hllj/quesmed huggingface dataset:
Case Presentation:  A 34-year-old woman is referred to rheumatology due to ongoing joint pain and facial rashes.  


**PMH** Nil

**DH** NKDA. Ibuprofen 200mg PO QDS

**SH** smokes 10 cigarettes a day (5 pack year history)

**Investigations**

Anti-CCP antibodies: -ve

ANA: +ve

Anti dsDNA antibodies: +ve

Rheumatoid factor: -ve

Based on her symptoms and blood results, she is diagnosed with systemic lupus erythematosus and the decision is made to start hydroxychloroquine sulfate.

Question: Select the most appropriate monitoring option required before initiating hydroxychloroquine sulfate.

Options:
explanation: An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited usefulness with respect to starting this drug
name: Troponin
label: e
answer: no
explanation: Impaired hepatic function isn't listed as a known side effect of hydroxychloroquine. Therefore it doesn't need to be routinely monitored.
name: Liver function tests
label: d
answer: no
explanation: Impaired renal function isn't listed as a known side effect of hydroxychloroquine. Therefore it doesn't need to be routinely monitored.
name: Renal function
label: c
answer: no
explanation: Hydroxychloroquine can cause a range of haematological disorders such as agranulocytosis, leucopenia and thrombocytopenia. The frequency of these side effects occurring however is unknown, therefore monitoring for them is not recommended.
name: Full blood count
label: b
answer: no
explanation: Retinopathy is a common side effect of hydroxychloroquine. It is important to ensure that there are no pre-existing issues with the retina prior to starting hydroxychloroquine due to the increased risk of worsening these pre-existing issues. Annual monitoring of the retina is initiated following 5 years of treatment (it can be started earlier if there is an increased risk of retinopathy).
name: Fundus photograph and Optical Coherence Tomography (OCT)
label: a
answer: yes

Correct answer: a
Case Presentation:  A 64-year-old gentleman is discharged from hospital following a diagnosis of atrial fibrillation. 


**PMH** Hypertension, Type 2 diabetes mellitus, Atrial fibrillation

**DH** Ramipril 10mg PO OD, Metformin 500mg PO BD, Atenolol 50mg PO OD, Apixaban 5mg PO BD

Both the atenolol and apixaban are new prescriptions.

Question: What routine monitoring is required for his new apixaban prescription?

Options:
explanation: No routine monitoring of factor V is required with apixaban use.
name: Factor V
label: d
answer: no
explanation: No routine monitoring is required with apixaban use. INR would be monitored in patients taking warfarin.
name: INR
label: b
answer: no
explanation: No routine monitoring of prothrombin concentration is required with apixaban use.
name: Prothrombin
label: e
answer: no
explanation: No routine monitoring is required with apixaban use. This is because direct oral anticoagulants have a predictable pharmacokinetic and pharmacodynamic response when given at a set dose, unlike warfarin for example which has a higher degree of unpredictability.
name: No routine monitoring required
label: a
answer: yes
explanation: No routine monitoring is required with apixaban use. Factor Xa is the clotting protein that apixaban inhibits, it does not need to be monitored.
name: Factor Xa
label: c
answer: no

Correct answer: a
Case Presentation: A 31-year-old female attends psychiatric outpatients for a review of her bloods.




 **PMH**
Schizophrenia
 **DH**
Clozapine 100mg PO BD
 **Investigations**



||||
|--------------|:-------:|---------------|
|White Cell Count|1.6x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|234x10<sup>9</sup>/L|150 - 400|
|Neutrophils|0.6x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|1.2x10<sup>9</sup>/L|1.5 - 4.0|
|Monocytes|0.5x10<sup>9</sup>/L|0.2 - 1.0|
|Eosinophils|0.2x10<sup>9</sup>/L|0 - 0.4|
|Basophils|0.08x10<sup>9</sup>/L|0 - 0.1|
|Sodium|136 mmol/L|135 - 145|
|Potassium|4.1 mmol/L|3.5 - 5.3|
|Urea|3.3 mmol/L|2.5 - 7.8|
|Creatinine|61 µmol/L|60 - 120|



