hllj/quesmed huggingface dataset:
A 20 year old woman comes to the emergency department with right iliac fossa pain, which started in the umbilicus. She is nauseated and has vomited. She has not eaten since yesterday.

Urinary beta-HCG is negative.

What is the most appropriate initial investigation?

Options:
explanation: There is nothing to suggest pathology in the colon at present.
name: Colonoscopy
label: e
answer: no
explanation: This may be considered if gynaecological pathology is suspected on abdominal ultrasound as it is more invasive.
name: Transvaginal ultrasound
label: d
answer: no
explanation: This is correct. This describes likely appendicits but an ultrasound scan is often used in females in the first instance to exclude ovarian and gynaecological pathology.
name: Abdominal ultrasound
label: a
answer: yes
explanation: This is the preferred diagnostic imaging modality in appendicitis but ovarian and gynaecological pathology can be quickly considered with an ultrasound.
name: CT Abdomen
label: b
answer: no
explanation: A pregnancy test has been performed already and is negative.
name: Repeat pregnancy test
label: c
answer: no

Correct answer: a


Learning point: In young women with right iliac fossa pain, abdominal ultrasound is crucial to exclude gynaecological conditions before diagnosing appendicitis.
A 50 year old woman presents to the emergency department short of breath. Examination reveals dullness to percussion on the right side.

A chest X ray is performed and shows:

[lightgallery]

What is the most appropriate course of management?

Options:
explanation: This may be appropriate if the effusion is exudative and felt to be secondary to a possible malignancy, but is not warranted at present.
name: CT Chest, abdomen and pelvis
label: d
answer: no
explanation: The examination findings and chest x ray do not suggest acute pulmonary oedema and therefore furosemide is not warranted at present.
name: Intravenous furosemide
label: e
answer: no
explanation: This may prove helpful in providing symptomatic relief, but the mainstay of treatment in cases of pleural effusion is establishing and treating the underlying cause.
name: Chest physiotherapy
label: c
answer: no
explanation: This is correct. This woman has a pleural effusion and the aetiology needs to be uncovered through aspiration and pleural fluid analysis of protein content, LDH, cell count, pH, glucose and microbiology testing to ascertain whether it is a transudative or exudative cause.
name: Pleural aspiration
label: a
answer: yes
explanation: This is the treatment of choice in cases of tension pneumothorax, which the examination and chest x-ray do not support.
name: Emergency needle decompression
label: b
answer: no

Correct answer: a


Learning point: Pleural aspiration is essential for diagnosing the cause of a pleural effusion (transudative vs exudative) through analysis of the pleural fluid and application of lights criteria
A 26 year old woman presents to the emergency department short of breath since yesterday. She is tachycardic on examination. She has systemic lupus erythematosus and has recently been struggling with hyperemesis gravidarum, causing her to take time off work in the last week.

Her chest x-ray is shown below. Further imaging investigations are not available until tomorrow.

[lightgallery]

What is the most appropriate management?

Options:
explanation: This is unlikely to prove helpful in cases of pulmonary embolism whereby the priority is treating the clot.
name: Chest physiotherapy
label: c
answer: no
explanation: This is not appropriate given her history and symptoms.
name: Discharge with reassurance
label: e
answer: no
explanation: This is the treatment of choice in cases of tension pneumothorax, which the examination and chest x ray do not support.
name: Emergency needle decompression
label: b
answer: no
explanation: This is correct. This woman likely has a pulmonary embolism with pro-thrombotic risk factors of SLE, pregnancy and immobilisation. Her chest x-ray is normal which is common in pulmonary embolism. She requires a CTPA or V/Q scan, but should be anticoagulated until this can be done.
name: Start on treatment dose low molecular weight heparin
label: a
answer: yes
explanation: There is nothing to suggest an infective pathology at present with the chest x-ray appearing normal.
name: Start on co-amoxiclav and clarithromyxin
label: d
answer: no

Correct answer: a


Learning point: Patients with systemic lupus erythematosus are at increased risk of pulmonary embolism, especially during pregnancy and periods of immobilisation.
A 75 year old man comes to the GP complaining of knee pain, stiffness and swelling. He is obese and smokes 20 cigarettes a day.

