hllj/quesmed huggingface dataset:
Case presentation: A 75-year-old man attends the Parkinson clinic with a 3-month history of rigidity, slow movement and a left-sided resting tremor. He denies any hallucination, incontinence or diplopia. Idiopathic Parkinson’s disease is suspected and a dopaminergic agent trial with 25/100mg Co-careldopa (carbidopa/levodopa) is to be initiated.




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

Options:
explanation: Co-careldopa could cause excessive daytime sleepiness and sudden onset of sleep. Hence, patients should be warned of the risk and need to exercise caution when driving or operating machinery
name: Co-careldopa could lead to excessive daytime sleepiness
label: a
answer: yes
explanation: Patients are reminded to take co-careldopa at the same time each day to help control their symptoms
name: He should take co-careldopa at different times of the day to decrease the risk of dizziness
label: d
answer: no
explanation: Patients are usually started on low dose to reduce chances of side effects
name: Maximum dose of careldopa is usually given at the start to ensure complete control of symptoms
label: c
answer: no
explanation: Dose of co-careldopa needs to be reduced gradually before it can be stopped completely to prevent withdrawal symptoms such as stiff muscles, fever and altered mental status
name: Co-careldopa can be stopped instantly once the symptoms have improved
label: e
answer: no
explanation: Co-careldopa consists of both levodopa and carbidopa. Levodopa is converted into dopamine to help replenish the level of dopamine in substantia niagra. Carbidopa prevents the levodopa from being broken down into dopamine in parts of the body other than the brain. It does not decrease the risk of impulsive behaviour
name: Carbidopa in the co-careldopa decreases the risk of impulsive behaviour associated with levodopa
label: b
answer: no

Correct answer: a
Case presentation: A 30-year-old woman attends the psychiatric clinic with her partner. She reports that she has been hearing voices talking about her and that her neighbor is plotting against her. She also believes that her mind is currently being controlled by the government and many random thoughts have been inserted against her wishes. She has been out of job for 6 months as a result of her current health situation. Her partner thinks that her beliefs are unfounded.  

The patient is advised to commence treatment with Haloperidol 2mg PO twice daily along with cognitive behavioural therapy.

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

Options:
explanation: At the beginning of treatment, patients are usually given a dose at the lower end of the licensed range and then slowly titrate upwards within the dose range to lower the risks of side effects
name: She will be given maximum dose at the start of treatment to ensure optimal control of her symptoms
label: b
answer: no
explanation: Muscle stiffness and confusion are not normal side effects of haloperidol. Patients should stop taking the medication and seek immediate medical help because these signs are suggestive of neuroleptic malignant syndrome
name: It is normal to experience muscle stiffness and confusion during the course of treatment
label: e
answer: no
explanation: Haloperidol is an anti-psychotic that is used to treat schizophrenia and other psychoses. It is linked to extra-pyramidal effects such as akathisia due to it being a dopamine D2 receptor antagonist. Akathisia is a movement disorder associated with restlessness and inability to stay still
name: Haloperidol can cause akathisia
label: a
answer: yes
explanation: Haloperidol is linked to hypotension rather than hypertension
name: Haloperidol commonly causes high blood pressure
label: d
answer: no
explanation: Hyperprolactinaemia is a common side effect of haloperidol. Hence, BNF advises to monitor prolactin concentration (not oxytocin concentration) at the beginning of therapy, at 6 months and then yearly
name: She will have her oxytocin level measured as part of the baseline investigation
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: 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 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: 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: 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: 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
A 45-year-old man is admitted to Resus after collapsing and diagnosed with DKA. He is prescribed 3L of 0.9% Normal saline over 5 hours and a fixed rate insulin infusion of 7 units/hr. After the second bag, a repeat ABG is done, and due to a low BM, the saline is switched to 1L of 10% dextrose over 8 hours.  
  


