hllj/quesmed huggingface dataset:
A 42-year-old female is admitted to A&E after a road traffic accident. She is found to have a tension pneumothorax and a chest tube must be inserted in the triangle of safety.

Which of the following describes the triangle of safety?

Options:
explanation: This is where the apex of the heart is located, which is made up of the left ventricle, insertion of a chest drain here would have life-threatening consequences.
name: Left Fifth intercostal space at the mid-clavicular line
label: c
answer: no
explanation: This area is the recommended site for an emergency tracheotomy in airway management but is not used for chest drain insertion.
name: Between the cricoid cartilage and sternal notch
label: d
answer: no
explanation: The triangle of safety is used as an anatomical guide for chest drain insertion when managing injuries to the thoracic cavity. These structures form its borders and this location is deemed to pose the least risk of injury to blood vessels, muscle, breast tissue and internal organs.
name: Between the anterior border of the latissimus dorsi, lateral border of the pectoralis major, apex below the axilla, and horizontal level of the nipple
label: a
answer: yes
explanation: This is where the apex of the lungs extends to superiorly. You do not insert a chest drain into the apex of the lung.
name: 3 cm above the medial third of the clavicle
label: e
answer: no
explanation: These structures form the border of the anterior triangle of the neck which houses important anatomical contents of the neck but is not related to chest drain insertion.
name: Between the midline of the neck, the anterior border of the sternocleidomastoid muscle and the inferior border of the mandible
label: b
answer: no

Correct answer: a
A 70-year-old male comes into the hospital with breathlessness and complaining of a cough with purulent sputum. His only known past medical history is a diagnosis of chronic obstructive pulmonary disease (COPD).

Which of the following would be the most likely ABG results in this patient?

Options:
explanation: This ABG shows a case of metabolic acidosis. There is a lowered PaCO2 as a result of respiratory compensation; in addition, the bicarbonate is reduced as the levels of H+ increase. This clinical picture is commonly observed in patients with diabetic ketoacidosis.
name: pH: 7.25 (7.35-7.45); PaCO2: 2.3( 4.5-6.0) kPa; pO2: 13.2 (10-14) kPa; HCO3: 14 (22-26) mmol/L
label: d
answer: no
explanation: This shows a picture of metabolic alkalosis with partial respiratory compensation. This could be caused by excessive vomiting that can result in a loss of H+ ions from the body.
name: pH: 7.49 (7.35-7.45); PaCO2: 6.5 (4.5-6.0) kPa; pO2: 12 (10-14) kPa; HCO3: 30 (22-26) mmol/L
label: c
answer: no
explanation: This ABG shows a picture of acute on chronic respiratory acidosis with type 2 respiratory failure. Given the patient's history of COPD, he is likely to be a chronic retainer of carbon dioxide and has lowered oxygen levels. This has resulted in chronic respiratory acidosis. In addition, the bicarbonate is raised due to partial metabolic compensation.
name: pH: 7.26 (7.35-7.45); PaCO2: 8.9 (4.5-6.0) kPa; pO2: 8.1 (10-14) kPa; HCO3: 32 (22-26) mmol/L
label: a
answer: yes
explanation: This ABG shows an acute respiratory alkalosis which can be caused by hyperventilation. In patients with diagnosed COPD, you would expect carbon dioxide and bicarbonate to be elevated.
name: pH: 7.49 (7.35-7.45); PaCO2: 2.3 (4.5-6.0) kPa; pO2: 11 (10-14) kPa; HCO3: 24 (22-26) mmol/L
label: b
answer: no
explanation: This is a normal ABG and would not be found in a patient with an acute exacerbation of COPD.
name: pH: 7.36 (7.35-7.45); PaCO2: 5.0 (4.5-6.0) kPa; pO2: 13.0 (10-14) kPa; HCO3: 24.5 (22-26) mmol/L
label: e
answer: no

Correct answer: a
A 16-year-old girl presents to her GP complaining of a wheeze and shortness of breath during exercise. She is diagnosed with asthma and prescribed a salbutamol inhaler.

What is the mechanism of action of salbutamol in asthma?

