data/cases.json

[
  {
    "id": "easy-workup-1",
    "task": "easy-workup",
    "chief_complaint": "A 47-year-old Caucasian woman with a history of congenital long QT syndrome Type 2, for which she has a dual‐chamber implantable cardioverter‐defibrillator (ICD) and beta‐blocker therapy, presented to",
    "history": {
      "hpi": "A 47-year-old Caucasian woman with a history of congenital long QT syndrome Type 2, for which she has a dual‐chamber implantable cardioverter‐defibrillator (ICD) and beta‐blocker therapy, presented to the emergency department after receiving an ICD shock during sleep. She arrived in an electrical storm, requiring six ICD shocks for recurrent ventricular fibrillation. Intravenous magnesium sulfate (2 g) successfully suppressed further episodes, and 10 mg of diazepam was given for anxiety. The patient denied chest pain but noted some paresthesia in both arms and the chest after the discharges. Her medical history included hypothyroidism (on levothyroxine) and depression; she smoked 25 pack‐years, had a body mass index of 26 kg/m^2, and was taking metoprolol 47.5 mg twice daily. On examination during sinus rhythm, her heart rate was 90 beats/min, blood pressure 105/66 mmHg, and cardiovascular findings were unremarkable. The initial 12‐lead ECG showed atrially triggered ventricular pacing, and despite the paced QRS complexes, there were distinct ST‐segment elevations in the inferior leads. The patient was loaded with aspirin and heparin intravenously, and primary coronary angiography w",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "blood_pressure": "105/66"
    },
    "labs": {},
    "imaging": {
      "EKG": "ECG showed atrially triggered ventricular pacing, and despite the paced QRS complexes, there were distinct ST‐segment elevations in the inferior leads."
    },
    "correct_diagnosis": "myocardial infarction",
    "icd10": "Z99.9",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "timi_nstemi",
        "inputs": {
          "age_gte_65": true,
          "gte_3_cad_risk_factors": true,
          "prior_stenosis_50": true,
          "st_deviation": true,
          "gte_2_anginal_events_24h": true,
          "aspirin_use_7d": false,
          "elevated_cardiac_markers": true
        },
        "expected": 6,
        "tolerance_pct": 0
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 76-year-old man comes to the emergency department because of an episode of seeing jagged edges followed by loss of central vision in his right eye.\n1 The episode occurred 6 hours ago and lasted approximately 5 minutes.\n2 The patient has no pain.\n3 He has a 3-month history of intermittent blurriness out of his right eye and reports a 10-minute episode of slurred speech and left-sided facial droop that occurred 2 months ago.\n4 He has hypercholesterolemia, stable angina pectoris, hypertension, and a 5-year history of type 2 diabetes mellitus.\n5 Medications include glyburide, atorvastatin, labetalol, isosorbide, lisinopril, and aspirin.\n6 He feels well.\n7 He is oriented to person, place, and time.\n8 His temperature is 37 C (98.6 F), pulse is 76/min, respirations are 12/min, and blood pressure is\n9 154/78 mm\n10 Hg.\n11 The extremities are well perfused with strong peripheral pulses.\n12 Ophthalmologic examination shows visual acuity of 20/30 in the left eye and 20/40 in the right eye.\n13 Visual fields are normal.\n14 Fundoscopic examination shows two pale spots along the supratemporal and inferotemporal arcade.\n15 Neurologic examination shows no focal findings.\n16 Cardiopulmonary examination shows systolic rumbling at the right carotid artery.\n17 The remainder of the examination shows no abnormalities.\n18 An ECG shows normal sinus rhythm with no evidence of ischemia.\n19 Echocardiography is ordered.",
    "note_error": {
      "sentence_id": "19",
      "error_sentence": "Echocardiography is ordered.",
      "correction": "Carotid duplex ultrasonography is performed.",
      "error_type": "management"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Electrical storm due to congenital LQTS Type 2 was initially considered — “Taking the patient’s history of congenital LQTS Type 2 with aborted SCD in early adulthood into account, an electrical storm due to impaired ventricular repolarization may be considered the most likely primary diagnosis.”  \n2. Myocardial infarction was suspected because of paced ECG changes — “the initial ECG showed distinct ST segment elevation following the paced QRS complex indicating acute MI.”  \n3. Myocarditis was"
  },
  {
    "id": "easy-workup-2",
    "task": "easy-workup",
    "chief_complaint": "An 81-year-old woman presented with 2 days of fever, dizziness, and weakness following a finger dog-bite three days earlier",
    "history": {
      "hpi": "An 81-year-old woman presented with 2 days of fever, dizziness, and weakness following a finger dog-bite three days earlier. She also noted nausea and vomiting. Her medical history included coronary artery disease on prasugrel, hypertension on amlodipine, ramipril, and metoprolol, and a peritonsillar abscess 6 months prior.  \n\nOn arrival: temperature 39.9°C, blood pressure 107/57 mmHg, pulse 110/min, respiratory rate 29/min, oxygen saturation 90% on 12 L by reservoir mask. Examination revealed a livid fingertip wound on the right third digit and marked mottling of both legs to the groin. Heart and lung sounds were normal.  \n\nLaboratory studies showed CRP 186.2 mg/L, creatinine 1.41 mg/dL, platelets 114 × 10^9/L, and arterial lactate 6.5 mmol/L. Chest radiograph demonstrated basal atelectasis. She was diagnosed with sepsis, received fluids and piperacillin–tazobactam, and was transferred to the ICU.  \n\nOver the next 48 hours she became anuric and required vasopressors. Repeat labs revealed hemoglobin 9.9 g/dL, platelets 24 × 10^9/L, leukocytes 21.1 × 10^9/L, total bilirubin 3.3 mg/dL, and haptoglobin 74 mg/dL. Twelve hours later platelets fell to 14 × 10^9/L and haptoglobin 37 mg/dL",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "temperature": "39.9",
      "heart_rate": "110",
      "blood_pressure": "107/57",
      "respiratory_rate": "29"
    },
    "labs": {
      "creatinine": "1.41",
      "hemoglobin": "9.9",
      "platelets": "114",
      "lactate": "6.5"
    },
    "imaging": {
      "CXR": "Chest radiograph demonstrated basal atelectasis."
