hllj/quesmed huggingface dataset:
A 92 year old male is undergoing a medication review at the GP surgery. He is frail, has a past medical history of hypertension, chronic kidney disease 3, osteoarthritis, osteoporosis, erectile dysfuction, and benign prostatic hyperplasia. His conditions and symptoms are well controlled.

Which of the following medications would be reasonable to discontinue due to lack of clinical benefit?

Options:
explanation: Statins are unlikely to confer much prognostic benefit at his age. Primary prevention dose statins are prescribed usually on the basis of QRISK score >10% (risk of a cardiac event within next 10 years). The QRISK tool cannot be used for people >84 years old, but NICE suggests using holistic clinical judgement as to whether to prescribe in this case, taking into account comorbidities, polypharmacy, general frailty, and life expectancy.
name: Atorvastatin 20mg OD
label: a
answer: yes
explanation: This is for BPH and therefore likely to be offering symptomatic benefit
name: Finasteride 5mg OD
label: e
answer: no
explanation: This patient may still have an active sex life despite his age and therefore may be important to continue. Also, as this is a PRN medication, if he is not taking it, stopping it would not significantly reduce polypharmacy.
name: Sildenafil 50mg PRN
label: b
answer: no
explanation: This is for pain likely related to his arthritis, and is therefore likely to be of symptomatic benefit
name: Paracetamol 1g QDS
label: d
answer: no
explanation: This is for hypertension and should be continued in this case
name: Amlodipine 5mg OD
label: c
answer: no

Correct answer: a
A 79 year old male presents to A&E after a fall 2 days ago. He was initially fine but has been increasingly confused since. He complains of mild headache and has vomited twice. CT head shows a subdural haemmorhage.

Which of the following describes the classical appearance of acute SDH on imaging?

Options:
explanation: Correct. The bleeding occurs from bridging veins between the dura and arachnoid layers just outside the cortex. This is a low pressure potential space and so blood diffuses around the curve of the brain.
name: Crescent-shaped hyperdense (i.e. appears bright) extra-axial collection that spreads diffusely over the affected hemisphere
label: a
answer: yes
explanation: This is an extradural haemorrhage, between the dura and the skull, which usually are tightly adherent, so the blood forces the layers apart like a balloon.
name: A peripheral, hyperdense (i.e. appears bright), bi-convex (lentiform) collection
label: c
answer: no
explanation: The collection would be expected to be hyperdense (bright) in the acute phase. The appearance is otherwise correct.
name: Crescent-shaped hypodense (i.e. appears dark) extra-axial collection that spreads diffusely over the affected hemisphere
label: b
answer: no
explanation: This is a extradural haemmorrhage as above. The collection would also be expected to be hyperdense (bright) in the acute phase.
name: A peripheral, hypodense (i.e. appears dark), bi-convex (lentiform) collection
label: d
answer: no
explanation: This is an intracerebral haemmorhage: a bleed in the brain itself. This can be related to chronic hypertension or underlying abnormal vasculature or lesions such as tumour or infarct. There is often surrounding hypodense (darker) oedema.
name: A hyperdense (i.e. appears bright) collection of blood within the parenchyma of the brain
label: e
answer: no

Correct answer: a
A 65-year-old man presents to the GP clinic with his wife, complaining of binge eating, impulsiveness, and increased sexual activity. His wife states that people have a hard time understanding his speech, and he often forgets the names of his close friends. Otherwise, there are no other memory problems. He can care for himself, manage his accounts, and mingle well. His past and family history are insignificant.

Vital signs and physical and neurological examination are unremarkable. The Montreal Cognitive Assessment (MCA) score is 26/30, and a recent brain MRI shows asymmetrical anterior left temporal atrophy.

What is the most likely diagnosis?

Options:
explanation: Frontotemporal dementia (FTD) is characterised by changes in behaviour, personality, and language. The patient in this scenario presents with symptoms that are consistent with FTD, due to degeneration of neurons in the frontal and temporal lobes. MCA is not a specific tool to diagnose FTD, it only indicates the patient's cognitive function which is normal in this case. The anterior temporal lobes are particularly affected in FTD, and this is reflected in the MRI finding of temporal lobe atrophy.
name: Frontotemporal dementia
label: a
answer: yes
explanation: Parkinson's dementia occurs more than one year after the diagnosis of Parkinson's disease, which is not the case here. On top of that, it is characterised by three cardinal features: parkinsonism in extremities, visual hallucinations, and fluctuations in lucidity. MRI findings in Parkinson's dementia are atrophy of the hippocampus and the amygdala, and decreased gray matter volume in the frontal and temporal lobes.
name: Parkinson's dementia
label: e
answer: no
explanation: Alzheimer's disease is characterised by a gradual onset (over several years) of memory impairment, which is followed by difficulties in language and executive function. It should be suspected in adults who demonstrate long-lasting problems with spatial navigation and visual awareness, and usually manifests as wandering or becoming lost.
name: Alzheimer's disease
label: c
answer: no
explanation: Dementia with Lewy bodies (DLB) is characterised by initial cognitive deterioration, prominent deficits in attention, visual hallucinations, fluctuating cognitive function, followed by extrapyramidal symptoms such as rigidity, bradykinesia, gait instability, and autonomic dysfunction which develop within one year of onset.
name: Lewy-body dementia
label: b
answer: no
explanation: Vascular dementia usually presents in patients with history of multiple cerebrovascular events, either transient ischaemic attacks or strokes. Typically there is a step-wise deterioration of cerebral function with each event. It should be considered in those with a history of cerebrovascular disease with global impairment of cognition.
name: Vascular dementia
label: d
answer: no

