hllj/quesmed huggingface dataset:
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: 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
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: 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

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: 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
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: 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

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: 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
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: 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: 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: 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

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: 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: 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
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: 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: 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

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: 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
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: 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: 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

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.
A 57-year-old woman attends GP due to moderate pain. The pain is localised over the same area of skin where she had shingles three months ago. She now experiences pain whenever that area becomes cold or whenever it is touched lightly.

The GP diagnoses post-herpetic neuralgia and advises the patient to wear cotton clothes over the affected area; to wrap the area in clingfilm, and advised her how to improve her sleep.

What pharmacological treatment could also be considered in the first instance?

Options:
explanation: Cannabis sativa extract should not be prescribed in a non-specialist setting
name: Cannabis sativa extract
label: e
answer: no
explanation: Tramadol should only be considered in cases where acute relief is needed. Therefore, it would not be appropriate in this case at this time
name: Tramadol
label: c
answer: no
explanation: Capsaicin cream should be offered only if oral medication is inappropriate
name: Capsaicin cream
label: d
answer: no
explanation: Non-steroidal anti-inflammatory drugs are not recommended in post-herpetic neuralgia as there is no evidence to support their use
name: Ibuprofen
label: b
answer: no
explanation: Post-herpetic neuralgia is treated as a type of neuropathic pain. Therefore, the first-line medication can be either amitriptyline, duloxetine, gabapentin or pregabalin
name: Amitriptyline
label: a
answer: yes

Correct answer: a


Learning point: Post-herpetic neuralgia is a type of neuropathic pain often treated with amitriptyline as a first-line pharmacological option.
A 42-year-old woman attends GP due to reduced sensation over a hypopigmented patch of skin. The symptoms have been getting worse for several months. The area of skin affected is a large plaque around 5cm by 6cm over the left upper arm. After taking a careful history, the GP finds out that the patient lived in Colombia before moving to the United Kingdom 5 years ago. On examination, the GP notes wasting of the hypothenar muscles of the left hand and reduced sensation over the lateral half of the 4th digit and the whole of the 5th digit.

Which of these would be the most appropriate management?

Options:
explanation: Daktacort is hydrocortisone with miconazole and is used mostly in mildly inflamed skin disorders with associated infection. It is not appropriate in this case due to the history being suggestive of leprosy
name: Daktacort (daily)
label: b
answer: no
explanation: Rifampin, isoniazid, pyrazinamide, ethambutol are the regimen for the treatment of tuberculosis. Cutaneous tuberculosis is rare and is due to direct inoculation with tubercle bacilli into the skin. It does not generally lead to paraesthesia. Other types of mycobacterial skin infections include leprosy, which is what the patient is suffering from in this case
name: Rifampin, isoniazid, pyrazinamide, ethambutol (all daily)
label: e
answer: no
explanation: Betnovate is a potent topical corticosteroid. It is often prescribed in severe inflammatory conditions. It is not appropriate in this case due to the history being suggestive of leprosy
name: Betnovate (as required)
label: c
answer: no
explanation: Metformin is the first line treatment of type II diabetes mellitus. The patient is displaying unilateral paraesthesia symptoms, which are less likely to be due to a peripheral nephropathy secondary to diabetes. The muscle wasting is a sign of peripheral nerve thickening, which suggests leprosy
name: Metformin (daily)
label: d
answer: no
explanation: This patient has presented with features of leprosy. Therefore, the best management would be for multidrug therapy. The gold standard for diagnosis would be to await a skin swab which showed Mycobacterium leprae. A positive swab plus hypopigmented skin lesions with reduced sensations and peripheral nerve thickening are the three features required to make a leprosy diagnosis. This patient is displaying signs of left ulnar nerve thickening
name: Rifampicin (monthly), dapsone (daily)
label: a
answer: yes

Correct answer: a


Learning point: Leprosy is treated with a combination of antibiotics, typically including rifampicin (monthly) and dapsone (daily), as part of multidrug therapy to effectively reduce the bacterial load and prevent transmission.
A 23-year-old woman presents to her GP with a rash. She has just undergone chemotherapy for acute lymphoblastic leukaemia.

[lightgallery]

What investigation would give a definitive diagnosis?

