SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Acute Kidney Injury & Critical Care Nephrology
A 60-year-old man is admitted to neurosurgical intensive care unit after experiencing a hemorrhagic stroke. A ventriculostomy drain is placed because of increased intracranial pressure. His course is complicated by contrast–induced AKI, which progresses to oliguric AKI after onset of pneumonia and sepsis. On physical examination, he is intubated and sedated. The blood pressure 110/50 mmHg. The chest examination shows crackles and decreased breath sounds in the right midlung zone. There is 2+ leg edema. Laboratory studies show sodium 130 mEq/L, potassium 6.2 mEq/L, chloride 94 mEq/L, total CO2 16 mmol/L, BUN 82 mg/dl, and creatinine 6.1 mg/dl (increased from 1.2 mg/dl 8 days ago). The leukocyte count is 14,700/µl, the hemoglobin is 9.2 g/dl, and the platelet count is 203,000/µl..
Question: Which ONE of the following is the BEST choice of renal replacement therapy (RRT) for this patient?
A. Intermittent hemodiaﬁltration
B. Intermittent hemodialysis
C. Continuous renal replacement therapy (RRT)
D. Sustained low-efﬁciency dialysis
Answer: C
Subject: Acute Kidney Injury & Critical Care Nephrology
A 75-year-old woman with metastatic melanoma with cutaneous and pulmonary involvement is admitted to the intensive care unit for management of symptomatic hyponatremia. She started treatment with ipilimumab 10 weeks ago and experienced bifrontal headache with progressive confusion over the past week. On physical examination, she is lethargic. The blood pressure is 118/60 mmHg, and the heart rate is 96/min. There is no cutaneous or mucosal hyperpigmen-tation. The heart and lung examination results are unremarkable, and there is no peripheral edema or focal neurologic deﬁcits. The deep tendon reﬂexes demonstrate a delayed relaxation phase. Laboratory studies show serum sodium 116 mEq/L, potassium 4.3 mEq/L, chloride 82 mEq/L, total CO2 24 mmol/L, BUN 18 mg/dl, creatinine 1.1 mg/dl, and osmolality 242 mOsm/kg. The urine osmolality is 426 mOsm/kg, and the urine sodium is 62 mEq/L. Magnetic resonance imaging of the brain with contrast material shows diffuse pituitary enlargement without focal mass lesions..
Question: Which ONE of the following is the MOST likely cause of the hyponatremia?
A. Ipilimumab-related hypophysitis with secondary adrenal insufﬁciency
B. Primary adrenal insufﬁciency because of ipilimumab-related autoimmune adrenalitis
C. Metastatic melanoma invading the pituitary gland
D. Primary polydipsia
Answer: A
Subject: Acute Kidney Injury & Critical Care Nephrology
A 70-year-old woman with stage G3b:A2 CKD due to diabetic nephropathy receives a diagnosis of metastatic renal cell carcinoma. She begins treatment with soraﬁnib, a tyrosine kinase inhibitor targeting the vascular endothelial growth factor receptor. Three weeks into therapy, she experiences edema, hypertension with a blood pressure of 180/100 mmHg, and increased proteinuria. Medications are amlodipine, lisinopril, chlorthalidone, and rosuvastatin. Laboratory studies show that the serum creatinine level has risen from a baseline level of 1.6 mg/dl to 2.3 mg/dl. A complete blood count with differential and serum complement levels are normal. The urinalysis shows ﬁne granular casts and oval fat bodies. The urine albumin-to-creatinine ratio is 6400 mg/g, increased from 106 mg/g 1 month ago..
Question: Which ONE of the following is the MOST likely diagnosis?
A. Focal and segmental glomerulosclerosis plus thrombotic microangiopathy
B. Renal vein thrombosis
C. Progression of diabetic nephropathy
D. Immune complex glomerulonephritis
Answer: A
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
As the medical director of a dialysis unit you are reviewing the medical records of a 56-year-old patient with diabetes mellitus, hypertension, and a history of intravenous drug abuse who is going to start in-center hemodialysis at your dialysis center. Laboratory studies reveal negative hepatitis B surface antigen, a negative hepatitis B e antigen, a positive hepatitis B surface antibody, a positive hepatitis B core antibody, and a negative IgM hepatitis B core antibody..
