hllj/quesmed huggingface dataset:
A 50-year-old male is bought into the emergency department after being found unresponsive at home. He opens his eyes to pain but makes only incomprehensible groans when asked questions.

He has a past medical history of depression and hay fever, and takes regular sertraline.

An arterial blood gas is performed which shows the following:

PaO2 =9

PaCO2 = 7

Which of the following is the most likely cause of this patient’s presentation?

Options:
explanation: Pneumonia causes type 1 respiratory failure, which occurs due to a ventilation-perfusion (V/Q) mismatch. This means that the volume of air that is passing into and out of the lungs is much smaller than the volume of blood perfusing the lungs, resulting in hypoxia but a normal serum carbon dioxide level. This patient demonstrates type 2 respiratory failure, with hypercapnia as well as hypoxia, making this option incorrect.
name: Pneumonia
label: b
answer: no
explanation: This is a cause of type 1 respiratory failure. The bronchoconstriction present in asthma causes areas of the lungs that have poor ventilation with oxygen but are well perfused by blood. This results in hypoxia, but a normal carbon dioxide level. This patient demonstrates type 2 respiratory failure, with hypercapnia as well as hypoxia, making this option incorrect.
name: Asthma
label: e
answer: no
explanation: This is a cause of type 1 respiratory failure. A pulmonary embolism causes a ventilation-perfusion mismatch, meaning the volume of air passing in and out of the lungs is smaller than the volume of blood perfusing the lungs. This results in hypoxia, but a normal carbon dioxide level. This patient demonstrates type 2 respiratory failure, with hypercapnia as well as hypoxia, making this option incorrect.
name: Pulmonary Embolism
label: d
answer: no
explanation: This is a cause of type 1 respiratory failure, not type 2.
name: Pneumothorax
label: c
answer: no
explanation: An opiate overdose causes depression of the respiratory centre, and therefore results in type 2 respiratory failure (hypoxia plus hypercapnia). Type 2 respiratory failure occurs due to a reduction in alveolar ventilation, meaning that the lungs fail both to effectively oxygenate the blood and to remove carbon dioxide. Other causes of type 2 respiratory failure include idiopathic pulmonary fibrosis, COPD, Guillain-Barre syndrome, and motor neuron disease.
name: Opiate overdose
label: a
answer: yes

Correct answer: a
A 77-year-old male is admitted to the cardiac ward with increasing shortness of breath over the last 2 months. You suspect a diagnosis of heart failure and conduct a N-terminal pro-B-type natriuretic peptide (BNP) blood test.

Which of the following factors would cause a decrease in this patient’s BNP level?

Options:
explanation: This would cause a decrease in the BNP levels. Other factors that cause BNP levels to decrease include: diuretics, ACE inhibitors, beta blockers, angiotensin receptor blockers and aldosterone antagonists.
name: Obesity
label: a
answer: yes
explanation: Diabetes causes BNP levels to increase rather than decrease.
name: Type 2 diabetes
label: d
answer: no
explanation: This causes an increase in BNP level.
name: COPD
label: e
answer: no
explanation: An age over 70 would cause BNP levels to increase. Other factors that cause an increase in BNP levels include: tachycardia, hypoxemia, sepsis, COPD and liver cirrhosis.
name: Age over 70
label: b
answer: no
explanation: This would cause an increase in BNP levels.
name: Left ventricular hypertrophy
label: c
answer: no

Correct answer: a
A 70-year-old male presents to the emergency department with a 1-month history of fever, weight loss and chest pain that is worse on inspiration. He tells you he has been feeling generally worn down with muscle and joint pains and he also noticed some night sweats.  You notice macules on the patient’s palms and soles consistent with Janeway lesions and splinter haemorrhages on the patient’s nails.

He underwent a prosthetic valve replacement 4 months ago, but is otherwise fit and well.

Given the likely diagnosis, which of the following is the most likely causative organism?

