hllj/quesmed huggingface dataset:
A 65 year old male patient is brought into A&E by ambulance. He had been feeling generally unwell with palpitations and dizziness for the last 3 hours. The paramedics state the only past medical history of note is high cholesterol for which the patient takes atorvastatin and they have no allergies. The paramedic crew have not yet administered any treatment.

Observations are as follows:
HR: 156bpm.
RR: 22.
BP: 130/78.
Temp: 36.7.
O2 Sats: 98% on room air.
BM: 6.2mmol.

Blood tests and a chest x-ray are requested. The ECG shows a supraventricular tachycardia with a regular rhythm

Which of the following is the first line management of this patient's condition?

Options:
explanation: The ECG shows a supraventricular tachycardia (SVT) with a regular rhythm, in the context of a clinically stable patient. The first line management is a Valsalva manoeuvre. By contrast, cardioversion should be used in a patient in SVT who is unstable and has adverse features such as heart failure, ischaemia, shock or syncope.
name: Synchronised direct current cardioversion
label: c
answer: no
explanation: The ECG shows a supraventricular tachycardia with a regular rhythm, in the context of a clinically stable patient. The first line management is a Valsalva manoeuvre. This aims to increase vagal tone and slow the conduction through the atrioventricular node, thus leading to a slowing of the heart rate.
name: Valsalva manoeuvre
label: a
answer: yes
explanation: The ECG shows a supraventricular tachycardia (SVT) with a regular rhythm, in the context of a clinically stable patient. By contrast, flecainide is the pharmacological management for rhythm control in a patient with fast atrial fibrillation.
name: Flecainide
label: d
answer: no
explanation: The ECG shows a supraventricular tachycardia with a regular rhythm, in the context of a clinically stable patient. The first line management is a Valsalva manoeuvre. By contrast, adenosine is the treatment of choice in a stable supraventricular tachycardia if vagal manoeuvres have failed. Adenosine temporarily blocks the conduction through the AV node and should always be followed by 20ml IV normal saline. Patients must be warned about experiencing difficulty in breathing, chest tightness and flushing.
name: Adenosine 6mg
label: b
answer: no
explanation: The ECG shows a supraventricular tachycardia (SVT) with a regular rhythm, in the context of a clinically stable patient. By contrast, amiodarone is used mainly for stable patients with a broad complex tachycardia or for both rate and rhythm control in atrial fibrillation. It is not the first line management for SVT.
name: Amiodarone
label: e
answer: no

Correct answer: a
A 63 year old female attends their GP practice with chest pain and shortness of breath on exertion, which has been present for around 6 months. Last week, she lost consciousness while cleaning the kitchen, preceded by light-headedness. Her daughter witnessed the episode, noting brief twitching but no tongue biting or incontinence.

She has a history of hypertension and high cholesterol, and smokes 10 cigarettes per day.


On examination:


 * HR: 78bpm.
 * BP: 146/87.
 * O2 sats: 96% on air.
 * RR 18.
 * Temp: 37.1.


The GP notes an ejection systolic murmur over the second intercostal space on the right side of the sternum.


Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is the most likely diagnosis. This patient has been experiencing angina, dyspnoea and one episode of syncope. Her past medical history includes risk factors for aortic stenosis such as hypertension, high cholesterol and cigarette smoking. The ejection systolic murmur indicates aortic stenosis as the diagnosis.
name: Aortic stenosis
label: a
answer: yes
explanation: This is incorrect. Although the patient experienced a loss of consciousness with twitching movements, this is also fairly common in vasovagal syncope due to a brief decrease in blood flow to the brain; especially given there is no past medical history of epilepsy. There is no evidence of a post-ictal period and no tongue-biting or incontinence. Her symptoms of angina, dyspnoea and syncope as well as an ejection systolic murmur are more in keeping with a diagnosis of aortic stenosis.
name: Hypoglycaemia
label: d
answer: no
explanation: This is incorrect. Although the patient most likely experienced vasovagal syncope, this is not the root cause of the issue. Her symptoms of angina, dyspnoea and syncope as well as an ejection systolic murmur are more in keeping with a diagnosis of aortic stenosis.
name: Vasovagal syncope
label: c
answer: no
explanation: This is incorrect. Although the patient presents with breathlessness on exertion and is a smoker, her symptoms of angina, dyspnoea and syncope as well as an ejection systolic murmur are more in keeping with a diagnosis of aortic stenosis.
name: Chronic Obstructive Pulmonary Disease
label: e
answer: no
explanation: This is incorrect. Although the patient experienced a loss of consciousness with twitching movements, this is also fairly common in vasovagal syncope due to a brief decrease in blood flow to the brain; especially given there is no past medical history of epilepsy. There is no evidence of a post-ictal period and no tongue-biting or incontinence. Her symptoms of angina, dyspnoea and syncope as well as an ejection systolic murmur are more in keeping with a diagnosis of aortic stenosis.
name: Tonic-clonic seizure
label: b
answer: no

