hllj/quesmed huggingface dataset:
Case presentation: A 52-year-old man was brought into the Emergency Department by the police under Section 136 following an episode of auditory hallucination. PH Schizophrenia, Severe depression, Hypertension, Ulcerative Colitis. DH His current regular medications are listed (below).


**Investigation**
ECG shows a prolonged QTc interval 460ms (normal≤ 430ms)

Question 1: Select the THREE prescriptions that are most likely to be contributing to his prolonged QTc interval (mark them with a tick in column A)
Question 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).

Options:
name: Risperidone;5mg;oral (PO);Daily
label: a
answer: no
name: Haloperidol;20mg;oral (PO);12-hourly
label: b
answer: no
name: Mirtazapine;30mg;oral (PO);Daily
label: c
answer: no
name: Mesalazine;2g;oral (PO);Daily
label: g
answer: no
name: Fluticasone;400micrograms;inhaled (INH);12-hourly
label: f
answer: no
name: Amlodipine;5mg;oral (PO); Daily
label: e
answer: no
name: Ramipril;10mg;oral (PO); Daily
label: d
answer: no


1. Typical (haloperidol), atypical (risperidone) antipsychotics and mirtazepine are known to increase the QTc interval.
2. Haloperidol, given to schizophrenic patients has a maximum dose of 20mg daily. The dose prescribed for this patient is likely to represent a transcription error of daily to 12-hrly.
Case presentation: A 65-year old man is admitted to the geriatric ward following a fall at home. He complains of generalised muscle weakness and lethargy.  


PH: Congestive heart failure, Diabetes Mellitus , Gout, Hypercholesterolaemia, Insomnia DH: Her current regular prescriptions are listed below


 **On examination**: Chest is clear with no added lung sounds. Heart sounds I + II + 0. Abdomen soft and non tender.


 **Vital signs**: BP 122/78, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18


 **Investigations**:


 - ECG: Flat P wave and tall tented T wave


||||
|--------------|:-------:|---------------|
|Haemoglobin|135   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|280x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|91 fL|80 - 96|
|Neutrophils|5x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|2x10<sup>9</sup>/L|1.5 - 4.0|
|Sodium|140 mmol/L|135 - 145|
|Potassium|6.1 mmol/L|3.5 - 5.3|
|Urea|7 mmol/L|2.5 - 7.8|
|Creatinine|280 µmol/L|60 - 120|



Question 1: Select the TWO prescriptions that are most likely to be a cause of his hyperkalaemia (mark them with a tick in column A)
Question 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B)

Options:
name: Allopurinol;900mg;Oral (PO);Daily
label: d
answer: no
name: Spironolactone;25mg;Oral (PO);Daily
label: c
answer: no
name: Gliclazide;40mg;Oral (PO);Daily
label: g
answer: no
name: Simvastatin;40mg;Oral (PO);Nightly
label: e
answer: no
name: Enalapril maleate;10mg;Oral (PO);Twice daily
label: b
answer: no
name: Zopiclone;3.75mg;Oral (PO);Nightly as required
label: h
answer: no
name: Bisoprolol fumarate;5mg;Oral (PO);Daily
label: a
answer: no
name: Metformin hydrochloride;500 mg;Oral (PO);Three times daily
label: f
answer: no


1. Both enalapril and spironolactone are known to cause hyperkalaemia. Enalapril is an angiotensin-converting enzyme inhibitor (ACE-i). It contributes to hyperkalaemia by inhibiting aldosterone synthesis. Spironolactone is an aldosterone antagonist. Aldosterone mediates the reabsorption of sodium and excretion of potassium in the distal tubules and collecting ducts of nephrons.
2. Up to 900mg of allopurinol can be prescribed in a day but must be done in divided doses. The maximum per dose is 300mg.
Case presentation: A 50-year-old man is admitted to the Cardiology ward following an episode of syncope. PH Angina, Seizure, AF, Ankylosing spondylitis, Gout, Cellulitis. DH. His regular medicines are listed (below). Weight 120kg.


