hllj/quesmed huggingface dataset:
Case presentation: A 78-year-old diabetic man attends an appointment with the diabetic nurse to monitor his blood glucose.



**PH**
Type 2 diabetes mellitus, hypertension, hypercholesterolaemia

**DH**
Metformin 500mg PO BD, ramipril 10mg OD, amlodipine 10mg OD, atorvastatin 20mg PO OD.

Investigations: HbA1c 68 mmols/mol (<48 mmols/mol)

As this gentleman has a high HbA1c it is decided he should be started on another anti-diabetic medication. One of the medications offered to treat his diabetes includes pioglitazone.

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

Options:
explanation: Visual acuity is not routinely measured before starting pioglitazone.
name: Visual acuity should be measured before starting pioglitazone
label: e
answer: no
explanation: There isn't an increased risk of prostate cancer when taking pioglitazone, there is however an increased risk of bladder cancer.
name: There is an increased risk of prostate cancer in patients who take pioglitazone
label: c
answer: no
explanation: Incidence of heart failure is increased when patients use insulin and pioglitazone together. If the patient has a previous cardiac history such as a myocardial infarction, the risk is also increased. If a patient develops heart failure on pioglitazone (or already has heart failure), the pioglitazone should be stopped.
name: If he needs to use insulin alongside pioglitazone he is at an increased risk of developing heart failure
label: a
answer: yes
explanation: Renal function is not routinely measured before starting pioglitazone.
name: Renal function should be measured before starting pioglitazone
label: d
answer: no
explanation: Insomnia is an uncommon side effect of pioglitazone, therefore it is not a likely side effect he will experience.
name: He is likely to experience insomnia after starting pioglitazone
label: b
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: 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
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

Correct answer: a
Case presentation: A 74-year-old man attends warfarin clinic to have his INR checked. He has recently had COVID-19.



**PH**
Atrial fibrillation, hypertension, hypercholesterolaemia

**DH**
7.5mg warfarin PO OD, ramipril 5mg PO OD, atorvastatin 20mg PO OD

**Investigations** INR 3.8 (2.0-3.0)

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

Options:
explanation: Acute illness can exaggerate the effect of warfarin and indicate a need to reduce dosage. Given this man has had a recent COVID-19 infection and his INR is out of therapeutic range for warfarin he will likely need his warfarin dose reducing.
name: His warfarin does should be reduced
label: a
answer: yes
explanation: Renal function is not routinely monitored in patients using warfarin.
name: He is likely to need renal monitoring if his warfarin dose needs changing
label: e
answer: no
explanation: There are no interactions between ramipril and warfarin, it therefore does not need to be changed.
name: He should switch his ramipril to amlodipine due to potential interactions between ramipril and warfarin
label: d
answer: no
explanation: Nausea is a rare/very rare side effect of warfarin so he is unlikely to experience it with a dose change.
name: He is likely to experience nausea if his warfarin dose needs changing
label: b
answer: no
explanation: This is incorrect, concurrent illness can exaggerate the effect of warfarin which requires a reduction in dosage. This doesn't mean that you should completely stop this patients warfarin.
name: He needs to stop his warfarin immediately
label: c
answer: no

Correct answer: a
Case presentation: A 64-year-old man is admitted to hospital for elective surgery. He has known oesophageal cancer and is having a subtotal oesophagectomy to remove his tumour.



**PH**
Oesophageal cancer, chronic kidney disease (stage 4)

**DH**
Ramipril 10mg PO OD, atorvastatin 20mg PO OD, epoetin alfa 3500 units IV BD

As this gentleman is having surgery, he needs to be prescribed unfractionated heparin

