hllj/quesmed huggingface dataset:
A 67-year-old woman is rushed to A+E as her partner believes she is having a stroke. On examination, power is 5/5 for both left limbs, but reduced to 2/5 for the right lower limb and 3/5 for the right lower limb. There is also sensory loss on the entire right-hand side.

Which artery has likely been affected?

Options:
explanation: The middle cerebral artery supplies the lateral parts of the cerebral hemispheres. Due to this, more functions are likely affected leading to symptoms such as aphasia. Also, the upper limb would be more affected than the lower limb as the upper limb is represented on the lateral part of the motor homunculus.
name: Left middle cerebral artery
label: c
answer: no
explanation: The anterior cerebral artery is correct as the motor and sensory cortexes are affected. However, nerves cross over after leaving the central nervous system so lesions on the left-hand side of the brain will affect the right-hand side of the body.
name: Right anterior cerebral artery
label: b
answer: no
explanation: A stroke in the basilar artery would lead to "locked-in" syndrome where the patient is unable to move at all, apart from eye movements.
name: Basilar artery
label: e
answer: no
explanation: As this patient's right-hand side is affected, the lesion will be in the left-hand side of the brain. This is because the nerve fibres cross over after leaving the central nervous system. Furthermore, if it were a middle cerebral artery occlusion, a homonymous hemianopia may be seen due to the involvement of the optic radiation.
name: Right middle cerebral artery
label: d
answer: no
explanation: The anterior cerebral artery supplies the medial portion of each hemisphere, including the parietal and frontal lobes. Therefore, both motor and sensory functions are impaired. The lower limb is more affected than the right in terms of motor function because the lower limb is represented more medially on the motor homunculus.
name: Left anterior cerebral artery
label: a
answer: yes

Correct answer: a
You are asked to review a 45-year-old woman who is complaining of fatigue and muscle cramping. She finished her third round of chemotherapy for metastatic breast cancer last week. She tells you that the chemotherapy made her lose her appetite completely, but since it finished she has gone back to her usual appetite. On examination, she appears very cachexic but otherwise well.
Blood results are shown below:


||||
|---------------------------|:-------:|--------------------|
|Sodium|136 mmol/L|135 - 145|
|Potassium|2.7 mmol/L|3.5 - 5.3|
|Magnesium|0.65 mmol/L|0.7 - 1.0|
|Phosphate|0.33 mmol/L|0.8 - 1.5|
|Urea|3.4 mmol/L|2.5 - 7.8|
|Creatinine|59 µmol/L|60 - 120|


What is the most likely cause of this electrolyte abnormality?

Options:
explanation: This would result in hyponatraemia which is not seen in this patient's blood results.
name: Syndrome of inappropriate anti-diureitc hormone secretion (SIADH)
label: c
answer: no
explanation: This describes a condition where the renal tubules can no longer handle acids effectively. This results in hypokalaemia, as the kidneys try to compensate for the acidosis. However, for this case, it would not explain the hypophosphataemia or hypomagnesemia.
name: Renal tubular acidosis
label: d
answer: no
explanation: This would make sense with this woman's history of chemotherapy. However, it only explains the hypokalaemia, not the other electrolyte abnormalities.
name: Prolonged vomiting
label: b
answer: no
explanation: The history of loss of appetite followed by sudden return to usual eating habits fits with the downregulation of enzymes in the urea cycle and then the build-up of toxic waste products once eating commences. The fact she is cachexic supports the idea that she has not been eating well for a long time and is therefore at risk of refeeding syndrome. The blood results show hypophosphatemia, hypokalaemia and hypomagnesemia which happens due to the shifting of electrolytes into the intracellular space from the extracellular spaces.
name: Refeeding syndrome
label: a
answer: yes
explanation: Vitamin D deficiency would explain the hypophosphataemia, but not the other electrolyte abnormalities.
name: Vitamin D deficiency
label: e
answer: no

Correct answer: a
A patient in the GP practice is started on dapagliflozin for their type 2 diabetes mellitus.

What is the mechanism of action of this drug?

