hllj/quesmed huggingface dataset:
Case Presentation:




A 25-year-old lady was admitted to the Respiratory Ward following an exacerbation of asthma. PMH Type 1 diabetes mellitus, Asthma. DH Salbutamol 200micrograms INH PRN, Fluticasone 50 micrograms BD INH 12-hrly, Biphasic insulin detemir (Levemir Penfill) 15 units SC 12-hrly.


 **On Examination**

HR 90/min and regular


BP 125/85 mmHg


RR 25/min


O2 sats 96% on room air


Temperature 37.5oC.


 **Investigations**

||||
|---------------------------|:-------:|--------------------|
|Sodium|140 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|85 µmol/L|60 - 120|


Urinary ketones negative.


Average capillary blood glucose readings are 15 mmol/L prior to breakfast and 5.8 mmol/L prior to evening meal (normal range 3.5-5.5 mmol/L).


VBG Ketones 0.3 mmol/L (<0.6mmol/L)


Question:
Select the most appropriate decision option with regard to the evening dose of insulin based on these data.

Options:
explanation: As his morning blood glucose level is persistently high, adjustments should be made to his long acting evening insulin dose instead of just giving a PRN short acting insulin
name: Biphasic insulin detemir (Levemir Penfill) 15 units SC and soluble insulin (Actrapid ®) 2 units SC
label: b
answer: no
explanation: Decreasing the insulin dose to 13 units would be inappropriate as this could worsen his glycaemic control
name: Decrease Biphasic insulin detemir (Levemir Penfill) to 13 units SC BD
label: c
answer: no
explanation: As his morning blood glucose level is high, the evening insulin dose should be increased, usually by 10% to 20%. As he normally takes 15 units of insulin in the evening, a 10% to 20% increase to 16.5 to 18 units should be made
name: Increase evening Biphasic insulin detemir (Levemir Penfill) to 22 units SC
label: d
answer: no
explanation: The patient has poorly controlled hyperglycaemia, with high levels of blood glucose in the morning. After ruling our DKA with serum and urinary ketones, a dose adjustment should be considered if glucose levels remain high. As his morning blood glucose level is high, the evening insulin dose should be increased, usually by 10% to 20%. As he normally takes 15 units of insulin in the evening, a 10% to 20% increase to 16.5 to 18 units should be made
name: Increase evening Biphasic insulin detemir (Levemir Penfill) to 17 units SC
label: a
answer: yes
explanation: Increasing to 22 units is more than 20% of his usual dose. Variable rate insulin infusion is considered in a hyperglycaemic patients who are nil by mouth and who have failed to respond to adjustments of their usual insulin regime
name: Stop biphasic insulin detemir (Levemir Penfill) SC and start variable rate insulin infusion
label: e
answer: no

Correct answer: a
Case Presentation:




A 75-year-old man is transferred from the Acute Medical Unit to the Care of the Elderly Ward for treatment of his urinary tract infection.


 **On Examination**
BP 115/75 mmHg, HR 95/min and regular, RR 12/min, Temperature 38 C. O2 sats 94% RA.


 **Investigations**
Urine dipstick ++ leucocytes and nitrates


Urine MCS


S Nitrofurantoin


S Trimethoprim


R Amoxicillin


R Co-Amoxiclav


||||
|---------------------------|:-------:|--------------------|
|Sodium|138 mmol/L|135 - 145|
|Potassium|4.8 mmol/L|3.5 - 5.3|
|Urea|8.5 mmol/L|2.5 - 7.8|
|Creatinine|210 µmol/L|60 - 120|
|eGFR|26 mL/min/1.73m<sup>2</sup>|> 60|


Question:
Select the most appropriate decision option with regard to the management of his infection based on these data.

