hllj/quesmed huggingface dataset:
A 45-year-old man with a diagnosis of myocarditis is assessed following an episode of hypotension on the ward. On assessment, he is tachycardic and tachypnoeic with a blood pressure of 90/50 mmHg. He has a raised jugular venous pressure (JVP) and his heart sounds are difficult to auscultate.

An urgent bedside ECHO shows cardiac tamponade.

Which of the following is the best definitive step in management?

Options:
explanation: Inotropes act to increase myocardial contractility and thereby increase cardiac output. They may be considered, but definitive management with pericardiocentesis should not be delayed
name: Inotropes
label: d
answer: no
explanation: This patient has obstructive shock due to pericardial fluid that is reducing ventricular filling and thereby causing reduced cardiac output. Fluid challenges are more useful in the initial management of hypovolaemic (e.g. blood loss) and distributive shock (e.g. sepsis) but would not be as useful in this context
name: 500ml fluid challenge
label: b
answer: no
explanation: Cardiac tamponade is a medical emergency caused by the accumulation of fluid in the pericardial space, leading to reduced ventricular filling and haemodynamic compromise. Management is with pericardiocentesis which aims to remove the pericardial fluid
name: Urgent pericardiocentesis
label: a
answer: yes
explanation: Thoracocentesis is a procedure that aims to remove fluid or air from the pleural space. An emergency thoracocentesis is used for urgent decompression of a tension pneumothorax
name: Emergency thoracocentesis
label: e
answer: no
explanation: Although the patient has a raised JVP, they are not in congestive cardiac failure or pulmonary oedema. The raised JVP indicates increased right atrial pressure due to the pericardial fluid causing strain on the heart. As the patient is not fluid overloaded, there would be no benefit of giving diuretics. In this case, it would likely drop the patient's blood pressure further
name: 40mg IV furosemide
label: c
answer: no

Correct answer: a


Learning point: Cardiac tamponade is a medical emergency requiring urgent pericardiocentesis to relieve fluid accumulation and restore haemodynamic stability.
A 35-year-old man with no previous past medical history presents with a 3-week history of intermittent fevers and night sweats. There are no localising symptoms of infection.

On examination, he is tachycardic and febrile with an early diastolic murmur noted over the left sternal edge.

He is treated empirically for infective endocarditis. Blood cultures subsequently grow methicillin-resistant staphylococcus aureus (MRSA).

Which of the following is the best antimicrobial regime?

Options:
explanation: MRSA indicates that the staphylococcus aureus species are resistant to flucloxacillin. IV flucloxacillin for 4-6 weeks would be the treatment of methicillin-susceptible Staphylococcus aureus in a patient with native valve (i.e. no prosthetic valves) endocarditis
name: IV flucloxacillin
label: b
answer: no
explanation: This would be a treatment option for a patient with native valve streptococcal endocarditis. Benzylpenicillin would not work for staphylococcal species
name: IV benzylpenicillin
label: c
answer: no
explanation: MRSA indicates that the staphylococcus aureus species are resistant to β-lactam antibiotics. In this case, for a patient with confirmed MRSA and without any prosthetic heart valves, the BNF advises treatment with vancomycin and rifampicin for 4 weeks
name: IV vancomycin and rifampicin
label: a
answer: yes
explanation: This is the empirical treatment for native valve endocarditis. As MRSA has been cultured, this regime needs to be escalated to vancomycin (and gentamicin) as amoxicillin will not cover MRSA
name: IV amoxicillin and gentamicin
label: d
answer: no
explanation: This would be the treatment of MRSA prosthetic valve endocarditis. It is also used as empirical treatment for prosthetic valve endocarditis whilst awaiting culture results or if cultures results are negative
name: IV vancomycin, rifampicin and gentamicin
label: e
answer: no

Correct answer: a


Learning point: Methicillin-resistant Staphylococcus aureus (MRSA) requires treatment with vancomycin and rifampicin, especially in cases of infective endocarditis.
A 23-year-old man presents to his General Practitioner (GP) with two brief episodes of syncope that were preceded by palpitations. He was admitted the previous year with palpitations which were found to be due to supraventricular tachycardia (SVT) that responded to initial management with vagal manoeuvres.

