agentclinic_nejm_extended.jsonl

{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20240111&width=1500&height=4000", "question": "A 55-year-old woman presented to the dermatology clinic with a 1-year history of skin darkening on her face. Two years before presentation, she had started applying a skin-lightening cream containing hydroquinone to her face daily to treat melasma. On physical examination, bluish-brown patches with background erythema and telangiectasias were observed on the cheeks, nasal bridge, and perioral region, with lesser involvement on the forehead (left). Dermoscopy of the affected areas revealed hyperchromic, pinpoint macules (middle). A skin-biopsy sample from the left cheek showed extracellular deposition of yellow-brown, banana-shaped bodies in the dermis (right, hematoxylin and eosin stain). What is the most likely diagnosis?", "patient_info": "For your role as a patient, you are a 55-year-old woman who has noticed your skin darkening on your face over the past year. You began using a skin-lightening cream containing hydroquinone daily two years ago to address melasma. You've observed bluish-brown patches on your cheeks, nasal bridge, and around your mouth, with some patches also appearing on your forehead. These patches have a background of redness and you've noticed some small, visible blood vessels in these areas. You haven't seen any specific test readings but are aware of the changes in your skin's appearance and texture.", "physical_exams": "The information extracted from the case report relevant to instrument readings and test results includes: 1. Dermoscopy findings: Hyperchromic, pinpoint macules observed in the affected areas. 2. Skin biopsy results: Extracellular deposition of yellow-brown, banana-shaped bodies in the dermis, as revealed by hematoxylin and eosin stain.", "answers": [{"text": "Contact dermatitis", "correct": false}, {"text": "Eczematous drug eruption", "correct": false}, {"text": "Exogenous ochronosis", "correct": true}, {"text": "Lichen planus pigmentosus", "correct": false}, {"text": "Solar lentigenes", "correct": false}], "type": ["dermatology"]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20240118&width=1500&height=4000", "question": "A 9-year-old boy who had recently emigrated from Brazil presented to the emergency department with a 3-week history of neck swelling, fevers, and weight loss. On physical examination, there was fixed, tender lymphadenopathy in the posterior auricular, submandibular, and occipital chains. Laboratory testing was notable for peripheral eosinophilia. Tests for cryptococcus, histoplasmosis, and human immunodeficiency virus were negative. CT scan of the neck showed hyperattenuating cervical lymphadenopathy on both sides. Lymph node biopsy results are shown. What is the most likely diagnosis?", "patient_info": "For your role as a patient actor, here's the minimal information you need to convey your symptoms accurately: - **Age and Background**: You are a 9-year-old boy who recently moved from Brazil. - **Symptoms**: - You've been experiencing swelling in your neck for the past 3 weeks. - You've had fevers during this period. - You've noticed that you've lost some weight without trying. - **Physical Discomfort**: - The swollen areas in your neck, specifically behind your ears (posterior auricular), under your jaw (submandibular), and at the back of your head (occipital), are tender to touch and don't move when you try to push them. - **Medical Tests and Results** (which you're not aware of, but might influence your portrayal): - You've had some blood tests done, but you don't know the details. - You've undergone a CT scan of your neck, but you haven't been told the results. - You've had a biopsy of the lymph nodes in your neck, but again, you don't know the outcomes. Remember, your character is aware of the symptoms and the discomfort they cause but does not know the specific medical terms, test readings, or the diagnosis.", "physical_exams": "Laboratory testing results: - Peripheral eosinophilia present - Tests for cryptococcus: Negative - Tests for histoplasmosis: Negative - Tests for human immunodeficiency virus (HIV): Negative Imaging results: - CT scan of the neck: Hyperattenuating cervical lymphadenopathy on both sides", "answers": [{"text": "Actinomycosis", "correct": false}, {"text": "Blastomycosis", "correct": false}, {"text": "Coccidiomycosis", "correct": false}, {"text": "Hodgkin\u2019s Lymphoma", "correct": false}, {"text": "Paracoccidiomycosis", "correct": true}], "type": ["CT scan", "hist/path"]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20240222&width=1500&height=4000", "question": "A 28-year-old woman presented to the hospital with a 6-month history of dry cough. She was a lifetime nonsmoker and reported no fevers, joint aches, eye pain, or rashes. On physical examination, auscultation of both lower lungs revealed fine crackles. High-resolution computed tomography (CT) of the chest showed mediastinal lymphadenopathy and diffuse ground-glass opacities (left, axial view). Also visible were areas of superimposed interlobular and intralobular septal thickening, a pattern known as crazy paving (left, box). A subsequent transbronchial lung biopsy showed multiple noncaseating granulomas (middle, inset showing granuloma; hematoxylin and eosin stain). Bronchoalveolar lavage cultures, histopathological analysis, and molecular testing were negative for infectious organisms, including Mycobacterium tuberculosis. Which of the following is the most likely diagnosis?", "patient_info": "For your role as a patient, you need to convey the following symptoms and history: - You are a 28-year-old woman. - You have been experiencing a dry cough for the past 6 months. - You have never smoked in your life. - You have not had any fevers, joint aches, eye pain, or rashes. - During a physical examination, it was noted that there were fine crackles when listening to both of your lower lungs. Remember, you are not aware of your diagnosis or the specific findings from the high-resolution computed tomography (CT) scan, biopsy, or any other tests. Your knowledge is limited to your symptoms and medical history as described above.", "physical_exams": "High-resolution computed tomography (CT) of the chest: Mediastinal lymphadenopathy and diffuse ground-glass opacities observed. Areas of superimposed interlobular and intralobular septal thickening, a pattern known as crazy paving. - Transbronchial lung biopsy: Showed multiple noncaseating granulomas (hematoxylin and eosin stain). - Bronchoalveolar lavage cultures: Negative for infectious organisms. - Histopathological analysis: Negative for infectious organisms. - Molecular testing: Negative for infectious organisms, including Mycobacterium tuberculosis.", "answers": [{"text": "Foreign body granulomatosis", "correct": false}, {"text": "Granulomatosis with polyangiitis", "correct": false}, {"text": "Pulmonary alveolar proteinosis", "correct": false}, {"text": "Pulmonary Langerhans cell histiocytosis", "correct": false}, {"text": "Pulmonary Sarcoidosis", "correct": true}], "type": ["CT scan", "hist/path"]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20231228&width=1500&height=4000", "question": "A 43-year-old woman presented to the dermatology clinic with an 8-year history of yellow-brown spots on her shins. The lesions had been asymptomatic, and she had not sought care for them until they had grown in size. She had no history of diabetes mellitus, hypertension, or thyroid disease. On physical examination, atrophic yellow-brown plaques with telangiectasias and irregular violaceous borders were observed on both shins. A skin biopsy of the right shin was performed. Histopathological analysis showed several layers of necrobiosis within the dermis, perivascular inflammatory-cell infiltrates, collagen degeneration, and findings consistent with granulomatous dermatitis. Which of the following is the most likely diagnosis?", "patient_info": "For your role as a patient, here's what you need to know: - You are a 43-year-old woman. - For the past 8 years, you've noticed yellow-brown spots on your shins. These spots have grown in size over time but haven't caused you any discomfort. - You've never been diagnosed with diabetes, high blood pressure, or thyroid problems. - Recently, you decided to seek medical advice because the spots on your shins have gotten bigger. - During the examination, the doctor noted that you have atrophic yellow-brown plaques with a network of small blood vessels (telangiectasias) and irregular purple edges on both shins. - You underwent a skin biopsy on your right shin to help diagnose your condition.", "physical_exams": "Skin biopsy of the right shin: Histopathological analysis revealed several layers of necrobiosis within the dermis, perivascular inflammatory-cell infiltrates, collagen degeneration, and findings consistent with granulomatous dermatitis.", "answers": [{"text": "Cutaneous sarcoidosis", "correct": false}, {"text": "Granuloma annulare", "correct": false}, {"text": "Necrobiosis lipoidica", "correct": true}, {"text": "Pigmented purpuric dermatosis", "correct": false}, {"text": "Stasis purpuric dermatosis", "correct": false}], "type": ["dermatology", "hist/path"]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20231130&width=1500&height=4000", "question": "A 53-year-old woman presented with a 3-month history of worsening vascular skin lesions and a 1-month history of fever. On physical examination, diffuse telangiectasis, hyperpigmented plaques, and several ulcerated nodules (arrows) were observed on the skin across the chest and abdomen (left) and the legs. No palpable lymphadenopathy or hepatosplenomegaly was noted. Laboratory studies were notable for a lactate dehydrogenase level of 35664 U per liter (reference range, 120 to 250). A deep skin biopsy specimen from the abdomen showed intravascular aggregation of round, atypical lymphocytes (right, hematoxylin and eosin staining). Subsequent immunohistochemical staining was positive for CD20, PAX-5, and MUM-1 in the neoplastic cells. Which of the following is the most likely diagnosis?", "patient_info": "As a patient actor, you are a 53-year-old woman who has been experiencing the following symptoms for the past few months: 1. **Worsening Vascular Skin Lesions**: You've noticed an increase in skin issues over the last three months, including changes in the appearance of your skin. 2. **Fever**: For the past month, you've had a persistent fever that doesn't seem to go away. 3. **Skin Changes**: You've observed diffuse telangiectasis (small, widened blood vessels on your skin), hyperpigmented plaques, and several ulcerated nodules across your chest, abdomen, and legs. 4. **No Swelling of Lymph Nodes or Liver/Spleen Enlargement**: You haven't noticed any swelling in your lymph nodes or any changes that would suggest your liver or spleen is enlarged. You are not aware of any specific test results or the technical details of your condition, such as laboratory findings or biopsy results.", "physical_exams": "Laboratory studies: - Lactate dehydrogenase level: 35664 U per liter (reference range, 120 to 250). Biopsy findings: - Deep skin biopsy specimen from the abdomen showed intravascular aggregation of round, atypical lymphocytes. - Immunohistochemical staining results: Positive for CD20, PAX-5, and MUM-1 in the neoplastic cells.", "answers": [{"text": "Chronic lymphocytic leukemia", "correct": false}, {"text": "Cutaneous small vessel vasculitis", "correct": false}, {"text": "Idiopathic multicentric Castleman", "correct": false}, {"text": "Intralymphatic histiocytosis", "correct": false}, {"text": "Intravascular lymphoma", "correct": true}], "type": ["CT scan", "biopsy"]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20231123&width=1500&height=4000", "question": "A 69-year-old woman with a history of asbestos exposure presented to the emergency department with a 3-year history of dyspnea on exertion. Physical examination showed signs of volume overload. A chest radiograph showed circumferential calcification of the pericardium and pleural effusions. Simultaneous left and right heart catheterization showed ventricular interdependence and discordance of the pressure tracings (right ventricular pressure, solid arrow; left ventricular pressure, dotted arrow). What is the diagnosis?", "type": ["xray"], "patient_info": "You are a 69-year-old woman who has been exposed to asbestos in the past. For the last three years, you've been experiencing difficulty breathing, especially when you exert yourself. You've noticed that you feel more full or bloated than usual, which has been concerning. You haven't seen any specific test results, but you're aware that your doctors have been looking closely at your heart and lungs, mentioning something about the shape and pressures in your heart being unusual.", "physical_exams": "Chest radiograph: Circumferential calcification of the pericardium and pleural effusions. - Simultaneous left and right heart catheterization: Ventricular interdependence and discordance of the pressure tracings (right ventricular pressure, solid arrow; left ventricular pressure, dotted arrow).", "answers": [{"text": "Cardiac Tamponade", "correct": false}, {"text": "Constrictive Pericarditis", "correct": true}, {"text": "Effusive-Constrictive Pericarditis", "correct": false}, {"text": "Primary Pericardial Mesothelioma", "correct": false}, {"text": "Restrictive Cardiomyopathy", "correct": false}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20231116&width=1500&height=4000", "question": "A 53-year-old man presented with a 3-year history of an itchy rash, Raynaud\u2019s phenomenon, dysphagia, and a burning sensation in his hands. Physical examination was notable for firm, greasy papules across his forehead that led to the formation of glabellar grooves (left). There were waxy papules on his hands, with associated skin thickening and finger flexion contractures (right). Similar skin changes were seen on his nose, lips, ears, trunk, and feet. There was no telangiectasia or calcinosis. Sensory neuropathy was present in his hands, arms, and face. Tests of thyroid function were normal. Serum protein electrophoresis with immunofixation identified an IgG-monoclonal gammopathy, and a bone marrow biopsy was normal. What is the most likely diagnosis?", "type": ["physical"], "patient_info": "For your role as a patient, here's the information you need to convey your symptoms accurately: - **Age and General Condition**: You are a 53-year-old man. - **Symptom Duration**: You've been experiencing your symptoms for 3 years. - **Skin Issues**: You have an itchy rash and firm, greasy papules (small bumps) on your forehead, which have caused deep lines between your eyebrows. Similar skin changes, like waxy papules and thickening, are on your nose, lips, ears, trunk, and feet. Your hands also show skin thickening and you have difficulty fully straightening your fingers due to tightness. - **Sensations**: You feel a burning sensation in your hands. - **Raynaud\u2019s Phenomenon**: You experience episodes where your fingers change color (white, then blue, then red) in the cold or during stress. - **Dysphagia**: Swallowing food and drinks has become difficult for you. - **Neuropathy**: You have noticed a decrease in sensation in your hands, arms, and face, making them feel numb or tingly. - **Other Tests**: You are aware that your thyroid function tests came back normal and that some blood work showed an abnormal protein, but you don't know the details or implications. Remember, you are not aware of your diagnosis or the specific test results, just these symptoms and general health checks.", "physical_exams": "Thyroid function tests: Normal - Serum protein electrophoresis with immunofixation: IgG-monoclonal gammopathy detected - Bone marrow biopsy: Normal", "answers": [{"text": "Light chain (AL) amyloidosis", "correct": false}, {"text": "Multiple myeloma", "correct": false}, {"text": "Scleredema", "correct": false}, {"text": "Scleromyxedema", "correct": true}, {"text": "Systemic sclerosis", "correct": false}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20231102&width=1500&height=4000", "question": "A 38-year-old man with end-stage renal disease who was undergoing hemodialysis presented to the hospital with several years of progressive difficulty in walking. Four years before presentation, acute pain and swelling in both knees had developed after he had stepped off an auto rickshaw. At that time, he had opted for conservative management of his injuries. On physical examination at the current presentation, there was a soft-tissue depression proximal to the patella on both sides (left). A palpable suprapatellar gap was also present on both sides at the site of the expected quadriceps tendon insertion (right). The patient was unable to extend his knees and walked with flexed knees. What is the most likely diagnosis?", "type": ["physical"], "patient_info": "For the patient actor: - **Age and Background**: You are a 38-year-old man with a history of end-stage renal disease, for which you are undergoing hemodialysis. - **Symptom Onset**: Your walking difficulties began to progressively worsen over the last four years. This started after an incident where you experienced acute pain and swelling in both knees after stepping off an auto rickshaw. - **Initial Management**: At the time of your knee injuries, you chose to manage the symptoms conservatively, without seeking aggressive medical or surgical treatment. - **Current Symptoms**: - You have noticed a soft-tissue depression just above your kneecaps. - There is a noticeable gap above your kneecaps where you would expect the thigh muscle to connect. - You are unable to straighten your legs fully. - You walk with your knees bent due to the difficulty in extending them. Remember, you are aware of these symptoms and physical changes but do not know your diagnosis.", "physical_exams": "The provided text does not include specific instrument readings or test results that can be extracted. It describes the patient's symptoms, physical examination findings, and history, but does not mention any laboratory tests, imaging studies, or other diagnostic tests that would provide numerical or specific instrument readings. Therefore, I cannot generate information based on instrument readings from the provided case report.", "answers": [{"text": "Femoral nerve injuries", "correct": false}, {"text": "Patellar stress fractures", "correct": false}, {"text": "Patellar tendon ruptures", "correct": false}, {"text": "Quadriceps strains", "correct": false}, {"text": "Quadriceps tendon ruptures", "correct": true}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20231026&width=1500&height=4000", "question": "An 83-year-old woman with a history of type 2 diabetes mellitus presented with a 4-month history of a pruritic rash on her back. Physical examination showed a linear array of crateriform lesions containing crusted material on an erythematous base. A skin biopsy showed a cup-shaped ulceration with transepidermal elimination of basophilic collagen and with cellular debris. What is the most likely diagnosis?", "type": ["physical", "hist/path"], "patient_info": "As a patient actor, you are an 83-year-old woman with a history of type 2 diabetes mellitus. For the past four months, you have been experiencing a pruritic (itchy) rash on your back. When you look at the rash or describe it to others, you notice it forms a linear pattern with crater-like lesions that have some crusted material on top, all set against a reddened skin area. You have not been informed of any diagnosis based on these symptoms.", "physical_exams": "The information provided does not include specific instrument readings or numerical test results. It describes physical examination findings and histopathological observations from a skin biopsy. Therefore, there are no instrument readings to report from the given case information.", "answers": [{"text": "Dermatofibroma", "correct": false}, {"text": "Folliculitis", "correct": false}, {"text": "Keratoacanthoma", "correct": false}, {"text": "Reactive perforating collagenosis", "correct": true}, {"text": "Prurigo nodularis", "correct": false}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230921&width=1500&height=4000", "question": "A 54-year-old woman with asthma and allergic rhinitis presented with a 3-month history of productive cough and dyspnea. She also reported fevers, chills, night sweats, and an unintentional 9-kg (20-lb) weight loss. On lung examination, there was expiratory wheezing and diffuse crackles. Laboratory testing showed pronounced hypereosinophilia. A computed tomography of the chest showed upper lobe\u2013predominant peripheral and subpleural consolidations that spared the perihilar region (shown). Serum testing for IgE against Aspergillus fumigatus, antibodies against coccidioides, and antineutrophil cytoplasmic antibodies was negative. Bronchoscopy with bronchoalveolar lavage was notable for 74% eosinophils in the cell count (reference value, <2) and negative tests for infectious diseases. What is the most likely diagnosis?", "type": ["CT scan"], "patient_info": "For your role as a patient, you are a 54-year-old woman with a history of asthma and allergic rhinitis. Over the past three months, you've been experiencing a productive cough and difficulty breathing. You've also had fevers, chills, night sweats, and noticed that you've unintentionally lost 20 pounds. When you breathe, there's a wheezing sound, and you can hear crackling noises in your lungs. You're not aware of your specific test results, but you know you've been feeling very unwell and that your doctors are concerned about your lung symptoms and recent weight loss.", "physical_exams": "Pronounced hypereosinophilia - Computed tomography (CT) of the chest: Upper lobe\u2013predominant peripheral and subpleural consolidations, sparing the perihilar region - Serum IgE against Aspergillus fumigatus: Negative - Antibodies against coccidioides: Negative - Antineutrophil cytoplasmic antibodies: Negative - Bronchoscopy with bronchoalveolar lavage cell count: 74% eosinophils (reference value, <2%) - Tests for infectious diseases (via bronchoalveolar lavage): Negative", "answers": [{"text": "Allergic bronchopulmonary aspergillosis", "correct": false}, {"text": "Chronic eosinophilic pneumonia", "correct": true}, {"text": "Cryptogenic organizing pneumonia", "correct": false}, {"text": "Drug-Induced eosinophilic pneumonia", "correct": false}, {"text": "Pulmonary tuberculosis", "correct": false}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230831&width=1500&height=4000", "question": "A 53-year-old man who had been admitted to the hospital after a fall was noted to have an abnormal indentation of the lower eyelids. He had a history of corneal transplantation in both eyes. He had recently experienced progressive visual impairment, which had led to his fall. Ophthalmologic examination was notable for a deflection of the lower eyelids when he was looking down, owing to dome-shaped eyes, and decreased visual acuity. What is the most likely diagnosis?", "type": ["ophthalmology"], "patient_info": "For the patient actor: - **Age and Background**: You are a 53-year-old man. - **Medical History**: You have had corneal transplantation in both eyes previously. - **Recent Experiences**: - You've been experiencing progressive visual impairment recently. - This worsening vision contributed