hllj/quesmed huggingface dataset:
Case Presentation: A 50 year old woman is a surgical inpatient recovering from an elective anterior resection of sigmoid adenocarcinoma. **PH** type 1 diabetes. **DH** insulin lispro (Humalog) 10 units SC TDS with meals, insulin glargine (Lantus) 22 units SC ON.


**O/E**

Alert and oriented. Vital observations stable, surgical site dressing clean with limited strikethrough. Loop ileostomy in RIF, stoma bag collecting yellow liquid stool.

She is currently on insulin glargine (Lantus) 17 units SC ON and has been receiving a variable rate insulin infusion (VRII) for 12 hours since 7pm yesterday. Her pain and nausea are well controlled, and she recently started eating and drinking. She is now due dinner.

Question: Select the most appropriate management with regard to her insulin at this stage.

Options:
explanation: The patient is able to eat and drink and there is no reason to delay returning to normal oral intake and the patient’s regular subcutaneous insulin
name: Continue VRII for another 12 hours and discontinue if BMs are stable
label: d
answer: no
explanation: When transitioning from a VRII to normal subcutaneous insulin, the infusion should be left running for 30-60 minutes afterwards to ensure stable BMs
name: Administer insulin lispro with next meal and discontinue VRII
label: c
answer: no
explanation: As the patient is able to eat and drink, she should restart her usual subcutaneous fast-acting insulin with her next meal with the VRII running for 30-60 minutes afterwards to ensure stable BMs
name: Administer insulin lispro with next meal and continue VRII for 1 hour afterwards
label: a
answer: yes
explanation: The patient’s long-acting insulin should only be returned to normal levels at the time of discharge and not whilst still on a VRII
name: Increase insulin glargine to 22 units SC ON and administer insulin lispro with next meal
label: e
answer: no
explanation: The patient is able to eat and drink and there is no reason to delay returning to normal oral intake and the patient’s regular subcutaneous insulin
name: Administer insulin lispro with tomorrow's evening meal and continue VRII for 1 hour afterwards
label: b
answer: no

Correct answer: a
Case Presentation: A 36 year old man is recovering on the high dependency unit following emergency repair of a proximal aortic dissection. **PH** Marfan syndrome. **DH** atenolol hydrochloride 50mg PO OD, co-codamol 8/500mg PO QDS.


**O/E**

Drowsy but maintaining own airway. HR 64, RR 21, BP 95/56, O2 97% 2L NC, Temperature 37.4°C. Peripheries cool, CRT 4s. HS I + II + 0. Midline sternotomy dressing intact, 3x Jackson Pratt drains collecting serosanguinous fluid. Oral mucous membranes appear dry, skin turgor normal.

Fluids prescribed: 1L 5% dextrose with 40mmol K over 10h, 1L 0.9% normal saline over 10h, 250ml 5% dextrose with 20mmol K over 4h

Urine output over last 24h = 1.3L

Surgical drain output over last 24h = 1.5L

Question: Select the most appropriate management at this stage.

Options:
explanation: The patient is in net negative fluid balance and acutely hypotensive. Slow fluid replacement is not an appropriate response to this situation
name: 1L 0.9% normal saline over 4 hours
label: b
answer: no
explanation: The patient is in net negative fluid balance and acutely hypotensive, which may be being exacerbated by beta-blockers and a blunted sympathetic response. A fluid challenge should be initiated and the blood pressure response carefully monitored
name: 500ml 0.9% normal saline over 15 minutes
label: a
answer: yes
explanation: Although it is increasingly becoming more popular as a maintenance fluid, dextro-saline has limited use as a plasma expander due to its high dextrose concentration and tendency to redistribute
name: 500ml 0.45% saline/4% dextrose over 15 minutes
label: d
answer: no
explanation: 5% dextrose is generally not used as a plasma expander as it redistributes quickly across all fluid compartments
name: 1L 5% dextrose over 1 hour
label: c
answer: no
explanation: A balanced crystalloid is a good option for fluid resuscitation. It should be administered far more rapidly than over 1 hour for its effects to be maximised
name: 1L Hartmann’s solution over 1 hour
label: e
answer: no

Correct answer: a
Case Presentation: A 7 year old boy attends a specialist paediatric assessment after being referred via his family GP. He has been reported to have significant difficulty concentrating in school and at home, often disrupting entire class lessons and refusing to sit still for longer than 5 minutes. His mother is now worried about allowing him to play outdoors as he tends towards climbing high objects like trees and fences, and has fallen from them on a number of occasions. His teachers feel that he does exhibit some difficulty in understanding instructions when spoken to, and sometimes makes inappropriate comments in reply to them.


