hllj/quesmed huggingface dataset:
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: 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: 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 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
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

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 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
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 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. 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

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: 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: 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: 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
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

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 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
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 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

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: 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 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: 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
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

Correct answer: a
A 19-year-old female presents to her GP with low mood. She describes experiencing weight gain, particularly around her abdomen, over the last six months despite attempts to loose weight. On examination, you notice weakness in all four proximal limbs, as well as circular hump on the back and a circular-shaped face.

Which of the following investigations would confirm the most likely diagnosis?

Options:
explanation: This patient is presenting with the signs and symptoms of Cushing's syndrome. A fluid deprivation test would be the test of choice for diabetes insipidus. Diabetes insipidus would present with symptoms like excessive thirst and producing large amounts of urine.
name: Fluid deprivation test
label: d
answer: no
explanation: The patient in the question is presenting with with central obesity, proximal weakness, depression and abdominal striae are typical of Cushing’s syndrome. A short synacthen test is the test of choice for adrenal sufficiency, not Cushing’s disease. Adrenal insufficiency would present with symptoms like hypotension, fatigue and weakness, gastrointestinal symptoms, and skin pigmentation.
name: Short synacthen test
label: b
answer: no
explanation: This is a typical presentation of a patient with Cushing's syndrome: low mood, weight gain, proximal myopathy and abdominal striae. Cushing's syndrome can also cause a moon-shaped face, a "buffalo hump" on the back, diabetes mellitus and hypokalaemia. The diagnostic investigation of choice for Cushing’s syndrome is a dexamethasone suppression test.
name: Dexamethasone suppression test
label: a
answer: yes
explanation: This patient is presenting with Cushing's syndrome, and therefore a dexamethasone suppression test would be the diagnostic test of choice. You could conduct a HbA1c if you suspected diabetes mellitus, but the diagnosis of Cushing's Syndrome would be confirmed with a dexamethasone suppression test.
name: HbA1c
label: e
answer: no
explanation: The patient in the question is presenting with with central obesity, proximal weakness, depression and abdominal striae are typical of Cushing’s syndrome. 24-hour plasma metanephrines would be the correct test if you suspected a pheochromocytoma. This would present with episodes of hypertension, anxiety and headaches. Therefore, the correct answer to this question is to conduct a dexamethasone suppression test.
name: 24-hour plasma metanephrines
label: c
answer: no

Correct answer: a
An 18-year-old male is found unconscious by his parents after six hours of nausea and vomiting. His parents tell you he has been complaining of excessive thirst and passing urine more frequently for the last month. When you examine him, you notice a sweet acetone smell to his breath.

Which of the following is included in the diagnostic criteria for diabetic ketoacidosis?

Options:
explanation: Diabetic ketoacidosis requires there to be hyperglycaemia, i.e a blood glucose of 11mmol/L or above.
name: Hyperglycaemia under 11mmol/L
label: d
answer: no
explanation: Diabetic ketoacidosis requires acidosis with a pH of less than 7.3, not more than 7.3. Other criteria include hyperglycaemia (a blood glucose over 11mmol/L) and ketosis (blood ketones above 3mmol/L).
name: pH more than 7.3
label: e
answer: no
explanation: To diagnose diabetic ketoacidosis, there are three criteria. First, there must be hyperglycaemia, i.e a blood glucose above 11mmol/L. Next, there must be blood ketones above 3mmol/L. Finally, there should be acidosis with a pH of less than 7.3.
name: Hyperglycaemia over 11mmol/L
label: a
answer: yes
explanation: To diagnose diabetic ketoacidosis, there are three criteria. First, there must be hyperglycaemia, i.e a blood glucose above 11mmolL, not under 20mmol/L.  Next, there must be blood ketones above 3mmol/L and acidosis with a pH of less than 7.3.
name: Hyperglycaemia under 20mmol/L
label: c
answer: no
explanation: Diabetic ketoacidosis requires the production of blood ketones to be above 3mmol/L, not below.
name: Blood ketones under 3mmol/L
label: b
answer: no

Correct answer: a
A 90-year-old female is brought in to the emergency department after being found unconscious in her home. She does not open her eyes but is making incomprehensible sounds. She flexes to withdraw from pain.

What is her Glasgow Coma Scale score?

