hllj/quesmed huggingface dataset:
Case Presentation: A 57-year-old gentleman presents to his GP with dyspepsia. He does not report any weight loss, no vomiting, no changes to appetite.


## PH

Obesity

## DH

NIL (Allergy to Omeprazole)

## FHx

No upper gastrointestinal cancer

## On examination

Alert and oriented. Mild epigastric tenderness, otherwise abdomen soft and non-tender, no masses palpated.

Temperature 36.8°C, HR 70, RR 13, BP 139/81, O<sub>2</sub> 98% RA, GCS 15, Weight 86kg

## Investigations

FBC: Hb 152, WCC 6.2, Plt 283
Urgent OGD performed: "Benign gastric ulceration noted, no oesophagitis, no masses seen."

Stool antigen test for _H. pylori_: negative

# Prescribing Request

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

Options:


# Drug choice feedback

This gentleman has benign gastric ulceration. Whilst a proton-pump inhibitor is first line, his allergy is a contra-indication. Hence, H2-antagonists have to be used. The options licensed in the UK are as above. Antacids only provide short-term symptomatic relief but do not definitively treat benign gastric ulceration.

# Dose/Route/Frequency/Duration feedback

Each medication has its own optimal dose. All are orally taken and have varying dosing frequencies.
Case Presentation: A 68-year-old gentleman admitted to the general ward for observation after a right hemicolectomy 7 days ago is being treated for sepsis. He is found to be drowsy and confused.




## PH


Colorectal cancer, Hyperlipidaemia, Gout


## DH


Atorvastatin 40mg PO ON, Allopurinol 300mg PO OD


## On examination


Appears delirious and not oriented to time and place. Peripheries warm, CRT 3s. HS I + II + 0, chest clear.


Temperature 38.9°C, HR 96, RR 27, BP 95/65, O2 95% RA, GCS 13, Weight 75kg


## Investigations


FBC: Hb 148, WCC 15.5, Plts 420


U&Es: Na<sup>+</sup> 141, K<sup>+</sup> 4.3, Cl<sup>-</sup> 98, Ur 9.2, Cr 110, eGFR 61mL/min/1.73m<sup>2</sup>


BM: 6.7mmol/L (normal rnage 3.5-5.5 mmol/L)


# Prescribing Request


Write a prescription for one fluid that is most appropriate for treating his current condition

Options:


# Drug choice feedback

This patient requires urgent fluid resuscitation as part of the management for his wound sepsis. Crystalloid fluids such as 0.9% sodium chloride or Hartmann's solution are first-line in such cases.

# Dose/Route/Frequency/Duration feedback

500mL is the standard dose used for a fluid bolus ('fluid challenge') in resuscitation. Vital observations such as heart rate and blood pressure are monitored after each dose to see if a further bolus is required. Fluids can only be given intravenously; this route of administration also ensures the fastest response to be seen in the patient. A duration of 15 minutes or less for every 500mL is acceptable.
Case Presentation: A 62-year-old gentleman has been admitted to the ward after being seen in the Emergency Department for episodes of chest pain on exertion which resolve when at rest.


## PH

Hypertension, Type 2 Diabetes Mellitus, Asthma

## DH

Ramipril 5mg PO OD, Metformin 500mg BD PO, Salbutamol metered dose inhaler 200 mcg/dose INH PRN, Beclometasone inhalation powder 200 mcg/dose INH BD. He was prescribed Glyceryl Trinitrate 400micrograms/dose aerosol sublingual spray, 1 spray PRN in the Emergency Department (Allergy to Clarithromycin)

## On examination

Appears well, oriented to time and place. HS I + II + 0, chest clear.

Temperature 36.2°C, HR 76, RR 14, BP 135/88, O<sub>2</sub> 99% RA, GCS 15, Weight 89kg

## Investigations

CXR: Normal, no cardiomegaly

ECG: Normal sinus rhythm, no Q-waves or inverted T-waves

# Prescribing Request

Write a prescription for one additional drug that is most appropriate for treating his episodes of chest pain.

