SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Hypertension

A 44-year-old woman has recently received a diagnosis of hypertension. She has no other comorbidities. Her BP has been poorly controlled, and it has been difﬁcult to ensure compliance with medications. Her BP is 168/ 98 mm Hg, and she has no edema. The rest of her physical examination results are unremarkable. The results of a workup for secondary causes of hypertension have been negative. In addition to lifestyle modiﬁcation, you urge her to monitor her BP at home twice daily and transmit her readings every week. She thinks this is a lot of extra work and wants to know if this is worth it and whether it will improve her BP..
Question: Which ONE of the following is the MOST accurate regarding use of home BP monitoring for care of patients with hypertension?
1. A recent study of physician perspectives showed high level of implementation of home blood pressure monitoring in routine care.
2. Use of home BP monitoring with use of pharmacist/healthcare provider feedback has been shown to be effective but more costly
3. Use of home BP monitoring with use of pharmacist/healthcare provider feedback has been shown to be ineffective and more costly
4. Use of home BP monitoring with transmission regularly for feedback to healthcare provider and adjustment of medications has been shown to signiﬁcantly improve BP
Answer: D
Subject: Hypertension

A 38-year-old man with hypertension and hyperlipidemia has issues with compliance and forgets to take his medications on occasion. His BP control has been variable. He has no other health issues. He is complaint with lifestyle modiﬁcations..
Question: He is currently taking losartan 50 mg daily, hydrochlorothiazide 12.5 mg daily, and amlodipine 2.5 mg at 1
Which ONE of the following is the MOST appropriate next step in management?
1. Switch to triple combination therapy to improve BP control and compliance
2. Increase amlodipine to 5 mg daily and continue other medications
3. Add spironolactone 12.5 mg daily
4. Add carvedilol 12.5 mg twice daily
5. No change in therapy
Answer: A
Subject: Hypertension

A 63-year-old woman is followed up in your clinic for hypertension. After 3 years clinic visits, her ofﬁce BP remains poorly controlled and largely unchanged at 160/80 mm Hg despite escalation of her antihypertensive regimen, which now includes maximal doses of candesartan, amlodipine, and hydrochlorothiazide. Owing to concerns over medication adherence, you proceed with directly observed therapy to assess her BP control. Two hours after direct observation of her taking her medications, her ofﬁce BP is 130/80 mm Hg..
Question: Which of the following is the best description of this patient’s condition?
1. Resistant hypertension
2. Pseudoresistant hypertension
3. Refractory hypertension
4. Secondary hypertension
Answer: B
Subject: Hypertension

A 45-year-old man is referred to your clinic for poorly controlled BP despite treatment with perindopril, amlodipine, and chlorthalidone. His ofﬁce BP is 155/ 85 mm Hg; however, he states that his home blood pressure readings are much better at 125/80 mm Hg. He has been told in the past that he has white-coat syndrome..
Question: Which of the following is the best approach to evaluate for the white-coat effect?
1. Ask the patient to maintain a daily log of home BP readings
2. Repeat the resting BP 10 minutes later while the patient is left unattended
3. Calibrate the home BP cuff against the ofﬁce BP cuff
4. Arrange for a 24-hour ambulatory BP monitor
Answer: D
Subject: Hypertension

A 50-year-old otherwise healthy woman is referred to you for hypertension (170/100 mm Hg) plus spontaneous hypokalemia (3.1 mmol/L). Plasma renin activity is < 1 ng/ml per hour, and plasma aldosterone concentration is 35 ng/dl. Dynamic conﬁrmatory testing via oral sodium loading conﬁrms the diagnosis of primary aldosteronism. A CT scan of the adrenal gland shows a left adrenal nodule..
Question: What is best next step in the treatment of this patient?
1. Order an adrenal MRI
2. Order adrenal vein sampling
3. Treat with lifelong spironolactone
4. Proceed with surgical adrenalectomy
Answer: B
Subject: Hypertension

