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q02-be904ba29c13b9e6 | 2026-06 | q02 | Case: A patient later diagnosed with primary HLH initially presented after 8 days of fever. The patient had splenomegaly and pancytopenia: hemoglobin 7.5 g/dL, platelets 49 × 10^9/L, and absolute neutrophil count 0.7 × 10^9/L. The reticulocyte count was 5.9%. Bone marrow examination showed 70% cellularity, erythroid hy... | (1) Ferritin is an acute-phase reactant whose rise in HLH depends on the degree of cytokine-driven hyperinflammation; early in the disease course, before substantial cytokine-mediated hyperinflammation has developed, ferritin can remain low or near-normal even though the underlying cytotoxic/immune defect and hemophago... | Requires synthesizing two independent evidence elements: the timing/pathophysiology of ferritin as an inflammation-dependent marker versus the fixed diagnostic threshold, and reconciling the hematologic finding of reticulocytosis/erythroid hyperplasia with the explicit negative finding of no TMA, favoring a cytokine-me... | Mechanism | Long Answer | Clinical Medicine | Pediatric Hematology/Immunology | en | {
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"quote": "Ferritin was 142.6 ng/mL, which may have remained within the normal range because the disease was still in an early phase, prior to the development of substantial cytokine-mediated hyperinflammation; in contrast, triglycerides (191mg/dL), sIL-2R (3,776.6pg/mL), and CXCL9 (6,892 pg/mL) ... | [] | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient later diagnosed with primary HLH initially presented with 8 days of fever, splenomegaly, and pancytopenia (hemoglobin 7.5 g/dL, platelets 49x10^9/L, absolute neutrophil count 0.7x10^9/L) plus reticulocytosis (5.9%) and a bone marrow showing 70% cellularity with erythroid hyperplasia and hemophagocytosis, with... | {
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q02-bfd342a0d7bb533d | 2026-06 | q02 | Case: A 24-year-old man with a mechanical aortic valve was taking warfarin and aspirin and had a therapeutic INR. Two days after blunt chest trauma, he developed an anterior-lateral STEMI.
Transoesophageal echocardiography showed apical and anterior left ventricular wall akinesia, an apical aneurysm, and a non-mobile ... | Blunt chest trauma likely caused myocardial contusion of the apex/anterior wall, producing regional wall-motion abnormality (akinesia) with aneurysmal remodeling; the resulting low-flow, stagnant blood pool in the akinetic apical segment favored local thrombus formation despite therapeutic anticoagulation; a fragment o... | The sequence trauma → contusion → wall motion abnormality/aneurysm → stasis → mural thrombus → distal embolization is the only chain that accounts for both the trauma history and the imaging findings; the normal IVUS wall excludes dissection as the cause of the LAD occlusion, and the normal valve function/absence of va... | Mechanism | Long Answer | Clinical Medicine | Cardiology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 24-year-old man with a mechanical aortic valve (on warfarin and aspirin, therapeutic INR) presented with anterior-lateral STEMI two days after blunt chest trauma. Transoesophageal echocardiography showed akinesia of the apical and anterior left ventricular walls with an apical aneurysm and a non-mobile apical mural t... | {
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q02-c350393fbf6516df | 2026-06 | q02 | Context: Exome sequencing found a homozygous nonsense c.551G>A variant in a cytoskeleton-regulatory gene. The variant is novel, predicted to cause disease, and absent from population databases. It creates a premature stop at residue 184 of a 477-amino-acid actin-binding/cyclase-associated protein.
The truncation lies ... | Because the stop codon at residue 184 truncates the protein immediately after the N-terminal helical domain, the protein loses both the actin-binding/nucleotide-exchange domain and the C-terminal dimerization/actin-binding domain. This abolishes the protein's ability to recycle G-actin (convert ADP-actin back to ATP-ac... | The variant truncates CAP2 after the HFD, removing the WH2 domain (G-actin binding/ADP-to-ATP exchange) and CARP domain (actin binding, dimerization, nuclear matrix anchoring). Loss of CAP2 disinhibits nuclear MRTF accumulation, hyperactivating SRF and causing overexpression of myosin/actin structural genes, impairing ... | Mechanism | Long Answer | Clinical Medicine | Cardiovascular Genetics/Molecular Cardiology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | Exome sequencing identified a homozygous nonsense variant in a cytoskeleton-regulatory gene (a novel c.551G>A substitution, predicted disease-causing, absent from population databases) that introduces a premature stop codon at residue 184 of a 477-amino-acid actin-binding/cyclase-associated protein. This truncation occ... | {
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q02-e156c0046851700a | 2026-06 | q02 | Case: During the first-stage operation for an arteriovenous malformation, an intraoperative aneurysm rupture caused active bleeding. Covered stent grafts sealed the dilated superficial femoral and popliteal arteries, achieving adequate arterial hemostasis. Follow-up CT angiography showed small vessels continuing to sup... | (1) They most likely arise from osseous (intraosseous/nutrient bone) arterial supply rather than from the excluded superficial femoral/popliteal arterial system. (2) Because these vessels originate directly from the intraosseous circulation rather than branching off the named limb arteries, they are not interrupted whe... | The stem establishes that the major named arteries were already sealed by stent grafts, so any persisting feeder vessels shown in the image must originate from a source outside that controlled circuit. Combined with the discussion-level fact that bone-origin AVM vessels resist tourniquet control, the respondent must in... | Complication | Long Answer | Clinical Medicine | Vascular Surgery | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | During the first-stage operation for this arteriovenous malformation, an intraoperative aneurysm rupture caused active bleeding, which was controlled by deploying covered stent grafts to seal the dilated superficial femoral and popliteal arteries; adequate arterial hemostasis was achieved. On follow-up CT angiography o... | {
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q03-21736830edee38b8 | 2026-06 | q03 | Case: A resected gastric submucosal tumor had a solid component measuring 4.7 × 2.4 × 2.4 cm and showed lymphovascular invasion. The mitotic rate was 0–2 per 10 mm², and the Ki-67 index was 2–4%. There was no significant nuclear atypia or atypical mitotic figures.
The published risk scheme for this tumor type assesses... | Despite meeting the size criterion (>2 cm) and showing lymphovascular invasion, the tumor lacks atypical mitotic figures, has a low mitotic rate, a low Ki-67 index, and no significant nuclear atypia, so by this scheme it is classified as a benign glomus tumor rather than one with malignant/uncertain potential. However,... | This requires applying a multi-criteria risk scheme to the case's specific mix of findings (some meeting malignant-potential criteria, most not) rather than simply repeating the criteria, and recognizing that a single discordant high-risk feature (lymphovascular invasion) modifies management (surveillance) even after a... | Prognosis | Long Answer | Clinical Medicine | Surgical Pathology/Oncology | en | {
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"title": "Gastric Glomus Tumor (GGT) Mi... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A resected gastric submucosal tumor measured 4.7 x 2.4 x 2.4 cm in its solid component (thus exceeding 2 cm) and showed lymphovascular invasion on histology. However, the mitotic rate was only 0-2 mitoses per 10 mm^2, the Ki-67 proliferation index was 2-4%, and there was no significant nuclear atypia or atypical mitoti... | {
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q03-21b4a16ce0e1a25a | 2026-06 | q03 | Case: Endoscopic vertebral-artery transposition is planned for trigeminal neuralgia. Multimodal MRI fusion maps the compressing vertebral-artery loop relative to the trigeminal nerve. The course and origin of another vascular structure must be assessed relative to the planned transposition corridor. The vertebral arter... | The anterior spinal artery (ASA). Because vertebrobasilar dolichoectasia with an ectatic vertebral artery can alter the normal course or origin of the anterior spinal artery, the surgeon cannot assume the ASA lies safely outside the planned transposition path based on typical anatomy alone; its position must be specifi... | The text states that preoperative MRI fusion maps the VA loop relative to the nerve, and separately that 'VBDE with an ectatic VA can also alter the course and origin of the anterior spinal artery (ASA); identifying and confirming the absence of the ASA within the planned transposition corridor is important to avoid in... | Investigation Interpretation | Short Answer | Clinical Medicine | Neurosurgery (Skull Base/Vascular Neurosurgery) | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | Before this endoscopic vertebral-artery transposition operation for trigeminal neuralgia, multimodal MRI image fusion was used to map the compressing vertebral artery loop relative to the trigeminal nerve. Beyond simply confirming which vessel is compressing the nerve, name one other specific vascular structure whose c... | {
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q03-2b1b1b38967a8b31 | 2026-06 | q03 | Case: A patient taking an ALK tyrosine kinase inhibitor develops symptoms during the weeks after treatment begins. She has uncontrollable crying and a pervasive sense that life is tragic. She also has episodes of derealization, described as feeling detached from her own body. She reports a sensation of blood in her mou... | This symptom cluster (marked affect lability with uncontrollable crying, derealization, and distressing somatic symptoms significant enough to prompt discontinuation and psychiatric referral, but not life-threatening and not associated with any organ toxicity) corresponds to Grade 2 (moderate) psychiatric adverse event... | The case explicitly states the patient was classified Grade 2 at baseline per CTCAE v5.0 with this symptom picture, and the article's proposed management states Grades 2-3 require lorlatinib interruption until toxicity is below Grade 1, then resumption at a lower dose — consistent with what actually happened (oncologis... | Treatment | Short Answer | Clinical Medicine | Psycho-oncology | en | {
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q03-3f270c29d2e82391 | 2026-06 | q03 | Case: A child with a duodenal web underwent open laparotomy with duodenoplasty and membrane excision. Endoscopic membrane-directed techniques, such as balloon dilation or membranectomy, have been described for congenital duodenal stenosis.
