hllj/quesmed huggingface dataset:
A 20-year-old female presents to the emergency department with fever and jaundice. Their LFTs are deranged, and their liver viral screen is negative. Autoimmune hepatitis (AIH) is suspected.

The presence of which of the following antibodies is classically associated with Type I AIH?

Options:
explanation: This is associated with type I AIH. Anti-smooth muscle antibodies are also associated with type I AIH
name: Anti-nuclear antibodies (ANA)
label: a
answer: yes
explanation: This antibody is associated with rheumatoid arthritis
name: Anti-cyclic citrullinated peptide antibody
label: d
answer: no
explanation: This is associated with myositis (e.g. dermatomyositis)
name: Anti-mi-2
label: e
answer: no
explanation: This is associated with type II AIH which only affects children
name: Anti-liver kidney microsomal type 1 (anti-LKM-1)
label: b
answer: no
explanation: This is associated with type III AIH
name: Soluble liver-kidney antigen
label: c
answer: no

Correct answer: a


Learning point: Anti-nuclear antibodies (ANA) are classically associated with Type I autoimmune hepatitis (AIH).
A 50-year-old female with known non-alcoholic fatty liver disease (NAFLD) and associated ascites presents to the emergency department unwell. She is pyrexial and has generalised abdominal pain. Paracentesis is performed.

Which of the following results from the ascitic fluid would confirm a diagnosis of spontaneous bacterial peritonitis (SBP)?

Options:
explanation: This is correct. Neutrophils will be raised in bacterial peritonitis due to the localised inflammatory response. Positive ascitic fluid bacterial cultures will also confirm. E.coli is the most common bacteria grown
name: Neutrophil count of more than 250/mm3
label: a
answer: yes
explanation: This is associated with malignancy or haemorrhagic pancreatitis. In SBP, the ascitic fluid may appear cloudy, but there should not be any visible blood
name: Bloody appearance to ascitic fluid
label: b
answer: no
explanation: Ascitic amylase is typically raised in pancreatic ascites and is usually normal in SBP
name: Raised amylase
label: e
answer: no
explanation: Ascitic glucose is typically normal in SBP and low in secondary bacterial peritonitis. However, a normal glucose would not **confirm** a diagnosis of SBP
name: Low glucose
label: c
answer: no
explanation: An ascitic pH of <7.0 suggests bacterial infection but will not confirm a diagnosis
name: pH 7.1
label: d
answer: no

Correct answer: a


Learning point: A neutrophil count exceeding 250/mm³ in ascitic fluid indicates spontaneous bacterial peritonitis in patients with liver disease.
A 25-year-old female presents to the emergency department with a paracetamol overdose. She has hepatic encephalopathy grade II.


She has the following blood tests:


||||
|--------------|:-------:|------------------|
|pH|7.2|7.35 - 7.45|
|Creatinine|200 µmol/L|60 - 120|
|Prothrombin Time (PT)|80   seconds|10 - 12|
|Lactate|3.1 mmol/L|0.6 - 1.4|


Which of the following means that she is a candidate for liver transplantation according to the modified King's College Criteria (KCC)?

Options:
explanation: According to the modified KCC, an arterial lactate of >3.5mmol/L on admission or >3.0mmol/L 24 hours after paracetamol ingestion or after fluid resuscitation meets the criteria for possible liver transplantation
name: Arterial lactate of 3.1mmol/L
label: e
answer: no
explanation: According to the modified KCC, hepatic encephalopathy grade III or IV and serum creatinine concentration >300umol/L and prothrombin time >100 seconds meets the criteria for possible liver transplantation
name: Prothrombin time of 80 seconds
label: d
answer: no
explanation: According to the modified KCC, hepatic encephalopathy grade III or IV and serum creatinine concentration >300umol/L and prothrombin time >100 seconds meets the criteria for possible liver transplantation
name: Hepatic encephalopathy grade II
label: b
answer: no
explanation: According to the modified KCC, an arterial pH of <7.3 is criteria for possible liver transplantation
name: Arterial pH of 7.2
label: a
answer: yes
explanation: According to the modified KCC, hepatic encephalopathy grade III or IV and serum creatinine concentration >300umol/L and prothrombin time >100 seconds meets the criteria for possible liver transplantation
name: Serum creatinine of 200umol/L
label: c
answer: no

Correct answer: a


Learning point: An arterial pH of less than 7.3 indicates a candidate for liver transplantation in paracetamol overdose according to modified King's College Criteria.
A 65 year old man presents to his general practice for a routine blood pressure check. He does not appear confused and he denies chest pain or cough.

