hllj/quesmed huggingface dataset:
The release of AgRP by cells of the arcuate nucleus inhibits signals through MC3/4R.

Which of the following effects does this have?

Options:
explanation: This function is achieved by the thyroid hormones T3 and T4 (T3 is the more active form) under the control of the thyroid (TSH).
name: Increase basal metabolic rate
label: e
answer: no
explanation: Thirst is rapidly decreased by neural afferents upon drinking and by hypothalamic osmoreceptor signals once the fluid drunk has been absorbed into the blood and restored the normal osmolality.
name: Decrease thirst
label: d
answer: no
explanation: AgRP-releasing neurons are stimulated by ghrelin which is released by the gastric fundus when it has not been stretched for several hours. These cells antagonise a-melanocyte stimulating hormone at melanocortin 3/4 receptors in the ventromedial hypothalamus to reduce the generation of satiety signals, thereby increasing appetite in response to an empty stomach.
name: Increase appetite
label: a
answer: yes
explanation: Thirst is increased by dipsogens such as angiotensin 2, generated upon dehydration by the renin-angiotensin system. Renin is secreted from juxtaglomerular cells upon hypotension, increased sympathetic activity or decreased GFR (decreases NaCl reaching the macula densa, altering paracrine ATP secretion to juxtaglomerular cells). Renin cleaves angiotensinogen to angiotensin 1 which is cleaved in the lungs by angiotensin-converting enzyme (ACE) into angiotensin 2 (which is a dipsogen).
name: Increase thirst
label: c
answer: no
explanation: Appetite is decreased by several hormones in contrast to the single hormone ghrelin which stimulates hunger. Early hormones include cholecystokinin (which also stimulates gallbladder contraction for bile secretion) and the incretin GLP-1, whilst later hormones include leptin from adipose tissue and insulin from pancreatic B-cells. These activate POMC/CART neurons in the arcuate nucleus of the hypothalamus which release a-melanocyte stimulating hormone to stimulate melanocortin 3/4 receptors in the ventromedial hypothalamus. This increases the generation of satiety signals, thereby decreasing appetite in response to feeding, and increasing glucose and adiposity.
name: Decrease appetite
label: b
answer: no

Correct answer: a
A 70-year-old male with dementia is admitted to the hospital following a fall at home. He has a productive cough and appears short of breath on observation.


On examination, he has a temperature of 38 degrees, a respiratory rate of 33 breaths per minute, and a blood pressure is 110/ 62.


Bloods show a urea of 9mmol/L.


What is this gentleman's CURB–65 score?

Options:
explanation: This man scores 3 points on the CURB-65 scoring system for community-acquired pneumonia (CAP): 1 point for urea > 7mmol/L, respiratory rate ≥ 30 breaths per minute and age ≥ 65 respectively. Although his AMTS score would most likely be less than 8, this would not count towards his CURB-65 score because his confusion is chronic due to dementia; confusion must be new-onset to score a point. He does not score a point for his blood pressure because his systolic blood pressure is not < 90mmHg and/or diastolic < 60mmHg.
name: 5
label: d
answer: no
explanation: This man scores 3 points on the CURB-65 scoring system for community-acquired pneumonia (CAP): 1 point for urea > 7mmol/L, respiratory rate ≥ 30 breaths per minute and age ≥ 65 respectively.

The full CURB-65 criteria are:

* **C** - Confusion
* **U** - Urea > 7 mmol/L
* **R** - Respiratory rate >30
* **B** - Blood pressure SBP <90 or DBP <60
* **65** - Age > 65
name: 3
label: a
answer: yes
explanation: This man scores 3 points on the CURB-65 scoring system for community-acquired pneumonia (CAP): 1 point for urea > 7mmol/L, respiratory rate ≥ 30 breaths per minute and age ≥ 65 respectively.
name: 1
label: c
answer: no
explanation: This man scores 3 points on the CURB-65 scoring system for community-acquired pneumonia (CAP): 1 point for urea > 7mmol/L, respiratory rate ≥ 30 breaths per minute and age ≥ 65 respectively. Although his AMTS score would most likely be less than 8, this would not count towards his CURB-65 score because his confusion is chronic due to dementia; confusion must be new-onset to score a point. He does not score a point for his blood pressure because his systolic blood pressure is not < 90mmHg and/or diastolic < 60mmHg.
name: 2
label: e
answer: no
explanation: This man scores 3 points on the CURB-65 scoring system:  1 point for urea > 7mmol/L, respiratory rate ≥ 30 breaths per minute and age ≥ 65 respectively. Although his AMTS score would most likely be less than 8, this would not count towards his CURB-65 score because his confusion is chronic due to dementia; confusion must be new-onset to score a point. He does not score a point for his blood pressure because his systolic blood pressure is not < 90mmHg and/or diastolic < 60mmHg.
name: 4
label: b
answer: no

Correct answer: a
A 17-year-old female with a history of asthma presents to Accident and Emergency with acute onset shortness of breath and chest pain.

