label: d
answer: no
explanation: This is unlikely to be the diagnosis here. Although the patient is likely to be at risk of developing infections such as pneumonia, no other signs of infection are present. Pneumonia does not usually produce fine crackles throughout the lung fields on auscultation
name: Community-acquired pneumonia
label: b
answer: no
explanation: Pleural effusions can be associated with malignancy, and these are usually exudative. Pleural effusions are usually associated with reduced air entry and dull percussion notes as opposed to fine crackles
name: Exudative pleural effusion
label: c
answer: no

Correct answer: a


Learning point: Bleomycin can cause pulmonary fibrosis, characterised by fine crackles on auscultation and progressive breathlessness in affected patients.
An 86 year old female is being referred to the bowel cancer multi-disciplinary team (MDT) for consideration of treatment.
She lives alone in a bungalow, is completely independent with self-care and has an active social life visiting her neighbours, but has to have help from her family with shopping, cleaning and cooking.

What is her WHO performance status?

Options:
explanation: Garde 1 would require her to be able to carry out light housework or work of a sedentary nature
name: Grade 1
label: c
answer: no
explanation: Grade 4 is completely disabled, unable to self-care, and confined to a chair or bed
name: Grade 4
label: e
answer: no
explanation: She is ambulatory and capable of all self-care but unable to carry out any work activities. She is up and about more than 50% of the day
name: Grade 2
label: a
answer: yes
explanation: Grade 3 would suggest that she is only capable of limited self-care and is confined to a bed or chair for >50% of the day
name: Grade 3
label: d
answer: no
explanation: Grade 0 would require her to be fully active and able to carry out all activities of daily living
name: Grade 0
label: b
answer: no

Correct answer: a


Learning point: A WHO performance status of Grade 2 indicates that the patient is "up and about more than 50% of waking hours but is not fully active", meaning they are able to perform light activities but are unable to carry out strenuous work or activities.
An 87-year-old male is admitted to hospital from a nursing home with aspiration pneumonia. He clinically deteriorates, and after discussion with his family, the decision is made to palliate and control his symptoms.
His family are concerned he is becoming increasingly agitated due to his respiratory secretions.

What medication might be of benefit here?

Options:
explanation: Glycopyrronium is a medication from the muscarinic anticholinergic group. It is often used for respiratory tract secretions in palliative care patients who can no longer manage their own secretions due to impaired cough reflex
name: Glycopyrronium
label: a
answer: yes
explanation: Nebulised salbutamol is used in the treatment of airway inflammation. As this patient does not currently have symptoms of airway inflammation, this is not currently indicated, and the use of the nebuliser may be more distressing for the patient
name: Nebulised salbutamol
label: d
answer: no
explanation: Haloperidol is often used in the palliative care setting for agitation and delirium. It may well be beneficial in this case; however, as this patient is likely agitated from his secretions, glycopyrronium will be of more help
name: Haloperidol
label: b
answer: no
explanation: Pain in the palliative setting is important to bear in mind and manage as patients may not be able to communicate fully. Morphine will cause respiratory depression, which again may be of benefit in this patient; however will not help with the distressing secretions
name: Morphine
label: c
answer: no
explanation: High flow oxygen can be very uncomfortable and not well tolerated. This patient's issues are related to respiratory secretions, and oxygen will not assist with those secretions
name: High flow nasal oxygen
label: e
answer: no

Correct answer: a


Learning point: Glycopyrronium is an effective anticholinergic medication used to reduce respiratory secretions in palliative care patients.
A 56-year-old woman presents to her GP with worsening shortness of breath which is worse on exertion. She also experiences breathlessness when lying flat and at night. She has a history of breast cancer, hyperthyroidism and type II diabetes mellitus. On examination, she has bilateral pitting oedema in her ankles. Her medications include tamoxifen, trastuzumab, carbimazole, metformin and linagliptin.

Which of her medications is most likely to be the cause of her symptoms?

