hllj/quesmed huggingface dataset:
A 77-year-old male complains of fatigue and low mood following the death of his wife.


He appears very dehydrated on examination.


His renal profile is shown below:


Currently:


||||
|---------------------------|:-------:|--------------------|
|Sodium|142 mmol/L|135 - 145|
|Potassium|4.8 mmol/L|3.5 - 5.3|
|Urea|11.2 mmol/L|2.5 - 7.8|
|Creatinine|180 µmol/L|60 - 120|


 2 months ago:


||||
|---------------------------|:-------:|--------------------|
|Sodium|138 mmol/L|135 - 145|
|Potassium|4.5 mmol/L|3.5 - 5.3|
|Urea|5.7 mmol/L|2.5 - 7.8|
|Creatinine|92 µmol/L|60 - 120|

Which of his regular medications should be temporarily stopped in light of these results?

Options:
explanation: These are not contraindicated in AKI.
name: Hypromellose eye drops
label: e
answer: no
explanation: This medication is not contraindicated in AKI.
name: Paracetamol
label: d
answer: no
explanation: These should be stopped if the AKI is due to rhabdomyolysis or if the patient complains of unexplained or persistent muscle pain. In this case, however, atorvastatin can be continued.
name: Atorvastatin
label: c
answer: no
explanation: ACE inhibitors should be held in AKI due to the risk of hyperkalaemia. They can also alter kidney perfusion and the ability to maintain GFR.
name: Ramipril
label: a
answer: yes
explanation: Whilst other NSAIDs may be held in AKI, low dose aspirin is usually continued.
name: Low-dose aspirin
label: b
answer: no

Correct answer: a


Learning point: In acute kidney injury, ACE inhibitors like ramipril should be temporarily discontinued to prevent worsening renal function and hyperkalaemia.
A 67-year-old female with a history of diabetes has a widespread maculopapular rash, fever and polyarticular joint pain.

On examination, her joints are swollen and mildly tender, with range of motion preserved.

Her blood tests show an elevated eosinophil count and raised creatinine, compared to previous results

She has recently completed a course of co-amoxiclav for an upper UTI.

What is the most likely diagnosis?

Options:
explanation: This would typically present with fevers, weight loss, flank pain and haematuria rather than the triad of fever, rash and eosinophilia classically seen in AIN.
name: Renal cell carcinoma
label: e
answer: no
explanation: This patient has presented with the classic triad of AIN; fever, rash and eosinophilia in a setting of decreased renal function. Beta-lactam antibiotics can commonly trigger AIN.
name: Acute interstitial nephritis
label: a
answer: yes
explanation: This is caused by nephrotoxic or ischaemic damage to the renal tubules and typically presents with hypotension and oliguria. Additionally, you would not expect to see the systemic symptoms or presence of eosinophilia.
name: Acute tubular necrosis
label: b
answer: no
explanation: Whilst a red, hot and swollen joint should raise suspicion for septic arthritis, it is rarely polyarticular and the pain is described as mild with preserved range of motion. Additionally, it would not explain the eosinophilia and presence of a rash.
name: Septic arthritis
label: c
answer: no
explanation: This may present with oedema and be seen in other signs of poor diabetic control (e.g. persistent hyperglycaemia, presence of neuropathy). Additionally, it would not explain the rash, joint pain or eosinophilia. AIN is a far more likely diagnosis in this case despite the past medical history of diabetes.
name: Diabetic nephropathy
label: d
answer: no

Correct answer: a


Learning point: Acute interstitial nephritis often presents with fever, rash, eosinophilia, and renal impairment, commonly triggered by beta-lactam antibiotics.
A 47-year-old man would like to cut down on his drinking

He says he usually drinks 6 x 500ml cans of 7.0% cider daily, plus a 750ml bottle of 40% vodka over the weekend.

How many units does he consume a week?

Options:
explanation: This would be the answer if the patient drank 2 x 750ml bottles of 40% vodka over the weekend.
name: 207 units
label: e
answer: no
explanation: Alcohol units can be calculated by:

1) Volume of alcohol (ml) x percentage alcohol by volume (ABV)
2) Divide by 1000

(500ml x 7.0)/1000 = 3.5 units per can
6 x cans a day = 21 units per day
21 x 7 days a week = 147 units per week

(750ml x 40)/1000 = 30 units per vodka bottle

147 units from cider + 30 units from vodka = 177 units per week.
name: 177 units
label: a
answer: yes
explanation: This would be the amount if the patient drank 1 x 500ml can of cider per day
name: 54.5 units
label: d
answer: no
explanation: This is incorrect by a factor of 10.
name: 17.7 units
label: b
answer: no
explanation: This does not include the bottle of vodka.
name: 147 units
label: c
answer: no

Correct answer: a


Learning point: To calculate alcohol units, use the formula:
Alcohol units = (Volume of drink in ml) × (ABV in %)/ 100
A 45 year old man with a history of Ehler’s Danlos syndrome comes to the emergency department with severe tearing chest pain.