Options:
explanation: Nitrofurantoin should not be prescribed with a eGFR <30 mL/min/1.73m<sup>2</sup>
name: Nitrofurantoin 50mg QDS for 7 days
label: d
answer: no
explanation: For trimethoprim, half the normal dose (200/2 = 100mg) should be used after 3 days if eGFR 15-30 mL/min/1.73m<sup>2</sup> 
name: Trimethoprim 200mg PO BD for 7 days
label: e
answer: no
explanation: Nitrofurantoin should not be prescribed with a eGFR <30 mL/min/1.73m<sup>2</sup>
name: Nitrofurantoin 50mg QDS for 3 days
label: b
answer: no
explanation: For trimethoprim, half the normal dose (200/2 = 100mg) should be used after 3 days if eGFR 15-30 mL/min/1.73m<sup>2</sup>. For UTI in males, antibiotic should be given over a total of 7 days
name: Trimethoprim 200mg PO BD for 3 days, 100mg PO BD for the next 4 days
label: a
answer: yes
explanation: Piperacillin-tazobactam is reserved for patients with complicated UTI and in this situation, there is no evidence to support the susceptibility of the microorganism to piperacillin-tazobactam, hence, is less ideal than trimethoprim
name: Piperacillin-tazobactam 4.5g TDS IV
label: c
answer: no

Correct answer: a
Case Presentation:




A 65-year-old man presents to his GP for review of his blood glucose. He was started on metformin a year ago when his HbA1c was found to be 55 and 58mmol/mol when tested on two separate occasions. PMH Type 2 Diabetes mellitus, Hypertension, Hypercholesterolemia, Chronic pancreatitis. DH Atorvastatin 20mg PO daily, Ramipril 2.5mg PO daily, Metformin 1g BD PO.


 **On Examination**
BP 125/85 mmHg


HR 90/min


RR 16


O2 sats 94% RA


 **Investigations**
HbA1c 65mmol/mol (normal range 20-48 mmol/mol)


Capillary blood glucose 15.3 mmol/L (normal <6.1 mmol/L)


Question:
Select the most appropriate decision option with regard to the treatment of his hyperglycaemia based on these data

Options:
explanation: This option is less ideal for the reason mentioned above with regards to risk involved in patients with acute pancreatitis and as he is only on metformin, he should be started on dual therapy before moving on to triple therapy
name: Triple therapy consisting of metformin 500mg TDS, sitagliptin 100mg OD, gliclazide 40mg OD
label: e
answer: no
explanation: This patient has poorly controlled hyperglycaemia (HbA1c 65) and is already on the maximum tolerable dose of metformin. Due to his background of pancreatitis, an alternative to GLP-1 (liraglutide) and DPP4 inhibitor (sitagliptin) should be considered. DPP4 inhibitor reduces the degradation of GLP-1 by inhibiting the activity of serum DPP-4. An increase in GLP-1 results in an increased availability of incretins, stimulating insulin secretion from pancreatic β-cells. Although the exact causal relationship between DPP-4 inhibitors and GLP-1 analogues with pancreatitis is not well-established, it is generally advised to avoid these classes of medication amongst patients with increased risk of acute pancreatitis due to the significant implication of the risk involved
name: Add gliclazide 40mg OD
label: a
answer: yes
explanation: Although the exact causal relationship between DPP-4 inhibitors and GLP-1 analogues with pancreatitis is not well-established, it is generally advised to avoid these classes of medication amongst patients with increased risk of acute pancreatitis due to the significant implication of the risk involved
name: Add sitagliptin 100mg PO OD to metformin
label: b
answer: no
explanation: Although the exact causal relationship between DPP-4 inhibitors and GLP-1 analogues with pancreatitis is not well-established, it is generally advised to avoid these classes of medication amongst patients with increased risk of acute pancreatitis due to the significant implication of the risk involved
name: Add liraglutide 0.6mg OD SC
label: c
answer: no
explanation: This patient is currently on maximal tolerable dose of metformin, there are other oral hypoglycaemic agents that should be considered prior to starting someone on insulin
name: Switch to biphasic insulin detemir 20 units SC
label: d
answer: no

Correct answer: a
Case Presentation:  A 79-year-old gentleman has been admitted to a general surgical ward. He has recently been treated for a pelvic collection with IV cefuroxime and metronidazole. He has finished his antibiotics and a repeat CT scan of his abdomen and pelvis shows that the collection has resolved. 