Options:
explanation: Salbutamol is a short-acting beta-2 agonist which is usually the first-line treatment for patients with asthma. It relaxes muscles of the airway leading to dilation and the reduction of breathlessness.
name: Stimulates bronchial smooth muscle Beta-2 receptors
label: a
answer: yes
explanation: This is the mechanism of action of inhaled corticosteroids such as beclomethasone which modify immune responses. These are usually prescribed second-line in addition to salbutamol in patients who remain symptomatic.
name: Binds to glucocorticoid receptors
label: b
answer: no
explanation: These drugs are used for the treatment of chronic obstructive pulmonary disease (COPD) rather than asthma and include ipratropium (short-acting) and tiotropium (long-acting). They have a bronchodilatory effect.
name: Muscarinic Antagonist
label: e
answer: no
explanation: Examples of this class of drugs include Montelukast. This is used in the management of chronic asthma and is prescribed after steroids and Beta-2 agonists have failed to control symptoms.
name: Leukotriene receptor antagonist
label: d
answer: no
explanation: This is the mechanism of action of theophylline and aminophylline which are used in the treatment of severe asthma attacks and chronic persistent asthma. They have both an anti-inflammatory and bronchodilator effect.
name: Phosphodiesterase inhibition
label: c
answer: no

Correct answer: a
Damage to which of the following nerves can result in paralysis of the diaphragm?

Options:
explanation: Provides motor supply to the serratus anterior muscle. Damage to this nerve results in winging of the scapula.
name: Long Thoracic Nerve
label: c
answer: no
explanation: The phrenic nerve consists of C3,4 and 5 ventral rami and provides the sole motor supply to the diaphragm. Remember, C3, 4 and 5 keep the diaphragm alive!
name: Phrenic nerve
label: a
answer: yes
explanation: Supplies motor innervation to the anterior abdominal wall muscles, rectus abdominal muscles and all intercostal muscles.
name: Subcostal nerve
label: e
answer: no
explanation: The accessory nerve is the 11th cranial nerve and supplies motor function to the sternocleidomastoid and trapezius muscles.
name: Accessory Nerve
label: d
answer: no
explanation: The vagus nerve is the 10th cranial nerve and provides parasympathetic supply to all organs of the thorax and abdomen.
name: Vagus nerve
label: b
answer: no

Correct answer: a
A 16-year-old boy presents to A&E with persistent epistaxis.

What arteries make up the anastomosis of the area likely affected?

Options:
explanation: These arteries all anastomose to form Littles Area which is the most common site for epistaxis.
name: Sphenopalatine artery, Anterior ethmoidal artery, inferior ethmoidal artery, branches of the greater palatine artery, branch of the superior labial artery
label: a
answer: yes
explanation: These arteries supply the frontal sinus and are not responsible for epistaxis.
name: Supra-orbital artery and anterior ethmoidal artery
label: c
answer: no
explanation: These arteries form the vascular supply of the trachea and are not responsible for epistaxis.
name: Inferior thyroid artery, bronchial arteries, tracheal branches of the aorta, mediastinal branches of internal thoracic artery
label: b
answer: no
explanation: These arteries are responsible for the blood supply of the larynx, not the nasal septum.
name: Superior and inferior laryngeal arteries
label: d
answer: no
explanation: These arteries make up the vascular supply of the ethmoid sinuses.
name: Anterior and posterior ethmoidal arteries, sphenopalatine arteries
label: e
answer: no

Correct answer: a
A 17-year-old girl is admitted to A&E for an acute asthma attack. She is too breathless to speak. Observations show that she has a heart rate of 115 (<100), a PEFR of 250ml (normal: 600ml) and a PaCO2 of 5.0 kPa (4.7-6.0 kPa).

Which of the following is the most appropriate classification of her asthma attack

Options:
explanation: A moderate asthma attack includes a PEFR of 50-75% best, normal speech, and a pulse of <110. The patient does not meet any of these criteria.
name: Moderate
label: b
answer: no
explanation: In a near-fatal asthma attack, the patient's PaCO2 levels are above the normal range indicating complete exhaustion and CO2 retention. The patient in this question has not yet reached this level.
name: Near-Fatal
label: d
answer: no
explanation: According to the NICE guidelines, asthma attacks are stratified into near-fatal, life-threatening, severe and moderate classifications. Therefore mild is not correct.
name: Mild
label: e
answer: no
explanation: While the heart rate and PEFR fall under the classification of a "severe" attack, the patient's pCO2 is in the normal range indicating that the patient is tired. Thus, it is classified as a life-threatening asthma attack.
name: Life-threatening
label: a
answer: yes
explanation: While the patient has a pulse rate of >110 and a PEFR that is at 41% of her normal baseline which would classify as a severe asthma attack, the normal CO2 levels indicate that this is life-threatening.
name: Severe
label: c
answer: no

Correct answer: a
Which of the following is a feature of idiopathic pulmonary fibrosis?

