hllj/quesmed huggingface dataset:
A clinical trial recruited 1000 participants to evaluate the efficacy of a new anti-hypertensive. 500 participants were randomly assigned to receive amlodipine whilst the other 500 participants were assigned to receive a new anti-hypertensive for 1 year. The primary objective of the study was to evaluate the efficacy of each drug in reducing blood pressure in both groups. However, 21 participants taking amlodipine and 57 participants taking the new anti-hypertensive left the clinical trial before it completed as they experienced unwanted side effects. The study did not include these participants in the final results and concluded that the new anti-hypertensive was not effective at reducing blood pressure compared to amlodipine.

Which of the following types of bias is this study at risk of?

Options:
explanation: Studies with positive or statistically significant results are more likely to be published in journals, whereas those without statistically significant results are less likely to be published. This may make effect sizes appear better or greater than they actually are. This is not the type of bias represented in this question.
name: Publication bias
label: e
answer: no
explanation: This is incorrect because time interval bias occurs when a clinical trial is stopped early once the desired conclusion is achieved.
name: Time interval bias
label: c
answer: no
explanation: Recall bias refers to a skew that occurs due to individuals with a certain outcome (or without a certain outcome) being more (or less) likely to recall an exposure, as the outcome has already been achieved. For example, individuals with lung cancer may be more likely to recall even small amounts of smoking history, which may positively skew the data.
name: Recall bias
label: d
answer: no
explanation: Sampling bias describes a skew in the data that occurs when some members of a population are more likely to be selected for inclusion within a study than others. There is no indication of this being an issue within the question, for example an inadequate mix of genders or ethnicities.
name: Sampling bias
label: b
answer: no
explanation: Bias refers to a skew in the data due to a systematic issue at any stage of a study. In this case, participants have dropped out due to unwanted side-effects, which is likely to give a negative skew to the results, as they are not followed up for long enough or included in the final results, to determine if the drug had an impact on their blood pressure or not. This is referred to as attrition bias.
name: Attrition bias
label: a
answer: yes

Correct answer: a


Learning point: Attrition bias occurs when participants drop out of a study or trial in a way that affects the validity of the results, leading to a biased sample that may not accurately represent the original population.
A 59-year-old male presents to the GP for a follow-up appointment after his hypertension annual review. He is currently asymptomatic and takes amlodipine 10mg once daily. His average blood pressure reading is 151/98mmHg.

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

Options:
explanation: Beta-blockers are used in the management of hypertension after conventional therapies - ACEi, calcium channel blockers, and thiazide-like diuretics - have been considered. It is a 4th line agent, alongside spironolactone and alpha-blockers; spironolactone is used when the potassium is <4.5, and a beta-blocker/alpha-blocker >4.5. Side effects of atenolol include vivid dreams, erectile dysfunction, and fatigue.
name: Prescribe atenolol
label: d
answer: no
explanation: Nifedipine is another dihydropyridine calcium channel blocker like amlodipine. It is unlikely he will respond to this when he has not responded to amlodipine, and the two would not be prescribed together. The next step is therefore to add an ACEi.
name: Prescribe nifedipine
label: e
answer: no
explanation: This is incorrect because this patient's blood pressure is greater than his target, and so his antihypertensive management requires escalation. He is already on maximum dose amlodipine and continuing this is unlikely to achieve his target.
name: Continue amlodipine
label: b
answer: no
explanation: Anti-hypertensives should only be discontinued if they produce  unwanted side effects or if the patient refuses to take them, since adding additional agents is more likely to produce better control than substituting with novel agents. Indapamide is a thiazide-like diuretic which is used after calcium channel blockers and ACEi as a third step. Common side effects of indapamide include hyperuricaemia, postural hypotension, and hypokalaemia.
name: Discontinue amlodipine and prescribe indapamide
label: c
answer: no
explanation: This is the correct answer because this patient is already taking amlodipine hence the next step in management is to add an ACE-inhibitor such as ramipril. Step 2 in the management of hypertension involves combining an ACE-inhibitor with a calcium channel blocker. The blood pressure target for this patient (an adult under 80) should be 140/90mmHg in clinic and 135/85mmHg at home. Remember common side effects of ACE-inhibitors such as a dry cough, delayed angioedema, and a dry mouth.
name: Prescribe ramipril
label: a
answer: yes

