SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Pregnancy and Kidney Disease
A 32-year-old woman with type 1 diabetes mellitus, hypertension, and hyperlipidemia desires pregnancy. She asks for your advice about how to achieve the most optimal pregnancy outcome. Her BP has been well controlled on enalapril and nifedipine. Other medications include subcutaneous injections of insulin and simvastatin. She has been adherent with her medications and physician visits. On physical examination, the body mass index (BMI) is 28 kg/m2, and the BP is 122/72 mmHg. The remainder of the examination is unremarkable. Laboratory studies show a serum creatinine level of 1.2 mg/dl, a hemoglobin A1c of 7.8%, a total serum cholesterol level of 176 mg/dl, and an albumin-to-creatinine ratio of 1526 mg/g..
Question: Which ONE of the following would you advise to optimize maternal and fetal outcomes?
A. Make no changes to the current regimen
B. Target the hemoglobin A1c to < 7.0% before conception
C. Stop enalapril at least 2 months before conception
D. Hold enalapril for the duration of breastfeeding
Answer: B
Subject: Pregnancy and Kidney Disease
A 35-year-old woman with lupus nephritis and chronic hypertension is evaluated at 32 weeks of gestation for worsening kidney function. Her lupus nephritis was in full remission at the time of conception (off immunosuppressive therapy). Her current medications include nifedipine and labetalol. Her BP has increased from 132/68 to 150/86 mmHg. The physical examination shows no rash or synovitis. There is 1+ pitting pretibial edema. Laboratory studies show that her serum creatinine level has risen from 0.5 mg/dl in the first trimester to 1.0 mg/dl. The alanine aminotransferase (ALT) level is 236 U/L (reference range 0–35), and the aspartate aminotransferase (AST) level is 342 U/L (reference range 0–35). The serum C3 is 82 mg/dl (reference range 55– 120), and the serum C4 is 26 mg/dl (reference range 15–48). The leukocyte count is 5600/µl, the hemoglobin is 8.6 g/dl, and the platelet count is 76,000/µl. A 24-hour urine collection shows 3260 mg protein, increased from 260 mg/d in the first trimester..
Question: Which ONE of the following laboratory results is MOST suggestive of the syndrome of hemolysis, elevated liver enzymes, and low platelets rather than worsening lupus nephritis?
A. Low hemoglobin
B. Low platelet count
C. Increased AST and ALT
D. Increasing proteinuria
Answer: C
Subject: Pregnancy and Kidney Disease
A 38-year-old woman with chronic hypertension who is 26-weeks pregnant asks you if she should liberalize or more strictly control her BP to prevent adverse pregnancy outcomes. Her current medications are labetalol at 300 mg twice daily and a prenatal vitamin. The BP is 128/85 mmHg, and she has 1+ bilateral ankle edema. Fetal growth is appropriate for gestational age..
Question: Which ONE of the following is the MOST appropriate management?
A. Implement a 2-g sodium-restricted diet
B. Add methyldopa
C. Stop labetalol
D. Add hydrochlorothiazide
E. Make no changes to the current regimen
Answer: E
Subject: Pregnancy and Kidney Disease
A 38-year-old woman, gravida 4, para 3, is evaluated at 37 weeks of gestation for new-onset hypertension and fetal bradycardia. She complains of a headache and vague right upper quadrant abdominal discomfort. On physical examination, the BP is 165/110 mmHg. A repeat BP reading 4 hours later is 162/112 mmHg. There is 1+ leg edema. Laboratory studies show serum creatinine of 1.1 mg/dl, albumin of 3.4 g/dl, leukocyte count of 7600/µl, hemoglobin of 10 g/dl, and platelets of 96,000/µl. Urinalysis shows 3+ protein, 1+ blood, and two to five dysmorphic erythrocytes per high-power field. The urine protein-to-creatinine ratio is 2100 mg/g. Serologic studies show positive antinuclear antibody titers of  > 1:640 and negative double–stranded DNA titers (dsDNA)..
Question: In addition to admission for fetal monitoring, which ONE of the following is the MOST appropriate management recommendation?