Options:
explanation: The causative organism of shingles is the reaction of varicella zoster rather than herpes simplex. Herpes simplex can also present with localised blistering, so it is a common differential of shingles
name: Swab for herpes simplex polymerase chain reaction (PCR)
label: d
answer: no
explanation: There are different types of skin biopsies which are used to both investigate skin lesions. A punch biopsy would not be appropriate in this case because the diagnosis is shingles, which can be identified via PCR
name: Punch skin biopsy
label: c
answer: no
explanation: The image shows the early onset of shingles. This is caused by the reactivation of the varicella zoster virus. The initial infection of the varicella virus would have caused chickenpox. The diagnosis is usually clinical, as often the virus is difficult to recover from swabs. The likelihood of developing shingles increased by up to 40% in patients diagnosed with cancer
name: Swab for varicella zoster polymerase chain reaction (PCR)
label: a
answer: yes
explanation: The image shows the early onset of shingles. This is caused by the reactivation of the varicella zoster virus. The initial infection of the varicella virus would have caused chickenpox. There are no signs of an overlying bacterial infection
name: Bacterial swab
label: b
answer: no
explanation: Ink burrow testing is performed to diagnose scabies. This is more commonly associated with fine, silvery lines usually seen in the interdigital spaces
name: Ink burrow test
label: e
answer: no

Correct answer: a


Learning point: The likelihood of developing shingles increased by up to 40% in patients diagnosed with cancer
A 56-year-old woman visits her GP due to the development of new mouth ulcers. She also complains about a sore throat. On examination, she is warm to the touch. She has started a new medication due to a recent diagnosis of hyperthyroidism.


Her bloods are as follows:


||||
|--------------|:-------:|---------------|
|Haemoglobin|101      g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|2.2x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|90x10<sup>9</sup>/L|150 - 400|


Which of these medications is most likely to be the cause?

Options:
explanation: Propylthiouracil is usually only prescribed by a specialist for hyperthyroidism. Propylthiouracil can lead to pancytopenia as well as hepatic disorders and hypersensitivity reactions. It is not first line because of the slightly increased likelihood of severe liver damage. Therefore, it is unlikely to have been prescribed to this patient
name: Propylthiouracil
label: c
answer: no
explanation: Beta-blockers can lead to thrombocytopenia; however, pancytopenia is less common. Other side effects include fatigue, cold extremities and bronchospasm
name: Metoprolol
label: d
answer: no
explanation: This patient has pancytopenia on their blood film and is displaying signs and symptoms of bone marrow depression. Bone marrow depression occurs in roughly 1 in 1000 patients who take carbimazole. The suppression is usually temporary and should improve within weeks if the carbimazole is stopped. More common side effects include headache, nausea and rashes
name: Carbimazole
label: a
answer: yes
explanation: Beta-blockers can lead to thrombocytopenia; however, pancytopenia is less common. Other side effects include fatigue, cold extremities and bronchospasm
name: Propranolol
label: b
answer: no
explanation: Beta-blockers can lead to thrombocytopenia; however, pancytopenia is less common. Other side effects include fatigue, cold extremities and bronchospasm
name: Nadolol
label: e
answer: no

Correct answer: a


Learning point: Pancytopenia, a condition characterized by the reduction of all blood cell types, can be a rare side effect of carbimazole, a medication used to treat hyperthyroidism, due to its impact on bone marrow function.
A 62-year-old male patient presents to A&E due to a history of intermittent confusion, sweating and dizziness. These often improved towards the end of the day. His bloods are as follows:


 - Fasting glucose 1.2 (normal range 3.5-5.5 mmol/L)
 - Proinsulin raised
 - C-peptide raised


A diagnosis of insulinoma is made. What is the most appropriate initial management?

Options:
explanation: This patient requires immediate glucose replacement. However, they are more likely to require potassium replacement rather than calcium. This is due to the effect that insulin has on increasing potassium uptake within cells
name: IV dextrose and calcium replacement
label: d
answer: no
explanation: This patient will need immediate glucose replacement most urgently. They may require alternative fluid therapy later on in their treatment, but the low glucose levels require correction first. They will also likely require potassium replacement because increased circulating insulin levels will lead to an increase in potassium being transported intracellularly
name: IV 0.9% sodium chloride and potassium replacement
label: b
answer: no
explanation: This patient requires immediate glucose replacement. They will also likely require potassium replacement because increased circulating insulin levels will lead to an increase in potassium being transported intracellularly
name: IV dextrose and potassium replacement
label: a
answer: yes
explanation: This patient requires immediate glucose replacement. However, they are more likely to require potassium replacement rather than sodium. This is due to the effect that insulin has on increasing potassium uptake within cells
name: IV dextrose and sodium replacement
label: c
answer: no
explanation: This patient will need immediate glucose replacement most urgently. They may require alternative fluid therapy later on in their treatment, but the low glucose levels require correction first. They are more likely to require potassium replacement rather than calcium. This is due to the effect that insulin has on increasing potassium uptake within cells
name: IV 0.9% sodium chloride and calcium replacement
label: e
answer: no

Correct answer: a


Learning point: An insulinoma is a pancreatic tumor that causes excessive insulin secretion and hypoglycemia. IV dextrose quickly raises blood glucose, and potassium replacement may be needed due to insulin-induced cellular potassium shifts.