hllj/quesmed huggingface dataset:
A 73-year-old man has presented to the GP with occasional palpitations. He has ischaemic heart disease, type 2 diabetes, and chronic kidney disease. Bloods reveal he is hypocalcaemic, with raised parathyroid hormone and phosphate and normal levels of vitamin D. ECG is unremarkable.

Which of the following is the most appropriate pharmacotherapy?

Options:
explanation: Cinacalcet is a treatment used to treat secondary hyperparathyroidism, although it is reserved for patients on dialysis. It mimics the action of calcium on the tissues (calcimimetic) and increases the sensitivity of calcium receptors on parathyroid cells to reduce PTH
name: Cinacalcet
label: d
answer: no
explanation: Calcitriol is the active form of vitamin D - 1,25-dihydroxycholecalciferol. It increases calcium uptake in the gastrointestinal tract, increases renal absorption of calcium, and stimulates osteoclastic activity. This then sequentially suppresses parathyroid hormone, helping to prevent progression from secondary hyperparathyroidism into tertiary hyperparathyroidism
name: Calcitriol
label: a
answer: yes
explanation: Colecalciferol should not be used to reduce PTH in those with normal vitamin D as an attempt to reduce the risk of progression into tertiary hyperparathyroidism. It can worsen hyperphosphataemia and lead to hypercalcaemia which can worsen cardiovascular morbidity. This would be exacerbated by additional calcium carbonate supplementation and would not improve survival benefit
name: Colecalciferol with calcium carbonate
label: e
answer: no
explanation: Calcitonin can occasionally be used in the treatment of hypercalcaemia by inhibiting osteoclast activity in bones and inhibiting renal reabsorption of calcium and phosphate. This patient is hypocalcaemic, and so this would reduce serum calcium levels further
name: Calcitonin
label: c
answer: no
explanation: Colecalciferol (vitamin D3) is the major form of vitamin D that provides nutritional supplementation. It should not be used to reduce PTH in those with normal vitamin D as an attempt to reduce the risk of progression into tertiary hyperparathyroidism. It can worsen hyperphosphataemia and lead to hypercalcaemia which can worsen cardiovascular morbidity
name: Colecalciferol
label: b
answer: no

Correct answer: a


Learning point: Calcitriol is essential in managing hypocalcaemia, particularly in chronic kidney disease, by enhancing calcium absorption and reducing parathyroid hormone levels.
A 26-year-old woman presents to the GP with paroxysmal allodynia and shock-like pains of the right side of her face. Cranial nerve examination and otoscopy are unremarkable.

Which of the following is the best next step in the management of this patient?

Options:
explanation: While duloxetine is used in other forms of neuropathic pain, there is no evidence for its use in trigeminal neuralgia
name: Duloxetine
label: b
answer: no
explanation: While amitriptyline is used in other forms of neuropathic pain, there is no evidence for its use in trigeminal neuralgia
name: Amitriptyline
label: c
answer: no
explanation: Gabapentin is used as a tertiary line therapy for trigeminal neuralgia, although there is little evidence of its use in randomised controlled trials. Carbamazepine is the only therapy with proven efficacy in randomised controlled trials
name: Gabapentin
label: d
answer: no
explanation: Lamotrigine is used as a tertiary line therapy for trigeminal neuralgia, although its evidence is limited, with a recent Cochrane review suggesting it has no efficacy in its management. Carbamazepine is the only therapy with proven efficacy in randomised controlled trials
name: Lamotrigine
label: e
answer: no
explanation: Carbamazepine is currently the first line for the treatment of trigeminal neuralgia. It acts by inhibiting voltage-gated sodium channels, thereby reducing excitability of neural membranes. It is the only therapy with proven efficacy in randomised controlled trials in treating trigeminal neuralgia
name: Carbamazepine
label: a
answer: yes

Correct answer: a


Learning point: Carbamazepine is the first-line treatment for trigeminal neuralgia, effectively reducing neural excitability by inhibiting voltage-gated sodium channels.
A 71-year-old woman presents to the GP with progressive bilateral facial weakness and diplopia for the past two months, worst in the evenings.

External examination findings are below:

[lightgallery]

Which of the following investigations is most likely to confirm the diagnosis?