Correct answer: a


Learning point: For patients with persistent hypertension who are already taking a calcium channel blocker (CCB), adding a second-line medication like an ACE inhibitor such as ramipril can be an effective to acheive an acceptable blood pressure.
A 55-year-old man presents to the gastroenterology outpatient clinic with his wife. His wife is very concerned because his voice has changed over the past year and his appetite has reduced, though he reports no dysphagia. He has no significant past medical history. He has been smoking since the age of 16. On examination, he appears significantly cachectic. An endoscopy shows evidence of an oesophageal adenocarcinoma and a CT chest, abdomen, pelvis identifies metastases to the liver. His consultant decides to begin a course of chemotherapy in a few weeks.

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

Options:
explanation: This is correct because patients with oesophageal adenocarcinoma who undergo chemotherapy or radiation therapy as supportive treatment can get painful sores in the mouth and throat. This reduces appetite causing further weight loss. A gastrostomy tube is a feeding tube which can provide nutrition. In the question stem, it states that he is significantly cachectic and not eating well. This feeding tube is placed into the stomach and can be removed when no longer needed. Note that in this context, chemotherapy will be palliative, to relieve symptoms and slow down the growth, rather than to cure the cancer.
name: Gastrostomy tube
label: a
answer: yes
explanation: This is incorrect because palliative radiotherapy, as would be offered in a patient with metastatic cancer, is used to control local, advanced symptoms, such as pain, bleeding, dysphagia, and spinal cord or cerebral metastases. This patient may have palliative radiotherapy needs, but he is going to start chemotherapy soon, and as such his nutrition  is the next priority, in the absence of any  other red flags necessitating early radiotherapy such as bleeding or cord compression.
name: Radiation therapy
label: b
answer: no
explanation: Oesophageal resection in the treatment of adenocarcinomas is an option for early stage presentations where curative intent is possible. In this case, our patient has evidence of metastases to the liver, and so treatment options available to him would only be palliative and supportive in nature.
name: Oesophageal resection
label: e
answer: no
explanation: This is incorrect because dilation is required for areas that are narrowed or blocked to improve difficulty swallowing. A balloon-like device is placed into the throat to stretch the area which can help with symptoms of dysphagia. However, this question stem points towards the main issue as poor nutrition and reduced appetite, leading to cachexia. He reports no dysphagia.
name: Oesophageal dilation
label: c
answer: no
explanation: This is incorrect because although an oesophageal stent can improve difficulty swallowing, this patient does not report any dysphagia. An oesophageal stent is a hollow tube which is placed in the area of a tumour resulting in oesophageal narrowing to relieve dysphagia.
name: Oesophageal stent placement
label: d
answer: no

Correct answer: a
A 70 year old man presents to the GP for a routine asthma check-up. He is incidentally noted to have a coarse tremor in his right hand whilst reaching for a pen. On examination, the tremor is present in both hands when outstretched, and also affects his jaw. Neurological examination is otherwise unremarkable. He mentions that several family members also have similar tremors.

Which condition is the most likely cause of his tremor?

