hllj/quesmed huggingface dataset:
A 72-year-old man presents to the GP with 3 months of general fatigue, malaise, and night sweats.


Bloods reveal the following:


||||
|--------------|:-------:|---------------|
|Haemoglobin|78  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.3x10<sup>9</sup>/L|3.0 - 10.0|
|Neutrophils|3.1x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|8.2x10<sup>9</sup>/L|1.5 - 4.0|


Peripheral blood film shows smudge cells and small mature lymphocytes with round nuclei and clumped chromatin.


Given the likely diagnosis, which of the following is the next best investigation?

Options:
explanation: This patient most likely has chronic lymphocytic leukaemia. Immunophenotyping detects tumour markers in peripheral blood by labelling the white blood cells with antibodies directed against cell surface proteins. This allows for differentiation of leukaemic cells to show which specific type of leukaemia the patient has and so which treatment would be most appropriate
name: Immunophenotyping
label: a
answer: yes
explanation: Chronic lymphocytic leukaemia can be subcategorised using immunophenotyping and flow cytometry from peripheral blood. Therefore, evaluation of bone marrow biopsy is not usually necessary unless there is diagnostic doubt from the former tests
name: Bone marrow biopsy
label: c
answer: no
explanation: Iron studies are commonly used to investigate the cause of anaemia and will likely be done in this patient as they are anaemic, but it is not the next best investigation for their leukaemia
name: Iron studies
label: e
answer: no
explanation: Chronic lymphocytic leukaemia can be subcategorised using immunophenotyping and flow cytometry from peripheral blood. Evaluation of lymph node biopsy is not usually necessary unless there is diagnostic doubt from the former tests
name: Lymph node biopsy
label: b
answer: no
explanation: Serum electrophoresis is commonly used to investigate multiple myeloma or monoclonal gammopathy of uncertain significance (MGUS). While chronic lymphocytic leukaemia may produce IgM paraproteinaemia, it is not routinely used in its diagnosis
name: Serum electrophoresis
label: d
answer: no

Correct answer: a


Learning point: Immunophenotyping in chronic lymphocytic leukemia (CLL) is a diagnostic process that uses flow cytometry to identify specific cell surface markers, such as CD5, CD19, CD20, and CD23, to confirm the presence of clonal B-cell populations and distinguish CLL from other lymphoid disorders.
A 12-year-old boy is brought to the GP by his father for 12 months of recurrent vandalism, frequent theft of other children's property, repeated episodes of lying to his teachers, and has started smoking. His son does not feel his behaviour is problematic. He often becomes "uncontrollable" at home breaking dishes and furniture with no guilt or remorse in harming others.

He has no history of mental health problems and there is no indication of an underlying mental health disorder. He does not have any developmental disorders or learning disabilities.

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

Options:
explanation: Methylphenidate is not recommended in conduct disorder but is occasionally used in attention deficit hyperactive disorder (ADHD) to control challenging behaviour
name: Start methylphenidate
label: c
answer: no
explanation: This would be appropriate if the child had a co-existing mental health problem, a neurodevelopmental condition, or learning disability, or if there was any indication of underlying mental health disorder
name: Refer to Child and Adolescent Mental Health Services (CAMHS)
label: b
answer: no
explanation: This child is exhibiting behaviour typical of conduct disorder. Child-focused programmes are usually offered to children aged 9-14 with conduct disorder, involving group social and cognitive behavioural problem-solving exercises with rehearsal and feedback to improve behaviour
name: Refer to child-focused programmes
label: a
answer: yes
explanation: In parent training programmes, parenting skills are improved by using modelling, rehearsing, and feedback. Parent training is usually focused on children younger than 11 years old and so would unlikely be suggested in this scenario
name: Refer the father to parent training programmes
label: e
answer: no
explanation: A health and social care assessment assesses what help and support can be provided at home, such as disability equipment and adaptations to the home, organising respite, and arrangements for parenting classes. In this case, there is no information suggesting they require functional adaptations to their home. Parent training is usually focused on children younger than 11 years old and so would unlikely be suggested in this scenario
name: Refer for a health and social care assessment by social services
label: d
answer: no

