hllj/quesmed huggingface dataset:
A 75 year old male presents with a 2 week history of fatigue and night sweats. On admission, he had a transient episode of word finding difficulty which resolved within an hour. On auscultation of the chest, an opening click at S1 and an ejection systolic murmur is heard loudest at the apex. There are no residual neurological deficits. He has a past medical history of rheumatic heart disease and a prosthetic mitral valve replacement one year ago.

Serial blood cultures have been negative so far. Transoesophageal echocardiogram (TOE) showed no vegetations and a functional prosthetic mitral valve with no leaks or stenoses. He has been started on IV antibiotics for 2 weeks with persistently raised inflammatory markers. Which is the next best investigation to evaluate the underlying cause?

Options:
explanation: This may be useful in evaluating for malignancy or metastatic lesions, which is less likely given the 2 week history of constitutional symptoms
name: CT chest, abdomen, pelvis (CT CAP)
label: e
answer: no
explanation: This may be useful to evaluate for stroke, however the patient is likely to have experienced a transient ischaemic attack and the scan would most likely be unremarkable in the absence of any lasting neurological deficits. Cerebral infarcts may be one of the complications of infective endocarditis, but this investigation would not help in confirming the underlying diagnosis
name: CT brain
label: d
answer: no
explanation: There is a high suspicion of infective endocarditis in this patient given the history of prosthetic valve replacement. PET CT is useful in patients for whom the diagnosis of prosthetic valve endocarditis remains uncertain following echocardiography, allowing the anatomic localisation of infection
name: Positron emission computed tomography scan (PET CT)
label: a
answer: yes
explanation: Transoesophageal echocardiogram is superior to CTCA for detection of vegetations. CTCA is useful for coronary imaging in patients who require surgical intervention, or to detect paravalvular infection, abscess or pseudoaneurysms
name: CT coronary angiography (CTCA)
label: c
answer: no
explanation: This is likely to be of low yield as TOE has already been done. TOE has a higher sensitivity than TTE for the diagnosis of endocarditis and should be performed in the absence of contraindications
name: Transthoracic echo (TTE)
label: b
answer: no

Correct answer: a


Learning point: PET CT can help identify infective endocarditis when echocardiography is inconclusive.
Forest plots are often used to summarise the results of meta-analyses in a graphical form. An example is shown below:

[lightgallery]

Which of the following statements is true of a forest plot?

Options:
explanation: The diamond shows the pooled result of all the studies. The vertical line indicates the line of no effect, i.e. the point at which there is statistically no significant difference between the control and intervention group. The width of the diamond illustrates the length of the confidence interval. Therefore, if the diamond touches the vertical line, it means that the overall result is **not** statistically significant
name: If the diamond touches the solid vertical line, it indicates that the overall outcome is not statistically significant
label: a
answer: yes
explanation: The horizontal lines through the boxes illustrate the length of the confidence interval. A shorter line means that the confidence interval is very narrow, hence implying that the study is more reliable as there is a more precise estimate of effects. This is more likely to happen in larger studies with greater numbers of participants
name: A shorter horizontal line suggests that the study is less reliable
label: b
answer: no
explanation: A larger box would indicate a greater weight of that particular study in the pooled result. The horizontal lines through the boxes illustrate the length of the confidence interval; the longer the line, the wider the interval
name: A larger box indicates a wider confidence interval for the study
label: c
answer: no
explanation: Each box represents an individual study with the 95% confidence interval plotted as a horizontal line
name: Each box with a horizontal line represents the results of a collection of studies
label: d
answer: no
explanation: The interpretation would depend on whether the outcome of interest is desirable (e.g. cure) or adverse (e.g. death). If the outcome is desirable, results to the right of the vertical line will favour the treatment over the control
name: If the results are to the right of the vertical line, it would always indicate that they favour the treatment over the control group
label: e
answer: no

Correct answer: a


Learning point: In forest plots, if the diamond intersects the vertical line, the overall result is statistically non-significant.
A 60 year old male is admitted to the general medical ward with a 2 day history of atypical chest pain. Serial troponin levels are normal and ECG shows no dynamic changes. He is a current smoker and has a past medical history of childhood asthma.

