SeanWu25/NEJM-AI_Benchmarking_Medical_Language_Models huggingface dataset:
Subject: Hypertension
A 35-year-old man is referred to you for the evaluation of persistently elevated diastolic BP despite lifestyle changes over the past 6 months. He feels well and has no other comorbid conditions other than the fact that he is overweight (body mass index (BMI) is 27.6 kg/m2). His father and grandfather had myocardial infarctions before age 50. He is worried about his cardiovascular risk. His BP is 130/102 mmHg and his exam is otherwise normal. A home BP log shows a home BP average of 126/97 mmHg. A basic evaluation for secondary causes of hypertension is negative. His diastolic BP has remained elevated despite a 6-month trial of lifestyle modification..
Question: In addition to ongoing lifestyle modification, which ONE of the following options would represent your BEST recommendation to him?
A. You should reassure him that his elevated diastolic BP does not have adverse prognostic implications because his systolic BP is normal
B. You should inform him that although his cardiovascular risk is increased, isolated diastolic hypertension does not require treatment
C. You should inform him that his cardiovascular risk is less than patients with systo-diastolic hypertension and that you would not treat him until his home diastolic BPs are > 100 mmHg
D. You should inform him that his cardiovascular risk is increased and that you recommend that he start drug treatment
Answer: D
Subject: Hypertension
You are asked to make a public health presentation about the current state of hypertension prevalence, diagnosis, and treatment in the United States at a local community fair..
Question: Which ONE of the following statements regarding the epidemiology of hypertension is CORRECT?
A. < 50% of hypertensive adults are aware that they have hypertension
B. About 50% of people with hypertension are receiving treatment
C. About 75% of people with hypertension are controlled and this rate is steadily improving
D. About 50% of people with hypertension are controlled
E. The prevalence of hypertension has steadily increased over the past decade
Answer: D
Subject: Hypertension
A 67-year-old woman is seen during a routine follow-up visit for hypertension. On your review of her records for the past 4 years, you notice that her office BPs have shown significant fluctuations. Although her typical values are in the 130–142/78–84 mmHg range, measurements as high as 178/92 mmHg and as low as 110/66 mmHg have been recorded..
Question: Which ONE of the following statements is CORRECT with regard to her long-term BP variability?
A. Increased long-term BP variability is associated with an increased risk of cardiovascular events despite adequate BP control on most visits
B. Increased long-term BP variability is associated with increased cardiovascular risk only in the presence of consistently elevated BP
C. Beta-blockers decrease long-term BP variability
D. Long-term BP variability has no relationship to cardiovascular events
Answer: A
Subject: Hypertension
Question: Question 2466:
Which ONE of the following statements is CORRECT regarding potassium intake, hypertension, and cardiovascular risk?
A. High potassium intake results in lower BP levels exclusively in individuals with low sodium intake
B. Low potassium intake is associated with an increased risk of cardiovascular but not all-cause mortality
C. High dietary potassium results in natriuresis and lower BP by decreasing aldosterone secretion
D. Low dietary potassium promotes hypertension by increasing the activity of the sodium chloride cotransporter (on a high sodium diet)
E. Dietary potassium has no significant role in BP regulation
Answer: D
Subject: Hypertension
A 56-year-old man with type 2 diabetes mellitus is referred for the management of proteinuria and resistant hypertension. His antihypertensive medications include chlorthalidone, lisinopril, diltiazem, and doxazosin. Spironolactone had been tried with a favorable BP response, but he experienced significant gastrointestinal side effects and stopped taking it. Home BP readings average 148/90 mmHg. On physical examination, his BP is 160/92 mmHg, his pulse rate is 60/min, and there is 1+ leg edema. Laboratory studies show an eGFR (Chronic Kidney Disease Epidemiology Collaboration [CKD-EPI]) of 78 ml/min per 1.73 m2, a serum potassium level of 3.8 mEq/L, and a urine albumin/creatinine ratio of 1182 mg/g..
Question: Which ONE of the following is the MOST appropriate treatment?
A. Add atenolol
B. Add minoxidil
C. Add clonidine
D. Add amiloride
Answer: D
Subject: Hypertension
You are seeing a 32-year-old black woman for a health-maintenance visit in a primary care practice. She is asymptomatic. Her BP is 128/80 mmHg, her BMI is 30 kg/m2, and her physical examination is negative..
Question: Which ONE of the following is the MOST appropriate time for her to have her blood pressure rechecked according to recommendations of the U.S. Preventive Services Task Force?
