hllj/quesmed huggingface dataset:
A 55-year-old female is diagnosed with a malignant melanoma after noticing a brown asymmetrical lesion on the sole of her foot. She is keen to learn more about her prognosis.

Which of the following is the primary prognostic indicator of melanoma?

Options:
explanation: Duke’s classification is used for the staging of colorectal cancer. It measures the depth of invasion of the tumour through the mucosa and bowel wall. It is not a helpful prognostic indicator of malignant melanoma.
name: Duke’s classification
label: c
answer: no
explanation: Histology is used to diagnose malignant melanoma, and Breslow thickness is used to measure the depth of the tumour. Breslow thickness is a strong predictor of outcome for malignant melanoma. If Breslow thickness is more than 1mm, a sentinel node biopsy should be carried out which will look for any evidence of metastases and the stage of the cancer.
name: Breslow thickness
label: a
answer: yes
explanation: Ann Arbor staging is the system used to stage both Hodgkin's and non-Hodgkin’s lymphoma. It is not a helpful prognostic indicator of malignant melanoma.
name: Ann Arbor staging
label: e
answer: no
explanation: The Barthel index is a scale that measures a patient’s functional independence by looking at their ability to perform Activities of Daily Living (ADL’s). Although a higher level of functional independence is generally associate with better outcomes, it is not a specific prognostic indicator in malignant melanoma.
name: Barthel index
label: b
answer: no
explanation: The Waterlow score is used to estimate a patient’s risk of developing a pressure sore. It is not a helpful prognostic indicator of malignant melanoma.
name: Waterlow score
label: d
answer: no

Correct answer: a
A 16-year-old male attends the emergency department with lip and tongue swelling that began 20 minutes ago. He is in noticeable distress and is finding it increasingly more difficult to breathe. On examination, his heart rate is 120, and his blood pressure 89/60.

Which type of hypersensitivity reaction is he experiencing?

Options:
explanation: Type 3 hypersensitivity reactions are immune complex-mediated. Examples of Type 3 Hypersensitivity reactions include serum sickness, post-streptococcal glomerulonephritis, and extrinsic allergic alveolitis. By contrast, symptoms of anaphylaxis as demonstrated by this patient are characteristic of a type 1 hypersensitivity reaction.
name: Type 3
label: b
answer: no
explanation: Type 4 hypersensitivity reactions are also known as delayed hypersensitivity. They are T cell-mediated rations. Examples of type 4 include TB, graft versus host disease, allergic contact dermatitis, scabies, Multiple sclerosis, and Guillain-Barré syndrome. By contrast, symptoms of anaphylaxis as demonstrated by this patient are characteristic of a type 1 hypersensitivity reaction.
name: Type 4
label: e
answer: no
explanation: This question describes a patient with clinical features of anaphylaxis: swollen lips and tongue, wheezing, shortness of breath, tachycardia, hypotension, urticaria, pruritus, and flushed skin. Anaphylaxis is an example of a Type 1 hypersensitivity reaction. These reactions occur when the antigen reacts with IgE bound to mast cells. Another example of a type 1 hypersensitivity reaction is atopy (asthma, eczema, and hay fever).
name: Type 1
label: a
answer: yes
explanation: Examples of type 5 hypersensitivity reactions include Grave’s disease and myasthenia gravis. These types of reactions occur when antibodies recognize and bind to cell surface receptors, which causes either stimulation or blockage of ligand binding. By contrast, symptoms of anaphylaxis as demonstrated by this patient are characteristic of a type 1 hypersensitivity reaction.
name: Type 5
label: d
answer: no
explanation: Type 2 hypersensitivity reactions are cell-bound. They occur when IgG or IgM binds to a cell surface antigen. Examples of type 2 hypersensitivity reactions include autoimmune haemolytic anaemia, Goodpasture’s syndrome, and rheumatic fever. By contrast, symptoms of anaphylaxis as demonstrated by this patient are characteristic of a type 1 hypersensitivity reaction.
name: Type 2
label: c
answer: no

Correct answer: a
A 41-year-old male presents to the GP with a productive cough and shortness of breath. On examination, his temperature is 38.8 degrees.

Which of the following cell types are responsible for increasing body temperature?