Options:


# Drug choice feedback

This patient is suffering from stable angina. Apart from symptomatic relief using glyceryl trinitrate spray, the first-line treatment is with either a beta-blocker or calcium-channel blocker. Since the patient has asthma, beta-blockers are contraindicated. Hence, only calcium-channel blockers are acceptable, among which all but Nifedipine (due to its side effect profile) are possible.

# Dose/Route/Frequency/Duration feedback

Each medication has its own optimal dose. All are orally taken and have varying dosing frequencies.
Case Presentation: A 51-year-old woman attends the GP with urinary frequency, foul-smelling urine and dysuria. She mentions the symptoms are causing her distress. She does not report any loin-to-groin pain nor rigours.


## PH

Breast cyst diagnosed 23 years ago, surgically removed without recurrence or complications

## DH

NIL (Allergy to Co-trimoxazole)

## On examination

Alert and oriented. No loin tenderness.

Temperature 36.5°C, HR 75, RR 12, BP 125/79, O<sub>2</sub> 98% RA, GCS 15, Weight 68kg

## Investigations

Haematuria 1+ on dipstick, otherwise normal

Urinary MC&S not appropriate as of now as clinically low risk of resistance.

# Prescribing Request

Write a prescription for one antibiotic that is most appropriate for treating her condition.

Options:


# Drug choice feedback

This woman likely has a lower urinary tract infection with no overt complications. In cases whereby there is a low risk of resistance, the two possible first line agents for non-pregnant women include nitrofurantoin or trimethoprim. Given that she is allergic to co-trimoxazole which contains trimethoprim, only nitrofurantoin can be prescribed.

# Dose/Route/Frequency/Duration feedback

The recommended dose is either 50mg or 100mg, and the frequency is QDS or BD, depending on whether the immediate- or modified-release form is prescribed respectively. It should be prescribed for 3 days. Women who are pregnant and all men who have a lower urinary tract infection require a longer prescription of 7 days.
Case presentation: A 3-year-old girl is brought to the emergency department by her mother in the middle of night. The little girl has developed a fever and a sudden-onset seal-like “barking” cough. Her weight is 15kg PH: Constipation, Anaemia, Rosacea, GORD DH: Her current regular prescriptions are listed below


**On examination**: Seal-like barking cough, hoarse cry and an inspiratory stridor when crying

**Vital signs**: Temperature 37.8°C, HR 125, O2 Sat 99% (room air), RR 30
Croup (acute laryngotracheobronchitis) is suspected and treatment is commenced.

Question 1: Select the ONE prescription that contains a serious dosing error. (mark them with a tick in column A)
Question 2: Select the ONE prescription that is contra-indicated. (mark it with a tick in column B)

Options:
name: Dexamethasone;22.5mg;Oral (PO);Once only
label: d
answer: no
name: Paracetamol;180 mg;Oral (PO);6-hourly
label: c
answer: no
name: Adrenaline;5mg;Nebulised (NEB);Once only
label: e
answer: no
name: Sodium feredetate;2.5ml;Oral (PO);Three times daily
label: a
answer: no
name: Tetracycline;500mg;Oral (PO);Twice daily
label: f
answer: no
name: Macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride;1 sachet;Oral (PO);Daily
label: b
answer: no


1. The dose of dexamethasone for croup is 150 micrograms/kg. The girl is 15kg in weight. Hence, the correct dose that should be prescribed is 2.25mg.
2. Tetracycline is contra-indicated in children under 12 years. Tetracycline binds to calcium and gets deposited in growing bone and teeth. Use of tetracycline in children is associated with teeth staining and dental hypoplasia.
Case presentation: A 80-year old man is taken to A&E via ambulance after being found lying on the floor by his daughter. His daughter reports that his father has become increasingly drowsy and confused over the past few days. His father has also been complaining of constipation recently. **PH:** Atrial fibrillation, Congestive Cardiac Failure, Type 2 Diabetes Mellitus, Hayfever, Neuropathic pain, Otitis externa **DH:** His current regular prescriptions are listed below