Correct answer: a
A 78-year-old woman in long-term residential care has recently become confused, disoriented and hallucinating following a chest infection. She has already been prescribed antibiotics for the chest infection, which she started taking a day ago. The staff are concerned that she is a risk to herself. They have attempted verbal and non-verbal de-escalation techniques; however, she continues to be agitated and restless.

What is the single most appropriate short-term medication?

Options:
explanation: Lithium is commonly used to treat bipolar disorder. There is a high chance of developing delirium following exposure to it. Therefore, it is avoided.
name: Lithium
label: e
answer: no
explanation: Trimipramine is a tricyclic antidepressant medication that is commonly used to treat depression. It is avoided due to the fear of drug-induced delirium.
name: Trimipramine
label: c
answer: no
explanation: Nortriptyline is commonly used to treat depression, anxiety, and chronic pain. Tricyclic antidepressants are avoided as they cause drug-induced delirium.
name: Nortriptyline
label: d
answer: no
explanation: Risperidone is an atypical antipsychotic medication that is commonly used to treat a wide range of psychiatric disorders, including psychosis, bipolar disorder, and schizophrenia.
name: Risperidone
label: b
answer: no
explanation: Delirium is an acute confusional state characterised by severe changes in behaviour and cognition. It is often triggered by an illness, medication, or withdrawal from a substance. Patients with delirium may present with visual hallucinations, delusions, and frank psychosis. The lowest possible dose of olanzapine or haloperidol is preferred if supportive management fails.
name: Olanzapine
label: a
answer: yes

Correct answer: a
A 76-year-old man presents to the GP clinic with chest pain. On further questioning, he breaks into tears and feels emotional about the loss of his wife six weeks ago. She passed away due to terminal-stage breast cancer metastasising to the brain. He now feels guilty for not taking care of her properly. He also mentions that he hears his wife's voice intermittently while cooking in the kitchen. His vital signs, serum troponin and ECG, are all normal. He has no past medical history.

What is the most appropriate next step in management?

Options:
explanation: While it is important to address the patient's emotional distress, a referral to a psychiatrist may not be necessary in this case. The patient's symptoms are consistent with normal grief reactions and do not suggest the presence of a mental health disorder.
name: Refer to a psychiatrist
label: b
answer: no
explanation: In this case, the patient is experiencing **normal grief reaction** after the loss of his wife. Grief can be a difficult and emotionally overwhelming experience, and it is important to provide support and reassurance to the patient. Offering social support, such as connecting the patient with a support group or community resources, can also help promote healing and coping with his grief.
name: Reassure and offer social support
label: a
answer: yes
explanation: As this patient's symptoms are related to a precipitating event, a diagnosis of depression should not be made until after a normal grieving period, usually for about six months or more. Therefore, SSRIs are not offered immediately.
name: Prescribe selective serotonin reuptake inhibitor (SSRI)
label: c
answer: no
explanation: Risperidone is an antipsychotic medication and is not typically used to treat a normal grief reaction. Illusions and hallucinations of the deceased person are not uncommon, which resolve spontaneously after a few weeks to months. Therefore, it is not an appropriate intervention in this case.
name: Risperidone
label: d
answer: no
explanation: ECT is considered for treating severe depression in cases where a rapid response is necessary (life-threatening) or if other treatments have been unsuccessful.
name: Electroconvulsive therapy (ECT)
label: e
answer: no

Correct answer: a
A 78-year-old woman was brought to the clinic by her daughter due to confusion and memory impairment. She had been exhibiting behaviours such as starting tasks, forgetting to finish them, and having difficulty naming objects. A diagnosis of Alzheimer's disease was confirmed, and the patient was started on donepezil.

However, she has since experienced significant gastrointestinal side effects and multiple episodes of syncope. Additionally, her daughter reports that the patient has been wandering randomly on the streets and hearing voices claiming to be aliens from the moon.

