hllj/quesmed huggingface dataset:
A 60-year-old man attends his GP for a routine check-up; he is noted to have a low pulse rate. His ECG is as follows:

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What incidental finding is seen?

Options:
explanation: First degree atrioventricular heart block involves a prolongation of the PR interval of more than 200ms. In this case, the ECG shows a PR interval of greater than 300ms. The ECG also shows sinus bradycardia
name: First degree atrioventricular heart block
label: a
answer: yes
explanation: Second degree atrioventricular heart block (type one) is also known as Mobitz type one or Wenckebach phenomenon. It leads to progressive elongation of the PR interval, which will lead to an eventual missed QRS complex. In this case, the ECG shows a constant PR interval of greater than 300ms, which indicates first degree atrioventricular heart block
name: Second degree atrioventricular heart block (type one)
label: c
answer: no
explanation: Sick sinus syndrome, also known as sinus node dysfunction, can lead to sinus bradycardia, seen in the ECG. However, there is also prolongation of the PR interval, which is less likely to be seen in sick sinus syndrome
name: Sick sinus syndrome
label: b
answer: no
explanation: Third degree atrioventricular heart block occurs when there is no direct communication between the atria and the ventricles. Therefore, the P waves and QRS complexes are found to be independent of one another on ECG. In this case, the ECG shows a constant PR interval of greater than 300ms, which indicates first degree atrioventricular heart block
name: Third degree atrioventricular heart block
label: e
answer: no
explanation: Second degree atrioventricular heart block (type two), also known as Mobitz type two, leads to intermittent dropping of QRS complexes. This usually follows a pattern of 3:1 or 4:1. In this case, the ECG shows a constant PR interval of greater than 300ms, which indicates first degree atrioventricular heart block
name: Second degree atrioventricular heart block (type two)
label: d
answer: no

Correct answer: a
A 56-year-old woman presents to her GP with worsening shortness of breath which is worse on exertion. She also experiences breathlessness when lying flat and at night. She has a history of breast cancer, hyperthyroidism and type II diabetes mellitus. On examination, she has bilateral pitting oedema in her ankles. Her medications include tamoxifen, trastuzumab, carbimazole, metformin and linagliptin.

Which of her medications is most likely to be the cause of her symptoms?

Options:
explanation: Metformin is the first line treatment for type 2 diabetes mellitus. Common side effects include nausea, diarrhoea and abdominal pain. An important, rare side effect is lactic acidosis. Heart failure is not a known side effect
name: Metformin
label: d
answer: no
explanation: Tamoxifen is an anti-oestrogen medication use to treat breast cancers that are oestrogen receptor positive. A common side effect is fluid retention, however, it is unlikely to also lead to breathing difficulties
name: Tamoxifen
label: b
answer: no
explanation: Linagliptin is a dipeptidylpeptidase-4 inhibitor that acts to increase insulin secretion. It is a second line treatment for type 2 diabetes mellitus. Heart failure is not a known side effect
name: Linagliptin
label: e
answer: no
explanation: Carbimazole is used in the treatment of hyperthyroidism. An important, rare side effect is bone marrow failure. Heart failure is not a known side effect
name: Carbimazole
label: c
answer: no
explanation: Trastuzumab (brand name Herceptin), is a monoclonal antibody against the HER2 receptor. It is prescribed in patients who have breast cancer that overexpresses the HER2 gene. Heart failure is a common side effect of this medication, affecting up to 1 in 10 patients and therefore, regular monitoring is required
name: Trastuzumab
label: a
answer: yes

Correct answer: a


Learning point: Trastuzumab is a targeted monoclonal antibody used to treat HER2-positive breast cancer by inhibiting the growth of cancer cells; however, it can cause heart failure, leading to symptoms like shortness of breath and peripheral edema, making regular cardiac monitoring essential during treatment.
A 52-year-old woman presented to her GP with a firm lump in her left breast. This was fast-growing and had noticeably increased in size over the last few weeks so that it is now 1cm by 2cm by 1cm. She was sent for an urgent mammogram, ultrasound and biopsy. The biopsy showed a benign phyllodes tumour.

