SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: ESRD & Dialysis
A 45-year-old man with ESRD secondary to hypertensive nephrosclerosis is evaluated for severe hyperparathyroidism refractory to medical therapy. He now has evidence of myopathy and intractable pruritus. His current regimen includes optimally dosed cinacalcet, sevelamer, and doxercalciferol. His most re-cent laboratory studies show hemoglobin of 11.5 g/dl, serum albumin of 3.4 g/dl, PTH of 1832 pg/ml, corrected serum calcium of 10.3 mg/dl, and serum phosphorus of 6.4 mg/dl. You recommend parathyroidectomy, and he asks about what he might expect following this procedure..
Question: Which ONE of the following would you advise him regarding the effect of parathyroidectomy?
A. He can expect a reduced risk of hospitalization for the ﬁrst year after surgery
B. He has about a 10% risk of persistent hyperparathyroidism
C. He is unlikely to develop hypocalcemia
D. He can expect an increased risk of mortality for 1 year following surgery
Answer: B
Subject: ESRD & Dialysis
Question: Question 2593:
Which ONE of the following long-term outcomes (over a median follow-up of 3.6 years) was found in the intervention group in the Frequent Hemodialysis Network (FHN) Daily Trial?
A. An increase in left ventricular mass
B. Higher Physical Health Composite scores
C. Improved relative mortality
D. A reduction in hospitalization rates
Answer: C
Subject: ESRD & Dialysis
Question: Question 2594:
Which ONE of the following outcomes has been found to be associated with use of dialyzable β-blockers compared with nondialyzable β-blockers in older patients undergoing intermittent hemodialysis?
A. Increased 6-month mortality
B. Increased risk of ventricular tachycardia
C. Increased risk of myocardial infarction
D. Increased risk of sudden cardiac death
Answer: A
Subject: ESRD & Dialysis
A 57-year-old man with ESRD maintained on thrice weekly in–center hemodialysis is evaluated for recurrent intradialytic hypotension. His prescribed dry weight is 90 kg, and he typically requires 6 L of volume removal during dialysis. He frequently cannot achieve his dry weight because his systolic BP decreases by an average of 40 mmHg, with intra-dialytic systolic BPs as low as 85 mmHg. He receives dialysis three times weekly for 4 hours. The dialysate sodium concentration is 138 mEq/L..
Question: Which ONE of the following ultraﬁltration goal targets is MOST appropriate to decrease his risk of intradialytic hypotension?
A. 6%–7% Weight gain
B. 5%–6% Weight gain
C. 4%–5% Weight gain
D. < 4% Weight gain
Answer: D
Subject: ESRD & Dialysis
A 62-year-old man with ESRD on maintenance hemodialysis is evaluated for hyperlipidemia during a routine ofﬁce visit. He has diet–controlled type 2 diabetes mellitus and hypertension. He does not have chest pain or dyspnea, and he walks 2 miles daily without difﬁculty. His medications are aspirin, irbesartan, amlodipine, and carvedilol. He has never received treatment with statins. Recent laboratory studies show total cholesterol of 223 mg/dl, LDL cholesterol of 124 mg/dl, HDL cholesterol of 46 mg/dl, and triglycerides of 267 mg/dl..
Question: In addition to lifestyle and dietary modiﬁcation, which ONE of the following is the MOST appropriate management?
A. Pravastatin plus ezetimibe
B. Pravastatin
C. Fenoﬁbrate
D. No additional management
Answer: D
Subject: ESRD & Dialysis
One of your patients with ESRD treated with hemodialysis recently read about the cardiovascular beneﬁts of cocoa ﬂavanols. She asks for your opinion about the efﬁcacy of these compounds in mitigating cardiovascular risk..
Question: Which ONE of the following options is CORRECT about the cardiovascular effects of cocoa ﬂavanols in ESRD?
