hllj/quesmed huggingface dataset:
A 72-year-old man presents with shortness of breath on exertion. He has a past medical history of a previous myocardial infarction, hypertension, and hyperlipidaemia. On examination, he has peripheral oedema and bibasal crackles on chest auscultation. An echocardiogram confirms heart failure, with a left ventricular ejection fraction of approximately 35%.

Select the single most significant prognostic factor from the list below. Select one option only.

Options:
explanation: Bibasal crackles on chest auscultation suggest pulmonary congestion due to heart failure. However, they are not the most significant prognostic factor. They indicate the severity of current symptoms but do not provide as much prognostic information as LVEF.
name: Pulmonary congestion
label: c
answer: no
explanation: A history of hypertension is a significant risk factor for developing heart failure, but it is not the most critical prognostic factor once heart failure has been diagnosed. The degree of left ventricular dysfunction (measured by LVEF) has a greater impact on prognosis.
name: History of hypertension
label: d
answer: no
explanation: While the presence of peripheral oedema indicates volume overload and congestion, it is not the most significant prognostic factor in heart failure. Peripheral oedema is a symptom that can be managed with diuretics, but it does not directly correlate with mortality as strongly as LVEF.
name: Peripheral oedema
label: b
answer: no
explanation: Hyperlipidaemia is a risk factor for coronary artery disease and subsequent heart failure. However, it is not the most significant prognostic factor in patients already diagnosed with heart failure. Management of lipid levels is important, but LVEF provides more direct prognostic information.
name: History of hyperlipidaemia
label: e
answer: no
explanation: From the list of options given here, left ventricular ejection fraction (LVEF) is the most significant prognostic factor in heart failure. A lower LVEF is associated with a worse prognosis, as it indicates more severe systolic dysfunction and a higher risk of morbidity and mortality. This patient should ideally be commenced on a beta-blocker and an ACE inhibitor, as these have been shown to reduce mortality overall.
name: Left ventricular ejection fraction
label: a
answer: yes

Correct answer: a


Learning point: In heart failure, reduced ejection fraction (HFrEF) refers to LVEF <40%, indicating systolic dysfunction, while preserved ejection fraction (HFpEF) refers to LVEF ≥50%, indicating diastolic dysfunction with normal contraction.
An 85-year-old woman is admitted to the emergency department following a fall at home, resulting in a head injury. She has a past medical history of atrial fibrillation and is on apixaban. On examination, she is drowsy and confused. An urgent CT head scan shows an intracranial haemorrhage. The patient dies shortly afterwards.

Select the single most appropriate next step in management from the list below. Select one option only.

Options:
explanation: Asking the family if they want the death to be referred to the coroner is inappropriate, as referral to the coroner is a legal requirement in certain circumstances, including this case involving trauma and injury. The family should be kept informed of the events.
name: Ask the family if they want the death to be referred to the coroner
label: e
answer: no
explanation: In England and Wales, certain deaths must be referred to the coroner, including those likely due to trauma or injury, whether accidental or not. This case involves a head injury from a fall, leading to an intracranial haemorrhage, which qualifies for referral. Other examples of deaths that should be referred to the coroner include deaths due to unknown causes, deaths during surgical procedures, deaths under suspicious circumstances, and deaths in custody.
name: Refer to coroner
label: a
answer: yes
explanation: Completing the death certificate with intracranial haemorrhage as the cause is not appropriate in this case. The death must be referred to the coroner due to the traumatic nature of the injury.
name: Complete death certificate with intracranial haemorrhage as the cause
label: b
answer: no
explanation: Completing the death certificate with a fall as the cause is not appropriate. The death must be referred to the coroner due to the traumatic injury and subsequent intracranial haemorrhage.
name: Complete death certificate with fall as the cause
label: c
answer: no
explanation: Completing the death certificate with atrial fibrillation as the cause is incorrect because the primary cause of death was the intracranial haemorrhage resulting from the fall. This death needs to be referred to the coroner. A phrase along the lines of "atrial fibrillation (treated)" will be likely to ultimately go in part 2 of the certificate, reflecting that the anticoagulation contributed to the death but was not part of the direct sequence of events.
name: Complete death certificate with atrial fibrillation as the cause
label: d
answer: no

Correct answer: a


Learning point: Deaths resulting from trauma, such as intracranial haemorrhage after a fall, must be referred to the coroner for investigation.
A medical emergency call is put out for a 70-year-old female patient on a medical ward. Ventricular tachycardia (VT) is present on her ECG. She is haemodynamically stable. On examination, she is well perfused, has a GCS of 15, and has pitting oedema to her knees bilaterally.

