hllj/quesmed huggingface dataset:
A 22-year-old patient with a background of asthma is admitted with a four-hour history of palpitations.

His heart rate is 180bpm, blood pressure 110/68mmHg, respiratory rate 18, SpO2 98% on air

His ECG shows a heart rate of 183 bpm and a regular narrow complex tachycardia. The admission chest x-ray is clear, and troponin levels are normal.

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

Options:
explanation: Unsynchronised DC cardioversion (defibrillation) is used in cases of cardiac arrest in the presence of a shockable rhythm. The shock is delivered at any point in the cardiac cycle
name: Unsynchronised DC cardioversion
label: c
answer: no
explanation: Adenosine is contraindicated in poorly controlled asthmatics as it can cause bronchospasm. Therefore verapamil is often preferred in this cohort of patients who present with SVT if vagal manoeuvres fail
name: Verapamil
label: e
answer: no
explanation: The history and ECG findings are suggestive of a supraventricular tachycardia (SVT). In the absence of adverse features (myocardial ischaemia, heart failure, syncope or shock), the first-line management of an SVT is vagal manoeuvres. These aim to stimulate the vagus nerve to slow down the heart rate
name: Valsalva manoeuvre
label: a
answer: yes
explanation: Synchronised DC cardioversion is used in cases of SVT where there are adverse features (myocardial ischaemic, heart failure, syncope or shock) present.

In synchronised cardioversion, the electrical shock is delivered during ventricular depolarisation in the cardiac cycle. This is important to reduce the risk of the rhythm changing into a life-threatening cardiac arrest rhythm (e.g. VF)
name: Synchronised DC cardioversion
label: b
answer: no
explanation: Adenosine is a medication that induces a transient block at the AV node. It is used if vagal manoeuvres are unsuccessful, initially at a dose of 6mg
name: Adenosine
label: d
answer: no

Correct answer: a


Learning point: The Valsalva manoeuvre is the first-line treatment for stable supraventricular tachycardia, promoting vagal stimulation to restore normal heart rhythm.
A 65-year-old man is diagnosed with giant cell arteritis (GCA) and is commenced on once-daily, high dose oral steroids as an inpatient.


He has no past medical history, and primary care records showed normal glycosylated haemoglobin (HBA1C) levels three months ago.


Routine capillary blood glucose testing consistently reveal levels in the range 14-19 mmol/L (normal <6.1 mmol/L) with normal serum ketone levels.


Which of the following is the most appropriate next step in management?

Options:
explanation: Insulin can be used for steroid-induced diabetes; however, NovoRapid is a fast-acting insulin and would not help maintain normal glucose levels throughout the day. Intermediate-acting human insulins such as Humulin I would be a better option and may be started as an alternative to gliclazide at a dose of around 10 Units in the morning
name: 4 Units of NovoRapid administered after breakfast
label: b
answer: no
explanation: Guidelines suggest starting treatment for steroid-induced diabetes if blood sugar levels are > 12mmol/L on two occasions in a single twenty-four hour period
name: Monitor blood sugars and consider treatment if levels > 20mmol/l
label: e
answer: no
explanation: Dapagliflozin is a sodium-glucose co-transporter 2 (SGLT2) inhibitor. There is no evidence to support its use in the management of steroid-induced diabetes
name: Start dapagliflozin
label: d
answer: no
explanation: Pioglitazone is not usually used as a treatment for steroid-induced diabetes unless gliclazide and insulin are not appropriate
name: Start pioglitazone
label: c
answer: no
explanation: This patient has steroid-induced diabetes, and guidelines recommend starting treatment if blood glucose levels are greater than 12 mmol/L on two occasions in a single twenty-four hour period. A once-daily short-acting sulphonylurea such as gliclazide is the most commonly advocated treatment option. The dose can be increased up to 240mg in the morning, and an evening dose may also be added to achieve a maximum daily dose of 320mg
name: Start gliclazide
label: a
answer: yes

Correct answer: a


Learning point: Giant cell arteritis can result in steroid-induced diabetes, requiring blood glucose monitoring and, if necessary, the use of oral hypoglycaemic agents such as gliclazide.
A 25-year-old man presents with a history of a painful neck lump. He reports noticing the lump over the last two weeks following an upper respiratory tract infection. He denies palpitations, tremors, weight loss or night sweats.

