hllj/quesmed huggingface dataset:
A 63-year-old woman is admitted to hospital after fracturing her tibia. She has developed progressive abdominal pain and has recently experienced a few episodes of watery diarrhoea. She has a poor appetite and is upset that her abdominal discomfort is interfering with her rehabilitation. She has been using multiple doses of PRN codeine to help with her pain.

Which intervention is most likely to relieve her discomfort?

Options:
explanation: This is inappropriate as the patient will be left in pain. After disimpaction with an enema, regular laxatives should be prescribed along with opiates to prevent this from happening again.
name: Stop codeine
label: e
answer: no
explanation: Oral vancomycin is an appropriate option for managing C.difficile-induced diarrhoea. The most likely diagnosis given the clinical scenario given is overflow diarrhoea.
name: Oral vancomycin
label: d
answer: no
explanation: While this may seem like a sensible option given the patient has diarrhoea, it is important to recognise that this is likely overflow due to severe constipation. Loperamide will make the situation worse.
name: Loperamide
label: b
answer: no
explanation: Bulk forming laxatives should not be used in opiate-induced constipation or faecal impaction, as they can draw further water out of the stools, exacerbating the issue. Disimpaction is required.
name: Ispaghula husk
label: c
answer: no
explanation: The history is suggestive of overflow diarrhoea, caused by constipation (and likely faecal impaction) due to poor mobility and opiate use. An enema will relieve the obstructing stool, hopefully providing the patient with some relief.
name: Phosphate enema
label: a
answer: yes

Correct answer: a


Learning point: A phosphate enema can be used to relieve opioid-induced constipation by stimulating bowel movements and helping to soften stool, providing effective, rapid relief when other laxatives are insufficient.
A 84-year-old woman is seen in the memory clinic after a recent diagnosis of Alzheimer's dementia. She lives at home with her family. As part of the consultation, a medication review is undertaken.

Which of the following is most likely to be stopped?

Options:
explanation: There is no reason apixaban should be stopped in Alzheimer's disease. An assesment should be made to weigh up the benefits/risks of anticoagulation, keeping in mind that the patient may be more prone to falls. Anticholinergic drugs (e.g. oxybutynin) can exacerbate cognitive decline and should be reviewed.
name: Apixaban
label: d
answer: no
explanation: Anticholinergic drugs create an effect similar to the acetylcholine decline that is seen in Alzheimer's disease. Pro-cholinergics (e.g. donepezil) are often used in managing Alzheimer's disease. Oxybutynin is likely to be reviewed and stopped/switched to a different drug if the patient still has urinary symptoms.
name: Oxybutynin
label: a
answer: yes
explanation: There is no reason why bisoprolol should be stopped in Alzheimer's disease. Anticholinergic drugs (e.g. oxybutynin) can exacerbate cognitive decline and should be reviewed.
name: Bisoprolol
label: e
answer: no
explanation: There is no reason why senna should be stopped in Alzheimer's disease. Anticholinergic drugs (e.g. oxybutynin) can exacerbate cognitive decline and should be reviewed.
name: Senna
label: b
answer: no
explanation: There is no reason why metformin should be stopped in Alzheimer's disease. Anticholinergic drugs (e.g. oxybutynin) can exacerbate cognitive decline and should be reviewed.
name: Metformin
label: c
answer: no

Correct answer: a


Learning point: Anticholinergic medications like oxybutynin may worsen cognitive function in Alzheimer's patients and are often discontinued during medication reviews.
A patient is reviewed in the dermatology clinic after a diagnosis of a 2mm basal cell carcinoma, close to the border of his lower lip.

What is the most appropriate management option?

Options:
explanation: Topical therapies are usually used in the management of actinic keratoses and low-grade squamous cell carcinomas, when excision is unsuitable. The BCC must be excised to prevent invasion into the lip.
name: Topical imiquimod
label: c
answer: no
explanation: The BCC should be excised, however a more precise approach than a wide local excision should be undertaken, given that the carcinoma is close to the lip border. A WLE may be suitable for a lesion on the limbs, for example.
name: Wide local excision
label: b
answer: no
explanation: Although basal cell carcinomas are slow-growing, they can invade structures and should be excised. Observation is not appropriate for this reason, and the lesion should be carefully removed using Mohs surgery.
name: Observation
label: e
answer: no
explanation: While basal cell carcinomas are slow-growing, they should be excised. Mohs micrographic surgery is the procedure of choice in this case as the lesion is on the face and in proximity to the border of the lip. This means tissue loss should be minimised to prevent a poor cosmetic and functional outcome.
name: Mohs micrographic surgery
label: a
answer: yes
explanation: Topical therapies are usually used in the management of actinic keratoses and low-grade squamous cell carcinomas, when excision is unsuitable. The BCC must be excised to prevent invasion into the lip.
name: Topical 5-flurouracil
label: d
answer: no