His observations are as follows:

- Pulse 70
- BP 125/80
- SpO<sub>2</sub> 100%
- Temperature 36.5°C

Bloods are sent off for cardiovascular risk factor screening and are as follows:

- HbA1c 7.2%
- Fasting glucose 7.8
- Lipid panel unremarkable

Urine albumin creatinine ratio shows microalbuminuria.

He is started on metformin by the consultant on the ward round. Which other medication should be started?

Options:
explanation: This may be indicated for primary prevention of cardiovascular disease, however his lipid panel is normal
name: Atorvastatin
label: b
answer: no
explanation: This would be indicated for the management of essential hypertension in patients >55 years old or in Afro-Caribbeans. However, ACE inhibitors are specifically indicated for albuminuria in diabetes
name: Amlodipine
label: c
answer: no
explanation: Lisinopril is an angiotensin converting enzyme inhibitor (ACE inhibitor) which are the drug class of choice in preventing progression of albuminuria and diabetic nephropathy. They are superior to diuretics and calcium channel blockers in this case
name: Lisinopril
label: a
answer: yes
explanation: Glipizide is a sulphonylurea which may be indicated if he is unable to achieve adequate blood glucose control or is unable to tolerate the gastrointestinal side effects of metformin
name: Glipizide
label: e
answer: no
explanation: There is no indication to start aspirin in the absence of acute coronary syndrome
name: Aspirin
label: d
answer: no

Correct answer: a


Learning point: Lisinopril is the preferred medication for preventing progression of albuminuria and diabetic nephropathy in patients with diabetes and microalbuminuria.
A 53 year old lady is admitted with a 2 week history of bilateral lower limb swelling. Albumin is 21g/L (normal range 35-50 g/L) and she has proteinuria of 6.5g/24h. She is referred to the nephrologist who decides to get a renal biopsy. This reveals a diffusely thickened glomerular basement membrane with IgG and C3 subepithelial deposits.

Which of the following is the most likely underlying cause of her condition?

Options:
explanation: This is most likely to cause diabetic glomerulosclerosis, which shows Kimmelsteil-Wilson nodules (nodules of hyaline material) on biopsy
name: Diabetes mellitus
label: b
answer: no
explanation: This woman has nephrotic syndrome, characterised by oedema, proteinuria and hypoalbuminaemia. The thickened glomerular basement membrane with subepithelial deposits is characteristic of membranous nephropathy as a cause of her nephrotic syndrome. Causes of membranous nephropathy include autoimmune disease and infection such as hepatitis B and hepatitis C. A renal biopsy would show a spike and dome pattern on a silver stain
name: Hepatitis B virus
label: a
answer: yes
explanation: This is most likely to cause focal segmental glomerulosclerosis, which would show focal scarring and areas of collagen sclerosis
name: HIV
label: d
answer: no
explanation: This is most likely to cause mesangiocapillary glomerulonephritis, which may lead to nephrotic or nephritic syndrome. This would appear as double contouring of the capillary walls or a "tram track" appearance on electron microscopy
name: Cryoglobulinaemia
label: e
answer: no
explanation: This is most likely to cause minimal change glomerulonephritis, the most common cause of nephrotic syndrome in children. This would appear as podocyte effacement on electron microscopy
name: Lithium
label: c
answer: no

Correct answer: a


Learning point: Hepatitis B infection is associated with membranous nephropathy (MN), a kidney disorder characterized by the thickening of the glomerular basement membrane. The association occurs due to immune complex deposition in the kidneys, which can lead to proteinuria and nephrotic syndrome.
A 65-year-old woman presents to the emergency department with temporary word finding difficulty that lasted for 15 minutes, occurring approximately 2 hours ago. Past medical history includes hypertension and gastroesophageal reflux disease.

