hllj/quesmed huggingface dataset:
A 7-year-old girl is seen in the outpatient paediatrics clinic with tiredness, weight gain and swelling of her hands and feet and around her eyes.

Investigations

Urine dip: Protein 3+

She is given a provisional diagnosis of nephrotic syndrome secondary to minimal change disease. She is prescribed prednisolone 25mg PO OD and given a follow-up appointment in 6 weeks.

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

Options:
explanation: The [BNFC](https://bnfc.nice.org.uk/drugs/prednisolone/#monitoring-requirements) states that for children taking oral prednisolone, blood pressure and urinary glucose should be monitored weekly
name: Blood pressure and urinary glucose 
label: b
answer: yes
explanation: The BNFC recommends that for oral prednisolone, blood pressure and urinary glucose should be monitored weekly.
name: Height and weight 
label: d
answer: no
explanation: The BNFC recommends urinary glucose measurements.
name: Capillary blood glucose
label: c
answer: no
explanation: It is not necessary to monitor serum ACTH during treatment with prednisolone
name: Serum ACTH
label: e
answer: no
explanation: The BNFC advises that for patients with systemic sclerosis, blood pressure and renal function, specifically creatinine, should be measured as there is an increased incidence of scleroderma renal crisis.
name: Blood pressure and renal function
label: a
answer: no

Correct answer: b
Case Presentation: A 52 year old man attends his GP to receive the results of an ambulatory blood pressure monitoring study. **PMH** stable angina pectoris. **DH** bisoprolol fumarate 10mg PO OD. NKDA


**Investigations**

Clinic BP: 151/95mmHg

Ambulatory daytime average: 142/84mmHg

His GP decides to prescribe ramipril 2.5mg PO OD and schedules a follow-up appointment in 2 weeks.

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

Options:
explanation: It is recommended that renal function be checked prior to and monitored during anti-hypertensive treatment with ACE inhibitors. The treatment may be modified or stopped if there is any evidence of new renal impairment
name: Renal function tests
label: a
answer: yes
explanation: It is not necessary to perform routine monitoring with spirometry during anti-hypertensive treatment with ACE inhibitors
name: Spirometry
label: d
answer: no
explanation: It is not necessary to perform routine monitoring with stress echocardiography during anti-hypertensive treatment with ACE inhibitors
name: Stress echocardiogram
label: c
answer: no
explanation: It is not necessary to monitor the heart rate during anti-hypertensive treatment with ACE inhibitors
name: Heart rate
label: b
answer: no
explanation: Although peripheral oedema is a documented side effect with ACE inhibitors, it is generally not necessary to monitor weight during treatment
name: Weight
label: e
answer: no

Correct answer: a
Case Presentation: A 72 year old woman is recovering on the surgical ward following a total hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer. She is receiving tinzaparin 3500 units SC ON as prophylaxis against deep vein thrombosis.


Question: Select the most appropriate option to monitor the effectiveness of this treatment.

Options:
explanation: This is of limited usefulness with regard to anticoagulation therapy
name: Factor VIII levels
label: c
answer: no
explanation: There are no routine monitoring parameters available for low molecular weight heparin, although one may consider assessing renal function prior to administering this drug. In some instances, Factor Xa levels can be checked and the dose modified but this usually guided by the haematology team
name: No routine monitoring parameter is available
label: a
answer: yes
explanation: Heparin has no effect on the production of white blood cells and routine monitoring is not necessary
name: White cell count
label: d
answer: no
explanation: This may be measured if the patient was receiving an unfractionated heparin infusion rather than low molecular weight heparin
name: Activated partial thromboplastin time
label: b
answer: no
explanation: This is not necessary when starting low molecular weight heparin
name: Prothrombin time
label: e
answer: no

Correct answer: a
Case Presentation:


A 38-week pregnant lady is admitted to the Emergency Department with generalized tonic-clonic seizure. Prior to the onset of the seizure, her husband mentioned she had been complaining of headache and abdominal pain. PMH Gestational diabetes. DH Metformin 1g BD PO. Weight 60kg


 **On Examination**
BP 205/100 mmHg (on admission) (<140/90mmHg), HR 92/min, RR 22
BP 92/50 mmHg (at 25 weeks)


 **Investigations**
Urine dipstick ++ protein

||||
|--------------|:-------:|---------------|
|Haemoglobin|110   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|8x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|80x10<sup>9</sup>/L|150 - 400|
|Bilirubin|1.5 µmol/L|< 17|
|Aspartate Aminotransferase (AST)|80IU/L|10 - 40|
|Alanine Aminotransferase (ALT)|140 IU/L|10 - 50|
|Creatinine|123 µmol/L|60 - 120|
|Creatinine|0.66 mmol/L|0.19 - 0.36|