Question: Why did the team choose open surgery instead of an endoscopic membran... | The main reason for choosing open surgery was that endoscopic techniques for treating congenital duodenal membranous stenosis (balloon dilation, membranectomy) are not yet well established and clinical experience with them remains limited, so open duodenoplasty was chosen to ensure procedural safety. During laparotomy,... | The discussion explicitly states that endoscopic management of CDS is not well established, and that open surgery was chosen to ensure procedural safety; separately, the case report states an inverted appendectomy was performed because of an incidentally found mobile cecum, a finding unrelated to the duodenal web. | Treatment | Short Answer | Clinical Medicine | Pediatric Surgery | en | {
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q03-42f3bbaa64560e06 | 2026-06 | q03 | Case: A 64-year-old man had longstanding hidradenitis suppurativa with chronic sinus tract and fistula formation. Decades earlier, he underwent colostomy for a presumed colonic mass and perianal hidradenitis suppurativa. The original pathology report was unavailable.
During a later admission for acute rectal bleeding,... | A chronic, approximately 2 cm ventral enterocutaneous fistula, dating back to the 1990s, was discovered during Foley catheter placement for acute urinary retention. It was located on the ventral abdominal wall, consistent with longstanding fistulizing disease related to his hidradenitis suppurativa/colostomy history, a... | The acute complication on hospital day four was urinary retention requiring a Foley catheter; during that urologic workup, a pre-existing chronic ventral enterocutaneous fistula (about 2 cm, present since the 1990s) was identified incidentally. This finding fits the patient's long history of fistulizing hidradenitis su... | Complication | Short Answer | Clinical Medicine | Gastroenterology/Urology | en | {
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q03-509dde6f17cb6599 | 2026-06 | q03 | Case: During several days of treatment for severe rhabdomyolysis, the patient's hemoglobin fell from 12.2 g/dL to 10.2 g/dL. Hematocrit fell from 36.8% to 30.2%. There was no clinical evidence of bleeding. Blood and urine cultures were negative. Hemodynamics remained stable throughout.
Question: What mechanism best ex... | This pattern most likely reflects rhabdomyolysis-associated anemia driven by heme pigment (myoglobin)-mediated iron sequestration, producing a functional iron-deficiency-like state analogous to inflammation-driven anemia, rather than true hemolysis or bleeding. Large amounts of released myoglobin/heme trigger sequestra... | The text explicitly notes the hemoglobin/hematocrit drop occurred without evidence of bleeding and attributes it to heme pigment-mediated iron sequestration and functional iron deficiency from myoglobin breakdown, distinguishing it from hemolysis or hemorrhage; the patient was managed conservatively with oral iron rath... | Complication | Short Answer | Clinical Medicine | Hematology | en | {
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q03-53147caf3da82ccd | 2026-06 | q03 | Case: About one year after the first native-kidney nephrectomy, a kidney transplant recipient developed suboptimal graft function. Transplant renal artery stenosis was suspected, but ultrasound excluded it. Serial testing was negative for BK virus and EBV. The CMV viral load was decreasing. A graft biopsy was performed... | The biopsy showed no evidence of acute rejection. Instead, it revealed fibrillary glomerulosclerosis with features of (most likely secondary) focal segmental glomerulosclerosis, along with minor stromal fibrosis and tubular atrophy — a glomerular/parenchymal disease process rather than rejection, infection, or vascular... | The case systematically excludes vascular (artery stenosis by ultrasound) and infectious (BKV, EBV negative; decreasing CMV) causes of graft dysfunction, then obtains a graft biopsy that shows no acute rejection but instead demonstrates fibrillary glomerulosclerosis/secondary FSGS with mild fibrosis and tubular atrophy... | Investigation Interpretation | Short Answer | Clinical Medicine | Transplant Nephrology / Renal Pathology | en | {
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q03-5f091b4daf951d19 | 2026-06 | q03 | Context: Complete excision of the fibrotic band and associated fat necrosis typically left a large glandular defect. The surgeons used a local flap rather than an implant. Autologous fat was grafted separately into the pedicle pillars and upper quadrants/cleavage, not directly into the resection cavity.
Question: What... | (1) A posterior glandular flap, pedicled on its posterior base, vascularized by perforators from the thoracoacromial artery and from intercostal artery branches/perforators. (2) Direct injection into the resection cavity (a relatively avascular dead space created by excision) was avoided because fat graft requires a we... | Text states the flap is 'pedicled on its posterior base and vascularized by perforators from the thoracoacromial artery and intercostal branches' and that 'care was taken to avoid direct injection into the resection cavity to reduce the risk of fat necrosis and oil cyst formation, mainly targeting the upper quadrants a... | Treatment | Short Answer | Clinical Medicine | Plastic and Reconstructive Surgery | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | After complete excision of the fibrotic band and associated fat necrosis in this series, the resulting glandular defect was typically large. Rather than using an implant, the surgeons filled the defect with a specific local flap, and separately performed autologous fat grafting using a defined protocol. (1) Name the fl... | {
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q03-6424e79af42590e1 | 2026-06 | q03 | Case: A patient with a septated gallbladder had chronic biliary-type pain for 10 years. The patient underwent laparoscopic cholecystectomy, and the pain resolved completely. A review of similar cases reported symptom relief after cholecystectomy in 17 of 25 patients. Despite these outcomes, published discussion conside... | (1) The rarity of the anomaly means case numbers are very small, so outcomes cannot be tested in controlled or adequately powered studies; and (2) HIDA scans (which could objectively demonstrate impaired/segmental emptying before surgery and confirm its correction afterward) are not routinely performed in the existing ... | The discussion directly states that the association between cholecystectomy and symptom resolution 'remains inferential given the rarity of the anomaly and the absence of routinely performed HIDA scans in existing literature,' explicitly naming small/rare case numbers and lack of routine functional (HIDA) confirmation ... | Prognosis | Short Answer | Clinical Medicine | General/Hepatobiliary Surgery | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient with a septated gallbladder (a fibrous septum partially dividing the gallbladder lumen) and a decade of chronic biliary-type pain underwent laparoscopic cholecystectomy, after which the pain resolved completely. In the broader literature on this anomaly, one cited review reported symptom relief in 17 of 25 si... | {
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q03-647c75e38243444a | 2026-06 | q03 | Case: A previously healthy woman in her mid-30s presented with fatigue and easy bruising. She had severe anemia, severe thrombocytopenia, and laboratory evidence of disseminated intravascular coagulopathy. An acute hematological malignancy, such as leukemia, was initially suspected. A bone marrow biopsy was performed. ... | The most likely diagnosis is rhabdomyosarcoma (alveolar subtype) confined to the bone marrow, without an identifiable primary soft-tissue tumor. Reaching this diagnosis (rather than a hematologic malignancy) required: (1) immunohistochemistry showing myogenic markers such as myogenin (and typically desmin/MyoD1), which... | Requires synthesizing the clinical mimicry of leukemia with the specific ancillary findings (myogenic IHC markers and a sarcoma-defining gene fusion) that overturn the initial hematologic hypothesis, rather than simply naming a diagnosis already stated verbatim in the source. | Diagnosis | Short Answer | Clinical Medicine | Hematopathology / Medical Oncology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A previously healthy woman in her mid-30s presented with fatigue, easy bruising, severe anemia, severe thrombocytopenia, and laboratory evidence of disseminated intravascular coagulopathy, a picture that was initially thought to represent an acute hematological malignancy such as leukemia. A bone marrow biopsy was perf... | {
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q03-6e4c690c89ea6e72 | 2026-06 | q03 | Case: The patient received intravenous antifungal therapy and systemic corticosteroids at the same time. His airway symptoms improved rapidly within days. After discharge on oral antifungal therapy, he returned twice with similar but milder symptoms. Each episode resolved with a short course of oral antifungal and ster... | (a) Because systemic corticosteroids were given at the same time and can rapidly reduce airway/mucosal edema and inflammation on their own, the concurrent steroid therapy confounds attribution of the rapid symptomatic improvement specifically to the antifungal agent; the response could be due mostly or entirely to the ... | Requires recognizing the steroid/antifungal confounding of treatment response (stated explicitly in the discussion) and separately identifying two independent, non-treatment-response evidence elements (microbiology and endoscopic appearance) that support the fungal etiology, testing synthesis across different sections ... | Treatment Response | Short Answer | Clinical Medicine | Otolaryngology / Infectious Disease | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The patient received intravenous antifungal therapy and systemic corticosteroids at the same time, and his airway symptoms improved rapidly within days. After discharge on oral antifungal therapy, he returned to clinic twice with similar but milder symptoms, each time resolving with a short course of oral antifungal pl... | {
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q03-73158bdf7dc510b6 | 2026-06 | q03 | Case: A renal mass was found during evaluation for acute bacterial pyelonephritis. It was round and well-circumscribed rather than wedge-shaped. The patient had no systemic features or laboratory abnormalities, including elevated serum IgG4, hypergammaglobulinemia, eosinophilia, or hypocomplementemia.
