hllj/quesmed huggingface dataset:
A 25-year-old woman, eight days postpartum after an uncomplicated vaginal delivery, presents with lower abdominal pain, heavy lochia (using 1-2 pads/hour), and nausea, expressing concern about the thickness of her discharge.



On examination, her abdomen is soft, uterus normally involuted, with tenderness in the lower abdomen.




A gentle speculum examination reveals copious thick bloody discharge, with an offensive smell.



Her observations are: heart rate 122 bpm, blood pressure 110/76 mmHg, respiratory rate 16 breaths/min, oxygen saturation 100% on room air, and temperature 37.1°C.  



Her full blood count test results are as follows:



||||
|--------------|:-------:|---------------|
|Haemoglobin|79 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|16.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|402x10<sup>9</sup>/L|150 - 400|




What is the most likely source of her vaginal bleeding?

Options:
explanation: Retained products of conception (RPOC) refer to the persistence of pregnancy tissues in the uterus following delivery. This can lead to endometritis and may or may not require treatment.
name: Retained products of conception
label: b
answer: no
explanation: Whilst the scenario suggests this woman had a perineal tear that required suturing, this is a less likely cause for secondary postpartum haemorrhage. Perineal tears can become infected, however would be unlikely to cause abdominal pain and nausea.
name: Perineal infection
label: c
answer: no
explanation: Abnormal involution of the placental site is a rare cause of secondary postpartum haemorrhage and describes the abnormal persistence of patent spiral arteries following delivery. This can present with profuse secondary postpartum haemorrhage.
name: Abnormal involution of the placental site
label: e
answer: no
explanation: Retained products of conception (RPOC) refer to the persistence of pregnancy tissues in the uterus following delivery. This can lead to endometritis and may or may not require treatment.
name: Normal lochia
label: d
answer: no
explanation: Endometritis is the most common cause of secondary postpartum haemorrhage, and typically presents between 2 and 10 days postpartum
name: Endometritis
label: a
answer: yes

Correct answer: a

Endometritis
A 44-year-old woman attends her general practitioner troubled by recent heavy periods. She describes her cycle as a regular 40-day cycle, with 7-10 days of bleeding. She has a progestogen-only implant as contraception, and has no past medical history of note.

Her smear tests are up to date, and she has no concerns about sexually transmitted infection.

What is the most appropriate management?

Options:
explanation: Transvaginal ultrasound scan should be requested for cases of new menorrhagia, looking for underlying causes such as fibroids or polyps. In this age group, fibroids are the most common cause of menorrhagia.
name: Refer for a transvaginal ultrasound scan
label: a
answer: yes
explanation: Mirena coil is licensed for management of heavy menstrual bleeding, however it is important to rule out pathology first.
name: Insertion of a Mirena coil
label: b
answer: no
explanation: Whilst the contraceptive implant can cause prolonged bleeding, this is a less likely underlying reason for new menorrhagia.
name: Removal of the progestogen-only subdermal implant
label: e
answer: no
explanation: An endometrial biopsy may be indicated if the transvaginal ultrasound shows a thickened endometrium, however the first-line investigation is an ultrasound.
name: Endometrial biopsy
label: c
answer: no
explanation: Tranexamic acid can be used for management of menorrhagia, however it is important to investigate for underlying pathology with a transvaginal ultrasound scan.
name: Tranexamic acid
label: d
answer: no

Correct answer: a
A 35-year-old woman attends her general practitioner with difficulties during penetrative sex. She describes painful penetration, which feels superficial. In addition, she states her vulva is always itchy, and she has used several over the counter thrush remedies without resolution of symptoms.

She had a spontaneous vaginal delivery two years ago, and has a past medical history of asthma which is treated with an inhaled corticosteroid inhaler.

On examination, her vulva generally appears pale, with some fissuring around the introitus. The clitoris is not visible. Digital vaginal examination is painful, and a gentle speculum examination reveals a normal vaginal mucosa with a thin, white non-odorous discharge present.

What is the most likely underlying cause of her symptoms?

