hllj/quesmed huggingface dataset:
Case presentation: A 23-year-old female attends the GP with migraines. 


**PH** Acne, Eczema, Anxiety, Migraines with aura.
**DH** Her regular medicines are listed (below).

**On Examination**

Temperature 37.2°C, HR 84, RR 16, BP 124/78
Weight 60kg

**Investigations**

Negative human chorionic gonadotrophin (HCG) pregnancy test

Question 1: Select the ONE prescription that is contraindicated in this patient (mark them with a tick in column A)

Question 2: Select the ONE prescription that is the most likely to cause weight gain (mark them with a tick in column B)

Options:
name: Lymecycline;408mg;PO (Oral);Once daily
label: b
answer: no
name: Paracetamol;1g;PO (Oral);PRN
label: i
answer: no
name: Benzoyl Peroxide;1 Application;Topically;Once daily (after washing)
label: d
answer: no
name: Propranolol;80mg;PO (Oral);Once daily
label: h
answer: no
name: Rigevidon (Ethinylestradiol with Levonorgesterel);1 Tablet;PO (Oral);Once daily
label: e
answer: no
name: Sumatriptan;100mg;PO (Oral) PRN for migraine;(max dose 300mg per day)
label: f
answer: no
name: Adapalene;1 Application (thinly);Topically;Once nightly
label: c
answer: no
name: Hydrocortisone cream;1 Application (thinly);Topically;Once daily
label: g
answer: no
name: Aveeno cream;1;Application Topically;Twice daily
label: a
answer: no


1. Rigevidon (Ethinylestradiol with Levonorgestrel) is a combined oral contraceptive pill (COCP). This patient suffers from migraine with aura. The COCP is contraindicated in patients with migraine with aura due to the increased risk of stroke.
2. A common side effect of the COCP is weight gain.
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: Ramipril;10mg;PO;OD
label: a
answer: no
name: Atorvastatin;20mg;PO;OD
label: c
answer: no
name: Apixaban;5mg;PO;BD
label: d
answer: no
name: Paracetamol;1g;PO;QDS
label: i
answer: no
name: Salbutamol;200 micrograms;INH;QDS
label: f
answer: no
name: Ibuprofen;400mg;PO;QDS
label: g
answer: no
name: Bisoprolol;5 micrograms;PO;OD
label: e
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 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: Senna;15mg;PO (Oral);Nightly
label: h
answer: no
name: Alendronic Acid;700mcg;PO (Oral);Once Weekly
label: e
answer: no
name: Colecalciferol;400 units;PO (oral);Once Daily
label: f
answer: no
name: Amlodipine;5mg;PO (Oral);Once Daily
label: c
answer: no
name: Carbamazepine;500mg;PO (Oral);Twice Daily
label: d
answer: no
name: Lisinopril;20mg;PO (Oral);Once Daily
label: b
answer: no
name: Prednisolone;15mg;PO (Oral);Once Daily
label: g
answer: no
name: Folic Acid;5mg;PO (Oral);Once Weekly
label: i
answer: no
name: Methotrexate;10mg;PO (Oral);Once Weekly
label: a
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 93-year-old female is admitted to the elderly care ward after having a fall.  **PH** Heart Failure, Hypertension, Anxiety, Depression, Osteoporosis, Back Pain **DH** Her regular medicines are listed (below). 



**On Examination**

Temperature 37.3°C, HR 84, RR 16

Weight 54kg

**Investigations**  Lying and Standing Blood Pressure: Lying 136/92mmHg, Standing after 2 minutes 110/84mmHg.

Question 1: Select the FOUR prescriptions that are most likely to have increased this patient's risk of falls.

Question 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).