A 70-year-old man who is a former smoker with coronary artery disease is referred to you from his primary care provider for increasing BP over the past year. Before this, his BP was well controlled with metoprolol and lisinopril. He has now required the additions of indapamide and amlodipine to maintain his BP in a normal range (currently 130/80 mm Hg). His kidney function remains normal. Out of concern for renovascular disease, his primary care provider obtained CT angiography, which demonstrated a 75% stenosis of the right proximal renal artery. The primary care provider wants your opinion on how to proceed given this ﬁnding..
Question: What would be the MOST appropriate treatment approach at this stage?
1. Order duplex ultrasonography
2. Arrange for renal arteriography
3. Proceed with percutaneous transluminal renal angioplasty and stent placement
4. Maintain current treatment
Answer: D
Subject: Hypertension

A 51-year-old woman presents in referral to your clinic with elevated BP along with periodic episodes of headache, palpitations, and diaphoresis. Her ofﬁce BP is 135/85 mm Hg on candesartan and amlodipine. Based on these symptoms, you order plasma free metanephrines, for which the metanephrine level is normal but the normetanephrine level is 30% above the upper limit of normal..
Question: What is the BEST next step to evaluate for pheochromocytoma/paraganglioma in this patient?
1. Repeat plasma free metanephrines
2. CT scan of the adrenal glands
3. MIBG scintigraphy
4. Clonidine suppression testing
Answer: A
Subject: Hypertension

A 63-year-old man with stable nonproteinuric stage 4 CKD (eGFR 25 ml/min per 1.73 m2) returns to see you in clinic with an elevated ofﬁce BP of 150/90 mm Hg. He also has new mild edema in his feet and ankles. He is currently treated with perindopril and amlodipine and maintains a low-sodium diet. You would like to prescribe him a diuretic..
Question: Which of the following is FALSE regarding diuretics in this scenario?
1. Loop diuretics are effective at lowering BP and reducing ﬂuid overload in advanced CKD
2. Thiazide diuretics are ineffective in patients with eGFR < 30 ml/min per 1.73 m2
3. Potassium-sparing diuretics should be used only with caution
4. Close monitoring of serum electrolytes and kidney function should be performed after starting or adjusting the dose of diuretics
Answer: B
Subject: Hypertension

A 58-year-old woman with longstanding hypertension returns to see you. Her BP is 155/95 mm Hg despite maximal doses of amlodipine, candesartan, and chlorthalidone. Her kidney function remains normal. Evaluation for secondary causes of hypertension has been unrevealing, and she appears to be compliant with her medications and your lifestyle recommendations. You would like to add an additional antihypertensive medication to help control her BP..
Question: Which ONE antihypertensive medication would be BEST to add-on to her current regimen?
1. Doxazosin
2. Hydralazine
3. Labetalol
4. Spironolactone
Answer: D
Subject: Hypertension

A 35-year-old woman is referred for evaluation of hypertension that developed at 27 weeks’ gestation. She has no signiﬁcant medical history, and her condition during prior prenatal visits, including BP measurements were normal. Recent onset of hypertension was conﬁrmed by home readings. Her BP during the visit is 149/89 mm Hg. The result of screening urinalysis was negative for hematuria and proteinuria. Urine protein-to-creatinine ratio was 0.15 mg/mg. Laboratory evaluation demonstrated creatinine of 0.6 mg/dl, normal blood counts including platelets, and normal liver function test results, aspartate aminotransferase and alanine aminotransferase. Serum levels of fms-like tyrosine kinase and placental growth factor ratios were within normal for gestational age..
Question: All of the following support gestational hypertension rather than preeclampsia EXCEPT:
1. Absence of increased proteinuria
2. Onset of hypertension after 20 weeks’ gestation
3. Normal serum creatinine, platelet count and liver function tests.
4. Normal values and ratios of angiogenic markers, fms-like tyrosine kinase and placental growth factor
Answer: B
Subject: Hypertension

