hllj/quesmed huggingface dataset:
Case Presentation: A 27-year-old gentleman is brought to the Emergency Department with abdominal pain, vomiting, polydipsia and polyuria. Intravenous fluids have already been commenced.
 

 

## PH
 

None
 

## DH
 

None
 

## On examination
 

Drowsy but able to answer in full sentences. Sick bowl present on side table. Rapid breathing. Dry mucous membranes, peripheries cool, CRT 3s.
 

Temperature 36.4°C, HR 105, RR 31, BP 95/78, O<sub>2</sub> 98% RA, GCS 14, Weight 75kg
 

## Investigations
 

|      |    |         |
| -------------- | :-------: | ------------------ |
| pH               |     7.2    | 7.35 - 7.45        |
| PaO₂             | 12 kPa       | 11 - 15          |
| PaCO₂            | 3.2 kPa      | 4.6 - 6.4         |
| Bicarbonate      | 12 mmol/L        | 22 - 30      |
| Sodium                      | 125 mmol/L          | 135 - 145     |
| Potassium                   | 4.7 mmol/L          | 3.5 - 5.3     |
| Non-fasting Glucose         | 28 mmol/L          | < 6.1               |
| Ketones (Serum)             | 4.5 mmol/L          | < 0.6               |


# Prescribing Request
 

Write a prescription for one drug that is most appropriate to specifically treat the high blood glucose levels.

Options:


# Drug choice feedback

Any rapid-acting or short-acting insulin is appropriate for the treatment of diabetic ketoacidosis. Common ones include NovoRapid/Humalog and Actrapid/Humilin S respectively. Prescribing insulin by brand name is acceptable; an exception is made as each brand of insulin may have different formulations even if it belongs to the same class as another.

# Dose/Route/Frequency/Duration feedback

The dose of insulin to be administered is 0.1units/kg/hour IV. Since the patient's weight is 75kg, the dose is 7.5 units per hour IV. S/C administration is not appropriate for the treatment of DKA.
Case Presentation: A 25-year-old lady is brought to the Emergency Department with sudden-onset high fever, headache, photophobia and stiff neck. She is confused and is disoriented to time and place. No seizures reported.




## PH and DH NIL (NKDA)


## On examination


Appears lethargic and irritable. Refuses food and drink. Photophobia noted. CRT 3s, peripheries cool. No rash, Kernig's and Brudzinski's sign positive. No neurological deficits.


Temperature 39.6°C, HR 98, RR 22, BP 110/88, O2 98% RA, GCS 12, Weight 68kg


## Investigations


||||
|--------------|:-------:|---------------|
|Haemoglobin|144   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|15.3x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|320x10<sup>9</sup>/L|150 - 400|
|Sodium|139 mmol/L|135 - 145|
|Potassium|4.2 mmol/L|3.5 - 5.3|
|Chloride|102 mmol/L|95 - 106|
|Urea|7.2 mmol/L|2.5 - 7.8|
|Creatinine|80 µmol/L|60 - 120|
|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|
|International Normalised Ratio (INR)|1.0|1.0|
|Non-fasting Glucose|6.2 mmol/L|< 6.1|


Blood cultures: pending


Lumbar puncture: not yet performed


# Prescribing Request


Write a prescription for one antibiotic that is most appropriate to treat her condition empirically.

Options:


# Drug choice feedback

Ceftriaxone is the antibiotic of choice as empirical treatment before identification of the causative organism. It is active against the three most common organisms: _Streptococcus pneumoniae_, _Neisseria meningitidis_ and _Haemophilus influenzae_. Antibiotic treatment should not be delayed by investigations. For your information, patients aged over 60 and/or who are immunocompromised should also empirically receive amoxicillin to cover for Listeria.

# Dose/Route/Frequency/Duration feedback

The correct dose is 2g once/twice daily or 4g once daily intravenously. Cefotaxime 2g QDS is an acceptable alternative. Ceftriaxone can be given intramuscularly as well, although the intravenous route is preferred in hospital due to more rapid onset of action.
Case presentation: An 80-year-old woman presents to her GP for her medication review, she complains of fatigue due to poor sleep. PH Osteoporosis, Type 2 diabetes, Dyspepsia, Parkinson Disease, hypertension. DH Her current regular medicines are listed (below).


Question 1: Select the TWO prescriptions that are most likely to be contributing to her sleeping disorders (mark them with a tick in column A)
Question 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).

