hllj/quesmed huggingface dataset:
A 20-year-old man presents to A&E with severe right-sided upper chest pain following a road-traffic accident. On examination, they appear to have a "dropped shoulder" appearance. A fracture around his area of pain is suspected.

An X-ray is taken and a diagnosis of a mid-clavicular fracture is made. [lightgallery]

Which of the following muscles contributes to the elevation of the medial segment of the clavicle?

Options:
explanation: The sternocleidomastoid has two origins. The medial head originates from the sternum and the lateral head originates from the medial clavicle. So when there is a mid-clavicular fracture (most commonly the middle 1/3rd of the clavicle), the sternocleidomastoid elevates the medial aspect of the clavicle, whilst the lateral aspect of the clavicle drops as the trapezius is unable to hold the lateral segment up against the weight of the upper limb.
name: Sternocleidomastoid
label: a
answer: yes
explanation: This muscle originates from the 3rd-5th ribs and inserts onto the coracoid process of the scapula. Therefore it does not exert any mechanical forces on the clavicle and is not responsible for this altered position.
name: Pectoralis minor
label: d
answer: no
explanation: This muscle originates from the transverse processes of C3-C6 vertebrae and inserts onto the upper face of the upper rib. Therefore, this muscle does not exert any mechanical forces onto the clavicle and does not contribute to the altered position of the clavicle in this form of fracture.
name: Scalenus anterior
label: e
answer: no
explanation: The clavicular head of pectoralis major originates from the clavicle and the sternocostal head originates from the sternum and the upper 6 costal cartilages. The fibres then collectively insert onto the intertubercular sulcus of the humerus. This muscle is responsible for medial rotation and adduction of the shoulder at the glenohumeral joint so following a fracture of the midclavicle, the shoulder is medially rotated and partially adducted.
name: Pectoralis major
label: c
answer: no
explanation: The trapezius does not originate or insert onto the medial aspect of the clavicle. This muscle is unable to hold the lateral aspect of the clavicle against the weight of the upper limb, leading to a dropped shoulder appearance when clavicle is broken.
name: Trapezius
label: b
answer: no

Correct answer: a
A 68-year-old woman presents to A&E following a fall onto her left hip. She reports pain around the hip and groin on the left-hand side. On examination her left leg is shortened, abducted and externally rotated and when palpating her greater trochanter area her pain is further exacerbated.

An X-ray is taken and a displaced intracapsular neck of femur fracture is seen.

Which of the following arteries is likely to be most disrupted in this form of fracture, resulting in avascular necrosis of the femoral head?

Options:
explanation: The artery of the ligamentum teres is a branch of the obturator artery, so it has some contribution to the blood supply of the femoral head. However, this artery is less likely to be damaged in this form of fracture compared to the medial femoral circumflex artery, making this option incorrect.
name: Obturator artery
label: e
answer: no
explanation: The lateral femoral circumflex artery is less likely to become damaged in a neck of femur fracture and does not supply the femoral head.
name: Lateral femoral circumflex artery
label: b
answer: no
explanation: The correct answer is the medial femoral circumflex artery (MFCA). The artery of the ligamentum teres  does provide some blood supply to the femoral head, however it does not supply the majority like the MFCA. This artery is also less likely to be damaged in an intracapsular neck of femur fracture.
name: Artery of the ligamentum teres
label: c
answer: no
explanation: The medial femoral circumflex artery (MFCA) is the most common artery to be damaged in a displaced intracapsular neck of femur fracture. This main thing to note is that this is a 68 year-old post-menopausal woman, who is likely to have osteoporosis due to oestrogen deficiency. The MFCA, especially the ascending (retinacular) branches provide a large proportion of the blood supply to the femoral head. This means that the artery of the ligamentum teres which also supplies the femoral head is no longer able to provide a sufficient blood supply to sustain the metabolic demand of the femoral head, which consequently leads to avascular necrosis.
name: Medial femoral circumflex artery
label: a
answer: yes
explanation: The correct answer is the medial femoral circumflex artery (MFCA). Whilst the MFCA is a branch of the profunda femoris artery, the profunda femoris itself is less likely to be damaged in this form of fracture, making this option incorrect.
name: Profunda femoris artery
label: d
answer: no

Correct answer: a
A 42-year-old woman with breast cancer is scheduled for a mastectomy with axillary clearance. After the operation she presents with a 'funny looking' right shoulder. On examination, her right scapula is noted to protrude when she is asked to place her right hand against a wall and push.

