hllj/quesmed huggingface dataset:
A 52-year-old man presents to the Emergency Department unable to produce coherent speech, however, his ability to understand speech is preserved. You are concerned about an ischaemic stroke.

Which area of his brain is most likely to be affected?

Options:
explanation: The limbic lobe is responsible for regulating behaviour and emotional responses.
name: Limbic lobe
label: e
answer: no
explanation: Broca's area is **most likely** to be found in the left frontal cortex rather than the right, where it has a 3% chance of being.
name: Right Frontal Cortex
label: b
answer: no
explanation: The occipital lobe is responsible for processing visual input from the eyes.
name: Occipital lobe
label: d
answer: no
explanation: The left parietal lobe is responsible for sensory perception, such as taste, touch, smell, and sound.
name: Left parietal lobe
label: c
answer: no
explanation: The area affected in this man is Broca's area (responsible for production of speech). This is found in the frontal cortex, behind the eye in 97% of people.
name: Left Frontal Cortex
label: a
answer: yes

Correct answer: a
Of the following options, where would you expect to find cerebrospinal fluid (CSF)?

Options:
explanation: The arachnoid mater is the middle layer of the meninges (three layers of membranes that protect the central nervous system), between the dura mater and the pia mater. Although the subarachnoid space has fluid and blood vessels, the arachnoid mater itself does not contain any CSF or blood vessels.
name: Arachnoid mater
label: c
answer: no
explanation: The extradural space is found between the cranium and the dura mater - in healthy individuals, nothing is found in this area. However, sometimes a haemorrhage can occur here when the head undergoes traumatic injury.
name: Extradural space
label: b
answer: no
explanation: The subarachnoid space is the space just underneath the arachnoid mater, between the arachnoid mater and the pia mater. This is filled with cerebrospinal fluid (CSF) and blood vessels.
name: Subarachnoid space
label: a
answer: yes
explanation: The dura mater is the outermost layer of the meninges - it also does not contain CSF.
name: Dura mater
label: e
answer: no
explanation: The pia mater is the innermost layer of the meninges - it does not contain CSF.
name: Pia mater
label: d
answer: no

Correct answer: a
Which of the following drugs would be appropriate for the treatment of epilepsy?

Options:
explanation: Beta-receptors are responsible for activating the sympathetic nervous system, whilst alpha-receptors are responsible for activating the parasympathetic nervous system. Antagonising the alpha receptors increases the release of hormones such as serotonin and noradrenaline. This has nothing to do with the excitation of neurones, and would not be appropriate for the treatment of epilepsy, in which you see an inappropriate increase in neurone excitation.
name: Mirtazapine (Alpha receptor antagonist)
label: b
answer: no
explanation: Epilepsy is a disorder diagnosed when someone has more than 2 unprovoked seizures - this is thought to be caused by increased neurone excitability.

Lamotrigine binds to voltage-gated sodium channels and inhibits them, preventing neurone excitation (sodium influx initiates action potentials in neurones).
name: Lamotrigine (inhibits voltage-gated sodium channels)
label: a
answer: yes
explanation: Serotonin does not affect nerve excitation - therefore, Ondansetron does not help in the management of epilepsy.
name: Ondansetron (serotonin 5-HT3 receptor blocker)
label: e
answer: no
explanation: Amphetamines increase monoamines in the brain, which increases the excitability of neurones in the brain - this is the opposite of what we want, as epilepsy itself is due to overexcitation of these neurones, leading to unprovoked seizures.
name: Amphetamines (increases excitatory neurotransmission)
label: d
answer: no
explanation: Epilepsy is characterised by an overexcitation of neurones. Serotonin is a neurotransmitter which does not affect nerve excitation - it controls other neurological functions such as mood, appetite and sleep.
name: Pizotifen (serotonin (5-HT2) receptor antagonist)
label: c
answer: no

Correct answer: a
A 79-year-old presents to the Emergency Department. Upon examination, you are worried that he may have a sixth cranial nerve palsy.

Which of the following signs and symptoms are likely to be found in a sixth nerve palsy?

