hllj/quesmed huggingface dataset:
The team are discussing a patient who they believe has Creutzfeldt-Jakob disease (CJD) which is caused by misfolded proteins.

What are these proteins called?

Options:
explanation: These are immunoglobulin proteins that are present in multiple sclerosis.
name: Oligoclonal bands
label: e
answer: no
explanation: These are one of the proteins implicated in Alzheimer's disease.
name: Tau proteins
label: c
answer: no
explanation: These bind to DNA to hold it into the chromosome structure and are involved in controlling gene expression.
name: Histone proteins
label: d
answer: no
explanation: These are abnormally structured proteins that can trigger misfolding of normal proteins in the brain - resulting in neurodegenerative conditions.
name: Prions
label: a
answer: yes
explanation: These are the proteins that are seen in multiple myeloma.
name: Bence Jone Proteins
label: b
answer: no

Correct answer: a
A patient presents to GP with symptoms suggestive of Guilliain-Barre syndrome, affecting the lower motor neurones.

Which of the following is a sign of a lower motor neurone lesion?

Options:
explanation: This occurs in upper motor neurone lesions. Normal/absent plantar reflexes occur in lower motor neurone lesions.
name: Upgoing plantar reflexes
label: b
answer: no
explanation: This is similar to hyperreflexia as it is a hyperactive stretch reflex. Hyperreflexia occurs in upper motor neurone lesions. Decreased or absent reflexes occur in lower motor neurone lesions.
name: Clonus
label: c
answer: no
explanation: This occurs in upper motor neurone lesions. Decreased or absent reflexes occur in lower motor neurone lesions.
name: Hyperreflexia
label: e
answer: no
explanation: This occurs in upper motor neurone lesions. Decreased muscle tone and muscle weakness occur in lower motor neurone lesions.
name: Increased muscle tone
label: d
answer: no
explanation: This is the only sign of a lower motor neurone lesion on the list.
name: Fasciculations
label: a
answer: yes

Correct answer: a
You assess the hearing of a woman presenting with progressive left-sided hearing loss. The results of Rinne's and Weber's tests suggest she has left-sided sensorineural loss.

Which of these examination results would be supportive of this diagnosis?

Options:
explanation: These Rinne's test results are indicative of left-sided conductive hearing loss but Weber's test results would indicate normal hearing. In conductive hearing loss, Weber's test lateralises to the affected side.
name: Rinne's test left: bone conduction>air conduction
Rinne's test right: air conduction>bone conduction
Weber's test: No lateralisation
label: e
answer: no
explanation: In sensorineural hearing loss, Weber's test will lateralise to the unaffected side.
name: Rinne's test left: air conduction>bone conduction
Rinne's test right: air conduction>bone conduction
Weber's test: lateralises to left
label: c
answer: no
explanation: These would be the results in normal hearing.
name: Rinne's test left: air conduction>bone conduction
Rinne's test right: air conduction>bone conduction
Weber's test: No lateralisation
label: d
answer: no
explanation: In sensorineural hearing loss, air conduction is still better than bone conduction, as it is in normal hearing. However, Weber's test lateralises away from the affected side.
name: Rinne's test left: air conduction>bone conduction
Rinne's test right: air conduction>bone conduction
Weber's test: lateralises to right
label: a
answer: yes
explanation: These would be the results if the patient has left-sided conductive hearing loss.
name: Rinne's test left: bone conduction>air conduction
Rinne's test right: air conduction>bone conduction
Weber's test: lateralises to left
label: b
answer: no

Correct answer: a
A patient with a history of renal transplant, taking immunosuppressants, presents with pain and tingling in only the left side of his chest affecting his nipple.

Which of the following dermatomes is most likely affected?

Options:
explanation: This dermatomal level covers the medial aspect of the arms.
name: T1
label: e
answer: no
explanation: This is the dermatomal level below the one of the nipples.
name: T5
label: c
answer: no
explanation: This dermatomal level is approximately the level of the xiphisternum.
name: T7
label: d
answer: no
explanation: The area of skin with the nipples is typically the dermatomal level T4. However, this may not always be the case in some women.
name: T4
label: a
answer: yes
explanation: This is the dermatomal level associated with the umbilicus.
name: T10
label: b
answer: no

Correct answer: a
A patient has just been diagnosed with medial epicondylitis.