On examination, there is a smooth central neck lump that moves with swallowing but not on protrusion of the tongue.

Blood tests, including thyroid function, are normal.

Which of the following is the most likely diagnosis?

Options:
explanation: A thyroglossal cyst would be expected to move upwards on protrusion of the tongue. It would also usually not present with pain
name: Thyroglossal cyst
label: b
answer: no
explanation: De Quervain's thyroiditis is a self-limiting thyroiditis that is often preceded by a viral infection. It can present with a painful goitre and thyrotoxicosis in the initial stages. The thyrotoxicosis is often followed by a transient period of hypothyroidism before thyroid function returns to normal. The normal thyroid function likely indicates that the patient is reaching the end of the illness. Treatment is symptomatic, and there is usually no role for anti-thyroid medications such as carbimazole
name: De Quervain’s thyroiditis
label: a
answer: yes
explanation: Grave's disease is the most common cause of thyrotoxicosis in the UK. It is an autoimmune condition that results in hyperthyroidism due to stimulatory autoantibodies against the thyroid-stimulating hormone (TSH) receptor. Normal thyroid function would exclude Grave's disease
name: Grave's disease
label: d
answer: no
explanation: Riedel thyroiditis usually presents as a painless thyroid mass that can be rapidly growing. It is characterised by a hardened, "woody" thyroid due to the replacement of the gland with fibrous tissue
name: Riedel thyroiditis
label: c
answer: no
explanation: Hodgkin's lymphoma usually presents with painless cervical or supra-clavicular lymphadenopathy that may be accompanied by B-symptoms (e.g. weight loss, night sweats, fevers)
name: Hodgkin's lymphoma
label: e
answer: no

Correct answer: a


Learning point: De Quervain's thyroiditis is a self-limiting condition often triggered by viral infections, presenting with a painful goitre and transient thyroid dysfunction.
A 45-year-old woman presents to her General Practitioner (GP) with weakness in her shoulders and hips. She also reports an unintentional weight gain of 5kg over the last three months and associated easy bruising.

On examination, she is hypertensive, with central adiposity and violaceous striae are present on her abdomen.

She is subsequently referred to an endocrinologist.

Which of the following is the best initial investigation given the likely underlying diagnosis?

Options:
explanation: Cushing's syndrome can be caused by an adrenal lesion such as an adenoma or carcinoma, and imaging may help confirm this diagnosis. However, this would usually be done once a diagnosis of Cushing's syndrome has been confirmed biochemically
name: CT adrenal glands
label: e
answer: no
explanation: The symptoms and signs described are suggestive of Cushing's syndrome. Although a 24 hour urinary free cortisol can be used as an intial investigation to confirm cushing's syndrome, cortisol can be raised by  high fluid intake, stress and medications. There are also difficulties with collecting 24 hour urine so an overnight dexamethasone suppression test is preferred these days. 
name: 24 hour urinary free cortisol
label: a
answer: no
explanation: 9 am cortisol levels are the initial screening test for primary adrenal insufficiency. Given that serum cortisol levels match the circadian rhythm, a serum 9 am cortisol has no use as a screening test for Cushing's syndrome
name: 9 am cortisol
label: b
answer: no
explanation: Cushing's disease is Cushing's syndrome caused by a pituitary adenoma. An MRI would be indicated to confirm the diagnosis of a pituitary adenoma; however, this would usually be done once a diagnosis of Cushing's syndrome has been confirmed biochemically
name: MRI pituitary gland
label: d
answer: no
explanation: The symptoms and signs described are suggestive of Cushing's syndrome. The ovrnight dexamthasone suppression test is preferred these days to 24 hour urinary free cortisol given it's practicality. 
name: Overnight dexamethasone suppression test
label: c
answer: yes

