hllj/quesmed huggingface dataset:
Case presentation: A 35-year-old man presents to the accident and emergency department with a two-day history of gradual onset confusion and muscle rigidity. He is highly agitated and sweats excessively.  

PMH: Schizophrenia, Depression, Type 2 Diabetes Mellitus, Hypertension, Hypercholesterolaemia
DH: Her current regular prescriptions are listed below
Observations: Temperature 40°C , blood pressure 181/95 mmHg, heart rate 100 bpm, respiratory rate 25; oxygen saturation 100% (on air)
On examination: Lead pipe rigidity. Normal pupillary sizes
Investigation: Negative urine toxicology screen

Question: Select the prescription that is most likely to be contributing to the clinical picture described above?

Options:
explanation: Sertraline is not associated with NMS but an overdose of sertraline can cause serotonin syndrome, which share some similarities with NMS. Both NMS and serotonin syndrome can bring about hypertension, tachycardia and hyperthermia. However, NMS is different from serotonin syndrome in that it is associated with hyporeflexia, normal pupillary sizes and a gradual onset while serotonin syndrom is characterised by hyperreflexia, myadriasis and a rapid onset
name: Sertraline 50 mg PO OD
label: b
answer: no
explanation: Lisinopril is not known to casuse NMS
name: Lisinopril 20 mg PO OD
label: d
answer: no
explanation: The clinical picture described above is that of neuroleptic malignant syndrome (NMS). NMS is an uncommon but potentially fatal side effect of all antipsychotic drugs. Antipsychotic medications lead to NMS through their antagonism of dopamine D2 receptors. NMS is characterised by a tetrad of hyperthermia, changed mental status, muscle rigidity and autonomic instability
name: Olanzapine 10 mg PO OD
label: a
answer: yes
explanation: Simvastatin is not known to cause NMS
name: Simvastatin 40 mg PO ON
label: e
answer: no
explanation: Metformin is not known to casuse NMS
name: Metformin hydrochloride 500 mg PO TDS
label: c
answer: no

Correct answer: a
Case presentation: A 65-year old man on the geriatric ward complains of nausea, vomiting and generalised muscle weakness. He was admitted to the hospital following a fall at home two days ago.  


PMH: Type 2 Diabetes Mellitus, Hypertension, Heart failure, Depression
DH: His current regular prescriptions are listed below
Examination: Dry lips and reduced skin turgor. Deep and laboured breathing. No added lung sounds. HS I+II+0. Abdomen soft non tender.
Investigation:

||||
|--------------|:-------:|------------------|
|pH|7.25|7.35 - 7.45|
|PaO₂|11 kPa|11 - 15|
|PaCO₂|3.8 kPa|4.6 - 6.4|
|Bicarbonate|12.1 mmol/L|22 - 30|
|Base Excess|-13.5 mmol/L|-2 to +2|
|Creatinine|300 µmol/L|60 - 120|
|Lactate|5.1 mmol/L|0.6 - 1.4|

Anion gap: 29 mmol/L
Negative urine toxicology


Question: Select the prescription that is most likely to be contributing to the clinical picture described above?

Options:
explanation: Clinical picture described above is that of a high anion gap metabolic acidosis with raised lactate level. Lactic acidosis is a rare or very rare, but potentially fatal side effect of metformin. Chronic stable heart failure is a risk factor for lactic acidosis. BNF advises that metformin should be witheld if dehydration occurs because acute kidney injury can precipiate lactic acidosis
name: Metformin hydrochloride 500 mg PO three times daily
label: a
answer: yes
explanation: Carvedilol is not known to cause lactic acidosis
name: Carvedilol 3.125 mg PO twice daily
label: b
answer: no
explanation: Simvastatin is not known to cause metabolic acidosis
name: Simvastatin 40 mg PO nightly
label: e
answer: no
explanation: Lisinopril is not known to cause metabolic acidosis
name: Lisinopril 10 mg PO once daily
label: c
answer: no
explanation: Sertraline not known to cause metabolic acidosis
name: Sertraline 50 mg PO once daily
label: d
answer: no

Correct answer: a
Case Presentation: A 82-year-old woman attends her GP. She has been feeling dizzy since being started on Oxybutynin for urge incontinence. Her regular medicines are listed (below).


