hllj/quesmed huggingface dataset:
Case Presentation: A 75 year old man attends the memory clinic with his partner. He has been having difficulty with remembering important personal details such as his debit card PIN as well as social appointments he has made with friends and family. **PMH** Bradycardia, diverticular disease, haemorrhoids. **DH** senna 7.5mg PO BD, Anusol cream topical ON.


**Investigations**

Addenbrooke’s Cognitive Examination: 81/100

A diagnosis of early Alzheimer’s disease is made and he is advised to start donepezil hydrochloride 5mg PO OD and to attend a follow-up appointment in 3 months.

Question: Select the most appropriate monitoring option required before starting donepezil hydrochloride.

Options:
explanation: This may be generally useful as mood disorders are common among patients with Alzheimer’s disease but is not essential
name: PHQ-9
label: d
answer: no
explanation: This is not necessary with this medication
name: Weight
label: e
answer: no
explanation: An ECG should be performed to rule out bradycardia or high-grade heart block prior to starting this drug
name: No routine monitoring is required
label: c
answer: no
explanation: This is not necessary with this medication
name: Full blood count
label: b
answer: no
explanation: Donepezil increases cholinergic activity not just in the central nervous system but also peripherally, and may exert a parasympathetic effect on the heart. As such it is contraindicated in patients with high-grade heart block or symptomatic bradycardia and this should be ruled out with an ECG beforehand
name: ECG
label: a
answer: yes

Correct answer: a
Case Presentation: A 36 year old woman is seen in the outpatient psychiatry clinic and is diagnosed with bipolar disorder. She is advised to commence treatment with lithium carbonate (Camcolit) 400mg PO OD.


Question: Select the most appropriate monitoring option to assess the need for dose adjustments of lithium carbonate in this patient.

Options:
explanation: Lithium levels should not be taken earlier than 12 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels 2 hours post-dose
label: b
answer: no
explanation: Lithium levels should not be taken earlier than 12 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels 6 hours post-dose
label: c
answer: no
explanation: Taking lithium levels more than 12 hours after the initial dose may lead to inaccurate dose adjustments being made from a falsely low level
name: Blood levels immediately before next dose
label: d
answer: no
explanation: This is the correct time to take a lithium level, which is 12 hours after the last dose
name: Blood levels 12 hours post-dose
label: a
answer: yes
explanation: Lithium levels should be taken no earlier than 12 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels immediately post-dose
label: e
answer: no

Correct answer: a
Case Presentation: A 55 year old woman presents to A&E with acute confusion, nausea and vomiting. **PMH** permanent atrial fibrillation. **DH** digoxin 187.5 micrograms PO OD.




 **Investigations**


Digoxin levels: 2.8µg/L (target 0.5 – 2.0µg/L)


Question: Select the most appropriate option to monitor for adverse effects of this treatment.

Options:
explanation: Whilst serum urea is part of routine renal function monitoring, it does not specifically affect digoxin toxicity. However, impaired renal function can lead to digoxin accumulation, so regular assessment of renal parameters (including creatinine) is recommended.
name: Serum urea
label: e
answer: no
explanation: Serum chloride levels are not significant in the context of digoxin toxicity. This electrolyte is not a direct factor in potentiating digoxin’s effects or its associated adverse events.
name: Serum chloride
label: b
answer: no
explanation: Increase in digoxin levels is known to be potentiated by electrolyte imbalances but particularly potassium, calcium and magnesium. These should be checked when a patient is presenting with symptoms of toxicity, but general renal function should be routinely monitored for the duration of treatment as well
name: Serum potassium
label: a
answer: yes
explanation: Phosphate levels are not directly related to digoxin toxicity. Monitoring serum phosphate may be relevant in other clinical contexts but is not a priority in patients treated with digoxin.
name: Serum phosphate
label: c
answer: no
explanation: Although abnormal sodium levels can indicate electrolyte imbalances, they do not directly potentiate digoxin toxicity. Monitoring sodium is important for general health but is not the primary concern in digoxin-treated patients.
name: Serum sodium
label: d
answer: no

Correct answer: a
Case Presentation: A 9 year old boy attends a specialist paediatric review with his parents. He has previously been suspended from school for being disruptive and refusing to settle during class. At home, his mother struggles to make him focus on his homework and conform to bedtimes, sometimes finding him awake and playing loudly in his bedroom past midnight. A trial of a low-sugar diet has failed to ameliorate his behavioural symptoms.


Treatment with methylphenidate hydrochloride 5mg PO OD is to be commenced.

