hllj/quesmed huggingface dataset:
An 85-year-old man with a background of COPD comes to the emergency department with a 3-day history of breathlessness, fever and a productive cough. His sputum is green. The patient is penicillin allergic.

What is the most appropriate antibiotic to prescribe in this scenario?

Options:
explanation: This would be an appropriate choice if the patient was not allergic to penicillin.
name: Oral amoxicillin
label: d
answer: no
explanation: This is not usually used in IECOPD and the patient is penicillin allergic.
name: IV Tazocin
label: b
answer: no
explanation: This contains penicillin, and co-amoxiclav is not routinely used for IECOPD.
name: Oral co-amoxiclav
label: c
answer: no
explanation: Sputum colour changes mean that  antibiotics are warranted in this scenario.
name: No antibiotics needed
label: e
answer: no
explanation: This describes an infective exacerbation of COPD. NICE guidelines recommend antibiotics in this scenario due to the his sputum being purulent. The three oral antibiotics recommended for IECOPD in the first instance are amoxicillin, doxycycline, or clarithromycin. In this case, the patient is penicillin allergic and therefore doxycycline is the only appropriate option.
name: Oral doxycycline
label: a
answer: yes

Correct answer: a


Learning point: In patients with exacerbation of COPD (IECOPD) who have a penicillin allergy, alternative antibiotics such as tetracyclines (e.g. doxycycline) are used.
A 75-year-old woman with a history of polymyalgia rheumatica is found collapsed by her partner. Her partner remarks that she is likely exhausted after her holiday. Her initial VBG shows:


||||
|---------------------------|:-------:|--------------------|
|Sodium|128 mmol/L|135 - 145|
|Potassium|6.2 mmol/L|3.5 - 5.3|
|Urea|8.4 mmol/L|2.5 - 7.8|
|Fasting Glucose|2.7 mmol/L|3.5 - 5.5|


What is the most likely cause of her collapse?

Options:
explanation: There is no mention of kidney disease, or of uraemic encephalopathy prior to collapse.
name: Uraemia
label: c
answer: no
explanation: Hypoglycaemia can be a feature of adrenal crisis, however the glucose is borderline low and is not the CAUSE of her collapse.
name: Hypoglycaemia
label: b
answer: no
explanation: This may contribute to syncope, but does not explain the electrolyte derangements.
name: Dehydration
label: e
answer: no
explanation: This presentation is representative of adrenal crisis. This patient is likely on long-term steroids for PMR which may have been interrupted whilst the patient was on holiday. Blood test results may show hyponatraemia, hyperkalaemia and hypoglcaemia.
name: Adrenal crisis
label: a
answer: yes
explanation: While the sodium is low, it is likely not low enough to cause collapse.
name: Hyponatraemia
label: d
answer: no

Correct answer: a


Learning point: A sudden stop or reduction in steroid treatment in individuals with a history of adrenal insufficiency can lead to life-threatening adrenal crisis characterised by hyponatraemia, hyperkalaemia, and hypoglycaemia.
A 62-year-old male with a significant alcohol history undergoes emergency endoscopy for haematemesis. Bleeding oesophageal varices are seen during endoscopy and are treated with band ligation.

After the patient is stabilised, what is the most appropriate medication to start to prevent a variceal re-bleed?

Options:
explanation: This is a cardioselective beta blocker, so is not suitable for use to reduce portal pressures.
name: Bisoprolol
label: e
answer: no
explanation: Terlipressin is used in acute phase of variceal bleeds to reduce portal pressures. It is not given prophylactically and has to be administered IV.
name: Terlipressin
label: c
answer: no
explanation: Propranolol is the only non-selective beta blocker listed here and therefore the only one that can reduce portal pressures; all the others are cardioselective.
name: Propranolol
label: a
answer: yes
explanation: This is a cardioselective beta blocker, so is not suitable for use to reduce portal pressures.
name: Metoprolol
label: d
answer: no
explanation: This is a cardioselective beta blocker, so is not suitable for use to reduce portal pressures.
name: Atenolol
label: b
answer: no

Correct answer: a


Learning point: In gastroenterology, non-selective beta blockers, such as propranolol, are the medication of choice for preventing re-bleeding from oesophageal varices due to their ability to reduce portal pressures.
A 24-year-old woman comes to the GP practice with a productive cough and fever. On examination, the GP hears an ejection systolic murmur which radiates to the carotids.

Given the diagnosis, what is the most likely aetiology?

