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+[
+    {
+        "Index": "NEJMcpc1408595",
+        "patient_info": "Chief Complaint: The patient, a 14-year-old boy, presented with abnormal liver-function test results persisting for approximately 1.5 years. He had a history of multiple chronic illnesses, including type 1 diabetes mellitus, primary hypothyroidism, and recurrent infections. The abnormal liver tests prompted referral to the gastroenterology clinic for further evaluation.\nPatient Information and Medical History: The patient is a 14-year-and-8-month-old male of Italian and Irish ancestry with a significant past medical history. He was born via vaginal delivery following an uncomplicated full-term gestation. At birth, he was noted to have cryptorchidism (undescended testis), which was later addressed with orchidopexy and inguinal herniorrhaphy at 15 months of age. During infancy, he was diagnosed with gastroesophageal reflux disease (GERD) and failure to thrive. His medical conditions include type 1 diabetes mellitus, primary hypothyroidism, mild speech delay, and learning disabilities. He has a history of recurrent infections, including sinusitis, streptococcal pharyngitis, and pneumonias, as well as nocturia and leukoplakia of the tongue. Genetic evaluation at 2 years of age demonstrated a normal karyotype. Additionally, he has sustained orthopedic injuries secondary to sports-related trauma. His family medical history is notable for a maternal uncle with learning disabilities, developmental delay, hypogammaglobulinemia, cryptogenic cirrhosis, splenic artery aneurysms, type 1 diabetes mellitus, and bone marrow failure; a maternal great-grandmother with scleroderma; and a paternal grandmother with type 1 diabetes mellitus. Current medications include insulin administered via continuous subcutaneous insulin infusion (insulin pump) and levothyroxine. The patient has no known medication allergies.",
+        "laboratory_tests": "Laboratory testing revealed several abnormal indicators, including a hematocrit of 30.9% (reference range: 36.0–49.0), hemoglobin of 10.5 g/dL (reference range: 12.0–16.9), and a platelet count of 140,000/mm³ (reference range: 150,000–450,000), consistent with anemia and thrombocytopenia. Liver function tests were notable for elevated total bilirubin at 3.6 mg/dL (reference range: 0.2–1.1), alkaline phosphatase at 402 U/L (reference range: 70–390), aspartate aminotransferase at 80 U/L (reference range: 2–40), alanine aminotransferase at 47 U/L (reference range: 3–30), and γ-glutamyltransferase at 75 U/L (reference range: 12–55), indicating hepatic dysfunction. Immunological studies demonstrated low IgM levels at 25 mg/dL (reference range: 55–334) and suboptimal pneumococcal antibody titers post-vaccination, suggesting impaired humoral immunity. In contrast, normal or negative results were observed for complete blood count, erythrocyte sedimentation rate, vitamin B₁₂ levels, C-reactive protein, antinuclear antibody titers, monospot test, Lyme disease testing, and DNA analysis for CADASIL. Additionally, prothrombin-time international normalized ratio, lipid profile, red-cell osmotic fragility, ceruloplasmin, iron studies, iron-binding capacity, IgG levels, and glucose-6-phosphate dehydrogenase (G6PD) levels were within normal limits.",
+        "imaging_studies": "Imaging studies reveal significant findings in both neurological and abdominal evaluations. A brain MRI performed at 10 years of age demonstrated numerous nonspecific focal lesions in the periventricular and corona radiata white matter, each measuring ≤8 mm in diameter, without gadolinium enhancement. These findings are suggestive of potential etiologies such as myelination disorders, vasculitis, or infections like Lyme disease. Abdominal imaging conducted at 14 years of age included an ultrasound, which revealed heterogeneously hypoechoic parenchymal nodules in the liver, consistent with macronodular cirrhosis, without a dominant mass. The portal vein was patent with normal flow, and splenomegaly was noted in the absence of varices. Subsequent abdominal MRI confirmed heterogeneous hepatic parenchymal enhancement and splenomegaly, with no evidence of bile-duct dilatation or ascites. ",
+        "diagnosis": "Dyskeratosis congenita (a telomere syndrome)\nNodular regenerative hyperplasia of the liver"
+    },
+    {
+        "Index": "NEJMcpc1410939",
+        "patient_info": "Chief Complaint: A 25-year-old man presented with sudden onset of severe abdominal pain, syncope, and hypotension. The abdominal pain began in the epigastrium and right upper quadrant, radiating throughout the abdomen, and was accompanied by tingling in the mouth, tongue, arms, and legs. Within minutes, he experienced blurred vision, fainting, nonbloody vomiting, and loss of consciousness. Symptoms occurred during strenuous physical activity (lifting heavy boxes).\nPatient Information and Medical History: The patient is a 25-year-old man born in Romania, living in the United States for six years. He has a history of appendectomy and no known allergies or medications. He does not smoke, drink alcohol, or use illicit drugs. He has a family history of cardiovascular disease (father died of myocardial infarction at age 59). He has traveled to Romania annually, where he was exposed to stray dogs, and has also traveled to India and China. He occasionally experiences pruritus when showering.",
+        "laboratory_tests": "Initial laboratory tests showed normal platelet count, alkaline phosphatase, alanine aminotransferase, albumin, globulin, troponin T, lipase, D-dimer, and renal function. Significant changes included transient lactic acidosis, increased serum bilirubin, and alanine aminotransferase levels, consistent with shock liver. Lymphopenia and eosinopenia were noted, likely due to glucocorticoid therapy. Serologic testing confirmed the presence of echinococcal antibodies.",
+        "imaging_studies": "Abdominal ultrasound revealed a hypoechoic abnormality with internal echoes in the liver. CT scan of the abdomen and pelvis showed a hypodense lesion measuring 6.5 cm in segment 6 of the liver, with a thin, undulating internal septation and bulging of the liver capsule. MRI of the liver confirmed a hyperintense cyst on T2-weighted images with undulating internal septation and a small amount of fluid around the cyst, suggesting rupture or leakage. Chest radiograph and CT scans of the brain and chest were normal.",
+        "diagnosis": "Acute anaphylaxis\nHepatic hydatid cyst\nEchinococcus granulosus infection"
+    },
+    {
+        "Index": "NEJMcpc1610099",
+        "patient_info": "Chief Complaint: A 50-year-old man presented with fatigue, malaise, multiple episodes of nonbloody, nonbilious vomiting, abdominal distention, diffuse abdominal pain, and jaundice. Symptoms developed over 6 days, with jaundice noted 3 days before admission. He also reported occasional dark stools and mild, diffuse abdominal pain exacerbated by deep breaths.\nPatient Information and Medical History: The patient is a 50-year-old male horticulturalist from rural northern India with cattle on his property. He had hyperlipidemia and previously took an unknown cholesterol-lowering medication for 2 months. He had a history of binge drinking (8–10 drinks several days per month) but last consumed alcohol 6 months prior. Two weeks before admission, he traveled to New England. His father died of unspecified liver disease in his sixth decade. He took an unknown nonprescription pain medication and one dose of ciprofloxacin provided by a family member before admission.",
+        "laboratory_tests": "Hematological findings included a markedly decreased hematocrit (21% on admission, reference range: 41–53%) and hemoglobin (7.3 g/dl on admission, reference range: 13.5–17.5 g/dl), consistent with severe anemia. The white-cell count was elevated at 26,000 per mm³ (reference range: 4500–11,000 per mm³), suggesting leukocytosis, while the platelet count was within normal limits at 231,000 per mm³ (reference range: 150,000–400,000 per mm³). Coagulation studies showed a prolonged prothrombin time of 22 seconds (reference range: 11–14 seconds), and D-dimer was significantly elevated at 2531 ng/ml (reference range: <500 ng/ml), indicating possible thromboembolic activity or fibrinolysis. Haptoglobin levels were decreased to <6 mg/dl (reference range: 16–199 mg/dl), consistent with hemolysis. Biochemical abnormalities included elevated total bilirubin (4.3 mg/dl, reference range: 0–1.0 mg/dl) and direct bilirubin (4.6 mg/dl), along with increased alanine aminotransferase (ALT, 116 U/liter, reference range: 10–55 U/liter) and aspartate aminotransferase (AST, 105 U/liter, reference range: 10–40 U/liter), indicating hepatic injury. Lactate dehydrogenase (LDH) was elevated at 38 U/liter (reference range: 110–210 U/liter), further supporting hemolysis or tissue damage. Renal function was impaired, with elevated creatinine (1.7 mg/dl, reference range: 0.6–1.5 mg/dl) and urea nitrogen (66 mg/dl, reference range: 8–25 mg/dl). Ferritin levels were notably elevated at 0.74 µg/liter (reference range: 20–300 µg/liter), suggesting iron overload or acute-phase response.",
+        "imaging_studies": "Abdominal ultrasound revealed a patent portal vein, coarse and heterogeneous liver echotexture, a contracted gallbladder with thickened wall and biliary sludge, and echogenic renal parenchyma. Magnetic resonance imaging (MRI) showed diffuse hepatic steatosis, gallbladder-wall edema, and fluid and fat stranding around the duodenum. The portal vein was not well visualized.",
+        "diagnosis": "Acute HEV infection"
+    },
+    {
+        "Index": "NEJMcpc1613467",
+        "patient_info": "Chief Complaint: The patient, an 18-year-old woman, presented to the emergency department with acute liver failure 11 weeks after the birth of her first child. Her symptoms began one week prior with rhinorrhea, sore throat, and cough, which progressed to abdominal discomfort, nausea, vomiting, diarrhea, vaginal bleeding, and jaundice. On the day of presentation, she experienced syncope, resulting in a chin laceration. She also reported tea-colored urine and easy gum bleeding.\nPatient Information and Medical History: The patient is an 18-year-old woman of Southeast Asian descent, born in the United States. She recently moved to an urban area of New England and lives with her daughter, boyfriend, and his parents. She has a history of mild asthma and an uncomplicated pregnancy until preterm labor at 32 weeks, complicated by placental abruption. She was hospitalized for one week postpartum due to unspecified abnormal lab results. She denies smoking, alcohol use, or illicit drug use. Her grandmother had unspecified liver disease. Medications include albuterol as needed, azithromycin, and promethazine-dextromethorphan syrup. She has no known allergies and is up-to-date on immunizations.",
+        "laboratory_tests": "Hematologic findings included persistently low hematocrit (19.6% at another hospital, 23.4% at this hospital) and hemoglobin (6.4 g/dl at another hospital, 7.9 g/dl at this hospital), consistent with severe anemia. The mean corpuscular volume was elevated (113.8 fl at another hospital, 105.9 fl at this hospital), suggesting macrocytic anemia. Platelet counts were reduced (140,000 per mm³ at another hospital, 175,000 per mm³ at this hospital), while white-cell counts remained within normal limits (10.1 per mm³ at another hospital, 11.1 per mm³ at this hospital). Coagulation studies revealed a prolonged prothrombin time (24.5 sec at this hospital), elevated INR (2.6 at another hospital, 2.1 at this hospital), and prolonged activated partial-thromboplastin time (43.4 sec at this hospital), alongside a mildly elevated D-dimer (591 ng/ml at this hospital), indicating potential coagulopathy. Liver function tests showed markedly elevated total bilirubin (19.7 mg/dl at another hospital, 26.3 mg/dl at this hospital) and direct bilirubin (21.9 mg/dl at this hospital), with elevated aspartate aminotransferase (152 U/liter at both hospitals) and γ-glutamyltransferase (116 U/liter at this hospital), suggesting significant hepatic dysfunction. Other abnormalities included hypocalcemia (7.2 mg/dl at both hospitals), hypophosphatemia (1.8 mg/dl at this hospital), hypoalbuminemia (2.1 g/dl at another hospital, 2.2 g/dl at this hospital), and elevated lactic acid (3.9 mmol/liter at another hospital, 1.7 mmol/liter at this hospital) and ammonia levels (49 μmol/liter at this hospital).",
+        "imaging_studies": "Chest radiograph and CT scan of the head were normal. Abdominal ultrasonography revealed mildly increased hepatic parenchymal echogenicity, suggestive of hepatic steatosis or diffuse parenchymal disease. The gallbladder was distended with wall edema, pericholecystic fluid, and layering sludge. The common bile duct was normal in diameter, with no intrahepatic biliary ductal dilatation. The spleen was mildly enlarged (13 cm). Doppler ultrasonography confirmed normal hepatic arterial, portal venous, and hepatic venous flow.",
+        "diagnosis": "Fulminant hepatic failure\nWilson's disease"
+    },
+    {
+        "Index": "NEJMcpc1616393",
+        "patient_info": "Chief Complaint: An 8-month-old girl presented with fever and an abdominal mass. Symptoms began approximately 6 days prior to admission, including passing a large stool surrounded by clotted blood, intermittent fevers, irritability, decreased oral intake, and a mild cough. The fever peaked at 40.3°C the day before admission.\nPatient Information and Medical History: The patient is an 8-month-old girl born after an uncomplicated 41-week gestation. She had a previous emergency department visit at 6.25 months for vomiting and abdominal pain, but no fever or bleeding. Her immunizations are up-to-date, and she takes no medications. Family history includes a maternal grandfather with colon cancer and a paternal aunt who died at 20 years old from cancer initially presenting as an abdominal cyst. There is no family history of inflammatory bowel disease.",
+        "laboratory_tests": "Abnormal laboratory results included: Hematocrit (29.1%), Hemoglobin (9.2 g/dl), Platelet count (490,000 per mm³), Carbon dioxide (20 mmol/liter), Urea nitrogen (3 mg/dl), Creatinine (0.23 mg/dl), Magnesium (2.6 mg/dl), Lipase (797 U/liter), and C-reactive protein (134.4 mg/liter). Other tests, including glucose, calcium, phosphorus, total protein, albumin, globulin, lactate dehydrogenase, uric acid, amylase, alpha fetoprotein, and human chorionic gonadotropin, were normal.",
+        "imaging_studies": "Abdominal radiography revealed the absence of bowel gas in the midabdomen and peripheral displacement of bowel loops, suggestive of an abdominal mass. Abdominal ultrasonography showed a large, thick-walled complex cystic mass in the midabdomen with internal dependent debris and multiple mural satellite cysts. CT imaging confirmed a 14.5 cm complex cystic mass in the midabdomen, separate from the bowel, with loculations abutting the pancreas. Contrast material injected into the cyst cavity showed communication with the pancreatic duct and ampulla.",
+        "diagnosis": "Congenital pancreatic hamartoma (multicystic adenomatoid hamartoma)"
+    },
+    {
+        "Index": "NEJMcpc1706100",
+        "patient_info": "Chief Complaint: The patient, a 65-year-old woman, presented with acute liver failure and was transferred for evaluation for liver transplantation. Her primary complaints included malaise, fatigue, jaundice, and delirium. She also reported nonbloody diarrhea and a single episode of coughing up blood-tinged sputum. The symptoms had developed over approximately 7 weeks, with a significant deterioration in the week before admission, including fever, shock, and acute kidney injury.\nPatient Information and Medical History: The patient is a 65-year-old woman with a history of presumed autoimmune hepatitis and cirrhosis, diagnosed 6 years prior. She had a history of heavy alcohol consumption but stopped after her diagnosis. She had been treated with glucocorticoids in the past but discontinued treatment and opted for natural supplements. She worked in healthcare, lived alone, and had no family history of liver disease. Her medical history included a tubal ligation, and she had no recent travel or significant animal exposure. She had been taking supplements such as milk thistle and buckthorn but no prescribed medications before admission.",
+        "laboratory_tests": "Laboratory tests revealed profoundly abnormal results, including elevated liver enzymes (alanine aminotransferase: 190 U/L, aspartate aminotransferase: 204 U/L), hyperbilirubinemia (total bilirubin: 12.1 mg/dL), coagulopathy (INR: 4.2), leukocytosis (white-cell count: 16,930/mm³), and acute kidney injury (creatinine: 4.22 mg/dL). Blood cultures grew gram-negative spiral-shaped bacteria, later identified as Campylobacter jejuni. Other notable findings included hypoalbuminemia (albumin: 3.5 g/dL) and elevated lactate dehydrogenase (348 U/L).",
+        "imaging_studies": "Imaging studies included abdominal ultrasonography, which revealed a nodular liver and ill-defined echogenicity in the right lobe. Chest radiography showed multifocal air-space opacities and bilateral pleural effusions. Computed tomography (CT) of the chest, abdomen, and pelvis confirmed diffuse ground-glass opacities in the upper lobes, central interlobular septal thickening, a nodular hepatic contour, prominent portal and perihepatic lymph nodes, and small-volume ascites.",
+        "diagnosis": "Campylobacter bacteremia\nAutoimmune hepatitis."
+    },
+    {
+        "Index": "NEJMcpc1900592",
+        "patient_info": "Chief Complaint: A 55-year-old man presented with jaundice, which he noticed one week prior to admission. He also reported symptoms of anorexia, malaise, nausea with dark-brown emesis, profuse nonbloody watery diarrhea, intermittent abdominal cramping, poor sleep, blurry vision, and episodes of forgetfulness and loss of concentration. These symptoms had persisted for two weeks. The patient had no fevers, chills, bleeding, or pulmonary or genitourinary symptoms.\nPatient Information and Medical History: The patient is a 55-year-old man with a history of opioid use disorder, hepatitis C virus (HCV) infection, osteoarthritis, depression, and anxiety. He was diagnosed with HCV while incarcerated but was not treated. He has a history of intravenous heroin use and had three episodes of overdose after his release from prison. He was previously treated with sublingual buprenorphine-naloxone for opioid use disorder. He is divorced, unemployed, homeless, and sleeps in a shelter. He has no known exposure to rodents or rodent excreta. He smokes cigarettes daily and previously consumed alcohol heavily but quit six years ago. His parents are deceased, and he is estranged from his siblings, whose medical history is unknown.",
+        "laboratory_tests": "Laboratory tests showed elevated liver enzymes (alanine aminotransferase and aspartate aminotransferase), elevated bilirubin levels, and elevated C-reactive protein. The hepatitis C virus antibody and RNA tests were positive, indicating active HCV infection. Blood levels of electrolytes, glucose, lipase, complete blood count, differential count, and renal-function tests were normal. Serum toxicologic screening did not detect acetaminophen, salicylates, tricyclics, or ethanol. Urinalysis revealed clear, dark-yellow urine with a specific gravity of 1.020, pH of 7.5, trace ketones, and 2+ urobilinogen.",
+        "imaging_studies": "Limited ultrasonography of the right upper quadrant revealed no bile-duct dilatation, a patent main portal vein with hepatopetal flow, and normal hepatic parenchymal echotexture. Diffuse, hypoechoic gallbladder-wall thickening was present, without gallbladder distention, cholelithiasis, or pericholecystic fluid. Trace perihepatic ascites was noted. Murphy’s sign was negative.",
+        "diagnosis": "Acute hepatitis B virus coinfection\nHepatitis delta virus coinfection\nChronic hepatitis C virus infection"
+    },
+    {
+        "Index": "NEJMcpc2027092",
+        "patient_info": "Chief Complaint: The patient, a 34-year-old woman, presented with acute abdominal and back pain that developed three years prior to her evaluation in the oncology clinic. The pain was severe enough to prompt her visit to the emergency department. Associated symptoms included biliary obstruction, as suggested by peripheral biliary dilatation observed on imaging studies.\nPatient Information and Medical History: The patient is a 34-year-old woman with a history of migraines and a previous allergic reaction to cisplatin. She does not smoke, drink alcohol, or use illicit drugs. She works full-time as a social worker and lives in New Jersey with her husband and child. Her family history includes breast cancer in her maternal grandmother, uterine cancer in a paternal aunt, and colon cancer in two paternal cousins. She was previously diagnosed with intrahepatic cholangiocarcinoma and underwent surgical resection followed by adjuvant chemotherapy.",
+        "laboratory_tests": "Laboratory tests showed elevated CA 19-9 levels (42 IU/mL), while alpha-fetoprotein and carcinoembryonic antigen levels were normal. Liver function tests indicated mild elevations in aspartate aminotransferase (49 IU/L), alanine aminotransferase (51 IU/L), and alkaline phosphatase (167 IU/L). Complete blood count, electrolytes, and renal function tests were within normal limits.",
+        "imaging_studies": "Initial abdominal ultrasonography revealed a lesion in the right lobe of the liver. Magnetic resonance imaging (MRI) showed a heterogeneous, hypoenhancing, lobulated lesion measuring 6.1 cm by 4.5 cm, with features suggestive of cholangiocarcinoma, including peripheral biliary dilatation, restricted diffusion, peripheral rim enhancement, and delayed central enhancement. Positron-emission tomography and computed tomography (PET-CT) confirmed FDG avidity in the hepatic mass without additional hypermetabolic sites. Follow-up imaging revealed disease progression, including new liver and lung lesions.",
+        "diagnosis": "Intrahepatic cholangiocarcinoma"
+    },
+    {
+        "Index": "NEJMcpc2201231",
+        "patient_info": "Chief Complaint: A 29-year-old woman presented with progressive pruritus, nausea, bloating, watery mustard-colored diarrhea, jaundice, right upper quadrant abdominal discomfort, amber-colored urine, fatigue, unintentional weight loss of 3.2 kg over the past month, and poor sleep. Symptoms began 7 weeks prior and persisted despite initial treatment with methylprednisolone, hydroxyzine, and diphenhydramine.\nPatient Information and Medical History: The patient is a 29-year-old woman with a history of anxiety and depression, no known drug allergies, and no regular medications. She occasionally smokes cigarettes, rarely drinks alcohol, and does not use illicit drugs. She works seasonally as an official at sporting events. Family history includes colon cancer in her maternal grandmother, maternal grandfather, and paternal grandmother; breast cancer in her maternal aunt and paternal aunt; thyroid cancer in her father; diabetes in her maternal grandmother; and coronary artery disease in both grandmothers.",
+        "laboratory_tests": "Abnormal laboratory findings included elevated alanine aminotransferase (327 U/L initially, decreased to 85 U/L), aspartate aminotransferase (104 U/L initially, increased to 267 U/L), total bilirubin (5.8 mg/dL initially, increased to 6.7 mg/dL), and carbohydrate antigen 19-9 (73 U/mL initially, increased to 959 U/mL). Other abnormal indicators included elevated glucose (162 mg/dL) and alkaline phosphatase (172 U/L). Normal findings included hemoglobin, hematocrit, white-cell count, platelet count, sodium, potassium, chloride, carbon dioxide, urea nitrogen, creatinine, calcium, lipase, globulin, and albumin.",
+        "imaging_studies": "Computed tomography (CT) of the abdomen revealed a distended gallbladder with sludge, dilated hepatic and pancreatic ducts, and a hypodense mass in the pancreatic head. Magnetic resonance cholangiopancreatography (MRCP) confirmed biliary and pancreatic duct dilatation with abrupt narrowing at the pancreatic head, along with a heterogeneously enhancing mass. Endoscopic ultrasonography (EUS) identified a hypoechoic mass in the pancreatic head. Follow-up imaging post-pancreaticoduodenectomy showed soft-tissue changes in the surgical bed and liver lesions suggestive of metastasis.",
+        "diagnosis": "Pancreatic ductal adenocarcinoma"
+    },
+    {
+        "Index": "NEJMcpc2201249",
+        "patient_info": "Chief Complaint: The patient, a 56-year-old man, presented with abnormal liver test results, including elevated levels of alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase. He also reported chronic dyspnea with exertion. The abnormal liver tests had been noted for at least three years, with recent development of thrombocytopenia and splenomegaly.\nPatient Information and Medical History: The patient is a 56-year-old man with a history of alcohol and opioid use disorder, currently in remission with buprenorphine-naloxone. He consumed six beers daily for approximately 30 years but had abstained for the past 18 months. He has a history of dyslipidemia, depression, insomnia, and multiple knee surgeries. Family history includes stroke in his father, diabetes in his mother, and rheumatoid arthritis in his sister. He previously tested positive for hepatitis C virus (HCV) antibodies, but HCV RNA was undetectable, ruling out active infection.",
+        "laboratory_tests": "Laboratory tests over the past three years showed persistently elevated liver enzymes, including alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP). Recent tests revealed pancytopenia, coagulopathy, and elevated ALP (427 U/liter), γ-glutamyltransferase (419 U/liter), and total bilirubin (3.3 mg/dl). Platelet count was low (43,000 per μl), and prothrombin time was prolonged (15.5 sec). Antimitochondrial antibodies were positive, and IgM levels were elevated (874 mg/dl).",
+        "imaging_studies": "Magnetic resonance cholangiopancreatography (MRCP) revealed a nodular hepatic contour, splenomegaly, portal vein thrombosis with cavernous transformation, and perigastric, paraesophageal, and splenorenal collateral vessels. No focal hepatic lesions or intrahepatic bile duct dilatation was observed. Abdominal ultrasound showed persistent splenomegaly and heterogeneous liver echotexture without ascites. A computed tomographic scan of the head was normal.",
+        "diagnosis": "Primary biliary cholangitis\nPortopulmonary hypertension"
+    },
+    {
+        "Index": "NEJMcpc2211363",
+        "patient_info": "Chief Complaint: A 31-year-old woman presented to the hospital 15 days after the birth of her first child with severe abdominal pain in the left upper quadrant, radiating to the left flank and back, and a fever of 38.3°C. The pain worsened with movement and deep breathing and was rated 10/10 in severity. Symptoms persisted despite prior treatment with antibiotics for presumed pyelonephritis.\nPatient Information and Medical History: The patient is a 31-year-old woman who recently delivered her first child via vaginal delivery at 38 weeks and 1 day of gestation. Her medical history includes high-grade cervical dysplasia treated with a loop electrosurgical excision procedure five years prior, a ruptured ovarian cyst three years prior, and nephrolithiasis five months prior. She had no prior pregnancies and had been on oral contraceptives for 12 years. She took prenatal vitamins and occasional medications like acetaminophen and ibuprofen. She has no known drug allergies and lives with her husband and newborn in an urban area of New England. Her family history includes multiple sclerosis in her mother and coronary artery disease in her father.",
+        "laboratory_tests": "Abnormal laboratory findings included elevated liver enzymes: alanine aminotransferase (ALT) 153 U/L, aspartate aminotransferase (AST) 44 U/L, and alkaline phosphatase 194 U/L. Hemoglobin decreased from 11.2 g/dL to 9.7 g/dL, suggesting hemorrhage. White blood cell count was elevated at 10,330/μL with increased neutrophils and decreased lymphocytes. Urinalysis showed 2+ blood and 1+ leukocyte esterase on Day 15. Glucose levels were elevated on both days.",
+        "imaging_studies": "A transverse ultrasound of the left lobe of the liver revealed a large exophytic, heterogeneous lesion. CT imaging confirmed a 11.1 cm x 9.5 cm x 10.8 cm mass arising from the left hepatic lobe, exerting mass effect on the stomach. The mass contained hyperdense material consistent with hematoma, a large nonenhancing necrotic component, and vividly enhancing peripheral components. No biliary dilatation, cirrhosis, lymphadenopathy, or metastases were observed.",
+        "diagnosis": "Hepatic adenoma"
+    },
+    {
+        "Index": "NEJMcpc2412516",
+        "patient_info": "Chief Complaint: A 62-year-old man presented with persistent postprandial abdominal pain, which worsened in severity and frequency over the past six weeks. The pain was associated with nausea and vomiting, and he reported a significant weight loss of 20 kg over the previous two months. The pain was less severe after consuming bland, low-fat foods. The patient also noted an irreducible umbilical hernia, which had been reducible three months prior.\nPatient Information and Medical History: The patient is a 62-year-old man who immigrated to the United States from Costa Rica. He has a history of cirrhosis diagnosed one year prior in Costa Rica, though details of the diagnostic process were unavailable. He reported a history of hepatitis in childhood, which resolved without treatment. Five years ago, he sustained abdominal trauma from a motor vehicle crash. He has no surgical history, does not consume alcohol, smoke, or use illicit drugs, and has no family history of liver disease or thrombosis. Medications include pantoprazole and nadolol. He worked in cattle farming in Costa Rica and had no travel history outside the country before immigrating to the United States.",
+        "laboratory_tests": "Laboratory tests showed a significantly low platelet count. Liver function tests revealed elevated alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, total bilirubin, and direct bilirubin. The international normalized ratio (INR) was slightly elevated. Total protein and albumin levels were within normal limits. Tests for causes of cirrhosis, including serum protein electrophoresis, ceruloplasmin, alpha-1-antitrypsin, and hepatitis B and C, were negative. Antinuclear antibodies, anti-smooth muscle antibodies, antimitochondrial antibodies, and antineutrophil cytoplasmic antibodies were not detected. Ferritin and iron levels were normal, with a transferrin saturation of 62%.",
+        "imaging_studies": "Computed tomography (CT) of the abdomen and pelvis revealed a paraumbilical hernia with a 3.6-cm neck containing a nonobstructed loop of small bowel. The liver appeared shrunken with a lobulated contour and diffuse hypoattenuation. Extensive paraesophageal and mesenteric varices were present, and the portal vein and superior mesenteric vein were not identified, suggesting cavernous transformation of the portal vein. The spleen was enlarged, measuring 18.2 cm in the craniocaudal dimension. Doppler ultrasonography showed no flow in the main portal vein but normal flow through the hepatic veins, hepatic artery, and inferior vena cava. A transjugular liver biopsy revealed hepatic parenchymal atrophy, portal vascular remodeling, and nodular regenerative hyperplasia-like changes without evidence of cirrhosis.",
+        "diagnosis": "Hepatic atrophy\nPortal vein thrombosis"
+    },
+    {
+        "Index": "NEJMcpc059014",
+        "patient_info": "Chief Complaint: The patient, a 58-year-old man, presented with vague discomfort in the left upper quadrant and left epigastrium, which he had experienced for approximately one year. The discomfort typically began one hour after meals and subsided after one to two hours. It was associated with a feeling of abdominal fullness, which increased with physical exertion but did not awaken him at night. He also reported unintentional weight loss of 2 to 3 kg, which he attributed to a reluctance to eat large meals. A trial of histamine H₂-receptor antagonists did not provide relief.\nPatient Information and Medical History: The patient is a 58-year-old man with a history of borderline hypertension, hypercholesterolemia, coronary artery disease (including an inferior-wall myocardial infarction nine years prior), and nephrolithiasis. He is a long-time smoker, having smoked 20 cigarettes a day for 40 years, though he recently reduced his intake to 5 or 6 cigarettes a day. He consumes one to two cups of coffee and one to two alcoholic beverages daily. He lives with his wife and two children and has a stressful job in sales. His mother died of a cerebral aneurysm, and his father has coronary artery disease. His medications include atorvastatin, aspirin, and frequent ibuprofen. He has no known allergies.",
