hllj/quesmed huggingface dataset:
A 25-year-old female presents to the Emergency Department with right-sided loin to groin pain that she describes as coming in waves and is associated with nausea but no vomiting. Her observations at triage show she is pyrexial at 38.8, tachycardic and hypotensive. Her urine dip is positive for blood and nitrites and negative for pregnancy, and her blood tests reveal raised inflammatory markers.
A CT of kidneys, ureters and bladder (KUB) is performed, demonstrating a right-sided 6mm obstructing calculus associated with hydroureter and hydronephrosis.

What treatment is urgently required?

Options:
explanation: Whilst the stone is 6mm and therefore unlikely to pass spontaneously, the main issue here is the infected obstructed system that requires urgent intervention. If she was not septic, then medical expulsive therapy with tamsulosin would be a reasonable choice
name: Tamsulosin
label: c
answer: no
explanation: This patient has an obstructed infected urinary system that needs urgent decompression. As her stone is 6mm and in the upper part of the urethra, decompression with a nephrostomy is indicated. She should also be managed in accordance with sepsis six and started on antibiotics
name: Urgent right nephrostomy
label: a
answer: yes
explanation: This patient has an infected obstructed system which requires urgent intervention. She is also septic, and therefore treatment with oral antibiotics is unlikely to be sufficient
name: Oral antibiotics
label: b
answer: no
explanation: Analgesia is indicated in this patient's case; however, it will not treat her underlying condition
name: Analgesia
label: e
answer: no
explanation: If medical expulsion therapy does not work in stable patients with stones >5mm, then ESWL is a reasonable choice. This patient is septic and therefore requires urgent decompression with a nephrostomy or ureteric stenting
name: Extracorporeal shockwave lithotripsy (ESWL)
label: d
answer: no

Correct answer: a


Learning point: In cases of obstructed pyelonephritis, urgent nephrostomy is essential to relieve obstruction and prevent further renal damage.
A 24-year-old male is treated for Hodgkin's lymphoma with chemotherapy.

As he has a high tumour burden, he is deemed at high risk of tumour lysis syndrome (TLS); which of the following blood tests would suggest tumour lysis syndrome?

Options:
explanation: Hyponatreamia can be a sign of paraneoplastic syndromes such as syndrome of inappropriate ADH. It is not in keeping with tumour lysis syndrome
name: Sodium 128 mmol/L
label: d
answer: no
explanation: This is a normal potassium level. A high potassium level would be associated with TLS
name: Potassium 4.2 mmol/L
label: e
answer: no
explanation: Breakdown of cells includes the breakdown of their nucleic acid, which has a phosphate group, and therefore a high phosphate is expected in TLS. As phosphate leads to calcium chelation, patients will also have low calcium rather than high calcium. High calcium is associated with malignancy with boney metastasis, for example, lung cancer, breast cancer and renal cancer
name: Adjusted Calcium 3.70 mmol/L
label: c
answer: no
explanation: As rapid cell breakdown releases potassium, a low potassium would be unusual in TLS
name: Potassium 2.9 mmol/L
label: b
answer: no
explanation: TLS is a severe metabolic disturbance caused by the abrupt release of cellular components following the rapid lysis of malignant cells upon initiation of treatment. Therefore high potassium, high urea, high phosphate and low calcium are expected.

Lactate, urate and LDH may also be increased and so should be monitored, but are not diagnostic.

It is usually within 1-5 days of starting chemotherapy and can cause seizures, cardiac arrhythmias, kidney injury and even death. Management is through prevention and careful monitoring and treatment of any complications should they occur
name: Urea 22 mmol/L
label: a
answer: yes

Correct answer: a


Learning point: Tumor lysis syndrome occurs when cancer cells rapidly die, releasing nucleic acids that break down into uric acid, overwhelming the kidneys, causing hyperuricemia, renal dysfunction, and elevated blood urea levels.
A 74-year-old male diagnosed with Non-Hodgkin's lymphoma and started on bleomycin. He presents to General Practice complaining about progressive breathlessness. On auscultation of his chest, you notice bilateral fine crackles.

What is the likely diagnosis?

