hllj/quesmed huggingface dataset:
A 78-year-old male presents to his GP. He was recently discharged from hospital for treatment of community-acquired pneumonia. He now complains of six to eight episodes of watery stool per day with some non-specific central abdominal cramps. His bloods reveal a white cell count of 13.5 x 10<sup>9</sup>/L (4.5 - 11).

Which of the following is the most likely diagnosis?

Options:
explanation: *Clostridium difficile* (CDI) is a gram-positive bacteria that can cause pseudomembranous colitis, commonly seen in patients who have recently been on a course of broad-spectrum antibiotics as likely in this case. Other risk factors include hospital stays and being over 65 years of age- both of which are present in this case too. Three of the most common symptoms are watery diarrhoea (which can be bloody), painful abdominal cramps and nausea.
name: *Clostridium difficile* infection
label: a
answer: yes
explanation: This is a diagnosis which more commonly causes constipation. Classically, acute appendicitis presents as progressive peri-umbilical pain that moves to the right iliac fossa. Nausea and one to two episodes of vomiting are also common and not present in this case.
name: Acute appendicitis
label: d
answer: no
explanation: Symptoms of IBS are abdominal discomfort or pain that is relieved by defecation or associated with altered bowel frequency or stool form which is present here. However, the diagnostic criteria is of these symptoms and at least two of: altered stool passage (e.g. straining or urgency), abdominal bloating, symptoms made worse by eating or passage of mucous. Two of these are not present in this case.
name: Irritable bowel syndrome (IBS)
label: c
answer: no
explanation: Symptoms of ulcerative colitis are classically diarrhoea containing blood or mucous, tenesmus or urgency and pain in the left iliac fossa. There is often associated weight loss and/or fever. The case described in this question is not in keeping with these.
name: Ulcerative colitis
label: b
answer: no
explanation: This can present with abdominal pain. However, the most common features are abdominal bloating and vomiting (bilious often), which are not mentioned here. They may also experience a failure to pass flatus or stool, rather than loose stool.
name: Small bowel obstruction
label: e
answer: no

Correct answer: a
A previously well 26-year-old female smoker presents to her GP. She complains of three weeks of crampy right iliac fossa abdominal pain with non-bloody diarrhoea on average 10x per day.

Which of the following is the most likely diagnosis?

Options:
explanation: Symptoms of ulcerative colitis classically include diarrhoea. However, the stool normally contains blood or mucus. Other symptoms include tenesmus or urgency, and pain in the left iliac fossa. There is often associated weight loss and/or fever. The case described in this question is less in keeping with this.
name: Ulcerative colitis
label: c
answer: no
explanation: Symptoms of IBS are abdominal discomfort or pain that is relieved by defecation or associated with altered bowel frequency or stool form which is present here. However, the diagnostic criteria is of these symptoms and at least two of: altered stool passage (e.g. straining or urgency), abdominal bloating, symptoms made worse by eating or passage of mucous. Two of these are not present in this case.
name: Irritable bowel syndrome (IBS)
label: d
answer: no
explanation: This is a condition most commonly seen in female smokers aged between 15 and 40. The right-sided abdominal pain and extreme number of diarrhoeal episodes are also indicative of Crohn's disease.
name: Crohn's disease
label: a
answer: yes
explanation: Bowel obstructions would usually present more acutely than over a three-week period. Additionally, the commonest causes of large bowel obstructions are cancer, volvulus and diverticular disease which are rare in a person of this age. Inflammatory bowel disease, which is most likely in this case, may lead to a small bowel obstruction but is unlikely to cause a large bowel obstruction. Lastly, bowel obstruction would likely present with an absence of passing stool and flatulus, whereas the opposite is true in this case.
name: Large bowel obstruction
label: b
answer: no
explanation: Clostridium difficile (CDI) is a gram-positive bacteria that can cause pseudomembranous colitis, commonly seen in patients who have recently been on a course of broad-spectrum antibiotics, which is not seen in this case. Other risk factors include hospital stays and being over 65 years of age, which are both absent in this case too. CDI does cause watery diarrhoea which can be bloody. However, it is classically associated with painful abdominal cramps and/or nausea.
name: Clostridium difficile infection
label: e
answer: no

Correct answer: a
A 52-year-old woman is seen in the General Practice surgery. She complains of progressive upper abdominal pain and heartburn for the last month despite lifestyle changes. This is the second time she has presented to her GP with this complaint. She is currently taking no medication and denies nausea and vomiting or weight loss. Her abdominal examination is unremarkable.