A 41-year-old woman is noted to be hypertensive at her ﬁrst prenatal appointment at 12 weeks. She describes being mildly hypertensive during her prior pregnancy 6 years ago, but she has not been followed up by a physician since then. She states that both her parents have hypertension. She further notes that she has measured her BP at home using her mother’s BP cuff, and it runs 139/92 mm Hg. Her BMI is 33, and her examination results are otherwise unremarkable. Laboratory investigation results, including urinalysis, protein-to-creatinine ratio, and serum creatinine, are normal..
Question: What is the MOST likely diagnosis?
1. Essential hypertension
2. Gestational hypertension
3. Preeclampsia
4. White-coat hypertension
Answer: A
Subject: Hypertension

A 29-year-old woman presents at 16 weeks’ gestation. She has a history of type 2 DM, hypertension, and CKD, with eGFR 42 ml/min per 1.73 m2. She has a history of prior pregnancy complicated by preeclampsia. She asks you, what is her risk having preeclampsia again?.
Question: Which of the following statements is the MOST accurate?
1. Her risk of preeclampsia is high, primarily because of her history of preeclampsia and hypertension; type 2 DM and CKD also contribute to risk but to a lesser degree than hypertension and prior preeclampsia
2. CKD confers the highest risk of preeclampsia; all other factors play a lesser role including history of preeclampsia
3. She is not at high risk for preeclampsia because she is < 30 years of age
4. Type 2 DM, CKD, hypertension, and prior history of preeclampsia all contribute equally to risk of preeclampsia
Answer: A
Subject: Hypertension

A 39-year-old woman at 16 weeks’ gestation presents with BP 142/86 mm Hg. She has a history of type 2 DM and hypertension, and has stable protein excretion for the past 2 years of approximately 1 gram per day. She is taking losartan 100 mg daily..
Question: According to the most recent data, what is the BEST approach to treating her hypertension?
1. Continue losartan because her BP is well controlled.
2. Stop the losartan and start labetalol
3. Continue losartan but add another agent to target BP < 140/90 mm Hg
4. Stop the losartan and add a calcium channel blocker
Answer: B
Subject: Hypertension

A 29-year-old woman presents at 13 weeks of her second pregnancy. During her ﬁrst pregnancy, she was treated with 81 mg/day of aspirin, based on her history of chronic hypertension. Her BP was well controlled on labetalol, but she went into preterm labor and delivered at 35 weeks’ gestation. Now, she presents for counseling about whether she needs aspirin again in this pregnancy. Her BP is 132/84 mm Hg on methyldopa 250 mg orally three times daily. This medication was started in place of losartan, which she took before pregnancy..
Question: Which ONE of the following is the best advice for this woman?
1. The woman should be prescribed 150 mg/day of aspirin to be taken from 20 weeks’ until 36 weeks’ gestation
2. The woman should understand that aspirin may not be effective for preeclampsia prevention in women with chronic hypertension, but if prescribed, it should be started before 16 weeks’ gestation
3. This woman did not experience preeclampsia in her ﬁrst pregnancy, and so the risk of preeclampsia in this pregnancy is very low, despite the his-tory of chronic hypertension
4. Aspirin is associated with no increased risk of bleeding in pregnancy
Answer: B
Subject: Primary and Secondary Glomerular Diseases

A 23-year-old man presents for evaluation of edema. He is found to have 6.2 g of protein over 24 hours. Serum albumin is 2.3 g/dl, and serum creatinine is 0.9 mg/dl. The patient undergoes a kidney biopsy that shows normal light microscopy. The IF shows evidence of ﬁne punctate staining for IgG. The EM results are pending..
Question: What is the MOST likely explanation for the ﬁnding on the immunoﬂuorescence?
1. Nonspeciﬁc entrapment of IgG in the glomeruli
2. Presence of anti-PLA2R antibody
3. Presence of antinephrin antibody
4. Presence of anti–NELL-1 antibody
Answer: C
Subject: Primary and Secondary Glomerular Diseases