**PH** Osteoporosis, Type 2 Diabetes Mellitus, Hayfever Overactive Bladder

**DH** Alendronic acid 10mg PO once weekly, Metformin 500mg PO BD, Gliclazide 80mg PO OD, Paracetamol 1g PO BD, Chlorphenamine 10mg PO PRN, Cholecalciferol 800U OD

**On examination**
BP 136/76mmHg, HR 71, RR 14, Weight 50kg

**Investigation**

Neurological examination is normal.

Question: Select the prescription that is most likely to interact with the patient’s oxybutynin to cause dizziness.

Options:
explanation: Chlorphenamine is a H1 antagonist used to treat hayfever. It can commonly cause drowsiness and dizziness; the latter is more likely when taken with oxybutynin as there is a higher risk of antimuscarinic side effects.
name: Chlorphenamine 10mg PO PRN
label: a
answer: yes
explanation: Metformin does not commonly cause dizziness.
name: Metformin 500mg PO BD
label: b
answer: no
explanation: Gliclazide does not commonly cause dizziness.
name: Gliclazide 80mg PO OD
label: c
answer: no
explanation: Paracetamol does not commonly cause dizziness.
name: Paracetamol 1g PO BD
label: d
answer: no
explanation: Cholecalciferol does not commonly cause dizziness.
name: Cholecalciferol 800U OD
label: e
answer: no

Correct answer: a
Case Presentation: A 30-year-old man presents to the GP for review of his mental health. He was recently diagnosed with depression and has been undergoing CBT over the last 2 months. He states these are helping but he describes ongoing anhedonia and sleeping difficulties. He has also recently come out of a relationship and he has had thoughts of self-harm but says he would never act on them.


The GP commences him on sertraline 50mg PO and arranges for a follow up in 2 weeks' time.

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

Options:
explanation: Alopecia is an uncommon side effect of sertraline.
name: Alopecia
label: b
answer: no
explanation: Palpitations are a common or very common side-effect of not just sertraline, but all selective serotonin re-uptake inhibitors (SSRIs).
name: Palpitations
label: a
answer: yes
explanation: Dehydration is not a side effect of sertraline. In fact, feeling of thirst is an uncommon side effect.
name: Dehydration
label: e
answer: no
explanation: Autonomic instability may be a feature of serotonin syndrome but is not a side effect of SSRIs.
name: Autonomic instability
label: d
answer: no
explanation: Galactorrhoea is a rare side effect of sertraline
name: Galactorrhoea
label: c
answer: no

Correct answer: a
Case Presentation: A 70 year old man is on the acute admissions unit being treated for exacerbation of congestive cardiac failure and new atrial fibrillation. **PMH** CCF, recurrent DVTs. **DH** lisinopril 15mg PO OD, carvedilol 25mg PO BD, spironolactone 50mg PO OD, isosorbide mononitrate 30mg PO BD, warfarin sodium 3mg PO OD. NKDA


On the morning drug round at 0800 hrs, he has been given his usual medications as well as 375 micrograms of digoxin in accordance with the rapid digitalisation protocol.

**Investigations**

U&Es: Na 144, K 3.9, Cl 99, Ur 4.2, Cr 117 (baseline 103), eGFR 52mL/min/1.73m^2

Question: Select the most appropriate monitoring option to assess the need for dose adjustments of digoxin in this patient.

Options:
explanation: Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels at 1200 hrs
label: c
answer: no
explanation: Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels at 1000 hrs
label: b
answer: no
explanation: Taking digoxin levels more than 6 hours after the initial dose may lead to inaccurate dose adjustments being made from a falsely low level
name: Blood levels immediately before next dose
label: d
answer: no
explanation: This is the correct time to take a digoxin level, which is 6 hours after the last dose
name: Blood levels at 1400 hrs
label: a
answer: yes
explanation: Digoxin levels should be taken no earlier than 6 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels immediately post-dose
label: e
answer: no

Correct answer: a
Case Presentation: A 75 year old man attends the memory clinic with his partner. He has been having difficulty with remembering important personal details such as his debit card PIN as well as social appointments he has made with friends and family. **PMH** Bradycardia, diverticular disease, haemorrhoids. **DH** senna 7.5mg PO BD, Anusol cream topical ON.