Options:
explanation: This patient is experiencing progressive facial weakness, bilateral ptosis, and diplopia - worse on progressive use, suggestive of myasthenia gravis. The first-line investigation is serum AChR antibodies (present in 85% of patients)
name: Acetylcholine receptor (AChR) antibodies
label: a
answer: yes
explanation: A lumbar puncture can be used to help diagnose a variety of neurological conditions. It has no role in the diagnosis of myasthenia gravis and so would only be considered if previous investigations were negative and the diagnosis was unknown
name: Lumbar puncture
label: e
answer: no
explanation: MRI brain can be used to help diagnose a variety of neurological conditions. For myasthenia gravis, it can be used to exclude compressive and inflammatory lesions of the cranial nerves and ocular muscles but is less likely to be diagnostic
name: MRI brain
label: d
answer: no
explanation: Anti-VGCC antibodies can be seen in Lambert-Eaton myasthenic syndrome. Given the patient is not complaining of proximal arm or leg weakness, but predominantly facial weakness, this favours myasthenia gravis as the most likely diagnosis
name: Anti-voltage-gated calcium channels (Anti-VGCC) antibodies
label: c
answer: no
explanation: Thyroid function tests should be done in patients with suspected myasthenia gravis as they can often co-exist together. The best diagnostic test for myasthenia gravis, however, are AChR antibodies
name: Thyroid function tests
label: b
answer: no

Correct answer: a


Learning point: Myasthenia gravis is an autoimmune neuromuscular disorder characterized by weakness and fatigue of voluntary muscles, often associated with the presence of acetylcholine receptor (AChR) antibodies that disrupt nerve signal transmission at the neuromuscular junction.
A 21-year-old woman presents to the emergency department having tripped and fallen onto her right hand. X-ray shows a minimally-displaced clavicular fracture.

On neurological exam, she has bilateral loss of vibration sense in her hands and feet with peripheral sensory loss. She has brisk knee reflexes and upgoing plantars bilaterally.

On further questioning, she states she has been tripping and falling more frequently recently. She reveals that she has been inhaling nitrous oxide recreationally every day for the last 6 months.

Which of the following is the most likely diagnosis?

Options:
explanation: Guillain-Barré Syndrome (GBS) presents with progressive ascending weakness of all limbs. Reflexes are reduced or absent and, if paraesthesia is present, it is often mild
name: Guillain-Barré Syndrome
label: d
answer: no
explanation: Hypoxic brain injury initially affects areas of high metabolic activity, predominantly the hippocampi, thalami, cerebral cortex, corpus striatum, and cerebellar vermi. The consequences of such can be predicted by the areas affected, such as memory impairment, ataxia, poor motor control, and difficulties with complex learning tasks. It would not present with a normal cognitive state and progressive peripheral paraesthesia
name: Hypoxic brain injury
label: b
answer: no
explanation: Excessive nitrous oxide inhalation oxidises the cobalt ion of vitamin B12, interfering with its bioavailability as a co-enzyme. Patients can then develop clinical symptoms of B12 deficiency, particularly subacute combined degeneration of the cord. This affects the posterior and lateral columns of the spinal cord, presenting with gradual upper and lower limb weakness, peripheral paraesthesia, and upper lower motor neurone signs, particularly with loss of vibration and touch sense
name: Subacute combined degeneration of the cord
label: a
answer: yes
explanation: While oxidative stress is known to result in neuroinflammation and subsequent neurodegeneration, it not a known complication from excessive nitrous oxide use
name: Oxidative toxic neuropathy
label: e
answer: no
explanation: Syringomyelia presents with a bilateral loss of sensation to pain and temperature, but with sparing of light touch, vibration, and proprioception. It typically affects the neck, shoulders, and arms when a syrinx is present in the cervical spine
name: Syringomyelia
label: c
answer: no

Correct answer: a


Learning point: Excessive nitrous oxide inhalation can lead to subacute combined degeneration of the cord due to vitamin B12 deficiency.
A 52-year-old woman presents to the GP with acute right foot drop and loss of sensation on the dorsum of the foot. One month ago, she developed ulnar nerve palsy in her left hand, and six months ago, she had developed isolated 4th nerve palsy.

Which of the following conditions is associated with this disorder?