Options:
explanation: Neutrophils are the most abundant of white blood cells and play an important role in fighting early stages of bacterial infections. They kill rapidly dividing bacteria. They are phagocytic and produce cytokines.
name: Neutrophils
label: b
answer: no
explanation: Eosinophils defend against protozoan and parasitic infections. They would not be responsible for increasing body temperature in this case.
name: Eosinophils
label: e
answer: no
explanation: Macrophages are responsible for increasing body temperature in fevers. They also act as antigen presenting cells and are involved in phagocytosis of cellular debris and pathogens.
name: Macrophages
label: a
answer: yes
explanation: Mast cells are responsible for triggering the inflammatory response. They are present in tissues and in a similar way to basophils, release histamine during the allergic response. They also express IgE receptors on their cell surfaces.
name: Mast cells
label: d
answer: no
explanation: Basophils release histamine and trigger allergic reactions. They express igE receptors on their cell surface. They have a Bi-lobed nucleus.
name: Basophils
label: c
answer: no

Correct answer: a
A 30-year-old pregnant woman attends the emergency department with left leg pain and swelling. An ultrasound doppler demonstrates a deep vein thrombosis. She is treated with low molecular weight heparin (LMWH).

Which of the following correctly describes the mechanism of action of LMWH?

Options:
explanation: This is the mechanism of action of warfarin, an oral anticoagulant used as first-line management of VTE for many years, before being surpassed by the use of direct oral anticoagulants (DOACs). Nowadays, warfarin use is indicated in patients with mechanical heart valves and as a second line after DOACs. This does not describe the mechanism of action of LMWH, which activates antithrombin 3.
name: Inhibits epoxide reductase
label: e
answer: no
explanation: This describes the mechanism of action of statins, not low molecular weight heparin. HMG-CoA reductase is the enzyme involved in hepatic cholesterol synthesis, which reduces the production of low-density lipoprotein (LDL) cholesterol In the blood. This does not describe the mechanism of action of LMWH, which activates antithrombin 3.
name: Inhibit HMG-CoA reductase
label: b
answer: no
explanation: This describes the mechanism of clopidogrel, an antiplatelet agent used in the management of cardiovascular disease. This does not describe the mechanism of action of LMWH, which activates antithrombin 3.
name: Antagonist of ADP receptor
label: d
answer: no
explanation: This is the mechanism of action of isoniazid, a drug given for tuberculosis. This does not describe the mechanism of action of LMWH, which activates antithrombin 3.
name: Inhibits mycolic acid synthesis
label: c
answer: no
explanation: This is the correct answer. LMWH activates antithrombin III, and then forms a complex that inhibits factor Xa. This brings about an anticoagulant effect. This means that LMWH can be monitored through anti-factor Xa, although routine monitoring is not usually required.
name: Activates antithrombin 3
label: a
answer: yes

Correct answer: a
A 50-year-old male presents to the GP with a red, painful right shin that began a week ago. He reports feeling unwell with a high temperature for the past 3 days.  The GP suspects cellulitis and the patient is treated with a course of clindamycin.

Which of the following correctly describes the mechanism of action of clindamycin?

Options:
explanation: Antibiotics like Metronidazole work by damaging DNA. Clindamycin does not work in this way but instead works by inhibiting protein synthesis.
name: Damages DNA
label: d
answer: no
explanation: This is the mechanism of action of sulphonamides and trimethoprim. Clindamycin does not work in this way but instead works by inhibiting protein synthesis.
name: Inhibits folic acid formation
label: c
answer: no
explanation: Antibiotics like Rifampicin work by inhibiting the synthesis of RNA. Clindamycin does not work in this way but instead works by inhibiting protein synthesis.
name: Inhibits RNA synthesis
label: e
answer: no
explanation: There are various classes of antibiotics that work by inhibiting cell wall formation. Some interrupt peptidoglycan cross-linking (penicillin and cephalosporins) and others inhibit peptidoglycan synthesis (glycopeptides like vancomycin). Clindamycin does not work in this way but instead works by inhibiting protein synthesis.
name: Inhibits cell wall formation
label: b
answer: no
explanation: This is the correct answer. Clindamycin inhibits protein synthesis by acting on the ribosome. Other antibiotics that act in the same way include: macrolides, aminoglycosides and tetracycline.
name: Inhibits protein synthesis
label: a
answer: yes

Correct answer: a
A 75-year-old female attends the emergency department after accidentally taking too much of her regular medication. She is keen to know for how long the medication will remain in her bloodstream.

