hllj/quesmed huggingface dataset:
A 50-year-old male with asthma is being treated for treatment-resistant hypertension.

Which of the following treatments is most appropriate for managing his hypertension without compromising his airways?

Options:
explanation: Blocking beta<sub>1</sub>-adrenoceptors would lead to a decrease in cardiac output as it would decrease ionotropism and chronotropism of the heart. However, blocking beta<sub>2</sub>-adrenoceptors would cause increased peripheral resistance and bronchoconstriction, which would be contraindicated in this asthmatic patient.
name: Combined beta<sub>1</sub> and beta<sub>2</sub> antagonist
label: c
answer: no
explanation: Beta<sub>1</sub> adrenoceptors cause positive ionotropism and chronotropism of the heart. Therefore, by blocking these receptors, cardiac output is reduced and blood pressure is reduced. Beta<sub>2</sub> adrenoceptors cause vasodilation in the peripheral vessels and lungs, so increasing the effect of these receptors will decrease peripheral resistance and increase bronchodilation. Therefore, this is the best choice, as there will be no bronchoconstriction side-effects, and his blood pressure will be lowered.
name: Combination beta<sub>1</sub> antagonist and beta<sub>2</sub> agonist
label: a
answer: yes
explanation: Beta<sub>1</sub>-adrenoceptors are located on the heart and cause increased ionotropism and chronotropism, so blocking them would decrease cardiac output, thus reducing his blood pressure, whilst theoretically having no adverse effects on his breathing or peripheral circulation. However, as we can cause bronchodilation via beta<sub>2</sub>agonism, a beta<sub>1</sub> antagonist + beta<sub>2</sub> agonist combination would be the best choice for this patient due to his asthma.
name: Selective beta<sub>1</sub> antagonist
label: d
answer: no
explanation: Alpha-adrenoceptors cause vasoconstriction whilst beta<sub>2</sub>-adrenoceptors cause vasodilation of the peripheral vessels and within the lungs. Beta<sub>1</sub>-adrenoceptors cause positive ionotropism and chronotropism within the cardiac muscle. Therefore, blocking Beta<sub>1</sub>-adrenoceptors would decrease cardiac output, and blocking alpha-adrenoceptors would decrease peripheral resistance, leading to a decrease in blood pressure. However, by blocking beta<sub>2</sub>-adrenoceptors bronchoconstriction may occur which would be a contraindication given that this patient has asthma.
name: Mixed alpha/beta antagonist
label: b
answer: no
explanation: Alpha-adrenoceptors are not found in the heart, they are found in the periphery and smooth muscle, where they cause vasoconstriction when bound to by noradrenaline. Therefore, blocking them simply causes vasodilation of the periphery and increased blood flow to the skin and gut, with no effect on the heart.
name: Selective alpha antagonist
label: e
answer: no

Correct answer: a
Which of the following combination of drugs is typically the first-line medical treatment used in chronic heart failure?

Options:
explanation: Both of these drugs are diuretics so would reduce the patient's fluid overload. However, ACE-inhibitors and beta-blockers are used first-line, alongside loop diuretics only for symptom control. Aldosterone antagonists are then only used if symptoms are not controlled by these three drugs and there is a reduced ejection fraction.
name: Loop diuretic + Aldosterone antagonist
label: c
answer: no
explanation: All of the above drugs act to interfere with the body's response to the low cardiac output in heart failure. ACE inhibitors (e.g. ramipril) decrease plasma fluid and cause vasodilation, both of which decrease venous pressure. Beta-blockers (e.g. bisoprolol) help protect the myocardium from overstimulation from the action of noradrenaline on beta-adrenoceptors. Additionally, diuretics (e.g. furosemide) also decrease pressure via removing fluid, which helps to relieve symptoms such as oedema and breathlessness. However, they are not necessary if the person is not having symptoms.
name: ACE inhibitor + Beta blocker
label: a
answer: yes
explanation: An ACE inhibitor and beta-blocker would be used first-line. However, an ARB would only be used in place of an ACE inhibitor, not as well as, and would only be used if ACE inhibitors were not tolerated. A loop diuretic e.g. furosemide would also be used to reduce fluid overload.
name: ACE-inhibitor + Beta-blocker + Angiotensin Receptor Blocker
label: b
answer: no
explanation: Beta-blockers are used first-line in chronic heart disease, as they protect the myocardium from noradrenaline by blocking the beta-adrenoreceptors. They also cause some vasodilation which helps to reduce venous pressure. However, a beta-blocker alone is not enough to treat chronic heart failure. An ACE-inhibitor (e.g. ramipril) and possibly a loop diuretic (e.g. furosemide) are also needed to adequately treat a chronic heart failure patient.
name: Beta-blocker alone
label: d
answer: no
explanation: ACE inhibitors, beta blockers and loop diuretics are the three drug classes typically used first-line in chronic heart failure. However, both ARBs and aldosterone antagonists are not used first-line. Aldosterone antagonists are used when symptoms are not controlled with ACE inhibitors and beta-blockers, and ARBs are used instead of ACE inhibitors if ACE inhibitors are not tolerated.
name: ACE inhibitor + Beta blocker + Loop diuretic + Aldosterone antagonist + Angiotensin Receptor Blocker (ARB)
label: e
answer: no