Question: Which ... | Renal infarction and IgG4-related kidney disease should both be considered unlikely. Renal infarction is argued against because it typically produces a wedge-shaped (geographic, peripherally based) perfusion defect rather than a round, well-circumscribed mass, and this lesion had a rounded, discrete morphology instead.... | The question supplies two independent discriminating features -- lesion shape and systemic/serologic status -- each of which maps to a different differential entity. Recognizing that a round (non-wedge) shape excludes an infarct pattern, and that absence of systemic/serologic markers excludes IgG4-related disease, requ... | Investigation Interpretation | Short Answer | Clinical Medicine | Genitourinary Radiology | en | {
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q03-74a862976a6adbda | 2026-06 | q03 | Case: A patient presented with a painful, firm, non-fluctuant swelling at a chronic biliary skin tract. CRP was 114 mg/L. The white cell count was normal. Haemoglobin was low. Albumin was low. Alkaline phosphatase was raised, while ALT and bilirubin were normal.
At surgery, purulent fluid was drained from the site. Mi... | The presentation is best explained by a foreign-body/mechanical process: a large calculus eroding through and mechanically obstructing the fistula tract, provoking a sterile inflammatory (foreign-body and chemical, from bile/cholesterol) reaction with local tissue damage and pus formation, rather than a primary bacteri... | Requires reconciling several evidence elements that individually could suggest infection (high CRP, purulent fluid) but together with a normal white cell count and negative culture instead point to a sterile/foreign-body inflammatory process; the selectively raised ALP against normal ALT/bilirubin further localizes the... | Complication | Short Answer | Clinical Medicine | General Surgery / Clinical Biochemistry | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | At presentation with a painful, firm, non-fluctuant swelling at a chronic biliary skin tract, laboratory testing showed a markedly raised CRP (114 mg/L), a normal white cell count, low haemoglobin, low albumin, a raised alkaline phosphatase, but a normal ALT and normal bilirubin. Purulent fluid was drained from the sit... | {
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q03-7675214922a59ac5 | 2026-06 | q03 | Case: During the same admission, another antiseizure drug caused progressive decreases in serum sodium and potassium over about 10 days. Sodium fell from about 140 mmol/L to 127.2 mmol/L, and potassium reached 2.42 mmol/L. The patient developed limb weakness, falls, and exertional dyspnoea.
Dose reduction did not reve... | The replacement drug (levetiracetam) was chosen because it is eliminated predominantly by renal (rather than hepatic) clearance, suiting the patient's CKD, and because it lacks hepatic CYP450 enzyme induction or inhibition, giving minimal drug-drug interaction potential. Despite these advantages, mild transaminase elev... | The oxcarbazepine-induced hyponatraemia/hypokalaemia episode did not fully resolve with dose reduction alone, prompting discontinuation and substitution with levetiracetam, selected for its renal elimination profile and absence of CYP450 interactions given the patient's CKD and prior electrolyte instability. Nonetheles... | Treatment | Short Answer | Clinical Medicine | Clinical Pharmacology / Neurology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | During the same admission, a different antiseizure drug caused progressive serum sodium decline (from a baseline around 140 mmol/L to a nadir of 127.2 mmol/L) and potassium decline (nadir 2.42 mmol/L) over about ten days, with associated limb weakness, falls, and exertional dyspnoea. A dose reduction alone did not reve... | {
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q03-bdbe07a8df56c4a3 | 2026-06 | q03 | Case: During emergency laparoscopic repair of an incarcerated diaphragmatic hernia, a non-viable segment of stomach required resection. The roughly 3 cm diaphragmatic defect was closed primarily with non-absorbable barbed sutures. Synthetic mesh and fundoplication were not used.
Question: Why was synthetic mesh avoide... | Mesh was avoided primarily because of an elevated risk of mesh infection: the operative field was not clean, since it involved resection of ischemic/necrotic gastric tissue (a contaminated, non-sterile focus), and the procedure was an emergency performed on a patient already immunosuppressed (chronic low-dose steroid a... | The report describes two intertwined risk factors that make mesh infection more likely here: presence of necrotic tissue requiring resection (a contaminated field) and the emergency, time-limited nature of the operation, on a patient receiving chronic immunosuppressive therapy. These combine to argue against placing pe... | Treatment | Short Answer | Clinical Medicine | Gastrointestinal Surgery | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | During an emergency laparoscopic repair of an incarcerated diaphragmatic hernia, the surgical team found a segment of stomach that was non-viable and required resection. The diaphragmatic defect (roughly 3 cm) was then closed primarily with non-absorbable barbed sutures. No synthetic mesh was placed to reinforce the cl... | {
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q03-cf5b397c5eb80830 | 2026-06 | q03 | Case: A patient with essential tremor began using a wrist-worn peripheral nerve stimulator. It delivers patterned high-frequency electrical bursts to the median and radial nerves.
About two and a half weeks later, he developed severe, brief throat pain on the side of the stimulated wrist. Swallowing and coughing trigg... | (1) A prior spontaneous, self-resolved episode of the same pain syndrome (glossopharyngeal neuralgia) about two years before device use, indicating pre-existing susceptibility/irritation at the nerve's root entry zone; and (2) a longstanding history of a different cranial neuralgia phenotype - cluster headaches - refle... | The case links two independent historical elements to the patient's vulnerability: a previously quiescent episode of the identical pain syndrome years earlier (evidence the root entry zone was already prone to abnormal firing) and a separate, longstanding cranial neuralgia phenotype (cluster headache), which the discus... | Complication | Short Answer | Clinical Medicine | Neurology - Movement Disorders and Cranial Neuralgia | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient with essential tremor began using a wrist-worn peripheral nerve stimulator that delivers patterned high-frequency electrical bursts to the median and radial nerves to reduce tremor. Within about two and a half weeks of starting therapy, he developed severe, brief, swallowing/coughing-triggered throat pain on ... | {
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q03-e14f44b658cc810c | 2026-06 | q03 | Case: A pregnant patient with G6PD deficiency completed seven days of quinine plus clindamycin for acute Plasmodium vivax blood-stage infection. She could not obtain anti-relapse prophylaxis and did not attend follow-up.
