hllj/quesmed huggingface dataset:
A 26-year-old man presents to the GP with pain on movement in his left knee and ankle. He has also noticed pain in his eyes at times, with some watery discharge and a stinging sensation when urinating. He was treated for chlamydia three weeks ago and has a past medical history of severe acne which has now resolved. On examination, the patient has bloodshot eyes, and pain on passive and active movement of the left knee and ankle joints. No discharge is seen from the penis. He is apyrexial and feels otherwise well.

Given the patient's presentation, what is the most likely diagnosis?

Options:
explanation: Although pseudogout can cause an inflammatory asymmetrical oligoarthritis, it more commonly affects just one joint, with pain that worsens over a number of weeks with associated swelling, warmth and tenderness. Pseudogout is typically seen in older patients, and microscopy of the joint fluid would show positively birefringent rhomboid-shaped crystals.
name: Pseudogout
label: e
answer: no
explanation: Reactive arthritis typically presents with the triad of arthritis, sterile urethritis, and conjunctivitis. This is a sterile inflammatory arthritis which typically occurs one-four weeks after a sexually-transmitted or gastrointestinal infection. When the inflammation also affects the eye and bladder or prostate, it can cause conjunctivitis and urethritis. This is typically a self-limiting condition and is usually managed conservatively with NSAIDs and rest.
name: Reactive arthritis
label: a
answer: yes
explanation: Septic arthritis would present as a systemically unwell patient, often with an acutely inflamed, hot, swollen joint. Movement of the joint will be limited. Aspiration and culture of the joint fluid will identify the causative agent - the most common of which is staphylococcus aureus.
name: Septic arthritis
label: d
answer: no
explanation: Rheumatoid arthritis classically presents as a symmetrical polyarthritis, with warm and tender joints. It usually affects the joints of the hands, wrists, and feet. Other signs of rheumatoid arthritis include improvement of symptoms during movement. It is associated with females and smokers.
name: Rheumatoid arthritis
label: c
answer: no
explanation: Psoriatic arthritis typically affects patients with pre-existing psoriasis, not acne. It is characterised by a personal history of psoriatic rash with arthritis. This may present as a symmetrical polyarthritis or an asymmetrical oligoarthritis. It is unlikely to cause the sterile urethritis and conjunctivitis seen in this patient.
name: Psoriatic arthritis
label: b
answer: no

Correct answer: a
A 24-year-old man falls onto an outstretched hand whilst playing football. He experiences bruising and tenderness on palpation of the anatomical snuff box, with pain on telescoping the thumb.

Based on the likely injury, which of the following complications is the patient most at risk of developing?

Options:
explanation: Cubital tunnel syndrome is compression of the ulnar nerve as it passes through the cubital tunnel at the elbow. This patient did not injure his elbow in his fall, making this incorrect. Cubital tunnel syndrome would present with pain at the elbow (medial), with sensory disturbance of the 4th and 5th digits, hypothenar eminence, and ulnar side of the dorsum of the hand.
name: Cubital tunnel syndrome
label: c
answer: no
explanation: This is a condition resulting from progressive fibrotic thickening of the palmar fascia and is not related to traumatic injury. It is most often idiopathic and would cause a fixed flexion deformity of the 4th and 5th digits.
name: Dupuytren's contracture
label: e
answer: no
explanation: The patient has likely suffered a scaphoid fracture following a fall onto an outstretched hand. The major risk of scaphoid fracture is avascular necrosis, which would present with pain and stiffness at the wrist. This complication is due to the artery supplying the scaphoid bone being at increased risk of damage due to its anatomical position in the hand and the fact that it provides a retrograde blood supply.
name: Avascular necrosis
label: a
answer: yes
explanation: The radial nerve may be damaged at a number of sites in the arm. However, this is unlikely given the mechanism of this injury. A radial nerve injury can result in reduced sensation in the anatomical snuff box, but is less likely to cause pain here. Damage may result in wrist/finger drop.
name: Radial nerve palsy
label: d
answer: no
explanation: Carpal tunnel syndrome is due to entrapment of the median nerve within the carpal tunnel of the wrist. It is often idiopathic, but may occur secondary to other conditions. The median nerve is unlikely to be affected when falling on an outstretched hand, and would not cause pain within the anatomical snuff box.
name: Carpal tunnel syndrome
label: b
answer: no

