hllj/quesmed huggingface dataset:
A 70-year-old female is brought to the emergency department by ambulance. Her husband reports that she has been unwell for the past 4 days with vomiting and diarrhoea. He found her this morning unconscious on the sofa and immediately dialled 999.

On examination, the patient is unresponsive, with a heart rate of 134 bpm, a blood pressure of 88/72 mmHg, and a temperature of 37.1 C. Her husband reports that she has a history of polymyalgia rheumatica for which she has taken prednisolone for 18 months. Which of the following is the most likely diagnosis?

Options:
explanation: Although this patient is indeed expressing signs and symptoms of hypovolaemic shock (tachycardia, hypotension), the underlying cause is an adrenal crisis which is therefore the most correct answer. Adrenal crisis is one of the most important and life-threatening complications of long-term steroid use and is most common following a gastrointestinal illness.
name: Hypovolaemic shock
label: e
answer: no
explanation: Although a vital differential diagnosis in patients presenting with impaired consciousness, tachycardia, and hypotension, sepsis is not the underlying cause in this case. The two key clues lie in the absence of pyrexia and the history of long-term prednisolone use in the context of GI illness. Adrenal crisis secondary to steroid therapy is therefore the most likely cause in this case.
name: Sepsis
label: b
answer: no
explanation: An unlikely underlying diagnosis in a patient with no history of thyroid disease, thyroid storm is very rarely the first presentation of thyrotoxicosis. There are also important differentiating factors in the clinical examination. Thyroid storm classically presents with fever, tachycardia, hypertension, and altered mental state. This patient is not pyrexic and is hypotensive, making thyroid storm an unlikely cause of their presentation.
name: Thyroid storm
label: d
answer: no
explanation: Another important differential in a patient presenting with cardiogenic symptoms. However, in a patient with a history of long-term steroid use who has been suffering from a gastrointestinal illness in the days preceding presentation, it is vital to rule out adrenal crisis.
name: Myocardial infarction
label: c
answer: no
explanation: This patient has presented with circulatory collapse (indicated by loss of consciousness, hypotension, and tachycardia) which has occurred secondary to an adrenal crisis. Long-term steroid use suppresses the body's natural production of glucocorticoids by negatively feeding back on the hypothalamic-pituitary-adrenal axis. Adrenal crisis can then occur in the presence of additional physiological stress or if the patient is unable to take their medication. This patient should be urgently managed with IV hydrocortisone and fluid replacement.
name: Adrenal crisis
label: a
answer: yes

Correct answer: a
A 24-year-old male presents to General Practice with a 3-week history of fatigue, malaise, and polyuria. After examination and further investigation, he is diagnosed with type 1 diabetes mellitus. He is due to begin insulin therapy after the consultation today and is interested in ways to improve his glycaemic control.

Which of the following advice is most appropriate to discuss with him?

Options:
explanation: Although intense exercise can increase the risk of hypoglycaemia, NICE recommend that patients should be counselled on self-monitoring and adjusting insulin doses for intense exercise, rather than avoiding it altogether. Physical activity is an important factor in improving T1DM prognosis.
name: Avoid intense exercise
label: b
answer: no
explanation: NICE guidelines suggest the provision of carbohydrate-counting courses as part of type 1 diabetes mellitus self-management. Carbohydrate counting is a meal planning method by which an individual manages blood glucose by approximating insulin doses with carbohydrate levels in each meal.
name: Meal planning courses
label: a
answer: yes
explanation: This is the opposite of what is recommended for insulin-injecting patients. Patients regularly self-administrating insulin should regularly rotate insulin injection sites to avoid lipodystrophy and cutaneous amyloidosis.
name: Avoid switching injection sites
label: d
answer: no
explanation: Individuals self-managing type 1 diabetes with insulin should never omit insulin doses, especially when unwell. Stopping insulin self-administration increases the risk of diabetic ketoacidosis (DKA). If a patient does not know how to adjust insulin doses when unwell, they should be advised to contact their diabetes team. When unwell, blood glucose monitoring should be increased to every 1-2 hours. Patients should be counselled to seek urgent medical advice if they experience symptoms of DKA.
name: Omit insulin doses when severely unwell
label: e
answer: no
explanation: Although patients beginning insulin therapy that will last >3 months must inform the DVLA, he does not need to stop driving as long as he maintains hypoglycaemia awareness. If an individual has more than one episode of severe hypoglycaemia per year they must stop driving and inform the DVLA.
name: He must inform the DVLA and stop driving his car
label: c
answer: no

Correct answer: a
A 43-year-old male presents to the clinic with a 2-month history of central weight gain and difficulty rising from chairs.