Investigations:
  
| | |  |
| -------------- | :-------: | ------------------ |
| pH  | 7.30  | 7.35 - 7.45 |
| PaO₂  | 11 kPa  | 11 - 15 |
| PaCO₂ | 4.5 kPa | 4.6 - 6.4  |
| Bicarbonate | 18 mmol/L | 22 - 30 |
| Non-fasting Glucose  | 10 mmol/L | < 6.1  |
| Ketones (Serum)  | 2 mmol/L | < 0.6  |
 

BP 125/85 mmHg (120/80mmHg on admission)
  

Fluid Chart:
  

* 1300 0.9% Normal Saline 1L over 1 hour
* 1400 0.9% Normal Saline 1L over 2 hour
* 1600 0.9% Normal Saline 1L over 2 hour
* 1600 10% Dextrose 1L over 8 hours
  
 

How much (g) glucose would have been given to the patient 2 hours after the first 10% dextrose 1L over 8 hours was initiated?

Options:


10% dextrose = 10g in 100mL = 100g in 1000mL
Amount of glucose in 2 hours
= 2/8 x 100g/1000mL
= 25g

Learning point: 10% dextrose = 10g in 100mL = 100g in 1000mL
 Amount of glucose in 2 hours
 = 2/8 x 100g/1000mL
 = 25g
A 12-year-old boy is came to the GP complaining of dry cough. The GP started him on pholcodine 5mg TDS PO.

Pholcodine solution is available in bottles of 5mg/5mL.
Weight 50kg.

What volume (mL) of pholcodine solution is required for a course of 3 days?

Options:


Dose of pholcodine = 5mg TDS
Concentration = 5mg/5mL
Volume of pholcodine per dose = 5mg ÷ 5mg/5mL = 5mL
Volume of pholcodine required a day = 5mL x 3 = 15 mL
Volume needed for 3 days = 15mL x 3 = 45mL
A 26-year-old gentleman who weighs 60kg requires 2% lignocaine as local anaesthesia for wound stitching. Local protocols state the maximum safe dose that can be administered is 3mg/kg.


What is the maximum safe volume of lignocaine that can be given?

Options:


The maximum safe dose that be given is: 3mg/kg x 80kg = 180mg. Now, 2% lignocaine is 2kg in 100L = 20mg in 1mL. Therefore, the maximum safe volume of lignocaine that can be given is 9mL.

Concentration ratios (2% in this case) are based on units of kilogram and litre as they belong to the International System of Units (SI units) which are used by convention.
A 38-year-old patient suffers from hypomagnesaemia. She is prescribed a magnesium sulphate infusion of 10g once-daily for five days in a 0.9% sodium chloride solution. The concentration of magnesium sulphate should not exceed 20%.


What is the minimum volume of 0.9% sodium chloride required to safely make up the magnesium sulphate solution?

Options:


A concentration of 20% is 20kg in 100L = 20mg in 0.1mL = 200mg in 1mL. Since the patient requires 10g of magnesium sulphate, the minimum volume of 0.9% sodium chloride is: 10g ÷ 200mg/mL = 50mL.

Concentration ratios (20% in this case) are based on units of kilogram and litre as they belong to the International System of Units (SI units) which are used by convention.
A 37-year-old patient with hypertension in pregnancy is prescribed labetalol by intravenous infusion. She was initially given 20mg/hour, which was increased to 40mg/hour after 30 minutes, and then to 80mg/hour after another 30 minutes. This continued for 15 minutes, after which the response was satisfactory and the infusion was stopped.


What is the total dose of labetalol given?

Options:


- Dose of labetalol given at 20mg/hour: 20mg/hour x 0.5 hours = 10mg
- Dose of labetalol given at 40mg/hour: 40mg/hour x 0.5 hours = 20mg
- Dose of labetalol given at 80mg/hour: 80mg/hour x 0.25 hours = 20mg

Total dose of labetalol given: 10mg + 20mg + 20mg = 50mg
Case Presentation: A 5-year-old boy was brought in to the GP three days ago by his parents following a cough and sore throat that has been present for the past 4 days. On examination, he was pyrexic with a temperature of 38.5oC, his cervical lymph nodes were tender and swollen. He was prescribed antibiotics by the GP who then provided the parents with safety-netting advice. Today, he re-attended the GP with a widespread, itchy, macular papular rash that developed this morning. PMH Atopic eczema, Asthma. DH His current regular medicines are listed (below).


Question: Select the prescription that is most likely to contribute to his rash.

