hllj/quesmed huggingface dataset:
Case presentation: A 30-year-old woman visits her GP complaining of weight loss, excessive thirst and frequent urination.  

PMH: Coeliac disease, Vitiligo
FH: Type 1 Diabetes Mellitus
Investigation: HbA1c 63 mmol/mol (20-42)
Treatment with insulin is to be initiated.

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

Options:
explanation: Insulin could cause hypoglycaemia, hence patients are encouraged to bring along a source of sugar with them at all times
name: Insulin is not known to cause hypoglycaemia
label: e
answer: no
explanation: Insulin may lead to weight gain
name: Insulin may cause weight loss
label: d
answer: no
explanation: Insulin should be stored in the fridge and not the freezer because very low temperatures might damage the insulin
name: She should store the insulin in the freezer when not using
label: c
answer: no
explanation: During sickness, patients are advised to check blood glucose levels every 2 to 4 hours and adjust the insulin dose accordingly. It is common for patients to need an increased insulin dose during sickness to help keep the blood glucose level within control. There is a need for insulin dose to be increased because adrenaline and cortisol produced by the body to fight against infection may contribute to insulin resistance, ultimately leading to stress hyperglycaemia. Hence, patients are advised to never omit their insulin (especially basal long-acting insulin) even if there is a reduction in dietary intake
name: She should continue her long-acting insulin during sickness
label: a
answer: yes
explanation: When administering insulin, patients are advised to inject it at a different spot each time to prevent lipohypertrophy
name: She should inject insulin at the same spot each time
label: b
answer: no

Correct answer: a
Case presentation: A 30-year-old man attends the psychiatric clinic for his medication review. He was diagnosed with schizophrenia three month ago and has been taking anti-psychotic and cognitive behavioural therapy. His symptoms have improved but he wishes to stop taking the medication because it is giving him continuous spasms and muscle contractions that greatly affect his daily living.  

DH: Chlorpromazine hydrochloride 25mg PO thrice daily
SH: Works as a carpenter, lives alone
The patient is advised to switch his current treatment regime to olanzapine 10mg PO daily under the supervision of his psychiatrist.

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

Options:
explanation: If patients have forgotten to take a dose, they should take the missed dose as soon as they remember. However, if it is almost time for them to take the next dose, they should skip the missed dose and take the next dose as usual. They should not take a double dose to make up the missed dose
name: If he forgets to take a dose of olanzapine, he should take a double dose to compensate for the forgotten dose
label: e
answer: no
explanation: Agranulocytosis is an uncommon but potentially fatal side effect of olanzapine
name: Agranulocytosis is a common side effect of olanzapine
label: d
answer: no
explanation: It is mandatory for all the patients taking clozapine, not olanzapine, to be registered with the patient monitoring service. The service provides centralised monitoring of leucocyte and neutrophil counts in order to manage the risk of agranulocytosis associated with clozapine
name: He will be registered with the patient monitoring service set up by the drug manufacturer
label: b
answer: no
explanation: Increased appetite leading to weight gain is a common side effect of olanzapine. Hence, it is recommended to measure blood lipids and weight at baseline, every 3 months for the first year and then yearly for all the patients taking olanzapine
name: Olanzapine can increase appetite and lead to weight gain
label: a
answer: yes
explanation: Olanzapine is linked to eosinophilia rather than low eosinophil counts
name: Olanzapine can cause low eosinophil count
label: c
answer: no

Correct answer: a
Case presentation: A 32-year-old man attends the psychiatric clinic to discuss the long-term treatment of his bipolar disorder. He had an episode of mania two months ago but his condition is now under good control with combination of anti-psychotic and cognitive behavioural therapy.  

DH: Olanzapine 15mg PO OD
SH: Works as a baker, lives with family
The patient is advised to commence long-term treatment with lithium to prevent relapse.

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

Options:
explanation: Coarse tremor and polyuria are examples of symptoms and signs of toxicity. Patients should contact their doctors immediately if they experience any signs suggestive of lithium toxicity
name: It is normal to experience frequent urination and coarse tremor during the course of treatment
label: d
answer: no
explanation: It is recommended by the manufacturer to assess renal, cardiac and thyroid functions before the treatment. Lithium does not commonly affect the lungs or cause respiratory problems. Hence, chest x-ray is not required before the commencement of treatment
name: He will need to take a chest x-ray before starting his medication
label: b
answer: no
explanation: Patients should refrain from dietary changes which reduce or increase sodium intake so that the lithium levels will not go deranged
name: He should go on a low salt diet to reduce the risk of lithium toxicity
label: e
answer: no
explanation: Lithium has a narrow therapeutic/ toxic ratio, hence it is important to ensure that the level stays within the safe range. Routine serum-lithium monitoring is done weekly after initiation and then 3-monthly for the first year when the levels have become stable. The test needs to be performed every 6 months after that and not only when lithium toxicity is suspected
name: Blood tests for lithium levels only need to be done if lithium toxicity is suspected
label: c
answer: no
explanation: Lithium functions as a mood stabiliser. It is important to highlight to patients that lithium can leave a metallic taste in mouth so that they would not treat it as a symptom of toxicity and stop taking the drug
name: Lithium can leave a metallic taste in mouth
label: a
answer: yes