On examination, you note central obesity and proximal muscle weakness.

Furthermore, you identify a blood pressure of 146/93 mmHg and a heart rate of 81 bpm. Which of the following investigations is first line for the most likely underlying condition?

Options:
explanation: Although dexamethasone suppression tests are used first line to diagnose Cushing's, low dose (overnight) tests are used not high dose. Morning and midnight ACTH measurements are the gold standards for Cushing's localisation, but a high dose dexamethasone tests can also be used to localise Cushing's pathology:

* Cortisol and ACTH suppressed: Pituitary pathology (Cushing's disease)
* Cortisol not suppressed, ACTH suppressed: adrenal pathology
* Neither cortisol nor ACTH suppressed: ectopic ACTH secretion (e.g. small cell lung cancer)
name: High-dose dexamethasone suppression test
label: d
answer: no
explanation: The aldosterone/renin ratio is the first line test for primary hyperaldosteronism, a condition characterised by excess production of the mineralocorticoid aldosterone by the adrenal gland. In individuals with hyperaldosteronism, the aldosterone/renin ratio is increased, due to elevated aldosterone production and the subsequent suppression of renin caused by sodium retention negatively feeding back.
name: Aldosterone/renin ratio
label: b
answer: no
explanation: Although a pituitary MRI may be used to identify the presence of a pituitary adenoma (Cushing's disease), it is not the first-line test to diagnose Cushing's syndrome. Instead, a low-dose dexamethasone suppression test should be used to establish the presence of excess cortisol production.
name: Pituitary MRI
label: e
answer: no
explanation: This patient is most likely suffering from Cushing's syndrome, a disease characterised by excess circulating cortisol which may have a range of causes including exogenous corticosteroid exposure or pituitary adenoma. Cushing's syndrome presents with features of glucocorticoid excess: hypertension, insulin insensitivity, central obesity, proximal muscle weakness, striae, moon facies, and menstrual irregularities. The low-dose dexamethasone suppression test is first line and assesses the body's response to exogenous glucocorticoid. In health, the body will suppress the morning cortisol spike due to the negative feedback effect. In individuals with Cushing's syndrome, the morning cortisol increase will still be present.
name: Low-dose dexamethasone suppression test
label: a
answer: yes
explanation: The ACTH stimulation test (also known as the short synacthen test) is the definitive investigation of Addison's disease, not Cushing's syndrome. Addison's disease is characterised by primary adrenal insufficiency, so the provision of exogenous ACTH does not stimulate cortisol production. ACTH measurement also plays a role in Cushing's syndrome diagnosis, but is not the first line investigation and is instead used to localise the pathology involved.
name: ACTH stimulation test
label: c
answer: no

Correct answer: a
A 46-year-old female presents to General Practise with a 3-week history of anxiety, palpitations and restlessness. She has also noticed a painful neck swelling which is causing significant discomfort. On examination, you identify a tender, diffuse, firm neck goitre.

Which of the following is the most likely diagnosis?

Options:
explanation: Anxiety is not an appropriate diagnosis in patients presenting with symptoms of thyrotoxicosis and painful goitre.
name: Anxiety
label: e
answer: no
explanation: Hashimoto's thyroiditis is a common cause of hypothyroidism and is not the most likely causative factor here. Hashimoto's classically presents with symptoms of hypothyroidism (e.g. weight gain, low mood, fatigue etc) as well as a firm, non-tender goitre. This patient has presented with symptoms of thyrotoxicosis and a tender goitre, therefore the most likely diagnosis is De Quervain's thyroiditis.
name: Hashimoto's thyroiditis
label: c
answer: no
explanation: Although Grave's disease is the most common cause of hypothyroidism, it is not the most likely cause here. It is very uncommon for Grave's disease to present with a tender goitre, typically goitre in Grave's disease is diffuse but painless. De Quervain's thyroiditis is the most common cause of painful goitre and is therefore the most likely diagnosis here.
name: Grave's disease
label: b
answer: no
explanation: De Quervain's thyroiditis (also known as subacute thyroiditis) is a transient inflammation of the thyroid gland. De Quervain's thyroiditis is characterised by three phases: initial thyrotoxicosis (due to the release of thyroglobulin during gland destruction) which is followed by hypothyroidism and finally a return to normal thyroid function. The initial phase of thyrotoxicosis classically presents with a painful goitre and symptoms of elevated thyroid hormone.
name: De Quervain's thyroiditis
label: a
answer: yes
explanation: An important differential but not the most likely cause here. Toxic multinodular goitre occurs due to the development of individual thyroid nodules which develop the autonomous ability to secrete thyroid hormone. Toxic multinodular goitre classically presents with a more subtle, subclinical hyperthyroidism as well as the development of an irregular and nodular goitre. This patient has presented with more acute thyrotoxicosis and a painful goitre, therefore De Quervain's thyroiditis is a much more likely diagnosis.
name: Toxic multinodular goitre
label: d
answer: no

