hllj/quesmed huggingface dataset:
A 58-year-old man with a past medical history of Type 2 diabetes and hypertension presents to A&E with a sudden loss of sensation and weakness in his right arm. On examination, the power of his right arm is 1/5 on the MRC scale and the reflexes of the right arm are absent. The power and sensation of the right leg is preserved.

Which artery is most likely to have been affected?

Options:
explanation: If this artery was affected, the patient would experience symptoms on the left as opposed to the right.
name: Right middle cerebral
label: b
answer: no
explanation: Middle cerebral artery strokes are more common than anterior cerebral artery strokes. Even though left anterior cerebral artery strokes affect the right side of the body, patients typically experience sensory loss and lower limb weakness.
name: Left anterior cerebral
label: d
answer: no
explanation: Cerebellar strokes affect balance and coordination and there are no signs of ataxia or loss of coordination in this patient, making this option unlikely.
name: Left superior cerebellar stroke
label: e
answer: no
explanation: It is less likely that this artery is affected because middle cerebral artery strokes are more common. If the anterior cerebral artery was affected then the patient would have experienced contralateral (left) sensory loss and lower limb weakness. This patient has weakness and sensory loss predominantly of the right upper limb.
name: Right anterior cerebral
label: c
answer: no
explanation: This patient is experiencing sensory loss and weakness on his right side, therefore the artery that is affected is on the contralateral side (i.e. the left).
middle cerebral artery strokes typically spare the leg which is the case with this patient. Anterior cerebral artery strokes, however, present with contralateral sensory loss and lower limb weakness.
name: Left middle cerebral
label: a
answer: yes

Correct answer: a
An 82-year-old man has been admitted to the acute medical unit because he has lumbar spine pain and he is worried that he has lost 5kg in the past month. He has a past medical history of osteoarthritis and polymyalgia rheumatica. Physical examination is unremarkable.


Blood tests show:

||||
|--------------|:-------:|---------------|
|Haemoglobin|115 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|2x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|100x10<sup>9</sup>/L|150 - 400|
|Erythrocyte Sedimentation Rate (ESR)|115 mm/hr|< 20|


What is the most likely diagnosis?

Options:
explanation: The patient has a past medical history of polymyalgia rheumatica which can explain the elevated ESR, however, does not explain the pancytopenia or his current symptoms. PMR would present with shoulder and pelvic girdle stiffness, not lumbar spine pain and weight loss.
name: Polymyalgia rheumatica (PMR)
label: c
answer: no
explanation: This would explain the patient's lumbar spine pain, weight loss as well as the elevated ESR. However, this would not explain the pancytopenia which makes this an unlikely diagnosis.
name: Discitis
label: e
answer: no
explanation: The symptoms of lumbar spine pain and unintentional weight loss suggest malignancy. There is also pancytopenia and raised ESR which is classically seen in multiple myeloma. Patients are also likely to have raised calcium and signs of renal impairment.
name: Multiple myeloma
label: a
answer: yes
explanation: This is a haematological cancer which can cause pancytopenia and unintentional weight loss. However, Hodgkin's lymphoma is less likely in patients of this age group than multiple myeloma.
name: Hodgkin's lymphoma
label: d
answer: no
explanation: This patient does have a past medical history of osteoarthritis, but this would not explain the presence of pancytopenia or red-flag symptoms like weight loss.
name: Osteoarthritis of the spine
label: b
answer: no

Correct answer: a
A 75-year-old female with a past medical history of Coeliac disease presents with worsening left hip pain. There is no recent history of falls, but she states feeling unsteady and weak when walking and getting up from sitting.


Blood tests show:


||||
|---------------------------|:-------:|------------------------------|
|Calcium|1.8 mmol/L|2.2 - 2.6|
|Phosphate|0.5 mmol/L|0.8 - 1.5|
|Alkaline Phosphatase (ALP)|148 IU/L|25 - 115|

What is the most likely diagnosis?

