hllj/quesmed huggingface dataset:
A 76-year-old man presents to the GP with his wife, who has noticed that his memory has worsened over the last 18 months. She thinks that his memory is worse on some days compared to others. The patient does not think he has a problem with his memory and is eager to leave as he left his dog tied up outside the GP surgery. His wife is confused as they do not own a dog. Neurological examination shows no abnormalities.

What is the most likely diagnosis?

Options:
explanation: Charles-Bonnet syndrome is a condition causing visual hallucinations (usually of people or animals) associated with severe visual impairment. There is nothing in this question to suggest this patient has any visual impairment; therefore, this is not the most likely diagnosis
name: Charles-Bonnet syndrome
label: c
answer: no
explanation: This is a progressive neurological condition characterised by Lewy Body (alpha-synuclein) deposition in the brain. Key features demonstrated in this question include fluctuating symptoms (worse on some days) and visual hallucinations (he has a dog his wife can't see). The patient may also present with Parkinsonism, but cognitive symptoms must occur either before, or within 12 months of the onset of motor symptoms
name: Dementia with Lewy Bodies
label: a
answer: yes
explanation: Parkinson's dementia presents with dementia in the presence of Parkinson's disease. Parkinsonism (e.g. resting tremor, bradykinesia, resting tremor) must occur at least 12 months before the onset of cognitive symptoms. As this patient has developed cognitive symptoms before symptoms of Parkinsonism, dementia with Lewy Bodies is the more likely diagnosis
name: Parkinson's dementia
label: b
answer: no
explanation: Alzheimer's disease typically presents with short term memory loss, word-finding difficulties and difficulty recognising objects and people. Alzheimer's does not typically present with visual hallucinations, making dementia with Lewy Bodies the more likely diagnosis
name: Alzheimer's disease
label: d
answer: no
explanation: Vascular dementia is characterised by a stepwise cognitive decline due to either macrovascular (e.g. stroke) or microvascular events. Symptoms are largely dependent on the area affected; however, it would not present as a fluctuant dementia with visual hallucinations. Therefore, dementia with Lewy Bodies is the more likely diagnosis
name: Vascular dementia
label: e
answer: no

Correct answer: a
A 25-year-old man presents to the emergency department after a transient loss of consciousness 15 minutes ago. His mother reports that he was getting ready for work when he suddenly went stiff, fell to the ground and then began shaking his limbs. He lost control of his bladder and bit both sides of his tongue. You attempt to gain a history from him, but he is drowsy.

What is the most likely diagnosis?

Options:
explanation: This is a typical description of a generalised tonic-clonic seizure. The onset of stiffness characterises the tonic part, which can cause a patient to fall. Rhythmic jerking motions characterise the clonic part. Incontinence and tongue biting are not unique to seizures but are also common features of seizure, with lateral tongue biting being more suggestive of seizure and tip tongue biting being more suggestive of syncope. Post-ictal state (drowsiness lasting up to 30 minutes post-seizure) is common after generalised tonic-clonic seizures
name: Generalised tonic-clonic seizure
label: a
answer: yes
explanation: Focal seizures originate in a single part of the brain, most often in the temporal lobe. Post-ictal state is common, and this seizure may progress to involve the whole brain (secondary generalisation). However, the seizure started as a generalised seizure, in this case, making a generalised tonic-clonic seizure more likely
name: Focal seizure with impairment of consciousness
label: b
answer: no
explanation: Atonic seizures are characterised by the sudden loss of muscle tone (atonia) without the patient losing consciousness. As this patient lost consciousness and had stiffness, not atonia, a diagnosis of atonic seizure is unlikely
name: Atonic seizures
label: d
answer: no
explanation: Vasovagal syncope usually occurs after prolonged standing or strong emotion (e.g. seeing blood). The patient may feel dizzy before the episode, will have a faint to the ground with or without some jerking of all four limbs, but will quickly recover within minutes. The presence of stiffness, lateral tongue biting, and a post-ictal state makes a vasovagal syncope diagnosis unlikely
name: Vasovagal syncope
label: e
answer: no
explanation: Myoclonic seizures present with involuntary contraction of muscles leading to jerking. However, the patient remains conscious and don't have any post-ictal state, making this diagnosis unlikely
name: Myoclonic seizure
label: c
answer: no

Correct answer: a
A 64-year-old man is brought to the emergency department with a stroke. Bloods are taken, and IV access is obtained. While in the emergency department, he begins to have a seizure. His oxygen saturations are 97%, and his blood glucose is 5.6 mmol/L (normal <6.1 mmol/L). Five minutes have now passed.