Options:
explanation: Whilst cerebellar dysfunction can cause a bilateral intention tremor (occurs at the end of a purposeful movement e.g. as a finger reaches almost to its target), you would expect other cerebellar signs on examination (remember neumonic DANISH: Disdiadochokinesis, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia). Again, the family history and jaw involvement make Essential tremor more likely.
name: Cerebellar lesion
label: e
answer: no
explanation: PD is characterised by a **resting** tremor, usually unilateral, and is often-described as 'pill-rolling' (small circular movements of thumb and forefinger) in nature. It would not usually affect the jaw and PD is usually idiopathic and so would not be expected to affect multiple other family members. There are no other features of parkinsonism in the question to support this.
name: Parkinson's Disease
label: c
answer: no
explanation: Essential tremor is a common condition characterised by an action/postural tremor which is classically bilateral and can also affect the neck/jaw/voice. There is often a family history and onset can be at any age. Symptoms can sometimes be transiently improved with alcohol or beta-blockade.
name: Essential Tremor
label: a
answer: yes
explanation: Whilst withdrawal tremors do affect both hands, there is no indication that this patient drinks excess alcohol, nor any other symptoms of withdrawal such as sweating/anxiety/nausea. These clues and the family history make it a less likely answer than Essential tremor.
name: Alcohol dependence syndrome
label: b
answer: no
explanation: Salbutamol use can cause a transient fine (rather than coarse) tremor in both hands. Whilst the patient is noted to have asthma, this is a red-herring and less likely to be causing his tremor. It also would not be expected to affect multiple family members or the jaw.
name: Salbutamol
label: d
answer: no

Correct answer: a
A 79 year old male with a urinary tract infection on the medical  ward is acutely agitated and confused. He is shouting, disturbing other patients and the ward nurses are struggling to cope. He is pulling out his lines and trying to climb out of bed. He is 70kg and only past medical history is gout.

Which of the following is the most appropriate initial management of this situation?

Options:
explanation: Whilst this is a good thought, de-escalation should be the initial management of delirium and part of this assessment would be whether pain is a contributing factor. Paracetamol should therefore only be given in certain circumstances rather than as a first line treatment for every delirious patient.
name: Give some paracetamol as he may be in pain
label: e
answer: no
explanation: It is important to use the least invasive or restrictive management option first. This includes verbal and non-verbal de-escalation techniques to help calm the patient down. This might include validating their distress,  re-orientation, calling in family members, and trying to reduce deliriogenic factors (PINCH ME: Pain, Infection, Nutrition, Constipation, Hydration, Medication, Environment).
name: De-escalation techniques
label: a
answer: yes
explanation: Sedation is a form of restraint, and carries risk. It should not be administered before trying to de-escalate with communication techniques first. Oral sedation is less invasive than intramuscular and therefore is preferable if possible in the given situation; however, Haloperidol is the NICE recommended pharmacological agent of choice.
name: Lorazepam 500 micrograms PO
label: d
answer: no
explanation: All sedation is a form of restraint, and carries risk. Sedation can worsen delirium, increase falls risk and have side-effects. It should not be administered before trying non-pharmacological interventions first. Haloperidol is first-line **pharmacological** acute treatment for delirium where a patient poses a risk to themselves or others. It has cardiac and neurological side-effects and is contraindicated in Parkinson's and Lewy Body Dementia.
name: Haloperidol 500 micrograms IM
label: b
answer: no
explanation: All sedation is a form of restraint, and carries risk. Sedation can worsen delirium, increase falls risk and have side-effects. It should not be administered before trying non-pharmacological interventions first. Lorazepam is a reasonable sedative option but haloperidol is the only agent recommended (with caution) by NICE.
name: Lorazepam 500 micrograms IM
label: c
answer: no

Correct answer: a
A 68 year old male is becoming increasingly aggressive and agitated on the ward. He is confused and lashing out at staff members despite several attempts at de-escalation. He has acute pneumonia, a past medical history of metastatic rectal cancer and Lewy Body Dementia.

