hllj/quesmed huggingface dataset:
Case presentation: A 35-year old woman presents to her GP with amenorrhoea. She reports that she has missed her period and that her menstrual cycle has been irregular for the past few months. She also notices white, milky discharge from her breasts. Besides that, she also informs that she has been trying to conceive for two years but is not successful. PH: Type 2 Diabetes Mellitus, Schizophrenia, Depression, Migraine, GORD, Gout DH: Her 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. Normal pelvic examination, normal breast examination


 **Investigation:**
Negative human chorionic gonadotrophin (HCG) pregnancy test
Serum prolactin: 850 mIU/L (<500)


Question 1: Select the THREE prescriptions that are most likely to be contributing to the hyperprolactinaemia (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: Chlorpromazine hydrochloride;150 mg;Oral (PO);Daily
label: a
answer: no
name: Metformin hydrochloride;500 mg;Oral (PO);Three times daily
label: b
answer: no
name: Ibuprofen;400mg;Oral (PO);4-hourly when required
label: d
answer: no
name: Fluoxetine;40 mg;Oral (PO);Daily
label: c
answer: no
name: Omeprazole;20mg;Oral (PO);Daily
label: f
answer: no
name: Allopurinol;100 mg;Oral (PO);Daily
label: g
answer: no
name: Metoclopramide hydrochloride;100mg;Oral (PO);8-hourly when required
label: e
answer: no


1. Hyperprolactinaemia is a common or very common side effect of chlorpromazine and an uncommon side effect of metoclopramide. Both chlorpromazine and metoclopramide have dopamine D2 receptor antagonistic property, leading to disinhibition of excessive prolactin production. Hyperprolactinaemia is also rare or very rare side effect of all selective serotonin reuptake inhibitors (SSRI). A SSRI like fluoxetine is thought to cause hyperprolactinaemia by inducing a 5HT receptor–mediated stimulation of prolactin secretion.
2. The correct dose of metoclopramide for acute migraine should be 10mg and not 100mg.
Case presentation: A 55-year-old gentleman presents to his GP with repeated episodes of epistaxis. PH Mild depressive episodes, Osteoarthritis of right knee, Vitamin D deficiency, GORD, Benign Prostatic Hyperplasia, HTN. DH His current regular medicines are listed (below).




 **Investigation**
Platelet count 100 x 109/L (Normal value 150-400 x 109/L )


Question 1: Select the ONE prescriptions that are most likely to be contributing to the low platelet count (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: Tamsulosin hydrochloride;400mg;oral (PO);Daily
label: e
answer: no
name: Citalopram;20mg;oral (PO);Daily
label: a
answer: no
name: Paracetamol;1g;oral (PO);6-hourly
label: d
answer: no
name: Ramipril;2.5mg;oral (PO);Daily
label: f
answer: no
name: Amoxicillin;500mg;oral (PO);8-hourly
label: g
answer: no
name: Omeprazole;20mg;oral (PO);Daily
label: c
answer: no
name: Colecalciferol (Vitamin D3);800 units;oral (PO);Daily
label: b
answer: no


1. Penicillin (amoxicillin) commonly or very commonly cause thrombocytopenia. PPI and paracetamol also cause thrombocytopenia but are significantly less common
2. Tamsulosin, an alpha blocker that is prescribed for benign prostatic hyperplasia, is given in 400 micrograms daily, not in milligrams.
Case Presentation: A 72 year old woman presents to A&E with acute shortness of breath and chest pain. **PH** congestive cardiac failure, recurrent DVTs, osteoporosis. **DH** bisoprolol fumarate 7.5mg PO OD, lisinopril 40mg PO OD, spironolactone 50mg PO OD, warfarin sodium 8mg PO OD, alendronic acid 70mg PO once weekly, calcichew D3.


**O/E**

HR 98, RR 36, BP 149/97, Temperature 37.2°C, O2 92% RA. HS I + II + ?III, bibasal fine creps. Pitting oedema to buttocks.

She has been sat upright and started on 6L O2 via simple face mask.

**Investigations**

ECG: sinus tachycardia

Question: Select the most appropriate management at this stage.

