hllj/quesmed huggingface dataset:
Case Presentation: A 16-year-old boy is brought to A&E by his mother as he is very drowsy. He is a known type 1 diabetic and treats this with insulin. He has recently had an ear infection, which is currently being treated with antibiotics by his GP. His regular medicines are listed (below).




 **PH** Type 1 diabetes mellitus, Depression, Eczema, Allergic Rhinitis


 **DH** Sertraline 50mg PO OD, Hydromol cream one application to affected area BD, Clarithromycin 500mg PO BD, Paracetamol 1g PO QDS, Cetirizine 10mg PO OD


Allergic to penicillin - comes out in a rash


 **On examination**
BP 109/68mmHg, HR 108, RR 24


Neurological exam: Difficult to rouse the patient.


 **Investigation**


||||
|--------------|:-------:|------------------|
|pH|7.27|7.35 - 7.45|
|PaO₂|10.0 kPa|11 - 15|
|PaCO₂|3.4 kPa|4.6 - 6.4|
|Bicarbonate|14 mmol/L|22 - 30|
|Lactate|3 mmol/L|0.6 - 1.4|


Serum BM 2.6 mmol/L (Fasting: 4.0 - 5.4 mmol/L, 2hrs post prandial: <7.8 mmol/L) , ketones 0.4mmol/L (<0.6 mmol/L)


Question: Select the medication that is most likely to have interacted with this patient's diabetes medication to produce this clinical picture.

Options:
explanation: Sertraline does not commonly interact with insulin to precipitate hypoglycaemia.
name: Sertraline 50mg PO OD
label: b
answer: no
explanation: Cetirizine does not commonly interact with insulin to precipitate hypoglycaemia.
name: Cetirizine 10mg PO OD
label: e
answer: no
explanation: Paracetamol does not commonly interact with insulin to precipitate hypoglycaemia.
name: Paracetamol 1g PO QDS
label: d
answer: no
explanation: Hydromol cream does not commonly interact with insulin to precipitate hypoglycaemia.
name: Hydromol cream one application to affected area BD
label: c
answer: no
explanation: Clarithromycin can increase the likelihood of hypoglycaemia when taken alongside insulin. Clarithromycin is a macrolide antibiotic that works by inhibiting bacterial protein synthesis by binding to the 50s ribosomal subunit.
name: Clarithromycin 500mg PO BD
label: a
answer: yes

Correct answer: a
Case Presentation: A 61-year-old gentleman attends his GP complaining of ankle swelling.  His regular medicines are listed (below). Weight 88kg.


**PH** Type 2 diabetes mellitus, Hypertension, Hypercholesterolaemia

**DH** Metformin 500mg PO BD, Ramipril 10mg PO OD, Amlodipine 5mg PO OD, Atorvastatin 200mg PO OD, Pioglitazone 30mg PO OD

**On examination**
BP 143/85mmHg, HR 74, RR 12, Weight 95kg

**Investigation**
Chest clear, no added breath sounds. Heart sounds I + II present, no added sounds. Abdomen soft and non-tender.

Bilateral pitting oedema in both ankles.

Question: Select the prescription that is most likely to have contributed to the patient's ankle swelling.

Options:
explanation: Amlodipine is a common cause of peripheral oedema. Calcium channel blockers cause oedema by increasing the pressure within capillaries. This in turn causes fluid to leak out which results in peripheral oedema.
name: Amlodipine 5mg PO OD
label: a
answer: yes
explanation: Ramipril does not commonly cause peripheral oedema
name: Ramipril 10mg PO OD
label: c
answer: no
explanation: Metformin does not commonly cause peripheral oedema
name: Metformin 500mg PO BD
label: b
answer: no
explanation: Atorvastatin does not commonly cause peripheral oedema
name: Atorvastatin 200mg PO OD
label: d
answer: no
explanation: Pioglitazone can cause peripheral oedema however this isn't as commonly seen as with amlodipine use.
name: Pioglitazone 30mg PO OD
label: e
answer: no

Correct answer: a
Case Presentation: A 46 year old woman attends a follow-up appointment at her GP. **PMH** hyperlipidaemia. **DH** atorvastatin 20mg PO OD, started three months ago. **FH** father died of heart attack at the age of 53. **SH** current smoker, 15-20 cigarettes a day but currently attending smoking cessation counselling.


