hllj/quesmed huggingface dataset:
A 67 year old man is noted to have an irregularly irregular pulse during a routine examination. His medical history is significant for hypertension and a previous TIA. His GFR is >90.

Observations:

* Heart rate: 73 beats per minute

* Blood pressure: 134/85 mmHg

* Temperature: 36.9 degrees

Investigations:

* ECG: No discernible P waves

* Echocardiogram: Moderate mitral stenosis

What is the most appropriate next step in management?

Options:
explanation: This would be appropriate for symptomatic control of paroxysmal atrial fibrillation, when patients are aware of the arrhythmia occurring.
name: PRN flecanide
label: b
answer: no
explanation: The patient's CHA2DS2-VASc score is 4. The BNF advises Edoxaban be used with caution in moderate to severe mitral stenosis as the safety and efficacy of the medication has not been established.
name: Edoxaban
label: d
answer: no
explanation: There is no indication for cardioversion. The patient is haemodynamically stable, and cardioversion is unlikely to resolve valvular AF
name: DC cardioversion
label: c
answer: no
explanation: Surgical intervention is only required when mitral stenosis is severe or symptomatic. In this case, it is moderate.
name: Mitral comissurotomy
label: e
answer: no
explanation: The patient's CHA2DS2-VASc score is 4 due to a history of TIA (2 points), hypertension (1 point) and age 65-74 years (1 point). The BNF advises that Edoxaban be prescribed with caution in patients with moderate to severe mitral stenosis, making warfarin the most appropriate anticoagulant of choice here.
name: Warfarin
label: a
answer: yes

Correct answer: a


Learning point: Patients with atrial fibrillation, a history of Transient Ischaemic Attack (TIA) or stroke, hypertension, and age over 65 years are often considered for anticoagulation to reduce the risk of thromboembolic events.
A 65-year-old woman with a history of breast cancer (managed with surgery and Doxorubicin chemotherapy) presents with a 6-month history of breathlessness on exertion. A chest x-ray shows cardiomegaly, bilateral infiltrates and pleural effusions.

What is the most likely cause of her clinical condition?

Options:
explanation: Ischaemic heart disease is a common cause of heart failure, however the absence of risk factors (smoking, diabetes, hypertension, ethnicity, etc.) and the history of breast cancer make this less likely.
name: Ischaemic heart disease
label: d
answer: no
explanation: Bilateral pleural effusions would be an unusual presentation of pleural metastases. Bilateral alveolar oedema is more in keeping with heart failure.
name: Pleural metastases
label: b
answer: no
explanation: Amyloidosis is a rare cause of heart failure.
name: Amyloidosis
label: e
answer: no
explanation: Patients presenting with ARDS generally have a more acute course of illness.
name: Acute respiratory distress syndrome
label: c
answer: no
explanation: Doxorubicin is commonly used in the treatment of breast cancer. Cardiotoxicity is an establised side-effect.
name: Dilated cardiomyopathy
label: a
answer: yes

Correct answer: a


Learning point: Chemotherapy drugs such as doxorubicin can cause dilated cardiomyopathy leading to breathlessness, cardiomegaly, bilateral infiltrates, and pleural effusions.
A 24-year-old man and 23-year-old woman with no medical history visit their GP with concerns of infertility. They have been trying to conceive for 1.5 years. A private blood test reveals that the woman has a normal FSH level and day 21 progesterone.

What is the next most appropriate step in management?

