SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
A 23-year-old man is evaluated for anemia, renal insufﬁciency, and severe hypercalcemia (serum calcium of 13.2 mg/dl). His main hobby is weight-lifting, and he had injected parafﬁn oil into his chest, arms, and back for the past 3 years to enhance his physical appearance. After the last injection 6 months ago, he developed local infection requiring two courses of oral antibiotics. On physical examination, he is afebrile and in no acute distress. Many warm, minimally tender, dense nodules in the skin and subcutaneous tissue overlying the pectoral, trapezius, and biceps muscles are identiﬁed. The rest of his examination is normal. Laboratory studies reveal serum calcium of 13.2 mg/dl, phosphorus of 4.6 mg/dl, creatinine of 4.1 mg/dl, hemoglobin of 7.4 g/dL, PTH of 6 pg/ml (reference range 17–70 pg/ml), albumin of 4.3 g/dl, and total protein of 6.7 g/dl..
Question: A biopsy of the affected area is MOST likely to show which ONE of the following pathologic lesions?
A. Lymphomatous inﬁltration
B. Necrotizing fasciitis
C. Giant cell granuloma formation
D. Tumoral calcinosis
E. Scleroderma
Answer: C
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
A 65-year-old woman with known multiple myeloma is referred for management of persistent hypercalcemia. She has been treated with a variety of agents for hypercalcemia in the past, but despite a recent infusion of zoledronic acid, her hypercalcemia has recurred. You are consulted regarding using denosumab as therapy. A physical examination reveals a cachectic-appearing woman in no acute distress. She is mildly con-fused. Laboratory studies show serum calcium of 13.7 mg/dl, phosphorus of 3.6 mg/dl, creatinine of 1.9 mg/dl, hemoglobin of 7.8 g/dL, albumin of 4.2 g/dl, and total protein of 7.9 g/dl..
Question: Which ONE of the following is the MOST likely potential complication of denosumab therapy in this woman?
A. Prolonged hypocalcemia
B. Prolonged hypomagnesemia
C. AKI
D. Induction of FSGS
E. Prolonged hypophosphatemia
Answer: A
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
A 45-year-old woman with metastatic breast cancer is admitted for evaluation of marked confusion and somnolence that developed gradually over the past 2 weeks. She developed a severe headache associated with nausea and vomiting 2 days before admission and sustained a generalized seizure on the day of admission. On physical examination, she is lethargic and confused. Her BP is consistently in the normal range throughout her hospital course. A neurologic examination shows diffuse muscle weakness graded at 5-/5. A 2-cm mass is palpable in her left breast. Laboratory tests show hemoglobin of 10.4 g/dl, serum creatinine of 2.5 mg/dl (increased from 1.2 mg/dl 1 year ago), calcium of 14.5 mg/dl (after correction for an albumin level of 2.3 g/dl), and phosphorus of 7.5 mg/dl. Cerebrospinal ﬂuid analysis is nor-mal. Magnetic resonance imaging (MRI) of the brain shows ﬁndings consistent with posterior reversible encephalopathy syndrome. A photoemission tomography-computed tomography (CT) scan revealed multiple metastatic lesions in liver and lung but no metastatic brain lesions..
Question: Which ONE of the following is the MOST likely cause of the MRI ﬁndings in this woman?
A. Hypercalcemia
B. Masked hypertension
C. Hyperphosphatemia
D. AKI
Answer: A
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
Question: Question 2573:
Which ONE of the following statements regarding the effects of hypomagnesemia in pa-tients receiving chronic hemodialysis therapy is CORRECT?
