hllj/quesmed huggingface dataset:
An 82 year old female is brought into the A&E department following a fall. The paramedics report she had been on the floor overnight for approximately 10 hours. The patient describes severe pain in her left leg, which she had been lying on.


On examination, the patient's left leg looks markedly swollen compared to her right. She can move her toes, and peripheral pulses are palpable. The patient is catheterised and her urine appears dark and tea-coloured.


Blood results are as follows:


||||
|---------------------------|:-------:|--------------------|
|Sodium|135 mmol/L|135 - 145|
|Potassium|6.2 mmol/L|3.5 - 5.3|
|Urea|8.1 mmol/L|2.5 - 7.8|
|Creatinine|170 µmol/L|60 - 120|
|Creatine Kinase|5100 U/L|(M) 25 - 200, (F) 25 - 175|

D-dimer is negative.


Which of the following is the most likely diagnosis?

Options:
explanation: This is incorrect. Although the patient is suffering from an AKI, the underlying cause is rhabdomyolysis.
name: Acute kidney injury
label: d
answer: no
explanation: This is the correct answer. The patient is at risk of this condition due to her fall with a long lie. Rhabdomyolysis occurs when skeletal muscle is injured and rapidly breaks down, causing the release of intracellular myoglobin and potassium. It can present with muscle pain and swelling, red/brown urine and acute kidney injury. Treatment is mostly supportive with intravenous fluids and hyperkalaemia correction.
name: Rhabdomyolysis
label: a
answer: yes
explanation: This is incorrect. Although the patient is suffering from pain and swelling in their lower limb, a deep vein thrombosis would not cause so significant a rise in creatinine kinase. Furthermore, the negative d-dimer makes a deep vein thrombosis extremely unlikely.
name: Deep vein thrombosis
label: c
answer: no
explanation: This is incorrect. Although the patient presented with a swollen and painful calf, there is no paralysis and peripheral pulses are palpable. The acute kidney injury along with the markedly raised creatinine kinase points towards an underlying diagnosis of rhabdomyolysis.
name: Compartment syndrome
label: b
answer: no
explanation: This is incorrect. This would not account for the extremely high creatinine kinase and acute kidney injury, and would not be expected to result from a fall with a long lie.
name: Myositis
label: e
answer: no

Correct answer: a
A 72 year old man attends his GP surgery with shortness of breath that has been present for around 3 months. He has also noticed that his clothes have become very loose. The patient's primary concern is that his face has become noticeably rounder and 'puffy', his skin has become more fragile and he is feeling low in mood.


His observations are all within normal limits. Blood tests reveal a potassium of 2.9mmol/L (normal range 3.5-5.3 mmol/L).


Which of the following is the most likely diagnosis?

Options:
explanation: This is incorrect. This is a progressive fibrotic lung disease associated with shortness of breath. However, the symptoms of Cushing's syndrome in this case point more towards a paraneoplastic small cell lung carcinoma.
name: Interstitial Lung Disease
label: d
answer: no
explanation: This is incorrect. The patient's shortness of breath and weight loss point towards lung cancer. However, adenocarcinoma is less likely to cause paraneoplastic syndromes such as Cushing's syndrome.
name: Adenocarcinoma
label: b
answer: no
explanation: This is incorrect. Squamous cell carcinomas often cause hypercalcaemia and can be associated with hypertrophic pulmonary osteoarthropathy. The symptoms of Cushing's syndrome point more towards a paraneoplastic small cell lung carcinoma.
name: Squamous Cell Carcinoma
label: c
answer: no
explanation: This is the most likely diagnosis. Small cell carcinomas arise from endocrine Kulchitsky cells in the lungs. These secrete polypeptides including adrenocorticotrophic hormone and can present as Cushing's syndrome: characterised by the patient's symptoms of fragile skin, low mood and a 'moon' shaped face.
name: Small cell lung carcinoma
label: a
answer: yes
explanation: This is incorrect. Although COPD can explain the shortness of breath, the symptoms of Cushing's syndrome point more towards a paraneoplastic small cell lung carcinoma.
name: Chronic Obstructive Pulmonary Disease (COPD)
label: e
answer: no

Correct answer: a
A 62 year old female is diagnosed with colorectal cancer and attends the oncology clinic for the results of her most recent CT scan. It is found that her cancer has metastasized to her liver.

By which of the following routes has the cancer spread?