**On examination**: Abbreviated Mental Test Score 6/10. Chest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender. Bruises on left hip with no active bleeding. Pain on external rotation of left leg.
**Vital signs**: BP 125/80, Temperature 36.8°C, HR 80, O2 Sat 99% (room air), RR 18

Question 1: Select the THREE prescriptions that are most likely to be a cause of the drowsiness and confusion (mark them with a tick in column A)
Question 2: Select the TWO prescriptions that are most likely to be a cause of his constipation (mark it with a tick in column B)

Options:
name: Amitriptyline hydrochloride;75mg;Oral (PO);Daily in the evening
label: h
answer: no
name: Amlodipine;5mg;Oral (PO);Daily
label: b
answer: no
name: 5% Chloramphenicol;2-3 drops;Ear drops;8-hourly
label: e
answer: no
name: Metformin hydrochloride;500mg;Oral (PO);8-hourly
label: a
answer: no
name: Promethazine hydrochloride;10mg;Oral (PO);8-hourly
label: f
answer: no
name: Carvedilol;3.125mg;Oral (PO);12-hourly
label: d
answer: no
name: Gliclazide;40mg;Oral (PO);Daily
label: g
answer: no
name: Warfarin sodium;5mg;Oral (PO);Daily
label: c
answer: no


1. Confusion is a common or very common side effect of a beta-adrenoceptor blocker such as carvedilol. Drowsiness is also listed as a common or very common side effect of amitriptyline. Promethazine is also known to cause drowsiness although the frequency of such side effect is unknown. Patients taking these medications should be reminded that their performance of skilled tasks like driving and operating heavy machinery could be affected.
2. Constipation is a common or very common side effect of amlodipine, and can also be caused by amitriptyline due to its anticholinergic activity.
Case presentation: A 9-year old boy arrives at A&E with shortness of breath and wheeze. He presented to his GP two days ago with increased urinary frequency and dysuria. A diagnosis of lower urinary tract infection was made and antibiotic treatment was commenced. He has a past medical history of asthma which has so far been well controlled. His weight is 30kg. His mother who is accompanying him informs that the family has just come back from Nigeria and that they have been taking malaria prophylaxis. PH: Asthma, Allergic rhinitis, Eczema, Lower urinary tract infection, vesicoureteral reflux, Glucose-6-phosphate dehydrogenase (G6PD) deficiency DH: Her current regular prescriptions are listed below


**On examination**: Breathing using accessory muscles, polyphonic expiratory wheeze

**Vital signs**: Temperature 36.6°C, HR 90, O2 Sat 92% (room air), RR 26

Question 1: Select the TWO prescriptions that are contra-indicated or should be used with caution in the context of G6PD deficiency (mark them with a tick in column A)
Question 2: Select the ONE prescription that is most likely to have led to exacerbation of asthma symptoms (mark it with a tick in column B)

Options:
name: Nitrofurantoin;22.5mg;Oral (PO);6-hourly
label: g
answer: no
name: Budesonide;200 micrograms;Inhaled (INH);Once daily in evening
label: b
answer: no
name: Azelastine hydrochloride;1 spray;Oral (PO);Twice daily
label: c
answer: no
name: Ibuprofen;200 mg;Oral (PO);8-hourly
label: d
answer: no
name: Dermacort hydrocortisone 0.1% cream;-;Topical;Daily
label: e
answer: no
name: Chloroquine;225mg;Nebulised (NEB);Once weekly
label: f
answer: no
name: Salbutamol (100 micrograms,dose metered-dose inhaler);200 micrograms;Inhaled (ING);When required
label: a
answer: no


