hllj/quesmed huggingface dataset:
A 22 year old female presents to A&E with a painful, swollen wrist and hand. She was out riding her bike earlier that day when she slipped and fell to the floor on an outstretched left hand. On examination, she has marked tenderness in the region between the extensor pollicis longus tendon and the extensor pollicis brevis and adductor pollicis longus tendon. She also reports pain upon axial loading of the thumb.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is incorrect. The triquetrum bone is too medial to be the bone broken in this question. The anatomical snuffbox occupies the lateral aspect of the hand (remember in anatomical position, the arm is supinated) and therefore tenderness in this area could not be explained by a triquetrum fracture.
name: Triquetrum fracture
label: c
answer: no
explanation: This is correct. The examination findings show marked tenderness in the anatomical snuffbox and pain when "telescoping" the thumb. This, paired with an injury sustained from falling on an outstretched hand is a classic presentation of a scaphoid fracture. These are clinically important as the scaphoid bone has a retrograde blood supply, meaning it is at risk of avascular necrosis if not managed promptly.
name: Scaphoid fracture
label: a
answer: yes
explanation: This is incorrect. The ulna is not typically fractured when falling on an outstretched hand. It is more likely to be fractured by direct impact or falling on a flexed elbow. It is not characterised by tenderness in the anatomical snuffbox or on axial loading of the thumb.
name: Ulna fracture
label: e
answer: no
explanation: This is incorrect. Whilst a distal radius (Colle's) fracture commonly results from falling onto an outstretched hand, it would not explain the tenderness in the anatomical snuffbox or on axial loading of the thumb.
name: Distal radius fracture
label: d
answer: no
explanation: This is incorrect. The pisiform bone is too medial to be the bone broken in this question. The anatomical snuffbox occupies the lateral aspect of the hand (remember in anatomical position, the arm is supinated) and therefore tenderness in this area could not be explained by a pisiform fracture.
name: Pisiform fracture
label: b
answer: no

Correct answer: a
A 65 year old male presents to A& after a fall, with a 6-month history of general health deterioration, increased fatigue, unsteadiness, and leg tingling.
  

  
 

A neurological examination reveals:
  
 

* Diminished vibration sense in the lower limbs bilaterally
* Diminished proprioception in the lower limbs bilaterally
* Slight weakness of the lower limbs bilaterally (power 3/5)
* Intact pain and temperature sensation throughout
  
 

Some blood tests are done and relevant results are as follows:
  
  
| |  |  |
| -------------- | :-------: | --------------- |
| Haemoglobin | 110 g/L | (M) 130 - 170, (F) 115 - 155  |  
| Mean Cell Haemoglobin (MCH)| 36 pg | 27 - 33  |
| Mean Cell Volume (MCV)  | 104 fL | 80 - 96  |
| Serum Vitamin B12  | 55 ng/L | 160 - 925  |
 

* Intrinsic factor antibody positive
  
 

Which of the following neurological tracts are most likely to be implicated in this pati

Options:
explanation: This is incorrect. The corticobulbar tracts terminate in the cranial nerves and are not associated with neurological changes in the lower limbs. The patient also shows a severe vitamin B12 deficiency which, in combination with his neurological symptoms, is in keeping with dorsal column damage as a result of subacute combined degeneration of the spinal cord.
name: Tectospinal tract
label: d
answer: no
explanation: This is incorrect. The lateral spinothalamic tract is responsible for carrying sensory information relating to pain and temperature. By contrast, lower limb deficits in vibration sensation and proprioception, in combination with the severe vitamin B12 deficiency, are more in keeping with dorsal column damage as a result of subacute combined degeneration of the spinal cord.
name: Lateral spinothalamic tract
label: e
answer: no
explanation: This is correct. The dorsal columns carry sensory fibres for vibration and proprioception, which are impaired in the neurological examination of this patient. The patient also shows a severe vitamin B12 deficiency which, in combination with his neurological symptoms, is in keeping with subacute combined degeneration of the spinal cord which affected the dorsal column.
name: Dorsal column
label: a
answer: yes
explanation: This is incorrect. The corticobulbar tracts terminate in the cranial nerves and are not associated with neurological changes in the lower limbs. The patient also shows a severe vitamin B12 deficiency which, in combination with his neurological symptoms, is in keeping with dorsal column damage as a result of subacute combined degeneration of the spinal cord.
name: Corticobulbar tracts
label: b
answer: no
explanation: This is incorrect. The reticulospinal tracts are responsible for voluntary movements and muscle tone, and are not associated with neurological changes in the lower limbs. The patient also shows a severe vitamin B12 deficiency which, in combination with his neurological symptoms, is in keeping with dorsal column damage as a result of subacute combined degeneration of the spinal cord.
name: Reticulospinal tracts
label: c
answer: no