Which of the following the spinal nerve roots and associated muscle is implicated in this injury?

Options:
explanation: This patient demonstrates winging of the scapula, a complication of surgical damage to the long thoracic nerve. C5,C6,C7 are the correct spinal nerve roots, making this option partially correct. However the pectoralis minor is not associated with damage to the long thoracic nerve, and not associated with winging of the scapula. Instead, pectoralis minor is innervated by the medial pectoral nerve which has spinal nerve roots C8-T1. This option is therefore incorrect.
name: C5,C6,C7 and pectoralis minor
label: c
answer: no
explanation: This patient demonstrates winging of the scapula, a recognised complication of surgery in the axilla. The nerve that is affected is known as the long thoracic nerve, which originates from the ventral rami of the C5,C6,C7 spinal roots of the brachial plexus. The muscle innervated by this nerve is known as the serratus anterior muscle, which is responsible for holding the medial border of the scapula against the ribcage. Hence when this muscle is paralysed, the medial border of the scapula is no longer held against the ribcage, resulting in winged scapula appearance.
name: C5,C6,C7 and serratus anterior
label: a
answer: yes
explanation: This patient demonstrates winging of the scapula, a complication of surgical damage to the long thoracic nerve. The long thoracic nerve is supplied by C5,C6,C7. By contrast, C3,C4,C5 are the roots of the phrenic nerve which innervates its own ipsilateral hemidiaphragm.
name: C3,C4,C5 and serratus anterior
label: b
answer: no
explanation: This patient demonstrates winging of the scapula, a complication of surgical damage to the long thoracic nerve (C5,C6,C7). The subscapularis is innervated by the upper and lower subscapular nerves, and paralysis of it does not lead to winging of the scapula.
name: C5,C6 and subscapularis
label: e
answer: no
explanation: This patient demonstrates winging of the scapula, a complication of surgical damage to the long thoracic nerve (C5,C6,C7). The pectoralis major muscle is innervated by the medial and lateral pectoral nerves, and paralysis of it does not lead to winging of the scapula.
name: C4,C5,C6 and pectoralis major
label: d
answer: no

Correct answer: a
A 68-year-old man presents to A&E with central crushing chest pain referring to the jaw and arm. He also reports feeling sweaty and nauseous. A subset of an acute coronary syndrome is suspected, in particular a myocardial infarction.

An ECG of this patient is taken shown below: [lightgallery]

Which of the following arteries is most likely to have become occluded?

Options:
explanation: This supplies the anterior region and apex of the heart, including the cardiac structures around the interventricular septum of the heart. Occlusion of the left anterior descending artery would appear as V1-V4 ST-segment elevations on an ECG. By contrast, this ECG shows ST-elevations in leads II, III and aVF.
name: Left anterior descending artery
label: b
answer: no
explanation: This artery is a branch of the left main coronary artery and supplies the lateral aspect of the left ventricle all the way to the apex. By contrast, this patient demonstrates ECG changes in the inferior region of the heart.
name: Left marginal artery
label: d
answer: no
explanation: This artery is a branch of the right coronary artery, which supplies the posterior aspect of the heart at the posterior interventricular septum. This can present as tall R waves in leads V1 and V2. By contrast, this patient demonstrates ECG changes in the inferior region of the heart.
name: Posterior interventricular artery
label: e
answer: no
explanation: The left circumflex coronary artery supplies the left atrium and the postero-lateral aspect of the left ventricle. This would lead to ST-segment elevations in the lateral leads, rather than inferior leads.
name: Left circumflex coronary artery
label: c
answer: no
explanation: The ECG shows ST-elevations in leads II, III and aVF. The leads II,III and aVF represent the electrical activity occurring in the inferior region of the heart which consists of the right ventricle and the right atrium of the heart. These are supplied by the right coronary artery.
name: Right coronary artery
label: a
answer: yes

Correct answer: a
A 65-year-old woman attends a cardiology clinic for an echocardiogram. She is diagnosed with left ventricular heart failure secondary to aortic valve stenosis. A set of values have been measured to determine her cardiac function, and are as follows:

Systolic/Diastolic Blood Pressure: 144/96 mmHg

Heart Rate: 86 beats/min

Cardiac Output: 3.5L/min

Stroke volume: 52 mL/beat

End diastolic volume: 92 mL/beat

Which of the following describes the ejection fraction and heart failure classification of this patient's heart?

