hllj/quesmed huggingface dataset:
A 17-year-old female with a history of Cystic Fibrosis complains of a worsening cough, productive of yellow sputum. She has had this cough for the last week. When asked, she denies chest pain or haemoptysis. As a result of her symptoms, a sputum culture is taken, which is subsequently positive for Pseudomonas aeruginosa.

What is the most appropriate initial treatment to commence?

Options:
explanation: Whilst Clarithromycin would be an appropriate option for a large number of lower respiratory tract infections, it would not successfully treat an infection caused by Pseudomonas aeruginosa.
name: Clarithromycin
label: c
answer: no
explanation: Whilst Aztreonam would successfully treat a pseudomonal infection, it would not be typically considered a first-line option. It can be given IV or IM but may be prescribed as a nebulised solution in specific cases of chronic Pseudomonas aeruginosa infection in patients with Cystic Fibrosis.
name: Aztreonam
label: d
answer: no
explanation: This penicillin antibiotic would not successfully treat an infection caused by Pseudomonas aeruginosa.
name: Amoxicillin
label: b
answer: no
explanation: This antibiotic is typically used to treat lower urinary tract infections and would not treat an infection caused by Pseudomonas aeruginosa.
name: Nitrofurantoin
label: e
answer: no
explanation: This antibiotic has antipseudomonal coverage and is a more appropriate first-line option than Aztreonam, which tends to be prescribed in more specialist settings.
name: Ciprofloxacin
label: a
answer: yes

Correct answer: a


Learning point: Ciprofloxacin is an effective initial treatment for respiratory infections caused by Pseudomonas aeruginosa in patients with cystic fibrosis.
A 27-year-old male has sudden onset shortness of breath. He denies any other respiratory symptoms but discloses that he smokes 15 cigarettes a day and has done so for the past 10 years. The examination of his chest is unremarkable, with no audible wheeze or crackles. He has no other relevant past medical history.


His ABG on room air shows:


||||
|--------------|:-------:|------------------|
|pH|7.46|7.35 - 7.45|
|PaO₂|15 kPa|11 - 15|
|PaCO₂|4 kPa|4.6 - 6.4|
|Bicarbonate|25 mmol/L|22 - 30|
|Sodium|135 mmol/L|135 - 145|
|Potassium|4.3 mmol/L|3.5 - 5.3|
|Lactate|0.6 mmol/L|0.6 - 1.4|


What is the most likely diagnosis?

Options:
explanation: Whilst this is another important differential in any sudden onset dyspnoea, especially in a younger patient with a smoking history, the normal respiratory examination points away from this. Additionally, the elevated oxygen further suggests anxiety is a more likely cause.
name: Pneumothorax
label: e
answer: no
explanation: This ABG shows a respiratory alkalosis with a high pO2. In conjunction with the age of the patient and normal respiratory examination, this suggests breathlessness caused by anxiety leading to hyperventilation.
name: Anxiety
label: a
answer: yes
explanation: This history does not suggest pneumonia as there is no mention of cough or fever accompanying the breathless. Pneumonia may cause a T1RF, however, the oxygen in this case is elevated (due to hyperventilation) rather than decreased.
name: Pneumonia
label: d
answer: no
explanation: Whilst this patient has a smoking history, they are likely too young to have developed COPD. The ABG shows no evidence of changes you may expect with COPD including hypoxaemia or acidosis due to CO2 retention.
name: COPD
label: c
answer: no
explanation: Whilst this is an important differential for any patient with sudden onset shortness of breath, this patient does not seem to have any strong risk factors for a pulmonary embolism. Additionally, they are not hypoxaemic, further pointing towards anxiety as a more likely cause.
name: Pulmonary embolism
label: b
answer: no

Correct answer: a


Learning point: Anxiety can manifest as sudden shortness of breath, often accompanied by respiratory alkalosis due to hyperventilation.
A 68-year-old smoker has an 8-month history of weight loss. He states he noticed the weight loss as his trousers have become looser over this period, which he thinks might be due to his decreased appetite. He also mentions he is becoming increasingly breathless, both at rest and on exertion. On examination, he has greatly reduced breath sounds throughout the right lung.