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

Options:
explanation: Increasing the dose would exacerbate the risk of agranulocytosis, as clozapine is directly linked to this haematological side effect.
name: Increase clozapine dose to 125mg PO BD
label: c
answer: no
explanation: Clozapine is associated with a risk of agranulocytosis, a severe reduction in neutrophils. This patient has neutropenia (neutrophils <1.5x10⁹/L) and agranulocytosis (neutrophils <0.5x10⁹/L), making the continuation of clozapine unsafe. Immediate discontinuation is necessary to prevent life-threatening infections and further haematological decline.
name: Stop clozapine immediately
label: a
answer: yes
explanation: Reducing the dose does not prevent further neutropenia or adequately address the agranulocytosis risk. This approach delays appropriate action and increases the risk of complications.
name: Reduce clozapine dose to 75mg PO BD and repeat bloods in one week
label: b
answer: no
explanation: Continuing clozapine in the presence of agranulocytosis is contraindicated. This approach puts the patient at significant risk of sepsis or other severe complications.
name: Continue treatment and repeat bloods in one week
label: e
answer: no
explanation: Monitoring at such an extended interval is unsafe given the acute risk of infection associated with agranulocytosis. The priority is immediate cessation and haematology referral.
name: Reduce clozapine dose to 75mg PO BD and repeat bloods in one month
label: d
answer: no

Correct answer: a
Case Presentation:  A 54-year-old woman attends her GP complaining of a sore leg.


**PMH**
Hypertension, hypercholesterolaemia
**DH**
Ramipril 10mg PO OD, amlodipine 10mg PO OD, atorvastatin 20mg PO OD, tamoxifen 20mg PO OD, paracetamol 1g PO QDS
**Examination**
The right calf appears red, swollen and painful to touch. When compared to the other leg it is around 3cm bigger. Their observations are normal.

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

Options:
explanation: Venous thromboembolism is not a recognised side effect of amlodipine. Therefore, there is no need to stop this drug.
name: Stop amlodipine
label: c
answer: no
explanation: This patient has presented with a DVT. Patients who are taking tamoxifen are at an increased risk of developing blood clots. This is because the liver produced more clotting factors in response to processing more oestrogen. This patient should have her hormone replacement therapy switched over to a patch or gel.
name: Stop tamoxifen
label: a
answer: yes
explanation: Venous thromboembolism is not a recognised side effect of paracetamol. Therefore there is no need to stop this drug.
name: Stop paracetamol
label: d
answer: no
explanation: Venous thromboembolism is not a recognised side effect of ramipril. Therefore, there is no need to stop this drug.
name: Stop ramipril
label: b
answer: no
explanation: Venous thromboembolism is not a recognised side effect of atorvastatin. Therefore, there is no need to stop this drug.
name: Stop atorvastatin
label: e
answer: no

Correct answer: a
Case Presentation:  A 66-year-old gentleman attends the diabetes clinic for a review of his type 2 diabetes mellitus. 


**PMH** Type 2 diabetes mellitus, hypercholesterolaemia, hypertension, depression

**DH** Metformin 500mg PO BD, simvastatin 20mg PO OD, lisinopril 10mg PO OD, mirtazapine 15mg PO BD

**Investigations**

HbA1c 3 months ago: 59 mmol/mol (< 42 mmol/mol)

HbA1c today: 51 mmol/mol (< 42 mmol/mol)

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

Options:
explanation: This patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol with 3 months of treatment. Stopping metformin now would be premature as his HbA1c is still above 48 mmol/mol.
name: Stop his metformin
label: c
answer: no
explanation: his patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol. There is no clinical indication to start gliclazide 40mg PO OD.
name: Add gliclazide 40mg PO OD
label: d
answer: no
explanation: This patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol with 3 months of treatment. 
name: Increase his metformin dose to 1g PO BD
label: b
answer: no
explanation: This patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol with 3 months of treatment. He should continue on this medication for another 3 months, if his HbA1c drops below 48 mmol/mol then his metformin dose may be reduced.
name: Make no changes to his anti diabetic medications
label: a
answer: yes
explanation: his patient's HbA1c level is being adequately controlled by his current antidiabetic medication. His HbA1c has dropped from 59 mmol/mol to 51 mmol/mol. There is no clinical indication to start insulin treatment.
name: Start humulin I long acting insulin
label: e
answer: no

Correct answer: a
Case Presentation:  A 48-year-old woman is attends her GP due to an ongoing cough. She has had this cough for the last 2 days. It is productive of green sputum. She has also been experiencing feverish symptoms since her cough started.


