hllj/quesmed huggingface dataset:
15 year old female presents to the GP with her concerned mother.

The mother states that her daughter hasn't had her period yet and hasn't noticed any breast growth.

On examination of the girl you note that she has a short stature, webbed neck, widely spaced nipples with no evidence of breast budding.

What condition is this presentation associated with?

Options:
explanation: This results from the family's inherited short stature.

Those affected may be short stature will be small for their age but they are expected to start puberty as normal with no developmental delay.
name: Familial short stature
label: e
answer: no
explanation: This is more commonly known as Down Syndrome.

Those with this syndrome experience the same pattern of hormonal changes as they grow and develop with the development of breast buds and menstruation.

There can be a developmental delay in emotions, social communication, abstract thinking and problem-solving ability.
name: Trisomy 21
label: d
answer: no
explanation: This is a hypogonadotrophic hypogonadism.

Signs and symptoms also include delayed puberty, low libido, primary amenorrhoea and erectile dysfunction.

Additional anomalies can include impaired renal development, cleft lip and loss of sense of smell.
name: Kallman Syndrome
label: c
answer: no
explanation: Puberty is expected to begin between ages 8 and 13 in girls and 9 and 14 for boys.

Delayed puberty is defined as no signs of testicular development by age 14 or no signs of breast development by age 13 in girls.

Turner Syndrome is a condition that. only affects females and results when one X chromosome is partially missing. This can result in a variety of developmental problems such as short stature, hart defects and failure of the development of the ovaries and therefore puberty.
name: Turner Syndrome
label: a
answer: yes
explanation: Hypothyroid can result in delayed growth and delayed puberty.

However, in this adolescent girl there are features characteristic of Turner syndrome such as widely spaced nipples and a webbed neck.

Short stature and ovarian failure are the main features.
name: Hypothyroidism
label: b
answer: no

Correct answer: a
A 75 year old man has recently been diagnosed with osteoporosis following hormone therapy for his prostate cancer.

He has a review in the bone clinic where they recommend starting Denosumab. This works by blocking the RANK ligand.

What is the role of the RANKL?

Options:
explanation: Osteoclasts are inhibited by calcitonin, a thyroid hormone.

This is released when there is hypercalcaemia so osteoclasts are inhibited to prevent more calcium being released into the bloodstream.

Drugs such as Denosumab which prevents the RANK ligand from binding can stop the activation of the osteoclasts to prevent bone reabsorption.
name: Inhibits the osteoclasts
label: c
answer: no
explanation: Osteocytes are found in mature bone matrix and originate from osteoblasts.

They sense various mechanical stress on bone and regulate bone formation and reabsorption in response to this.
name: Activates the osteocytes
label: e
answer: no
explanation: Osteoblasts can be activated by osteoclasts in the normal bone modelling cycle.

They can also be upregulated by thyroxine a thyroid hormone and growth hormone.
name: Activates the osteoblasts
label: b
answer: no
explanation: Rank ligand is produced by osteoblasts and play a crucial role in the bone remodelling cycle by binding and activating osteoclasts.

Osteoclasts are the cells that degrade bone and initiate normal bone remodelling. Osteoblasts then become activated and form new bone.

In osteoporosis where bone has become weaker, it can be beneficial to inhibit osteoclasts and bone degradation to maintain the bones strength.

Parathyroid also stimulates osteoclasts in response to low calcium in the blood.
name: Activates the osteoclasts
label: a
answer: yes
explanation: RANK ligand is released by osteoblasts when they proliferate and become active. This activates osteoclasts. Osteoclasts then send signals to osteoblasts to reactivate them

This feedback is crucial in the bone turnover and remodelling.
name: Inhibits the osteoblasts
label: d
answer: no

Correct answer: a
A 20 year old female presents to the GP with irritability, palpitations, excessive sweating and weight loss with increased appetite.

Primary hyperthyroidism is suspected.

What would support this on the blood test?

Options:
explanation: This is a classical presentation of hyperthyroidism so is likely to have raised T3 and T4 levels.
name: Normal TSH and normal T3 and T4
label: e
answer: no
explanation: This is the picture of secondary hypothyroidism. The decrease in thyroid hormones is in response to the lack of TSH which stimulates the release of thyroid hormones.

