hllj/quesmed huggingface dataset:
A 27 year old patient attends the GP with physical symptoms of anxiety. They are subsequently started on Propanolol. They present to the emergency department the same day with severe breathlessness and lightheadedness. They have a past medical history of cluster headaches for which they take verapamil for prophylaxis. Their ECG is shown below:

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What is the most likely diagnosis?

Options:
explanation: This ECG does not show second degree heart block, mobitz type 1. An ECG of second degree heart block, mobitz type 1 typically shows progressive elongation of the PR interval followed by non-conduction of the P wave and a skipped QRS. This is not shown in this ECG, which shows complete non-conduction of the P waves
name: Second degree heart block, mobitz type 1
label: c
answer: no
explanation: This ECG does not show atrial fibrillation. An ECG in atrial fibrillation would be irregularly irregular with absent P waves. This ECG is regular and although P waves can be difficult to observe, they are visible on more detailed inspection of the ECG
name: Atrial fibrillation
label: e
answer: no
explanation: This ECG does not show second degree heart block, mobitz type 2. An ECG of second degree heart block, mobitz type 2 typically shows occasionally dropped QRS complexes (due to non-conduction of P waves) in the absence of progressive prolongation of the P-R interval. This can either be somewhat random or in a fixed ratio e.g. 2:1. This is in contrast to this ECG where no P waves are conducted, making it more in keeping with complete heart block
name: Second degree heart block, mobitz type 2
label: b
answer: no
explanation: Complete heart block is caused by failure of the atrioventricular node, preventing the electrical impulses generated by the sinoatrial node reaching the ventricles. This leads to a complete dissociation of the ventricles from the atria. In this case, this was caused by the combination of a beta blocker with a non-dihydropyridine calcium channel blocker, which should never be given in combination due to the risk of bradyarrhythmia and complete heart block. This is a typical ECG of complete heart block, with complete dissociation of the P waves from the QRS complexes. P waves are around the normal atrial rate of around 100-180/min and the QRS complexes are at ventricular escape rhythm which is around 20-40/min. If this patient remains untreated they are at significant risk of asystole and death
name: Complete heart block
label: a
answer: yes
explanation: This is not a normal ECG. In a normal ECG, every P wave is followed by a QRS and every QRS is preceded by a P wave
name: Normal ECG
label: d
answer: no

Correct answer: a
An 88 year old man presents to the GP with exertional chest pain, breathlessness and occasional syncope. On auscultation, an ejection systolic murmur is heard in the 2nd intercostal space at the right sternal edge. No other murmurs are heard.

What is the most likely diagnosis?

Options:
explanation: This a typical presentation of aortic stenosis. Older age is a risk factor, as the aortic valve becomes more calcified over time. Mild to moderate aortic stenosis is generally asymptomatic, but severe aortic stenosis can present with anginal chest pain, syncope, exertional breathlessness and heart failure. An ejection systolic murmur heard in the 2nd intercostal space at the right sternal edge is the classic murmur heard in aortic stenosis. This murmur also radiates to the carotid areas, so can be heard upon auscultation here. Symptomatic aortic stenosis generally has poor outcomes, so are usually considered for repair via open aortic valve replacement or transcatheter aortic valve implantation (TAVI)
name: Aortic stenosis
label: a
answer: yes
explanation: Aortic regurgitation does not present with this murmur. The murmur heard in aortic regurgitation is an early diastolic murmur heard loudest over the left sternal edge. This is not the murmur in this case and is therefore more likely to be aortic stenosis
name: Aortic regurgitation
label: c
answer: no
explanation: Angina is a feature of severe aortic stenosis. Although it may seem sensible to choose this answer, there is a clear cause of angina in this case as this patient has other symptoms and examination findings suggesting aortic stenosis. Therefore, aortic stenosis is the single best answer
name: Stable angina pectoris
label: d
answer: no
explanation: Mitral regurgitation does not present with this murmur. The murmur heard in mitral regurgitation is a pansystolic murmur heard loudest in the 5th intercostal space midclavicular line, which radiates to the axilla. This is not the murmur in this case and is therefore more likely to be aortic stenosis
name: Mitral regurgitation
label: b
answer: no
explanation: Mitral stenosis does not present with this murmur. The murmur heard in mitral stenosis is a mid diastolic murmur heard loudest in the 5th intercostal space midclavicular line, with or without an audible opening click. This is not the murmur in this case and is therefore more likely to be aortic stenosis
name: Mitral stenosis
label: e
answer: no

Correct answer: a
A 28 year old female presents to the emergency department with palpitations. Her ECG is shown below:

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What is the most likely diagnosis?

