hllj/quesmed huggingface dataset:
A 65-year-old man presents to his GP with symptoms of fatigue and orthopnea. On examination, S3 is present and there is a holosystolic (pansystolic) murmur, heard best at the apex with the diaphragm of the stethoscope when the patient is in the left lateral decubitus position.

Which of the following is the most likely diagnosis?

Options:
explanation: This is a rare condition often caused by pulmonary hypertension or infective endocarditis. It is usually asymptomatic. The murmur of pulmonary regurgitation is an early decrescendo murmur heard loudest over the left sternal edge during inspiration.
name: Pulmonary regurgitation
label: e
answer: no
explanation: The murmur described is the classic examination finding of mitral regurgitation. Patients may also present with dyspnoea (usually on exertion), lower limb oedema, palpitations, and/or decreased exercise tolerance. First-line investigations would be an ECG and transthoracic echocardiogram.
name: Mitral regurgitation
label: a
answer: yes
explanation: Mitral stenosis is usually caused by rheumatic valvulitis. There is often a history of rheumatic fever, but other symptoms do include dyspnoea and orthopnoea. On examination, a loud S1 is heard with a low-pitched, rumbling, mid-diastolic murmur, loudest over the apex.
name: Mitral stenosis
label: b
answer: no
explanation: Often caused by calcification of the aortic valve, aortic stenosis is characterised by an ejection systolic murmur heard loudest over the aortic area. The murmur may radiate to the carotid arteries and is typically loudest on expiration and when the patient is sitting forwards.
name: Aortic stenosis
label: d
answer: no
explanation: Aortic regurgitation is the diastolic leakage of blood from the aorta into the left ventricle. It has a typical decrescendo early diastolic murmur, heard loudest at the left sternal edge. Other examination features include a collapsing pulse or displaced hyperdynamic apex beat.
name: Aortic regurgitation
label: c
answer: no

Correct answer: a
A 45-year-old male is reviewed in the infectious diseases ward. He is a known intravenous drug user and has been injecting heroin daily for the last five years. He reports feeling feverish and having extreme malaise over the last 5 days. On examination, he has numerous splinter haemorrhages and janeway lesions on his hands. The rest of his examination is unremarkable, and he has no audible murmur.

Which of the following is the most appropriate first-line diagnostic investigation?

Options:
explanation: The most likely diagnosis here is infective endocarditis. Intravenous drug use is a risk factor for this. Splinter haemorrhages and janeway lesions are cardinal signs too. First-line imaging investigation in endocarditis is transthoracic echo and it should be performed as soon the diagnosis of endocarditis is suspected. It is required as part of the major Duke criteria for diagnosis. Vegetation, abscess, partial dehiscence of prosthetic valve or new valvular regurgitation may be identified. Transoesophageal echocardiogram has a higher sensitivity of 90% but is much more invasive and often not available as promptly as required.
name: Transthoracic echocardiogram
label: a
answer: yes
explanation: This test should be performed at admission and throughout to check for new changes but again does not form part of the diagnostic Duke criteria and is therefore not as appropriate as an echocardiogram. A new AV block is suggestive of abscess formation.
name: Resting 12-lead ECG
label: d
answer: no
explanation: This is a scan which images the pulmonary arteries, often reserved to diagnose or exclude pulmonary emboli - an unlikely diagnosis here.
name: CT Pulmonary Angiogram
label: e
answer: no
explanation: Chest x-ray does not form part of the diagnostic Duke criteria and is therefore not as appropriate as an echocardiogram. A chest x-ray in infective endocarditis may show evidence of heart failure and cardiomegaly in extreme cases though. A combination of sepsis and pulmonary infiltrates on a chest x-ray is highly suggestive of right-sided endocarditis.
name: Chest X-ray
label: b
answer: no
explanation: CT Chest also does not form part of the diagnostic Duke criteria and is therefore not as appropriate as an echocardiogram. It may have value in identifying septic emboli or if a chest x-ray shows pathology which is not certain.
name: CT Chest
label: c
answer: no

Correct answer: a
A 60-year-old male lifelong smoker presents to the emergency department with crushing, central 10/10 chest pain which radiates to his left jaw. His ECG reveals ST elevation in V3-V6.

