hllj/quesmed huggingface dataset:
Case Presentation: A 21 year old woman is in the process of terminating a 9 week intrauterine pregnancy. She has received mifepristone 600mg PO two days ago and is about to receive gemeprost 1mg pessary and doxycycline 100mg PO BD for three days as antibiotic prophylaxis.


Question: Select the most appropriate immediate monitoring option required once her pregnancy has been terminated.

Options:
explanation: It is not necessary to check liver function tests following a medical termination of pregnancy
name: Liver function tests
label: d
answer: no
explanation: It is recommended that blood pressure be monitored closely for at least 3 hours following a medical termination of pregnancy with oral mifepristone and gemeprost pessary as there is a risk of severe hypotension
name: Blood pressure
label: a
answer: yes
explanation: It is not necessary to measure C-reactive protein following a medical termination of pregnancy
name: C-reactive protein
label: b
answer: no
explanation: A urine pregnancy test should be performed at 3 weeks following termination of pregnancy but not immediately after as it is likely to be still positive
name: Urine pregnancy test
label: e
answer: no
explanation: This may be performed if there is a clinical suspicion of STI or pelvic inflammatory disease but there is no information in the stem to suggest that
name: High vaginal swabs
label: c
answer: no

Correct answer: a
Case Presentation:


A 80-year-old man was admitted into the Care of the Elderly Ward a week ago for chest infection. His condition has worsened over the last few days and he is not for cardiopulmonary resuscitation. PMH Osteoarthritis, GORD, HTN, Heart failure, pancreatic cancer. DH Morphine sulphate M/R (MST Continus ® ) 75mg PO 12-hrly, Morphine sulphate 10mg/5mL (Oramorph ®) 5mL PO as required, Omeprazole 20mg OD PO, Bisoprolol 10mg PO OD, Ramipril 2.5mg PO OD. He has taken 5 doses of immediate release morphine in the last 24 hour.
A decision is made by the palliative care team to stop all inappropriate medication and convert his analgesic regimen to a continuous subcutaneous infusion via a syringe driver.

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

Options:
explanation: 200mg oral morphine sulphate is equivalent to 60mg diamorphine SC. 100mg SC diamorphine will be uptitrating her pain control, which is not necessary when it is currently well controlled
name: Diamorphine sulphate 100mg SC and 17mg SC PRN
label: e
answer: no
explanation: To convert oral morphine sulphate into subcutaneous infusion, the regular dose has to be half the daily amount of PO morphine sulphate (200/2 = 100mg)
name: Morphine sulphate 75mg SC and 13mg SC PRN
label: b
answer: no
explanation: The patient is currently on a total of 200mg morphine sulphate PO a day (75mg 12 hrly regular Morphine sulphate and 5 doses of 10mg/5mL of Oramorph® = 150mg + 5 x10mg = 200mg). To convert into subcutaneous infusion, the regular dose has to be half the daily amount of PO morphine sulphate (200/2 = 100mg) and the PRN dose one sixth the total amount given regularly (1/6 x 100 = 16.7mg)
name: Morphine sulphate 100mg SC and 17mg SC PRN
label: a
answer: yes
explanation: 200mg oral morphine sulphate is equivalent to 60mg diamorphine SC
name: Diamorphine sulphate 50mg SC and 13mg SC PRN
label: d
answer: no
explanation: 200mg morphine sulphate approximates to a buprenorphine '70' patch and a '15' patch
name: Buprenorphine 70 microgram/h transfermal patch applied 72-hrly
label: c
answer: no

Correct answer: a
Case Presentation:


A 5-year-old is admitted to the Emergency Department 3 hours ago and is being treated for Diabetic Ketoacidosis with 0.9% normal saline and fixed rate insulin Actrapid infusion 1.8units/hour IV.


 **On Examination**
RR 45/min (22-34).


Temperature 37.5 <sup>o</sup> C


HR 100/min (75-110)


O2 sats 96% RA.


Weight 18kg.


BP 110/80 mmHg.