Options:
explanation: This ECG is not in keeping with someone who is presenting with anxiety. Anxiety can present with palpitations, however they would have a normal ECG or sinus tachycardia. In this case, the ECG is abnormal meaning anxiety is not the single best answer
name: Anxiety
label: d
answer: no
explanation: This ECG does not show ventricular tachycardia. Ventricular tachycardia is a broad complex tachycardia (QRS complexes >120ms) whereas this ECG is a narrow complex tachycardia (QRS complexes <120ms). Therefore this ECG is more in keeping with supraventricular tachycardia
name: Ventricular tachycardia
label: c
answer: no
explanation: This ECG does not show atrial fibrillation. While supraventicular tachycardia and atrial fibrillation can both be classified as narrow complex tachycardias and both have absent P waves, the key difference is that atrial fibrillation is an irregularly irregular rhythm and supraventricular tachycardia is a regular rhythm. As the rhythm of this ECG is regular, this is more in keeping with a supraventricular tachycardia
name: Atrial fibrillation
label: b
answer: no
explanation: This is a typical ECG demonstrating supraventricular tachycardia. Key features in keeping with supraventricular tachycardia are a ventricular rate >100, regular ventricular rhythm, QRS complexes <120ms and the absence of P waves. This condition is also relatively common in young patients with no underlying cardiac disease
name: Supraventricular tachycardia (SVT)
label: a
answer: yes
explanation: This ECG does not show Wolff-Parkinson-White syndrome. The triad of features in Wolff-Parkinson-White syndrome are delta waves (slurred upstroke in the QRS), wide QRS and a short PR interval. Although Wolff-Parkinson-White syndrome is associated with supraventricular tachycardia, there is nothing that suggests this patient has an underlying diagnosis of Wolff-Parkinson-White syndrome in the question. Therefore, the single best answer is supraventricular tachycardia
name: Wolff-Parkinson-White syndrome
label: e
answer: no

Correct answer: a
A 70 year old patient who has been admitted on the cardiology ward has been found unconscious. They are not breathing and have no pulse on palpation. Their current ECG strip is shown below:

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What is the most likely diagnosis?

Options:
explanation: Pulseless electrical activity presents as discernable P waves and QRS complexes in the absence of a pulse. There are no discernable P waves or QRS complexes, therefore they do not have pulseless electrical activity
name: Pulseless electrical activity
label: c
answer: no
explanation: Asystole appears as a 'flatline' on the ECG, where the heart has no electrical activity. It has a very poor mortality and is the most serious form of cardiac arrest. This ECG has electrical activity and is therefore not asystole
name: Asystole
label: d
answer: no
explanation: This patient has no discernible P waves or QRS complexes and they are unconscious and pulseless. They are in cardiac arrest
name: Normal ECG
label: b
answer: no
explanation: This patient has a typical ECG showing ventricular fibrillation. Their ECG shows chaotic, polymorphic, irregular deflections with no discernible QRS complexes. This is a medical emergency that should be managed with unsynchronised DC cardioversion
name: Ventricular fibrillation
label: a
answer: yes
explanation: ECG signs of ventricular tachycardia include regular, wide QRS complexes of equal amplitude (monomorphic) with an absence of P waves. This is not the case with this ECG as the rhythm and amplitude are not regular
name: Ventricular tachycardia
label: e
answer: no

Correct answer: a
A 19 year old female presents to the GP with a 4 month history of breathlessness on exertion. She also has a dry cough that mainly occurs at night, which affects her sleep. She has a past medical history of allergic rhinitis and atopic eczema. On auscultation a widespread polyphonic wheeze is heard, with normal heart sounds.

What is the most likely diagnosis?

