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Add difficulty 4 question gap batch

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hz
2026-07-26 16:32:41 -05:00
parent efe60f36c5
commit 1d5d03a4f6
3 changed files with 325 additions and 0 deletions
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step3.sln
+17
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@@ -9,6 +9,10 @@ Project("{FAE04EC0-301F-11D3-BF4B-00C04F79EFBC}") = "QuestionsApi", "api\Questio
EndProject
Project("{FAE04EC0-301F-11D3-BF4B-00C04F79EFBC}") = "QuestionsApi.Tests", "api\QuestionsApi.Tests\QuestionsApi.Tests.csproj", "{1897C6D6-452D-4142-BCCC-FA1A46E7C869}"
EndProject
Project("{2150E333-8FDC-42A3-9474-1A3956D46DE8}") = "tools", "tools", "{07C2787E-EAC7-C090-1BA3-A61EC2A24D84}"
EndProject
Project("{FAE04EC0-301F-11D3-BF4B-00C04F79EFBC}") = "Difficulty4GapSeeder", "tools\Difficulty4GapSeeder\Difficulty4GapSeeder.csproj", "{EC397984-398E-49E6-B6F0-42269A629585}"
EndProject
Global
GlobalSection(SolutionConfigurationPlatforms) = preSolution
Debug|Any CPU = Debug|Any CPU
@@ -43,6 +47,18 @@ Global
{1897C6D6-452D-4142-BCCC-FA1A46E7C869}.Release|x64.Build.0 = Release|Any CPU
{1897C6D6-452D-4142-BCCC-FA1A46E7C869}.Release|x86.ActiveCfg = Release|Any CPU
{1897C6D6-452D-4142-BCCC-FA1A46E7C869}.Release|x86.Build.0 = Release|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Debug|Any CPU.ActiveCfg = Debug|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Debug|Any CPU.Build.0 = Debug|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Debug|x64.ActiveCfg = Debug|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Debug|x64.Build.0 = Debug|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Debug|x86.ActiveCfg = Debug|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Debug|x86.Build.0 = Debug|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Release|Any CPU.ActiveCfg = Release|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Release|Any CPU.Build.0 = Release|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Release|x64.ActiveCfg = Release|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Release|x64.Build.0 = Release|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Release|x86.ActiveCfg = Release|Any CPU
{EC397984-398E-49E6-B6F0-42269A629585}.Release|x86.Build.0 = Release|Any CPU
EndGlobalSection
GlobalSection(SolutionProperties) = preSolution
HideSolutionNode = FALSE
@@ -50,5 +66,6 @@ Global
GlobalSection(NestedProjects) = preSolution
{0B2F6FEF-3C08-4A72-BBA9-90C225BC24EC} = {D82C56D6-B2CD-F611-9E31-04638F7EC30E}
{1897C6D6-452D-4142-BCCC-FA1A46E7C869} = {D82C56D6-B2CD-F611-9E31-04638F7EC30E}
{EC397984-398E-49E6-B6F0-42269A629585} = {07C2787E-EAC7-C090-1BA3-A61EC2A24D84}
EndGlobalSection
EndGlobal
tools/Difficulty4GapSeeder/Difficulty4GapSeeder.csproj
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@@ -0,0 +1,11 @@
<Project Sdk="Microsoft.NET.Sdk">
<PropertyGroup>
<OutputType>Exe</OutputType>
<TargetFramework>net8.0</TargetFramework>
<ImplicitUsings>enable</ImplicitUsings>
<Nullable>enable</Nullable>
</PropertyGroup>
<ItemGroup>
<ProjectReference Include="..\..\api\QuestionsApi\QuestionsApi.csproj" />
</ItemGroup>
</Project>
tools/Difficulty4GapSeeder/Program.cs
+297
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@@ -0,0 +1,297 @@
using Microsoft.Extensions.Configuration;
using QuestionsApi.Models;
using QuestionsApi.Services;
const string accessedOn = "2026-07-26";
var apply = args.Contains("--apply", StringComparer.OrdinalIgnoreCase);
var connectionString = Environment.GetEnvironmentVariable("STEP3_MONGODB_CONNECTION_STRING")
?? "mongodb://192.168.86.50:27017";
var databaseName = Environment.GetEnvironmentVariable("STEP3_MONGODB_DATABASE")
?? "promiscuity";
var definitions = new[]
{
new Seed("myasthenic-crisis-respiratory-failure", "Nervous System", "Medicine", "Diagnosis",
"A 63-year-old woman with myasthenia gravis develops pneumonia. She has increasing dysphagia, a weak cough, shallow breathing, and can count only to 8 on one breath. Oxygen saturation is 96% on room air. Vital capacity is 12 mL/kg and negative inspiratory force is -18 cm H2O.",
"Which is the most appropriate next step in management?",
"Electively intubate and begin ventilatory support", "Give pyridostigmine only and reassess in 4 hours", "Administer supplemental oxygen without ventilatory support", "Perform an edrophonium challenge", "Begin noninvasive ventilation on an unmonitored ward",
