hllj/quesmed huggingface dataset:
A patient is referred to the neurology clinic after burning her right hand in hot water without realising it.

On examination, the patient has impaired pain and thermal sensation, but position and vibration sensation are both intact.

The neurologist suspects syringomyelia.

What tract is affected and which side of the spine has the cyst formed?

Options:
explanation: The spinothalamic tracts are affected due to this patient having impaired pain and thermal sensation. However, the cyst has to be on the left-hand side as the spinothalamic tract decussates within the spinal cord. If the cyst was on the right-hand side, there would be symptoms on the left-hand side.
name: The spinothalamic tract on the right-hand side
label: b
answer: no
explanation: The spinothalamic tracts are affected due to this patient having impaired pain and thermal sensation. It is on the left-hand side because the spinothalamic tract decussates within the spinal cord, meaning that the cyst will have to be on the left-hand side to cause right-hand symptoms.
name: The spinothalamic tract on the left-hand side
label: a
answer: yes
explanation: The dorsal column is responsible for vibration and proprioception. This patient has intact vibration sense so the tract affected is the spinothalamic tract. The cyst affects the left-hand side as the symptoms affect the right-hand side: the spinothalamic tracts decussated within the spinal cord, meaning the side affected is opposite to the side of the lesion.
name: The dorsal column on the left-hand side
label: c
answer: no
explanation: The corticospinal tract is responsible for voluntary movements of the body. As this patient has normal limb movement, we can assume that this tract isn't affected. As the patient has reduced temperature and pain sensation, this indicates that the spinothalamic tract has been affected.
name: The corticospinal tract on the left-hand side
label: e
answer: no
explanation: The dorsal column is responsible for vibration and proprioception. This patient has intact vibration sense so the tract affected is the spinothalamic tract. The cyst affects the left-hand side as the symptoms affect the right-hand side: the spinothalamic tracts decussated within the spinal cord, meaning the side affected is opposite to the side of the lesion. If the cyst was on the right-hand side, there would be symptoms on the left-hand side.
name: The dorsal column on the right-hand side
label: d
answer: no

Correct answer: a
A 24-year-old female comes into the ED via ambulance with a tibia fracture after falling off a horse while horse riding. The doctor requests an x-ray which shows that there are multiple fragments of bone resulting from the fracture.

What kind of fracture does this patient likely have?

Options:
explanation: There is no indication of malignancy of the bone or osteoporosis in this question, and there are no signs of these conditions on the x-ray. Hence, it is unlikely this patient has a pathological fracture. The patient has a comminuted fracture as there are multiple fragments of bone on the x-ray.
name: Comminuted, pathological fracture
label: e
answer: no
explanation: A simple fracture is where there is a clean break of the bone, leading to 2 segments, not multiple segments. This patient likely has a transverse fracture as the impact from the fall would have been a direct blow to the leg.
name: Simple, transverse fracture
label: b
answer: no
explanation: There is no indication of malignancy of the bone or osteoporosis in this question, and there are no signs of these conditions on the x-ray. Hence, it is unlikely this patient has a pathological fracture. Indeed, she has a comminuted fracture as there are multiple fragments of bone shown on the x-ray. The fracture is likely transverse as the impact from the fall would have been a direct blow to the leg.
name: Transverse, pathological fracture
label: c
answer: no
explanation: This is correct as the patient fell off a horse, so the impact would have been a direct blow to the leg. Since there are multiple fragments of bone on the x-ray, the fracture is comminuted.
name: Transverse, comminuted fracture
label: a
answer: yes
explanation: There was no pulling force from a tendon or muscle that caused this fracture; it was due to a fall from a horse. The patient has a comminuted fracture as there are multiple fragments of bone on the X-ray.
name: Comminuted, avulsion fracture
label: d
answer: no

Correct answer: a
A 58-year-old male with a background of previous disc herniation presents to the GP with sharp shooting pains going down his left arm. He says that the pain is constant and is stopping him from performing daily tasks. He also reports that sometimes his arm and hand go numb and tingly. He has tried paracetamol and amitriptyline which both have not helped the pain. The GP decides to prescribe him gabapentin.

