hllj/quesmed huggingface dataset:
A 45-year-old male found to have a QRESEARCH cardiovasclar risk algorithm (QRISK) score that is over 10%. His GP recommends he begins a medication called atorvastatin.

Which of the following correctly descibes the mechanism of action of statins?

Options:
explanation: Antibiotics like metronidazole work by damaging DNA. Statins do not work in this way, but instead by inhibiting HMG-CoA reductase.
name: Damage DNA
label: e
answer: no
explanation: This is the correct answer. Statins inhibit HMG-CoA reductase which, in turn, reduces the amount of cholesterol made by the liver (and also helps the liver remove cholesterol that has already been formed and deposited in the blood).
name: Inhibit HMG-CoA reductase
label: a
answer: yes
explanation: This is the mechanism of action of warfarin, not statins. Statins inhibit HMG-CoA reductase, which reduces the amount of cholesterol in the blood.
name: Inhibit vitamin K epoxide reductase complex 1
label: b
answer: no
explanation: Antibiotics like macrolides and tetracycline work to inhibit protein synthesis. Statins instead work by inhibiting HMG-CoA reductase.
name: Inhibit protein synthesis
label: d
answer: no
explanation: This is the mechanism of action of sulphonamides and trimethoprim. Statins do not work in this way, but instead by inhibiting HMG-CoA reductase.
name: Inhibit folic acid formation
label: c
answer: no

Correct answer: a
Which is the first immunoglobulin to be secreted in repsonse to infection?

Options:
explanation: This immunoglobin is the only type that is able to pass into the foetal circulation. IgG is also involved in phagocytosis of bacteria and viruses, and is the most abundant type of immunoglobulin found in the blood serum. However, the first immunoglobulin to be secreted in infection is IgM.
name: IgG
label: b
answer: no
explanation: The defining feature of IgM is that it is the first immunoglobulin to be secreted in response to infection. It is secreted as a pentamer.
name: IgM
label: a
answer: yes
explanation: The role of IgD is less clear than that of the other antibodies. It is possible that it enhances the response of the other classes of antibodies, or helps to block viral replication. It is not the first immunoglobulin to be secreted in infection, this is IgM.
name: IgD
label: e
answer: no
explanation: IgA is the most predominant immunoglobulin found in breast milk. It can also be found in secretions of the digestive, respiratory and urogenital systems. The other main role of IgA is to provided protection on cell mucus membranes. It is not the first immunoglobulin to be secreted in infection, this is IgM.
name: IgA
label: c
answer: no
explanation: IgE is associated with Type 1 Hypersensitivity reactions. It is synthesized by plasma cells and provides immunity to parasites such as helminths. It is not the first immunoglobulin to be secreted in infection, this is IgM.
name: IgE
label: d
answer: no

Correct answer: a
A 71-year-old male attends his GP to receive the results for his routine blood test. His medications include furosemide, metformin, propranolol, ramipril and nicorandil. His potassium levels are found to be 6.0mmol/L (normal range 3.5-5.3 mmol/L).

Which of the following medications is likely to be the biggest contributor to his hyperkalaemia?

Options:
explanation: Ramipril can cause high potassium levels as it blocks the aldosterone pathway, and therefore leads to more potassium being retained in the body. Hyperkalaemia is defined as a serum potassium of higher than 5.5mmol/L.
name: Ramipril
label: a
answer: yes
explanation: Furosemide is a loop diuretic that works by inhibiting the Na-K-Cl co-transporter in the loop of Henle- in the kidney. This means that furosemide causes hypokalaemia, rather than hyperkalaemia.
name: Furosemide
label: b
answer: no
explanation: Metformin is not a direct cause of hyperkalaemia.  Instead, this high potassium level is more likely to be caused by use of an angiotensin-converting enzyme (ACE) inhibitor.
name: Metformin
label: c
answer: no
explanation: Nicorandil is a vasodilatory drug used used in the treatment of angina. It does not cause hyperkalemia but can, however, have a range of other side effects including headaches, flushing and skin ulceration.
name: Nicorandil
label: d
answer: no
explanation: Beta blockers can cause a number of side effects including bronchospasm, insomnia and erectile dysfunction. They do not, however, cause hyperkalemia.
name: Propranolol
label: e
answer: no

Correct answer: a
A nine-year-old male attends his GP with recurrent haemarthroses. He undergoes multiple blood tests, which reveal low levels of factor VIII.

