diff --git a/QBANK_DISTRACTOR_ENRICHMENT_RUNBOOK.md b/QBANK_DISTRACTOR_ENRICHMENT_RUNBOOK.md index 91b7d94..5170e9d 100644 --- a/QBANK_DISTRACTOR_ENRICHMENT_RUNBOOK.md +++ b/QBANK_DISTRACTOR_ENRICHMENT_RUNBOOK.md @@ -52,6 +52,8 @@ existing IDs. For each question, verify: for the correct choice; - every follow-up has exactly A-C choices and a valid keyed answer; - new `choiceSelectionPercentages` entries start at zero; +- authoritative sources supporting approved additions are merged into the + question's `references` array without duplicating existing URLs; - no unresolved coverage issue remains unless documented as a waiver. Deserialize the payload as `BulkUpsertQuestionsRequest` and run the actual diff --git a/QBANK_PDF_IMPORT_RUNBOOK.md b/QBANK_PDF_IMPORT_RUNBOOK.md index 9aa1432..9481915 100644 --- a/QBANK_PDF_IMPORT_RUNBOOK.md +++ b/QBANK_PDF_IMPORT_RUNBOOK.md @@ -25,10 +25,10 @@ distinctive fact combinations, answer wording, or images. mismatches. Known gap in that historical run: model-based medical review was completed, but -authoritative references were not added to `QUESTION_REFERENCE_REVIEWS.md` for -the `nbme5-*` records. Future runs must complete the reference-review gate below -before setting `isPublished` to `true`. The historical records should be treated -as awaiting that separate reference review. +authoritative references were not embedded in the `nbme5-*` question documents. +Future runs must complete the reference-review gate below before setting +`isPublished` to `true`. The historical records should be treated as awaiting +that separate reference review. ## Prerequisites @@ -169,6 +169,8 @@ The generation prompt must require: - Celsius and Fahrenheit together for every temperature; - labs only when useful and only when their values also appear in the stem; - `media: []` unless separately reviewed, licensed media will be added later; +- a `references` array that the reference-review gate populates with complete + authoritative source records before publication; - selection percentages for every authored choice initialized to zero; - established Step categories, 3-6 tags, and a unique deterministic ID. @@ -236,8 +238,9 @@ Model agreement is not authoritative medical verification. Before publication: 1. Verify each keyed answer and material explanatory claim against current, direct, authoritative sources such as professional guidelines, government agencies, official labeling, or primary research. -2. Add an entry for every question to `QUESTION_REFERENCE_REVIEWS.md`, including - title, publisher, direct URL, supported claim, access date, and reviewer. +2. Add every verified source to the question document's `references` array, + including title, publisher, direct HTTPS URL, supported claim, ISO access + date, and reviewer. Do not maintain a separate repository reference ledger. 3. Search the entire question bank for exact and near-duplicate learning tasks, not just duplicate text or IDs. 4. Record duplicate-review dispositions and substantially differentiate or @@ -280,6 +283,7 @@ Verification is complete only when all of these pass: - the API reports the expected upsert count; - the database contains every expected external ID exactly once; - every stored `correctChoiceId` matches the final payload; +- every stored `references` array exactly matches the verified payload; - a targeted deployed-API search returns at least one newly inserted question; - the returned question has the expected choices, answer key, and publication state; @@ -304,9 +308,10 @@ API_READ_RESULTS= ## 10. Retain Reviews, Then Clean Up -Retain the reference ledger, duplicate-review record, validation summary, audit -decisions, and final ID/answer-key manifest according to project policy. These -are review records, not disposable generation scratch files. +Retain authoritative references in each question document. Retain the +duplicate-review record, validation summary, audit decisions, and final +ID/answer-key manifest according to project policy. These are review records, +not disposable generation scratch files. After production verification: @@ -332,7 +337,7 @@ generated-artifact cleanup. - [ ] All anchoring and source-overlap warnings reviewed. - [ ] Independent content audit approved every question. - [ ] Every rejected question regenerated and re-audited. -- [ ] Authoritative references recorded for every question. +- [ ] Authoritative references embedded in every question document. - [ ] Full-bank duplicate review completed. - [ ] Image rights cleared for every media-bearing question. - [ ] Final payload contains only intended new or intentionally updated IDs. diff --git a/QUESTION_REFERENCE_REVIEWS.md b/QUESTION_REFERENCE_REVIEWS.md deleted file mode 100644 index 44664aa..0000000 --- a/QUESTION_REFERENCE_REVIEWS.md +++ /dev/null @@ -1,1353 +0,0 @@ -# Question Reference Reviews - -This ledger records verification references for questions when the Questions API -schema cannot store question-level source metadata. See the verification policy -in `README.md`. - -## step3-biostatistics-diagnostic-threshold-sensitivity-specificity-3976 - -- Source: [Appendix: Test Performance Metrics](https://www.ncbi.nlm.nih.gov/sites/books/NBK98249/pdf/Bookshelf_NBK98249.pdf) -- Publisher: National Center for Biotechnology Information -- Supports: Raising the positive cutoff of a continuous test decreases - sensitivity and increases specificity. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-cardiovascular-new-hypertension-3101 - -- Source: [Hypertension in Adults: Screening](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hypertension-in-adults-screening) -- Publisher: U.S. Preventive Services Task Force -- Supports: Adults should be screened with office blood pressure measurement, - but a positive screen should be confirmed with validated ambulatory or home - blood pressure monitoring before treatment is started. -- Source: [Home Blood Pressure Monitoring](https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home) -- Publisher: American Heart Association -- Supports: Home monitoring can confirm a hypertension diagnosis; repeated - measurements over time are more informative than one elevated reading. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-infectious-bacterial-meningitis-3001 - -- Source: [WHO guidelines on meningitis diagnosis, treatment and care](https://www.who.int/publications/i/item/9789240108042) -- Publisher: World Health Organization -- Supports: Acute community-acquired bacterial meningitis requires prompt - intravenous antibiotic treatment. Ceftriaxone or cefotaxime is first-line, - with vancomycin added where resistant pneumococci are a concern; adjunctive - dexamethasone should be given with the first antibiotic dose in non-epidemic - settings. -- Source: [CDC Public Health Image Library: Streptococcus pneumoniae](https://wwwn.cdc.gov/phil/Details.aspx?pid=21340) -- Publisher: Centers for Disease Control and Prevention -- Supports: Streptococcus pneumoniae appears as gram-positive, lancet-shaped - diplococci on Gram stain. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pulmonary-endobronchial-obstruction-5714 - -- Source: [Pediatric Bronchoscopy Guidelines](https://archbronconeumol.org/en-pediatric-bronchoscopy-guidelines-articulo-S1579212911000231) -- Publisher: Archivos de Bronconeumologia -- Supports: Persistent or recurrent localized pulmonary opacities can reflect an - unrecognized endobronchial foreign body and warrant airway evaluation. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-obgyn-antiphospholipid-syndrome-5862 - -- Source: [The 2023 ACR/EULAR Antiphospholipid Syndrome Classification Criteria](https://acrjournals.onlinelibrary.wiley.com/doi/10.1002/art.42624) -- Publisher: American College of Rheumatology and EULAR -- Supports: Venous thrombosis and obstetric morbidity are clinical APS domains; - anticardiolipin antibodies are among the qualifying laboratory antibodies. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-cardiology-vasospastic-angina-3827 - -- Source: [2023 AHA/ACC Guideline for the Management of Patients With Chronic Coronary Disease](https://www.ahajournals.org/doi/10.1161/CIR.0000000000001168) -- Publisher: American Heart Association and American College of Cardiology -- Supports: Nitrate-responsive rest angina, especially between night and early - morning, supports suspected vasospastic angina; definitive diagnosis also - requires transient ischemic ECG changes or documented coronary spasm. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-biostatistics-odds-ratio-confidence-interval-417 - -- Source: [Analyzing and Interpreting Data](https://www.cdc.gov/field-epi-manual/php/chapters/analyze-interpret-data.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Case-control studies use odds ratios, and the null hypothesis is not - rejected when a 95% confidence interval includes the null association value - of 1. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pediatrics-congenital-cmv-638 - -- Source: [Clinical Overview of CMV and Congenital CMV](https://www.cdc.gov/cytomegalovirus/hcp/clinical-overview/index.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Congenital CMV is confirmed by PCR testing of saliva, urine, or blood - within the first 2-3 weeks of life; urine testing confirms a positive saliva - screen and distinguishes congenital from postnatal infection. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-epidemiology-dose-response-causality-431 - -- Source: [Analyzing and Interpreting Data](https://www.cdc.gov/field-epi-manual/php/chapters/analyze-interpret-data.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Increasing outcome risk with increasing exposure is a dose-response - relationship, and evidence of this gradient adds weight to causal inference. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-neurology-papilledema-neuroimaging-438 - -- Source: [ACR Appropriateness Criteria: Headache](https://acsearch.acr.org/list/TopicNarrativePdf?topicId=140) -- Publisher: American College of Radiology -- Supports: Papilledema is a red flag for intracranial hypertension, and - noncontrast head CT can promptly evaluate secondary causes such as mass, - edema, or hydrocephalus before lumbar puncture. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pediatrics-abusive-head-trauma-ct-447 - -- Source: [Abusive Head Trauma in Infants and Children: Technical Report](https://publications.aap.org/pediatrics/article/155/3/e2024070457/201049/Abusive-Head-Trauma-in-Infants-and-Children) -- Publisher: American Academy of Pediatrics -- Supports: Head CT is the acute imaging modality of choice for cranial and - intracranial injury in children with neurologic symptoms and concern for - abuse; children age 2 years or younger also require a skeletal survey. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-ethics-decision-making-capacity-521 - -- Source: [Decisions for Adult Patients Who Lack Capacity](https://code-medical-ethics.ama-assn.org/ethics-opinions/decisions-adult-patients-who-lack-capacity) -- Publisher: American Medical Association -- Supports: When an adult lacks decision-making capacity, physicians should - identify and work with the surrogate designated through a durable power of - attorney for health care; ethics consultation is reserved for absent, - disputed, or inappropriate surrogate decision-making. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-biostatistics-screening-snout-412 - -- Source: [Diagnostic Testing Accuracy: Sensitivity, Specificity, Predictive Values and Likelihood Ratios](https://www.ncbi.nlm.nih.gov/sites/books/NBK557491/) -- Publisher: National Center for Biotechnology Information -- Supports: Sensitivity is the true-positive proportion, high sensitivity - minimizes false negatives, and negative likelihood ratios provide a fuller - measure of how strongly a negative result lowers disease probability. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-biostatistics-test-characteristics-486 - -- Source: [Performance Measures: Assessment of Cancer Screening](https://www.ncbi.nlm.nih.gov/books/NBK550207/) -- Publisher: National Center for Biotechnology Information -- Supports: Sensitivity, specificity, PPV, and NPV derive from the diagnostic - 2x2 table, and PPV can remain low for a rare disease despite high sensitivity - and specificity. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-preventive-care-smoking-cessation-593 - -- Source: [Tobacco Smoking Cessation in Adults: Interventions](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions) -- Publisher: U.S. Preventive Services Task Force -- Supports: Clinicians should ask adults about tobacco use, advise cessation, - and provide behavioral interventions and FDA-approved pharmacotherapy to - nonpregnant adults who smoke. -- Source: [Colorectal Cancer Screening](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening) -- Publisher: U.S. Preventive Services Task Force -- Supports: Average-risk colorectal cancer screening begins at age 45. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pediatrics-kawasaki-coronary-aneurysm-701 - -- Source: [Update on Diagnosis and Management of Kawasaki Disease](https://professional.heart.org/en/science-news/update-on-diagnosis-and-management-of-kawasaki-disease/top-things-to-know) -- Publisher: American Heart Association -- Supports: Kawasaki disease can cause coronary artery dilation and aneurysms; - coronary Z-score assessment and ongoing cardiac imaging guide risk assessment - and follow-up. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-heartfailure-aldosterone-antagonist-884 - -- Source: [2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure](https://www.ahajournals.org/doi/10.1161/CIR.0000000000001063) -- Publisher: American Heart Association, American College of Cardiology, and - Heart Failure Society of America -- Supports: An MRA is recommended to reduce morbidity and mortality in - symptomatic HFrEF when eGFR is greater than 30 mL/min/1.73 m2 and potassium - is below 5.0 mEq/L. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-gastroenterology-peptic-ulcer-prognosis-905 - -- Source: [ACG Guideline on Treatment of Helicobacter pylori](https://gi.org/journals-publications/ebgi/schoenfeld_sep2024/) -- Publisher: American College of Gastroenterology -- Supports: H. pylori infection should be treated and eradication confirmed at - least 4 weeks after antibiotic therapy, with PPIs held before testing. -- Source: [The Role of Endoscopy in Peptic Ulcer Disease](https://www.asge.org/docs/default-source/education/practice_guidelines/doc-the-role-of-endoscopy-in-the-management-of-patientswith-peptic-ulcer-disease.pdf) -- Publisher: American Society for Gastrointestinal Endoscopy -- Supports: Surveillance endoscopy for a gastric ulcer is individualized based - on clinical and endoscopic circumstances rather than universally required. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-infectious-disease-antibiotic-stewardship-viral-uri-962 - -- Source: [Outpatient Clinical Care for Adults: Antibiotic Prescribing](https://www.cdc.gov/antibiotic-use/hcp/clinical-care/adult-outpatient.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Antibiotics are not recommended for nonspecific viral upper - respiratory infections, and outpatient evaluation should distinguish - syndromes requiring antibacterial treatment from self-limited viral illness. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-musculoskeletal-occult-hip-fracture-mri-1007 - -- Source: [ACR Appropriateness Criteria: Acute Hip Pain](https://acsearch.acr.org/docs/3082587/narrative) -- Publisher: American College of Radiology -- Supports: When traumatic hip fracture is suspected despite negative or - indeterminate radiographs, MRI without contrast and CT without contrast are - appropriate next imaging studies. -- Source: [NICE Hip Fracture Management](https://www.nice.org.uk/guidance/cg124/chapter/recommendations) -- Publisher: National Institute for Health and Care Excellence -- Supports: Offer MRI for suspected occult hip fracture after negative x-rays; - consider CT when MRI is unavailable within 24 hours or contraindicated. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pediatrics-jia-sports-participation-1134 - -- Source: [Exercise and Arthritis](https://rheumatology.org/exercise-and-arthritis) -- Publisher: American College of Rheumatology -- Supports: Exercise is recommended for juvenile idiopathic arthritis and can - be individualized with physical or occupational therapy when modification is - needed. -- Source: [2021 ACR JIA Guideline: Nonpharmacologic Therapies](https://pmc.ncbi.nlm.nih.gov/articles/PMC10231687/) -- Publisher: American College of Rheumatology -- Supports: Physical and occupational therapy are conditionally recommended in - JIA but are supportive interventions rather than universal prerequisites for - activity. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-psychiatry-acute-mania-antipsychotic-1208 - -- Source: [VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder](https://www.healthquality.va.gov/guidelines/MH/bd/VA-DoD-CPG-BD-Full-CPGFinal508.pdf) -- Publisher: U.S. Department of Veterans Affairs and Department of Defense -- Supports: Quetiapine is an evidence-based monotherapy option for acute mania. -- Source: [NICE Bipolar Disorder Recommendations](https://www.nice.org.uk/guidance/cg185/chapter/recommendations) -- Publisher: National Institute for Health and Care Excellence -- Supports: An antipsychotic such as quetiapine should be offered for mania when - the patient is not already taking an antipsychotic or mood stabilizer. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-dermatology-acne-comedonal-initial-1209 - -- Source: [Acne Clinical Guideline](https://www.aad.org/member/clinical-quality/guidelines/acne) -- Publisher: American Academy of Dermatology -- Supports: Current acne guidelines recommend topical retinoids as an effective - topical therapy and recommend limiting systemic antibiotic use. -- Source: [Acne: Diagnosis and Treatment](https://www.aad.org/public/diseases/acne/derm-treat/treat) -- Publisher: American Academy of Dermatology -- Supports: Topical retinoids, including adapalene, clear pores and treat - blackheads and whiteheads, supporting their use for isolated comedonal acne. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-infectious-bat-rabies-pep-1847 - -- Source: [Preventing Rabies from Bats](https://www.cdc.gov/rabies/prevention/bats.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Bat bites can be difficult to detect; public health or animal - control should coordinate safe capture and rabies testing of a bat found in - a home. -- Source: [Human Rabies Prevention: ACIP Recommendations](https://www.cdc.gov/mmwr/preview/mmwrhtml/rr57e507a1.htm) -- Publisher: Centers for Disease Control and Prevention -- Supports: A bat found with an unattended child can constitute a potential - exposure, but prophylaxis is unnecessary when the captured bat tests - negative. The 10-day observation rule applies to dogs, cats, and ferrets. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-geriatrics-unintentional-weight-loss-social-isolation-2314 - -- Source: [Choosing Wisely](https://www.healthinaging.org/choosing-wisely) -- Publisher: American Geriatrics Society, Health in Aging Foundation -- Supports: For anorexia or cachexia in older adults, clinicians should optimize - social supports, provide appealing food and feeding assistance, and address - contributing medications rather than routinely prescribing appetite - stimulants or supplements. -- Source: [Unintentional Weight Loss in Older Adults](https://www.aafp.org/afp/2021/0700/p34) -- Publisher: American Academy of Family Physicians -- Supports: Clinically significant weight loss requires an initial evaluation; - social isolation can reduce intake, and treatment should address social - support and the eating environment. Mirtazapine lacks evidence when used - solely for weight loss and can cause adverse effects in older adults. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-cardiovascular-atrial-fibrillation-stroke-prevention-5172 - -- Source: [2023 ACC/AHA/ACCP/HRS Guideline for Atrial Fibrillation](https://www.heart.org/-/media/Files/Professional/Quality-Improvement/Get-With-the-Guidelines/Get-With-The-Guidelines-AFIB/AFib-Month/joglaretal20232023accahaaccphrsguidelineforthediagnosisandmanagementofatrialfibrillation.pdf) -- Publisher: American College of Cardiology, American Heart Association, - American College of Chest Physicians, and Heart Rhythm Society -- Supports: Anticoagulation is recommended for men with atrial fibrillation and - CHA2DS2-VASc score of at least 2; direct oral anticoagulants are preferred in - the absence of moderate-to-severe rheumatic mitral stenosis or a mechanical - valve, and aspirin is not an acceptable substitute for anticoagulation. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-obgyn-abortion-complications-counseling-6815 - -- Source: [Abortion Care](https://www.acog.org/womens-health/faqs/induced-abortion) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: First-trimester abortion is safe and effective; vaginal bleeding - and cramping are expected, major complications are rare, and abortion does - not increase infertility risk. -- Source: [Abortion Care](https://www.rcog.org.uk/for-the-public/browse-our-patient-information/abortion-care/) -- Publisher: Royal College of Obstetricians and Gynaecologists -- Supports: Bleeding and abdominal cramping occur with both medical and - procedural abortion, and patients should receive anticipatory guidance about - expected bleeding and warning symptoms. