hllj/quesmed huggingface dataset:
Case Presentation: A 11-year-old boy has been low in mood and energy. He has been unable to function well at school and socially. He reports being tearful and anxious, although has no thoughts of self-harm. There has been increased stress due to recent changes in his home situation. A trial of talking therapy has been initiated which although effective, has not resulted in the patient returning to his baseline.


## PH

None

## DH

None (NKDA)

## On examination

No cyanosis. Normal consciousness but mildly distressed and agitated. 

Temperature 36.3°C, HR 80, RR 16, BP 110/68, O<sub>2</sub> 98% RA, GCS 15, Weight 42kg

## Investigations

None

# Prescribing Request

Write a prescription for one additional drug that is most appropriate for treating his condition.

Options:


# Drug choice feedback

As this adolescent is suffering from severe major depressive disorder, and it has not been effectively controlled with cognitive behavioural therapy, pharmacological management may be initiated in conjunction. Fluoxetine should be prescribed, as this is the only antidepressant for which trials show that the risks are outweighed by the benefits. It has a long half-life which makes it useful in younger group of patients whose adherence to medication may be sub-optimal.

# Dose/Route/Frequency/Duration feedback

The initial dose is 10mg once-daily orally, which can be administered as a single or divided dose.
Case presentation: A 65-year-old gentleman is admitted to the respiratory ward following a chest infection. PH. Renal transplant, Seizure, Type 2 Diabetes, Hypertension. DH. His regular medicines are listed (below). Weight 70kg.




 **On Examination**
Multiple purpuric rash noted on his ankles bilaterally.


 **Investigation**

||||
|--------------|:-------:|---------------|
|Haemoglobin|100 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|0.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|70x10<sup>9</sup>/L|150 - 400|



Question 1: Select the ONE prescriptions that is most likely to be a cause of his pancytopenia. (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: Carbamazepine;1g;oral (PO);Twice daily
label: b
answer: no
name: Atorvastatin;20mg;oral (PO);Daily
label: f
answer: no
name: Tacrolimus (Adoport ®);4mg;oral (PO);Twice daily
label: a
answer: no
name: Piperacillin-tazobactam;4.5mg;intravenous (IV);Four times daily
label: c
answer: no
name: Ramipril;10mg;oral (PO);Daily
label: g
answer: no
name: Nifedipine (Tensipine® MR);10mg;oral (PO);Twice daily
label: h
answer: no
name: Metformin;500mg;oral (PO);Thrice daily
label: e
answer: no
name: Paracetamol;1g;oral (PO);Four times daily
label: i
answer: no
name: Dalteparin sodium;5000 units;subcutaneous (SC);Daily
label: d
answer: no


1. Oral use of tacrolimus commonly causes anaemia, leucopenia and thrombocytopenia. The risk of any bone marrow lineage failure is relatively insignificant compared to tacrolimus. ACEi rarely or very rarely cause pancytopenia. Paracetamol causes mainly agranulocytosis although frequency is not known. Atorvastatin, heparin, piperacillin-tazobactam and carbamazepine causes mainly thrombocytopenia.
2. Piperacillin-tazobactam is commonly used as the first line treatment in neutropenic sepsis. Doses are usually 4.5g 6-hrly. The dose prescribed for this patient is likely to represent a transcription error of g to mg.
Case presentation: A 36-year old woman presents to her GP with amenorrhoea. She reports that her period was supposed to due three weeks ago. She is quite concerned about this because her menstrual cycle has always been regular. Besides that, she notices that she has put on some weight and feels nauseous regularly. PH: Hypertension, Type 2 diabetes mellitus, Hypercholesterolemia, venous thromboembolism, otitis media, constipation 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. Normal pelvic examination, normal breast examination