Correct answer: a


Learning point: Children with conduct disorder should be reffered to child-focused programmes that utilise cognitive behavioural strategies to improve social skills and behaviour.
A 75 year old man presents to the emergency department (ED) after a sudden collapse at home. This was preceded by a four hour history of feeling clammy and nauseous. He has a past medical history of type 2 diabetes and hypertension. He also has a body mass index (BMI) of 38.

Observations show: HR 112 bpm, RR 20 bpm, SpO2 92% on air, BP 88/74 mmHg and temperature of 37.6.

What is the most likely cause of the patient's symptoms?

Options:
explanation: This patient has multiple risk factors for MI, including diabetes, hypertension and obesity. Diaphoresis (sweating) and nausea are both important symptoms to recognise as potential indicators of cardiac pathology. They can also present with shortness of breath as the primary symptom. In addition, older male patients are the most likely demographic to experience MI without chest pain
name: Myocardial infarction (MI)
label: a
answer: yes
explanation: DKA occurs more often in type 1 diabetes compared with type 2, however, some patients with type 2 diabetes are ketone producing. It would be unlikely for ketoacidosis to cause collapse without first experiencing notable vomiting, confusion or drowsiness, none of which are mentioned in the stem
name: Diabetic ketoacidosis (DKA)
label: e
answer: no
explanation: A TIA is characterised by sudden onset neurological deficit that usually lasts for minutes to hours, but resolves within 24 hours. A TIA could be an explanation for a patient presenting following a collapse. However, it is not classically preceded by an extended period of symptoms from other systems, such as nausea and sweating
name: Transient ischaemic attack (TIA)
label: c
answer: no
explanation: This patient does have a risk factor for pulmonary embolism in his obesity, but his risk profile for a MI is greater. In addition, there are no other identifiable triggers for pulmonary embolism in the history, such as recent long distance travel or immobility
name: Pulmonary embolism
label: b
answer: no
explanation: It is always important to consider arrhythmia as a potential cause of collapse. However, there is no mention of preceding palpitations, shortness of breath or pre-syncopal episodes. Given the diaphoresis, nausea and risk factors for MI, this would be a more likely explanation
name: Arrhythmia
label: d
answer: no

Correct answer: a
A 91 year old woman presents to the general practice (GP) with shortness of breath and peripheral oedema to the mid-thighs which has been worsening for the past month. The shortness of breath is worse on exertion and when lying flat - as a result she reports often waking up very breathless in the night and having to sleep propped up on 4 pillows, where previously she only used 2. She is a heavy smoker with a 70 pack year history and has a past medical history of myocardial infarction 10 years previously.

What is the most likely cause of this acute breathlessness?

Options:
explanation: Shortness of breath, which is worse when lying flat, and peripheral oedema are two of the hallmarks of heart failure. Patients often describe increasing their number of pillows to combat this, as well as the sensation of waking up from sleep with breathlessness (paroxysmal nocturnal dyspnoea). In addition, the patients history of previous myocardial infarction, along with her ago, puts her at increased risk of developing heart failure
name: Heart failure
label: a
answer: yes
explanation: This patient is a heavy smoker may well have undiagnosed COPD, but it does not appear to be the cause of her **acute** breathlessness. In acute COPD you would expect the patient to be wheezy and they may have a chronic cough - symptoms would also be expected to come on gradually over many years, rather than quickly over the course of 1 month
name: Chronic Obstructive Pulmonary Disease (COPD)
label: b
answer: no
explanation: There are no infective symptoms, such as fever or cough productive of purulent sputum, to suggest pneumonia
name: Pneumonia
label: c
answer: no
explanation: The patient is a heavy smoker which does increase the risk of bronchial carcinoma, however there are no other signs to point in this direction, such as haemoptysis, chronic cough or weight loss
name: Lung cancer
label: d
answer: no
explanation: ILD can cause gradually progressive shortness of breath on exertion, but this is classically more slow in its progression and is not strongly associated with fluid overload
name: Interstitial lung disease (ILD)
label: e
answer: no

Correct answer: a
A 30 year old man has a cardiac arrest whilst playing rugby and is brought into the emergency department (ED) by ambulance. Cardiopulmonary resuscitation (CPR) is ongoing and it is time for a rhythm check.