Which of the following movements will they most likely find painful?

Options:
explanation: This would occur in lateral epicondylitis as the wrist extensors originate from the lateral epicondyle.
name: Wrist extension
label: b
answer: no
explanation: The muscles involved in supination - supinator and biceps brachii- do not originate from the medial epicondyle
name: Supination
label: c
answer: no
explanation: The forearm flexor muscles originate from the medial epicondyle and so overuse causes medial epicondylitis, causing pain on wrist flexion.
name: Wrist flexion
label: a
answer: yes
explanation: This is done by the rotator cuff muscles located at the shoulder joint, and so would not be impacted by medial epicondylitis.
name: Shoulder external rotation
label: e
answer: no
explanation: This is done by the rotator cuff muscles located at the shoulder joint, and so would not be impacted by medial epicondylitis.
name: Shoulder internal rotation
label: d
answer: no

Correct answer: a
You are observing a cardiac arrest and, as part of the protocol, the patient is given IV adrenaline.

Which of these is an effect of adrenaline?

Options:
explanation: This is a side effect of amiodarone, not adrenaline.
name: Thyroid dysfunction
label: e
answer: no
explanation: Adrenaline acts on the beta-2 adrenergic receptors in the lungs to cause bronchodilation.
name: Bronchospasm
label: c
answer: no
explanation: It acts on the beta-1 adrenergic receptors in the heart to increase the firing rate of the sinoatrial node.
name: Increased heart rate
label: a
answer: yes
explanation: Adrenaline increases blood glucose by stimulating glycogenolysis in the liver, and skeletal muscles and gluconeogenesis in the liver.
name: Hypoglycaemia
label: b
answer: no
explanation: This can be caused by steroids. Adrenaline is more likely to cause anxiety.
name: Drug-induced psychosis
label: d
answer: no

Correct answer: a
A 70-year-old gentleman with a history of heart attack presents with symptoms suggestive of left-sided heart failure.

Which of these is a symptom more suggestive of left-sided heart failure, as opposed to right-sided heart failure?

Options:
explanation: This is a sign of right-sided heart failure due to backing up of blood into the inferior vena cava causing fluid accumulation in the liver.
name: Hepatomegaly
label: c
answer: no
explanation: This is a sign of macrocytic anaemia which occurs in B12 or folate deficiency, hypothyroidism and chronic alcohol use. Anaemia associated with heart failure is more likely to be microcytic or normocytic.
name: Pins and needles
label: d
answer: no
explanation: This is a sign of pulmonary oedema, which occurs in left-sided heart failure because the blood backs up into the pulmonary veins from the left heart chambers.
name: Shortness of breath worse when lying flat
label: a
answer: yes
explanation: This is a sign of right-sided heart failure due to backing up of blood into the superior and inferior vena cavas, causing fluid to leak out of blood vessels into peripheral tissues.
name: Bilateral pedal oedema
label: e
answer: no
explanation: This is a sign of right-sided heart failure due to backing up of blood into the superior vena cava.
name: Raised jugular venous pressure (JVP)
label: b
answer: no

Correct answer: a
A 45-year-old man is on the ward with advanced colorectal cancer. He explains to you that he has an inherited condition that puts him at significantly higher risk of bowel cancer called familial adenomatous polyposis.

Which of the genes is mutated in this condition?

Options:
explanation: This is associated with an increased risk of breast and ovarian cancers.
name: BRCA 1
label: c
answer: no
explanation: This is a fusion gene caused by a translocation between chromosomes 9 and 22 and is associated with chronic myeloid leukaemia.
name: BCR-ABL1
label: d
answer: no
explanation: Mutation of this gene causes cystic fibrosis
name: CFTR
label: e
answer: no
explanation: This is associated with Lynch syndrome/hereditary non-polyposis colorectal cancer, which is also associated with colorectal cancer.
name: MSH2
label: b
answer: no
explanation: This APC gene codes for a tumour suppressor protein. When the gene is mutated, this function is lost, increasing the risk of cancer.
name: APC (adenomatous polyposis coli)
label: a
answer: yes

Correct answer: a
You are reviewing a neonate born two hours ago. The baby is unresponsive and floppy. You assess for danger and then approach to assess for breathing. There are no breath sounds so you call for help, and open the airway. You cannot see any obvious obstruction.