Options:
explanation: This organism is associated with colorectal cancer. The patient in this question does not have colorectal cancer, therefore colonization with streptococcus bovis is unlikely. Staphylococcus aureus is the most common cause of infective endocarditis overall and is the most likely causative organism in this case.
name: Streptococcus Bovis
label: b
answer: no
explanation: This is the most common cause of endocarditis in patients following prosthetic valve surgery. However, the risk of this is only within the first 2 months after surgery. We are told our patient had prosthetic valve surgery 4 months ago; therefore his chance of colonization with staph epidermis has returned to normal. Staphylococcus aureus is the most common cause of infective endocarditis overall and is the most likely causative organism in this case.
name: Staphlococcus epidermis
label: d
answer: no
explanation: This is an uncommon cause of infective endocarditis and therefore is not the most likely causative organism of this patient’s infective endocarditis. Staphylococcus aureus is the most common cause of infective endocarditis overall and is the most likely causative organism in this case.
name: Coxiella burnetii
label: e
answer: no
explanation: This organism is found in dental plaque and is a common cause of endocarditis in patients with poor dental hygiene or following a dental procedure. It is also the most common cause of endocarditis in developing countries. However, staphylococcus aureus is the most common cause of infective endocarditis overall and is the most likely causative organism in this case.
name: Streptococcus viridans
label: c
answer: no
explanation: This patient has the typical findings of infective endocarditis: fevers (most common), weight loss, pleuritic chest pain, night sweats, and lethargy. During the first 2 months following prosthetic valve surgery, the patient is at risk of infective endocarditis caused by staphylococcus epidermis. However, this patient had surgery 4 months ago, and the risk of staphylococcus epidermis colonization has now returned to normal. The most common causative organism of infective endocarditis overall is staphylococcus aureus, and therefore this is the most likely finding in this case.
name: Staphylococcus aureus
label: a
answer: yes

Correct answer: a
A 77-year-old female is reviewed in cardiology clinic after suffering an anterior myocardial infarction two months ago. Her ECG shows intermittent non-conducted P waves with constant PR intervals.

Which of the following is the most appropriate management?

Options:
explanation: A beta blocker is not the correct treatment for Mobitz type II heart block.
name: Bisoprolol
label: e
answer: no
explanation: This may be an option if the patient was presenting with a second STEMI within 12 hours of symptoms. However, this ECG shows a type of second degree heart block called Mobitz type II. Therefore, the most appropriate management would be to insert a pacemaker.
name: Percutaneous Coronary Intervention
label: d
answer: no
explanation: This would be an appropriate treatment if the patient was presenting with a Type A aortic dissection. However, this patient has no clinical features of this, and their ECG shows a type of heart block known as Mobitz type II.
name: Aortic graft
label: b
answer: no
explanation: This may be an option if the ECG was showing first-degree heart block. First-degree heart block can be identified on an ECG by finding a PR interval over 200ms. However, this patient demonstrates Mobitz type II  heart block, the treatment of which is with a permanent pacemaker as these patients are at risk of going into complete heart block
name: No treatment needed
label: c
answer: no
explanation: This patient’s ECG describes a type of heart block called Mobitz type II. This is a type of second degree AV block where there are intermittent non-conducted P waves but the PR interval remains constant. It is commonly caused by a conduction system failure at the His-Purkinje system. The management of Mobitz type II is with a permanent pacemaker as these patients are at risk of going into complete heart block.
name: Pacemaker
label: a
answer: yes

Correct answer: a
A 50-year-old female presents to the emergency department with central crushing chest pain that began one hour ago. An ECG shows ST elevation in leads V1-4.

In which of the following coronary arteries is the most likely site of occlusion?

Options:
explanation: The ECG changes shown in the question correspond to the left anterior descending artery, not the right marginal artery.
name: Right marginal artery
label: e
answer: no
explanation: An occlusion in the left circumflex artery would cause changes in leads I and aVL.
name: Left Circumflex
label: b
answer: no
explanation: The right coronary artery corresponds to leads II, III and aVF.
name: Right coronary artery
label: c
answer: no
explanation: The proximal left anterior descending artery would cause changed in leads V1-6 as well as leads I and AVL.
name: Proximal left anterior descending
label: d
answer: no
explanation: The ECG changes shown in this question (V1-V4) correspond to the left anterior descending artery, therefore making this the correct answer.
name: Left Anterior Descending
label: a
answer: yes

Correct answer: a
A 40-year-old female is discovered to have an HbA1c of 52mmol/L (normal range 20-42 mmol/L) on a routine blood test. She denies any symptoms of polyuria or polydipsia.


