hllj/quesmed huggingface dataset:
Case Presentation: A 68 year old man attends his GP for a COPD review as he is feeling breathless.


**PH** COPD, hypertension, hypercholesterolaemia

**DH** salbutamol 200 micrograms INH QDS, amlodipine 10mg PO OD, atorvastatin 20mg PO OD. NKDA

**On examination**

Temperature 37.4°C, HR 74, RR 22, BP 115/78, O2 96% RA.

Audible wheeze heard in all lung fields.

**Investigations**

Hb 126, WCC 8.3, Plts 303 x 10<sup>9</sup>, eosinophils 0.1 x 10<sup>9</sup>L, CRP 2

Question: Select the most appropriate management at this stage.

Options:
explanation: You cannot increase the dose of salbutamol to 400 micrograms INH QDS, he is already on the max dose of 200 micrograms INH QDS.
name: Increase the dose of salbutamol to 400 micrograms INH QDS
label: c
answer: no
explanation: This patient has COPD that isn't controlled on his current medication. This treatment option is for a pneumonia/acute infective exacerbation of COPD which this gentleman doesn't have.
name: Prescribe amoxicillin 500mg PO TDS
label: e
answer: no
explanation: This patient has COPD that isn't controlled on his current medication. It wouldn't be the correct decision to stop his salbutamol as his condition isn't controlled on this - stopping this medication would make his condition worse.
name: No change to his medication
label: b
answer: no
explanation: This patient has COPD that isn't controlled on his current medication. This isn't an acute exacerbation as his observations are stable and his bloods are unremarkable. He has no signs of steroid responsiveness so should be stepped up the COPD treatment ladder to a LAMA + LABA.
name: Prescribe a long acting muscarinic antagonist and a long acting beta agonist
label: a
answer: yes
explanation: This patient has COPD that isn't controlled on his current medication. This treatment option is for a pneumonia/acute infective exacerbation of COPD which this gentleman doesn't have.
name: Admit to hospital with co-amoxiclav 1.2g IV TDS and clarithromycin 500mg IV BD
label: d
answer: no

Correct answer: a
Case Presentation: A 16 year old boy is brought to the emergency department with shortness of breath. His mother says he has been complaining of feeling really thirsty for the last couple days. 




 **PH** Nil.


 **DH** Nil. NKDA


 **On examination**
Temperature 37.6°C, HR 104, RR 24, BP 114/72, O2 95% RA.


Respiratory exam: deep laboured breathing seen.


 **Investigations**

||||
|--------------|:-------:|------------------|
|pH|7.31|7.35 - 7.45|
|PaO₂|8.0 kPa|11 - 15|
|PaCO₂|3.8 kPa|4.6 - 6.4|
|Bicarbonate|23 mmol/L|22 - 30|


Blood glucose: 22 mmol/L (<6.1 mmol/L)


Blood ketones: 3.4 mmol/L (normal <0.6 mmol/L)


Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.
name: Prescribe and give a fixed rate insulin infusion of 0.1 units/kg/hour first
label: b
answer: no
explanation: This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.
name: Prescribe and give 500ml of 0.9% NaCl STAT first
label: a
answer: yes
explanation: Whilst you would want to give a fluid bolus first, 250ml is not enough. There is no evidence in the stem of the question that you should be concerned about fluid overload in this patient therefore 500ml STAT is an appropriate volume of fluid to give.
name: Prescribe and give 250ml of 0.9% NaCl STAT first
label: e
answer: no
explanation: This patient has diabetic ketoacidosis. This can be inferred due to the high blood glucose, high blood ketones and acidosis seen on the ABG. The first thing that should be prescribed and given in DKA is a 500ml fluid bolus STAT, then a fixed rate insulin infusion should be set up.
name: Prescribe and give a fixed rate insulin infusion of 1 units/kg/hour first
label: d
answer: no
explanation: This is an incorrect option. This patient is in DKA and needs pharmacological intervention otherwise their condition will deteriorate.
name: Continue to monitor observations, blood glucose and blood ketones
label: c
answer: no

Correct answer: a
Case Presentation: A 31-year-old female attends the GP complaining of pain on urination and urinating more frequently. She is 12 weeks pregnant, and the pregnancy has been uncomplicated so far. She is afebrile and there is no visible haematuria. **PH** Nil **DH** Nil Allergy to penicillin.


**On examination**

Warm and well perfused, CRT 2s. Mild suprapubic tenderness on palpation.

Temperature 37.1°C, HR 84, RR 12, BP 115/78, O2 94% RA

**Investigations**

Urine dipstick: Nitrites ++, all other parameters negative.