Options:
explanation: This does not explain the murmur and is unlikely in a young patient.
name: Atherosclerosis
label: e
answer: no
explanation: An ASD would cause a soft ejection systolic murmur, but this is unlikely to radiate to the carotids.
name: Atrial septal defect
label: b
answer: no
explanation: The murmur described is likely aortic stenosis. The most common cause of aortic stenosis in a young patient is a bicuspid aortic valve. The fever is likely related to the URTI with the murmur being an incidental finding.
name: Congenitally bicuspid valve
label: a
answer: yes
explanation: Rheumatic fever is a less common cause of aortic stenosis in the UK. Rheumatic fever is classically associated with mitral stenosis.
name: Rheumatic fever
label: d
answer: no
explanation: This is a more likely cause of aortic stenosis in an older patient.
name: Valvular calcification
label: c
answer: no

Correct answer: a


Learning point: In young adults, an ejection systolic murmur radiating to the carotids is most commonly caused by a bicuspid aortic valve resulting in aortic stenosis.
A 12-year-old boy is brought in by ambulance to the emergency department with angioedema and stridor after attending a friend's birthday party.

Which correctly describes the likely diagnosis?

Options:
explanation: This is anaphylaxis, a Type I hypersensitivity reaction mediated by IgE antibodies. Mast cell degranulation and histamine release occur.
name: Type I Hypersensitivity Reaction
label: a
answer: yes
explanation: This involves immune complexes. An example if this would be hypersensitivity pneumonitis, or systemic lupus erythematosus (SLE).
name: Type III Hypersensitivity Reaction
label: c
answer: no
explanation: This involves IgM or IgG antibody mediated reactions. An example of this would be haemolytic disease of the newborn.
name: Type II Hypersensitivity Reaction
label: b
answer: no
explanation: Type V hypersensitivity is a type where stimulating antibodies are produced against a specific receptor (e.g. Graves' disease).
name: Type V Hypersensitivity Reaction
label: e
answer: no
explanation: This is a delayed reaction mediated by T cells, as seen in contact dermatitis.
name: Type IV Hypersensitivity Reaction
label: d
answer: no

Correct answer: a


Learning point: Anaphylaxis is a severe Type I hypersensitivity reaction characterised by rapid onset angioedema and respiratory distress due to IgE-mediated mast cell degranulation.
A 75-year-old male comes to the emergency department with a productive cough, fever, and confusion.

Given the likely diagnosis, which of the following is the least helpful in estimating mortality?

Options:
explanation: This forms a part of the CURB-65 score (Age > 65).
name: Patient's age
label: b
answer: no
explanation: This forms a part of the CURB-65 score (Urea greater than 7 mmol/L).
name: Urea and electrolytes
label: c
answer: no
explanation: This scenario describes a community acquired pneumonia. The CURB-65 score is used to estimate mortality and thus helps inform choice of antibiotic and whether the patient can be managed in the community. LFTs are the only option which do not form a part of the CURB-65 score.
name: Liver function tests
label: a
answer: yes
explanation: Confusion is a component of the CURB-65 (AMTS less than/equal to 8).
name: AMTS
label: e
answer: no
explanation: This forms a part of the CURB-65 score (RR over or equal to 30 breaths per minute, SBP 90mmHg or less or DBP 60mmHg or less).
name: Basic observations
label: d
answer: no

Correct answer: a


Learning point: In estimating the mortality of a patient with suspected community-acquired pneumonia, liver function tests are less relevant compared to other parameters included in the CURB-65 scoring system.
A 68-year-old male comes to the GP with macroscopic haematuria. He denies any dysuria and a urine MCS does not indicate infection. He has a past medical history of GORD, IHD and COPD. He has a 20 pack-year smoking history.

Which of the following malignancies is the most likely cause of the haematuria?

Options:
explanation: This is a less common cause of painless haematuria and there is no mention of an abdominal mass or flank pain.
name: Clear cell renal carcinoma
label: c
answer: no
explanation: Urethral cancer is a much rarer cause of painless haematuria.
name: Squamous cell carcinoma of the urethra
label: e
answer: no
explanation: Painless haematuria in an older male with a significant smoking history is most likely to be caused by transitional cell carcinoma of the bladder.
name: Transitional cell carcinoma of the bladder
label: a
answer: yes
explanation: This is more likely in a patient with chronic inflammation of the bladder (e.g. long term catheter or history of schistosomiasis). It is also less common than TCC of the bladder.
name: Squamous cell carcinoma of the bladder
label: d
answer: no
explanation: This is a less common cause of painless haematuria.
name: Acinar adenocarcinoma of the prostate
label: b
answer: no

Correct answer: a


Learning point: Painless visible blood in the urine in older men, particularly those who smoke, should raise concern for bladder cancer.
A 58-year-old male has some routine blood tests as part of a wellness check. They are found to be hyponatraemic. As a part of further investigation, their GP checks their serum osmolality.