A 43-year-old woman is seen in your clinic for evaluation of proteinuria. Her serum creatinine is 2.5 mg/dl, which has been slowly increasing over the past 10 years. Her serum albumin is 4.2 mg/dl. Her 24-hour urinary protein shows 5.6 g of protein (up from 4.2 g/24 h last year). Her renal US shows two kidneys about 11 cm each in size. Her only other medical his-tory is hypertension, for which she is on losartan 100 mg daily with BP averaging about 120/75 mm Hg. Her body mass index (BMI) is normal, and she has no known family history of kidney disease. A kidney biopsy from 5 years ago was consistent with FSGS on the basis of light microscopy with negative immunoﬂuorescence and EM that showed segmental foot process effacement. She has never received immunosuppressive therapy..
Question: What is the next BEST step in management of this patient?
1. Add an antihypertensive agent to tighten her BP control
2. Initiate a trial of prednisone therapy
3. Repeat her kidney biopsy
4. Send for genetic testing
Answer: D
Subject: Primary and Secondary Glomerular Diseases

A 33-year-old woman is found to have proteinuria on insurance examination. Additional workup reveals serum creatinine of 0.7 mg/dl and serum albumin of 3.3 g/dl. She has 4.2 g of protein per 24 hours. She undergoes a kidney biopsy that is consistent with membranous nephropathy (MN). PLA2R staining on biopsy is negative, but the biopsy stained positive for exostosin 1/exostosin 2 (EXT1/EXT2)..
Question: Which of the following is MOST correct with regard to EXT1/EXT2 MN?
1. The patients typically have a poor prognosis and are more likely to progress to ESKD
2. EXT1/EXT2 is seen more commonly in patients with underlying autoimmune diseases
3. EXT1/EXT2 is commonly associated with an underlying malignancy
4. EXT1/EXT2 is more common in pediatric population
Answer: B
Subject: Primary and Secondary Glomerular Diseases

A 56-year-old man is referred for a second opinion with regard to management of FSGS. He was diagnosed a year ago after presenting with creatinine of 1.5 mg/dl, serum albumin of 3.9 g/dl, and proteinuria of 3.9 g/24 h. His biopsy showed FSGS with 15% interstitial ﬁbrosis and tubular atrophy; electron microscopy showed segmental foot process effacement. He was initiated on lisinopril; it was up titrated to 40 mg daily, which he has been tolerating. He is also on amlodipine 5 mg daily and metoprolol 50 mg twice daily. His BP in the ofﬁce is 115/72 mm Hg, and heart rate is 68 beats per minute. Creatinine is 1.7 mg/dl, albumin is 3.8 mg/dl, and proteinuria is down to 2.3 g/24 h. His BMI is 39 kg/m2, and he has sleep apnea that is treated with CPAP. He has no known family history of FSGS..
Question: Which of the following is the next BEST step?
1. Initiate an SGLT2 inhibitor
2. Make no changes
3. Refer for genetic testing
4. Add ARB to help lower proteinuria
Answer: A
Subject: Primary and Secondary Glomerular Diseases

A 53-year-old man is referred by his primary care provider for assessment of nephrotic syndrome. He recently experienced weight gain and ankle edema. He was found to have 3+ proteinuria and increased creatinine to 1.8 mg/dl, from a prior baseline of 0.8 mg/dl. His 24-hour urine collection shows 9.8 g proteinuria, and his PLA2R antibody is positive at 93 RU/ml. A kidney biopsy is performed that shows MN, and PLA2R staining is also positive..
Question: When considering a treatment plan, which of the following is MOST correct?
1. Holding immunosuppressive therapy, initiating an ACE-I, and monitoring PLA2R change are the ﬁrst steps in managing all patients with MN
2. Cyclophosphamide in combination with corticosteroids has been shown to be superior to rituximab on the basis of the RI-CYCLO trial
3. In the MENTOR study, patients treated with rituximab and cyclosporin had similar eGFR at 24-month follow-up
4. In the MENTOR study, those treated with rituximab had higher rates of remission at 24-month follow-up
Answer: D
Subject: Primary and Secondary Glomerular Diseases