Options:
explanation: Vulvovaginal candidiasis is one of the most common causes of vaginal itch, however does not typically cause changes in the architecture of the vulva. With vulvovaginal candidiasis, a thick, lumpy discharge is usually evident.
name: Vulvovaginal candiasis
label: e
answer: no
explanation: Lichen sclerosus is an inflammatory skin condition that presents with itch and soreness. The tissues can lose their normal architecture, the introitus can become narrowed, and the labia minora and clitoral hood can become fused, burying the clitoris itself. The tissues appear pale and white, and fissuring or erosions may be evident. Lichen sclerosus is associated with other atopic conditions such as asthma and eczema.
name: Lichen sclerosus
label: a
answer: yes
explanation: Whilst premature ovarian failure can cause the vulva to appear white and atrophied, and also may cause dyspareunia, the tissues do not tend to become fused. In addition, she does not complain of any other symptoms of premature ovarian failure.
name: Premature ovarian failure
label: b
answer: no
explanation: Vaginismus occurs when the pelvic floor muscles involuntarily spasm with touch or penetration. Whilst this can cause dyspareunia, it would not cause the changes seen in the vulval skin.
name: Vaginismus
label: c
answer: no
explanation: Lichen planus presents in a similar way to lichen sclerosus; however, lichen planus involves the mucous membranes such as the vagina as well as the skin. The usual presentation is with white or purple raised plaques.

Lichen planus is characterised by the 6 Ps:

- Purple
- Pruritic (itchy)
- Polygonal (multiple sides)
- Planar (flat-topped)
- Papules/plaques
name: Lichen planus
label: d
answer: no

Correct answer: a
A 23-year-old woman attends the emergency gynaecology clinic having been referred by her general practitioner with vulval pain. On examination, there is a 1.5cm fluctuant swelling at the medial aspect of her right labia minora near
the vaginal introitus which is exquisitely tender. She has palpable superficial inguinal lymphadenopathy. There is no evidence of vaginal discharge, and the woman denies unprotected intercourse.

What is the most appropriate procedural management?

Options:
explanation: Cervical cerclage is the placement of a suture into the cervix of a pregnant woman where there is premature shortening of the cervix, with an aim to prolong gestation.
name: Cerclage
label: c
answer: no
explanation: Hymenectomy is a surgical procedure to open the hymen to allow for the passage of menstrual blood and sexual intercourse. It is often necessary for people born with an imperforate hymen, or who have a septate hymen.
name: Hymenectomy
label: d
answer: no
explanation: Deinfibulation refers to a surgical procedure to restore the vaginal introitus in women who have undergone type III female genital mutilation (infibulation, or surgical closure/narrowing of the vaginal introitus).
name: Deinfibulation
label: b
answer: no
explanation: Insertion of a balloon catheter (often referred to as a Word catheter) is one of the preferred management strategies for symptomatic Bartholin's cyst abscess. Under local anaesthesia, a stab incision is made into the labia minora, over the abscess, and the contents of the abscess drained. A balloon catheter is then inserted into the cyst cavity and the balloon inflated with 2-4mL of saline. A suture may be placed to keep the catheter in place. The catheter remains in place for up to 4 weeks to allow epithelialisation of the tract to occur.
name: Insertion of a balloon catheter
label: a
answer: yes
explanation: Vaginal ring pessaries are used for the conservative management of pelvic organ prolapse such as a cystocele or rectocele.
name: Insertion of a vaginal ring pessary
label: e
answer: no

Correct answer: a
A 23-year-old primiparous woman attends accident and emergency following a head-on car collision in which she was driving. She is currently 19 weeks pregnant. She has sustained minor bruising to the abdomen and chest from the seatbelt, but otherwise has no injuries. The foetal heart is auscultated and foetal wellbeing confirmed. There is no vaginal bleeding. The woman is reported to be rhesus negative.

What is the most appropriate management?

Options:
explanation: For potentially sensitising events after 20 weeks gestation, a minimum anti-D Ig dose of 500 IU should be administered within 72 hours of the event. A test for FMH is also required to guide further dosing.
name: Administer 500 IU anti-D Ig prophylaxis within 72 hours, and perform a test for fetomaternal haemorrhage (FMH)
label: d
answer: no
explanation: Rhesus isoimmunisation can occur when a rhesus negative mother has a baby which is rhesus positive. If any foetal red blood cells enter the maternal circulation (e.g. during birth or a "sensitising event"), the mother will form anti-D antibodies against them, which can cause rhesus haemolytic disease in the newborn.