Correct answer: a
A 62-year-old female presents to General Practice with a 6-month history of bilateral knee pain which is worse on walking and alleviated by rest. She finds her joints are stiff in the morning but this lasts no longer than 10 minutes. On examination, there is crepitus and a limited range of motion in both knees. You refer the patient for an X-Ray.

Which of the following is most likely to be seen on X-ray?

Options:
explanation: This patient suffers from osteoarthritis. Osteoarthritis classically presents with joint pain worst on movement and improved by rest. Morning stiffness in osteoarthritis is characteristically short-lived, quite distinct from the lengthy morning stiffness of rheumatoid arthritis. Furthermore, crepitus is a classical finding of osteoarthritis on examination.

There are 4 key signs of osteoarthritis to be aware of on X-ray. They can be remembered by the acronym LOSS:

* Loss of joint space
* Osteophytes
* Subchondral sclerosis
* Subchondral cysts
name: Loss of joint space
label: a
answer: yes
explanation: Pseudo-fractures are a type of insufficiency fracture which describes the damage caused by normal stress on the dysfunctional bone. In this case, pseudo-fractures are a radiological hallmark of osteomalacia (vitamin D deficiency). Pseudo-fractures occur in osteomalacia due to impaired calcium homeostasis caused by vitamin d deficiency/malabsorption.
name: Pseudo-fractures
label: d
answer: no
explanation: Osteoporosis of bone that neighbours a joint is an X-ray sign of rheumatoid arthritis, rather than osteoarthritis. Loss of bone mineral density occurs as a result of inflammatory cytokines, which increase osteoclast activation and recruitment.
name: Periarticular osteoporosis
label: b
answer: no
explanation: Soft tissue swelling is a radiological sign of rheumatoid arthritis which occurs due to the inflammatory nature of the disease.
name: Soft tissue swelling
label: c
answer: no
explanation: Marginal erosions describe erosions that occur at areas of the bone within the joint capsule not covered by cartilage. Such erosions are often among the earliest radiological signs of rheumatoid arthritis and do not occur in osteoarthritis.
name: Marginal erosions
label: e
answer: no

Correct answer: a
A 45-year-old male presents to the clinic after a recent diagnosis of psoriatic arthritis. He is enthusiastic about engaging with treatment and is seeking advice and further information on his condition.

Which of the following is true regarding psoriatic arthritis?

Options:
explanation: This is incorrect, psoriatic arthritis has several different patterns of joint involvement. The most common is symmetrical joint involvement, but asymmetrical joint disease is present in up to 30% of patients.
name: Joint involvement is always asymmetrical
label: e
answer: no
explanation: This is incorrect. Psoriatic arthritis can occur before the onset of psoriasis or even in the absence of skin disease.
name: Psoriatic skin lesions are always present
label: b
answer: no
explanation: Psoriatic arthritis is a seronegative inflammatory arthropathy, therefore rheumatoid factor is negative.
name: Rheumatoid factor is positive
label: d
answer: no
explanation: Psoriatic arthritis is a chronic inflammatory seronegative arthritis which is associated with psoriasis. Psoriatic arthritis occurs in around 30% of individuals with psoriasis but can develop in absence of the skin condition, and, crucially, the severity of psoriasis does not correlate with the severity of psoriatic arthritis. Psoriatic arthritis can occur symmetrically or asymmetrically and distal interphalangeal joint involvement occurs in around 10% of patients.  Psoriatic arthritis can be difficult to differentiate from rheumatoid arthritis but there are several key differentiating factors:

* DIP joint involvement is more common in psoriatic arthritis
* Dactylitis is more common in psoriatic arthritis
* Psoriatic arthritis is rheumatoid factor negative
* Psoriatic arthritis is associated with psoriatic skin lesions and nail changes
* Psoriatic arthritis is more likely to be asymmetrical than rheumatoid arthritis
name: Arthritis can involve the distal interphalangeal joints
label: a
answer: yes
explanation: Although nail involvement is common in psoriatic arthritis, leukonychia is not a sign of psoriatic nail disease. Signs of psoriatic nail involvement include pitting, onycholysis, and nail hyperkeratosis.
name: Nail leukonychia is a common finding
label: c
answer: no

Correct answer: a
A 67-year-old male presents to the emergency department with a 10-hour history of excruciating pain in his big toe. The pain began in the morning and has worsened in intensity throughout the day. He is unable to walk on the affected foot due to the pain. On examination, you identify that the patient's left 1st metatarsophalangeal joint is erythematous and swollen.

Which of the following is a predisposing factor to this patient's condition?

Options:
explanation: Corticosteroid use is not associated with an increased risk of gout. Predisposing factors that increase the risk of gout typically act through one of two mechanisms: increased production of uric acid or reduced excretion of uric acid. Corticosteroid use does not cause either of these to occur.
name: Corticosteroid use
label: e
answer: no
explanation: A vegetarian diet is not associated with an increased risk of gout. Red meat, on the other hand, is rich in purines and so results in elevated uric acid levels, thereby increasing the risk of gout.
name: Vegetarian diet
label: d
answer: no
explanation: Hypouricaemia is decreased presence of uric acid within the blood and therefore reduces the risk of gout.
name: Hypouricaemia
label: b
answer: no
explanation: This patient has presented with an acute episode of gout. Gout occurs due to the accumulation of urate crystals within joints, causing acute crystal arthropathies. Gout presents with severe pain and most commonly affects the 1st metatarsophalangeal joint but affects other joints such as the knee, ankle, and wrist. Diuretics cause reduced excretion of uric acid and are therefore an important predisposing factor to the development of gout.
name: Diuretic use
label: a
answer: yes
explanation: Non-Steroidal Anti-Inflammatory drugs (NSAIDs) do not increase the risk of gout. The BNF does not state gout as a recognized side-effect of NSAID use. Indeed, NSAIDs are actually used in the management of acute gout.
name: Non-Steroidal Anti-Inflammatory drugs
label: c
answer: no

Correct answer: a
A 36-year-old female presents to the clinic with a 4-month history of fatigue, facial rash, and arthralgia. Examination reveals a malar rash and after further investigation, the patient is diagnosed with systemic lupus erythematosus (SLE).

Which of the following antibody tests is most specific for SLE?

Options:
explanation: SLE is a condition with a complex autoimmune background. There are many different antibodies implicated in SLE, but the most specific antibodies are those targeted against double-stranded DNA (anti-dsDNA). Although highly specific (>99%), anti-dsDNA is less sensitive (~70%).
name: Anti-dsDNA
label: a
answer: yes
explanation: This antibody is typically associated with diffuse systemic sclerosis, though is sometimes also present in SLE patients. It is therefore not the most specific antibody test for the diagnosis of SLE.
name: Anti-scl-70
label: e
answer: no
explanation: An extremely sensitive test but with poor specificity, anti-nuclear antibodies are positive in most SLE patients but are also positive in a range of other autoimmune conditions such as Sjögren's or systemic sclerosis.
name: Anti-nuclear antibodies
label: b
answer: no
explanation: Although anti-ro antibodies may be positive in SLE, they are not a very specific test. Anti-ro antibodies are also positive in ~70% of Sjögren's patients, and so are not the most specific test here.
name: Anti-Ro
label: c
answer: no
explanation: Another non-specific antibody which may be positive in SLE, rheumatoid factor is positive in a wide spectrum of autoimmune conditions including rheumatoid arthritis and Sjögren syndrome.
name: Rheumatoid factor
label: d
answer: no

Correct answer: a
A 39-year-old female presents to the clinic. She reports a 2-month history of her fingers turning blue in the cold as well as some skin thickening in her hands. On examination, you identify the presence of digital ulcers as well as thickened, sclerotic skin that involves the hands and wrists bilaterally. There is also some sclerotic skin on her face.