A knee x ray is performed and is shown below:

[lightgallery]

What is the most appropriate management?

Options:
explanation: Codeine is not first line analgesia for osteoarthritis and this option does not address lifestyle measures.
name: Offer co-codamol
label: c
answer: no
explanation: There is nothing to suggest a diagnosis of gout at present warranting allopurinol.
name: Offer allopurinol
label: d
answer: no
explanation: This is correct. This man's history and imaging suggest osteoarthritis which is initially treated by lifestyle measures including exercise, weight loss and analgesics including paracetamol and NSAIDs. Topical NSAIDs are first line for knee osteoarthritis.
name: Lifestyle advice and offer topical ibuprofen
label: a
answer: yes
explanation: This may be a treatment option later down the line.
name: Refer for steroid joint injections
label: b
answer: no
explanation: This is not appropriate given the patient likely has osteoarthritis which is chronic and not an emergency, as a last resort ,elective surgery may be required in severe osteoarthritis.
name: Admit to hospital for emergency surgery
label: e
answer: no

Correct answer: a


Learning point: Osteoarthritis management includes lifestyle modifications, weight loss, and topical NSAIDs as first-line treatment for knee pain and stiffness.
A 10-month old girl is rushed into the Emergency Department with sudden onset cough, respiratory distress, and noisy breathing. This started 20 minutes ago whilst at a playdate, and she had previously been well. On examination she is making a high-pitched inspiratory sound whilst breathing and is coughing ineffectively. There is no wheeze, rash, or angioedema. Her respiratory rate is elevated at 48 (30-40) and she is tachycardic at 152 bpm (80-140), her other vital signs are normal.

What is the most appropriate management?

Options:
explanation: Croup is a common cause of stridor in children and can also cause respiratory distress, this would be treated with steroids. However, the onset would not be so sudden and there is usually a history of low grade fever and coryzal illness. The history and examination is more consistent with an inhaled foreign body.
name: Dexamethasone, STAT dose
label: c
answer: no
explanation: Anaphylaxis is an important differential for respiratory distress and stridor, however is is accompanied by hypotension, and allergic symptoms such as angioedema. The history and examination is more consistent with an inhaled foreign body.
name: 150 micrograms IM adrenaline
label: d
answer: no
explanation: The sudden onset and lack of temperature in this patient is not consistent with an infectious cause of respiratory distress. The history and examination is more consistent with an inhaled foreign body.
name: Amoxicillin
label: e
answer: no
explanation: The history and examination is consistent with an inhaled foreign body. The immediate management is a rigid bronchoscopy to remove it. Foreign body inhalations are often unwitnessed in children and it is an important differential for anyone presenting with stridor and respiratory distress. Although not common practice, this question has appeared in previous writers' MLA AKT exams so we have included it in our bank.
name: Rigid bronchoscopy
label: a
answer: yes
explanation: Bronchoconstriction can cause respiratory distress in infants, however a wheeze rather than stridor would be found on examintation. The history and examination is more consistent with an inhaled foreign body.
name: Nebulised salbutamol
label: b
answer: no

Correct answer: a


Learning point: Inhaled foreign bodies in children can cause sudden respiratory distress and stridor, necessitating immediate rigid bronchoscopy for removal.
Case Presentation: A 67-year-old lady attends her GP for a follow up appointment after her recent blood tests. She had previously presented with feeling cold all the time despite the weather being warm, drier skin than usual and she has also noticed small amounts of hair loss. Her blood test results are below.




## PH


Vitiligo


## DH


NKDA


## On examination


No cyanosis. Alert and orientated. Two patches of hair loss noted on the scalp.