A. Induction of labor and delivery
B. Kidney biopsy now
C. Pulse methylprednisolone at 500 mg intravenously once daily for 3 days
D. Antenatal betamethasone for fetal lung maturation
Answer: A
Subject: Pregnancy and Kidney Disease
A 38-year-old woman is evaluated in the immediate postpartum period after induction of labor and normal vaginal delivery for preeclampsia with severe features. Her reflexes remain brisk, and she complains of a slight headache. Her medications include intravenous magnesium, intravenous labetalol, and oral nifedipine. On physical examination, the BP is 150/90 mmHg. There is 1+ pretibial edema. The remainder of the examination is unremarkable. Laboratory studies show a serum creatinine of 1.2 mg/dl..
Question: Which ONE of the following is the MOST appropriate management?
A. Discontinue intravenous magnesium, intravenous labetalol, and oral nifedipine
B. Discontinue intravenous magnesium but continue intravenous labetalol and oral nifedipine
C. Discontinue intravenous magnesium and initiate furosemide
D. Continue intravenous magnesium and transition to oral antihypertensive medications
Answer: D
Subject: Pregnancy and Kidney Disease
A 32-year-old woman with autosomal dominant polycystic kidney disease and chronic hypertension who is 8-weeks pregnant is referred for management of hypertension. Her BP had been previously well controlled on losartan at 50 mg daily. She discontinued it when she decided to become pregnant several months ago. Her office BP is 162/95 mmHg, and her home BP readings have been 150–160/90–95 mmHg. The remainder of the examination is normal. Her serum electrolytes, creatinine, and urinalysis are normal..
Question: Which ONE of the following is the MOST appropriate management?
A. Labetalol
B. Continued observation
C. Lisinopril
D. Spironolactone
E. Atenolol
Answer: A
Subject: Pregnancy and Kidney Disease
A 37-year-old woman, gravida 2, para 1, is seen for chronic hypertension at 8-weeks gestation. She has a history of preeclampsia complicating her first pregnancy 3 years ago. She says that she has been eating well and adheres to a well-balanced Western diet. Her medications are labetalol and a prenatal vitamin. A physical examination shows that the BMI is 32 kg/m2. The BP is 130/80 mmHg. There is no edema. She is concerned that she may develop preeclampsia again and asks for advice about how to prevent it from occurring..
Question: Which ONE of the following is the MOST appropriate intervention to reduce her risk of preeclampsia?
A. Supplemental vitamins C and E
B. Weight loss targeting a BMI of < 30 kg/m2
C. Aspirin at 81 mg daily
D. Calcium carbonate at 600 mg twice daily
Answer: C
Subject: Pregnancy and Kidney Disease
A 32-year-old woman is seen in follow-up one month after an initial episode of preeclampsia. She delivered at 34-weeks gestation, and her baby weighed 1063 g. She currently is on no medications and has no other past medical history. Her BP is 122/78 mmHg, and the remainder of her physical examination is normal. The serum creatinine level is 0.6 mg/dl. She asks about the effect of preeclampsia on her future health..
Question: Which ONE of the following would you advise regarding the effect of her prior episode of preeclampsia on her long-term health?
A. It will have no effect
B. It increases the risk of hyperthyroidism
C. It increases the risk of cardiovascular disease
D. She has a 5% risk of developing ESRD over the next 20 years
E. It increases her risk for endometrial cancer
Answer: C
Subject: Pregnancy and Kidney Disease
A 19-year-old woman with a history of vesicoureteral reflux and frequent urinary tract infections during childhood is evaluated at 12 weeks of gestation. Her last urinary tract infection was at age 6 years old. Her physical examination is normal. The serum creatinine level is 0.4 mg/dl. The urinalysis is normal. An intravenous urogram at age 6 years old showed no scarring. A recent kidney ultrasound is normal. She asks about the effect of her history of vesicoureteral reflux on her pregnancy..
Question: Which ONE of the following would you advise regarding the effect of vesicoureteric reflux on her pregnancy?