On examination her PEFR is 39%, her oxygen saturation is 90%, her lips are blue-tinged, and her heart rate is 120 beats per minute. She is diagnosed with a life-threatening asthma attack.

Which of the following features is most strongly associated with a life-threatening asthma attack?

Options:
explanation: In a life-threatening asthma attack, CO2 levels are normal because patients are still able to blow off CO2 as they breathe. Only in near-fatal asthma attacks does PaCO2 rise as patients become exhausted and are no longer able to blow off CO2. This results in them becoming hypercapnic.
name: High PaCO2
label: c
answer: no
explanation: Although wheeze is heard on auscultation during most asthma exacerbations, it can sometimes not be heard in life-threatening asthma attacks. A patient's chest in life-threatening exacerbations can actually be silent due to there not being enough airflow inside the lungs for a wheezing sound to be formed. This tends to occur when a patient's chest becomes really tight and their respiratory muscles become tired.
name: Wheeze
label: b
answer: no
explanation: This is a sign of a severe asthma exacerbation. As a patient's symptoms worsen, they become more short of breath and are unable to complete sentences in a single breath.
name: Unable to complete sentences in one breath
label: d
answer: no
explanation: CO2 levels are normal in a life-threatening asthma attack because patients still have enough energy to blow off CO2 through rapid breathing. Only in near-fatal asthma attacks does PaCO2 rise as patients become exhausted and are no longer able to blow off CO2. This results in them becoming hypercapnic.
name: Normal PaCO2
label: a
answer: yes
explanation: Although coughing is a symptom of asthma, it is not indicative of the severity of an asthma exacerbation and therefore cannot be used to identify a life-threatening asthma attack.
name: Cough
label: e
answer: no

Correct answer: a
A 23-year-old male presents in the Emergency Department with sudden onset chest pain and shortness of breath. His vital signs are normal and he has no significant past medical history.

On auscultation, there are absent breath sounds and increased vocal resonance over the right lung, and the trachea is central. A chest X-ray shows a 3cm right-sided pneumothorax.

Which of the following is the best management option for this patient?

Options:
explanation: A chest drain is indicated in a pneumothorax if it is a tension pneumothorax which has already been treated with needle decompression, if it is a primary pneumothorax which has not resolved with aspiration, or if it is a secondary pneumothorax >2cm/the patient is breathless.
name: Chest drain
label: e
answer: no
explanation: This would be appropriate in a secondary pneumothorax 1-2cm in size, however, this patient has no underlying lung disease so does not meet the criteria for a secondary pneumothorax.
name: High flow oxygen
label: d
answer: no
explanation: This is a primary pneumothorax which is >2cm, therefore the patient requires aspiration in the second intercostal space mid-clavicular line.
name: Aspiration
label: a
answer: yes
explanation: This would be appropriate if the primary pneumothorax was <2cm and the patient was not breathless.
name: Discharge and follow up in 2 weeks
label: c
answer: no
explanation: This is the treatment for a tension pneumothorax which would be indicated by tracheal deviation, hypotension and tachycardia.
name: Needle decompression
label: b
answer: no

Correct answer: a
A 40-year-old lorry driver presents to the GP with a 6-month history of headaches when he wakes up. He explains that he is tired during the day and finds himself occasionally falling asleep whilst driving. His wife, who is with him, also mentions that he seems to stop breathing when sleeping at night.

On observation, the patient is of large body habitus and appears to have large hands and apparent prognathism. On examination, his blood pressure is 130/80 and his heart rate is 115.

Given the most likely diagnosis, which is the following is the most likely ABG finding?