to a fall, which is why you were admitted to the hospital. - **Symptoms to Report**: - Mention noticing an unusual indentation of your lower eyelids. - When looking down, you've observed that your lower eyelids seem to deflect oddly due to the shape of your eyes. - Your vision has been getting worse, affecting your daily activities and leading to a fall.", "physical_exams": "The provided text does not contain specific instrument readings or test results related to the patient's condition. It mentions clinical observations and history, such as an abnormal indentation of the lower eyelids, a history of corneal transplantation, progressive visual impairment, and a deflection of the lower eyelids due to dome-shaped eyes, along with decreased visual acuity. For an instrument reader actor, there are no numerical or specific test results to report from this text.", "answers": [{"text": "Astigmatism", "correct": false}, {"text": "Corneal ulcer", "correct": false}, {"text": "Keratoconus", "correct": true}, {"text": "Keratoglobus", "correct": false}, {"text": "Pellucid marginal degeneration", "correct": false}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230810&width=1500&height=4000", "question": "A 3-year-old girl presented to the emergency department with a 1-day history of dark urine and jaundice after the development of an upper respiratory tract infection 1 week earlier. The physical examination was notable for pharyngeal erythema and exudates, conjunctival pallor, and scleral icterus. There was no hepatosplenomegaly, rash, or acrocyanosis. Laboratory studies showed a new anemia and findings consistent with hemolysis. A direct antiglobulin test was positive for C3d and weakly positive for IgG. A subsequent peripheral blood smear is shown. What is the most likely diagnosis?", "type": ["hist/path"], "patient_info": "As a patient actor, you should be aware of the following symptoms and history: - You have been experiencing dark urine for the past day. - You have developed jaundice, which is a yellowing of the skin and eyes. - About a week ago, you had symptoms of an upper respiratory tract infection. - During a physical examination, it was noted that you have a sore throat with redness and white spots (pharyngeal erythema and exudates), pale-looking eyes (conjunctival pallor), and yellowing of the whites of your eyes (scleral icterus). - You do not have an enlarged liver or spleen (no hepatosplenomegaly), no skin rash, and no blueness of the extremities (no acrocyanosis). Remember, you are not aware of your diagnosis or specific test results, just these symptoms and findings.", "physical_exams": "Laboratory studies indicated: - New anemia - Findings consistent with hemolysis - Direct antiglobulin test positive for C3d - Direct antiglobulin test weakly positive for IgG", "answers": [{"text": "Cold agglutinin syndrome", "correct": true}, {"text": "G6PD Deficiency", "correct": false}, {"text": "Hemolytic uremic syndrome", "correct": false}, {"text": "Hereditary spherocytosis", "correct": false}, {"text": "Warm autoimmune hemolytic anemia", "correct": false}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230727&width=1500&height=4000", "question": "A 13-year-old boy from Mali was referred to the pediatric urology clinic with a 3-month history of gross hematuria. He reported no fevers, flank pain, or dysuria. A physical examination was normal. Laboratory studies showed normal kidney function and an absolute eosinophil count of 2660 per cubic millimeter (reference range, 40-200). A urinalysis showed hematuria and pyuria, and a urine culture was negative. Microsopic examination of the urine is shown. What is the most likely diagnosis?", "type": ["hist/path"], "patient_info": "You are a 13-year-old boy who has been experiencing blood in your urine for the past 3 months. You haven't had any fever, pain in your side or back, or burning when you urinate. Your doctor did some tests, and everything seemed normal with your kidney function, but they found you have more eosinophils (a type of white blood cell) than usual. Also, when they looked at your urine under a microscope, besides the blood, they found some white blood cells, but no infection was found when they tried to grow bacteria from your urine.", "physical_exams": "Laboratory studies: - Kidney function: Normal - Absolute eosinophil count: 2660 per cubic millimeter (reference range, 40-200) Urinalysis: - Hematuria: Present - Pyuria: Present - Urine culture: Negative", "answers": [{"text": "Balantidium coli", "correct": false}, {"text": "Schistosoma hematobium", "correct": true}, {"text": "Schistosoma mansoni", "correct": false}, {"text": "Strongyloides stercoralis", "correct": false}, {"text": "Trichomonas vaginalis", "correct": false}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230713&width=1500&height=4000", "question": "A 78-year-old man with chronic obstructive pulmonary disease (COPD) presented with a 2-month history of dysphonia. For the past 10 years, he had used an inhaled glucocorticoid daily to manage his COPD. Fiberoptic laryngoscopy revealed white plaques on both vocal cords. A biopsy showed hyperkeratinized stratified squamous epithelium and threadlike filaments that stained with Grocott-Gomori methenamine silver stain. What is the most likely diagnosis?", "patient_info": "You are a 78-year-old man who has been managing chronic obstructive pulmonary disease (COPD) for many years, primarily using an inhaled glucocorticoid daily. Recently, you've noticed a change in your voice, which has become hoarse over the past two months. Upon examination by a specialist, they found white patches on your vocal cords.", "type": ["surgical", "biopsy"], "physical_exams": "Fiberoptic laryngoscopy: White plaques on both vocal cords. Biopsy: Hyperkeratinized stratified squamous epithelium and threadlike filaments. Grocott-Gomori methenamine silver stain: Positive staining of threadlike filaments.", "answers": [{"text": "Laryngeal amyloidosis", "correct": false}, {"text": "Laryngeal candidiasis", "correct": true}, {"text": "Laryngeal papillomatosis", "correct": false}, {"text": "Leukoplakia", "correct": false}, {"text": "Vocal-cord dysfunction", "correct": false}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230622&width=1500&height=4000", "question": "A 39-year-old man with human immunodeficiency virus infection that was being treated with antiretroviral therapy presented to the dermatology clinic with a 1-year history of recurrent, painful penile ulcers. Approximately once per month, erosions would appear ulcerate, heal spontaneously and then recur. Laboratory testing showed a CD4 cell count of 494 per cubic millimeter (reference range, 414 to 1123) and an HIV viral load of 450 copies per milliliter (reference range, <20). Biopsies of the lesions revealed epidermal necrosis, pseudoepitheliomatous epidermal hyperplasia, and a dense infiltrate of inflammatory cells in the dermis and subcutaneous tissue. Next-generation sequencing (NGS) of the tissue was performed. What is the most likely diagnosis?", "type": ["physical"], "patient_info": "You are a 39-year-old man who has been living with HIV and are on antiretroviral therapy. For the past year, you've been experiencing painful sores on your penis that seem to follow a cycle: they appear, ulcerate, heal on their own, and then come back about once a month. You haven't been keeping track of any specific test readings, but you are aware that your HIV is being managed with medication. You've sought help from a dermatology clinic to understand what's causing these recurrent ulcers.", "physical_exams": "Laboratory testing results for the patient are as follows: - CD4 cell count: 494 per cubic millimeter (Reference range: 414 to 1123) - HIV viral load: 450 copies per milliliter (Reference range: <20) Biopsy findings of the lesions include: - Epidermal necrosis - Pseudoepitheliomatous epidermal hyperplasia - Dense infiltrate of inflammatory cells in the dermis and subcutaneous tissue Next-generation sequencing (NGS) of the tissue was performed.", "answers": [{"text": "Chancroid", "correct": false}, {"text": "Condyloma acuminata", "correct": false}, {"text": "Condyloma lata", "correct": false}, {"text": "Herpes vegetans", "correct": true}, {"text": "Pemphigus vegetans", "correct": false}]}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230615&width=1500&height=4000", "question": "A 67-year-old man with chronic lymphocytic leukemia (CLL) presented with a painful rash. On physical examination, there was purple discoloration of the ear along with livedoid skin changes on the cheek and purpura on both calves. A skin biopsy showed leukocytoclastic vasculitis. Laboratory testing was notable for a low complement 4 level. What is the most likely diagnosis?",  "type": ["physical"],"answers": [{"text": "Beh\u00e7et\u2019s disease", "correct": false}, {"text": "Cryoglobulinemic vasculitis", "correct": true}, {"text": "Granulomatosis with polyangiitis", "correct": false}, {"text": "Leukemia cutis", "correct": false}, {"text": "Microscopic polyangiitis", "correct": false}], "patient_info": "For the patient actor: You are a 67-year-old man who has been previously diagnosed with chronic lymphocytic leukemia (CLL). You have recently developed a painful rash. You've noticed a purple discoloration on your ear, livedoid (net-like) skin changes on your cheek, and purpura (purple spots) on both of your calves. You have not been informed of any test results or specific diagnoses related to these symptoms.", "physical_exams": "Laboratory testing information:\n- Low complement 4 level"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230601&width=1500&height=4000", "question": "A 35-year-old man with IgA nephropathy presented with confusion, blurry vision, and seizures. Two weeks before presentation, he had started receiving cyclosporine. Physical examination was notable for a blood pressure of 160/80 mm Hg, drowsiness, and decreased visual acuity. A fundoscopic examinations was normal. T2-weighted magnetic resonance imaging (MRI) with fluid-attenuated inversion recovery sequencing of the head was performed. What is the most likely diagnosis?", "type": ["MRI"], "answers": [{"text": "Acute demyelinating encephalomyelitis", "correct": false}, {"text": "Methanol ingestion", "correct": false}, {"text": "Multifocal ischemic infarcts", "correct": false}, {"text": "Posterior reversible encephalopathy syndrome", "correct": true}, {"text": "West Nile virus encephalitis", "correct": false}], "patient_info": "For your role as the patient, you are a 35-year-old man who has been diagnosed with IgA nephropathy in the past. Recently, you've started experiencing some concerning symptoms, including confusion, blurry vision, and seizures. You've noticed these symptoms developing over the last two weeks, which coincides with the time you began taking a new medication called cyclosporine. You've also been feeling unusually drowsy and have noticed that your vision isn't as sharp as it used to be. During a recent check-up, your doctor mentioned that your blood pressure was higher than normal, recorded at 160/80 mm Hg. Despite these vision changes, you were told that your eye examination (fundoscopic examination) didn't show any abnormalities. You've undergone an MRI scan of your head, but you're awaiting the results and the final diagnosis from your healthcare team.", "physical_exams": "Blood pressure: 160/80 mm Hg\nT2-weighted MRI with fluid-attenuated inversion recovery sequencing of the head: Performed (specific findings not provided)"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230511&width=1500&height=4000", "question": "A 55-year-old man who had been admitted to the intensive care unit had a sudden-onset vesicular rash appear across his trunk and arms, as shown. He had undergone a small-bowel resection; his post-operative course had been complicated by sepsis, fevers, and respiratory failure. On exam, he was wrapped tightly in blankets. The vesicles did not rupture with light palpation but broke when more pressure was applied. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Drug eruption", "correct": false}, {"text": "Dyshidrotic eczema", "correct": false}, {"text": "Herpes zoster due to virus reactivation", "correct": false}, {"text": "Miliaria crystallina", "correct": true}, {"text": "Pityrosporum folliculitis", "correct": false}], "patient_info": "You are a 55-year-old man who recently had surgery to remove part of your small intestine. After the surgery, you've been feeling very unwell, with fevers and difficulty breathing, which led to you being cared for in the intensive care unit. You've noticed a sudden appearance of blister-like rashes across your chest and arms. These rashes are raised and filled with fluid, but they don't burst easily unless they're pressed on quite firmly. You've been feeling very cold and have been keeping yourself wrapped in blankets to stay warm.", "physical_exams": "The provided text does not contain specific instrument readings or test results that can be extracted. It describes a clinical scenario and physical examination findings without mentioning laboratory tests, imaging studies, or other diagnostic instrument readings."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230504&width=1500&height=4000", "question": "A 66-year-old man presented with an 8-month history of painful skin tightening and swelling of his arms and legs. The symptoms had progressed on glucocorticoids and methotrexate. On physical exam, there was symmetric, woody induration of the trunk, arms, and legs, sparing the hands and feet. The involved skin had a dimpled appearance. Elevation of the arms resulted in visible indentions along the course of superficial veins. Elbow contractures were also noted. What is the most likely diagnosis?",  "type": ["physical"], "answers": [{"text": "Eosinophilic fasciitis", "correct": true}, {"text": "Myxedema", "correct": false}, {"text": "Scleredema", "correct": false}, {"text": "Scleroderma", "correct": false}, {"text": "Scleromyxedema", "correct": false}], "patient_info": "For the patient actor: - Age: 66 years old - Symptoms started 8 months ago - Experiencing painful skin tightening and swelling in your arms and legs - Your symptoms have gotten worse even after taking glucocorticoids and methotrexate - Your trunk, arms, and legs feel very hard to the touch, but your hands and feet are not affected - Your skin looks dimpled - When you lift your arms, you can see indentations along where your veins are - You have difficulty fully bending your elbows", "physical_exams": "The provided text does not contain specific instrument readings or test results to extract."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230427&width=1500&height=4000", "question": "A 75-year-old woman presented to the infectious diseases clinic with a 10-day history of painful lesions on the right hand and forearm. An aspiration of the hand lesion was performed. Bacterial culture of the aspirate grew filamentous, gram-positive, acid-fast branching rods. Which of the following activities likely preceded development of the lesions?",  "type": ["dermatology"], "answers": [{"text": "Cleaning a fish tank", "correct": false}, {"text": "Gardening", "correct": true}, {"text": "Getting bitten by a sandfly", "correct": false}, {"text": "Handling feline waste", "correct": false}, {"text": "Petting an armadillo", "correct": false}], "patient_info": "You are playing the role of a 75-year-old woman who has been experiencing painful lesions on your right hand and forearm for the past 10 days. You have sought medical attention due to the discomfort and concern about these lesions. During your visit to the clinic, a doctor performed an aspiration of one of the lesions on your hand to better understand the cause of your symptoms. You are aware that a sample was taken and sent for bacterial culture, but you do not know the results or the specifics of the findings. Your primary concern is the discomfort and appearance of the lesions on your hand and forearm. You have not been informed of any diagnosis yet.", "physical_exams": "The test information from the case report is as follows:\n\n- An aspiration of the hand lesion was performed.\n- Bacterial culture of the aspirate grew filamentous, gram-positive, acid-fast branching rods."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230420&width=1500&height=4000", "question": "A 60-year-old left-handed woman presented to the emergency department with pain in her left forearm. The arm was swollen and tender, especially with passive pronation and supination. The overlying skin was intact, and the results of neurovascular examination were normal. Radiographs of the left forearm were performed (upper image, anteroposterior view; lower image, lateral view). The findings should raise concern for which contributory factor?",  "type": ["xray"], "answers": [{"text": "Assault", "correct": true}, {"text": "Fall", "correct": false}, {"text": "Malignancy", "correct": false}, {"text": "Osteoporosis", "correct": false}, {"text": "Repetitive strain", "correct": false}], "patient_info": "You are a 60-year-old left-handed woman who has come to the emergency department because you are experiencing pain in your left forearm. You've noticed that your arm is swollen and feels tender, especially when you try to rotate it inward or outward. The skin on your arm looks normal, and you haven't noticed any changes in sensation or blood flow. You haven't seen the X-ray results yourself, but you came in because of these symptoms.", "physical_exams": "The radiographs of the left forearm included two views: an anteroposterior view and a lateral view."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230413&width=1500&height=4000", "question": "A 34-year-old woman with tobacco use disorder was referred to the pulmonary clinic for worsening dyspnea and dry cough. She had chronic hypoxemic respiratory failure of unknown cause, requiring supplemental oxygen. Computed tomography of the chest showed diffuse ground-glass opacities and areas of peripheral consolidation but no basilar reticulations or honeycombing. Bronchoalveolar lavage was not diagnostic, so surgical lung biopsy was performed. Histopathological analysis showed extensive alveolar filling with pigment-laden macrophages. What is the most likely diagnosis?",  "type": ["CT scan", "hist/path"], "answers": [{"text": "Desquamative interstitial pneumonia", "correct": true}, {"text": "Diffuse alveolar hemorrhage", "correct": false}, {"text": "Idiopathic pulmonary fibrosis", "correct": false}, {"text": "Lipoid pneumonia", "correct": false}, {"text": "Pulmonary alveolar proteinosis", "correct": false}], "patient_info": "For your role as a patient, here's the information you need to convey your symptoms and situation without knowing the diagnosis: - You are a 34-year-old woman who smokes. - Recently, you've been experiencing worsening shortness of breath and a dry cough. - You've been told you have chronic hypoxemic respiratory failure, which means you've been needing extra oxygen to help you breathe. - You've undergone several tests, including a CT scan of your chest, which showed some unusual patterns in your lungs, but you're not sure what they mean. - You also had a procedure where they took a small sample from your lung to examine it more closely because the usual tests didn't give them enough information. - You're still waiting to hear back about the results from the latest tests and what they mean for your health.", "physical_exams": "Computed tomography (CT) of the chest: Diffuse ground-glass opacities and areas of peripheral consolidation. No basilar reticulations or honeycombing observed.\n\nBronchoalveolar lavage: Not diagnostic.\n\nHistopathological analysis (from surgical lung biopsy): Extensive alveolar filling with pigment-laden macrophages."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230406&width=1500&height=4000", "question": "An 87-year-old man with chronic kidney disease, hypertension, and atrial fibrillation presented to the emergency department with a 3-day history of constipation and lower abdominal pain. Physical examination was notable for abdominal distention and tenderness to palpation of the right lower quadrant without rebound or guarding. A plain radiograph of the abdomen is shown. What is the most likely diagnosis?",  "type": ["xray"], "answers": [{"text": "Cecal volvulus", "correct": true}, {"text": "Constipation", "correct": false}, {"text": "Hiatal hernia", "correct": false}, {"text": "Ogilvie\u2019s Syndrome (acute colonic pseudo-obstruction)", "correct": false}, {"text": "Small bowel obstruction", "correct": false}], "patient_info": "For the patient actor: You are an 87-year-old man with a history of chronic kidney disease, hypertension, and atrial fibrillation. You've come to the emergency department because for the past three days, you've been experiencing constipation and pain in your lower abdomen. You've noticed your abdomen seems swollen and feels tender when touched, especially on the right lower side. However, you don't feel pain when the pressure is released after your abdomen is pressed. You haven't had any recent injuries or unusual activities that might explain this discomfort.", "physical_exams": "The information provided for the instrument reader actor is as follows:\n\n- Patient's age: 87 years old\n- Relevant medical history: Chronic kidney disease, hypertension, atrial fibrillation\n- Symptoms: 3-day history of constipation and lower abdominal pain\n- Physical examination findings: Abdominal distention, tenderness to palpation of the right lower quadrant without rebound or guarding\n- Diagnostic test performed: Plain radiograph of the abdomen"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230330&width=1500&height=4000", "question": "A pregnant 33-year-old woman at 35 weeks\u2019 gestation presented with redness on both palms without pain and pruritus. She was otherwise asymptomatic. The skin changes had first appeared during the second trimester of pregnancy. Skin examination was notable for mottled, blanching erythema across the palms and fingers of both hands. What is the diagnosis?",  "type": ["dermatology"], "answers": [{"text": "Atopic eruption of pregnancy", "correct": false}, {"text": "Intrahepatic cholestasis of pregnancy", "correct": false}, {"text": "Palmar erythema of pregnancy", "correct": true}, {"text": "Polymorphic eruption of pregnancy", "correct": false}, {"text": "Tinea manuum", "correct": false}], "patient_info": "For the patient actor: You are a 33-year-old woman who is currently 35 weeks pregnant. You've noticed that since your second trimester, both of your palms and fingers have developed a redness. This redness doesn't cause any pain or itching. Other than this skin change, you feel generally well and haven't experienced any other symptoms.", "physical_exams": "The provided text does not contain specific instrument readings or test results to extract. It describes a clinical presentation and physical examination findings without mentioning any laboratory or diagnostic test outcomes."