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: 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: 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
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: Haemolytic anaemia is a rare side effect of carbimazole
name: Haemolytic anaemia is a common side effect of carbimazole
label: e
answer: no
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

Correct answer: a
Case presentation: A 34-year-old woman attends the emergency department with abdominal pain, dysuria and rigors.


**Observations**

* Heart rate: 84 bpm
* Respiratory rate: 14
* Blood pressure: 111/84 mmHg
* Temperature: 38.2 degrees celsius
* Oxygen saturations: 97% on room air

**PH**
Chronic kidney disease stage II

**DH**
Nil

**Investigations**
Urine dip:

* Nitrates ++
* White blood cells ++
* Red blood cells -

Urine pregnancy test -ve

It is decided based on her presentation she has pyelonephritis, and she is due to be commenced on IV gentamicin. She is expected to be on antibiotics for a number of days. She has been reading about gentamicin online, and has some concerns given her past medical history.

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

Options:
explanation: Gentamicin can cause drug induced nephrotoxicity. In patients with CKD however it is safe to use if it is used in the short term or at a reduced dosage. Gentamicin is thought to mainly contribute to a reduction in renal function in part due to apoptosis of proximal convoluted tubule cells.
name: Although this drug can cause acute kidney injury, it is safe to use in patients with chronic kidney disease
label: a
answer: yes
explanation: The frequency of vertigo occurring as a result of gentamicin treatment is unknown, therefore it is not something the patient needs to be told is likely to occur.
name: She is likely to experience vertigo when taking gentamicin
label: b
answer: no
explanation: Thyroid function is not routinely monitored in patients taking gentamicin.
name: She will need to have her thyroid function regularly monitored
label: c
answer: no
explanation: Hallucinations are a very rare side effect of enteral use of gentamicin.
name: She should report any hallucinations she experiences
label: d
answer: no
explanation: Depression is a very rare side effect of gentamicin.
name: She is likely to experience changes to her mood when on gentamicin
label: e
answer: no

Correct answer: a
Case presentation: A 68-year-old man attends the emergency  with jaw pain. He mentions that he has found it difficult to chew and the side of his head is sore to touch.



**PH** Hypertension, hypercholesterolaemia

**DH** Ramipril 10mg PO OD, amlodipine 10mg PO OD, atorvastatin 20mg PO OD

**Investigations** ESR 42 mm/hr (1-13 mm/hr)

It is decided that this gentleman likely has giant cell arteritis and he is promptly started on 40mg prednisolone PO OD.

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

Options:
explanation: Hepatic monitoring is not routinely performed for patients taking prednisolone.
name: He will need regular hepatic function monitoring whilst taking prednisolone
label: d
answer: no
explanation: Height and weight are monitored in paediatric patients taking prednisolone not adult patients. Weight may be monitored in adult patients as weight gain is a common side effect of steroid use.
name: His height and weight should be monitored whilst taking prednisolone
label: c
answer: no
explanation: Hyperhydrosis is a uncommon side effect of corticosteroid use therefore it is not likely that this patient will experience this.
name: He is likely to experience excess sweating
label: b
answer: no
explanation: Vertigo is a uncommon side effect of corticosteroid use therefore it is not likely that this patient will experience this.
name: He is likely to experience vertigo when taking prednisolone
label: e
answer: no
explanation: Prednisolone treatment for GCA occurs at high doses and can last a very long time, in some cases as long as two years. With prolonged use there is likely to be adrenal suppression, if there is abrupt withdrawal this can lead to acute adrenal insufficiency, hypotension and even death. A tapering regime in which the corticosteroid dose is slowly reduced over time is preferred due to this.
name: He should not abruptly stop taking his prednisolone
label: a
answer: yes

Correct answer: a
Case Presentation: A 70-year-old man was admitted to the respiratory ward two days ago following a recent chest infection. PMH Community acquired pneumonia, Mild COPD, TB, Diabetic foot infection. DH His current regular medicines are listed (below).


