hllj/quesmed huggingface dataset:
A 72-year-old female presents to the emergency department with a 1-hour history of sudden onset weakness of her right arm and leg, as well as facial drooping. On examination, you identify a right hemiparesis with sensory function intact. You suspect a diagnosis of stroke.

Which of the following is the most appropriate next step?

Options:
explanation: In an acute ischaemic stroke setting, 300mg of aspirin is used rather than 1g. Furthermore, the provision of aspirin must be delayed until haemorrhagic stroke has been ruled out with brain imaging.
name: Aspirin 1g
label: c
answer: no
explanation: NICE stroke and TIA guidelines state that a non-contrast CT head scan should be performed immediately for anyone suspected of an acute stroke who meets the following criteria:

* Indications for thrombolysis/thrombectomy
* On anticoagulant treatment
* Known bleeding tendency
* Depressed consciousness
* Unexplained progressive or fluctuant symptoms
* Papilloedema, neck stiffness or fever
* Severe headache at symptom onset

Brain imaging must be performed before the provision of aspirin as haemorrhagic stroke has to be ruled out.
name: Non-contrast CT head
label: a
answer: yes
explanation: Although aspirin forms an important part of stroke management, it is vital to rule out the presence of a haemorrhagic stroke before the provision of antiplatelet therapy. NICE and Royal College of Physician guidelines recommend the use of a non-contrast CT-head scan immediately to rule out bleeding before aspirin is prescribed.
name: Aspirin 300mg
label: b
answer: no
explanation: Although this patient would fall under the time limit for thrombolysis, it is not the first step in the acute stroke management scenario. A non-contrast CT scan must be performed as soon as possible to rule out haemorrhage. After a diagnosis of haemorrhagic stroke has been ruled out and ischaemic stroke confirmed, other management options such as thrombolysis or thrombectomy can be considered and aspirin 300mg can be started.
name: Thrombolysis
label: e
answer: no
explanation: Although brain imaging is vital to perform immediately to rule out haemorrhagic stroke, a non-contrast CT scan is performed and not an MRI. In the stroke management setting, time is vital and so the speed of a non-contrast CT makes it preferable to the slower MRI. CT scan also retains high sensitivity for haemorrhagic stroke so is a reliable rule-out tool.
name: MRI head
label: d
answer: no

Correct answer: a
A 31-year-old female presents to the outpatient neurology clinic with a 10-day history of vision loss in her left eye. She says that the eye is painful whenever she moves it. Upon taking her history, she reveals that 3 months ago she experienced a sensation of pins and needles in both legs that lasted 2 weeks and resolved spontaneously. Examination reveals no focal neurological abnormality but visual acuity in the left eye is reduced.

Which of the following is the best diagnostic investigation?

Options:
explanation: Diagnosis of multiple sclerosis requires the presence of white matter lesions disseminated in space and time. This requires the use of imaging, and an MRI has the highest sensitivity and positive predictive value. Although the presence of oligoclonal bands can be diagnostically useful, non-invasive investigations should be performed first.
name: Lumbar puncture and CSF analysis
label: c
answer: no
explanation: The most important diagnosis to rule out here is multiple sclerosis (MS). This patient has presented with optic neuritis and has previously experienced spontaneously remitting neurological abnormalities. A diagnosis of multiple sclerosis requires white matter lesions disseminated in space and time. The history has revealed symptoms disseminated in time. An MRI of the brain and spinal cord has the highest sensitivity for demyelinating white matter lesions disseminated in space and is therefore the best diagnostic investigation.
name: MRI Brain and Spinal Cord
label: a
answer: yes
explanation: The most likely diagnosis in this patient is MS. This patient has presented with optic neuritis, which is a common first MS presentation and is characterized by reduced visual acuity and pain which is worse on eye movement. Ocular tonometry has no place in the diagnosis of MS and is much more likely to be used in the diagnosis of glaucoma.
name: Ocular tonometry
label: e
answer: no
explanation: Although evoked potential studies can be useful in the diagnosis of MS, the BMJ state they should typically be performed in patients for whom an MRI is contraindicated, which is not the case here. Evoked potential studies in a patient with MS typically demonstrate prolonged conduction.
name: Evoked potential studies
label: d
answer: no
explanation: The most likely diagnosis here is MS. Although imaging is required to confirm this diagnosis, CT scans have low positive predictive value for multiple sclerosis and are therefore much less suitable than an MRI.
name: CT Head
label: b
answer: no

Correct answer: a
A 56-year-old male presents to the clinic with a 6-week history of having difficulty climbing stairs which has gotten progressively worse. Examination reveals bilateral spastic leg weakness. Ankle jerk reflexes and patellar reflexes are absent but all other reflexes are present and normal. There are no identifiable sensory changes.