Which of the following is the most likely diagnosis?

Options:
explanation: Acute myeloid leukaemia would present with symptoms such as weight loss, frequent infections, tiredness and shortness of breath. This question is more typical of a presentation of haemophilia.
name: Acute myeloid leukaemia
label: e
answer: no
explanation: This is a typical description of a patient with haemophilia A. Haemophilia A can vary in severity, but typically presents with bleeding into soft tissues, muscles and joints. It is diagnosed with a factor VIII assay and genetic testing. It is caused by deficiency of clotting factor VIII, an important part of the intrinsic component of the coagulation cascade.
name: Haemophilia A
label: a
answer: yes
explanation: Alexander's disease is a rare genetic bleeding disorder, which would show a deficiency in factor VII, not factor VIII. Alexander's disease presents with easy bruising, frequent nosebleeds and prolonged bleeding after physical injury. It does not commonly present with haemarthroses.
name: Alexander's disease
label: c
answer: no
explanation: Acute lymphoid leukaemia does occur in children, and can present with increased bleeding. It is an important diagnosis to rule out. However, it would not explain the low levels of Factor VIII. It would also be likely to present with other symptoms such as pallor, frequent infections, weight loss and fatigue.
name: Acute lymphoid leukaemia
label: d
answer: no
explanation: Haemophilia B would show a deficiency in clotting factor IX, not clotting factor VIII.
name: Haemophilia B
label: b
answer: no

Correct answer: a
A 58-year-old man is started on a new medication for hypertension by his GP. Eight days later, he returns to his GP complaining of a dry cough.

Which of the following medications is the patient most likely to have been started on?

Options:
explanation: This patient's dry cough is most likely to be caused by starting an ACE inhibitor, rather than an angiotensin II receptor antagonist (ARB) such as losartan.
name: Losartan
label: e
answer: no
explanation: This patient's dry cough is most likely to be caused by starting an ACE inhibitor, rather than beginning Indapamide. Indapamide can cause patients to become constipated, cause hyperuricaemia or, in rare cases, agranulocytosis.
name: Indapamide
label: c
answer: no
explanation: This patient's dry cough is most likely to have been caused by starting an angiotensin-converting enzyme (ACE) inhibitor such as Ramipril. When an ACE inhibitor is not tolerated in the treatment of hypertension, patients are offers an angiotensin II receptor blocker (ARB) instead.
name: Ramipril
label: a
answer: yes
explanation: This patient's dry cough is most likely to be caused by starting an ACE inhibitor such as ramipril, rather than spironolactone.
name: Spironolactone
label: b
answer: no
explanation: This patient's dry cough is most likely to be caused by starting an ACE inhibitor, not a calcium channel blocker like amlodipine. Calcium channel blockers can have a range of side effects, including abdominal pain, peripheral oedema or gingival hyperplasia.
name: Amlodipine
label: d
answer: no

Correct answer: a
A 33-year-old female presents to A+E with shortness of breath that began four hours ago. She also reports having chest pain that is worse breathing in and has brought up some small flecks of bright red blood when coughing. She has recently returned from a two-week holiday in Australia. On examination, she has a heart rate of 120 and respiratory rate of 18. Her oxygen saturations are 90%. She has a temperature of 38.0.

Which of the following is the most appropriate initial investigation?