Question: Select the most appropriate option to monitor for adverse effects of this treatment.

Options:
explanation: It is recommended to monitor parameters of growth (height and weight) for the duration of treatment with methylphenidate. It is not necessary to routinely check for a full blood count or to monitor renal function
name: Full blood count, renal function and weight
label: d
answer: no
explanation: It is recommended to monitor parameters of growth (height and weight) for the duration of treatment with methylphenidate. It is not necessary to routinely check for a full blood count or to monitor serum prolactin
name: Height, full blood count and serum prolactin
label: e
answer: no
explanation: It is recommended to perform an ECG before commencing methylphenidate and to monitor blood pressure for the duration of treatment. Monitoring serum prolactin is not necessary
name: Blood pressure, ECG and serum prolactin
label: b
answer: no
explanation: It is recommended to monitor blood pressure as well as parameters of growth (height and weight) for the duration of treatment with methylphenidate
name: Blood pressure, height and weight
label: a
answer: yes
explanation: It is recommended to monitor blood pressure as well as parameters of growth (height and weight) for the duration of treatment with methylphenidate. It is not necessary to monitor renal function
name: ECG, height and renal function
label: c
answer: no

Correct answer: a
Case Presentation:




A 65-year-old man presents to his GP for review of his blood glucose. He was started on metformin a year ago when his HbA1c was found to be 55 and 58mmol/mol when tested on two separate occasions. PMH Type 2 Diabetes mellitus, Hypertension, Hypercholesterolemia, Chronic pancreatitis. DH Atorvastatin 20mg PO daily, Ramipril 2.5mg PO daily, Metformin 1g BD PO.


 **On Examination**
BP 125/85 mmHg


HR 90/min


RR 16


O2 sats 94% RA


 **Investigations**
HbA1c 65mmol/mol (normal range 20-48 mmol/mol)


Capillary blood glucose 15.3 mmol/L (normal <6.1 mmol/L)


Question:
Select the most appropriate decision option with regard to the treatment of his hyperglycaemia based on these data

Options:
explanation: Although the exact causal relationship between DPP-4 inhibitors and GLP-1 analogues with pancreatitis is not well-established, it is generally advised to avoid these classes of medication amongst patients with increased risk of acute pancreatitis due to the significant implication of the risk involved
name: Add liraglutide 0.6mg OD SC
label: c
answer: no
explanation: This option is less ideal for the reason mentioned above with regards to risk involved in patients with acute pancreatitis and as he is only on metformin, he should be started on dual therapy before moving on to triple therapy
name: Triple therapy consisting of metformin 500mg TDS, sitagliptin 100mg OD, gliclazide 40mg OD
label: e
answer: no
explanation: This patient has poorly controlled hyperglycaemia (HbA1c 65) and is already on the maximum tolerable dose of metformin. Due to his background of pancreatitis, an alternative to GLP-1 (liraglutide) and DPP4 inhibitor (sitagliptin) should be considered. DPP4 inhibitor reduces the degradation of GLP-1 by inhibiting the activity of serum DPP-4. An increase in GLP-1 results in an increased availability of incretins, stimulating insulin secretion from pancreatic β-cells. Although the exact causal relationship between DPP-4 inhibitors and GLP-1 analogues with pancreatitis is not well-established, it is generally advised to avoid these classes of medication amongst patients with increased risk of acute pancreatitis due to the significant implication of the risk involved
name: Add gliclazide 40mg OD
label: a
answer: yes
explanation: Although the exact causal relationship between DPP-4 inhibitors and GLP-1 analogues with pancreatitis is not well-established, it is generally advised to avoid these classes of medication amongst patients with increased risk of acute pancreatitis due to the significant implication of the risk involved
name: Add sitagliptin 100mg PO OD to metformin
label: b
answer: no
explanation: This patient is currently on maximal tolerable dose of metformin, there are other oral hypoglycaemic agents that should be considered prior to starting someone on insulin
name: Switch to biphasic insulin detemir 20 units SC
label: d
answer: no

Correct answer: a
Case Presentation:


A 52-year-old man presents to his GP for review of his blood glucose. He was started on metformin 3 months ago when his HbA1c was found to be 52 and 56mmol/mol when tested on two separate occasions. PMH Type 2 diabetes mellitus, Hypertension, Hypercholesterolemia. DH Atorvastatin 20mg PO daily, Ramipril 2.5mg PO daily, Metformin 500mg TDS PO.
 **On Examination**
BP 125/85 mmHg


 **Investigations**


||||
|---------------------------|:-------:|------------------------------|
|Non-fasting Glucose|13.1 mmol/L|< 6.1|
|HbA1c (Glycated Haemoglobin)|60 mmol/mol or %|20 - 42 or 4-6%|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|85 µmol/L|60 - 120|


Question:
Select the most appropriate decision option with regard to the treatment of his hyperglycaemia based on these data.