Which of the following is the most appropriate next step?

Options:
explanation: This patient is asymptomatic and therefore would require a second HbA1c result above 48mmol/L in order to diagnose type 2 diabetes mellitus. Therefore, it would not be appropriate to begin insulin.
name: Commence insulin replacement regime
label: b
answer: no
explanation: This patient is asymptomatic but does have a HbA1c of above 48mmol/L. In order to diagnose Type 2 diabetes mellitus, the patient would need a second Hba1c above 48mmol/L measured on a different day. It would not be diagnostic to have a second HbA1c done immediately.
name: Repeat HbA1c immediately
label: e
answer: no
explanation: This patient is asymptomatic and therefore would require a second HbA1c result above 48mmol/L in order to diagnose type 2 diabetes mellitus. Therefore, it would not be appropriate to begin metformin at this stage.
name: Commence metformin
label: c
answer: no
explanation: This patient has an HbA1C of 52mmol/L. The diagnostic threshold of diabetes is an HbA1c greater than or equal to 48mmol/L. However, this patient is asymptomatic. In patients with no symptoms, the test must be repeated on a different day to confirm the diagnosis.
name: Repeat HbA1c in 2 weeks
label: a
answer: yes
explanation: Type 2 diabetes mellitus cannot be diagnosed in this patient at this stage. This is because the patient is asymptomatic and has only had 1 HbA1c above 48mmol/L. Therefore, the test must be repeated on a different day to confirm the diagnosis.
name: Diagnose Type 2 Diabetes Mellitus
label: d
answer: no

Correct answer: a
A 19-year-old female attends the GP surgery with reports of extreme tiredness for the past four months. She is also troubled by hair loss and dry skin, and has noticed that her clothes are becoming too tight for her. On further questioning, you also find out she is more constipated than usual, despite no change to her diet.

Which of the following is the most likely diagnosis?

Options:
explanation: Hyperthyroidism would present with weight loss rather than gain, as well as symptoms like sweating, anxiety, palpitations, sensitivity to heat, and diarrhoea.
name: Hyperthyroidism
label: d
answer: no
explanation: This is a typical presentation of hypothyroidism. The patient describes general symptoms of weight gain and lethargy, and is experiencing anhydrosis and hair loss. Hypothyroidism also impacts the gastrointestinal system causing constipation. It can also cause menorrhagia in some patients, although this is not specifically mentioned.
name: Hypothyroidism
label: a
answer: yes
explanation: A presentation of Addison's disease can present with symptoms such as lethargy and weakness similar to those seen in this patient. However, you would expect Addison’s to cause weight loss, rather than gain and would also expect symptoms such as nausea and vomiting, hyperpigmentation of the skin, and vitiligo. Addison's is also typically associated with hyponatremia and hyperkalaemia.
name: Addison's Disease
label: b
answer: no
explanation: Type 1 diabetes mellitus typically causes weight loss rather than gain, as well as symptoms such as polyuria and polydipsia. A first presentation of type 1 diabetes can present as an episode of diabetic ketoacidosis with abdominal pain, vomiting, and reduced consciousness level.
name: Type 1 Diabetes Mellites
label: c
answer: no
explanation: Iron deficiency anaemia would present with a different clinical picture.  Symptoms include lethargy, weakness, jaundice, heavy periods, and a change in bowel habits. It is not typically associated with weight gain. Hypothyroidism is therefore a more likely diagnosis.
name: Iron Deficiency Anaemia
label: e
answer: no

Correct answer: a
A 25-year-old male attends the GP surgery after noticing a large amount of weight gain, particularly around his abdomen. He has also felt low in mood recently.

On examination, you observe abdominal striae and weakness in all four of his proximal limbs.

Which of the following is the next best investigation?

Options:
explanation: Central obesity, proximal weakness, depression and abdominal striae are typical of Cushing’s syndrome. The diagnostic investigation for Cushing’s syndrome is a low dose dexamethasone suppression test.

