hllj/quesmed huggingface dataset:
Case Presentation: A 76 year old man is brought to the emergency department due to a PR bleed. He is unsure how much blood he has lost. 




 **PH** Diverticular disease, atrial fibrillation, hypercholesterolaemia


 **DH** Bisoprolol 5mg PO OD, apixaban 5mg PO BD, atorvastatin 20mg PO OD. NKDA


 **On examination**


Temperature 37.4°C, HR 108, RR 18, BP 94/68, O2 95% RA.


 **Investigations**


||||
|--------------|:-------:|---------------|
|Haemoglobin|68 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|7.3x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|333x10<sup>9</sup>/L|150 - 400|
|C Reactive Protein|48 mg/L|< 5|


Question: Select the most appropriate management at this stage.

Options:
explanation: These are all management options that you would do however this option is missing giving a unit of blood which is crucial in this case due to the haemodynamic instability.
name: Stop his apixaban, take a group and save blood sample and continue to monitor
label: b
answer: no
explanation: These are management options that you would do however this option is missing giving a unit of blood which is crucial in this case due to the haemodynamic instability. You should also get a group and save and crossmatch sample.
name: Stop his apixaban and continue to monitor
label: c
answer: no
explanation: This patient has suffered an acute bleed. They are haemodynamically unstable due to the hypotension and tachycardia. They also have a low Hb of 68 with the transfusion threshold being a Hb of 70 (80 in patients with a significant cardiac history). He should therefore have all blood thinners suspended and a unit of O negative blood given STAT. You should also get a group and save and crossmatch sample.
name: Stop his apixaban, take a group and save blood sample and prescribe a unit of O negative blood STAT
label: a
answer: yes
explanation: Stopping the apixaban would be one of the correct steps in the management of this patient. Giving vitamin K however will have no effect as this reverses the effects of warfarin NOT apixaban. You should also give a unit of blood STAT.
name: Stop his apixaban, prescribe vitamin K 2mg PO STAT
label: d
answer: no
explanation: Whilst a unit of blood is needed as soon as possible you should always also stop medications that will exacerbate the bleed - in this case the apixaban needs to be stopped.
name: Prescribe a unit of O negative blood STAT
label: e
answer: no

Correct answer: a
Case Presentation: A 24 year old pregnant woman attends her GP due to dysuria. She is 12 weeks pregnant.


**PH** Nil.

**DH** Nil. NKDA

**Investigations**

Urine dip:

* Blood: -
* Nitrates: ++
* White blood cells: ++
* Red blood cells: -

Question: Select the most appropriate management at this stage.

Options:
explanation: This patient has a lower UTI. If she was not pregnant then this treatment option would be okay however it is contraindicated during pregnancy due to its anti-folate properties.
name: Trimethoprim 200mg PO BD
label: b
answer: no
explanation: This patient has a lower UTI. As she is pregnant she should NOT be prescribed trimethoprim which leaves nitrofurantoin as the first line medication she should be prescribed.
name: Nitrofurantoin MR 100mg PO BD
label: a
answer: yes
explanation: Amoxicillin can be used to treat lower UTIs however it is a second line option. Nitrofurantoin should be trialled first.
name: Amoxicillin 500mg PO TDS
label: c
answer: no
explanation: Clarithromycin isn't typically prescribed to treat lower UTIs. This particular dose of clarithromycin is used to treat cellulitis.
name: Clarithromycin 500mg PO BD
label: e
answer: no
explanation: Cefalexin can be used to treat lower UTIs however it is a second line option. Nitrofurantoin should be trialled first.
name: Cefalexin 500mg PO BD
label: d
answer: no

Correct answer: a
Case presentation: A 60-year-old woman attends the rheumatology clinic with a two-week history of fatigue and morning stiffness in the shoulder. She complains that the stiffness usually lasts more than 1 hour.  


Investigations:
 -ESR 45mm/hr [(age+10)/2]
 -CRP 20 mg/l (<10 )
A diagnosis of polymyalgia rheumatica is made and patient is advised to commence treatment with Prednisolone 10 mg PO daily.