Options:
explanation: Heart failure can lead to exertional breathlessness and polyphonic wheeze (referred to as cardiac asthma). However, this patient has no orthopnoea or paroxysmal nocturnal dyspnoea, no peripheral oedema and no obvious cause for heart failure
name: Heart failure
label: d
answer: no
explanation: Chronic obstructive pulmonary disease (COPD) presents as shortness of breath, chronic productive cough and polyphonic wheeze. This diagnosis is very rare in patients under the age of 35 and this patient does not have any significant smoking history mentioned in this question
name: Chronic obstructive pulmonary disease
label: b
answer: no
explanation: Cystic fibrosis can cause breathlessness, however they are more likely to have presented earlier and with additional features. Other expected features would include failure to thrive, malabsorption, diabetes mellitus and frequent chest infections, none of which are present in the case. There is also no clear family history of cystic fibrosis which, although not essential, would be supportive of cystic fibrosis
name: Cystic fibrosis
label: e
answer: no
explanation: This is a typical presentation of asthma. Breathlessness, dry cough and polyphonic wheeze are typical symptoms and common triggers include exercise. Symptoms of asthma also tend to get worse at night. A history of atopy (e.g. allergic rhinitis, atopic eczema) is characteristic of asthma
name: Asthma
label: a
answer: yes
explanation: Alpha-1 antitrypsin deficiency is a rare autosomal recessive condition that causes early onset liver fibrosis and chronic obstructive pulmonary disease (COPD). However, given the variability in this patient's symptoms and history of atopy, asthma is a more likely diagnosis
name: Alpha-1 antitrypsin deficiency
label: c
answer: no

Correct answer: a
A 66-year-old man presents to the emergency department with breathlessness, productive cough and fever. He is admitted and commenced on 15L high flow oxygen as his oxygen saturation is 89% and his respiratory rate is 22/min. He has a past medical history of COPD.

Thirty minutes later, he is drowsy and has a respiratory rate of 13/min. His ABG is shown below:

pH: 7.29 [7.35-7.45]

PaO2: 10 [9.5-14]

PaCO2: 7.1 [4.6-6]

HCO3-: 33 [22-30]

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

Options:
explanation: Infective exacerbation of COPD would be a likely differential for this patient's initial clinical presentation. However, the history of new-onset drowsiness and this man's ABG findings in the context of COPD and the initiation of oxygen therapy is more suggestive of acute on chronic retention of CO2
name: Infective exacerbation of COPD
label: c
answer: no
explanation: Pulmonary embolism would typically present with type 1 respiratory failure. This would mean they have a low oxygen and a low to normal CO2 on an ABG. As this patient has a high CO2, they are in type 2 respiratory failure, not type 1
name: Pulmonary embolism
label: d
answer: no
explanation: Pneumonia would be a likely differential for this patient's initial clinical presentation (differentiated based on chest x-ray findings). However, the history of new-onset drowsiness and this man's ABG findings in the context of COPD and the initiation of oxygen therapy is more suggestive of acute on chronic retention of CO2
name: Pneumonia
label: b
answer: no
explanation: Myasthenia gravis can present with type 2 respiratory failure, and the typical age of onset in men is between 60 and 70 years old. However, it usually presents with diplopia, swallowing difficulties and arm weakness that worsens with repeated usage. Given this patient's history, acute on chronic retention of CO2 on a background of COPD and high flow oxygen administration is the more likely diagnosis
name: Myasthenia gravis
label: e
answer: no
explanation: This patient is presenting with type 2 respiratory failure secondary to oxygen therapy. Patients with COPD can develop a reduction in hypercapnic drive due to increased carbon dioxide content in the blood. This means they are reliant on hypoxic drive. Therefore, when given high flow oxygen therapy, they lose hypoxic drive, which means they have a lower respiratory effort and retain CO2. This presents clinically as drowsiness. This patient may also have an element of chronic hypercapnoea, as they have a raised bicarbonate. This is a typical ABG of someone in type 2 respiratory failure: a low pH and high CO2 indicating respiratory acidosis and high bicarbonate, suggesting this is an acute on chronic retention of carbon dioxide. Of note, if a patient is presenting with severe hypoxia and a history of COPD, they should still be commenced on high flow oxygen as their hypoxia is immediately threatening to life. However, in this case (patient with COPD who is a known retainer), it is more appropriate to keep them on a Venturi mask and aim for saturations of 88-92%
name: High flow oxygen therapy
label: a
answer: yes

Correct answer: a
A 23-year-old man presents to the emergency department complaining of vomiting blood. He started vomiting last night at a house party, followed by forceful retching a few hours later. Physical examination shows no abnormalities, and he is haemodynamically stable.