Given the likely diagnosis, which of the following may be noted on examination?

Options:
explanation: A blood pressure difference of greater than 20mmHg should raise suspicion of an aortic dissection.
name: Equivalent blood pressure in both arms
label: c
answer: no
explanation: This is more suggestive of heart failure than aortic dissection.
name: Bilateral pitting oedema
label: e
answer: no
explanation: The most likely diagnosis given the nature of the pain and the presence of a connective tissue disorder is an acute aortic dissection.  Neurological symptoms occur because of occlusion of carotid, vertebral, or spinal arteries.
name: Focal neurological deficits
label: a
answer: yes
explanation: An early diastolic murmur may be noted due to aortic regurgitation in a dissection, rather than an end systolic one.
name: New-onset end-systolic murmur
label: d
answer: no
explanation: An early diastolic murmur may be noted due to aortic regurgitation in a dissection, rather than a holosystolic one.
name: New-onset holosystolic murmur
label: b
answer: no

Correct answer: a


Learning point: Focal neurological deficits in the context of acute aortic dissection can occur when the dissection compromises blood flow to the brain or spinal cord, leading to symptoms such as weakness, sensory changes, or paralysis, which indicate potential involvement of the arterial branches supplying these areas.
A 68 year old man is reviewed by his GP six weeks after he developed an anterior myocardial infarction. The GP performs an ECG which demonstrates ST elevation in the anterior leads. The patient reports fatigue but denies other symptoms.

What is the most likely diagnosis?

Options:
explanation: This is correct. Persistent ST elevation with fatigue is suggestive of an left ventricle aneurysm post-myocardial infarction.
name: Left Ventricular Aneurysm
label: a
answer: yes
explanation: This is a form of acute pericarditis post myocardial infarction. This is less likely as the patient only reports fatigue and no chest pain and the ECG does not show global ST elevation or PR depression.
name: Dressler's Syndrome
label: c
answer: no
explanation: This is unlikely as the patient is asymptomatic. Silent myocardial infarctions, whereby no pain is felt do occur, but these are more common in females and diabetics. Persistent territorial ST elevation is more characteristic of a left ventricular aneurysm.
name: Repeat myocardial infarction
label: b
answer: no
explanation: The patient has no symptoms suggestive of pulmonary oedema such as breathlessness or peripheral oedema.
name: Pulmonary Oedema
label: d
answer: no
explanation: This may be more acute than Dressler's in timeframe. This is less likely as the patient only reports fatigue and no chest pain and the ECG does not show global ST elevation or PR depression.
name: Pericarditis
label: e
answer: no

Correct answer: a


Learning point: Persistent ST elevation after a myocardial infarction, along with fatigue, may indicate the development of a left ventricular aneurysm.
A 72 year old man presents with crushing central chest pain at rest, four days following a lateral myocardial infarction.

Which of the following findings is most suggestive of a repeat infarction?

Options:
explanation: BNP is not specific to myocardial ischaemia and is more commonly used to diagnose heart failure.
name: Elevated BNP
label: d
answer: no
explanation: Troponins remain elevated for days following a myocardial infarction and so are less useful to assess re-infarct.
name: Elevated Troponin I
label: b
answer: no
explanation: This is correct. As CK-MB levels normalise 48 to 72 hours after myocardial ischemia (vs. troponins, which can persist for days), it is the best marker to assess whether re-infarct has occurred.
name: Elevated creatine kinase MB (CK-MB)
label: a
answer: yes
explanation: Myoglobin levels rise within the first few hours following a myocardial infarction, making them useful early indicators of ischaemia. They are less specific to re-assess for re-infarct.
name: Elevated myoglobin
label: e
answer: no
explanation: Troponins remain elevated for days following a myocardial infarction and so are less useful to assess re-infarct.
name: Elevated Troponin T
label: c
answer: no

Correct answer: a


Learning point: Elevated creatine kinase MB (CK-MB) levels suggest a recurrent myocardial infarction and typically return to normal within 48 to 72 hours after ischemia.
A 34 year old man comes to the emergency department due to fevers and rigors. He is of no fixed abode at present and uses intravenous drugs. On fundoscopic examination, roth spots are noted.