+        "laboratory_tests": "Laboratory tests revealed an elevated CA 19-9 level of 510 U/mL, which is a tumor marker associated with pancreatic cancer. Other tests, including complete blood count, liver function tests, and levels of electrolytes, total protein, and albumin, were within normal ranges. Urinalysis was also normal.",
+        "imaging_studies": "Initial abdominal CT, performed to evaluate a kidney stone, incidentally revealed a small abdominal aortic aneurysm. Follow-up abdominal ultrasonography showed an ectatic aorta with a maximal anteroposterior diameter of 2.9 cm, but no definite aneurysm. Subsequent abdominal and pelvic CT with contrast revealed an aneurysm measuring 3.8 cm in diameter with a mural thrombus. Additionally, a rounded, low-attenuation mass (1.9 cm by 2.4 cm) was identified in the head and neck of the pancreas, accompanied by pancreatic duct dilatation and pancreatic tail atrophy. Endoscopic retrograde cholangiopancreatography (ERCP) showed abrupt termination of the main pancreatic duct within the neck of the pancreas, and endoscopic ultrasonography revealed an irregular hypoechoic mass in the pancreatic head (23 mm in diameter) encasing the confluence of the superior mesenteric vein and portal vein. Fine-needle aspiration of the pancreas confirmed adenocarcinoma in the neck of the pancreas. Staging laparoscopy revealed benign findings in the liver and peritoneum.",
+        "diagnosis": "Ductal adenocarcinoma of the pancreas, with residual microscopic tumor after chemoradiation therapy\nPancreatic intraepithelial neoplasia, grade 3, present at the distal resection margin"
+    },
+    {
+        "Index": "NEJMcpc059016",
+        "patient_info": "Chief Complaint: A four-week-old male infant was admitted to the hospital due to jaundice, hyperbilirubinemia, thrombocytopenia, and abdominal distention. The jaundice was persistent, and the abdominal distention was noted by the father four days prior to admission. The infant also exhibited hypotonia and mild respiratory distress.\nPatient Information and Medical History: The infant was born at term via spontaneous vaginal delivery to a 37-year-old woman with an uncomplicated pregnancy. Prenatal screening indicated the mother had type A Rh-positive blood, with negative results for hepatitis B surface antigen and group B streptococcus. The mother was immune to rubella, and a rapid plasma reagin test was nonreactive. At birth, the infant was limp, cyanotic, apneic, and without a heartbeat, requiring resuscitation. Apgar scores improved from 0 at 1 minute to 8 at 10 minutes. The infant was transferred to a special care nursery and later to a tertiary care pediatric hospital due to persistent jaundice, respiratory distress, and abnormal liver function tests.",
+        "laboratory_tests": "Laboratory tests showed type A Rh-positive blood with negative results for antibodies to red-cell antigens, glucose-6-phosphate dehydrogenase deficiency, Coombs' test, and Heinz-body preparation. Urinalysis showed trace blood, few red cells, and bilirubin. Blood cultures were negative. Liver function tests revealed persistent direct hyperbilirubinemia and elevated transaminase levels. Screening tests for galactosemia and tyrosinemia were negative. Iron overload was suggested by MRI findings of decreased signal intensity in the liver and pancreas.",
+        "imaging_studies": "Chest radiography showed cardiomegaly and clear lungs. Cardiac ultrasonography revealed right ventricular hypertrophy, right ventricular hypertension, mild mitral regurgitation, trace tricuspid regurgitation, septal hypertrophy, a dilated ascending aorta, and a patent foramen ovale with bidirectional blood flow. Abdominal ultrasonography showed mild heterogeneity of the liver, splenomegaly, and no intrahepatic biliary dilatation. MRI of the liver revealed diffuse nodularity consistent with cirrhosis, heterogeneous liver parenchyma, and abnormal vasculature. A magnetic resonance angiogram showed an unusually large left portal vein and hypoplastic right portal vein.",
+        "diagnosis": "Neonatal giant-cell hepatitis\nBridging fibrosis\nEarly regenerative nodules\nIron deposition in hepatocytes and Kupffer cells"
+    },
+    {
+        "Index": "NEJMcpc059019",
+        "patient_info": "Chief Complaint: A 57-year-old man was admitted to the hospital due to a mass in the liver. The mass was initially detected five months prior to admission during a surveillance ultrasonographic examination, which revealed a 3 cm diameter mass in the right lobe of the liver. The mass grew to 4 cm in diameter by the time of admission, as confirmed by CT and MRI scans. The patient reported no significant symptoms other than a weight loss of 1.4 kg over the preceding five months.\nPatient Information and Medical History: The patient is a 57-year-old man of Chinese origin who immigrated to the United States 15 years ago. He has a history of chronic active hepatitis B virus (HBV) infection, diagnosed two years prior to admission. He was started on lamivudine one year before admission, which normalized liver function tests and reduced viral load. He underwent a cholecystectomy nine years earlier. He has a 10 pack-year smoking history but quit two years ago, rarely consumes alcohol, and has no history of intravenous drug abuse. His family history includes two siblings with HBV infection, and his mother died of congestive heart failure in her seventies. His father is alive and well in his eighties.",
+        "laboratory_tests": "Complete blood count, serum glucose, electrolytes, albumin, globulin, bilirubin, renal function, and coagulation tests were all within normal ranges. Alanine aminotransferase (ALT) was elevated at 135 U/L, and aspartate aminotransferase (AST) was 78 U/L. Carcinoembryonic antigen (CEA) was 1.6 ng/mL, and alpha-fetoprotein (AFP) was 2.6 ng/mL, both within normal limits.",
+        "imaging_studies": "Initial ultrasonography revealed a 3 cm mass in the right lobe of the liver. Subsequent CT and MRI scans confirmed the presence of a 4 cm mass in the dome of the right lobe, with multiple hepatic cysts. Triphasic CT and gadolinium-enhanced MRI showed a 4.7 cm by 4.5 cm mass with heterogeneous arterial enhancement, portal venous phase enhancement, and delayed peripheral rim enhancement. The mass straddled the middle hepatic vein but showed no evidence of venous invasion, lymphadenopathy, or cirrhosis. MRI provided greater intrinsic tissue characterization, confirming the mass as most consistent with hepatocellular carcinoma.",
+        "diagnosis": "Hepatocellular carcinoma"
+    },
+    {
+        "Index": "NEJMcpc059037",
+        "patient_info": "Chief Complaint: A 63-year-old woman presented with a pancreatic mass, initially noticed due to symptoms of dysuria, dark urine, pruritus, intermittent epigastric pain, weight loss of 5 kg over three months, light-colored stool, and a small purple area on her right arm. These symptoms persisted for four months before admission.\nPatient Information and Medical History: The patient is a 63-year-old woman who recently immigrated to the United States from the Dominican Republic. She has a significant family history of cerebrovascular disease, myocardial infarction, liver cancer, and asthma. She reported nasal congestion, nocturnal cough with watery sputum for the past year, and no history of fever, chills, or exposure to toxins. She does not drink alcohol, smoke, or use illicit drugs.",
+        "laboratory_tests": "Urinalysis showed 3+ bilirubin and 2+ occult blood. Other tests, including electrolytes, calcium, phosphorus, magnesium, serum lipids, renal function, and complete blood count, were normal. Cytologic examination of fine-needle aspirates revealed reactive epithelial cells, acute and chronic inflammation, multinucleated giant cells, and epithelioid histiocytes forming granulomas. Acid-fast staining and fungal cultures were negative, but lymph node cultures later grew Mycobacterium tuberculosis.",
+        "imaging_studies": "Initial abdominal CT revealed intrahepatic and extrahepatic bile duct dilatation, a periportal mass (3.1 cm by 3.6 cm), a complex cystic mass in the pancreatic head (2.9 cm by 2.4 cm), another cystic mass near the pancreatic tail (2.7 cm by 1.4 cm), and a low-density splenic lesion. Follow-up CT showed resolution of the pancreatic head mass but persistent retroperitoneal lymphadenopathy with low-density centers and enhancing rims. Chest radiographs revealed bilateral apical opacities. ERCP confirmed biliary stricture and successful stent placement.",
+        "diagnosis": "Mycobacterium tuberculosis infection of the pancreas and peripancreatic lymph nodes"
+    },
+    {
+        "Index": "NEJMcpc059044",
+        "patient_info": "Chief Complaint: The patient, a 35-year-old woman, presented with recurrent severe abdominal pain in the right upper quadrant, associated with jaundice, nausea, constipation, chills, and fever (up to 38.3°C). The pain was constant, did not radiate, and was not relieved by any maneuver. This episode of pain was similar to previous episodes that had led to prior hospitalizations and interventions for biliary stones.\nPatient Information and Medical History: The patient is a 35-year-old woman born in Vietnam who immigrated to the United States in her early 20s. She has a history of type 2 diabetes mellitus, hyperlipidemia, and depression. At age 18, she underwent an abdominal operation in Vietnam for unspecified abdominal pain. She has a history of hepatitis C infection, diagnosed one year prior to admission, and recurrent biliary stones requiring multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures. She resides with her mother and sister and has no recent travel history or contact with sick persons. She takes unknown medications for migraine and hyperlipidemia.",
+        "laboratory_tests": "Laboratory results showed elevated white-cell count (11,400/mm³) with 84% neutrophils, low calcium (7.9 mg/dL), elevated phosphorus (200 mg/dL), low albumin (3.0 g/dL), and mildly elevated liver enzymes (AST 55 U/L, ALT 46 U/L). Bilirubin, alkaline phosphatase, lipase, and creatinine levels were normal. Blood cultures grew Klebsiella pneumoniae. Tests for hepatitis B and C antibodies were positive, but hepatitis B antigen was negative. Stool examination revealed a few Strongyloides stercoralis rhabditiform larvae.",
+        "imaging_studies": "Abdominal CT with contrast showed abnormal perfusion of the left lobe of the liver, dilatation of the left biliary radicles, and multiple filling defects suggestive of stones or sludge. MRI and MRCP revealed a stricture in the left hepatic duct, multiple filling defects (stones) in the dilated left hepatic ducts, and abnormal enhancement of the left lobe of the liver without a discrete mass. Periportal lymphadenopathy was also noted. ERCP demonstrated partial obstruction of the left main hepatic duct due to extrinsic compression, with purulent bile and small stones above the stenosis.",
+        "diagnosis": "Ascaris lumbricoides infection\nGram-negative bacterial infection\nHepatolithiasis\nRecurrent pyogenic cholangiohepatitis\nChronic hepatitis C\nChronic cholecystitis"
+    },
+    {
+        "Index": "NEJMcpc069006",
+        "patient_info": "Chief Complaint: A 46-year-old woman presented with rapidly increasing abdominal girth over five weeks, accompanied by a rapid weight gain (from 56.7 kg to 70.3 kg), right upper abdominal discomfort, nausea, and vomiting. She also developed dyspnea, which worsened when lying flat, and continued to experience nausea, vomiting, anorexia, and early satiety. Three days after discharge from a previous hospitalization, she returned to the emergency department due to recurrent abdominal distension despite ongoing diuretic therapy.\nPatient Information and Medical History: The patient is a 46-year-old woman born in Egypt, who emigrated to the United States seven years ago. She is a university professor near Boston, divorced, and lives with her teenage son. She does not use alcohol or tobacco. Her maternal grandmother had a history of deep venous thromboses and intestinal cancer. The patient has no personal history of thrombosis and does not take oral contraceptives. She had one pregnancy with a normal vaginal delivery and no miscarriages. Past medical history includes a partial thyroidectomy at age 22 for 'hyperactivity,' an appendectomy, and a tonsillectomy during childhood. She has no known allergies. Current medications include warfarin, spironolactone, zolpidem, and prochlorperazine as needed for nausea.",
+        "laboratory_tests": "The serum-ascites albumin gradient was 1.2 g/dL, indicating portal hypertension. Liver biopsy showed venous outflow obstruction with changes suggestive of partial or incomplete cirrhosis. Hypercoagulability testing revealed heterozygosity for the factor V Leiden mutation. Additional abnormal findings included elevated liver enzymes and low ascitic fluid total protein (<2.5 g/dL).",
+        "imaging_studies": "Abdominal Doppler ultrasonography revealed ascites, hepatofugal flow in the right portal vein, hepatopedal flow in the left portal and splenic veins, and a recanalized umbilical vein. The left and right hepatic veins were not visualized. Abdominal CT showed a narrow intrahepatic inferior vena cava. Venography confirmed narrowing of the intrahepatic inferior vena cava, and intravascular ultrasonography failed to visualize the hepatic veins. Ultrasonography of the right leg revealed deep venous thrombosis involving the right common femoral vein, superficial femoral vein, deep femoral vein, and popliteal vein.",
+        "diagnosis": "Budd–Chiari syndrome, with centrilobular hepatocellular necrosis, sinusoidal dilatation, congestion, and red-cell extravasation consistent with the presence of venous outflow obstruction\nHeterozygosity for factor V Leiden\nV617F mutation in JAK2"
+    },
+    {
+        "Index": "NEJMcpc069024",
+        "patient_info": "Chief Complaint: The patient, a 43-year-old white man, presented with hypogonadism, characterized by fatigue, decreased libido, and erectile dysfunction over the past six months. Ten weeks prior to evaluation, he developed additional symptoms of dry mouth and polyuria. He also reported a 4.5-kg weight loss and arthralgias in the ankles during this period.\nPatient Information and Medical History: The patient is a 43-year-old white man with a history of pulmonary sarcoidosis diagnosed three years earlier, which resolved after six months of corticosteroid therapy. He consumes 5 to 10 alcoholic beverages per week and has never smoked. He works as an engineer and has no significant changes in exercise tolerance. He has a family history of heart disease (father died at 49 years old) and no relevant family history of hemochromatosis. He has traveled extensively to South America, Cuba, Asia, and Egypt. He is married with one adopted child.",
+        "laboratory_tests": "Laboratory tests revealed elevated transferrin saturation (97% on two occasions) and serum ferritin levels, consistent with iron overload. Liver function tests were abnormal, and iron indexes supported hemochromatosis. HFE genotyping confirmed homozygosity for the C282Y mutation.",
+        "imaging_studies": "Cranial MRI revealed a partially empty sella turcica with no pituitary mass lesion. Abdominal and pelvic CT showed an enlarged liver and spleen. Abdominal MRI demonstrated decreased signal intensity in the myocardium, liver, and pancreas on T2-weighted images, with pancreatic atrophy, findings pathognomonic of hemochromatosis.",
+        "diagnosis": "Hereditary hemochromatosis due to a homozygous C282Y mutation in the HFE gene\nHepatic cirrhosis\nDiabetes\nHypogonadism"
+    },
+    {
+        "Index": "NEJMcpc0801192",
+        "patient_info": "Chief Complaint: The patient, a 45-year-old man, was admitted for orthotopic liver transplantation due to end-stage liver disease caused by hepatitis C virus (HCV) and hepatitis B virus (HBV) infections, compounded by chronic alcoholism. His primary complaints included recurrent jaundice, chronic pruritus, ascites, hepatic encephalopathy, and esophageal varices. In the weeks leading to admission, he experienced worsening encephalopathy, ascites, and hyponatremia.\nPatient Information and Medical History: The patient is a 45-year-old man with a history of non-A, non-B hepatitis diagnosed at age 18, likely due to tattoo exposure. He developed chronic hepatitis C and B infections, leading to hepatic cirrhosis diagnosed two years prior to admission. Complications included esophageal varices, fluid retention, ascites, and hepatic encephalopathy. He had a history of heavy alcohol use and underwent multiple therapeutic paracenteses for ascites. Past surgeries included umbilical hernia repair, left orchidopexy, tonsillectomy, and adenoidectomy. Family history includes coronary disease in his father and breast cancer in his mother. He worked in a factory with solvent exposure and had no history of intravenous drug use or blood transfusions.",
+        "laboratory_tests": "Laboratory tests revealed significant abnormalities: 1) Hematocrit and hemoglobin levels were consistently low, with values as low as 17.4% and 6.0 g/dl, respectively. 2) Platelet counts fluctuated, dropping to 44,000/mm³ on the 6th hospital day. 3) Elevated bilirubin levels (total bilirubin peaked at 16.5 mg/dl). 4) Elevated liver enzymes (AST peaked at 1401 U/liter, ALT at 837 U/liter). 5) Hyponatremia (sodium levels as low as 129 mmol/liter) and hyperkalemia (potassium levels as high as 5.6 mmol/liter). 6) Positive stool test for Clostridium difficile toxin on hospital day 17. 7) Cryptococcal antigen detected in serum and cerebrospinal fluid, confirming cryptococcal meningitis.",
+        "imaging_studies": "Imaging studies included: 1) Abdominal ultrasound showing mild ascites and patent hepatic, splenic, and pancreatic vessels post-transplantation. 2) CT scan of the brain on hospital day 14, which showed no evidence of intracranial hemorrhage, mass, or infarct. 3) MRI on hospital day 16, revealing abnormal hyperintensity in the basal ganglia, likely due to hepatic dysfunction. 4) Cholangiography on the 6th postoperative day showed no extravasation of contrast material or bile duct stones.",
+        "diagnosis": "Disseminated cryptococcosis\nCryptococcal meningitis"
+    },
+    {
+        "Index": "NEJMcpc0807506",
+        "patient_info": "Chief Complaint: A 58-year-old man with hemophilia A was admitted to the hospital due to recurrent bleeding, hepatitis C infection, and hepatocellular carcinoma. The patient had a history of multiple hemarthroses and was treated with blood products and clotting factors, which led to hepatitis C infection. The primary concern was the progression of hepatocellular carcinoma and recurrent bleeding episodes.\nPatient Information and Medical History: The patient is a 58-year-old man with a long-standing history of hemophilia A (factor VIII deficiency), diagnosed in infancy. He has a history of multiple hemarthroses and was treated with blood products and clotting factors, which led to hepatitis C infection (genotype 1a). Two years before admission, a liver biopsy revealed chronic hepatitis with bridging fibrosis but no cirrhosis. The patient also has a history of essential hypertension, benign prostatic hypertrophy, and urinary tract infections. Family history includes Parkinson’s disease, prostate cancer, rheumatoid arthritis, and coronary artery disease. One grandson has hemophilia and spina bifida.",
+        "laboratory_tests": "Laboratory tests revealed the following abnormal indicators: Factor VIII levels were <1% (reference range 50–150%), indicating severe hemophilia A. Activated partial-thromboplastin time (aPTT) was prolonged (89.6 seconds). HCV RNA levels were >700,000 IU/mL. Alpha-fetoprotein levels were elevated (10.1 ng/mL). D-Dimer levels were significantly elevated (2457 ng/mL). Other abnormal findings included elevated aspartate aminotransferase (45 U/L) and low albumin (3.7 g/dL).",
+        "imaging_studies": "Eight months before admission, surveillance ultrasonography revealed a solid, hypoechoic mass in the right hepatic lobe. MRI confirmed an encapsulated mass (3.8 cm by 3.8 cm) in the right lobe of the liver, with features suggestive of focal nodular hyperplasia, and an ill-defined mass (1.5 cm in diameter) near the tip of the right lobe. Seven months before admission, a fine-needle aspiration biopsy confirmed hepatocellular carcinoma. CT of the chest and abdomen confirmed the findings and revealed no abnormalities in the chest. Follow-up MRI after radiofrequency ablation showed residual disease and stable satellite lesions.",
+        "diagnosis": "Hepatocellular carcinoma(pathologically T1, with undetermined presence or absence of metastases)\nChronic hepatitis C\nBridging fibrosis"
+    },
+    {
+        "Index": "NEJMcpc1000965",
+        "patient_info": "Chief Complaint: A 58-year-old woman presented with severe, sharp pain in the right upper quadrant that developed suddenly two weeks prior. The pain was intermittent, rated up to 7/10 in severity, and worsened with movement or coughing. There was no radiation of pain, nausea, vomiting, or food intolerance. The pain persisted but decreased in intensity (rated 2/10) by the time of her visit to the hospital.\nPatient Information and Medical History: The patient is a 58-year-old woman with a medical history of diabetes mellitus type 2, hyperlipidemia, hypertension, glaucoma, arthritis, scoliosis, irritable bowel syndrome, and recurrent bronchitis and pneumonia. Previous surgeries include tonsillectomy, adenoidectomy, sinus surgery, and hysterectomy for uterine prolapse. She is currently prescribed lisinopril, timolol, lorazepam, and oxycodone for pain management. She has allergies to sulfa drugs, penicillin, and cephalosporins. She is divorced, lives with relatives, works in an office, and does not smoke, drink alcohol, or use illicit drugs. Family history includes Alzheimer's disease in her mother, colon cancer and end-stage renal disease in her father, and bilateral breast cancer in her sister in her 40s.",
+        "laboratory_tests": "Plasma cortisol level was elevated at 23.5 µg/dL (reference range: 5-15 µg/dL). Vasoactive intestinal polypeptide was within normal limits at 32 pg/mL (reference range: <75 pg/mL). Cytologic examination of the liver mass revealed malignant cells positive for pancytokeratin and synaptophysin, with focal positivity for cytokeratin 7, and negative for chromogranin, cytokeratin 20, and thyroid transcription factor 1.",
+        "imaging_studies": "Initial ultrasonography revealed an 11 cm mass in the right lobe of the liver. CT of the chest showed subsegmental atelectasis in the right lung. CT of the abdomen revealed a hypodense lesion (7.8 cm x 5.3 cm x 11 cm) in the right hepatic lobe, abutting the gallbladder, with slight heterogeneous enhancement. MRI of the liver with gadolinium confirmed a 9.4 cm x 12.3 cm x 8.5 cm lesion in the right lobe, with heterogeneous enhancement, and an additional 5 mm lesion in segment seven suggestive of metastasis. SPECT imaging showed decreased pentetreotide uptake in the right hepatic lobe corresponding to the mass. Colonoscopy revealed a large cecal mass, which was biopsied.",
+        "diagnosis": "Poorly differentiated neuroendocrine carcinoma arising in a tubulovillous adenoma of the cecum, with metastasis to the liver."
+    },
+    {
+        "Index": "NEJMcpc1013928",
+        "patient_info": "Chief Complaint: A 9-month-old boy presented with fever, diarrhea, and signs of liver failure. Symptoms began 2 days prior to admission and included lethargy, irritability, rhinorrhea, intermittent vomiting, nonbloody diarrhea, and decreased oral intake. The fever peaked at 38.1°C, and symptoms worsened despite initial treatment for presumed viral gastroenteritis.\nPatient Information and Medical History: The patient was born full-term via vaginal delivery with normal Apgar scores (8 and 9 at 1 and 5 minutes, respectively). Routine newborn metabolic screening was normal, and he received the hepatitis B vaccine. One month before admission, he had a respiratory infection, and 3 days prior, he sustained a forehead bruise from a fall. He had been otherwise healthy with normal growth and development. His only medication was acetaminophen (120 mg every 4-6 hours as needed for fever) for 1 day. His mother had recent respiratory symptoms and a history of childhood seizures. The patient had no known allergies, toxic exposures, or travel history.",
+        "laboratory_tests": "Initial lab results showed hematocrit 24.7%, hemoglobin 9.2 g/dl, and white blood cell count 19,300/mm³, which decreased over three days. Platelet count dropped from 400,000 to 280,000/mm³. Prothrombin time increased to 18.7 seconds, and INR rose to 1.8. D-dimer levels spiked to 2353 ng/ml. Fibrinogen was low at 91 mg/dl. Electrolytes showed sodium 132 mmol/liter, potassium 5.7 mmol/liter, and carbon dioxide 18.7 mmol/liter. Liver function tests revealed normal bilirubin levels. Tests for viral infections (EBV, hepatitis A, B, C, and respiratory viruses) were negative. Blood, urine, and stool cultures were sterile.",
+        "imaging_studies": "A CT scan of the brain without contrast was normal. Abdominal ultrasound revealed diffusely increased echogenicity in the liver parenchyma, consistent with fatty infiltration, and a small amount of pericholecystic fluid. A CT scan of the abdomen showed a markedly enlarged liver with diffuse hypoattenuation, consistent with fatty infiltration, and mild hepatomegaly. MRI of the brain showed advanced myelination of the white matter and abnormal lipid peaks on magnetic resonance spectroscopy.",
+        "diagnosis": "Microvesicular hepatic steatosis due to CACT deficiency"
+    },
+    {
+        "Index": "NEJMcpc1100920",
+        "patient_info": "Chief Complaint: The patient, a 19-year-old man, presented with recurrent episodes of severe epigastric pain, rated 7/10 in severity, which intermittently increased in intensity and radiated to the flanks and back. The pain was associated with constipation, difficulty sleeping, decreased appetite, and a weight loss of 4.5 kg over the previous week. Symptoms began approximately 6 months prior and were not relieved by antacids, acetaminophen, or other medications. The patient also reported a dry throat, subjective fever, and frontal headache during the initial episode.\nPatient Information and Medical History: The patient is a 19-year-old college student with a BMI of 40 (>97th percentile), indicating obesity. He has a history of consuming one or two alcoholic beverages twice weekly for the past five weeks, with a notable binge of six alcoholic drinks (0.7–1.0 liters of vodka and two beers) three days before the onset of symptoms. He smokes one or two cigarettes weekly but denies illicit drug use. Family history includes paternal high cholesterol, maternal grandfather with coronary artery disease, maternal grandmother with throat cancer, and other relatives with type 1 diabetes mellitus, gallstones, and alcoholism. The patient’s girlfriend recently had infectious mononucleosis. He has received routine immunizations and was generally healthy prior to these episodes.",
+        "laboratory_tests": "Abnormal laboratory findings included elevated lipase (256 U/liter initially, peaking at 440 U/liter) and amylase (180 U/liter initially, peaking at 246 U/liter), consistent with pancreatitis. Urinalysis showed 1+ bilirubin, 2+ ketones, and trace albumin and urobilinogen. White-cell count was elevated during episodes (18,100/mm³), with neutrophilia (87%). High-density lipoprotein cholesterol was low (21 mg/dL). Other tests, including renal function, electrolytes, glucose, and liver enzymes, were within normal limits.",
+        "imaging_studies": "Initial CT scan showed fat stranding and inflammation of the pancreas, consistent with pancreatitis, with a normal gallbladder and no biliary tree obstruction. Abdominal ultrasound revealed mild splenomegaly (14 cm) but no cholelithiasis, cholecystitis, or ascites. MRI of the abdomen with gadolinium and MRCP showed a normal pancreas, pancreatic duct, and common bile duct, with no evidence of structural abnormalities such as pancreas divisum or choledochal cysts.",
+        "diagnosis": "Recurrent pancreatitis due to CFTR and SPINK1 mutations, triggered by alcohol."
+    },
+    {
+        "Index": "NEJMcpc010028",
+        "patient_info": "Chief Complaint: The patient, a 44-year-old woman, presented with abdominal pain, chills, fever, and jaundice. The symptoms began eight days prior to admission and were accompanied by nausea, vomiting, and diarrhea. The abdominal pain was severe and persistent, with associated systemic symptoms indicative of infection.\nPatient Information and Medical History: The patient is a 44-year-old woman with a history of intrahepatic stones treated by lithotripsy five years prior to admission. She immigrated to the United States two years after the procedure. Nineteen months before admission, she experienced similar symptoms of abdominal pain, fever, and chills, which were diagnosed as intrahepatic bile duct dilatation and multiple intrahepatic calculi. She underwent cholecystectomy, choledochoscopy, stone extraction, and choledochojejunostomy two weeks later. Pathological findings revealed chronic cholecystitis and cholelithiasis, with cultures positive for alpha-hemolytic streptococci, enterococci, and rare gram-negative rods. She does not drink alcohol and her only medication is acetaminophen.",
+        "laboratory_tests": "Blood tests revealed elevated total and conjugated bilirubin, slightly elevated protein, low albumin, and normal globulin levels. Urea nitrogen increased during hospitalization, while creatinine remained normal. Glucose was slightly elevated on admission. Enzymes such as alkaline phosphatase, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, lipase, amylase, and creatine kinase showed varying degrees of elevation. Urinalysis showed bile, protein, urobilinogen, and red and white blood cells. Stool was positive for occult blood, though the patient was menstruating. Cultures from abscess drainage grew Streptococcus milleri group, alpha-hemolytic streptococci, peptostreptococcus, bacteroides species, and rare Escherichia coli.",
+        "imaging_studies": "Initial abdominal CT scans revealed marked intrahepatic bile duct dilatation and multiple intrahepatic calculi. Subsequent imaging showed decompression of the intrahepatic bile ducts but persistent calculi. On admission, a CT scan revealed multiple irregular areas of low attenuation in the left hepatic lobe, suggesting abscesses, and pneumobilia. Ultrasound confirmed pneumobilia and heterogeneous hepatic parenchyma with hypoechoic foci. Endoscopic retrograde cholangiopancreatography (ERCP) showed marked dilatation of the intrahepatic ducts, particularly on the left side, with possible bile-duct stenosis and multiple calculi up to 3.5 cm in diameter. A percutaneous transhepatic cholangiogram later confirmed communication between the left biliary ducts and an abscess cavity.",
+        "diagnosis": "Recurrent pyogenic cholangitis (Oriental cholangiohepatitis)"
+    },
+    {
+        "Index": "NEJMcpc020003",
+        "patient_info": "Chief Complaint: A 17-year-old boy presented with nearly constant crampy, nonradiating pain in the epigastrium, right upper quadrant, and periumbilical area, exacerbated by eating and accompanied by nausea. He also reported intermittent loose stools, a dry cough, left-sided pleuritic chest pain, and intermittent fever up to 38.3°C over the past several weeks. The symptoms began several weeks before admission and worsened in the two weeks prior, with a 3 kg weight loss noted during this period.\nPatient Information and Medical History: The patient is a 17-year-old male student with no history of alcohol or illicit drug use. Seventeen months prior, he was hospitalized for bloody diarrhea, diagnosed with Clostridium difficile infection, and treated with a one-month course of metronidazole. He had no family history of inflammatory bowel disease or rheumatic disorders. His immunizations were up to date, including hepatitis B vaccination. Physical examination revealed mild scleral icterus, sternal tenderness, and slight right upper quadrant abdominal tenderness. Stool was positive for occult blood, and urine was dark.",