Correct answer: a
Which of the following options is the most appropriate interpretation for the above ECG?

[lightgallery]

Options:
explanation: The ECG does not show third-degree heart block. Third-degree heart block appears on an ECG as a much slower ventricular rate (30-40bpm), regular spaced QRS complexes, and mis-shaped/upside down QRS complexes with escape beats. Also, an inferior STEMI is seen on this ECG.
name: Third-degree heart block
label: d
answer: no
explanation: An inferior STEMI is seen on this ECG in the ST segment elevation in leads II, III, and aVF. However, Mobitz type I second-degree heart block can also be seen as the PR interval progressively increases until a dropped QRS complex occurs and the cycle repeats.
name: Inferior STEMI
label: e
answer: no
explanation: This ECG does show an inferior STEMI, as seen by the ST segment elevation in leads II, III, and aVF. However, it shows Mobitz type I second-degree heart block, not first-degree heart block. First -degree heart block would show a continuously raised PR interval with no blocked P waves, unlike this ECG which shows a progressively increasing PR interval until a P wave is blocked.
name: First-degree heart block + inferior STEMI
label: c
answer: no
explanation: Whilst a second-degree heart block is seen, it is type I rather than type II. This ECG shows a progressive increase in PR interval until a dropped QRS complex occurs, which is diagnostic of type I second-degree heart block. Type II second-degree heart block is diagnosed via occasional blocked P waves which are not followed by QRS complexes. However, the PR interval remains the same. This ECG also shows an inferior STEMI.
name: Mobitz type II second-degree heart block only
label: b
answer: no
explanation: An inferior STEMI can be seen due to ST elevation in leads II, III, and aVF. Mobitz type I second-degree heart block can also be seen as the PR interval progressively increases until a dropped QRS complex occurs and the cycle repeats.
name: Mobitz type I second-degree heart block + inferior STEMI
label: a
answer: yes

Correct answer: a
A 42-year-old caucasian male has a clinic blood pressure reading of 144/98 despite treatment with 10mg Ramipril OD for the past six months.

Which of the following is the most appropriate next step in the management of this patient?

Options:
explanation: Amlodipine is a calcium-channel blocker, which is the correct drug to give to this patient for the management of his hypertension. However, it should be added to the maximum dose of an ACE inhibitor, such as ramipril 10mg OD (which he already takes).
name: Switch to 5mg amlodipine OD
label: b
answer: no
explanation: Amlodipine is a calcium-channel blocker, which is the second step in the hypertension treatment pathway once the first step drug is at the maximum dose. It should be added to the patients existing medication, which in this case is 10mg Ramipril.
name: Add amlodipine 5mg OD
label: a
answer: yes
explanation: Indapamide is a thiazide-like diuretic, which is used as the third step in the treatment of hypertension - E.g. if a patient is still hypertensive despite both an ACE inhibitor (e.g. ramipril) and a calcium channel blocker (e.g. amlodipine). In this case, the patient would continue taking their ramipril, whilst being prescribed a calcium channel blocker for a number of weeks/months before a thiazide-like diuretic would be considered.
name: Add Indapamide 2.5mg OD
label: d
answer: no
explanation: Bisoprolol is a beta-blocker, which may be used to treat hypertension. However, it does not form part of the usual NICE guidelines for hypertension management, and is usually only considered in patients with raised serum potassium (>4.5mmol/) - which this patient history does not mention. Therefore, following the stepwise approach of hypertension management would lead us to prescribe a calcium-channel blocker e.g. amlodipine for this patient to take as well as his regular ACE inhibitor (ramipril).
name: Bisoprolol 10mg OD
label: e
answer: no
explanation: Amlodipine is a calcium-channel blocker, which is the correct drug to add to this patient's existing maximum-dose ACE inhibitor (ramipril). However, indapamide is a thiazide-like diuretic and is the third step in managing hypertension, so would not be added to this patient's regime until he was established on a both maximum dose ACE inhibitor and calcium channel blocker, and had tried alternative drugs within those classes, whilst still having uncontrolled hypertension.
name: Add amlodipine 5mg OD + indapamide 2.5mg OD
label: c
answer: no