On examination, the patient is agitated and disoriented and keeps asking the same questions during the interview. Which of the following medication is the most appropriate next step in management for this patient?

Options:
explanation: In rare cases, aggression, violence, or agitation may pose a safety risk and require urgent treatment with benzodiazepines or antipsychotics after other measures have been unsuccessful. However, it is not the case here.
name: Lorazepam
label: d
answer: no
explanation: Antidepressants may be helpful if there are symptoms of depression simultaneously with Alzheimer's disease. However, they are not helpful here and are not the most appropriate option.
name: Citalopram
label: e
answer: no
explanation: In rare cases, aggression, violence, or agitation may pose a safety risk and require urgent treatment with benzodiazepines or antipsychotics after other measures have been unsuccessful. However, it is not the case here.
name: Haloperidol
label: c
answer: no
explanation: The patient has already tried donepezil and could not tolerate it due to gastrointestinal side effects. Continuing treatment with an increased dose of donepezil would not be an appropriate management plan as well as the next step.
name: Increase the dose of Donepezil
label: b
answer: no
explanation: **Memantine is the second-line medication**, and it is effective in slowing the progression of cognitive symptoms in patients with moderate to severe Alzheimer's disease. It is a preferred medication for patients who cannot tolerate donepezil.
name: Memantine
label: a
answer: yes

Correct answer: a
A 45-year-old chef presents to the emergency department following a fall in the kitchen after cooking for many hours. He reports feeling lightheaded and dizzy before losing consciousness. He has no memory of the fall and did not experience any convulsions or twitching, or tongue biting. He further mentions that he had soiled his pants unconsciously. Past medical and family history is unremarkable. His vital signs are within normal limits, there is no significant change in BP from sitting to standing, and there are no apparent injuries from the fall. ECG is unremarkable.

Which of the following is the most likely diagnosis in this patient?

Options:
explanation: Cardiac arrhythmias are abnormal heart rhythms that can cause dizziness, fainting, and even sudden cardiac arrest. However, the patient's vital signs are within normal limits, there is no evidence of cardiac injury or dysfunction, and a normal ECG makes a cardiac arrhythmia less likely in this case.
name: Cardiac arrhythmia
label: d
answer: no
explanation: Orthostatic hypotension is characterised by a drop in blood pressure upon standing up from a sitting posture, which can cause dizziness, light-headedness, and fainting. It is often caused by low blood volume, medications, or underlying medical conditions that affect blood pressure regulation. However, there is no variation in blood pressure from sitting to standing posture, which suggests that his fall was not due to orthostatic hypotension.
name: Orthostatic hypotension
label: c
answer: no
explanation: Epilepsy is characterised by recurrent seizures due to abnormal electrical activity in the brain. Seizures typically involve convulsions or twitching and may be accompanied by altered consciousness or behaviour. In this case, the patient did not have any post-ictal state, which suggests that the fall was not due to a seizure.
name: Epilepsy
label: b
answer: no
explanation: Vasovagal syncope occurs due to a sudden drop in blood pressure and heart rate, usually triggered by a physiological stimulus such as standing for a long time, emotional distress, or pain. It is characterised by a feeling of light-headedness or dizziness, followed by loss of consciousness, and often involves incontinence due to the relaxation of the sphincter muscles.
name: Vasovagal syncope
label: a
answer: yes
explanation: Alcohol intoxication can cause dizziness, light-headedness, and loss of consciousness, as well as impair judgment and coordination. However, the patient did not report consuming alcohol, and there are no other indications of alcohol use, such as slurred speech or the smell of alcohol on the breath.
name: Alcohol intoxication
label: e
answer: no

Correct answer: a
A 28-year-old unconscious woman is brought to the Emergency Department after a road traffic accident, exhibiting signs of shock and drifting in and out of consciousness. A FAST scan reveals a large collection of free fluid in the peritoneal cavity, requiring immediate blood transfusion. However, her husband objects to the transfusion, citing their devotion to the Jehovah's Witnesses and their opposition to blood transfusion.

What is the most appropriate next step in management?