Options:
explanation: Tamoxifen is an anti-oestrogen medication use to treat breast cancers that are oestrogen receptor positive. A common side effect is fluid retention, however, it is unlikely to also lead to breathing difficulties
name: Tamoxifen
label: b
answer: no
explanation: Trastuzumab (brand name Herceptin), is a monoclonal antibody against the HER2 receptor. It is prescribed in patients who have breast cancer that overexpresses the HER2 gene. Heart failure is a common side effect of this medication, affecting up to 1 in 10 patients and therefore, regular monitoring is required
name: Trastuzumab
label: a
answer: yes
explanation: Carbimazole is used in the treatment of hyperthyroidism. An important, rare side effect is bone marrow failure. Heart failure is not a known side effect
name: Carbimazole
label: c
answer: no
explanation: Metformin is the first line treatment for type 2 diabetes mellitus. Common side effects include nausea, diarrhoea and abdominal pain. An important, rare side effect is lactic acidosis. Heart failure is not a known side effect
name: Metformin
label: d
answer: no
explanation: Linagliptin is a dipeptidylpeptidase-4 inhibitor that acts to increase insulin secretion. It is a second line treatment for type 2 diabetes mellitus. Heart failure is not a known side effect
name: Linagliptin
label: e
answer: no

Correct answer: a


Learning point: Trastuzumab is a targeted monoclonal antibody used to treat HER2-positive breast cancer by inhibiting the growth of cancer cells; however, it can cause heart failure, leading to symptoms like shortness of breath and peripheral edema, making regular cardiac monitoring essential during treatment.
A 52-year-old woman presented to her GP with a firm lump in her left breast. This was fast-growing and had noticeably increased in size over the last few weeks so that it is now 1cm by 2cm by 1cm. She was sent for an urgent mammogram, ultrasound and biopsy. The biopsy showed a benign phyllodes tumour.

What is the most appropriate initial management?

Options:
explanation: If the tumour is benign, the usual treatment is a lumpectomy. However, if the tumour is larger, then a mastectomy may be more likely to be performed
name: Mastectomy
label: b
answer: no
explanation: The tumour is benign; therefore, lymph node clearance is not necessary
name: Mastectomy plus lymph node clearance
label: c
answer: no
explanation: Chemotherapy may be recommended if the tumour was malignant
name: Chemotherapy
label: d
answer: no
explanation: This tumour is benign; therefore, radiotherapy is not required. Radiotherapy is not often performed in phyllodes tumours
name: Radiotherapy
label: e
answer: no
explanation: Phyllodes tumours account for less than 1% of all breast cancers. Surgery is the main treatment. Tumours can either be benign, borderline or malignant. In this case, the tumour is benign; therefore, a lumpectomy is the best management choice
name: Lumpectomy
label: a
answer: yes

Correct answer: a


Learning point: Phyllodes tumors are rare breast tumors that can be benign or malignant and are characterized by rapid growth; management typically involves surgical removal with a lumpectomy to ensure complete excision and reduce the risk of recurrence.
A 44-year-old woman visits her GP practice because of problems with intermittent, fluctuating hearing loss. She has accompanying symptoms of vertigo and tinnitus. These occurrences tend to last around an hour and have happened a few times in the last month. They were initially in her right ear, but she now experiences the same problems in both ears.

What is the most likely diagnosis?

Options:
explanation: Vertigo, tinnitus and fluctuating hearing loss are classic Ménière's disease symptoms. The hallmark of the disease is that these symptoms are episodic and fluctuating in nature
name: Ménière's disease
label: a
answer: yes
explanation: Otitis media in adults is most likely to present with otalgia. Otitis media can rarely cause vertigo or tinnitus; however it is unlikely to be intermittent or affect both ears simultaneously
name: Otitis media
label: e
answer: no
explanation: BPPV is unlikely, as episodes of vertigo usually last for seconds to minutes and are related to head movement. Hearing loss and tinnitus are not typical features
name: Benign paroxysmal positional vertigo (BPPV)
label: b
answer: no
explanation: Vestibular neuritis and labyrinthitis are sometimes used interchangeably. However, vestibular neuritis refers to inflammation of the vestibular nerve only, whereas labyrinthitis refers to inflammation of the vestibular nerve and the labyrinth. Vestibular neuritis leads to sudden severe vertigo, which is unlikely to be affected by head movement. There is no accompanying hearing loss or tinnitus
name: Vestibular neuritis
label: c
answer: no
explanation: Labyrinthitis and vestibular neuritis are sometimes used interchangeably. However, labyrinthitis refers to inflammation of the vestibular nerve and the labyrinth, whereas vestibular neuritis refers to inflammation of the vestibular nerve only. Labyrinthitis can present with vertigo, hearing loss and tinnitus; however, it is more likely to present suddenly and does not follow a fluctuating course. Labyrinthitis is also more likely to be unilateral
name: Labyrinthitis
label: d
answer: no