Correct answer: a
A 55-year-old female presents with a five-year history of dyspnoea and recurrent chest infections. She has smoked 20 cigarettes a day for 30 years. She undergoes lung function testing which produces the following results:

FVC 2.47 (predicted: 3.15)

FEV1 1.50 (predicted 1.70)

TLC 5.87 (predicted 4.39)

Which of the following is her most likely diagnosis?

Options:
explanation: Pulmonary oedema may cause a restrictive pattern of lung function results due to decreased lung compliance (which is not fitting with this patient's obstructive results). Also, pulmonary oedema may be caused by issues such as heart failure (which this patient shows no symptoms of, other than dyspnoea). Therefore, pulmonary oedema would be low down in this patient's differential diagnoses.
name: Pulmonary oedema
label: e
answer: no
explanation: Asthma is an obstructive disease, and this patient's results show an obstructive pattern (with FEV1:FVC ratio of <70%), so this would be fitting. However, the age of this patient, and her smoking history, would make COPD the more likely diagnosis. Additionally, a five-year history would be unusual for asthma. However, we would exclude this diagnosis by testing for bronchodilator reversibility - which is present in asthma and not in COPD.
name: Asthma
label: b
answer: no
explanation: Fibrotic lung disease is a restrictive disease, and so does not fit with the obstructive pattern of these results. In restrictive disease, we would also expect the TLC to be decreased, rather than increased as it is in this patient.
name: Fibrotic lung disease
label: c
answer: no
explanation: In a healthy patient, the FEV1:FVC ratio should be >70%. However, the lung function results for this patient show an obstructive pattern as the FEV1:FVC ratio is <70% (1.50/2.47 = 0.60), meaning that less than 70% of the FVC is exhaled within the first second. COPD also causes hyperinflation of the lungs, which would explain this patient's increased TLC. Finally, her chronic history of dyspnoea and extensive smoking history, along with recurrent infections, fits with the clinical picture of COPD - making it the most likely diagnosis.
name: Chronic Obstructive Pulmonary Disease (COPD)
label: a
answer: yes
explanation: Kyphoscoliosis is a chest wall disease which may cause restrictive lung disease. This would not be fitting with the obstructive pattern seen in this patient's results. It also would not explain the five-year history of symptoms, nor the recurrent infections.
name: Kyphoscoliosis
label: d
answer: no

Correct answer: a
A 24-year-old male, previously diagnosed with asthma, presents with repeated episodes of dyspnoea and wheezing. He uses both a salbutamol inhaler and a low-dose beclometasone inhaler one to two times daily.

Which of the following is the most appropriate next step in the management of this patient?

Options:
explanation: This is the final step in the guidelines, and is only used when all treatments have failed to control a patient's symptoms. With this patient only being on step two of the drug treatment for asthma, it would not be appropriate to refer for specialist management.
name: Refer for specialist treatments
label: c
answer: no
explanation: Oral steroids are only used in patients with chronically poorly-controlled asthma. This is also a hospital-directed treatment so would only occur under specialist supervision. Additionally, the next step in this patient's treatment is the initial add-on therapy of a LABA e.g. salmeterol, not altering his steroid inhaler dosage or type.
name: Switch inhaled beclometasone to low-dose oral prednisolone
label: e
answer: no
explanation: Montelukast is a Leukotriene Receptor Antagonist (LTRA), which may be used as an additional controller therapy in this patient. However, the initial add-on therapy used in the current guidelines is an inhaled LABA e.g. salmeterol. If this was then found to not work, then an LTRA may be used instead.
name: Add oral montelukast to his existing drug regime
label: d
answer: no
explanation: This patient's asthma symptoms are not being appropriately controlled with a regular inhaled corticosteroid (Beclometasone) and SABA (Salbutamol). Therefore, he should move onto the next step of treatment. The BTS/SIGN 2019 guidelines direct us to add a LABA inhaler, such as Salmeterol, to his existing inhalers - and to continue this treatment if he has a good response.
name: Add a salmeterol inhaler to his existing drug regime
label: a
answer: yes
explanation: We should follow the current BTS/SIGN guidelines and first prescribe an inhaled LABA, e.g. salmeterol, in addition to his current drug regime, before making any changes to his ICS inhaler dose. Changing his beclometasone dose would only be indicated if initial add-on therapies (e.g. salmeterol) failed to control his symptoms.
name: Increase the beclometasone inhaler to a high-dose inhaled corticosteroid inhaler
label: b
answer: no

Correct answer: a
A 53-year-old man presents to A&E with a two-week history of productive cough. He is unsure of what day of the week it is, despite having no background of reduced cognition.