Clinical examination is unremarkable and his observations are normal. An ECG shows a short PR interval and a widespread slurred upstroke on the QRS complexes.

Which of the following is the best step in management?

Options:
explanation: This patient has a history and ECG findings consistent with symptomatic Wolff-Parkinson-White (WPW) syndrome. This is a condition in which there is a congenital accessory pathway through which there can be aberrant conduction and pre-excitation of the ventricles.

Key ECG findings are a short PR interval and a broad QRS complex with a slurred upstroke (known as a delta wave).

Definitive management is a referral to an electrophysiologist for ablation of the accessory pathway
name: Referral for accessory pathway ablation
label: a
answer: yes
explanation: Digoxin is an AV nodal blocking agent and should be avoided in WPW as it may precipitate conduction down the accessory pathway and thereby trigger an arrhythmia
name: Digoxin
label: e
answer: no
explanation: Pulmonary vein ablation (PVA) is a treatment for symptomatic atrial fibrillation (AF). The area where tissue from the atrium and pulmonary veins meet is the source of ectopic atrial depolarisation that drives AF. PVA aims to destroy this area of tissue using radiofrequency energy or cryoablation
name: Referral for pulmonary vein ablation
label: b
answer: no
explanation: Verapamil is an AV nodal blocking agent and should be avoided in WPW as it may precipitate conduction down the accessory pathway and thereby trigger an arrhythmia
name: Verapamil
label: d
answer: no
explanation: Flecainide can be used in WPW in patients who are not suitable for or who refuse accessory pathway ablation
name: Flecainide
label: c
answer: no

Correct answer: a


Learning point: Wolff-Parkinson-White (WPW) syndrome is characterized by an abnormal extra electrical pathway in the heart, leading to episodes of rapid heart rate. Referral for accessory pathway ablation is recommended for patients with symptomatic WPW or those at risk of serious arrhythmias
A 56-year-old man with a history of angina presents to his GP with central chest pain on exercise that is now occurring more frequently. The pain usually lasts a few minutes and is relieved by sublingual glyceryl trinitrate (GTN) spray. He denies any pain at rest, and an ECG shows no ischaemic changes.

His only current medications anti-anginal medication is bisoprolol which has been up-titrated to the maximum tolerated dose.

Which of the following is the next step in management?

Options:
explanation: Ranolazine is a potassium channel activator. NICE guidelines suggest adding ranolazine only after considering the use of both a calcium channel blocker and beta-blocker
name: Ranolazine
label: d
answer: no
explanation: Ivabradine blocks sodium channels in the sinus node. NICE guidelines suggest adding ivabradine only after considering the use of both a calcium channel blocker and a beta-blocker
name: Ivabradine
label: e
answer: no
explanation: NICE guidelines suggest that the first-line management for patients with angina is either a beta-blocker (e.g. bisoprolol) or a calcium-channel blocker (e.g. amlodipine). The initial drug should be up-titrated before switching to the other option or using a combination of the two
name: Add amlodipine
label: a
answer: yes
explanation: ISMN is a long-acting nitrate. NICE guidelines suggest adding ISMN only after considering the use of both a calcium channel blocker and beta-blocker
name: Add isosorbide mononitrate (ISMN)
label: c
answer: no
explanation: Verapamil is a non-dihydropyridine calcium channel blocker that acts on the heart. It should not be combined with a beta-blocker due to the risk of heart block
name: Add verapamil
label: b
answer: no

Correct answer: a


Learning point: In patients with stable angina, combining a beta-blocker with a calcium-channel blocker can enhance symptom control when monotherapy is insufficient.
A 24-year-old patient presents with tender red nodules on the anterior shins that developed over the last week. Full systems review is negative, and the patient cannot find any triggers that may have lead to the lesions.

A chest x-ray and initial blood tests are normal.

Which of the following is the most likely cause of this patient's rash?

