hllj/quesmed huggingface dataset:
Case presentation: A 63-year-old man attends his GP appointment with a 3-month history of chest pain on exertion. He reports that he sometimes gets out of breath and feels a constricting chest pain when climbing up the stairs. The pain usually goes away a few minutes after he sits down.  

PMH: Erectile dysfunction
SH: Retired, lives with his wife

The patient is advised to take Glyceryl Trinitrate (GTN) spray to relieve the chest pain.

Question: Select the most appropriate information that should be provided for this patient.

Options:
explanation: Manufacturer advises against the concurrent use of GTN and sildenafil because it increases the risk of severe hypotension and circulatory collapse
name: GTN can be safely used together with sildenafil
label: c
answer: no
explanation: Patients are advised to repeat the dose at 5 minutes interval if required and to seek immediate medical attention if symptoms have not resolved after 3 doses
name: GTN can be taken at 10 minutes interval if required
label: d
answer: no
explanation: Restlessness is a rare side effect of GTN
name: Restlessness is a common side effect of GTN
label: e
answer: no
explanation: Patients are advised to repeat the dose at 5 minutes interval if required and to seek immediate medical attention if symptoms have not resolved after 2 doses
name: He should seek immediate medical help if symptoms have not resolved after 2 consecutive doses
label: a
answer: yes
explanation: Glyceryl Trinitrate (GTN) is a medication used for prophylaxis and treatment of angina. It converts into nitric oxide, leading to vasodilation and increased blood flow to the heart
name: GTN works by making the heart beat faster and stronger so that more blood can be delivered to meet the body’s demand
label: b
answer: no

Correct answer: a
Case presentation: A 25-year-old man attends his GP appointment with a three-month history of wheeze and chest tightness. He reports that the symptoms usually happen after his morning runs and on exposure to cold air.  

PMH: Eczema
Examination: Widespread expiratory polyphonic wheeze
Investigation: Fractional exhaled nitric oxide(FENO) > 50 parts per billion (ppb); Forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) < 65%; Expiratory peak flow variability >25%
The patient is to be offered a salbutamol inhaler (Ventolin Accuhaler®)as reliever therapy.

Question: Select the most appropriate information that should be provided for this patient.

Options:
explanation: Salbutamol is not associated with oral thrush. Oral thrush is a potential side effect of inhaled corticosteroids that are commonly used in asthma maintenance therapy
name: Salbutamol inhaler increases risk of developing oral thrush
label: d
answer: no
explanation: . In a sudden asthma attack, patients should sit up straight and take one puff of reliever inhaler every 30 seconds up to 10 puffs. They should call 999 for an ambulance if the symptoms still do not resolve after 10 puffs
name: In an asthma attack, he can take salbutamol up to 50 puffs with a time interval of 2 minutes between each puff
label: c
answer: no
explanation: Salbutamol is a short-acting beta 2 adrenergic receptor agonist that treats bronchoconstriction by opening up the airway muscles
name: Salbutamol is an alpha-1-agonist that relieves symptoms of asthma by relaxing the muscles of airway
label: b
answer: no
explanation: Salbutamol is a short-acting beta 2 adrenergic receptor agonist that treats bronchoconstriction by opening up the airway muscles. Patients should talk to their doctors if they need to use the inhaler for more than 3 times in a week. This may be a sign that the asthma is still not well controlled and that an adjustment needs to be made to the current regime
name: He should talk to his doctor if he uses his salbutamol inhaler for more than 3 times a week
label: a
answer: yes
explanation: Salbutamol can cause potentially serious hypokalaemia not hyperkalaemia. It stimulates the entry of potassium into the cells, thus lowering serum potassium concentration
name: Salbutamol can lead to hyperkalaemia
label: e
answer: no

Correct answer: a
Case presentation: A 74-year-old man attends warfarin clinic to have his INR checked. He has recently had COVID-19.



**PH**
Atrial fibrillation, hypertension, hypercholesterolaemia

**DH**
7.5mg warfarin PO OD, ramipril 5mg PO OD, atorvastatin 20mg PO OD

**Investigations** INR 3.8 (2.0-3.0)

Question: Select the most important information that should be provided for this patient.

