hllj/quesmed huggingface dataset:
A 62-year-old woman presents to the Accident and Emergency department with a sudden onset of palpitations 6 hours earlier. In the department, her ECG shows atrial fibrillation at a rate of 95 beats per minute. She has a past medical history of asthma, and had an NHS Health Check the day before, where she was noted to be in sinus rhythm.

Which of the following is the most suitable next step in the management of this patient?

Options:
explanation: Anticoagulation is indicated if her CHA<sub>2</sub>DS<sub>2</sub>-VASc score is 2 or more. She only has a score of 1 for being female
name: Long term anticoagulation
label: c
answer: no
explanation: We can be fairly certain that this woman's onset of atrial fibrillation is less than 48 hours, and since she's presented to an acute medical unit, DC cardioversion would be the most appropriate management. Factors favouring rhythm control over rate control in this case include being symptomatic, the first presentation of atrial fibrillation, and her age. She may require anticoagulation prior to cardioversion.

Had this patient presented to the GP, management in primary care could also be considered, depending on patient preferences and clinical judgement
name: Direct current (DC) cardioversion
label: a
answer: yes
explanation: Bisoprolol may be used to rate control atrial fibrillation (AF). However, as this is her first presentation of AF, she is young and symptomatic, and she has presented to the emergency department, rhythm control would be more favourable in the first instance.

In primary care, rate control may be initiated rather than cardioversion, depending on patient preference and clinical judgement
name: Bisoprolol
label: e
answer: no
explanation: TOEs may sometimes be used to exclude a left atrial appendage thrombus before cardioversion if the onset of AF was more than 48 hours prior to the planned cardioversion, as an alternative to anticoagulation
name: Transoesophageal Echocardiogram (TOE)
label: b
answer: no
explanation: Digoxin may be used second line for rate control of atrial fibrillation if a beta blocker or rate limiting calcium channel blocker is not sufficient in the first instance
name: Digoxin
label: d
answer: no

Correct answer: a


Learning point: In acute atrial fibrillation onset within 48 hours, direct current (DC) cardioversion is often the preferred management approach to quickly restore normal sinus rhythm and reduce the risk of complications.
An 18 year old man attends to his GP with chest pain and shortness of breath on exertion. He has no significant past medical history. An ECG is performed:

[lightgallery]

Which of the following is the most likely to account for the ECG findings?

Options:
explanation: There is no indication of ST-elevation on this ECG. A STEMI will cause ST elevation acutely, but it is important to note that the ECG changes will evolve over time
name: ST-elevation myocardial infarction (STEMI)
label: b
answer: no
explanation: Acute pericarditis is associated with global concave ST elevation and PR depression, which is not seen on this ECG
name: Acute pericarditis
label: c
answer: no
explanation: This ECG shows left ventricular hypertrophy (increased amplitude of the QRS complex, particularly noticeable in V1-V4) and non-specific T-wave inversion. In an otherwise young, healthy person, the most likely cause of left ventricular hypertrophy is HCM. This would also explain his symptoms of chest pain and shortness of breath on exertion. He should be referred for an urgent cardiology review for consideration of an implantable cardioverter-defibrillator (ICD)
name: Hypertrophic cardiomyopathy (HCM)
label: a
answer: yes
explanation: Hyperkalaemia is classically associated with "tall tented T waves" on an ECG, which are not seen on this ECG
name: Hyperkalaemia
label: d
answer: no
explanation: RBBB is associated with a QRS duration of >120ms and an RSR' pattern in V1-V3 ("M-shaped" as in "WiLLiaM MaRRoW"), which is not seen on this ECG
name: Right bundle branch block (RBBB)
label: e
answer: no

Correct answer: a


Learning point: Hypertrophic obstructive cardiomyopathy (HOCM) often presents on ECG with left ventricular hypertrophy (increased amplitude of the QRS complex, especially in leads V1-V4) and non-specific T-wave inversion, indicating the presence of abnormal heart muscle.
A 52-year-old Polish man is brought to the accident and emergency department by ambulance. He speaks no English, but he points to his chest to suggest that he is in pain. Blood tests have not yet returned. His ECG is as follows:

[lightgallery]

Which of the following is the most likely cause for this man's presentation?