**Investigations**

He has not had any significant developmental delay and has received all his scheduled childhood vaccinations. Baseline ECG normal sinus rhythm. Weight and height on 70th centile for his age and gender. He weighs 30kg.

Question: Select the most appropriate management at this stage.

Options:
explanation: This is an alternative treatment for ADHD, but is unlicensed for that indication and is less preferred than first line options
name: Dexamfetamine sulfate 2.5mg PO TDS
label: c
answer: no
explanation: This is an alternative treatment for ADHD if there is inadequate response to first line treatments
name: Atomoxetine 15mg PO OD
label: b
answer: no
explanation: Risperidone may be used to manage behavioural problems associated with ADHD but would not be initiated as a first line treatment
name: Risperidone 250 micrograms PO OD
label: e
answer: no
explanation: This is recommended first line to treat ADHD. Lisdexamfetamine mesilate is an alternative first line treatment
name: Methylphenidate hydrochloride 5mg PO OD
label: a
answer: yes
explanation: Fluoxetine is licensed for the treatment of depression in young children. It has no role in treating ADHD alone
name: Fluoxetine 10mg PO OD
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: 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
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
name: Maintain his current fluoxetine dose and review after 2 weeks
label: c
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: 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

Correct answer: a
Case Presentation: A 34 year old woman presents to GP with her male partner to solicit advice in conceiving a child. They have been having regular unprotected penetrative sex at least twice a week for four months. She has had one previous pregnancy and termination at the age of 18, and bleeds regularly with a 28 day cycle. She has a background of T2DM which is diet-controlled. She wonders if the GP can prescribe anything that she should be taking while trying to conceive.


**Investigations**

FBC: Hb 115, WCC 5.2, Plts 240 x 10^9, MCV 91

Question: Select the most appropriate management at this stage.

Options:
explanation: Metformin hydrochloride may have some beneficial effects on fertility in patients with polycystic ovarian syndrome, but there is nothing in the stem to suggest that the patient has PCOS
name: Metformin hydrochloride 500mg PO OD
label: e
answer: no
explanation: This is a selective oestrogen receptor modulator that stimulates ovulation. It should not be prescribed without a full assessment by a fertility specialist, and is not likely to be indicated as the patient is having regular bleeds which indicates she is ovulating
name: Clomifene citrate 50mg PO OD
label: b
answer: no
explanation: While megaloblastic anaemia can have a detrimental effect on fertility, this patient is clearly not anaemic
name: Hydroxocobalamin 1mg IM monthly
label: d
answer: no
explanation: All women who are attempting to conceive and low risk should be taking folic acid to reduce the risk of neural tube defects. Women at high risk (e.g. previous tube defects, family history, diabetics, on epilepsy medication, high BMI) should be on high dose folic acid (5mg OD). As this woman has diabetes she would be considered high-risk and hence 5mg is the correct answer.
name: Folic acid 5mg PO OD
label: a
answer: yes
explanation: While iron deficiency anaemia can have a detrimental effect on fertility, this patient is clearly not anaemic
name: Ferrous sulfate 200mg PO TDS
label: c
answer: no

Correct answer: a
Case Presentation: A 29-year-old man is brought to A&E after taking an overdose of paracetamol 20 minutes ago. He has ingested 18 tablets (9g) of paracetamol. **PH** Depression **DH** Citalopram 40mg Oral once daily, NKDA


**On examination**
The patient looks well, not visibly jaundiced.

BP 116/86, HR90, RR 16, Temperature 36.5°C

Weight 75kg

**Investigations**

Blood to be taken 4hr after ingestion

Question: Select the most appropriate management at this stage.

Options:
explanation: It may be appropriate to give a patient with a paracetamol overdose a resuscitation fluid bolus where they vital signs are deranged, however, the patient in this case is currently stable.
name: 500mL NaCl 0.9% in 10 minutes
label: e
answer: no
explanation: This patient has taken a paracetamol overdose and presented to A&E in under 1 hour, Activated charcoal should therefore be considered as the initial management of this patient.
name: Activated Charcoal 50g PO (Oral)
label: a
answer: yes
explanation: Diazepam is used in patients who have taken an overdose of stimulant drugs or antipsychotics.
name: Diazepam 10mg PO (Oral)
label: d
answer: no
explanation: Haemodialysis is the treatment in severe salicylate poisoning. It would not be appropriate here.
name: Haemodialysis
label: b
answer: no
explanation: Acetylcysteine is used in the treatment of paracetamol poisoning. However, it is used; when a plasma paracetamol concentration is within the treatment threshold, where patients present later than 8 hours and have taken over 150mg/kg of paracetamol or where patients are visibly jaundiced.
name: Acetylcysteine IV
label: c
answer: no

Correct answer: a
Case Presentation: A 73 year old woman attends her GP for a diabetes review. 