Options:
explanation: This would be symptomatic of a loss of function in the superior oblique, which would be responsible for deviating the eye down and inwards.
name: The affected eye is deviated up and out
label: d
answer: no
explanation: The abducens (6th) cranial nerve is responsible for the motor control of the lateral rectus, which is responsible for the abduction (outward movement) of the eye. Loss of abducens function means the eye cannot be pulled outward, so it will deviate inwards instead.
name: The affected eye deviates inwards
label: a
answer: yes
explanation: This would be symptomatic of an injury to the superior rectus, which allows the eye to move upwards - it is unlikely for the superior rectus to be affected in isolation. This is not consistent with a lesion in the abducens nerve.
name: The affected eye is deviated down
label: c
answer: no
explanation: These are the classic symptoms you would find in a third cranial nerve palsy, affecting the oculomotor nerve. The third nerve innervates all the ocular muscles except the lateral rectus (pulling the eye out) and the superior oblique (pulling the eye down) - these are therefore the direction the eye will go when the oculomotor nerve function is lost.
name: The affected eye deviates down and out
label: b
answer: no
explanation: This would be due to a lesion in the inferior rectus, which pulls the eye downwards.
name: The affected eye is deviated up
label: e
answer: no

Correct answer: a
A 73-year-old woman presents to the Emergency Department with an eye that is deviated down and out.

A lesion to which cranial nerve would cause these symptoms?

Options:
explanation: The presentation described is consistent with a third nerve palsy - a lesion affecting the oculomotor nerve. When this nerve is affected, there is unopposed movement of the superior oblique (controlled by the trochlear nerve) and the lateral rectus (controlled by the abducens nerve). These two muscles pull the eye down and out respectively.
name: Oculomotor nerve
label: a
answer: yes
explanation: The trigeminal nerve (fifth cranial nerve) is responsible for the motor and sensory function of the masseter and the temporalis muscles (muscles of mastication). A lesion in the trigeminal nerve would not produce ocular muscle palsies.
name: Trigeminal nerve
label: d
answer: no
explanation: The facial nerve (seventh cranial nerve), controls muscles of facial expression and receives sensory information from the anterior 2/3 of the tongue. A lesion in the facial nerve would not result in ocular muscle palsies either.
name: Facial nerve
label: e
answer: no
explanation: The abducens nerve (sixth cranial nerve) innervates the lateral rectus, which pulls the eye outwards. A lesion in the abducens nerve would present as an eye that deviates inwards.
name: Abducens nerve
label: b
answer: no
explanation: The trochlear nerve (fourth cranial nerve) innervates the superior oblique, which pulls the eye down and inwards. A lesion in the trochlear nerve would result in an eye that is deviated up and out.
name: Trochlear nerve
label: c
answer: no

Correct answer: a
A 20-year-old man presents to General Practice with anhedonia, anergia and low mood.

Which physical symptoms would you also expect to see in this patient if his symptoms are consistent with a diagnosis of major depressive disorder (MDD)?

Options:
explanation: A change in appetite (either an increase or a decrease) is a typical physical change found in patients with MDD. A diurnal variation in mood, such as waking up at 4 am with very low mood that improves as the day progresses is also a classic sign of MDD.
name: Loss of appetite, diurnal variation in mood
label: a
answer: yes
explanation: Loss of appetite is a physical symptom that can be found in MDD, however, double vision is not.
name: Increased appetite, double vision
label: c
answer: no
explanation: Hair loss, constipation and cold intolerance are symptoms consistent with hypothyroidism. Although hypothyroidism can also cause depressive symptoms, these symptoms are not consistent with a diagnosis of major depressive disorder (MDD) on their own.
name: Hair loss, constipation, cold intolerance
label: b
answer: no
explanation: These are symptoms consistent with a diagnosis of MDD, however, these are **psychological** symptoms, not **physical** ones that the question is asking for.
name: Feelings of guilt, suicidal ideation
label: e
answer: no
explanation: The presence of tactile hallucinations would be pointing towards a level of psychosis in this patient - perhaps psychotic depression, not MDD. Insomnia on its own can be a physical symptom of MDD.
name: Tactile hallucinations, insomnia
label: d
answer: no

Correct answer: a
The mother of a 29-year-old man reports that her son has been acting strangely and talking to himself often. He also has a fixed false belief that aliens are about to land on earth.