Options:
explanation: Streptococcal infections are associated with erythema nodosum, but there is nothing in the history to suggest that this may be the cause in this case
name: Post-streptococcal infection
label: d
answer: no
explanation: The lesions described are typical of erythema nodosum. This is an inflammatory disorder affecting the subcutaneous fat. The cause is unknown in approximately 55% of patients, and most cases resolve within days to weeks
name: Idiopathic
label: a
answer: yes
explanation: Sarcoidosis is an important cause of erythema nodosum; however, the normal chest x-ray, blood tests and absence of symptoms make this unlikely
name: Sarcoidosis
label: c
answer: no
explanation: IBD is associated with erythema nodosum. The normal blood tests and absence of gastrointestinal or systemic symptoms would make this unlikely in this case
name: Inflammatory bowel disease (IBD)
label: e
answer: no
explanation: TB is an important cause of erythema nodosum; however, the absence of systemic symptoms, risk factors and normal chest x-ray makes this unlikely
name: Tuberculosis (TB)
label: b
answer: no

Correct answer: a


Learning point: Erythema nodosum presents as tender red nodules on the shins and often has an idiopathic aetiology, resolving spontaneously within weeks.
A 34-year-old man presents with a two-week history of a purple coloured rash on his lower limbs. He also reports approximately 5kg weight loss in the last two months. He is otherwise well, and his only significant past medical history is of recurrent episodes of sinusitis in the past year.

On examination, there is a widespread palpable purpuric rash on the anterior aspects of both legs. Examination and observations are otherwise normal.

Which of the following is the next best step in management?

Options:
explanation: This is an important test to look for any evidence of proteinuria (especially in a patient who is likely to have significant renal disease) but a simple urine dipstick should be done in the first instance
name: Urine Protein Creatinine ratio
label: b
answer: no
explanation: CRP levels are indicative of infective and inflammatory states and therefore are likely to be raised in vasculitis. However, it is a non-specific test. A urine dipstick is preferable as an initial test to exclude potentially life-threatening renal vasculitis
name: Measure C-reactive protein (CRP) levels
label: e
answer: no
explanation: Meningococcal septicaemia can present with a purpuric rash, similar to that seen in small vessel vasculitis. However, the absence of any infective symptoms, normal observations and chronicity of the history favour a diagnosis of vasculitis
name: Blood cultures
label: c
answer: no
explanation: The rash combined with systemic symptoms and recurrent sinusitis is suggestive of small vessel vasculitis. In this context, recurrent sinusitis, in particular, is indicative of granulomatosis with polyangiitis (GPA). Vasculitis, in general, is commonly associated with renal disease, which can manifest with proteinuria and haematuria. Therefore, it is important to do a urine dipstick in all patients with this presentation to exclude significant renal complications
name: Urine dipstick
label: a
answer: yes
explanation: Tryptase levels are increased in anaphylaxis. The rash in anaphylaxis is typically an urticarial rash, characterised by itchy weals and surrounding erythema. Also, there are no other signs or symptoms of anaphylaxis described
name: Serum tryptase levels
label: d
answer: no

Correct answer: a


Learning point: Recurrent sinusitis and a purpuric rash could suggest granulomatosis with polyangiitis, making urine dipstick testing important to evaluate potential renal involvement.
A 32-year-old woman presents with a three-day history of a worsening rash across her body.

On examination, there is an erythematous rash covering the majority of the patient's skin, both anteriorly and posteriorly. The skin is hot to touch, and there is associated scaling. Systemic examination is otherwise normal.

Blood tests reveal increased urea to creatinine ratio but no other significant findings.

Which of the following is the most likely cause of the rash described?

Options:
explanation: Around 30% of cases of erythroderma are idiopathic. Most cases of erythroderma are associated with a pre-existing skin condition
name: Idiopathic
label: b
answer: no
explanation: The rash is highly suggestive of erythroderma. Erythroderma is a dermatological emergency where there is widespread erythema affecting >90% of the skin surface. The increased urea level suggests dehydration, an important complication of erythroderma, and highlights the importance of the skin's function in fluid balance.

The most common cause of erythroderma is a pre-existing skin condition such as eczema or psoriasis
name: Pre-existing skin condition
label: a
answer: yes
explanation: Sezary syndrome is a type of cutaneous T-cell lymphoma and is a rare cause of erythroderma
name: Sezary syndrome
label: d
answer: no
explanation: Haematological malignancies can cause erythroderma; however, the lack of systemic symptoms, largely normal blood tests and absence of lymphadenopathy would go against this
name: Haematological malignancy
label: e
answer: no
explanation: Drug reactions can cause erythroderma; however, this is less likely than a pre-existing skin condition preceding erythroderma.
name: Drug-reaction
label: c
answer: no

Correct answer: a


Learning point: A pre-existing skin condition, such as psoriasis, atopic dermatitis, or seborrheic dermatitis, is a risk factor for erythroderma
A 65-year-old man is diagnosed with giant cell arteritis (GCA) and is commenced on once-daily, high dose oral steroids as an inpatient.