**PH** Type 2 diabetes mellitus, hypercholesterolaemia

**DH** Metformin 500mg PO BD, simvastatin 20mg PO OD. NKDA

**Investigations**

HbA1c 3 months ago: 62 mmol/mol (< 42 mmol/mol)

HbA1c today: 53 mmol/mol (< 42 mmol/mol)

Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.
name: Add 10 units Humulin I Insulin to take once in the morning
label: e
answer: no
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.
name: Add pioglitazone 30mg PO OD
label: d
answer: no
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin. She should be encouraged to keep taking metformin and keep any dietary/lifestyle changes she has employed and the HbA1c should be rechecked in 3 months.
name: Make no changes to her medications
label: a
answer: yes
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.
name: Add sitagliptin 100mg PO OD
label: c
answer: no
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.
name: Add gliclazide 40mg PO OD
label: b
answer: no

Correct answer: a
Case Presentation: A 26 year old man attends his GP for a review of his asthma. He is still feeling wheezy at night and struggling to exercise. His inhaler technique is good and he is taking his medications as recommended.

**PMH** Asthma

**DH** Low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler as required

**On examination**

FEV1/FVC ratio: 53%

Question: Select the most appropriate management at this stage.


Options:
explanation: This patient isn't having an acute asthma exacerbation nor is he at the point in the asthma treatment ladder in which oral corticosteroids would be considered (this would only be initiated by a specialist).
name: Add oral prednisolone 5mg PO OD
label: d
answer: no
explanation: This patient isn't having an acute asthma exacerbation therefore this option is inappropriate.
name: Admit to hospital
label: e
answer: no
explanation: Moderate-dose MART may be considered for patients whose asthma remains uncontrolled on low-dose MART. However, a stepwise approach is essential in asthma management, and since this patient has not yet trialed low-dose MART, moderate-dose MART would be premature at this stage.
name: Moderate dose daily maintenance and reliever therapy (MART)
label: a
answer: no
explanation: Montelukast, a leukotriene receptor antagonist, is not typically considered as a first-line step in asthma management. It may be added as adjunct therapy if symptoms remain uncontrolled on moderate-dose MART. However, since the patient has not yet trialed low-dose or moderate-dose MART, montelukast is not indicated at this stage. 
name: Add montelukast 10 mg PO OD
label: b
answer: no
explanation: The patient's symptoms of nighttime wheezing and exercise limitation, coupled with an FEV1/FVC ratio of 53%, indicate suboptimal asthma control despite adherence to his current as-needed low-dose ICS/formoterol regimen. The most appropriate next step is to initiate low-dose daily maintenance and reliever therapy (MART), which involves using a low-dose ICS/formoterol combination both as a daily maintenance inhaler and as needed for symptom relief. 
name: Low dose daily maintenance and reliever therapy (MART)
label: c
answer: yes

Correct answer: c
Case presentation: A 25-year-old man attends his GP with a 3-month history of low mood and energy. He reports that he no can no longer derive joy from gardening which he used to enjoy. He denies having any suicidal ideation.  

Physical examination: HS 1+11 + 0, vesicular breathing with no added lung sounds, abdomen SNT, normal neurological exam
Questionnaire: Patient Health Questionnaire (PHQ-9) score is 10/27.
He has previously tried computerised cognitive behavioural therapy but found it to be less effective. The patient is advised to commence treatment with sertraline 50mg PO daily and attend another appointment in two weeks’ time to review the medication.

Question: Select the most important information that should be provided for this patient.