What are these fixed false beliefs known as in Psychiatry?

Options:
explanation: Flight of ideas describes when a person is speaking quickly, continuously and erratically.
name: Flight of ideas
label: d
answer: no
explanation: Hallucinations are another hallmark of psychotic disorders - they occur when a person hears, sees, feels or smells something that does not exist in reality, though it feels like reality to them.
name: Hallucinations
label: b
answer: no
explanation: Disturbed speech is a way of describing when a person jumps from one topic to another mid-sentence.
name: Disturbed speech
label: e
answer: no
explanation: A formal thought disorder is when a person is unable to sustain a coherent conversation or written text.
name: Formal thought disorder
label: c
answer: no
explanation: A delusion is an unshakeable, fixed false belief that a person holds when they experience psychotic symptoms. These beliefs are inconsistent with the person's culture. This is a common symptom and a hallmark of psychotic disorders such as schizophrenia.
name: Delusions
label: a
answer: yes

Correct answer: a
A 60-year-old man presents with pain in his back, that radiates down his left hand and foot. He also has a pins and needles sensation in his foot. Sensation above his lower back is intact.

A lesion within which section of the spinal vertebrae would produce these symptoms?

Options:
explanation: Cervical vertebrae (C1-7) are found in the neck - a lesion in this area would affect all the structures below the patient's head.
name: Cervical vertebrae
label: c
answer: no
explanation: The sacral vertebrae, S1 to S5, are found in the pelvis - this patient is having symptoms in the lower back as well, which makes a lesion in the lumbar area more likely.
name: Sacral vertebrae
label: b
answer: no
explanation: The coccyx is the last segment of the spinal cord, at the end of the sacral spine. It sits in the buttock region, and would therefore produce symptoms in the legs, without any symptoms in the lower back.
name: Coccygeal vertebrae
label: e
answer: no
explanation: The lumbar vertebrae contain 5 bones - L1 to L5. These are found in the lower back. The symptoms that this patient is presenting with are consistent with a lesion in this area, as the symptoms begin here and affect all the structures under the lumbar spine. This constellation of symptoms is also known as sciatica and can be caused by a slipped disc or lumbar spinal stenosis (narrowing of the space the spinal nerves pass through the lumbar spine).
name: Lumbar vertebrae
label: a
answer: yes
explanation: Thoracic vertebrae (T1-T12) are found in the thorax - this would mean that structures above the lumbar spine would also be affected if the lesion was in the thoracic spine. This is not the case in this man - the lesion is therefore unlikely to be in the thoracic spine.
name: Thoracic vertebrae
label: d
answer: no

Correct answer: a
A 26-year-old man presents to the Emergency Department after he fell during a game of football, twisting his knee in the process.

An MRI scan confirms a left anterior cruciate ligament (ACL) tear - which of the following signs and symptoms would you expect to find in this patient?

Options:
explanation: The cruciate ligaments of the knee help stabilise the movements of the knee - particularly whilst it is rotating.

The anterior cruciate ligament specifically prevents the tibia from sliding in front of the femur - preventing excessive anterior translation.

Tests that would help confirm a diagnosis of an ACL tear include a positive Lachmann's, Anterior Drawer or Pivot Shift tests. It is worth searching for a video of these on Youtube to have an idea of what they look like.
name: Excessive anterior translation of the knee
label: a
answer: yes
explanation: The ACL is a soft-tissue structure in the knee, being a ligament. Therefore, you would not expect to see any change to the bony structures to the knee - if there are changes, you would then be expecting to be making another diagnosis on top of the ACL tear!
name: MRI changes to the patellar bone
label: e
answer: no
explanation: This would be a sign seen in an Achilles (calcaneal) tendon rupture. The Achilles tendon connects the calf muscles to the foot and allows for plantarflexion of the foot (i.e. pointing your feet).

Therefore, you would expect someone with an Achilles tendon rupture to be unable to do a heel raise (this is the same movement as pointing their feet). This would **not** be found in an ACL injury.
name: Inability to perform heel raises
label: c
answer: no
explanation: This is also what you would find in an Achilles tendon rupture, not an ACL tear.

