hllj/quesmed huggingface dataset:
A 42-year-old man attends his GP after a 6-month history of difficulty sleeping. He reports waking up multiple times a night gasping for breath and then napping more regularly in the day. His wife has also noticed that he tends to act out his dreams while asleep and snores heavily. On examination, his body mass index is 35 and otherwise unremarkable.

What is the best next investigation for his poor sleep?

Options:
explanation: Acting out dreams can indicate a REM disorder. This can be an early feature of Parkinson's disease, where a DaTscan can illustrate loss of dopaminergic neurones in the basal ganglia. However, given the patient demographics and the absence of any parkinsonian features, the more likely underlying cause of the REM sleep disorder is OSA. The first-line investigation would be polysomnography.
name: DaTscan
label: b
answer: no
explanation: Waking in the middle of the night can occur in the context of heart failure, where the patient reports waking up breathless and coughing pink, frothy sputum (paroxysmal nocturnal dyspnoea (PND)). In this case, there are no reported heart failure symptoms, such as shortness of breath, PND, orthopnoea or ankle swelling. The clinical presentation is more in keeping with OSA.
name: Brain natriuretic peptide
label: e
answer: no
explanation: The history of snoring and daytime somnolence in a patient who is obese points towards a diagnosis of obstructive sleep apnoea (OSA). Acting out dreams can be a rapid eye movement (REM) disorder, which can also be seen in a small number of these patients. The first-line investigation for OSA would be polysomnography.
name: Polysomnography
label: a
answer: yes
explanation: Enlarged tonsils, adenoids or a narrowed airway can be risk factors for OSA. A laryngoscopy could be used to evaluate any structural abnormalities narrowing the airway. However, this is not first line and is generally reserved for patients undergoing potential surgical treatment, where standard medical therapy such as continuous positive airway pressure has failed or not been tolerated.
name: Laryngoscopy
label: d
answer: no
explanation: A sleep diary is unlikely to yield much additional information since the patient and his wife have already given detailed accounts of his sleep patterns. Their accounts point towards a diagnosis of OSA; therefore, he should be referred for polysomnography.
name: Sleep diary
label: c
answer: no

Correct answer: a


Learning point: Polysomnography is the gold standard investigation for diagnosing obstructive sleep apnoea, it simultaneously records brain activity, eye movement, muscle activity, heart rate, respiratory effort, airflow, and oxygen saturation during sleep to identify apneic episodes and assess their severity.
A 32-year-old woman is brought to A&E by ambulance accompanied by her mother. She was discharged from hospital 3 d ago after a total thyroidectomy for papillary thyroid cancer. Today, her mother witnessed her having a tonic-clonic seizure, which terminated after a single dose of lorazepam provided by paramedics. There have been no further seizures. On examination, gentle tapping over the facial nerve produces spasm of her face ipsilaterally.

What is the first-line initial treatment for her diagnosis?

Options:
explanation: This patient is likely vitamin D-deficient due to parathyroid gland removal during total thyroidectomy surgery. Correcting the hypocalcaemia is the first port of call due to her having had a seizure. Vitamin D replacement is important for long-term management.
name: Oral high-dose vitamin D
label: c
answer: no
explanation: This would be the treatment of choice for mild hypocalcaemia. This patient likely has profound hypocalcaemia due parathyroid gland removal during total thyroidectomy surgery. This patient has had serious complication of hypocalcaemia, including a seizure, and therefore IV calcium gluconate is the most appropriate initial treatment.
name: Oral calcium carbonate
label: b
answer: no
explanation: This patient has had a seizure, terminated by one dose of lorazepam. Phenytoin is given after multiple unsuccessful doses of lorazepam 10 min apart. The likely cause of the seizure is hypocalcaemia and therefore it is best to treat the underlying cause to prevent further seizures.
name: Phenytoin
label: d
answer: no
explanation: This patient likely has hypocalcaemia, secondary to parathyroid gland removal during total thyroidectomy. The sign elicited on examination is Chvostek sign, one of the two signs for hypocalcaemia, the other being Trousseau's. Trousseau's sign is carpopedal spasm when a blood pressure cuff is applied and inflated on the arm. The patient has also presented with a seizure, suggesting profound hypocalcaemia. An ECG would also be an important investigation due to these patients being at risk of prolonged QTc and subsequent torsades de pointes.
name: IV calcium gluconate
label: a
answer: yes
explanation: This patient has had a seizure, which has terminated with one dose of lorazepam. If she had another seizure then another dose may be given as part of the emergency management. However, given that there are no current seizures, treating the underlying cause to prevent further episodes is the best next step. Therefore, calcium gluconate is the best answer.
name: Lorazepam
label: e
answer: no

Correct answer: a


Learning point: Hypocalcaemia can occur after total thyroidectomy, presenting with seizures and Chvostek's sign; immediate treatment includes intravenous calcium gluconate.
A 42-year-old woman presents to her GP with frequent leaking of small volumes of urine. This is worse when she drinks coffee, coughs or eats a large meal. She denies urinary urgency or any other urinary symptoms. She is a current smoker and on examination her body mass index is 30.