Which of the following statements is correct about zero order kinetics?

Options:
explanation: This is incorrect. In zero-order reactions, the half-life can vary. In fact, the half-life will get longer as the concentration of the drug increases.
name: The half life is always constant
label: d
answer: no
explanation: This is incorrect. Phenytoin works by pseudo-zero order reactions. This means that at high concentrations the elimination process is saturated, and processing appears similar to zero-order reactions in which the rate of the reaction is independent of the drug concentration. However, at lower concentrations, the process is not saturated and the reaction appears like first-order reactions. Here, the rate of the reaction is proportional to the concentration of the reactant.
name: Phenytoin works by zero order reactions
label: b
answer: no
explanation: This is the correct answer. Zero-order reactions have a rate of elimination that is independent of the drug concentration.
name: The rate of degradation is independent of the plasma concentration
label: a
answer: yes
explanation: This is incorrect. Zero-order reactions are rare. The most common order of elimination is first-order reactions, whereby the half-life is constant, and the rate of elimination increases with plasma concentration.
name: It is the most common order of elimination
label: e
answer: no
explanation: This answer is incorrect. The rate of degradation does not rely on the concentration of the reactant in zero-order reactions.
name: The rate of degradation is dependent on the concentration of reactant
label: c
answer: no

Correct answer: a
A 29-year-old pregnant female attends a routine 28-week antenatal appointment. She is keen to know more about the foetal immune system. The midwife explains that there are five different types of immunoglobulin found in the body, but only one can cross the placenta to reach the foetal circulation.

Which of the following immunoglobulins can cross the placenta?

Options:
explanation: IgA is the most predominant immunoglobulin found in breast milk. It can also be found in secretions of the digestive, respiratory and urogenital systems. The other role of IgA is to provided protection on cell mucus membranes. It does not pass into the foetal circulation.
name: IgA
label: b
answer: no
explanation: IgE is associated with Type 1 Hypersensitivity reactions. It is synthesized by plasma cells and provides immunity to parasites such as helminths. It is not typically seen in foetal circulation.
name: IgE
label: c
answer: no
explanation: This immunoglobin is the only type that is able to pass into the foetal circulation. IgG is also involved in the phagocytosis of bacteria and viruses, and is the most abundant type of immunoglobulin found in the blood serum.
name: IgG
label: a
answer: yes
explanation: IgG is the immunoglobulin involved in activation of B cells. It cannot cross the placenta.
name: IgD
label: e
answer: no
explanation: IgM cannot pass into fetal circulation. However, it does fix to complement in a similar way to IgG. The defining feature of IgM is that it is the first immunoglobulin to be secreted in response to infection. It is secreted as a pentamer.
name: IgM
label: d
answer: no

Correct answer: a
A 21-year-old male requires an emergency blood transfusion after arriving in the emergency department following a road traffic collision. He has never received a blood transfusion before, and his blood group is unknown.

Which of the following blood types can he receive?

Options:
explanation: Group O blood can be universally donated, so is the most appropriate choice for a patient with an unknown blood group. Group O blood does not contain any A or B antigens on its surface, and therefore no circulating antibodies, which prevents an immune reaction from occurring.
name: Group O
label: a
answer: yes
explanation: We cannot give this patient group B blood as we do not know this patient’s blood group. The only blood group that he can receive is group O blood. This is because group O blood does not contain any A or B antigens or antibodies, and therefore whatever blood group this patent happens to be, we know there will be no transfusion reaction. By contrast, Group B blood has B antigens on the red blood cell surface and anti-A antibodies in the plasma.
name: Group B
label: d
answer: no
explanation: We haven’t been told this patient’s blood group. Therefore, the only blood group that can be donated to them is group O blood. Group O blood does not contain any A or B antigens or antibodies, so will not react with any blood groups. By contrast, Group A blood has A antigens on the red blood cell surface and anti-B antibodies in the plasma.
name: Group A
label: b
answer: no
explanation: We cannot transfuse group AB blood as we do not know this patient’s blood group. Therefore, the only blood group we are able to donate at this point will be group O blood.
name: Group AB
label: c
answer: no
explanation: We can only donate group O blood to this patient. This is because group O blood does not contain any A or B antigens and therefore it is the only blood group that can be universally donated. If this patient had group B blood and we gave them group A blood, their anti- A antibodies will attack the group A cells.
name: Group A and O
label: e
answer: no

Correct answer: a
An 8-year-old female attends her GP surgery with recurrent haemarthrosis. She undergoes multiple blood tests and is diagnosed with haemophilia A.