She was admitted to hospital three days prior for an exacerbation of heart failure and was being treated with intravenous furosemide.

Which of the following treatments is most appropriate to manage VT in this patient?

Options:
explanation: Although this patient does have signs of heart failure (an "adverse feature"), this is chronic and long standing and doesn't appear to be secondary to her arrhythmia. Therefore, cardioversion is not indicated in this instance
name: Direct current (DC) cardioversion: one shock only
label: b
answer: no
explanation: Flecainide can be used to treat VT, but is not as effective as amiodarone
name: Flecainide
label: d
answer: no
explanation: Her heart failure is chronic and not secondary to her arrhythmia so this is not an indication for cardioversion. She has no other indications for cardioversion such as shock, syncope or myocardial ischaemia. If she did have any of these symptoms then up to 3 synchronised DC shocks can be given in attempt to cardiovert
name: Direct current (DC) cardioversion: up to 3 shocks
label: c
answer: no
explanation: According to NICE guidelines, amiodarone is the preferred drug to manage VT
name: Amiodarone
label: a
answer: yes
explanation: IV furosemide would not treat this patient's ventricular tachycardia
name: Bolus of IV furosemide
label: e
answer: no

Correct answer: a


Learning point: Amiodarone is the first-line treatment for stable ventricular tachycardia in patients with heart failure.
A 33-year-old woman presents to the out of hours general practitioner with a tender, fluctuant mass in her left breast, with associated erythema of the overlying skin. She is currently breast feeding. A breast abscess is confirmed on ultrasound and percutaneous drainage is performed uneventfully.

Her observations are as follows:

Pulse 80 beats per minute

Respiratory rate 17 breaths per minute

Blood pressure 115/75mmHg

Temperature 37.2°

She looks otherwise well, and is alert and orientated. Her renal function and liver function is within normal limits and she has an allergy to penicillin

Which of the following is the most appropriate antibiotic therapy?

Options:
explanation: This patient has a known penicillin allergy and therefore flucloxacillin is contraindicated
name: IV flucloxacillin
label: c
answer: no
explanation: She is haemodynamically stable and apyrexial and therefore intravenous antibiotics are not indicated at this point
name: IV erythromycin
label: d
answer: no
explanation: This patient has a known penicillin allergy and therefore co-amoxiclav is contraindicated
name: IV co-amoxiclav
label: e
answer: no
explanation: This patient has a known penicillin allergy and therefore flucloxacillin is contraindicated
name: Oral flucloxacillin
label: b
answer: no
explanation: As a penicillin allergic patient, this is the most appropriate antibiotic. As she is haemodynamically stable and apyrexial, oral antibiotics are appropriate
name: Oral erythromycin
label: a
answer: yes

Correct answer: a


Learning point: In breastfeeding women with a breast abscess, oral erythromycin is a suitable antibiotic choice for those allergic to penicillin.
A 70-year-old female is referred to the breast clinic with a left breast lump. A biopsy is obtained which shows a ductal carcinoma which is oestrogen receptor (ER) positive, HER2 negative, and progestogen receptor (PR) negative.

Which of the following medical therapies is indicated for the management of this patient's breast cancer?

