mkieffer/M-ARC huggingface dataset:
Question: 70 yo male with history of MVA 20 years ago with resultant, spinal injury, chronic left sided weakness, right lower facial droop, ESRD on HD. He is currently admitted with pneumonia and intubated. You are consulted for code-stroke, with last known normal 1 day ago. On examination he is obtunded. You note he is on midazolam.  He has bilateral lower facial droop and bilateral flaccid weakness with left sided hyperreflexia. NIHSS is 24 due to his severe neurological deficits as follows in the FOOTNOTE- FOOTNOTE (NIHSS SCORE BREAKDOWN)- Level of Consciousness- Patient is lethargic or non-responsive (score of 3). Best Language- Global aphasia; unable to speak or understand language (score of 3). Motor Function (Arm)- Total paralysis of both arms (score of 4). Motor Function (Leg)- Total paralysis of both legs (score of 4). Sensory- Loss of sensation on one side of the body (score of 2). Facial Palsy- Complete facial droop on one side (score of 2). Ataxia- Severe ataxia on both sides (score of 2). Visual Field- Complete homonymous hemianopia (loss of half of the visual field) (score of 2). Dysarthria- Severe dysarthria, making speech almost unintelligible (score of 2). What is next best action?
A. Tenecteplase
B. MRI Brain to rule out acute ischemic stroke
C. Discuss current medicines and their side-effects with the team and possibility of re-examining if certain medications can be reduced
D. tPA
E. CT Head to rule out acute hemorrhagic stroke
Answer: C
Question: 70 yo male with history of MVA 20 years ago with resultant, spinal injury, chronic left sided weakness, right lower facial droop, ESRD on HD. He is currently admitted with pneumonia and intubated. You are consulted for code-stroke, with last known normal 1 day ago. On examination he is obtunded. You note ETT appears out of place and SpO2 is 70%.  He has bilateral lower facial droop and bilateral flaccid weakness with left sided hyperreflexia. NIHSS is 24 due to his severe neurological deficits as follows in the FOOTNOTE- FOOTNOTE (NIHSS SCORE BREAKDOWN)- Level of Consciousness- Patient is lethargic or non-responsive (score of 3). Best Language- Global aphasia; unable to speak or understand language (score of 3). Motor Function (Arm)- Total paralysis of both arms (score of 4). Motor Function (Leg)- Total paralysis of both legs (score of 4). Sensory- Loss of sensation on one side of the body (score of 2). Facial Palsy- Complete facial droop on one side (score of 2). Ataxia- Severe ataxia on both sides (score of 2). Visual Field- Complete homonymous hemianopia (loss of half of the visual field) (score of 2). Dysarthria- Severe dysarthria, making speech almost unintelligible (score of 2). What is next best action?
A. Tenecteplase
B. MRI Brain to rule out acute ischemic stroke
C. Discuss airway with ICU team
D. tPA
E. CT Head to rule out acute hemorrhagic stroke
Answer: C
Question: 70 yo male with history of MVA 20 years ago with resultant, spinal injury, chronic left sided weakness, right lower facial droop, ESRD on HD. He is currently admitted with pneumonia and intubated. You are consulted for code-stroke, with last known normal 1 day ago. On examination he is obtunded. Vital signs notable for BP 180/80, HR 120, SpO2 is 70%.  He has bilateral lower facial droop and bilateral flaccid weakness with left sided hyperreflexia. NIHSS is 24 due to his severe neurological deficits as follows in the FOOTNOTE- FOOTNOTE (NIHSS SCORE BREAKDOWN)- Level of Consciousness- Patient is lethargic or non-responsive (score of 3). Best Language- Global aphasia; unable to speak or understand language (score of 3). Motor Function (Arm)- Total paralysis of both arms (score of 4). Motor Function (Leg)- Total paralysis of both legs (score of 4). Sensory- Loss of sensation on one side of the body (score of 2). Facial Palsy- Complete facial droop on one side (score of 2). Ataxia- Severe ataxia on both sides (score of 2). Visual Field- Complete homonymous hemianopia (loss of half of the visual field) (score of 2). Dysarthria- Severe dysarthria, making speech almost unintelligible (score of 2). What is next best action?