Correct answer: a

Aortic stenosis
A 57 year old male presents to A&E with palpitations and dizziness for the past 7 days. He denies any chest pain or loss of consciousness.

He has a past medical history of high cholesterol and chronic obstructive pulmonary disease (COPD), but is able to stay fit and active, and enjoys country walks.

On examination:
A - clear and patent.
B - chest clear, bilateral equal air entry, trachea central.
C - bilateral equal radial pulses, irregularly irregular pulse, heart sounds I+II+0.
D - BM 6.5, temperature 37.2.

Observations are as follows:
HR 125.
RR 20.
Saturations 95% on air.
GCS 15/15.
BP 138/84.

An ECG shows fast atrial fibrillation.

Which of the following is the first-line treatment?

Options:
explanation: This is incorrect. Beta-blockers are contraindicated in COPD. Therefore a rate-limiting calcium channel blocker is the medication of choice.
name: Bisoprolol
label: b
answer: no
explanation: This is incorrect. The patient is stable and there is no clear onset time of the atrial fibrillation. If it were persistent the patient would need to be anticoagulated before cardioversion due to the increased risk of throwing off a clot. A rate-limiting calcium channel blocker is the medication of choice.
name: DC cardioversion
label: c
answer: no
explanation: This is incorrect. This is usually considered in those with non-paroxysmal atrial fibrillation who are sedentary. It would not be used first line in this situation. A rate-limiting calcium channel blocker is the medication of choice.
name: Digoxin
label: d
answer: no
explanation: This is the correct answer. The patient is suffering from fast atrial fibrillation (AF). The patient is stable and there is no clear onset time of their AF, thus it should be managed by rate control. As they have COPD beta-blockers are contra-indicated. Therefore a rate-limiting calcium channel blocker is the medication of choice.
name: Diltiazem
label: a
answer: yes
explanation: This is incorrect. This is used in rhythm control of fast atrial fibrillation if the onset time is <48hrs. As the onset time appears to be around 7 days in this case, the patient should be rate-controlled. Therefore a rate-limiting calcium channel blocker is the medication of choice.
name: Flecainide
label: e
answer: no

Correct answer: a
An 80 year old female attends her GP surgery for a routine review. The clinician auscultates the heart, and notes the first heart sound (S1) and second heart sounds (S2), with no murmurs.

Which of the following heart valves closes during the second heart sound (S2)?

Options:
explanation: This is incorrect. Both aortic and pulmonary valves close during S2.
name: Pulmonary only
label: c
answer: no
explanation: This is incorrect. The tricuspid valve closes during S1 along with the mitral valve. Both aortic and pulmonary valves close during S2.
name: Tricuspid only
label: d
answer: no
explanation: This is incorrect. The mitral valve closes during S1 along with the tricuspid valve. Both aortic and pulmonary valves close during S2.
name: Mitral only
label: e
answer: no
explanation: This is the correct answer. During S2 the ventricles relax and the pressure in the aorta and pulmonary artery exceeds the ventricular pressure. Both valves close, however the aortic will close slightly before the pulmonary valve.
name: Aortic and pulmonary
label: a
answer: yes
explanation: This is incorrect. Both aortic and pulmonary valves close during S2.
name: Aortic only
label: b
answer: no

Correct answer: a
A 6-year-old girl presents to A&E with a week of feeling unwell, including sore throat, reduced appetite, abdominal pain, and joint pain. The parents are concerned as she has now developed a rash that they noticed earlier in the day. They deny any diarrhoea or vomiting.

On, the patient is generally tender across her abdomen. A petechial rash is seen across the back of her legs and buttocks. Neurological examination is unremarkable.