Options:
explanation: Unstable angina does not produce ST elevation on an ECG. Much like NSTEMI, unstable angina can produce ECG changes such as ST-segment depression and T wave flattening or inversion. Unstable angina can be differentiated from NSTEMIs as unstable angina does not cause a rise in cardiac enzymes 8-12 after the onset of symptoms
name: Unstable angina
label: c
answer: no
explanation: An NSTEMI, by definition, does not produce ST elevation on an ECG. ECG changes in an NSTEMI include ST-segment depression and T wave flattening or inversion, and can be differentiated from unstable angina by raised cardiac enzymes 8-12 after the onset of symptoms
name: Non-ST elevation myocardial infarction (NSTEMI)
label: b
answer: no
explanation: GORD will not produce ECG changes, however, does manifest as burning chest pain
name: Gastro-oesophageal reflux disease (GORD)
label: d
answer: no
explanation: Musculoskeletal chest pain will not produce ECG changes
name: Musculoskeletal chest pain
label: e
answer: no
explanation: The ECG demonstrates ST elevation (>0.1mV) in the inferior leads (II, III and aVF) as well as reciprocal depression in the anterior leads. Central crushing chest pain is the classical symptom associated with a STEMI
name: ST-elevation myocardial infarction (STEMI)
label: a
answer: yes

Correct answer: a


Learning point: ST-elevation myocardial infarction (STEMI) typically presents with central crushing chest pain and ST elevation in specific ECG leads.
A medical emergency call is put out for a 70-year-old female patient on a medical ward. Ventricular tachycardia (VT) is present on her ECG. She is haemodynamically stable. On examination, she is well perfused, has a GCS of 15, and has pitting oedema to her knees bilaterally.

She was admitted to hospital three days prior for an exacerbation of heart failure and was being treated with intravenous furosemide.

Which of the following treatments is most appropriate to manage VT in this patient?

Options:
explanation: Flecainide can be used to treat VT, but is not as effective as amiodarone
name: Flecainide
label: d
answer: no
explanation: According to NICE guidelines, amiodarone is the preferred drug to manage VT
name: Amiodarone
label: a
answer: yes
explanation: Although this patient does have signs of heart failure (an "adverse feature"), this is chronic and long standing and doesn't appear to be secondary to her arrhythmia. Therefore, cardioversion is not indicated in this instance
name: Direct current (DC) cardioversion: one shock only
label: b
answer: no
explanation: Her heart failure is chronic and not secondary to her arrhythmia so this is not an indication for cardioversion. She has no other indications for cardioversion such as shock, syncope or myocardial ischaemia. If she did have any of these symptoms then up to 3 synchronised DC shocks can be given in attempt to cardiovert
name: Direct current (DC) cardioversion: up to 3 shocks
label: c
answer: no
explanation: IV furosemide would not treat this patient's ventricular tachycardia
name: Bolus of IV furosemide
label: e
answer: no

Correct answer: a


Learning point: Amiodarone is the first-line treatment for stable ventricular tachycardia in patients with heart failure.
A 75-year-old man is brought to the emergency department by ambulance with a collapse. He reportedly lost consciousness with no pre-syncopal symptoms, was unconscious for approximately 20 seconds, and regained consciousness quickly. He reports this has happened twice in the last few weeks. Part of the rhythm strip from his ECG performed by the ambulance service may be seen below.

[lightgallery]

Which of the following is the most suitable treatment for this patient?

Options:
explanation: This is the management for hyperkalaemia. There are no signs of hyperkalaemia on this ECG
name: Insulin and dextrose infusion
label: b
answer: no
explanation: As this patient is symptomatic, he should have treatment. Patients with 2:1 heart block who are asymptomatic will not necessarily need treatment
name: Watch and wait
label: e
answer: no
explanation: The ECG shows a 2:1 heart block (second degree atrioventricular block). As this patient is symptomatic, he may benefit from the placement of a temporary or permanent pacemaker
name: Cardiac pacemaker
label: a
answer: yes
explanation: There is no indication for DC cardioversion in second degree atrioventricular block
name: Direct current (DC) cardioversion
label: c
answer: no
explanation: This is the management for rate control in atrial fibrillation. The ECG demonstrates that the patient is in 2:1 atrioventricular block
name: Bisoprolol
label: d
answer: no

Correct answer: a
An 80 year old female is admitted to hospital with heart failure. Her ECG demonstrates sinus rhythm with wide QRS complexes of approximately 190ms. Her blood pressure is 130/85 mmHg, her heart rate is 78 bpm.