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

Options:
explanation: IV phenytoin is given third-line for status epilepticus after the patient has received two doses of benzodiazepine (e.g. IV lorazepam), 10 minutes apart
name: Give IV Phenytoin 15mg/kg
label: e
answer: no
explanation: PR diazepam (or buccal midazolam) is given first-line in status epilepticus in the community as these patients usually don't have IV access. As this patient is in hospital and has IV access, lorazepam is more appropriate
name: Give PR diazepam 10 mg
label: c
answer: no
explanation: Rapid sequence induction is considered after seizure activity for 45 minutes, reserved for patients who cannot have their seizures terminated with benzodiazepines or other drugs like phenytoin
name: Rapid sequence induction with sodium thiopentone
label: d
answer: no
explanation: 50 ml of IV glucose 50% is given to patients in status epilepticus who have hypoglycaemia. This patient has a normal glucose, however, so this therapy is not appropriate
name: Give 50 ml of IV glucose 50%
label: b
answer: no
explanation: This patient is in status epilepticus, as they have had a seizure lasting more than 5 minutes. As they are in status epilepticus, they should be treated with a seizure terminating medication. The first-line medication in status epilepticus in a hospital setting is IV lorazepam if the patient has IV access
name: Give IV lorazepam 4mg
label: a
answer: yes

Correct answer: a
A 21-year-old female patient presents to the GP with a three-month history of recurrent headaches. The headache starts as a throbbing pain on one side of her head and worsens with bright lights and noise. She typically takes paracetamol, lays down in a dark room, and sleeps, which helps the headaches. She does not notice any symptoms preceding the headache, and physical examination shows no abnormalities. The headaches have caused her to have several days off of university. She is currently trying to conceive.

What is the most appropriate treatment for this patient?

Options:
explanation: The headaches are having a significant impact on this patient’s quality of life so continuing to only manage the acute attacks with simple analgesia is not adequate treatment. Prophylaxis of future attacks should be offered for this patient.
name: Continue with paracetamol as required
label: b
answer: no
explanation: Topiramate is contraindicated in pregnancy or in patients trying to conceive.
name: Topiramate
label: c
answer: no
explanation: Verapamil is used as prophylaxis for cluster headaches. These presents as multiple short-lived headaches in a short period of time and usually involve tearing or redness of the eye on the affected side. The patient here has a clear history of migraines.
name: Verapamil
label: e
answer: no
explanation: Carbamazepine is offered to patients with trigeminal neuralgia and not with migraines. Trigeminal neuralgia would presents with electric shock like painful episodes occurring across one cheek.
name: Carbamazepine
label: d
answer: no
explanation: This patient is presenting with recurrent migraines. A migraine is a primary headache disorder that typically presents with a unilateral throbbing pain, worsened by light and noise. Patients will often describe needing to go to sleep or rest in a dark room to help the headache, which interferes with carrying out daily activities. Management includes trigger avoidance, and treatment of acute episodes with an oral triptan or simple analgesia like paracetamol/NSAIDs.

In patients where the headaches are having a significant impact on their daily function, as in this patient, prophylaxis should be offered. NICE recommends prophylaxis of attacks with propranolol, topiramate or amitriptyline. Topiramate is contraindicated in pregnancy or in those trying to conceive, so propranolol is the most appropriate option here.
name: Propranolol
label: a
answer: yes

Correct answer: a
A 72-year-old man presents to the emergency department with right-sided arm and face weakness that occurred 40 minutes ago. These symptoms lasted for 1 minute and then resolved. He has a past medical history of two myocardial infarctions and peripheral vascular disease.

What is the most likely diagnosis?