A. Hypermagnesemia but not hypomagnesemia is associated with an increased risk of premature mortality
B. Hypomagnesemia but not hypermagnesemia is associated with an increased risk of premature mortality
C. Both hypomagnesemia and hypermagnesemia increase the risk of premature mortality in dialysis patients
D. Supplementation with magnesium reduces the risk of increased premature mortality
Answer: C
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
A 69-year-old woman with primary hyperparathyroidism is referred for management of hypercalcemia. She has severe coronary artery disease complicated by three myocardial infarctions, and she has required coronary artery bypass grafting and multiple percutaneous interventions over the past 5 years. Her most recent coronary intervention was 4 months ago. At this point, she experiences mild chest pain on exertion. The patient refuses to undergo parathyroidectomy because of concern regarding her cardiovascular risk for surgery. A physical examination reveals a BP of 110/80 mmHg. The rest of the physical examination is unremarkable. Laboratory studies show serum calcium of 11.7 mg/dl, phosphorus of 2.6 mg/dl, creatinine of 1.4 mg/dl, PTH of 157 pg/ml (reference range 17–70 pg/ml), hemoglobin of 11.8 g/L, and albumin of 4.3 g/dl..
Question: Which ONE of the following is the MOST ap-propriate management strategy for this woman?
A. Cinacalcet therapy
B. Calcitonin
C. Estrogen
D. Zoledronic acid
E. Observation
Answer: A
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
A 54-year-old woman is referred for evaluation of possible hyperparathyroidism. A screening examination revealed an elevated serum calcium level of 10.6 mg/dl. She notes that her mood has been somewhat depressed over the past 6 months, a difﬁculty that she attributes to some minor ﬁnancial difﬁculties. She has no other symptoms. A physical examination is within normal limits. Laboratory studies show serum calcium of 10.3 mg/dl, phosphorus of 3.5 mg/dl, creatinine of 0.9 mg/dl, PTH of 69 pg/ml (reference range 17–70 pg/ml), and albumin of 3.8 g/dl..
Question: Which ONE of the following tests should be checked NEXT in this woman's diagnostic evaluation?
A. A repeat PTH level
B. A 25-hydroxy vitamin D level
C. A serum estrogen level
D. No further testing is required
Answer: B
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
An 80-year-old woman with a history of open-angle glaucoma is admitted for evaluation of profound muscle weakness. She had been living independently and was last seen by her daughter 1 day before admission. At that time, she complained of a 2-week history of progressive muscle weakness, but she had no other speciﬁc complaints. She had a hip fracture 2 years ago that required surgery and a myocardial infarction 6 years ago. Medications include acetazolamide, which was started 2 weeks ago for glaucoma. A physical examination shows profound and diffuse muscle weakness. There are no focal neurologic deﬁcits. The remainder of the examination is normal. Laboratory studies show serum sodium of 134 mEq/L, potassium of 3.5 mEq/L, chloride of 100 mEq/L, total CO2 of 22 mmol/L, BUN of 18 mg/dl, creatinine of 1.2 mg/dl, calcium of 9.1 mg/dl, phosphorus of 0.6 mg/dl, and albumin of 4.3 g/dl. The fractional excretion of phosphorus is 25%..
Question: Which ONE of the following is the MOST likely cause of this patient's hypophosphatemia?
A. Oncogenic osteomalacia
B. Primary hyperparathyroidism
C. Secondary hyperparathyroidism caused by vitamin D deﬁciency
D. Acetazolamide
E. Acute respiratory alkalosis
Answer: D
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
You are asked to see a 47-year-old man who underwent a partial hepatectomy 3 days ago for treatment of an isolated metastatic lesion from colon cancer for hypophosphatemia. Before surgery, the patient had been in good health, and the only manifestation of his colon carcinoma was occasional rectal bleeding. The surgery went well, but postoperatively, the patient was found to have a serum phosphate level of 0.9 mg/dl. He has been maintained on nasogastric suction. His only complaint is generalized weakness. Pre-operative laboratory studies showed a serum calcium of 9.6 mg/dl and a serum phosphorus of 4.1 mg/dl. The patient had been on no medications before surgery. The surgical procedure required the transfusion of 4 U packed red blood cells. There were no episodes of hypotension during surgery. On physical examination, he is afebrile, and his vital signs are normal. Laboratory studies show serum sodium of 133 mEq/L, potassium of 3.8 mEq/L, chloride of 100 mEq/L, total CO2 of 24 mmol/L, BUN of 14 mg/dl, creatinine of 1.1 mg/dl, calcium of 9.0 mg/dl, phosphorus of 0.8 mg/dl, and albumin of 4.2 g/dl. The fractional excretion of phosphorus is 18%..