The Achilles tendon allows the foot to perform plantarflexion - essentially allowing someone to point their feet. Without an Achilles tendon, the tendons responsible for dorsiflexion (the opposite of plantarflexion) take over, keeping the affected foot held in dorsiflexion.
name: Left foot held in dorsiflexion
label: d
answer: no
explanation: The cruciate ligaments of the knee also help stabilise the backwards movement of the knee - whilst the ACL prevents excessive **anterior** movement of the tibia over the femur, the posterior cruciate ligament (PCL) prevents excessive movement of the tibia under the femur.

An injury in the **posterior** cruciate ligament would result in excessive posterior subluxation, but this would not be found in an ACL injury.
name: Excessive posterior subluxation of the knee
label: b
answer: no

Correct answer: a
Which of the following options correctly states the stages of the ligament healing process in order?

Options:
explanation: The inflammatory stage is the correct beginning for the healing process, however, the reparative (proliferative stage) follows it.

During the proliferative stage, the body sends increased growth factors, stem cells and biomaterials such as collagen to the injured limb to help the tear heal. Without this stage, the ligament cannot move onto the remodelling stages, where the healed ligament is strengthened.
name: Inflammation, Remodelling (consolidation), Remodelling (maturation), Reparative (proliferative)
label: b
answer: no
explanation: The inflammation stage of the ligament healing process must come first - this is where the body reacts to the injury and increases pro-inflammatory markers, which recruit neutrophils and macrophages to the injured limb.

This is what causes swelling, redness and pain in the first 48 hours of the injury.
name: Reparative (proliferative), Inflammation, Remodelling (consolidation), Remodelling (maturation)
label: e
answer: no
explanation: The inflammatory and reparative (proliferative) stages are the correct two beginnings of the ligament healing process. However, the remodelling (consolidation) stage comes before the remodelling (maturation) stage.

The consolidation stage occurs between 6 - 10 weeks after the injury and this is when the limb receives extra collagen type I to strengthen the ligament after it has healed.

The maturation stage occurs after 10 weeks and can last up to a year - this is when extra fibrous tissue is turned into scar tissue.
name: Inflammation, Reparative (proliferative), Remodelling (maturation), Remodelling (consolidation)
label: c
answer: no
explanation: The remodelling stage comes after the inflammation and reparative stages of ligament healing.

The remodelling stages are where the ligament is strengthened after it heals in the reparative stage.
name: Remodelling (consolidation), Reparative (proliferative), Remodelling (maturation), Inflammation
label: d
answer: no
explanation: After a ligament is injured, the first 48 hours are characterised by inflammation, during which stage the injury triggers an increase of pro-inflammatory markers, neutrophils, and macrophages to the injured area. This can produce lots of heat, pain and redness, which is why resting the limb and applying ice is essential in the first 48 hours.

After the inflammatory process, the reparative process begins - this is where new tissue forms. Growth factors, stem cells and biomaterials now surround the injured limb - this lasts several weeks.

The two remodelling sections come last - this is where the tissue is strengthened. The consolidation phase occurs between 6 - 10 weeks of injury, where the limb produces an increased synthesis of collagen type I.

After 10 weeks, the limb enters the maturation stage, where excess fibrous tissue is turned into scar tissue - this can last up to a year.
name: Inflammation, Reparative (proliferative), Remodelling (consolidation), Remodelling (maturation)
label: a
answer: yes

Correct answer: a
A 67-year-old man presents to General Practice with early morning stiffness and bilateral pain in his hands and wrists.

Which of the following blood markers would be the next best investigations to guide you towards the diagnosis?

Options:
explanation: TRAb is an autoantibody found in Graves' disease, which causes hyperthyroidism. Our patient is not having heat intolerance, weight loss or any other hyperthyroid symptoms. This test would be inappropriate for this patient.

ANA testing, although a positive marker can be indicative of RA, is mainly used in the diagnosis of Systemic Lupus Erythematosus (SLE).
name: TSH receptor antibody (TRAb), Antinuclear antibody test (ANA)
label: b
answer: no
explanation: This patient is presenting with symptoms of Rheumatoid Arthritis (RA.