Options:
explanation: Hilar lymphadenopathy is not a feature of pulmonary fibrosis but rather of sarcoidosis, another interstitial restrictive lung disease.
name: Hilar lymphadenopathy
label: d
answer: no
explanation: Pulmonary fibrosis is characterized by a dry cough rather than a purulent one.
name: Purulent cough
label: c
answer: no
explanation: Idiopathic pulmonary fibrosis usually presents with fine bi-basal end-inspiratory crackles on auscultation.
name: Course bi-basal crackles
label: e
answer: no
explanation: This ratio describes a pattern of obstructive lung disease. Idiopathic pulmonary fibrosis is a restrictive lung disease and therefore FEV1/FVC >0.7.
name: FEV1/FVC <0.7
label: b
answer: no
explanation: Honeycomb lung is a common finding of pulmonary fibrosis on CT. It describes enlarged air spaces with fibrotic walls and is seen in end-stage fibrosis.
name: Honeycomb Lung
label: a
answer: yes

Correct answer: a
A 45-year-old patient presents to his GP complaining of difficulty breathing. A respiratory exam is performed and upon percussion, there is a stony dull resonance at the base of the left lung.

Which of the following is the most likely diagnosis?

Options:
explanation: A common finding in patients with chronic obstructive pulmonary disease, which involves increased air spaces in the lung. Percussion will show hyper-resonance.
name: Emphysema
label: b
answer: no
explanation: A pneumothorax is defined as the presence of air within the pleural space. Percussion will result in hyper-resonance.
name: Pneumothorax
label: d
answer: no
explanation: Pleural effusion is known to cause "stony dullness" upon percussion.
name: Pleural Effusion
label: a
answer: yes
explanation: Typically the patient will have some degree of consolidation on the lung which will lead to dullness on percussion but not stony dullness.
name: Pneumonia
label: c
answer: no
explanation: Asthmatic patients will present with normal resonance upon percussion.
name: Asthma
label: e
answer: no

Correct answer: a
A 12-year-old girl presents to the GP complaining of breathlessness and wheezing during light exercise. She uses her salbutamol inhaler but finds it is not helping.

Which of the following medications should be considered as the next line of management?

Options:
explanation: This is a long-acting Beta-2 agonist and is prescribed once salbutamol and steroids have been trialled.
name: Salmeterol
label: c
answer: no
explanation: This is an inhaled steroid. If short-acting beta-2 agonists are not a sufficient monotherapy in asthma, NICE recommends the addition of a steroid.
name: Beclomethasone
label: a
answer: yes
explanation: This is an anti-mucolytic agent used in the treatment of conditions such as chronic obstructive pulmonary disease, bronchiectasis and cystic fibrosis.
name: Carbocisteine
label: e
answer: no
explanation: This is a short-acting muscarinic antagonist used first-line to treat patients with chronic obstructive pulmonary disease.
name: Ipratropium
label: d
answer: no
explanation: This is a leukotriene receptor antagonist which is prescribed after short-acting and long-acting beta-2 agonists in adjunct with corticosteroids have failed to manage symptoms.
name: Montelukast
label: b
answer: no

Correct answer: a
A 67-year-old man presents to A&E complaining of palpitations. He mentions he has recently been diagnosed with Wolff-Parkinson-White syndrome.

Which of the following ECG findings is classically seen in this condition?

Options:
explanation: This is a classical ECG finding in patients with hypokalemia and describes a small deflection immediately following the T wave.
name: U waves
label: c
answer: no
explanation: Described as a slurring upstroke of the QRS complex. This is indicative of an additional pathway conducting electrical activity between the atria and ventricles.
name: Delta waves
label: a
answer: yes
explanation: Describes alternating QRS complex amplitudes on an ECG. This is found in patients with cardiac tamponade.
name: Electrical alternans
label: e
answer: no
explanation: This is observed in patients who have hyperkalemia.
name: Tall tented T waves
label: b
answer: no
explanation: This is an ECG finding commonly observed in patients with hypothermia.
name: J waves
label: d
answer: no

Correct answer: a
A 60-year-old Caucasian male with type one diabetes presents to his GP for a regular check-up. His recent average ambulatory blood pressure readings were 150/95mmHg. his only regular medication is insulin.

Which of the following is the next best step of management for this patient?