About two months later, at 17 weeks’ gestation, she returned with recurrent fever, abdominal pain,... | The relapse is most plausibly due to reactivation of dormant liver-stage hypnozoites, which are not cleared by blood-stage-only therapy (quinine-clindamycin treats circulating parasitemia but has no activity against the hepatic hypnozoite reservoir); without an 8-aminoquinoline to eradicate this hepatic phase, hypnozoi... | The case explicitly attributes P. vivax relapse to dormant hepatic hypnozoites that persist unless cleared with 8-aminoquinolines, and states the acute regimen used (quinine-clindamycin) only addressed blood-stage infection. It then reports that hydroxychloroquine, rather than chloroquine, was selected for suppressive ... | Mechanism | Long Answer | Clinical Medicine | Infectious Disease / Obstetric Medicine | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A pregnant patient with G6PD deficiency completed a seven-day course of quinine plus clindamycin for acute Plasmodium vivax blood-stage infection but could not obtain the medication for anti-relapse prophylaxis afterward and did not attend follow-up. About two months later, at 17 weeks' gestation, she returned with rel... | {
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q03-eb17a22db8dbdb7b | 2026-06 | q03 | Case: Four months after starting combined BRAF/MEK inhibitor therapy and a PD-1/CTLA-4 bispecific antibody for melanoma with liver metastases, a patient developed bilateral drug-related VKH-like panuveitis. HLA-DRB1 typing found two alleles not previously reported with VKH disease. HLA-B27 was positive, and ESR was ele... | Rationale: because it was unclear which drug was causally responsible, and because the tumor was still being actively controlled (stable hepatic metastases with continued cadonilimab), clinicians discontinued the more easily interrupted/substitutable targeted therapy (dabrafenib/trametinib) first while preserving the c... | The case explicitly balances the need for continued antitumor control against uncertainty about drug causation, opting to stop the reversible targeted therapy while keeping the immunotherapy that was controlling metastatic disease. The persistence of FFA leakage and skin depigmentation after DabTram cessation is the di... | Treatment | Long Answer | Clinical Medicine | Medical Oncology / Ocular immune-related adverse events | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient developed bilateral drug-related VKH-like panuveitis 4 months after starting combined BRAF/MEK inhibitor therapy plus a PD-1/CTLA-4 bispecific antibody for melanoma with liver metastases. HLA-DRB1 typing showed two alleles that have not previously been reported in association with VKH disease. Genetic testing... | {
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q03-febed7ddb3fb00fb | 2026-06 | q03 | Case: During an episode of sinking flap syndrome after decompressive craniectomy, the brain had a 19.2 mm midline shift. The collapsed skin flap over the cranial defect was sigmoid, with an upper concave segment and a lower convex segment. At the inflection point where its curvature reverses, ICP equals atmospheric pre... | Because ICP equals atmospheric pressure (0 mmHg relative) at the inflection point, and the EAM lies 5 cm below the inflection point, the ICP at the EAM level is higher than atmospheric by the hydrostatic column height: 5 cm x 0.735 mmHg/cm = approximately 3.7 mmHg above atmospheric pressure. Because the ICP at this bra... | The 5 cm distance and the identity of the inflection point can only be obtained from the image; combining it with the stated hydrostatic gradient yields the quantitative ICP estimate, and combining that sign (positive, i.e. above atmospheric) with the independently stated midline shift yields the mechanistic conclusion... | Mechanism | Short Answer | Clinical Medicine | Neurosurgery / Intracranial Pressure Physiology | en | {
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q01-00bd5e334bc52aae | 2026-07 | q01 | Case: An elderly woman underwent neck CTA. Sternoclavicular cortical contact was about 20% on the right and 21% on the left, below the 25% threshold for normal articulation. The brachiocephalic trunk shared an origin with the left common carotid artery, rose 2.11 cm above the manubrium, and crossed the trachea from lef... | (1) Bilateral poor sternoclavicular joint (SCJ) articulation (less than 25% clavicular-manubrial cortical contact on both sides) converts the normal suprasternal notch into an open interclavicular space/window. (2) The left brachiocephalic vein (the smaller vascular structure seen below the brachiocephalic trunk and an... | The coronal image shows the interclavicular space directly anterior to the trachea and superior to the manubrium, bounded by the two clavicular heads, which only exists because both SCJs have less than 25% cortical contact (quantitatively confirmed at ~20% and ~21%). The sagittal image shows the sequence of structures ... | Complication | Long Answer | Clinical Medicine | Radiology / Surgical Anatomy | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An elderly woman underwent neck CTA. The left panel of the provided image is a sagittal CT slice through the lower neck/upper thorax (left lateral view); from top to bottom it shows the lower cervical spine, a round vascular structure just anterior to the trachea, the air-filled trachea, a second smaller vascular struc... | {
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q01-138d6ba8104a7f8b | 2026-07 | q01 | Case: An adolescent boy gained 20 kg over 2 months and developed truncal acne, abdominal striae, and a hypertensive crisis. His blood pressure was 180/120 mmHg. He had hypokalemia, with potassium levels of 2.16–3.0 mmol/L (reference 3.7–5.2).
ACTH was 190 pg/mL (reference 0–46). Cortisol exceeded the reference range a... | The lesion represents hemorrhagic infarction (apoplexy) occurring within a small ACTH-secreting (functioning) corticotroph pituitary microadenoma. The pre-contrast image shows a focal T1-hyperintense area within the cystic lesion, consistent with subacute blood products, and the post-contrast image shows no enhancement... | The case shows a 6mm x5mm cystic left adenohypophyseal lesion with patchy T1-hyperintensity (blood products) precontrast and no enhancement postcontrast, findings the authors state can mimic a Rathke's cleft cyst. However, the patient had markedly elevated ACTH and a disrupted cortisol circadian rhythm (elevated at lat... | Investigation Interpretation | Long Answer | Clinical Medicine | Endocrinology | en | {
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},
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q01-1a84f61d5448bbc5 | 2026-07 | q01 | Case: An immunosuppressed woman in her early 50s with systemic lupus erythematosus and Sjögren syndrome developed a slowly worsening lateral wrist lesion about three days after a farm visit. It was initially attributed to an unwitnessed spider bite.
Images: The supplied image shows the lesion about 2.5 weeks after ons... | Mycobacterium marinum (a nontuberculous mycobacterium). Confirmation requires an acid-fast bacilli (AFB) culture incubated for a prolonged period at a lower-than-standard temperature (approximately 30-32°C), since M. marinum grows poorly or not at all under routine bacterial culture conditions and standard incubation t... | The chronic, indolent, nonhealing ulcerated lesion that failed multiple courses of broad-spectrum antibacterial therapy, combined with persistently normal inflammatory markers/CBC and imaging showing only superficial soft-tissue involvement without abscess, is inconsistent with typical bacterial cellulitis or an evolvi... | Diagnosis | Short Answer | Clinical Medicine | Infectious Disease / Dermatology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An immunosuppressed woman in her early 50s (systemic lupus erythematosus, Sjogren syndrome, prior breast cancer, on chronic immunosuppressive therapy) developed a slowly worsening lesion on the lateral wrist about three days after a farm visit, initially attributed to an unwitnessed spider bite. The provided image show... | {
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q01-1cabe519e6093880 | 2026-07 | q01 | Case: An 11-year-old girl had a large deletion spanning most of one X chromosome, with a 45,X karyotype. She had chronic, poorly controlled hypertension reaching 159/111 mmHg. Her renin-angiotensin-aldosterone axis was markedly activated: plasma renin was >500 pg/mL, supine aldosterone was 27.9 ng/dL, and angiotensin I... | The circled findings represent aortic wall calcification of the descending and abdominal aorta with a probable mural thrombus. Two contributing mechanisms: (1) Chromosomal/developmental - monosomy X (45,X) is associated with an intrinsic aortopathy/vascular wall fragility (connective tissue and elastin abnormalities), ... | The image shows circled foci at the same anatomic site (aortic wall) at thoracic and abdominal levels, consistent with wall calcification and possible mural thrombus. The stem provides two independent evidence threads: the karyotype (chromosomal substrate for aortopathy) and the hypertension/RAAS values (hemodynamic su... | Investigation Interpretation | Long Answer | Clinical Medicine | Pediatric Cardiology / Vascular Medicine | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An 11-year-old girl was found on genetic testing to have a large deletion spanning most of one X chromosome (45,X karyotype). She also had chronic, poorly controlled hypertension (blood pressure up to 159/111 mmHg) with a markedly activated renin-angiotensin-aldosterone axis (plasma renin >500 pg/mL, aldosterone 27.9 n... | {
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q01-2514a9b136586539 | 2026-07 | q01 | Case: A young child with severe factor IX deficiency and a low-titer FIX inhibitor received a subcutaneous anti-TFPI antibody for hemostatic prophylaxis. Treatment began with a loading dose, followed by daily maintenance dosing. Steady-state trough concentrations were measured immediately before the next scheduled dose... | The disproportionate rise reflects non-linear pharmacokinetics driven by the drug's weight-dependent clearance: for this antibody, apparent clearance and volume of distribution decrease as body weight increases. Because this was a small, actively growing toddler, weight gain occurring during the escalation interval red... | The report explicitly states that per the drug label, apparent clearance and volume of distribution decrease with increasing body weight, and that this likely contributed to drug accumulation as the patient gained weight over the observation period, explaining the disproportionate rise from 153.24 to 2909.9 ng/mL after... | Investigation Interpretation | Long Answer | Clinical Medicine | Pediatric Hematology / Clinical Pharmacology | en | {
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q01-28b2fb3e867f3052 | 2026-07 | q01 | Case: An adolescent boy underwent diagnostic laparoscopy for right lower quadrant pain that recurred and worsened one day after an initial emergency visit. His white cell count was 12 × 10^9/L, and CRP was 54 mg/L. No perforation was identified. Outpatient endoscopic evaluation of the colon was planned.
Images: Image ... | The structure in the right image (the appendix) appears macroscopically normal, so it should be left in place (appendectomy deferred/not performed) rather than removed. The main reason is that resecting a normal appendix adds risk without benefit and creates a stump that must heal, which could delay the planned subsequ... | The left image corresponds to the inflamed cecal diverticulum found adherent to the parietal peritoneum; the right image shows the appendix and terminal ileum with a normal, non-inflamed appearance. Because the appendix looked normal on direct visual inspection, and because the patient still needed a colonoscopy during... | Treatment | Long Answer | Clinical Medicine | Pediatric Surgery | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An adolescent boy underwent diagnostic laparoscopy for right lower quadrant pain that had recurred and worsened a day after an initial emergency visit, with white cell count 12x10^9/L and CRP 54 mg/L. Two intraoperative photographs from that operation are provided, in this order: left image shows the structure that pro... | {
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q01-2999fa1554cc4c23 | 2026-07 | q01 | Case: A woman developed acute chest pain after emotional stress. High-sensitivity troponin I was 617 ng/L and fell to 545 ng/L over 2 hours. Electrocardiography showed no T-wave changes. Coronary CT angiography showed patent left anterior descending, left circumflex, and right coronary arteries without obstructive sten... | The polar map shows reduced wall-motion amplitude (blue/magenta) concentrated in the mid-cavity ring segments (with the most severe involvement anteriorly and lesser involvement inferiorly), while the outer basal ring and the central apical cap show preserved (green/yellow) motion — i.e., circumferential midventricular... | Diagnosis of Takotsubo variants requires demonstrating (1) exclusion of obstructive coronary disease and (2) a regional wall-motion abnormality that crosses more than one coronary territory. The image supplies the segmental localization (mid-ring hypokinesia, base/apex spared) that must be cross-referenced against the ... | Diagnosis | Short Answer | Clinical Medicine | Cardiovascular Imaging | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman presented with acute chest pain after emotional stress. High-sensitivity troponin I was 617 ng/L, falling to 545 ng/L over the next 2 hours, and electrocardiography showed no T-wave changes. Coronary CT angiography confirmed patent left anterior descending, left circumflex, and right coronary arteries without o... | {
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q01-6236e42a6040c208 | 2026-07 | q01 | Case: A young child has had focal-to-bilateral tonic-clonic seizures since early infancy. Each focal seizure has the same onset: right-hand clonic jerking with forced turning of the head and eyes to the right. The jerking then spreads up the right arm, down the right leg, and to the right side of the face.