Question: Select the most appropriate management at this stage.

Options:
explanation: This is the correct choice of antibiotic, dose and duration for uncomplicated lower UTI without visible haematuria in pregnancy, in accordance to NICE Guidelines.
name: Nitrofurantoin MR 100mg BD for 7 days
label: a
answer: yes
explanation: Trimethoprim should be avoided in the first trimester of pregnancy as it is a folate antagonist and so would be teratogenic (increasing risk of neural tube defects).
name: Trimethoprim 200mg BD 3 days
label: e
answer: no
explanation: Cefelexin is a 2nd line antibiotic for lower UTIs in pregnancy.
name: Cefelexin 500mg for 7 days
label: d
answer: no
explanation: This is the correct choice of antibiotic and dose, however the duration should be 7 days. 3 day courses are reserved for uncomplicated lower UTIs outside of pregnancy.
name: Nitrofurantoin MR 100mg BD for 3 days
label: b
answer: no
explanation: NICE recommend amoxicillin only in the presence of culture results and proven sensitivity. This patient is also allergic to penicillin and so it would not be appropriate regardless.
name: Amoxicillin 500mg TDS for 7 days
label: c
answer: no

Correct answer: a
Case presentation: A 55-year-old man attends the diabetes clinic for review of his diabetic medication. He still complains of thirst and frequent urination despite the up-titration of his metformin dose 3 months ago.  

PMH: Type 2 Diabetes Mellitus, Hypertension
DH: Metformin hydrochloride 1g PO BD, Captopril 50mg PO BD
Investigations: HbA1c 65 mmol/mol (20-42)
The patient is advised to add a new prescription of gliclazide 40mg PO daily to his current treatment regime.

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

Options:
explanation: Gliclazide is usually taken life-long
name: Gliclazide can only be used for short-term treatment to prevent long-term side effects
label: b
answer: no
explanation: Gliclazide is a sulfonylurea that increases the amount of insulin produced by the body
name: Gliclazide is a biguanide that decreases glucose production by liver
label: c
answer: no
explanation: If a dose of gliclazide is missed, patients are advised to take the next dose at the usual time. Patients should not take a double dose to make up for the forgotten dose
name: If he has forgotten to take gliclazide the day before, he should take a double dose to make up for the forgotten dose
label: d
answer: no
explanation: Gliclazide can cause weight gain by increasing the concentration of insulin, which is an anabolic hormone that promotes fat storage
name: Gliclazide may cause weight loss
label: e
answer: no
explanation: Gliclazide can sometimes lead to hypoglycaemia due to the increase in insulin synthesis. Hence, patients are advised to avoid missing meals and to carry a source of sugar with them at all times
name: He should avoid missing meals to prevent low blood sugar from happening
label: a
answer: yes

Correct answer: a
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 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
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 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

Correct answer: a
Case presentation: A 35-year-old man attends the inflammatory bowel clinic to discuss about the maintenance therapy for his Crohn’s disease. The thiopurine methyltransferase (TPMT) test that was done shows that he has absent TPMT activity.  

PMH: Crohn’s disease, Vitiligo, Grave’s disease
DH: Carbimazole PO 15mg OD
He is advised to commence treatment with Methotrexate 10mg PO once weekly.

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

Options:
explanation: Before treatment, patients should have full blood count and renal and liver function tests done. ECG does not constitute part of the pre-treatment screening
name: He needs to get an ECG as part of the pre-treatment screening
label: c
answer: no
explanation: Patients should report to their doctors if they experience painful oral ulcers that come and go because they maybe suggestive of ulcerative stomatitis which is one of the first signs of gastro-intestinal toxicity
name: It is normal to get painful oral ulcers that come and go during the course of treatment and that he should not discontinue treatment because of this
label: e
answer: no
explanation: Methotrexate is an immunosuppressant that functions as anti-folate. Hence, folic acid is usually co-prescribed to reduce the mucosal and gastrointestinal side effects of methotrexate. Patients are advised to take their folic acid on the day after their methotrexate as taking them on the same day may prevent methotrexate from working properly
name: He should take folic acid right after taking methotrexate to reduce mucosal side effects of methotrexate
label: b
answer: no
explanation: Methotrexate is an immunosuppressant that functions as anti-folate. It is teratogenic, hence patients are advised to stop taking methotrexate for 6 months before attempting to conceive a baby with their partners
name: He needs to stop taking methotrexate for 6 months before attempting to conceive a baby with his partner
label: a
answer: yes
explanation: Methotrexate commonly causes diarrhoea and not constipation
name: Constipation is a common side effect of methotrexate
label: d
answer: no

Correct answer: a
Case Presentation: A 38-year-old woman attends a follow up appointment at her GP for the results of her blood tests.