Apart from lifestyle advice, what is the next best step in management?

Options:
explanation: This woman gives a typical history of stress incontinence. She passes small amounts of urine involuntarily when her abdominal pressure is increased, such as when coughing or after eating a large meal. She has risk factors for stress incontinence such as being female, overweight, smoking and drinking coffee. She would be advised to limit her alcohol and coffee intake and be offered help to lose weight and quit smoking. She would also be referred for pelvic floor exercises.
name: Pelvic floor exercises
label: a
answer: yes
explanation: Duloxetine is a serotonin-noradrenaline reuptake inhibitor used to manage stress incontinence by increasing urethral tone. However, this is after lifestyle changes and pelvic floor exercises for at least 3 months.
name: Duloxetine
label: b
answer: no
explanation: This patient is yet to try lifestyle changes and pelvic floor exercises. Failure to respond to medical therapy may prompt surgical management. In this procedure, a bulking agent is injected into the bladder neck (usually under local anaesthetic) to improve its contraction and reducing urine leakage.
name: Intramural urethral bulking
label: e
answer: no
explanation: This is a beta 3 agonist used for the management of urge (overactive bladder) incontinence. The history here is not consistent with urge incontinence.
name: Mirabegron
label: d
answer: no
explanation: This patient is yet to try lifestyle changes and pelvic floor exercises. Failure to respond to medical therapy may prompt surgical management.
name: Referral for mesh repair surgery
label: c
answer: no

Correct answer: a


Learning point: Pelvic floor exercises are the first-line management for stress incontinence, particularly in women with risk factors like obesity and smoking.
A 72-year-old female presents to her GP with leakage of urine. She says that urine leaks continuously throughout the day and is affecting her ability to leave the house since she frequently has to change her underwear. She does not report her symptoms worsening with alcohol, caffeine, straining or coughing. She does not report any urinary urgency or any other urinary symptoms. She underwent radiotherapy after resection of a rectal tumour 4 months ago. There has been no signs of recurrence from her most recent follow-up. She is otherwise well, has never smoked and has a body mass index of 25. She had one child via caesarian section 40 years ago.

What is the most likely diagnosis?

Options:
explanation: This patient denies any symptoms of leakage following raised abdominal pressure, for example, with coughing or sneezing. Urine leakage is consistent throughout the day, which is most in keeping with a vesicovaginal fistula, especially in the context of recent radiotherapy to the pelvis.
name: Stress incontinence
label: c
answer: no
explanation: A rectovaginal fistula would cause the passage of faeces through the vagina, with an increased risk of urinary tract infections. This patient describes a continuous urine leakage throughout the day, with recent pelvic radiotherapy, making a vesicovaginal fistula the most likely diagnosis.
name: Rectovaginal fistula
label: d
answer: no
explanation: Chronic cystitis would more typically give a history of dysuria, pelvic pain, urinary urgency and frequency. This patient describes urinary leakage throughout the day with no mention of pain in the history. The most likely diagnosis is a vesicovaginal fistula given the painless continuous leakage of urine plus recent pelvic radiotherapy.
name: Chronic cystitis
label: e
answer: no
explanation: This patient denies any symptoms of urgency. The urine leakage is consistent throughout the day, which is most in keeping with a vesicovaginal fistula, especially in the context of recent radiotherapy to the pelvis.
name: Urge incontinence
label: b
answer: no
explanation: This patient has recently undergone radiotherapy to the pelvis for the treatment of a rectal tumour. This has likely caused a vesicovaginal fistula, which would mean a constant leakage of urine from the bladder through to the vagina. There are no clinical features suggestive or urge or stress incontinence, such as urgency or leakage on coughing respectively.
name: Vesicovaginal fistula
label: a
answer: yes

Correct answer: a


Learning point: Vesicovaginal fistula can occur post-radiotherapy, leading to continuous urinary leakage without urgency or stress-related symptoms.
A 28-year-old man presents to A&E after an overdose of paracetamol. He said he took 40 tablets over a 6-h period yesterday evening. It is now 11 a.m.

Which of the following tests provides the best prognostic indicator?