Options:
explanation: This is incorrect. Colorectal cancer will primarily spread through the portal vein system to the liver.
name: Endoluminal spread
label: d
answer: no
explanation: This is correct. Colorectal cancer will primarily spread through the portal vein system to the liver. Veins are more likely to be invaded than arteries as their walls are thinner.
name: Haematogenously via the portal vein
label: a
answer: yes
explanation: This is incorrect. Colorectal cancer can spread through the lymphatic system but it will cause metastatic deposits in the lymph nodes before reaching the liver.
name: Lymphatic spread
label: b
answer: no
explanation: This is incorrect. Transcoelomic spread occurs when the cancer penetrates the surface of the peritoneal cavity and spreads through it. Ovarian tumours are likely to take this route to metastasize to the liver, however colorectal cancer will primarily spread through the portal vein system to the liver.
name: Transcoelomic spread
label: c
answer: no
explanation: This is incorrect. Haematogenous spread is the most likely route of metastasis of colorectal cancer to the liver however it would most likely spread via the portal vein.
name: Haematogenously via the hepatic artery
label: e
answer: no

Correct answer: a
A 43 year old male attends eye casualty complaining of a painful right eye. He describes the pain as 9/10 in severity which becomes worse when he moves his eye. He denies any headaches or blurred vision.

The only medical history of note is rheumatoid arthritis for which he takes methotrexate and folic acid.

On examination, the sclera is diffusely erythematous. Fluorescein eye stain does not detect any foreign bodies, and episcleral vessels do not move or blanch when pressed with a cotton bud. Visual acuity and colour vision is normal.

Which of the following is the most likely diagnosis?

Options:
explanation: This is incorrect. Anterior uveitis should be considered in patients with a painful red eye. However, it is typically also associated with blurred vision and headaches.
name: Anterior uveitis
label: e
answer: no
explanation: This is incorrect. Although this can also present with a red eye, eye itching, irritation and excessive tearing would also be present. Pain is typically not as severe.
name: Conjunctivitis
label: c
answer: no
explanation: This is correct. Scleritis presents with a painful red eye and pain on eye movements. It is more common in those with autoimmune conditions such as rheumatoid arthritis. Mild scleritis tends to be treated with NSAIDs and more severe or necrotising scleritis can be treated with corticosteroids.
name: Scleritis
label: a
answer: yes
explanation: This is incorrect. This is inflammation of the optic nerve and causes painful eye movements. However, optic neuritis is also associated with vision loss and red-green colour discrimination deficits, which this patient does not have.
name: Optic neuritis
label: d
answer: no
explanation: This is incorrect. Although episcleritis also presents with a red eye, episcleritis is inflammation of the episclera underneath the conjunctiva. Episcleritis tends to present with milder pain, and episcleral vessels will blanch. Management is mostly supportive and can include the use of artificial tears for symptomatic relief.
name: Episcleritis
label: b
answer: no

Correct answer: a
An 81 year old male presents to the A&E department due to back pain. He reports shooting pains in his buttocks radiating down both legs for 5 days. He became particularly concerned earlier that day whilst using the toilet; he noticed he was unable to feel the toilet paper when wiping.

The patient has a past medical history of prostate cancer, but is not currently receiving chemotherapy.

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

Options:
explanation: This is incorrect. The gold standard investigation for cauda equina syndrome is a whole spine MRI.
name: Order an x-ray spine
label: c
answer: no
explanation: This is incorrect. This patient presents with symptoms concerning for cauda equina syndrome. The gold standard investigation for cauda equina syndrome is a whole spine MRI.
name: Insert a urinary catheter
label: e
answer: no
explanation: This is incorrect. It is important to confirm and find the cause of the patient's cauda equina before considering surgery.
name: Lumbar decompression surgery
label: d
answer: no
explanation: This is incorrect. The gold standard investigation for cauda equina syndrome is a whole spine MRI.
name: Order a CT spine
label: b
answer: no
explanation: This is the correct answer. Whole spine MRI is the gold standard test for suspected cauda equina syndrome. This will identify the cause and location of the cord compression. The patient has a past medical history of prostate cancer and therefore the cause of their cauda equina is likely to be spinal metastasis.
name: Order a whole spine MRI
label: a
answer: yes

Correct answer: a
A 73 year old female is brought into A&E by ambulance following a fall in her garden. She is normally fit and well aside from mild hay fever, and does not use any walking aids. She reports pain in her left hip despite intravenous paracetamol and oramorph. Her left leg appears to be shortened and internally rotated.