Serum osmolality 285 mosm/kg (275 – 295 mosm/kg)

What is the most likely cause of these blood results?

Options:
explanation: This would cause low serum osmolality and a genuine hypovolaemic hyponatraemia.
name: Loop diuretic use
label: c
answer: no
explanation: This is a pseudohyponatremia as the serum osmolality is normal. All the other options cause a genuine hyponatraemia. Other causes of a similar picture could be hyperglycaemia or the presence of paraproteins in the plasma (such as in myeloma). Hyperlipidaemia causes psuedohyponatremia as sodium is dissolved in plasma and in extreme hyperlipidemia the plasma is displaced by lipids, leading to an inaccurate measurement of sodium
name: Hyperlipidaemia
label: a
answer: yes
explanation: This would cause low serum osmolality and a genuine hypervolaemic hyponatraemia.
name: Cirrhosis of the liver
label: d
answer: no
explanation: This would cause low serum osmolality and a genuine euvolaemic hyponatraemia.
name: SIADH
label: b
answer: no
explanation: This would cause low serum osmolality and a genuine hyponatraemia.
name: Psychogenic polydipsia
label: e
answer: no

Correct answer: a


Learning point: In cases of severe hyperlipidaemia, the displacement of plasma by lipids may result in an artificially low sodium measurement, leading to a diagnosis of hyponatraemia.
A 21-year-old male comes to eye casualty with a red, painful eye. He has a past medical history of Crohn's disease. On slit lamp examination with fluorescein dye, dendritic corneal lesions are seen.

Given the likely diagnosis, what is the most appropriate management?

Options:
explanation: While eye hygiene and warm compresses may help in cases of blepharitis or conjunctivitis, they are not effective for treating viral corneal infections like herpes simplex keratitis.
name: Advise eye hygiene and warm compresses
label: c
answer: no
explanation: This male presenting with a red, painful eye and dendritic corneal lesions on slit lamp examination has a classic presentation of herpetic keratitis (caused by the herpes simplex virus, HSV). His history of Crohn's disease is not directly related to this eye condition, but it is relevant to his overall health. Topical aciclovir eye drops are the first-line treatment for herpetic keratitis. They directly target the herpes simplex virus, reducing viral replication and preventing further damage to the cornea. Early treatment is essential to avoid complications like corneal scarring or vision loss.
name: Topical aciclovir eye drops
label: a
answer: yes
explanation: This combination may be useful in other inflammatory eye conditions, such as uveitis, but in herpes simplex keratitis, it could lead to corneal ulceration and scarring, worsening the prognosis.
name: Topical corticosteroid eye drops and cyclopentolate
label: d
answer: no
explanation: Chloramphenicol eye drops are used primarily for bacterial conjunctivitis, which often presents with a red, itchy eye with discharge. This patient's presentation is more consisent with HSV keratitis and so this is not appropriate.
name: Topical chloramphenicol eye drops
label: e
answer: no
explanation: While oral aciclovir can be effective in treating systemic herpes infections or severe cases, topical treatment is generally preferred for localised herpetic keratitis. Oral aciclovir is used if there is a lack of response to topical therapy or in severe recurrent cases.
name: Oral aciclovir
label: b
answer: no

Correct answer: a


Learning point: Herpetic keratitis presents with dendritic corneal lesions and is treated with topical aciclovir to prevent complications such as corneal scarring.
An 18-year-old male attends the GP complaining of weakness and tingling of their legs. They have just started university and state they are drinking 40 units of alcohol a week and taking nitrous oxide recreationally. They have no other past medical history. On examination, they have a positive Babinski sign bilaterally with brisk ankle jerks and absent knee jerks. They also have loss of proprioception.

What is the most likely diagnosis?