Observations are as follows:
BP - 100/62.
HR - 89bpm.
Saturations - 98% on room air.
RR - 24.
Temperature - 37.8C.


The rash can be seen below. [lightgallery]


Blood tests show a raised CRP and IgA levels.


Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is incorrect. Although an important differential diagnosis to consider, it is unlikely in this case. Leukaemia can present with a petechial rash and raised inflammatory markers, however a raised white cell count and pancytopenia are also likely to be present on a full blood count.
name: Leukaemia
label: e
answer: no
explanation: This is incorrect. This would usually not present with abdominal pain or arthritis and is often associated with thrombocytopenia.
name: Immune thrombocytopenic purpura
label: c
answer: no
explanation: This is incorrect. Although presenting with a rash of a similar nature and raised inflammatory markers, meningitis would usually present with neck stiffness, photophobia and fever. On examination Brudzinski's and Kernig's signs may be present.
name: Meningitis
label: b
answer: no
explanation: This is the correct answer. Henoch-Schonlein Purpura (HSP) is a small vessel vasculitis mediated by IgA. It mainly affects the skin, gastrointestinal tract and the kidneys. This child is suffering from the classical symptoms of abdominal pain, arthritis and the palpable purpuric rash over the extensor surfaces of the lower limbs. Renal function will need to be monitored, and she will need to be monitored for signs of intussusception.
name: Henoch-Schonlein Purpura
label: a
answer: yes
explanation: This is incorrect. Although presenting with a rash of a similar nature and raised inflammatory markers, meningitis would usually present with neck stiffness, photophobia and fever. On examination Brudzinski's and Kernig's signs may be present.
name: Haemolytic Uraemic Syndrome
label: d
answer: no

Correct answer: a

Henoch-Schonlein Purpura
A 52 year old male of Chinese descent presents to the GP with a feeling of persistent feeling of nasal congestion. They have tried over the counter allergy medications which have not improved their symptoms. As well as nasal congestion, the patient reports frequent sneezing and a tickly cough. He is otherwise well, with no past medical history and no regular medications, although he notes that his diet can be quite high in salt.

He has a family history of nasopharyngeal carcinoma, and is very worried about also having cancer.

Which of the following symptoms would prompt the GP to make a 2 week suspected cancer referral to Ear Nose and Throat (ENT)?

Options:
explanation: This is the incorrect answer. This would usually indicate the patient is suffering from a sinusitis.
name: Purulent nasal discharge
label: b
answer: no
explanation: This is the correct answer. Unilateral polyps are concerning for nasopharyngeal carcinomas and require urgent referral.
name: Worsening unilateral nasal obstruction
label: a
answer: yes
explanation: This is incorrect. Although unilateral sinus pain is a red flag symptom, bilateral pain is more suggestive of sinusitis, and would not requite a 2 week wait suspected cancer referral.
name: Bilateral sinus pain
label: d
answer: no
explanation: This is incorrect. Sneezing is a common symptom in allergic rhinitis, rhinosinusitis and nasal obstruction and does not in itself prompt an urgent ENT referral.
name: Sneezing
label: e
answer: no
explanation: This is incorrect. Nasal pruritis is a common symptoms in seasonal allergies and allergic rhinitis. It often improves with anti-histamines, and does not requite a 2 week wait suspected cancer referral.
name: Nasal pruritis
label: c
answer: no

Correct answer: a
A 25-year-old female is brought to A&E by ambulance on day 2 of antibiotics for a suspected UTI. She reports feeling extremely unwell with nausea and lower back pain. She has no past medical history and no allergies to any medication.



On examination:



She is alert to voice, appears pale and has an elevated work of breathing.



Her observations are as follows:



RR - 24.
HR - 123.
BP - 81/55.
Temperature - 38.5C.
O2 saturations - 97% on air.



An venous blood gas is obtained and the results are shown below:



||||
|--------------|:-------:|------------------|
|pH|7.2|7.35 - 7.45|
|PaO₂|12.5 kPa|11 - 15|
|PaCO₂|4.6 kPa|4.6 - 6.4|
|Bicarbonate|20 mmol/L|22 - 30|
|Lactate|5 mmol/L|0.6 - 1.4|
|Non-fasting Glucose|9.7 mmol/L|< 6.1|



What is the most important initial management step?