Options:
explanation: Salbutamol does not commonly cause rash
name: Salbutamol 2 puff PRN INH
label: b
answer: no
explanation: Hydrocortisone does not commonly cause rash
name: Hydrocortisone 0.5% cream TOP BD
label: e
answer: no
explanation: Dermol cream does not commonly cause rash
name: Dermol cream TOP OD
label: d
answer: no
explanation: Prescribing amoxicillin in patients presenting with infectious mononucleosis can result in a widespread maculopapular rash. Drug induced maculopapular eruptions are due to delayed type hypersensitivity reactions and these eruptions are enhanced by viral infections such as EBV, possibly due to molecular mimicry between amoxicillin and viral molecules, inducing a loss of tolerance state towards amoxicillin and a transient immune reaction
name: Amoxicillin 500mg PO TDS
label: a
answer: yes
explanation: Fluticasone does not commonly cause rash
name: Fluticasone 50 micrograms BD INH
label: c
answer: no

Correct answer: a
A 67-year-old woman presents to the accident and emergency department with nausea, vomiting and confusion. Two days ago her GP started digoxin 125 micrograms PO once daily for her atrial fibrillation.
 **PMH:** Type 2 Diabetes Mellitus, Atrial fibrillation, Heart failure
**Observations:** Temperature 36.5°C , blood pressure 125/80 mmHg, heart rate 54 bpm, respiratory rate 18; oxygen saturation 100% (on air).
 
 **On examination:** Irregular S1, S2 with presence of S3; chest is clear with no added lung sounds; abdomen soft and non tender

 **ECG:** Downsloping ST depression with a ‘hockeystick’ pattern, flattened T wave, shortened QT interval
Select the prescription that is most likely to have interacted with digoxin to cause the clinical picture described above?

Options:
explanation: Chlortalidone is a thiazide-like diuretic that can be used to treat oedema secondary to heart failure. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, thereby leading to reduced sodium reabsorption and decreased water retention. Chlortalidone is predicted to increase the risk of digoxin toxicity when given with digoxin. (Severity of interaction: Severe; Evidence for interaction: Study). Chlortalidone can lead to hypokalaemia that increases risk of digoxin toxicity. Digoxin normally competes with potassium to bind to cellular Na+/K+-ATPase pumps. Hence, when potassium levels are low, digoxin can more easily bind to the pumps
name: Chlortalidone 50 mg PO OD
label: a
answer: yes
explanation: Carvedilol is not known to interact with digoxin, although it can increase the risk of bradycardia.
name: Rivaroxaban 20 mg PO OD
label: d
answer: no
explanation: Metformin is not known to interact with digoxin
name: Metformin hydrochloride 500 mg PO TDS
label: c
answer: no
explanation: Carvedilol is not known to interact with digoxin, although it can increase the risk of bradycardia.
name: Carvedilol 3.125 mg PO BD
label: b
answer: no
explanation: Lisinopril is not known to interact with digoxin
name: Lisinopril 2.5mg PO OD
label: e
answer: no

Correct answer: a

Chlortalidone 50 mg PO OD
Case Presentation: A 70-year-old man was admitted to the respiratory ward two days ago following a recent chest infection. PMH Community acquired pneumonia, Mild COPD, TB, Diabetic foot infection. DH His current regular medicines are listed (below).


On examination
There is visible yellowing of his sclera and evidence of pruritus on his arm.
Investigation

||||
|---------------------------|:-------:|--------------------|
|Alanine Aminotransferase (ALT)|150 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|50 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|450 IU/L|25 - 115|
|Bilirubin|60 µmol/L|< 17|
|Gamma Glutamyl Transferase (GGT)|50 U/L|9 - 40|


Question: Select the prescription that is most likely to contribute to his cholestatic jaundice.

Options:
explanation: Ipratroprium bromide does not commonly cause cholestatic jaundice
name: Ipratroprium bromide 40 micrograms INH TDS
label: d
answer: no
explanation: Clarithyomycin does not cause cholestatic jaundice
name: Clarithromycin 500mg BD PO
label: a
answer: no
explanation: Clindamycin does not commonly cause cholestatic jaundice
name: Clindamycin 300mg QDS PO
label: c
answer: no
explanation: Salbutamol does not commonly cause cholestatic jaundice
name: Salbutamol 200 micrograms INH QDS
label: e
answer: no
explanation: Fusidic acid is associated with elevated liver enzymes, hyperbilirubinaemia and jaundice with systemic use. These effects are usually reversible following withdrawal of therapy.
name: Fusidic acid  250mg BD PO
label: b
answer: yes

Correct answer: b
Case Presentation: A 45-year-old gentleman attended his psychiatry follow-up appointment in the clinic. He was recently diagnosed with schizophrenia and was started on risperidone. PMH Schizophrenia DH Risperidone 3mg PO BD.