Which of the following is the most likely diagnosis?

Options:
explanation: This patient is suffering from motor neuron disease which classically presents with both upper (UMN) and lower motor neuron (LMN) signs. In this patient, spastic weakness is a UMN sign and hyporeflexia is an LMN sign. Furthermore, motor neurone disease does not present with sensory signs or symptoms. Diagnosis is typically clinical and needs to be made by a specialist.
name: Motor neuron disease
label: a
answer: yes
explanation: The diagnosis cannot be mononeuritis multiplex (MNM) for several reasons. Firstly, MNM is a peripheral nerve condition commonly caused by vasculitis and therefore presents only with LMN and sensory signs in the distribution of the affected nerve. This patient has UMN signs and so this is contrary to a diagnosis of MNM. Furthermore, MND does not present with sensory signs as it is characterised by progressive loss of motor, not sensory, neurons. Lastly, MNM commonly presents with neuropathic pain which is not present in this case.
name: Mononeuritis multiplex
label: c
answer: no
explanation: This patient has both UMN and LMN signs, which is pathognomonic of motor neuron disease. Multiple sclerosis typically only features UMN signs as it is a demyelinating disease of the central nervous system. Furthermore, MS is most common in females between the ages of 20-40, whereas the average age of MND diagnosis is ~57. Lastly, MS most commonly presents in a relapsing-remitting fashion though the less common subtype of primary progressive MS presents with progressive symptomatology.
name: Multiple sclerosis
label: b
answer: no
explanation: Lumbosacral radiculopathy occurs as a result of nerve root compression or inflammation, commonly due to herniation of intervertebral discs. It commonly presents with back pain or radicular pain in the distribution of impinged nerve roots. This is an unlikely diagnosis as no pain is present in this case. Furthermore, because nerve roots are impinged, lumbosacral radiculopathy will only present with LMN signs, whereas both UMN and LMN signs are present in this case.
name: Lumbosacral Radiculopathy
label: e
answer: no
explanation: Although an important differential, myasthenia gravis (MG) cannot explain this presentation. MG is an autoimmune condition caused by antibodies against the acetylcholine receptors of the post-synaptic neuromuscular junction. The characteristic presentation of MG is fatigable weakness which is not described here. Furthermore, MG commonly affects the extra-ocular muscles due to their high concentration of ACh receptors, whereas MND classically spares these muscles. The BMJ also state that MG also does not present with specific UMN and LMN signs, which are present here.
name: Myasthenia gravis
label: d
answer: no

Correct answer: a
A 66-year-old male presents to general practice as he has noticed changes in his movement. You suspect Parkinson's disease and refer him to neurology for specialist input.

Which of the following best characterises the classic triad of Parkinson's symptoms?

Options:
explanation: Parkinson's disease is a chronic neurological disorder characterised by the loss of dopaminergic neurons in the substantia nigra. This results in impairment of basal ganglia function and subsequent motor dysfunction. BMJ classify the classic triad of Parkinson's features as bradykinesia, rest tremor, and rigidity and these symptoms manifest as a consequence of basal ganglia impairment.
name: Bradykinesia, rest tremor, rigidity
label: a
answer: yes
explanation: Although these are all potential features of Parkinson's disease, these are atypical symptoms of early disease. Indeed, NICE suggest that symptoms such as recurrent falls and severe autonomic dysfunction may suggest a diagnosis of a different cause of parkinsonism, such as multiple system atrophy or progressive supranuclear palsy.
name: Bradykinesia, autonomic dysfunction, recurrent falls
label: b
answer: no
explanation: These symptoms indicate a "Parkinson's plus" diagnosis of Lewy body dementia. Lewy body dementia and Parkinson's disease have a close but complicated relationship and so it is important to differentiate the two. The BMJ recommend as a general rule that Parkinson's disease with dementia is diagnosed if Parkinson's was diagnosed at least 1 year before dementia onset and that Lewy body dementia should be diagnosed if dementia is present at symptom onset or within 1 year of parkinsonism onset.
name: Cognitive impairment, bradykinesia, visual hallucinations
label: c
answer: no
explanation: This is the clinical triad of Wernicke's encephalopathy, a neurological condition caused by vitamin B1 (thiamine) deficiency.
name: Altered mental status, gait ataxia, ophthalmoplegia
label: e
answer: no
explanation: This is the classical clinical triad of normal pressure hydrocephalus, not Parkinson's disease. This is an important diagnosis to be aware of as it is one of the few reversible causes of dementia.
name: Dementia, urinary incontinence, gait abnormalities
label: d
answer: no