**PMH** Addison's disease

**DH** Hydrocortisone 20mg PO BD, Fludrocortisone 50 micrograms PO OD

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

Options:
explanation: This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.
name: Increase her hydrocortisone to 40mg PO BD and increase her fludrocortisone dose to 100 micrograms PO OD
label: c
answer: no
explanation: This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.
name: Increase her hydrocortisone to 40mg PO BD, don't change her fludrocortisone dose
label: a
answer: yes
explanation: This patient has Addison's disease and will be steroid dependent. Her corticosteroid and mineralocorticosteroid medications must not be stopped.
name: Stop both her hydrocortisone and fludrocortisone immediately
label: e
answer: no
explanation: This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.
name: Increase her fludrocortisone dose to 100 micrograms PO OD, do not change her hydrocortisone dose
label: b
answer: no
explanation: This patient has Addison's disease. When patients with Addison's disease have a concurrent illness their hydrocortisone dose should be doubled whilst their fludrocortisone dose should remain unchanged.
name: Make no changes to her medications
label: d
answer: no

Correct answer: a
Case Presentation: A 33-year-old female attends her GP to review her blood tests.




 **PMH** Hypothyroidism


 **DH** Levothyroxine 75 micrograms PO OD


 **Investigations**


||||
|---------------------------|:-------:|------------------------------|
|Thyroid Stimulating Hormone|9.8 mU/L|0.3 - 4.2|
|Free T4|21 pmol/L|9 - 25|
|Free T3|5 pmol/L|3.1 - 6.8|




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

Options:
explanation: This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Decrease this patients levothyroxine to 25 micrograms PO OD
label: d
answer: no
explanation: This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Increase this patients levothyroxine to 125 micrograms PO OD
label: e
answer: no
explanation: This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Decrease this patients levothyroxine to 50 micrograms PO OD
label: c
answer: no
explanation: This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Increase this patients levothyroxine to 100 micrograms PO OD
label: b
answer: no
explanation: This patient hasn't been taking her levothyroxine medication as intended as indicated by the normal T3/T4 level and raised TSH. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Make no changes to her medication
label: a
answer: yes

Correct answer: a
Case Presentation:  A 9-year-old boy attends an asthma clinic with his mother following a new diagnosis. She explains that he is still feeling short of breath despite using his brother's blue inhaler. 


**PMH**
Asthma

**DH**
None

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

Options:
explanation: This is the first step in management of asthma in children over 5 years of age. Salbutamol monotherapy is no longer recommended. Indications for escalating treatment if symptoms remain uncontrolled include: using an inhaled short-acting beta2 agonist three times a week or more, having symptoms of asthma three times a week or more, or waking at night due to asthma symptoms at least once a week.
name: Prescribe salbutamol and a regular low dose inhaled corticosteroid 
label: a
answer: yes
explanation: The first step of asthma management is a SABA (salbutamol) and an inhaled corticosteroid, rather than a preventer inhaler alone.
name: Prescribe regular low dose inhaled corticosteroid
label: b
answer: no
explanation: This would be inappropriate as he is not suffering an acute exacerbation and should be managed with inhaled corticosteroids.
name: Prescribe oral prednisolone
label: d
answer: no
explanation: Salbutamol monotherapy is no longer recommended at any stage of asthma treatment across all age groups.
name: Prescribe salbutamol inhaler
label: c
answer: no
explanation: This is a combination inhaler which is first line management in patients >12 years old, and may be considered as part of a MART regimen if this patient's symptoms remain uncontrolled.
name: Prescribe formoterol/beclometasone combined inhaler
label: e
answer: no

Correct answer: a
Case Presentation: A 52-year-old patient has been admitted to the general surgical ward due to an episode of acute diverticulitis. They are prescribed antibiotics for this infection, one of which is a STAT dose of gentamicin. Gentamicin can be given IV 5-7mg/kg once daily at a maximum of 7mg/kg. He weighs 95kg.

