hllj/quesmed huggingface dataset:
Case presentation: A 65-year-old man on the urology ward underwent a left-sided nephrectomy 2 days ago. Since the surgery, he had not been able to open his bowels. PH Benign prostatic hyperplasia, Osteoarthritis of left knee, Giant cell arteritis, mild hayfever, Back pain. DH His current regular medicines are listed (below).


**On Examination**
HR 84/min regular rhythm, BP 130/80 mmHg, symmetrical bipedal pitting oedema to mid calves

Question 1: Select the THREE prescriptions that are most likely to be contributing to his constipation (mark them with a tick in column A).
Question 2: Select the ONE prescription that is most likely to be contributing to his fluid retention (mark it with a tick in column B).

Options:
name: Ibuprofen;400mg micrograms;oral (PO);PRN
label: c
answer: no
name: Cetirizine;10mg;oral (PO);PRN
label: d
answer: no
name: Tramadol hydrochloride;100mg;oral (PO);6-hourly
label: b
answer: no
name: Morphine sulphate;10mg;intravenous (IV);6- hourly
label: h
answer: no
name: Paracetamol;1g;oral (PO);6-hourly
label: f
answer: no
name: Ondansetron;4mg;intravenous (IV);Daily
label: g
answer: no
name: Tamsulosin;400 micrograms;oral (PO);Daily
label: e
answer: no
name: Prednisolone;10mg;oral (PO);Daily
label: a
answer: no


1. Opioids (tramadol and morphine sulphate) act on 𝜇-opioid receptors in the myenteric plexus to slow down bowel movements, which can lead to constipation. Ondansetron commonly causes constipation by delaying the colonic transit although the exact mechanism remains unclear. Cetirizine, tamsulosin and ibuprofen rarely cause constipation.
2. Systemic corticosteroids (prednisolone) commonly cause fluid retention via the stimulation of mineralocorticoid receptors, which lead to sodium and water retention.
Case presentation: A 75-year-old man is admitted to the care of the elderly ward following a urinary tract infection. PH Hypertension, Alzheimer’s Disease, BPH, Osteoarthritis, Severe anxiety. DH. His current regular medications are listed (below).




 **On Examination**

HR 50/min regular, BP 135/75mmHg. He appears confused.


 **Investigation**


||||
|---------------------------|:-------:|--------------------|
|Urea|8.5 mmol/L|2.5 - 7.8|
|Creatinine|125 µmol/L|60 - 120|


Question 1: Select the THREE prescriptions that are most likely to be contributing to his confusion (mark them with a tick in column A)

Question 2: Select the ONE prescriptions that are most likely to be a cause of his bradycardia (mark them with a tick in column B).

Options:
name: Acebutolol;400mg;oral (PO);12-hourly
label: d
answer: no
name: Diazepam;2mg;oral (PO);8-hourly
label: i
answer: no
name: Indapamide;1.5mg;oral (PO);Daily
label: c
answer: no
name: Amlodipine;10mg;oral (PO);Daily
label: a
answer: no
name: Ramipril;2.5mg;oral (PO);Daily
label: b
answer: no
name: Co-codamol 8-500mg;1 tablet;oral (PO);6-hourly
label: h
answer: no
name: Tamsulosin;400micrograms;oral (PO);Daily
label: e
answer: no
name: Omeprazole;40mg;oral (PO);Daily
label: g
answer: no
name: Dexibuprofen;200mg;oral (PO);8-hourly
label: f
answer: no


1. The patient has developed AKI, which can result in a reduction in the clearance of his medication and an increase in adverse effects. The mechanism for confusion caused by benzodiazepine and codeine remains unknown, although the incidence is noted to be higher in the elderly population and in patient with decreased renal function due to a reduction in the clearance of the medication. Similarly, in geriatric patients, the bioavailability of acebutolol and its metabolite increases approximately by two-fold, due to the decrease in first pass metabolism and renal function in the elderly. Retention of codeine (co-codamol), diazepam and acebutolol in this patient may contribute to the patient’s confusion
2. Acebutolol is a cardio-selective beta-adrenergic antagonist, which acts on the beta-1 receptors in the heart causing a reduction in heart rate and contractility. Ramipril can cause arrythmia but acebutolol, specifically, causes bradycardia.
Case presentation: A 65-year old man is admitted to the geriatric ward following a fall at home. He complains of generalised muscle weakness and lethargy.  


PH: Congestive heart failure, Diabetes Mellitus , Gout, Hypercholesterolaemia, Insomnia 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.


