hllj/quesmed huggingface dataset:
Case presentation: A 42-year-old woman is admitted to the general surgical ward due to gallstones. It is decided that she should have an outpatient laparoscopic cholecystectomy.


**PH** Depression, hypercholesterolaemia, hypertension, type 2 diabetes mellitus, asthma, chronic fatigue syndrome, allergic rhinitis

**DH** Her current medicines are listed (below). Weight 118kg.

**On Examination**
HR 81/min, BP 112/80mm Hg, RR 14, O2 Sats 96% RA, temperature 37.1

Abdomen soft, tender in RUQ. Bowel sounds present.

**Investigation**

USS abdomen - thickened gallbladder wall and multiple gallstones within the gallbladder. No perforation.

Question 1: Select the THREE prescriptions that are most likely to be stopped before her elective surgery (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: Salbutamol;200mg;INH;PRN
label: a
answer: no
name: Cetirizine;10mg;PO;OD
label: h
answer: no
name: Ramipril;10mg;PO;OD
label: e
answer: no
name: Paracetamol;1g;PO;QDS
label: b
answer: no
name: Microgynon 30;1 tablet;PO;daily for 21 days with a pill free week following this
label: g
answer: no
name: Simvastatin;20mg;PO;OD
label: f
answer: no
name: Fluticasone;100 micrograms;intranasal, one application;OD
label: i
answer: no
name: Sertraline;50mg;PO;OD
label: c
answer: no
name: Metformin;500mg;PO;TDS
label: d
answer: no


1. Ramipril, microgynon 30 and metformin should be held before surgery. COCPs should be held for 4 weeks prior to surgery due to the increased risk of thromboembolism. ACE inhibitors/angiotensin-II receptor antagonists should be omitted the day before surgery due to an increases risk of severe hypotension after induction of anaesthesia. Metformin can also be held before surgery if there is an increased risk of lactic acidosis occurring.

2. The maximum dose of salbutamol per administration is 200 micrograms NOT milligrams.
Case presentation: A 69-year-old gentleman attends his lithium clinic appointment  




 **PH** Bipolar disorder, seizures, hypertension, depression, asthma, osteoarthritis


 **DH** His regular medicines are listed (below). Weight Xkg.


 **Investigation**


Lithium concentration 1.5 mEq/L (0.8-1.2 mEq/L)


Question 1: Select the THREE prescriptions that are most likely to be interacting with his lithium to increase its serum concentration (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: Sertraline;50mg;PO;OD
label: i
answer: no
name: Lithium carbonate (Liskonum);450mg;PO;OD
label: a
answer: no
name: Ibuprofen;400mg;PO;QDS
label: f
answer: no
name: Captopril;10mg;PO;OD
label: b
answer: no
name: Lansoprazole;30mg;PO;OD
label: g
answer: no
name: Carbamazepine;400mg;PO;TDS
label: e
answer: no
name: Bendroflumethiazide;2.5g;PO;OD
label: d
answer: no
name: Salbutamol;200 micrograms;INH;QDS
label: h
answer: no
name: Amlodipine;10 mg;PO;OD
label: c
answer: no


1. ACE inhibitors, NSAIDs and thiazide like diuretics all increase the serum concentration of lithium. This is due to their effects on kidney function, a reduction in kidney function results in a reduced clearance of lithium. This in turn then leads to higher serum concentration of lithium.
2. Bendroflumethiazide should be given as a 2.5mg tablet once daily in hypertensive patients, NOT 2.5g.
Case Presentation: A 62 year old man is brought to A&E with fever, productive cough and shortness of breath. **PH** Parkinson’s disease, osteoarthritis. **DH** co-careldopa 25/250mg PO TDS, codeine phosphate 30mg PO PRN (max 6-hourly), senna 7.5mg PO BD. NKDA


**O/E**

Drowsy but able to answer in full sentences. Appears sweaty. Peripheries warm, CRT < 2s. Coarse creps L mid to lower zone.

Temperature 38.4°C, HR 112, RR 32, BP 115/78, O2 94% RA, AMTS 6/10

**Investigations**

FBC: Hb 124, WCC 16.3, Plts 203 x 10^9, MCV 82

U&Es: Na 133, K 4.6, Cl 100, Ur 8.1, Cr 117, eGFR 83mL/min/1.73m^2

CRP 155

Question: Select the most appropriate management at this stage.