Options:
explanation: No, this is not the right answer using the ejection fraction calculation.
name: 38% and Heart Failure with Reduced Ejection Fraction
label: c
answer: no
explanation: There are many values present here to mislead you. In order to calculate ejection fraction, you need to know the stroke volume and the end diastolic volume. Ejection fraction = stroke volume / end diastolic volume. This is calculated as 52/92 = ~ 57%.

If the ejection fraction were <40% the classification of heart failure would be HFrEF (Heart Failure with Reduced Ejection Fraction). If it was >50%, it would be HFpEF (Heart failure with Preserved Ejection Fraction). As the ejection fraction is 57% (> 50%), this patient has HFpEF.
name: 57% and Heart Failure with Preserved Ejection Fraction
label: a
answer: yes
explanation: This is the correct ejection fraction value. However, an ejection fraction of 57% is classified as Heart Failure with Preserved Ejection Fraction.
name: 57% and Heart Failure with Reduced Ejection Fraction
label: d
answer: no
explanation: No, this is not the right answer using the ejection fraction calculation.
name: 38% and Heart Failure with Preserved Ejection Fraction
label: e
answer: no
explanation: No, this is not the right answer using the ejection fraction calculation.
name: 63% and Heart failure with Preserved Ejection Fraction
label: b
answer: no

Correct answer: a
A 28-year-old pregnant woman visits the antenatal clinic for a third trimester review. A ventricular septal defect (VSD) is detected, presenting as a shunt between the left and right ventricles. The process of developing this heart defect is due to the failure in part of an embryological process during pregnancy.

Which of the following embryological processes is likely to have resulted in this defect?

Options:
explanation: This is the cause of a patent ductus arteriosus, which forms a shunt between the aorta and the pulmonary trunk. It does not cause the development of a VSD.
name: Failure of the ductus arteriosus to close at birth
label: e
answer: no
explanation: The ostium secundum is present in the embryology of the inter-atrial septum (the septum between the right and left atria). If it is too large within the septum primum, it can result in an atrial septal defect. It does not cause the development of a VSD.
name: Ostium secundum defect with an abnormally large opening
label: c
answer: no
explanation: Atherosclerotic damage occurs as a result of plaque build-up over the lifespan. It is not a cause of congenital heart defects in a developing foetus. It is not a cause of a VSD.
name: Atherosclerotic damage to the interventricular septum
label: b
answer: no
explanation: This occurs in a AVSD - atrioventricular septal defect. It does not cause the development of a VSD.
name: Failure of the endocardial cushions to develop properly
label: d
answer: no
explanation: The foetus has a congenital heart defect responsible for the flow of oxygenated blood from the left ventricle to the right ventricle. This is due to a VSD (ventricular septal defect). You may recall from embryology of the heart that the muscular portion of the interventricular septum grows cranially from the base of the heart tissue towards the endocardial cushions. Then, the membranous portion grows caudally from the endocardial cushions to close the primary interventricular foramen. In a VSD, the membranous portion of the interventricular septum is most likely to fail in development.
name: Membranous portion of the interventricular septum fails to develop
label: a
answer: yes

Correct answer: a
A 56-year-old man attends the cardiology clinic with reports of intermittent chest pain and dyspnoea. He has also experienced unexplained loss of consciousness on two occasions.

An ECG for this patient is taken shown below. [lightgallery]

The cardiologist explains that it shows an impairment of electrical conduction between the atria and the ventricles of the heart.

Which of the following is the most likely diagnosis?