Options:
explanation: A pelvic ultrasound can be helpful in assessing the structural integrity of the reproductive organs, including the uterus and ovaries. However, since the woman has normal FSH and progesterone levels, indicating normal ovulatory function, and there is no indication of structural abnormalities from the history provided, a pelvic ultrasound is not the immediate next step. A semen analysis would be prioritised first.
name: Pelvic ultrasound
label: b
answer: no
explanation: Whilst pregnancy is likely to happen within 2 years of unprotected intercourse, it would be inappropriate to not investigate the couple further at this stage.
name: Reassure them that pregnancy is likely to take place in the next six months
label: c
answer: no
explanation: NICE recommend investigations (and consideration for onward referral) for couples who have tried to conceive unsucessfully for one year. The woman has already had first line investigations (mid-luteal phase progesterone). The man also requires investigation with semen analysis. Both partners should be screened for STIs (especially Chlamydia).
name: Semen analysis
label: a
answer: yes
explanation: Invasive tests may be required in the future, however, this would not be the next most appropriate step.
name: Salpingogram
label: e
answer: no
explanation: While a referral to a fertility specialist is often warranted in cases of prolonged infertility, it usually occurs after completing basic investigations, including semen analysis and assessments of ovulation. Once these preliminary tests are done, if an issue is identified or if the results are inconclusive, a referral would be appropriate. Therefore, semen analysis is the step that should precede a specialist referral.
name: Referral to a fertility clinic
label: d
answer: no

Correct answer: a


Learning point: Infertile couples who have tried unsuccessfully to conceive for one year should undergo semen analysis as part of their investigation, alongside screening for sexually transmitted infections for both partners.
A 43-year old woman experiences sudden-onset painless visual loss. She has a history of rheumatoid arthritis and poorly controlled type 2 diabetes mellitus.

Which of the following management plans is likely to treat the cause of her condition?

Options:
explanation: This would be appropriate for giant cell arteritis, which would present with pain and tenderness over the temporal arteries, along with systemic upset.
name: IV methylprednisolone
label: b
answer: no
explanation: There  is no evidence of a viral infection of the eye.
name: Valganciclovir
label: e
answer: no
explanation: This would be the correct treatment for giant cell arteritis with no visual involvement. As the patient has no pain or tenderness over the temporal arteries, giant cell arteritis is unlikely.
name: PO prednisolone
label: c
answer: no
explanation: Timolol would be useful in the treatment of acute angle closure glaucoma, which would be painful.
name: Topical timolol
label: d
answer: no
explanation: The most likely diagnosis is vitrial haemorrhage, which is treated by a vitrectomy. This is because patients with poorly controlled diabetes often develop proliferative diabetic retinopathy, in which fragile blood vessels which are prone to bleeding form.
name: Vitrectomy
label: a
answer: yes

Correct answer: a


Learning point: In patients with poorly controlled diabetes, bleeding from fragile retinal vessels due to proliferative diabetic retinopathy can cause sudden painless visual loss, requiring urgent intervention such as vitrectomy.
A 23-year old medical student visits her GP after developing a cough and multiple annular lesions across her trunk. Blood tests show evidence of low haemoglobin and high reticulocyte count.

Which of the following investigations is best for establishing the diagnosis?

Options:
explanation: Mycoplasma cannot be detected on conventional light microscopy.
name: Microscopy
label: e
answer: no
explanation: Mycoplasma is not a virus. Without the mention of the cough, herpes simplex could have a likely cause of the erythema multiformae.
name: Viral PCR
label: b
answer: no
explanation: Urinary antigen testing is useful for legionella and pneumococcus, rather than mycoplasma.
name: Urinary antigen
label: d
answer: no
explanation: The diagnosis is most likely mycoplasma pneumoniae, for which serology is the best test (from those provided). The rash the patient is experiencing is erythema multiformae, which can be caused by mycoplasma, a common cause of pneumonia in young adults. The patient has evidence of haemolysis as indicated by the low haemoglobin level and elevated reticulocytes which can occur in the context of mycoplasma. Additional testing may show elevated Cold agglutinin titers and a positive Coombs test. It often causes outbreaks amongst those in crowded areas/living conditions, such as university students.
name: Serology
label: a
answer: yes
explanation: Mycoplasma is not a retrovirus.
name: RT-PCR
label: c
answer: no

Correct answer: a


Learning point: In young adults presenting with atypical pneumonia and erythema multiforme, serological testing is crucial for diagnosing mycoplasma pneumoniae infections, characterised by haemolysis and elevated reticulocytes.
A 75 year old man is brought to the emergency department after being found unwell at home. His ECG shows evidence of fast atrial fibrillation.

