hllj/quesmed huggingface dataset:
A 61-year-old man with a background of type 1 diabetes and hypertension presents with a 30-minute history of chest pain radiating to the left jaw, which is unrelieved by rest or glyceryl trinitrate (GTN). He has anterolateral ST elevation on his ECG and is sent for urgent coronary angiography.

Coronary angiography shows significant stenosis of the left anterior descending, left circumflex and right coronary artery.

Which of the following is the best step in management?

Options:
explanation: Coronary stenting is often used in the management of acute coronary syndrome (ACS); however, for three-vessel coronary disease, outcomes are better with the use of CABG
name: Insertion of drug-eluting coronary stents
label: b
answer: no
explanation: This patient has significant three-vessel coronary artery disease. This is the most severe form of coronary atherosclerosis and management is usually with a CABG. This is a surgical procedure that aims to divert blood flow away from the areas of stenosis by using a graft from the chest, arm or leg
name: Coronary artery bypass graft (CABG)
label: a
answer: yes
explanation: A heart transplant would be reserved for patients with severe heart failure or coronary artery disease that is refractory to all medical and surgical management options. A CABG would be considered first for a patient with triple-vessel disease
name: Cardiac transplantation
label: d
answer: no
explanation: Urgent revascularisation has a prognostic benefit in patients with ST-elevation myocardial infarction (STEMI). Therefore it would not be appropriate to manage this patient with medical management alone
name: Medical management with dual antiplatelet therapy (DAPT)
label: e
answer: no
explanation: Drug-coated balloons only (i.e. without stents) are used in certain centres for the treatment of certain cases of de novo coronary artery disease. They have the advantage that they avoid the risk of stent thrombosis and thereby reduce the length of dual antiplatelet treatment. However, for 3 vessel disease, CABG would be a better option
name: Drug-coated balloon only angioplasty
label: c
answer: no

Correct answer: a


Learning point: Coronary artery bypass grafting (CABG) is indicated for patients with significant three-vessel coronary artery disease to improve blood flow and reduce ischaemia.
A 45-year-old man with a diagnosis of myocarditis is assessed following an episode of hypotension on the ward. On assessment, he is tachycardic and tachypnoeic with a blood pressure of 90/50 mmHg. He has a raised jugular venous pressure (JVP) and his heart sounds are difficult to auscultate.

An urgent bedside ECHO shows cardiac tamponade.

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

Options:
explanation: This patient has obstructive shock due to pericardial fluid that is reducing ventricular filling and thereby causing reduced cardiac output. Fluid challenges are more useful in the initial management of hypovolaemic (e.g. blood loss) and distributive shock (e.g. sepsis) but would not be as useful in this context
name: 500ml fluid challenge
label: b
answer: no
explanation: Inotropes act to increase myocardial contractility and thereby increase cardiac output. They may be considered, but definitive management with pericardiocentesis should not be delayed
name: Inotropes
label: d
answer: no
explanation: Thoracocentesis is a procedure that aims to remove fluid or air from the pleural space. An emergency thoracocentesis is used for urgent decompression of a tension pneumothorax
name: Emergency thoracocentesis
label: e
answer: no
explanation: Cardiac tamponade is a medical emergency caused by the accumulation of fluid in the pericardial space, leading to reduced ventricular filling and haemodynamic compromise. Management is with pericardiocentesis which aims to remove the pericardial fluid
name: Urgent pericardiocentesis
label: a
answer: yes
explanation: Although the patient has a raised JVP, they are not in congestive cardiac failure or pulmonary oedema. The raised JVP indicates increased right atrial pressure due to the pericardial fluid causing strain on the heart. As the patient is not fluid overloaded, there would be no benefit of giving diuretics. In this case, it would likely drop the patient's blood pressure further
name: 40mg IV furosemide
label: c
answer: no

Correct answer: a


Learning point: Cardiac tamponade is a medical emergency requiring urgent pericardiocentesis to relieve fluid accumulation and restore haemodynamic stability.
A 35-year-old man with no previous past medical history presents with a 3-week history of intermittent fevers and night sweats. There are no localising symptoms of infection.

