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q01-04cfddb40624b468 | 2026-03 | q01 | Case: A neonate had a solid left neck mass. Preoperative MRI was interpreted as showing a well-defined, intact tumor border. The internal and external carotid arteries appeared displaced laterally rather than involved. There was no apparent invasion of adjacent muscle or skull-base tissue. At surgery, the tumor had no ... | The sagittal image (right) is the more reliable clue. It shows the tumor's superior margin blending indistinctly into the adjacent skull-base tissue (loss of a clear separating margin/fat plane), rather than a crisp capsule line. That ill-defined superior boundary is a sign of infiltrative growth and is more consistent... | The transverse section shows an apparently well-circumscribed lateral border, which was the basis for the preoperative impression of an intact capsule with vessels merely displaced. However, the sagittal section shows the tumor's superior aspect merging indistinctly with skull-base tissue, a finding not reflected in th... | Investigation Interpretation | Short Answer | Clinical Medicine | Pediatric Head and Neck Surgical Oncology / Neuroradiology | en | {
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"quote": "The tumor lacks a well-defined capsule and encases both the internal (ICA) and external carotid arteries (ECA)."
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A neonate had a solid mass in the left side of the neck. Preoperative MRI of the mass was interpreted as showing an intact, well-defined tumor border, with the internal and external carotid arteries simply pushed laterally rather than involved, and no invasion of adjacent muscle or skull-base tissue. The two images pro... | {
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... | |
q01-051597128c053307 | 2026-03 | q01 | Case: A woman in her twenties had newly identified antinuclear antibodies, anti-double-stranded DNA antibodies, lupus anticoagulant, anticardiolipin IgG, and anti-β2-glycoprotein I IgG. She was afebrile, and blood cultures obtained without prior antibiotics were negative. Echocardiography showed severe mitral regurgita... | The marked valve masses (vegetations) look essentially unchanged in size, shape, and echogenicity between the baseline and follow-up images despite immunosuppressive therapy, and severe mitral regurgitation persisted, whereas LVEF improved from 45% to 52%. This indicates that the reversible component was ventricular/my... | The two images must be compared directly: the vegetations marked by arrows are present in essentially the same location and appearance in both, showing no regression despite therapy. This is contrasted with the numeric LVEF trend (45% to 52%) stated in the text, which is a different disease compartment (myocardial func... | Treatment Response | Short Answer | Clinical Medicine | Cardiology/Rheumatology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her twenties with newly identified antinuclear antibodies, anti-double-stranded DNA antibodies, lupus anticoagulant, anticardiolipin IgG, and anti-β2-glycoprotein I IgG presented with severe mitral regurgitation and echogenic masses on both mitral leaflets on echocardiography (blood cultures negative, no pri... | {
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q01-0f0dd69644414d4e | 2026-03 | q01 | Case: A man in his 70s had 3 months of stereotyped, brief, dystonic-appearing spells. Twisting of the right face, arm, and leg ended in a brief sustained abnormal posture. The spells occurred about twice per minute.
During the symptomatic period, plasma glucose was 494 mg/dL and HbA1c was 16.1%. Serum electrolytes, EE... | Neither panel shows an acute basal ganglia lesion that directly explains the movements. Panel A (MRI, taken while symptomatic) shows only a small chronic-appearing lacunar infarct in the left basal ganglia (anatomically concordant with the right-sided symptoms via the crossed motor/striatal pathway) plus age-related at... | The case superficially resembles diabetic striatopathy, where the textbook expectation is an acute contralateral striatal MRI/CT abnormality and reduced basal ganglia metabolism on PET. Here neither image shows that: the MRI lesion is chronic (not acute) and the PET, done after resolution, shows normal basal ganglia up... | Investigation Interpretation | Long Answer | Clinical Medicine | Neurology / Movement Disorders | en | {
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"quote": "Brain 18F-FDG PET/CT shows mild asymmetric relative cerebellar hypometabolism, more evident in the left cerebellar hemisphere, with preserved uptake in the basal ganglia and cerebral cortex."
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"quote": "Brain MRI showed only a small chronic lacunar infarct i... | [
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"title": "Paroxysmal Hemidystonia as the Presenting... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man in his 70s had a 3-month history of stereotyped brief dystonic-appearing spells (twisting movements ending in a brief sustained abnormal posture) affecting the right face, arm, and leg, occurring roughly twice per minute. During the symptomatic period, plasma glucose was markedly elevated (494 mg/dL) with HbA1c 1... | {
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q01-2937c0e54268f3d4 | 2026-03 | q01 | Case: A patient had synchronous glioblastoma and early-stage lung adenocarcinoma. The lung cancer received no directed treatment. The lung nodule’s longest diameter was 18 mm at diagnosis (week 0), 12 mm at week 13, and 9 mm at week 19.
Images: The top row shows the brain-tumor treatment timeline with corresponding br... | Cranial radiotherapy was delivered only from week 5 to week 8. Both regression intervals occurred after radiotherapy had already ended: the first (18 mm to 12 mm) spans weeks 0-13, so its latter half (weeks 8-13) occurred during temozolomide-only adjuvant therapy with no active irradiation; the second (12 mm to 9 mm, w... | The image's timeline shows radiotherapy confined to weeks 5-8, temozolomide continuing before and after that window, and bevacizumab added at week 13. Overlaying the nodule measurements onto this timeline shows the bulk of the observed regression occurred outside the radiation window, which undercuts the reflexive radi... | Mechanism | Short Answer | Clinical Medicine | Oncology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient had synchronous glioblastoma and an early-stage lung adenocarcinoma. No lung-directed therapy of any kind was ever given. The lung nodule's longest diameter was 18 mm at diagnosis (week 0), 12 mm at week 13, and 9 mm at week 19. The provided image shows the treatment timeline for the brain tumor (top row, wit... | {
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q01-2bf9320c0f5eeb2f | 2026-03 | q01 | Case: In children with heterozygous loss-of-function variants in the NF-kB regulator A20 (TNFAIP3), one child had a ~2.1-Mb deletion at 6q23. It removed TNFAIP3 plus a peroxisomal matrix-protein import receptor gene—whose complete loss classically causes skeletal chondrodysplasia with punctate epiphyseal calcification—... | The arthritis is best explained by haploinsufficiency of the co-deleted peroxisomal-targeting-receptor gene (PEX7), not by loss of A20 itself. PEX7 loss impairs peroxisomal matrix protein import and is mechanistically linked to skeletal/joint pathology (as seen in rhizomelic chondrodysplasia punctata type 1, which PEX7... | Table 1 shows arthritis present only in the patient with the segmental 6q23 deletion and absent in all four patients with isolated OTU- or ZnF-domain point/frameshift variants, despite all five sharing A20 haploinsufficiency. The discussion explicitly notes the deleted region contains PEX7, IL20RA, and IL22RA2, and lin... | Mechanism | Long Answer | Clinical Medicine | Pediatric Immunology/Medical Genetics | en | {
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"partial_credit": "Full credit for naming PEX7 or clearly describing 'the peroxisomal receptor gene' with correct mechanism; partial credit (3 pts) if answer correctly separates the arthritis mechanism from NF-kB but misidentifies or omits the specific gene",
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"quote": "The deleted segment contains the PEX7, IL20RA, and IL22RA2 genes."
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"quote": "In patient 3, the observed arthritis may be associated with PEX7 deficiency, while the absence of IL20RA and IL22RA2 may exacerbate inflammatory dysregulation or rashes."
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | In a case series of children with heterozygous loss-of-function variants in the NF-kB regulator gene A20 (TNFAIP3), one child's genetic testing showed something different from the others: instead of a small frameshift or nonsense change confined to TNFAIP3 itself, this child carried a large heterozygous deletion of abo... | {
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q01-38c704a402bdd4c0 | 2026-03 | q01 | Case: A woman in her 80s on hemodialysis had an unusable right radiocephalic AV fistula and later received a right brachio-axillary AV graft. After graft placement, she developed severe hand pain, numbness, and progressive weakness, reaching 2/5 finger strength with inability to make a fist.
Electrodiagnostic findings... | (1) Localization: the distal segments of the median, ulnar, and radial nerves in the forearm/hand (the watershed territory supplied by the vasa nervorum), with sparing of nerve segments proximal to that watershed. The normal antebrachial cutaneous sensory nerves - which branch off the same plexus/cords proximal to the ... | Localization requires combining the antebrachial cutaneous sparing (rules out proximal plexus lesion) with the normal contralateral studies (rules out diabetic polyneuropathy) - neither fact alone is sufficient. The mechanism question requires noticing that ulnar CMAP, though reduced, is stable across segments (no cond... | Investigation Interpretation | Long Answer | Clinical Medicine | Neurology (Electrodiagnostics) | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her 80s on maintenance hemodialysis had a right radiocephalic AV fistula that had already been judged unusable for dialysis, and, months later, a new right brachio-axillary AV graft. After the graft was placed she developed severe pain, numbness, and progressive weakness of that hand, eventually with 2/5 fin... | {
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q01-4cb026bfa87c532c | 2026-03 | q01 | Case: A 66-year-old man underwent staged antegrade recanalization of a heavily calcified chronic total occlusion at the ostium of the LAD. The LAD arose independently from the circumflex, with no left main.
Repeated guidewire attempts, escalating from a polymer-jacketed wire to a stiffer tapered-tip wire, entered the ... | The right-hand image shows an unintentional rupture of the angioplasty balloon at the proximal LAD cap, producing focal contrast extravasation/staining and a transient 'grenade-like' blush within the calcified segment (balloon-assisted microdissection, i.e., 'grenadoplasty') without vessel perforation. Mechanistically,... | The stem establishes that multiple wire strategies had failed to find the true lumen through a calcified, resistant cap, and that a balloon was inflated at the ambiguous entry point. The image pair shows a pre-intervention baseline versus a post-inflation frame with new contrast staining and a transient blush, indicati... | Mechanism | Long Answer | Clinical Medicine | Interventional Cardiology | en | {
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{
"id": "c1",
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"points": 5,
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 66-year-old man presented with an inferolateral ST-segment elevation myocardial infarction. Angiography showed a critical stenosis of a dominant left circumflex artery (treated acutely) and a separate, heavily calcified chronic total occlusion (CTO) at the origin of the left anterior descending artery (LAD), which ar... | {
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"omitted_... | |
q01-55ea587e1ed2f1dc | 2026-03 | q01 | Case: A man in his late 50s had received thoracic radiotherapy for a mediastinal malignancy. He also had severe COVID-19 complicated by pericarditis and pericardial tamponade.
Years later, he presented with anasarca and exertional dyspnea. Echocardiography and right heart catheterization showed marked reciprocal respi... | The constrictive physiology is caused by direct malignant tumor infiltration that circumferentially encases the pericardium, mediastinal pleura, and epicardial surface of the heart (malignant extrinsic cardiac encasement / 'pseudo-constriction'), rather than by primary inflammatory or radiation-fibrotic pericardial dis... | Two independent pieces of evidence must be combined: (1) imaging showing a mediastinal mass directly infiltrating/inseparable from the pericardium and epicardial fat with RA deformity and IVC compression — i.e., a mechanical encasing process rather than isolated pericardial disease; and (2) the complete absence of resp... | Mechanism | Long Answer | Clinical Medicine | Cardio-oncology | en | {
"criteria": [
{
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"partial_credit": "Full credit for any answer identifying tumor infiltration/encasement of the pericardium or heart as the driver, using equivalent terminology (e.g., 'malignant pericardial infiltration', 'extrinsic tumor shell', 'neoplastic encasement'); partial credit (... | [
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"doi": "10.7759/cureus.105678",
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"title": "When Constriction Is Not Just... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man in his late 50s with a history of thoracic radiotherapy for a mediastinal malignancy and a prior episode of severe COVID-19 complicated by pericarditis and pericardial tamponade presented, years later, with anasarca and exertional dyspnea. Echocardiography and right heart catheterization showed the classic hemody... | {
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"single_target_question",
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],
"summary": "Reorganized the case chronologically and replaced the compound prompt with one direct mechanism question while preserving the clinical an... | |
q01-56628130e44911ae | 2026-03 | q01 | Case: A patient has slowly progressive hoarseness for several years, worse over the last 3 months, without dysphagia, dyspnoea, cough, or a neck mass. Chest radiography shows a right aortic arch. CT angiography shows, in order, the left common carotid, right common carotid, right subclavian, and an aberrant left subcla... | 1) The right vocal cord is paralysed - the image shows right-sided dilatation of the laryngeal ventricle and pyriform sinus, medial displacement/fixation of the right vocal cord and aryepiglottic fold, and loss of the right subglottic arch with a preserved normal arch on the left. 2) In this type of right aortic arch (... | The case requires rejecting the intuitive 'right arch causes right palsy' pattern match by first testing it against the actual branch order (RSA arises normally, so the nerve's textbook path is undisturbed) and then invoking the reported variant nerve course (hooking around the arch instead of the subclavian artery) as... | Mechanism | Long Answer | Clinical Medicine | Diagnostic Radiology / Otolaryngology | en | {
"criteria": [
{
"id": "c1",
"partial_credit": "No partial credit; must state right side specifically, not just 'asymmetry present'",
"points": 2,
"requirement": "Correctly identifies the right vocal cord as paralysed based on the image asymmetry",
"summary": null
},
{
... | [
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"page": 1,
"quote": "Fiberoptic indirect laryngoscopy revealed a paramedian position and restricted movement of the right vocal cord with a phonatory gap, suggesting right VCP."
},
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"quote": "The first branch to originate from the RAA was the left common carotid artery followed by ... | [
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"title": "Atypical cardiovocal sy... | {
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... | {
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"is_primary_dual_model_failure": true,
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient has several years of slowly progressive hoarseness that worsened over the last 3 months. There is no dysphagia, dyspnoea, cough, or palpable neck mass. A chest radiograph shows a right-sided aortic arch. CT angiography of the thoracic aorta shows: the arch gives off, in order, the left common carotid artery, ... | {
"strategy": [
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],
"summary": "Separated the vascular anatomy, laryngeal image map, and four mechanism questions while preserving every causal constraint.",
"omitted_content": [
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q01-6072d93f5434080b | 2026-03 | q01 | Case: A woman with hepatitis B carrier status and compensated cirrhosis was hospitalized with fever, generalized rash, fatigue, anemia, thrombocytopenia, and hepatosplenomegaly. Tests for EBV, CMV, HIV, hepatitis C/D/E, brucellosis, leptospirosis, syphilis, and tuberculosis were negative. Leishmania serology was weakly... | The trigger is an occult non-hematolymphoid malignancy — specifically an HHV-8-associated vascular neoplasm (Kaposi sarcoma) causing malignancy-associated secondary HLH, diagnosed on excisional lymph node biopsy. Infection is argued against by the extensive negative/non-contributory microbiologic and serologic work-up ... | The case systematically excludes the two most statistically likely triggers of secondary HLH in an adult (infection and hematologic malignancy) through negative serologies/cultures, lack of antimicrobial response, and negative marrow clonality studies (flow cytometry, FISH), while diffuse FDG-avid multi-organ disease w... | Diagnosis | Short Answer | Clinical Medicine | Hematology-Oncology / Infectious Disease | en | {
"criteria": [
{
"id": "c1",
"partial_credit": "Award 3/6 if answer states 'occult malignancy/neoplasm' generically without specifying a non-lymphoid/vascular process; award 0 if answer concludes infection, autoimmune disease, or lymphoma as the primary trigger",
"points": 6,
"requirement... | [
{
"page": 9,
"quote": "Bone marrow flow cytometry | No diagnostic clonal population"
},
{
"page": 9,
"quote": "FISH panel | No rearrangement detected"
},
{
"page": 10,
"quote": "the pathology result of the excisional lymph node biopsy was reported as consistent with KS"
}
] | [] | {
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"title": "Kaposi Sarcoma Presenting as ... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman with known hepatitis B carrier status and compensated cirrhosis was hospitalized for fever, a generalized rash, fatigue, bicytopenia (anemia and thrombocytopenia), and hepatosplenomegaly. Over several weeks, an extensive infectious work-up was negative or non-contributory: serologies for EBV, CMV, HIV, hepatiti... | {
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"summary": "Grouped the exclusionary work-up by disease category and shortened the HLH and biopsy sequence without changing the target.",
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q01-723984efc0d481da | 2026-03 | q01 | Case: A patient with bilateral proximal retinal arteriolar macroaneurysms, retinal vasculitis, and peripapillary oedema received monthly bilateral intravitreal anti-VEGF injections for about 19 months, an initial tapering course of high-dose oral corticosteroids, and later extensive circumferential peripheral scatter l... | The left-eye OCT shows dense subfoveal hard exudates together with marked vitreomacular traction and a small foveal lamellar hole — a fixed mechanical/tractional disruption of the foveal architecture with residual exudate infiltration. The right-eye OCT at the same time point shows peripapillary/parafoveal thickening a... | The stem supplies the BCVA divergence (0.9 OD vs ~0.4 OS after the same treatment) and explicitly states both eyes still had active leakage/vasculitis, ruling out 'the left eye simply had more active inflammation' as the explanation. The images must be read to find the differentiating structural lesion: the left-eye OC... | Mechanism | Short Answer | Clinical Medicine | Ophthalmology (Retina/Uveitis) | en | {
"criteria": [
{
"id": "c1",
"partial_credit": "Award 3/5 if only traction or only the hole is named without exudates, or if described loosely as 'tractional maculopathy'/'macular hole' without specifying vitreomacular traction; award 5/5 for any answer capturing both the traction/hole component and ... | [
{
"page": 3,
"quote": "OCT confirmed cystoid macular oedema with dense subfoveal hard exudates and marked vitreomacular traction with a small lamellar hole."
},
{
"page": 4,
"quote": "by the end of this treatment period BCVA reached up to 0.9 in OD and around 0.4 in OS, with reduced macular oede... | [
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"doi": "10.1186/s12886-026-04692-1",
"doi_url": "https://doi.org/10.1186/s12886-026-04692-1",
"title": "Adalimumab in ... | {
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"is_primary_dual_model_failure": true,
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient with bilateral proximal retinal arteriolar macroaneurysms, retinal vasculitis, and peripapillary oedema underwent about 19 months of treatment consisting of monthly bilateral intravitreal anti-VEGF injections, an initial tapering course of high-dose oral corticosteroids, and (later, under continued anti-VEGF ... | {
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"o... | |
q01-75d4564f3a8d51b9 | 2026-03 | q01 | Case: A patient with a permanent pacemaker presents with acute chest pain and hypotension. The 12-lead ECG shows a ventricular paced rhythm.