Options:
explanation: There are no interactions between ramipril and warfarin, it therefore does not need to be changed.
name: He should switch his ramipril to amlodipine due to potential interactions between ramipril and warfarin
label: d
answer: no
explanation: Renal function is not routinely monitored in patients using warfarin.
name: He is likely to need renal monitoring if his warfarin dose needs changing
label: e
answer: no
explanation: This is incorrect, concurrent illness can exaggerate the effect of warfarin which requires a reduction in dosage. This doesn't mean that you should completely stop this patients warfarin.
name: He needs to stop his warfarin immediately
label: c
answer: no
explanation: Nausea is a rare/very rare side effect of warfarin so he is unlikely to experience it with a dose change.
name: He is likely to experience nausea if his warfarin dose needs changing
label: b
answer: no
explanation: Acute illness can exaggerate the effect of warfarin and indicate a need to reduce dosage. Given this man has had a recent COVID-19 infection and his INR is out of therapeutic range for warfarin he will likely need his warfarin dose reducing.
name: His warfarin does should be reduced
label: a
answer: yes

Correct answer: a
Case presentation: A 64-year-old man is admitted to hospital for elective surgery. He has known oesophageal cancer and is having a subtotal oesophagectomy to remove his tumour.



**PH**
Oesophageal cancer, chronic kidney disease (stage 4)

**DH**
Ramipril 10mg PO OD, atorvastatin 20mg PO OD, epoetin alfa 3500 units IV BD

As this gentleman is having surgery, he needs to be prescribed unfractionated heparin

Question: Select the most important information that should be provided for this patient.

Options:
explanation: Hepatic function is not routinely monitored in patients using unfractionated heparin.
name: He will need regular hepatic monitoring
label: b
answer: no
explanation: This patient has chronic kidney disease stage 4, this means his eGFR is 15-29 ml/min. Hyperkalaemia is a recognised risk of chronic kidney disease, especially in the later stages of the disease. Unfractionated heparin inhibits aldosterone secretion, this in turn increases the risk of hyperkalaemia. As this patient is already predisposed to hyperkalaemia it is important to measure their potassium levels before giving unfractionated heparin and during their stay in hospital.
name: He will need to have his potassium checked before he has his heparin
label: a
answer: yes
explanation: Alopecia is listed as a rare/very rare side effect of unfractionated heparin use, therefore they are not very likely to occur.
name: He is likely to experience hair loss whilst taking unfractionated heparin
label: d
answer: no
explanation: Thyroid function is not routinely monitored in patients using unfractionated heparin.
name: He will need regular thyroid function tests for monitoring
label: c
answer: no
explanation: Metallic taste is not a listed side effect of unfractionated heparin.
name: He is likely to experience a metallic taste in his mouth as a side effect of unfractionated heparin
label: e
answer: no

Correct answer: a
A 9-year-old boy is brought to his Neurology outpatients appointment by his father for review of his epilepsy medication. He is commenced on sodium valproate 30 mg/kg maintenance PO in two divided doses. He weighs 30 kg.


Sodium valproate is available as a 200 mg/5 mL oral solution. What volume (mL) of sodium valproate oral solution should the patient be given for each dose? Round your answer to 2 decimal places.

Options:


Total daily dose = 30 kg x 30 mg = 900 mg
In two divided doses = 900 / 2 = 450 mg per dose
Volume of solution for each dose =  450 mg / (5 mL/ 200 mg) = 11.25 mL
Case Presentation: A 54-year-old man is admitted to the medical ward with acute gout. PMH AF, gout, hypertension. DH His current regular medicines, in addition to rivaroxaban, are listed on the right.


On examination
Swollen, red and tender left metatarsophalangeal joint.
Dark, black tarry stools reported.

Investigation
FBC Hb 13g/dL (13.5-17.5g/dL)
Fine needle aspiration of joint: negative birefringent urate crystals seen in polarized light.