What is the mechanism of action of this drug?

Options:
explanation: GABA-alpha antagonists are used in benzodiazepine overdoses and have no neuropathic pain-relieving properties.
name: GABA-alpha antagonists
label: e
answer: no
explanation: These drugs, such as baclofen, act on GABA-beta receptors to decrease spasticity in conditions such as cerebral palsy.
name: GABA-beta agonists
label: b
answer: no
explanation: Selective serotonin reuptake inhibitors (SSRI) stop the reuptake of serotonin in the brain, resulting in increased concentrations of serotonin within synapses. SSRIs such as sertraline and fluoxetine are mainly used to treat depression and anxiety.
name: Selective serotonin reuptake inhibitor
label: c
answer: no
explanation: Serotonin and noradrenaline reuptake inhibitors (SNRI) stop the reuptake of serotonin and noradrenaline, resulting in increased concentrations of these neurotransmitters within synapses. SNRIs such as duloxetine are used as second-line treatment for depression and anxiety, as well as for neuropathic pain.
name: Serotonin and noradrenaline reuptake inhibitor
label: d
answer: no
explanation: Gabapentin acts to bind and inhibit pre-synaptic voltage-gated calcium channels, therefore reducing the density of these channels that are available for neurotransmission. This results in reduced excitatory neurotransmitter release which, in turn, reduces pain perception.
name: Binds to pre-synaptic voltage-gated calcium channels
label: a
answer: yes

Correct answer: a
An 18-year-old male presents to the walk-in clinic after twisting his ankle during a football game.

The doctor examines his ankle and asks him to perform some movements. There is pain upon eversion and plantarflexion of the foot. The doctor thinks that the fibularis longus muscle has been damaged.

What is the innervation to the fibularis longus muscle?

Options:
explanation: This nerve innervates all the muscles of the posterior forearm, but not any structures of the leg and ankle. It has nerve roots from C5-T1.
name: Deep branch of the radial nerve
label: d
answer: no
explanation: The tibial nerve innervates the muscles within the superficial and deep layers of the posterior compartment of the leg, not the lateral compartment of the leg. The tibial nerve is a continuation of the sciatic nerve once it passes through the popliteal fossa.
name: Tibial nerve
label: e
answer: no
explanation: The sural nerve only provides sensation to the cutaneous part of the posteolateral leg. It does not innervate any muscles of the leg.
name: Sural nerve
label: c
answer: no
explanation: The muscles of the lateral compartment of the leg (fibularis longus and brevis) are innervated by the superficial fibular nerve which has roots from L4-S1.
name: Superficial fibular nerve
label: a
answer: yes
explanation: The deep fibular nerve innervates the anterior compartment muscles of the leg.
name: Deep fibular nerve
label: b
answer: no

Correct answer: a
A 64-year-old woman attends the rheumatology clinic to discuss her recent blood results. She is found to be rheumatoid factor (RF) positive. The rheumatologist explains to the patient what this means.

Which antibody does rheumatoid factor (RF) have a high affinity for?

Options:
explanation: RF does have a high affinity for the IgG antibody but it is specifically the Fc region, not the Fab region.
name: Fab region of IgG antibody
label: b
answer: no
explanation: This is not an antibody but a cytokine which is produced in rheumatoid arthritis and recruits monocytes, lymphocytes, basophils and eosinophils into the synovial joint.
name: CCL3
label: e
answer: no
explanation: RF has a high affinity for the Fc region of IgG antibodies, not the Fab region of IgE antibodies.
name: Fab region of IgE antibody
label: d
answer: no
explanation: RF has a high affinity for the Fc region of IgG antibodies, not the Fc region of IgM antibodies. RF itself can be an IgM, IgG, IgA or IgE class antibody.
name: Fc region of IgM antibody
label: c
answer: no
explanation: RF has a high affinity for the Fc region of the IgG antibody.
name: Fc region of IgG antibody
label: a
answer: yes

Correct answer: a
A 53-year-old female presents to the GP with a 3-month history of swelling in her left hand and legs. She says that the pain and stiffness last for an hour in the morning and that she also has difficulty opening jars. She reports no fevers or recent infections. There has been no trauma to those areas either.