Which of the following is most likely to aid diagnosis?

Options:
explanation: This is correct. Transoesophageal echocardiography is vital in the diagnosis of infective endocarditis to visualise vegetations on the valves in the heart. Multiple blood cultures are also essential.
name: Transoesophageal echocardiogram
label: a
answer: yes
explanation: A routine CT- CAP is not indicated in the diagnosis of infective endocarditis.
name: CT chest, abdomen and pelvis
label: d
answer: no
explanation: Transthoracic echocardigrams are less specific and less sensitive than transoesophageal echocardigrams for the diagnosis of infective endocarditis.
name: Transthoracic echocardiogram
label: b
answer: no
explanation: This may be useful in patients with prosthetic heart valves but is not first line.
name: SPECT-CT
label: c
answer: no
explanation: CT Aortogram is generally used to assess for aneurysms or dissections within the aorta.
name: CT Aortogram
label: e
answer: no

Correct answer: a


Learning point: Transoesophageal echocardiography is crucial for diagnosing infective endocarditis by visualising vegetations on cardiac valves.
A 69 year old man is brought to the emergency department acutely confused and unable to recall the events of the last few days. He describes a green-yellow tinge to his vision. His current medications include bisoprolol, ramipril and digoxin. His blood pressure has been measured on repeat GP appointments at ~110/60mmHg.

Which of the following is the most likely to explain the patient’s presentation?

Options:
explanation: Primary hyperaldosteronism would cause hypokalaemia which could precipitate digoxin toxicity, however the patient would be expected to be hypertensive. This is also not a common diagnosis.
name: Conn's syndrome
label: b
answer: no
explanation: This is correct. This scenario describes digoxin toxicity which is known to be precipitated by hypokalaemia. Normally digoxin binds to the ATPase pump at the same site as potassium, therefore hypokalaemia precipitates digoxin toxicity as there is less competition to bind to the ATPase pump and digoxin exerts more of an inhibitory effect. Diarrhoea and vomiting due to a gastroenteritis are likely to account for this clinical picture.
name: Gastroenteritis
label: a
answer: yes
explanation: Rhabdomyolysis may be associated with severe hyperkalaemia, rather than hypokalaemia.
name: Rhadbomyolysis
label: e
answer: no
explanation: Potassium concentration is typically normal in SIADH.
name: Syndrome of inappropriate ADH
label: d
answer: no
explanation: Ramipril may cause hyperkalaemia which would protect against developing digoxin toxicity.
name: Ramipril
label: c
answer: no

Correct answer: a


Learning point: Gastroenteritis can increase the risk of digoxin toxicity because it can lead to dehydration, electrolyte imbalances (such as low potassium or magnesium levels), and reduced kidney function, all of which can enhance the effects of digoxin and increase the likelihood of toxic side effects.
A 28 year old gentleman has been hospitalised due to a painful flare of ankylosing spondylitis and, on examination, has urinated in the bed.
On PR examination, there is loss of perianal sensation.
What is the most appropriate management?

Options:
explanation: This may be advice given for a self limiting flare of ankylosing spondylitis but is not appropriate given the severe pain and red flags of cauda equina syndrome in this case.
name: Discharge and advise to continue on prescribed NSAIDs
label: e
answer: no
explanation: This is likely to form the initial management of cases of spinal trauma.
name: Immobilisation and stabilisation surgery
label: b
answer: no
explanation: This is correct. This scenario describes cauda equina syndrome, for which ankylosing spondylitis is a risk factor. This is a neurosurgical emergency which requires surgical decompression.
name: Surgical decompression and laminectomy
label: a
answer: yes
explanation: This is the preferred treatment for cases of spinal abscess.
name: Antibiotics and surgical evacuation
label: c
answer: no
explanation: These represent treatment options for spinal metastases/metastatic spinal cord compression.
name: Vertebrectomy and radiotherapy
label: d
answer: no

Correct answer: a


Learning point: Cauda equina syndrome, often associated with ankylosing spondylitis, necessitates urgent surgical decompression to prevent permanent neurological damage.
A 60 year old woman complains of daily headaches. She has no associated scalp tenderness, photophobia, phonophobia, nasal discharge or eye watering.