He has a blood pressure monitor at home and presents a piece of paper with his recordings on it:

- Monday AM: 132/95mmHg
- Monday PM: 136/92mmHg
- Tuesday AM: 142/105mmHg
- Tuesday PM: 135/95mmHg
- Wednesday AM: 143/105mmHg
- Wednesday PM: 139/101mmHg

The patient currently takes the following medications:

- Ramipril 10mg OD
- Amlodipine 10mg OD
- Metformin 500mg BD

A fundoscopy examination is normal. At the practice, his blood pressure is 155/100mmHg.

What is the next best step in the management of this patient?

Options:
explanation: According to NICE guidelines, specialist assessment on the same day is only indicated if the patient has a blood pressure of more than 180/120mmHg and either signs of retinal haemorrhage of papilloedema or life threatening symptoms such as a new onset confusion, chest pain, signs of heart failure or acute kidney injury
name: Refer for immediate specialist assessment for the same day
label: e
answer: no
explanation: Referral to hypertension clinic should only be required if the patient has resistant hypertension which remains uncontrolled when taking the optimal tolerated doses of 4 drugs. This patient is currently only taking 2 drugs
name: Refer to hypertension clinic
label: c
answer: no
explanation: This is not appropriate as he is currently above the threshold for uncontrolled blood pressure
name: Continue current medication regimen and schedule next blood pressure check for 3 months time
label: d
answer: no
explanation: An ACE inhibitor (eg. ramipril) can be switched to a angiotensin II receptor blocker (eg. candesartan) if the ACE inhibitor is causing adverse effects such as a cough. This does not appear to be the case in this patient
name: Stop ramipril and start candesartan
label: b
answer: no
explanation: This is correct. According to NICE guidelines, the third step after commencing an ACE inhibitor (ramipril) and calcium channel blocker (amlodipine) is a thiazide-like diuretic such as indapamide. This man's blood pressure is still not controlled, particularly his diastolic blood pressure values, as demonstrated by his home monitoring values and the clinic blood pressure and therefore the third medication is indicated
name: Commence indapamide
label: a
answer: yes

Correct answer: a


Learning point: In patients with resistant hypertension, adding a thiazide-like diuretic such as indapamide is recommended after an ACE inhibitor and calcium channel blocker.
A 85 year old man is seen at the neurology clinic with his daughter. The daughter reports that he has been increasingly forgetful, has a shortened attention span compared to his usual self and has become very clumsy. She says that this has been a gradual decline over several months. The patient denies any changes in mood or any suicidal ideation.

His only significant past medical history is chronic obstructive pulmonary disease (COPD) for which he takes salbutamol PRN. He has no significant psychiatric history.

On examination, he has normal tone of his upper and lower limbs, a normal gait, and normal power throughout.

The neurologist decides to start him on Donepazil. Which investigation should be performed prior to commencing this medication?

Options:
explanation: Although this patient has COPD, there is no requirement for a routine chest x-ray prior to initiation of Donepazil
name: Perform a chest x-ray
label: c
answer: no
explanation: This patient likely has Alzheimer's disease. Donepazil is an acetylcholinesterase inhibitor which can prolong the QT-interval (QTc). Therefore it is important to perform a 12 lead ECG and document baseline heart rhythm and QTc interval prior to initiation
name: Electrocardiogram (ECG)
label: a
answer: yes
explanation: Although Donepazil is primarily excreted renally, there is no indication this man has impaired renal function, and there is no routine requirement to check renal function prior to initiating Donepazil
name: Perform blood tests for baseline urea and electrolytes
label: e
answer: no
explanation: This patient has no focal neurological signs so there is no indication for a CT head at this stage
name: Refer for a computed tomography (CT) scan of the head
label: b
answer: no
explanation: Although this patient has COPD, there is no requirement for spirometry testing prior to initiation of Donepazil
name: Perform spirometry testing
label: d
answer: no

Correct answer: a


Learning point: Before starting Donepezil, an ECG is important to assess the baseline heart rhythm and QTc interval, as the medication can potentially prolong the QT interval and increase the risk of arrhythmias.
A 55 year old man presents to his GP with a 6 month history of multiple hypopigmented patches over his torso. He also has multiple burn marks on his hands from accidentally touching hot pans whilst cooking. Nerve conduction studies reveal reduced conduction velocity in the ulnar and median nerves. He is diagnosed with leprosy and started on dapsone.