Observations show:

* Pulse rate 130

* Blood pressure 96/64

* Temperature 38.8 degrees celcius

* Respiratory rate 24 breaths/minute

What is the most appropriate next step in management?

Options:
explanation: There is no indication for adenosine, which is used in SVT in the absence of adverse features.
name: Adenosine
label: c
answer: no
explanation: Flecanide is used for paroxysmal AF. The patient appears septic and this is the likely cause for this patient's arrythmia and thus should be addressed first.
name: Flecanide
label: e
answer: no
explanation: Although DC cardioversion can be considered if the patient is significantly hypotensive in the context of a tachyarrythmia, a common cause of fast atrial fibrillation is dehydration and sepsis, both of which can be treated initially with a fluid bolus as part of routine resuscitation, which is the next best step. 
name: DC cardioversion
label: b
answer: no
explanation: This patient appears to be septic. Their tachycardia and hypotension suggest a fluid bolus is required. If shock remains fluid unresponsive, the patient may require inotropes. Additionally, a common cause of Atrial Fibrillation is dehydration so a reasonable first line treatment in ED is to give a fluid bolus to manage this.
name: Fluid bolus
label: a
answer: yes
explanation: Beta blockers should not be used in sepsis or hypotension.
name: Bisoprolol
label: d
answer: no

Correct answer: a


Learning point: A septic patient with tachycardia and hypotension may benefit from initial management with a fluid bolus.
A 45-year-old man visits his GP complaining of erectile dysfunction. He describes a gradual onset of symptoms, and is frustrated that while he has normal libido, he cannot maintain an erection. He has diabetes and a history of angina, for which he takes metformin and isosorbide mononitrate.

What is the most appropriate management for his symptoms?

Options:
explanation: The patient's insidious presentation and normal libido suggests an organic cause for his erectile dysfunction.
name: Cognitive behavioural therapy
label: e
answer: no
explanation: The patient's insidious presentation and normal libido suggests an organic cause for his ED. Further, SSRIs may cause/exacerbate erectile dysfunction.
name: Sertraline
label: d
answer: no
explanation: The patient's insidious presentation and normal libido suggests an organic cause for his ED. As sildenafil is contraindicated due to his nitrate use (concurrent use of both of these may cause profound hypotension), this is the most appropriate management.
name: Intracavernosal prostaglandins
label: a
answer: yes
explanation: The patient's insidious presentation and normal libido suggests an organic cause for his erectile dysfunction.
name: Psychosexual therapy
label: c
answer: no
explanation: Concurrent use of nitrates (such as ISMN) and sildenafil can cause profound hypotension.
name: Sildenafil
label: b
answer: no

Correct answer: a


Learning point: Organic causes of erectile dysfunction in men with normal libido may require treatment with intracavernosal prostaglandins if they have contraindications to phosphodiesterase inhibitors.
A 32-year-old gentleman has three episodes of red urine that have now resolved. A urine microscopy shows red cell casts, with no white cells and no bacteria seen.

What is the single most appropriate investigation for definitive diagnosis?

Options:
explanation: The presence of casts on microscopy suggests a glomerular pathology, for which a renal biopsy would be the gold standard for diagnosis.
name: Renal biopsy
label: a
answer: yes
explanation: This is not yet indicated and would not give a definitive diagnosis.
name: CT abdomen and pelvis
label: c
answer: no
explanation: This would be indicated to visualise the urinary bladder if red blood cells (rather than red cell casts) were seen. A cystoscopy may be paired with a US KUB or CT urogram.
name: Flexible cystoscopy
label: b
answer: no
explanation: This is not indicated as an investigation for haematuria.
name: PET scan
label: d
answer: no
explanation: An abdominal ultrasound may be required to image the urinary tract, however this will not reveal the definitive diagnosis of a glomerulonephritis.
name: Abdominal ultrasound
label: e
answer: no

Correct answer: a


Learning point: Red cell casts on urine microscopy suggest a glomerular condition
A 29-year-old female has a dense left-sided hemiparesis. A CT head shows no evidence of haemorrhage, but an MRI brain shows an area of infarcted tissue. She is found to have a right-sided deep vein thrombosis and has a history of being immobilised following a tibial plateau fracture. She has never had any miscarriages and has no family history of clotting pathologies.