    },
    "correct_diagnosis": "Capnocytophaga canimorsus sepsis",
    "icd10": "Z99.9",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "qsofa",
        "inputs": {
          "rr": 22,
          "sbp": 120,
          "ams": false
        },
        "expected": 1,
        "tolerance_pct": 0
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 2-year-old boy is brought to the physician for evaluation of pallor and increasing lethargy for 2 days.\n1 One week ago, he experienced abdominal pain, vomiting, and bloody diarrhea that have since subsided.\n2 The patient's father states that they returned early from a 6-week roadtrip in Mexico because of these symptoms.\n3 His parents have been giving him oral rehydration solution.\n4 His immunizations are up-to-date.\n5 He appears pale.\n6 His temperature is 38.4 C (101.1 F), pulse is 130/min, respirations are 35/min, and blood pressure is 95/50 mm\n7 Hg.\n8 Examination shows scleral icterus.\n9 The abdomen is soft and nontender; there is no rebound or guarding.\n10 Bowel sounds are hyperactive.\n11 The remainder of the examination shows no abnormalities.\n12 Laboratory studies show:\n13 Hemoglobin 8.5 g\n14 /dL\nMean corpuscular volume\n15 94 μm3\nLeukocyte count 18,000/\n16 mm3\nPlatelet count 45,000/mm3\n17 Prothrombin time 12 sec\n18 Partial thromboplastin time 34 sec\n19 Serum\n20 Urea nitrogen 28\n21 mg/dL\n22 Creatinine 1.6 mg/dL\n23 Bilirubin\n24 Total 2.5 mg/dL\n25 Direct\n26 0.1 mg/dL\n27 Lactate dehydrogenase 1658\n28 U/L\n29 A blood smear shows schistocytes.\n30 Diagnosis is hemolytic uremic syndrome.",
    "note_error": {
      "sentence_id": "-1",
      "error_sentence": "NA",
      "correction": "NA",
      "error_type": "NA"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. DIC was considered but deemed unlikely — “the patient scored only three points in the ISTH DIC score… Therefore, DIC was considered but not the most likely diagnosis.”  \n2. Typical HUS was unlikely — “HUS is most common following infection with Shiga toxin–producing Escherichia coli and typically accompanied by bloody diarrhea, which was missing in our case.”  \n3. Atypical HUS remained a possibility but required biopsy confirmation — “A small proportion of patients with HUS do not present wit"
  },
  {
    "id": "easy-workup-3",
    "task": "easy-workup",
    "chief_complaint": "A 59-year-old man presented with 10 days of pleuritic, band-like lower chest pain worsened by deep inspiration, accompanied by pharyngitis and odynophagia",
    "history": {
      "hpi": "A 59-year-old man presented with 10 days of pleuritic, band-like lower chest pain worsened by deep inspiration, accompanied by pharyngitis and odynophagia. He reported daily cocaine use and a 12–pack-year smoking history but denied prior lung disease, childhood asthma, sick contacts, travel, or mold/pet exposures. Vital signs were notable for no fever. Examination showed red conjunctiva, diffuse expiratory wheezes, and basilar crackles without chest wall tenderness. Urine toxicology was positive for cocaine and cannabis. Laboratory tests revealed a white-cell count of 9.2×10^3/μL with 11.8% eosinophils (absolute count 1.1×10^3/μL); HIV testing was negative. Chest radiography showed bilateral nodular opacities most prominent in mid to lower lung zones without effusion. Chest CT demonstrated innumerable nodular densities scattered throughout both lungs with surrounding ground-glass opacity (halo sign) and a 3.6×3.1 cm consolidation with air bronchograms in the left upper lobe. Infectious workup was negative, including urine Legionella, Mycoplasma pneumoniae, Aspergillus antibodies, procalcitonin, blood cultures, sputum AFB and culture. Autoimmune serologies (ANA, ANCA, anti-GBM, etc.",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "temperature": "1.1"
    },
    "labs": {},
    "imaging": {
      "CXR": "Chest radiography showed bilateral nodular opacities most prominent in mid to lower lung zones without effusion.",
      "ECHO": "ttered throughout both lungs with surrounding ground-glass opacity (halo sign) and a 3."
    },
    "correct_diagnosis": "Cocaine-induced eosinophilic pneumonia",
    "icd10": "Z99.9",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 138.0,
          "cl": 102.0,
          "bicarb": 24.0
        },
        "expected": 12.0,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 55-year-old man comes to the physician because of a 4-month history of episodic, pressure-like chest pain.\n1 The chest pain occurs when he is walking up stairs and improves with rest.\n2 He has hypertension and type 2 diabetes mellitus.\n3 His father died from a myocardial infarction at the age of 50 years.\n4 Current medications include hydrochlorothiazide and metformin.\n5 His pulse is 85/min, respirations are 12/min, and blood pressure is 140/90 mm\n6 Hg.\n7 Cardiac examination shows normal heart sounds without any murmurs, rubs, or gallops.\n8 An ECG shows high amplitude of the S wave in lead V3.\n9 An exercise stress test is performed but stopped after 4 minutes because the patient experiences chest pain.\n10 Dilitiazem is started after an ECG obtained during the stress test shows sinus tachycardia and ST-segment depressions in leads V1–V4.",
    "note_error": {
      "sentence_id": "10",
      "error_sentence": "Dilitiazem is started after an ECG obtained during the stress test shows sinus tachycardia and ST-segment depressions in leads V1–V4.",
      "correction": "Metoprolol is started after an ECG obtained during the stress test shows sinus tachycardia and ST-segment depressions in leads V1–V4.",
      "error_type": "pharmacotherapy"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Infectious pneumonia — “Urine Legionella, M. Pneumonia, and Aspergillus antibodies were negative...Blood cultures revealed no growth after 5 days.”  \n2. Hypersensitivity pneumonitis — “The patient reported having no pets or birds or mold in his apartment.”  \n3. Eosinophilic granulomatosis with polyangiitis — “He had no history of lung disease and denied childhood asthma...ANCA...were all negative.”  \n4. Idiopathic acute eosinophilic pneumonia — “Patients who have idiopathic acute eosinophilic"
  },
  {
    "id": "medium-differential-1",
    "task": "medium-differential",
    "chief_complaint": "A 46-year-old man presented with acute onset of dyspnea, chest pain, and near syncope",
    "history": {
      "hpi": "A 46-year-old man presented with acute onset of dyspnea, chest pain, and near syncope. Three weeks earlier, he had undergone liver transplantation complicated by heart failure requiring an intra-aortic balloon pump, renal failure requiring hemodialysis, and prolonged ventilation requiring tracheostomy. At the time of presentation, his heart failure had resolved with normal biventricular function; he no longer required dialysis and was stable on a tracheostomy collar.\n\nOn examination, he was normotensive, tachypneic at 30 breaths/min, tachycardic at 120 beats/min, and had worsened hypoxia. The electrocardiogram was unremarkable.\n\nHis past medical history was notable for alcoholic cirrhosis. The differential diagnosis included pulmonary embolism, heart failure, and hospital-acquired pneumonia.\n\nInvestigations:\n• Computed tomography angiography revealed filling defects in the proximal right pulmonary artery and the main left pulmonary artery, with an RV-to-LV diameter ratio of 1.8:1, consistent with pulmonary embolism and RV strain.  \n• Transthoracic echocardiography confirmed RV dilation (RV/LV ratio, 1.6:1), severely reduced RV function, and preserved LV function.  \n• Troponin I was",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "temperature": "30"
    },
    "labs": {},
    "imaging": {
      "EKG": "electrocardiogram was unremarkable.",
      "ECHO": "echocardiography confirmed RV dilation (RV/LV ratio, 1."