Correct answer: c


Learning point: The diagnosis of Cushing's syndrome can be confirmed using a 24-hour urinary free cortisol test, which measures the amount of cortisol excreted in urine over a 24-hour period. Elevated levels of urinary free cortisol are indicative of hypercortisolism, supporting the diagnosis of Cushing's syndrome.
A 56-year-old man presents to his GP with a history of burning and numbness in his feet and lower legs for the last two months. His past medical history is significant for poorly controlled Type 1 diabetes and a previous duodenal ulcer.

On neurological examination, there is reduced sensation to pin-prick and fine-touch bilaterally from the feet to the knees.

Given the likely diagnosis, which of the following is the next best step in management?

Options:
explanation: Low strength capsaicin cream can be used for the treatment of localised neuropathic pain. This patient's pain is more widespread and so topical treatment is unlikely to be beneficial. A patch containing 8% capsaicin is an option for peripheral neuropathic pain and could be considered under specialist supervision
name: Start 0.075% capsaicin cream
label: e
answer: no
explanation: Neuropathic pain may be responsive to treatment with opioids such as morphine. However, it should be reserved for persistent symptoms refractory to treatment with anti-depressants (e.g. amitriptyline or duloxetine) and anti-epileptics (pregabalin or gabapentin)
name: Start modified-release morphine sulphate
label: d
answer: no
explanation: Regular paracetamol would not be particularly useful for the treatment of neuropathic pain
name: Start regular paracetamol
label: c
answer: no
explanation: This patient has signs and symptoms of diabetic neuropathy. Other symptoms of neuropathic pain include tingling, sensitivity to touch and electric-like sensations. NICE guidelines suggest using amitriptyline, duloxetine, pregabalin or gabapentin as the first-line treatment for neuropathic pain
name: Start duloxetine
label: a
answer: yes
explanation: Ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) and is not particularly useful for treating neuropathic pain. It would also not be appropriate in this case, given the history of a duodenal ulcer, as NSAIDs are a major cause of gastric and duodenal ulceration
name: Start ibuprofen
label: b
answer: no

Correct answer: a


Learning point: Duloxetine is an effective first-line treatment for neuropathic pain in patients with diabetic neuropathy.
A 56-year-old man with progressive motor neurone disease is assessed by the speech and language team due to concerns about his swallowing.

Following the assessment, the recommendation is that he would benefit from a pureed diet to reduce the risk of aspiration.

Having explained the recommendation and the risks associated with continuing with a normal diet, the patient refuses and states that he wishes to continue with a normal diet. He can understand, retain and weigh up the decision but only able to communicate in writing.

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

Options:
explanation: The patient has capacity and can communicate his decision. There's no indication of psychiatric illness here so a referral to psychiatry is not indicated or appropriate
name: Refer to psychiatry for a full psychiatric assessment
label: c
answer: no
explanation: As long as the patient has retained, understood, weighed up and communicated a decision, there is no need for further justification unless you are unsure of the patient's understanding
name: Ask the patient to justify his decision
label: e
answer: no
explanation: The three key components for informed consent are capacity, provision of adequate information and non-coercion. The patient has the capacity to decide about his feeding as he can understand, retain, weigh up, and communicate a decision. Therefore, his wishes should be accepted
name: Accept the patient's decision and continue with risk-feeding
label: a
answer: yes
explanation: The patient has the capacity to make this decision as he can understand, retain, weigh up, and communicate his wishes
name: Start a pureed diet as the patient lacks capacity
label: b
answer: no
explanation: As the patient has met the criteria for having the capacity to make a decision regarding his feeding, there is no need to reassess
name: Reassess capacity the following day
label: d
answer: no

Correct answer: a


Learning point: Patients with capacity have the right to refuse medical recommendations, even if it poses risks to their health.
A junior medical student has learnt that all patients have a legal right to confidentiality. However, he is unsure of the circumstances in which confidentiality can be breached.

