hllj/quesmed huggingface dataset:
A 45-year-old woman presents to the accident and emergency department complaining of severe colicky abdominal pain in the right upper quadrant. It came on shortly after eating dinner the previous night. The pain does not radiate through to her back, but she does describe pain in her right shoulder when breathing deeply. She comments that she has noticed her urine has been darker and her stools pale for the past few days.

On examination, she is visibly jaundiced and appears unwell. There is localised tenderness around the right subcostal margin, that is exacerbated by breathing in. Her temperature is 37.9. Her BMI is 35.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: Incorrect - The location of pain, in this case, does not correlate with that expected in appendicitis, which begins centrally and then migrates to the right iliac fossa. Appendicitis typically causes a raised temperature, but does not cause pale stool, jaundice, or dark urine.
name: Appendicitis
label: c
answer: no
explanation: Incorrect - Peptic ulcers are lesions in the mucosa of the digestive tract. They occur more frequently in the duodenum than in the stomach. Peptic ulcers are associated with epigastric pain and patients will often report heartburn. A peptic ulcer would not cause the patient to have pain worse on inspiration, pale stool, jaundice, or dark urine.
name: Peptic Ulcer
label: e
answer: no
explanation: Correct - This is obstructive jaundice. Bile flow is obstructed by the gallstones, causing conjugated bilirubin to enter the blood. Conjugated bilirubin, being water soluble, is excreted in the urine, which makes the urine dark. By contrast, less conjugated bilirubin enters the bowel, leading to pale faeces. The pain in the right subcostal margin is called Murphy's sign and occurs due to irritation of the gallbladder.
name: Gallstones
label: a
answer: yes
explanation: Incorrect - Abdominal aortic aneurysms do cause abdominal pain. However, they would not cause pale stool, jaundice, or dark urine.
name: Abdominal Aortic Aneurysm
label: b
answer: no
explanation: Incorrect - Acute pancreatitis can be caused by gallstones (remember the acronym I GET SMASHED) but this does not correlate with the entire clinical picture. Pain caused by pancreatitis is typically epigastric in nature and can radiate through to the back. Pale stool, dark urine, and jaundice also indicate the presence of biliary obstruction.
name: Acute Pancreatitis
label: d
answer: no

Correct answer: a
A 76-year-old woman with a history of congestive heart failure and hypertension presents with dyspnoea and orthopnoea. She denies having chest pain, chills, or fever. On examination you note pitting oedema in her ankles. A diuretic is prescribed to relieve her symptoms.

Which of the following classes of diuretics inhibits the action of the transporter that is primarily involved in generating the osmotic gradient in the medulla?

Options:
explanation: Correct - Loop diuretics increase the amount of NaCl delivered to the distal nephron through inhibition of the Na/2Cl/K transporter. NaCl remains in the tubule of the thick ascending loop of Henley, reducing the osmotic concentration of the renal medulla. This therefore causes more water to be excreted as urine.
name: Loop Diuretics
label: a
answer: yes
explanation: Incorrect - Thiazide diuretics inhibit the Na+/Cl- co-transporter within the early distal tubule. These drugs are weaker and produce only a moderate diuresis, but are typically well tolerated. They last longer than loop diuretics but exert a lesser effect on the concentration gradient of the medulla.
name: Thiazide Diuretics
label: c
answer: no
explanation: Incorrect - Carbonic anhydrase inhibitors block the reabsorption of HCO3, Na, and prevent the exchange and secretion of H+. Preventing the reabsorption of Na induces diuresis and there is decreased H+ formation inside the cell. This reduces the activity of the Na/H antiporter, and increases Na and HCO3 concentration in the lumen.
name: Carbonic Anhydrase Inhibitors
label: e
answer: no
explanation: Incorrect - Osmotic diuretics increase the osmolality of the filtrate and reduce water reabsorption. They act best where most osmotic reabsorption occurs (i.e. the proximal tubule and descending loop of Henle). They do not work on a transporter.
name: Osmotic Diuretics
label: d
answer: no
explanation: Incorrect - Potassium-sparing diuretics act on principle cells in the late distal and cortical collecting tubule. They inhibit either sodium channels or mineralocorticoid receptors, reducing potassium secretion into the tubular lumen. They do not affect the osmotic gradient of the medulla, or the transporter associated with it.
name: Potassium-sparing Diuretics
label: b
answer: no

Correct answer: a
A 68-year-old female patient suffered a peritoneal infection following abdominal surgery. She later complains of pain in her right hypochondrium, which radiates to the right side of her back and shoulder.

