hllj/quesmed huggingface dataset:
A 34-year-old patient with Epilepsy has a seizure in the GP waiting room. She begins to shake in one finger, before the shaking travels up her arm. She does not lose consciousness during this episode.

In which of the following brain regions is her seizure likely to originate?

Options:
explanation: This patient is experiencing a seizure called Jacksonian march. Shaking or tingling begins in one area of the body and spreads gradually up to another area. The patient does not lose consciousness during these episodes. Jacksonian march seizures are caused by electrical activity in the frontal lobe of the brain.
name: Frontal Lobe
label: a
answer: yes
explanation: This patient is experiencing a seizure called Jacksonian march. Shaking or tingling begins in one area of the body and spreads gradually up to another area. They are caused by electrical activity in the frontal lobe of the brain.
name: Occipital lobe
label: e
answer: no
explanation: Although seizure activity has been observed in the cerebellum, focal motor dysfunction without a loss of consciousness is more typical of a frontal lobe seizure.
name: Cerebellum
label: d
answer: no
explanation: Parietal lobe seizures typically involve sensory symptoms such as numbness or weakness. By contrast, the Jacksonian features demonstrated by this patient are associated with a frontal lobe seizure.
name: Parietal lobe
label: b
answer: no
explanation: Temporal lobe seizures are associated with lip-smacking and emotional disturbances such as sudden terror or déjà vu. They can also involve auditory or olfactory hallucinations. By contrast, the Jacksonian features demonstrated by this patient are associated with a frontal lobe seizure.
name: Temporal lobe
label: c
answer: no

Correct answer: a
A 22-year-old female attends her GP surgery after experiencing a frightening episode of sleep paralysis. She recalls being asleep but unable to move her body.

Which part of the brain controls REM atonia?

Options:
explanation: The suprachiasmatic nucleus controls the circadian rhythm, meaning it controls the regulation of sleep across 24 hours. Circadian rhythm is affected by both light and melatonin. It does not control REM atonia.
name: Suprachiasmatic nucleus
label: b
answer: no
explanation: This structure stabilizes the sleep wake switch. It does not control REM atonia during sleep states.
name: Hypothalamic orexin
label: e
answer: no
explanation: This structure inhibits the ascending arousal system during sleep. It does not control REM atonia.
name: Ventrolateral preorbital nucleus
label: d
answer: no
explanation: This structure is located in the brainstem and controls REM atonia, thus causing you to be paralyzed in sleep.
name: Locus Coeruleus
label: a
answer: yes
explanation: This is an excitatory neurotransmitter that interacts with nuclei in the midbrain during sleep. It does not control REM atonia.
name: Hypocretin
label: c
answer: no

Correct answer: a
A 66-year-old male attends the GP for a blood pressure review. He is of African-Caribbean origin and is currently taking amlodipine (10mg). His blood pressure reading comes back as 144/95.

Which of the following is the most appropriate next step?

Options:
explanation: This patient is currently taking the maximum dose of Amlodipine (10mg) and therefore you cannot increase the dose further. He therefore requires the addition of a second agent to control their blood pressure; in this case, losartan.
name: Increase dose of Amlodipine
label: c
answer: no
explanation: Spironolactone is used as a 4th step in hypertension management, where serum potassium is below 4.5mmol/l. The patient in this question is taking amlodipine only, therefore requires a second agent to control blood pressure. In this case, the best second step is losartan.
name: Add Spironolactone
label: d
answer: no
explanation: This patient requires an additional treatment as their blood pressure is not controlled (i.e under 140/90 in clinic) with amlodipine alone. Patients of African-Caribbean origin already taking a calcium channel blocker, who require a second agent, should be given an angiotensin receptor blocker rather than an ACE inhibitor. Therefore, losartan should be given to this patient.
name: Add Ramipril
label: b
answer: no
explanation: A beta blocker like bisoprolol is used as a 4th step treatment in hypertension. It is used if potassium is over 4.5mmol/l. The patient in this question is taking amlodipine only, therefore requires a second agent to control blood pressure. In this case, the best second step is losartan.
name: Add Bisoprolol
label: e
answer: no
explanation: This patient requires an additional treatment as their blood pressure is not controlled (i.e under 140/90 in clinic) with amlodipine alone. Patients of African-Caribbean origin already taking a calcium channel blocker, who require a second agent, should be given an angiotensin receptor blocker rather than an ACE inhibitor. Therefore, losartan should be given to this patient.
name: Add Losartan
label: a
answer: yes