Options:
explanation: Haemorrhagic stroke can present similarly; however, symptoms would not self resolve within 24 hours
name: Haemorrhagic stroke
label: c
answer: no
explanation: Transient ischaemic attack (TIA) is an ischaemic cerebrovascular event that self-resolves within 24 hours. Risk factors include age, pre-existing cardiovascular disease, hypertension, atrial fibrillation and smoking. This patient has a history of cardiovascular disease in the presence of symptoms suggestive of an ischaemic cerebrovascular event. As this has since resolved, this is most likely a TIA. This patient should be given 300mg of aspirin and referred to the TIA clinic (within 24 hours) to confirm the diagnosis
name: Transient ischaemic attack
label: a
answer: yes
explanation: Hypoglycaemia should be ruled out in every patient presenting with a TIA. However, there are no risk factors for hypoglycaemia like insulin therapy, sulphonylurea therapy, liver disease, malnutrition or insulinoma. There is also no mention of this patient's symptoms resolving upon eating sugar. Therefore TIA is the more likely diagnosis
name: Hypoglycaemia
label: d
answer: no
explanation: Bell's palsy is an idiopathic lower motor neurone lesion of the facial nerve. It presents with ipsilateral weakness of the whole side of the face, with no sparing of the eyebrows. It does not present with arm weakness and will not resolve after one minute
name: Bell's palsy
label: e
answer: no
explanation: Ischaemic stroke can present similarly; however, symptoms would not self resolve within 24 hours
name: Ischaemic stroke
label: b
answer: no

Correct answer: a
An 82-year-old female presents to the emergency department with sudden onset left-sided face and arm weakness. The patient cannot give a full history as she is unable to speak, but she gestures that the left side of her vision is missing on visual field testing.

What is the most likely diagnosis?

Options:
explanation: Features present in a posterior circulation stroke include either: cerebellar symptoms, bilateral motor/sensory symptoms, ipsilateral cranial nerve palsy + contralateral motor/sensory symptoms or bilateral anopia. This patient is not presenting with any of these symptoms, making this diagnosis unlikely
name: Posterior circulation infarct
label: c
answer: no
explanation: A partial anterior circulation infarct is diagnosed when a patient presents with 2 of the 3 features used to define a total anterior circulation infarct. As this patient presents with all 3 of these features, she is presenting with a total anterior circulation infarct
name: Partial anterior circulation infarct
label: b
answer: no
explanation: A total anterior circulation infarct is diagnosed when a patient has a combination of: contralateral hemiplegia/hemiparesis + contralateral homonymous hemianopia + higher cerebral dysfunction (aphasia). This patient is presenting with all these features, making this the most likely diagnosis
name: Total anterior circulation infarct
label: a
answer: yes
explanation: Lacunar infarcts (affecting vessels supplying internal capsule and thalamus) present affecting either: just motor function, just sensory function, just sensory and motor function or as an ataxic hemiparesis. This patient presents with a visual field defect and aphasia, so this cannot be a lacunar stroke
name: Lacunar infarct
label: d
answer: no
explanation: Haemorrhagic stroke can cause these symptoms; however, 85% of strokes are ischaemic. This makes ischaemic stroke less likely than haemorrhagic stroke (in the absence of risk factors like malignant hypertension and anticoagulation)
name: Haemorrhagic stroke
label: e
answer: no

Correct answer: a
A 20-year-old university student presents to the emergency department with a one-day history of headache. On examination, you notice he is wearing sunglasses. He is unable to touch his chin to his chest, but tone, power, and reflexes are all normal, and there are no rashes. His temperature is 38.7ºC, heart rate 88/min and his blood pressure is 120/80mmHg.

What is the most likely diagnosis?

Options:
explanation: Migraine typically presents with unilateral throbbing pain, worsened by light and noise. Although this patient has photophobia, the presence of neck stiffness and fever is more suggestive of a diagnosis of meningitis
name: Migraine
label: d
answer: no
explanation: Meningococcal septicaemia is caused by Neisseria meningitidis infecting the blood. This can present as a petechial rash (usually non-blanching) with or without haemodynamic compromise. This patient does not present with these features; therefore, this is less likely than meningitis
name: Meningococcal septicaemia
label: c
answer: no
explanation: Subarachnoid haemorrhage presents as a "thunderclap headache" to the back of the head, which is very painful and may feel as though they have been hit in the back of the head. They may also have features of meningism (neck stiffness, photophobia) as blood irritates the meninges. The longer history and presence of fever, in this case, make meningitis more likely
name: Subarachnoid haemorrhage
label: b
answer: no
explanation: Meningitis is caused by inflammation of the meninges lining the brain. Clinical presentation includes: a triad of headache, neck stiffness and photophobia; fever; focal neurology; seizure or features of meningococcal septicaemia. As this patient is presenting with features of meningism and fever, meningitis is the most likely diagnosis
name: Meningitis
label: a
answer: yes
explanation: Space occupying lesions typically present with red flag symptoms including: morning headache; headache on coughing, straining or lying down; vomiting; focal neurological signs; personal history of cancer. This patient is not presenting with any of these symptoms, and the history of meningism and fever make a diagnosis of meningitis more likely
name: Space occupying neoplasm
label: e
answer: no