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

Options:
explanation: Metallic taste is not a listed side effect of unfractionated heparin.
name: He is likely to experience a metallic taste in his mouth as a side effect of unfractionated heparin
label: e
answer: no
explanation: This patient has chronic kidney disease stage 4, this means his eGFR is 15-29 ml/min. Hyperkalaemia is a recognised risk of chronic kidney disease, especially in the later stages of the disease. Unfractionated heparin inhibits aldosterone secretion, this in turn increases the risk of hyperkalaemia. As this patient is already predisposed to hyperkalaemia it is important to measure their potassium levels before giving unfractionated heparin and during their stay in hospital.
name: He will need to have his potassium checked before he has his heparin
label: a
answer: yes
explanation: Alopecia is listed as a rare/very rare side effect of unfractionated heparin use, therefore they are not very likely to occur.
name: He is likely to experience hair loss whilst taking unfractionated heparin
label: d
answer: no
explanation: Hepatic function is not routinely monitored in patients using unfractionated heparin.
name: He will need regular hepatic monitoring
label: b
answer: no
explanation: Thyroid function is not routinely monitored in patients using unfractionated heparin.
name: He will need regular thyroid function tests for monitoring
label: c
answer: no

Correct answer: a
Case Presentation: A 34-year-old gentleman attends his GP complaining of weight gain.  His regular medicines are listed (below).


**PH** Asthma, Schizophrenia, Rheumatoid Arthritis

**DH** Sertraline 50mg PO OD, Folic acid 5mg PO once weekly, Olanzapine 10mg PO OD, Methotrexate 20mg PO once weekly, Ibuprofen 400mg PO TDS

**On examination**

BP 129/69mmHg, HR 68, RR 14, Weight 89kg (84kg one month ago)

Question: Select the medication that is most likely to have contributed to this patient's weight gain.

Options:
explanation: Methotrexate does not commonly cause weight gain.
name: Methotrexate 20mg PO once weekly
label: d
answer: no
explanation: Ibuprofen does not commonly cause weight gain.
name: Ibuprofen 400mg PO TDS
label: e
answer: no
explanation: Folic acid does not commonly cause weight gain.
name: Folic acid 5mg PO once weekly
label: c
answer: no
explanation: Weight gain is a very common side effect of atypical antipsychotics. Olanzapine and clozapine are the atypical antipsychotics most likely to cause weight gain whereas atypical antipsychotics such as aripiprazole have a lower risk of causing weight gain.
name: Olanzapine 10mg PO OD
label: a
answer: yes
explanation: Salbutamol does not commonly cause weight gain.
name: Salbutamol 200micrograms INH QDS
label: b
answer: no

Correct answer: a
Case Presentation: A 18-year-old woman attends her GP asking for the combined oral contraceptive pill.  Her regular medicines are listed (below).


**PH** Asthma, Epilepsy, Eczema, Allergic rhinitis

**DH** Salbutamol 200micrograms INH QDS, Budesonide 400 micrograms INH BD, Carbamazepine 200mg PO BD, Cetirizine 10mg PO OD, Hydromol cream one application to affected area BD

Question: Select the prescription that is most likely to reduce the efficacy of the combined oral contraceptive pill.

Options:
explanation: Budesonide does not commonly interact with combined oral contraception
name: Budesonide 400 micrograms INH BD
label: c
answer: no
explanation: Carbamazepine is a PY450 enzyme inducer, this is the enzyme responsible for the metabolism of the combined oral contraceptive pills. Increased activity of said enzyme results in the combined oral contraceptive pill being metabolised quicker and therefore having a lower efficacy. Other PY450 inducers include phenytoin, phenobarbital, felbamate, topiramate, oxcarbazepine and primidone.
name: Carbamazepine 200mg PO BD
label: a
answer: yes
explanation: Cetirizine does not commonly interact with combined oral contraception
name: Cetirizine 10mg PO OD
label: d
answer: no
explanation: Hydromol does not commonly interact with combined oral contraception
name: Hydromol cream one application to affected area BD
label: e
answer: no
explanation: Salbutamol does not commonly interact with combined oral contraception
name: Salbutamol 200micrograms INH QDS
label: b
answer: no

Correct answer: a
Case Presentation: A 68-year-old female attends her GP complaining of constipation.  Her regular medicines are listed (below). Weight 50kg.