 **Vital signs**: BP 122/78, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18


 **Investigations**:


 - ECG: Flat P wave and tall tented T wave


||||
|--------------|:-------:|---------------|
|Haemoglobin|135   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|280x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|91 fL|80 - 96|
|Neutrophils|5x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|2x10<sup>9</sup>/L|1.5 - 4.0|
|Sodium|140 mmol/L|135 - 145|
|Potassium|6.1 mmol/L|3.5 - 5.3|
|Urea|7 mmol/L|2.5 - 7.8|
|Creatinine|280 µmol/L|60 - 120|



Question 1: Select the TWO prescriptions that are most likely to be a cause of his hyperkalaemia (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: Simvastatin;40mg;Oral (PO);Nightly
label: e
answer: no
name: Zopiclone;3.75mg;Oral (PO);Nightly as required
label: h
answer: no
name: Bisoprolol fumarate;5mg;Oral (PO);Daily
label: a
answer: no
name: Spironolactone;25mg;Oral (PO);Daily
label: c
answer: no
name: Allopurinol;900mg;Oral (PO);Daily
label: d
answer: no
name: Enalapril maleate;10mg;Oral (PO);Twice daily
label: b
answer: no
name: Metformin hydrochloride;500 mg;Oral (PO);Three times daily
label: f
answer: no
name: Gliclazide;40mg;Oral (PO);Daily
label: g
answer: no


1. Both enalapril and spironolactone are known to cause hyperkalaemia. Enalapril is an angiotensin-converting enzyme inhibitor (ACE-i). It contributes to hyperkalaemia by inhibiting aldosterone synthesis. Spironolactone is an aldosterone antagonist. Aldosterone mediates the reabsorption of sodium and excretion of potassium in the distal tubules and collecting ducts of nephrons.
2. Up to 900mg of allopurinol can be prescribed in a day but must be done in divided doses. The maximum per dose is 300mg.
Case presentation: A 75-year old man attends the Parkinson clinic with increasing frequencies of involuntary movement. PH: Parkinson’s disease, Atrial fibrillation, Congestive Heart Failure, Migraine, Schizophrenia DH: His current regular prescriptions are listed below


**On examination**: Pill-rolling resting tremor seen on right hand, cog-wheel rigidity, bradykinesia, micrographia
**Vital signs**: BP 122/78, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18

Question 1: Select the TWO prescriptions that are most likely to be a cause for the worsening of his Parkinson’s signs and symptoms? (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: Prochlorperazine;75mg;Oral (PO);Daily
label: h
answer: no
name: Metoclopramide hydrochloride;10mg;Oral (PO);8-hourly when required
label: g
answer: no
name: Digoxin;187.5mg;Oral (PO);Daily
label: e
answer: no
name: Co-careldopa;125mg;Oral (PO);8-hourly
label: a
answer: no
name: Enalapril maleate;10mg;Oral (PO);12-hourly
label: b
answer: no
name: Ibuprofen;400mg;Oral (PO);6-hourly when required
label: f
answer: no
name: Rivaroxaban;20mg;Oral (PO);Daily
label: c
answer: no
name: Carvedilol;3.125mg;Oral (PO);12-hourly
label: d
answer: no


1. Both metoclopramide and prochlorperazine are dopamine D2 receptor antagonists that can precipitate and worsen parkinsonian symptoms. Hence, BNF advises that they should be used with caution in patients already diagnosed with Parkinson’s disease.
2. The maintenance dose of digoxin for atrial fibrillation is 125–250 micrograms daily. Hence, the dose prescribed is likely to be a transcription error of the micrograms to mg.
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: Furosemide;40mg;PO (Oral);Once daily
label: f
answer: no
name: Alendronic Acid;70mg;PO (Oral);Once weekly
label: a
answer: no
name: Ramipril;10mg;PO (Oral);Once daily
label: b
answer: no
name: Movicol;1 Sachet;PO (Oral);Once daily
label: h
answer: no
name: Amlodipine;5mg;PO (Oral);Once daily
label: c
answer: no
name: Paracetamol;1g;PO (Oral);Six times daily
label: i
answer: no
name: Cholecalciferol;400 units;PO (Oral);Once daily
label: g
answer: no
name: Mirtazapine;45mg;PO (Oral);Nightly
label: d
answer: no
name: Diazepam;5mg;PO (Oral);Once daily
label: e
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 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: Fluticasone;50 micrograms, one application per nostril; intranasal;OD
label: h
answer: no
name: Nifedipine;10mg;PO;TDS
label: c
answer: no
name: Paracetamol;1g;PO;QDS
label: a
answer: no
name: Carbamazepine;4g;PO;BD
label: g
answer: no
name: Cetirizine;10mg;PO;OD
label: b
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: Fluticasone;500 micrograms;INH;BD
label: i
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 68-year-old man is recovering following an elective coronary artery bypass graft (CABG) procedure. Post-operatively, he has acute kidney injury (see investigations below) and has not passed urine for 13-hours.




