hllj/quesmed huggingface dataset:
Case Presentation:  A 42-year-old man is due to be started on Allopurinol following a diagnosis of Gout in his left great toe. 


**PMH**

* Type 1 Diabetes
* Depression

**DH**

* Citalopram 40mg OD
* Humulin M3 12 units BD

Question: Which of the following is the most appropriate monitoring for the adverse effects of Allopurinol?

Options:
explanation: Allopurinol is known to cause hepatic impairment, LFTs should be monitored every three months during the first year of taking allopurinol to monitor for this.
name: LFTs every 3 months for the first year
label: a
answer: yes
explanation: Allopurinol is known to cause hepatic impairment, LFTs should be monitored every three months during the first year of taking allopurinol to monitor for this. An ultrasound of the liver would not be involved in the routine monitoring of allopurinol therapy.
name: Ultrasound of liver at 6 months
label: e
answer: no
explanation: Serum urate level is used in the first few weeks of allopurinol therapy in order to guide dosing, however, it would not be useful in monitoring the adverse effects of the drug.
name: Serum urate levels monthly
label: b
answer: no
explanation: Signs of gout may be able to be seen on X-ray, however, they are not routinely repeated in the long-term management of gout. X-ray findings of gout include tophi (soft tissue deposits of urate) and punched-out erosions.
name: Repeat X-Ray of left toe in 6 months
label: c
answer: no
explanation: Foods rich in purines such as offal, oily fish, game and red meat can increase the risk of gout. These should be avoided/reduced in the management of gout. Patients' diets are not routinely monitored. A healthy, balanced diet, rich in fruit and vegetables is encouraged.
name: Food diary
label: d
answer: no

Correct answer: a
Case Presentation:  A 64 year old man is sent to the rapid access chest pain clinic by his GP following the reported results of a 24 hour ECG Holter monitor. 


**PMH** myocardial infarction with 100% LAD occlusion, hypertension, hypercholesterolaemia, COPD

**DH** aspirin 75mg PO OD, bisoprolol fumarate 2.5mg PO OD, ramipril 10mg PO OD, amlodipine 5mg PO OD, salmeterol 50micrograms INH BD, tiotropium 5micrograms INH OD, atorvastatin 80mg PO OD.  NKDA

**Investigations**

24 hour ECG holter monitor: infrequent runs of ventricular tachycardia lasting 30-40 seconds

It is recommended to start amiodarone hydrochloride 200mg PO TDS whilst awaiting implantation of an Implantable Cardioverter Defibrillator (ICD).

Question: Select the most appropriate monitoring option required before initiating amiodarone hydrochloride.

Options:
explanation: Amiodarone is a potassium channel blocker and as such imbalances in potassium should be corrected prior to starting this drug, rather than magnesium.
name: Serum magnesium
label: b
answer: no
explanation: An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited utility with respect to starting this drug.
name: Troponin
label: c
answer: no
explanation: While pancreatitis as a result of amiodarone use has been reported, this is a very rare side effect of amiodarone use. HPL also isn't a useful test as it can be raised for many reasons, it is also used for the **diagnosis** of acute pancreatitis, not for screening for acute pancreatitis.
name: Human pancreatic lipase
label: d
answer: no
explanation: Amiodarone contains iodine which in turn can commonly cause thyroid disorders. Both hypothyroidism and hyperthyroidism have been linked to amiodarone use. Amiodarone doesn't need to be withdrawn if it is essential and causes hypothyroidism, this can be treated with replacement therapy.
name: Thyroid function tests
label: a
answer: yes
explanation: While blood dyscrasias have been reported with use of amiodarone, these are very rare and as such a full blood count would be useful as a baseline but is not routinely done.
name: Full blood count
label: e
answer: no

Correct answer: a
Case Presentation:  A 36-year-old female patient attends the outpatient rheumatology clinic.  He is due to commence treatment on methotrexate for rheumatoid arthritis. Weight 63kg.


**PMH**
Depression

**DH**
Cerazette, 1 tablet daily
Citalopram, 20mg OD

Question: Which of the following is the most appropriate monitoring of a patient starting methotrexate?