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

Options:
explanation: Dose of prednisolone needs to be reduced gradually before the treatment is stopped completely to reduce the risk of withdrawal symptoms
name: She should immediately stop taking prednisolone once her symptoms have improved to reduce the risk of developing side effects
label: c
answer: no
explanation: Prednisolone could cause insomnia through the release of catecholamines. Hence, patients are usually advised to take prednisolone in the morning so that it does not keep them awake at night
name: She should take prednisolone at night before sleeping
label: b
answer: no
explanation: Peptic ulcer is a common side effect of all systemic corticosteroids
name: Prednisolone decreases the risk of peptic ulcer
label: d
answer: no
explanation: Prednisolone is not known to cause hypoglycaemia
name: Prednisolone increases the risk of hypoglycaemia
label: e
answer: no
explanation: Prednisolone is a steroid medication used to reduce inflammation in rheumatological condition such as polymyalgia rheumatica. During sickness, patients are advised to increase the dose of prednisolone for two days before returning to the usual dose. This action aims to mimic the natural response of adrenal glands that increase the production of steroid hormones during illness
name: She should double the dose of prednisolone during sickness
label: a
answer: yes

Correct answer: a
Case presentation: A 75-year-old woman is admitted to the hospital with left hip pain following a minor fall. She appears frail and has a low body mass index (BMI) of 18kg/m².  

Investigations: Hip x-ray reveals an intracapsular fracture at the neck of femur. Dual-energy x-ray absorptiometry (DEXA) reveals a T-score of -2.8.
A diagnosis of osteoporosis is made and patient is advised to commence treatment with Alendronic acid 70mg PO once weekly.

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

Options:
explanation: Alendronic acid reduces the rate of bone turnover
name: Alendronic acid works by increasing the rate of bone turnover
label: c
answer: no
explanation: Alendronic acid is a bisphosphonate that treats osteoporosis by inhibiting osteoclast-mediated bone resorption
name: Alendronic acid is a Vitamin D3 supplement that helps to strengthen the bone
label: b
answer: no
explanation: It is important to remind the patients to take it while sitting up or standing and stay upright for 30 minutes after taking it to reduce oesophageal irritation
name: She should take it while siting straight or standing and keep upright for 30 minutes after taking it
label: a
answer: yes
explanation: Patients should stop taking alendronic acid if they experience worsening heartburn or chest pain because these symptoms may be suggestive of ulceration
name: It is common for people to experience worsening heartburn while taking the medication and that she should persists as the heartburn usually settles after the first few doses
label: e
answer: no
explanation: Patients are advised to take it first thing in the morning on an empty stomach
name: She should take it with food to reduce irritation to the food pipe
label: d
answer: no

Correct answer: a
Case presentation: A 8-year-old boy attends the paediatrics clinic accompanied by his mother.His mother reports that he has been experiencing night-time wheeze over the past month. He used his salbutamol metered-dose inhaler (MDI) three times last week to help him fall back to sleep.  

PMH: Eczema, asthma
DH: Salbutamol (Ventolin Accuhaler) INH 200 micrograms PRN, emollient (ImuDERM)
The patient is advised to commence maintenance therapy with Beclometasone Dipropionate 100 micrograms PO twice daily.

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

Options:
explanation: Beclometasone dipropionate is a steroid inhaler that constitutes the maintenance therapy for patients whose asthma symptoms are not controlled by a beta-agonist reliever alone. It is important to remind patients that unlike beta-agonist inhaler, a beclometasone inhaler needs to be used every day even if they do not experience any symptoms
name: He should not use his beclometasone inhaler if he does not experience any symptoms
label: b
answer: no
explanation: Beclometasone dipropionate is a steroid inhaler that constitutes the maintenance therapy for patients whose asthma symptoms are not controlled by a beta-agonist reliever alone. Patients are advised to rinse their mouths after using the inhaler to prevent infection such as candidiasis
name: He should rinse his mouth after using the beclometasone inhaler
label: a
answer: yes
explanation: Spacers slow down the drug as it comes out of the inhaler and more of the drug gets delivered to the lungs as a result
name: He should avoid using a spacer if possible as spacer tends to trap some of the drug and reduce the total amount of drug being delivered to the lungs
label: c
answer: no
explanation: If patients have forgotten to use their inhalers, they should use the inhalers as soon as they remember. However, if it is almost time for them to take the next dose, they should skip the missed dose and take the next dose as usual
name: If he forgets to use it, he should take a double dose to compensate for the forgotten dose
label: d
answer: no
explanation: It is imperative to highlight to the patients that with inhaled beclometasone, only very little of the drug gets into the rest of the body and that systemic side effects of steroids are only more likely to happen if the beclometasone is taken at high doses over a long period of time
name: He is very likely to experience stunted growth as a result of his current dose of beclometasone
label: e
answer: no

