hllj/quesmed huggingface dataset:
A 62-year-old woman attends a follow-up appointment with her surgeon following a radical mastectomy for breast cancer 6 weeks ago. She complains of pain and weakness in her right shoulder.

On examination, the right scapula is visibly protruding from the back and there is weakness on flexion and abduction of the right shoulder. There are no sensory deficits.

Which of the following nerves was most likely damaged during the operation?

Options:
explanation: This answer is correct. The examination findings describe winging of the scapula that occurs due to paralysis of serratus anterior which normally keeps the scapula against the thoracic cage. This is caused by damage to the long thoracic nerve, which can occur during radical mastectomy.
name: Long thoracic nerve
label: a
answer: yes
explanation: This answer is incorrect. The axillary nerve innervates the deltoid. Whilst damage would result in weakness of shoulder abduction, it would also cause loss of sensation over the regimental badge area. The axillary nerve is most commonly damaged by shoulder dislocation.
name: Axillary nerve
label: b
answer: no
explanation: This answer is incorrect. The radial nerve does not innervate the muscles that move the shoulder joint. Damage to the radial nerve results in wrist drop and sensory loss over the first 3.5 digits of the dorsum of the hand.
name: Radial nerve
label: e
answer: no
explanation: This answer is incorrect. The spinal accessory nerve (CN XI) innervates the trapezius and sternocleidomastoid and is not commonly damaged during radical mastectomy. Whilst damage would result in weak shoulder abduction, scapular winging is much less prominent than in long thoracic nerve injury.
name: Spinal accessory nerve
label: d
answer: no
explanation: This answer is incorrect. The thoracodorsal nerve innervates latissumus dorsi and damage would result in weakness of shoulder extension and adduction.
name: Thoracodorsal nerve
label: c
answer: no

Correct answer: a
A 22-year-old man presents to A&E with left shoulder pain and deformity following a fall onto an abducted, externally rotated arm.

On examination, there is pain and deformity of the left shoulder.

Which of the following nerves originating from the brachial plexus is most likely to have been injured?

Options:
explanation: This answer is incorrect. Damage to the musculocutaneous nerve results in weakness of arm flexion. Whilst it can become damaged in shoulder dislocation, damage to the axillary nerve is much more common.
name: Musculocutaneous nerve
label: d
answer: no
explanation: This answer is incorrect. The ulnar nerve can be injured in fractures to the medial epicondyle of the humerus. Damage results in atrophy of the intrinsic muscles of the hand, leading to a claw-hand appearance.
name: Ulnar nerve
label: e
answer: no
explanation: This answer is correct. The axillary nerve runs inferior to the glenohumeral joint and is the nerve most at risk in a shoulder dislocation.
name: Axillary nerve
label: a
answer: yes
explanation: This answer is incorrect. The median nerve can be injured in supracondylar fractures of the humerus. Damage results in weakness of forearm flexion.
name: Median nerve
label: c
answer: no
explanation: This answer is incorrect. The radial nerve is most commonly injured in fractures to the mid-shaft of the humerus. Damage results in wrist drop and weakness of arm and forearm extension.
name: Radial nerve
label: b
answer: no

Correct answer: a
A 53-year-old woman is referred to a rheumatologist by her GP with suspected rheumatoid arthritis affecting the joints of her hands, feet, and knees.

Which of the following is most likely to be present in the joints of this patient?

Options:
explanation: This answer is correct. In rheumatoid arthritis, there is pannus formation where there is hyperplasia of the subintima and synovial lining of joint capsules. The pannus is full of inflammatory cells which erode the articular cartilage and underlying bone.
name: Pannus formation
label: a
answer: yes
explanation: This answer is incorrect. In rheumatoid arthritis, there is a higher volume of synovial fluid. This is due to cytokine release which causes capillaries near the synovial surface to leak more fluid.
name: Reduced volume of synovial fluid
label: e
answer: no
explanation: This answer is incorrect. In rheumatoid arthritis, there is decreased synovial fluid viscosity due to the degradation of hyaluronate. The concentration of hyaluronate is proportional to the synovial fluid viscosity, so with reduced hyaluronate, the fluid is less viscous.
name: Increased synovial fluid viscosity
label: b
answer: no
explanation: This answer is incorrect. Neutrophils are the most predominant cell type in synovial fluid in rheumatoid arthritis. Lymphocytes are the most predominant cell type in the subintima.
name: Predominantly lymphocytes in synovial fluid
label: c
answer: no
explanation: This answer is incorrect. In rheumatoid arthritis, there is increased osteoclast activity and reduced osteoblast activity, leading to net destruction of bone.
name: Increased osteoblast activity
label: d
answer: no

Correct answer: a
A 92-year-old woman who is admitted to the elderly care ward following a fall is found by the nurse to be more drowsy than usual.