What is the most likely diagnosis?

Options:
explanation: Boerhaave's syndrome is caused by perforation of the oesophagus. It can also be caused by vomiting and retching; however the patient would be much more unwell as this is a life-threatening condition. Pain, dysphagia, massive haematemesis, haemodynamic instability and surgical emphysema are much more typical features of Boerhaave's syndrome. Given how well this patient is, Mallory-Weiss tear is a much more likely diagnosis
name: Boerhaave's syndrome
label: e
answer: no
explanation: One of the complications of peptic ulcer disease is an upper GI bleed. Peptic ulcer disease can present in young adults, with causes including alcohol, H. pylori infection and regular NSAID use. However, given that vomiting and straining are typical causes of a Mallory-Weiss tear, this patient is more likely to be presenting with a Mallory-Weiss tear
name: Peptic ulcer disease
label: c
answer: no
explanation: One of the complications of oesophageal cancer is an upper GI bleed. However, it is exceedingly rare for a 22-year-old to develop oesophageal cancer, especially in the absence of any specific risk factors in the history
name: Oesophageal cancer
label: d
answer: no
explanation: A Mallory-Weiss tear is caused by tears in the oesophageal mucosa. This is typically caused by vomiting and retching, increasing the pressure at the gastro-oesophageal junction. This typically presents with haematemesis or blood-stained vomitus in the presence of vomiting or retching. In this case, this is on a background of acute alcohol intoxication leading to excessive vomiting. These patients will typically have a normal examination/examination in keeping with the cause of vomiting, although there can be haemodynamic instability if a significant amount of blood is lost. The majority of patient resolve spontaneously with no complications. All patients with an upper GI bleed should receive oesophagogastroduodenoscopy, with urgency based on clinical presentation and Glasgow-Blatchford score
name: Mallory-Weiss tear
label: a
answer: yes
explanation: Oesophageal varices are enlarged veins that develop due to portal hypertension. These can rupture, leading to life-threatening upper GI bleeds and are generally associated with cirrhosis. This patient is relatively young, so is unlikely to have developed cirrhosis at the age of 22. They also have no features of chronic liver disease on examination. Although alcohol is a common cause of cirrhosis, there is no evidence this patient has chronic harmful alcohol use or alcohol dependency. It is more likely that this patient was acutely intoxicated with alcohol
name: Oesophageal variceal bleed
label: b
answer: no

Correct answer: a
A 24-year-old male presents to the GP with a one-month history of epigastric pain. This gets better after he eats a meal but is at its worst again a few hours later. On examination, the abdomen is soft with tenderness in the epigastrium. A urea breath test is performed, which is positive.

What is the most likely diagnosis?