Correct answer: a
A 45-year-old male presents with symmetrical ascending limb weakness which began in his legs and has progressed proximally. 2 weeks ago he suffered an episode of gastroenteritis. He is diagnosed with Guillain-Barre syndrome, an immune-mediated demyelinating disease.

What cells produce the myelin involved in this disease?

Options:
explanation: Astrocytes are one of the most populous cell types of the brain and central nervous system and maintain vital roles in CNS structure, neuronal metabolism, neurogenesis, maintenance of the blood-brain barrier and much more. They do not, however, produce myelin in the peripheral nervous system.
name: Astrocytes
label: d
answer: no
explanation: Satellite glial cells are found within ganglia and are thought to play the role of the astrocyte within the PNS including support of neuronal metabolism. However, they are not involved in the production of myelin.
name: Satellite glial cells
label: e
answer: no
explanation: Guillain-Barre syndrome is an acute inflammatory demyelinating disease of the peripheral nervous system (PNS). In the PNS, myelin is produced by Schwann cells.
name: Schwann cells
label: a
answer: yes
explanation: The microglia cells are the immune cells of the central nervous system. Although they promote myelination by encouraging the differentiation of oligodendrocytes and clearing old myelin debris, they do not produce myelin themselves.
name: Microglia
label: c
answer: no
explanation: Oligodendrocytes are the myelin-producing cells of the central nervous system (CNS). Therefore they are not involved in Guillain-Barre syndrome but do produce the myelin involved in multiple sclerosis.
name: Oligodendrocytes
label: b
answer: no

Correct answer: a
A 12-year-old female presents to general practice with her mother, who reports that teachers have mentioned her daughter has been losing awareness in class. These episodes last 90-120 seconds, during which she chews her lip. The girl states she can feel something is wrong beforehand but does not remember anything that happens during the episode. She always feels confused and disorientated afterwards. After referral to secondary care, she is diagnosed with epilepsy.

Which of the following most accurately describes her seizure classification?

Options:
explanation: A generalised tonic-clonic seizure is characterized by loss of consciousness followed by phases of limb stiffening (tonic) and limb jerking (clonic). Individuals suffering from generalised tonic-clonic seizures also suffer from aura and post-ictal symptoms. They may also experience urinary or bowel incontinence during the episode.
name: Generalised tonic-clonic seizure
label: c
answer: no
explanation: Although an important differential, this patient is not suffering from absence seizures. Absence seizures can be differentiated from focal impaired awareness seizures through several factors: absence seizures typically last less than 60 seconds, focal impaired awareness seizures often have postictal states, and patients may have an aura before focal impaired awareness seizures. Absence seizures do not have an aura or postictal symptoms.
name: Absence seizure
label: b
answer: no
explanation: Myoclonic seizures are characterised by brief, shock-like jerks of muscle groups. This patient does not express these muscle jerks, and so this is an unlikely diagnosis.
name: Myoclonic seizure
label: e
answer: no
explanation: Although this individual is suffering from focal seizures, the history indicates a loss of awareness during seizure episodes. Therefore the diagnosis is unlikely to be focal aware seizures
name: Focal aware seizure
label: d
answer: no
explanation: This young patient is suffering from focal impaired awareness epilepsy. Focal seizures arise in one portion of the brain. Focal impaired awareness seizures are characterized by loss of awareness, memory loss, pre-seizure aura, and post-ictal symptoms, and individuals may express automatisms during the seizure.
name: Focal impaired awareness seizure
label: a
answer: yes

Correct answer: a
A 68-year-old female presents to the clinic with her husband. She reports a recent history of morning headaches. Her husband also reports that she has become more aggressive and often swings from joy to anger suddenly and without provocation. Examination reveals no motor or sensory abnormalities but fundoscopy revealed papilloedema.