What is the next best step?

Options:
explanation: This should be done during the paediatric basic life support algorithm. However, that should not be done prior to rescue breaths and should not delay starting chest compressions.
name: Attach defibrillator
label: e
answer: no
explanation: This is the next step after five rescue breaths in paediatric basic life support. However, additionally, as this child is a neonate, it may be that the neonatal ward uses a 3:1 ratio of chest compressions to rescue breaths.
name: 15 chest compressions
label: c
answer: no
explanation: In the paediatric basic life support, algorithm the first step is 5 rescue breaths. Two rescue breaths are done between each set of chest compressions. However, additionally, as this child is a neonate, it may be that the neonatal ward uses a 3:1 ratio of chest compressions to rescue breaths.
name: Two rescue breaths
label: b
answer: no
explanation: In paediatric basic life support, 15 chest compressions are done at a time, or three chest compressions at a time in neonatal life support.
name: 30 chest compressions
label: d
answer: no
explanation: In children, the most likely trigger for cardiac arrest is due to a respiratory cause and so rescue breaths are the priority in paediatric basic life support.
name: Five rescue breaths
label: a
answer: yes

Correct answer: a
A 25-year-old female presented with sudden onset left iliac fossa pain and a transvaginal ultrasound shows an ectopic pregnancy.

Which site are ectopic pregnancies most commonly found?

Options:
explanation: Ectopic pregnancies can occur in previous caesarean-section scars, but this is much rarer than in the fallopian tubes and can only occur in women who have previously had a section.
name: Caesarean-section scar
label: c
answer: no
explanation: This is the part of the fallopian tube closest to the uterine cavity. Ectopic pregnancies can occur in this part of the fallopian tube but less frequently than in the ampulla.
name: Interstitium of the fallopian tube
label: d
answer: no
explanation: Ectopic pregnancies can occur in this part of the fallopian tube but less frequently than in the ampulla. However, this is the most common site of ectopic pregnancy rupture.
name: Isthmus of the fallopian tube
label: b
answer: no
explanation: This is the part of the fallopian tube furthest from the uterine cavity. Ectopic pregnancies can occur here, but less frequently than in the ampulla.
name: Fimbrae of the fallopian tube
label: e
answer: no
explanation: The majority of ectopic pregnancies occur in this part of the fallopian tube.
name: Ampulla of the fallopian tube
label: a
answer: yes

Correct answer: a
A 75 year old male with a past medical history of COPD presents to the emergency department with worsening breathlessness, wheezing and a productive cough with green sputum.

His vital signs are taken:

>Respiratory rate: 22 breaths per minute
>
>Oxygen Saturations 87% on air
>
>Blood pressure 95/60mmHg
>
>Heart rate 110 beats per minute
>
>Temperature 38.7ºC
>
>Alert

Infective exacerbation of COPD and Sepsis is suspected.

Which of the following is least appropriate in the initial management?

Options:
explanation: This is important to identify the causative organism so the most effective antibiotic can be given.
name: Take blood cultures
label: c
answer: no
explanation: The aim is to keep saturations above 94%.

However, people with moderate to severe COPD naturally have a degree of hypercapnia and are unable to respond to this as a respiratory driver. They therefore relay on hypoxia as a respiratory driver. In these cases saturations should be maintained between 88-92% to maintain a respiratory drive.

Oxygen is important to avoid organ damage due to hypoxia.
name: Administer oxygen
label: b
answer: no
explanation: Infective exacerbation of COPD is suspected due to the previous diagnosis of COPD and features of infection such as pyrexia and green sputum. Sepsis can be diagnosed as there is a suspected infection + more than 2 out of the 4 criteria for systemic inflammatory response syndrome (SIRS): fever, tachycardia and tachypnoea. The other being white blood cell count which is unknown.

CRP can be performed as part of the work up to determine the degree of inflammation in the body and to monitor the response to treatment overtime but is not essential within the first hour of diagnosis.
name: Take blood CRP
label: a
answer: yes
explanation: Lactate can be a marker of tissue hypoperfusion. The more raised the worse the prognosis.