His CXR is seen below:

[lightgallery]

What is the most likely diagnosis?

Options:
explanation: In this case, the trachea would be central and the CXR changes would be bilateral. It would also present with an acute deterioration, as the name suggests.
name: Acute respiratory distress syndrome
label: e
answer: no
explanation: Pneumonia would likely present with a shorter history of productive cough and fever. Additionally, the deviation of the trachea away from the opacified side makes a pleural effusion more likely.
name: Massive pneumonia
label: c
answer: no
explanation: This history is suggestive of a lung malignancy, This CXR shows a large white-out of the right lung with the trachea deviated away from the opacified side, suggesting a large malignant pleural effusion.
name: Pleural effusion
label: a
answer: yes
explanation: This would result in a CXR with the trachea pulled towards the opacified side, rather than deviated away from the opacified side.
name: Pneumonectomy
label: b
answer: no
explanation: This would result in a CXR with the trachea pulled towards the opacified side rather than deviated away from the opacified side.
name: Collapsed lung
label: d
answer: no

Correct answer: a


Learning point: Pleural effusion can result from malignancy, presenting with breathlessness and weight loss, often requiring imaging for diagnosis.
A 47-year-old male complains of urine discolouration. He has recently been started on treatment for tuberculosis following a 6-month history of a chronic cough, night sweats and weight loss. When asked, he describes the urine as red/orange in colour and denies any dysuria or increased urinary frequency.

Which of the following medications is most likely to have caused this presentation?

Options:
explanation: Pyrazinamide is not known to cause urine discolouration. Side effects of Pyrazinamide include hepatitis and arthralgia.
name: Pyrazinamide
label: c
answer: no
explanation: Isoniazid is not known to cause urine discolouration. A more established side effect of Isoniazid in the treatment of TB is peripheral neuropathy.
name: Isoniazid
label: b
answer: no
explanation: Ethambutol is not known to cause urine discolouration. An important side effect of Ethambutol in the treatment of TB is optic neuritis.
name: Ethambutol
label: d
answer: no
explanation: A well-established side effect of rifampicin is red/orange discolouration of secretions including tears, urine and semen.
name: Rifampicin
label: a
answer: yes
explanation: This is used to treat travellers’ diarrhoea or hepatic encephalopathy rather than TB. It is poorly absorbed and is not typically used to treat systemic infections.
name: Rifaximin
label: e
answer: no

Correct answer: a


Learning point: Rifampicin can cause red/orange discolouration of urine and other secretions, a common and benign side effect of the medication.
An 87-year-old female has a productive cough and appears more confused than normal according to her carers. The carers state that her sputum is green in colour and that the patient seems to be slightly breathless when talking. She has a poor functional baseline and has lived in a care home, since her diagnosis of Alzheimer’s disease 5 years ago.

Her CXR is seen below:

[lightgallery]

What is the most likely diagnosis?

Options:
explanation: The costophrenic angles are well-defined in the CXR with no obvious effusion.
name: Pleural effusion
label: c
answer: no
explanation: This history is less suggestive of a malignancy, which would be more likely to present with chronic systemic symptoms.
name: Adenocarcinoma of the lung
label: b
answer: no
explanation: This history is not suggestive of pneumothorax and there is no evidence of pneumothorax seen on this CXR.
name: Pneumothorax
label: e
answer: no
explanation: This is a complication of severe pneumonia. Radiolucency over the region of consolidation may instead be seen on CXR.
name: Cavitating pneumonia
label: d
answer: no
explanation: This history suggests a patient who is at higher risk of aspiration due to the patient’s poor functional baseline and cognitive impairment. The CXR shows a right-sided pneumonia typical of aspiration.
name: Aspiration pneumonia
label: a
answer: yes

Correct answer: a


Learning point: Aspiration pneumonia commonly occurs in patients with cognitive impairment and poor functional status, leading to increased risk of respiratory infections.
A 92-year-old male has a fall when trying to get out of bed to use the toilet in the middle of the night. He describes feeling dizzy and light-headed on standing before falling onto his knees and staying there for a few minutes. He denies hitting his head or any other injury.

