hllj/quesmed huggingface dataset:
A 56-year-old white man presents after home blood pressure monitoring (HBPM). He has already been offered lifestyle advice which has been ineffective in lowering his blood pressure. He has no history of type 2 diabetes.

You are considering starting a medication, which would be the most appropriate?

Options:
explanation: This is an example of an angiotensin-converting enzyme (ACE) inhibitor. These are considered first-line anti-hypertensives for people who are aged under 55 and not of black African or African-Caribbean family origin. Another consideration for patients with type 2 diabetes.
name: Ramipril
label: b
answer: no
explanation: This is a beta blocker, which is only considered in resistant hypertension after three other drugs have already been added.
name: Bisoprolol
label: d
answer: no
explanation: This is an example of a thiazide-like diuretic. It is used in the pharmacological management of hypertension, but it is not first-line.
name: Indapamide
label: e
answer: no
explanation: This man is over 55 without a diagnosis of type 2 diabetes so a calcium channel blocker such as amlodipine is most appropriate.
name: Amlodipine
label: a
answer: yes
explanation: Angiotensin-II receptor blockers (ARBs) are considered first-line for people who are aged under 55 and not of black African or African-Caribbean family origin or those with type 2 diabetes. They may also be considered if someone does not tolerate ACE inhibitors.
name: Candesartan
label: c
answer: no

Correct answer: a
A 45-year-old woman presents for a review. She has had ongoing dyspepsia which is not controlled with omeprazole. This has been occurring for most of her adult life. She is at risk of Barrett's oesophagus due to this.

Which of the following best describes the pathophysiology of Barrett's oesophagus?

Options:
explanation: Barrett's may progress to an adenocarcinoma which would be a neoplasm. However, Barrett's by itself is not a malignant condition.
name: Neoplasia of the distal oesophagus
label: c
answer: no
explanation: There is damage to the oesophagus in Barrett's, but it does not cause tearing. It damages the cells themselves rather than the structure.
name: Oesophageal tears
label: e
answer: no
explanation: Dysplasia refers to the presence of abnormal cells- which can sometimes be present in later stages of Barrett's. However, this is not always the case so does not make up the usual pathophysiology.
name: Dysplasia of the distal oesophagus
label: b
answer: no
explanation: This would more closely describe achalasia, which would present with difficulty swallowing rather than reflux.
name: Narrowing of the oesophagus
label: d
answer: no
explanation: The normal oesophageal epithelium is stratified squamous. In long-term exposure to stomach acid, this changes to columnar epithelium like in the stomach. This change from one cell type to another is called metaplasia.
name: Metaplasia of the distal oesophagus
label: a
answer: yes

Correct answer: a
A 15-year-old female patient presents to A+E having injured herself during a PE lesson at school. She describes "landing funny" on her left foot and that she "went over on it". Since this incident, she has been unable to weight bear. On examination, the left foot is swollen and there is bony tenderness along the lateral aspect of the left foot.

What is the most likely diagnosis?

Options:
explanation: There are a few factors that make a fracture more likely than a simple sprain or strain. The inability to weight bear, immediate swelling and bony tenderness all suggest a fracture. The mechanism of injury suggests a base of the 5th metatarsal fracture.
name: Ankle sprain
label: b
answer: no
explanation: There are factors suggesting a fracture such as the inability to weight bear. However, the bony tenderness to just the lateral aspect of the foot makes a metatarsal fracture more likely than an ankle fracture.
name: Ankle fracture
label: c
answer: no
explanation: The patient describes sudden inversion of her foot, this will put pressure on the tendon to the 5th metatarsal. This causes an avulsion fracture as the force pulls off part of the bone.
name: 5th metatarsal fracture
label: a
answer: yes
explanation: Charcot arthropathy describes a damaged joint secondary to loss of sensation. It is common in diabetics. For this patient, there is no description of loss of sensation and her symptoms have started more acutely following an injury.
name: Charcot arthropathy
label: e
answer: no
explanation: This patient's description of her injury does not fit with an Achilles tendon rupture. She may have described a loud pop or snap. The twisting she describes is not typical for the mechanism of injury of Achilles tendon rupture. Furthermore, this injury is most common in men aged 30-50 years old.
name: Achilles tendon rupture
label: d
answer: no

Correct answer: a
A 54-year-old woman is seen after an episode of syncope. During this, an ECG is performed which shows absent P waves and an irregularly irregular rhythm. Atrial fibrillation is diagnosed and subsequently, rivaroxaban is started.