Observations on triage were:

- Temperature 36.5°C
- Pulse 90
- Blood pressure (BP) 170/85
- SpO2 98% on room air

An electrocardiogram shows non-valvular atrial fibrillation. On examination, she has no neurological deficits.

Which of the following is the next best step in initial management?

Options:
explanation: The main priority is to initiate antiplatelet treatment with aspirin. The blood pressure is not dangerously high at this point and she does not have any serious concomitant medical issues requiring strict BP control (e.g. hypertensive encephalopathy, nephropathy or cardiac failure). In patients with a TIA who have recovered to their neurologic baseline and have no other evidence of infarction, anti-hypertensive treatment may be reinitiated
name: Start amlodipine
label: c
answer: no
explanation: While this patient does have a history of gastroesophageal reflux, the priority is to start her on an antiplatelet therapy (i.e. aspirin). She may require a H2 receptor antagonist such as ranitidine as an adjunct
name: Start ranitidine
label: d
answer: no
explanation: This is only recommended in acute ischaemic stroke within 4.5 hours of onset, where intracranial haemorrhage has been excluded on brain imaging. In this case, the patient has a transient ischaemic attack which would not warrant this
name: Start alteplase
label: b
answer: no
explanation: The patient has suffered a transient ischaemic attack (TIA) on a background of non-valvular atrial fibrillation (AF). In this case, as AF is likely the underlying cause of the TIA, anticoagulation (rivaroxaban) is superior to aspirin in stroke prevention. Therefore, aspirin would not be the best choice in this scenario.
name: Start aspirin
label: a
answer: no
explanation: NICE recommend commencing anticoagulant in secondary care for people with ischaemic stroke or TIA and paroxysmal, persistent, or permanent atrial fibrillation or atrial flutter. The choice of anticoagulant is a DOAC in non-valvular AF. 
name: Start rivaroxaban
label: e
answer: yes

Correct answer: e


Learning point: In suspected transient ischaemic attack (TIA), immediate aspirin administration is recommended to reduce the risk of subsequent stroke.
A 29 year old female presents to the GP with a 5-day history of clouding of vision and difficulty differentiating colours. She has a past history of a 2-week period of left upper limb weakness that spontaneously resolved without intervention.

An MRI reveals several hyperintensities in the periventricular white matter at various regions.

What investigation is most likely to give a definitive diagnosis?

Options:
explanation: This patient has a history suggestive of multiple sclerosis, clinically isolated neurological deficits separated in time. The MRI confirmed several hyperintensities in the periventricular white matter. The next investigation is CSF examination, looking for the typical finding of oligoclonal bands, the presence of which gives a definitive diagnosis of MS
name: Lumbar puncture looking for oligoclonal IgG bands in the cerebrospinal fluid (CSF)
label: a
answer: yes
explanation: Anti-aquaporin 4 (AQP4) antibodies are specific for neuromyelitis optica spectrum disorders (NMOSD). Testing would be recommended in patients with long segments of spinal cord demyelination with or without optic neuritis, and in patients with recurrent optic neuritis with normal brain imaging
name: Testing for anti-aquaporin 4 (AQP4) antibodies
label: c
answer: no
explanation: Whilst fundoscopy should be considered in any patient with a new visual deficit, it would be unlikely to lead to a definitive diagnosis in the context of a history suggesting MS, with an abnormal MRI. Fundoscopy is likely to be normal in MS
name: Fundoscopy
label: e
answer: no
explanation: This patient has already undergone an MRI which has demonstrated white matter lesions separated in space. A CT head is not likely to provide further information, nor a definitive diagnosis
name: Computed tomography (CT) scan of the head
label: b
answer: no
explanation: While B12 deficiency can lead to neurological signs, it would not lead to abnormal findings on MRI, nor would symptoms resolve as spontaneously and rapidly
name: B12 level
label: d
answer: no

Correct answer: a


Learning point: Oligoclonal IgG bands in cerebrospinal fluid are a definitive diagnostic marker for multiple sclerosis.
A 25-year-old football player presents to Accident & Emergency with a sudden onset right-sided foot drop. X-rays of the right lower limb do not show any fractures. On examination, he cannot dorsiflex or evert his foot, but can plantarflex and invert his foot.

