General Question Writing Guidelines


This is a brief general guide to writing high-quality questions on geekyquiz.com to improve the chances that your question is published after review by our Editors.


Spelling and grammar

Excellent spelling and grammar are essential to writing high-quality clinical questions, so please review your question prior to submission for errors. 

Sentences

Throughout a question and its explanation, full sentences should be used (avoid shorthand).

Capitalisation

Generic drugs (e.g. aspirin) do not need to be capitalised.

Medical conditions do not need to be capitalised (unless they are eponymous e.g. Conn’s syndrome).

Anatomical terms do not need to be capitalised (unless they are eponymous).

Phrases for which there is a commonly used acronym (e.g. disseminated intravascular coagulation) do not need to be capitalised.

The first word of an answer option should be capitalised but the following words do not need to be.

Acronyms

You are welcome to use acronyms, however, the full word/phrase needs to be written out with the acronym following it in the first instance.

Tip: Consider installing the Grammarly browser plugin which analyses spelling and grammar in real-time, highlighting issues and suggesting corrections. After you have installed Grammarly, make sure that it is set to use British English (as it may initially be set up for US English).


Question

Things to do

Things to do when writing a question:

  • Make sure the question is clear and has a question mark at the end.
  • If a question stem is used, ensure the question itself is on its own line, rather than being part of the stem’s paragraph, to improve clarity.
  • Highlight the key part of the question to improve clarity (e.g. ‘What is the most likely diagnosis?’), but don’t use bold elsewhere in the question stem.
  • Please include the relevant reference ranges in brackets beside the laboratory value(s) in your question to make it easier for students to quickly assess whether the value is too high or low.
  • If values are used (e.g. vital signs, laboratory values) make sure that the units used match those of our reference ranges (click the reference range icon to quickly access them).

Things to avoid

Things to avoid when writing a question include:

  • The inclusion of irrelevant background information.
  • The inclusion of the reader in the question (e.g. “You are a junior doctor working in A&E when a 37-year-old patient presents with…”) – a better format would be (e.g. “A 37-year-old man presents to the A&E department with…”).
  • The use of names for patients in the clinical vignette (e.g. “A 23-year-old woman presents with…” not “Sally, a 23-year-old woman presents with”).
  • The use of negative questions (e.g. ‘What is the LEAST likely diagnosis’).
  • Avoid using bold text in the question stem and only use it (sparingly) in the question to help improve clarity (e.g. ‘What is the most likely diagnosis?’).
  • Only use italics for the names of micro-organisms.
Example question

A 27-year-old man presents to his GP with a swollen, painful knee that has developed over the last 3 days. He feels generally unwell, and since this morning he has noticed that his eyes are sore. He has never experienced anything like this before and he has no significant past medical history. He had a few days of bloody diarrhoea which he did not seek medical review for. On examination, you note slight redness of the conjunctiva, but no discharge. The right knee is noticeably swollen and warm to palpation. A patella tap test is positive and there is a limited range of movement due to pain. His vital signs are all within normal limits.

What is the most likely diagnosis?

Adding images to questions (or explanations)

If images are included in a question or explanation, it’s important that an attribution link is provided (within the image caption).

To add an image to a question or explanation, you can use Google image search:

1. Search for the image you want in Google and then click the  “Tools” menu.

2. After you click “Tools” you’ll be presented with a sub-menu that has an option for “Usage rights”.

3. Choose the “Creative Commons” filter from the list, which will exclude any images which are not appropriate to use.

4.When you locate an appropriate image, check the attribution details which you’ll need for referencing. Wikipedia-based images usually have a “Use this file on the Web” button, which will produce suggested reference text you can use when clicked (see image example below).

 


Answer options

Things to do

Things to do when writing out answer options:

  • Begin each answer option with a capital letter (subsequent words should not be capitalised).
  • Try to provide 5 succinct answer options.
  • The correct answer(s) should be evidence-based and widely agreed upon by experts.