1. Nitrofurantoin is an antibiotic that works by damaging bacterial DNA. Chloroquine is a medication used to prevent and treat malaria. Nitrofurantoin and chloroquine are contra-indicated in patients with G6PD-deficiency because are they known to cause severe haemolytic anaemia.
2. Ibuprofen is known to cause bronchospasm in patients with asthma, especially those with a history of hypersensitivity to aspirin or any other NSAID. Ibuprofen inhibits the activity cyclooxygenase-1 (Cox-1). The inhibition leads to activation of lipoxygenase pathway that in turn increases the release of cysteinyl leukotrienes (Cys-LTs) that induces bronchospasm.
Case presentation: A 70-year-old Afro-Carribean gentleman presents to the GP for his annual flu vaccine. PH Infective exacerbation of COPD, for which he has been receiving treatment for the past 5 days, Hypertension. DH His current regular medicines are listed (below).


**On Examination** Red swellings beneath the surface of his eyelid consistent with angioedema.

Question 1: Select the ONE prescription that is most likely to be contributing to the angioedema (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: Perindopril arginine;8mg;oral (PO);Daily
label: a
answer: no
name: Atorvastatin;20mg;oral (PO);Daily
label: g
answer: no
name: Salbutamol;200micrograms;inhaled (INH);as required
label: b
answer: no
name: Bisoprolol;20mg;oral (PO);12-hourly
label: h
answer: no
name: Amlodipine;5mg;oral (PO);Daily
label: e
answer: no
name: Ipratropium bromide;40micrograms;inhaled (INH);8-hourly
label: c
answer: no
name: Bendroflumethiazide;2.5mg;oral (PO);Daily
label: f
answer: no
name: Prednisolone;30mg;oral (PO);Daily
label: d
answer: no


1. ACEi (perindopril arginine) and tetracycline (oxytetracycline) commonly cause angioedema with the former more common in the Afro-Carribean population. Calcium channel blockers (amlodipine) also cause angioedema but are not common.
2. Bisoprolol fumarate, given for the treatment of hypertension is given at 5-10mg daily with a maximum dose of 20mg daily. Hence, the correct prescription for 20mg should be daily instead of 12-hrly.
Case presentation: A 45-year old man attends his GP appointment complaining of nausea and tiredness. PH: Hypertension, Allergic rhinitis, Hypercholesterolaemia, Peripheral oedema, Vitamin D deficiency DH: His 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**:

||||
|--------------|:-------:|---------------|
|Haemoglobin|130   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|300x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|90 fL|80 - 96|
|Neutrophils|5x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|2x10<sup>9</sup>/L|1.5 - 4.0|
|Sodium|125 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Urea|7 mmol/L|2.5 - 7.8|
|Creatinine|109 µmol/L|60 - 120|
|Thyroid Stimulating Hormone|3.8 mU/L|0.3 - 4.2|
|Free T4|17 pmol/L|9 - 25|


Question 1: Select the THREE prescriptions that are most likely to be a cause of his hyponatraemia (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: Bumetanide;1mg;Oral (PO);Daily
label: f
answer: no
name: Simvastatin;40mg;Oral (PO);Daily
label: e
answer: no
name: Chlortalidone;50mg;Oral (PO);Daily
label: c
answer: no
name: Cetirizine hydrochloride;10mg;Oral (PO);Daily
label: d
answer: no
name: Fluoxetine;100mg;Oral (PO);Daily
label: g
answer: no
name: Amlodipine;5mg;Oral (PO);Daily
label: a
answer: no
name: Losartan potassium;50mg;Oral (PO);Daily
label: b
answer: no
name: Colecalciferol (Vit D3);800 units;Oral (PO);Daily
label: h
answer: no