Options:
explanation: This is correct. Anastrozole is an aromatase inhibitor which is used for ER positive breast cancer in post-menopausal women
name: Anastrozole
label: a
answer: yes
explanation: Tamoxifen is indicated in pre- and peri-menopausal women with ER-positive breast cancer not previously treated with tamoxifen
name: Tamoxifen
label: b
answer: no
explanation: Trastuzumab (Herceptin) is only useful in HER2 positive breast cancers
name: Trastuzumab
label: d
answer: no
explanation: This is not a treatment for breast cancer. In fact, HRT can increase a patient's risk of breast cancer
name: Hormone replacement therapy (HRT)
label: c
answer: no
explanation: This is a hormone therapy (LHRH agonist) used in the treatment of prostate cancer
name: Goserelin
label: e
answer: no

Correct answer: a


Learning point: Anastrozole is an aromatase inhibitor indicated for the treatment of oestrogen receptor-positive breast cancer in post-menopausal women.
A 30 year old man is referred to the outpatient ENT clinic with gradual onset bilateral sensorineural hearing loss and tinnitus.

On examination, he has absent corneal reflexes bilaterally.

An MRI cerebellopontine angle confirms bilateral vestibular schwannomas.

What is the most likely underlying diagnosis?

Options:
explanation: This is age-related sensorineural hearing loss. We can be fairly certain that the hearing loss are from his bilateral vestibular schwannomas which are shown on the MRI. This would not explain why he has bilateral vestibular schwannomas
name: Presbycusis
label: e
answer: no
explanation: Neurofibromatosis type 2 is a genetic condition characterised by tumour formation within nervous tissue. It is associated with bilateral vestibular schwannomas. They normally present by this age, unlike unilateral vestibular schwannomas which tend to present in older people
name: Neurofibromatosis type 2 (NF2)
label: a
answer: yes
explanation: Neurofibromatosis type 1 is also a genetic condition characterised by tumour formation within nervous tissue, and is more common than NF2, however is not associated with bilateral vestibular schwannomas. NF1 is associated with optic gliomas
name: Neurofibromatosis type 1 (NF1)
label: b
answer: no
explanation: There is no known association between HIV/acquired immune deficiency syndrome (AIDS) and vestibular schwannomas
name: HIV
label: c
answer: no
explanation: This is not a cause of bilateral vestibular schwannomas
name: Benign paroxysmal positional vertigo (BPPV)
label: d
answer: no

Correct answer: a


Learning point: Neurofibromatosis type 2 is characterised by bilateral vestibular schwannomas, typically presenting in young adults with hearing loss and tinnitus.
An 88 year old woman presents to her GP with recurrent episodes of dizziness and vertigo which she says is often brought on when rolling over in bed. The GP performs the Dix-Hallpike manoeuvre which is positive. She is keen for something to manage her symptoms.

What is the next best step in managing this patient's dizziness?

Options:
explanation: NICE guidelines suggest that ENT referral is only warranted if the signs of symptoms are atypical or do not resolve in 4 weeks, or there have been at least 3 periods during which the patient has experienced episodes of vertigo
name: Refer to ENT
label: c
answer: no
explanation: This is correct. This patient has benign paroxysmal positional vertigo (BPPV), as confirmed by the Dix-Hallpike manoeuvre. The patient can be taught Brandt-Daroff exercises to do at home. The patient should be advised to return after 4 weeks if her dizzy spells have not resolved
name: Brandt-Daroff exercises
label: a
answer: yes
explanation: Symptomatic drug treatment is of limited value in managing BPPV
name: Betahistine
label: b
answer: no
explanation: This is an anti-emetic to reduce vomiting.
name: Ondansetron
label: e
answer: no
explanation: Drug treatment is of limited value in the management of BPPV. Prochlorperazine may sometimes be used in viral labyrinthitis to manage dizziness
name: Prochlorperazine
label: d
answer: no

Correct answer: a


Learning point: Brandt-Daroff exercises involve a series of head and body movements performed at home to help reposition the otoliths in the inner ear, reducing the frequency and severity of vertigo episodes in benign paroxysmal positional vertigo (BPPV).
A 24 year old male presents to the Emergency Department with epistaxis which started 1 hour prior to being seen. The nurse practitioner has already applied nasal pressure for 15 minutes. On examination using a nasal speculum, there is an obvious bleeding site in the anterior aspect of the septum. The patient is haemodynamically stable.