On examination, he is tachycardic and febrile with an early diastolic murmur noted over the left sternal edge.

He is treated empirically for infective endocarditis. Blood cultures subsequently grow methicillin-resistant staphylococcus aureus (MRSA).

Which of the following is the best antimicrobial regime?

Options:
explanation: This would be a treatment option for a patient with native valve streptococcal endocarditis. Benzylpenicillin would not work for staphylococcal species
name: IV benzylpenicillin
label: c
answer: no
explanation: MRSA indicates that the staphylococcus aureus species are resistant to β-lactam antibiotics. In this case, for a patient with confirmed MRSA and without any prosthetic heart valves, the BNF advises treatment with vancomycin and rifampicin for 4 weeks
name: IV vancomycin and rifampicin
label: a
answer: yes
explanation: This is the empirical treatment for native valve endocarditis. As MRSA has been cultured, this regime needs to be escalated to vancomycin (and gentamicin) as amoxicillin will not cover MRSA
name: IV amoxicillin and gentamicin
label: d
answer: no
explanation: MRSA indicates that the staphylococcus aureus species are resistant to flucloxacillin. IV flucloxacillin for 4-6 weeks would be the treatment of methicillin-susceptible Staphylococcus aureus in a patient with native valve (i.e. no prosthetic valves) endocarditis
name: IV flucloxacillin
label: b
answer: no
explanation: This would be the treatment of MRSA prosthetic valve endocarditis. It is also used as empirical treatment for prosthetic valve endocarditis whilst awaiting culture results or if cultures results are negative
name: IV vancomycin, rifampicin and gentamicin
label: e
answer: no

Correct answer: a


Learning point: Methicillin-resistant Staphylococcus aureus (MRSA) requires treatment with vancomycin and rifampicin, especially in cases of infective endocarditis.
A 23-year-old man presents to his General Practitioner (GP) with two brief episodes of syncope that were preceded by palpitations. He was admitted the previous year with palpitations which were found to be due to supraventricular tachycardia (SVT) that responded to initial management with vagal manoeuvres.

Clinical examination is unremarkable and his observations are normal. An ECG shows a short PR interval and a widespread slurred upstroke on the QRS complexes.

Which of the following is the best step in management?

Options:
explanation: Pulmonary vein ablation (PVA) is a treatment for symptomatic atrial fibrillation (AF). The area where tissue from the atrium and pulmonary veins meet is the source of ectopic atrial depolarisation that drives AF. PVA aims to destroy this area of tissue using radiofrequency energy or cryoablation
name: Referral for pulmonary vein ablation
label: b
answer: no
explanation: Flecainide can be used in WPW in patients who are not suitable for or who refuse accessory pathway ablation
name: Flecainide
label: c
answer: no
explanation: Digoxin is an AV nodal blocking agent and should be avoided in WPW as it may precipitate conduction down the accessory pathway and thereby trigger an arrhythmia
name: Digoxin
label: e
answer: no
explanation: This patient has a history and ECG findings consistent with symptomatic Wolff-Parkinson-White (WPW) syndrome. This is a condition in which there is a congenital accessory pathway through which there can be aberrant conduction and pre-excitation of the ventricles.

Key ECG findings are a short PR interval and a broad QRS complex with a slurred upstroke (known as a delta wave).

Definitive management is a referral to an electrophysiologist for ablation of the accessory pathway
name: Referral for accessory pathway ablation
label: a
answer: yes
explanation: Verapamil is an AV nodal blocking agent and should be avoided in WPW as it may precipitate conduction down the accessory pathway and thereby trigger an arrhythmia
name: Verapamil
label: d
answer: no

Correct answer: a


Learning point: Wolff-Parkinson-White (WPW) syndrome is characterized by an abnormal extra electrical pathway in the heart, leading to episodes of rapid heart rate. Referral for accessory pathway ablation is recommended for patients with symptomatic WPW or those at risk of serious arrhythmias
A 56-year-old man with a history of angina presents to his GP with central chest pain on exercise that is now occurring more frequently. The pain usually lasts a few minutes and is relieved by sublingual glyceryl trinitrate (GTN) spray. He denies any pain at rest, and an ECG shows no ischaemic changes.