What is the most appropriate initial management?

Options:
explanation: Chemotherapy may be recommended if the tumour was malignant
name: Chemotherapy
label: d
answer: no
explanation: The tumour is benign; therefore, lymph node clearance is not necessary
name: Mastectomy plus lymph node clearance
label: c
answer: no
explanation: Phyllodes tumours account for less than 1% of all breast cancers. Surgery is the main treatment. Tumours can either be benign, borderline or malignant. In this case, the tumour is benign; therefore, a lumpectomy is the best management choice
name: Lumpectomy
label: a
answer: yes
explanation: If the tumour is benign, the usual treatment is a lumpectomy. However, if the tumour is larger, then a mastectomy may be more likely to be performed
name: Mastectomy
label: b
answer: no
explanation: This tumour is benign; therefore, radiotherapy is not required. Radiotherapy is not often performed in phyllodes tumours
name: Radiotherapy
label: e
answer: no

Correct answer: a


Learning point: Phyllodes tumors are rare breast tumors that can be benign or malignant and are characterized by rapid growth; management typically involves surgical removal with a lumpectomy to ensure complete excision and reduce the risk of recurrence.
An 84-year-old woman is admitted to A&E due to severe drowsiness. She cannot speak in full sentences, but her daughter states that she had been complaining of increased nausea and vomiting over the last few days. Her bloods are as follows:


||||
|---------------------------|:-------:|------------------------------|
|Fasting Glucose|4.5 mmol/L|3.5 - 5.5|
|Sodium|118 mmol/L|135 - 145|
|Potassium|4.2 mmol/L|3.5 - 5.3|
|Urea|4 mmol/L|2.5 - 7.8|
|Creatinine|65 µmol/L|60 - 120|
|eGFR|75 mL/min/1.73m<sup>2</sup>|> 60|
|Blood Urea Nitrogen|11.2 mg/dL|7 - 22|



Using the formula below, calculate the patient's plasma osmolality.


Plasma osmolality = 2 [Na+ mEq/L] + [Glucose mmol/L + [Blood Urea Nitrogen mg/dL]/2.8

Options:
explanation: Be careful to multiply the sodium concentration by two rather than square it
name: 13933.5 mOsmo/kg
label: d
answer: no
explanation: Remember to use the blood urea nitrogen rather than urea. In reality, these two are often used interchangeably. However, in this exercise, the urea is in the wrong units for the equation
name: 241.9 mOsmo/kg
label: c
answer: no
explanation: Remember that division should be performed before addition in calculations. The order of mathematical operations can be remembered using the BODMAS mnemonic: brackets, orders, division, multiplications, addition, subtraction
name: 10.3 mOsmo/kg
label: b
answer: no
explanation: Ensure that the glucose concentration used is in mg/dL rather than mmol/L
name: 240.3 mOsmo/kg
label: e
answer: no
explanation: Plasma osmolality = (2 [118]) + (81/18) + (11.2/2.8)

Note the units used in this calculation are not the same as the units usually given for blood results. In reality, it is safer to calculate plasma osmolality on an online calculator, be aware that units of calculators are often interchangeable
name: 244.5 mOsmo/kg
label: a
answer: yes

Correct answer: a
A 63-year-old woman attends A&E. She has a background of type 2 diabetes mellitus and is usually on metformin. She has been experiencing vomiting and diarrhoea since returning from holiday to Sri Lanka. On examination, she is breathing rapidly.


An arterial blood gas (ABG) is performed:


||||
|--------------|:-------:|------------------|
|pH|7.29|7.35 - 7.45|
|PaO₂|11.2 kPa|11 - 15|
|PaCO₂|3.5 kPa|4.6 - 6.4|
|Bicarbonate|10 mmol/L|22 - 30|
|Chloride|117 mmol/L|96-106|
|Sodium|137 mmol/L|134-145|
|Potassium|5.2 mmol/L|3.5 - 5.3|
|Glucose|20 mmol/L|5-8|



What is the most likely cause of these blood gas results?