A. In 6 months
B. In 1 year
C. In 3–5 years
D. As needed, according to her symptoms
Answer: B
Subject: Hypertension
A 56-year-old woman is referred for further evaluation and management of hypertension. She has had several elevated office BPs for the past year despite dietary sodium reduction, increased physical activity, and weight loss. She is otherwise well and is on no medications. Home BP readings average 134/85 mmHg. On physical examination, her BP is 152/94 mmHg..
Question: In addition to continued monitoring of her BP, which ONE of the following is the MOST appropriate next step in management?
A. No change in management
B. Obtain 24-hour ambulatory BP monitoring
C. Obtain an echocardiogram
D. Start drug treatment
Answer: B
Subject: Hypertension
A 45-year-old man with hypertension is referred to you for the evaluation of treatment resistance. His antihypertensive medications include amlodipine 10 mg daily, valsartan 320 mg daily, chlorthalidone 25 mg daily, and metoprolol 50 mg twice daily. He has been adherent to therapy. A physical examination shows a BP of 160/98 mmHg. His body mass index is 30 kg/m2. His pulse rate is 60/min. The remainder of the examination is normal. Laboratory studies show a serum potassium level of 4.2 mEq/L and a serum creatinine (SCr) level of 0.8 mg/dl. The urinalysis is normal, and the urine albumin/creatinine ratio is 28 mg/g. You decide to order a 24-hour ambulatory BP monitoring study to confirm treatment resistance. Results of this study show the following average BPs..
Question: 24-hour: 134/83 mmHg Daytime (awake): 140/87 mmHg Nighttime (sleep): 122/78 mmHg
Which ONE of the following is the MOST appropriate management?
A. No change in management
B. Add doxazosin
C. Increase the dose of metoprolol
D. Add spironolactone
Answer: D
Subject: Hypertension
Question: Question 2471:
Which ONE of the following statements is CORRECT regarding strategies for population based management of hypertension?
A. Use of self-monitored BP at home results in worse BP control rates
B. Home BP tele-monitoring supervised by a health care provider results in higher rates of BP control than usual care
C. Self-treatment titration on the basis of home BP readings is suitable for more than 75% of hypertensive patients
D. Self-treatment titration on the basis of home readings is safe for uncomplicated hypertensive patients, but not for patients with comorbid conditions
E. Financial incentives to physicians do not result in any measurable improvement in BP control rates
Answer: B
Subject: Hypertension
You are seeing a 31-year-old woman with autosomal dominant polycystic kidney disease. She is asymptomatic and feels well. She has liver cysts, but no other known extrarenal manifestations of autosomal dominant polycystic kidney disease. She is on no medications. On physical examination, her BP is 132/80 mmHg. Her home BP monitoring shows readings that average 130/82 mmHg. Laboratory studies show an eGFR (CKD-EPI) of 82 ml/min per 1.73 m2 and a potassium level of 4.1 mEq/L..
Question: Which ONE of the following is the MOST appropriate target BP to attenuate increases in total kidney volume in this patient?
A. 140/80 mmHg
B. 130/80 mmHg
C. 120/75 mmHg
D. 110/75 mmHg
Answer: D
Subject: Hypertension
A 70-year-old man with multiple system atrophy is referred to you for assistance in the management of orthostatic hypotension complicated by supine hypertension. He has poor orthostatic tolerance and has had multiple episodes of syncope. A trial of fludrocortisone had been terminated because of excessive edema and supine hypertension (BP approximately 200/110 mmHg). Midodrine caused pruritus and a severe headache, requiring discontinuation. He is taking no vasoactive medications. His supine BP is 152/86 mmHg. His standing BP is 80/52 mmHg (measured 3 minutes after standing), and is accompanied by significant dizziness. Laboratory studies are all normal..
Question: In addition to usual nonpharmacologic measures, which ONE of the following is the MOST appropriate treatment recommendation to improve his orthostatic hypotension?
A. Droxidopa
B. Pyridostigmine
C. Clonidine
D. Erythropoietin
E. A caffeinated beverage with each meal
Answer: A
Subject: Hypertension
A 64-year-old woman with essential hypertension is evaluated in routine follow-up. She has seen information about the new BP guidelines published by the Joint National Committee (JNC) in 2014 and she is worried that her BP may be too low. She feels well and is asymptomatic. She does not have diabetes mellitus or coronary artery disease. Her  medications include lisinopril 10 mg daily and hydrochlorothiazide (HCTZ) 12.5 mg daily. Her current BP is 132/74 mmHg. The remainder of the findings from the examination are unremarkable. Laboratory studies show a SCr level of 0.7 mg/dl..
Question: Which ONE of the following is the MOST appropriate management of her hypertension, according to the Eighth JNC 2014 evidence based guidelines for the management of high blood pressure in adults?