Correct answer: a
A 26-year-old female is brought into A&E after taking an overdose of Paracetamol.

Which of the following acid base disorders is most likely to be found in this patient?

Options:
explanation: Metabolic alkalosis is caused by either retention of base or loss of acid. Its causes include vomiting, diuretics, diarrhoea, primary hyperaldosteronism, Cushing’s syndrome or massive transfusion. By contrast, a paracetamol overdose usually results in metabolic acidosis.
name: Metabolic alkalosis
label: b
answer: no
explanation: Paracetamol overdose can result in severe metabolic acidosis. On an arterial blood gas, this would mean a low pH, low bicarbonate and low carbon dioxide levels (particularly if the patient were compensating by hyperventilation).
name: Metabolic acidosis
label: a
answer: yes
explanation: This is caused by hypoventilation or impaired transfer of gas across alveolar membranes. Common causes of respiratory acidosis include opiate overdose, neuromuscular disorders, exhaustion or airway obstruction. By contrast, a paracetamol overdose usually results in metabolic acidosis.
name: Respiratory acidosis
label: d
answer: no
explanation: Lactic acidosis occurs when there is an increased lactate in the blood stream. It is caused by tissue hypoxia (shock, limb ischemia, severe anaemia) or abnormalities in metabolism of lactate (diabetic ketoacidosis, cancer, liver disease, metformin or aspirin). By contrast, a paracetamol overdose usually results in metabolic acidosis.
name: Lactic acidosis
label: e
answer: no
explanation: Respiratory alkalosis is caused by hyperventilation. It would happen as a result of things like CNS infections, subarachnoid haemorrhage, aspirin overdose, anaemia or panic attacks. By contrast, a paracetamol overdose usually results in metabolic acidosis.
name: Respiratory alkalosis
label: c
answer: no

Correct answer: a
A 33-year-old woman is reviewed on the orthopaedic ward. She underwent foot surgery 3 days ago, and has been struggling to mobilise ever since. Now she reports a painful and swollen left calf.

On examination, her left calf is noticeably swollen compared to the right. It appears erythematous, and is tender on palpation. Both lower limbs are peripherally warm and well-perfused with strong peripheral pulses.

Which of the following is the next best investigation?

Options:
explanation: This would be an appropriate investigation if a pulmonary embolism is suspected in a patient with renal impairment, contrast allergy or who is pregnant. This patient has high clinical suspicion of a DVT, not a PE, and therefore V/Q scan is not the correct answer.
name: V/Q scan
label: b
answer: no
explanation: This is the investigation of choice when DVT is suspected. This patient has a high clinical suspicion of DVT, therefore they do not need to have a D-Dimer measured first.
name: Doppler ultrasound
label: a
answer: yes
explanation: A D-dimer is used in patients where there is a low clinical suspicion of DVT. This patient is presenting with a unilateral swollen, erythematous lower limb after recent surgery, which means there is a high clinical suspicion of DVT. Therefore, a D-dimer is not necessary.
name: D-dimer
label: d
answer: no
explanation: This is used in the treatment of massive DVTs. The most appropriate investigation for this patient would be to perform a Doppler ultrasound, to first identify whether a DVT is present.
name: Percutaneous mechanical thrombectomy
label: e
answer: no
explanation: This is the diagnostic investigation for pulmonary embolism, not DVT.
name: CT pulmonary angiogram
label: c
answer: no

Correct answer: a
A 20-year-old female has recently returned from traveling around Asia. She attends the GP with pain in her right upper quadrant that has been troubling her for the last 10 days. She has also noticed some yellowing of her eyes and reports dark urine.

