hllj/quesmed huggingface dataset:
A 55-year-old lady presents to her GP with fatigue, low mood, and generalised bone pains. She had an episode of renal colic one week ago which resolved without medical intervention. She has a past medical history of hypertension and currently takes ramipril. She has a 15 pack-year history of smoking.
Blood tests show: 


|                    |    |        |
| --------------------------- | :-------: | -------------------- |
| Calcium                     | 2.93 mmol/L          | 2.2 - 2.6     |
| Phosphate                   | 0.69 mmol/L          | 0.8 - 1.5     |
| Parathyroid Hormone         | 6.9 pmol/L          | 1.6 - 8.5                |
| Sodium                      | 142 mmol/L          | 135 - 145     |
| Potassium                   | 4.0 mmol/L          | 3.5 - 5.3     |
| Creatinine                  | 94 µmol/L          | 60 - 120      |


What is the most likely diagnosis?

Options:
explanation: Secondary hyperparathyroidism is caused by a physiological increase in PTH secretion in response to low calcium levels. The low calcium is typically attributed to kidney, liver, or bowel disease. The calcium levels in this patient are raised, which makes this diagnosis incorrect.
name: Secondary hyperparathyroidism
label: c
answer: no
explanation: Addison's disease may also present with fatigue and low mood, but hypercalcaemia is a rare finding. Patients may also have increased pigmentation, and blood tests typically demonstrate hyperkalaemia and hyponatraemia.
name: Addison's disease
label: d
answer: no
explanation: Primary hyperparathyroidism is most commonly caused by a parathyroid adenoma, which secretes excess parathyroid hormone (PTH), leading to hypercalcaemia. Hypercalcaemia is typically the cause of symptoms in hyperparathyroidism which include bone pain, fatigue, renal stones, and GI upset - which can be remembered as 'stones, moans, bones, groans'. This patient has elevated serum calcium and low phosphate, and an inappropriately high PTH based on these results. PTH may be within normal ranges in primary hyperparathyroidism, as they would normally fall in a patient with hypercalcaemia.
name: Primary hyperparathyroidism
label: a
answer: yes
explanation: Sarcoidosis can result in a transient hypercalcaemia, but it is less likely to be the primary cause of the patient's symptoms. Patients with sarcoidosis would typically present with a dry cough, shortness of breath, and non-pulmonary features such as erythema nodosum.
name: Sarcoidosis
label: b
answer: no
explanation: Multiple myeloma is an important differential diagnosis in patients with hypercalcaemia. However, back pain is the most common presentation. Patients will commonly also have renal impairment (raised Cr), anaemia, and bone lesions. PTH would be expected to be low in myeloma as a physiological response to hypercalcaemia.
name: Multiple myeloma
label: e
answer: no

Correct answer: a
A 34-year-old female attends her GP complaining of feeling more tired and weak than usual over the last few weeks. On further discussion, she mentions that she has lost weight recently and that her boyfriend has said she looks more tanned than usual despite spending less time outdoors. She has a past medical history of coeliac disease and does not smoke or drink alcohol. On examination, pigmentation is noted in the palmar creases and posterior neck. Blood tests are ordered which show a raised potassium and low sodium. Salivary cortisol is low.

What further investigation is most likely to be diagnostic for the likely underlying condition?

Options:
explanation: The likely underlying diagnosis is Addison’s disease. It is caused by autoimmune destruction of the adrenal cortex resulting in a decreased production of mineralocorticoids, glucocorticoids, and androgens. The main presenting features include lethargy, mood changes, anorexia, and hyperpigmentation. The diagnostic test is a short synacthen test. This involves measuring plasma cortisol before and after the administration of tetrosactide (an ACTH analogue). In Addison’s disease, there is a failure of exogenous ACTH to increase plasma cortisol - pointing to an adrenal cause. The presence of another autoimmune condition (coeliac disease) also makes the diagnosis of Addison’s more likely.
name: Short synacthen test
label: a
answer: yes
explanation: This is used to test for Cushing’s syndrome, which is caused by an increase in circulating glucocorticoids. In a healthy patient, cortisol production will be suppressed. However, in Cushing’s syndrome, there is a failure to suppress cortisol.
name: 48-hour dexamethasone suppression test
label: b
answer: no
explanation: These markers would be raised in a patient suffering from a pheochromocytoma.
name: Urinary catecholamines & metabolites
label: d
answer: no
explanation: Thyroid function tests would be an important test to rule out the differential diagnosis of hypothyroidism. However, given the presentation of this patient, a diagnosis of Addison’s disease is more likely. Hypothyroidism is more likely to present with weight gain rather than weight loss.
name: Thyroid function tests
label: e
answer: no
explanation: This is a test used to identify diabetes insipidus. It would not be of use in this patient.
name: Water deprivation test
label: c
answer: no