Which of the following clotting factors is the patient deficient in?

Options:
explanation: A deficiency in clotting factor IX would mean the patient has haemophilia B, not haemophilia A.
name: IX
label: c
answer: no
explanation: Factor X deficiency would mean the patient had a rare genetic bleeding disorder. Haemophilia A is a deficiency in factor VIII.
name: X
label: d
answer: no
explanation: Haemophilia A is deficiency in factor VIII rather than factor XI.
name: XI
label: e
answer: no
explanation: Factor 7 deficiency would mean the patient has a rare genetic bleeding disorder, known as Alexander’s disease, not haemophilia A. Deficiency in factor VII would cause nosebleeds, easy bruising, prolonged bleeding following physical injury or surgery. It would rarely cause bleeding into joint spaces.
name: VII
label: b
answer: no
explanation: Haemophilia A is caused by a deficiency of clotting factor VIII, an important part of the intrinsic component of the coagulation cascade. Haemophilia A typically presents with severe bleeding into soft tissues, muscles, and joints, and is diagnosed with a factor VIII assay.
name: VIII
label: a
answer: yes

Correct answer: a
An 81-year-old female presents to the emergency department with severe back pain. On further investigation, you discover she has normocytic anaemia, raised serum creatinine, and a high calcium level. X-ray shows a fracture of the left femur.

Which of the following is the most likely diagnosis?

Options:
explanation: This does not fit with the clinical picture described. Stress fractures often occur after low-grade repetitive stress to a joint. Anaemia and hypercalcaemia are not typically seen.
name: Stress fracture
label: c
answer: no
explanation: Sarcoidosis would present differently from the clinical picture described. Acute sarcoidosis presents with fever, joint pains, erythema nodosum, and bilateral hilar lymphadenopathy. Chronic sarcoidosis is characterised by pulmonary symptoms such as a dry cough, dyspnoea, reduced exercise tolerance, and crepitations on examination.
name: Sarcoidosis
label: d
answer: no
explanation: Osteosarcoma is a type of bone cancer typically found in children or young adults. X-ray would commonly find a 'sunburst' pattern.
name: Osteosarcoma
label: b
answer: no
explanation: This is a typical presentation of multiple myeloma. The clinical features can be remembered with the mnemonic CRABI: hypercalcemia, renal impairment, anaemia, bone pathology, and infections.
name: Multiple myeloma
label: a
answer: yes
explanation: Acute myeloid leukaemia (AML) can present with some similar features to multiple myeloma, for example, symptoms of bone marrow failure like anaemia and frequent infections. However, AML commonly involves examination findings such as hepatomegaly, splenomegaly or gum hypertrophy. By contrast, hypercalcaemia and back pain point towards a diagnosis of multiple myeloma.
name: Acute myeloid leukaemia
label: e
answer: no

Correct answer: a
A 28-year-old man presents to the emergency department with pleuritic chest pain and shortness of breath that began 6 hours ago. On further questioning, he also reports bringing up small flecks of bright red blood when coughing. He has recently begun a course of chemotherapy for renal carcinoma.

On examination, he has a heart rate of 107 and respiratory rate of 20. His oxygen saturations are 88%.

Which of the following ECG findings is the most likely to be seen?