What is the maximum dose of gentamicin that this gentleman should receive in one day.

Options:


This question asks for the maximum dose possible therefore the answer would be (95 x 7) which is 665mg.
Case Presentation:

A 65-year-old gentleman is discharged from the hospital following a diagnosis of Giant Cell Arteritis (GCA).

He has been given the following information on how his condition is to be treated:

Prednisolone PO 40mg/day for 7 days.

Prednisolone PO 30mg/day for 7 days

Prednisolone PO 20mg/day for 7 days.

Prednisolone PO 10mg/day for 7 days.

He has been told to take 5mg prednisolone tablets to treat his condition.

How many prednisolone tablets does this patient require to complete his GCA treatment?

Options:


WEEK 1: 40mg dose / 5 = 8

Therefore 8 x 5mg tablets are needed per day for 7 days.

8 x 7 = 56 tablets are needed in week 1.

WEEK 2: 30mg dose / 5 = 6

Therefore 6 x 5mg tablets are needed per day for 7 days.

6 x 7 = 42 tablets are needed in week 2.

WEEK 3: 20mg dose / 5 = 4

Therefore 4 x 5mg tablets are needed per day for 7 days.

4 x 7 = 28 tablets are needed in week 3.

WEEK 4: 10mg dose / 5 = 2

Therefore 2 x 5mg tablets are needed per day for 7 days.

2 x 7 = 14 tablets are needed in week 2.

56 + 42 + 28 + 14 = 140 tablets needed
Case Presentation:

A 4-year-old boy is admitted to the paediatric ward with diarrhoea and vomiting. Weight 18kg.

**On examination**

BP 104/62mmHg, HR 110, RR 23, patient is alert.

Mucus membranes appear to be dry.

Capillary refill time <2 seconds.

This patient is determined to be 5% dehydrated. It is therefore determined that they require fluid replacement therapy alongside their regular maintenance therapy.

What **total** volume of 0.9% sodium chloride + 5% glucose should be prescribed for this patient's daily fluid intake?

Options:


The first 10kg of weight replaces fluid at a rate of 100 ml/kg/day.

The second 10kg of weight replaces fluid at a rate of 50 ml/kg/day.

Then any extra kg in weight above 20kg total weight is replaced at a rate of 20 ml/kg/day.

This patient weighs 18kg. Therefore he will need 1000ml for his first 10kg of weight and 400ml for his next 10kg of weight. Therefore this patient requires 1400ml of **maintenance** fluid therapy.

He is also 5% dehydrated. To calculate the amount of **replacement** fluid therapy you use the following equation:

Fluid deficit (mL) = % dehydration x weight (kg) x 10

So in this case the amount of fluid that needs to be replaced would be:

5 x 18 x 10 = 900ml

900 + 1400 = 2300ml total fluid needed over 24 hours.
Case Presentation:

A 6 year old boy is admitted to the paediatric ward with abdominal pain and nausea. Weight 24kg.

**On examination**
BP 102/64mmHg, HR 101, RR 22, patient is alert.

Mucus membranes appear moist.

Skin turgor is normal.

Capillary refill time is > 2 seconds.

Due to the boy's nausea he is unable to tolerate oral fluids. It is decided that IV maintenance fluids should be prescribed to ensure adequate hydration is maintained.

What **total** volume of 0.9% sodium chloride + 5% glucose should be prescribed for this patient's daily maintenance fluids?

Options:


The first 10kg of weight replaces fluid at a rate of 100 ml/kg/day.

The second 10kg of weight replaces fluid at a rate of 50 ml/kg/day.

