hllj/quesmed huggingface dataset:
A 42-year-old male is admitted to the hospital with sepsis following surgery for colorectal cancer.

His respiratory rate is 25, oxygen saturations are 92%, heart rate is 120bpm, and temperature is 38.2.

On examination, he is not oriented to time and place, and a purpuric rash is noted over his arms. There is also blood oozing from his cannula sites. His past medical history is unremarkable.

Which of the following is most likely to be his blood results?

Options:
explanation: D-dimer is high in DIC because it is a fibrin degradation product and fibrinolysis occurs in DIC.
name: Low platelets, low fibrinogen, raised APTT, low d-dimer
label: c
answer: no
explanation: APTT is raised in DIC because fibrinolysis is taking place. Fibrinogen and fibrin are key components of the intrinsic clotting pathway, therefore the consumption of these clotting products in DIC results in a prolonged APTT.
name: Low platelets, low fibrinogen, normal APTT, low d-dimer
label: d
answer: no
explanation: Fibrinogen is low in DIC because fibrinolysis is activated which results in the consumption of fibrin and fibrinogen.
name: Low platelets, high fibrinogen, raised APTT, raised d-dimer
label: e
answer: no
explanation: Platelets are low in DIC because the activation of the clotting pathway leads to excess thrombus formation which consumes platelets.
name: High platelets, low fibrinogen, raised APTT, raised d-dimer
label: b
answer: no
explanation: This patient has DIC. In DIC, the coagulation pathway is activated throughout the body which consumes platelets and clotting factors and leads to a low platelet count. Fibrinogen is low because fibrinolysis is activated, and d-dimer is high as it is a fibrin degradation product.
name: Low platelets, low fibrinogen, raised APTT, raised d-dimer
label: a
answer: yes

Correct answer: a
A 60-year-old male presents to A&E with central crushing chest pain that has been ongoing for 1 hour. He says the pain came on while he was playing tennis. The pain radiates to his left arm and his jaw.

The paramedics gave him GTN spray in the ambulance which reduces the severity of his symptoms. An ECG is done which shows ST elevation in V1 - V4.

What is the most likely diagnosis?

Options:
explanation: If the right coronary artery was involved, the ST elevation would be seen in the inferior leads: II, III and AVf.
name: Right coronary artery STEMI
label: c
answer: no
explanation: Unstable angina is a good differential due to the chest pain relieved by GTN spray, however unstable angina is often brought on without triggers such as exercise. Furthermore, the ECG changes, in this case, are more suggestive of a STEMI.
name: Unstable angina
label: e
answer: no
explanation: Although this patient experienced chest pain on exertion which was relieved by GTN spray, the ECG changes and pain radiation are more suggestive of a STEMI.
name: Stable angina
label: b
answer: no
explanation: The chest pain and ST elevation here suggest that the patient is having a STEMI. The V1-V4 ECG leads view the heart from the anteroseptal plane, so it is most likely that the left anterior descending artery is blocked.
name: Left anterior descending artery STEMI
label: a
answer: yes
explanation: If the left circumflex artery was involved, ST elevation would be seen in the lateral leads; I, AVL, V5 and V6.
name: Left circumflex artery infarct causing STEMI
label: d
answer: no

Correct answer: a
A 65-year-old patient attends his abdominal aortic aneurysm monitoring appointment. 12 months ago, his abdominal aortic aneurysm diameter measured 4.2cm, today it measures 5.3cm. He has a 25-pack-year smoking history. His vital signs are normal and he is well in himself.

Which of the following is the most appropriate management?

Options:
explanation: Only patients with abdominal aortic aneurysm diameters <3cm can be discharged with no further action.
name: No further action
label: e
answer: no
explanation: This is good advice for patients who smoke, but may only impact the growth in a low rupture-risk patient. It is more important that the patient undergoes surgery within 2 weeks to prevent rupture.
name: Smoking cessation advice
label: d
answer: no
explanation: Medium aneurysms (4.5-5.4cm) are normally rescanned every 3 months as a part of the screening programme. However, the diameter of this man's abdominal aorta has increased by >1cm within a year, so the patient has a high rupture risk and must be treated.
name: Repeat ultrasound in 3 months
label: b
answer: no
explanation: This patient has a high rupture risk because his abdominal aorta is rapidly enlarging and has increased by >1cm within a year. Therefore, this patient must be treated with EVAR or open repair despite being asymptomatic.
name: Urgent 2-week referral to vascular surgery for intervention
label: a
answer: yes
explanation: The diameter of the abdominal aorta has increased by >1cm within a year, so the patient has a high rupture risk and must be treated.
name: Repeat ultrasound in 12 months
label: c
answer: no

Correct answer: a
A 70-year-old female presents to her GP with a 3-month history of worsening shortness of breath. She also describes intermittent palpitations before episodes of dizziness.