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230323&width=1500&height=4000", "question": "A baby girl was noted to have vesicular skin lesions immediately after spontaneous vaginal delivery at 32 weeks\u2019 gestation. Her 37-year-old mother had premature rupture of membranes 12 days before the delivery. On physical examination, clusters of vesicles were seen on the infant\u2019s torso (left), periumbilical region (right), and pharyngeal, nasal, and conjunctival mucosa. No lesions were seen on the mother\u2019s genitals or the placenta. What is the most likely diagnosis?",  "type": ["dermatology"], "answers": [{"text": "Bullous impetigo", "correct": false}, {"text": "Epidermolysis bullosa", "correct": false}, {"text": "Molluscum contagiosum", "correct": false}, {"text": "Neonatal herpes simplex virus", "correct": true}, {"text": "Transient pustular melanosis", "correct": false}], "patient_info": "For the patient actor portraying the baby girl: - **Symptoms to portray:** - You have clusters of vesicles (small, fluid-filled blisters) on your torso, around your belly button (periumbilical region), and inside your mouth, nose, and around your eyes (pharyngeal, nasal, and conjunctival mucosa). - **Background context (not symptoms, but useful for understanding the scenario):** - You were born prematurely at 32 weeks after your mother had premature rupture of membranes 12 days before giving birth. - Your mother is 37 years old. - There were no visible lesions on your mother's genitals or the placenta at the time of your birth.", "physical_exams": "The provided text does not contain specific instrument readings or test results to extract. It describes clinical observations and the medical history of the case. For an instrument reader actor looking for test information, there are no details such as laboratory values, imaging findings, or other diagnostic test results mentioned in the text provided."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230316&width=1500&height=4000", "question": "A 12-year-old boy with a history of obesity presented with a 2-week history of limping and dull pain in the right hip. The symptoms had begun after he had slipped and fallen at school. On physical exam, active and passive ranges of motion of the right hip were limited by pain. Radiographs of the pelvis were performed (frog-leg lateral view is shown). What is the most likely diagnosis?",  "type": ["xray"], "answers": [{"text": "Chondrosarcoma", "correct": false}, {"text": "Legg-Calve-Perthes disease", "correct": false}, {"text": "Osgood-Schlatter disease", "correct": false}, {"text": "Osteoarthritis", "correct": false}, {"text": "Slipped capital femoral epiphysis", "correct": true}], "patient_info": "For the patient actor: - **Age and Background**: You are a 12-year-old boy who has a history of being overweight. - **Symptoms**: - You've been limping for the past two weeks. - You are experiencing a dull pain in your right hip. - These symptoms started after you slipped and fell at school. - **Physical Limitations**: - You find it painful to move your right hip, both when you try to move it yourself and when someone else tries to move it for you. - **Recent Events**: Remember, you had an accident at school where you slipped and fell, which is when the pain and limping started.", "physical_exams": "The information provided does not include specific instrument readings or test results, such as numerical values or specific findings from the radiographs of the pelvis. It only mentions that radiographs were performed, without detailing the outcomes of these tests. Therefore, based on the information given, I cannot generate specific instrument readings or test results."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230309&width=1500&height=4000", "question": "A 30-year-old woman presented with a 3-month history of progressive skin lesions on her face. On physical examination, there were hyperpigmented, yellow, papillomatous papules and plaques on the face (left). Hyperpigmented velvety plaques were also seen on the skin of the neck, groin and axillae. She also reported new-onset heartburn, fatigue, and unintentional 15-kg weight loss. A skin biopsy of the facial lesion showed epidermal papillomatosis, acanthosis, hyperkeratosis, and negative staining for human papillomavirus. A computed tomography (CT) of the  abdomen and pelvis was performed (right). What is the most likely diagnosis?",  "type": ["physical", "CT scan"], "answers": [{"text": "Erythrasma", "correct": false}, {"text": "Ichthyosis hystrix", "correct": false}, {"text": "Malignant acanthosis nigricans", "correct": true}, {"text": "Pellagra (Vitamin B3 deficiency)", "correct": false}, {"text": "Pemphigus vegetans", "correct": false}], "patient_info": "For your role as a patient, here's the information you need to convey your symptoms accurately: - You are a 30-year-old woman. - Over the last 3 months, you've noticed progressive skin changes on your face. - These changes include hyperpigmented (darker than your normal skin tone), yellow, raised, wart-like spots (papules) and larger raised areas (plaques) on your face. - You've also observed similar hyperpigmented, velvety textured plaques on your neck, groin, and underarms. - Recently, you've started experiencing heartburn. - You've been feeling unusually tired. - You've lost 15 kilograms (about 33 pounds) without trying. - You haven't been told the results of any tests, including the skin biopsy or the CT scan, but you're aware these tests have been done. Remember, you're not aware of your diagnosis; you only know these symptoms and the tests you've undergone.", "physical_exams": "Based on the provided case report, the test information includes:\n\n1. **Skin Biopsy of the Facial Lesion:**\n   - Findings: Epidermal papillomatosis, acanthosis, hyperkeratosis.\n   - Staining: Negative for human papillomavirus.\n\n2. **Computed Tomography (CT) of the Abdomen and Pelvis:**\n   - The specific findings from the CT scan are not detailed in the provided information."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230302&width=1500&height=4000", "question": "A 62-year-old man undergoing abdominal ultrasonography for the evaluation of gallstones was found to have a retroperitoneal mass. A physical examination and the results of routine laboratory studies were normal. A computed tomographic (CT) urogram was completed (left), and a subsequent positron-emission tomography\u2013CT showed no hypermetabolic activity. He underwent stent placement in both ureters, and a core-biopsy of the perinephric soft tissue was obtained. Hematoxylin and eosin staining of the specimen is shown (right). What is the diagnosis?",  "type": ["CT scan", "hist/path"], "answers": [{"text": "Erdheim\u2013Chester disease", "correct": true}, {"text": "IgG4-related disease", "correct": false}, {"text": "Langerhans cell histiocytosis", "correct": false}, {"text": "Lymphoma", "correct": false}, {"text": "Sarcoidosis", "correct": false}], "patient_info": "For the patient actor: You are a 62-year-old man who initially went to the doctor for an evaluation of gallstones. During this process, an abdominal ultrasonography revealed a retroperitoneal mass. You haven't noticed any unusual symptoms, and your physical examination and routine lab tests didn't show anything abnormal. To further investigate the mass, you underwent a CT urogram and a PET-CT, which did not show any signs of the mass being metabolically active. To manage the situation and ensure your kidneys function properly, stents were placed in both of your ureters. A biopsy was taken from the soft tissue around your kidneys for further examination.", "physical_exams": "- Abdominal ultrasonography: Found a retroperitoneal mass.\n- Routine laboratory studies: Results were normal.\n- Computed tomographic (CT) urogram: Completed.\n- Positron-emission tomography\u2013CT: Showed no hypermetabolic activity.\n- Core-biopsy of the perinephric soft tissue: Obtained and hematoxylin and eosin staining performed."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230223&width=1500&height=4000", "question": "A 52-year-old woman with end-stage kidney disease that was being managed with peritoneal dialysis presented with a 1-month history of bloody dialysate. She had had 3 episodes of bacterial peritonitis in the past 12 years. Physical examination and laboratory studies were unremarkable. Computed tomography of the abdomen was performed. What is the most likely diagnosis?",  "type": ["CT scan"], "answers": [{"text": "Calciphylaxis", "correct": false}, {"text": "Encapsulating peritoneal sclerosis", "correct": true}, {"text": "Fungal peritonitis", "correct": false}, {"text": "Peritoneal carcinomatosis", "correct": false}, {"text": "Tuberculous peritonitis", "correct": false}], "patient_info": "For the patient actor: You are a 52-year-old woman who has been managing end-stage kidney disease with peritoneal dialysis. Over the past month, you've noticed that the dialysate, the fluid used in your dialysis treatment, has been bloody on several occasions. You have a history of bacterial peritonitis, having experienced it three times in the last 12 years. You haven't noticed any other unusual symptoms recently, and your routine physical exams and blood tests haven't shown anything out of the ordinary. You've just had a CT scan of your abdomen to investigate the cause of the bloody dialysate.", "physical_exams": "The patient's laboratory studies were unremarkable."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230216&width=1500&height=4000", "question": "An 80-year-old woman was admitted to the intensive care unit with severe second- and third-degree burns. On laboratory studies, she was noted to have a platelet count of 930,000 per cubic millimeter. Manual analysis of a subsequent peripheral-blood smear identified a platelet count of 115,000 per cubic millimeter. What is the cause for this discrepancy?",  "type": ["hist/path"], "answers": [{"text": "Pseudothrombocytopenia due to giant platelets", "correct": false}, {"text": "Pseudothrombocytopenia due to plate clumping associated with EDTA", "correct": false}, {"text": "Pseudothrombocytosis due to cryoglobulin-related interference by cryoprecipitates", "correct": false}, {"text": "Pseudothrombocytosis due to presence of microorganisms", "correct": false}, {"text": "Pseudothrombocytosis due to red cell fragments", "correct": true}], "patient_info": "As an 80-year-old woman, you were admitted to the intensive care unit due to severe burns. You are experiencing a significant health issue that has led to confusion regarding your blood test results. Specifically, there's a discrepancy in your platelet counts from different tests. One test showed a very high platelet count of 930,000 per cubic millimeter, which is unusually high, while a manual check of a blood smear showed a much lower count of 115,000 per cubic millimeter, which is within a normal range. You are unaware of the underlying reason for this discrepancy in platelet counts.", "physical_exams": "Laboratory studies indicated a platelet count of 930,000 per cubic millimeter. A manual analysis of a subsequent peripheral-blood smear identified a platelet count of 115,000 per cubic millimeter."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230209&width=1500&height=4000", "question": "A 77-year-old man with metastatic lung adenocarcinoma presented to the emergency department with a 2-week history of dyspnea. Imaging studies showed a pleural effusion on the right side, previously known liver metastases and perihepatic fluid, and new intrahepatic dilatation of the biliary ducts. A chest tube was placed, and the color of the drained pleural fluid was olive brown. What additional pleural-fluid test is most likely to reveal the diagnosis?",  "type": ["xray", "instrument"], "answers": [{"text": "Bacterial gram stain and culture", "correct": false}, {"text": "Bilirubin", "correct": true}, {"text": "Cytology", "correct": false}, {"text": "Fungal stain and culture", "correct": false}, {"text": "Triglycerides", "correct": false}], "patient_info": "You are a 77-year-old man who has been experiencing difficulty breathing for the past two weeks. You have a history of lung cancer that has spread to other parts of your body. Recently, you went to the hospital because your breathing problems got worse. The doctors found fluid in the lining of your lungs, some issues with your liver, and changes in the ducts inside your liver. To help with your breathing, the doctors placed a tube in your chest to drain the fluid, which was an unusual olive brown color.", "physical_exams": "Imaging studies:\n- Pleural effusion on the right side\n- Previously known liver metastases\n- Perihepatic fluid\n- New intrahepatic dilatation of the biliary ducts\n\nChest tube placement:\n- Drained pleural fluid color: Olive brown"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230202&width=1500&height=4000", "question": "A previously healthy 42-year-old woman presented to the dental clinic with a 6-month history of swelling and pain on the right side of her chin (left). She reported no history of chin trauma, tooth pain, or fevers, but did recall injuring her right lateral incisor 10 years prior. Palpation of the lesion caused pain and serosanguinous fluid drainage. Intra-oral examination showed discoloration of the right lateral mandibular incisor (right). What is the most likely diagnosis?",  "type": ["physical"], "answers": [{"text": "Odontogenic cutaneous fistula", "correct": true}, {"text": "Osteosarcoma", "correct": false}, {"text": "Pilar cyst", "correct": false}, {"text": "Sebaceous cyst", "correct": false}, {"text": "Squamous cell carcinoma", "correct": false}], "patient_info": "For the patient actor: - Age: 42 years old - Gender: Female - Medical History: Previously healthy, no significant medical history. Recalls injuring her right lateral incisor 10 years ago. No history of chin trauma, tooth pain, or fevers recently. - Current Symptoms: - Swelling and pain on the right side of the chin, ongoing for 6 months. - Pain upon palpation of the lesion on the chin, accompanied by serosanguinous fluid drainage. - Discoloration of the right lateral mandibular incisor observed during intra-oral examination.", "physical_exams": "The provided text does not contain specific instrument readings or test results that can be extracted for an instrument reader actor. It describes symptoms and clinical findings observed during a physical examination, such as swelling, pain, and serosanguinous fluid drainage from the chin area, as well as discoloration of the right lateral mandibular incisor. No numerical or measurable test results are mentioned."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230126&width=1500&height=4000", "question": "A previously healthy 14-year-old boy who lived on a farm presented with a 1-month history of episodic headaches associated with vomiting. Magnetic resonance imaging of the head was performed. Which of the following is the most likely diagnosis?", "type": ["MRI"], "answers": [{"text": "Arachnoid cysts", "correct": false}, {"text": "Colloid cyst", "correct": false}, {"text": "Cystic echinococcosis", "correct": true}, {"text": "Neurocysticercosis", "correct": false}, {"text": "Pineal cyst", "correct": false}], "patient_info": "For the patient actor: You are a 14-year-old boy who has been feeling generally healthy until about a month ago. You live on a farm. Recently, you've started experiencing headaches that come and go. These headaches are severe enough that they make you feel like vomiting, and sometimes you do vomit. You haven't noticed anything specific that triggers these headaches; they seem to happen randomly. You haven't had any major health issues before this started happening.", "physical_exams": "The information provided does not include specific instrument readings or test results from the magnetic resonance imaging (MRI) of the head. To generate information for an instrument reader actor, details about the MRI findings are necessary, but they are not provided in the text you've shared."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230119&width=1500&height=4000", "question": "A 37-year-old primigravid woman presented at 30 weeks\u2019 gestation with a 4-month history of pruritic pustules on her torso, arms, and legs. On examination, there were papules, nodules, and follicular pustules with surrounding erythema, with no lesions on the palms and soles. A skin biopsy showed subepidermal pustules and perifollicular neutrophilic infiltration. Gram\u2019s stain, periodic acid\u2013Schiff stain, and Grocott methenamine silver stain were all negative. What is the most likely diagnosis?",  "type": ["dermatology"], "answers": [{"text": "Atopic eruption of pregnancy", "correct": true}, {"text": "Disseminated herpes zoster", "correct": false}, {"text": "Pemphigoid gestationis", "correct": false}, {"text": "Polymorphic eruption of pregnancy", "correct": false}, {"text": "Secondary syphilis", "correct": false}], "patient_info": "You are a 37-year-old woman who is pregnant for the first time and currently 30 weeks along. For the past four months, you've been experiencing itchy pustules on your torso, arms, and legs. Upon examination, doctors noted that you have bumps, larger nodules, and pustules around hair follicles, all of which are red and inflamed, but you haven't noticed any issues on your palms or soles. Skin tests were done, but they didn't show any signs of bacterial or fungal infections.", "physical_exams": "Skin biopsy: Subepidermal pustules and perifollicular neutrophilic infiltration observed.\nGram\u2019s stain: Negative\nPeriodic acid\u2013Schiff stain: Negative\nGrocott methenamine silver stain: Negative"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230112&width=1500&height=4000", "question": "A previously healthy 5-year-old boy was brought to the surgery clinic with a 2-day history of intermittent abdominal pain. On palpation of the abdomen there was pain in the periumbilical region, but no rebound or guarding. An ultrasound was normal, and a computed tomography of the abdomen was performed (Panels A,B). Based on the CT findings, what is the most likely etiology of the patient\u2019s symptoms?",  "type": ["CT scan"], "answers": [{"text": "Crohn\u2019s disease", "correct": false}, {"text": "Colocolonic intussusception", "correct": true}, {"text": "Colonic pseudo-obstruction", "correct": false}, {"text": "Ileocolic intussusception", "correct": false}, {"text": "Sigmoid volvulus", "correct": false}], "patient_info": "You are a 5-year-old boy who has been feeling intermittent abdominal pain for the past 2 days. The pain seems to be centered around your belly button area. You haven't experienced any other symptoms like fever or vomiting, just the pain. You've been to the doctor, and they've checked your tummy by pressing on it, which hurt a bit around your belly button, but it didn't make the pain worse when they let go, and your tummy didn't feel hard to them. They also did a couple of tests, including an ultrasound and a special scan of your tummy, but you're not sure what those showed. You're just aware of the pain in your belly button area.", "physical_exams": "The patient underwent the following tests:\n\n1. Ultrasound of the abdomen - Result: Normal\n2. Computed Tomography (CT) of the abdomen - Panels A,B were performed (specific findings not provided in the text)."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20230105&width=1500&height=4000", "question": "A 17-year-old girl presented with a 1-month history of pruritic genital lesions. Three months before presentation, she had unprotected sexual intercourse with multiple male partners. On exam, multiple smooth, grayish-white papules and plaques were noted on the vulva and upper inner thighs. The lesions had a smooth, moist appearance. What is the most likely diagnosis?",  "type": ["physical"], "answers": [{"text": "Condylomata acuminata", "correct": false}, {"text": "Condylomata lata", "correct": true}, {"text": "Extraintestinal Crohn\u2019s disease", "correct": false}, {"text": "Herpes vegetans", "correct": false}, {"text": "Mpox", "correct": false}], "patient_info": "For the patient actor: - **Age and Background**: You are a 17-year-old girl. - **Symptom Duration**: You have been experiencing symptoms for 1 month. - **Sexual History**: You had unprotected sexual intercourse with multiple partners about three months ago. - **Symptoms**: - Itchy lesions in the genital area. - **Physical Observations**: - You have noticed multiple smooth, grayish-white papules (small bumps) and plaques (flat, raised lesions) on your vulva and upper inner thighs. These lesions have a smooth, moist appearance.", "physical_exams": "The provided text does not include specific instrument readings or test results to extract."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221229&width=1500&height=4000", "question": "A 34-year-old man was admitted to the hospital with diabetic ketoacidosis. He reported having had blurry vision, increasing shoe size, and a change in his facial features over the past several years. On exam, he was found to have bitemporal hemianopsia. Which of the following is the most likely cause of his presentation?", "type": ["physical"], "answers": [{"text": "Anabolic steroid use",   "correct": false}, {"text": "Beckwith\u2013Wiedemann syndrome", "correct": false}, {"text": "Nelson\u2019s syndrome", "correct": false}, {"text": "Pachydermoperiostosis", "correct": false}, {"text": "Somatotropic pituitary adenoma", "correct": true}], "patient_info": "For the patient actor: - **Age and Gender**: 34-year-old man - **Symptoms**: - Blurry vision - Increasing shoe size - Change in facial features - Experiencing vision problems, specifically losing vision on the outer halves of both the right and left field of vision (though you, as the patient, wouldn't necessarily know the medical term for this). Remember, you are not aware of your diagnosis or the specific medical terms related to your condition. You've noticed these changes over the past few years and have come to the hospital because your symptoms have worsened.", "physical_exams": "The provided text does not contain specific instrument readings or test results related to the patient's condition. It describes symptoms and clinical findings (diabetic ketoacidosis, blurry vision, increasing shoe size, change in facial features, bitemporal hemianopsia) but does not include numerical or specific test results from laboratory tests, imaging studies, or other diagnostic procedures. Therefore, I cannot extract instrument readings or test information from this case report as it stands."