He has no past medical history, and primary care records showed normal glycosylated haemoglobin (HBA1C) levels three months ago.


Routine capillary blood glucose testing consistently reveal levels in the range 14-19 mmol/L (normal <6.1 mmol/L) with normal serum ketone levels.


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

Options:
explanation: Dapagliflozin is a sodium-glucose co-transporter 2 (SGLT2) inhibitor. There is no evidence to support its use in the management of steroid-induced diabetes
name: Start dapagliflozin
label: d
answer: no
explanation: Insulin can be used for steroid-induced diabetes; however, NovoRapid is a fast-acting insulin and would not help maintain normal glucose levels throughout the day. Intermediate-acting human insulins such as Humulin I would be a better option and may be started as an alternative to gliclazide at a dose of around 10 Units in the morning
name: 4 Units of NovoRapid administered after breakfast
label: b
answer: no
explanation: This patient has steroid-induced diabetes, and guidelines recommend starting treatment if blood glucose levels are greater than 12 mmol/L on two occasions in a single twenty-four hour period. A once-daily short-acting sulphonylurea such as gliclazide is the most commonly advocated treatment option. The dose can be increased up to 240mg in the morning, and an evening dose may also be added to achieve a maximum daily dose of 320mg
name: Start gliclazide
label: a
answer: yes
explanation: Guidelines suggest starting treatment for steroid-induced diabetes if blood sugar levels are > 12mmol/L on two occasions in a single twenty-four hour period
name: Monitor blood sugars and consider treatment if levels > 20mmol/l
label: e
answer: no
explanation: Pioglitazone is not usually used as a treatment for steroid-induced diabetes unless gliclazide and insulin are not appropriate
name: Start pioglitazone
label: c
answer: no

Correct answer: a


Learning point: Giant cell arteritis can result in steroid-induced diabetes, requiring blood glucose monitoring and, if necessary, the use of oral hypoglycaemic agents such as gliclazide.
A 25-year-old man presents with a history of a painful neck lump. He reports noticing the lump over the last two weeks following an upper respiratory tract infection. He denies palpitations, tremors, weight loss or night sweats.

On examination, there is a smooth central neck lump that moves with swallowing but not on protrusion of the tongue.

Blood tests, including thyroid function, are normal.

Which of the following is the most likely diagnosis?

Options:
explanation: Riedel thyroiditis usually presents as a painless thyroid mass that can be rapidly growing. It is characterised by a hardened, "woody" thyroid due to the replacement of the gland with fibrous tissue
name: Riedel thyroiditis
label: c
answer: no
explanation: Hodgkin's lymphoma usually presents with painless cervical or supra-clavicular lymphadenopathy that may be accompanied by B-symptoms (e.g. weight loss, night sweats, fevers)
name: Hodgkin's lymphoma
label: e
answer: no
explanation: A thyroglossal cyst would be expected to move upwards on protrusion of the tongue. It would also usually not present with pain
name: Thyroglossal cyst
label: b
answer: no
explanation: De Quervain's thyroiditis is a self-limiting thyroiditis that is often preceded by a viral infection. It can present with a painful goitre and thyrotoxicosis in the initial stages. The thyrotoxicosis is often followed by a transient period of hypothyroidism before thyroid function returns to normal. The normal thyroid function likely indicates that the patient is reaching the end of the illness. Treatment is symptomatic, and there is usually no role for anti-thyroid medications such as carbimazole
name: De Quervain’s thyroiditis
label: a
answer: yes
explanation: Grave's disease is the most common cause of thyrotoxicosis in the UK. It is an autoimmune condition that results in hyperthyroidism due to stimulatory autoantibodies against the thyroid-stimulating hormone (TSH) receptor. Normal thyroid function would exclude Grave's disease
name: Grave's disease
label: d
answer: no

Correct answer: a


Learning point: De Quervain's thyroiditis is a self-limiting condition often triggered by viral infections, presenting with a painful goitre and transient thyroid dysfunction.
A 45-year-old woman presents to her General Practitioner (GP) with weakness in her shoulders and hips. She also reports an unintentional weight gain of 5kg over the last three months and associated easy bruising.