Correct answer: a


Learning point: Ménière's disease is characterized by episodic and fluctuating symptoms, including vertigo, tinnitus, and hearing loss, often accompanied by a feeling of fullness in the ear.
A 75-year-old woman visits her GP because she has noticed a facial swelling. This has occurred on the right side of her face and has been slowly growing over the last few months. On examination, the GP feels a small, non-tender, non-fixed lump superior to her right temporomandibular joint. She also notices a slight eversion of the right ear lobe.

What is the most likely cause of this lump?

Options:
explanation: An oncocytoma is a type of tumour that is usually benign and develops from oncocytes. These are epithelial cells that have a high concentration of mitochondria. These most often present in the kidneys, salivary glands or thyroid
name: Oncocytoma
label: e
answer: no
explanation: Pilocytic astrocytomas are brain tumours which most commonly occur in children or young adults. They most often occur in the cerebellum
name: Pilocytic astrocytoma
label: c
answer: no
explanation: Pleomorphic adenoma is the most common tumour of the parotid gland. It is a benign tumour, but in a very small minority of cases can become malignant. Signs of malignant tumours in the parotids are: fast-growth, pain, facial palsy and fixation
name: Pleomorphic adenoma
label: a
answer: yes
explanation: This is the most common malignant tumour of the lacrimal gland. However, it is less common than pleomorphic adenomas and is more likely to present in younger adults. It is more likely to present as fast-growing, painful, with possible accompanying facial palsy and fixation
name: Adenoid cystic carcinoma
label: b
answer: no
explanation: Warthin's tumours are painless and slow growing. However, they are the second most common type of benign tumour occurring in the salivary gland. The most common is a pleomorphic adenoma
name: Warthin's tumour
label: d
answer: no

Correct answer: a


Learning point: Pleomorphic adenoma is the most common benign tumour of the parotid gland, often presenting as a slow-growing, non-tender lump.
A 19-year-old woman presents to her general practitioner (GP) with pain and discharge from her right ear. She reports the symptoms began two days ago after returning from a beach holiday in Spain.

She has no significant past medical history, and her observations are all normal.

On examination, there is tenderness on gentle movement of the right ear. Otoscopy reveals a mildly inflamed and erythematous ear canal with scant white discharge. The tympanic membrane remains intact.

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

Options:
explanation: Ribbon gauze can be used in severe otitis externa if there is significant inflammation of the ear canal that prevents ear drops from passing into the canal. There is only mild inflammation in this case, making topical antibiotics a better first-line option
name: Insert ribbon gauze (Pope wick)
label: d
answer: no
explanation: Acetic acid can be used in the very early stages of infection. In this case, the inflammation, discharge and pain favour using a combination antibiotic/steroid ear drop
name: 2% acetic acid ear drops
label: e
answer: no
explanation: Oral antibiotics are usually not used in otitis externa due to poor penetration of the skin that lines the external ear canal. However, if there is spread beyond this (i.e. to bone or face), then oral antibiotics should be considered
name: Oral flucloxacillin
label: c
answer: no
explanation: The likely diagnosis is acute otitis externa, given the ear pain and characteristic appearances on otoscopy. Swimming and water sports are common risk factors for this condition. Treatment is with topical antibiotic/steroid drops and keeping the ear dry for 7-10 days
name: Offer topical antibiotic/steroid drops and advise keeping the ear dry
label: a
answer: yes
explanation: Uncomplicated otitis externa does not require referral to ENT. Persistent infection and infections in which there is concern about spread beyond the external ear canal would warrant referral
name: Urgent referral to ENT
label: b
answer: no

Correct answer: a


Learning point: Patients with acute otitis externa require topical antibiotic/steroid drops and should be advised to keep the ear dry