 **PMH** Depression, Asthma


 **DH** Salbutamol 200 micrograms INH PRN, Sertraline 50mg PO OD. NKDA


 **SH** Active smoker, smoking 10 cigarettes a day (5 pack year history). Drinks 20-30 units of alcohol a week.


 **Investigations**


||||
|---------------------------|:-------:|------------------------------|
|Thyroid Stimulating Hormone|<0.1 mU/L|0.3 - 4.2|
|Free T4|44 pmol/L|9 - 25|
|Free T3|18 pmol/L|3.1 - 6.8|


Based on her blood results she is diagnosed with hyperthyroidism. It is decided that she will be started on carbimazole 15mg PO OD.


Question: Select the most appropriate piece of information that should be relayed to this patient prior to starting carbimazole

Options:
explanation: There is no recognised interaction between sertraline and carbimazole
name: To stop taking her sertraline
label: e
answer: no
explanation: Smoking can potentially reduce the efficacy of hyperthyroidism treatment however this isn't the most important thing to tell her out of the options provided.
name: To stop smoking
label: c
answer: no
explanation: Treatment with carbimazole can cause bone marrow suppression. This is very serious side effect of carbimazole and needs to be mentioned when counselling on the drug. Any signs of infection, especially a sore throat should be reported immediately. After this, a full blood count should be taken. If this full blood count shows neutropenia then carbimazole should be stopped immediately.
name: To report having a sore throat
label: a
answer: yes
explanation: Mood changes are not a recognised side effect of carbimazole treatment
name: To report any changes to mood
label: b
answer: no
explanation: Alcohol can still be consumed whilst taking carbimazole. This patient however is above the recommended weekly limit so should look to reduce her alcohol consumption if possible.
name: To stop drinking alcohol
label: d
answer: no

Correct answer: a
Case presentation: A 19-year-old man attends the dermatology clinic for his acne vulgaris medication. He has been taking tetracycline as instructed however his condition is not improving.



**PH**
Acne vulgaris

**DH**
Tetracycline 500mg PO BD

Due to his ongoing issues with his acne, his dermatologist commences him on isotretinoin.

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

Options:
explanation: Patients who are taking isotretinoin require their hepatic function and serum lipids to be measured before starting treatment, one month after starting treatment and then on a three monthly basis.
name: That he will require serum lipid monitoring every 6 months
label: c
answer: no
explanation: Patients who are taking isotretinoin require their hepatic function and serum lipids to be measured before starting treatment, one month after starting treatment and then on a three monthly basis.
name: That he will require annual visual acuity monitoring
label: e
answer: no
explanation: Dizziness is listed as a rare/very rare side effect of isotretinoin so he is unlikely to experience this.
name: That he will likely experience dizziness when taking isotretinoin
label: b
answer: no
explanation: Isotretinoin has been linked to increased risk of depression and suicide therefore it is very important that the patient is informed to report any changes in their behaviour or mood after starting isotretinoin.
name: To report any changes in his mood or behaviour
label: a
answer: yes
explanation: Nausea is listed as a rare/very rare side effect of isotretinoin so he is unlikely to experience this.
name: That he will likely experience nausea when taking isotretinoin
label: d
answer: no

Correct answer: a
Case presentation: A 59-year-old man attends his GP complaining of chest pain. This chest pain is central, comes on with exercise and goes away with rest.






 **PH**
Hypertension


 **DH**
Ramipril 5mg PO OD


 **Investigations**


ECG - normal sinus rhythm


Troponin I 3 ng/L (<14 ng/L)


It is decided that this gentleman has stable angina and should be given GTN (glyceryl trinitrate) spray for symptomatic relief.


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

Options:
explanation: Regular blood pressure monitoring is only required in patients receiving IV nitrates.
name: He will need regular blood pressure monitoring
label: c
answer: no
explanation: Regular heart monitoring is only required in patients receiving IV nitrates.
name: He will need regular heart rate monitoring
label: d
answer: no
explanation: Dizziness is a very common side effect of GTN, therefore when taking GTN it is advised that patient's sit down so that they do not fall.
name: He should sit down if possible when taking his GTN spray
label: a
answer: yes
explanation: GTN is administered sublingually (under the tongue), not into the buccal mucosa.
name: He should administer his GTN spray into the buccal mucosa
label: e
answer: no
explanation: Diarrhoea is an uncommon side effect of GTN therefore he is not likely to experience it.
name: He is likely to experience diarrhoea when taking GTN
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: 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
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: Amlodipine does not commonly cause weight gain
name: Amlodipine 10mg PO daily
label: b
answer: no

