hllj/quesmed huggingface dataset:
Case presentation: A 50-year-old woman visits her GP for medication review  


PMH: Bipolar disoder, Type 2 Diabetes Mellitus, Hypertension, Hypercholesterolaemia
DH: Her current regular prescriptions, in addition to lithium carbonate 600 mg PO twice daily, are listed in the options below
Investigations:


||||
|---------------------------|:-------:|--------------------|
|Sodium|138 mmol/L|135 - 145|
|Potassium|3.2 mmol/L|3.5 - 5.3|
|Urea|5 mmol/L|2.5 - 7.8|
|Creatinine|120 µmol/L|60 - 120|
|Thyroid Stimulating Hormone|2.5 mU/L|0.3 - 4.2|
|Total T4|120 nmol/L|60 - 150|


Question: Select the prescription that is most likely to interact with lithium carbonate to cause the abnormal blood test results?

Options:
explanation: Metformin is not known to interact with lithium to cause hypokalaemia
name: Metformin hydrochloride 500 mg PO TDS
label: c
answer: no
explanation: Indapamide is a thiazide-like diuretic that is used in the treatment of hypertension. It inhibits the Na+/Cl- cotransporter at the distal convoluted tubule of nephron, thereby leading to reduced sodium reabsorption and decreased water retention. It is important to note that it can cause hypokalaemia when given with lithium, thus potentially increasing the risk of torsade de pointes
name: Indapamide 2.5 mg PO daily in the morning
label: a
answer: yes
explanation: Captopril can increase the concentration of lithium but is not known to interact with lithium to cause hypokalaemia. Angiotensin-converting-enzyme inhibitors like captopril are known to cause hyperkalaemia
name: Captopril 75 mg PO BD
label: d
answer: no
explanation: Amlodipine is not known to interact with lithium to cause hypokalaemia
name: Amlodipine 10 mg PO OD
label: b
answer: no
explanation: Simvastatin is not known to interact with lithium to cause hypokalaemia
name: Simvastatin 40 mg PO ON
label: e
answer: no

Correct answer: a
Case Presentation: A 64-year-old gentleman is admitted to AMU with leg pain.




 **PH** Hypertension, COPD, Hypercholesterolaemia


 **DH** Atorvastatin 20mg PO daily, Losartan 100mg PO daily, Salmeterol 50micrograms INH BD, Tiotropium 5micrograms INH daily, Paracetamol 1g PO QDS


 **On examination**


BP 142/82mmHg, HR 82, RR 12, Weight 80kg


 **Investigation**

||||
|---------------------------|:-------:|--------------------|
|Sodium|138 mmol/L|135 - 145|
|Potassium|4.3 mmol/L|3.5 - 5.3|
|Urea|8.0 mmol/L|2.5 - 7.8|
|Creatinine|182 µmol/L|60 - 120|
|eGFR|48 mL/min/1.73m<sup>2</sup>|> 60|


Question: Select the medication that is most likely to have contributed to the reduction in renal function.

Options:
explanation: Atorvastatin does not commonly cause renal impairment.
name: Atorvastatin
label: b
answer: no
explanation: Salmeterol does not commonly cause renal impairment.
name: Salmeterol
label: c
answer: no
explanation: Paracetamol does not commonly cause renal impairment. It can sometimes cause renal impairment if taken as an overdose, however in this scenario the patient has not taken an overdose.
name: Paracetamol
label: e
answer: no
explanation: Tiotropium does not commonly cause renal impairment.
name: Tiotropium
label: d
answer: no
explanation: Losartan is a cause of renal acute kidney injury. It alters the vascular tone of both the afferent and efferent arterioles. In turn, the blood flowing across the glomerulus is altered. This then reduces the glomerular filtration rate which causes a reduction in renal function.
name: Losartan
label: a
answer: yes

Correct answer: a
Case Presentation: A 68-year-old female attends her GP complaining of constipation.  Her regular medicines are listed (below). Weight 50kg.