Things to avoid

Things to avoid when writing out answer options:

  • Don’t add numbers or letters before each answer option (our software does this automatically).
  • Don’t worry about the order of the answers as they are randomised by the software for each user.
Example answer options
  • Reactive arthritis
  • Gout
  • Rheumatoid arthritis
  • Septic arthritis
  • Psoriatic arthritis

Explanation

Structure and formatting

Identify and explain the correct answer

The explanation should first identify the correct answer and explain why this is the most appropriate answer. You should provide some educational value relating to the answer (i.e. if the answer were a diagnosis, you would explain what the diagnosis is, how it typically presents). Avoid trying to include too much additional information, the explanation should be succinct and focused on briefly explaining the specific piece of knowledge that was being tested (e.g. if the answer is a diagnosis, you do not need to start discussing relevant investigations or management options).

The first mention of the correct answer should be formatted in bold.

Move on to explain why the other answer options were less correct/wrong

After explaining the correct answer, the explanation should then move on to discuss why the other possible answers were less correct. You should briefly explain each of the incorrect answers where possible (e.g. if they are diagnoses, you would briefly describe how each might typically present to highlight how their presentation doesn’t fit with the clinical features of the stem).

The explanation of each distractor should be focused and around one to three sentences in length.

The first mention of each incorrect answer (distractor) should be underlined to make it easy for users to quickly scan for why a particular distractor was incorrect.

The explanation of each distractor should be written in a way that sounds natural:

  • The mention of the distractor doesn’t need to be the beginning of the sentence (although it can be if that results in a natural-sounding sentence, as in example explanation 1).
  • See example explanation 2 to get an idea of how to integrate mentions of distractors in a natural way, using underlining to highlight the distractor wherever it lies in the sentence (it also does not have to match the answer option text exactly).
Example explanation

The most likely diagnosis is reactive arthritis which typically presents 2-4 weeks after a urinary tract or gastrointestinal infection. A single lower limb joint is typically affected and there is often systemic symptoms of malaise and fever. Conjunctivitis and urethritis can also be present and are referred to as Reiter’s triad. The common causative organisms include C. trachomatis, campylobacter, salmonella and shigella. In this case, the episode of bloody diarrhoea most likely represents campylobacteriosis.

Gout often presents with swelling, pain and erythema in a single joint (most commonly the first metatarsophalangeal joint). Systemic symptoms such as malaise and conjunctivitis are not associated with this diagnosis.

Rheumatoid arthritis typically presents with symmetrical polyarthritis and morning stiffness.

Septic arthritis often presents with a single, hot, tender and swollen joint as in this case. The absence of fever or rigors makes the diagnosis less likely but does not rule it out. The presence of conjunctivitis is not a feature of septic arthritis and the recent history of likely Campylobacter infection makes a diagnosis of reactive arthritis more likely. However, urgent synovial fluid analysis would be warranted to rule out bacterial infection of the joint.

Example explanation 2 (demonstrating how to naturally integrate mentions of distractors)

This patient has an asymptomatic, unruptured abdominal aortic aneurysm (AAA) measuring 5.7cm in diameter. NICE guidelines suggest all patients with an asymptomatic AAA measuring 5.5cm or larger in diameter should be referred to a regional vascular service to be seen within 2-weeks of diagnosis.

NICE guidelines recommend that all people with an AAA that is between 3.0 and 5.4cm should be seen within 12-weeks by the regional vascular service.

People with a suspected or confirmed ruptured AAA should undergo emergency transfer to regional vascular services. In this patient, the AAA is neither symptomatic nor ruptured; therefore, it would not warrant emergency transfer. 

In patients presenting with a ruptured AAA, volume resuscitation will likely be required in the interim to emergency surgery. As this patient has not experienced a rupture, it is not indicated as the stem does not describe features of hypotension. 

As this patient has been identified as having an asymptomatic but large AAA, it would not be suitable to discharge and arrange follow-up in one year.  NICE guidelines recommend that all people with aneurysms >3.0cm be referred to their regional vascular services for follow-up; within 2-weeks for those ≥5.5 cm and within 12-weeks for those between 3.0-5.4 cm. 


Further reading link

Provide a link to a resource that provides some background/evidence relevant to the question (e.g. NICE guidelines/NICE CKS/ further reading on the topic).