Auscultation of the heart reveals a mid-diastolic murmur which is loudest in the apex and louder on expiration with the patient laying on her left side. The patient appears comfortable at rest and her vital signs are normal.

What is the most likely diagnosis?

Options:
explanation: A high-pitched early diastolic murmur would be heard on auscultation aortic regurgitation.
name: Aortic regurgitation
label: e
answer: no
explanation: A pan-systolic murmur loudest on inspiration would be heard on auscultation in tricuspid regurgitation.
name: Tricuspid regurgitation
label: d
answer: no
explanation: A pan-systolic murmur radiating to the axilla would be heard on auscultation in mitral regurgitation.
name: mitral regurgitation
label: c
answer: no
explanation: An ejection systolic murmur would be heard on auscultation in aortic stenosis and may radiate to the carotid arteries.
name: Aortic stenosis
label: b
answer: no
explanation: This patient is experiencing shortness of breath and dizziness alongside a mid-diastolic murmur which indicates mitral stenosis. Other symptoms of mitral stenosis include haemoptysis and chest pain.
name: Mitral stenosis
label: a
answer: yes

Correct answer: a
A 44-year-old male has been started on amiodarone for ventricular tachycardia.

Which of the following is a side effect of amiodarone therapy?

Options:
explanation: Amiodarone may cause hyper or hypothyroidism, but it is more likely to cause hypothyroidism than hyperthyroidism.
name: Hyperthyroidism
label: a
answer: yes
explanation: Amiodarone use may cause a slate-grey appearance to the skin.
name: Green discolouration of the skin
label: d
answer: no
explanation: Amiodarone can cause pneumonitis which can develop into pulmonary fibrosis, a restrictive lung pathology.
name: Pneumonia
label: e
answer: no
explanation: Amiodarone may cause hypotension in acute settings due to vasodilation.
name: Hypertension
label: c
answer: no
explanation: Amiodarone does not contribute to the development of obstructive lung diseases such as asthma.
name: Asthma
label: b
answer: no

Correct answer: a
A 66-year-old female presents to A&E with sudden onset pain in her right foot. On examination, the foot is cold and pale, and the posterior tibial pulse is absent. Her past medical history includes hypertension and diabetes. She takes statins once daily and has a 15-pack-year smoking history.

What is the most likely diagnosis?

Options:
explanation: In chronic limb ischaemia, patients gradually develop a reduced blood supply to the limbs as a result of atherosclerosis. This patient presents with factors suggesting chronic limb ischaemia such as a smoking history and pain. However, the sudden onset nature of the pain is suggestive of acute limb ischaemia, as opposed to chronic. Furthermore, chronic limb ischaemia typically presents with intermittent claudication which is triggered by exercise and relieved by rest.
name: Chronic limb ischaemia
label: b
answer: no
explanation: Compartment syndrome usually occurs secondary to trauma which this patient does not have a history of.
name: Compartment syndrome
label: e
answer: no
explanation: This patient is suffering from acute limb ischaemia characterised by sudden onset pain caused by the blockage of the arterial supply to the foot. The features of acute limb ischaemia can be remembered using the 6 Ps: pain, pallor, paresthesia, pulselessness, perishingly cold and paralysis.
name: Acute limb ischaemia
label: a
answer: yes
explanation: Patients with critical limb ischaemia typically present with worsening pain and ischaemic lesions such as ulcers. A patient with critical limb ischaemia would be expected to experience pain at rest for more than 2 weeks.
name: Critical limb ischaemia
label: c
answer: no
explanation: This patient does not present with risk factors for deep vein thrombosis (DVT). In a patient with DVT, you would not expect the foot to be pulseless, cold and pale; it is more likely to be swollen, red and warm.
name: Deep vein thrombosis
label: d
answer: no

Correct answer: a
A 66-year-old male presents to his GP with a 6-month history of intermittent palpitations and breathlessness. He has a past medical history of hypertension and type 2 diabetes. On examination, his vitals are normal apart from a blood pressure of 142/84. An ECG is done which shows atrial fibrillation.