**PH** Hayfever, COPD, iron deficiency anaemia, Systemic lupus erythematosus

**DH** Cetirizine 10mg PO OD, Salbutamol 200micrograms INH QDS, Ferrous sulfate 200mg PO BD, Hydroxychloroquine 200mg PO OD, Ibuprofen 200mg PO QDS

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

Options:
explanation: Salbutamol does not commonly cause constipation.
name: Salbutamol 200micrograms INH QDS
label: c
answer: no
explanation: Hydroxychloroquine does not commonly cause constipation.
name: Hydroxychloroquine 200mg PO OD
label: d
answer: no
explanation: Ferrous sulfate commonly causes constipation. The mechanism by which iron supplementation causes constipation is unclear. It is thought to either be through interactions with the gut flora or through facilitating the movement of water from the lower GI system via an osmotic gradient which in turn causes stool hardening and constipation.
name: Ferrous sulfate 200mg PO BD
label: a
answer: yes
explanation: Cetirizine is not known to cause constipation.
name: Cetirizine 10mg PO OD
label: b
answer: no
explanation: Ibuprofen can cause constipation, however this is listed as a rare/very rare side effect whereas ferrous sulfate has constipation listed as a common side effect.
name: Ibuprofen 200mg PO QDS
label: e
answer: no

Correct answer: a
Case Presentation: A 7-year-old boy in the emergency department collapses after being given oral amoxicillin.



**On examination** Wheezy and breathless. CRT 3s, HR 101/min, BP 70/50 mmHg

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

Options:
explanation: This is most likely an anaphylactic reaction to this child's first exposure to a penicillin antibiotic. The child is showing respiratory distress and circulatory dysfunction and require urgent treatment with adrenaline. In children aged 6-12 years, the recommended dose is 300 micrograms and it is given intramuscularly.
name: Adrenaline 300 micrograms IM STAT
label: a
answer: yes
explanation: This is the correct drug and dose however adrenaline should be given intramuscularly in this circumstance. It can be given intravenously by specialists however the dose for this is 1 microgram/kg.
name: Adrenaline 300 micrograms IV STAT
label: b
answer: no
explanation: This is the correct drug and route however it should be in *micrograms* not *milligrams*.
name: Adrenaline 300 milligrams IM STAT
label: c
answer: no
explanation: This is the correct dose for children >12 and adults.
name: Adrenaline 500 micrograms IM STAT
label: e
answer: no
explanation: This is the correct dose for children younger than 6 years of age.
name: Adrenaline 150 micrograms IM STAT
label: d
answer: no

Correct answer: a
Case Presentation: A 55 year old woman presents to A&E with acute confusion, nausea and vomiting. **PMH** permanent atrial fibrillation. **DH** digoxin 187.5 micrograms PO OD.




 **Investigations**


Digoxin levels: 2.8µg/L (target 0.5 – 2.0µg/L)


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

Options:
explanation: Whilst serum urea is part of routine renal function monitoring, it does not specifically affect digoxin toxicity. However, impaired renal function can lead to digoxin accumulation, so regular assessment of renal parameters (including creatinine) is recommended.
name: Serum urea
label: e
answer: no
explanation: Serum chloride levels are not significant in the context of digoxin toxicity. This electrolyte is not a direct factor in potentiating digoxin’s effects or its associated adverse events.
name: Serum chloride
label: b
answer: no
explanation: Although abnormal sodium levels can indicate electrolyte imbalances, they do not directly potentiate digoxin toxicity. Monitoring sodium is important for general health but is not the primary concern in digoxin-treated patients.
name: Serum sodium
label: d
answer: no
explanation: Phosphate levels are not directly related to digoxin toxicity. Monitoring serum phosphate may be relevant in other clinical contexts but is not a priority in patients treated with digoxin.
name: Serum phosphate
label: c
answer: no
explanation: Increase in digoxin levels is known to be potentiated by electrolyte imbalances but particularly potassium, calcium and magnesium. These should be checked when a patient is presenting with symptoms of toxicity, but general renal function should be routinely monitored for the duration of treatment as well
name: Serum potassium
label: a
answer: yes