Images: Review the supplied ECG using the original, unmodified Sgarbossa criteria.
Question: Which two ECG findings meet the criteria, where are they seen, and which criterion i... | (1) Concordant ST-segment depression ≥1 mm in a right-to-mid precordial lead (V2), which fulfils the criterion for concordant ST depression in leads V1-V3. (2) Excessive discordant ST elevation (≥5 mm) in the inferior leads (II, III, aVF), which show predominantly negative paced QRS complexes, fulfilling the discordant... | The ECG shows a ventricular paced rhythm. In V2 there is ST depression in a lead where the QRS is not predominantly positive, i.e., concordant depression, satisfying the V1-V3 concordant depression criterion. In the inferior leads the paced QRS complexes are predominantly negative and the ST segments show elevation in ... | Investigation Interpretation | Short Answer | Clinical Medicine | Cardiology - Electrophysiology/Interventional Cardiology | en | {
"criteria": [
{
"id": "c1",
"partial_credit": "Award 2/4 if depression in the correct region is noted without the word 'concordant' or without naming V2/V1-V3; award 4/4 for correct criterion and lead.",
"points": 4,
"requirement": "Identifies concordant ST depression ≥1 mm in V1-V3/V2 a... | [
{
"page": 2,
"quote": "Figure 1 Twelve-lead ECG at presentation demonstrating a ventricular paced rhythm with concordant and excessively discordant ST-segment changes fulfilling Sgarbossa and modified Sgarbossa criteria"
},
{
"page": 1,
"quote": "This ECG demonstrates concordant ST depression ≥1... | [
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"doi": "10.1093/ehjcr/ytag166",
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"title": "Electrocardiogram challenge: ... | {
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"is_primary_dual_model_failure": true,
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image is a 12-lead ECG recorded in a patient with a permanent pacemaker (ventricular paced rhythm) who presented with acute chest pain and hypotension. Using the original (unmodified) Sgarbossa criteria for diagnosing acute coronary occlusion in the setting of a paced or bundle-branch-block QRS morphology,... | {
"strategy": [
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"summary": "Reorganized the presentation and condensed the image-interpretation task while retaining every requested criterion and lead localization.",
"omitted_content": [
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q01-840ae4270c407003 | 2026-03 | q01 | Case: A patient had locally advanced rectal adenocarcinoma, with a semicircumferential anterior rectal wall lesion and several involved mesorectal and pelvic lymph nodes. The patient received total neoadjuvant chemoradiotherapy followed by interval chemotherapy.
The patient also had biopsy-proven intermediate-risk pro... | This is not a confirmed complete clinical response (cCR) — it is a near-complete/indeterminate response. Standard cCR criteria require both a normal exam/endoscopy AND no residual abnormality on MRI; here the exam is clean but the MRI still shows a residual diffusion-restricted focus, so the two modalities are discorda... | The question requires combining three independent facts that are each insufficient alone: (1) the exam/endoscopy vs MRI discordance and the precise definition of cCR (both modalities must be clear), (2) knowledge that early post-chemoradiation MRI diffusion restriction is a known imaging pitfall that can represent fibr... | Treatment Response | Long Answer | Clinical Medicine | Radiation Oncology / Colorectal Oncology | en | {
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... | [
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"quote": "Physical examination demonstrated the complete regression of the rectal tumor intraluminally. However, the MRI of the pelvis revealed residual tumor with a small T2 signal focus of restricted diffusion."
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient with locally advanced rectal adenocarcinoma (baseline: semicircumferential anterior rectal wall lesion with several involved mesorectal/pelvic lymph nodes) received total neoadjuvant chemoradiotherapy, then interval chemotherapy. This was coordinated with androgen deprivation therapy (ADT) started for a separ... | {
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"... | |
q01-85d4de123a9e8f5b | 2026-03 | q01 | Case: A man with type 2 diabetes underwent elective lumbar spine surgery through a retroperitoneal approach. Major intraoperative blood loss required transfusion.
On postoperative day 1, he developed fever and severe abdominal pain. Lipase, amylase, and inflammatory markers were markedly elevated. Initial CT (Image 1,... | (1) Pancreatic inflammatory/necrotic fluid does not stay confined to the peripancreatic space; it dissects along retroperitoneal fascial planes and the paracolic gutters (particularly on the left/around the descending colon and mesentery) under gravity, allowing it to track caudally from the upper abdomen down into the... | The question requires synthesizing two independent, non-obvious pieces of evidence: the spatial discordance between the pancreas (upper abdomen) and the necrosis (pelvis) on imaging, which points to fascial-plane/gravitational spread rather than direct spread; and the temporal discordance between initial improvement, t... | Mechanism | Long Answer | Clinical Medicine | General Surgery / Gastroenterology | en | {
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"points": 5,
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man with type 2 diabetes underwent elective spinal surgery via a retroperitoneal approach to the lumbar spine, complicated intraoperatively by major blood loss requiring transfusion. On postoperative day 1 he developed fever and severe abdominal pain; labs showed markedly elevated lipase/amylase and inflammatory mark... | {
"strategy": [
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"summary": "Reorganized the postoperative course chronologically and replaced the numbered instructions with one direct question retaining both mechanism targets.",
... | |
q01-8975369c944dd1eb | 2026-03 | q01 | Case: A woman in her 60s with no traditional cardiovascular risk factors presented with acute chest pain at rest. Coronary imaging showed that the RCA, LAD, and a small LCx arose from one ostium in a single aortic sinus. An intimal dissection flap in the shared sinus extended into the LCx. A separate dissection flap in... | The right-hand (immediately post-catheterization) tracing shows new/accentuated lateral ischemic changes (ST elevation in aVL with reciprocal/downsloping ST changes toward V5-V6), which were not the dominant feature on the pre-catheterization tracing (which was dominated by anterior/anteroseptal ST elevation in V2-V5).... | The pre-procedure tracing is dominated by marked ST elevation across V2-V5 (anteroseptal/anterior, LAD territory). On the post-procedure tracing this anterior elevation has diminished while a new pattern of ST elevation appears in aVL with downsloping ST changes extending toward the lateral precordial leads - a lateral... | Investigation Interpretation | Short Answer | Clinical Medicine | Interventional Cardiology / Coronary Artery Disease | en | {
"criteria": [
{
"id": "c1",
"partial_credit": "Award 3/6 if 'lateral' territory is named without referencing which leads changed, or if leads are cited without explicitly stating the territory is lateral",
"points": 6,
"requirement": "Identifies that the new/accentuated abnormality on th... | [
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"quote": "Immediately post-catheterization qR pattern and 1.5 mm of ST-segment elevation in aVL and downsloping ST straightening in V3 to V5, suggestive of active lateral ischemia."
},
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"title": "Spontane... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her 60s with no traditional cardiovascular risk factors presented with acute chest pain at rest. Coronary imaging later showed that her right coronary artery, left anterior descending artery (LAD), and a small left circumflex artery (LCx) all arose from a single ostium in one aortic sinus. An intimal dissect... | {
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... | |
q01-8a12199c1c2bd9be | 2026-03 | q01 | Case: A 44-year-old immunocompetent man developed subacute headache and hydrocephalus. MRI showed extensive leptomeningeal enhancement.
A mediastinal/paratracheal lymph node biopsy showed abundant broad-based budding yeast. Serum antibody tests were positive for two dimorphic fungal genera. Empiric antifungal therapy ... | Coccidioides immitis was the definitive cause. Broad-based budding yeast on histopathology is the classic morphology taught for Blastomyces, which is why blastomycosis was initially treated, but this was a red herring — the organism that actually grew in fungal culture from the same lymph node aspirate, later corrobora... | The question requires the reader to recognize that broad-based budding yeast is classically associated with Blastomyces (a plausible but wrong anchor), that dual antibody positivity does not resolve the ambiguity, that a negative dural biopsy is a non-discriminating negative, and that culture plus organism-specific ser... | Investigation Interpretation | Short Answer | Clinical Medicine | Infectious Disease / Neurosurgery | en | {
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"partial_credit": "Full credit for 'Coccidioides' or 'Coccidioides immitis' or 'coccidioidomycosis'; no credit if answer names Blastomyces, tuberculosis, or another organism as the final diagnosis",
"points": 5,
"requirement": "Identifies Coccidioides (immitis... | [
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"quote": "Initial pathology from the right paratracheal lymph node showed abundant broad-based budding yeasts, raising concern for possible blastomycosis, and elevated Blastomyces and Coccidioides antibodies were detected at that time."
},
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"quote": "fungal cultures from... | [] | {
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"doi": "10.7759/cureus.105643",
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"title": "Management of Coccidioidal Me... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 44-year-old immunocompetent man developed subacute headache and hydrocephalus with extensive leptomeningeal enhancement on MRI. During workup, a mediastinal/paratracheal lymph node was biopsied. Histopathology of the lymph node showed abundant broad-based budding yeast forms. At the same time, serum antibody testing ... | {
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q01-8bd04b3cf34b3699 | 2026-03 | q01 | Case: Two adults had the same fibrosing skin and subcutaneous disorder confirmed by full-thickness skin biopsy. Both developed symmetric limb edema and skin tightening, with a positive groove sign and sparing of the hands and feet. Patient A had a normal peripheral blood eosinophil count at diagnostic work-up. Patient ... | The right image belongs to Patient B (the patient with the elevated peripheral eosinophil count), and the left image belongs to Patient A (normal peripheral eosinophil count). This is the opposite of the naive expectation: the right image shows a lymphocyte- and plasma-cell-predominant infiltrate along the fascia with ... | Case 1 (Patient A): bloodwork at diagnosis showed eosinophils within normal range, but the diagnostic forearm biopsy showed 'lymphocytic infiltrate and occasional eosinophils.' Case 2 (Patient B): bloodwork at diagnosis showed eosinophils 1.1x10^9/L (elevated, roughly double the typical upper limit of ~0.5x10^9/L), but... | Investigation Interpretation | Short Answer | Clinical Medicine | Rheumatology / Dermatopathology | en | {
"criteria": [
{
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"partial_credit": "Award 3 points if only one of the two image-to-patient assignments is correctly stated, or if the correct assignment is given without acknowledging it is counterintuitive.",
"points": 6,
"requirement": "Correctly states that the right image ... | [
{
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"quote": "normal erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), hemoglobin, eosinophils, creatinine, liver function test (LFT), and mild thrombocytopenia"
},
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"quote": "showing sclerosis of the deep dermis and full-thickness subcutis, with involvement by... | [
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | Two adults were each diagnosed with the same fibrosing skin/subcutaneous disorder by full-thickness skin biopsy after developing symmetric limb edema, skin tightening, and a positive "groove sign" that spared the hands and feet. At the time of their diagnostic work-up, Patient A's peripheral blood eosinophil count was ... | {
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q01-9716a67bdba0c4ac | 2026-03 | q01 | Case: A 34-year-old woman presents with painless gross hematuria. Urinalysis, renal function, and serum tumor markers are normal.
Imaging shows a solitary, well-circumscribed right renal mass measuring approximately 6 cm. It is centered in the renal medulla and compresses the upper collecting system.
Images: Image A ... | The most likely diagnosis is ALK-rearranged renal cell carcinoma (ALK-RCC). Renal medullary carcinoma is unlikely despite matching the patient's young age and medullary tumor location, because the mass shows internal calcifications (visible on the image) and is purely localized with no renal sinus invasion or nodal spr... | The vignette requires synthesizing three independent evidence elements, each individually insufficient: (1) young age plus medullary location, which overlaps with renal medullary carcinoma; (2) the image, showing punctate/curvilinear intratumoral calcifications and a hyperdense focus, which is atypical for both renal m... | Diagnosis | Long Answer | Clinical Medicine | Uroradiology / Renal Oncology | en | {
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"partial_credit": "Award 2 points if the response names an unspecified rare/molecularly-defined RCC subtype or hedges between ALK-RCC and another rare subtype but shows correct discriminating reasoning; 0 if the final answer is clear-cell RCC, renal medullary carcinoma, p... | [
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"quote": "Renal medullary carcinoma, a rare and aggressive tumor, overlaps with ALK-RCC in terms of young patient a... | [
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... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 34-year-old woman presents with painless gross hematuria. Urinalysis, renal function, and serum tumor markers are all normal. Cross-sectional imaging shows a solitary, well-circumscribed right renal mass, roughly 6 cm across, centered in the renal medulla and compressing the upper collecting system. The provided imag... | {
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q01-a85ae9d331d6de4a | 2026-03 | q01 | Case: A woman had biopsy-proven primary FSGS, not-otherwise-specified variant; PLA2R and THSD7A antibodies and hereditary podocytopathy testing were negative. High-dose corticosteroids plus a calcineurin inhibitor produced only partial remission, with persistent proteinuria and hypoalbuminemia plus steroid-related Cush... | The most likely mechanism is incomplete depletion of tissue-resident (secondary lymphoid organ) B cells / persistent autoreactive memory B-cell clones outside the peripheral blood compartment, despite full and sustained peripheral B-cell depletion - i.e., a compartmental rather than a peripheral-blood problem. Reasonin... | The case textually states each supporting fact: complete peripheral CD20 depletion after RTX with persistent proteinuria (page 2), that RTX was given after proteinuria had already fallen to partial-remission range making urinary drug loss less likely (page 5), that the patient had no prior anti-CD20 exposure and antidr... | Mechanism | Long Answer | Clinical Medicine | Nephrology | en | {
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q01-a9871ac39b119d83 | 2026-03 | q01 | Case: A woman in her forties had extensive DCIS (~12 cm) diagnosed by core needle biopsy, which disrupted a duct/cyst wall and caused a hematoma-like change. She underwent skin-sparing mastectomy with immediate autologous flap reconstruction. Pathology showed papillary/cribriform DCIS only, with no invasion, clear marg... | The most likely explanation is that a small, occult invasive (micropapillary) focus was already present at the time of the original mastectomy but was missed on the initial pathological work-up, and this focus subsequently grew into the 23-25 mm invasive tumor. This is favored over pure anatomically-residual-tissue rec... | The question requires synthesizing three independent pieces of evidence that are each insufficient alone: (1) spatial concordance (same quadrant) is consistent with either anatomic residual tissue or an occult pre-existing focus, so it cannot discriminate between them; (2) the retrospective histology showing micropapil... | Mechanism | Long Answer | Clinical Medicine | Breast Surgical Oncology / Breast Pathology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her forties had extensive ductal carcinoma in situ (DCIS, ~12 cm span) of one breast, diagnosed after a core needle biopsy (CNB) that disrupted a duct/cyst wall and produced a hematoma-like change at the biopsy site. She underwent skin-sparing mastectomy with immediate autologous flap reconstruction. The mas... | {
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q01-ae67e68ac55bf286 | 2026-03 | q01 | Case: A child has two positive islet autoantibodies: glutamic acid decarboxylase and insulin autoantibodies. The oral glucose tolerance test is normal. The child develops recurrent symptomatic hypoglycemia, with home glucose readings as low as 30 mg/dL. No exposure to sulfonylureas, other oral hypoglycemic agents, or e... | The hypoglycemia reflects dysregulated, inappropriately timed endogenous insulin secretion from a partially destroyed, autoimmune-affected islet (an early type 1 diabetes-related hypoglycemia mechanism) — intermittent residual beta-cell insulin release that is enough to cause hypoglycemic episodes but insufficient in m... | The combination of low (not high) insulin/C-peptide with hypoglycemia rules out classic hyperinsulinism. Appropriate cortisol and GH responses rule out counterregulatory hormone deficiencies. An appropriate glucose rise after glucagon rules out defective glycogenolysis/gluconeogenesis. That leaves autoimmune islet dysf... | Mechanism | Long Answer | Clinical Medicine | Pediatric Endocrinology | en | {
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q01-cc4ad160007454a4 | 2026-03 | q01 | Case: A patient has had severe, constant lower-molar pain for 4 days. Hot, cold, and pressure worsen the pain. There is no facial or gingival swelling.
Images: The left image shows the molar before treatment. Two arrows mark a vertical defect extending from the chewing surface to the gumline. The right image shows the... | The defect exposes the dental pulp (the neurovascular core of the tooth) through a full-thickness carious breach reaching from the occlusal surface to the gumline. Sealing the exposed pulp with an inert material physically isolates it from direct contact with the oral cavity, blocking the thermal, mechanical, and chemi... | The clinical vignette (severe pain worsened by thermal/pressure stimuli, no swelling, defect extending to expose the pulp) is classic for pulpitis from carious pulp exposure. The image shows the exposed pulp before covering and the same site with a temporary cement filling the defect after. The report's discussion expl... | Investigation Interpretation | Short Answer | Clinical Medicine | Emergency Medicine - Dental Emergencies | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image shows two intraoral photographs of the same lower molar in a patient with a 4-day history of severe, constant tooth pain that intensifies with hot or cold stimuli and with pressure, but with no facial or gingival swelling on exam. Left: the tooth before any intervention, with two arrows marking the w... | {
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... | |
q01-d1758a3536b1695f | 2026-03 | q01 | Case: A woman in her early 60s had CIN II–III with focal 1-mm invasion treated by hysterectomy about 11 years earlier and remained disease-free. She later developed unexplained thrombocytopenia and cough, blood-streaked sputum, chest tightness, and exertional dyspnea, without fever or chest pain. Pulmonary artery systo... | Most likely a very late, isolated metastatic recurrence of the original cervical squamous cell carcinoma, not an independent second primary (e.g., lung) that seeded the heart. | Three independent pieces of evidence point to a single unifying cervical-origin metastasis rather than a new, separate primary: (1) An exhaustive staging work-up (chest/abdomen/pelvis CT, cranial CT, contrast pelvic MRI) found no mass anywhere else in the body, including no lung mass despite the patient's respiratory s... | Diagnosis | Long Answer | Clinical Medicine | Cardio-oncology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her early 60s had cervical squamous intraepithelial neoplasia (CIN II-III) with only focal early invasion (depth 1 mm), treated by hysterectomy about 11 years earlier; she had been disease-free since. She now presents with two problems: (1) thrombocytopenia that had been worked up extensively by hematology w... | {
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q01-e7c8fc73b089d9b7 | 2026-03 | q01 | Case: A tumor arose in the anal canal region of an elderly woman.