**On Examination**
HR 50/min, BP 95/85mm Hg, RR 18, O2 sats 94% RA. HS I + II with no added heart sounds.

Question 1: Select the TWO prescriptions that should not be co-prescribed. (mark them with a tick in column A)
Question 2: Select the ONE prescription that contains a serious dosing error (mark it with a tick in column B).

Options:
name: Levetiracetam;750mg;oral (PO);Twice daily
label: b
answer: no
name: Verapamil;120mg;oral (PO);Thrice daily
label: e
answer: no
name: Allopurinol;100mg;oral (PO);Daily
label: g
answer: no
name: Fusidic acid;250mg;oral (PO);Twice daily
label: h
answer: no
name: Sodium valproate;3.6g;oral (PO);Daily
label: d
answer: no
name: Bisoprolol fumarate;10mg;oral (PO);Daily
label: a
answer: no
name: Adalimumab;40mg;subcutaneous (SC);Two-weekly
label: f
answer: no
name: Ibuprofen;400mg;oral (PO);Thrice times daily
label: c
answer: no


1. Beta blockers and non-dihydropyridine calcium channel blockers should not be co-prescribed as both exert a negative inotropic and chronotropic effect on the heart, causing a depression in both mechanical and electrical activity resulting in bradycardia and hypotension.
2. Sodium valproate used for seizure management is prescribed at 20-30mg/kg daily. However, the maximum recommended dose is 2.5g daily. Hence this patient should only be prescribed 2.5g daily and not 3.6g daily.
Case presentation: A 80-year old woman is on a surgical ward recuperating from her total hip replacement that took place three days ago. She complains that she has been having difficulty fully emptying her bladder. The stream is weak and only a small of urine is passed during the day PH: Hypertension, Type 2 Diabetes Mellitus, Depression, Constipation DH: Her current regular prescriptions are listed below




 **On examination**: Chest is clear with no added lung sounds. Heart sounds I + II + 0. Slight tenderness on palpation of hypogastric region


 **Vital signs**: BP 125/80, Temperature 36.8°C, HR 80, O2 Sat 99% (room air), RR 18


 **Investigations**:
Negative urine dipstick
Bladder scan reveals a post-void residual volume of 500ml

||||
|--------------|:-------:|---------------|
|Haemoglobin|130   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|9.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|270x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|88 fL|80 - 96|
|Neutrophils|6.5x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|2.8x10<sup>9</sup>/L|1.5 - 4.0|
|Sodium|141 mmol/L|135 - 145|
|Potassium|4.2 mmol/L|3.5 - 5.3|
|Urea|7 mmol/L|2.5 - 7.8|
|Creatinine|130 µmol/L|60 - 120|


Question 1: Select the THREE prescriptions that are most likely to be a cause of the urinary retention?
Question 2: Select the ONE prescription that is most appropriate to withhold until her renal function improves?

Options:
name: Senna;15mg;Oral (PO);Nightly
label: h
answer: no
name: Paracetamol;1 g;Oral (PO);6-hourly
label: d
answer: no
name: Codeine phosphate;60 mg;Oral (PO);6-hourly
label: e
answer: no
name: Morphine sulfate immediate release (oramorph);10mg;Oral (PO);8-hourly
label: f
answer: no
name: Imipramine hydrochloride;50mg;Oral (PO);Daily
label: g
answer: no
name: Enoxaparin sodium;40mg;Subcutaneous (SC);Daily
label: c
answer: no
name: Metformin hydrochloride;500mg;Oral (PO);8-hourly
label: a
answer: no
name: Enalapril maleate;20mg;Oral (PO);Daily
label: b
answer: no


1. Codeine phosphate and morphine sulfate are examples of opioids and urinary retention is a common or very common side effect of all opioids. Imipramine sulfate is an example of tricyclic antidepressant. Urinary disorder is a side effect of imipramine and BNF has cautioned against the use of imipramine in patients with known urinary retention
2. Enalapril maleate is an example of angiotensin-converting enzyme inhibitor (ACE-i). ACE-I should be stopped whenever an AKI arises because it is nephrotoxic and might lead to further renal injury. ACE-I inhibits efferent renal arteriolar vasoconstriction, thus lowering the glomerular filtration pressure.
Case presentation: A 40-week pregnant woman is admitted electively for induction of labour. PH Type 2 diabetes mellitus, Depression, Bipolar disorder, Hypothyroid, Tension headache, Acne rosacea. DH Her current regular medications are listed (below).