A. They lower systolic BP
B. They reduce C–reactive protein levels
C. They enhance ﬂow–mediated brachial artery dilation
D. They have no effect on platelet aggregation
Answer: C
Subject: ESRD & Dialysis
A 69-year-old man with ESRD, hypertension, obstructive sleep apnea, and type 2 diabetes mellitus is evaluated for hypertension during weekly dialysis rounds. Over the past 2 weeks, he has felt excessively tired and is sleeping through most of the day. His wife indicates that he has been using continuous positive airway pressure as prescribed at night, but she has witnessed several episodes of apnea during daytime naps. Review of his dialysis records over the last week shows an average predialysis BP of 168/94 mmHg and an average postdialysis BP of 154/90 mmHg. He usually achieves his target weight, although he occasionally sustains an asymptomatic fall in BP to approximately 100/ 60 mmHg during treatment. He has been adherent with his dialysis treatments, and his inter-dialytic weight gains are 1.5 kg. Medications include carvedilol 25 mg twice daily, fosinopril 40 mg daily, amlodipine 10 mg daily, long- and short-acting insulin, and epoetin with each dialysis treatment. The dialysis prescription is for 225 minutes three times per week, with an average blood ﬂow rate of 450 ml/min, and a dialysate ﬂow rate of 800 ml/min. The dialysate composition is sodium 138 mEq/L, potassium 2.0 mEq/L, total buffer 37 mEq/L, and calcium 2.5 mEq/L. The physical examination shows a pulse of 72 per mi-nute and trace pedal edema. The remainder of the examination is unremarkable. The monthly laboratory studies show a single-pool Kt/V of 1.5 and a hemoglobin of 10.4 g/dl..
Question: Which ONE of the following is the MOST appropriate next step in managing this man’s hypertension?
A. Decrease the dialysate sodium to 136 mEq/L
B. Decrease epoetin
C. Gradual lowering of the target weight
D. Increase carvedilol
Answer: C
Subject: ESRD & Dialysis
As medical director, you are reviewing the policies of your outpatient dialysis facility with your nursing staff..
Question: Which ONE of the following measures should be included in the policies of your outpatient dialysis center?
A. Isolation of patients who test positive for hepatitis C antibody
B. Use of product water for dialysate only when microbial counts are < 50 CFU Immunization of all patients against Staphylococcus aureus
C. Hand hygiene after removal of gloves and other personal protective equipment
D. Monthly interdisciplinary team meetings with every patient
Answer: D
Subject: ESRD & Dialysis
You have been appointed to the quality oversight committee of your health care system. You have been charged with developing recommendations for improving the value of care for patients with ESRD. The committee chair asks you to make a recommendation for the most important intervention that would reduce the cost of care for patients with ESRD..
Question: Which ONE of the following would you recommend as the BEST strategy to reduce the overall cost of care for patients with ESRD?
A. Increase organ procurement by instituting opt–out donation policies
B. Increase the utilization of home–suitable dialysis modalities
C. Referral to nephrologists when patients are anticipated to require renal replacement therapy (RRT) at least 1 year in advance
D. Provision of ﬁnancial incentives to care providers for achievement of laboratory goals before the initiation of dialysis
Answer: C
Subject: ESRD & Dialysis
An 87-year-old man with ESRD is admitted to the hospital for management of line sepsis related to his tunneled dialysis catheter. A left forearm arteriovenous ﬁstula was placed 2 weeks ago. He has a prolonged hospital course resulting in severe deconditioning. He is no longer able to ambulate independently, and requires placement at a skilled nursing facility for physical therapy. Following discharge, the patient returns to his outpatient hemodialysis center for continued renal replacement therapy (RRT). As the medical director of his dialysis unit and his provider, you are invested in reducing his risk for a repeat hospitalization..
Question: Which ONE of the following is MOST likely to be associated with a decreased risk of a readmission within 30 days of discharge for this patient?
A. His inability to ambulate
B. His age
C. His stable residence in a nursing home
D. An additional provider visit within one month following discharge
Answer: D
Subject: ESRD & Dialysis
A 47-year-old woman with ESRD, type 2 diabetes mellitus, hypertension, and hyperlipidemia is admit-ted to your dialysis facility. She has a mature and functional arteriovenous ﬁstula and is well informed about RRTs. She tells you that she has several family members who also have ESRD, and she expresses concern that two of her ﬁrst cousins died during routine maintenance dialysis treatments. You review her history and laboratory studies before her hemodialysis treatment. These include a serum potassium level of 5.2 mEq/L, a serum calcium level of 9.2 mg/dl, a serum magnesium level of 2.4 mg/dl, a serum phosphorus level of 4.5 mg/dl, and a serum PTH level of 482 pg/ml. Her current medications include propanolol, long-acting insulin, atorvastatin, and ergocalciferol..
Question: Which ONE of the following MOST strongly increases her risk for sudden cardiac arrest?
A. Propanolol therapy
B. The serum potassium concentration of 5.2 mEq/L
C. The serum magnesium of 2.4 mg/dl
D. Her family history
E. The serum PTH concentration of 482 pg/ml
Answer: D
Subject: ESRD & Dialysis
A 68-year-old man with autosomal dominant polycystic kidney disease has been on conventional hemodialysis for 7 years. His arteriovenous ﬁstula provides stable vascular access, he achieves a single-pool Kt/V urea of 1.7, and his BP and electrolytes are stable. He dialyzes with a high-ﬂux membrane for 4 hours three times per week. His predialysis hemoglobin is 11g/dl without erythropoiesis–stimulating agent support, and his serum albumin his 3.6 g/dl. He complains that his exercise tolerance has deteriorated over the past ﬁve years. He has read newspaper reports of a procedure called hemodiaﬁltration, and he asks you if he should consider changing to this treatment modality..