A 62-year-old man is seen in your clinic for evaluation of nephrotic syndrome. Workup reveals serum creatinine of 0.8 mg/dl, serum albumin of 3.2 g/dl, and 3.4 g/24 h of proteinuria. BP is 133/82 mm Hg. Additional serologic workup reveals that PLA2R antibody is positive at 35 RU/ml..
Question: Which of the following is the next BEST step in man-aging this patient?
1. Obtain a kidney biopsy
2. Initiate immunosuppressive therapy with a calcineurin inhibitor
3. Initiate immunosuppressive therapy with rituximab
4. Initiate an ACE-I
Answer: D
Subject: Primary and Secondary Glomerular Diseases

A 34-year-old woman is referred for evaluation of new-onset edema. She has noted increasing lower-extremity edema and weight gain over the last 2 weeks. Her history is signiﬁcant for morbid obesity with BMI of 37 kg/m2 and diabetes mellitus type 2, with the most recent A1c being 7.2% on metformin therapy. Her creatinine is 0.7 mg/dl, serum albumin is 2.2 g/dl, and 24 hours show 8.8 g/24 h of protein. She undergoes a kidney biopsy that showed normal appearance on light microscopy but diffuse foot process effacement on electron microscopy..
Question: Regarding the management of minimal change disease, which of the following is MOST correct?
1. In patients with contraindication to glucocorticoids, calcineurin inhibitors would be an appropriate ﬁrst line of therapy
2. Rituximab has been shown to be beneﬁcial in those who fail to respond to steroid or calcineurin inhibitor therapy
3. Calcineurin inhibitor is associated with a lower rate of remission compared with corticosteroids
4. When compared with a tacrolimus-based treatment protocol, treatment with rituximab was associated with a greater cumulative steroid dose
Answer: A
Subject: Primary and Secondary Glomerular Diseases

You are asked to give a second opinion on a 67-year-old man with biopsy-demonstrated IgA nephropathy with hematuria on urinalysis. His creatinine is 0.9 mg/dl. He has microalbuminuria of 600 mg/g creatinine..
Question: BP is 119/80 mm Hg on losartan 100 mg.
On the basis of current data, what is the next BEST course of treatment?
1. Add dapagliﬂozin 10 mg/d
2. No additional therapy is needed; the normal eGFR and proteinuria < 1 g suggest that he will not progress
3. Add chlorthalidone 25 mg daily to target lower BP
4. Add lisinopril 10 mg/d
Answer: A
Subject: Primary and Secondary Glomerular Diseases

You are evaluating a 69-year-old man for hematuria and proteinuria approximately 1.5 g/d. eGFR is stable at 72 ml/min per 1.73 m2. Biopsy demonstrates IgA nephropathy with an MEST score T0. He has a history of diabetes, hypertension, and obesity, with a BMI of 32. He is on lisinopril 40 mg/d and chlorthalidone 25 mg/d, with BP of 124/80 mm Hg. You add dapagliﬂozin. Six months later, his eGFR is still 70 ml/min per 1.73 m2, but his proteinuria has increased to 2.4 g/d..
Question: Which of the following statements is MOST accurate?
1. The 2021 Kidney Disease Improving Global Out-comes (KDIGO) guidelines recommend glucocorticoids for all patients with IgA nephropathy who have high-grade proteinuria after a trial of nonimmunosuppressive therapy
2. Rituximab reduces proteinuria in patients with IgA nephropathy and should be used rather than glucocorticoids
3. Glucocorticoids have not been shown to be effective in preventing decline in GFR in patients with IgA nephropathy
4. Glucocorticoids reduce the risk of progression of kidney disease but are associated with an increased risk of adverse events; this risk is markedly attenuated, although still present, at lower doses (0.4 mg/kg per day)
Answer: D
Subject: Primary and Secondary Glomerular Diseases