**Investigations**

Addenbrooke’s Cognitive Examination: 81/100

A diagnosis of early Alzheimer’s disease is made and he is advised to start donepezil hydrochloride 5mg PO OD and to attend a follow-up appointment in 3 months.

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

Options:
explanation: This may be generally useful as mood disorders are common among patients with Alzheimer’s disease but is not essential
name: PHQ-9
label: d
answer: no
explanation: This is not necessary with this medication
name: Full blood count
label: b
answer: no
explanation: An ECG should be performed to rule out bradycardia or high-grade heart block prior to starting this drug
name: No routine monitoring is required
label: c
answer: no
explanation: Donepezil increases cholinergic activity not just in the central nervous system but also peripherally, and may exert a parasympathetic effect on the heart. As such it is contraindicated in patients with high-grade heart block or symptomatic bradycardia and this should be ruled out with an ECG beforehand
name: ECG
label: a
answer: yes
explanation: This is not necessary with this medication
name: Weight
label: e
answer: no

Correct answer: a
Case Presentation: A 24 year old man has been detained under a Section 2 order for an acute psychotic episode on a background of treatment-resistant schizophrenia. The consultant psychiatrist decides to commence clozapine (Clozaril) 12.5mg PO OD with dose escalation planned over the next few days and weeks.


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

Options:
explanation: Clozapine is known to be cardiotoxic and serious adverse effects include myocarditis and cardiomyopathy. In the absence of symptoms or clinical suspicion it is not necessary to conduct routine monitoring with stress echocardiography
name: Stress echocardiogram
label: e
answer: no
explanation: A rare but serious adverse effect of clozapine is agranulocytosis. The white cell count must be checked at the start and closely monitored throughout the duration of treatment
name: Full blood count
label: a
answer: yes
explanation: It is not necessary to check or monitor bone profile in treatment with clozapine
name: Bone profile
label: b
answer: no
explanation: It is not necessary to check or monitor serum magnesium in treatment with clozapine
name: Serum magnesium
label: d
answer: no
explanation: This may be checked at the start of treatment but it is not necessary to monitor renal function during treatment
name: Renal function tests
label: c
answer: no

Correct answer: a
Case Presentation: A 36 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 option to assess the need for dose adjustments of lithium carbonate in this patient.

Options:
explanation: Taking lithium levels more than 12 hours after the initial dose may lead to inaccurate dose adjustments being made from a falsely low level
name: Blood levels immediately before next dose
label: d
answer: no
explanation: Lithium levels should be taken no earlier than 12 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels immediately post-dose
label: e
answer: no
explanation: Lithium levels should not be taken earlier than 12 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels 2 hours post-dose
label: b
answer: no
explanation: This is the correct time to take a lithium level, which is 12 hours after the last dose
name: Blood levels 12 hours post-dose
label: a
answer: yes
explanation: Lithium levels should not be taken earlier than 12 hours after a dose as this may lead to inaccurate dose adjustments being made from a falsely elevated level
name: Blood levels 6 hours post-dose
label: c
answer: no

Correct answer: a
Case Presentation: A 52 year old man attends his GP to receive the results of an ambulatory blood pressure monitoring study. **PMH** stable angina pectoris. **DH** bisoprolol fumarate 10mg PO OD. NKDA


**Investigations**

Clinic BP: 151/95mmHg

Ambulatory daytime average: 142/84mmHg

His GP decides to prescribe ramipril 2.5mg 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 perform routine monitoring with stress echocardiography during anti-hypertensive treatment with ACE inhibitors
name: Stress echocardiogram
label: c
answer: no
explanation: Although peripheral oedema is a documented side effect with ACE inhibitors, it is generally not necessary to monitor weight during treatment
name: Weight
label: e
answer: no
explanation: It is not necessary to perform routine monitoring with spirometry during anti-hypertensive treatment with ACE inhibitors
name: Spirometry
label: d
answer: no
explanation: It is recommended that renal function be checked prior to and monitored during anti-hypertensive treatment with ACE inhibitors. The treatment may be modified or stopped if there is any evidence of new renal impairment
name: Renal function tests
label: a
answer: yes
explanation: It is not necessary to monitor the heart rate during anti-hypertensive treatment with ACE inhibitors
name: Heart rate
label: b
answer: no

Correct answer: a
Case Presentation:  A 72-year-old female patient is admitted to the acute medical ward with breathlessness. She is due to commence treatment on Furosemide for congestive cardiac failure. Weight 72kg.