"Bulbar weakness plus markedly reduced vital capacity and inspiratory force indicates impending myasthenic respiratory failure. Oxygen saturation can remain normal until late; airway control should not wait for hypoxemia.",
"Impending ventilatory failure is identified by respiratory mechanics and bulbar function, not pulse oximetry alone.", "vital capacity 12 mL/kg with weak cough and dysphagia", "normal oxygen saturation", "edrophonium is diagnostic, not airway therapy",
"International Consensus Guidance for Management of Myasthenia Gravis: Executive Summary", "Neurology", "https://www.neurology.org/doi/10.1212/WNL.0000000000002790", "Management of impending myasthenic crisis and respiratory failure."),
new Seed("pituitary-apoplexy-emergency-steroids", "Endocrine System", "Medicine", "Management",
"A 48-year-old man has sudden severe headache, vomiting, diplopia, and hypotension. Examination shows bitemporal visual field loss and left third-nerve palsy. Sodium is 128 mEq/L and glucose is 54 mg/dL. CT shows a sellar mass with acute hemorrhage.",
"Which treatment should be administered immediately?",
"Intravenous hydrocortisone", "Cabergoline", "Levothyroxine before glucocorticoids", "Mannitol", "Emergent transsphenoidal surgery before medical stabilization",
"Pituitary apoplexy can cause acute ACTH deficiency and fatal adrenal crisis. Hemodynamic instability, hypoglycemia, and hyponatremia require immediate empiric IV hydrocortisone while endocrine and neurosurgical evaluation proceeds.",
"In unstable pituitary apoplexy, treat possible acute adrenal insufficiency before definitive imaging or surgery.", "sellar hemorrhage with hypotension and hypoglycemia", "visual field loss alone", "thyroid hormone can worsen untreated adrenal insufficiency",
"Emergency management of pituitary apoplexy in adult patients", "Society for Endocrinology", "https://pmc.ncbi.nlm.nih.gov/articles/PMC5314810/", "Immediate empirical glucocorticoid treatment in pituitary apoplexy."),
new Seed("necrotizing-fasciitis-surgical-source-control", "Skin and Subcutaneous Tissue", "Surgery", "Management",
"A 56-year-old man with diabetes has rapidly worsening leg pain 18 hours after a minor abrasion. Temperature is 39.2 C. The leg is swollen with violaceous bullae; pain is far greater than the skin findings. Crepitus is absent. Lactate is 5.1 mmol/L. Broad-spectrum antibiotics are started.",
"Which is the most appropriate next step?",
"Immediate operative exploration and debridement", "MRI before surgical consultation", "Bedside incision and drainage only", "Hyperbaric oxygen as sole therapy", "Observe response to antibiotics for 12 hours",
"Necrotizing soft-tissue infection is a surgical emergency. High clinical suspicion warrants immediate surgical exploration and debridement; imaging must not delay source control.",
"Disproportionate pain, systemic toxicity, and rapid progression demand immediate surgical exploration even without crepitus.", "rapid progression with shock and violaceous bullae", "absence of crepitus", "antibiotics cannot replace debridement",
"Clinical Practice Guidelines for Skin and Soft Tissue Infections", "Infectious Diseases Society of America", "https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/", "Prompt surgical consultation and debridement for suspected necrotizing fasciitis."),
new Seed("sjs-ten-immediate-drug-withdrawal", "Skin and Subcutaneous Tissue", "Medicine", "Management",
"A 35-year-old woman started lamotrigine 3 weeks ago. She now has fever, painful dusky targetoid lesions, epidermal detachment over 12% of her body, oral erosions, and conjunctivitis. Blood pressure is stable.",
"Which immediate intervention most improves prognosis?",
"Stop lamotrigine and transfer for specialized supportive care", "Continue lamotrigine and add topical corticosteroids", "Begin oral acyclovir", "Debride all detached epidermis at bedside", "Discharge with an oral antihistamine",
"This is Stevens-Johnson syndrome/toxic epidermal necrolysis. Immediate withdrawal of the culprit drug is the key first step, followed by burn-unit or ICU-level supportive and multidisciplinary care.",
"Early culprit-drug withdrawal is the most important immediately modifiable intervention in SJS/TEN.", "mucosal erosions with epidermal detachment after a high-risk drug", "target lesions alone", "infection treatment does not replace drug withdrawal",
"UK guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis in adults 2016", "British Association of Dermatologists", "https://academic.oup.com/bjd/article/174/6/1194/6617016", "Immediate withdrawal of the culprit drug and specialized supportive care."),