Which of the following is the next best investigation?

Options:
explanation: NICE clinical guideline CG184 states dyspepsia in unselected people in primary care is defined broadly to include people with recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting. They state to offer H pylori 'test and treat' to people with dyspepsia.
name: Stool antigen test for Helicobacter pylori (H. pylori) infection
label: a
answer: yes
explanation: This investigation is not used in the work-up for dyspepsia. It is often the first imaging test used to evaluate and diagnose the source of acute pain in the abdominal region and/or lower back as well as unexplained nausea and vomiting.
name: Abdominal X-ray
label: d
answer: no
explanation: The test is commonly performed in people who have difficulty swallowing, a sensation of food being “stuck”, or pain on swallowing. Indigestion or dyspepsia are rarely indications, but would not be considered before H. pylori is ruled out and is not favoured over endoscopy.
name: Barium swallow
label: e
answer: no
explanation: There are no red flags in this case as yet to merit an endoscopy and certainly a H. pylori test would be first-line before invasive endoscopy is considered. In this patient, a full-dose proton pump inhibitor for four to eight weeks should also be trialled before considering endoscopy.
name: Upper GI endoscopy
label: b
answer: no
explanation: This investigation has no place in the work-up for dyspepsia. It is often used to visualise the kidneys, liver, gallbladder, bile ducts, abdominal aorta and pancreas.
name: USS Abdomen
label: c
answer: no

Correct answer: a
A normally well 19-year-old male presents to the GP with a three-week history of insidious onset crampy left iliac fossa abdominal pain, bloody diarrhoea 12-14 times per day and significant weight loss.

Which of the following is the most likely diagnosis?

Options:
explanation: The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years. It is more common in men. The three symptoms described in the stem are the typical presenting features. Others include urgency and tenesmus.
name: Ulcerative Colitis
label: a
answer: yes
explanation: Symptoms of IBS are abdominal discomfort or pain that is relieved by defecation OR associated with altered bowel frequency or stool form which is present here. However, the diagnostic criteria is of these symptoms and at least two of: altered stool passage (e.g. straining or urgency), abdominal bloating, or symptoms made worse by eating or passage of mucous. Two of these are not present in this case.
name: Irritable bowel syndrome (IBS)
label: b
answer: no
explanation: This is a diagnosis which more commonly causes constipation. Classically, acute appendicitis presents as progressive peri-umbilical pain that moves to the right iliac fossa and not cramping. Nausea and one to two episodes of vomiting are also common, and not present in this case.
name: Acute appendicitis
label: d
answer: no
explanation: This can present with abdominal pain. However, the most common features are abdominal bloating and vomiting (often bilious) not mentioned here. They may also experience a failure to pass flatus or stool, rather than loose stool as in this case.
name: Small bowel obstruction
label: c
answer: no
explanation: This is a condition most commonly seen in those aged between 15 and 40. However, it is more common in females. The typical presentation is most often non-bloody diarrhoea although blood can be seen in rarer advanced Crohn's colitis. The right iliac fossa is where abdominal pain is most often described in Crohn's, rather than the left as in this case.
name: Crohn's disease
label: e
answer: no

Correct answer: a
A 68-year-old male presents to the emergency department after four recurrent episodes of haematemesis. He reports each episode was approximately two tablespoons of fresh red blood. On further questioning, he reveals an eight-week history of progressive dysphagia to solids, especially meat, and associated fatigue. He denies abdominal pain. He has a past medical history of diverticulosis and hypertension. His medications are ramipril only. He is a long-term smoker of ten cigarrettes per day and he does not drink alcohol.