Options:
explanation: This presentation is most likely to be a pulmonary embolism (PE). ST depression is not an ECG finding typically seen in PE. It is indicative of cardiac ischaemia.
name: ST depression
label: e
answer: no
explanation: The presence of U waves on ECG is characteristic of hypokalaemia. U waves would be seen as a deflection immediately following the T wave. Hypokalaemia may present with symptoms such as muscle cramps, dizziness, polyuria, polydipsia, and in severe cases, arrhythmias. This history gives no indication of hypokalaemia. This presentation is most likely to be a pulmonary embolism (PE).
name: U waves
label: c
answer: no
explanation: This is a relatively uncommon ECG finding in PE, only presenting in around 20% of patients. An ECG finding of sinus tachycardia is a more likely finding.
name: S1Q3T3
label: b
answer: no
explanation: This presentation is most likely to be a pulmonary embolism (PE). T wave inversion is not an ECG finding typically seen in PE. It is indicative of cardiac ischaemia, past or present.
name: T wave inversion
label: d
answer: no
explanation: This presentation is most likely to be a pulmonary embolism (PE). Sudden onset shortness of breath, pleuritic chest pain and haemoptysis is the typical triad for a PE in exam questions. The most common finding on ECG in a PE is sinus tachycardia. The classic S1Q3T3 (deep S waves in lead I, pathological Q waves in lead III, and inverted T waves in lead III) is uncommon, presenting in around 20% of patients.
name: Sinus tachycardia
label: a
answer: yes

Correct answer: a
A 19-year-old female attends her asthma review complaining of worsening shortness of breath and chest tightness for the past 3 months, as well as a dry cough that is worse at night. She has a beclomethasone dipropionate inhaler which she takes as instructed, as well as a salbutamol inhaler to use as required. She has been needing to use her salbutamol inhaler almost every day to get on top of her symptoms.

All observations are normal: she is apyrexial and feeling otherwise well. She has no other medical conditions.

Which of the following is the most appropriate management?

Options:
explanation: It is important to first trial a long-acting B2-agonist like salmeterol. A high-dose steroid may be considered later in the management plan if salmeterol is not considered sufficient.
name: High dose steroid
label: e
answer: no
explanation: This patient requires additional treatment for her chronic asthma.  She is already taking a short-acting inhaled B2-agonist (salbutamol) and a low-dose inhaled corticosteroid (beclomethasone dipropionate). As per the NICE guidelines, the next step in treatment is to add a leukotriene receptor antagonist first, and then trial a long-acting B2 agonist such as  Salmeterol.
name: Salmeterol
label: a
answer: no
explanation: The patient is taking a short-acting inhaled B2 agonist as well as a low-dose inhaled corticosteroid. The next step would be to add a long-acting B2 agonist like salmeterol alongside the low-dose inhaled corticosteroid.
name: Stop beclomethasone dipropionate and begin salmeterol
label: d
answer: no
explanation: Adding an oral leukotriene receptor antagonist would be appropriate at this stage, as per the NICE guidelines. 
name: Montelukast
label: c
answer: yes
explanation: This patient is apyrexial and her symptom exacerbation is chronic in nature, making an infective picture less likely. Poorly controlled asthma is the most likely underlying diagnosis. Therefore the best treatment option would be to manage this patient with salmeterol, a long-acting B2-agonist.
name: Oral antibiotics
label: b
answer: no

Correct answer: c
A 50-year-old male presents to the emergency department with a high temperature and non-productive cough that began 2 weeks ago. His past medical history includes type 2 diabetes mellitus and HIV. His last CD4 count was 177 cells/uL.

Which of the following is the most likely organism causing his lower respiratory tract infection?

Options:
explanation: This most commonly occurs in patients who have an unsafe swallow, including those with myasthenia gravis, stroke, bulbar palsy, alcoholism, or achalasia. This type of pneumonia most commonly affects the right lung, as the right bronchus is wider than the left, making it more likely to facilitate the aspirate.
name: Aspiration pneumonia
label: b
answer: no
explanation: Klebsiella pneumonia usually affected patients with weakened immune systems, like the elderly, alcoholics and patients with diabetes. It mostly affects the upper lobes and produces ‘’red currant’’ sputum.
name: Klebsiella pneumoniae
label: d
answer: no
explanation: This is a typical presentation of pneumocystis pneumonia: exertional dyspnoea, dry cough and fever in a HIV positive patient. In patients who are HIV positive, the risk of PCP increases when their CD4 count is under 200 cells/uL.
name: Pneumocystis Jirovecii
label: a
answer: yes
explanation: Mycoplasma pneumonia is typically seen in younger patients with flu-like symptoms. It can also cause autoimmune haemolytic anaemia.
name: Mycoplasma pneumoniae
label: c
answer: no
explanation: Legionella pneumonia presents with fever and muscle pain, followed by shortness of breath and a dry cough. In exams, look out for hyponatremia and deranged liver function tests.
name: Legionella Pneumophila
label: e
answer: no

Correct answer: a