 **PH** Ischaemic heart disease, Angina, Hypercholesterolaemia, Osteoarthritis, GORD, Hypertension


 **DH** His current regular medicines are listed (below).
Allergies - aspirin, ramipril


 **Investigations**
Cr 156 µmol/L (60-120 µmol/L), baseline 80 µmol/L


Question 1: Select the ONE prescription that should be stopped one week prior to his operation (mark them with a tick in column A)
Question 2: Select the TWO prescriptions that should be withheld until his renal function improves. (mark it with a tick in column B).

Options:
name: Candesartan;8mg;oral (PO);Daily
label: d
answer: no
name: Amlodepine;5mg;oral (PO);Daily
label: f
answer: no
name: Clopidogrel;75mg;oral (PO);Daily
label: c
answer: no
name: Ibuprofen;400mg;oral (PO);TDS
label: g
answer: no
name: Paracetamol;500mg;oral (PO);PRN
label: e
answer: no
name: Atorvastatin;80mg;oral (PO);Daily
label: b
answer: no
name: Omeprazole;30mg;oral;(PO) Daily
label: h
answer: no
name: GTN;400mcg;sublingual (SL);PRN
label: a
answer: no


1. NICE guidelines advise that clopidogrel should be stopped 7 days prior to surgical procedures
2. NSAIDs and Angiotensin receptor blockers may lead to the worsening of renal function and hence, should be stopped during an AKI.
Case Presentation: A 53 year old woman who has recently moved to the UK from Vietnam attends an appointment for initial assessment after registering at her new GP. **PH** Takayasu arteritis, hypertension, generalised anxiety disorder. **DH** felodipine 10mg PO OD, escitalopram 15mg PO OD, ferrous fumarate 210mg PO BD, calcichew D3.


**O/E**

HR 86, RR 14, BP 134/92, Temperature 37.0°C, O2 99% RA. HS I + II + 0, lungs clear. Alert and comfortable at rest. She has an irregularly irregular pulse peripherally and centrally. This is not recorded on her most recent health documentation from her home country a year prior and she denies any troublesome symptoms.

**Investigations**

ECG: atrial fibrillation.

FBC, U&Es, LFTs and clotting studies all NAD.

Question: Select the most appropriate management at this stage.

Options:
explanation: This would be correct if the patient was presenting with unstable AF causing haemodynamic compromise. However there is nothing in the stem to suggest that this is the case
name: Make an urgent referral to A&E for synchronised DC cardioversion
label: b
answer: no
explanation: As the patient has AF and a CHA₂DS₂-VASc of 2, anticoagulation should be initiated to lower the risk of a cerebrovascular event
name: Start rivaroxaban 20mg OD
label: a
answer: yes
explanation: There is no role for aspirin in the management of AF absent some cerebrovascular event
name: Start aspirin 75mg PO OD
label: c
answer: no
explanation: This would be a possible option as a ‘pill in pocket’ strategy if the patient had paroxysmal AF. However there is nothing in the stem to suggest that this is the case
name: Start flecainide acetate 50mg PO BD
label: e
answer: no
explanation: This would be a possible option in rate-controlling fast AF or to manage symptoms such as palpitations
name: Start bisoprolol fumarate 5mg PO OD
label: d
answer: no

Correct answer: a
Case Presentation: A 26 year old woman is admitted to the maternity ward following induction of labour 12 hours previously. She is G2P1 and has no outstanding health problems, but is known to have swabbed positive for group B streptococcus during her initial booking appointment for her current pregnancy. NKDA


**O/E**

HR 94, RR 15, BP 132/82. Cervix dilated to 4cm, foetal head engaged. Contractions 1 in 10 minutes.

**Investigations**

Cardiotocography is reassuring.

Question: Select the most appropriate management at this stage.

