hllj/quesmed huggingface dataset:
56 year old female is referred to neurology due to progressive weakness in her left arm. She describes feeling numb in her hand and has recently been unable to open jars and write text messages using this hand.

The neurologist suspects amyotrophic lateral sclerosis presenting with upper motor neurone signs and symptoms.

What is another sign of an upper motor neurone lesion that may be found in this patient?

Options:
explanation: This sign of a lower motor neurone lesion.

The damage to A-motor neurones with the lower motor neurones leads to less muscle contraction and therefore decreased use of the muscle.

This can lead to loss of muscle mass due to disuse.
name: Muscle Atrophy
label: e
answer: no
explanation: This sign is elicited by firmly stroking the lateral border of the plantar surface of the foot. If positive, the big toe extends and the toes fan out with abduction.

A positive sign is present up until the age of 2. This is because the inhibitory neurones are not yet developed.

However, if over the age of two and the Babinski sign is present, it is suggestive that the inhibitory neurones are damaged and therefore is a lesion in the upper motor neurones.

Therefore, this is a normal finding.
name: Negative Babinski sign
label: b
answer: no
explanation: Inhibitory neurones are found within the upper motor neurones which provide crucial regulation of muscle tone.

When these are damaged, descending inhibition is lost which results in brisk reflexes.
name: Brisk reflexes
label: a
answer: yes
explanation: This sign of a lower motor neurone lesion.

There is no damage to the inhibitory neurones found within the upper motor neurones, so these are still working optimally.

A-motor neurones are found within the lower motor neurones that are essential in muscle contraction. Damage to these, causes a loss of muscle tension at rest, i.e. a loss of muscle tone.
name: Loss of muscle tone
label: c
answer: no
explanation: This sign of a lower motor neurone lesion.

A-motor neurones with the lower motor neurones that contribute to muscle contraction are damaged. This leads to an overall loss of tone. However, they can still fire spontaneously causing small contractions in the muscle unit which can be seen very subtly as twitching of the muscle.
name: Fasciculations
label: d
answer: no

Correct answer: a
60 year old presents to the emergency department with complete paralysis on the right side.

There is a loss of proprioception and vibration on the right side and a loss of temperature and pain sensation on the left

Where is the lesion in the spinal cord?

Options:
explanation: This would present similarly to the case above but the signs would be found on the other side of the body. This would be a hemisection on the other side of the cord
name: Left
label: d
answer: no
explanation: This would cause symmetrical symptoms as the lesion would be found on both sides of the cord.

Dorsal columns would largely be affected so the loss of proprioception and fine touch would be found on both sides.

The spinothalamic tracts would be spared so pain and temperature would not be affected.
name: Posterior
label: c
answer: no
explanation: All tracts would be damaged and the signs would be found bilaterally.
name: Complete transaction
label: e
answer: no
explanation: This question is testing your understanding of the anatomy of the spinal cord. including where the tracts decussate and where they are found in the spinal cord.

The corticospinal tract carries motor information from the frontal lobe to the LMN. The fibres decussate at the medulla and remain contralaterally down the spinal cord. Therefore, a lesion anywhere along the spinal cord will cause paralysis on the same side.

The spinothalamic tracts are found in the anterior cord and carry pain and temperature up to the cortex. The fibres decussate at the level of the spinal cord. Therefore, a lesion anywhere along the spinal cord will cause loss of pain and temperature on the opposite side.

The dorsal columns are found in the posterior cord where they carry proprioception and touch up to the cortex. The fibres decussate at the medulla and remain on the same side up the spinal cord. Therefore, a lesion anywhere along the spinal cord will cause proprioception loss on the same side.
name: Right
label: a
answer: yes
explanation: This would cause symmetrical symptoms as the lesion would be found on both sides of the cord.

The spinothalamic tracts would be largely affected. Loss of pain and temperature would be found on both sides.

Dorsal columns would be spared so proprioception and fine touch would still be intact.
name: Anterior
label: b
answer: no

Correct answer: a
40 year old female presents with symmetrical weakness of the face.