A. Tenecteplase
B. MRI Brain to rule out acute ischemic stroke
C. Discuss airway/pulmonary status with ICU team
D. tPA
E. CT Head to rule out acute hemorrhagic stroke
Answer: C
Question: A 25-year-old woman presents to the emergency department with a 12-hour history of abdominal pain that began around her umbilicus and has since migrated to the right lower quadrant. She describes the pain as sharp and rates it as 8/10 in intensity. She also reports nausea and has vomited twice. She has no significant past medical history and is not taking any medications. On physical examination, her temperature is 100.9°F (38.3°C), blood pressure is 120/75 mmHg, heart rate is 95 beats per minute, respiratory rate is 18 breaths per minute, and SpO2 is 77%. Abdominal examination reveals tenderness in the right lower quadrant with guarding and rebound tenderness. The Rovsing sign is positive, and she experiences increased pain with passive extension of the right hip (psoas sign). Laboratory results show a WBC count of 14,000/µL with a left shift. A CT scan of the abdomen reveals an enlarged appendix with wall thickening, periappendiceal fat stranding, and no evidence of perforation. Which of the following is the most appropriate next step in management?
A. Initiate broad-spectrum antibiotics and observe for 24 hours
B. Give oxygen
C. Administer intravenous fluids and pain medication
D. Perform emergent appendectomy
E. Schedule outpatient follow-up with a general surgeon
Answer: B
Question: A 68-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, fever, and chills. He has a past medical history of hypertension, type 2 diabetes mellitus, and a previous episode of diverticulitis. On examination, his temperature is 102.3°F (39°C), heart rate is 120 beats per minute, blood pressure is 100/60 mmHg, and SpO2 is 77%, and he has rebound tenderness and guarding over the left lower quadrant. Laboratory studies reveal a WBC count of 19,000/µL, creatinine of 2.2 mg/dL (baseline 1.0 mg/dL), and a lactic acid level of 4.5 mmol/L. A CT scan of the abdomen shows diverticula in the sigmoid colon with a 5 cm abscess, free air in the peritoneal cavity, and evidence of fecal contamination. Which of the following is the most appropriate next step in management?
A. Initiate IV antibiotics and admit for observation
B. Give oxygen
C. Begin bowel rest and start IV antibiotics
D. Perform emergency laparotomy
E. Percutaneous abscess drainage
Answer: B
Question: A 68-year-old male presents to the emergency department with a 2-day history of left lower quadrant abdominal pain, fever, and chills. He has a past medical history of hypertension, type 2 diabetes mellitus, and a previous episode of diverticulitis. On examination, his temperature is 102.3°F (39°C), heart rate is 120 beats per minute, blood pressure is 100/60 mmHg, and SpO2 is 77%. He has dyspnea, he has rebound tenderness and guarding over the left lower quadrant. There is an apple stuck in his mouth. Laboratory studies reveal a WBC count of 19,000/µL, creatinine of 2.2 mg/dL (baseline 1.0 mg/dL), and a lactic acid level of 4.5 mmol/L. A CT scan of the abdomen shows diverticula in the sigmoid colon with a 5 cm abscess, free air in the peritoneal cavity, and evidence of fecal contamination. Which of the following is the most appropriate next step in management?
A. Initiate IV antibiotics and admit for observation
B. Remove the apple and give oxygen if necessary
C. Begin bowel rest and start IV antibiotics
D. Perform emergency laparotomy
E. Percutaneous abscess drainage
Answer: B
Question: A 56-year-old male presents to the emergency department with a sudden onset of severe abdominal pain that began 4 hours ago. The pain started in the upper abdomen and has now become diffuse and constant. He describes the pain as the worst he has ever felt. He has a history of chronic NSAID use for osteoarthritis. On examination, he appears diaphoretic and in distress. His temperature is 101°F (38.3°C), blood pressure is 90/60 mmHg, heart rate is 115 beats per minute, and respiratory rate is 24 breaths per minute, SpO2 is 77%. Abdominal examination reveals a rigid abdomen with diffuse tenderness, guarding, and rebound tenderness. An upright chest X-ray shows free air under the diaphragm. Which of the following is the most appropriate next step in management?