**PH** Hayfever, COPD, iron deficiency anaemia, Systemic lupus erythematosus

**DH** Cetirizine 10mg PO OD, Salbutamol 200micrograms INH QDS, Ferrous sulfate 200mg PO BD, Hydroxychloroquine 200mg PO OD, Ibuprofen 200mg PO QDS

Question: Select the medication that is most likely to have contributed to this patient's constipation

Options:
explanation: Salbutamol does not commonly cause constipation.
name: Salbutamol 200micrograms INH QDS
label: c
answer: no
explanation: Ferrous sulfate commonly causes constipation. The mechanism by which iron supplementation causes constipation is unclear. It is thought to either be through interactions with the gut flora or through facilitating the movement of water from the lower GI system via an osmotic gradient which in turn causes stool hardening and constipation.
name: Ferrous sulfate 200mg PO BD
label: a
answer: yes
explanation: Ibuprofen can cause constipation, however this is listed as a rare/very rare side effect whereas ferrous sulfate has constipation listed as a common side effect.
name: Ibuprofen 200mg PO QDS
label: e
answer: no
explanation: Cetirizine is not known to cause constipation.
name: Cetirizine 10mg PO OD
label: b
answer: no
explanation: Hydroxychloroquine does not commonly cause constipation.
name: Hydroxychloroquine 200mg PO OD
label: d
answer: no

Correct answer: a
Case Presentation: A 72-year-old gentleman attends his GP for his blood results. His regular medicines are listed (below).




 **PH** Hypertension, Hypercholesterolaemia


 **DH** Atorvastatin 20mg PO OD, Ramipril 10mg PO OD, Amlodipine 10mg PO OD, Indapamide 2.5mg PO OD, Paracetamol 1g PO QDS


 **On examination**
BP 148/90mmHg, HR 84, RR 12, Weight 70kg


 **Investigation**


||||
|---------------------------|:-------:|--------------------|
|Sodium|136 mmol/L|135 - 145|
|Potassium|4.1 mmol/L|3.5 - 5.3|
|Urea|6.0 mmol/L|2.5 - 7.8|
|Creatinine|100 µmol/L|60 - 120|
|Calcium|3.0 mmol/L|2.2 - 2.6|
|eGFR|70 mL/min/1.73m<sup>2</sup>|> 60|


Question: Select the medication that is most likely to have contributed to the abnormality in his blood results.

Options:
explanation: Ramipril does not commonly cause hypercalcaemia.
name: Ramipril 10mg PO OD
label: b
answer: no
explanation: Atorvastatin does not commonly cause hypercalcaemia.
name: Atorvastatin 20mg PO OD
label: d
answer: no
explanation: Indapamide is a thiazide-like diuretic. Thiazide-like diuretics work via increasing the availability of Na<sup>+</sup> in the urine, water then follows this and reduces the blood pressure. One way they do this is by increasing calcium reabsorption across the nephron in exchange for sodium - this in turn results in hypercalcaemia.
name: Indapamide 2.5mg PO OD
label: a
answer: yes
explanation: Paracetamol does not commonly cause hypercalcaemia.
name: Paracetamol 1g PO QDS
label: e
answer: no
explanation: Amlodipine does not commonly cause hypercalcaemia. In very rare cases it has been found to cause hypocalcaemia.
name: Amlodipine 10mg PO OD
label: c
answer: no

Correct answer: a
Case Presentation: A 61-year-old gentleman attends his GP complaining of ankle swelling.  His regular medicines are listed (below). Weight 88kg.


**PH** Type 2 diabetes mellitus, Hypertension, Hypercholesterolaemia

**DH** Metformin 500mg PO BD, Ramipril 10mg PO OD, Amlodipine 5mg PO OD, Atorvastatin 200mg PO OD, Pioglitazone 30mg PO OD

**On examination**
BP 143/85mmHg, HR 74, RR 12, Weight 95kg

**Investigation**
Chest clear, no added breath sounds. Heart sounds I + II present, no added sounds. Abdomen soft and non-tender.

Bilateral pitting oedema in both ankles.

Question: Select the prescription that is most likely to have contributed to the patient's ankle swelling.