On examination
There is visible yellowing of his sclera and evidence of pruritus on his arm.
Investigation

||||
|---------------------------|:-------:|--------------------|
|Alanine Aminotransferase (ALT)|150 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|50 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|450 IU/L|25 - 115|
|Bilirubin|60 µmol/L|< 17|
|Gamma Glutamyl Transferase (GGT)|50 U/L|9 - 40|


Question: Select the prescription that is most likely to contribute to his cholestatic jaundice.

Options:
explanation: Ipratroprium bromide does not commonly cause cholestatic jaundice
name: Ipratroprium bromide 40 micrograms INH TDS
label: d
answer: no
explanation: Salbutamol does not commonly cause cholestatic jaundice
name: Salbutamol 200 micrograms INH QDS
label: e
answer: no
explanation: Clindamycin does not commonly cause cholestatic jaundice
name: Clindamycin 300mg QDS PO
label: c
answer: no
explanation: Clarithyomycin does not cause cholestatic jaundice
name: Clarithromycin 500mg BD PO
label: a
answer: no
explanation: Fusidic acid is associated with elevated liver enzymes, hyperbilirubinaemia and jaundice with systemic use. These effects are usually reversible following withdrawal of therapy.
name: Fusidic acid  250mg BD PO
label: b
answer: yes

Correct answer: b
Case Presentation: A 75-year-old man was admitted to the Care of the Elderly Ward following a urinary tract infection 3 days ago. A day after his admission, he felt nauseous and vomited twice in the morning. There was no blood noted in the vomitus. He was prescribed a medication for symptomatic relief of his nausea and vomiting by the on call doctor. However, on the next day, he started experiencing visual hallucinations. PMH Lewy Body Dementia. DH Rivastigmine, Levodopa.


Question: Select the prescription that is most likely to contribute to his visual hallucinations.

Options:
explanation: Cyclizine does not commonly cause visual hallucinations
name: Cyclizine 50mg PO TDS
label: d
answer: no
explanation: Selegiline would not be prescribed for nausea and vomiting, and does not commonly cause visual hallucinations
name: Selegiline hydrochloride 5mg PO OD
label: b
answer: no
explanation: Haloperidol exert its anti-emetic effect by blocking central dopamine receptors in the chemoreceptor trigger zone in the brain. Its inhibition on D2 receptors, in particular, can worsen the symptoms of LBD as patients with LBD has increased neuroleptic sensitivity and when given typical antipsychotics like haloperidol, they can experience worsening hallucination, cognition and increased parkinsonism
name: Haloperidol 5mg PO BD
label: a
answer: yes
explanation: Ondansetron does not commonly cause visual hallucinations
name: Ondansetron 8mg PO BD
label: e
answer: no
explanation: Clozapine would not be prescribed for nausea and vomiting, and does not commonly cause visual hallucinations
name: Clozapine 12.5mg PO OD
label: c
answer: no

Correct answer: a
Case Presentation: A 5-year-old boy was brought in to the GP three days ago by his parents following a cough and sore throat that has been present for the past 4 days. On examination, he was pyrexic with a temperature of 38.5oC, his cervical lymph nodes were tender and swollen. He was prescribed antibiotics by the GP who then provided the parents with safety-netting advice. Today, he re-attended the GP with a widespread, itchy, macular papular rash that developed this morning. PMH Atopic eczema, Asthma. DH His current regular medicines are listed (below).


Question: Select the prescription that is most likely to contribute to his rash.

Options:
explanation: Dermol cream does not commonly cause rash
name: Dermol cream TOP OD
label: d
answer: no
explanation: Salbutamol does not commonly cause rash
name: Salbutamol 2 puff PRN INH
label: b
answer: no
explanation: Hydrocortisone does not commonly cause rash
name: Hydrocortisone 0.5% cream TOP BD
label: e
answer: no
explanation: Fluticasone does not commonly cause rash
name: Fluticasone 50 micrograms BD INH
label: c
answer: no
explanation: Prescribing amoxicillin in patients presenting with infectious mononucleosis can result in a widespread maculopapular rash. Drug induced maculopapular eruptions are due to delayed type hypersensitivity reactions and these eruptions are enhanced by viral infections such as EBV, possibly due to molecular mimicry between amoxicillin and viral molecules, inducing a loss of tolerance state towards amoxicillin and a transient immune reaction
name: Amoxicillin 500mg PO TDS
label: a
answer: yes

Correct answer: a
Case Presentation: A 45 year old man was admitted following an episode of productive cough and fever. Sputum culture was positive for Pseudomonas Aeruginosa, sensitive to ciprofloxacin and gentamicin. He had completed a 6 day course of gentamicin during his admission and has clinically improved since. He will be discharged with a 14 day course of 750mg BD ciprofloxacin.