What is the mechanism of action of this drug?

Options:
explanation: This is the mechanism of action of warfarin, which acts as an anticoagulant by preventing the production of vitamin K-dependent factors (II, VII, IX and X).
name: Inhibits vitamin K epoxide reductase complex
label: e
answer: no
explanation: This is the mechanism of action of clopidogrel and ticagrelor (thienopyridines).
name: P2Y12 receptor antagonist
label: d
answer: no
explanation: This describes the mechanism of action of low molecular weight heparins (LMWH) such as dalteparin.
name: Forms a complex that inhibits factor Xa
label: c
answer: no
explanation: Rivaroxaban is an example of a direct oral anticoagulant. These drugs have this mechanism of action on the blood clotting pathway.
name: Direct factor Xa inhibitor
label: a
answer: yes
explanation: This describes the anticoagulant mechanism of action of aspirin.
name: Inhibits thromboxane A2
label: b
answer: no

Correct answer: a
A 67-year-old man presents after a fall down the stairs. Luckily, there are no obvious injuries at present. On further questioning, he mentions he has been struggling when coming down the stairs for a few weeks as he feels he can not see where he is going. As part of the examination, a full neurological assessment is carried out which shows difficulty looking down.

Which cranial nerve is likely affected?

Options:
explanation: Damage to the optic nerve (e.g. glaucoma) would present with more generalised visual loss or diplopia. As this man's double vision is only on looking down this makes optic nerve damage less likely.
name: Optic nerve (CN II)
label: d
answer: no
explanation: The trochlear nerve innervates the superior oblique muscle which is responsible for depression of the eye. As this muscle is not working, there will be diplopia whilst looking down.
name: Trochlear nerve (CN IV)
label: a
answer: yes
explanation: The trigeminal nerve is not involved in eye movement so a palsy of the trigeminal nerve would not cause diplopia. The trigeminal nerve is instead involved in providing sensation to the face and innervating the muscles of mastication.
name: Trigeminal nerve (CN V)
label: e
answer: no
explanation: The oculomotor nerve innervates most of the muscles of the eye. The presentation of a third nerve palsy is the action of the other extra-ocular muscles. The eye will be "down and out" due to the action of the superior oblique and lateral rectus.
name: Oculomotor never (CN III)
label: b
answer: no
explanation: The abducens nerve innervates the lateral rectus muscle which is responsible for abduction of the eyes. This would present with diplopia when looking away from the midline as well as bumping into things on the affected side.
name: Abducens nerve (CN VI)
label: c
answer: no

Correct answer: a
An 80-year-old woman is brought to A+E after being found on the floor in the kitchen by her carers this morning. They believe she may have been there all night. Your main differential is an acute kidney injury (AKI) secondary to rhabdomyolysis. Using the U+E results table below, what is the stage of this woman's AKI?
 
|                    |    |        |
| --------------------------- | :-------: | -------------------- |
| Sodium                      | 134 mmol/L          | 135 - 145     |
| Potassium                   | 4.7 mmol/L          | 3.5 - 5.3     |
| Urea                        | 5.2 mmol/L          | 2.5 - 7.8     |
| Creatinine                  | 78 µmol/L          | 60 - 120      |
| eGFR                        | >90 mL/min/1.73m<sup>2</sup>   | > 60 |

Options:
explanation: The stage of an AKI can be calculated based on how many times the creatinine has increased from the baseline. In this example, 78 has increased to 242 which is more than 3 times. This means there is a stage 3 AKI. Stage 1 is creatinine 1.5-1.9 times the baseline value.
name: AKI stage 1
label: c
answer: no
explanation: The stage of an AKI can be calculated based on how many times the creatinine has increased from the baseline. In this example, 78 has increased to 242 which is more than 3 times. This means there is a stage 3 AKI. Stage 2 is creatinine 2-2.9 times the baseline value.
name: AKI stage 2
label: d
answer: no
explanation: There is no stage 4 for AKI.
name: AKI stage 4
label: e
answer: no
explanation: The creatinine level at present is 3 times the baseline, hence AKI stage 3.
name: AKI stage 3
label: a
answer: yes
explanation: The raised creatinine, urea and low eGFR all suggest an acute kidney injury. The history given is also consistent with rhabdomyolysis, following a fall with a long lie the muscles start to break down and release myoglobin which in turn damages the glomeruli.
name: Consider an alternative diagnosis
label: b
answer: no

Correct answer: a
A 23-year-old man presents after falling onto an outstretched hand (FOOSH). He now complains of pain in his wrist. An X-ray is taken (see below), and the arrow indicates the fracture. Which bone of the wrist is fractured?

