hllj/quesmed huggingface dataset:
Case Presentation:




A 55-year-old man presents to his GP for review of his blood cholesterol. He was started on atorvastatin 3 months ago for his hypercholesterolemia as his QRISK score was 20%. PMH Type 2 diabetes mellitus, Hypercholesterolemia. DH Atorvastatin 20mg PO daily, Metformin 500mg TDS PO.


 **On Examination**
BP 125/85 mmHg


HR 85/min


RR 14


O2 stats 95% RA


 **Investigations**
 3 months ago, prior to treatment:


||||
|---------------------------|:-------:|--------------------|
|Albumin|40 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|30 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|15 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|100 IU/L|25 - 115|
|Gamma Glutamyl Transferase (GGT)|30 U/L|9 - 40|
|Bilirubin|15 µmol/L|< 17|
|Prothrombin Time (PT)|15    seconds|10 - 12|



 3 days ago:


||||
|---------------------------|:-------:|--------------------|
|Albumin|45 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|85 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|40 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|120 IU/L|25 - 115|
|Gamma Glutamyl Transferase (GGT)|35 U/L|9 - 40|
|Bilirubin|13 µmol/L|< 17|
|Prothrombin Time (PT)|14    seconds|10 - 12|


Question:
Select the most appropriate decision option with regard to the treatment of his hypercholesterolemia based on these data.

Options:
explanation: There is no clinical indication to change his form of statin or the frequency of his medication
name: Switch to simvastatin 20mg PO 12-hrly
label: d
answer: no
explanation: In this case, his transaminases are raised, his LFT should be repeated in 1 months time. There is no clinical indication to increase the frequency of his medication
name: Atorvastatin 20mg PO 12-hrly
label: b
answer: no
explanation: His LFT is not raised by more than 3 times the upper limit, there is no need to discontinue his statin at this point
name: Stop atorvastatin
label: e
answer: no
explanation: In this case, his transaminases are raised, his LFT should be repeated in 1 months time. There is no clinical indication to increase the dose of his medication
name: Atorvastatin 40mg PO daily
label: c
answer: no
explanation: LFT should be done 3 months after initiation of statin medication. If the transaminase levels are raised by more than 3 times upper limit of normal, discontinue statin and repeat LFT in a month. If the transaminase are raised but less than 3 times upper limit of normal , continue statin and repeat LFT in a month. In this case, his transaminases are raised but not more than 3 times the upper limit, hence, his medication can be continued and LFT should be repeated in a months time
name: Atorvastatin 20mg PO daily
label: a
answer: yes

Correct answer: a
Case Presentation:  A 26-year-old female patient takes the combined oral contraceptive pill (COCP) for endometriosis. She feels well in herself. 


**PMH**
Endometriosis

**DH**
Microgynon 30 one tablet daily

**On Examination**

* HR 84 bpm
* Blood pressure 166/92 mm/Hg

Question: Given the results of the above investigations, what is the most appropriate next step?

Options:
explanation: Whilst this patient is hypertensive, she is asymptomatic and systemically well. Hypertension with a systolic pressure of over 180mmHg and signs of end-organ damage such as retinal haemorrhage, papilloedema, new confusion, chest pain or signs of heart or kidney failure would require immediate admission as this would suggest malignant hypertension. It would therefore not be appropriate to admit this patient. The most important step at this stage would be stopping her COCP as this could be a cause of her hypertension. (!)
name: Admit to hospital
label: e
answer: no
explanation: Microgynon and Dianette are both combined oral contraceptive pills. Dianette is used specifically to treat acne. This patient has a blood pressure of over 160mmHg systolic and so any COCP would be inappropriate.
name: Change microgynon to dianette
label: b
answer: no
explanation: This patient is hypertensive. A systolic blood pressure of over 160mmHg (or >100mmHg diastolic) is a contraindication to COCP usage and it should be stopped.
name: Stop microgynon
label: a
answer: yes
explanation: Ramipril is an angiotensin-converting enzyme inhibitor (ACE-i) used to treat hypertension. Although an ACE-i would be the first choice of antihypertensive in a patient under the age of 55, stopping microgynon would be a more appropriate initial step. The patient's blood pressure may improve on cessation of the combined oral contraceptive pill.
name: Start ramipril
label: c
answer: no
explanation: This patient has a blood pressure of over 160mmHg systolic and the combined oral contraceptive pill should be stopped. Taking a 7-day break from the pill would not be appropriate here. Breaks from the combined oral contraceptive pill are used to induce withdrawal bleeds.
name: Take a 7-day break from microgynon
label: d
answer: no

