hllj/quesmed huggingface dataset:
A 32 year old pregnant woman presents to her GP with tingling and pain in her left hand. This is limited to her thumb, index and middle finger. It is much worse at night but can also be troublesome during the day.

On examination there is reduced sensation of the thumb, index and middle finger, as well as slight wasting of the thenar eminence.

Which of the following nerves is most likely implicated in this patient's presentation?

Options:
explanation: This is incorrect. The signs of a radial nerve injury vary depending on where the damage occurs. Damage at the axilla or proximal humerus is associated with unopposed flexion of the wrist, and sensory loss over the lateral and posterior arm.
name: Radial nerve
label: c
answer: no
explanation: This is incorrect. Injury to the musculocutaneous nerve presents with weakness in shoulder and elbow flexion as well as loss of sensation over the lateral forearm.
name: Musculocutaneous nerve
label: e
answer: no
explanation: This is incorrect. The axillary nerve is commonly injured following shoulder dislocation. It presents as weakness in shoulder abduction and sensory loss over the inferior deltoid.
name: Axillary nerve
label: d
answer: no
explanation: This is incorrect. Ulnar nerve compression occurs in cubital tunnel syndrome. Symptoms are similar to that of carpal tunnel syndrome; including pain, paresthesia and numbness of the medial one and a half fingers.
name: Ulnar nerve
label: b
answer: no
explanation: This is correct. The patient is presenting with carpal tunnel syndrome, which is the compression of the median nerve as it passes through the carpal tunnel to the hand. Classic symptoms include pain, paresthesia, numbness in the distribution of the median nerve and wasting of the thenar eminence.
name: Median nerve
label: a
answer: yes

Correct answer: a
A 25 year old woman presents to A&E after sustaining a right knee injury whilst playing football. Her boot became stuck in the ground, causing her knee to twist. She reports a popping sensation, accompanied by sudden severe pain. On examination, there is significant swelling and tenderness in the right knee. The anterior draw test is positive.

An MRI shows a tear to the structure that attaches to the anterior intercondylar region of the tibia and the intercondylar fossa of the femur.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is incorrect, injuries to the lateral collateral ligament are typically seen following a blow to the lateral side of the knee in a planted foot. On examination, lateral rotation of the leg would elicit pain. MRI would show a tear to a ligament which attaches at the lateral epicondyle of the femur and lateral surface of the fibular head.
name: Lateral collateral ligament tear
label: e
answer: no
explanation: This is correct. The patient demonstrates a typical ACL injury involving a twisting motion, a popping sensation and rapid swelling. Other indicators include a positive anterior draw test that is consistent with ACL weakness. The MRI also describes an ACL tear: it attaches to the anterior intercondylar region of the tibia and the intercondylar fossa of the femur.
name: Anterior cruciate ligament (ACL) tear
label: a
answer: yes
explanation: This is incorrect. The PCL is often injured following a direct blow to a flexed knee. This would show on examination as a positive posterior draw test. The PCL inserts at the posterior intercondylar region of the tibia and the anteromedial femoral condyle. These factors make an ACL tear more likely than a PCL tear in this case.
name: Posterior cruciate ligament (PCL) tear
label: b
answer: no
explanation: This is incorrect. Injuries to the medial collateral ligament are typically seen following a blow to the medial side of the knee in a planted foot. On examination, medial rotation of the leg would elicit pain. MRI would show a tear to a ligament which attaches to the medial epicondyle of the femur and medial condyle of the tibia. It would also likely show a meniscal tear as these structures are closely related. An ACL tear is therefore a more likely underlying diagnosis.
name: Medial collateral ligament tear
label: d
answer: no
explanation: This is incorrect. The patellar ligament is a continuation of the quadriceps femoris tendon and attaches to the tibial tuberosity. Injury to this ligament would present with a popping sensation and swelling, but examination would elicit an inability to straighten the knee. An ACL tear is therefore a more likely underlying diagnosis.
name: Patellar ligament tear
label: c
answer: no

Correct answer: a
A 17 year old patient attends a neurology clinic following a recent suspected epileptic fit. He is commenced on anti-epileptic medication.