Options:
explanation: Doxycycline is an acceptable alternative in patients who are penicillin-allergic. However a discharge is inappropriate as the patient has a CURB-65 of 3D
name: Discharge with doxycycline 200mg PO OD and clarithromycin 500mg PO BD
label: e
answer: no
explanation: The patient has a CURB-65 score of 3 and has a higher risk of mortality. Meropenem is a broad-spectrum carbapenem antibiotic that would not be initiated without specialist input from microbiology
name: Admit with meropenem 1g IV TDS
label: c
answer: no
explanation: This would be a possible option with a CURB-65 of 2. However the patient scores 3 and warrants more intensive treatment
name: Admit with amoxicillin 500mg PO TDS and clarithromycin 500mg PO BD
label: b
answer: no
explanation: This would be a possible option with a CURB-65 of 0. However the patient scores 3 and warrants admission and more intensive treatment
name: Discharge with amoxicillin 500mg PO TDS
label: d
answer: no
explanation: The patient has a CURB-65 score of 3 and has a higher risk of mortality, thus warranting intensive inpatient treatment with IV antibiotics
name: Admit with co-amoxiclav 1.2g IV TDS and clarithromycin 500mg IV BD
label: a
answer: yes

Correct answer: a
Case Presentation: A 72 year old woman presents to A&E with acute shortness of breath and chest pain. **PH** congestive cardiac failure, recurrent DVTs, osteoporosis. **DH** bisoprolol fumarate 7.5mg PO OD, lisinopril 40mg PO OD, spironolactone 50mg PO OD, warfarin sodium 8mg PO OD, alendronic acid 70mg PO once weekly, calcichew D3.


**O/E**

HR 98, RR 36, BP 149/97, Temperature 37.2°C, O2 92% RA. HS I + II + ?III, bibasal fine creps. Pitting oedema to buttocks.

She has been sat upright and started on 6L O2 via simple face mask.

**Investigations**

ECG: sinus tachycardia

Question: Select the most appropriate management at this stage.

Options:
explanation: Digoxin is a cardiac glycoside that increases myocardial contractility and decreases AV node conduction. It is a useful adjunct in patients with CCF and concomitant AF
name: Digoxin 750 micrograms PO
label: c
answer: no
explanation: A glyceryl trinitrate infusion can be a useful adjunct treatment in fluid overload secondary to CCF. The patient’s blood pressure must be monitored closely due to its potent vasodilatory effects
name: Glyceryl trinitrate 100 micrograms/kg IV
label: d
answer: no
explanation: This would be an option in acute pulmonary oedema unresponsive to initial medical therapy
name: CPAP therapy
label: b
answer: no
explanation: This novel drug combination is used in the chronic medical management of CCF with reduced ejection fraction and has no role in treating acute fluid overload
name: Sacubitril/valsartan 49/51mg PO
label: e
answer: no
explanation: The patient is clearly fluid overloaded and requires immediate diuresis with a powerful loop diuretic like furosemide
name: Furosemide 40mg IV
label: a
answer: yes

Correct answer: a
Case Presentation: A 45 year old man attends A&E with a painful swollen left calf. **PH** type 2 diabetes, previous myocardial infarction. **DH** metformin hydrochloride 500mg PO TDS, glimepiride 4mg PO OD, aspirin 75mg PO OD, bisoprolol fumarate 5mg PO OD, ramipril 5mg PO OD. Previous adverse drug reaction to Tazocin – urticarial rash.


**O/E**

Large erythematous patch on left calf, very tender to touch. Temperature 38.0°C. All other observations stable.

**Investigations**

WCC 15.9, CRP 89. Blood cultures pending.

Question: Select the most appropriate management at this stage.

Options:
explanation: Flucloxacillin would be the first-line agent to treat cellulitis, but should not be used in view of the patient’s previous adverse reaction to penicillin
name: Flucloxacillin 500mg PO QDS
label: b
answer: no
explanation: Vancomycin is an aminoglycoside antibiotic with anti-MRSA activity and is used to treat severe skin and soft tissue infections. Due to its narrow therapeutic range and side effects it is not a first-line agent to treat cellulitis
name: Vancomycin 15mg/kg IV BD
label: e
answer: no
explanation: Linezolid is a very broad spectrum oxazolidinone antibiotic with powerful anti Gram-positive activity and is used to treat severe skin and soft tissue infections. It should not be initiated without specialist microbiology input
name: Linezolid 600mg PO BD
label: c
answer: no
explanation: Phenoxymethylpenicillin is sometimes used as prophylaxis against skin and soft tissue infections in some patients, but should not be used to treat cellulitis as it likely has limited activity against Staphylococcus species
name: Phenoxymethylpenicillin 500mg PO QDS
label: d
answer: no
explanation: Clarithromycin is a second-line agent to treat cellulitis in patients who are penicillin-allergic
name: Clarithromycin 500mg PO BD
label: a
answer: yes

Correct answer: a
Case Presentation: A 73 year old man attends his GP with a 3 day history of a painful rash. **PH** aortic abdominal aneurysm (<5.5cm), benign prostatic hypertrophy. **DH** tamsulosin hydrochloride 400 micrograms PO OD. NKDA


**O/E**

HR 70, RR 13, BP 132/65, O2 100% RA, Temperature 36.4°C. Erythematous vesicular rash on right side of abdomen in the distribution of T10 dermatome.