[lightgallery]

Options:
explanation: This bone is on the ulnar side of the wrist, the fractured bone is seen just above the radius. Hence, the fractured bone is the scaphoid.
name: Hammate
label: c
answer: no
explanation: This bone is in the distal row of carpal bones (Trapezium, Trapezoid, Capitate, Hamate) whereas the fractured bone in the image is seen in the proximal row (Scaphoid, Lunate, Triquetrum, Pisiform). As the fractured bone is under the thumb (on the radial side), it is the scaphoid.
name: Capitate
label: e
answer: no
explanation: This bone is on the ulnar side of the wrist, but the fractured bone is seen just above the radius. Hence the bone fractured is the scaphoid.
name: Pisiform
label: d
answer: no
explanation: While the fractured bone can be seen under the thumb, the trapezium is in the distal row of carpal bones rather than directly articulating with the radius.
name: Trapezium
label: b
answer: no
explanation: The fractured bone is just above the radius so is the scaphoid bone. On gross anatomy, this would represent the anatomical snuffbox which is a site of tenderness in scaphoid fractures.
name: Scaphoid
label: a
answer: yes

Correct answer: a
A 44-year-old woman presents to her GP with low mood. She describes feeling down and tired for a few months now. Nothing seems to have triggered this episode. She also has gained some weight in this time, but she puts this down to comfort eating. You notice that in the consulting room, she is wearing multiple layers despite it being 20 degrees outside.

What is the most likely diagnosis?

Options:
explanation: Low mood has a very wide differential list. However, the fact she is experiencing cold intolerance and weight gain makes hypothyroidism the most likely.
name: Hypothyroidism
label: a
answer: yes
explanation: The low mood and tiredness could be explained by iron deficiency anaemia, but the weight gain is not typical. Furthermore, it is likely that there would be additional features such as pallor and shortness of breath.
name: Iron deficiency anaemia
label: c
answer: no
explanation: This would affect the patient in the opposite way to described. They may be losing weight and becoming intolerant to heat. They may still be fatigued.
name: Hyperthyroidism
label: d
answer: no
explanation: The low mood and tiredness could be explained by anaemia, however, it is likely that there would be additional symptoms such as shortness of breath and pallor. For pernicious anaemia, in particular, there is an association with autoimmune conditions such as type 1 diabetes.
name: Pernicious anaemia
label: e
answer: no
explanation: Depression is a good differential diagnosis for low mood and tiredness, however, physical health conditions need to be ruled out first as they can be managed and the low mood treated. Furthermore, the weight gain and cold intolerance are more indicative of hypothyroidism.
name: Depression
label: b
answer: no

Correct answer: a
A 68-year-old woman comes to you complaining of vaginal bleeding. She states she went through menopause over 10 years ago so she is not sure why her periods have suddenly come back. Upon further questioning, she tells you that she has not had a period for 5 years, but before that there was some spotting and irregular bleeding. She thinks she may have lost some weight recently as her clothes feel a bit baggier. She does not have any children and has never been pregnant. She also has been taking hormone replacement therapy (HRT) to help manage her menopausal symptoms for 3 years.

In terms of her current symptoms, what is the most important diagnosis to consider?