new Seed("anti-gbm-pulmonary-renal-treatment", "Renal and Urinary System", "Medicine", "Management",
"A 29-year-old man has hemoptysis, dyspnea, and oliguria. Creatinine rose from 0.9 to 4.8 mg/dL in 5 days. Urinalysis shows dysmorphic erythrocytes and red-cell casts. Chest imaging shows bilateral alveolar opacities. Anti-GBM antibody is strongly positive.",
"Which is the best initial disease-directed treatment?",
"Plasma exchange plus glucocorticoids and cyclophosphamide", "Glucocorticoids alone", "Rituximab alone after renal biopsy", "Hemodialysis without immunosuppression", "Broad-spectrum antibiotics only",
"Anti-GBM disease with pulmonary hemorrhage and rapidly progressive glomerulonephritis requires urgent plasma exchange to remove antibody plus glucocorticoids and cyclophosphamide to suppress further production.",
"Do not delay combined plasma exchange and immunosuppression when anti-GBM disease is strongly suspected.", "pulmonary hemorrhage plus rapidly progressive nephritis and anti-GBM antibody", "alveolar opacities alone", "dialysis supports kidney failure but does not stop antibody injury",
"KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases", "KDIGO", "https://kdigo.org/wp-content/uploads/2024/05/KDIGO-2021-Glomerular-Diseases-Guideline_English_2024-Chapter-Updates.pdf", "Immediate plasma exchange, cyclophosphamide, and glucocorticoids for anti-GBM disease."),
new Seed("atherosclerotic-ras-flash-pulmonary-edema", "Renal and Urinary System", "Medicine", "Management",
"A 72-year-old man with diffuse atherosclerosis has resistant hypertension despite 4 drugs and three admissions for sudden flash pulmonary edema. Creatinine increased 35% after an ACE inhibitor. Duplex ultrasonography shows severe bilateral renal artery stenosis.",
"Which intervention is most appropriate?",
"Evaluate for renal artery revascularization", "Increase the ACE inhibitor dose", "Start high-dose glucocorticoids", "Perform unilateral nephrectomy", "Continue medical therapy without further evaluation",
"Most atherosclerotic renal artery stenosis is treated medically, but recurrent flash pulmonary edema, resistant hypertension, and bilateral high-grade disease identify a selective high-risk phenotype that may benefit from revascularization.",
"Recurrent flash pulmonary edema is a classic high-risk presentation in which renal revascularization should be considered.", "recurrent flash edema with bilateral severe stenosis", "atherosclerosis alone", "routine stenting is not indicated for stable incidental stenosis",
"Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association", "American Heart Association", "https://pmc.ncbi.nlm.nih.gov/articles/PMC11731842/", "Selective revascularization for high-risk renovascular syndromes including flash pulmonary edema."),
new Seed("fournier-gangrene-immediate-debridement", "Male Reproductive System", "Surgery", "Management",
"A 61-year-old man with poorly controlled diabetes has fever, severe perineal pain, scrotal edema, and a patch of dusky skin extending toward the anus. CT shows fascial gas. Fluids and broad-spectrum antibiotics are started.",
"Which is the most appropriate next step?",
"Urgent wide surgical debridement", "Needle aspiration of the scrotum", "Topical antimicrobial therapy", "Elective orchiectomy next week", "Wait for wound-culture speciation",
"Fournier gangrene is necrotizing fasciitis of the perineum. Survival depends on immediate, aggressive operative debridement in addition to resuscitation and broad antimicrobial therapy.",
"Fournier gangrene requires immediate operative source control; cultures and imaging must not delay debridement.", "perineal toxicity with fascial gas", "scrotal swelling alone", "antibiotics do not penetrate devitalized tissue adequately",
"Clinical Practice Guidelines for Skin and Soft Tissue Infections", "Infectious Diseases Society of America", "https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/", "Urgent surgical management of Fournier gangrene."),
new Seed("vasa-previa-fetal-hemorrhage", "Pregnancy, Childbirth, and the Puerperium", "Obstetrics", "Management",
"A 35-year-old woman at 35 weeks has sudden painless vaginal bleeding immediately after spontaneous rupture of membranes. Maternal blood pressure is 122/76 mm Hg. Fetal heart rate falls to 70/min with a sinusoidal pattern. Prenatal imaging showed a velamentous cord insertion.",
"Which is the most appropriate next step?",