She drinks 1-2 units of alcohol per week and has never smoked. She admits to having unprotected sex whilst traveling.

Which of the following is the most likely diagnosis?

Options:
explanation: Malaria is accompanied by symptoms such as fevers, headaches, muscle aches, and tiredness. It is not specifically associated with right upper quadrant pain or jaundice.
name: Malaria
label: d
answer: no
explanation: Acute infections with schistosomiasis cause itching, fevers, urticaria, arthralgia, cough, and diarrhoea. It would not explain this patient’s jaundice.
name: Schistosomiasis
label: c
answer: no
explanation: Hepatitis B is a blood borne viral infection that can be transmitted by sexual contact, contaminated needles, and blood products. The patient has also travelled to an area of high prevalence which makes hepatitis B more likely.
name: Hepatitis B
label: a
answer: yes
explanation: This is an autosomal recessive condition that causes raised unconjugated bilirubin. It causes episodes of jaundice in response to stress, fasting, infection, or exercise. It does not cause abdominal pain. This, in combination with the acute history and risk factors for hepatitis, makes Gilbert's syndrome an incorrect option.
name: Gilbert’s syndrome
label: b
answer: no
explanation: This type of hepatitis is transmitted via a faecal-oral route. It has a longer incubation period than hepatitis A at 3-8 weeks. Hepatitis B is therefore a more likely diagnosis.
name: Hepatitis E
label: e
answer: no

Correct answer: a
A 25-year-old male on the surgical ward begins shouting at other patients as he believes they are trying to poison him. He has a known diagnosis of paranoid schizophrenia but unfortunately stopped taking his medication during this admission.

He becomes agitated and tries to leave the ward. The nurse believes he is suffering from a mental disorder and feels he needs to remain in hospital for an assessment.

Which of the following sections of the mental health act can be used by nurses for this purpose?

Options:
explanation: Section 5(4) allows nurses to detain a patient for up to 6 hours, if they believe they are suffering from a mental disorder. This allows more time for the patient to be assessed.
name: Section 5(4)
label: a
answer: yes
explanation: This section can be used by police to enter private premises and remove a person to a place of safety. This can last up to 24 hours. It is not used by nurses, or in a hospital setting.
name: Section 135
label: d
answer: no
explanation: A nurse would need to use section 5(4) in order to detain a person who they think is mentally unwell.
name: Section 5(3)
label: c
answer: no
explanation: A section 136 can be used by police to bring someone in from a public place if the police believe they are mentally unwell. This section can last up to 24hours, after which they should have a mental health act assessment. It is not used by nurses, or in a hospital setting.
name: Section 136
label: e
answer: no
explanation: A section 5(2) can be used by doctors to detain a patient for up to 72 hours. It is not used by nurses.
name: Section 5(2)
label: b
answer: no

Correct answer: a
A 33-year-old male with a known diagnosis of schizophrenia is commenced on clozapine by his Psychiatrist.

Which of the following side effects is he most likely to experience?

Options:
explanation: Clozapine is associated with a risk of agranulocytosis. It is therefore important to closely monitor white cell counts in these patients.
name: Agranulocytosis
label: a
answer: yes
explanation: Dystonia is most associated with first generation antipsychotics like haloperidol. It does not commonly occur as a result of clozapine, a second generation antipsychotic.
name: Dystonia
label: c
answer: no
explanation: Akathisia is associated with first generation antipsychotics like haloperidol. It is less commonly associated with clozapine, which is a second generation antipsychotic.
name: Akathisia
label: b
answer: no
explanation: Both first and second generation antipsychotics result in a reduction of seizure threshold, not an increased seizure threshold.
name: Increased seizure threshold
label: e
answer: no
explanation: Clozapine is associated with weight gain, rather than weight loss. Other prominent side effects include worsening glycaemic control and dyslipidaemia.
name: Weight loss
label: d
answer: no

Correct answer: a
A 30-year-old female is bought into A&E after taking a deliberate overdose of paracetamol. She says she wanted to end her life following a stressful argument with her boyfriend. This is the third time she has presented to A&E after taking an overdose for similar reasons.