Options:
explanation: Multiple sclerosis typically presents with temporary visual or sensory loss with gradual progression. It can cause spastic weakness, ataxia, and tremor, but wouldn't present with sudden neurological deficit
name: Multiple sclerosis
label: b
answer: no
explanation: Syringomyelia presents with a bilateral loss of sensation to pain and temperature, but with sparing of light touch, vibration, and proprioception. It typically affects the neck, shoulders, and arms when a syrinx is present in the cervical spine. While it can present suddenly with sensory loss, it would not provide the pattern of distribution found in this patients examination findings
name: Syringomyelia
label: e
answer: no
explanation: This patient is experiencing symptoms of mononeuritis multiplex, sporadically developing peripheral neuropathies most commonly from nerve ischaemia secondary to primary or secondary vasculitis. There are multiple causes for this, broadly classifying them into ischaemic (e.g. diabetes mellitus & peripheral nerve vasculitis), inflammatory (e.g. sarcoidosis, rheumatoid arthritis, and Guillain-Barré Syndrome), infectious (e.g. Lyme disease and cytomegalovirus), drug-induced (sulfonamides and hydralazine), genetic, malignant, or primary vasculitides (e.g. giant cell arteritis, granulomatosis with polyangiitis, or polyarteritis nodosa)
name: Rheumatoid arthritis
label: a
answer: yes
explanation: Motor neurone disease presents with gradual progression of upper and lower motor neurone signs. It would not present with the sensory deficit and would not present as rapidly as this
name: Motor neurone disease
label: d
answer: no
explanation: B12 deficiency presents with gradually progressive peripheral paraesthesia. It would not present with such sudden onset with a seemingly random distribution of the peripheral nerves
name: B12 deficiency
label: c
answer: no

Correct answer: a


Learning point: Mononeuritis multiplex can occur in rheumatoid arthritis, presenting as multiple isolated peripheral neuropathies due to nerve ischaemia or inflammation.
A 68-year-old man has presented to accident and emergency with sudden onset vertigo, unchanged on position, with no hearing impairment or tinnitus. He has new hoarseness and dysphagia, struggling to swallow his saliva.

On examination head impulse test is negative; he has right-sided unilateral vertical nystagmus and right-sided skew deviation. He has reduced sensation on the right side of his face with right-sided ptosis and miosis.

Which of the following is the most likely diagnosis?

Options:
explanation: Lacunary infarcts present with relatively distinct symptoms based on the location within the internal capsule. 1) contralateral hemiparesis with dysarthria and dysphagia 2) ipsilateral cerebellar symptoms 3) hemiparesis with contralateral sensory impairment 4) Pure hemisensory loss. It would unlikely present with Horner's syndrome
name: Lacunar infarct
label: e
answer: no
explanation: Vertebrobasilar insufficiency may present in this way, although symptoms are transient, similar to a posterior circulation TIA. They are often triggered by causes of transient reduced cerebral perfusion, such as orthostatic hypotension, which can accentuate previously unknown symptoms
name: Vertebrobasilar insufficiency
label: d
answer: no
explanation: Pontine infarcts can present with a range of signs from ipsilateral cranial nerve palsy (CN V, VI, VII, and VIII) with contralateral motor/sensory impairment to locked-in syndrome. A similar condition to PICA syndrome - lateral pontine syndrome - would likely produce similar symptoms with the addition of ipsilateral facial nerve palsy due to involvement of the facial nucleus
name: Pontine infarct
label: c
answer: no
explanation: Weber syndrome presents as ipsilateral oculomotor nerve palsy and contralateral weakness
name: Weber syndrome
label: b
answer: no
explanation: Sudden onset vertigo, nystagmus, and ipsilateral dysphagia, reduced facial sensation, and Horner's syndrome suggests a central cause, particularly dysfunction of the lateral part of the medulla. This is commonly caused by a posterior inferior cerebellar artery or vertebral artery ischaemia. The sensation of vertigo and nystagmus arises from disruption of the lateral vestibular nucleus; dysphagia due to damage to cranial nerves IX & X; reduced facial sensation from the trigeminal nerve root; and Horner's syndrome from the hypothalamospinal fibres where sympathetic fibres run
name: Posterior inferior cerebellar artery syndrome (PICA syndrome)
label: a
answer: yes

Correct answer: a


Learning point: Posterior inferior cerebellar artery syndrome presents with vertigo, nystagmus, dysphagia, facial sensory loss, and Horner's syndrome due to medullary ischaemia.
A 23-year-old woman with antiphospholipid syndrome is 14 weeks pregnant and develops lower abdominal pain and subsequent vaginal bleeding. A transvaginal ultrasound scan confirms an inevitable miscarriage. She is known to be rhesus negative.