Options:
explanation: This patient's GCS is 7, not 4. She scores a 1 as she does not open her eyes, a 2 in verbal response (due to incomprehensible sounds) and a 4 in motor response.
name: 4
label: e
answer: no
explanation: This patient's GCS is 7. She scores a 1 for eye opening response as she does not open her eyes. She is making incomprehensible sounds, scoring a 2 for verbal response. She flexes to withdraw from pain, meaning she scores a 4 in motor response.
name: 7
label: a
answer: yes
explanation: This patient's GCS is 7, not 6. She scores a 1 in eye opening response, a 2 in verbal response (due to incomprehensible sounds) and a 4 in motor response.
name: 6
label: c
answer: no
explanation: This patient's GCS is 7, not 8. She scores a 1 in eye opening response, a 2 in verbal response (due to incomprehensible sounds) and a 4 in motor response.
name: 8
label: b
answer: no
explanation: This patient's GCS is 7, not 5. She scores a 1 in eye opening response, a 2 in verbal response (due to incomprehensible sounds) and a 4 in motor response.
name: 5
label: d
answer: no

Correct answer: a
You are called to see a 17-year-old girl who has been having a seizure for nine minutes. She has been given two doses of IV lorazepam, but her seizures have not stopped.

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

Options:
explanation: This patient remains in status epilepticus despite two doses of IV lorazepam. Therefore, she requires a second-line treatment in the form of phenytoin.
name: Phenytoin
label: a
answer: yes
explanation: This patient is in status epilepticus and has already had two doses of lorazepam. This patient therefore requires a second-line treatment in the form of phenytoin.
name: A further dose of lorazepam
label: b
answer: no
explanation: This patient requires a second-line drug for treatment of her status epilepticus. Sodium valproate would not be an appropriate drug to give in this scenario. This is for stabilising patients with epilepsy, not for use in the acute phase.
name: Sodium valproate
label: d
answer: no
explanation: Midazolam can be given instead of lorazepam in the initial treatment of status epilepticus. It is usually given if there is no intravenous access as it can be given via the buccal route.
name: Midazolam
label: c
answer: no
explanation: Diazepam can be given instead of lorazepam in the initial treatment of status epilepticus. It is usually given if there is no intravenous access as it can be given rectally.
name: Diazepam
label: e
answer: no

Correct answer: a
A 40-year-old male presents to his GP with yellowing of his eyes. The GP conducts a thorough abdominal examination in which he notes a palpable gallbladder. The patient does not complain of any pain.

Which of the following is the most likely diagnosis?

Options:
explanation: Gastric cancer would present with symptoms such as persistent reflux, bloating and weight loss. This patient is more likely to be suffering from pancreatic cancer.
name: Gastric Cancer
label: d
answer: no
explanation: Colorectal cancer would be an important diagnosis to exclude if the patient was over 60 and reported a change in bowel habit. However, this patient's symptoms are more suggestive of pancreatic cancer, so this would be the most important diagnosis to exclude.
name: Colorectal Cancer
label: b
answer: no
explanation: Pancreatic cancer would be the most important diagnosis to exclude in this case. It presents with the classic symptoms of painless jaundice and a palpable gallbladder.
name: Pancreatic cancer
label: a
answer: yes
explanation: You would expect Gilbert’s syndrome to cause intermitted jaundice in relation to stress, infection or exercise. It would not account for the palpable gallbladder and therefore is not the most likely diagnosis in this case.
name: Gilbert's syndrome
label: e
answer: no
explanation: You would expect pancreatitis to present with symptoms like epigastric pain radiating to the back, pain relived by sitting forward and associated symptoms like nausea and vomiting. Bloods may show an extremely high amylase level. This patient does not present with any pain, nausea or vomiting. Therefore, acute pancreatitis is not a likely diagnosis. This patient's symptoms are more likely to be due to pancreatic cancer.
name: Acute pancreatitis
label: c
answer: no

Correct answer: a
A 55-year-old man attends his GP with constipation and tiredness. He also reports gaining some weight recently and feeling low in mood. His thyroid function tests show a high thyroid-stimulating hormone (TSH) and low T4.

Which of the following drugs is most likely to have caused this presentation?

Options:
explanation: Omeprazole is not a cause of hypothyroidism. The most likely drug that has caused this patients symptoms is amiodarone.
name: Omeprazole
label: e
answer: no
explanation: This patient's symptoms are most likely to be caused by amiodarone. An important side effect of carbamazepine is agranulocytosis.
name: Carbamazepine
label: c
answer: no
explanation: Bisoprolol is not the most likely drug to have caused this patient's presentation. Amiodarone is most likely to be the cause of this patients symptoms as their symptoms are are suggestive of hypothyroidism. Bisoprolol can cause symptoms such as bradycardia, diarrhoea and erectile dysfunction.
name: Bisoprolol
label: d
answer: no
explanation: Amiodarone is most likely to be the cause of this patients symptoms as they are suggestive of hypothyroidism. Amiodarone can also less commonly cause patients to present with hyperthyroidism.
name: Amiodarone
label: a
answer: yes
explanation: Simvastatin is not the most likely cause of this patients symptoms. The most likely cause of this patients hypothyroidism is amiodarone. Simvastatin can cause symptoms such as arthralgia and muscle pain.
name: Simvastatin
label: b
answer: no

Correct answer: a
An 80-year-old male presents to the emergency department with central crushing chest pain. An ECG shows ST elevation in leads II,III and aVF.