Options:
explanation: Whilst Paget's disease commonly affects the pelvis and patients often experience bone pain, they do not typically complain of muscle weakness. Patient's with Paget's disease tend to have normal phosphate and calcium levels, and a raised ALP.
name: Paget's disease
label: d
answer: no
explanation: If the patient had polymyalgia rheumatica, then they would have complained of shoulder and pelvic girdle stiffness as opposed to worsening left hip pain. They would also have normal phosphate and calcium concentrations (but may have elevated ALP).
name: Polymyalgia rheumatica
label: e
answer: no
explanation: Whilst patients with osteoarthritis would also present with hip pain, they would not experience muscle weakness nor would there be any changes to their phosphate, calcium or ALP levels.
name: Osteoarthritis
label: c
answer: no
explanation: Polymyositis is associated with bilateral proximal muscle weakness developing over weeks to months. 5-15% of cases of polymyositis are secondary to an underlying malignancy; there are no red flag symptoms in this case. Patients who have polymyositis also tend to have a raised creatine kinase.
name: Polymyositis
label: b
answer: no
explanation: Osteomalacia occurs due to inadequate levels of calcium, phosphate or vitamin D. This patient has Coeliac disease which can cause malabsorption and lead to osteomalacia. The symptoms that the patient experiences are also characteristic of this - bone pain (typically lower back, pelvis and lower extremities), myalgia, and weakness of quadriceps and gluteal muscles. Low phosphate and calcium and raised ALP point to
osteomalacia as the likely diagnosis.
name: Osteomalacia
label: a
answer: yes

Correct answer: a
A 36-year-old man presents following a car crash with knee pain. On examination, there is inflammation over the knee and it is tender on palpation anteriorly and posteriorly. There is also a posterior sag present and the posterior draw test is positive.

Which ligament is most likely to be affected?

Options:
explanation: Lateral collateral ligament tears commonly occur when there is a blow to the medial aspect of the knee, pushing it outwards (laterally), which can happen during contact sports. It also presents with inflammation and tenderness; however, it is not associated with a posterior sag or a positive posterior draw test.
name: Lateral collateral ligament
label: d
answer: no
explanation: Medial collateral ligament tears occur when a lateral force or pressure pushes the knee inwards (medially), which can happen during contact sports. It also presents with inflammation and tenderness; however, it is not associated with a posterior sag or a positive posterior draw test.
name: Medial collateral ligament
label: e
answer: no
explanation: Common causes of an anterior cruciate ligament tear are sudden twisting motions of the knee such as landing awkwardly whilst playing sports. On examination, patients have a positive anterior draw test as opposed to a positive posterior draw test.
name: Anterior cruciate ligament
label: b
answer: no
explanation: A common cause of injury to the posterior cruciate ligament is a "dashboard injury", in which there is a powerful force on the knee anteriorly which causes a tear. The examination findings, in this case, are consistent with a posterior cruciate ligament injury as there is inflammation, tenderness, posterior sag and a positive posterior draw test.
name: Posterior cruciate ligament
label: a
answer: yes
explanation: The medial meniscus is a structure within the knee joint, but it's not a ligament; it is a type of cartilage between the medial tibia and the medial femur. A medial meniscus tear would present with inflammation and pain; however, it is not associated with a posterior sag or a positive posterior draw test.
name: Medial meniscus
label: c
answer: no

Correct answer: a
A 17-year-old male presents to A&E with a painful right foot. He states that he was playing football and landed heavily on his right foot and that it rolled inwards. On examination, he has a reduced ability to weight bear on the right foot, and there is swelling and pain, particularly over the lateral aspect of the foot.

Which ligament is most likely to be torn?