Question: Select the prescription that is most likely to interact with the patient’s rivaroxaban to cause gastrointestinal bleeding.

Options:
explanation: Bisoprolol does not commonly cause bleeding
name: Bisoprolol fumarate 5mg PO daily
label: b
answer: no
explanation: Ramipril does not commonly cause bleeding
name: Ramipril 2.5mg PO daily
label: d
answer: no
explanation: Digoxin does not commonly cause bleeding
name: Digoxin 125 micrograms PO daily
label: c
answer: no
explanation: Amlodipine does not commonly cause bleeding
name: Amlodipine 10mg PO daily
label: e
answer: no
explanation: NSAIDs (indomethacin) and antiplatelet (rivaroxaban) interact to increase the risk of gastrointestinal bleeding. Indomethacin is a non-selective COX inhibitor, its effect on COX-1, in particular, decreases the production of thromboxane A2 and prevents platelet aggregation. When used in combination with antiplatelet or anticoagulant agents, it can increase the bleeding risk in patients
name: Indomethacin 100mg PO BD
label: a
answer: yes

Correct answer: a
Case Presentation: A 75-year-old gentleman was admitted to the acute medical unit two days ago due to acute pulmonary edema secondary to decompensated heart failure. Subsequently, he complained of severe loin to groin pain that started this morning and was subsequently reviewed by the urology team. PMH HTN, Familial hypercholesterolemia, Heart failure, BPH. DH His current regular medicines are listed (below).

Investigation
Non contrast CT scan revealed radiopaque stones in the right ureter.

Question: Select the prescription that is most likely to contribute to his renal stones

Options:
explanation: Atorvastatin does not commonly cause renal stones
name: Atorvastatin 10mg PO OD
label: c
answer: no
explanation: Loop diuretics act by competing for the chloride site on the Na-K-2Cl cotransporter and inhibiting sodium and calcium reabsorption in the thick ascending limb of Loop of Henle. This results in an increased excretion of calcium in the urine and a hypercalciuric state, which results in the formation of renal calculi
name: Furosemide 40mg PO OD
label: a
answer: yes
explanation: Dalteparin does not commonly cause renal stones
name: Dalteparin 5000 units SC OD
label: d
answer: no
explanation: Tamsulosin does not commonly cause renal stones
name: Tamsulosin 400 micrograms PO OD
label: e
answer: no
explanation: Bisoprolol does not commonly cause renal stones
name: Bisoprolol 10mg PO OD
label: b
answer: no

Correct answer: a
Case Presentation: An 85-year-old man is transferred to the care of the elderly ward following an episode of syncope. PMH Hypertension, BPH, Epilepsy, Parkinson disease. DH His current regular medicines are listed (below).


On examination
Lying BP 120/85mmHg, HR 80/min; standing BP 90/70mmHg, HR 100/min

Question: Select the prescription that is most likely to contribute to his orthostatic hypotension.


Options:
explanation: Daleparin does not commonly cause orthostatic hypotension
name: Dalteparin sodium 2500 units SC OD
label: e
answer: no
explanation: Amlodipine can cause dizziness but is not known to commonly cause orthostatic hypotension
name: Amlodipine 5mg PO daily
label: d
answer: no
explanation: Tamsulosin, an alpha1-adrenoreceptor blocker is known to cause postural hypotension due to the inhibition of alpha-1 receptors, leading to vascular smooth muscle relaxation and vasodilation the loss of reflex vasoconstriction upon standing
name: Tamsulosin 400 micrograms PO OD
label: a
answer: yes
explanation: Carbamazepine does not commonly cause orthostatic hypotension
name: Carbamazepine
label: c
answer: no
explanation: Co-careldopa does not commonly cause orthostatic hypotension
name: Co-careldopa 25/100 TDS PO
label: b
answer: no

Correct answer: a
Case Presentation: A 21-year-old female patient is brought to A&E drowsy and confused. Her friend reports that she has been taking recreational drugs. 


**PMH**
None

**On examination**
* Chest: clear, RR 12
* HS: S1 S2 + no added sounds
* Cranial Nerves: Nystagmus and dysarthria. Pupils are equal and reactive to light, normal size.