Which of the following symptoms is the patient most likely to also experience?

Options:
explanation: Butterfly rash (aka malar rash) is a sign most commonly associated with systemic lupus erythematosus. Although facial skin sclerosis can occur in limited systemic sclerosis, it does not manifest as a butterfly rash.
name: Butterfly rash
label: c
answer: no
explanation: Inflammatory arthritis is an extremely uncommon presentation of systemic sclerosis and may instead suggest overlap with another autoimmune condition (or indeed a different diagnosis altogether). Although patients may experience arthralgia, an inflammatory arthritis is unlikely in limited systemic sclerosis.
name: Inflammatory joint pain
label: d
answer: no
explanation: This patient suffers from limited systemic sclerosis, as indicated by the presence of Raynaud's phenomenon as well as sclerotic skin changes limited to the face and distal limbs (i.e. below elbow/knee). Oesophageal dysmotility is a very common symptom of limited systemic sclerosis and typically manifests as heartburn, dysphagia, and gastro-oesophageal reflux. Patients with limited systemic sclerosis may also develop telangiectasia, calcifications, and sclerodactyly. Late in the disease patients may develop interstitial lung disease and pulmonary artery hypertension.
name: Heartburn
label: a
answer: yes
explanation: Jaundice is not a typical symptom of limited systemic sclerosis. Although primary biliary cirrhosis (chronic inflammatory destruction of hepatic bile ducts) can uncommonly occur in diffuse systemic sclerosis, it does not occur in limited disease.
name: Jaundice
label: b
answer: no
explanation: Dry eyes are a classical symptom of Sjögren's syndrome. Dry eyes and mouth are two clinical hallmarks of this autoimmune disease but would not be found in systemic sclerosis (at least not without the presence of disease overlap).
name: Dry eyes
label: e
answer: no

Correct answer: a
A 71-year-old male presents to the Emergency Department with sudden onset urinary incontinence and pins and needles across his perineum. He also notes a 4-week history of lower back pain. His past medical history includes prostate cancer for which he is currently receiving treatment.

On examination, you identify reduced sensation across his perineum as well as reduced anal tone on digital rectal examination.

Which of the following investigations is most likely to be diagnostic of the underlying condition?

Options:
explanation: Although an MRI is the imaging modality of choice for the investigation and assessment of cauda equina syndrome, a non-urgent MRI is inappropriate given the emergency nature of the condition. If cauda equina syndrome remains untreated, there is a risk of permanent neurological damage such as leg weakness, sensory changes, and incontinence.
name: Non-urgent MRI lumbar spine
label: d
answer: no
explanation: This patient suffers from cauda equina syndrome, which occurs due to compression of the cauda equina lumbosacral nerve roots. This pathology is best assessed with an MRI due to the quality of soft tissue imaging and accurate aetiological assessment. The BMJ states that a CT lumbar spine should only be carried out if an MRI is unavailable or contraindicated.
name: Urgent CT lumbar spine
label: b
answer: no
explanation: This answer is incorrect for several reasons. Firstly, MRI lumbar spine is the imaging modality of choice due to superior soft tissue imaging. Secondly, cauda equina syndrome is a neurosurgical emergency and requires urgent investigation and intervention.
name: Non-urgent CT lumbar spine
label: e
answer: no
explanation: This patient is suffering from cauda equina syndrome, which is a neurosurgical emergency caused by compression of the cauda equina. This can occur due to disc prolapse, trauma, infection or malignancy. In this patient, bony metastases from his prostatic cancer are the most likely underlying cause. Cauda equina presents with lower back pain, sciatica, urinary and/or faecal incontinence, changes in perineal sensation, and reduced anal sphincter tone. The BMJ states that an urgent lumbar spine MRI is the best imaging modality due to soft tissue detail as well as the ability to examine the spinal canal, allowing accurate assessment of aetiology.
name: Urgent MRI lumbar spine
label: a
answer: yes
explanation: A spinal radiograph is not an appropriate investigation in the assessment of cauda equina syndrome. Plain radiographs have extremely poor soft tissue image quality and are unlikely to delineate compression of the lumbosacral nerve roots of the cauda equina.
name: Plain spinal radiograph
label: c
answer: no

Correct answer: a