hllj/quesmed huggingface dataset:
Case Presentation:




A 56-year-old man presents to his GP for review of his medication. PMH Hypertension. DH Ramipril 10mg PO OD, Amlodipine 10mg PO OD, Indapamide 2.5mg PO OD


 **On Examination**
BP 157/60 mmHg


HR 85/min


RR 14


O2 sats 96% RA


 **Investigations**


||||
|---------------------------|:-------:|--------------------|
|Sodium|140 mmol/L|135 - 145|
|Potassium|4 mmol/L|3.5 - 5.3|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|85 µmol/L|60 - 120|




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

Options:
explanation: There are 2 types of calcium channel blocker, dihydropyridine like nifedipine and amlodipine are used as antihypertensive medication. Non-dihydropyridine like verapamil and diltiazem are for rate control medication in arrythmias
name: Start verapamil 80mg PO TDS
label: c
answer: no
explanation: Starting on spironolactone would be the most appropriate management for a poorly controlled hypertension patient who have been started on ACEi, CCB and diuretics with a K <4.5mmol. [Click here for more information on NICE guidance](https://pathways.nice.org.uk/pathways/hypertension)
name: Start spironolactone 25mg PO OD
label: a
answer: yes
explanation: This patient has resistant hypertension as his BP remains high despite on three different antihypertensives. NICE recommends the use of spironolactone as the next step if the patients potassium is 4.5 or less. If his K is more than 4.5, an alpha or beta blocker can be considered
name: Start doxazosin 1mg PO OD
label: b
answer: no
explanation: Although his BP remains poorly controlled with three antihypertensive, the maximal recommended dose for ramipril is 10mg OD. 15mg OD will be more than the recommended dose
name: Increase dose of ramipril to 15mg PO OD
label: e
answer: no
explanation: This patient has resistant hypertension as his BP remains high despite on three different antihypertensives. NICE recommends the use of spironolactone as the next step if the patients potassium is 4.5 or less. If his K is more than 4.5, an alpha or beta blocker can be considered
name: Start bisoprolol fumarate 5mg PO OD
label: d
answer: no

Correct answer: a
Case Presentation:




A 56-year-old man presents to his GP for review of his medication. PMH Hypothyroidism for 3 years. DH Levothyroxine sodium 100 micrograms PO daily.


 **Investigations**
TSH 10 mU/L (0.4-5.0)


Total T4 0.5 nmol/L (1.1-3)


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

Options:
explanation: 25micrograms of liothyronine is bioquivalent to 100micrograms of levothyroxine sodium. As he is thyroid function is poorly controlled with this dose of thyroid replacement, changing it to another form that is of similar bioequivalence would not be beneficial for him
name: Change to liothyronine sodium 25 micrograms PO daily
label: d
answer: no
explanation: High TSH and low total T4 level indicate inadequate replacement of levothyroxine and hence should be uptitrated. The increase in dose should be done in steps of 25-50 micrograms every 3-4 weeks
name: Increase levothyroxine sodium to 125 micrograms PO daily
label: a
answer: yes
explanation: The recommended increment in levothyroxine is a gradual increment of 25-50 micrograms every 3-4 weeks
name: Increase levothyroxine sodium to 175 micrograms PO daily
label: c
answer: no
explanation: His thyroid function test suggest inadequate replacement and hence his medication should be increased and not decreased
name: Decrease levothyroxine sodium to 75 micrograms PO daily
label: b
answer: no
explanation: His thyroid function test, particularly the high TSH is suggestive of poor thyroid control. Continueing him on the similar dose of thyroid replacement will not be help his thyroid function
name: Continue levothyroxine sodium 100 micrograms PO daily
label: e
answer: no

Correct answer: a
Case Presentation:  A 86-year-old female patient attends A&E with epistaxis, this has stopped within 30 minutes after nasal packing. She takes Warfarin for atrial fibrillation. 