A capillary blood glucose reading is found to be 2.1 mmol/L (3.5-5.5 mmol/L) and she is treated with 1mg intramuscular glucagon.


Which of the following is not a physiological action of glucagon?

Options:
explanation: This answer is correct. Glucagon increases lipolysis via activating hormone-sensitive lipase. This allows triglycerides to break down into glycerol and fatty acids.
name: Decreases lipolysis
label: a
answer: yes
explanation: This answer is incorrect. Glucagon inhibits glycolysis to prevent the breakdown of glucose and thus a further drop in blood glucose levels.
name: Inhibits glycolysis
label: e
answer: no
explanation: This answer is incorrect. Glucagon increases gluconeogenesis in the liver to increase blood glucose levels.
name: Increases gluconeogenesis
label: d
answer: no
explanation: This answer is incorrect. Glucagon decreases glycogenesis and promotes glycogenolysis to increase blood glucose levels.
name: Decreases glycogenesis
label: b
answer: no
explanation: This answer is incorrect. Glucagon increases glycogenolysis to increase blood glucose levels.
name: Increases glycogenolysis
label: c
answer: no

Correct answer: a
A 25-year-old woman presents to the GP with weight loss, irritability, and a tremor.

On examination, she is found to have a goitre and protruding eyes.

Bloods:

* T4 - 14.3 micrograms/dL (5.0-12.0)
* TSH - 0.2 ml/IU (0.5-5.0)
* Anti-TSH receptor antibodies - postive
* Anti-TPO antibodies - positive

Which of the following is the most likely diagnosis?

Options:
explanation: This answer is incorrect. Iodine deficiency is a cause of goitre but more commonly causes hypothyroidism. This patient has presented with symptoms of hyperthyroidism which is confirmed with thyroid function tests.
name: Iodine deficiency
label: c
answer: no
explanation: This answer is incorrect. De Quervains thyroiditis is a cause of subacute hyperthyroidism which is associated with low TSH levels but normal levels of T4.
name: De Quervain's thyroiditis
label: b
answer: no
explanation: This answer is incorrect. Hashimoto's thyroiditis is a cause of hypothyroidism. This patient has presented with symptoms of hyperthyroidism which is confirmed with thyroid function tests.
name: Hashimoto's thyroiditis
label: e
answer: no
explanation: This answer is correct. The vignette describes classical symptoms of hyperthyroidism. The presence of a goitre and protruding eyes (proptosis) points towards a diagnosis of Grave's disease. In Grave's disease, up to 95% have anti-TSH receptor antibodies and up to 75% have anti-TPO antibodies.
name: Grave's disease
label: a
answer: yes
explanation: This answer is incorrect. A TSH secreting pituitary adenoma is a cause of secondary hyperthyroidism, where there are high TSH levels as well as high T4 levels.
name: TSH secreting pituitary adenoma
label: d
answer: no

Correct answer: a
A 67-year-old man with type 2 diabetes is commenced on a new anti-diabetic medication by his GP due to poor glucose control.

Which of the following anti-diabetic drugs work by increasing insulin secretion via binding to receptors on the surface of pancreatic beta cells?

Options:
explanation: This answer is incorrect. Canagliflozin is an example of an SGLT-2 inhibitor which works by increasing the excretion of glucose in the urine.
name: Canagliflozin
label: d
answer: no
explanation: This answer is incorrect. Metformin is an example of a biguanide which inhibits hepatic gluconeogenesis and increases insulin sensitivity in the liver and muscles.
name: Metformin
label: b
answer: no
explanation: This answer is incorrect. Sitagliptin is an example of a DPP-4 inhibitor, which works by increasing levels of GLP-1. GLP-1 stimulates insulin release and suppresses appetite.
name: Sitagliptin
label: c
answer: no
explanation: This answer is incorrect. Pioglizatone is an example of a PPARG (peroxisome proliferator-activated receptor gamma) agonist which works by reducing insulin resistance and increasing glucose uptake into liver and muscle
name: Pioglitazone
label: e
answer: no
explanation: This answer is correct. Gliclazide is an example of a sulphonylurea which binds to pancreatic beta cells to increase insulin secretion.
name: Gliclazide
label: a
answer: yes

Correct answer: a
One night, an 18-year-old student with type 1 diabetes goes out clubbing with his friends. Before going out, he drinks 8 cans of beer and he accidentally forgets to take his usual insulin after dinner.