Question: Which ONE of the following is the MOST likely cause of this man's hypophosphatemia?
A. The release of a phosphaturic factor from the liver
B. A paraneoplastic phosphate wasting disorder
C. Primary hyperparathyroidism
D. Phosphate malabsorption
E. Vitamin D deﬁciency
Answer: A
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
A 65-year-old man is assessed in the emergency department for the acute onset of severe right ﬂank pain. He had two episodes of symptomatic nephrolithiasis over the past 15 years, although no stone has ever been analyzed. He does not have visible hematuria, fever, or a change in bowel habits. His only medication is atorvastatin at 40 mg/d. The serum calcium and phosphorus levels have always been normal. On physical examination, he is writhing in pain. He is afebrile. There is moderate right ﬂank and right lower quadrant abdominal tenderness. The rest of the examination is unremarkable. Laboratory studies reveal serum sodium of 137 mEq/L, potassium of 4.1 mEq/L, chloride of 101 mEq/L, total CO2 of 25 mmol/L, BUN of 18 mg/dl, creatinine of 1.2 mg/dl, calcium of 9.2 mg/dl, and phosphorus of 3.9 mg/dl. A urinalysis shows pH 5.2, 1+ protein, and 2+ blood. A microscopic examination shows 8–10 monomorphic erythrocytes per high power ﬁeld and rare leukocytes. No crystals are seen..
Question: After treatment with analgesics, which ONE of the following diagnostic studies should be performed NEXT?
A. Spiral CT scan without contrast
B. Spiral CT scan with contrast
C. Point of care ultrasonography
D. MRI without contrast
E. Abdominal radiographs
Answer: C
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
A 48-year-old man is evaluated for a long-standing history of recurrent nephrolithiasis. He emigrated from North Africa to the United States 12 years ago. Since arriving in the United States, he has passed six calcium stones. Because of his eco-nomic status, he has not received consistent medical care but has been told that his serum calcium was elevated in the past. His father had a history of recurrent nephrolithiasis. He now has medical insurance and seeks further evaluation for his condition. A physical examination is un-remarkable. Laboratory studies show serum sodium of 136 mEq/L, potassium of 3.8 mEq/L, chloride of 99 mEq/L, total CO2 of 23 mmol/L, BUN of 36 mg/dl, creatinine of 2.1 mg/dl, calcium of 11.1 mg/dl, and phosphorus of 4.8 mg/dl; 1,25-dihydroxy vitamin D level is 47.6 pg/ml (reference range 20–42 pg/ml), and 24,25-dihydroxy vita-min D level is not detected in the serum. The serum PTH level is 8 pg/ml (reference range 17–70 pg/ml). The 24-hour urine calcium excretion is 561 mg. A recent chest radiograph is normal..
Question: Which ONE of the following is the MOST appropriate treatment?
A. Calcitonin
B. Zoledronic acid
C. Ketoconazole
D. Prednisone
E. Parathyroidectomy
Answer: C
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
Question: Question 2580:
Which ONE of the following statements regarding the relationship between kidney stones and cardiovascular events is CORRECT?