Which of the following is the best next step in the management of this patient with regards to anti-D?

Options:
explanation: An indirect Coombs test can be used to determine whether there are antibodies to the Rhesus factor in the mother's blood and therefore whether she has been "sensitised". A positive Coombs test indicates whether a Rh-positive foetus has the possibility of being harmed from rhesus D alloimmunisation. In this case, a sensitisation event has occurred in a miscarriage >12 weeks, and so anti-D must be given regardless
name: Perform indirect Coombs test before administration of anti-D
label: e
answer: no
explanation: Anti-D is given regardless of the biological father's rhesus status
name: Anti-D only required if the biological father is rhesus positive
label: c
answer: no
explanation: A Kleihauer test measures the amount of foetal haemoglobin transferred from a foetus to a mother's bloodstream following exposure to a sensitising event from a RhD positive baby. It is conducted on all RhD negative women who have delivered a RhD positive baby, in pregnant women who have had a potentially sensitising event at >20 weeks gestation, and on all pregnant women who have had an invasive procedure. The test helps with dosing Anti-D immunoglobulin. In this case, however, a sensitisation event has occurred in a miscarriage >12 weeks, and so anti-D must be given regardless
name: Perform a Kleihauer test before administration of anti-D
label: d
answer: no
explanation: In pregnancies between 12 and 20 weeks gestation, anti-D immunoglobulin should be given in any sensitising event such as miscarriage, even if managed medically. No tests are required prior to administration
name: Give anti-D immunoglobulin within 72hrs
label: a
answer: yes
explanation: Miscarriage in pregnancies >12 weeks require anti-D given to prevent rhesus D alloimmunisation and haemolytic disease of the newborn. It is also required in a number of conditions, including termination of pregnancy, ectopic pregnancy, or abdominal trauma
name: No need for anti-D immunoglobulin
label: b
answer: no

Correct answer: a


Learning point: Administer anti-D immunoglobulin within 72 hours after a miscarriage in Rh-negative women to prevent sensitisation.
A 29-year-old primigravida woman has delivered a healthy baby via vaginal delivery. The placenta was intact on delivery, and there were no initial complications. Unfortunately, the mother continues to bleed following delivery and has now lost 1.1L. Bimanual uterine compression is conducted and the mother is catheterised to empty the bladder. Despite this, she continues to haemorrhage and you begin transfusing blood.

Which of the following is the best next step in the management of this patient?

Options:
explanation: Recombinant factor VIIa is increasingly used in the treatment and control of acute bleeding. While it can be a useful adjunct in achieving haemostasis, simple measures first with IV syntocinon must be given first
name: Give recombinant factor VIIa
label: c
answer: no
explanation: This woman is experiencing significant postpartum haemorrhage, most likely due to uterine atony. After standard resuscitation measures and bimanual uterine compression, the next step is to give IV syntocinon (oxytocin) to induce uterine contractions
name: IV syntocinon
label: a
answer: yes
explanation: Misoprostol is a synthetic prostaglandin E1 analogue and induces uterine contractions to combat postpartum haemorrhage from uterine atony. NICE guidance currently opts for intravenous syntocinon first, although PR misoprostol may be helpful, particularly in low resource settings as it does not need refrigeration or infusion
name: PR misoprostol
label: d
answer: no
explanation: Following basic resuscitation measures, IV or IM ergometrine is given 2nd line for postpartum haemorrhage if IV syntocinon is unsuccessful or contraindicated
name: IV ergometrine
label: b
answer: no
explanation: Selective arterial embolisation is reserved for uncontrolled postpartum haemorrhage despite physical and pharmacological measures. Embolising the artery under radiological guidance reduces the blood supply to the uterus and, therefore capacity to bleed. Conservative measures such as IV syntocinon should be imitated first in this case
name: Selective arterial embolisation
label: e
answer: no

Correct answer: a


Learning point: IV syntocinon (oxytocin) is commonly used in the management of postpartum hemorrhage to stimulate uterine contractions, helping to reduce bleeding by promoting uterine tone.
A 38-year old pregnant woman presents with gradual-onset bilateral painless hearing loss with tinnitus. Otoscopy is unremarkable with a normal tympanic membrane. Weber's test shows no localisation and she is Rinne's negative bilaterally.