Today he is complaining of loose stools.

**PMH** Depression, hypertension, hypercholesterolaemia, osteoporosis,

**DH**

Omeprazole 20mg PO BD, sertraline 50mg PO OD, atorvastatin 20mg PO OD, alendronic acid 10mg PO OD, colecalciferol 800 units PO OD

**Investigations**
Observations:

HR 65 bpm, RR 12, blood pressure 123/67 mmHg, O2 saturations 96% on room air, temperature 37.4

Stool type - 7

C. difficile toxin - positive

Question: Select the most appropriate decision option based on this data

Options:
explanation: Starting vancomycin would be correct however there is no clinical indication for stopping this patient's colecalciferol.
name: Suspend his colecalciferol and start vancomycin 125mg PO QDS
label: b
answer: no
explanation: There is no clinical indication for stopping this patient's colecalciferol.
name: Suspend his colecalciferol
label: c
answer: no
explanation: Starting this patient on vancomycin would be the right thing to do however this is the wrong dose, and you would still also need to suspend the PPI he is taking due to it exacerbating c. difficile infections.
name: Start vancomycin 100mg PO QDS
label: e
answer: no
explanation: This question requires you to know that PPIs increase the risk of clostridium difficile infection. In this case, the gentleman's omeprazole may be contributing to his c. difficile infection and therefore it should be stopped. The c. difficile infection should be treated, the first line treatment is vancomycin 125mg PO QDS (this patient is stable and therefore doesn't need a higher dose).
name: Suspend his omeprazole and start vancomycin PO QDS
label: a
answer: yes
explanation: This patient has a c. difficile infection. Precipitants of said infection should be stopped (in this case the PPI) and antibiotics to treat the c. difficile should be given.
name: No change in treatment required
label: d
answer: no

Correct answer: a
Case Presentation:


A 82-year-old male is brought to the GP by his carer with worsening dysphagia. He has stage 4 Oesophageal cancer for which he is receiving palliative care for.

**PMH** Oesophageal carcinoma, GORD, Hypertension.

**DH** Morphine sulfate M/R 80mg PO BD, Morphine sulfate 10 mg/5 mL solution (Oramorph) 5 mL PO PRN. Paracetamol 1g PO QDS, Ibuprofen 400mg PO TDS, Omeprazole 30mg PO OD, Ramipril 5mg PO OD. He has taken 8 doses of her Oramorph in the last 24 hours.

Due to his worsening dysphagia, the GP decides to convert his analgesic medication to a transdermal fentanyl patch at the same dose equivalent of morphine he is currently receiving.

Question:
Select the most appropriate decision option with regard to his pain management based on these data.

Options:
explanation: This would be equivalent to 90mg Morphine sulfate PO daily.
name: Fentanyl 37.5 microgram/h transdermal patch  72-hourly
label: d
answer: no
explanation: This would be equivalent to 120mg Morphine sulfate PO daily.
name: Fentanyl 50 microgram/h transdermal patch  72-hourly
label: c
answer: no
explanation: Transdermal fentanyl is not available in this preparation.
name: Fentanyl 90 microgram/h transdermal patch  72-hourly
label: e
answer: no
explanation: This would be equivalent to 180mg Morphine sulfate PO daily.
name: Fentanyl 75 microgram/h transdermal patch  72-hourly
label: b
answer: no
explanation: He is currently receiving 80+80+(8x10) = 240mg Morphine sulfate PO daily. This is equivalent to 100 microgram/h fentanyl using a transdermal patch. More information can be found [here.](https://bnf.nice.org.uk/medicines-guidance/prescribing-in-palliative-care/)
name: Fentanyl 100 microgram/h transdermal patch  72-hourly
label: a
answer: yes

Correct answer: a
Case Presentation: A 54-year-old woman attends the GP to discuss her most recent blood test results. She was commenced on atorvastatin 20mg PO ON for primary prevention of cardiovascular events. She describes no issues with the medication and reports no side effects. Her blood test results are below. **Investigations** ALT before treatment: 21 (10 - 50 IU/L) ALT 3 weeks later: 65 (10 - 50 IU/L) 

Question: Select the most appropriate decision option with regard to the atorvastatin based on these data.