Then any extra kg in weight above 20kg total weight is replaced at a rate of 20 ml/kg/day.

This patient weighs 24kg. Therefore he will need 1000ml for his first 10kg of weight, 500ml for his next 10kg of weight and another 80ml for the last 4kg.
Case Presentation:

A 47-year-old patient with generalised tonic clonic seizures was initially prescribed sodium valproate at a maintenance dose of 800mg twice daily.

Due to co-existing renal impairment, it has been decided that the dose should be reduced by 25% as per the manufacturer's advice. Each dose needs to be diluted in 5mL of 0.9% sodium chloride solution prior to injection.

What is the dose of sodium valproate per ml given in each injection?

Options:


This faces a 25% reduction due to his renal impairment:

(800/100) x 75 = 600mg per dose

This 600mg is given in a 5ml injection.

So the amount given in 1ml = 600/5 = 120mg per 1 ml
Case Presentation:

A 86-year-old gentleman is currently on the care of the elderly ward. His regular medicines are listed below. Weight 60kg.

**PH** Metastatic prostate cancer, Osteoarthritis, Hypertension, Hypercholesterolaemia

**DH** Morphine 15mg PO QDS, ramipril 5mg PO OD, Atorvastatin 20mg PO OD

In addition to his regular morphine, this patient requires **TWO** breakthrough doses of morphine throughout the day. This manages his pain.

He has been having difficulty swallowing and the decision has been made to switch the formulation of his medication from oral to another formulation that doesn't require swallowing.

What is the total dose of morphine required daily to manage this patient's pain if it is given subcutaneously?

Options:


4 x 15 = 60mg needed as a baseline

60/6 = 10mg x 2 = 20mg needed as a breakthrough dose

60 + 20 = 80mg needed orally to manage pain.

80/2 = 40mg needed subcutaneously to manage pain.
A 32-year-old man is brought in by ambulance to A&E after a road traffic collision. On examination, he has a large wound at the back of his head. His Glasgow Coma Score is 3. A CT scan of the head shows no abnormalities. A rapid sequence induction of anaesthetic is performed to secure his airway. A week into his admission, extubation is attempted on the Intensive Care Unit but this is unsuccessful. A gag reflex is documented as being absent in his medical notes.

Where is the lesion causing his clinical presentation?

Options:
explanation: The occipital lobe is involved in visuospatial processing, colour perception and facial recognition. It is not involved in the gag reflex. Occipital lobe damage may present with the above features, alongside a visual field defect of contralateral homonymous hemianopia with macular sparing.
name: Occipital lobe
label: e
answer: no
explanation: The midbrain may be damaged as a consequence of head injury; however, the nuclei of CN IX and X are found in the medulla, not the midbrain. The midbrain contains the nuclei of CN III and IV. These are not involved in the gag reflex.
name: Midbrain
label: c
answer: no
explanation: Skull fractures sustained during head injury can be a risk factor for septic cavernous sinus thrombosis. However, in this scenario, there is no fracture (the CT head is normal) and no clinical features of a septic cavernous sinus thrombosis, including involvement of nerves III, IV, Va, Vb and VI, which run through the cavernous sinus.
name: Cavernous sinus
label: d
answer: no
explanation: The pons may be damaged as a consequence of head injury; however, the nuclei of CN IX and X are found in the medulla, not the pons. The pons contains the nuclei of CN V, VI, VII and VIII. These are not involved in the gag reflex.
name: Pons
label: b
answer: no
explanation: The gag reflex is an evolutionary reflex with the primary role being to prevent foreign body inhalation. This reflex is made up of the glossopharyngeal nerve (CN IX) as the afferent limb and the vagus nerve (CN X) as the efferent. These two nerves have their nuclei in the brainstem medulla, alongside CN XI and XII. Compression may be as a result of raised intracranial pressure secondary to injury, given that no focal abnormalities were noted on his head scan.
name: Medulla oblongata
label: a
answer: yes

Correct answer: a


Learning point: Lesions in the medulla oblongata can impair the gag reflex, indicating potential brainstem injury or raised intracranial pressure.