Please only reference resources that are freely accessible (e.g. not UpToDate/other resources behind a paywall).


High-quality example 1

Question

A 27-year-old man presents to his GP with a swollen, painful knee that has developed over the last 3 days. He feels generally unwell, and since this morning he has noticed that his eyes are sore. He has never experienced anything like this before and he has no significant past medical history. He had a few days of bloody diarrhoea which he did not seek medical review for. On examination, you note slight redness of the conjunctiva, but no discharge. The right knee is noticeably swollen and warm to palpation. A patella tap test is positive and there is a limited range of movement due to pain. His vital signs are all within normal limits.

What is the most likely diagnosis?

Answer options

  • Correct answer: Reactive arthritis
  • Distractor: Gout
  • Distractor: Rheumatoid arthritis
  • Distractor: Septic arthritis
  • Distractor: Psoriatic arthritis

Explanation

The most likely diagnosis is reactive arthritis which typically presents 2-4 weeks after a urinary tract or gastrointestinal infection. A single lower limb joint is typically affected and there is often systemic symptoms of malaise and fever. Conjunctivitis and urethritis can also be present and are referred to as Reiter’s triad. The common causative organisms include C. trachomatis, campylobacter, salmonella and shigella. In this case, the episode of bloody diarrhoea most likely represents campylobacteriosis.

Gout often presents with swelling, pain and erythema in a single joint (most commonly the first metatarsophalangeal joint). Systemic symptoms such as malaise and conjunctivitis are not associated with this diagnosis.

Rheumatoid arthritis typically presents with symmetrical polyarthritis and morning stiffness.

Septic arthritis often presents with a single, hot, tender and swollen joint as in this case. The absence of fever or rigors makes the diagnosis less likely but does not rule it out. The presence of conjunctivitis is not a feature of septic arthritis and the recent history of likely Campylobacter infection makes a diagnosis of reactive arthritis more likely. However, urgent synovial fluid analysis would be warranted to rule out bacterial infection of the joint.

Further reading

https://patient.info/doctor/reactive-arthritis-pro


High-quality example 2

Question

A 65-year-old man attends his local hospital for abdominal aortic aneurysm screening.

He has not had any symptoms; however, he is found to have an unruptured abdominal aortic aneurysm that is 5.7cm in diameter.

He has a past medical history of hypertension, managed with amlodipine 10mg and candesartan 8mg. He drinks 20 units of alcohol a week and has a 50-pack-year tobacco history.

What is the most appropriate initial management step?

Answer options

  • Correct answer: Begin resuscitation immediately
  • Distractor: Refer to regional vascular services to be seen within 2 weeks
  • Distractor: Discharge and arrange a follow-up ultrasound in 1 year
  • Distractor: Refer to regional vascular services to be seen within 12 weeks
  • Distractor: Emergency transfer to regional vascular services

Explanation

This patient has an asymptomatic, unruptured abdominal aortic aneurysm (AAA) measuring 5.7cm in diameter. NICE guidelines suggest all patients with an asymptomatic AAA measuring 5.5cm or larger in diameter should be referred to a regional vascular service to be seen within 2-weeks of diagnosis.

NICE guidelines recommend that all people with an AAA that is between 3.0 and 5.4cm should be seen within 12-weeks by the regional vascular service.

People with a suspected or confirmed ruptured AAA should undergo emergency transfer to regional vascular services. In this patient, the AAA is neither symptomatic nor ruptured; therefore, it would not warrant emergency transfer. 

In patients presenting with a ruptured AAA, volume resuscitation will likely be required in the interim to emergency surgery. As this patient has not experienced a rupture, it is not indicated as the stem does not describe features of hypotension. 

As this patient has been identified as having an asymptomatic but large AAA, it would not be suitable to discharge and arrange follow-up in one year.  NICE guidelines recommend that all people with aneurysms >3.0cm be referred to their regional vascular services for follow-up; within 2-weeks for those ≥5.5 cm and within 12-weeks for those between 3.0-5.4 cm. 