**PMH**
Myocardial infarction
Type 2 diabetes mellitus

**DH**

* Atorvastatin, 40mg nightly
* Clopidogrel, 75mg OD
* Bisoprolol, 5mg OD
* Ramipril, 7.5mg OD
* Metformin, 500mg BD

Question: Which of the following is the most appropriate monitoring of the beneficial effects of Furosemide therapy?

Options:
explanation: Furosemide is a loop diuretic used in the symptomatic treatment of cardiac failure. Daily weights are an effective way to measure the effectiveness of furosemide by quantifying fluid losses.
name: Daily weight measurements
label: a
answer: yes
explanation: NT-proBNP is a hormone secreted by cardiomyocytes in response to stretching as a result of increased ventricular blood volume, it is therefore used diagnostically in cardiac failure. NT-proBNP is of little value in monitoring the symptomatic benefits of furosemide.
name: NT-ProBNP after 1 week
label: b
answer: no
explanation: Furosemide has been shown to lead to some haematological adverse effects such as agranulocytosis and aplastic anaemia, however, a full blood count has little efficacy in demonstrating the beneficial symptomatic effects of furosemide.
name: Full Blood Count daily
label: e
answer: no
explanation: Urea and Electrolytes (U&Es) should be monitored during furosemide therapy as furosemide can lead to electrolyte imbalance and AKI. However, U&Es have little efficacy in demonstrating the symptomatic benefits of Furosemide.
name: Urea and Electrolytes daily
label: d
answer: no
explanation: Echocardiograms are used in the diagnostic and prognostic monitoring of cardiac failure, however, it has little value in monitoring the symptomatic benefits of furosemide.
name: Echocardiogram after 1 week
label: c
answer: no

Correct answer: a
Case Presentation:  A 64 year old man is sent to the rapid access chest pain clinic by his GP following the reported results of a 24 hour ECG Holter monitor. 


**PMH** myocardial infarction with 100% LAD occlusion, hypertension, hypercholesterolaemia, COPD

**DH** aspirin 75mg PO OD, bisoprolol fumarate 2.5mg PO OD, ramipril 10mg PO OD, amlodipine 5mg PO OD, salmeterol 50micrograms INH BD, tiotropium 5micrograms INH OD, atorvastatin 80mg PO OD.  NKDA

**Investigations**

24 hour ECG holter monitor: infrequent runs of ventricular tachycardia lasting 30-40 seconds

It is recommended to start amiodarone hydrochloride 200mg PO TDS whilst awaiting implantation of an Implantable Cardioverter Defibrillator (ICD).

Question: Select the most appropriate monitoring option required before initiating amiodarone hydrochloride.

Options:
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 utility with respect to starting this drug.
name: Troponin
label: c
answer: no
explanation: While blood dyscrasias have been reported with use of amiodarone, these are very rare and as such a full blood count would be useful as a baseline but is not routinely done.
name: Full blood count
label: e
answer: no
explanation: Amiodarone contains iodine which in turn can commonly cause thyroid disorders. Both hypothyroidism and hyperthyroidism have been linked to amiodarone use. Amiodarone doesn't need to be withdrawn if it is essential and causes hypothyroidism, this can be treated with replacement therapy.
name: Thyroid function tests
label: a
answer: yes
explanation: While pancreatitis as a result of amiodarone use has been reported, this is a very rare side effect of amiodarone use. HPL also isn't a useful test as it can be raised for many reasons, it is also used for the **diagnosis** of acute pancreatitis, not for screening for acute pancreatitis.
name: Human pancreatic lipase
label: d
answer: no
explanation: Amiodarone is a potassium channel blocker and as such imbalances in potassium should be corrected prior to starting this drug, rather than magnesium.
name: Serum magnesium
label: b
answer: no

Correct answer: a
Case Presentation: A 9-year-old girl is seen in the outpatient paediatrics with swollen, stiff and painful knees. This has been going on for the last 10 weeks.