Options:
explanation: Rather than excessive salivation, sertraline more commonly causes dry mouth
name: Sertraline can lead to excessive salivation
label: d
answer: no
explanation: Patients should discuss with their doctors before stopping the medication because an abrupt discontinuation could lead to discontinuation symptoms such as restlessness and irritability. Besides that, sertraline has not been shown to cause addiction problems
name: He should discontinue his medication once he feels better as sertraline is linked to addiction
label: c
answer: no
explanation: Sertraline is linked to low sex drive and erectile dysfunction
name: Sertraline can lead to increased sex drive
label: e
answer: no
explanation: Sertraline is a selective serotonin reuptake inhibitor (SSRI) that works by increasing serotonin levels in the brain. An increase in serotonin levels has been shown to bring about an improvement in symptoms
name: Sertraline works by increasing dopamine levels in the brain
label: b
answer: no
explanation: Sertraline is a selective serotonin reuptake inhibitor (SSRI) that works by increasing serotonin levels in the brain. It is important to highlight to the patients about the gradual development of full antidepressant effect of SSRI. Patients should be advised to not stop the medication early on even though they might not have felt an improvement because SSRI usually needs to be taken for up to 6 weeks before the benefit is felt
name: He should continue taking the medication even if he does not feel any improvements in the first 6 weeks
label: a
answer: yes

Correct answer: a
A 30-year-old woman presents to her GP with a 3-week history of depression, hopelessness, fatigue, poor appetite, and difficulty sleeping. She recently gave birth to her first child a month ago. She denies hallucinations or thoughts of harming her baby. Her Edinburgh Postnatal Depression Scale score is 8/30.

Physical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT, normal neurological exam
PMH, DH: NIL
The patient is advised to commence treatment with citalopram 20mg PO once daily along with cognitive behavioural therapy and attend another appointment in two weeks’ time to review the medication.


Question: Select the most important information that should be provided for this patient.

Options:
explanation: Agitation and sweating are not normal side effects of citalopram. Patients should stop taking the medication and seek immediate medical help because these signs are suggestive of serotonin syndrome
name: It is normal to experience agitation and sweating during the course of treatment
label: e
answer: no
explanation: Citalopram is not a tricyclic antidepressant. It is a selective serotonin reuptake inhibitor (SSRI) that works by increasing the serotonin levels in the brain. An increase in serotonin level has been shown to bring about an improvement in symptoms
name: Citalopram can lead to addiction
label: d
answer: no
explanation: Citalopram is generally safe to be used during breastfeeding. Citalopram usually only passes into breast milk in small quantities and has only been associated with adverse effects in very few breastfed babies. Moreover, grey baby syndrome is more commonly linked with antibiotic chloramphenicol
name: She should not breastfeed if she is taking citalopram because citalopram passes into breast milk in large quantities and can lead to grey baby syndrome
label: c
answer: no
explanation: If a patient has been feeling better for 6 months or more, he/she might be suggested to come off citalopram. However, patients should be reminded to discuss with their doctors before stopping the medication because abrupt discontinuation could lead to discontinuation symptoms such as restlessness and irritability. Dose of citalopram should be tapered and reduced gradually over 4 weeks
name: She should not abruptly discontinue her medication when she is feeling better
label: a
answer: yes
explanation: Citalopram is not a tricyclic antidepressant. It is a selective serotonin reuptake inhibitor (SSRI) that works by increasing the serotonin levels in the brain. An increase in serotonin level has been shown to bring about an improvement in symptoms
name: Citalopram is a tricyclic antidepressant that works by increasing levels of adrenaline in the brain
label: b
answer: no

Correct answer: a

She should not abruptly discontinue her medication when she is feeling better
Case presentation: A 35-year-old woman attends the breast clinic to discuss about hormonal therapy for her oestrogen-receptor positive breast cancer.  

PMH: Breast cancer, Hypertension
DH: Amlodipine 5mg OD
SH: Lives alone, smoker (10 pack-year history)
She is advised to commence treatment with Tamoxifen 20mg PO daily.

Question: Select the most appropriate information that should be provided for this patient.

Options:
explanation: Angioedema is a rare side effect of tamoxifen
name: Angioedema is a common side effect of tamoxifen
label: d
answer: no
explanation: Cataract is a common side effect while corneal changes are rarely caused by Tamoxifen
name: Tamoxifen more commonly causes corneal changes than cataract
label: e
answer: no
explanation: Tamoxifen is associated with increased endometrial changes that can subsequently lead to hyperplasia, polyps and cancer
name: Tamoxifen reduces the risk of endometrial hyperplasia and polyps
label: c
answer: no
explanation: Tamoxifen increases risk of thromboembolism. Hence, patients should seek medical attention straightaway if they suddenly experience breathlessness, chest pain and other signs that are suggestive of pulmonary embolus
name: She should immediately seek medical help if she experiences sudden onset breathlessness and chest pain
label: a
answer: yes
explanation: Tamoxifen is contraindicated during pregnancy due to its teratogenicity. Patients should use effective contraception during treatment and for 2 months after cessation of treatment
name: She could attempt to get pregnant during the course of treatment
label: b
answer: no

Correct answer: a