Options:
explanation: The plantar fascia can tear or rupture when jumping or falling from a height. Patients with this injury are likely to experience sharp pain, bruising, and swelling around the heel of their foot as well their arch.
name: Plantar fascia
label: b
answer: no
explanation: Posterior talofibular ligament tears are also due to inversion injuries, so they would present similarly with reduced ability to weight bear, pain and tenderness laterally. However, this is less common than an
anterior talofibular ligament tear.
name: Posterior talofibular ligament
label: d
answer: no
explanation: In inversion injuries of the ankle, the most common ligament group affected is the lateral ligament complex. Within that, the most commonly damaged ligament is the anterior talofibular ligament. Patients experience pain and inflammation, just like the patient in this scenario.
name: Anterior talofibular ligament
label: a
answer: yes
explanation: The lateral collateral ligament is part of the knee joint, not the ankle joint, so whilst a patient with a lateral collateral ligament injury would have reduced ability to weight bear, they would not have pain and tenderness of the ankle like the patient in this question.
name: Lateral collateral ligament
label: e
answer: no
explanation: Deltoid ligament tears are very rare and usually happen after eversion injuries or if there is direct trauma to the ankle. Patients with deltoid ligament tears similarly experience a reduced ability to weight bear, but they also have pain and swelling over the medial aspect of their ankle.
name: Deltoid ligament
label: c
answer: no

Correct answer: a
A 79-year-old man presents to the GP as he has continued to have joint pain even whilst on the maximum paracetamol dose and after applying topical capsaicin. He has a past medical history of peptic ulcers and
chronic kidney disease.

What is the most appropriate additional analgesic?

Options:
explanation: Normally, the second-line management would be to add an NSAID; however, this patient has contraindications to NSAID by way of his peptic ulcers and impaired renal function. Hence, a weak opioid such as tramadol should be opted for instead.
name: Tramadol
label: a
answer: yes
explanation: This is a strong opioid which can be given to arthritis patients if they experience severe pain, but this is not the most appropriate analgesic to add at this stage because a weaker opioid has not been trialled yet.
name: Morphine
label: e
answer: no
explanation: This is a disease-modifying antirheumatic drug (DMARD) which is commonly used in the management of rheumatoid arthritis. It has no place in the pain management of osteoarthritis.
name: Methotrexate
label: c
answer: no
explanation: This is an NSAID which can be used to manage pain caused by osteoarthritis, but not in this patient as they have peptic ulcers and impaired kidney function.
name: Diclofenac
label: b
answer: no
explanation: This is a tricyclic antidepressant which can be used for neuropathic pain and chronic pain associated with osteoarthritis. However, tramadol should be trialled before neuropathic agents.
name: Amitriptyline
label: d
answer: no

Correct answer: a
A 6-year-old boy presents to his GP with a gradual onset limp and intermittent groin pain whilst climbing the stairs. The pain has persisted for 5 weeks now. On examination, there is reduced movement of the hip joint. The patient is otherwise well.

An X-ray shows sclerosis and fragmentation of the epiphysis.

What is the most likely diagnosis?

Options:
explanation: This is unlikely because it is the most common hip disorder in adolescents and does not typically affect children. It would also have different X-ray findings: short displaced epiphysis and widened growth
plate.
name: Slipped upper femoral epiphysis
label: c
answer: no
explanation: Perthes disease is common in boys aged 4-8 and tends to persist for > 4 weeks which is consistent with the child in this question. The diagnosis of Perthes disease is supported by the X-ray findings of sclerosis and fragmentation of the epiphysis, which are characteristic of this disease.
name: Perthes disease
label: a
answer: yes
explanation: The patient does experience pain, but there are no other signs or symptoms of osteomyelitis such as fever, erythema or swelling. The patient also does not have any risk factors for osteomyelitis as they are generally well.
name: Osteomyelitis
label: e
answer: no
explanation: This is also a cause of a limp in children and commonly affects children aged 3-11. However, this is generally preceded by a viral infection 1-2 weeks before the development of pain and the limp. The pain and limp do not typically last for longer than 2 weeks.
name: Transient synovitis
label: b
answer: no
explanation: This is unlikely because whilst the patient has groin pain, there is no mention of joint swelling. The patient also experiences no other systemic symptoms and is otherwise well.
name: Juvenile idiopathic arthritis
label: d
answer: no

Correct answer: a
A 22-year-old female presents to A&E with a 4-hour history of chest tightness and shortness of breath. On examination, you notice she has an end-expiratory wheeze.