Options:
explanation: Pleural effusions can be associated with malignancy, and these are usually exudative. Pleural effusions are usually associated with reduced air entry and dull percussion notes as opposed to fine crackles
name: Exudative pleural effusion
label: c
answer: no
explanation: This is unlikely to be the diagnosis here. Although the patient is likely to be at risk of developing infections such as pneumonia, no other signs of infection are present. Pneumonia does not usually produce fine crackles throughout the lung fields on auscultation
name: Community-acquired pneumonia
label: b
answer: no
explanation: Pulmonary fibrosis is a recognised side effect of bleomycin, and fine crackles on auscultation should prompt this diagnosis. A chest x-ray should be performed, and the medication may need to be stopped
name: Pulmonary fibrosis
label: a
answer: yes
explanation: Transudative pleural effusions are usually caused by fluid overload, such as organ failure (kidney, liver, heart) or through iatrogenic causes. Pleural effusions are usually associated with reduced air entry and dull percussion notes as opposed to fine crackles
name: Transudative pleural effusion
label: d
answer: no
explanation: Asthma can cause breathlessness, but this is not usually progressive in nature. Auscultation of the chest would reveal polyphonic wheeze or, in a severe attack, may be silent
name: Asthma
label: e
answer: no

Correct answer: a


Learning point: Bleomycin can cause pulmonary fibrosis, characterised by fine crackles on auscultation and progressive breathlessness in affected patients.
An 86 year old female is being referred to the bowel cancer multi-disciplinary team (MDT) for consideration of treatment.
She lives alone in a bungalow, is completely independent with self-care and has an active social life visiting her neighbours, but has to have help from her family with shopping, cleaning and cooking.

What is her WHO performance status?

Options:
explanation: She is ambulatory and capable of all self-care but unable to carry out any work activities. She is up and about more than 50% of the day
name: Grade 2
label: a
answer: yes
explanation: Grade 0 would require her to be fully active and able to carry out all activities of daily living
name: Grade 0
label: b
answer: no
explanation: Garde 1 would require her to be able to carry out light housework or work of a sedentary nature
name: Grade 1
label: c
answer: no
explanation: Grade 4 is completely disabled, unable to self-care, and confined to a chair or bed
name: Grade 4
label: e
answer: no
explanation: Grade 3 would suggest that she is only capable of limited self-care and is confined to a bed or chair for >50% of the day
name: Grade 3
label: d
answer: no

Correct answer: a


Learning point: A WHO performance status of Grade 2 indicates that the patient is "up and about more than 50% of waking hours but is not fully active", meaning they are able to perform light activities but are unable to carry out strenuous work or activities.
An 87-year-old male is admitted to hospital from a nursing home with aspiration pneumonia. He clinically deteriorates, and after discussion with his family, the decision is made to palliate and control his symptoms.
His family are concerned he is becoming increasingly agitated due to his respiratory secretions.

What medication might be of benefit here?

Options:
explanation: Nebulised salbutamol is used in the treatment of airway inflammation. As this patient does not currently have symptoms of airway inflammation, this is not currently indicated, and the use of the nebuliser may be more distressing for the patient
name: Nebulised salbutamol
label: d
answer: no
explanation: Glycopyrronium is a medication from the muscarinic anticholinergic group. It is often used for respiratory tract secretions in palliative care patients who can no longer manage their own secretions due to impaired cough reflex
name: Glycopyrronium
label: a
answer: yes
explanation: High flow oxygen can be very uncomfortable and not well tolerated. This patient's issues are related to respiratory secretions, and oxygen will not assist with those secretions
name: High flow nasal oxygen
label: e
answer: no
explanation: Pain in the palliative setting is important to bear in mind and manage as patients may not be able to communicate fully. Morphine will cause respiratory depression, which again may be of benefit in this patient; however will not help with the distressing secretions
name: Morphine
label: c
answer: no
explanation: Haloperidol is often used in the palliative care setting for agitation and delirium. It may well be beneficial in this case; however, as this patient is likely agitated from his secretions, glycopyrronium will be of more help
name: Haloperidol
label: b
answer: no

Correct answer: a


Learning point: Glycopyrronium is an effective anticholinergic medication used to reduce respiratory secretions in palliative care patients.
Your colleague has a particular way of performing inguinal hernia repairs that is less commonly used. She wants to know whether her technique has a higher or lower rate of recurrence. She finds five studies that use her method compared to the routine method and plots them in a forest plot (x-axis represents the relative risk of recurrence in your colleague's method compared to the routine method).