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

Options:
explanation: Antiepileptics including phenytoin should not be given, likewise for tocolytics, as this woman is 38 weeks pregnant and delivery would help with her eclampsia
name: Terbutaline 5 micrograms/minute for 20 minutes
label: d
answer: no
explanation: This patient has a history of headache, abdominal pain and presented with generalized tonic clonic seizure. In addition, her blood pressure at 25 weeks was normal but is currently significantly elevated. Her signs and symptoms in combination with her investigation results of haemolytic anaemia, elevated liver transaminases and lower platelet count is suggestive of eclampsia with HELLP syndrome. Magnesium sulphate should be given to treat eclampsia alongside antihypertensive medications such as labetalol
name: Magnesium sulphate IV 4g over 5-15minutes, labetalol hydrochloride 20mg/hour IV
label: a
answer: yes
explanation: Magnesium sulphate should be given to treat eclampsia alongside antihypertensive medications such as labetalol. Dexamethasone is not necessary as this woman is currently 38 weeks pregnant
name: Magnesium sulphate IV 4g over 5-15minutes, labetalol hydrochloride 20mg/hour IV,
dexamethasone 8mg IV
label: b
answer: no
explanation: Antiepileptics including phenytoin should not be given, likewise for tocolytics, as this woman is 38 weeks pregnant and delivery would help with her eclampsia
name: Atosiban 6.75mg IV over 1 minute
label: e
answer: no
explanation: Antiepileptics including phenytoin should not be given, likewise for tocolytics, as this woman is 38 weeks pregnant and delivery would help with her eclampsia
name: Two doses of Lorazepam 6mg IV followed by phenytoin 1.2g IV
label: c
answer: no

Correct answer: a
Case Presentation:




A 55-year-old man presents to his GP for review of his blood cholesterol. He was started on atorvastatin 3 months ago for his hypercholesterolemia as his QRISK score was 20%. PMH Type 2 diabetes mellitus, Hypercholesterolemia. DH Atorvastatin 20mg PO daily, Metformin 500mg TDS PO.


 **On Examination**
BP 125/85 mmHg


HR 85/min


RR 14


O2 stats 95% RA


 **Investigations**
 3 months ago, prior to treatment:


||||
|---------------------------|:-------:|--------------------|
|Albumin|40 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|30 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|15 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|100 IU/L|25 - 115|
|Gamma Glutamyl Transferase (GGT)|30 U/L|9 - 40|
|Bilirubin|15 µmol/L|< 17|
|Prothrombin Time (PT)|15    seconds|10 - 12|



 3 days ago:


||||
|---------------------------|:-------:|--------------------|
|Albumin|45 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|85 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|40 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|120 IU/L|25 - 115|
|Gamma Glutamyl Transferase (GGT)|35 U/L|9 - 40|
|Bilirubin|13 µmol/L|< 17|
|Prothrombin Time (PT)|14    seconds|10 - 12|


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

Options:
explanation: There is no clinical indication to change his form of statin or the frequency of his medication
name: Switch to simvastatin 20mg PO 12-hrly
label: d
answer: no
explanation: In this case, his transaminases are raised, his LFT should be repeated in 1 months time. There is no clinical indication to increase the dose of his medication
name: Atorvastatin 40mg PO daily
label: c
answer: no
explanation: His LFT is not raised by more than 3 times the upper limit, there is no need to discontinue his statin at this point
name: Stop atorvastatin
label: e
answer: no
explanation: LFT should be done 3 months after initiation of statin medication. If the transaminase levels are raised by more than 3 times upper limit of normal, discontinue statin and repeat LFT in a month. If the transaminase are raised but less than 3 times upper limit of normal , continue statin and repeat LFT in a month. In this case, his transaminases are raised but not more than 3 times the upper limit, hence, his medication can be continued and LFT should be repeated in a months time
name: Atorvastatin 20mg PO daily
label: a
answer: yes
explanation: In this case, his transaminases are raised, his LFT should be repeated in 1 months time. There is no clinical indication to increase the frequency of his medication
name: Atorvastatin 20mg PO 12-hrly
label: b
answer: no

Correct answer: a
Case Presentation:




A 45-year-old man was admitted to Psychiatry Ward following a failed suicidal attempt due to a depressive episode. PMH Bipolar disorder. DH Lithium carbonate 400mg PO OD.
Due to the acute relapse of her bipolar disorder, it has been decided that her lithium carbonate will be increased to 500mg OD and the first dose was given at 0800 today. Weight 75kg.