**PMH**

* Atrial fibrillation
* Aortic Stenosis
* Psoriasis
* Psoriatic Arthritis

**DH**

* Warfarin 6mg OD
* Hydromol intensive cream QDS
* Paracetamol 1g QDS

**On Examination**

* HR 78bpm
* Blood pressure 124/80 mm/Hg
* Oxygen saturation 96%
* RR 16
* Temperature 36.8

**Investigations**

* INR: 6.5
* Target INR: 2-3

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

Options:
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. As the INR is between 5 and 8, IV vitamin K should be given. INR should then be rechecked and Warfarin restarted if INR is less than 5.
name: Stop warfarin and give phytomenadione (vitamin K) by slow intravenous injection Restart warfarin when INR is less than 5
label: a
answer: yes
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. Withholding 1-2 doses of Warfarin may be appropriate if this patient had an INR of 6.5 but no evidence of bleeding. As this patient has experienced some bleeding, treatment with vitamin K is recommended.
name: Withhold 1 or 2 doses of warfarin and reduce subsequent maintenance dose
label: c
answer: no
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. Oral vitamin K should be given when INR is greater than 8 and there is no evidence of bleeding.
name: Stop warfarin and give phytomenadione (vitamin K) orally
label: b
answer: no
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. As the INR is between 5 and 8, IV vitamin K should be given. INR should then be rechecked and Warfarin restarted if INR is less than 5.  Dried prothrombin complex concentrate or fresh frozen plasma would be appropriate where a severe bleeding episode has occurred.
name: Stop warfarin, give urgent intravenous treatment with phytomenadione (vitamin K) and dried prothrombin complex concentrate (factors II, VII, IX, and X), or fresh frozen plasma if the dried prothrombin complex is unavailable
label: d
answer: no
explanation: This patient has an INR out of the target range and has experienced a minor bleeding episode. As the INR is between 5 and 8, IV vitamin K should be given. If INR is consistently raised, a decrease in dose may be appropriate but is not the most important next step.
name: Decrease Warfarin dose to 5mg
label: e
answer: no

Correct answer: a
Case Presentation: A 49-year-old gentleman is attends his GP for a review of his blood pressure medication. 




 **PMH**
Hypertension


 **DH**
Ramipril 5mg PO OD.


 **Investigations**
Today's bloods:


||||
|---------------------------|:-------:|--------------------|
|Sodium|141 mmol/L|135 - 145|
|Potassium|3.6 mmol/L|3.5 - 5.3|
|Urea|3.4 mmol/L|2.5 - 7.8|
|Creatinine|66 µmol/L|60 - 120|



Bloods from 3 months ago:


||||
|---------------------------|:-------:|--------------------|
|Sodium|139 mmol/L|135 - 145|
|Potassium|4.4 mmol/L|3.5 - 5.3|
|Urea|3.6 mmol/L|2.5 - 7.8|
|Creatinine|71 µmol/L|60 - 120|


Today's blood pressure: 141/82 mmHg


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

Options:
explanation: Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.
name: Don't change his treatment
label: a
answer: yes
explanation: Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.
name: Stop his ramipril now
label: b
answer: no
explanation: Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.
name: Switch him to amlodipine
label: d
answer: no
explanation: There is no indication to increase this gentleman's ramipril dose as his blood pressure reading isn't too high.
name: Increase ramipril to 10mg PO OD
label: c
answer: no
explanation: Whilst this gentleman's potassium has raised, it hasn't risen significantly. There are no other mentions of any side effects associated with ramipril in the question - therefore he should continue on ramipril.
name: Switch him to candesartan
label: e
answer: no

Correct answer: a
Case Presentation:




An 83-year-old woman is on the Senior Health ward for treatment of delirium secondary to a urinary tract infection.


 **On Examination**
BP 121/82 mmHg, HR 80/min and regular, RR 10/min, Temperature 37.3 C. O2 sats 99% RA.


 **Investigations**
Urine dipstick: +++ leucocytes and nitrates


Urine MCS


R Nitrofurantoin


R Trimethoprim


S Co-Amoxiclav


||||
|---------------------------|:-------:|--------------------|
|Sodium|135 mmol/L|135 - 145|
|Potassium|4.6 mmol/L|3.5 - 5.3|
|Urea|10.5 mmol/L|2.5 - 7.8|
|creatinine clearance |25 mL/minute|100-150 ml/min|
|eGFR|28 mL/min/1.73m<sup>2</sup>|> 60|


Question:
Select the most appropriate decision option with regard to the management of her infection based on these data.