Options:
explanation: There is no current indication to stop statin therapy. Statins should be discontinued if serum transaminases are greater than 3 times the upper limit of the reference range, or there are side effects which the patient cannot cope with.
name: Stop atorvastatin 20mg
label: b
answer: no
explanation: Other classes of lipid lowering drugs include ezetimibe, fibrates and new monoclonal antibodies. At this stage there is no indication for stopping or switching to a different medication.
name: Switch to a fibrate
label: e
answer: no
explanation: This is the dose for secondary prevention of cardiovascular events. There is currently no indication for this and given the ALT increase, it would be unwise to increase the dose at this stage.
name: Increase to atorvastatin 80mg
label: d
answer: no
explanation: Although the ALT has increased since commencing treatment, current guidance is that unless serum transaminases are greater than 3 times the upper limit of the reference range, there is no need to discontinue statin therapy.
name: Continue atorvastatin 20mg
label: a
answer: yes
explanation: There is no indication for stopping or switching the statin for this patient.
name: Switch to simvastatin
label: c
answer: no

Correct answer: a
Case presentation: A 85-year-old man was admitted to the Acute Medical Unit for infective exacerbation of COPD.


**PH** Severe COPD, Migraine, GORD, Osteoporosis.

**DH** His current regular medications are listed (below). Weight 60kg.

**On Examination**
Patient complained of loose stools over the past 3 days. Dry mucous membrane, peripheral CRT 3s.

Question 1: Select the TWO prescriptions that are most likely to be contributing to his loose stools (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: Ibuprofen;400mg;oral (PO);8-hourly
label: b
answer: no
name: Omeprazole;40mg;oral (PO);Daily
label: c
answer: no
name: Co-amoxiclav;625mg;oral (PO);Three times a day
label: a
answer: no
name: Ipratropium bromide;40micrograms;inhaled (INH);6-hourly
label: e
answer: no
name: Dalteparin sodium;12500 units;subcutaneous (SC);Daily
label: g
answer: no
name: Colecalciferol (Vitamin D3);800units;oral (PO);Daily
label: f
answer: no
name: Salbutamol;200 micrograms;inhaled (INH);Daily
label: d
answer: no


1. Co-amoxiclav, proton pump inhibitors (omeprazole) commonly cause diarrhea. Oral use of ibuprofen generally do not cause diarrhea.
2. Dalteparin sodium, given for prophylaxis of DVT in medical patients are prescribed at 5000 units daily. 12 500 units is given as treatment dose for a 60kg patient. The indication of dalteparin in this patient is for prophylactic use, not for treatment.
Case presentation: A 55-year-old gentleman presents to his GP with repeated episodes of epistaxis. PH Mild depressive episodes, Osteoarthritis of right knee, Vitamin D deficiency, GORD, Benign Prostatic Hyperplasia, HTN. DH His current regular medicines are listed (below).




 **Investigation**
Platelet count 100 x 109/L (Normal value 150-400 x 109/L )


Question 1: Select the ONE prescriptions that are most likely to be contributing to the low platelet count (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;oral (PO);Daily
label: c
answer: no
name: Paracetamol;1g;oral (PO);6-hourly
label: d
answer: no
name: Ramipril;2.5mg;oral (PO);Daily
label: f
answer: no
name: Tamsulosin hydrochloride;400mg;oral (PO);Daily
label: e
answer: no
name: Citalopram;20mg;oral (PO);Daily
label: a
answer: no
name: Colecalciferol (Vitamin D3);800 units;oral (PO);Daily
label: b
answer: no
name: Amoxicillin;500mg;oral (PO);8-hourly
label: g
answer: no


1. Penicillin (amoxicillin) commonly or very commonly cause thrombocytopenia. PPI and paracetamol also cause thrombocytopenia but are significantly less common
2. Tamsulosin, an alpha blocker that is prescribed for benign prostatic hyperplasia, is given in 400 micrograms daily, not in milligrams.
Case presentation: An 80-year-old woman presents to her GP for her medication review, she complains of fatigue due to poor sleep. PH Osteoporosis, Type 2 diabetes, Dyspepsia, Parkinson Disease, hypertension. DH Her current regular medicines are listed (below).


