hllj/quesmed huggingface dataset:
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: 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
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

Correct answer: a
Case presentation: A 30-year-old man attends the psychiatric clinic for his medication review. He was diagnosed with schizophrenia three month ago and has been taking anti-psychotic and cognitive behavioural therapy. His symptoms have improved but he wishes to stop taking the medication because it is giving him continuous spasms and muscle contractions that greatly affect his daily living.  

DH: Chlorpromazine hydrochloride 25mg PO thrice daily
SH: Works as a carpenter, lives alone
The patient is advised to switch his current treatment regime to olanzapine 10mg PO daily under the supervision of his psychiatrist.

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

Options:
explanation: If patients have forgotten to take a dose, they should take the missed dose 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. They should not take a double dose to make up the missed dose
name: If he forgets to take a dose of olanzapine, he should take a double dose to compensate for the forgotten dose
label: e
answer: no
explanation: It is mandatory for all the patients taking clozapine, not olanzapine, to be registered with the patient monitoring service. The service provides centralised monitoring of leucocyte and neutrophil counts in order to manage the risk of agranulocytosis associated with clozapine
name: He will be registered with the patient monitoring service set up by the drug manufacturer
label: b
answer: no
explanation: Olanzapine is linked to eosinophilia rather than low eosinophil counts
name: Olanzapine can cause low eosinophil count
label: c
answer: no
explanation: Agranulocytosis is an uncommon but potentially fatal side effect of olanzapine
name: Agranulocytosis is a common side effect of olanzapine
label: d
answer: no
explanation: Increased appetite leading to weight gain is a common side effect of olanzapine. Hence, it is recommended to measure blood lipids and weight at baseline, every 3 months for the first year and then yearly for all the patients taking olanzapine
name: Olanzapine can increase appetite and lead to weight gain
label: a
answer: yes

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: 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: 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
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: 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

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. 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: 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: 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: 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: 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
A 45-year-old woman in the Psychiatric Ward with severe agitation on admission was started on diazepam 500 micrograms/kg by slow IV infusion over 6 hours. 12 hours after the completion of this infusion, she requires a repeat diazepam infusion. Weight 70kg.


What is the total dose (mg) of diazepam that she will receive over the 24 hour period since her admission?

Options:


Dose of diazepam = 500micrograms/kg
Weight = 70kg
Each dose of diazepam
= 500micrograms/kg x 70kg
= 35 000 micrograms = 35mg
Total dose in 24 hours
= 35mg x 2 = 70mg
A 5-year-old patient who weighs 30kg has mild pyrexia. He is prescribed paracetamol orally.

What is the maximum total dose (in milligrams) of paracetamol he can be given per day?

Options:


The dose of paracetamol to be given for a 5-year-old is 240mg. The maximum number of doses that can be given per day is four. Therefore, the maximum total dose he can be given is: 240mg x 4 = 960mg.
A 58-year-old patient suffers from bacteraemia and MRSA was isolated from blood cultures. He is prescribed a vancomycin infusion of 20mg/kg twice a day. The maximum that can given per dose is 2g. The infusion runs at a maximum rate of 10mg/min. His weight is known to be 75kg.


What is the shortest time period (in hours) over which vancomycin can be safely infused?

Options:


The total dose to be given is: 20mg/kg x 75kg = 1500mg. We are not constrained by the maximum dose that can be given (2g) as 1500mg i.e. 1.5g is less than this limit. The shortest time period that vancomycin can be safely infused assumes it is run at at the maximum rate given. Hence, the time period is: 1500mg ÷ 10mg/min = 150 minutes. Given that there are 60 minutes in an hour, this is equivalent to 2 hours and 30 minutes.
A 8-year-old patient who weighs 35kg has community-acquired pneumonia. He is prescribed amoxicillin orally.

What is the maximum total dose (in grams) of amoxicillin he can be given per day?

Options:


The dose of amoxicillin normally for an 8-year-old child is 500mg three times a day. This can be increased to 30mg/kg three times a day. Based on the patient's weight of 35kg, the dose would be: 35kg x 30mg/kg = 1050mg. However, there is restricted to the cap of 1g per dose. Since this is given three times a day, the maximum dose is: 1g x 3 times a day = 3g a day.
A 25-year-old patient is brought to the Emergency Department after overdosing on paracetamol. A paracetamol level is taken which is shown to be above the treatment line of the nomogram. N-acetylcysteine is prescribed at a dose of 150mg/kg over 1 hour, which is to be given in a 200mL intravenous infusion of 5% dextrose. Her weight is estimated to be 60kg.


What is the concentration of (in milligrams per millilitre) of the N-acetylcysteine infusion?