Which of the following is the most appropriate immediate pharmacotherapy?

Options:
explanation: Heparin (i.e. “unfractionated”) bolus dose of 5000 units should be given in cases of patients who are to receive the percutaneous coronary intervention (PCI) for their STEMI. It is not considered an immediate pharmacotherapy.
name: Unfractionated heparin
label: b
answer: no
explanation: This drug is a glycoprotein IIb/IIIa inhibitor. These drugs are used alongside heparin at the time of PCI among patients who have high-risk clinical and angiographic characteristics or who continue to have ischemia despite other treatments.
name: Tirofiban
label: d
answer: no
explanation: Bivalirudin is a direct thrombin inhibitor. It may be considered as an alternative to glycoprotein IIb/IIIa inhibition and heparin among patients with acute coronary syndromes undergoing PCI with clinical features associated with an increased risk of bleeding or requiring femoral instead of radial access.
name: Bivalirudin
label: e
answer: no
explanation: The most likely diagnosis here is ST-elevation myocardial infarction (STEMI). NICE guideline NG185 states that in the treatment of this, you should offer a 300mg loading dose of aspirin as soon as possible and continue aspirin indefinitely unless contraindicated.
name: Aspirin
label: a
answer: yes
explanation: Beta-blockers are generally reserved for secondary prevention following STEMI. They are appropriate lifelong therapies in haemodynamically stable patients with reduced left ventricular systolic function (left ventricular ejection fraction < 40%) unless contraindicated. In those without reduced LVEF, it may be appropriate to discontinue beta-blocker therapy after 12 months.
name: Atenolol
label: c
answer: no

Correct answer: a
A 45-year-old female is seen in the urgent cardiology clinic. She describes sharp, pleuritic, retrosternal chest pain. She says the pain is improved by sitting up and leaning forward. On examination, she has a low-grade fever of 38.1 degrees. There is a scratchy noise heard on her left lower sternal edge. The noise is best heard with the diaphragm of the stethoscope and with her holding her breath.

Which of the following is the next best investigation?

Options:
explanation: Chest X-ray is frequently normal in acute pericarditis unless there is a sizeable pericardial effusion. It is therefore of limited value initially.
name: Chest X-ray
label: c
answer: no
explanation: This is a typical description of a patient presenting with acute pericarditis. ECG is a quick and easy bedside test which can exclude other more sinister causes of the chest pain. ECG signs of saddle-shaped ST-elevation and/or PR-depression also form part of the diagnostic criteria for pericarditis alongside pericarditic chest pain, pericardial rub and non-trivial new or worsening pericardial effusion.
name: 12-lead ECG
label: a
answer: yes
explanation: This is an investigation most commonly reserved for the detection of coronary artery disease in symptomatic patients without known heart disease. It is used for those who do not wish to proceed with invasive coronary angiography or in those who coronary angiography may be problematic or high-risk (e.g. coronary artery bypass grafts, severe aortic stenosis, adult congenital heart disease).
name: Cardiac CT
label: d
answer: no
explanation: This is an investigation often used in the work-up of myocarditis, unclear heart failure or cardiomyopathy and in acute coronary syndromes without angiographic evidence.
name: Cardiac MRI
label: e
answer: no
explanation: This is an investigation used to visualise the coronary arteries and is generally reserved for those presenting with ischaemic symptoms and signs suggestive of coronary artery disease.
name: Coronary angiography
label: b
answer: no

Correct answer: a
An 18-year-old female, with a past medical history significant for asthma, presents to the emergency department. She complains of a two-hour history of worsening dyspnoea, wheeze and a cough that is not responding to her blue salbutamol inhaler. On examination her airway is patent. Her oxygen saturations are 90% on air, her respiratory rate is 26 and she is unable to speak in full sentences. She is tachycardic with a pulse rate of 112 and her peak expiratory flow rate is 45% of her normal.