Options:
name: Pramipexole;2mg;oral (PO);12-hourly
label: a
answer: no
name: Atenolol;50mg;oral (PO);Daily
label: b
answer: no
name: Paracetamol;1000mg;oral (PO);Daily
label: g
answer: no
name: Alendronic acid;70mg;oral (PO);Weekly
label: c
answer: no
name: Cholecalciferol 200 units + calcium carbonate 750mg (Adcal D3 ®);2 tablets;oral (PO);Daily
label: d
answer: no
name: Metformin;500mg;oral (PO);8-hourly
label: f
answer: no
name: Lansoprazole;15mg;oral (PO);Daily
label: e
answer: no


1. Pramipexole, a non-ergoline dopamine agonist and systemic beta blockers (atenolol) commonly cause sleeping disorders. Although excess daytime sleepiness and sleep attacks are recognized side effects of pramipexole, the underlying pathophysiology remained controversial. Beta blockers cause night awakening and nightmares, likely due to the inhibition of melatonin secretion, a hormone that is involved in sleep and the body’s circadian clock
2. Pramipexole, given for treatment of Parkinson's Disease has a maximum dose of 3.3mg daily. 2mg 12-hrly is more than the recommended maximum dose and alternative adjuncts should be considered instead.
Case presentation: A 22-week pregnant woman who is 30 years old is admitted to the emergency department with suspected pre-eclampsia. PH Type 2 Diabetes mellitus, Epilepsy, Depression, Hashimoto’s Disease. DH Her current regular medications are listed (below).




 **On Examination**
Abdominal tenderness, bilateral swelling of ankles.


 **Investigation**
BP 145/95 mmHg. Na 120 mmol/L (135-145) Urine dipstick ++ protein


Question 1: Select the THREE prescriptions that are most likely to be contributing to her hyponatremia (mark them with a tick in column A)
Question 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).

Options:
name: Labetalol;80mg;hourly;intravenous (IV)
label: a
answer: no
name: Levothyroxine sodium;100mg;Daily;oral (PO)
label: e
answer: no
name: Carbamazepine;100mg;12-hourly;oral (PO)
label: c
answer: no
name: Gabapentin;300mg;8-hourly;oral (PO)
label: d
answer: no
name: Metformin;1g; Daily;oral (PO)
label: g
answer: no
name: Fluoxetine;20mg;Daily;oral (PO)
label: b
answer: no
name: Aspirin;75mg;Daily;oral (PO)
label: f
answer: no


1. Hyponatremia is a recognised complication of selective serotonin re-uptake inhibitors (fluoxetine), carbamazepine and gabapentin, via syndrome of inappropriate antidiuretic hormone secretion (SIADH).
2. Maintenance dose of levothyroxine sodium is prescribed as 100-200 micrograms daily, not milligrams.
Case presentation: A 75-year-old man is admitted to the care of the elderly ward following a urinary tract infection. PH Hypertension, Alzheimer’s Disease, BPH, Osteoarthritis, Severe anxiety. DH. His current regular medications are listed (below).




 **On Examination**

HR 50/min regular, BP 135/75mmHg. He appears confused.


 **Investigation**


||||
|---------------------------|:-------:|--------------------|
|Urea|8.5 mmol/L|2.5 - 7.8|
|Creatinine|125 µmol/L|60 - 120|


Question 1: Select the THREE prescriptions that are most likely to be contributing to his confusion (mark them with a tick in column A)

Question 2: Select the ONE prescriptions that are most likely to be a cause of his bradycardia (mark them with a tick in column B).

Options:
name: Acebutolol;400mg;oral (PO);12-hourly
label: d
answer: no
name: Dexibuprofen;200mg;oral (PO);8-hourly
label: f
answer: no
name: Amlodipine;10mg;oral (PO);Daily
label: a
answer: no
name: Diazepam;2mg;oral (PO);8-hourly
label: i
answer: no
name: Co-codamol 8-500mg;1 tablet;oral (PO);6-hourly
label: h
answer: no
name: Ramipril;2.5mg;oral (PO);Daily
label: b
answer: no
name: Indapamide;1.5mg;oral (PO);Daily
label: c
answer: no
name: Omeprazole;40mg;oral (PO);Daily
label: g
answer: no
name: Tamsulosin;400micrograms;oral (PO);Daily
label: e
answer: no