Options:
explanation: This is a calcium channel blocker. This is first line in Afro-Caribbean patients or those who are >55. 
name: Amlodipine
label: b
answer: yes
explanation: This is an angiotensin-converting enzyme (ACE) inhibitor and is the first line according to NICE guidelines for patients who are < 55 or have type 2 diabetes mellitus.
name: Ramipril
label: a
answer: no
explanation: This is an aldosterone antagonist and is prescribed in patients with treatment-resistant hypertension. Patients must have a serum K+ < 4.5 mmol/L as this is a potassium-sparing diuretic.
name: Spironolactone
label: d
answer: no
explanation: This is a thiazide diuretic. This is used as an anti-hypertensive agent in patients where both angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB) and calcium channel blocker therapy fail to lower BP.
name: Indapamide
label: c
answer: no
explanation: This is a beta-blocker which can be prescribed for physical sympathetic symptoms including those seen in anxiety. It is also indicated in treatment-resistant hypertension as an alternative to spironolactone if serum potassium is >4.5 mmol/L.
name: Propranolol
label: e
answer: no

Correct answer: b
A 50-year-old female is on the cardiology ward after a recent diagnosis of tricuspid regurgitation secondary to infective endocarditis.

Where is the best place to auscultate this murmur?

Options:
explanation: This is where needle decompression is performed for the management of tension pneumothorax.
name: 2nd intercostal space mid-clavicular line
label: e
answer: no
explanation: This is the best location to listen to the tricuspid valve.
name: 4th intercostal space left sternal edge
label: a
answer: yes
explanation: This is the location of the apex of the heart. Additionally, this is where the mitral valve can be heard best.
name: 5th intercostal space left mid-clavicular line
label: b
answer: no
explanation: This is where the pulmonary valve is auscultated.
name: 2nd intercostal space left sternal edge
label: c
answer: no
explanation: This is where the aortic valve is auscultated.
name: 2nd intercostal space right sternal edge
label: d
answer: no

Correct answer: a
A 30-year-old male presents to A&E complaining of severe, sudden-onset chest pain radiating to his back. He has no past medical history although he is very tall and has extremely long arms.

Which of the following underlying conditions has predisposed this patient to the most likely diagnosis?

Options:
explanation: This is an inherited blood condition whereby the patient is unable to produce normal haemoglobin. It is not linked to aortic dissection and patients are often diagnosed as children.
name: Thalassemia
label: c
answer: no
explanation: This is an inherited disease that results in damage to peripheral nerves. It is not linked to an increased risk of aortic dissection.
name: Charcot Marie Tooth Disease
label: e
answer: no
explanation: This is an inherited disorder that affects the lungs and digestive tract resulting in increased secretion of thick mucous. It does not increase the risk of aortic dissection.
name: Cystic Fibrosis
label: d
answer: no
explanation: This is a disorder characterized by progressive muscle degeneration and weakness. These patients often lose the ability to walk and have a life expectancy of less than 50 years old. This patient is not showing any evidence of muscle weakness.
name: Duchenne's muscular dystrophy
label: b
answer: no
explanation: This is an inherited connective tissue disorder. Patients often are extremely tall and slim and can have disproportionately long arms, legs and fingers. These patients often have aortic wall abnormalities and are at increased risk of aortic dissection (tear of the aortic wall), which is what the patient is presenting to A&E with.
name: Marfan's syndrome
label: a
answer: yes

Correct answer: a
A 1-year-old infant is placed in a knee-to-chest position on the neonatal ward after suddenly turning blue.

What condition is this infant likely suffering from?

Options:
explanation: Approximately 25% of people have a PFO. It is an opening between the right and left atria and is not considered a congenital heart defect as there is no septal tissue missing and no significant shunting. Rarely it can cause a paradoxical embolic event.
name: Patent foramen ovale
label: c
answer: no
explanation: This is characterized by a hole in the ventricular septum. It can result in blood flow from the left to the right ventricle which can lead to heart failure and stunted growth. It is not linked to profound attacks of cyanosis.
name: Ventricular septal defect
label: b
answer: no
explanation: This is characterized by a constricted aortic segment. Patients can present with diminished femoral pulses and differential blood pressures between the upper and lower extremities. Treatment can be either primary surgical repair or balloon angioplasty.
name: Coarctation of the aorta
label: d
answer: no
explanation: This involves the narrowing of the pulmonary valve. Most children who have this defect only present with a murmur. In severe cases, infants may have signs of heart failure.
name: Pulmonary valve stenosis
label: e
answer: no
explanation: Tetralogy of Fallot is the most common complex congenital heart condition. It consists of 4 defects: pulmonary valve stenosis, a large ventricle septal defect, an overriding aorta and right ventricular hypertrophy. Patients with unrepaired tetralogy of Fallot can experience sudden episodes of cyanosis and hypoxia (tet spell) which is what the infant is presenting with here. This is managed by putting the child into a knee-chest position to increase blood flow to the lungs.
name: Tetralogy of Fallot
label: a
answer: yes