**Investigation**:
Positive human chorionic gonadotrophin (HCG) pregnancy test

Question 1: Select the TWO prescriptions that should be avoided in the context of a pregnancy? (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: Phenoxymethylpenicillin;5 mg;Oral (PO);6-hourly
label: f
answer: no
name: Paracetamol;1 g;Oral (PO);6 -hourly
label: d
answer: no
name: Ibuprofen;400mg;Oral (PO);8-hourly when required
label: e
answer: no
name: Omeprazole;20 mg;Oral (PO);Daily
label: g
answer: no
name: Enalapril maleate;20 mg;Oral (PO);Daily
label: a
answer: no
name: Simvastatin;40mg;Oral (PO);Nightly
label: c
answer: no
name: Metformin hydrochloride;500 mg;Oral (PO);Three times daily
label: b
answer: no


1. BNF advises that angiotensin-converting enzyme inhibitor (ACE-i) like enalapril ACE should be avoided in pregnancy unless essential. This is because it may adversely affect fetal and neonatal blood pressure control and renal function. ACE-I has also been reported to cause skull defects and oligohydramnios
-BNF advises that all vitamin K agonists should be avoided in first trimester of pregnancy. Warfarin may cross the placenta and increase the risk of congenital malformations and neonatal haemorrhage, especially during the last few weeks of pregnancy and at delivery.
-BNF advises that statins should be avoided in pregnancy due to the increased risk of congenital anomalies. The decrease in synthesis of cholesterol is thought to affect fetal development. Hence, BNF recommends the discontinuation of statin 3 months before attempting to conceive.
2. The correct dose of phenoxymethylpenicillin for otitis media should be 500 mg to 1 g every 6 hours and not 5 mg 6-hourly.
Case presentation: A 45-year-old woman on the gynaecology ward is recovering from an elective total abdominal hysterectomy. PH Mild COPD, Polymyalgia rheumatica, Uterine fibroids, Familial hypercholestrolaemia. DH. Her current regular medications are listed (below).




 **Investigation**

||||
|---------------------------|:-------:|--------------------|
|Urea|8.5 mmol/L|2.5 - 7.8|
|Creatinine|145 µmol/L|60 - 120|



Question 1: Select the TWO prescriptions that should not be co-prescribed. (mark them with a tick in column A)
Question 2: Select the TWO prescription that are most appropriate to withhold until her renal function recovers.

Options:
name: Co-codamol 8-500mg;1 tablet;oral (PO);6-hourly
label: b
answer: no
name: Ipratropium bromide;40 micrograms;inhaled (INH);6-hourly
label: f
answer: no
name: Nicotine patch;14mg;transdermal (TD);Daily
label: g
answer: no
name: Ibuprofen;400mg;oral (PO);8-hourly
label: d
answer: no
name: Salbutamol;200 micrograms;inhaled (INH);Daily
label: e
answer: no
name: Paracetamol;1g;oral (PO);6-hourly
label: a
answer: no
name: Atorvastatin;10mg;oral (PO);Daily
label: c
answer: no


1. Paracetamol 1g 6-hrly is the maximum recommended dose of paracetamol. Hence, it should not be co-prescribed with another medication which contains paracetamol in it (co-codamol).
2. NSAIDs may lead to the worsening of renal function and hence, should be stopped during an AKI. Similarly, codeine (co-codamol) should be avoided in AKI due to the risk of adverse effects with reduced excretion.
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: Cetirizine;10mg;oral (PO);PRN
label: d
answer: no
name: Tramadol hydrochloride;100mg;oral (PO);6-hourly
label: b
answer: no
name: Ibuprofen;400mg micrograms;oral (PO);PRN
label: c
answer: no
name: Prednisolone;10mg;oral (PO);Daily
label: a
answer: no
name: Tamsulosin;400 micrograms;oral (PO);Daily
label: e
answer: no
name: Paracetamol;1g;oral (PO);6-hourly
label: f
answer: no
name: Ondansetron;4mg;intravenous (IV);Daily
label: g
answer: no
name: Morphine sulphate;10mg;intravenous (IV);6- hourly
label: h
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 65-year-old woman is admitted to hospital with native valve infective endocarditis. On the third day of her admission, she develops pulmonary oedema secondary to decompensated heart failure. She also complains of tinnitus and bilateral hearing loss. Her weight is 70kg. PH: Hypertension, Type 2 diabetes mellitus, GORD, Mitral valve prolapse DH: Her current regular prescriptions are listed below


