hllj/quesmed huggingface dataset:
Case Presentation: A 67 year old man is admitted to the medical ward for treatment of a diabetic foot ulcer. **PMH** type 2 diabetes, hypertension, diabetic nephropathy. **DH** metformin hydrochloride MR tablets 2g PO OD, insulin glargine (Lantus) 9 units SC BD, doxazosin 4mg PO OD. Allergic to penicillin – urticarial rash. Allergic to gentamicin – anaphylaxis.


**Investigations**

FBC: Hb 130, WCC 17.3, Plts 235 x 10^9, MCV 87

U&Es: Na 145, K 4.8, Cl 96, Ur 3.1, Cr 197, eGFR 48mL/min/1.73m^2

LFTs: AST 16, ALT 23, ALP 54

CRP 155

Ulcer swab MCS: mixed growth. Primary species Staphylococcus aureus and Staphylococcus epidermidis, isolated Elizabethkingia meningoseptica

Based on the sensitivities and advice from microbiology, the patient’s consultant decides to start co-trimoxazole 960mg IV BD for 7 days.

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

Options:
explanation: It is advised to avoid using co-trimoxazole in patients with severe hepatic impairment but monitoring liver function is not routinely done
name: Liver function tests
label: e
answer: no
explanation: Monitoring of blood co-trimoxazole concentrations may be useful for planning dose adjustments but aberrant levels do not necessarily correspond with development of adverse effects
name: Co-trimoxazole levels
label: b
answer: no
explanation: Hypoglycaemia is a very rare side effect of treatment with co-trimoxazole but it is not routine to monitor blood glucose whilst on this drug
name: Blood glucose monitoring
label: c
answer: no
explanation: Co-trimoxazole has anti-folate activity and monitoring haematics could be considered if taken for an extended period of time or in combination with another anti-folate drug such as methotrexate. However the planned treatment course here is only for 7 days and is unlikely to result in a significant effect
name: Haematinics (ferritin, B12, folate)
label: d
answer: no
explanation: Co-trimoxazole is known to cause hyperkalaemia in patients who are at risk of or have pre-existing renal impairment
name: Urea and electrolytes
label: a
answer: yes

Correct answer: a
Case Presentation: A 70 year old man is seen in the outpatient urology clinic for consideration of starting tamsulosin hydrochloride 400 micrograms PO OD to treat benign prostatic hypertrophy. **PMH** temporal arteritis, depression. **DH** venlafaxine modified release 150mg PO OD


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

Options:
explanation: It is recommended that tamsulosin be avoided in patients with severe liver dysfunction but routine monitoring of liver function is not necessary
name: Liver function tests
label: d
answer: no
explanation: This is not necessary prior to starting this drug
name: Arterial doppler ultrasound
label: b
answer: no
explanation: It is recommended that tamsulosin be avoided in patients with severe renal dysfunction but routine monitoring of renal function is not necessary
name: Urea and electrolytes
label: e
answer: no
explanation: As an alpha-blocker, tamsulosin may exacerbate orthostatic hypotension, particularly in the elderly
name: Blood pressure
label: a
answer: yes
explanation: Tamsulosin blocks alpha adrenergic receptors rather than beta adrenergic receptors and has very limited activity on the heart
name: ECG
label: c
answer: no

Correct answer: a
Case Presentation: An 88 year old woman attends a follow-up appointment for review at her GP. One month ago she was seen in the outpatient dermatology clinic for a surgical excision of a basal cell carcinoma. She was incidentally diagnosed at the time with multiple-nail onychomycosis on her left foot and started on terbinafine 250mg PO OD.


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

Options:
explanation: It is recommended to measure liver function prior to and at 4-6 weeks after starting this drug as terbinafine is known to be hepatotoxic
name: No routine monitoring is required
label: c
answer: no
explanation: It is recommended that the dose of terbinafine should be reduced in patients with renal impairment, but routine monitoring of renal function is not necessary
name: Serum creatinine
label: e
answer: no
explanation: This is not a necessary monitoring requirement for this drug
name: Fasting lipid profile
label: b
answer: no
explanation: It is recommended to measure liver function prior to and at 4-6 weeks after starting this drug as terbinafine is known to be hepatotoxic
name: Liver function tests
label: a
answer: yes
explanation: This is not a necessary monitoring requirement for this drug
name: Platelet count
label: d
answer: no

Correct answer: a
Case Presentation: A 27 year old woman attends the walk-in GUM clinic requesting emergency contraception. She had forgotten to take her combined contraceptive pill for two days in a row at the start of the week and had unprotected sex in the same period.


Her LMP was 5 days ago and she has a regular cycle of 28 days. She has never been pregnant before.