Under-production of TSH can be due to a non-secretory pituitary adenoma.
name: Low TSH and low T3 and T4
label: d
answer: no
explanation: TSH is released by the anterior pituitary and stimulates the release of T3 (triiodothyronine) and T4 (thyroxine).

Primary hyperthyroidism originates from the thyroid gland itself which suppresses the release of TSH by negative feedback.

The main causes of hyperthryoidism include Graves' disease, toxic multinodular goitre and toxic adenoma.

Women are more at risk than men.
name: Low TSH and High T3 and T4
label: a
answer: yes
explanation: This is the picture of secondary hyperthyroidism. This is in response to the secretion of high levels of TSH which stimualates the release of thyroid hormones.

overproduction of TSH can be due to a pituitary adenoma.
name: High TSH and high T3 and T4
label: b
answer: no
explanation: This is the picture of mild or early onset hypothyroidism.

The thyroid hormones are in normal ranges but TSH is released in greater quantities to help maintain these levels.

Treatment is required only if TSH is higher than >10mlU/L.
name: High TSH and normal T3 and T4
label: c
answer: no

Correct answer: a
70 year old male attends the orthopaedic clinic complaining of pain and stiffness in his left hip that has gradually worsened over 6 months.

He says that he wakes up feeling pain-free with no morning stiffness. However, as he carries out activities such as walking for his newspaper the pain and stiffness worsen.

Which od the following is the most likely diagnosis?

Options:
explanation: Gout is usually an acute presentation of sudden, severe attacks of pain, swelling and tenderness of one or more joints.

Common joints affected tend to be those in the lower limb such as toes, feet, ankles and knees.

Diagnosis is done by aspirating the affected joint. Microscopy identifies negatively bifringent, needle shaped crystals.

Xrays are not crucial for diagnosis but will show soft tissue swelling and bony erosions.
name: Gout
label: c
answer: no
explanation: NICE guidelines state that adults over the age of 45 can be diagnosed clinically with osteoarthritis.

They do not require investigations if they have no joint-related morning pain or stiffness or have joint-related morning pain and stiffness that does not persist longer than 30 minutes.

An X-ray would demonstate subchondral sclerosis, cyst formation, loss of joint space and osteophyte formation.
name: Osteoarthritis
label: a
answer: yes
explanation: This is an auto-inflammatory disease so is associated with pain and stiffness in the morning that lasts for longer than 30 minutes.

Activity tends to relieve the pain, whilst rest can exacerbate it.

Patients tend to present with 3 or more tender, warm, swollen joints bilaterally with systemic features such as fatigue and fevers.

Diagnosis is made with a combination of the clinical picture and MRI or ultrasound scan of joints.
name: Rheumatoid arthritis
label: e
answer: no
explanation: This is an auto-inflammatory condition which is associated with the HLA-B27 gene.

This condition tends to present in young men under 45 years of age. They have morning pain and stiffness that persists over 30 minutes and is relieved by exercise.

Inflammation in the axial skeleton can cause new bone formation and fusion of the bones in the spine - known as a bamboo spine.

Sacroilitis is seen on Xray which is part of the diagnostic New York criteria.
name: Ankylosing spondylitis
label: b
answer: no
explanation: Osteoporosis refers to thinning of the bone. Bone density measurement by a DEXA scan at the hip and spine is generally considered the most reliable way to diagnose the condition.

Osteoporosis has no clinical features until there is a fracture and tends to be an incidental finding.
name: Osteoporosis
label: d
answer: no

Correct answer: a
21 year old male presents to the GP with prolonged morning stiffness over 30 minutes that also worsens in the evening.

He says he has taken up running and that seems to relieve the pain.

He says he is really struggling with fatigue and is finding it difficult to carry on with his office-based job.

He is subsequently diagnosed with ankylosing spondylitis.

What gene is most associated with this?

Options:
explanation: CFTR stands for cystic fibrosis transmembrane conductance regulator. This allows chlorine and salt to leave the cell so water can follow and properly hydrate the cellular surface.

When mutated, cystic fibrosis occurs. Salt cannot leave the cells and the mucus on cells becomes thick and sticky causing infertility in men and recurrent chest infections in men and women.
name: CFTR gene
label: d
answer: no
explanation: Dystrophin is a protein within muscle that plays a crucial role in the structure and function of the muscle.