A level over 4mmol indicates severe sepsis with a poorer prognosis.
name: Take blood Lactate
label: e
answer: no
explanation: Sepsis patients usually have a low blood pressure. IV fluids are important to increase the blood pressure to allow blood supply to vital organs.
name: Administer IV fluids
label: d
answer: no

Correct answer: a
10 year old girl presents to the emergency department pale and clammy with wheeze, severe shortness of breath and some tongue swelling. This began within an hour of recieving her first dose of penecillin for a tonsolitis.

Mother is distressed and cannot recall whether she has had penecillin before.

Anaphylaxis is suspected and 300mcg of adrenaline is given.

Which of these can be tested within 4 hours of symptom onset to confirm the diagnosis of anaphylaxis?

Options:
explanation: This is the predominant antibody in a primary response to a viral or bacterial infection. It is not routinely tested for.
name: IgM
label: c
answer: no
explanation: If raised, this can indicate inflammation in the body. It can help monitor conditions with a high level of inflammation such as Inflammatory Bowel Disease and Arthritis.
name: ESR
label: d
answer: no
explanation: This can help diagnose anaphylaxis but is rarely performed as the blood test must be processed extremely quickly after collection.
name: Histamine
label: e
answer: no
explanation: This protein is released during activation of mast cells and levels will increase in anaphylaxis. Important to consider if this is the first episode of anaphylaxis as it can mimic other emergencies such as asthma.

This should be taken 1-2 hours after symptom onset and no longer than 4 hours after.

Confirms diagnosis if positive and helps to assist in correct treatment and minimisation of risk for future infections. Negative result does not exclude diagnosis.

Should be tested for in a follow-up to measure baseline.
name: Mast cell tryptase
label: a
answer: yes
explanation: This antibody is found raised in blood in type 1 hypersensitivity reactions.

These include atopic diseases such as asthma, hayfever and eczema. It can also be raised allergies/anaphylaxis but is not specific to this.

However, allergen-specific IgE antibodies to an allergen such as penicillin can be tested for. A positive test only indicates sensitisation and may not indicate allergy as re-exposure does not always cause symptoms.
name: IgE
label: b
answer: no

Correct answer: a
A 60 year old female presents to the GP suffering from pain and stiffness in her hands, wrists and knees. She has noticed more weakness and fatigue that are getting her down.

Rheumatoid arthritis is suspected and an X-ray showing typical features along with a positive anti-CCP supports this diagnosis.

She is wanting to know more about the cause of her condition. You explain it is an autoimmune condition where immune complexes deposit onto tissues causing inflammation and the symptoms she is experiencing.

What hypersensitivity reaction is this?

Options:
explanation: Mediated by IgE. These antibodies first increase when exposed to the antigen for the first time/ known as sensitisation. They attach to mast cells so that when the allergen is encountered again histamines are released by the mast cells producing signs and symptoms of allergy.

Onset within minutes.

These include allergies, and atopic diseases such as asthma, hayfever and eczema.
name: Type I
label: b
answer: no
explanation: Antibody-mediated cytotoxic reaction. Antibodies are specific to a cell surface that directly bind and cause damage.

Onset can be hours to days.

This can be in autoimmune haemolytic anaemia and haemolytic disease of the newborn.
name: Type II
label: c
answer: no
explanation: Antigen-antibody complexes deposit into tissues causing activation of the classical
complement system. this activates immune cells that release enzymes and free radicals that cause tissue damage.

Onset can be hours to weeks.

This can be seen in rheumatoid arthritis, post-streptococcal glomerulonephritis and serum sickness.
name: Type III
label: a
answer: yes
explanation: There is no type 6 hypersensitivity reaction.
name: Type VI
label: e
answer: no
explanation: T- cell-mediated. When first exposed, the T cells are activated and sensitised to the antigen so that when they are exposed again there will be an inflammatory response.

Delayed hypersensitivity; typically occurs 24-48 hours after exposure to the antigen.

Local inflammation and damage are caused such as in contact dermatitis and the Mantoux test for Tuberculosis.
name: Type IV
label: d
answer: no

Correct answer: a
44 year old male attends a sexual health clinic after 30 occasions of unprotected sexual intercourse over 12 months.

He describes feeling 'not quite right' for 1 week with headaches, general body aches and a sore throat.