Her past medical history includes rheumatoid arthritis for which she has recently been started on daily tramadol.

Which of the following is the most appropriate management plan?

Options:
explanation: These represent initial treatment options for cluster headaches.
name: Prescribe 100% oxygen and subcutaneous sumatriptan
label: d
answer: no
explanation: This may be an option in flares of rheumatoid arthritis but this vignette does not describe any joint pain, making this less likely.
name: IV Methylprednisolone
label: e
answer: no
explanation: This is correct. This scenario describes medication overuse headache, for which the treatment is to cease analgesics. Opiods should be tapered as opposed to stopped due to risk of withdrawal.
name: Gradually taper tramadol
label: a
answer: yes
explanation: The scenario does not describe a migraine and this treatment is unlikely to help with medication overuse.
name: Prescribe oral triptans + NSAID
label: c
answer: no
explanation: This is likely to precipitate opioid withdrawal.
name: Immediately cease all analgesics
label: b
answer: no

Correct answer: a


Learning point: The treatment for medication overuse headache is to cease analgesics, with opioids being tapered gradually rather than stopped abruptly to reduce the risk of withdrawal symptoms.
A 72 year old man has been increasingly confused for the last few months. He has become increasingly forgetful and has had several falls. He describes feeling more thirsty and urinating more frequently over the same timeframe.

Which of the following is the best management option, given the likely diagnosis?

Options:
explanation: This is correct. This scenario describes normal pressure hydrocephalus for which the treatment is to insert a ventriculoperitoneal shunt to relieve the hydrocephalus, which tends to reverse the symptoms. NPH patients present with polyuria, confusion, rapidly progressive dementia with gait abnormalities.
name: Ventriculoperitoneal shunt
label: a
answer: yes
explanation: These represent treatment options for Parkinsonism which would present with bradykinesia, shuffling gait and rigidity.
name: L- Dopa & medication review
label: d
answer: no
explanation: This may be indicated in cases of metastatic brain cancer but is not appropriate here as NPH is more likely due to absence of headaches and focal neurology.
name: Palliative care
label: e
answer: no
explanation: This is an option in various mental health diagnoses and may be used to treat symptoms of depression and anxiety that often arise in patients with dementia.
name: Cognitive behavioural therapy
label: c
answer: no
explanation: This is an option in Alzheimer's dementia, which is not the case here.
name: Donepezil
label: b
answer: no

Correct answer: a


Learning point: Normal pressure hydrocephalus presents with confusion, gait abnormalities, and polyuria, often improving with ventriculoperitoneal shunt placement.
A 35 year old woman is referred to a 'first fit' clinic by her GP.

She describes multiple episodes of gradual onset limb shaking and jerking, during which she is responsive and after which she cries. Her mother has epilepsy.

An EEG is performed which does not show any epileptiform activity.

What is the most appropriate course of action?

Options:
explanation: The most likely diagnosis is non-epileptic attack disorder. A ketogenic diet may be advised in certain forms of epilepsy, after initiation of anti-epileptic drugs.
name: Advise a ketogenic diet
label: c
answer: no
explanation: The most likely diagnosis is non-epileptic seizure disorder, which is not treated with anti-epileptic drugs. Valproate may be initiated if further evidence of epilepsy comes to light, but would likely be avoided in a woman of childbearing age.
name: Initiate on valproate
label: d
answer: no
explanation: This is correct. This description is typical for non-epileptic seizures whereby patients remain alert, the onset is gradual, and an emotional response may follow. The non-epileptiform EEG supports this diagnosis. Non-epileptic seizures may be related to underlying anxiety or stresses and psychotherapy is the preferred treatment.
name: Refer for psychotherapy
label: a
answer: yes
explanation: The most likely diagnosis is non-epileptic seizure disorder, which is not treated with anti-epileptic drugs. Lamotrigine may be initiated if further evidence of epilepsy comes to light, as it is preferred to valproate (as it is less teratogenic) in a woman of childbearing age.
name: Initiate on lamotrigine
label: e
answer: no
explanation: This is not appropriate given CBT and psychotherapies are the preferred treatment for non-epileptic attack disorder. It is important to note that these episodes can have a significant impact on patients' lives.
name: Reassurance with no further action
label: b
answer: no

Correct answer: a


Learning point: Non-epileptic seizures are characterised by preserved awareness and emotional responses, often requiring psychotherapy rather than pharmacological treatment.
A 21 year old man presents to the GP with rectal bleeding and fatigue. He reports his dad having bowel cancer for which he had a colostomy bag from early adolescence. Colonoscopy reveals hundreds of polyps throughout his bowel.