Which of the following is the most likely diagnosis?

Options:
explanation: Hydrocephalus is another important differential, however, is not the most likely diagnosis here. Although hydrocephalus would present with evidence of raised ICP, localised prefrontal symptoms are unlikely to be present (though cognitive impairment may be). Furthermore, adult-onset hydrocephalus typically presents with gait disturbance and incontinence, which are not present in this presentation.
name: Adult-onset hydrocephalus
label: e
answer: no
explanation: This is an unlikely diagnosis here. Alzheimer's typically presents with early memory dysfunction and loss of executive function. Personality is typically preserved until later in the disease progression. Furthermore, Alzheimer's does not present with signs of raised intracranial pressure.
name: Alzheimer's disease
label: d
answer: no
explanation: This patient has presented with evidence of raised intracranial pressure such as morning headaches and papilloedema. Other signs of raised ICP include nausea, vomiting, reduced consciousness and gait disturbance. This patient has also presented with personality change and emotional lability, which are both signs of a pre-frontal cortex involvement (situated in the frontal lobe).
name: Frontal lobe tumour
label: a
answer: yes
explanation: Although an important differential as frontotemporal dementia can manifest as personality change and emotional lability, this patient has evidence of a space-occupying lesion due to papilloedema. As frontotemporal dementia does not result in raised ICP, it is not the correct diagnosis here.
name: Frontotemporal dementia
label: b
answer: no
explanation: A parietal lobe tumour would not result in personality change and emotional symptoms. Parietal lobe tumours typically present with sensory changes, visual field defects, and left-right neglect/confusion.
name: Parietal lobe tumour
label: c
answer: no

Correct answer: a
An 11-year-old male presents to the emergency department with a 6-hour history of gradual-onset severe headache and fever. On examination, you identify nuchal rigidity. You suspect meningitis and perform a lumbar puncture to obtain a CSF sample.


||||
|---------------------------------|:-------:|-------------------------|
|Opening Pressure|normal|50 - 180|
|Total Protein|0.54 g/L|0.15 - 0.45|
|Glucose|3.4 mmol/L|3.2 - 4.4|
|Lymphocyte Count|546/ µL|<5/               µL|
|Plasma Glucose|4.9 mmol/L|3.5 - 5.5|


 * CSF Appearance: Clear


Which of the following is the most likely causative organism?

Options:
explanation: Although streptococcus pneumoniae is one of the most common causes of bacterial meningitis, this patient is suffering from viral meningitis. CSF analysis of bacterial meningitis is characterised by:

* Cloudy or turbid appearance
* Low glucose
* Elevated WCC, predominantly polymorphs
* Elevated protein
* Elevated opening pressure
name: Streptococcus pneumoniae
label: c
answer: no
explanation: Although this young patient is indeed suffering from a case of viral meningitis, enteroviruses are the most common cause of viral meningitis and are therefore the most likely causative organism.
name: Herpes simplex virus
label: b
answer: no
explanation: Cryptococcus neoformans is the most common cause of fungal meningitis. Fungal meningitis is an unlikely presentation in individuals with no history of immunosuppression and usually presents with systemic involvement. Furthermore, the CSF analysis does not support a diagnosis of fungal meningitis, which is characterised by:

* Cloudy appearance
* Low glucose
* Elevated, predominantly lymphocytes
* Elevated protein
* Elevated opening pressure
name: Cryptococcus neoformans
label: e
answer: no
explanation: Another organism commonly implicated in meningitis, this bacteria is unlikely to be the cause due to the results of the CSF analysis which indicate viral meningitis.
name: Neisseria meningitidis
label: d
answer: no
explanation: This young patient is suffering from viral meningitis. Enteroviruses are the most common cause of viral meningitis. CSF analysis of viral meningitis is characterised by:

* Clear appearance
* Normal glucose
* Elevated WCC, predominantly lymphocytes
* Normal or raised protein
* Normal or elevated opening pressure
name: Enterovirus
label: a
answer: yes

Correct answer: a
You are asked to assess a 44-year-old female patient on the ward who has not improved since admission. She was admitted 2 days ago with a 24-hour history of high volume vomiting. This has continued throughout her admission, for a total of 3 days.