The patient was primarily supine both during and in the days following the operation.

In which of the following anatomical sites is the infected fluid most likely to have collected?

Options:
explanation: Incorrect - The lesser sac is located behind the stomach and lesser omentum, the only entrance and exit being through the epiploic foramen. In cases of pancreatitis and certain perforated gastric ulcers, fluid can collect in the lesser sac. However, it would not typically cause pain in the right hypochondrium.
name: Lesser Sac
label: c
answer: no
explanation: Incorrect - The vesico-uterine pouch is located between the uterus and the bladder. It is rarely a site of fluid collection in supine patients, and would not cause right upper quadrant pain.
name: Vesico-uterine pouch
label: e
answer: no
explanation: Incorrect -  The subphrenic space is a peritoneal space between the anterior part of the liver and the diaphragm. It is separated into the right and left sides by the falciform ligament. The subphrenic spaces can be sites of fluid collection following procedures. However, the presence of an abscess here would not cause pain to radiate to the right back and shoulder.
name: Left Subphrenic Space
label: b
answer: no
explanation: Correct - The hepatorenal recess is a common site of fluid collection in unwell or postoperative patients who are supine. Fluid collection and subsequent abscess formation would cause pain in the right hypochondrium which radiates to the back and shoulder.
name: Hepatorenal recess
label: a
answer: yes
explanation: Incorrect - Fluid in the pouch of Douglas can accumulate due to menstrual blood refluxing through the fallopian tubes, or from the release of fluids from ruptured cysts. The pouch of Douglas is located posteriorly to the uterus and anteriorly to the rectum. Fluid can collect here following surgical procedures, however, it would not cause pain in the right hypochondrium.
name: Pouch of Douglas
label: d
answer: no

Correct answer: a
A 45-year-old woman presents to A&E with epigastric pain radiating through to her back. She reports nausea, but has not vomited. On examination, she does not appear jaundiced but has a temperature of 38.1 degrees Celsius. It is suspected she has gallstone pancreatitis.

Which of the following hormones directly stimulates the pancreas to secrete bicarbonate ions?

Options:
explanation: Incorrect - Cholecystokinin stimulates the exocrine pancreas to release enzymes and stimulates the gallbladder to contract -releasing bile into the small intestine- in response to fat entering the duodenum.
name: Cholecystokinin
label: b
answer: no
explanation: Incorrect - Gastric inhibitory peptide stimulates insulin release, inhibits gastric secretion, and elicits pyloric sphincter constriction. It does not stimulate the pancreas to release bicarbonate
name: Gastric Inhibitory Peptide
label: d
answer: no
explanation: Incorrect - Gastrin is secreted by gastric glands and does not act on the pancreas. Its function is to control gastric acid secretion.
name: Gastrin
label: c
answer: no
explanation: Correct - Secretin is secreted by the small intestine and stimulates the pancreas to secrete bicarbonate ions and the liver to secrete bile. It also elicits pyloric sphincter constriction.
name: Secretin
label: a
answer: yes
explanation: Incorrect - Glucagon is secreted from alpha cells in the islets of Langerhans, in response to drops in blood glucose concentration. It does not stimulate the pancreas to release bicarbonate
name: Glucagon
label: e
answer: no

Correct answer: a
A 25-year-old male motorcyclist suffered a road traffic accident, sustaining multiple fractures to the lower part of his sacrum from S2 inferiorly. Whilst in the emergency department after the accident, he is able to sense that his bladder is full but is unable to void urine.

Which of the following is the most likely cause of his urinary retention?