A. Discontinue lisinopril and HCTZ
B. Discontinue lisinopril
C. Discontinue HCTZ
D. Make no changes to the current regimen
Answer: D
Subject: Hypertension
A 56-year-old black woman is evaluated for inadequately controlled hypertension. She has stage 3 CKD, but does not have diabetes mellitus. Her home blood pressure readings range between 150–170/80–95 mmHg. She is currently only taking enalapril 40 mg daily. On physical examination, her body mass index (BMI) is 20 kg/m2 and her blood pressure is 165/95 mmHg. There is trace pretibial edema. The remainder of the examination is normal. Laboratory studies disclosed the following values: sodium 138 mEq/L, potassium 3.9 mEq/L, chloride 106 mEq/L, total CO2 22 mmol/L, SCr 1.9 mg/dl, and an eGFR of 44 ml/min per 1.73 m2. You decide to start a thiazide diuretic, and consider the risk of hyponatremia during your discussion of potential side effects of this intervention with the patient..
Question: Which ONE of the following factors is associated with the greatest risk of thiazide-associated hyponatremia for this patient?
A. Female sex
B. Her eGFR
C. Use of chlorthalidone over HCTZ at equipotent dosing
D. Her BMI
Answer: D
Subject: Hypertension
Question: Question 2476:
Which ONE of the following MOST likely contributes the most to the pathogenesis of salt-sensitive hypertension in obese individuals?
A. Decreased expression of angiotensin 1 receptors in the proximal tubule
B. Increased serum renin levels
C. Inappropriately low atrial natriuretic peptide levels
D. Decreased renal expression of Rac1
Answer: C
Subject: Hypertension
A 66-year-old obese man is evaluated for poorly controlled hypertension. Ambulatory BP monitoring shows a mean daytime BP of 160/94 mmHg, and a mean nighttime BP of 152/92 mmHg without nocturnal dipping. He has sleep apnea, but finds it difficult to use the continuous positive airway pressure machine. His medications include lisinopril 40 mg daily, amlodipine 10 mg daily, and chlorthalidone 25 mg daily. A physical examination shows a BMI of 40 kg/m2, a BP of 162/94 mmHg, and a pulse rate of 68/min. His abdomen is obese. The remainder of the examination is unremarkable..
Question: In addition to weight loss, which ONE of the following is the MOST effective nonpharmacologic intervention to lower BP further and improve the nocturnal BP pattern?
A. Nocturnal oxygen supplementation
B. Psychotherapy
C. Device-guided breathing
D. Regular use of continuous positive airway pressure for at least 4 hours per night
Answer: D
Subject: Hypertension
A 34-year-old white woman is referred for evaluation of recent-onset severe hypertension. She is asymptomatic. She does not have witnessed nocturnal choking or gasping, headaches, palpitations, or sweating. There is no family history of hypertension. Her regular medications are: losartan 100 mg daily, felodipine 10 mg daily, metoprolol 100 mg twice daily, and chlorthalidone 25 mg daily. A physical examination shows a BMI of 24 kg/m2, a BP of 172/102 mmHg without arm discrepancy or postural changes, and a pulse rate of 60/min. There is no radiofemoral delay. No abdominal bruits are detected. The remainder of the examination is normal. Laboratory studies disclose the following values: serum sodium 138 mEq/L, potassium 3.5 mEq/L, chloride 99 mEq/L, total CO2 29 mmol/L, BUN 12 mg/dl, SCr 1.2 mg/dl, TSH 2.0 U/L, supine plasma aldosterone 18 ng/dl per hour (reference range 2–5 ng/dl per hour), and standing plasma renin activity 12 ng/ml per hour (reference range 0.6–3.0 ng/ml per hour). An MRI of the abdomen shows no adrenal or kidney abnormalities..
Question: Which ONE of the following is the MOST appropriate next step in the diagnostic evaluation of this patient?
A. Measure plasma metanephrines
B. Refer for adrenal vein sampling
C. Refer for polysomnography
D. Order a CT angiogram
Answer: D
Subject: Hypertension
A 55-year-old man has severe resistant hypertension and is referred for further evaluation. He has no other medical problems. A physical examination shows a BP of 164/88 mmHg, a pulse rate of 72/min, and a body mass index (BMI) of 29 kg/m2. Laboratory studies show a serum creatinine (SCr) level of 1.0 mg/dl and potassium level of 3.9 mEq/L. You perform an appropriate workup for secondary hypertension. His plasma renin activity is 0.3 ng/ml per hour (reference range, 0.6–3.0 ng/ml per hour) and his plasma aldosterone level is 44 ng/dl (reference range, 2–5 ng/dl). He had a right adrenal adenoma shown on  abdominal CT scan..