Correct answer: a
Case Presentation: A 75-year-old man is recovering on the Orthopaedic Ward following an elective left knee replacement two days ago. Post-operatively, he was prescribed paracetamol, an NSAID and a weak opioid for pain relief. On the second day after his operation, he developed tachycardia. An ECG was performed showing sinus tachycardia with prolongation of QT interval. PMH Severe depression, Parkinson’s disease, IBD. DH Citalopram 40mg OD, Paracetamol 1g QDS PO, Ibuprofen 400mg TDS, Co-beneldopa 50mg BD, Rotigotine 8mg TD OD


Question: Select the prescription that is most likely to contribute to the prolongation of his QT interval

Options:
explanation: Rotigotine does not commonly prolongs QT interval
name: Rotigotine 8mg OD
label: e
answer: no
explanation: Paracetamol does not commonly prolongs QT interval
name: Paracetamol 1g QDS
label: c
answer: no
explanation: Citalopram and escitalopram are examples of drugs that are used for depressive illness. They can commonly cause side effects including prolongation of QT interval especially when other risk factors are present such as age extremity, stress or shock. The exact mechanism of the effect of citalopram on QT interval, however, is not known
name: Citalopram 40mg OD
label: a
answer: yes
explanation: Ibuprofen does not commonly prolongs QT interval
name: Ibuprofen 400mg TDS
label: b
answer: no
explanation: C0-beneldopa does not commonly prolongs QT interval
name: Co-beneldopa 50mg BD
label: d
answer: no

Correct answer: a
Case presentation: A 40-year-old man visits his GP for medication review.  

PMH: Diabetes Mellitus, Hypertension
DH: Metformin Hydrochloride 500 mg PO TDS, Captopril 75 mg PO BD
Observations: Temperature 36.5, Respiratory rate 14, Blood pressure 165/95, Heart rate 76, Oxygen saturation 100% (on air)
The patient is advised to add Amlodipine 5 mg PO OD to his current treatment regime in view that his blood pressure is not well controlled

Question: Select the adverse effect that is most likely to be caused by this treatment

Options:
explanation: Gingival hyperplasia is an uncommon side effect of all calcium channel blockers
name: Gingival hyperplasia
label: b
answer: no
explanation: Hyperglycaemia is a rare or very rare side effect of amlodipine
name: Hyperglycaemia
label: c
answer: no
explanation: Peripheral neuropathy is a rare or very rare side effect of amlodipine
name: Peripheral neuropathy
label: e
answer: no
explanation: Peripheral oedema is a common or very common side effect of all calcium channel blockers. It is thought to be caused by arteriolar dilation that leads to increasing capillary pressure and extravasation of fluids into the surrounding tissues
name: Peripheral oedema
label: a
answer: yes
explanation: Increased muscle tone is a rare or very rare side effect of amlodipine
name: Increased muscle tone
label: d
answer: no

Correct answer: a
Case presentation: A 34-year-old pregnant woman is admitted to hospital for community-acquired pneumonia. She is a primigravida and is currently 22 weeks into her pregnancy. She has hyperemesis gravidarum and is not able to tolerate oral medication well.  

Observations: Temperature 37.5, Respiratory rate 32, Blood pressure 88/64, Heart rate 76
On examination: Coarse crackles at left lung base, normal antenatal examination
The junior doctor would like to discuss with the obstetric consultant commencing treatment with Co-amoxiclav 1.2 g TDS because the junior doctor is concerned that co-amoxiclav may increase the risk of a particular neonatal condition.

Question: Select the neonatal condition that is most likely to be caused by Co-amoxiclav

Options:
explanation: Co-amoxiclav is not known to cause auditory nerve damage. On the other hand, streptomycin is associated with foetal ototoxicity
name: Auditory nerve damage
label: d
answer: no
explanation: Co-amoxiclav is not known to discolour the teeth. On the other hand, tetracycline and doxycycline are associated with bone and teeth discolouration
name: Teeth discolouration
label: c
answer: no
explanation: Co-amoxiclav is not known to cause hepatic failure in neonates
name: Hepatic failure
label: e
answer: no
explanation: Co-amoxiclav is associated with an increased risk of necrotising enterocolitis in neonates
name: Necrotising enterocolitis
label: a
answer: yes
explanation: Co-amoxiclav is not known to cause cholestatic jaundice in neonates
name: Cholestatic jaundice
label: b
answer: no

Correct answer: a