    },
    "correct_diagnosis": "Pulmonary embolism",
    "icd10": "I26.99",
    "diagnosis_synonyms": [
      "pe",
      "acute pe",
      "pulmonary thromboembolism"
    ],
    "required_calculations": [
      {
        "formula": "wells_pe",
        "inputs": {
          "dvt_symptoms": false,
          "alt_dx_less_likely": true,
          "hr_gt_100": true,
          "immobilisation": false,
          "prior_dvt_pe": false,
          "hemoptysis": false,
          "malignancy": false
        },
        "expected": 4.5,
        "tolerance_pct": 20
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A previously healthy 61-year-old man comes to the physician because of a 3-month history of intermittent fever, easy fatiguability, and a 4.4-kg (9.7-lb) weight loss.\n1 Physical examination shows conjunctival pallor.\n2 The spleen is palpated 5 cm below the left costal margin.\n3 Laboratory studies show a leukocyte count of 75,300/mm3 with increased basophils, a platelet count of 455,000/mm3, and a decreased leukocyte alkaline phosphatase score.\n4 Patient was diagnosed with acute promyelocytic leukemia after a peripheral blood smear showed increased numbers of promyelocytes, myelocytes, and metamyelocytes.",
    "note_error": {
      "sentence_id": "4",
      "error_sentence": "Patient was diagnosed with acute promyelocytic leukemia after a peripheral blood smear showed increased numbers of promyelocytes, myelocytes, and metamyelocytes.",
      "correction": "Patient was diagnosed with chronic myeloid leukemia after a peripheral blood smear showed increased numbers of promyelocytes, myelocytes, and metamyelocytes.",
      "error_type": "diagnosis"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Pulmonary embolism was supported by imaging evidence of vascular obstruction and RV strain — “Computed tomography (CT) angiography (CTA) revealed filling defects of the proximal right pulmonary artery (RPA) and the main left pulmonary artery (LPA), as well as a right ventricular (RV)–to–left ventricular (LV) diameter ratio of 1.8:1 consistent with PE with RV strain.”  \n2. Heart failure was considered but excluded by prior resolution of cardiac dysfunction and preserved LV function on echo — “"
  },
  {
    "id": "medium-differential-2",
    "task": "medium-differential",
    "chief_complaint": "A 78-year-old man was admitted with three days of diffuse abdominal pain, obstipation, nausea, and vomiting",
    "history": {
      "hpi": "A 78-year-old man was admitted with three days of diffuse abdominal pain, obstipation, nausea, and vomiting. He had no significant medical history. On examination, his temperature was 37.2 °C, pulse 88 beats/min, blood pressure 130/75 mm Hg, and respiratory rate 18 breaths/min. His abdomen was distended and diffusely tender, without peritoneal signs. Laboratory tests showed WBC 5560/mm3, hemoglobin 11.8 g/dL, platelets 252 000/mm3, glucose 99 mg/dL, AST 15 U/L, ALT 15 U/L, creatinine 1.17 mg/dL, and urea 40 mg/dL. \nAbdominal radiography demonstrated hydroaerial levels in the right abdomen and hypogastrium. Ultrasound noted marked aerocolia in the colon but no free fluid. Contrast-enhanced CT scan of the abdomen and pelvis revealed marked distension of small and large bowel with pneumatosis up to the hepatic flexure, where a 10 mm focal thickening of the bowel wall was noted. A clinical diagnosis of large-bowel obstruction due to a stenosing colonic lesion was made. \nAn emergency laparotomy identified a firm, stenosing mass at the hepatic flexure causing obstruction. A right hemicolectomy with ileotransverse anastomosis was performed, and the specimen was sent for histopathological",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "temperature": "15",
      "heart_rate": "88",
      "blood_pressure": "130/75",
      "respiratory_rate": "18"
    },
    "labs": {
      "creatinine": "1.17",
      "glucose": "99",
      "wbc": "5560",
      "hemoglobin": "11.8",
      "platelets": "252"
    },
    "imaging": {
      "ECHO": "tted with three days of diffuse abdominal pain, obstipation, nausea, and vomiting."
    },
    "correct_diagnosis": "Malakoplakia",
    "icd10": "Z99.9",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "fena",
        "inputs": {
          "ucr": 120.0,
          "pcr": 1.17,
          "una": 20.0,
          "pna": 138.0
        },
        "expected": 0.14,
        "tolerance_pct": 10
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 Twelve hours after delivery a 2700-g (5-lb 15-oz)\n1 male newborn has 3 episodes of bilious vomiting.\n2 He was born at 36 weeks' gestation to a 27-year-old woman.\n3 Pregnancy was complicated by polyhydramnios.\n4 The mother has smoked one half-pack of cigarettes daily and has a history of intravenous cocaine use.\n5 Vital signs are within normal limits.\n6 Examination shows a distended upper abdomen.\n7 Bowel sounds are hypoactive.\n8 After reviewing imaging, the newborn was diagnosed with duodenal atresia.\n9 An x-ray of the abdomen showed 3 gas shadows in the upper abdomen with a gasless distal abdomen.",
    "note_error": {
      "sentence_id": "8",
      "error_sentence": "After reviewing imaging, the newborn was diagnosed with duodenal atresia.",
      "correction": "After reviewing imaging, the newborn was diagnosed with jejunal atresia.",
      "error_type": "diagnosis"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Colorectal adenocarcinoma was suspected given the patient’s age and a stenosing mass on imaging — “stenosing mass located in the hepatic angle of the ascending colon” — but was excluded because “no invasive dysplastic or neoplastic stigmata were identified.”  \n2. Miliary tuberculosis was considered in the macroscopic differential of granulomatous colonic lesions but was excluded as “Neither areas of necrosis, nor viable microorganisms were detected.”  \n3. Crohn’s disease was part of the macro"
  },
  {
    "id": "medium-differential-3",
    "task": "medium-differential",
    "chief_complaint": "A 39-year-old previously healthy man was admitted after a high-impact fall from a forklift with an axial load injury to his cranium",
    "history": {
      "hpi": "A 39-year-old previously healthy man was admitted after a high-impact fall from a forklift with an axial load injury to his cranium. In the emergency department, he was alert (Glasgow Coma Scale 15), protecting his airway, and had normal vital signs. He had a scalp laceration without active bleeding, bilaterally clear lung fields, and no chest wall trauma. A focused assessment with sonography in trauma examination was negative. CT scans of the head, thoracic spine, and lumbar spine were unremarkable. Cervical CT showed a superior endplate fracture at C7, and MRI revealed an acute traumatic disc herniation at C7 with cortical degeneration; CT angiography of the neck showed no vascular injury.\n\nOn neurologic examination, he had loss of sensation below the nipple line, loss of motor function in both lower extremities, and absent rectal tone. Upper extremity strength was full on the right and mildly decreased on the left. He had no thoracic or lumbar spine step-offs.\n\nHe underwent C6–C7 anterior cervical discectomy and fusion, C6–C7 laminectomy, and C4–T2 posterior instrumented fusion, plus closure of the scalp laceration. Postoperatively in the ICU, he was started on phenylephrine to",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "note": "See HPI for vitals"
    },
    "labs": {},
    "imaging": {
      "CXR": "chest x-ray showed perihilar infiltrates; he received furosemide and required high-flow nasal cannula support.",
      "ECHO": "tted after a high-impact fall from a forklift with an axial load injury to his cranium."