Correct answer: a
A 57-year-old male with poorly controlled type 2 diabetes presents to the diabetes clinic. His HbA1c was recently measured and was found to be raised at 67 mmol/mol. This is only a slight improvement from his last HbA1c measurement which was 70mmol/mol three months previously. He is obese, and is currently taking metformin and atorvastatin. He is started on a new drug which the doctor explains works by increasing glucose excretion in the urine.

Which of the following has most likely been prescribed to the patient?

Options:
explanation: Sitagliptin is a DPP-4 inhibitor, and acts by potentiating GLP-1 resulting in increased insulin release and decreased glucagon release. It is currently recommended as a second-line treatment option for T2DM.
name: Sitagliptin
label: e
answer: no
explanation: Exanatide is a GLP-1 agonist, which is currently recommended as a management option for patients in whom triple therapy with metformin and two other drugs has been ineffective. GLP-1 agonists increase insulin release in response to food, and also have the beneficial side effect of weight loss.
name: Exanatide
label: d
answer: no
explanation: Gliclazide is a sulphonylurea, which increases the release of insulin from pancreatic B-cells. It increases the risk of hypoglycaemia, and may cause weight gain.
name: Gliclazide
label: b
answer: no
explanation: Dapagliflozin is correct. This is an SGLT-2 inhibitor, which prevents glucose reabsorption in the proximal convoluted tubule, resulting in increased urinary glucose excretion. An SGLT-2 inhibitor is the second-line pharmacological option for patients with T2DM with established cardiovascular disease or a high risk of developing cardiovascular disease. SGLT-2 inhibitors can increase the risk of developing urinary tract infections, but can also result in the beneficial side effect of weight loss.
name: Dapagliflozin
label: a
answer: yes
explanation: Modified-release metformin may be started in patients with type 2 diabetes who experience gastrointestinal side effects with standard-release metformin. It acts via the same mechanism as metformin.
name: Modified-release metformin
label: c
answer: no

Correct answer: a
A 63-year-old female presents complaining of anxiety and significant weight loss. She has been passing looser stools than normal over the preceding few weeks and is wearing just a t-shirt and shorts, despite it being a cold winter's day. On examination, she has a rough goitre which is not painful, and a slight tremor bilaterally.
Blood tests show a TSH of 0.05, and a free T4 of 39. A nuclear scintigraphy scan is organised which shows patchy uptake.
Which of the following is the most likely diagnosis in this patient?

Options:
explanation: Thyroid cancer is unlikely in this patient as, although the patient has experienced weight loss, given the other symptoms, this is more likely to be caused by the patient's hyperthyroid state. Individuals with thyroid cancer typically present in advanced stages of the disease, with hoarseness of the voice, sore throat, difficulty swallowing, and goitre being common symptoms. Other symptoms of hyperthyroidism are rare in thyroid cancer.
name: Thyroid cancer
label: d
answer: no
explanation: Hashimoto's disease is an autoimmune disorder which causes hypothyroidism, not hyperthyroidism. Examples of symptoms would include fatigue, weight gain, cold intolerance and constipation. It may cause a goitre.
name: Hashimotos disease
label: e
answer: no
explanation: Graves disease is the most common cause of thyrotoxicosis, and usually presents with signs of hyperthyroidism (such as anxiety, palpitations, heat intolerance, sweating, and weight loss). Graves disease is unlikely in this patient due to the rough goitre (smooth in Graves' disease), and patchy nuclear scintigraphy uptake (would be diffuse in Graves').
name: Graves disease
label: c
answer: no
explanation: De Quervain's thyroiditis, also known as subacute thyroiditis, commonly presents with a painful goitre which is absent in this patient. It follows a course of hyperthyroidism followed by euthyroidism, hypothyroidism, and then returns to euthyroidism. They are often associated with recent viral upper respiratory tract infections.
name: De Quervain's thyroiditis
label: b
answer: no
explanation: Toxic multinodular goitre presents with a rough goitre, and nuclear scintigraphy typically shows patchy uptake. This is a cause of hyperthyroidism in which excess thyroid hormone is secreted from multiple autonomous thyroid nodules. These secrete thyroid hormones independently of TSH and are typically benign.
name: Toxic multinodular goitre
label: a
answer: yes

Correct answer: a
A 64-year-old lady who is an inpatient on a respiratory ward for small cell lung carcinoma has been experiencing nausea and headache for the past two days. She has also vomited twice today and is complaining of cramping in her right leg. Blood tests are performed and her serum sodium is found to be reduced at 114 mmol/L (normal range 135-145 mmol/L).