Options:
explanation: This would occur if the patient was blowing off carbon dioxide due to a high respiratory rate. However, in obstructive sleep apnoea airway obstruction leads to carbon dioxide retention. Furthermore, it is very difficult for patients to maintain a raised respiratory rate for long enough for renal compensation to occur.
name: Compensated respiratory alkalosis
label: c
answer: no
explanation: This would occur if there was a build-up of acid due to a metabolic cause which was then compensated for through hyperventilation and blowing off carbon dioxide. However, the most likely diagnosis in this gentleman is obstructive sleep apnoea which results in hypercapnia, not hypocapnia.
name: Compensated metabolic acidosis
label: d
answer: no
explanation: The most likely diagnosis is obstructive sleep apnoea (OSA). The airway obstruction in OSA leads to type 2 respiratory failure as patients retain carbon dioxide, however as OSA is a chronic disease, the kidneys have time to produce bicarbonate and compensate for the hypercapnia.
name: Compensated respiratory acidosis
label: a
answer: yes
explanation: This would occur if there was a reduction of acid due to a metabolic cause which was then compensated for by the patient hyperventilating and retaining carbon dioxide.
name: compensated metabolic alkalosis
label: e
answer: no
explanation: In obstructive sleep apnoea, airway obstruction leads to hypercapnia as well as hypoxemia due to air retention in the lungs.
name: Type 1 respiratory failure
label: b
answer: no

Correct answer: a
A 70-year-old male presents to the Emergency Department with a 1-week history of pleuritic chest pain and a new cough. His past medical history includes a 20-year history of hypertension and he has smoked for 40 years.


On examination, there is stony dullness to percussion in the left lung base, reduced breath sounds, and reduced vocal resonance.


A chest x-ray shows a left-sided pleural effusion. The fluid aspirated has a protein level of 30g/L.


What is the most likely cause of this patient's pleural effusion?

Options:
explanation: Lung cancer is a cause of exudative pleural effusions (>35g/L). Furthermore, a patient with lung cancer would more likely present with a several-month history of dry cough and chest pain as opposed to a one week history.
name: Lung Cancer
label: c
answer: no
explanation: This is a cause of transudative pleural effusion, however, only occurs alongside an ovarian tumour which would not be possible for this male patient.
name: Meig's syndrome
label: b
answer: no
explanation: This is a cause of exudative pleural effusions and on aspiration presents with frank pus and pH <7.2.
name: Empyema
label: e
answer: no
explanation: Pneumothorax would present with pleuritic chest pain as well as increased vocal resonance and hype resonance on percussion. It is not a cause of pleural effusions.
name: Pneumothorax
label: d
answer: no
explanation: Heart failure is a cause of transudative pleural effusions with low protein levels (<35g/L) as per light's criteria. Light's criteria states that an effusion is an exudate if: the pleural fluid to serum protein ratio is >0.5, the pleural fluid to serum LDH ratio is >0.6, or the pleural fluid LDH is >2/3 the upper reference limit for serum LDH. If these criteria are not satisfied, then the effusion is transudative.
name: Heart Failure
label: a
answer: yes

Correct answer: a
A 16-year-old female presents to hospital with complaints of perioral paraesthesia and tingling in her fingers and toes. She admits to episodes of shortness of breath and chest tightness over the last 2 months at school.


An arterial blood gas is done which demonstrates the following:

||||
|--------------|:-------:|------------------|
|pH|7.47|7.35 - 7.45|
|PaO₂|14 kPa|11 - 15|
|PaCO₂|3.9 kPa|4.6 - 6.4|
|Bicarbonate|24 mmol/L|22 - 30|



What is the most likely cause of this patient's presentation?

Options:
explanation: This causes a metabolic acidosis with a raised anion gap. It is unlikely in this case as there is no history which indicates tricyclic antidepressant use.
name: Tricyclic antidepressant overdose
label: d
answer: no
explanation: Patients with chronic kidney disease develop a metabolic acidosis with raised anion gap. This occurs because the kidneys are unable to clear acids from the bloodstream.
name: Chronic kidney disease
label: e
answer: no
explanation: Vomiting would result in a metabolic alkalosis due to the gastrointestinal loss of H+ ions.
name: vomiting
label: b
answer: no
explanation: Diarrhoea would result in a metabolic acidosis with a normal anion gap. This is due to the loss of bicarbonate ions in the stool.
name: Diarrhoea
label: c
answer: no
explanation: This ABG shows a respiratory alkalosis which is likely to be secondary to a panic attack. The patient is breathing faster due to her panicked state and is blowing off carbon dioxide, resulting in her low PaCO2 and paraesthesia.
name: Panic attack
label: a
answer: yes

Correct answer: a
An 80-year-old female presents to her GP with a 2-month history of shortness of breath and dry cough.