Temperature 37.0°C, HR 60, RR 14, BP 130/73, O<sub>2</sub> saturation 96% RA, GCS 15, Weight 94kg


## Investigations


||||
|---------------------------|:-------:|------------------------------|
|Thyroid Stimulating Hormone|10 mU/L|0.3 - 4.2|
|Free T4|8 pmol/L|9 - 25|
|Free T3|0.8 pmol/L|3.1 - 6.8|

Anti-TPO (thyroid peroxidase) assay: positive


# Prescribing Request


Write a prescription for one drug that is most appropriate for managing this patient's condition.



Options:


# Drug choice feedback

This is a patient presenting with symptoms and signs of hypothyroidism (dry skin, cold intolerance, alopecia), and the blood tests confirm the likely cause is Hashimoto's thyroiditis (commonest cause of hypothyroidism in the UK). As such, she should be commenced on thyroxine replacement therapy with levothyroxine.

# Dose/Route/Frequency/Duration feedback

NICE recommend considering starting levothyroxine at a dosage of 25–50 *micrograms* per day with titration for adults aged 65 years and over, and adults with a history of cardiovascular disease. It should be taken in the morning on an empty stomach and before any other medication has been taken. The dose can be uptitrated every 4 weeks by 25-50mcg. The patient should be reviewed and have TSH levels every 3 months after initiation of levothyroxine therapy and adjust the dose according to symptoms and TFT results.
Case presentation: A 45-year-old woman on the gynaecology ward is recovering from an elective total abdominal hysterectomy. PH Mild COPD, Polymyalgia rheumatica, Uterine fibroids, Familial hypercholestrolaemia. DH. Her current regular medications are listed (below).




 **Investigation**

||||
|---------------------------|:-------:|--------------------|
|Urea|8.5 mmol/L|2.5 - 7.8|
|Creatinine|145 µmol/L|60 - 120|



Question 1: Select the TWO prescriptions that should not be co-prescribed. (mark them with a tick in column A)
Question 2: Select the TWO prescription that are most appropriate to withhold until her renal function recovers.

Options:
name: Paracetamol;1g;oral (PO);6-hourly
label: a
answer: no
name: Salbutamol;200 micrograms;inhaled (INH);Daily
label: e
answer: no
name: Ipratropium bromide;40 micrograms;inhaled (INH);6-hourly
label: f
answer: no
name: Atorvastatin;10mg;oral (PO);Daily
label: c
answer: no
name: Ibuprofen;400mg;oral (PO);8-hourly
label: d
answer: no
name: Co-codamol 8-500mg;1 tablet;oral (PO);6-hourly
label: b
answer: no
name: Nicotine patch;14mg;transdermal (TD);Daily
label: g
answer: no


1. Paracetamol 1g 6-hrly is the maximum recommended dose of paracetamol. Hence, it should not be co-prescribed with another medication which contains paracetamol in it (co-codamol).
2. NSAIDs may lead to the worsening of renal function and hence, should be stopped during an AKI. Similarly, codeine (co-codamol) should be avoided in AKI due to the risk of adverse effects with reduced excretion.
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: Fluticasone;400micrograms;inhaled (INH);12-hourly
label: f
answer: no
name: Mirtazapine;30mg;oral (PO);Daily
label: c
answer: no
name: Mesalazine;2g;oral (PO);Daily
label: g
answer: no
name: Risperidone;5mg;oral (PO);Daily
label: a
answer: no
name: Haloperidol;20mg;oral (PO);12-hourly
label: b
answer: no
name: Ramipril;10mg;oral (PO); Daily
label: d
answer: no
name: Amlodipine;5mg;oral (PO); Daily
label: e
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 70-year-old Afro-Carribean gentleman presents to the GP for his annual flu vaccine. PH Infective exacerbation of COPD, for which he has been receiving treatment for the past 5 days, Hypertension. DH His current regular medicines are listed (below).