Which one of the following tests should be performed before starting treatment?

Options:
explanation: Dapsone does not cause arrhythmias or cardiovascular events
name: Electrocardiogram (ECG)
label: c
answer: no
explanation: This is not required
name: HIV testing
label: e
answer: no
explanation: Dapsone carries the risk of severe haemolytic anaemia in patients with severe G6PD deficiency
name: Glucose-6-phosphate dehydrogenase (G6PD) levels
label: a
answer: yes
explanation: Dapsone inhibits folic acid synthesis and should be given with folate supplementation. It does not affect B12 levels
name: Vitamin B12 levels
label: d
answer: no
explanation: Dapsone undergoes hepatic metabolism and does not require dosage adjustment in renal impairment
name: Renal function testing
label: b
answer: no

Correct answer: a


Learning point: Dapsone carries the risk of severe haemolytic anaemia in patients with severe G6PD deficiency
A 75 year old male presents with a 2 week history of fatigue and night sweats. On admission, he had a transient episode of word finding difficulty which resolved within an hour. On auscultation of the chest, an opening click at S1 and an ejection systolic murmur is heard loudest at the apex. There are no residual neurological deficits. He has a past medical history of rheumatic heart disease and a prosthetic mitral valve replacement one year ago.

Serial blood cultures have been negative so far. Transoesophageal echocardiogram (TOE) showed no vegetations and a functional prosthetic mitral valve with no leaks or stenoses. He has been started on IV antibiotics for 2 weeks with persistently raised inflammatory markers. Which is the next best investigation to evaluate the underlying cause?

Options:
explanation: Transoesophageal echocardiogram is superior to CTCA for detection of vegetations. CTCA is useful for coronary imaging in patients who require surgical intervention, or to detect paravalvular infection, abscess or pseudoaneurysms
name: CT coronary angiography (CTCA)
label: c
answer: no
explanation: This is likely to be of low yield as TOE has already been done. TOE has a higher sensitivity than TTE for the diagnosis of endocarditis and should be performed in the absence of contraindications
name: Transthoracic echo (TTE)
label: b
answer: no
explanation: There is a high suspicion of infective endocarditis in this patient given the history of prosthetic valve replacement. PET CT is useful in patients for whom the diagnosis of prosthetic valve endocarditis remains uncertain following echocardiography, allowing the anatomic localisation of infection
name: Positron emission computed tomography scan (PET CT)
label: a
answer: yes
explanation: This may be useful in evaluating for malignancy or metastatic lesions, which is less likely given the 2 week history of constitutional symptoms
name: CT chest, abdomen, pelvis (CT CAP)
label: e
answer: no
explanation: This may be useful to evaluate for stroke, however the patient is likely to have experienced a transient ischaemic attack and the scan would most likely be unremarkable in the absence of any lasting neurological deficits. Cerebral infarcts may be one of the complications of infective endocarditis, but this investigation would not help in confirming the underlying diagnosis
name: CT brain
label: d
answer: no

Correct answer: a


Learning point: PET CT can help identify infective endocarditis when echocardiography is inconclusive.
A 60 year old male is admitted to the general medical ward with a 2 day history of atypical chest pain. Serial troponin levels are normal and ECG shows no dynamic changes. He is a current smoker and has a past medical history of childhood asthma.

His observations are as follows:

- Pulse 70
- BP 125/80
- SpO<sub>2</sub> 100%
- Temperature 36.5°C

Bloods are sent off for cardiovascular risk factor screening and are as follows:

- HbA1c 7.2%
- Fasting glucose 7.8
- Lipid panel unremarkable

Urine albumin creatinine ratio shows microalbuminuria.

He is started on metformin by the consultant on the ward round. Which other medication should be started?

Options:
explanation: This would be indicated for the management of essential hypertension in patients >55 years old or in Afro-Caribbeans. However, ACE inhibitors are specifically indicated for albuminuria in diabetes
name: Amlodipine
label: c
answer: no
explanation: This may be indicated for primary prevention of cardiovascular disease, however his lipid panel is normal
name: Atorvastatin
label: b
answer: no
explanation: Lisinopril is an angiotensin converting enzyme inhibitor (ACE inhibitor) which are the drug class of choice in preventing progression of albuminuria and diabetic nephropathy. They are superior to diuretics and calcium channel blockers in this case
name: Lisinopril
label: a
answer: yes
explanation: There is no indication to start aspirin in the absence of acute coronary syndrome
name: Aspirin
label: d
answer: no
explanation: Glipizide is a sulphonylurea which may be indicated if he is unable to achieve adequate blood glucose control or is unable to tolerate the gastrointestinal side effects of metformin
name: Glipizide
label: e
answer: no