Options:
explanation: Doing nothing and not transfusing blood is also incorrect because it could further deteriorate the patient's condition and potentially harm or even death. If the patient is unconscious, the healthcare professional is deemed to act in the best interest of the patient's health.
name: Do not transfuse blood, as there is no patient consent
label: b
answer: no
explanation: Requesting the husband to sign a disclaimer is also incorrect because it does not address the patient's lack of capacity to make decisions and the need for urgent medical intervention.
name: Request the husband to sign a disclaimer
label: e
answer: no
explanation: Waiting for a second opinion from another consultant is an incorrect answer because time is of the essence in this situation and the patient's condition is critical.
name: Wait for a second opinion from another consultant
label: c
answer: no
explanation: In this case, the patient lacks the capacity to make an informed decision about blood transfusion due to her unconscious state. There is no indication that the patient has an advance directive that allows her husband to make this decision on her behalf. While most Jehovah's Witnesses may carry a blood refusal card, it is not mentioned in this case. Therefore, the appropriate course of action is to **treat the patient as you would any other unconscious patient who presents to the emergency department** until she regains the capacity to make an informed decision.
name: Transfuse blood without consent
label: a
answer: yes
explanation: Seeking judicial review instructions and contacting the Jehovah's Witnesses council is also an incorrect answer because it would take too long, and the patient's condition is not stable enough to wait. This might have been the best choice if the patient was relatively stable and conscious in a non-emergency scenario.
name: Seek judicial review instructions and contact Jehovah's witness council
label: d
answer: no

Correct answer: a
An 80-year-old woman is admitted to the hospital for shortness of breath and coughing up blood-stained sputum. Imaging studies show a mass in her lung that is likely to be cancer. A biopsy confirms the diagnosis. The patient's family requests the doctor not to tell her about the cancer diagnosis because they believe it will be too much for her to handle, given that her husband recently died of prostate cancer. The family asks for the results to be presented as inconclusive instead.

What is the most appropriate course of action?

Options:
explanation: It is not appropriate for family members to be responsible for disclosing the results of medical investigations or aspects of care to the patient without a doctor disclosing and discussing it with the patient directly in the first place.
name: Suggest that the family inform the patient of the diagnosis at a later time that they deem appropriate
label: e
answer: no
explanation: The patient should be given all relevant information about their health and treatment options, regardless of whether they specifically ask about it.
name: Only reveal the diagnosis to the patient if she specifically asks about it
label: c
answer: no
explanation: It is not appropriate to delegate the task of disclosing a diagnosis to another healthcare provider, especially one who was not involved in ordering the diagnostic test and treatment of the patient.
name: Wait until the patient has finished grieving and have her GP break the news to her once she is out of the hospital
label: d
answer: no
explanation: It is essential to respect the patient's right to be fully informed about their health and treatment options. In this case, the patient has the right to know about her cancer diagnosis, regardless of the family's concerns about how they may handle the news. It is important to have an **open and honest conversation with the patient about their diagnosis and treatment options** while also being sensitive to their emotional state and providing support and resources as needed. It is inappropriate to withhold this information from the patient or present the results as inconclusive, as this could affect their ability to make informed decisions about their care.
name: Acknowledge the family's concerns but still inform the patient of her diagnosis, as she has the right to know
label: a
answer: yes
explanation: By withholding the diagnosis from the patient, the healthcare professional would be denying the patient the opportunity to make informed decisions about their treatment and care. Additionally, it could have serious negative consequences for their well-being, as they would not be aware of the true nature of their condition. Therefore, it is paramount to inform the patient of their diagnosis, regardless of their mental state or the potential emotional impact it may have.
name: Agree to keep the patient's cancer diagnosis a secret out of compassion for her mental state
label: b
answer: no

Correct answer: a
A 60-year-old Caribbean-origin woman with a history of asthma, hypertension, hyperlipidaemia, and osteoporosis presents to the clinic with swelling in both ankles and shortness of breath. Her current medication regimen includes albuterol and fluticasone for asthma, metformin for diabetes, amlodipine and furosemide for hypertension, atorvastatin for hyperlipidaemia and alendronate for osteoporosis.

What is the most appropriate course of action?

Options:
explanation: While diuretics can be used to treat swelling, it would not be appropriate to add another diuretic without first reviewing the patient's medication regimen and considering all potential causes.
name: Add another diuretic
label: b
answer: no
explanation: While it may be appropriate to provide reassurance to the patient, it is important to also take action to address the underlying cause of the patient's symptoms.
name: Reassure
label: d
answer: no
explanation: It is important for the healthcare professional to carefully review the patient's medication regimen to identify any potential causes of the patient's symptoms, particularly in **elderly patients who may be at an increased risk for drug interactions and adverse side effects due to polypharmacy**. Her complaints are probably related to intolerance to the calcium channel blocker (amlodipine). Additionally, the diuretic (furosemide) may have contributed to the progression of oedema. The most appropriate next step would be to stop amlodipine and furosemide and switch to another antihypertensive medication, such as ACE inhibitors.
name: Review medication
label: a
answer: yes
explanation: While limb elevation may help to reduce swelling in some cases, it would not address the underlying cause of the patient's symptoms.
name: Limb elevation
label: c
answer: no
explanation: It is important to review the patient's medication regimen as soon as possible to identify any potential causes of the patient's symptoms and determine the most appropriate course of action. Reviewing after some time would only worsen her condition.
name: Review after six weeks
label: e
answer: no

Correct answer: a