Her clinic appointment was at 5pm.

On examination, she appears to have dry red eyes with ptosis and a drooping smile on both sides of her face. When asked to raise her eyebrows she is unable to do so.

She explains that she also experiences trouble chewing and swallowing and that it usually improves with rest and progressively worsens throughout the day.

What is affected by this autoimmune condition?

Options:
explanation: This is found within the brain and contains dopaminergic neurones.

Dopamine within this structure are lost in Parkinson's disease and can cause rigidity, tremor and slow movements/ bradykinesia.
name: Substantia nigra
label: d
answer: no
explanation: This is affected by the condition Horner's syndrome which presents with the triad of miosis, ptosis and anhidrosis.

A lesion anywhere along this lesion can cause these symptoms.

Not an autoimmune condition. Can be caused by a pancoast tumour in the lungs.
name: Oculosympathetic pathway
label: b
answer: no
explanation: This case is describing the presentation of Myasthenia Gravis syndrome.

This is due to antibodies blocking the acetylcholine receptors at the neuromuscular junction.

This case may make you think about Bell's palsy - remember this would present asymmetrically and due to damage of the facial nerve (forehead is not spared in LMN lesion).
name: Acetylcholine receptor
label: a
answer: yes
explanation: This is not targeted in this condition.

Guillian Barre can cause demyelination following infections such as campylobacter. This is due to molecular mimicry - the antibodies produced in this infection can target and destroy myelin on neurones.

This presents with a symmetrical, ascending polyneuropathy (weakness and numbness).
name: Myelin sheath
label: c
answer: no
explanation: Calcium channels are found within the pre-synaptic terminals. Calcium channels allow the influx of calcium which causes the release of Ach into the synapse of the neuromuscular junction.

These are affected by Lambert Eaton syndrome.

This causes proximal muscle weakness and typically occurs in small-cell lung cancer where antibodies target these channels.
name: Calcium channels
label: e
answer: no

Correct answer: a
A 45 year old male is admitted to the hospital following an acquired traumatic brain injury.

He can speak in full sentences but it takes a while for him to do so. He is getting frustrated because he cannot find the words to express how he feels and cannot name objects around him.

Which of the following best describes the patient's presentation?

Options:
explanation: Also known as receptive aphasia.

When the Wernicke's area is damaged in the temporal lobe, the person is unable to understand what other people are saying to them.

they speak fluently but with words that don't make sense. However, they do not realise what they are saying is nonsense.
name: Wernicke's aphasia
label: b
answer: no
explanation: This is a loss of muscle coordination which can result in difficulties in formulating speech.
name: Dyspraxia
label: e
answer: no
explanation: Also known as expressive aphasia.

When the Broca area in the frontal lobe is damaged, the person can understand what is said to them but struggles to communicate back.

They are able to form sentences that make sense but it takes them a while to select the correct words - speech is often limited.
name: Broca's aphasia
label: a
answer: yes
explanation: This refers to swallowing difficulty.
name: Dysphagia
label: d
answer: no
explanation: Dysarthria is a disorder of speech whereas dysphasia is a disorder of language.

In dysarthria, the person is able to understand language, form sentences and have no difficulty finding words.

However, those with dysarthria may have difficulty producing speech due to weak facial muscles.
name: Dysarthria
label: c
answer: no

Correct answer: a
80 year old attends the emergency department distressed saying he has had a stroke.

He begins to explain that he has experienced an episode of facial drooping and arm weakness on the same left side. This began 2 hours ago and was resolved within 15 minutes. There was some vision loss during this time but resolved at the same time as the weakness.

There was no loss of consciousness.

On examination he seems alert and orientated, his vital signs are normal with no fever.

What is the likely diagnosis?

Options:
explanation: This is described as a rapid, transient loss of consciousness followed by a spontaneous, complete recovery.

Causes can be due to emotion or stress which is referred to as reflex syncope or fainting. Other causes include low blood pressure, bradycardia and other arrhythmias.