**Investigation**

Routine blood tests are normal.

Question: Which recreational drug is most likely to have caused these clinical signs?

Options:
explanation: This patient is suffering from benzodiazepine toxicity. Benzodiazepine toxicity leads to muscarinic effects such as ataxia, dysarthria and nystagmus and in severe cases, respiratory depression which can be fatal.
name: Diazepam
label: a
answer: yes
explanation: MDMA is a stimulant recreational drug known as 'ecstasy'. MDMA toxicity leads to confusion, coma, convulsions, ventricular arrhythmias, hyperthermia, rhabdomyolysis, acute renal failure, acute hepatitis, disseminated intravascular coagulation, adult respiratory distress syndrome, hyperreflexia, hypotension and intracerebral haemorrhage. Self-induced water intoxication can also lead to hyponatraemia.
name: Methylenedioxymethamphetamine (MDMA)
label: c
answer: no
explanation: Amphetamines are stimulant recreational drugs. Toxicity leads to signs such as wakefulness, excessive activity, paranoia, hallucinations, hypertension and in more severe cases; exhaustion, convulsions, hyperthermia, and coma.
name: Amphetamine
label: e
answer: no
explanation: Oxycodone is an opioid that is sometimes used recreationally. Opioid overdose has a similar clinical presentation to this patient in the form of respiratory depression and drowsiness. However, opioid toxicity causes different eye signs, most notably, constricted pinpoint pupils.
name: Oxycodone
label: b
answer: no
explanation: Cocaine is a stimulant drug used recreationally. Cocaine toxicity can lead to effects signs such as agitation, dilated pupils, tachycardia, hypertension, hallucinations, hyperthermia, hypertonia, and hyperreflexia. In severe cases, cocaine can cause myocardial infarction and arrhythmias.
name: Cocaine
label: d
answer: no

Correct answer: a
Case Presentation: A 62-year-old gentleman has recently undergone surgery for a broken neck of femur which was treated with a total hip replacement. He has been managing his post-operative pain with morphine. His regular medicines are listed (below). Weight 85kg.




 **PH** Depression, COPD, Hypercholesterolaemia, Ethanol excess


 **DH** Tranylcypromine 10mg PO OD, Atorvastatin 20mg PO OD, Salmeterol 50micrograms INH BD, Tiotropium 5micrograms INH OD, Paracetamol 1g PO QDS


 **On examination**
BP 109/68mmHg, HR 88, RR 4


Neurological exam: Difficult to rouse the patient. Pupils appear small.


 **Investigation**



||||
|--------------|:-------:|------------------|
|pH|7.24|7.35 - 7.45|
|PaO₂|6.0 kPa|11 - 15|
|PaCO₂|9.4kPa|4.6 - 6.4|
|Bicarbonate|18 mmol/L|22 - 30|



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

Options:
explanation: Atorvastatin does not commonly interact with morphine.
name: Atorvastatin 20mg PO OD
label: b
answer: no
explanation: Salmeterol does not commonly interact with morphine.
name: Salmeterol 50micrograms INH BD
label: c
answer: no
explanation: Tiotropium does not commonly interact with morphine.
name: Tiotropium 5micrograms INH OD
label: d
answer: no
explanation: Paracetamol does not commonly interact with morphine.
name: Paracetamol 1g PO QDS
label: e
answer: no
explanation: This patient is experiencing opioid toxicity. Tranylcypromine is a monoamine oxidase B inhibitor that is used to treat major depressive disorder. It has been shown to potentially increase the risk of opioid toxicity if taken alongside morphine.
name: Tranylcypromine 10mg PO OD
label: a
answer: yes

Correct answer: a
Case Presentation: A 72-year-old gentleman attends his GP for his blood results. His regular medicines are listed (below).