+        "laboratory_tests": "Laboratory findings included leukocytosis with a leftward shift, elevated aspartate aminotransferase (75 U/L), elevated alkaline phosphatase, low albumin, calcium, and cholesterol levels, and prolonged prothrombin time. Stool microscopy showed undigested muscle fibers and yeasts, with no protozoa or helminthic ova. Urine was positive for bile and minimally positive for urobilinogen. Stool culture was negative for enteric pathogens, and C. difficile toxin assay was negative.",
+        "imaging_studies": "Chest radiographs showed bilateral prominence of interstitial markings and suggested right lower lobe pneumonia. Abdominal ultrasonography revealed no abnormalities. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to evaluate biliary obstruction, showing narrowing of intrahepatic bile ducts. Liver biopsy revealed preserved hepatic architecture with periductal edema and fibrosis, characteristic of primary sclerosing cholangitis.",
+        "diagnosis": "Primary sclerosing cholangitis\nCrohn’s disease"
+    },
+    {
+        "Index": "NEJMcpc020023",
+        "patient_info": "Chief Complaint: A 54-year-old man presented with severe, diffuse abdominal pain, lethargy, fever (up to 38.3°C), night sweats, and unintentional weight loss of 16.1 kg over six weeks. He also reported a 6-to-12-month history of hematochezia. The patient noted abdominal distension and believed his liver was enlarged.\nPatient Information and Medical History: The patient is a 54-year-old male executive with no significant past medical history. He drinks two bottles of beer daily and does not smoke. He reported recent difficulty concentrating but denied chest pain, headache, nausea, vomiting, or diarrhea. Family history includes his mother’s death from leukemia at age 33. No other family history of malignancy was reported.",
+        "laboratory_tests": "Abnormal indicators included elevated bilirubin (conjugated 5.1 mg/dl, total 5.8 mg/dl), decreased albumin (2.4 g/dl to 1.8 g/dl), elevated alkaline phosphatase (632 U/liter), elevated aspartate aminotransferase (324 U/liter), and extremely high lactate dehydrogenase (4,003 U/liter). CA 19-9 was elevated at 81 U/ml. Hematocrit decreased from 41.3% to 38.0% on admission. Urinalysis showed bilirubin and protein positivity, with red cells and calcium oxalate crystals in the sediment.",
+        "imaging_studies": "CT scan of the thorax revealed numerous pulmonary nodules (≤0.6 cm) and mediastinal lymph nodes (largest 1.0 cm). Bilateral axillary lymph nodes (up to 2.0 cm) were noted. Abdominal and pelvic CT showed hepatomegaly with heterogeneous attenuation, a small amount of free fluid around the liver, and enlarged retroperitoneal, mesenteric, pelvic, and iliac lymph nodes. MRI of the brain revealed a 1.3 cm focal hyperintensity. No abnormalities were noted in the gallbladder, spleen, pancreas, adrenal glands, kidneys, or bowel.",
+        "diagnosis": "Diffuse large-B-cell lymphoma, presenting in the liver"
+    },
+    {
+        "Index": "NEJMcpc030004",
+        "patient_info": "Chief Complaint: The patient, a 14-year-old boy with a history of ulcerative colitis, was admitted to the hospital due to vomiting and severe abdominal pain. The abdominal pain was constant, diffuse, and worsening, with no associated fever, diarrhea, or urinary symptoms. The pain was most severe in the right upper quadrant and could not be controlled with oral opiates.\nPatient Information and Medical History: The patient is a 14-year-old boy diagnosed with ulcerative colitis at the age of three. His disease progression was well-controlled with mesalamine and short courses of adrenocorticosteroids for flares. He has a history of primary sclerosing cholangitis (PSC), diagnosed 14 months prior to the current admission, with multiple hospital admissions for complications including cholangitis, pancreatitis, and acute acalculous cholecystitis. He underwent a cholecystectomy and multiple endoscopic retrograde cholangiopancreatography (ERCP) procedures with stent placements. There is no family history of gastrointestinal or autoimmune diseases.",
+        "laboratory_tests": "Laboratory tests showed elevated total bilirubin (peaking at 15.9 mg/dl) and conjugated bilirubin (peaking at 14.9 mg/dl). Albumin levels decreased significantly (from 2.7 mg/dl to 1.9 mg/dl). Amylase and lipase levels were initially elevated but decreased over time. Blood cultures grew Klebsiella oxytoca, indicating bacterial cholangitis. CA 19-9 antigen levels were extremely elevated (3000 U/ml), suggesting malignancy.",
+        "imaging_studies": "Multiple imaging studies were performed, including abdominal and pelvic CT scans, which revealed biliary duct dilatation, bile lakes, and edema within the liver parenchyma. A biliary stent was noted in the porta hepatis. The pancreatic head was enlarged, but no discrete mass was observed. An upper gastrointestinal series showed a markedly enlarged stomach with a 7 cm stricture in the proximal duodenum. ERCP studies demonstrated strictures and dilatations in the intrahepatic biliary ducts, consistent with primary sclerosing cholangitis, and a stricture in the pancreatic duct.",
+        "diagnosis": "Cholangiocarcinoma\nDuodenal stricture"
+    },
+    {
+        "Index": "NEJMcpc030022",
+        "patient_info": "Chief Complaint: A 36-year-old man presented with recurrent epigastric pain lasting for five months. The pain was persistent and associated with elevated amylase levels, which did not normalize over time. There were no episodes of nausea, vomiting, or diarrhea.\nPatient Information and Medical History: The patient is a 36-year-old man with a history of hypertension managed with moexipril hydrochloride. He had a sigmoid colon resection 11 months prior due to diverticulitis, with no recurrence of symptoms. He does not smoke, drinks alcohol moderately on weekends, and exercises regularly. He reported a 5.5 kg weight loss recently, along with constipation and urinary frequency. Family history includes a paternal grandmother who died of 'stomach cancer,' but no family history of pancreatitis.",
+        "laboratory_tests": "1. **Amylase**: Persistently elevated (349 U/L initially, 355 U/L at hospital admission; normal range: 25–115 U/L). 2. **Lipase**: Elevated (79.6 U/L; normal range: 0–60 U/L). 3. **Urinary Amylase**: Elevated (4258 U/L). 4. **Amylase-Clearance Ratio**: 3.6, inconsistent with acute pancreatitis but suggestive of smoldering pancreatitis. 5. **Other Tests**: Normal white-cell count, liver function tests, and hematocrit. Platelet count slightly elevated (382,000/mm³).",
+        "imaging_studies": "1. **Abdominal Radiographs**: No evidence of bowel obstruction or perforation. 2. **Abdominal Ultrasonography**: No gallstones detected. 3. **Contrast-Enhanced CT Scan**: Enlargement of the pancreatic head and body, with stranding in the peripancreatic fat. No pancreatic duct or common bile duct dilatation. 4. **Endoscopic Retrograde Cholangiopancreatography (ERCP)**: Initial study showed a smooth stricture in the distal common bile duct and possible stricture in the left hepatic duct. Follow-up after corticosteroid therapy showed resolution of the bile duct stricture but persistent irregularity and obstruction of the pancreatic duct. 5. **Endoscopic Ultrasonography**: Diffuse parenchymal abnormalities in the pancreas, including hyperechoic strands, hypoechoic foci, and lobularity, suggestive of inflammatory or malignant infiltration.",
+        "diagnosis": "Lymphoplasmacytic sclerosing pancreatitis"
+    },
+    {
+        "Index": "NEJMcpc030027",
+        "patient_info": "Chief Complaint: The patient, a 75-year-old man, presented with a cystic lesion of the pancreas. He reported intermittent, mild, vague upper abdominal pain with possible early satiety for several years. The pain did not radiate to the back, and he had not experienced weight loss. He also had a history of gastroesophageal reflux, which was managed with pantoprazole.\nPatient Information and Medical History: The patient is a 75-year-old retired engineer with a history of hypertension, well-controlled with doxazosin and hydrochlorothiazide. He previously consumed four to five alcoholic beverages daily but reduced this to one drink daily in recent years. He does not smoke. Past imaging studies revealed a hyperechoic mass in the right hepatic lobe (hemangioma) and multiple hepatic cysts. Liver function tests were normal, but iron saturation was elevated at 53%. Physical examination revealed no abnormalities, with normal vital signs and no signs of rash, lymphadenopathy, or organomegaly.",
+        "laboratory_tests": "Laboratory results were largely normal, including hematocrit (38.3%), white-cell count (6400/mm³), platelet count (359,000/mm³), and mean corpuscular volume (92 μm³). Liver function tests, electrolytes, glucose, bilirubin, and pancreatic enzymes (amylase, lipase) were within normal ranges. Cyst fluid analysis revealed elevated carcinoembryonic antigen (8960 ng/mL) and CA 72-4 (400 U/mL), consistent with a mucinous tumor. Cytologic examination showed mucinous glandular epithelial cells with moderate atypia, indicating a borderline tumor.",
+        "imaging_studies": "Abdominal CT with contrast revealed a cystic lesion in the pancreatic duct at the junction of the body and tail of the pancreas, with slight ductal dilatation. A 2 cm fluid-filled structure contiguous with the duct was noted. The pancreatic duct was beaded and dilated from the head to the tail. The liver showed multiple cysts and a hemangioma, but no biliary duct dilatation or peripancreatic lymph node enlargement. Endoscopic ultrasound confirmed diffuse dilatation of the main pancreatic duct (3 mm) and identified a unilocular, thin-walled cyst communicating with the duct. Chest radiographs showed a questionable nodular opacity in the right hilar region and a tortuous thoracic aorta.",
+        "diagnosis": "Intraductal papillary mucinous carcinoma of the pancreas"
+    },
+    {
+        "Index": "NEJMcpc030040",
+        "patient_info": "Chief Complaint: A 28-year-old man presented with severe abdominal pain localized to the right upper and right lower quadrants, which began as mild epigastric pain 10 days prior. The pain became constant and severe two days before admission, accompanied by nausea, chills, and a fever of 38.3°C. No vomiting, jaundice, or gastrointestinal bleeding was reported.\nPatient Information and Medical History: The patient is a 28-year-old man from Morocco who immigrated to the United States 13 months prior. He has no history of abdominal surgery, diarrhea, hematochezia, melena, or contact with ill persons. He smokes cigarettes but does not consume alcohol. His family history includes a brother who had active tuberculosis during childhood.",
+        "laboratory_tests": "Urinalysis showed ketones (+), 2 red cells, 3-5 white cells, and a few bacteria per high-power field. Hematologic tests revealed a white-cell count of 11,000/mm³ (79% neutrophils) and a hematocrit of 39.6%. Liver function tests, amylase, lipase, and other biochemical markers were normal. A serologic test for Helicobacter pylori was positive. Fine-needle aspiration of the lesion showed acute inflammation with chronic inflammation and reactive ductal epithelium, suggesting an abscess.",
+        "imaging_studies": "Abdominal radiographs showed air-filled loops of small bowel without dilatation or air-fluid levels, and no free intraperitoneal air. Abdominal and pelvic CT scans revealed a well-defined, 5 cm mass in the head of the pancreas, with no evidence of metastatic disease. A specialized CT study showed a complex, multicytic mass (3.2 x 5.1 cm) contiguous with the pancreatic head, with heterogeneous enhancement and multiple cystic nodules near the porta hepatis. Endoscopic ultrasonography confirmed a heterogeneous, mixed lesion with solid and cystic components adjacent to the pancreas.",
+        "diagnosis": "Tuberculous lymphadenitis"
+    }
+]

Journal_part2.json

@@ -0,0 +1,142 @@
+[
+    {
+        "Index": "曾诊为胆囊原位癌患者发生皮肤转移1例",
+        "patient_info": "患者为 81 岁男性，10 年前因右上腹部疼痛在当地医院诊断为 “胆囊癌” 并进行胆囊摘除术，术后病理显示为胆囊原位腺癌，但术后患者及家属未重视，未进行随访。2014 年 12 月，患者因 “右下腹结节斑块伴疼痛 10 月余” 前往普外科就诊。此时患者神志清，生命体征平稳，但呈恶病质面容。其右下腹可触及一包块，该包块进行性增大，致使右腹部皮肤逐渐变硬、形成瘢痕，局部出现萎缩、褶皱，弹性差，呈盔甲状，有少许脓性分泌物，压痛明显，疼痛觉敏感，皮温正常，无黏液性水疱或黏稠液体流出。皮肤科检查发现右下腹可触及约 10cm×12cm 的片状结节及斑块，位置固定、质地坚硬、压痛明显，部分有瘢痕形成，皮肤较敏感，皮温正常，无破溃及糜烂，双手指外形及功能未见异常，雷诺氏现象（-）。",
+        "laboratory_tests": "对皮损处脓性分泌物进行细菌培养，结果显示为化脓链球菌（A 群）。免疫学检查中，IgG 为 6.81，KAP 为 5.91，LAM 为 2.99 ，抗核抗体谱呈阴性。皮损组织病理检查可见真皮内胶原纤维及脂肪层、肌肉组织间有穿插走行的癌细胞，部分呈团块状，异型细胞大小不等、形状不规则，有明显核分裂，核深染，胶原纤维局部硬化。免疫组化结果显示，右下腹壁病变支持转移性低分化腺癌，具体表现为 CK 广（+） ，CK7（+） ，Villin（+） ，CK8（+）；CK 广（+） ，LCA（灶 +） ，Villin（+） ，EMA（+） ，CEA（+） ，而 CD3、CD4（-） ，S100（-） ，C68（-） ，MPO（-） ，CA125 为 46.4U/mL。",
+        "imaging_studies": "PET-CT 检查结果显示，中下腹壁皮下存在结节状高代谢灶，符合恶性病变征象；左肾及左侧输尿管上段明显扩张积水；前列腺增生且内部有不规则钙化灶；双侧睾丸鞘膜积液；有慢性支气管炎征象；双侧胸腔积液，双下肺膨胀不全，主动脉壁钙化；但全身其他部位 PET/CT 显像未发现明显异常征象。",
+        "diagnosis": "胆囊原位癌皮肤转移"
+    },
+    {
+        "Index": "表现为原位癌改变的肝囊肿1例",
+        "patient_info": "患者为 45 岁男性，无特殊病史。1 个月前因胃部不适就诊当地医院，发现肝囊肿，入院时诉上腹部少许胀满感，无腹痛，查体无特殊。",
+        "laboratory_tests": "CEA、AFP、CA19 - 9 正常，肝功能检查中 ALT 为 436u/L，AST 为 254u/L，ALP 为 218u/L，GGT 为 223u/L。",
+        "imaging_studies": "腹部彩超提示肝巨大囊肿，约 14cm×11cm；腹部 CT 平扫提示肝内多发大小不等类圆形、团块状液性低密度影，边界清，较大者为 14.3cm×11.6cm×12.7cm，大部分突出肝包膜外，CT 值 8HU。术后 8 个月复查 CT 增强提示肝内新增多发低密度结节，考虑转移瘤，伴腹膜转移。",
+        "diagnosis": "肝囊肿\n被覆上皮重度异型增生-原位癌改变"
+    },
+    {
+        "Index": "肝昏迷患者经人工肝治疗后成功行跨血型肝移植1例报告",
+        "patient_info": "患者为 51 岁男性，既往体健，已戒烟戒酒 20 年，无特殊药物服用史。因 “体检发现转氨酶高 1 个月” 就诊，在外院接受保肝、利胆及人工肝治疗 3 次后病情加重，从清醒逐渐发展至昏迷，遂转入本院。入院查体显示身高 173cm，体质量 81kg，BMI 27.06kg/m² ，处于浅昏迷状态，有肝病面容，皮肤黏膜及巩膜黄染，双侧瞳孔等大等圆，直径约 5mm，对光反射迟钝，深大呼吸，双肺呼吸音粗且散在湿性啰音，腹部膨隆，移动性浊音阳性，双下肢及低垂部位轻度水肿。",
+        "laboratory_tests": "2021 年 10 月 26 日入院时，血常规显示白细胞计数12.11×10^9/L，红细胞计数3.20×10^12/L，血红蛋白 106g/L，红细胞压积未提及，血小板58×10^9/L；全血 C 反应蛋白 23.96mg/L；降钙素原 1.9ng/mL；血凝常规显示凝血酶原时间 25.90s，凝血酶原活动度 31.00%，国际标准化比值 2.42，纤维蛋白原 0.93g/L，部分凝血活酶时间 74.90s，APTT 比值 2.2；血氨 431μmol/L；肝功能指标为血清 AST 483U/L，ALT 262U/L，白蛋白 43.8g/L，总胆红素 739.1μmol/L；肾功能指标为尿素氮 10.1mmol/L，肌酐 155.47μmol/L，乳酸 13.2mmol/L。甲胎蛋白等肿瘤标志物无升高，肝炎及自身抗体相关化验均阴性，梅毒及 HIV 阴性",
+        "imaging_studies": "2021 年 10 月 28 日腹部 CT 提示肝硬化、脾肿大、门静脉高压、腹水表现、胆囊区高密度影；当日胸部 CT 提示左肺上叶炎性结节可能，双肺坠积性炎症可能性大，双侧胸膜增厚，右侧少量胸腔积液、心腔密度减低。",
+        "diagnosis": " 慢加急性肝衰竭\n肝性脑病\n高胆红素血症\n高氨血症\n肝硬化\n脾肿大\n门静脉高压\n腹水\n高乳酸血症\n凝血功能障碍\n肺部感染\n急性肾功能不全"
+    },
+    {
+        "Index": "肝结核1例报告并文献复习",
+        "patient_info": "患者为 53 岁男性，自 2013 年底逐渐出现消瘦、纳差症状，近期精神欠佳但体力正常，近半年体重减轻约 10kg。2014 年 5 月转入本院，入院时全身浅表淋巴结未扪及肿大，双肺呼吸音清，未闻及干湿啰音，腹软，无压痛、反跳痛、肌紧张，移动性浊音阴性，双下肢不肿。",
+        "laboratory_tests": "2014 年 3 月外院糖类抗原测定显示 CA19 - 9 为 3.33U/ml，CA125 为 173.4U/ml，CA15 - 3 为 42.85U/ml。转入本院后，血、尿、便常规均未见异常，结核杆菌干扰素释放试验阳性，血沉 24mm/h 。",
+        "imaging_studies": "2014 年 3 月外院胃镜示胃窦炎，肠镜示慢性结肠炎，腹部彩超示肝周腹膜上减低回声结节，腹腔及腹膜后多发淋巴结肿大，腹腔积液，肝脏实性小结节。转入本院后，胸部平片及 CT 均未见异常，PET - CT 示部分肝包膜、裂间隙、腹膜部分大网膜、肠系膜及盆底腹膜不规则伴 2－氟－2－脱氧－D－葡萄糖代谢异常增高，肝门、胰头区及腹膜后增大淋巴结影伴 FDG 代谢异常增高，腹盆腔少量积液。",
+        "diagnosis": "肝结核"
+    },
+    {
+        "Index": "肝结核1例报告",
+        "patient_info": "患者为 43 岁女性，既往无乙型肝炎和结核病史，无其他传染病接触史。入院前 5 个月无明显诱因出现纳差症状，曾在院外使用 “喹诺酮类” 药物 “抗炎” 治疗，3 天前行腹部 B 超发现肝占位（右前叶 40mm×51mm），于 2014 年 8 月入院。",
+        "laboratory_tests": "甲胎蛋白 (AFP)、癌胚抗原 (CEA) 和糖类抗原 19 - 9 均正常，血结核抗体检查为阴性，连续 3 天痰涂片找结核杆菌阴性。",
+        "imaging_studies": "腹部 B 超显示肝右前叶占位（40mm×51mm）；腹部平扫 + 增强 CT 示肝右前叶占位 42mm×47mm，平扫呈稍低密度（CT 值 38Hu），增强可见不均匀强化（CT 值 70Hu），门静脉期及延迟扫描强化程度有所减低（CT 值 60Hu），考虑肝癌转移可能。",
+        "diagnosis": "肝结核"
+    },
+    {
+        "Index": "肝结核误诊为肝转移癌1例报告",
+        "patient_info": "45 岁女性，5 天前出现上腹间断性疼痛，可自行缓解，伴发热，体温最高 38.5℃，于 2016 年 4 月 22 日入院。2012 年 7 月行右乳肿物切除术，病理回报右侧乳腺不除外结核，查体腋下淋巴结肿大，一般状态尚可，饮食睡眠欠佳，近期体重未见明显减轻。",
+        "laboratory_tests": "血沉 59mm/h，CRP24mg/L，结核分枝杆菌感染 T 淋巴细胞斑点试验阳性，肿瘤标志物正常。",
+        "imaging_studies": "腹部彩超示肝脏多发占位，考虑转移癌；肝胆脾 CT（平扫 + 增强）示肝脏形态欠规整，内有多发类圆形低密度影，增强扫描病灶边缘强化呈 “牛眼” 样改变；PET-CT 示右侧腋窝淋巴结肿大伴代谢增高及肝脏多发高代谢灶，考虑淋巴瘤可能性大，建议结合病理学检查除外结核可能。",
+        "diagnosis": "肝结核"
+    },
+    {
+        "Index": "孤立性肝门区淋巴结结核 1 例报告",
+        "patient_info": "青年女性，1 周前体检偶然发现肝门区占位，于 2018 年 10 月 18 日收入院。入院时无腹痛、腹泻，否认低热、乏力、纳差、尿色加深等症状，自幼体健，无结核病史及接触史。专科查体未见皮肤及巩膜黄染，未触及肿大浅表淋巴结，腹部叩诊鼓音，无压痛、反跳痛及肌紧张，移动性浊音阴性，肠鸣音 4 次 /min 。",
+        "laboratory_tests": "血常规中白细胞数量及淋巴细胞比例正常；肝功能检验示 ALT 57.9U/L、GGT 267.3U/L、ALP 197.5U/L，其余结果正常；肿瘤标志物中 CA -125 为 36.59U/ml，其余肿瘤标志物均正常；红细胞沉降率及结核感染 T 细胞斑点实验（T -SPOT 实验）结果均为阴性。术中快速病理、术后慢病理提示淋巴结结核，术中送检 XpertMTB/RIF 快速检测，提示结核分枝杆菌复合物 DNA 阳性。",
+        "imaging_studies": "腹部增强 CT 显示肝门区有团块状软组织密度影，内有结节状钙化影，大小约 5.3cm×4.3cm，增强扫描呈多房低密度影，分隔区不均匀强化，病变包绕门静脉主干，与胆总管、胰颈部、肝脏分界不清，局部胆总管管腔变窄，管壁增厚并延迟强化，继发肝内外胆管扩张；肺部平扫 CT 提示双肺纹理略增强，肺内支气管分支管壁略增厚，右肺内部有少量结节状钙化灶，考虑为支气管炎。",
+        "diagnosis": "肝门区淋巴结结核"
+    },
+    {
+        "Index": "慢性酒精性肝炎肝昏迷并戒酒综合征一例",
+        "patient_info": "患者为 44 ��男性，有 20 年饮酒史，每日饮酒约 500g，无乙肝家族史。近 6 个月常感乏力、有时厌油腻，7 小时前饮酒后呕吐，先是食物后为鲜血，量约 500ml，伴有头痛头晕、反应迟钝、表情淡漠、计算力差，无腹痛腹泻及黑便，经急诊止血、补液治疗后症状稍好转转入消化内科。入院查体体温 37.2℃，脉搏 78 次 / 分，呼吸 20 次 / 分，血压 145/85mmHg，神志清但表情淡漠，巩膜黄染，无肝掌蜘蛛痣，腹膨隆，肝肋下未及，剑下约 7cm，质韧、表面不平、触痛，莫非氏征阴性，腹水征阴性，扑击样震颤（+）。",
+        "laboratory_tests": "急查肝功显示 ALT 23U/L、AST 92U/L、ALP 125U/L、GGT 549U/L、TBil 89.4μmol、DBil 25.1μmol/L、T 81g/L、A 49g/L、G 32g/L ，HBsAg（-），CEA5.7ng/ml（正常值 0 - 2.5），AFP 20.4ng/ml（正常值 < 8.1ng/ml），PIP13 秒。",
+        "imaging_studies": "上腹部 CT、B 超均显示肝硬化、脾大、门脉高压。",
+        "diagnosis": "慢性酒精性肝炎\n肝硬化\n肝昏迷\n戒酒综合征"
+    },
+    {
+        "Index": "胰腺结核的诊断及治疗",
+        "patient_info": "39 岁女性，既往体健，近 10 余天出现中上腹不适感伴午后低热。查体体温 37.2℃，巩膜无黄染，心肺无异常，中上腹触及质硬、固定且有压痛的肿块。",
+        "laboratory_tests": "血红蛋白 103g/L，红细胞 3.6×10¹²/L，白细胞 4.1×10⁹/L，中性 0.704，血沉 105mm/h，肝功能正常，CA125 为 430.3U/L，CA19 - 9 为 16.68U/ml。",
+        "imaging_studies": "B 超显示胰头周围及第一肝门实质肿块伴多发性淋巴结肿大，胆囊大小为 57mm×15mm，总胆管直径为 5mm；CT、MRCP 提示胰头钩突占位，考虑系胰腺癌；CT 还显示轻度胃窦炎。",
+        "diagnosis": "腹腔结核\n胰腺结核"
+    },
+    {
+        "Index": "胰腺结核的诊断及治疗",
+        "patient_info": "72 岁女性，既往有颈淋巴结结核病史，近 2 周余出现无痛性进行性黄疸。查体体温 37℃，皮肤巩膜明显黄染，右中上腹轻压痛 。",
+        "laboratory_tests": "血红蛋白 136g/L，红细胞 4.3×10¹²/L ，白细胞 5.9×10⁹/L，中性 0.664，CEA 30.72μg/ml，CA19 - 9＞900U/ml，血清总胆红素 69μmol/L，结合胆红素 39μmol/L，ALT 215U/L，γ - GT 156U/L。",
+        "imaging_studies": "B 超显示阻塞性黄疸，胆总管下段胰腺区实质占位，胆囊大小为 98mm×35mm，胆囊炎，胆胰管扩张；CT 显示胆囊炎，胆囊底部结石；MRI 显示肝内外胆管明显扩张，主胰管扩张，考虑系胰头部占位性病变；ERCP 显示胆总管下端梗阻，胆总管下端癌可能。",
+        "diagnosis": "胰头部结核"
+    },
+    {
+        "Index": "胰腺结核致门静脉高压1例报告",
+        "patient_info": "患者为 23 岁男性，有 7 年余乙型肝炎病原学阳性史，4 年前行阑尾切除术，3 年前确诊淋巴结结核并接受左侧颈部淋巴结切除术和系统抗结核治疗，自述已治愈。因间断腹部不适、乏力伴发热 3 个月入院，入院查体呈贫血貌，全身浅表淋巴结无肿大，皮肤及巩膜无黄染，无肝掌、蜘蛛痣，左侧颈部有手术瘢痕，余查体无明显阳性体征。",
+        "laboratory_tests": "血常规显示 WBC4.64×10^9/L，中性粒细胞百分比 0.79，淋巴细胞百分比 0.08，单核细胞百分比 0.13，RBC 3.55×10^12/L，Hb88g/L，PLT 241×10^9/L；HBsAg、抗 - HBc、HBV 前 S1 抗原阳性，HBVDNA 定量4.70×10 ^2IU/ml，HCV 抗体阴性，肝功能、肾功能、离子、血淀粉酶、脂肪酶、自身免疫系列、T 淋巴细胞斑点试验、尿常规等大致正常；结核分支杆菌抗体阳性，血沉 120mm/1h，T 淋巴细胞斑点试验阴性。",
+        "imaging_studies": "外院腹部彩超提示肝左叶占位性病变（待除外肝癌）、胰腺占位性病变（可疑胰腺癌）、脾肿大、腹腔积液；本院 CT 平扫 + 三期增强提示肝脏密度稍欠均匀，胰腺及其周围渗出性改变（考虑胰腺炎所致可能性大），继发肝内外胆管及胰管略扩张，肝门区局部及胰腺周围多发异常密度影（考虑胰腺假性囊肿可能性大），脾略肿大，少量腹腔积液，腹腔及腹膜后淋巴结略肿大；胃镜提示食管静脉曲张 。",
+        "diagnosis": "胰腺结核\n区域性门静脉高压"
+    },
+    {
+        "Index": "以假性肝硬化起病的乳腺癌肝转移一例报告并文献复习",
+        "patient_info": "患者,女,46岁,因“腹胀2个月余,尿黄1个月余” 于2019年1月3日入院｡入院前2月余无诱因出现腹 胀,间断上腹部隐痛不适､恶心､食欲下降,自服奥美拉唑等治疗,症状无改善｡人院前1月余逐渐出现尿黄,伴少尿,腹胀逐渐加重,就诊当地医院,查肝功能: ALT76 U/L,T—BIL 51.1 IzmoYL,GGT577 U/L,HBsAg 阴性,抗HCV阴性,腹部超声提示肝硬化､腹水,腹部MRI提示肝弥漫性结节��腹水､下腔静脉肝段狭窄,考 虑“布加综合征”,给予保肝､退黄､利尿､抗凝等治疗, 肝功进行性加重恶化｡查体:神清,精神弱,消瘦,慢性肝病面容,皮肤巩 膜重度黄染,心肺未见异常,腹部膨隆,全腹无压痛､ 反跳痛及肌紧张,肝脾肋下未及肿大,移动性浊音阳 性,双下肢无水肿｡患者1年前当地医院诊断(左乳) 乳腺导管原位癌,行左乳切除治疗,术后长期服用托瑞米芬治疗｡人院前7个月体检时查腹部CT未见明显异常。",
+        "laboratory_tests": "1.实验室检查:血常规:WBC 7.54×10^9/L､Hb 102 g/L､PLT 144×10^9/L;肝功能:ALT 70.2 U/L､AST 192.2 U/L､T—BIL 266.6 Ixmol /L､D—BIL 243.7斗mol /L､ ALB 29.8 g/L;凝血酶原活动度(prot hrombi n t i me acti vi ty,PTA)44%;嗜肝病毒血清学标志物阴性;自身 抗体谱:ANA 1:100,余阴性;铜蓝蛋白水平正常;肿瘤 标志物:AFP:2.18 ng/ml ,CEA:5.27 ng/ml ,CAl 25: 382 U/ml ,CAl 9- 9:33.98 U/ml ,CA72—4:6.3 U/ml , CAl 5- 3:18.09 U/ml。经颈内静脉肝组织活检，肝组织病理提示肝组织内可见大量浸润的低分化癌；免疫组化结果为 CK7 (+++)、CK19 (+++)、ER ( - )、PR ( - )、HER - 2 (+++)、GCDFP - 15 (+)、E - cad (+)、Hepa (肝细胞 +)、GS (肝细胞 +)、P53 (+++)、MUM1 ( - )、Ki67 (约 70%)、GPC - 3 ( - )、Masson (+)、D - PAS ( - )。",
+        "imaging_studies": "腹部 CT 提示肝硬化、脾大、侧支循环形成、腹水、肝多发再生结节可能、下腔静脉肝段局部狭窄；腹部 MRI 提示肝硬化伴多发再生结节形成、脾大、侧支循环形成、肝门静脉右后支及肠系膜上静脉栓子形成、大量腹水、肝右叶前上段和前下段结节；胃镜检查提示食管静脉重度曲张、胃静脉曲张（GOV1 型）、门静脉高压性胃病。",
+        "diagnosis": "乳腺癌肝转移"
+    },
+    {
+        "Index": "原发性胰腺结核的诊断及治疗(附4例报告)",
+        "patient_info": "43 岁男性，曾行右手背 “皮下结节” 切除，病理为 “滑膜结核”，术后单用 PAS 治疗半年。此次因进行性黄疸伴腹痛、消瘦半月入院，查体皮肤巩膜深度黄染，剑突下压痛，可扪及约 5cm×5cm 较硬、固定肿块。",
+        "laboratory_tests": "AKP 954.9IU/L，TBil 69.1μmol/L，其余无异常。",
+        "imaging_studies": "B 超及 CT 均显示胰头部实质性占位，胆总管受压扩张。",
+        "diagnosis": "胰腺结核"
+    },
+    {
+        "Index": "原发性胰腺结核的诊断及治疗(附4例报告)",
+        "patient_info": "24 岁男性，上腹胀半年，伴恶心、呕吐、黑便 2 周入院，巩膜轻度黄染。心肺未见异常，剑下及左上腹轻微压痛",
+        "laboratory_tests": "血沉 86mm/h，大便隐血试验阳性。",
+        "imaging_studies": "B 超显示右上腹 5.0cm×6.2cm 回声强弱不等团块，形态欠规则，边界欠清，有腹水；CT 增强扫描见胰头（钩突）处肿块，强化不规则，十二指肠管壁增厚，管腔狭窄、推移，肝门区、腹膜后间隙多个低密度肿大淋巴结，环形强化并融合成多房状，有少量腹水。",
+        "diagnosis": "胰腺结核\n淋巴结结核"
+    },
+    {
+        "Index": "原发性胰腺结核的诊断及治疗(附4例报告)",
+        "patient_info": "70 岁女性，既往有颈淋巴结结核病史，因无痛性进行性黄疸 3 周余入院，体温 37℃，皮肤巩膜明显黄染，右中上腹轻压痛",
+        "laboratory_tests": "AKP 846.9IU/L，TBil 72.1μmol/L，血沉 105mm/h。",
+        "imaging_studies": "B 超显示阻塞性黄疸，胆总管下段胰腺区实质占位，胆囊炎，胆胰管扩张；CT 显示胆囊炎，胆囊底部结石；MRI 显示肝内外胆管明显扩张，主胰管扩张；ERCP 显示胆总管下端梗阻，考虑胆总管下端癌可能。",
+        "diagnosis": "胰头部结核"
+    },
+    {
+        "Index": "原发性胰腺结核的诊断及治疗(附4例报告)",
+        "patient_info": "42 岁女性，既往体健，中上腹不适感伴午后低热 15 天入院，体温 37.6℃，巩膜无黄染，中上腹触及质硬、固定且有压痛的肿块。",
+        "laboratory_tests": "血沉 101mm/h，肝功能正常。",
+        "imaging_studies": "B 超显示胰头周围及第一肝门实质肿块伴多发性淋巴结肿大，胆囊大小为7.8cm×3.6cm，总胆管直径为0.6cm；CT 和 ERCP 显示胰头钩突占位，考虑系胰腺癌；MRI 显示肝内外胆管不扩张，主胰管不扩张。",
+        "diagnosis": "腹腔结核\n胰腺结核"
+    },
+    {
+        "Index": "NEJMicm1800360",
+        "patient_info": "患者为一名29岁男性，人类免疫缺陷病毒感染者，因持续2天的发热及右上腹疼痛至急诊科就诊。其最近一次CD4细胞计数为520个/微升。",
+        "laboratory_tests": "实验室检查结果显示，天冬氨酸氨基转移酶水平为208 IU/L（参考范围，10 至 42），丙氨酸氨基转移酶水平为467 IU/L��参考范围，10 至 40），总胆红素水平为每分升 2.4 毫克（参考范围，0.2 至 1.0）。抗阿米巴抗体间接血凝试验呈阳性，滴度为 1:256。粪便聚合酶链反应检测证实感染了溶组织内阿米巴。脓肿经皮引流后获得红褐色物质。显微镜检查发现有伪足的单细胞生物。",
+        "imaging_studies": "注射造影剂后进行的腹部计算机断层扫描显示肝脏有一个环状增强病变，提示有脓肿。",
+        "diagnosis": "阿米巴肝脓肿"
+    },
+    {
+        "Index": "肝包虫囊肿肝内破裂引起猝死三例, B67,8",
+        "patient_info": "男性, 19 岁, 哈族。平素身体健康, 因被他人拳击右上腹部。当即倒地, 频繁呕吐, 昏迷, 四肢末梢发凉, 全身出冷汗, 血压测不到, 20 分钟左右呼吸心跳停止, 死亡。追问死前有与狗和羊接触史。尸体解剖: 腹腔无包虫液。肝右叶下缘有一 7cm 的包虫囊肿, 约1/3囊肿在肝的表面, 囊肿壁无明显陷, 在囊肿紧贴肝侧下壁有一 1. 5cm 的裂口, 通向肝内。肝组织结构基本正常。肠系膜血管及腹腔其它脏器均见明显淤血肿胀。",
+        "laboratory_tests": "暂无",
+        "imaging_studies": "暂无",
+        "diagnosis": "肝包虫囊肿破裂导致过敏性休克"
+    },
+    {
+        "Index": "艾滋病合并阿米巴肝脓肿及阿米巴肺脓肿一例, A06,1",
+        "patient_info": "患者，男性，51岁，上海人，因“发热、咳嗽、咯痰伴胸闷气促4个月，抗-HIV阳性确诊1周”入院，患者有冶游史。4个月前无明显诱因出现发热，最高40 ℃，伴畏寒、寒战，咳嗽、咯脓血痰，活动后胸闷气促，右侧胸部闷痛；伴乏力、纳差，外院胸部CT提示肺部感染伴胸水，先后予青霉素、头孢美唑、左氧氟沙星抗感染治疗，症状进行性加重，体重下降5 kg。1周前自行到疾病预防控制中心行抗-HIV检测阳性。为进一步诊治来本院。入院查体：T 38.3 ℃，R 23次/min，轻度贫血貌，口唇无紫绀，右侧胸廓饱满，语音震颤增强，右下肺叩诊实音，呼吸音消失，左肺呼吸音粗，双上肺可闻及湿啰音。腹软，右上腹略饱满，轻压痛，无反跳痛及肌紧张，肝脏边缘触不清，脾脏未触及，Murphy征阴性，移动性浊音阴性，肠鸣音4次/min。因患者原胸腔脓肿引流管引流不畅，行右侧胸腔切开闭式引流术，引流出大量烂肉样及果酱样液体约500 ml，留置胸腔闭式引流瓶。引流物化验结果显示，间接免疫荧光法查抗-阿米巴阳性，未找到阿米巴滋养体；抗酸杆菌阴性；细菌培养阴性。",
+        "laboratory_tests": "血常规：白细胞计数为10.8 × 10^9/L，中性粒细胞计数为67.5%，血红蛋白为98.5g/L，血小板计数为471 × 10^9/L；粪常规：白细胞计数为25～28/HP，潜血阴性；抗-结核阴性；肝功能：白蛋白为24.8 g/L，丙氨酸氨基转移酶（ALT）为54 U/L，天门冬氨酸氨基转移酶（AST）为53 U/L；痰抗酸杆菌涂片阴性；红细胞沉降率为125 mm/h；C-反应蛋白为139 mg/L；CD4+ T细胞175 cell/µl。",
+        "imaging_studies": "胸部CT：1.右侧大量胸腔积液（局部包裹）伴右肺部分不张，考虑结核性胸膜炎可能。2.左肺上叶炎症。3.肝包膜下块状低密度灶。超声检查显示：肝右叶膈面及右侧胸腔脓肿（贯通膈面），肝脾肿大，胆囊壁水肿。",
+        "diagnosis": "获得性免疫缺陷综合征\n阿米巴肝脓肿\n阿米巴肺脓肿"
+    },
+    {
+        "Index": "小儿阿米巴肝脓肿2例",
+        "patient_info": "女,4岁。患儿于入院前1个月无明显诱因发热体温 38~39.5℃,伴阵发性上腹隐痛,尤以发热时疼痛明显。外院超声示左肝内 8.6 cmx8.0 cm 混合性包块。胸部 CT示:(1)双肺下叶背段纤维化灶，并胸膜粘连;(2)心包积液。心脏彩超示:(1)先天性动脉导管未闭(管型);(2)包腔少量积液。诊断肝脓肿,先天性心脏病,以头孢曲松钠和克林霉素等静脉滴注治疗 10余天,仍发热、腹痛。患病后饮食差,大便稍干燥,无黏液脓血,体质量下降约2kg。有阿米巴病接触史。检查:消瘦,面色苍白,颈部、下颌、腋下、腹股沟均可触及多个淋巴结肿大,质韧,活动度可,无触痛,无粘连,双肺未闻及啰音,心率 130 次/min、律齐,心音有力,第二肋间可闻及 2~3/6 级收缩期吹风样杂音。腹平软,肝于右肋下 1.5 cm,剑下6 cm,质中,边缘钝,肝区叩痛,脾未触及。",
+        "laboratory_tests": "血 Hb 85 ghL, WBC 19.40X10°,N 0.65,L 0.26,CRE62 mglL,白蛋白 30.9 g。大小便常规、肾功能、血电解质心肌酶学正常。抗结核抗体(-)。",
+        "imaging_studies": "胸部X线摄片、彩色多普勒超声心动图和腹部 CT(平扫+增强)检查示:(1)先天性动脉导管未闭;(2)肝左叶可见一 10.0 cmx19.5 cm 低密度灶增强后边界清,呈典型双环征,壁有强化。血培养(-)。",
+        "diagnosis": "阿米巴肝脓肿\n先天性心脏病\n营养不良性贫血。"
+    }
+]

Journal_part3.json

@@ -0,0 +1,485 @@
+[
+    {
+        "patient_info": "Female, 50 years old, previously healthy. The patient presented with 3 weeks of fatigue, nausea, dark urine, pruritus, and scleral icterus. Medical history includes treatment for Graves disease approximately 20 years previously. No known family history of autoimmune disease. Rare alcohol use, no consumption of herbal products, no new medications, and no illicit drug use. No known viral exposures, recent vaccinations, or recent travel. On examination: jaundiced, epigastric abdominal discomfort, no edema or encephalopathy.",
+        "laboratory_tests": "Blood testing for hepatitis A, B, and C and COVID-19 polymerase chain reaction testing were negative. Additional laboratory data are shown in the Table (not provided in the case).",
+        "imaging_studies": "Abdominal ultrasonography with Doppler findings were normal.",
+        "question": "WHAT WOULD YOU DO NEXT?",
+        "diagnosis": "Request an expedited liver biopsy"
+    },
+    {
+        "patient_info": "Male, 36 years old. The patient presented for evaluation of elevated liver enzymes 2 months after undergoing a liver transplant for acute-on-chronic liver failure due to alcohol-associated hepatitis. He had metabolic comorbidities including obesity (body mass index of 30.6) and dyslipidemia. After the liver transplant, there was no evidence of organ rejection or biliary complications. He was asymptomatic and reported last alcohol use was prior to liver transplant. Vital signs were normal and physical examination revealed a well-healed abdominal surgical scar.",
+        "laboratory_tests": "Serum alcohol level was undetectable. Urine drug screening results were positive for cannabinoids.",
+        "imaging_studies": "Liver ultrasonography findings were normal. Liver biopsy showed 50% to 60% macrovesicular steatosis (normal <5%), mild portal inflammation, scattered apoptotic bodies, and hepatocyte ballooning.",
+        "question": "HOW DO YOU INTERPRET THESE TEST RESULTS?",
+        "diagnosis": "Alcohol-associated liver disease."
+    },
+    {
+        "patient_info": "Male, 55 years old, no significant medical history. Presented with several weeks of malaise and a 6.8-kg weight loss associated with poor appetite. No fevers, night sweats, abdominal pain, emesis, or diarrhea reported. Physical examination revealed a thin habitus; no palmar erythema, spider angiomata, or gynecomastia observed.",
+        "laboratory_tests": "Complete blood cell count and chemistry panel findings were normal. Hepatic panel showed: elevated alkaline phosphatase (209 U/L; ULN, 150 U/L [3.49 μkat/L; ULN, 2.5 μkat/L]), normal total bilirubin (0.4 mg/dL [6.84 μmol/L]), elevated alanine aminotransferase (41 U/L; ULN, 35 U/L [0.68 μkat/L; ULN, 0.58 μkat/L]), normal aspartate aminotransferase (27 U/L [0.45 μkat/L]). α-Fetoprotein (AFP) level was elevated (1252 ng/mL; ULN, 9 ng/mL); levels of carbohydrate antigen 19-9 (<2 U/mL) and carcinoembryonic antigen (2.8 ng/mL) were normal.",
+        "imaging_studies": "Single-phase CT scan of the abdomen revealed: multiple hypodense liver masses with rim enhancement throughout the liver, intussusception of the small bowel, and normal liver contour with no signs of portal hypertension. Triple-phase CT scan revealed: no small bowel abnormalities but demonstrated a 3.3 × 2.8-cm heterogeneously enhancing pancreatic tail mass not seen on the previous single-phase CT.",
+        "question": "WHAT WOULD YOU DO NEXT?",
+        "diagnosis": "Perform an endoscopic ultrasound of the pancreas with fine-needle aspiration"
+    },
+    {
+        "patient_info": "Male, 18 years old, from India, emigrated to the United States 4 weeks earlier. Presented with fever, malaise, and anorexia for 4 days. No prescription, over-the-counter, or herbal medications; alcohol; or illicit drugs reported. On physical examination: afebrile, scleral icterus, and palpable liver edge.",
+        "laboratory_tests": "White blood cell count: 3.9 × 10^9/L. Total bilirubin: 5.6 mg/dL, direct bilirubin: 3.6 mg/dL, alkaline phosphatase: 240 U/L, aspartate aminotransferase: 3322 U/L, alanine aminotransferase: 6114 U/L. Platelet count: 126 000 × 10^9/L, prothrombin time: 17 seconds. Viral hepatitis testing performed. Antinuclear, antismooth muscle, and liver/kidney microsomal antibodies not detected. Immunoglobulin G: 1294 mg/dL (normal), ceruloplasmin: 22 mg/dL (normal).",
+        "imaging_studies": "Right upper quadrant ultrasonography findings: liver span of 16 cm, common bile duct measuring 0.3 cm, patent hepatic vasculature.",
+        "question": "WHAT WOULD YOU DO NEXT?",
+        "diagnosis": "Anti-hepatitis E virus (HEV) IgM testing"
+    },
+    {
+        "patient_info": "Female, 70 years old. The patient has hypertension, atrial fibrillation, congestive heart failure, and gallstones. She presented to the emergency department with 3 days of nausea, vomiting, and abdominal pain. She reported no hematemesis, hematochezia, or melena and had no history of abdominal surgery. On admission, she was afebrile, her blood pressure was 80/60 mm Hg, and heart rate was 122/min. On physical examination, her abdomen was distended, tympanic, and slightly tender to palpation diffusely.",
+        "laboratory_tests": "Blood testing showed a white blood cell count of 10,450/µL (84.1% neutrophils), C-reactive protein level, 9.5 mg/dL; potassium level, 3.0 mEq/L (reference, 3.6-5.2 mEq/L); and creatinine level, 5.57 mg/dL (429.39 µmol/L, up from a baseline level of 0.80 mg/dL [70.72 µmol/L]). Sodium and liver function values were normal.",
+        "imaging_studies": "A non-contrast-enhanced abdominal computed tomography (CT) scan was performed.",
+        "question": "WHAT WOULD YOU DO NEXT?",
+        "diagnosis": "Plan for surgical intervention after intravenous fluid resuscitation in the intensive care unit (ICU)"
+    },
+    {
+        "patient_info": "Female, 58 years old. The patient has a history of intravenous heroin use and chronic inactive hepatitis B virus (HBV) infection with a low serum HBV DNA value, normal liver enzyme values, and no evidence of cirrhosis. Presented to the emergency department with sudden onset of painless jaundice and 8 days of malaise. Last intravenous heroin use occurred 9 days prior to presentation. Not taking any prescription or herbal medications and had not been prescribed suppressive antiviral medication for chronic HBV infection. No history of travel outside the US and no raw meat ingestion. Vital signs, mentation, and physical examination were normal except for scleral icterus.",
+        "laboratory_tests": "Blood testing results: negative for hepatitis C virus RNA, anti-hepatitis A IgM, and HIV antibody. Other selected laboratory values are shown in the Table (details not provided in the case).",
+        "imaging_studies": "Liver ultrasound performed 6 months prior to presentation and a repeat liver ultrasound with Doppler revealed no abnormalities.",
+        "question": "WHAT WOULD YOU DO NEXT?",
+        "diagnosis": "Order testing for hepatitis delta virus (HDV) IgM and IgG antibodies and, if positive, test for HDV RNA"
+    },
+    {
+        "patient_info": "Female, 27 years old. No pertinent medical history. Presented with elevated transaminase levels and a positive hepatitis B surface antigen (HBsAg) test result. Further serologic testing was performed due to elevated liver enzymes and lack of anti-HBs following vaccination.",
+        "laboratory_tests": "Hepatitis B surface antigen (HBsAg) test result: positive. Hepatitis B surface antibody (anti-HBs) testing: initially performed 11 months after hepatitis B virus (HBV) vaccination. Further serologic testing was performed due to elevated liver enzymes and lack of anti-HBs.",
+        "imaging_studies": "Not available",
+        "question": "HOW DO YOU INTERPRET THESE TEST RESULTS?",
+        "diagnosis": "The patient has chronic HBV infection."