1. Chlortalidone is a thiazide-like diuretic that inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, leading to reduced Na+ reabsorption. Bumetanide is a loop diuretic that acts on the Na+-K+-2Cl− symporter (NKCC2) in the thick ascending limb of the loop of Henle to inhibit sodium, chloride and potassium reabsorption. Both chlortalidone and bumetanide are known to cause hyponatraemia. Hyponatraemia is also a recognised side effect of fluoxetine. BNF cautions against prescribing fluoxetine to elderly patients with significant hyponatraemia i.e. serum sodium less than 130 mmol/L due to risk of exacerbating or precipitating hyponatraemia.
2. The maximum daily dose of fluoxetine is 60mg.
Case Presentation: A 73 year old man attends his GP with a 3 day history of a painful rash. **PH** aortic abdominal aneurysm (<5.5cm), benign prostatic hypertrophy. **DH** tamsulosin hydrochloride 400 micrograms PO OD. NKDA


**O/E**

HR 70, RR 13, BP 132/65, O2 100% RA, Temperature 36.4°C. Erythematous vesicular rash on right side of abdomen in the distribution of T10 dermatome.

Question: Select the most appropriate management at this stage.

Options:
explanation: Foscarnet is an antiviral drug with activity against some herpesviruses such as CMV. It has no role in the acute management of shingles
name: Foscarnet 40mg/kg IV TDS
label: c
answer: no
explanation: This patient is presenting with shingles. Oral acyclovir has been shown to reduce the duration and intensity of symptoms, but not to reduce the incidence of post-herpetic neuralgia
name: Aciclovir 800mg PO 5 times a day
label: a
answer: yes
explanation: Gabapentin is used to treat neuropathic pain and some types of seizures. It has no role in the acute management of shingles but can be prescribed to treat post-herpetic neuralgia
name: Gabapentin 300mg PO OD
label: d
answer: no
explanation: Paracetamol may provide some pain relief from symptoms but does not treat shingles itself
name: Paracetamol 1g PO QDS
label: e
answer: no
explanation: Duloxetine is an SNRI used to treat neuropathic pain. It has no role in the acute management of shingles but can be prescribed to treat post-herpetic neuralgia
name: Duloxetine 60mg PO OD
label: b
answer: no

Correct answer: a
Case Presentation: A 68-year-old man has been having pain in his legs for six months. The pain typically comes on when he is climbing stairs or has been walking for longer than 30 minutes, and is concentrated in the backs of his calves. **PH** hypertension. **DH** amlodipine 10mg PO OD. **SH** current smoker 10-20 per day, total 45 pack year history. NKDA


**O/E**

HR 74 regular, RR 14, BP 134/85. No pain at rest. Lower limbs pale and cool to knee level. Weak dorsalis pedis and posterior tibial pulses bilaterally. Normal power and tone, reflexes and sensation preserved. Capillary refill at toes 3s.

**Investigations**

ABPI: 0.7 bilaterally

Question: Select the most appropriate management at this stage.

Options:
explanation: The initial medical management of peripheral vascular disease generally involves a single antiplatelet with preference for clopidogrel over aspirin as supported by the best available evidence. In addition, a high-dose statin should be prescribed
name: Clopidogrel 75mg PO OD and atorvastatin 80mg PO OD
label: a
answer: yes
explanation: Dual antiplatelet therapy may be eventually indicated in the medical management of peripheral vascular disease but is no longer recommended as an initial treatment option. In addition, a high-dose statin should be prescribed
name: Aspirin 75mg PO OD and clopidogrel 75mg PO OD
label: c
answer: no
explanation: While antiplatelet therapy is recommended for the medical management of peripheral vascular disease, the current evidence supports the use of clopidogrel over aspirin. Aspirin may still be prescribed if clopidogrel is not tolerated
name: Aspirin 75mg PO OD and atorvastatin 80mg PO O
label: b
answer: no
explanation: This patient should be prescribed lipid-lowering therapy on account of likely peripheral vascular disease. However a statin should be the first line agent of choice rather than a fibrate, which are prescribed as adjuncts to statins or if statins are not appropriate
name: Clopidogrel 75mg PO OD and fenofibrate 200mg PO OD
label: d
answer: no
explanation: This patient is presenting with symptoms of intermittent claudication and risk factors suggesting he has peripheral vascular disease. As such he should be prescribed an antiplatelet drug such as clopidogrel and a high-dose statin. In this option the dosages are incorrect – the dose of clopidogrel is too high and the dose of atorvastatin is too low
name: Clopidogrel 300mg PO OD and atorvastatin 20mg PO OD
label: e
answer: no

Correct answer: a
Case Presentation: A 4 year old girl is brought to GP by her parents as she has been unsettled and complaining of right-sided ear pain for the past 24 hours.