Options:
explanation: Although this should also be considered, this patient's tachycardia is likely due to her septic shock rather than primary cardiac pathology. Fluid resuscitation should therefore be prioritised.
name: Perform a head-tilt chin-lift manouvre
label: d
answer: no
explanation: This is the correct answer. It is important to correct the patient's severe hypotension first. This, along with her tachycardia, indicates septic shock which may be secondary to a urinary tract infection.
name: Administer 500ml bolus of 0.9% saline
label: a
answer: yes
explanation: This answer is incorrect. The patient's saturations are within normal limits. It is therefore more important to address her hypotension.
name: Give 15L oxygen through a non-rebreather mask
label: c
answer: no
explanation: This answer is incorrect. Blood glucose can be used to guide management in sepsis however glucose is already reported on the patient's venous blood gas.
name: Measure capillary blood glucose
label: e
answer: no
explanation: Although this should also be considered, this patient's tachycardia is likely due to her septic shock rather than primary cardiac pathology. Fluid resuscitation should therefore be prioritised.
name: Perform a 12 lead ECG
label: b
answer: no

Correct answer: a

Administer 500ml bolus of 0.9% saline
A 60 year old male patient is recovering from a myocardial infarction on the cardiology ward. A medical student plans to obtain a blood sample, but on arrival at the cubicle, the patient is unresponsive.

On examination, there is obvious work of breathing and no central pulse.

Which of the following is the most important initial management step?

Options:
explanation: This is correct. Resuscitation is a team effort and it is important to be able to delegate tasks. Cardiopulmonary rescusitation can begin as long as help is on the way.
name: Call for help
label: a
answer: yes
explanation: This is incorrect. This might be necessary once advanced life support in in progess however it is not the most important initial management step.
name: Administer 500ml bolus of 0.9% saline through an IV cannula
label: b
answer: no
explanation: This is incorrect. As soon as help is on the way CPR can be started however resuscitation is a team effort and the patient will have a more favourable outcome if tasks are delegated effectively.
name: Begin cardiopulmonary resuscitation (CPR)
label: d
answer: no
explanation: This is incorrect. Although useful in managing an airway during cardiac arrest, it is not helpful at this stage.
name: Perform a jaw-thrust manouvre
label: c
answer: no
explanation: This is incorrect. It is most important to call for help in this scenario. Administering five initial rescue breaths forms part of paediatric resuscitation guidelines. High quality CPR and early defibrillation are prioritised in adult resuscitation.
name: Administer five initial breaths through a bag-valve-mask (BVM)
label: e
answer: no

Correct answer: a
A 30 year old female presents to her GP surgery with extreme fatigue for the past 6 months. She also report bouts of abdominal pain over this time that are accompanied by nausea, and has lost approximately 6kg unintentionally over this time. The only medication they take is levothyroxine for Hashimoto's thyroiditis. They have no other past medical history.

On examination, there is bronzing to the skin of their palms. Observations are within normal limits except for their blood pressure which is 126/82 when lying down and 100/71 when standing.

Their blood results are as follows:

Glucose 3.9mmol.
Sodium 130.
Potassium 5.7.
Normal thyroid panel.

Which of the following is the next best investigation?

Options:
explanation: This is incorrect. This is a test for pheochromocytoma. Fatigue, weight loss and bronzing of the palmar creases are classic signs of adrenal insufficiency. An ACTH (short synacthen) test is the gold standard investigation to confirm the diagnosis.
name: Plasma metanephrines
label: d
answer: no
explanation: This is incorrect. This is a test for Cushing's syndrome. Fatigue, weight loss and bronzing of the palmar creases are classic signs of adrenal insufficiency. An ACTH (short synacthen) test is the gold standard investigation to confirm the diagnosis.
name: Low dose dexamethasone suppression test
label: c
answer: no
explanation: This is incorrect. This is a test for acromegaly. Fatigue, weight loss and bronzing of the palmar creases are classic signs of adrenal insufficiency. An ACTH (short synacthen) test is the gold standard investigation to confirm the diagnosis.
name: IGF1
label: b
answer: no
explanation: This is incorrect. This is a test used when hyperaldosteronism or Conn's is suspected. Fatigue, weight loss and bronzing of the palmar creases are classic signs of adrenal insufficiency. An ACTH (short synacthen) test is the gold standard investigation to confirm the diagnosis.
name: Aldosterone/Renin ratio
label: e
answer: no
explanation: This is correct. Fatigue, weight loss and bronzing of the palmar creases are classic signs of adrenal insufficiency. Hyponatraemia and hyperkalaemia, as well as postural hypotension, are also characteristic. A significant autoimmune past medical history also makes primary adrenal insufficiency (Addison's disease) more likely. The short synacthen test is the gold standard investigation to confirm the diagnosis of adrenal insufficiency. Her 9 am cortisol level would most likely be low.
name: Short synacthen test
label: a
answer: yes