Question: Which ONE of the following is MOST likely to result from a change to hemodiaﬁltration in this patient?
A. A reduction in his left ventricular mass
B. An increase in the serum albumin concentration
C. Stabilization of systemic markers of inﬂammation
D. A decrease in quality of life
Answer: C
Subject: ESRD & Dialysis
You are reviewing a case from your hospital’s acute dialysis unit of a patient who suffered a cardiac arrest immediately after his dialysis session. The patient was a 72-year-old man with ESRD due to diabetic nephropathy who was admitted for foot cellulitis. He had been receiving three times per week hemodialysis sessions via an arteriovenous graft for the past 7 years. You review his medications, recent laboratory results, and the technical aspects of his dialysis treatment. In addition to his usual medications that included calcium acetate, carvedilol, enalapril, and amlodipine, he was also receiving ceftazidime and vancomycin. The patient had what appeared to be an uncomplicated dialysis session on the day of the event, receiving 2.2 L ultraﬁltration over a 225-minute session (corresponding to an ultraﬁltration rate of 9.8 ml/min and an ultraﬁltration volume of 3.2% postdialysis weight). He did not have antecedent hives, rash, pruritus, angioedema, or bronchospasm. The dialysate had a sodium concentration of 140 mEq/L, potassium of 2.0 mEq/L, ﬁnal buffer concentration of 36 mEq/L, and calcium of 2.0 mEq/L. Predialysis laboratory studies on the day of the arrest showed hemoglobin 9.8 g/dl, sodium 140 mEq/L, potassium 5.1 mEq/L, chloride 105 mEq/L, total CO2 20 mmol/L, calcium 8.9 mg/dl, phosphorus 5.9 mg/dl, and albumin 3.2 g/dl. You discuss the episode during a quality assurance and safety meeting..
Question: Which ONE of the following factors in this case has been shown to be associated with sudden cardiac death in patients with ESRD receiving hemodialysis?
A. A dialysate calcium level of 2.0 mEq/L
B. A dialysate sodium concentration of 140 mEq/L
C. A dialysate potassium concentration of 2 mEq/L
D. His ultraﬁltration rate
E. Vancomycin use
Answer: A
Subject: ESRD & Dialysis
A 57-year-old man with CKD due to FSGS is evaluated in the clinic. He has hypertension, hyperlipidemia, and gout. His medications are losartan, furosemide, allopurinol, and pravastatin of 40 mg daily. He is on the active kidney transplant waiting list, and a living donor trans-plant is planned in approximately 2 months. He has mild uremic symptoms, and you are now transitioning him to a hemodialysis regimen. His last fasting lipid proﬁle performed 2 weeks ago while on the current dose of simvastatin showed total cholesterol 150 mg/dl, LDL cholesterol 67 mg/dl, HDL cholesterol 52 mg/dl, and triglycerides 155 mg/dl..
Question: Which ONE of the following is the MOST appropriate management of this patient’s statin therapy?
A. Discontinue pravastatin now
B. Discontinue pravastatin at the time of transplantation
C. Increase pravastatin to 80 mg daily
D. Continue pravastatin at the current dose
Answer: D
Subject: ESRD & Dialysis
A 52-year-old woman with ESRD due to IgA nephropathy and hypertension is evaluated during an interval clinic visit. She has been on three-times-per-week hemodialysis for 3 years, and she has been medically stable. She walks several miles each day without difﬁculty and continues to work part time. She denies depressed mood, chest pain, or dyspnea. When you ask her how her life is at home, she indicates that she and her partner have had some difﬁculties due to a lack of sexual activity. On physical examination, her BP is 130/78 mmHg. She has a well matured left radiocephalic ﬁstula. The remainder of the examination is normal..
Question: Which ONE of the following is MOST likely contributing to her sexual inactivity?