Options:
explanation: This will be raised in hepatitis but it is not a measure of synthetic liver function or a good prognosticator for fulminant hepatic failure.
name: Alanine transaminase
label: b
answer: no
explanation: This will be raised in hepatitis but it is not a measure of synthetic liver function or a good prognosticator for fulminant hepatic failure.
name: Aspartate transaminase
label: c
answer: no
explanation: The international normalised ratio is the best prognostic indicator for patients who have sustained hepatic injury due to paracetamol overdose. This is because it represents the synthetic function of the liver.
name: International normalised ratio
label: a
answer: yes
explanation: The liver produces albumin, the main component of the blood-maintaining oncotic pressure. When albumin levels drop, fluid moves from the intravascular space to the interstitial space, causing peripheral oedema and ascites. The half-life of albumin is 3 weeks; therefore, it is not a good measure of liver function in the acute setting.
name: Albumin
label: e
answer: no
explanation: Liver injury typically causes prolongation of the prothrombin time and therefore the international normalised ratio. The activated partial thromboplastin time is usually spared.
name: Activated partial thromboplastin time
label: d
answer: no

Correct answer: a


Learning point: In paracetamol overdose, an elevated International Normalised Ratio (INR) is an important prognostic indicator, as it signifies liver dysfunction and a higher risk of severe complications, including bleeding and potential liver failure
A 42-year-old man has some blood tests conducted by his hepatology team in the outpatient department. The results are shown below:

Hepatitis B surface antigen - negative
Anti-hepatitis B surface antibody - positive
IgM anti-HBc - negative
IgG anti-HBc - positive

Which of the following is the most likely explanation for these results?

Options:
explanation: This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. This is in keeping with previous exposure to hepatitis B virus with recovery and the presence of current antibodies.
name: Previous exposure and recovery to hepatitis B
label: a
answer: yes
explanation: This patient has positive IgG antibodies to the core antigen of the hepatitis B virus and positive surface antigen antibodies. Previous vaccination would mean only antibodies for the surface antigen would be present since there is no core antigen present in the vaccine. This patient has antibodies to both, indicating previous infection with immunity.
name: Vaccination against hepatitis B
label: d
answer: no
explanation: This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. Early acute infection would have a positive surface antigen present, without presence of antibodies. The first type of antibody to appear would then be IgM.
name: Early acute hepatitis B virus infection
label: e
answer: no
explanation: This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. If the infection were chronic, we would expect a positive surface antigen to be present due to ongoing virus particle production. The surface antigen is currently negative, indicating recovery from the infection.
name: Chronic infection with hepatitis B
label: b
answer: no
explanation: This patient has positive IgG antibodies to the core antigen of hepatitis B virus and positive surface antigen antibodies. If this were an acute infection, we would expect positive IgM antibodies to the core antigen, as well as positive surface antigen due to the presence of virus particle production.
name: Acute infection with hepatitis B
label: c
answer: no

Correct answer: a


Learning point: Positive IgG anti-HBc and positive anti-HBs indicate previous hepatitis B infection with subsequent recovery and immunity.
A 65-year-old woman with known stress incontinence presents to her GP after having completed 6 months of pelvic floor exercises and lifestyle changes without significant improvement of her incontinence. She reports good compliance with her pelvic floor exercises. She has no significant past medical history or drug allergies. She does not want any surgical treatment at this stage.

What is the next most appropriate management to offer her?

Options:
explanation: Duloxetine is a serotonin-noradrenaline reuptake inhibitor, which works by increasing urethral tone and reducing urinary leaks. It is indicated as a second-line option to surgery where surgery is not a possible treatment (ie. if the patient is not fit for, or does not want to have, surgery, as in this case). Common side effects include gastrointestinal disturbance and drowsiness. It is used with caution in the elderly and may reduce the seizure threshold.
name: Duloxetine
label: a
answer: yes
explanation: An oestrogen pessary can improve vaginal dryness in postmenopausal women. It will not help in the case of an overactive bladder.
name: Oestrogen pessary
label: c
answer: no
explanation: This patient does not want surgical management. Colposuspension is a surgical treatment for stress urinary incontinence, which involves securing the bladder neck with stitches, so that it does not drop down and cause urinary leakage.
name: Referral for colposuspension
label: e
answer: no
explanation: This patient has committed to pelvic floor exercises for 6 months without improvement of her symptoms. National Institute for Health and Care Excellence guidelines state that at least 3 months of pelvic floor exercises should be trialled and further treatments considered if this fails. Therefore, it would be inappropriate to ask her to complete another 6 months of pelvic floor exercises and she should now be considered for pharmacological or surgical management.
name: Further 6 months of pelvic floor exercises
label: b
answer: no
explanation: Mirabegron is a beta 3 agonist approved for use in overactive bladder, otherwise known as urge incontinence. It has been shown to have equal efficacy to tolterodine and solifenacin for urge incontinence. Its side effects include raised blood pressure and increased risk of urinary tract infection. This would not be a treatment for stress incontinence.
name: Mirabegron
label: d
answer: no

Correct answer: a


Learning point: Duloxetine is an effective second-line treatment for stress incontinence, enhancing urethral tone when conservative measures fail.
A 32-year-old man presents to the Neurology Clinic with impaired sensation over his neck and upper back. He says he cannot feel pain over this region when he pinches the skin, as well as weakness in his hands. On examination, he has a loss of pain and temperature sensation over his neck, back and upper shoulders. There is some clawing of his hands bilaterally with atrophy of the muscles of the forearm. Fine touch, proprioception and vibration are spared. There are no sensory or motor abnormalities of the lower limbs.

