hllj/quesmed huggingface dataset:
A 23-year-old female experiences rapid "closing in" of her vision and then collapses when travelling as a standing passenger on a busy tube train. Passers-by witness convulsing movements of her arms and legs for approximately 15 seconds following the collapse. She regains consciousness immediately after and has a Glasgow Coma Scale (GCS) of 15.

What is the most likely diagnosis?

Options:
explanation: This patient has had a simple faint, or vasovagal syncope. This is commonly positional, such as here following a long period of standing on the tube, and is often described as being preceded by tunnel vision or vision "closing in". A short period of convulsions can be normal. It can be differentiated from proper seizure activity by the lack of a post-ictal phase
name: Vasovagal syncope
label: a
answer: yes
explanation: If this were an epileptic seizure, it might last longer than 15 seconds, be accompanied by classic seizure indicators such as incontinence or tongue biting and be followed by a post-ictal period. The positional nature of this episode, combined with the short course of the convulsions and rapid recovery of the patient to GCS 15, makes an epileptic event very unlikely
name: Epileptic seizure
label: b
answer: no
explanation: If a patient has severe enough hypoglycaemia to cause a collapse, you would expect some residual drowsiness, reflected in reduced GCS. Symptoms would also be expected to come on more gradually than in this stem
name: Hypoglycaemia
label: e
answer: no
explanation: In syncope relating to arrhythmia, the history would usually elude to some preceding symptoms such as palpitations, chest pain or shortness of breath to indicate a cardiac origin. In this context, an arrhythmogenic collapse would be a much less likely cause than a simple faint
name: Cardiac arrhythmia
label: c
answer: no
explanation: If this patient has been sat down on the tube for a prolonged period and had then stood up prior to collapsing, postural hypotension could be a possible explanation
name: Postural hypotension
label: d
answer: no

Correct answer: a
A 27-year-old female with a history of epilepsy is brought into the Emergency Department by ambulance following a seizure at home 20 minutes ago. She usually takes levetiracetam. She is post-ictal and has intravenous access established by the ambulance crew. During your assessment, she starts having a second seizure.

What is the first-line agent to stop this patients seizure?

Options:
explanation: This would be the last resort treatment option in refractory status epilepticus where the seizure activity is unable to be controlled with other agents
name: Rapid sequence induction of anaesthesia
label: e
answer: no
explanation: Intravenous sodium valproate is an anticonvulsant drug; however, it is less appropriate agent in this context. The patient is known to be on levetiracetam normally to good effect, is any anticonvulsant were to be given, it should be the patient's usual medication. Additionally, valproate should be avoided where possible in women of child-bearing age
name: Intravenous sodium valproate
label: d
answer: no
explanation: The patient is usually on levetiracetam, and this may be given intravenously if the seizure cannot be terminated with benzodiazepines alone; however, it is not a first-line agent for the management of status epilepticus
name: Intravenous levetiracetam
label: c
answer: no
explanation: This may be used in the community, and family members can be trained to administer this if loved ones are prone to having seizures. Where the patient is in hospital and has intravenous access, lorazepam would be more appropriate
name: Rectal diazepam
label: b
answer: no
explanation: Benzodiazepines are the first-line agents for terminating seizures. They can be given in the form of intravenous lorazepam, buccal midazolam or rectal diazepam, depending on the context, access and availability of medication. Where possible, intravenous lorazepam should be the first choice. A second dose can be given if the seizure does not terminate within 10 minutes of the first dose
name: Intravenous lorazepam
label: a
answer: yes

Correct answer: a
A 52-year-old man presents to the Emergency Department following a temporary loss of vision in his right eye. He was cleaning the kitchen and suddenly lost vision in his right eye. This returned within approximately 5 minutes. The left eye was not affected, and there were no other associated symptoms. He has a past medical history of hypercholesterolaemia, type 2 diabetes, hypertension, obesity and has had a previous myocardial infarction 18 months ago.

What is the most likely diagnosis?