Abdominal trauma is a potentially sensitising event. For potentially sensitising events between 12 and 20 weeks gestation, a minimum dose of 250 IU of anti-D Ig prophylaxis should be administered within 72 hours of the event.
name: Administer 250 IU anti-D Ig prophylaxis within 72 hours
label: a
answer: yes
explanation: Routine antenatal anti-D prophylaxis is indicated where a rhesus negative mother has not been sensitised. Anti-D has no effect after sensitisation has already occurred.
name: Arrange for two doses of 500IU anti-D Ig prophylaxis to be given at 28 and 34 weeks of pregnancy
label: b
answer: no
explanation: For potentially sensitising events between 12 and 20 weeks gestation, a minimum dose of 250 IU anti-D Ig prophylaxis should be administered within 72 hours of the event. A test for FMH is not required.
name: Perform a test for fetomaternal haemorrhage (FMH)
label: e
answer: no
explanation: Abdominal trauma is a potentially sensitising event, so anti-D is indicated.
name: Advise the woman to return for anti-D Ig prophylaxis only if vaginal bleeding occurs. If the pregnancy was less than 12 weeks gestation, anti-D would not be indicated unless there was repeated or heavy vaginal bleeding, or bleeding associated with abdominal pain
label: c
answer: no

Correct answer: a
A 28-year-old woman attends her general practitioner with painful periods. She describes a 7-year history of pain in her lower abdomen and back alongside her period each month. She was commenced on the combined oral contraceptive pill (COCP) six months ago and advised to take this using an extended regime, having a withdrawal bleed once every three months.

She is having trouble with breakthrough bleeding with the COCP, and is still experiencing significant pain. She is taking ibuprofen 400mg three times daily, co-codamol 30/500 two tablets four times per day, and often requires time off work due to the intensity of the pain.

What is the most appropriate next step in the management of this patient?

Options:
explanation: This is unlikely to have a significant benefit over her current regime. The management of likely endometriosis aside from analgesia aims to reduce menstrual bleeding and induce amenorrhoea.
name: Switch the co-codamol to codeine phosphate 60mg four times per day alongside paracetamol 1g four times per day
label: b
answer: no
explanation: This woman likely has endometriosis, as evidenced by the cyclical pain. Contraceptives likely to induce amenorrhoea are likely to be most beneficial in the medical management. Medroxyprogesterone acetate is likely to induce amenorrhoea, with over 70% of users amenorrhoeic after a year of use.
name: Medroxyprogesterone acetate (depo) injection
label: a
answer: yes
explanation: A copper intrauterine device can make menses heavier and more painful, therefore is not suitable for the management of dysmenorrhoea.
name: Insertion of a copper intrauterine device
label: e
answer: no
explanation: Mefenamic acid is a non-steroidal anti-inflammatory drug (NSAID). It should not be taken alongside other NSAIDs, e.g. ibuprofen.
name: Advise the addition of mefenamic acid on the days when pain is worst
label: d
answer: no
explanation: Whilst oophorectomy will induce menopause and therefore stop menstrual bleeding, surgical management of endometriosis is usually only considered where medical management has failed. In addition, it is not clear this woman's future fertility desires.
name: Bilateral oophorectomy
label: c
answer: no

Correct answer: a
Case Presentation: A 56-year-old gentleman, attends GP surgery with 3 episodes of central crushing chest pain on exertion. These have come on twice whilst walking up some stairs and once after running for a bus. The pain during each episode subsided after around 2 minutes. 



## PMH
Hyperlipidaemia
Hypertension
Obesity

## DH
Atorvastatin
Amlodipine

## On examination
He looks well at rest.

HR 90, RR 16, BP 134/92

## Investigations
ECG is normal

# Prescribing Request

Write a prescription for one drug to rapidly relieve the patient's symptoms.

Options:


## Drug choice feedback

Glyceryl Trinitrate (GTN) is a vasodilator which works to relax the vascular smooth muscle of the coronary vessels to restore blood flow to the myocardium. It is the first-line drug in the treatment of the symptoms of angina. Calcium channel blockers and beta-blockers may help reduce the frequency of angina attacks but will not relieve the symptoms of an attack as rapidly as GTN.

## Dose/Route/Frequency/Duration feedback

GTN should be prescribed as 400-800 micrograms in the form of sublingual tablets or a sublingual spray. Tablets come in 500 or 600 micrograms. A single spray is 400 micrograms and up to two sprays may be given per dose. 400, 500, 600 and 800 micrograms are therefore all acceptable doses. Dosing can also be written as 1 tablet or 1-2 sprays. Route MUST be sublingual, NOT oral. GTN should be given as and when the patient is experiencing symptoms, or before an activity known to cause angina symptoms. The frequency of use is therefore PRN.
Case Presentation: A 8-year-old boy is brought to the GP by his mother due to otalgia. This is affecting his right ear, his hearing on this side is 'muffled' according to his mother. 


## PH
Nil.

## DH
Nil. NKDA.

## On examination

Temperature 37.2°C, HR 98, RR 22, BP 111/68, O<sub>2</sub> 99% RA, GCS 15, Weight 25kg

There is a yellow, purulent discharge from his right ear.