Options:
name: Alendronic Acid;70mg;PO (Oral);Once weekly
label: a
answer: no
name: Diazepam;5mg;PO (Oral);Once daily
label: e
answer: no
name: Mirtazapine;45mg;PO (Oral);Nightly
label: d
answer: no
name: Paracetamol;1g;PO (Oral);Six times daily
label: i
answer: no
name: Movicol;1 Sachet;PO (Oral);Once daily
label: h
answer: no
name: Ramipril;10mg;PO (Oral);Once daily
label: b
answer: no
name: Amlodipine;5mg;PO (Oral);Once daily
label: c
answer: no
name: Cholecalciferol;400 units;PO (Oral);Once daily
label: g
answer: no
name: Furosemide;40mg;PO (Oral);Once daily
label: f
answer: no


1. Ramipril is an angiotensin-converting enzyme inhibitor (ACEi) used to treat hypertension and heart failure. Antihypertensive medications such as ACEi and diuretics (i.e Furosemide) increase the risk of postural hypotension and therefore falls. This patient has a significant postural drop in their blood pressure (>20mmHg systolic) and this may have contributed to their fall. Mirtazapine also lists postural hypotension as a common side effect. Diazepam is a benzodiazepine used to treat muscle spasms and anxiety. Diazepam has sedative effects and may impair balance, increasing the risk of falls. 

2. Paracetamol should be prescribed in 500mg-1g doses 4-6 times per day with a maximum daily dose of 4g. This patient has been prescribed 6g daily, exceeding the maximum dose and therefore putting this patient at risk of paracetamol toxicity.
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: Amlodipine;10mg;PO;OD 
label: a
answer: no
name: Metformin;500mg;PO;BD
label: c
answer: no
name: Paracetamol;1g;PO;QDS
label: g
answer: no
name: Allopurinol;100mg;PO;OD
label: h
answer: no
name: Salbutamol;200 micrograms;INH;QDS
label: e
answer: no
name: Colchicine;500 micrograms;PO;BD
label: b
answer: no
name: Atorvastatin;20mg;PO;ON
label: d
answer: no
name: Metronidazole;500mg;IV;TDS
label: i
answer: no
name: Cefuroxime;2.5g;IV;TDS
label: f
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 33-year-old female attends the emergency department. She is complaining of feeling nauseous and has vomited 3 times. She also has a headache.




 **PH** Depression, seizures, gastro-oesophageal reflux disease, Raynaud's syndrome, asthma, allergic rhinitis


 **DH** Her current medications are listed (below). Weight 53kg.


 **On Examination**


 * GCS 15/15
 * Neurological examination: grossly intact
 * HS 1 + 2 + 0
 * Chest clear
 * Abdomen soft and non tender


 **Investigation**


Bloods:


||||
|---------------------------|:-------:|--------------------|
|Sodium|128 mmol/L|135 - 145|
|Potassium|3.9 mmol/L|3.5 - 5.3|
|Creatinine|67 µmol/L|60 - 120|
|eGFR|90 mL/min/1.73m<sup>2</sup>|> 60|


CT head - no abnormalities detected


Question 1: Select the THREE prescriptions that are most likely to be a cause of her abnormal blood results (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: Nifedipine;10mg;PO;TDS
label: c
answer: no
name: Omeprazole;20mg;PO;OD
label: d
answer: no
name: Salbutamol;200 micrograms;INH;QDS
label: f
answer: no
name: Sertraline;50mg;PO;OD
label: e
answer: no
name: Carbamazepine;4g;PO;BD
label: g
answer: no
name: Paracetamol;1g;PO;QDS
label: a
answer: no
name: Cetirizine;10mg;PO;OD
label: b
answer: no
name: Fluticasone;500 micrograms;INH;BD
label: i
answer: no
name: Fluticasone;50 micrograms, one application per nostril; intranasal;OD
label: h
answer: no