 **His observations are as follows:**


RR 32/min


HR 104 bpm


BP 100/95


Temp 39C


He also has a Blood Urea of 7.6mmol/L.


What is his CURB-65 score?

Options:
explanation: CURB-65 is scored from 0-5. This patient scores 3 as he has a raised respiratory rate (>30/min), raised blood urea (>7 mmol/L), and is showing signs of confusion. Therefore, he scores 3 on the CURB-65 score, with C = Confusion, U = Urea, and R = Respiratory rate, all being raised. He does not score for B or 65 because his blood pressure (B) is within normal range, and he is less than 65-years-old.
name: 3
label: a
answer: yes
explanation: This patient scores 3 on the CURB-65 score, due to his confusion (C), raised blood urea (U) (>7mmol/L), and raised respiratory rate (R) (>30/min). His temperature is also slightly raised at 39C, and his heart rate at 104bpm. However, these are not measured in the CURB-65 score, so would not count towards the points.
name: 5
label: e
answer: no
explanation: He would score 3 on the CURB-65 score, as he has signs of confusion (C), a raised urea (U) (>7 mmol/L), and a raised respiratory rate (>30/min) (R). 1 point is given for each raised sign or positive symptom. Therefore, he has 3 points. His normal blood pressure (B), and age of less than 65-years-old would not score any points - for these to score points they must have a low BP (< 95/60) or be older than 65-years-old.
name: 2
label: b
answer: no
explanation: This patient scores 3 on the CURB-65 score, due to his confusion (C), raised blood urea (U) (>7mmol/L), and raised respiratory rate (R) (>30/min). His temperature is also slightly raised at 39C, and his heart rate at 104bpm. However, these are not measured in the CURB-65 score, so would not count towards the points.
name: 4
label: d
answer: no
explanation: This patient definitely scores on the CURB-65 score. He has signs of confusion (C), a raised blood urea (U) (>7mmol/L), and a raised respiratory rate (R) (>30/min). This gives him a score of 3.
name: 0
label: c
answer: no

Correct answer: a
What is the acronym used when helping patients to create objectives for lifestyle changes?

Options:
explanation: The acronym used to help patients set objectives for lifestyle changes is 'SMART'. It works as follows: S = Specific, M= Measurable, A = Achievable, R = Relevant, and T = Time-limited.
name: GOAL
label: e
answer: no
explanation: Goals set for patients should be specific (e.g. to only consume nicotine through patches and gum), measurable (e.g. to have cut down from three patches a day to one patch a day in the next month), achievable e.g. (to have quit smoking cigarettes completely in the next six months with the use of cessation therapies), relevant (e.g. to attend one monthly smoking cessation meeting), and time-limited (e.g. to be free from all nicotine in 12-months time).
name: SMART
label: a
answer: yes
explanation: The acronym used to help patients set objectives for lifestyle changes is 'SMART'. It works as follows: S = Specific, M= Measurable, A = Achievable, R = Relevant, and T = Time-limited.
name: BRAIN
label: c
answer: no
explanation: The acronym used to help patients set objectives for lifestyle changes is 'SMART'. It works as follows: S = Specific, M= Measurable, A = Achievable, R = Relevant, and T = Time-limited.
name: NOW
label: d
answer: no
explanation: The acronym used to help patients set objectives for lifestyle changes is 'SMART'. It works as follows: S = Specific, M= Measurable, A = Achievable, R = Relevant, and T = Time-limited.
name: HARD
label: b
answer: no

Correct answer: a
A 55-year-old male who suffered an ST-elevation myocardial infarction (STEMI) has been treated acutely and referred to a cardiac rehabilitation centre.

Which of the following is the most appropriate medical management for prevention of a further ischaemic event?