Question: Select the adverse effect that is most likely to be caused by prolonged use of this medication.

Options:
explanation: Risperidone does not commonly cause tinnitus
name: Tinnitus
label: e
answer: no
explanation: Antipsychotics including risperidone common or very commonly causes galactorrhea. Antipsychotics, whose effects are mediated by the inhibition of dopamine D2 and D4 receptors, can result in extrapyramidal side effects when the D2 receptors in the hypothalamic tuberoinfundibular system is inhibited. This results in an increase in prolactin level causing symptoms such as galactorrhea, amenorrhea and impotence
name: Galactorrhea
label: a
answer: yes
explanation: Carbamazepine causes thrombocytopenia but not risperidone
name: Thrombocytopenia
label: d
answer: no
explanation: Risperidone does not commonly cause hypoglycaemia
name: Hypoglycaemia
label: c
answer: no
explanation: Antipsychotics does not commonly cause alopecia
name: Alopecia
label: b
answer: no

Correct answer: a
Case Presentation: A 65-year-old man attended his GP for the results of his blood test. PMH Type 2 diabetes mellitus, Hypercholesterolemia, Hypertension. DH Atorvastatin 20mg PO daily, Pioglitazone 30mg PO daily, Amlodipine 10mg PO daily, Cholecalciferol 400U OD, Ramipril 2.5mg PO OD.


**On Examination**

BP 135/80mmHg, HR 85, RR 14, Weight 65kg (63kg 4 months ago)

**Investigation**

Total cholesterol 150 mg/dL (100-200), LDL 50mg/dL (0-99), HDL 100mg/dL (39-150)

Question: After ruling out poor diet and lack of exercise, select the prescription that is most likely to contribute to his weight gain.

Options:
explanation: Amlodipine does not commonly cause weight gain
name: Amlodipine 10mg PO daily
label: b
answer: no
explanation: Ramipril does not commonly cause weight gain
name: Ramipril 2.5mg PO daily
label: e
answer: no
explanation: Atorvastatin does not commonly cause weight gain
name: Atorvastatin 20mg PO daily
label: c
answer: no
explanation: Weight gain is recognised as a common or very common side effect of pioglitazone due to fluid retention although the exact mechanism underlying this process is not known
name: Pioglitazone 30mg PO daily
label: a
answer: yes
explanation: Cholecalciferol does not commonly cause weight gain
name: Cholecalciferol 400U PO daily
label: d
answer: no

Correct answer: a
Case Presentation: A 46 year old woman attends a follow-up appointment at her GP. **PMH** hyperlipidaemia. **DH** atorvastatin 20mg PO OD, started three months ago. **FH** father died of heart attack at the age of 53. **SH** current smoker, 15-20 cigarettes a day but currently attending smoking cessation counselling.


**Investigations**

Q-risk score: 14%

Question: Select the most appropriate option to monitor for adverse effects of the atorvastatin at this stage.

Options:
explanation: This should be measured if statin-associated myopathy or rhabdomyolysis is suspected. It is not part of routine monitoring while taking a statin
name: Creatinine kinase
label: b
answer: no
explanation: This has no role or relevance in the monitoring of patients taking statins
name: Full blood count
label: c
answer: no
explanation: It is recommended to measure renal function prior to starting atorvastatin but routine monitoring is not necessary
name: Urea and electrolytes
label: e
answer: no
explanation: It is recommended that lipids be measured prior to starting treatment and may be measured for the duration of taking atorvastatin, but not for assessing the adverse effects of this drug
name: Lipid profile
label: d
answer: no
explanation: It is recommended that liver function should be measured prior to starting treatment and at 3 months and 12 months afterwards as atorvastatin is known to be hepatotoxic
name: Liver function tests
label: a
answer: yes

Correct answer: a
Case Presentation: A 27 year old woman attends the walk-in GUM clinic requesting emergency contraception. She had forgotten to take her combined contraceptive pill for two days in a row at the start of the week and had unprotected sex in the same period.


