hllj/quesmed huggingface dataset:
Case presentation: A 45-year old man attends his GP appointment complaining of nausea and tiredness. PH: Hypertension, Allergic rhinitis, Hypercholesterolaemia, Peripheral oedema, Vitamin D deficiency DH: His 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.


 **Vital signs**: BP 125/80, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18


 **Investigations**:

||||
|--------------|:-------:|---------------|
|Haemoglobin|130   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|300x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|90 fL|80 - 96|
|Neutrophils|5x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|2x10<sup>9</sup>/L|1.5 - 4.0|
|Sodium|125 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Urea|7 mmol/L|2.5 - 7.8|
|Creatinine|109 µmol/L|60 - 120|
|Thyroid Stimulating Hormone|3.8 mU/L|0.3 - 4.2|
|Free T4|17 pmol/L|9 - 25|


Question 1: Select the THREE prescriptions that are most likely to be a cause of his hyponatraemia (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: Chlortalidone;50mg;Oral (PO);Daily
label: c
answer: no
name: Bumetanide;1mg;Oral (PO);Daily
label: f
answer: no
name: Colecalciferol (Vit D3);800 units;Oral (PO);Daily
label: h
answer: no
name: Losartan potassium;50mg;Oral (PO);Daily
label: b
answer: no
name: Simvastatin;40mg;Oral (PO);Daily
label: e
answer: no
name: Amlodipine;5mg;Oral (PO);Daily
label: a
answer: no
name: Fluoxetine;100mg;Oral (PO);Daily
label: g
answer: no
name: Cetirizine hydrochloride;10mg;Oral (PO);Daily
label: d
answer: no


1. Chlortalidone is a thiazide-like diuretic that inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, leading to reduced Na+ reabsorption. Bumetanide is a loop diuretic that acts on the Na+-K+-2Cl− symporter (NKCC2) in the thick ascending limb of the loop of Henle to inhibit sodium, chloride and potassium reabsorption. Both chlortalidone and bumetanide are known to cause hyponatraemia. Hyponatraemia is also a recognised side effect of fluoxetine. BNF cautions against prescribing fluoxetine to elderly patients with significant hyponatraemia i.e. serum sodium less than 130 mmol/L due to risk of exacerbating or precipitating hyponatraemia.
2. The maximum daily dose of fluoxetine is 60mg.
Case presentation: A 3-year-old girl is brought to the emergency department by her mother in the middle of night. The little girl has developed a fever and a sudden-onset seal-like “barking” cough. Her weight is 15kg PH: Constipation, Anaemia, Rosacea, GORD DH: Her current regular prescriptions are listed below


**On examination**: Seal-like barking cough, hoarse cry and an inspiratory stridor when crying

**Vital signs**: Temperature 37.8°C, HR 125, O2 Sat 99% (room air), RR 30
Croup (acute laryngotracheobronchitis) is suspected and treatment is commenced.

Question 1: Select the ONE prescription that contains a serious dosing error. (mark them with a tick in column A)
Question 2: Select the ONE prescription that is contra-indicated. (mark it with a tick in column B)

Options:
name: Sodium feredetate;2.5ml;Oral (PO);Three times daily
label: a
answer: no
name: Tetracycline;500mg;Oral (PO);Twice daily
label: f
answer: no
name: Adrenaline;5mg;Nebulised (NEB);Once only
label: e
answer: no
name: Macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride;1 sachet;Oral (PO);Daily
label: b
answer: no
name: Dexamethasone;22.5mg;Oral (PO);Once only
label: d
answer: no
name: Paracetamol;180 mg;Oral (PO);6-hourly
label: c
answer: no