Immunohistochemistry showed:
- Positive: CK7, GATA3 (90%), TTF-1 (10%), and MUC5AC (5%).
- Negative: ER, PR, GCDFP-15, PAX-8, PAX-2, WT1, NapsinA, CK20, CDX-2, SATB2, CK5/6, and p63.
Next-generation sequencing detected no mutations in KRAS, NRAS, BRAF,... | The two competing diagnoses are (1) mesonephric-like (mesonephroid) adenocarcinoma, which is excluded by the absence of PAX-8 expression (reinforced by the absence of a KRAS mutation and no uterine/adnexal mass), and (2) metastatic pulmonary (lung) adenocarcinoma, which is excluded by the clean high-resolution chest CT... | GATA3 positivity classically suggests breast or urothelial carcinoma, while TTF-1 positivity classically suggests pulmonary or thyroid origin; the co-expression of both markers in one tumor is unusual and specifically mimics mesonephric-like adenocarcinoma, which characteristically co-expresses GATA3, TTF-1, and PAX-8 ... | Diagnosis | Short Answer | Clinical Medicine | Surgical Pathology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A tumor arising in the anal canal region of an elderly woman showed the following immunohistochemical and molecular findings: CK7 positive; GATA3 90% positive; TTF-1 10% positive; MUC5AC 5% positive; but negative for ER, PR, GCDFP-15, PAX-8, PAX-2, WT1, NapsinA, CK20, CDX-2, SATB2, CK5/6, and p63. Next-generation seque... | {
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q01-ef04fa2bd9cfad3e | 2026-03 | q01 | Case: A 68-year-old man with primary hyperparathyroidism (calcium 12.1 mg/dL; intact PTH 451 pg/mL) had surgery postponed for 6 months and took cinacalcet 30 mg twice daily. He had no neck pain, dysphagia, or rapidly enlarging mass. At 6 months, paresthesias developed gradually over several days; calcium was 6.8 mg/dL ... | Gradual cinacalcet (CaSR)-mediated regression is favored over spontaneous apoplexy/infarction. Supporting evidence: (1) on ultrasound the lesion looks the same homogeneous, hypoechoic, well-marginated structure at both time points, just smaller — there is no heterogeneous, cystic, or hemorrhagic change that would be ex... | The discussion explicitly frames this differential: spontaneous infarction/apoplexy presents acutely (neck pain, dysphagia, sudden hypocalcemia) with hemorrhagic/necrotic change, whereas cinacalcet-induced regression evolves gradually over weeks to months with preserved echotexture. The patient had no neck pain, the pa... | Mechanism | Short Answer | Clinical Medicine | Endocrinology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 68-year-old man with severe primary hyperparathyroidism (baseline serum calcium 12.1 mg/dL, intact PTH 451 pg/mL) had parathyroid surgery postponed 6 months for cardiac reasons and was instead treated with cinacalcet, titrated to and then held stable at 30 mg twice daily. At no point did he report neck pain, dysphagi... | {
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q02-0c1ddea17ecf7b05 | 2026-03 | q02 | Case: A patient with a known infiltrative frontal brain tumor completed radiotherapy with a total dose of 54.4 Gy. Four months later, before any chemotherapy, follow-up MRI showed new or increased contrast enhancement in the tumor bed. This could represent treatment-related pseudoprogression or true tumor progression.
... | True tumor progression, not pseudoprogression. The perfusion map shows elevated relative cerebral blood volume (rCBV, red/orange signal) within and around the enhancing region, whereas pseudoprogression typically shows low or unchanged perfusion relative to normal brain. Elevated rCBV in an enhancing lesion indicates v... | Pseudoprogression classically presents with new or increased enhancement in the post-chemoradiation window but with low or stable perfusion, since it reflects treatment-related inflammation/necrosis rather than viable angiogenic tumor. True progression is distinguished by elevated rCBV corresponding to hypervascular, p... | Investigation Interpretation | Short Answer | Clinical Medicine | Neuro-oncologic Imaging | en | {
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"quote": "Unfortunately, after 4 months, an MRI showed disease progression again."
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"quote": "Tumor progression is evident, with an increase in the infiltrative lesion (A,B) and areas of contrast enhancement (C,D) associated with elevated cerebral blood volume (E)."
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"title": "From a Polymorpho... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient with a known infiltrative frontal brain tumor completed radiotherapy (total dose 54.4 Gy). Four months after finishing radiotherapy, a follow-up brain MRI was obtained; no chemotherapy had yet been given. The provided image shows, from that same follow-up study and the same axial slice: left, a post-contrast ... | {
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q02-1b991f7e2dbd9c64 | 2026-03 | q02 | Case: A three-dimensional model reconstructed from postoperative CT shows the anterior chest wall after a large sternal defect was rebuilt. Three vascularized bone segments form a triangular construct highlighted in blue. Bead-like metal plates fix the construct to the ribs.
Images: The single postoperative image show... | The image shows: (1) a gap/malalignment where one upper corner of the triangular bone construct does not cleanly meet its adjacent horizontal rib fixation plate (loss of flush bone-to-bone/plate contact at that junction), and (2) a plate segment that sits raised or 'proud' above the rib surface rather than lying flush ... | The virtual surgical plan called for all plates to be pre-bent on a 3D-printed model. The clinical course states an unplanned plate to a rib was required intraoperatively due to a short fixation point, and this plate had not been pre-bent, which explains a visibly imperfect (proud, malaligned) fit on postoperative imag... | Investigation Interpretation | Short Answer | Clinical Medicine | Thoracic / Reconstructive Surgery | en | {
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"quote": "Virtual model of the chest wall using post-operative CT showing failure of right superior corner to meet 2nd rib and proud plate over lateral part of 3rd rib."
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image is a 3D virtual model, reconstructed from postoperative CT, of the anterior chest wall after a large sternal defect was rebuilt using a triangular construct of three vascularized bone segments (highlighted in blue) fixed to the ribs with metal plates (shown as bead-like chains). Looking at this singl... | {
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q02-52e5a103910d25b4 | 2026-03 | q02 | Case: Pelvic examination showed a cystocele and vaginal-wall ulceration attributed to long-standing pessary use. Histopathology of the resected endometrial-cavity mass showed diffuse endometrial-type glands with widespread squamous metaplasia. The stroma was largely replaced by fibrous tissue and lacked smooth muscle. ... | Chronic local inflammation (plausibly related to mechanical irritation/erosion from long-standing pessary use, as reflected by the vaginal wall ulceration and the background endometrial surface erosion with inflammatory infiltration) drove extensive squamous metaplasia of the tumor's surface epithelium. Metaplastic, ch... | This requires linking three separate observations that individually do not explain the enhancement kinetics: a mechanical/inflammatory insult (pessary-related erosion), a specific histologic substrate (diffuse squamous metaplasia over fibrous, muscle-poor stroma), and an unusual imaging kinetic (weak early enhancement ... | Mechanism | Long Answer | Clinical Medicine | Radiology / Gynecologic Pathology | en | {
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"title": "MRI Findings of Uterine Adeno... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | In the same patient, pelvic examination showed a cystocele and ulceration of the vaginal wall attributed to long-standing pessary use. Histopathology of the resected endometrial-cavity mass showed epithelial components that were diffuse endometrial-type glands with widespread squamous metaplasia, sitting on a stroma th... | {
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q02-56dadfab8ab8f11e | 2026-03 | q02 | Case: This surveillance scan was obtained after treatment for ovarian carcinoma. Current and prior follow-up imaging showed no new, enlarging, or irregular masses. Calcified pulmonary micronodules seen elsewhere measured about 2–5 mm, were uniformly small, and remained unchanged over time. The patient has no history of... | The pattern reflects silicosis (part of the patient's Erasmus syndrome). The peripheral rim ("egg-shell") pattern of the calcified lymph nodes, and the uniform, stable, small (2-5 mm) size of the calcified pulmonary micronodules, both argue against metastatic tumor deposits, which are typically randomly distributed, va... | Metastatic calcified nodules from a prior malignancy are usually random in distribution, heterogeneous/irregular in size and calcification, and tend to grow over serial imaging. In contrast, this patient's nodal calcification shows a peripheral egg-shell rim pattern and the micronodules are uniformly small and stable, ... | Investigation Interpretation | Long Answer | Clinical Medicine | Thoracic Radiology / Oncologic Imaging | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image is an axial chest CT (mediastinal window) from the same patient. Nonvisual context: this scan was obtained for surveillance after previously treated ovarian carcinoma; no new, enlarging, or irregular masses were seen on this or prior follow-up imaging, and the calcified lung micronodules noted elsewh... | {
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q02-5bf4714f68286140 | 2026-03 | q02 | Case: A patient with intra-abdominal sepsis from bowel perforation develops purulent meningomyelitis. On admission, the lumbar puncture opening pressure is 360 mmH₂O. Broad-spectrum antimicrobials and supportive care are started immediately, including coagulopathy correction, fluids, seizure control, and electrolyte re... | Because the pressure rise was being driven by an evolving tension pneumocephalus: gas-forming organisms (E. coli and others) were continuing to proliferate within necrotic, infected brain and meningeal tissue and kept producing gas, while that gas was poorly absorbed from the closed cranial/spinal compartments. With no... | This requires linking three points across the timeline rather than a single fact: the mechanism is not the classic post-traumatic 'ball-valve' tension pneumocephalus (ruled out because skull base imaging showed no fracture/leak), it is infection-driven; the CSF/imaging findings established that a necrotizing polymicrob... | Mechanism | Short Answer | Clinical Medicine | Neurology/Critical Care | en | {
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"partial_credit": "Full credit for stating ongoing infectious gas production outpacing absorption; partial (3 pts) if only states 'infection worsened' without addressing the gas-production/absorption imbalance",
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"quote": "the intraventricular pressure was measured as 410 mmH₂O"
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient with intra-abdominal sepsis from bowel perforation develops purulent meningomyelitis. On admission, a lumbar puncture opening pressure is 360 mmH2O and broad-spectrum antimicrobials plus supportive care (coagulopathy correction, fluids, seizure control, electrolyte repletion) are started immediately. Two days... | {
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q02-75feb30eed5df3bf | 2026-03 | q02 | Case: A standard antegrade guidewire could not cross a severely tortuous circumflex artery bifurcation. The angle between a marginal branch and the proximal vessel exceeded 270°. An over-the-wire balloon was used to advance the wire distally into the branch. On the next attempt, an alternative wiring strategy succeeded... | The technique (a "reverse wire"/loop-wire approach) works by using a wire placed in the neighboring (usually less angulated) branch as a mechanical rail or fulcrum: the second wire is looped back from that branch across the ostium of the difficult branch, changing the effective takeoff angle the target wire has to nego... | Extreme angulation (>270°) between a branch and the parent vessel makes direct antegrade wiring geometrically very difficult because the guidewire tip must reverse direction almost completely at the bifurcation. The reverse/loop wire technique circumvents this by using a wire in the companion branch as a mechanical gui... | Mechanism | Short Answer | Clinical Medicine | Interventional Cardiology | en | {
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q02-8b1f8beb90833ffb | 2026-03 | q02 | Case: Five animals at one wildlife rescue center died with acute neurological disease. Histopathology in two animals was essentially identical to that in the other three. All had severe, acute, non-suppurative encephalitis with perivascular mononuclear cuffing, multifocal glial clusters, and neuronal necrosis.
In the ... | The flavivirus cannot be confirmed as the cause of the fatal encephalitis in the two negative animals. Despite a pathologically indistinguishable CNS lesion, exhaustive testing excluded the suspected flavivirus, a related flavivirus, rabies, parvovirus, and identifiable bacterial pathogens, so their actual cause of dea... | Table 2 shows cases 1 and 2 had histopathology (subacute/acute non-suppurative meningoencephalitis with perivascular cuffing, glial reaction, neuronal changes) broadly comparable to cases 3-5. Table 3 shows cases 1 and 2 were completely negative (Ct >42) for both USUV target genes and for WNV in both brain and liver/he... | Investigation Interpretation | Short Answer | Clinical Medicine | Veterinary Virology / Infectious Disease | en | {
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q02-b1d3aa436fc3b057 | 2026-03 | q02 | Case: In a large multicenter cohort of biopsy-proven eosinophilic myocarditis, only 57% of patients had peripheral eosinophilia. Among those patients, the median absolute eosinophil count was about 630 cells/µL.
Another patient developed drug-induced hypereosinophilia with cardiac inflammation confined to the pericard... | Peripheral eosinophil count reflects the number of eosinophils circulating in blood, not the number that have migrated into cardiac tissue; end-organ damage is driven by tissue recruitment/infiltration of eosinophils (via chemokines and adhesion molecules), not by how high the circulating count is. A drug that blocks t... | This requires synthesizing two independent data points that point in opposite directions from what a naive count-severity relationship would predict: a much higher peripheral count in the less anatomically extensive (pericardium-only) case, and a lower or absent peripheral count in many biopsy-confirmed myocarditis cas... | Mechanism | Short Answer | Clinical Medicine | Allergy-Immunology/Cardiology | en | {
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q02-dbe329adecfec30d | 2026-03 | q02 | Case: A whole-body PET-CT shows markedly FDG-hypermetabolic lymph nodes at every imaged level. Additional axillary, mediastinal, and inguinal nodal stations are involved but not pictured. A lymph node biopsy performed around the same time showed only reactive changes, with no malignancy or infectious organisms. Tubercu... | The overall pattern reflects systemic reactive immune activation driven by uncontrolled HIV infection, producing both diffuse reactive lymphoid/splenic hyperplasia and large-vessel (aortic) vasculitis, rather than a lymphoproliferative malignancy. The intensity and extent of the nodal and splenic FDG uptake would ordin... | Extensive multi-station FDG-avid adenopathy plus diffuse splenic uptake mimics lymphoma, but a reactive-only biopsy with negative infectious/TB workup rules out that alternative, leaving systemic HIV-driven immune activation as the explanation for the nodal/splenic findings. Because the aortic wall uptake occurs with n... | Investigation Interpretation | Long Answer | Clinical Medicine | Infectious Disease / Nuclear Medicine | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image shows five axial PET-CT cross-sections (left to right, panels A-E) from a single whole-body scan: (A) mandibular level, (B) cervical level, (C) thoracic level at the aortic arch, (D) abdominal level showing the spleen, and (E) pelvic level. Nodal stations at every level shown (and additional axillary... | {
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q02-e570a7f7976d89b7 | 2026-03 | q02 | Case: A fetus had bilateral renal agenesis, an absent bladder, anorectal atresia, a single umbilical artery, and vertebral segmentation defects. A de novo heterozygous deletion of approximately 48 kb was found at 12q24.31. It removes two non-coding small nuclear RNA genes, a neighboring sirtuin gene, and the first exon... | Reasons for VUS classification: (1) there were no other reported cases with a similar deletion of this region to corroborate pathogenicity; (2) the fetal phenotype (renal/urogenital and anorectal/vertebral malformations) diverges substantially from the established neurodevelopmental phenotype (microcephaly, brain malfo... | Requires combining the explicit classification rationale (no replicate cases, divergent phenotype, unproven haploinsufficiency of flanking genes) with the discussion's dosage/splicing-demand mechanistic hypothesis (residual function from point variants vs. near-total loss from deletion, and vulnerability of rapidly org... | Genetics | Long Answer | Clinical Medicine | Medical Genetics / Prenatal Diagnosis | en | {
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q02-f20361fbbfcfc6bb | 2026-03 | q02 | Context: For drug-resistant temporal lobe epilepsy associated with hippocampal sclerosis, a disconnective technique leaves the anterior temporal lobe and its vasculature in place. It severs all white-matter connections between the lobe and the rest of the brain instead of removing the lobe.
After resective epilepsy su... | Most favored: older patients (roughly over 50 years) with drug-resistant temporal lobe epilepsy due to hippocampal sclerosis, especially those with associated cerebral atrophy, in whom preserving the lobe and its blood supply in situ lowers the risk of hemorrhagic/ischemic complications compared with resection. Exclude... | The text states that patients over 50 face a 30% increased complication risk with resective surgery and that the disconnective technique, by preserving the lobe in situ, may reduce complications such as subdural collections, particularly in elderly or atrophic patients — identifying the favored subgroup. Separately, th... | Treatment | Short Answer | Clinical Medicine | Neurosurgery - Epilepsy Surgery | en | {
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q02-fae0fd6e965a8cff | 2026-03 | q02 | Case: A patient with biopsy-confirmed reactive perforating dermatosis associated with uremic pruritus from chronic kidney disease began biologic treatment after 7 months of oral antihistamines, potent topical corticosteroids, and emollients had failed.
Images: Both panels show the same posterior lower-limb region. The... | Postinflammatory hyperpigmentation (residual brown/tan macular discoloration) remains at 10 months even though the papules and nodules have resolved. Its persistence indicates that the injury and the eventual transepidermal elimination process were confined largely to the epidermis and superficial dermis, producing mel... | The report states that at 6 months lesions 'healed completely, leaving only postinflammatory hyperpigmentation,' and the 10-month photographs (Fig 3B/C) still show hyperpigmented macules without nodules. Recognizing that this residual finding is pigmentary rather than scarring requires the image (to see flat pigmented ... | Treatment Response | Short Answer | Clinical Medicine | Dermatology | en | {
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q03-07d787f3a32afeee | 2026-03 | q03 | Case: During brief spontaneous tachycardia episodes, conventional activation mapping showed an incomplete local activation-time circuit without a clear head-meets-tail re-entry pattern. The tachycardia could not be sustained long enough for complete activation mapping.