Question 1: Select the TWO prescriptions that are most likely to be contributing to congenital heart defects (mark them with a tick in column A)
Question 2: Select the FOUR prescriptions that are contraindicated in breastfeeding (mark it with a tick in column B).

Options:
name: Metformin;500mg;oral (PO);12-hourly
label: g
answer: no
name: Aspirin;150mg;oral (PO);Daily
label: c
answer: no
name: Amitriptyline;50mg;oral (PO);Daily
label: f
answer: no
name: Tetracycline;500mg;oral (PO);12-hourly
label: b
answer: no
name: Lithium carbonate;500mg;oral (PO);12-hourly
label: d
answer: no
name: Fluoxetine;20mg;oral (PO);Daily
label: a
answer: no
name: Levothyroxine;200micrograms;oral (PO);Daily
label: e
answer: no


1. The use of SSRI such as fluoxetine is known to cause congenital heart diseases especially when taken during early pregnancy. Lithium, a medication used for bipolar disorder, is associated with increased risk of Ebstein’s anomaly when taken in the first trimester.
2. Despite evidence showing that calcium in breast milk prevents the absorption of tetracycline, it is currently still avoided in breastfeeding women. Aspirin increases the risk of Reye’s syndrome. Fluoxetine and lithium carbonate is present in milk and can carry a risk of toxicity in infant.
Case Presentation: A 26 year old woman is admitted to the maternity ward following induction of labour 12 hours previously. She is G2P1 and has no outstanding health problems, but is known to have swabbed positive for group B streptococcus during her initial booking appointment for her current pregnancy. NKDA


**O/E**

HR 94, RR 15, BP 132/82. Cervix dilated to 4cm, foetal head engaged. Contractions 1 in 10 minutes.

**Investigations**

Cardiotocography is reassuring.

Question: Select the most appropriate management at this stage.

Options:
explanation: Amoxicillin has activity against GBS but has a much broader spectrum of activity than would normally be required
name: Amoxicillin 500mg IV
label: b
answer: no
explanation: Clindamycin has historically been used to treat GBS but due to increasing resistance, it is recommended that sensitivities be performed before its use
name: Clindamycin 300mg IV
label: e
answer: no
explanation: This formulation of benzylpenicillin is used to treat syphilis rather than GBS
name: Benzathine benzylpenicillin 2.4m units IM
label: c
answer: no
explanation: All mothers who have swabbed positive for GBS should receive intrapartum antibiotics to reduce the risk of neonatal sepsis. Benzylpenicillin sodium is recommended first line
name: Benzylpenicillin sodium 3g IV
label: a
answer: yes
explanation: Ceftriaxone has activity against GBS but has a much broader spectrum of activity than would normally be required
name: Ceftriaxone 2g IV
label: d
answer: no

Correct answer: a
Case Presentation: A 53 year old woman who has recently moved to the UK from Vietnam attends an appointment for initial assessment after registering at her new GP. **PH** Takayasu arteritis, hypertension, generalised anxiety disorder. **DH** felodipine 10mg PO OD, escitalopram 15mg PO OD, ferrous fumarate 210mg PO BD, calcichew D3.


**O/E**

HR 86, RR 14, BP 134/92, Temperature 37.0°C, O2 99% RA. HS I + II + 0, lungs clear. Alert and comfortable at rest. She has an irregularly irregular pulse peripherally and centrally. This is not recorded on her most recent health documentation from her home country a year prior and she denies any troublesome symptoms.

**Investigations**

ECG: atrial fibrillation.

FBC, U&Es, LFTs and clotting studies all NAD.

Question: Select the most appropriate management at this stage.