**On examination**:
Pansystolic murmur that is heard loudest at the apex and radiates to the axilla, coarse crackles at both lung bases, peripheral oedema until the level of mid-shins

**Investigations**:

- Transthoracic echocardiograms shows presence of vegetation at mitral valves
- Positive blood cultures (streptococcus viridans)

Question 1: Select the THREE prescriptions that are most likely to be contributing to the hearing loss. (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: Furosemide;40mg;Intravenous infusion (IV);Daily
label: e
answer: no
name: Cisplatin;75mg/m2;Intraperitoneal infusion;On day 2, repeat every 3 weeks for 6 cycles
label: f
answer: no
name: Warfarin sodium;5 mg;Oral (PO);Daily
label: h
answer: no
name: Paclitaxel;135mg/m2;Intravenous infusion;On day 1 and day 8, repeat every 3 weeks for 6 cycles
label: g
answer: no
name: Bisacodyl;5mg;Oral (PO);Nightly
label: i
answer: no
name: Enalapril maleate;20 mg;Oral (PO);Daily
label: a
answer: no
name: Metformin hydrochloride;500 mg;Oral (PO);Three times daily
label: b
answer: no
name: Gentamicin;700mg;Intravenous infusion (IV);12-hourly
label: c
answer: no
name: Ceftriaxone;2g;Intravenous infusion (IV);Daily
label: d
answer: no


1. Ototoxicity is a recognised side effect of all aminoglycoside. The exact mechanism of gentamicin-related ototoxicity remains unknown.Furosemide is known to cause deafness, especially in patients with renal impairment. Ototoxicity is also a known side effect of cisplatin, a chemotherapy medication that interferes with DNA replication. The ototoxicity is likely to be dose-related and accumulative.
2. The correct dose of gentamicin for Gram-positive bacterial endocarditis is usually about 1mg/kg every 12 hours. Hence, the correct dose for this patient should be 70mg not 700mg IV 12-hourly
Case Presentation: A 36 year old man is recovering on the high dependency unit following emergency repair of a proximal aortic dissection. **PH** Marfan syndrome. **DH** atenolol hydrochloride 50mg PO OD, co-codamol 8/500mg PO QDS.


**O/E**

Drowsy but maintaining own airway. HR 64, RR 21, BP 95/56, O2 97% 2L NC, Temperature 37.4°C. Peripheries cool, CRT 4s. HS I + II + 0. Midline sternotomy dressing intact, 3x Jackson Pratt drains collecting serosanguinous fluid. Oral mucous membranes appear dry, skin turgor normal.

Fluids prescribed: 1L 5% dextrose with 40mmol K over 10h, 1L 0.9% normal saline over 10h, 250ml 5% dextrose with 20mmol K over 4h

Urine output over last 24h = 1.3L

Surgical drain output over last 24h = 1.5L

Question: Select the most appropriate management at this stage.

Options:
explanation: Although it is increasingly becoming more popular as a maintenance fluid, dextro-saline has limited use as a plasma expander due to its high dextrose concentration and tendency to redistribute
name: 500ml 0.45% saline/4% dextrose over 15 minutes
label: d
answer: no
explanation: 5% dextrose is generally not used as a plasma expander as it redistributes quickly across all fluid compartments
name: 1L 5% dextrose over 1 hour
label: c
answer: no
explanation: The patient is in net negative fluid balance and acutely hypotensive, which may be being exacerbated by beta-blockers and a blunted sympathetic response. A fluid challenge should be initiated and the blood pressure response carefully monitored
name: 500ml 0.9% normal saline over 15 minutes
label: a
answer: yes
explanation: A balanced crystalloid is a good option for fluid resuscitation. It should be administered far more rapidly than over 1 hour for its effects to be maximised
name: 1L Hartmann’s solution over 1 hour
label: e
answer: no
explanation: The patient is in net negative fluid balance and acutely hypotensive. Slow fluid replacement is not an appropriate response to this situation
name: 1L 0.9% normal saline over 4 hours
label: b
answer: no