"Immediate cesarean delivery", "Maternal observation with repeat hemoglobin", "Oxytocin augmentation for vaginal delivery", "Digital examination for cervical dilation", "Administer methotrexate",
"Bleeding after membrane rupture with acute fetal compromise and velamentous insertion indicates ruptured vasa previa and fetal hemorrhage. Immediate cesarean delivery is required.",
"In vasa previa, the fetus—not the mother—can exsanguinate rapidly after membrane rupture.", "bleeding after rupture with fetal bradycardia and velamentous insertion", "stable maternal vital signs", "expectant management risks fetal death",
"SMFM Consult Series #37: Diagnosis and management of vasa previa", "Society for Maternal-Fetal Medicine", "https://publications.smfm.org/publications/215-society-for-maternal-fetal-medicine-consult-series-37/", "Emergency cesarean delivery for bleeding or rupture of membranes with vasa previa."),
new Seed("placenta-accreta-planned-cesarean-hysterectomy", "Pregnancy, Childbirth, and the Puerperium", "Obstetrics", "Management",
"A 39-year-old gravida 5 para 4 at 32 weeks has placenta previa and three prior cesarean deliveries. Ultrasound shows placental lacunae and loss of the retroplacental clear zone, consistent with placenta accreta spectrum. She is stable and desires no future fertility.",
"Which delivery plan is most appropriate?",
"Planned preterm cesarean hysterectomy with the placenta left in situ", "Attempt manual placental removal after vaginal delivery", "Wait for spontaneous labor at 40 weeks", "Perform dilation and curettage after cesarean delivery", "Give methotrexate before delivery",
"Suspected placenta accreta spectrum should be managed at an experienced center with planned cesarean hysterectomy, avoiding placental disruption because attempted removal can trigger catastrophic hemorrhage.",
"For placenta accreta spectrum, planned multidisciplinary cesarean hysterectomy with placenta left in situ minimizes hemorrhage.", "previa plus multiple cesareans and accreta ultrasound signs", "desire for sterilization alone", "manual removal can cause massive bleeding",
"Placenta Accreta Spectrum", "American College of Obstetricians and Gynecologists", "https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2018/12/placenta-accreta-spectrum", "Timing and operative approach for placenta accreta spectrum."),
new Seed("ovarian-torsion-detorsion-preservation", "Female Reproductive System and Breast", "Obstetrics and Gynecology", "Management",
"A 17-year-old girl has sudden severe right lower-quadrant pain with vomiting. Ultrasound shows a 7-cm ovarian cyst and an enlarged ovary with absent venous flow. Laparoscopy shows a twisted, dark blue ovary.",
"Which is the most appropriate management?",
"Laparoscopic detorsion with ovarian preservation", "Oophorectomy because the ovary appears necrotic", "Needle aspiration and discharge", "Observe for return of Doppler flow", "Begin combined oral contraceptives only",
"Adnexal torsion requires prompt laparoscopy. The adnexa should be detorsed and preserved regardless of its dark appearance because gross color poorly predicts viability and ovarian function commonly recovers.",
"A dark torsed ovary should usually be detorsed and preserved, especially in adolescents.", "sudden pain, vomiting, enlarged ovary, and twisted pedicle", "absent Doppler flow alone", "delay reduces ovarian salvage",
"Adnexal Torsion in Adolescents", "American College of Obstetricians and Gynecologists", "https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/08/adnexal-torsion-in-adolescents", "Prompt detorsion and ovarian preservation regardless of appearance."),
new Seed("amniotic-fluid-embolism-resuscitation", "Pregnancy, Childbirth, and the Puerperium", "Obstetrics", "Management",
"A 30-year-old woman suddenly develops hypoxemia, hypotension, and cardiac arrest during labor. After return of spontaneous circulation, she has profuse bleeding from venipuncture sites and severe hypofibrinogenemia. No fever or rash is present.",
"Which management is most appropriate?",
"Supportive cardiopulmonary resuscitation plus early massive transfusion for coagulopathy", "Heparin infusion for presumed pulmonary thromboembolism", "Immediate bronchoscopy to remove an obstruction", "High-dose epinephrine autoinjector only", "Wait for a confirmatory serum test before treatment",
"The abrupt triad of hypoxia, cardiovascular collapse, and disseminated intravascular coagulation during labor is amniotic fluid embolism. It is a clinical diagnosis treated with high-quality resuscitation, hemodynamic support, and prompt correction of coagulopathy.",