Options:
explanation: The patient is clearly fluid overloaded and requires immediate diuresis with a powerful loop diuretic like furosemide
name: Furosemide 40mg IV
label: a
answer: yes
explanation: This novel drug combination is used in the chronic medical management of CCF with reduced ejection fraction and has no role in treating acute fluid overload
name: Sacubitril/valsartan 49/51mg PO
label: e
answer: no
explanation: Digoxin is a cardiac glycoside that increases myocardial contractility and decreases AV node conduction. It is a useful adjunct in patients with CCF and concomitant AF
name: Digoxin 750 micrograms PO
label: c
answer: no
explanation: This would be an option in acute pulmonary oedema unresponsive to initial medical therapy
name: CPAP therapy
label: b
answer: no
explanation: A glyceryl trinitrate infusion can be a useful adjunct treatment in fluid overload secondary to CCF. The patient’s blood pressure must be monitored closely due to its potent vasodilatory effects
name: Glyceryl trinitrate 100 micrograms/kg IV
label: d
answer: no

Correct answer: a
Case Presentation: A 54 year old man attends a follow-up appointment at his GP. Six months ago, he was previously diagnosed with type 2 diabetes and started on metformin hydrochloride 500mg PO OD. This has since been up-titrated to 500mg PO TDS, then 500mg PO QDS.


**Investigations**

HbA1C (3 months ago): 64 mmol/mol

HbA1C (now): 61 mmol/mol

Urine dipstick: NAD

Question: Select the most appropriate management at this stage.

Options:
explanation: In treating type 2 diabetes, it is recommended that a second antidiabetic drug be added following an inadequate response to maximal therapy with metformin
name: Add gliclazide 40mg PO OD to his current prescription
label: a
answer: yes
explanation: Repaglinide is an oral antidiabetic medication used to treat type 2 diabetes. It is less preferred than sulfonylureas
name: Add repaglinide 500 micrograms PO with meals to his current prescription
label: c
answer: no
explanation: This prescription would exceed the recommended maximum dose of metformin which is 2g per day
name: Change his prescription to metformin hydrochloride 1g PO TDS
label: d
answer: no
explanation: The patient is already receiving 2g of metformin hydrochloride and as such this prescription would not effect any significant change to the overall medical treatment this patient is currently receiving
name: Change his prescription to metformin hydrochloride modified release 2g PO OD
label: e
answer: no
explanation: This is a GLP-1 mimetic that is used to treat type 2 diabetes. It should not be prescribed in the primary care setting and is usually only considered failing treatment with more preferred oral antidiabetic medications
name: Add exenatide 5 micrograms SC BD to his current prescription
label: b
answer: no

Correct answer: a
Case Presentation: An 83 year old man is on the geriatric ward being treated for a grade III pressure sore. Today he is complaining of a foul taste in his mouth and some associated throat discomfort. **PH** hypertension, hyperlipidaemia, bilateral hemiarthroplasties. **DH** ramipril 2.5mg PO OD, amlodipine 10mg PO OD, simvastatin 40mg PO ON, paracetamol 1g PO QDS, senna 7.5mg PO BD, lactulose 15ml PO OD. NKDA


**O/E**

Dry oral mucous membranes with halitosis. Visible white patches covering proximal 2/3rds of tongue that slough off when scraped with wooden depressor.

Question: Select the most appropriate management at this stage.

Options:
explanation: This is a medicated mouthwash with anti-inflammatory and analgesic properties. It has no role in the acute management of oral candidiasis
name: Benzydamine hydrochloride mouthwash 15ml PO TDS
label: b
answer: no
explanation: Terbinafine is an antifungal drug commonly used to treat onychomycosis and ringworm. It has no role in the acute management of oral candidiasis
name: Terbinafine 250mg PO OD
label: e
answer: no
explanation: Nystatin is a first-line antifungal treatment in the acute management of oral candidiasis. It is usually presecribed for 7 days
name: Nystatin 100,000 units PO QDS
label: a
answer: yes
explanation: Doxycycline may be prescribed to treat recurrent aphthous stomatitis that may be idiopathic or secondary to herpesviruses. It has no role in the acute management of oral candidiasis
name: Doxycycline orodispersible tablets 100mg PO QDS
label: c
answer: no
explanation: Itraconazole may be an option for oral candidiasis that has not responded to first-line treatments
name: Itraconazole oral solution 100mg PO BD
label: d
answer: no

Correct answer: a
Case Presentation: A 45 year old man attends A&E with a painful swollen left calf. **PH** type 2 diabetes, previous myocardial infarction. **DH** metformin hydrochloride 500mg PO TDS, glimepiride 4mg PO OD, aspirin 75mg PO OD, bisoprolol fumarate 5mg PO OD, ramipril 5mg PO OD. Previous adverse drug reaction to Tazocin – urticarial rash.


**O/E**

Large erythematous patch on left calf, very tender to touch. Temperature 38.0°C. All other observations stable.

**Investigations**

WCC 15.9, CRP 89. Blood cultures pending.