**Investigations**

Q-risk score: 14%

Question: Select the most appropriate option to monitor for adverse effects of the atorvastatin at this stage.

Options:
explanation: This has no role or relevance in the monitoring of patients taking statins
name: Full blood count
label: c
answer: no
explanation: This should be measured if statin-associated myopathy or rhabdomyolysis is suspected. It is not part of routine monitoring while taking a statin
name: Creatinine kinase
label: b
answer: no
explanation: It is recommended that lipids be measured prior to starting treatment and may be measured for the duration of taking atorvastatin, but not for assessing the adverse effects of this drug
name: Lipid profile
label: d
answer: no
explanation: It is recommended to measure renal function prior to starting atorvastatin but routine monitoring is not necessary
name: Urea and electrolytes
label: e
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
name: Liver function tests
label: a
answer: yes

Correct answer: a
Case Presentation: A 72 year old woman is recovering on the surgical ward following a total hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer. She is receiving tinzaparin 3500 units SC ON as prophylaxis against deep vein thrombosis.


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

Options:
explanation: This is not necessary when starting low molecular weight heparin
name: Prothrombin time
label: e
answer: no
explanation: This may be measured if the patient was receiving an unfractionated heparin infusion rather than low molecular weight heparin
name: Activated partial thromboplastin time
label: b
answer: no
explanation: This is of limited usefulness with regard to anticoagulation therapy
name: Factor VIII levels
label: c
answer: no
explanation: There are no routine monitoring parameters available for low molecular weight heparin, although one may consider assessing renal function prior to administering this drug. In some instances, Factor Xa levels can be checked and the dose modified but this usually guided by the haematology team
name: No routine monitoring parameter is available
label: a
answer: yes
explanation: Heparin has no effect on the production of white blood cells and routine monitoring is not necessary
name: White cell count
label: d
answer: no

Correct answer: a
Case Presentation: A 67 year old man attends a follow-up appointment at his GP after being discharged from hospital. He had been admitted for three days to manage an acute infective exacerbation of COPD, during which it was noted that his recorded blood pressure consistently ran above 150/90mmHg. The medical team have requested the GP to prescribe antihypertensive treatment.


The GP decides to prescribe amlodipine 5mg PO OD and schedules a follow-up appointment in 2 weeks.

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

Options:
explanation: It is not necessary to monitor creatine kinase during anti-hypertensive treatment with calcium channel blockers
name: Creatine kinase
label: c
answer: no
explanation: It is not necessary to monitor bone profile during anti-hypertensive treatment with calcium channel blockers
name: Bone profile
label: b
answer: no
explanation: It is generally not necessary to perform routine monitoring during anti-hypertensive treatment with calcium channel blockers apart from asking about adverse symptoms to optimise adherence
name: No routine monitoring is required
label: a
answer: yes
explanation: Calcium channel blockers are not known to cause renal impairment. It is not necessary to monitor renal function during treatment
name: Renal function tests
label: e
answer: no
explanation: It is not necessary to perform routine ECG monitoring during anti-hypertensive treatment with calcium channel blockers
name: ECG
label: d
answer: no

Correct answer: a
Case Presentation: A 56 year old woman with no significant past medical history attends her GP with intermittent chest pain. The pain is central and constricting with no radiation into her jaw or arms. She only has the pain a few times a week and notices that it comes on when she is either climbing stairs or running for the bus. She denies syncope, sweating, shortness of breath or any other symptoms of ill health.


**Investigations**

ECG: Normal sinus rhythm

Her GP decides to make a routine referral to the outpatient cardiology clinic and prescribes bisoprolol fumarate 5mg PO OD.

Question: Select the most appropriate option to assess the beneficial effects of this treatment.

Options:
explanation: An increase in exercise tolerance due to a reduction in angina symptoms indicates effective treatment with bisoprolol
name: Exercise tolerance
label: a
answer: yes
explanation: An elevation in cardiac enzymes may suggest some ongoing myocardial ischaemia and can be useful in the general clinical setting on a background of acute chest pain, but is of limited usefulness to determine effectiveness of treatment with bisoprolol
name: Troponin
label: e
answer: no
explanation: Stress echocardiography may be indicated following a full specialist assessment but is unlikely to be used to demonstrate effectiveness of treatment with bisoprolol
name: Stress echocardiogram
label: d
answer: no
explanation: Her heart rate is likely to be lowered due to beta blockade and blunting of the sympathetic response, but it is not a useful marker of effective treatment
name: Heart rate
label: c
answer: no
explanation: Her blood pressure is likely to be lowered due to beta blockade and blunting of the sympathetic response, but it is not a useful marker of effective treatment
name: Blood pressure
label: b
answer: no