Which of the following is indicated in this patient?

Options:
explanation: There is no indication that this patient has an arrhythmia, angina or hypertension which are the indications for verapamil. In fact, you should avoid calcium channel blockers in heart failure as they are negatively inotropic so can further exacerbate heart failure by reducing cardiac function
name: Verapamil
label: d
answer: no
explanation: There are no indications for ibuprofen in this patient and, in fact, non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in heart failure
name: Ibuprofen
label: e
answer: no
explanation: Implantation of a cardiac resynchronisation therapy (CRT) device is indicated in patients with heart failure and a wide QRS complex on their ECG
name: Implantation of a cardiac resynchronisation therapy (CRT) pacemaker device
label: a
answer: yes
explanation: There is no indication that this patient is she haemodynamically unstable and requires cardioversion
name: Synchronised Direct current (DC) cardioversion
label: b
answer: no
explanation: There is no indication that this patient has an arrhythmia which is what amiodarone is used to treat
name: Amiodarone
label: c
answer: no

Correct answer: a


Learning point: Cardiac resynchronisation therapy (CRT) is beneficial for heart failure patients with wide QRS complexes to improve cardiac function and symptoms.
A 33-year-old woman presents to the out of hours general practitioner with a tender, fluctuant mass in her left breast, with associated erythema of the overlying skin. She is currently breast feeding. A breast abscess is confirmed on ultrasound and percutaneous drainage is performed uneventfully.

Her observations are as follows:

Pulse 80 beats per minute

Respiratory rate 17 breaths per minute

Blood pressure 115/75mmHg

Temperature 37.2°

She looks otherwise well, and is alert and orientated. Her renal function and liver function is within normal limits and she has an allergy to penicillin

Which of the following is the most appropriate antibiotic therapy?

Options:
explanation: She is haemodynamically stable and apyrexial and therefore intravenous antibiotics are not indicated at this point
name: IV erythromycin
label: d
answer: no
explanation: This patient has a known penicillin allergy and therefore flucloxacillin is contraindicated
name: Oral flucloxacillin
label: b
answer: no
explanation: This patient has a known penicillin allergy and therefore co-amoxiclav is contraindicated
name: IV co-amoxiclav
label: e
answer: no
explanation: This patient has a known penicillin allergy and therefore flucloxacillin is contraindicated
name: IV flucloxacillin
label: c
answer: no
explanation: As a penicillin allergic patient, this is the most appropriate antibiotic. As she is haemodynamically stable and apyrexial, oral antibiotics are appropriate
name: Oral erythromycin
label: a
answer: yes

Correct answer: a


Learning point: In breastfeeding women with a breast abscess, oral erythromycin is a suitable antibiotic choice for those allergic to penicillin.
A 70-year-old female is referred to the breast clinic with a left breast lump. A biopsy is obtained which shows a ductal carcinoma which is oestrogen receptor (ER) positive, HER2 negative, and progestogen receptor (PR) negative.

Which of the following medical therapies is indicated for the management of this patient's breast cancer?

Options:
explanation: Trastuzumab (Herceptin) is only useful in HER2 positive breast cancers
name: Trastuzumab
label: d
answer: no
explanation: This is a hormone therapy (LHRH agonist) used in the treatment of prostate cancer
name: Goserelin
label: e
answer: no
explanation: This is not a treatment for breast cancer. In fact, HRT can increase a patient's risk of breast cancer
name: Hormone replacement therapy (HRT)
label: c
answer: no
explanation: This is correct. Anastrozole is an aromatase inhibitor which is used for ER positive breast cancer in post-menopausal women
name: Anastrozole
label: a
answer: yes
explanation: Tamoxifen is indicated in pre- and peri-menopausal women with ER-positive breast cancer not previously treated with tamoxifen
name: Tamoxifen
label: b
answer: no

Correct answer: a


Learning point: Anastrozole is an aromatase inhibitor indicated for the treatment of oestrogen receptor-positive breast cancer in post-menopausal women.
An inpatient being treated for an acute kidney injury (AKI) has their potassium level returned at 6.2 mmol/L (normal range 3.5-5.3 mmol/L). The day before it had been 5.9 mmol/L. There are no hyperkalaemic changes on the ECG.