An x-ray is taken and a garden stage IV fracture can be seen with displacement.

Which of the following is the definitive management for this patient?

Options:
explanation: This is incorrect. This would generally be used for non-displaced intracapsular fractures and therefore would be inappropriate for this patient.
name: Cannulated screw fixation
label: e
answer: no
explanation: This is incorrect. This would generally be used for more stable extracapsular fractures.
name: Dynamic hip screw
label: d
answer: no
explanation: This is incorrect. This would be used if the patient had significant comorbidities or was generally less mobile. As the patient is generally well and mobile, she is likely to tolerate a total hip arthroplasty with good outcomes.
name: Hemiarthroplasty
label: c
answer: no
explanation: This is incorrect. Although can be useful for pain management it is not the definitive treatment for a neck of femur fracture. She requires surgical intervention; likely a total hip arthroplasty.
name: Femoral nerve block
label: b
answer: no
explanation: This is the correct answer. Garden stage IV represents a complete fracture of the femoral neck. As the patient is generally well and mobile, she is likely to tolerate the procedure with good outcomes. A total hip arthroplasty would be used to replace both the femoral head and the acetabulum.
name: Total hip arthroplasty
label: a
answer: yes

Correct answer: a
A 6 week old baby is brought into A&E by their mother as they are concerned they are not feeding properly and appear pale. On examination, the baby is tachypnoeic and does not appear to be gaining weight appropriately. The doctor is concerned the infant might have a congenital heart disease.

Which of the following is an example of an acyanotic heart disease?

Options:
explanation: This is correct. Coarctation of the aorta, ventricular septal defects and patent ductus arteriosus are all forms of acyanotic heart disease. These conditions do not cause cyanosis and instead might present with tachypnoea, feeding difficulties, poor weight gain, pallor and tachycardia.
name: Coarctation of the aorta
label: a
answer: yes
explanation: This is incorrect. This is an example of a cyanotic heart disease in which the aorta and pulmonary trunk insertions are swapped around.
name: Transposition of the great arteries
label: b
answer: no
explanation: This is incorrect. This is an example of a cyanotic heart disease in which pulmonary stenosis is coupled with a large ventricular septal defect and results in a left-to-right ventricular shunt.
name: Tetralogy of Fallot
label: e
answer: no
explanation: This is incorrect. This is an example of a cyanotic heart disease in which the pulmonary valve controlling blood flow from the right side of the heart does not form.
name: Pulmonary atresia
label: c
answer: no
explanation: This is incorrect. This is an example of a cyanotic heart disease in which the tricuspid valve controlling blood flow from the right side of the heart does not form.
name: Tricuspid atresia
label: d
answer: no

Correct answer: a
A 14 week old baby boy is brought into the GP for a routine review.

Which of the following is a red flag for abnormal development?

Options:
explanation: This is incorrect. Although babies should be able to pincer grasp by 10 months it is not a red flag for referral. If they are still unable to pincer grasp by 12 months this is a red flag.
name: No pincer grip by 10 months
label: c
answer: no
explanation: This is incorrect. Hand regard is usually present by 3-4 months.
name: No hand regard by 6 weeks
label: d
answer: no
explanation: This is incorrect. Palmar grasp is usually established by 6 months along with being able to transfer objects between hands. No palmar grasp by 3 months is not a red flag.
name: No palmar grasp by 3 months
label: e
answer: no
explanation: This is correct. Fixing and following refers to the ability to accurately fixate on and follow stimuli in the environment with their eye. This is usually achieved by 2-3 months of age. Not fixing and following by 3 months is a red flag and would warrant further investigation.
name: Not fixing and following by 3 months
label: a
answer: yes
explanation: This is incorrect. Most children will be able to point with their finger and look at pictures by 12 months. Failing to point with a finger by 6 months is not a red flag.
name: Does not point with a finger by 6 months
label: b
answer: no

Correct answer: a
A 15 year old female patient attends her GP practice as she would like some contraception advice. She requests the combined oral contraceptive pill, as she is thinking of having sexual intercourse with her boyfriend who is also 15. She appears to understand the importance of safe sex and understands how to take the combined contraceptive pill correctly.