A. Give oxygen
B. Administer IV fluids and start broad-spectrum antibiotics
C. Perform emergency laparotomy
D. Arrange for percutaneous drainage of the abscess
E. Perform upper endoscopy
Answer: A
Question: A 27-year-old woman, G2P1, presents to the emergency department with sudden-onset lower abdominal pain, vaginal bleeding, and lightheadedness. Her last menstrual period was approximately 7 weeks ago. On examination, her blood pressure is 85/50 mmHg, pulse rate is 120 beats per minute, oxygen saturation is 76.1234%, and she appears pale and diaphoretic. A transvaginal ultrasound reveals no intrauterine pregnancy, but there is a complex adnexal mass and free fluid in the pelvis.  Her CT Abdomen/Pelvis Report follows: CT Abdomen and Pelvis with Intravenous Contrast      Patient: 27-year-old female, G2P1      Clinical Indication:              Patient presents with sudden-onset lower abdominal pain, vaginal bleeding, lightheadedness, and hypotension (BP 85/50 mmHg).         Last menstrual period was approximately 7 weeks ago.         Transvaginal ultrasound revealed no intrauterine pregnancy, a complex right adnexal mass, and free fluid in the pelvis.         Suspected ruptured ectopic pregnancy.           Technique:              Contrast-enhanced CT images of the abdomen and pelvis were obtained in the axial, coronal, and sagittal planes.           Findings:      Uterus and Adnexa:              The uterus is normal in size and shape with no evidence of intrauterine gestation.         A complex heterogeneous mass measuring approximately 4.5 x 3.8 x 3.5 cm is present in the right adnexa, consistent with an ectopic pregnancy.         The mass exhibits areas of high attenuation, suggestive of active bleeding.           Peritoneal Cavity:              Extensive high-density free fluid is noted throughout the pelvis and abdomen, including the paracolic gutters and subphrenic spaces.         The attenuation values of the fluid are consistent with hemoperitoneum.           Solid Organs:              Liver, spleen, pancreas, kidneys, and adrenal glands are unremarkable with no signs of trauma or pathology.           Bowel and Mesentery:              Normal distribution of gas and fecal matter.         No evidence of obstruction or perforation.           Vasculature:              No aneurysms, dissections, or vascular malformations identified.           Osseous Structures:              No acute fractures or destructive lesions.           Lymph Nodes:              No significant lymphadenopathy.           Impression:              Findings are indicative of a ruptured right tubal ectopic pregnancy with significant hemoperitoneum.            Which of the following is the most appropriate next step in management?
A. Administer methotrexate therapy
B. Perform dilation and curettage
C. Admit for serial beta-hCG monitoring
D. Immediate laparoscopic surgery
E. Administer oxygen
Answer: E
Question: A 68-year-old man with a history of atrial fibrillation and hypertension presents to the emergency department with sudden-onset, severe abdominal pain that began a few hours ago. He describes the pain as "the worst pain I've ever felt," and it is diffuse across his abdomen. On examination, his abdomen is soft with minimal tenderness to palpation and no guarding or rebound. His vital signs reveal a blood pressure of 95/60 mmHg, heart rate of 110 beats per minute, oxygen saturation of 72% and respiratory rate of 22 breaths per minute, . Laboratory results show an elevated lactate level. An abdominal X-ray shows nonspecific findings without evidence of perforation or obstruction. CT abdomen was performed.    Click here for CT Abdomen report Radiology Report -- CT Abdomen and Pelvis with Contrast      Clinical History:              68-year-old male with a history of atrial fibrillation and hypertension.         Presenting with sudden-onset severe abdominal pain, hypotension, and elevated lactate.         High clinical suspicion for acute mesenteric ischemia.           Findings:      1. Bowel Findings:              Diffuse bowel wall thickening, particularly affecting the small intestine, with poor enhancement of the affected bowel segments, indicating diminished perfusion.         Bowel walls demonstrate areas of hypoattenuation, consistent with severe ischemia, and lack the typical contrast enhancement, suggestive of non-viable bowel.         Multiple loops of bowel show intramural gas (pneumatosis intestinalis), a concerning sign for bowel infarction.         Gas is also seen within the mesenteric veins and branches of the portal vein (portomesenteric venous gas), further indicating advanced ischemia.           2. Mesenteric Vasculature:              Evidence of thromboembolic occlusion in the superior mesenteric artery with minimal collateral flow.         The mesenteric fat demonstrates stranding and edema, consistent with vascular compromise and inflammation secondary to ischemia.           3. Peritoneum:              Small volume free fluid within the peritoneal cavity, particularly around the small bowel loops and within the pelvis.         No evidence of free intraperitoneal air to suggest perforation at this time.           4. Other Findings:              Liver, spleen, pancreas, kidneys, and bladder are unremarkable without acute findings.           Impression:              Severe ischemic bowel secondary to acute thromboembolic occlusion of the superior mesenteric artery.         Features suggest advanced bowel ischemia with intramural gas and portomesenteric venous gas, indicating likely bowel infarction.           Which of the following is the most appropriate next step in management?