 **Investigations**
 3 hours ago:


||||
|--------------|:-------:|------------------|
|pH|7.2|7.35 - 7.45|
|PaO₂|11 kPa|11 - 15|
|PaCO₂|4 kPa|4.6 - 6.4|
|Bicarbonate|12 mmol/L|22 - 30|
|Potassium|6 mmol/L|3.5 - 5.3|
|Non-fasting Glucose|18 mmol/L|< 6.1|
|Ketones (Serum)|3 mmol/L|< 0.6|


Now:

||||
|--------------|:-------:|------------------|
|pH|7.25|7.35 - 7.45|
|PaO₂|10 kPa|11 - 15|
|PaCO₂|4.5 kPa|4.6 - 6.4|
|Bicarbonate|15 mmol/L|22 - 30|
|Potassium|4 mmol/L|3.5 - 5.3|
|Non-fasting Glucose|16 mmol/L|< 6.1|
|Ketones (Serum)|2 mmol/L|< 0.6|




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

Options:
explanation: Variable rate insulin infusion is only started when ketone levels falls below 0.6mmol/L
name: Change to variable rate insulin infusion
label: c
answer: no
explanation: As K has dropped to 3.5-5.5mmol, 40mmol of KCl should be added to the bag of fluid as this patient would require continuous insulin infusion, which can result in the redistribution of potassium into the cells and the serum potassium level to decrease further
name: Increase fixed rate insulin Actrapid infusion to 2.8 units/hour
label: b
answer: no
explanation: This patient is on 0.1units/kg/hour of fixed rate insulin infusion, however, the response is inadequate (ketone reduction <0.5mM/h, glucose reduction < 3mM/h). Hence, decreasing the rate of insulin infusion will not be appropriate
name: Decrease fixed rate insulin Actrapid infusion to 1.5units/hour
label: d
answer: no
explanation: Starting 1L of 10% dextrose over 8 hours is not necessary at this point as the blood glucose level is still above 14mmol/L but should be considered if the glucose level falls below 14mmol/L
name: Start 1L 10% dextrose over 8hours
label: e
answer: no
explanation: This patient is on 0.1units/kg/hour of fixed rate insulin infusion, however, the response is inadequate (ketone reduction <0.5mM/h, glucose reduction < 3mM/h). Hence, an increase in insulin rate by 1unit/hour increments hourly is necessary until the ketones are falling at target rates. As K has dropped to 3.5-5.5mmol, 40mmol of KCl should be added to the bag of fluid as this patient would require continuous insulin infusion, which can result in the redistribution of potassium into the cells and the serum potassium level to decrease further
name: Increase fixed rate insulin Actrapid infusion to 2.8 units/hour and add 40mmol/L potassium chloride to 0.9% normal saline bag
label: a
answer: yes

Correct answer: a
Case Presentation:




A 75-year-old man is transferred from the Acute Medical Unit to the Care of the Elderly Ward for treatment of his urinary tract infection.


 **On Examination**
BP 115/75 mmHg, HR 95/min and regular, RR 12/min, Temperature 38 C. O2 sats 94% RA.


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


Urine MCS


S Nitrofurantoin


S Trimethoprim


R Amoxicillin


R Co-Amoxiclav


||||
|---------------------------|:-------:|--------------------|
|Sodium|138 mmol/L|135 - 145|
|Potassium|4.8 mmol/L|3.5 - 5.3|
|Urea|8.5 mmol/L|2.5 - 7.8|
|Creatinine|210 µmol/L|60 - 120|
|eGFR|26 mL/min/1.73m<sup>2</sup>|> 60|


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

Options:
explanation: Nitrofurantoin should not be prescribed with a eGFR <30 mL/min/1.73m<sup>2</sup>
name: Nitrofurantoin 50mg QDS for 3 days
label: b
answer: no
explanation: Nitrofurantoin should not be prescribed with a eGFR <30 mL/min/1.73m<sup>2</sup>
name: Nitrofurantoin 50mg QDS for 7 days
label: d
answer: no
explanation: For trimethoprim, half the normal dose (200/2 = 100mg) should be used after 3 days if eGFR 15-30 mL/min/1.73m<sup>2</sup>. For UTI in males, antibiotic should be given over a total of 7 days
name: Trimethoprim 200mg PO BD for 3 days, 100mg PO BD for the next 4 days
label: a
answer: yes
explanation: Piperacillin-tazobactam is reserved for patients with complicated UTI and in this situation, there is no evidence to support the susceptibility of the microorganism to piperacillin-tazobactam, hence, is less ideal than trimethoprim
name: Piperacillin-tazobactam 4.5g TDS IV
label: c
answer: no
explanation: For trimethoprim, half the normal dose (200/2 = 100mg) should be used after 3 days if eGFR 15-30 mL/min/1.73m<sup>2</sup> 
name: Trimethoprim 200mg PO BD for 7 days
label: e
answer: no

Correct answer: a
Which of the following drugs is a folate antagonist?