In which of the following situations does a doctor have a legal duty to breach confidentiality?

Options:
explanation: Drivers have a legal duty to inform the Driver and Vehicle Licensing Agency (DVLA) if they have a condition that impairs their ability to drive. A doctor should inform the patient of this duty and make every reasonable effort to make sure they do this. However, if a patient continues not to disclose the information, doctors have a **_professional duty_** to break confidentiality in the public's best interests
name: Conditions that impair the ability to drive
label: b
answer: no
explanation: In these cases, the doctor should first try and convince the patient to make the disclosure themselves. If this is not possible, a doctor should disclose the necessary information only and try and avoid identifying the patient where possible. This would be considered a case where a doctor may have a **legal defence** for breaching confidentiality in the public's best interests
name: Disclosing personal information to a sexual partner
label: e
answer: no
explanation: If the harm is only to the patient, a doctor should accept a competent adult's refusal to disclose information. However, if there are any children involved, a referral to social services is mandated
name: Domestic violence involving a young couple
label: c
answer: no
explanation: Identification of patients who are suspected of committing a road traffic offence is one of the specific statutory requirements where doctors have a legal duty to break confidentiality
name: Identification of a patient who committed a road traffic offence
label: a
answer: yes
explanation: General Medical Council (GMC) guidance in 2017 has highlighted that there is no duty to inform the police in the case of serious crime. However, a doctor may still break confidentiality if they believe that it is in the public's best interests. In these cases, there may be a **legal defence** for breaching confidentiality
name: Gunshot/knife wounds
label: d
answer: no

Correct answer: a


Learning point: Doctors have a legal duty to breach confidentiality when a patient is suspected of committing a road traffic offence.
An 85-year-old man with a background of metastatic prostate cancer is admitted to hospital with a stroke. On examination, he has significant left-sided weakness and sensory loss but no disturbance in cognition or speech.

Which of the following is the most appropriate next step in regards to advanced care planning?

Options:
explanation: CPR should be discussed with the patient prior to making a decision on whether they should be for it or not.
name: Proceed with full treatment and keep the patient for CPR
label: e
answer: no
explanation: It is good practice to discuss patients' wishes regarding CPR even in cases such as this where it is unlikely to be successful. This is important to maintain an honest and transparent patient-doctor relationship
name: Explore the patient's wishes regarding CPR
label: a
answer: yes
explanation: Although CPR is unlikely to be successful, it would be inappropriate to complete a DNACPR form without a discussion regarding the matter with the patient
name: Complete a do not attempt cardiopulmonary resuscitation (DNACPR) as CPR is not likely to be successful
label: c
answer: no
explanation: It would not be appropriate to ask the patient's family for their opinion without the patient's prior consent unless this was done in the patient's best interest. There are no signs to suggest that the patient lacks capacity in this case so it would be worth speaking to the patient first
name: Ask the patient's family about their thoughts on CPR
label: d
answer: no
explanation: Although CPR is unlikely to be successful, there is no reason why active treatment for the patient's stroke and cancer should not continue
name: Explain to the patient why active treatment will not be offered
label: b
answer: no

Correct answer: a


Learning point: In advanced care planning, it is essential to discuss patients' wishes regarding CPR, regardless of their prognosis.
A 32-year-old woman attends an appointment in the emergency surgery clinic due to persistent abdominal pain.

The patient is seen by a doctor and listed for an outpatient cholecystectomy following a review of the imaging she had the previous day.

However, it transpires that the doctor has mistakenly reviewed the imaging of a patient with the same name, having failed to check the patient's age and hospital number.