On examination her mucosal membranes are dry and she has reduced skin turgor.


After bedside observations, you note that she has a blood pressure of 98/71 mmHG, a heart rate of 132 bpm, and a temperature of 36.5C. Blood tests reveal that her creatinine has increased by 40µmol/L since admission (normal range 60-120 µmol/L).


She has a 2-year history of hypertension and well-controlled diabetes for which she takes ramipril and metformin respectively. Which of the following is the most likely cause of her acute kidney injury?

Options:
explanation: Metformin is a very unlikely cause of AKI in this patient. Metformin is not inherently nephrotoxic so is not a cause of AKI. It is, however, important to be aware of metformin in AKI as most metformin excretion is performed by the kidneys, therefore the risk of toxicity is increased when kidney function is impaired.
name: Metformin
label: d
answer: no
explanation: Nephrolithiasis is not a likely cause of AKI in this patient. Kidney stones classically present with acute renal colic which manifests as acute, severe loin-to-groin pain. There is no pain reported in this patient which makes obstructive nephrolithiasis an unlikely diagnosis. Furthermore, the presence of clinical fluid depletion and ongoing high volume vomiting should indicate an underlying cause of hypovolaemia.
name: Nephrolithiasis
label: e
answer: no
explanation: Although ACE inhibitors can cause AKI, it is not the most likely cause here. ACEis cause AKI by dilating the efferent renal arteriole, thereby reducing glomerular hydrostatic pressure. However, hypovolaemia is a far more likely underlying cause, given the acute history of fluid loss from vomiting and the subsequent clinical manifestation of hypovolaemia.
name: Ramipril
label: b
answer: no
explanation: Another important risk factor for AKI, diabetic nephropathy is important to keep in mind. Diabetic nephropathy is a significant risk factor for chronic kidney disease, which in turn increases the risk of AKI. However, this patient's diabetes is well-controlled and CKD caused by diabetes would likely have been identified on admission blood tests. On top of this, the acute history of vomiting is a far more likely cause of AKI, given the clinical evidence of fluid depletion.
name: Diabetic nephropathy
label: c
answer: no
explanation: This patient's acute kidney injury (AKI) has occurred secondary to hypovolaemia caused by her recent history of vomiting. Hypovolaemia and hypotension are common causes of pre-renal AKI and may be caused by sepsis, fluid loss, or poor fluid intake (especially in frail patients). AKI should be diagnosed in patients featuring any of the following:

* Rise in serum creatinine of ≥26µmol/L within 48 hours
* Rise in serum creatinine to ≥1.5x baseline within 7 days
* A fall in urine output to <0.5ml/kg/hr for more than 6 hours
name: Hypovolaemia
label: a
answer: yes

Correct answer: a
A 67-year-old male presents to General Practice with a 3-month history of lethargy and fatigue. His past medical history is significant for poorly controlled type 2 diabetes. You suspect he may be suffering from chronic kidney disease (CKD) as a consequence of his diabetes. After further investigation, you establish an eGFR of 25ml/min.

Which of the following best describes his classification of CKD?

Options:
explanation: Stage 5 CKD is diagnosed when eGFR = <15ml/min. This represents kidney failure and at this stage, patients require renal replacement therapy which takes the form of either dialysis or kidney transplant. Haemodialysis is the most common type of renal replacement therapy and involves the filtration of the patient's blood through a dialysis machine.
name: Stage 5
label: e
answer: no
explanation: Stage 4 CKD covers an eGFR range of 15-29ml/min. This represents a severe reduction in kidney function. Typically CKD remains asymptomatic until the kidney function is severely reduced.
name: Stage 4
label: a
answer: yes
explanation: Stage 3a CKD is diagnosed when eGFR = 45-59ml/min and represents a mild to moderate reduction in kidney function.
name: Stage 3a
label: c
answer: no
explanation: Stage 1 CKD is indicated by an eGFR >90ml/min PLUS evidence of renal dysfunction on other tests. If there is no other evidence of renal dysfunction, CKD is not present as eGFR >90ml/min is an otherwise normal result.
name: Stage 1
label: b
answer: no
explanation: Stage 3b CKD is diagnosed when eGFR = 30-44ml/min and represents a moderate to severe reduction in kidney function.
name: Stage 3b
label: d
answer: no

Correct answer: a