Correct answer: a

Dorsal column
A 60 year old man presents to A&E after sustaining burns to both of his feet. He had not noticed the temperature of his bath when he got in it. On examination, as well as second-degree burns to the plantar aspects of both feet, he also has impaired sensation of pain bilaterally. His sensation of fine touch, vibration and proprioception is intact.

The patient had a recent hospital admission after sustaining a traumatic spinal cord injury, but was discharged the previous week. Other than the spinal cord injury he has a past medical history of type 2 diabetes mellitus, but takes no regular medications.

Which of the following is the most likely location of the pathology?

Options:
explanation: Whilst the pons does contain the spinothalamic tracts responsible for pain and temperature sensation, this is not the most site of the lesion likely given the patient's history of spinal trauma.
name: Pons
label: e
answer: no
explanation: This is incorrect. Whilst peripheral neuropathy would be an appropriate differential for bilateral sensory changes in a distal limb for a patient with type 2 diabetes, this is not the most likely explanation. The recent spinal trauma and absence of pain and temperature sensation are consistent with damage to the lateral spinothalamic tracts.
name: Peripheral nerves
label: b
answer: no
explanation: This is correct. The lateral spinothalamic tracts are responsible for pain and temperature sensation, both of which are impaired in this patient. They can be damaged following spinal injury, and individuals with spinothalamic tract damage often present with burns.
name: Lateral spinothalamic tracts
label: a
answer: yes
explanation: This is incorrect. The patient did not present with any cerebellar signs. These can be remembered with the mnemonic DANISH (Dysmetria and dysdiadochokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia). In this case, the recent spinal trauma and absence of pain and temperature sensation are consistent with damage to the lateral spinothalamic tracts.
name: The cerebellum
label: c
answer: no
explanation: This is incorrect. The dorsal column tracts are responsible for proprioception and vibration sense, both of which are intact in this vignette. The recent spinal trauma and absence of pain and temperature sensation are consistent with damage to the lateral spinothalamic tracts.
name: Dorsal column
label: d
answer: no

Correct answer: a
A 33 year old man presents to the GP as his friends noticed some changes to the appearance of his face. On examination, he has left-sided ptosis, loss of the nasolabial fold and drooping of the left side of the mouth. Motor function on the right side of his face is intact. Sensation is unaffected bilaterally

Which of the following cranial nerves is most likely implicated in this presentation?

Options:
explanation: This is incorrect, the abducens nerve (CN VI) is responsible for innervating the lateral rectus muscle of the eye. CN VI palsy results in horizontal diplopia when attempting to abduct the affected eye.
name: CN VI
label: b
answer: no
explanation: This is correct. The patient is presenting with a facial nerve (CN VII) palsy. The facial nerve is responsible for motor innervation of the muscles of facial expression, as well as lacrimation and taste from the anterior 2/3 of the tongue.
name: CN VII
label: a
answer: yes
explanation: This is incorrect, the trigeminal nerve (CN V) is responsible for facial sensation and innervation of the muscles of mastication. Damage to this cranial nerve can cause trigeminal neuralgia, loss of facial sensation and loss of the corneal reflex.
name: CN V
label: c
answer: no
explanation: This is incorrect, the vestibulocochlear nerve (CN VIII) is responsible for hearing and balance. Patients with damage to this cranial nerve commonly present with hearing loss and vertigo.
name: CN VIII
label: d
answer: no
explanation: This is incorrect. The hypoglossal nerve (CN XII) is responsible for tongue movement; a lesion in CN XII would present with tongue deviation to the side of the lesion, as well as tongue wasting.
name: CN XII
label: e
answer: no

Correct answer: a
A 72 year old male attends neurology clinic regarding a new diagnosis of Parkinson's disease. The patient has been having recurrent falls and his wife has noticed he moves a lot slower than he used to, and has developed a tremor that is worse on the right-hand side. On examination, the patient demonstrates 'cog wheel' rigidity and a 'pill-rolling' tremor of the right hand.