"Amniotic fluid embolism has no confirmatory bedside test or specific antidote; immediate supportive resuscitation is lifesaving.", "peripartum collapse followed by DIC", "hypoxemia alone", "anticoagulation can worsen the profound coagulopathy",
"SMFM Clinical Guidelines #9: Amniotic fluid embolism", "Society for Maternal-Fetal Medicine", "https://publications.smfm.org/publications/581-society-for-maternal-fetal-medicine-clinical-guidelines-9/", "Immediate supportive resuscitation and management of coagulopathy."),
new Seed("myxedema-coma-steroids-before-thyroxine", "Endocrine System", "Medicine", "Management",
"A 74-year-old woman is found confused in winter. Temperature is 32.8 C, pulse is 42/min, and blood pressure is 82/50 mm Hg. She has dry skin, delayed reflex relaxation, sodium 124 mEq/L, low free T4, and markedly elevated TSH.",
"Which treatment regimen should be initiated?",
"Intravenous hydrocortisone followed by intravenous levothyroxine", "Oral levothyroxine after discharge", "Intravenous levothyroxine without glucocorticoids", "Methimazole and propranolol", "Rapid active external rewarming alone",
"Myxedema coma requires ICU supportive care and IV thyroid hormone. Empiric IV glucocorticoids should precede levothyroxine because coexisting adrenal insufficiency may be present and thyroid replacement can precipitate adrenal crisis.",
"In myxedema coma, give stress-dose glucocorticoids before IV thyroid hormone.", "hypothermia, bradycardia, hypotension, hyponatremia, and severe hypothyroidism", "elevated TSH alone", "oral therapy is unreliable in critical illness",
"Guidelines for the Treatment of Hypothyroidism", "American Thyroid Association", "https://pmc.ncbi.nlm.nih.gov/articles/PMC4267409/", "IV levothyroxine and empiric glucocorticoids in myxedema coma."),
new Seed("hhs-initial-fluid-resuscitation", "Endocrine System", "Medicine", "Management",
"An 81-year-old man with type 2 diabetes is confused and profoundly dehydrated. Glucose is 980 mg/dL, effective osmolality is 348 mOsm/kg, pH is 7.37, bicarbonate is 22 mEq/L, beta-hydroxybutyrate is 1.2 mmol/L, and potassium is 4.8 mEq/L.",
"Which is the most appropriate initial treatment?",
"Intravenous isotonic crystalloid with close electrolyte and osmolality monitoring", "Immediate bicarbonate infusion", "Subcutaneous long-acting insulin only", "Fluid restriction to prevent cerebral edema", "Immediate hemodialysis",
"This is hyperosmolar hyperglycemic state without substantial ketoacidosis. Initial management prioritizes restoration of intravascular volume with IV isotonic crystalloid, followed by carefully monitored insulin and electrolyte therapy.",
"Volume resuscitation comes first in HHS; osmolality must fall gradually with frequent monitoring.", "severe hyperosmolality and dehydration without acidosis", "hyperglycemia alone", "insulin before adequate volume assessment can worsen circulatory collapse",
"Hyperglycemic Crises in Adults With Diabetes: A Consensus Report", "American Diabetes Association", "https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A", "Initial fluid, insulin, electrolyte, and monitoring strategy for HHS."),
new Seed("serotonin-syndrome-cyproheptadine", "Behavioral Health", "Medicine", "Management",
"A 42-year-old woman taking sertraline is given linezolid for pneumonia. Hours later she becomes agitated and diaphoretic with temperature 39.4 C, diarrhea, inducible ankle clonus, ocular clonus, and hyperreflexia. Sertraline and linezolid are stopped, IV fluids and benzodiazepines are given, but severe symptoms persist.",
"Which additional treatment is most appropriate?",
"Cyproheptadine", "Dantrolene", "Bromocriptine", "Physostigmine", "Haloperidol",
"Rapid onset after serotonergic drug interaction plus clonus and hyperreflexia identifies serotonin syndrome. After stopping causative drugs and giving supportive care and benzodiazepines, cyproheptadine is the serotonin antagonist used for persistent moderate-to-severe toxicity.",
"Clonus and hyperreflexia distinguish serotonin syndrome; cyproheptadine is used when supportive care is insufficient.", "rapid onset with clonus after sertraline-linezolid interaction", "fever and rigidity alone", "dantrolene treats malignant hyperthermia, not serotonergic excess",