His only current medications anti-anginal medication is bisoprolol which has been up-titrated to the maximum tolerated dose.

Which of the following is the next step in management?

Options:
explanation: Verapamil is a non-dihydropyridine calcium channel blocker that acts on the heart. It should not be combined with a beta-blocker due to the risk of heart block
name: Add verapamil
label: b
answer: no
explanation: NICE guidelines suggest that the first-line management for patients with angina is either a beta-blocker (e.g. bisoprolol) or a calcium-channel blocker (e.g. amlodipine). The initial drug should be up-titrated before switching to the other option or using a combination of the two
name: Add amlodipine
label: a
answer: yes
explanation: Ranolazine is a potassium channel activator. NICE guidelines suggest adding ranolazine only after considering the use of both a calcium channel blocker and beta-blocker
name: Ranolazine
label: d
answer: no
explanation: Ivabradine blocks sodium channels in the sinus node. NICE guidelines suggest adding ivabradine only after considering the use of both a calcium channel blocker and a beta-blocker
name: Ivabradine
label: e
answer: no
explanation: ISMN is a long-acting nitrate. NICE guidelines suggest adding ISMN only after considering the use of both a calcium channel blocker and beta-blocker
name: Add isosorbide mononitrate (ISMN)
label: c
answer: no

Correct answer: a


Learning point: In patients with stable angina, combining a beta-blocker with a calcium-channel blocker can enhance symptom control when monotherapy is insufficient.
A 32-year-old woman presents to her General Practitioner (GP) with a right-sided breast lump. She first noticed it one week ago and denies any other symptoms including breast pain, discharge, skin or nipple changes. She has no personal or family history of any cancers.

On examination, there is a smooth 1cm lump in the upper inner quadrant of the left breast. The borders are well defined, and the lump moves under the skin on palpation. There is no associated lymphadenopathy.

Which of the following is the best step in management?

Options:
explanation: Although this is likely a fibroadenoma, the patient should be referred for further investigations
name: Reassure the patient that this is a benign breast lump
label: b
answer: no
explanation: Although this is likely a benign breast lump, guidelines recommended an urgent referral to secondary care
name: Follow up assessment in primary care in 6 months
label: d
answer: no
explanation: An urgent (two-week wait) referral is recommended for all women over 30 with an unexplained breast lump. For younger patients with no worrying features, a non-urgent referral is indicated
name: Non-urgent referral to secondary care
label: c
answer: no
explanation: Although this is likely a benign breast lump, guidelines recommended an urgent referral to secondary care
name: Follow up assessment in primary care in 12 months
label: e
answer: no
explanation: The breast lump is likely to be a fibroadenoma based on its characteristics and the patient's age. This is a common, benign breast lump that is common in younger women due to increased sensitivity to oestrogen. However, all women over 30 with an unexplained breast lump should be urgently referred to the breast clinic for further assessment. This is likely to include further clinical assessment, imaging and biopsy or fine-needle aspiration (FNA)
name: Urgent referral to secondary care
label: a
answer: yes

Correct answer: a


Learning point: All women over 30 with an unexplained breast lump should be urgently referred for further assessment, regardless of lump characteristics.
A 56-year-old woman is diagnosed with HER2 (human epidermal growth factor receptor 2) positive breast cancer. Her case is discussed at the breast cancer multidisciplinary team (MDT) meeting, and it is decided that she would benefit from neoadjuvant therapy before surgery.

Which of the following is the most important investigation to perform before starting treatment?