Which investigation is best for confirming why she has had a stroke?

Options:
explanation: Sickle cell testing may occur if there are other features of the disease, however this is not likely based on the scenario.
name: Haemoglobin electrophoresis
label: c
answer: no
explanation: Antiphospholipid syndrome can be part of a 'young stroke' work-up and is known to cause arterial and venous clots, however the history of immobilisation explains the cause of DVT. An investigation is required to uncover why this embolus has moved from the venous to the arterial circulation.
name: Antiphospholipid antibodies
label: e
answer: no
explanation: This may be tested for as part of a 'young stroke' work-up, although the history of immobilisation explains the DVT. However, an investigation is required to uncover why this embolus has moved from the venous to the arterial circulation.
name: Factor V Leiden testing
label: b
answer: no
explanation: Tests for myeloma or other paraproteinaemias may occur as part of a 'young stroke' work-up, however the history of immobilisation explains the DVT. However, an investigation is required to uncover why this embolus has moved from the venous to the arterial circulation.
name: Serum protein electrophoresis
label: d
answer: no
explanation: Thrombi in the venous circulation (e.g. DVTs) tend to stay within the veins and cause pulmonary emboli. In this case, the thrombus appears to have moved into the arterial circulation, causing a stroke. A reason for this could be a cardiac defect such as a patent foramen ovale, which would be detected on a bubble echocardiogram.
name: Bubble echocardiogram
label: a
answer: yes

Correct answer: a


Learning point: A patent foramen ovale could explain the passage of thrombi from the venous to arterial circulation, causing a stroke.
A 42-year-old man has a CT head to investigate acute confusion and left-sided weakness. The scan shows a crescentic hyperdense area around the brain on the right-hand side.

Given the most likely diagnosis, which aspect of his history is likely to have contributed to his condition?

Options:
explanation: Whilst trauma can cause subdural haemorrhages, the hyperdense (white) appearance suggests this is acute. Historical trauma would not account for an acute subdural haemorrhage.
name: Head trauma as a child
label: d
answer: no
explanation: A ruptured aneurysm would most likely cause a subarachnoid haemorrhage, presenting as blood filling the basal cisterns on CT scan.
name: Berry aneurysm
label: c
answer: no
explanation: This is unlikely to contribute to the development of a subdural haematoma.
name: Family history of Alzheimer's disease
label: b
answer: no
explanation: Patients who are chronically hypertensive are prone to deep lacunar haemorrhages. There is no known association between subdural haemorrhages and hypertension.
name: Hypertension
label: e
answer: no
explanation: The diagnosis from the scan is an acute subdural haematoma, which occurs when the bridging veins between the brain and saggital sinus rupture. Risk factors include older age and alcohol use, as these both cause brain atrophy, which stretches the veins.
name: Chronic alcohol use
label: a
answer: yes

Correct answer: a


Learning point: Subdural haemorrhages are more common in older adults and heavy alcohol users due to brain atrophy and vein stretching.
A patient with prostate cancer is referred to hospital by his GP due to severe back pain. On examination, he has altered perineal sensation and global hyperreflexia in both lower limbs.

Which is the most important next step in management?

Options:
explanation: This may be required if the patient is not a candidate for neurosurgery and is found to have MSCC, however this is not the most appropriate next step in management.
name: External beam radiotherapy
label: e
answer: no
explanation: This may be required following the MRI whole spine, but not before dexamethasone is given.
name: Refer to neurosurgery
label: d
answer: no
explanation: An urgent MRI whole spine will be required, but waiting for this before administering dexamethasone is not appropriate. The most important next step is to give dexamethasone.
name: MRI spinal cord
label: b
answer: no
explanation: An MRI brain (looking for metastases) may be required if the MRI spine does not yield a diagnosis, however the most likely cause is MSCC given the bilateral symptoms and saddle anaeshesia.
name: MRI brain
label: c
answer: no
explanation: The likely diagnosis is metastatic spinal cord compression. 16mg dexamethasone (either PO or IV) should be administered without delay, as per NICE guidelines. After this, the maintenance dose is 8mg BD.
name: Dexamethasone
label: a
answer: yes

Correct answer: a


Learning point: In cases of suspected metastatic spinal cord compression, prompt administration of dexamethasone is essential to reduce inflammation and prevent further damage.
A 19-year-old man is referred to the emergency department by his GP after he experiences 'one of the worst headaches of his life'. He describes a throbbing pain above his right eye, accompanied by severe nausea and light intolerance.