Which of the following neuronal subtypes are lost in Parkinson's disease?

Options:
explanation: This is incorrect. The substantia nigra includes two pathways, intrinsic and extrinsic, which together are responsible for the initiation of movement. The neurons within these pathways are dopaminergic, not serotonergic.
name: Serotonergic cells of the substantia nigra
label: b
answer: no
explanation: This is incorrect. The main location of pathology in Parkinson's disease is the substantia nigra, located within the basal ganglia.
name: Dopaminergic cells of the medulla oblongata
label: e
answer: no
explanation: This is incorrect. Damage to neuronal myelin sheaths is not specifically implicated in Parkinson's disease. The myelin sheath is wrapped around the axon and allows action potentials to be conducted at a faster pace. Damage to the myelin sheath in the central nervous system is seen in conditions such as multiple sclerosis.
name: Myelin sheath of the central nervous system
label: d
answer: no
explanation: This is correct. Whilst the exact cause of Parkinson's disease is unclear, it is believed to be caused by the loss of dopaminergic neurons in the substantia nigra of the basal ganglia. Functions of the basal ganglia include the initiation of movement, motor learning and motor control.
name: Dopaminergic cells of the substantia nigra
label: a
answer: yes
explanation: This is incorrect. The main location of pathology in Parkinson's is the substantia nigra, located within the basal ganglia.
name: Dopaminergic cells of the cerebellum
label: c
answer: no

Correct answer: a
A 60 year old man presents to A&E after his sister notices that the appearance of his eyes has changed. The patient also notes some double vision and pain behind the right eye since waking up that morning. On examination, the patient's right eye is fixed in a downward, lateral position. There is also ptosis and fixed pupil dilatation. His visual acuity is intact in both eyes. There is no sensory loss or weakness throughout the rest of his body.

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

Options:
explanation: This is incorrect. The abducens nerve (CN VI) innervates the lateral rectus muscle. Patients with sixth nerve palsy present with diplopia that is worse in the horizontal plane.
name: CN VI
label: d
answer: no
explanation: This is incorrect, the olfactory nerve (CN I) is responsible for smell. Patients with damage to this cranial nerve may experience a change or lack of their sense of smell.
name: CN I
label: e
answer: no
explanation: This is incorrect. The trochlear nerve (CN IV) controls the superior oblique muscle. Damage to this cranial nerve presents with diplopia that is worse in the vertical plane, classically experienced when reading or going downstairs.
name: CN IV
label: c
answer: no
explanation: Correct - this presentation is consistent with a third nerve palsy, caused by damage to the oculomotor nerve (CN III). CN III innervates most of the ocular muscles, except the superior oblique and lateral rectus muscles which are innervated by CN IV and CN VI respectively. In third nerve palsy, the superior oblique and lateral rectus muscles are the only functioning ocular muscles. Their unopposed activity pulls the eye into a characteristic 'down and out' resting position of the eye.
name: CN III
label: a
answer: yes
explanation: This is incorrect. The optic nerve (CN II) is responsible for vision. A CN II lesion would present with visual loss, rather than problems with eye movements.
name: CN II
label: b
answer: no

Correct answer: a
A 71 year old woman is reviewed by the bone health team following a hospital admission for a right neck of femur fracture. She undergoes a DEXA scan, which identifies osteoporosis.

Which of the following is a feature of osteoporosis?