On examination, the proximal interphalangeal joints on her left hand are swollen but they are not hot to touch.

What is the cause of this patient's swollen hands?

Options:
explanation: This patient has symptoms typical of rheumatoid arthritis, including swollen joints in the hands, and pain and stiffness that is worst in the morning but improves after roughly an hour. The pain in the morning is what differentiates this from osteoarthritis, as in osteoarthritis, the pain will be longer than 1 hour and might get worse throughout the day.
name: Rheumatoid arthritis
label: a
answer: yes
explanation: As this patient has reported no fevers or recent infections, it is more likely that she has rheumatoid or osteoarthritis. Septic arthritis typically causes a single hot swollen joint, rather than multiple swollen cool joints.
name: Septic arthritis
label: c
answer: no
explanation: Fracturing all of the left proximal interphalangeal joints is very unlikely and would result in an inability to move one's hands and fingers. There has been no history of trauma in this patient as well.
name: Proximal interphalangeal joint fractures
label: e
answer: no
explanation: Gout usually affects the first metatarsophalangeal joint (big toe joint) and is usually very sudden in onset. This patient's pain has been over months so it is unlikely to be gout. Gout is caused by the crystallisation of uric acid within the synovial space.
name: Gout
label: d
answer: no
explanation: Osteoarthritis has similar symptoms such as swollen hands, but the morning stiffness usually lasts for longer than an hour. The joints usually affected are the distal interphalangeal joints, not the proximal interphalangeal joints.
name: Osteoarthritis
label: b
answer: no

Correct answer: a
A 28-year-old male presents to the GP with pain in his left elbow, which has been present for 2 months. He finds that it is worse when his arm is outstretched and he extends his wrist.

There is no numbness or tingling in his left arm and his radial pulses are strong. There is no swelling of the elbow joint.

He is a keen sportsman, playing a variety of sports including tennis and golf.

What is the cause of his elbow pain?

Options:
explanation: There is no indication of septic arthritis in this patient as the joint is not swollen and the pain is not acute-onset; the pain has been present for the last 2 months. This case is a classical presentation of lateral epicondylitis (tennis elbow).
name: Septic arthritis
label: c
answer: no
explanation: Lateral epicondylitis occurs when the muscles of the posterior compartment of the forearm are used repetitively, causing strain on those muscles, and subsequent pain. The classic presentation of tennis elbow is pain on wrist extension at the elbow.
name: Lateral epicondylitis (tennis elbow)
label: a
answer: yes
explanation: This is where the ulnar nerve is compressed in the cubital fossa, leading to numbness and tingling in the ring and little finger. As this patient describes no numbness or tingling, this diagnosis is unlikely.
name: Cubital tunnel syndrome
label: e
answer: no
explanation: Medial epicondylitis (golfer's elbow) occurs when the muscles of the anterior compartment of the forearm are used repetitively, leading to pain. This typically presents as elbow pain worse on wrist flexion, not extension.
name: Medial epicondylitis (golfer's elbow)
label: b
answer: no
explanation: This would present with pain in the whole arm, not just the elbow joint. There would also be numbness and tingling.
name: Brachial plexus injury
label: d
answer: no

Correct answer: a
A 42-year-old male presents with neuropathic back pain. It does not radiate anywhere and is sharp in nature. The doctor orders an MRI which shows that there is a posterior disc herniation at T9.

Which ligament is affected in this patient to allow a posterior disc herniation?