Options:
explanation: Pioglitazone can cause peripheral oedema however this isn't as commonly seen as with amlodipine use.
name: Pioglitazone 30mg PO OD
label: e
answer: no
explanation: Atorvastatin does not commonly cause peripheral oedema
name: Atorvastatin 200mg PO OD
label: d
answer: no
explanation: Metformin does not commonly cause peripheral oedema
name: Metformin 500mg PO BD
label: b
answer: no
explanation: Ramipril does not commonly cause peripheral oedema
name: Ramipril 10mg PO OD
label: c
answer: no
explanation: Amlodipine is a common cause of peripheral oedema. Calcium channel blockers cause oedema by increasing the pressure within capillaries. This in turn causes fluid to leak out which results in peripheral oedema.
name: Amlodipine 5mg PO OD
label: a
answer: yes

Correct answer: a
Case Presentation: A 64-year-old gentleman is admitted to AMU with leg pain.




 **PH** Hypertension, COPD, Hypercholesterolaemia


 **DH** Atorvastatin 20mg PO daily, Losartan 100mg PO daily, Salmeterol 50micrograms INH BD, Tiotropium 5micrograms INH daily, Paracetamol 1g PO QDS


 **On examination**


BP 142/82mmHg, HR 82, RR 12, Weight 80kg


 **Investigation**

||||
|---------------------------|:-------:|--------------------|
|Sodium|138 mmol/L|135 - 145|
|Potassium|4.3 mmol/L|3.5 - 5.3|
|Urea|8.0 mmol/L|2.5 - 7.8|
|Creatinine|182 µmol/L|60 - 120|
|eGFR|48 mL/min/1.73m<sup>2</sup>|> 60|


Question: Select the medication that is most likely to have contributed to the reduction in renal function.

Options:
explanation: Atorvastatin does not commonly cause renal impairment.
name: Atorvastatin
label: b
answer: no
explanation: Paracetamol does not commonly cause renal impairment. It can sometimes cause renal impairment if taken as an overdose, however in this scenario the patient has not taken an overdose.
name: Paracetamol
label: e
answer: no
explanation: Salmeterol does not commonly cause renal impairment.
name: Salmeterol
label: c
answer: no
explanation: Losartan is a cause of renal acute kidney injury. It alters the vascular tone of both the afferent and efferent arterioles. In turn, the blood flowing across the glomerulus is altered. This then reduces the glomerular filtration rate which causes a reduction in renal function.
name: Losartan
label: a
answer: yes
explanation: Tiotropium does not commonly cause renal impairment.
name: Tiotropium
label: d
answer: no

Correct answer: a
Case Presentation: A 9-year-old girl is seen in the outpatient paediatrics with swollen, stiff and painful knees. This has been going on for the last 10 weeks.




 **Investigations**


Both knees are red in appearance. Both are swollen. Limited range of motion due to pain and stiffness.


ANA: +ve


Rheumatoid factor: +ve


CRP: 36 mg/L (< 5mg/L)


It is decided that she is likely suffering from juvenile idiopathic arthritis and requires treatment with ibuprofen, methotrexate and prednisolone.


Question: If she takes the prednisolone for a prolonged period of time, what parameters should be monitored?

Options:
explanation: Hepatic function monitoring isn't routinely used for corticosteroid treatment
name: Liver function tests
label: d
answer: no
explanation: Cardiac monitoring is not routinely used for corticosteroid treatment
name: ECG
label: e
answer: no
explanation: Prolonged steroid treatment is linked with growth alterations. Paediatric patients are likely to weigh more and have a reduced height if they are taking steroids for a prolonged time. Any slowing in growth should prompt a referral to a paediatrician
name: Height and weight
label: a
answer: yes
explanation: Fundoscopy isn't routinely used to monitor for adverse effects of corticosteroid treatment
name: Fundoscopy
label: b
answer: no
explanation: A chest x-ray isn't routinely used to monitor for adverse effects of corticosteroid treatment
name: Chest X-ray
label: c
answer: no

Correct answer: a
Case Presentation: A 24-year-old gentleman is admitted to hospital following 2 weeks of abdominal pain, diarrhoea and blood in his stool. Weight 60kg.