Correct answer: a
Case Presentation: A 19 year old man presents to A&E with chest pain and shortness of breath. **PMH** asthma, has had 3x previous A&E attendances for acute exacerbations and 1x hospitalisation stay. **DH** salbutamol 200 micrograms inhaler PRN, beclomethasone with formoterol (Fostair NEXThaler) 100/6 micrograms powder inhaler 2 puffs BD. Allergic to pollen and cat fur – exacerbates asthma.


**O/E**

Visibly short of breath with tripoding and use of accessory neck muscles. Sweaty. Peripherals warm and well-perfused. HR 103, RR 29, BP 129/68, O2 100% 15L reservoir mask. Widespread polyphonic wheeze on chest auscultation.

**Investigations**

CXR: No consolidation or pneumothoraces

PEFR: 45% of normal predicted value

He has been given back to back salbutamol and ipratropium nebulisers and is being started on an aminophylline infusion.

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

Options:
explanation: This would be useful as a baseline as aminophylline is metabolised hepatically. However routine monitoring is not necessary
name: Liver function tests
label: c
answer: no
explanation: This patient is at risk of hypokalaemia due to repeated salbutamol nebulisers and commencement of an aminophylline infusion. Renal function should be monitored
name: Urea and electrolytes
label: a
answer: yes
explanation: Intravenous magnesium is commonly given for severe acute exacerbations of asthma and levels may be monitored during treatment. However it is not being used here
name: Serum magnesium
label: e
answer: no
explanation: This would be a useful marker of beneficial effects of the treatment rather than adverse effects
name: Respiratory rate
label: d
answer: no
explanation: This would be a useful marker of beneficial effects of the treatment rather than adverse effects
name: Bedside spirometry
label: b
answer: no

Correct answer: a
Case Presentation: A 9 year old boy attends a specialist paediatric review with his parents. He has previously been suspended from school for being disruptive and refusing to settle during class. At home, his mother struggles to make him focus on his homework and conform to bedtimes, sometimes finding him awake and playing loudly in his bedroom past midnight. A trial of a low-sugar diet has failed to ameliorate his behavioural symptoms.


Treatment with methylphenidate hydrochloride 5mg PO OD is to be commenced.

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

Options:
explanation: It is recommended to monitor blood pressure as well as parameters of growth (height and weight) for the duration of treatment with methylphenidate. It is not necessary to monitor renal function
name: ECG, height and renal function
label: c
answer: no
explanation: It is recommended to perform an ECG before commencing methylphenidate and to monitor blood pressure for the duration of treatment. Monitoring serum prolactin is not necessary
name: Blood pressure, ECG and serum prolactin
label: b
answer: no
explanation: It is recommended to monitor parameters of growth (height and weight) for the duration of treatment with methylphenidate. It is not necessary to routinely check for a full blood count or to monitor renal function
name: Full blood count, renal function and weight
label: d
answer: no
explanation: It is recommended to monitor blood pressure as well as parameters of growth (height and weight) for the duration of treatment with methylphenidate
name: Blood pressure, height and weight
label: a
answer: yes
explanation: It is recommended to monitor parameters of growth (height and weight) for the duration of treatment with methylphenidate. It is not necessary to routinely check for a full blood count or to monitor serum prolactin
name: Height, full blood count and serum prolactin
label: e
answer: no

Correct answer: a
Case Presentation: An 8 year old girl has been having a nocturnal cough and reduction in exercise tolerance for three weeks. **PMH** hay fever. **DH** salbutamol 100 micrograms inhaler PRN. **SH** non-smoking household, no pets.


**O/E**

RR 11, Temperature 36.7°C. Chest clear.

PEFR: 78% of predicted

She is prescribed beclometasone dipropionate 100 micrograms inhaler, 2 puffs in the morning and 2 puffs in the evening.