A. She is at increased risk for preeclampsia
B. She is at increased risk of urinary tract infection
C. She is at increased risk for gestational hypertension
D. There is an increased risk for low birth weight
Answer: B
Subject: Pregnancy and Kidney Disease
A 20-year-old woman at 25-weeks gestation is evaluated for AKI. She has had nausea, vomiting, and abdominal pain for 2 days. On physical examination, she is afebrile and in moderate distress from the abdominal pain. The BP is 140/80 mmHg, and the pulse rate is 130/min. She has scleral icterus. The abdomen is gravid, with mild diffuse tenderness to palpation. Laboratory studies show sodium of 140 mEq/L, potassium of 3.2 mEq/L, chloride of 106 mEq/L, total CO2 of 12 mmol/L, BUN of 26 mg/ dl, creatinine of 1.6 mg/dl, and glucose of 34 mg/dl. The AST is 1256 U/L, the ALT is 1540 U/L, the total bilirubin is 2.5 mg/dl (direct bilirubin 1.6 mg/dl), the alkaline phosphatase is 249 U/L, the albumin is 3.5 g/dl, and the international normalized ratio is 2.68. The leukocyte count is 20,000/µl, the hemoglobin is 10.1 g/dl, and the platelet count is 102,000/µl. Serologic studies for hepatitis A, B, and C and autoimmune disorders are negative. The urinalysis shows 1+ protein. An abdominal ultrasound shows hepatomegaly with patent hepatic vasculature and normal portal flow direction on Doppler..
Question: Which ONE of the following is the MOST likely diagnosis?
A. Budd–Chiari syndrome
B. Syndrome of hemolysis, elevated liver enzymes, and low platelets
C. Thrombotic thrombocytopenic purpura
D. Acute fatty liver of pregnancy (AFLP)
Answer: D
Subject: Pregnancy and Kidney Disease
A 27-year-old woman, para 1, undergoes emergent cesarean section at 32 weeks for fetal distress and bradycardia. She was being followed weekly for poor fetal growth. The surgery is complicated by hemorrhage, and significant pooling of blood is noted in the pelvis. The BP rises from 119/69 to 150/97 mmHg. The pulmonary and cardiac examinations are normal. Admission lab tests:  Creatinine 0.4 mg/dl, AST 13 U/L, ALT 12 U/L,  Hemoglobin 12.2  g/dl,  Platelet count 215,000 per ml, Prothrombin time 12.2/1.0 s/internationalnormalized ratio. Postoperative lab tests were:  Creatinine 1.7 mg/dl, AST 1554 U/L, ALT 486 U/L,  Hemoglobin 8.3  g/dl,  Platelet count 32,000 per ml, Prothrombin time 13.3/1.3 s/international normalized ratio. The urine output is 50 ml/h. The peripheral blood smear reveals one to two schistocytes per high power field (< 1%) as well as decreased and giant platelets. The urinalysis shows trace protein, 1+ blood, and hyaline casts..
Question: Which ONE of the following is the MOST appropriate management?
A. Transfuse platelets and packed red blood cells
B. Provide plasma Exchange
C. Eculizumab
D. Dexamethasone
E. Recombinant factor VIIa
Answer: A
Subject: Pregnancy and Kidney Disease
A 26-year-old woman is evaluated 2 months after recovering from AFLP. She is interested in pursuing another pregnancy, but is concerned about her risk of recurrent AFLP..
Question: Detection of an abnormality in which ONE of the following is MOST likely to predict her risk for recurrent AFLP?
A. A disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 activity
B. Long–chain 3-hydroxyl CoA dehydrogenase
C. Factor H activity
D. Multidrug resistance P-glycoprotein 3
E. Palmitoyltransferase 1 deficiency
Answer: B
Subject: Pregnancy and Kidney Disease
A 27-year-old woman, gravida 1, para 0, develops new-onset hypertension at 35-weeks gestation. She is asymptomatic. On physical examination, she is not in acute distress. The BP is 146/90 mmHg. There is trace pretibial edema. The urinalysis shows 2+ protein. Laboratory studies show serum creatinine of 0.8 mg/dl, AST of 12 U/L (reference range 0–35), ALT of 25 U/L (reference range 0–35), leukocyte count of 7,400/µl, hemoglobin of 9.8 g/dl, and platelet count of 138,000/ml. Fetal testing is reassuring..