Options:
explanation: Migraine aura can be in the form of visual or sensory phenomena. Patients describe different experiences, which can including blurring of vision, seeing flashes or floaters or the sensation of pins and needles/ tingling in the arms +/- legs or face. These symptoms can mimic stroke; however, in migraine, they would typically be followed by other migraine symptoms such as nausea/vomiting, aversion to lights (photophobia) and characteristic unilateral headache
name: Migraine aura
label: d
answer: no
explanation: In stroke, the deficit would not self-resolve as described in the stem
name: Stroke
label: b
answer: no
explanation: GCA most commonly affects women over 50 and is not associated with poor vascular health. Symptoms of GCA classically include a characteristic headache with tenderness over the temple region and jaw claudication pain. _It can cause amaurosis fugax_ but it would not present as the sole symptom of the condition, as can be the case in the context of a TIA. Visual loss in GCA can be irreversible, which is why it is important to promptly treat the condition with corticosteroids to prevent this from occurring
name: Giant cell arteritis (GCA)
label: c
answer: no
explanation: Patients with angle-closure glaucoma get an acutely red and painful eye. Their vision can become blurred, and patients often report seeing haloes around lights. If the condition is not treated in time and total visual loss occurs, this is **irreversible**
name: Glaucoma
label: e
answer: no
explanation: Amaurosis fugax refers to painless temporary loss of vision (classically monocular, though more rarely can be binocular) and, in this instance, is reflective of a form of TIA. A TIA is defined as a sudden neurological deficit that entirely resolves within a 24-hour window and classically lasts only minutes. It often reflects carotid artery stenosis. This patient has significant vascular risk factors and a history of a previous vascular event which makes this option even more likely
name: Transient Ischaemic Attack (TIA)
label: a
answer: yes

Correct answer: a
A 71-year-old man presents to the Emergency Department via ambulance. On waking this morning, his wife noted he had incoherent speech with an inability to move his right arm. He has a past medical history of hypercholesterolaemia, type 2 diabetes, atrial fibrillation, and alcohol excess. His regular medications include atorvastatin, metformin, bisoprolol and apixaban. He still drinks heavily - his wife estimates 1 litre of whiskey most days - and has poor compliance with his medications.

What is the most likely diagnosis?

Options:
explanation: An intracranial neoplasm can cause focal neurological symptoms depending on its location; however, you would expect this to have a more gradual/ insidious onset, accompanied by more classic symptoms of malignancy such as weight loss. The symptoms would be highly unlikely to start suddenly, as is the case in this stem
name: Brain tumour
label: c
answer: no
explanation: Neurological symptoms can be due to psychosomatic causes; however, this is a diagnosis of exclusion and cannot be assumed to be the most likely cause of a new, sudden neurological deficit. Classically in these cases, the neurological signs and symptoms are inconsistent with one another, not fitting into one vascular territory and unable to be localised
name: Conversion disorder
label: e
answer: no
explanation: The patient's wife has called the ambulance as she noted his behaviour and symptoms as atypical for him. That patient drinks to excess daily - it is unlikely that his wife is unable to recognise his behaviour whilst intoxicated. Additionally, the history notes the new symptoms being present on waking, which suggests he is likely to be at his most sober
name: Alcohol intoxication
label: b
answer: no
explanation: Dysphasia and unilateral motor disturbance (either weakness or total paralysis) are common symptoms of a stroke. They are included in the 'FAST' (face, arms, speech, time) pneumonic, which forms part of early recognition advertising campaigns. This patient also has multiple risk factors for vascular disease, as well as atrial fibrillation, which also poses a risk of thrombus formation, particularly given that he is known to have poor compliance with his medications (including his anticoagulation)
name: Ischaemic stroke
label: a
answer: yes
explanation: Wernicke's encephalopathy refers to thiamine deficiency (classically relating to a long history of alcohol excess) which can cause a typical tried of Confusion, Ophthalmoplegia and ATaxia (helpful pneumonic - COAT). Although this patient does have a history of alcohol excess, which would put him at an increased group of developing the condition, this stem does not mention any eye signs of gait disturbance, two key parts of the syndrome
name: Wernicke's encephalopathy
label: d
answer: no

Correct answer: a
An 18-year-old female student presents to the emergency department on a Monday morning with 24 hours of severe headache and vomiting.