Options:
explanation: This is the correct drug regime for the secondary prevention of a STEMI, it should be offered to all patients following a STEMI.
name: ACE inhibitor + dual antiplatelet therapy + beta-blocker + statin
label: a
answer: yes
explanation: Dual antiplatelet therapy would be given but other drugs would need to be given alongside it. Examples include an ACE inhibitor, beta blocker, and statin.
name: Dual antiplatelet therapy alone
label: d
answer: no
explanation: This is a surgery which would have been carried out in hospital to treat the initial STEMI. It would not be used as secondary prevention. Cardiac rehabilitation centres advise for further management e.g. long-term drug management and lifestyle advice.
name: PCI (Percutaneous Coronary Intervention)
label: c
answer: no
explanation: This would be appropriate in cardiac rehab. However, medical management requires a drug regime as well as any lifestyle advice and education being given.
name: Lifestyle advice and education e.g. weight loss, smoking cessation
label: e
answer: no
explanation: Omega-3 should not be offered or advised to patients to take to prevent another MI. However, if they chose to take Omega-3, then there is no evidence of harm.
name: Omega-3 capsules
label: b
answer: no

Correct answer: a
A 32-year-old male tested positive for HIV two years ago. He is taking anti-retrovirals to suppress the virus and feels generally well. His CD4 count was 105 cell/mL when last tested one week ago.

Given this result, which of the following is the most appropriate next step in management?

Options:
explanation: This patient has a low CD4 count which puts him at risk of opportunistic infections such as Pneumocystis pneumonia. He should be given prophylactic antibiotics. Dapsone can be given, but it is only used second-line if the first-line antibiotic (co-trimoxazole) is not tolerated or inappropriate. Antibiotics should also only be used until the CD4 count is >200cell/mL.
name: Dapsone PO until CD4 >300 cell/mL
label: e
answer: no
explanation: This patient has a low CD4 count which puts him at risk of opportunistic infections such as Pneumocystis pneumonia. He should be given prophylactic antibiotics, and the first-line choice is co-trimoxazole. However, it should be given until his CD4 count is >200cell/mL.
name: Co-trimoxazole PO until CD4 >150 cell/mL
label: c
answer: no
explanation: This patient has a low CD4 count which puts him at risk of opportunistic infections such as Pneumocystis pneumonia. He should be given prophylactic antibiotics until his CD4 count is >200cell/mL. However, the first-line antibiotic is co-trimoxazole. Dapsone would not be given unless co-trimoxazole was not appropriate or tolerated.
name: Dapsone PO until CD4 >200 cell/mL
label: b
answer: no
explanation: This patient has a low CD4 count which puts him at risk of opportunistic infections such as Pneumocystis pneumonia. He should be given prophylactic antibiotics until his CD4 count is >200cell/mL, with the first-line antibiotic being co-trimoxazole.
name: Co-trimoxazole PO until CD4 >200 cell/mL
label: a
answer: yes
explanation: This patient has a low CD4 count which puts him at risk of opportunistic infections such as Pneumocystis pneumonia. He should be given prophylactic antibiotics until his CD4 count is >200cell/mL. However, erythromycin would not be an appropriate antibiotic for this. Instead, co-trimoxazole would be used.
name: Erythromycin PO until CD4 > 200 cell/mL
label: d
answer: no

Correct answer: a
Which of the following muscles line the anterior abdominal wall?

Options:
explanation: These are the four muscles which line the anterior abdominal wall. They work to move the trunk, and support and compress the abdominal viscera.
name: External oblique, internal oblique, transversus abdominis, and rectus abdominis
label: a
answer: yes
explanation: These muscles line the posterior abdominal wall, and act as hip flexors. There are four muscles which line the anterior abdominal wall. These are the external oblique, internal oblique, transversus abdominis, and rectus abdominis.
name: Iliacus and psoas
label: e
answer: no
explanation: These are the four muscles found surrounding the posterior abdominal wall. The muscles which line the anterior abdominal wall are the external oblique, internal oblique, transversus abdominis, and rectus abdominis.
name: Diaphragm, quadratus lumborum, iliacus, and psoas
label: b
answer: no
explanation: The internal oblique does line the anterior abdominal wall. However, the diaphragm surrounds the posterior abdominal wall. Additionally, there are three more muscles which line the anterior abdominal wall in addition to the internal oblique. These are the external oblique, transversus abdominis, and rectus abdominis.
name: Diaphragm and internal oblique
label: d
answer: no
explanation: These muscles are a mixture of the posterior abdominal wall muscles and anterior abdominal wall muscles. There are four muscles which line the anterior abdominal wall. They are the external oblique, internal oblique, transversus abdominis, and rectus abdominis.
name: Quadratus lumborum, transversus abdominis, internal oblique, and psoas
label: c
answer: no

Correct answer: a