Correct answer: a


Learning point: Lisinopril is the preferred medication for preventing progression of albuminuria and diabetic nephropathy in patients with diabetes and microalbuminuria.
A 53 year old lady is admitted with a 2 week history of bilateral lower limb swelling. Albumin is 21g/L (normal range 35-50 g/L) and she has proteinuria of 6.5g/24h. She is referred to the nephrologist who decides to get a renal biopsy. This reveals a diffusely thickened glomerular basement membrane with IgG and C3 subepithelial deposits.

Which of the following is the most likely underlying cause of her condition?

Options:
explanation: This is most likely to cause diabetic glomerulosclerosis, which shows Kimmelsteil-Wilson nodules (nodules of hyaline material) on biopsy
name: Diabetes mellitus
label: b
answer: no
explanation: This woman has nephrotic syndrome, characterised by oedema, proteinuria and hypoalbuminaemia. The thickened glomerular basement membrane with subepithelial deposits is characteristic of membranous nephropathy as a cause of her nephrotic syndrome. Causes of membranous nephropathy include autoimmune disease and infection such as hepatitis B and hepatitis C. A renal biopsy would show a spike and dome pattern on a silver stain
name: Hepatitis B virus
label: a
answer: yes
explanation: This is most likely to cause mesangiocapillary glomerulonephritis, which may lead to nephrotic or nephritic syndrome. This would appear as double contouring of the capillary walls or a "tram track" appearance on electron microscopy
name: Cryoglobulinaemia
label: e
answer: no
explanation: This is most likely to cause focal segmental glomerulosclerosis, which would show focal scarring and areas of collagen sclerosis
name: HIV
label: d
answer: no
explanation: This is most likely to cause minimal change glomerulonephritis, the most common cause of nephrotic syndrome in children. This would appear as podocyte effacement on electron microscopy
name: Lithium
label: c
answer: no

Correct answer: a


Learning point: Hepatitis B infection is associated with membranous nephropathy (MN), a kidney disorder characterized by the thickening of the glomerular basement membrane. The association occurs due to immune complex deposition in the kidneys, which can lead to proteinuria and nephrotic syndrome.
A 65-year-old woman presents to the emergency department with temporary word finding difficulty that lasted for 15 minutes, occurring approximately 2 hours ago. Past medical history includes hypertension and gastroesophageal reflux disease.

Observations on triage were:

- Temperature 36.5°C
- Pulse 90
- Blood pressure (BP) 170/85
- SpO2 98% on room air

An electrocardiogram shows non-valvular atrial fibrillation. On examination, she has no neurological deficits.

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

Options:
explanation: NICE recommend commencing anticoagulant in secondary care for people with ischaemic stroke or TIA and paroxysmal, persistent, or permanent atrial fibrillation or atrial flutter. The choice of anticoagulant is a DOAC in non-valvular AF. 
name: Start rivaroxaban
label: e
answer: yes
explanation: The patient has suffered a transient ischaemic attack (TIA) on a background of non-valvular atrial fibrillation (AF). In this case, as AF is likely the underlying cause of the TIA, anticoagulation (rivaroxaban) is superior to aspirin in stroke prevention. Therefore, aspirin would not be the best choice in this scenario.
name: Start aspirin
label: a
answer: no
explanation: The main priority is to initiate antiplatelet treatment with aspirin. The blood pressure is not dangerously high at this point and she does not have any serious concomitant medical issues requiring strict BP control (e.g. hypertensive encephalopathy, nephropathy or cardiac failure). In patients with a TIA who have recovered to their neurologic baseline and have no other evidence of infarction, anti-hypertensive treatment may be reinitiated
name: Start amlodipine
label: c
answer: no
explanation: This is only recommended in acute ischaemic stroke within 4.5 hours of onset, where intracranial haemorrhage has been excluded on brain imaging. In this case, the patient has a transient ischaemic attack which would not warrant this
name: Start alteplase
label: b
answer: no
explanation: While this patient does have a history of gastroesophageal reflux, the priority is to start her on an antiplatelet therapy (i.e. aspirin). She may require a H2 receptor antagonist such as ranitidine as an adjunct
name: Start ranitidine
label: d
answer: no

Correct answer: e


Learning point: In suspected transient ischaemic attack (TIA), immediate aspirin administration is recommended to reduce the risk of subsequent stroke.
A 29 year old female presents to the GP with a 5-day history of clouding of vision and difficulty differentiating colours. She has a past history of a 2-week period of left upper limb weakness that spontaneously resolved without intervention.