By contrast, 24-hour plasma metanephrines would be a diagnostic investigation if you suspect pheochromocytoma. The classic presentation of pheochromocytoma includes symptoms of episodic hypertension, anxiety, palpations, headaches and signs like tremor and hypertensive retinopathy.
name: 24-hour plasma metanephrines
label: d
answer: no
explanation: This patient presents with the key symptoms of Cushing’s syndrome: proximal myopathy, striae, obesity, and depression. It can also manifest as osteoporosis, a 'moon' shaped face, diabetes mellitus, hypokalaemia and hypertension. The diagnostic investigation for Cushing’s syndrome is a low dose dexamethasone suppression test.
name: Dexamethasone suppression test
label: a
answer: yes
explanation: Central obesity, proximal weakness, depression and abdominal striae are typical of Cushing’s syndrome. A fluid deprivation test can be performed to diagnose diabetes insipidus, but would not be diagnostic in this case. The diagnostic investigation for Cushing’s syndrome is a low dose dexamethasone suppression test.

Diabetes insipidus is characterized by patients producing large volumes of dilute urine, nocturia and excessive thirst. Before a fluid deprivation test, some baseline investigations involve renal function tests, blood glucose, urine dip and serum and urine osmolality tests.
name: Fluid deprivation test
label: c
answer: no
explanation: Central obesity, proximal weakness, depression and abdominal striae are typical of Cushing’s syndrome. HbA1c is a useful diagnostic test for diabetes mellitus, but would not be diagnostic in this case. The diagnostic investigation for Cushing’s syndrome is a low dose dexamethasone suppression test.
name: HbA1c
label: b
answer: no
explanation: Central obesity, proximal weakness, depression and abdominal striae are typical of Cushing’s syndrome. The diagnostic investigation for Cushing’s syndrome is a low dose dexamethasone suppression test.

By contrast, a short synacthen test would confirm the diagnosis of Adrenal sufficiency, not Cushing’s disease. Adrenal insufficiency would present with symptoms like hypotension, fatigue and weakness, gastrointestinal symptoms, syncope and skin pigmentation. Blood tests would also show low sodium and high potassium.
name: Short synacthen test
label: e
answer: no

Correct answer: a
A 46-year-old male attends his GP surgery with concerns that he is becoming more short of breath on exertion. He undergoes blood tests, which demonstrate a raised ALT at 68IU/L (normal range 10-50 IU/L). Bilirubin, ALP and albumin are all within the normal range.


He does not drink alcohol and his BMI is 24. His father has emphysema.


Which of the following is the most likely reason for this liver abnormality?

Options:
explanation: This is a disorder of iron metabolism where excessive iron accumulates in the body and is deposited in a number of sites including the liver, heart, joints, pancreas and skin. You would expect haemochromatosis to show deranged LFTs as well as a raised serum ferritin and raised transferring saturation.
name: Haemochromatosis
label: c
answer: no
explanation: You would expect pancreatitis to present with symptoms like epigastric pain radiating to the back, pain relived by sitting forward and nausea and vomiting. Bloods may show leukocytosis and an extremely high amylase level.
name: Acute Pancreatitis
label: d
answer: no
explanation: You would expect Wilson's disease to show low serum ceruloplasmin and copper levels. It would not account for the high ALT.
name: Wilson’s disease
label: e
answer: no
explanation: You would expect Gilbert’s syndrome to cause a mildly raised bilirubin but otherwise normal blood results. It would not account for the raised ALP. Gilbert’s can cause a mild intermittent jaundice in relation to stress, infection, fasting, or exercise.
name: Gilbert’s syndrome
label: b
answer: no
explanation: An isolated raised ALP is indicative of alpha-1 antitrypsin deficiency. This is an inherited condition that affects the lungs (causing emphysema) and the liver (causing cirrhosis and hepatocellular carcinoma).
name: Alpha-1 Antitrypsin deficiency
label: a
answer: yes

Correct answer: a
A 55-year-old female is admitted to the hospital after an unwitnessed fall and long lie. She has a history of alcohol excess, with poor oral intake. Since her admission to the hospital, nursing staff report she has been eating well. However, two days later, she becomes drowsy and confused.

On examination she appears pale and malnourished, with long and dirty fingernails. She is neurologically intact, with no external evidence of a head injury.

Which of the following would you expect to find on the patient’s blood results?