Options:
explanation: The most likely diagnosis in this woman is pulmonary embolism. This is due to the classic triad of symptoms: sudden onset shortness of breath, pleuritic chest pain and haemoptysis. Her observations of tachycardia and tachypnoea further confirm this diagnosis. The best initial investigation for this woman would be a CT pulmonary angiogram, which would likely show a filling defect in the pulmonary vasculature.
name: CT pulmonary angiogram
label: a
answer: yes
explanation: This patient is presenting with a pulmonary embolism after a long flight (one of the risk factors for a pulmonary embolism). The best initial investigation for this woman would be a CT pulmonary angiogram.
name: Blood pressure
label: e
answer: no
explanation: The most likely diagnosis in this woman in pulmonary embolism. The best initial investigation for this woman would be a CT pulmonary angiogram.
name: Doppler ultrasound
label: b
answer: no
explanation: This would be the best initial investigation for a pulmonary embolism if the patient had renal impairment, a contrast allergy or was pregnant. The question mentions none of these criteria, so the best initial investigation for this woman would be a CT pulmonary angiogram.
name: V/Q scan
label: c
answer: no
explanation: An echocardiogram can be a useful investigation if you want to check for signs of right heart strain or hypotension in patients with high-risk pulmonary embolisms. However, the best initial investigation in this woman’s case would be to conduct a CT pulmonary angiogram.
name: Echocardiogram
label: d
answer: no

Correct answer: a
A 23-year-old female presents to A&E with a non-productive cough and fever for five days. She is diagnosed with a lower respiratory tract infection. Blood results show low sodium levels and deranged liver function tests (LFTs).

Given the likely diagnosis, which of the following is the most likely causative organism?

Options:
explanation: *Legionella pneumoniae* presents with fevers, muscle pain, shortness of breath, and a dry cough. It causes low sodium levels and deranged LFTs on blood results.
name: *Legionella pneumoniae*
label: a
answer: yes
explanation: *Streptococcus pneumoniae* is one of the most common causes of community-acquired pneumonia so is a good differential. However, the low sodium and deranged LFTs here are indicative of a legionella pneumonia.
name: *Streptococcus pneumoniae*
label: e
answer: no
explanation: *Pneumocystis jirovecii* usually presents as a lower respiratory tract infection in patients who are immunosuppressed e.g. those who are HIV-positive and have a CD4 count is under 200 cells/uL. This patient is most likely to have an infection caused by *legionella pneumoniae* given their blood results.
name: *Pneumocystis jirovecii*
label: d
answer: no
explanation: *Mycoplasma pneumoniae* would typically appear present with flu-like symptoms and a possible rash. It also has the potential to cause autoimmune haemolytic anaemia. This patient is most likely to have an infection caused by *legionella pneumoniae* given their blood results.
name: *Mycoplasma pneumoniae*
label: b
answer: no
explanation: *Klebsiella pneumoniae* usually affects patients with weakened immune systems, which includes elderly patients and those with diabetes. It is also a common cause of aspiration pneumonia so may be seen in patients with risk factors for aspiration, such as alcoholics. The patient would usually describe having  ‘’red currant’’ sputum.
name: *Klebsiella pneumoniae*
label: c
answer: no

Correct answer: a
A 23-year-old female attends the emergency department complaining of palpations for the last 15 minutes. She describes feeling dizzy and lightheaded. An ECG is conducted which shows a narrow complex tachycardia with a rate of 150bpm.

Which of the following is the most appropriate initial management for this patient?

Options:
explanation: Adenosine is a treatment option used to terminate episodes of SVT. However, vagal manoeuvres such as the valsalva manoeuvre should be attempted before adenosine is given.
name: Adenosine
label: b
answer: no
explanation: In rare cases, a pacemaker can be inserted to prevent recurrent episodes of SVT. However, in this case it would first be appropriate to attempt vagal manoeuvres to try to terminate this patients SVT.
name: Pacemaker
label: e
answer: no
explanation: This patient is currently experiencing an epiosde of supraventricular tachycardia (SVT). The first-line treatment for SVT is to conduct vagal manoeuvres, such as the valsalva manoeuvre where a patient can close their mouth, clamp their nose shut and exhale. Another example of a vagal manoeuvre in this stage would be carotid artery massage.
name: Valsalva manoeuvre
label: a
answer: yes
explanation: Verapamil is a treatment option used to terminate episodes of SVT. However, vagal manoeuvres such as the valsalva manoeuvre should be attempted before adenosine is given.
name: Verapamil
label: c
answer: no
explanation: Catheter ablation of an accessory pathway is a treatment option to terminate episodes of SVT. However, vagal manoeuvres such as the valsalva manoeuvre should be attempted before adenosine is given.
name: Catheter ablation of an accessory pathway
label: d
answer: no

Correct answer: a
A 64-year-old female presents to the GP for a blood pressure review. She is currently taking amlodipine 10mg once a day. She is of African-Caribbean origin. Her blood pressure reading comes back as 151/96.