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221222&width=1500&height=4000", "question": "An 18-year-old man presented with a 2-day history of fever, vomiting, and diarrhea. Three weeks before presentation, he had fallen into a canal. Physical exam was notable for the findings shown in the image. Laboratory studies showed acute kidney injury and elevations in aminotransferase and total bilirubin levels. What is the most likely diagnosis?",  "type": ["physical"], "answers": [{"text": "Acute hemorrhagic conjunctivitis", "correct": false}, {"text": "Ebola hemorrhagic fever", "correct": false}, {"text": "Giardiasis", "correct": false}, {"text": "Leptospirosis", "correct": true}, {"text": "Subarachnoid hemorrhage", "correct": false}], "patient_info": "For your role as the patient, you are an 18-year-old man who has been experiencing fever, vomiting, and diarrhea for the past two days. You remember falling into a canal about three weeks ago. Currently, you are feeling unwell and have noticed some changes in your body, but you're not sure what they mean. You haven't been told about any test results or specific medical terms, but you are seeking medical attention because of how you've been feeling.", "physical_exams": "The laboratory studies indicated:\n- Acute kidney injury\n- Elevated aminotransferase levels\n- Elevated total bilirubin levels"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221215&width=1500&height=4000", "question": "A 58-year-old woman with a history of metastatic uterine leiomyosarcoma presented with a 1-month history of a nonpruritic rash on her arms. On examination, hyperpigmented plaques were observed on the dorsa of both hands at the sites of previous intravenous access. The darkened skin extended up the arms in a linear pattern along the network of superficial veins; the lesions were palpable but non-tender. What is the most likely diagnosis?",  "type": ["physical"], "answers": [{"text": "Bleomycin-induced flagellate erythema", "correct": false}, {"text": "Erythema ab igne", "correct": false}, {"text": "Phlegmasia cerulea dolens", "correct": false}, {"text": "Serpentine supravenous hyperpigmentation", "correct": true}, {"text": "Superficial thrombophlebitis", "correct": false}], "patient_info": "You are a 58-year-old woman who has been dealing with a type of cancer called uterine leiomyosarcoma that has spread to other parts of your body. For the past month, you've noticed a rash on your arms that doesn't itch. When you look at your arms, you see dark, raised patches on the backs of your hands where you've had IVs placed before. These dark patches go up your arms, following the path of your veins, but they don't hurt when you touch them.", "physical_exams": "The provided text does not contain specific instrument readings or test results to extract. It describes clinical observations and the patient's history."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221208&width=1500&height=4000", "question": "An 81-year-old woman with a history of hepatitis C virus\u2013related cirrhosis and hepatocellular carcinoma, who was treated 9 days earlier with transarterial chemoembolization with the use of doxorubicin-eluting beads, presented with painful, progressively worsening skin lesions over the abdomen. A skin biopsy revealed epidermal necrosis and occlusion of small vessels in the reticular dermis. What is the most likely cause of the epidermal necrosis?",  "type": ["physical", "hist/path"], "answers": [{"text": "Air Embolism", "correct": false}, {"text": "Bacterial Embolism", "correct": false}, {"text": "Drug-Eluting Bead Embolism", "correct": true}, {"text": "Cholesterol Embolism", "correct": false}, {"text": "Tumor Embolism", "correct": false}], "patient_info": "You are an 81-year-old woman who has a medical history that includes liver issues due to hepatitis C and liver cancer. You recently underwent a treatment involving a procedure to target cancer in your liver. About 9 days after this treatment, you started experiencing painful skin lesions on your abdomen, which have been getting worse.", "physical_exams": "The information provided does not include specific instrument readings or test results. It mentions a skin biopsy that revealed epidermal necrosis and occlusion of small vessels in the reticular dermis, but no numerical or specific instrument readings are provided."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221201&width=1500&height=4000", "question": "A 26-year-old man presented to the outpatient clinic with a 1-month history of pain and swelling in the scrotum and low-grade fevers. On examination, there was swelling and tenderness of the right side of the scrotum. Laboratory studies showed peripheral eosinophilia. An ultrasound of the scrotum showed echogenic, linear structures moving within the lymphatic channels (arrowhead) adjacent to the epididymal head and testis (asterisk) \u2014 a finding known as \u201cfilarial dance sign.\u201d What vector is responsible for transmitting the nematode causing this disease?",  "type": ["ultrasound"], "answers": [{"text": "Aquatic snail", "correct": false}, {"text": "Blackfly", "correct": false}, {"text": "Mosquito", "correct": true}, {"text": "Sandfly", "correct": false}, {"text": "Tsetse fly", "correct": false}], "patient_info": "For your role as a patient, you should be aware of the following symptoms and history: - You are a 26-year-old man. - You have been experiencing pain and swelling in your scrotum for the past month. - You have also had low-grade fevers. - The right side of your scrotum is swollen and tender to touch. You are not aware of your diagnosis or the specific test results, such as the ultrasound findings or the term \"filarial dance sign.\" You also do not know about the laboratory finding of peripheral eosinophilia.", "physical_exams": "Laboratory studies: Peripheral eosinophilia.\nUltrasound of the scrotum: Echogenic, linear structures moving within the lymphatic channels adjacent to the epididymal head and testis, known as \u201cfilarial dance sign.\u201d"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221124&width=1500&height=4000", "question": "A 70-year-old woman with depression and irritable bowel syndrome presented to the emergency department with a 3-day history of altered mental status, shortness of breath, nausea, and vomiting. She had recently been self-medicating worsening irritable bowel symptoms. Physical examination was notable for a respiratory rate of 22 breaths per minute, confusion, and mild, diffuse abdominal pain. Laboratory testing showed primary anion-gap metabolic acidosis and primary respiratory alkalosis. Toxicity of which of the following is the most likely cause of her acute symptoms and the findings seen in this non-contrast abdominal radiograph?", "type": ["xray"], "answers": [{"text": "Bismuth Salicylate",  "correct": true}, {"text": "Calcium Carbonate", "correct": false}, {"text": "Ferrous Sulfate", "correct": false}, {"text": "Magnesium hydroxide", "correct": false}, {"text": "Simethicone", "correct": false}], "patient_info": "For your role as a patient actor, here's the minimal information you need to convey your symptoms accurately: - **Age and Background**: You are a 70-year-old woman with a history of depression and irritable bowel syndrome. - **Symptoms Duration**: You've been experiencing your current symptoms for 3 days. - **Symptoms**: - Altered mental status (you're confused and possibly disoriented). - Shortness of breath. - Nausea and vomiting. - You've also been trying to manage worsening symptoms of your irritable bowel syndrome on your own recently. - **Physical Discomfort**: You feel a mild, diffuse pain in your abdomen. - **Breathing**: You're breathing faster than usual, at a rate of about 22 breaths per minute. Remember, you're not aware of your diagnosis or the specific test results, just these symptoms and your recent attempts at self-medication.", "physical_exams": "The patient's laboratory testing indicated primary anion-gap metabolic acidosis and primary respiratory alkalosis."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221117&width=1500&height=4000", "question": "A 45-year-old woman presented with a 6-week history of a painless upper-lip lesion. The lesion had rapidly increased in size over the previous 3 weeks and bled when lightly touched. Examination showed an erythematous, round, smooth, pedunculated mass that was friable and non-tender. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Arteriovenous malformation", "correct": false}, {"text": "Cherry hemangioma", "correct": false}, {"text": "Malignant melanoma", "correct": false}, {"text": "Pyogenic granuloma", "correct": true}, {"text": "Strawberry hemangioma", "correct": false}], "patient_info": "For the patient actor: - You are a 45-year-old woman. - You have noticed a lesion on your upper lip that has been present for 6 weeks. - The lesion has grown quickly in the last 3 weeks. - It bleeds when it's lightly touched but doesn't cause you any pain. - The lesion appears red, round, smooth, and is attached by a stalk (pedunculated). - It feels soft and crumbles easily (friable) but does not hurt when touched.", "physical_exams": "The provided text does not include specific instrument readings or test results that can be extracted for an instrument reader actor. It only describes the physical examination findings of the patient's condition."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221110&width=1500&height=4000", "question": "A previously healthy 25-year-old man presented to the general medicine clinic with a 3-month history of worsening fatigue, nausea, and dry cough following administration of a folk remedy for tinea cruris. Laboratory studies showed a hemoglobin level of 6.5 g per deciliter (reference range, 12.0 to 16.0), and normal renal function. Chest and abdominal radiographs were obtained. Which of the following is the appropriate treatment for this condition?", "type": ["xray"], "answers": [{"text": "Chelation Therapy", "correct": true}, {"text": "Exchange Transfusion", "correct": false}, {"text": "Hemodialysis", "correct": false}, {"text": "Plasma Exchange Therapy", "correct": false}, {"text": "Therapeutic Phlebotomy", "correct": false}], "patient_info": "For your role as a patient, you are a 25-year-old man who has been feeling increasingly tired over the last three months. You've also been experiencing nausea and a persistent dry cough. These symptoms started after you tried a folk remedy for a skin condition in your groin area. You haven't been told any specific test results or diagnoses, but you are aware that you've been feeling unwell and sought medical help because of these symptoms.", "physical_exams": "Laboratory studies showed:\n- Hemoglobin level: 6.5 g per deciliter (reference range, 12.0 to 16.0)\n- Renal function: Normal"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221103&width=1500&height=4000", "question": "A 5-year-old boy from China with a history of IgA vasculitis at 2 years of age presented with a 1-month history of progressively painful skin ulcerations on his extremities. Two months prior, he had had an episode of nasal pustules that had not responded to antimicrobial therapy or surgical d\u00e9bridement, but had ultimately improved with 2 days of systemic glucocorticoid therapy. At the current presentation, laboratory and radiographic studies showed no signs of underlying systemic disease, such as cancer, inflammatory bowel disease, or autoimmune conditions. Biopsy samples from the lesions showed a dense neutrophilic infiltrate with negative tissue cultures. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Cutaneous leishmaniasis", "correct": false}, {"text": "Cutaneous polyarteritis nodosa", "correct": false}, {"text": "Cutaneous tuberculosis", "correct": false}, {"text": "Ecthyma gangrenosum", "correct": false}, {"text": "Pyoderma gangrenosum", "correct": true}], "patient_info": "For the patient actor: You are a 5-year-old boy who has been experiencing progressively painful skin ulcerations on your arms and legs for the past month. You remember having some sores inside your nose about two months ago that didn't get better with antibiotics or a small surgery, but they did start to improve after you were given a special medicine that helps with swelling and immune system reactions for two days. You've had a condition called IgA vasculitis when you were 2 years old. You've been to the doctor recently, and they did a lot of tests and even took a small piece of the skin from the sore area to look at it under the microscope, but they told you that everything else in your body seems to be working fine and there's no sign of any big sickness like cancer or problems with your stomach and intestines or your body's defense system acting against itself.", "physical_exams": "The information provided from the case report for an instrument reader actor would include:\n\n- Laboratory studies showed no signs of underlying systemic disease, such as cancer, inflammatory bowel disease, or autoimmune conditions.\n- Radiographic studies also showed no signs of underlying systemic disease.\n- Biopsy samples from the lesions showed a dense neutrophilic infiltrate.\n- Tissue cultures from the biopsy samples were negative."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221027&width=1500&height=4000", "question": "A 75-year-old man presented to the emergency department with a 6-month history of epigastric pain, watery diarrhea, and weight loss. Esophagogastroduodenoscopy revealed severe esophagitis, antral erosions, and duodenal ulcers (left). The gastric pH was below 2, and a fasting serum gastrin level was above 1000 pg per milliliter (reference range, 13-115). Cross-sectional imaging identified a single tumor along the distal duodenum that was resected (right). Histopathological analysis showed a well-differentiated neuroendocrine tumor that was positive for gastrin on immunohistochemical staining. The diagnosis in this case is most closely associated with which of the following syndromes?", "type": ["surgical", "physical"], "answers": [{"text": "Li\u2013Fraumeni syndrome", "correct": false}, {"text": "Multiple endocrine neoplasia type 1", "correct": true}, {"text": "Multiple endocrine neoplasia type 2A", "correct": false}, {"text": "Multiple endocrine neoplasia type 2B", "correct": false}, {"text": "Von Hippel\u2013Lindau syndrome", "correct": false}], "patient_info": "You are a 75-year-old man who has been experiencing stomach pain, frequent watery diarrhea, and noticeable weight loss over the past six months. You've noticed these symptoms have been persistent and troubling.", "physical_exams": "Gastric pH: below 2\nFasting serum gastrin level: above 1000 pg per milliliter (reference range, 13-115)"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221020&width=1500&height=4000", "question": "A 37-year-old man presented to the emergency department with a 1-week history of pain and swelling in the left upper arm that had started after blunt trauma during soccer practice. The heart rate was 120 beats per minute, the blood pressure 96/54 mm Hg, and the body temperature 37.9\u00b0C. Examination of the left upper arm was notable for swelling, tenderness, and crepitus. The overlying skin was red and warm to the touch. An initial radiograph is shown. Which of the following factors is most associated with increased mortality in this diagnosis?", "type": ["xray"], "answers": [{"text": "Delay in surgical intervention >24 hours", "correct": true}, {"text": "Involvement of the upper extremity", "correct": false}, {"text": "Negative Blood Cultures", "correct": false}, {"text": "Patient age <60 years", "correct": false}, {"text": "Presence of erythema", "correct": false}], "patient_info": "You are a 37-year-old man who has come to the emergency department because you've been experiencing pain and swelling in your left upper arm for a week. This started after you got hurt during soccer practice. You've noticed that your arm is not only swollen and tender but also makes a crackling sound when touched. The skin over your arm is red and feels warm. You're not aware of your heart rate, blood pressure, or body temperature, but you do know that you're feeling quite unwell.", "physical_exams": "Heart rate: 120 beats per minute\nBlood pressure: 96/54 mm Hg\nBody temperature: 37.9\u00b0C"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221013&width=1500&height=4000", "question": "A 19-year-old woman presented with a 6-month history of a slowly growing asymptomatic dark spot on her left palm. Examination was notable for a nonscaling, nonpalpable brown patch (left). Dermatoscopy revealed pigmented spicules, and palmar skin scrapings were prepared (right). What is the most likely diagnosis?", "type": ["dermatology", "hist/path"], "answers": [{"text": "Acral lentiginous melanoma", "correct": false}, {"text": "Lichen planus", "correct": false}, {"text": "Secondary syphilis", "correct": false}, {"text": "Tinea nigra", "correct": true}, {"text": "Tinea versicolor", "correct": false}], "patient_info": "For the patient actor: You are a 19-year-old woman who has noticed a slowly growing dark spot on your left palm over the last 6 months. You haven't felt any pain or discomfort from it. When you look closely, the spot doesn't seem to be raised or flaky. You've come in because you're concerned about the changes in your skin's appearance.", "physical_exams": "The information provided does not include specific instrument readings or test results, such as numerical values or specific findings from laboratory tests. The only test-related information mentioned is the use of dermatoscopy, which revealed pigmented spicules, and the preparation of palmar skin scrapings. No specific results or readings from these procedures are provided."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20221006&width=1500&height=4000", "question": "A 34-year-old woman presented with a 3-year history of changes in skin color. Examination was notable for hypopigmented macules on a background of hyperpigmentation, creating a raindrop-like appearance on the chest and back. Neighbors who drank water from the same well had similar skin changes. What is the most likely diagnosis?", "type": ["dermatology"], "answers": [{"text": "Arsenic toxicity", "correct": true}, {"text": "Cadmium toxicity", "correct": false}, {"text": "Copper toxicity", "correct": false}, {"text": "Lead toxicity", "correct": false}, {"text": "Mercury toxicity", "correct": false}], "patient_info": "For the patient actor: - **Age and Gender**: You are a 34-year-old woman. - **Symptom Duration**: You have noticed changes in your skin color for the past 3 years. - **Symptoms Description**: - You have observed spots on your skin that are lighter in color than your normal skin tone (hypopigmented macules). - These lighter spots are on a background of darker skin (hyperpigmentation), giving a raindrop-like appearance. - These changes are primarily on your chest and back. - **Environmental Note**: You are aware that neighbors who share the same water source as you, specifically a well, have experienced similar skin changes.", "physical_exams": "The provided text does not contain specific instrument readings or test results to extract. It only describes the patient's symptoms and physical examination findings."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220929&width=1500&height=4000", "question": "A 24-year-old woman presented with a 2-month history of rash on her shins. The rash was asymptomatic and was more prominent in the left leg. It had first appeared during the winter, at which time she had been sitting by an electric heater that was closer to her left leg. Exam was without palpable purpura, subcutaneous nodules, or areas of gangrene. What is the diagnosis?", "type": ["dermatology"], "answers": [{"text": "Cryoglobulinemia", "correct": false}, {"text": "Cutaneous polyarteritis nodosa", "correct": false}, {"text": "Erythema ab igne", "correct": true}, {"text": "Livedo reticularis", "correct": false}, {"text": "Livedoid vasculitis", "correct": false}], "patient_info": "You are a 24-year-old woman who has noticed a rash on your shins for the past two months. The rash doesn't cause you any discomfort and seems to be more noticeable on your left leg. You first observed the rash during the winter, around the time you were frequently sitting by an electric heater, which was positioned closer to your left leg. Upon checking, you haven't found any raised purple spots (purpura), hard lumps under the skin (subcutaneous nodules), or dead, blackened tissue (gangrene) around the area.", "physical_exams": "The provided case report does not include specific instrument readings or test results. It only describes the patient's symptoms and physical examination findings. Therefore, there is no instrument reading information to extract from this case report."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220922&width=1500&height=4000", "question": "A 40-year-old man presented to the dermatology clinic with a 1-year history of painless swelling of his earlobes. He also reported nasal congestion and intermittent nosebleeds. Which of the following is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Cauliflower ear", "correct": false}, {"text": "Eosinophilic Granulomatosis and Polyangiitis", "correct": false}, {"text": "Lepromatous Leprosy", "correct": true}, {"text": "Malignant Otitis Externa", "correct": false}, {"text": "Relapsing Polychondritis", "correct": false}], "patient_info": "For your role as a patient, you are a 40-year-old man who has been experiencing painless swelling of your earlobes for the past year. Additionally, you have been dealing with nasal congestion and have had intermittent nosebleeds. You are seeking medical advice for these symptoms.", "physical_exams": "The provided text does not contain specific instrument readings or test information related to the patient's condition. Therefore, I cannot generate information based on instrument readings from the given text."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220915&width=1500&height=4000", "question": "A 58-year-old man with coronary artery disease presented to the emergency department with a 1-day history of intermittent chest pain at rest. An ECG was obtained on arrival, at which time the patient reported no chest pain. Which of the following is the most likely site of the culprit lesion?", "type": ["ECG"], "answers": [{"text": "Right coronary artery", "correct": false}, {"text": "Left circumflex artery", "correct": false}, {"text": "Left coronary artery", "correct": false}, {"text": "Posterior descending artery", "correct": false}, {"text": "Left anterior descending artery", "correct": true}], "patient_info": "For your role as a patient actor, you need to portray a 58-year-old man who has a history of coronary artery disease. You've come to the emergency department because you've been experiencing intermittent chest pain that occurs even when you're at rest. This has been happening for the past day. You should act as though you're not currently experiencing chest pain at the moment you're speaking with the healthcare provider. You do not know the specifics of your ECG results or the exact cause of your symptoms.", "physical_exams": "The patient underwent an ECG (Electrocardiogram) upon arrival at the emergency department."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220908&width=1500&height=4000", "question": "A 79-year-old woman with a history of prior stroke was referred for an abnormal X-ray finding along the left heart border, first noticed 6 years prior. In the absence of symptoms, the patient was monitored with serial radiographs which showed a gradual increase in size of the finding. Which of the following is the most likely diagnosis?", "type": ["xray"], "answers": [{"text": "Giant Coronary Aneurysm", "correct": true}, {"text": "Left Atrial Appendage Thrombus", "correct": false}, {"text": "Mediastinal Hematoma", "correct": false}, {"text": "Pericardial Cyst", "correct": false}, {"text": "Teratoma", "correct": false}], "patient_info": "For your role as a patient, you are a 79-year-old woman with a history of a stroke in the past. You've been referred to a specialist because of an unusual finding on an X-ray along the left side of your heart, which was first noticed 6 years ago. Since then, you haven't experienced any symptoms related to this finding, but you've had regular X-rays to monitor it, and these have shown that it has been gradually getting larger over time.", "physical_exams": "The information provided does not include specific instrument readings or test results, only a description of serial radiographs showing a gradual increase in size of an abnormal finding along the left heart border. No specific measurements, values, or other quantitative data are provided in the text you've shared."