hllj/quesmed huggingface dataset:
Case presentation: A 66-year-old female comes to the GP for a medication review. She reports that she currently has pain in her hands. 


**PH** Hypertension, Epilepsy, Rheumatoid Arthritis, Osteoporosis, Constipation

**DH** Her regular medicines are listed (below).

**On Examination** - Patient looks well, Hands: red erythematous swelling of metacarpophalangeal (MCPs) joints in the left hand, swelling of third proximal interphalangeal (PIPs) joint on the left hand. Pain on palpation of MCPs and PIPs. Reduced range of movement of left hands and wrists.

Temperature 37.5°C, HR 88, RR 18, BP 134/94

**Investigation** - Recent X-Ray of left-hand shows loss of joint space at MCPs and PIPs, Erosion at the third PIP and soft tissue swelling around the MCPs and third PIP.

Weight 56kg.

Question 1: Select the TWO prescriptions that increase the risk of osteoporosis (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: Folic Acid;5mg;PO (Oral);Once Weekly
label: i
answer: no
name: Lisinopril;20mg;PO (Oral);Once Daily
label: b
answer: no
name: Senna;15mg;PO (Oral);Nightly
label: h
answer: no
name: Prednisolone;15mg;PO (Oral);Once Daily
label: g
answer: no
name: Amlodipine;5mg;PO (Oral);Once Daily
label: c
answer: no
name: Colecalciferol;400 units;PO (oral);Once Daily
label: f
answer: no
name: Carbamazepine;500mg;PO (Oral);Twice Daily
label: d
answer: no
name: Methotrexate;10mg;PO (Oral);Once Weekly
label: a
answer: no
name: Alendronic Acid;700mcg;PO (Oral);Once Weekly
label: e
answer: no


1. Long-term use of glucocorticoids such as prednisolone increase the risk of osteoporosis. Glucocorticoids should therefore only be used in short courses (up to 4 weeks) to treat flares of rheumatoid arthritis. Some antiepileptics (carbamazepine, phenytoin and sodium valproate) have been shown to increase the risk of osteoporosis when used long term.
2. Alendronic Acid is used to treat osteoporosis, it should be prescribed in a weekly dose of 70mg or a daily dose of 10mg. 700mcg = 0.7mg. 700mcg would not be an effective dose to treat osteoporosis.
Case presentation: A 68-year-old gentleman is admitted to the general surgical ward following an episode of diverticulitis. He is prescribed IV antibiotics to treat his diverticulitis.


**PH** Diverticular disease, hypertension, hypercholesterolaemia, COPD, type 2 diabetes mellitus, gout

**DH** His current medications are listed (below). Weight 88kg.

**On Examination**
HR 65/min, BP 135/95mmHg, RR 16, O2 sats 96% RA, temperature 37.7. Abdomen soft, tender in LIF region.

**Investigation**

CT abdomen and pelvis - uncomplicated sigmoid diverticulitis with no localised perforations.

Question 1: Select the TWO prescriptions that should not be co-prescribed. (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: Colchicine;500 micrograms;PO;BD
label: b
answer: no
name: Atorvastatin;20mg;PO;ON
label: d
answer: no
name: Cefuroxime;2.5g;IV;TDS
label: f
answer: no
name: Metformin;500mg;PO;BD
label: c
answer: no
name: Amlodipine;10mg;PO;OD 
label: a
answer: no
name: Paracetamol;1g;PO;QDS
label: g
answer: no
name: Allopurinol;100mg;PO;OD
label: h
answer: no
name: Metronidazole;500mg;IV;TDS
label: i
answer: no
name: Salbutamol;200 micrograms;INH;QDS
label: e
answer: no


1. Colchicine should not be prescribed in patients with gout flare-ups who are taking statins. This is due to the reported increase in rhabdomyolysis when these medications are given together.

2. Cefuroxime dosing is between 750mg to 1.5g IV TDS. This patient would be receiving 3g of cefuroxime over the maximum daily dose each day.
Case presentation: A 74-year-old gentleman attends his GP complaining of dizziness. 