Which of the following is not a cause of hyponatraemia?

Options:
explanation: Diabetes insipidus is characterised by loss of ADH function resulting in polyuria, polydipsia, and hypernatraemia. Serum osmolality is typically raised (>300), whilst urine osmolality is decreased (<300). Diabetes insipidus may have a cranial cause (lack of ADH release), or a nephrogenic cause (resistance to ADH action).
name: Diabetes insipidus
label: a
answer: yes
explanation: SIADH would cause hyponatraemia, and is a known complication of small-cell lung cancer. This is caused by excess ADH release resulting in increased reabsorption of water in the nephron and a decrease in blood osmolality. The subsequent increase in glomerular filtration rate due to increased blood volume causes reduced aldosterone release, resulting in less sodium reabsorption and increased urine osmolality. SIADH would typically present as a euvolaemic hyponatraemia.
name: Syndrome of inappropriate ADH secretion (SIADH)
label: b
answer: no
explanation: Heart failure can result in a hypervolaemic hyponatraemia. In heart failure, decreased cardiac output and blood pressure result in increased release of ADH causing increased water reabsorption.
name: Heart failure
label: e
answer: no
explanation: Addison's disease is caused by adrenal insufficiency, and characteristically presents with hyponatraemia and hyperkalaemia. This is due to the decreased aldosterone release by the adrenal cortex, and thus decreased sodium reabsorption in the nephron.
name: Addison's disease
label: d
answer: no
explanation: Diarrhoea is a cause of hypovolaemic hyponatraemia. It results in excess sodium and water loss in the GI tract.
name: Diarrhoea
label: c
answer: no

Correct answer: a
A 74-year-old female has been suffering from vomiting and diarrhoea for the past four days on an inpatient ward. On examination, she appears dehydrated. Her renal function tests show a creatinine of 110 µmol/L (normal range 60-120µmol/L), and a urea of 16 mmol/L (normal range 2.5-7.8 mmol/L). She has a past medical history of hypertension, hypercholesterolaemia, hypothyroidism and osteoarthritis.

Which of the following medications is most likely to worsen this patient's acute kidney injury?

Options:
explanation: Levothyroxine is not associated with kidney injury. Levothyroxine has been shown to have some protective effects on the kidneys in certain patients with hypothyroidism.
name: Levothyroxine
label: e
answer: no
explanation: Atorvastatin is not associated with kidney injury. However, it is recommended that the dose be reduced in cases of severe AKI.
name: Atorvastatin
label: d
answer: no
explanation: This patient may be taking amolidipine for her hypertension, but it is not known to be nephrotoxic. It is an antihypertensive agent typically used as first-line treatment in patients of Afro-Carribean descent or those above the age of 55. ACE-inhibitors however, another common antihypertensive, are nephrotoxic and should be avoided in AKI.
name: Amlodipine
label: c
answer: no
explanation: This patient's AKI is likely secondary to dehydration and subsequent hypovolaemia caused by her vomiting and diarrhoea. This results in a lack of blood flow to the kidneys. Ibuprofen is an NSAID, which is nephrotoxic, and may worsen this patient's acute kidney injury. Swapping to an alternative pain relief medication for her osteoarthritis would be appropriate whilst she is in AKI.
name: Ibuprofen
label: a
answer: yes
explanation: Lansoprazole is not known to be nephrotoxic. The patient is likely taking this for the prevention of NSAID-related gastric ulcer formation.
name: Lansoprazole
label: b
answer: no

Correct answer: a
A 34-year-old woman presents to her GP complaining of urgency and stinging on urination. She is sexually active, but always uses contraception. On examination, there is some slight suprapubic tenderness. She has a past medical history of folic acid deficiency and asthma for which she takes a salbutamol inhaler. The GP suspects a lower urinary tract infection.