Options:
explanation: There is no indication for fundoscopy before starting neoadjuvant therapy in a patient with breast cancer
name: Fundoscopy
label: e
answer: no
explanation: An ETT may be useful as part of an anaesthetic assessment before surgery; however, the most important investigation before neoadjuvant therapy with trastuzumab is an ECHO
name: Exercise tolerance test (ETT)
label: c
answer: no
explanation: A DEXA scan is used to assess for osteoporosis. It would not routinely be performed before starting neoadjuvant therapy in breast cancer in a patient without any clear risk factors for osteoporosis
name: Dual-energy X-ray absorptiometry (DEXA) scan
label: d
answer: no
explanation: There is no clear evidence of decreased lung function with trastuzumab, and pulmonary function testing is not usually indicated
name: Pulmonary function testing
label: b
answer: no
explanation: Neoadjuvant therapy for a patient with HER2 positive breast cancer is likely to involve the monoclonal antibody trastuzumab (Herceptin). Cardiomyopathy is an important risk of trastuzumab treatment and therefore all patients should have a baseline ECHO before treatment
name: Echocardiogram (ECHO)
label: a
answer: yes

Correct answer: a


Learning point: Baseline echocardiogram is essential before initiating neoadjuvant therapy in HER2 positive breast cancer to assess the risk of trastuzumab-induced cardiomyopathy.
A 45-year-old man with a history of hepatitis C with liver cirrhosis presents to his General Practitioner (GP) with increasing swelling of his legs, causing him discomfort when he walks. He denies any other symptoms including cough or shortness of breath.

He is currently on anticoagulation for an unprovoked deep-vein thrombosis (DVT) that occurred one month ago. Liver function tests at that point were at baseline.

On examination, his JVP is not raised with heart and lung sounds normal. The abdomen is soft and non-tender with no palpable masses. There is bilateral pitting oedema to the knees bilaterally.

Which of the following is the most appropriate initial investigation?

Options:
explanation: This patient has no risk factors for heart failure. It would be reasonable to check BNP levels as it has a high negative predictive value for heart failure, but, in this context, testing for proteinuria is more pertinent
name: Serum brain natriuretic peptide (BNP)
label: b
answer: no
explanation: An ECHO to assess for heart failure would usually be performed after checking serum BNP levels
name: Echocardiogram (ECHO)
label: c
answer: no
explanation: Hypothyroidism is a rare cause of generalised oedema. This patient does not have any other symptoms of hypothyroidism which makes it less likely
name: Check thyroid function
label: d
answer: no
explanation: Checking renal function is vital given the likely diagnosis of nephrotic syndrome. However, renal function can be normal in the early stages of nephrotic syndrome and therefore the most important initial test is to check for proteinuria
name: Check renal function
label: e
answer: no
explanation: Chronic hepatitis C infection is a risk factor for membranoproliferative glomerulonephritis (MPGN). This can present with features of nephrotic syndrome, which include generalised oedema, hypoalbuminaemia and proteinuria. Nephrotic syndrome is also a pro-thrombotic state, and the recent DVT raises further suspicion in this context. The next best investigation is therefore a bedside urine dipstick to assess for proteinuria. If there is proteinuria, then this should be quantified using a UPCR. Nephrotic range proteinuria is > 3.5g/day which is equivalent to a UPCR value of 350 mg/mmol
name: Urine dipstick +/- urinary protein:creatinine ratio (UPCR)
label: a
answer: yes

Correct answer: a
A 67-year-old woman presents with increasing lethargy and dizziness on standing. Her past medical history is significant for lung cancer which was treated with chemotherapy two years ago.

On examination, there is hyperpigmentation of the buccal mucosa and a drop in blood pressure of 25mmHg on standing.

Blood tests show mild eosinophilia, mild hypercalcaemia, hyperkalaemia and hypotonic hyponatraemia.

Which of the following is most likely to identify the cause of this patient's symptoms?

Options:
explanation: Mild hypercalcaemia is a feature of primary adrenal insufficiency of all causes. Infiltrative diseases such as sarcoidosis can cause primary adrenal insufficiency but this is rare
name: Serum angiotensin-converting enzyme (ACE) levels
label: e
answer: no
explanation: Pituitary disease can cause secondary adrenal insufficiency; however, this would not lead to hyperkalaemia (as potassium level homeostasis is not dependent on the pituitary-adrenal axis - it is mainly controlled by the renin-angiotensin-aldosterone system) or hyperpigmentation.