She does not want her parents to know as they do not think they would understand. She also notes that if she were not prescribed the pill they would have sexual intercourse regardless, however would rather be safe.

Which of the following is the most appropriate management option?

Options:
explanation: This is incorrect. The Fraser guidelines are criteria that must be met for children under 16 to be advised on sexual health without breaking confidentiality. As this patient meets these criteria, a contraceptive may be prescribed despite her age.
name: Do not prescribe the pill as the patient is not of legal age
label: c
answer: no
explanation: This is correct. According to the Fraser Guidelines, if the patient has the maturity and intelligence to understand the treatment, cannot be persuaded to tell their parents, is likely to begin sexual intercourse without contraception, or if their mental health is likely to suffer without the treatment it is in their best interests to provide this treatment.
name: Prescribe the contraceptive pill
label: a
answer: yes
explanation: This is incorrect. This would be inappropriate as the patient is 'Fraser competent' and can therefore receive advice and or treatment without breaking confidentiality.
name: Prescribe the contraceptive pill and tell the patient's parents
label: b
answer: no
explanation: This is incorrect. The patient is unlikely to abstain and would be likely to come to harm if this advice is given.
name: Advise the patient to abstain from sexual intercourse until they are 16
label: e
answer: no
explanation: This is incorrect. This would breach confidentiality as the patient is fraser competent.
name: Ask the patient's parents for consent to prescribe
label: d
answer: no

Correct answer: a
A 21 year old male attends their GP surgery as they are experiencing uncomfortable abdominal cramps and loose stool. They state they are under a lot of pressure in their final year of university. These symptoms started approximately 3 weeks ago when they started writing their dissertation.

A blood test is unremarkable, and their faecal calprotectin is negative. He is diagnosed with irritable bowel syndrome (IBS).

Which of the following is an anti-spasmodic medication used to treat the symptoms associated with IBS?

Options:
explanation: This is correct. This is used to relieve abdominal cramps and bloating associated with IBS. Other examples of antispasmodics include peppermint oil tablets and buscopan.
name: Mebeverine
label: a
answer: yes
explanation: This is incorrect. Although paracetamol can help the pain associated with IBS, it is not specifically an antispasmodic medication.
name: Paracetamol
label: c
answer: no
explanation: This is incorrect. This is a laxative agent usually avoided in IBS as it can cause bloating.
name: Lactulose
label: e
answer: no
explanation: This is incorrect. This is a laxative. Although IBS can involve constipation, this patient's primary symptom is loose stool. Ispaghula husk would therefore not be appropriate.
name: Ispaghula husk
label: d
answer: no
explanation: This is incorrect. This is a laxative. Although IBS can involve constipation, this patient's primary symptom is loose stool. Bisacodyl would therefore not be appropriate.
name: Bisacodyl
label: b
answer: no

Correct answer: a
A 50 year old female with a past medical history of hypertension, osteoarthritis, irritable bowel syndrome and high cholesterol is admitted to the ward with an acute kidney injury (AKI).

Which of the following medications could have caused her AKI?

Options:
explanation: This is incorrect. Simvastatin can be used with caution in those with renal impairment: it is unlikely to cause AKI. Statins tend to affect the liver more than the kidneys.
name: Simvastatin
label: b
answer: no
explanation: This is incorrect. Diclofenac is a non-steroidal anti-inflammatory drug (NSAID). Although NSAIDs can cause or exacerbate AKI, it is unlikely to have caused AKI if given in topical form.
name: Topical diclofenac gel
label: c
answer: no
explanation: This is correct. ACE inhibitors are a known cause of AKI along with NSAIDs, aminoglycosides, angiotensin receptor blockers and diuretics.
name: Ramipril
label: a
answer: yes
explanation: This is incorrect. Amlodipine is not known to cause or exacerbate an AKI.
name: Amlodipine
label: e
answer: no
explanation: This is incorrect. Mebeverine is not known to cause or exacerbate an AKI.
name: Mebeverine
label: d
answer: no

Correct answer: a
A 62 year old male attends their GP practice following a recent diagnosis of chronic kidney disease (CKD). He is keen to learn more about his condition.

Which of the following electrolytes are most likely to be deranged in CKD?