Options:
explanation: Due to this patient's renal impairment, intravenous co-amoxiclav should be given every 12 hours, not every 8 hours.
name: Co-amoxiclav 1.2g IV every 8 hours
label: e
answer: no
explanation: There is only sensitivity to co-amoxiclav and so this is the correct choice of antibiotic. When it comes to dosing, the BNF advises that if CrCl 10–30 mL/min/1.73m<sup>2</sup>, the options are one 250/125 strength tablet every 12 hours or one 500/125 strength tablet every 12 hours.
name: Co-amoxiclav 250/125 PO every 12 hours
label: a
answer: yes
explanation: While this would likely be effective, piperacillin-tazobactam is reserved for patients with complicated UTI and in this situation, and there is no evidence to support the susceptibility of the microorganism to piperacillin-tazobactam.
name: Piperacillin-tazobactam 4.5g IV every 6 hours
label: c
answer: no
explanation: This is incorrect because due to the patient's renal function, they need to have reduced frequency of co-amoxiclav. It should be 12-hourly instead of 8-hourly.
name: Co-amoxiclav 250/125 PO every 8 hours
label: b
answer: no
explanation: Nitrofurantoin should not be prescribed with a eGFR <30 mL/min/1.73m<sup>2</sup>. The causative agent is also resistant to nitrofurantoin.
name: Nitrofurantoin 50mg PO every 6 hours
label: d
answer: no

Correct answer: a
Case Presentation: A 26-year-old woman presents to the GP complaining of worsening symptoms of anxiety including panic attacks. There has been increased stress due to her job as a corporate lawyer. She has previously tried CBT in the past and currently has private counselling sessions weekly.


## PH

Anxiety, OCD, Menorrhagia, Migraine

## DH

Ibuprofen 400mg PO PRN

NKDA

## On examination

No cyanosis. Normal consciousness but mildly distressed and agitated. Good air entry bilaterally.

Temperature 37.0°C, HR 90, RR 14, BP 110/68, O<sub>2</sub> saturation 96% RA, GCS 15, Weight 70kg

## Investigations

None

# Prescribing Request

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


Options:


# Drug choice feedback

This is a patient with known anxiety and OCD, who has already tried CBT and with ongoing symptoms. For these patients, the next line of treatment is medication, with selective serotonin reuptake inhibitors (SSRI) first line. There are several SSRIs which can be used, with sertraline and escitalopram very popular in the UK.

# Dose/Route/Frequency/Duration feedback

Most of these drugs can be uptitrated if the desired treatment effects are not being witnessed. 2nd line medication treatments include selective serotonin-noradrenaline re-uptake inhibitors (SNRI), such as duloxetine or venlafaxine.  In patients younger than 30 years of age, when initiating SSRI therapy, a follow-up at 1 week should be arranged to review effectiveness and adverse effects as during this initial period there is an increased risk of worsening symptoms.
Case Presentation: A 28-year-old presents to the GP complaining of severe pelvic pain around the time of menstruation. The pain is so severe it requires her to take time off work. This has been going on for several months and she takes regular paracetamol however the pain still persists. She is currently married and actively trying to conceive with her husband.


## PH

Eczema

## DH

Allergies - penicillin

## On examination

No cyanosis. Alert and orientated. Abdominal examination normal, with no palpable masses.

Temperature 36.9°C, HR 76, RR 12, BP 120/88, O<sub>2</sub> saturation 97% RA, GCS 15, Weight 64kg

## Investigations

Urine beta-HCG -ve

# Prescribing Request

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



Options:


# Drug choice feedback

This patient presents with symptoms of primary dysmenorrhoea. Management of this condition if simple analgesia such as paracetamol is ineffective involves the use of nonsteroidal anti-inflammatory drugs (NSAIDs). If the patient does not wish to conceive, the combined oral contraceptive pill can also be considered, however this is not the case in the above scenario.