 **On Examination**
Patient had fine tremor on both hands and complained of a lingering metallic taste.
BP 118/75 mmHg, HR 75/min, RR 12, moist mucous membrane with CRT 2s.


 **Investigations**
Serum lithium at 2200 is 1.2 mmol/L (Therapeutic dose 0.6-1.0 mmol/L)


Question:
Select the most appropriate decision option based on these data.

Options:
explanation: As there are no signs of toxicity such as coarse tremor, dysarthria or ataxia, there is no need to stop his lithium immediately or carry out haemodialysis
name: Carry out haemodialysis on the patient
label: c
answer: no
explanation: It is also not advisable to ignore the raised serum level and maintain his current dose, appropriate investigation should be done to identify the cause of elevated lithium in order to guide management
name: Maintain the dose of lithium carbonate
label: e
answer: no
explanation: As there are no signs of toxicity such as coarse tremor, dysarthria or ataxia, there is no need to stop his lithium immediately or carry out haemodialysis
name: Stop the lithium and restart at a 300mg OD
label: b
answer: no
explanation: In this case, the patient had a serum lithium of 1.2mmol/L, which is higher than the target range, hence, further increasing the dose of lithium is inappropriate
name: Increase the dose of lithium carbonate to 550mg OD
label: d
answer: no
explanation: Lithium carbonate has a narrow therapeutic index and hence monitoring of serum lithium is often done to ensure it is within therapeutic range. Concentrations are often taken 12 hours after administration and target range of 0.8-1.0 mmol/L is required. The patient’s examination findings are mainly side effects of the medication and not signs of toxicity. Hence, it is necessary to repeat a serum lithium level and check if his renal function is affecting the clearance of lithium
name: Recheck the level of lithium and his renal function
label: a
answer: yes

Correct answer: a
Case Presentation:




A 25-year-old lady was admitted to the Respiratory Ward following an exacerbation of asthma. PMH Type 1 diabetes mellitus, Asthma. DH Salbutamol 200micrograms INH PRN, Fluticasone 50 micrograms BD INH 12-hrly, Biphasic insulin detemir (Levemir Penfill) 15 units SC 12-hrly.


 **On Examination**

HR 90/min and regular


BP 125/85 mmHg


RR 25/min


O2 sats 96% on room air


Temperature 37.5oC.


 **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|


Urinary ketones negative.


Average capillary blood glucose readings are 15 mmol/L prior to breakfast and 5.8 mmol/L prior to evening meal (normal range 3.5-5.5 mmol/L).


VBG Ketones 0.3 mmol/L (<0.6mmol/L)


Question:
Select the most appropriate decision option with regard to the evening dose of insulin based on these data.

Options:
explanation: Decreasing the insulin dose to 13 units would be inappropriate as this could worsen his glycaemic control
name: Decrease Biphasic insulin detemir (Levemir Penfill) to 13 units SC BD
label: c
answer: no
explanation: As his morning blood glucose level is high, the evening insulin dose should be increased, usually by 10% to 20%. As he normally takes 15 units of insulin in the evening, a 10% to 20% increase to 16.5 to 18 units should be made
name: Increase evening Biphasic insulin detemir (Levemir Penfill) to 22 units SC
label: d
answer: no
explanation: As his morning blood glucose level is persistently high, adjustments should be made to his long acting evening insulin dose instead of just giving a PRN short acting insulin
name: Biphasic insulin detemir (Levemir Penfill) 15 units SC and soluble insulin (Actrapid ®) 2 units SC
label: b
answer: no
explanation: Increasing to 22 units is more than 20% of his usual dose. Variable rate insulin infusion is considered in a hyperglycaemic patients who are nil by mouth and who have failed to respond to adjustments of their usual insulin regime
name: Stop biphasic insulin detemir (Levemir Penfill) SC and start variable rate insulin infusion
label: e
answer: no
explanation: The patient has poorly controlled hyperglycaemia, with high levels of blood glucose in the morning. After ruling our DKA with serum and urinary ketones, a dose adjustment should be considered if glucose levels remain high. As his morning blood glucose level is high, the evening insulin dose should be increased, usually by 10% to 20%. As he normally takes 15 units of insulin in the evening, a 10% to 20% increase to 16.5 to 18 units should be made
name: Increase evening Biphasic insulin detemir (Levemir Penfill) to 17 units SC
label: a
answer: yes