Correct answer: a
A 55 year old male has recently been started on a medication for their atrial fibrillation. They attend their GP due to heat intolerance, weight loss, diarrhoea and restlessness. They explain they have not been sleeping well recently and they are feeling nervous a lot of the time. Their symptoms began approximately three weeks ago.


On examination the patient appears diaphoretic and has a fine tremor. Their pulse is fast at 115bpm.


A blood test is ordered and results are below:


||||
|---------------------------|:-------:|------------------------------|
|Thyroid Stimulating Hormone|6.7 mU/L|0.3 - 4.2|
|Free T4|30 pmol/L|9 - 25|
|Free T3|10 pmol/L|3.1 - 6.8|

Which of the following medications is most likely to cause this presentation?

Options:
explanation: This is the correct answer. Amiodarone-induced thyrotoxicosis is a recognized complication. The patient is suffering from symptoms of hyperthyroidism. Amiodarone is rich in iodine which is a compound of thyroid hormone, manifestations can occur in both iodine-deficient and iodine sufficient patients.
name: Amiodarone
label: a
answer: yes
explanation: This is incorrect. This is an anti-arrhythmic used in the treatment of atrial fibrillation however side effects would mostly likely be arrhythmias and dizziness.
name: Flecainide
label: c
answer: no
explanation: This is incorrect. Apixaban is a direct oral anticoagulant medication used to prevent clot formation in atrial fibrillation. This medication is more likely to cause complications such as haemorrhage and anemia.
name: Apixaban
label: b
answer: no
explanation: This is incorrect. Digoxin side effects include arrhythmias, conduction disorders, dizziness and vomiting. Overdose can cause gastrointestinal upset, visual symptoms and ECG abnormalities.
name: Digoxin
label: e
answer: no
explanation: This is incorrect. Beta-blockers such as propranolol can be used to treat the symptoms of hyperthyroidism.
name: Bisoprolol
label: d
answer: no

Correct answer: a
A 52 year old female attends her GP surgery to discuss her latest blood results, which show an HbA1c of 55 and a new diagnosis of type 2 diabetes. The GP recommends taking metformin to manage her diabetes.

Which of the following describes the mechanism of action of metformin?

Options:
explanation: This is correct. Metformin is a biguanide medication that reduces gluconeogenesis in the liver and increases glucose uptake, therefore improving insulin sensitivity. This is the first-line oral anti-diabetic drug.
name: Increased insulin sensitivity
label: a
answer: yes
explanation: This is incorrect. Thiazolidenediones such as Pioglitazone have this mechanism of action. This promotes increased storage of free fatty acids reducing the amount available to be used by the cells. Peripheral tissues therefore become more depending on carbohydrates for energy.
name: Stimulates nuclear receptor (peroxisome proliferator activated receptors)
label: b
answer: no
explanation: This is incorrect. This is the mechanism of action of GLP-1 analogues such as Liraglutide. These stimulate insulin release and inhibit glucagon release.
name: Incretin effects
label: c
answer: no
explanation: This is incorrect. Sulfonylureas work in this way by closing ATP sensitive potassium channels on pancreatic beta cells causing membrane depolarisation and a calcium influx into the cell. This leads to insulin secretion.
name: Increased insulin release
label: e
answer: no
explanation: This is incorrect. Dapagliflozin is an example of a medication with this mechanism of action. THey work by binding to SGLT2 receptors in the proximal convoluted tubule leading to increased glycosuria and reduced reabsorption of glucose.
name: Sodium dependent glucose cotransporter 2 inhibitor
label: d
answer: no

Correct answer: a