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

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

Options:
explanation: Bisoprolol may be used to rate control atrial fibrillation (AF). However, as this is her first presentation of AF, she is young and symptomatic, and she has presented to the emergency department, rhythm control would be more favourable in the first instance.

In primary care, rate control may be initiated rather than cardioversion, depending on patient preference and clinical judgement
name: Bisoprolol
label: e
answer: no
explanation: We can be fairly certain that this woman's onset of atrial fibrillation is less than 48 hours, and since she's presented to an acute medical unit, DC cardioversion would be the most appropriate management. Factors favouring rhythm control over rate control in this case include being symptomatic, the first presentation of atrial fibrillation, and her age. She may require anticoagulation prior to cardioversion.

Had this patient presented to the GP, management in primary care could also be considered, depending on patient preferences and clinical judgement
name: Direct current (DC) cardioversion
label: a
answer: yes
explanation: Digoxin may be used second line for rate control of atrial fibrillation if a beta blocker or rate limiting calcium channel blocker is not sufficient in the first instance
name: Digoxin
label: d
answer: no
explanation: TOEs may sometimes be used to exclude a left atrial appendage thrombus before cardioversion if the onset of AF was more than 48 hours prior to the planned cardioversion, as an alternative to anticoagulation
name: Transoesophageal Echocardiogram (TOE)
label: b
answer: no
explanation: Anticoagulation is indicated if her CHA<sub>2</sub>DS<sub>2</sub>-VASc score is 2 or more. She only has a score of 1 for being female
name: Long term anticoagulation
label: c
answer: no

Correct answer: a


Learning point: In acute atrial fibrillation onset within 48 hours, direct current (DC) cardioversion is often the preferred management approach to quickly restore normal sinus rhythm and reduce the risk of complications.
A 52-year-old Polish man is brought to the accident and emergency department by ambulance. He speaks no English, but he points to his chest to suggest that he is in pain. Blood tests have not yet returned. His ECG is as follows:

[lightgallery]

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

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

Correct answer: a


Learning point: ST-elevation myocardial infarction (STEMI) typically presents with central crushing chest pain and ST elevation in specific ECG leads.
An 80 year old female is admitted to hospital with heart failure. Her ECG demonstrates sinus rhythm with wide QRS complexes of approximately 190ms. Her blood pressure is 130/85 mmHg, her heart rate is 78 bpm.

Which of the following is indicated in this patient?

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

Correct answer: a


Learning point: Cardiac resynchronisation therapy (CRT) is beneficial for heart failure patients with wide QRS complexes to improve cardiac function and symptoms.
A 60-year-old lady presents to the emergency department with confusion. She has the following blood tests:


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


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


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


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

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

Correct answer: a


Learning point: Trimethoprim can falsely lower estimated glomerular filtration rate (eGFR) by inhibiting tubular creatinine secretion, affecting serum creatinine levels.
A 40-year-old man presents to the accident and emergency department with a painful rash which has established quickly over the last few hours. He is pyrexial and reports general arthralgia. He was started on a course of amoxicillin for sinusitis the preceding day. He has no significant past medical or dermatological history.

His rash can be seen below.

[lightgallery]

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

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

Correct answer: a


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

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

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

Correct answer: a


Learning point: In bullous pemphigoid, IgG and C3 are located at the epidermal basement membrane, indicating an autoimmune response against hemidesmosome proteins.
A 18 year old patient presents to his GP with ongoing issues managing acne vulgaris. On examination he has open and closed comedones with papules, pustules but no scarring, and the acne is confined to his face and back. He has tried using benzoyl peroxide and adapalene (a topical retinoid) with no significant effect.

Which of the following treatments would be a suitable next step for managing this patient's acne vulgaris?

Options:
explanation: This is a topical antibiotic and is not indicated for acne vulgaris. It may be used to treat a skin infection however
name: Topical fusidic acid 2%
label: e
answer: no
explanation: Lymecycline is an antibiotic which will is active again the bacteria Propionebacterium acnes which is associated with acne vulgaris. The topical retinoid should be continued alongside this to reduce the risk of antibiotic resistance
name: Add in oral lymecycline, in addition to current therapy
label: a
answer: yes
explanation: Oral antibiotics should be prescribed along with benzoyl peroxide and/or a topical retinoid to reduce the risk of antibiotic resistance
name: Stop current therapy and start oral lymecycline
label: b
answer: no
explanation: According to NICE guidelines, referral to dermatology is only warranted if the acne is severe, there is scarring, and multiple treatments in primary care have failed
name: Refer to dermatology
label: c
answer: no
explanation: This is a topical steroid and is not indicated in acne vulgaris
name: Topical hydrocortisone 1%
label: d
answer: no

Correct answer: a


Learning point: Lymecycline is an antibiotic which will is active again the bacteria Propionebacterium acnes which is associated with acne vulgaris.
A 75 year old is brought to the emergency department by his son who believes he has taken an intentional overdose of his bisoprolol. On arrival to the department he has a reduced GCS, a blood pressure of 88/58 mmHg, and a heart rate of 40 beats per minute. He is initially given atropine, but his heart rate only increases to 50 beats per minute and he remains hypotensive.