Options:
explanation: This is incorrect, low BMI and low body weight are risk factors for osteoporosis rather than obesity.
name: High BMI is a risk factor
label: d
answer: no
explanation: This is incorrect. There is a decrease in bone mineral density in osteoporosis, caused by osteoclast activity exceeding osteoblast activity. If there were higher osteoblast activity, we would expect an increase in bone bone mineral density rather than a reduction.
name: Osteoblast activity exceeds osteoclast activity
label: c
answer: no
explanation: This is correct. Osteoclasts are responsible for bone resorption whilst osteoblasts are responsible for bone growth. These two cells usually work together to maintain healthy bones. However, in osteoporosis, osteoclast activity exceeds osteoblast activity, thus reducing bone mineral density. This increases an individual's risk of fractures as the less-dense bone fractures more easily.
name: Osteoclast activity exceeds osteoblast activity
label: a
answer: yes
explanation: This is incorrect. Osteoclasts and osteoblasts are responsible for bone resorption and bone remodelling respectively. In osteoporosis, the bone is less dense meaning it is being resorbed at a faster rate than it is being remodelled. Therefore, an increase in osteoclast activity compared to osteoblast is a factor in the development of osteoporosis.
name: Osteoporosis occurs independent of osteoclast and osteoblast activity
label: e
answer: no
explanation: This is incorrect. There is a decrease in bone mineral density in osteoporosis which increases an individual's risk of fractures.
name: Increase in bone mineral density
label: b
answer: no

Correct answer: a
A 22 year old male patient presents to the GP with ankle pain. This pain is at the back of his left ankle and has been present intermittently for the past six months. There is no history of trauma.

The GP diagnoses Achilles tendonitis.

In which of the following structures does the Achilles tendon insert?

Options:
explanation: This is incorrect. The Achilles tendon inserts at the calcaneus bone, specifically the calcaeneal tuberosity. The navicular bone contains a tuberosity for the insertion of the part of the tibialis posterior tendon.
name: Navicular bone
label: c
answer: no
explanation: This is incorrect. The Achilles tendon inserts at the calcaneus bone, specifically the calcaneal tuberosity, not at the tibia.
name: Tibia
label: e
answer: no
explanation: This is incorrect. The Achilles tendon inserts at the calcaneus bone, specifically the calcaneal tuberosity. The talus is part of the ankle joint, articulating with the calcaneus to form the heel. Being the most superior of the tarsal bones it is responsible for transmitting the weight of the body to the calcaneus.
name: Talus bone
label: b
answer: no
explanation: This is correct. The Achilles tendon inserts at the calcaneal tuberosity of the calcaneus bone of the foot.
name: Calcaneal tuberosity
label: a
answer: yes
explanation: This is incorrect. The Achilles tendon inserts at the calcaneus bone, specifically the calcaneal tuberosity. The cuneiforms are the location of insertion for many muscles including but not limited to tibialis anterior and part of tibialis posterior.
name: The cuneiforms
label: d
answer: no

Correct answer: a
A 60 year old male presents to A&E with excruciating left arm pain. It came on suddenly that afternoon while he was lifting a heavy box above his head. On examination there is significant pain in the distal aspect of the left biceps, accompanied by swelling. He is diagnosed with a biceps tendon rupture.

Which of the following movements is most likely to be impaired?

Options:
explanation: This is incorrect. This is not one of the functions of the biceps brachii, so would not be impaired due to a biceps tendon rupture. Instead, extension of the arm at the elbow is achieved by the action of the triceps brachii.
name: Extension of the arm at the elbow
label: c
answer: no
explanation: This is correct. The biceps brachii are responsible for supination of the forearm and flexion of the arm at the elbow and shoulder. Tendon rupture can occur with heavy overhead lifting and can result in what is known as 'pop eye' deformity. A biceps tendon rupture is therefore most likely to result in an impairment of supination of the forearm.
name: Supination of the forearm
label: a
answer: yes
explanation: This is incorrect. Flexion at the wrist is not one of the functions of the biceps brachii. and so would not be impaired due to a biceps tendon rupture. Flexion at the wrist is achieved by multiple muscles in the anterior compartment of the forearm; mainly flexor carpi ulnaris and flexor carpi radialis.
name: Flexion at the wrist
label: d
answer: no
explanation: This is incorrect. Pronation is not one of the functions of the biceps brachii, and so would not be impaired due to a biceps tendon rupture. Instead, pronation is achieved through the action of pronator teres, pronator quadratus and brachioradialis.
name: Pronation of the forearm
label: b
answer: no
explanation: This is incorrect. Extension at the shoulder is not one of the functions of the Biceps brachii, and so would not be impaired due to a biceps tendon rupture. Extension at the shoulder is achieved by the action of latissimus dorsi, teres major, pectoralis major, deltoid and the long head of triceps brachii.
name: Extension at the shoulder
label: e
answer: no