A. Although there is an excess risk of cardiovascular events associated with passing a kidney stone, the risk is attributable to an increased incidence of hypertension in the population
B. When corrected for other factors that may predispose to cardiovascular events, kidney stone formation is not associated with cardiovascular events
C. Although there is an excess risk of cardio-vascular events associated with passing a kidney stone, the risk is predominantly found in older individuals
D. Even correcting for diabetes, hypertension, and albuminuria, kidney stone formation is associated with an increased risk of cardiovascular events
E. Those individuals who form multiple kidney stones are at increased risk for cardio-vascular events compared with those who form a single stone
Answer: D
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
A 57-year-old man is evaluated in the emergency department for moderate right ﬂank pain. He has been in good health, except for three episodes of nephrolithiasis. Although no stone analysis was performed after passage of the ﬁrst two kidney stones, his last stone was analyzed and found to contain calcium oxalate. He has been treated with a thiazide diuretic for hypercalciuria, and he has been adherent with therapy. After institution of hydrochlorothiazide, his urinary calcium fell from 280 to 190 mg/d. Laboratory studies reveal normal serum calcium, phosphate, and serum creatinine levels. Urinalysis shows many erythrocytes with normal morphology. A kidney ultrasound shows mild hydroureter to ureterovesicular junction. The pain remits, and he passes a 5-mm stone..
Question: Which ONE of the following is the next MOST appropriate step in management?
A. Follow-up ultrasonography imaging in 10 days
B. Repeat evaluation of urinary parameters in 2 weeks
C. The stone should be sent for chemical analysis
D. No further diagnostic studies are necessary
E. The patient should undergo a spiral CT study at this time
Answer: C
Subject: Disorders of Divalent Ions Renal Bone Disease & Nephrolithiasis
A 41-year-old man is evaluated in the emergency department for severe left ﬂank pain. He had one previous episode of nephrolithiasis 2 years ago. The stone was analyzed and found to contain 100% calcium oxalate. His management has been limited to an increase in his daily ﬂuid intake. Laboratory studies reveal normal serum calcium, phosphate, and serum creatinine levels. Urinalysis shows many monomorphic erythrocytes. An ultrasound examination shows minimal hydroureter to the midureter with a 6-mm stone, with urine passage around the stone. The patient is treated with analgesics with good relief..
Question: Which ONE of the following would lead to the MOST rapid stone passage and relief of symptoms for this patient?
A. Infusion of 0.9% saline
B. Tamsulosin
C. Silodosin
D. Tadalaﬁl
Answer: C
Subject: ESRD & Dialysis
A 62-year-old man with ESRD is evaluated during a follow-up visit 6 months after an episode of refractory culture–negative peritonitis that required catheter removal. He has since been treated with hemodialysis. He now hopes to switch back to peritoneal dialysis (PD) because that modality better suits his lifestyle. Since starting hemodialysis, his residual renal function has declined, and he is now anuric. His dialysis adequacy while on PD was consistently above recommended guidelines, with weekly Kt/V values greater than 2.2. On physical examination, his weight is 68 kg. His abdomen is soft with normal bowel sounds and no masses evident on palpation. The remainder of the examination is normal..
Question: Which ONE of the following would be the BEST advice regarding his outcomes of returning to PD?
A. PD is unlikely to be successful because of adhesions and inadequate peritoneal mem-brane transport
B. His peritonitis-free survival after switching back to PD is comparable with that of those who did not require transfer to hemodialysis after experiencing peritonitis
C. PD is not recommended because he is anuric
D. PD is not recommended because of an in-creased risk for recurrent peritonitis after an episode of culture-negative peritonitis
Answer: B
Subject: ESRD & Dialysis
A 62-year-old woman with ESRD maintained on PD for the last 8 years is evaluated in the PD clinic. Over the last 3 months, she has developed increased dyspnea on exertion and leg edema. She has lost 3 kg in weight in association with intermittent diffuse abdominal pain, constipation, anorexia, and nausea. She has had no problems with inﬂow. She had peritonitis due to coagulase-negative staphylococcus 6 months ago that cleared after a 2-week course of intraperitoneal cefazolin. On physical examination, the abdo-men is ﬁrm to palpation. There are basilar crackles in both lung ﬁelds. She has 2+ leg edema. A rapid 2-L exchange shows no prob-lem with inﬂow and return of 1900 ml of clear efﬂuent. Results of her peritoneal equilibrium tests over the past several years performed using 4.25% dextrose-containing ﬂuid are as follows:  4 years ago D/Pcreatinine (dialystate to plasma creatinine ratio) was 0.65 and D/Pglucose (dialystate to plasma glucose ratio) was 0.41. 3 years ago ago D/Pcreatinine was 0.82 and D/Pglucose was 0.29. 2 years ago D/Pcreatinine was 0.68 and D/Pglucose was 0.40. 1 year ago D/Pcreatinine was 0.52 and D/Pglucose was 0.48. Currently the D/Pcreatinine is 0.38 and  D/Pglucose is 0.59..