Her friends mention she has regular outbursts of extreme emotions, that can make it challenging for her to maintain relationships at work and at home.

Which of the following is the most likely diagnosis?

Options:
explanation: Emotionally unstable personality disorder (EUPD) is characterized by abrupt mood swings, unstable relationships and instability in self image. Relationships go from idealization to devaluation. Self harm is common.
name: Emotionally Unstable Personality Disorder
label: a
answer: yes
explanation: Schizotypal personality disorder is characterized by bizarre or magical thinking which often means patients have difficulty interacting socially. By contrast this patient demonstrates mood swings, unstable relationships and self harm, but no bizarre or magical thinking. Emotionally unstable personality disorder (EUPD) is therefore a more likely diagnosis.
name: Schizotypal personality disorder
label: b
answer: no
explanation: Histrionic personality disorder is characterized by excessive displays of emotions, and will often involve behaviour that is sexually inappropriate. By contrast this patient demonstrates mood swings, unstable relationships and self harm, making emotionally unstable personality disorder (EUPD) is therefore a more likely diagnosis.
name: Histrionic personality disorder
label: e
answer: no
explanation: This is characterized by an intense need to be cared for by others. Patients often rely on other people to make decisions for them, and have an intense fear of abandonment. By contrast this patient demonstrates mood swings, unstable relationships and self harm, making emotionally unstable personality disorder (EUPD) is therefore a more likely diagnosis.
name: Dependent Personality Disorder
label: d
answer: no
explanation: Bipolar disorder can be diagnosed when a person has at least one major depressive episode and one episode of mania or hypomania. Manic episodes are characterised by elated mood or irritability, often involving people making dangerous decisions with little thought for the consequences. Although this patient does demonstrate mood swings, there is also evidence of unstable relationships and self harm. Emotionally unstable personality disorder (EUPD) is therefore a more likely diagnosis.
name: Bipolar Disorder
label: c
answer: no

Correct answer: a
A 20-year-old male presents to his GP with his mother. She is worried about a change in his behaviour, and describes him spending a lot of time of his own recently. On further questioning, the patient admits to hearing voices that comment on his actions throughout the day. The GP suspects a diagnosis of schizophrenia.

Which of the following factors is associated with a better prognosis of this condition?

Options:
explanation: This is associated with a worse prognosis. A sudden onset of symptoms is associated with better prognosis in those with schizophrenia.
name: Gradual onset
label: b
answer: no
explanation: This is correct. Individuals with a higher IQ are more likely to have a better prognosis of schizophrenia than those with a lower IQ.
name: High IQ
label: a
answer: yes
explanation: Having a strong support network is associated with better prognosis in those with schizophrenia.
name: No support network
label: e
answer: no
explanation: An obvious precipitating factor, such as a traumatic life event before the onset of schizophrenia, is associated with better prognosis in those with schizophrenia.
name: No obvious precipitating factor
label: d
answer: no
explanation: Schizophrenia that features primarily positive symptoms is associated with a better prognosis, compared to when negative symptoms predominate. Positive symptoms of schizophrenia include hallucinations, delusions, and thought disorders such as thought insertion/withdrawal and delusions. Negative symptoms include alogia (poverty of speech), anhedonia (inability to derive pleasure), incongruity and avolition (poor motivation).
name: Negative symptom predominant
label: c
answer: no

Correct answer: a
A 55-year-old man presents to A&E with severe lower back pain. A sagittal MRI of the lumbar spine is taken, and he is diagnosed with a paracentral disc herniation of the lumbar spine [lightgallery]. On examination, the patient is found to have weakness of ankle plantarflexion on the right-hand side and reduced sensation in a specific area of the lower limb.