1. This patient is hyponatraemic. The three medications she is taking that are likely contributing to her hyponatremia are her omeprazole, carbamazepine and sertraline. It is thought that PPIs cause hyponatremia due to SIADH/salt-losing nephropathy due to acute interstitial nephritis however the mechanism is not fully understood. SSRIs cause hyponatremia due to SIADH, they inhibit the reuptake of noradrenaline which in turn stimulates ADH release. Finally, carbamazepine also causes hyponatremia due to SIADH. It does this via increasing ADH secretion, increasing sensitivity of the renal tubules to ADH activity and increasing aquaporin 2 channel expression.
2. This patient would be taking 8g of carbamazepine daily, the maximum daily dose of carbamazepine is 2g.
Case Presentation: A 29-year-old man is brought to A&E after taking an overdose of paracetamol 20 minutes ago. He has ingested 18 tablets (9g) of paracetamol. **PH** Depression **DH** Citalopram 40mg Oral once daily, NKDA


**On examination**
The patient looks well, not visibly jaundiced.

BP 116/86, HR90, RR 16, Temperature 36.5°C

Weight 75kg

**Investigations**

Blood to be taken 4hr after ingestion

Question: Select the most appropriate management at this stage.

Options:
explanation: Acetylcysteine is used in the treatment of paracetamol poisoning. However, it is used; when a plasma paracetamol concentration is within the treatment threshold, where patients present later than 8 hours and have taken over 150mg/kg of paracetamol or where patients are visibly jaundiced.
name: Acetylcysteine IV
label: c
answer: no
explanation: Haemodialysis is the treatment in severe salicylate poisoning. It would not be appropriate here.
name: Haemodialysis
label: b
answer: no
explanation: It may be appropriate to give a patient with a paracetamol overdose a resuscitation fluid bolus where they vital signs are deranged, however, the patient in this case is currently stable.
name: 500mL NaCl 0.9% in 10 minutes
label: e
answer: no
explanation: Diazepam is used in patients who have taken an overdose of stimulant drugs or antipsychotics.
name: Diazepam 10mg PO (Oral)
label: d
answer: no
explanation: This patient has taken a paracetamol overdose and presented to A&E in under 1 hour, Activated charcoal should therefore be considered as the initial management of this patient.
name: Activated Charcoal 50g PO (Oral)
label: a
answer: yes

Correct answer: a
Case Presentation: A 76 year old man is brought to the emergency department due to a PR bleed. He is unsure how much blood he has lost. 




 **PH** Diverticular disease, atrial fibrillation, hypercholesterolaemia


 **DH** Bisoprolol 5mg PO OD, apixaban 5mg PO BD, atorvastatin 20mg PO OD. NKDA


 **On examination**


Temperature 37.4°C, HR 108, RR 18, BP 94/68, O2 95% RA.


 **Investigations**


||||
|--------------|:-------:|---------------|
|Haemoglobin|68 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|7.3x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|333x10<sup>9</sup>/L|150 - 400|
|C Reactive Protein|48 mg/L|< 5|


Question: Select the most appropriate management at this stage.

Options:
explanation: Whilst a unit of blood is needed as soon as possible you should always also stop medications that will exacerbate the bleed - in this case the apixaban needs to be stopped.
name: Prescribe a unit of O negative blood STAT
label: e
answer: no
explanation: Stopping the apixaban would be one of the correct steps in the management of this patient. Giving vitamin K however will have no effect as this reverses the effects of warfarin NOT apixaban. You should also give a unit of blood STAT.
name: Stop his apixaban, prescribe vitamin K 2mg PO STAT
label: d
answer: no
explanation: These are all management options that you would do however this option is missing giving a unit of blood which is crucial in this case due to the haemodynamic instability.
name: Stop his apixaban, take a group and save blood sample and continue to monitor
label: b
answer: no
explanation: These are management options that you would do however this option is missing giving a unit of blood which is crucial in this case due to the haemodynamic instability. You should also get a group and save and crossmatch sample.
name: Stop his apixaban and continue to monitor
label: c
answer: no
explanation: This patient has suffered an acute bleed. They are haemodynamically unstable due to the hypotension and tachycardia. They also have a low Hb of 68 with the transfusion threshold being a Hb of 70 (80 in patients with a significant cardiac history). He should therefore have all blood thinners suspended and a unit of O negative blood given STAT. You should also get a group and save and crossmatch sample.
name: Stop his apixaban, take a group and save blood sample and prescribe a unit of O negative blood STAT
label: a
answer: yes

Correct answer: a
Case Presentation: A 34 year old man attends an outpatient IBD clinic for a review of his ulcerative colitis. 