Correct answer: a
Case Presentation: A 34 year old woman presents to GP with her male partner to solicit advice in conceiving a child. They have been having regular unprotected penetrative sex at least twice a week for four months. She has had one previous pregnancy and termination at the age of 18, and bleeds regularly with a 28 day cycle. She has a background of T2DM which is diet-controlled. She wonders if the GP can prescribe anything that she should be taking while trying to conceive.


**Investigations**

FBC: Hb 115, WCC 5.2, Plts 240 x 10^9, MCV 91

Question: Select the most appropriate management at this stage.

Options:
explanation: This is a selective oestrogen receptor modulator that stimulates ovulation. It should not be prescribed without a full assessment by a fertility specialist, and is not likely to be indicated as the patient is having regular bleeds which indicates she is ovulating
name: Clomifene citrate 50mg PO OD
label: b
answer: no
explanation: Metformin hydrochloride may have some beneficial effects on fertility in patients with polycystic ovarian syndrome, but there is nothing in the stem to suggest that the patient has PCOS
name: Metformin hydrochloride 500mg PO OD
label: e
answer: no
explanation: While iron deficiency anaemia can have a detrimental effect on fertility, this patient is clearly not anaemic
name: Ferrous sulfate 200mg PO TDS
label: c
answer: no
explanation: While megaloblastic anaemia can have a detrimental effect on fertility, this patient is clearly not anaemic
name: Hydroxocobalamin 1mg IM monthly
label: d
answer: no
explanation: All women who are attempting to conceive and low risk should be taking folic acid to reduce the risk of neural tube defects. Women at high risk (e.g. previous tube defects, family history, diabetics, on epilepsy medication, high BMI) should be on high dose folic acid (5mg OD). As this woman has diabetes she would be considered high-risk and hence 5mg is the correct answer.
name: Folic acid 5mg PO OD
label: a
answer: yes

Correct answer: a
Case Presentation: A 9 year old girl attends a CAMHS appointment with her worried father. He explains that she has ‘not been herself’ for a very long time and has been getting worse over the last two months. Where she once enjoyed attending school and performed well academically, her teachers now report frequent truancies and a markedly steep decline in the quality of her schoolwork. She is not known to be bullied at school and has no past medical history of note.


**O/E**

During the appointment, she refuses to make eye contact with the CAMHS worker and answers most questions with ‘I don’t know’, but does report significant difficulty sleeping and not eating as much as she used to. When pressed about a horizontal scar on her left arm, she tearfully admits to self-harming herself with a penknife a few weeks ago.

Question: Select the most appropriate management at this stage.

Options:
explanation: Fluoxetine is an SSRI antidepressant that is licensed for use in children 8 years and older
name: Fluoxetine 10mg PO OD
label: a
answer: yes
explanation: Sertraline is an SSRI antidepressant that is not licensed for use in children under the age of 12
name: Sertraline 25mg PO OD
label: d
answer: no
explanation: Venlafaxine is an SNRI antidepressant that is not licensed for use in children
name: Venlafaxine MR tablets 75mg PO OD
label: e
answer: no
explanation: Citalopram is an SSRI antidepressant that is not licensed for use in children under the age of 12
name: Citalopram 10mg PO OD
label: b
answer: no
explanation: Mirtazapine is a noradrenergic and specific serotonergic antidepressant (NaSSA) that is not licensed for use in children
name: Mirtazapine 15mg PO OD
label: c
answer: no

Correct answer: a
Case Presentation: A 12 year old boy is brought by his parents into a walk-in clinic with fever, throat pain and malaise. He has had these symptoms for the past 48 hours. **PH** asthma. **DH** salbutamol 200 micrograms inhaler PRN. NKDA


**O/E**

HR 110, RR 16, BP 110/75, Temperature 38.4°C, O2 100% RA. Alert and oriented. Bilaterally enlarged tonsils with patchy exudates. Swollen submandibular and anterior cervical lymph nodes.