Correct answer: a


Learning point: Mohs micrographic surgery is the preferred treatment for basal cell carcinoma located on the face to ensure minimal tissue loss and optimal cosmetic results.
A 52-year-old woman with a long history of rosacea visits her GP as she is becoming increasingly distressed with her appearance.

She reports good compliance with UV-blocking sunscreen, topical brimonidine (used as needed for flushing) and topical ivermectin with oral doxycycline.

On examination, the following appearance is noted:

[lightgallery]

What is the most appropriate next step in management?

Options:
explanation: The image shows inflamed phymatous disease, which may require treatment in secondary care with oral isotretinoin, despite good compliance with first line topical and oral therapy.
name: Refer to dermatology
label: a
answer: yes
explanation: Ivermectin is the first choice topical treatment, with metronidazole and azelaic acid reserved for patients for whom this is inappropriate (e.g. breastfeeding or where ivermectin is unavailable). Current guidelines do not suggest switching through the different topical preparation choices.
name: Switch ivermectin to metronidazole
label: b
answer: no
explanation: Ivermectin is the first choice topical treatment, with metronidazole and azelaic acid reserved for patients for whom this is inappropriate (e.g. breastfeeding or where ivermectin is unavailable). Current guidelines do not suggest switching through the different topical preparation choices.
name: Add azelaic acid
label: c
answer: no
explanation: Doxycycline is the first choice oral antibiotic in moderate to severe disease. It is also the preferred agent when inflamed phymatous disease is present. Tetracyclines are alternative preparations for when doxycycline cannot be used. Current guidelines do not suggest switching between oral agents.
name: Switch doxycycline to oxytetracycline
label: d
answer: no
explanation: This would be appropriate if there was prominent NON-inflamed phymatous disease. As the nose appears to be inflamed, a dermatology referral should be undertaken first, so the disease can be controlled.
name: Refer to plastic surgery
label: e
answer: no

Correct answer: a


Learning point: Phymatous rosacea may necessitate referral to dermatology for advanced treatment options, such as oral isotretinoin, when first-line therapies are insufficient.
A 7-year-old boy who has been living in a refugee camp is brought to hospital feeling generally unwell. His mother describes a history of a sore throat a few weeks ago. He has no past medical history and had an otherwise normal development.

On examination, he looks unwell, with multiple swollen joints and a fever. He also has a very short mid-diastolic murmur.

Which test would help confirm the most likely diagnosis?

Options:
explanation: The ESR in rheumatic fever is likely to be prolonged, however this is a minor Jones criterion. Evidence of a recent streptococcal infection (e.g. a raised ASOT), in addition to the 2 major criteria present (carditis and arthritis) would confirm the diagnosis.
name: Erythrocyte sedementation rate (ESR)
label: c
answer: no
explanation: The most likely diagnosis is rheumatic fever, acquired after a streptococcal throat infection. The patient has risk factors for this being untreated. Polyarthritis is one of the major Jones criteria, as it is evidence of cardiac involvement (the murmur, which is the Carey Coombs murmur of acute rheumatic fever). Evidence of a streptococcal infection (e.g. throat culture or an elevated ASOT) are required in addition to 2 major criteria, or 1 major and 2 minor criteria.
name: Anti-streptolysin O titre (ASOT)
label: a
answer: yes
explanation: An echocardiogram may show cardiac involvement (which is a major Jones criterion for rheumatic fever), however this has already been evidenced by the findings of a murmur on auscultation. An echocardiogram would not provide more evidence to confirm the diagnosis. Evidence of a recent streptococcal infection (e.g. a raised ASOT), in addition to the 2 major criteria present (carditis and arthritis) would confirm the diagnosis.
name: Echocardiogram
label: d
answer: no
explanation: An ECG may show a prolonged PR interval in rheumatic fever due to cardiac involvement, however this is a minor Jones criterion. Evidence of a recent streptococcal infection (e.g. a raised ASOT), in addition to the 2 major criteria present (carditis and arthritis) would confirm the diagnosis.
name: ECG
label: b
answer: no
explanation: This would certainly be an important test to carry out. The white cell count in rheumatic fever is likely to be raised, however this is a minor Jones criterion. Evidence of a recent streptococcal infection (e.g. a raised ASOT), in addition to the 2 major criteria present (carditis and arthritis) would confirm the diagnosis.
name: Full blood count
label: e
answer: no