**On Examination** Red swellings beneath the surface of his eyelid consistent with angioedema.

Question 1: Select the ONE prescription that is most likely to be contributing to the angioedema (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: Atorvastatin;20mg;oral (PO);Daily
label: g
answer: no
name: Bendroflumethiazide;2.5mg;oral (PO);Daily
label: f
answer: no
name: Amlodipine;5mg;oral (PO);Daily
label: e
answer: no
name: Ipratropium bromide;40micrograms;inhaled (INH);8-hourly
label: c
answer: no
name: Salbutamol;200micrograms;inhaled (INH);as required
label: b
answer: no
name: Prednisolone;30mg;oral (PO);Daily
label: d
answer: no
name: Perindopril arginine;8mg;oral (PO);Daily
label: a
answer: no
name: Bisoprolol;20mg;oral (PO);12-hourly
label: h
answer: no


1. ACEi (perindopril arginine) and tetracycline (oxytetracycline) commonly cause angioedema with the former more common in the Afro-Carribean population. Calcium channel blockers (amlodipine) also cause angioedema but are not common.
2. Bisoprolol fumarate, given for the treatment of hypertension is given at 5-10mg daily with a maximum dose of 20mg daily. Hence, the correct prescription for 20mg should be daily instead of 12-hrly.
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: Enalapril maleate;20mg;Oral (PO);Daily
label: b
answer: no
name: Senna;15mg;Oral (PO);Nightly
label: h
answer: no
name: Imipramine hydrochloride;50mg;Oral (PO);Daily
label: g
answer: no
name: Paracetamol;1 g;Oral (PO);6-hourly
label: d
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: 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


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 56-year old woman visits her GP for medication review. She reports that she has been putting on weight despite following a healthy diet and exercising regularly. She also complains of feeling drowsy PH: Type 2 Diabetes Mellitus, Depression, GORD, Osteoporosis, Constipation 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.

**Investigation**:

- Weight 71kg (66kg 6 months ago)
- BMI: 27
- HbA1c: 53 mmol/mol

Question 1: Select the THREE prescriptions that are most likely to be contributing to the weight gain (mark them with a tick in column A)
Question 2: Select the ONE prescription that is most likely be contributing to the drowsiness (mark it with a tick in column B)

Options:
name: Senna;15 mg;Oral (PO);Nightly
label: g
answer: no
name: Pioglitazone;45 mg;Oral (PO);Daily
label: d
answer: no
name: Gliclazide (Modified release);120 mg;Oral (PO);Daily
label: c
answer: no
name: Metformin hydrochloride;500 mg;Oral (PO);Three times daily
label: b
answer: no
name: Mirtazapine;30 mg;Oral (PO);Daily
label: a
answer: no
name: Alendronic acid;70 mg;Oral (PO);Once weekly
label: f
answer: no
name: Omeprazole;20mg;Oral (PO);Daily
label: e
answer: no


1. Mirtazapine is a presynaptic alpha2-adrenoreceptor antagonist that is used to treat depression. It works by increasing central noradrenergic and serotonergic neurotransmission. Weight gain is a common or very common side effect of mirtazapine. Gliclazide is a sulfonylurea that works by increasing insulin secretion. Gliclazide is also known to cause weight gain. Pioglitazone is a peroxisome proliferator-activated receptor gamma (PPAR-γ) agonist that works by reducing peripheral insulin resistance. Weight gain is a common or very common side effect of pioglitazone.
2. Drowsiness is a common or very common side effect of mirtazapine. Drowsiness is also listed as an uncommon side effect of omeprazole in BNF.
Case presentation: A 78-year-old female is admitted to the cardiology ward. During her stay she has been complaining of cold peripheries.


**PH** Congestive cardiac failure, type 2 diabetes mellitus, hypertension, oseteoarthritis hypercholesterolaemia, COPD, ADHD, depression

**DH** Her current medications are listed (below). Weight 110kg.

**On Examination**

HR 88/min, BP 114/89mm Hg, RR 24, O2 sats 92% RA. HS I + II with no added heart sounds. Bilateral basal crepitations heard on auscultation of the lungs.