    },
    "correct_diagnosis": "vasopressin-induced hyponatremia",
    "icd10": "Z99.9",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 138.0,
          "cl": 102.0,
          "bicarb": 24.0
        },
        "expected": 12.0,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 45-year-old man comes to the physician because of intermittent lower back pain for 1 week.\n1 His symptoms began shortly after lifting heavy boxes at work.\n2 He has not had any fever, chills, or weight loss.\n3 He has a history of peptic ulcer disease.\n4 Ibuprofen was prescribed.\n5 He does not smoke or drink alcohol.\n6 His vital signs are within normal limits.\n7 Examination shows mild paraspinal lumbar tenderness.\n8 Neurologic examination shows no focal findings.\n9 An x-ray of the spine shows no abnormalities.",
    "note_error": {
      "sentence_id": "4",
      "error_sentence": "Ibuprofen was prescribed.",
      "correction": "Acetaminophen was prescribed.",
      "error_type": "pharmacotherapy"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Hyperglycemia-induced hyponatremia was excluded because “blood glucose was within the normal range, noted as 110 mg/dL during the onset of hyponatremia, which concluded that hyperglycemia was not present.”  \n2. Pseudohyponatremia was excluded because “neither hyperlipidemia nor hyperproteinemia were suspected as the serum was not lipemic, the patient did not exhibit jaundice, or have a history of plasma cell dyscrasia.”  \n3. Hypovolemic hyponatremia was deemed unlikely as “his euvolemic statu"
  },
  {
    "id": "medium-differential-4",
    "task": "medium-differential",
    "chief_complaint": "A 50‐year‐old man of Indian ancestry with a 3‐year history of multiple myeloma presented with progressive abdominal and lower‐extremity edema and dyspnea",
    "history": {
      "hpi": "A 50‐year‐old man of Indian ancestry with a 3‐year history of multiple myeloma presented with progressive abdominal and lower‐extremity edema and dyspnea. He reported a 15‐lb weight gain over 2 weeks. His only other chronic condition was mild hypertension. His myeloma had advanced despite corticosteroids, cyclophosphamide, etoposide, cisplatin, stem‐cell transplant, thalidomide, and bortezomib.\n\nOn examination, he was afebrile, heart rate 100/min, blood pressure 97/50 mm Hg, and oxygen saturation 96% on 3 L/min nasal oxygen. He had bilateral basal crackles, jugular venous distension to 12 cm, a 2/6 systolic flow murmur at the left upper sternal border, distended abdomen with shifting dullness, a liver edge 4 cm below the costal margin, warm extremities, and 3+ bilateral pitting edema with scrotal swelling.\n\nLaboratory studies showed hemoglobin 9.1 g/dL, platelets 10,000/µL, blood urea nitrogen 55 mg/dL, creatinine 1.0 mg/dL, albumin 3.6 g/dL, and calcium 13 mg/dL. ECG showed sinus tachycardia with normal voltage and diffuse T‐wave flattening. Chest radiograph revealed mild cardiomegaly and pulmonary edema. Echocardiography demonstrated a hyperdynamic left ventricle with normal wall",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "heart_rate": "100",
      "blood_pressure": "97/50"
    },
    "labs": {
      "creatinine": "1.0",
      "hemoglobin": "9.1",
      "platelets": "10"
    },
    "imaging": {
      "CXR": "Chest radiograph revealed mild cardiomegaly and pulmonary edema.",
      "EKG": "ECG showed sinus tachycardia with normal voltage and diffuse T‐wave flattening.",
      "ECHO": "ttening."
    },
    "correct_diagnosis": "High-output heart failure",
    "icd10": "Z99.9",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 138.0,
          "cl": 102.0,
          "bicarb": 24.0
        },
        "expected": 12.0,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 An otherwise healthy 10-day-old boy is brought to the physician by his parents because of progressively enlarging breasts bilaterally for the last 4 days.\n1 The parents report that they have sometimes noticed a discharge of small quantities of a white liquid from the left breast since yesterday.\n2 During pregnancy, the mother was diagnosed with hypothyroidism and was treated with L-thyroxine.\n3 The patient's maternal grandmother died of breast cancer.\n4 The patient currently weighs 3100-g (6.8-lb) and is 51 cm (20 in) in length.\n5 Vital signs are within normal limits.\n6 Based on exam, labs were ordered to measure serum gonadotropin levels.\n7 Examination showed symmetrically enlarged, nontender breasts, with bilaterally inverted nipples.\n8 The remainder of the examination showed no abnormalities.",
    "note_error": {
      "sentence_id": "6",
      "error_sentence": "Based on exam, labs were ordered to measure serum gonadotropin levels.",
      "correction": "Based on exam, reassurance is provided.",
      "error_type": "management"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Systemic amyloidosis was considered but excluded by echocardiographic findings — “When new onset heart failure is seen in the setting of multiple myeloma, systemic amyloidosis with light chain deposition in the myocardium is often at the top of the differential diagnosis … echocardiogram conveyed a hyperdynamic left ventricle with normal wall thickness, no regional wall motion abnormalities and normal diastolic function.”\n2. Former drug therapies and underlying ischemia were considered but ca"
  },
  {
    "id": "medium-differential-5",
    "task": "medium-differential",
    "chief_complaint": "An 8-year-old neutered male domestic shorthair cat was referred for acute-onset paraplegia of less than 12 hours’ duration",
    "history": {
      "hpi": "An 8-year-old neutered male domestic shorthair cat was referred for acute-onset paraplegia of less than 12 hours’ duration. History included hyperthyroidism diagnosed 20 months earlier (elevated total T4), chronic systemic hypertension, and ataxia; management comprised carbimazole, unilateral thyroidectomy, atenolol, and later amlodipine with recurrent elevated urea, phosphorus, and total T4.\n\nFourteen months after thyroidectomy, the cat had an ataxic gait, gallop rhythm, weight loss, and blood pressure of 208/140 mmHg. Ophthalmic examination then revealed bilateral mydriasis, pupillary reflexes present, bilateral retinal hemorrhage, and left retinal detachment.\n\nAt presentation for paraplegia: mental status was depressed; cranial nerves were intact except for absent bilateral menace responses with partially preserved vision; flaccid paraplegia with absent pelvic limb nociception and reflexes; absent cutaneous trunci reflex caudal to the thoracolumbar junction; normal thoracic limb reflexes; absent anal tone and perineal reflexes; overflow urinary incontinence; no tail movement or nociception. Neurolocalisation was multifocal (forebrain, thoracolumbar, lumbosacral). Differentials i",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "temperature": "24.8"
    },
    "labs": {
      "potassium": "2.6",
      "chloride": "130"
    },
    "imaging": {
      "ECHO": "teen months after thyroidectomy, the cat had an ataxic gait, gallop rhythm, weight loss, and blood pressure of 208/140 mmHg."