Question: Which ONE of the following statements is TRUE regarding his need for isolation and hepatitis B status?
A. The patient does not need to be isolated because he likely has chronic hepatitis B infection
B. The patient does not need to be isolated because he has developed immunity as a result of immunization
C. The patient does not need to be isolated because the anti-hepatitis B core antibody is likely a false positive result
D. The patient does not need to be isolated because he has developed immunity as the result of a prior hepatitis B infection
E. The patient does not need to be isolated because he is recovering from an acute hepatitis B infection
Answer: D
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
A 55-year-old man who has been receiving maintenance hemodialysis for 5 years is under-going evaluation for kidney transplantation. Se-rum liver chemistries are normal. Serologic studies show a positive hepatitis C antibody, a positive hepatitis B surface antibody, a positive hepatitis B total core antibody, a negative hepatitis B surface antigen, and a negative hepatitis B e antigen. The hepatitis C RNA level by polymerase chain reaction is 26,000,000 U/ml..
Question: Which ONE of the following interpretations is CORRECT?
A. He has both active hepatitis B and hepatitis C infection
B. He has hepatitis C infection and has been vaccinated against hepatitis B
C. He has hepatitis C infection and has previously been infected with hepatitis B
D. He has immunity to both hepatitis B and hepatitis C because of prior infection
Answer: C
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
A 70-year old man with advanced chronic kidney disease due to IgA nephropathy is evaluated 1 week before the planned initiation of hemodialysis. He was born in South Korea and moved to the United States 25 years ago. A 5-tuberculin-units puriﬁed protein derivative (PPD) tuberculin skin test shows 15 mm of induration. He does not recall receiving Bacillus Calmette-Guerin (BCG) vaccination..
Question: Which ONE of the following is the next BEST step in this patient’s management?
A. Perform a 10-tuberculin-units PPD tuberculin skin test
B. Order an interferon-γ release assay
C. Order a chest radiograph
D. Inform the patient that this test result is likely a false positive because of prior BCG vaccination
E. Initiate isoniazid prophylaxis at 300 mg daily
Answer: C
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
A 68-year-old man visiting from an outside dialysis center is evaluated during routine dialysis rounds. He has been receiving hemodialysis for the past 3 months after a kidney transplantation failed because of chronic rejection. His immuno-suppression has been tapered to prednisone 5 mg daily. He has had low-grade fever, malaise, and a pruritic rash that is intermittently painful over the chest, abdomen, and thighs for 1 week. On physical examination, his temperature is 37.9 C. Other vital signs are normal. Many clusters of dry and crusted skin lesions are noted on the left side of the chest. Numerous vesicles, pustules, and scabs in various stages of eruption are seen over his lower abdominal wall and proximal thighs. The face, neck, upper extremities, and skin overlying a left brachiobasilic ﬁstula are spared. His vaccination record is unavailable..
Question: In addition to standard precautions, which ONE of the following is the MOST appropriate management?
A. Cover the lesions and administer dialysis at the outpatient facility in a regular chair
B. Cover the lesions and administer dialysis at the outpatient facility in an isolation room under contact precautions
C. Transfer the patient to a tertiary care hospital after outpatient hemodialysis treatment
D. Immediately transfer the patient to a hospital for both airborne and contact isolation
Answer: D
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
Since the launch of the Nephrologists Trans-forming Dialysis Safety by the American Society of Nephrology with the support of the United States Centers for Disease Control and Prevention, you and your interdisciplinary team have made infection control a priority at your dialysis facility. The “Days Since Infection” Poster has been downloaded from the American Society of Nephrology website and has been prominently displayed in your unit. Before weekly dialysis rounds, you decide to inconspicuously observe dialysis staff performing hand hygiene..
Question: In which ONE of the following situations is hand washing with soap and water preferred for dialysis staff over the use of alcohol-based hand rubs?