Which of the following is the most likely diagnosis?

Options:
explanation: Tympanosclerosis is a cause of bilateral conductive hearing loss, and usually shows signs of scarring of the tympanic membrane with whitish discolouration
name: Tympanosclerosis
label: b
answer: no
explanation: Chronic suppurative otitis media would typically present with chronic inflammation of the middle ear and mastoid cavity with recurrent otorrhoea through a tympanic membrane. It produces a bilateral conductive hearing loss, although otoscopy would show an oedematous auditory canal, discharge, and granulation tissue in the medial canal with possible perforation of the tympanic membrane
name: Chronic suppurative otitis media
label: c
answer: no
explanation: Presbycusis is the leading cause of bilateral sensorineural hearing loss and is characterised by age-related loss of hearing acuity, predominantly at high frequencies. The examination would be Rinne's positive bilaterally in this case with non-localisation in Weber's test
name: Presbycusis
label: d
answer: no
explanation: Multiple sclerosis can rarely present with hearing loss, although it would unlikely produce bilateral hearing loss. It would produce sensorineural hearing loss and so would the patient would be Rinne's positive in one or both ears
name: Multiple sclerosis
label: e
answer: no
explanation: This patient has presented with history and examination findings consistent with bilateral conductive hearing loss and tinnitus. The most common cause of this in young patients is ear wax, although otosclerosis is an important cause, particularly when otoscopy is unremarkable. It is treated with hearing aids and consideration of stapedectomy
name: Otosclerosis
label: a
answer: yes

Correct answer: a
A 28-year-old man with antiphospholipid syndrome presents with sudden painless monocular vision loss while driving. Fundoscopy shows macular oedema and multiple intra-retinal haemorrhages in each quadrant in the right eye. There is also a relative afferent pupillary defect.

Which of the following is the most likely diagnosis?

Options:
explanation: Vertebral artery dissection presents as a severe occipital headache as well as posterior fossa ischaemic symptoms manifesting as ataxia, dysarthria, lateral medullary syndrome, and visual symptoms. It would not present with monocular vision loss or with the fundoscopy findings above
name: Vertebral artery dissection
label: e
answer: no
explanation: Optic neuritis is a gradual worsening of vision due to inflammation of the optic nerve, such as in multiple sclerosis. It would not present with sudden monocular vision loss and would not produce intra-retinal haemorrhages on fundoscopy
name: Optic neuritis
label: d
answer: no
explanation: Retinal detachment typically presents with amaurosis fugax, floaters, and flashing lights. If the retinal detachment were so severe that it would cause full monocular blindness, then it would be visible on fundoscopy. Given the patient's history of antiphospholipid syndrome with a hypercoagulable state, thromboembolic disease is more likely such as central retinal artery/vein occlusion
name: Retinal detachment
label: c
answer: no
explanation: Usually, CRVO presents in older patients with cardiovascular history, diabetes, or hyperlipidaemia. This patient has antiphospholipid syndrome, a condition known to cause a hypercoagulable state, and so puts them at increased risk of thromboembolic disease. Sudden onset monocular vision loss with relative afferent pupillary defect (RAPD) implies a lesion of the optic nerve. As the retinal artery and veins are the sole source of blood supply to the retina, occlusion of either causes severe damage, blindness, and macular oedema
name: Central retinal vein occlusion (CRVO)
label: a
answer: yes
explanation: Ocular migraines can present with transient monocular blindness or flashing lights. They would not produce the fundoscopy findings shown above
name: Ocular migraine
label: b
answer: no

Correct answer: a


Learning point: Antiphospholipid syndrome is a significant risk factor for central retinal vein occlusion (CRVO) as it promotes hypercoagulability, increasing the likelihood of blood clot formation in the retinal veins.