Which of the following is the next best step in the management of this patient's bisoprolol overdose?

Options:
explanation: This is a chelating agent used to reverse an overdose of iron
name: Desferrioxamine
label: e
answer: no
explanation: Naloxone is used in the management of opioid overdose
name: Naloxone
label: d
answer: no
explanation: N-acetylcysteine is used in the management of paracetamol overdose
name: N-acetylcysteine
label: b
answer: no
explanation: IV bicarbonate is used in the management of salicylate (eg. aspirin) or tricyclic antidepressant overdose
name: IV bicarbonate
label: c
answer: no
explanation: Glucagon can be used to manage beta blocker overdoses. Atropine may be tried when the patient is bradycardic and haemodynamically unstable (as in this case)
name: Glucagon
label: a
answer: yes

Correct answer: a


Learning point: Glucagon is an effective treatment for beta-blocker overdose, particularly in cases of bradycardia and hypotension.
A 30-year-old female presents to the Emergency Department with a one-week history of polyuria, reduced appetite, nausea and vomiting. On examination, her abdomen is soft and non-tender. She has the following blood tests:

||||
|---------------------------|:-------:|------------------------------|
|Non-fasting Glucose|5.8 mmol/L|< 6.1|
|Bicarbonate|17.5 mmol/L|22 - 29|
|pH|7.26|7.35 - 7.45|
|Anion gap|20 mEq/L|6 - 12|


She has a background of type 2 diabetes, for which she takes dapagliflozin and metformin.


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

Options:
explanation: This is unlikely if her abdomen is soft and non-tender. Metabolic acidosis may occur in patients with peritonitis secondary to a perforated appendix, but they would almost certainly have a tender and rigid abdomen if this was the case
name: Appendicitis
label: d
answer: no
explanation: This is likely euglycaemic DKA. Although this is a rare phenomenon, one of the most known causes is SGLT2 inhibitors. These are typical symptoms associated with DKA, and her blood tests are all typical of DKA, with the exception of the normal glucose. Therefore, this is euglycaemic DKA. She should be treated with the local DKA protocol
name: Diabetic ketoacidosis (DKA)
label: a
answer: yes
explanation: Gastroenteritis is unlikely to cause polyuria and acidosis such as this
name: Gastroenteritis
label: c
answer: no
explanation: HHS leads to a significantly elevated glucose and not such a significant acidosis
name: Hyperosmolar hyperglycaemic state (HHS)
label: b
answer: no
explanation: Pyelonephritis is associated with dysuria and urinary frequency, not polyuria. It may cause nausea and vomiting. It would not normally cause an acidosis such as this
name: Pyelonephritis
label: e
answer: no

Correct answer: a


Learning point: Euglycaemic diabetic ketoacidosis can occur in patients on SGLT2 inhibitors, presenting with typical DKA symptoms despite normal glucose levels.
A 70-year-old female presents with acute back pain, and an x-ray spine reveals a fracture of the 4th lumbar vertebra.


She has the following blood tests:


||||
|---------------------------|:-------:|--------------------|
|Alkaline Phosphatase (ALP)|110 IU/L|25 - 115|
|Vitamin D|45 nmol/L|>50|
|Calcium|2.4 mmol/L|2.2 - 2.6|
|Phosphate|1.0 mmol/L|0.8 - 1.5|


A DEXA scan is later performed, which produces a T-score of -2.3.


What is the most likely diagnosis in this patient?

Options:
explanation: Paget's disease classically causes a raised ALP level
name: Paget's disease
label: e
answer: no
explanation: A T-score between -1.0 and -2.5 is consistent with a diagnosis of osteopenia
name: Osteopenia
label: a
answer: yes
explanation: A T-score of <-2.5 is the threshold for a diagnosis of osteoporosis
name: Osteoporosis
label: b
answer: no
explanation: Advanced osteoarthritis can, in fact, produce a higher than normal T-score on DEXA scan due to osteophytes and disc narrowing, making the bone appear denser than it is. This patient has a low T-score
name: Osteoarthritis
label: c
answer: no
explanation: Osteomalacia classically causes low vitamin D levels, low calcium, low phosphate, and a raised alkaline phosphate. This is not the case in this patient who has normal levels for all of these investigations
name: Osteomalacia
label: d
answer: no

Correct answer: a


Learning point: Osteopenia is diagnosed when a DEXA scan shows a T-score between -1.0 and -2.5, indicating reduced bone density.
A 40-year-old type 1 diabetic presents to her GP for a routine check-up. She has poor glycaemic control, her renal function has been deteriorating over the last few years, and she now has end-stage renal disease. She has a renal biopsy, and the histology is displayed below.

[lightgallery]

Which of the following is the most likely diagnosis?