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

Options:
explanation: Symptoms of progressive dysphagia and weight loss in a smoker are always highly suggestive of oesophageal malignancy. Unfortunately, these malignancies can bleed as they advance and cause haematemesis as seen here. Most often it is a small volume of blood, except as a preterminal event with erosion of major vessels. The bleeding may be recurrent until the malignancy is effectively managed.
name: Oesophageal malignancy
label: a
answer: yes
explanation: Similar to gastric ulcers, this diagnosis usually has known antecedent reflux-type symptoms. It presents with a smaller volume of fresh blood, often streaking vomit. Medications are frequently responsible which include tetracycline antibiotics, NSAIDs and bisphosphonates.
name: Oesophagitis
label: e
answer: no
explanation: This occurs following bouts of repeated vomiting, often secondary to acute alcohol intoxication.
name: Mallory-Weiss tear
label: d
answer: no
explanation: Varices usually present with a much larger volume of fresh blood. They are often associated with haemodynamic compromise too. Varices may stop spontaneously but re-bleeds are common until they are appropriately managed. They arise through portal hypertension, most commonly secondary to cirrhosis, not present in this case.
name: Oesophageal varices
label: c
answer: no
explanation: This is a fairly rare diagnosis with duodenal ulcers being four times more common. Gastric ulcers may well cause frank haematemesis or may present with altered blood mixed with vomit. There are usually prodromal features of dyspepsia and/or medication culprits such as NSAIDs, steroids or SSRIs though. Alcohol is another risk factor not present in this case.
name: Gastric ulcer
label: b
answer: no

Correct answer: a
A 42-year-old male presents to his GP with a flare of his chronic plaque psoriasis on his knee. It is not significantly scaly. He is currently using over-the-counter emollients which control the plaque when not flared.

Which of the following is the most appropriate initial pharmacotherapy to treat his flare?

Options:
explanation: If there is a poor response after the initial four weeks of treatment with no obvious explanation then stopping the potent corticosteroid and only applying a topical vitamin D preparation twice a day for up to 12 weeks can be considered. It is not used alone as an initial flare-up treatment.
name: Topical vitamin D preparation alone
label: d
answer: no
explanation: Courses of topical treatments (including corticosteroids) are used as needed to maintain satisfactory control of psoriasis, reinforcing the advice on the safe use of potent topical corticosteroids. For significant flares, a topical Vitamin D preparation should be used as well.
name: Potent topical corticosteroid alone
label: c
answer: no
explanation: This would only be offered if there is still a poor response after eight to twelve weeks of treatment with a vitamin D preparation alone twice a day.
name: Coal tar preparation
label: e
answer: no
explanation: This is generally considered if the scale is the primary problematic feature of the psoriasis, which is specifically mentioned not to be the case here.
name: Salicylic acid preparation
label: b
answer: no
explanation: According to the current NICE CKS guidance on trunk and limb psoriasis, the first-line treatment for a flare of plaque psoriasis affecting extensors is a potent topical corticosteroid plus a topical vitamin D preparation (both applied once a day, but at different times of day). This is then reviewed at four weeks to assess the response of treatment. Generally, one should not prescribe potent corticosteroids for more than eight weeks at any one site.
name: Potent topical corticosteroid plus a separate topical vitamin D preparation
label: a
answer: yes

Correct answer: a
A 78-year-old female admitted for falls is reviewed by the dermatology doctors on the geriatric ward. She has itchy, tense and firm fluid-filled blisters symmetrically distributed over her trunk only. Nikolsky's sign is negative.

Which of the following is the most likely explanation for this patient’s physical findings?