What is the most appropriate next step in management?

Options:
explanation: Lifestyle modifications always play a part in the management of hypertension. However, this patient has consistently high blood pressure despite taking amlodipine so lifestyle modifications alone would not be enough. This patient requires the addition of another treatment to control their blood pressure.
name: Advise lifestyle modifications
label: d
answer: no
explanation: This patient's blood pressure has remained above 140/90 despite treatment with amlodipine. Therefore, she requires the addition of a second medication to control her blood pressure.
name: Continue with current regime
label: e
answer: no
explanation: This patient is currently taking the maximum dose of amlodipine and therefore you cannot increase the dose further. This patient therefore requires the addition of another agent to control their blood pressure. In this case, NICE guidelines suggest the addition of an ARB such as losartan.
name: Increase dose of amlodipine
label: b
answer: no
explanation: Spironolactone is a potassium-sparing diuretic that can be used in management of hypertension through its effects on the renin-angiotensin-aldosterone system (RAAS). However, it is not used before a calcium channel blocker and an ACE inhibitor or ARB have been tried together.
name: Spironolactone
label: c
answer: no
explanation: This patient requires a second-line treatment to control their blood pressure. As she is already taking a calcium channel blocker (amlodipine), she should be given an angiotensin receptor blocker (ARB). ARBs are the preferred choice over angiotensin-converting enzyme (ACE) inhibitors for patients of African-Caribbean origin.
name: Add in losartan
label: a
answer: yes

Correct answer: a
A 60-year-old male presents to the emergency department with chest pain. He describes the pain as 'tearing' and radiating to his back. He has a past medical history of hypertension and Marfan's syndrome. On observation, his heart rate is 89, blood pressure 116/79 and oxygen saturations 93%.

Which investigation will confirm the most likely diagnosis?

Options:
explanation: This patient is presenting with symptoms of an aortic dissection- chest pain described as 'tearing' radiating to the back. He also has a background of hypertension and Marfan's syndrome (two important risk factors). Therefore, this patient requires a CT angiogram to confirm this diagnosis.
name: CT angiogram
label: a
answer: yes
explanation: This patient is most likely to be having an aortic dissection. A chest X-ray can be useful in ruling out other causes of his chest pain, but the definitive diagnostic investigation is a CT angiogram.
name: Chest X-ray
label: c
answer: no
explanation: This patient is most likely to be having an aortic dissection. The definitive diagnostic investigation for an aortic dissection is a CT angiogram.
name: Blood pressure
label: d
answer: no
explanation: This patient is most likely to be having an aortic dissection. An ECG can be useful in ruling out other causes of his chest pain, but the definitive diagnostic investigation is a CT angiogram.
name: ECG
label: b
answer: no
explanation: This patient is most likely to be having an aortic dissection. The definitive diagnostic investigation for an aortic dissection is a CT angiogram.
name: CT head
label: e
answer: no

Correct answer: a
You are called to conduct a cardiology examination on an 89-year-old female on the cardiology ward. On examination, you hear a pansystolic murmur at the fifth intercostal space in the mid -clavicular line.

Which of the following is the most likely cause of her murmur?