Options:
explanation: This is the mechanism of action of metformin, which is a biguanide.
name: Decreases gluconeogenesis and increases insulin sensitivity
label: c
answer: no
explanation: This is the mechanism of action of exenatide. It stimulates insulin secretion and reduces glucagon secretion.
name: Analogue to glucagon-like peptide-1 (GLP-1) receptors
label: e
answer: no
explanation: This is the mechanism of action of SGLT-2 inhibitors such as dapagliflozin.
name: Inhibits sodium-glucose co-transporters (SGLTs) in the proximal convoluted tubules
label: a
answer: yes
explanation: This is the mechanism of action of sulfonylureas such as gliclazide.
name: Stimulates pancreatic beta cells
label: b
answer: no
explanation: This is the mechanism of action of sitagliptin.
name: Inhibits dipeptidyl peptidase (DPP-4)
label: d
answer: no

Correct answer: a
A father brings his four-year-old daughter into the GP concerned about a rash on her face. Based on the image below, what is the most likely diagnosis?

[lightgallery]

Options:
explanation: Cold sores, or HSV infections will cause a vesicular rash. There will be fluid-filled lesions, which are not seen in this case.
name: Herpes simplex virus (HSV) infection
label: d
answer: no
explanation: The image shows a superficial erosion with the classic golden crusting seen in impetigo.
name: Impetigo
label: a
answer: yes
explanation: Atopic dermatitis, or eczema, is typically seen on the flexor surfaces of the elbows and knees. It can be seen on the face, but the golden crusting in this case is more suggestive of an infective cause, such as impetigo.
name: Atopic dermatitis
label: c
answer: no
explanation: This normally involves an erythematous, pruritic rash. There is also often a pattern suggestive of the contact allergen e.g. on hands.
name: Contact dermatitis
label: b
answer: no
explanation: Tinea Corporis, or ringworm, usually causes a rash that is circular and erythematous with central paleness. In the image, the lesions are the same colour throughout and are golden/ yellow rather than erythematous.
name: Tinea Corporis
label: e
answer: no

Correct answer: a
A woman is in the maternity centre giving birth. It has been an uncomplicated pregnancy and delivery so far. However, the baby now seems to be stuck. The registrar tells you this is shoulder dystocia as the infant's shoulder is behind the maternal pubic symphysis despite delivery of the head.

Which neurological problem is the infant most at risk of?

Options:
explanation: Shoulder dystocia is a risk factor for upper brachial plexus injuries as it is stretched due to traction when trying to deliver the stuck infant. Erb's palsy presents with the affected limb being held internally rotated, adducted and extended.
name: Erb's palsy
label: a
answer: yes
explanation: The axillary nerve is a terminal nerve of the brachial plexus, so does not arise until after the plexus has passed through the axilla. In this case, the actual brachial plexus is more likely to be injured as the neck is being stretched during delivery.
name: Axillary nerve palsy
label: c
answer: no
explanation: The median nerve is a terminal nerve of the brachial plexus, so does not arise until after the plexus has passed through the axilla. In this case, the actual brachial plexus is more likely to be injured as the neck is being stretched during delivery.
name: Median nerve palsy
label: d
answer: no
explanation: This is a lower brachial plexus injury which is caused when the lower part of the brachial plexus is stretched e.g. catching onto a tree when falling from height. In this case, the upper brachial plexus injury is more likely as the neck is where traction is applied to try and deliver the baby.
name: Klumpke's palsy
label: b
answer: no
explanation: The musculocutaneous nerve is a terminal nerve of the brachial plexus, so does not arise until after the plexus has passed through the axilla. In this case, the actual brachial plexus is more likely to be injured as the neck is being stretched during delivery.
name: Musculocutaneous nerve palsy
label: e
answer: no

Correct answer: a
A 23-year-old man is involved in a fight outside the pub, and is stabbed in his back. An MRI spine is taken and shows a hemisection of the spinal cord at the L2 level on the right-hand side.

What examination findings would be expected?