There is no loss of consciousness in this case so can be ruled out.
name: Syncope
label: b
answer: no
explanation: This type of stroke is caused by the rupture of aneurysms within the brain. This can be spontaneous but risk factors include hypertension, drug use, age or trauma.

stroke is a clinical syndrome characterised by rapid focal disturbance of cerebral function. This can include motor weakness, sensory loss, speech and swallowing impairment.

When a patient presents with these features an urgent CT scan is required to confirm the diagnosis and guide further management. This is important as you cannot tell the difference between ischaemic strokes from haemorrhagic strokes just from the clinical picture.
name: Haemorrhagic Stroke
label: c
answer: no
explanation: Presents with similar symptoms of a stroke but is less than 24 hours. The episodes usually last about an hour and have resolved by the time they seek medical attention.

These patients should be taken seriously as TIA can increase the risk of stroke in the future.

Refer to a TIA stroke clinic for urgent assessment in 24 hours if this is suspected. Do not discharge with no follow-up.
name: Transient Ischaemic attack (TIA)
label: a
answer: yes
explanation: According to the Monro-Kellie doctrine of ICP, the skull is a fixed box and there is an equilibrium between the CSF, blood and brain. If one of these components increases in volume another would have to decrease to compensate.

When there is too much change in volume and compensatory mechanisms fail, the ICP can quickly increase and cause displacement of the brain parenchyma.

This presentation can include headaches, stiff neck, slow pulse, weakness and loss of consciousness. This can be very serious and deteriorate quickly.

Focal neurological deficits aren't usually seen.
name: Brain herniation
label: e
answer: no
explanation: This refers to the inflammation of the meninges that surround the brain.

This usually presents with confusion, fevers, headache and neck stiffness.

Focal neurological deficits aren't usually seen but if encephalitis has developed, this could be elicited on examination
name: Meningitis
label: d
answer: no

Correct answer: a
30 year old woman is struggling with recurrent migraines.

When she brushes her or even touches her head it provokes the pain to worsen.

Which of the following terms defines this symptom?

Options:
explanation: This refers to a diminished response to a painful stimulus.

Analgesia is the absence of pain and hypoalgesia is reduced pain to a painful stimulus.
name: Hypoalgesia
label: e
answer: no
explanation: This refers to pain resulting from a stimulus such as light touch which shouldn't normally cause pain.

This is often described as migraines and tension headaches.
name: Allodynia
label: a
answer: yes
explanation: This refers to the absence of pain in response to a stimulus which would normally cause pain.

This is why painkillers such as morphine and paracetamol are also referred to as analgesia.
name: Analgesia
label: b
answer: no
explanation: An abnormal, additional sensory response such as pins and needles can be spontaneous or provoked.
name: Paraesthesia
label: d
answer: no
explanation: This refers to a disproportionately increased pain response to a painful stimulus.

This can be due to neuropathy where a specific nerve becomes more sensitive to pain.
name: Hyperalgesia
label: c
answer: no

Correct answer: a
80 year old with diabetes has an eGFR of 50 ml/min/1.73m2 on a routine check.

He says he has felt more tired than usual but has no specific symptoms.

Which of these are you most likely to find with the further investigation?

Options:
explanation: In CKD, albumin is often lost in the urine.

Albuminuria and eGFR together are used to stage CKD in the KDIGO criteria.

Hyperalbuminaemia is uncommon and usually suggests dehydration.
name: Hyperalbuminaemia
label: e
answer: no
explanation: The kidneys have a Na+/K+ pump in the DCT which results in the reabsorption of sodium and the excretion of potassium.

This pump can become faulty in CKD so sodium is not reabsorbed as it should be.

Hypernatraemia results when more is reabsorbed by the kidneys. This can be a response to dehydration as absorption of water will increase also.
name: Hypernatraemia
label: c
answer: no
explanation: The kidneys have a Na+/K+ pump in the DCT which results in the reabsorption of sodium and the excretion of potassium.