Correct answer: a
A 71-year-old lady presents to her GP complaining of worsening back pain and fatigue over the last three months. She has a past medical history of depression, multiple hip fractures, and pneumonia for which she was hospitalised earlier this year.
Blood tests are performed which show the following: 


||||
|--------------|:-------:|---------------|
|Haemoglobin|101  g/L|(M) 130 - 170, (F) 115 - 155|
|Platelets|109x10<sup>9</sup>/L|150 - 400|
|Creatinine|134 µmol/L|60 - 120|
|Calcium|3.2 mmol/L|2.2 - 2.6|


The GP suspects myeloma and organises an urgent referral for the patient to receive further investigations. Based on the diagnosis, investigations looking for which of the following is most likely to be positive?

Options:
explanation: Spherocytes are found in some immune-mediated haemolytic anaemias and in hereditary spherocytosis. They are misshapen but otherwise healthy red blood cells which are broken down by the spleen (auto-haemolysis). Increased reticulocytes would also be seen - a marker of increased red blood cell turnover.
name: Spherocytes
label: d
answer: no
explanation: Urinary catecholamines would be investigated in a patient with suspected phaeochromocytoma - a rare catecholamine-secreting tumour causing the triad of headache, palpitations and diaphoresis. These would not be raised in a patient with multiple myeloma.
name: Urinary catecholamines
label: e
answer: no
explanation: These are pathognomonic findings in Hodgkin lymphoma, following a core needle biopsy of an affected lymph node. These are not associated with multiple myeloma.
name: Reed-Sternberg cells
label: c
answer: no
explanation: This patient is likely to have multiple myeloma. This typically presents with hypercalcaemia, renal impairment, anaemia, and bone lesions (mnemonic - CRAB). The most common presenting complaint in patients with multiple myeloma is back pain, which may be accompanied by frequent infections (bone marrow suppression). Bence-Jones proteins form a part of regular antibodies called light chains, which are not normally found in urine. In multiple myeloma, plasma cells divide uncontrollably increasing the total number of antibodies as well as the amount of free Bence-Jones protein. These proteins are small enough to be filtered out by the kidneys on their own which can be detected.
name: Bence-Jones protein
label: a
answer: yes
explanation: Smear cells are associated with chronic lymphoid leukaemia (CLL), not multiple myeloma. CLL is the most common form of leukaemia in older people, and is often found incidentally in asymptomatic patients. It typically presents with bone marrow failure causing anaemia, infections and bleeding, and may also have lymphadenopathy and hepatosplenomegaly. Smear cells are lymphpocytes whose cell membranes have ruptured during the preparation of the blood film.
name: Smear cells
label: b
answer: no

Correct answer: a
An 82-year-old female inpatient on the diabetes and endocrine ward falls after going to the toilet and suffers a fractured hip. A DEXA scan is ordered for the patient which gives a T-score of -1.7. An X-ray of her hip shows reduced bone trabecular bone density. She has no past medical history of any fractures other than a broken leg at the age of 24. The patient's serum vitamin D and calcium are within normal ranges and she denies any pain other than in her hip.

What is the most likely underlying cause for the patient's hip fracture?