[lightgallery]

Which of these statements about her findings is true?

Options:
explanation: This is incorrect as the horizontal line on a forest plot indicates the confidence intervals as opposed to the range of the data sets. A wide confidence interval indicates instability of results, for example, due to a very small data set
name: James et al. have the largest range of results
label: b
answer: no
explanation: This is false as all of the forest plot lines are above 1. In risk ratios or relative risk, if the ratio is >1, then this means that the intervention has a less favourable risk than in the group not subject to the intervention, i.e. greater risk of hernia recurrance.
name: All the studies suggest that her method has a lower risk of hernia recurrence
label: e
answer: no
explanation: This is incorrect as the horizontal line is a representation of the confidence intervals. A wide confidence interval is more likely to be representative of a smaller data set
name: James et al. likely had the most participants in their study
label: d
answer: no
explanation: This is true as all of the forest plot lines are at or above 1. In risk ratios or relative risk, if the ratio is >1, then this means that the intervention has a less favourable risk than in the group not subject to the intervention, i.e. greater risk of hernia recurrance.
name: None of the studies suggest that her method has a lower risk of hernia recurrence
label: a
answer: yes
explanation: This is incorrect as the ratio here is very close to 1, indicating that the risk of recurrence from her technique is very similar to the risk of recurrence from other techniques
name: Edwards et al. show the biggest difference in the risks of hernia recurrence between her technique and other techniques
label: c
answer: no

Correct answer: a


Learning point: A forest plot visually displays results from multiple studies, showing effect sizes with confidence intervals; points crossing the line of no effect indicate non-significance
A 90-year-old woman is brought to A&E because she has been complaining of chest pain. She is a poor historian because of known Alzheimer's dementia. She also has a past medical history of Parkinson's and a previous suspected transient ischaemic attack. On examination, she is visibly short of breath.

On her ECG, there is complete dissociation of the P waves and QRS complexes.

Her current medication is as follows: donepezil, ropinirole, amlodipine, atorvastatin, aspirin. Which of these medications is most likely to have caused this problem?

Options:
explanation: Ropinirole is a dopamine agonist used to treat Parkinson's. Side effects include postural hypotension, hallucinations and movement disorders. It is unlikely to lead to third degree heart block
name: Ropinirole
label: b
answer: no
explanation: Atorvastatin is a HMG-CoA reductase inhibitor that is used in secondary prevention post-suspected transient ischaemic attack. Side effects include myalgia and myopathy
name: Atorvastatin
label: d
answer: no
explanation: Aspirin is an anti-platelet medication that is used in secondary prevention post-suspected trans ischaemic attack. Aspirin can lead to bronchospasm but would not lead to third degree heart block
name: Aspirin
label: e
answer: no
explanation: Amlodipine is a calcium channel blocker that is used in secondary prevention post-suspected transient ischaemic attack. Side effects of amlodipine are more likely to be tachycardia than bradycardia
name: Amlodipine
label: c
answer: no
explanation: Donepezil is an anticholinesterase inhibitor that is used to treat Alzheimer's dementia. It can lead to third degree heart block, which is where there is complete dissociation of P waves and QRS complexes
name: Donepezil
label: a
answer: yes

Correct answer: a


Learning point: Donepezil can cause third-degree heart block, characterised by complete dissociation of P waves and QRS complexes, particularly in elderly patients.
A 67-year-old woman attends A&E with anxiety and fatigue. She has been experiencing worsening shortness of breath and is unable to talk in full sentences. On examination, she has raised jugular venous pressure and bibasal crepitations, and it is difficult to hear heart sounds. Her observations are as follows:

- Temperature - 37.1 (36 - 38 degrees centigrade)
- Respiratory rate - 25 (12-20 breaths per minute)
- Heart rate - 110 (50-90 beats per minute)
- Blood pressure - 87/64 (systolic blood pressure 111-219 mmHg)
- Oxygen saturations - 92 (>96%)

What is the definitive treatment?