Question: Which ONE of the following is the MOST appropriate management?
A. Kidney biopsy
B. Immediate delivery (within 24 hours)
C. Observation with expectant medical management
D. Intravenous magnesium
Answer: C
Subject: Pregnancy and Kidney Disease
Question: Question 2506:
Which ONE of the following physiologic changes occurs by the end of the third trimester of pregnancy?
A. GFR is decreased by 10% compared to pre-pregnancy levels
B. GFR returns to pre-pregnancy levels
C. Renal blood flow is increased by 50% compared to pre-pregnancy levels
D. Renal blood flow returns to pre-pregnancy levels
Answer: D
Subject: Pregnancy and Kidney Disease
A 23-year-old woman, para 1, is evaluated at  27-weeks gestation for new-onset hypertension confirmed on repeat testing. She reports a new headache and visual scotomata for the past 2 days. A physical examination shows a BP of 154/94 mmHg that persists on repeat testing. The remainder of the examination is normal. The complete blood count, renal function, liver chemistries, and urinalysis are normal..
Question: Which ONE of the following is the MOST likely diagnosis?
A. Gestational hypertension
B. Migraine headache
C. Central venous thrombosis
D. Preeclampsia
Answer: D
Subject: Pregnancy and Kidney Disease
A 26-year-old woman is evaluated for AKI 1 day after successful induction of labor and delivery for preeclampsia. The serum creatinine level has risen from 1.1 to 1.3 mg/dl over the past 24 hours. The urine output has averaged 50 ml/h. She complains of weakness and nausea. Medications include labetalol and intravenous magnesium. On physical examination, she is lethargic and unable to sit up or stand because of weakness. Her weight is 70 kg. The BP is 110/60 mmHg. The pulse rate is 56/min. The cardiac and pulmonary examinations are normal. There is 1+ peripheral edema. The neurologic examination is significant for loss of deep tendon reflexes and generalized weakness graded at 3/5. Laboratory studies show sodium of 138 mEq/L, potassium of 5.6 mEq/L, chloride of 105 mEq/L, total CO2 of 19 mmol/L, BUN of 56 mg/dl, creatinine of 1.3 mg/dl, glucose of 92 mg/dl, calcium of 8.6 mg/dl, magnesium of 10.1 mg/dl, and phosphorus of 5.6 mg/dl. The urinalysis shows 1+ protein and occasional fine granular casts. An electrocardiogram shows sinus bradycardia at 54 beats per minute with a P to R interval of 0.24 seconds, increased QRS duration of 0.13 seconds, and an increased Q to T interval of 0.52 seconds..
Question: In addition to holding intravenous magnesium and labetalol and administering intravenous calcium, which ONE of the following is the MOST appropriate next step in management?
A. Intravenous normal saline plus furosemide
B. Urgent hemodialysis
C. No additional interventions
D. Intravenous insulin (1-U/kg bolus and 1–10 U/kg per hour as a continuous infusion)
Answer: A
Subject: Pregnancy and Kidney Disease
A 24-year-old woman with ESRD caused by diabetic kidney disease is found to be pregnant at 6-weeks gestation. She has been on hemodialysis for 5 years and is currently maintained on hemodialysis thrice weekly for 4 hours via a right radiocephalic arteriovenous fistula. Her equilibrated Kt/V is 1.3. Her monthly laboratory studies have been maintained in the desired range. Her BP is 130/80 mmHg, and the rest of the examination is unremarkable..
Question: Which ONE of the following dialysis strategies is MOST appropriate for this woman?
A. Continue current dialysis regimen
B. Hemodialysis totaling 16 hours/week
C. Hemodialysis totaling 20 hours/week
D. Hemodialysis totaling greater than or equal to 36 hours/week
Answer: D
Subject: Pregnancy and Kidney Disease
A 32-year-old woman, gravida 2, para 1, with a  31-week singleton gestation presents for a routine prenatal visit. She has no chronic medical problems, and her first pregnancy was uncomplicated, with a spontaneous vaginal delivery at 39-weeks gestation. Thus far, her BP readings have been normal during pregnancy. She reports a new headache starting 2 days ago. The BP is 135/82 mmHg, increased from 118/65 mmHg at her last visit. Urinalysis shows 1+ protein, which is new compared with prior urinalyses..