Which rhythm can be identified on this ECG trace?

[lightgallery]

Options:
explanation: SVT, by definition, originates from _above_ the ventricles - as a result, it is a **narrow** complex tachycardia - conduction in the ventricles is by the usual mechanism
name: Supraventricular tachycardia (SVT)
label: c
answer: no
explanation: Polymorphic ventricular tachycardia (otherwise known as _torsades de pointes_) has a characteristic twisting of the QRS complexes around the baseline, compared to monomorphic VT in which each complex is very homogenous to the next
name: Polymorphic ventricular tachycardia
label: e
answer: no
explanation: Though VF is a broad complex tachycardia, this rhythm is too regular in morphology to represent VF. VF is caused by chaotic and uncoordinated electrical activity in the ventricles and as such produces an irregular rhythm with broad QRS complexes of differing amplitudes
name: Ventricular fibrillation (VF)
label: b
answer: no
explanation: ECG findings in monomorphic VT show wide QRS complexes at a rate of ≥100bpm. This rhythm originates in the ventricles, meaning no P waves are present (indicating the absence of atrial conduction) and often runs very fast, with no discernible ST segment or T wave. If VT occurs without a pulse, it is a shockable rhythm in the resuscitation. If VT occurs with a pulse, this is a peri-arrest rhythm and requires urgent assessment and treatment to stabilise the patient
name: Monomorphic ventricular tachycardia (VT)
label: a
answer: yes
explanation: At this time in the stem it is not certain if the patient has a pulse; therefore we could not name any ECG trace accurately as PEA
name: Pulseless electrical activity (PEA)
label: d
answer: no

Correct answer: a
A 60 year old man presents to the emergency department (ED) following an episode of collapse. He reports lots of similar attacks in recent months.

An electrocardiogram (ECG) is performed, which shows P waves that are completely dissociated from the QRS complexes, with a ventricular rate of 47 beats per minute.

What is the definitive treatment for this patient's arrhythmia?

Options:
explanation: This ECG is describing complete or third degree heart block which can cause severe and symptomatic bradycardia. In patients with heart block that are severely symptomatic, or with the more dangerous forms of heart block that threaten to progress to ventricular standstill (second degree type 2 and complete/third degree) treatment with a PPM is needed. This device provides the "pace" for the ventricles, which the atria are not providing
name: Permanent pacemaker (PPM)
label: a
answer: yes
explanation: Bisoprolol is a rate controlling agent used in the management of tachycardias, and is also used in patients with heart failure and post-myocardial infarction where it confers prognostic benefit
name: Bisoprolol
label: d
answer: no
explanation: Amiodarone is a drug used for cardioversion most commonly used in the management of tachyarrhythmias. It does not have a role in treatment of complete heart block or other bradycardias
name: Amiodarone
label: b
answer: no
explanation: Atropine acts to block the effects of the parasympathetic nervous system on the heart, increasing heart rate. It is used acutely in patients who are unstable with a bradyarrhythmia, however it is not a definitive solution and the patient will need a PPM to sustain their heart rate longer term
name: Atropine
label: e
answer: no
explanation: Transcutaneous pacing involves using a manual defibrillator to capture and conduct the heart's electrical rhythm to sustain adequate cardiac output in patients with severe bradycardia. This may be required in the short term to stabilise the patient until a PPM can be sited. It is not a long term, definitive treatment
name: Transcutaneous pacing
label: c
answer: no

Correct answer: a
A 71 year old woman presents to the GP with central chest pain on exertion, alleviated within 5 minutes of resting. This is associated with significant shortness of breath.