They are being managed with intravenous (IV) 0.9% NaCl at 100ml/hr. They feel well and have no symptoms to report.


What is the best next step for this patient?

Options:
explanation: Hyperkalaemia is defined as serum potassium concentration >5.5mmol/L, and can be further categorised as mild (5.5-5.9 mmol/l), moderate (6.0-6.4 mmol/l) or severe (≥ 6.5 mmol/l).

Moderate or severe hyperkalaemia, or any hyperkalaemia with ECG changes should be treated with insulin/dextrose or insulin/glucose infusion, particularly if the patient is systemically unwell (e.g. with an AKI). Insulin promotes potassium to shift into cells and the dextrose is to counteract the hypoglycaemic effects of insulin.

According to the UK Kidney Association Guidelines, Calcium Gluconate should only be given if (1) there is severe hyperkalaemia >6.5 mmol/l irregardless of ECG changes or (2) there is mild to moderate (5.5-6.5 mmol/l) hyperkalaemia in the presences of ECG changes.


name: Insulin and dextrose infusion
label: a
answer: yes
explanation: Dialysis is considered for some patients with refractory hyperkalaemia where other less invasive treatments have failed
name: Dialysis
label: e
answer: no
explanation: According to the UK Kidney Association Guidelines, Calcium Gluconate should only be given if (1) there is severe hyperkalaemia >6.5 mmol/l irregardless of ECG changes or (2) there is mild to moderate (5.5-6.5 mmol/l) hyperkalaemia in the presences of ECG changes.
name: Calcium gluconate
label: b
answer: no
explanation: This would not directly treat the hyperkalaemia and if sustained over a long period may risk overloading the patient
name: Increase rate of 0.9% NaCl to 500ml/hr
label: d
answer: no
explanation: According to the latest Renal guidelines, a moderate hyperkalaemia should be treated with insulin/dextrose or insulin/glucose infusion, particularly if the patient is systemically unwell (e.g. with an AKI), to prevent further deterioration
name: Continue current treatment
label: c
answer: no

Correct answer: a
A 60-year-old lady presents to the emergency department with confusion. She has the following blood tests:


||||
|---------------------------|:-------:|--------------------|
|Sodium|136 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|300 µmol/L|60 - 120|
|eGFR|15 mL/min/1.73m<sup>2</sup>|> 60|


Her previous blood tests from 2 months ago suggest that her baseline creatinine is approximately 70umol/L.


There is no information on the computer system about her medications but you find the following medications in her bag: trimethoprim, nitrofurantoin, bisoprolol, ramipril, and atorvastatin.


Which of the following medications would lead to a falsely low estimated glomerular filtration rate (eGFR)?

Options:
explanation: Trimethoprim inhibits tubular creatinine secretion, leading to an increase in serum creatinine independent of the true glomerular filtration rate (GFR). This leads to a falsely low eGFR as creatinine concentration is used in the calculation of GFR
name: Trimethoprim
label: a
answer: yes
explanation: Nitrofurantoin is not a nephrotoxic itself and will not cause an increase in serum creatinine, however, it is contraindicated in those with renal impairment due to reduced renal elimination of the antibiotic in these patients
name: Nitrofurantoin
label: b
answer: no
explanation: Statins may cause rhabdomyolysis which leads to an increased creatinine level but this would be due to a **true** decrease in glomerular filtration rate
name: Atorvastatin
label: e
answer: no
explanation: Ramipril is an ACE inhibitor which is a nephrotoxic. It may cause an increase in serum creatinine but this is because of a **true** decrease in glomerular filtration rate
name: Ramipril
label: d
answer: no
explanation: Bisoprolol is not a nephrotoxic and has no effect on serum creatinine
name: Bisoprolol
label: c
answer: no

Correct answer: a


Learning point: Trimethoprim can falsely lower estimated glomerular filtration rate (eGFR) by inhibiting tubular creatinine secretion, affecting serum creatinine levels.
A 73-year-old man is being investigated for hyponatraemia (serum Na 129 mmol/L; normal range 135-145 mmol/L) which was found on routine blood tests.