Options:
explanation: This would be a possible option in rate-controlling fast AF or to manage symptoms such as palpitations
name: Start bisoprolol fumarate 5mg PO OD
label: d
answer: no
explanation: As the patient has AF and a CHA₂DS₂-VASc of 2, anticoagulation should be initiated to lower the risk of a cerebrovascular event
name: Start rivaroxaban 20mg OD
label: a
answer: yes
explanation: This would be correct if the patient was presenting with unstable AF causing haemodynamic compromise. However there is nothing in the stem to suggest that this is the case
name: Make an urgent referral to A&E for synchronised DC cardioversion
label: b
answer: no
explanation: There is no role for aspirin in the management of AF absent some cerebrovascular event
name: Start aspirin 75mg PO OD
label: c
answer: no
explanation: This would be a possible option as a ‘pill in pocket’ strategy if the patient had paroxysmal AF. However there is nothing in the stem to suggest that this is the case
name: Start flecainide acetate 50mg PO BD
label: e
answer: no

Correct answer: a
Case Presentation: A 39 year old woman attends her GP for a routine diabetic review. **PH** type 1 diabetes, hypothyroidism, Addison’s disease. **DH** soluble insulin (Humulin S) 10-12 units SC TDS with meals, insulin detemir (Levemir) 16 units SC ON, levothyroxine sodium 125 micrograms PO OD, hydrocortisone 20mg PO in the morning and 10mg PO in the evening. NKDA


**O/E**

HR 71, RR 11, BP 134/82, O2 100% RA, Temperature 36.6°C. HS I + II + 0. Chest clear. Vitiliginous patches on hands. Visual acuity and colour vision grossly normal.

**Investigations**

TSH: 1.2 (0.4-5.5)

HbA1c: 46 (target <48)

ECG: normal sinus rhythm

Urine dipstick:

Blood -ve

Nitrites -ve

Protein +1

Leucocytes -ve

A:Cr ratio: 3 mg/mmol

Question: Select the most appropriate management at this stage.

Options:
explanation: This is an unlicensed treatment for vitiligo and may be prescribed off-label by experienced clinicians
name: Start tacrolimus 0.1% ointment topical BD
label: d
answer: no
explanation: Without a blood sugar diary to monitor for labile BMs, it is inadvisable to make changes to a patient’s daily insulin regimen
name: Increase nightly insulin detemir to 20 units
label: c
answer: no
explanation: As the patient’s TSH level is normal and she is not complaining of any symptoms indicative of undertreating her hypothyroidism, this is not a necessary course of action
name: Increase dose of levothyroxine sodium to 150 micrograms PO OD
label: b
answer: no
explanation: Without a blood sugar diary to monitor for labile BMs, it is inadvisable to make changes to a patient’s daily insulin regimen
name: Switch her insulin regime to a biphasic preparation e.g 30% insulin lispro/70% insulin aspart (Novomix 30)
label: e
answer: no
explanation: As there is evidence of nephropathy in this patient, she should be started on a renoprotective agent pending a repeat urine dip and/or confirmation of end-organ damage
name: Start lisinopril 2.5mg PO OD
label: a
answer: yes

Correct answer: a
Case Presentation: A 50 year old woman is a surgical inpatient recovering from an elective anterior resection of sigmoid adenocarcinoma. **PH** type 1 diabetes. **DH** insulin lispro (Humalog) 10 units SC TDS with meals, insulin glargine (Lantus) 22 units SC ON.


**O/E**

Alert and oriented. Vital observations stable, surgical site dressing clean with limited strikethrough. Loop ileostomy in RIF, stoma bag collecting yellow liquid stool.

She is currently on insulin glargine (Lantus) 17 units SC ON and has been receiving a variable rate insulin infusion (VRII) for 12 hours since 7pm yesterday. Her pain and nausea are well controlled, and she recently started eating and drinking. She is now due dinner.

Question: Select the most appropriate management with regard to her insulin at this stage.