She has a past medical history of type 2 diabetes and hypercholesterolaemia.

What would be the best, first line investigation to perform?

Options:
explanation: Referring a patient for an echocardiogram without first doing an ECG would not be a sensible use of resources. Many patients do undergo echocardiography during their work up for ischaemic heart disease, but this would not be a first line test. It would take much longer to access the test and get the result - so is less helpful in assessing the patient in the short term
name: Echocardiogram
label: b
answer: no
explanation: An invasive angiogram is performed in circumstances where initial investigations suggest coronary artery disease, and where therapeutic action (e.g. stenting) is suspected to be needed. As with any invasive procedure, it has risks associated with it and is therefore not used for initial investigation/diagnostic purposes
name: Invasive coronary angiography
label: c
answer: no
explanation: An ECG is the most appropriate first investigation to perform in any patient who is suspected of having ischaemic heart disease. It is particularly important in primary care, as it can identify if there is any ongoing ischaemia that requires urgent assessment in the hospital setting, or whether this can be investigated further as an outpatient
name: Electrocardiogram (ECG)
label: a
answer: yes
explanation: A CTPA would be performed if there was a high suspicion of pulmonary embolism. This may present with chest pain more pleuritic in nature, and shortness of breath, rather than central chest pain which is classically more cardiac in nature
name: Computed tomography pulmonary angiography (CTPA)
label: e
answer: no
explanation: Performing a full blood count is reasonable and would likely be done. Some patients can have ischaemia due to a deficiency in myocardial oxygen supply that is not due to atherothrombotic disease, and instead may be precipitated by a low haemoglobin (i.e. a type 2 myocardial infarction). However, performing a full blood count is a significantly less specific investigation in the context of this patients symptoms
name: Full blood count
label: d
answer: no

Correct answer: a
A 79 year old man with no prior history of heart disease is examined by his GP. They note an ejection systolic murmur, heard loudest in the aortic region.

What is the most likely cause of this murmur?

Options:
explanation: HOCM is classically a disease of the young. It does cause an ejection systolic murmur similar in quality to aortic stenosis, but it would be rare for a patient with significant HOCM to survive to 79 years of age without diagnosis and intervention
name: Hypertrophic obstructive cardiomyopathy (HOCM)
label: c
answer: no
explanation: Aortic regurgitation is an early diastolic murmur that may become pan systolic as the regurgitation becomes more severe. It is heard loudest at the left sternal edge (representing the direction of regurgitant blood flow from the faulty valve)
name: Aortic regurgitation
label: b
answer: no
explanation: Pulmonary stenosis is a much rarer cause of an ejection systolic murmur, particularly in adults (most commonly caused by congenital heart disease and identified early on). It is also heard best in the pulmonary, rather than aortic region
name: Pulmonary stenosis
label: d
answer: no
explanation: Aortic stenosis is the cause of most valvular heart disease in the developed world and most commonly presents in those above 70 years of age. It occurs with age as the aortic valve becomes calcified, and is related to the usual cardiovascular risk factors of smoking, hypercholesterolaemia, obesity, diabetes and hypertension. In addition, congenital bicuspid valves are more prone to becoming stenosed at an earlier age - these patients may present in their 50's, or sometimes even younger
name: Aortic stenosis
label: a
answer: yes
explanation: Mitral regurgitation is a pan systolic murmur which is sometimes described as "blowing" in character. It is also heard loudest at the apex
name: Mitral regurgitation
label: e
answer: no

Correct answer: a
A 29 year old man presents to the emergency department (ED) with palpitations and vomiting. His ECG shows supraventricular tachycardia (SVT) at a rate of 170 beats per minute. The patient is stable with no adverse features.

What is the first line treatment for this patient?