Post-pacing-interval measurements during these ep... | The critical substrate is located in the right atrial septal wall, in a low-voltage, fractionated-electrogram zone directly adjacent to the surgical atrial septotomy scar. Activation mapping alone was insufficient because the tachycardia terminated spontaneously before a complete re-entrant circuit could be traced on t... | This synthesizes three independent pieces of evidence from different parts of the report: (1) the RA circuit suggestion from post-pacing interval data during brief tachycardia, (2) the anatomical voltage-mapping finding of a low-voltage zone adjacent to the septotomy line, and (3) the pace-mapping/iPASO finding that th... | Diagnosis | Short Answer | Clinical Medicine | Cardiac Electrophysiology | en | {
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q03-5ec0eab4e391efb1 | 2026-03 | q03 | Case: The patient reportedly had an ataxic gait and dysarthria since toddlerhood, with motor and some cognitive delay. Two brain MRIs obtained roughly a decade apart in later childhood showed no cerebellar atrophy. The only abnormality was left-greater-than-right mesial temporal sclerosis, attributed to severe infantil... | (a) Clinical ataxia can precede detectable structural cerebellar volume loss; given the patient's young age, the underlying cerebellar degenerative process may simply be too early-stage or mild to have yet produced atrophy visible on MRI, even though ataxic signs are already present clinically. (b) The cognitive delay ... | The report notes lack of cerebellar atrophy despite ataxic history and hypothesizes this reflects insufficient degeneration given young age, while separately flagging uncontrolled infantile epilepsy with mesial temporal sclerosis as a plausible alternative contributor to cognitive delay, since developmental delay is no... | Investigation Interpretation | Short Answer | Clinical Medicine | Neurology - Movement Disorders / Neurogenetics | en | {
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q03-6dfd9d1357a0c480 | 2026-03 | q03 | Case: An infant had 1.5 weeks of intermittent fever and rapidly progressive mucocutaneous ulcers. Tests showed leukopenia (2.8 × 10^3/µL), an absolute neutrophil count of 190/µL, reticulocytopenia (0.2%), and anemia (hemoglobin 5 g/dL), indicating trilineage cytopenia. Respiratory viral PCR was positive only for rhinov... | A bone marrow biopsy was performed, which revealed newly diagnosed B-cell acute lymphoblastic leukemia (B-ALL). | Simultaneous reduction in all three cell lines (leukopenia/neutropenia, reticulocytopenia/anemia) without circulating blasts points toward marrow infiltration or failure that a peripheral smear cannot fully characterize; bone marrow biopsy is the definitive next step, and in this case it uncovered B-ALL, explaining bot... | Investigation Interpretation | Short Answer | Clinical Medicine | Pediatric Hematology-Oncology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An infant presented with 1.5 weeks of intermittent fever and rapidly progressive mucocutaneous ulcers. Laboratory testing showed leukopenia (2.8x10^3/uL) with an absolute neutrophil count of 190/uL, reticulocytopenia (0.2%), and anemia (hemoglobin 5 g/dL) — that is, all three blood cell lines were reduced. A respirator... | {
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q03-bbf5e4db7a3699a6 | 2026-03 | q03 | Case: A child had a large tracheobronchial tumor that nearly occluded the airway and extended into the lower trachea. Histopathology showed a low-grade malignant tumor with a fusion linking a CREB-regulated transcriptional coactivator to a Notch pathway coactivator.
Complete resection at presentation would have requir... | The drug is an EGFR tyrosine-kinase inhibitor; by blocking EGFR signaling it can reduce proliferative/growth signaling in tumor cells that express or have alterations in this receptor, providing a rationale for pre-surgical (neoadjuvant) tumor shrinkage even though most low-grade tracheobronchial mucoepidermoid tumors ... | The report identifies the drug as an EGFR-targeting tyrosine kinase inhibitor given as neoadjuvant therapy specifically to avoid pneumonectomy by shrinking the tumor for a less invasive sleeve resection. It states the course was discontinued early due to rash, pruritus, and pain, but that repeat CT still demonstrated a... | Mechanism | Long Answer | Clinical Medicine | Pediatric Thoracic Oncology / Interventional Pulmonology | en | {
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q03-e4a060c1f1614d3f | 2026-03 | q03 | Case: A patient underwent bilateral lung transplantation for occupational hypersensitivity pneumonitis. Maintenance immunosuppression included oral corticosteroids and a calcineurin inhibitor with fluctuating trough levels. The patient developed new-onset hyperglycemia with an HbA1c of 7.8%. At follow-up, HbA1c was 6.5... | This is post-transplant (new-onset) diabetes mellitus driven by two synergistic diabetogenic drug classes: (1) corticosteroids, which increase hepatic gluconeogenesis, promote peripheral (skeletal muscle/adipose) insulin resistance, and can blunt insulin secretion; and (2) the calcineurin inhibitor, which is directly t... | Page 9 documents that this patient (post-transplant) had 'tacrolimus trough levels fluctuated, and type 2 diabetes mellitus (HbA1c 7.8%) was newly diagnosed, prompting treatment with metformin and empagliflozin alongside continuation of oral prednisolone (10 mg daily)' and later 'HbA1c improved to 6.5%' while continuin... | Complication | Long Answer | Clinical Medicine | Transplant Medicine/Occupational Medicine | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | After bilateral lung transplantation for occupational hypersensitivity pneumonitis, a patient maintained on oral corticosteroids plus a calcineurin-inhibitor immunosuppressant (with fluctuating trough drug levels) developed new-onset hyperglycemia, with HbA1c measured at 7.8%. On subsequent follow-up testing, HbA1c had... | {
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q01-045e3a514655b10d | 2026-04 | q01 | Case: An elderly woman with a right frontal high-grade glioma underwent gross total resection and combined chemoradiation. After recovery, she received two cycles of adjuvant temozolomide. During the second cycle, she developed new impulsivity, disorientation, visual hallucinations, worsening somnolence, and urinary in... | The decline is best explained by a coexisting neurodegenerative tauopathy (a primary age-related tauopathy/PART-type process) involving the hippocampal-entorhinal memory circuits, which was clinically unmasked or accelerated by cancer treatment rather than by the tumor itself. This is supported because the second MRI s... | The question requires integrating two independent evidence streams: (1) the imaging comparison showing anatomic/radiologic stability of the resection site at the time of clinical decline (ruling out tumor recurrence as the proximate cause), and (2) the postmortem neuropathology showing a distinct tau-predominant, low-a... | Investigation Interpretation | Long Answer | Clinical Medicine | Neuro-Oncology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An elderly woman with a right frontal high-grade glioma underwent gross total resection followed by combined chemoradiation and, after recovery, two cycles of adjuvant temozolomide. During her second adjuvant cycle she developed new impulsivity, disorientation, visual hallucinations, progressively worsening somnolence,... | {
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q01-0668defa86bcaa23 | 2026-04 | q01 | Case: A dog with spinal pain underwent MRI of the mid-thoracic spine. A well-circumscribed extradural mass was parasagittal to the right dorsal vertebral compartment. It was isointense to muscle on T1-weighted images and enhanced vividly after contrast. It remained dorsal to the vertebrae, without extension into the ve... | High-grade (poorly differentiated), grade III chondrosarcoma. Mechanism: well-differentiated (low-grade) cartilaginous tumors mature in an organized, zonal fashion, producing discrete regions of mineralized/endochondral-ossified matrix (which appear as focal T1-hypointense foci) that are spatially distinct from separat... | The report states that MRI heterogeneity in vertebral chondrosarcoma reflects the histologic architecture: T2-hyperintense lobulated regions correspond to high water content of neoplastic cartilage matrix, while T1-hypointense foci represent endochondral ossification within mineralized matrix. Distinct heterogeneity (c... | Investigation Interpretation | Long Answer | Clinical Medicine | Veterinary Surgical Oncology / Neuroradiology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A dog was evaluated for spinal pain. The provided image shows T2-weighted MRI of the mid-thoracic spine: the left panel is a sagittal view spanning several vertebrae, and the two right panels are transverse views at two adjacent vertebral levels (each labeled with the vertebra shown). Red arrows mark a well-circumscrib... | {
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q01-092b434ed74d6936 | 2026-04 | q01 | Case: A man in his 40s has had sharp, constant, non-radiating right lower quadrant pain for 3 days. Movement worsens the pain. He has no fever, nausea, vomiting, or diarrhea. He is hemodynamically stable and afebrile. Examination shows localized tenderness without guarding or rebound. His blood counts, renal and liver ... | The most likely diagnosis is (primary) omental infarction. The CT shows a focal, well-defined area of heterogeneous fatty stranding/inflammatory change confined to the greater omentum in the right lower quadrant, with a normal-appearing appendix and no periappendiceal inflammation or wall thickening — i.e., the inflamm... | The clinical picture (localized RLQ pain without systemic toxicity, normal WBC, only mild CRP elevation, no peritonism) is compatible with several RLQ processes, but the CT clearly localizes the abnormality to fatty tissue (the omentum) rather than to a tubular, thick-walled structure (the appendix). Fat stranding conf... | Diagnosis | Long Answer | Clinical Medicine | Emergency Medicine/General Surgery | en | {
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"title": "Primary Omental Infarction Mi... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man in his 40s presents with a 3-day history of sharp, constant, non-radiating right lower quadrant abdominal pain that worsens with movement, without fever, nausea, vomiting, or diarrhea. He is hemodynamically stable and afebrile. Exam shows localized right lower quadrant tenderness but no guarding or rebound. Labs ... | {
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q01-09853bbe350348bf | 2026-04 | q01 | Case: An anteroposterior pelvic radiograph was obtained immediately after posterior dislocation of a cemented bipolar hip hemiarthroplasty and before reduction. The implant has an outer metal shell that articulates with the native acetabulum and an inner femoral head within the shell.
Images: The image is a magnified ... | The outer ring shows asymmetric wall thickness (radiodensity)-thicker along one arc and thinner along the opposite arc-even though the overall outline still traces a continuous circle. This asymmetry indicates the outer shell is tilted/rotated out of the coronal imaging plane (axial rotation), not lying flat en face to... | The case shows that a grossly circular outer-shell outline on AP radiograph can coexist with asymmetric cortical/wall thickness reflecting anterior rotation of the shell, and that CT was required to reveal eccentric positioning of the inner femoral head that the plain radiograph alone under-called, indicating early dis... | Investigation Interpretation | Long Answer | Clinical Medicine | Musculoskeletal Radiology / Orthopedic Surgery | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image is a magnified crop of the femoral head region on an anteroposterior pelvic radiograph. It was obtained immediately after a posterior dislocation of a cemented bipolar hip hemiarthroplasty (an implant in which an outer metal shell articulates with the native acetabulum while an inner femoral head sit... | {
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q01-0a17e634ca714f1b | 2026-04 | q01 | Case: A woman in her mid-40s presented with progressive abdominal enlargement and persistent inability to lose weight. She had no abdominal pain, gastrointestinal symptoms, or urinary complaints.
Ultrasound showed a giant multiloculated cystic adnexal mass. It had predominantly anechoic content and some thickened sept... | The image shows thick, enhancing internal septa within an otherwise simple-appearing multiloculated cystic mass; in a mass of this extreme size, compressed/redundant septa create pseudo-solid-appearing areas that mimic mural nodularity, which drives the high-risk O-RADS score. Combined with normal tumor markers, the mo... | O-RADS 5 was assigned based on thick enhancing septations and apparent solid-appearing components on MRI. However, giant mucinous cystadenomas frequently generate pseudo-solid areas from compression/redundancy of septa as the cyst reaches extreme size, and MRI specificity for adnexal masses declines substantially above... | Investigation Interpretation | Long Answer | Clinical Medicine | Gynecologic Oncology/Radiology | en | {
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"points": ... | [
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q01-0ee6777822c565cb | 2026-04 | q01 | Case: A pregnant patient in the early second trimester sustained high-energy blunt pelvic trauma. She has severe left-sided pain and shortening of the left lower limb.
Images: Image 1 is an axial CT section at the sacroiliac joints. Image 2 is an oblique axial reconstruction at the acetabula.
Question: Is the pelvic ... | The injury is a rotationally UNSTABLE pelvic ring injury (equivalent to a Tile B pattern), unstable in the horizontal/rotational plane but not vertically translated/unstable. The left image shows diastasis/disjunction of the left sacroiliac joint (an open-book-type injury), and the right image shows a comminuted fractu... | The left axial CT shows widening/diastasis of the left sacroiliac joint, an open-book pattern classically caused by anteroposterior compression that opens the pelvic ring anteriorly and posteriorly but preserves vertical stability of the posterior arch. The right oblique reconstruction shows a comminuted left acetabula... | Investigation Interpretation | Short Answer | Clinical Medicine | Orthopedic Trauma / Musculoskeletal Radiology | en | {
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"title": "CBCT-Guided Iliosacral Screw Osteos... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A pregnant patient in the early second trimester sustained high-energy blunt pelvic trauma with severe left-sided pain and shortening of the left lower limb. The provided images are two axial CT sections obtained at presentation (left: axial view through the level of the sacroiliac joints; right: oblique axial reconstr... | {
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q01-11f4e45f441b4cf2 | 2026-04 | q01 | Case: A woman in her mid-60s has a large left retroperitoneal mass. She has no refractory hypertension. Preoperative testing showed mildly elevated supine aldosterone (280 pg/mL; upper limit 240 pg/mL) and early-morning aldosterone (132 pg/mL; upper limit 65 pg/mL). ACTH, cortisol, renin, and the aldosterone-to-renin r... | The findings argue against (1) a paraganglioma/pheochromocytoma (including an extra-adrenal paraganglioma), and (2) a schwannoma. Paraganglioma is excluded primarily by the hormonal profile (no significant catecholamine/aldosterone-driven hypertension or biochemical excess beyond a trivial aldosterone elevation) plus t... | The case text states the tumor's CT attenuation was <40 HU and that enhanced CT/MRI suggested a neurogenic tumor; ganglioneuroma (GN) is described as showing homogeneous low-density/enhancement, contrasted with paraganglioma (marked enhancement, associated with catecholamine excess/hypertension) and schwannoma (heterog... | Investigation Interpretation | Short Answer | Clinical Medicine | Diagnostic Radiology / Surgical Oncology | en | {
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"quote": "the CT value of GN is generally less than 40 HU, while paragangliomas demonstrate marked enhancement on CT scans"
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{
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"quote": "schwannomas exhibit heterogeneous enhancement and attenuation on imaging, whereas GN shows homogeneous enhancement and attenuation"
... | [
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her mid-60s is found to have a large left retroperitoneal mass. Preoperative endocrine workup showed only a mild elevation of supine aldosterone (280 pg/mL; upper limit of normal 240 pg/mL) and of early-morning aldosterone (132 pg/mL; upper limit of normal 65 pg/mL), with ACTH, cortisol, renin, and the aldos... | {
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q01-130abe9544454321 | 2026-04 | q01 | Case: A patient with locally advanced hepatocellular carcinoma and portal vein thrombosis presented with undifferentiated shock. Point-of-care ultrasound of the right flank used a curvilinear probe in the coronal plane, with the probe marker directed cephalad.
Images: Image 1 is the earlier frame, and Image 2 was obta... | The later frame shows a kidney (identifiable by its oval/reniform shape and echogenic central renal sinus) at a depth of roughly 6 cm, lying cephalad to the curved hyperechoic line. Because the kidney is normally caudal to the diaphragm, a kidney appearing cephalad to that line means the line cannot be the diaphragm; t... | Normal sonographic anatomy places the kidney caudal to the diaphragm/liver interface. The second frame reveals a reniform structure with an echogenic sinus cephalad to the presumed 'diaphragm' line, which is anatomically impossible if that line were truly the diaphragm — it indicates the entire imaged field is intra-ab... | Investigation Interpretation | Long Answer | Clinical Medicine | Point-of-Care Ultrasound / Emergency and Hospital Medicine | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A curvilinear-probe point-of-care ultrasound was performed on the right flank in the coronal plane (probe marker cephalad) in a patient with locally advanced hepatocellular carcinoma and portal vein thrombosis who presented in undifferentiated shock. The provided images are two still frames from the same clip, about tw... | {
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q01-169bd79b6976cf29 | 2026-04 | q01 | Case: An older man receiving maintenance hemodialysis for end-stage renal disease has a shaggy aorta associated with chronic aortic dissection. He previously had cholesterol crystal embolization. He presents with mild lower abdominal pain, stable vital signs, mild leukocytosis, and a slightly elevated CRP. Intravenous ... | The interval change shows progression from localized ischemic/inflammatory jejunal wall thickening to free intraperitoneal air with fluid leakage, indicating that the ischemic bowel segment has perforated (microperforation progressing to a small full-thickness defect) despite the patient's only mild symptoms and stable... | Fig. 1A shows localized wall thickening of the pelvic jejunum at presentation, nonspecific for enteritis vs ischemia-reperfusion injury. Fig. 1C (repeat CT the next day) shows a moderate amount of free air with intraperitoneal fluid leakage at the same site, indicating interval perforation. The text states this tempora... | Investigation Interpretation | Short Answer | Clinical Medicine | General Surgery / Gastroenterology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An older man on maintenance hemodialysis for end-stage renal disease, with a known shaggy (atheromatous) aorta from a chronic aortic dissection and a prior episode of cholesterol crystal embolization, presents with only mild lower abdominal pain, stable vital signs, mild leukocytosis, and a slightly elevated CRP. He ca... | {
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q01-17d21f3e57e4629d | 2026-04 | q01 | Case: A man in his early 70s has 48 hours of colicky central abdominal pain, worsening distension, bilious vomiting, and constipation. He has no history of abdominal surgery. Rectal examination shows an empty rectum, and no external hernia is found. Abdominal radiographs show multiple air-fluid levels and dilated bowel... | The arrow points to a whirled, twisted loop of bowel/mesentery (a whirl sign) at the site of the transition point, indicating that the bowel has rotated around a fixed point. Combined with the lack of prior surgery (making adhesions unlikely) and no external hernia, this indicates a closed-loop obstruction caused by sm... | The image shows a whirled appearance of a dilated, twisted small-bowel loop with its mesenteric vessels coiling around a central point, the classic 'whirl sign' of volvulus. In a patient with no previous abdominal surgery, the leading causes of mechanical SBO (adhesions) are excluded, raising suspicion for an intra-abd... | Investigation Interpretation | Short Answer | Clinical Medicine | General Surgery / Abdominal Radiology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man in his early 70s presents with 48 hours of colicky central abdominal pain, worsening distension, bilious vomiting, and constipation. He has no history of prior abdominal surgery, and rectal exam shows an empty rectum with no external hernia. Erect abdominal radiograph shows multiple air-fluid levels; supine radio... | {
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q01-1a201c381ea36883 | 2026-04 | q01 | Case: A woman presented with isolated right-sided tongue weakness, deviation, and atrophy, along with dysarthria. Imaging showed a 17 mm mass dorsal to the right internal carotid artery near the hypoglossal canal. No other cranial nerve findings were present, and she was managed conservatively.