Which coronary artery is the most likely site of occlusion?

Options:
explanation: An occlusion in the left circumflex artery would cause changes in leads I and aVL.
name: Left circumflex artery
label: c
answer: no
explanation: The proximal left anterior descending artery would cause changed in leads V1-6 as well as leads I and AVL. The ECG changes in this question correlate to the right coronary artery.
name: Proximal left anterior descending artery
label: e
answer: no
explanation: The ECG changes described represent an occlusion in the right coronary artery, not the right marginal artery.
name: Right marginal artery
label: d
answer: no
explanation: An occlusion in the left anterior descending artery would cause changes in leads V1-V4.
name: Left anterior descending artery
label: b
answer: no
explanation: An occlusion in the right coronary artery correspond to leads II,III and aVF. These leads represent the inferior region of the heart.
name: Right coronary artery
label: a
answer: yes

Correct answer: a
A 23-year-old female presents to her GP with a one-month history of tiredness and weight loss. On closer inspection, you notice her skin looks bronze in colour.  Her blood tests results show low sodium and high potassium levels.

Which of the following is the most likely diagnosis?

Options:
explanation: Cushing's disease would present with symptoms such as depression, proximal myopathy and central obesity. Furthermore, Cushing's disease would show a hypokalaemia, rather than hyperkalaemia. The patient in this question is more likely to have Addison's disease.
name: Cushing's disease
label: b
answer: no
explanation: This patient is presenting with the typical signs and symptoms of Addison's disease: fatigue, weakness, weight loss, bronze skin pigmentation, and low sodium and high potassium on blood results.
name: Addison's disease
label: a
answer: yes
explanation: Pheochromocytoma usually presents as episodes of hypertension, anxiety, palpitations headaches, as well as signs like tremor and hypertensive retinopathy.
name: Pheochromocytoma
label: d
answer: no
explanation: Diabetes insipidus usually presents with producing large volumes of dilute urine, nocturia and excessive thirst.
name: Diabetes Insipidus
label: c
answer: no
explanation: This patient is presenting with the typical signs and symptoms of Addison's disease: fatigue, weakness, weight loss and bronze skin pigmentation. Blood tests also show a low sodium and high potassium which is typical of Addison's disease.
name: Anxiety
label: e
answer: no

Correct answer: a
A 25-year-old male presents to the emergency department with right upper quadrant pain for the last six hours. On further questioning, he tells you his urine has looked quite dark and his stools are pale. You notice yellowing of the eyes. On examination, he looks jaundice and has a temperature of 37.4 degree Celsius.

Which of the following is the most likely diagnosis?

Options:
explanation: Yellow fever usually presents with a sudden onset fever, followed by a headache, muscle aches, vomiting and tiredness. This patient's symptoms fit more with a diagnosis of hepatitis.
name: Yellow fever
label: e
answer: no
explanation: Infective endocarditis usually presents with a new heart murmur, fever, tachycardia and specific nail signs like splinter haemorrhages. This patient is more likely to have hepatitis given the position of his abdominal pain, his jaundice, and pale stools and dark urine.
name: Infective endocarditis
label: d
answer: no
explanation: This patient is presenting with classic symptoms of hepatitis: right upper quadrant pain, jaundice, dark urine and pale stools. Hepatitis A is the most common type of hepatitis in the world, but is quite rare in the UK.
name: Hepatitis A
label: a
answer: yes
explanation: Malaria would be accompanied with symptoms such as fevers, headache, muscle aches and tiredness. This patient has more specific symptoms of right upper quadrant pain and jaundice which fits better with a diagnosis of hepatitis.
name: Malaria
label: c
answer: no
explanation: Coeliac Disease is a possible differential for a presentation of abdominal pain and weight loss. However, this patient has a typical presentation of hepatitis with right upper quadrant pain, jaundice, pale stools and dark urine.
name: Coeliac Disease
label: b
answer: no

Correct answer: a