Of the following medications, which is the most likely to have caused these symptoms?

Options:
explanation: Alendronic acid has a common side effect of dizziness, however, it is less likely to cause postural hypotension than tamsulosin, as described by the feeling of light-headedness.
name: Alendronic acid
label: e
answer: no
explanation: Although a common regular medication for older patients, macrogol is unlikely to cause this presentation unless the laxative effect contributes to severe dehydration.
name: Macrogol
label: b
answer: no
explanation: Atorvastatin is a common regular medication, however, it is unlikely to cause this presentation as it is not known to cause dizziness or postural hypotension.
name: Atorvastatin
label: d
answer: no
explanation: Aspirin is an anti-platelet agent which is unlikely to cause this presentation as it is not commonly known to cause dizziness or postural hypotension.
name: Aspirin
label: c
answer: no
explanation: Tamsulosin is an alpha blocker used to treat benign prostatic hyperplasia, a common symptom of which is nocturia. It can commonly cause postural hypotension, classically depicted by dizziness on standing, as outlined in this scenario.
name: Tamsulosin
label: a
answer: yes

Correct answer: a


Learning point: Tamsulosin can cause postural hypotension by blocking alpha-1 adrenergic receptors, which leads to relaxation of smooth muscles in blood vessels and a subsequent drop in blood pressure when standing, increasing the risk of dizziness and falls, especially in elderly patients.
A 93-year-old female has 2 days of confusion and loss of appetite. She does not answer questions directly when asked and appears drowsy throughout the assessment. She lives with her daughter who states she is much more confused than normal and reports she was otherwise well before this presentation.

Observations:

* Respiratory rate: 14
* Oxygen saturations: 95% on room air
* Heart rate: 58
* Blood pressure: 95/58 with no significant postural drop
* Temperature: 37.2 degrees celsius

On examination, she has moist mucous membranes. Her chest is clear and no added heart sounds are heard. Her abdomen is mildly tender on palpation of the left iliac fossa with bowel sounds present.

What is the most likely cause of her presentation?

Options:
explanation: The patient is afebrile without any audible crackles, making this an unlikely option.
name: Pneumonia
label: b
answer: no
explanation: This is a case of delirium, of which constipation is a common cause. Given the patient is afebrile and appears euvolaemic based on her observations and examination, the most likely cause is constipation, which can present with mild lower abdominal tenderness.
name: Constipation
label: a
answer: yes
explanation: Whilst pain itself can cause delirium, the abdominal pain is described as mild. Additionally, the patient has normal observations, which you may not expect in the case of acute pain. This makes constipation a more likely cause of this patient’s delirium.
name: Pain
label: c
answer: no
explanation: As the patient has moist mucous membranes, is not tachycardic and is normotensive for an older female, this is unlikely to be the cause of her delirium. This is however an important cause of delirium that should always be considered.
name: Dehydration
label: e
answer: no
explanation: As this patient was acutely confused before medical attention was sought, this is unlikely to have caused her delirium.
name: Change of environment to a medical setting
label: d
answer: no

Correct answer: a


Learning point: Constipation is a common cause of delirium in elderly patients, often presenting with confusion and mild abdominal tenderness.
An 81-year-old male is noted to have memory loss, decreased ability to make decisions and increased drowsiness noted by his wife. She also describes that the patient will sometimes say things about seeing their dog running around, despite her dog having passed away 5 years ago. She is very concerned about her husband and is worried that he may have had a stroke.

What is the most likely diagnosis?