On Saturday, she went on a night out clubbing, and when she woke up on Sunday morning, she felt extremely unwell with headache, photophobia, nausea and vomiting. This has persisted, and she feels no better this morning. Her neck is also feeling stiff and painful - she wonders if this may be due to her excessive vomiting over the past 24 hours. Overnight she also reports waking up very sweaty and shaky.

What is the most likely diagnosis?

Options:
explanation: Migraine can cause a headache with classical photophobia and significant nausea and vomiting. Alcohol can also act as a trigger for migraines. However, if this were a migraine, it would usually have resolved within 24 hours, but more rarely can persist for up to 72 hours. The headache would usually be noted as being unilateral and pulsatile in nature. Migraines are not usually associated with significant neck stiffness or infective symptoms
name: Migraine
label: c
answer: no
explanation: A gastrointestinalgastrointestinal infection could cause significant vomiting and infective symptoms of fever and rigors; however, this would usually also be associated with some accompanying abdominal pain or diarrhoea. It would be uncommon for this condition to present with headache as the primary symptom
name: Severe dehydration secondary to gastro-enteritis
label: e
answer: no
explanation: Student populations are one of the higher risk groups for bacterial meningitis, and it is vital to always consider this diagnosis in patients of this cohort presenting with headache or vomiting so as not to miss a potentially fatal infection. This patient has several key signs of meningitis, including headache, photophobia, vomiting and neck stiffness, as well as symptoms that sound like fevers and rigors overnight. Neisseria meningitidis is the classical organism causing meningitis in student populations
name: Meningitis
label: a
answer: yes
explanation: SAH can also cause a severe headache with photophobia, vomiting and neck stiffness. However, in SAH, you may expect a history of more sudden onset "thunderclap" headache, with the severity of the pain being the primary symptom, with patients often describing it as the "worst pain I've ever felt". This diagnosis would also not explain the notable infective sounding symptoms of fevers and rigors overnight. Additionally, in this population, meningitis would be a more common cause of these symptoms
name: Subarachnoid haemorrhage (SAH)
label: b
answer: no
explanation: Though it does happen, it would be rare for a simple hangover to cause severe enough symptoms for a patient to present to the hospital. Additionally, it would be rare for this to be causing such severe symptoms for more than 24 hours with no improvement. A hangover would not cause infective symptoms. Neck stiffness is quite a specific symptom that should point you towards significant central nervous system pathology (indicating inflammation of the meninges)
name: Hangover
label: d
answer: no

Correct answer: a
A 69-year-old woman presents to the Emergency Department following a fall at home. She reports standing up from her chair and then falling forwards. She did not injure her head or lose consciousness following the fall, but does have significant pain in her left hip and is unable to weight bear. She has a past medical history of hypothyroidism and polymyalgia rheumatica, and current medications include levothyroxine and prednisolone.

On inspection, there bruising over the lateral aspect of the left hip and the left leg appears shortened and externally rotated, though there is no visible deformity.

What is the most likely diagnosis?

Options:
explanation: In femoral shaft fractures, the area over the fracture site (the thigh) is often visibly deformed. Additionally, you would expect the pain to be located primarily at this site rather than in the hip
name: Left femoral shaft fracture
label: d
answer: no
explanation: Posterior dislocations account for 90% of hip dislocations – in these cases, the leg may be observed to be flexed at the hip, internally rotated and adducted. In anterior hip dislocations, which are rarer, the leg can be positioned as externally rotated, but this is usually accompanied by significant abduction, which is not present in this patient. Both forms of dislocation can cause variable amounts of leg shortening
name: Left hip dislocation
label: b
answer: no
explanation: A simple soft tissue injury would not cause shortening and external rotation of the leg (it would not cause any deformity of the leg) but may present with bruising and swelling. Weight-bearing would usually be possible, although it may still be uncomfortable for the patient
name: Soft tissue injury
label: c
answer: no
explanation: In fracture of the pubic rami the leg rarely presents as shortened and externally rotated (the leg itself is not involved in the fracture so should not be deformed or displaced significantly)
name: Left-sided pubic rami fracture
label: e
answer: no
explanation: This patient is above the age of 65 and has risk factors for osteoporosis (steroid use and levothyroxine use) – this puts her at high risk of hip fracture. She has presented following a fall from standing, which is also the most common mechanism of injury for hip fracture in this cohort. Displaced hip fractures cause shortening of the leg due to bone overlap, and external rotation occurs due to the non-anatomical action of muscle groups pulling on the now discontinuous femur. Difficulty in weight-bearing and significant bruising over the area are also common following hip fracture
name: Left hip fracture
label: a
answer: yes