Correct answer: a
A 77-year-old female presents to her GP with symptoms which are consistent with heart failure.

Which of the following clinical presentations would suggest right-sided heart failure?

Options:
explanation: This is a result of pulmonary congestion which occurs as a result of left-sided heart failure.
name: Cough with frothy sputum
label: d
answer: no
explanation: This is described as breathlessness on lying in the recumbent position that is relieved on sitting up. Often patients are breathless at night time. This is a sign of left-sided heart failure.
name: Orthopnoea
label: b
answer: no
explanation: This is often caused by decreased cardiac output and is a sign of left-sided heart failure.
name: Activity intolerance
label: e
answer: no
explanation: A characteristic sign of right heart failure is peripheral oedema. Less blood reaches the lungs and builds up in the systemic circulation resulting in oedema.
name: Peripheral Oedema
label: a
answer: yes
explanation: This indicates decreased tissue perfusion as a result of reduced cardiac output. This is a sign of left-sided heart failure.
name: Peripheral cyanosis
label: c
answer: no

Correct answer: a
Which of the following describes the relationship between stroke volume and end-diastolic volume in heart failure according to the Frank-Starling Law?

Options:
explanation: In heart failure, the ventricular wall is stretched over a favourable point according to the frank-starling mechanism. The actin-myosin overlap becomes ineffective and you actually get a decrease in the force the heart can generate.
name: An increase in ventricular end-diastolic volume results in reduced stroke volume
label: a
answer: yes
explanation: This is incorrect as it is not in line with the Frank-starling law principles.
name: Increased cardiac output with reduced ventricular end-diastolic pressure
label: d
answer: no
explanation: This is the frank starling law under normal physiological conditions. In heart failure, this relationship fails.
name: As ventricular end-diastolic pressure increases, cardiac output increases
label: b
answer: no
explanation: This is incorrect as in heart failure both cardiac output and end-diastolic pressure are affected.
name: Cardiac output and end-diastolic pressure do not change
label: e
answer: no
explanation: In heart failure, while cardiac output is reduced, ventricular end-diastolic volume continues to increase as there is a backlog of blood failing to be pumped around the body. Therefore this answer is incorrect.
name: The ventricular end-diastolic volume reduces along with the cardiac output
label: c
answer: no

Correct answer: a
What percentage of blood circulating the body does the heart receive at rest?

Options:
explanation: This is the percentage of blood that goes to the skin at rest.
name: 9%
label: c
answer: no
explanation: At rest, there is approximately 5000ml/min of blood circulating the body. 4% of this (215ml/min) goes towards the heart.
name: 4%
label: a
answer: yes
explanation: This is the percentage of blood flow that goes to the brain at rest.
name: 13%
label: b
answer: no
explanation: This is the percentage of blood that goes to the abdominal organs at rest.
name: 24%
label: e
answer: no
explanation: This is the percentage of blood that goes to the kidneys at rest.
name: 20%
label: d
answer: no

Correct answer: a
Which of the following complications is a patient with asymptomatic patent foramen ovale at risk of developing?

Options:
explanation: This is when a thrombus crosses an intracardiac defect, in this case, the patent foramen ovale, and goes into the systemic circulation. Often this gets lodged in the brain causing a stroke.
name: Paradoxical embolism
label: a
answer: yes
explanation: This is a type of skin infection and has no connection to having a patent foramen ovale.
name: Cellulitis
label: e
answer: no
explanation: While a severe complication of patent foramen ovale includes a heart attack, this is extremely rare and far less likely to occur than a paradoxical embolus.
name: Myocardial infarction
label: c
answer: no
explanation: This is a sudden and profound episode of cyanosis which is found in infants who have tetralogy of Fallot.
name: Tet spells
label: b
answer: no
explanation: Pneumonia is not a known complication of patent foramen ovale.
name: Pneumonia
label: d
answer: no

Correct answer: a