A. Sexual dysfunction
B. Lack of interest
C. Physical debility
D. An arteriovenous ﬁstula rather than a tunneled central venous access
Answer: B
Subject: ESRD & Dialysis
A 54-year-old man with ESRD is admitted for management of presumed catheter–related bacteremia. He had no pre–ESRD nephrology care and recently started maintenance hemodialysis on an urgent basis for symptomatic uremia. Two days ago, he developed acute onset of fever to 40 C, chills, and rigors during dialysis. After obtaining blood cultures, he received intravenous vancomycin and ceftazidime at the outpatient dialysis center before admission. His tunneled dialysis catheter is removed because of erythema and purulent exudate at the exit site. His fever is now resolved. He does not have back pain, cough, dental complaints, or rash. On physical examination, he is now afebrile. The BP is 136/88 mmHg. There is a 1-cm area of erythema at the tunneled dialysis catheter removal site. He has no stigmata of emboli. He has no obvious dental issues on gross inspection of the oropharynx. The cardiac examination shows a grade 2 early peaking systolic crescendo-decrescendo murmur along the right sternal border without radiation. The remainder of the examination is unremarkable. The blood cultures drawn before implementation of antibiotic therapy grew S. aureus within 12 hours. The results of sensitivity testing and repeat blood cultures are pending. Laboratory studies show sodium 138 mEq/L, potassium 3.8 mEq/L, chloride 102, total CO2 25 mmol/L, BUN 45 mg/dl, and creatinine 6.4 mg/dl..
Question: In addition to continued antibiotic therapy, which ONE of the following is the next BEST step in management?
A. Arrange for placement of a tunneled dialysis catheter today
B. Transesophageal echocardiography
C. Magnetic resonance imaging of the spine
D. Bone scintigraphy (bone scan)
E. Examination for an occult dental source of bacteremia
Answer: B
Subject: ESRD & Dialysis
A 52-year-old-man with ESRD on maintenance hemodialysis is diagnosed with proximal calciﬁc uremic arteriolopathy with exquisitely painful lesions on his thighs and lower abdomen. He has type 2 diabetes, hypertension, and obesity. He does not smoke. He is dialyzed for 4 hours on a three times weekly schedule. The dialysate composition is sodium 140 mEq/L, potassium 2 mEq/L, total buffer 36 mEq/L, and calcium 2.5 mEq/L. His medications are insulin detemir once daily, insulin as part before each meal, irbesartan, carvedilol, felodipine, lanthanum carbonate with meals, and intravenous epoetin with each dialysis treatment. On physical examination, the BP is 160/94 mmHg. A representative skin lesion is shown in Figure 2. His laboratory studies show single-pool Kt/V 1.6, hemoglobin 11.4 g/dl, sodium 139 mEq/L, potassium 5.3 mEq/L, chloride 103 mEq/L, total CO2 20 mmol/L, calcium 9.4 mg/dl, phosphorus 5.8 mg/dl, albumin 3.5 g/dl, and PTH 396 pg/ml..
Question: Which ONE of the following has MOST likely increased this man’s risk for calciﬁc uremic arteriolopathy?
A. Hypertension
B. Irbesartan
C. Dialysate calcium of 2.5 mEq/L
D. Intravenous epoetin
E. Multiple daily insulin injections
Answer: E
Subject: ESRD & Dialysis
A 44-year-old woman with ESRD on maintenance hemodialysis has been reading information on the internet about the accumulation of indoxyl sulfate and cardiovascular risk in ESRD. She asks about whether there are any interventions that could potentially lower her serum indoxyl sulfate levels. She is maintained on three-times-per-week hemodialysis, with an average blood ﬂow rate of 400 ml/min and a dialysate ﬂow rate of 800 ml/min. The monthly laboratory studies show an average single–pool Kt/V of 1.3..
Question: Which ONE of the following interventions is MOST likely to lower this woman’s serum levels of indoxyl sulfate?
A. Decreased dietary ﬁber
B. An oral charcoal adsorbent
C. Increased blood ﬂow rate to 450 ml/min
D. Increased dialysis time to achieve a Kt/V of 1.7
Answer: B
Subject: ESRD & Dialysis
A 72-year-old woman has ESRD and chronic atrial ﬁbrillation. She is noted to have increasing frequency of symptomatic atrial ﬁbrillation during her hemodialysis sessions. Today, she was found to have a pulse rate of 120 per minute 30 minutes into her dialysis treatment. Her medications include amlodipine of 5 mg daily, aspirin, and epoetin. On physical examination, her systolic BP is 110 mmHg, and her pulse is irregular, with a rate of 134/min. Her lungs are clear, and she has no edema. Her heart rate decreases to > 100 per minute with a decrease in the ultraﬁltration rate, but she is unable to achieve her dry weight, despite an increase in her dialysis time by 15 minutes..
Question: Which ONE of the following is the BEST initial pharmacologic intervention for maintaining rate control in this woman with atrial ﬁbrillation during dialysis?