Options:
explanation: The patient’s long-acting insulin should only be returned to normal levels at the time of discharge and not whilst still on a VRII
name: Increase insulin glargine to 22 units SC ON and administer insulin lispro with next meal
label: e
answer: no
explanation: As the patient is able to eat and drink, she should restart her usual subcutaneous fast-acting insulin with her next meal with the VRII running for 30-60 minutes afterwards to ensure stable BMs
name: Administer insulin lispro with next meal and continue VRII for 1 hour afterwards
label: a
answer: yes
explanation: When transitioning from a VRII to normal subcutaneous insulin, the infusion should be left running for 30-60 minutes afterwards to ensure stable BMs
name: Administer insulin lispro with next meal and discontinue VRII
label: c
answer: no
explanation: The patient is able to eat and drink and there is no reason to delay returning to normal oral intake and the patient’s regular subcutaneous insulin
name: Continue VRII for another 12 hours and discontinue if BMs are stable
label: d
answer: no
explanation: The patient is able to eat and drink and there is no reason to delay returning to normal oral intake and the patient’s regular subcutaneous insulin
name: Administer insulin lispro with tomorrow's evening meal and continue VRII for 1 hour afterwards
label: b
answer: no

Correct answer: a
Case Presentation: A 71 year old woman is on the acute admissions unit being treated for acute confusion, urinary frequency and dysuria. **PH** breast cancer, focal segmental glomerulosclerosis. **DH** anastrozole 1mg PO OD, furosemide 120mg PO BD, atorvastatin 40mg PO ON, calcichew D3. Previous adverse drug reaction to penicillin – angioedema.


**O/E**

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

**Investigations**

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

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

Trimethoprim – R

Nitrofurantoin – S

Pivmecillinam – S

Amoxicillin – S

Fosfomycin – S

Question: Select the most appropriate management at this stage.

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

Correct answer: a
Case presentation: A 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: 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: 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 commonly causes diarrhoea and not constipation
name: Constipation is a common side effect of methotrexate
label: d
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: 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

Correct answer: a
A 30-year-old woman presents to her GP with a 3-week history of depression, hopelessness, fatigue, poor appetite, and difficulty sleeping. She recently gave birth to her first child a month ago. She denies hallucinations or thoughts of harming her baby. Her Edinburgh Postnatal Depression Scale score is 8/30.

Physical examination: HS 1+11 + 0, chest clear with no added lung sounds, abdomen SNT, normal neurological exam
PMH, DH: NIL
The patient is advised to commence treatment with citalopram 20mg PO once daily along with cognitive behavioural therapy and attend another appointment in two weeks’ time to review the medication.


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

Options:
explanation: Citalopram is not a tricyclic antidepressant. It is a selective serotonin reuptake inhibitor (SSRI) that works by increasing the serotonin levels in the brain. An increase in serotonin level has been shown to bring about an improvement in symptoms
name: Citalopram is a tricyclic antidepressant that works by increasing levels of adrenaline in the brain
label: b
answer: no
explanation: If a patient has been feeling better for 6 months or more, he/she might be suggested to come off citalopram. However, patients should be reminded to discuss with their doctors before stopping the medication because abrupt discontinuation could lead to discontinuation symptoms such as restlessness and irritability. Dose of citalopram should be tapered and reduced gradually over 4 weeks
name: She should not abruptly discontinue her medication when she is feeling better
label: a
answer: yes
explanation: Citalopram is generally safe to be used during breastfeeding. Citalopram usually only passes into breast milk in small quantities and has only been associated with adverse effects in very few breastfed babies. Moreover, grey baby syndrome is more commonly linked with antibiotic chloramphenicol
name: She should not breastfeed if she is taking citalopram because citalopram passes into breast milk in large quantities and can lead to grey baby syndrome
label: c
answer: no
explanation: Citalopram is not a tricyclic antidepressant. It is a selective serotonin reuptake inhibitor (SSRI) that works by increasing the serotonin levels in the brain. An increase in serotonin level has been shown to bring about an improvement in symptoms
name: Citalopram can lead to addiction
label: d
answer: no
explanation: Agitation and sweating are not normal side effects of citalopram. Patients should stop taking the medication and seek immediate medical help because these signs are suggestive of serotonin syndrome
name: It is normal to experience agitation and sweating during the course of treatment
label: e
answer: no

Correct answer: a

She should not abruptly discontinue her medication when she is feeling better