Where is the lesion responsible for his sensory symptoms?

Options:
explanation: This patient has evidence of corticospinal tract involvement since there is evidence of motor dysfunction with associated hand clawing. However, this would not explain his sensory symptoms, which is the question being asked.
name: Corticospinal tracts
label: b
answer: no
explanation: The dorsal columns are responsible for fine touch, vibration and proprioception. The patient has no issues with these sensory modalities and so this is not responsible for his symptoms. Progression of the syrinx can, over time, impinge on the dorsal columns and cause deficiencies within these sensory modalities.
name: Dorsal columns
label: c
answer: no
explanation: The description of loss of pain and temperature over the neck and back (in a cape-like distribution) and predominant upper-limb dysfunction with bilateral hand clawing fits with a diagnosis of syringomyelia. Syringomyelia is a fluid-filled cyst (syrinx) that forms within the centre of the spinal cord, initially compressing the decussation of the spinothalamic tract and leading to localised loss of pain and temperature sensation. Over time, it gets larger and can expand to multiple levels of the cord as well as other structures, such as the anterolateral corticospinal tracts, which this patient has evidence of due to the presence of motor symptoms, and the dorsal columns.
name: Spinothalamic tract
label: a
answer: yes
explanation: The motor cortex is a cerebral structure within the frontal lobe. A lesion in the motor cortex causes upper motor neurone pathology and spasticity (hyperreflexia, pyramidal distribution of weakness and a velocity-dependent increase in tone). Sensory involvement is spared. A lesion in the motor cortex will therefore not explain this patient's symptoms.
name: Motor cortex
label: d
answer: no
explanation: The somatosensory cortex is a cerebral structure within the parietal lobe. Depending on the precise location of the lesion in the somatosensory cortex, any sensory modality may be lost in the distribution as dictated by the sensory homunculus. However, sensory loss with cerebral lesions do not have such a defined pattern of presentation, with dorsal column sparing and a cape-like distribution. Loss of sensation in this pattern should raise clinical suspicion of a spinal lesion.
name: Somatosensory cortex
label: e
answer: no

Correct answer: a


Learning point: Syringomyelia causes a characteristic 'cape-like' distribution of pain and temperature loss due to compression of the spinothalamic tract in the spinal cord.
A 35-year-old female presents to the GP with a 6-month history of fatigue. During this time, she also describes feeling short of breath when running for the bus and recurrent episodes of tingling down her leg. On examination, she has swollen lymph nodes and crepitations on chest auscultation. She has a temperature of 37.7.

Which of the following is the next best investigation?

Options:
explanation: CRP can be raised in any infection or conditions that cause inflammation in the body. It is a non-specific marker which would not be helpful in determining the cause of this patient's symptoms, since it may be raised in conditions such as sarcoidosis,  but also other inflammatory conditions, including pneumonia.
name: C-reactive protein
label: c
answer: no
explanation: This scan can be requested later on by a specialist within the hospital setting. A CT chest is useful to further characterise how the sarcoidosis has affected the patient's lungs. This would be requested after a CXR, since starting with simple, least invasive/harmful investigations is most appropriate in the first instance.
name: CT chest
label: d
answer: no
explanation: This is a specialist investigation which would not be requested by the GP.  This investigation can be diagnostic for sarcoidosis, but it does not represent the next best investigation. Typically, you would find non-caseating granulomas on a biopsy.
name: Lung biopsy
label: e
answer: no
explanation: This patient has sarcoidosis which explains her long-term symptoms. In the early stages, a CXR may show evidence of bilateral hilar lymphadenopathy and fibrosis in the later stages. It can also rule out other causes of shortness of breath and crepitations, such as pneumonia.
name: Chest X-Ray
label: a
answer: yes
explanation: Serum ACE levels are raised in sarcoidosis, however it would not be the next best investigation since ACE is neither specific to, nor diagnostic of, sarcoidosis.
name: Angiotensin-converting enzyme (ACE) levels
label: b
answer: no

Correct answer: a


Learning point: Sarcoidosis commonly presents with fatigue, shortness of breath, and lymphadenopathy; a chest X-ray is essential for diagnosis and assessment.