    },
    "correct_diagnosis": "hypertensive myelopathy",
    "icd10": "Z99.9",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 138.0,
          "cl": 130.0,
          "bicarb": 24.0
        },
        "expected": -16.0,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 2-day old male newborn delivered vaginally at 36 weeks to a 29-year-old woman, gravida 3, para 2, has generalized convulsions lasting 2 minutes.\n1 Previous to the event, he had difficulty feeding and was lethargic.\n2 Pregnancy and delivery were uncomplicated.\n3 Apgar scores were 7 and 8 at 1 and 5 minutes, respectively.\n4 Pregnancy and delivery of the mother's first 2 children were also uncomplicated.\n5 Medications of the mother include folic acid and a multivitamin.\n6 The mother's immunizations are up-to-date.\n7 The infant appears icteric.\n8 His vital signs are within normal limits.\n9 The infant's weight and length are at the 5th percentile, and his head circumference at the 99th percentile for gestational age.\n10 There are several purpura of the skin.\n11 Ocular examination shows posterior uveitis.\n12 Suspected of congenital CMV infection.\n13 The patient does not pass his auditory screening tests.\n14 Cranial ultrasonography shows ventricular dilatation, as well as hyperechoic foci within the cortex, basal ganglia, and periventricular region.",
    "note_error": {
      "sentence_id": "12",
      "error_sentence": "Suspected of congenital CMV infection.",
      "correction": "Suspected of congenital toxoplasmosis.",
      "error_type": "diagnosis"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Edema was considered as a cause of the MRI lesion — “Differential diagnoses for the MRI findings included oedema…”  \n2. Intramedullary hemorrhage was considered as a cause of the MRI lesion — “…haemorrhage…”  \n3. Inflammation or infection was considered given the imaging appearance — “…inflammation/infection…”  \n4. Neoplasia was considered given an ill-defined spinal cord lesion — “…neoplasia…”  \n5. Haemorrhagic myelomalacia was suspected based on the acute neuro progression and MRI features "
  },
  {
    "id": "hard-deceptive-1",
    "task": "hard-deceptive",
    "chief_complaint": "A 57-year-old woman was brought to the emergency department with altered mental status, nausea, vomiting, and abdominal pain",
    "history": {
      "hpi": "A 57-year-old woman was brought to the emergency department with altered mental status, nausea, vomiting, and abdominal pain. Two days earlier, she had developed intermittent dull epigastric pain that progressed on the day of presentation to severe persistent pain with nonbilious vomiting. She became somnolent and tachypneic.\n\nHer medical history was significant for diabetes mellitus managed with insulin monotherapy; family members reported that she had been noncompliant with insulin for several weeks. On arrival, temperature was 37.0 °C, pulse 120/min, blood pressure 134/78 mmHg, respiratory rate 24/min, and oxygen saturation 95% on 2 L nasal cannula. On examination, she was obtunded and did not respond to deep sternal rub, had dry oral mucosa, and a weak gag reflex. Pulmonary and cardiovascular examinations were unremarkable.\n\nArterial blood gas revealed pH 7.02, PaCO2 14 mmHg, PaO2 134 mmHg, calculated bicarbonate 4 mEq/L, and oxygen saturation 97%. Serum chemistries showed sodium 137 mEq/L, potassium 4.4 mEq/L, chloride 82 mEq/L, bicarbonate <10 mEq/L, blood urea nitrogen 32 mg/dL, creatinine 2.84 mg/dL, glucose 172 mg/dL, measured anion gap 46 mEq/L, and measured osmolality 32",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "heart_rate": "120",
      "blood_pressure": "134/78",
      "respiratory_rate": "24"
    },
    "labs": {
      "sodium": "137",
      "potassium": "4.4",
      "bicarbonate": "4",
      "chloride": "82",
      "creatinine": "2.84",
      "glucose": "172",
      "ph": "7.02"
    },
    "imaging": {
      "CXR": "Chest radiograph was unremarkable.",
      "ECHO": "ttent dull epigastric pain that progressed on the day of presentation to severe persistent pain with nonbilious vomiting."
    },
    "correct_diagnosis": "euglycemic diabetic ketoacidosis",
    "icd10": "E13.10",
    "diagnosis_synonyms": [
      "euglycemic dka",
      "edka"
    ],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 137.0,
          "cl": 82.0,
          "bicarb": 4.0
        },
        "expected": 51.0,
        "tolerance_pct": 5
      },
      {
        "formula": "corrected_sodium",
        "inputs": {
          "na": 137.0,
          "glucose": 172.0
        },
        "expected": 138.2,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 65-year-old woman comes to the physician because of a 2-month history of intermittent bleeding from her vagina.\n1 She has no history of serious illness and takes no medications.\n2 Patient was diagnosed with a serous cystadenocarcinoma based on the following findings.\n3 Pelvic ultrasound showed a thickened endometrial stripe and a left adnexal mass.\n4 Endometrial biopsy showed a well-differentiated adenocarcinoma.\n5 Laboratory studies showed increased levels of inhibin B.",
    "note_error": {
      "sentence_id": "2",
      "error_sentence": "Patient was diagnosed with a serous cystadenocarcinoma based on the following findings.",
      "correction": "Patient was diagnosed with a granulosa cell tumor based on the following findings.",
      "error_type": "diagnosis"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Toxic alcohol ingestion was considered due to the high anion-gap metabolic acidosis but excluded because “serum ethanol, methanol, ethylene glycol, and propylene glycol were undetectable on admission labs…”  \n2. Alcoholic ketoacidosis was considered given ketonemia and acidosis but excluded by the absence of ethanol in serum “serum ethanol … were undetectable on admission labs…”  \n3. Starvation ketoacidosis was considered given her poor oral intake but excluded because “The serum bicarbonate "
  },
  {
    "id": "hard-deceptive-2",
    "task": "hard-deceptive",
    "chief_complaint": "A 68‐year‐old man who heated his home by burning wood or coal was found 16 days earlier unconscious in his room, with vomit and incontinence; the stove had gone out",
    "history": {
      "hpi": "A 68‐year‐old man who heated his home by burning wood or coal was found 16 days earlier unconscious in his room, with vomit and incontinence; the stove had gone out. He regained alertness and complained of left‐sided weakness; a local hospital brain CT was reportedly unremarkable and he was treated with antiplatelet agents and a statin for presumed cerebral infarction. Two days before transfer, he became slow to respond and refused to eat, and he was admitted to our hospital. His history included untreated prostatic hyperplasia and a 40‐year history of heavy alcohol use. On admission, blood pressure was 140/90 mmHg. He was apathetic with memory loss; his left nasolabial fold was shallow, but there were no other focal neurologic signs. On hospital day 3 he developed worsening cognitive impairment, including language, memory, and spatial‐orientation deficits; his tongue deviated slightly to the right, and right lower‐extremity strength was proximally grade 4+, distally grade 3. Emergency brain CT and electrocardiography remained normal. Comprehensive laboratory evaluation, including arterial carboxyhemoglobin, metabolic panels, infectious and autoimmune studies, and cerebrospinal flu",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "note": "See HPI for vitals"
    },
    "labs": {},
    "imaging": {
      "ECHO": "tted to our hospital."