# Dose/Route/Frequency/Duration feedback

Each of these NSAIDs can be taken orally, and a short course has been prescribed so that the medication is only taken around the time of menstruation, which can last from 2 to 7 days.
Case presentation: A 65-year-old gentleman is admitted to the respiratory ward following a chest infection. PH. Renal transplant, Seizure, Type 2 Diabetes, Hypertension. DH. His regular medicines are listed (below). Weight 70kg.




 **On Examination**
Multiple purpuric rash noted on his ankles bilaterally.


 **Investigation**

||||
|--------------|:-------:|---------------|
|Haemoglobin|100 g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|0.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|70x10<sup>9</sup>/L|150 - 400|



Question 1: Select the ONE prescriptions that is most likely to be a cause of his pancytopenia. (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: Dalteparin sodium;5000 units;subcutaneous (SC);Daily
label: d
answer: no
name: Tacrolimus (Adoport ®);4mg;oral (PO);Twice daily
label: a
answer: no
name: Metformin;500mg;oral (PO);Thrice daily
label: e
answer: no
name: Paracetamol;1g;oral (PO);Four times daily
label: i
answer: no
name: Piperacillin-tazobactam;4.5mg;intravenous (IV);Four times daily
label: c
answer: no
name: Nifedipine (Tensipine® MR);10mg;oral (PO);Twice daily
label: h
answer: no
name: Atorvastatin;20mg;oral (PO);Daily
label: f
answer: no
name: Ramipril;10mg;oral (PO);Daily
label: g
answer: no
name: Carbamazepine;1g;oral (PO);Twice daily
label: b
answer: no


1. Oral use of tacrolimus commonly causes anaemia, leucopenia and thrombocytopenia. The risk of any bone marrow lineage failure is relatively insignificant compared to tacrolimus. ACEi rarely or very rarely cause pancytopenia. Paracetamol causes mainly agranulocytosis although frequency is not known. Atorvastatin, heparin, piperacillin-tazobactam and carbamazepine causes mainly thrombocytopenia.
2. Piperacillin-tazobactam is commonly used as the first line treatment in neutropenic sepsis. Doses are usually 4.5g 6-hrly. The dose prescribed for this patient is likely to represent a transcription error of g to mg.
Case presentation: A 22-week pregnant woman who is 30 years old is admitted to the emergency department with suspected pre-eclampsia. PH Type 2 Diabetes mellitus, Epilepsy, Depression, Hashimoto’s Disease. DH Her current regular medications are listed (below).




 **On Examination**
Abdominal tenderness, bilateral swelling of ankles.


 **Investigation**
BP 145/95 mmHg. Na 120 mmol/L (135-145) Urine dipstick ++ protein


Question 1: Select the THREE prescriptions that are most likely to be contributing to her hyponatremia (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: Gabapentin;300mg;8-hourly;oral (PO)
label: d
answer: no
name: Carbamazepine;100mg;12-hourly;oral (PO)
label: c
answer: no
name: Fluoxetine;20mg;Daily;oral (PO)
label: b
answer: no
name: Aspirin;75mg;Daily;oral (PO)
label: f
answer: no
name: Labetalol;80mg;hourly;intravenous (IV)
label: a
answer: no
name: Levothyroxine sodium;100mg;Daily;oral (PO)
label: e
answer: no
name: Metformin;1g; Daily;oral (PO)
label: g
answer: no


1. Hyponatremia is a recognised complication of selective serotonin re-uptake inhibitors (fluoxetine), carbamazepine and gabapentin, via syndrome of inappropriate antidiuretic hormone secretion (SIADH).
2. Maintenance dose of levothyroxine sodium is prescribed as 100-200 micrograms daily, not milligrams.
Case presentation: A 49-year old man presents to the emergency walk-in clinic with muscle weakness and constipation. He also complains that he has been having pain in the muscles of his upper arms. PH: Hypertension, Asthma, GORD, Hypercholesterolaemia 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 125/80, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18


 **Investigations**:


 - ECG: Prolonged QT, mild ST depression, presence of U wave


||||
|--------------|:-------:|---------------|
|Haemoglobin|130   g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|320x10<sup>9</sup>/L|150 - 400|
|Mean Cell Volume (MCV)|95 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|3 mmol/L|3.5 - 5.3|
|Urea|7 mmol/L|2.5 - 7.8|
|Creatinine|109 µmol/L|60 - 120|