Options:
explanation: Histologically, IgA nephropathy is associated with proliferation and hypercellularity of the mesangium of the glomerulus. Immunostaining would reveal IgA deposits
name: IgA nephropathy
label: e
answer: no
explanation: In minimal change disease the histology is normal, which is not seen on this slide. Minimal change disease is the most common cause of nephrotic syndrome in children.
name: Minimal change disease
label: b
answer: no
explanation: Renal amyloidosis would histologically demonstrate amyloid deposits, which this slide does not
name: Amyloidosis
label: c
answer: no
explanation: The histology above displays Kimmelstiel-Wilson nodules which are the spherical, eosinophilic, sclerotic nodules characteristic of nodular diabetic glomerulosclerosis
name: Nodular glomerulosclerosis
label: a
answer: yes
explanation: This is a genetic condition that produces the characteristic biopsy finding of longitudinal splitting of the glomerular basement membrane, which resembles a "basket weave" appearance
name: Alport syndrome
label: d
answer: no

Correct answer: a


Learning point: Nodular glomerulosclerosis, characterised by Kimmelstiel-Wilson nodules, is a common complication of long-standing type 1 diabetes leading to end-stage renal disease.
A 70-year-old patient is admitted to hospital with a stroke. During their hospital stay, they are started on enteral feeding via a nasogastric tube. They are persistently hyperglycaemic with their blood glucose monitoring as follows:


 - Monday AM: 14mmol/l
 - Monday PM: 13mmol/l
 - Tuesday AM: 15mmol/l
 - Tuesday PM: 16mmol/l
 (normal <6.1 mmol/l)

Their glucose levels were stable and consistently below 10mmol/l before enteral feeding was commenced. They have no past medical history of diabetes mellitus.


Which of the following is the best medication to start in this patient?

Options:
explanation: This is a sulphonylurea. It is recommended that patients who are hyperglycaemic after commencing enteral feeding should be started on insulin
name: Gliclazide
label: c
answer: no
explanation: According to the Joint British Diabetes Societies guideline, insulin should be commenced in those with persistent hyperglycaemia who have recently started enteral feeding
name: Insulin
label: a
answer: yes
explanation: This is a DPP-4 inhibitor. It is recommended that patients who are hyperglycaemic after commencing enteral feeding should be started on insulin
name: Sitagliptin
label: d
answer: no
explanation: This is a GLP-1 analogue. It is recommended that patients who are hyperglycaemic after commencing enteral feeding should be started on insulin
name: Dulaglutide
label: e
answer: no
explanation: This would be the first-line drug of choice in type 2 diabetes mellitus. However, as it would seem that the hyperglycaemia is a consequence of commencing enteral feeding, it is recommended that this patient is managed with insulin
name: Metformin
label: b
answer: no

Correct answer: a


Learning point: In patients with persistent hyperglycaemia following enteral feeding, insulin therapy is recommended to manage blood glucose levels effectively.
A 30-year-old female presents feeling unwell for the last 12 hours.


She has a background of Crohn's disease, for which she takes infliximab.


Her observations are as follows:


 - Heart rate 90 beats per minute
 - Blood pressure 110/90 mmHg
 - Temperature 38.1 °C


Her blood tests return as follows:

||||
|--------------|:-------:|---------------|
|Haemoglobin|120  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|
|C Reactive Protein|<5 mg/L|< 5|


What is the best next step in the management of this patient?

Options:
explanation: Although this patient has normal inflammatory markers, she is on a monoclonal antibody which can hide an inflammatory response, and so she should be admitted for further investigations +/- IV antibiotics. Those on biologics such as infliximab are at higher risk of more severe infection. CRP can often remain normal in patients with Crohn's disease, and serious complications such as an abscess or collection may not cause a rise in CRP
name: Admit for further investigations
label: a
answer: yes
explanation: This is not appropriate as she is on infliximab and is therefore at higher risk of serious infection
name: Discharge home with GP follow up in one week
label: b
answer: no
explanation: There are no specific guidelines about stopping, continuing or restarting biologics whilst pyrexial. She is not suitable for discharge as her infliximab may be hiding her inflammatory response, and she is more likely to have a serious infection
name: Discharge home with advice to withhold infliximab whilst pyrexial
label: c
answer: no
explanation: This patient is not suitable for discharge as her biologic may be hiding her inflammatory response, and she is more at risk of having a serious infection. However, sending urine for culture would be sensible if her urine is positive for leucocytes or nitrites when a dipstick test is performed
name: Discharge home after sending urine for culture
label: d
answer: no
explanation: This patient is not suitable for discharge as her biologic may be hiding her inflammatory response, and she is more at risk of having a serious infection. However, sending a stool sample is sensible if this the suspected source of infection, e.g. if she has diarrhoea
name: Discharge home after sending stool sample
label: e
answer: no

Correct answer: a


Learning point: Patients on infliximab for Crohn's disease may have normal inflammatory markers despite serious infections