 **PH** Hypertension, atrial fibrillation, COPD, hypercholesterolaemia, osteoarthritis


 **DH** His regular medicines are listed (below). Weight 83kg.


 **Investigations**



||||
|--------------|:-------:|---------------|
|Haemoglobin|111 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|4.8x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|236x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|72 fL|80 - 96|
|Neutrophils|2.2x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|1.3x10<sup>9</sup>/L|1.5 - 4.0|
|Monocytes|0.4x10<sup>9</sup>/L|0.2 - 1.0|
|Eosinophils|0.1x10<sup>9</sup>/L|0 - 0.4|
|Basophils|0.03x10<sup>9</sup>/L|0 - 0.1|


Question 1: Select the ONE prescription that is most likely to be a cause of his anaemia (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: Lansoprazole;30mg;PO;OD
label: h
answer: no
name: Amlodipine;10mg;PO;OD
label: b
answer: no
name: Atorvastatin;20mg;PO;OD
label: c
answer: no
name: Bisoprolol;5 micrograms;PO;OD
label: e
answer: no
name: Salbutamol;200 micrograms;INH;QDS
label: f
answer: no
name: Ibuprofen;400mg;PO;QDS
label: g
answer: no
name: Paracetamol;1g;PO;QDS
label: i
answer: no
name: Apixaban;5mg;PO;BD
label: d
answer: no
name: Ramipril;10mg;PO;OD
label: a
answer: no


1. Apixaban is a common cause of anaemia. As apixaban is a blood thinner, one of its common side effects is bleeding. This in turn then leads to anaemia. Ibuprofen and lansoprazole can also cause anaemia however this is much rarer.
2. Bisoprolol dosages come in milligrams, not micrograms. This patient is receiving a much lower dose than they should be.
Case presentation: A 73-year-old man is admitted to the acute medical ward with cellulitis. While an inpatient he also developed swelling and pain in his right knee and was commenced on medication for presumed gout.  One day after starting this medication he started to experience non-bloody diarrhoea.


**PH** Gout, Hypertension, Type 2 Diabetes, Gout, Chronic kidney disease, Osteoarthritis, Benign Prostatic Hyperplasia

**DH** His current regular medicines are listed (below).

Allergies - Penicillin (anaphylaxis)

**On Examination**
Afebrile, HR 84/min regular rhythm, BP 137/80 mmHg, mildly tender swollen right knee.

Question 1: Select the TWO prescriptions that are most likely to be contributing to his diarrhoea. (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: Metformin;500mg;oral (PO);Daily
label: a
answer: no
name: Gliclazide;40mg;oral (PO);Daily
label: f
answer: no
name: Tamsuolosin;400mcg;oral (PO);Daily
label: h
answer: no
name: Amlodipine;5mg;oral (PO);Daily
label: d
answer: no
name: Colchicine;500mg;oral (PO);8-hourly
label: e
answer: no
name: Paracetamol;500mg;oral (PO);PRN
label: g
answer: no
name: Clindamycin;600mg;intravenous (IV);12-hourly
label: b
answer: no
name: Ramipril;5mg;oral (PO);Daily
label: c
answer: no


1. Diarrhoea is a well recognised side-effect of both clindamycin and colchicine, and patients should be informed of this before initiating the latter as it is often a reason for non-compliance. Given the patient is being given intravenous clindamycin they should also have a stool sample taken to rule out C.difficile infection.
2. Colchicine is used to manage acute gout in patients with renal impairment in preference to allopurinol. It is important to recognise it is prescribed as *micrograms* not milligrams as in the prescription above.
Case Presentation: A 12 year old boy is brought by his parents into a walk-in clinic with fever, throat pain and malaise. He has had these symptoms for the past 48 hours. **PH** asthma. **DH** salbutamol 200 micrograms inhaler PRN. NKDA


**O/E**

HR 110, RR 16, BP 110/75, Temperature 38.4°C, O2 100% RA. Alert and oriented. Bilaterally enlarged tonsils with patchy exudates. Swollen submandibular and anterior cervical lymph nodes.

Question: Select the most appropriate management at this stage.

