hllj/quesmed huggingface dataset:
Case presentation: A 72-year-old gentleman attends his GP complaining of constipation


**PH** Benign prostatic hyperplasia, osteoarthritis, hypertension, prior myocardial infarction, hypercholesterolaemia, allergic rhinitis, gastro-oesophageal reflux disease,

**DH** His current medicines are listed (below). Weight 81kg.

Question 1: Select the FOUR prescriptions that are most likely to be contribute to his constipation (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: Omeprazole;20mg;PO;OD
label: a
answer: no
name: Ibuprofen;400mg;PO;QDS
label: g
answer: no
name: Tamsulosin;400mg;PO;OD
label: h
answer: no
name: Ramipril;10mg;PO;OD
label: e
answer: no
name: Bisoprolol;10mg;PO;OD
label: f
answer: no
name: Atorvastatin;80mg;PO;OD
label: b
answer: no
name: Clopidogrel;75mg;PO;OD
label: d
answer: no
name: Cetirizine;10mg;PO;OD
label: i
answer: no
name: Aspirin;75mg;PO;OD
label: c
answer: no


1. PPIs, ACE inhibitors, beta blockers and statins commonly cause constipation. Whilst other medications that this patient is on such as clopidogrel, tamsulosin and ibuprofen can cause constipation, these aren't listed as common/very common side effects unlike the omeprazole, ramipril, bisoprolol and atorvastatin.

2. The normal dose for tamsulosin when treating benign prostatic hyperplasia is 400 micrograms. This patient is receiving 400 milligrams of tamsulosin which is much higher than the maximum dose he should be receiving.
Case Presentation: A 68 year old man attends his GP for a COPD review as he is feeling breathless.


**PH** COPD, hypertension, hypercholesterolaemia

**DH** salbutamol 200 micrograms INH QDS, amlodipine 10mg PO OD, atorvastatin 20mg PO OD. NKDA

**On examination**

Temperature 37.4°C, HR 74, RR 22, BP 115/78, O2 96% RA.

Audible wheeze heard in all lung fields.

**Investigations**

Hb 126, WCC 8.3, Plts 303 x 10<sup>9</sup>, eosinophils 0.1 x 10<sup>9</sup>L, CRP 2

Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has COPD that isn't controlled on his current medication. This isn't an acute exacerbation as his observations are stable and his bloods are unremarkable. He has no signs of steroid responsiveness so should be stepped up the COPD treatment ladder to a LAMA + LABA.
name: Prescribe a long acting muscarinic antagonist and a long acting beta agonist
label: a
answer: yes
explanation: This patient has COPD that isn't controlled on his current medication. This treatment option is for a pneumonia/acute infective exacerbation of COPD which this gentleman doesn't have.
name: Admit to hospital with co-amoxiclav 1.2g IV TDS and clarithromycin 500mg IV BD
label: d
answer: no
explanation: You cannot increase the dose of salbutamol to 400 micrograms INH QDS, he is already on the max dose of 200 micrograms INH QDS.
name: Increase the dose of salbutamol to 400 micrograms INH QDS
label: c
answer: no
explanation: This patient has COPD that isn't controlled on his current medication. It wouldn't be the correct decision to stop his salbutamol as his condition isn't controlled on this - stopping this medication would make his condition worse.
name: No change to his medication
label: b
answer: no
explanation: This patient has COPD that isn't controlled on his current medication. This treatment option is for a pneumonia/acute infective exacerbation of COPD which this gentleman doesn't have.
name: Prescribe amoxicillin 500mg PO TDS
label: e
answer: no

Correct answer: a
Case Presentation: A 78 year old man is currently an inpatient on the elderly care ward. The nursing staff are worried due to him exhibiting aggressive behaviour, he has struck one of the HCAs trying to assist him. Efforts to calm him down verbally have failed.

**PH** Parkinson's disease, hypertension, hypercholesterolaemia

**DH** Co-beneldopa 200mg PO BD, ramipril 5mg PO OD, atorvastatin 40mg PO OD. NKDA

**On examination**
Temperature 37.2°C, HR 84, RR 16, BP 134/82, O2 97% RA.

**Investigations**

Bloods:

- FBC: Hb 138, WCC 7.8, Plts 283 x 10^9
- CRP 3
- U&Es: Na 143, K 4.7, Ur 6.0, Cr 103 (baseline 100), eGFR >90mL/min/1.73m<sup>2</sup>
- Ca2+ (adjusted): 2.3
- Mg2+: 0.9
- Phosphate: 0.83
- LFTs: ALP 36, ALT 28, bilirubin 18
- TFTs: TSH 1.2, T4 12, T3 7
- Vitamin B12: 488 pg/ml

MSU: no organisms detected.

Chest X-ray: no abnormalities detected.

Question: Select the most appropriate management at this stage.