Question 1: Select the TWO prescriptions that are most likely to be contributing to her sleeping disorders (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: Metformin;500mg;oral (PO);8-hourly
label: f
answer: no
name: Lansoprazole;15mg;oral (PO);Daily
label: e
answer: no
name: Paracetamol;1000mg;oral (PO);Daily
label: g
answer: no
name: Pramipexole;2mg;oral (PO);12-hourly
label: a
answer: no
name: Atenolol;50mg;oral (PO);Daily
label: b
answer: no
name: Cholecalciferol 200 units + calcium carbonate 750mg (Adcal D3 ®);2 tablets;oral (PO);Daily
label: d
answer: no
name: Alendronic acid;70mg;oral (PO);Weekly
label: c
answer: no


1. Pramipexole, a non-ergoline dopamine agonist and systemic beta blockers (atenolol) commonly cause sleeping disorders. Although excess daytime sleepiness and sleep attacks are recognized side effects of pramipexole, the underlying pathophysiology remained controversial. Beta blockers cause night awakening and nightmares, likely due to the inhibition of melatonin secretion, a hormone that is involved in sleep and the body’s circadian clock
2. Pramipexole, given for treatment of Parkinson's Disease has a maximum dose of 3.3mg daily. 2mg 12-hrly is more than the recommended maximum dose and alternative adjuncts should be considered instead.
Case presentation: A 80-year old man is taken to A&E via ambulance after being found lying on the floor by his daughter. His daughter reports that his father has become increasingly drowsy and confused over the past few days. His father has also been complaining of constipation recently. **PH:** Atrial fibrillation, Congestive Cardiac Failure, Type 2 Diabetes Mellitus, Hayfever, Neuropathic pain, Otitis externa **DH:** His current regular prescriptions are listed below


**On examination**: Abbreviated Mental Test Score 6/10. Chest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender. Bruises on left hip with no active bleeding. Pain on external rotation of left leg.
**Vital signs**: BP 125/80, Temperature 36.8°C, HR 80, O2 Sat 99% (room air), RR 18

Question 1: Select the THREE prescriptions that are most likely to be a cause of the drowsiness and confusion (mark them with a tick in column A)
Question 2: Select the TWO prescriptions that are most likely to be a cause of his constipation (mark it with a tick in column B)

Options:
name: Amlodipine;5mg;Oral (PO);Daily
label: b
answer: no
name: Metformin hydrochloride;500mg;Oral (PO);8-hourly
label: a
answer: no
name: Gliclazide;40mg;Oral (PO);Daily
label: g
answer: no
name: Warfarin sodium;5mg;Oral (PO);Daily
label: c
answer: no
name: Carvedilol;3.125mg;Oral (PO);12-hourly
label: d
answer: no
name: Amitriptyline hydrochloride;75mg;Oral (PO);Daily in the evening
label: h
answer: no
name: 5% Chloramphenicol;2-3 drops;Ear drops;8-hourly
label: e
answer: no
name: Promethazine hydrochloride;10mg;Oral (PO);8-hourly
label: f
answer: no


1. Confusion is a common or very common side effect of a beta-adrenoceptor blocker such as carvedilol. Drowsiness is also listed as a common or very common side effect of amitriptyline. Promethazine is also known to cause drowsiness although the frequency of such side effect is unknown. Patients taking these medications should be reminded that their performance of skilled tasks like driving and operating heavy machinery could be affected.
2. Constipation is a common or very common side effect of amlodipine, and can also be caused by amitriptyline due to its anticholinergic activity.
Case presentation: A 9-year old boy arrives at A&E with shortness of breath and wheeze. He presented to his GP two days ago with increased urinary frequency and dysuria. A diagnosis of lower urinary tract infection was made and antibiotic treatment was commenced. He has a past medical history of asthma which has so far been well controlled. His weight is 30kg. His mother who is accompanying him informs that the family has just come back from Nigeria and that they have been taking malaria prophylaxis. PH: Asthma, Allergic rhinitis, Eczema, Lower urinary tract infection, vesicoureteral reflux, Glucose-6-phosphate dehydrogenase (G6PD) deficiency DH: Her current regular prescriptions are listed below