    },
    "correct_diagnosis": "Delayed encephalopathy after acute carbon monoxide poisoning",
    "icd10": "Z99.9",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 138.0,
          "cl": 102.0,
          "bicarb": 24.0
        },
        "expected": 12.0,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 70-year-old man comes to the emergency department because of severe lower back pain for 3 weeks.\n1 The pain was initially exacerbated by activity but now presents also at rest.\n2 The patient has not had a headache or a cough.\n3 He reports no changes in bowel movements or urination.\n4 He has type 2 diabetes mellitus and hypertension.\n5 He does not smoke or drink alcohol.\n6 His current medications include metformin and lisinopril.\n7 His temperature is 37.8 C (100 F), pulse is 86/min, and blood pressure is 134/92 mm\n8 Hg.\n9 Examination shows tenderness over the spinous processes of the second and third lumbar vertebrae with significant paraspinal spasm.\n10 Skeletal scintigraphy was obtained.\n11 The remainder of the examination shows no abnormalities.\n12 Laboratory studies show:\n\n13 Hemoglobin 14\n14 g/dL\n\n15 Leukocyte count 10,800\n16 /mm3\n\n17 Erythrocyte sedimentation rate 75 mm/h\n\n18 CRP 82 mg/L (N = 0–10 mg/L)\n\n19 Serum\nCa2\n20 + 9.6 mg/dL\n\n21 Urea nitrogen\n22 22 mg/dL\n\n23 Glucose 216 mg/dL\n\n24 Creatinine 1.1 mg/dL\n\n25 Albumin 3.7\n26 g/dL\n\n27 Alkaline phosphatase\n28 55 U/L\n\n29 An x-ray of the lumbar spine shows bone destruction, sequestrum formation, and periosteal reactions along the second and third lumbar vertebrae.\n30 An MRI of the lumbar spine shows increased T2 signals within the second and third lumbar vertebrae without signs of epidural abscess.\n31 A blood culture is taken and he is started on appropriate analgesia.",
    "note_error": {
      "sentence_id": "10",
      "error_sentence": "Skeletal scintigraphy was obtained.",
      "correction": "CT-guided biopsy was scheduled.",
      "error_type": "management"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Cerebral infarction — “He was diagnosed with a cerebral infarction and treated with antiplatelets and statin.”  \n   Excluded by “No obvious abnormalities were revealed during his emergency brain CT and electrocardiography.”  \n2. Ischemic stroke of the cerebral peduncles — considered because DWI/ADC changes can indicate infarction in posterior circulation — “Especially it needs to be distinguished from ischemic stroke when high signals are present on DWI while low signals occur in ADC.”  \n3. D"
  },
  {
    "id": "hard-deceptive-3",
    "task": "hard-deceptive",
    "chief_complaint": "A 43-year-old previously healthy man of Sephardic-Jewish descent presented with sudden-onset chest pain and exertional dyspnea that began that morning, following a week of anorexia and diarrhea which",
    "history": {
      "hpi": "A 43-year-old previously healthy man of Sephardic-Jewish descent presented with sudden-onset chest pain and exertional dyspnea that began that morning, following a week of anorexia and diarrhea which had resolved one day earlier. In the emergency department, he was diagnosed with acute pulmonary embolism with a saddle embolus, large bilateral thrombotic burden, right ventricular (RV) systolic dysfunction, and mildly elevated serum troponin levels. He was admitted to the cardiac intensive care unit and started on therapeutic unfractionated heparin. Over the next several days, serial echocardiograms showed further deterioration of RV function, and he was transferred to a tertiary center. On arrival, he was asymptomatic with stable vital signs. Laboratory tests showed normal renal function, normal high-sensitivity troponin I, and normal lactate. Physical examination was notable only for jugular venous distention. Electrocardiography demonstrated normal sinus rhythm, a normal QRS axis, and T-wave inversion in leads V1–V4. Transthoracic echocardiography revealed a dilated RV with moderately reduced systolic function and an estimated systolic pulmonary artery pressure of 50 mmHg. The fol",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "temperature": "88"
    },
    "labs": {},
    "imaging": {
      "ECHO": "tted to the cardiac intensive care unit and started on therapeutic unfractionated heparin."
    },
    "correct_diagnosis": "Heparin-induced thrombocytopenia",
    "icd10": "T45.515A",
    "diagnosis_synonyms": [
      "hit",
      "hit type 2",
      "heparin induced thrombocytopenia"
    ],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 138.0,
          "cl": 102.0,
          "bicarb": 24.0
        },
        "expected": 12.0,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 39-year-old man comes to the physician because of frequent urination for the past 2 months.\n1 He has been urinating 10–12 times during the day and 3–4 times during the night.\n2 He says he is drinking a lot of water to compensate for any dehydration.\n3 He has no history of serious illness and takes no medications.\n4 Vital signs are within normal limits.\n5 Physical examination shows no abnormalities.\n6 He is concerned he may have diabetes mellitus like his parents.\n7 Laboratory studies show:\n\n8 Hemoglobin 14.3 g\n9 /dL\n\n10 Serum\n\n11 Na+ 149 mEq/L\nK+ 3.9 mEq/\n12 L\nCl-\n13 102 mEq/\n14 L\n\n15 Glucose 90 mg/dL\n\n16 Osmolality 306 mOsmol/kg\n17 H2O\n\n18 Urine\nOsmolality 210 mOsmol/\n19 kg\n20 H2O\n\n21 A water deprivation test is conducted.\n22 After 2 hours of fluid restriction, his plasma osmolality is 315 mOsmol/kg H2O and his urine osmolality is 210 mOsmol/kg H2O. One hour after an ADH analog injection, his plasma osmolality is 276 mOsmol/kg H2O and his urine osmolality is 425 mOsmol/kg H2O. Hydrochlorothiazide therapy is recommended.",
    "note_error": {
      "sentence_id": "22",
      "error_sentence": "After 2 hours of fluid restriction, his plasma osmolality is 315 mOsmol/kg H2O and his urine osmolality is 210 mOsmol/kg H2O. One hour after an ADH analog injection, his plasma osmolality is 276 mOsmol/kg H2O and his urine osmolality is 425 mOsmol/kg H2O. Hydrochlorothiazide therapy is recommended. \n",
      "correction": "After 2 hours of fluid restriction, his plasma osmolality is 315 mOsmol/kg H2O and his urine osmolality is 210 mOsmol/kg H2O. One hour after an ADH analog injection, his plasma osmolality is 276 mOsmol/kg H2O and his urine osmolality is 425 mOsmol/kg H2O. Desmopressin therapy is recommended. \n",
      "error_type": "management"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Heparin-induced thrombocytopenia was suspected because of the temporal relationship with heparin exposure and a drop in platelet levels meeting the 4Ts score criteria — “This meant that the patient met the more minor platelet-level criteria for HIT… as well as fulfilling the other three criteria of the 4 t’s score for HIT for a total of 6 points, which is classified as high probability.”  \n2. Antiphospholipid syndrome was considered but excluded because anticardiolipin and related antibodies "
  },
  {
    "id": "hard-deceptive-4",
    "task": "hard-deceptive",
    "chief_complaint": "An 87-year-old woman presented to the emergency department with acute, intense thoracic pain radiating to her back and upper abdomen, accompanied by nausea, dyspnea, sweating, and a hypertensive spike",
    "history": {
      "hpi": "An 87-year-old woman presented to the emergency department with acute, intense thoracic pain radiating to her back and upper abdomen, accompanied by nausea, dyspnea, sweating, and a hypertensive spike. Her history included hypertension and prior hip arthroplasty complicated by pulmonary embolism, for which she received temporary anticoagulation and then daily aspirin with cilostazol. On examination, her chest radiograph showed an enlarged mediastinum. Despite morphine and nitroglycerin, her pain persisted but she remained hemodynamically stable. Cardiac enzymes and electrocardiogram were normal, and the D-dimer was elevated at 8.02 μg/mL. CT angiography of the chest demonstrated ectasia of the ascending aorta (4.0 cm), an aneurysm of the descending aorta with mural thrombus, and mediastinal fluid, without evidence of pulmonary embolism. Echocardiography revealed mild aortic insufficiency. She was admitted to the ICU and managed conservatively.\n\nThree days later, she developed severe epigastric pain and hematemesis; her hemoglobin fell from 11.9 g/dL to 7.9 g/dL, and she became hypotensive (80/40 mm Hg) and tachycardic (113 bpm). She was made NPO, received IV fluids, blood transfusi",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "temperature": "8.02"
    },
    "labs": {},
    "imaging": {
      "CXR": "chest radiograph showed an enlarged mediastinum.",
      "EKG": "electrocardiogram were normal, and the D-dimer was elevated at 8.",
      "ECHO": "Echocardiography revealed mild aortic insufficiency."