An MRI reveals several hyperintensities in the periventricular white matter at various regions.

What investigation is most likely to give a definitive diagnosis?

Options:
explanation: Anti-aquaporin 4 (AQP4) antibodies are specific for neuromyelitis optica spectrum disorders (NMOSD). Testing would be recommended in patients with long segments of spinal cord demyelination with or without optic neuritis, and in patients with recurrent optic neuritis with normal brain imaging
name: Testing for anti-aquaporin 4 (AQP4) antibodies
label: c
answer: no
explanation: While B12 deficiency can lead to neurological signs, it would not lead to abnormal findings on MRI, nor would symptoms resolve as spontaneously and rapidly
name: B12 level
label: d
answer: no
explanation: Whilst fundoscopy should be considered in any patient with a new visual deficit, it would be unlikely to lead to a definitive diagnosis in the context of a history suggesting MS, with an abnormal MRI. Fundoscopy is likely to be normal in MS
name: Fundoscopy
label: e
answer: no
explanation: This patient has a history suggestive of multiple sclerosis, clinically isolated neurological deficits separated in time. The MRI confirmed several hyperintensities in the periventricular white matter. The next investigation is CSF examination, looking for the typical finding of oligoclonal bands, the presence of which gives a definitive diagnosis of MS
name: Lumbar puncture looking for oligoclonal IgG bands in the cerebrospinal fluid (CSF)
label: a
answer: yes
explanation: This patient has already undergone an MRI which has demonstrated white matter lesions separated in space. A CT head is not likely to provide further information, nor a definitive diagnosis
name: Computed tomography (CT) scan of the head
label: b
answer: no

Correct answer: a


Learning point: Oligoclonal IgG bands in cerebrospinal fluid are a definitive diagnostic marker for multiple sclerosis.
A 25-year-old football player presents to Accident & Emergency with a sudden onset right-sided foot drop. X-rays of the right lower limb do not show any fractures. On examination, he cannot dorsiflex or evert his foot, but can plantarflex and invert his foot.

In view of the underlying diagnosis, which of the following examination findings will most likely be present in his right leg?

Options:
explanation: This would suggest an S1 radiculopathy, which would involve loss of plantarflexion, weakness of leg extension and knee flexion and loss of the ankle jerk reflex. Sensation would be reduced on the posterior aspect of the leg and the lateral edge of the foot
name: Loss of sensation on the lateral edge of the foot
label: e
answer: no
explanation: This would be present in a common peroneal nerve or L5 level lesion. The patient has suffered a common peroneal nerve lesion, the most common aetiologies of which are compression and trauma. Patients present with a loss of eversion and dorsiflexion (supplied by the common peroneal nerve), with intact inversion and plantarflexion (supplied by the tibial nerve). The common peroneal nerve also provides sensation to the anterolateral surface of the leg and dorsal aspect of the foot. Both the common peroneal and tibial nerve branches arise from the sciatic nerve
name: Loss of sensation on the dorsum of the foot
label: a
answer: yes
explanation: This would suggest an L5 radiculopathy or anterior horn cell dysfunction, which would also present with loss of dorsiflexion and eversion, but would also affect foot inversion, internal rotation and abduction of the hip. Patients typically present with back pain radiating down the lateral aspect of the leg
name: Inability to internally rotate the hip
label: d
answer: no
explanation: This would suggest a saphenous nerve lesion or L4 level lesion. The saphenous nerve is the largest branch of the femoral nerve, and entrapment may result in deep thigh ache, knee pain and paraesthesia of the anteromedial aspect of the leg
name: Loss of sensation on the medial aspect of the leg
label: c
answer: no
explanation: This would suggest a sciatic nerve lesion or S1 level lesion. Peripheral neuropathy and cauda equina syndrome may also result in a loss of the ankle jerk reflex; however, this is more likely to present with bilateral foot drop. In common peroneal nerve lesions, the ankle deep tendon reflex is intact
name: Absent ankle jerk
label: b
answer: no

Correct answer: a


Learning point: A common peroneal nerve lesion causes foot drop, loss of dorsiflexion, eversion, and sensory loss over the dorsum of the foot.