Correct answer: a
Case Presentation:


A 75-year-old woman is recovering in the Orthopedic Ward following a total hip replacement of her left hip 2 days ago. PMH Osteoarthritis, Type 2 Diabetes Mellitus, Hypertension. DH Paracetamol 1g QDS PO, Ibuprofen 400mg TDS PO, Omeprazole 20mg PO OD, Metformin 1g BD PO, Amlodipine 10mg PO OD, Morphine sulphate M/R (MST Continus ®) 20mg BD PO, Morphine sulphate I/R (Oramorph ®) 10mg/5mL PRN.
Her surgery is uncomplicated and her postoperative pain is controlled with her usual analgesia. She has not taken any PRN Oramorph over the past 24 hours.

**On Examination**
HR 75/min and regular

BP 120/75 mmHg

RR 12/min

O2 sats 97% RA

Temp 37oC.

Question:
Select the most appropriate decision option with regard to her pain management based on these data.

Options:
explanation: Stopping strong opioids and NSAIDS simultaneously without additional PRN medication would result in a huge decrease in the pain relief for this patient
name: Stop regular morphine sulphate M/R and ibuprofen
label: b
answer: no
explanation: Similarly, stopping all three steps of the analgesic ladder without additional PRN medication would result in a huge decrease in the pain relief for this patient
name: Stop regular morphine sulphate M/R, ibuprofen and paracetamol
label: c
answer: no
explanation: 40mg regular Morphine sulphate approximates to buprenorphine 20 micrograms/h transdermal patch. Changing to 70 micrograms/h patch would be unnecessarily stepping up her pain control
name: Substitute morphine sulphate M/R with buprenorphine 70 micrograms/h transdermal patch
label: d
answer: no
explanation: 40mg regular Morphine sulphate is equivalent to 400mg dihydrocodeine. Although decreasing the equivalent dose of dihydrocodeine is appropriate, 250mg is still more than the maximum recommended dose per day (240mg)
name: Substitute morphine sulphate M/R with dihydrocodeine 250mg PO
label: e
answer: no
explanation: Pain medication should be down titrated using the reverse ladder starting with strong opioids followed by weak opioids, NSAIDs and paracetamol. PRN Morphine sulphate can be prescribed as an intermediate step to provide analgesia when required. The patient is currently on a total of 40mg regular Morphine sulphate a day and her pain relief is well controlled with no PRN medication required. To step down her analgesic management, her regular morphine sulphate could be stopped while maintaining her usual PRN dose of morphine sulphate if additional pain relief is required
name: Stop regular morphine sulphate M/R and continue PRN morphine sulphate
label: a
answer: yes

Correct answer: a
Case Presentation: A 58-year-old gentleman is brought to the Emergency Department by his relative. He is noted to have moderate confusion, double vision and unsteady walking.


## PH

Alcoholism, Chronic pancreatitis, Depression

## DH

Sertraline 100mg PO OD (NKDA)

## On examination

Appears alert, but confabulation and retrograde amnesia suspected.

Temperature 36.2°C, HR 67, RR 13, BP 125/78, O<sub>2</sub> 98% RA, GCS 14, Weight 81kg

## Investigations

None

# Prescribing Request

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

Options:


# Drug choice feedback

This gentleman is likely suffering from Wernicke's encephalopathy. Apart from addressing problems of alcohol abuse and diet, stable patients require multivitamins including vitamins B1 and C. Pabrinex is recommended in such cases.

# Dose/Route/Frequency/Duration feedback

The intravenous route is recommended in the treatment of Wernicke's encephalopathy. The dose is expressed in pairs of ampoules, whereby each pair contains distinct vitamins that are only mixed just prior to administration. 2-3 pairs of ampoules are recommended TDS for 3 to 5 days, followed by 1 pair OD for a further 3 to 5 days guided by clinical improvement.
Case Presentation: A 73-year-old woman admitted to the general ward for observation after a gastrectomy 12 hours ago complains of nausea and has vomited three times. She has been given adequate analgesia.


## PH

Stomach cancer, severe heart failure, Type 2 Diabetes Mellitus, Obesity, Hyperlipidaemia, Mild Parkinson's Disease

## DH

Ramipril 5mg OD PO, Bisoprolol 2.5mg PO, Spironolactone 50mg PO OD, Metformin 1g BD PO, Empaglifozin 10mg PO OD, Atorvastatin 40mg PO OD (NKDA)

## On examination

Appears unwell, not oriented to time and place. Peripheries warm, CRT 2s. Cannula in situ.