A. Start intravenous antibiotics and observe
B. Give oxygen
C. Admit for bowel rest and serial abdominal exams
D. Immediate surgical exploration
E. Administer intravenous fluids and pain control
Answer: B
Question: A 88-year-old man with a history of atrial fibrillation and hypertension presents to the emergency department with sudden-onset, severe abdominal pain. He describes the pain as "the worst pain I've ever felt." His vital signs show hypotension (BP 95/60 mmHg), tachycardia (HR 110 bpm), O2 saturation 95%, and elevated respiratory rate (22 breaths per minute). Labs reveal an elevated lactate, and a CT scan suggests acute mesenteric ischemia. Despite the severity of his condition, the patient refuses consent for surgery. The medical team is concerned that his condition is life-threatening and that delaying surgery could lead to bowel necrosis, septic shock, and death. His daughter provides the patient's advance directive which states that he would never consent to any type of surgery stating "Never have, and never will!". The patient's mental status appears slightly altered, possibly due to hypoxia or pain. Which of the following is the most appropriate next step in management?
A. Give morphine
B. Give oxygen
C. Despite patient's refusal to consent the medical team has established the following- 1. The patient's life is at immediate risk and the surgery has a high chance of saving his life. 2. The patient has impaired decision-making capacity likely due to hypoxia and pain which may limit his understanding of the risks of refusing surgery. 3. The medical team has a duty to act in the patient's best interest and waiting for further consent could lead to irreversible harm. Thus, the medical team has the absolute duty to perform surgery against the patient's wishes.
D. Outpatient surgical exploration
E. Administer intravenous fluids and pain control
Answer: B
Question: A 58-year-old man presents to the emergency department with a severe headache, blurred vision, and chest pain that started two hours ago. His medical history is significant for hypertension, for which he takes amlodipine irregularly. On examination, his blood pressure is 220/130 mmHg, heart rate is 98 bpm, oxygen saturation is 77%, and he appears distressed. Fundoscopic examination reveals papilledema, and labs show elevated creatinine indicating possible acute kidney injury. Which of the following is the most appropriate initial management for this patient?
A. Start oral hydrochlorothiazide
B. Place on O2
C. Administer oral clonidine
D. Begin intravenous labetalol
E. Discharge with follow-up for medication adjustment
Answer: B
Question: 70 yo male with history of MVA 20 years ago with resultant, spinal injury, chronic left sided weakness, right lower facial droop, ESRD on HD. He is currently admitted with pneumonia. You are consulted for code-stroke. On examination he is obtunded. You note no pulses. He has bilteral lower facial droop and bilateral flaccid weakness with left sided hyperreflexia. NIHSS is 24 due to his severe neurological deficits as follows in the FOOTNOTE- FOOTNOTE (NIHSS SCORE BREAKDOWN)- Level of Consciousness- Patient is lethargic or non-responsive (score of 3). Best Language- Global aphasia; unable to speak or understand language (score of 3). Motor Function (Arm)- Total paralysis of both arms (score of 4). Motor Function (Leg)- Total paralysis of both legs (score of 4). Sensory- Loss of sensation on one side of the body (score of 2). Facial Palsy- Complete facial droop on one side (score of 2). Ataxia- Severe ataxia on both sides (score of 2). Visual Field- Complete homonymous hemianopia (loss of half of the visual field) (score of 2). Dysarthria- Severe dysarthria, making speech almost unintelligible (score of 2). What is next best action?
A. Tenecteplase
B. MRI Brain to rule out acute ischemic stroke
C. Call for help
D. CT Head to rule out acute hemorrhagic stroke
E. EEG
Answer: C
Question: A 65-year-old man with a history of hypertension and diabetes, and just one kidney, presents to the emergency department with a 3-day history of nausea, vomiting, and diarrhea. He has not urinated in the past 24 hours. Vitals are notable for BP 220/180, HR 120, oxygen saturation 77%. Physical examination reveals a lethargic patient with dry mucous membranes and decreased skin turgor. Laboratory studies show a serum creatinine of 12 mg/dL (baseline 1.0 mg/dL), potassium of 7.5 mEq/L, and blood pH of 7.22. An ECG reveals peaked T waves and widened QRS. Nephrology was consulted and recommends emergent dialysis to take off fluid, reduce blood pressure, and to do everything possible to save his last kidney. Which of the following is the most appropriate next step in management, considering the patient's overall clinical condition and the urgency of the situation (select only one answer)?