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


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

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

**Investigations**

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

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

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

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

Correct answer: a
Case Presentation: A 59-year-old man attends the GP to discuss his most recent blood test results. He was commenced on atorvastatin 20mg PO ON for primary prevention of cardiovascular events. 


 **Investigations**
ALT before treatment: 40 (10 - 50 IU/L)
ALT 3 weeks later: 163 (10 - 50 IU/L)


Question: Select the most appropriate decision option with regard to the atorvastatin based on these data.

Options:
explanation: Given the BNF advises stopping statin therapy if serum transaminases are greater than 3 times the upper limit of the reference range it would be unwise to continue the statin
name: Continue atorvastatin 20mg
label: b
answer: no
explanation: The BNF advises if serum transaminases are greater than 3 times the upper limit of the reference range then statin therapy should be discontinued.
name: Stop atorvastatin 20mg
label: a
answer: yes
explanation: There is no suggestion that the patient is acutely unwell or needs secondary care input, despite the abnormal blood test results.

name: Admit to hospital
label: c
answer: no
explanation: This is incorrect as statin therapy should be discontinued.
name: Increase to atorvastatin 80mg
label: d
answer: no
explanation: Although other classes of lipid lowering drugs may be considered as a result, the most important action is to stop this patient's atorvastatin, in light of the recent blood test results.
name: Add ezetimibe
label: e
answer: no

Correct answer: a
Case Presentation: A 34-year-old gentleman attends his GP complaining of weight gain.  His regular medicines are listed (below).


**PH** Asthma, Schizophrenia, Rheumatoid Arthritis

**DH** Sertraline 50mg PO OD, Folic acid 5mg PO once weekly, Olanzapine 10mg PO OD, Methotrexate 20mg PO once weekly, Ibuprofen 400mg PO TDS

**On examination**

BP 129/69mmHg, HR 68, RR 14, Weight 89kg (84kg one month ago)

Question: Select the medication that is most likely to have contributed to this patient's weight gain.

Options:
explanation: Ibuprofen does not commonly cause weight gain.
name: Ibuprofen 400mg PO TDS
label: e
answer: no
explanation: Folic acid does not commonly cause weight gain.
name: Folic acid 5mg PO once weekly
label: c
answer: no
explanation: Salbutamol does not commonly cause weight gain.
name: Salbutamol 200micrograms INH QDS
label: b
answer: no
explanation: Methotrexate does not commonly cause weight gain.
name: Methotrexate 20mg PO once weekly
label: d
answer: no
explanation: Weight gain is a very common side effect of atypical antipsychotics. Olanzapine and clozapine are the atypical antipsychotics most likely to cause weight gain whereas atypical antipsychotics such as aripiprazole have a lower risk of causing weight gain.
name: Olanzapine 10mg PO OD
label: a
answer: yes

Correct answer: a
Case Presentation: A 55-year-old man with type 2 diabetes presents to the GP for his annual diabetes review. His HbA1c is worse than before, and this is despite being on 3 anti-diabetic agents. The GP decides to commence the patient on semaglutide 3mg OD PO.


Question: Select the adverse affect most likely to be caused by this treatment.