Options:
explanation: Erythema multiforme (EM) is also a hypersensitivity reaction that in 90% of cases is triggered by infection. The commonest infective cause is Herpes simplex virus. It presents with well-defined circular papules which evolve at different stages to form a 'target-shaped' lesion of three concentric rings of different colours. The rash tends to start on the palms/soles and spreads up the limbs to the trunk.
name: Erythema multiforme
label: e
answer: no
explanation: This is a condition most often seen in children with atopic eczema. It often presents as a rapidly progressing painful rash. On examination, monomorphic punched-out erosions (circular, depressed, ulcerated lesions) usually 1–3 mm in diameter are typically seen.
name: Eczema herpeticum
label: d
answer: no
explanation: This is a type II hypersensitivity reaction condition most often seen in the elderly. It presents with deep, tense blisters. Unlike pemphigus vulgaris, the oral mucosa is rarely affected, although this is not mentioned here. Nikolsky sign is negative importantly.
name: Bullous pemphigoid
label: a
answer: yes
explanation: This condition typically features fragile, superficial blisters that rupture easily and desquamation. Nikolsky sign is most often positive.
name: Pemphigus vulgaris
label: b
answer: no
explanation: This is an autoimmune blistering condition but is associated with coeliac disease. It presents with itchy, vesicular skin lesions on the extensor surfaces (e.g. elbows, knees, buttocks). It is slightly more common in men too.
name: Dermatitis herpetiformis
label: c
answer: no

Correct answer: a
A six-year-old male presents to his GP with his mother. Over the last week, he has developed an itchy, erythematous, poorly demarcated rash. It is approximately 5cm x 3cm and is located in the region over the flexural aspect of his left elbow. His medication is salbutamol for asthma only. On further questioning, his mum reveals he suffered from some dry skin on his hands a few months ago too which cleared with over-the-counter emollients.

Which of the following is the most likely diagnosis?

Options:
explanation: This presents as an annular patch or plaque with a slightly raised, sometimes scaly, border and central clearing.
name: Fungal infection
label: c
answer: no
explanation: This typically presents with red, sharply marginated lesions with greasy scales; usually confined to areas with sebaceous gland activity (for example ears, beard area, eyebrows, scalp, and nasolabial folds).
name: Seborrhoeic dermatitis
label: b
answer: no
explanation: The National Institute for Health and Care Excellence (NICE) states that atopic eczema is likely if there is an itchy skin condition plus visible flexural eczema involving the skin creases, a personal history of asthma or allergic rhinitis (hayfever) and a personal history of dry skin in the last 12 months. Other criteria not present here include onset of signs and symptoms before the age of two years and personal history of flexural eczema.
name: Atopic dermatitis
label: a
answer: yes
explanation: This is a less itchy rash. It normally presents with well-circumscribed, reddish, flat-topped plaques with silvery scales. It is also typically symmetrical and on the extensor surfaces.
name: Psoriasis
label: e
answer: no
explanation: Scabies or other infestations should be suspected when there is a recent onset of an itchy rash in a family. It features widespread pruritus with linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist.
name: Scabies
label: d
answer: no

Correct answer: a
An otherwise well 68-year-old female presents with pain after activity in her right groin. It started over a year ago and has been gradually worsening. Her GP sends her for a weight-bearing pelvic x-ray which reports loss of joint space, obvious osteophytes and subchondral sclerosis in the right hip joint.

Which of the following is the most likely diagnosis?