Correct answer: a


Learning point: An anti-streptolysin O (ASOT) titre is a blood test used to detect recent streptococcal throat infection and is often elevated in cases of rheumatic fever, helping to confirm the diagnosis when combined with clinical findings
A care home resident is admitted to hospital with rigors and fevers. They have a past medical history of diabetes and ischaemic heart disease. They have no known allergies.

On examination, they have a tender, erythematous area on the left shin.

Inflammatory markers are raised. Blood cultures show gram positive cocci in clusters.

What is the most appropriate management at this stage?

Options:
explanation: The signs and investigations so far point towards cellulitis. There are no convincing signs of a DVT. It is important to remember that the d-dimer will likely be raised due to infection in this case.
name: Test d-dimer
label: e
answer: no
explanation: Benzylpenicllin has a fairly narrow spectrum. Most staphylococci are resistant to benzylpenicillin as they produce penicillinases. Flucloxacillin is resistant to these enzymes, and therefore is a good choice for treating cellulitis.
name: Benzylpenicillin
label: d
answer: no
explanation: This is not appropriate; the patient is febrile, has evidence of cellulitis, and is bactaraemic. Culture results can be used to refine antibiotic choice, however treatment must be started as soon as possible.
name: Wait for sensitivity results before commencing antibiotics
label: b
answer: no
explanation: This is not an unreasonable investigation if there is exudate present on the leg, however it is unlikely to change management. Antibiotics need to be administered.
name: Send a skin swab
label: c
answer: no
explanation: The most likely diagnosis is cellulitis caused by staphylococci, which is also supported by the growth of clustered cocci. Flucloxacillin has good anti-staphylococcal activity and is usually the first line antibiotic for cellulitis (in the absence of a penicillin allergy).
name: Flucloxacillin
label: a
answer: yes

Correct answer: a


Learning point: The first-line treatment for cellulitis is oral flucloxacillin, but in patients with a penicillin allergy, clindamycin or cephalexin (if the allergy is not severe) are typically used as alternatives.
A 48-year-old man has had flu-like symptoms for the past week. He visits his GP as he has noticed multiple swellings around his neck and in both armpits. He also reports a low-grade fever.

On examination, the patient appears to have a widespread macular rash. He also has scars in both antecubital fossae.

He has not visited a doctor for 20 years and is currently homeless.

What is the most important diagnosis to consider?

Options:
explanation: The combination of flu-like symptoms, lymphadenopathy, a macular rash, and potential IV drug use/homelessness raise concerns for HIV seroconversion illness. This affects up to 80% of people who newly acquire the virus. HIV testing should be carried out. If negative, this should be repeated, in case infection has taken place inside the window period.
name: HIV infection
label: a
answer: yes
explanation: This describes a phenomenon that occurs within 24 hours of antibiotic treatment in spirochete infections, e.g. syphilis, leptospirosis, and Lyme disease. There is no clinical history to indicate the patient has been treated for such an infection, and the presentation is incompatible with this reaction.
name: Jarisch Herxheimer reaction
label: d
answer: no
explanation: Tertiary syphilis presents with significant neurological and cardiovascular complications. This would not explain the symptoms the patient is experiencing. Secondary syphilis (which causes a widespread maculopapular rash) could be a differential, and should be tested for, along with HIV.
name: Tertiary syphilis
label: c
answer: no
explanation: EBV infection is a differential given the widespread lymphadenopathy, fevers, and rash. However, symptomatic EBV usually affects the teenage population. The risk factors mean that HIV seroconversion illness is the diagnosis that is most important to investigate for.
name: Epstein Barr virus infection
label: e
answer: no
explanation: Primary syphilis presents with a painless ulcer (a chancre), usually on the genitals. This would not explain the symptoms the patient is experiencing. Secondary syphilis (which causes a widespread maculopapular rash) could be a differential, and should be tested for, along with HIV.
name: Primary syphilis
label: b
answer: no