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

Options:
explanation: Tiotropium is a long-acting muscarinic agonist predominantly used in the maintenance treatment of COPD and occassionally in severe but stable asthma. It is not recommended in the acute setting.
name: Inhaled tiotropium
label: d
answer: no
explanation: IV aminophylline may be considered following consultation with senior medical staff for patients who fail to respond and are requiring senior critical care support. They should be treated in an appropriate ITU/HDU setting if requiring IV aminophylline.
name: IV Aminophylline
label: c
answer: no
explanation: This is a treatment commonly reserved for life-threatening asthma or unresponsive severe asthma. BTS notes that the evidence base is mixed for this treatment.
name: IV Magnesium Sulphate
label: b
answer: no
explanation: This is a classic presentation of an acute attack of asthma. According to the BTS classification, this acute asthma is classified as severe. Initial management should consist of oxygen to ensure saturations of 94-98%, nebulised salbutamol and ipratropium and a five-day course of oral prednisolone.
name: Nebulised salbutamol and ipratropium
label: a
answer: yes
explanation: Umeclidinium is a long-acting muscarinic antagonist used in the maintenance treatment of COPD or in severe (but stable) asthma. It is not recommended in the acute setting.
name: Inhaled umeclidinium
label: e
answer: no

Correct answer: a
A 65-year-old male is reviewed in the chronic obstructive pulmonary disease (COPD) clinic. He was diagnosed with COPD five years ago and is currently maintained on a salbutamol inhaler as required. He has recently started nicotine replacement therapy and stopped smoking. His latest FEV1 was 41% of predicted. Despite his current therapy he complains of frequent exacerbations. There is no history of asthma, eosinophilia or FEV1 variation.

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

Options:
explanation: This would be the next best step if there were asthmatic features or features suggesting steroid-responsiveness.
name: Combined long-acting beta 2 agonist and inhaled corticosteroid
label: e
answer: no
explanation: According to the relevant 2018 NICE guideline, this should be combined with a long-acting muscarinic antagonist (such as ipratropium) for optimum control.
name: Long-acting beta 2 agonist
label: b
answer: no
explanation: Following the 2018 NICE guidelines, the next step in management would be a combined long-acting beta 2 agonist (such as salmeterol) + a long-acting muscarinic antagonist (such as ipratropium). This is because there are no 'asthmatic features/features suggesting steroid responsiveness'.
name: Combined long-acting beta 2 agonist and long-acting muscarinic antagonist
label: a
answer: yes
explanation: This may be considered following a trial of a combined long-acting beta 2 agonist and long-acting muscarinic antagonist if the person still has one severe or two moderate exacerbations within a year.
name: Combined long-acting beta 2 agonist, long-acting muscarinic antagonist and inhaled corticosteroid
label: d
answer: no
explanation: According to the relevant 2018 NICE guideline, this should be combined with a long-acting beta 2 agonist (such as salmeterol) for optimum control.
name: Long-acting muscarinic antagonist
label: c
answer: no

Correct answer: a
A 75-year-old male presents to his GP. He complains of right-sided shoulder pain and of his face looking unusual for a reason he cannot pinpoint. With his face only, he has also been noticing that one side does not sweat at all. On further questioning, he reveals he has had significant weight loss in the past few months too. On examination, it is noted that he has right sided-miosis, ptosis and this is also the side he complains of facial anhidrosis.

Which of the following is the most likely diagnosis?