Options:
explanation: The supraspinous ligament extends from the sacrum to C7 where it merges with the nuchal ligament. Its role is to limit flexion of the spine.
name: Supraspinous ligament
label: d
answer: no
explanation: The interspinous ligament extends from the C1 axis to S1. Anteriorly, it connects with ligamentum flavum and posteriorly, it connects to the supraspinous ligament. Its role is to limit flexion of the spine.
name: Interspinous ligament
label: e
answer: no
explanation: The posterior longitudinal ligament extends from the C2 axis vertebra to the sacrum along the vertebral canal on the posterior aspect of the vertebral bodies. The function of this ligament is to help prevent posterior disc herniations along with weakly resisting vertebral hyperflexion.
name: Posterior longitudinal ligament
label: a
answer: yes
explanation: The anterior longitudinal ligament extends from the pelvic surface of the sacrum to the anterior tubercle of vertebra C1 and the occipital bone. It covers and connects the anterolateral aspects of the vertebral bodies and intervertebral discs. It prevents hyperflexion and limits extension of the spine.
name: Anterior longitudinal ligament
label: b
answer: no
explanation: The intertransverse ligament is found between a superior transverse process and the transverse process of the vertebra below it. Its role is to limit lateral flexion of the spine.
name: Intertransverse ligament
label: c
answer: no

Correct answer: a
A 23-year-old female attends a sports and exercise medicine clinic. The doctor monitors her cardiac output as she is performing different exercises.

Which of the following causes an increase in cardiac output?

Options:
explanation: Metabolic hyperaemia causes **vasodilation** of blood vessels during exercise, not vasoconstriction. The increase in waste products such as lactic acid and CO2 decreases the pH of the extracellular fluid. This causes localised vasodilation of blood vessels, to help flush out the waste products and allow more oxygen to get there to meet the demand of the muscles. The increased blood flow leads to an increase in venous return, leading to a greater cardiac output.
name: Metabolic hyperaemia causes vasoconstriction of blood vessels
label: d
answer: no
explanation: Sympathetic venoconstriction decreases venous volume so increases mean systemic filling pressure. This increases the pressure gradient between veins and the heart so increases venous return to the heart, leading to a greater cardiac output.
name: Sympathetic venoconstriction
label: a
answer: yes
explanation: Inactive skeletal muscles **vasoconstrict**, not vasodilate during exercise. If the vessels vasodilated during exercise, the total peripheral resistance would drop, resulting in reduced blood pressure.
name: Vasodilation of inactive skeletal muscles
label: e
answer: no
explanation: Muscle contraction leads to the **compression** of veins and therefore increases blood pressure. This increase in blood pressure leads to an increase in venous return, leading to a greater cardiac output.
name: Muscle contraction causing the expansion of veins
label: b
answer: no
explanation: Pulmonary artery pressure **increases** during exercise. This leads to a decrease in pulmonary vascular resistance, causing alveolar vessels to open up and distend more. This respiratory muscle pump allows for an increase in venous return, leading to a greater cardiac output.
name: Pulmonary artery pressure decreases
label: c
answer: no

Correct answer: a
A 56-year-old male presents to the GP for his annual check-up. The GP records his blood pressure as 153/102mmHg and decides to prescribe him ramipril to help control his blood pressure.

What is the mechanism of action of this drug?

Options:
explanation: ARBs, such as losartan, work by binding to the angiotensin II receptor, preventing endogenous angiotensin II from binding to them. This results in vasodilation which reduces blood pressure. Ramipril is an ACE inhibitor, not an angiotensin receptor blocker.
name: Angiotensin receptor blocker (ARB)
label: b
answer: no
explanation: Beta-blockers, such as propranolol, work by blocking beta-2 adrenoreceptors in blood vessels. This results in less cAMP formation, which leads to vasodilation. Ramipril is an ACE inhibitor, not a beta blocker.
name: Beta-blocker
label: e
answer: no
explanation: Ramipril is an ACE inhibitor, therefore it inhibits the formation of angiotensin-II. It also increases bradykinin levels in the blood, causing vasodilation which leads to reduced blood pressure.
name: ACE inhibitor
label: a
answer: yes
explanation: Thiazide-like diuretics, such as indapamide, work by inhibiting sodium reabsorption, and by extension, decreasing fluid reabsorption via osmotic gradients. This, in turn, reduces blood pressure. Ramipril is an ACE inhibitor, not a thiazide-like diuretic.
name: Thiazide-like diuretic
label: d
answer: no
explanation: CCBs, such as amlodipine, work by blocking voltage-dependent L-type calcium channels, therefore inhibiting the influx of calcium and causing smooth muscle relaxation and vasodilation. This decreases blood pressure. Ramipril is an ACE inhibitor, not a calcium channel blocker.
name: Calcium channel blocker (CCB)
label: c
answer: no

Correct answer: a
A 24-year-old female presents to the ED with prolonged bleeding after a small cut on her leg. She has tried to put pressure on the wound but it has not helped. She is not on any anticoagulant medications.