Question: Select the adverse effect that is most likely to be caused by this treatment.

Options:
explanation: Ciprofloxacin does not commonly cause symptoms of reflux
name: Reflux
label: c
answer: no
explanation: Ciprofloxacin does not commonly cause ototoxicity
name: Ototoxicity
label: d
answer: no
explanation: Ciprofloxacin does not commonly cause optic neuritis
name: Optic neuritis
label: e
answer: no
explanation: Ciprofloxacin is the only oral antibiotic available for pseudomonal infection. Along with other antibiotic classes such as cephalosporins, penicillins and clindamycin, it is commonly associated with causing C difficile diarrhoea due to its destructive effect on the gut flora, allowing C difficile to grow out of control, leading to C. difficile infections and diarrhoea
name: Diarrhoea
label: a
answer: yes
explanation: Ciprofloxacin does not commonly cause cholestatic hepatitis
name: Cholestatic hepatitis
label: b
answer: no

Correct answer: a
Case presentation: A 60-year-old man visits his GP for medication review. He complains of a recent-onset persistent dry cough but denies having fever or any coryzal symptoms. The cough is not worse when lying down. The patient is not a smoker and the cough only happened after he started on a new prescription.  

PMH: Diabetes Mellitus, Hypertension, Depression
DH: Metformin 500 mg PO TDS, Lisinopril 20 mg PO OD, Sertraline 50 mg PO OD
Observations: Temperature 36.5, Respiratory rate 12, Blood pressure 125/85, Heart rate 78
On Examination: Chest is clear with no added sounds. HS I+II+0.

Question: Select the most appropriate option for the management of the adverse drug reaction.

Options:
explanation: Captopril is another example of ACE-i and so is unlikely to help with the dry cough
name: Stop lisinopril in exchange for captopril 25 mg PO twice daily
label: c
answer: no
explanation: Metformin is not known to cause dry cough
name: Stop metformin hydrochloride in exchange for gliclazide 40 mg PO once daily
label: b
answer: no
explanation: Lisinopril is an angiotensin converting enzyme inhibitor (ACE-I) that is used as a first line antihypertensive for patients with type 2 diabetes mellitus. Dry cough is a common or very common side effect of ACE-I. The mechanism of action is believed to be related to a decrease in degradation and subsequently an increase in buildup of bradykinin. NICE guidance recommends for an angiotensin receptor block (ARB), for example losartan potassium, to be offered if ACE-i is not tolerated
name: Stop lisinopril in exchange for losartan potassium 50 mg PO once daily
label: a
answer: yes
explanation: Sertraline is not known to cause dry cough. Amoxicillin is not required because the dry cough is less likely to be caused by infection in view of the clinical picture described
name: Stop sertraline and commence treatment with amoxicillin 500 mg PO three times daily
label: e
answer: no
explanation: Sertraline is not known to cause dry cough
name: Stop sertraline in exchange for citalopram 20 mg PO once daily
label: d
answer: no

Correct answer: a
Case Presentation: A 67-year-old man attends GP for follow-up after discharge from hospital following a crescendo TIA. His medications are listed on the right. He is discharged on dual antiplatelet therapy for 90 days.  


**PMH**

* Stroke
* Hypertension
* Hyperlipidaemia
* GORD

**On examination**

* Chest: Clear, RR 18
* HS: S1 S2 + no added sounds

Question: Which of the following medications should the GP consider stopping due to an adverse drug reaction to clopidogrel?

Options:
explanation: Ramipril is an angiotensin-converting enzyme inhibitor used to treat hypertension. It is not known to interact with clopidogrel.
name: Ramipril 5mg OD
label: b
answer: no
explanation: Amlopidine is a calcium channel blocker used to treat hypertension. It is not known to interact with clopidogrel.
name: Amlodipine 10mg OD
label: c
answer: no
explanation: Simvastatin is used to treat hypercholesterolaemia and reduce the risk of ischaemic events. Simvastatin is not known to interact with clopidogrel.
name: Simvastatin  40mg OD
label: d
answer: no
explanation: Aspirin is an anti-platelet used in conjunction with clopidogrel in dual antiplatelet therapy. Although used together there is an increased risk of bleeding, the benefits in preventing atherothrombotic events outweigh this risk when used short-term following high-risk TIAs.
name: Aspirin 75mg OD
label: e
answer: no
explanation: Esomeprazole is a proton pump inhibitor used to treat gastro-oesophageal reflux disease. Esomeprazole has been shown to decrease the efficacy of clopidogrel. Alternatives to esomeprazole such as H2 receptor antagonists should be considered.
name: Esomeprazole 40mg BD
label: a
answer: yes

Correct answer: a