Temperature 36.6°C, HR 97, RR 23, BP 113/80, O2 96% RA, GCS 14, Weight 95kg

## Investigations

FBC: Hb 144, WCC 7.3, Plts 324

U&Es: Na<sup>+</sup> 136, K<sup>+</sup> 4.2, Cl<sup>-</sup> 105, Ur 6.8, Cr 98, eGFR 51mL/min/1.73m<sup>2</sup>

ECG: Normal sinus rhythm, QTc 430ms (<460ms)

# Prescribing Request

Write a prescription for one medication that is most appropriate for treating her post-operative nausea and vomiting.

Options:


# Drug choice feedback

This patient requires an anti-emetic. Ondansetron is the most appropriate. Cyclizine is contra-indicated in light of her severe heart failure, whilst prochlorperazine is contra-indicated due to her mild Parkinson's disease, as it can result in extra-pyramidal side effects. Metoclopramide is contra-indicated as it is a pro-kinetic in the context of thias patient's gastrectomy

# Dose/Route/Frequency/Duration feedback

The dose of IV ondansetron in post-operative nausea and vomiting is 4mg. Whilst it can be given IM, this patient already has a cannula in situ, hence the IV route is preferred.
Case Presentation: A 41-year-old woman, G1P0, who is 32 weeks pregnant is brought to the Emergency Department by her partner with severe headache, blurry vision, severe abdominal pain, nausea and sudden swelling of hands.


## PH

Type 2 Diabetes Mellitus, Obesity

## DH

Metformin 1g PO OD, Aspirin 75mg PO OD (started from 12th week of gestation) (NKDA)

## On examination

Alert but in pain. Hyperreflexia noted. Mild tenderness in right upper quadrant of abdomen. Generalised oedema noted. No clonus. Cannula in situ.

Temperature 36.2°C, HR 67, RR 13, BP 162/98, O<sub>2</sub> 98% RA, GCS 14, Weight 98kg

## Investigations

Proteinuria 2+ on dipstick, no blood noted

FBC, U&E, LFT and Clotting: Normal, HEELP syndrome negative.

# Prescribing Request

Write a prescription for one drug that is most appropriate for treating her blood pressure. 

Options:


# Drug choice feedback

This woman is likely suffering from pre-eclampsia. As her systolic blood pressure is above 150mmHg, pharmacological management is indicated. The first line agent for controlling this is with labetalol. Other options include nifedipine or methyldopa. As she does not have any major complications (haemodynamically unstable, coagulation abnormalities or HELLP syndrome), she can be managed conservatively for now i.e. without delivery of the foetus.

# Dose/Route/Frequency/Duration feedback

There is no fixed dose stated for labetalol as it is given as a continuous infusion, hence a rate instead is recommended which is titrated every 30 minutes according to clinical improvement. Although labetalol can be taken orally, the patient is having nausea and a cannula has been inserted, making the intravenous route preferred.
Case Presentation: A 24-year-old gentleman was found collapsed on the street and was brought to the Emergency Department.




## PH


Type 1 Diabetes Mellitus


## DH


Insulin Glargine (Lantus) 18 units, Insulin Aspart (Novorapid) 6 units at mealtimes


## On examination


Appears sweaty, drowsy, not oriented to time and place. Tremor noted in hands bilaterally. Cannula is in situ.


Temperature 36.7°C, HR 117, RR 25, BP 123/80, O2 97% RA, GCS 11, Weight 72kg


## Investigations


BM: 2.1 mmol/L (normal range 3.5-5.5 mmol/L)


TFT: Normal


ECG: Sinus Tachycardia


# Prescribing Request


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

Options:


# Drug choice feedback

This patient is suffering from hypoglycaemia and the intravenous fluid required urgently is glucose. Glucose 10% or 20% are the most appropriate. The next higher concentration is Glucose 50%, a possible alternative, but due to its high concentration, it can extravasate and is an irritant. Hence, it is not preferred. The next lower concentration is Glucose 5%, which is too low for any clinical effect unless a large volume is administered which is impractical.

# Dose/Route/Frequency/Duration feedback

A dose of 15g-20g of glucose needs to be administered, hence as long as the volume of a particular intravenous glucose concentration given achieves this dose, as stated above, it is acceptable. The duration of administration should not exceed 15 minutes, so that the hypoglycaemic episode is not unduly prolonged.