Options:
explanation: This patient is experiencing refeeding syndrome. It can occur in any patient who is malnourished and subsequently resumes feeding, however alcohol excess is a particular risk factor. Refeeding syndrome causes a fall in magnesium levels. It would also cause phosphate and potassium levels to be low, as well as  hyperglycaemia.
name: Low magnesium
label: a
answer: yes
explanation: This patient is experiencing refeeding syndrome. It can occur in any patient who is malnourished and subsequently resumes feeding, however alcohol excess is a particular risk factor. Refeeding syndrome would cause low B1 levels, not high.
name: High B1 levels
label: e
answer: no
explanation: This patient is experiencing refeeding syndrome. It can occur in any patient who is malnourished and subsequently resumes feeding, however alcohol excess is a particular risk factor. Refeeding syndrome would cause low phosphate levels, not high.
name: High phosphate
label: b
answer: no
explanation: This patient is experiencing refeeding syndrome. It can occur in any patient who is malnourished and subsequently resumes feeding, however alcohol excess is a particular risk factor. Refeeding syndrome would cause hyperglycaemia, not hypoglycaemia.
name: Hypoglycaemia
label: d
answer: no
explanation: This patient is experiencing refeeding syndrome. It can occur in any patient who is malnourished and subsequently resumes feeding, however alcohol excess is a particular risk factor. Refeeding syndrome would cause low potassium levels, not high.
name: High potassium
label: c
answer: no

Correct answer: a
A 66-year-old male presents to the GP with lower abdominal pain that began 6 weeks ago. He also reports diarrhoea and has noticed some blood in his stool. He is pleased to report weight loss of around half a stone, despite no change to his diet.

His abdominal examination is normal.

Which of the following diagnoses is most important to exclude?

Options:
explanation: Irritable Bowel Syndrome is a possible differential for a patient presenting with a change in bowel habits. However, it is a diagnosis of exclusion. It is essential to first rule out other serious causes of his symptoms like colorectal cancer.
name: Irritable Bowel Syndrome
label: c
answer: no
explanation: Ulcerative colitis is a possible differential for diarrhoea and blood in the stool. However, it is important to first exclude the possibility of malignancy causing his symptoms.
name: Ulcerative colitis
label: b
answer: no
explanation: Malignancy would be the most important diagnosis to exclude in this case. This patient is aged over 60 and has a change in bowel habits. He therefore qualifies for a 2-week wait referral for possible colorectal cancer.
name: Colorectal cancer
label: a
answer: yes
explanation: Coeliac Disease is a possible differential for a presentation of diarrhoea and weight loss. However, it is important to first exclude the possibility of a malignancy causing his symptoms.
name: Coeliac Disease
label: d
answer: no
explanation: Gastroenteritis is a possible differential for a change in bowel habit. However, the duration of his symptoms and absence of nausea or vomiting makes this less likely.
name: Gastroenteritis
label: e
answer: no

Correct answer: a
A 40-year-old male presents to A&E with central abdominal pain that has been increasing over the past 3-4 days. His abdomen is distended with tinkling bowel sounds, and he reports not opening his bowels for around a week. You suspect he has a large bowel obstruction.

What is the most common cause of large bowel obstruction?

Options:
explanation: This is the most common cause of large bowel obstruction. Once the diagnosis of large bowel obstruction has been established, it would be useful to perform a CT abdomen to identify any tumours.
name: Colonic tumour
label: a
answer: yes
explanation: This is an important cause of large bowel obstruction, but not the most common cause. Strictures can occur secondary to diverticular disease or can happen in other conditions such as inflammatory bowel disease. They can also occur as a result of post-surgery as anastomosis.
name: Stricture
label: b
answer: no
explanation: Adhesions can cause large and small bowel obstructions. Adhesions are the most common cause of small bowel obstructions, whereas large bowel obstructions are most commonly caused by colonic malignancy.
name: Adhesion
label: e
answer: no
explanation: Hernias can cause large bowel obstructions, but the most common cause of large bowel obstruction is a colonic tumour.
name: Hernia
label: d
answer: no
explanation: This is an important cause of large bowel obstruction but not the most common cause. The most common cause of large bowel obstruction are colonic tumours.
name: Volvulus
label: c
answer: no

Correct answer: a