Options:
explanation: Postmenopausal bleeding is a red flag for gynaecological malignancy, as well as the fact this patient is losing weight. The fact she is nulliparous is a risk factor for endometrial cancer.
name: Endometrial cancer
label: a
answer: yes
explanation: Postmenopausal bleeding is a red flag for gynaecological malignancy, as well as the fact this patient is losing weight. The fact she is nulliparous is a risk factor for endometrial cancer. There is no mention of risk factors for cervical cancer such as smoking or multiple sexual partners. Additionally, post-menopausal bleeding should always be considered endometrial cancer until proven otherwise.
name: Cervical cancer
label: d
answer: no
explanation: This is the most common cause of postmenopausal bleeding, however, malignancy should be considered and ruled out first. There are also some red flag symptoms in this patient's history such as weight loss.
name: Vaginal atrophy
label: e
answer: no
explanation: Cyclical combined HRT can cause vaginal bleeding- it is quite common in the first six months of use. However, this woman has been taking HRT for three years so any side effects are unlikely to start now.
name: Side effect of HRT
label: b
answer: no
explanation: There is no mention of bleeding anywhere else in the body, such as recurrent epistaxis, that would suggest a systemic bleeding disorder.
name: Bleeding disorder
label: c
answer: no

Correct answer: a
A 75-year-old woman presents complaining of chest pain. She describes a burning pain on the left side of her chest which has been there for three days now. When asked to point to where the pain is, she points to just below her breast. She has also been experiencing a headache and fever for the last few days.

What is the most likely diagnosis for this woman's chest pain?

Options:
explanation: This is a very important differential for chest pain. However, it is unlikely in this case because of the description of the pain and the duration of symptoms. Classically, acute coronary syndromes cause crushing, central chest pain which may radiate to the left jaw or shoulder. The duration of symptoms is also likely to be a lot shorter.
name: Acute coronary syndrome
label: c
answer: no
explanation: The fever and feeling unwell with chest pain could suggest pneumonia. However, this is not a typical description of pleuritic chest pain, which would be sharp in nature and worse on breathing in. Also, there is no cough or difficulty breathing to suggest pathology within the lungs.
name: Community-acquired pneumonia
label: b
answer: no
explanation: Costochondritis is inflammation of the cartilage between the ribs and the sternum. This causes sharp, well-localised pain in this area. As this patient describes a burning pain, this makes this less likely.
name: Costochondritis
label: d
answer: no
explanation: The burning pain is a typical description of neuropathic pain, which is seen in shingles due to the reactivation of the varicella-zoster virus in the dorsal root ganglion of nerves. This patient may have the classical vesicular rash but be unable to see it due to it being beneath her breast, and often the pain may be present before the characteristic rash appears.
name: Shingles
label: a
answer: yes
explanation: The burning pain described could apply to GORD, however, this is more likely to be central and higher up the chest. It may also get worse after eating.
name: Gastro-oesophageal reflux disease (GORD)
label: e
answer: no

Correct answer: a
A 25-year-old man presents for a review of his Crohn's disease.

Which of these extra-intestinal features is more suggestive of Crohn's disease rather than ulcerative colitis?

Options:
explanation: Both Crohn's and ulcerative colitis can cause inflammatory arthritis as they are both inflammatory bowel conditions.
name: Inflammatory arthritis
label: d
answer: no
explanation: This is inflammation of the subcutaneous fat, typically on the shins. It causes tender, erythematous, nodular lesions. Both Crohn's and ulcerative colitis can cause erythema nodosum as they are both inflammatory conditions.
name: Erythema nodosum
label: c
answer: no
explanation: Crohn's disease causes transmural inflammation of the intestinal mucosa so connections between two epithelial-lined surfaces (fistulae) can form.
name: Perianal fistulae
label: a
answer: yes
explanation: This is more commonly associated with ulcerative colitis. Primary sclerosing cholangitis describes inflammation of the bile ducts.
name: Primary sclerosing cholangitis
label: e
answer: no
explanation: This is inflammation of the iris and ciliary body, causing an acutely red eye. It is associated with many inflammatory conditions, including both Crohn's disease and ulcerative colitis.
name: Anterior uveitis
label: b
answer: no

Correct answer: a
The second stage of labour ends with what?

Options:
explanation: This is also a feature of the first stage of labour.
name: Rupture of membranes
label: e
answer: no
explanation: The second stage of labour starts with complete cervical dilation and ends with the delivery of the foetus.
name: Delivery of the foetus
label: a
answer: yes
explanation: This is a feature of the first stage of labour, the foetal head descends into the pelvis.
name: Descent of the foetus
label: d
answer: no
explanation: This is the end of the third stage of labour, which is the last stage of labour.
name: Delivery of the placenta and foetal membranes
label: b
answer: no
explanation: This is the process that indicates the end of the first stage and the start of the second stage of labour.
name: Complete cervical dilation
label: c
answer: no

Correct answer: a
A 72-year-old man presents complaining of difficulty seeing out of his right eye. On general examination, he appears cachexic. On closer inspection, his right pupil is constricted. There is also a partial ptosis on the right-hand side. He is a lifelong smoker.