Question: Select the most appropriate management at this stage.

Options:
explanation: Foscarnet is an antiviral drug with activity against some herpesviruses such as CMV. It has no role in the acute management of shingles
name: Foscarnet 40mg/kg IV TDS
label: c
answer: no
explanation: Duloxetine is an SNRI used to treat neuropathic pain. It has no role in the acute management of shingles but can be prescribed to treat post-herpetic neuralgia
name: Duloxetine 60mg PO OD
label: b
answer: no
explanation: This patient is presenting with shingles. Oral acyclovir has been shown to reduce the duration and intensity of symptoms, but not to reduce the incidence of post-herpetic neuralgia
name: Aciclovir 800mg PO 5 times a day
label: a
answer: yes
explanation: Paracetamol may provide some pain relief from symptoms but does not treat shingles itself
name: Paracetamol 1g PO QDS
label: e
answer: no
explanation: Gabapentin is used to treat neuropathic pain and some types of seizures. It has no role in the acute management of shingles but can be prescribed to treat post-herpetic neuralgia
name: Gabapentin 300mg PO OD
label: d
answer: no

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: 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: 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
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: 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

Correct answer: a
Case Presentation: A 24 year old woman has had pain in her left breast for the last three days. She is currently 6 weeks post-partum, and while she has been taking simple oral analgesia and continuing to express milk at the advice of her health visitor, her symptoms remain unresolving. She has no known drug allergies.


**O/E**

Right breast grossly normal, no palpable lumps. Left breast area of erythema at 3 o’ clock position from the areola, measuring approximately 2 x 3 cm. Warm and very tender to touch, but no nipple fissuring or fluctuant lumps on palpation.

Temperature 37.1°C. HR 70, RR 12.

Question: Select the most appropriate management at this stage.

Options:
explanation: flucloxacillin is recommended first line to treat lactational mastitis
name: Flucloxacillin 500mg PO QDS for 14 days
label: a
answer: yes
explanation: Erythromycin is an acceptable second line agent to treat lactational mastitis
name: Erythromycin 500mg PO QDS for 14 days
label: e
answer: no
explanation: All tetracycline antibiotics are contraindicated in breastfeeding due to the risk of irreversible teeth discolouration in the infant
name: Doxycycline 200mg PO OD for 14 days
label: d
answer: no
explanation: Ciprofloxacin is a fluoroquinolone antibiotic with a mid to broad spectrum of activity. It is not generally used to treat lactational mastitis
name: Ciprofloxacin 400mg PO BD for 7 days
label: b
answer: no
explanation: Clindamycin has activity against common Gram-positive bacteria responsible for skin and soft tissue infections, but would not be a first line option to treat uncomplicated lactational mastitis
name: Clindamycin 300mg PO TDS for 7 days
label: c
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: 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: 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: 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
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: 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

Correct answer: a
Case Presentation: A 43-year-old man attends A&E with nausea, worsening tremor and says he is feeling very anxious and 'on edge'. He is a frequent attender with similar presentations and decided two days he was going to stop drinking completely. He says it has been at least 36 hours since his last drink. **PH** Chronic alcohol abuse, Depression **DH** Omeprazole 30mg PO daily, Sertraline 50mg PO daily NKDA




 **On examination**


Appears anxious and sweaty, but orientated in time and place. Peripheries warm, CRT < 2s. Pulse regular.


Temperature 37.4°C, HR 112, RR 14, BP 115/78, O2 94% RA, AMTS 8/10


 **Investigations**


FBC, U+E, LFT, clotting profile - in-lab


Point of care glucose: 7 mmol/L (normal <6.1 mmol/L)


Question: Select the most appropriate management at this stage.