Options:
explanation: Flucloxacillin is a narrow-spectrum penicillin antibiotic that is most commonly used to treat skin and soft tissue infections. It is not used in the treatment of streptococcal tonsillitis
name: Flucloxacillin 500mg PO QDS
label: e
answer: no
explanation: While benzylpenicillin has activity against susceptible Gram-positive streptococci, an intravenous antibiotic would not be appropriate to treat likely uncomplicated streptococcal tonsillitis
name: Benzylpenicillin sodium 900mg IV TDS
label: d
answer: no
explanation: Co-amoxiclav is a safer option than amoxicillin alone as it has a lower risk of morbilliform drug eruption in the event of misdiagnosed infectious mononucleosis. However it has a much broader spectrum of activity which may not be necessary to treat likely uncomplicated streptococcal tonsillitis
name: Co-amoxiclav 625mg PO TDS
label: b
answer: no
explanation: Amoxicillin should not be given alone to treat suspected streptococcal tonsillitis due to the risk of misdiagnosed infectious mononucleosis and morbilliform drug eruption
name: Amoxicillin 500mg PO TDS
label: c
answer: no
explanation: Phenoxymethylpenicillin is recommended first line to treat streptococcal tonsillitis in all age groups. Clarithromycin is an acceptable alternative option in penicillin-allergic patients
name: Phenoxymethylpenicillin 500mg PO QDS
label: a
answer: yes

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: 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: 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: 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: 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: 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: 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: 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: 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: 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
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

Correct answer: a
Case Presentation: A 15 month old boy is brought to A&E by his parents with fever, cough and reduced oral intake.


**O/E**

Temperature 37.8°C. HR 104, RR 32 with persistent non-productive cough. O2 95% RA. Scattered fine crepitations and audible wheeze on auscultation. Appears pale pink and not cyanosed. Weight 10kg.

He has been given paracetamol oral suspension (Calpol Infant 120mg/5ml) 120mg PO and started on 4L oxygen wafted via simple face mask.

Question: Select the most appropriate management at this stage.

Options:
explanation: Although fluid resuscitation may be necessary if the child is dehydrated due to reduced oral intake, there is nothing in the stem to support this
name: 0.9% normal saline 200ml IV
label: b
answer: no
explanation: Phenoxymethylpenicillin may be given to treat streptococcal infections. There is no evidence such an infection is present in the stem
name: Phenoxymethylpenicillin 125mg PO
label: e
answer: no
explanation: Dexamethasone is an anti-inflammatory steroid medication commonly used to treat croup in the paediatric population. It has no role in the acute management of bronchiolitis
name: Dexamethasone 1.5mg PO
label: c
answer: no
explanation: Bronchiolitis is generally managed conservatively unless there is evidence of disease severity (e.g cyanosis, <50% oral intake)
name: No additional treatment is required
label: a
answer: yes
explanation: Palivizumab is a humanised monoclonal antibody that is used to prevent RSV infections in children at higher risk of severe disease. It is not routinely given without specialist paediatric input
name: Palivizumab 15mg IM
label: d
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: 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
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: Clarithromycin is an acceptable option in treating acute otitis media where antibiotics are required
name: Clarithromycin 250mg PO BD
label: d
answer: no
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: 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

Correct answer: a
Case Presentation: A 30 year old woman attends a walk-in GUM clinic to request emergency contraception. She had protected sexual intercourse the evening before but realised afterwards that the condom had split without her noticing, and she is now worried about getting pregnant as she is not taking any other form of contraception. **PH** polycystic ovarian syndrome, trigeminal neuralgia, asthma. **DH** carbamazepine 300mg PO TDS, salbutamol 200 micrograms inhaler PRN, beclometasone dipropionate 200 micrograms inhaler BD, regular multivitamins. NKDA.


Her last menstrual bleed was 16 days ago, but she has an irregular cycle ranging from between 24 days to 40 days. She has never been pregnant before and has never been admitted to hospital. On counselling, she mentions having used a Mirena coil in the past but had it removed due to pelvic pain, and feels she would not consider trying intrauterine devices again.

Question: Select the most appropriate management at this stage.