The mutation in this gene leads to a faulty protein and causes changes in the muscle fibres leading to scarring and muscle dysfunction.

Over time, this leads to muscle weakening and increasing disability.
name: Dystrophin gene
label: e
answer: no
explanation: Ankylosing Spondylitis (AS) has a strong family history and is greatly associated with HLA B27.

75-92% of patients with AS have this gene. Among those in the population who have the gene, 1-2% have AS.

Other spondyloarthropathies that are associated with HLA B27 include reactive arthritis and enteropathic arthritis that is associated with IBD.
name: HLA B27
label: a
answer: yes
explanation: These have been most consistently associated with Systemic Lupus Erythematosus (SLE).
name: HLA DR2 and 3
label: c
answer: no
explanation: These genes are associated with the development of coeliac disease.
name: HLA DQ8 and 2
label: b
answer: no

Correct answer: a
A 50 year old female presents to the GP with widespread pain that is worse in her back and neck. She describes the pain as a constant ache but can be burning in nature. This has been present for 5 months.

She also struggles with fatigue and headaches.

Past medical history of high blood pressure and inflammatory bowel syndrome (IBS).

A full blood work up is performed which is all normal. What is the likely diagnosis?

Options:
explanation: This is an important differential as this can present very vague such as tiredness and fatigue.

Widespread pain is less likely and bloods would show a low haemaglobin.
name: Anaemia
label: e
answer: no
explanation: This patient likely has fibromyalgia. The main symptom is widespread pain that can vary in severity. This condition can result in extreme sensitivity to touch and painful stimuli.

This condition can cause tiredness, poor sleep quality, memory and cognitive impairment.

Fibromyalgia is often associated with IBS.

The pathophysiology is not fully understood but is thought to be influenced by abnormal pain signalling.
name: Fibromyalgia
label: a
answer: yes
explanation: This is an auto-inflammatory disease so is associated with pain and stiffness in the morning that lasts for longer than 30 minutes.

Activity tends to relieve the pain, whilst rest can exacerbate it.

Patients tend to present with 3 or more tender, warm, swollen joints bilaterally with systemic features such as fatigue and fevers.
name: Rheumatoid arthritis
label: b
answer: no
explanation: Hypothyroid is due to decreased T3 and T4 levels in the blood. Symptoms include constipation, feeling cold, dry skin and nails, fatigue and memory changes.

Hypothyroid can cause muscle aches and stiffness as in this case but investigations would show low T3 and T4.
name: Hypothyroidism
label: c
answer: no
explanation: This condition tends to present in young men under 45 years of age. They have morning pain and stiffness that persists over 30 minutes and is relieved by exercise.

People with AS tend to have stiffness and aching pains in the lower back which can progress up the spine.

'Widespread pain' is very unique to fibromyalgia.
name: Ankylosing spondylitis
label: d
answer: no

Correct answer: a
65 year old male presents to accident and emergency with a very hot, swollen and extremely tender big toe that has developed over 2 hours.

Aspiration of the joint is undertaken and crystal microscopy shows negatively bifringent needles.

What is the direct cause of this condition?

Options:
explanation: Septic arthritis can present very similarly to this case with acute, severe pain developing over hours.

Patients may have a history of a urinary tract infection or a respiratory tract infection. The bacteria may have spread to the knee leading to septic arthritis. it can also be caused by direct innoculation by a penetrating injury for example an animal bite.

Aspiration would be negative for crystals with a high white blood cell and neutrophil count with a positive gram stain for bacteria.
name: Infection
label: b
answer: no
explanation: Pseudogout is caused by the deposition of a calcium-based crystal in the joint. These are called calcium pyrophosphate dihydrate crystals that appear positively bifringent and rhomboid shape on crystal microscopy.

The presentation would be similar and the aspiration allows you to differentiate the conditions.
name: Hypercalcaemia
label: c
answer: no
explanation: Aspiration of the joint along with the clinical picture supports the diagnosis of gout rather than an autoimmune pathogenesis.