1. The dose of dexamethasone for croup is 150 micrograms/kg. The girl is 15kg in weight. Hence, the correct dose that should be prescribed is 2.25mg.
2. Tetracycline is contra-indicated in children under 12 years. Tetracycline binds to calcium and gets deposited in growing bone and teeth. Use of tetracycline in children is associated with teeth staining and dental hypoplasia.
Case presentation: A 35-year old woman presents to her GP with amenorrhoea. She reports that she has missed her period and that her menstrual cycle has been irregular for the past few months. She also notices white, milky discharge from her breasts. Besides that, she also informs that she has been trying to conceive for two years but is not successful. PH: Type 2 Diabetes Mellitus, Schizophrenia, Depression, Migraine, GORD, Gout 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:**
Negative human chorionic gonadotrophin (HCG) pregnancy test
Serum prolactin: 850 mIU/L (<500)


Question 1: Select the THREE prescriptions that are most likely to be contributing to the hyperprolactinaemia (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: f
answer: no
name: Metoclopramide hydrochloride;100mg;Oral (PO);8-hourly when required
label: e
answer: no
name: Allopurinol;100 mg;Oral (PO);Daily
label: g
answer: no
name: Metformin hydrochloride;500 mg;Oral (PO);Three times daily
label: b
answer: no
name: Chlorpromazine hydrochloride;150 mg;Oral (PO);Daily
label: a
answer: no
name: Ibuprofen;400mg;Oral (PO);4-hourly when required
label: d
answer: no
name: Fluoxetine;40 mg;Oral (PO);Daily
label: c
answer: no


1. Hyperprolactinaemia is a common or very common side effect of chlorpromazine and an uncommon side effect of metoclopramide. Both chlorpromazine and metoclopramide have dopamine D2 receptor antagonistic property, leading to disinhibition of excessive prolactin production. Hyperprolactinaemia is also rare or very rare side effect of all selective serotonin reuptake inhibitors (SSRI). A SSRI like fluoxetine is thought to cause hyperprolactinaemia by inducing a 5HT receptor–mediated stimulation of prolactin secretion.
2. The correct dose of metoclopramide for acute migraine should be 10mg and not 100mg.
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: Ibuprofen;400mg;Oral (PO);8-hourly when required
label: e
answer: no
name: Omeprazole;20 mg;Oral (PO);Daily
label: g
answer: no
name: Paracetamol;1 g;Oral (PO);6 -hourly
label: d
answer: no
name: Phenoxymethylpenicillin;5 mg;Oral (PO);6-hourly
label: f
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 24-year-old woman attends the emergency department due to diarrhoea, vomiting and muscle spasms.

**PH** Depression, anxiety, bipolar disorder, fibromyalgia, Raynaud's syndrome, systemic lupus erythematosus

**DH** Her regular medicines are listed (below). Weight 67kg.

**On Examination**
HR 128/min regular rhythm, BP 164/97 mmHg, profusely sweating, dilated pupils.

Question 1: Select the TWO prescriptions that are most likely to have interacted with her sertraline to cause this presentation (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: Hydroxychloroquine;200mg;PO;OD
label: f
answer: no
name: Nifedipine;5mg;PO;TDS
label: e
answer: no
name: Tramadol hydrochloride;1g;PO;QDS
label: d
answer: no
name: Sertraline;50mg;PO;OD
label: a
answer: no
name: Ibuprofen;400mg;PO;QDS
label: g
answer: no
name: Lithium carbonate (Liskonum);450mg;PO;OD
label: b
answer: no
name: Lansoprazole;30mg;PO;OD
label: h
answer: no
name: Paracetamol;1g;PO;QDS
label: i
answer: no
name: Gabapentin;300mg;PO;TDS
label: c
answer: no


1. This patient is experiencing serotonin syndrome. This can be inferred from the classic symptoms of diarrhoea, vomiting and muscle spasms combined with the dilated pupils and profuse sweating seen on examination. Tramadol and lithium increase the risk of serotonin syndrome in patient's taking sertraline. Tramadol is does this by increasing the concentration of serotonin in the synapses between the serotonergic neurones in the brain stem.
2. The max dose of tramadol should be 400mg daily. This patient would be receiving 10 times the maximum daily dose.
Case presentation: A 83-year-old gentleman attends his GP due to issues with his sleep.