1. The patient has developed AKI, which can result in a reduction in the clearance of his medication and an increase in adverse effects. The mechanism for confusion caused by benzodiazepine and codeine remains unknown, although the incidence is noted to be higher in the elderly population and in patient with decreased renal function due to a reduction in the clearance of the medication. Similarly, in geriatric patients, the bioavailability of acebutolol and its metabolite increases approximately by two-fold, due to the decrease in first pass metabolism and renal function in the elderly. Retention of codeine (co-codamol), diazepam and acebutolol in this patient may contribute to the patient’s confusion
2. Acebutolol is a cardio-selective beta-adrenergic antagonist, which acts on the beta-1 receptors in the heart causing a reduction in heart rate and contractility. Ramipril can cause arrythmia but acebutolol, specifically, causes bradycardia.
Case presentation: A 49-year old man presents to the emergency walk-in clinic with muscle weakness and constipation. He also complains that he has been having pain in the muscles of his upper arms. PH: Hypertension, Asthma, GORD, Hypercholesterolaemia DH: Her current regular prescriptions are listed below




 **On examination**: Chest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender.


 **Vital signs**: BP 125/80, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18


 **Investigations**:


 - ECG: Prolonged QT, mild ST depression, presence of U wave


||||
|--------------|:-------:|---------------|
|Haemoglobin|130   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|320x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|95 fL|80 - 96|
|Neutrophils|5x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|2x10<sup>9</sup>/L|1.5 - 4.0|
|Sodium|140 mmol/L|135 - 145|
|Potassium|3 mmol/L|3.5 - 5.3|
|Urea|7 mmol/L|2.5 - 7.8|
|Creatinine|109 µmol/L|60 - 120|


Question 1: Select the THREE prescriptions that are most likely to be a cause of his hypokalaemia (mark them with a tick in column A)
Question 2: Select the ONE prescription that should be withheld in view of the patient’s myopathy? (mark it with a tick in column B)

Options:
name: Omeprazole;20mg;Oral (PO);Daily
label: d
answer: no
name: Bendroflumethiazide;2.5 mg;Oral (PO);Daily
label: c
answer: no
name: Salmeterol;50 micrograms;Inhaled (INH);12-hourly
label: f
answer: no
name: Bisoprolol;5 mg;Oral (PO);OD
label: h
answer: no
name: Perindopril erbumine;8 mg;Oral (PO);Daily
label: b
answer: no
name: Theophylline (Uniphyllin Continus®);200mg;Oral (PO);12-hourly
label: g
answer: no
name: Simvastatin;40mg;Oral (PO);Daily
label: e
answer: no
name: Amlodipine;5mg;Oral (PO);Daily
label: a
answer: no


1. Bendroflumethiazide is a thiazide-like diuretic. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, leading to reduced Na+ reabsorption. As a result of the reduced reabsorption, the concentration of Na+ left in the urine increases. The increase in Na+ availability increases the activity of Na+/K+-ATPase in the collecting duct and brings about an increase in excretion of K+ into the urine. Salmeterol is a long-acting β2 adrenergic receptor agonist (LABA). β2 adrenergic receptor agonist decreases the serum K+ level via an inward shift of K+ into the cells. Theophylline is a phosphodiesterase inhibitor. It is also known to cause hypokalaemia. BNF highlights that concomitant treatment of β2 adrenergic receptor agonist with theophylline may potentiate potentially serious hypokalaemia.
2. Myalgia is a common or very common side effect of simvastatin.
Case presentation: A 85-year-old man was admitted to the Acute Medical Unit for infective exacerbation of COPD.


**PH** Severe COPD, Migraine, GORD, Osteoporosis.

**DH** His current regular medications are listed (below). Weight 60kg.

**On Examination**
Patient complained of loose stools over the past 3 days. Dry mucous membrane, peripheral CRT 3s.

Question 1: Select the TWO prescriptions that are most likely to be contributing to his loose stools (mark them with a tick in column A)
Question 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).

Options:
name: Omeprazole;40mg;oral (PO);Daily
label: c
answer: no
name: Salbutamol;200 micrograms;inhaled (INH);Daily
label: d
answer: no
name: Co-amoxiclav;625mg;oral (PO);Three times a day
label: a
answer: no
name: Colecalciferol (Vitamin D3);800units;oral (PO);Daily
label: f
answer: no
name: Ibuprofen;400mg;oral (PO);8-hourly
label: b
answer: no
name: Dalteparin sodium;12500 units;subcutaneous (SC);Daily
label: g
answer: no
name: Ipratropium bromide;40micrograms;inhaled (INH);6-hourly
label: e
answer: no


1. Co-amoxiclav, proton pump inhibitors (omeprazole) commonly cause diarrhea. Oral use of ibuprofen generally do not cause diarrhea.
2. Dalteparin sodium, given for prophylaxis of DVT in medical patients are prescribed at 5000 units daily. 12 500 units is given as treatment dose for a 60kg patient. The indication of dalteparin in this patient is for prophylactic use, not for treatment.
Case Presentation: A 19 year old man attends a follow-up appointment at his GP. **PH** acne vulgaris. **DH** 3% benzoyl peroxide with 1% clindamycin gel (Duac). He has been using this for twelve weeks following failure to improve his condition with benzoyl peroxide gel alone.