In the club, he starts to feel unwell. He feels dizzy and begins to vomit. His friends decide to to call an ambulance.


The paramedics measure his capillary blood glucose and ketones:


 * Glucose - 42 mmol/L (normal <6.1 mmol/L)
 * Ketones - 5 mmol/L (<0.6 mmol/L)


Which of the following is the most likely diagnosis?

Options:
explanation: This answer is incorrect. Whilst sepsis will need to be excluded in hospital, this patient is more likely to have DKA due to his hyperglycaemia and high ketones in the context of type 1 diabetes.
name: Sepsis
label: e
answer: no
explanation: This answer is incorrect. Patients with acute appendicitis usually present with severe pain in the right iliac fossa. Appendicitis would not explain his high blood ketones.
name: Acute appendicitis
label: c
answer: no
explanation: This answer is incorrect. Whilst his symptoms fit with acute alcohol intoxication, this would not explain his hyperglycaemia and ketonuria.
name: Alcohol intoxication
label: b
answer: no
explanation: This answer is correct. Diabetic ketoacidosis (DKA) is a medical emergency. It occurs most commonly in type 1 diabetics and presents with hyperglycaemia, ketonaemia, and acidosis. It can be precipitated by a number of causes, including an alcohol binge and forgetting to take insulin.
name: Diabetic ketoacidosis
label: a
answer: yes
explanation: This answer is incorrect. Hyperosmolar hypoglycaemic state (HHS) typically occurs in people with type 2 diabetes. Patients have very high blood sugars, but no ketones.
name: Hyperosmolar hyperglycaemic state
label: d
answer: no

Correct answer: a
A 55-year-old man presents to the GP with abdominal weight gain and stretch marks on his stomach. He also reports that his face is becoming increasingly more round in shape.

Which of the following circulating hormones is most likely to be raised?

Options:
explanation: This answer is incorrect. This patient presents with features of Cushing's syndrome which is caused by excess levels of cortisol. Excess T4 levels are seen in hyperthyroidism which causes features such as weight loss, irritability and palpitations.
name: T4
label: c
answer: no
explanation: This answer is correct. This patient presents with features of Cushing's syndrome, which is caused by excess circulating cortisol.
name: Cortisol
label: a
answer: yes
explanation: This answer is incorrect. This patient presents with features of Cushing's syndrome which is caused by excess levels of cortisol. Excess circulating growth hormone causes acromegaly.
name: Growth hormone
label: b
answer: no
explanation: This answer is incorrect. This patient presents with features of Cushing's syndrome which is caused by excess levels of cortisol. High insulin levels occur in type 2 diabetes where there is insulin resistance.
name: Insulin
label: e
answer: no
explanation: This answer is incorrect. This patient presents with features of Cushing's syndrome which is caused by excess levels of cortisol. Excess adrenaline can cause symptoms such as palpitations, hypertension and sweating.
name: Adrenaline
label: d
answer: no

Correct answer: a
A 58-year-old man is brought into A&E by ambulance as he is projectile vomiting blood.

On examination, he is noted to have a distended abdomen and a yellow tinge to his skin. His partner discloses that drinks 1L of whisky a day, which he has done for the last 8 years.

Which of the following is the most likely underlying pathology?