What is this patient's CHADS-VASc?

Options:
explanation: This patient has a CHADS-VASc score of 3.
name: 1
label: d
answer: no
explanation: This patient has a CHADS-VASc score of 3.
name: 6
label: e
answer: no
explanation: The CHADS2VASc score is based on the following components:

* C: 1 point for congestive cardiac failure.
* H: 1 point for hypertension.
* A2: 2 points if the patient is aged 75 or over.
* D: 1 point if the patient has diabetes mellitus.
* S2: 2 points if the patient has previously had a stroke or transient ischaemic attack (TIA).
* V: 1 point if the patient has known vascular disease.
* A: 1 point if the patient is aged 65-74.
* Sc: 1 point if the patient is female.

This patient scores 1 for being aged 65-74, 1 for hypertension and 1 for diabetes.
name: 3
label: a
answer: yes
explanation: This patient has a CHADS-VASc score of 3.
name: 4
label: c
answer: no
explanation: This patient has a CHADS-VASc score of 3.
name: 2
label: b
answer: no

Correct answer: a
A 60-year-old female presents to A&E with sudden onset right-sided facial numbness. On examination, her gait is unsteady and she has right-sided ptosis, meiosis and anhidrosis. She also reports dizziness with the sensation of the room spinning. She has a past medical history of hypertension and hypercholesterolaemia. Her vital signs are within normal ranges.

Based on the most likely diagnosis, which of the following arteries is most likely to be affected?

Options:
explanation: Anterior inferior cerebellar artery occlusion would result in lateral pontine syndrome. Patients also tend to experience facial paralysis and deafness.
name: Right anterior inferior cerebellar artery
label: c
answer: no
explanation: Posterior cerebral artery occlusion would result in visual field defects such as contralateral homonymous hemianopia, and sensory impairment such as facial numbness.
name: Left posterior cerebral artery
label: d
answer: no
explanation: Basilar artery occlusion would result in locked-in syndrome, characterised by quadriparesis with preserved consciousness and ocular movements.
name: Basilar artery
label: b
answer: no
explanation: Occlusion in the ophthalmic artery would result in amaurosis fugax.
name: Ophthalmic artery
label: e
answer: no
explanation: This patient is having a stroke, specifically a lateral medullary syndrome (Wallenberg's syndrome). The features of Wallenberg's syndrome can be remembered using the DANVAH mnemonic: **D**ysphagia, ipsilateral **a**taxia, ipsilateral **n**ystagmus, **v**ertigo, **a**naesthesia (ipsilateral facial numbness and contralateral loss of pain sensation in the body), and ipsilateral **H**orner's syndrome.
name: Right posterior inferior cerebellar artery
label: a
answer: yes

Correct answer: a
A 40-year-old female presents to A&E with chest pain. She has a heart rate of 110 bpm, respiratory rate of 22 breaths per minute, blood pressure of 110/70, temperature of 38.7 and oxygen saturations are 94% on room air.

On examination, she appears drowsy but is responsive to voice. There are needle track marks in her antecubital fossae. On auscultation of her chest, an ejection systolic murmur is heard.

She is diagnosed with infective endocarditis.

Which of the following pathogens is most likely to be the cause of her infective endocarditis?

Options:
explanation: This is the most likely causative organism in patients with poor dental hygiene or following a dental procedure.
name: *Streptococcus viridans *
label: d
answer: no
explanation: This is the most likely causative organism in patients with adenomas/adenocarcinomas of the colon and IBD.
name: *Streptococcus bovis*
label: c
answer: no
explanation: *Staphylococcus aureus* is the most common cause of infective endocarditis and is most associated with IV drug use (this patient has signs of IV drug use, indicated by her needle track marks).
name: *Staphylococcus aureus*
label: a
answer: yes
explanation: This is the most likely causative organism in patients who have been in contact with farm animals, cats and dogs.
name: *Coxiella burnetti*
label: e
answer: no
explanation: This is the most likely causative organism in patients with prosthetic valves.
name: *Staphylococcus epidermis *
label: b
answer: no

Correct answer: a
A 45-year-old male presents to his GP with a 6-month history of intermittent chest pain. He describes the pain as 'chest tightening' and explains that it is triggered on exertion and relieved by rest. He is referred to A&E where blood tests reveal a normal troponin.