This pump can become faulty in CKD so potassium is not excreted as it should be.
name: Hypokalaemia
label: d
answer: no
explanation: Hypocalcaemia is most likely to result from CKD.

This is because there is diminished renal production of the active form of vitamin D. Vitamin D is required for increased absorption of calcium from the intestine
name: Hypercalcaemia
label: b
answer: no
explanation: Chronic Kidney Disease (CKD) is the most likely diagnosis in this case as he has a risk factor of diabetes and a reduced eGFR. The vague symptoms of tiredness suggests that it has developed over a long period.

In CKD, the most common imbalances that occur are hyponatraemia (low sodium) and hyperkalaemia (high potassium).

The kidneys have a Na+/K+ pump in the DCT which results in the reabsorption of sodium and the excretion of potassium.

This pump can become faulty in CKD so sodium is not reabsorbed as it should be.
name: Hyponatraemia
label: a
answer: yes

Correct answer: a
A 56 year old, post-menopausal woman presents with early satiety, bloating and weight loss.

The GP wants to rule out Ovarian cancer and intends to work out a (Risk of Malignancy Index) RMI score.

Which of these factors are not included in the Risk of Malignancy score?

Options:
explanation: This is an ultrasound scan feature that scored 1 point in the RMS.

Ultrasound result is based on how malignant the mass appears. Complex, multiocular has a more complex appearance with multiple septae within the cyst, this suggests it is more likely to be cancerous.

Be aware that a benign lesion is more likely to be unilateral and look uniocular/ simple on ultrasound, this means that they are uniformly thin-walled with a single cavity. Benign lesions are likely to be smooth, well-circumscribed and are not able to spread.
name: Complex, multiocular cysts on ultrasound scan
label: d
answer: no
explanation: Levels over 35U/ml may indicate the presence of cancer within the body and are most associated with ovarian cancer.

This can be raised in pre-menopausal women due to conditions other than ovarian cancer such as endometriosis and pregnancy.

This marker should not be used in isolation when assessing the risk of ovarian cancer. Therefore is combined with menopausal status and ultrasound features to produce the risk score.
name: Ca-125
label: b
answer: no
explanation: The risk of Malignancy index (RMI) is a combined score that predicts the risk of an adnexal mass being malignant.

It includes a raised Ca-125 (the ovarian cancer marker), menopausal status and ultrasound scan features. These are then multiplied together to determine the risk and best next steps for investigations of the patient.

As with most cancers, the risk of ovarian cancer does increase with age but the majority develop after menopause which is a better predictor.
name: Age
label: a
answer: yes
explanation: Most cases of ovarian cancer happen in those that have already gone through menopause.

The definition of a post-menopausal female has not had a period for more than 12 months. The average age is 50 years old.

Pre-menopausal women score 1 point, post- menopausal score 3 points.
name: Menopausal status
label: c
answer: no
explanation: This is a USS feature that is highly suggestive of malignancy.
name: Metastases on ultrasound scan
label: e
answer: no

Correct answer: a
60 year old attends the GP concerned that he may have prostate cancer. He is aware that his father died from prostate cancer and is now seeing a lot about it in the media. He explains he feels as though he is going to the toilet more to empty his bladder at night.

The GP decides to measure the prostate-specific antigen (PSA) and perform a digital rectal examination (DRE).

PSA is raised and DRE reveals a slightly hard, craggy prostate.

Where is the most common site for prostate cancers?

Options:
explanation: These ducts arise from the seminal vesicles and ductus deferens. These pass through the central zone but are not part of the prostate itself.
name: Ejaculatory ducts
label: d
answer: no
explanation: This case is suggestive of prostate cancer due to the raised PSA and a DRE suggestive of a malignant growth.

You would expect the prostate to feel smooth and spongy with a central sulcus. In prostate cancer, it tends to feel harder and nodular with a loss of the sulcus.

PSA is often not very specific as it can be raised in other circumstances such as in infection, following recent ejaculation and cycling. It is therefore not routinely tested for but those over 50 can ask the GP for a test if they would like one.