Otoscopy: injection of blood vessels on the tympanic membrane and diffuse erythema of the mid ear. There is a small perforation in the roof of the tympanic membrane.

No neurological abnormalities detected. No signs of mastoiditis.

## Investigations

Nil

## Prescribing Request

Write a prescription for one drug that is most appropriate to treat his otitis media.

Options:


## Drug choice feedback

This patient has otitis media, this can be inferred due to the otalgia, otorrhoea and findings on examination. The first line treatment for otitis media in children is amoxicillin. If the patient has a penicillin allergy then you should prescribe clarithromycin.

## Dose/Route/Frequency/Duration feedback

The following prescription is appropriate to treat this patient's ear infection:

- Amoxicillin 500mg PO TDS 5-7 days
Case Presentation: A 67-year-old gentleman attends his GP for a blood pressure review. He had high blood pressure at a previous review and has returned with his home blood pressure monitoring.



## PH
Nil.

## DH
Nil. NKDA.

## Investigations

Blood pressure at previous visit: 151/88 mmHg

Blood pressure at today's visit: 148/90 mmHg

Home blood pressure reading average: 149/89 mmHg

## Prescribing Request

Write a prescription for one drug that is most appropriate to treat his hypertension.

Options:


## Drug choice feedback

This gentleman has hypertension. This is confirmed based on the readings at the GP and the at home readings he has measured himself. As he is older than 55 years of age, the first line medication he should be prescribed is a calcium channel blocker.

## Dose/Route/Frequency/Duration feedback

The options to treat this gentleman's hypertension are as follows:

- Amlodipine 5mg PO OD
- Felodipine 5mg PO OD
- Lacidipine 2mg PO OD
- Lercanidipine hydrochloride 10mg PO OD
- Nicardipine hydrochloride 20mg PO TDS
Case Presentation: A 4-year-old boy is brought to the GP by his mother with abdominal pain and infrequent bowel movements. He has been passing 1-2 hard stools per week. His mother reports that he experiences pain when passing stools. He has a good diet and good fluid intake. He has reached all of his developmental milestones. 


## PH
None

## DH
None

NKDA

## On examination
The patient looks well.

On palpation of the abdomen, there is generalised tenderness with no guarding and no palpable faecal mass.

Height: 100cm

Weight: 16kg

# Prescribing Request

Write a prescription for one drug that is most appropriate to treat his condition.

Options:


## Drug choice feedback
This child is suffering from constipation. There are no signs of faecal impaction and so a regular maintenance laxative should be prescribed.

Osmotic (stool softening) laxatives are the first-line drug prescribed in children with constipation. The macrogol 'Movicol' (Polyethylene glycol 3350 plus electrolytes) or Lactulose are recommended as first-line treatment.

Stimulant laxatives such as Senna and sodium picosulphate should be used as second-line and so would not be appropriate in this instance.

## Dose/Route/Frequency/Duration feedback
Movicol is prescribed in sachets. The maintenance dose for a 4-year-old is 1 sachet daily.

Lactulose is a liquid prescribed in mL, the dose for a 4-year-old is 2.5-5mL twice daily.
Case Presentation: A 63-year-old gentleman attends his GP with dyspepsia. He does not report any weight loss, no vomiting, no changes to appetite.


## PH
Obesity, hypercholesterolaemia, hypertension

## DH
Atorvastatin 40mg PO OD, ramipril 5mg PO OD.

He is allergic to penicillin.

## FHx

No upper gastrointestinal cancer

## On examination

He is alert and oriented. Upon palpation of the abdomen, there is epigastric tenderness, there are no other abnormalities.

Temperature 36.9°C, HR 80, RR 16, BP 143/92mmHg O<sub>2</sub> 98% RA, GCS 15, Weight 106kg

## Investigations

FBC: Hb 146, WCC 5.2, Plt 328

2ww OGD performed: "Benign gastric ulceration noted, no oesophagitis, no masses seen."

Stool antigen test for _H. pylori_: positive

## Prescribing Request

It is decided he should be started on triple therapy. He has already had omeprazole and clarithromycin prescribed.

Write a prescription for one drug that is most appropriate to treat his helicobacter pylori infection.

Options:


## Drug choice feedback

This gentleman has a gastric ulcer secondary to helicobacter pylori infection. He should therefore be prescribed triple therapy. Classically, triple therapy consists of a proton pump inhibitor, and two antibiotics - clarithromycin and amoxicillin. This patient has a penicillin allergy however so amoxicillin is replaced by metronidazole.