After counselling, it is agreed that she should take ulipristal acetate 30mg PO as a one-off dose for emergency contraception.

Question: Select the most appropriate monitoring option required before administering ulipristal acetate.

Options:
explanation: The patient is reporting regular bleeds with her last one occurring 5 days ago. There still is a minuscule chance she may be pregnant and one may choose to perform a urine pregnancy test before administering ulipristal acetate, but this is not strictly necessary
name: Urine pregnancy test
label: e
answer: no
explanation: There are generally no monitoring requirements prior to administering ulipristal acetate as emergency contraception
name: No routine monitoring is required
label: a
answer: yes
explanation: Hyper/hypotension is not a known adverse effect of this drug
name: Blood pressure
label: b
answer: no
explanation: It is not necessary to measure height and weight prior to administering ulipristal acetate
name: Height and weight
label: d
answer: no
explanation: Ulipristal acetate is metabolised by the liver and as such liver function tests are recommended when it is being used long-term to treat fibroids. This is not necessary if it is taken as a single dose for emergency contraception
name: Liver function tests
label: c
answer: no

Correct answer: a
A 15 year old girl attends her GP to ask for the combined oral contraceptive pill. During the consultation, her GP is satisfied that there are no safeguarding concerns regarding her partner and that she meets the Fraser guidelines. She is prescribed ethinylestradiol with desogestrel 1 tablet daily for 21 days and a 7-day pill free break.


Question: Select the most appropriate monitoring option required before starting her contraception.

Options:
explanation: While deep-vein thromboses are a well-known adverse effect of taking oestrogen-containing contraception, it is not necessary to rule out an existing DVT prior to starting contraception
name: Venous doppler ultrasound
label: c
answer: no
explanation: Hypertension is a common adverse effect of the combined oral contraceptive pill and it is recommended that blood pressure should be checked before and while taking the COCP
name: Blood pressure
label: a
answer: yes
explanation: A D-dimer is a specific blood test that is useful in helping to guide clinical diagnosis of a DVT. It is not necessary to perform one prior to starting contraception
name: D-dimer
label: d
answer: no
explanation: It is not necessary to perform an ECG prior to starting contraception
name: ECG
label: b
answer: no
explanation: It is recommended to monitor the blood pressure and weight prior to starting and while taking the COCP
name: No routine monitoring is required
label: e
answer: no

Correct answer: a
Case Presentation: Case Presentation: An 82-year-old man is diagnosed with non-valvular atrial fibrillation during an inpatient stay. Following discussion regarding the available options, he is commenced on edoxaban 30mg PO OD for stroke prophylaxis.



Question: Select the most appropriate monitoring option to assess for adverse effects of the drug.

Options:
explanation: Although this would be part of a panel of investigations if the patient were to suffer adverse bleeding, it would not be a part of routine monitoring.
name: FBC
label: d
answer: no
explanation: Edoxaban has no effect on platelets and thus they have no role in monitoring either the dosing or adverse effects of edoxaban.
name: Platelet count
label: c
answer: no
explanation: Edoxaban as a DOAC and just like any other anticoagulant, can increase the risk of bruising. Patients being initiated on anticoagulation should be warned to look out for signs of bleeding and report these immediately.
name: Patient reports of bruising
label: a
answer: yes
explanation: INR is used to monitor warfarin, an alternative anticoagulant.
name: INR
label: b
answer: no
explanation: Prothrombin time is not a reliable test for factor Xa inhibitors, such as Edoxaban.
name: Prothrombin time
label: e
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: 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
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

Correct answer: a
Case Presentation:


A 52-year-old man presents to his GP for review of his blood glucose. He was started on metformin 3 months ago when his HbA1c was found to be 52 and 56mmol/mol when tested on two separate occasions. PMH Type 2 diabetes mellitus, Hypertension, Hypercholesterolemia. DH Atorvastatin 20mg PO daily, Ramipril 2.5mg PO daily, Metformin 500mg TDS PO.
 **On Examination**
BP 125/85 mmHg


 **Investigations**


||||
|---------------------------|:-------:|------------------------------|
|Non-fasting Glucose|13.1 mmol/L|< 6.1|
|HbA1c (Glycated Haemoglobin)|60 mmol/mol or %|20 - 42 or 4-6%|
|Urea|6 mmol/L|2.5 - 7.8|
|Creatinine|85 µmol/L|60 - 120|