Correct answer: a
A 78-year-old female presents to the emergency department with left hip pain that came on immediately following a fall. She is a current smoker and has a body mass index of 18.8. On examination, the left leg is shortened and externally rotated.

What is the most likely diagnosis?

Options:
explanation: Femoral shaft fractures can occur from a fall from standing in patients with a history of osteoporosis; however, most femoral shaft fractures occur in road traffic accidents. Other causes include a fall from height and gunshot wounds. Patients can present similarly, with a shortened externally rotated leg. However, in an elderly patient presenting with a fall, a neck of femur fracture is the more common aetiology
name: Femoral shaft fracture
label: c
answer: no
explanation: Osteoarthritis is a degenerative arthritis that comes on over years and is worsened by movement. The rapid onset of pain and examination findings, in this case, make a diagnosis of neck of femur fracture more likely
name: Osteoarthritis
label: e
answer: no
explanation: Neck of femur fractures are a relatively common fracture, typically occurring in elderly patients. Neck of femur fractures typically occur after a minor fall and present with sudden onset pain, with a shortened and externally rotated leg on examination. This position is formed by several muscles (including iliopsoas and hip abductors) creating force, pulling up and externally rotating the leg. Smoking and low BMI are risk factors for osteoporosis. The diagnosis is confirmed by hip x-ray (AP and lateral view), and management varies on fracture classification, e.g. intracapsular/extracapsular, non-displaced/displaced
name: Left neck of femur fracture
label: a
answer: yes
explanation: Hip dislocation typically occurs after a road traffic accident. It usually presents with shortening of the leg, as in this case. However, the leg is internally rotated, not externally rotated. This is because most hip dislocations are posterior, meaning the femoral head travels posteriorly to the acetabulum
name: Hip dislocation
label: b
answer: no
explanation: Septic arthritis is a life-threatening condition associated with infection in the joint. It presents with a history of red, hot, swollen joint that comes on over hours-days, which may be accompanied by fever and sepsis. The history of onset of pain after a fall and the examination findings make a diagnosis of neck of femur fracture more likely
name: Septic arthritis
label: d
answer: no

Correct answer: a
A 55-year-old patient is on the cardiology ward with an exacerbation of heart failure. They have been commenced on spironolactone and are currently taking bisoprolol and ramipril. They are complaining of palpitations, and their most recent ECG is shown below:

[lightgallery]

What is the most likely diagnosis?

Options:
explanation: Hyperkalaemia is defined as a potassium level >5.5mmol/L. There are many causes; in this case, it is most likely due to the initiation of a potassium-sparing diuretic (especially as it is given in combination with an ACE inhibitor). This patient also presents with ECG features of hyperkalaemia, including tall tented T waves and flattened P waves. Other ECG features include broad QRS and a "sine wave" pattern. Management should include calcium gluconate (cardiac stabiliser), insulin and dextrose with or without salbutamol (to lower potassium level), and potentially reducing the dose of spironolactone
name: Hyperkalaemia
label: a
answer: yes
explanation: ECG signs associated with hypercalcaemia include PR shortening and J waves (if severe). Other systemic signs of hypercalcaemia include renal stones, bone pain, constipation, nausea, abdominal pain, confusion, polydipsia, polyuria, depression and psychosis. The features on this ECG are more in keeping with hyperkalaemia
name: Hypercalcaemia
label: c
answer: no
explanation: ECG signs associated with hypokalaemia include QTc prolongation, PR prolongation and U waves. This ECG is more in keeping with an ECG showing hyperkalaemia. This patient is also unlikely to develop hypokalaemia now after initiation with a potassium-sparing diuretic
name: Hypokalaemia
label: b
answer: no
explanation: This is not a normal ECG. There are tall tented T waves and flattened P waves, which is in keeping with hyperkalaemia
name: Normal ECG
label: e
answer: no
explanation: ST-elevation myocardial infarction present with ST-elevation (≥1mm in limb leads, ≥2mm in chest leads) or new-onset left bundle branch block. These features are not present on this ECG. The features on this ECG are more in keeping with hyperkalaemia
name: ST-elevation myocardial infarction
label: d
answer: no