Options:


Based on the patient's weight, the total dose to be given is: 150mg/kg x 60kg = 9000mg. Given that the volume of 5% dextrose used is 200mL , the concentration of the infusion is: 9000mg ÷ 200mL = 45mg/mL. The time period over which the infusion is given (1 hour) and the concentration of the dextrose fluid bag are distractions.
Case Presentation: A 45 year old man was admitted following an episode of productive cough and fever. Sputum culture was positive for Pseudomonas Aeruginosa, sensitive to ciprofloxacin and gentamicin. He had completed a 6 day course of gentamicin during his admission and has clinically improved since. He will be discharged with a 14 day course of 750mg BD ciprofloxacin.


Question: Select the adverse effect that is most likely to be caused by this treatment.

Options:
explanation: Ciprofloxacin does not commonly cause cholestatic hepatitis
name: Cholestatic hepatitis
label: b
answer: no
explanation: Ciprofloxacin is the only oral antibiotic available for pseudomonal infection. Along with other antibiotic classes such as cephalosporins, penicillins and clindamycin, it is commonly associated with causing C difficile diarrhoea due to its destructive effect on the gut flora, allowing C difficile to grow out of control, leading to C. difficile infections and diarrhoea
name: Diarrhoea
label: a
answer: yes
explanation: Ciprofloxacin does not commonly cause ototoxicity
name: Ototoxicity
label: d
answer: no
explanation: Ciprofloxacin does not commonly cause symptoms of reflux
name: Reflux
label: c
answer: no
explanation: Ciprofloxacin does not commonly cause optic neuritis
name: Optic neuritis
label: e
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: Bisorprolol does not commonly cause gynaecomastia
name: Bisoprolol fumarate 10mg OD PO
label: e
answer: no
explanation: Ramipril does not commonly cause gynaecomastia
name: Ramipril 5mg BD PO
label: d
answer: no
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: 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

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: 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
explanation: Metformin is not known to interact with simvastatin to cause myalgia
name: Metformin hydrochloride 500 mg PO TDS
label: b
answer: no

Correct answer: a
Case presentation: A 60-year-old man visits his GP for medication review. He complains of a recent-onset persistent dry cough but denies having fever or any coryzal symptoms. The cough is not worse when lying down. The patient is not a smoker and the cough only happened after he started on a new prescription.  

PMH: Diabetes Mellitus, Hypertension, Depression
DH: Metformin 500 mg PO TDS, Lisinopril 20 mg PO OD, Sertraline 50 mg PO OD
Observations: Temperature 36.5, Respiratory rate 12, Blood pressure 125/85, Heart rate 78
On Examination: Chest is clear with no added sounds. HS I+II+0.

Question: Select the most appropriate option for the management of the adverse drug reaction.

Options:
explanation: Lisinopril is an angiotensin converting enzyme inhibitor (ACE-I) that is used as a first line antihypertensive for patients with type 2 diabetes mellitus. Dry cough is a common or very common side effect of ACE-I. The mechanism of action is believed to be related to a decrease in degradation and subsequently an increase in buildup of bradykinin. NICE guidance recommends for an angiotensin receptor block (ARB), for example losartan potassium, to be offered if ACE-i is not tolerated
name: Stop lisinopril in exchange for losartan potassium 50 mg PO once daily
label: a
answer: yes
explanation: Sertraline is not known to cause dry cough. Amoxicillin is not required because the dry cough is less likely to be caused by infection in view of the clinical picture described
name: Stop sertraline and commence treatment with amoxicillin 500 mg PO three times daily
label: e
answer: no
explanation: Sertraline is not known to cause dry cough
name: Stop sertraline in exchange for citalopram 20 mg PO once daily
label: d
answer: no
explanation: Metformin is not known to cause dry cough
name: Stop metformin hydrochloride in exchange for gliclazide 40 mg PO once daily
label: b
answer: no
explanation: Captopril is another example of ACE-i and so is unlikely to help with the dry cough
name: Stop lisinopril in exchange for captopril 25 mg PO twice daily
label: c
answer: no

Correct answer: a
Case presentation: A 65-year old man on the geriatric ward complains of nausea, vomiting and generalised muscle weakness. He was admitted to the hospital following a fall at home two days ago.  


PMH: Type 2 Diabetes Mellitus, Hypertension, Heart failure, Depression
DH: His current regular prescriptions are listed below
Examination: Dry lips and reduced skin turgor. Deep and laboured breathing. No added lung sounds. HS I+II+0. Abdomen soft non tender.
Investigation:

||||
|--------------|:-------:|------------------|
|pH|7.25|7.35 - 7.45|
|PaO₂|11 kPa|11 - 15|
|PaCO₂|3.8 kPa|4.6 - 6.4|
|Bicarbonate|12.1 mmol/L|22 - 30|
|Base Excess|-13.5 mmol/L|-2 to +2|
|Creatinine|300 µmol/L|60 - 120|
|Lactate|5.1 mmol/L|0.6 - 1.4|

Anion gap: 29 mmol/L
Negative urine toxicology


Question: Select the prescription that is most likely to be contributing to the clinical picture described above?