He has recently been discharged after having a first flair of mild-moderate disease. He is experiencing no symptoms.

**PH** Ulcerative colitis

**DH** Nil. NKDA.

**On examination**

Temperature 36.9°C, HR 62, RR 12, BP 114/73, O2 98% RA

Abdomen is soft and non-tender.

Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has had a mild-moderate exacerbation of his ulcerative colitis. Prescribing oral prednisolone to maintain remission is not appropriate.
name: Prescribe prednisolone 10mg PO OD
label: b
answer: no
explanation: This patient has just had their first exacerbation of ulcerative colitis. Offering no pharmacological intervention would most certainly mean a further exacerbation of ulcerative colitis in the near future.
name: Offer lifestyle advice
label: e
answer: no
explanation: Whilst it is correct to prescribe an oral aminosalicylate, this dosage of sulfasalazine is for inducing remission NOT maintaining it.
name: Prescribe sulfasalazine 2g PO QDS
label: d
answer: no
explanation: This patient has had a mild-moderate exacerbation of his ulcerative colitis. To maintain remission following this severity of episode it is appropriate to prescribe an oral aminosalicylate, in this case sulfasalazine.
name: Prescribe sulfasalazine 500mg PO QDS
label: a
answer: yes
explanation: This patient is clinically well, there is no need to readmit him.
name: Admit to hospital for a course of IV prednisolone
label: c
answer: no

Correct answer: a
Case Presentation: A 76-year-old man is admitted to the stroke ward following a TIA. **PH** TIA, Hyperlipidaemia, Gout **DH** Atorvastatin 20mg oral OD, Ramipril 5mg oral OD, Allopurinol 100mg oral OD. NKDA



**On examination**

* Irregularly irregular radial pulse and central pulse.
* HS S1+S2
* Chest clear on auscultation.
* BP 130/80, HR 88, Temperature 37.1°C, O2 98% on room air

**Investigations**

 - ECG: Irregularly irregular rhythm, no p waves
 - Transthoracic echocardiogram: normal
 - CT head normal
 - FBC,U&Es, LFTs and clotting studies are all NAD.

Question: Select the most appropriate initial management at this stage, given the results of the investigations.

Options:
explanation: This patient has atrial fibrillation and a CHA₂DS₂-VASc of 5. (Age=2, TIA=2, treated hypertension = 1. 2+2+1=5.) Anticoagulation should therefore be initiated. Direct oral anticoagulants such as apixaban are the first-line medications used.
name: Start Apixaban 5mg Oral
label: a
answer: yes
explanation: This patient has atrial fibrillation (AF). Warfarin was historically first line for anticoagulation in patients with AF although DOACs are now preferred as they have a lower bleeding risk and do not require regular monitoring.
name: Start Warfarin 5mg OD Oral and book follow-up in INR clinic
label: c
answer: no
explanation: This patient has atrial fibrillation (AF) . Flecainide is a treatment option in paroxysmal atrial fibrillation as a ‘pill in pocket’ initiated by. This would not be appropriate here as it is a specialist treatment, this patient has a normal heart rate and there is no suggestion that their AF is paroxysmal.
name: Start Flecainide 50mg OD Oral
label: e
answer: no
explanation: This would be correct if the patient was presenting with unstable AF causing haemodynamic compromise. However, all of this patient's vital signs are stable.
name: Start DC Cardioversion
label: b
answer: no
explanation: This patient has atrial fibrillation (AF). Although clopidogrel is used in the management of patients after a TIA, where patients have AF, anticoagulation with DOACs is more appropriate than antiplatelet treatment as they have a greater risk of clot formation.
name: Start Clopidogrel 75mg OD Oral
label: d
answer: no