Correct answer: a
A 67-year-old man presents to the emergency department after having a generalised seizure at home. He has been drowsy for the last week and had a CT head three days ago, which was normal. He has a past medical history of small cell lung cancer. Blood tests show a sodium of 129.

What is the most likely diagnosis?

Options:
explanation: Hyponatraemia is defined as a sodium level <135 mmol/L). There are many causes, but in this case, the most likely cause is syndrome of inappropriate antidiuretic hormone (SIADH) secondary to small cell lung cancer. Hyponatraemia presents with drowsiness, headache, seizures and coma.

Management depends on the severity of hyponatraemia and whether it is acute or chronic in onset. Rapid correction of chronic severe hyponatraemia is associated with central pontine myelinolysis, a severe neurological disorder associated with high morbidity and mortality. For this reason, severe hyponatraemia (<120 mmol/L) should only be raised by 12 mmol/L/day
name: Hyponatraemia
label: a
answer: yes
explanation: Brain metastases can present with seizures. However, you would expect some other associated focal neurological deficit. This patient also had a normal CT scan, which did not show any metastatic brain lesions. This makes metastatic lung cancer very unlikely
name: Brain metastases
label: b
answer: no
explanation: Epilepsy is a disorder characterised by recurrent seizures. This patient has only had one seizure in the absence of a clear seizure syndrome. Other underlying causes have not yet been ruled out. Given his history of small cell lung cancer, hyponatraemia should be ruled out (along with other causes of seizures) before a diagnosis of epilepsy is made
name: Epilepsy
label: c
answer: no
explanation: Migraine headaches can present with hemiparesis and other motor features; however, they do not present with transient loss of consciousness or features resembling a tonic-clonic seizure. There is also no history of migraines in this case. In a patient with seizures with a diagnosis of small cell lung cancer, syndrome of inappropriate antidiuretic hormone (SIADH) and associated hyponatraemia should be ruled out
name: Migraine
label: e
answer: no
explanation: Encephalitis is a condition (usually infective) where there is inflammation of the brain. Patients typically present with fever, headache, personality change, focal neurological signs and seizures. This patient is not presenting with fever, personality change or focal neurological signs making it not a specific presentation for encephalitis. In a patient presenting with a generalised presentation with a history of small cell lung cancer, hyponatraemia is the more likely diagnosis
name: Encephalitis
label: d
answer: no

Correct answer: a
Case Presentation: A 52-year-old gentleman sees his GP for low mood and energy with anhedonia. He has trouble sleeping and has low self-confidence. He does not report major problems with eating nor any suicidal thoughts.


## PH

Hyperlipidaemia, Type 2 Diabetes Mellitus, Myocardial Infarct (3 months ago)

## DH

Atorvastatin 80mg PO OD, Enalapril maleate 10mg PO OD, Bisoprolol 2.5mg PO OD, Metformin 1g PO BD (NKDA)

## On examination

Appears low in mood, speech volume reduced. Slow spontaneous movement and reactivity noted.

Temperature 36.2°C, HR 76, RR 14, BP 135/88, O<sub>2</sub> 99% RA, GCS 15, Weight 89kg

## Investigations

ECG: Normal sinus rhythm

# Prescribing Request

Write a prescription for one drug that is most appropriate for treating his condition.

Options:


# Drug choice feedback

This gentleman is suffering from moderate to severe major depressive disorder. Apart from recommending cognitive behavioural therapy, the first line pharmacological therapy is a selective serotonin reuptake inhibitor (SSRI). Given his recent myocardial infarct, sertraline is the optimal choice in light of its safety being studied in this group of patients and a lower propensity of interactions with other medications. All other SSRIs should be considered only if the patient is intolerant to sertraline or no significant clinical effect is seen.

# Dose/Route/Frequency/Duration feedback

The initial dose is 50mg orally once-daily. This needs to be reviewed regularly.