Options:
explanation: This would not cause sensory symptoms.
name: Motor neurone disease
label: b
answer: no
explanation: This would cause a stamping gait and is usually seen in older patients.
name: Tabes dorsalis
label: d
answer: no
explanation: There is no mention of fever, back pain, or risk factors for abscess formation.
name: Epidural abscess
label: e
answer: no
explanation: This is a classic combination of symptoms and signs seen in subacute degeneration of the spinal cord, of which nitrous oxide use is a significant risk factor. B12 deficiency can also cause this.
name: Subacute combined degeneration of the spinal cord
label: a
answer: yes
explanation: The history does not mention multiple presentations over time across different areas of the body.
name: Multiple sclerosis
label: c
answer: no

Correct answer: a


Learning point: Subacute combined degeneration of the spinal cord, characterized by progressive weakness, sensory deficits, and impaired coordination, is commonly associated with vitamin B12 deficiency, which impairs myelin synthesis, and can also result from nitrous oxide use, which inactivates vitamin B12 and disrupts normal neurological function.
A 67 year old male smoker has haemoptysis and 5kg of weight loss over the last 3 months. On examination, a loud monophonic wheeze is heard over the medial aspect of the right middle zone. His renal profile shows hyponatraemia.

What is the most likely diagnosis?

Options:
explanation: Whilst this is the most common type of non-small cell lung cancer, it tends to be associated with hypertrophic pulmonary osteoarthropathy rather than hyponatraemia. This would present as bony inflammation in the wrists/ankles.
name: Adenocarcinoma of the lung
label: c
answer: no
explanation: This history suggests lung cancer based on the patient being a smoker combined with the weight loss and haemoptysis. A monophonic wheeze indicates one airway being obstructed rather than multiple, further indicating a possible tumour. Hyponatraemia is caused by paraneoplastic SIADH, which is more commonly associated with small cell lung cancer rather than the other options listed. Furthermore, small cell lung cancer tends to be more centrally located rather than peripherally.
name: Small cell lung cancer
label: a
answer: yes
explanation: Large cell lung cancer is least common type of non-small cell lung cancer listed as an option here and does not tend to be associated with SIADH. More commonly they are associated with gynaecomastia due to B-hCG production.
name: Large cell lung cancer
label: b
answer: no
explanation: Although, this is more commonly centrally located, it is associated with different paraneoplastic syndromes. Namely, hypercalcaemia due to PTHrP.
name: Squamous cell carcinoma of the lung
label: d
answer: no
explanation: Whilst haemoptysis and weight loss can occur in active pulmonary TB. The smoking history, examination findings and presence of hyponatraemia all suggest lung cancer is more likely than TB.
name: Active pulmonary tuberculosis
label: e
answer: no

Correct answer: a


Learning point: Small cell lung cancer often presents with haemoptysis, weight loss, and can cause hyponatraemia due to paraneoplastic syndromes like SIADH.
A 47 year old female has shortness of breath 2 days after her subtotal colectomy. She has reduced air entry in both lung bases and a slightly elevated respiratory rate with normal oxygen saturations. Her calves are soft and non tender.

Given the likely diagnosis, what is the most appropriate management option?

Options:
explanation: This patient is not wheezy and the history does not suggest an asthma/COPD exacerbation. This is unlikely to improve the clinical picture.
name: Give STAT salbutamol nebulisers
label: c
answer: no
explanation: The history does not describe acute abdomen or other concerning features that could be addressed by a return to theatre such as peritonitis or abdominal distension.
name: Immediate return to theatre for emergency surgery
label: d
answer: no
explanation: Although pneumonia could cause shortness of breath, there is no history of a cough or fever, or description of crackles. Whilst a CXR would definitely be sensible, starting antibiotics based on this presentation alone would not be appropriate.
name: Commence clarithromycin 500mg BD PO
label: e
answer: no
explanation: Whilst sudden onset SOB in a post operative patient  should always lead to consideration of PE, the Well’s score in this case is 1.5, which means an initial d-dimer would be more appropriate than going straight to a CTPA. Additionally, the examination findings would be inconsistent with the diagnosis of PE.
name: Arrange a CTPA
label: b
answer: no
explanation: This describes atelectasis, small areas of collapse which often occur following abdominal surgery due to pain on deep breathing and coughing, leading to incomplete clearing of secretions. This is usually managed conservatively at first, with chest physiotherapy and pain relief to allow proper clearing of secretions.
name: Chest physiotherapy and optimise pain control
label: a
answer: yes

Correct answer: a


Learning point: Post-operative atectasis following abdominal surgery is often managed initially with chest physiotherapy and pain control to facilitate clearance of secretions.
A 57 year old male has a dry cough. His past medical history includes ischaemic heart disease and a previous renal transplant. On examination, his chest is clear but his saturations drop after walking around the room. He has no medication allergies.