Options:
explanation: Flecainide is classically used to cardiovert patients who have acutely gone into atrial fibrillation. It has an emerging role in the management of SVT; however would still not be used before attempting vagal manoeuvres. It is contraindicated if there is known structural heart disease
name: Flecainide
label: c
answer: no
explanation: The first line treatment that should be attempted in patients with SVT to cardiovert back to sinus rhythm is vagal manoeuvres. These include the Valsalva manoeuvre (in practice, this is often getting the patient to blow into a closed syringe) or carotid massage
name: Vagal manoeuvres
label: a
answer: yes
explanation: Amiodarone is another pharmacological agent that can produce cardioversion. It would be given to patients who become unstable (ie. show adverse features) with their tachycardia. Adverse features include evidence of heart failure, myocardial ischaemia, shock or syncope
name: Amiodarone
label: d
answer: no
explanation: Adenosine 6mg IV is the first line pharmacological agent for cardioversion and would be the next course of action to consider if vagal manoeuvres were not successful
name: Adenosine
label: b
answer: no
explanation: Atropine is used in the acute management of bradycardia, not tachycardia, and would not be recommended for use in acute SVT
name: Atropine
label: e
answer: no

Correct answer: a
A 39 year old woman collapses in the corridor of the cardiology ward. It is safe to approach and a nearby doctor goes to her aid.

From the options below, what is the next most appropriate action for the doctor to perform?

Options:
explanation: Once establishing if the patient is conscious/rousable, an assessment of airway would be the next priority
name: Check the patient's airway
label: e
answer: no
explanation: After assessing for any airway compromise, an unconscious patient should be assessed for evidence of a pulse and respiratory effort to establish if they are in cardiac or respiratory arrest. This requires early identification so that appropriate management - with CPR or assisted ventilation - can be commenced. However you would first check for a response from the patient
name: Look, listen and feel for a central pulse and respiratory effort for a minimum of 10 seconds
label: d
answer: no
explanation: The patient may be in cardiac arrest - but this has not yet been identified. Chest compressions should be started as soon as possible following the identification of cardiac arrest
name: Start cardiopulmonary resuscitation (CPR)
label: b
answer: no
explanation: In any emergency situation, you should follow your DR ABC (danger, response, airway, breathing, circulation) approach. Ascertaining if the patient is conscious/rousable is the first step in the assessment
name: Try to elicit a response from the patient
label: a
answer: yes
explanation: Simply putting the patient in the recovery position would not be an appropriate thing for the doctor to do given their level of training in assessing acutely unwell patients
name: Put the patient in the recovery position
label: c
answer: no

Correct answer: a
A 33 year old man presents to the GP complaining of chest tightness and a nocturnal cough. He is diagnosed with asthma.

What is the first line inhaled agent used for relief of symptoms in asthma?

Options:
explanation: Montelukast (a leukotriene receptor antagonist) is not a first line agent in asthma management. Additionally, it is a tablet, rather than an inhaled drug
name: Montelukast
label: e
answer: no
explanation: Corticosteroid inhalers are "**preventer**" inhalers; they take some time to have an effect. They act by reducing inflammation in the airways, which worsens airway obstruction
name: Corticosteroids
label: d
answer: no
explanation: Short acting muscarinic antagonists play a more significant role in the management of chronic obstructive pulmonary disease (COPD), rather than asthma
name: Short acting muscarinic antagonist
label: b
answer: no
explanation: Long-acting beta<sub>2</sub> agonists are typically used more for the prevention of asthma symptoms and are sometimes used in combination devices alongside inhaled corticosteroids
name: Long-acting beta<sub>2</sub> agonist
label: c
answer: no
explanation: Inhaled short acting beta<sub>2</sub> agonists are "**relievers**" – these agents work quickly to relax smooth muscle in the airways and produce a bronchodilator effect, resulting in rapid relief of symptoms
name: Short-acting beta<sub>2</sub> agonist
label: a
answer: yes

Correct answer: a