Options:
explanation: Retinoblastoma is a malignant tumour of the retina, and the most common intraocular tumour of childhood. The most common sign of retinoblastoma is leukocoria (white pupil). However, it may also present as deteriorating vision, strabismus or failure to thrive if not recognised early. It is not a relevant differential in this case.
name: Retinoblastoma
label: b
answer: no
explanation: This is a typical description of Horner's syndrome which is characterised by ptosis and miosis, with or without anhidrosis. It is due to an interruption of the sympathetic nerve supply to the eye and can be classified into pre-ganglion causes, post-ganglionic causes and central causes. In this case, with the weight loss and shoulder pain, the most likely underlying cause is a pancoast tumour of the apex of the lung. Pancoast tumours are pre-ganglionic lesions and, thereby, the anhydrosis affects the face only.
name: Horner's syndrome
label: a
answer: yes
explanation: A cluster headache is a unilateral headache that is typically worse around the eye. Typical features include a bloodshot or teary eye, vomiting and severe headache. None of these symptoms feature in this case.
name: Cluster headache
label: d
answer: no
explanation: Multiple sclerosis, not unlike cerebrovascular disease is a multifocal condition which causes wildly variable clinical features dependent on the affected area of the brain or spinal cord. This said, there are typical presentations which may occur more commonly, in particular sensory disease (patchy paraesthesia), optic neuritis (loss of central vision and painful eye movements) and internuclear ophthalmoplegia (a lesion in the medial longitudinal fasciculus of the brainstem). It is highly unlikely to present with shoulder pain or anhidrosis.
name: Multiple sclerosis
label: c
answer: no
explanation: Neuroblastoma is a rare cancer that affects children, mostly under the age of five years. It develops in early nerve cells called neuroblasts and often starts with a lump in the abdomen. It is not a relevant differential in this case.
name: Neuroblastoma
label: e
answer: no

Correct answer: a
A 59-year-old male is seen in the Acute Medical Unit. He complains of sudden onset pleuritic chest pain and three episodes of coughing up blood. On examination, he has a unilateral swollen, red and tender left calf. His oxygen saturations are slightly low at 95% on air and he is tachycardic with a pulse rate of 105. He is known to have a background of bowel malignancy for which he is awaiting surgery.

Which of the following is the next best investigation?

Options:
explanation: V/Q scan is a viable scan to diagnose PE but is preferred if the patient has renal impairment, a contrast allergy or is pregnant.
name: V/Q scan
label: e
answer: no
explanation: The most likely diagnosis here is a pulmonary embolism from an underlying deep vein thrombosis (DVT). CT pulmonary angiogram (CTPA) is the diagnostic test of choice for a PE and will show a filling defect in the pulmonary vasculature.
name: CT pulmonary angiogram
label: a
answer: yes
explanation: Lower limb Duplex can be helpful if a DVT is thought to be the cause of the PE as in this case but does not provide a definitive diagnosis for the cause of the oxygen desaturation and tachycardia which needs treating more urgently. Therefore, CTPA remains the next best investigation.
name: Doppler USS left leg
label: d
answer: no
explanation: Chest x-rays are typically normal in PE and therefore not the next best investigation. However, possible findings include Fleischner sign (an enlarged pulmonary artery), Hampton's hump (a peripheral wedge-shaped opacity), and Westermark's sign (regional oligaemia). The chest x-ray can be helpful in ruling out differentials (e.g. pneumonia, pneumothorax) too.
name: Chest x-ray
label: b
answer: no
explanation: D-dimer is a highly non-specific test but has a 95% negative predictive value i.e. it is useful in ruling out a PE if negative. The Well's score in this case is at least 9.5 and only if the Well's score is 4 or less, a D-dimer should be measured.
name: D-dimer
label: c
answer: no

Correct answer: a
A 45-year-old male presents to his GP. He reports five weeks of daily small amounts of haemoptysis along with unintentional significant weight loss over the last six months. He is a lifelong smoker. On examination he is apyrexial and his chest sounds are clear.

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

Options:
explanation: According to local antimicrobial guidelines, this antibiotic would be first-line for a community-acquired pneumonia. However, provided the lack of chest sounds and pyrexia, this is a less likely diagnosis.
name: Amoxicillin
label: e
answer: no
explanation: Scottish Referral Guidelines for Suspected Cancer stipulate that an urgent suspicion of cancer chest x-ray should be arranged for anyone with unexplained haemoptysis or unexplained and persistent (more than three weeks) weight loss.
name: Urgent suspicion of cancer chest x-ray
label: a
answer: yes
explanation: This is an investigation usually requested by specialist doctors and would be indicated if a chest x-ray reported ambiguous findings or for planning of biopsy and/or surgery.
name: CT Chest
label: b
answer: no
explanation: This is a scan which images the pulmonary arteries, often reserved to diagnose or exclude pulmonary emboli - a less likely diagnosis here.
name: CT Pulmonary Angiogram
label: d
answer: no
explanation: Bronchoscopy is the primary procedure a doctor will perform to obtain a biopsy. Initially though, a suspicious lesion or area must be identified from chest x-ray and CT.
name: Bronchoscopy
label: c
answer: no

