hllj/quesmed huggingface dataset:
A 72-year-old male presents to neurology with worsening attention, reduced executive function, and some visual hallucinations. His wife mentions that these symptoms have been worsening over the past year. She also notices that he has recently started to develop a resting tremor in his left hand.

What is the most likely diagnosis?

Options:
explanation: This patient is presenting with symptoms of Lewy body dementia, demonstrated by progressive cognitive impairment, hallucinations, and more recent Parkinsonian changes.
name: Lewy body dementia
label: a
answer: yes
explanation: Vascular dementia would typically present with a shorter history of cognitive impairment, usually following a stroke.
name: Vascular dementia
label: b
answer: no
explanation: Multiple sclerosis typically presents with episodes of fatigue, numbness, muscle weakness and vision problems. Although it can present at any age, it usually occurs in females between 20-40 years of age.
name: Multiple sclerosis
label: e
answer: no
explanation: Whilst there is some overlap between Alzheimer's disease and Lewy body dementia, the recent development of a resting tremor (Parkinsonian sign) is more suggestive of Lewy body dementia.
name: Alzheimer's disease
label: d
answer: no
explanation: Frontotemporal dementia would typically present with extreme changes in personality, difficulties with language, and cognitive impairment.
name: Frontotemporal dementia
label: c
answer: no

Correct answer: a
An 82-year-old male presents to orthopaedics with a fracture following a recent fall. His wife mentions that he has recently been having more falls than usual, and is beginning to struggle with his activities of daily living. He has a past medical history of type 2 diabetes and a previous myocardial infarction. His current medications include metformin, gliclazide, losartan, bisoprolol, aspirin, prasugrel and atorvastatin. The blood pressure for this patient is measured:

Lying blood pressure: 144/82 mmHg

Standing blood pressure: 106/70 mmHg

Given the most likely diagnosis, which of the following options should be considered in the management of this patient?

Options:
explanation: This patient is presenting with signs of postural hypotension, as demonstrated by the > 20 mmHg drop in systolic blood pressure when switching from a lying to a standing position. Many factors can increase the risk of postural hypotension, including diuretics, antihypertensives, antidepressants, and Parkinson's medications. In this case, the beta-blocker (bisoprolol) may be a likely precipitating factor for this patient's symptoms, and a change in dosage should be considered.
name: Lower bisoprolol dose
label: a
answer: yes
explanation: There is currently no association between atorvastatin and the development of postural hypotension.
name: Lower atorvastatin dose
label: c
answer: no
explanation: There is currently no association between prasugrel use and the development of postural hypotension.
name: Lower prasugrel dose
label: e
answer: no
explanation: There is currently no association between aspirin use and the development of postural hypotension.
name: Lower aspirin dose
label: d
answer: no
explanation: There is currently no association between metformin and the development of postural hypotension.
name: Lower metformin dose
label: b
answer: no

Correct answer: a
Which of the following scoring systems can be used as a screening tool for assessing delirium in a patient?

Options:
explanation: The patient health questionnaire (PHQ-9) score can be used to screen patients for major depressive disorder, as opposed to delirium.
name: PHQ-9 score
label: d
answer: no
explanation: The GAD-7 score screens patients for generalised anxiety disorder, as opposed to delirium.
name: GAD-7 score
label: c
answer: no
explanation: The 4AT score is a useful screening tool for assessing whether a patient may have delirium, with a score of more than 4 out of 12 suggesting delirium. The score takes into account the alertness, memory and attention of the patient, as well as whether their symptoms fluctuate throughout the day.
name: 4AT score
label: a
answer: yes
explanation: The MMSE may be used as a screening tool for Alzheimer's disease or other types of dementia, as opposed to delirium.
name: Mini-mental state examination (MMSE)
label: b
answer: no
explanation: The disease activity score (DAS28) is used to assess the severity of rheumatoid arthritis symptoms, as opposed to delirium.
name: DAS28 score
label: e
answer: no

Correct answer: a
A 47-year-old woman visits her GP for a routine review of her Type 2 diabetes medication. The GP performs her blood pressure which reads 165/110 mmHg.

What is the best interpretation and appropriate course of action for this reading?