Options:
explanation: This is incorrect. Phosphate is more likely to accumulate in CKD.
name: Hypophosphataemia
label: b
answer: no
explanation: This is incorrect. Higher levels of urate can be expected in CKD. This can lead to uraemic encephalopathy.
name: Hypouricemia
label: e
answer: no
explanation: This is correct. Phosphate accumulates in CKD as the kidneys are unable to remove excess phosphate. This is why patients are often counselled on a low phosphate diet in CKD. They might also be given phosphate binding medication.
name: Hyperphosphataemia
label: a
answer: yes
explanation: This is incorrect. Sodium levels are more likely to be low in CKD. With higher fluid intake the kidneys are unable to dilute urine further, therefore resulting in hyponatremia and oedema.
name: Hypernatremia
label: d
answer: no
explanation: This is incorrect. Potassium is more likely to be raised in CKD as the kidney is unable to excrete potassium effectively.
name: Hypokalaemia
label: c
answer: no

Correct answer: a
A 67 year old patient attends their GP practice for monitoring of their serum potassium level. They have required treatment for hyperkalaemia in the past and are keen to know more about how potassium levels are regulated in the body.

Which of the following parts of the nephron is responsible for the majority of potassium reabsorption?

Options:
explanation: This is incorrect. Although some potassium reabsorption occurs here, there is also secretion of potassium.
name: Collecting Duct
label: d
answer: no
explanation: This is incorrect. Potassium is freely filtered at the renal glomerulus, not reabsorbed.
name: The glomerulus
label: e
answer: no
explanation: This is incorrect. Potassium is passively secreted here via the sodium-potassium pump.
name: Distal Convoluted Tubule
label: b
answer: no
explanation: This is incorrect. Although potassium reabsorption does occur in the Loop of Henle, more occurs in the proximal convoluted tubule.
name: Loop of Henle
label: c
answer: no
explanation: This is correct. Potassium is filtered in the glomerulus of the kidney. It then passes through to the PCT, where most of it is reabsorbed. There is some reabsorption in the Loop of Henle, as well as the distal convoluted tubule and collecting duct. However, potassium secretion also occurs at these sites.
name: Proximal convoluted tubule
label: a
answer: yes

Correct answer: a
A 67 year old male attends A&E with worsening shortness of breath and a productive cough for one month. He has no significant medical history or medication allergies. A former smoker (10/day for 30 years), he quit at 45. He denies asbestos exposure or owning pets.

On examination, the patient uses accessory muscles to breathe, with decreased breath sounds and a loud bilateral wheeze. Percussion is resonant.




Spirometry shows an obstructive pattern of lung disease. An arterial blood gas (ABG) gives the following results:



||||
|--------------|:-------:|------------------|
|pH|7.23|7.35 - 7.45|
|PaO₂|9 kPa|11 - 15|
|PaCO₂|8.9 kPa|4.6 - 6.4|
|Bicarbonate|28 mmol/L|22 - 30|
|Base Excess|+3 mmol/L|-2 to +2|


Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is incorrect. While a panic attack may cause shortness of breath and hyperventilation, it is not associated with a cough or with type two respiratory failure as shown on the ABG. The patient is more likely to be suffering from an exacerbation of COPD.
name: Asthma
label: d
answer: no
explanation: This is incorrect. The patient presents with globally reduced breath sounds which is likely due to limitations in airflow or poor sound transmission in COPD. In pleural effusion, breath sounds are usually reduced or absent over one area and percussion would generate a stony dull note.
name: Pleural effusion
label: e
answer: no
explanation: This is incorrect. While a panic attack may cause shortness of breath and hyperventilation, it is not associated with a cough or with type two respiratory failure as shown on the ABG. The patient is more likely to be suffering from an exacerbation of COPD.
name: Panic attack
label: b
answer: no
explanation: This is incorrect. Although pulmonary fibrosis is also associated with a cough and shortness of breath, this is associated with restrictive rather than obstructive changes on spirometry. The lack of exposure to occupational triggers or pets is another clue that COPD is a more likely diagnosis.
name: Pulmonary fibrosis
label: c
answer: no
explanation: This is correct. It is likely that the patient is suffering from an exacerbation of COPD. The ABG demonstrates a type two respiratory failure with hypoxia and hypercapnia. There is some metabolic compensation, meaning it is likely that the respiratory derangement is chronic.
name: Chronic Obstructive Pulmonary Disease (COPD)
label: a
answer: yes

Correct answer: a

Chronic Obstructive Pulmonary Disease (COPD)