Given the likely diagnosis, what is the most appropriate antibiotic to prescribe?

Options:
explanation: This antibiotic is typically not used to treat pneumonia and would not cover for suspected Pneumocystis jirovecii pneumonia.
name: Cefuroxime
label: d
answer: no
explanation: Whilst this would cover some other causative organisms of atypical pneumonia it is not a treatment of choice for suspected Pneumocystis jirovecii pneumonia.
name: Clarithromycin
label: b
answer: no
explanation: This antibiotic is typically not used to treat pneumonia and would not cover for suspected Pneumocystis jirovecii pneumonia.
name: Ciprofloxacin
label: e
answer: no
explanation: Whilst this forms part of the first line treatment for severe community acquired pneumonia it would cover for suspected Pneumocystis jirovecii pneumonia.
name: Co-amoxiclav
label: c
answer: no
explanation: In a patient who is immunosuppressed with a dry cough and exercise induced desaturations, Pneumocystis jirovecii pneumonia should be suspected. This is initially treated with co-trimoxazole and would not be covered by the other antibiotics listed below.
name: Co-trimoxazole
label: a
answer: yes

Correct answer: a


Learning point: Immunosuppressed patients with dry coughs and exercise-induced desaturations should be suspected of having Pneumocystis jirovecii pneumonia, which requires co-trimoxazole for treatment.
A 67 year old woman has not opened her bowels 5 days after an emergency open splenectomy. On examination, she has abdominal distension, mild generalised tenderness with no guarding and absent bowel sounds. She has a past medical history of heart failure.

What is the most likely diagnosis?

Options:
explanation: This would likely present with signs of peritonitis; rebound tenderness, guarding and a rigid abdomen.
name: Bowel perforation
label: d
answer: no
explanation: Whilst this could explain an absence of bowel movements post operatively, it would normally present with lower abdominal discomfort and no change in bowel sounds.
name: Faecal loading
label: c
answer: no
explanation: Small bowel obstruction would likely present with more predominant nausea and vomiting. Bowel sounds are classically described as “tinkling” rather than absent.
name: Small bowel obstruction
label: b
answer: no
explanation: In a post-operative patient with absent bowel sounds and a distended abdomen, ileus is most likely. This is a functional obstruction due to decreased bowel motility. Risk factors for it include manual handling of the bowel during surgery (more likely in open surgery) and certain pre-existing medical conditions, including heart failure.
name: Post-operative ileus
label: a
answer: yes
explanation: Whilst this could explain some of the symptoms, there would often be more severe pain than described in the scenario above. Bowel sounds are classically described as “tinkling” rather than absent.
name: Large bowel obstruction
label: e
answer: no

Correct answer: a


Learning point: Post-operative ileus is a common complication characterised by reduced bowel motility, often following abdominal surgery, particularly in patients with pre-existing conditions.
A 23 year old man with known ulcerative colitis is referred to the Emergency Department by his GP for management of an acute flare. A CT scan shows evidence of colitis. He has a temperature of 38.6 degrees.

What is the most appropriate management?

Options:
explanation: Topical aminosalicylates may be used for mild-moderate IBD flares. As this patient has a temperature over 37.8 degrees, they are experiencing a severe flare.
name: Rectal mesalazine foam
label: b
answer: no
explanation: The patient is suffering from a severe flare of ulcerative colitis according to the Trulove and Witts critera, as he has a temperature of over 37.8 degrees. Other severe features are tachycardia (>90bpm), >6 bloody stools a day, haemoglobin <105g/L, or an ESR >30mm/h / CRP >30 mg/dL. IV steroids are indicated.
name: Intravenous corticosteroids
label: a
answer: yes
explanation: Steroids should be administered first, with non-responders progressing to biologic rescue therapy.
name: Start infliximab
label: d
answer: no
explanation: This may be required if the patient fails conservative management or has features of perforation.
name: Pancolectomy
label: e
answer: no
explanation: Oral antibiotics are not indicated in flares of IBD.
name: Oral antibiotics
label: c
answer: no

Correct answer: a


Learning point: A severe ulcerative colitis flare is indicated by a temperature above 37.8 degrees, requiring intravenous corticosteroids as part of the management.