In view of the underlying diagnosis, which of the following examination findings will most likely be present in his right leg?

Options:
explanation: This would suggest an S1 radiculopathy, which would involve loss of plantarflexion, weakness of leg extension and knee flexion and loss of the ankle jerk reflex. Sensation would be reduced on the posterior aspect of the leg and the lateral edge of the foot
name: Loss of sensation on the lateral edge of the foot
label: e
answer: no
explanation: This would suggest a saphenous nerve lesion or L4 level lesion. The saphenous nerve is the largest branch of the femoral nerve, and entrapment may result in deep thigh ache, knee pain and paraesthesia of the anteromedial aspect of the leg
name: Loss of sensation on the medial aspect of the leg
label: c
answer: no
explanation: This would be present in a common peroneal nerve or L5 level lesion. The patient has suffered a common peroneal nerve lesion, the most common aetiologies of which are compression and trauma. Patients present with a loss of eversion and dorsiflexion (supplied by the common peroneal nerve), with intact inversion and plantarflexion (supplied by the tibial nerve). The common peroneal nerve also provides sensation to the anterolateral surface of the leg and dorsal aspect of the foot. Both the common peroneal and tibial nerve branches arise from the sciatic nerve
name: Loss of sensation on the dorsum of the foot
label: a
answer: yes
explanation: This would suggest a sciatic nerve lesion or S1 level lesion. Peripheral neuropathy and cauda equina syndrome may also result in a loss of the ankle jerk reflex; however, this is more likely to present with bilateral foot drop. In common peroneal nerve lesions, the ankle deep tendon reflex is intact
name: Absent ankle jerk
label: b
answer: no
explanation: This would suggest an L5 radiculopathy or anterior horn cell dysfunction, which would also present with loss of dorsiflexion and eversion, but would also affect foot inversion, internal rotation and abduction of the hip. Patients typically present with back pain radiating down the lateral aspect of the leg
name: Inability to internally rotate the hip
label: d
answer: no

Correct answer: a


Learning point: A common peroneal nerve lesion causes foot drop, loss of dorsiflexion, eversion, and sensory loss over the dorsum of the foot.
A 45-year-old woman develops a persistent headache of 4 days duration, not resolving with over the counter painkillers. She presented to Accident & Emergency with bilateral eye pain and blurred vision. At triage, she suffers a generalised tonic-clonic seizure which is terminated with one dose of IV lorazepam. Computed tomography (CT) brain was done immediately, which showed a large clot in the cavernous sinus.

Which is the next best step in acute management?

Options:
explanation: Direct oral anticoagulants can be considered for longer-term prophylaxis of venous thromboembolism
name: Dabigatran
label: e
answer: no
explanation: This patient has presented with cerebral venous sinus thrombosis, for which the initial management would be subcutaneous low molecular weight heparin
name: Low molecular weight heparin
label: a
answer: yes
explanation: Evidence suggests that low molecular weight heparin results in better outcomes than unfractionated heparin (UFH) for initial anticoagulation in cerebral venous sinus thrombosis. UFH may be considered in patients with renal impairment or those requiring very rapid reversal of anticoagulation, e.g. imminent surgical intervention
name: Unfractionated heparin
label: c
answer: no
explanation: In cerebral venous sinus thrombosis, recurrent seizures are more likely to develop in those who present with seizures and in those with supratentorial brain lesions on imaging. This would not be appropriate in the initial management, but may be considered later on for seizure prophylaxis
name: Valproate
label: b
answer: no
explanation: This may be considered after the acute stage for longer-term prophylaxis of further cerebral and extracerebral venous thrombosis (i.e. deep vein thrombosis, pulmonary embolism). It would not be appropriate to start warfarin acutely as it has prothrombotic activity on initiation
name: Warfarin
label: d
answer: no

Correct answer: a


Learning point: Cerebral venous sinus thrombosis is managed acutely with low molecular weight heparin to prevent further thrombus formation.
A 38 year old pregnant female at 32 weeks gestation presents to Maternity Triage with mild upper abdominal pain, vomiting and blurred vision. Her observations are normal, and cardiotocograph reveals no abnormalities with the foetus. Urinalysis is normal.