Options:
explanation: Methotrexate is a competitive inhibitor of the dihydrofolate reductase enzyme, which is involved with catalyzing dihydrofolate to the active tetrahydrofolate. 



This is needed for the synthesis of the nucleoside thymidine, and is part of the synthesis of purine and pyrimidine. In essence, methotrexate inhibits the synthesis of DNA and RNA
name: Methotrexate
label: a
answer: yes
explanation: Vinblastine is a vinka alkaloid, which works by affecting the microtubule assembly, and subsequently the spindle formation
name: Vinblastine
label: e
answer: no
explanation: This option is incorrect as it is not a folate antagonist, but rather an alkylating agent. Alkylating agents work by adding an alkyl group to some of the proteins of the double helix structure of a DNA molecule. This prevents the linking up of the proteins, causing breakage of the DNA strands (the lack of which causes death of the cancer cell)
name: Cisplatin
label: b
answer: no
explanation: This option is incorrect as it is not a folate antagonist, but rather an alkylating agent. Alkylating agents work by adding an alkyl group to some of the proteins of the double helix structure of a DNA molecule. This prevents the linking up of the proteins, causing breakage of the DNA strands (the lack of which causes death of the cancer cell)
name: Cyclophosphamide
label: c
answer: no
explanation: Bleomycin works by inducing DNA strand breaks. It is often used in combination with doxorubicin in Hodgkin’s lymphoma as they have additive and complementary effects on the DNA (doxorubicin acts by intercalating between DNA strands)
name: Bleomycin
label: d
answer: no

Correct answer: a
Case Presentation: A 62-year-old white gentleman returns to his GP to receive the results of his ambulatory blood pressure monitoring. It is determined to be 158/97mmHg. His estimated 10-year risk of cardiovascular disease is 7%.




## PH


Allergic rhinitis, Migraine


## DH


Fexofenadine hydrochloride 120mg PO OD PRN, Propranolol 80mg PO BD (NKDA)


## On examination


Alert and oriented. Neurological examination normal. Fundoscopy normal.


Temperature 36.0°C, HR 72, RR 14, BP 161/94, O<sub>2</sub> 100% RA, GCS 15, Weight 82kg


## Investigations


Urine dipstick negative


BM: 5.2 mmol/L (normal range 3.5-5.5 mmol/L)


# Prescribing Request


Write a prescription for one drug that is most appropriate for treating his condition.

Options:


# Drug choice feedback

This gentleman has new-onset stage 2 hypertension and requires pharmacological treatment based on NICE guidelines. Given his age and ethnicity, and the absence of diabetes mellitus, he qualifies for a calcium-channel blocker. In light of the use of a beta-blocker for prophylaxis of migraine, any non-dihydropyridine calcium-channel blockers are contra-indicated. The above options include only those that are of the dihydropyridine type.

# Dose/Route/Frequency/Duration feedback

Each medication has its own optimal dose. All are orally taken and have varying dosing frequencies.
Case Presentation: A 19-year-old gentleman is brought to the Emergency Department with a sudden-onset 2-hour history of shortness of breath and wheezing




## PH


Asthma


## DH


Salbutamol metered dose inhaler 200 mcg/dose INH PRN, Beclometasone inhalation powder 200 mcg/dose INH BD (NKDA)


## On examination


Appears distressed, barely able to answer in full sentences. Wheeze heard throughout both lung fields, no crackles. Use of accessory muscles seen. No cyanosis.


Temperature 36.6°C, HR 105, RR 29, BP 110/78, O2 95% RA, GCS 15, Weight 67kg


## Investigations


||||
|--------------|:-------:|------------------|
|pH|7.41|7.35 - 7.45|
|PaO₂|16 kPa|11 - 15|
|PaCO₂|3.8 kPa|4.6 - 6.4|
|Bicarbonate|25 mmol/L|22 - 30|

CXR normal


# Prescribing Request


Write a prescription for one drug that is most appropriate to treat his bronchospasm.

Options:


# Drug choice feedback

Any short-acting beta-2 agonist is appropriate as first line agent for the treatment of acute asthma. These include salbutamol and terbutaline sulphate, although the former is more commonly prescribed as it is less expensive but no different in efficacy.