 **Investigations**


CRP: 65 mg/L (< 5mg/L)


Imaging: Sigmoidoscopy shows oedematous mucosa, erythema and bowel inflammation shown up to the level of the sigmoid colon.


It is decided that based on his history and investigations that he has a diagnosis of ulcerative colitis. This is treated acutely with IV hydrocortisone.


To maintain remission, azathioprine 120mg PO OD is prescribed.


Question: Which investigation is necessary before this patient can start his azathioprine?

Options:
explanation: The enzyme thiopurine methyltransferase is responsible for the metabolism of thiopurine drugs. If TPMT activity is reduced, there is an increased risk of myelosuppression (and subsequent severe infection) as there is improper clearance of azathioprine.
name: TPMT activity
label: a
answer: yes
explanation: There are no common ophthalmic side effects associated with azathioprine use. Therefore monitoring is not required.
name: Fundoscopy
label: e
answer: no
explanation: Azathioprine is not known to impair hepatic function. If hepatic function is impaired when taking azathioprine, a full blood count should be monitored more frequently.
name: Liver function tests
label: b
answer: no
explanation: Azathioprine is not known to impair renal function. If renal function is impaired when taking azathioprine, a full blood count should be monitored more frequently.
name: Renal function
label: c
answer: no
explanation: There are no common cardiovascular side effects associated with azathioprine use. Therefore monitoring is not required.
name: ECG
label: d
answer: no

Correct answer: a
Case Presentation:  A 31-year-old woman attends the outpatient gynaecology department.


**PMH** Polycystic ovary syndrome, Depression

**DH** Sertraline 50mg PO OD

She wants to conceive and has already been treated with clomifene citrate. Unfortunately, this hasn't worked and her Gynaecologist has recommended metformin 500mg PO OD as the next step in her management.

Question: Which investigation should this patient undergo prior to starting metformin?

Options:
explanation: Metformin doesn't cause cardiac side effects therefore ECG monitoring isn't warranted.
name: ECG
label: c
answer: no
explanation: One of the most important side effects of metformin is lactic acidosis. Renal impairment increases the likelihood of this occurring due to improper clearance of metformin. It is therefore very important to monitor renal function prior to starting metformin therapy.
name: Renal function
label: a
answer: yes
explanation: Whilst metformin can cause a reduced absorption of vitamin B12, this is a very rare side effect and therefore isn't routinely monitored.
name: Full blood count
label: d
answer: no
explanation: Metformin doesn't cause side effects involving the thyroid therefore thyroid function test monitoring isn't warranted.
name: Thyroid function tests
label: e
answer: no
explanation: Whilst metformin can cause hepatic injury through hepatitis, this is a very rare side effect and therefore isn't routinely monitored for.
name: Liver function tests
label: b
answer: no

Correct answer: a
Case presentation: A 28 year old woman is seen in the outpatient psychiatry clinic and is diagnosed with bipolar disorder. She is advised to commence treatment with lithium carbonate (Camcolit) 400mg PO OD.


Question: Select the most appropriate monitoring that this patient should undergo prior to starting lithium carbonate.

Options:
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Renal function is monitored due to the risk of toxicity if there is improper clearance of lithium. Cardiac function is monitored due to the risk of cardiac disease such as QT interval prolongation.
Body weight should also be measured prior to starting treatment and a full blood count should be taken.
name: ECG, renal function, thyroid function tests
label: a
answer: yes
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. Whilst there have been reported LFT abnormalities in patients taking lithium, these are rare and do not require monitoring. A CT head is not a required part of monitoring either.
name: ECG, liver function, CT head
label: e
answer: no
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. Whilst there have been reported LFT abnormalities in patients taking lithium, these are rare and do not require monitoring.
name: ECG, liver function, renal function
label: c
answer: no
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. A chest x-ray is not routinely be used for monitoring prior to starting lithium.
name: Chest X-ray, thyroid function test, renal function
label: d
answer: no
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. A chest x-ray wouldn't routinely be used for monitoring prior to starting lithium.
name: Chest X-ray, ECG, renal function
label: b
answer: no

Correct answer: a