Observations show:
* Temperature 37.2 degrees celsius
* Heart rate 76 beats/minute
* Blood pressure 124/85mmHg
* Respiratory rate 14 breaths/minute

On examination, he looks well although is obviously in pain. There are no focal neurological deficits, nuchal rigidity, or photophobia.

Given the most likely diagnosis, what is the most appropriate management?

Options:
explanation: Given that the most likely cause here is a migraine it would be unnecessary to perform a MRI. A CT head would often be performed acutely to exclude an intercranial haemorrhage but this would not be a likely diagnosis given the overall clinical picture.
name: MRI head
label: c
answer: no
explanation: There is no evidence that this patient is experiencing an infective meningitis, given the lack of fever and meningism.
name: IV cefuroxime
label: e
answer: no
explanation: The history and examination findings are consistent with the diagnosis of a migraine. High dose NSAIDs + paracetamol should be used in the first instance. According to NICE guidelines, the first line treatment for acute attacks of migraine include Ibuprofen 400mg, Aspirin 900mg or Paracetamol 1g. 
name: Ibuprofen 400mg
label: a
answer: yes
explanation: NSAIDs should be tried in the first instance, following the WHO pain ladder. Opioids should not routinely be used in migraines. Overuse of weak opioids (e.g. codeine) can contribute to medication overuse headaches.
name: Morphine sulphate (oral)
label: d
answer: no
explanation: There is no evidence that this patient is experiencing an infective meningitis or subarachnoid haemorrhage. A lumbar puncture is not yet indicated.
name: Lumbar puncture
label: b
answer: no

Correct answer: a


Learning point: In acute migraine attacks, Ibuprofen 400mg is an effective first-line treatment as per NICE guidelines.
A 32-year-old female junior doctor is seen in a 'first fit' clinic after experiencing a generalised tonic-clonic seizure. They are awaiting further investigations, however the decision is made to start anti-epipleptic medication as the risk that a seizure at work would pose is very high. They have no known drug allergies and a past medical history of hypothyroidism.

What would be the most appropriate medication to start?

Options:
explanation: Ethosuximide is usually used for generalised absence seizures, rather than tonic-clonic seizures.
name: Ethosuximide
label: b
answer: no
explanation: Carbamazepine is not a first-line drug for any seizure type. It is a second-line option for focal seizures not well controlled on lamotrigine/levetiracetam.
name: Carbamazepine
label: d
answer: no
explanation: While sodium valproate is the first line choice in generalised tonic-clonic seizures, it should not be used in women of child bearing potential due to extreme teratogenicity. It can be used in girls under the age of 10, and in women who are unable to have children (e.g. those who have had a hysterectomy). Lamotrigine/levetiracetam are the preferred options.
name: Sodium valproate
label: e
answer: no
explanation: As this patient is experiencing generalised tonic-clonic seizures and are starting treatment, they require a broad-spectrum antiepileptic. Valproate (the first line drug in this situation) is contraindicated due to its teratogenicity; it should not be prescribed to females of child-bearing age. Lamotrigine or levetiracetam are good alternatives.
name: Levetiracetam
label: a
answer: yes
explanation: Clobazam is a second-line drug for generalised tonic-clonic seizures, if the patient is not well controlled on first line options. Other second-line drugs include perampanel and topiramate.
name: Clobazam
label: c
answer: no

Correct answer: a


Learning point: Valproate is contraindicated in women of childbearing age due to its high risk of teratogenic effects, making levetiracetam a preferred first-line treatment for generalized tonic-clonic seizures because of its safer profile during pregnancy.