Options:
explanation: Visual hallucinations are not typically seen in Alzheimer’s disease.
name: Alzheimer’s Disease
label: b
answer: no
explanation: This usually presents in younger patients and will present with features of behaviour change and disinhibition, rather than visual hallucinations.
name: Fronto-temporal dementia
label: c
answer: no
explanation: This is a classic description of Dementia with Lewy Bodies, which presents with memory loss and hallucinations. This patient may go on to develop Parkinsonism.
name: Dementia with Lewy Bodies
label: a
answer: yes
explanation: This presents with visual hallucinations due to sight loss, it would not normally involve memory loss and cognitive impairment.
name: Charles-Bonnet syndrome
label: d
answer: no
explanation: Visual hallucinations are not typically seen in Vascular dementia.
name: Vascular dementia
label: e
answer: no

Correct answer: a


Learning point: Dementia with Lewy Bodies is characterised by memory loss, visual hallucinations, and may progress to Parkinsonism.
A 53-year-old female has a fever and malaise. She states she has felt more anxious and experienced palpitations in the 3 days. On examination, she has a symmetrical swelling around the midline of her lower neck. It is very tender on palpation. She describes having a sore throat 3 weeks ago but denies any other symptoms including weight loss.

What is the most likely diagnosis?

Options:
explanation: This is a rare disease characterised by fibrosis of the thyroid, which leads to hypothyroidism and a goitre which would typically be painless. In this scenario, the patient describes symptoms of hyperthyroidism and has a painful goitre, making this a less likely option.
name: Ridel’s thyroiditis
label: c
answer: no
explanation: Whilst Graves' disease is the most common cause of hyperthyroidism in the UK it would not typically present with a tender goitre. The recent viral infection also points towards subacute thyroiditis.
name: Graves’ disease
label: b
answer: no
explanation: This would usually cause a unilateral, pulsatile neck mass and would not cause any symptoms of hyperthyroidism.
name: Carotid aneurysm
label: d
answer: no
explanation: The patient denied any history of weight loss and this is less likely to cause a painful goitre.
name: Thyroid adenoma
label: e
answer: no
explanation: This is a classic description of a case of subacute thyroiditis in the thyrotoxic phase, with symptoms of hyperthyroidism and a tender goitre. it is a transient inflammation of the thyroid gland which often can be triggered by a viral infection.
name: Subacute thyroiditis
label: a
answer: yes

Correct answer: a


Learning point: Subacute thyroiditis presents with fever, malaise, and a tender goitre, often following a viral infection, leading to transient hyperthyroid symptoms.
A 32-year-old female has a 6-month history of weight loss and persistent fatigue throughout the day. The fatigue is present regardless of how much sleep she had the night before. She has a past medical history of type 1 diabetes mellitus, which she feels is well-controlled with no recent episodes of hypoglycaemia. On examination, she is noted to have dark patches on the inside of her mouth as well as her palms.

Given the most likely diagnosis, which initial investigation should be performed?

Options:
explanation: This describes a likely case of Addison’s disease, given the presence of risk factors (female patient with autoimmune history) and hyperpigmented lesions. Confirming low cortisol is therefore the most useful initial investigation.
name: 9 AM cortisol
label: a
answer: yes
explanation: This is unlikely to be a helpful test in a patient with an established diagnosis of type 1 diabetes. It additionally would not be useful for this specific clinical scenario.
name: Oral glucose tolerance test
label: e
answer: no
explanation: This is used in the diagnosis of Cushing’s syndrome rather than Addison’s disease as it assesses for loss of negative feedback in the HPA axis.
name: Dexamethasone suppression test
label: c
answer: no
explanation: This is usually used as a test for Cushing’s syndrome to show increased urinary cortisol over 24 hours rather than the 9 AM cortisol which is used to investigate Addison’s disease.
name: 24-hour urinary free cortisol
label: b
answer: no
explanation: Whilst hypothyroidism could present with fatigue and is more common in a patient with a pre-existing autoimmune condition, it would more commonly cause weight gain and does not explain the hyperpigmented patches.
name: Thyroid function tests
label: d
answer: no

Correct answer: a


Learning point: In Addison's disease, a condition characterized by insufficient production of adrenal hormones, a 9 a.m. cortisol level is typically measured to assess adrenal function, as cortisol levels are usually low in affected individuals.
A 78-year-old male with a history of uncontrolled type 2 diabetes mellitus has burning pain and tingling in his right foot, which has worsened over the last 6 months. On examination, he has objective loss of pinprick sensation and light touch in the L5 dermatome of the right foot. The patient would like to be prescribed a medication which can help with the pain.