Options:
explanation: GORD can present with dyspepsia, but it more typically presents with retrosternal pain and a bitter, acidic taste in the mouth. Pain associated with GORD typically gets worse, not better, after meals
name: Gastro-oesophageal reflux disease (GORD)
label: d
answer: no
explanation: Duodenal ulcers are the most common type of peptic ulcer. 90% of them are related to H. pylori infection. They are typically improved by eating and worsened a few hours after meals or when the patient is hungry. They may present with epigastric tenderness on examination. All suspected ulcers should be investigated for _H. pylori_, the positive urea breath test, in this case, indicating _H. pylori_ as the primary cause. Other common causes include NSAIDs and corticosteroids. First-line treatment of _H. pylori_ associated duodenal ulcers is eradication therapy using a one week course of amoxicillin, clarithromycin and a PPI, e.g. omeprazole. They should be tested 4-8 weeks later to ensure eradication
name: Duodenal ulcer
label: a
answer: yes
explanation: Gastric ulcers are peptic ulcers in the gastric mucosa. Gastric ulcers and duodenal ulcers have very similar risk factors, including H. pylori. Gastric ulcers are typically exacerbated upon eating, whereas in this case, eating relieves these symptoms. These symptoms are more typical of a duodenal ulcer; therefore this is the most likely diagnosis
name: Gastric ulcer
label: b
answer: no
explanation: Gastric cancer can present with dyspepsia. However, it is an exceedingly rare diagnosis in a 24-year-old and would usually have red flag symptoms such as weight loss, vomiting or loss of appetite. Of note, mucosa-associated lymphoid tissue (MALT) lymphoma is a rare non-Hodgkin's lymphoma associated with H. pylori infection. However, given the typical temporal relation of symptoms to eating and the rarity of MALT lymphoma, duodenal ulcers are the most likely diagnosis
name: Gastric cancer
label: c
answer: no
explanation: Biliary colic typically occurs after a heavy, fatty meal. This patient also isn't in the typical demographics, with biliary colic typically affecting middle-aged women with a high BMI. As eating makes this pain better, and this patient has _H. pylori_, a diagnosis of duodenal ulcer is more likely
name: Biliary colic
label: e
answer: no

Correct answer: a
A 19-year-old man presents to the emergency department with diffuse abdominal pain and nausea. He has been feeling very thirsty for the past two weeks and lost some weight over that time period. On examination, he has dry mucous membranes, is tachypnoeic and breathing deeply. His capillary blood glucose level is 26.

What is the most likely diagnosis?

Options:
explanation: Hypercalcaemia has a broad range of features, including renal stones, bone pain, constipation, nausea, abdominal pain, confusion, polydipsia, polyuria, depression and psychosis. Over 90% of cases of hypercalcaemia are due to either primary hyperparathyroidism or malignancy, with other causes including sarcoidosis and Paget's disease of the bone. Although hypercalcaemia can cause polyuria and polydipsia (due to nephrogenic diabetes insipidus), diffuse abdominal pain and nausea, this does not explain the presence of Kussmaul breathing or hyperglycaemia. Therefore diabetic ketoacidosis is the most likely diagnosis
name: Hypercalcemia
label: e
answer: no
explanation: Diabetes insipidus is a rare condition affecting either the production of antidiuretic hormone (cranial) or the kidney's sensitivity to antidiuretic hormone (nephrogenic). These patients present with very severe dehydration, polydipsia and polyuria. However, they would not present with Kussmaul breathing or hyperglycaemia, making diabetic ketoacidosis the more likely diagnosis
name: Diabetes insipidus
label: d
answer: no
explanation: Hyperglycaemic hyperosmolar state (HHS) is a rare condition associated with type 2 diabetes. As a 19-year-old patient, in the absence of obesity, this patient is very unlikely to have type 2 diabetes. In addition, they have Kussmaul breathing suggesting metabolic acidosis. Metabolic acidosis is not a feature of HHS
name: Hyperglycaemic hyperosmolar state
label: b
answer: no
explanation: Appendicitis will typically have a shorter history over a few hours. They will typically have more localised abdominal pain, with nausea and low-grade fever. Kussmaul breathing, polydipsia, dehydration and hyperglycaemia are not typical features of appendicitis
name: Appendicitis
label: c
answer: no
explanation: This is a typical presentation of diabetic ketoacidosis (DKA). This patient presents with a prodrome of type 1 diabetes symptoms (including polydipsia and weight loss) which have now worsened. They have deep, laboured breathing in keeping with Kussmaul breathing, a sign of metabolic acidosis. They are also dehydrated, which is common in DKA. Their capillary glucose is 26, which is >11 mmol/L (part of the diagnostic criteria for DKA). Other diagnostic criteria include blood ketones ≥3 mmol/L and metabolic acidosis (pH <7.3 or bicarbonate <15). Management of this patient would include IV 0.9% NaCl (initially 1L over 1 hour), a fixed rate insulin infusion (0.1 units/kg/hour). Potassium is added to further bags of 0.9% NaCl (as insulin can cause hypokalaemia), and the underlying cause of their DKA should be considered (e.g. sepsis, non-compliance, myocardial infarction)
name: Diabetic ketoacidosis
label: a
answer: yes

Correct answer: a