Question: Which ONE of the following is the MOST likely cause of this patient’s ultraﬁltration failure?
A. A peritoneal dialysate leak
B. Increased lymphatic absorption
C. Encapsulating peritoneal sclerosis
D. A high transport membrane
Answer: C
Subject: ESRD & Dialysis
A 45-year-old woman with slowly progressive advanced CKD is evaluated for symptoms of worsening fatigue and intermittent nausea over the past several months. An arteriovenous ﬁstula was placed 4 weeks ago and is maturing as expected. A conversation about dialysis options ensues, and she asks about home–suitable dialysis modalities..
Question: Which ONE of the following would be the BEST advice regarding the differences between PD and home hemodialysis (HHD)?
A. She can expect an increased risk of all-cause mortality with HHD
B. HHD would confer a lower risk of hospitalization compared with PD
C. Technique failure is more common in HHD patients compared with PD patients
D. If she chooses HHD, dialysis should begin in center and then transition to home to facilitate access maturation
Answer: B
Subject: ESRD & Dialysis
A 27-year old woman with ESRD due to lupus nephritis maintained on continuous cycling peritoneal dialysis (CCPD) is evaluated in the emergency department for 2 days of abdominal pain, nausea, and vomiting. This morning, she noted that her dialysate efﬂuent was somewhat darker than usual. She does not have fever, rash, or arthralgias. On physical examination, she is afebrile. The abdomen shows mild diffuse tenderness. The PD catheter exit site shows no erythema, purulent drainage, or tenderness. An emergency department nurse obtains 50 ml peritoneal ﬂuid from the 250-ml day dwell that the patient infused just 15 minutes ago..
Question: Peritoneal ﬂuid analysis shows a cell count of 45 total nucleated cells/mm3 with 36% neutrophils Which ONE of the following is the next MOST appropriate step in management?
A. Repeat the cell count after infusing 1 L of dialysate that dwells for 1–2 hours
B. Check serum complement levels
C. Obtain a computed tomography scan of the abdomen and pelvis
D. Discharge home and repeat the cell count in 24 hours
Answer: A
Subject: ESRD & Dialysis
Your patient, who is maintained on CCPD, is admitted to a hospitalist service for severe PD–related peritonitis. The hospitalist, who recently rotated on the nephrology service during training, asks if PD should be performed with dextrose-containing solution or icodextrin..
Question: Which ONE of the following would you advise regarding the use of icodextrin during PD-associated peritonitis?
A. It leads to a faster resolution of peritonitis
B. It results in improved ﬂuid balance
C. It decreases sodium sieving
D. Its use is associated with increased mortality
Answer: B
Subject: ESRD & Dialysis
A 50-year-old woman with ESRD secondary to polycystic kidney disease recently initiated in-center hemodialysis. She has a well matured right upper extremity arteriovenous ﬁstula and uses a rope ladder or rotating site cannulation technique (needle placement that is rotated along the length of the ﬁstula). She has not had any access-related events. She would like to transition from standard in–center hemodialysis to frequent hemodialysis performed at home 5 d/wk. She has heard about buttonhole needling and inquiries about advantages and disadvantages of that technique. You begin a discussion about the relative merits and risks of using the buttonhole needling technique..