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

Options:
explanation: Mast cell tryptase is usually measured following a suspected allergic reaction and has no role in assessing disease control in asthma
name: Serum mast cell tryptase
label: d
answer: no
explanation: This is not a useful marker of disease control in asthma
name: Respiratory rate
label: c
answer: no
explanation: This is not a useful marker of disease control in asthma
name: Serum potassium
label: e
answer: no
explanation: This will give a full assessment of asthma severity and disease control, but should not be used routinely
name: Lung function tests
label: b
answer: no
explanation: A peak flow diary will give useful information about disease control and whether any modifications to treatment or referral to secondary care is necessary
name: Peak flow
label: a
answer: yes

Correct answer: a
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 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: 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
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: It is not necessary to check liver function tests following a medical termination of pregnancy
name: Liver function tests
label: d
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

Correct answer: a
Case Presentation:  A 42-year-old man is due to be started on Allopurinol following a diagnosis of Gout in his left great toe. 


**PMH**

* Type 1 Diabetes
* Depression

**DH**

* Citalopram 40mg OD
* Humulin M3 12 units BD

Question: Which of the following is the most appropriate monitoring for the adverse effects of Allopurinol?

Options:
explanation: Allopurinol is known to cause hepatic impairment, LFTs should be monitored every three months during the first year of taking allopurinol to monitor for this. An ultrasound of the liver would not be involved in the routine monitoring of allopurinol therapy.
name: Ultrasound of liver at 6 months
label: e
answer: no
explanation: Serum urate level is used in the first few weeks of allopurinol therapy in order to guide dosing, however, it would not be useful in monitoring the adverse effects of the drug.
name: Serum urate levels monthly
label: b
answer: no
explanation: Signs of gout may be able to be seen on X-ray, however, they are not routinely repeated in the long-term management of gout. X-ray findings of gout include tophi (soft tissue deposits of urate) and punched-out erosions.
name: Repeat X-Ray of left toe in 6 months
label: c
answer: no
explanation: Allopurinol is known to cause hepatic impairment, LFTs should be monitored every three months during the first year of taking allopurinol to monitor for this.
name: LFTs every 3 months for the first year
label: a
answer: yes
explanation: Foods rich in purines such as offal, oily fish, game and red meat can increase the risk of gout. These should be avoided/reduced in the management of gout. Patients' diets are not routinely monitored. A healthy, balanced diet, rich in fruit and vegetables is encouraged.
name: Food diary
label: d
answer: no

Correct answer: a
Case Presentation:  A 34-year-old woman is referred to rheumatology due to ongoing joint pain and facial rashes.  


**PMH** Nil

**DH** NKDA. Ibuprofen 200mg PO QDS

**SH** smokes 10 cigarettes a day (5 pack year history)

**Investigations**

Anti-CCP antibodies: -ve

ANA: +ve

Anti dsDNA antibodies: +ve

Rheumatoid factor: -ve

Based on her symptoms and blood results, she is diagnosed with systemic lupus erythematosus and the decision is made to start hydroxychloroquine sulfate.

Question: Select the most appropriate monitoring option required before initiating hydroxychloroquine sulfate.

Options:
explanation: Impaired hepatic function isn't listed as a known side effect of hydroxychloroquine. Therefore it doesn't need to be routinely monitored.
name: Liver function tests
label: d
answer: no
explanation: Hydroxychloroquine can cause a range of haematological disorders such as agranulocytosis, leucopenia and thrombocytopenia. The frequency of these side effects occurring however is unknown, therefore monitoring for them is not recommended.
name: Full blood count
label: b
answer: no
explanation: Impaired renal function isn't listed as a known side effect of hydroxychloroquine. Therefore it doesn't need to be routinely monitored.
name: Renal function
label: c
answer: no
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 with respect to starting this drug
name: Troponin
label: e
answer: no
explanation: Retinopathy is a common side effect of hydroxychloroquine. It is important to ensure that there are no pre-existing issues with the retina prior to starting hydroxychloroquine due to the increased risk of worsening these pre-existing issues. Annual monitoring of the retina is initiated following 5 years of treatment (it can be started earlier if there is an increased risk of retinopathy).
name: Fundus photograph and Optical Coherence Tomography (OCT)
label: a
answer: yes

Correct answer: a
Case Presentation:  A 64-year-old gentleman is discharged from hospital following a diagnosis of atrial fibrillation. 