Options:
explanation: Methotrexate increased the risk of blood dyscrasias, liver cirrhosis and blood dyscrasias. Bloods should be checked every 1-2 weeks until dosing stabilised and then every 2-3 months.
name: FBC, U&E and LFTs every 1-2 weeks until stabilised
label: a
answer: yes
explanation: Methotrexate is teratogenic and may also reduce fertility. It is therefore recommended that effective contraception is used during treatment and for 6 months afterwards for both men and women. Despite this, pregnancy prevention programmes are not routinely used in methotrexate therapy.
name: Pregnancy prevention programme
label: c
answer: no
explanation: Methotrexate is not known to cause any cardiac adverse reactions. An ECG is therefore not routine in the monitoring of methotrexate therapy.
name: ECG before starting
label: d
answer: no
explanation: Methotrexate level is not used in the monitoring of methotrexate therapy.
name: Methotrexate level every week
label: e
answer: no
explanation: Although Methotrexate is a folate antagonist, Haematinics (B12, folate, ferritin and intrinsic factor) are rarely monitored. Folic acid is instead taken weekly, to prevent deficiency.
name: Haematinics every 1-2 weeks until stabilised
label: b
answer: no

Correct answer: a
Case Presentation:  A 56 year old gentleman attends a follow-up appointment at his GP. 


**PMH** hypertension

**DH** ramipril 10mg PO OD, paracetamol 1g PO QDS

**FH** Father died of heart attack at the age of 50. Mother died of an ischaemic stroke at the age of 64

**SH** current smoker, 25-30 cigarettes a day but currently attending smoking cessation counselling.

**Investigations**

Q-risk score: 11%

It is decided that starting atorvastatin 20mg PO OD would help lower his risk of a cardiac event. A repeat consultation is booked in for 3 months later to assess treatment response.

Question: Select the most appropriate option to monitor for treatment response at the next consultation.

Options:
explanation: Statins work by inhibiting the enzyme HMG-CoA reductase, an enzyme that is responsible for the synthesis of cholesterol. By blocking this pathway, statins reduce the total level of circulating cholesterol and LDLs. A lipid profile at the start of treatment and in subsequent consultations is important in monitoring treatment response.
name: Lipid profile
label: a
answer: yes
explanation: This should only be measured if statin-associated myopathy or rhabdomyolysis is suspected. It is not part of routine monitoring while taking a statin. It also would not be used to measure treatment response.
name: Creatinine kinase
label: e
answer: no
explanation: Full blood count has no role in the monitoring of patients taking statins.
name: Full blood count
label: b
answer: no
explanation: It is recommended to measure renal function prior to starting atorvastatin to assess for adverse effects. Monitoring renal function would not assess for treatment response.
name: Urea and electrolytes
label: d
answer: no
explanation: It is recommended that liver function should be measured prior to starting treatment and at 3 months and 12 months afterwards as atorvastatin is known to be hepatotoxic. However, this would be monitoring the treatment for an **adverse** effect, the question asks for the test that monitors treatment response.
name: Liver function test
label: c
answer: no

Correct answer: a
Case Presentation:  A 72-year-old female patient is admitted to the acute medical ward with breathlessness. She is due to commence treatment on Furosemide for congestive cardiac failure. Weight 72kg.


**PMH**
Myocardial infarction
Type 2 diabetes mellitus

**DH**

* Atorvastatin, 40mg nightly
* Clopidogrel, 75mg OD
* Bisoprolol, 5mg OD
* Ramipril, 7.5mg OD
* Metformin, 500mg BD

Question: Which of the following is the most appropriate monitoring of the beneficial effects of Furosemide therapy?

Options:
explanation: Furosemide has been shown to lead to some haematological adverse effects such as agranulocytosis and aplastic anaemia, however, a full blood count has little efficacy in demonstrating the beneficial symptomatic effects of furosemide.
name: Full Blood Count daily
label: e
answer: no
explanation: NT-proBNP is a hormone secreted by cardiomyocytes in response to stretching as a result of increased ventricular blood volume, it is therefore used diagnostically in cardiac failure. NT-proBNP is of little value in monitoring the symptomatic benefits of furosemide.
name: NT-ProBNP after 1 week
label: b
answer: no
explanation: Echocardiograms are used in the diagnostic and prognostic monitoring of cardiac failure, however, it has little value in monitoring the symptomatic benefits of furosemide.
name: Echocardiogram after 1 week
label: c
answer: no
explanation: Furosemide is a loop diuretic used in the symptomatic treatment of cardiac failure. Daily weights are an effective way to measure the effectiveness of furosemide by quantifying fluid losses.
name: Daily weight measurements
label: a
answer: yes
explanation: Urea and Electrolytes (U&Es) should be monitored during furosemide therapy as furosemide can lead to electrolyte imbalance and AKI. However, U&Es have little efficacy in demonstrating the symptomatic benefits of Furosemide.
name: Urea and Electrolytes daily
label: d
answer: no

Correct answer: a
Case Presentation: A 49-year-old gentleman is attends his GP for a review of his blood pressure medication. 