Question: Which ONE of the following is the MOST appropriate next step in the management of this patient?
A. Refer for surgery
B. Add spironolactone 50 mg daily
C. Add amiloride 5 mg twice daily
D. Refer for adrenal vein sampling
Answer: D
Subject: Hypertension
Question: Question 2480:
Which ONE of the following indices best identifies individuals with primary aldosteronism who are MOST likely to benefit from surgery?
A. An aldosterone/renin ratio of 40
B. A selectivity index of 6
C. A lateralization index of 6
D. Contralateral suppression of aldosterone
E. A low peripheral venous aldosterone/cortisol ratio
Answer: C
Subject: Hypertension
A 26-year-old man develops an acute and severe elevation in BP to 220/140 mmHg during elective surgery for a hernia repair. The surgery is abandoned because of persistently high and uncontrolled BP. He has no prior history of hypertension, but does have a family history of hypertension..
Question: Which ONE of the following is the MOST appropriate diagnostic test to order next?
A. Aldosterone/renin ratio
B. Polysomnography
C. CT angiography
D. Plasma metanephrines
E. Plasma catecholamines
Answer: D
Subject: Hypertension
A 44-year-old man with paroxysmal hypertension has recently been diagnosed with an 8 cm paraaortic paraganglioma in the organ of Zuckerkandl observed on computed tomography imaging. His plasma catecholamines and metanephrines are ten times above the upper limit of the reference range. He is referred for surgical management..
Question: In addition to adequate preoperative combined alpha- and beta-blockade before surgery, which ONE of the following is the next MOST appropriate step in management?
A. 123-I-metaiodobenzylguanidine scintigraphy
B. Fluorodeoxyglucose positron emission tomography
C. Genetic testing
D. Urine catecholamines
Answer: C
Subject: Hypertension
A 72-year-old man with a history of poorly controlled hypertension is evaluated 3 months after a left-sided middle cerebral artery stroke. He wants advice about the optimal BP for which he should aim in order to prevent a future stroke. On physical examination, his BP is 156/80mmHg. He does not have carotid bruits or a cardiac murmur. He has decreased strength in the right arm graded at 5-/5. The remainder of the examination is normal. Review of a magnetic resonance imaging/angiography study of the brain performed during his hospitalization 3 months ago shows no evidence of large vessel disease and an infarct in the distribution of the left middle cerebral artery..
Question: Which ONE of the following is associated with the highest 5-year risk of stroke, acute myocardial infarction, and death for this patient?
A. A discharge systolic BP of > 140 mmHg
B. Maintenance of his systolic BP <140 mmHg
C. Maintenance of his systolic BP <130 mmHg
D. Maintenance of his systolic BP <120 mmHg
Answer: D
Subject: Hypertension
A 65-year-old woman with hypertension and atrial fibrillation is evaluated in the emergency department for acute onset of headache, right sided weakness, and lethargy. A CT scan of her head reveals a left-sided frontal lobe hemorrhage. She has been adherent with warfarin anticoagulation, and her admission international normalized ratio (INR) is 2.4. A physical examination shows a BP of 184/88 mmHg. A neurologic examination shows lethargy, a dense right-leg paresis, and decreased strength in the right arm..
Question: In addition to discontinuing warfarin, which ONE of the following is the MOST appropriate in the management of this patient?
A. Reversal of INR to 2.0 < 4 hours
B. Reversal of INR to 1.3 <  4 hours
C. Reversal of INR to < 1.3 plus lowering of systolic BP < 160 mmHg within 4 hours
D. Reversal of INR to <  1.3 plus lowering of systolic BP < 140 mmHg within 4 hours
Answer: C
Subject: Hypertension
An 84-year-old woman with hypertension is evaluated during a routine follow-up visit. Her daughter is concerned that her memory has gradually declined over the past year. She has been on a stable antihypertensive regimen over the past 10 years that includes lisinopril, amlodipine, and chlorthalidone. A physical examination shows a BP of 138/76 mmHg and a pulse rate of 66/min. She has no edema. The findings of the examination are otherwise unremarkable. Ambulatory BP monitoring shows a mean daytime BP of 140/80 mmHg, and a mean nighttime BP of 136/84 mmHg without nocturnal dipping. The results of a 24-hour urine test shows 130 mEq of sodium excretion..
Question: Which ONE of the following findings is MOST predictive of cognitive decline in this woman?