Which of the following regions of the lower limb would be expected to show reduced sensation?

Options:
explanation: The upper anterior thigh and lateral thigh corresponds to the L2 dermatome. If the patient had reduced sensation in this area we would expect it to be associated with weakness in the L2 myotome which is hip flexion. This is not the pattern of motor dysfunction seen.
name: Upper anterior thigh and lateral thigh
label: e
answer: no
explanation: The lateral calf correspond to the L5 dermatome. If the patient had reduced sensation in this area we would expect it to be associated with weakness in the L5 myotome which is great toe extension. This is not the pattern of motor dysfunction seen.
name: Lateral calf
label: d
answer: no
explanation: This patient has experienced a paracentral disc herniation, where the traversing nerve root (the spinal nerve root which exits below the level of the intervertebral disc) is compressed. On examination, the patient is found to have weakness of ankle plantarflexion, which corresponds to the S1 myotome. This suggests compression of the S1 spinal nerve route. Since spinal nerves carry general sensory information from the upper limb, the patient is likely to have reduced sensation of the S1 dermatome. This corresponds to the lateral border of the foot and the sole of the foot.
name: Lateral border and sole of the foot
label: a
answer: yes
explanation: The medial leg and medial ankle correspond to the L4 dermatome. If the patient had reduced sensation in this area, the patient would have weakness in the L4 myotome which is ankle dorsiflexion.
name: Medial calf and medial ankle
label: b
answer: no
explanation: The anterior knee and medial thigh corresponds to the L3 dermatome. If the patient had reduced sensation in this area we would expect it to be associated with weakness in the L3 myotome which is knee extension. This is not the pattern of motor dysfunction seen.
name: Anterior knee and medial thigh
label: c
answer: no

Correct answer: a
A 27-year-old woman visits A&E with severe left-sided shoulder pain following an injury that involved a fall onto her outstretched left hand. An X-ray of the shoulder is taken. [lightgallery]

On examination, the patient demonstrates reduced sensation on the lateral aspect of her upper arm. A nerve injury is suspected.

Which of the following muscle(s) are likely to be paralysed?

Options:
explanation: This is partially correct. The subscapularis is innervated by the upper and lower subscapular nerves, which is likely to be spared in this form of fracture.
name: Teres minor and subscapularis
label: d
answer: no
explanation: This answer is partially correct. The deltoid is innervated by the axillary nerve, and so is likely to be paralysed. However the teres major muscle is innervated by the lower subscapular nerve, and so would likely be spared.
name: Teres major and deltoid
label: b
answer: no
explanation: The x-ray demonstrates what appears to be a surgical neck of humerus fracture. The humerus has a very important anatomical relation to the axillary nerve, which wraps around the surgical neck of this bone. This fracture leads to damage to axillary nerve which subsequently paralyses the teres minor and deltoid muscles, which are both innervated by the axillary nerve.

The patient also demonstrates paraesthesia on the upper lateral arm (the skin overlying the insertion of the deltoid on the deltoid tuberosity of the humerus, more commonly known as the regimental badge region) which further points towards injury to the axillary nerve.
name: Teres minor and deltoid
label: a
answer: yes
explanation: The teres major muscle is innervated by the lower subscapular nerve, which is likely to be spared in this type of fracture.
name: Teres major
label: e
answer: no
explanation: These muscles are innervated by the musculocutaneous nerve, which is likely to be spared in this type of fracture. If the musculocutaneous nerve was damaged, the patient would experience paraesthesia on the lateral aspect of the forearm (innervated by the lateral cutaneous nerve of the forearm, which is a distal branch of the musculocutaneous nerve), rather than her upper arm.
name: Biceps brachii and coracobrachialis
label: c
answer: no

Correct answer: a