Over the next several y... | The tumor most likely arises from the accessory nerve (CN XI) in the jugular foramen (a jugular foramen/accessory nerve schwannoma), not from the hypoglossal nerve itself. The CT shows bony enlargement of the hypoglossal canal that is directly continuous with enlargement of the adjacent jugular foramen, indicating the ... | The illustrative case describes a tumor originating from the accessory nerve within the jugular foramen that extended into the extracranial hypoglossal canal, compressing but not invading the hypoglossal nerve. Bone-window CT showed hypoglossal canal enlargement continuous with jugular foramen enlargement, which the au... | Mechanism | Long Answer | Clinical Medicine | Neurosurgery / Skull Base Surgery | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman initially presented with isolated right-sided tongue weakness, deviation, and atrophy plus dysarthria; imaging at that time showed only a small (~17 mm) mass dorsal to the right internal carotid artery near the hypoglossal canal, with no other cranial nerve findings. She was managed conservatively. Over the nex... | {
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q01-1ac22b2032e89655 | 2026-04 | q01 | Case: A man in his twenties has had nonspecific bone- and joint-type pain in his chest, abdomen, and hip for several years. Plain radiographs and abdominal ultrasonography were normal.
A slow-growing, lobulated retroperitoneal mass lies beside the lumbosacral spine. It displaces an exiting nerve root or the lumbar ple... | Most likely diagnosis: ganglioneuroma (a benign, well-differentiated neuroblastic/neural crest tumor). The images show only mild, non-avid contrast enhancement of a solid mass (comparing pre- and post-contrast T1), consistent with the mild enhancement typical of ganglioneuroma rather than the more avid/washout patterns... | The vignette gives an indolent, painful retroperitoneal mass in a young adult with normal tumor markers (AFP, beta-hCG, metanephrines) and low PET avidity, pointing away from germ cell tumor, lymphoma, and paraganglioma. The image adds the key visual datum -- only mild post-contrast enhancement of a solid lesion -- whi... | Diagnosis | Long Answer | Clinical Medicine | Surgical Oncology / Radiology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man in his twenties has a multi-year history of nonspecific bone/joint-type pain in his chest, abdomen, and hip. Plain x-rays and abdominal ultrasound were normal. A slow-growing, lobulated retroperitoneal mass was later found adjacent to the lumbosacral spine, displacing (but not invading or arising from) an exiting... | {
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q01-1f0a8062a48fb79e | 2026-04 | q01 | Case: An adult has had slowly enlarging, non-healing annular plaques at several separate body sites for decades. The plaques have indurated, scaling edges and central atrophic scarring. Complete blood count, ESR, organ function tests, and chest radiography were normal. Fine-needle aspiration cytology showed numerous ly... | The most likely diagnosis is tuberculosis verrucosa cutis (a paucibacillary, exogenous form of cutaneous tuberculosis from reinfection in an already TB-sensitized host). The AFB stain and molecular (GeneXpert/PCR) test were negative because paucibacillary cutaneous TB forms like TVC contain very few organisms in the ti... | The chronicity (decades), multifocal annular verrucous/atrophic plaques, normal systemic labs and chest imaging, and FNAC showing necrotizing granulomatous inflammation (lymphocytes, epithelioid granulomas, giant cells, necrosis) without demonstrable systemic disease are classic for TVC, a paucibacillary exogenous CTB ... | Diagnosis | Short Answer | Clinical Medicine | Dermatology/Infectious Disease | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An adult with a several-decades-long history of non-healing, slowly enlarging annular plaques (indurated, scaling edges with central atrophic scarring) affecting multiple separate body sites was worked up. Baseline complete blood count, ESR, organ function tests, and chest X-ray were all normal. Fine-needle aspiration ... | {
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q01-1f2873ce09817edf | 2026-04 | q01 | Case: An adult has pain on biting and discoloration of a previously restored maxillary anterior tooth after orthodontic treatment. The tooth is unresponsive to pulp sensibility testing, while adjacent teeth respond normally. Periodontal probing is normal, with no sinus tract or swelling. Access under an operating micro... | 1. The images show internal (pulpal-origin) root resorption that has perforated the root wall — a resorptive cavity beginning in the pulp space that breaches through to communicate with the external root surface/periodontal tissues, with an associated periapical bone defect. Because this communication exists, the canal... | The case describes perforating internal root resorption diagnosed by CBCT; profuse bleeding on access reflects vascularized granulation tissue in the resorptive cavity, and persistent exudation despite asymptomatic status reflects ongoing communication with the periodontium that orthograde treatment alone cannot resolv... | Investigation Interpretation | Long Answer | Clinical Medicine | Endodontics | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An adult patient had pain on biting and discoloration of a maxillary anterior tooth with a prior composite restoration and a history of orthodontic treatment. The tooth did not respond to pulp sensibility testing while neighboring teeth tested normally, periodontal probing depths were within normal limits, and there wa... | {
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q01-2435219fe02118c6 | 2026-04 | q01 | Case: A woman in her early 30s has had pruritic, hyperkeratotic, skin-colored papules and plaques since her late teens. The eruption is limited to one side of her body and follows Blaschko's lines in a swirling pattern. She has no family history of similar lesions. Heat and friction worsen the pruritus. A shave biopsy ... | The histologic pattern (focal acantholytic dyskeratosis with corps ronds and grains, papillomatosis) is shared by both localized/linear Darier disease and Grover disease (transient acantholytic dermatosis) — the two are histologically indistinguishable. The distinguishing feature is the clinical distribution and course... | The images alone show acantholytic dyskeratosis with corps ronds/grains, which is compatible with either Darier disease or Grover disease per the report's own discussion ('Histopathologic considerations included both Grover disease and Darier disease'). The report resolves the differential using clinical-pathologic cor... | Investigation Interpretation | Short Answer | Clinical Medicine | Dermatology/Dermatopathology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her early 30s has had a pruritic eruption of hyperkeratotic, skin-colored papules and plaques confined to a swirling pattern on only one side of her body (following Blaschko's lines) since her late teens, with no family history of similar lesions and pruritus worsened by heat and friction. A shave biopsy was... | {
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q01-330ecbed7d16d50b | 2026-04 | q01 | Case: A man in his 80s had remote invasive fungal sinusitis of the left maxillary sinus treated with endoscopic sinus surgery. He developed a left chronic subdural hematoma that repeatedly recurred after several burr-hole evacuations. Coil embolization completely occluded the extracranial segment of the left middle men... | Chronic granulomatous/inflammatory change from the prior invasive fungal sinusitis tracked from the maxillary sinus along the skull base to involve the dura at the cavernous sinus/middle cranial fossa region (the site of thickening marked on the image) — territory through which the middle meningeal artery courses as it... | The case links three facts that individually are insufficient but together localize the mechanism: (1) prior invasive fungal sinusitis of the maxillary sinus, (2) an MRI finding (only visible in the image) of dural thickening extending toward the cavernous sinus/middle fossa — anatomically along the MMA's path — and (3... | Mechanism | Long Answer | Clinical Medicine | Neurosurgery/Interventional Neuroradiology | en | {
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"partial_credit": "Award 3/5 if answer states MMA was damaged/degenerated but does not link it to the inflammatory extension shown near the skull base in the image; 0 if mechanism of MMA compromise is omitted or incorrect (e.g., attributes it to trauma or coagulopathy)",
... | [
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An elderly man (80s) with a remote history of invasive fungal sinusitis of the left maxillary sinus (treated years earlier with endoscopic sinus surgery) developed a left chronic subdural hematoma that recurred repeatedly despite several burr-hole evacuations. Coil embolization achieved complete angiographic occlusion ... | {
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q01-40be7b1224f7f182 | 2026-04 | q01 | Case: A subcentimeter peripheral lung nodule was resected because primary lung cancer could not be excluded. The intraoperative frozen section was interpreted as adenocarcinoma. Re-evaluation of formalin-fixed tissue from the same block supported a benign diagnosis.
Images: Both panels are H&E-stained sections at the ... | The feature is ciliated columnar epithelium (cilia) lining the bland, bilayered glandular proliferation — visible on the formalin-fixed section but not clearly identifiable on the frozen section. Its presence, together with an underlying continuous basal cell layer, supports a benign bronchiolar-type lesion (bronchiola... | The stem describes a paired frozen-section vs. formalin-fixed comparison of the same tissue. The report states ciliated cells were not clearly identifiable on the frozen section (leading to an adenocarcinoma call) but became appreciable after formalin fixation of the same tissue, prompting reconsideration toward a beni... | Investigation Interpretation | Short Answer | Clinical Medicine | Thoracic Pathology / Pulmonology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A subcentimeter peripheral lung nodule was resected because primary lung cancer could not be excluded. The provided image shows two H&E-stained sections of the same surgical specimen at the same magnification: left is the intraoperative frozen section (evaluated immediately during surgery), and right is a section from ... | {
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q01-42842b017d565e1c | 2026-04 | q01 | Case: A 15-year-old girl with repeated self-harm had 2 months of auditory hallucinations. She was diagnosed with dissociative identity disorder (three identity states) and severe major depression with psychotic features: a male voice commanded her to die, and she believed her death would reduce her family's financial b... | The discordant time courses suggest her auditory hallucinations and guilt-based delusions arise from a trauma-related, dissociation-linked mechanism intrinsic to her DID (i.e., internally generated pseudo-psychotic phenomena tied to dissociation) rather than from the same mechanism that produces classic depressive psyc... | The report explicitly notes a 'mixed response to ECT' in which personality/identity symptoms subsided after two sessions while auditory hallucinations and delusions of guilt required further treatment, contradicting literature where ECT resolves depressive hallucinations/delusions promptly. The authors hypothesize the ... | Mechanism | Long Answer | Clinical Medicine | Child and Adolescent Psychiatry | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 15-year-old female was hospitalized for two months of auditory hallucinations and repeated self-harm. She was diagnosed with dissociative identity disorder (three distinct identity states) and a severe major depressive episode with psychotic features, including command auditory hallucinations from a male voice tellin... | {
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q01-4369a87bf15f37b2 | 2026-04 | q01 | Case: An infant with pertussis had a nasal swab tested by direct Sanger sequencing of the 23S rRNA gene and by culture. The same gene region was then sequenced from two individual colonies from that swab. Susceptibility testing showed that colony type 1 was highly resistant to erythromycin, azithromycin, and clarithrom... | The macrolide-resistant colony type (matching the taller/darker peak seen alone in the middle trace) was present in relatively greater abundance in the direct swab specimen, since its corresponding peak is the taller of the two overlapping peaks at the marked position in the top trace. This illustrates the pitfall that... | The text states the swab chromatogram showed 'a predominant G peak...along with a minor wild-type A peak,' and that the resistant colony (BP715-type) carried the G allele while the susceptible colony (BP716-type) carried the wild-type A allele. Because the swab trace's dominant peak matches the resistant genotype's pea... | Investigation Interpretation | Short Answer | Clinical Medicine | Pediatric Infectious Diseases / Clinical Microbiology | en | {
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"points": 6,
... | [
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"quote": "initially indicated an A2047G mutation in the 23S rRNA gene of B. pertussis, indicating MRBP infection, although the electropherogram was unclear"
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An infant with pertussis had a nasal swab sent for both direct molecular testing and bacterial culture. Direct Sanger sequencing of the 23S rRNA gene from swab DNA, and separately from two individual bacterial colonies isolated from that same swab, produced the chromatogram traces shown in the provided image (top: dire... | {
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"summary": "Retained the resistance phenotype, lineage distinction, and top-middle-bottom trace mapping while focusing the task on abundance and minority-allele maski... | |
q01-5baf370dd061bb9b | 2026-04 | q01 | Case: A woman in her mid-40s has had asymptomatic bilateral areolar erythema and fine scaling since adolescence. No breast mass was palpable, and mammography and ultrasonography were normal. Malignant and inflammatory nipple conditions remained possible, so a full-thickness areolar skin biopsy was performed.
Images: T... | An ectoparasitic mite of the genus Demodex (D. folliculorum or D. brevis) is seen encysted within a hair-follicle/sebaceous-gland infundibulum; the resulting skin condition is termed demodicosis (Demodex dermatitis). | The image shows a segmented arthropod (mite) cross-section housed within a keratin-lined cystic structure that opens into the follicular/sebaceous infundibulum of the epidermis, a location and morphology characteristic of Demodex mites rather than other ectoparasites (e.g., scabies mites reside in stratum corneum burro... | Investigation Interpretation | Short Answer | Clinical Medicine | Dermatopathology | en | {
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{
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"points": 6,
"requirement": "Identifies the organism as Demodex mite (folliculorum/brevis or genus-level ... | [
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"quote": "Demodex mites are identified in both the keratin layer and the openings of hair follicles and sebaceous glands. These findings are consistent with Demodex dermatitis (demodicosis)"
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"title": "Asymptomatic Bilateral Demodi... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her mid-40s was found on routine breast screening to have chronic (present since adolescence), asymptomatic bilateral erythema and fine scaling limited to the areolar skin around both nipples, with no palpable mass and no abnormality on mammogram or ultrasound. Because malignant and inflammatory nipple-skin ... | {
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... | |
q01-662414131c431db2 | 2026-04 | q01 | Case: A patient with post-radiation cervicofacial fibrosis after head-and-neck radiotherapy has severe trismus. Fibrotic scarring has displaced both carotid arteries laterally, away from the anatomic midline and their usual paramedian positions. Surface landmarks for the cricothyroid membrane are unreliable.
Images: T... | The tracheal air shadow sits to the left of the marked midline line by roughly 1-1.5 cm (about one scale-bar increment). Because the trachea itself is shifted left of the classic anatomic midline, an emergency cricothyroidotomy or other front-of-neck access should be sited over the ultrasound-marked (leftward-shifted) ... | The image shows the hyperechoic tracheal air-mucosal interface with posterior acoustic shadowing lying to the left of the midline reference line, measurable against the 1 cm scale bar as roughly 1-1.5 cm of leftward shift. Combined with the stated bilateral lateral splaying of the carotid arteries (a non-visual fact), ... | Investigation Interpretation | Short Answer | Clinical Medicine | Anesthesiology / Airway Management | en | {
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{
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"points": 5,
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"page": 4,
"quote": "is displaced approximately 1.5 cm to the left of the anatomical midline (green vertical line)"
},
{
"page": 3,
"quote": "palpable carotid pulsations, raising a serious concern for potential vascular injury during any airway intervention"
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"title": "Ultrasound-Guided Airway Mapp... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient with post-radiation cervicofacial fibrosis (prior head-and-neck radiotherapy) has severe trismus and bilateral carotid arteries that are both displaced laterally away from the anatomic midline by fibrotic scarring. Standard surface landmarks for locating the cricothyroid membrane are unreliable in this settin... | {
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"summary": "Reorganized the case and image guidance into short sections while preserving both requested location judgments.",
"omitted_content": [
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q01-7dc0eb7d426b572a | 2026-04 | q01 | Case: An adult has had an antibody-deficiency syndrome for several years, with persistently low IgG and IgA and low-normal IgM. The patient developed chronic productive cough, stage III dyspnea with mild exertion, unintentional weight loss, asthenia, and new cervical lymph-node enlargement. An acid-fast bacilli smear a... | The most likely explanation is malignant (neoplastic) infiltration of the mediastinal/cervical lymph nodes by a solid-organ malignancy (an adenocarcinoma), not tuberculosis or a purely reactive/infectious lymphadenopathy — reflecting the increased risk of solid tumors from impaired immune surveillance in this type of p... | The CT shows enlarged, rounded mediastinal lymph nodes. Clinically, tuberculosis was the initial concern given the chronicity and constitutional symptoms, but AFB smear and MTB PCR were negative on repeated testing and bronchoscopy was normal, making infectious/granulomatous lymphadenopathy unlikely. Patients with anti... | Investigation Interpretation | Short Answer | Clinical Medicine | Pulmonology/Immunology-Oncology | en | {
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"points": 6,
"requirement": "Identifies malignant/neoplastic (... | [
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"quote": "A chest CT scan showed bilateral consolidations, traction bronchiectasis, and mediastinal lymphadenopathy"
},
{
"page": 5,
"quote": "Cervical lymph node biopsy revealed adenocarcinoma of probable biliodigestive origin"
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"title": "Genetic Analysis of Patients ... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image is an axial chest CT (mediastinal window) from an adult with a several-year history of an antibody-deficiency syndrome (persistently low IgG and IgA, with IgM at the low end of normal). This patient developed a chronic productive cough, stage III dyspnea (breathless on mild exertion), unintentional w... | {
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"omitted_content": ... | |
q01-7ebdbac3a8734d60 | 2026-04 | q01 | Case: A patient on maximal topical glaucoma therapy started a once-daily topical ROCK inhibitor for additional intraocular pressure reduction. Before treatment, central corneal thickness was 485 µm. Gonioscopy showed an open, unobstructed drainage angle.