Options:
explanation: Whilst the patient's hypertension is classified as Stage 2, Amlodipine, a Calcium-Channel Blocker would be inappropriate first-line therapy as this woman has Type 2 Diabetes Mellitus.
name: Stage 2 Hypertension and commence the patient on Amlodipine
label: d
answer: no
explanation: This is incorrect as Stage 3 hypertension is defined as a blood pressure of >180/120 in the clinic and IV Nitroprusside would only be administered where there are signs of papilloedema and/or retinal haemorrhage.
name: Stage 3 Hypertension and immediate administration of IV Nitroprusside
label: c
answer: no
explanation: This is incorrect as stage 1 hypertension is defined as clinic BP of 140/90 - 159/99 mmHg. ABPM is used to confirm the clinical diagnosis of both stage 1 & stage 2 hypertension.
name: Stage 1 Hypertension and confirm via Ambulatory Blood Pressure Measurements (ABPM)
label: e
answer: no
explanation: This patient's reading is 165/110 mmHg, and the threshold for stage 2 Hypertension in the clinic is ≥ 160/100 mmHg. NICE guidelines recommend the use of ABPM to confirm the diagnosis.
name: Stage 2 Hypertension and confirm via Ambulatory Blood Pressure Measurements (ABPM)
label: a
answer: yes
explanation: While this patient does have stage 2 hypertension in the clinic measurements, and Ramipril would be the appropriate first-line treatment for this patient, NICE guidelines recommend ABPM to exclude the possibility of white coat hypertension before commencing any pharmacological interventions.
name: Stage 2 Hypertension and commence the patient on Ramipril
label: b
answer: no

Correct answer: a
A 73-year-old woman with a longstanding history of hypertension has been observed on fundoscopy to have silver wiring.

Which of the following is the Keith-Wagener classification of her hypertensive retinopathy?

Options:
explanation: There is no stage 5 in the Keith-Wagener classification.
name: Stage 5
label: e
answer: no
explanation: This is incorrect as stage 3 is due to ischaemic changes and retinal infarction which causes damage to nerve fibres. This is what results in the cotton-wool-like patches. Stage 3 is also where hard exudates and haemorrhages are seen due to lipids and blood leaking into the retina from damaged vessels.
name: Stage 3
label: c
answer: no
explanation: This is correct, the silver wiring is due to the walls of the arterioles becoming thickened and sclerosed, resulting in an increase in light reflection, which gives the characteristic silver look.
name: Stage 1
label: a
answer: yes
explanation: This is incorrect as stage 4 is characterised by papilloedema, which is a result of ischaemia to the optic nerve, causing oedema of the optic nerve and blurring of the disc margins.
name: Stage 4
label: d
answer: no
explanation: This is incorrect as stage 2 is due to the focal constriction of blood vessels and arteriovenous nipping where the arterioles compress the veins they cross.
name: Stage 2
label: b
answer: no

Correct answer: a
A 40-year-old Black Male has just been diagnosed with hypertension after having a clinic blood pressure of 163/102 mmHg and later confirmed via Ambulatory Blood Pressure Measurements (APBM).

What is appropriate first-line management?

Options:
explanation: This is incorrect as Thiazide-like diuretics are reserved for second and/or third-line treatment in the management of Hypertension.
name: Bendroflumethiazide 2.5mg once daily
label: d
answer: no
explanation: This is incorrect as this patient is from an afro-caribbean background and does not have type 2 diabetes mellitus, therefore under NICE guidelines for hypertension would not be suitable for an ACE inhibitor.
name: Ramipril 2.5mg once daily
label: c
answer: no
explanation: This is incorrect as Angiotensin receptor blockers (ARBs), such as Candesartan are used for second and/or third-line management of hypertension in patients from Afro-Caribbean backgrounds who do not have Type 2 diabetes mellitus.
name: Candesartan 8mg once daily
label: e
answer: no
explanation: As the patient is of Afro-Caribbean origin and does not have Type 2 diabetes mellitus, a calcium-channel blocker such as amlodipine is the correct drug to prescribe as first-line management in this case.
name: Amlodipine 5mg once daily
label: a
answer: yes
explanation: Whilst a calcium-channel blocker, such as amlodipine is appropriate first-line management for this patient, NICE guidelines recommend an initial dose of 5mg once daily for hypertension, which can be increased up to 10mg if necessary.
name: Amlodipine 10mg once daily
label: b
answer: no

Correct answer: a
You are on the Cardiology Ward Round when the consultant asks the FY2 to listen to the heart valve which controls the flow of blood into the left ventricle, what is this valve called and where is it best auscultated?