**O/E**

Temperature 37.0°C. HR 84, RR 15, O2 99% RA. Visibly restless and tugging at right pinna. Oropharynx pale pink with moist mucous membranes. Cervical lymph nodes not palpable. Otoscopy – left ear unremarkable, right ear hyperaemic tympanic membrane with loss of light reflex but no visible effusion.

Cardiovascular examination unremarkable. She has no known drug allergies.

Question: Select the most appropriate management at this stage.

Options:
explanation: This is a combination medication given topically to treat acute otitis externa, or acute otitis media with grommets present
name: Ciprofloxacin with dexamethasone topical ear drops BD
label: c
answer: no
explanation: Clarithromycin is an acceptable option in treating acute otitis media where antibiotics are required
name: Clarithromycin 250mg PO BD
label: d
answer: no
explanation: Amoxicillin may be given to treat acute otitis media that has not resolved after 3-4 days or if there is any evidence of complications
name: Amoxicillin 250mg PO TDS
label: b
answer: no
explanation: While most cases of acute otitis media are self-limiting and resolve in a few days, the child is clearly in some pain and distress. At the very least, simple oral analgesia should be prescribed
name: No additional treatment is required
label: e
answer: no
explanation: Paracetamol is available as a flavoured syrup for young children who will not tolerate tablets or are adverse to the bitter taste
name: Paracetamol oral suspension 240mg PO QDS
label: a
answer: yes

Correct answer: a
Case Presentation: A 62 year old man is brought to A&E with fever, productive cough and shortness of breath. **PH** Parkinson’s disease, osteoarthritis. **DH** co-careldopa 25/250mg PO TDS, codeine phosphate 30mg PO PRN (max 6-hourly), senna 7.5mg PO BD. NKDA


**O/E**

Drowsy but able to answer in full sentences. Appears sweaty. Peripheries warm, CRT < 2s. Coarse creps L mid to lower zone.

Temperature 38.4°C, HR 112, RR 32, BP 115/78, O2 94% RA, AMTS 6/10

**Investigations**

FBC: Hb 124, WCC 16.3, Plts 203 x 10^9, MCV 82

U&Es: Na 133, K 4.6, Cl 100, Ur 8.1, Cr 117, eGFR 83mL/min/1.73m^2

CRP 155

Question: Select the most appropriate management at this stage.

Options:
explanation: The patient has a CURB-65 score of 3 and has a higher risk of mortality. Meropenem is a broad-spectrum carbapenem antibiotic that would not be initiated without specialist input from microbiology
name: Admit with meropenem 1g IV TDS
label: c
answer: no
explanation: This would be a possible option with a CURB-65 of 0. However the patient scores 3 and warrants admission and more intensive treatment
name: Discharge with amoxicillin 500mg PO TDS
label: d
answer: no
explanation: The patient has a CURB-65 score of 3 and has a higher risk of mortality, thus warranting intensive inpatient treatment with IV antibiotics
name: Admit with co-amoxiclav 1.2g IV TDS and clarithromycin 500mg IV BD
label: a
answer: yes
explanation: This would be a possible option with a CURB-65 of 2. However the patient scores 3 and warrants more intensive treatment
name: Admit with amoxicillin 500mg PO TDS and clarithromycin 500mg PO BD
label: b
answer: no
explanation: Doxycycline is an acceptable alternative in patients who are penicillin-allergic. However a discharge is inappropriate as the patient has a CURB-65 of 3D
name: Discharge with doxycycline 200mg PO OD and clarithromycin 500mg PO BD
label: e
answer: no

Correct answer: a