A. Her diastolic BP
B. Her systolic BP
C. Her dietary sodium intake
D. The absence of nocturnal dipping
Answer: D
Subject: Hypertension
A 72-year-old white man with a history of CKD is referred for evaluation of resistant hypertension. His average blood pressure is 170/95 mmHg on a regimen that includes optimally dosed valsartan, amlodipine, carvedilol, and chlorthalidone. A physical examination shows a BMI of 24 kg/m2, and a BP of 172/96 mmHg without arm discrepancy. He has grade 2 hypertensive retinopathy and an S4 gallop. He does not have edema. The remainder of the examination is unremarkable. Laboratory studies show a stable SCr level of 2.1 mg/dl (eGFR, 38 ml/min per 1.73 m2)..
Question: Which ONE of the following is MOST likely to be associated with resistant hypertension in this man?
A. His BMI
B. Underlying CKD
C. His age
D. His race
Answer: B
Subject: Hypertension
A 55-year-old woman with hypertension, hyperlipidemia, and active smoking is evaluated in follow-up for hypertension. She asymptomatic. She is currently taking lisinopril 40 mg daily and chlorthalidone 25 mg daily for her hypertension. Her office BP is 139/78 mmHg in the seated position and 135/76 mmHg after standing for 2 minutes. The findings from her physical examination and laboratory tests are unremarkable..
Question: Based on the findings of the Systolic Blood Pressure Intervention Trial (SPRINT), which ONE of the following would be the MOST appropriate next step in her management?
A. Continue the same treatment
B. Decrease the dose of lisinopril to allow her systolic BP to increase above 140 mmHg
C. Add amlodipine, targeting a systolic BP of < 140 mmHg
D. Add amlodipine, targeting a systolic BP of < 120 mmHg
E. Stop lisinopril and substitute amlodipine
Answer: D
Subject: Hypertension
The SPRINT study compared a systolic BP target of 140 mmHg with a target of 120 mmHg in patients without diabetes who had hypertension and a high risk for cardiovascular disease..
Question: Which ONE of the following statements is correct about SPRINT?
A. The study results were difficult to interpret because the separation of systolic BP between the two groups was only 4 mmHg (130 mmHg versus 126 mmHg)
B. The low BP target (120 mmHg) was associated with acute kidney injury in 20% of patients
C. The low BP target (120 mmHg) resulted in a 38% reduction in the risk of heart failure
D. The standard BP target (140 mmHg) resulted in a 14% reduction in the risk of myocardial infarction
E. Among study subjects older than 75 years, randomization to the low BP target (120 mmHg) group resulted in a 22%-higher rate of cardiovascular events
Answer: C
Subject: Hypertension
A 28-year-old woman is referred to you for the evaluation of hypertension that has been present for the past 6 months. She has no significant medical problems and is taking no medications. On physical examination, her BP is 150/98 mmHg. There are no other relevant findings. As part of her evaluation, a computed tomography angiogram shows  a segment of multifocal left main renal artery stenosis, consistent with medial fibroplasia..
Question: Which ONE of the following is the MOST appropriate next step in her management?
A. Start losartan, aspirin, and atorvastatin
B. Obtain a renal scintigraphy scan with captopril
C. Refer for percutaneous renal angioplasty
D. Refer for percutaneous renal angioplasty and stenting
E. Refer for renal artery bypass
Answer: C
Subject: Hypertension
Question: Question 2491:
Which ONE of the following statements about 25-hydroxyvitamin D (25OHD) deficiency and hypertension is correct?
A. 25OHD deficiency is associated with higher rates of hypertension in individuals below age 50 but not among older patients
B. 25OHD replacement in elderly patients with 25OHD deficiency and isolated systolic hypertension effectively lowers systolic BP compared with placebo
C. 25OHD replacement is an effective therapy for orthostatic hypotension
D. 25OHD treats the white-coat effect in patients with white-coat hypertension, but does not lower ambulatory BP
E. 25OHD replacement has no effect on BP in hypertensive patients with 25OHD deficiency
Answer: E
Subject: Hypertension
One of your patients with hypertension who is currently treated with amlodipine and benazepril, informs you that he would like to start drinking beetroot juice on the basis of what he has read on the Internet. He asks you for your opinion on its safety and efficacy with regard to hypertension..
Question: Which ONE of the following options is correct about the effects of beetroot juice on BP?
A. Beetroot juice lowers BP by decreasing aldosterone production
B. Beetroot juice has an acute BP-lowering effect over the first 4–7 days, but tachyphylaxis develops after this initial period
C. Beetroot juice lowers ambulatory BP by about 8/5 mmHg compared with placebo
D. Beetroot juice increases pulse wave reflection
E. Beetroot juice is a well known cause of hypertension and should be avoided
Answer: C