 **PH** Hypertension, Hypercholesterolaemia


 **DH** Atorvastatin 20mg PO OD, Ramipril 10mg PO OD, Amlodipine 10mg PO OD, Indapamide 2.5mg PO OD, Paracetamol 1g PO QDS


 **On examination**
BP 148/90mmHg, HR 84, RR 12, Weight 70kg


 **Investigation**


||||
|---------------------------|:-------:|--------------------|
|Sodium|136 mmol/L|135 - 145|
|Potassium|4.1 mmol/L|3.5 - 5.3|
|Urea|6.0 mmol/L|2.5 - 7.8|
|Creatinine|100 µmol/L|60 - 120|
|Calcium|3.0 mmol/L|2.2 - 2.6|
|eGFR|70 mL/min/1.73m<sup>2</sup>|> 60|


Question: Select the medication that is most likely to have contributed to the abnormality in his blood results.

Options:
explanation: Paracetamol does not commonly cause hypercalcaemia.
name: Paracetamol 1g PO QDS
label: e
answer: no
explanation: Amlodipine does not commonly cause hypercalcaemia. In very rare cases it has been found to cause hypocalcaemia.
name: Amlodipine 10mg PO OD
label: c
answer: no
explanation: Atorvastatin does not commonly cause hypercalcaemia.
name: Atorvastatin 20mg PO OD
label: d
answer: no
explanation: Indapamide is a thiazide-like diuretic. Thiazide-like diuretics work via increasing the availability of Na<sup>+</sup> in the urine, water then follows this and reduces the blood pressure. One way they do this is by increasing calcium reabsorption across the nephron in exchange for sodium - this in turn results in hypercalcaemia.
name: Indapamide 2.5mg PO OD
label: a
answer: yes
explanation: Ramipril does not commonly cause hypercalcaemia.
name: Ramipril 10mg PO OD
label: b
answer: no

Correct answer: a
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: Ibuprofen;400mg;oral (PO);8-hourly
label: e
answer: no
name: Bisoprolol fumarate;10mg;oral (PO);Daily
label: a
answer: no
name: Amlodipine;5mg;oral (PO);Daily
label: c
answer: no
name: Morphine sulphate;10mg;intravenous (IV);4-hourly
label: j
answer: no
name: Warfarin;5mg;oral (PO);Daily
label: i
answer: no
name: Ramipril;2.5mg;oral (PO);Daily
label: b
answer: no
name: Senna;7.5mg;oral (PO);Daily
label: h
answer: no
name: Ondansetron;4mg;oral (PO);PRN
label: g
answer: no
name: Tramadol;100mg;oral (PO);6-hourly
label: f
answer: no
name: Paracetamol;1g;oral (PO);4-hourly
label: d
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 40-week pregnant woman is admitted electively for induction of labour. PH Type 2 diabetes mellitus, Depression, Bipolar disorder, Hypothyroid, Tension headache, Acne rosacea. DH Her current regular medications are listed (below).


Question 1: Select the TWO prescriptions that are most likely to be contributing to congenital heart defects (mark them with a tick in column A)
Question 2: Select the FOUR prescriptions that are contraindicated in breastfeeding (mark it with a tick in column B).

Options:
name: Lithium carbonate;500mg;oral (PO);12-hourly
label: d
answer: no
name: Aspirin;150mg;oral (PO);Daily
label: c
answer: no
name: Metformin;500mg;oral (PO);12-hourly
label: g
answer: no
name: Tetracycline;500mg;oral (PO);12-hourly
label: b
answer: no
name: Levothyroxine;200micrograms;oral (PO);Daily
label: e
answer: no
name: Amitriptyline;50mg;oral (PO);Daily
label: f
answer: no
name: Fluoxetine;20mg;oral (PO);Daily
label: a
answer: no


1. The use of SSRI such as fluoxetine is known to cause congenital heart diseases especially when taken during early pregnancy. Lithium, a medication used for bipolar disorder, is associated with increased risk of Ebstein’s anomaly when taken in the first trimester.
2. Despite evidence showing that calcium in breast milk prevents the absorption of tetracycline, it is currently still avoided in breastfeeding women. Aspirin increases the risk of Reye’s syndrome. Fluoxetine and lithium carbonate is present in milk and can carry a risk of toxicity in infant.