What is the most likely diagnosis?

Options:
explanation: There may be drooping of the face which appears like ptosis in Bell's palsy. However, it will affect the entire side of the face.
name: Bell's palsy
label: d
answer: no
explanation: In Horner's syndrome, only the sympathetic fibres along the oculomotor nerve are affected. In a true oculomotor nerve palsy, there will also be ophthalmoplegia due to the loss of innervation to the extraocular muscles.
name: Oculomotor nerve palsy
label: b
answer: no
explanation: Ptosis may be a feature of myasthenia gravis, but it varies throughout the day. There may also be muscle weakness and fatigue which is not mentioned in this case.
name: Myasthenia gravis
label: c
answer: no
explanation: The combination of partial ptosis, miosis and oculomotor nerve palsy suggests Horner's syndrome. In this case, it may be due to a pancoast tumour in the apex of the lung. He is cachexic and has a significant smoking history. Horner's syndrome also includes anhydrosis (lack of sweating) on the affected side.
name: Horner's syndrome
label: a
answer: yes
explanation: More symptoms are going on than just simple age-related vision loss. Miosis and partial ptosis suggest a problem with the cranial nerves. In this case, the sympathetic fibres of CN III.
name: Age-related vision loss
label: e
answer: no

Correct answer: a
A 72-year-old woman has been referred to the pulmonary clinic. She presents with progressively worsening breathlessness and a dry cough. She smokes a pack a day and has done so for 50 years. Her spirometry results are shown below:

| FEV1        | FVC           |
| ------------- |:-------------:|
| 1.57 L (50% of predicted)      |  1.63 L (40% of predicted)|

What is the most likely diagnosis?

Options:
explanation: COPD shows an obstructive rather than restrictive pattern on spirometry. This would result in a FEV1/ FVC ratio less than 0.7.
name: Chronic obstructive pulmonary disease
label: b
answer: no
explanation: Pneumoconiosis (coal miner's lung) does cause a restrictive pattern on spirometry so would match this patient. However, there is no significant history of coal exposure to make that possible.
name: Pneumoconiosis
label: c
answer: no
explanation: The spirometry results show a restrictive pattern as the FEV1/FEVC ratio is greater than 0.7. The smoking history alongside this makes idiopathic pulmonary fibrosis the most likely.
name: Idiopathic pulmonary fibrosis
label: a
answer: yes
explanation: Bronchiectasis is an obstructive lung disease so the FEV1/ FVC ratio would be reduced (less than 0.7).
name: Bronchiectasis
label: d
answer: no
explanation: Lung cancer may affect the functioning of the lungs but spirometry is not usually diagnostic. There would likely be other features of underlying malignancy such as weight loss, haemoptysis and hoarseness of voice. This makes lung cancer less likely in this patient.
name: Lung cancer
label: e
answer: no

Correct answer: a
A 20-year-old woman presents with ongoing fatigue, joint pains and alopecia. She has also noticed she is bruising more easily. On examination, there is an erythematous rash across her cheeks.

Given the most likely diagnosis, which autoantibody is most likely to be positive?

Options:
explanation: The most likely diagnosis is systemic lupus erythematosus (SLE). 99% of patients with SLE are ANA positive.
name: Anti-nuclear antibodies (ANA)
label: a
answer: yes
explanation: This is the pathophysiology of myasthenia gravis, which does not match the symptoms of this woman.
name: Anti-acetylcholine receptor antibodies
label: b
answer: no
explanation: This is the autoantibody driving Grave's disease. Antibodies against the thyroid-stimulating hormone (TSH) receptor are formed causing hyperthyroidism.
name: Anti-TSH receptor
label: e
answer: no
explanation: This autoantibody is positive in patients with polymyositis. This patient has features of SLE: malar rash, fatigue, joint pains and thrombocytopenia.
name: Anti-Jo-1
label: d
answer: no
explanation: This is the autoantibody-positive in rheumatoid arthritis, it can be positive in patients with SLE but is less likely than ANA.
name: Anti-Rheumatoid factor
label: c
answer: no

Correct answer: a