Options:
explanation: This is highly unlikely given nothing in the history is mentioned about possible overdose or suicidal ideation. Furthermore, ethylene glycol poisoning would result in a high anion gap metabolic acidosis.
name: Ethylene glycol poisoning
label: e
answer: no
explanation: Uraemia could occur as a result of an acute kidney injury secondary to the vomiting and diarrhoea. However, this would cause an increased anion gap metabolic acidosis and the anion gap here is normal.
name: Uraemia
label: d
answer: no
explanation: Lactic acidosis would cause a metabolic acidosis with a low pH and patients with renal impairment can get a metformin induced lactic acidosis. However, this would cause a raised anion gap metabolic acidosis, and the anion gap here is normal.
name: Lactic acidosis
label: c
answer: no
explanation: Diabetic ketoacidosis would cause a metabolic acidosis with a low pH, but the anion gap would be high as there is excess acid in the blood. The anion gap in this case is normal.
name: Diabetic ketoacidosis
label: b
answer: no
explanation: The pH here is below the normal range, implying an acidosis. The carbon dioxide also also below the normal range, implying that this must be a metabolic acidosis with partial respiratory compensation.

The anion gap is calculated as follow: [Na+] - ( [Cl-] + [HCO3-] ). A normal anion gap is 8-12 mmol/L. The anion gap in this case is 137-(117+10)=10. This represents a normal anion gap acidosis. One of the most common causes of a normal anion gap metabolic acidosis is diarrhoea, due to the significant bicarbonate loss from the gut.
name: Gastroenteritis
label: a
answer: yes

Correct answer: a
A 63-year-old woman attends A&E due to abdominal pain. The pain was sudden onset and is localised to the epigastric region and radiates to the back. The patient has also vomited twice whilst in the department. The consultant suspects pancreatitis and orders some investigations.


||||
|--------------|:-------:|---------------|
|Haemoglobin|109   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|12x10<sup>9</sup>/L|3.0 - 10.0|
|Calcium|1.9 mmol/L|2.2 - 2.6|
|Urea|11 mmol/L|2.5 - 7.8|
|Albumin|33 g/L|35 - 50|


Which of these most indicates a poor prognosis?

Options:
explanation: The white cell count is slightly raised. However, it is not raised above the levels required to score a point in the Glasgow score. The Glasgow score is used to assess whether a patient needs to be treated in the intensive care unit
name: White cell count
label: c
answer: no
explanation: Although the Haemoglobin is slightly low, it does not indicate a poor prognosis. Haemoglobin is not one of the Glasgow score criteria used to assess whether a patient needs to be treated in the intensive care unit
name: Haemoglobin
label: b
answer: no
explanation: The albumin is slightly low. However, it is not at the level where it would score a point in the Glasgow score. The Glasgow score is used to assess whether a patient needs to be treated in the intensive care unit
name: Albumin
label: e
answer: no
explanation: The calcium is the only marker in this example where the value would score a point on the Glasgow score. A Glasgow score of more than 3 indicates severe pancreatitis, and the patient may need to go to the intensive care unit. The values used to calculate the Glasgow score can be remembered by the PANCREAS mnemonic.

- P - PO2 <8 kPa
- A - Age > 55
- N - Neutrophils: WCC > 15x109/L
- C - Calcium, < 2mmol/L
- R - renal function: urea >16 mmol/L
- E - Enzymes: LDH > 600iu/L or AST >200iu/L
- A - Albumin <32g/L
- S - sugar: blood glucose > 10mmol/L

Therefore, it is important to request all of these investigations when assessing a patient with suspected pancreatitis because it will inform you next stages of management
name: Calcium
label: a
answer: yes
explanation: The urea is raised. However, it is not raised above the levels required to score a point in the Glasgow score. The Glasgow score is used to assess whether a patient needs to be treated in the intensive care unit
name: Urea
label: d
answer: no

Correct answer: a


Learning point: A low calcium level in a patient with suspected pancreatitis is a sign of severe disease requiring closer monitoring and potential intensive care unit admission.
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: 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
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

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: 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: 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: 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
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: 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

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.