Options:
explanation: Incorrect - Sacral splanchnic nerves arise from the sacral sympathetic chain. They provide both motor and sensory innervation to the posterior thigh, part of the pelvis, and the majority of the lower leg and foot. They do not typically innervate the bladder, and damage to these nerves is not associated with urinary retention.
name: Damage to sacral splanchnic nerves
label: b
answer: no
explanation: Correct - The pelvic splanchnic nerve is made up of preganglionic parasympathetic fibres that arise from the S2-4 nerve roots of the sacral plexus. The internal urethral sphincter is supplied by the pelvic splanchnic nerves. The pelvic splanchnic nerves can trigger contraction in the detrusor muscle of the bladder and trigger micturition. As the patient is able to sense his bladder is full but unable to void urine voluntarily, his pelvic splanchnic nerves are likely damaged.
name: Damage to pelvic splanchnic nerve
label: a
answer: yes
explanation: Incorrect - The phrenic nerve provides motor innervation to the diaphragm. It does not supply the bladder, and therefore damage to the phrenic nerve would not lead to urinary retention.
name: Damage to the phrenic nerve
label: c
answer: no
explanation: Incorrect - It is unlikely that a bladder stone is the cause of this patient's inability to void given the history of recent trauma. Bladder stones typically present with suprapubic pain and haematuria, making this option highly unlikely.
name: Bladder stone
label: d
answer: no
explanation: Incorrect -  Damage to the pudendal nerve is likely to cause urinary incontinence rather than an inability to void. The pudendal nerve controls the external urethral sphincter and is responsible for maintaining continence.
name: Pudendal Nerve
label: e
answer: no

Correct answer: a
A 55-year-old man with chronic kidney disease presents to his GP with increased swelling in his legs. He also reports a loss of appetite and persistent nausea, but no vomiting.

Which of the following types of epithelium forms the filtration barrier in the glomerulus?

Options:
explanation: Incorrect - Pseudostratified columnar is found in areas where secretion and protection are the primary functions. For example, the respiratory tract. It does not form the filtration barrier in the renal glomerulus.
name: Pseudostratified Columnar
label: d
answer: no
explanation: Correct - Simple squamous epithelium facilitates exchange functions, including the exchange of gases or chemicals. It is found in the alveoli of the lungs, glomerulus of the kidneys, and capillaries.
name: Simple Squamous
label: a
answer: yes
explanation: Incorrect - Stratified squamous epithelium is designed for protection. It is the epithelium found at many of the body openings, such as the vagina, anal canal, and mouth. It does not form the filtration barrier in the renal glomerulus.
name: Stratified Squamous
label: b
answer: no
explanation: Incorrect - Transitional epithelium lines the bladder, urethra, and ureters. It has multiple layers and allows tissues to stretch. It does not form the filtration barrier in the renal glomerulus.
name: Transitional
label: e
answer: no
explanation: Incorrect - Simple columnar epithelium is designed to facilitate motility, absorption, and processing. It has a high organelle density and potential for energy reserves. It does not form the filtration barrier in the renal glomerulus.
name: Simple Columnar
label: c
answer: no

Correct answer: a
A 67-year-old male presents to his GP with a swelling in his groin. On examination, the swelling originates superiorly and medially to the pubic tubercle. It is painless, soft, and reducible. The swelling remains reduced whilst pressure is applied to the deep inguinal ring.

Which of the following is the most likely underlying diagnosis?

Options:
explanation: Incorrect - A direct inguinal hernia would not remain reduced when pressure is applied to the deep inguinal ring. Direct inguinal hernias occur due to weakness of the conjoint tendon or the transversalis fascia.
name: Direct Inguinal Hernia
label: c
answer: no
explanation: Incorrect - The root of an umbilical hernia would begin superior to this location, although with time it could grow and protrude.
name: Umbilical Hernia
label: d
answer: no
explanation: Incorrect - Femoral hernias are inferior and lateral to the pubic tubercle, rather than superior and medial. Femoral hernias are more commonly found in women.
name: Femoral Hernia
label: b
answer: no
explanation: Incorrect - A saphena varix is a dilation of the saphenous vein, typically at its junction to the femoral vein within the groin. Saphena varices can sometimes be mistaken for femoral hernias: the key differentiation is that a saphena varix is reducible, whereas femoral hernias are not.
name: Saphena Varix
label: e
answer: no
explanation: Correct - This presentation has all the classic characteristics of an indirect inguinal hernia. Remember, indirect inguinal hernias pass through both the deep and superficial inguinal ring, rather than bursting through the fascia of the abdominal wall. The key feature in identifying this as an indirect inguinal hernia is that it remains reduced whilst pressure is applied to the deep inguinal ring.
name: Indirect inguinal hernia
label: a
answer: yes

Correct answer: a
A 35-year-old woman presents to her GP with unexplained weight loss over the past few months. She states she has recently missed several periods and has noticed her heart beating faster.