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220901&width=1500&height=4000", "question": "A 59-year-old woman was admitted to the hospital with unheralded syncope. She had lost a son to sudden cardiac death when he was 29 years of age. On hospital day 2, the patient developed sustained monomorphic ventricular tachycardia treated with synchronized cardioversion and intravenous amiodarone. An electrocardiogram was performed after the event (Panel A). A transesophageal echocardiogram showed a severely dilated right ventricle (Panel B). Cardiac magnetic resonance imaging showed a right ventricular ejection fraction of 27% with regional akinesis. What is the most likely diagnosis?", "type": ["echocardiogram", "ECG"], "answers": [{"text": "Arrhythmogenic right ventricular cardiomyopathy", "correct": true}, {"text": "Brugada Syndrome", "correct": false}, {"text": "Cardiac sarcoidosis", "correct": false}, {"text": "Inferior Myocardial Infarction", "correct": false}, {"text": "Pulmonary Embolism", "correct": false}], "patient_info": "For the patient actor, you should be aware of the following symptoms and history: - You are a 59-year-old woman. - You experienced a sudden fainting episode (unheralded syncope) without any prior warning. - You have a family history of sudden cardiac death, as your son passed away at the age of 29 from such an event. - On the second day of your hospital stay, you developed a rapid heart rhythm that felt abnormal and was medically identified as sustained monomorphic ventricular tachycardia. This condition was serious enough to require immediate medical intervention. - You were treated with a procedure called synchronized cardioversion to restore your heart's normal rhythm and were given a medication called intravenous amiodarone to help maintain this rhythm. - You do not know the specific findings of the tests (electrocardiogram, transesophageal echocardiogram, and cardiac MRI) but are aware that these tests were conducted to assess your heart's function and structure. Remember, you are not aware of your diagnosis, only these symptoms and the interventions you received.", "physical_exams": "- Electrocardiogram performed after the event of sustained monomorphic ventricular tachycardia.\n- Transesophageal echocardiogram showed a severely dilated right ventricle.\n- Cardiac magnetic resonance imaging indicated a right ventricular ejection fraction of 27% with regional akinesis."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220825&width=1500&height=4000", "question": "A 32-year-old man presented with a 6-week history of tingling in his arms and legs and a 2-week history of inability to walk. A positive Romberg test, sensory ataxia, impaired proprioception and vibratory sensation, and preserved nociception were noted. Magnetic resonance imaging of the whole spine showed hyperintensity in the posterior spinal cord from C1 to T12 and hyperintense lesions in the dorsal column on T2-weighted images. A vitamin B12 level was 107 pg per ml (reference value, >231) without macrocytic anemia. Toxicity of which of the following is the most likely cause of this presentation?", "type": ["MRI"], "answers": [{"text": "Copper", "correct": false}, {"text": "Nitrous oxide", "correct": true}, {"text": "Organophosphates", "correct": false}, {"text": "Tetrodotoxin (pufferfish poisoning)", "correct": false}, {"text": "Thallium", "correct": false}], "patient_info": "For your role as a patient, here's the minimal information you need to convey your symptoms accurately: - You've been experiencing a tingling sensation in your arms and legs for the past six weeks. - For the last two weeks, you've found yourself unable to walk. - You've noticed some difficulties with balance, especially when you can't see your feet (like when it's dark or when you close your eyes). - You feel like you can't quite tell where your limbs are unless you're looking at them. - Despite these issues, you can still feel pain normally. Remember, you're not aware of your diagnosis or the specific test results, just these symptoms you've been experiencing.", "physical_exams": "- Vitamin B12 level: 107 pg per ml (reference value, >231)"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220818&width=1500&height=4000", "question": "A 13-year-old girl presented with new onset blurry vision in the left eye associated with painful eye movements. Three weeks earlier, weakness and paresthesias had developed in her left leg that spontaneously resolved. When a light was swung from the normal right eye (Panel A) to the affected left eye, the left pupil dilated (Panel B) \u2013 a finding known as a relative afferent pupillary defect. Fundoscopic examination of both eyes was normal. Examination of the brain and whole spine by means of magnetic resonance imaging showed multiple, oblong hyperintense lesions on T2-weighted images. What is the most likely etiology?", "type": ["physical"], "answers": [{"text": "Acute disseminated encephalomyelitis", "correct": false}, {"text": "Leber hereditary optic neuropathy", "correct": false}, {"text": "Mononeuritis multiplex", "correct": false}, {"text": "Multiple sclerosis", "correct": true}, {"text": "Retinal detachment", "correct": false}], "patient_info": "For your role as a patient, you are a 13-year-old girl who has been experiencing the following symptoms: 1. You recently started having blurry vision in your left eye. 2. Moving your left eye causes pain. 3. About three weeks ago, you felt weakness and a tingling sensation in your left leg, but these symptoms went away on their own. 4. When a light is shone from your right eye to your left eye, your left pupil gets bigger instead of smaller. You have not been told any specific diagnosis or the results of any tests, including any imaging of your brain or spine.", "physical_exams": "The instrument readings and test results from the case report are as follows:\n\n1. **Pupillary Light Reflex Test:**\n   - When a light was swung from the normal right eye to the affected left eye, the left pupil dilated, indicating a relative afferent pupillary defect.\n\n2. **Fundoscopic Examination:**\n   - The examination of both eyes was normal, showing no abnormalities on fundoscopy.\n\n3. **Magnetic Resonance Imaging (MRI) of the Brain and Whole Spine:**\n   - The MRI revealed multiple, oblong hyperintense lesions on T2-weighted images."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220811&width=1500&height=4000", "question": "An 86-year-old woman presented with 1 day of nausea, vomiting, and right-sided abdominal pain. Computed tomography of the abdomen and pelvis revealed a distended gallbladder with a thickened wall outside the gallbladder fossa. There was also swirling of the cystic artery and duct but no dilatation of the common bile duct. Which of the following is most likely diagnosis?", "type": ["CT scan"], "answers": [{"text": "Acalculous cholecystitis", "correct": false}, {"text": "Cholangiocarcinoma", "correct": false}, {"text": "Cholangitis", "correct": false}, {"text": "Ectopic gallbladder", "correct": false}, {"text": "Gallbladder volvulus", "correct": true}], "patient_info": "For the patient actor: You are an 86-year-old woman who has been experiencing nausea, vomiting, and right-sided abdominal pain for the past day. You have not been informed of any specific test results or diagnoses but are aware of your symptoms.", "physical_exams": "Computed tomography of the abdomen and pelvis showed:\n- Distended gallbladder with a thickened wall outside the gallbladder fossa\n- Swirling of the cystic artery and duct\n- No dilatation of the common bile duct"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220804&width=1500&height=4000", "question": "A 71-year-old man presented with an 8-year history of enlarging nodules on his nose. On physical examination, he had painless, violaceous, indurated nodules on his nose, ears, fingers, and toes. Computed tomography of the chest revealed hilar and mediastinal lymphadenopathy. Skin biopsy showed non-caseating granulomas. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Entomophthoramycosis", "correct": false}, {"text": "Leprosy", "correct": false}, {"text": "Lupus pernio", "correct": true}, {"text": "Lupus vulgaris", "correct": false}, {"text": "Rhinophyma", "correct": false}], "patient_info": "For the patient actor: You are a 71-year-old man who has been noticing that nodules have been growing on your nose for the past 8 years. These nodules are painless, have a purplish color, and feel hard to the touch. You've also noticed similar nodules on your ears, fingers, and toes. You haven't experienced any pain from these nodules.", "physical_exams": "Computed tomography (CT) of the chest: Hilar and mediastinal lymphadenopathy.\nSkin biopsy: Non-caseating granulomas."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220728&width=1500&height=4000", "question": "A 68-year-old woman living in Japan presented to the clinic with a 5-day history of fevers, myalgias, and petechial rash spreading on her arms, trunk, palms, and soles. On exam, there was also an eschar on the right medial ankle. Laboratory studies showed thrombocytopenia, elevated inflammatory markers, and elevated liver transaminases. Which of the following is the most appropriate treatment?", "type": ["dermatology"], "answers": [{"text": "Antihistamine", "correct": false}, {"text": "Glucocorticoid", "correct": false}, {"text": "Observation", "correct": false}, {"text": "Tetracycline", "correct": true}, {"text": "Valacyclovir", "correct": false}], "patient_info": "For your role as a patient, you are a 68-year-old woman who has been experiencing the following symptoms for the past 5 days: - Fevers - Muscle aches (myalgias) - A rash with small, round spots (petechiae) that started on your arms and has spread to your trunk, palms, and soles - A black, scab-like sore (eschar) on your right medial ankle You have not been informed of any specific test results or readings.", "physical_exams": "Laboratory studies indicated:\n- Thrombocytopenia\n- Elevated inflammatory markers\n- Elevated liver transaminases"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220721&width=1500&height=4000", "question": "A 23-year-old man presented with a 1-month history of double vision and right eyelid drooping that worsened at the end of the day. On examination, manual raising of the ptotic right eyelid resulted in dropping of the left eyelid. What is the most likely diagnosis?", "type": ["ophthalmology"], "answers": [{"text": "Botulism", "correct": false}, {"text": "Horner\u2019s syndrome", "correct": false}, {"text": "Miller Fisher syndrome", "correct": false}, {"text": "Multiple sclerosis", "correct": false}, {"text": "Myasthenia gravis", "correct": true}], "patient_info": "For the patient actor: You are a 23-year-old man who has been experiencing double vision and your right eyelid has been drooping. You've noticed these symptoms become more pronounced towards the end of the day. When someone tries to manually lift your drooping right eyelid, your left eyelid starts to droop.", "physical_exams": "The provided text does not include specific instrument readings or test results that can be extracted for an instrument reader actor. The information given is related to the patient's symptoms and physical examination findings, not to quantitative data or test results from medical instruments."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220714&width=1500&height=4000", "question": "A 26-year-old woman with recurrent tonsillitis presents with progressive sore throat and pain with swallowing. She was febrile and had a white-cell count of 19,450 cells per cubic millimeter. CT scan of the neck is shown. What is the diagnosis?", "type": ["CT scan"], "answers": [{"text": "Epiglottitis", "correct": false}, {"text": "Peritonsillar abscess", "correct": false}, {"text": "Retropharyngeal abscess", "correct": true}, {"text": "Septic thrombophlebitis of the internal jugular vein (Lemierre\u2019s syndrome)", "correct": false}, {"text": "Submandibular space infection (Ludwig\u2019s angina)", "correct": false}], "patient_info": "For the patient actor: - **Age and Gender**: 26-year-old woman - **Symptoms**: - Recurrent tonsillitis - Progressive sore throat - Pain with swallowing - Fever You are not aware of your test results or the findings from the CT scan of your neck.", "physical_exams": "White-cell count: 19,450 cells per cubic millimeter"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220707&width=1500&height=4000", "question": "A 30-year-old man was admitted to the hospital with 2 weeks of rash and fever that had started one month after taking a course of trimethoprim\u2013sulfamethoxazole for the treatment of folliculitis. Physical examination was notable for fever, a diffuse morbilliform rash, submandibular lymphadenopathy, and facial erythema with periorbital sparing. Four days after admission, facial edema developed. Labs showed elevated absolute eosinophils and aminotransferase levels. What\u2019s the most likely diagnosis?", "type": ["dermatology", "physical"], "answers": [{"text": "Acute generalized exanthematous pustulosis", "correct": false}, {"text": "Drug reaction with eosinophilia and systemic symptoms", "correct": true}, {"text": "Erythroderma", "correct": false}, {"text": "Hypereosinophilic syndrome", "correct": false}, {"text": "Stevens-Johnson syndrome/toxic epidermal necrolysis", "correct": false}], "patient_info": "For the patient actor: - Age: 30 years old - Symptoms started one month after taking trimethoprim\u2013sulfamethoxazole for folliculitis. - Presenting symptoms: - Rash for 2 weeks - Fever for 2 weeks - Diffuse morbilliform rash - Submandibular lymphadenopathy (swollen glands under the jaw) - Facial erythema (redness) with periorbital sparing (area around the eyes not affected) - Facial edema (swelling) developed four days after hospital admission - You are not aware of your lab test results or their implications.", "physical_exams": "The patient, a 30-year-old man, presented with the following laboratory findings:\n\n- Elevated absolute eosinophil count\n- Elevated aminotransferase levels"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220630&width=1500&height=4000", "question": "A 28-year-old woman with a history of ulcerative colitis and pulmonary embolism presented with a 3-day history of dry cough and pleuritic chest pain. A chest radiograph was obtained. What is the name of this imaging finding?", "type": ["xray"], "answers": [{"text": "Fleischner sign", "correct": false}, {"text": "Hampton\u2019s hump", "correct": true}, {"text": "Palla sign", "correct": false}, {"text": "Spine sign", "correct": false}, {"text": "Westermark sign", "correct": false}], "patient_info": "For your role as a patient, you are a 28-year-old woman with a history of ulcerative colitis and pulmonary embolism. You've been experiencing a dry cough and pleuritic chest pain for the past 3 days. You've had a chest radiograph (X-ray) done recently due to these symptoms. You are aware of your symptoms and medical history but not of the diagnosis or the specific findings of the chest radiograph.", "physical_exams": "The patient underwent a chest radiograph."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220623&width=1500&height=4000", "question": "An 8-month-old girl presented with strabismus and developmental delay. On examination, she was noted to have macrocephaly, intermittent exotropia in the left eye, and hypotonia. Fundoscopic exam results are shown in the image. MRI of the brain revealed inadequate myelination diffusely and a thin corpus callosum. What is the diagnosis?", "type": ["ophthalmology"], "answers": [{"text": "Myotonic dystrophy", "correct": false}, {"text": "Pompe disease", "correct": false}, {"text": "Prader-Willi syndrome", "correct": false}, {"text": "Spinal muscular atrophy", "correct": false}, {"text": "Tay-Sachs disease", "correct": true}], "patient_info": "For the patient actor portraying an 8-month-old girl, you should be aware of and able to describe the following symptoms: 1. **Strabismus**: You've noticed that your eyes don't always look in the same direction at the same time. Specifically, you might mention that your left eye tends to drift outward away from your nose, which is known as exotropia. 2. **Developmental Delay**: You or your caregivers have observed that you're not reaching developmental milestones as expected for your age, such as sitting up, babbling, or showing interest in crawling. 3. **Macrocephaly**: Your head is larger than typical for your age and sex. This might have been noticed by your caregivers or a healthcare professional during a routine check-up. 4. **Hypotonia**: You exhibit signs of low muscle tone, which might make you seem floppy or less able to control your movements effectively. Remember, you're not aware of your diagnosis or specific test results, such as the MRI findings or the details of the fundoscopic exam. Your portrayal is based solely on observable symptoms and what you or your caregivers might have noticed.", "physical_exams": "The information relevant to an instrument reader from the provided case report includes:\n\n1. MRI of the brain findings:\n   - Inadequate myelination diffusely\n   - A thin corpus callosum\n\n2. Fundoscopic exam results: The specific findings are not detailed in the text provided."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220616&width=1500&height=4000", "question": "A 3-year-old girl was brought to the emergency department with a 2-month history of a white pupil and a 1-day history of redness and pain in the right eye. An eye examination showed leukocoria, as well as iris neovascularization and a white, nodular mass in the posterior chamber. The left eye was normal. B-scan ultrasonography showed calcification of the mass and vitreous seeding in the affected eye. Which of the following is the most likely diagnosis?", "type": ["ophthalmology"], "answers": [{"text": "Cataract", "correct": false}, {"text": "Coats' disease", "correct": false}, {"text": "Ocular toxocariasis", "correct": false}, {"text": "Retinal detachment", "correct": false}, {"text": "Retinoblastoma", "correct": true}], "patient_info": "For the patient actor portraying a 3-year-old girl, you should be aware of the following symptoms and presentation: - You've been experiencing a white pupil for about 2 months. - Recently, you've started to have redness and pain in your right eye, which began just 1 day ago. - You are not aware of any specific diagnosis or test results. Remember, your portrayal is based on these symptoms without knowledge of the underlying condition or the results of any diagnostic tests.", "physical_exams": "- Age: 3 years old\n- Symptoms: White pupil for 2 months, redness and pain in the right eye for 1 day\n- Eye Examination Findings: Leukocoria, iris neovascularization, white nodular mass in the posterior chamber of the right eye. Left eye normal.\n- B-scan Ultrasonography Findings: Calcification of the mass, vitreous seeding in the affected eye."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220609&width=1500&height=4000", "question": "A 67-year-old man presented with a 1-year history of bilateral eye swelling and right eye protrusion and a 2-week history of blurry vision. There was no swelling of the parotid or submandibular glands. MRI of the orbits showed bilateral lacrimal gland and lateral rectus muscle swelling as well as mass lesions surrounding the optic nerves. He was initiated on daily prednisone with improvement in his symptoms. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "IgG4-related ophthalmic disease", "correct": true}, {"text": "Non-Hodgkin's lymphoma", "correct": false}, {"text": "Sjogren\u2019s syndrome", "correct": false}, {"text": "Tuberculosis-related dacryoadenitis", "correct": false}, {"text": "Thyroid eye disease", "correct": false}], "patient_info": "You are a 67-year-old man who has been experiencing swelling around both of your eyes and your right eye sticking out more than usual for the past year. Recently, over the last two weeks, you've also started having blurry vision. You haven't noticed any swelling in the glands around your jaw. You've been treated with a medication called prednisone every day, and since starting it, you've noticed some improvement in your symptoms.", "physical_exams": "The information provided does not include specific instrument readings or test results, such as numerical values or specific findings from laboratory tests or imaging studies, beyond the description of the MRI findings. Here are the relevant MRI findings from the case:\n\n- Bilateral lacrimal gland swelling\n- Bilateral lateral rectus muscle swelling\n- Mass lesions surrounding the optic nerves"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220602&width=1500&height=4000", "question": "A 4-year-old boy was brought to the orthopedic clinic with a 2-day history of pain in the right hip and limping. There had been no preceding trauma or fever. Physical exam showed normal hip range of motion and an antalgic gait favoring the right side. A radiograph of the pelvis was performed. What is the most likely diagnosis?", "type": ["xray"], "answers": [{"text": "Legg\u2013Calv\u00e9\u2013Perthes disease", "correct": true}, {"text": "Juvenile idiopathic arthritis", "correct": false}, {"text": "Osteoid osteoma", "correct": false}, {"text": "Septic arthritis", "correct": false}, {"text": "Slipped capital femoral epiphysis", "correct": false}], "patient_info": "For the patient actor portraying a 4-year-old boy: - **Symptoms to Present:** - Mention that you've been experiencing pain in your right hip for the past two days. - You've started limping because of the discomfort in your right hip. - Make sure to note that you didn't have any injuries or falls that you remember before the pain started. - You haven't had a fever or felt sick recently. - **Behavior to Exhibit:** - Walk with a noticeable limp, favoring your right side to avoid putting too much weight on it. - During any physical examination or when asked about your hip, show discomfort or wince when moving your right hip, but clarify that you can still move it normally; it just hurts. - **What Not to Mention:** - Specific test results or readings, as you're not aware of them. - Any specific diagnosis or medical terms, since you don't know what's causing the pain and limping.", "physical_exams": "The information provided for the instrument reader actor is as follows:\n\n- Patient: 4-year-old boy\n- Test performed: Radiograph of the pelvis"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220526&width=1500&height=4000", "question": "A 27-year-old man with a history of obesity presented to the dermatology clinic with an asymptomatic rash on his back, arms, and hands that had developed 1 week earlier. On physical examination, scattered pink-yellow papules were present on the upper back, extensor surfaces of the upper arms, and dorsa of the hands. A fasting blood sample was grossly lipemic. Which of the following is the most likely diagnosis?", "type": ["dermatology"], "answers": [{"text": "Eruptive xanthomas", "correct": true}, {"text": "Generalized eruptive histiocytoma", "correct": false}, {"text": "Granuloma annulare", "correct": false}, {"text": "Molluscum contagiosum", "correct": false}, {"text": "Sebaceous hyperplasia", "correct": false}], "patient_info": "You are a 27-year-old man who has noticed a rash on your back, arms, and hands about a week ago. You haven't felt any discomfort or symptoms from the rash. It looks like scattered pink-yellow bumps on your upper back, the outer sides of your upper arms, and the backs of your hands. You also recently had a blood test done while fasting, and the results showed that your blood was very fatty.", "physical_exams": "The fasting blood sample was grossly lipemic."