Based on the most likely diagnosis, what is the first-line diagnostic investigation to request?

Options:
explanation: This patient has stable angina; a stress echocardiogram can be used as a 2nd line investigation if the results of a CTCA are not diagnostic.
name: Stress echocardiography
label: c
answer: no
explanation: This patient has stable angina as indicated by the constriction-like chest pain brought on by exertion and relieved by rest. The first-line diagnostic investigation is CTCA.
name: CT coronary angiogram (CTCA)
label: a
answer: yes
explanation: This patient has stable angina; a myocardial perfusion scan can be used as a 2nd line investigation if the results of a CTCA are not diagnostic.
name: Myocardial perfusion scan
label: e
answer: no
explanation: Based on the normal troponin levels and chest pain exacerbated by exercise and relieved by rest, it is likely that this patient has stable angina. An ECG would not be useful in confirming the diagnosis of stable angina.
name: ECG
label: b
answer: no
explanation: A chest x-ray would not provide a view of the heart with enough detail to be able to diagnose stable angina.
name: Chest x-ray
label: d
answer: no

Correct answer: a
A 60-year-old female presents to clinic with chest pain. She has a history of AKI. She reports muscle weakness in her lower limbs and intermittent palpitations. Blood results show hyperkalaemia.

Which of the following findings are most likely to be found on her ECG?

Options:
explanation: P waves are flat on ECG in hyperkalaemia.
name: Tall P waves
label: c
answer: no
explanation: U waves are found on ECG in hypocalcaemia and hypothermia.
name: U waves
label: d
answer: no
explanation: This is a characteristic ECG finding in hyperkalaemia.
name: Tall tented T waves
label: a
answer: yes
explanation: The QRS complex is widened on ECG in hyperkalaemia.
name: Narrow QRS complex
label: b
answer: no
explanation: The PR interval is prolonged on ECG in hyperkalaemia.
name: Shortened PR interval
label: e
answer: no

Correct answer: a
A 78-year-old man has severe clostridium difficile (*c.difficile*) and is prescribed an antibiotic that specifically targets anaerobic bacteria. He has previously had an anaphylactic reaction to amoxicillin.

Which antibiotic is he most likely to have been prescribed?

Options:
explanation: This is a good broad-spectrum antibiotic and is used first-line in conditions such as sepsis, where the offending pathogen is unknown, or if cultures and sensitivities are pending. It covers both aerobic and anaerobic bacteria. However, this question asks specifically about anaerobic cover used in c.diff infection, of which metronidazole is the antibiotic of choice according to NICE guidelines. This patient is also allergic to penicillin. Therefore, this antibiotic should be avoided.
name: Piperacillin with tazobactam (tazocin)
label: b
answer: no
explanation: Monotherapy with either nitrofurantoin or trimethoprim is used first-line in the management of urinary tract infections. Nitrofurantoin covers gram-negative and some gram-positive aerobic bacteria. However, this question asks specifically about anaerobic cover used in c.diff infection, of which metronidazole is the antibiotic of choice according to NICE guidelines.
name: Nitrofurantoin
label: c
answer: no
explanation: IV metronidazole is used alongside oral vancomycin in the management of severe *c.difficile* infection. Metronidazole is that it is the mainstay treatment for anaerobic bacteria due to its mechanism of action of being cytotoxic to anaerobic microbes. It is therefore used in conditions such as *c.difficile* and also diverticulitis.
name: Metronidazole
label: a
answer: yes
explanation: Flucloxacillin is the first-line management for cellulitis in non-penicillin allergic patients. It has activity against gram-positive and gram-negative aerobic and anaerobic bacteria. However, this question asks specifically about anaerobic cover used in c.diff infection, of which metronidazole is the antibiotic of choice according to NICE guidelines. This patient is also allergic to penicillin therefore this antibiotic should be avoided.
name: Flucloxacillin
label: e
answer: no
explanation: Ceftriaxone is used first-line in the management of meningococcal meningitis. Although ceftriaxone has coverage against both gram-positive and gram-negative aerobic and anaerobic bacteria, β-lactam antibiotics such as ceftriaxone should be used with caution in patients with known anaphylaxis to penicillins due to structural similarities. In addition, this question asks specifically about anaerobic cover used in c.diff infection, of which metronidazole is the antibiotic of choice according to NICE guidelines.
name: Ceftriaxone
label: d
answer: no

Correct answer: a
A 57-year-old female attends the rheumatology outpatient department for a review of her methotrexate. She mentions that she has been experiencing burning when passing urine. She is diagnosed with a urinary tract infection (UTI). The doctor is aware that caution must be taken when prescribing a specific antibiotic.