Correct answer: a
Case Presentation: A 2-year-old girl is brought into A&E by her father. She has been unwell for 24 hours. She is drowsy and disinterested in playing. She has recently developed a non-blanching rash over her torso. **PH** None **DH**  NKDA


**On examination**
The patient is drowsy with her eyes closed.

Non-blanching erythematous rash seen over her torso.

HR 134, RR 32, Capillary Refill 3 seconds

Weight: 13kg

**Investigations**

None performed yet

Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has suspected meningitis with meningococcal septicaemia. Intramuscular Benzylpenicillin is the most appropriate treatment in a pre-hospital environment, i.e. general practice, community, or ambulance. As this patient is already at A&E, IV treatments would be available and more appropriate.
name: Benzylpenicillin 600mg IM
label: b
answer: no
explanation: Flucloxacillin is the chosen antibiotic to treat infections such as otitis externa and severe pneumonia in children. This patient has suspected meningitis with meningococcal septicaemia.
name: Flucloxacillin 325mg IM
label: d
answer: no
explanation: IV Amoxicillin is the treatment for meningitis caused by listeria. This patient has suspected meningitis with meningococcal septicaemia.
name: Amoxicillin 650mg IV
label: c
answer: no
explanation: Phenoxymethylpenicillin is the chosen antibiotic to treat tonsillitis, oral infections and otitis media. This patient has suspected meningitis with meningococcal septicaemia.
name: Phenoxymethylpenicillin 125mg PO (Oral)
label: e
answer: no
explanation: This patient has suspected meningitis with meningococcal septicaemia. IV Cefotaxime or Ceftriaxone would be the most appropriate initial treatment in a hospital setting.
name: Cefotaxime 650mg IV
label: a
answer: yes

Correct answer: a
Case Presentation: A 38-year-old woman attends a follow up appointment at her GP for the results of her blood tests.




 **PMH** Depression, Asthma


 **DH** Salbutamol 200 micrograms INH PRN, Sertraline 50mg PO OD. NKDA


 **SH** Active smoker, smoking 10 cigarettes a day (5 pack year history). Drinks 20-30 units of alcohol a week.


 **Investigations**


||||
|---------------------------|:-------:|------------------------------|
|Thyroid Stimulating Hormone|<0.1 mU/L|0.3 - 4.2|
|Free T4|44 pmol/L|9 - 25|
|Free T3|18 pmol/L|3.1 - 6.8|


Based on her blood results she is diagnosed with hyperthyroidism. It is decided that she will be started on carbimazole 15mg PO OD.


Question: Select the most appropriate piece of information that should be relayed to this patient prior to starting carbimazole

Options:
explanation: Mood changes are not a recognised side effect of carbimazole treatment
name: To report any changes to mood
label: b
answer: no
explanation: Smoking can potentially reduce the efficacy of hyperthyroidism treatment however this isn't the most important thing to tell her out of the options provided.
name: To stop smoking
label: c
answer: no
explanation: There is no recognised interaction between sertraline and carbimazole
name: To stop taking her sertraline
label: e
answer: no
explanation: Treatment with carbimazole can cause bone marrow suppression. This is very serious side effect of carbimazole and needs to be mentioned when counselling on the drug. Any signs of infection, especially a sore throat should be reported immediately. After this, a full blood count should be taken. If this full blood count shows neutropenia then carbimazole should be stopped immediately.
name: To report having a sore throat
label: a
answer: yes
explanation: Alcohol can still be consumed whilst taking carbimazole. This patient however is above the recommended weekly limit so should look to reduce her alcohol consumption if possible.
name: To stop drinking alcohol
label: d
answer: no

Correct answer: a