Hyperpigmentation and hyperkalaemia are suggestive of primary adrenal insufficiency
name: CT pituitary
label: b
answer: no
explanation: The clinical vignette and blood test findings are suggestive of primary adrenal insufficiency. This would need to be confirmed with a screening test (usually 9 am cortisol level) and, if positive, a short-synacthen test.

In a patient with previous lung cancer, the most likely cause of primary adrenal insufficiency would be metastatic adrenal disease, for which a CT scan is the best investigation of choice. Imaging of the chest and pelvis is useful to assess for further sites of metastasis
name: CT scan of the chest abdomen and pelvis (CT CAP)
label: a
answer: yes
explanation: MRI is the best modality to image the pituitary; however, as described above the history and blood tests findings are more suggestive of primary adrenal insufficiency in this case
name: MRI pituitary
label: c
answer: no
explanation: Autoimmune disease is the most common cause of primary adrenal insufficiency in the UK. However, the history of recent lung cancer in an older patient makes metastatic disease more likely in this case
name: Autoantibody screen
label: d
answer: no

Correct answer: a
A 32-year-old man who had thyroid surgery three days ago presents with numbness and tingling in his fingertips. He also reports intermittent muscle spasms.


Bloods shows a serum calcium level of 1.8 mmol/L (normal range 2.2-2.6 mmol/L).


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

Options:
explanation: Hypomagnesaemia can lead to hypocalcaemia, and it is important to check magnesium levels after urgent treatment has been started
name: Check serum magnesium levels
label: e
answer: no
explanation: ECG monitoring is essential as severe hypocalcaemia can lead to a prolongation of the QT interval, which in turn can trigger arrhythmias
name: IV calcium gluconate
label: c
answer: no
explanation: PTH testing is important to determine the aetiology of hypocalcaemia. However, severe hypocalcaemia should be treated urgently. In this case, the recent thyroid surgery is likely to be the cause, and PTH levels would likely be low due to disruption of the parathyroid glands during surgery
name: Urgent parathyroid hormone (PTH) level testing
label: d
answer: no
explanation: This is severe hypocalcaemia which is defined as a serum calcium level of < 1.9 mmol/L or symptomatic with any calcium level below the reference range.

It is a medical emergency that should be managed with 10-20mL of IV calcium gluconate in 50-100mL of 5% dextrose over 10 mins. This should be followed up with a calcium infusion.

ECG monitoring is essential as hypocalcaemia can lead to a prolongation of the QT interval, which in turn can trigger arrhythmias
name: IV calcium gluconate with cardiac monitoring
label: a
answer: yes
explanation: Oral calcium replacement can be used for asymptomatic patients with a serum calcium of > 1.9 mmol/L. It is not suitable for severe hypocalcaemia
name: Oral calcium replacement
label: b
answer: no

Correct answer: a
A 24-year-old patient presents with tender red nodules on the anterior shins that developed over the last week. Full systems review is negative, and the patient cannot find any triggers that may have lead to the lesions.

A chest x-ray and initial blood tests are normal.

Which of the following is the most likely cause of this patient's rash?

Options:
explanation: IBD is associated with erythema nodosum. The normal blood tests and absence of gastrointestinal or systemic symptoms would make this unlikely in this case
name: Inflammatory bowel disease (IBD)
label: e
answer: no
explanation: The lesions described are typical of erythema nodosum. This is an inflammatory disorder affecting the subcutaneous fat. The cause is unknown in approximately 55% of patients, and most cases resolve within days to weeks
name: Idiopathic
label: a
answer: yes
explanation: Streptococcal infections are associated with erythema nodosum, but there is nothing in the history to suggest that this may be the cause in this case
name: Post-streptococcal infection
label: d
answer: no
explanation: Sarcoidosis is an important cause of erythema nodosum; however, the normal chest x-ray, blood tests and absence of symptoms make this unlikely
name: Sarcoidosis
label: c
answer: no
explanation: TB is an important cause of erythema nodosum; however, the absence of systemic symptoms, risk factors and normal chest x-ray makes this unlikely
name: Tuberculosis (TB)
label: b
answer: no

Correct answer: a


Learning point: Erythema nodosum presents as tender red nodules on the shins and often has an idiopathic aetiology, resolving spontaneously within weeks.