A. Metoprolol
B. Enalapril
C. Bisoprolol
D. Digoxin
Answer: C
Subject: ESRD & Dialysis
A 56-year-old woman with ESRD is evaluated during her initial interdisciplinary team meeting after recently starting hemodialysis on an urgent basis. She did not receive pre-ESRD care and is currently dialyzing via a tunneled central venous catheter. Her dialysis facility is a nonproﬁt center that serves a diverse population of patients, 40% of which have incomes below the poverty level. She currently has employer group health insurance coverage. She asks about moving forward with a transplant evaluation..
Question: Which ONE of the following factors is MOST likely to be associated with an increased rate of referral for transplantation within 1 year of starting dialysis for this woman?
A. The absence of pre–ESRD nephrology care
B. Dialysis at a nonproﬁt dialysis facility
C. The proportion of patients treated at her center who are below the poverty level
D. Her insurance status
Answer: D
Subject: ESRD & Dialysis
A 76-year-old woman with ESRD due to membranous nephropathy on maintenance PD is found to have asymptomatic atrial ﬁbrillation during a routine ofﬁce visit. She has an excellent functional status and does not have a history of falls or bleeding complications. She has hypertension that is controlled on lisinopril. On physical examination, her body mass index is 25 kg/m2. Her cardiac examination shows an irregularly irregular rhythm and no murmur or rub. The remainder of the examination is un-remarkable. After a detailed discussion regarding the beneﬁts and risks of anticoagulation, she is in favor of anticoagulation to reduce her risk of stroke. Her laboratory studies show hemoglobin 11.3 g/dl, platelet count 256,000/µl, albumin 4.2 g/dl, calcium 9.0 mg/dl, phosphorus 4.2 mg/dl, and PTH 176 pg/ml..
Question: Which ONE of the following is the MOST appropriate treatment strategy to reduce the subsequent risk of stroke for this woman?
A. Enoxaparin 70 mg once daily
B. Rivaroxaban 20 mg daily
C. Warfarin with time in the therapeutic range > 70%
D. Dabigatran 75 mg twice daily
E. Apixaban 5 mg twice daily
Answer: C
Subject: Electrolyte Acid-Base Disorders
A 67-year-old woman with chronic systolic heart failure and stage 3a:A1 CKD is evaluated for persistent congestive symptoms despite recent initiation of furosemide 2 weeks ago. During the ﬁrst week after initiation of furosemide, the weight decreased by 4 kg. Over the past week, however, her weight has remained stable, and she continues to have orthopnea and dyspnea on exertion. Medications are furosemide at 40 mg daily, lisinopril at 30 mg daily, and spironolactone at 25 mg daily. On physical examination, the BP is 115/80 mmHg, and the pulse rate is 68/min. The jugular venous pressure is 8 cm H2O. There are bibasilar crackles and 2+ leg edema. Laboratory studies show sodium of 134 mEq/L, potassium of 5.0 mEq/L, chloride of 96 mEq/L, total CO2 of 28 mmol/L, BUN of 34 mg/dl, and creatinine of 2.1 mg/dl (increased from 1.8 mg/dl 2 weeks ago). A urinalysis shows no protein, cells, or casts..
Question: In addition to ongoing assessment of this woman’s serum electrolytes and kidney function, which ONE of the following is the MOST appropriate next step in management?
A. Discontinue furosemide
B. Discontinue lisinopril
C. Increase furosemide to 80 mg/d
D. Increase furosemide to 40 mg twice daily
Answer: D
Subject: Electrolyte Acid-Base Disorders
A 72-year-old man with recently diagnosed non-small cell lung cancer is referred for evaluation of asymptomatic hyponatremia. He was recently found to have a serum sodium level of 125 mEq/L, despite  adherence to 1.5 L/d of ﬂuid restriction. Review of the medical record indicates that his serum sodium was 139 mEq/L on laboratory studies obtained 1 year ago. He is not on any medications. On physical examination, he is alert and oriented. The BP is 138/82 mmHg, and the pulse is 70/min. He has no edema. The remainder of the examination is unremarkable. Laboratory studies show sodium of 125 mEq/L, potassium of 4.9 mEq/L, chloride of 91 mEq/L, total CO2 of 24 mmol/L, BUN of 7 mg/dl, and creatinine of 0.8 mg/dl. His urinary studies show osmolality of 560 mOsm/kg, sodium of 80 mEq/L, and potassium of 60 mEq/L..
Question: In addition to continued ﬂuid restriction, which ONE of the following is the BEST initial treatment for this patient?
A. Decrease water intake further to 1.0 L/d
B. Decrease water intake further to 750 ml/d
C. 100 ml 3% saline intravenously over 6 hours
D. Furosemide at 40 mg/d plus sodium chloride tablets at 1 g three times daily
Answer: D