# Dose/Route/Frequency/Duration feedback

The correct dose is 2.5mg-5mg for nebulised salbutamol and 5mg-10mg for nebulised terbutaline sulphate respectively. The nebulised route is most preferred in the initial stages of asthma management.
Case Presentation: A 52-year-old woman has been admitted to the orthopaedic ward for observation after an elective hip replacement. 


## PH

Fibroids, hypertension, previous facial squamous cell carcinoma

## DH

Nifedipine (extended-release) 30mg PO OD

## On examination

Appears well and oriented to time and place. Bedbound - awaiting her first physiotherapy assessment. Anti-embolism stockings seen.

Temperature 36.3°C, HR 72, RR 13, BP 135/78, O2 98% RA, GCS 15, Weight 82kg

## Investigations

FBC: Hb 139, WCC 11.3, Plts 278

U&Es: Na<sup>+</sup> 142, K<sup>+</sup> 4.7, Cl<sup>-</sup> 105, Ur 7.2, Cr 69, eGFR >90mL/min/1.73m<sup>2</sup>

Clotting: normal

# Prescribing Request

Write a prescription for one drug that is most appropriate for prophylaxis of venous thromboembolism in this patient.

Options:


# Drug choice feedback

Apart from mechanical means, administration of a low-molecular weight heparin should be offered to all surgical patients in whom the risk of venous thromboembolism outweighs the risk of bleeding. In certain situations, such as in high-risk patients and/or those undergoing orthopaedic procedures, DOACs can also be given as prophylaxis, as per the BNF.

# Dose/Route/Frequency/Duration feedback

The correct dose depends on the individual low-molecular weight heparin offered. This can only be given subcutaneously and once-daily. It should be continued until mobility is no longer reduced (generally 5-7 days) and reviewed at discharge.
Case Presentation: A 91-year-old gentleman has been admitted to the hospice for end-of-life care after being diagnosed with end-stage pancreatic cancer 1 year ago. The nurses looking after him has reported increased noisy respiratory secretions which is causing the family distress.


## PH

Pancreatic cancer, Hypertension, Chronic Kidney Disease, Type 2 Diabetes Mellitus.

## DH

Current: Morphine 30mg SC, cyclizine 150mg SC, midazolam 20mg SC via a syringe driver diluted with sterile water given over 24 hours. Discontinued: Ramipril 5mg PO OD, Bendroflumethiazide 2.5mg PO OD, Metformin 1g BD PO (NKDA)

## On examination

Appears comatose, noisy respiratory secretions audible from the bedside.

# Prescribing Request

Write a prescription for one additional drug that is most appropriate for treating his noisy respiratory secretions

Options:


# Drug choice feedback

A trial of medicine to treat noisy respiratory secretions should be considered if they are causing distress to the family of the patient at the end-of-life. They can be treated using anticholinergics such as those given above, at their starting doses, before uptitrating. Atropine can also be used as recommended by NICE but it is used off-label.

# Dose/Route/Frequency/Duration feedback

If the patient continues to have significant secretions not managed with PRN subcutaneous doses, the addition of these medications to the syringe driver can be considered.
Case Presentation: A 51-year-old gentleman sees his GP with a 12-hour history of a painful rash that appeared overnight which was preceded by a mild flu-like illness and itch in the same area. She mentions she has been facing increased stress at work recently.


## PH

Type 2 Diabetes Mellitus

## DH

Metformin 500mg BD PO (NKDA)

## On examination

Appears well, oriented to time and place. Vesicular rash seen along dermatome T5 on the torso. Otherwise normal.

Temperature 36.1°C, HR 72, RR 13, BP 130/80, O2 96% RA, GCS 15, Weight 82kg

## Prescribing Request

Write a prescription for one drug that is most appropriate for treating her rash.

Options:


# Drug choice feedback

This patient is suffering from shingles, the appropriate treatment of which is aciclovir, an anti-viral effective against the Herpes simplex family.

# Dose/Route/Frequency/Duration feedback

The optimal dose is 800mg, and should be given five times a day for 7 days, as licensed. Although the intravenous route exists, this is not required as the patient is generally well and is in the community setting.
Case presentation: A 65-year-old gentleman on the gastroenterology ward is recovering from an abdominal peritoneal resection for anal cancer. PH. Hypertension, Type 2 Diabetes, Heart failure, AF. DH. His current regular medications are listed (below).