Options:
explanation: Hypotension and raised jugular venous pressure may occur in pneumothorax, especially a tension pneumothorax. However, this is likely to be accompanied by sudden onset pleuritic chest pain, making it less likely. Therefore, a needle thoracostomy would not be appropriate
name: Needle thoracostomy
label: e
answer: no
explanation: Sertraline is a selective serotonin reuptake inhibitor (SSRI), which may be appropriate if the patient was suffering from a panic disorder. Although the patient is anxious, a panic disorder is less likely due to the pattern of the observations and the examination findings
name: Sertraline
label: c
answer: no
explanation: The patient cannot talk in full sentences, which is one of the features of an acute severe asthma attack. However, this is less likely when considering the raised jugular venous pressure and bibasal crepitations without wheeze. Therefore, nebulised salbutamol would not be appropriate
name: Nebulised salbutamol
label: d
answer: no
explanation: The patient is displaying all the three hallmarks of Beck's triad. These are distended neck veins, hypotension and muffled heart sounds. When presenting acutely, the first presentation may be anxiety and fatigue. Dyspnoea, tachycardia and tachypnoea are also seen. Therefore, the definitive treatment is pericardiocentesis, where a needle is inserted into the pericardium to drain fluid
name: Pericardiocentesis
label: a
answer: yes
explanation: This would be appropriate in acute heart failure. The patient does display some signs and symptoms in keeping with acute heart failure, such as dyspnoea, raised jugular venous pressure, and bibasal crepitations. However, this wouldn't explain the muffled heart sounds
name: IV furosemide
label: b
answer: no

Correct answer: a


Learning point: Pericardiocentesis is the definitive treatment for cardiac tamponade, characterised by Beck's triad: distended neck veins, hypotension, and muffled heart sounds.
A 68-year-old woman attends A&E due to new-onset left shoulder pain with accompanying nausea. She has an ECG (shown below):

[lightgallery]

Which coronary artery has most likely been affected?

Options:
explanation: The left anterior descending artery supplies the anterior section of the heart. An anterior STEMI would usually show ST elevation in V1, V2, V3 and V4. Anterior infarcts have the poorest outcomes
name: Left anterior descending artery
label: b
answer: no
explanation: There is marked ST elevation present in leads II, III and aVF. There is reciprocal ST depression in aVL. This pattern of ST elevation suggests an inferior ST-elevation myocardial infarction (STEMI). Therefore, this is most likely due to blockage of either the right coronary artery or the circumflex branch of the left coronary artery. In this case, it is the right coronary artery as the ST elevation is most significant in lead III compared to II, and there are reciprocal changes in lead I, plus mildly elevated ST waves in V1 and V2. These findings point towards right ventricular damage
name: Right coronary artery
label: a
answer: yes
explanation: Occlusion of the circumflex branch of the left coronary artery can lead to inferior STEMI. However, this would be more likely if there was ST elevation higher in lead II compared to lead III, without any reciprocal changes in lead I
name: Circumflex branch of the left coronary artery
label: c
answer: no
explanation: The sinoatrial artery supplies the atrial node. Therefore, it operates in the superior part of the heart. It is a branch of the right coronary artery which means that some acute inferior STEMIs may also have concurrent problems with the area supplied by the sinoatrial artery. This occurs if the occlusion to the right coronary artery is proximal to the branch of the sinoatrial artery. However, the ECG of this patient shows ischaemia in the inferior leads II, III and aVF. Occlusion to only the sinoatrial artery could not lead to these changes
name: Sinoatrial artery
label: e
answer: no
explanation: Blockage of the diagonal branch of the left coronary artery leads to lateral STEMI. Therefore, the leads that are most likely to be affected are the so-called lateral leads. These are leads I, aVL, V5 and V6
name: Diagonal branch of the left coronary artery
label: d
answer: no

Correct answer: a


Learning point: Inferior ST-elevation myocardial infarction (STEMI) is commonly associated with right coronary artery occlusion, presenting with ST elevation in leads II, III, and aVF.
A 60-year-old male patient attends GP due to hypertension. He is currently taking four different medications to try and control it:


Amlodipine, ramipril, indapamide, spironolactone.