Options:
explanation: The patient's T-score of -1.7 represents a diagnosis of osteopenia. Osteopenia is diagnosed with T-scores between -1 and -2.5. The patient has a reduction in her bone density 1.7 standard deviations below the young adult mean value, which puts her at an increased risk for fractures. If her bone density continues to fall, she may eventually be classed as having osteoporosis.
name: Osteopenia
label: a
answer: yes
explanation: This is a bone remodelling disorder comprised of increased bone resorption followed by the formation of new weaker bone, increased blood flow and fibrous tissue. It is common in older adults, and may be asymptomatic or present with bone and joint pain, specific bone deformities and bony changes on X-ray.
name: Paget's disease
label: e
answer: no
explanation: Osteomalacia is caused by a severe vitamin D deficiency, causing inadequate mineralisation of bones. These patients have soft bones causing rickets in children and osteomalacia in adults following epiphyseal closure. Although low bone density can be a manifestation of osteomalacia, patients are often asymptomatic. Severe vitamin D deficiency would be the hallmark of this condition, which is not present in this patient.
name: Osteomalacia
label: b
answer: no
explanation: The most common presenting complaint for patients suffering from myeloma is back pain. The key clinical features can be remembered using the mnemonic CRAB (hyperCalcaemia, Renal impairment, Anaemia, Bone lesions). This is a neoplastic proliferation of plasma cells within the bone marrow and may present with fractures. However deranged blood tests including hypercalcaemia, evidence of renal impairment, and urinary Bence-Jones protein would be expected.
name: Multiple myeloma
label: d
answer: no
explanation: Osteoporosis is likely to present very similar to osteopenia, but a diagnosis is only made following a T-score lower than or equal to -2.5. This score represents a bone mass density more than 2.5 standard deviations below the young adult mean value. This puts individuals at high risk of developing fractures without any major trauma, and represents a more severe version of osteopenia.
name: Osteoporosis
label: c
answer: no

Correct answer: a
A 10-year-old boy presents to A&E with a three-day history of severe abdominal pain, vomiting, and diarrhoea which has been bloody for the past two days. The patient takes no regular medications and has no significant past medical history. He attended a barbeque at a friend's house five days previously. The patient has a temperature of 37.8 degrees. Blood tests show the following:
Hb 98, Creatinine 140, Urea 11, Platelets 32. A urine dipstick demonstrates proteinuria.
A blood film shows the presence of schistocytes and reticulocytes.
Which of the following is the most likely cause for his presentation?

Options:
explanation: The patient is most likely presenting with haemolytic uraemic syndrome (HUS). This is caused by a toxin, usually produced by E. coli 0157, which is most often associated with undercooked meat and petting farms. The toxin causes endothelial damage and thrombus formation in the renal arteries. It presents with the triad of microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury. Blood tests typically show haemolytic anaemia, with raised creatinine & urea, and low platelets. Schistocytes and reticulocytes may be seen on blood film. HUS is most often managed conservatively with supportive measures.
name: Haemolytic uraemic syndrome
label: a
answer: yes
explanation: ITP involves immune-mediated platelet destruction resulting in easy bruising (purpura) and bleeding, typically following a recent infection. ITP would show an isolated thrombocytopenia, but with normal red blood cell morphology. It is more common in children but is not associated specifically with E.coli-0157. There is no sign that the patient is experiencing widespread bruising.
name: Immune thrombocytopenic purpura
label: e
answer: no
explanation: This would also present with fever, anaemia, thrombocytopenia, and evidence of renal impairment. The presence of schistocytes on blood film may also be seen. It does not present with bloody diarrhoea or vomiting and is not associated with food. TTP is caused by genetic or acquired ADAMST-13 deficiency, resulting in inhibition of von Willebrand factor. Neurological symptoms are also seen in TTP.
name: Thrombotic thrombocytopenic purpura
label: d
answer: no
explanation: Nephritic syndrome presents with haematuria and proteinuria (<2g). It may also present with oliguria and oedema. It may follow an infection and is more common in children, but it is an unlikely cause in this case as it is more associated with URTI's than gastroenteritis, so would not explain the diarrhoea and vomiting or blood film.
name: Nephritic syndrome
label: c
answer: no
explanation: Although the patient likely did suffer a bout of gastroenteritis (E.coli) which may have led to the development of HUS, a simple gastroenteritis infection is unlikely to cause this patient's presentation on its own. Gastroenteritis may present with bloody diarrhoea for example with salmonella poisoning which is usually transmitted from undercooked chicken. The presence of schistocytes, deranged blood tests and signs of AKI rule out gastroenteritis as the cause.
name: Gastroenteritis
label: b
answer: no