Options:
explanation: The maximum tolerated dose of metformin is 2g a day
name: Metformin 1g TDS PO
label: b
answer: no
explanation: His metformin can be up titrated to the maximum before starting on dual therapy
name: Add sitagliptin 100mg PO OD to metformin
label: d
answer: no
explanation: This patient has poorly controlled hyperglycaemia (HbA1c 60) despite being started on metformin 500mg TDS. The maximum tolerated dose of metformin is 2g a day. His metformin can be up titrated to the maximum before starting on dual therapy
name: Metformin 1g BD PO
label: a
answer: yes
explanation: His metformin can be up titrated to the maximum before starting on dual therapy. If the patient fails to respond to dual oral hypoglycaemic agents, triple therapy can then be considered
name: Triple therapy consisting of metformin 500mg TDS, sitagliptin 100mg OD, gliclazide 40mg OD
label: e
answer: no
explanation: Patients with T2DM are often trialled on different combination of oral hypoglycaemic agent prior to initiation of insulin. In this case, uptitrating his metformin should be considered prior to changing his medication to insulin
name: Switch to biphasic insulin detemir 20 units SC
label: c
answer: no

Correct answer: a
Case Presentation:




A 56-year-old man presents to his GP for review of his medication. PMH Hypertension. DH Ramipril 10mg PO OD, Amlodipine 10mg PO OD, Indapamide 2.5mg PO OD


 **On Examination**
BP 157/60 mmHg


HR 85/min


RR 14


O2 sats 96% RA


 **Investigations**


||||
|---------------------------|:-------:|--------------------|
|Sodium|140 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|85 µmol/L|60 - 120|




Question:
Select the most appropriate decision option with regard to the treatment of his hypertension based on these data.

Options:
explanation: This patient has resistant hypertension as his BP remains high despite on three different antihypertensives. NICE recommends the use of spironolactone as the next step if the patients potassium is 4.5 or less. If his K is more than 4.5, an alpha or beta blocker can be considered
name: Start bisoprolol fumarate 5mg PO OD
label: d
answer: no
explanation: Starting on spironolactone would be the most appropriate management for a poorly controlled hypertension patient who have been started on ACEi, CCB and diuretics with a K <4.5mmol. [Click here for more information on NICE guidance](https://pathways.nice.org.uk/pathways/hypertension)
name: Start spironolactone 25mg PO OD
label: a
answer: yes
explanation: There are 2 types of calcium channel blocker, dihydropyridine like nifedipine and amlodipine are used as antihypertensive medication. Non-dihydropyridine like verapamil and diltiazem are for rate control medication in arrythmias
name: Start verapamil 80mg PO TDS
label: c
answer: no
explanation: Although his BP remains poorly controlled with three antihypertensive, the maximal recommended dose for ramipril is 10mg OD. 15mg OD will be more than the recommended dose
name: Increase dose of ramipril to 15mg PO OD
label: e
answer: no
explanation: This patient has resistant hypertension as his BP remains high despite on three different antihypertensives. NICE recommends the use of spironolactone as the next step if the patients potassium is 4.5 or less. If his K is more than 4.5, an alpha or beta blocker can be considered
name: Start doxazosin 1mg PO OD
label: b
answer: no

Correct answer: a
Case Presentation:




A 55-year-old lady presents to the emergency department with rigor and pyrexia complaining of 3 day history of dysuria and urinary frequency. A urine dipstick was performed, which showed positive leucocyte esterase and nitrates. Microscopy, culture and sensitivity confirmed urosepsis, with sensitivity showing susceptibility to gentamicin. She is started on gentamicin 5mg/kg IV OD. Her first dose of gentamicin was administered at 1600 today. Weight 75kg.