Options:
explanation: Transient osteoporosis of the hip is a rare condition that causes bone loss temporarily in the superior section of the femur. It is mostly found in young or middle-aged men between the ages of 30 and 60, and women in their later stages of pregnancy or early postpartum period (following childbirth). The majority of patients present with a sudden onset of pain in the groin area.
name: Transient osteoporosis
label: d
answer: no
explanation: This is is the death of the femoral head as a result of the vascular disruption. Symptoms are often similar to osteoarthritis. In mild-to-moderate AVN, radiographs may demonstrate sclerosis, although normally concomitant changes in bone density are noted. In advanced disease, bone deformities, such as flattening, subchondral radiolucent lines (crescent sign), and collapse of the femoral head, are evident.
name: Avascular necrosis (AVN)
label: e
answer: no
explanation: This causes lateral hip pain and is thought to be caused by inflammation of the trochanteric bursa. It often presents with pain which can radiate to the lateral knee when side-lying on the affected side or when sitting down for prolonged periods. It is typically investigated with ultrasound and then MRI if required.
name: Trochanteric bursitis
label: b
answer: no
explanation: Pain in a joint which is worse with activity is typical of osteoarthritis. X-ray signs associated with osteoarthritis are nonuniform joint space loss, osteophyte formation, cyst formation and subchondral sclerosis.
name: Osteoarthritis
label: a
answer: yes
explanation: This would be unusual to present initially in the hip region. It would also normally present with morning stiffness lasting over an hour and/or systemic symptoms of fatigue, fever or loss of appetite. The pain generally gets better after activity. X-ray features would include erosions or significant soft tissue swelling.
name: Rheumatoid arthritis
label: c
answer: no

Correct answer: a
A 74-year-old diabetic man attends his GP with a six-week history of a painful and slightly stiff right shoulder. He complains of not being able to dry his hair or sleep at night due to the pain. On examination, there is restriction in all movements of his shoulder due to the pain but most significantly reduced passive external rotation. You suspect adhesive capsulitis (frozen shoulder).

Which of the following is the best next step in the management of this patient in primary care?

Options:
explanation: NICE guidance states to offer analgesia, particularly in the early, painful phase. Paracetamol is considered first-line. Regular dosing is more effective than 'as required use'. If paracetamol is ineffective, consider an oral NSAID (for example, ibuprofen) or codeine.
name: Simple analgesia
label: a
answer: yes
explanation: This is a type of scan typically only requested by secondary care specialists.
name: MRI
label: e
answer: no
explanation: This is appropriate if the person has had pain and/or stiffness for up to three months and has not benefited from conservative measures.
name: Referral to secondary care
label: c
answer: no
explanation: NICE states to consider an intra-articular (glenohumeral) corticosteroid injection early in the course of frozen shoulder if there is no, or slow, progress with initial conservative treatment.
name: Intra-articular (glenohumeral) corticosteroid injection
label: b
answer: no
explanation: This is typically only requested by secondary care specialists to investigate the rotator cuff and is particularly useful in diagnosing shoulder impingement, shoulder instability or rotator cuff disorders.
name: Ultrasound scan
label: d
answer: no

Correct answer: a
A 30-year-old mother of a six-month-old infant presents to the orthopaedic outpatient clinic with a complaint of pain in her right wrist for three weeks. The pain is on the radial side of the wrist and, on examination, Finkelstein test is found to be positive.

Which of the following is the most likely diagnosis?

Options:
explanation: De Quervain's tenosynovitis is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30-50 years old. Finkelstein's test is positive (on grasping the patient's thumb and abducting the hand to the ulnar side, there is pain over the radial styloid process). Having a young child is a risk factor as the inflammation can occur due to repeatedly lifting up a child.
name: De Quervain's Tenosynovitis
label: a
answer: yes
explanation: Radial nerve entrapment may occur at any point along the anatomic course of the nerve. The most frequent site of compression is in the proximal forearm. It results in numbness, paresthesia, pain, and weakness in the radial nerve distribution.
name: Radial nerve entrapment
label: d
answer: no
explanation: A scaphoid fracture is fracture of the scaphoid bone, mostly caused by trauma. Symptom includes pain at the base of the thumb, which is worse with use of the hand.
name: Scaphoid fracture
label: c
answer: no
explanation: Osteoarthritis is a chronic inflammatory condition of joints and is unlikely in this young patient.
name: Osteoarthritis
label: e
answer: no
explanation: Carpal tunnel syndrome occurs following compression of the median nerve within the carpal tunnel. The symptoms include numbness, paresthesia, and pain in the median nerve distribution.
name: Carpal Tunnel Syndrome
label: b
answer: no

Correct answer: a