Question: Select the most appropriate management at this stage.

Options:
explanation: Co-amoxiclav is a safer option than amoxicillin alone as it has a lower risk of morbilliform drug eruption in the event of misdiagnosed infectious mononucleosis. However it has a much broader spectrum of activity which may not be necessary to treat likely uncomplicated streptococcal tonsillitis
name: Co-amoxiclav 625mg PO TDS
label: b
answer: no
explanation: Flucloxacillin is a narrow-spectrum penicillin antibiotic that is most commonly used to treat skin and soft tissue infections. It is not used in the treatment of streptococcal tonsillitis
name: Flucloxacillin 500mg PO QDS
label: e
answer: no
explanation: While benzylpenicillin has activity against susceptible Gram-positive streptococci, an intravenous antibiotic would not be appropriate to treat likely uncomplicated streptococcal tonsillitis
name: Benzylpenicillin sodium 900mg IV TDS
label: d
answer: no
explanation: Phenoxymethylpenicillin is recommended first line to treat streptococcal tonsillitis in all age groups. Clarithromycin is an acceptable alternative option in penicillin-allergic patients
name: Phenoxymethylpenicillin 500mg PO QDS
label: a
answer: yes
explanation: Amoxicillin should not be given alone to treat suspected streptococcal tonsillitis due to the risk of misdiagnosed infectious mononucleosis and morbilliform drug eruption
name: Amoxicillin 500mg PO TDS
label: c
answer: no

Correct answer: a
Case Presentation: A 30 year old woman attends a walk-in GUM clinic to request emergency contraception. She had protected sexual intercourse the evening before but realised afterwards that the condom had split without her noticing, and she is now worried about getting pregnant as she is not taking any other form of contraception. **PH** polycystic ovarian syndrome, trigeminal neuralgia, asthma. **DH** carbamazepine 300mg PO TDS, salbutamol 200 micrograms inhaler PRN, beclometasone dipropionate 200 micrograms inhaler BD, regular multivitamins. NKDA.


Her last menstrual bleed was 16 days ago, but she has an irregular cycle ranging from between 24 days to 40 days. She has never been pregnant before and has never been admitted to hospital. On counselling, she mentions having used a Mirena coil in the past but had it removed due to pelvic pain, and feels she would not consider trying intrauterine devices again.

Question: Select the most appropriate management at this stage.

Options:
explanation: Ulipristal acetate may be given as oral emergency contraception for up to 120 hours following unprotected sexual intercourse. However the dose here is indicated for treatment of fibroids rather than as emergency contraception
name: Ulipristal acetate 5mg PO
label: d
answer: no
explanation: This is a progesterone-only contraceptive that has no emergency contraception effects
name: Noresthisterone 15mg PO
label: c
answer: no
explanation: This may be given as oral emergency contraception for up to 72 hours following unprotected sexual intercourse. 1.5mg is a standard dose but this should be doubled as the patient is taking a p450 inducer
name: Levonorgestrel 1.5mg PO
label: b
answer: no
explanation: Ulipristal acetate may be given as oral emergency contraception for up to 120 hours following unprotected sexual intercourse. However the dose here is much too low to be used as emergency contraception
name: Ulipristal acetate 10mg PO
label: e
answer: no
explanation: This may be given as oral emergency contraception for up to 72 hours following unprotected sexual intercourse. The doubled dose accounts for increased metabolisation of the drug due to the patient taking a p450 inducer
name: Levonorgestrel 3mg PO
label: a
answer: yes

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: 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
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: 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

Correct answer: a