Options:
explanation: The Mitral valve is correct, as it is located between the left atrium and left ventricle, thus controlling the flow of blood into the left ventricle. The Mitral valve is best auscultated in the fifth intercostal space, mid-clavicular line.
name: Mitral Valve, fifth intercostal space, mid-clavicular line
label: a
answer: yes
explanation: Whilst the mitral valve being located between the left atria and left ventricle means it controls the flow of blood into the left ventricle, this option is incorrect as the mitral valve is best auscultated in the mid-clavicular line in the fifth intercostal space.
name: Mitral Valve, second intercostal space, mid-clavicular line
label: e
answer: no
explanation: The aortic valve is incorrect, as it is located between the left ventricle and ascending aorta, meaning it controls the flow of blood out of the left ventricle.
name: Aortic Valve, second intercostal space, right sternal border
label: b
answer: no
explanation: The Tricuspid valve is incorrect as it is located in between the right atrium and right ventricle, therefore it controls the flow of blood into the right ventricle.
name: Tricuspid Valve, fifth intercostal space, left sternal border
label: c
answer: no
explanation: The Pulmonary valve is incorrect as it is located between the right ventricle and the pulmonary trunk, controlling the flow of blood out of the right ventricle.
name: Pulmonary Valve, Second intercostal space, left sternal border
label: d
answer: no

Correct answer: a
A 60-year-old male with a 40-pack-year history of smoking presents to the Emergency Department with central crushing chest pain that radiates to the jaw, shortness of breath and clamminess, what is the most urgent investigation to perform?

Options:
explanation: Despite an Echocardiogram being useful in investigating Ejection Fraction and the status of the heart valves, it would not be an immediate investigation in this case.
name: Echocardiogram
label: e
answer: no
explanation: ECG is the correct answer. An urgent ECG is required in every patient that has a suspected Acute Coronary Syndrome (ACS). ECG is the gold-standard method for helping to diagnose and differentiate between Acute Coronary Syndromes.
name: ECG
label: a
answer: yes
explanation: Gastroscopy is an investigation indicated in suspected GORD with red flag symptoms such as weight loss. As this patient has strong indicators from the history pointing to an ACS, gastroscopy would not be an appropriate investigation.
name: Gastroscopy
label: d
answer: no
explanation: Although a CT Pulmonary Angiography is useful in diagnosing/ excluding a pulmonary embolism as a cause for chest pain, it would not be a first-line investigation in this case.
name: CTPA
label: c
answer: no
explanation: Whilst a Chest X-ray can be useful in assessing for signs of heart failure, other causes of chest pain and pulmonary oedema, it is not the most urgent investigation required in this case.
name: Chest X-Ray
label: b
answer: no

Correct answer: a
A 76-year-old female has been diagnosed with Left Ventricular Systolic dysfunction and Heart failure after being referred to a cardiologist by her GP following swollen ankles. The cardiologist prescribes some medication which she has to take once a day.

What is the name of this medication and what is the mechanism of action?

Options:
explanation: Although amlodipine is a Calcium-Channel Blocker that reduces peripheral vascular resistance by inhibiting vascular smooth muscle contraction and cardiac muscle contraction, it is not indicated in heart failure.
name: Amlodipine - lowers heart rate
label: d
answer: no
explanation: Whilst propanolol causes lower arterial blood pressure, it is not due to vasodilation, it is instead due to less calcium influx through L-type calcium channels on cardiomyocytes, decreasing the heart rate. Propanolol is not used in patients with heart failure
name: Propanolol - causes vasodilation
label: c
answer: no
explanation: Although Ivabradine reduces heart rate by acting on the sinoatrial node, it is second-line management in heart failure.
name: Ivabradine - reduces heart rate
label: e
answer: no
explanation: Ramipril is an ACE inhibitor (ACEi) that inhibits the conversion of Angiotensin I into Angiotensin II. Amongst other funstions, angiotensin II causes vasoconstriction, so by inhibiting its production, the ACEi Ramipril is able to cause vasodilation, reducing strain on the heart. Angiotensin II has a number of other effects that lead to lowering of blood pressure, including: sympathetic activation, sodium reabsorption in the kidneys, aldosterone release and ADH release.
name: Ramipril - causes vasodilation
label: a
answer: yes
explanation: Whilst Furosemide inhibits Na-K-Cl cotransporters in the thick ascending loop of Henle, it is nor first line management in heart failure.
name: Furosemide - loop diuretic
label: b
answer: no

Correct answer: a
A 58-year-old male presents to his GP after becoming breathless in everyday activities such as climbing the stairs for the past 6 months. The patient remarks he has a productive cough, but there is no blood and has been getting more chest infections recently. The patient has a 30-pack-year smoking history. On examination, the patient is afebrile and coarse crackles are auscultated at the base of the lungs bilaterally.