"FDA Drug Safety Communication: Serious CNS reactions possible when linezolid is given to patients taking serotonergic psychiatric medications", "U.S. Food and Drug Administration", "https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-serious-cns-reactions-possible-when-linezolid-zyvox-given-patients", "Recognition and urgent management of serotonin toxicity from linezolid interactions."),
new Seed("postpartum-psychosis-emergency-hospitalization", "Behavioral Health", "Psychiatry", "Management",
"A 29-year-old woman 8 days after delivery has slept 2 hours total in 3 days. She says her infant is possessed and reports a command voice telling her to purify the baby in the bathtub. She is pacing, euphoric, and refuses to let relatives hold the infant.",
"Which is the most appropriate next step?",
"Emergency psychiatric hospitalization with protection of mother and infant", "Routine outpatient psychotherapy next week", "Reassurance that postpartum blues is self-limited", "Start an SSRI and leave the infant in her care", "Ask the family to monitor her at home",
"Delusions, mania, severe insomnia, and commands to harm an infant indicate postpartum psychosis, a psychiatric emergency with high suicide and infanticide risk. Immediate hospitalization and separation from unsupervised infant care are required.",
"Postpartum psychosis requires emergency psychiatric care and immediate safety protection for both mother and infant.", "postpartum delusions with command hallucinations and mania", "tearfulness alone", "postpartum blues does not cause psychosis or dangerous commands",
"Screening and Diagnosis of Mental Health Conditions During Pregnancy and Postpartum", "American College of Obstetricians and Gynecologists", "https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2023/06/screening-and-diagnosis-of-mental-health-conditions-during-pregnancy-and-postpartum", "Recognition of acute postpartum psychosis as a perinatal mental health emergency."),
new Seed("noninferiority-trial-ci-interpretation", "Biostatistics and Epidemiology", "Biostatistics", "Study Interpretation",
"A randomized trial compares a shorter antibiotic course with standard therapy. The prespecified noninferiority margin for risk difference (short minus standard) is +5 percentage points, where positive values favor standard therapy. Treatment failure is 10% versus 9%, with a risk difference of +1 percentage point and a 95% confidence interval of -2 to +4.",
"Which conclusion is best supported?",
"The shorter course is noninferior but superiority is not established", "The shorter course is both noninferior and superior", "Noninferiority is not established because the interval crosses zero", "The treatments are proven equivalent", "The standard course is superior because the point estimate is positive",
"The entire confidence interval lies below the prespecified +5% harm margin, establishing noninferiority. Because the interval includes zero, superiority of either treatment is not established; noninferiority does not prove equivalence.",
"Noninferiority depends on excluding the harm margin, whereas superiority depends on excluding the null.", "upper confidence bound +4% is below the +5% margin", "the interval crosses zero", "crossing zero prevents superiority but not noninferiority",
"CONSORT extension for reporting noninferiority and equivalence randomized trials", "CONSORT Group", "https://www.consort-statement.org/extensions/non-inferiority-and-equivalence-trials", "Interpretation of confidence intervals relative to noninferiority margins and the null."),
new Seed("verification-bias-diagnostic-study", "Biostatistics and Epidemiology", "Biostatistics", "Bias",
"Investigators evaluate a new test for pulmonary embolism. All patients with positive index tests receive CT pulmonary angiography, but only 15% of patients with negative index tests receive the reference standard. The unverified negative patients are classified as disease-free.",
"Which bias most directly threatens the reported test accuracy?",
"Verification bias", "Recall bias", "Lead-time bias", "Immortal-time bias", "Ecologic fallacy",
"Verification bias occurs when receipt of the reference standard depends on the index-test result. Missed disease among unverified test-negative patients can distort sensitivity and specificity.",
"A diagnostic study must apply the reference standard independently of the index-test result or account for partial verification.", "reference testing depends on index-test positivity", "retrospective symptom reporting", "classifying unverified negatives as disease-free inflates apparent accuracy",