Which inflammatory cell is most likely to be found in her sputum?

Options:
explanation: Mast cells can sometimes be elevated, but it is not the most common inflammatory cell type associated with asthma.
name: Mast cells
label: d
answer: no
explanation: In some patients with asthma, there are elevated neutrophils, but it is not the most common inflammatory cell type associated with asthma.
name: Neutrophils
label: b
answer: no
explanation: Monocytes are not commonly associated with asthma.
name: Monocytes
label: e
answer: no
explanation: This patient is having an asthma attack. The main inflammatory cell associated with this is eosinophils - this indicates that there is airway inflammation.
name: Eosinophils
label: a
answer: yes
explanation: Basophils can sometimes be elevated in asthma, but it is not the most common inflammatory cell type associated with it.
name: Basophils
label: c
answer: no

Correct answer: a
A 62-year-old man who is overweight and a smoker presents to the GP with pain in his buttocks and thighs while walking, which is relieved by rest. He has a past medical history of diabetes and stable angina.

On examination, his lower extremities appear normal and his ABPI reading is 0.8.

What is the most appropriate management for this patient?

Options:
explanation: This is a type of revascularisation which is recommended if there is severe pain that disrupts activities of daily living. It involves a blocked artery being widened by inflating a small balloon within the vessel. This patient does not require this currently as their pain is tolerable. Revascularisation is usually performed in severe disease and if other management options have not worked.
name: Angioplasty
label: c
answer: no
explanation: Blood thinners are prescribed to patients with peripheral arterial disease to reduce the risk of blood clots, however, this would be prescribed after lifestyle management has been attempted.
name: Prescribe clopidogrel
label: b
answer: no
explanation: Lifestyle management is the best management for this patient as they are experiencing symptoms of peripheral arterial disease and have an ABPI of 0.8. They also have modifiable risk factors such as smoking and increased weight which, once managed, should reduce their symptoms.
name: Provide guidance on smoking cessation and weight loss
label: a
answer: yes
explanation: The patient should be advised to modify their lifestyle by stopping smoking and reducing their weight through a healthy diet and regular exercise. Doing nothing would be a mistake as they have signs and symptoms of peripheral arterial disease: buttock and thigh pain when walking and an ABPI of 0.8.
name: Do nothing
label: e
answer: no
explanation: This is a type of revascularisation which is recommended if there is severe pain that disrupts activities of daily living. It involves blood vessels being taken from another part of the body and being used to bypass the blockage in the culprit artery. This patient does not require this currently as their pain is tolerable. Revascularisation is usually performed in severe disease and if other management options have not worked.
name: Artery bypass graft
label: d
answer: no

Correct answer: a
A 65-year-old man attends his national screening ultrasound scan for abdominal aortic aneurysms (AAA). He is found to have an aneurysm measuring 4.7cm.

What is the best next course of action?

Options:
explanation: Surgery is generally recommended in those with a large AAA (>5.5cm) or if there is rapid expansion (increase in diameter >5mm in 6 months or >10mm in one year).
name: Offer open repair surgery
label: c
answer: no
explanation: 6 monthly abdominal ultrasounds are not normally performed to assess the abdominal aorta for growth.
name: Offer repeat ultrasound every 6 months
label: e
answer: no
explanation: Surgery is generally recommended in those with a large AAA (>5.5cm) or if there is rapid expansion (increase in diameter >5mm over 6 months or >10mm over one year).
name: Offer endovascular aneurysm repair surgery
label: d
answer: no
explanation: This is a medium AAA (4.5-5.4cm) and should be scanned via abdominal ultrasound every 3 months to assess for any changes in size.
name: Offer repeat ultrasound every 3 months
label: a
answer: yes
explanation: Yearly repeat ultrasounds are offered to those with a small AAA (3-4.4cm) to assess for any changes in size.
name: Offer yearly repeat ultrasound
label: b
answer: no

Correct answer: a
A couple presents to the genetic counselling clinic as they both have family histories of Duchenne muscular dystrophy and want to know if their future children will be affected.