Which one of the following laboratory findings is most likely in HELLP (haemolysis, elevated liver enzymes, and low platelets) syndrome?

Options:
explanation: This is typical of glucose-6-phosphate dehydrogenase (G6PD) deficiency. In HELLP syndrome, the usual finding is schistocytes and burr cells, which are fragmented red blood cells indicating microangiopathic haemolytic anaemia
name: Peripheral blood film showing blister and bite cells
label: d
answer: no
explanation: Haptoglobin level is a specific marker of haemolysis, and a level of ≤25mg/dL would suggest haemolysis which occurs in HELLP syndrome
name: Low serum haptoglobin
label: a
answer: yes
explanation: In HELLP syndrome, LDH is typically elevated ≥600 IU/L, a non-specific marker associated with severe haemolysis or acute hepatocellular injury
name: Normal lactate dehydrogenase (LDH)
label: e
answer: no
explanation: In HELLP syndrome, the PT, APTT and coagulation screen are normal. If prolonged, this may suggest disseminated intravascular coagulation, which is one complication of HELLP syndrome
name: Prolonged prothrombin time (PT)/activated partial thromboplastin clotting time (APTT)
label: c
answer: no
explanation: This is a normal physiologic finding in pregnancy. In HELLP syndrome, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are typically elevated ≥2 times the upper limit of normal
name: Elevated ALP 2 times the upper limit of normal
label: b
answer: no

Correct answer: a


Learning point: In HELLP syndrome, low serum haptoglobin levels indicate haemolysis.
A 45-year-old woman presents to Accident & Emergency with a one-week history of persistent headache. She was worried as she started experiencing bilateral blurring of vision in the past day. She also reports hearing the sound of 'rushing water' in both ears. Fundoscopy reveals bilateral swelling of the optic discs.

The consultant reviews her and decides to start her on medication. What is the mechanism of action of the most likely drug used?

Options:
explanation: The most likely drug to be used here is acetazolamide, a carbonic anhydrase inhibitor. The patient has idiopathic intracranial hypertension, with the typical features of raised intracranial pressure (headache, tinnitus, papilloedema, visual loss). The treatment involves carbonic anhydrase inhibitors to decrease the rate of cerebrospinal fluid production
name: Carbonic anhydrase inhibitor
label: a
answer: yes
explanation: This is the mechanism of action of furosemide, which may be considered as an adjunct to acetazolamide
name: Inhibitor of the luminal Na-K-Cl cotransporter in the ascending loop of Henle
label: b
answer: no
explanation: This is the mechanism of action of sumatriptan, which may be used in the treatment of acute migraine. However, this would not be effective here as the headache is secondary to idiopathic intracranial hypertension
name: 5HT1 receptor agonist
label: e
answer: no
explanation: This is the mechanism of action of prednisolone. Steroids are not recommended for use in idiopathic intracranial hypertension as their withdrawal can cause severe rebound intracranial hypertension with visual loss, and may worsen weight gain, which is a risk factor for the condition. It may, however, be useful as a temporary measure prior to surgery in the setting of acute visual loss
name: Decreases inflammation via suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability
label: d
answer: no
explanation: This is the mechanism of action of ibuprofen, a nonsteroidal inflammatory drug that may be used for pain relief of migraines but would not be the treatment in this case
name: Reversible inhibitor of cyclooxygenase-1 and 2 (COX-1 and 2) enzymes
label: c
answer: no

Correct answer: a


Learning point: Carbonic anhydrase inhibitors, like acetazolamide, reduce cerebrospinal fluid production, aiding in the management of idiopathic intracranial hypertension.