With rheumatoid arthritis, it is usually a slower onset > 6 weeks with multiple joint involvements on both sides of the body.
name: Autoimmunity
label: e
answer: no
explanation: alcohol can increase uric acid in the bloodstream which increases risk of gout and increase the frequency and severity of attacks.

Uric acid is the direct cause of gout as this is what deposits into the joint.
name: Alcohol
label: d
answer: no
explanation: Gout is caused by a build up of uric acid in the blood. This deposits in the joint as needle shaped crystals. There is an increased risk with a high purine diet, family history, renal impairment and therefore reduced clearance of uric acid.

Gout attacks are acute and severe in nature and usually develop over several hours.
name: Hyperuricaemia
label: a
answer: yes

Correct answer: a
A 35 year old woman is taken into surgery for an open appendicectomy.

What is the next layer of the abdomen the surgeon will cut through after the transverse abdominis?

Options:
explanation: This is the muscle that is cut first in surgery.
name: External oblique
label: c
answer: no
explanation: This muscle will be cut just before the transverse abdominis. A way to remember the order of the muscles (superficial to deep):

> E > Elegant (External oblique)

> I > Innocent (Internal oblique)

> R > Rabbits (Rectus abdominis)

> T > Toddled (Transverse abdominis)
name: Rectus abdominis
label: b
answer: no
explanation: The peritoneum is cut after the fascia of the abdominis muscle.
name: Peritoneum
label: d
answer: no
explanation: The transversus abdominis muscle is the last muscle the surgeon will cut through. After this will be the corresponding fascia deep to this structure then the perineum.

The structures that the surgeon will cut through superficial to deep are; skin, subcutaneous fat, anterior fascia, external oblique muscle, internal oblique muscle, rectus abdoiminis muscle, transverse abdominis, transversalis fascia and peritoneum.
name: Transversalis fascia
label: a
answer: yes
explanation: This muscle is found between the external and internal oblique muscles
name: Rectus abdominis
label: e
answer: no

Correct answer: a
30 year old female presents to the GP concerned she has felt some lumps on her left breast in the left upper quadrant over a year ago. She also describes the area of the breast becoming more tender just before she is due to start her period.

The GP examines the patient and observes tht there are no skin changes but some three small lumps measuring around 2cm in the upper quadrant of the left breast which are smooth and fluctuant.

She is referred to breast clinic where an ultrasound and an ultrasound-guided biopsy are performed.

These investigations lead to a diagnosis of fibrocystic breast changes.

She is really concerned with this diagnosis and wants to know more about it.

Which of these options is correct about this condition?

Options:
explanation: fibrocystic breast change is a common non-cancerous condition that does not increase the risk of cancer. The changes include fibrosis, epithelial hyperplasia, dilation of ducts and apocrine metaplasia.

It is thought to arise from excessive local hormonal stimulation of the terminal duct-lobular unit. Therefore, pain can increase before menstruation.

This mainly affects premenopausal women between the ages of 20-50 years of age.
name: It is benign with no increased risk of malignancy
label: a
answer: yes
explanation: It is a benign, common condition in premenopausal women that does not increase the risk of malignancy.
name: It is benign but has an increased risk of malignancy
label: b
answer: no
explanation: Fibrocystic change is a benign condition it does not require any treatment.
name: Is a malignant diagnosis
label: c
answer: no
explanation: Mastitis can be caused by infection and mainly affects breastfeeding women. The breast will likely be tender, red and sore and is more of an acute presentation.

There are no skin changes that may indicate an infection and the patient is systemically well.
name: Is caused by an infection
label: d
answer: no
explanation: This is not always the case in those with fibrocystic changes.

Symptoms tend to be hormonal-driven and cyclical and can fluctuate with time.

After menopause, the lumps can become less noticable and even disappear completely.
name: Grows and symptoms become worse with time
label: e
answer: no

Correct answer: a
What is the process by which the kidneys develop?

Options:
explanation: This is how the germ layers form
name: Histogenesis
label: b
answer: no
explanation: This is the process for forming the blastocyst
name: Blastulation
label: e
answer: no
explanation: This is how the neural tube forms
name: Neurulation
label: c
answer: no
explanation: This process generates "epithelial trees". Signaling pathways determine the branch position, orientation, and shape of the kidneys.
name: Branching morphogenesis
label: a
answer: yes
explanation: This directs the movement of the sperm towards the ovum
name: Chemotaxis
label: d
answer: no

Correct answer: a
What structure does the ductus venosus bypass?