His most recent bloods are as follows:


||||
|---------------------------|:-------:|--------------------|
|Sodium|135 mmol/L|135 - 145|
|Potassium|5.7 mmol/L|3.5 - 5.3|
|Urea|3.6 mmol/L|2.5 - 7.8|
|Creatinine|74 µmol/L|60 - 120|
|eGFR|85 mL/min/1.73m<sup>2</sup>|> 60|



His blood pressure in the GP was 145/95.


What is the most likely cause of his hyperkalaemia?

Options:
explanation: Indapamide is a thiazide-type diuretic, it inhibits sodium reabsorption in the distal convoluted tubules. It is more likely to lead to hypokalaemia than hyperkalaemia
name: Indapamide
label: b
answer: no
explanation: Pheochromocytoma is a tumour found in the adrenal medulla. As well as hypertension, typical symptoms include tachycardia and sweating. It is unlikely to lead to hyperkalaemia
name: Pheochromocytoma
label: d
answer: no
explanation: Spironolactone is a potassium-sparing diuretic which acts as an anti-mineralocorticoid. A common side effect of spironolactone is hyperkalaemia
name: Spironolactone
label: a
answer: yes
explanation: Conn's syndrome, also known as primary aldosteronism, leads to hypersecretion of aldosterone from the adrenal glands. It is more likely to lead to hypokalaemia than hyperkalaemia
name: Conn's syndrome
label: c
answer: no
explanation: Renal artery stenosis is a cause of secondary hypertension. It is most likely to occur due to atherosclerosis, and results in activation of the renin-angiotensin system and is more likely to lead to hypokalaemia than hyperkalaemia
name: Renal artery stenosis
label: e
answer: no

Correct answer: a


Learning point: Spironolactone causes hyperkalemia because it inhibits the action of aldosterone in the kidneys, which normally promotes the excretion of potassium. By blocking aldosterone, spironolactone reduces potassium excretion, leading to an accumulation of potassium in the blood.
A 75-year-old woman presents to A&E with pleuritic chest pain radiating to her left shoulder, which is worse on lying flat. She also feels hot and sweaty. She had an ST-elevation myocardial infarction (STEMI) 4 weeks ago and had two drug-eluting stents inserted. Her ECG shows widespread ST elevation.

What is the most appropriate initial management?

Options:
explanation: Anticoagulation should be avoided in Dressler's syndrome due to the risk of haemorrhage into the pericardium and cardiac tamponade
name: Treatment dose low molecular weight heparin
label: c
answer: no
explanation: The first-line management for Dressler's syndrome is NSAID therapy with aspirin. If the patients symptoms do not resolve, elective coronary angiography may be indicated
name: Elective coronary angiogram
label: e
answer: no
explanation: Corticosteroids are not the first line treatment in this case. However, corticosteroids may be used to treat Dressler's syndrome if non-steroidal anti-inflammatory drugs (NSAIDs) are contra-indicated or if symptoms are refractory or recurrent. This regimen is typically given in severe or critical COVID-19 patients
name: Hydrocortisone
label: b
answer: no
explanation: This patient likely has Dressler's syndrome. Dressler's syndrome is a self-limiting secondary pericarditis which occurs after myocardial injury such as a myocardial infarction. High doses of non-steroidal anti-inflammatory drugs (NSAIDs), tapered down after two weeks, are the first line treatment
name: Higher doses of aspirin
label: a
answer: yes
explanation: Non-steroidal anti-inflammatory drugs (NSAIDs) are the first line treatment in Dressler's syndrome. In the absence of new ECG changes or raised troponin levels, angiogram is not indicated
name: Urgent coronary angiogram
label: d
answer: no

Correct answer: a


Learning point: Dressler's syndrome, a type of autoimmune pericarditis that can occur after a myocardial infarction or heart surgery, is typically treated with high doses of non-steroidal anti-inflammatory drugs (NSAIDs), which are tapered down after two weeks to manage inflammation and symptoms.