You are evaluating a 30-year-old woman who was diagnosed with IgA nephropathy by biopsy 1 year ago. She initially presented with 1.2 g proteinuria and with eGFR of 94 mg/min per 1.73 m2. She was normo-tensive on initial presentation. She was treated with lisinopril, but uptitration of the dose has been limited by hypotension. Her insurance did not cover an SGLT2 inhibitor, and she was unable to afford an SGLT2 inhibitor. She now has approximately 900 mg protein with stable creatinine. She asks about the chances of ESKD..
Question: Which ONE of the following is MOST correct regarding the International IgAN Prediction Tool?
1. The tool is recommended by the 2021 KDIGO guidelines to inform whether or not the patient will respond to glucocorticoids
2. Clinical variables, such as proteinuria, but not histology inform the risk score
3. The tool was updated to more accurately predict risk with variables obtained 1–2 years after biopsy
4. The tool is expensive and requires sophisticated software
Answer: C
Subject: Primary and Secondary Glomerular Diseases

You are evaluating a 19-year-old man with increased creatinine of 1.9 mg/dl, hematuria, and proteinuria 1.2 g/d. He describes a ﬂu-like syndrome about 6 weeks ago. His grandfather died of ESKD, and he has two cousins, both living in Greece, who have undergone kidney transplantation. Tests for hepatitis are negative. ANCA, ANA, RF, and dsDNA are all negative. C3 is mildly low. Biopsy demonstrates a diffuse proliferative pattern. Immunoﬂuorescence reveals both C3 and IgG deposition..
Question: Which ONE of the following statements is MOST correct?
1. Although exceptions may occur, immunoﬂuorescence microscopy generally shows both IgG and C3 deposits in postinfectious GN but not C3GN
2. Although exceptions may occur, immunoﬂuorescence microscopy generally shows both IgG and C3 deposits in C3GN but not postinfectious GN
3. Light microscopy can distinguish between C3GN and postinfectious GN
4. Genetic screen would be of little utility in distinguishing postinfectious from C3GN
Answer: A
Subject: Primary and Secondary Glomerular Diseases

A 62-year-old man presents with creatinine 1.7 mg/dl, proteinuria 2.5 g, and hematuria. Review of the chart shows multiple urinalyses in the past that were negative for hematuria and proteinuria. Laboratory evaluations, including ANCA, ANA, anti-GBM, hepatitis B virus, and hepatitis C virus (HCV), are negative or normal. C3 is mildly low, and C4 is normal. Biopsy demonstrates a membranoproliferative pattern of histology. Immuno-ﬂuorescence shows 3+ C3 deposition and no Ig. Free kappa and lambda-light chains are elevated, with a kappa-lambda ratio of 12. Family history is negative for ESKD or hematuria..
Question: Which ONE of the following statements is MOST correct?
1. Among patients with C3GN, monoclonal gammopathy is less common among patients older than 50
2. The absence of IgG on biopsy excludes monoclonal gammopathy–associated C3GN
3. Low C3 strongly suggests heritable complement disorder
4. C3GN in this patient is likely caused by an acquired autoantibody to components of the alter-native complement pathway
Answer: D
Subject: Primary and Secondary Glomerular Diseases

You are evaluating a previously healthy 23-year-old woman who initially presented with hematuria and proteinuria during a brief hospitalization for coronavirus disease 2019 (COVID-19). BP is 135/89 mm Hg, and examination is otherwise unremarkable. Her creatinine is 0.95 mg/d; eGFR 588 ml/min per 1.73 m2. Urine protein measured over 24 hours is 3.6g/24h.SerumC3 is mildly low. Kidney biopsy shows a membranoproliferative pattern with marked C3 deposition and virtually no Ig deposition by immunoﬂuorescence microscopy..
Question: Which of the following variables BEST predicts her risk of developing ESKD?
1. The presence of electron-dense intramembranous deposits on electron microscopy
2. Low C3
3. A high chronicity score
4. BP
Answer: C