Correct answer: a
Which of the following is not a notifiable disease in the UK?

Options:
explanation: COVID-19 was added to the list of notifiable diseases in the UK on 5 March 2021. This means that GPs and other doctors have a statutory duty to notify a government authority if there is suspicion of COVID-19 in a patient.
name: COVID-19
label: b
answer: no
explanation: HIV is not classed as a notifiable disease in the UK. This is because people living with HIV present no risk of onward transmission in everyday contact. This means that doctors are not required to tell anyone that an individual has HIV. Despite this, if there is evidence that a patient with HIV is knowingly putting another individual at risk through their positive HIV status, a doctor may be required to break confidentiality.
A notifiable disease is reported to an appropriate government authority by the treating doctor. Contact tracing is also typically carried out for most notifiable diseases to identify anyone who has been in contact with the affected individual.
name: HIV
label: a
answer: yes
explanation: Malaria is a notifiable disease in the UK.
name: Malaria
label: d
answer: no
explanation: Bacterial meningitis and meningococcal disease are both notifiable diseases in the UK.
name: Acute meningitis
label: e
answer: no
explanation: Whooping cough is a notifiable disease in the UK. Diagnosis of whooping cough may be made purely on clinical grounds without the need for laboratory confirmation, and notifying suitable authorities is necessary once this diagnosis is made.
name: Whooping cough
label: c
answer: no

Correct answer: a
A study is performed on screening for breast cancer. The study states that screening patients for breast cancer resulted in a higher breast cancer survival rate. On closer analysis, the overall mortality rate was the same for screening and non-screening groups. However, those who were diagnosed through screening were generally found to have more slow-progressing forms of the disease.

Which of the following most appropriately describes the bias described in this study?

Options:
explanation: Lead-time bias occurs when a disease is detected during a screening procedure while the patient is asymptomatic, and hence an earlier than usual diagnosis would be made for a given disease. Screening may only lengthen the time-period a person is considered a patient. This can be misinterpreted as an earlier diagnosis through asymptomatic screening causing an increased survival time.
name: Lead-time bias
label: b
answer: no
explanation: Length-time bias occurs when patients with less severe disease are more likely to have those diseases detected through screening. Length-time bias leads to the incorrect assumption that screening was responsible for the higher survival rates, when in reality these results could have been caused by the difference in rates of disease progression. A rapidly-progressing disease will often present with severe symptoms which require immediate attention and are less likely to be detected through screening. These are also more likely to result in mortality. Slowly progressing diseases often remain asymptomatic for a period of time and are more likely to be detected by screening. These patients tend to have a longer survival period.
name: Length-time bias
label: a
answer: yes
explanation: Measurement bias is due to an error in data collection during measurement. No evidence of any measurement bias is shown here.
name: Measurement bias
label: e
answer: no
explanation: Confirmation bias reflects the tendency to process information by specifically looking for information which is consistent with one's existing beliefs. This can often be unintentional, and may result in the ignoring of inconsistent information.
name: Confirmation bias
label: d
answer: no
explanation: Selection bias occurs when the subjects in a study differ from the population of interest, resulting in an error of association or outcome. Ideally, the subjects in a study should be very similar to one another and to the larger population from which they are drawn. Insufficient information on the patient sample is provided here to determine whether selection bias is present.
name: Selection bias
label: c
answer: no

Correct answer: a
Which of the following is an example of secondary prevention?