**On examination**: Breathing using accessory muscles, polyphonic expiratory wheeze

**Vital signs**: Temperature 36.6°C, HR 90, O2 Sat 92% (room air), RR 26

Question 1: Select the TWO prescriptions that are contra-indicated or should be used with caution in the context of G6PD deficiency (mark them with a tick in column A)
Question 2: Select the ONE prescription that is most likely to have led to exacerbation of asthma symptoms (mark it with a tick in column B)

Options:
name: Azelastine hydrochloride;1 spray;Oral (PO);Twice daily
label: c
answer: no
name: Chloroquine;225mg;Nebulised (NEB);Once weekly
label: f
answer: no
name: Ibuprofen;200 mg;Oral (PO);8-hourly
label: d
answer: no
name: Salbutamol (100 micrograms,dose metered-dose inhaler);200 micrograms;Inhaled (ING);When required
label: a
answer: no
name: Dermacort hydrocortisone 0.1% cream;-;Topical;Daily
label: e
answer: no
name: Nitrofurantoin;22.5mg;Oral (PO);6-hourly
label: g
answer: no
name: Budesonide;200 micrograms;Inhaled (INH);Once daily in evening
label: b
answer: no


1. Nitrofurantoin is an antibiotic that works by damaging bacterial DNA. Chloroquine is a medication used to prevent and treat malaria. Nitrofurantoin and chloroquine are contra-indicated in patients with G6PD-deficiency because are they known to cause severe haemolytic anaemia.
2. Ibuprofen is known to cause bronchospasm in patients with asthma, especially those with a history of hypersensitivity to aspirin or any other NSAID. Ibuprofen inhibits the activity cyclooxygenase-1 (Cox-1). The inhibition leads to activation of lipoxygenase pathway that in turn increases the release of cysteinyl leukotrienes (Cys-LTs) that induces bronchospasm.
Case presentation: A 23-year-old female attends the GP with migraines. 


**PH** Acne, Eczema, Anxiety, Migraines with aura.
**DH** Her regular medicines are listed (below).

**On Examination**

Temperature 37.2°C, HR 84, RR 16, BP 124/78
Weight 60kg

**Investigations**

Negative human chorionic gonadotrophin (HCG) pregnancy test

Question 1: Select the ONE prescription that is contraindicated in this patient (mark them with a tick in column A)

Question 2: Select the ONE prescription that is the most likely to cause weight gain (mark them with a tick in column B)

Options:
name: Aveeno cream;1;Application Topically;Twice daily
label: a
answer: no
name: Rigevidon (Ethinylestradiol with Levonorgesterel);1 Tablet;PO (Oral);Once daily
label: e
answer: no
name: Paracetamol;1g;PO (Oral);PRN
label: i
answer: no
name: Sumatriptan;100mg;PO (Oral) PRN for migraine;(max dose 300mg per day)
label: f
answer: no
name: Hydrocortisone cream;1 Application (thinly);Topically;Once daily
label: g
answer: no
name: Propranolol;80mg;PO (Oral);Once daily
label: h
answer: no
name: Lymecycline;408mg;PO (Oral);Once daily
label: b
answer: no
name: Adapalene;1 Application (thinly);Topically;Once nightly
label: c
answer: no
name: Benzoyl Peroxide;1 Application;Topically;Once daily (after washing)
label: d
answer: no


1. Rigevidon (Ethinylestradiol with Levonorgestrel) is a combined oral contraceptive pill (COCP). This patient suffers from migraine with aura. The COCP is contraindicated in patients with migraine with aura due to the increased risk of stroke.
2. A common side effect of the COCP is weight gain.