On examination, her fingernails are clubbed and on auscultation of the lungs there are fine end-inspiratory crackles.

Based on the most likely diagnosis, which of the following spirometry findings is the patient most likely to have?

Options:
explanation: Idiopathic lung fibrosis is a restrictive lung disease so we would expect the FEV1/FVC ratio should be > 70%. The FEV1/FVC ratio for this answer choice is 72% which is suggestive of restrictive lung disease. However, in restrictive lung diseases, the total lung capacity of carbon monoxide (TLCO) is reduced due to the reduction in lung volume.
name: FEV1 2.1, FVC 3.2, TLCO increased
label: c
answer: no
explanation: Idiopathic lung fibrosis is a restrictive lung disease so we would expect the FEV1/FVC ratio should be > 70%. This answer choice shows an FEV1/FVC ratio of 66% making it incorrect.
name: FEV1 2.1, FVC 3.2, TLCO increased
label: b
answer: no
explanation: Idiopathic lung fibrosis is a restrictive lung disease so we would expect the FEV1/FVC ratio should be > 70%. The FEV1/FVC ratio for this answer choice is 86% which is suggestive of restrictive lung disease.  However, in restrictive lung diseases, the total lung capacity of carbon monoxide (TLCO) is reduced due to the reduction in lung volume.
name: FEV1 2.4, FVC 2.8, TLCO normal
label: d
answer: no
explanation: The most likely diagnosis is idiopathic pulmonary fibrosis which is a restrictive lung disease. As a result, we would expect this patient's FEV1/FVC ratio to be above 70%. Indeed, her FEV1/FVC ratio is 83%. Her total lung capacity of carbon monoxide (TLCO) is reduced because there is a reduction in overall lung volume.
name: FEV1 2.5, FVC 3.0, TLCO reduced
label: a
answer: yes
explanation: Idiopathic lung fibrosis is a restrictive lung disease so we would expect the FEV1/FVC ratio should be > 70%. This answer choice shows an FEV1/ FVC ratio of 66% making it incorrect. Also, in restrictive lung diseases, the total lung capacity of carbon monoxide (TLCO) is reduced due to the reduction in lung volume.
name: FEV1 2.5, FVC 3.7, TLCO normal
label: e
answer: no

Correct answer: a
A 50-year-old woman presents to Accident and Emergency with a one week history of worsening shortness of breath and productive cough.

On auscultation of the lungs, there is a widespread audible wheeze.

Her oxygen saturation is 90%, heart rate is 110 beats per minute, blood pressure is 125/80 and temperature is 37.7 degrees.

A chest x-ray is done which shows:

[lightgallery]

What is the most likely diagnosis?

Options:
explanation: A patient with idiopathic pulmonary fibrosis would suffer from a dry cough as opposed to a productive cough. IPF is typically seen as honeycombing of the lungs on High-Resolution CT (HRCT), or interstitial shadowing on an x-ray.
name: Idiopathic pulmonary fibrosis (IPF)
label: d
answer: no
explanation: Sarcoidosis on an x-ray would show bilateral hilar lymphadenopathy.
name: Sarcoidosis
label: c
answer: no
explanation: X-rays are not typically used in the diagnosis of asthma but might show some pulmonary hyperinflation as seen in the image. However, a flattened diaphragm is not consistent with asthma.
name: Asthma
label: e
answer: no
explanation: Although this patient is pyrexic, has shortness of breath and has a productive cough, the x-ray findings are not consistent with a diagnosis of pneumonia. In pneumonia, we would expect to see consolidation of the affected zone.
name: Pneumonia
label: b
answer: no
explanation: The x-ray shows hyperinflation of the lungs with 10 posterior ribs visible and flattened hemidiaphragms which are characteristic of COPD.
name: COPD
label: a
answer: yes

Correct answer: a
A 30-year-old Afro–Caribbean female presents to Accident and Emergency with a 5-day history of shortness of breath and complaints of pain in both legs.

On examination, there are red lesions on her shins as well as a violaceous rash across her nose and cheeks. There are widespread crackles on auscultation of the lungs.

Chest x-ray shows bilateral hilar lymphadenopathy.

Given the most likely diagnosis, which of the following is the most appropriate management plan?