Options:
explanation: Low mood is not a known side effect of semaglutide.
name: Low mood
label: d
answer: no
explanation: Semaglutide causes decreased appetite, which contributes to weight loss.
name: Increased appetite
label: c
answer: no
explanation: Semaglutide and other GLP-1 analogues work to cause weight loss, not weight gain.
name: Weight gain
label: b
answer: no
explanation: Altered taste is a side effect of semaglutide however it is not as common as nausea.
name: Altered taste
label: e
answer: no
explanation: Nausea and vomiting are of the most common side effects of semaglutide, which is a GLP-1 analogue and one of the newer treatments licensed for management of type 2 diabetes and obesity. It is also one of the commonest reasons for non-compliance and discontinuation of the medication, and is worst when patients are first started on the medication.
name: Nausea
label: a
answer: yes

Correct answer: a
Case Presentation: A 65 year old man is admitted to the surgical ward prior to an elective total knee replacement. He is due to receive gentamicin 300mg IV as a one-off dose for surgical prophylaxis prior to the procedure.


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

Options:
explanation: Renal function should be checked at baseline and during ongoing treatment as gentamicin is nephrotoxic
name: Renal function tests
label: a
answer: yes
explanation: This is not necessary as there is nothing to make one suspicion of any inflammatory process or ongoing infection
name: C-reactive protein
label: b
answer: no
explanation: This may be useful as a baseline but is not routinely done prior to administering gentamicin
name: Liver function tests
label: d
answer: no
explanation: This is not necessary as there is nothing to make one suspicion of any ongoing infection
name: Full blood count
label: c
answer: no
explanation: This is not necessary prior to administering gentamicin
name: Visual fields assessment
label: e
answer: no

Correct answer: a
A 7-year-old girl is seen in the outpatient paediatrics clinic with tiredness, weight gain and swelling of her hands and feet and around her eyes.

Investigations

Urine dip: Protein 3+

She is given a provisional diagnosis of nephrotic syndrome secondary to minimal change disease. She is prescribed prednisolone 25mg PO OD and given a follow-up appointment in 6 weeks.

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

Options:
explanation: It is not necessary to monitor serum ACTH during treatment with prednisolone
name: Serum ACTH
label: e
answer: no
explanation: The [BNFC](https://bnfc.nice.org.uk/drugs/prednisolone/#monitoring-requirements) states that for children taking oral prednisolone, blood pressure and urinary glucose should be monitored weekly
name: Blood pressure and urinary glucose 
label: b
answer: yes
explanation: The BNFC advises that for patients with systemic sclerosis, blood pressure and renal function, specifically creatinine, should be measured as there is an increased incidence of scleroderma renal crisis.
name: Blood pressure and renal function
label: a
answer: no
explanation: The BNFC recommends that for oral prednisolone, blood pressure and urinary glucose should be monitored weekly.
name: Height and weight 
label: d
answer: no
explanation: The BNFC recommends urinary glucose measurements.
name: Capillary blood glucose
label: c
answer: no

Correct answer: b
Case Presentation: A 25 year old man is seen in the primary care psychiatry outreach clinic and diagnosed with schizophrenia with predominantly positive symptoms. He is advised to commence treatment with aripiprazole 15mg PO OD and to attend a follow-up appointment in two weeks.


Question: Select the most appropriate monitoring option required before starting aripiprazole.

Options:
explanation: It is recommended to check serum prolactin at baseline prior to treatment as the anti-dopaminergic effects of all antipsychotic drugs may cause hyperprolactinaemia
name: No routine monitoring is required
label: e
answer: no
explanation: Blood dyscrasias are a rare adverse effect of antipsychotic medications but routine full blood count monitoring is usually not necessary (exception: clozapine)
name: Leucocyte count
label: c
answer: no
explanation: It is recommended to check serum prolactin at baseline prior to treatment as the anti-dopaminergic effects of all antipsychotic drugs may cause hyperprolactinaemia
name: Serum prolactin
label: a
answer: yes
explanation: This questionnaire will give an indication of the severity of any co-existing affective disorders. It is not used routinely to determine adverse effects of antipsychotic treatment on mood
name: PHQ-9
label: b
answer: no
explanation: It is not necessary to check or monitor liver function during treatment with aripiprazole
name: Liver function tests
label: d
answer: no

Correct answer: a
Case Presentation:  A 56 year old gentleman attends a follow-up appointment at his GP. 