+    },
+    {
+        "patient_info": "Male, 68 years old. Diagnosed with chronic hepatitis C genotype 1b 5 years ago. No evidence of advanced liver disease (eg, thrombocytopenia). Hepatitis C was cured with simeprevir and sofosbuvir for 12 weeks. Presents for follow-up.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Liver ultrasound showed no signs of cirrhosis, such as nodularity. Vibration-controlled transient elastography (VCTE) performed prior to treatment was negative for significant fibrosis at 6.7 kPa. Follow-up VCTE was performed.",
+        "question": "HOW DO YOU INTERPRET THESE RESULTS?",
+        "diagnosis": "The patient has cirrhosis."
+    },
+    {
+        "patient_info": "Female, 61 years old. The patient has a history of uncontrolled type 2 diabetes mellitus and presented with progressive right upper quadrant abdominal pain of 1 month's duration. The pain was sharp, intermittent without radiation, and not exacerbated by eating. She had no subjective fevers, nausea, vomiting, diarrhea, or weight loss. She had immigrated from Chuuk, Micronesia, to Hawaii 10 years ago and had not traveled overseas since. She denied alcohol use or contact with animals such as pigs. On examination, her temperature was 38.5°C (101.3°F); pulse rate, 104/min; blood pressure, 205/92 mm Hg; and respiratory rate, 33/min with normal saturation. Mild conjunctival icterus and a positive Murphy sign were noted.",
+        "laboratory_tests": "White blood cell count: 16.4 × 109/L (neutrophils, 87.4%; eosinophils, 0.5% [absolute count, 82/μL]); hemoglobin level: 14.9 g/dL; platelet count: 254 × 109/L; aspartate aminotransferase level: 514 U/L; alanine aminotransferase level: 236 U/L; alkaline phosphatase level: 208 IU/L; total bilirubin level: 2.5 mg/dL; direct bilirubin level: 1.1 mg/dL; lipase level: 247 U/L. Results of serologic testing for hepatitis A, B, and C are negative.",
+        "imaging_studies": "Abdominal ultrasound showed no cholecystitis or pancreatobiliary abnormalities. Magnetic resonance cholangiopancreatography was notable for a linear filling defect within the common bile duct extending through the left hepatic duct. During endoscopic retrograde cholangiopancreatography (ERCP), numerous worms were discovered within the biliary trees, with 1 visible outside the ampulla of Vater.",
+        "question": "WHAT WOULD YOU DO NEXT?",
+        "diagnosis": "Prescribe antibiotics followed by anthelmintic therapy"
+    },
+    {
+        "patient_info": "Male, in his 50s. The patient presented with an abdominal skin eruption of 2 days' duration. Medical history includes hepatitis C, cirrhosis, and an orthotopic liver transplant (OLT) 3 years prior, treated with tacrolimus (5 mg, twice daily) and mycophenolate (750 mg, twice daily). Approximately 2½ years post-transplant, he developed gastric outlet obstruction secondary to an infiltrative gastric wall mass associated with plasmablastic posttransplantation lymphoproliferative disorder (pPTLD). Treatment included discontinuation of mycophenolate, reduction of tacrolimus to 0.25 mg daily, and 1 cycle of CHOP chemotherapy (cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and prednisone) and lenalidomide, resulting in improvement. Five weeks post-CHOP, he developed an acute-onset abdominal skin eruption without fever or pain.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Computed tomographic scan of the abdomen and pelvis showed possible abdominal wall cellulitis.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Post transplantation lymphoproliferative disorder"
+    },
+    {
+        "patient_info": "Female, 64 years old. The patient has borderline resectable pancreatic adenocarcinoma and a history of hormone receptor-positive left-sided breast cancer (treated with lumpectomy and radiation in 2014). She was transferred for management of a displaced percutaneous hepatobiliary drain. Diagnosed with pancreatic adenocarcinoma in September 2019 after developing right upper quadrant pain and jaundice, prompting imaging and endoscopic biopsy of a pancreatic head mass. Established oncologic care in Kentucky and received 1 dose of gemcitabine plus nanoparticle albumin-bound (nab)-paclitaxel in early October 2019. Posttreatment complications included elevated transaminases, significant fatigue, and infusion port thrombosis (right-sided, later removed). She was given 1.5 mg/kg of enoxaparin daily for anticoagulation.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Chest computed tomography scan revealed several hypodense lesions in the apex of her heart. Transthoracic echocardiogram showed several discrete, partially mobile frondlike masses originating from her cardiac apex. Cardiac magnetic resonance imaging was requested for further clarification of the findings.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Apical left ventricular thrombus"
+    },
+    {
+        "patient_info": "Female, 66 years old. The patient has a history of chronic hepatitis B infection and hepatocellular carcinoma (HCC). She presented with subacute epigastric pain. Three years prior, she was diagnosed with a solitary HCC and underwent surgical resection with curative intent (pathology: poorly differentiated HCC, 1.6 cm, large vein involvement, T3bNXM0, R0 resection). One and a half years prior, she had elevated α-fetoprotein (AFP) and multiple lung nodules consistent with metastases, treated with nivolumab, achieving biochemical and radiographic complete response. Current symptoms include nonradiating epigastric pain (1 month), nausea, anorexia, water brash, chronic abdominal bloating, and no constitutional or gastrointestinal symptoms.",
+        "laboratory_tests": "Liver function tests, amylase, lipase, and AFP were within normal limits. Hepatitis B virus polymerase chain reaction was undetectable.",
+        "imaging_studies": "Computed tomography with multiphasic liver protocol showed new enlarged mesenteric nodes and diffuse thickening of the gastric body. Esophagogastroduodenoscopy (EGD) identified diffuse inflammation and ulcerations in the gastric body and antrum. Biopsy specimens showed chronic and active mixed inflammatory infiltrate, including intraepithelial lymphocytosis. No overt viral cytopathic effects were observed, and immunostaining results for Helicobacter pylori, cytomegalovirus, and adenovirus were negative.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Immunotherapy-related gastritis"
+    },
+    {
+        "patient_info": "Male, in his 50s. The patient was previously healthy and presented with right upper abdominal pain for 20 days, accompanied by high-grade fever and chills since the first week. No history of trauma or alcohol intake. Clinical examination revealed no icterus or significant lymphadenopathy. Guarding and tenderness in the right upper quadrant; the liver was firm, smooth, and palpable 3 cm below the right costal margin.",
+        "laboratory_tests": "White blood cell counts: 13,200/µL (to convert to × 10^9 per liter, multiply by 0.001). Alkaline phosphatase: 259 U/L (to convert to microkatals per liter, multiply by 0.0167).",
+        "imaging_studies": "Ultrasonography of the abdomen revealed a large hypoechoic area in the right lobe of the liver along with gallstones. A contrast-enhanced computed tomography (CECT) scan was performed (results not specified).",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Acute cholecystitis \n intrahepatic perforation of the gallbladder"
+    },
+    {
+        "patient_info": "Female, early 50s. The patient has a history of hepatitis B and was admitted to the hospital with complaints of asthenia, anorexia, and intermittent fever over the past 6 months. The highest recorded temperature was 39°C, which was treatable with antifebrile drugs. Physical examination at admission showed no positive signs of the symptoms.",
+        "laboratory_tests": "Blood samples, fecal occult blood tests, liver function tests, and tests for alpha fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19-9 had normal results. The patient's erythrocyte sedimentation rate was 84 mm/h (reference range, 0-20 mm/h). Test results were positive for hepatitis B surface antigen, hepatitis B e antibody, and hepatitis B c antibody. Treponema pallidum particle agglutination test results indicated a signal to cutoff ratio of 41.72 (reference range, 0-1). The results of an enzyme-linked immunospot test for tuberculosis (T-SPOT.TB; Oxford Immunotec) were negative.",
+        "imaging_studies": "Ultrasonographic examination revealed multiple lesions in the liver, suggestive of liver metastases. Positron emission tomography/computed tomography showed abnormally intense and high metabolic activity in all of the liver lesions, with a maximum standardized uptake value of 12.1. Abdominal contrast-enhanced computed tomography was performed.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Hepatic tertiary syphilis"
+    },
+    {
+        "patient_info": "Male, 58 years old. The patient is admitted to the cardiac intensive care unit with fevers and night sweats. He has a history of a fall and a large hematoma on his right thigh and buttock.",
+        "laboratory_tests": "White blood cell (WBC) count is elevated to 29,000 cells/µL without a left shift, and serum hemoglobin level is 9.3 g/dL. Mildly elevated troponin levels without electrocardiographic changes. On the fourth hospital day, his WBC count increases to 44,000 cells/µL and his hemoglobin level decreases to 6.6 g/dL.",
+        "imaging_studies": "Transthoracic echocardiogram reveals valvular vegetations. Chest radiograph is unrevealing. Abdominal computed tomography (CT) scan obtained to evaluate for blood loss reveals an abnormal gallbladder finding.",
+        "question": "WHAT WOULD YOU DO NEXT?",
+        "diagnosis": "Do nothing for the CT scan findings"
+    },
+    {
+        "patient_info": "Male, 63 years old. The patient is admitted for evaluation of recurrent abdominal pain and a 2-month history of tender nodules on the extremities. He has a history of hepatitis B, hepatocellular carcinoma, and idiopathic pancreatitis. The lesions are initially very painful and slow to resolve. New lesions tend to appear with, or immediately after, episodes of acute pancreatitis. Examination of the skin reveals erythematous subcutaneous nodules symmetrically distributed on the bilateral lower and upper extremities, primarily on the lower legs and feet. One of the largest nodules has a small amount of yellow, oily discharge. The patient is afebrile and reports nausea, vomiting, and arthralgias. Previous treatments have included incision and drainage of a nodule on the right foot as well as oral and intravenous administration of antistaphylococcal antibiotics for presumed cellulitis.",
+        "laboratory_tests": "Elevated levels of serum lipase (2700 IU/L) and amylase (3400 IU/L).",
+        "imaging_studies": "Not available",
+        "question": "WHAT WOULD YOU DO NEXT?",
+        "diagnosis": "Perform an incisional skin biopsy"
+    },
+    {
+        "patient_info": "Female, 50s years old. A healthy woman without diabetes or obesity presented for an annual physical examination. Born between 1945 and 1965. Asymptomatic.",
+        "laboratory_tests": "Hepatitis C antibody (anti-HCV) result was positive. Alanine aminotransferase of 34 U/L (reference range, 7-35), aspartate aminotransferase of 28 U/L (reference range, 8-30), total bilirubin of 0.4 mg/dL (reference range, 0.2-1.2), alkaline phosphatase of 95 IU/L (reference range, 30-130), albumin of 4.0 g/dL (reference range, 3.0-16), white blood cell count of 7.1×10^9/L (reference range, 4-10), platelet count of 210×10^9/L (reference range, 150-400), INR of 1.0. Other laboratory values are shown in the Table.",
+        "imaging_studies": "Baseline abdominal ultrasound showed mild increased echogenicity of the liver. The liver was not nodular and the spleen not enlarged.",
+        "question": "HOW DO YOU INTERPRET THESE TEST RESULTS?",
+        "diagnosis": "This patient is infected with the most common strain of HCV in the United States and it has lower response rates to interferon-based therapy."
+    },
+    {
+        "patient_info": "Male, 31 years old, Asian. The patient has hepatitis C cirrhosis complicated by variceal hemorrhage and ascites. He was a graduate student who developed decompensated cirrhosis with variceal hemorrhage, leading to hypovolemic shock from acute blood loss. Treated with blood transfusions and variceal banding procedures. Transferred to the liver unit on hospital day 25 with mostly recovered liver test abnormalities and no further gastrointestinal bleeding. Physical examination noted jaundice, alert and oriented with normal cognitive function, no abdominal tenderness, and mild ascites. No confusion, insomnia, or decreased mental alertness. Cognitive capacity and mental status remained stable during evaluation with no symptoms of encephalopathy. Managed with oral diuretics for ascites.",
+        "laboratory_tests": "Serum ammonia level measured as part of routine liver transplant evaluation (specific value not provided). Other laboratory test results not available.",
+        "imaging_studies": "Not available",
+        "question": "HOW DO YOU INTERPRET THESE TEST RESULTS?",
+        "diagnosis": "The patient does not have hepatic encephalopathy so no treatment is necessary."
+    },
+    {
+        "patient_info": "White woman in her 60s with undifferentiated connective tissue disease and longstanding pulmonary arterial hypertension. The patient reported no alcohol or drug use and no personal or family history of liver disease. Medications included diltiazem and furosemide. On physical examination, her blood pressure was 108/54 mm Hg and pulse was 64/min. She was anicteric with mild bilateral temporal wasting and jugular venous distension. Further pertinent findings included regular heart rate and rhythm with an accentuated P2, grade 1/6 holosystolic murmur in the left lower sternal border, full bulging abdomen with flank dullness, and scattered spider angiomata on her chest.",
+        "laboratory_tests": "Not available (results including diagnostic paracentesis are mentioned but not detailed in the case).",
+        "imaging_studies": "Doppler ultrasound revealed an irregular liver echo pattern without lesions, normal common bile duct, patent portal and hepatic vasculature, splenomegaly, and ascites.",
+        "question": "HOW DO YOU INTERPRET THESE TEST RESULTS?",
+        "diagnosis": "Her ascites is primarily due to chronically elevated pressures on the right side of her heart."
+    },
+    {
+        "patient_info": "Male, 26 years old. The patient was admitted for fever (temperature, 39°C) and right hypochondrium abdominal pain, accompanied by nausea, vomiting, and asthenia. Medical history includes pharyngitis associated with scarlet fever treated with clarithromycin (500 mg twice daily for a week) one month prior. No throat culture or rapid antigen test for group A streptococci was performed. Physical examination revealed mild right upper abdominal quadrant tenderness. The patient met all criteria for systemic inflammatory response syndrome.",
+        "laboratory_tests": "Blood tests showed a marked increase in inflammatory markers. Blood and urine cultures were negative. Serological detection test for echinococcosis was negative. Carcinoembryonic antigen, carbohydrate antigen 19-9, and α-fetoprotein blood levels were normal. Serological markers for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative. Study of leukocyte populations and immunoglobulin electrophoresis did not reveal any disorder of the immune system.",
+        "imaging_studies": "Chest radiograph was normal. Abdominal ultrasonography revealed a 6-cm, solid, inhomogeneous mass in liver segment 6. Contrast-enhanced computed tomographic scan of the abdomen showed the lesion was hypodense with numerous septa without contrast enhancement. Magnetic resonance imaging evidenced a mixed solid-liquid lesion, with some septa delimiting large areas of necrosis.",
+        "question": "WHAT IS THE DIAGNOSIS?",
+        "diagnosis": "Hepatic abscess"
+    },
+    {
+        "patient_info": "Female, 89 years old. The patient presented with abdominal pain for 2 days, localized to her right abdomen (both upper and lower quadrants), with acute tenderness to palpation. She had some nausea and vomiting.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Ultrasonographic findings gave concern for acute cholecystitis. A computed tomographic scan was ordered after admission to the hospital.",
+        "question": "WHAT IS THE DIAGNOSIS?",
+        "diagnosis": "Gallbladder volvulus"
+    },
+    {
+        "patient_info": "White woman, late 40s. The patient presented for a routine annual checkup with abdominal distention, early satiety, and heat intolerance. Physical examination revealed orthostatic hypotension and an immobile, nontender abdominal mass.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Abdominal computed tomographic scan was obtained. Findings led to surgical resection.",
+        "question": "WHAT IS THE DIAGNOSIS?",
+        "diagnosis": "Pheochromocytoma"
+    },
+    {
+        "patient_info": "Female, 30 years old, immigrant from Laos. The patient was referred for right upper quadrant abdominal pain with associated nausea and vomiting. No previous medical or surgical history. On examination, mild right upper quadrant tenderness to palpation without signs of peritonitis.",
+        "laboratory_tests": "Routine laboratory values were within normal limits, except for a mildly elevated amylase level.",
+        "imaging_studies": "Abdominal magnetic resonance cholangiopancreatography revealed a cystic abnormality in the region of the porta hepatis. A computed tomographic scan was obtained to further delineate the abnormality.",
+        "question": "WHAT IS THE DIAGNOSIS?",
+        "diagnosis": "Type I choledochal cyst"
+    },
+    {
+        "patient_info": "Male, 37 years old. A previously healthy man presented for a routine physical examination during which a pulsatile mass in his mid-epigastrium was palpated.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Abdominal ultrasonography showed a well-defined hypoechoic lesion abutting the pancreas. Further imaging by contrast-enhanced computed tomography (CT) and 3-dimensional reconstruction revealed a well-circumscribed, 3-cm lesion surrounding the common hepatic artery. The lesion demonstrated patchy arterial enhancement, and a small irregularity of the common hepatic artery was present within the lesion. Endoscopic ultrasonography demonstrated a hypoechoic, well-defined mass.",
+        "question": "WHAT IS THE DIAGNOSIS?",
+        "diagnosis": "Angioleiomyoma"
+    },
+    {
+        "patient_info": "Female, 64 years old. The patient presented to the emergency department with a 1-day temperature of 38.9°C (102°F), accompanied by cough, nausea, and arthralgias. She denied dyspnea, emesis, and chest or abdominal pain. Medical history includes non-Hodgkin lymphoma, chronic diarrhea, myelodysplastic syndrome (treated with chemotherapy), and Behçet syndrome (treated with prednisone acetate, 6 mg daily). Surgical history includes a right-sided hemicolectomy due to recurrent right-sided diverticulitis. Vital signs: blood pressure 150/59 mm Hg, heart rate 127 bpm, respiratory rate 20 breaths/min, temperature 38.5°C (101.3°F) (oral), oxygen saturation 99% (room air). Physical examination was unremarkable.",
+        "laboratory_tests": "White blood cell count 2700/µL (reference range: 4800-10 800/µL), lactic acid 19.8 mg/dL, platelet count 72×103/µL. Urinalysis: trace blood, positive nitrite, +1 leukocyte esterase, white blood cell count 2000/µL to 5000/µL. Urine culture positive for Klebsiella pneumoniae. Blood culture positive for Enterobacter sakazakii (Cronobacter sakazakii).",
+        "imaging_studies": "Computed tomographic scan of the abdomen/pelvis with contrast showed marked inflammatory changes involving the gallbladder with air within the lumen. Previous scans had shown multiple large gallstones (no longer present). There is an intimate association of the gallbladder fundus with the adjacent hepatic flexure of the colon, with loss of a defined plane between the two structures.",
+        "question": "WHAT IS THE DIAGNOSIS?",
+        "diagnosis": "Cholecystocolonic fistula"
+    },
+    {
+        "patient_info": "Female, 60s. The patient presented with abdominal pain and increasing asthenia over the previous 4 months. She reported a weight loss of 40 kg during the previous 12 months concomitant with depression. Medical history includes cardiac arrhythmia, hypertension, and sigmoidectomy for diverticulitis. Current medications: lasixil, amiodipine, amiodarone, and atenolol. On examination, the patient appeared well with normal vital signs. The abdomen was soft without distension, but a positive Murphy sign was observed.",
+        "laboratory_tests": "White blood cell count: 11400/µL (11.4 ×109/L), hemoglobin: 11.5 g/dL (115 g/L), platelet count: 233 ×103/µL (233 ×109/L). C-reaction protein: 41 mg/L (390.484 nmol/L). Renal and liver function, coagulation, blood electrolytes, total protein, albumin, antigen carcino embryonnaire, carbohydrate antigen 19-9, carbohydrate antigen 125, and β2 microglobulin tests were normal.",
+        "imaging_studies": "Ultrasonography revealed a 10 × 8-cm mass in the right hypochondrium. Abdominal computed tomography scan showed a thickened gallbladder wall infiltrating the liver parenchyma and 3 perihepatic lymph nodes. Magnetic resonance imaging indicated a greatly enlarged gallbladder with a thickened wall without invading adjacent structures, a continuous mucosal line, and a hypoattenuated intramural nodule. Esophagogastroduodenoscopy and colonoscopy were normal.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Xanthogranulomatous cholecystitis (XGC)"
+    },
+    {
+        "patient_info": "Female, 75 years old. Previously healthy. Medical history significant for hypertension and a previous laparoscopic cholecystectomy approximately 6 years ago. Presented with abdominal pain and jaundice, revealing a duodenal mass.",
+        "laboratory_tests": "Total bilirubin level of 6.8 mg/dL, aspartate aminotransferase level of 394 U/L, alanine transaminase level of 746 U/L, and alkaline phosphatase level of 1146 U/L.",
+        "imaging_studies": "High-resolution computed tomography revealed a 3 × 4-cm circumferential lesion in the second and third portions of the duodenum involving the pancreatic head. Multiple nodules were noted along the peritoneal reflection of the right paracolic gutter.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Dropped gallstones"
+    },
+    {
+        "patient_info": "Male, in his 50s. Previously underwent renal transplantation for polycystic kidney disease. Presented with worsening chronic malaise, fatigue, dyspnea, early satiety, and abdominal distention with extreme discomfort.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Abdominal magnetic resonance image (Figure1A) revealed a giant multinodular mass (Figure 1B).",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Polycystic liver disease"
+    },
+    {
+        "patient_info": "Female, 57 years old. The patient has a medical history of recurrent biliary colic and was admitted with symptoms consistent with mild gallstone pancreatitis.",
+        "laboratory_tests": "Total bilirubin: 4.74 mg/dL (to convert to millimoles per liter, multiply by 17.104). Amylase: 1,041 U/L (to convert to microkatals per liter, multiply by 0.0167).",
+        "imaging_studies": "Abdominal ultrasonography scan demonstrated gallstones and a mildly dilated common bile duct (CBD). Magnetic resonance imaging of the abdomen confirmed these results and revealed choledolithiasis. Intraoperative cholangiography revealed an unusual anatomical variant and subsequent transcytic choledochoscopy demonstrated a double lumen at the distal CBD. Multiple gallstones were found within a dilated region of cystic duct.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Choledochal cyst \n long common biliopancreatic channel"
+    },
+    {
+        "patient_info": "Male, 40 years old. The patient was admitted with acute abdominal pain on the right flank, with a similar episode occurring 1 month prior that improved spontaneously. Physical examination revealed no clinical abnormalities, but the patient reported dysuria and abnormally frequent urination. Medical history was uneventful, with no weight loss. Family history includes the patient's father dying of pancreatic carcinoma at the age of 65 the previous year.",
+        "laboratory_tests": "Laboratory values, including cancer antigen 19-9 and carcinoembryonic antigen levels, were normal.",
+        "imaging_studies": "Computed tomographic scan of the abdomen revealed nephrolithiasis with a 4-mm kidney stone on the right side and a slightly congested right kidney. Incidentally found a 10 × 10 × 8-cm mass in the tail of the pancreas, as well as thrombosis of the splenic vein.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Hydatid cyst of the pancreas"
+    },
+    {
+        "patient_info": "Male, 64 years old, from the Philippines. The patient presented with 5 months of progressive fatigue, worsening jaundice, and a 13-kg weight loss. He denied fever, chills, and abdominal pain.",
+        "laboratory_tests": "Total bilirubin level of 14.4 mg/dL, mildly elevated transaminases, white blood cell count of 13,300/mL with a normal differential. Serum carcinoembryonic antigen level was 1.9 ng/mL, cancer antigen 19-9 level was 293 U/mL. QuantiFERON (interferon-γ release assay), serum cryptococcal antigen, and serum Histoplasma capsulatum antigen results were all negative. Aerobic, anaerobic, mycobacterial, and fungal cultures from the CT-guided liver biopsy were negative.",
+        "imaging_studies": "CT of the abdomen and pelvis demonstrated a heterogeneous enhancing hepatic hilar mass (4.4 × 4.3 × 3.5 cm) with extensive intrahepatic biliary ductal dilatation; the gallbladder was calcified. CT scan of the chest demonstrated a 7-mm left upper lobe partially calcified nodule and cardiophrenic and gastroesophageal lymphadenopathy. Endoscopic retrograde cholangiopancreatography demonstrated focal biliary strictures involving the right and left hepatic ducts. Endoscopic ultrasonography with fine-needle aspirates revealed inflammatory cells with granulomatous changes. Laparoscopic biopsy of several hepatic lesions demonstrated necrotizing granulomatous inflammation with giant cells and central necrosis. Grocott methenamine silver and acid-fast bacilli staining were negative for fungal or mycobacterial organisms, respectively.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Hepatic tuberculosis"
+    },
+    {
+        "patient_info": "Female, 57 years old. The patient presented to the emergency department with a 1-day history of upper abdominal pain localized to the epigastrium, with acute onset that prevented her from working for the rest of the day. No association between the pain and eating. No history of nausea, vomiting, diarrhea, melena, hematochezia, constipation, or fevers. No alcohol abuse or smoking history. Medical history includes dyslipidemia and a transient ischemic attack 3 years prior. No prior colonoscopy or gastroscopy. Medications: atorvastatin and acetylsalicylic acid. Past operation: carpal tunnel syndrome treatment. Occupation: sheep breeder with close animal contact (8-12 hours/day). Physical examination: normal heart and lungs, soft abdomen with epigastric tenderness.",
+        "laboratory_tests": "Normocytic anemia (hematocrit 28.1%, hemoglobin 9.3 g/dL). Normal white blood cell count (7600/μL). Complete metabolic panel results were normal.",
+        "imaging_studies": "Abdominal radiography was performed. Further details not available.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Gallstone"
+    },
+    {
+        "patient_info": "Male, 51 years old. The patient presented with a 2-day history of right upper quadrant abdominal pain. He underwent a laparoscopic cholecystectomy. Postoperatively, he experienced persistent mild abdominal pain and later returned with progressive abdominal pain, nausea, and vomiting. He denied fever and chills. Physical examination revealed mild abdominal tenderness in the left lower quadrant.",
+        "laboratory_tests": "Laboratory findings were unremarkable.",
+        "imaging_studies": "Ultrasonography of the abdomen's right upper quadrant showed gallbladder wall thickening with gallstones in the neck of the gallbladder consistent with acute calculous cholecystitis. Computed tomography (CT) of the abdomen showed a 2.5-cm calcified mass with adjacent inflammatory changes in the left hemiabdomen that was most consistent with a lost gallstone. A second abdominal CT was performed.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Gallstone ileus"
+    },
+    {
+        "patient_info": "Young adult, male (implied by 'him'). The patient presented with a progressively growing abdominal lump causing dull ache and heaviness. Ten weeks prior, he was hospitalized and conservatively managed for acute pancreatitis. He has a history of prolonged alcohol abuse. Physical examination revealed stable vital signs, normothermia, and a nontender, nonpulsatile, fixed lump in the upper abdomen.",
+        "laboratory_tests": "Routine blood test revealed leukocytosis (white blood cell count of 12,000/μL). Liver and kidney function test results were unremarkable. Serum amylase level was 487 U/L (normal range, 28-100 U/L).",
+        "imaging_studies": "Contrast-enhanced computed tomography (CT) scan of the abdomen was performed. Results not specified in the case.",
+        "question": "WHAT IS YOUR DIAGNOSIS?",
+        "diagnosis": "Pancreatic pseudocyst"
+    },
+    {
+        "patient_info": "Male, 36 years old. The patient sought care after 1 week of right upper quadrant and epigastric abdominal pain. The pain was dull, constant, at times radiated to his back, and was worse postprandially. He denied nausea, vomiting, fever, or chills. On initial examination, he was afebrile with moderate tenderness in the right upper quadrant, without guarding or rebound. A right upper quadrant mass was visible and palpable.",
+        "laboratory_tests": "White blood cell count was 16.3 x 10^9 uL. Results of liver function tests were normal.",
+        "imaging_studies": "Computed tomographic scan of the abdomen showed a markedly thickened and heterogeneous enhancing gallbladder wall. Gallbladder ultrasound revealed a grossly abnormal gallbladder with a thickened and hypereperic wall. An open cholecystectomy was performed, revealing a hard and extremely edematous gallbladder with a thickened wall and a small lumen full of pigmented stones.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Acute Cholecystitis \n Chronic Cholecystitis"
+    },
+    {
+        "patient_info": "Male, 27 years old. The patient presented with a 2-year history of progressive painless abdominal distention. Clinically, he was thin, had normal vital signs, and did not have pallor, jaundice, or lymphadenopathy. The abdomen revealed a huge mass causing marked distention in the upper abdomen, mostly in the right upper quadrant with minimal deep tenderness.",
+        "laboratory_tests": "Routine blood tests including liver function test, tumor markers, Echinococcus and Entamoeba serology, lipase level, and amylase level were all within normal limits.",
+        "imaging_studies": "Ultrasonography and computed tomography revealed a huge cystic lesion of the liver. Operative findings included hypertrophied caudate lobe, tense and distended liver with stretched porta hepatitis, and distorted anatomy.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Mucinous Cystadenoma of the Liver"
+    },
+    {
+        "patient_info": "Male, 66 years old. The patient is otherwise healthy and presented with a palpable lump in his right flank. He denied fever, chills, or constitutional symptoms and had no history of trauma. Medical history includes polycystic kidney disease. Surgical history: laparoscopic cholecystectomy 3 years earlier for acute gangrenous cholecystitis with cholelithiasis and excision of a lipoma from the right side of the abdominal wall 1 year earlier. On examination, the mass was approximately 10×5 cm and mobile, with no overlying erythema, tenderness, ecchymosis, or induration. Other physical examination results were unremarkable.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Ultrasonography (US) and computed tomography (CT) were performed to evaluate the etiology of the abscess. The US image and CT scan showed a complex retroperitoneal mass just behind the right kidney. The soft-tissue inflammation extended to the skin.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Retroperitoneal Retained Gallstone"