Correct answer: a


Learning point: Consider HIV infection in patients presenting with flu-like symptoms, lymphadenopathy, and a macular rash, especially in high-risk populations.
A 18-year-old female has been suffering with a cold and is feeling increasingly unwell. She is admitted to hospital after blood tests performed by her GP were abnormal:


||||
|---------------------------|:-------:|--------------------|
|Alanine Aminotransferase (ALT)|2044 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|1023 IU/L|10 - 40|
|Bilirubin|54 µmol/L|< 17|
|Creatinine|100 µmol/L|60 - 120|
|International Normalised Ratio (INR)|2.6|1.0|


A venous blood gas taken in the emergency department is normal.


On further questioning, she reports taking regular doses of paracetamol, along with regular over the counter cold and flu tablets over the past week.


What is the single best course of action to take?

Options:
explanation: There is no current indication for referral, however this may be necessary in the future. Criteria for referral are either a pH of <7.3 (note that the VBG has been reported to be normal), or all three of: INR >6.5, creatinine >300 umol/L, grade III/IV encephalopathy.
name: Refer to liver transplant centre
label: d
answer: no
explanation: This is correct. The patient has suffered from a (likely unintentional) staggered paracetamol overdose, which means that N-acetylcysteine should be started straight away.
name: Commence N-acetylcysteine
label: a
answer: yes
explanation: This is inappropriate. The history and blood results are suggestive of an staggered overdose which should be treated promptly. Waiting for the paracetamol level is not necessary in a staggered overdose.
name: Await paracetamol levels
label: c
answer: no
explanation: This is not the single best course of action to take. Activated charcoal may be administered in a single (not staggered) overdose, within an hour of ingestion.
name: Administer activated charcoal
label: b
answer: no
explanation: This is inappropriate. The history and blood results are suggestive of a staggered paracetamol overdose which should be treated promptly.
name: Observe for 12 hours
label: e
answer: no

Correct answer: a


Learning point: N-acetylcysteine should be started in paracetamol overdose if serum levels are above the treatment line on the nomogram, the timing of ingestion is uncertain, signs of liver damage are present or expected, or a significant amount of paracetamol has been ingested (e.g., >150 mg/kg in adults or >200 mg/kg in children).
A patient is brought in to the emergency department by ambulance after being found seizing on the street. They are carrying no identification and their past medical history is unknown. They are not currently seizing. An A-E assessment is performed:


 * Airway - patent, nil added sounds
 * Breathing - no signs of respiratory distress, clear chest, oxygen saturations 100% on 15lpm oxygen
 * Circulation - cool and clammy, no added heart sounds, heart rate 94 beats/minute, blood pressure 100/68 mmHg, 2x cannulae in situ
 * Disability - rouses to pain. Blood glucose 1.2 mmol/L
 * Exposure - no obvious wounds or rashes, abdomen soft


What is the most important next intervention?

Options:
explanation: This is inappropriate; the patient may aspirate if oral intake is encouraged. They should receive IV glucose. Carbohydrates are useful after the intial episode has been managed to help build glucose stores.
name: Carbohydrate snack (e.g. a slice of toast)
label: e
answer: no
explanation: This is inappropriate; the patient may aspirate if oral intake is encouraged. They should receive IV glucose.
name: A glass (200ml) of orange juice
label: d
answer: no
explanation: This would be inappropriate as the patient has reduced consciousness and has IV access in situ, meaning they can receive IV glucose to rapidly correct their hypoglycaemia.
name: 10g oral glucogel
label: b
answer: no
explanation: This would be appropriate if IV access had not been gained, however glucagon can take some time to work, so IV glucose is the most important next intervention.
name: Intramuscular glucagon
label: c
answer: no
explanation: This patient is suffering from severe hypoglycaemia. As they have IV access in situ, IV glucose should be administered to rapidly correct this.
name: 100ml of 20% intravenous glucose
label: a
answer: yes

Correct answer: a


Learning point: 100 ml of 20% intravenous glucose contains 20 grams of glucose and is used to rapidly correct severe hypoglycaemia by providing an immediate source of glucose to raise blood sugar levels.
A 66-year-old man with a background of diabetes and hypertension arrives at the emergency department with central, crushing chest pain.