Question: Which ONE of the following outcomes can she expect if she decides to implement the buttonhole needling technique?
A. An increased risk of infectious complications
B. An increased rate of access survival
C. A decrease in cannulation-associated pain
D. An increased rate of hematoma formation
Answer: A
Subject: ESRD & Dialysis
A 56-year-old man who recently started hemodialysis is evaluated during weekly hemodialysis rounds. He indicates that his treatments have been difﬁcult, because he feels “drained” for several hours after undergoing dialysis. He receives 3.5 hours of hemodialysis thrice weekly, with an average blood ﬂow of 400 ml/min and a dialysate ﬂow of 800 ml/min. The dialysate composition is sodium 135 mEq/L, potassium 2 mEq/L, total buffer 37 mEq/L, and calcium 2.5 mEq/L. His average interdialytic weight gain is 1.0 kg, and the average predialysis and postdialysis BPs are 142/76 and 130/68 mmHg, respectively. On physical examination, he does not have postural hypotension following dialysis. He does not have edema. The remainder of the examination is unremarkable. The monthly laboratory studies show single-pool Kt/V of 1.4, hemoglobin of 11.2 g/dl, sodium of 138 mEq/L, potassium of 4.2 mEq/L, chloride of 103 mEq/L, total CO2 of 23 mmol/L, calcium of 9.0 mg/dl, phosphorus of 4.8 mg/dl, and albumin of 3.8 g/dl. His residual renal function is estimated to be approximately 5 ml/min per 1.73 m2..
Question: Which ONE of the following interventions is MOST likely to reduce the duration of the recovery time after dialysis for this man?
A. An increase in dialysate potassium
B. A reduction in the blood ﬂow rate
C. An increase in dialysate sodium to 140 mEq/L
D. A decrease in dialysis frequency to twice weekly
Answer: C
Subject: ESRD & Dialysis
A 57-year-old man with ESRD due to hyper-tensive nephrosclerosis is evaluated during routine hemodialysis rounds. He started hemodialysis 3 weeks ago and has had to curtail his exercise regimen because of the time committed to dialysis and his ongoing part–time work. He recently saw a report on the internet about an exercise regimen that used modest resistance exercise with weights and elastic bands during the ﬁrst 2 hours of dialysis..
Question: Which ONE of the following outcomes can he expect from implementing such an exercise regimen during dialysis?
A. A decline in dialysis adequacy
B. An increase in musculoskeletal injuries
C. An increase in cardiovascular events
D. An improvement in peak oxygen consumption
Answer: D
Subject: ESRD & Dialysis
A 54-year-old woman with ESRD is evaluated during dialysis rounds. She complains of several weeks of increased pruritus but is otherwise asymptomatic. You review her most recent lab-oratory results with her. During this discussion, you explain that her serum parathyroid hormone (PTH) has shown progressive elevation over the past 6 months and that it is now outside of the target range. This has occurred despite optimization of the serum calcium, phosphorus, and vitamin D status. Her medications include sevelamer 2400 mg thrice daily with meals and paricalcitol 8 µg with hemodialysis. Her most recent laboratory studies show a corrected calcium of 9.8 mg/dl, a serum phosphorus of 4.9 mg/dl, and a PTH level of 730 pg/ml. In addition to continuing vitamin D sterol and phosphate binder therapy, you recommend initiation of cinacalcet therapy. She is concerned about the cost of this agent, but indicates that she would be willing to take it if cinacalcet offered significant beneﬁt..
Question: Which ONE of the following would you indicate is the MOST likely beneﬁt of cinacalcet therapy in this patient?
A. It will reduce her mortality risk
B. It will reduce her risk of fracture
C. It will likely delay or obviate the need for future parathyroidectomy
D. It will decrease her risk for cardiovascular events
Answer: C