Question: Which ONE of the following features is most useful for excluding the diagnosis of preeclampsia within the next week?
A. The absence of edema
B. The absence of preeclampsia in her first pregnancy
C. A low soluble fms-like tyrosine kinase-1 to placental growth factor ratio
D. A normal serum uric acid
Answer: C
Subject: Pregnancy and Kidney Disease
A 35-year-old woman with chronic hypertension and type 2 diabetes mellitus is evaluated at 3 weeks postpartum. She did not require treatment for hypertension during pregnancy. However, her BP is now rising to pre-pregnancy levels. A physical examination shows a BP of 150/95 mmHg. There is trace pretibial edema. The remainder of the examination is normal. Laboratory studies show normal serum electrolytes, a serum creatinine level of 0.8 mg/dl, and a urine albumin-to-creatinine ratio of 800 mg/g. She is breastfeeding..
Question: Which ONE of the following is the MOST appropriate treatment?
A. Hydrochlorothiazide
B. Atenolol
C. Enalapril
D. Metoprolol
Answer: C
Subject: Pregnancy and Kidney Disease
A 23-year-old woman with ESRD secondary to reflux nephropathy who received a living donor kidney transplant 3 years ago is interested in becoming pregnant. Current medications are tacrolimus, mycophenolate mofetil, and amlodipine. Laboratory studies show a serum creatinine level of 0.8 mg/dl. The urine albumin-to-creatinine ratio is 15 mg/g..
Question: Which ONE of the following would you recommend?
A. She should have a cesarean section to avoid trauma to the graft during labor
B. She should start aspirin at 81 mg daily immediately after pregnancy is diagnosed
C. Switching mycophenolate mofetil to azathioprine should be delayed until immediately after pregnancy is diagnosed
D. She should start prednisone after delivery to prevent transplant rejection
Answer: B
Subject: Pregnancy and Kidney Disease
A 38-year-old woman with autosomal dominant polycystic kidney disease with a known mutation of PKD1 wishes to discuss possible pregnancy outcomes associated with preimplantation genetic testing (PGT). Her only medication is ramipril. Her BP is 120/70 mmHg. The rest of the physical examination is normal. Laboratory studies show that serum creatinine is 1.3 mg/dl. The albumin to-creatinine ratio is 50 mg/g..
Question: Which ONE of the following would you advise regarding the effect of PGT on her pregnancy outcomes?
A. The probability of achieving pregnancy is reduced compared with spontaneous conception
B. PGT is associated with an increased risk of fetal anomalies compared with routine assisted reproductive technology
C. PGT is associated with an increased risk of fetal growth restriction
D. PGT is associated with an increased risk of impaired cognitive development
Answer: A
Subject: Pregnancy and Kidney Disease
A 34-year-old woman who is a deceased donor kidney transplant recipient informs you that she is pregnant. An ultrasound examination confirms viability of a healthy fetus at 16-weeks gestation. Her immunosuppression includes mycophenolate mofetil and tacrolimus..
Question: In addition to repeat fetal imaging at 20–22 weeks, which ONE of the following is the MOST appropriate management?
A. No change in management
B. Stop mycophenolate mofetil and start azathioprine
C. Stop mycophenolate mofeil and start sirolimus
D. Stop mycophenolate mofetil and continue tacrolimus monotherapy
E. Immediate termination
Answer: B
Subject: Pregnancy and Kidney Disease
A 23-year-old woman who received a deceased donor kidney transplant 3 years ago is evaluated after a urine pregnancy test returned positive. She is at approximately 6-weeks gestation. She has a history of ESRD caused by lupus nephritis. Her immunosuppression was changed to tacrolimus, azathioprine, and prednisone 3 months ago after preconception counseling and planning. Her BP is 130/80 mmHg. The cardiac and pulmonary examinations are normal. The allograft is nontender and does not have a bruit. There is no peripheral edema. Laboratory studies show a stable serum creatinine level of 1.2 mg/dl and a glucose level of 96 mg/dl. A urinalysis is normal..