His initial ECG shows:
 [lightgallery]


Repeat ECGs show some evolving T wave inversion in the inferior leads.


His symptoms are somewhat relieved by GTN spray and morphine. He has received 300mg aspirin and a loading dose of clopidogrel.


High-sensitivity troponin T levels:
 1st sample - 54 ng/L (<10 ng/L)
 2nd sample - 232 ng/L (<10 ng/L)


Which term best describes the diagnosis?

Options:
explanation: This is incorrect - unstable angina is diagnosed when biomarkers (e.g. troponin) are not raised. In this case, the baseline troponin was raised, and there is evidence that it is rising further.
name: Unstable angina
label: b
answer: no
explanation: While this is correct, acute coronary syndrome (ACS) does not best describe the diagnosis. ACS encompasses ST elevation myocardial infarctions, Non-ST elevation myocardial infarctions, and unstable angina.
name: Acute coronary syndrome
label: c
answer: no
explanation: This is the correct answer, as the patient has classic cardiac chest pain, a raised (and rising) troponin, and evolving ECG changes (but without ST elevation). It is important to note that even if the ECG remained normal, this would still be categorised as an NSTEMI due to the troponin rise.
name: Non-ST elevation myocardial infarction (NSTEMI)
label: a
answer: yes
explanation: This is incorrect; stable angina is  characterised by exertional chest pain that is fully relieved by rest and/or nitrate therapy. It is not associated with dynamic ECG changes or rising cardiac biomarkers.
name: Stable angina
label: d
answer: no
explanation: This is incorrect; there is no evidence of ST elevation on the ECGs. This is a non-ST elevation myocardial infarction.
name: ST elevation myocardial infarction
label: e
answer: no

Correct answer: a


Learning point: Non-ST elevation myocardial infarction (NSTEMI) is characterised by elevated troponin levels and typical chest pain without ST segment elevation on ECG.
A 54-year-old woman is seen by her GP for a routine diabetes review. During the consultation, she mentions that she has had a few episodes of passing fresh red blood along with her bowel motions.

Other than type 2 diabetes, she has no significant past medical or family history.

On examination, she looks very well. Her abdomen is soft and non-tender with no masses palpable. A rectal examination is normal.

What is the most appropriate next step?

Options:
explanation: As per new NICE guidance, anybody over the age of 50 with unexplained rectal bleeding should have a FIT test as opposed to a 2 week wait referral, and if positive (more than or equal to 10 nanograms), they should be referred for a colonoscopy within 2 weeks.
name: Refer to 2-week wait clinic
label: a
answer: no
explanation: The FOB test was historically used to detect invisible traces of blood, and triage the need for a 2-week wait referral. It has now been replaced by the FIT test. In any case, it is not a useful test in this circumstance - the patient reports passing fresh red blood.
name: Faecal occult blood (FOB) test
label: d
answer: no
explanation: The most important diagnosis to consider and exclude in this case is colorectal carcinoma. A faecal calprotectin test may be useful in some cases, however this is not the most appropriate next step. It is important to note that faecal calprotectin can be raised in cases of colorectal carcinoma as well as inflammatory bowel disease, especially when PR bleeding is present.
name: Faecal calprotectin test
label: c
answer: no
explanation: This would not be the most appropriate next step for a general practitioner to take. They should refer this patient along the 2-week wait pathway, where the lower GI team will choose the most appropriate investigations (likely a colonoscopy). A CT may be required if a malignancy is found on endoscopy.
name: CT abdomen pelvis (with contrast)
label: e
answer: no
explanation: As per NICE guidelines, anybody over the age of 50 with unexplained rectal bleeding should have a FIT test, and if positive (more than or equal to 10 nanograms), they should be referred for a colonoscopy within 2 weeks.
name: Faecal immunochemistry (FIT) test
label: b
answer: yes

Correct answer: b


Learning point: NICE advise FIT testing in patients over 50 with unexplained rectal bleeding prior to 2 week wait referral