Correct answer: a
Case presentation: A 30-year-old woman visits the GP to discuss about contraception. She prefers hormonal pills over other methods of contraception. Her last menstrual period was 10 days ago and her pregnancy test has come back as negative.  

Physical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT

PMH: Allergic rhinitis

DH: Cetirizine hydrochloride PO 10mg OD

The patient is advised to start taking ethinylestradiol 30 micrograms/ levonorgestrel 150 micrograms one tablet PO daily for 21 days of each cycle starting from today. She does not have any contraindications to the medication.

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

Options:
explanation: It is important to remind the patients that COCP does not offer protection against sexually transmitted disease as it is not a form of barrier contraception
name: She will be protected against sexually transmitted disease
label: d
answer: no
explanation: Contraceptive implants are more than 99% effective while as COCPs are generally less than 95% effective with typical use (NHS website: https://www.nhs.uk/conditions/contraception/which-method-suits-me/). Percentage of women experiencing an unintended pregnancy within the first year of typical use is 0.005% for progestogen-only implant and 9% for COCP. [NICE CKS: https://cks.nice.org.uk/contraception-assessment#!backgroundSub]
name: With typical use, it is more effective than contraceptive implant in preventing pregnancy
label: b
answer: no
explanation: COCP is associated with a small increased risk of cervical cancer if used for 5 years or longer
name: It decreases the risk of developing cervical cancer
label: e
answer: no
explanation: Ovarian cancer is classified by UK Medical Eligibility Criteria for Contraceptive Use (UKMEC) as a Category 1 condition. UKMEC defines category 1 condition as “a condition for which there is no restriction for the use of the method”
name: Ovarian cancer is an absolute contraindication
label: c
answer: no
explanation: Combined oral contraceptive pill (COCP) contains combination of an oestrogen and progestogen. It is imperative to highlight to patients that there is a small increase in the risk of developing breast cancer so that they can make a more informed choice
name: It is linked to an increased risk of developing breast cancer
label: a
answer: yes

Correct answer: a
Case presentation: A 14-year-old girl attends the GP with erythematous, itchy and sore skin in her elbow and knee flexures. The GP prescribes her 1% Hydrocortisone cream to manage this. 


**PH**
Atopic eczema

**DH**
E45 Lotion
NKDA

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

Options:
explanation: Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. Steroid creams should be applied in the direction of hair growth to reduce the risk of irritation to hair follicles.
name: Apply to the skin against the direction of hair growth
label: d
answer: no
explanation: Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. The slowing of growth in children is a serious but very rare side effect of prolonged corticosteroid use. This is very unlikely where low doses are used short-term, as in this case, and so would be inappropriate information to provide at this stage.
name: Slowing growth is a common side effect
label: e
answer: no
explanation: Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. The dose of steroid creams is often given in FTUs. One FTU is the amount of cream in a line squeezed out from the tip of the finger to the first crease, this is approximately 500mg. One FTU is enough to cover one hand, front and back.
name: One fingertip unit (FTU) is enough to cover the palm of one hand
label: c
answer: no
explanation: Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. Steroid creams should only be applied once or twice daily to reduce the risk of side effects such as skin thinning and skin depigmentation. Emollients used to moisturise the eczematous skin should be applied 3-4 times daily.
name: Apply the cream 3-4 times daily
label: b
answer: no
explanation: Hydrocortisone cream is a corticosteroid cream used to treat eczema and other skin conditions such as psoriasis. Steroid creams should be applied thinly to reduce the risk of side effects such as skin thinning and skin depigmentation.
name: Apply the cream thinly to the affected areas
label: a
answer: yes

Correct answer: a
Case presentation: An 8-year-old boy receives a new diagnosis of type 1 diabetes mellitus after being admitted to the hospital with diabetic ketoacidosis. 