Options:
explanation: Tricuspid regurgitation would also present as a pan-systolic murmur. However, this type of murmur would be found at the left sternal border of the fifth intercostal space, rather than in the mid-clavicular line. Therefore, the murmur in this question is most likely to be mitral regurgitation.
name: Tricuspid regurgitation
label: b
answer: no
explanation: Pulmonary stenosis is an ejection systolic murmur that is heard at the left sternal border of the second intercostal space. This is a pan-systolic murmur heard best in the fifth intercostal space at the mid-clavicular line, and is therefore more likely to be mitral regurgitation.
name: Pulmonary stenosis
label: d
answer: no
explanation: Hypertrophic obstructive cardiomyopathy would produce an ejection-systolic murmur, rather than a pan-systolic murmur. It would be heard best at the fourth intercostal space on the left sternal border.
name: Hypertrophic obstructive cardiomyopathy
label: e
answer: no
explanation: Aortic stenosis is an ejection systolic murmur, rather than a pan-systolic murmur. It is heard best in the second intercostal space at the right sternal border. The patient in this question is therefore most likely to have mitral regurgitation.
name: Aortic stenosis
label: c
answer: no
explanation: Mitral Regurgitation is a pan-systolic murmur heard best in the fifth intercostal space at the mid-clavicular line.
name: Mitral Regurgitation
label: a
answer: yes

Correct answer: a
A 70-year-old male presents to his GP complaining of episodes of central crushing chest pain. On further questioning, you find that he has had five episodes similar to this in the past last week, and the pain begins on exertion and is always relieved by rest.

Which of the following is the most likely diagnosis?

Options:
explanation: This patient describes episodes of chest pain that begins on exertion and is always relieved by rest.  This is most likely a presentation of stable angina. NSTEMIs would present with additional symptoms like pain radiating to the jaw, nausea and vomiting and shortness of breath.
name: Non-ST-elevation myocardial infarction (NSTEMI)
label: e
answer: no
explanation: This patient describes episodes of chest pain that begins on exertion and is always relieved by rest.  This is most likely a presentation of stable angina.
name: Anxiety
label: d
answer: no
explanation: Patients with unstable angina would experience symptoms when at rest. Symptoms of this would not be relieved by rest and occur at random. Therefore, this presentation is most likely to be caused by stable angina.
name: Unstable angina
label: b
answer: no
explanation: This patient describes episodes of chest pain that begins on exertion and is always relieved by rest.  This is most likely a presentation of stable angina. STEMI's would present with additional symptoms like pain radiating to the jaw, nausea and vomiting and shortness of breath.
name: ST elevation myocardial infarction (STEMI)
label: c
answer: no
explanation: This patient describes episodes of cardiac-type chest pain that begins on exertion and is always relieved by rest. This is a description of stable angina.
name: Stable Angina
label: a
answer: yes

Correct answer: a
A 40-year-old female presents to the emergency department with palpations for ten hours. An  ECG shows complete dissociation between P waves and QRS complexes with a rate of 46.

What is the most likely diagnosis?

Options:
explanation: First-degree heart block would present on an ECG as a PR interval over 200ms. This ECG shows complete dissociation between P waves and QRS which is typical of third-degree heart block.
name: First-degree heart block
label: d
answer: no
explanation: This patient's ECG is typical of third-degree heart block, not a STEMI. A STEMI would show an elevated ST segment in a regional pattern on the ECG.
name: ST-elevation myocardial infarction (STEMI)
label: e
answer: no
explanation: Mobitz type II heart block is a type of second-degree heart block where there is intermittent non-conducted P waves while the PR interval remains the same. This patient's ECG describes third-degree heart block. Third-degree heart block is classically described as complete dissociation between P waves and QRS complexes.
name: Second-degree heart block Mobitz type II
label: c
answer: no
explanation: Mobitz type I heart block is a type of second-degree heart block commonly caused by a conduction system failure at the His-Purkinje system. An ECG will show increasingly prolonging PR intervals until there is a non-conducted P wave. The PR interval is longest just before the dropped beat, and then the cycle repeats again.
name: Second-degree heart block Mobitz type I
label: b
answer: no
explanation: This patient's ECG describes third-degree heart block. Third degree heart block is classically described as complete dissociation between P waves and QRS complexes.
name: Third-degree heart block
label: a
answer: yes

Correct answer: a