Options:
explanation: Vitamin replacement is an important aspect of managing patients with chronic alcohol consumption however this will not treat his acute withdrawal symptoms.
name: Thiamine 100 mg PO OD
label: b
answer: no
explanation: Though this patient describes nausea, the most appropriate management at this stage is to give a benzodiazepine to treat his acute withdrawal. Anti-emetics may be a part of his management plan but are not the most important aspect of it.
name: Ondansetron 4 mg PO TDS
label: d
answer: no
explanation: Benzodiazepines such as chlordiazepoxide are the recommended first-line treatment of acute alcohol withdrawal. This is an acceptable starting dose, with a formal regime to be decided based on this patient's CIWA scoring.
name: Chlordiazepoxide 20mg PO 6-hourly
label: a
answer: yes
explanation: While this patient has a tremor, he is suffering acute alcohol withdrawal and propranolol is not appropriate for this.
name: Propranolol 50mg PO PRN
label: e
answer: no
explanation: This may be given if the patient was very agitated and either a risk to himself and/or others with verbal de-escalation tactics failing, however there is no description of this behaviour in the stem.
name: Lorazepam 2 mg PO STAT
label: c
answer: no

Correct answer: a
Case presentation: A 65-year-old man presents to the emergency department with sudden-onset shortness of breath. He also complains of stabbing chest pain during inhalation and exhalation.  

PMH: Prostate cancer, Hypertension, Diabetes Mellitus
DH: Enalapril maleate 20mg PO OD, Metformin Hydrochloride 500mg TDS
Investigation: Computed tomographic pulmonary angiography confirms the diagnosis of pulmonary embolus.
Treatment with 80mg Enoxaparin subcutaneous injection twice daily was initiated. Treatment with warfarin is to be commenced after 5 days.

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

Options:
explanation: Warfarin can interact with many other drugs because it is metabolised by cytochromes P450 enzymes. CP450 inhibitors such as erythromycin can potentiate the anti-coagulatory effect and make bleeding more likely
name: Warfarin can be safely taken along with antibiotics such as erythromycin and co-trimoxazole
label: c
answer: no
explanation: With regards to blood test monitoring, patients only require a blood test once every 6 to 8 weeks if the INR levels have become stable
name: Once the international normalised ratio (INR) is within the therapeutic range, he still requires lifelong blood test on a weekly basis to ensure that the INR remains stable
label: e
answer: no
explanation: If a patient has forgotten to take a dose the day before, the patient is advised to skip the missed dose and take the normal dose at usual time. Patient is reminded to not take more than 1 dose a day
name: If he has forgotten to take a dose of warfarin the day before, he should take 2 doses today to make up
label: d
answer: no
explanation: Warfarin is a Vitamin K antagonist that promotes anticoagulation. Food that contains a lot of vitamin K, for example green leafy vegetables and liver, can interfere with how warfarin works. Hence, patients are advised to keep a stable diet and consult their doctors before changing to a completely new diet
name: He should keep his diet stable and speak to his doctor before changing to a completely new diet
label: a
answer: yes
explanation: Warfarin is a Vitamin K antagonist that promotes anticoagulation
name: Warfarin decreases blood clotting by working against Vitamin A
label: b
answer: no

Correct answer: a
Case presentation: A 65-year-old man attends the Parkinson clinic with increasing frequencies of involuntary and uncontrollable movement.  

PMH: Parkinson’s disease, Diabetes Mellitus, Hypertension
DH: Co-Beneldopa (immediate-release) 200mg PO QDS, Metformin hydrochloride 500mg PO TDS, Captopril 50mg PO BD
The patient is advised to add pramipexole 88 micrograms PO TDS as an adjunct to his current treatment regime to help control the dyskinesia.

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

Options:
explanation: Pramipexole is linked with impulsive control disorders such as binge eating, pathological gambling and hypersexuality. 
name: Pramipexole is associated with impulsive control disorder
label: a
answer: yes
explanation: Pramipexole increases risk of postural hypotension, especially at the start of treatment. Hence, it is recommended to monitor the blood pressure of patients on initiation of the treatment
name: Pramipexole could lead to high blood pressure
label: e
answer: no
explanation: Patients are usually given a small dose to start with before the dose gets gradually increased over time to reduce side effects such as dizziness
name: Maximum dose of pramipexole is usually given at the start to ensure complete control of the symptoms
label: c
answer: no
explanation: Pramipexole is a dopamine-receptor agonist that is used alone or as an adjunct to co-careldopa or co-beneldopa to treat Parkinson’s disease
name: Pramipexole is converted into dopamine in the body
label: b
answer: no
explanation: Dose of pramipexole needs to be reduced gradually before it can be stopped completely to reduce the risk of neuroleptic malignant syndrome(NMS). NMS is characterised by fever, altered mental status, muscle rigidity and autonomic dysfunction
name: He should immediately stop taking pramipexole if it causes him to feel dizzy
label: d
answer: no

Correct answer: a