Options:
explanation: This is an incorrect option. This patient is agitated, has been aggressive towards staff and conservative managements to control his behaviour have failed.  'Sun-downing' refers to the phenomenon of patients with delirium experiencing worsening of their symptoms at night. Pharmacological management is indicated, no intervention could lead to further harm to members of staff, other patients or the patient himself.
name: No intervention required as this is likely 'sun-downing'
label: e
answer: no
explanation: Efforts to re-orientate this gentleman have already failed and he has been aggressive to staff. Pharmacological intervention is indicated.
name: Continue to try and re-orientate him, no pharmacological management required
label: b
answer: no
explanation: Conservative efforts to calm this patient down have failed, it is therefore indicated to prescribe a pharmacological agent that treats his agitation. In this case the gentleman has Parkinson's disease which means haloperidol should NOT be prescribed. In its place lorazepam 1mg PO OD should be prescribed as it does NOT actively block dopamine receptors like haloperidol does.
name: Prescribe lorazepam 1mg PO OD
label: a
answer: yes
explanation: You should NEVER prescribe haloperidol to a patient with Parkinson's disease. Haloperidol blocks dopamine receptors in the corpus striatum and in turn can seriously worsen pre-existing Parkinson's disease.
name: Prescribe haloperidol 10mg IM STAT
label: c
answer: no
explanation: This would be correct if it was likely infection was driving this patient's delirious state however there is no evidence within the stem of this question indicating that this patient has an infection.
name: Prescribe IV broad spectrum antibiotics and monitor observations, WCC and CRP
label: d
answer: no

Correct answer: a
Case Presentation: A 16 year old boy is brought to the emergency department with shortness of breath. His mother says he has been complaining of feeling really thirsty for the last couple days. 




 **PH** Nil.


 **DH** Nil. NKDA


 **On examination**
Temperature 37.6°C, HR 104, RR 24, BP 114/72, O2 95% RA.


Respiratory exam: deep laboured breathing seen.


 **Investigations**

||||
|--------------|:-------:|------------------|
|pH|7.31|7.35 - 7.45|
|PaO₂|8.0 kPa|11 - 15|
|PaCO₂|3.8 kPa|4.6 - 6.4|
|Bicarbonate|23 mmol/L|22 - 30|


Blood glucose: 22 mmol/L (<6.1 mmol/L)


Blood ketones: 3.4 mmol/L (normal <0.6 mmol/L)


Question: Select the most appropriate management at this stage.

Options:
explanation: This is an incorrect option. This patient is in DKA and needs pharmacological intervention otherwise their condition will deteriorate.
name: Continue to monitor observations, blood glucose and blood ketones
label: c
answer: no
explanation: This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.
name: Prescribe and give 500ml of 0.9% NaCl STAT first
label: a
answer: yes
explanation: This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.
name: Prescribe and give a fixed rate insulin infusion of 1 units/kg/hour first
label: d
answer: no
explanation: This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.
name: Prescribe and give a fixed rate insulin infusion of 0.1 units/kg/hour first
label: b
answer: no
explanation: Whilst you would want to give a fluid bolus first, 250ml is not enough. There is no evidence in the stem of the question that you should be concerned about fluid overload in this patient therefore 500ml STAT is an appropriate volume of fluid to give.
name: Prescribe and give 250ml of 0.9% NaCl STAT first
label: e
answer: no

Correct answer: a
Case Presentation: A 24 year old pregnant woman attends her GP due to dysuria. She is 12 weeks pregnant.


**PH** Nil.

**DH** Nil. NKDA

**Investigations**

Urine dip:

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

Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has a lower UTI. As she is pregnant she should NOT be prescribed trimethoprim which leaves nitrofurantoin as the first line medication she should be prescribed.
name: Nitrofurantoin MR 100mg PO BD
label: a
answer: yes
explanation: Cefalexin can be used to treat lower UTIs however it is a second line option. Nitrofurantoin should be trialled first.
name: Cefalexin 500mg PO BD
label: d
answer: no
explanation: This patient has a lower UTI. If she was not pregnant then this treatment option would be okay however it is contraindicated during pregnancy due to its anti-folate properties.
name: Trimethoprim 200mg PO BD
label: b
answer: no
explanation: Amoxicillin can be used to treat lower UTIs however it is a second line option. Nitrofurantoin should be trialled first.
name: Amoxicillin 500mg PO TDS
label: c
answer: no
explanation: Clarithromycin isn't typically prescribed to treat lower UTIs. This particular dose of clarithromycin is used to treat cellulitis.
name: Clarithromycin 500mg PO BD
label: e
answer: no

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


**PH** Type 2 diabetes mellitus, hypertension

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

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

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

Question: Select the most appropriate management at this stage.

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

Correct answer: a
Case Presentation: A 73 year old woman attends her GP for a diabetes review. 