Question 1: Select the THREE prescriptions that should be stopped prior to his surgery. (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: Paracetamol;1g;oral (PO);4-hourly
label: d
answer: no
name: Senna;7.5mg;oral (PO);Daily
label: h
answer: no
name: Morphine sulphate;10mg;intravenous (IV);4-hourly
label: j
answer: no
name: Bisoprolol fumarate;10mg;oral (PO);Daily
label: a
answer: no
name: Tramadol;100mg;oral (PO);6-hourly
label: f
answer: no
name: Ibuprofen;400mg;oral (PO);8-hourly
label: e
answer: no
name: Amlodipine;5mg;oral (PO);Daily
label: c
answer: no
name: Warfarin;5mg;oral (PO);Daily
label: i
answer: no
name: Ondansetron;4mg;oral (PO);PRN
label: g
answer: no
name: Ramipril;2.5mg;oral (PO);Daily
label: b
answer: no


1. Common drugs that are stopped prior to surgeries include NSAIDs, diuretics, ACEi and ARBs. ACEi and ARBs are stopped due to the increased risk of peri- and postoperative hypotension. Bisoprolol and calcium channel blockers (amlodipine) are safe and have potential benefits when taken preoperatively. Anticoagulants are also stopped when the surgical bleeding risk outweighs the individual’s thromboembolic risk . Bisoprolol is also generally continued due to the additional risk of ischemia following acute withdrawal. The use of beta blockers cause a sympathetic blockade, which lead to an upregulation of beta receptors and an increase in its responsiveness to circulating catecholamines. Catecholamine levels are elevated during surgery, this results in an increase in myocardial oxygen demand and an exacerbation of ischaemic events. NSAIDs are generally stopped due to its antiplatelet effects (via the inhibition of COX-1 and decreased production of thromboxane A2, preventing platelet aggregation). This increases the bleeding risk perioperatively. Diuretics are stopped due to concerns of hypokalaemia, which increases the risk of perioperative arrhythmia and hypovolaemia, which, in addition to the vasodilating effect of anaesthetic agents can lead to hypotension. Analgesia apart from NSAIDs are generally continued pre-operatively.
b) Paracetamol is the first step in the WHO analgesic ladder and is commonly used for pain relief. Paracetamol tablets are available in 500mg and 1g tablets but the maximum dose per day is 4g spread evenly over 6 hours or four times a day. The dose prescribed for this patient is likely to represent a transcription error of 6-hrly to 4-hrly.
Case presentation: A 75-year old man attends the Parkinson clinic with increasing frequencies of involuntary movement. PH: Parkinson’s disease, Atrial fibrillation, Congestive Heart Failure, Migraine, Schizophrenia DH: His current regular prescriptions are listed below


**On examination**: Pill-rolling resting tremor seen on right hand, cog-wheel rigidity, bradykinesia, micrographia
**Vital signs**: BP 122/78, Temperature 36.5°C, HR 80, O2 Sat 99% (room air), RR 18

Question 1: Select the TWO prescriptions that are most likely to be a cause for the worsening of his Parkinson’s signs and symptoms? (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: Digoxin;187.5mg;Oral (PO);Daily
label: e
answer: no
name: Metoclopramide hydrochloride;10mg;Oral (PO);8-hourly when required
label: g
answer: no
name: Enalapril maleate;10mg;Oral (PO);12-hourly
label: b
answer: no
name: Rivaroxaban;20mg;Oral (PO);Daily
label: c
answer: no
name: Carvedilol;3.125mg;Oral (PO);12-hourly
label: d
answer: no
name: Ibuprofen;400mg;Oral (PO);6-hourly when required
label: f
answer: no
name: Co-careldopa;125mg;Oral (PO);8-hourly
label: a
answer: no
name: Prochlorperazine;75mg;Oral (PO);Daily
label: h
answer: no


1. Both metoclopramide and prochlorperazine are dopamine D2 receptor antagonists that can precipitate and worsen parkinsonian symptoms. Hence, BNF advises that they should be used with caution in patients already diagnosed with Parkinson’s disease.
2. The maintenance dose of digoxin for atrial fibrillation is 125–250 micrograms daily. Hence, the dose prescribed is likely to be a transcription error of the micrograms to mg.
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: Metformin hydrochloride;500 mg;Oral (PO);Three times daily
label: b
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: Senna;15 mg;Oral (PO);Nightly
label: g
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
name: Mirtazapine;30 mg;Oral (PO);Daily
label: a
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.