Images: The... | Semiology localizes to the LEFT hemisphere: right-hand/right-arm/right-leg/right-face clonic activity is controlled by the contralateral (left) motor cortex, and forced (versive) head/eye turning to the right is a classic sign of contralateral (left) frontal lobe seizure onset. So both lateralizing signs point to a lef... | Right-sided clonic seizure activity and contraversive (turning away from the ictal focus) head/eye deviation are both well-established contralateral lateralizing signs, so the semiology should localize to the left hemisphere. The image itself must be inspected to assess whether the EEG discharge is unilateral or bilate... | Investigation Interpretation | Long Answer | Clinical Medicine | Pediatric Epileptology/Clinical Neurophysiology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A young child has had focal-to-bilateral tonic-clonic seizures since early infancy. Every focal seizure begins the same way: clonic jerking of the right hand together with forced turning of the head and eyes to the right, which then spreads up the right arm, down to the right leg, and into the right side of the face. T... | {
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q01-6ece3eac597d72dd | 2026-07 | q01 | Case: A patient developed shoulder pain after a heavy-lifting injury. Contrast-enhanced CT of the proximal humerus showed a well-defined, expansile osteolytic lesion measuring about 4 × 3 × 6 cm. The cortex was thinned, without breakthrough or periosteal reaction. Enhanced-phase attenuation was about 87 HU.
Images: Le... | The non-enhancing low-signal foci represent hemosiderin deposition (from prior intralesional hemorrhage), possibly with residual blood products/osseous trabeculae. The overall pattern (marked heterogeneous enhancement, cortical thinning without periosteal reaction or soft-tissue mass, and hemosiderin-related non-enhanc... | The case report describes a proximal humeral lesion with marked heterogeneous contrast enhancement and focal non-enhancing low-signal areas on coronal contrast-enhanced T1WI, explicitly attributed to hemosiderin deposition, hemorrhagic components, or residual osseous trabeculae. The discussion section explicitly contra... | Investigation Interpretation | Long Answer | Clinical Medicine | Musculoskeletal Radiology / Orthopedic Oncology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient developed shoulder pain after a heavy-lifting injury. Contrast-enhanced CT of the proximal humerus showed a well-defined expansile osteolytic lesion (about 4x3x6 cm) with cortical thinning but no cortical breakthrough or periosteal reaction, and a contrast attenuation of roughly 87 Hounsfield units on the enh... | {
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q01-78223c4cff6ad763 | 2026-07 | q01 | Case: An elderly man has recurrent melena and severe iron-deficiency anemia (hemoglobin 6.8 g/dL) requiring transfusion. Multiphasic contrast-enhanced abdominal CT shows a roughly 4-cm broad-based endoluminal small-bowel mass. The mass is markedly hyperenhancing and internally heterogeneous in the arterial phase. There... | A hypervascular polypoid small-bowel melanoma (primary or metastatic) is the most compatible entity. The image shows a smoothly marginated, broad-based polypoid intraluminal mass with only partial luminal narrowing rather than a circumferential, shouldered, annular stricture — the pattern expected for adenocarcinoma — ... | Table 2 in the source lists radiologic clues: adenocarcinoma produces an annular constricting lesion with shouldered edges and less marked arterial hyperenhancement, whereas hypervascular metastases/melanoma present as polypoid, markedly arterial-enhancing lesions. The image shows a broad-based polypoid mass with parti... | Investigation Interpretation | Short Answer | Clinical Medicine | Abdominal Radiology / Gastrointestinal Oncology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An elderly man presented with recurrent melena and severe iron-deficiency anemia (hemoglobin 6.8 g/dL) requiring transfusion. A multiphasic contrast-enhanced abdominal CT was obtained. Nonvisual findings from the same study: a broad-based endoluminal small-bowel mass roughly 4 cm in size, marked hyperenhancement in the... | {
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q01-7f0f92f0cce145e8 | 2026-07 | q01 | Case: During minimally invasive cardiac surgery, a large-bore femoral venous drainage cannula was intended to pass from the inferior vena cava, through the right atrium, and into the superior vena cava. The cannula had numerous side holes along a long perforated segment. Vacuum-assisted venous drainage was used.
After... | The cannula tip has perforated the anterior free wall of the right ventricle and protruded through it into the pericardial cavity (the arrow points to the cannula tip lying free in the pericardial space). Mechanistically, the cannula probably did not run straight along the IVC-RA-SVC axis; instead it deviated acutely f... | The stem supplies the clinical sequence (poor drainage, blind advancement, immediate improvement, later pericardial bleeding) and cannula design (many side holes over a long segment, VAVD). The image supplies the anatomic finding (an instrument tip freely visible in the open pericardial space after sternotomy) that the... | Mechanism | Long Answer | Clinical Medicine | Cardiac Surgery / Cardiac Anesthesiology | en | {
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q01-8cbf3464bfa665a7 | 2026-07 | q01 | Case: An adult has an incidentally discovered right ventricular outflow obstruction. The right ventricular outflow tract peak pressure gradient is 28 mmHg. Peak flow velocity across the obstruction is 263 cm/s. The full MRI study shows no ventricular septal defect.
Images: The supplied short-axis late-gadolinium-enhan... | Type 1 (moderator-band type) intracavitary right ventricular obstruction. The distinguishing criterion is whether a discrete hypertrophied moderator band crosses the RV cavity and causes the obstruction (type 1) versus obstruction arising from diffuse parietal and septal muscle hypertrophy without a hypertrophied moder... | The case describes a hypertrophied moderator band dividing the RV into proximal and distal chambers (type 1 double-chambered right ventricle pattern). The discussion notes that type 1 obstruction (moderator band) tends to have higher intraventricular pressure gradients than type 2 (parietal/septal hypertrophy without m... | Investigation Interpretation | Short Answer | Clinical Medicine | Cardiovascular Radiology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | The provided image is a short-axis late-gadolinium-enhancement cardiac MRI slice through the right ventricle in an adult with an incidentally discovered right ventricular outflow obstruction. An arrow marks a discrete muscular band crossing the ventricular cavity. Additional workup in the same patient found: a right ve... | {
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q01-96a12edab9afec41 | 2026-07 | q01 | Case: A woman presented with acute chest pain. Within one hour, high-sensitivity cardiac troponin I rose from about 160 to more than 300 times the upper limit of normal. Serial 12-lead ECGs were normal.
Coronary angiography showed no stenosis, occlusion, or plaque. Quantitative flow ratios in the three major coronary ... | The pattern supports true ischemic infarction, not myocarditis. The hyperenhancement begins at the subendocardial surface and extends toward the epicardium in a focal, coronary-territory-like (septal/inferior wall) distribution with a transmural component — this subendocardial-to-transmural pattern is the hallmark of i... | CMR LGE pattern recognition is central to differentiating ischemic from non-ischemic myocardial injury when coronary arteries are angiographically normal. Subendocardial or transmural LGE following a vascular territory is specific for infarction (regardless of epicardial patency), whereas mid-wall/epicardial or diffuse... | Investigation Interpretation | Long Answer | Clinical Medicine | Cardiology | en | {
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q01-c354223b65c89994 | 2026-07 | q01 | Case: A previously healthy young child had weeks of intermittent colicky abdominal pain and non-bilious vomiting. White blood cell and platelet counts were normal. Echinococcus serology was negative. There was no history of exposure to livestock or unpasteurized dairy.