Question 1: Select the THREE prescriptions that are most likely to be a cause of his hypokalaemia (mark them with a tick in column A)
Question 2: Select the ONE prescription that should be withheld in view of the patient’s myopathy? (mark it with a tick in column B)

Options:
name: Salmeterol;50 micrograms;Inhaled (INH);12-hourly
label: f
answer: no
name: Amlodipine;5mg;Oral (PO);Daily
label: a
answer: no
name: Perindopril erbumine;8 mg;Oral (PO);Daily
label: b
answer: no
name: Bendroflumethiazide;2.5 mg;Oral (PO);Daily
label: c
answer: no
name: Simvastatin;40mg;Oral (PO);Daily
label: e
answer: no
name: Bisoprolol;5 mg;Oral (PO);OD
label: h
answer: no
name: Omeprazole;20mg;Oral (PO);Daily
label: d
answer: no
name: Theophylline (Uniphyllin Continus®);200mg;Oral (PO);12-hourly
label: g
answer: no


1. Bendroflumethiazide is a thiazide-like diuretic. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, leading to reduced Na+ reabsorption. As a result of the reduced reabsorption, the concentration of Na+ left in the urine increases. The increase in Na+ availability increases the activity of Na+/K+-ATPase in the collecting duct and brings about an increase in excretion of K+ into the urine. Salmeterol is a long-acting β2 adrenergic receptor agonist (LABA). β2 adrenergic receptor agonist decreases the serum K+ level via an inward shift of K+ into the cells. Theophylline is a phosphodiesterase inhibitor. It is also known to cause hypokalaemia. BNF highlights that concomitant treatment of β2 adrenergic receptor agonist with theophylline may potentiate potentially serious hypokalaemia.
2. Myalgia is a common or very common side effect of simvastatin.
Case presentation: A 65-year-old woman is admitted to hospital with native valve infective endocarditis. On the third day of her admission, she develops pulmonary oedema secondary to decompensated heart failure. She also complains of tinnitus and bilateral hearing loss. Her weight is 70kg. PH: Hypertension, Type 2 diabetes mellitus, GORD, Mitral valve prolapse DH: Her current regular prescriptions are listed below


**On examination**:
Pansystolic murmur that is heard loudest at the apex and radiates to the axilla, coarse crackles at both lung bases, peripheral oedema until the level of mid-shins

**Investigations**:

- Transthoracic echocardiograms shows presence of vegetation at mitral valves
- Positive blood cultures (streptococcus viridans)

Question 1: Select the THREE prescriptions that are most likely to be contributing to the hearing loss. (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: Bisacodyl;5mg;Oral (PO);Nightly
label: i
answer: no
name: Furosemide;40mg;Intravenous infusion (IV);Daily
label: e
answer: no
name: Ceftriaxone;2g;Intravenous infusion (IV);Daily
label: d
answer: no
name: Metformin hydrochloride;500 mg;Oral (PO);Three times daily
label: b
answer: no
name: Paclitaxel;135mg/m2;Intravenous infusion;On day 1 and day 8, repeat every 3 weeks for 6 cycles
label: g
answer: no
name: Enalapril maleate;20 mg;Oral (PO);Daily
label: a
answer: no
name: Gentamicin;700mg;Intravenous infusion (IV);12-hourly
label: c
answer: no
name: Warfarin sodium;5 mg;Oral (PO);Daily
label: h
answer: no
name: Cisplatin;75mg/m2;Intraperitoneal infusion;On day 2, repeat every 3 weeks for 6 cycles
label: f
answer: no


1. Ototoxicity is a recognised side effect of all aminoglycoside. The exact mechanism of gentamicin-related ototoxicity remains unknown.Furosemide is known to cause deafness, especially in patients with renal impairment. Ototoxicity is also a known side effect of cisplatin, a chemotherapy medication that interferes with DNA replication. The ototoxicity is likely to be dose-related and accumulative.
2. The correct dose of gentamicin for Gram-positive bacterial endocarditis is usually about 1mg/kg every 12 hours. Hence, the correct dose for this patient should be 70mg not 700mg IV 12-hourly