What is the most likely underlying diagnosis?

Options:
explanation: Due to the significant smoking history, and classical clinical features of breathlessness on exertion, productive cough but no haemoptysis, COPD is the most likely diagnosis.
name: COPD
label: a
answer: yes
explanation: PE is a good differential, however as the breathlessness has been present for 6 months, and there is no haemoptysis, this makes it a very unlikely underlying cause of the patients' symptoms.
name: Pulmonary Embolism (PE)
label: d
answer: no
explanation: CAP is unlikely as the patient is not reporting a fever, or showing other signs of infection.
name: Community-Acquired Pneumonia (CAP)
label: c
answer: no
explanation: Whilst Asthma and COPD can be hard to differentiate, in this case, the age and smoking history points to COPD.
name: Asthma
label: e
answer: no
explanation: Whilst lung cancer is a relevant differential diagnosis, considering the patient's smoking history, there is no weight loss reported in the scenario nor haemoptysis so malignancy is unlikely.
name: Lung Cancer
label: b
answer: no

Correct answer: a
An 8-year-old girl was helping her mother clean out an old dusty garage. Soon she becomes breathless and has a feeling of tightness in her chest.

What type of hypersensitivity reaction has occurred?

Options:
explanation: This is incorrect as Type II hypersensitivity reactions occur in hours-days. An example of Type II hypersensitivity reactions is autoimmune haemolytic anaemia. Type III reactions are mediated by IgG and IgM.
name: Type II reaction
label: b
answer: no
explanation: This is incorrect as Type V hypersensitivity reactions occur when antibodies are produced to stimulate specific cell targets, for example Graves disease.
name: Type V
label: e
answer: no
explanation: This is correct as Type I hypersensitivity reactions occur in asthma. This involves an immediate reaction (a matter of minutes) mediated by IgE.
name: Type I reaction
label: a
answer: yes
explanation: This is incorrect as Type IV hypersensitivty is delayed, typically occurring 24-72 hours after exposure. This type of reaction is also T-cell mediated. An example is contact dermatitis.
name: Type IV reaction
label: d
answer: no
explanation: This is incorrect as Type III hypersensitivity reactions can occur over hours, days or even weeks. A common example of Type III hypersensitivity reaction is rheumatoid arthritis. This reaction is mediated by an antigen-antibody complex.
name: Type III reaction
label: c
answer: no

Correct answer: a
A 55-year-old man presents to his GP with a 2-week history of a productive cough with yellow sputum and a fever. On examination, there is dullness when percussing over the left lower lobe.

What is the likely causative organism?

Options:
explanation: This is incorrect as *Klebsiella pneumoniae* are more commonly implicated in cases of ventilator-associated pneumonia.
name: *Klebsiella pneumoniae*
label: d
answer: no
explanation: This is correct as *Streptococcus pneumoniae* is the most common type of community-acquired pneumonia (CAP).
name: *Streptococcus pneumoniae*
label: a
answer: yes
explanation: This is incorrect as *Pseudomonas aeruginosa* are more likely to be seen in hospital-acquired pneumonia.
name: *Pseudomonas aeruginosa*
label: c
answer: no
explanation: This is incorrect as *E. coli* pneumonia is typically seen in cases of aspiration pneumonia.
name: *Escherichia coli*
label: e
answer: no
explanation: This is incorrect as *Mycoplasma pneumoniae* are rare in the community and are classed as atypical pneumonia.
name: *Mycoplasma pneumonia*
label: b
answer: no

Correct answer: a
In the first step of alcohol metabolism in the liver, a reactive and toxic product is formed.

What type of reaction occurs and what is the product?