Correct answer: a
A 68-year-old female well-known to speech and language therapy for numerous swallow assessments following a recent stroke is seen by the junior doctor on the ward. The nurses were concerned as her temperature was 40 degrees, her respiratory rate was 24 with oxygen saturations of 87% on air, and her systolic blood pressure was 92mmHg. Her observations were normal 24 hours ago. The junior doctor arranged an urgent chest x-ray which has revealed new consolidation of her right middle and lower zones.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: Pulmonary embolism would rarely cause such significant pyrexia. Sudden-onset shortness of breath, pleuritic chest pain, and haemoptysis are the classic symptoms of pulmonary embolism, none of which are mentioned here.
name: Pulmonary embolism
label: b
answer: no
explanation: Fibrosis would be very unlikely to make a patient so acutely unwell within 24 hours as it is usually a slowly progressive condition. Additionally, chest x-rays commonly show bilateral lower zone reticulo-nodular shadowing.
name: Idiopathic pulmonary fibrosis
label: e
answer: no
explanation: Aspiration pneumonia is seen in patients with a dysfunctional or unsafe swallow. Examples include stroke (as in this case), myasthenia gravis and bulbar palsy. This patient is septic, most likely as a result of their aspiration pneumonia. On the chest x-ray, the right lower lobe is most frequently involved in aspiration pneumonia, in fitting with this case.
name: Aspiration pneumonia
label: a
answer: yes
explanation: Lung cancer is unlikely to cause such significant pyrexia without concomitant pneumonia. Chest malignancy would also be unlikely to cause hypotension so quickly.
name: Lung malignancy
label: c
answer: no
explanation: Patients with acute pulmonary oedema usually present with dyspnoea, orthopnoea and ankle swelling. Pyrexia and hypotension are not typical features.
name: Pulmonary oedema
label: d
answer: no

Correct answer: a
A 62-year-old alcohol-dependent male presents to the acute medical unit with an 18-hour history of severe stabbing-like epigastric pain which radiates to his back. He has vomited three times in the past six hours too. On examination, periumbilical discolouration is noted.

Which of the following serum investigations may be diagnostic if significantly raised?

Options:
explanation: LFTs are usually attained to investigate the underlying cause of pancreatitis. They may be abnormal if there is gallstone disease or alcohol use amongst others. They are not 'diagnostic' of acute pancreatitis per se and are used more often in the severity scoring of pancreatitis.
name: Liver function tests (LFTs)
label: e
answer: no
explanation: The CRP level is a prognostic factor, rather than diagnostic test, for severe acute pancreatitis and has been identified as a predictive factor for both pancreatic necrosis and infective pancreatic cysts.
name: C-reactive protein (CRP)
label: c
answer: no
explanation: Leucocytosis can indicate the presence of necrotising pancreatitis but a full blood count in itself is not useful in confirmation of 'acute' pancreatitis as it is often largely unchanged.
name: Full Blood Count (FBC)
label: b
answer: no
explanation: ESR level is a prognostic factor, rather than diagnostic test, for severe acute pancreatitis. Literature suggests it is slightly inferior to CRP and as such is not routinely used in pancreatitis investigation or monitoring.
name: Erythrocyte sedimentation rate (ESR)
label: d
answer: no
explanation: The most likely diagnosis here, given the description of the pain and Cullen's sign on examination, is acute pancreatitis. An amylase 3x the upper limit of normal is extremely suggestive of acute pancreatitis and is the only serum investigation in the diagnostic criteria. It is important to note that the degree of elevation of amylase is not related to the severity of the disease.
name: Amylase
label: a
answer: yes

Correct answer: a