+    },
+    {
+        "patient_info": "Male, 34 years old. The patient presented with gastrointestinal bleeding related to esophageal varices in 2002. The varices were controlled with endoscopic ligation. Evaluation revealed extrahepatic portal vein thrombosis with normal findings on liver biopsy.",
+        "laboratory_tests": "Increased alkaline phosphatase level; no other laboratory abnormalities of the liver were found, including the serum bilirubin level.",
+        "imaging_studies": "Computed tomographic cholangiography documented intrahepatic biliary ductal dilation. Computed tomographic portography demonstrated a patent intrahepatic portal vein and a patent confluence of the splenic and superior mesenteric veins, but with an occluded portal vein between the confluence and the intrahepatic portal vein with extensive venous collaterals.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Portal Hypertensive Biliopathy"
+    },
+    {
+        "patient_info": "35-year-old Hispanic man. The patient presented to the emergency department with a 5-week history of abdominal pain radiating from the right upper quadrant to his back. He denied nausea, vomiting, fevers, chills, or changes in bowel habits. Medical history includes non-insulin-dependent diabetes (managed with metformin and pioglitazone). Social history: smokes 5-6 cigarettes per day, denies alcohol use. Physical examination revealed right upper quadrant tenderness; ocular examination was negative for sclera icterus.",
+        "laboratory_tests": "Total bilirubin: 1.8 mg/dL, indirect bilirubin: 1.0 mg/dL. Remainder of liver function tests were within the reference range. Complete blood cell count: white cell count of 5.2 without a left shift.",
+        "imaging_studies": "Preoperative gallbladder ultrasound demonstrated a complex heterogeneous mass in the gallbladder fossa (5.4×3.1×4.6 cm), with no common bile duct dilatation. Magnetic resonance imaging obtained preoperatively (details not specified). Pathology specimen obtained during the operation (details not specified).",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Xanthogranulomatous Cholecystitis"
+    },
+    {
+        "patient_info": "Male, 71 years old. The patient was admitted for a routine checkup, during which an incidental cystic mass in the liver was discovered. Past medical history includes obesity (BMI 34.7), 1.4 oz daily alcohol consumption since adolescence, atrial fibrillation, type 2 diabetes mellitus, and past exposure to an endemic zone of hydatid disease.",
+        "laboratory_tests": "Blood analysis showed an elevated serum level of γ-glutamyltransferase (90 U/L). Liver function tests, complete blood cell count, level of tumor markers, and serologic tests for amoebae and hydatid disease were within normal ranges.",
+        "imaging_studies": "Computed tomography revealed a dysmorphic liver and a 5-cm septated cystic mass of segment 8 with peripheral heterogeneous enhancement in portal and delayed phases, without enhancement in the arterial phase. Internal septations were present, but no calcifications in the wall. No portal hypertension was observed. Magnetic resonance imaging was performed but was not contributory.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Cystic Hepatocellular Carcinoma"
+    },
+    {
+        "patient_info": "Female, 83 years old. The patient presented with nearly 1 month of mild, intermittent right upper quadrant pain and noticed a slowly growing mass in this area. She denied fever, chills, nausea, or a history of trauma. Physical examination revealed a fluctuant, palpable mass in the right upper quadrant with overlying erythema and mild tenderness to palpation.",
+        "laboratory_tests": "White blood cell count of 13.4 million/µL (to convert to ×109/L, multiply by .001).",
+        "imaging_studies": "Noncontrast abdominal computed tomography demonstrated a large hiatal hernia, small bilateral pleural effusions, and a right anterior abdominal wall subcutaneous lesion that was approximately 5 × 9 cm. In addition, there were multiple large gallstones within an edematous gallbladder with pericholecystic fat stranding.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Cholecystocutaneous Fistula"
+    },
+    {
+        "patient_info": "Female, 28 years old, gravida 4, para 3, aborta 0 (35 weeks). The patient presented with a 36-hour history of acute onset of postprandial right upper quadrant pain, nausea, and vomiting. She described similar episodes of this pain during the preceding month. Physical examination revealed right upper quadrant tenderness, temperature 36.2°C.",
+        "laboratory_tests": "White blood cell count 7.1×109/L. Liver function tests were normal.",
+        "imaging_studies": "Ultrasonography of the right upper quadrant showed a distended gallbladder with multiple stones. Findings in Figure 1 and Figure 2 were noted during surgery (perihepatic adhesions and inability to visualize the gallbladder).",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Gallbladder volvulus"
+    },
+    {
+        "patient_info": "Female, 27 years old. The patient was admitted on an emergency basis with acute pain in the right upper abdominal quadrant, nausea, and vomiting for the previous 3 days. Her medical history was normal. On physical examination, she was dehydrated, with a positive Murphy sign and mild fever.",
+        "laboratory_tests": "Blood cell count was normal. Blood chemistry results demonstrated mild hyperbilirubinemia (total bilirubin level: 1.8 mg/dL, direct bilirubin level: 1.6 mg/dL) and mildly elevated alkaline phosphatase (150 U/L) and γ-glutamino-transpeptidase (105 U/L) levels.",
+        "imaging_studies": "Abdominal ultrasonography revealed cholelithiasis and a cystic mass in contact with the second portion of the duodenum containing stones. The distal common bile duct was dilated (maximum diameter: 1.4 cm). Endoscopy revealed a smooth, round mass protruding into the lumen and obstructing the second portion of the duodenum. Computed tomographic scan of the abdomen showed cholelithiasis and a cystic mass containing stones, obstructing the second portion of the duodenum, and causing distention of the stomach and the proximal duodenum.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Choledochocele"
+    },
+    {
+        "patient_info": "Male, 89 years old. The patient presented with recurrent upper abdominal pain, jaundice, rigors, and vomiting. His medical history included type 2 diabetes mellitus, myocardial infarction, and an abdominal aortic aneurysm under regular ultrasonographic surveillance. On examination, a nontender pulsatile mass was palpable midabdomen.",
+        "laboratory_tests": "Bilirubin, 3.4 mg/dL; alkaline phosphatase, 739 U/L; alanine transaminase, 120 U/L; amylase, 127 U/L; C-reactive protein, 77 mg/L; white blood cell count, 10 400/µL; hemoglobin, 11.1 g/dL. (Conversion factors provided for bilirubin, alkaline phosphatase, alanine transaminase, amylase, C-reactive protein, white blood cell count, and hemoglobin). Later, peripheral neutrophilia was noted (16 680/µL).",
+        "imaging_studies": "Abdominal ultrasonographic and computed tomographic scans showed multiple stones within a dilated common bile duct and an uncomplicated 9-cm infrarenal abdominal aortic aneurysm. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the presence of 2 large stones impacted at the distal end of the common bile duct and noted a periampullary duodenal diverticulum. A subsequent urgent computed tomographic scan was obtained, preceded by an anteroposterior scout radiograph.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Jejunal Diverticular Perforation Secondary to Delayed Distal Migrationof Biliary Endoprosthesis"
+    },
+    {
+        "patient_info": "Female, 70 years old. The patient experienced sharp abdominal pain in the left lower quadrant for 7 hours, accompanied by vomiting. Bowel function was normal, and she had no high temperature at home. Medical history includes hypertension (treated) and type 2 diabetes mellitus (controlled with oral therapy). On examination: temperature 39.6°C, abdomen tender to deep palpation with mild resistance, no rebound tenderness, barely audible bowel sounds. Digital rectal examination revealed stools without blood.",
+        "laboratory_tests": "Blood tests: normal white cell count and C-reactive protein level, slight increase in total bilirubin (1.39 mg/dL) and creatinine (1.27 mg/dL), significant increase in aspartate aminotransferase (518 U/L) and alanine aminotransferase (215 U/L).",
+        "imaging_studies": "Abdominal radiograph: normal, no substantial free intra-abdominal gas. Abdominal CT: free retroperitoneal air in the celiac area, devastation at the hepatic hilum; gas surrounded the portal vein and splenic vein, spreading along the periportal spaces inside the hepatic parenchyma up to the extremity of the liver. Thick-walled gallbladder surrounded by a liquid film with minimal calcified opacity inside. Little fluid in the Douglas space and a small amount around the liver.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Necrosis of the Bile Duct System"
+    },
+    {
+        "patient_info": "Male, 63 years old. History of diabetes mellitus and liver transplantation 2 years prior to admission. Presented with severe abdominal pain, jaundice, and vomiting 2 days after endoscopic retrograde cholangiopancreatography for investigation of increasingly abnormal liver function test results. No history of cardiac disease. No fever in the last days prior to admission. Physical examination revealed diffuse abdominal tenderness but no rebound tenderness or guarding. Vital signs were normal except for tachycardia (heart rate, 120 beats/min).",
+        "laboratory_tests": "Total bilirubin level: 32.2 mg/dL; lactate level: 157.7 mg/dL.",
+        "imaging_studies": "Computed tomography of the abdomen and pelvis was performed. Results not available.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Portal Vein Gas Associated With Pneumatosis Intestinalis"
+    },
+    {
+        "patient_info": "Male, 63 years old. The patient had a history of stage IV metastatic melanoma arising from the back and subsequently metastatic to the cervical nodes, brain, and stomach. Metastatic lesions were managed with chemotherapy, interleukin 2, gamma-knife radiotherapy, and partial gastrectomy, rendering the patient free of disease for 8 years. The patient remained asymptomatic at the time of surveillance staging.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Surveillance staging revealed lesions on his gallbladder with increased signal on positron emission tomography. Computed tomography demonstrated abnormal frondlike gallbladder wall nodularity with eccentric masses within the gallbladder lumen.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Primary Adenocarcinoma"
+    },
+    {
+        "patient_info": "Female, 32 years old. No recent contraceptive use or significant medical history. Presented with 2 episodes of intra-abdominal hemorrhage, severe posterolateral pain on the right side of the neck, mild generalized abdominal pain, and later worsening abdominal pain with right shoulder pain. No history of abdominal trauma. Diagnosed with ectopic pregnancy of approximately 5 weeks' gestation.",
+        "laboratory_tests": "Hemoglobin level of 8.0 g/dL (80 g/L), increased human chorionic gonadotropin level of 1500 mIU/mL (1500 IU/L). Follow-up human chorionic gonadotropin level remained elevated at 1600 mIU/mL (1600 IU/L). Hemoglobin level dropped from 9 g/dL (90 g/L) to 6 g/dL (60 g/L) during subsequent evaluation.",
+        "imaging_studies": "Transvaginal ultrasonography failed to show intrauterine products of conception. Computed tomographic (CT) scan showed a large perihepatic clot.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Ruptured Ectopic Pregnancy"
+    },
+    {
+        "patient_info": "Male, 18 years old. The patient had a 3-month history of worsening diffuse abdominal pain irradiating to the back, abdominal distension, malaise, weight loss (10 kg), and diarrhea. Six months before that, he presented with bilateral exophthalmos of uncertain origin (ie, an absence of endocrine or intracranial pathologies).",
+        "laboratory_tests": "Thyroid function test results: thyrotropin level, 1230 mIU/L; free triiodothyronine level, 380 pg/dL; free thyroxine level, 12.9 ng/dL. Liver function test results: albumin level, 4.1 g/dL; hemoglobin level, 9.1 g/dL. White blood cell count was normal. Serum tumor markers were within the normal range, except for cancer antigen 125 level, which was elevated at 145.5 U/mL. Neuron-specific enolase, gastrin, and chromogranin A serum levels were normal (6.5 ng/mL, 72 pg/mL, and 34.632 pmol/mL, respectively).",
+        "imaging_studies": "Computed tomographic scan of the abdomen revealed a bulky heterogeneous solid mass (33×27×18 cm) with large necrotic and cystic areas that was located in the abdominal cavity up to the pelvis and that was in close contact with the left hepatic lobe, the posterior surface of the stomach (adjacent to the minor curvature), the pancreatic head, the transverse colon, the mesenteric root, and the retroperitoneal vessels, without clear cleavage planes. The body and the tail of the pancreas were not identifiable. No ascitic fluid, enlarged lymph node, periportal nodule, or liver metastasis was detected. After injection of the contrast medium, the mass was revealed to have intense arterial vascularization.",
+        "question": "What is the Diagnosis?",
+        "diagnosis": "PNET of the Pancreas"
+    },
+    {
+        "patient_info": "Male, 54 years old. The patient has a history of chronic alcoholic pancreatitis and hepatitis. He presented with epigastric pain and melena, with a loss of 6 kg of body weight during the last month. He appeared anemic rather than icteric. Physical examination on admission revealed mild hepatomegaly and upper abdominal tenderness, without splenomegaly or ascites.",
+        "laboratory_tests": "Severe anemia (hemoglobin, 7.6 g/dL). Mild liver dysfunction (aspartate aminotransferase, 130 U/L; alanine aminotransferase, 96 U/L).",
+        "imaging_studies": "Emergent esophagogastroduodenoscopy revealed active bleeding from the papilla of Vater. Abdominal ultrasonography showed that the gallbladder was filled with debris, which color Doppler flow studies indicated was consistent with a blood clot. Enhanced abdominal computed tomographic (CT) scans were performed (results not detailed in the case).",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Pseudoaneurysm"
+    },
+    {
+        "patient_info": "Female, 67 years old. The patient was referred due to a 1-year history of intermittent right upper quadrant pain associated with anorexia and weight loss (5 kg in 6 months). Medical history includes vulvar epidermoid carcinoma (T3G2N0) 6 years ago, treated with vulvectomy, radiotherapy, and curettage, with no recurrence. Also underwent a complicated cholecystectomy with common bile duct exploration 10 years ago (operative records not available). On admission, the patient was afebrile with normal vital signs and slight right upper quadrant tenderness.",
+        "laboratory_tests": "White blood cell count, C-reactive protein level, and liver/pancreatic function test results were within normal ranges.",
+        "imaging_studies": "Positron emission tomographic/computed tomographic scan showed a 1-cm lesion with central fluid density on segment VI of the liver, enhanced with contrast injection and hypermetabolic on PET images.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Abscess Due to a “Lost” Stone During the Previous Cholecystectomy"
+    },
+    {
+        "patient_info": "Female, 50 years old, of Caribbean descent. The patient presented with a history of several months of recurrent postprandial right upper quadrant pain associated with nausea and vomiting.",
+        "laboratory_tests": "White blood cell count and liver function test results were within normal limits. Serologic test results for Echinococcus were negative.",
+        "imaging_studies": "Abdominal ultrasonography and computed tomography scan of the abdomen showed cholelithiasis and a questionable cystic dilatation of the common bile duct. Magnetic resonance cholangiopancreatography revealed a round lesion centered in the hepatic hilum measuring 1.9 × 1.9 × 2.1 cm with thin internal septations. Although it was in proximity to biliary structures, a direct communication was not visualized. There was no evidence of lymphadenopathy.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Cystadenoma of the Cystic Duct"
+    },
+    {
+        "patient_info": "Female, 88 years old. The patient presented to the emergency department with a 2-day history of gradual-onset, increasing right upper quadrant pain with aggravation on movement and cough. No nausea, vomiting, or changes in bowel habits were reported. Medical and surgical history includes hypertension, gout, hypercholesterolemia, hysterectomy, diverticulosis, and hip replacement complicated by deep vein thrombosis. Physical examination revealed normal vital signs and respiratory/cardiac functions. Abdominal examination showed no asymmetry or hernia, present bowel sounds, a palpable tender mass in the right upper quadrant with significant guarding, and a positive Murphy sign. The rest of the abdominal examination was unremarkable.",
+        "laboratory_tests": "White blood cell count: 13600/µL (neutrophil count: 11700/µL). Liver function tests were normal except for mildly raised bilirubin level: 1.8 mg/dL.",
+        "imaging_studies": "Ultrasonography revealed thickening of the gallbladder wall with multiple calculi. Diameter of the common bile duct and the intrahepatic biliary system were normal.",
+        "question": "What is the Diagnosis?",
+        "diagnosis": "Gallbladder Volvulus"
+    },
+    {
+        "patient_info": "Female, 44 years old. The patient complained of progressive nausea, vomiting, and increasing right upper quadrant pain. Approximately 1 month earlier, she had presented to the emergency department with a generalized tonic-clonic seizure. At the time of surgical consultation, she had been experiencing 2 days of nausea, vomiting, and right upper quadrant pain that radiated to the right scapula. She was also severely anorectic because of her symptoms. On physical examination, she was cachectic and had a palpable, distended, tender gallbladder and a tender liver.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Computed tomographic scan showed a left temporal hematoma and 2 hyperattenuated lesions located in the left thalamus and left caudate lobe. Subsequent magnetic resonance imaging showed multiple hemorrhagic lesions throughout the brain that were worrisome for metastatic disease. Abdominal computed tomographic scan showed a 2 x 5-cm lesion in the left lobe of the liver with some small scattered lesions of unknown significance. Ultrasound examination of the gallbladder noted the possibility of sludge or polyps. A computed tomographic scan was obtained prior to surgery.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Malignant Melanoma of the Gallbladder"
+    },
+    {
+        "patient_info": "Female, 45 years old. The patient presented with a 3-year history of confusion and seizures refractory to anticonvulsant therapy. She had no history of peptic ulcer disease, nipple discharge, or hypercalcemia. Her neuroglycopenic symptoms were relieved by intravenous glucose administration.",
+        "laboratory_tests": "Serum glucose level of 46 mg/dL, serum insulin level of 4 μIU/mL, C-peptide level of 0.9 ng/mL, proinsulin level of 19.9 pmol/L, negative sulfonylurea screen, serum gastrin level of <25 pg/mL, serum calcium level of 9.6 mg/dL. Postoperative fasting laboratory values: serum glucose level of 44 mg/dL, serum insulin level of 6.6 μIU/mL, C-peptide level of 0.7 ng/mL, negative sulfonylurea screen.",
+        "imaging_studies": "Preoperative transabdominal ultrasound identified a 1-cm hypervascular mass in the body of the posterior pancreas. No additional masses were identified intraoperatively by palpation.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "A Second Insulinoma"
+    },
+    {
+        "patient_info": "Female, 22 years old, previously healthy. The patient presented with a self-palpable left upper quadrant abdominal mass that she had for 6 months. She was otherwise asymptomatic. Physical examination revealed a 6-cm nontender mass in the left hypochondrium.",
+        "laboratory_tests": "Blood test results including complete blood cell counts, renal and liver functions, amylase level, carcinoembryonic antigen level, and alpha-fetoprotein level were all normal.",
+        "imaging_studies": "Plain abdominal radiography revealed a calcified mass lesion. Contrast computed tomography of the abdomen showed a pancreatic tail lesion and incidentally noted a 5-cm lesion at the right lobe of the liver. A whole-body positron emission tomographic scan showed hypermetabolic, heterogeneously enhancing masses at both the pancreatic tail and the right lobe of the liver. No other hypermetabolic lesion was noted in the rest of the body. At laparotomy, a 12-cm cystic tumor was noted at the tail of the pancreas near the splenic hilum and a 6-cm solitary metastatic tumor at segment 7/8 of the liver was found.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Solid Pseudopapillary Carcinoma of Pancreas With Liver Metastasis"
+    },
+    {
+        "patient_info": "Female, 69 years old. The patient had epilepsy and hypertension, and presented with a 5-month history of weight loss (5 kg), vague pain, and discomfort in the lower quadrants of the abdomen. She had no fever, vomiting, or diarrhea and no history of clinical pancreatitis. Physical examination findings were unremarkable.",
+        "laboratory_tests": "General laboratory test results and serum levels of tumor markers were within normal limits.",
+        "imaging_studies": "Ultrasonographic examination revealed a predominantly cystic mass (7 x 6 x 5 cm) in the body and tail of the pancreas. A contrast-enhanced computed tomographic scan showed a well-defined, round, low-density mass in the region of the pancreatic tail, consisting of a predominantly cystic area with corpuscular content. After the injection of contrast medium, enhancement of posterior polypoid lesions and of the external wall was seen.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Retroperitoneal Schwannoma"
+    },
+    {
+        "patient_info": "Male, 69 years old. The patient presented with occasional melena since April 2006. He denied abdominal pain, vomiting, fever, weight loss, or jaundice. Except for mild pallor, the physical examination findings were essentially unremarkable.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Upper gastrointestinal endoscopy revealed a bulging ampulla of Vater that bled on touch. The biopsy specimen was suggestive of inflammatory cells. Contrast-enhanced computed tomographic scan of the upper abdomen reported a heterogeneously enhancing tumor in the ampullary region. Endosonography (EUS) was performed for further characterization.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Gastrointestinal Stromal Tumor of the Ampulla of Vater"
+    },
+    {
+        "patient_info": "Female, 34 years old. Previously healthy. The patient was admitted with acute epigastric pain, a palpable abdominal mass, nausea, and weight loss of 2 kg in the last 2 weeks. Physical examination findings: weight 51 kg, height 170 cm, good general health, right upper quadrant tenderness, slight peritoneal symptoms, nondistended abdomen, normal bowel sounds. Body temperature was 38.2°C.",
+        "laboratory_tests": "Leukocyte count slightly elevated at 9.8×10^9/L (reference, <9.5×10^9/L). C-reactive protein level was 18 mg/L (reference, <5 mg/L).",
+        "imaging_studies": "Chest radiograph yielded normal findings. Abdominal sonography revealed a cystic lesion 8×4 cm in greatest diameter next to a small gallbladder, without other intraabdominal pathologic findings. Subsequent magnetic resonance cholangiopancreatography confirmed the cystic lesion. Laparotomy revealed a cystic tumor 8 cm in greatest diameter at the lateral border of the hepatoduodenal ligament.",
+        "question": "What is the Diagnosis?",
+        "diagnosis": "Choledochal Cyst"
+    },
+    {
+        "patient_info": "White, 80-year-old woman. The patient was admitted with postprandial pain in the right hypochondrium for 2 months. Medical history includes arterial hypertension, diabetes mellitus, and hypercholesterolemia for 10 years. Surgical history includes bilateral inguinal herniography.",
+        "laboratory_tests": "Blood test results, including complete blood cell counts, renal and liver functions, amylase level, carcinoembryonic antigen level, and α-fetoprotein level, were all normal.",
+        "imaging_studies": "Abdominal echography revealed a parietal anterior thickening of the gallbladder with a 1.8-cm echogenic intraluminal formation. Computed tomographic scan results were normal.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Neuroendocrine Carcinoma of the Gallbladder"
+    },
+    {
+        "patient_info": "Female, 35 years old. A FEMALE HEPATITIS B CARRIER, had received regular liver screenings by ultrasonography. It had been noted for several years that the gallbladder was difficult to locate, and contracted gallbladder was presumed. More recently, a palpable mass of about 5 cm was detected at the right periumbilical area.",
+        "laboratory_tests": "The laboratory data were normal.",
+        "imaging_studies": "Ultrasonography noted hepatic hilar lymphadenopathy. Further ultrasonography revealed a target mass approximately 4 cm between the liver, right kidney, and duodenal gas. The corresponding enhanced axial computed tomographic scans revealed a hypodense mass with central rim enhancement. The reconstructed coronal computed tomographic images revealed a large gallbladder mass with markedly thickened walls and hypertrophic mucosa. Magnetic resonance imaging clearly demonstrated multiple small cystic lesions within the hypertrophic wall and surrounding the contracted lumen.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Gallbladder adenomyomatosis"
+    },
+    {
+        "patient_info": "Male, 70 years old. The patient visited the emergency department with a 3-day history of right upper quadrant pain. He was febrile (temperature, 37.6°C). He had a history of splenectomy for hereditary spherocytosis at age 40 years and a history of upper gastrointestinal tract bleeding from a gastric ulcer 7 years prior to admission. He had gallstone disease for the last 12 years. His abdomen was soft and tender at the right upper quadrant with a positive Murphy sign.",
+        "laboratory_tests": "White blood cell count was 19×10^9/L.",
+        "imaging_studies": "Abdominal ultrasonographic scan showed acute cholecystitis with gallbladder wall thickening and pericholecystic fluid collection. Chest radiography revealed a mass of the right lower lobe. Further investigation included a biopsy guided by magnetic resonance imaging and computed tomography (results inconclusive).",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Extramedullary Hematopoiesis"
+    },
+    {
+        "patient_info": "Male, 68 years old, white. The patient is otherwise healthy and presented with a 4-day history of hyperthermia, a 6/10 dull pain (analogic pain scale) at the right superior abdominal quadrant, and nausea. Physical examination revealed a temperature of 40.1°C and mild right subcostal tenderness without rebound.",
+        "laboratory_tests": "Perturbation of hepatic enzymes, alteration of renal function, and elevated white blood cell count. Specific values not available.",
+        "imaging_studies": "Ultrasound revealed the presence of gallbladder stones and a round hypoechoic image in the fourth hepatic segment (5 cm in diameter). Abdominal CT scan confirmed the presence of a hypodense image in the liver and revealed gas in the gallbladder.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Cholecystocolonic fistula \n hepatic abscess"
+    },
+    {
+        "patient_info": "Male, 50 years old. The patient has a history of chronic hepatitis C and was undergoing surveillance liver CT for hepatoma monitoring.",
+        "laboratory_tests": "α-fetoprotein level increased from 46.7 ng/mL to 333.7 ng/mL over the monitoring period. Other laboratory tests were not available.",
+        "imaging_studies": "Liver CT scans over a 6-month period revealed a new splenic lesion increasing in size from 2.4 × 2.09 cm to 4.6 × 3.7 cm. Intraoperative ultrasonography showed a complex hypoechoic lesion in the cephalad posterior aspect of the spleen, measuring approximately 4 cm in diameter, with no focal liver lesions detected.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Primary Splenic High-Grade Lymphoma"
+    },
+    {
+        "patient_info": "Male, 57 years old. The patient was admitted for a left cervical and submandibular nodal mass and continuous right-sided abdominal pain. Medical history includes type 2 diabetes mellitus and B-cell chronic lymphocytic leukemia (B-CCL) diagnosed 4 years earlier (stage II according to Rai et al; stage C according to Binet et al). Previous treatments included multiple cycles of intravenous chemotherapy (chlorambucil plus prednisone and fludarabine) and human monoclonal antibodies (anti-CD52 MAbCampath; Bayer HealthCare Pharmaceuticals, Leverkusen, Germany) for CLL, which were unsuccessful.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Restaging computed tomographic total body scan showed a new suspicious mass arising from the thickened posterior wall of the gallbladder. The lesion was solid, homogeneous, poorly enhanced, and had a large base that adhered to the liver bed. Ultrasound examination documented liver steatosis, no focal parenchymal lesion or dilatation of the bile ducts, and no biliary sludge or stones, and confirmed a nodular mass of the posterior wall of the gallbladder not infiltrating the liver bed.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Richter Syndrome With Gallbladder Localization"
+    },
+    {
+        "patient_info": "Female, 57 years old. The patient presented with colic pain and jaundice. Twelve years before, she had a hysterectomy with the unexpected histological finding of leiomyosarcoma, and in a 'second-look' procedure, a bilateral salpingo-oophorectomy was done without any evidence of residual tumor.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Ultrasonography showed small stones in the gallbladder and a dilated common bile duct; ultrasonographic assessment of the pancreas was difficult because of interposed gas-containing loops. A computed tomographic scan showed, in the portal phase, a round and well-defined mass with inhomogeneous enhancement at the level of the head of the pancreas with dilatation of the main pancreatic duct. Endoscopic ultrasonography confirmed the mass but cytologic examination of the fine-needle aspiration biopsy specimen was unremarkable.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Metastasis From Leiomyosarcoma"
+    },
+    {
+        "patient_info": "Female, 50 years old. The patient had laparoscopic cholecystectomy for symptomatic cholelithiasis at an outside hospital and developed symptoms of abdominal pain, nausea, and vomiting 1 week postoperatively.",
+        "laboratory_tests": "Not available",
+        "imaging_studies": "Abdominal ultrasound (no abnormalities detected), Endoscopic retrograde cholangiopancreatography (ERCP) (failed to reveal the cause of symptoms), Abdominal computed tomographic scan (demonstrated a biloma adjacent to the gallbladder fossa), Hepatobiliary iminodiacetic acid scan (showed a persistent biliary leak).",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Transected Right Posterior Hepatic Duct"
+    },
+    {
+        "patient_info": "Female, 54 years old. The patient presented with chronic intermittent sharp midepigastric abdominal pain. She denied having jaundice or a change in her bowel function but admitted to a 5.4-kg weight loss over 3 months. Medical, surgical, family, and social histories were unremarkable. There was no history of neurofibromatosis 1. The results of physical examination were normal.",
+        "laboratory_tests": "Routine laboratory tests, including liver function tests, were normal.",