 **PMH**
Hypertension


 **DH**
Ramipril 5mg PO OD.


 **Investigations**
Today's bloods:


||||
|---------------------------|:-------:|--------------------|
|Sodium|141 mmol/L|135 - 145|
|Potassium|3.6 mmol/L|3.5 - 5.3|
|Urea|3.4 mmol/L|2.5 - 7.8|
|Creatinine|66 µmol/L|60 - 120|



Bloods from 3 months ago:


||||
|---------------------------|:-------:|--------------------|
|Sodium|139 mmol/L|135 - 145|
|Potassium|4.4 mmol/L|3.5 - 5.3|
|Urea|3.6 mmol/L|2.5 - 7.8|
|Creatinine|71 µmol/L|60 - 120|


Today's blood pressure: 141/82 mmHg


Question: Select the most appropriate decision option based on this data

Options:
explanation: Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.
name: Don't change his treatment
label: a
answer: yes
explanation: There is no indication to increase this gentleman's ramipril dose as his blood pressure reading isn't too high.
name: Increase ramipril to 10mg PO OD
label: c
answer: no
explanation: Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.
name: Stop his ramipril now
label: b
answer: no
explanation: Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.
name: Switch him to amlodipine
label: d
answer: no
explanation: Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.
name: Switch him to candesartan
label: e
answer: no

Correct answer: a
Case Presentation:  A 79-year-old gentleman has been admitted to a general surgical ward. He has recently been treated for a pelvic collection with IV cefuroxime and metronidazole. He has finished his antibiotics and a repeat CT scan of his abdomen and pelvis shows that the collection has resolved. 


Today he is complaining of loose stools.

**PMH** Depression, hypertension, hypercholesterolaemia, osteoporosis,

**DH**

Omeprazole 20mg PO BD, sertraline 50mg PO OD, atorvastatin 20mg PO OD, alendronic acid 10mg PO OD, colecalciferol 800 units PO OD

**Investigations**
Observations:

HR 65 bpm, RR 12, blood pressure 123/67 mmHg, O2 saturations 96% on room air, temperature 37.4

Stool type - 7

C. difficile toxin - positive

Question: Select the most appropriate decision option based on this data

Options:
explanation: Starting vancomycin would be correct however there is no clinical indication for stopping this patient's colecalciferol.
name: Suspend his colecalciferol and start vancomycin 125mg PO QDS
label: b
answer: no
explanation: There is no clinical indication for stopping this patient's colecalciferol.
name: Suspend his colecalciferol
label: c
answer: no
explanation: This question requires you to know that PPIs increase the risk of clostridium difficile infection. In this case, the gentleman's omeprazole may be contributing to his c. difficile infection and therefore it should be stopped. The c. difficile infection should be treated, the first line treatment is vancomycin 125mg PO QDS (this patient is stable and therefore doesn't need a higher dose).
name: Suspend his omeprazole and start vancomycin PO QDS
label: a
answer: yes
explanation: This patient has a c. difficile infection. Precipitants of said infection should be stopped (in this case the PPI) and antibiotics to treat the c. difficile should be given.
name: No change in treatment required
label: d
answer: no
explanation: Starting this patient on vancomycin would be the right thing to do however this is the wrong dose, and you would still also need to suspend the PPI he is taking due to it exacerbating c. difficile infections.
name: Start vancomycin 100mg PO QDS
label: e
answer: no

Correct answer: a
Case Presentation:  A 26-year-old female patient takes the combined oral contraceptive pill (COCP) for endometriosis. She feels well in herself. 


**PMH**
Endometriosis

**DH**
Microgynon 30 one tablet daily

**On Examination**

* HR 84 bpm
* Blood pressure 166/92 mm/Hg

Question: Given the results of the above investigations, what is the most appropriate next step?