Images:
- Image 1 is an early axial contrast-enha... | The lesion most likely represents a mobile, inflamed segment of small bowel (a Meckel-type diverticulum) whose lumen contains a foreign body/enterolith complex, producing internal rounded debris that mimics hydatid daughter cysts. True hydatid (echinococcal) cysts are fixed peritoneal/organ-based lesions that do not ch... | Key discriminators: (1) interval migration of the lesion between the two studies is incompatible with a fixed peritoneal/hydatid cyst and instead indicates the mass is attached to a mobile bowel loop; (2) peripheral rim enhancement plus mesenteric stranding indicates surrounding inflammation, consistent with an inflame... | Mechanism | Long Answer | Clinical Medicine | Pediatric Radiology / Gastrointestinal Imaging | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A previously healthy young child presented with weeks of intermittent colicky abdominal pain and non-bilious vomiting. White cell count and platelets were normal, Echinococcus serology was negative, and there was no exposure history to livestock or unpasteurized dairy. The provided images are two axial cross-sectional ... | {
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q01-c8e103d3a68435cf | 2026-07 | q01 | Case: An adolescent or young adult man from a leprosy-hyperendemic region has had widespread lesions for several months. The lesions are smooth, skin-colored to erythematous papules and nodules. Facial findings include nasal enlargement and alar distortion. Lesions involve the dorsal fingers and periarticular regions, ... | Lepromatous (multibacillary) leprosy (Hansen's disease), representing the diffuse, anergic/lepromatous pole of the Ridley-Jopling spectrum. | The combination of diffuse, symmetric, smooth-surfaced papulonodular skin lesions with facial (nasal/perioral) infiltration, acral/periarticular nodules, and palatal mucosal nodules is a classic multisystem distribution for lepromatous leprosy, which spreads hematogenously to cooler body sites (face, extremities, oral ... | Diagnosis | Short Answer | Clinical Medicine | Oral and Maxillofacial Pathology / Infectious Disease | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | An adolescent/young adult male from a leprosy-hyperendemic region presents with a several-month history of widespread, smooth-surfaced, skin-colored to erythematous papulonodular lesions on the face (with nasal enlargement and alar distortion) and on the dorsal surfaces of the fingers/periarticular regions (some with d... | {
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q01-db71c45ebab5b79f | 2026-07 | q01 | Case: A woman in her early 40s has markedly elevated alkaline phosphatase and gamma-glutamyl transferase, mildly elevated aminotransferases, and mild hyperbilirubinemia. Antimitochondrial antibody is positive. Antinuclear antibody is positive at a high titer with a centromere pattern. Her immunoglobulin G level is at t... | Autoimmune hepatitis-primary biliary cholangitis (AIH-PBC) overlap syndrome. The image shows a portal tract expanded by a dense lymphoplasmacytic inflammatory infiltrate that spills across the limiting plate into the periportal parenchyma (interface hepatitis, the hallmark of AIH) together with the infiltrate tracking ... | Interface hepatitis alone suggests AIH; a purely cholestatic/ductopenic picture alone suggests PBC. The AMA positivity plus cholestatic enzymes indicates a biliary process, while the dense lymphoplasmacytic interface hepatitis on biopsy indicates concurrent hepatocellular autoimmune injury. Neither antibody profile nor... | Diagnosis | Short Answer | Clinical Medicine | Hepatology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A woman in her early 40s has a predominantly cholestatic liver profile (markedly elevated alkaline phosphatase and gamma-glutamyl transferase, mildly elevated aminotransferases, mild hyperbilirubinemia), a positive antimitochondrial antibody, a high-titer antinuclear antibody with a centromere pattern, an immunoglobuli... | {
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... | |
q01-ea9a728f8924aa19 | 2026-07 | q01 | Case: A patient underwent metallic-coil embolization of a right hepatic artery pseudoaneurysm. The patient later developed recurrent choledocholithiasis and cholangitis.
Images:
- Panel A: A T-tube cholangiogram after endoscopic treatment of the first recurrence shows a dilated biliary tree and metallic density near t... | Both images are two-dimensional projectional studies (cholangiogram/fluoroscopy) obtained at the hepatic hilum, where the right hepatic artery and common bile duct lie in very close anatomical proximity and their silhouettes overlap on a flat projection. A coil or wire fragment that is merely abutting or superimposed o... | The case text states that after the first recurrent episode, T-tube cholangiography showed a metallic density in the hepatic hilum but its 'exact relationship to the bile duct lumen could not be determined because of anatomical overlap between the biliary tree and adjacent vascular structures.' At the second recurrent ... | Investigation Interpretation | Short Answer | Clinical Medicine | Interventional Radiology / Gastroenterology (ERCP) | en | {
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{
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"po... | [
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"quote": "its precise relationship to the bile duct lumen cannot be definitively determined because of anatomical overlap between the hepatic artery and the biliary system"
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A patient with a metallic-coil embolization of a right hepatic artery pseudoaneurysm later developed recurrent choledocholithiasis and cholangitis. The provided image has two panels obtained at different times during the subsequent work-up: left, a T-tube cholangiogram obtained after endoscopic treatment of the first r... | {
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q02-1a967463f8f5e0df | 2026-07 | q02 | Case: During resection of a large, encapsulated anterior mediastinal mass, the surgeons followed a hypovascular plane separating the tumor from the mediastinum and lung. They could not find the feeding vessel seen on preoperative imaging within this plane. A discrete fibrous stalk connected the tumor directly to the su... | The tumor is a solitary fibrous tumor (SFT) that most likely originated from the visceral pleura of the left upper lobe (consistent with the fibrous pedicle attaching to the lung surface and the CD34+/STAT6+ spindle cell histology). It grew from the visceral pleura into the mediastinum and, once adjacent to the interna... | CD34/STAT6 positivity is diagnostic of SFT, a tumor arising overwhelmingly from the visceral pleura. The presence of a fibrous pedicle to the lung, a hypovascular mediastinal dissection plane, and failure to find the feeding artery within the mediastinal tissue together indicate the tumor's true vascular pedicle and or... | Mechanism | Long Answer | Clinical Medicine | Thoracic Surgery / Pathology | en | {
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{
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"title": "Solitary Fibrous Tum... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | During resection of a large, encapsulated anterior mediastinal mass, the surgical team dissected along a hypovascular tissue plane between the tumor and the mediastinum/lung; the feeding vessel that had been shown on preoperative imaging to supply the tumor could not be located anywhere within this mediastinal dissecti... | {
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q02-1bad73fe62551316 | 2026-07 | q02 | Case: A 9-year-old boy had a traumatic posterior hip dislocation. Closed reduction was performed under general anesthesia on the day of injury. He remained non-weight-bearing without traction.
Three days later, he developed increased hip pain during normal activity. The same hip had redislocated and was reduced again.... | The redislocation occurred because the posterior osteochondral fragment (avulsed acetabular rim bone still attached to the labrum) became interposed in the joint, preventing a truly concentric articulation between the femoral head and acetabulum even though the hip appeared reduced. Because this fragment was a fixed st... | The narrative shows reduction achieved, then loss of reduction 3 days later without new trauma, i.e., during routine daily activity. This pattern, combined with imaging showing a labrum-attached osteochondral fragment and an epiphyseal defect, indicates a structural (mechanical) block to stable reduction rather than a ... | Mechanism | Short Answer | Clinical Medicine | Orthopedic Surgery / Pediatric Trauma | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A 9-year-old boy sustains a traumatic posterior hip dislocation and undergoes closed reduction under general anesthesia on the day of injury, followed by a non-weight-bearing protocol without traction. Three days later, he develops increased hip pain during normal activity and is found to have redislocated the same hip... | {
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q02-50b36fd691d29dcb | 2026-07 | q02 | Case: A right atrial tumour extended widely along the atrial wall without forming a discrete mass. A separate left ventricular apical mass did not reach the endocardial surface. The patient also had peripheral pulmonary nodules. A fistula allowed free blood flow from the right atrium into the pericardial space.
The cl... | Transbronchial lung biopsy, CT-guided percutaneous lung biopsy, and open lung biopsy were all rejected because the pulmonary nodules were peripherally located and not accessible/safely reachable by these routes. Catheter-based (transvenous) endomyocardial biopsy of the cardiac lesions was rejected because the right atr... | This requires synthesizing distinct constraints from different parts of the case: pulmonary nodule location, the non-discrete/non-endocardial morphology of the cardiac lesions, and the fistulous anatomy that made pericardiocentesis dangerous, to explain why surgery was the only viable diagnostic-and-therapeutic route. | Treatment | Long Answer | Clinical Medicine | Cardiovascular Surgery / Multidisciplinary Oncology | en | {
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"title": "Right atrial rupture due to c... | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A right atrial tumour extended widely along the atrial wall without forming a discrete mass, and a separate mass at the left ventricular apex did not reach the endocardial surface. The patient also had peripherally located pulmonary nodules, and there was a fistulous communication allowing free flow of blood from the r... | {
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q02-602c53a9c474ecd9 | 2026-07 | q02 | Case: A patient with breast malignancy has elevated tumor markers and axillary and supraclavicular lymphadenopathy. The patient had lower back pain for several months before admission.