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220519&width=1500&height=4000", "question": "A 40-year-old man presented with a 2-week history of scaly foot rash, joint swelling, penile rash, knee swelling, tongue changes, red eyes, and low back pain. He had had diarrhea and urethral discharge 7 days before the onset of symptoms. On examination, yellow pustules with hyperkeratosis were seen on his plantar feet. What is the name of this physical examination sign?", "type": ["dermatology", "physical"], "answers": [{"text": "Keratoderma blenorrhagicum", "correct": true}, {"text": "Palmoplantar keratoderma", "correct": false}, {"text": "Pitted keratolysis", "correct": false}, {"text": "Porokeratosis", "correct": false}, {"text": "Pustular psoriasis", "correct": false}], "patient_info": "You are a 40-year-old man who has been experiencing a variety of symptoms for the past two weeks. These symptoms include: - A scaly rash on your feet - Swelling in your joints and knees - A rash on your penis - Changes in the appearance of your tongue - Redness in your eyes - Pain in your lower back Additionally, about a week before these symptoms started, you had diarrhea and a discharge from your urethra. Upon examination, a doctor noted yellow pustules with a thickening of the skin on the soles of your feet.", "physical_exams": "The information provided does not include specific instrument readings or test results. It describes symptoms and physical examination findings without detailing any laboratory or diagnostic test outcomes. Therefore, there are no instrument readings to report from the given case information."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220512&width=1500&height=4000", "question": "A 73-year-old man presented with 1-month history of fatigue and diffuse bone pain. Laboratory studies showed pancytopenia and a whole-body MRI showed osteonecrosis of the right humerus and right femur. A bone marrow biopsy showed macrophages with a \u201cwrinkled tissue paper\u201d appearance in the cytoplasm. What is the diagnosis?", "type": ["biopsy"], "answers": [{"text": "Chronic lymphocytic leukemia", "correct": false}, {"text": "Gaucher\u2019s disease", "correct": true}, {"text": "Mucopolysaccharidosis type 1", "correct": false}, {"text": "Niemann-Pick disease", "correct": false}, {"text": "Non-Hodgkin\u2019s lymphoma", "correct": false}], "patient_info": "For the patient actor: You are a 73-year-old man who has been feeling very tired for the past month. You've also been experiencing pain in your bones all over your body. You haven't had any specific tests done yourself, but you've been feeling these symptoms strongly enough to seek medical attention.", "physical_exams": "Laboratory studies showed pancytopenia. Whole-body MRI showed osteonecrosis of the right humerus and right femur. Bone marrow biopsy showed macrophages with a \u201cwrinkled tissue paper\u201d appearance in the cytoplasm."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220505&width=1500&height=4000", "question": "A 74-year-old man with coronary artery disease presented to the emergency department with 3 days of anorexia and weakness. Computed tomography of the chest was performed, and blood cultures were drawn. What is the most likely diagnosis?", "type": ["CT scan"], "answers": [{"text": "Emphysematous aortitis due to Clostridium septicum", "correct": true}, {"text": "Granulomatosis with polyangiitis", "correct": false}, {"text": "Pyogenic aortitis due to Salmonella enteritidis", "correct": false}, {"text": "Syphilitic aortitis due to Treponema pallidum", "correct": false}, {"text": "Tuberculous aortitis", "correct": false}], "patient_info": "For the patient actor: - Age: 74 years old - Medical history: Coronary artery disease - Symptoms: - Anorexia (loss of appetite) for 3 days - Generalized weakness for 3 days - Recent medical procedures: - Underwent a computed tomography (CT) scan of the chest - Had blood cultures drawn", "physical_exams": "The information provided does not include specific instrument readings or test results from the computed tomography (CT) of the chest or the blood cultures. Therefore, I cannot generate information based on instrument readings or test results from this case report."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220428&width=1500&height=4000", "question": "A 53-year-old landscaper presented to the dermatology clinic with a 4-month history of red, raised, itchy skin lesions on his left lower back and buttock. Physical examination showed numerous verrucous nodules and plaques with overlying crusting and surrounding erythema on the left lower back and buttock. Grocott-Gomori methenamine silver staining showed broad-based budding organisms. Chest imaging showed no abnormalities. Which of the following is the best treatment?", "type": ["physical"], "answers": [{"text": "Clarithromycin and amikacin", "correct": false}, {"text": "Itraconazole", "correct": true}, {"text": "Penicillin", "correct": false}, {"text": "Rifampicin, isoniazid, pyrazinamide, and ethambutol", "correct": false}, {"text": "Trimethoprim-sulfamethoxazole", "correct": false}], "patient_info": "For the patient actor: You are a 53-year-old landscaper. For the past four months, you've been experiencing red, raised, itchy skin lesions on your left lower back and buttock. These lesions look like numerous verrucous (wart-like) nodules and plaques, with some crusting on top and redness around them. You haven't noticed any other symptoms, and your chest feels fine without any issues.", "physical_exams": "Grocott-Gomori methenamine silver staining: Showed broad-based budding organisms.\nChest imaging: Showed no abnormalities."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220421&width=1500&height=4000", "question": "A 56-year-old man with sickle hemoglobin C disease and proliferative sickle cell retinopathy presented for a routine eye examination. He was asymptomatic. What is seen on this examination of the anterior segment of the eye?", "type": ["ophthalmology"], "answers": [{"text": "Bilateral acute depigmentation of the iris (BADI)", "correct": false}, {"text": "Cornea verticillata", "correct": false}, {"text": "Iris atrophy", "correct": true}, {"text": "Mutton-fat keratic precipitates", "correct": false}, {"text": "Sunflower cataract", "correct": false}], "patient_info": "For your role as a 56-year-old man with a history of sickle cell disease, you are visiting the eye doctor for a routine examination. You do not have any symptoms affecting your eyes at the moment. During your visit, the doctor will examine the front part of your eye, known as the anterior segment, to check for any abnormalities or changes. Remember, you are not aware of any specific findings or diagnoses from this examination yet.", "physical_exams": "The provided text does not include specific instrument readings or test results from the examination of the anterior segment of the eye. It only mentions that the patient presented for a routine eye examination and was asymptomatic, without detailing any findings or measurements from the examination."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220414&width=1500&height=4000", "question": "A 64-year-old man with metastatic lung adenocarcinoma who had recently started high-dose steroids for malignant spinal cord compression developed an itchy rash and diarrhea. He had a 3-year history of intermittent peripheral eosinophilia of unknown cause. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Cutaneous larva migrans", "correct": false}, {"text": "Cutaneous schistosomiasis", "correct": false}, {"text": "Larva currens from Strongyloides", "correct": true}, {"text": "Lichen striatus", "correct": false}, {"text": "Scabies", "correct": false}], "patient_info": "For the patient actor: - Age: 64 years old - Medical history: Metastatic lung adenocarcinoma, recently started high-dose steroids for malignant spinal cord compression, and a 3-year history of intermittent peripheral eosinophilia of unknown cause. - Current symptoms: Itchy rash and diarrhea.", "physical_exams": "The provided text does not contain specific instrument readings or test results to extract. It mentions a clinical scenario without detailing any laboratory values, imaging findings, or other diagnostic test results. Therefore, I cannot generate information based on instrument readings from the given text."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220407&width=1500&height=4000", "question": "A 30-year-old man with Crohn\u2019s disease presented to the dermatology clinic with multiple painful ulcers in his groin and perineal area, as well as an ongoing Crohn\u2019s disease flare with fatigue, abdominal pain, and bloody diarrhea. Physical examination of the skin showed deep, linear erosions across the perineum and inguinal folds, on the scrotum and penile shaft, and in the intergluteal cleft. Which of the following is the most likely etiology underlying the genital ulcers?", "type": ["physical"], "answers": [{"text": "Ecthyma gangrenosum", "correct": false}, {"text": "Knife-cut ulcers from Crohn\u2019s disease", "correct": true}, {"text": "Lichen sclerosus", "correct": false}, {"text": "Linear IgA disease", "correct": false}, {"text": "Pemphigus foliaceus", "correct": false}], "patient_info": "You are a 30-year-old man who has been dealing with Crohn's disease. Recently, you've been experiencing a flare-up of your Crohn's disease, which includes symptoms like feeling very tired, having abdominal pain, and noticing blood in your diarrhea. Along with these symptoms, you've also developed multiple painful ulcers in your groin area, including your perineum (the area between your genitals and anus), inguinal folds (the areas where your legs meet your groin), on your scrotum and penile shaft, and in the intergluteal cleft (the area between your buttocks). These ulcers are deep and have a linear shape.", "physical_exams": "The provided text does not contain specific instrument readings or test results that can be extracted for an instrument reader actor. It describes the patient's symptoms, physical examination findings, and medical history, but does not mention any laboratory tests, imaging studies, or other diagnostic procedures that would yield instrument readings."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220331&width=1500&height=4000", "question": "A 53-year-old man presented with several hours of right eye itching after gardening near a horse and sheep farm. A physical exam was performed. What is the most likely diagnosis?", "type": ["ophthalmology"], "answers": [{"text": "Allergic conjunctivitis", "correct": false}, {"text": "Anterior uveitis", "correct": false}, {"text": "Bacterial conjunctivitis", "correct": false}, {"text": "Ophthalmomyiasis", "correct": true}, {"text": "Superficial punctate keratitis", "correct": false}], "patient_info": "For the patient actor: - **Age**: 53 years old - **Symptoms**: You've been experiencing itching in your right eye for several hours. - **Recent Activities**: You were gardening near a horse and sheep farm shortly before the symptoms started.", "physical_exams": "The provided text does not contain any specific test or instrument readings to extract. It only describes a scenario of a 53-year-old man presenting with symptoms of right eye itching after being near a horse and sheep farm, and mentions that a physical exam was performed. No specific results or readings from the physical exam or any other tests are provided in the text."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220324&width=1500&height=4000", "question": "A 63-year-old man developed purplish discoloration of his face after he underwent stenting and balloon dilation of the left common carotid artery. Cholesterol embolization syndrome was diagnosed. What is the name of this physical exam finding?", "type": ["physical"], "answers": [{"text": "Cutis marmorata", "correct": false}, {"text": "Harlequin syndrome", "correct": false}, {"text": "Livedo racemosa", "correct": false}, {"text": "Livedo reticularis", "correct": true}, {"text": "Telangiectasia", "correct": false}], "patient_info": "For the patient actor: You are a 63-year-old man who recently underwent a medical procedure involving stenting and balloon dilation of your left common carotid artery. After this procedure, you noticed a purplish discoloration of your face. You have not been informed of your diagnosis yet.", "physical_exams": "The provided text does not contain specific instrument readings or test results. It only describes a clinical diagnosis and a physical exam finding (purplish discoloration of the face) related to a medical procedure. For accurate instrument readings or test results, details such as blood tests, imaging studies, or other diagnostic tests would be needed."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220317&width=1500&height=4000", "question": "A 37-year-old man presented early in life with nephrolithiasis and pyelonephritis. Two weeks before this encounter, he was treated for a urinary tract infection. Microscopic examination of a spun urine specimen is shown, demonstrating two crystal types. What are these crystals, demonstrated in panels A and B, respectively?", "type": ["instrument"], "answers": [{"text": "Calcium oxalate and triple phosphate (struvite) crystals", "correct": false}, {"text": "Cholesterol and acyclovir crystals", "correct": false}, {"text": "Cystine and triple phosphate (struvite) crystals", "correct": true}, {"text": "Sulfonamide and cystine crystals", "correct": false}, {"text": "Uric acid and calcium oxalate crystals", "correct": false}], "patient_info": "For the patient actor: You are a 37-year-old man who has had a history of kidney stones and kidney infections. Recently, you were treated for a urinary tract infection. You've been experiencing symptoms that led to a urine test, where they found something unusual in your urine under the microscope, specifically two different types of crystals.", "physical_exams": "The case report provides information on microscopic examination findings from a spun urine specimen, demonstrating two types of crystals. However, the specific types of crystals observed in panels A and B are not mentioned in the provided text. Therefore, I cannot specify the crystal types without additional information from the case report."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220310&width=1500&height=4000", "question": "A 42-year-old man with human immunodeficiency virus (HIV) infection presented with painful skin ulcerations and systemic symptoms. Physical exam showed large ulcers with overlying keratosis and crusting scattered across his scalp, face, perineum, and limbs. Laboratory studies showed a CD4 count of 399 cells/mm3. Skin biopsy showed superficial dermal infiltration of lymphocytes, histiocytes, and plasma cells in a lichenoid pattern with psoriasiform epidermal hyperplasia. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Bacillary angiomatosis", "correct": false}, {"text": "Disseminated histoplasmosis", "correct": false}, {"text": "Lupus vulgaris (tuberculosis luposa)", "correct": false}, {"text": "Malignant syphilis", "correct": true}, {"text": "Norwegian scabies", "correct": false}], "patient_info": "You are a 42-year-old man who has been living with HIV. Recently, you've started experiencing painful skin ulcerations that have been bothering you quite a bit. These ulcers are not just limited to one part of your body; they are scattered across your scalp, face, around your private areas, and on your limbs. They look quite severe, with some hard, crusty layers forming on top. You've also been feeling generally unwell, but you're not sure what's causing these symptoms.", "physical_exams": "CD4 count: 399 cells/mm3"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220303&width=1500&height=4000", "question": "A 48-year-old woman who lived in rural India presented with diarrhea, weight loss, and a rash. Physical examination showed well-demarcated areas of hyperpigmentation on the sun-exposed areas of her neck, chest, and forearms. What is the most likely diagnosis?", "type": ["dermatology", "physical"], "answers": [{"text": "Cobalamin (vitamin B12) deficiency", "correct": false}, {"text": "Pellagra", "correct": true}, {"text": "Phytophotodermatitis", "correct": false}, {"text": "Porphyria cutanea tarda", "correct": false}, {"text": "Zinc deficiency", "correct": false}], "patient_info": "For the patient actor: - You are a 48-year-old woman. - You have been experiencing diarrhea and weight loss. - You have noticed a rash, specifically well-demarcated areas of hyperpigmentation, on the sun-exposed areas of your neck, chest, and forearms.", "physical_exams": "The provided text does not include specific instrument readings or test results to extract. It only describes symptoms and physical examination findings."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220224&width=1500&height=4000", "question": "A 31-year-old man presented with 10 years of progressive fingertip and toe enlargement and intermittent aches of his distal forearms and lower legs. Physical exam was notable for digital clubbing, proximal nail fold hyperpigmentation, and forearm and lower leg tenderness of palpation. Plain radiographs of the ankles showed increased periosteal bone formation at the distal tibia and fibula. Serum laboratory tests, echocardiogram, and a whole-body PET-CT were normal. What is the most likely diagnosis?", "type": ["physical", "xray"], "answers": [{"text": "Acromegaly", "correct": false}, {"text": "Osteopetrosis", "correct": false}, {"text": "Paget\u2019s disease", "correct": false}, {"text": "Primary hypertrophic osteoarthropathy", "correct": true}, {"text": "Scleromyxedema", "correct": false}], "patient_info": "For the patient actor: - Age: 31 years old - Symptoms: - Progressive enlargement of fingertips and toes over 10 years - Intermittent aches in the distal forearms and lower legs - Physical findings: - Digital clubbing (enlarged fingertips) - Proximal nail fold hyperpigmentation (darker skin around the nail base) - Tenderness upon touching the forearms and lower legs", "physical_exams": "- Plain radiographs of the ankles: Increased periosteal bone formation at the distal tibia and fibula.\n- Serum laboratory tests: Normal.\n- Echocardiogram: Normal.\n- Whole-body PET-CT: Normal."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220217&width=1500&height=4000", "question": "A 50-year-old man with a history of several months of productive cough presented to the emergency department with stupor and hypercarbic respiratory failure. He was intubated. Chest radiograph several days later revealed complete collapse of the left lung. On bronchoscopy, several casts, as shown, were retrieved. Follow-up CT of the chest showed only bibasilar atelectasis. What is the etiology of his casts?", "type": ["physical"], "answers": [{"text": "Asthma", "correct": false}, {"text": "Bronchiectasis", "correct": false}, {"text": "Cystic fibrosis", "correct": false}, {"text": "Plastic bronchitis", "correct": true}, {"text": "Tuberculosis", "correct": false}], "patient_info": "For the patient actor, you should be aware of the following symptoms and history to accurately portray your role: - You are a 50-year-old man. - You have been experiencing a productive cough for several months. - Recently, you presented to the emergency department in a state of stupor and were found to be in hypercarbic respiratory failure, which required intubation. - You are not aware of the specific findings of your medical tests, but you know that after being admitted, your condition led to the complete collapse of your left lung. - During a procedure (which you're not aware of as being a bronchoscopy), something was retrieved from your lung, but you don't know the details. - You've been told that a follow-up scan (CT of the chest) showed bibasilar atelectasis, but you might not fully understand what that means. Remember, you are not aware of the diagnosis or the specific nature of the casts retrieved during the bronchoscopy. Your portrayal should focus on the symptoms you've experienced and your recent medical emergency without knowledge of the underlying cause.", "physical_exams": "Based on the provided case report, the test information includes:\n\n1. **Chest Radiograph**: Revealed complete collapse of the left lung.\n2. **Bronchoscopy**: Several casts were retrieved.\n3. **CT of the Chest**: Showed only bibasilar atelectasis."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220210&width=1500&height=4000", "question": "A 21-year-old woman with a history of surgically corrected Hirschsprung\u2019s disease presented with 6-week history of abdominal pain and constipation. Her blood pressure was 162/108 mm Hg. She had an elevated creatinine and CT showed large subcapsular urinomas and hydronephrosis caused by distal ureteral obstruction from a rectal mass. What is the likely mechanism of her hypertension?", "type": ["CT scan"], "answers": [{"text": "Atherosclerotic renal artery stenosis", "correct": false}, {"text": "Fibromuscular dysplasia", "correct": false}, {"text": "Medullary sponge kidney", "correct": false}, {"text": "Page kidney", "correct": true}, {"text": "Polycystic kidney disease", "correct": false}], "patient_info": "You are a 21-year-old woman who has been experiencing abdominal pain and constipation for the past 6 weeks. Previously, you had surgery for Hirschsprung\u2019s disease. Recently, you've noticed your blood pressure is quite high when measured, but you're not sure of the exact numbers. You haven't been feeling well, and there seems to be a problem related to your kidneys, but you don't know the specifics.", "physical_exams": "Blood pressure: 162/108 mm Hg\nCreatinine: Elevated\nCT findings: Large subcapsular urinomas and hydronephrosis caused by distal ureteral obstruction from a rectal mass"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220203&width=1500&height=4000", "question": "A 60-year-old man with HIV presented to the ophthalmology clinic with eyelid and facial lesions. His CD4 cell count was 20 per cubic millimeter and his HIV viral load was 120,000 copies/ml. Physical exam showed numerous dome-shaped papules with central umbilication. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Basal-cell carcinoma", "correct": false}, {"text": "Cryptococcosis", "correct": false}, {"text": "Histoplasmosis", "correct": false}, {"text": "Molluscum contagiosum", "correct": true}, {"text": "Verruca vulgaris", "correct": false}], "patient_info": "For your role as a patient, you are a 60-year-old man who has been living with HIV. You've recently noticed some concerning changes on your face and eyelids, prompting you to visit an ophthalmology clinic. You are aware that you have been experiencing symptoms including: - Numerous small, dome-shaped bumps on your face and eyelids. These bumps have a notable characteristic: a central dip or indentation, which might look like a little crater at the top of each bump. You are not aware of your recent CD4 cell count or HIV viral load numbers, nor have you been informed of your diagnosis based on these symptoms. Your primary concern is the appearance and potential implications of these facial and eyelid lesions.", "physical_exams": "CD4 cell count: 20 per cubic millimeter\nHIV viral load: 120,000 copies/ml"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220127&width=1500&height=4000", "question": "A 40-year-old man with neurofibromatosis type 1 presented for a yearly eye exam and was found to have multiple well-defined, light-brown nodules elevated above the iris bilaterally. What is the most likely diagnosis?", "type": ["ophthalmology"], "answers": [{"text": "Brushfield spots", "correct": false}, {"text": "Iris melanoma", "correct": false}, {"text": "Lisch nodules", "correct": true}, {"text": "Multiple iris nevi", "correct": false}, {"text": "Sarcoid-associated uveitis", "correct": false}], "patient_info": "For the patient actor: You are a 40-year-old man who has a condition known as neurofibromatosis type 1. You've come in for your yearly eye examination. During the exam, you notice that the doctor is paying close attention to your eyes, particularly the colored part of your eyes. You've observed multiple light-brown spots on your iris, the colored part, in both eyes. These spots seem to be slightly raised above the surface of the iris. You haven't experienced any pain or vision changes because of these spots.", "physical_exams": "The provided text does not contain specific instrument readings or test results that can be extracted for an instrument reader actor. It only describes clinical findings observed during an eye exam."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220120&width=1500&height=4000", "question": "A 48-year-old woman with advanced cirrhosis presented with fatigue, jaundice, and abdominal distention. Laboratory studies showed a hemoglobin level of 5.8 g per deciliter (reference range, 12.0 to 15.5), a lactate dehydrogenase level of 1219 U per liter (reference range, 125 to 220), a low haptoglobin level, and an elevated reticulocyte count. Coombs\u2019 antiglobulin testing was normal. The result of a peripheral-blood smear is shown. What is the diagnosis?", "type": ["biopsy"], "answers": [{"text": "Autoimmune hemolytic anemia", "correct": false}, {"text": "Babesiosis", "correct": false}, {"text": "Hypersplenism", "correct": false}, {"text": "Microangiopathic hemolytic anemia", "correct": false}, {"text": "Spur-cell hemolytic anemia", "correct": true}], "patient_info": "For your role as a patient, you are a 48-year-old woman who has been experiencing significant fatigue, a noticeable yellowing of your skin and eyes (jaundice), and an increase in the size of your abdomen, making it feel swollen or distended. You have a medical history of advanced liver disease, known as cirrhosis. You haven't been told specific test results or numbers, but you are aware that you've undergone several blood tests due to your symptoms.", "physical_exams": "Certainly, here is the extracted test information relevant for an instrument reader:\n\n- Hemoglobin level: 5.8 g per deciliter (Reference range: 12.0 to 15.5)\n- Lactate dehydrogenase (LDH) level: 1219 U per liter (Reference range: 125 to 220)\n- Haptoglobin level: Low (Specific reference range not provided)\n- Reticulocyte count: Elevated (Specific value and reference range not provided)\n- Coombs\u2019 antiglobulin testing: Normal\n- Peripheral-blood smear: Result provided but not specified in the extract provided"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220113&width=1500&height=4000", "question": "A 35-year-old woman with idiopathic pulmonary arterial hypertension and a pulmonary aneurysm presented with chest pain. Computed tomography (CT) of the chest is shown. What is the most likely diagnosis?", "type": ["CT scan"], "answers": [{"text": "Aortic dissection", "correct": false}, {"text": "Aortic pseudoaneurysm", "correct": false}, {"text": "Intramural hematoma", "correct": false}, {"text": "Pulmonary-artery dissection", "correct": true}, {"text": "Pulmonary-artery rupture", "correct": false}], "patient_info": "For the patient actor: You are a 35-year-old woman who has been experiencing chest pain. You have a history of high blood pressure in the arteries of your lungs, which was not caused by any other diseases or conditions that the doctors could identify. Additionally, you have been told that you have a pulmonary aneurysm, which means there is an abnormal bulge in one of the blood vessels in your lungs. You have not been informed of any specific findings from recent tests, including the CT scan of your chest, but you are seeking medical attention because of your symptoms.", "physical_exams": "The patient underwent a Computed Tomography (CT) of the chest."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20220106&width=1500&height=4000", "question": "A 59-year-old tile layer presented with fatigue and one year of progressive skin darkening on his palms and soles. Physical examination showed a smooth tongue with patchy areas of mucosal darkening, as well as hyperpigmented palms and soles. Laboratory studies showed a hemoglobin level of 9.4 g per deciliter (reference range, 14 to 18), a mean corpuscular volume of 117 femtoliters (reference range, 80 to 94), and mild leukopenia and thrombocytopenia. Which of the following is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Adrenal insufficiency", "correct": false}, {"text": "Contact dermatitis", "correct": false}, {"text": "Hyperthyroidism", "correct": false}, {"text": "Melanoma", "correct": false}, {"text": "Vitamin B12 deficiency", "correct": true}], "patient_info": "For your role as a patient, here's the information you need to convey your symptoms accurately: - You are 59 years old and work as a tile layer. - Over the past year, you've noticed that you're feeling more tired than usual. - You've observed your skin, especially on your palms and soles, becoming darker. - You've noticed changes in your tongue, which now appears smoother and has patchy areas of darkening. - You haven't been informed of any specific test results or readings, but you are aware that you've been undergoing some tests due to these symptoms.", "physical_exams": "- Hemoglobin level: 9.4 g per deciliter (Reference range: 14 to 18)\n- Mean corpuscular volume: 117 femtoliters (Reference range: 80 to 94)\n- Presence of mild leukopenia\n- Presence of mild thrombocytopenia"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211230&width=1500&height=4000", "question": "A 48-year-old woman presented to the emergency department with a 1-week history of fatigue and painful, swollen gums. On examination, she was febrile and tachycardic with a well-demarcated region of gingival infiltration and whitening and submandibular lymphadenopathy. A white-cell count was 225,000 per cubic millimeter. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Gingival candidiasis", "correct": false}, {"text": "Leukemic infiltration of the gingiva", "correct": true}, {"text": "Oral lichen planus", "correct": false}, {"text": "Proliferative verrucous leukoplakia", "correct": false}, {"text": "White sponge nevus", "correct": false}], "patient_info": "For the patient actor: - Age: 48 years old - Symptoms you've been experiencing for the past week: - Feeling very tired (fatigue) - Your gums are painful and swollen - Additional details you've noticed: - Your gums have a clear area of redness/swelling and seem to have some whitening areas - You've felt feverish - Your heart seems to be beating faster than usual (tachycardia) - You've noticed some swelling under your jaw (submandibular lymphadenopathy)", "physical_exams": "White-cell count: 225,000 per cubic millimeter"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211223&width=1500&height=4000", "question": "A 65-year-old man presented to the dermatology clinic with a 7-month history of painless skin thickening over the left side of his chest and on his left arm. Physical examination showed sclerotic skin over his left chest and nipple, multiple erythematous nodules over the left arm, axilla, and posterior trunk, left axillary adenopathy, and left arm lymphedema. A skin biopsy showed metastatic carcinoma suggestive of primary breast cancer. What is the diagnosis?", "type": ["dermatology"], "answers": [{"text": "Carcinoma en cuirasse", "correct": true}, {"text": "Carcinoma erysipeloides", "correct": false}, {"text": "Inflammatory breast cancer", "correct": false}, {"text": "Morphea", "correct": false}, {"text": "Paget's disease", "correct": false}], "patient_info": "You are a 65-year-old man who has been experiencing painless skin thickening on the left side of your chest and on your left arm for the past 7 months. You've noticed your skin becoming hard in these areas, and you've also found multiple red, raised bumps over your left arm, under your arm, and on your back. Additionally, you've observed swelling in your left arm and some enlargement of the lymph nodes under your left arm.", "physical_exams": "The information provided from the medical case report for an instrument reader actor would be:\n\n- Skin biopsy results: Metastatic carcinoma suggestive of primary breast cancer."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211216&width=1500&height=4000", "question": "A 37-year-old man presented to the neurosurgery clinic with blurry vision, headache, and difficulty looking upward. On exam, he had diplopia, upward gaze palsy, and vertical misalignment of the eyes. His pupils only minimally constricted to light but constricted to near objects. What is the name of this pupillary exam finding?", "type": ["ophthalmology", "MRI"], "answers": [{"text": "Adie\u2019s pupil", "correct": false}, {"text": "Anisocoria", "correct": false}, {"text": "Argyll Robertson pupil", "correct": false}, {"text": "Light-near dissociation", "correct": true}, {"text": "Relative afferent pupillary defect (e.g., Marcus Gunn pupil)", "correct": false}], "patient_info": "For your role as a patient, you are a 37-year-old man who has been experiencing blurry vision and headaches. You've also found it difficult to look upward. When you try, you notice that your vision doubles. You've observed that your eyes don't seem to align correctly when you attempt to look up. Additionally, you've noticed that while your pupils don't constrict much when exposed to light, they do constrict when you look at objects close to you. You are unaware of the specific medical terms or potential diagnosis related to these symptoms.", "physical_exams": "The information provided does not include specific instrument readings or test results. It describes clinical findings and symptoms observed during a physical examination. Therefore, there are no instrument readings to report from the given case information."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211209&width=1500&height=4000", "question": "A 74-year-old woman presented with a 3-day history of headaches and tongue swelling and several hours of blindness in the right eye. On examination, the tongue was discolored and ulcerated. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Carcinoma of the tongue", "correct": false}, {"text": "Carotid artery stenosis", "correct": false}, {"text": "Giant-cell arteritis", "correct": true}, {"text": "Oral lichen planus", "correct": false}, {"text": "Thromboembolic disease", "correct": false}], "patient_info": "For the patient actor: - Age: 74 years old - Symptoms started 3 days ago with: - Headaches - Swelling of the tongue - Several hours ago, experienced: - Blindness in the right eye - Current condition: - The tongue is discolored and has ulcers", "physical_exams": "The provided text does not include specific instrument readings or test results to extract. It only describes symptoms and physical examination findings. For an instrument reader actor, there are no instrument readings given in this scenario to report on."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211202&width=1500&height=4000", "question": "A female infant delivered at term had a \u201cblueberry muffin\u201d rash at birth. Laboratory tests and imaging studies were normal. Skin biopsy showed a dense infiltrate of cells with kidney-shaped nuclei and positive S100+ and CD1a+ on immunohistochemistry. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Congenital cytomegalovirus infection", "correct": false}, {"text": "Congenital rubella syndrome", "correct": false}, {"text": "Langerhans-cell histiocytosis", "correct": true}, {"text": "Leukemia cutis", "correct": false}, {"text": "Transient myeloproliferative disorder of Down syndrome", "correct": false}], "patient_info": "For the patient actor: You are the mother of a newborn baby girl. Your baby was born at full term and appeared healthy except for a noticeable rash all over her body right after birth. This rash looked like small, purple spots, similar to blueberries, which is why you might hear it referred to as a \u201cblueberry muffin\u201d rash. You haven't been told of any abnormal results from her laboratory tests or imaging studies, as everything came back normal. However, a skin biopsy was performed because of the unusual rash. You're aware that the doctors found something under the microscope, but you don't know the specifics of those findings.", "physical_exams": "The laboratory tests and imaging studies were reported as normal. Skin biopsy revealed a dense infiltrate of cells with kidney-shaped nuclei, which were positive for S100 and CD1a on immunohistochemistry."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211125&width=1500&height=4000", "question": "A 38-year-old man presented to the otolaryngology clinic with chronic difficulty breathing through his right nostril. Physical examination showed nasal septal deviation, calcified septal spurs, and a 2-cm perforation in the posterior septum. On rhinoscopy, a hard, nontender, white mass was observed in the floor of the right nostril. CT of the paranasal sinuses showed a well-defined, radiodense mass. Which of the following is the most likely etiology of the nasal mass?", "type": ["CT scan"], "answers": [{"text": "Calcified polyp", "correct": false}, {"text": "Enchondroma", "correct": false}, {"text": "Osteoma", "correct": false}, {"text": "Rhinolith", "correct": false}, {"text": "Tooth", "correct": true}], "patient_info": "For the patient actor: You are a 38-year-old man who has been experiencing chronic difficulty breathing through your right nostril. You've noticed that breathing isn't as easy as it used to be, and this issue has been persistent. You haven't seen any visible changes on the outside, but you feel like something is not right internally in your nose. You decided to seek medical advice because of this ongoing discomfort and difficulty with breathing.", "physical_exams": "CT of the paranasal sinuses: Showed a well-defined, radiodense mass."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211118&width=1500&height=4000", "question": "A 50-year-old woman with a history of Crohn\u2019s disease presented with 10 days of tongue and inner cheek pain. Laboratory studies showed an absolute eosinophil count of 870 per cubic millimeter (reference range, 50 to 500). What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Herpes simplex gingivostomatitis", "correct": false}, {"text": "Herpetic geometric glossitis", "correct": false}, {"text": "Lichen planus", "correct": false}, {"text": "Oral candidiasis", "correct": false}, {"text": "Pyostomatitis vegetans", "correct": true}], "patient_info": "For the patient actor: - **Age and Background**: You are a 50-year-old woman with a history of Crohn's disease. - **Symptoms**: For the past 10 days, you have been experiencing pain in your tongue and the inner cheeks. - **Medical History Note**: You have not been informed of any specific test results or readings, just that you've been feeling this discomfort for a while now.", "physical_exams": "Absolute eosinophil count: 870 per cubic millimeter (Reference range: 50 to 500)"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211111&width=1500&height=4000", "question": "A 61-year-old woman presented with discoloration along her gums that had rapidly expanded over the past year. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Amalgam tattoo", "correct": false}, {"text": "Gingival melanoma", "correct": true}, {"text": "Kaposi\u2019s sarcoma", "correct": false}, {"text": "Oral melanoacanthoma", "correct": false}, {"text": "Physiologic pigmentation", "correct": false}], "patient_info": "For the patient actor: You are a 61-year-old woman who has noticed a change in the color of your gums. This discoloration started about a year ago and has been spreading or getting more noticeable since then. You haven't experienced any pain or discomfort from this change, but the visible difference in your gum color has been concerning for you. You haven't observed any other significant changes in your health, oral hygiene habits, or diet that you think could be related to this issue.", "physical_exams": "I'm sorry, but you haven't provided any specific test or instrument readings from the medical case report for me to extract and generate information from. Please provide details on any laboratory tests, imaging studies, or other diagnostic procedures that were performed, including their results, for me to assist you accordingly."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211104&width=1500&height=4000", "question": "A 53-year-old woman presented with pain, swelling, and discoloration of her right fifth finger. Physical examination showed a demarcated, brightly erythematous plaque with a dusky center. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Dactylitis", "correct": false}, {"text": "Erythema multiforme", "correct": false}, {"text": "Herpetic whitlow", "correct": false}, {"text": "Spider bite", "correct": true}, {"text": "Sporotrichosis", "correct": false}], "patient_info": "As a patient actor, you are a 53-year-old woman. You've come in because you've been experiencing some concerning symptoms with your right fifth finger. You've noticed that it's been painful, swollen, and has changed color. When you look at it, you see that the skin around it is very red and there's a specific area in the center that looks darker compared to the rest. You don't know what's causing these symptoms.", "physical_exams": "The provided text does not contain specific instrument readings or test information to extract. It only describes the physical examination findings of a patient."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211028&width=1500&height=4000", "question": "A 26-year-old woman presented with recurrent hemoptysis coinciding with her menstrual cycles. Noncontrast computed tomography (CT) imaging of the lungs showed a cavitary nodule with ground-glass appearance in the right lower lobe. What is the most likely diagnosis?", "type": ["CT scan"], "answers": [{"text": "Accessory breast tissue", "correct": false}, {"text": "Catamenial pneumothorax", "correct": false}, {"text": "Ectopic pregnancy", "correct": false}, {"text": "Progestogen hypersensitivity", "correct": false}, {"text": "Thoracic endometriosis", "correct": true}], "patient_info": "For the patient actor: - You are a 26-year-old woman. - You have been experiencing coughing up blood, and this seems to happen around the time of your menstrual cycles. - You have undergone a CT scan of your lungs, which showed a specific type of lung nodule in the right lower part of your lungs.", "physical_exams": "Noncontrast computed tomography (CT) imaging of the lungs showed a cavitary nodule with ground-glass appearance in the right lower lobe."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211021&width=1500&height=4000", "question": "A 49-year-old woman, who had undergone kidney transplantation 4 months earlier, presented to the emergency department with a 2-week history of headache, dizziness, and rash. On exam she had diffuse, umbilicated papules. What is the most likely pathogen?", "type": ["physical", "hist/path"], "answers": [{"text": "Blastomyces dermatitidis", "correct": false}, {"text": "Cryptococcus neoformans", "correct": true}, {"text": "Histoplasma capsulatum", "correct": false}, {"text": "Molluscum contagiosum", "correct": false}, {"text": "Mycobacterium tuberculosis", "correct": false}], "patient_info": "For your role as a patient, you are a 49-year-old woman who has had a kidney transplant 4 months ago. Recently, you've been experiencing a headache and dizziness for the past two weeks. Additionally, you've noticed a rash on your skin, characterized by diffuse, umbilicated papules. You are concerned about these symptoms and have come to the emergency department for evaluation.", "physical_exams": "The provided text does not include specific instrument readings or test results related to the medical case. It only describes symptoms and clinical findings (headache, dizziness, rash, and diffuse, umbilicated papules) without mentioning any laboratory or diagnostic test outcomes. Therefore, there is no instrument reading information to extract from this case report."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211014&width=1500&height=4000", "question": "An 82-year-old man with diabetes presented to the emergency department with fever and confusion. Liver function test showed aspartate aminotransferase level of 1380 u/l (reference range, 5 to 40) and alanine aminotransferase level of 1121 u/l (reference range, 5 to 40). A computed tomographic scan of the abdomen was performed. What is the most likely diagnosis?", "type": ["CT scan"], "answers": [{"text": "Acute hepatic necrosis", "correct": false}, {"text": "Cholecystoduodenal fistula", "correct": false}, {"text": "Emphysematous hepatitis", "correct": true}, {"text": "Pyogenic liver abscess", "correct": false}, {"text": "Ruptured hydatid cyst", "correct": false}], "patient_info": "You are an 82-year-old man with a history of diabetes. Recently, you've been experiencing fever and confusion, which prompted you to seek medical attention. You are not aware of your specific test results or their implications, but you know you've been feeling unwell with these symptoms.", "physical_exams": "Aspartate aminotransferase level: 1380 u/l (Reference range: 5 to 40)\nAlanine aminotransferase level: 1121 u/l (Reference range: 5 to 40)"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20211007&width=1500&height=4000", "question": "A 80-year-old man undergoing treatment for multiple myeloma presented with fevers and confusion. Magnetic resonance imaging (MRI) of the head showed ring-enhancing lesions. Gram stain of cerebrospinal fluid (CSF) showed gram-positive bacilli. What is the most likely diagnosis?", "type": ["MRI", "biopsy"], "answers": [{"text": "Clostridium septicum", "correct": false}, {"text": "Listeriosis", "correct": false}, {"text": "Nocardiosis", "correct": true}, {"text": "Peptostreptococcus species", "correct": false}, {"text": "Propionibacterium acnes", "correct": false}], "patient_info": "For the patient actor: You are an 80-year-old man who has been receiving treatment for a condition affecting your blood cells. Recently, you've started experiencing fevers and periods of confusion, which prompted further medical investigation. You haven't been informed about the specific findings of these investigations, but you are aware of your symptoms.", "physical_exams": "- MRI of the head: Showed ring-enhancing lesions.