Options:
explanation: Clindamycin has historically been used to treat GBS but due to increasing resistance, it is recommended that sensitivities be performed before its use
name: Clindamycin 300mg IV
label: e
answer: no
explanation: All mothers who have swabbed positive for GBS should receive intrapartum antibiotics to reduce the risk of neonatal sepsis. Benzylpenicillin sodium is recommended first line
name: Benzylpenicillin sodium 3g IV
label: a
answer: yes
explanation: This formulation of benzylpenicillin is used to treat syphilis rather than GBS
name: Benzathine benzylpenicillin 2.4m units IM
label: c
answer: no
explanation: Ceftriaxone has activity against GBS but has a much broader spectrum of activity than would normally be required
name: Ceftriaxone 2g IV
label: d
answer: no
explanation: Amoxicillin has activity against GBS but has a much broader spectrum of activity than would normally be required
name: Amoxicillin 500mg IV
label: b
answer: no

Correct answer: a
Case Presentation: A 19 year old man attends a follow-up appointment at his GP. **PH** acne vulgaris. **DH** 3% benzoyl peroxide with 1% clindamycin gel (Duac). He has been using this for twelve weeks following failure to improve his condition with benzoyl peroxide gel alone.


**O/E**

He has a uniform distribution of open and closed comedones with occasional pustules on his face and upper back. No scarring or nodularity present.

Question: Select the most appropriate management at this stage.

Options:
explanation: This is an alternative oral antibiotic agent used to treat acne vulgaris where first line oral treatments are unsuitable
name: Erythromycin 500mg PO BD
label: c
answer: no
explanation: Tetracyclines are recommended as first line oral agents to treat acne vulgaris that has not responded to topical treatments. NICE recommends combination therapy (as opposed to antibiotic monotherapy), with topical azelaic acid.
name: Topical azelaic acid and Doxycycline 100mg PO OD
label: a
answer: yes
explanation: This is an alternative oral antibiotic agent used to treat acne vulgaris where first line oral treatments are unsuitable
name: Trimethoprim 300mg PO BD
label: e
answer: no
explanation: Isotretinoin is a retinoid medication used to treat severe acne vulgaris. It should not be prescribed in the primary care setting without specialist assessment
name: Isotretinoin 20mg PO BD
label: d
answer: no
explanation: This is an alternative topical treatment for acne vulgaris which is less effective than the treatment that the patient is currently using
name: Azelaic acid 20% cream (Skinoren) topical BD
label: b
answer: no

Correct answer: a
Case Presentation: A 39 year old woman attends her GP for a routine diabetic review. **PH** type 1 diabetes, hypothyroidism, Addison’s disease. **DH** soluble insulin (Humulin S) 10-12 units SC TDS with meals, insulin detemir (Levemir) 16 units SC ON, levothyroxine sodium 125 micrograms PO OD, hydrocortisone 20mg PO in the morning and 10mg PO in the evening. NKDA


**O/E**

HR 71, RR 11, BP 134/82, O2 100% RA, Temperature 36.6°C. HS I + II + 0. Chest clear. Vitiliginous patches on hands. Visual acuity and colour vision grossly normal.

**Investigations**

TSH: 1.2 (0.4-5.5)

HbA1c: 46 (target <48)

ECG: normal sinus rhythm

Urine dipstick:

Blood -ve

Nitrites -ve

Protein +1

Leucocytes -ve

A:Cr ratio: 3 mg/mmol

Question: Select the most appropriate management at this stage.

Options:
explanation: As there is evidence of nephropathy in this patient, she should be started on a renoprotective agent pending a repeat urine dip and/or confirmation of end-organ damage
name: Start lisinopril 2.5mg PO OD
label: a
answer: yes
explanation: Without a blood sugar diary to monitor for labile BMs, it is inadvisable to make changes to a patient’s daily insulin regimen
name: Switch her insulin regime to a biphasic preparation e.g 30% insulin lispro/70% insulin aspart (Novomix 30)
label: e
answer: no
explanation: As the patient’s TSH level is normal and she is not complaining of any symptoms indicative of undertreating her hypothyroidism, this is not a necessary course of action
name: Increase dose of levothyroxine sodium to 150 micrograms PO OD
label: b
answer: no
explanation: Without a blood sugar diary to monitor for labile BMs, it is inadvisable to make changes to a patient’s daily insulin regimen
name: Increase nightly insulin detemir to 20 units
label: c
answer: no
explanation: This is an unlicensed treatment for vitiligo and may be prescribed off-label by experienced clinicians
name: Start tacrolimus 0.1% ointment topical BD
label: d
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 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
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

Correct answer: a