Images: Coronal whole-body images from the same PET-CT study are shown in the same orientation. The left panel is a CT bone-window ima... | The CT panel shows multiple ill-defined lucent (bone-destructive/osteolytic) defects scattered through the vertebral bodies, pelvis, and proximal femora rather than sclerotic/blastic densities, and these same sites correspond to focal areas of intensely increased FDG uptake on the PET panel. This concordant pattern (ly... | Requires the respondent to read the CT panel for lucent/lytic morphology and the PET panel for co-localized hypermetabolism, then integrate that visual pattern with nonvisual clinical clues (tumor markers, lymphadenopathy, preceding back pain) to characterize lesion type and disease activity/chronicity - the answer is ... | Investigation Interpretation | Short Answer | Clinical Medicine | Nuclear Medicine/Musculoskeletal Oncologic Imaging | en | {
"criteria": [
{
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"partial_credit": "No credit if lesions called sclerotic/blastic or mixed without justification",
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q02-9e748ec1b707a6b9 | 2026-07 | q02 | Case: A woman with irradiated nasopharyngeal carcinoma developed massive nasal bleeding. Emergency catheter angiography showed an outpouching (pseudoaneurysm) arising from the C3 segment of the right internal carotid artery (ICA). The right internal and external carotid arteries were significantly narrowed. She underwe... | (a) In the first image, the marked site shows an abnormal contrast-filled outpouching (the pseudoaneurysm sac) projecting from the artery; in the second image, this outpouching no longer fills with contrast — it has been excluded/obliterated, consistent with successful coil packing and thrombosis of the sac. (b) This i... | The images alone show the before/after appearance of the lesion; the text supplies the clinical framing (massive bleeding, urgent coil embolization, associated arterial narrowing) needed to interpret the visual change correctly. Answering requires synthesizing the visual disappearance of the aneurysm sac with the clini... | Treatment Response | Short Answer | Clinical Medicine | Interventional Neuroradiology / Head and Neck Oncology | en | {
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q02-9f8be9b3daebab9d | 2026-07 | q02 | Case: A patient with Graves disease-related thyroid eye disease and type 2 diabetes was taking oral agents. Baseline HbA1c was about 7%, HOMA-IR was 4.57, and HOMA-β was 68.5%.
Teprotumumab was started. Over 3 weeks, serum GH changed from about 1.2 to 2.2 ng/mL and remained within the normal range. IGF-1 rose from +0.... | The marked rise in IGF-1 despite a near-normal, only mildly changed random GH level indicates an increase in integrated (pulsatile) GH secretion, since IGF-1 is a stable surrogate for 24-hour GH output while a single GH measurement is not. This GH-driven state increases hepatic gluconeogenesis and insulin resistance, e... | This requires linking two independent evidence pairs: (1) GH vs IGF-1 discordance, which requires knowing IGF-1 is an integrated GH secretion marker, and (2) FPG vs IRI discordance, which requires recognizing an inadequate insulin secretory response. Combining both with the baseline HOMA indices yields the synthesis th... | Investigation Interpretation | Short Answer | Clinical Medicine | Endocrinology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | In a patient with Graves disease-related TED and preexisting type 2 diabetes (on oral agents, baseline HbA1c ~7%), teprotumumab was started. At baseline, HOMA-IR was 4.57 and HOMA-β was 68.5%. Serum GH changed only minimally, from about 1.2 ng/mL at baseline to 2.2 ng/mL at 3 weeks (both within the normal reference ran... | {
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q02-a7779b9fd423dffe | 2026-07 | q02 | Case: A patient underwent emergency open repair of a complex abdominal wall hernia containing her stomach. By postoperative day 6, subcutaneous drain output was below 30 mL/24 h. She tolerated an advancing oral diet. Her stoma showed no ischaemia, and she had no wound or mesh complications.
An unrelated event during t... | She sustained a spontaneous, atraumatic rupture of the extensor tendon of her index finger, attributed to long-term corticosteroid (prednisolone) therapy causing poor tissue/collagen quality (steroid-induced tendinopathy/tissue fragility) rather than any trauma or hernia-related event. This mattered specifically becaus... | The text explicitly states the patient sustained a spontaneous, atraumatic index finger extensor tendon rupture 'due to her long-term treatment with steroids and extremely poor tissue quality,' and that this 'prevent[ed] discharge as she was unable to care for her stoma with the impairment of her hand function.' This i... | Complication | Long Answer | Clinical Medicine | General/Colorectal Surgery (Abdominal Wall & Hernia) | en | {
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q02-b6b0c374cfacc7cc | 2026-07 | q02 | Case: A patient had BRAF V600E-mutant metastatic colorectal cancer. Primary-tumor sequencing showed BRAF V600E at a variant allele frequency of 25.3%, a tumor mutational burden of 10 mutations/Mb, and stable microsatellite status.
A liquid biopsy obtained around the same time did not detect BRAF V600E. Its tumor DNA f... | (a) The discordance reflects differing amounts of circulating tumor DNA shed into blood at the two sampling times, not a true change in the tumor's BRAF genotype: at the first liquid biopsy the ctDNA (tumor) fraction was too low/indeterminate to allow mutation detection despite tissue-confirmed BRAF V600E, whereas by t... | Text states tissue NGS found BRAF V600E VAF 25.3%, TMB 10 Muts/Mb, MSS, while liquid biopsy at the same time was negative for BRAF with tumor fraction 'cannot be determined,' explicitly offered by the authors as the explanation for the tissue/liquid discordance. Later, a liquid biopsy performed outside protocol around ... | Genetics | Long Answer | Clinical Medicine | Molecular Oncology / Genomics | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | In a BRAF V600E-mutant metastatic colorectal cancer, sequencing of the primary tumor tissue showed BRAF V600E at a variant allele frequency (VAF) of 25.3%, tumor mutational burden of 10 mutations/Mb, and stable microsatellite status. A liquid biopsy obtained around the same time failed to detect the BRAF mutation, with... | {
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q02-d7dd626a667fa622 | 2026-07 | q02 | Case: Several unrelated individuals had different truncating mutations in the same autism-associated Mediator-complex kinase-module subunit gene. The mutations included nonsense variants, frameshift variants, and large deletions.
Truncation sites varied widely. Early truncations removed most of the downstream protein ... | Individuals whose mutations truncated the protein earlier in the coding sequence (eliminating a larger fraction of the protein, including both functional domains) tended to show more severe autistic features, whereas individuals with later, more C-terminal truncations tended to show milder autistic features. This patte... | This requires synthesizing genotype (truncation position/extent of protein loss) across multiple independently reported individuals with phenotype severity ratings, then inferring the underlying dosage/haploinsufficiency mechanism rather than simply restating a single individual's diagnosis. | Mechanism | Short Answer | Clinical Medicine | Medical Genetics | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | In a comparison of several unrelated individuals, each carrying a different truncating mutation (nonsense variant, frameshift variant, or large deletion) in the same autism-associated Mediator-complex kinase-module subunit gene, the position of the truncation along the coding sequence varied considerably: some mutation... | {
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q02-e26af14bd30a6a85 | 2026-07 | q02 | Case: A patient has primary gastric signet ring cell adenocarcinoma. Simultaneous lesions in the stomach, duodenum, distal ileum, ileocecal valve, and colorectum have identical biopsy histology. The lesions are flat-elevated, ulcerative, or polypoid.
Staging shows enlarged abdominal lymph nodes and multiple bone metas... | Peritoneal (transcoelomic) seeding is the most likely route by which the tumor spread to the distal small bowel and colorectum, rather than hematogenous spread. | Hematogenous dissemination from gastric cancer typically produces liver metastases first because tumor emboli travel via the portal venous system; the absence of any liver or visceral metastasis in this patient argues against a hematogenous route to the bowel. Peritoneal/transcoelomic seeding, by contrast, can deposit ... | Mechanism | Short Answer | Clinical Medicine | Gastrointestinal Oncology | en | {
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q03-26549df3ee0385ff | 2026-07 | q03 | Case: A young adult male strength athlete underwent open repair of a complete pectoralis major tear 12 days after injury.
At surgery, only a small tendon remnant remained attached to the retracted muscle. Substantial tendon remained at the humeral footprint. The surgeon left this humeral-side tissue in place instead o... | The humeral-side tendon tissue was left undisturbed because mobilizing/freeing it risked further weakening the already-limited tendon and myotendinous tissue remaining on the muscle side (disrupting shared or adjacent fibers/blood supply and tension), which would have compromised the muscle-side tissue that had to carr... | The report states the humeral-side tendon material was preserved specifically because complete mobilization risked further weakening the limited tendon remaining on the muscle side, and describes extensive whipstitching of the muscle-side tendon/myotendinous tissue as the fixation strategy. Answering requires connectin... | Treatment | Short Answer | Clinical Medicine | Orthopedic Surgery / Sports Medicine | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | A young adult male strength athlete underwent open repair of a complete pectoralis major tear 12 days after injury. At surgery, only a small tendon remnant was attached to the retracted muscle, while substantial tendon remained at the humeral footprint; the surgeon chose to leave that humeral-side tendon tissue in plac... | {
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q03-4324517b48a811a6 | 2026-07 | q03 | Case: An early CT showed a pediatric intra-abdominal cystic lesion with a multivesicular internal pattern. Hydatid disease was initially favored.