Correct answer: a
A 40 year old male presents to the GP with persistent right elbow pain that has been present intermittently for around two months. There is no history of trauma. The patient is usually fit and well, and is a keen sportsman. On examination, there is severe pain in the lateral aspect of the elbow that is reproduced on resisted elbow extension.

Which of the following tendon insertion sites is implicated in the patient's presentation?

Options:
explanation: This is incorrect. The greater tuberosity is the site of insertion of supraspinatus, infraspinatus and teres minor of the rotator cuff muscles. Pathology at this insertion site would not cause pain reproducible with resisted extension of the forearm.
name: Greater tuberosity of the humerus
label: c
answer: no
explanation: This is incorrect. This is the site of insertion of the flexors of the forearm. Pain would therefore be reproduced when resisting flexion of the forearm. This would give rise to the chronic overuse syndrome 'golfer's elbow', also known as medial epicondylitis.
name: Medial epicondyl of the humerus
label: b
answer: no
explanation: This is correct. This presentation is characteristic of 'tennis elbow', also known as lateral epicondylitis. This is a chronic overuse syndrome, with pain at the site of the forearm extensor muscle insertion; the lateral epicondyle of the humerus.
name: Lateral epicondyl of the humerus
label: a
answer: yes
explanation: This is incorrect. The lesser tuberosity is the site of insertion of the subscapularis muscle of the rotator cuffs. Pathology at this insertion site would not cause pain reproducible on resisted extension of the forearm.
name: Lesser tuberosity of the humerus
label: d
answer: no
explanation: This is incorrect. The olecranon is the site of attachment of triceps brachii. Pathology at this insertion site would not cause pain reproducible on resisted extension of the forearm.
name: Olecranon of the ulna bone
label: e
answer: no

Correct answer: a
A 65 year old female patient presents to the GP with chronic left knee pain. This has been troubling her for around three months, and is worse after walking long distances. She also reports stiffness first thing in the morning, although this eases after around five minutes. Other than her pain she feels well. She takes medication for hypertension and type 2 diabetes.

On examination there is mild swelling of the left knee, but no erythema. There is tenderness and crepitus on passive flexion and extension of the left knee. No popliteal lumps.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: This is incorrect. Psoriatic arthritis is an inflammatory arthritis associated with nail changes, dactylitis and psoriatic skin changes. None of these are present in this case.
name: Psoriatic arthritis
label: d
answer: no
explanation: This is correct. Risk factors for the development of osteoarthritis include age (60 and above) and female sex. It is associated with pain in the affected joint during and after use. Although there is morning stiffness, as this lasts for less than 30 minutes it is not an indicator of inflammatory arthritis.
name: Osteoarthritis
label: a
answer: yes
explanation: This is incorrect. Rheumatoid arthritis is an inflammatory arthritis. Unlike osteoarthritis, it tends to present with multiple joint involvement, is often symmetrical and is sometimes accompanied by systemic symptoms. It is also characterised by morning stiffness lasting for more than 30 minutes. Unlike in osteoarthritis, pain often improves with movement of the joints.
name: Rheumatoid arthritis
label: b
answer: no
explanation: This is incorrect. Septic arthritis presents acutely with a swollen, painful and red joint, as well as signs of systemic infection. This patient is otherwise well, making osteoarthritis a more likely diagnosis.
name: Septic arthritis
label: e
answer: no
explanation: This is incorrect. Gout is associated with acute attacks of pain, swelling and erythema of a joint; classically in the big toe or ankle. The chronicity of this patient's symptoms and lack of erythema make gout less likely than osteoarthritis in this case.
name: Gout
label: c
answer: no

Correct answer: a