    },
    "correct_diagnosis": "aortic dissection",
    "icd10": "I71.00",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 138.0,
          "cl": 102.0,
          "bicarb": 24.0
        },
        "expected": 12.0,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 53-year-old woman comes to the physician because of a 3-month history of intermittent severe left neck, shoulder, and arm pain and paresthesias of the left hand.\n1 The pain radiates to the radial aspect of her left forearm, thumb, and index finger.\n2 She first noticed her symptoms after helping a friend set up a canopy tent.\n3 There is no family history of serious illness.\n4 She appears healthy.\n5 Vital signs are within normal limits.\n6 When the patient extends and rotates her head to the left and downward pressure is applied, she reports paresthesias along the radial aspect of her left forearm and thumb.\n7 There is weakness when extending the left wrist against resistance.\n8 The brachioradialis reflex is 1+ on the left and 2+ on the right.\n9 The radial pulse is palpable bilaterally.\n10 The remainder of the examination shows no abnormalities.\n11 Diagnosis is thoracic outlet syndrome.",
    "note_error": {
      "sentence_id": "11",
      "error_sentence": "Diagnosis is thoracic outlet syndrome.",
      "correction": "Diagnosis is C5-C6 disc herniation.",
      "error_type": "diagnosis"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Intramural neoplasia was considered because of the subepithelial mass on endoscopy, but CT density and appearance favored a hematoma over a solid tumor — “CTA…showed a slightly hyperdense wall thickening of the corpus (4.0 cm) and fundus (2.5 cm), a small amount of blood compatible material in the lumen and perigastric adipose tissue hyperdensity.”  \n2. Dissecting visceral aneurysm was considered as a source of intramural bleeding, but angiography demonstrated no contrast extravasation or vis"
  },
  {
    "id": "hard-deceptive-5",
    "task": "hard-deceptive",
    "chief_complaint": "A 27-year-old, 68-kg man with multiple endocrine neoplasia type IIb—manifested by metastatic medullary thyroid carcinoma and pheochromocytomas—presented for excision of a vocal cord neuroma",
    "history": {
      "hpi": "A 27-year-old, 68-kg man with multiple endocrine neoplasia type IIb—manifested by metastatic medullary thyroid carcinoma and pheochromocytomas—presented for excision of a vocal cord neuroma. He had no cardiac history and reported good exercise tolerance. Surgical history included bilateral adrenalectomies five years earlier and total thyroidectomy. Medications were hydrocortisone 15 mg in the morning and 10 mg in the evening, fludrocortisone 0.05 mg daily, and levothyroxine 137 µg daily; he took his usual thyroid and steroid replacement on the morning of surgery. Preoperative vital signs showed a heart rate of 106 bpm and blood pressure of 115/68 mmHg; other vitals and laboratory results were within normal limits.\n\nAfter placement of standard monitors, anesthesia was induced with propofol 120 mg, rocuronium 50 mg, and fentanyl 75 µg. A 5.5-mm laser endotracheal tube was inserted under C-MAC guidance to avoid trauma to mucosal neuromas. Dexamethasone 10 mg IV was administered for prophylaxis against airway edema and postoperative nausea. Ten minutes after incision, the patient developed persistent hypotension—systolic blood pressure < 70 mmHg and mean arterial pressure < 50 mmHg for",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "note": "See HPI for vitals"
    },
    "labs": {},
    "imaging": {},
    "correct_diagnosis": "Primary adrenal insufficiency",
    "icd10": "E27.1",
    "diagnosis_synonyms": [
      "adrenal insufficiency",
      "addison's disease"
    ],
    "required_calculations": [
      {
        "formula": "fena",
        "inputs": {
          "ucr": 120.0,
          "pcr": 1.5,
          "una": 20.0,
          "pna": 138.0
        },
        "expected": 0.18,
        "tolerance_pct": 10
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A previously healthy 20-year-old woman comes to her physician because of pain during sexual intercourse.\n1 She recently became sexually active with her boyfriend.\n2 She has had no other sexual partners.\n3 She is frustrated because she has consistently been experiencing a severe, sharp vaginal pain on penetration.\n4 She has tried lubricants without significant relief.\n5 She has not been able to use tampons in the past due to similar pain with tampon insertion.\n6 External vulvar examination shows no abnormalities.\n7 She is unable to undergo a bimanual or speculum exam due to intracoital pain with attempted digit or speculum insertion.\n8 Testing for Chlamydia trachomatis and\n9 Neisseria gonorrhoeae is negative.\n10 Vaginal botox injections were done.",
    "note_error": {
      "sentence_id": "10",
      "error_sentence": "Vaginal botox injections were done.",
      "correction": "Pelvic floor physical therapy was ordered.",
      "error_type": "management"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Anesthetic overdose was unlikely — “The end tidal concentration of desflurane never exceeded 4.4%.”  \n2. Hypovolemia was excluded — “lack of blood loss and fluid shifts.”  \n3. Sepsis was excluded — “the general health of the patient (not septic).”  \n4. Anaphylaxis was excluded — “lack of evidence for anaphylaxis.”  \n5. Adrenal insufficiency was considered — “we considered adrenal insufficiency as a possible etiology for the refractory hypotension.”"
  },
  {
    "id": "hard-deceptive-6",
    "task": "hard-deceptive",
    "chief_complaint": "A 76-year-old man with hypertension, coronary heart disease, and peripheral arterial disease presented with 3 months of fluctuating headache, fatigue, proximal muscle weakness, low-grade fevers up to",
    "history": {
      "hpi": "A 76-year-old man with hypertension, coronary heart disease, and peripheral arterial disease presented with 3 months of fluctuating headache, fatigue, proximal muscle weakness, low-grade fevers up to 38.3 °C, weight loss (7 kg), jaw and joint pain, and temporal tenderness. Neurologic examination was notable for proximal muscle tenderness, mild distal neuropathy, and essential tremor; there was no nuchal rigidity. ESR was elevated at 28 mm/h; C-reactive protein was normal. Serum electrophoresis showed a monoclonal IgA gammopathy and slight elevation of IgA. Repeated blood leukocyte counts were normal except one marginal elevation. Extensive imaging (skull, spine, pelvis X-rays; thoracic and abdominal CT; cranial CT), blood cultures, Candida antigen titer, echocardiography, and endoscopic studies were all unrevealing. The patient declined both bone marrow biopsy and lumbar puncture. A presumptive diagnosis of polymyalgia rheumatica was made, and prednisolone (30 mg/day) rapidly relieved his symptoms; he was discharged.\n\nTen days after starting prednisolone (4 months after symptom onset), he developed rapid exertional exhaustion and was readmitted (day 0). On day 3, he had fever to 39",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "temperature": "28"
    },
    "labs": {
      "lactate": "9.6"
    },
    "imaging": {
      "ECHO": "echocardiography, and endoscopic studies were all unrevealing."