Which of the following results would be diagnostic of syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Options:
explanation: Patients with SIADH are usually euvolaemic or hypervolaemic. Clinical dehydration suggests other causes for hyponatraemia such as secondary to diuretics or acute kidney injury
name: Clinical dehydration
label: e
answer: no
explanation: A low serum cortisol and hyponatraemia suggests Addison's disease
name: Low serum cortisol
label: c
answer: no
explanation: In SIADH there are high levels of antidiuretic hormone (ADH) in the blood. This leads to increased retention of water, but not sodium. There is therefore low levels of salt in the blood and therefore low plasma osmolality. Urine produced is more concentrated (as less water is excreted) and has more sodium, leading to a high urine osmolality and high urine sodium level. Urine osmolality greater than plasma osmolality can only be induced by inappropriately high levels of ADH in the bloodstream
name: Urine osmolality greater than plasma osmolality
label: a
answer: yes
explanation: Hypothyroidism is one of the potential causes for SIADH and so TFTs should be checked when investigating for SIADH. However, whether TFTs are normal or abnormal has no bearing on the diagnosis of SIADH
name: Normal thyroid function tests (TFTs)
label: d
answer: no
explanation: In SIADH, due to increased water retention secondary to the high levels of ADH, concentrated urine with high sodium levels is produced (high urine osmolality). As excessive sodium is being excreted and water is excessively retained, plasma sodium is low and plasma osmolality is high. Therefore, by definition, urine osmolality will be greater than plasma osmolality
name: Plasma osmolality greater than urine osmolality
label: b
answer: no

Correct answer: a
A 40-year-old man presents to the accident and emergency department with a painful rash which has established quickly over the last few hours. He is pyrexial and reports general arthralgia. He was started on a course of amoxicillin for sinusitis the preceding day. He has no significant past medical or dermatological history.

His rash can be seen below.

[lightgallery]

Which of the following is the most likely diagnosis in this patient?

Options:
explanation: This is an autoimmune condition causing blistering urticarial lesions. This can sometimes have mucosal involvement. It is not drug induced, as this question is implying is the cause of this man's rash. It does not normally produce systemic symptoms
name: Bullous Pemphigoid
label: b
answer: no
explanation: Pyoderma gangrenosum usually manifests as a painful pustule or nodule with rapid progression. There is normally just one nodule, and is usually on the lower limbs. There is no mucosal involvement. It can sometimes be accompanied by fever and systemic symptoms
name: Pyoderma gangrenosum
label: c
answer: no
explanation: Stevens-Johnson syndrome typically produces a maculopapular rash with target lesions. There is normally mucosal involvement, as can be seen in the image above. Stevens-Johnson syndrome is usually drug-induced. This will require a hospital admission for treatment
name: Stevens-Johnson syndrome
label: a
answer: yes
explanation: SCC would not establish over such a short time frame
name: Squamous cell carcinoma (SCC) of the skin
label: d
answer: no
explanation: Eczema herpeticum is a disseminated infection of a herpes virus that produces itchy blisters or punched-out erosions. It is normally seen in children with eczema. It can be accompanied by systemic symptoms such as fever
name: Eczema herpeticum
label: e
answer: no

Correct answer: a


Learning point: Stevens-Johnson syndrome is a severe drug-induced condition characterised by a maculopapular rash, often with mucosal involvement, requiring urgent medical attention.
A patient presents with blistering of the skin. Bullous pemphigoid is suspected. Direct immunofluorescence is carried out and detects IgG and C3 in a linear pattern.

In what location would the IgG and C3 be located to confirm a diagnosis of bullous pemphigoid?

Options:
explanation: The glomerular basement membrane is the kidneys - there will be IgG/C3 deposition in glomerulonephritis (eg. post-infectious)
name: The glomerular basement membrane
label: d
answer: no
explanation: Immunofluorescence will detect IgG and/or C3 on the epithelial cell surface in pemphigus vulgaris
name: Epithelial cell surface
label: b
answer: no
explanation: IgG staining in intercellular space is seen in all types of pemphigus (except IgA pemphigus)
name: Intercellular space
label: c
answer: no
explanation: Bullous disorders  affect the epidermal layer and basement membrane rather than the dermis
name: The dermis
label: e
answer: no
explanation: This is correct. Bullous pemphigoid is an autoimmune condition caused by antibodies against hemidesmosome proteins in the epithelial basement membrane
name: The epidermal basement membrane
label: a
answer: yes

Correct answer: a


Learning point: In bullous pemphigoid, IgG and C3 are located at the epidermal basement membrane, indicating an autoimmune response against hemidesmosome proteins.