**PH**
Type 1 Diabetes Mellitus
Downs Syndrome

**DH**
NKDA

Management with an insulin regime is initiated.

Question: Select the most important information that should be provided to this patient and their parents.

Options:
explanation: Patients are advised to inject insulin at a different site each time to prevent lipohypertrophy and excessive skin irritation.
name: Insulin should be injected at the same site each time
label: b
answer: no
explanation: Blood glucose measurements should generally be taken before each meal and at bedtime. These measurements may be taken more regularly when a child is newly diagnosed with Diabetes.
name: Blood glucose should be checked after each meal with a finger prick
label: d
answer: no
explanation: Insulin pens should be kept in the fridge. The low temperatures of a  freezer may damage the insulin.
name: Insulin pens should be kept in the freezer
label: e
answer: no
explanation: A side effect of insulin is weight gain, not weight loss.
name: Insulin may lead to weight loss
label: c
answer: no
explanation: Glucose tablets and glucose gel, as well as sugary sweets and drinks, can be used to treat hypoglycaemia. Insulin therapy leaves patients at a greater risk of hypoglycaemia. Patients and their parents should be educated on what to do if they experience hypoglycaemia.
name: Start carrying glucose tablets or glucose gel
label: a
answer: yes

Correct answer: a
A 19 year-old woman is brought into resus by ambulance already in status epilepticus. It is decided she should be commenced on an infusion of Phenytoin (20 mg/kg). She weighs 73 kg.


Phenytoin is infused at a maximum rate of 50 mg/min.

What is the shortest time period (to the nearest whole minute) over which the phenytoin infusion can be infused?

Options:


Dose = 20 x 73 = 1460 mg
Time = 1460 mg / 50 mg/min = 29.2 minutes

This is then rounded **up** to 30 minutes, as 29 minutes would not be able to deliver the total dosage required.
Case Presentation: A 45-year-old gentleman attended his psychiatry follow-up appointment in the clinic. He was recently diagnosed with schizophrenia and was started on risperidone. PMH Schizophrenia DH Risperidone 3mg PO BD.


Question: Select the adverse effect that is most likely to be caused by prolonged use of this medication.

Options:
explanation: Risperidone does not commonly cause tinnitus
name: Tinnitus
label: e
answer: no
explanation: Antipsychotics does not commonly cause alopecia
name: Alopecia
label: b
answer: no
explanation: Antipsychotics including risperidone common or very commonly causes galactorrhea. Antipsychotics, whose effects are mediated by the inhibition of dopamine D2 and D4 receptors, can result in extrapyramidal side effects when the D2 receptors in the hypothalamic tuberoinfundibular system is inhibited. This results in an increase in prolactin level causing symptoms such as galactorrhea, amenorrhea and impotence
name: Galactorrhea
label: a
answer: yes
explanation: Carbamazepine causes thrombocytopenia but not risperidone
name: Thrombocytopenia
label: d
answer: no
explanation: Risperidone does not commonly cause hypoglycaemia
name: Hypoglycaemia
label: c
answer: no

Correct answer: a
Case Presentation: A 55-year-old man was admitted to the Cardiology Ward for recovery following a PCI for his STEMI. PMH Heart Failure, Hypertension, GORD, AF. DH His current regular medicines are listed (below).

**On Examination**

BP 125/85mmHg, RR 12, HR 75/min, Temp 37.2oC.
HS I + II + S3
No radio-radial delay noted, CRT 2s, gynaecomastia noted.
Fine inspiratory crackles heard bilaterally.
Weight 85kg

Question: Select the prescription that is most likely to contribute to his gynaecomastia.