Her LMP was 5 days ago and she has a regular cycle of 28 days. She has never been pregnant before.

After counselling, it is agreed that she should take ulipristal acetate 30mg PO as a one-off dose for emergency contraception.

Question: Select the most appropriate monitoring option required before administering ulipristal acetate.

Options:
explanation: The patient is reporting regular bleeds with her last one occurring 5 days ago. There still is a minuscule chance she may be pregnant and one may choose to perform a urine pregnancy test before administering ulipristal acetate, but this is not strictly necessary
name: Urine pregnancy test
label: e
answer: no
explanation: There are generally no monitoring requirements prior to administering ulipristal acetate as emergency contraception
name: No routine monitoring is required
label: a
answer: yes
explanation: Hyper/hypotension is not a known adverse effect of this drug
name: Blood pressure
label: b
answer: no
explanation: Ulipristal acetate is metabolised by the liver and as such liver function tests are recommended when it is being used long-term to treat fibroids. This is not necessary if it is taken as a single dose for emergency contraception
name: Liver function tests
label: c
answer: no
explanation: It is not necessary to measure height and weight prior to administering ulipristal acetate
name: Height and weight
label: d
answer: no

Correct answer: a
Case Presentation: An 8 year old girl has been having a nocturnal cough and reduction in exercise tolerance for three weeks. **PMH** hay fever. **DH** salbutamol 100 micrograms inhaler PRN. **SH** non-smoking household, no pets.


**O/E**

RR 11, Temperature 36.7°C. Chest clear.

PEFR: 78% of predicted

She is prescribed beclometasone dipropionate 100 micrograms inhaler, 2 puffs in the morning and 2 puffs in the evening.

Question: Select the most appropriate option to assess the beneficial effects of this treatment.

Options:
explanation: Mast cell tryptase is usually measured following a suspected allergic reaction and has no role in assessing disease control in asthma
name: Serum mast cell tryptase
label: d
answer: no
explanation: This is not a useful marker of disease control in asthma
name: Respiratory rate
label: c
answer: no
explanation: A peak flow diary will give useful information about disease control and whether any modifications to treatment or referral to secondary care is necessary
name: Peak flow
label: a
answer: yes
explanation: This is not a useful marker of disease control in asthma
name: Serum potassium
label: e
answer: no
explanation: This will give a full assessment of asthma severity and disease control, but should not be used routinely
name: Lung function tests
label: b
answer: no

Correct answer: a
Case Presentation: A 34-year-old woman attends her GP with symptoms of tiredness, menstrual irregularities and feeling cold all the time. **PMH** coeliac disease


**O/E**

HR 53, RR 10, BP 106/65, Temperature 35.7°C. Peripheries cool. Mild periorbital oedema. Smooth non-tender goitre on palpation.

Her GP makes a provisional diagnosis of Hashimoto’s thyroiditis. She books the patient for a blood test and prescribes levothyroxine sodium 100 micrograms PO OD.

Question: Select the most appropriate monitoring option to assess the beneficial effects of this treatment.

Options:
explanation: Effective treatment with levothyroxine would be indicated by a resolution of symptoms. The patient’s body temperature may well rise with successful treatment and as a result she may report feeling less cold, but monitoring temperature in of itself is generally not useful as a marker of benefit
name: Temperature
label: e
answer: no
explanation: The patient’s respiratory rate is unlikely to change significantly with successful treatment and is thus not a useful marker of benefit
name: Respiratory rate
label: d
answer: no
explanation: Effective treatment with levothyroxine would be indicated by a resolution of symptoms. A lower heart rate may be purely physiological in some patients and is not a useful marker of effective treatment with levothyroxine
name: Heart rate
label: c
answer: no
explanation: Effective treatment with levothyroxine would be indicated by a resolution of symptoms including an improvement in the patient’s energy levels
name: Patient reports of energy levels
label: a
answer: yes
explanation: The patient’s blood pressure is unlikely to change significantly with successful treatment and is thus not a useful marker of benefit
name: Blood pressure
label: b
answer: no

Correct answer: a