Options:
explanation: This answer is incorrect. Whilst a perforated peptic ulcer can cause significant upper GI bleeds, the examination findings and chronic excess alcohol intake make a diagnosis of ruptured oesophageal varices from chronic liver disease more likely.
name: Perforated peptic ulcer
label: b
answer: no
explanation: This answer is incorrect. Alcoholic gastritis typically presents with a long-standing history of epigastric pain and vomiting without haematemesis. The acute presentation of this patient, with signs of chronic liver disease, points more toward a diagnosis of ruptured oesophageal varices.
name: Alcoholic gastritis
label: e
answer: no
explanation: This answer is incorrect. Gastric cancer is more commonly associated with occult upper GI bleeding rather than severe haematemesis.
name: Gastric cancer
label: d
answer: no
explanation: This answer is correct. This patient presents with an upper GI bleed which is most likely secondary to ruptured oesophageal varices. His examination findings and chronic excess alcohol intake point toward a diagnosis of chronic liver disease. Portal hypertension resulting from chronic liver disease causes the development of oesophageal varices which are friable and easily rupture, causing major haemorrhage.
name: Ruptured oesophageal varices
label: a
answer: yes
explanation: This answer is incorrect. A Mallory-Weiss tear is a superficial tear in the oesophageal lining which typically occurs after prolonged episodes of vomiting. This patient's examination findings and chronic excess alcohol intake make a diagnosis of ruptured oesophageal varices from chronic liver disease more likely.
name: Mallory-Weiss tear
label: c
answer: no

Correct answer: a
A 32-year-old woman attends her GP following spirometry and is newly diagnosed with emphysema. On further questioning, it is revealed that her father has COPD and was diagnosed with cirrhosis in his teens for which he received a liver transplant.

Routine bloods show deranged LFTs.

The GP suspects an underlying genetic disease as the cause of her symptoms.

Which of the following is the most likely diagnosis?

Options:
explanation: This answer is incorrect. COPD alone does not explain the deranged LFTs in this patient. COPD changes can occur early in patients with alpha-1 antitrypsin deficiency.
name: Chronic obstructive pulmonary disease
label: d
answer: no
explanation: This answer is incorrect. Wilson's disease is a genetic condition inherited in an autosomal recessive manner where there is abnormal accumulation of copper in tissues. It presents with Parkinsonian symptoms and psychological abnormalities. Early onset emphysema and liver cirrhosis is characteristic of alpha-1 antitrypsin deficiency.
name: Wilson's disease
label: b
answer: no
explanation: This answer is correct. A1AT deficiency is inherited in an autosomal dominant fashion and affects the lungs (causing emphysema) and liver (causing cirrhosis) at an early age.
name: Alpha-1 antitrypsin (A1AT) deficiency
label: a
answer: yes
explanation: This answer is incorrect. Budd-Chiari syndrome is a condition affecting the liver where there is hepatic vein obstruction. It would not explain the respiratory symptoms in this patient.
name: Budd-Chiari Syndrome
label: e
answer: no
explanation: This answer is incorrect. Hereditary haemochromatosis is a condition where there is an abnormal accumulation of iron in body tissues, affecting the heart, liver, and pancreas. It most commonly presents with joint pain, hyperpigmented skin, fatigue, and weight loss. Early onset emphysema and liver cirrhosis are characteristic of alpha-1 antitrypsin deficiency.
name: Hereditary haemochromatosis
label: c
answer: no

Correct answer: a
A 45 year old man presents to his GP with swollen, bleeding gums and easy bruising. On further questioning, it is discovered that he does not eat a balanced diet.

Which of the following vitamin deficiencies is most likely in this patient?

Options:
explanation: This answer is incorrect. Vitamin A deficiency presents with night blindness and xerophthalmia (risking corneal ulceration).
name: Vitamin A
label: d
answer: no
explanation: This answer is correct. Swollen, bleeding gums and easy bruising are symptoms of scurvy which results from a deficiency in vitamin C.
name: Vitamin C
label: a
answer: yes
explanation: This answer is incorrect. Vitamin D deficiency in adults causes osteomalacia, which presents with bone pain, fractures, and muscle weakness.
name: Vitamin D
label: b
answer: no
explanation: This answer is incorrect. Vitamin B1 deficiency can present with Wernicke's encephalopathy (confusion, ataxia and ophthalmoplegia, wet beriberi (high output cardiac failure) or dry beriberi (peripheral neuropathy).
name: Vitamin B1
label: e
answer: no
explanation: This answer is incorrect. Vitamin B3 deficiency causes pellagra which presents with the '3 D's' - diarrhoea, dermatitis and dementia.
name: Vitamin B3
label: c
answer: no

Correct answer: a
A 82-year-old woman with a history of heart failure attends A&E with worsening shortness of breath.