Options:
explanation: Whilst this patient is hypertensive, she is asymptomatic and systemically well. Hypertension with a systolic pressure of over 180mmHg and signs of end-organ damage such as retinal haemorrhage, papilloedema, new confusion, chest pain or signs of heart or kidney failure would require immediate admission as this would suggest malignant hypertension. It would therefore not be appropriate to admit this patient. The most important step at this stage would be stopping her COCP as this could be a cause of her hypertension. (!)
name: Admit to hospital
label: e
answer: no
explanation: This patient has a blood pressure of over 160mmHg systolic and the combined oral contraceptive pill should be stopped. Taking a 7-day break from the pill would not be appropriate here. Breaks from the combined oral contraceptive pill are used to induce withdrawal bleeds.
name: Take a 7-day break from microgynon
label: d
answer: no
explanation: This patient is hypertensive. A systolic blood pressure of over 160mmHg (or >100mmHg diastolic) is a contraindication to COCP usage and it should be stopped.
name: Stop microgynon
label: a
answer: yes
explanation: Microgynon and Dianette are both combined oral contraceptive pills. Dianette is used specifically to treat acne. This patient has a blood pressure of over 160mmHg systolic and so any COCP would be inappropriate.
name: Change microgynon to dianette
label: b
answer: no
explanation: Ramipril is an angiotensin-converting enzyme inhibitor (ACE-i) used to treat hypertension. Although an ACE-i would be the first choice of antihypertensive in a patient under the age of 55, stopping microgynon would be a more appropriate initial step. The patient's blood pressure may improve on cessation of the combined oral contraceptive pill.
name: Start ramipril
label: c
answer: no

Correct answer: a
Case Presentation:  A 86-year-old female patient attends A&E with epistaxis, this has stopped within 30 minutes after nasal packing. She takes Warfarin for atrial fibrillation. 


**PMH**

* Atrial fibrillation
* Aortic Stenosis
* Psoriasis
* Psoriatic Arthritis

**DH**

* Warfarin 6mg OD
* Hydromol intensive cream QDS
* Paracetamol 1g QDS

**On Examination**

* HR 78bpm
* Blood pressure 124/80 mm/Hg
* Oxygen saturation 96%
* RR 16
* Temperature 36.8

**Investigations**

* INR: 6.5
* Target INR: 2-3

Question: Given the results of the above investigation, what is the most appropriate next step?

Options:
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. Oral vitamin K should be given when INR is greater than 8 and there is no evidence of bleeding.
name: Stop warfarin and give phytomenadione (vitamin K) orally
label: b
answer: no
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. As the INR is between 5 and 8, IV vitamin K should be given. INR should then be rechecked and Warfarin restarted if INR is less than 5.  Dried prothrombin complex concentrate or fresh frozen plasma would be appropriate where a severe bleeding episode has occurred.
name: Stop warfarin, give urgent intravenous treatment with phytomenadione (vitamin K) and dried prothrombin complex concentrate (factors II, VII, IX, and X), or fresh frozen plasma if the dried prothrombin complex is unavailable
label: d
answer: no
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. As the INR is between 5 and 8, IV vitamin K should be given. INR should then be rechecked and Warfarin restarted if INR is less than 5.
name: Stop warfarin and give phytomenadione (vitamin K) by slow intravenous injection Restart warfarin when INR is less than 5
label: a
answer: yes
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. As the INR is between 5 and 8, IV vitamin K should be given. If INR is consistently raised, a decrease in dose may be appropriate but is not the most important next step.
name: Decrease Warfarin dose to 5mg
label: e
answer: no
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. Withholding 1-2 doses of Warfarin may be appropriate if this patient had an INR of 6.5 but no evidence of bleeding. As this patient has experienced some bleeding, treatment with vitamin K is recommended.
name: Withhold 1 or 2 doses of warfarin and reduce subsequent maintenance dose
label: c
answer: no

Correct answer: a
Case Presentation: A 34-year-old gentleman is admitted to ED with generalised abdominal pain.




 **PMH** Nil


 **DH** Nil


 **Investigations**


Observations: HR 112 bpm, RR 21, blood pressure 84/44 mmHg, temperature 38.4, O2 saturations 93% on RA


Abdominal examination: tender to palpation in RUQ, bowel sounds present.