To which antibiotic is he referring?

Options:
explanation: Monotherapy with either trimethoprim or nitrofurantoin is first-line in the management of urinary tract infection according to NICE guidelines. Pivmecillinam is used second-line if no improvement is seen in lower UTI symptoms after taking the first-line antibiotic taken for at least 48 hours, or when the first choice is not suitable.
name: Pivmecillinam
label: d
answer: no
explanation: Monotherapy with either trimethoprim or nitrofurantoin is first-line in the management of urinary tract infections according to NICE guidelines. Trimethoprim works by inhibiting folic acid production. This patient is already established on methotrexate for rheumatoid arthritis. Methotrexate is an anti-folate drug, and therefore other anti-folate drugs should be avoided. Examples of anti-folate drugs include methotrexate, trimethoprim, pemetrexed and proguanil (anti-malarial). Patients taking anti-folate medication should be counselled on their medication and have supplemental folic acid on a different day to their methotrexate dose.
name: Trimethoprim
label: a
answer: yes
explanation: Monotherapy with either trimethoprim or nitrofurantoin is first-line in the management of urinary tract infection according to NICE guidelines. Common side effects of gentamicin include ototoxicity and nephrotoxicity. Gentamicin is not used in the treatment of a simple urinary tract infection.
name: Gentamicin
label: c
answer: no
explanation: Monotherapy with either trimethoprim or nitrofurantoin is first-line in the management of urinary tract infection according to NICE guidelines. Cefalexin is used second-line in pregnant women aged 12+ if no improvement is seen in lower UTI symptoms on first-line antibiotic taken for at least 48 hours, or when the first choice is not suitable.
name: Cefalexin
label: e
answer: no
explanation: Monotherapy with either trimethoprim or nitrofurantoin is first-line in the management of urinary tract infections according to NICE guidelines. This patient is likely to be commenced on nitrofurantoin for management of her UTI.
name: Nitrofurantoin
label: b
answer: no

Correct answer: a
A 14-year-old boy presents with weight loss and increased thirst. He is diagnosed with an autoimmune condition affecting his body's ability to regulate blood sugar.

Given the likely diagnosis, which hormone is deficient in this condition?

Options:
explanation: Glucagon is a hormone involved in blood sugar regulation, but it is not deficient in type 1 diabetes. In fact, it actually counteracts the actions of insulin by stimulating hepatic glucose production and thereby increasing blood glucose levels.
name: Glucagon
label: c
answer: no
explanation: Lipase is an enzyme secreted by the pancreas and transferred to the duodenum to participate in the hydrolysis and digestion of fat, cholesterol esters, and fat-soluble vitamins. It is not involved in the regulation or transport of glucose from the blood into cells.
name: Lipase
label: e
answer: no
explanation: Glucose is not a hormone. It is the breakdown molecule of food such as carbohydrates. It is the molecule on which insulin acts. Glucose levels in the blood are high in type 1 diabetes due to the absolute deficiency of insulin and the subsequent inability of the body to transport glucose intracellularly.
name: Glucose
label: b
answer: no
explanation: The diagnosis for this patient is Type 1 Diabetes Mellitus. In type 1 diabetes, the immune system targets and destroys the insulin-producing cells of the pancreas. When food is eaten, the body breaks down food into molecules, one of which is glucose. Insulin is responsible for stimulating cells to take up this glucose from the bloodstream into insulin-dependent cells/tissues, such as the liver, muscle, and adipose tissue.
name: Insulin
label: a
answer: yes
explanation: Amylase is an enzyme produced by the pancreas. It hydrolyzes the glycosidic bonds in starch molecules, converting complex carbohydrates to simple sugars. It is not involved in the regulation or transport of glucose from the blood into cells.
name: Amylase
label: d
answer: no

Correct answer: a