RA classically presents with bilateral joint pain (throbbing or aching), swelling and early morning stiffness.

In RA, the two main autoinflammatory markers that **can** be elevated are Rheumatoid Factor (Rf) and Anti-CCP (cyclic citrullinated peptide) - these are the blood markers you would test for.
name: Rheumatoid factor (Rf), Anti-cyclic citrullinated peptide
label: a
answer: yes
explanation: Anti-La and Anti-Ro are used to diagnose Sjögren's Syndrome, a disease where the body is unable to produce an adequate amount of bodily fluids.

The patient is presenting with classical symptoms of Rheumatoid Arthritis, for which you would test for Rheumatoid Factor (Rf) and Anti-CCP first line.
name: Anti-La, Anti-Ro
label: d
answer: no
explanation: Rheumatoid factor (Rf) would indeed be tested for in a patient presenting with symptoms of Rheumatoid Arthritis. However, it would be most appropriate to start with measuring Anti-cyclic citrullinated peptide before antinuclear antibodies. The latter is more commonly used for the diagnosis of systemic lupus erythematosus (SLE).
name: Antinuclear antibody test (ANA), Rheumatoid factor (Rf)
label: c
answer: no
explanation: You would measure Anti-CCP levels when investigating this patient as he is presenting with classical symptoms of Rheumatoid Arthritis.

However, measuring TRAb levels would be inappropriate, as this is raised in Graves' Disease. Only if the patient were presenting with hyperthyroid symptoms would this be measured.
name: Anti-cyclic citrullinated peptide (Anti-CCP), TSH Receptor Antibody (TRAb)
label: e
answer: no

Correct answer: a
An 85-year-old man presents to the General Practice with knee pain. An X-Ray of his knee is taken, showing loss of bone space, osteophytes, sclerosis and subchondral cysts.

He has a history of gastric ulcers and is unable to mobilise unsupported.

Which of the following would be the most appropriate way to manage this condition?

Options:
explanation: This patient has little mobility - telling the patient to exercise on their own, when they cannot move independently, is ineffective as they won't be able to do the exercise. If they do try to mobilise by themselves, it increases their risk of falling.

Physiotherapy - exercise guided by a specialist - is the appropriate option to increase this patient's activity.
name: Exercise, weight loss
label: e
answer: no
explanation: The most likely diagnosis for this patient is Osteoarthritis. Osteoarthritis is a degenerative condition of bone cartilage occurring with old age.

This can lead to joint pain and X-ray changes.

An easy way to remember the classical X-Ray changes seen in osteoarthritis is the acronym LOSS: **L**oss of joint space, **O**steophytes (bone spurs), **S**clerosis (whitening showing up on the X-Ray), **S**ubchondral cysts (fluid-filled cysts in the bone).
name: Physical therapy, paracetamol
label: a
answer: yes
explanation: Whilst surgery is an appropriate management for osteoarthritis, this patient's symptoms are in the knee - therefore, a hip replacement would do little to alleviate this patient's symptoms.

A Knee Replacement Surgery on the other hand may be an appropriate way of managing this patient's symptoms if he had a better functional baseline.
name: Hip Replacement Surgery
label: c
answer: no
explanation: Methotrexate is a medication used to treat autoimmune arthritides such as Rheumatoid Arthritis. These would not present with the classical X-Ray changes for osteoarthritis that is seen in this patient.

X-Ray changes for someone with Rheumatoid Arthritis would be fusiform soft tissue swelling or juxta-articular osteoporosis. You do not need the X-Ray changes for Rheumatoid Arthritis in much detail, bus it is important to know the changes for Osteoarthritis.
name: Methotrexate
label: b
answer: no
explanation: This would be an appropriate choice for pain management if the patient did **not** have gastric ulcers.

NSAIDs increase the stomach's acidity and are therefore contraindicated in patients who already have gastric ulcers.

This patient would be more safely managed on paracetamol or using the WHO pain ladder for his pain relief.
name: NSAIDs
label: d
answer: no

Correct answer: a