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

Options:
explanation: This patient has poorly controlled hyperglycaemia (HbA1c 60) despite being started on metformin 500mg TDS. The maximum tolerated dose of metformin is 2g a day. His metformin can be up titrated to the maximum before starting on dual therapy
name: Metformin 1g BD PO
label: a
answer: yes
explanation: His metformin can be up titrated to the maximum before starting on dual therapy
name: Add sitagliptin 100mg PO OD to metformin
label: d
answer: no
explanation: His metformin can be up titrated to the maximum before starting on dual therapy. If the patient fails to respond to dual oral hypoglycaemic agents, triple therapy can then be considered
name: Triple therapy consisting of metformin 500mg TDS, sitagliptin 100mg OD, gliclazide 40mg OD
label: e
answer: no
explanation: Patients with T2DM are often trialled on different combination of oral hypoglycaemic agent prior to initiation of insulin. In this case, uptitrating his metformin should be considered prior to changing his medication to insulin
name: Switch to biphasic insulin detemir 20 units SC
label: c
answer: no
explanation: The maximum tolerated dose of metformin is 2g a day
name: Metformin 1g TDS PO
label: b
answer: no

Correct answer: a
Case Presentation:  A 54-year-old woman attends her GP complaining of a sore leg.


**PMH**
Hypertension, hypercholesterolaemia
**DH**
Ramipril 10mg PO OD, amlodipine 10mg PO OD, atorvastatin 20mg PO OD, tamoxifen 20mg PO OD, paracetamol 1g PO QDS
**Examination**
The right calf appears red, swollen and painful to touch. When compared to the other leg it is around 3cm bigger. Their observations are normal.

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

Options:
explanation: Venous thromboembolism is not a recognised side effect of atorvastatin. Therefore, there is no need to stop this drug.
name: Stop atorvastatin
label: e
answer: no
explanation: Venous thromboembolism is not a recognised side effect of amlodipine. Therefore, there is no need to stop this drug.
name: Stop amlodipine
label: c
answer: no
explanation: Venous thromboembolism is not a recognised side effect of paracetamol. Therefore there is no need to stop this drug.
name: Stop paracetamol
label: d
answer: no
explanation: This patient has presented with a DVT. Patients who are taking tamoxifen are at an increased risk of developing blood clots. This is because the liver produced more clotting factors in response to processing more oestrogen. This patient should have her hormone replacement therapy switched over to a patch or gel.
name: Stop tamoxifen
label: a
answer: yes
explanation: Venous thromboembolism is not a recognised side effect of ramipril. Therefore, there is no need to stop this drug.
name: Stop ramipril
label: b
answer: no

Correct answer: a
Case Presentation: A 31-year-old female attends psychiatric outpatients for a review of her bloods.




 **PMH**
Schizophrenia
 **DH**
Clozapine 100mg PO BD
 **Investigations**



||||
|--------------|:-------:|---------------|
|White Cell Count|1.6x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|234x10<sup>9</sup>/L|150 - 400|
|Neutrophils|0.6x10<sup>9</sup>/L|2.0 - 7.5|
|Lymphocytes|1.2x10<sup>9</sup>/L|1.5 - 4.0|
|Monocytes|0.5x10<sup>9</sup>/L|0.2 - 1.0|
|Eosinophils|0.2x10<sup>9</sup>/L|0 - 0.4|
|Basophils|0.08x10<sup>9</sup>/L|0 - 0.1|
|Sodium|136 mmol/L|135 - 145|
|Potassium|4.1 mmol/L|3.5 - 5.3|
|Urea|3.3 mmol/L|2.5 - 7.8|
|Creatinine|61 µmol/L|60 - 120|



Question: Select the most appropriate decision option based on this data

Options:
explanation: Monitoring at such an extended interval is unsafe given the acute risk of infection associated with agranulocytosis. The priority is immediate cessation and haematology referral.
name: Reduce clozapine dose to 75mg PO BD and repeat bloods in one month
label: d
answer: no
explanation: Increasing the dose would exacerbate the risk of agranulocytosis, as clozapine is directly linked to this haematological side effect.
name: Increase clozapine dose to 125mg PO BD
label: c
answer: no
explanation: Continuing clozapine in the presence of agranulocytosis is contraindicated. This approach puts the patient at significant risk of sepsis or other severe complications.
name: Continue treatment and repeat bloods in one week
label: e
answer: no
explanation: Reducing the dose does not prevent further neutropenia or adequately address the agranulocytosis risk. This approach delays appropriate action and increases the risk of complications.
name: Reduce clozapine dose to 75mg PO BD and repeat bloods in one week
label: b
answer: no
explanation: Clozapine is associated with a risk of agranulocytosis, a severe reduction in neutrophils. This patient has neutropenia (neutrophils <1.5x10⁹/L) and agranulocytosis (neutrophils <0.5x10⁹/L), making the continuation of clozapine unsafe. Immediate discontinuation is necessary to prevent life-threatening infections and further haematological decline.
name: Stop clozapine immediately
label: a
answer: yes

Correct answer: a
Case Presentation:  A 9-year-old boy attends an asthma clinic with his mother following a new diagnosis. She explains that he is still feeling short of breath despite using his brother's blue inhaler. 