 **Investigations**


Both knees are red in appearance. Both are swollen. Limited range of motion due to pain and stiffness.


ANA: +ve


Rheumatoid factor: +ve


CRP: 36 mg/L (< 5mg/L)


It is decided that she is likely suffering from juvenile idiopathic arthritis and requires treatment with ibuprofen, methotrexate and prednisolone.


Question: If she takes the prednisolone for a prolonged period of time, what parameters should be monitored?

Options:
explanation: Fundoscopy isn't routinely used to monitor for adverse effects of corticosteroid treatment
name: Fundoscopy
label: b
answer: no
explanation: Hepatic function monitoring isn't routinely used for corticosteroid treatment
name: Liver function tests
label: d
answer: no
explanation: Cardiac monitoring is not routinely used for corticosteroid treatment
name: ECG
label: e
answer: no
explanation: A chest x-ray isn't routinely used to monitor for adverse effects of corticosteroid treatment
name: Chest X-ray
label: c
answer: no
explanation: Prolonged steroid treatment is linked with growth alterations. Paediatric patients are likely to weigh more and have a reduced height if they are taking steroids for a prolonged time. Any slowing in growth should prompt a referral to a paediatrician
name: Height and weight
label: a
answer: yes

Correct answer: a
Case Presentation:


A 75-year-old woman is recovering in the Orthopedic Ward following a total hip replacement of her left hip 2 days ago. PMH Osteoarthritis, Type 2 Diabetes Mellitus, Hypertension. DH Paracetamol 1g QDS PO, Ibuprofen 400mg TDS PO, Omeprazole 20mg PO OD, Metformin 1g BD PO, Amlodipine 10mg PO OD, Morphine sulphate M/R (MST Continus ®) 20mg BD PO, Morphine sulphate I/R (Oramorph ®) 10mg/5mL PRN.
Her surgery is uncomplicated and her postoperative pain is controlled with her usual analgesia. She has not taken any PRN Oramorph over the past 24 hours.

**On Examination**
HR 75/min and regular

BP 120/75 mmHg

RR 12/min

O2 sats 97% RA

Temp 37oC.

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

Options:
explanation: Stopping strong opioids and NSAIDS simultaneously without additional PRN medication would result in a huge decrease in the pain relief for this patient
name: Stop regular morphine sulphate M/R and ibuprofen
label: b
answer: no
explanation: Pain medication should be down titrated using the reverse ladder starting with strong opioids followed by weak opioids, NSAIDs and paracetamol. PRN Morphine sulphate can be prescribed as an intermediate step to provide analgesia when required. The patient is currently on a total of 40mg regular Morphine sulphate a day and her pain relief is well controlled with no PRN medication required. To step down her analgesic management, her regular morphine sulphate could be stopped while maintaining her usual PRN dose of morphine sulphate if additional pain relief is required
name: Stop regular morphine sulphate M/R and continue PRN morphine sulphate
label: a
answer: yes
explanation: 40mg regular Morphine sulphate is equivalent to 400mg dihydrocodeine. Although decreasing the equivalent dose of dihydrocodeine is appropriate, 250mg is still more than the maximum recommended dose per day (240mg)
name: Substitute morphine sulphate M/R with dihydrocodeine 250mg PO
label: e
answer: no
explanation: 40mg regular Morphine sulphate approximates to buprenorphine 20 micrograms/h transdermal patch. Changing to 70 micrograms/h patch would be unnecessarily stepping up her pain control
name: Substitute morphine sulphate M/R with buprenorphine 70 micrograms/h transdermal patch
label: d
answer: no
explanation: Similarly, stopping all three steps of the analgesic ladder without additional PRN medication would result in a huge decrease in the pain relief for this patient
name: Stop regular morphine sulphate M/R, ibuprofen and paracetamol
label: c
answer: no

Correct answer: a