Correct answer: a
A 49-year-old male presents to the Emergency Department with palpitations and nausea. He has a past medical history of hypertension, migraine and gout. His regular medications include amlodipine, ramipril, indapamide, propranolol and allopurinol.


Blood tests reveal hyperkalaemia at 6.4 mmol/L (normal range 3.5-5.3 mmol/L).


Which of his regular medications should be suspended during treatment of his hyperkalaemia?

Options:
explanation: Amlodipine does not cause hyperkalaemia and, as such, is safe to continue during the management of this condition
name: Amlodipine
label: c
answer: no
explanation: Propranolol can be used for the prevention of migraines (as is the case here), as well as in lower doses for ischaemic heart disease secondary prevention. It would be very rare for propranolol to be significantly contributing to hyperkalaemia, and this agent is safe to continue during hyperkalaemia management
name: Propranolol
label: b
answer: no
explanation: Allopurinol is a xanthine oxidase inhibitor that acts to reduce levels of uric acid in the body and prevent gout flares. Hyperkalaemia is not a reported side effect of allopurinol therapy
name: Allopurinol
label: e
answer: no
explanation: Ramipril is a commonly used medication in the treatment of hypertension. It can commonly cause increased potassium levels - this should be monitored, along with GFR, when the medication is commenced. Ramipril should be stopped during treatment of hyperkalaemia as it is likely to be contributory
name: Ramipril
label: a
answer: yes
explanation: Indapamide is a thiazide-like diuretic that is used to treat hypertension. They can cause **hypo**kalaemia
name: Indapamide
label: d
answer: no

Correct answer: a
A 76-year-old female presents to the Emergency Department. She has been brought in by her carers, who feel she is more confused and drowsy than normal. She has a past medical history of type 2 diabetes, hypertension and depression. Her regular medications include metformin, gliclazide, ramipril, amlodipine and sertraline.


Blood tests reveal hyponatraemia at 125 mmol/L (normal range 135-145 mmol/L).


Which medication is most likely contributing to this patients hyponatraemia?

Options:
explanation: In terms of electrolyte imbalance, angiotensin-converting enzyme (ACE) inhibitors are notable for causing hyperkalaemia, not hyponatraemia
name: Ramipril
label: e
answer: no
explanation: The most notable side effect of amlodipine is the potential to cause leg swelling. It does not cause hyponatraemia
name: Amlodipine
label: b
answer: no
explanation: Gliclazide can cause hypoglycaemia but does not cause hyponatraemia
name: Gliclazide
label: d
answer: no
explanation: Hyponatraemia is an important potential side effect of selective serotonin reuptake inhibitor (SSRI) medications
name: Sertraline
label: a
answer: yes
explanation: Immediate release metformin can commonly cause gastrointestinalgastrointestinal upset but does not classically cause hyponatraemia
name: Metformin
label: c
answer: no

Correct answer: a
A 64 year old woman presents to the emergency department with breathlessness, palpitations and lightheadedness. She has a ECG taken, which is shown below:

[lightgallery]

What is the most likely diagnosis?