+        "imaging_studies": "A right upper quadrant ultrasonographic and computed tomographic (CT) scan with contrast revealed a 1.4-cm enhancing lesion in the head of the pancreas without duct dilation.",
+        "question": "What Is the Diagnosis?",
+        "diagnosis": "Pancreatic Schwannoma"
+    },
+    {
+        "patient_info": "Female, 27 years old, healthy-appearing. Presented with vague abdominal discomfort. Medical history included only oral contraception. Physical examination revealed a palpable mass of mild tenderness in the upper right quadrant.",
+        "laboratory_tests": "Serum levels of tumor markers (carcinoembryonic antigen, carbohydrate antigen 19-9, and α-fetoprotein) and serology results for echinococcosis were negative.",
+        "imaging_studies": "Abdominal computed tomography and hepatic magnetic resonance imaging showed a 9-cm-diameter, solid, heterogeneous, encapsulated mass with scattered calcifications that had developed from the inferior part of segment VI of the liver. Gastroscopy and colonoscopy results were normal.",
+        "question": "What is the Diagnosis?",
+        "diagnosis": "Hepatic Calcifying Fibrous Pseudotumor"
+    }
+]

cnqa-subset-200.json

@@ -0,0 +1,1602 @@
+[
+    {
+        "question": "在急性肝功能衰竭的治疗中，以下哪项是需要严格限制的？",
+        "options": "A. 脂肪\nB. 蛋白质\nC. 热量\nD. 牛奶\nE. 糖",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位75岁男性患者，长期患有慢性支气管炎和乙型肝炎。最近两个月出现下肢水肿、尿量减少和气短症状。体检显示颈静脉怒张，肝脏在肋下2cm可触及，有少量腹水和下肢水肿。实验室检查显示转氨酶轻度升高。请问以下哪项临床表现最能帮助区分右心衰竭和肝硬化？",
+        "options": "A. 肝脏肿大\nB. 下肢水肿\nC. 腹腔积液\nD. 颈静脉怒张\nE. 转氨酶增高",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在原发性肝癌的诊断中，以下哪项是最关键的指标？",
+        "options": "A.放射性核素肝扫描显示占位性病变\nB.右膈肌升高及运动受限\nC.A型超声波检查肝区有束状波\nD.碱性磷酸酶、γ-谷氨酰转肽酶水平升高\nE.甲胎蛋白持续阳性",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位58岁男性患者，近半年出现进行性贫血、消瘦和乏力，偶尔感到右腹隐痛，但无腹泻。体检发现右中腹部可触及肿块，肠鸣音活跃。若需进行手术治疗，术前最重要的准备工作是",
+        "options": "A. 纠正营养\nB. 肠道准备\nC. 心肺功能检查\nD. 肝肾功能检查\nE. 心理准备",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在原发性肝癌的发病机制中，以下哪个因素被认为是最主要的诱因？",
+        "options": "A. 饮用水污染\nB. 病毒性肝炎\nC. 黄曲霉毒素\nD. 肝硬化\nE. 寄生虫",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性重型肝炎的病理变化中，以下哪一项描述是不正确的？",
+        "options": "A. 肝细胞广泛坏死\nB. 肝窦扩张充血及出血\nC. 网状支架塌陷\nD. 淋巴细胞及巨噬细胞浸润\nE. 可见明显的肝细胞再生结节",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下药物中，哪一种不会导致急性胰腺炎的发生？",
+        "options": "A.氢氧化铝\nB.乙醇（酒精）\nC.硫唑嘌呤\nD.氢氯噻嗪\nE.促肾上腺皮质激素",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在原发性肝癌的相关描述中，以下哪一项是错误的？",
+        "options": "A. 肝癌可以起源于肝细胞\nB. 乙型肝炎病毒是肝癌的直接致病因素\nC. 胆汁性肝硬化与肝癌的发生没有关联\nD. 肝癌也可以起源于肝内胆管细胞\nE. 黄曲霉毒素的暴露可能与肝癌的发病有关",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一位66岁的女性患者因长期肝区不适、食欲减退、恶心呕吐等症状被诊断为肝癌。家属担心患者无法承受病情真相，要求医生保密。当实习医生被患者询问病情时，应如何回应最为妥当？",
+        "options": "A. 如实告知患者所有病情信息\nB. 坚持患者有权知晓真实病情，不应隐瞒\nC. 出于对患者心理承受能力的考虑，暂时隐瞒真实病情\nD. 建议患者向家属询问病情详情\nE. 以诚实守信为原则，向患者坦白病情",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位50岁男性患者，因右中上腹疼痛伴恶心、呕吐1天，症状加重并伴有腹胀12小时前来就诊。患者体型肥胖，体温38.9℃，呼吸频率30次/分，心率120次/分，血压110/80mmHg。体检发现全腹胀，伴有压痛、反跳痛及肌紧张，移动性浊音阳性。实验室检查显示血淀粉酶1000索氏单位，白细胞计数20×10^9/L，血钙水平降低。根据这些临床表现和检查结果，最可能的诊断是（）。",
+        "options": "A.急性水肿性胰腺炎\nB.急性腹膜炎\nC.急���胃肠炎\nD.出血坏死性胰腺炎\nE.胃溃疡穿孔",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝硬化腹水合并功能性肾衰竭的患者中，以下哪一项不是常见的临床表现？",
+        "options": "A.少尿或无尿\nB.尿钠低\nC.自发性氮质血症\nD.稀释性低钠血症\nE.肾小管缺血性坏死",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科手术中，胆管梗阻的定位通常分为哪几个关键区域？",
+        "options": "A.肝门段\nB.胰腺段\nC.胰上段\nD.壶腹段",
+        "answer": "ABCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性胆囊炎的临床表现中，哪一项描述是不正确的？",
+        "options": "A. 进食高脂肪食物后易诱发症状\nB. 右上腹出现持续性疼痛，并伴有阵发性加剧\nC. 疼痛通常向右侧肩部或背部放射\nD. 检查时墨菲征呈阳性反应\nE. 大多数患者会出现黄疸症状",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位38岁男性患者，出现右上腹疼痛、寒战、高热和黄疸症状已持续1天。体检显示体温高达39.6℃，血压为83/60mmHg，皮肤和巩膜明显黄染，右上腹及剑突下区域有压痛，并可触及肿大的胆囊。血常规检查显示白细胞计数为26×109/L。根据这些临床表现，最可能的诊断是（）。",
+        "options": "A.急性坏死性胰腺炎\nB.胆囊穿孔\nC.急性化脓性胆囊炎\nD.急性梗阻性化脓性胆管炎\nE.肝内胆管结石并发胆道感染",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一位患者因肝脏疾病出现昏睡和精神错乱症状，此时最可能处于肝性脑病的哪个阶段？",
+        "options": "A.肝性脑病前驱期\nB.肝性脑病昏迷前期\nC.肝性脑病昏睡期\nD.肝性脑病昏迷期\nE.亚临床肝性脑病",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下哪种情况下，肝脏穿刺活检不推荐作为诊断手段？",
+        "options": "A. 肝粟粒状结核\nB. 肝硬化\nC. 慢性肝炎\nD. 血吸虫肝病\nE. 肝包虫病",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性化脓性胆囊炎的情况下，胆囊的哪个部位最容易发生穿孔？",
+        "options": "A. 胆囊颈部\nB. 胆囊壶腹部\nC. 胆囊前壁\nD. 胆囊底部\nE. 胆囊后壁",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在诊断细菌性肝脓肿时，以下哪种检查方法能够提供确诊依据？",
+        "options": "A. 血常规\nB. B超\nC. CT\nD. 放射线核素扫描\nE. 诊断性肝穿刺",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在病毒性肝炎的病理变化中，哪种类型的肝炎会表现出明显的碎片状坏死和桥接坏死？",
+        "options": "A. 急性黄疸型肝炎\nB. 亚急性重型肝炎\nC. 慢性持续性肝炎\nD. 慢性活动性肝炎\nE. 急性重型肝炎",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位50岁男性患者，近期出现上腹部闷胀感，黄疸逐渐加重，并伴有体重下降，持续2个月。体检发现患者消瘦，巩膜和皮肤明显黄染，腹部柔软，肝脏在肋下可触及2指，伴有触痛和轻叩痛，胆囊未触及肿大。患者既往无胆道疾病史。实验室检查显示尿胆红素显著升高（+++），而尿胆原未见增加。为明确诊断，应优先考虑进行哪项检查？",
+        "options": "A.静脉胆道造影\nB.口服法胆囊造影\nC.MRCP\nD.上消化道钡餐检查\nE.胃、十二指肠液检查",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一位65岁男性患者，近3个月来出现进行性黄疸，伴有中上腹持续性胀痛，夜间平卧时疼痛加重，体重明显下降。体检发现患者呈慢性消耗性面容，皮肤和巩膜黄染，腹部平坦，Courvoisier征阳性。最可能的诊断是",
+        "options": "A. 肝门部胆管癌\nB. 壶腹癌\nC. 原发性肝癌\nD. 胃癌\nE. 胰头癌",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在临床实践中，哪种检测方法被认为是确诊胰岛素瘤的金标准？",
+        "options": "A. 监测空腹血糖水平低于2.2mmol/L\nB. 进行Wipple三联征评估\nC. 实施葡萄糖耐量试验\nD. 开展饥饿试验\nE. 测定血液中胰岛素水平",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性胰腺炎的发病机制中，以下哪项是关键的初始步骤？",
+        "options": "A.胰蛋白酶原转化成胰蛋白酶\nB.胰酶在胰腺管内被激活\nC.磷脂酶A2分解细胞膜的磷脂产生溶血卵磷脂\nD.弹力蛋白酶水解血管壁的弹力纤维\nE.激肽酶原水解为缓激肽",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位58岁的男性患者，既往有肝硬化病史，因大量呕血1天后出现神志恍惚、淡漠少言、口齿不清、嗜睡及昼睡夜醒等症状。护士应警惕患者可能出现了以下哪种并发症？",
+        "options": "A. 肺性脑病\nB. 肝性脑病\nC. 呼吸衰竭\nD. 肝癌\nE. 急性胰腺炎",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下疾病中，除原发性肝癌外，哪种疾病可能导致AFP水平超过500μg/L？",
+        "options": "A. 多囊肝\nB. 慢性肝炎\nC. 生殖腺胚胎瘤\nD. 肾脏胚胎瘤\nE. 肝硬化",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位55岁女性患者，有8年乙肝病史，最近一个月感到明显乏力，并伴有间断性的右上腹疼痛。体检显示血压为115/60mmHg，巩膜出现黄染，结膜无苍白，右上腹饱满且有压痛，无反跳痛及肌紧张，肝区叩痛阳性，移动性浊音阴性，双下肢无水肿。超声检查发现肝内结节呈均匀低回声伴中心点状增强。根据这些信息，最可能的诊断是什么？",
+        "options": "A.肝脓肿\nB.继发性肝癌\nC.活动性肝炎\nD.乙型病毒性肝炎复发\nE.原发性肝癌",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝胆外科手术中，了解胆总管的长度对于手术规划至关重要。根据解剖学研究，胆总管的平均长度是多少？",
+        "options": "A. 5~7cm\nB. 7~9cm\nC. 9~11cm\nD. 12~14cm\nE. 15~17cm",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在乙肝患者的实验室检查中，以下哪项指标的阳性结果最能提示患者具有较高的传染性？",
+        "options": "A. HBsAg\nB. HBsAb\nC. HBeAg\nD. 抗-HBe\nE. 抗HBc-IgM",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在门静脉高压症的诊断中，以下哪项临床表现最具特异性？",
+        "options": "A. 腹水\nB. 脾大脾亢\nC. 肝功能障碍\nD. 呕血或便血\nE. 食管下段、胃底静脉曲张",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝性脑病患者的护理中，以下哪项措施是不恰当的？",
+        "options": "A. 使用镇静剂处理烦躁患者\nB. 采用弱酸溶液进行灌肠\nC. 确保患者大便通畅\nD. 实施禁蛋白饮食\nE. 密切监测生命体征",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在胆道系统的生理功能中，以下哪几项描述是正确的？",
+        "options": "A. 胆囊每日可储存和浓缩胆汁约500ml\nB. 促胰液素是促进胆汁分泌的主要激素\nC. 毛细胆管在胆汁的流量和成分调节中发挥重要作用\nD. 肝细胞是胆汁的唯一来源",
+        "answer": "ABC",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝血管瘤的肝血池显像中，血管瘤区域的放射性强度与周围肝组织相比如何？",
+        "options": "A. 增高\nB. 明显增高\nC. 稍低\nD. 明显减低\nE. 相似",
+        "answer": "AB",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "对于疑似胆石症的患者，以下哪种影像学检查方法应作为首选？",
+        "options": "A. 腹部CT\nB. 腹部超声\nC. 腹部平片\nD. 腹部MRI\nE. ERCP",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝功能不全的患者中，由于雌激素的灭活作用减弱，可能会出现以下哪些症状？",
+        "options": "A. 蜘蛛痣\nB. 肝掌\nC. 男子乳房发育\nD. 女子月经失调",
+        "answer": "ABCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在临床诊断中，下列哪项特征是区分肝硬化腹水与右心衰伴大量腹水的关键指标？",
+        "options": "A. 颈静脉怒张\nB. 下肢浮肿\nC. 呈现蛙腹\nD. 肝大质硬\nE. 伴黄疸",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科诊断中，以下哪种标本最有可能检测到溶组织内阿米巴包囊？",
+        "options": "A. 肝脓肿穿刺液\nB. 黏液脓血便\nC. 脓血痰液\nD. 成形粪便\nE. 肺脓肿穿刺液",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下患者中，哪一类患者需要遵循低脂肪饮食？",
+        "options": "A. 甲状腺功能亢进患者\nB. 烧伤患者\nC. 大手术后患者\nD. 急性肾炎患者\nE. 肝胆胰疾病患者",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "男性，59岁，长期饮酒史，反复左上腹持续性隐痛伴腹胀、消瘦、脂肪泻4年，腹痛发作时加剧并向腰背部放射，呈束腰带状。查体：皮肤巩膜无黄染。实验室检查：尿淀粉酶450U/L，空腹血糖11.5mmol/L。最可能的诊断是？",
+        "options": "A. 胃溃疡\nB. 慢性结肠炎\nC. 慢性胰腺炎\nD. 胰头癌\nE. 十二指肠溃疡",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在胆管癌的相关描述中，以下哪一项是正确的？",
+        "options": "A.胆管癌是胆道系统中最常见的恶性肿瘤\nB.肝外胆管癌中，肝门部是最常见的发病部位\nC.胆管癌在青壮年人群中更为常见\nD.胆管癌的组织学病理类型以鳞癌为主\nE.胆管癌的发病与华支睾吸虫感染无关",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在原发性胆汁性肝硬化的病理学特征中，哪一项描述最为准确？",
+        "options": "A. 肝内血循环紊乱、血管床缩小、闭塞和扭曲\nB. 汇管区纤维结缔组织增生\nC. 肝内细小胆管慢性非化脓性破坏性炎症\nD. 广泛的肝细胞变性坏死\nE. 汇管区可见程度不等的炎症细胞浸润",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "对于肝硬化腹水患者，每日的液体摄入量应控制在什么范围内？",
+        "options": "A. 1000-1500ml\nB. 500-1000ml\nC. 小于500ml\nD. 1500-2000ml\nE. 2000-2500ml",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在胆色素结石的形成过程中，以下哪一项因素不参与其中？",
+        "options": "A. 双葡萄糖醛酸胆红素\nB. β-葡萄糖醛酸胆红素\nC. 葡萄糖醛酸-1，4-内酯\nD. 胆道蛔虫病\nE. 肝胆管狭窄",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性期及肝功能明显受损的情况下，以下哪种药物应避免使用？",
+        "options": "A. 山药\nB. 六味地黄丸\nC. 砒石\nD. 山楂\nE. 牛黄",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在继发性肝癌的诊断和治疗中，以下哪一项描述是不准确的？",
+        "options": "A. 血清AFP水平通常为阴性\nB. 常见的原发癌灶包括胃癌、结肠癌和胰腺癌\nC. 通常表现为单个结节，而非多发结节\nD. 主要症状通常由肝外原发癌肿引起\nE. 诊断的核心在于确定原发癌灶的位置",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝癌的初步诊断中，最推荐的首选检查方法是什么？",
+        "options": "A. CT扫描\nB. 磁共振成像（MRI）\nC. 超声检查\nD. 肝动脉造影\nE. 超声检查联合甲胎蛋白（AFP）定量测定",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性肝衰竭患者出现肝性脑病的情况下，以下哪种治疗方法是不推荐的？",
+        "options": "A. 使用硫喷妥钠\nB. 进行过度换气\nC. 将体温降低至32℃-33℃\nD. 实施腹膜透析",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位患者因突发上腹部剧烈疼痛入院，伴有高热（体温39℃）、巩膜黄染及剑突下压痛。在观察期间，患者多次出现寒战，脉搏加快至110次/分，血压升高至22/14kPa(165/105mmHg)。根据这些症状，最可能的诊断是什么？",
+        "options": "A.急性胰腺炎\nB.慢性胆囊炎合并胆囊结石\nC.急性梗阻性化脓性胆管炎\nD.急性化脓性胆囊炎\nE.胆道蛔虫病",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一名6岁男孩被诊断为胆道蛔虫病，以下哪项病史或体征最不符合该诊断？",
+        "options": "A. 发病12～24小时常有明显黄疸\nB. 曾有粪便中排出蛔虫的病史\nC. 腹痛呈间歇性发作\nD. 病情严重时可出现急性胆管炎症状\nE. 伴有恶心、呕吐症状",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝脓肿的X线平片检查中，以下哪些表现是常见的？",
+        "options": "A.膈肌升高\nB.肝向下增大\nC.右下肺盘状不张\nD.结肠肝曲上移\nE.右侧胸腔积液",
+        "answer": "ABCE",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在先天性胆管扩张症的患者中，以下哪种症状通常不会出现？",
+        "options": "A. 右上腹肿块\nB. 黄疸\nC. 发热、上腹痛\nD. 右上腹阵发性绞痛\nE. 出现症状时间可由新生儿、儿童至成年",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科临床实践中，以下哪种症状组合最可能提示原发性肝癌的诊断？",
+        "options": "A. 持续性肝区疼痛伴呕血\nB. 轻度上腹部不适\nC. 进行性食欲减退和体重下降\nD. 皮肤和巩膜黄染\nE. 腹部膨隆伴腹水",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在下列疾病中，哪种疾病最常导致肝细胞性黄疸的发生？",
+        "options": "A. 胆管癌\nB. 急性黄疸性肝炎\nC. 胆管结石\nD. 原发性胆汁性肝硬化\nE. 胰头癌",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位50岁男性患者，因肝硬化导致腹水、尿量减少、下肢水肿以及端坐呼吸。在这种情况下，应立即采取以下哪种措施？",
+        "options": "A. 口服呋塞米片\nB. 洋地黄静推\nC. 毛花苷C静推\nD. 口服硫酸镁导泻\nE. 呋塞米静推",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "对于肝硬化腹水患者，每日的进水量应控制在多少？",
+        "options": "A. 250ml左右\nB. 500ml左右\nC. 750ml左右\nD. 1000ml左右\nE. 1500ml左右",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在中医古籍中，哪一部医书首次明确指出胁痛与肝胆病变之间存在直接关联？",
+        "options": "A.《难经》\nB.《伤寒杂病论》\nC.《景岳全书》\nD.《证治汇补》\nE.以上都不是",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "患者因胆道砂石阻塞出现黄疸、右胁疼痛并放射至肩背，伴有寒热交替及大便呈灰白色，应选用哪种治疗方案？",
+        "options": "A.茵陈蒿汤\nB.麻黄连翘赤小豆汤\nC.栀子柏皮汤\nD.大柴胡汤",
+        "answer": "AD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下关于胆汁的描述中，哪一项是不正确的？",
+        "options": "A.胆汁呈金黄色，pH7.8〜8.6\nB.胆汁中除97%是水外，还有胆盐等有机物及Na+等无机物\nC.正常人每天分泌胆汁600〜1200ml\nD.在胆囊中贮存胆汁，因被浓缩而颜色加深\nE.消化期时，胆汁进入胆囊储存",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝脏触诊的临床实践中，以下哪项描述是不正确的？",
+        "options": "A. 触诊过程中需要与患者的呼吸动作密切配合\nB. 单手触诊法是临床上较为常用的触诊方法\nC. 当肝脏位置较深时，应采用浮沉触诊法（冲击触诊法）\nD. 正常肝脏在肋缘下的触诊范围通常不超过1厘米\nE. 正常肝脏在剑突下的触诊范围通常在3至5厘米之间",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在评估肝硬化患者是否并发原发性肝癌时，以下哪项检查最具诊断价值？",
+        "options": "A. 胃镜检查显示食管下段及胃底静脉曲张\nB. 腹水分析\nC. 白蛋白与球蛋白比例显著倒置\nD. 靛青绿清除试验\nE. 肝脾超声检查",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下哪种情况下，胆囊结石患者应考虑进行胆囊切除术？",
+        "options": "A. 无症状的年轻患者\nB. 经常出现右上腹疼痛\nC. 结石直径超过2厘米\nD. 同时患有糖尿病",
+        "answer": "BCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝脏的多种功能中，哪一项描述是不正确的？",
+        "options": "A. 分泌胆汁\nB. 参与代谢过程\nC. 具有解毒功能\nD. 参与免疫反应\nE. 将维生素A转化为凝血酶原",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在日本血吸虫病中，最常见的肝硬化类型是",
+        "options": "A.胆汁性肝硬化\nB.门脉性肝硬化\nC.干线型肝硬化\nD.坏死后性肝硬化",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科手术中，TIPSS手术的主要路径和连接部位是？",
+        "options": "A.经颈静脉途径在肝静脉与肝内门脉之间建立通道\nB.经股静脉途径在下腔静脉与肝动脉之间建立通道\nC.经颈静脉途径在肝动脉与肝内门脉之间建立通道\nD.经股静脉途径在下腔静脉与门脉之间建立通道\nE.经股动脉途径在肝动脉与门脉之间建立通道",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝细胞再生的研究中，以下哪项陈述是不正确的？",
+        "options": "A. 肝细胞属于不稳定细胞，肝部分切除后可快速再生\nB. 肝脏干细胞具有分化为胆管上皮细胞和肝细胞的双向潜能\nC. 肝细胞广泛变性伴点状坏死时可完全再生修复\nD. 肝细胞坏死，网状支架完整，可通过再生恢复正常结构\nE. 肝细胞大片坏死，网状支架塌陷，则再生肝细胞难以恢复原来小叶结构",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝性脑病的诊���中，以下哪项陈述是不正确的？",
+        "options": "A. 前驱期症状常被误认为精神病\nB. 血氨水平不升高可以排除肝性脑病\nC. 扑翼样震颤、血氨升高和脑电图异常同时出现有助于诊断\nD. 急性肝功能衰竭引起的肝性脑病血氨水平通常正常",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝脓肿的超声检查中，以下哪种表现最为罕见？",
+        "options": "A.病变呈不均匀的低至中等回声区，边界模糊，似肝脏恶性肿瘤\nB.囊壁厚而不光滑\nC.囊壁薄而光滑\nD.囊内不规则低回声，可随体位改变出现光点漂浮现象\nE.囊壁可有钙化",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下因素中，哪一项不是导致肝硬化的常见原因？",
+        "options": "A. 胆汁淤积\nB. 丙型肝炎\nC. 酒精中毒\nD. 乙型肝炎\nE. 甲型肝炎",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝性脑病的患者中，哪种情况通常预后最差？",
+        "options": "A. 肝硬化伴腹腔积液者\nB. 暴发性肝炎所致者\nC. 诱因明确，且易消除者\nD. 肝硬化伴黄疸者\nE. 肝硬化伴自发性腹膜炎者",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位38岁男性患者，在餐后2小时突然出现腹痛、恶心、呕吐，并伴有发热。第二天出现黄疸，血液检查显示淀粉酶和胆红素水平显著升高。请问导致黄疸的最可能原因是什么？",
+        "options": "A. 肝细胞性黄疸\nB. 胆结石并胰腺炎\nC. 肿大的胰腺压迫胆管所致\nD. 胆囊炎所致\nE. 胆总管下端狭窄",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在急性梗阻性化脓性胆管炎的治疗中，哪一项措施是最为关键的？",
+        "options": "A. 输液，补充血容量\nB. 胆道减压手术\nC. 静滴大量抗生素\nD. 纠正酸中毒\nE. 营养支持",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位患者出现无痛性进行性黄疸，最可能的诊断是？",
+        "options": "A.急性胰腺炎\nB.慢性胆囊炎\nC.胰头癌\nD.急性胆囊炎\nE.急性化脓性胆管炎",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在日本血吸虫病导致的肝脏病变中，最常见的肝硬化类型是",
+        "options": "A. 胆汁性肝硬化\nB. 门脉性肝硬化\nC. 干线型肝硬化\nD. 游血性肝硬化\nE. 坏死后性肝硬化",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在原发性肝癌的诊断中，以下哪一项症状通常不会出现？",
+        "options": "A. 持续不规则发热\nB. 低胆固醇血症\nC. 肝硬化表现\nD. 低血糖症\nE. 门静脉血栓形成",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科临床实践中，放射性核素肝胆动态显像技术可用于以下哪些情况？",
+        "options": "A. 急性胆囊炎的诊断\nB. 肝外胆道梗阻与肝内胆汁淤积的鉴别诊断\nC. 先天性胆道闭锁与新生儿肝炎的鉴别诊断\nD. 胆总管囊肿等先天性胆道异常的诊断\nE. 肝胆系统术后疗效评估及胆汁漏的诊断",
+        "answer": "ABCDE",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一位65岁男性患者因急性胰腺炎入院，随后发展为多器官功能不全综合征。在分析其发病机制时，以下哪项不属于主要的损害因子？",
+        "options": "A. 细胞因子\nB. 炎性介质\nC. 生长因子\nD. 全身炎性反应\nE. 组织缺血—再灌注过程",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "关于乙型肝炎患者的病情发展，以���哪项描述是不正确的？",
+        "options": "A. 同时感染HDV等其他肝炎病毒会加重病情\nB. 重型肝炎患者常伴有细菌感染\nC. 乙型肝炎是导致肝细胞癌的主要原因\nD. 急性淤胆型肝炎容易发展为胆汁性肝硬化\nE. 成年人感染HBV后不易发展为慢性肝炎",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位34岁男性患者，主诉肝区疼痛并伴有间歇性发热。影像学检查（B超、CT）显示左肝外叶胆管扩张伴结石，胆囊肿大，胆总管增粗且内有泥沙样结石。术中证实胆总管远端明显狭窄，F9号导尿管无法通过。请问以下哪些手术方式适用于该患者？",
+        "options": "A. 胆囊切除术\nB. 胆肠吻合术\nC. 胆总管探查术\nD. 左肝外叶切除术\nE. Oddi括约肌成形术",
+        "answer": "ABCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝硬化门静脉高压症患者中，脾切除联合贲门周围血管离断术用于治疗食管静脉曲张破裂出血。关于该手术的优点，以下哪项说法尚未得到广泛认同？",
+        "options": "A. 手术创伤相对较小\nB. 止血效果较为理想\nC. 术后肝性脑病发生率较低\nD. 术后肝功能得到改善",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科手术中，医生需要准确识别肝脏的各个叶段。附图中直线所指部位的解剖名称为",
+        "options": "A. 肝脏右前叶\nB. 肝脏左外叶下段\nC. 肝脏左内叶\nD. 肝脏右后叶\nE. 肝脏左外叶上段",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位50岁男性患者因胆囊结石需要进行B型超声检查，检查前一晚最适合进食的食物是",
+        "options": "A. 油煎鸡蛋\nB. 牛奶\nC. 红烧牛肉\nD. 清汤面\nE. 炖豆腐",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝胆外科手术中，Calot三角是由哪些结构组成的解剖区域？",
+        "options": "A.胆囊管，脾静脉，肝下缘\nB.胆囊管，肝总管，肝下缘\nC.主胰管，肝总管，肝下缘\nD.胆囊管，肝总管，肝上缘\nE.胆囊底，胆总管，肝上缘",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "关于胰岛素瘤的临床表现，下列哪一项描述是不正确的？",
+        "options": "A. 葡萄糖耐量试验显示低平曲线\nB. 饥饿试验可以诱发相关症状\nC. 血液中胰岛素水平增加超过50%\nD. 患者常出现低血糖症状\nE. 确诊后通常建议手术切除肿瘤",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在门脉高压的临床表现中，以下哪一项最具特异性？",
+        "options": "A. 肝掌\nB. 脾功能亢进\nC. 周身水肿\nD. 食管静脉曲张\nE. 腹水",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PortalHypertension",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在T1加权成像（T1WI）中，以下哪种病变的信号强度高于正常肝组织？",
+        "options": "A. 肝脓肿\nB. 肝脏血管瘤\nC. 单纯性肝囊肿\nD. 转移性肝癌\nE. 肝脏脂肪瘤",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝脏功能受损的早期阶段，下列哪种凝血因子的活性会首先降低？",
+        "options": "A. FⅡ：C\nB. FⅤ：C\nC. FⅦ：C\nD. FⅧ：C\nE. FⅩ：C",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在诊断不明原因的肝外阻塞性黄疸时，推荐进行哪种手术？",
+        "options": "A. 胆囊造瘘术\nB. 胆道探查及引流术\nC. 胆总管十二指肠吻合术\nD. 肝叶切除术\nE. 胆囊切除",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在诊断细菌性肝脓肿时，以下哪项病史不应出现？",
+        "options": "A. 胆道化脓性感染史\nB. 阿米巴原虫感染史\nC. 全身化脓性感染史\nD. 肝肿大伴疼痛\nE. 可见右膈升高、运动受限",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科中，夏科(Charcot)三联症是以下哪种疾病的典型表现？",
+        "options": "A. 急性胰腺炎\nB. 急性胆管炎\nC. 急性十二指肠憩室炎\nD. 急性胃炎\nE. 急性胆囊炎",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在胆固醇结石的形成过程中，以下哪项因素起主要作用？",
+        "options": "A.胆汁中钙离子浓度升高\nB.胆盐与磷脂的微胶粒不足\nC.胆固醇绝对含量增加\nD.大肠杆菌产生的β葡萄糖醛酸酶过量\nE.胆汁酸分泌量增加",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝性脑病症状显现之前，哪种检测方法能够早期发现病情？",
+        "options": "A.空腹血糖\nB.脑电图\nC.肝功能全套\nD.视觉诱发电位\nE.血氨",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位30岁女性患者，近2年多来反复出现右上腹疼痛，并伴有肩背部放射痛。根据超声检查结果，最可能的诊断是",
+        "options": "A. 胆囊息肉\nB. 胆囊腺瘤\nC. 胆囊结石\nD. 胆囊蛔虫\nE. 胆囊癌",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "患者李某，男性，60岁，一年前因肝细胞癌接受了左半肝切除术。术后需定期随访，以下哪种检查方法对早期发现肿瘤复发最为敏感？",
+        "options": "A. 定期进行ALT水平监测\nB. 定期进行GGT水平监测\nC. 定期进行腹部超声检查\nD. 定期进行甲胎蛋白（AFP）检测\nE. 选择性进行肝动脉造影",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一位63岁的女性患者，近3年来在冬季反复出现上腹部疼痛，疼痛通常在餐后半小时开始，餐前缓解。最近一周症状复发。体检显示患者神志清醒，无贫血表现，剑突下有压痛，肝脾未触及。根据这些症状和体征，最可能的诊断是什么？",
+        "options": "A. 胃癌\nB. 慢性胃炎\nC. 十二指肠溃疡\nD. 慢性胆囊炎\nE. 胃溃疡",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在诊断阿米巴肝脓肿时，以下哪项特征最具特异性？",
+        "options": "A. 突发寒战、高热，肝区疼痛，肝肿大\nB. 右上腹绞痛及黄疸\nC. 穿刺抽出棕褐色脓液\nD. 补体结合试验阳性",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在治疗肝性脑病时，医生可能会给患者开新霉素口服，其主要目的是什么？",
+        "options": "A. 抑制肠道细菌生长\nB. 预防肠道感染\nC. 减少尿素酶的产生\nD. 预防原发性腹膜炎",
+        "answer": "AC",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性胰腺炎的病因中，高三酰甘油血症的诊断标准是血三酰甘油水平应达到多少？",
+        "options": "A.大于2.3mmol/L\nB.达到正常上限的3倍\nC.大于11.0mmol/L\nD.大于20.0mmol/L\nE.达到正常上限的3倍，伴血胆固醇升高",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位58岁男性患者，患有肝炎已有10余年，最近因感到无力、食欲不振和腹胀20天，被诊断为乙肝后肝硬化（失代偿期）并入院。肝功能测试显示显著异常，特别是白蛋白水平降低，球蛋白水平升高，白蛋白与球蛋白比率倒置。为了治疗其低蛋白血症，应首选哪种血液制品？",
+        "options": "A. 全血\nB. 新鲜冰冻血浆\nC. 普通冰冻血浆\nD. 低分子右旋糖酐\nE. 白蛋白",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "患者出现发热和肝痛症状，阿米巴血清学检查结果为阴性，最可能的诊断是什么？",
+        "options": "A. 确诊阿米巴肝病\nB. 排除阿米巴肝病\nC. 阿米巴原虫携带者\nD. 肠阿米巴病普通型\nE. 肠阿米巴病普通型",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝胆外科诊断中，超声检查对于以下哪种疾病的诊断作用有限？",
+        "options": "A. 胆囊炎\nB. 胆结石\nC. 胆囊积液\nD. 胃肠炎\nE. 阻塞性黄疸",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在原发性肝癌的转移过程中，哪个脏器最常受到影响？",
+        "options": "A. 肺\nB. 脑\nC. 肝内\nD. 骨\nE. 胃",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在下列哪种疾病中，Reynolds征最为典型？",
+        "options": "A. 急性化脓性胆囊炎\nB. 急性梗阻性化脓性胆管炎\nC. 急性出血性坏死性胰腺炎\nD. 急性坏死性小肠炎\nE. 绞窄性小肠梗阻",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位40岁男性患者，3天前体检时通过B超发现右肝内有一个直径3cm的肿物，血AFP水平为500μg/L。针对这种情况，最有效的治疗方法是什么？",
+        "options": "A.经股动脉插管化疗\nB.经皮肿瘤穿刺注无水酒精\nC.行肝段切除术\nD.放射治疗\nE.全身化疗",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一位44岁男性患者，长期患有肝病，近期随访发现肝右叶有一个8cm的占位性病变，周围有多个卫星灶，但肝肾功能正常。在这种情况下，首选的治疗方案是什么？",
+        "options": "A. 全身化学治疗\nB. 肿瘤局部放射治疗\nC. 手术切除\nD. 介入治疗\nE. 肿瘤局部无水酒精注射",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在诊断胰岛素瘤时，以下哪项实验室检查结果通常会出现异常？",
+        "options": "A. 血浆胰岛素原与总胰岛素的比值超过20%\nB. C肽水平升高\nC. 血浆胰岛素浓度增加\nD. 胰岛素原水平上升\nE. 胰岛素分泌功能下降",
+        "answer": "ABCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位长期在牧区生活的患者，通过超声检查发现肝右叶有一个8cm×10cm的无回声包块，囊壁厚且外壁光滑整齐，囊内可见多个大小不等的圆形无回声小囊。根据这些表现，最可能的诊断是什么？",
+        "options": "A. 阿米巴肝脓肿\nB. 肝包虫囊肿\nC. Caroli病\nD. 肝血肿\nE. 肝囊肿分隔型",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科中，胆囊结石可能引发哪些并发症？",
+        "options": "A. 胰腺炎\nB. 梗阻性黄疸\nC. 胆囊癌\nD. 肠梗阻",
+        "answer": "ABCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一名8岁女孩，右侧腹部发现一肿块，表面光滑，触诊有囊性感。进一步询问病史发现肿块的大小和张力有变化。最可能的诊断是",
+        "options": "A. 肠系膜囊肿\nB. 肾积水\nC. 胆总管囊肿\nD. 肾母细胞瘤\nE. 卵巢囊肿",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝胆外科中，乳腺、胰腺等腺癌转移至肝脏的转移性肿瘤，其常见的超声影像特征是什么？",
+        "options": "A. 高回声型\nB. 强回声型\nC. 低回声型\nD. 弱回声型\nE. 混合回声型",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位46岁男性在健康体检中通过B超发现右肝有一个1.5cm×2cm的占位性病变，接下来应首选哪种检查？",
+        "options": "A. ALP\nB. GGT\nC. AFP\nD. AFα（α-岩藻糖苷酶）\nE. CA19-9",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下因素中，哪一个与肝细胞癌的发生没有直接关联？",
+        "options": "A. 乙型肝炎病毒（HBV）感染\nB. 丙型肝炎病毒（HCV）感染\nC. 华支睾吸虫感染\nD. 黄曲霉素暴露\nE. 亚硝胺类化合物摄入",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位35岁女性患者，因胆囊结石反复发作急性胆囊炎，B超显示胆总管直径为6mm，口服胆囊造影检查胆囊未显影。此时，最合适的治疗方案是？",
+        "options": "A. 胆囊造瘘术\nB. 胆囊切除术\nC. 胆囊切开取石术\nD. 胆总管探查术II体外碎石\nE. 胆囊切除",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝血管瘤的超声检查中，以下哪种表现是不正确的？",
+        "options": "A. 高回声型\nB. 低回声型\nC. 血管聚集型\nD. 囊性型\nE. 混合回声型",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝性脑病伴有肾功能损害的患者中，下列哪种口服抗生素是合适的选择？",
+        "options": "A. 新霉素\nB. 卡那霉素\nC. 氨苄西林(氨苄青霉素）\nD. 甲硝唑（灭滴灵）\nE. 庆大霉素",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位67岁的男性患者，近期出现皮肤和巩膜黄染且逐渐加重，大便颜色持续变浅，体重明显下降。最可能的诊断是",
+        "options": "A. 急性病毒性肝炎\nB. 肝硬化\nC. 肝癌\nD. 胰头癌\nE. 胆总管结石",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在胆囊结石的临床表现中，以下哪项描述是不正确的？",
+        "options": "A. 所有胆囊结石患者都会出现明显症状\nB. 摄入高脂肪食物后症状会加剧\nC. 较大的单发结石较少发生嵌顿\nD. 结石卡在胆囊颈部时，可能引发急性胆囊炎\nE. 胆绞痛常向右侧肩部放射",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝性脑病的临床表现中，以下哪一项描述是不正确的？",
+        "options": "A. 所有患者都会出现昏迷\nB. 病程可分为急性、亚急性和慢性\nC. 可能表现为性格和行为异常\nD. 可能出现理解能力下降\nE. 可能出现神经系统体征",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在原发性肝癌的临床诊断中，以下哪项方法是错误的？",
+        "options": "A. 对于有肝病病史、HBsAg阳性、肝硬化或慢性肝炎，年龄在40~60岁的患者，应定期进行AFP和B超检查\nB. 如果AFP水平大于400μg/L，且影像学检查显示肝内实质性占位，可以明确诊断\nC. 如果AFP水平小于400μg/L，但影像学检查显示肝内实质性占位，且AFP异质体阳性，可以明确诊断\nD. 如果AFP阴性，但B超或CT显示肝内实质性占位，可以进行肝动脉造影或B超引导下细针经皮肝穿刺细胞学检查\nE. 如果AFP水平大于400μg/L，但B超或CT未发现肝内明确占位，可以排除肝癌诊断",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下关于肝脂肪变性原因的陈述中，哪一项是不正确的？",
+        "options": "A. 化学毒物干扰脂蛋白合成，引起肝脂肪变性\nB. 糖尿病状态下，过量脂肪酸进入肝脏，导致肝脂肪变性\nC. 缺氧环境可诱发肝脂肪变性\nD. 摄入过多脂肪直接导致肝脂肪变性\nE. 白喉杆菌外毒素干扰脂肪酸代谢，引发肝脂肪变性",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位肝硬化患者两个月前被诊断出腹水，昨天突然出现剧烈腹痛，伴��呕吐和发热，腹水迅速增加，并排出少量暗红色血便。这种情况最可能的原因是",
+        "options": "A.急性胰腺炎\nB.食管静脉曲张破裂出血\nC.合并肝癌破裂\nD.门静脉血栓形成\nE.合并脾破裂出血",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在评估胰腺病变的CT影像时，以下哪项表现最符合胰腺癌的诊断？",
+        "options": "A. 胰周及腹腔渗出，胰腺实质内有不规则低密度区，强化后低密度区增强不明显\nB. 胰头有3cmx4cm不均匀低密度区，强化后有不均匀增强\nC. 胰头部增大，密度与其他部位胰腺组织密度一致，胰周界限模糊\nD. 胰头均匀低密度区，CT值10 Hu，不被强化，胰体尾萎缩，胰管扩张\nE. 胆管扩张明显，胆总管下端可见2 cmxlcm的极强密度区",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科手术中，了解血管解剖至关重要。以下哪支动脉的起源与肠系膜上动脉无关？",
+        "options": "A. 胰十二指肠上动脉\nB. 结肠中动脉\nC. 回结肠动脉\nD. 胰十二指肠下动脉\nE. 结肠右动脉",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位50岁男性患者，长期有吸烟和饮酒习惯，并有胆道结石病史。昨晚在大量饮酒和暴食后，突然感到左上腹剧烈疼痛。根据这些症状，最可能的诊断是什么？",
+        "options": "A. 胆囊穿孔\nB. 胆道阻塞\nC. 肝硬化\nD. 急性胰腺炎\nE. 原发性肝癌",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一位59岁男性患者，既往有慢性支气管炎和肝炎病史。最近一周出现精神错乱和尿量减少。体检发现患者处于昏睡状态，口腔有异味，心肺检查无异常，腹部膨隆，腹水征阳性，未引出扑翼样震颤。针对该患者的治疗，以下哪项措施不适宜？",
+        "options": "A. 适量利尿剂\nB. 抗生素\nC. 静滴高渗葡萄糖液\nD. 高蛋白质饮食鼻饲\nE. 精氨酸",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位肝硬化患者出现血性腹水，但没有腹痛和发热的症状，最可能的诊断是什么？",
+        "options": "A. 结核性腹膜炎\nB. 原发性肝癌\nC. 门静脉血栓形成\nD. 肝-肾综合征\nE. 自发性腹膜炎",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝脏的微观结构中，胆小管的位置是",
+        "options": "A.肝板与血窦间\nB.肝小叶之间\nC.肝板内相邻肝细胞间\nD.窦周隙内\nE.肝板间",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位60岁男性患者，出现无痛性黄疸已持续一个多月，体重逐渐下降，但无明显不适。超声检查显示肝内外胆管和胆囊明显扩张，胰管未扩张，胆总管下段发现低回声团块，与胆管壁界限不清，彩色多普勒超声显示团块内有血流信号，脉冲多普勒检测到动脉频谱。以下哪种疾病不需要与该病进行鉴别？",
+        "options": "A. 胰头部实性占位\nB. 壶腹周围实性占位\nC. 胆总管下段结石\nD. 十二指肠壁占位\nE. 胆总管上段实性占位",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在急性胰腺炎发病后，血清淀粉酶水平通常在何时开始上升？",
+        "options": "A. 1～2小时\nB. 6～12小时\nC. 13～16小时\nD. 20～24小时\nE. 26～48小时",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝癌的诊断中，以下哪种肿瘤标志物最为关键？",
+        "options": "A. CEA（癌胚抗原）\nB. PSA（前列腺特异抗原）\nC. AFP（甲胎蛋白）\nD. HCG（绒毛膜促性腺激素）\nE. AKP（碱性磷酸酶）",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在胆总管探查术后，关于T形引流管的拔除指征，以下哪一项是不正确的？",
+        "options": "A.术后一周\nB.血胆红素水平恢复正常\nC.患者体温稳定\nD.患者无腹痛、腹胀等不适症状\nE.T管造影显示肝内外胆管显影正常",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在解剖学中，胆总管下段与胰头的关系是（）。",
+        "options": "A. 前方\nB. 后方\nC. 外侧\nD. 内侧\nE. 实质内",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在门静脉高压症的手术治疗中，主要的手术目标是什么？",
+        "options": "A. 治疗腹水\nB. 改善肝功能\nC. 去除门静脉高压症的病因\nD. 治疗肝性脑病\nE. 预防和控制食管、胃底曲张静脉出血",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PortalHypertension",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在以下疾病中，哪一项通常不会导致肝脏体积增大？",
+        "options": "A. 急性病毒性肝炎伴黄疸\nB. 肝硬化伴腹水\nC. 肝癌伴肝性脑病\nD. 肝脓肿伴右侧胸水\nE. 右心衰竭伴下肢水肿",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝细胞肝癌的诊断中，以下哪项血液检查具有较高的特异性？",
+        "options": "A. 血甲胎蛋白\nB. 血碱性磷酸酶\nC. 血胆红素\nD. 血尿素氮\nE. 胰岛素",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性胰腺炎的影像学检查中，增强扫描的主要目的是什么？",
+        "options": "A.观察胰腺与脾静脉的关系\nB.判断有无胰腺坏死灶及其范围，推断病变的程度\nC.观察胰腺与结肠肝曲及脾曲的关系\nD.观察胰腺与肾前筋膜的关系\nE.观察胰腺与十二指肠的关系",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝性脑病患者的饮食管理中，以下哪种饮食成分是不推荐的？",
+        "options": "A. 高热量\nB. 高碳水化合物\nC. 高维生素\nD. 高蛋白质\nE. 对于不能进食的患者，可以使用鼻饲或静脉滴注葡萄糖",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在慢性肝炎患者中，毛玻璃样肝细胞的出现主要与以下哪种细胞器内的物质积累有关？",
+        "options": "A.滑面内质网内有大量HBsAg颗粒\nB.高尔基复合体内有大量HBsAg颗粒\nC.粗面内质网内有大量HBsAg颗粒\nD.线粒体肿胀\nE.核糖体增多",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位33岁女性患者，有8年乙型肝炎病史，近5个月来反复出现肝区疼痛，伴有间歇性恶心和体重下降。B超检查发现左肝叶有一个3cm的低回声肿块，血清AFP水平为530ng/ml。根据这些信息，最可能的诊断是什么？",
+        "options": "A. 早期肝硬化\nB. 活动性肝炎\nC. 生殖腺胚胎肿瘤\nD. 原发性肝癌\nE. 滋养层细胞肿瘤",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在临床实践中，用于确诊细菌性肝脓肿的首选影像学检查方法是",
+        "options": "A. 腹部X线平片\nB. 超声检查\nC. 计算机断层扫描\nD. 血常规分析\nE. 血液细菌培养",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在原发性肝癌的早期筛查中，以下哪种组合检查方法最具临床价值？",
+        "options": "A. AFP联合肝动脉造影\nB. AFP联合γ-谷氨酰转移酶检测\nC. AFP联合放射性核素肝扫描\nD. AFP联合超声检查",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "关于胆总管的解剖结构，以下哪项描述是正确的？",
+        "options": "A. 直径0.3～0.5cm\nB. 位于肝固有动脉的左侧\nC. ���于肝胃韧带内\nD. 由左、右肝管汇合形成\nE. 由肝总管和胆囊管汇合形成",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "患者张某，因胆囊炎需要进行胆囊造影检查。在第一次摄片后，胆囊显影良好，此时患者可以进食以下哪种食物？",
+        "options": "A. 水 500ml\nB. 馒头 1个\nC. 苹果 2个\nD. 面条 1碗\nE. 油煎荷包蛋2个",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝性脑病患者的饮食管理中，当开始增加动物蛋白摄入时，以下哪项是正确的？",
+        "options": "A. 选择产氨较多的蛋白质\nB. 不宜供给含植物蛋白质的食品\nC. 应增加含氮多的动物蛋白\nD. 动物性蛋白中牛奶含氮最少\nE. 动物性蛋白中鸡肉含氮最少",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位48岁男性患者，有5年肝硬化病史，近半年来腹胀症状加重，并伴有双下肢水肿。以下哪项治疗措施是不恰当的？",
+        "options": "A. 卧床休息\nB. 低蛋白质饮食\nC. 低盐限水\nD. 定期补充白蛋白\nE. 快速、大量利尿以加快腹水消退",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一位32岁男性患者，已有肝脾肿大病史3年。10天前帮助同事搬家后，出现极度乏力、食欲减退、恶心、厌油、腹胀以及深度巩膜黄染。体检发现肝右肋下未触及，实验室检查显示血清ALT为60u/L，总胆红素324umol/L，凝血酶原活动度30%，一分钟胆红素188.6umol/L。根据这些信息，最可能的诊断是什么？",
+        "options": "A. 慢性肝炎重度\nB. 淤胆型肝炎\nC. 急性重症肝炎\nD. 亚急性重症肝炎\nE. 慢性重症肝炎",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科的诊断中，下列哪项不是肝胆动态显像的常见适应证？",
+        "options": "A. 诊断急性胆囊炎\nB. 诊断胆囊结石\nC. 诊断慢性胆囊炎\nD. 胆管先天性囊状扩张症\nE. 先天性胆管闭锁",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在脂肪肝的发病机制中，以下哪项因素与其形成密切相关？",
+        "options": "A. 脂蛋白合成增多\nB. 肝内形成的甘油三酯增多或氧化减少\nC. 碳水化合物摄入过多\nD. 蛋白质摄入过多\nE. 进入肝脏的脂肪酸过少",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在超声检查中，测量脾脏大小的正确方法是",
+        "options": "A. 通过肋间斜切，显示脾门和脾静脉，测量其厚度及最大长径\nB. 通过肋间斜切，显示脾门和胰尾，测量其厚度及长径\nC. 通过肋间斜切，显示腹腔动脉，测量其厚度及长径\nD. 通过肋下斜切，显示腹主动脉，测量其长径\nE. 通过肋下斜切，显示下腔静脉，测量其长径",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "对于肝性脑病患者，在治疗后神志恢复时，哪种蛋白质饮食是最合适的？",
+        "options": "A.动物蛋白质\nB.蔬菜、水果\nC.碳水化合物\nD.蛋白质在60g/d以上\nE.植物蛋白质",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位50岁男性患者，近3个月来持续感到肝区疼痛，肝脏逐渐增大，频繁出现低血糖症状，且外周血中红细胞计数明显升高。根据这些症状，最可能的诊断是：",
+        "options": "A. 真性红细胞增多症\nB. 重症肝炎\nC. 肺源性心脏病\nD. 原发性肝癌\nE. 继发性红细胞增多症",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在急性化脓性梗阻性胆管炎中，以下哪些病理改变是常见的？",
+        "options": "A.胆管扩张\nB.胆管内脓液\nC.胆管壁广泛性炎症\nD.肝细胞损害",
+        "answer": "ABCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性出血坏死型胰腺炎中，以下哪项描述最能概括其严重的临床表现？",
+        "options": "A. 上腹剧痛，高热持续l周以上\nB. 常伴有休克\nC. 腹胀显著，腹壁紧张与上腹肿块，可并发胰腺脓肿\nD. 血尿淀粉酶不增高\nE. 以上各点都是",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科中，肝血管瘤介入治疗的适应证有哪些？",
+        "options": "A. 瘤体直径大于等于5cm\nB. 肿瘤位于肝脏表面或破裂出血者\nC. 伴腹胀、疼痛\nD. 瘤体直径小于5cm，但影响患者工作、学习、生活者",
+        "answer": "ABCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝癌的诊断和治疗中，关于肿瘤标志物AFP的临床应用，以下哪项描述是错误的？",
+        "options": "A. AFP是早期诊断肝癌的有效筛查工具\nB. AFP在肝癌的鉴别诊断中具有重要价值\nC. AFP水平的变化可用于评估治疗效果\nD. AFP升高是确诊肝癌的唯一标准\nE. AFP监测有助于发现肝癌的复发和转移",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆外科中，门静脉高压症最常见的原因是什么？",
+        "options": "A. 门静脉主干先天性畸形\nB. 肝静脉血栓形成、狭窄\nC. 肝段下腔静脉阻塞\nD. 肝硬化\nE. 各种原因致脾静脉血流量过大",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在一位患者的超声检查中，发现右肝前叶有一斑状强回声区域，声影不明显，且不沿肝管走行。根据这些特征，最可能的诊断是什么？",
+        "options": "A. 肝血管瘤\nB. 肝结核\nC. 肝内胆管结石\nD. 肝内钙化灶\nE. 肝内胆管积气",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一名12岁男孩因突发阵发性右上腹绞痛，伴有恶心、呕吐，症状反复发作，持续时间不一。查体显示体温正常，巩膜无黄染，无肌紧张。以下哪种治疗方案不适用于此患者？",
+        "options": "A.胆囊切除术\nB.针刺足三里\nC.解痉利胆驱虫\nD.胆总管探查取虫引流\nE.手术后驱虫治疗",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在原发性肝细胞肝癌的诊断中，以下哪种肿瘤标记物被认为是最理想的？",
+        "options": "A. AFP\nB. GGT2\nC. CA19-9\nD. CA125\nE. CEA",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝脏的解剖结构中，哪一结构负责将左内叶与左外叶分隔开来？",
+        "options": "A. 肝镰状韧带\nB. 肝圆韧带\nC. 静脉韧带\nD. 肝冠状韧带\nE. 门静脉的分支",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "张某，妊娠39周，因恶心、食欲不振和呕吐症状被诊断为急性病毒性肝炎，现已入院待产。以下哪项处理措施是不正确的？",
+        "options": "A.立即终止妊娠\nB.新生儿注射乙肝疫苗\nC.胎儿娩出后注射缩宫素\nD.缩短第二产程\nE.新生儿注射免疫球蛋白",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝胆超声检查中，正常肝总管及胆总管上段的内径通常小于伴行门静脉的多少？",
+        "options": "A.1/2\nB.2/3\nC.3/4\nD.1/3\nE.二者内径相等",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在解剖学中，胆总管根据其走行路径可以被划分为几个部分？",
+        "options": "A. 二段\nB. 三段\nC. 四段\nD. 五段\nE. 六段",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一名16岁女性患者，近10个月来出现右上腹疼痛并伴有黄疸，症状逐渐加重，大便呈陶土色。患者曾于出生后6天接受过先天性胆总管囊肿十二指肠吻合术。经过消炎利胆治疗后未见好转。该患者最可能的合并症是什么？",
+        "options": "A. 胆道造影\nB. 吻合口狭窄\nC. 肝硬化\nD. 结石\nE. 癌变",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在胰腺癌的影像学诊断中，以下哪项描述是不正确的？",
+        "options": "A. 血糖水平升高可能降低FDG PET的检测灵敏度\nB. 胰头癌可能导致胆管和胰管同时扩张，形成“双管征”\nC. 慢性胰腺炎在FDG PET显像中可能出现假阳性结果\nD. CT灌注成像显示病灶通常为富血供\nE. 黏液腺癌在影像学检查中可能产生假阴性结果",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在慢性病毒性肝炎的治疗中，以下哪种药物是有效的？",
+        "options": "A.干扰素\nB.金刚烷胺\nC.两性霉素B\nD.齐多夫定\nE.阿昔洛韦",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "患者李某，男性，52岁，因右上腹持续性疼痛2天入院。既往有慢性胆囊炎病史。在护理评估中，以下哪项内容不属于护士需要重点关注的方面？",
+        "options": "A. 疼痛的诱发因素\nB. 疼痛的具体位置、性质和强度\nC. 患者的日常饮食习惯\nD. 患者的体位变化\nE. 是否伴有其他不适症状",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在胆囊三角的解剖结构中，下列哪一项不属于其组成部分？",
+        "options": "A. 胆囊动脉\nB. 肝右动脉\nC. 肝总管\nD. 副右肝管\nE. 胆囊淋巴结",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在放射性核素肝脾胶体显像中，显像剂的主要作用机制是什么？",
+        "options": "A. 显像剂通过胆管排泄\nB. 显像剂被肝脏内的星状细胞吞噬\nC. 显像剂能够进入肝囊肿\nD. 脓肿组织特异性摄取显像剂\nE. 显像剂滞留在肝血管瘤中",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在细菌性肝脓肿的诊断和治疗中，以下哪项描述是不正确的？",
+        "options": "A. 大多数病例与胆道系统感染有关\nB. 主要致病菌通常是革兰氏阳性球菌\nC. 脓液常呈棕褐色，且细菌涂片可能为阴性\nD. 脓肿通常位于肝脏右叶且为单发\nE. 手术引流是唯一有效的治疗方法",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位42岁男性患者因上腹部疼痛1天前来就诊，血淀粉酶水平为600U（Somogyi法），诊断为急性胰腺炎。经过治疗后痊愈，为了防止疾病复发，以下哪项措施是不合适的？",
+        "options": "A.避免暴饮暴食\nB.避免酗酒\nC.忌食油腻食物\nD.积极治疗胆石症\nE.定期预防性应用抑肽酶",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在急性胰腺炎患者中，血钙浓度的变化规律是怎样的？",