**PMH**
Asthma

**DH**
None

Question: Select the most appropriate decision option based on this data

Options:
explanation: The first step of asthma management is a SABA (salbutamol) and an inhaled corticosteroid, rather than a preventer inhaler alone.
name: Prescribe regular low dose inhaled corticosteroid
label: b
answer: no
explanation: This is a combination inhaler which is first line management in patients >12 years old, and may be considered as part of a MART regimen if this patient's symptoms remain uncontrolled.
name: Prescribe formoterol/beclometasone combined inhaler
label: e
answer: no
explanation: Salbutamol monotherapy is no longer recommended at any stage of asthma treatment across all age groups.
name: Prescribe salbutamol inhaler
label: c
answer: no
explanation: This would be inappropriate as he is not suffering an acute exacerbation and should be managed with inhaled corticosteroids.
name: Prescribe oral prednisolone
label: d
answer: no
explanation: This is the first step in management of asthma in children over 5 years of age. Salbutamol monotherapy is no longer recommended. Indications for escalating treatment if symptoms remain uncontrolled include: using an inhaled short-acting beta2 agonist three times a week or more, having symptoms of asthma three times a week or more, or waking at night due to asthma symptoms at least once a week.
name: Prescribe salbutamol and a regular low dose inhaled corticosteroid 
label: a
answer: yes

Correct answer: a
Case Presentation: A 33-year-old female attends her GP to review her blood tests.




 **PMH** Hypothyroidism


 **DH** Levothyroxine 75 micrograms PO OD


 **Investigations**


||||
|---------------------------|:-------:|------------------------------|
|Thyroid Stimulating Hormone|9.8 mU/L|0.3 - 4.2|
|Free T4|21 pmol/L|9 - 25|
|Free T3|5 pmol/L|3.1 - 6.8|




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

Options:
explanation: This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Increase this patients levothyroxine to 125 micrograms PO OD
label: e
answer: no
explanation: This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Increase this patients levothyroxine to 100 micrograms PO OD
label: b
answer: no
explanation: This patient hasn't been taking her levothyroxine medication as intended as indicated by the normal T3/T4 level and raised TSH. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Make no changes to her medication
label: a
answer: yes
explanation: This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Decrease this patients levothyroxine to 50 micrograms PO OD
label: c
answer: no
explanation: This patient hasn't been taking her levothyroxine medication as intended. This can be inferred due to the blood results in the investigations section of this question. She therefore doesn't need her levothyroxine dose adjusting and instead requires counselling on the importance of taking her levothyroxine as prescribed.
name: Decrease this patients levothyroxine to 25 micrograms PO OD
label: d
answer: no

Correct answer: a
Case presentation: A 50-year-old man is admitted to the Cardiology ward following an episode of syncope. PH Angina, Seizure, AF, Ankylosing spondylitis, Gout, Cellulitis. DH. His regular medicines are listed (below). Weight 120kg.


**On Examination**
HR 50/min, BP 95/85mm Hg, RR 18, O2 sats 94% RA. HS I + II with no added heart sounds.

Question 1: Select the TWO prescriptions that should not be co-prescribed. (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: Verapamil;120mg;oral (PO);Thrice daily
label: e
answer: no
name: Allopurinol;100mg;oral (PO);Daily
label: g
answer: no
name: Levetiracetam;750mg;oral (PO);Twice daily
label: b
answer: no
name: Adalimumab;40mg;subcutaneous (SC);Two-weekly
label: f
answer: no
name: Bisoprolol fumarate;10mg;oral (PO);Daily
label: a
answer: no
name: Ibuprofen;400mg;oral (PO);Thrice times daily
label: c
answer: no
name: Sodium valproate;3.6g;oral (PO);Daily
label: d
answer: no
name: Fusidic acid;250mg;oral (PO);Twice daily
label: h
answer: no


1. Beta blockers and non-dihydropyridine calcium channel blockers should not be co-prescribed as both exert a negative inotropic and chronotropic effect on the heart, causing a depression in both mechanical and electrical activity resulting in bradycardia and hypotension.
2. Sodium valproate used for seizure management is prescribed at 20-30mg/kg daily. However, the maximum recommended dose is 2.5g daily. Hence this patient should only be prescribed 2.5g daily and not 3.6g daily.