Beyond English benchmarks: clinical llm evaluation in Brazilian Portuguese

Large Language Models are transforming the support for clinical decision and their application in real scenarios. Yet, most benchmarks are conducted in English, and cross-lingual evaluation is needed to tackle the language gaps in global access. We introduce ClinicalBr, the first bilingual benchmark for clinical decision built from real Brazilian case reports. The corpus contains 2,892 cases drawn from 28 SciELO medical journals, spanning 18 specialties, and is structured as parallel Portuguese-English pairs. Each case supports four evaluation tasks: diagnosis retrieval, differential diagnosis, exam recommendation, and treatment planning. We evaluate four models: MedGemma-27B, Sabiá-4, DeepSeek-R1, and o3-mini, across both languages. The central finding is that the Portuguese-English performance gap is task-dependent, not general. In diagnosis retrieval, English yields a consistent advantage across all models, with +7.5-12.1 accuracy points. This advantage disappears in differential diagnosis, exam recommendation, and treatment planning, where confidence intervals cross zero for most models and Portuguese completeness scores are marginally higher. Brazilian-endemic conditions proved easier than the full corpus, not harder, indicating that tropical presentations are adequately represented in current pre-training. Exam recommendation was the hardest task across all models and both languages, with F1 scores below 0.10, well below the differential diagnosis ceiling of 0.20-0.27.