Which of the following drugs works by increasing the refractory period of sodium channels?

Options:
explanation: This is incorrect. Gabapentinoids such as pregabalin work by inhibiting pre-synaptic calcium channels, reducing the calcium influx into neurons. This prevents the release of excitatory neurotransmitters such as glutamate.
name: Pregabalin
label: e
answer: no
explanation: This is correct. Phenytoin is a non-specific sodium channel blocker and acts by increasing the refractory period of these channels, blocking the positive feedback loop that encourages action potentials. This in turn reduces the over-activity of excitatory neurons that generate seizures. As it is a non-selective sodium channel blocker it should be used with caution in heart block or sinus bradycardia.
name: Phenytoin
label: a
answer: yes
explanation: This is incorrect. Levetiracetam targets the synaptic vesicle protein 2A which is expressed throughout the brain. Through this action it modulates the release of neurotransmitters, preventing the activation of excitatory neurons.
name: Levetiracetam
label: c
answer: no
explanation: This is incorrect. Sodium valproate works by increasing the production of the inhibitory neurotransmitter GABA. This reduces the neuronal excitability causing seizures.
name: Sodium valproate
label: b
answer: no
explanation: This is incorrect. Benzodiazepines such as lorazepam increase the activity of the inhibitory neurotransmitter GABA by binding to postsynaptic benzodiazepine receptors.
name: Lorazepam
label: d
answer: no

Correct answer: a
A 66 year old female presents to A&E after a week long history of palpitations, breathlessness and fatigue. She is found to have an irregularly irregular pulse. An ECG confirms atrial fibrillation at a rate of 120 beats per minute. She is prescribed atenolol to control her heart rate.

Which of the following Vaughan-Williamson (V-W) classifications does atenolol belong to?

Options:
explanation: This is incorrect. Atenolol is a beta-blocker which belongs to the V-W class II. An example of an antiarrhythmic drug from class IV would be verapamil. These drugs inhibit calcium channels, affecting phases 0 and 4 of the cardiac action potential.
name: Class IV
label: e
answer: no
explanation: This is incorrect. Atenolol is a beta-blocker which belongs to the V-W class II. An example of an antiarrhythmic drug from class Ib would be lidocaine. This class of drugs acts by blocking fast sodium channels.
name: Class Ib
label: c
answer: no
explanation: This is incorrect. Atenolol is a beta-blocker which belongs to the V-W class II. An example of an antiarrhythmic drug from class III would be amiodarone. Class III drugs act by blocking potassium channels, increasing the action potential recovery period of key structures within the heart.
name: Class III
label: d
answer: no
explanation: This is correct. Atenolol is a beta-blocker which belongs to the V-W class II. Beta-blockers are beta-1-adrenergic antagonists, which work to decrease the heart rate.
name: Class II
label: a
answer: yes
explanation: This is incorrect. Atenolol is a beta-blocker which belongs to the V-W class II. An example of an antiarrhythmic drug from class Ia would be procainamide. This class of drugs acts by blocking fast sodium channels.
name: Class Ia
label: b
answer: no

Correct answer: a
A 65 year old male presents to A&E feeling generally unwell. For the past 2 days, he has had a cough productive of purulent sputum and becomes breathless walking only short distances. He has no regular medications and no past medical history. He consumes one glass of wine on a Saturday and has never smoked cigarettes.

On examination, there is dullness to percussion over the left lower lobe, as well as increased vocal resonance. A chest x-ray shows consolidation in the left lower lobe.

Which of the following is the most likely causative microorganism?