A. After inadvertently touching a hemodialysis machine
B. After documenting notes on a portable computer
C. After contact with a patient with a recent diagnosis of Clostridium difﬁcile–induced diarrhea
D. Before preparation of medications for par-enteral administration
E. Before changing the dressing covering the exit site of a central venous catheter (CVC)
Answer: C
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
A hemodialysis center has received notice from a state health agency regarding several infection control deﬁciencies, including poor compliance with recommended hand hygiene procedures that were observed during a recent on-site audit..
Question: Which ONE of the following strategies is MOST likely to improve adherence of staff with recommended hand hygiene practices?
A. Encourage the staff to wash their hands with soap and water before and after each contact with a patient
B. Promote the frequent use of gloves during the dialysis procedure because hand hygiene is not necessary if gloves are worn during patient care
C. Make alcohol-based hand rub readily avail-able near dialysis stations, and observe hand hygiene opportunities monthly, pro-viding staff with feedback regarding their performance
D. Minimize the time needed for hand hygiene by training staff to apply a small amount of an alcohol-based hand rub for 10 seconds
Answer: C
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
An investigation is initiated at a hemodialysis clinic after it is discovered that six patients have acquired hepatitis C over a period of 1 year. Nucleotide sequencing analysis by the Centers for Disease Control and Prevention revealed high homology and close clustering of hepatitis C virus quasispecies among these patients. Multiple lapses in infection control practices at the dialysis center were identiﬁed..
Question: Which ONE of the following infection control gaps has frequently been associated with outbreaks of hepatitis C virus infection in hemodialysis units?
A. Dialyzing hepatitis C-positive patients in the main area of the unit instead of dialyzing the patient using a dedicated room, machine, and equipment
B. Failure of personnel to change gloves and perform hand hygiene when moving be-tween patients, between patients and potentially contaminated surfaces, and between machines
C. Poor compliance by staff with recommended use of gowns when caring for patients with open skin wounds with drainage not contained by dressings
D. Failure to adequately reprocess reusable dialyzers
Answer: B
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
Outbreaks of hepatitis C and, less frequently, hepatitis B and bacterial bloodstream infections in outpatient hemodialysis centers have often been due to poor adherence to infection control practices. Inappropriate handling and administration of parenteral medications in hemodialysis clinics pose an additional risk for the transmission of such pathogens..
Question: Which ONE of the following medication injection safety measures minimizes the risk of blood-borne pathogen transmission in outpatient hemodialysis facilities?
A. Use a mobile cart to transport injectable medications to multiple patients
B. Prepare medications at the patient’s dialysis station whenever possible
C. Avoid administration of medications from the same syringe to more than one patient
D. When using single-dose vials of medication, refrigerate vials containing residual (excess) medication before pooling for administration to subsequent patients.
Answer: C
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
You are making rounds with two ﬁrst-year nephrology fellows at an outpatient dialysis clinic. The fellows ask you about the removal of endotoxins during water puriﬁcation..
Question: Which ONE of the following components of water puriﬁcation should you instruct them is responsible for the removal of the majority of endotoxins before the ﬁnal pass through endotoxin ultraﬁlters prior to feeding the distribution loop?
A. Water softener resin
B. Brine tank
C. Carbon medium
D. Reverse osmosis membrane
Answer: D
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
As medical director of a hemodialysis facility you are reviewing four possible occurrences with the care team that would necessitate disinfection of the internal hemodialysis components before the machine is used for the subsequent treatment..
Question: Which ONE of the circumstances would warrant disinfection of the internal hydraulic components of the hemodialysis machine between treatments?
A. An air leak
B. A blood leak due to a ruptured dialyzer membrane
C. Completion of hemodialysis in a patient with hepatitis C virus infection
D. Completion of hemodialysis in a patient with HIV infection
Answer: B
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
A 62-year-old man who initiated hemodialysis is evaluated during weekly rounds. The charge nurse has placed the patient in isolation because the hepatitis B surface antigen returned positive on admission laboratory studies. A review of his record indicates that he had no prior history of hepatitis. Serologic studies performed 3 months ago as part of an evaluation for transplantation showed that the hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis B core IgM were all negative. He is up to date on pneumococcal vaccination, received inﬂuenza vaccination several weeks ago, and received his ﬁrst dose of hepatitis B vaccine 5 days ago. On physical examination, his vital signs are normal. He has no pallor or jaundice. The remainder of his physical examination results are normal. Laboratory studies show normal liver chemistries, nor-mal prothrombin time, normal albumin, negative hepatitis B surface antibody, negative hepatitis B core IgM, and negative total hepatitis B core antibody..