Options:
explanation: This is incorrect as whilst this is an oxidation reaction, alcohol dehydrogenase is the enzyme that catalyses this reaction and not the product.
name: Oxidation and Alcohol Dehydrogenase
label: e
answer: no
explanation: This is incorrect as whilst this is an oxidation reaction, the product of the first step of alcohol metabolism is acetaldehyde, not acetate which is the final product.
name: Oxidation and Acetate
label: c
answer: no
explanation: This answer is correct as Ethanol is oxidised by Alcohol dehydrogenase to form Acetaldehyde. Acetaldehyde is a very reactive and toxic substance and is quickly converted into acetate.
name: Oxidation and Acetaldehyde
label: a
answer: yes
explanation: This option is incorrect as this reaction is neither reduction nor is the product for step 1 metabolism acetate, it is acetaldehyde.
name: Reduction and Acetate
label: d
answer: no
explanation: This is incorrect as whilst Acetaldehyde is the correct product, this is an oxidation reaction.
name: Reduction and Acetaldehyde
label: b
answer: no

Correct answer: a
A 47-year-old man recently returned from a 3-week long holiday in Central America. He is now jaundiced, has nausea and vomiting, and deranged LFTs. He reports having eaten a lot of shellfish whilst on holiday.

What is the most likely underlying cause?

Options:
explanation: Consumption of raw and undercooked shellfish are a major risk factor for the contraction of Hepatitis A. If the shellfish are living in water that has been contaminated with the stool containing the virus, the shellfish could be carrying the virus.
name: Hepatitis A
label: a
answer: yes
explanation: Hepatitis D is incorrect as it cannot be transmitted faecal-orally. Hep D can be transmitted through sharing of body fluids. Moreover, Hep D requires co-infection of Hep B as it attaches to HBsAg to survive.
name: Hepatitis D
label: d
answer: no
explanation: Hepatitis C is incorrect as it cannot be transmitted faecal-orally. Hep C can be transmitted through sharing of body fluids.
name: Hepatitis C
label: c
answer: no
explanation: This is incorrect as there is no indication that the patient drank an excessive amount of alcohol to cause alcoholic hepatitis.
name: Alcoholic Hepatitis
label: e
answer: no
explanation: Hepatitis B is incorrect as it cannot be transmitted faecal-orally. Hep B can be transmitted through sharing of body fluids.
name: Hepatitis B
label: b
answer: no

Correct answer: a
A 15-year-old girl is brought into the Emergency Department after consuming 64 tablets of paracetamol around 12 hours ago.

What is the most appropriate immediate step to take?

Options:
explanation: This is incorrect as Gastric Lavage would only be effective within an hour of ingesting.
name: Gastric Lavage
label: e
answer: no
explanation: This is incorrect as activated charcoal is only considered in adults who present within an hour of taking an overdose.
name: Activated Charcoal
label: b
answer: no
explanation: This is correct. NAC is a precursor of glutathione which will bind to the NAPQI that can then be excreted really.
name: IV N-acetylcysteine (NAC)
label: a
answer: yes
explanation: This is incorrect, as transplantation is only considered where the overdose has progressed into Acute Liver Failure.
name: Liver Transplantation
label: c
answer: no
explanation: Whilst this is an important referral to consider, it is incorrect in this context as it needs to be ensured the patient is medically stable before a psychiatric referral.
name: Urgent Psychiatric Assessment
label: d
answer: no

Correct answer: a
A 49-year-old female presents with a 3-day history of fever, jaundice and right-upper quadrant pain. The patient also reported pale stools and dark urine. On examination, scleral icterus was noted and RUQ tenderness.

What is the most underlying cause?

Options:
explanation: Based on the history, we can tell this patient is suffering from post-hepatic jaundice as she has both pale stools and dark urine, indicating there is a build of conjugated bilirubin which solely occurs in post-hepatic jaundice.
name: Biliary Stricture
label: a
answer: yes
explanation: This is incorrect as sickle cell anaemia is a cause of pre-hepatic jaundice and results in an increased unconjugated bilirubin production.
name: Sickle Cell anaemia
label: b
answer: no
explanation: This is incorrect as thalassaemia is a cause of pre-hepatic jaundice and results in an increased unconjugated bilirubin production.
name: Thalassaemia
label: c
answer: no
explanation: This is inccorrect as Gilberts' syndrome is a hereditary condition that is more common in men, causing pre-hepatic jaundice.
name: Gilberts' Syndrome
label: d
answer: no
explanation: This is incorrect as Criggler-Najjar syndrome is hereditary resulting in defects in bilirubin metabolism.
name: Crigler-Najjar Syndrome
label: e
answer: no

Correct answer: a