Given the likely diagnosis, which medication would be most appropriate to commence?

Options:
explanation: This is only recommended for a short course in patients awaiting referral after initial treatment has failed and is therefore not the most appropriate medication to commence.
name: Tramadol
label: c
answer: no
explanation: Fluoxetine is not recommended for the treatment of neuropathic pain in the UK.
name: Fluoxetine
label: b
answer: no
explanation: NICE guidance states that more than one neuropathic pain drug should not be prescribed at the same.
name: Duloxetine and Amitriptyline
label: e
answer: no
explanation: NICE guidance states that more than one neuropathic pain drug should not be prescribed at the same time.
name: Duloxetine and Pregabalin
label: d
answer: no
explanation: NICE guidance recommends a choice of amitriptyline, duloxetine, gabapentin or pregabalin alone for patients with painful diabetic neuropathy. This is therefore the only appropriate answer.
name: Duloxetine
label: a
answer: yes

Correct answer: a


Learning point: Duloxetine is an effective treatment option for managing painful diabetic neuropathy in patients with type 2 diabetes mellitus.
A 45-year-old male has noticed tingling in the lateral aspect of his right hand and finds he is having difficulty doing up his shirt buttons with his right hand. He also states he has noticed that his shoes no longer fit and he has had to buy a larger size. On examination, his visual fields are found to be abnormal.

Given the likely diagnosis, what is the most likely visual field defect to be elicited on examination?

Options:
explanation: This describes a case of acromegaly, with the presence of carpal tunnel syndrome, soft tissue swelling and visual field defects. Acromegaly can cause bitemporal hemianopia as a result of compression of the optic chiasm by the pituitary tumour.
name: Bitemporal hemianopia
label: a
answer: yes
explanation: This is usually due to a lesion involving the temporal lobe optic radiations, rather than a pituitary tumour compressing the optic chiasm as in the case of a pituitary tumour in acromegaly.
name: Superior homonymous hemianopia
label: d
answer: no
explanation: This is loss of vision in a single eye, usually caused by retinal or optic nerve damage.
name: Monocular anopia
label: b
answer: no
explanation: This is due to a lesion of the optic tract or the optic cortex and is normally seen in the case of stroke.
name: Homonymous hemianopia
label: c
answer: no
explanation: This is usually due to a lesion involving the parietal lobe optic radiations, rather than a pituitary tumour compressing the optic chiasm as in the case of a pituitary tumour in acromegaly.
name: Inferior homonymous hemianopia
label: e
answer: no

Correct answer: a


Learning point: Acromegaly can lead to bitemporal hemianopia due to optic chiasm compression from a pituitary tumour.
A 22-year-old female with type 1 diabetes presents to the GP feeling dizzy, flushed and extremely fatigued. She has recently been diagnosed with type 1 diabetes and is still getting used to her insulin regimen. When she checks her blood sugar, it is 2.6mmol/L (normal fasting range 3.5-5.3 mmol/L).

What is the most appropriate initial management?

Options:
explanation: This would be an appropriate first-line option if the patient was unconscious without IV access.
name: IM glucogen
label: c
answer: no
explanation: This is viscous and hypertonic so it is not recommended for the treatment of hypoglycaemia, unlike 10% or 20% glucose.
name: IV glucose 50%
label: e
answer: no
explanation: This is not appropriate as the high fat content of biscuits may delay gastric emptying and they have a lower sugar content than oral glucose gel. They are better given as a snack to provide a form of long-acting carbohydrates in patients once their blood glucose increases above 4mmol/L.
name: Chocolate biscuits
label: b
answer: no
explanation: This would be an appropriate first-line option if the patient was unconscious and had IV access.
name: IV glucose 10%
label: d
answer: no
explanation: In a conscious patient, oral glucose gel is the most appropriate first option to manage hypoglycaemia. If this fails after 3 treatment cycles or 30-45 minutes, then IM glucogen or IV glucose should be considered.
name: Oral glucose gel
label: a
answer: yes

Correct answer: a


Learning point: For conscious patients with low blood sugar, using oral glucose gel is the best first step to quickly restore blood sugar levels.