It is found that she has haemophilia A.

Which molecule is depleted in haemophilia A and which pathway of the coagulation cascade does this affect?

Options:
explanation: In haemophilia A, there is a deficiency of factor VIII, not VII. Factor VII combines with tissue factor in the extrinsic pathway to initiate the coagulation cascade via factor X.
name: Clotting factor VII which affects the extrinsic pathway
label: c
answer: no
explanation: Haemophilia A occurs due to a deficiency in clotting factor VIII. Factor VIII is part of the intrinsic pathway and has many downstream effects, including increasing the conversion of factor XIII to factor XIIIa, and increasing the conversion of fibrin into a fibrin clot.
name: Clotting factor VIII which affects the intrinsic pathway
label: a
answer: yes
explanation: In haemophilia A, there is a deficiency of factor VIII, not II. Factor II (thrombin) activates fibrinogen to form fibrin in the intrinsic pathway, which helps with the formation of a clot.
name: Clotting factor II which affects the the intrinsic pathway
label: d
answer: no
explanation: In haemophilia A, there is a deficiency in factor VIII, not XI. Factor XI deficiency is called haemophilia C. Both haemophilia A and C play a role in the intrinsic pathway.
name: Clotting factor XI which affects the intrinsic pathway
label: e
answer: no
explanation: There is indeed a deficiency in clotting factor VIII in haemophilia A, but it is the intrinsic coagulation pathway that is affected, not the extrinsic pathway.
name: Clotting factor VIII which affects the extrinsic pathway
label: b
answer: no

Correct answer: a
A 74-year-old male is experiencing palpitations and comes to the ED. An ECG is performed which shows prolonged early after-depolarisations (EADs). The patient is on a variety of medications which the doctor thinks could be contributing to his EADs.

Which of the following medications can cause EADs?

Options:
explanation: This is an angiotensin receptor blocker, which like ACE inhibitors is associated with hyperkalaemia, not hypokalaemia.
name: Candesartan
label: d
answer: no
explanation: This is an ACE inhibitor which causes hyperkalaemia, not hypokalaemia.
name: Ramipril
label: b
answer: no
explanation: Digoxin causes delayed after-depolarisations (DADs), not early after-depolarisations. It causes DADs by inhibiting Na+/K+ ATPase which leads to an increased intracellular Na+ conc (usually pumps Na+ out and K+ in) as well as reduced Ca2+ efflux via NCX. This results in high concentrations of Ca2+ inside the myocyte. When the Ca2+ content in the sarcoplasmic reticulum is too high, RyR receptors spontaneously open during diastole which releases Ca2+ without an action potential stimulus. This increases Ca2+ efflux via NCX (increasing the intracellular Na+ concentration) and causes depolarisation leading to a delayed after depolarisation. If this depolarisation reaches the threshold to open voltage-gated Na+ channels, it causes an action potential to be formed.
name: Digoxin
label: e
answer: no
explanation: This is a loop diuretic which can cause hypokalaemia. Hypokalaemia reduces the activity of K+ channels and the Na/K pump. This prolongs the plateau phase of the cardiac action potential, leading to increased Ca2+ influx via L-type Ca2+ channels. This results in an increase in the cytosolic Ca2+ concentration, so more Ca2+ leaves the cell via NCX (sodium-calcium-exchangers) and more Na+ is brought into the cell. This can cause depolarisation and action potentials before a cell has a chance to repolarise, leading to EADs.
name: Furosemide
label: a
answer: yes
explanation: This is a potassium-sparing diuretic which can cause hyperkalemia, not hypokalaemia.
name: Spironolactone
label: c
answer: no

Correct answer: a