Question: Which ONE of the following additional investigations should be requested for this woman now (at 6-weeks gestation)?
A. Fetal cardiac monitoring
B. Echocardiography
C. Donor–specific antibody titers
D. Anti-Ro and anti-La antibodies
Answer: D
Subject: Pregnancy and Kidney Disease
A 38-year-old woman with type 2 diabetes mellitus, proteinuric CKD, and hypertension is evaluated at 36-weeks gestation for a 1-week history of increasing leg edema, dyspnea, and weight gain. On physical examination, she is in modest respiratory distress at rest, with a respiratory rate of 28/min. The oxygen saturation on ambient air is 86%, and it improves to 92% on 3 L/min oxygen via nasal cannula. The BP is 146/80 mmHg. The pulse is 120/min. The jugular venous pressure is elevated at 10 cm H2O. The lungs show bibasilar crackles. The abdomen is gravid. There is 2+ pitting pretibial edema. Laboratory studies show sodium of 132 mEq/L, potassium of 4.2 mEq/L, chloride of 105 mEq/L, total CO2 of 26 mmol/L, BUN of 15 mg/dl, creatinine of 1.1 mg/dl, glucose of 96 mg/dl, and albumin of 2.6 g/dl. The urine protein-to creatinine ratio is 3800 mg/g. An echocardiogram shows a global reduction in left ventricular systolic function with an left ventricular ejection fraction of 35%..
Question: In addition to admission for fetal monitoring and urgent delivery, which ONE of the following is the MOST appropriate management?
A. Begin intravenous insulin
B. Sodium restriction and compression stockings
C. Furosemide
D. Labetalol plus intravenous nitrates
Answer: C
Subject: Pregnancy and Kidney Disease
A 27-year-old kidney transplant recipient is evaluated at 33-weeks gestation for an asymptomatic rise in the serum creatinine. She developed ESRD because of reflux nephropathy, received a deceased donor kidney transplant 3 years ago, and has enjoyed excellent allograft function without acute rejection. The serum creatinine was noted to rise from 0.9 mg/dl 2 weeks ago to the current level of 1.3 mg/dl on surveillance studies. Medications include tacrolimus, prednisone, labetalol, aspirin, and a prenatal vitamin. The BP is 120/77 mmHg. She does not have edema. Laboratory studies show a normal complete blood count, a serum creatinine of 1.3 mg/dl, and a tacrolimus level of 10 ng/ml (confirmed on repeat testing) that increased from 5 ng/ml over the past 2 months. A urinalysis shows 1+ protein, negative blood, and two to three leukocytes per high power field. The urine protein-to-creatinine ratio is 305 mg/g. An ultrasound of the renal allograft shows mild hydronephrosis..
Question: Which ONE of the following is the MOST appropriate next step in management?
A. Nephrostomy tube placement
B. Reduce the tacrolimus dose
C. Pulse intravenous methylprednisolone
D. Dexamethasone followed by induction of labor and delivery
Answer: B
Subject: Pregnancy and Kidney Disease
A 29-year-old woman, gravida 1, para 0, with known Fabry disease is now 26-weeks pregnant. Before pregnancy, she was asymptomatic, except for occasional acroparesthesias. She has not received treatment with enzyme replacement therapy with α-galactosidase-β. Over the past 2 weeks, however, she has noted onset of worsening acroparesthesias. On physical examination, the BP is 108/75 mmHg. The neurologic examination shows diminished light–touch sensation in the legs. The remainder of the examination is normal. Laboratory studies show a serum creatinine of 0.9 mg/dl. The urine albumin-to-creatinine ratio is 360 mg/g, increased from 15 mg/g before pregnancy..
Question: Which ONE of the following is the MOST appropriate management?
A. No additional management
B. Enzyme replacement therapy
C. Gabapentin
D. Diltiazem
Answer: B