"STARD 2015: An Updated List of Essential Items for Reporting Diagnostic Accuracy Studies", "EQUATOR Network", "https://www.equator-network.org/reporting-guidelines/stard/", "Avoidance and reporting of partial verification in diagnostic accuracy studies."),
new Seed("cluster-randomized-analysis-unit", "Biostatistics and Epidemiology", "Biostatistics", "Study Design",
"Twenty primary care clinics are randomized to a handoff intervention or usual care. Investigators analyze outcomes from 4,000 patients as if every patient were independently randomized and do not adjust for clinic membership.",
"What is the most likely consequence of this analytic error?",
"Standard errors will usually be underestimated", "The intervention effect will necessarily reverse direction", "Selection bias will be eliminated", "Statistical power will always decrease", "The intracluster correlation will become zero",
"Patients within a clinic share clinicians and processes, so their outcomes are correlated. Ignoring clustering treats observations as more independent than they are, commonly underestimating standard errors and inflating type I error.",
"Cluster-randomized trials require analyses that account for intracluster correlation.", "randomization occurred at the clinic level", "large patient sample size", "ignoring clusters creates falsely narrow confidence intervals",
"CONSORT extension to cluster randomised trials", "CONSORT Group", "https://www.consort-statement.org/extensions/cluster-trials", "Design and analysis requirements for cluster-randomized trials."),
new Seed("sentinel-event-root-cause-analysis", "Social Sciences and Patient Safety", "Patient Safety", "Systems Improvement",
"A patient receives a 10-fold heparin overdose after a pharmacist stocks two look-alike vial concentrations in adjacent automated-dispensing bins and a nurse bypasses barcode scanning during a network outage. The patient has an intracranial hemorrhage.",
"Which response best reduces the risk of recurrence?",
"Conduct a multidisciplinary root cause analysis and implement monitored system-level corrective actions", "Terminate the nurse and close the investigation", "Remind all staff to be more careful", "Wait to see whether the same event happens again", "Keep the event confidential from the safety office",
"A severe preventable harm is a sentinel event. A credible root cause analysis examines interacting system and human factors, leads to strong corrective actions, and monitors whether those actions prevent recurrence.",
"Sentinel-event review should identify system causes and produce measurable, monitored corrective actions rather than stop at individual blame.", "multiple interacting medication-system failures causing death or severe harm", "one nurse bypassed a scanner", "punishment alone leaves look-alike stocking and downtime vulnerabilities intact",
"Sentinel Event Policy and Procedures", "The Joint Commission", "https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/sentinel-event-policy-and-procedures", "Comprehensive systematic analysis and action planning after sentinel events."),
new Seed("medical-error-disclosure", "Social Sciences and Patient Safety", "Ethics", "Communication",
"A physician realizes that she prescribed a drug despite a documented allergy, causing anaphylaxis and an ICU admission. The patient is now stable. The hospital safety team has been notified.",
"What should the physician do next?",
"Promptly disclose the error, known consequences, and next steps to the patient and apologize", "Wait until the patient asks whether an error occurred", "Describe the event only as an unpredictable allergic reaction", "Ask risk management to speak while she avoids the patient", "Alter the note to remove the allergy documentation",
"Patients should be informed promptly and honestly about errors that caused harm, including what is known, the consequences, ongoing care, and prevention efforts. A sincere apology and continued clinical support are appropriate.",
"Disclosure of harmful error is an ethical duty and should be timely, factual, compassionate, and paired with ongoing care.", "known preventable medication error with patient harm", "fear of litigation", "concealment undermines autonomy, trust, and safety learning",
"Code of Medical Ethics Opinion 8.6: Promoting Patient Safety", "American Medical Association", "https://code-medical-ethics.ama-assn.org/ethics-opinions/promoting-patient-safety", "Ethical duty to disclose medical errors and support affected patients.")