Options:
explanation: Carvedilol is not known to cause lactic acidosis
name: Carvedilol 3.125 mg PO twice daily
label: b
answer: no
explanation: Clinical picture described above is that of a high anion gap metabolic acidosis with raised lactate level. Lactic acidosis is a rare or very rare, but potentially fatal side effect of metformin. Chronic stable heart failure is a risk factor for lactic acidosis. BNF advises that metformin should be witheld if dehydration occurs because acute kidney injury can precipiate lactic acidosis
name: Metformin hydrochloride 500 mg PO three times daily
label: a
answer: yes
explanation: Lisinopril is not known to cause metabolic acidosis
name: Lisinopril 10 mg PO once daily
label: c
answer: no
explanation: Sertraline not known to cause metabolic acidosis
name: Sertraline 50 mg PO once daily
label: d
answer: no
explanation: Simvastatin is not known to cause metabolic acidosis
name: Simvastatin 40 mg PO nightly
label: e
answer: no

Correct answer: a
Case Presentation: A 24 year old man has been detained under a Section 2 order for an acute psychotic episode on a background of treatment-resistant schizophrenia. The consultant psychiatrist decides to commence clozapine (Clozaril) 12.5mg PO OD with dose escalation planned over the next few days and weeks.


Question: Select the most appropriate option to monitor for adverse effects of this treatment.

Options:
explanation: It is not necessary to check or monitor bone profile in treatment with clozapine
name: Bone profile
label: b
answer: no
explanation: A rare but serious adverse effect of clozapine is agranulocytosis. The white cell count must be checked at the start and closely monitored throughout the duration of treatment
name: Full blood count
label: a
answer: yes
explanation: Clozapine is known to be cardiotoxic and serious adverse effects include myocarditis and cardiomyopathy. In the absence of symptoms or clinical suspicion it is not necessary to conduct routine monitoring with stress echocardiography
name: Stress echocardiogram
label: e
answer: no
explanation: It is not necessary to check or monitor serum magnesium in treatment with clozapine
name: Serum magnesium
label: d
answer: no
explanation: This may be checked at the start of treatment but it is not necessary to monitor renal function during treatment
name: Renal function tests
label: c
answer: no

Correct answer: a
Case Presentation: A 67 year old man is admitted to the medical ward for treatment of a diabetic foot ulcer. **PMH** type 2 diabetes, hypertension, diabetic nephropathy. **DH** metformin hydrochloride MR tablets 2g PO OD, insulin glargine (Lantus) 9 units SC BD, doxazosin 4mg PO OD. Allergic to penicillin – urticarial rash. Allergic to gentamicin – anaphylaxis.


**Investigations**

FBC: Hb 130, WCC 17.3, Plts 235 x 10^9, MCV 87

U&Es: Na 145, K 4.8, Cl 96, Ur 3.1, Cr 197, eGFR 48mL/min/1.73m^2

LFTs: AST 16, ALT 23, ALP 54

CRP 155

Ulcer swab MCS: mixed growth. Primary species Staphylococcus aureus and Staphylococcus epidermidis, isolated Elizabethkingia meningoseptica

Based on the sensitivities and advice from microbiology, the patient’s consultant decides to start co-trimoxazole 960mg IV BD for 7 days.

Question: Select the most appropriate option to monitor for adverse effects of this treatment.

Options:
explanation: Monitoring of blood co-trimoxazole concentrations may be useful for planning dose adjustments but aberrant levels do not necessarily correspond with development of adverse effects
name: Co-trimoxazole levels
label: b
answer: no
explanation: Co-trimoxazole is known to cause hyperkalaemia in patients who are at risk of or have pre-existing renal impairment
name: Urea and electrolytes
label: a
answer: yes
explanation: Hypoglycaemia is a very rare side effect of treatment with co-trimoxazole but it is not routine to monitor blood glucose whilst on this drug
name: Blood glucose monitoring
label: c
answer: no
explanation: It is advised to avoid using co-trimoxazole in patients with severe hepatic impairment but monitoring liver function is not routinely done
name: Liver function tests
label: e
answer: no
explanation: Co-trimoxazole has anti-folate activity and monitoring haematics could be considered if taken for an extended period of time or in combination with another anti-folate drug such as methotrexate. However the planned treatment course here is only for 7 days and is unlikely to result in a significant effect
name: Haematinics (ferritin, B12, folate)
label: d
answer: no

Correct answer: a