Question: Select the most appropriate management at this stage.

Options:
explanation: Linezolid is a very broad spectrum oxazolidinone antibiotic with powerful anti Gram-positive activity and is used to treat severe skin and soft tissue infections. It should not be initiated without specialist microbiology input
name: Linezolid 600mg PO BD
label: c
answer: no
explanation: Flucloxacillin would be the first-line agent to treat cellulitis, but should not be used in view of the patient’s previous adverse reaction to penicillin
name: Flucloxacillin 500mg PO QDS
label: b
answer: no
explanation: Vancomycin is an aminoglycoside antibiotic with anti-MRSA activity and is used to treat severe skin and soft tissue infections. Due to its narrow therapeutic range and side effects it is not a first-line agent to treat cellulitis
name: Vancomycin 15mg/kg IV BD
label: e
answer: no
explanation: Phenoxymethylpenicillin is sometimes used as prophylaxis against skin and soft tissue infections in some patients, but should not be used to treat cellulitis as it likely has limited activity against Staphylococcus species
name: Phenoxymethylpenicillin 500mg PO QDS
label: d
answer: no
explanation: Clarithromycin is a second-line agent to treat cellulitis in patients who are penicillin-allergic
name: Clarithromycin 500mg PO BD
label: a
answer: yes

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: 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
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: 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 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: 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

Correct answer: a
Case presentation: A 35-year-old woman attends her GP with a two-month history of weight loss, heat intolerance and sweating.  


PMH: Vitiligo
Investigations:


||||
|---------------------------|:-------:|------------------------------|
|Thyroid Stimulating Hormone|0.1 mU/L|0.3 - 4.2|
|Free T4|30 pmol/L|9 - 25|

 - TSH receptor antibodies - Positive

#
The patient is advised to commence treatment with carbimazole 15mg PO daily.


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

Options:
explanation: The starting dose of carbimazole will be reduced gradually once the patients have become euthyroid. Patients will usually be started on a dose of 15-40 mg daily, taken divided into 2-3 doses a day. This may then be reduced after 4-8 weeks to a lower maintenance dose of 5-15 mg, taken once daily
name: She would be started on a low dose before the dose gets titrated upwards in a gradual manner in order to reduce risk of side effects
label: d
answer: no
explanation: Haemolytic anaemia is a rare side effect of carbimazole
name: Haemolytic anaemia is a common side effect of carbimazole
label: e
answer: no
explanation: As the bone marrow disorder may happen at any time during the course of treatment, NICE currently does not recommend monitoring white blood cell count on a regular basis. Instead, white blood cell count will only be performed if there is any clinical evidence of infection
name: A white blood cell count should be performed before the treatment and then three monthly throughout the course of treatment
label: b
answer: no
explanation: Carbimazole is a medication that is used to treat hyperthyroidism. A rare but serious side effect of carbimazole is bone marrow suppression leading to agranulocytosis. As the bone marrow disorder may happen at any time during the course of treatment, NICE currently does not recommend monitoring white blood cell count on a regular basis. Instead, white blood cell count will only be performed if there is any clinical evidence of infection. Hence, patients are advised to report immediately any signs and symptoms such as sore throat and infection
name: She should immediately report to her doctor if sore throat develops
label: a
answer: yes
explanation: Patients who are women of childbearing age are encouraged to use effective contraception during treatment because carbimazole is linked to an increased risk of congenital malformations during pregnancy
name: It is safe for her to attempt to get pregnant during treatment
label: c
answer: no

Correct answer: a
Case presentation: A 27-year-old woman attends the sexual health clinic to discuss about emergency contraception. She had unprotected sexual intercourse yesterday and the first day of her last menstrual period was 15 days ago. She is not on any regular forms of contraception. She dislikes the notion of having hormonal pills.  

Physical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT, normal neurological exam
She is advised to use intrauterine device (IUD)

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

Options:
explanation: Intrauterine device (IUD) is a small device made from copper and plastic that is inserted into the uterus by a trained health professional. The copper alters the cervical mucus and makes it harder for sperms to get through the cervix to fertilise the ovum. It also prevents the implantation of fertilised ovum by altering the endometrial lining
name: IUD works by preventing ovulation through the release of gonadotropins
label: b
answer: no
explanation: IUD can be fitted at any time during the menstrual cycle and it offers instantaneous protection once it is inserted
name: She needs to use an additional barrier contraception during the first 7 days of the IUD insertion because IUD takes time to reach its full protective effect
label: d
answer: no
explanation: Breast cancer is not a contraindication to IUD. It is classified by UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) as a Category 1 condition. UKMEC defines category 1 condition as “a condition for which there is no restriction for the use of the method”
name: Breast cancer is an absolute contraindication
label: c
answer: no
explanation: Intrauterine device (IUD) is a small device made from copper and plastic that is inserted into the uterus by a trained health professional. It is important to highlight to patients that they might experience heavier, longer or more painful periods, especially in the first few months after insertion. They should report this to their doctors so that a discussion about an alternative contraceptive method can take place
name: She might experience heavier, longer or more painful periods
label: a
answer: yes
explanation: IUD does not contain any hormones, so it is not associated with hormonal side effects such as weight gain, acne or breast tenderness
name: Weight gain is a common side effect of IUD
label: e
answer: no