Question: Which ONE of the following is the BEST explanation of the positive hepatitis B surface antigen serologic result?
A. Acquired immunity from vaccination against hepatitis B virus
B. Prior hepatitis B virus infection
C. Acute hepatitis B infection
D. Recent exposure to hepatitis B vaccine
Answer: D
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
In your role as medical director of a dialysis facility you decide to observe dialysis staff during a shift change. A newly hired technician is observed taking a patient off dialysis. The technician is observed returning a patient’s blood, followed by clamping of the arteriovenous lines. The lines are then disconnected from the dialysis machine. The technician places a nonsterile pad over the arterial site and removes the arterial needle while wearing nonsterile gloves. After hemostasis is achieved, a nonsterile gauze pad is placed on the arterial site. This same procedure is repeated for the removal of the venous needle. He then moves to the next patient, dons a new set of gloves, and repeats the same takeoff procedure..
Question: Which ONE of the following represents a breach in proper infection control practices?
A. Placement of a nonsterile gauze pad at the cannulation site
B. Failure to apply antibiotic ointment at the arterial or venous sites cannulation sites before placing the dressing
C. Failure to perform proper hand hygiene between patient encounters
D. Failure to use sterile gloves during decannulation
Answer: C
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
A recent continuous quality improvement analysis at your dialysis unit revealed that the frequency of CVC infections has recently risen to > 1 per 1000 catheter days (equivalent to > 3 per 100 patient-months). Current procedures include cleansing of exit sites with povidine-iodine and use of sterile gauze to cover the exit at each treatment. An antibiotic lock solution is currently being used in one patient with a history of recurrent catheter-related bloodstream infections (CRBSIs)..
Question: Which ONE of the following interventions is the next BEST step to reduce the frequency of CRBSIs in your unit?
A. Change sterile gauze to a transparent semi-permeable dressing after each treatment
B. Use an alcohol-based chlorhexidine (.0.5%) solution for cleansing the exit site skin, and scrub the hub with 70% alcohol
C. Use needle-free connectors for all CVC hubs
D. Use gentamicin-citrate lock solution in all patients
E. Use an alteplase lock solution in all patients
Answer: B
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
One afternoon, you enter the treatment area of your dialysis facility and notice fresh blood (about 30 ml) on the ﬂoor from a patient who experienced post procedure bleeding from the access site. After appropriate measures are taken, the bleeding has subsided and the patient is clinically stable. You review the policy for cleaning and disinfection of blood spills as the staff proceed to clean the treatment area..
Question: Which ONE of the following is the MOST appropriate method for removing blood on the ﬂoor?
A. Single application of soap and water
B. Double application of soap and water
C. Single application of tuberculocidal disinfectant
D. Double application of tuberculocidal disinfectant
E. Soap and water followed by tuberculocidal disinfectant
Answer: D
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
An outpatient hemodialysis facility’s medical director became concerned upon receipt of the updated National Healthcare Safety Network Facility Rate Table. The table indicated that the facility’s bloodstream catheter infection rate was signiﬁcantly higher than the national average. The interdisciplinary team, under the leadership of the medical director, reviewed and analyzed data, including the results of CDC Infection-Related Audit Tools through the facility’s Quality Assurance Performance Improvement program (QAPI). Deﬁciencies were found in the areas of hand hygiene, catheter connection and disconnection, dialysis station routine disinfection, and catheter exit site care. The medical director recommended corrective actions to improve the facility culture of safety rather than addressing each process individually..
Question: Which ONE of the following BEST describes how medical directors can inﬂuence the culture of safety in dialysis facilities?