+        "options": "A. 起病后6〜12小时升高，48小时下降，持续3〜5天\nB. 起病后12〜14小时升高，下降缓慢，持续1〜2周\nC. 起病后24〜72小时上升，持续7〜10天\nD. 降低程度与临床症状平行\nE. 起病后3〜4小时上升，12小时高峰，24小时下降",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位62岁女性患者被诊断为急性化脓性胆管炎，目前血压为75/60 mmHg，心率为132次/分，每小时尿量少于20毫升。在这种情况下，应首选哪种心血管药物进行治疗？",
+        "options": "A. 异丙肾上腺素\nB. 去甲肾上腺素\nC. 苯肾上腺素\nD. 间羟胺（阿拉明）\nE. 多巴胺",
+        "answer": "E",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "一位57岁男性患者，主诉右胁疼痛并伴有发热已持续3个月。体检发现肝脏在肋下3cm处可触及，质地坚硬，并可闻及血管杂音。实验室检查显示ALT为45U/L，γ-GT为400U/L。尽管接受了多种治疗，症状未见改善。首先应考虑的诊断是？",
+        "options": "A. 慢性活动性肝炎\nB. 肝硬化并糖尿病\nC. 原发性肝癌\nD. 肝脓肿\nE. 肝性脑病",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在胰源性胰腺炎中，导致休克的主要病理生理机制是",
+        "options": "A.胰酶外溢-脂肪酶-脂肪坏死\nB.胰蛋白酶-磷脂酶A-组织坏死\nC.胰蛋白酶-胰舒血管素-激肽原-激肽\nD.大量胰消化酶被激活\nE.胰酶-弹力纤维酶-血管损害出血",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性梗阻性化脓性胆管炎的治疗中，哪一项措施最为关键？",
+        "options": "A. 输液、输血维持有效血容量\nB. 纠正代谢性酸中毒\nC. 静脉输入大量抗生素\nD. 胆道减压引流解除梗阻\nE. 急诊行胆囊切除术",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位肝硬化患者因食管-胃底静脉曲张破裂导致大量呕血入院，以下哪种止血方法最为简便且有效？",
+        "options": "A. 静滴垂体后叶素\nB. 口服去甲肾上腺素溶液\nC. 应用三腔两囊\nD. 盐水洗胃\nE. 静滴酚磺乙胺",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PortalHypertension",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位55岁男性患者，饮酒后12小时出现中上腹疼痛，随后呕出200ml鲜红色血液前来急诊。体检发现腹部柔软，中上腹有压痛，肝脏未触及，脾脏在肋下1.5cm处可触及，血压正常。经过初步处理后，出血仍未停止，此时应首先采取以下哪项措施？",
+        "options": "A. 门腔静脉分流术\nB. 凝血酶原复合物静脉滴注\nC. 三腔气囊管压迫止血\nD. 普萘洛尔（心得安）\nE. 反复输血",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在急性胆囊炎患者中，以下哪些情况属于可能的并发症？",
+        "options": "A.胆囊穿孔\nB.胆囊内瘘\nC.急性气肿性胆囊炎\nD.胆囊积脓\nE.梗阻性黄疸",
+        "answer": "ABCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在治疗慢性肝病患者时，以下哪种药物需要特别谨慎使用？",
+        "options": "A. 辅酶A\nB. 异烟肼\nC. 法莫替丁\nD. 硝苯地平\nE. 地高辛",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位56岁男性患者因门静脉高压症接受了门腔静脉分流手术。在术后48小时内，医护人员应特别关注以下哪种并发症的发生？",
+        "options": "A. 肝性脑病\nB. 血管吻合口破裂内出血\nC. 腹腔感染\nD. 肠系膜血管栓塞\nE. 血小板过度增高",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PortalHypertension",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝胆外科临床实践中，下列哪种疾病最可能同时出现呕吐和黄疸症状？",
+        "options": "A. 急性胃炎\nB. 幽门梗阻\nC. 胆石症\nD. 急性肾盂肾炎\nE. 急性阑尾炎",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在肝硬化患者中，若出现血性腹水，最可能的原因是",
+        "options": "A. 结核性腹膜炎\nB. 原发性腹膜炎\nC. 肝硬化癌变\nD. 门静脉血栓形成\nE. 功能性肾衰竭（肝肾综合征）",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在胆道蛔虫症的治疗方案中，以下哪种方法被认为是不恰当的？",
+        "options": "A. 胆囊切除术\nB. 针刺足三里\nC. 解痉利胆驱虫\nD. 胆总管探查取虫引流\nE. 手术后驱虫治疗",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝豆状核变性患者中，起病较早者主要受累的器官是哪个？",
+        "options": "A. 神经系统损害\nB. 肝脏损害为主\nC. 急性溶血病\nD. 裂隙灯下可见角膜边缘的K-F环\nE. 肾小管性酸中毒",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在重症肝炎患者中，最常见的致命并发症是以下哪一项？",
+        "options": "A. 肝性脑病\nB. 严重感染\nC. 心力衰竭\nD. 弥散性血管内凝血（DIC）\nE. 酮症酸中毒",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位患有门脉肝硬化并伴有腹水的患者，最近两天出现腹泻、恶寒发热、腹痛，全腹压痛及反跳痛，最可能的诊断是什么？",
+        "options": "A. 肝癌破裂\nB. 自发性腹膜炎\nC. 门静脉血栓形成\nD. 结核性腹膜炎\nE. 腹腔转移癌",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位40岁男性患者，近20余天出现持续性黄疸并伴有皮肤瘙痒，症状近日加重。超声检查发现肝内外胆管及胆囊均扩张，胆总管下端呈截断阻塞，局部可见一实性结节。主胰管扩张，内径为0.5cm。最可能的阻塞病因是？",
+        "options": "A.壶腹周围癌\nB.胆总管下段结石\nC.硬化性胆管炎\nD.先天性胆总管囊肿\nE.非特异性胆管炎症",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在临床诊断中，A/G（白蛋白/球蛋白）比值主要用于评估哪个器官的疾病严重程度？",
+        "options": "A. 肺脏疾病的严重性\nB. 心脏疾病的严重性\nC. 肝脏疾病的严重性\nD. 肾脏疾病的严重性\nE. 脾脏疾病的严重性",
+        "answer": "C",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在肝性脑病的患者中，支链氨基酸与芳香氨基酸的摩尔比值通常会下降到哪个范围？",
+        "options": "A. 5以下\nB. 4以下\nC. 3以下\nD. 2以下\nE. 1以下",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性胰腺炎的诊断中，以下哪种生化指标异常提示可能为重症胰腺炎？",
+        "options": "A. 高血糖\nB. 低钙血症\nC. 血、尿淀粉酶显著升高\nD. 代谢性碱中毒\nE. 血小板计数明显下降",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在胆道蛔虫病的临床表现中，下列哪一项描述是不正确的？",
+        "options": "A. 中上腹“钻顶样”剧烈绞痛\nB. 突然发病，突然缓解\nC. 可能有蛔虫吐出史\nD. 常伴有中上腹部反跳痛及肌紧张\nE. 可能伴有轻度黄疸",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在原发性肝癌的早期阶段，最常见的转移方式是什么？",
+        "options": "A. 通过肝内血管系统扩散\nB. 通过淋巴系统转移至肺部\nC. 通过淋巴系统转移至锁骨上淋巴结\nD. 直接侵入胸腔\nE. 直接扩散到腹腔",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在排除其他疾病后，以下哪项是诊断原发性肝癌的标准？",
+        "options": "A. AFP大于500μg/L持续2周\nB. AFP大于500μg/L持续4周\nC. AFP大于200μg/L持续2周\nD. AFP大于200μg/L持续4周\nE. AFP大于200μg/L持续6周",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在进行十二指肠引流液检查时，如果发现胆囊液（B胆汁）的流出量显著增加，这可能与以下哪种情况有关？",
+        "options": "A.胆总管上段梗阻\nB.胆囊收缩不良\nC.胆囊摘除术后\nD.Oddi括约肌松弛\nE.慢性胰腺炎",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位45岁的男性患者，患有肝硬化并伴有腹水，计划进行肠内营养支持。在这种情况下，最合适的肠内营养制剂是哪种？",
+        "options": "A.必需氨基酸配方\nB.高糖配方\nC.低蛋白配方\nD.高支链氨基酸配方\nE.高维生素配方",
+        "answer": "D",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "ClinicalDiagnosis"
+    },
+    {
+        "question": "在进行静脉胆道造影术时，胆管显影达到最清晰状态的时间点是（）。",
+        "options": "A. 30分钟\nB. 60分钟\nC. 90分钟\nD. 120分钟\nE. 150分钟",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位25岁的初孕妇，在妊娠36周时因急性乙型肝炎入院。以下哪项措施是不恰当的？",
+        "options": "A.卧床休息，加强营养，避免过劳\nB.静滴红霉素预防感染\nC.静滴葡萄糖液内加维生素C\nD.静滴保肝药\nE.肌注维生素K",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在急性胆囊炎的超声检查中，以下哪些表现是典型的？",
+        "options": "A.胆囊增大、胆囊壁轮廓线模糊，外壁线不规则\nB.胆囊壁弥漫性增厚，增厚的胆囊壁呈增强回声带\nC.胆囊内可见结石强回声后方伴声影\nD.脂肪餐试验胆囊收缩功能差或丧失\nE.超声Murphy征阴性",
+        "answer": "ABCD",
+        "answer_format": "MultipleChoice",
+        "disease_domain": "BiliaryDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "一位肝硬化腹水患者近期出现低热和腹痛症状，腹水量明显增加。腹水检查结果显示：外观淡黄色，比重1.018，蛋白含量25g/L，李凡他试验阳性，细胞总数为800/μl，其中多核细胞占76%。这些临床表现最可能提示并发哪种疾病？",
+        "options": "A. 结核性腹膜炎\nB. 自发性腹膜炎\nC. 门静脉血栓形成\nD. 功能性肾衰竭\nE. 原发性肝癌结节破裂",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "OtherDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在胰泌素的作用下，胰腺分泌的胰液具有以下哪种特点？",
+        "options": "A. 水和HCO3-含量高，酶含量低\nB. 水和HCO3-含量低，酶含量高\nC. 水含量高，HCO3-和酶含量低\nD. 水、HCO3-和酶含量都低\nE. 水、HCO3-和酶含量都高",
+        "answer": "A",
+        "answer_format": "SingleChoice",
+        "disease_domain": "PancreaticDisease",
+        "inquiry_type": "KnowledgeQA"
+    },
+    {
+        "question": "在筛查原发性肝癌时，以下哪种方法被认为是最简便且有效的？",
+        "options": "A. B超\nB. AFP\nC. 腹部CT\nD. 肝MRI\nE. 同位素肝扫描",
+        "answer": "B",
+        "answer_format": "SingleChoice",
+        "disease_domain": "LiverDisease",
+        "inquiry_type": "KnowledgeQA"
+    }
+]

enqa-subset-153.json

@@ -0,0 +1,770 @@
+[
+    {
+        "question": "A patient presents with jaundice, fatigue, and elevated liver enzymes due to mild to moderate Acute Cholestatic Viral Hepatitis E. Which of the following is the most appropriate initial management option?",
+        "options": "A. Antiviral therapy B. Ursodeoxycholic acid C. Liver transplantation D. Supportive care with hydration and monitoring",
+        "answer": "D"
+    },
+    {
+        "question": "A pregnant lady is diagnosed to be HBs Ag positive. Which of the following is the best way to prevent infection to the child:\n ",
+        "options": "A. Hepatitis vaccine to the child\n B. Full course of Hepatitis B vaccine and immunoglobulin to the child\n C. Hepatitis B immunoglobulin to the mother\n D. Hepatitis B immunization to mother",
+        "answer": "B"
+    },
+    {
+        "question": "Drug-induced hepatitis, such as that caused by isoniazid, differs from toxic liver disease in what critical mechanism?",
+        "options": "A. It involves direct chemical toxicity without immune involvement B. It often involves immune-mediated mechanisms C. It is caused by bacterial infections D. It is always genetic",
+        "answer": "B"
+    },
+    {
+        "question": "What is the definitive intervention for irreversible liver failure in acute hepatitis B with delta-agent coinfection?",
+        "options": "A. Antiviral therapy B. Liver transplantation C. Nutritional support D. Hydration therapy",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with drug-induced hepatitis presents with signs of immune-mediated reactions. Which of the following therapies is most appropriate for managing these reactions?",
+        "options": "A. Antihistamines B. Corticosteroids C. Immunosuppressants D. Plasmapheresis",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is a typical symptom of insulin resistance?",
+        "options": "A. Steatorrhea B. Hyperglycemia C. Gallstones D. Fasting hypoglycemia",
+        "answer": "B"
+    },
+    {
+        "question": "In a patient with advanced pancreatic head cancer presenting with obstructive jaundice, what is the primary focus of palliative care?",
+        "options": "A. Pain management with opioids B. Biliary stenting for jaundice relief C. Weight gain strategies D. Nutritional support via enteral feeding",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is a typical symptom of chronic cholecystitis?",
+        "options": "A. Left lower quadrant pain B. Recurrent right upper quadrant pain C. Chest pain D. Lower back pain",
+        "answer": "B"
+    },
+    {
+        "question": "Which symptom is most commonly associated with insulinomas?",
+        "options": "A. Peptic ulcers B. Hypoglycemia C. Flushing and diarrhea D. Hyperglycemia",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is a common symptom of chronic active hepatitis, a form of toxic liver disease?",
+        "options": "A. Jaundice B. Fatigue C. Abdominal pain D. Headache",
+        "answer": "B"
+    },
+    {
+        "question": "A male with a history of chronic alcohol use presents with jaundice and elevated liver enzymes. Which diagnostic method is most appropriate to confirm the diagnosis of Alcoholic Liver Disease (ALD)?",
+        "options": "A. Serum ferritin level B. Liver biopsy C. Abdominal ultrasound D. Serum ammonia level",
+        "answer": "B"
+    },
+    {
+        "question": "What is the primary mode of transmission for Hepatitis B virus (HBV)?",
+        "options": "A. Contaminated food or water B. Blood or bodily fluids C. Airborne droplets D. Direct skin contact",
+        "answer": "B"
+    },
+    {
+        "question": "What is a common clinical presentation of hepatoblastoma?",
+        "options": "A. Severe abdominal pain B. Painless right upper abdominal mass C. Chronic diarrhea D. Persistent cough",
+        "answer": "B"
+    },
+    {
+        "question": "What is the mainstay of treatment for acute hepatitis A without hepatic coma?",
+        "options": "A. Antiviral therapy B. Supportive care C. Liver transplantation D. Antibiotics",
+        "answer": "B"
+    },
+    {
+        "question": "Which condition is characterized by pus accumulation around the gallbladder?",
+        "options": "A. Acute Cholecystitis B. Pericholecystic Abscess C. Necrosis of Gallbladder D. Acute Exacerbation of Chronic Cholecystitis",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with jaundice and abdominal pain. Imaging reveals a biliary abnormality. What is the main anatomical difference between choledochal cysts and choledochal hypertrophy?",
+        "options": "A. Cysts are dilated structures; hypertrophy denotes wall thickening B. Cysts are more commonly associated with pancreatitis C. Cysts are congenital; hypertrophy is acquired D. Cysts require surgical intervention; hypertrophy may resolve with conservative management",
+        "answer": "A"
+    },
+    {
+        "question": "Which treatment is specifically required for Chronic Viral Hepatitis B with Delta-Agent without Hepatic Coma?",
+        "options": "A. Tenofovir B. Entecavir C. Pegylated interferon-alpha D. Corticosteroids",
+        "answer": "C"
+    },
+    {
+        "question": "A patient undergoes abdominal imaging for unexplained weight loss, revealing a solitary liver mass with features suspicious for malignancy. Which of the following benign lesions is most likely to mimic hepatocellular carcinoma on imaging?",
+        "options": "A. Focal nodular hyperplasia B. Hepatic adenoma C. Inflammatory pseudotumor of the liver D. Non-alcoholic steatohepatitis",
+        "answer": "C"
+    },
+    {
+        "question": "Which condition is characterized by gallbladder wall necrosis due to prolonged ischemia?",
+        "options": "A. Cholelithiasis with Acute Cholecystitis B. Cholelithiasis with Gangrenous Cholecystitis C. Cholelithiasis with Acute Suppurative Cholecystitis D. Chronic cholecystitis",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is a leading cause of chronic liver failure in Western countries?",
+        "options": "A. Hepatitis B and C viral infections B. Chronic alcohol abuse C. Parasitic infections D. Metabolic disorders",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is a key difference in the replication mechanisms of HBV/HDV and HCV infections?",
+        "options": "A. HCV requires HBV for replication B. HBV acute infections frequently become chronic C. HCV does not require a helper virus for replication D. HDV can only replicate in the presence of HBV",
+        "answer": "C"
+    },
+    {
+        "question": "A patient presents with jaundice, confusion, and coagulopathy, diagnosed with acute hepatitis B and hepatic coma. What is the key distinguishing feature between this condition and acute hepatitis B with hepatic coma accompanied by hepatitis D virus (HDV) coinfection?",
+        "options": "A. Presence of hepatitis D virus (HDV) B. Severity of hepatic coma C. Duration of symptoms D. Presence of liver fibrosis",
+        "answer": "A"
+    },
+    {
+        "question": "What is the primary treatment approach for mild acute idiopathic pancreatitis?",
+        "options": "A. Surgical intervention B. Aggressive fluid resuscitation and fasting C. Long-term antibiotic therapy D. Immediate oral refeeding with solid foods",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is a treatment option for advanced cases of ampullary cancer?",
+        "options": "A. Surgery alone B. Adjuvant chemotherapy/radiotherapy C. Endoscopic ultrasound D. Physical therapy",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is a common etiology of secondary biliary cirrhosis?",
+        "options": "A. Primary biliary cholangitis B. Gallstones C. Chronic hepatitis B infection D. Non-alcoholic fatty liver disease",
+        "answer": "B"
+    },
+    {
+        "question": "What is the standard surgical treatment for carcinoma in situ of the ampulla of Vater?",
+        "options": "A. Partial hepatectomy B. Endoscopic ampullectomy C. Cholecystectomy D. Whipple procedure",
+        "answer": "B"
+    },
+    {
+        "question": "What is the primary cause of a pancreatic fistula?",
+        "options": "A. Obesity B. Surgery, trauma, or pancreatitis C. Metabolic syndrome D. Chronic inflammation",
+        "answer": "B"
+    },
+    {
+        "question": "Public health researchers are reviewing data from an outbreak of hepatitis A that was traced to contaminated produce from a popular restaurant. A case series investigation with prospective and retrospective follow-up found that 500 individuals dined at the restaurant during the week of study. The incidence of hepatitis A infection was found to be 25%, and the total number of deaths recorded among the incident cases was 5 individuals. What was the case-fatality rate for the hepatitis A outbreak?\n ",
+        "options": "A. 4%\n B. 5%\n C. 10%\n D. 20%\n E. 25%",
+        "answer": "A"
+    },
+    {
+        "question": "What is the main focus of treatment for chronic persistent hepatitis?",
+        "options": "A. Surgical intervention B. Addressing the underlying cause C. Radiation therapy D. Chemotherapy",
+        "answer": "B"
+    },
+    {
+        "question": "What is the primary goal of surgical intervention in open injuries of the pancreas?",
+        "options": "A. Control bleeding and repair ducts B. Remove the entire pancreas C. Administer chemotherapy D. Perform a biopsy",
+        "answer": "A"
+    },
+    {
+        "question": "What is the primary cell of origin for hepatic angiosarcoma?",
+        "options": "A. Hepatocytes B. Endothelial cells C. Macrophages D. Dendritic cells",
+        "answer": "B"
+    },
+    {
+        "question": "What is the most likely cause of Obstruction of the Common Bile Duct in adults?",
+        "options": "A. Congenital malformation B. Chronic pancreatitis C. Gallstones D. Primary sclerosing cholangitis",
+        "answer": "C"
+    },
+    {
+        "question": "In the context of chronic liver disease progression, which of the following best distinguishes Alcoholic Liver Disease (ALD) from isolated alcoholic liver damage in terms of clinical management implications?",
+        "options": "A. ALD can be reversible with early abstinence and intervention B. Alcoholic liver damage consistently leads to portal hypertension C. ALD requires histologic confirmation of fibrosis/cirrhosis for diagnosis D. Alcoholic liver damage necessitates lifelong immunosuppressive therapy",
+        "answer": "C"
+    },
+    {
+        "question": "Colorectal cancer with synchronous liver metastases: does global management at the same centre improve results?\n Contexts: Synchronous liver metastases (SLM) occur in 20% of colorectal cancers (CRC). Resection of SLM and CLC can be undertaken at different centres (separate management, SM) or at the same centre (global management, GM).\nRetrospective study of SLM and CRC resections carried out during 01/2000 - 12/2006 by SM or GM, using a combined or delayed strategy.\nMorphologic characteristics and type of CRC and SLM resection were similar for the GM (n = 45) or SM (n = 66) groups. In patients with delayed liver resection (62 SM, 17 GM), chemotherapy prior to liver surgery was used in 92% and 38% of SM and GM patients (P<0.0001) and the median delay between procedures was 212 and 182 days, respectively (P = 0.04). First step of liver resection was more often performed during colorectal surgery in the GM group (62 vs. 6% for SM, P<0.0001) and the mean number of procedures (CRC+SLM) was lower (1.6 vs. 2.3, P = 0.003). Three-month mortality was 3% for GM and 0% for SM (n.s.). Overall survival rates were 67% and 51% for SM and GM at 3 years (n.s.), and 35 and 31% at 5 years (n.s.). Disease-free survival to 5 years was higher in SM patients (14% vs. 11%, P = 0.009).\n",
+        "options": "A. yes \n B. no \n C. maybe",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with obesity and type 2 diabetes presents with elevated liver enzymes and evidence of liver fibrosis on imaging. Which of the following conditions is most likely contributing to the fibrosis due to underlying metabolic dysfunction?",
+        "options": "A. Non-alcoholic fatty liver disease (NAFLD)/Non-alcoholic steatohepatitis (NASH) B. Hereditary hemochromatosis C. Autoimmune hepatitis D. Chronic hepatitis B infection",
+        "answer": "A"
+    },
+    {
+        "question": "Which of the following is a common symptom of larger benign neoplasms of the gallbladder?",
+        "options": "A. Jaundice B. Right upper quadrant pain C. Itching D. Fever",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is true about simple hepatic cysts?",
+        "options": "A. They are usually symptomatic B. They require surgical resection C. They are fluid-filled benign lesions D. They are associated with parasitic infections",
+        "answer": "C"
+    },
+    {
+        "question": "Acute severe pancreatitis, though rare, requires prompt recognition due to its high morbidity. Which of the following is a distinguishing feature of acute severe pancreatitis, as opposed to mild acute pancreatitis?",
+        "options": "A. Resolution within 48 hours with conservative management B. Pancreatic necrosis C. Mild symptoms D. No need for hospitalization",
+        "answer": "B"
+    },
+    {
+        "question": "Which symptom is most characteristic of gallbladder obstruction?",
+        "options": "A. Left upper quadrant pain B. Severe right upper quadrant pain radiating to the back or shoulder C. Lower abdominal cramping D. Chest pain",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with a history of gallstones reports persistent symptoms over several months. Which symptom is most characteristic of chronic cholecystitis in this stable, non-acute presentation?",
+        "options": "A. Fever and chills B. Mild, intermittent right upper quadrant discomfort C. Recurrent dull abdominal pain after meals D. Persistent nausea with vomiting",
+        "answer": "C"
+    },
+    {
+        "question": "A patient presents with jaundice and episodic right upper quadrant pain. Imaging reveals multiple benign symptomatic bile duct polyps. What is the primary treatment?",
+        "options": "A. Transarterial embolization B. Surgical resection C. Oral synthetic bile acids D. Percutaneous aspiration E. Endoscopic surveillance F. Broad-spectrum antibiotic therapy",
+        "answer": "B"
+    },
+    {
+        "question": "A 65-year-old man comes to the physician because of a 1-week history of yellowish discoloration of his skin and generalized pruritus. Examination shows jaundice of the skin and scleral icterus. Urinalysis shows an elevated concentration of bilirubin and a low concentration of urobilinogen. Which of the following is the most likely underlying cause of these findings?\n ",
+        "options": "A. Absent UDP-glucuronosyltransferase activity\n B. Increased hemoglobin breakdown\n C. Increased intestinal bilirubin reabsorption\n D. Defective hepatic bile excretion\n E. Presence of stones within the gallbladder",
+        "answer": "D"
+    },
+    {
+        "question": "What is the main goal of treatment for chronic hepatitis?",
+        "options": "A. Managing life-threatening complications B. Viral suppression and fibrosis prevention C. Liver transplantation D. Supportive care",
+        "answer": "B"
+    },
+    {
+        "question": "What is the genetic basis of Progressive familial intrahepatic cholestasis (PFIC)?",
+        "options": "A. Mutations in bile transport genes B. Exposure to industrial chemicals C. Adverse drug reactions D. Viral infections",
+        "answer": "A"
+    },
+    {
+        "question": "What is the primary diagnostic method for confirming secondary malignant neoplasm of the biliary tract?",
+        "options": "A. Blood test B. ERCP, MRCP, or biopsy C. Physical examination D. Urine test",
+        "answer": "B"
+    },
+    {
+        "question": "Differentiation of nonalcoholic from alcoholic steatohepatitis: are routine laboratory markers useful?\n Contexts: Specific markers for differentiation of nonalcoholic (NASH) from alcoholic steatohepatitis (ASH) are lacking. We investigated the role of routine laboratory parameters in distinguishing NASH from ASH.\nLiver biopsies performed at our hospital over a 10-year period were reviewed, 95 patients with steatohepatitis identified and their data prior to biopsy reevaluated. The diagnosis NASH or ASH was assigned (other liver diseases excluded) on the basis of the biopsy and history of alcohol consumption (<140 g/week). Logistic regression models were used for analysis.\nNASH was diagnosed in 58 patients (61%; 30 f) and ASH in 37 (39%; 9 f). High-grade fibrosis (59% vs. 19%, P<0.0001) and an AST/ALT ratio>1 (54.1% vs 20.7%, P = 0.0008) were more common in ASH. The MCV was elevated in 53% of ASH patients and normal in all NASH patients (P<0.0001). Multivariate analysis identified the MCV (P = 0.0013), the AST/ALT ratio (P = 0.011) and sex (P = 0.0029) as relevant regressors (aROC = 0.92). The AST/ALT ratio (P<0.0001) and age (P = 0.00049) were independent predictors of high-grade fibrosis. Differences in MCV were more marked in high-grade fibrosis.\n",
+        "options": "A. yes \n B. no \n C. maybe",
+        "answer": "A"
+    },
+    {
+        "question": "A male presents with fatigue and elevated liver enzymes. Which of the following is the most common cause of chronic inflammatory liver disease in this patient?",
+        "options": "A. Viral infections B. Alcohol abuse C. Autoimmune reactions D. Metabolic abnormalities",
+        "answer": "A"
+    },
+    {
+        "question": "What is the primary cause of pseudocyst formation in the pancreas?",
+        "options": "A. Neoplastic growth B. Parasitic infections C. Inflammatory conditions D. Genetic disorders",
+        "answer": "C"
+    },
+    {
+        "question": "A 13-month-old boy is brought to the physician for a well-child examination. Physical examination shows hepatosplenomegaly. A venous blood sample obtained for routine screening tests is milky. After refrigeration, a creamy supernatant layer appears on top of the sample. Genetic analysis shows a mutation in the apolipoprotein C-II gene (APOC2) on chromosome 19. This patient is at greatest risk for developing which of the following complications?\n ",
+        "options": "A. Acute pancreatitis\n B. Myocardial infarction\n C. Corneal arci\n D. Cholesterol embolization syndrome\n E. Cerebrovascular accident",
+        "answer": "A"
+    },
+    {
+        "question": "A patient with a history of smoking presents with jaundice and weight loss. Genetic testing reveals a mutation associated with pancreatic cancer. Which of the following mutations is most likely responsible?",
+        "options": "A. BRCA1 B. KRAS C. EGFR D. SMAD4",
+        "answer": "B"
+    },
+    {
+        "question": "Clonorchiasis is a parasitic infection caused by the liver fluke Clonorchis sinensis, primarily transmitted through the consumption of undercooked freshwater fish. How can Clonorchiasis be prevented?",
+        "options": "A. Avoiding consumption of raw or undercooked shellfish B. Thoroughly cooking freshwater fish C. Drinking only boiled water D. Properly disposing of human feces to prevent contamination of water sources",
+        "answer": "B"
+    },
+    {
+        "question": "What is a key histological feature of Chronic Viral Hepatitis B, Moderate Activity?",
+        "options": "A. No significant fibrosis B. Minimal liver inflammation C. Necroinflammation on biopsy D. Severe cirrhosis",
+        "answer": "C"
+    },
+    {
+        "question": "Which of the following is NOT a typical symptom of acute pancreatitis?",
+        "options": "A. Nausea B. Vomiting C. Fever D. Joint pain",
+        "answer": "D"
+    },
+    {
+        "question": "A 59-year-old man is brought to the emergency department with a history of black, tarry stools but denies vomiting of blood or abdominal pain. His family has noticed progressive confusion. History is significant for liver cirrhosis and alcoholism. His heart rate is 112/min, temperature is 37.1°C (98.7°F), and blood pressure is 110/70 mm Hg. On examination, he is jaundiced, lethargic, is oriented to person and place but not date, and has moderate ascites. Neurological examination reveals asterixis, and his stool is guaiac-positive. Liver function test are shown below:\nTotal albumin 2 g/dL\nProthrombin time 9 seconds\nTotal bilirubin 5 mg/dL\nAlanine aminotransferase (ALT) 100 U/L\nAspartate aminotransferase (AST) 220 U/L\nWhich of the following is a feature of this patient condition?\n ",
+        "options": "A. It carries a good prognosis\n B. Ammonia level is the best initial test to confirm the diagnosis\n C. It is a diagnosis of exclusion\n D. It only occurs in patients with cirrhosis\n E. Electroencephalography (EEG) usually shows focal localising abnormality",
+        "answer": "C"
+    },
+    {
+        "question": "An otherwise healthy 49-year-old woman has a routine full blood count complete prior her elective cholecystectomy. The lab test results are as follows:\nLaboratory test\nHemoglobin\n12.1 g/dL\nMean corpuscular volume (MCV)\n85 μm3\nMean corpuscular hemoglobin concentration (MCHC)\n47%\nReticulocyte count\n3.4 %\nWhite blood cell count\n9700/mm3\nPlatelet count\n229,000/mm3\nA peripheral blood smear reveals spherocytes. The Coombs test is negative. The physical examination is remarkable for scleral icterus and moderate splenomegaly. Which of the following is the most appropriate diagnostic test of this patient’s underlying disorder?\n ",
+        "options": "A. Eosin-5-maleimide binding test\n B. Flow cytometry for CD55/CD59\n C. Anti parvovirus B19 antibodies\n D. Bone marrow biopsy\n E. Liver function tests",
+        "answer": "A"
+    },
+    {
+        "question": "A chronic alcoholic patient came to emergency with severe pain in epigastrium and multiple episodes of vomiting. On examination, guarding was present in upper epigastrium. Chest X-ray was normal. What is the next best step?\n ",
+        "options": "A. Upper GI endoscopy\n B. Serum lipase\n C. Alcohol breath test\n D. CECT",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is a primary cause of liver cirrhosis?",
+        "options": "A. Chronic alcohol abuse B. Hypertension C. Diabetes mellitus D. Hyperthyroidism",
+        "answer": "A"
+    },
+    {
+        "question": "Hepatorenal syndrome is a rare but severe complication of advanced liver disease. Which of the following laboratory findings is most characteristic of type 1 hepatorenal syndrome?",
+        "options": "A. Elevated urinary sodium B. Dilutional hyponatremia C. Elevated serum creatinine D. Low urinary osmolality",
+        "answer": "B"
+    },
+    {
+        "question": "Which diagnostic test is commonly used to detect nodular liver in cirrhosis?",
+        "options": "A. Blood tests B. Liver biopsy C. Ultrasound/CT D. Endoscopy",
+        "answer": "C"
+    },
+    {
+        "question": "What is a key symptom of hepatic encephalopathy?",
+        "options": "A. Jaundice B. Confusion C. Hypertension D. Hyperglycemia",
+        "answer": "B"
+    },
+    {
+        "question": "What histological feature is characteristic of chronic interstitial hepatitis?",
+        "options": "A. Extensive hepatocellular necrosis B. Prominent fibrous tissue involvement C. Absence of inflammation D. Normal liver architecture",
+        "answer": "B"
+    },
+    {
+        "question": "What is the most common cause of gallbladder perforation?",
+        "options": "A. Abdominal trauma B. Gallstones C. Vasculitis D. Iatrogenic procedures",
+        "answer": "B"
+    },
+    {
+        "question": "In the management of Type 1 hepatorenal syndrome (HRS), albumin is administered primarily to address which of the following pathophysiological mechanisms?",
+        "options": "A. To improve renal perfusion B. To counteract splanchnic vasodilation C. To increase urinary sodium excretion D. To reduce systemic inflammation",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with untreated, prolonged gallbladder obstruction due to a large impacted stone presents with worsening right upper quadrant pain and fever. Which of the following complications is most likely to develop in this setting?",
+        "options": "A. Mirizzi syndrome (chronic complication from extrinsic bile duct compression) B. Empyema or gangrene of the gallbladder (acute infective/septic complications) C. Ascending cholangitis (biliary tree infection) D. Acute pancreatitis (gallstone migration)",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with a history of biliary disease presents with recurrent episodes of vomiting. On examination, the vomitus appears bilious. What is the primary symptom of a choledochogastric fistula in this patient? What additional diagnostic finding would most strongly support this diagnosis?",
+        "options": "A. Jaundice B. Bilious vomiting C. Abdominal pain D. Weight loss E. Presence of bile in gastric aspirate",
+        "answer": "B"
+    },
+    {
+        "question": "What is hepatomegaly primarily considered in clinical practice?",
+        "options": "A. A disease B. A clinical sign C. A genetic disorder D. A bacterial infection",
+        "answer": "B"
+    },
+    {
+        "question": "A patient is evaluated for risk factors of pancreatic adenocarcinoma. Which of the following is NOT a well-established risk factor for this malignancy?",
+        "options": "A. Smoking B. Chronic pancreatitis C. New-onset diabetes in individuals ≥50 years D. Family history of breast cancer",
+        "answer": "D"
+    },
+    {
+        "question": "A patient with metastatic islet cell tumors presents with symptoms of hormone hypersecretion. Which of the following is a first-line treatment option?",
+        "options": "A. Surgical resection only B. Somatostatin analogs C. Antibiotic therapy D. Physical therapy E. Chemotherapy F. Targeted therapy",
+        "answer": "B",
+        "rationale": "Somatostatin analogs (e.g., octreotide) are first-line for symptom control in metastatic islet cell tumors due to their ability to inhibit hormone secretion. While chemotherapy (E) and targeted therapy (F) may be used in advanced cases, they are not first-line. Surgical resection (A) is rarely curative in metastatic disease."