## Dose/Route/Frequency/Duration feedback

400mg BD for 7 days is the optimum dose of metronidazole to treat helicobacter (alongside the rest of the prescribed triple therapy).
Case Presentation: A 83-year-old gentleman was admitted to the acute medical ward 4 days ago unwell with a cough and worsening shortness of breath. He has Stage IV small cell lung cancer with spinal metastases. He has been treated with intravenous antibiotics but unfortunately, his condition has worsened. He is now considered to be end-of-life. He was previously on 120mg of oral morphine daily but can no longer tolerate oral medication. 


## PMH
Stage IV small cell lung cancer

## DH
Midazolam 20mg SC over 24 hours

Hyoscine Hydrobromide 40mg SC over 24 hours

Discontinued: Morphine Sulphate 60mg BD, Amlodipine 5mg OD

## On examination
The patient is drowsy.

On auscultation of the chest, there is reduced air entry and bronchial breath sounds bilaterally.

HR 90, RR 24, BP 110/84, Temperature 37.5°C

# Prescribing Request

Write a prescription for one drug that to treat this patient's pain and dyspnoea to be given via a syringe driver.

Options:


## Drug choice feedback
Morphine sulphate and Diamorphine hydrochloride are opioids used in palliative care to manage pain. Opioids also help relieve dyspnoea and slow the respiratory rate. As this patient was already established on oral morphine, morphine sulphate would be an appropriate choice. Diamorphine hydrochloride can also be used and is more soluble and can be delivered in a smaller volume. Guidance on palliative prescribing in the BNF in the medicines guidance section under 'prescribing in palliative care'.

## Dose/Route/Frequency/Duration feedback
Subcutaneous morphine should be given at half the daily dose of oral morphine. 120/2 = 60

Subcutaneous diamorphine should be given at a third of the daily dose of oral morphine. 120/3 = 40

Syringe drivers are a machine used to infuse medications slowly via a subcutaneous needle, they are used in palliative care as they are less invasive than intravenous and intramuscular delivery.

Subcutaneous medications are generally prescribed in 24 hourly doses.

*NB - oral oxycodone potency is between 1.3-2x that of oral morphine. Different trusts will adopt different guidance on which you should use.
Case Presentation: A 19-year-old woman attends her GP asking for emergency contraception. She has had unprotected sex 48 hours ago. She does not want an invasive procedure or injection.


## PH
Nil.

## DH
Nil.

## On examination

Nil.

## Investigations

Nil.

## Prescribing Request

Write a prescription for one drug that is most appropriate to provide her with emergency contraception.

Options:


## Drug choice feedback

This patient is asking for emergency contraception in the form of a pill. There are two options you can prescribe - levonorgestrel or ulipristal acetate. Levonorgestrel is only effective if the episode of unprotected sex has occurred within 72 hours of presentation whereas ulipristal is effective up to 120 hours after the episode of unprotected sex.

## Dose/Route/Frequency/Duration feedback

The following prescriptions would provide emergency contraception for this patient:

- Levonorgestrel (Levonelle) 1.5mg PO ONCE
- Ulipristal acetate (ellaOne) 30mg PO ONCE
Case Presentation: A 68-year-old female patient is on the orthopaedic ward after having an elective knee replacement for osteoarthritis. She is now 10 hours post-surgery. She is needle phobic and categorically refuses any further injections. 




## PH
Hypothyroidism


## DH
Levothyroxine 75mg OD


## On examination
The patient looks well at rest.


Weight 72kg


HR 86, RR 18, BP 128/84, Temperature 36.8°C


## Investigations


||||
|---------------------------|:-------:|--------------------|
|Sodium|138 mmol/L|135 - 145|
|Potassium|4.5 mmol/L|3.5 - 5.3|
|Urea|5.0 mmol/L|2.5 - 7.8|
|Creatinine|100 µmol/L|60 - 120|
|eGFR|80 mL/min/1.73m<sup>2</sup>|> 60|


# Prescribing Request


Write a prescription for one drug for prophylaxis of venous thromboembolism in this patient.

Options:


## Drug choice feedback

As this patient is needle phobic, Low Molecular Weight Heparins (LMWHs) are not appropriate as these are delivered by subcutaneous injection. Alternatives include low-dose aspirin, Apixaban and Rivaroxaban.

Venous thromboembolism (VTE) prophylaxis is a common topic for PSA questions. Make sure to read the details of the question carefully and use the BNF treatment summary guidance on venous thromboembolism prophylaxis carefully.

## Dose/Route/Frequency/Duration feedback

Apixaban/Aspirin/Rivaroxaban should be given at a 2.5mg/75mg/10mg dose as an oral tablet for 10-14 days when given for VTE prophylaxis.