Most cancers arise in the peripheral zone and are further away from the urethra. The peripheral zone consists of mainly glandular tissue so often produces of adenocarcinomas. They do not always cause urinary symptoms in early disease.
name: Peripheral zone
label: a
answer: yes
explanation: This part of the prostate surrounds the ejaculatory ducts and is a common site for BPH but not prostate cancer.
name: Central zone
label: c
answer: no
explanation: As men get older over the age of 50, the prostate gland naturally becomes larger. This is known as benign prostatic hyperplasia.

This most likely arises in the transition zone of the prostate. This is what surrounds the urethra and is most likely to cause lower urinary tract symptoms such as nocturia, frequency, urgency and post-micturition dribbling.
name: Transition zone
label: b
answer: no
explanation: There are four major zones of a normal prostate: the peripheral zone, the central zone, the transition zone and the anterior fibromuscular stroma.

The anterior fibromuscular stroma has no glandular tissue and is not a common site for prostate cancer or BPH.
name: Anterior fibromuscular stroma
label: e
answer: no

Correct answer: a
A 38 year old woman attends a pharmacy asking for an ovulation test. She states she has a 28-day cycle.

The pharmacist explains that ovulation occurs 14 days before the menstrual period. Therefore she must take the test on days 10-14 after her menstrual period.

What hormone spikes just before ovulation that is measured in the ovulation test?

Options:
explanation: This hormone is released by the pituitary and is mainly present in the follicular phase (before ovulation).

This hormone stimulates the growth of eggs in the ovaries and triggers the release of oestrogen from the granulosa cells that surround the follicles.
name: Follicle- stimulating hormone (FSH)
label: b
answer: no
explanation: This hormone rises after ovulation.

Progesterone helps maintain the endometrial lining during the luteal phase after oestrogen has helped proliferation in the follicular phase.

The decrease in progesterone causes the lining to be shed and menstruation to begin.
name: Progesterone
label: c
answer: no
explanation: This hormone rises during the follicular phase triggered by the FSH.

It helps the endometrium proliferate and triggers LH to be released for the initiation of ovulation.
name: Oestrogen
label: d
answer: no
explanation: This surge occurs about 24-36 hours before ovulation.

It triggers the release of the egg from the ovary.
name: Luteinising hormone (LH)
label: a
answer: yes
explanation: This hormone is produced by the corpus luteum in the ovary if fertilisation occurs.
name: Human Chorionic Gonadotropin (HCG)
label: e
answer: no

Correct answer: a
30 year old female attends a sexual health clinic after she noticed multiple fleshy flat, papular growths on washing.

They do not itch or cause pain.

Diagnosis of genital warts is made.

Which of the following are most liklet to be responsible for this presentation?

Options:
explanation: HSV1 and 2 are responsible for oral herpes. Also known as cold sores.

HSV1 is most associated with oral herpes and HSV2 is most associated with genital herpes.

However, they both can cause oral and genital herpes. HSV2 is most likely associated with recurrent symptoms.
name: Herpes Simplex Virus (HSV)
label: c
answer: no
explanation: These are most responsible for HPV-related cervical cancer.

They are classed as high-risk and are screened for cervical smears.
name: Human papilloma virus (HPV) 16 and 18
label: b
answer: no
explanation: This is a type of chlamydia trachomatis infection.

This can often cause swollen lymph glands in the groin on one or both sides or an ulcer around the genitals which is painful.
name: Lymphogranuloma Venereum (LGV)
label: d
answer: no
explanation: bacterial Vaginosis is due to the overgrowth of this bacteria and reduced growth of lactobacillus. This results in increased PH with offensive, fishy-smelling discharge.
name: Gardnerella vaginalis
label: e
answer: no
explanation: HPV 6 and 11 are low-risk and cause about 90% of genital warts.

Warts rarely develop into cancer.
name: Human Papilloma Virus (HPV) 6 and 11
label: a
answer: yes

Correct answer: a