Options:
explanation: This ECG does not show atrial flutter. Characteristic ECG changes seen in atrial flutter include a sawtooth baseline, an atrial rate of 300/min and a ventricular rate that is an exact ratio of the atrial rate. As there is rapid atrial contraction (300/min), not every p wave is conducted. This creates a atrioventricular conduction ratio of either 2:1 (most common), 3:1, 4:1, 5:1 (least common). This will be seen on the ECG as a ventricular rate of 150/min, 100/min, 75/min and 60/min respectively. The rate of the ECG shown is ~90/min, making it unlikely to be atrial flutter. In addition, it is an irregularly irregular rhythm, while atrial flutter has a regular rhythm
name: Atrial flutter
label: d
answer: no
explanation: This ECG does not show ventricular fibrillation. The characteristic ECG changes seen in ventricular fibrillation are chaotic, polymorphic, irregular deflections with no discernible QRS complexes. In addition, patients are almost always unconsciousness with ventricular fibrillation, whereas this patient is conscious in this stem
name: Ventricular fibrillation
label: b
answer: no
explanation: This patient is presenting with atrial fibrillation. They are presenting with typical clinical symptoms (including breathlessness, palpitations and lightheadness) and a typical ECG. ECG features include an irregularly irregular rhythm with the absence of P waves. Management options available to this patient include long term anticoagulation, rate control (e.g. with bisoprolol) and rhythm control (e.g. with chemical or electrical cardioversion). The preferred management options would depend on whether the patient is clinically stable, whether there is a reversible underlying cause and how long she has been in atrial fibrillation for
name: Atrial fibrillation
label: a
answer: yes
explanation: Anxiety can present with similar features including breathlessness and palpitations. In addition, they may have symptoms like intense fear and worry, tingling of the lips and mouth, chest pain and tremor. However, they will have a normal ECG or sinus tachycardia, whereas this ECG shows atrial fibrillation
name: Anxiety
label: c
answer: no
explanation: This ECG does not show features of hyperkalaemia. Characteristic ECG changes seen in hyperkalaemia include: tall tented T waves, widened QRS and flattened P waves
name: Hyperkalaemia
label: e
answer: no

Correct answer: a
A 67 year old patient is on the cardiology ward following a myocardial infarction. They received percutaneous coronary intervention six hours ago. They now feels breathless and dizzy, and their current ECG trace is shown below:

[lightgallery]

What is the most likely diagnosis?

Options:
explanation: This is not a normal ECG. There are no discernible P waves and the QRS complexes are very broad
name: Normal ECG
label: e
answer: no
explanation: This a typical ECG showing monomorphic ventricular tachycardia. This is characterised by regular, wide QRS complexes of equal amplitude (monomorphic) with an absence of P waves. This patient is conscious (and would have a pulse if felt for) so they are not in cardiac arrest, however they do require urgent management. This patient would need urgent escalation to a senior colleague, with consideration for agents such as amiodarone to cardiovert them back to normal rhythm
name: Ventricular tachycardia
label: a
answer: yes
explanation: This ECG does not show atrial fibrillation. Atrial fibrillation is characterised by an irregularly irregular rhythm and absent P waves. Although this ECG does not have P waves, the rhythm is regular. This is also a broad complex tachycardia, whereas atrial fibrillation presents with narrow complexes
name: Atrial fibrillation
label: b
answer: no
explanation: Torsades de pointes is also known as polymorphic ventricular tachycardia. Monomorphic and polymorphic ventricular tachycardia are both broad complex tachycardias with a regular rhythm. However, polymorphic ventricular tachycardia has QRS complexes of varying amplitude, whereas monomorphic ventricular tachycardia has QRS complexes with no significant difference in amplitude (as shown in this question)
name: Torsades de pointes
label: c
answer: no
explanation: Cardiac tamponade can occur after myocardial infarction, and is associated with rupture of the ventricular wall. However this question does not mention the characteristic features of Beck's triad (muffled heart sounds, hypotension, raised jugular venous pressure (JVP)) and this ECG does not show electrical alternans (the amplitude of the QRS complexes swapping between beats)
name: Cardiac tamponade
label: d
answer: no

Correct answer: a