Correct answer: a
Case Presentation: A 34-year-old woman attends her GP with symptoms of tiredness, menstrual irregularities and feeling cold all the time. **PMH** coeliac disease


**O/E**

HR 53, RR 10, BP 106/65, Temperature 35.7°C. Peripheries cool. Mild periorbital oedema. Smooth non-tender goitre on palpation.

Her GP makes a provisional diagnosis of Hashimoto’s thyroiditis. She books the patient for a blood test and prescribes levothyroxine sodium 100 micrograms PO OD.

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

Options:
explanation: Effective treatment with levothyroxine would be indicated by a resolution of symptoms. The patient’s body temperature may well rise with successful treatment and as a result she may report feeling less cold, but monitoring temperature in of itself is generally not useful as a marker of benefit
name: Temperature
label: e
answer: no
explanation: Effective treatment with levothyroxine would be indicated by a resolution of symptoms. A lower heart rate may be purely physiological in some patients and is not a useful marker of effective treatment with levothyroxine
name: Heart rate
label: c
answer: no
explanation: The patient’s respiratory rate is unlikely to change significantly with successful treatment and is thus not a useful marker of benefit
name: Respiratory rate
label: d
answer: no
explanation: The patient’s blood pressure is unlikely to change significantly with successful treatment and is thus not a useful marker of benefit
name: Blood pressure
label: b
answer: no
explanation: Effective treatment with levothyroxine would be indicated by a resolution of symptoms including an improvement in the patient’s energy levels
name: Patient reports of energy levels
label: a
answer: yes

Correct answer: a
Case Presentation:  A 26-year-old known schizophrenic is seen in the outpatient psychiatric department.


**Investigations**

Cardiovascular examination: Heart sounds I + II present, no added sounds.

ECG today: normal sinus rhythm

Prolactin today: 6 ng/mL (<20 ng/mL)

He is complaining of ongoing symptoms despite being treated with risperidone. He has also previously been treated with quetiapine which had to be switched due to lack of efficacy.

It is decided that he should be switched from risperidone to clozapine.

Question: What monitoring is required if a patient is taking clozapine?

Options:
explanation: Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. A full blood count is part of routine monitoring due to the high risk of agranulocytosis when taking clozapine. A lipid profile is part of routine monitoring due to the increased risk of dyslipidaemia. A fasting blood glucose part of routine monitoring due to the increased risk of developing diabetes mellitus.
name: Full blood count, lipid profile, fasting blood glucose
label: a
answer: yes
explanation: Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. Hepatic function is not normally monitored in patients taking clozapine.
name: Full blood count, liver function tests, lipid profile
label: c
answer: no
explanation: Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. Hepatic function is not normally monitored in patients taking clozapine. A chest x-ray is also not a part of the routine monitoring.
name: Full blood count, chest x-ray, liver function tests
label: d
answer: no
explanation: Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. Renal function is not normally monitored in patients taking clozapine.
name: Full blood count, renal function, fasting blood glucose
label: b
answer: no
explanation: Clozapine monitoring includes: ECG, prolactin, full blood count, lipid profile and fasting blood glucose. Renal and hepatic function tests are not normally monitored in patients taking clozapine.
name: Full blood count, renal function, liver function tests
label: e
answer: no

Correct answer: a
Case Presentation: A 24-year-old gentleman is admitted to hospital following 2 weeks of abdominal pain, diarrhoea and blood in his stool. Weight 60kg.




 **Investigations**


CRP: 65 mg/L (< 5mg/L)


Imaging: Sigmoidoscopy shows oedematous mucosa, erythema and bowel inflammation shown up to the level of the sigmoid colon.


It is decided that based on his history and investigations that he has a diagnosis of ulcerative colitis. This is treated acutely with IV hydrocortisone.


To maintain remission, azathioprine 120mg PO OD is prescribed.


Question: Which investigation is necessary before this patient can start his azathioprine?