On examination, she appears agitated and sweaty with noticeable bilateral exophthalmos. Her thyroid gland appears to be enlarged but is smooth and symmetrical to palpation. There is also evidence of pretibial myxoedema. The doctor orders a thyroid function blood test.

Which of the following findings is most likely?

Options:
explanation: Incorrect - This patient demonstrates signs and symptoms of hyperthyroidism. The presence of exophthalmos specifically points towards Grave's disease. By contrast, reduced T4 levels are seen in cases of hypothyroidism such as Hashimoto's thyroiditis.
name: Reduced T4, Raised TSH
label: d
answer: no
explanation: Incorrect - This patient demonstrates signs and symptoms of hyperthyroidism. The presence of exophthalmos specifically points toward Grave's disease. A normal T4 and reduced TSH may be seen in a patient with subclinical hyperthyroidism.
name: Normal T4, Reduced TSH
label: e
answer: no
explanation: Incorrect - This patient demonstrates signs and symptoms of hyperthyroidism. The presence of exophthalmos specifically points toward Grave's disease. By contrast, reduced T4 levels are seen in cases of hypothyroidism. Both reduced T4 and reduced TSH is indicative of a central/secondary cause of hypothyroidism such as a pituitary malfunction.
name: Reduced T4, Reduced TSH
label: c
answer: no
explanation: Incorrect - This patient demonstrates signs and symptoms of hyperthyroidism. The presence of exophthalmos specifically points toward Grave's disease. In Grave's disease the auto-antibody TSI (thyroid stimulating immunoglobulin) is produced. This mimics the action of TSH, stimulating the TSH receptor, and therefore increasing T4 levels. TSH levels fall as part of a negative feedback cycle. Failure of TSH to fall in response to raised T4 indicates a central cause, such as a problem with the pituitary gland.
name: Raised T4, Raised TSH
label: b
answer: no
explanation: Correct - This patient demonstrates signs and symptoms of hyperthyroidism. The presence of exophthalmos specifically points towards Grave's disease. This is a hypersensitivity reaction involving autoimmune activation of the TSH receptor. In Grave's disease the auto-antibody TSI (thyroid stimulating immunoglobulin) is produced. This mimics the action of TSH, stimulating the TSH receptor, and therefore increasing T4 levels. TSH levels fall as part of a negative feedback cycle.
name: Raised T4, Reduced TSH
label: a
answer: yes

Correct answer: a
A 23-year-old female patient is brought to Accident and Emergency after falling off a horse. She reports severe lower back pain, and is unable to feel her legs. The team is worried about the possibility of a spinal cord injury.

At which of the following vertebral levels does the spinal cord commonly terminate in adults?

Options:
explanation: Correct - In adults the spinal cord commonly terminates at the L1 vertebral level. The dural sac terminates between S1 and S2. The lumbar cistern is found below the point at which the spinal cord terminates.
name: L1
label: a
answer: yes
explanation: Incorrect -  In adults, the spinal cord commonly terminates at the L1 vertebrae. Sympathetic nerves come off the spinal cord at vertebral levels T11-T12.
name: T12
label: e
answer: no
explanation: Incorrect - In adults the spinal cord commonly terminates at the L1 vertebral level.  L3-4 and L5-S1 is the region in which lumbar punctures are typically performed in order to avoid nerve damage.
name: L4
label: c
answer: no
explanation: Incorrect - The dural sac terminates at S1/S2. In adults the spinal cord commonly terminates at the L1 vertebral level.
name: S1/S2
label: b
answer: no
explanation: Incorrect - The spinal cord typically terminates at L3 in children, not adults. In adults, the spinal cord commonly terminates at the L1 vertebral level.
name: L3
label: d
answer: no

Correct answer: a
An 18-year-old woman consults her GP about starting the oral contraceptive pill. She lives at home with her parents, and is concerned they would disapprove if they found out about her request.

Which of the following circumstances would necessitate the disclosure of patient information?