Options:
explanation: No, this is not the correct answer. This would result in a wide QRS complex with the atrial and ventricular rate being independent of each other. This due to the ventricular pacemaker cells taking over the control of ventricular depolarisation.
name: 3rd degree heart block
label: e
answer: no
explanation: No, this is not the correct answer. This would result in a PR interval that is >0.2 seconds without any skipped beats.
name: 1st degree heart block
label: c
answer: no
explanation: No, this is not the correct answer. This would present with successively longer PR intervals until one QRS complex is dropped. There is no progression in the PR interval on this ECG.
name: 2nd degree heart block mobitz type I
label: b
answer: no
explanation: No, this is not the correct answer. This would lead to a wide QRS complex with no change to the PR interval.
name: Bundle branch block
label: d
answer: no
explanation: The ECG shows a sudden drop in the QRS complex without any PR interval elongation. The P waves remain normal and the QRS complexes are of a normal width. This can be differentiated from 2nd degree heart block mobitz type I, which shows PR intervals that become successively longer until one QRS complex is dropped.
name: 2nd degree heart block mobitz type II
label: a
answer: yes

Correct answer: a
An 86-year-old man presents to the GP with central chest pain that occurs when he is walking around, and three episodes of 'blacking out'. The patient has no other signs and symptoms currently. On auscultation of the patient's heart valves a murmur is detected.

Blood Pressure: 108/72 mmHg

Heart Rate: 89 bpm

JVP: 7.5 cm H2O (6 - 8 cm H2O)

Stroke Volume: 54 mL/beat

End Diastolic Volume = 120 mL/beat

Which of the following auscultation findings is most likely to be heard?

Options:
explanation: This patient has symptoms of aortic valve stenosis. Angina occurs due to reduced perfusion through the aorta and into the coronary arteries of the heart. Syncope occurs due to reduced perfusion of oxygenated blood to the brain via the internal carotid arteries (branches of the aortic arch). The patient is also 86 years old, which may suggest a senile calcification or fibrosis of this patient's aortic valve, resulting in stenosis. The aortic valve is auscultated on the right 2nd intercostal space on the sternal edge.
name: Ejection-systolic murmur on the right 2nd intercostal space sternal edge
label: a
answer: yes
explanation: This patient has symptoms of aortic valve stenosis. This option describes the correct murmur, but this is the incorrect location of the aortic valve.
name: Ejection-systolic murmur on the left 2nd intercostal space sternal edge
label: b
answer: no
explanation: This is the incorrect murmur. A mid-diastolic murmur is often seen in mitral valve stenosis, which is likely to cause symptoms of pulmonary oedema (dyspnoea) or dysphagia, due to compression of the oesophagus.
name: Mid-diastolic murmur on the left 4th intercostal space sternal edge
label: d
answer: no
explanation: This is the incorrect murmur. An early diastolic murmur is often seen in aortic valve regurgitation, which is likely to cause an increased systolic pressure and a decreased diastolic pressure, which is not seen in this patient. The patient may also present with a bounding pulse such as Quinke's sign (visible capillary pulsations following light compression applied to the tip of the fingernail bed) and head bobbing.
name: Early diastolic murmur on the right 2nd intercostal space sternal edge
label: e
answer: no
explanation: This is the incorrect murmur. A mid-diastolic murmur is often seen in mitral valve stenosis, which is likely to cause symptoms of pulmonary oedema (dyspnoea) or dysphagia, due to compression of the oesophagus.
name: Mid-diastolic murmur on the left 5th intercostal space mid-clavicular line
label: c
answer: no

Correct answer: a
A 45-year-old man presents to the GP with fatigue and recent weight loss. He reports having suffered some episodes of sweating during the night and also a loss of appetite.

On examination of his hands, he appears to have symptoms related to septic thrombi, such as Osler nodes and splinter haemorrhages. He also mentions having some upper teeth pain due to his recent dental surgery. Prior to this episode, he was fit and well, with no significant past medical history.

A diagnosis of infective endocarditis is made.

Which of the following is the most likely causative pathogen?