**PH** Atrial fibrillation, hypercholesterolaemia, COPD, gout, benign prostatic hyperplasia, hypertension, depression

**DH** His regular medicines are listed (below). Weight 54kg.

Question 1: Select the THREE prescriptions that are most likely to be a cause of his issues with sleeping (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: Bisoprolol;10mg;PO;OD
label: b
answer: no
name: Tamsulosin;400 micrograms;PO;OD
label: g
answer: no
name: Allopurinol;200mg;PO;OD
label: e
answer: no
name: Mirtazapine;30mg;PO;OD
label: f
answer: no
name: Apixaban;5mg;PO;BD
label: a
answer: no
name: Paracetamol;1g;PO;QDS
label: h
answer: no
name: Atorvastatin;40mg;PO;OD
label: c
answer: no
name: Felodipine;5mg;PO;OD
label: i
answer: no
name: Salbutamol;200 micrograms;INH;PRN
label: d
answer: no


1. Beta blockers, statins and mirtazapine all commonly can cause sleep disorders. Beta-blockers interfere with sleep by reducing melatonin levels due to inhibition of beta-1 adrenergic receptors. SSRIs disturb the regulation of muscle tone during REM sleep and exacerbate bruxism.
2. The maximum dose of apixaban in this patient is 2.5mg BD, as they are >80 years of age and <60kg. Other indications for reduced apixaban usage include: serum creatinine 133 micromol/litre and over, and patients with two of these criteria require reduced dosing.
Case Presentation: A 71 year old woman is on the acute admissions unit being treated for acute confusion, urinary frequency and dysuria. **PH** breast cancer, focal segmental glomerulosclerosis. **DH** anastrozole 1mg PO OD, furosemide 120mg PO BD, atorvastatin 40mg PO ON, calcichew D3. Previous adverse drug reaction to penicillin – angioedema.


**O/E**

HR 84, RR 14, BP 147/76, O2 98% RA, Temperature 37.8°C, AMTS 4/10.

**Investigations**

U&Es: Na 143, K 4.7, Cl 103, Ur 6.0, Cr 210 (baseline 180), eGFR 32mL/min/1.73m^2

Urine MCS grows gram-negative rods (R=resistant, S=sensitive):

Trimethoprim – R

Nitrofurantoin – S

Pivmecillinam – S

Amoxicillin – S

Fosfomycin – S

Question: Select the most appropriate management at this stage.

Options:
explanation: Pivmecillinam cannot be given as the patient is penicillin-allergic
name: Pivmecillinam hydrochloride 200mg PO TDS
label: d
answer: no
explanation: Once a good first-line agent to treat uncomplicated lower urinary tract infections, there have been rising rates of antimicrobial resistance to trimethoprim recorded in many localities. Trust antibiotic guidelines should be consulted before prescribing this drug
name: Trimethoprim 200mg PO BD
label: e
answer: no
explanation: Amoxicillin cannot be given as the patient is penicillin-allergic
name: Amoxicillin 500mg PO TDS
label: b
answer: no
explanation: Nitrofurantoin concentrates well in urine but requires adequate remaining renal function and should be avoided in patients with eGFR <45
name: Nitrofurantoin 100mg PO BD
label: c
answer: no
explanation: Fosfomycin is an acceptable alternative in treating uncomplicated lower urinary tract infections if first-line treatments are ineffective or contraindicated
name: Fosfomycin 3g PO OD
label: a
answer: yes

Correct answer: a
Case Presentation: A 28 year old woman presents to her GP with a longstanding history of acne. She has tried various topical creams and ointments in the past that have only resulted in very modest improvement, and wonders if there is anything else that can be prescribed. **PH** acne vulgaris. **DH** benzoyl peroxide gel, azelaic acid 20% cream (Skinoren).


Her BMI is 28kg/m^2. On further questioning, she also reveals that she has had to engage in waxing her upper lip and chin since the age of 17, and describes erratic menstrual cycles ranging anywhere from 21 days to as long as 90 days. She has never been pregnant before, is sexually active and uses barrier protection as contraception as she is not looking to start a family.

Question: Select the most appropriate management at this stage.