    },
    "correct_diagnosis": "Candida albicans meningitis",
    "icd10": "Z99.9",
    "diagnosis_synonyms": [],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 138.0,
          "cl": 102.0,
          "bicarb": 24.0
        },
        "expected": 12.0,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A 65-year old man comes to the emergency department because of altered mental status for 1 day.\n1 He has had headaches, severe nausea, vomiting, and diarrhea for 2 days.\n2 He has a history of hypertension, insomnia, and bipolar disorder.\n3 His medications include lisinopril, fluoxetine, atorvastatin, lithium, olanzapine, and alprazolam.\n4 His temperature is 37.2  C (99.0  F), pulse is 90/min, respirations are 22/min, and\n5 blood pressure is 102/68 mm\n6 Hg.\n7 He is somnolent and confused.\n8 His mucous membranes are dry.\n9 Neurological examination shows dysarthria, decreased muscle strength throughout, and a coarse tremor of the hands bilaterally.\n10 The remainder of the examination shows no abnormalities.\n11 Oral cyproheptadine is required.",
    "note_error": {
      "sentence_id": "11",
      "error_sentence": "Oral cyproheptadine is required.",
      "correction": "Hemodialysis is required.",
      "error_type": "management"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Polymyalgia rheumatica suspected — “Because of the pain and sensitivity to pressure of the muscles of the proximal upper extremities, the weight loss and the elevated erythrocyte sedimentation rate, polymyalgia rheumatica was suspected.”  \n2. Bacterial meningitis considered — “treatment was started with ceftriaxone, ampicillin, and acyclovir on Day 3.”  \n3. Viral meningitis considered — “PCRs for Herpes simplex and Varicella zoster viruses… were negative.”  \n4. Tuberculous meningitis consider"
  },
  {
    "id": "hard-deceptive-7",
    "task": "hard-deceptive",
    "chief_complaint": "A 35-year-old woman, gravida 3 para 2 at 34 weeks 5 days’ gestation with gestational diabetes mellitus treated with 6 units of insulin detemir daily, presented with a 1-week history of dyspnea, myalgi",
    "history": {
      "hpi": "A 35-year-old woman, gravida 3 para 2 at 34 weeks 5 days’ gestation with gestational diabetes mellitus treated with 6 units of insulin detemir daily, presented with a 1-week history of dyspnea, myalgia, headache, tachycardia, fatigue, and productive cough causing chest pain. Symptoms worsened over the preceding 2 days despite outpatient IV fluids.  \nHer history included papillary thyroid carcinoma diagnosed by fine-needle aspiration in early pregnancy, for which surgery was deferred postpartum; she was taking levothyroxine for hypothyroidism. She had mild gestational diabetes since 20 weeks’ gestation and pre-pregnancy propranolol therapy that was stopped for pregnancy.  \nOn admission, blood glucose was 70 mg/dL; blood pressure 110/70 mm Hg; heart rate 120 bpm; respiratory rate 35 breaths/min; oxygen saturation 97% on room air. She reported household exposure to COVID-19; SARS-CoV-2 PCR returned positive the next day.  \nChest CT demonstrated 40% bilateral patchy pulmonary infiltration with subpleural and ground-glass opacities. Platelet count was 70,000/µL with no schistocytes on smear.  \nArterial blood gas showed pH 7.33, PCO₂ 16.7 kPa, bicarbonate 8.2 mmol/L, with an anion gap of",
      "pmh": "See case prompt",
      "medications": "See case prompt",
      "allergies": "NKDA (unless specified)",
      "social_history": "See case prompt"
    },
    "vitals": {
      "temperature": "34",
      "heart_rate": "120",
      "blood_pressure": "110/70",
      "respiratory_rate": "35"
    },
    "labs": {
      "bicarbonate": "8",
      "ph": "7.33"
    },
    "imaging": {},
    "correct_diagnosis": "euglycemic diabetic ketoacidosis",
    "icd10": "E13.10",
    "diagnosis_synonyms": [
      "euglycemic dka",
      "edka"
    ],
    "required_calculations": [
      {
        "formula": "anion_gap",
        "inputs": {
          "na": 135.0,
          "cl": 98.0,
          "bicarb": 8.0
        },
        "expected": 29.0,
        "tolerance_pct": 5
      },
      {
        "formula": "corrected_sodium",
        "inputs": {
          "na": 135.0,
          "glucose": 100.0
        },
        "expected": 135.0,
        "tolerance_pct": 5
      }
    ],
    "necessary_tests": [
      "chart.history",
      "chart.vitals",
      "chart.labs.BMP"
    ],
    "unnecessary_tests": [
      "chart.labs.LIPIDS",
      "chart.labs.THYROID",
      "chart.labs.IRON"
    ],
    "soap_note": "0 A previously healthy 4-year-old boy is brought to the physician by his parents because he has had a fever, diffuse joint pain, and a rash on his abdomen for the past week.\n1 Acetaminophen did not improve his symptoms.\n2 He emigrated from China with his family 2 years ago.\n3 He attends daycare.\n4 His immunization records are not available.\n5 His temperature is 38.5 C (101.3 F), pulse is 125/min, and blood pressure is 100/60 mm\n6 Hg.\n7 A viral immunoglobulin antibody assay was ordered based on the following findings.\n8 Examination showed polymorphous truncal rash.\n9 The eyes were pink with no exudate.\n10 The tongue was shiny and red, and the lips were cracked.\n11 The hands and feet were red and swollen.\n12 There was right-sided anterior cervical lymphadenopathy.",
    "note_error": {
      "sentence_id": "7",
      "error_sentence": "A viral immunoglobulin antibody assay was ordered based on the following findings.",
      "correction": "Echocardiography was ordered based on the following findings.",
      "error_type": "management"
    },
    "correct_plan": "See diagnostic_reasoning in dataset",
    "teaching_point": "1. Alcohol intoxication — “Serum osmolarity of 296.2 mOsmol/KG, and an osmolarity gap of 7 mOsm/kg, ruled out the alcohol intoxication in this patient.”  \n2. Renal tubular acidosis — “High anion gap of 21 mmol/L and stage 2 chronic kidney disease epidemiology collaboration also excluded renal tubular acidosis…”  \n3. Uremic acidosis — “…and stage 2 chronic kidney disease epidemiology collaboration also excluded… uremic acidosis from our differential diagnoses, respectively.”  \n4. Pulmonary emboli"
  }
]