\n- Gram stain of cerebrospinal fluid (CSF): Showed gram-positive bacilli."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210930&width=1500&height=4000", "question": "A healthy 15-year-old boy presented with a 3-month history of asymptomatic papules on his glans penis. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Condyloma acuminatum", "correct": false}, {"text": "Fordyce spots", "correct": false}, {"text": "Molluscum contagiosum", "correct": false}, {"text": "Pearly penile papules", "correct": true}, {"text": "Sebaceous hyperplasia", "correct": false}], "patient_info": "For the patient actor: You are a healthy 15-year-old boy who has noticed some small, bump-like spots on the head of your penis. These spots have been there for about three months. You haven't felt any pain or discomfort from them, and there haven't been any other symptoms that you've noticed. You're seeking medical advice to understand what these spots are.", "physical_exams": "The provided text does not contain any specific test or instrument readings related to the medical case. Therefore, I cannot generate information based on instrument readings from the given text."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210923&width=1500&height=4000", "question": "A 65-year-old man presented with painful, erythematous, and purplish plaques on the extensor surfaces of his hands and elbows. Laboratory examinations showed leukocytosis and thrombocytopenia. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Gottron\u2019s papules", "correct": false}, {"text": "Guttate psoriasis", "correct": false}, {"text": "Immune thrombocytopenia purpura (ITP)", "correct": false}, {"text": "Leukemia cutis", "correct": true}, {"text": "Solar purpura", "correct": false}], "patient_info": "For the patient actor: - Age: 65 years old - Symptoms: You have been experiencing painful, red, and purplish patches on the outer parts of your hands and elbows. - You are not aware of any specific test results but have been told that some blood counts were abnormal.", "physical_exams": "The laboratory examinations revealed the following:\n\n- Leukocytosis\n- Thrombocytopenia"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210916&width=1500&height=4000", "question": "A 73-year-old man presented with a 5-month history of blurry vision, photophobia, and burning in both eyes. On examination, he was found to have filmlike adhesions between the bulbar and palpebral conjunctivae, as well as scattered vesicles and bullae on his arms and back. What is the eye exam finding?", "type": ["ophthalmology"], "answers": [{"text": "Conjunctivitis", "correct": false}, {"text": "Episcleritis", "correct": false}, {"text": "Pinguecula", "correct": false}, {"text": "Pterygium", "correct": false}, {"text": "Symblepharon", "correct": true}], "patient_info": "For your role as the patient, you are a 73-year-old man who has been experiencing blurry vision, sensitivity to light (photophobia), and a burning sensation in both eyes for the past five months. Additionally, you've noticed some blister-like formations (vesicles and bullae) on your arms and back. During your eye examination, the doctor found that there are film-like adhesions, which are essentially thin layers of tissue sticking together, between the inner surface of your eyelids and the white part of your eyes.", "physical_exams": "The eye exam findings for the 73-year-old man are:\n- Filmlike adhesions between the bulbar and palpebral conjunctivae\n- Blurry vision\n- Photophobia"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210909&width=1500&height=4000", "question": "A 50-year-old man presented with a lesion on his eye that developed over the preceding month. He also had violaceous plaques on his back and lower limbs. Testing for HIV was positive. What is the diagnosis?", "type": ["ophthalmology"], "answers": [{"text": "Angiosarcoma", "correct": false}, {"text": "Bacillary angiomatosis", "correct": false}, {"text": "Herpes simplex keratoconjunctivitis", "correct": false}, {"text": "Kaposi\u2019s sarcoma", "correct": true}, {"text": "Ocular surface squamous neoplasia", "correct": false}], "patient_info": "For the patient actor: - Age: 50 years old - Symptoms: - A lesion on the eye that has developed over the last month. - Violaceous (purple-colored) plaques on the back and lower limbs. - Additional Information: The patient has recently tested positive for HIV.", "physical_exams": "The information extracted for an instrument reader actor from the provided case report is as follows:\n\n- HIV test result: Positive"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210902&width=1500&height=4000", "question": "A 7-year-old girl presented with an itchy rash while taking amoxicillin for pharyngitis. Physical exam showed purulent tonsils, along with a maculopapular rash involving her face, trunk, arms, and legs. What is the most likely diagnosis?", "type": ["dermatology", "ophthalmology"], "answers": [{"text": "Amoxicillin rash in infectious mononucleosis", "correct": true}, {"text": "Guttate psoriasis", "correct": false}, {"text": "Hand, foot, and mouth disease", "correct": false}, {"text": "Scarlet fever", "correct": false}, {"text": "Serum sickness-like reaction", "correct": false}], "patient_info": "For the patient actor portraying the 7-year-old girl, you should be aware of the following symptoms and history: - You have been taking amoxicillin for a sore throat. - You have developed an itchy rash that has spread to your face, trunk, arms, and legs. - You also have sore and possibly pus-covered tonsils, which might make swallowing uncomfortable. Remember, you are not aware of your diagnosis; you only know these symptoms and your recent medical history of taking amoxicillin for pharyngitis.", "physical_exams": "The case report does not provide specific instrument readings or test results to extract."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210826&width=1500&height=4000", "question": "A 54-year-old woman presented with abdominal pain and difficulty walking. Abdominal imaging showed multiple abscesses surrounding an intrauterine device (IUD). Aspiration with gram stain identified branching, filamentous, gram-positive rods. What is the most likely diagnosis?", "type": ["CT scan"], "answers": [{"text": "Actinomycosis", "correct": true}, {"text": "Aspergillosis", "correct": false}, {"text": "Crohn\u2019s disease", "correct": false}, {"text": "Listeriosis", "correct": false}, {"text": "Nocardiosis", "correct": false}], "patient_info": "For the patient actor: - **Age and Gender**: 54-year-old woman - **Symptoms**: - Abdominal pain - Difficulty walking You are not aware of your diagnosis or the specific test results, but you know you have an intrauterine device (IUD) and have been experiencing these symptoms.", "physical_exams": "The test information from the case report includes:\n\n- Abdominal imaging results: Multiple abscesses surrounding an intrauterine device (IUD).\n- Aspiration with gram stain results: Branching, filamentous, gram-positive rods identified."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210819&width=1500&height=4000", "question": "A 30-year-old man presented with a rash on his face, hands, and feet. He had a history of HIV with a CD4+ T-cell count of 374 per cubic millimeter. Physical examination showed circinate lesions on the palms, soles, and face and patchy alopecia. What is the likely diagnosis?", "type": ["physical"], "answers": [{"text": "Disseminated granuloma annulare", "correct": false}, {"text": "Erythema annulare centrifugum", "correct": false}, {"text": "Syphilis", "correct": true}, {"text": "Tinea corporis", "correct": false}, {"text": "Tuberculoid leprosy", "correct": false}], "patient_info": "For the patient actor: - Age: 30 years old - Symptoms: - Rash on the face, hands, and feet - Circinate (ring-shaped) lesions on the palms, soles, and face - Patchy hair loss (alopecia) - Medical history: HIV positive", "physical_exams": "CD4+ T-cell count: 374 per cubic millimeter"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210812&width=1500&height=4000", "question": "A 26-year-old woman with the Peutz\u2013Jeghers syndrome presented to the emergency department with abdominal pain and nonbilious vomiting. A tender mass was palpable in the upper abdomen. What is the most likely diagnosis?", "type": ["CT scan"], "answers": [{"text": "Acute necrotizing pancreatitis", "correct": false}, {"text": "Cholangiocarcinoma", "correct": false}, {"text": "Gastric leiomyosarcoma", "correct": false}, {"text": "Gastrogastric intussusception", "correct": true}, {"text": "Pancreatic adenocarcinoma with gastric invasion", "correct": false}], "patient_info": "For the patient actor: - **Age/Gender**: 26-year-old woman - **Medical History**: Known case of Peutz\u2013Jeghers syndrome - **Symptoms**: - Abdominal pain - Nonbilious vomiting - A tender mass can be felt in the upper abdomen when touched", "physical_exams": "The provided text does not include specific instrument readings or test results that can be extracted for an instrument reader actor. It only describes the patient's symptoms and physical examination findings without mentioning any laboratory tests, imaging studies, or other diagnostic procedures."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210805&width=1500&height=4000", "question": "A 62-year-old woman with recent travel to Colombia presented with pruritic, draining nodules with a central punctum on her back and buttocks. The lesions were unchanged after a trial of antibiotics. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Cutaneous leishmaniasis", "correct": false}, {"text": "Epidermoid cyst", "correct": false}, {"text": "Furunculosis", "correct": false}, {"text": "Myiasis", "correct": true}, {"text": "Tungiasis", "correct": false}], "patient_info": "For the patient actor: - You are a 62-year-old woman. - You recently traveled to Colombia. - You have been experiencing itchy, draining nodules with a central punctum on your back and buttocks. - You tried taking antibiotics, but the lesions have not changed or improved.", "physical_exams": "The provided text does not include specific instrument readings or test results to extract. It only describes the patient's symptoms and history."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210729&width=1500&height=4000", "question": "A 42-year-old woman receiving induction chemotherapy for acute monocytic leukemia developed edematous, erythematous plaques on her face. Biopsy showed perieccrine neutrophilic infiltration with eccrine duct necrosis. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Eccrine miliaria rubra", "correct": false}, {"text": "Leukemia cutis", "correct": false}, {"text": "Erysipelas", "correct": false}, {"text": "Drug-induced lupus", "correct": false}, {"text": "Neutrophilic eccrine hidradenitis", "correct": true}], "patient_info": "For the patient actor: You are a 42-year-old woman who has recently started treatment for a serious blood condition. After beginning your treatment, you've noticed some concerning changes to your skin, particularly on your face. You've developed swollen, red patches that are unlike anything you've seen before. These changes prompted you to seek further medical advice.", "physical_exams": "The provided text does not contain specific instrument readings or test results that can be extracted for an instrument reader actor. It mentions a biopsy result showing \"perieccrine neutrophilic infiltration with eccrine duct necrosis\" but does not provide numerical or specific test readings."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210722&width=1500&height=4000", "question": "A 26-year-old heathy woman developed an axillary mass with white discharge after a spontaneous vaginal delivery. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Eosinophilic folliculitis", "correct": false}, {"text": "Polymastia", "correct": true}, {"text": "Bacterial lymphadenitis", "correct": false}, {"text": "Hidradenitis suppurativa", "correct": false}, {"text": "Lactational mastitis", "correct": false}], "patient_info": "For the patient actor: You are a 26-year-old woman who has recently given birth through a spontaneous vaginal delivery. Since the delivery, you have noticed a mass in your armpit (axillary area) that sometimes releases a white discharge. You haven't experienced any significant health issues before this. You are concerned about this new development and are seeking medical advice to understand what is happening.", "physical_exams": "The provided text does not contain any specific test or instrument readings related to the medical case. Therefore, I cannot generate information for an instrument reader actor based on the given text."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210715&width=1500&height=4000", "question": "Examination of a 68-year-old man with interstitial lung disease was notable for skin changes characterized by alternating areas of hypopigmentation and hyperpigmentation on sclerotic skin. What is the most likely diagnosis?", "type": ["physical"], "answers": [{"text": "Amyopathic dermatomyositis", "correct": false}, {"text": "Leprosy", "correct": false}, {"text": "Diffuse cutaneous systemic sclerosis", "correct": true}, {"text": "Subacute cutaneous lupus erythematosus", "correct": false}, {"text": "Adult-onset Still\u2019s disease", "correct": false}], "patient_info": "For the patient actor: You are a 68-year-old man who has been experiencing some breathing difficulties, which you've been told is due to a condition affecting your lungs. Recently, you've noticed some changes in your skin. Specifically, you've observed areas where your skin seems lighter than usual, alongside patches where it appears darker, all of this on skin that feels hard or thickened. You haven't noticed any other major symptoms, but these skin changes and your breathing issues have been concerning for you.", "physical_exams": "The provided text does not include specific instrument readings or test results that can be extracted for an instrument reader actor. It only describes the physical examination findings of a 68-year-old man with interstitial lung disease, noting skin changes characterized by alternating areas of hypopigmentation and hyperpigmentation on sclerotic skin. No laboratory or diagnostic test results are mentioned."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210708&width=1500&height=4000", "question": "A 16-day-old girl was brought to the emergency department with lethargy. Physical exam showed tachypnea and marked hepatomegaly, as well as small hemangiomas on the skin. TSH was elevated. MRI showed numerous hepatic lesions and cardiomegaly. What is the most likely diagnosis?", "type": ["MRI"], "answers": [{"text": "Hepatic adenoma", "correct": false}, {"text": "Pyogenic liver abscess", "correct": false}, {"text": "Hepatocellular carcinoma", "correct": false}, {"text": "Infantile hepatic hemangiomas", "correct": true}, {"text": "Undifferentiated embryonal sarcoma", "correct": false}], "patient_info": "For the patient actor: You are playing the role of the parent of a 16-day-old girl. You've brought your daughter to the emergency department because she's been unusually lethargic. You've noticed that she seems to be breathing rapidly (tachypnea) and has an enlarged liver (hepatomegaly) when you touch her belly. Additionally, you've observed small, red birthmark-like spots (hemangiomas) on her skin. You are unaware of any specific test results or medical terms but are concerned about these symptoms.", "physical_exams": "- TSH: Elevated\n- MRI findings: Numerous hepatic lesions, Cardiomegaly"}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210701&width=1500&height=4000", "question": "A 34-year-old woman presented to the rheumatology clinic with a 3-month history of a rash on her cheeks and an 18-month history of joint pain in her hands and knees. Physical examination showed indurated plaques on her cheeks. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Polymyalgia rheumatica", "correct": false}, {"text": "Rheumatoid arthritis", "correct": false}, {"text": "Systemic lupus erythematosus", "correct": true}, {"text": "Adult-onset Still\u2019s disease", "correct": false}, {"text": "Psoriatic arthritis", "correct": false}], "patient_info": "For the patient actor: - Age: 34 years old - Symptoms: - Rash on cheeks for the past 3 months - Joint pain in hands and knees for the past 18 months - Physical findings: Indurated plaques on cheeks", "physical_exams": "The provided text does not include specific instrument readings or test results related to the diagnosis. Therefore, I cannot generate information based on instrument readings from the given case report."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210624&width=1500&height=4000", "question": "An 83-year-old woman presented to the emergency department with a 1-day history of right-sided tongue swelling. Sensory examination of the tongue was normal. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Thromboembolism", "correct": true}, {"text": "Sjogren's disease", "correct": false}, {"text": "Hematoma", "correct": false}, {"text": "Anti-neutrophil cytoplasm antibodies (ANCA) vasculitis", "correct": false}, {"text": "Hereditary angioedema", "correct": false}], "patient_info": "For the patient actor: - Age: 83 years old - Symptoms: You've been experiencing swelling on the right side of your tongue for the past day. - Sensory Experience: You haven't noticed any changes in sensation or feeling in your tongue; it feels normal to you in that regard.", "physical_exams": "The provided text does not include any specific test or instrument readings related to the medical case. Therefore, I cannot generate information based on instrument readings from the given case report."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210617&width=1500&height=4000", "question": "A 66-year-old woman presented with a pruritic rash. Physical examination showed dyschromic patches, plaques, and poikiloderma on her upper back. Strength testing noted weakness in proximal arms and legs. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Polymyositis", "correct": false}, {"text": "Dermatomyositis", "correct": true}, {"text": "Subacute cutaneous lupus erythematosus", "correct": false}, {"text": "Discoid lupus", "correct": false}, {"text": "Psoriasis", "correct": false}], "patient_info": "For the patient actor: - Age: 66 years old - Symptoms: - Itchy rash - Changes in skin color and texture, including patches and plaques - Noticeable skin changes on the upper back that may look mottled or show different colors (poikiloderma) - Physical challenges: - Feeling weaker than usual in the muscles close to the body, specifically in the upper arms and legs", "physical_exams": "The provided text does not include specific instrument readings or test results. It only describes symptoms and physical examination findings. For an instrument reader actor, there are no specific instrument readings to report from this text."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210610&width=1500&height=4000", "question": "A 53-year-old man who worked as a gardener presented to the emergency department with sudden onset of paralysis in the lower legs. He had a 2-month history of intermittent fevers and had undergone a bioprosthetic aortic-valve replacement 6 months prior to presentation. Computed tomographic angiography showed an aortic pseudoaneurysm with emboli. An embolectomy was performed, and a histopathological analysis is as shown. Which organism was the cause of his infection?", "type": ["biopsy"], "answers": [{"text": "Mucormycosis", "correct": false}, {"text": "Aspergillus fumigatus", "correct": false}, {"text": "Curvularia alcornii", "correct": true}, {"text": "Scedosporium apiospermum", "correct": false}, {"text": "Sporothrix schenckii", "correct": false}], "patient_info": "You are a 53-year-old man who works as a gardener. Recently, you've experienced sudden paralysis in your lower legs. Over the past two months, you've also had intermittent fevers. About six months ago, you had a bioprosthetic aortic-valve replacement surgery.", "physical_exams": "The case report does not provide specific instrument readings or test results directly. It mentions the use of computed tomographic angiography, which showed an aortic pseudoaneurysm with emboli, and a histopathological analysis was performed. However, the specific findings or measurements from these tests are not detailed in the provided information."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210603&width=1500&height=4000", "question": "A 65-year-old man presented with six months of worsening lesions on his hands and forearms as well as fingernail thickening. His medical history included end-stage renal disease and untreated hepatitis C virus infection. What is the diagnosis?", "type": ["physical"], "answers": [{"text": "Buruli ulcers", "correct": false}, {"text": "Peripheral vascular disease", "correct": false}, {"text": "Antineutrophil cytoplasmic antibody (ANCA)\u2013associated vasculitis", "correct": false}, {"text": "Porphyria cutanea tarda", "correct": true}, {"text": "Blastomycosis", "correct": false}], "patient_info": "For the patient actor: - Age: 65 years old - Symptoms: You have been experiencing worsening lesions on your hands and forearms for the past six months. Additionally, you've noticed your fingernails have become thicker. - Medical History: You have end-stage renal disease and an untreated hepatitis C virus infection.", "physical_exams": "The provided text does not include specific instrument readings or test results to extract. For an instrument reader actor to interpret, details such as laboratory values, imaging findings, or other diagnostic test results are necessary, and none are provided in the given case report excerpt."}
{"image_url": "https://csvc.nejm.org/ContentServer/images?id=IC20210527&width=1500&height=4000", "question": "A 60-year-old woman with a history of rheumatoid arthritis presented with diarrhea, nausea, and anorexia. Endoscopic examination of the colon and biopsy specimens with Congo red staining under polarized light are shown. What is the diagnosis?", "type": ["surgical", "hist/path"], "answers": [{"text": "Gastrointestinal Kaposi\u2019s sarcoma", "correct": false}, {"text": "Gastrointestinal amyloidosis", "correct": true}, {"text": "Lynch syndrome", "correct": false}, {"text": "Crohn\u2019s disease", "correct": false}, {"text": "Gastrointestinal leiomyosarcoma", "correct": false}], "patient_info": "For the patient actor: You are a 60-year-old woman who has been dealing with rheumatoid arthritis for some time. Recently, you've started experiencing frequent bouts of diarrhea, feeling nauseous quite often, and you've noticed a significant decrease in your appetite. These symptoms have been persistent enough to concern you and seek medical attention.", "physical_exams": "The information provided does not include specific instrument readings or test results that can be extracted for an instrument reader actor. It mentions an endoscopic examination and biopsy specimens with Congo red staining under polarized light, but does not provide the outcomes of these tests. To generate information for an instrument reader actor, specific results or findings from these procedures would be needed."}