**O/E**

He has a uniform distribution of open and closed comedones with occasional pustules on his face and upper back. No scarring or nodularity present.

Question: Select the most appropriate management at this stage.

Options:
explanation: Tetracyclines are recommended as first line oral agents to treat acne vulgaris that has not responded to topical treatments. NICE recommends combination therapy (as opposed to antibiotic monotherapy), with topical azelaic acid.
name: Topical azelaic acid and Doxycycline 100mg PO OD
label: a
answer: yes
explanation: This is an alternative topical treatment for acne vulgaris which is less effective than the treatment that the patient is currently using
name: Azelaic acid 20% cream (Skinoren) topical BD
label: b
answer: no
explanation: This is an alternative oral antibiotic agent used to treat acne vulgaris where first line oral treatments are unsuitable
name: Trimethoprim 300mg PO BD
label: e
answer: no
explanation: This is an alternative oral antibiotic agent used to treat acne vulgaris where first line oral treatments are unsuitable
name: Erythromycin 500mg PO BD
label: c
answer: no
explanation: Isotretinoin is a retinoid medication used to treat severe acne vulgaris. It should not be prescribed in the primary care setting without specialist assessment
name: Isotretinoin 20mg PO BD
label: d
answer: no

Correct answer: a
Case Presentation: A 27 year old man attends a follow-up appointment with his GP. He initially presented one month ago with markedly low mood, loss of interest in his usual activities and feeling tired all the time. His GP diagnosed him with major depressive disorder and prescribed fluoxetine 20mg PO OD.


**O/E**

When asked about any improvement in his symptoms, the patient reports only a very slight lift to his mood that ‘may as well be the same as before’. He still experiences difficulty sleeping and only leaves the house to work his part-time job as a landscaper, but is finding that increasingly challenging. He says he has infrequent suicidal thoughts, and while he is adamant that he would never act on them in reality, he feels that he really ‘can’t go on like this for much longer’.

Question: Select the most appropriate management at this stage.

Options:
explanation: Up-titrating doses of SSRIs should be done where there has been an inadequate response to the initial starting dose
name: Maintain his current fluoxetine dose and review after 2 weeks
label: c
answer: no
explanation: Combination therapy with SSRIs is not routinely recommended due to the increased risk of developing serotonin syndrome
name: Add sertraline 50mg PO OD to his current prescription
label: b
answer: no
explanation: Switching to a non-SSRI antidepressant may be done in the primary care setting by experienced clinicians, but it is recommended to attempt to elicit a beneficial response with at least two SSRIs beforehand
name: Switch his prescription to mirtazapine 15mg PO OD
label: e
answer: no
explanation: Up-titrating doses of SSRIs should be done where there has been an inadequate response to the initial starting dose. The highest dose of fluoxetine that can be prescribed is 60mg
name: Increase the dose of fluoxetine to 40mg PO OD and review after 1 week
label: a
answer: yes
explanation: SSRIs may be switched where there has been an inadequate response to previously tried SSRIs after up-titration
name: Switch his prescription to citalopram 20mg PO OD
label: d
answer: no

Correct answer: a
Case Presentation: A 48 year old man presents to his GP with a 48 hour history of pain in his right foot. **PH** type 2 diabetes, GORD, gout. **DH** metformin hydrochloride 500mg PO TDS, sitagliptin 100mg PO OD, esomeprazole 20mg PO OD, allopurinol 200mg PO OD, paracetamol 1g PO QDS.


**O/E**

Swollen, erythematous 1st metatarsophalangeal joint on right foot. No other joints involved. Left foot grossly normal.

Temperature 36.4°C.

Question: Select the most appropriate management at this stage.