Options:
explanation: This is incorrect. Klebsiella pneumonia is most commonly seen in patients with alcohol dependence. A classic sign is red-currant jelly sputum. As the patient in this case only has around 3 units of alcohol per week, Streptococcus pneumoniae is a more likely causative organism.
name: Klebsiella pneumoniae
label: b
answer: no
explanation: This is incorrect. Haemophilus influenzae is the second most common cause of pneumonia, and is often associated with bronchiectasis exacerbations. It is not as common as Streptococcus pneumoniae, making this option incorrect.
name: Haemophilus influenzae
label: c
answer: no
explanation: This is incorrect. Pneumocystis jirovecii typically only causes pneumonia in patients who are immunocompromised or HIV positive (particularly if CD4 count is below 200cells/uL). As this patient has no past medical history, Pneumocystis jirovecii is an unlikely causative organism.
name: Pneumocystis jirovecii
label: e
answer: no
explanation: This is incorrect. Legionella pneumonia is associated with Legionnaire's disease. It is classically seen in a patient recently exposed to poor hotel air conditioning. Blood tests may show hyponatraemia and deranged liver function tests. It is not as common as Streptococcus pneumoniae, making this option incorrect.
name: Legionella pneumophila
label: d
answer: no
explanation: This is correct. The patient has classic signs and symptoms of a lower respiratory tract infection, or pneumonia. Their symptoms (shortness of breath and cough), examination findings and imaging results are all consistent with this diagnosis. The most common causative microorganism is streptococcus pneumoniae.
name: Streptococcus pneumoniae
label: a
answer: yes

Correct answer: a
A 43 year old female patient presents to A&E with acute breathlessness and haemoptysis. She has had a cough for around 3 months and has required treatment for five chest infections over the last 6 months. She reports 2 stone of unintentional weight loss across this period.

Her past medical history includes osteoarthritis of the right hip, for which she takes occasional paracetamol. She has never smoked and drinks alcohol rarely. She denies any exposure to asbestos.

A chest x-ray shows a right-sided mass associated with mediastinal lymphadenopathy and pleural effusion in the right lower lung field.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is correct. The following aspects of the history make this the most likely answer:
* Age of the patient- adenocarcinoma is the most common lung cancer subtype in patients aged under 45
* Sex of the patient- adenocarcinoma is more common in women
* Smoking status of the patient- adenocarcinoma is the most common lung cancer subtype in non-smokers
* Pleural effusion on chest x-ray: adenocarcinomas commonly cause pleural effusion
name: Adenocarcinoma
label: a
answer: yes
explanation: This is incorrect. Small cell carcinoma is commonly seen alongside paraneoplastic syndromes such as the syndrome of inappropriate antidiuretic hormone (SIADH), Cushing's syndrome or Lambert Eaton myasthenic syndrome. With no indication of paraneoplastic syndromes, adenocarcinoma is a more likely underlying diagnosis.
name: Small cell carcinoma
label: c
answer: no
explanation: This is incorrect. Large cell carcinoma is a poorly differentiated subtype of lung cancer which is often a diagnosis of elimination. This is more common in men and has a strong relationship with smoking. It is associated with beta-hCG secretion and can cause gynaecomastia. It is less common than adenocarcinoma.
name: Large cell carcinoma
label: e
answer: no
explanation: This is incorrect. Squamous cell carcinoma is strongly associated with cigarette smoking and cavitations on imaging. This subtype is also associated with paraneoplastic syndromes including ectopic parathyroid hormone secretion (hypercalcaemia) and hypertrophic pulmonary osteoarthropathy (which involves painful, swollen joints).
name: Squamous cell carcinoma
label: d
answer: no
explanation: This is incorrect. Whilst mesothelioma is commonly associated with pleural effusions, it is strongly associated with occupational exposure to asbestos which this patient does not have. There is a median latency period of 40 years, meaning it would be extremely rare to see this condition in a 43 year old.
name: Mesothelioma
label: b
answer: no

Correct answer: a
A 55 year old woman presents to her GP with a 5 day history of palpitations. An ECG shows tachycardia of 120 beats per minute. The rhythm is irregularly irregular. There are no identifiable P waves, and the QRS complex is narrow.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is correct. Classic ECG features of AF include tachycardia, an irregularly irregular rhythm and the absence of p-waves. An irregular peripheral pulse may also be identified. Symptoms include palpitations as well as chest pain, shortness of breath and syncope in some cases.
name: Atrial fibrillation (AF)
label: a
answer: yes
explanation: This is incorrect. On an ECG, ventricular tachycardia is associated with regular but broad QRS complexes as well as a fast rate (>100 beats per minute). It can occur with a pulse or it may be pulseless.
name: Ventricular tachycardia
label: c
answer: no
explanation: This is incorrect. Ventricular fibrillation is an irregular broad complex tachycardia. It is a medical emergency, and patients will not have a pulse.
name: Ventricular fibrillation
label: d
answer: no
explanation: This is incorrect. Typical ECG findings of atrial flutter include flutter waves, or a characteristic 'saw tooth' like pattern, as well as tachycardia.
name: Atrial flutter
label: b
answer: no
explanation: This is incorrect. An ECG showing a narrow QRS complex, irregularly irregular rhythm and absent p waves is consistent with atrial fibrillation.
name: Normal variation
label: e
answer: no