Options:
explanation: Immunisation programmes are an example of a primary prevention strategy. They aim to prevent disease before it occurs.
name: MMR (measles, mumps and rubella) immunisation
label: d
answer: no
explanation: Eye screening in diabetic patients is an example of tertiary screening, which aims to reduce the impact of an illness or injury which has lasting effects. This may be achieved by helping individuals manage complications of a pre-existing condition and improving their quality of life.
name: Diabetic retinopathy screening
label: e
answer: no
explanation: Statin use in patients with other risk factors for cardiovascular disease is an example of primary prevention. The use of statins decreases the risk of a patient suffering a cardiovascular event. Therefore, the aim is to prevent disease prior to it occurring.
name: Statin prescription in a patient with a QRISK > 10
label: c
answer: no
explanation: This is an example of primary screening, the aim of which is to prevent disease before it occurs. Smoking is linked to a number of health conditions and represents a significant source of morbidity and mortality. Programmes designed to decrease the incidence of smoking aim to reduce these downstream adverse health effects from occurring.
name: Distribution of smoking cessation information packets
label: b
answer: no
explanation: Long-term low-dose aspirin reduces the overall mortality, re-infarction rate, and risk of stroke in patients who have previously had a myocardial infarction. Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. Secondary prevention can involve early detection and treatment to halt or slow a disease process (screening), encouraging patient behaviours to prevent reinjury or recurrence, and helping patients return to their original health.
name: Long-term aspirin following a myocardial infarction
label: a
answer: yes

Correct answer: a
A 52-year-old lady presents to the emergency department following two episodes of haematemesis. She also says that she had passed dark and foul-smelling stool earlier today. She denies any abdominal pain. She has a past medical history of hypothyroidism and anxiety, and is currently taking levothyroxine and sertraline. She was prescribed naproxen 500mg BD 14 days ago following an ankle injury.
The patient was seen lying down, with her observations showing: BP 95/38, HR 125bpm.
The only abnormality found on initial blood tests was a Hb of 102 g/L (normal range 115-155 g/L). An endoscopy was carried out which identified a haemorrhaging gastric ulcer which was cauterised, stopping the bleeding. A urea breath test is negative. Which of the following is most likely to have caused the patient's symptoms?

Options:
explanation: Levothyroxine is used to treat hypothyroidism, and is not associated with gastric ulceration or haematemesis.
name: Levothyroxine
label: d
answer: no
explanation: A Mallory-Weiss tear is a tear in the mucosa of the oesophagus which results in severe and prolonged vomiting with haematemesis. Patients may also present with melena. A Mallory-Weiss tear is associated with sudden rises in intra-gastric pressure (e.g. severe vomiting) and binge-drinking, which are absent in this case. It is also likely to cause upper abdominal pain, which is absent in this patient.
name: Mallory-Weiss tear
label: e
answer: no
explanation: The patient has suffered from a ruptured stomach ulcer which led to her becoming haemodynamically unstable and necessitating urgent treatment. This was likely caused by the unopposed use of naproxen for the past 14 days. Naproxen is a non-steroidal anti-inflammatory drug (NSAID) which is strongly associated with the development of stomach ulcers and other gastrointestinal side effects. NSAIDs are often prescribed alongside proton pump inhibitors (PPIs) to minimise these potential side effects. However, a PPI has not been prescribed to this patient.
name: Naproxen
label: a
answer: yes
explanation: Although sertraline has a small risk of gastric ulceration, the recently started NSAID is a much more likely cause in this case.
name: Sertraline
label: c
answer: no
explanation: H.pylori is an important differential in a patient presenting with signs of stomach ulcers, and may present similarly to this. However, the negative urea breath test in this case rules it out. H. pylori is a gram-negative urease-producing bacteria which can cause ulceration of the gastric epithelium.
name: Helicobacter pylori
label: b
answer: no

Correct answer: a