Options:
explanation: For females with PCOS that have not improved following treatment with a first line option such as topical treatments, consider adding ethinylestradiol with cyproterone (co-cyprindiol) and review at 6 months, as per [NICE Guidance.](https://www.nice.org.uk/guidance/ng198/chapter/Recommendations)
name: Co-cyprindiol 2000/35 micrograms PO OD
label: a
answer: yes
explanation: This is a combined contraceptive pill formulation. This is recommended as second line treatment (though it is unlicensed) for acne in patients with PCOS if co-cyprindiol is ineffective, as per [NICE Guidelance.](https://www.nice.org.uk/guidance/ng198/chapter/Recommendations)
name: Combined oral contraceptive pill
label: c
answer: no
explanation: Isotretinoin is a retinoid medication used to treat severe acne vulgaris. It should not be prescribed in the primary care setting or to a woman of childbearing age absent a pregnancy prevention plan due to its potent teratogenic effects
name: Isotretinoin 20mg PO BD
label: b
answer: no
explanation: This is an alternative topical treatment for acne vulgaris
name: Nicotinamide gel topical BD
label: d
answer: no
explanation: This is an oral treatment option for acne vulgaris that has not responded to topical treatments
name: Tetracycline 500mg PO BD
label: e
answer: no

Correct answer: a
Case Presentation: A 48 year old man presents to his GP with a 48 hour history of pain in his right foot. **PH** type 2 diabetes, GORD, gout. **DH** metformin hydrochloride 500mg PO TDS, sitagliptin 100mg PO OD, esomeprazole 20mg PO OD, allopurinol 200mg PO OD, paracetamol 1g PO QDS.


**O/E**

Swollen, erythematous 1st metatarsophalangeal joint on right foot. No other joints involved. Left foot grossly normal.

Temperature 36.4°C.

Question: Select the most appropriate management at this stage.

Options:
explanation: Patients with gout who are taking anti-uric acid medications should not discontinue their drugs during an acute flare as this can worsen symptoms
name: Stop allopurinol and prescribe prednisolone 20mg PO for 7 days
label: e
answer: no
explanation: Patients with gout who are taking anti-uric acid medications should not discontinue their drugs during an acute flare as this can worsen symptoms
name: Stop allopurinol and prescribe naproxen sodium 500mg PO stat
label: d
answer: no
explanation: Patients with gout who are taking anti-uric acid medications should not switch their drugs during an acute flare as this can worsen symptoms
name: Change allopurinol to febuxostat 120mg PO OD
label: b
answer: no
explanation: Patients with gout who are taking anti-uric acid medications should continue their drugs and receive treatment with anti-inflammatories. As NSAIDs should be avoided in this patient, colchicine can be given as an alternative
name: Continue allopurinol and prescribe colchicine 500 micrograms PO BD for 3 days
label: a
answer: yes
explanation: Patients with gout who are taking anti-uric acid medications should continue their drugs and receive treatment with anti-inflammatories. NSAIDs are generally recommended first line but this patient has a history of GORD and hence they would not be suitable
name: Continue allopurinol and prescribe diclofenac sodium 75mg PO BD for 7 days
label: c
answer: no

Correct answer: a
Case Presentation: A 54 year old man attends a follow-up appointment at his GP. Six months ago, he was previously diagnosed with type 2 diabetes and started on metformin hydrochloride 500mg PO OD. This has since been up-titrated to 500mg PO TDS, then 500mg PO QDS.


**Investigations**

HbA1C (3 months ago): 64 mmol/mol

HbA1C (now): 61 mmol/mol

Urine dipstick: NAD

Question: Select the most appropriate management at this stage.