**PMH** hypertension

**DH** ramipril 10mg PO OD, paracetamol 1g PO QDS

**FH** Father died of heart attack at the age of 50. Mother died of an ischaemic stroke at the age of 64

**SH** current smoker, 25-30 cigarettes a day but currently attending smoking cessation counselling.

**Investigations**

Q-risk score: 11%

It is decided that starting atorvastatin 20mg PO OD would help lower his risk of a cardiac event. A repeat consultation is booked in for 3 months later to assess treatment response.

Question: Select the most appropriate option to monitor for treatment response at the next consultation.

Options:
explanation: It is recommended to measure renal function prior to starting atorvastatin to assess for adverse effects. Monitoring renal function would not assess for treatment response.
name: Urea and electrolytes
label: d
answer: no
explanation: It is recommended that liver function should be measured prior to starting treatment and at 3 months and 12 months afterwards as atorvastatin is known to be hepatotoxic. However, this would be monitoring the treatment for an **adverse** effect, the question asks for the test that monitors treatment response.
name: Liver function test
label: c
answer: no
explanation: Statins work by inhibiting the enzyme HMG-CoA reductase, an enzyme that is responsible for the synthesis of cholesterol. By blocking this pathway, statins reduce the total level of circulating cholesterol and LDLs. A lipid profile at the start of treatment and in subsequent consultations is important in monitoring treatment response.
name: Lipid profile
label: a
answer: yes
explanation: This should only be measured if statin-associated myopathy or rhabdomyolysis is suspected. It is not part of routine monitoring while taking a statin. It also would not be used to measure treatment response.
name: Creatinine kinase
label: e
answer: no
explanation: Full blood count has no role in the monitoring of patients taking statins.
name: Full blood count
label: b
answer: no

Correct answer: a
Case Presentation:  A 36-year-old female patient attends the outpatient rheumatology clinic.  He is due to commence treatment on methotrexate for rheumatoid arthritis. Weight 63kg.


**PMH**
Depression

**DH**
Cerazette, 1 tablet daily
Citalopram, 20mg OD

Question: Which of the following is the most appropriate monitoring of a patient starting methotrexate?

Options:
explanation: Methotrexate is not known to cause any cardiac adverse reactions. An ECG is therefore not routine in the monitoring of methotrexate therapy.
name: ECG before starting
label: d
answer: no
explanation: Methotrexate is teratogenic and may also reduce fertility. It is therefore recommended that effective contraception is used during treatment and for 6 months afterwards for both men and women. Despite this, pregnancy prevention programmes are not routinely used in methotrexate therapy.
name: Pregnancy prevention programme
label: c
answer: no
explanation: Methotrexate level is not used in the monitoring of methotrexate therapy.
name: Methotrexate level every week
label: e
answer: no
explanation: Methotrexate increased the risk of blood dyscrasias, liver cirrhosis and blood dyscrasias. Bloods should be checked every 1-2 weeks until dosing stabilised and then every 2-3 months.
name: FBC, U&E and LFTs every 1-2 weeks until stabilised
label: a
answer: yes
explanation: Although Methotrexate is a folate antagonist, Haematinics (B12, folate, ferritin and intrinsic factor) are rarely monitored. Folic acid is instead taken weekly, to prevent deficiency.
name: Haematinics every 1-2 weeks until stabilised
label: b
answer: no

Correct answer: a
Case presentation: A 28 year old woman is seen in the outpatient psychiatry clinic and is diagnosed with bipolar disorder. She is advised to commence treatment with lithium carbonate (Camcolit) 400mg PO OD.


Question: Select the most appropriate monitoring that this patient should undergo prior to starting lithium carbonate.