Correct answer: a
Case presentation: A 63-year-old man attends his GP appointment with a 3-month history of chest pain on exertion. He reports that he sometimes gets out of breath and feels a constricting chest pain when climbing up the stairs. The pain usually goes away a few minutes after he sits down.  

PMH: Erectile dysfunction
SH: Retired, lives with his wife

The patient is advised to take Glyceryl Trinitrate (GTN) spray to relieve the chest pain.

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

Options:
explanation: Glyceryl Trinitrate (GTN) is a medication used for prophylaxis and treatment of angina. It converts into nitric oxide, leading to vasodilation and increased blood flow to the heart
name: GTN works by making the heart beat faster and stronger so that more blood can be delivered to meet the body’s demand
label: b
answer: no
explanation: Manufacturer advises against the concurrent use of GTN and sildenafil because it increases the risk of severe hypotension and circulatory collapse
name: GTN can be safely used together with sildenafil
label: c
answer: no
explanation: Restlessness is a rare side effect of GTN
name: Restlessness is a common side effect of GTN
label: e
answer: no
explanation: Patients are advised to repeat the dose at 5 minutes interval if required and to seek immediate medical attention if symptoms have not resolved after 2 doses
name: He should seek immediate medical help if symptoms have not resolved after 2 consecutive doses
label: a
answer: yes
explanation: Patients are advised to repeat the dose at 5 minutes interval if required and to seek immediate medical attention if symptoms have not resolved after 3 doses
name: GTN can be taken at 10 minutes interval if required
label: d
answer: no

Correct answer: a
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: 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: Rather than excessive salivation, sertraline more commonly causes dry mouth
name: Sertraline can lead to excessive salivation
label: d
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
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 linked to low sex drive and erectile dysfunction
name: Sertraline can lead to increased sex drive
label: e
answer: no

Correct answer: a
Case presentation: A 25-year-old man attends his GP appointment with a three-month history of wheeze and chest tightness. He reports that the symptoms usually happen after his morning runs and on exposure to cold air.  

PMH: Eczema
Examination: Widespread expiratory polyphonic wheeze
Investigation: Fractional exhaled nitric oxide(FENO) > 50 parts per billion (ppb); Forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) < 65%; Expiratory peak flow variability >25%
The patient is to be offered a salbutamol inhaler (Ventolin Accuhaler®)as reliever therapy.

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

Options:
explanation: . In a sudden asthma attack, patients should sit up straight and take one puff of reliever inhaler every 30 seconds up to 10 puffs. They should call 999 for an ambulance if the symptoms still do not resolve after 10 puffs
name: In an asthma attack, he can take salbutamol up to 50 puffs with a time interval of 2 minutes between each puff
label: c
answer: no
explanation: Salbutamol is not associated with oral thrush. Oral thrush is a potential side effect of inhaled corticosteroids that are commonly used in asthma maintenance therapy
name: Salbutamol inhaler increases risk of developing oral thrush
label: d
answer: no
explanation: Salbutamol is a short-acting beta 2 adrenergic receptor agonist that treats bronchoconstriction by opening up the airway muscles. Patients should talk to their doctors if they need to use the inhaler for more than 3 times in a week. This may be a sign that the asthma is still not well controlled and that an adjustment needs to be made to the current regime
name: He should talk to his doctor if he uses his salbutamol inhaler for more than 3 times a week
label: a
answer: yes
explanation: Salbutamol is a short-acting beta 2 adrenergic receptor agonist that treats bronchoconstriction by opening up the airway muscles
name: Salbutamol is an alpha-1-agonist that relieves symptoms of asthma by relaxing the muscles of airway
label: b
answer: no
explanation: Salbutamol can cause potentially serious hypokalaemia not hyperkalaemia. It stimulates the entry of potassium into the cells, thus lowering serum potassium concentration
name: Salbutamol can lead to hyperkalaemia
label: e
answer: no

Correct answer: a