 **Investigations**
Serum gentamicin at 2300 6mg/L


||||
|---------------------------|:-------:|--------------------|
|Urea|6.5 mmol/L|2.5 - 7.8|
|Creatinine|100 µmol/L|60 - 120|
|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|


Question:
Select the most appropriate decision option based on these data and using the[Hartford Nomogram](http://www.leedsformulary.nhs.uk/docs/RxGentamicinHartford.pdf)

Options:
explanation: Gentamicin nomogram is used to determine when the next dose of gentamicin is due. In this situation, the trough level (taken 6-14 hours after the initiation of gentamicin) is 6mg/mL. Referring to the Hartford nomogram, the next dose should be given in the next 24 hours from the 1st dose, hence, 375mg IV at 1600 tomorrow
name: Gentamicin 375mg IV 1600 tomorrow
label: a
answer: yes
explanation: According to the nomogram, his trough level falls under the every 24 hour frequency, hence, the next dose should be given at 1600 tomorrow and not the day after
name: Gentamicin 375mg IV 2300 the day after
label: d
answer: no
explanation: As his trough level falls within the 24 hour frequency, the next dose should be given 24 hours from the first dose which was at 1600 and not from the time the sample was taken
name: Gentamicin 375mg IV 2300 tomorrow
label: e
answer: no
explanation: There is no need to repeat the blood test as the serum gentamicin level was taken accurately within 6 - 14 hours, allowing interpretation of the timing of the next dose
name: Repeat the blood test at 1600 tomorrow
label: c
answer: no
explanation: There is no need to repeat the blood test as the serum gentamicin level was taken accurately within 6 - 14 hours, allowing interpretation of the timing of the next dose
name: Repeat the blood test at 0400 today
label: b
answer: no

Correct answer: a
Case Presentation:




A 56-year-old man presents to his GP for review of his medication. PMH Hypothyroidism for 3 years. DH Levothyroxine sodium 100 micrograms PO daily.


 **Investigations**
TSH 10 mU/L (0.4-5.0)


Total T4 0.5 nmol/L (1.1-3)


Question:
Select the most appropriate decision option with regard to the levothyroxine sodium prescription based on these data.

Options:
explanation: 25micrograms of liothyronine is bioquivalent to 100micrograms of levothyroxine sodium. As he is thyroid function is poorly controlled with this dose of thyroid replacement, changing it to another form that is of similar bioequivalence would not be beneficial for him
name: Change to liothyronine sodium 25 micrograms PO daily
label: d
answer: no
explanation: His thyroid function test, particularly the high TSH is suggestive of poor thyroid control. Continueing him on the similar dose of thyroid replacement will not be help his thyroid function
name: Continue levothyroxine sodium 100 micrograms PO daily
label: e
answer: no
explanation: High TSH and low total T4 level indicate inadequate replacement of levothyroxine and hence should be uptitrated. The increase in dose should be done in steps of 25-50 micrograms every 3-4 weeks
name: Increase levothyroxine sodium to 125 micrograms PO daily
label: a
answer: yes
explanation: His thyroid function test suggest inadequate replacement and hence his medication should be increased and not decreased
name: Decrease levothyroxine sodium to 75 micrograms PO daily
label: b
answer: no
explanation: The recommended increment in levothyroxine is a gradual increment of 25-50 micrograms every 3-4 weeks
name: Increase levothyroxine sodium to 175 micrograms PO daily
label: c
answer: no

Correct answer: a
Case Presentation: A 3-year-old boy attends the Emergency Department with his mother with a high fever and cough. No changes in urinary habit and no travel history noted. While waiting to be seen, he suddenly begins seizing.




## PH


Febrile seizures


## DH


None (NKDA)


## FHx


Father had febrile seizures as a child


## On examination


The child is having generalised, tonic-clonic seizure. He was not noted to be irritable, drowsy beforehand. No neck stiffness, no rash seen, fontanelle not bulging.
No cannula has been inserted.


Temperature 38.9°C, HR 120, RR 25, BP 96/68, O<sub>2</sub> 98% RA, GCS 15 (before seizure began), Weight 15kg


## Investigations


BM: 5.5 mmol/L (normal range 3.5-5.5 mmol/L).


All other investigation results are pending.


# Prescribing Request


Write a prescription for one drug that is most appropriate for treating his condition should it still persist after five minutes.

Options:


# Drug choice feedback

This child is most probably suffering from febrile seizures secondary to the ongoing viral infection, and given his past and family history of febrile seizures. Importantly, other major causes of paediatric seizures such as meningococcal disease or hypoglycaemia are excluded based on the examination findings and his blood glucose being normal respectively. As he is still seizing after five minutes, emergency treatment with either diazepam or midazolam should be initiated.

# Dose/Route/Frequency/Duration feedback

Diazepam should be given PR while midazolam should be given buccally. The optimal doses are as above.
Case Presentation: A 58-year-old gentleman is brought to the Emergency Department with sudden-onset 1-hour history of chest pain radiating to his left shoulder, accompanied by shortness of breath, nausea and diaphoresis.