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

Options:
explanation: De-escalation has already been tried and failed in this case. It is reasonable to also take more restrictive measures i.e. pharmacological intervention.
name: De-escalation techniques
label: d
answer: no
explanation: Phenobarbital is a long-acting sedative-hypnotic anti-epileptic agent that is not recommended. Haloperidol would usually be first-line treatment but Lewy Body Dementia (and Parkinson's disease) contraindicate its use. Other notable contraindications include recent myocardial infarction, long QTc, hypokalaemia, and decompensated heart failure.
name: Phenobarbital
label: b
answer: no
explanation: While bloods may be useful for identifying underlying causes of his delirium, it would be practically dangerous if the patient is resisting intervention and not useful in the acute setting where rapid de-escalation or sedation is  needed in the first instance.
name: Take some blood tests
label: e
answer: no
explanation: Lorazepam is a reasonable first-choice benzodiazepine for sedation in this case as it is rapid onset and short acting. Haloperidol would usually be first-line treatment but Lewy Body Dementia (and Parkinson's Disease) contraindicate its use. Other notable contraindications include recent myocardial infarction, long QTc, hypokalaemia, and decompensated heart failure.
name: Lorazepam
label: a
answer: yes
explanation: Diazepam is a long-acting benzodiazepine; a short-acting agent like lorazepam would be preferable to minimise restraint and adverse effects. Haloperidol would usually be first-line treatment but Lewy Body Dementia (and Parkinson's disease) contraindicate its use. Other notable contraindications include recent myocardial infarction, long QTc, hypokalaemia, and decompensated heart failure.
name: Diazepam
label: c
answer: no

Correct answer: a
A 77 year old female with acute constipation and a recent diagnosis of Alzheimer's disease has a 2 day history of worsening confusion. She was highly disorientated this morning however is lucid on review later that afternoon.

Which of the following tools would be most appropriate to diagnose and assess this patient's new confusion?

Options:
explanation: The PHQ-9 is a tool for assessment of depression severity in primary care. The acute and fluctuating confusion and clinical context suggests delirium in this case, rather than depression or pseudo-dementia.
name: PHQ-9 (Patient Health Questionnaire-9)
label: e
answer: no
explanation: NICE recommend the short-CAM to assess and confirm a diagnosis of delirium. The acute and fluctuating course, and clinical context suggest delirium rather than other causes of confusion.
name: Short-CAM (Confusion Assessment Method)
label: a
answer: yes
explanation: The MoCA is used for assessment of cognitive impairment rather than delirium. The acute and fluctuating course suggest delirium rather than worsening dementia. Dementia is a risk factor for delirium.
name: MoCA (Montreal Cognitive Assessment)
label: d
answer: no
explanation: The MMSE is used for assessment of cognitive impairment rather than delirium. The acute and fluctuating course suggest delirium rather than worsening dementia. Dementia is a risk factor for delirium.
name: MMSE (Mini-Mental Status Exam)
label: b
answer: no
explanation: The MSE is a tool for assessment of psychiatric conditions by way of observation and interaction with a patient. The acute and fluctuating confusion and clinical context suggests delirium rather than psychosis or pseudo-dementia.
name: MSE (Mental State Examination)
label: c
answer: no

Correct answer: a
A 67 year old male is brought to GP by his family over concerns for his memory. He has type 2 diabetes, a previous CABG and COPD. He has had a sudden deterioration in his cognition three weeks ago, with persistent confusion and difficulty with word finding. He had a similar abrupt decline last year and needed additional support ever since.

Which of the following is the most likely diagnosis?

Options:
explanation: FTD is classically characterised by behavioural and personality changes, and would be expected to have a progressive rather than step-wise decline.
name: Frontotemporal dementia
label: e
answer: no
explanation: Lewy Body Dementia (LBD) has a progressive onset and distinguishing features can include Parkinsonism, REM sleep disorder and visual hallucinations.
name: Lewy Body Dementia
label: c
answer: no
explanation: Vascular dementia tends to have a 'step-wise' decline, with multiple vascular events causing acute on chronic deficits. This patient has risk factors and evidence of vasculopathy.
name: Vascular dementia
label: a
answer: yes
explanation: Pseudodementia is a term used to describe cognitive impairment associated with psychiatric disorders especially depression in the elderly. There is no suggestion of depression in the question; therefore, dementia is more likely.
name: Pseudodementia
label: d
answer: no
explanation: While there can be overlap in that vascular dementia can affect any part of the brain and therefore mimic Alzheimer's Disease, AD has a slow and progressive onset.
name: Alzheimer's dementia
label: b
answer: no

Correct answer: a
Which of the following best describes the mechanism of action of Levodopa in the treatment of Parkinson's disease?