Options:
explanation: Patients with gout who are taking anti-uric acid medications should not switch their drugs during an acute flare as this can worsen symptoms
name: Change allopurinol to febuxostat 120mg PO OD
label: b
answer: no
explanation: Patients with gout who are taking anti-uric acid medications should not discontinue their drugs during an acute flare as this can worsen symptoms
name: Stop allopurinol and prescribe prednisolone 20mg PO for 7 days
label: e
answer: no
explanation: Patients with gout who are taking anti-uric acid medications should continue their drugs and receive treatment with anti-inflammatories. As NSAIDs should be avoided in this patient, colchicine can be given as an alternative
name: Continue allopurinol and prescribe colchicine 500 micrograms PO BD for 3 days
label: a
answer: yes
explanation: Patients with gout who are taking anti-uric acid medications should not discontinue their drugs during an acute flare as this can worsen symptoms
name: Stop allopurinol and prescribe naproxen sodium 500mg PO stat
label: d
answer: no
explanation: Patients with gout who are taking anti-uric acid medications should continue their drugs and receive treatment with anti-inflammatories. NSAIDs are generally recommended first line but this patient has a history of GORD and hence they would not be suitable
name: Continue allopurinol and prescribe diclofenac sodium 75mg PO BD for 7 days
label: c
answer: no

Correct answer: a
Case Presentation: A 28 year old woman presents to her GP with a longstanding history of acne. She has tried various topical creams and ointments in the past that have only resulted in very modest improvement, and wonders if there is anything else that can be prescribed. **PH** acne vulgaris. **DH** benzoyl peroxide gel, azelaic acid 20% cream (Skinoren).


Her BMI is 28kg/m^2. On further questioning, she also reveals that she has had to engage in waxing her upper lip and chin since the age of 17, and describes erratic menstrual cycles ranging anywhere from 21 days to as long as 90 days. She has never been pregnant before, is sexually active and uses barrier protection as contraception as she is not looking to start a family.

Question: Select the most appropriate management at this stage.

Options:
explanation: Isotretinoin is a retinoid medication used to treat severe acne vulgaris. It should not be prescribed in the primary care setting or to a woman of childbearing age absent a pregnancy prevention plan due to its potent teratogenic effects
name: Isotretinoin 20mg PO BD
label: b
answer: no
explanation: This is an alternative topical treatment for acne vulgaris
name: Nicotinamide gel topical BD
label: d
answer: no
explanation: This is an oral treatment option for acne vulgaris that has not responded to topical treatments
name: Tetracycline 500mg PO BD
label: e
answer: no
explanation: For females with PCOS that have not improved following treatment with a first line option such as topical treatments, consider adding ethinylestradiol with cyproterone (co-cyprindiol) and review at 6 months, as per [NICE Guidance.](https://www.nice.org.uk/guidance/ng198/chapter/Recommendations)
name: Co-cyprindiol 2000/35 micrograms PO OD
label: a
answer: yes
explanation: This is a combined contraceptive pill formulation. This is recommended as second line treatment (though it is unlicensed) for acne in patients with PCOS if co-cyprindiol is ineffective, as per [NICE Guidelance.](https://www.nice.org.uk/guidance/ng198/chapter/Recommendations)
name: Combined oral contraceptive pill
label: c
answer: no

Correct answer: a
Case Presentation: A 15 month old boy is brought to A&E by his parents with fever, cough and reduced oral intake.


**O/E**

Temperature 37.8°C. HR 104, RR 32 with persistent non-productive cough. O2 95% RA. Scattered fine crepitations and audible wheeze on auscultation. Appears pale pink and not cyanosed. Weight 10kg.

He has been given paracetamol oral suspension (Calpol Infant 120mg/5ml) 120mg PO and started on 4L oxygen wafted via simple face mask.

Question: Select the most appropriate management at this stage.

Options:
explanation: Palivizumab is a humanised monoclonal antibody that is used to prevent RSV infections in children at higher risk of severe disease. It is not routinely given without specialist paediatric input
name: Palivizumab 15mg IM
label: d
answer: no
explanation: Bronchiolitis is generally managed conservatively unless there is evidence of disease severity (e.g cyanosis, <50% oral intake)
name: No additional treatment is required
label: a
answer: yes
explanation: Phenoxymethylpenicillin may be given to treat streptococcal infections. There is no evidence such an infection is present in the stem
name: Phenoxymethylpenicillin 125mg PO
label: e
answer: no
explanation: Dexamethasone is an anti-inflammatory steroid medication commonly used to treat croup in the paediatric population. It has no role in the acute management of bronchiolitis
name: Dexamethasone 1.5mg PO
label: c
answer: no
explanation: Although fluid resuscitation may be necessary if the child is dehydrated due to reduced oral intake, there is nothing in the stem to support this
name: 0.9% normal saline 200ml IV
label: b
answer: no

Correct answer: a