Weeks later, follow-up imaging and additional serologic testing were performed. Surgical exploration eventually revealed an inflamed bowel-derived diverticulum containing an... | Two plausible negative consequences: (1) the child could have been started on unnecessary antiparasitic (antihelminthic) therapy for a disease he did not have, and (2) definitive surgical treatment of the true underlying bowel pathology could have been delayed, risking ongoing or worsening complications (e.g., divertic... | Misclassifying a bowel-related inflammatory lesion as hydatid disease risks two categories of harm: inappropriate pharmacologic treatment (antiparasitic therapy with no benefit and potential side effects) and delayed definitive management of the true surgical problem (risking progression of bowel inflammation/obstructi... | Complication | Long Answer | Clinical Medicine | Pediatric Surgery / Radiology | en | {
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q03-57fd89d0a8294272 | 2026-07 | q03 | Case: Before an emergency procedure, bedside Doppler of an ischemic hand showed a proximal ulnar artery peak systolic velocity of 25 cm/s. The procedure stopped arterial inflow into the dialysis fistula. It did not directly treat the ulnar artery or the chronically occluded proximal vein. After 24 hours, the ulnar arte... | Because the ulnar artery itself was never directly treated, yet its velocity nearly doubled after the procedure, the flow-limiting problem could not have been a fixed stenosis or thrombus within the ulnar artery — confirming it was downstream/extrinsic: elevated venous and interstitial pressure from the fistula-driven ... | Since the intervention did not touch the ulnar artery or the venous occlusion, the velocity rise after fistula ligation is a hemodynamic readout that the pretreatment flow limitation was due to elevated downstream (microvascular/venous) resistance from venous congestion, not intrinsic arterial disease — directly suppor... | Treatment Response | Short Answer | Clinical Medicine | Vascular Surgery | en | {
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q03-9c2b4a89b5f2e71d | 2026-07 | q03 | Case: A patient had a multifocal papulonodular process involving the vulva and groin. Only the two largest nodules were surgically excised. The patient was clinically disease-free 4 months after surgery, but long-term surveillance was recommended.
Question: Why is longer follow-up warranted? | Longer follow-up is warranted mainly because the excision was incomplete relative to the overall disease burden: only the two largest nodules were removed, while other, smaller lesions in the same multifocal field were left in place, and the 4-month interval is too short to exclude recurrence or growth of these residua... | The report explicitly notes that only the two largest nodules were excised, that the lesions were multifocal, and that the 4-month follow-up duration is relatively short given this multifocality, so longer surveillance is recommended to watch for recurrence at excision sites or new/enlarging lesions elsewhere in the fi... | Prognosis | Short Answer | Clinical Medicine | Dermatology | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | Two of the largest nodules from a multifocal vulvar/groin papulonodular process were surgically excised, and the patient was clinically disease-free at a follow-up examination performed 4 months after surgery. Despite this favorable short-term result, continued long-term surveillance was recommended rather than conside... | {
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q03-a39e175eadfda8ea | 2026-07 | q03 | Case: A patient developed immune-related cystitis and stage 2 acute kidney injury. High-dose methylprednisolone (200 mg/day) was started. Urinary symptoms improved within about one week, and steroids were tapered over the following weeks. The urinary symptoms resolved by about seven weeks. During the same treatment cou... | The close temporal parallel between resolution of the urinary tract (bladder/ureteral) inflammation and normalization of renal function, along with the fact that renal function recovered fully using the same corticosteroid regimen directed at the cystitis without any kidney-specific intervention, supports the AKI being... | The report explicitly notes the lack of renal biopsy limited definitive characterization of concurrent interstitial nephritis, but states the rapid response to corticosteroids and resolution of AKI alongside the urinary tract disease imply the renal injury was primarily confined to/secondary to the urinary tract proces... | Complication | Short Answer | Clinical Medicine | Nephrology / Immune-related adverse events | en | {
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"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | After a patient's immune-related cystitis and stage 2 acute kidney injury were diagnosed, high-dose methylprednisolone (200 mg/day) was started. Urinary symptoms began improving within about a week, allowing tapering over the following weeks, and all urinary symptoms had resolved by roughly seven weeks after starting s... | {
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q03-e7b18e5d67a79329 | 2026-07 | q03 | Case: A patient with dermatomyositis is scheduled for surgery. Dermatomyositis is associated with hypercoagulability and about a 16-fold higher risk of pulmonary embolism during the first year. D-dimer was 3.42 µg/ml at admission and 3.87 µg/ml on reassessment before surgery. Lower-extremity venous ultrasonography show... | Anticoagulation was not started before surgery: the D-dimer change was small and not considered clinically significant, and the venous ultrasound found no evidence of deep vein thrombosis, so there was no direct evidence of a thrombus to justify anticoagulation — particularly weighed against the added bleeding risk fro... | The discussion states the PE risk in polymyositis/DM is 16.44 times higher than the general population within the first year, and the results section reports D-dimer of 3.87 µg/ml versus 3.42 µg/ml at admission 'without a clinically significant increase' and a negative lower-extremity venous ultrasound, explicitly stat... | Complication | Long Answer | Clinical Medicine | Anesthesiology / Hematology | en | {
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"simplified_syntax",
"primary_target_only"
],
"summary": "Reorganized the clinical facts and retained the primary preoperative anticoagulation decision as the single answer target.",
"omitted_content": [
{
"content": "The re... | |
q03-fd096e353120b1e0 | 2026-07 | q03 | Case: Ibuprofen reaches peak plasma concentration within about 2 hours of ingestion. Its elimination half-life is approximately 1–3 hours, so it is expected to be almost fully cleared spontaneously within about 5–15 hours.
In a comparison case, plasma exchange began about 5 hours after admission. The serum ibuprofen l... | Because ibuprofen is cleared quickly on its own (half-life of only 1-3 hours), a delay between ingestion and starting plasma exchange allows a large fraction of the drug to already leave the plasma compartment (via hepatic metabolism and redistribution) before the procedure begins. The fractional removal achieved by pl... | This requires linking ibuprofen's short half-life/rapid spontaneous clearance to the concept that TPE's percentage removal is calculated against whatever level is present at the time of the procedure; earlier intervention preserves more drug in the removable (intravascular, still-peak) pool, so timing relative to inges... | Treatment Response | Short Answer | Clinical Medicine | Clinical Pharmacology/Toxicology | en | {
"criteria": [
{
"id": "c1",
"partial_credit": "Award 3-4/7 for a vague statement that 'earlier treatment is better' without explaining that percent removal is relative to the pre-exchange level and that spontaneous elimination shrinks that level if delayed",
"points": 7,
"requirement": "... | [
{
"page": 6,
"quote": "in Geith et al., the plasma ibuprofen level decreased 50% spontaneously from the time of admission until the start of TPE, which was a period of approximately 5 h"
},
{
"page": 6,
"quote": "Ibuprofen peaks within up to 2 h after ingestion and has a half-life ranging from 1... | [] | {
"source_id": "source_d0a26e74a289",
"pdf_sha256": "d0a26e74a2894c03dd0f574c6907e77beb65e6b637267fdca2ce257edf8ddc74",
"original_pdf_filename": "10.3390_reports9030228-1670144158.pdf",
"doi": "10.3390/reports9030228",
"doi_url": "https://doi.org/10.3390/reports9030228",
"title": "Plasma Exchange in the Set... | {
"decision": "keep",
"solver_model": "gemini-3.1-pro-preview",
"judge_model": "gemini-3.1-pro-preview",
"closed_book": {
"score": 0,
"max_score": 10,
"passing_score": 7,
"passed": false,
"criteria": [
{
"id": "c1",
"points_awarded": 0,
"met": false,
"re... | {
"record_sha256": "075ce6e8b415a9a3d5392cc703de8f3778ace8c4c2757131b7f1bbc2482ba01f",
"source_question_json_sha256": "1df896530c36427efd3e7a8aa6d5b9327f0aa2e8a3a424eb6ba2fc5bbeeb7fe5",
"source_record_path": "2026_month4567/2026-07/q03-fd096e353120b1e0/question.json",
"input_index": 2
} | {
"basis": "score >= passing_score",
"gemini_closed_book": {
"model": "gemini-3.1-pro-preview",
"score": 0,
"max_score": 10,
"passing_score": 7,
"passed": false,
"result": "wrong"
},
"opus_closed_book": {
"model": "anthropic.claude-opus-5",
"score": 0,
"max_score": 10,
"p... | {
"split": "challenge_2026_03_07",
"dataset_version": "1.3.0",
"label": "dual_model_failure",
"inclusion_reason": "all_evaluated_models_strictly_below_6",
"is_primary_dual_model_failure": true,
"linked_dual_model_failure_item_keys": [],
"primary_rule": "gemini_closed_book_score < 6 AND opus_closed_book_sc... | Ibuprofen reaches peak plasma concentration within about 2 hours of ingestion and has an elimination half-life of roughly 1-3 hours, so the drug is expected to be almost fully cleared spontaneously within about 5-15 hours (five half-lives) after ingestion. In one published case, plasma exchange was not started until th... | {
"strategy": [
"structured_comparison",
"chronological_reordering",
"direct_mechanism_question"
],
"summary": "Reorganized the pharmacokinetic information and exchange timelines into a direct comparison followed by one mechanism question.",
"omitted_content": [
{
"content": "Publication-o... |
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