One month later, the patient developed redness and hazy vision. ... | The fluid on the image is loculated within the corneal epithelium (bullae/intraepithelial edema) rather than diffusely within the stroma. ROCK inhibitors have a dual effect: they enhance endothelial pump function, which draws fluid out of the stroma and can normalize or improve stromal hydration/deturgescence, while at... | The discussion section explains that ROCK inhibition enhances endothelial pump function while altering tight junction permeability, facilitating fluid translocation from stroma toward epithelium; in eyes with pre-existing stromal edema, this can make stromal edema appear to improve while epithelial edema/bullae become ... | Mechanism | Long Answer | Clinical Medicine | Ophthalmology - Cornea | en | {
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{
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"points": 6,
"requirement": "Identifies... | [
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"page": 6,
"quote": "ROCK inhibition enhances endothelial pump function while simultaneously altering tight junction permeability"
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{
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"quote": "AS-OCT) line scan of the cornea demonstrated epithelial edema with bullae, without associated stromal edema"
}
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"title": "Persistent Epithelial Defect ... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient on maximal topical glaucoma therapy was started on a topical Rho-associated protein kinase (ROCK) inhibitor eye drop once daily to further lower intraocular pressure. Before starting this drop, central corneal thickness was normal (485 µm) and gonioscopy showed an open, unobstructed drainage angle. One month ... | {
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q01-838c3bef3c2b6129 | 2026-04 | q01 | Case: A patient has a dorsal/posterolateral extradural mass compressing the cervical spinal cord.
Images: Panel B (top) is an axial T2-weighted image. Panel C (bottom) is an axial contrast-enhanced T1-weighted image from the same study and cervical level. Arrows mark the mass in both panels.
Question: What is the mas... | The mass is most likely a hematoma (blood products). The T2-weighted panel shows the mass as hypointense causing cord compression, and the contrast-enhanced T1 panel shows no enhancement of the mass. Lack of contrast enhancement argues against a vascular malformation (e.g., arteriovenous malformation/dural AV fistula),... | On MRI, blood breakdown products (e.g., deoxyhemoglobin) commonly appear T2-hypointense, and organized hematomas lack a blood supply/neovascularity so they do not enhance with contrast. Vascular malformations enhance due to abnormal vessels/shunting, and most neoplasms enhance due to disrupted blood-brain/blood-cord ba... | Investigation Interpretation | Long Answer | Clinical Medicine | Neuroradiology | en | {
"criteria": [
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"id": "c1",
"partial_credit": "Full credit for 'hematoma', 'blood clot', or equivalent; no credit if answer names tumor, AVM, or abscess as most likely.",
"points": 4,
"requirement": "Identifies hematoma/blood products as the most likely composition",
"summary": nul... | [
{
"page": 3,
"quote": "(B) Axial T2-weighted image reveals a hypointense mass causing spinal cord compression (white arrow). (C) Axial contrast-enhanced T1-weighted image shows no enhancement of the mass (white arrow), confirming the absence of vascular malformation or neoplasm."
}
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"title": "Case Report: A pa... | {
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... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image shows two axial MRI slices obtained at the same cervical spinal level in a patient being investigated for a dorsal/posterolateral extradural mass compressing the spinal cord: top panel is a T2-weighted image, bottom panel is a contrast-enhanced T1-weighted image from the same MRI study (arrows mark t... | {
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q01-83d2ae1a08385ed9 | 2026-04 | q01 | Case: A 68-year-old man was under surveillance after thyroid cancer surgery. A subcarinal mediastinal mass enlarged slightly over about 2 years and developed a thin peripheral rim of calcification. Serum thyroglobulin remained normal. PET showed only mildly increased FDG uptake, so nodal metastasis could not be exclude... | The non-enhancing area marked by the arrowheads represents thrombosed blood (clot) filling the lumen of a bronchial artery aneurysm; because the lumen is occluded by thrombus rather than flowing blood, it does not take up intravenous contrast the way patent vessels or perfused tissue do. This enhancement pattern, toget... | The case describes a subcarinal mass that enlarged over 2 years with peripheral calcification and internal low-attenuation change, mimicking lymph node metastasis. The discussion explicitly states that due to thrombotic occlusion, the aneurysmal lumen showed no contrast enhancement, which is why its imaging appearance ... | Investigation Interpretation | Long Answer | Clinical Medicine | Thoracic Radiology | en | {
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"summary": null... | [
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"page": 2,
"quote": "The mass showed slight enlargement with development of peripheral calcification and internal low-attenuation changes"
},
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The two images below are axial CT sections of the same subcarinal mediastinal mass (marked by arrowheads) in a 68-year-old man under surveillance after thyroid cancer surgery. Left: non-contrast CT obtained at the time of the original thyroid surgery. Right: contrast-enhanced CT obtained about 2 years later, by which t... | {
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"summary": "Reorganized the case chronologically and reframed the two-part request as a single diagnostic question that still requires interpreting the nonenhancing region.",
... | |
q01-847acfdc4a65afea | 2026-04 | q01 | Case: Two intraoperative photographs show a retained impaling foreign body before removal in a patient with penetrating thoracoabdominal trauma. Before imaging or exploration, the shock index remained below 0.9. Mild hypoxia corrected to an oxygen saturation above 92% with supplemental oxygen.
Images: Image 1 shows an... | Abdominal: the stomach (greater curvature) and the spleen, because the entry site is in the left upper quadrant, where these two structures sit immediately deep to the abdominal wall. Thoracic: the left lower lobe of the lung and the pericardium/heart, because the object's course angles superiorly from the left upper q... | The images show the entry point in the left upper abdomen with the object angled cephalad toward the left chest. Anatomically, the left upper quadrant overlies the stomach and spleen, and a trajectory continuing superiorly must cross the left hemidiaphragm to reach the left lower lung lobe and the pericardium/heart. Th... | Investigation Interpretation | Long Answer | Clinical Medicine | Trauma / General Surgery | en | {
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{
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"points": 3,
"requirement": "Correctly identifies the at-risk abdominal structures (stomach and/or spleen, left-upper-quadrant organs)",
"summary":... | [
{
"page": 2,
"quote": "a single metallic impalement entering the left upper quadrant of the abdomen and tracking superiorly toward the thorax"
},
{
"page": 2,
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}
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"title": "Management of Penetrating Tho... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The two images are intraoperative photographs of a retained impaling foreign body in a patient with penetrating thoracoabdominal trauma, taken before the object was removed (left: anterior view of the torso; right: lateral/oblique view of the same torso, showing the object's course into the body). On arrival, before an... | {
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q01-95f1240384e9ef58 | 2026-04 | q01 | Case: A patient had a prolonged pulseless electrical activity arrest, requiring about 16 minutes of resuscitation before return of spontaneous circulation. Posterior-circulation CT angiography around hospital day 2 showed patent vessels without large-vessel occlusion. Brain MRI on hospital day 4 was delayed because of ... | The CT shows a focal hypodense lesion in the left cerebellar hemisphere consistent with an acute-to-subacute infarct, but the MRI obtained four days later at the same level shows no acute diffusion restriction. This discordance is best explained by the well-recognized limitation of delayed diffusion-weighted MRI in pos... | CT (day 2) documented a discrete left cerebellar hypodensity consistent with infarct, with patent posterior circulation on CTA (excluding large-vessel occlusion as an alternate explanation for a negative MRI). MRI on day 4 was negative for diffusion restriction, but the report explicitly frames this as reflecting known... | Investigation Interpretation | Long Answer | Clinical Medicine | Neuroradiology / Critical Care Neurology | en | {
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"points": 6,
"requirement": "Identif... | [
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"quote": "Noncontrast CT of the head demonstrated a 3 cm hypodense lesion in the left cerebellar hemisphere, consistent with an acute-to-subacute infarct"
},
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"title": "Pulseless Electrical Activity... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided images are two non-contrast axial brain scans from the same patient, obtained after a prolonged pulseless electrical activity arrest (about 16 minutes of resuscitation before return of spontaneous circulation). First image: CT performed on hospital day 2. Second image: MRI performed on hospital day 4; the ... | {
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... | |
q01-9f31fe32d17a62c4 | 2026-04 | q01 | Case: A compulsive craving to smell pine-scented cleaning products appeared at the earliest marked time point, when symptomatic iron deficiency was worsening. The craving resolved shortly after the first intravenous iron infusion. It did not recur when the iron indices declined before a second infusion.
Images: The gr... | Ferritin tracks the symptom most closely: it sits near zero at the time the craving first appears, rises sharply to its peak coincident with the first IV iron infusion (when the craving resolves), and later declines again before the second infusion without the craving recurring — consistent with the second decline not ... | The image shows ferritin (red) beginning near 0 at the 'worsening symptomatic iron deficiency' marker, spiking sharply at the 'first IV iron' marker (matching symptom resolution), then declining again toward the 'second IV iron' marker without symptom recurrence — a pattern that maps tightly onto the described symptom ... | Investigation Interpretation | Long Answer | Clinical Medicine | Hematology | en | {
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{
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"partial_credit": "Award 3/6 if ferritin is identified as the best-tracking biomarker without describing the specific trough/peak inflection points",
"points": 6,
"requirement": "Correctly identifies ferritin as the biomarker whose trajectory most closely para... | [
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"quote": "Notably, desiderosmia did not recur when ferritin was approximately 20 ng/mL in January 2025, suggesting a possible threshold below which the symptom emerges."
},
{
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"title": "Desiderosmia-Associated Iron ... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image plots a patient's serial total iron (mcg/dL, left axis) and ferritin (ng/mL, left axis) together with hemoglobin (g/dL, right axis) from October 2023 through June 2025. Vertical dashed markers indicate, in chronological order: onset of worsening symptomatic iron deficiency, a first intravenous (IV) i... | {
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q01-a044bf3798354766 | 2026-04 | q01 | Case: A patient developed a slowly enlarging, band-like eruption on one side of the trunk. It measured about 24 × 11 cm and did not cross the midline. Some lesions were soft nodules with central depression. Others were rough, verrucous papules. Separate biopsies were taken from an older soft nodule and a newly develope... | Left image: lobules of mature adipocytes (ectopic fat) proliferating within the dermis beneath a normal-appearing epidermis - a dermal/mesenchymal adipocytic proliferation. Right image: papillomatous hyperplasia of the epidermis with hyperkeratosis (and basal pigmentation), with unremarkable underlying dermis - a purel... | The left panel shows well-circumscribed lobules of mature fat cells within the dermis (an adipocytic/mesenchymal hamartomatous change, as in nevus lipomatosus cutaneus superficialis), while the right panel shows undulating papillomatous epidermal hyperplasia with compact hyperkeratosis and basal hyperpigmentation and n... | Investigation Interpretation | Short Answer | Clinical Medicine | Dermatology/Dermatopathology | en | {
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{
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"partial_credit": "Full credit for 'fat/adipose tissue in the dermis' or equivalent; half credit if only 'dermal proliferation' stated without specifying adipose tissue",
"points": 3,
"requirement": "Correctly identifies the left image as a dermal proliferatio... | [
{
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"quote": "The waist lesion showed mature adipose tissue proliferating in lobules within the dermis, consistent with a diagnosis of nevus lipomatosus cutaneous superficialis (NLCS)"
},
{
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"quote": "The back lesion demonstrated epidermal papillomatous hyperplasia, hyperkerat... | [
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"title": "Multiple superfic... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient developed a slowly enlarging, band-like (zosteriform) eruption on one side of the trunk, measuring about 24 x 11 cm, that did not cross the midline. Within this eruption, some lesions were soft nodules with central depression while others had a rough, verrucous surface. To find out whether this represented a ... | {
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q01-a0d6c2bb2fe58c42 | 2026-04 | q01 | Case: A woman in her early 60s developed hydrocephalus after treatment of a ruptured intracranial aneurysm and received a ventriculoperitoneal shunt. About 10 days later, she developed intermittent fever and abdominal distension. Three days after transfer, lumbar CSF showed WBC 9 × 10^6/L, glucose 2.65 mmol/L, protein ... | On imaging, the small perihepatic fluid collection seen at this level on admission has resolved by day 7 (right panel shows a clean space around the liver where the earlier collection was). This apparent improvement did not mean the intra-abdominal infection was resolving: instead the infective process persisted/spread... | The paired CT images show resolution of the perihepatic collection, which could be misread as improvement. But the report states a new pelvic collection appeared the same day and an aspirate grew bacteria, and the CSF/blood markers worsened in parallel with clinical deterioration (fever to 39C, worsening distension). T... | Mechanism | Long Answer | Clinical Medicine | Neurosurgery / Infectious Disease | en | {
"criteria": [
{
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"partial_credit": "Full credit for stating the infection persisted/redistributed rather than resolved, citing the new pelvic fluid and/or positive aspirate; half credit if only vaguely states 'infection continued' without linking to the new collection or aspirate",
... | [
{
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"quote": "WBC 9 × 10^6/L, glucose 2.65 mmol/L, and protein 370.5 mg/L"
},
{
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"quote": "CSF count yielded WBC 1,147 × 10^6/L, glu- cose 0.86 mmol/L, and protein 1,509.7 mg/L"
},
{
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"quote": "CT showed that the fluid collection around the liver disappea... | [
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"title": "Pseudomonas xanth... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her early 60s developed hydrocephalus after treatment for a ruptured intracranial aneurysm and received a ventriculoperitoneal (VP) shunt. About 10 days after shunt placement she developed intermittent fever and was transferred for further care, with abdominal distension noted on admission. Cerebrospinal flu... | {
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q01-a2a566a5a496606c | 2026-04 | q01 | Case: An elderly woman underwent TAVI with a self-expandable valve for severe calcified aortic stenosis. During deployment, the partially expanded valve popped out with antegrade flow, was recaptured, and was redeployed slightly deeper. Transesophageal echocardiography showed a mobile ascending-aortic flap, but valve-f... | The contrast-filled false lumen extending down to the sinus/root level indicates that the primary intimal entry tear is proximal, at the aortic root/sinus of Valsalva, rather than distal in the ascending aorta. A tear at this proximal level places it near the coronary ostia and pericardial reflection, carrying a high r... | The case explicitly reasons that finding the entry tear at the sinus of Valsalva (rather than the ascending aorta) implied high risk of coronary obstruction/tamponade and justified root replacement over conservative or ascending-only surgery. The image shows contrast opacifying the false lumen at the root level, which ... | Investigation Interpretation | Long Answer | Clinical Medicine | Cardiovascular Surgery/Interventional Cardiology | en | {
"criteria": [
{
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"partial_credit": "full credit for 'proximal/root/sinus' location stated with reference to the image finding; half credit if only vaguely states 'proximal' without linking to image evidence",
"points": 5,
"requirement": "States the entry tear is proximal, at t... | [
{
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"quote": "The dissection flap extended at least to the level of the non-coronary cusp, with contrast enhancement within the false lumen at this level."
},
{
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"quote": "However, in this case, the dissection extended proximally into the sinus of Valsalva, suggesting that the... | [
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"title": "Acute Stanford Type A Aortic ... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An elderly woman underwent transcatheter aortic valve implantation (TAVI) with a self-expandable valve for severe calcified aortic stenosis. During deployment the valve partially expanded, was displaced ('popped out') by antegrade aortic flow, was recaptured, and was then successfully redeployed slightly deeper. Post-p... | {
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q01-ac34b965d8373a1e | 2026-04 | q01 | Case: A woman in early pregnancy has had several first-trimester pregnancy losses and one prior term cesarean delivery for breech presentation.
Images: The transabdominal pelvic ultrasound labels the right (RT) and left (LT) sides. Arrows mark the uterine anatomy to assess.
Question: What congenital uterine anomaly i... | Uterine didelphys, caused by failure of fusion of the paired Müllerian ducts (a bicorporeal anomaly). The image excludes septate uterus because it shows two entirely separate, discrete uterine cavities (one containing a gestational sac/yolk sac, the other empty) rather than a single uterine cavity with a normal externa... | The ultrasound shows two clearly separate uterine cavities side by side, one on the right containing a gestational sac with yolk sac and one on the left that is empty. This pattern of two fully separate, distinct endometrial cavities is the hallmark of a bicorporeal anomaly (uterine didelphys), which arises from failur... | Investigation Interpretation | Long Answer | Clinical Medicine | Obstetrics and Gynecology / Reproductive Endocrinology | en | {
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"p... | [
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image is a transabdominal pelvic ultrasound obtained early in a pregnancy in a woman with a history of several first-trimester pregnancy losses and one prior term cesarean delivery for breech presentation. Based solely on the anatomy shown in the image, state the specific congenital uterine anomaly demonst... | {
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q01-ae1ef1dd5c138616 | 2026-04 | q01 | Case: A 20-year-old man had two hemiparetic episodes 2 months apart. The first involved a unilateral basal ganglia lesion with restricted diffusion, was treated as acute ischemic stroke, and resolved completely; 3 months later, the region showed no residual tissue damage. The second episode caused a deficit on the oppo... | The left panel shows abnormal radial/linear streaky enhancement radiating outward from and perpendicular to the wall of the lateral ventricle (a perivascular/periventricular enhancement pattern); this enhancement has resolved on the right (post-treatment) panel. Combined with bilateral, non-vascular-territory basal gan... | The imaging pattern of linear enhancement perpendicular to the ventricular wall that resolves after immunosuppression, combined with bilateral non-territorial basal ganglia lesions, a negative vasculitic/autoimmune-encephalitis/infectious work-up, and antibody positivity concordant in serum and CSF, together point away... | Diagnosis | Long Answer | Clinical Medicine | Neurology / Neuroimmunology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 20-year-old man had two hemiparetic episodes two months apart. In the first episode he had a unilateral basal ganglia lesion with restricted diffusion that was diagnosed and treated as acute ischemic stroke, with complete recovery; a follow-up scan of that region three months later showed no residual tissue damage. I... | {
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q01-b0656be8e4571a07 | 2026-04 | q01 | Case: A man underwent resection of colon adenocarcinoma followed by several months of adjuvant chemotherapy. About 10 months after surgery, a new focal liver lesion was detected and treated as a probable metastasis. He poorly tolerated a chemotherapy doublet plus an anti-VEGF antibody, so treatment was changed to anti-... | The lesion was stable with no significant growth between the 10-month and 22-month images, indicating that the hepatic metastasis was controlled for about a year on anti-PD-1 monotherapy. By the 31-month MRI, however, the lesion shows an interval increase in size with abnormal/increased T2 signal, indicating radiologic... | Panel-by-panel visual comparison shows a low-density subcapsular hepatic lesion at 10 months that is essentially unchanged in size at 22 months (period of checkpoint-inhibitor monotherapy after poor tolerance of the chemotherapy/anti-VEGF combination), consistent with disease stability/response. At 31 months the same l... | Treatment Response | Long Answer | Clinical Medicine | Medical Oncology / Abdominal Imaging | en | {
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"quote": "Follow-up CT at approximately 22 months revealed no significant progression of liver lesions (Figure 1C). However, magnetic resonance imaging (MRI) at 31 months showed multiple abnormal liver signals suspicious for metastasis (Figure 1D)."