Bloods: CRP 211 mg/L (<5 mg/L), WCC 18.9 x 10<sup>9</sup>)L (3.6 – 11.0 x 10<sup>9</sup>)L)


Question: Select the most appropriate decision option based on this data

Options:
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. 30 minutes would take too long to give the fluid in this type of scenario.
name: A fluid bolus of 500ml should be prescribed and given over 30 minutes
label: c
answer: no
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. 30 minutes would take too long to give the fluid in this type of scenario. A 250ml bolus is also not enough, this would typically be used in patients with pre-existing heart failure.
name: A fluid bolus of 250ml should be prescribed and given over 30 minutes
label: d
answer: no
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. Giving a 250ml bolus is preferred if the patient has pre-existing heart failure.
name: A fluid bolus of 250ml should be prescribed and given over <15 minutes
label: b
answer: no
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes.
name: A fluid bolus of 500ml should be prescribed and given over <15 minutes
label: a
answer: yes
explanation: This patient is very unwell, likely due to biliary sepsis. This question requires you to identify that this patient needs urgent fluid resuscitation - this includes giving a 500ml bolus of fluid in less than 15 minutes. 45 minutes would take too long to give the fluid in this type of scenario.
name: A fluid bolus of 500ml should be prescribed and given over 45 minutes
label: e
answer: no

Correct answer: a
Case Presentation: A 73-year-old gentleman takes Digoxin for atrial fibrillation. He attends the GP for a medication review. He is feeling well. His regular medicines are listed below. 




 **PMH**


 * Atrial fibrillation
 * Previous MI
 * Peripheral vascular disease


 **DH**


 * Digoxin 250 micrograms OD
 * Ramipril 10mg OD
 * Amlodipine 5mg OD
 * Aspirin 75mg OD


 **On Examination**


 * HR 108 bpm
 * Blood pressure 126/84 mm/Hg


 **Investigations**


 * Digoxin level: 0.3nanograms/mL (Therapeutic range: 0.7-2nanograms/mL)


Blood tests:



||||
|---------------------------|:-------:|--------------------|
|Sodium|140 mmol/L|135 - 145|
|Potassium|4.2 mmol/L|3.5 - 5.3|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|90 µmol/L|60 - 120|



Question: Given the results of the above investigations, what is the most appropriate next step?

Options:
explanation: This patient's U&Es are normal. U&Es may become deranged in cases of digoxin toxicity (and as a consequence of ACE inhibitor therapy). In this case, there are no signs of digoxin toxicity and digoxin levels are below the therapeutic range. There is no indication to repeat the U&Es at this point.
name: Repeat Urea and Electrolytes
label: e
answer: no
explanation: This patient's digoxin level is below the therapeutic range. Poor adherence to treatment could explain why this is the case. This patient is also tachycardic, suggesting that digoxin that their atrial fibrillation is poorly controlled. Checking adherence to digoxin would be the most appropriate next step before increasing the dose.
name: Check adherence
label: a
answer: yes
explanation: This patient's digoxin level is below the therapeutic range, they are therefore unlikely to be experiencing digoxin toxicity. An ECG may be helpful if toxicity is suspected to check for severe cardiac effects such as; sinoatrial and atrioventricular block,
premature ventricular contractions (resulting in bigeminy or trigeminy) and PR prolongation and ST-segment depression.
name: ECG
label: d
answer: no
explanation: This patient's digoxin level is below the therapeutic range, decreasing the patient's dose of digoxin would therefore be inappropriate.
name: Decrease the digoxin dose
label: b
answer: no
explanation: This patient's digoxin level is below the therapeutic range, stopping digoxin in this patient would not be effective in controlling their atrial fibrillation.
name: Stop digoxin
label: c
answer: no

Correct answer: a
A 93-year-old man has acute hyperactive delirium. He has become aggressive towards nursing staff and attempts to calm him down have failed. The medical registrar decides to give a dose of 500micrograms of Haloperidol intramuscularly. The solution for injection of contains 5mg/ml of Haloperidol.

How many millilitres of the solution should be given?

Options:


500micrograms = 0.5mg

0.5mg needed

5mg in every 1ml

0.5 / 5 = 0.1

0.1mL of haloperidol solution should be delivered.