He undergoes a full sexual health screen and the results are shown below:

>HIV NAAT test for viral load positive
>
>Syphilis antibody negative
>
>Gonorrhoea and Chlamydia urine NAAT negative
>
>Hepatitis B surface antigen negative

He is commenced on anti-retroviral therapy (ART) for HIV infection - what is the aim of this treatment?

Options:
explanation: HIV is the human immunodeficiency virus that attacks T helper cells/ CD4+ cells in the blood. Therefore the number declines in HIV.

This increases the risk for opportunistic infections such as Herpes Simplex Virus.

By increasing the T helper cells, it minimises the risk of infection and complications that can result from these.

This patient is presenting with an acute illness of HIV which usually occurs 1-6 weeks after infection. This is described as flu-like and is a result of seroconversion.
name: Normal CD4+ count and undetectable viral load
label: a
answer: yes
explanation: Seroconversion is when antibodies are produced in the blood in response to HIV infection. This is usually between 1-6 weeks following exposure.

Once seroconversion has started HIV infection cannot be stopped/ cured. The aim is to then maintain CD4+ count and reduce HIV viral load

However, if ART is used within 72 hours of possible exposure it is called post-exposure prophylaxis (PEP) and can prevent seroconversion and HIV infection.

The second part of the answer is correct - viral load should be undetectable so that it is not transmitted to other sexual partners.
name: Stop seroconversion
label: e
answer: no
explanation: This is important in anti-retroviral therapy as these are the cells targeted in HIV infection.

However, the aim is to also lower HIV viral load completely so that it is not detected in the blood. This is so that it is not transmitted to other sexual partners.
name: Normal CD4+ count
label: c
answer: no
explanation: Aims of the treatment are to increase CD4+ cells to prevent opportunistic infections.

It is important to treat infections that develop and therefore lower CRP in this way. However, anti-retroviral therapy aims to stop the attack of CD4+ cells and therefore increase these numbers.

The second part of the answer is correct - viral load should be undetectable so that it is not transmitted to other sexual partners.
name: Normal CRP level and undetectable viral load
label: b
answer: no
explanation: HIV is the human immunodeficiency virus that attacks T helper cells/ CD4+ cells in the blood, not T killer cells/ CD8+ cells.

The second part of the answer is correct - viral load should be undetectable so that it is not transmitted to other sexual partners.
name: Normal CD8+ count and undetectable viral load
label: d
answer: no

Correct answer: a
A 60 year old diabetic female presents to the GP with a 3-day history of a red, swollen, painful right knee.

On examination, there is limited movement in the knee due to the pain associated. The GP notices that it is warm to touch as he tries to mobilise it.

She is systematically well and there are no signs of sepsis.

The GP suspects septic arthritis.

Joint aspiration is carried out and was sent for Gram stain, leucocyte count, polarising microscopy and fluid culture.

Fluid culture shows aerobic gram-positive cocci in clumps. A coagulase test is carried out which is positive. What organism is this likely to be?

Options:
explanation: This is also an aerobic gram-positive bacteria. However, the cocci are arranged in pairs or 'string of beads'.

Just think of strep as in strip - they arrange themselves into strips.
name: *Streptococcus pyogenes*
label: c
answer: no
explanation: This is an aerobic, gram-positive organism which is arranged in clumps of spheres/ cocci. However, this would test negative on a coagulase test.

The coagulase test is done by identifying the presence of bound coagulase or clumping factor on the wall of the bacteria.

Coagulase-negative Staphylococci commonly live on the skin and don't tend to cause infection unless someone is immunocompromised.
name: *Staphylococcus Epidermis*
label: d
answer: no
explanation: This is a gram-negative bacteria.
name: *Neisseria Gonnorhoea*
label: e
answer: no
explanation: This is an Aerobic, gram-positive organism which is arranged in clumps of spheres/ cocci.

This is the most common cause of septic arthritis. The main aim of this question is to identify which bacteria are gram-negative/ positive and which are aerobic and anaerobic. You are not expected to know about septic arthritis.
name: *Staphylococcus Aureus*
label: a
answer: yes
explanation: This is a gram-negative bacteria that cause UTI. This bacteria can also cause septic arthritis but is ruled out by the joint culture.
name: *Escherichia coli*
label: b
answer: no

Correct answer: a