**PMH** Hypertension, Type 2 diabetes mellitus, Atrial fibrillation

**DH** Ramipril 10mg PO OD, Metformin 500mg PO BD, Atenolol 50mg PO OD, Apixaban 5mg PO BD

Both the atenolol and apixaban are new prescriptions.

Question: What routine monitoring is required for his new apixaban prescription?

Options:
explanation: No routine monitoring of prothrombin concentration is required with apixaban use.
name: Prothrombin
label: e
answer: no
explanation: No routine monitoring of factor V is required with apixaban use.
name: Factor V
label: d
answer: no
explanation: No routine monitoring is required with apixaban use. Factor Xa is the clotting protein that apixaban inhibits, it does not need to be monitored.
name: Factor Xa
label: c
answer: no
explanation: No routine monitoring is required with apixaban use. INR would be monitored in patients taking warfarin.
name: INR
label: b
answer: no
explanation: No routine monitoring is required with apixaban use. This is because direct oral anticoagulants have a predictable pharmacokinetic and pharmacodynamic response when given at a set dose, unlike warfarin for example which has a higher degree of unpredictability.
name: No routine monitoring required
label: a
answer: yes

Correct answer: a
Case Presentation:




A 55-year-old lady presents to the emergency department with rigor and pyrexia complaining of 3 day history of dysuria and urinary frequency. A urine dipstick was performed, which showed positive leucocyte esterase and nitrates. Microscopy, culture and sensitivity confirmed urosepsis, with sensitivity showing susceptibility to gentamicin. She is started on gentamicin 5mg/kg IV OD. Her first dose of gentamicin was administered at 1600 today. Weight 75kg.


 **Investigations**
Serum gentamicin at 2300 6mg/L


||||
|---------------------------|:-------:|--------------------|
|Urea|6.5 mmol/L|2.5 - 7.8|
|Creatinine|100 µmol/L|60 - 120|
|eGFR|>90 mL/min/1.73m<sup>2</sup>|> 60|


Question:
Select the most appropriate decision option based on these data and using the[Hartford Nomogram](http://www.leedsformulary.nhs.uk/docs/RxGentamicinHartford.pdf)

Options:
explanation: There is no need to repeat the blood test as the serum gentamicin level was taken accurately within 6 - 14 hours, allowing interpretation of the timing of the next dose
name: Repeat the blood test at 0400 today
label: b
answer: no
explanation: There is no need to repeat the blood test as the serum gentamicin level was taken accurately within 6 - 14 hours, allowing interpretation of the timing of the next dose
name: Repeat the blood test at 1600 tomorrow
label: c
answer: no
explanation: Gentamicin nomogram is used to determine when the next dose of gentamicin is due. In this situation, the trough level (taken 6-14 hours after the initiation of gentamicin) is 6mg/mL. Referring to the Hartford nomogram, the next dose should be given in the next 24 hours from the 1st dose, hence, 375mg IV at 1600 tomorrow
name: Gentamicin 375mg IV 1600 tomorrow
label: a
answer: yes
explanation: As his trough level falls within the 24 hour frequency, the next dose should be given 24 hours from the first dose which was at 1600 and not from the time the sample was taken
name: Gentamicin 375mg IV 2300 tomorrow
label: e
answer: no
explanation: According to the nomogram, his trough level falls under the every 24 hour frequency, hence, the next dose should be given at 1600 tomorrow and not the day after
name: Gentamicin 375mg IV 2300 the day after
label: d
answer: no

Correct answer: a