Options:
explanation: This case is a description of Brown-Sequard syndrome. While very rare, it explains the physiology of the ascending tracts well. The fibres of the spinothalamic tract (pain and temperature sensation) cross over at the level of innervation. Hence, in this case, the fibres from the left lower limb are affected.
name: Hemiparesis of the right below L2, loss of proprioception and vibration sense on the right lower limb, and loss of pain and temperature sensation on the left lower limb
label: a
answer: yes
explanation: This would be the case for a complete transection of the spinal cord but, in this case, only half of the spinal cord is affected.
name: Complete loss of all movement and sensation below L2
label: e
answer: no
explanation: It is the spinothalamic fibres that cross over at the level of innervation so pain and temperature sensation would be lost on the left for this patient.
name: Hemiparesis of the right below L2, loss of proprioception and vibration sense of the left lower limb, and loss of pain and temperature sensation of the right lower limb
label: d
answer: no
explanation: This is incorrect because the spinal cord nerves on the right-hand side are innervating the right side of the body, except the spinothalamic fibres. This results in hemiparesis and loss of dorsal column modalities on the right and loss of spinothalamic modalities on the left.
name: Hemiparesis of the left below L2, and loss of all sensory modalities on the left
label: c
answer: no
explanation: This would make sense for a hemisection of the right-hand side. However, the spinothalamic fibres cross over at the level of their innervation. So in this case, there will be fibres from the left-hand side involved. This will mean that pain and temperature sensation will be lost on the left but maintained on the right.
name: Hemiparesis of the right side below L2, and loss of all sensation modalities on the right side
label: b
answer: no

Correct answer: a
A mother brings her two-year-old daughter to a GP appointment. She tells you that her child has been unwell for four days with a fever and is generally irritable. This morning, she noticed her daughter was making a high-pitched noise as she was breathing in. On examination, the child looks unwell and has a temperature of 38.0. You notice she is drooling as well as having some difficulty breathing. On inspection of the oral cavity, the tonsils are not inflamed or covered in exudate.

Given the likely diagnosis, what is the most appropriate management?

Options:
explanation: This patient is acutely unwell, a referral is very unlikely to happen in time to help. Therefore, an urgent hospital admission is needed to assess for and treat acute epiglottitis.
name: Refer to Respiratory
label: e
answer: no
explanation: This would be an appropriate management for tonsilitis. However, this patient would score only a two on the feverPAIN score. This would be for her fever and absent cough. The fact the tonsils are not inflamed or covered by exudate makes tonsilitis less likely.
name: Prescribe phenoxymethylpenicillin
label: c
answer: no
explanation: This patient is having difficulty breathing and experiencing stridor which both suggest inflammation causing an airway obstruction. Therefore, urgent hospital admission is necessary.
name: Encourage oral fluids and analgesia with safety netting advice
label: b
answer: no
explanation: This patient has some red flag features of epiglottitis which requires urgent hospital admission. The fact she has developed stridor, drooling and difficulty breathing are key indicators of this condition.
name: Ring for an ambulance
label: a
answer: yes
explanation: This would be an appropriate management for tonsilitis, in this case, the patient is scoring 2 on the feverPAIN score so a backup antibiotic prescription is indicated. However, the child is more acutely unwell with epiglottitis so needs to be urgently assessed at the hospital.
name: Prescribe a backup course of phenoxymethylpenicillin
label: d
answer: no

Correct answer: a
A 47-year-old woman makes an appointment to discuss stopping smoking. She has smoked 25 cigarettes a day since she was 17.

What are her pack years?

Options:
explanation: This is the number of cigarettes this woman smokes a day. The number of years she has been smoking also needs to be taken into consideration for the pack years calculation.
name: 25
label: c
answer: no
explanation: This is the number of years this woman has been smoking. The amount she smokes a day also needs to be accounted for.
name: 30
label: b
answer: no
explanation: The pack years calculation is done by multiplying the number of years a person has been smoking by how many packs a day. There are 20 cigarettes in a pack so this woman smokes 1.25 a day. 1.25 times 30 is 37.5
name: 37.5
label: a
answer: yes
explanation: The pack years calculation is done by multiplying the number of years a person has been smoking by how many packs a day. There are 20 cigarettes in a pack so this woman smokes 1.25 a day. 1.25 times 30 is 37.5
name: 32.5
label: d
answer: no
explanation: The pack years calculation is done by multiplying the number of years a person has been smoking by how many packs a day. There are 20 cigarettes in a pack so this woman smokes 1.25 a day. 1.25 times 30 is 37.5
name: 27.5
label: e
answer: no

Correct answer: a
The tympanic membrane is a derivative of which pharyngeal arch?