Options:
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. A chest x-ray is not routinely be used for monitoring prior to starting lithium.
name: Chest X-ray, thyroid function test, renal function
label: d
answer: no
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. A chest x-ray wouldn't routinely be used for monitoring prior to starting lithium.
name: Chest X-ray, ECG, renal function
label: b
answer: no
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. Whilst there have been reported LFT abnormalities in patients taking lithium, these are rare and do not require monitoring. A CT head is not a required part of monitoring either.
name: ECG, liver function, CT head
label: e
answer: no
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Body weight should also be measured prior to starting treatment and a full blood count should be taken. Whilst there have been reported LFT abnormalities in patients taking lithium, these are rare and do not require monitoring.
name: ECG, liver function, renal function
label: c
answer: no
explanation: Prior to starting lithium renal, cardiac and thyroid function should be monitored. Renal function is monitored due to the risk of toxicity if there is improper clearance of lithium. Cardiac function is monitored due to the risk of cardiac disease such as QT interval prolongation.
Body weight should also be measured prior to starting treatment and a full blood count should be taken.
name: ECG, renal function, thyroid function tests
label: a
answer: yes

Correct answer: a
Case Presentation: A 91-year-old man attends A&E with worsening shortness of breath and pitting oedema to both knees.


**PMH** Congestive cardiac failure, Hypertension, Type 2 Diabetes

**DH** Ramipril 5mg PO OD, Furosemide 20mg PO OD, Bisoprolol 2.5mg PO OD, Metformin 500mg PO BD

She is admitted to the acute medical ward and commenced on Furosemide 40mg IV PO.

Question: Select the most appropriate monitoring option to assess efficacy of this treatment during his admission.

Options:
explanation: An echocardiogram may form a part of monitoring his heart function in the long term and may be performed during this admission if it has not been done for a while, however it will not show effective the furosemide is working.
name: Echocardiogram
label: b
answer: no
explanation: Daily weights should be part of any inpatient diuresis management plan as reduction in weight suggests effective treatment.
name: Weight
label: a
answer: yes
explanation: A BNP blood test may be valuable in diagnosis of heart failure however it will not specifically or accurately measure furosemide efficacy in the same way that daily weights would.
name: NT-proBNP test
label: e
answer: no
explanation: Blood pressure can be affected my various factors and is not a good marker of furosemide efficacy.
name: Blood pressure
label: c
answer: no
explanation: Although imaging may form a part of diagnosing an exacerbation of heart failure, and may be done at intervals to assess progress, this would be with a chest x-ray rather than a CT scan.
name: CT Thorax
label: d
answer: no

Correct answer: a
Case Presentation: An 88-year-old woman is diagnosed with non-valvular atrial fibrillation during an inpatient stay and is commenced on apixaban 2.5mg PO BD for stroke prophylaxis.


**PMH** Congestive cardiac failure, TIA, Hypertension

**DH** Amlodepine 5mg PO OD, Aspirin 75mg PO OD, Omeprazole 20mg PO OD, Ramipril 2.5mg PO OD

Question: Select the most appropriate monitoring option to assess the effectiveness of this treatment.

Options:
explanation: Although this patient has ana irregular rhythm, they do not require daily ECGs.
name: Daily ECG
label: d
answer: no
explanation: This is correct. One of the main advantages of DOACs such as apixaban is that they do not require routine monitoring, as opposed to warfarin, which was previously more commonly used for anticoagulation in patients with AF.
name: No routine monitoring is required
label: a
answer: yes
explanation: The thrombin time has no role in monitoring the effectiveness of apixaban.
name: Thrombin time
label: e
answer: no
explanation: This is not a routine blood test and is not indicated.
name: Apixaban levels
label: b
answer: no
explanation: INR is used to monitor warfarin, an alternative but now less popular anticoagulant, primarily due to the monitoring that is required.
name: INR
label: c
answer: no

Correct answer: a