**Investigation**

CXR shows bilateral pleural effusions

Question 1: Select the TWO prescriptions that are most likely to be the cause of her cold peripheries (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: Spironolactone;100mg;PO;OD
label: c
answer: no
name: Furosemide;40mg;PO;OD
label: b
answer: no
name: Methylphenidate hydrochloride;20 mg;PO;TDS
label: g
answer: no
name: Ramipril;20mg;PO;OD
label: a
answer: no
name: Atorvastatin;80mg;PO;OD
label: d
answer: no
name: Bisoprolol;7.5 mg;PO;OD
label: e
answer: no
name: Paracetamol;500mg;PO;BD
label: h
answer: no
name: Metformin;500mg;PO;BD
label: f
answer: no
name: Sertraline;50mg;PO;OD
label: i
answer: no


1. Both bisoprolol and methylphenidate can cause patient's to experience cold peripheries. Bisoprolol commonly causes cold peripheries as they reduce the amount of blood that is delivered to the fingers and toes.
2. The maximum dose of ramipril that a patient can take is 10mg PO OD therefore this prescription contains a mistake.
Case presentation: A 72-year-old gentleman attends his GP complaining of constipation


**PH** Benign prostatic hyperplasia, osteoarthritis, hypertension, prior myocardial infarction, hypercholesterolaemia, allergic rhinitis, gastro-oesophageal reflux disease,

**DH** His current medicines are listed (below). Weight 81kg.

Question 1: Select the FOUR prescriptions that are most likely to be contribute to his constipation (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: Cetirizine;10mg;PO;OD
label: i
answer: no
name: Aspirin;75mg;PO;OD
label: c
answer: no
name: Tamsulosin;400mg;PO;OD
label: h
answer: no
name: Ibuprofen;400mg;PO;QDS
label: g
answer: no
name: Omeprazole;20mg;PO;OD
label: a
answer: no
name: Ramipril;10mg;PO;OD
label: e
answer: no
name: Clopidogrel;75mg;PO;OD
label: d
answer: no
name: Bisoprolol;10mg;PO;OD
label: f
answer: no
name: Atorvastatin;80mg;PO;OD
label: b
answer: no


1. PPIs, ACE inhibitors, beta blockers and statins commonly cause constipation. Whilst other medications that this patient is on such as clopidogrel, tamsulosin and ibuprofen can cause constipation, these aren't listed as common/very common side effects unlike the omeprazole, ramipril, bisoprolol and atorvastatin.

2. The normal dose for tamsulosin when treating benign prostatic hyperplasia is 400 micrograms. This patient is receiving 400 milligrams of tamsulosin which is much higher than the maximum dose he should be receiving.
Case presentation: A 28-year-old woman is attends her GP complaining of nausea in the morning.  


**PH** Bipolar disorder, asthma, type 2 diabetes mellitus, acne, allergic rhinitis

**DH** Her regular medicines are listed (below). Weight 108kg.

**Investigation**

Urinary beta hCG ++

Question 1: Select the FOUR prescriptions that she will need to stop taking given her urinary beta hCG test results (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: Metformin;500mg;PO;BD
label: c
answer: no
name: Paracetamol;1mg;PO;QDS
label: b
answer: no
name: Isotretinoin;20mg;PO;OD
label: d
answer: no
name: Salbutamol;200 micrograms;INH;QDS
label: e
answer: no
name: Fluoxetine;60mg;PO;OD
label: h
answer: no
name: Cetirizine;10mg;PO;OD
label: i
answer: no
name: Lithium carbonate (Liskonum);450mg;PO;OD
label: a
answer: no
name: Fluticasone;200 micrograms;INH;BD
label: f
answer: no
name: Gliclazide;80mg;PO;OD
label: g
answer: no


1. Lithium and isotretinoin are teratogenic. Lithium is linked with an increased risk of Ebstein's anomaly occurring. Isotretinoin is linked with an increased risk of cardiovascular and ear malformations. Gliclazide should be stopped due to the increased risk of neonatal hypoglycaemia. The BNF advises that antihistamines should be avoided during pregnancy. NB: newer research now suggests that SSRIs including fluoxetine can be safely taken during pregnancy, however the pros and cons should be considered, and it should be given at the lowest effective dose.

2. The dose of paracetamol should be 1g PO QDS in this patient, 1mg is an incorrect dose.