Options:
explanation: Due to the acute presentation of sarcoidosis, it is most appropriate for the patient to be treated with bed rest and NSAIDs (to control pain and act as an antipyretic).
name: Bed rest and NSAIDs
label: a
answer: yes
explanation: Methotrexate is used to treat sarcoidosis if it does not respond to oral corticosteroids. This presentation does not meet the criteria to be treated with steroids as there is no eye involvement, hypercalcaemia, neurological involvement or cardiac involvement.
name: Methotrexate
label: e
answer: no
explanation: In order for sarcoidosis to be treated with steroids there must be eye involvement, hypercalcaemia, neurological involvement or cardiac involvement. Steroids are also indicated in severe and persistent erythema nodosum; the 5-day history from this patient does not fulfil this criterion.
name: Oral prednisolone
label: b
answer: no
explanation: Supportive treatment is required for this acute presentation with NSAIDs to target pain and prevent pyrexia.
name: No treatment required
label: c
answer: no
explanation: This is the treatment for Tuberculosis. Although bilateral hilar lymphadenopathy may be visible on an x-ray for tuberculosis, the clinical features in this patient including lupus pernio and erythema nodosum make sarcoidosis a much more likely diagnosis.
name: Rifampicin, isoniazid, pyrazinamide, ethambutol quadruple therapy
label: d
answer: no

Correct answer: a
A 70-year-old female presents to the clinic with a 3-month history of shortness of breath and chest pain. She mentions that she has noticed blood in his sputum.

On examination, she has finger clubbing and appears frail, confused and disorientated.

An ECG is carried out which shows a shortened QT interval.

What is the most likely diagnosis?

Options:
explanation: This is a good differential when considering the cause of haemoptysis, frail appearance (which could be due to weight loss) and shortness of breath. However, TB would not explain this patient's confusion and ECG results.
name: Tuberculosis
label: d
answer: no
explanation: This would present with systemic subacute symptoms. You would also expect a fever alongside her chest pain, shortness of breath and clubbing.
name: Lung abscess
label: c
answer: no
explanation: This patient has symptoms suggesting lung cancer and hypercalcemia. Hypercalcemia is associated with squamous cell lung cancers due to the release of parathyroid hormone-related protein (PTHrp).

A helpful way to remember the signs of hypercalcaemia is by learning 'bones (bone pain), stones (renal stones), abdominal groans (abdominal pain and GI upset) and psychiatric moans (confusion)'. This woman has psychiatric moans by way of her confusion and disorientation. In addition, hypercalcemia is associated with shortened QT intervals on ECG.
name: Squamous cell lung cancer
label: a
answer: yes
explanation: Although it is likely that this patient has lung cancer due to her haemoptysis and clubbing, small-cell lung cancers are not associated with hypercalcemia. In fact, small-cell lung cancers are associated with Cushing's syndrome due to the ectopic release of ACTH.
name: Small cell lung cancer
label: b
answer: no
explanation: Asthma would not present with clubbing or haemoptysis and would be associated with shortness of breath on exertion and a diurnal variation in symptoms.
name: Asthma
label: e
answer: no

Correct answer: a
A 6-year-old female presents to Accident & Emergency after falling off her bike.

On examination, she cries out in pain on passive movement of her right foot which appears pale. She also complains of tingling in her toes.

X-ray shows a closed fracture to the right distal tibia.

A diagnosis of compartment syndrome is confirmed.

Which of the following is the definitive treatment for this condition?

Options:
explanation: An osteotomy is not indicated for the treatment of compartment syndrome or fractures as it involves cutting bone to shorten or lengthen it.
name: Osteotomy
label: e
answer: no
explanation: This would be indicated to aid the healing of the broken bone but it is not the definitive management for compartment syndrome (which needs to be addressed imminently to prevent further complications). A plaster cast would be counterproductive in this acute situation as it would apply further compression to the leg.
name: Plaster cast
label: d
answer: no
explanation: This would be indicated if she had developed further neurovascular complications and if a fasciotomy would not be able to save the leg. In addition to the pain, pallor and paraesthesia, she could develop pulselessness and paralysis of the muscle group.
name: Amputation
label: b
answer: no
explanation: This is the definitive management for compartment syndrome, and a delay in performing it could result in amputation. Fasciotomy is performed by incisions being made to the appropriate leg compartment to relieve the pressure.
name: Urgent fasciotomy
label: a
answer: yes
explanation: Morphine is indicated for the pain but is not the definitive management for compartment syndrome.
name: Oral morphine
label: c
answer: no

Correct answer: a