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man underwent surgical resection of a colon adenocarcinoma followed by several months of adjuvant chemotherapy. About 10 months after surgery, a new focal liver lesion was found and treated as a probable metastasis. He was started on a chemotherapy doublet combined with an anti-VEGF antibody, but because he tolerated... | {
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q01-be5960688a438359 | 2026-04 | q01 | Case: A man in his mid-20s had JAK2 V617F-negative polycythemia vera and was taking oral anticoagulation. He presented with acute diffuse abdominal pain, vomiting, and absent stool and flatus. His INR was subtherapeutic at 1.2. He had marked leukocytosis, a CRP of 241.6 mg/L, and a D-dimer of 4.27 mg/L FEU.
CT angiogr... | The superior mesenteric artery (SMA) occlusion (the one ~35 mm from its origin) is responsible for the small-bowel ischemia, not the splenic or left hepatic artery lesions (which affect the spleen/celiac territory). At laparotomy this produced a jejunal perforation, located approximately 30 cm distal to the ligament of... | The vignette lists four separate vascular findings (splenic artery, left hepatic artery, SMA, and non-enhancing spleen). Only the SMA supplies the jejunum/small bowel; the splenic and hepatic artery lesions explain splenic infarction-type findings but not small-bowel ischemia. The clinical deterioration and laparotomy ... | Investigation Interpretation | Short Answer | Clinical Medicine | Vascular Surgery / Hematology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man in his mid-20s with previously diagnosed, JAK2 V617F-negative polycythemia vera, maintained on oral anticoagulation, presented with acute diffuse abdominal pain, vomiting, and absent stool/flatus. Labs showed marked leukocytosis, CRP 241.6 mg/L, D-dimer 4.27 mg/L FEU, and a subtherapeutic INR of 1.2. CT angiograp... | {
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q01-c1ca454c886dabfb | 2026-04 | q01 | Case: A young man has a rapidly enlarging, painful mass in one hemiscrotum. Serum beta-hCG and LDH are markedly elevated, while AFP is normal.
Images: The coronal contrast-enhanced CT image shows the scrotal mass extending toward the upper abdomen along a cord-like structure.
Question: What germ cell tumor lineage is... | Pure seminoma is the most likely lineage: an elevated beta-hCG and LDH with a normal AFP is the classic marker pattern of seminoma, since AFP elevation would instead point to a yolk-sac/non-seminomatous component. The tumor tissue tracking superiorly along the cord-like structure connecting the scrotal mass to the retr... | The case shows elevated beta-hCG (131 IU/L) and LDH (1084 U/L) with normal AFP, a marker pattern indicating a seminomatous rather than non-seminomatous germ cell tumor. Imaging showed the mass extending superiorly along the course of the testicular vessels/spermatic cord toward the retroperitoneum. Histopathology confi... | Investigation Interpretation | Short Answer | Clinical Medicine | Urologic Oncology | en | {
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"quote": "Serum tumour markers demonstrated an elevated β-human chorionic gonadotropin (β-hCG) level of 131 IU/L and lactate dehydrogenase (LDH) of 1084 U/L, with a normal alpha-fetoprotein (AFP)."
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"title": "Giant testicular seminoma with a... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A young man has a rapidly enlarging, painful mass in one hemiscrotum. Serum tumor markers show a markedly elevated beta-hCG, a markedly elevated LDH, and a normal AFP. The provided image is a coronal contrast-enhanced CT image showing the scrotal mass and the structures immediately above it leading into the abdomen. Ba... | {
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q01-c8804d811e240d22 | 2026-04 | q01 | Case: A 62-year-old man with chronic alcohol use presents with weight loss and generalized weakness. Alkaline phosphatase is 375 IU/L (reference 40–129), AST and ALT are mildly elevated, and CEA, CA19-9, and alpha-fetoprotein are normal. MRI shows multiple well-defined lobulated hepatic lesions that are T2-hyperintense... | The hepatic lesions most likely represent a primary (multifocal) extra-gastrointestinal stromal tumor arising within the liver itself, mimicking metastatic disease, rather than metastases from a gastroesophageal junction (or other GI) primary. This is supported because: (1) the junctional wall thickening biopsy showed ... | The question requires synthesizing the CT/MRI imaging pattern with two independent negative findings (benign GEJ biopsy and normal tumor markers) plus the whole-body PET-CT distribution to exclude metastatic disease and favor a primary hepatic mesenchymal neoplasm, rather than simply naming the report's headline diagno... | Diagnosis | Short Answer | Clinical Medicine | Radiology/Hepatobiliary Oncology | en | {
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"quote": "markedly elevated alkaline phosphatase levels and mildly elevated serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) levels"
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 62-year-old man with chronic alcohol use presents with weight loss and generalized weakness. Labs show markedly elevated alkaline phosphatase (375 IU/L, reference 40-129), mildly elevated AST/ALT, but normal CEA, CA19-9, and alpha-fetoprotein. The provided image shows four axial contrast-enhanced CT panels through th... | {
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q01-cfb5fe915e5ebbe4 | 2026-04 | q01 | Case: Dogs with traumatic glenohumeral luxation were treated with a temporary transarticular locking plate spanning the scapula and humerus. In most dogs, the most distal humeral screw engaged only the near cortex to reduce stress concentration and avoid humeral fracture. At scheduled plate removal 5–9 weeks after surg... | Dog A: mild loosening/backout of the three distal humeral screws (screws appear slightly displaced/proud from the bone with a widened lucent line around the shafts), without frank fracture. Dog B: fracture of the penultimate distal screw plus failure at the bone-screw interface of the most distal screw, causing that se... | The stem supplies the nonvisual facts (monocortical distal screw placement rationale, timing of imaging at plate removal, absence of clinical deterioration) that must be combined with visual interpretation of the two radiographs (loosening vs. fracture/pullout) to answer completely. The image alone shows implant appear... | Investigation Interpretation | Long Answer | Clinical Medicine | Veterinary Orthopedic Surgery | en | {
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"quote": "(A) follow-up medio-lateral radiograph of case 1 showing mild backout of the three distal screws; (B) follow-up medio-lateral radiograph of case 2 showing fracture of the penultimate distal screw and failure at the bone-screw interface of the most distal screw, resulting in backout of... | [
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | In a case series of dogs treated for traumatic shoulder (glenohumeral) joint luxation with a temporary transarticular locking plate spanning the humerus and scapula, the most distal screw placed in the humerus was intentionally driven through only the near cortex (monocortical) in most dogs to reduce stress concentrati... | {
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q01-d6ce42128645513e | 2026-04 | q01 | Case: A woman underwent gross-total resection of an expansile lytic occipital bone lesion with benign aneurysmal bone cyst morphology. The operative report documented that the dura remained intact.
Nineteen months later, she developed dizziness, vomiting, and gait instability. MRI showed multiple mixed-signal masses c... | The images show a discrete, rounded, separately enhancing nodule within the posterior fossa/cerebellum that is distinguishable from, though contiguous/connected with, the larger enhancing skull-based (occipital bone) mass -- i.e., two linked but distinct enhancing components rather than a single continuous extradural m... | The first operative note explicitly documents an intact dura, so any intracranial (intradural) tumor seen at recurrence must be acquired rather than pre-existing. The MRI shows a discrete round enhancing lesion separate from, but connected to, the main skull-based mass, which is the imaging signature of a lesion that h... | Investigation Interpretation | Short Answer | Clinical Medicine | Neurosurgical Oncology / Neuroradiology | en | {
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"quote": "the recurrent mass was partly extradural, with tumor erosion creating two dural defects and extension into the intradural compartment"
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman underwent gross-total resection of an expansile lytic occipital bone lesion. The operative report from that first surgery states the dura was intact throughout the procedure, and the resected tissue showed classic benign aneurysmal bone cyst (ABC) morphology (blood-filled cystic spaces, numerous multinucleated ... | {
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"omitted... | |
q01-d78e70667976f4b0 | 2026-04 | q01 | Case: A previously healthy young child has 6 days of small-volume, bright-red, odorless hematochezia with periumbilical and lower-abdominal discomfort. Tests show leukocytosis, fecal occult blood, and a markedly elevated antistreptolysin O titer. Blood and stool cultures, ANA, anti-Saccharomyces cerevisiae antibody, an... | The descending colon (top-right panel) shows the most severe injury, with dense white erosions/exudate and confluent hemorrhage exceeding the other three segments. The unifying diagnosis is ischemic colitis (segmental, patchy left-sided colonic mucosal injury from transient hypoperfusion), supported by the skip pattern... | The four panels show progressively more erosive, hemorrhagic mucosa with the descending colon panel displaying the densest white erosive/exudative change and confluent bleeding, exceeding the transverse, sigmoid, and rectal panels. Segmental patchy injury with a spared ascending colon argues against continuous inflamma... | Diagnosis | Long Answer | Clinical Medicine | Pediatric Gastroenterology | en | {
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"quote": "Colonoscopy identified segmental, patchy mucosal hyperemia and superficial erosions extending from the distal transverse colon to the rectum, with maximal involvement in the descending colon"
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"quote": "Histopathological examination demonstrated chronic acti... | [
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"title": "Ischemic colitis ... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A previously healthy young child was admitted for 6 days of small-volume, bright-red, odorless hematochezia with periumbilical/lower-abdominal discomfort. Labs: leukocytosis, positive fecal occult blood, markedly elevated antistreptolysin O (ASO) titer, but normal blood/stool cultures, normal ANA, anti-Saccharomyces ce... | {
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q01-df79b89046fcb62c | 2026-04 | q01 | Case: A patient with atrial fibrillation underwent contrast-enhanced cardiac CT before ablation.
Images: Both panels are axial CT views. In the left panel, blue arrowheads mark a bony structure immediately behind a short shared venous channel marked in green. Two veins form this channel before it enters the left atriu... | The variant is a confluent (common) inferior pulmonary vein trunk: both inferior pulmonary veins join into one shared venous channel before entering the left atrium, and this trunk plus the left inferior vein's ostium are compressed/abutted by the adjacent vertebral body (spine). The short-axis diameter of the left inf... | The left panel shows the spine (blue arrowheads) directly adjacent to a common venous trunk (green arrowheads) that gives rise to the left inferior pulmonary vein (yellow arrowheads) with a compressed, narrow ostium (red arrowhead) — this is the classic appearance of a confluent/common inferior pulmonary vein trunk com... | Investigation Interpretation | Short Answer | Clinical Medicine | Cardiac Electrophysiology | en | {
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{
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"partial_credit": "Award 3/6 if only 'common/shared inferior pulmonary vein trunk' is stated without mentioning spinal compression; award 6/6 for equivalent phrasing such as 'confluent inferior pulmonary vein' or 'common ostium of both inferior PVs abutting the vertebral ... | [
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"quote": "Contrast-enhanced cardiac computed tomography (CT) revealed that both inferior PVs originated from the common trunk (Figure 1A). The common trunk and ostium of the left inferior PV were compressed by the spine (Figure 1B). The diameter of the left inferior PV ostium was 22.9 × 5.1 mm ... | [
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"title": "Pulsed-Field Ablation of Conf... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image shows two related contrast-enhanced cardiac CT axial views from the same patient, obtained during pre-ablation planning for atrial fibrillation. Left panel: an axial slice near the posterior left atrium, with color-coded arrowheads marking (blue) a bony structure lying immediately behind the veins, (... | {
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q01-e928f34b7ffc9201 | 2026-04 | q01 | Case: A man had a left upper-quadrant intra-abdominal abscess from a contained perforation at the splenic flexure. He was treated with percutaneous catheter drainage and broad-spectrum antibiotics. Over the next 6 days, he had no worsening abdominal pain, rebound tenderness, or guarding. His C-reactive protein and othe... | Between day 3 and day 9: the intrasplenic gas-containing abscess enlarged (from its initial appearance to roughly 6 cm in maximum diameter), while the portal venous gas seen in the liver on day 3 had resolved by day 9 (along with resolution of the small amount of free intraperitoneal air). This dissociation—resolution ... | Fig. 3 (day 3) demonstrates a newly appeared gas-containing intrasplenic abscess and portal venous gas while the perisplenic collection is shrinking after drainage. Fig. 4 (day 9) shows resolution of the portal venous gas and free air but further enlargement of the intrasplenic abscess to ~6 cm. The absence of worsenin... | Investigation Interpretation | Long Answer | Clinical Medicine | Abdominal Radiology / General Surgery | en | {
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"points": 6,
"requirement": "Correctly identifies both interval im... | [
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"quote": "CT showed shrinkage of the perisplenic abscess, but newly demonstrated portal venous gas in the liver and a gas-containing abscess within the splenic parenchyma"
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"quote": "CT showed the disappearance of the portal venous gas and free intraperitoneal air, al... | [
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"title": "Splenic Flexure Colon Cancer ... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man being treated with percutaneous catheter drainage and broad-spectrum antibiotics for a left upper quadrant intra-abdominal abscess (secondary to a contained perforation at the colon's splenic flexure) underwent two axial contrast-enhanced abdominal CT scans at the level of the liver and spleen. The provided image... | {
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q01-f1736ff05624b46e | 2026-04 | q01 | Case: A 36-year-old competitive endurance athlete had manifest ventricular pre-excitation on a routine ECG. He had self-terminating palpitations at approximately 200 bpm while cycling but was otherwise asymptomatic. Echocardiography and laboratory results were normal, with no structural heart disease.
Images: The base... | Right-sided paraseptal (anteroseptal/right paraseptal) accessory pathway. Justification: the delta wave is negative in V1 (suggesting a right-sided rather than left-sided pathway), essentially isoelectric/absent in the inferior leads (II, III, aVF) which points away from a posteroseptal location, and becomes positive b... | Delta-wave polarity algorithms (e.g., Pambrun-type) localize accessory pathways using lead V1 polarity (negative suggests right-sided pathway, positive suggests left-sided), inferior lead polarity (negative/isoelectric suggests posteroseptal, positive suggests anterior/superior paraseptal locations), and precordial tra... | Investigation Interpretation | Short Answer | Clinical Medicine | Cardiac Electrophysiology | en | {
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"points... | [
{
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"quote": "12-lead ECG of a 36-year-old man showing pre-excitation with negative delta wave in V1, absent in inferior leads, and positive in V3-consistent with right paraseptal accessory pathway per pambrun et al."
}
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"title": "Case Report: Puls... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 36-year-old competitive endurance athlete was found to have manifest ventricular pre-excitation on a routine ECG. He was otherwise asymptomatic except for self-terminating palpitations at ~200 bpm during cycling. Echocardiography and labs were normal (structurally normal heart). The provided image shows his baseline ... | {
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q01-f45b5be6eb0b128d | 2026-04 | q01 | Case: A man in his early 90s underwent dual-chamber pacemaker implantation through the subclavian vein for high-grade AV conduction disease. He was clinically stable at discharge on day 1. Four days later, he returned with worsening fatigue.
Images: Contrast-enhanced chest CT was obtained at that visit. The left panel... | The lead traverses beyond the expected intracardiac course and exits through the left ventricular free wall (having taken a septal/paraseptal path), extending extracardially toward the left pleural space/lung parenchyma. The absence of pericardial effusion does not exclude perforation because the leaking/perforating tr... | On the axial image the lead tip is seen coursing beyond the cardiac silhouette at the anterolateral heart border rather than terminating within a ventricular chamber; on the paired sagittal/coronal view the same lead is seen angling further laterally toward the pleural space adjacent to the lung, indicating an extracar... | Investigation Interpretation | Long Answer | Clinical Medicine | Cardiology/Cardiothoracic Surgery | en | {
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"quote": "Computed tomography performed at the local facility demonstrated perforation of the pacemaker ventricular lead along a course most consistent with septal/paraseptal traversal and exit through the left ventricular free wall, with extension toward the left lung parenchyma"
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A man in his early 90s underwent dual-chamber pacemaker implantation via the subclavian vein for high-grade AV conduction disease. He was discharged clinically stable on day 1. Four days later he presented with worsening fatigue. The provided image shows two contrast-enhanced chest CT views obtained at that visit: left... | {
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q01-f699885cdb1b0173 | 2026-04 | q01 | Case: A child had recurrent episodic abdominal pain for many months. The pain had previously been treated as a gastrointestinal problem.
Images:
- Panel A shows the right kidney with a dilated renal pelvis and an area of thinned renal cortex marked by arrows.
- Panel B shows the same kidney with dilated major and mino... | No. Pyeloplasty is favored when meaningful renal function remains and is expected to improve with relief of obstruction. Here, the ultrasound shows cortical thinning (structural/irreversible parenchymal loss, i.e., scarring/fibrosis from chronic obstruction) together with severe calyceal dilation, and the functional st... | Cortical thinning on ultrasound reflects structural parenchymal loss; combined with a markedly prolonged washout half-time and severely reduced split function, these three independent findings converge on chronic, longstanding obstruction with irreversible damage rather than acute/reversible obstruction, which is the p... | Treatment | Short Answer | Clinical Medicine | Pediatric Urology/Nephrology | en | {
"criteria": [
{
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"quote": "cortical thinning (dashed arrow)"
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image shows two ultrasound views of the same kidney, obtained while investigating a child with many months of recurrent, episodic abdominal pain that had previously been treated as a gastrointestinal problem (left: view with an arrow marking the dilated renal pelvis and a second arrow marking an area of th... | {
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"omi... | |
q01-f99adac62dd09b92 | 2026-04 | q01 | Case: A child developed a solid unilateral choroidal mass. Another center treated it as a presumed choroidal hemangioma with two photodynamic therapy sessions and plaque radiotherapy. Vision did not improve, and the eye later became exotropic.