Options:
explanation: There are no common ophthalmic side effects associated with azathioprine use. Therefore monitoring is not required.
name: Fundoscopy
label: e
answer: no
explanation: The enzyme thiopurine methyltransferase is responsible for the metabolism of thiopurine drugs. If TPMT activity is reduced, there is an increased risk of myelosuppression (and subsequent severe infection) as there is improper clearance of azathioprine.
name: TPMT activity
label: a
answer: yes
explanation: There are no common cardiovascular side effects associated with azathioprine use. Therefore monitoring is not required.
name: ECG
label: d
answer: no
explanation: Azathioprine is not known to impair hepatic function. If hepatic function is impaired when taking azathioprine, a full blood count should be monitored more frequently.
name: Liver function tests
label: b
answer: no
explanation: Azathioprine is not known to impair renal function. If renal function is impaired when taking azathioprine, a full blood count should be monitored more frequently.
name: Renal function
label: c
answer: no

Correct answer: a
Case Presentation:  A 31-year-old woman attends the outpatient gynaecology department.


**PMH** Polycystic ovary syndrome, Depression

**DH** Sertraline 50mg PO OD

She wants to conceive and has already been treated with clomifene citrate. Unfortunately, this hasn't worked and her Gynaecologist has recommended metformin 500mg PO OD as the next step in her management.

Question: Which investigation should this patient undergo prior to starting metformin?

Options:
explanation: Metformin doesn't cause cardiac side effects therefore ECG monitoring isn't warranted.
name: ECG
label: c
answer: no
explanation: Whilst metformin can cause a reduced absorption of vitamin B12, this is a very rare side effect and therefore isn't routinely monitored.
name: Full blood count
label: d
answer: no
explanation: Whilst metformin can cause hepatic injury through hepatitis, this is a very rare side effect and therefore isn't routinely monitored for.
name: Liver function tests
label: b
answer: no
explanation: Metformin doesn't cause side effects involving the thyroid therefore thyroid function test monitoring isn't warranted.
name: Thyroid function tests
label: e
answer: no
explanation: One of the most important side effects of metformin is lactic acidosis. Renal impairment increases the likelihood of this occurring due to improper clearance of metformin. It is therefore very important to monitor renal function prior to starting metformin therapy.
name: Renal function
label: a
answer: yes

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: 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: 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: 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 45-year-old man was admitted to Psychiatry Ward following a failed suicidal attempt due to a depressive episode. PMH Bipolar disorder. DH Lithium carbonate 400mg PO OD.
Due to the acute relapse of her bipolar disorder, it has been decided that her lithium carbonate will be increased to 500mg OD and the first dose was given at 0800 today. Weight 75kg.


 **On Examination**
Patient had fine tremor on both hands and complained of a lingering metallic taste.
BP 118/75 mmHg, HR 75/min, RR 12, moist mucous membrane with CRT 2s.


 **Investigations**
Serum lithium at 2200 is 1.2 mmol/L (Therapeutic dose 0.6-1.0 mmol/L)


Question:
Select the most appropriate decision option based on these data.

Options:
explanation: As there are no signs of toxicity such as coarse tremor, dysarthria or ataxia, there is no need to stop his lithium immediately or carry out haemodialysis
name: Carry out haemodialysis on the patient
label: c
answer: no
explanation: As there are no signs of toxicity such as coarse tremor, dysarthria or ataxia, there is no need to stop his lithium immediately or carry out haemodialysis
name: Stop the lithium and restart at a 300mg OD
label: b
answer: no
explanation: It is also not advisable to ignore the raised serum level and maintain his current dose, appropriate investigation should be done to identify the cause of elevated lithium in order to guide management
name: Maintain the dose of lithium carbonate
label: e
answer: no
explanation: Lithium carbonate has a narrow therapeutic index and hence monitoring of serum lithium is often done to ensure it is within therapeutic range. Concentrations are often taken 12 hours after administration and target range of 0.8-1.0 mmol/L is required. The patient’s examination findings are mainly side effects of the medication and not signs of toxicity. Hence, it is necessary to repeat a serum lithium level and check if his renal function is affecting the clearance of lithium
name: Recheck the level of lithium and his renal function
label: a
answer: yes
explanation: In this case, the patient had a serum lithium of 1.2mmol/L, which is higher than the target range, hence, further increasing the dose of lithium is inappropriate
name: Increase the dose of lithium carbonate to 550mg OD
label: d
answer: no

Correct answer: a