Which of the following choices of antibiotic is most appropriate for this patient?

Options:
explanation: Doxycycline has a number of indications including in sexually transmitted infections, malaria prophylaxis, and lyme disease. It is not used to treat a lower urinary tract infection.
name: Doxycycline
label: e
answer: no
explanation: Nitrofurantoin is the first-line antibiotic of choice in a suspected lower urinary tract infection.
name: Nitrofurantoin
label: a
answer: yes
explanation: Trimethoprim is contraindicated in this patient due to her history of folic acid deficiency, but may be used as an alternative to nitrofurantoin in eligible patients. Trimethoprim inhibits folic acid synthesis so may result in decreased levels in this patient.
name: Trimethoprim
label: b
answer: no
explanation: Flucloxacillin is typically used in skin infections e.g. cellulitis. It would not be used to treat a urinary tract infection.
name: Flucloxacillin
label: d
answer: no
explanation: Co-amoxiclav is the first-line antibiotic of choice in an upper urinary tract infection (pyelonephritis). However, nitrofurantoin or trimethoprim are first-line in a lower urinary tract infection.
name: Co-amoxiclav
label: c
answer: no

Correct answer: a
A 32-year-old male presents with haemoptysis and worsening shortness of breath which started yesterday. He has been feeling more tired and weak than usual over the past week. A urine dipstick reveals microhaematuria and proteinuria. Blood tests show anaemia, with raised urea and creatinine demonstrating an acute kidney injury.

Based on the likely diagnosis, which of the following is most likely to be seen on blood tests?

Options:
explanation: HLA-DR4 is not associated with anti-GBM disease. It is associated with conditions such as rheumatoid arthritis, felty's syndrome and multiple sclerosis.
name: HLA-DR4
label: d
answer: no
explanation: ANCA (anti-neutrophil cytoplasmic antibodies) is associated with a number of medical conditions including microscopic polyangiitis, Wegener's granulomatosis, Churg-Strauss syndrome, and drug-induced vasculitis. It would not be raised in anti-GBM disease.
name: ANCA-positive
label: c
answer: no
explanation: HLA-B27 is a blood test used to look for a protein present on white blood cells. It is associated with a number of conditions including ankylosing spondylitis, psoriatic arthritis, reactive arthritis, and uveitis among others. It would not be raised as a result of anti-GBM disease.
name: HLA-B27
label: b
answer: no
explanation: Anti-TPO (anti-thyroperoxidase) antibodies are raised in Hashimoto's thyroiditis - an autoimmune thyroid condition which leads to hypothyroidism.
name: Anti-TPO antibodies
label: e
answer: no
explanation: This patient has anti-glomerular basement membrane disease, or Goodpasture's syndrome. This disease is a small-vessel vasculitis involving antibodies directed against antigens found on the glomerular basement membrane in the kidneys and lungs (anti-GBM). It is associated with pulmonary haemorrhage and rapidly progressive glomerulonephritis, and rapid treatment with plasmapheresis and steroids are needed to minimise long-term renal damage. Renal biopsy may show IgG deposits along the glomerular basement membrane, and a raised transfer factor may be present secondary to pulmonary haemorrhages. Although a minority of patients may be ANCA-positive, anti-GBM antibodies are much more likely to be seen.
name: Anti-GBM antibodies
label: a
answer: yes

Correct answer: a
A 74-year-old male presents to A&E with his wife following a fall the day before. On questioning, the wife revealed that he has had several minor falls over the past four months and has become progressively more unsteady on his feet. The patient's wife also explained that he has had three events of faecal and urinary incontinence at home, and that he has been increasingly confused recently. 
The patient's observations are stable and within normal ranges, and the gait is observed to be shuffling. A neurological examination is normal. Initial blood tests are normal.

Which of the following investigations would be most appropriate to confirm the likely diagnosis?