On examination, she has bibasal crackles, a raised JVP, and bilateral pitting oedema to the mid-thigh.

As part of her treatment, she is commenced on IV furosemide.

Which of the following describes the site of action of furosemide?

Options:
explanation: This answer is incorrect. The collecting duct is the site of action of potassium sparing diuretics such as spironolactone and amiloride. Furosemide acts on the ascending limb of the loop of Henle.
name: Collecting duct
label: d
answer: no
explanation: This answer is incorrect. Furosemide acts at the ascending limb of the loop of Henle where it binds to the Na/K/Cl cotransporter.
name: Loop of Henle - descending limb
label: b
answer: no
explanation: This answer is incorrect. The distal convoluted tubule is the site of action of thiazide diuretics such as bendroflumethiazide. Furosemide acts on the ascending limb of the loop of Henle.
name: Distal convoluted tubule
label: c
answer: no
explanation: This answer is correct. Furosemide inhibits the Na/K/Cl cotransporter in the thick ascending limb of the loop of Henle. This causes more sodium, chloride, potassium, and water to be excreted in the urine.
name: Loop of Henle - ascending limb
label: a
answer: yes
explanation: This answer is incorrect. The proximal convoluted tubule is the site of action of carbonic anhydrase inhibitors such as acetazolamide. Furosemide acts on the ascending limb of the loop of Henle.
name: Proximal convoluted tubule
label: e
answer: no

Correct answer: a
A 63-year-old man has a telephone consultation with his GP following abnormal blood results.

His estimated glomerular filtration rate (eGFR) was reported as 63 ml/min, and he is diagnosed with stage 2 chronic kidney disease.

Which of the following variables is not used in the Modification of Diet in Renal Disease (MDRD) equation for estimating renal function?

Options:
explanation: This answer is incorrect. Age is one of the four variables used in the MDRD equation for estimating GFR. The other variables are creatinine, gender and ethnicity.
name: Age
label: c
answer: no
explanation: This answer is incorrect. Creatinine is one of the four variables used in the MDRD equation for estimating GFR. The other variables are age, gender and ethnicity.
name: Creatinine
label: b
answer: no
explanation: This answer is incorrect. Ethnicity is one of the four variables used in the MDRD equation for estimating GFR. The other variables are age, gender and creatinine.
name: Ethnicity
label: e
answer: no
explanation: This answer is incorrect. Gender is one of the four variables used in the MDRD equation for estimating GFR. The other variables are age, creatinine and ethnicity.
name: Gender
label: d
answer: no
explanation: This answer is correct. Body weight is included in the Cockcroft-Gault equation for calculating eGFR but is not included in the MDRD equation. The four variables in the MDRD equation are creatinine, age, gender and ethnicity.
name: Body weight
label: a
answer: yes

Correct answer: a
A 28-year-old woman in labour requires an episiotomy to aid delivery of the foetal head. A pudendal nerve block is performed prior to making the incision.

Which of the following nerve roots are involved in a pudendal nerve block?

Options:
explanation: This answer is incorrect. The pudendal nerve is formed from S2-S4 nerve roots, which are the roots involved in a pudendal nerve block.
name: S2-S3
label: e
answer: no
explanation: This answer is incorrect. The spinal nerves S1-S4 form the sacral plexus. The pudendal nerve is formed from S2-S4 fibres only, which are those involved in a pudendal nerve block.
name: S1-S4
label: b
answer: no
explanation: This answer is correct. A pudendal nerve block is a peripheral nerve block involving the S2-S4 nerve roots. It numbs the perineum and lower vagina and is performed before episiotomy.
name: S2-S4
label: a
answer: yes
explanation: This answer is incorrect. The nerve roots L4-S1 form the superior gluteal nerve which innervates the gluteus medius, maximus and tensor fascia lata. The nerve roots S2-S4 form the pudendal nerve, which are those involved in a pudendal nerve block.
name: L4-S1
label: c
answer: no
explanation: This answer is incorrect. Nerve roots from L4-S3 form the sciatic nerve which supply the majority of the lower limb. The pudendal nerve is formed from S2-S4 nerve roots, which are those involved in a pudendal nerve block.
name: L4-S3
label: d
answer: no

Correct answer: a