During follow-up, the previously unaffected eye developed multiple discrete... | The unifying diagnosis is Erdheim-Chester disease (a non-Langerhans-cell histiocytosis) with bilateral choroidal and intracranial (CNS) infiltration. The B-scan shows a solid, well-defined, homogeneously echogenic mass without the mushroom/collar-button configuration and dense heterogeneous internal echoes typical of c... | The case requires synthesizing four independent lines of evidence: (1) imaging morphology (homogeneous, well-circumscribed solid echo pattern rather than melanoma's mushroom-shaped, heterogeneous mass), (2) treatment non-response ruling out hemangioma, (3) the systemic distribution pattern (bilateral choroid plus multi... | Diagnosis | Short Answer | Clinical Medicine | Ophthalmology / Histiocytic disorders | en | {
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"quote": "The patient underwent two sessions of photodynamic therapy (PDT) and plaque radiotherapy (PRT) for suspected choroidal hemangioma at another hospital, with no visual improvement and left eye exotropia subsequently developed."
},
{
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A child developed a solid unilateral choroidal mass that was treated at another center as a presumed choroidal hemangioma with two sessions of photodynamic therapy plus plaque radiotherapy; there was no visual improvement, and the eye later became exotropic. On referral, the provided B-scan ultrasound images were obtai... | {
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q01-fa25441b7b76c7be | 2026-04 | q01 | Case: An adult man has a longstanding, rigid thoracolumbar deformity. Pedicle screws were placed bilaterally at T7–T9 and L2–L4, with one additional right-sided screw. No screws were placed within the fused segment at the apex. Pedicles were congenitally absent at three consecutive thoracic levels. Only a dysplastic, p... | (a) The vertebral bodies lose their normal, individually distinct outline and disc-space separation from roughly T9/T10 down through T12-L1 (i.e., the region between the labeled T9 and L1 levels appears collapsed, rotated, and fused). (b) This region (T10-T12) had congenitally absent pedicles, and the next vertebra dow... | The image shows a visible loss of normal vertebral segmentation between T9 and L1, corresponding to the aplastic/dysgenetic segment. The text states pedicles were absent at D10-D12 (T10-T12) with a dysplastic right L1 pedicle, and that screws were planned only at T7-T9, right L1, and L2-L4 — i.e., bypassing the aplasti... | Investigation Interpretation | Long Answer | Clinical Medicine | Orthopedic Surgery - Spine | en | {
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"partial_credit": "Award 2 points if the range is stated but off by one adjacent level or described only vaguely as 'lower thoracic to upper lumbar'",
"points": 4,
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},
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"quote": "Pedicle screws were planned at D7-D9 bilaterally, right L1, and L2-L4 bilaterally. Vertebral resection was avoided."
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image is a coronal 3D-CT bone reconstruction of the spine from an adult man with a longstanding, rigid thoracolumbar deformity, with vertebral levels labeled from C2 down to the sacrum (S). During surgical planning, pedicle screws were placed bilaterally at T7-T9 and bilaterally at L2-L4, plus a single scr... | {
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q02-1d322f985b32997b | 2026-04 | q02 | Case: A deep-seated soft-tissue mass was resected. The differential diagnoses were sarcomatoid carcinoma, leiomyosarcoma, malignant peripheral nerve sheath tumor, synovial sarcoma, and dedifferentiated liposarcoma.
Immunohistochemistry showed:
- No pan-cytokeratin, CK8/18, or p40 expression.
- No desmin or smooth musc... | Sarcomatoid carcinoma is excluded by negative pan-cytokeratin, CK8/18, and p40, which argue against any epithelial differentiation. Leiomyosarcoma is excluded by negative desmin and smooth muscle actin, arguing against smooth-muscle differentiation. Malignant peripheral nerve sheath tumor is excluded by negative S100 a... | UPS diagnosis requires systematically ruling out epithelial, smooth-muscle, neural, synovial, and adipocytic sarcoma mimics using a negative immunopanel; markers that are positive but non-lineage-specific (CD34, CD56, p16, focal TLE1) cannot be used to assign a specific lineage and instead support the residual 'undiffe... | Diagnosis | Long Answer | Clinical Medicine | Surgical Pathology / Sarcoma Oncology | en | {
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"summary"... | [
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A deep-seated soft-tissue mass was resected. On immunohistochemistry the tumor cells were negative for pan-cytokeratin, CK8/18, and p40; negative for desmin and smooth muscle actin; negative for S100 and SOX10; negative for ALK with only weak focal TLE1 positivity; and negative for MDM2 with no lipogenic differentiatio... | {
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q02-2d176892d315be95 | 2026-04 | q02 | Case: A cat has aortic valve vegetations and severe aortic regurgitation. The regurgitant jet velocity is 3.8 m/s, with a pressure gradient of 58.9 mmHg.
Ejection fraction is 83%, and fractional shortening is 47%; both conventional systolic function indices are normal. Two-dimensional speckle-tracking echocardiography... | GLS/speckle-tracking directly measures regional myocardial fiber deformation and is more sensitive than volumetric indices like EF or FS, which only reflect global chamber-level pump performance. Because subendocardial longitudinal fibers are most vulnerable to early injury (ischemia, inflammation, or hemodynamic stres... | The report states GLS (-19.4%) was mildly reduced despite preserved EF%/FS%, and attributes this to 2D-STE's greater sensitivity to early/subclinical myocardial dysfunction versus conventional indices, since longitudinal fibers are affected first. The localized LVFW strain reduction (vs normal septal strain) is attribu... | Investigation Interpretation | Long Answer | Clinical Medicine | Veterinary Cardiology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | In this cat with aortic valve vegetations and severe aortic regurgitation (regurgitant jet velocity 3.8 m/s, pressure gradient 58.9 mmHg), conventional systolic function indices were normal (ejection fraction 83%, fractional shortening 47%). However, two-dimensional speckle-tracking echocardiography showed a global lon... | {
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q02-39fcd63b0c85a910 | 2026-04 | q02 | Case: An adult had fever, hepatomegaly, anemia, and thrombocytopenia. Ferritin was above 6,000 ng/mL, triglycerides exceeded the hyperinflammation-score threshold, and AST was mildly elevated. There was no known immunosuppression.
Fibrinogen was not measured. Extensive bone marrow necrosis with no viable cells prevent... | (a) The scoring system weights hyperferritinemia and hypertriglyceridemia very heavily, and fever, organomegaly, and bicytopenia also each contribute substantial points; because this patient met all of these heavily-weighted criteria (extreme ferritin elevation, triglycerides above threshold, fever, hepatomegaly, two-l... | The HScore in this case totaled 193 (80-88% probability of HLH) built almost entirely from fever (33), hepatomegaly (23), bicytopenia (24), extreme hyperferritinemia (50), hypertriglyceridemia (44), and elevated AST (19) - fibrinogen and marrow hemophagocytosis contributed 0 points each because they were unmeasured/not... | Investigation Interpretation | Long Answer | Clinical Medicine | Hematology/Oncology | en | {
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"quote": "Immunohistochemical staining (CKAE1/AE3 and CK8/18) demonstrated positivity in necrotic cells, strongly suggesting metastatic epithelial infiltration in the appropriate clinical context."
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An adult presented with fever, hepatomegaly, and bicytopenia (anemia and thrombocytopenia). Laboratory testing showed ferritin markedly above 6,000 ng/mL, triglycerides above the threshold used in hyperinflammation scoring, and mildly elevated AST, with no known immunosuppression. Fibrinogen was not measured, and a bon... | {
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q02-4b02e65795deaa49 | 2026-04 | q02 | Case: Full-field electroretinography (ffERG) was recorded from both eyes of a child.
Images: Each numbered panel shows the right eye on the left and the left eye on the right:
1. Dark-adapted 0.01 rod-isolating stimulus
2. Dark-adapted 3.0 mixed stimulus
3. Dark-adapted 3.0 oscillatory potentials
4. Dark-adapted 10.0 ... | The cone system is far more severely affected than the rod system (a cone-rod pattern of dysfunction, not a rod-cone/retinitis pigmentosa pattern). The dark-adapted 0.01 (rod-isolated) response is only mildly reduced, showing the rod pathway is relatively preserved. In contrast, the dark-adapted 10.0 bright-flash b-wav... | In cone-rod dystrophies, cone function on light-adapted testing and on the cone-weighted components of bright dark-adapted flashes is disproportionately lost while the rod-isolated dim-flash response remains largely intact, the opposite pattern from rod-cone dystrophies (e.g., typical retinitis pigmentosa) where the di... | Investigation Interpretation | Long Answer | Clinical Medicine | Ophthalmology (Electrophysiology) | en | {
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... | [
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image shows six full-field electroretinography (ffERG) trace panels recorded from both eyes of the same child described in this case (right eye traces on the left of each panel pair, left eye traces on the right). The panels correspond to, in order: (1) dark-adapted rod-isolating stimulus (0.01), (2) dark-... | {
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q02-4e14c4882fe6a340 | 2026-04 | q02 | Case: A child developed acute, moderately severe bilateral vision loss. Visual acuity had been normal and did not fall to light perception. Pupillary light reflexes and colour vision were normal, with orthophoria. Dilated fundoscopy showed completely normal optic discs without swelling. Brain and orbital MRI showed inf... | The lesion is localized to the retrobulbar (postbulbar) portion of the optic nerve — the segment of the nerve posterior to the optic disc/nerve head, rather than the anterior nerve head itself (which would produce papillitis). Because the inflammatory demyelination is behind the point where the nerve is visualized on f... | The case explicitly notes normal optic nerve function tests and 'dilated fundoscopy revealed no optic disc swelling in either eye,' yet MRI showed inflammatory demyelinating changes explaining the visual loss. The discussion states the presentation 'was consistent with retrobulbar optic neuritis, as evidenced by the in... | Diagnosis | Short Answer | Clinical Medicine | Neuro-ophthalmology | en | {
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"title": "Bilateral Optic Neuritis in P... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A child had acute bilateral vision loss of moderate severity (visual acuity reduced from normal but not to light perception), with normal pupillary light reflex, normal colour vision, and orthophoria. On dilated fundoscopic examination, both optic discs appeared completely normal with no swelling, yet brain and orbital... | {
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q02-51abbc702227cd52 | 2026-04 | q02 | Case: A woman in her mid-30s had chronic right-upper-quadrant pain for about two years, followed by acute worsening. A hepatobiliary scan showed a gallbladder ejection fraction of 7% without gallstones. Biliary dyskinesia was diagnosed, and elective cholecystectomy was scheduled.
During surgery, a 4–5 cm omental segme... | Because she had no prior surgery or trauma, the adhesion fixing the omentum to the peritoneum beneath the liver was most likely congenital rather than postsurgical scarring. A congenital adhesion creates a fixed pivot point: the freely mobile portion of the omentum can rotate around this fixation point, twisting its ow... | The report notes she had no significant past surgical/trauma history, suggesting a congenital adhesion etiology; such fixation points predispose the omentum to torsion and strangulation. It also states small omental infarctions are difficult to detect on CT due to limited sensitivity, and that the prior 'normal' CT was... | Mechanism | Long Answer | Clinical Medicine | General Surgery | en | {
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"quote": "Small omental infarctions... are difficult to detect on CT due to limited sensitivity and would likely be missed without a laparoscopic evaluation"
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{
... | [] | {
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"doi": "10.7759/cureus.106593",
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"title": "Incidentally Discovered Oment... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her mid-30s had a roughly two-year history of chronic right-upper-quadrant pain that acutely worsened. A hepatobiliary nuclear scan showed a low gallbladder ejection fraction (7%) with no gallstones, consistent with biliary dyskinesia, and this finding was used to schedule an elective cholecystectomy. During... | {
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q02-596a210a26f63443 | 2026-04 | q02 | Case: A heart-transplant recipient was taking tacrolimus and mycophenolic acid. He developed progressive tonsillar lymphoproliferation and was ultimately diagnosed with post-transplant lymphoproliferative disorder (PTLD). EBV and CMV infections were both active at the time.
Question: Beyond pharmacologic immunosuppres... | CMV co-infection depletes a specific natural killer (NK) cell subset (CD56-dim, NKG2A-positive, KIR-negative NK cells) that is normally critical for immune surveillance against EBV-infected B cells. By reducing this NK cell population, CMV impairs the host's ability to control ongoing EBV-driven lymphoproliferation, al... | The case links EBV/CMV co-positivity to tonsillar PTLD. The mechanism requires synthesizing that EBV establishes latency in tonsillar B cells (the tissue reservoir) while CMV's independent contribution is immunologic: CMV depletes the CD56dim NKG2A+KIR- NK cell subset that normally suppresses EBV-infected B cells, comp... | Mechanism | Short Answer | Clinical Medicine | Transplant Immunology | en | {
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"title": "Tonsillar Post-transplant Lym... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A heart-transplant recipient maintained on tacrolimus and mycophenolic acid was found to have active, concurrent Epstein-Barr virus (EBV) and cytomegalovirus (CMV) infection at the time he developed progressive tonsillar lymphoproliferation that was ultimately diagnosed as post-transplant lymphoproliferative disorder (... | {
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q02-5b7b12c75bf08dfa | 2026-04 | q02 | Case: A patient underwent open esophageal diverticulectomy through a left thoracotomy with Heller myotomy. The myotomy was performed on the esophageal wall 180° opposite the diverticulectomy site and extended from the lower chest to the gastric wall. Esophageal manometry was not performed during the workup.
Images: Im... | Between the two images, the large saccular outpouching seen before surgery is dramatically reduced in size after surgery, consistent with successful diverticulectomy and relief of the outflow obstruction (matching the patient's reported symptomatic improvement). However, a smaller residual outpouching at the same locat... | The pre-operative image documents the large diverticulum and its dysmotile proximal segment; the post-operative image documents the same anatomic region after diverticulectomy plus myotomy. Direct visual comparison shows marked size reduction (evidence of successful debulking/decompression) but incomplete resolution (a... | Treatment Response | Long Answer | Clinical Medicine | Gastroenterology/Thoracic Surgery | en | {
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"quote": "Post-operative barium swallow showing residual, but much smaller, epiphrenic esophageal diverticulum."
... | [
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"title": "Large Epiphrenic Esophageal D... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The same patient later underwent open (left thoracotomy) resection of the esophageal diverticulum combined with a Heller myotomy performed on the esophageal wall roughly opposite (180 degrees around the circumference from) the diverticulectomy site, extending from the lower chest down to the gastric wall. Esophageal ma... | {
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... | |
q02-65f4e09aec0ef3e0 | 2026-04 | q02 | Case: Hypopigmented patches first appeared on the face during infancy. Over several years, they gradually spread to the neck and trunk. They never developed scale, itching, or surface changes. There was no preceding rash, trauma, or infection at the affected sites.
One differential diagnosis typically causes fluctuati... | The course fits poorly with pityriasis alba because that condition is typically facial-predominant with subtle scale and a fluctuating course, whereas this patient's patches are scale-free, have steadily extended beyond the face to the neck and trunk, and have been persistent rather than fluctuating. It also fits poorl... | Differentiating hypopigmenting disorders relies on matching the temporal/distributional pattern and any preceding trigger to each entity's expected natural history. Pityriasis alba is excluded by the lack of scale and fluctuation and by extension beyond the face. Post-inflammatory hypopigmentation is excluded by the ab... | Diagnosis | Long Answer | Clinical Medicine | Dermatology | en | {
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"title": "Hypopigmented Patches in an A... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | In the same patient, the hypopigmented patches were first noticed on the face during infancy and gradually extended to involve the neck and trunk over years, without ever developing scale, itching, or surface change, and without any identifiable preceding rash, trauma, or infection at the affected sites. Two entities i... | {
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q02-6ace2d8110f13f6e | 2026-04 | q02 | Context: The common bile duct normally opens into the second portion of the duodenum (D2). In this biliary variant, it opens into the third portion (D3).
Question: What embryological mechanism involving hepatic diverticulum development and ductal fusion explains drainage into D3 rather than D2? | During normal embryogenesis the hepatic diverticulum splits into a pars hepatica (which forms the hepatic ducts) and a pars cystica (which forms the gallbladder and cystic duct); the common bile duct arises from the shared proximal portion, and its fusion with the developing pancreatic duct normally establishes a singl... | The discussion explicitly attributes D3 drainage to a failure of regression or distal migration of the bile-pancreatic fusion point, distinguishing it from the separate mechanism (early hepatic diverticulum separation before stomach-duodenum separation) that produces gastric or bulbar ectopic openings. Answering requir... | Mechanism | Long Answer | Clinical Medicine | Anatomy/Embryology / Gastroenterology | en | {
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"quote": "If an accessory bile duct forms before the separation of the stomach and duodenum, it may open into the stomach; if it develops after this separation, it t... | [] | {
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"title": "A Rare Case of Ectopic Bile D... | {
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... | {
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... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | In the biliary variant where the common bile duct is found to open into the third portion of the duodenum (D3) instead of the second portion (D2), explain the embryological mechanism that produces drainage at this unusually distal site rather than at the normal D2 location. Base your answer on how the hepatic diverticu... | {
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q02-702880b5aa3bbe3c | 2026-04 | q02 | Case: A patient with a giant proximal LAD aneurysm and severe disease in other coronary branches was scheduled for coronary bypass. During the preoperative workup and intraoperative inspection, both internal thoracic arteries were found unsuitable as conduits. The surgeons instead used a free gastroepiploic artery graf... | The left internal thoracic artery had poor flow due to atherosclerotic calcification, and the right internal thoracic artery had its own 10-mm proximal aneurysm, making both unsuitable as bypass conduits. | The operative note states that flow of the left ITA was poor from atherosclerotic calcification, and a 10-mm proximal aneurysm was present in the right ITA, so both conduits were unsuitable for grafting; the team therefore harvested a free gastroepiploic artery graft and a saphenous vein graft instead. | Treatment | Short Answer | Clinical Medicine | Cardiothoracic Surgery | en | {
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"requirement": "States the left ITA was unsuitable due to poor flow from atherosclero... | [
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"doi": "10.1186/s13019-026-04167-w",
"doi_url": "https://doi.org/10.1186/s13019-026-04167-w",
"title": "Acute mitral r... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | During planning for coronary bypass in a patient with a giant proximal LAD aneurysm plus severe disease in other coronary branches, the surgical team found that both internal thoracic arteries (left and right) were unsuitable as bypass conduits and instead used a free gastroepiploic artery graft together with a sapheno... | {
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"summary": "Reorganized the operative scenario into chronological sentences and retained the request for the distinct problem affecting each artery.",
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"status"... |
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