Options:
explanation: AN MRI scan of the head would not be the most appropriate investigation in normal pressure hydrocephalus, as it can be diagnosed more easily using a CT scan. MRI would, however, also be diagnostic for NPH, and may also demonstrate ventriculomegaly and deep white matter ischaemia.
name: Urine culture
label: d
answer: no
explanation: This patient is presenting with features typical of normal pressure hydrocephalus (NPH). A patient will typically have the triad of gait disturbance, cognitive impairment, and incontinence. A CT scan of the head is the most appropriate investigation, demonstrating hydrocephalus with dilated ventricles in the absence of sulcal enlargement. This condition is typically managed using a ventriculoperitoneal (VPL) shunt.
name: CT head
label: a
answer: yes
explanation: AN MRI scan of the head would not be the most appropriate investigation in normal pressure hydrocephalus, as it can be diagnosed more easily using a CT scan. MRI would, however, also be diagnostic for NPH, and may also demonstrate ventriculomegaly and deep white matter ischaemia.
name: MRI head
label: b
answer: no
explanation: Nerve conduction studies would not aid a diagnosis of normal pressure hydrocephalus. It may be used to help diagnose Guillain-Barre syndrome.
name: Nerve conduction studies
label: e
answer: no
explanation: A lumbar puncture may be a useful investigation for ruling out differential diagnoses, and a large volume lumbar puncture can be used to see if the removal of CSF results in an improvement of symptoms. It would not typically be used on its own to diagnose normal pressure hydrocephalus.
name: Lumbar puncture
label: c
answer: no

Correct answer: a

CT head
Which of the following cranial nerves supplies taste sensation to the posterior one-third of the tongue?

Options:
explanation: CNVII is the facial nerve. This supplies taste to the anterior two-thirds of the tongue, hard palate, and soft palate. It also provides motor control to the muscles of facial expression, and the lacrimal, submandibular and sublingual glands.
name: Cranial nerve VII (seventh cranial nerve)
label: b
answer: no
explanation: CNIX is the glossopharyngeal nerve. This supplies taste and general sensation to the posterior one-third of the tongue. The glossopharyngeal nerve also supplies the stylopharyngeal muscle, which raises and lowers the pharynx and larynx during speech and swallowing.
name: Cranial nerve IX (ninth cranial nerve)
label: a
answer: yes
explanation: CNX is the vagus nerve. This provides sensation to the external ear, larynx and pharynx, and controls the muscles of the pharynx, larynx and most of the gastro-intestinal tract. It does not provide input to the tongue.
name: Cranial nerve X (tenth cranial nerve)
label: e
answer: no
explanation: CNV is the trigeminal nerve. The mandibular branch of the trigeminal nerve supplies general sensation to the anterior two-thirds of the tongue, as well as the skin over the mandible and lower teeth. It also supplies the muscles of mastication.
name: Cranial nerve V (fifth cranial nerve)
label: c
answer: no
explanation: The hypoglossal nerve supplies motor input to the intrinsic and extrinsic muscles of the tongue. It carries no sensory fibres.
name: Cranial nerve XII (twelfth cranial nerve)
label: d
answer: no

Correct answer: a
A 78-year-old male presents following a stroke. Imaging reveals a left middle cerebral artery infarct.

Which of the following presenting features is most in line with the imaging findings?

Options:
explanation: The patient has had an infarction of his left middle cerebral artery which supplies the lateral aspect of the left hemisphere, and therefore Brocas (and Wernicke's) area which is responsible for language production and comprehension. An infarct to this area would result in an expressive aphasia characterised by partial loss of the ability to produce spoken and written language. They may lose their ability to comprehend speech if Wernicke's area is also affected, and would exhibit an increased work of speech.
name: Expressive aphasia
label: a
answer: yes
explanation: Motor control of the lower limbs is principally controlled by the medial aspect of the brain (outlined by the motor homunculus). The lower limbs are therefore more likely to be affected by an anterior cerebral artery infarct, whereas a middle cerebral artery infarct would affect the upper limbs more than the lower limbs.
name: Right-sided lower limb weakness
label: b
answer: no
explanation: A bitemporal hemianopia represents a loss in the peripheral visual field bilaterally. This may be caused by a stroke in rare circumstances, but is more commonly seen following the enlargement of a pituitary mass which presses on the optic chiasm.
name: Bitemporal hemianopia
label: c
answer: no
explanation: A middle cerebral artery infarction can result in a one-sided hemiplegia (affecting arms more than legs). However, this patient suffered a left-sided infarct, which would cause motor symptoms on the contralateral (right) side, making this answer incorrect.
name: Left-sided hemiplegia
label: d
answer: no
explanation: Dysdiadochokinesia is a sign of impaired coordination, typically due to cerebellar damage. It would not be seen as a result of a middle cerebral artery infarct.
name: Dysdiadochokinesia
label: e
answer: no

Correct answer: a