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pediatrics-sports-clearance-innocent-murmur-1427 - -- Source: [Heart Murmurs in Children: Evaluation and Management](https://www.aafp.org/afp/2022/0300/p250) -- Publisher: American Academy of Family Physicians -- Supports: In a child older than 2 years, disappearance of a murmur with - standing strongly supports an innocent murmur; sports clearance is - appropriate when history and examination are otherwise benign. -- Source: [The Preparticipation Sports Evaluation](https://www.aafp.org/afp/2015/0901/p371) -- Publisher: American Academy of Family Physicians -- Supports: Athletes with well-controlled asthma can participate safely and - should have a rescue inhaler available; routine pulmonary function testing is - not required solely for clearance in an asymptomatic athlete with established - controlled asthma. -- Source: [Heart Murmurs](https://www.heart.org/en/health-topics/heart-murmurs) -- Publisher: American Heart Association -- Supports: Children with innocent murmurs do not require activity limitation. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-immunization-mmr-transient-arthralgia-615 - -- Source: [MMR Vaccine Safety](https://www.cdc.gov/vaccine-safety/vaccines/mmr.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Joint pain or stiffness occurs in up to one-quarter of susceptible - postpubertal females, generally begins 1 to 3 weeks after MMR vaccination, - is usually mild, lasts about 2 days, and rarely recurs. -- Source: [Pink Book, Chapter 20: Rubella](https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-20-rubella.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Arthralgia after MMR vaccination is associated with the rubella - component and occurs much more often in adult women than in children or men. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-integumentary-contaminated-laceration-delayed-closure-2841 - -- Source: [Clinical Guidance for Wound Management to Prevent Tetanus](https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: A soil-contaminated wound is a dirty wound; a patient with unknown - tetanus vaccination history should receive a tetanus-containing vaccine and - tetanus immune globulin in addition to wound cleaning and debridement. -- Source: [Skin Lacerations](https://www.msdmanuals.com/professional/injuries-poisoning/lacerations-and-abrasions/skin-lacerations) -- Publisher: MSD Manual Professional Edition -- Supports: Delayed primary closure is appropriate for significantly - contaminated wounds, particularly those containing organic debris; initial - care includes thorough exploration, debridement, and loose moist-gauze - packing followed by reassessment for closure. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-tetanus-prophylaxis-001 - -- Source: [Clinical Guidance for Wound Management to Prevent Tetanus](https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Puncture wounds and wounds containing soil are dirty or major - wounds. Patients with unknown vaccination history require a tetanus - toxoid-containing vaccine, and those with dirty or major wounds also require - tetanus immune globulin for immediate passive protection. -- Source: [Pink Book, Chapter 21: Tetanus](https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-21-tetanus.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Patients with non-clean wounds and unknown or fewer than three - prior tetanus vaccine doses should receive both vaccine and tetanus immune - globulin; Tdap is preferred when prior Tdap history is unknown. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-derm-alopecia-areata-001 - -- Source: [Alopecia Areata: Diagnosis and Treatment](https://www.aad.org/public/diseases/hair-loss/types/alopecia/treatment) -- Publisher: American Academy of Dermatology -- Supports: Intralesional corticosteroid injections are considered the most - effective treatment for adults with a few patches of alopecia areata; hair - regrowth is often seen within approximately 3 months when treatment works. -- Source: [Alopecia Areata: Signs and Symptoms](https://www.aad.org/public/diseases/hair-loss/types/alopecia/symptoms) -- Publisher: American Academy of Dermatology -- Supports: Alopecia areata commonly presents with sudden round or oval smooth - patches of nonscarring hair loss without scalp irritation. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-cardiology-pci-restenosis-001 - -- Source: [SCAI Expert Consensus Statement on Management of In-Stent Restenosis and Stent Thrombosis](https://www.scai.org/publications/clinical-documents/scai-expert-consensus-statement-management-stent-restenosis-and) -- Publisher: Society for Cardiovascular Angiography and Interventions -- Supports: In-stent restenosis and stent thrombosis are distinct post-PCI - complications with different mechanisms and management considerations. -- Source: [Antiplatelet Strategies in Percutaneous Coronary Interventions](https://www.acc.org/-/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Membership/Coronary-Interventions-Handbook/Chapter-4_Antiplatelet-Strategies.pdf) -- Publisher: American College of Cardiology -- Supports: Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is a - cornerstone of peri-procedural and post-stent therapy to reduce stent - thrombosis. -- Source: [2021 ACC/AHA/SCAI Revascularization Guideline: Key Perspectives](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2021/12/08/21/19/2021-guideline-for-revascularization-gl-revasc) -- Publisher: American College of Cardiology -- Supports: Antiplatelet therapy after PCI is selected and continued according - to ischemic and bleeding risk; drug-eluting stents are standard contemporary - PCI devices. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-gi-barrett-gerd-001 - -- Source: [Barrett's Esophagus](https://gi.org/topics/barretts-esophagus/) -- Publisher: American College of Gastroenterology -- Supports: Most patients with Barrett esophagus receive proton pump inhibitor - therapy; antireflux surgery is used for GERD indications rather than as a - cancer-prevention treatment, and nondysplastic Barrett esophagus is managed - with surveillance rather than eradication therapy. -- Source: [Acid Reflux/GERD](https://gi.org/topics/acid-reflux/) -- Publisher: American College of Gastroenterology -- Supports: Proton pump inhibitors and lifestyle measures are effective GERD - therapy; objective reflux testing is particularly useful when symptoms are - not controlled or antireflux surgery is being considered. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-gi-cdiff-complication-001 - -- Source: [C. diff: Facts for Clinicians](https://www.cdc.gov/c-diff/hcp/clinical-overview/) -- Publisher: Centers for Disease Control and Prevention -- Supports: Recognized severe complications of C. difficile infection include - toxic megacolon, colonic perforation, sepsis, and death. -- Source: [SHEA/IDSA Clinical Practice Guideline for C. difficile Infection](https://www.idsociety.org/practice-guideline/clostridium-difficile/) -- Publisher: Infectious Diseases Society of America and Society for Healthcare - Epidemiology of America -- Supports: Fulminant C. difficile infection may be characterized by - hypotension or shock, ileus, or megacolon; megacolon and perforation may - require urgent surgical management. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-rheumatology-cppd-acute-treatment-734 - -- Source: [Calcium Pyrophosphate Deposition](https://rheumatology.org/patients/calcium-pyrophosphate-deposition-cppd) -- Publisher: American College of Rheumatology -- Supports: Acute CPP crystal arthritis may be treated with joint aspiration - and glucocorticoid injection or systemic anti-inflammatory therapy including - NSAIDs, oral glucocorticoids, or colchicine. -- Source: [Calcium Pyrophosphate Deposition Disease](https://www.msdmanuals.com/professional/musculoskeletal-and-connective-tissue-disorders/crystal-induced-arthritides/calcium-pyrophosphate-deposition-disease) -- Publisher: MSD Manual Professional Edition -- Supports: Colchicine is an accepted treatment for acute CPP arthritis flares; - NSAIDs and glucocorticoids are alternatives selected according to the number - of affected joints and patient-specific contraindications. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-infectious-tuberculosis-screening-conversion-237 - -- Source: [Clinical Testing Guidance for Tuberculosis: Tuberculin Skin Test](https://www.cdc.gov/tb/hcp/testing-diagnosis/tuberculin-skin-test.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: A positive tuberculin skin test requires evaluation for TB disease; - the result must be interpreted according to exposure and progression risk. -- Source: [ATS/CDC/IDSA Diagnosis of Tuberculosis Guideline](https://www.idsociety.org/practice-guideline/diagnosis-of-tb-in-adults-and-children/) -- Publisher: American Thoracic Society, Centers for Disease Control and - Prevention, and Infectious Diseases Society of America -- Supports: Active TB is excluded by symptom assessment and chest radiography; - respiratory sampling follows when symptoms or radiographic abnormalities - suggest pulmonary disease. Confirmatory testing is mainly advised for an - unexpected positive result in a person unlikely to be infected. -- Source: [CDC Contact Investigation Recommendations](https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a1.htm) -- Publisher: Centers for Disease Control and Prevention and National - Tuberculosis Controllers Association -- Supports: TST conversion is conventionally defined by an increase of at least - 10 mm within 2 years. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-gastro-sbp-saag-241 - -- Source: [Recognition and Management of Spontaneous Bacterial Peritonitis](https://www.hepatitisc.uw.edu/go/management-cirrhosis-related-complications/spontaneous-bacterial-peritonitis-recognition-management/core-concept/all/) -- Publisher: University of Washington Hepatitis C Online -- Supports: Ascitic fluid PMN count of at least 250 cells/mm3 warrants prompt - empiric antibiotics; community-acquired SBP is treated with intravenous - cefotaxime or a similar third-generation cephalosporin, whereas nosocomial - infection may require broader therapy. -- Source: [AASLD: Why Timing Matters, Paracentesis on Admission](https://www.aasld.org/liver-fellow-network/core-series/why-series/why-timing-matters-paracentesis-admission-cirrhosis) -- Publisher: American Association for the Study of Liver Diseases -- Supports: In a patient with cirrhosis and ascites, an ascitic PMN count of at - least 250 cells/uL carries a high likelihood of SBP and should prompt - antibiotic treatment without waiting for culture results. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-cardiovascular-thiazide-followup-251 - -- Source: [2025 High Blood Pressure Guideline: Top Things to Know](https://professional.heart.org/en/science-news/2025-high-blood-pressure-guideline/top-things-to-know) -- Publisher: American Heart Association and American College of Cardiology -- Supports: Stage 2 hypertension is preferably treated with two first-line - agents; home blood pressure monitoring and frequent follow-up are important - while therapy is being adjusted, and a potassium-rich DASH-style diet is - recommended when clinically appropriate. -- Source: [Chlorthalidone Prescribing Information](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=36ef8d83-45f2-4873-b7cb-1be096d14d18) -- Publisher: U.S. National Library of Medicine DailyMed -- Supports: Chlorthalidone can cause dose-related potassium reduction; - electrolytes should be checked periodically, dose titration should follow a - suitable therapeutic trial, and elderly patients should generally begin at - the low end of the dose range. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-psych-acute-psychosis-261 - -- Source: [Adult Psychiatric Emergencies](https://www.acep.org/siteassets/new-pdfs/policy-statements/adult-psychiatric-emergencies.pdf) -- Publisher: American College of Emergency Physicians -- Supports: Psychosis and homicidal or violent behavior are psychiatric - emergencies requiring risk stratification, acute treatment, and a safe - disposition rather than routine outpatient follow-up. -- Source: [Crisis Services: Meeting Needs, Saving Lives](https://988crisissystemshelp.samhsa.gov/sites/default/files/2024-01/crisis-services-meeting-needs-saving-lives-compendium.pdf) -- Publisher: Substance Abuse and Mental Health Services Administration -- Supports: Acute psychiatric symptoms may require inpatient stabilization; - risk of injury to others is a common civil-commitment criterion, although - specific involuntary-hold procedures vary by jurisdiction. -- Source: [What Is Schizophrenia?](https://www.samhsa.gov/mental-health/what-is-mental-health/conditions/schizophrenia) -- Publisher: Substance Abuse and Mental Health Services Administration -- Supports: Hospitalization may be needed during a severe schizophrenia - episode to ensure safety and stabilization. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pulmonary-copd-niv-271 - -- Source: [GOLD 2026 Report](https://goldcopd.org/wp-content/uploads/2026/01/GOLD-REPORT-2026-v1.3-8Dec2025_WMV2.pdf) -- Publisher: Global Initiative for Chronic Obstructive Lung Disease -- Supports: NIV is the initial ventilatory mode for hospitalized COPD - exacerbations with acute respiratory failure and is indicated with - respiratory acidosis, including PaCO2 at least 45 mm Hg and pH at or below - 7.35; it reduces intubation, complications, and mortality. -- Source: [ERS/ATS Guideline on NIV for Acute Respiratory Failure](https://publications.ersnet.org/content/erj/50/2/1602426.full) -- Publisher: European Respiratory Society and American Thoracic Society -- Supports: Bilevel NIV is strongly recommended for acute or acute-on-chronic - respiratory acidosis due to COPD exacerbation, particularly at pH 7.25 to - 7.35 when the patient is not immediately deteriorating and can be closely - monitored with rapid access to intubation. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-supportive-care-acupuncture-cinv-2801 - -- Source: [Acupuncture PDQ, Health Professional Version](https://www.cancer.gov/about-cancer/treatment/cam/hp/acupuncture-pdq) -- Publisher: National Cancer Institute -- Supports: Among cancer-related symptoms studied, acupuncture has its most - convincing evidence for chemotherapy-induced nausea and vomiting; it may be - used as an adjunct to standard antiemetic therapy, although study quality and - effects on specific nausea and vomiting outcomes vary. -- Source: [Nausea and Vomiting Related to Cancer Treatment PDQ](https://www.cancer.gov/about-cancer/treatment/side-effects/nausea/nausea-hp-pdq) -- Publisher: National Cancer Institute -- Supports: Persistent CINV can cause dehydration and nutritional depletion; - management requires optimized pharmacologic antiemetics, dietary support, - and selected nonpharmacologic adjuncts such as acupuncture or acupressure. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pulmonary-silicosis-progressive-fibrosis-2901 - -- Source: [Engineered Stone and Silicosis](https://www.cdc.gov/niosh/bulletin/2026/engineered-stone-cos.html) -- Publisher: National Institute for Occupational Safety and Health -- Supports: Engineered stone typically contains very high crystalline silica - content, and respirable exposure during fabrication can cause irreversible - occupational silicosis. -- Source: [Outbreak of Silicosis Among Engineered Stone Countertop Workers](https://www.cdc.gov/niosh/bulletin/2019/silicosis-countertop.html) -- Publisher: National Institute for Occupational Safety and Health -- Supports: Silicosis is progressive, debilitating, incurable, and sometimes - fatal; high-level engineered-stone exposure can produce severe disease. -- Source: [Severe Silicosis in Engineered Stone Fabrication Workers](https://www.cdc.gov/mmwr/volumes/68/wr/mm6838a1.htm) -- Publisher: Centers for Disease Control and Prevention -- Supports: Progressive massive fibrosis is the most advanced form of - silicosis and can cause continued lung-function decline requiring lung - transplantation evaluation; silicosis also increases tuberculosis risk. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-neurology-tia-secondary-prevention-3201 - -- Source: [2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke](https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke/top-things-to-know) -- Publisher: American Heart Association/American Stroke Association -- Supports: Eligible patients with disabling acute ischemic stroke deficits - should receive rapid intravenous thrombolysis within 4.5 hours regardless of - NIHSS score, whereas dual antiplatelet therapy is preferred for selected - nondisabling events. -- Source: [2021 Guideline for Prevention of Stroke in Patients With Stroke and TIA](https://professional.heart.org/en/science-news/2021-guideline-for-the-prevention-of-stroke-in-patients-with-stroke-and-transient-ischemic-attack/top-things-to-know) -- Publisher: American Heart Association/American Stroke Association -- Supports: Short-term dual antiplatelet therapy is recommended only for - selected patients, including early-arriving minor ischemic stroke and - high-risk transient ischemic attack; occult atrial-fibrillation monitoring - is also appropriate when no other cause is identified. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-neuro-acute-dystonia-337 - -- Source: [Reglan injection prescribing information](https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/017862s64lbl.pdf) -- Publisher: U.S. Food and Drug Administration -- Supports: Metoclopramide can cause acute dystonic reactions within the first - 24-48 hours, including torticollis, trismus, and oculogyric crisis; - diphenhydramine or benztropine can treat the reaction, and metoclopramide - should be discontinued when extrapyramidal symptoms develop. -- Source: [Treatment of acute adverse effects of antipsychotics](https://www.merckmanuals.com/professional/psychiatric-disorders/schizophrenia-and-related-disorders/antipsychotic-medications) -- Publisher: Merck Manual Professional Edition -- Supports: Acute dystonic reactions such as oculogyric crisis and torticollis - are treated with intravenous or intramuscular diphenhydramine or benztropine. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-endocrine-diabetic-nephropathy-401 - -- Source: [Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes - 2026](https://diabetesjournals.org/care/article/49/Supplement_1/S246/163914/11-Chronic-Kidney-Disease-and-Risk-Management) -- Publisher: American Diabetes Association -- Supports: In nonpregnant people with diabetes and hypertension, an ACE - inhibitor or ARB is recommended when UACR is 30-299 mg/g and is strongly - recommended with UACR at least 300 mg/g and/or eGFR below 60. Evidence does - not establish kidney-outcome benefit for moderately increased albuminuria - without hypertension, and abnormal UACR should be confirmed because of - biological variability. -- Source: [ADA-KDIGO consensus report on diabetes management in CKD](https://diabetesjournals.org/care/article/45/12/3075/147614/Diabetes-Management-in-Chronic-Kidney-Disease-A) -- Publisher: American Diabetes Association and Kidney Disease: Improving Global Outcomes -- Supports: ACE inhibitor or ARB therapy is recommended and titrated to the - highest tolerated dose in patients with diabetes, hypertension, and - albuminuria. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-genitourinary-chronic-bacterial-prostatitis-302 - -- Source: [EAU Guidelines on Urological Infections: Bacterial Prostatitis](https://uroweb.org/guidelines/urological-infections/chapter/the-guideline?s=04) -- Publisher: European Association of Urology -- Supports: Chronic bacterial prostatitis should receive culture-guided - antimicrobial treatment; fluoroquinolones are recommended first-line for - susceptible typical gram-negative pathogens and are generally given for - 4-6 weeks because of their prostatic penetration. -- Source: [Fluoroquinolone safety reminder](https://www.gov.uk/drug-safety-update/fluoroquinolone-antibiotics-reminder-of-the-risk-of-disabling-and-potentially-long-lasting-or-irreversible-side-effects) -- Publisher: UK Medicines and Healthcare products Regulatory Agency -- Supports: Fluoroquinolones can cause disabling, prolonged, or irreversible - adverse effects and require patient counseling and prompt discontinuation if - serious tendon, muscle, joint, peripheral nerve, or central nervous system - symptoms develop. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-em-criticalcare-hypothermia-403 - -- Source: [AHA Special Circumstances of Resuscitation](https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-and-pediatric-special-circumstances-of-resuscitation) -- Publisher: American Heart Association -- Supports: Full resuscitation and rewarming should continue in life-threatening - environmental hypothermia without an obviously lethal injury. Prognosis for - extracorporeal rewarming should use the validated HOPE score, which includes - age, sex, asphyxia, CPR duration, serum potassium, and core temperature; - isolated clinical or laboratory findings should not determine futility. -- Source: [2025 Special Circumstances Guidelines](https://www.resus.org.uk/professional-library/2025-resuscitation-guidelines/special-circumstances-guidelines) -- Publisher: Resuscitation Council UK -- Supports: In-hospital prognostication for successful rewarming after - hypothermic cardiac arrest should be based on the HOPE score. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-obgyn-hellp-urgent-delivery-404 - -- Source: [Preeclampsia and High Blood Pressure During Pregnancy](https://www.acog.org/womens-health/faqs/preeclampsia-and-high-blood-pressure-during-pregnancy) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: HELLP syndrome is a medical emergency. Preeclampsia with severe - features at or beyond 34 weeks should be managed in the hospital with - maternal stabilization, seizure prophylaxis and blood-pressure treatment as - indicated, followed by delivery once stable. -- Source: [ACOG overview: 7 Things to Know About Preeclampsia](https://www.acog.org/womens-health/experts-and-stories/the-latest/7-things-to-know-about-preeclampsia) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: HELLP requires immediate delivery; severe preeclampsia at or after - 34 weeks generally warrants delivery, with antihypertensive medication and - magnesium sulfate used during stabilization. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-endocrine-primary-aldosteronism-medical-therapy-506 - -- Source: [Primary Aldosteronism: Endocrine Society Clinical Practice Guideline](https://www.endocrine.org/clinical-practice-guidelines/primary-aldosteronism-2) -- Publisher: Endocrine Society -- Supports: Primary aldosteronism should receive aldosterone-specific therapy. - Lifelong mineralocorticoid receptor antagonist treatment is appropriate for - bilateral disease, unknown lateralization, patients who decline surgery, or - those who are not surgical candidates; spironolactone is suggested because - of cost and availability, with potassium, renal function, renin, and blood - pressure monitored during titration. -- Source: [Primary Aldosteronism guideline full text](https://academic.oup.com/jcem/article/110/9/2453/8196671) -- Publisher: Journal of Clinical Endocrinology & Metabolism -- Supports: CT imaging cannot reliably determine functional lateralization. - Patients who desire and are candidates for adrenalectomy generally require - CT plus adrenal venous sampling before choosing surgical therapy. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-infectious-mrsa-pneumonia-linezolid-707 - -- Source: [ATS/IDSA Community-Acquired Pneumonia Guideline Executive Summary](https://www.idsociety.org/globalassets/idsa/practice-guidelines/community-acquired-pneumonia-in-adults/executive_summary.pdf) -- Publisher: American Thoracic Society and Infectious Diseases Society of America -- Supports: Recommended MRSA-active treatment options for hospitalized adults - with community-acquired pneumonia include vancomycin or linezolid. -- Source: [ATS/IDSA HAP/VAP Guideline](https://www.idsociety.org/practice-guideline/hap_vap/) -- Publisher: American Thoracic Society and Infectious Diseases Society of America -- Supports: Confirmed MRSA pneumonia should be treated with vancomycin or - linezolid; patient-specific factors such as renal function, blood counts, - serotonergic medications, and cost can guide selection. -- Source: [Daptomycin prescribing information](https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/217630s000lbl.pdf) -- Publisher: U.S. Food and Drug Administration -- Supports: Daptomycin is not indicated for treatment of pneumonia. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-endocrine-new-diabetes-lipid-screen-842 - -- Source: [Cardiovascular Disease and Risk Management: Standards of Care in Diabetes - 2026](https://diabetesjournals.org/care/article/49/Supplement_1/S216/163933/10-Cardiovascular-Disease-and-Risk-Management) -- Publisher: American Diabetes Association -- Supports: Adults with diabetes aged 40-75 years without ASCVD should receive - at least moderate-intensity statin therapy. A lipid profile establishes the - baseline needed to assess LDL reduction, identify severe dyslipidemia, and - monitor response and adherence after therapy begins. -- Source: [Comprehensive Medical Evaluation: Standards of Care in Diabetes - 2026](https://diabetesjournals.org/care/article/49/Supplement_1/S61/163931/4-Comprehensive-Medical-Evaluation-and-Assessment) -- Publisher: American Diabetes Association -- Supports: Adults with type 2 diabetes should also be assessed for metabolic - liver fibrosis risk with FIB-4, which uses age, AST, ALT, and platelet count; - therefore hepatic enzymes and CBC components should not be presented as - categorically unnecessary distractors in an initial diabetes evaluation. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-neuro-missed-antiseizure-dose-316 - -- Source: [Levetiracetam Medication Guide](https://www.dailymed.nlm.nih.gov/dailymed/medguide.cfm?setid=0f60b9fb-5305-4488-99b7-a01a693994b4) -- Publisher: U.S. National Library of Medicine DailyMed -- Supports: A missed levetiracetam dose should be taken when remembered unless - it is almost time for the next dose; in that case, the missed dose should be - skipped and the next dose taken at the regular time without doubling. -- Source: [How and when to take levetiracetam](https://www.nhs.uk/medicines/levetiracetam/how-and-when-to-take-levetiracetam/) -- Publisher: National Health Service -- Supports: For twice-daily levetiracetam, if fewer than 8 hours remain before - the next dose, skip the missed dose and take the next dose normally; never - take an extra dose to compensate. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-ethics-shared-decision-oncology-481 - -- Source: [Surgery to Reduce the Risk of Breast Cancer](https://www.cancer.gov/types/breast/causes-risk-factors/prevention/preventive-breast-surgery) -- Publisher: National Cancer Institute -- Supports: Contralateral risk-reducing mastectomy lowers contralateral cancer - incidence but is generally discouraged for average-risk patients because - contralateral risk is low, complications may increase, and available evidence - does not show reduced mortality; benefits and harms should be individualized - and discussed. -- Source: [Mastectomy: Single vs. Double Mastectomy](https://www.cancer.gov/types/breast/treatment/surgery/mastectomy) -- Publisher: National Cancer Institute -- Supports: Patients without a high-risk mutation or strong family history do - not generally live longer after double rather than single mastectomy, but - concerns about recurrence, surveillance, symmetry, body image, reconstruction, - risks, and patient preferences should be discussed in shared decision-making. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-neuro-ischemic-stroke-supportive-bp-615 - -- Source: [2026 Guideline for the Early Management of Patients With Acute Ischemic Stroke](https://professional.heart.org/en/science-news/2026-guideline-for-the-early-management-of-patients-with-acute-ischemic-stroke) -- Publisher: American Heart Association/American Stroke Association -- Supports: Current acute ischemic stroke guidance emphasizes rapid assessment for - intravenous thrombolysis and endovascular thrombectomy, including expanded - thrombectomy eligibility, and warns against intensive blood pressure lowering - around reperfusion treatment. -- Source: [2025 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults](https://www.ahajournals.org/doi/10.1161/HYP.0000000000000249) -- Publisher: American Heart Association/American College of Cardiology -- Supports: In acute ischemic stroke, blood pressure treatment depends on - reperfusion status, a pressure above 220/120 mm Hg, or another comorbid - indication; rapid reduction can be detrimental because ischemic tissue depends - on systemic perfusion pressure. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-urogynecology-stress-incontinence-pessary-612 - -- Source: [Urinary Incontinence](https://www.acog.org/womens-health/faqs/urinary-incontinence) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: Stress urinary incontinence causes leakage with coughing, laughing, - walking, running, or exercise; a fitted pessary can support the vaginal walls, - bladder, and urethra and provide symptom relief without surgery. -- Source: [Pelvic Support Problems](https://www.acog.org/womens-health/faqs/pelvic-support-problems) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: Anterior vaginal wall prolapse results from weakened pelvic support; - pessaries can be used for short- or long-term support and many patients obtain - immediate relief, while pelvic floor exercises may also improve incontinence. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-cardiology-preop-ecg-incidental-552 - -- Source: [2024 Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery](https://professional.heart.org/en/-/media/PHD-Files-2/Science-News/2/2024/2024-Guideline-for-Perioperative-Cardiovascular-Management-slide-set.pdf) -- Publisher: American Heart Association/American College of Cardiology -- Supports: Routine resting ECG is not recommended for asymptomatic patients - undergoing low-risk surgery; further evaluation is reasonable for new ECG - abnormalities, not an unchanged chronic finding. -- Source: [2024 AHA/ACC Perioperative Cardiovascular Management Guideline: Key Points](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/09/23/04/15/2024-aha-acc-perioperative-guideline-gl) -- Publisher: American College of Cardiology -- Supports: Patients with good functional capacity, low predicted perioperative - risk, or a planned low-risk procedure should not undergo routine preoperative - stress testing. -- Media: Original ECG schematic created for this question; no third-party image - was uploaded. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-psychiatry-late-life-depression-mirtazapine-714 - -- Source: [VA/DoD Clinical Practice Guideline: Management of Major Depressive Disorder](https://www.healthquality.va.gov/guidelines/MH/mdd/) -- Publisher: U.S. Department of Veterans Affairs and Department of Defense -- Supports: Major depressive disorder should be treated with evidence-based - pharmacotherapy and/or psychotherapy selected according to clinical features, - patient preferences, comorbidities, and adverse-effect profiles. -- Source: [Mirtazapine Prescribing Information](https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=98ad1917-a094-44f5-a28f-a64a8cfcd887) -- Publisher: U.S. National Library of Medicine DailyMed -- Supports: Mirtazapine is indicated for major depressive disorder; common - effects include somnolence, increased appetite, weight gain, and dizziness, - which informs individualized use and monitoring in an older patient with - insomnia and clinically significant weight loss. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-bone-health-osteoporosis-bisphosphonate-815 - -- Source: [Pharmacological Management of Osteoporosis in Postmenopausal Women](https://www.endocrine.org/clinical-practice-guidelines/osteoporosis-in-postmenopausal-women) -- Publisher: Endocrine Society -- Supports: Bisphosphonates are recommended as initial therapy for postmenopausal - women at high fracture risk; raloxifene is limited to women at low DVT risk, - menopausal hormone therapy is limited to selected younger women at low DVT - risk, and calcitonin is reserved for patients unable to use preferred agents. -- Source: [Raloxifene Prescribing Information](https://www.accessdata.fda.gov/drugsatfda_docs/review/2018/090842Orig1s000.pdf) -- Publisher: U.S. Food and Drug Administration -- Supports: Raloxifene is contraindicated in women with an active or past history - of venous thromboembolism, including deep venous thrombosis and pulmonary - embolism. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-endocrine-dka-dextrose-potassium-916 - -- Source: [Hyperglycemic Crises in Adults With Diabetes: A Consensus Report](https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A) -- Publisher: American Diabetes Association and European Association for the Study of Diabetes -- Supports: When glucose falls below 250 mg/dL during DKA treatment, add 5%-10% - dextrose and reduce but continue intravenous insulin until ketonemia resolves; - add potassium when serum potassium falls below 5.0 mmol/L to maintain 4-5 - mmol/L, and reserve bicarbonate for severe acidosis with pH below 7.0. -- Source: [Hyperglycemic Crises in Adults With Diabetes: Full Consensus Report](https://pmc.ncbi.nlm.nih.gov/articles/PMC11272983/) -- Publisher: Diabetes Care via PubMed Central -- Supports: DKA resolution requires beta-hydroxybutyrate below 0.6 mmol/L plus - venous pH at least 7.3 or bicarbonate at least 18 mmol/L; glucose normalization - alone is not sufficient to stop insulin. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-substance-use-alcohol-blackout-counseling-917 - -- Source: [Interrupted Memories: Alcohol-Induced Blackouts](https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/interrupted-memories-alcohol-induced-blackouts) -- Publisher: National Institute on Alcohol Abuse and Alcoholism -- Supports: During an alcohol-induced blackout a person remains awake but cannot - consolidate new memories; even one blackout is concerning, predicts increased - risk of alcohol-related harms, and should prompt discussion and assessment of - drinking behavior. -- Source: [Screening, Brief Intervention, and Referral to Treatment](https://www.samhsa.gov/substance-use/treatment/sbirt) -- Publisher: Substance Abuse and Mental Health Services Administration -- Supports: Emergency departments are appropriate settings for validated - substance-use screening, brief intervention for at-risk use, and referral for - additional assessment or treatment when indicated. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-gastroenterology-splenic-infarction-post-sclerotherapy-918 - -- Source: [Splenic Abscess: A Possible Complication of Endoscopic Variceal Sclerotherapy](https://pubmed.ncbi.nlm.nih.gov/8340143/) -- Publisher: PubMed-indexed case report -- Supports: Splenic abscess is a reported rare complication of endoscopic - variceal sclerotherapy, potentially related to bacteremia or retrograde portal - venous thrombosis after the procedure. -- Source: [AAST Acute Care Surgery Curriculum: Splenic Abscess](https://www.aast.org/Assets/732276a6-7a75-44d8-99c8-a364158e7833/638578976049130000/e15-splenic-abscess-pdf) -- Publisher: American Association for the Surgery of Trauma -- Supports: CT establishes the diagnosis; initial treatment includes hospital - admission and broad-spectrum antibiotics, with definitive source control by - percutaneous drainage or splenectomy selected according to anatomy and clinical - status. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-gynecology-pessary-vaginitis-919 - -- Source: [Vaginal Pessary Use and Management for Pelvic Organ Prolapse](https://www.augs.org/clinical-patient-resources/clinical-guidance-documents/) -- Publisher: American Urogynecologic Society and Society of Urologic Nurses and Associates -- Supports: AUGS identifies its joint clinical consensus statement as current - guidance for pessary use, surveillance, and management of pessary-related - complications. -- Source: [Updates in Pessary Care for Pelvic Organ Prolapse: A Narrative Review](https://pmc.ncbi.nlm.nih.gov/articles/PMC12028327/) -- Publisher: Journal of Clinical Medicine via PubMed Central -- Supports: Pessary-associated discharge is common and does not necessarily - indicate infection; pessary-related epithelial changes are classified by - direct examination, and management may include cleaning, temporary removal, - vaginal assessment, and treatment directed by the observed complication. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pulmonary-copd-exacerbation-bronchodilator-920 - -- Source: [Global Initiative for Chronic Obstructive Lung Disease 2026 Report](https://goldcopd.org/wp-content/uploads/2026/01/GOLD-REPORT-2026-v1.3-8Dec2025_WMV2.pdf) -- Publisher: Global Initiative for Chronic Obstructive Lung Disease -- Supports: Short-acting inhaled beta2-agonists, with or without short-acting - anticholinergics, are the initial bronchodilators for an acute COPD - exacerbation. Systemic corticosteroids improve recovery, and antibiotics are - indicated when increased sputum purulence accompanies other cardinal symptoms - or mechanical ventilation is required. -- Source: [Chronic Obstructive Pulmonary Disease in Over 16s: Diagnosis and Management](https://www.nice.org.uk/guidance/ng115/chapter/recommendations) -- Publisher: National Institute for Health and Care Excellence -- Supports: Acute exacerbation management includes increased short-acting - bronchodilator therapy, controlled oxygen when needed, systemic corticosteroids - for significant breathlessness, and antibiotics when sputum changes suggest a - bacterial trigger. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-obgyn-tuboovarian-abscess-641 - -- Source: [Pelvic Inflammatory Disease: STI Treatment Guidelines](https://www.cdc.gov/std/treatment-guidelines/pid.htm) -- Publisher: Centers for Disease Control and Prevention -- Supports: Tubo-ovarian abscess is an indication for hospitalization and more - than 24 hours of inpatient observation. Recommended parenteral therapy includes - ceftriaxone, doxycycline, and metronidazole, with continued anaerobic coverage - when an abscess is present. -- Source: [Pelvic Inflammatory Disease](https://www.acog.org/womens-health/faqs/pelvic-inflammatory-disease) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: PID can produce a tubo-ovarian abscess; antibiotics are the usual - initial treatment, while selected abscesses may require a procedure or surgery. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-musculoskeletal-scoliosis-screen-422 - -- Source: [Adolescent Idiopathic Scoliosis: Screening](https://www.uspreventiveservicestaskforce.org/uspstf/index.php/recommendation/adolescent-idiopathic-scoliosis-screening) -- Publisher: U.S. Preventive Services Task Force -- Supports: The forward bend test is commonly used to evaluate adolescents for - scoliosis, a scoliometer can quantify trunk rotation, and an angle of 5-7 - degrees commonly prompts radiography. The USPSTF concludes that evidence is - insufficient to determine the benefits and harms of universal screening. -- Source: [Scoliosis](https://www.srs.org/Patients/Conditions/Scoliosis) -- Publisher: Scoliosis Research Society -- Supports: The Adams forward bend test reveals asymmetric rib or lumbar - prominence and is the most frequently used clinical screening maneuver for - scoliosis. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-ethics-geriatric-cataract-capacity-923 - -- Source: [Decisions for Adult Patients Who Lack Capacity](https://code-medical-ethics.ama-assn.org/ethics-opinions/decisions-adult-patients-who-lack-capacity) -- Publisher: American Medical Association Code of Medical Ethics -- Supports: Patients should participate in decisions according to their - decision-making capacity; a surrogate exercises authority when the patient - lacks capacity for the decision, not merely because a cognitive disorder is - present. -- Source: [Cataract Surgery](https://www.nei.nih.gov/eye-health-information/eye-conditions-and-diseases/cataracts/cataract-surgery) -- Publisher: National Eye Institute -- Supports: Cataract surgery is considered when vision loss interferes with - everyday activities such as reading; it is common, generally outpatient, and - improves vision in most patients, although individualized risks must be - discussed. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-obstetrics-initial-prenatal-blood-type-1024 - -- Source: [Routine Tests During Pregnancy](https://www.acog.org/womens-health/faqs/routine-tests-during-pregnancy) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: Initial prenatal laboratory testing includes maternal blood type and - Rh status; early identification of Rh-negative patients and alloantibodies - guides prophylaxis and monitoring. -- Source: [Screening for Fetal Chromosomal Abnormalities](https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2026/01/screening-for-fetal-chromosomal-abnormalities) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: Cell-free DNA is the most sensitive and specific screening test for - common fetal aneuploidies and should be made available to all obstetric - patients after counseling, regardless of baseline risk. -- Source: [Oocyte or Embryo Donation to Women of Advanced Reproductive Age](https://integration.asrm.org/globalassets/_asrm/practice-guidance/ethics-opinions/pdf/oocyte_or_embryo_donation_to_women_of_advanced_maternal_age_an_ethics_commitee_opinion.pdf) -- Publisher: American Society for Reproductive Medicine Ethics Committee -- Supports: In donor-oocyte pregnancies, the incidence of age-related genetic - abnormalities in offspring relates primarily to the age of the oocyte donor - rather than the gestational carrier. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-urology-testicular-torsion-811 - -- Source: [AUA Medical Student Curriculum: The Acute Scrotum](https://www.auanet.org/documents/education/Acute-Scrotum.pdf) -- Publisher: American Urological Association -- Supports: Definitive treatment of testicular torsion is immediate scrotal - exploration. The affected testis is detorsed and fixed if viable, and the - contralateral testis undergoes orchiopexy because the bell-clapper deformity is - assumed to be bilateral. -- Source: [Acute Scrotal Pain Clinical Pathway](https://www.hopkinsmedicine.org/-/media/files/allchildrens/clinical-pathways/acute-scrotal-pain-clinical-pathway-12_8_2022.pdf) -- Publisher: Johns Hopkins All Children's Hospital -- Supports: Sudden severe pain with a high-riding or transverse testis and absent - cremasteric reflex can establish torsion clinically and should prompt immediate - surgical consultation; Doppler ultrasonography is used for equivocal cases. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pediatrics-hsp-prognosis-517 - -- Source: [IPNA Clinical Practice Recommendations for Children With IgA Nephropathy and IgA Vasculitis Nephritis](https://pmc.ncbi.nlm.nih.gov/articles/PMC11666671/) -- Publisher: International Pediatric Nephrology Association -- Supports: Mild IgA vasculitis nephritis with normal blood pressure and kidney - function can recover without treatment. Persistent proteinuria, particularly - substantial proteinuria at 1 year, is associated with worse long-term kidney - prognosis; children with renal involvement require prolonged monitoring. -- Source: [National Recommendations for the Management of Children and Young People With IgA Vasculitis](https://pmc.ncbi.nlm.nih.gov/articles/PMC11671997/) -- Publisher: UK Kidney Association-aligned multidisciplinary guideline group -- Supports: All children with IgA vasculitis require surveillance for nephritis; - persistent moderate or severe proteinuria, acute kidney injury, and nephrotic - syndrome identify more severe renal disease requiring additional evaluation. -- Accessed: 2026-07-12 -- Reviewer: Codex - -## step3-pediatrics-asthma-environmental-control-388 - -- Source: [Global Strategy for Asthma Management and Prevention, 2025](https://ginasthma.org/wp-content/uploads/2025/07/GINA-2025-Strategy-Report_25_05_25-WMS-2.pdf) -- Publisher: Global Initiative for Asthma -- Supports: Parents and caregivers of children with asthma should be advised not - to smoke or vape and not to permit smoking or vaping in rooms or vehicles used - by their children; cessation support should be provided. -- Source: [Asthma and Secondhand Smoke](https://www.cdc.gov/tobacco/campaign/tips/diseases/secondhand-smoke-asthma.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Tobacco smoke is a common asthma trigger; families should not smoke - or allow smoking in the home or car, and opening a window does not protect a - child from secondhand smoke. -- Source: [Secondhand Tobacco Smoke and Indoor Air Quality](https://www.epa.gov/indoor-air-quality-iaq/secondhand-tobacco-smoke-and-indoor-air-quality) -- Publisher: U.S. Environmental Protection Agency -- Supports: Secondhand smoke causes more frequent and severe asthma attacks in - children, has no safe exposure level, and cannot be eliminated by ventilation - or air cleaning. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-infectious-facial-cellulitis-cefazolin-929 - -- Source: [Clinical Guidance for Group A Streptococcal Cellulitis](https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/cellulitis.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Nonpurulent cellulitis should receive an antibiotic active against - streptococci; intravenous options for systemic infection include cefazolin. -- Source: [Practice Guidelines for Skin and Soft Tissue Infections](https://www.idsociety.org/practice-guideline/skin-and-soft-tissue-infections/) -- Publisher: Infectious Diseases Society of America -- Supports: Moderate nonpurulent cellulitis requires systemic antibiotics; - cefazolin covers streptococci and MSSA, while MRSA coverage is reserved for - defined risk factors or severe infection. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-hematology-hemophilia-hemarthrosis-928 - -- Source: [WFH Guidelines for the Management of Hemophilia, 3rd Edition: Prophylaxis](https://www1.wfh.org/publications/files/pdf-1907.pdf) -- Publisher: World Federation of Hemophilia -- Supports: Children with severe hemophilia should receive early, regular - prophylaxis; long-term prophylaxis reduces hemarthrosis, slows hemophilic - arthropathy, and improves joint outcomes compared with episodic treatment. -- Source: [About Hemophilia](https://www.cdc.gov/hemophilia/about/index.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Joint bleeding is a common manifestation of hemophilia and can cause - chronic joint disease and pain; regular prophylaxis can prevent most bleeding - episodes. -- Source: [Testing for Inhibitors and Hemophilia](https://www.cdc.gov/hemophilia/testing/testing-for-inhibitors-and-hemophilia.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Factor VIII inhibitors are a separate serious treatment complication - that can render replacement factor ineffective and warrant regular testing. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-cardiovascular-aaa-surveillance-930 - -- Source: [2022 ACC/AHA Aortic Disease Guideline: Key Perspectives](https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2022/11/01/12/21/2022-Guideline-on-Aortic-Disease-2-gl-ad) -- Publisher: American College of Cardiology / American Heart Association -- Supports: Men with an AAA measuring 4.0-4.9 cm should undergo annual - surveillance; repair is recommended at 5.5 cm or for aneurysm-related symptoms. -- Source: [Patients with Abdominal Aortic Aneurysm](https://vascular.org/node/87) -- Publisher: Society for Vascular Surgery -- Supports: AAA measuring 4.0-4.9 cm should receive surveillance imaging at - 12-month intervals; vascular-surgery referral is recommended at diagnosis. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-gastrointestinal-bowel-obstruction-imaging-731 - -- Source: [ACR Appropriateness Criteria: Suspected Small-Bowel Obstruction](https://acsearch.acr.org/docs/69476/Narrative/) -- Publisher: American College of Radiology -- Supports: CT abdomen and pelvis with intravenous contrast is preferred for - acute suspected obstruction because it identifies the level, cause, bowel - perfusion, and complications; oral contrast is unnecessary in high-grade SBO. -- Source: [ASGE Guideline on Colonic Volvulus and Acute Colonic Pseudo-Obstruction](https://www.asge.org/docs/default-source/guidelines/american-society-for-gastrointestinal-endoscopy-guideline-on-the-role-of-endoscopy-in-the-management-of-acute-colonic-pseudo-obstruction-and-colonic-volvulus-2020-february-gie.pdf) -- Publisher: American Society for Gastrointestinal Endoscopy -- Supports: Cross-sectional CT distinguishes volvulus, pseudo-obstruction, and - other mechanical obstruction and has replaced plain radiography as the - preferred diagnostic study for suspected sigmoid or cecal volvulus. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-preventive-cervical-screening-sexual-orientation-932 - -- Source: [Screening for Cervical Cancer](https://www.acog.org/clinical/clinical-guidance/committee-statement/articles/2026/07/screening-for-cervical-cancer) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: Under the 2026 ACOG/WPSI guidance, average-risk patients age 21-29 - years should receive cervical cytology alone every 3 years. -- Source: [Women Who Have Sex with Women](https://www.cdc.gov/std/treatment-guidelines/wsw.htm) -- Publisher: Centers for Disease Control and Prevention -- Supports: HPV can be transmitted between female partners, and routine cervical - cancer screening should be offered regardless of sexual orientation or practices. -- Source: [HPV Infection and Vaccination](https://www.acog.org/womens-health/faqs/hpv-vaccination) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: HPV vaccination does not protect against all HPV types and does not - remove the need for age-appropriate cervical cancer screening. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-cardiovascular-risk-smoking-841 - -- Source: [Tobacco Smoking Cessation in Adults: Interventions](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions) -- Publisher: U.S. Preventive Services Task Force -- Supports: Adults who smoke should receive behavioral interventions and - FDA-approved pharmacotherapy; the net benefit of cessation treatment is substantial. -- Source: [Smoking and Cardiovascular Disease](https://www.cdc.gov/tobacco/patient-care/care-settings/pdfs/cdc-osh-hcp-cardio-factsheet-508.pdf) -- Publisher: Centers for Disease Control and Prevention -- Supports: Smoking cessation improves cardiovascular health, with coronary - heart disease risk falling sharply within 1-2 years after cessation. -- Source: [Aspirin Use to Prevent Cardiovascular Disease](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/aspirin-to-prevent-cardiovascular-disease-preventive-medication) -- Publisher: U.S. Preventive Services Task Force -- Supports: For adults age 40-59 years with elevated cardiovascular risk, - aspirin initiation is individualized because the average net benefit is small. -- Source: [Vitamin and Multivitamin Supplementation to Prevent CVD and Cancer](https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/vitamin-supplementation-to-prevent-cvd-and-cancer-preventive-medication) -- Publisher: U.S. Preventive Services Task Force -- Supports: Evidence is insufficient to recommend multivitamins for preventing - cardiovascular disease, and trials have not shown cardiovascular mortality benefit. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-cardiovascular-exercise-hdl-614 - -- Source: [Physical Activity as First-Line Treatment for Elevated Blood Pressure or Cholesterol](https://professional.heart.org/en/science-news/physical-activity-as-a-critical-component-of-first-line-treatment-for-elevated-bp-or-cholesterol/top-things-to-know) -- Publisher: American Heart Association -- Supports: At least 150 minutes of moderate aerobic activity weekly raises HDL - by about 1-2 mg/dL, lowers LDL by 3-6 mg/dL and triglycerides by 4-12 mg/dL, - and lowers systolic and diastolic blood pressure by roughly 3-4 mm Hg. -- Source: [Physical Activity Guidelines for Americans, 2nd Edition](https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf) -- Publisher: U.S. Department of Health and Human Services -- Supports: Regular activity improves blood pressure and lipid profiles, and - substantial cardiovascular benefit occurs at 150 minutes of moderate activity weekly. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-musculoskeletal-lateral-ankle-sprain-935 - -- Source: [Lateral Ankle Ligament Sprains Clinical Practice Guideline](https://www.orthopt.org/uploads/content_files/files/jospt.2021.0302.pdf) -- Publisher: Academy of Orthopaedic Physical Therapy / Journal of Orthopaedic & Sports Physical Therapy -- Supports: Acute lateral ankle sprains should receive external support and - progressive weight bearing; intermittent ice may be used with therapeutic exercise. -- Source: [ACR Appropriateness Criteria: Acute Trauma to the Ankle](https://acsearch.acr.org/docs/69436/Narrative/) -- Publisher: American College of Radiology -- Supports: Ankle radiography is usually not appropriate when Ottawa ankle rules - are negative, with no relevant bony tenderness and preserved four-step ambulation. -- Source: [Sprained Ankle](https://orthoinfo.aaos.org/en/diseases--conditions/sprained-ankle/) -- Publisher: American Academy of Orthopaedic Surgeons -- Supports: Mild sprains are treated conservatively with early weight bearing, - removable support when needed, and early functional rehabilitation. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-obstetrics-prenatal-cocaine-exposure-674 - -- Source: [Cocaine](https://www.ncbi.nlm.nih.gov/books/NBK582649/) -- Publisher: MotherToBaby / Organization of Teratology Information Specialists -- Supports: Late prenatal cocaine exposure can be followed by irritability, - tremors, stiffness, poor feeding, sleep disturbance, and hyperactivity; exposure - also increases risks of low birth weight, prematurity, and placental abruption. -- Source: [Neonatal Drug Withdrawal](https://publications.aap.org/pediatrics/article/129/2/e540/32573/Neonatal-Drug-Withdrawal) -- Publisher: American Academy of Pediatrics -- Supports: Cocaine-exposed neonates can have irritability, hyperactivity, - tremors, and feeding abnormalities, but a distinct stimulant abstinence - syndrome is not clearly defined and findings may reflect residual drug effect. -- Source: [Management of Stillbirth](https://www.acog.org/clinical/clinical-guidance/obstetric-care-consensus/articles/2020/03/management-of-stillbirth) -- Publisher: American College of Obstetricians and Gynecologists -- Supports: Maternal cocaine and tobacco use are important contributors to - placental abruption and stillbirth risk. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-fetal-alcohol-earlyintervention-037 - -- Source: [Treatment of Fetal Alcohol Spectrum Disorders](https://www.cdc.gov/fasd/treatment/index.html) -- Publisher: Centers for Disease Control and Prevention -- Supports: Early intervention can improve development; infants and toddlers - with fetal alcohol syndrome commonly qualify immediately without waiting for - an established developmental delay. -- Source: [IDEA Regulation 34 CFR 303.21: Infant or Toddler with a Disability](https://sites.ed.gov/idea/regs/c/a/303.21) -- Publisher: U.S. Department of Education -- Supports: Part C eligibility includes diagnosed conditions with a high - probability of developmental delay and specifically names fetal alcohol syndrome. -- Source: [IDEA Part C Early Intervention Program](https://www.ed.gov/grants-and-programs/formula-grants/formula-grants-special-populations/idea-early-intervention-program-infants-and-toddlers-disabilities-part-c) -- Publisher: U.S. Department of Education -- Supports: Part C provides coordinated, multidisciplinary, family-centered - services for eligible children from birth through age 2 years. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-congenital-hypothyroidism-adoptedinfant-038 - -- Source: [Congenital Hypothyroidism: Screening and Management](https://publications.aap.org/pediatrics/article/151/1/e2022060419/190311/Congenital-Hypothyroidism-Screening-and-Management) -- Publisher: American Academy of Pediatrics -- Supports: Confirmed congenital hypothyroidism requires prompt levothyroxine; - treatment timing is critical for neurodevelopment, and imaging must never delay therapy. -- Source: [Congenital Hypothyroidism](https://www.thyroid.org/congenital-hypothyroidism/) -- Publisher: American Thyroid Association -- Supports: Low free T4 with elevated TSH confirms primary congenital - hypothyroidism; levothyroxine is standard treatment with frequent biochemical - monitoring and pediatric endocrine follow-up. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-delirium-collateral-history-039 - -- Source: [Delirium: prevention, diagnosis and management](https://www.nice.org.uk/guidance/cg103/chapter/Recommendations) -- Publisher: National Institute for Health and Care Excellence -- Supports: Recent changes or fluctuations suggesting delirium may be reported - by a relative or carer; identified cases require formal delirium assessment and - evaluation and management of contributing causes. -- Source: [Dementia: assessment, management and support](https://www.nice.org.uk/guidance/ng97/chapter/Recommendations) -- Publisher: National Institute for Health and Care Excellence -- Supports: Initial cognitive assessment includes history from the patient and, - when possible, someone who knows the patient well to characterize cognition, - behavior, and effects on daily life. -- Source: [Syphilis: STI Treatment Guidelines](https://www.cdc.gov/std/treatment-guidelines/syphilis.htm) -- Publisher: Centers for Disease Control and Prevention -- Supports: A reactive nontreponemal test such as RPR requires confirmation with - a treponemal test; a single serologic test is insufficient for diagnosis. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-pediatrics-physiologic-anemia-infancy-940 - -- Source: [Well Care for Formerly Preterm Infants](https://publications.aap.org/first1000days/module/27506/section/1cd7f046-cb2d-4e02-b460-4ffc870c33e9) -- Publisher: American Academy of Pediatrics -- Supports: Physiologic anemia in term infants reaches a hemoglobin nadir at - approximately 8-12 weeks, later and at a higher level than in preterm infants. -- Source: [Perinatal Anemia](https://www.msdmanuals.com/professional/pediatrics/perinatal-hematologic-disorders/perinatal-anemia) -- Publisher: MSD Manual Professional Edition -- Supports: Increased oxygenation after birth suppresses erythropoietin and - erythropoiesis; the shorter neonatal erythrocyte lifespan also contributes to - the fall over the first 2-3 months, followed by recovery without treatment in - healthy term infants. -- Source: [Pathophysiology of Anemia During the Neonatal Period, Including Anemia of Prematurity](https://pmc.ncbi.nlm.nih.gov/articles/PMC2867612/) -- Publisher: NeoReviews / U.S. National Library of Medicine -- Supports: Healthy term infants are generally asymptomatic as hemoglobin falls - to its physiologic nadir at approximately 8-10 weeks and then gradually rises. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-oncology-metastatic-adenocarcinoma-prognosis-941 - -- Source: [Cancer of Unknown Primary Treatment (PDQ), Health Professional Version](https://www.cancer.gov/types/unknown-primary/hp/unknown-primary-treatment-pdq) -- Publisher: National Cancer Institute -- Supports: CUP generally has poor prognosis, with approximately 30% of patients - alive at 1 year; adenocarcinoma histology, older age, hepatic involvement, poor - performance status, and elevated LDH are associated with worse survival. -- Source: [SEOM-GECOD Clinical Guideline for Cancer of Unknown Primary, Update 2025](https://pmc.ncbi.nlm.nih.gov/articles/PMC13099792/) -- Publisher: Spanish Society of Medical Oncology / Springer Nature -- Supports: Approximately 80% of CUP cases belong to an unfavorable subgroup - with median overall survival of roughly 6-12 months; performance status and LDH - further refine prognosis, and selected favorable clinicopathologic subsets - require separate management. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-geriatrics-depression-weightloss-mirtazapine-942 - -- Source: [Unintentional Weight Loss in Older Adults](https://www.aafp.org/pubs/afp/issues/2021/0700/p34.html) -- Publisher: American Academy of Family Physicians -- Supports: Mirtazapine can cause appetite increase and weight gain when used to - treat depression, but evidence does not support prescribing it solely as an - appetite stimulant; somnolence and dizziness may increase fall risk. -- Source: [Choosing Wisely](https://www.healthinaging.org/choosing-wisely) -- Publisher: American Geriatrics Society / Health in Aging Foundation -- Supports: Avoid prescription appetite stimulants for nonspecific anorexia in - older adults; megestrol has minimal benefit and increases thrombotic events, - fluid retention, and death, whereas mirtazapine may increase appetite when it - is being used for coexisting depression. -- Source: [American Geriatrics Society 2023 Updated AGS Beers Criteria](https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.18372) -- Publisher: American Geriatrics Society -- Supports: Megestrol should be avoided in older adults because its effect on - weight is minimal and it increases thrombotic events and possibly death. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-postoperative-fluid-overload-diuresis-943 - -- Source: [Acute Heart Failure: Diagnosis and Management](https://www.nice.org.uk/guidance/cg187/chapter/Recommendations) -- Publisher: National Institute for Health and Care Excellence -- Supports: Acute pulmonary congestion should be treated with intravenous loop - diuretics, with close monitoring of renal function, weight, and urine output; - ventilatory support is considered when severe respiratory failure or persistent - distress is present. -- Source: [2013 ACCF/AHA Guideline for the Management of Heart Failure, Executive Summary](https://www.acc.org/~/media/Non-Clinical/Files-PDFs-Excel-MS-Word-etc/Tools%20and%20Practice%20Support/Quality%20Programs/Heart%20Failure%20Roundtable%202016/Heart%20Failure%20Guidelines/HFG%203%202013%20ACCFAHA%20Guideline.pdf) -- Publisher: American College of Cardiology / American Heart Association -- Supports: Hospitalized patients with significant fluid overload should receive - prompt intravenous loop diuretics, with serial assessment of urine output, - congestion, renal function, and electrolytes. -- Source: [Diuretic Therapy for Patients With Heart Failure](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2020/03/09/15/28/Diuretic-Therapy-for-Patients-With-Heart-Failure) -- Publisher: American College of Cardiology -- Supports: Loop diuretic dosing is guided by volume status and decongestion; - renal function changes must be interpreted in the context of persistent congestion. -- Accessed: 2026-07-13 -- Reviewer: Codex - -## step3-cardiovascular-white-coat-hypertension-device-check-944 - -- Source: [Home Blood Pressure Monitoring](https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home) -- Publisher: American Heart Association -- Supports: Patients should use a validated upper-arm device with the correct - cuff size, bring it to clinic so accuracy and technique can be checked, and use - standardized preparation, positioning, and repeated measurements. -- Source: [Device Calibration Test for Self-Measured Blood Pressure Devices](https://www.ama-assn.org/system/files/2019-04/smbp-device-accuracy-test.pdf) -- Publisher: American Medical Association -- Supports: When home results are unreasonably discrepant from office results, - compare sequential readings from the patient's device and a validated office - device after confirming proper preparation, positioning, and technique. -- Source: [Harmonization of ACC/AHA and ESC/ESH Blood Pressure Guidelines](https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2022/08/22/16/48/harmonization-of-the-acc-aha) -- Publisher: American College of Cardiology -- Supports: Accurate measurement using validated devices and multiple readings - is foundational; home or ambulatory monitoring is recommended to identify and - confirm white-coat and masked blood pressure patterns. -- Accessed: 2026-07-13 -- Reviewer: Codex diff --git a/README.md b/README.md index 547e919..13cbb58 100644 --- a/README.md +++ b/README.md @@ -104,9 +104,10 @@ For each question, document: References must support the keyed answer and any management recommendations, diagnostic thresholds, formulas, or numerical claims. A citation does not grant permission to copy wording or media; the separate text-originality and image- -copyright requirements still apply. If the question schema does not expose a -reference field, retain this information in the associated authoring or review -record until it can be stored with the question. +copyright requirements still apply. Store each verified source in the question +document's `references` array; published question writes require at least one +complete reference. Legacy questions with an empty array remain readable while +awaiting reference review. ## Variable Distractor Pools