Options:
explanation: The 1st pharyngeal arch forms the trigeminal nerve, maxillary artery, bones of the middle ear, muscles of mastication and the tympanic membrane.
name: 1st
label: a
answer: yes
explanation: The 4th pharyngeal nerve forms parts of the vagus nerve and the muscles it supplies as well as the thyroid cartilage structures.
name: 4th
label: d
answer: no
explanation: The 5th pharyngeal arch is also involved in forming the vagus nerve and the muscles it supplies as well as the thyroid cartilage structures.
name: 5th
label: e
answer: no
explanation: The 2nd pharyngeal arch forms the facial nerve and its associated muscles of facial expression. It also forms the bones of the middle ear, but not the tympanic membrane.
name: 2nd
label: b
answer: no
explanation: The 3rd pharyngeal arch forms the glossopharyngeal nerve, common carotid artery, hyoid bone and stylopharyngeus. All these structures are below the tympanic membrane.
name: 3rd
label: c
answer: no

Correct answer: a
A 35-year-old woman is admitted to the ICU with a number of injuries following a high-speed road traffic collision. She is currently unconscious and intubated. However, a purpuric rash is noted across her chest and she starts bleeding from the cannula sites and her blood pressure is dropping.

What is the likely diagnosis?

Options:
explanation: von Willebrand's disease is a lifelong coagulopathy. It is less likely in this case because there is no mention of recurrent bleeding before this episode. The acute history after a major trauma makes DIC more likely.
name: von Willebrand's disease
label: d
answer: no
explanation: Haematological malignancy can cause disseminated intravascular coagulation (DIC) but is less likely in this cause because of the acute setting, following a major trauma.
name: Haematological malignancy
label: c
answer: no
explanation: Haemophilia is a lifelong coagulopathy which increases bleeding. For this case, the acute history following a major trauma makes DIC more likely.
name: Haemophilia
label: b
answer: no
explanation: Vitamin K deficiency is an acquired coagulopathy. It is unlikely in this case because of the acute onset and associated major trauma.
name: Vitamin K deficiency
label: e
answer: no
explanation: DIC is a condition where the clotting cascade is inappropriately activated, resulting in many small thrombi forming and using up the clotting factors. The thrombi cause a purpuric rash under the skin and the absence of clotting factors means that the patient is more likely to bleed. The risk factors for DIC include major trauma (in this case), sepsis, obstetric emergencies and malignancy.
name: Disseminated intravascular coagulation (DIC)
label: a
answer: yes

Correct answer: a
A 64-year-old man presents with a headache, which has been going on for a few months now. Over this time, he also mentions he is bumping into doorways in his home. On examination, you note large hands and large prominent facial features. He states that his wife thinks he looks different in recent years. An MRI head reveals a pituitary adenoma.

Given the clinical picture, which hormone is being secreted?

Options:
explanation: Prolactinomas are the most common hormone-secreting tumours from the pituitary gland. However, there are no features to suggest this in this case, except for the bitemporal hemianopia which is a result of the tumour itself, not the hormone it is secreting. If a tumour is secreting prolactin, there may be galactorrhea, erectile dysfunction and oligomenorrhea.
name: Prolactin
label: b
answer: no
explanation: TSH is made in the anterior pituitary so could be produced in a pituitary adenoma. However, there are no features of hypothyroidism that would indicate excess TSH. These features may include weight gain, low mood, and fatigue.
name: Thyroid-stimulating hormone (TSH)
label: c
answer: no
explanation: ACTH stimulates the adrenal gland to produce cortisol, therefore excess cortisol would result in Cushing's syndrome. Features of Cushing's syndrome include abdominal obesity, rounding of the face and purple striae on the abdomen. An ACTH-secreting pituitary adenoma is also called Cushing's disease.
name: Adrenocorticotrophic hormone (ACTH)
label: e
answer: no
explanation: This patient has features of acromegaly (large hands and more prominent facial features). Acromegaly is caused by excess growth hormone.
name: Growth hormone
label: a
answer: yes
explanation: Oxytocin is produced by the hypothalamus and then secreted by the posterior pituitary gland. Therefore, it could not be produced in excess by a pituitary adenoma.
name: Oxytocin
label: d
answer: no

Correct answer: a
A 60-year-old man with a background of liver cirrhosis due to chronic alcohol abuse is admitted for an ascitic drain.

Which additional sign is most likely to be found on examination?