On examination, she is hypertensive, with central adiposity and violaceous striae are present on her abdomen.

She is subsequently referred to an endocrinologist.

Which of the following is the best initial investigation given the likely underlying diagnosis?

Options:
explanation: The symptoms and signs described are suggestive of Cushing's syndrome. Although a 24 hour urinary free cortisol can be used as an intial investigation to confirm cushing's syndrome, cortisol can be raised by  high fluid intake, stress and medications. There are also difficulties with collecting 24 hour urine so an overnight dexamethasone suppression test is preferred these days. 
name: 24 hour urinary free cortisol
label: a
answer: no
explanation: 9 am cortisol levels are the initial screening test for primary adrenal insufficiency. Given that serum cortisol levels match the circadian rhythm, a serum 9 am cortisol has no use as a screening test for Cushing's syndrome
name: 9 am cortisol
label: b
answer: no
explanation: Cushing's syndrome can be caused by an adrenal lesion such as an adenoma or carcinoma, and imaging may help confirm this diagnosis. However, this would usually be done once a diagnosis of Cushing's syndrome has been confirmed biochemically
name: CT adrenal glands
label: e
answer: no
explanation: Cushing's disease is Cushing's syndrome caused by a pituitary adenoma. An MRI would be indicated to confirm the diagnosis of a pituitary adenoma; however, this would usually be done once a diagnosis of Cushing's syndrome has been confirmed biochemically
name: MRI pituitary gland
label: d
answer: no
explanation: The symptoms and signs described are suggestive of Cushing's syndrome. The ovrnight dexamthasone suppression test is preferred these days to 24 hour urinary free cortisol given it's practicality. 
name: Overnight dexamethasone suppression test
label: c
answer: yes

Correct answer: c


Learning point: The diagnosis of Cushing's syndrome can be confirmed using a 24-hour urinary free cortisol test, which measures the amount of cortisol excreted in urine over a 24-hour period. Elevated levels of urinary free cortisol are indicative of hypercortisolism, supporting the diagnosis of Cushing's syndrome.
A 56-year-old man presents to his GP with a history of burning and numbness in his feet and lower legs for the last two months. His past medical history is significant for poorly controlled Type 1 diabetes and a previous duodenal ulcer.

On neurological examination, there is reduced sensation to pin-prick and fine-touch bilaterally from the feet to the knees.

Given the likely diagnosis, which of the following is the next best step in management?

Options:
explanation: Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) and is not particularly useful for treating neuropathic pain. It would also not be appropriate in this case, given the history of a duodenal ulcer, as NSAIDs are a major cause of gastric and duodenal ulceration
name: Start ibuprofen
label: b
answer: no
explanation: This patient has signs and symptoms of diabetic neuropathy. Other symptoms of neuropathic pain include tingling, sensitivity to touch and electric-like sensations. NICE guidelines suggest using amitriptyline, duloxetine, pregabalin or gabapentin as the first-line treatment for neuropathic pain
name: Start duloxetine
label: a
answer: yes
explanation: Regular paracetamol would not be particularly useful for the treatment of neuropathic pain
name: Start regular paracetamol
label: c
answer: no
explanation: Neuropathic pain may be responsive to treatment with opioids such as morphine. However, it should be reserved for persistent symptoms refractory to treatment with anti-depressants (e.g. amitriptyline or duloxetine) and anti-epileptics (pregabalin or gabapentin)
name: Start modified-release morphine sulphate
label: d
answer: no
explanation: Low strength capsaicin cream can be used for the treatment of localised neuropathic pain. This patient's pain is more widespread and so topical treatment is unlikely to be beneficial. A patch containing 8% capsaicin is an option for peripheral neuropathic pain and could be considered under specialist supervision
name: Start 0.075% capsaicin cream
label: e
answer: no

Correct answer: a


Learning point: Duloxetine is an effective first-line treatment for neuropathic pain in patients with diabetic neuropathy.