Options:
explanation: Warfarin does not commonly cause gynaecomastia
name: Warfarin 5mg OD PO
label: c
answer: no
explanation: Gaviscon does not commonly cause gynaecomastia
name: Sodium alginate with potassium bicarbonate 10ml PRN PO
label: b
answer: no
explanation: Bisorprolol does not commonly cause gynaecomastia
name: Bisoprolol fumarate 10mg OD PO
label: e
answer: no
explanation: Spironolactone, an aldosterone antagonist decreases testosterone production and increases the peripheral conversion of testosterone to estradiol. This results in an increase in the levels of estrogen which causes gynecomastia. This adverse effect is seen in many antihypertensive medication but is more common with spironolactone. PPIs can cause gynecomastia but is not as commonly seen as with spironolactone
name: Spironolactone 50mg OD PO
label: a
answer: yes
explanation: Ramipril does not commonly cause gynaecomastia
name: Ramipril 5mg BD PO
label: d
answer: no

Correct answer: a
Case presentation: A 70-year-old woman is admitted to hospital for community-acquired pneumonia. During the ward round, she reports that she has been having muscle pain in both her arms and legs.  

PMH: Diabetes Mellitus, Hypertension, Myocardial infarction, Reflux oesophagitis
DH: Her current regular prescriptions, in addition to Simvastatin 80 mg PO nightly, are listed below
Observations: Temperature 37.5, Respiratory rate 32, Blood pressure 88/64, Heart rate 76

Question: Select the prescription that is most likely to have interacted with simvastatin to cause the muscle pain

Options:
explanation: Aspirin is not known to interact with simvastatin to cause myalgia
name: Aspirin 75 mg PO OD
label: e
answer: no
explanation: Co-amoxiclav is not known to interact with simvastatin to cause myalgia
name: Co-amoxiclav 1.2 g IV TDS
label: c
answer: no
explanation: Metformin is not known to interact with simvastatin to cause myalgia
name: Metformin hydrochloride 500 mg PO TDS
label: b
answer: no
explanation: Clarithromycin is a potent CYP3A4 inhibitor, which prevents the metabolism of simvastatin. This increases simvastatin plasma levels, significantly raising the risk of muscle pain, myopathy, and potentially life-threatening rhabdomyolysis. Patients on simvastatin should avoid clarithromycin or temporarily discontinue simvastatin when macrolides are prescribed.
name: Clarithromycin 500 mg PO BD
label: a
answer: yes
explanation: Lisinopril is not known to interact with simvastatin to cause myalgia
name: Lisinopril 20 mg PO OD
label: d
answer: no

Correct answer: a
Case presentation: A 55-year-old woman presents to her GP with a 2-month history of upper abdominal pain. He describes the pain as a dull ache that is relieved by food. He also notices three episodes of black, sticky stools. He denies having any change in bowel habits or rapid loss in weight.  

PMH: Depression, Rheumatic arthritis, Type 2 Diabetes Mellitus, Hypertension, Hypercholesterolaemia
DH: Her current regular prescriptions, in addition to Diclofenac 50 mg PO three times daily, are listed below
On examination: Mild epigastric tenderness on palpation. Bowel sounds present. Chest is clear with no added lung sounds. Heart sounds I+II+0.

Question: Select the prescription that is most likely to be contributing to the melaena along with diclofenac?

Options:
explanation: Lisinopril can increase the risk of hyperkalaemia if used together with diclofenac. However, it is not known to to interact with diclofenac to cause ulceration or gastrointestinal bleeding
name: Lisinopril 20 mg PO OD
label: d
answer: no
explanation: Metformin is not known to interact with diclofenac to cause ulceration or gastrointestinal bleeding
name: Metformin hydrochloride 500 mg PO TDS
label: c
answer: no
explanation: Simvastatin is not known to interact with diclofenac to cause ulceration or gastrointestinal bleeding
name: Simvastatin 40 mg PO nightly
label: e
answer: no
explanation: Methotrexate is not known to interact with diclofenac to cause ulceration or gastrointestinal bleeding
name: Methotrexate 7.5 mg once weekly
label: b
answer: no
explanation: Both sertraline and diclofenac can increase risk of bleeding. Hence, it is generally recommended to prescribe a gastroprotective drug such as a proton pump inhibitor in people who are taking non-steroidal anti-inflammatory drugs (NSAID), especially for elderly patients
name: Sertraline 50 mg PO OD
label: a
answer: yes

Correct answer: a