Options:
explanation: Due to endocrine dysfunction, males with liver cirrhosis may experience gynaecomastia.
name: Gynaecomastia
label: a
answer: yes
explanation: Dyspnoea in someone with established liver disease may suggest hepatopulmonary syndrome, which is uncommon and only present in patients with advanced liver disease. For those reasons, this is not the most likely additional sign.
name: Dyspnoea
label: d
answer: no
explanation: In ascites, the excess fluid collects in the peritoneal space. Due to the mechanism of fluid retention, it is unlikely that fluid will also collect in the peripheries such as the lower legs.
name: Peripheral oedema
label: c
answer: no
explanation: Portal hypertension is a common complication of liver cirrhosis. However, it does not typically cause hypertension in the systemic circulation.
name: Hypertension
label: e
answer: no
explanation: In liver cirrhosis, the liver becomes fibrotic and therefore smaller. This is especially true in more established disease, like this man.
name: Hepatomegaly
label: b
answer: no

Correct answer: a
A 24-year-old woman presents to the neurology clinic for a review of her epilepsy. She says she has been thinking of starting a family but is aware she will need advice about her medication before starting to try for a pregnancy.

Which anti-epileptic drug would be most important to switch out if she was taking it?

Options:
explanation: Lamotrigine is considered to be safe in pregnancy, so would not need to be stopped in this case. There are some concerns as the data is quite limited, but it is safer for both the foetus and the mother to have adequate seizure control.
name: Lamotrigine
label: b
answer: no
explanation: There is an increased risk of congenital malformations with the use of carbamazepine. Therefore, it should be avoided in pregnancy. However, it is not as important to stop as valproate, as this has a known highly teratogenic effect.
name: Carbamazepine
label: e
answer: no
explanation: Valproate has an established highly teratogenic side effect. It should definitely be avoided in pregnancy as it can cause neural tube defects. This woman ideally should be taking a different anti-epileptic for this reason but valproate may be the only option for adequate seizure control.
name: Sodium valproate
label: a
answer: yes
explanation: There is a possibility of adverse effects on neurodevelopment with the use of phenytoin in pregnancy. As the risk is there, it should be avoided but it is not as important to stop as valproate.
name: Phenytoin
label: d
answer: no
explanation: Levetiracetam is considered to be safe in pregnancy, so would not need to be stopped in this case. There are some concerns as the data is quite limited, but it is safer for both the foetus and the mother to have adequate seizure control.
name: Levetiracetam
label: c
answer: no

Correct answer: a
In appendicitis, what is the most common description of the pain?

Options:
explanation: This is a description of the pain in pancreatitis. In terms of anatomy, the epigastric region is roughly where the pancreas is located. However, the appendix is in the right lower quadrant.
name: Epigastric pain which radiates to the back
label: e
answer: no
explanation: This is a description of the pain caused by renal stones. The pain follows this pattern because of where the kidneys are and how the ureters descend to enter the pelvis.
name: Severe back or loin pain which radiates to the lower abdomen
label: b
answer: no
explanation: Suprapubic pain is a common symptom of urinary tract infections or cystitis. This is because of where the bladder is located anatomically. During the first part of appendicitis, patients may complain of suprapubic pain as part of the generalised pain they are feeling.
name: Suprapubic pain
label: c
answer: no
explanation: Correct, this change in pain sensation is due to the afferent nerve fibres from the visceral and parietal peritoneum surrounding the appendix. When the appendix is first inflamed only the visceral peritoneum is irritated which is innervated by nerve fibres from T8-T10. Once the appendix is more inflamed, the parietal peritoneum is also involved which is innervated by the somatic nerve fibres from T10-L1. As these fibres are somatic the pain is more accurately localised to where the appendix is anatomically located.
name: Generalised or central abdominal discomfort which progresses to localised pain in the right iliac fossa
label: a
answer: yes
explanation: This is a description of the pain felt in cholecystitis (inflammation of the gallbladder). The right side of the body is correct for the appendix but it is in the lower quadrant rather than the upper. The pain radiates to the shoulder tip due to the involvement of the phrenic nerve. This could also happen in appendicitis if the appendix ruptures causing peritonitis.
name: Right upper quadrant pain which radiates to the shoulder tip
label: d
answer: no

Correct answer: a