Options:
explanation: The patient is already receiving 2g of metformin hydrochloride and as such this prescription would not effect any significant change to the overall medical treatment this patient is currently receiving
name: Change his prescription to metformin hydrochloride modified release 2g PO OD
label: e
answer: no
explanation: Repaglinide is an oral antidiabetic medication used to treat type 2 diabetes. It is less preferred than sulfonylureas
name: Add repaglinide 500 micrograms PO with meals to his current prescription
label: c
answer: no
explanation: This is a GLP-1 mimetic that is used to treat type 2 diabetes. It should not be prescribed in the primary care setting and is usually only considered failing treatment with more preferred oral antidiabetic medications
name: Add exenatide 5 micrograms SC BD to his current prescription
label: b
answer: no
explanation: In treating type 2 diabetes, it is recommended that a second antidiabetic drug be added following an inadequate response to maximal therapy with metformin
name: Add gliclazide 40mg PO OD to his current prescription
label: a
answer: yes
explanation: This prescription would exceed the recommended maximum dose of metformin which is 2g per day
name: Change his prescription to metformin hydrochloride 1g PO TDS
label: d
answer: no

Correct answer: a
Case Presentation: A 2-year-old girl is brought into A&E by her father. She has been unwell for 24 hours. She is drowsy and disinterested in playing. She has recently developed a non-blanching rash over her torso. **PH** None **DH**  NKDA


**On examination**
The patient is drowsy with her eyes closed.

Non-blanching erythematous rash seen over her torso.

HR 134, RR 32, Capillary Refill 3 seconds

Weight: 13kg

**Investigations**

None performed yet

Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has suspected meningitis with meningococcal septicaemia. Intramuscular Benzylpenicillin is the most appropriate treatment in a pre-hospital environment, i.e. general practice, community, or ambulance. As this patient is already at A&E, IV treatments would be available and more appropriate.
name: Benzylpenicillin 600mg IM
label: b
answer: no
explanation: This patient has suspected meningitis with meningococcal septicaemia. IV Cefotaxime or Ceftriaxone would be the most appropriate initial treatment in a hospital setting.
name: Cefotaxime 650mg IV
label: a
answer: yes
explanation: Phenoxymethylpenicillin is the chosen antibiotic to treat tonsillitis, oral infections and otitis media. This patient has suspected meningitis with meningococcal septicaemia.
name: Phenoxymethylpenicillin 125mg PO (Oral)
label: e
answer: no
explanation: Flucloxacillin is the chosen antibiotic to treat infections such as otitis externa and severe pneumonia in children. This patient has suspected meningitis with meningococcal septicaemia.
name: Flucloxacillin 325mg IM
label: d
answer: no
explanation: IV Amoxicillin is the treatment for meningitis caused by listeria. This patient has suspected meningitis with meningococcal septicaemia.
name: Amoxicillin 650mg IV
label: c
answer: no

Correct answer: a
Case Presentation: A 34 year old man attends an outpatient IBD clinic for a review of his ulcerative colitis. 


He has recently been discharged after having a first flair of mild-moderate disease. He is experiencing no symptoms.

**PH** Ulcerative colitis

**DH** Nil. NKDA.

**On examination**

Temperature 36.9°C, HR 62, RR 12, BP 114/73, O2 98% RA

Abdomen is soft and non-tender.

Question: Select the most appropriate management at this stage.

Options:
explanation: Whilst it is correct to prescribe an oral aminosalicylate, this dosage of sulfasalazine is for inducing remission NOT maintaining it.
name: Prescribe sulfasalazine 2g PO QDS
label: d
answer: no
explanation: This patient has had a mild-moderate exacerbation of his ulcerative colitis. To maintain remission following this severity of episode it is appropriate to prescribe an oral aminosalicylate, in this case sulfasalazine.
name: Prescribe sulfasalazine 500mg PO QDS
label: a
answer: yes
explanation: This patient is clinically well, there is no need to readmit him.
name: Admit to hospital for a course of IV prednisolone
label: c
answer: no
explanation: This patient has had a mild-moderate exacerbation of his ulcerative colitis. Prescribing oral prednisolone to maintain remission is not appropriate.
name: Prescribe prednisolone 10mg PO OD
label: b
answer: no
explanation: This patient has just had their first exacerbation of ulcerative colitis. Offering no pharmacological intervention would most certainly mean a further exacerbation of ulcerative colitis in the near future.
name: Offer lifestyle advice
label: e
answer: no

Correct answer: a