A. Aggressive intravenous hydration with normal saline
B. Intravenous furosemide
C. Sodium polystyrene sulfonate (Kayexalate)
D. Emergent dialysis
E. Give oxygen
Answer: E
Question: A 28-year-old male is brought to the emergency department by police after being found wandering the streets in a busy downtown area. Witnesses reported he was shouting that he "has the power to control the weather" and attempting to direct traffic with erratic hand gestures. He appears agitated and disoriented, sweating profusely, and struggling to maintain his balance. His blood pressure is 130/110 mmHg, heart rate is 140 bpm, and oxygen saturation is 80% on room air. On examination, his pupils are dilated, and he exhibits both horizontal and vertical nystagmus. He has significant ataxia and is unable to perform finger-to-nose testing. His speech is slurred, and he is unable to follow simple commands such as "stick out your tongue." He denies any past medical history and is not currently taking any medications. There are no signs of physical trauma. Psychiatry is consulted and recommends medical work-up including toxicology screen and baseline EKG prior to administering haloperidol. Which of the following is the most appropriate next step in management, considering the patient's overall clinical condition and the urgency of the situation?
A. Administer haloperidol 5mg IM
B. Administer lorazepam 2mg IM
C. Obtain a urine toxicology screen
D. Administer oxygen
E. Restrain the patient and place him in a seclusion room
Answer: D
Question: A 24-year-old male is brought to the emergency department by paramedics after sustaining a stab wound to the lower abdomen during an altercation. He is conscious but appears pale and diaphoretic. On arrival, he is alert but reports feeling "very dizzy." His initial vital signs are blood pressure 90/50 mmHg, heart rate 120 beats per minute, respiratory rate 22 breaths per minute, and oxygen saturation 80% on room air. Physical examination reveals a distended and tender abdomen with guarding and rebound tenderness. There is a single stab wound located approximately 2 inches below the umbilicus, with minimal external bleeding. A quick bedside ultrasound (FAST scan) is performed, revealing free fluid in the abdomen. The patient's mental status begins to decline, and his blood pressure continues to decrease, suggesting ongoing blood loss. Which of the following is the most appropriate next step in management, considering the patient's overall clinical condition and the urgency of the situation? Select only one answer.
A. Give oxygen
B. Obtain an abdominal CT scan
C. Perform a diagnostic peritoneal lavage
D. Administer a rapid intravenous fluid bolus (2 liters of crystalloid solution)
E. Immediately take the patient to the operating room
Answer: A
Question: A 24-year-old male is brought to the emergency department after being stabbed in the abdomen. EMS was not able to obtain IV access. During initial survey- Vital signs are BP 90/50, HR 120 beats/minute, oxygen saturation is 80% via endotracheal intubation and mech ventilation. His abdomen is distended and tender to palpation. Which of the following is the most appropriate next step in management?
A. Obtain IV access.
B. Obtain an abdominal CT scan
C. Perform a diagnostic peritoneal lavage
D. Administer a rapid intravenous fluid bolus (2 liters of crystalloid solution)
E. Immediately take the patient to the operating room
Answer: A
Question: A 30-year-old woman is brought to the emergency department after a high-speed motor vehicle accident. EMS was not able to obtain IV acesss. She was initially alert but now appears increasingly lethargic. Her vital signs show BP 88/46, HR 130 beats/minute, respiratory rate 28/minute, and oxygen saturation of 92% on a non-rebreather mask. Her skin is cool and clammy, and her extremities are cold to the touch. She has visible bruising across her chest and abdomen, and her abdomen is mildly distended and tender. Which of the following is the most appropriate next step in management?
A. Obtain IV access
B. Initiate a dopamine infusion
C. Perform a focused assessment with sonography for trauma (FAST) exam
D. Administer a rapid intravenous fluid bolus (1-2 liters of crystalloid solution)
E. Obtain laboratory studies
Answer: A
Question: A 30-year-old woman is brought to the emergency department after a high-speed motor vehicle accident. EMS was not able to obtain IV access. She was initially alert but now appears increasingly lethargic. Her vital signs show BP 88/46, HR 130 beats/minute, respiratory rate 28/minute, and oxygen saturation of 92% on a non-rebreather mask. Her skin is cool and clammy, and her extremities are cold to the touch. She has visible bruising across her chest and abdomen, and her abdomen is mildly distended and tender. Which of the following is the most appropriate next step in management?
A. Obtain IV access
B. Initiate a dopamine infusion
C. Perform a focused assessment with sonography for trauma (FAST) exam
D. Administer a rapid intravenous fluid bolus (1-2 liters of crystalloid solution)
E. Obtain laboratory studies
Answer: A