Correct answer: a
A 14-year-old teenage boy presents to their GP with shortness of breath and a cough that is worse at night. His only medical history is allergic rhinitis and eczema.

Spirometry shows an obstructive pattern of lung disease and positive reversibility testing. He is prescribed a salbutamol inhaler.

Which of the following is true of a salbutamol inhaler?

Options:
explanation: This is incorrect. Salbutamol is a short-acting β2-adrenoreceptor agonist used in acute asthma management. Its duration of action is up to around four hours. By contrast, long-acting β2-adrenoreceptor agonists such as salmeterol are effective for up to 12 hours.
name: It is effective for up to 12 hours by inhalation
label: b
answer: no
explanation: This is correct. Salbutamol is a short-acting β2-adrenoreceptor agonist used in acute asthma management. It binds selectively and reversibly to receptors of the respiratory tract. This inhibits the contraction of bronchial smooth muscle, resulting in bronchodilation.
name: It acts by relaxing bronchial smooth muscle
label: a
answer: yes
explanation: This is incorrect.  Salbutamol is a short-acting β2-adrenoreceptor agonist used in acute asthma management. It has little to no action on the β1 adrenoreceptors of the heart.
name: They have a high affinity for the β1 adrenoreceptors of the heart
label: c
answer: no
explanation: This is incorrect.  Salbutamol is a short-acting β2-adrenoreceptor agonist used in acute asthma management. It is not an antagonist. Antagonism of these receptors would prevent bronchodilation, exacerbating the bronchoconstriction seen in asthma.
name: It belongs to the β2-adrenoreceptor antagonist class of drugs
label: d
answer: no
explanation: This is incorrect. Salbutamol is a short-acting β2-adrenoreceptor agonist used in acute asthma management. It is used as reliever therapy when required. If it is required more than three times a week then the patient is said to have uncontrolled asthma and should be offered a regular 'preventer' inhaler.
name: They should be used once a day for well controlled asthma
label: e
answer: no

Correct answer: a
A 58 year old male attends his GP surgery after noticing his blood pressure was high on his husband's home blood pressure monitor. He would like to know more about hypertension and its causes.

Which of the following is associated with an increase in blood pressure?

Options:
explanation: This is incorrect. Excretion of sodium from the kidney would in turn increase water excretion, which follows sodium via osmosis. This would therefore reduce the circulating blood volume and consequently reduce the stroke volume of the heart. This would reduce mean arterial blood pressure.
name: Increasing renal excretion of sodium
label: c
answer: no
explanation: This is correct. Activation of the sympathetic nervous system increases heart rate and increases peripheral vascular resistance. Mean arterial pressure is determined by the cardiac output multiplied by total peripheral resistance. Cardiac output is determined by the heart rate and stroke volume. Therefore by increasing heart rate, the cardiac output and consequently the mean arterial pressure also increase. The increase in peripheral vascular resistance further contributes to an increase in mean arterial pressure.
name: Sympathetic nervous system activation
label: a
answer: yes
explanation: This is incorrect. An increase in body temperature would cause vasodilation, thus reducing peripheral vascular resistance. This in turn reduces mean arterial blood pressure.
name: Increase in body temperature
label: d
answer: no
explanation: This is incorrect. Histamine causes vasodilation, thus reducing peripheral vascular resistance. This in turn reduces mean arterial blood pressure.
name: Histamine release
label: e
answer: no
explanation: This is incorrect. The parasympathetic system decreases heart rate. This reduces cardiac output, consequently reducing mean arterial pressure. Activation of the parasympathetic nervous thus causes a decrease in blood pressure.
name: Parasympathetic nervous system activation
label: b
answer: no

Correct answer: a
A 70-year-old woman presents with a chronic productive cough, breathlessness, and recurrent chest infections over the past year. She denies haemoptysis or weight loss but experiences shortness of breath when walking upstairs, though she can walk comfortably on flat surfaces. She does not drink alcohol but has smoked one packet of cigarettes a day for the last 55 years.