Options:
explanation: Ulipristal acetate may be given as oral emergency contraception for up to 120 hours following unprotected sexual intercourse. However the dose here is much too low to be used as emergency contraception
name: Ulipristal acetate 10mg PO
label: e
answer: no
explanation: This may be given as oral emergency contraception for up to 72 hours following unprotected sexual intercourse. The doubled dose accounts for increased metabolisation of the drug due to the patient taking a p450 inducer
name: Levonorgestrel 3mg PO
label: a
answer: yes
explanation: This may be given as oral emergency contraception for up to 72 hours following unprotected sexual intercourse. 1.5mg is a standard dose but this should be doubled as the patient is taking a p450 inducer
name: Levonorgestrel 1.5mg PO
label: b
answer: no
explanation: Ulipristal acetate may be given as oral emergency contraception for up to 120 hours following unprotected sexual intercourse. However the dose here is indicated for treatment of fibroids rather than as emergency contraception
name: Ulipristal acetate 5mg PO
label: d
answer: no
explanation: This is a progesterone-only contraceptive that has no emergency contraception effects
name: Noresthisterone 15mg PO
label: c
answer: no

Correct answer: a
Case Presentation: A 78 year old man attends his GP due to low mood. He has issues with getting to sleep, concentration, general low mood and appetite. His main complaint is his appetite, he no longer eats as he used to and subsequently has lost weight. He has no suicidal ideation or impulse to hurt others.


**PH** COPD, osteoarthritis

**DH** Salbutamol 200 micrograms INH QDS, ibuprofen 400mg PO QDS, lansoprazole 30mg PO OD. NKDA

**On examination**

Visibly low mood. Lacking in engagement throughout the consultation.

Weight 3 months ago: 76kg.

Weight today: 68kg.

Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Since his main issue is lack of appetite and weight loss it would make most sense to prescribe him mirtazapine. Fluoxetine is the first line medication for depression in children.
name: Fluoxetine 20mg PO OD
label: d
answer: no
explanation: This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Since his main issue is lack of appetite and weight loss it would make most sense to prescribe him mirtazapine as this is an antidepressant that is linked with increasing appetite the most.
name: Mirtazapine 15mg PO OD
label: a
answer: yes
explanation: This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Since his main issue is lack of appetite and weight loss it would make most sense to prescribe him mirtazapine.
name: Escitalopram 10mg PO OD
label: e
answer: no
explanation: This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Sertraline would usually be the first line treatment however his issues with weight loss make mirtazapine a more appropriate choice.
name: Sertraline 50mg PO OD
label: b
answer: no
explanation: This patient has depression, he is exhibiting a variety of psychological and biological symptoms of depression. Since his main issue is lack of appetite and weight loss it would make most sense to prescribe him mirtazapine. Venlafaxine is often a second line medication in major depressive disorder.
name: Venlafaxine 25mg PO TDS
label: c
answer: no

Correct answer: a
Case Presentation: A 68 year old man attends his GP to a new rash. This rash is on his leg, is red and hot. 


**PH** Type 2 diabetes mellitus, hypertension

**DH** Metformin 500mg PO BD, ramipril 5mg PO OD. NKDA

**On examination**
Temperature 37.6°C, HR 74, RR 15, BP 136/86, O2 98% RA.

A 3x4cm rash is visualised on the anterior aspect of the right leg. It is hot and painful to touch.

Question: Select the most appropriate management at this stage.

Options:
explanation: Doxycycline can be used to treat patient's cellulitis however it is reserved as a treatment option if the patient has a penicillin allergy - which this patient doesn't.
name: Doxycycline 200mg PO OD for the first day then 100mg PO OD thereafter
label: b
answer: no
explanation: Clarithromycin can be used to treat patient's cellulitis however it is reserved as a treatment option if the patient has a penicillin allergy - which this patient doesn't.
name: Clarithromycin 500mg PO BD
label: c
answer: no
explanation: This patient has cellulitis. He is systemically well therefore doesn't need to be admitted to hospital. He has no penicillin allergy therefore flucloxacillin is the appropriate management option for this patient.
name: Flucloxacillin 500mg PO QDS
label: a
answer: yes
explanation: Co-amoxiclav can be used to treat patient's cellulitis however it is reserved as a treatment option if the patient has an infection near the eyes or nose - which this patient doesn't have.
name: Co-amoxiclav 500/125mg PO TDS
label: d
answer: no
explanation: Erythromycin can be used to treat patient's cellulitis however it is reserved as a treatment option if the patient has a penicillin allergy - which this patient doesn't. If the patient is pregnant and has a penicillin allergy then this is the first line treatment option.
name: Erythromycin 500mg PO QDS
label: e
answer: no

Correct answer: a