Options:
explanation: Levodopa, also known as L-DOPA, can cross the blood-brain barrier (unlike dopamine), where it is then converted into dopamine by DOPA-decarboxylase to replenish depleted dopamine supplies in the brain.
name: It is a dopamine precursor and therefore acts as a prodrug
label: a
answer: yes
explanation: Dopamine analogues have a similar but different structure to dopamine and therefore can work as dopamine agonists. Example include cabergoline, bromocriptine, pramipexole, ropinirole and rotigotine.
name: It is a dopamine analogue
label: e
answer: no
explanation: Dopamine re-uptake inhibitors are not commonly used to treat Parkinson's disease. Examples of noradrenaline/dopamine-reuptake inhibitors include buproprion and modafnil.
name: It is a dopamine re-uptake inhibitor
label: d
answer: no
explanation: Levodopa is a substrate for this enzyme, rather than acting to increase the rate of its metabolism
name: It accelerates DOPA-decarboxylase activity
label: b
answer: no
explanation: This enzyme converts levodopa to dopamine. Notably, its inhibition it would reduce dopamine production and therefore not be desirable.
name: It inhibits DOPA-decarboxylase
label: c
answer: no

Correct answer: a
A 65 year old male presents to GP with 2 day history of diarrhoea and soiling. He denies fevers; he feels nauseous but is otherwise well with no vomiting. Previously he has tended towards constipation and opens his bowels on average three times per week. He denies weight loss or bleeding per rectum.
On examination he has diffuse mild abdominal tenderness, and hard stool in his rectum but no blood.

Which of the following is the most likely diagnosis?

Options:
explanation: The change is bowel habit is very acute and there are no other red flags in context. It would not be the most likely diagnosis at this point.
name: Colorectal cancer
label: b
answer: no
explanation: A good differential, however, hard stool in the rectum and history of constipation would go against this. There are no infective symptoms or vomiting to support this.
name: Gastroenteritis
label: c
answer: no
explanation: Common in this age group; however, you would not expect hard stool on per rectum examination, and might expect a more inflammatory history.
name: Diverticulitis
label: d
answer: no
explanation: Coeliac disease would classically present younger, more chronically and with general symptoms such as weight loss. There may other auto-immune history.
name: Coeliac disease
label: e
answer: no
explanation: Severe constipation can lead to diarrhoea as liquid stool flows around immovable solid stool in the bowel.
name: Overflow diarrhoea
label: a
answer: yes

Correct answer: a
Which of the following is most commonly used as an end of life 'anticipatory' medication to treat symptoms of nausea and vomiting?

Options:
explanation: Levomepromazine is a typical antipsychotic drug that affects multiple receptor types (adrenergic, dopaminergic, histamine, muscarinic and serotonin receptors). It is used primarily for its anti-emetic and sedative properties in palliative care.
name: Levomepromazine
label: a
answer: yes
explanation: Midazolam is a rapid acting benzodiazepine used to treat terminal agitation at the end of life.
name: Midazolam
label: c
answer: no
explanation: Betahistine is used as a treatment for vertigo in menieres disease
name: Betahistine
label: e
answer: no
explanation: Glycopyrronium is an anti-cholinergic (anti-muscarinic) agent used to reduce excessive secretions at the end of life.
name: Glycopyrronium
label: b
answer: no
explanation: Hyoscine Butylbromide (commonly referred to by a brand name, Buscopan) is an anti-spasmodic, not used as an anti-emetic.
name: Hyoscine Butylbromide
label: d
answer: no

Correct answer: a