Options:
explanation: The ductus arteriosus connects the pulmonary artery to the aorta
name: Pulmonary artery
label: b
answer: no
explanation: The ductus venosus is a shunt that allows oxygenated blood in the umbilical vein to bypass the liver on its' journey from the placenta to the right atrium
name: Liver
label: a
answer: yes
explanation: The blood that travels through the ductus venosus has travelled through the placenta
name: Placenta
label: e
answer: no
explanation: The ductus venosus allows blood to reach the right atrium
name: Right atrium
label: d
answer: no
explanation: The ductus venosus bypasses the liver, not the spleen
name: Spleen
label: c
answer: no

Correct answer: a
Which is the correct option for the order of the 3 stages of kidney development and corresponding dates?

Options:
explanation: The pronephros forms on day 18, the mesonephros on day 24, and the metanephros on day 35
name: Pronephros (day 2)

Mesonephros (day 18)

Metanephros (day 22)
label: d
answer: no
explanation: The kidneys develop through the process of branching morphogenesis. This starts in the kidney when the ureteric bud grows out from the nephric duct and contacts the metanephric mesenchyme. Pronephros is the earliest nephric stage in humans. Mesonephros develops by the formation of mesonephric tubules from the intermediate mesoderm, it is the principal excretory organ for the early embryo. Metanephros is the permanent kidney and develops by the 10th week from the lower part of the Wolffian duc.
name: Pronephros (day 18)

Mesonephros (day 24)

Metanephros (day 35)
label: a
answer: yes
explanation: The pronephros forms 1st, the mesonephros is 2nd and metanephros develops afterwards and is the permanent kidney that forms by the 10th week
name: Mesonephros (day 18)

Metanephros (day 24)

Pronephros (day 35)
label: c
answer: no
explanation: The pronephros forms 1st, the mesonephros is 2nd and metanephros develops afterwards and is the permanent kidney that forms by the 10th week. The pronephros forms on day 18, the mesonephros on day 24, and the metanephros on day 35
name: Mesonephros (day 35)

Metanephros (day 47)

Pronephros (day 52)
label: e
answer: no
explanation: The mesonephros forms 2nd, the metanephros develops afterwards and is the permanent kidney that forms by the 10th week
name: Pronephros (day 18)

Metanephros (day 24)

Mesonephros (day 35)
label: b
answer: no

Correct answer: a
What cells and skin layer are involved in psoriasis?

Options:
explanation: In the stratum germinativum basal cells continuously divide and push cells upwards, they are not involved in psoriasis
name: Basal cells in the stratum germinativum
label: b
answer: no
explanation: Langerhans cells attach to antigens of pathogens that invade damaged skin and alert the immune system to their presence and are not involved in psoriasis
name: Langerhans cells in the stratum spinosum
label: d
answer: no
explanation: In psoriasis, there is abnormal proliferation of keratinocytes which are the primary cell found in the stratum corneum of the epidermis
name: Keratinocytes in the stratum corneum
label: a
answer: yes
explanation: Merkel cells are are tactile cells of neuroectodermal origin and are not involved in psoriasis
name: Merkel cells in the stratum germinativum
label: e
answer: no
explanation: Melanocytes produce the skin pigment and are not involved in psoriasis
name: Melanocytes in the stratum germinativum
label: c
answer: no

Correct answer: a
Which of the following is a side effect of steroid creams (such as clobetasone)?

Options:
explanation: NSAIDs such as ibuprofen can cause gastric ulcers
name: Gastric ulcers
label: e
answer: no
explanation: This is a common side effect of Calcium channel blockers such as amlodipine
name: Ankle oedema
label: c
answer: no
explanation: This is a common side effect of ACE inhibitors such as ramipril
name: Dry cough
label: b
answer: no
explanation: Exposure to UV light, either from the sun or tanning beds increases the risk of skin cancer
name: Melanoma
label: d
answer: no
explanation: Skin thinning is an important side effect of steroid creams, to avoid skin thinning, steroid creams must not be used all the time, and small fingertip units are applied.
name: Thinning of the skin
label: a
answer: yes

Correct answer: a