## PH


Hyperlipidaemia, Type 2 Diabetes Mellitus


## DH


Atorvastatin 40mg PO ON, Metformin 1g PO BD (reports allergy to aspirin)


## On examination


Appears distressed, very sweaty. Seated up in bed. Percussion resonant throughout. HS I + II + 0, chest clear. Calves soft and non-tender. No cyanosis.


Temperature 36.6°C, HR 98, RR 28, BP 140/88, O2 98% RA, GCS 15, Weight 89kg


## Investigations

||||
|--------------|:-------:|---------------|
|Haemoglobin|144  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|7.3x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|223x10<sup>9</sup>/L|150 - 400|
|Sodium|137 mmol/L|135 - 145|
|Potassium|4.6 mmol/L|3.5 - 5.3|
|Chloride|100 mmol/L|95 - 106|
|Urea|8.1 mmol/L|2.5 - 7.8|
|Creatinine|97 µmol/L|60 - 120|
|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|
|Troponin T|30 ng/L|<14|
|Non-fasting Glucose|12 mmol/L|< 6.1|

CXR: normal


ECG: ST-elevation in leads II, III and aVL with reciprocal changes


# Prescribing Request


Write a prescription for one drug that is most appropriate to reduce the chance of recurrent atherothrombotic events.

Options:


# Drug choice feedback

Normally, a stat dose of 300mg of aspirin and clopidogrel each are given to patients with ST-elevation myocardial infarct. However, due to the patient's allergy to aspirin, only clopidogrel can be given. Alternatives are Ticagrelor or Prasugel.

# Dose/Route/Frequency/Duration feedback

For clopidogrel, the correct dose is 300mg initially once-off. This is then decreased to 75mg per day for the next 12 months. It can only be given PO; no other routes of administration exist for clopidogrel.

For Ticagrelor or Prasugel, the doses are as stated above. Similarly, they can only be given PO; no other routes of administration exist.
Case Presentation: A 53-year-old gentleman presents to his GP with severe pain in his left big toe. It has become swollen, tender and erythematous over the last 12 hours.


## PH

Hypertension, chronic kidney disease

## DH

Ramipril 5mg PO OD (allergy to Naproxen)

## On examination

Alert and oriented. Left 1st metatarsophalangeal joint noted to be red, swollen, extremely tender with florid synovitis.

Temperature 36.8°C, HR 85, RR 16, BP 129/81, O<sub>2</sub> 98% RA, GCS 15, Weight 82kg

## Investigations

None

# Prescribing Request

Write a prescription for one drug that is most appropriate for treating his condition acutely.

Options:


# Drug choice feedback

This gentleman most likely has gout. In the acute setting, the first line agent is usually any NSAID. In light of his chronic kidney disease, this is contra-indicated and the second line agent colchicine has to be used. Recall that allopurinol is not used in the acute setting as it is not effective may prolong the gout attack if started.

# Dose/Route/Frequency/Duration feedback

The recommended dose is 500 micrograms. It can be given twice to four times a day, as long as the maximum dose given is 6mg. Therefore, the answer given for the duration has to correspond to the dose and frequency chosen.
Case Presentation: A 37-year-old gentleman attends an annual review with his GP. He is currently asymptomatic.


## PH

Type 1 Diabetes Mellitus, diagnosed 11 years ago

## DH

Insulin Glargine (Lantus) 15 units, Insulin Aspart (Novorapid) 5 units at mealtimes (NKDA)

## On examination

Alert and oriented. Neurological examination normal. Fundoscopy normal.

Temperature 36.2°C, HR 72, RR 13, BP 130/88, O<sub>2</sub> 98% RA, GCS 15, Weight 60kg

## Investigations

Proteinuria 2+ on dipstick, no blood noted

# Prescribing Request

Write a prescription for one lipid-lowering drug that is most appropriate for prevention of cardiovascular events.

Options:


# Drug choice feedback

This gentleman qualifies for lipid-lowering therapy as part of primary prevention of cardiovascular events as he is at high risk of a first cardiovascular event. He has had type 1 diabetes mellitus for more than 10 years and has established nephropathy; either alone qualifies him for lipid-lowering therapy. The recommended pharmacological management is with atorvastatin.

# Dose/Route/Frequency/Duration feedback

The recommended starting dose by NICE is 20mg. Atorvastatin, like most other statins, is taken orally once a day.