};
var questions = definitions.Select(Build).ToList();
var errors = questions
.Select(question => (question.ExternalId, Error: QuestionValidator.Validate(question)))
.Where(result => result.Error is not null)
.ToList();
if (errors.Count > 0)
{
foreach (var error in errors) Console.Error.WriteLine($"{error.ExternalId}: {error.Error}");
return 1;
}
if (questions.Count != 20 || questions.Select(q => q.ExternalId).Distinct().Count() != 20)
{
Console.Error.WriteLine("Expected exactly 20 unique questions.");
return 1;
}
Console.WriteLine($"Validated {questions.Count} difficulty-4 questions.");
if (!apply)
{
Console.WriteLine("Dry run only. Pass --apply to upsert into the configured development database.");
return 0;
}
var configuration = new ConfigurationBuilder().AddInMemoryCollection(new Dictionary<string, string?>
{
["MongoDB:ConnectionString"] = connectionString,
["MongoDB:DatabaseName"] = databaseName
}).Build();
var store = new QuestionStore(new MongoDatabaseProvider(configuration));
var upserted = await store.UpsertManyByExternalIdAsync(questions);
var saved = await store.GetByExternalIdsAsync(questions.Select(q => q.ExternalId));
var invalidSaved = saved.Values.Where(q => q.Difficulty != 4 || !q.IsPublished || q.References.Count == 0).ToList();
if (upserted != 20 || saved.Count != 20 || invalidSaved.Count != 0)
{
Console.Error.WriteLine($"Verification failed: upserted={upserted}, found={saved.Count}, invalid={invalidSaved.Count}.");
return 1;
}
Console.WriteLine($"Upserted and verified 20 questions in database '{databaseName}'.");
return 0;
UpsertQuestionRequest Build(Seed seed)
{
var answers = new[] { seed.Correct, seed.Wrong1, seed.Wrong2, seed.Wrong3, seed.Wrong4 };
var ids = new[] { "A", "B", "C", "D", "E" };
var choices = ids.Zip(answers, (id, text) => new QuestionChoice { Id = id, Text = text }).ToList();
var explanations = ids.ToDictionary(
id => id,
id => id == "A"
? seed.Explanation
: $"This choice does not address the decisive finding: {seed.Discriminator}. {seed.Pitfall2}.");
var wrongFollowups = ids.Skip(1).ToDictionary(
id => id,
id => new WrongAnswerFollowup
{
Prompt = $"In this same vignette, which finding most strongly favors {seed.Correct} over {choices.Single(c => c.Id == id).Text}?",
Choices =
[
new() { Id = "1", Text = seed.Discriminator },
new() { Id = "2", Text = seed.Pitfall1 },
new() { Id = "3", Text = "The patient's age by itself" }
],
CorrectChoiceId = "1",
TeachingPoint = seed.Takeaway
});
return new UpsertQuestionRequest
{
ExternalId = $"gap-d4-20260726-{seed.Slug}",
Stem = seed.Stem,
LeadIn = seed.LeadIn,
Choices = choices,
CorrectChoiceId = "A",
Explanation = seed.Explanation,
KeyTakeaway = seed.Takeaway,
UsmlePearl = seed.Pitfall2,
ReviewFollowups =
[
new()
{
Prompt = $"Which principle is most important for the patient in this vignette?",
Choices =
[
new() { Id = "1", Text = seed.Takeaway },
new() { Id = "2", Text = seed.Pitfall1 },
new() { Id = "3", Text = "Delay intervention until every possible diagnosis is excluded" }
],
CorrectChoiceId = "1",
TeachingPoint = seed.Takeaway
}
],
ChoiceExplanations = explanations,
WrongAnswerFollowups = wrongFollowups,
ChoiceSelectionPercentages = [],
Discipline = seed.Discipline,
System = seed.System,
PerformanceCategory = seed.Category,
Difficulty = 4,
Labs = [],
Media = [],
Tags = [seed.Slug.Replace('-', ' '), "difficulty 4", "gap coverage", seed.Category.ToLowerInvariant()],
References =
[
new()
{
Title = seed.ReferenceTitle,
Publisher = seed.Publisher,
Url = seed.Url,
Supports = seed.Supports,
AccessedOn = accessedOn,
Reviewer = "OpenAI Codex medical content review"
}
],
IsPublished = true
};
}
record Seed(
string Slug, string System, string Discipline, string Category, string Stem, string LeadIn,
string Correct, string Wrong1, string Wrong2, string Wrong3, string Wrong4,
string Explanation, string Takeaway, string Discriminator, string Pitfall1, string Pitfall2,
string ReferenceTitle, string Publisher, string Url, string Supports);