Which of the following principles is most pertinent following identification of this error?

Options:
explanation: Shared decision refers to a process where both the doctor and the patient contribute towards making a personalised decision on management
name: Shared decision making
label: e
answer: no
explanation: Duty of candour states that "all healthcare professionals should be open and honest with patients when treatment or care causes, or has the potential to cause, harm or distress". In this situation, the doctor should contact the patient as soon as possible and inform them of the error. They should also report the incident so it can be investigated internally to reduce similar occurrences in the future
name: Professional duty of candour
label: a
answer: yes
explanation: Informed consent relies on the principles of the patient being fully informed, having mental capacity and not being coerced into a decision. It is not applicable in this case as the patient has consented to a surgery based on the wrong information
name: Informed consent
label: d
answer: no
explanation: The doctrine of double effect states that if the primary intervention was in a patient's best interests, then an unintended adverse effect is not necessarily unlawful. It does not apply in this case
name: The doctrine of double effect
label: c
answer: no
explanation: Confidentiality is a legal right that all patients have. Although the doctor has inadvertently breached confidentiality by informing the patient of another patients test results, duty of candour is more pertinent given that a patient is likely to undergo an unnecessary operation
name: Confidentiality
label: b
answer: no

Correct answer: a


Learning point: Duty of candour states that "all healthcare professionals should be open and honest with patients when treatment or care causes, or has the potential to cause, harm or distress"
A 56-year-old man with a background of type 2 diabetes and hypertension presents to his GP for a routine set of blood tests.


He reports regularly drinking approximately 14 Units of alcohol per week. His body mass index (BMI) is 30, and a set of routine observations are unremarkable.


The blood tests reveal an alanine transaminase (ALT) of 195 U/L (7-56 U/L) and a gamma-glutamyl transferase (GGT) level of 85 U/L (<10 U/L). Glycosylated haemoglobin levels (HBA1C) are noted to be 52 mmol/l (42-47 mmol/l).


Which of the following is the most likely explanation for the deranged liver function tests?

Options:
explanation: Haemochromatosis is a disorder of iron overload and can either be primary (an autosomal recessive disorder that results in an inability to regulate iron absorption) or secondary (due to frequent blood transfusions in conditions such as thalassaemia major). Haemochromatosis can cause liver disease and diabetes; however, the strong metabolic risk factors make NAFLD more likely in this case
name: Haemochromatosis
label: c
answer: no
explanation: Although this patient drinks regular alcohol, his consumption is not excessive. It is, therefore, unlikely that he has alcoholic liver disease
name: Alcoholic liver disease
label: b
answer: no
explanation: This patient has diabetes, hypertension and obesity, which are three major risk factors for NAFLD. NAFLD is the most common cause of liver disease worldwide and is characterised by fatty infiltration of hepatocytes without a secondary cause. It is strongly linked to metabolic syndrome, and the most typical liver enzyme abnormality is a raised ALT and/or GGT
name: Non-alcoholic fatty liver disease (NAFLD)
label: a
answer: yes
explanation: Viral hepatitis is less likely as the patient has no risk factors (e.g. recent travel, history of intravenous drug use, recent tattoos/piercings, blood transfusion etc.) or symptoms. Viral hepatitis would also usually present with a more significant rise in transaminases (i.e. ALT and AST). It should, however be excluded by conducting a full viral screen
name: Viral hepatitis
label: d
answer: no
explanation: Autoimmune hepatitis is a rare cause of chronic liver disease that is more common in women and those with a background of other autoimmune diseases (e.g. type 1 diabetes, autoimmune thyroid disease, ulcerative colitis). NAFLD is more likely in this case
name: Autoimmune hepatitis
label: e
answer: no

Correct answer: a


Learning point: Non-alcoholic fatty liver disease (NAFLD) is commonly associated with obesity, diabetes, and hypertension, leading to elevated liver enzymes.