Which of the following is likely to form definitive management of this patient?

Options:
explanation: These are treatment options for cases of colorectal cancer, however colonoscopy has not demonstrated a malignancy in this patient.
name: Initiate on chemotherapy and radiotherapy
label: d
answer: no
explanation: This is correct. This description is suspicious for familial adenomatous polyposis which confers an extremely high chance of developing colorectal cancer and is normally prophylactically treated with a panproctocolectomy at a young age.
name: Prophylactic panproctocolectomy
label: a
answer: yes
explanation: This may reduce the chances of developing malignancy but given that the polyps in FAP are dispersed through the entire bowel, there is still a high chance of developing colorectal cancer.
name: Prophylactic right hemicolectomy
label: e
answer: no
explanation: There is nothing to suggest a palliative approach is required here.
name: Palliative care
label: c
answer: no
explanation: This is not ideal given the near certainty the patient will develop colorectal cancer.
name: Watch and wait approach
label: b
answer: no

Correct answer: a


Learning point: Familial adenomatous polyposis (FAP) is a hereditary condition marked by the formation of numerous polyps in the colon and rectum, which have a high cancer risk if untreated, and prophylactic panproctocolectomy is a preventive surgery that removes the entire colon, rectum, and anus to greatly reduce this risk.
A 75 year old man comes to the emergency department with excruciating abdominal pain following a meal. An ECG shows an irregularly irregular rhythm with no P waves visible.

Examination demonstrates guarding and rigidity and on VBG his lactate level is raised.

Which of the following investigations is diagnostic of the underlying condition?

Options:
explanation: This is not the investigation of choice for acute mesenteric ischaemia. It is useful in cases of suspected bowel obstruction.
name: Abdominal X Ray
label: b
answer: no
explanation: This is generally indicated in cases of rectal surgery to visualise whether an anastomosis is intact.
name: Gastrograffin enema
label: d
answer: no
explanation: CT angiography is required here to visualise the blood supply to the bowel, there is currently no indication for a full CT-CAP.
name: CT Chest, abdomen and pelvis
label: e
answer: no
explanation: There is nothing to suggest a colonoscopy would prove beneficial here with no PR bleeding, unexplained changes in bowel habit or malignancy.
name: Colonoscopy
label: c
answer: no
explanation: This is correct. This description is suspicious for acute mesenteric ischaemia with severe pain out of keeping with examination findings and a raised lactate (suggestive of ischaemia) on a background of atrial fibrillation. CT angiography is the preferred imaging modality to assess the blood supply to the bowel.
name: CT Angiography
label: a
answer: yes

Correct answer: a


Learning point: Acute mesenteric ischaemia presents with severe abdominal pain, often in patients with atrial fibrillation, and is diagnosed using CT angiography.
A 45 year old woman is undergoing pre-assessment for bariatric surgery. Imaging reveals gallstones in the gallbladder. She denies any symptoms of indigestion, nausea or vomiting.

Which of the following treatment options is most appropriate?

Options:
explanation: Some complications of gallstones may be treated conservatively in the initial instance with a cholecystectomy perfomed a few weeks later, but this patient is asymptomatic and there is no evidence of cholecystitis/cholangitis.
name: Intravenous fluids and antibiotics
label: e
answer: no
explanation: There is nothing to suggest an emergency in this presentation.
name: Urgent laparotomy
label: d
answer: no
explanation: This is correct. This describes asymptomatic gallstones which are common and require no treatment unless symptoms develop.
name: Reassurance with safety netting
label: a
answer: yes
explanation: This is not indicated in the absence of symptoms, it is indicated if the patient develops symptoms or complications of gallstones.
name: Elective laparascopic cholecystectomy
label: b
answer: no
explanation: This is indicated to clear stones in the bile duct in cases of obstructive jaundice with indications including pancreatic ductal disease.
name: Endoscopic Retrograde Cholangio-Pancreatography
label: c
answer: no

Correct answer: a


Learning point: Asymptomatic gallstones are common and typically do not require treatment. Patients should be safety-netted and advised to seek medical attention if symptoms such as pain, jaundice, fever, or vomiting occur, indicating potential complications like biliary colic or cholecystitis.