+    },
+    {
+        "question": "A woman with Primary Biliary Cirrhosis (PBC) presents with compensated cirrhosis and small esophageal varices on endoscopy. She is currently on ursodeoxycholic acid (UDCA) but is not yet a candidate for liver transplantation. What is the recommended long-term strategy to prevent esophageal varices bleeding in this patient?",
+        "options": "A. Ursodeoxycholic acid (UDCA) monotherapy B. Endoscopic variceal ligation and non-selective beta-blockers C. Antibiotic prophylaxis D. Vitamin K supplementation",
+        "answer": "B"
+    },
+    {
+        "question": "What is a common manifestation of advanced pancreatic head cancer?",
+        "options": "A. Increased appetite B. Obstructive jaundice C. Weight gain D. Improved energy levels",
+        "answer": "B"
+    },
+    {
+        "question": "In a male after laparoscopic cholecystectomy, the specimen is sent for histopathology which shows carcinoma gallbladder stage T1a. What is the most appropriate management in this patient?\n ",
+        "options": "A. Conservative and follow up.\n B. Extended cholecystectomy\n C. Simple cholecystectomy\n D. Radiotherapy",
+        "answer": "C"
+    },
+    {
+        "question": "What is a primary diagnostic tool for hepatomegaly with splenomegaly?",
+        "options": "A. Electrocardiogram (ECG) B. Ultrasound/CT imaging C. Pulmonary function test D. Skin biopsy",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with biopsy-proven nonalcoholic steatohepatitis (NASH) and advanced fibrosis is being evaluated for treatment. Which of the following medications is most appropriate for this high-risk case of Non-Alcoholic Fatty Liver Disease (NAFLD)?",
+        "options": "A. Vitamin E B. Pioglitazone C. Statins D. Antihistamines",
+        "answer": "A"
+    },
+    {
+        "question": "Which imaging technique is commonly used in the diagnosis of pancreatic cancer?",
+        "options": "A. X-ray B. Ultrasound C. CT/MRI D. PET scan",
+        "answer": "C"
+    },
+    {
+        "question": "A male child with coarse facial features, macroglossia, thick lips presents with copious mucous discharge from nose at 10 months of age. The child was absolutely normal at bih. On examination he was found to have enlarged Liver and Spleen. Diagnosis is:\n ",
+        "options": "A. Hurler's syndrome\n B. Beckwith-Weidman syndrome\n C. Hypothyroidism\n D. Proteus syndrome",
+        "answer": "A"
+    },
+    {
+        "question": "A patient with a history of chronic bile duct obstruction presents with fatigue and gastrointestinal complaints. Which of the following clinical manifestations is most characteristic of secondary biliary cirrhosis during early disease progression?",
+        "options": "A. Abdominal pain B. Jaundice C. Pruritus D. Dark urine E. Weight loss",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with jaundice and abdominal pain. Imaging reveals a mass. What is the key anatomical difference between secondary malignant neoplasm of the gallbladder and secondary malignant neoplasm of the biliary tract that would guide further diagnostic workup?",
+        "options": "A. The gallbladder neoplasm targets the bile ducts B. The biliary tract neoplasm primarily affects the gallbladder wall C. The gallbladder neoplasm primarily affects the gallbladder wall, while the biliary tract neoplasm targets the bile ducts D. Both conditions primarily affect the bile ducts but differ in their metastatic origins",
+        "answer": "C"
+    },
+    {
+        "question": "Which intervention may be required in severe cases of alcoholic chronic pancreatitis?",
+        "options": "A. Chemotherapy B. Endoscopic or surgical interventions C. Radiation therapy D. Physical therapy",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with acute liver failure characterized by rapid clinical deterioration. Which of the following findings is most specific for Acute Yellow Atrophy of the Liver?",
+        "options": "A. Gradual onset of jaundice over weeks B. Marked reduction in liver size (shrinkage) on imaging C. Moderately prolonged INR (1.5-2.5) D. Transient mild confusion without coma",
+        "answer": "B"
+    },
+    {
+        "question": "What surgical intervention may be required in severe cases of central hemorrhagic necrosis of the liver?",
+        "options": "A. Hepatic artery embolization or partial hepatectomy B. Cholecystectomy C. Appendectomy D. Gastric bypass surgery",
+        "answer": "A"
+    },
+    {
+        "question": "What is a common symptom of a pancreatic pseudocyst?",
+        "options": "A. Persistent epigastric pain radiating to the back B. High fever C. Severe headache D. Chest pain",
+        "answer": "A"
+    },
+    {
+        "question": "Which of the following is a key component of treatment for alcoholic hepatitis?",
+        "options": "A. Antiviral therapy B. Absolute alcohol cessation C. Insulin therapy D. Chemotherapy",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is NOT a primary cause of liver fibrosis with cirrhosis?",
+        "options": "A. Chronic viral hepatitis (HBV, HCV) B. Alcohol abuse C. Genetic conditions like hemochromatosis D. Acute bacterial infections",
+        "answer": "D"
+    },
+    {
+        "question": "Which of the following is a common symptom of pericholecystitis?",
+        "options": "A. Left lower quadrant pain B. Persistent right upper quadrant pain radiating to the back C. Chest pain D. Headache",
+        "answer": "B"
+    },
+    {
+        "question": "A male presents with painless jaundice, unintentional weight loss, and clay-colored stools. Which of the following is the most likely underlying cause of his symptoms?",
+        "options": "A. Epigastric pain radiating to the back (chronic pancreatitis) B. Obstructive jaundice (pancreatic head neoplasm) C. Hematemesis (gastric ulcer) D. Dysuria (urinary tract infection)",
+        "answer": "B",
+        "explanation": "Painless jaundice with weight loss and acholic stools is a classic triad for pancreatic head neoplasms, which often obstruct the common bile duct. Option A suggests chronic pancreatitis (typically painful), C suggests upper GI bleeding, and D is unrelated to biliary pathology."
+    },
+    {
+        "question": "What is a key symptom of traumatic rupture of the liver?",
+        "options": "A. Left shoulder pain B. Right shoulder pain (Kehr’s sign) C. Neck stiffness D. Leg weakness",
+        "answer": "B"
+    },
+    {
+        "question": "What is the primary cause of Primary Biliary Cholangitis (PBC)?",
+        "options": "A. Viral infection B. Autoimmune attack on intrahepatic bile ducts C. Prolonged alcohol consumption D. Genetic mutation",
+        "answer": "B"
+    },
+    {
+        "question": "What is a key distinction between uncomplicated cholecystitis and gallbladder perforation?",
+        "options": "A. Presence of gallstones B. Structural wall breach with peritoneal contamination C. Mild symptoms D. No need for surgical intervention",
+        "answer": "B"
+    },
+    {
+        "question": "Which subtype of Chronic Pancreatitis is marked by extensive collagen deposition and often secondary to alcohol or genetic causes?",
+        "options": "A. Chronic Interstitial Pancreatitis B. Chronic Cystic Pancreatitis C. Chronic Fibrosing Pancreatitis D. Chronic Autoimmune Pancreatitis",
+        "answer": "C"
+    },
+    {
+        "question": "Which of the following statements concerning hepatitis infection in pregnancy is true?:\n ",
+        "options": "A. Hepatitis B core antigen status is the most sensitive indicator of positive vertical transmission of disease\n B. Hepatitis B is the most common form of hepatitis after blood transfusion\n C. The proper treatment of infants born to infected mothers includes the administration of hepatitis B immune globulin as well as vaccine\n D. Patients who develop chronic active hepatitis should undergo MTP",
+        "answer": "C"
+    },
+    {
+        "question": "An asymptomatic patient undergoes abdominal imaging for an unrelated issue, and a benign liver mass is incidentally discovered. Which of the following is the most likely cause of this finding?",
+        "options": "A. Chronic hepatitis C B. Cirrhosis C. Hepatic hemangioma D. Aflatoxin exposure",
+        "answer": "C"
+    },
+    {
+        "question": "Hepatoblastoma is associated with mutations in the Wnt pathway, leading to aberrant activation of β-catenin. In patients with hepatoblastoma harboring Wnt pathway mutations, what is a potential novel therapeutic target?",
+        "options": "A. β-catenin inhibitors B. Immunotherapy C. Radiation therapy D. Surgical resection",
+        "answer": "A"
+    },
+    {
+        "question": "A patient presents with fever, abdominal pain, and elevated inflammatory markers. Which diagnostic tool is most commonly used to identify portal vein phlebitis?",
+        "options": "A. Doppler ultrasound B. Contrast-enhanced CT/MRI C. Liver function tests D. Abdominal X-ray",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with abdominal pain and jaundice. Which of the following symptoms is most commonly associated with bile duct neoplasms?",
+        "options": "A. Abdominal pain B. Jaundice C. Weight loss D. Hematuria",
+        "answer": "A"
+    },
+    {
+        "question": "Which of the following environmental or genetic factors is NOT associated with the etiology of hepatoblastoma in children?",
+        "options": "A. Low birth weight B. Familial syndromes (e.g., Beckwith-Wiedemann syndrome) C. Maternal smoking during pregnancy D. Fetal alcohol exposure",
+        "answer": "C. Maternal smoking is not directly linked to hepatoblastoma, whereas low birth weight, familial syndromes, and fetal alcohol exposure are known risk factors."
+    },
+    {
+        "question": "A child has bilirubin of 4 mg. Conjugated bilirubin and alkaline phosphatase are normal, bile salts and bile in urine are absent. However urobilinogen in urine is raised. What is the likely diagnosis –\n ",
+        "options": "A. Obstructive jaundice\n B. Rotor's syndrome\n C. Biliary cholestasis\n D. Hemolytic jaundice",
+        "answer": "D"
+    },
+    {
+        "question": "Two hours following an elective cholecystectomy, a 43-year-old woman has fever and chills. The patient received cephalexin for antibiotic prophylaxis and one unit of packed red blood cells during the procedure. She underwent a hysterectomy 9 years ago for leiomyomata uteri. She has a 5-year history of hypertension treated with lisinopril. Her temperature is 39.5°C (102.3°F), pulse is 90/min, respirations are 18/min, and blood pressure is 125/90 mm Hg. Examination shows a mildly tender abdominal wound without erythema. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. She had a Foley catheter and peripheral line access placed at the time of the procedure. Which of the following is the most likely cause of this patient's symptoms?\n ",
+        "options": "A. Adverse effect of medication\n B. Malignant hyperthermia\n C. Surgical site infection\n D. Urinary tract infection\n E. Transfusion reaction",
+        "answer": "E"
+    },
+    {
+        "question": "In advanced alcoholic cirrhosis of the liver, which of the following is a characteristic feature?",
+        "options": "A. Reversible fibrosis B. Progressive nodular regeneration and fibrosis C. Portal hypertension D. Steatosis without inflammation",
+        "answer": "B"
+    },
+    {
+        "question": "What is the primary cause of both acute and chronic cholecystitis?",
+        "options": "A. Bacterial infection B. Gallstones C. Viral infection D. Autoimmune disease",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with cholestatic liver disease. Which of the following features is most likely to distinguish Pericholangitis from Primary Cholangitis?",
+        "options": "A. Association with systemic diseases such as inflammatory bowel disease B. Autoimmune markers such as anti-mitochondrial antibodies C. Predominance in middle-aged women with fatigue and pruritus D. Improvement with antibiotic therapy targeting bacterial overgrowth",
+        "answer": "A"
+    },
+    {
+        "question": "What biomarker is often tested for hepatocellular carcinoma?",
+        "options": "A. C-reactive protein B. Alpha-fetoprotein C. Prostate-specific antigen D. Hemoglobin A1c",
+        "answer": "B"
+    },
+    {
+        "question": "What is the prognosis for most benign pancreatic neoplasms post-resection?",
+        "options": "A. Poor B. Favorable C. Uncertain D. High recurrence risk",
+        "answer": "B"
+    },
+    {
+        "question": "Which hepatoprotective medication is specifically mentioned for acetaminophen toxicity in toxic liver disease?",
+        "options": "A. Metformin B. N-acetylcysteine C. Ibuprofen D. Prednisone",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with chronic right upper quadrant pain and recurrent episodes of cholangitis. Imaging reveals retained gallstones in the cystic duct stump following a previous cholecystectomy. Which intervention is most appropriate for definitive management of this condition?",
+        "options": "A. Open cholecystectomy B. Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction C. Long-term antibiotic prophylaxis D. Percutaneous drainage of the cystic duct stump",
+        "answer": "B"
+    },
+    {
+        "question": "A male with a history of chronic liver disease presents with dyspnea and hypoxemia. Hepatopulmonary Syndrome (HPS) is characterized by intrapulmonary vascular dilatations in the setting of liver disease. What is the primary underlying cause of his condition?",
+        "options": "A. Chronic liver disease leading to vascular changes B. Genetic predisposition C. Acute liver trauma D. Primary pulmonary vascular disease",
+        "answer": "A"
+    },
+    {
+        "question": "Which organ is primarily affected in Hepatitis B Virus-Associated Nephritis?",
+        "options": "A. Liver B. Kidneys C. Spleen D. Pancreas",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with abdominal pain and a liver mass on imaging. Which diagnostic method confirms an inflammatory pseudotumor of the liver?",
+        "options": "A. Serum markers B. Imaging C. Biopsy D. Endoscopic ultrasound",
+        "answer": "C"
+    },
+    {
+        "question": "A patient presents with recurrent episodes of severe right upper quadrant pain lasting 30 minutes, associated with nausea. Imaging confirms gallstones without evidence of acute cholecystitis. How should this patient be managed?",
+        "options": "A. Immediate surgery for acute cholecystitis B. Pain relief with NSAIDs and elective cholecystectomy C. Long-term dietary restrictions D. Observation and follow-up without intervention",
+        "answer": "B"
+    },
+    {
+        "question": "What is a common cause of chronic liver failure related to chronic environmental exposure to heavy metals? (Focus on rare diseases linked to environmental exposure)",
+        "options": "A. Hepatitis B B. Chronic exposure to heavy metals like lead or mercury C. Autoimmune diseases D. Metabolic disorders",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with a history of chronic lobular hepatitis reports episodic yellowing of the skin and eyes. Which of the following symptoms is most consistent with this condition?",
+        "options": "A. Persistent fever B. Episodic jaundice C. Recurrent abdominal pain D. Fatigue and malaise",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following treatments is commonly used for Autoimmune Hepatitis (AIH)?",
+        "options": "A. Antiviral drugs B. Immunosuppressants C. Antibiotics D. Antifungal drugs",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following is the most likely route of transmission for acute viral hepatitis with mixed infections involving hepatitis B and C viruses?",
+        "options": "A. Exposure to contaminated food B. Exposure to contaminated blood or bodily fluids C. Consumption of contaminated water D. Occupational exposure to chemicals",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with a history of recurrent biliary colic presents with jaundice and epigastric pain. Imaging reveals inflammation-induced stricture of the duodenal papilla. Which condition is most likely responsible?",
+        "options": "A. Stenosis of sphincter of Oddi B. Stenosing papillitis of the duodenum C. Pancreatic pseudocyst D. Biliary atresia",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with a history of long-term acetaminophen use presents with fatigue and mild hepatomegaly. Liver biopsy reveals chronic persistent hepatitis due to toxic liver disease. Which laboratory finding is most likely to be observed in this patient?",
+        "options": "A. Decreased ALT/AST levels B. Elevated ALT/AST levels C. Normal bilirubin levels D. Elevated alkaline phosphatase levels",
+        "answer": "B"
+    },
+    {
+        "question": "A 38-year-old woman is brought to the emergency department because of three 1-hour episodes of severe, sharp, penetrating abdominal pain in the right upper quadrant. During these episodes, she has had nausea and vomiting. She has no diarrhea, dysuria, or hematuria and is asymptomatic between episodes. She has hypertension and hyperlipidemia. Seven years ago, she underwent resection of the terminal ileum because of severe Crohn's disease. She is 155 cm (5 ft 2 in) tall and weighs 79 kg (175 lb); BMI is 32 kg/m2. Her temperature is 36.9°C (98.5°F), pulse is 80/min, and blood pressure is 130/95 mm Hg. There is mild scleral icterus. Cardiopulmonary examination shows no abnormalities. The abdomen is soft, and there is tenderness to palpation of the right upper quadrant without guarding or rebound. Bowel sounds are normal. The stool is brown, and test for occult blood is negative. Laboratory studies show:\nHemoglobin 12.5 g/dL\nLeukocyte count 9,500 mm3\nPlatelet count 170,000 mm3\nSerum\nTotal bilirubin 4.1 mg/dL\nAlkaline phosphatase 348 U/L\nAST 187 U/L\nALT 260 U/L\nAbdominal ultrasonography shows a normal liver, a common bile duct caliber of 10 mm (normal < 6 mm) and a gallbladder with multiple gallstones and no wall thickening or pericholecystic fluid. Which of the following is the most likely cause of these findings?\"\n ",
+        "options": "A. Acute hepatitis A\n B. Choledocholithiasis\n C. Autoimmune hepatitis\n D. Cholecystitis\n E. Pancreatitis\n\"",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with hepatomegaly and splenomegaly accompanied by fatigue and early satiety. What is the most critical step in their initial management?",
+        "options": "A. Monitoring without intervention for 6 months B. Early intervention with diagnostic workup (e.g., imaging, labs) C. Immediate referral to a hepatologist D. Symptomatic treatment only (e.g., pain relief)",
+        "answer": "B"
+    },
+    {
+        "question": "What is the primary cause of obstructive cholangitis?",
+        "options": "A. Autoimmune conditions B. Bacterial infection C. Physical blockage (e.g., tumors, stones) D. Drug-induced cholestasis",
+        "answer": "C"
+    },
+    {
+        "question": "How does pericholecystitis differ from isolated cholecystitis in terms of management?",
+        "options": "A. Requires shorter antibiotic therapy B. May require extended antibiotic therapy C. Does not require imaging D. Can be managed with oral antibiotics alone",
+        "answer": "B"
+    },
+    {
+        "question": "What is the primary cause of chronic passive congestion of the liver?",
+        "options": "A. Left-sided heart failure B. Right-sided heart failure C. Viral hepatitis D. Alcoholic liver disease",
+        "answer": "B"
+    },
+    {
+        "question": "A woman presents with acute abdominal pain and jaundice. Imaging reveals bile duct perforation. What is the most likely cause?",
+        "options": "A. Gallstones B. Trauma C. Iatrogenic injury during surgery D. Infections like cholangitis",
+        "answer": "A (Gallstones are the most common cause due to obstruction and increased pressure in the biliary system.)"
+    },
+    {
+        "question": "A patient presents with right upper quadrant pain and elevated liver enzymes. Which imaging technique is most appropriate for the initial evaluation of a suspected liver mass?",
+        "options": "A. X-ray B. Ultrasound C. CT scan D. MRI",
+        "answer": "B"
+    },
+    {
+        "question": "A male with a history of recurrent abdominal trauma presents with signs of portal hypertension (ascites, splenomegaly). Imaging reveals intrahepatic vascular shunts. Given the rarity of this condition, which of the following is the most likely acquired cause of these shunts and the underlying mechanism?",
+        "options": "A. Genetic defect (congenital malformation of hepatic vasculature) B. Trauma (mechanical disruption of hepatic parenchyma and vasculature) C. Parasitic infection (Schistosoma-induced granulomatous inflammation) D. Chronic inflammation (cirrhosis-induced sinusoidal remodeling)",
+        "answer": "B"
+    },
+    {
+        "question": "A 60-year-old man with a long-standing history of chronic hepatitis C infection comes to the emergency department because of abdominal distention and scleral icterus for the past month. His heart rate is 76/min, respiratory rate is 14/min, temperature is 36.0°C (96.8°F), and blood pressure is 110/86 mm Hg. Physical examination show signs suggestive of liver cirrhosis. Which of the following signs is a direct result of hyperestrinism in cirrhotic patients?\n ",
+        "options": "A. Coagulopathy\n B. Gynecomastia\n C. Jaundice\n D. Lower limb swelling\n E. Caput medusae",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with Acute hepatitis B with delta-agent presents with confusion, asterixis, and markedly elevated liver enzymes. What is the primary clinical distinction between this patient's condition and Acute hepatitis B with delta-agent without hepatic coma?",
+        "options": "A. Duration of symptoms B. Severity of liver failure C. Mode of transmission D. Response to antiviral therapy",
+        "answer": "B"
+    },
+    {
+        "question": "A patient is diagnosed with carcinoma in situ of the liver during a routine screening. What is the most likely prognosis if the condition is detected at this early stage (e.g., before metastasis)?",
+        "options": "A. Poor, with a high likelihood of progression to invasive cancer B. Moderate, with a significant risk of recurrence C. High curability, with a low risk of progression D. Variable, depending on the specific organ and treatment approach",
+        "answer": "C"
+    },
+    {
+        "question": "A patient presents with mild transaminitis (ALT 120 U/L, AST 98 U/L) and nonspecific fatigue. Liver biopsy reveals nonspecific reactive hepatitis. Which of the following is the most common underlying cause of this condition?",
+        "options": "A. Autoimmune disorders B. Viral hepatitis C. Systemic bacterial infections D. Chronic alcohol use",
+        "answer": "B"
+    },
+    {
+        "question": "A woman presents with right upper quadrant discomfort and is found to have a 6 cm hepatic hemangioma on imaging. She reports intermittent pain exacerbated by movement. Which of the following is the most appropriate management for this symptomatic benign liver mass?",
+        "options": "A. Chemotherapy B. Radiation therapy C. Surgical resection D. Targeted therapy E. Observation F. Transarterial embolization",
+        "answer": "C"
+    },
+    {
+        "question": "A 55-year-old man with chronic hepatitis B virus infection comes to the physician because of generalized fatigue and a 5.4 kg (12 lb) weight loss over the past 4 months. Physical examination shows hepatomegaly. Laboratory studies show an α-fetoprotein concentration of 380 ng/ml (N < 10 ng/mL). A CT scan of the abdomen with contrast shows a solitary mass in the left lobe of the liver that enhances in the arterial phase. Which of the following is the most likely underlying pathogenesis of this patient's current condition?\n ",
+        "options": "A. Overexpression of secretory hepatitis antigen\n B. Intracellular accumulation of misfolded protein\n C. Gain of function mutation of a proto-oncogene\n D. Viral cytotoxin-induced cellular dysplasia\n E. Integration of foreign DNA into host genome\n\"",
+        "answer": "E"
+    },
+    {
+        "question": "What is the primary cause of acute cholecystitis in 90% of cases?",
+        "options": "A. Bacterial infections B. Gallstones obstructing the cystic duct C. Ischemia D. Systemic conditions like vasculitis",
+        "answer": "B"
+    },
+    {
+        "question": "What is the primary cause of chronic cholecystitis?",
+        "options": "A. Bacterial infection B. Recurrent gallstones obstructing the cystic duct C. Autoimmune inflammation D. Viral infection",
+        "answer": "B"
+    },
+    {
+        "question": "A 23-year-old man comes to the clinic for yellowing of his eyes. The patient has been relatively healthy and just recently started “intermittent fasting” to try to lose weight. He recalls a similar episode 4 years ago when he was recovering from an emergency appendectomy. The patient denies smoking but endorses an episode of binge drinking 2 days ago. He is sexually active with both men and women. His physical examination is unremarkable besides scleral icterus. What is the most likely explanation for this patient’s symptoms?\n ",
+        "options": "A. Autoimmune-mediated fibrosis of biliary tract\n B. Chronic viral infection of the liver\n C. Decreased activity of UDP-glucuronosyltransferase\n D. Defective bilirubin excretion\n E. Macrovesicular steatosis",
+        "answer": "C"
+    },
+    {
+        "question": "What is a key diagnostic feature of liver cancer on imaging?",
+        "options": "A. Hypovascular masses B. Hypervascular masses C. Cystic lesions D. Calcifications",
+        "answer": "B"
+    },
+    {
+        "question": "In the palliative care setting for a patient with malignant neoplasm of the tail of the pancreas, which of the following is the primary focus of multidisciplinary management?",
+        "options": "A. Surgical resection B. Symptom control, nutritional support, and palliative care C. Radiation therapy D. Chemotherapy only E. Early detection and screening",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with Mirizzi Syndrome presents with worsening jaundice and right upper quadrant abdominal pain. Which of the following complications is most likely responsible for these symptoms?",
+        "options": "A. Secondary biliary cirrhosis B. Acute cholangitis C. Biliary fistula D. Gastric ulcer",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with a history of long-term acetaminophen use presents with suspected toxic liver disease and chronic persistent hepatitis. Which of the following is the most common symptom in this condition?",
+        "options": "A. Severe abdominal pain B. Fatigue C. Mild jaundice D. Loss of appetite",
+        "answer": "B"
+    },
+    {
+        "question": "What is a potential complication of untreated Clonorchiasis?",
+        "options": "A. Hepatitis B. Cholangiocarcinoma C. Pancreatitis D. Gastric ulcer",
+        "answer": "B"
+    },
+    {
+        "question": "Which of the following symptoms is most characteristic of acute pancreatitis?",
+        "options": "A. Chest pain B. Severe epigastric pain radiating to the back C. Diarrhea D. Headache",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with jaundice, and imaging reveals a biliary tumor. Which of the following best distinguishes proximal from distal biliary tumors in terms of resectability?",
+        "options": "A. Proximal tumors are always resectable B. Distal tumors are often unresectable C. Proximal tumors are often unresectable D. Distal tumors are less likely to cause early jaundice compared to proximal tumors",
+        "answer": "C"
+    },
+    {
+        "question": "Which of the following surgical management strategies is most specific to intrahepatic bile duct tumors compared to common bile duct tumors?",
+        "options": "A. Intrahepatic tumors require extensive biliary reconstruction B. Common bile duct lesions are typically managed with biliary stenting or resection without hepatectomy C. Intrahepatic tumors may necessitate hepatectomy",
+        "answer": "C"
+    },
+    {
+        "question": "What is the primary treatment approach for Acute Postprocedural Pancreatitis, Mild?",
+        "options": "A. Steroids B. Bowel rest and IV fluids C. Antibiotics D. Endoscopic drainage",
+        "answer": "B"
+    },
+    {
+        "question": "What is a key risk factor for intrahepatic bile duct cancer?",
+        "options": "A. Colorectal cancer B. Chronic bile duct inflammation C. Lung cancer D. Breast cancer",
+        "answer": "B"
+    },
+    {
+        "question": "A patient with acute hepatitis B presents with worsening jaundice and fatigue. Serologic testing confirms hepatitis D virus (HDV) coinfection. Which of the following treatments is specifically recommended for HDV in this setting, and what is the primary rationale for its use?",
+        "options": "A. Tenofovir (reduces HBV DNA replication) B. Entecavir (potent HBV suppression) C. Pegylated interferon-alpha (direct antiviral activity against HDV) D. Ribavirin (adjunctive therapy for HCV) E. Sofosbuvir (NS5B inhibitor for HCV) F. Lamivudine (older HBV nucleoside analog)",
+        "answer": "C"
+    },
+    {
+        "question": "Which of the following imaging techniques is critical for diagnosing benign bile duct neoplasms?",
+        "options": "A. CT scan B. MRI C. MRCP D. X-ray",
+        "answer": "C"
+    },
+    {
+        "question": "What is the primary cause of alcoholic chronic pancreatitis?",
+        "options": "A. Genetic predisposition B. Prolonged excessive alcohol consumption C. Viral infection D. Autoimmune disease",
+        "answer": "B"
+    },
+    {
+        "question": "A patient presents with acute hepatitis due to toxic liver disease. What is the first step in treatment?",
+        "options": "A. Immediate cessation of the toxic agent B. Initiation of N-acetylcysteine therapy C. Liver transplantation D. Supportive care with hydration",
+        "answer": "A",
+        "explanation": "The most critical initial step in toxic liver disease is stopping exposure to the causative agent to prevent further liver injury. While N-acetylcysteine (B) and supportive care (D) may be part of management, they are secondary to eliminating the toxin. Liver transplantation (C) is reserved for irreversible liver failure."
+    },
+    {
+        "question": "A male presents with severe epigastric pain radiating to the back, nausea, and vomiting. Which diagnostic marker is most indicative of idiopathic acute pancreatitis?",
+        "options": "A. Elevated serum amylase/lipase (≥3x normal) B. Elevated serum creatinine C. Normal serum calcium levels D. Decreased serum albumin",
+        "answer": "A"
+    },
+    {
+        "question": "In a patient presenting with an incidentally discovered liver mass, what is a key histological difference between benign liver neoplasms and benign bile duct neoplasms? Although both conditions are rare, understanding their differences is crucial for accurate diagnosis and management.",
+        "options": "A. Liver neoplasms are always symptomatic B. Bile duct neoplasms are hormone-related C. Liver neoplasms primarily affect hepatocytes D. Bile duct neoplasms often present with obstructive jaundice",
+        "answer": "C"
+    },
+    {
+        "question": "A patient presents with right upper quadrant pain and fever. Which imaging modality is most important for differentiating hydrops from mucocele of the gallbladder based on anatomical detail?",
+        "options": "A. MRI B. X-ray C. Ultrasound D. CT E. PET scan",
+        "answer": "C"
+    },
+    {
+        "question": "A female with a known history of systemic lupus erythematosus (SLE) presents with fatigue, jaundice, and elevated liver enzymes (AST 250 U/L, ALT 300 U/L). Which of the following features most reliably distinguishes Lupus Hepatitis from Autoimmune Hepatitis (AIH) in this patient?",
+        "options": "A. Presence of anti-smooth muscle antibodies (ASMA) B. Association with systemic lupus erythematosus (SLE) C. Rapid normalization of liver enzymes with corticosteroids D. Detection of hepatitis B surface antigen (HBsAg)",
+        "answer": "B"
+    },
+    {
+        "question": "A patient develops a hepatic duct-intestinal fistula (an abnormal connection between the hepatic duct and intestine, often due to surgical trauma) following abdominal surgery. What is the most likely immediate complication?",
+        "options": "A. Bile peritonitis B. Sepsis C. Hemorrhage D. Intestinal obstruction",
+        "answer": "A"
+    },
+    {
+        "question": "Which syndrome is most frequently associated with gastrinomas?",
+        "options": "A. Zollinger-Ellison syndrome B. Cushing's syndrome C. Addison's disease D. Graves' disease",
+        "answer": "A"
+    },
+    {
+        "question": "What is a distinguishing feature of Clonorchiasis compared to other liver parasitic diseases?",
+        "options": "A. It primarily affects the liver parenchyma B. It is transmitted through contaminated water C. It specifically targets the biliary system D. It is caused by a bacterial infection",
+        "answer": "C"
+    },
+    {
+        "question": "A male with poorly controlled diabetes mellitus presents with fever, right upper quadrant pain, and elevated inflammatory markers. Imaging reveals a solitary liver abscess. Which of the following pathogens is most commonly implicated in this clinical scenario?",
+        "options": "A. Klebsiella pneumoniae B. Escherichia coli C. Streptococcus spp. D. Staphylococcus aureus",
+        "answer": "A"
+    }
+]