A. Develop action plans to improve infection control practices, explaining the rationale of each plan with provision of feedback on the plan’s impact
B. Provide educational materials to both nephrology physicians and facility staff directed toward best infection prevention and control practices
C. Develop new policies and guidelines that are easier to understand compared with those currently being used
D. Ensure that error-prone staff members undergo disciplinary actions and re-education
E. Designate an individual among the facility staff who is charged with assuring proper infection prevention and control techniques throughout the facility
Answer: A
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
During a Quality Assessment and Performance Improvement (QAPI) meeting, the clinical manager informs the medical director and dialysis team that the clinic has experienced an increased rate of bloodstream infections (BSI) and a high rate of CVC access use over the past 6 months..
Question: Which ONE of the following BEST characterizes the expected role of medical director with regard to this clinical issue according to the United States Center for Medicare and Medicaid Services Conditions for Coverage for ESRD facilities?
A. Medical directors are responsible for the oversight of all care-related activities, including the high BSI and CVC rates at that facility
B. Medical directors manage the interdisciplinary team (IDT) for all patients, and the IDT evaluates the causes of high BSI and CVC rates
C. Medical directors should serve as the attending physician for all patients at their designated facility
D. The nurse manager is the clinician who oversees the QAPI program that would address the high infection rate
Answer: A
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
You are employed as a full-time nephrologist by a regional for-proﬁt health care (HC) system that owns three local hospitals. The management team of this HC entity plans to open an outpatient dialysis facility in close proximity to their hospitals. You are asked to provide expertise in the design of the dialysis facility. Speciﬁcally, they ask your opinion about hemodialyzer reuse at the facility..
Question: Which ONE of the following should you tell the management team about hemodialyzer reuse?
A. Infection risk with hemodialyzer reuse is equal to that of a single-use dialyzer
B. Gram-negative bloodstream infections have been reported with hemodialyzer reuse
C. Dialyzer reprocessing of reuse dialyzers is an easy-to-perform single-step procedure with the latest automated reprocessing machines
D. The current Association for the Advancement of Medical Instrumentation (AAMI) guidelines mandate a single speciﬁc step-by-step procedure for hemodialyzer reuse to minimize risks
Answer: B
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
Your dialysis facility technician and nurse manager contact you for recommendations after cultures from the last outlet of the distribution loop reveal a bacterial level of 300 colony forming units/ml. Hemodialysis is actively being performed during the receipt of the culture report..
Question: Which ONE of the following is the MOST appropriate management?
A. Prescribe prophylactic antibiotics for the patients receiving hemodialysis
B. Immediately discontinue dialysis and order blood cultures
C. Decrease dialysate ﬂow and blood ﬂow rates to minimize diffusive exposure
D. Assess whether continuing dialysis is less detrimental than withholding treatment
E. Change to a different hemodialysis machine with new dialyzer and blood line
Answer: D
Subject: Infection Control & Prevention in Outpatient Hemodialysis Facilities
A 54-year-old woman receives maintenance hemodialysis treatments through a left internal jugular tunneled catheter. She has exhausted all other options for permanent dialysis access. Upon arrival for a scheduled hemodialysis treatment, she reports having fever and chills but no additional symptoms. On physical examination, the patient is in no acute distress. Her temperature is 38.6C, her blood pressure is 140/86 mmHg, her heart rate 96/min, and her respiratory rate is 14/min. The catheter exit site is unremarkable, and the patient is alert and otherwise clinically stable. No peripheral veins are identiﬁed for peripheral blood cultures..
Question: Which ONE of the following is the next BEST step in this patient’s management?
A. Obtain two sets of blood cultures from the hemodialysis catheter before administering antibiotics
B. Obtain one set of blood cultures from the hemodialysis catheter and one set of blood cultures from the hemodialysis circuit, both before antibiotic administration
C. Cancel the scheduled dialysis treatment and send the patient to the emergency room for evaluation and management
D. Administer antibiotics immediately, then obtain two sets of blood cultures from the hemodialysis circuit–one from the arterial port and another from the venous port
Answer: B