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

Options:
explanation: This is not indicated at this stage as the patient is haemodynamically stable
name: Urgent transfer to ITU
label: c
answer: no
explanation: This is only indicated if the patient has had nasal packing
name: Refer to ENT for admission for observation
label: d
answer: no
explanation: This would be the next step if the bleeding stopped with first aid measures
name: Naseptin cream
label: e
answer: no
explanation: Nasal packing should only be considered in primary care if nasal cautery has been ineffective or the bleeding point cannot be seen
name: Nasal packing
label: b
answer: no
explanation: This is the next step in managing epistaxis if first aid measures have not worked and given that the appropriate expertise and facilities are available
name: Nasal cautery
label: a
answer: yes

Correct answer: a


Learning point: Nasal cautery is indicated for managing anterior epistaxis when initial measures, such as nasal pressure, are ineffective.
A 55 year old presents to the emergency department with sudden onset of breathlessness. He is known to have chronic obstructive pulmonary disease (COPD) and has smoked 20 cigarettes per day for approximately 40 years. His chest x-ray shows a pneumothorax of approximately 3cm in size.

His observations are all normal and his saturations are 96% on air.

What is the next step in this patient's management?

Options:
explanation: This patient has a pneumothorax with high-risk characteristics and so this patient requires admission and insertion of a chest drain
name: Discharge with safety netting advice
label: e
answer: no
explanation: This is correct. As this man is over 50 and has a significant smoking history, and is known to have lung disease, this is a pneumothorax with high-risk characteristics. The pneumothorax is over 2cm in size and is therefore amenable to drainage, with chest drain the best option.
name: Admit to hospital for a chest drain
label: a
answer: yes
explanation: High flow oxygen is not indicated at this stage. He has normal saturations on room air and, in addition to this, it is not unreasonable to suspect that this patient might be oxygen sensitive given his background of COPD
name: High flow oxygen
label: d
answer: no
explanation: This would be the case if the patient's pneumothorax was less than 1cm
name: Observe for 24h
label: c
answer: no
explanation: This would be the case if the patient's pneumothorax was an acceptable size without high-risk characteristics
name: Aspiration
label: b
answer: no

Correct answer: a


Learning point: For a pneumothorax greater than 2 cm in a high-risk patient, management typically involves needle aspiration or chest tube insertion to relieve pressure, improve lung expansion, and prevent complications like tension pneumothorax.
A cardiac arrest is called to a medical ward. On arrival, the patient is unresponsive and not breathing. Nursing staff on the ward have already commenced cardiopulmonary resuscitation (CPR) at a rate of 30:2 and attached the defibrillator. An ECG shows normal sinus rhythm, but central pulses cannot be felt.

According to the advanced life support (ALS) guidelines, what is the next step in this instance?

Options:
explanation: This patient has pulseless electrical activity (PEA), which is a non-shockable rhythm. The management should include immediate resumption of CPR, with a rhythm check in 2 minutes
name: Immediately resume CPR and then reassess rhythm in 2 minutes
label: a
answer: yes
explanation: PEA is a non-shockable rhythm and therefore shocks are not indicated
name: Give 1 shock, immediately resume CPR and reassess rhythm in 2 minutes
label: c
answer: no
explanation: This should only be attempted after ROSC
name: Examine the patient using an ABCDE approach
label: e
answer: no
explanation: Rhythm should be reassessed in 2 minutes
name: Immediately resume CPR and then reassess rhythm in 5 minutes
label: b
answer: no
explanation: This should only be done after return of spontaneous circulation (ROSC)
name: 12 lead ECG
label: d
answer: no

Correct answer: a


Learning point: In pulseless electrical activity (PEA), immediate CPR resumption is crucial, followed by rhythm reassessment after two minutes.
A known type 2 diabetic presents to the emergency department with generalised fatigue and vomiting. They have a reduced level of consciousness and are clinically dehydrated.


They are currently prescribed metformin 500mg once daily for their type 2 diabetes.