What is the inheritance pattern of Duchenne muscular dystrophy?

Options:
explanation: Duchenne muscular dystrophy is inherited in an X-linked recessive pattern.  An example of a mitochondrial disorder is MELAS (mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes).
name: Mitochondrial
label: e
answer: no
explanation: Duchenne muscular dystrophy is inherited in an X-linked recessive pattern. An example of an X-linked dominant condition is Rett syndrome.
name: X-linked dominant
label: b
answer: no
explanation: Duchenne muscular dystrophy is inherited in an X-linked recessive pattern. An example of an autosomal dominant disorder is Marfan syndrome.
name: Autosomal dominant
label: c
answer: no
explanation: Duchenne muscular dystrophy is inherited in an X-linked recessive pattern. An example of an autosomal recessive disorder is cystic fibrosis.
name: Autosomal recessive
label: d
answer: no
explanation: Duchenne muscular dystrophy is inherited in an X-linked recessive pattern which means that males are more likely to be affected by the disease than females. This is because females can be carriers if they inherit one faulty and one normal X chromosome. Males cannot be carriers: they can either have the disease or not have the disease due to only inheriting one X chromosome.
name: X-linked recessive
label: a
answer: yes

Correct answer: a
A 35-year-old female with a past medical history of rheumatoid arthritis presents to A&E with an erythematous, swollen, tender left knee.

On examination, it is warm and tender across the entire left knee and there is a reduced range of all movements. The examination of the right knee was unremarkable.

Her basic observations show:

* O2 sats - 96% on room air
* Respiratory rate - 25 breaths per minute
* Blood pressure - 110/75 mmHg
* Heart rate - 130 bpm
* Temperature - 37.9 degrees Celcius.

What is the most important diagnosis to exclude?

Options:
explanation: Whilst this would also present with an acutely hot swollen joint, it is not the most important diagnosis to exclude immediately as it would not cause as much harm as undiagnosed septic arthritis. A past medical history of rheumatoid arthritis is also a risk factor for developing septic arthritis.
name: A flare-up of rheumatoid arthritis
label: b
answer: no
explanation: A patient that has presented with an acutely hot swollen joint that is showing signs of systemic unwellness, such as haemodynamic instability and a raised temperature, should immediately have investigations to rule out septic arthritis. This is done through a joint aspiration for microscopy, culture and sensitivity. Early diagnosis is crucial to prevent the development of sepsis and subsequent death.
name: Septic arthritis
label: a
answer: yes
explanation: Whilst this would also present with an acutely hot swollen joint, it is not the most important diagnosis to exclude immediately as it would not cause as much harm as undiagnosed septic arthritis. Gout is also more common in older men and most commonly affects the big toe, whereas this patient is a 35-year-old woman with a swollen knee.
name: Gout
label: c
answer: no
explanation: This would cause a swollen and tender knee and reduced movement. In addition, the patient would be unable to straighten the knee and may have a hypermobile patella. It is less likely to be erythematous and would likely be bruised instead. It would also not cause as many systemic symptoms as septic arthritis.
name: Knee dislocation
label: e
answer: no
explanation: Whilst this would also present with an acutely hot swollen joint, it is not the most important diagnosis to exclude immediately as it would not cause as much harm as undiagnosed septic arthritis.
name: Pseudogout
label: d
answer: no

Correct answer: a