Options:
explanation: This is the most common cause of infective endocarditis, but not in this patient. His recent dental surgery makes streptococcus mutans a more likely diagnosis.
name: Staphylococccus aureus
label: b
answer: no
explanation: As the stem mentioned, the patient is diagnosed with infective endocarditis. In most cases the most common causative pathogen would be staphylococcus aureus. However the patient mentions that he has had recent dental surgery. In dental surgery, there is likely to be bleeding within the gums/oral cavity. Streptococcus mutans is a gram-positive bacterium that is a commensal in the oral cavity and hence it is possible for some of the bacteria from the oral cavity to be transferred into the bloodstream. These bacteria can lodge onto a vegetation within the heart and cause further fibrin deposition and platelet aggregation. They can also form microcolonies, in which the superficial colonies embolise to further tissues such as the skin of the hands, leading to e.g. Osler nodes.
name: Streptococcus mutans
label: a
answer: yes
explanation: No, this is not a common cause of infective endocarditis.
name: Streptococcus pyogenes
label: d
answer: no
explanation: No, this is a coagulase negative staphylococci which would be present in prosthetic valve replacement <1 year post-operation.
name: Staphylococcus epidermidis
label: c
answer: no
explanation: No, this is not a common cause of infective endocarditis.
name: Escherichia coli
label: e
answer: no

Correct answer: a
A 67-year-old man presents to the GP with symptoms of headache, fever and pruritic skin changes on his back. On examination, the GP notes the presence of small vesicles distributed in a specific anatomical pattern around the skin. A diagnosis of shingles is made, where the causative pathogen is varicella-zoster-virus.

In which part of the central nervous system is the varicella-zoster virus most likely to remain dormant?

Options:
explanation: No, this is not the correct answer. The ventral root provided motor supply via the spinal nerves. The varicella-zoster virus remains dormant in the dorsal root ganglion.
name: Ventral root
label: b
answer: no
explanation: Yes, this is the correct answer. The varicella-zoster virus remains dormant within the dorsal root ganglion of the central nervous system and once activated the virus can travel more distally through the spinal nerve and infect the skin in the distribution of the specific spinal nerve. This often presents as dermatomal lesions. Note that a dermatome refers to an area of skin supplied/innervated by a single spinal nerve.
name: Dorsal root ganglion
label: a
answer: yes
explanation: No this is not the correct answer. The varicella-zoster virus remains dormant in the dorsal root ganglion.
name: Cerebellum
label: c
answer: no
explanation: No this is not the correct answer. The sympathetic ganglion is where pre-ganglionic sympathetic neurons synapse with post-ganglionic sympathetic neurons to supply the autonomic functions of tissues. The varicella-zoster virus remains dormant in the dorsal root ganglion.
name: Sympathetic ganglion
label: d
answer: no
explanation: No this is not the answer. Varicella-zoster can remain dormant in this structure, however, this only occurs in trigeminal herpes zoster. In trigeminal herpes zoster, there are vesicles located in the skin of the face. By contrast, this patient has skin lesions on his back, making this option less likely.
name: Trigeminal ganglion
label: e
answer: no

Correct answer: a
A 23-year-old woman presents to the GP with a persistent dry cough and pleuritic chest pain.

A set of observations are measured:

Respiratory Rate: 25 breaths/min

Temperature: 39.8° C

Blood Pressure 100/72 mmHg

Heart Rate: 78 beats/min

A diagnosis of  pneumonia is made, for which she is prescribed clarithromycin.

Which of the following describes the mechanism of action of clarithromycin?

Options:
explanation: Clarithromycin is a macrolide antibiotic that inhibits bacterial protein synthesis. It does not have any anti-viral actions.
name: Inhibit viral protein synthesis
label: b
answer: no
explanation: No, this is the wrong mechanism of action.
name: Disrupt cell wall synthesis by inhibiting the beta-lactamase enzyme
label: e
answer: no
explanation: No, this is the wrong mechanism of action.
name: Inhibit topoisomerase II enzyme therefore preventing bacterial DNA transcription
label: d
answer: no
explanation: No, this is the wrong mechanism of action.
name: Disrupt cell wall synthesis by inhibiting the transpeptidation enzyme
label: c
answer: no
explanation: Clarithromycin is a macrolide antibiotic, hence this is the correct mechanism of action
name: Inhibits bacterial protein synthesis by binding to the 50S subunit
label: a
answer: yes

Correct answer: a