On examination, there is a bilateral expiratory wheeze, hyper-resonance on percussion throughout the lung fields, and a mildly elevated respiratory rate of 22 breaths per minute, with otherwise normal observations.

A chest x-ray shows hyperinflation of the chest with no masses, effusions or lymphadenopathy. Spirometry shows a reduced FEV1/FVC ratio of 0.6.


Which of the following is the most likely underlying diagnosis?

Options:
explanation: Whilst lung cancer is an important differential to consider, the absence of weight loss and haemoptysis is reassuring. Furthermore, lung cancer would be expected to show a mass or effusion on chest x-ray. The absence of these features makes COPD a more likely underlying diagnosis.
name: Lung cancer
label: b
answer: no
explanation: Whilst lung cancer is an important differential to consider, the absence of weight loss and haemoptysis is reassuring. Furthermore, lung cancer would be expected to show a mass or effusion on chest x-ray. The absence of these features makes COPD a more likely underlying diagnosis.
name: Asthma
label: d
answer: no
explanation: This is incorrect. Whilst a lower respiratory tract infection or pneumonia can present with a productive cough and shortness of breath, the chronic duration of these symptoms and the absence of a temperature make COPD a more likely underlying diagnosis. This is also supported by the chest x-ray and spirometry findings.
name: Pneumonia
label: e
answer: no
explanation: This is incorrect. Interstitial lung disease shows a restrictive pattern on spirometry. FEV1 and FVC are equally reduced, resulting in a preserved FEV1/FVC. Given the reduced FEV1/FVC ratio seen in this case, an obstructive lung disease such as COPD is a more likely underlying explanation.
name: Interstitial lung disease
label: c
answer: no
explanation: This is correct. COPD typically presents as chronic breathlessness and cough in an elderly patient with a significant smoking history. The examination finding of bilateral expiratory wheeze is also typical of COPD, while the hyper-resonant percussion note is due to 'barrel chest' or lung hyperinflation which is also seen on x-ray.
 

 COPD also shows an obstructive pattern of disease on spirometry which is an FEV1/FVC ratio of less than 0.7, as seen in this case.
name: Chronic obstructive pulmonary disease (COPD)
label: a
answer: yes

Correct answer: a

Chronic obstructive pulmonary disease (COPD)
A 55 year old Caucasian female presents to A&E with sudden onset crushing chest pain that radiates down her left arm. She has never smoked, drinks 1-2 glasses of wine at weekends and has a past medical history of osteoarthritis and hypertension. She has a BMI of 24.9kg/m2.


An ECG shows inferior ST-elevation, while a high-sensitivity troponin I assay yields a level of 35ng/litre (<11.6ng/litre).


Which of the following is a risk factor for the patient's presentation?

Options:
explanation: This is incorrect. Female sex is associated with a relatively lower risk of coronary artery disease compared to males.
name: Sex
label: c
answer: no
explanation: This is incorrect. Osteoarthritis is not directly related to an individual's risk of coronary artery disease.
name: Osteoarthritis
label: d
answer: no
explanation: This is incorrect. Although ethnicity is related to an individual's risk of developing coronary artery disease, those of Caucasian origin are at a relatively lower risk. Being of South Asian descent is a known risk factor.
name: Ethnicity
label: e
answer: no
explanation: This is correct. This vignette is typical of a non-ST elevation myocardial infarction. Hypertension leads to atherosclerosis which can either lead to thrombus or ischaemia through reduced blood flow through the coronary arteries.
name: Hypertension
label: a
answer: yes
explanation: This is incorrect. Although drinking alcohol significantly above recommended limits can increase the risk of coronary artery disease, drinking 1-2 glasses of wine a week is not a risk factor.
name: Alcohol intake
label: b
answer: no

Correct answer: a