Their biochemical results may be seen below:

||||
|---------------------------|:-------:|------------------------------|
|Non-fasting Glucose|35 mmol/L|< 6.1|
|Sodium|144 mmol/L|135 - 145|
|Potassium|4.5 mmol/L|3.5 - 5.3|

 - Serum osmolarity: raised
 - Ketones: normal


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

Options:
explanation: This is the management of hyponatraemia in a euvolaemic patient. This patient has a normal sodium level and has is noted to be clinically dehydrated. This patient likely has hyperosmolar hyperglycaemic state (HHS) which leads to severe dehydration which is managed with IV fluids (not restricting)
name: Fluid restriction to 1L per day
label: d
answer: no
explanation: This is the first line fluid for management of hyperosmolar hyperglycaemic state (HHS). Compared to the serum of a patient with HHS, 0.9% is relatively hypotonic so should restore serum osmolarity to a normal level
name: IV 0.9% NaCl
label: a
answer: yes
explanation: This patient has hyperosmolar hyperglycaemic state (HHS) which should be addressed and treated before consideration of adjusting their long term diabetic medication
name: Increase their metformin to 500mg twice daily
label: e
answer: no
explanation: This is the management for hyperkalaemia. This patient has a normal potassium level and likely has hyperosmolar hyperglycaemic state (HHS). There is evidence to suggest that patients with HHS actually tend to have worse outcomes if they are treated with the diabetic ketoacidosis (DKA) protocol such as with an insulin infusion
name: Insulin and dextrose infusion
label: c
answer: no
explanation: This is incorrect. This patient has hyperosmolar hyperglycaemic state (HHS) which should be treated with fluids. There is evidence to suggest that patients with HHS actually tend to have worse outcomes if they are treated with the diabetic ketoacidosis (DKA) protocol such as with an insulin infusion
name: Sliding scale insulin infusion
label: b
answer: no

Correct answer: a


Learning point: In hyperosmolar hyperglycaemic state (HHS), intravenous 0.9% NaCl is the first-line treatment to restore fluid balance and serum osmolarity.
A 21 year old female presents to the emergency department. She claims she has taken an overdose of aspirin 90 minutes ago. She has a GCS of 15 and her blood tests reveal a salicylate concentration of 550 mg/L (normal therapeutic range 15-30 mg/dL).


Which of the following is the best management for this patient?

Options:
explanation: This is only indicated in patients with plasma salicylate concentration >700mg/L, severe acidosis, acute kidney injury, congestive cardiac failure or pulmonary oedema
name: Emergency haemodialysis
label: c
answer: no
explanation: This is correct. This patient should be considered for urinary alkalinisation with IV sodium bicarbonate, although local protocols should be consulted
name: IV sodium bicarbonate
label: a
answer: yes
explanation: Gastric lavage should only be considered within 1 hour of a potentially life threatening overdose
name: Gastric lavage
label: d
answer: no
explanation: Oral bicarbonate is not advisable as raising the pH of the gastrointestinal lumen can lead to remaining salicylate tablets in the gastrointestinal tract to dissolve and increase absorption of salicylates
name: Oral bicarbonate
label: b
answer: no
explanation: This is the management for opioid overdose
name: Naloxone
label: e
answer: no

Correct answer: a


Learning point: Urinary alkalinisation with intravenous sodium bicarbonate is a key treatment for severe salicylate toxicity.
A patient self presents after taking an overdose of their amitriptyline approximately two and a half hours ago. An ECG shows a ventricular arrhythmia.

Which of the following is indicated in this patient?

Options:
explanation: This, or IV lorazepam, is a second line option after IV sodium bicarbonate
name: Diazepam
label: c
answer: no
explanation: This is used in the management of paracetamol overdose
name: N-acetylcysteine
label: e
answer: no
explanation: Sodium bicarbonate is indicated in patients with a tricyclic antidepressant (TCA) overdose who have an arrhythmia. This should be bolused, and once narrowing of the QRS is shown, this should be switched to an infusion
name: Sodium bicarbonate
label: a
answer: yes
explanation: Vitamin K may be used to reverse warfarin ovedose
name: Vitamin K
label: b
answer: no
explanation: This is a tertiary option after IV sodium bicarbonate and IV benzodiazepine
name: Phenobarbital
label: d
answer: no

Correct answer: a


Learning point: Sodium bicarbonate is the treatment of choice for ventricular arrhythmias in tricyclic antidepressant overdose, particularly to narrow the QRS complex.