**PH** Type 2 diabetes mellitus, hypercholesterolaemia

**DH** Metformin 500mg PO BD, simvastatin 20mg PO OD. NKDA

**Investigations**

HbA1c 3 months ago: 62 mmol/mol (< 42 mmol/mol)

HbA1c today: 53 mmol/mol (< 42 mmol/mol)

Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.
name: Add sitagliptin 100mg PO OD
label: c
answer: no
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin. She should be encouraged to keep taking metformin and keep any dietary/lifestyle changes she has employed and the HbA1c should be rechecked in 3 months.
name: Make no changes to her medications
label: a
answer: yes
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.
name: Add 10 units Humulin I Insulin to take once in the morning
label: e
answer: no
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.
name: Add gliclazide 40mg PO OD
label: b
answer: no
explanation: This patient has had a response to her metformin treatment. Her HbA1c has dropped from 62 mmol/mol to 53 mmol/mol in 3 months on metformin she therefore does not need a further anti-diabetic adding to her treatment regime.
name: Add pioglitazone 30mg PO OD
label: d
answer: no

Correct answer: a
Case Presentation: A 26 year old man attends his GP for a review of his asthma. He is still feeling wheezy at night and struggling to exercise. His inhaler technique is good and he is taking his medications as recommended.

**PMH** Asthma

**DH** Low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler as required

**On examination**

FEV1/FVC ratio: 53%

Question: Select the most appropriate management at this stage.


Options:
explanation: Moderate-dose MART may be considered for patients whose asthma remains uncontrolled on low-dose MART. However, a stepwise approach is essential in asthma management, and since this patient has not yet trialed low-dose MART, moderate-dose MART would be premature at this stage.
name: Moderate dose daily maintenance and reliever therapy (MART)
label: a
answer: no
explanation: The patient's symptoms of nighttime wheezing and exercise limitation, coupled with an FEV1/FVC ratio of 53%, indicate suboptimal asthma control despite adherence to his current as-needed low-dose ICS/formoterol regimen. The most appropriate next step is to initiate low-dose daily maintenance and reliever therapy (MART), which involves using a low-dose ICS/formoterol combination both as a daily maintenance inhaler and as needed for symptom relief. 
name: Low dose daily maintenance and reliever therapy (MART)
label: c
answer: yes
explanation: This patient isn't having an acute asthma exacerbation nor is he at the point in the asthma treatment ladder in which oral corticosteroids would be considered (this would only be initiated by a specialist).
name: Add oral prednisolone 5mg PO OD
label: d
answer: no
explanation: This patient isn't having an acute asthma exacerbation therefore this option is inappropriate.
name: Admit to hospital
label: e
answer: no
explanation: Montelukast, a leukotriene receptor antagonist, is not typically considered as a first-line step in asthma management. It may be added as adjunct therapy if symptoms remain uncontrolled on moderate-dose MART. However, since the patient has not yet trialed low-dose or moderate-dose MART, montelukast is not indicated at this stage. 
name: Add montelukast 10 mg PO OD
label: b
answer: no

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


**PH** COPD, osteoarthritis

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

**On examination**

Visibly low mood. Lacking in engagement throughout the consultation.

Weight 3 months ago: 76kg.

Weight today: 68kg.

Question: Select the most appropriate management at this stage.

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

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: 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: 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: 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: 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: 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 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: 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: 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: 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: 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: 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 19-year-old man attends the dermatology clinic for his acne vulgaris medication. He has been taking tetracycline as instructed however his condition is not improving.



**PH**
Acne vulgaris

**DH**
Tetracycline 500mg PO BD

Due to his ongoing issues with his acne, his dermatologist commences him on isotretinoin.

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

Options:
explanation: Isotretinoin has been linked to increased risk of depression and suicide therefore it is very important that the patient is informed to report any changes in their behaviour or mood after starting isotretinoin.
name: To report any changes in his mood or behaviour
label: a
answer: yes
explanation: Patients who are taking isotretinoin require their hepatic function and serum lipids to be measured before starting treatment, one month after starting treatment and then on a three monthly basis.
name: That he will require serum lipid monitoring every 6 months
label: c
answer: no
explanation: Patients who are taking isotretinoin require their hepatic function and serum lipids to be measured before starting treatment, one month after starting treatment and then on a three monthly basis.
name: That he will require annual visual acuity monitoring
label: e
answer: no
explanation: Nausea is listed as a rare/very rare side effect of isotretinoin so he is unlikely to experience this.
name: That he will likely experience nausea when taking isotretinoin
label: d
answer: no
explanation: Dizziness is listed as a rare/very rare side effect of isotretinoin so he is unlikely to experience this.
name: That he will likely experience dizziness when taking isotretinoin
label: b
answer: no

Correct answer: a