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What investigation would give a definitive diagnosis?

Options:
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
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 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: 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: 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

Correct answer: a


Learning point: The likelihood of developing shingles increased by up to 40% in patients diagnosed with cancer
A 44-year-old woman visits her GP practice because of problems with intermittent, fluctuating hearing loss. She has accompanying symptoms of vertigo and tinnitus. These occurrences tend to last around an hour and have happened a few times in the last month. They were initially in her right ear, but she now experiences the same problems in both ears.

What is the most likely diagnosis?

Options:
explanation: Vertigo, tinnitus and fluctuating hearing loss are classic Ménière's disease symptoms. The hallmark of the disease is that these symptoms are episodic and fluctuating in nature
name: Ménière's disease
label: a
answer: yes
explanation: Otitis media in adults is most likely to present with otalgia. Otitis media can rarely cause vertigo or tinnitus; however it is unlikely to be intermittent or affect both ears simultaneously
name: Otitis media
label: e
answer: no
explanation: Vestibular neuritis and labyrinthitis are sometimes used interchangeably. However, vestibular neuritis refers to inflammation of the vestibular nerve only, whereas labyrinthitis refers to inflammation of the vestibular nerve and the labyrinth. Vestibular neuritis leads to sudden severe vertigo, which is unlikely to be affected by head movement. There is no accompanying hearing loss or tinnitus
name: Vestibular neuritis
label: c
answer: no
explanation: Labyrinthitis and vestibular neuritis are sometimes used interchangeably. However, labyrinthitis refers to inflammation of the vestibular nerve and the labyrinth, whereas vestibular neuritis refers to inflammation of the vestibular nerve only. Labyrinthitis can present with vertigo, hearing loss and tinnitus; however, it is more likely to present suddenly and does not follow a fluctuating course. Labyrinthitis is also more likely to be unilateral
name: Labyrinthitis
label: d
answer: no
explanation: BPPV is unlikely, as episodes of vertigo usually last for seconds to minutes and are related to head movement. Hearing loss and tinnitus are not typical features
name: Benign paroxysmal positional vertigo (BPPV)
label: b
answer: no

Correct answer: a


Learning point: Ménière's disease is characterized by episodic and fluctuating symptoms, including vertigo, tinnitus, and hearing loss, often accompanied by a feeling of fullness in the ear.
A 75-year-old woman visits her GP because she has noticed a facial swelling. This has occurred on the right side of her face and has been slowly growing over the last few months. On examination, the GP feels a small, non-tender, non-fixed lump superior to her right temporomandibular joint. She also notices a slight eversion of the right ear lobe.

What is the most likely cause of this lump?

Options:
explanation: Pleomorphic adenoma is the most common tumour of the parotid gland. It is a benign tumour, but in a very small minority of cases can become malignant. Signs of malignant tumours in the parotids are: fast-growth, pain, facial palsy and fixation
name: Pleomorphic adenoma
label: a
answer: yes
explanation: Warthin's tumours are painless and slow growing. However, they are the second most common type of benign tumour occurring in the salivary gland. The most common is a pleomorphic adenoma
name: Warthin's tumour
label: d
answer: no
explanation: This is the most common malignant tumour of the lacrimal gland. However, it is less common than pleomorphic adenomas and is more likely to present in younger adults. It is more likely to present as fast-growing, painful, with possible accompanying facial palsy and fixation
name: Adenoid cystic carcinoma
label: b
answer: no
explanation: Pilocytic astrocytomas are brain tumours which most commonly occur in children or young adults. They most often occur in the cerebellum
name: Pilocytic astrocytoma
label: c
answer: no
explanation: An oncocytoma is a type of tumour that is usually benign and develops from oncocytes. These are epithelial cells that have a high concentration of mitochondria. These most often present in the kidneys, salivary glands or thyroid
name: Oncocytoma
label: e
answer: no

Correct answer: a


Learning point: Pleomorphic adenoma is the most common benign tumour of the parotid gland, often presenting as a slow-growing, non-tender lump.