Further reading

https://www.nice.org.uk/guidance/ng156


High-quality example 3

Question

A 67-year-old woman presents to her GP regarding an event that occurred earlier that day. She was sat at her breakfast table when she experienced sudden-onset left arm weakness and heaviness. This lasted for about 15 minutes before resolving spontaneously. She had no headache or any other symptoms accompanying this episode and now, 5 hours later, feels her usual self. She reports a similar episode that happened the previous night and also lasted around 15 minutes.

She has a past medical history of hypertension and migraine and takes amlodipine 5mg daily. She has no known allergies.

On examination she has a normal neurological examination, is slightly hypertensive at 159/86 mmHg and has an irregularly-irregular heartbeat at a rate of 105 beats per minute.

What is the single most appropriate initial management step for this patient?

Answer options

  • Correct answer: Give aspirin 300mg and discuss with hospital stroke physician regarding urgent same-day assessment
  • Distractor: Arrange urgent outpatient appointment for an ECG
  • Distractor: Commence anticoagulation with warfarin or direct oral anticoagulant (DOAC)
  • Distractor: Give aspirin 300mg and arrange a TIA outpatient clinic review for the following day
  • Distractor: Administer a nasal triptan

Explanation

The most likely diagnosis is a transient ischaemic attack (TIA) – an episode of sudden onset neurological deficit which lasted for less than one hour. It is likely that the previous episode was also a TIA. A possible underlying aetiology of this is atrial fibrillation, as the patient has a slightly fast irregularly-irregular heartbeat. Given that the patient has had more than one TIA with a possible cardio-embolic source, the most appropriate step in management is to give 300mg aspirin and contact a hospital stroke physician regarding urgent same-day assessment. This is in keeping with NICE guidance regarding stroke and TIA management, and the patient has no contraindications to aspirin therapy.

Giving aspirin 300mg and arranging a next-day TIA outpatient clinic appointment without first discussing with a stroke specialist is not appropriate for this patient, as they are at high-risk for a stroke because they have had more than one TIA and a possible cardioembolic source.

Commencing anticoagulation will likely be indicated in future, especially if atrial fibrillation is confirmed, but is inappropriate without further assessment and investigation.

nasal triptan may be useful in cases of migraine but is not indicated here. Although neurological deficit can occur with some types of migraine, new sudden-onset neurological deficit requires prompt investigation for cerebrovascular causes regardless of the presence or absence of headache.

An urgent outpatient ECG is not appropriate for this patient given the presence of neurological deficit likely secondary to the underlying arrhythmia. An ECG needs to be performed more urgently than this to aid diagnosis and plan management to prevent stroke.

Further reading

https://cks.nice.org.uk/stroke-and-tia#!scenario:1


Low-quality example

Question

A male patient presents to his GP with a cough. The patient describes feeling unwell. They have a past medical history of an appendectomy.

Answer

What is the most likely diagnosis?

  • Correct answer: Pneumonia
  • Distractor (1): COPD
  • Distractor (2): Hypersensitivity pneumonitis
  • Distractor (3): Lung cancer
  • Distractor (4): Tuberculosis

Explanation

The correct answer is pneumonia, as it is statistically the most likely diagnosis in a patient presenting to their GP with a cough.

Why is this a poor-quality question?

The stem is vague – in order to correctly answer the question, the reader would need more details such as the patient’s age, related symptoms, smoking history, occupational history, travel history, etc. The past medical history of an appendectomy is entirely irrelevant to the stem.

The patient could have any of the above conditions – all may present with a cough and “feeling unwell”. Of course, statistically speaking, pneumonia is likely the most common diagnosis made in someone presenting to their GP with a cough. However, this question isn’t testing any diagnostic skills in the reader. Questions should be asking what the most likely diagnosis is in a patient given the information and background provided.


Submit your question

Once you’ve reviewed your question and feel it meets the standards set out in these guidelines you can submit it for review using the “Finalise and Submit” button. Once this is pressed, the question is added to a queue where our Editors will review it. You will be notified if your question is accepted, rejected or if it requires further changes. 

If you want to save your question but not yet submit it, use the “Save Changes” button. You can then access and continue editing your question at a later date via your profile.