Options:
explanation: Incorrect - 18-year-olds are adults. Even when patients are aged under 18, as long as they are deemed Gillick competent to make their own decisions, confidentiality would still be respected. This is not sufficient justification to break confidentiality.
name: The patient is 18-years-old
label: e
answer: no
explanation: Incorrect - Just like other medical consultations, discussions around contraception should be kept confidential unless there is a specific reason to disclose information. The subject of contraception is not sufficient reason in itself.
name: The consultation relates to contraception
label: d
answer: no
explanation: Incorrect - Having a learning disability does not usually necessitate the sharing of patient information. As long as the patient is able to understand, retain, weigh, and communicate information relating to their decision, they would be deemed to have the capacity to make their own decisions. Such decisions would be kept confidential.
name: Patient has a learning disability
label: c
answer: no
explanation: Incorrect - Being a first degree relative does not give individuals the right to access the medical records of others. In this case, there is no reason to suggest the patient's information should be shared with family members, particularly as she specifically asks for it not to be. Her confidentiality should be respected.
name: If the person making the request is a first-degree relative
label: b
answer: no
explanation: Correct - If disclosure is required by law then an individual's medical records can be disclosed. However, it is important the the minimum necessary amount of information should be released.
name: Disclosure is required by law
label: a
answer: yes

Correct answer: a
A 14-year-old boy attends the GP surgery with his mother, who is concerned that he has been 'moody' lately. He is prone to outbreaks of acne on his face and back, and has undergone a growth spurt over the last 6 months. The GP suggests he is going through puberty.

Which of the following cells does follicle-stimulating hormone (FSH) directly act upon within the testes?

Options:
explanation: Incorrect - FSH acts only indirectly on Leydig cells through increased androgen production.
name: Leydig Cells
label: b
answer: no
explanation: Correct - FSH acts directly on Sertoli cells to stimulate spermatogenesis within the testes.
name: Sertoli Cells
label: a
answer: yes
explanation: Incorrect - Granular cells are found in the juxtaglomerular apparatus in the kidney.  FSH does not directly act upon them.
name: Granular Cells
label: e
answer: no
explanation: Incorrect - Lacis cells, also known as mesangial cells, are found in the juxtaglomerular apparatus in the kidney. FSH does not directly act upon them.
name: Lacis Cells
label: d
answer: no
explanation: Incorrect - Myoid cells aid in transport of the spermatozoa and testicular fluid within the seminiferous tubules of the testes. FSH does not directly act upon them.
name: Myoid Cells
label: c
answer: no

Correct answer: a
A 34-year-old man underwent a thyroidectomy. Shortly after the procedure, he was noted to be extremely breathless, with an increased respiratory rate and audible stridor.

Which of the following is the most likely underlying pathophysiology?

Options:
explanation: Incorrect - The external laryngeal nerve innervates the cricothyroid muscle and is at risk during thyroid surgery. It provides mucosal sensation above the vocal folds. Damage to the external laryngeal nerve would cause a reduced range in pitch and a monotonous voice. It would not cause vocal cord palsy, and therefore patients would not present with stridor or breathlessness.
name: Bilateral damage to the external laryngeal nerve
label: c
answer: no
explanation: Incorrect - The recurrent laryngeal nerve only supplies its respective signs of the larynx. The right recurrent laryngeal nerve recurs under the right subclavian artery at the apex of the lung. A right recurrent laryngeal nerve injury would therefore cause unilateral vocal fold paralysis, which typically presents as a weak or hoarse voice.
name: Damage to the right recurrent laryngeal nerve
label: b
answer: no
explanation: Incorrect - The recurrent laryngeal nerve only supplies its respective side of the larynx. The left recurrent laryngeal nerve recurs under the aortic arch. A left recurrent laryngeal nerve injury would therefore cause unilateral vocal fold paralysis, which typically presents as a weak or hoarse voice. Patients would not immediately present with stridor or breathlessness.
name: Damage to the left recurrent laryngeal nerve
label: d
answer: no
explanation: Incorrect - The external laryngeal nerve innervates the cricothyroid muscle and is at risk during thyroid surgery. It provides mucosal sensation above the vocal folds. Damage to the external laryngeal nerve would cause a reduced range in pitch and a monotonous voice. It would not cause vocal cord palsy, and therefore patients would not present with stridor or breathlessness.
name: Damage to the right external laryngeal nerve
label: e
answer: no
explanation: Correct - In contrast to unilateral vocal cord paralysis, where hoarseness or shortness of breath may not manifest for days to weeks after the damage has occurred, bilateral vocal cord paralysis usually manifests immediately after extubation. Patients may present with biphasic stridor, respiratory distress, or both, due to dysfunctional vocal cords narrowing and obstructing the airway.
name: Bilateral damage to the recurrent laryngeal nerve
label: a
answer: yes

Correct answer: a